When hypertension is resistant we think it over!

Objective: Hypertension is defined as resistant when the treatment strategy fails to lower office SBP and DBP values to <140 mmHg and/or <90 mmHg, respectively, and the inadequate control of blood pressure is confirmed by ABPM or HBPM in patients whose adherent to therapy. We report a case of resistant hypertension of a 64-year-old woman who referred to our Center in August 2021 for uncontrolled BP (160/94 mmHg) despite anti-hypertensive treatment with ramipril/hydrochlorothiazide 5/25 mg, atenolol 50 mg, ramipril 5 mg and lacidipine 4 mg daily and mild hypokalaemia (3.3 mmol/L). Design and method: Clinical history revealed dyslipidemia in treatment with simvastatin 20 mg/daily, osteoporosis in treatment with calcium and vitamin D supplements, parathyroid nodules in follow-up,family history of CAD. Laboratory tests confirmed hypokalaemia (3.1 mmol/L). Blood glucose, creatinine,lipids thyroid function were normal; no proteinuria was observed. The echocardiogram showed left ventricular hypertrophy with EF 60% and grade-1 diastolic dysfunction. Results: After wash-out of anti-hypertensive drugs, the screening tests revealed high aldosterone plasma levels (1166 pg/mL) and low renin level (1.6 microu/mL) with an ARR of 729. Other adrenal hormone levels were within normal limits. The saline infusion test confirmed the hyper-aldosteronism and an abdominal CT scan revealed a left adrenal neoformation of 17 x 15 mm in seize (Figure 1A). The patient underwent adrenal venous sampling which did not show lateralization and patients refuse to repeat the procedure. Anti-hypertensive therapy with spironolactone, eplerenone, canrenone and amiloride was stopped due to diarrhoea and rectal tenesmus (colonscopy excluded microscopic colitis). A 131I-norcholesterol adrenal scintigraphy with dexamethasone suppression documented early uptake only in the left adrenal gland (Figure 1B). After surgical evaluation, the patient underwent a video-laparoscopic left adrenalectomy and the histological examination revealed an adrenal cortical adenoma. The post-operative course was complicated by a syncopal episode due to hypotension (80/50 mmHg) with head injury for which antihypertensive therapy was revised and at the discharged she takes valsartan 80 mg, verapamil 40 mg twice. Conclusions: Primary aldosteronism intolerant to potassium-sparing diuretics and aldosterone antagonists is a rare condition and the establishment of a multidisciplinary team can improve its management.