Clinical Commander

All dossiers
cardio.htn.resistant.v1

Resistant hypertension (≥3 meds at max + diuretic)

cardiologychronicadultoutpatienttransitionacute
Start encounter →Print handoutPRODUCTION

Resistant HTN dossier includes mandatory ABPM + secondary HTN workup (PA, pheo, renovascular, OSA, Cushing, coarctation, drug-induced). PATHWAY-2 evidence drives spironolactone as preferred 4th drug; eplerenone for gynecomastia; renal denervation Class IIa per 2025 AHA + 2024 ESC/ESH. ED playbook for crisis presentation; outpatient + transition for chronic management. Next steps: (1) author manifest at prisma/seed/manifests/cardio.htn.resistant.v1.ts; (2) atoms; (3) design brief; (4) RxCUI verification via npm run research:rxnav:validate; (5) engine-specific test file. Calculator gaps: PREVENT, ABPM analyser, ARR scorer not yet in clinical-tools-registry.ts — add before promoting to AUTHORED.

Entry points (5)

  • problem_list
    Resistant HTN — referred from primary HTN engine (ACC/AHA 2017; Carey AHA 2018)
    resistant_htn_referred
  • vital_abnormality
    Office BP above target on ≥3 antihypertensives at max dose (ACC/AHA 2017; ESC/ESH 2023)
    persistent_office_bp_above_target_on_3_meds
  • vital_abnormality
    BP controlled on ≥4 antihypertensives (ACC/AHA 2017; ESC/ESH 2023)
    controlled_on_4_or_more_meds
  • history
    Positive secondary HTN screen (Carey AHA 2018)
    pa_pheo_renovascular_screen_positive
  • symptom
    BP ≥180/120 with end-organ damage — possible hypertensive emergency (ACC/AHA 2017)
    severe_htn_with_end_organ

Required inputs (23)

  • agerequired
    demographic • used at CONTEXT
    Age-specific secondary HTN differential — PA peaks 30-60; renovascular in elderly + atherosclerosis (Carey AHA 2018)
  • sbprequired
    vital • used at CONTEXT
    Office + ABPM/HBPM SBP defines true vs pseudo-resistant (ACC/AHA 2017; ESC/ESH 2023)
  • dbprequired
    vital • used at CONTEXT
    Diastolic component for grading (ACC/AHA 2017)
  • hrrequired
    vital • used at CONTEXT
    BB / non-DHP CCB titration; pheo screen (Carey AHA 2018)
  • home_bp_averagerequired
    vital • used at CONTEXT
    HBPM ≥7 days excludes white-coat resistance (ACC/AHA 2017; ESC/ESH 2023)
  • abpm_averagerequired
    vital • used at INITIAL_WORKUP
    24-h ABPM gold standard — excludes white-coat resistance (ACC/AHA 2017; ESC/ESH 2023)
  • creatininerequired
    lab • used at CONTEXT
    eGFR for chlorthalidone/loop crossover; ACEi/ARB titration; CKD modifier (ACC/AHA 2017)
  • potassiumrequired
    lab • used at CONTEXT
    Hypokalaemia → screen primary aldo; baseline before spironolactone (Williams Lancet 2015 PATHWAY-2; Carey AHA 2018)
  • sodium
    lab • used at CONTEXT
    Volume status + spironolactone monitoring (ACC/AHA 2017)
  • aldosterone_renin_ratiorequired
    lab • used at BRANCHING_WORKUP
    PA screen — mandatory in resistant HTN (Carey AHA 2018; ACC/AHA 2017)
  • plasma_metanephrines
    lab • used at BRANCHING_WORKUP
    Pheo screen — paroxysmal symptoms / labile BP / family history (Carey AHA 2018)
  • tsh
    lab • used at INITIAL_WORKUP
    Hyper/hypothyroidism reversible HTN driver (ACC/AHA 2017)
  • urine_acrrequired
    lab • used at INITIAL_WORKUP
    CKD/HTN end-organ damage; risk-stratification (ACC/AHA 2017; ESC/ESH 2023)
  • a1c
    lab • used at INITIAL_WORKUP
    DM target <130/80; comorbid driver (ACC/AHA 2017)
  • cortisol_dexamethasone_suppression
    lab • used at BRANCHING_WORKUP
    Cushing screen — features of weight gain, central obesity, easy bruising, glucose intolerance (Carey AHA 2018)
  • renal_artery_doppler_or_cta
    imaging • used at BRANCHING_WORKUP
    Renovascular screen — atherosclerotic vs FMD (Carey AHA 2018)
  • ecgrequired
    imaging • used at INITIAL_WORKUP
    LVH / ischemia / arrhythmia screen (ACC/AHA 2017; ESC/ESH 2023)
  • echo
    imaging • used at INITIAL_WORKUP
    LVH severity, LVEF, valvular HD (ESC/ESH 2023)
  • osa_symptomsrequired
    history • used at BRANCHING_WORKUP
    OSA dominant in resistant HTN — STOP-BANG + sleep study (Carey AHA 2018)
  • medication_adherencerequired
    history • used at CONTEXT
    Non-adherence is the most common cause of pseudo-resistant HTN (Carey AHA 2018; ACC/AHA 2017)
  • lifestyle_diet_alcohol_nsaidrequired
    history • used at CONTEXT
    High Na, alcohol, NSAIDs, sympathomimetics, OCP, COCs reverse with removal (ACC/AHA 2017; ESC/ESH 2023)
  • pregnancy_statusrequired
    history • used at CONTEXT
    AVOID ACEi/ARB/spironolactone; use labetalol / methyldopa / nifedipine ER (ACC/AHA 2017; ESC/ESH 2023)
  • current_medsrequired
    medication • used at CONTEXT
    Verify true 3+ antihypertensives at max dose with diuretic; flag drug-induced HTN — NSAIDs, decongestants, COCs, stimulants, glucocorticoids, VEGF inhibitors (ACC/AHA 2017; Carey AHA 2018)

