Case Report

A Complicated Case of Resistant Hypertension


A 47-year-old woman presented with a history of resistant arterial hypertension, associated with disabling headache. She was subjected to an enormous number of tests in order to identify an underlying cause of secondary hypertension, such as pheochromocytoma or Cushing syndrome, but all the most common causes of secondary hypertension were investigated and gradually excluded. Factitious use of amphetamine or cocaine was excluded, and therapy compliance was verified by witnessed ingestion of drug therapy, in order to rule out Munchausen syndrome. The patient underwent a first transcatheter renal denervation (RDN) with poor effect on blood pressure (BP) at long term follow up. Because of extremely poor control of BP values, a second RDN was performed two years later, again with inadequate long term efficacy. Despite an uncontrollable pre-procedural BP, RDN had an excessive BP lowering effect in this patient, but only for few months. In conclusion, a definitive diagnosis was not performed in our patient, despite an extremely deepened examination of the most common cause of refractory hypertension.

D. A. Calhoun, D. Jones, S. Textor, D. C. Goff, T. P. Murphy, R. D. Toto, A. White, W. C. Cushman, W. White, D. Sica, K. Ferdinand, T. D. Giles, B. Falkner, and R. M. Carey, “Resistant hypertension: diagnosis, evaluation, and treatment. A scientific statement from the American Heart Association Professional Education Committee of the Council for High Blood Pressure Research.,” Hypertension, vol. 51, no. 6, pp. 1403–19, Jun. 2008.

W. B. White, J. R. Turner, D. A. Sica, J. D. Bisognano, D. A. Calhoun, R. R. Townsend, H. D. Aronow, D. L. Bhatt, and G. L. Bakris, “Detection, evaluation, and treatment of severe and resistant hypertension: proceedings from an American Society of Hypertension Interactive forum held in Bethesda, MD, U.S.A., October 10th 2013.,” J. Am. Soc. Hypertens., vol. 8, no. 10, pp. 743–57, Oct. 2014.

B. M. Egan, Y. Zhao, R. N. Axon, W. A. Brzezinski, and K. C. Ferdinand, “Uncontrolled and Apparent Treatment Resistant Hypertension in the United States, 1988 to 2008,” Circulation, vol. 124, no. 9, pp. 1046–1058, Aug. 2011.

T. G. Pickering, J. E. Hall, L. J. Appel, B. E. Falkner, J. Graves, M. N. Hill, D. W. Jones, T. Kurtz, S. G. Sheps, and E. J. Roccella, “Recommendations for blood pressure measurement in humans and experimental animals: Part 1: blood pressure measurement in humans: a statement for professionals from the Subcommittee of Professional and Public Education of the American Heart Association Cou,” Hypertension, vol. 45, no. 1, pp. 142–61, Jan. 2005.

M. Moerland, A. J. Kales, L. Schrier, M. G. J. van Dongen, D. Bradnock, and J. Burggraaf, “Evaluation of the EndoPAT as a Tool to Assess Endothelial Function.,” Int. J. Vasc. Med., vol. 2012, p. 904141, Jan. 2012.

J. Stone, C. Warlow, and M. Sharpe, “The symptom of functional weakness: a controlled study of 107 patients.,” Brain, vol. 133, no. Pt 5, pp. 1537–51, May 2010.

J. Jordan, H. R. Toka, K. Heusser, O. Toka, J. R. Shannon, J. Tank, A. Diedrich, C. Stabroth, M. Stoffels, R. Naraghi, W. Oelkers, H. Schuster, H. P. Schobel, H. Haller, and F. C. Luft, “Severely impaired baroreflex-buffering in patients with monogenic hypertension and neurovascular contact.,” Circulation, vol. 102, no. 21, pp. 2611–8, Nov. 2000.

T. Pepersack, S. Allegre, X. Jeunemaître, M. Leeman, and J.-P. Praet, “Liddle syndrome phenotype in an octogenarian.,” J. Clin. Hypertens. (Greenwich)., vol. 17, no. 1, pp. 59–60, Jan. 2015.

L.-A. Martínez-Martínez, T. Mora, A. Vargas, M. Fuentes-Iniestra, and M. Martínez-Lavín, “Sympathetic nervous system dysfunction in fibromyalgia, chronic fatigue syndrome, irritable bowel syndrome, and interstitial cystitis: a review of case-control studies.,” J. Clin. Rheumatol., vol. 20, no. 3, pp. 146–50, Apr. 2014.

M. Esler, “Renal denervation for hypertension: observations and predictions of a founder.,” Eur. Heart J., vol. 35, no. 18, pp. 1178–85, May 2014.

F. Sciurba and S. I. Rennard, “Rationale for a redundant formulary. The Hawthorne effect and the art of medicine.,” Am. J. Respir. Crit. Care Med., vol. 191, no. 11, pp. 1224–5, Jun. 2015.

D. L. Bhatt, D. E. Kandzari, W. W. O’Neill, R. D’Agostino, J. M. Flack, B. T. Katzen, M. B. Leon, M. Liu, L. Mauri, M. Negoita, S. A. Cohen, S. Oparil, K. Rocha-Singh, R. R. Townsend, and G. L. Bakris, “A controlled trial of renal denervation for resistant hypertension.,” N. Engl. J. Med., vol. 370, no. 15, pp. 1393–401, Apr. 2014.

A. Briasoulis and G. Bakris, “Efficacy of baroreflex activation therapy for the treatment of resistant hypertension.,” EuroIntervention, vol. 9 Suppl R, pp. R136–9, May 2013.

N. K. Patel, S. Javed, S. Khan, M. Papouchado, A. L. Malizia, A. E. Pickering, and J. F. R. Paton, “Deep brain stimulation relieves refractory hypertension.,” Neurology, vol. 76, no. 4, pp. 405–7, Jan. 2011.

IssueVol 55, No 8 (2017) QRcode
SectionCase Report(s)
Hypertension Refractory hypertension Renal denervation

Rights and permissions
Creative Commons License This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
How to Cite
Chiarito M, Scotti A, A Pivato C, Cottone G, Ballarotto C, Godino C, Margonato A. A Complicated Case of Resistant Hypertension. Acta Med Iran. 2017;55(8):525-529.