Resistant or difficult-to-control hypertension.

Copyright © 2006 Massachusetts Medical Society. A 70-year-old woman with a long-standing history of hypertension comes for follow-up. Her medications include atenolol (100 mg daily), hydrochlorothiazide (12.5 mg daily), lisinopril (40 mg daily), and ibuprofen (400 mg twice daily for osteoarthritis). She does not smoke or drink alcohol. Her body-mass index (the weight in kilograms divided by the square of the height in meters) is 32. Her systolic and diastolic blood pressures (measured three times while she was seated) range from 164 to 170 mm Hg and 92 to 96 mm Hg, respectively, and the pulse rate is 72 per minute. Examination of her ocular fundi reveals arteriolar narrowing. The results of cardiovascular examination are normal. There are no abdominal bruits. The serum potassium level is 3.8 meq per liter, and the serum creatinine level is 1.2 mg per deciliter (106 μmol per liter); there is no microalbuminuria. How should this patient be further evaluated and treated?