12-phase flow (12)

  1. 1FRAME
    Confirm true resistant HTN — BP ≥130/80 on ≥3 max-dose antihypertensives including thiazide-like diuretic + ACEi/ARB + CCB, OR controlled on ≥4 (ACC/AHA 2017; Carey AHA 2018)
    inputs: sbp, dbp, current_meds
    advance: definition met or refuted
  2. 2ENTRY
    Capture trigger — referral from primary HTN engine, persistent office HTN, secondary screen positive (ACC/AHA 2017)
    inputs: age
    advance: trigger captured
  3. 3CONTEXT
    Adherence + lifestyle + medication review — NSAIDs, decongestants, OCP, stimulants, glucocorticoids, VEGF inhibitors; verify diuretic class; pregnancy (Carey AHA 2018; ACC/AHA 2017)
    inputs: sbp, dbp, hr, home_bp_average, creatinine, potassium, medication_adherence, lifestyle_diet_alcohol_nsaid, pregnancy_status, current_meds
    advance: pseudo-resistance excluded
  4. 4RED_FLAGS
    Hypertensive emergency — BP ≥180/120 + end-organ: neuro deficit, CP, pulm edema, AKI, eclampsia (ACC/AHA 2017)
    inputs: sbp, dbp
    actions: htn_emergency
    advance: emergency ruled out or routed to acute pathway
  5. 5INITIAL_WORKUP
    ABPM 24-h gold standard, HBPM ≥7 days; BMP, lipids, A1c, urine ACR, TSH, ECG, echo for LVH (ACC/AHA 2017; ESC/ESH 2023)
    inputs: abpm_average, urine_acr, tsh, ecg, echo, a1c
    actions: panel.renal, panel.lipid, panel.thyroid, panel.glucose_a1c
    advance: ABPM confirms true resistant + baseline workup complete
  6. 6BRANCHING_WORKUP
    Secondary HTN workup — PA with ARR mandatory (Carey AHA 2018), pheo (plasma free metanephrines), renovascular (renal artery duplex / CT-A or MR-A), OSA (STOP-BANG → sleep study), CKD, Cushing if features, coarctation if young / arm-leg gradient, drug-induced
    inputs: aldosterone_renin_ratio, plasma_metanephrines, osa_symptoms, cortisol_dexamethasone_suppression, renal_artery_doppler_or_cta
    actions: secondary_htn
    advance: secondary HTN ruled out or specific phenotype confirmed
  7. 7DIFFERENTIAL
    Categorise: pseudo-resistant (non-adherence/white-coat/inadequate regimen) vs true resistant (apparent / refractory) vs secondary — PA, pheo, renovascular, OSA, CKD, Cushing, coarctation, drug-induced (Carey AHA 2018)
    advance: phenotype assigned
  8. 8RISK_STRATIFICATION
    PREVENT calculator + end-organ damage assessment — LVH, urine ACR, eGFR, retinopathy; CV death risk doubled in resistant HTN (ACC/AHA 2017; ESC/ESH 2023)
    inputs: age, sbp
    advance: risk + end-organ damage documented
  9. 9TREATMENT
    4th drug = spironolactone 25-50 mg (Williams Lancet 2015 PATHWAY-2); alternatives = eplerenone, doxazosin, BB, centrally acting, hydralazine + minoxidil for refractory; renal denervation Class IIa (ACC/AHA 2017; ESC/ESH 2023; Azizi Lancet 2021 RADIANCE-HTN TRIO)
    inputs: sbp, creatinine, potassium
    advance: BP at goal or maximal therapy + renal denervation considered
  10. 10DISPOSITION
    Hypertension specialist clinic for refractory; renal denervation referral; sleep clinic if OSA; endocrine clinic if PA / pheo / Cushing (ACC/AHA 2017; Carey AHA 2018)
    advance: specialist referral made if applicable
  11. 11MONITORING
    BMP within 1-2 wks of spironolactone start; HBPM weekly during titration; ABPM at 6 months (Williams Lancet 2015 PATHWAY-2; ACC/AHA 2017)
    inputs: creatinine, potassium
    actions: panel.renal
    advance: monitoring cadence documented
  12. 12FOLLOWUP
    q3 mo until controlled, then q6 mo; ASCVD prevention bundle; reassess adherence at every visit (ACC/AHA 2017; ESC/ESH 2023)
    advance: follow-up scheduled