Resistant hypertension: A stepwise approach
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* Leslie E. F. Page

**To the Editor:** I read with interest the review article by Yahr et al1 in the February issue, about resistant hypertension. Under the heading “Does the patient have lifestyle factors that raise blood pressure?” there is no mention of stress (chronic or acute crisis) or of psychiatric conditions such as generalized anxiety disorder. In treating the whole patient, these factors should be considered.

An example: a thin 77-year-old White man with no chronic illnesses other than moderate hypertension, well-controlled until 6 months previous to presenting with 180/95 mm Hg pressures (despite adhering to diet and medications), and with a normal lipid profile and normal renal and hepatic function. On questioning, the patient says his spouse was diagnosed with dementia and a movement disorder 8 months before this visit. The patient is the sole caregiver, doing all cooking, cleaning, care related to activities of daily living, and supervision for a “nocturnal wanderer” spouse in her late 70s. He reports 4 to 5 hours of uninterrupted sleep daily.

This is why I think that changes in relationships and environment should be questioned.

Otherwise, an excellent article.

*   Copyright © 2023 The Cleveland Clinic Foundation. All Rights Reserved.

## REFERENCES

1.  Yahr J, Thomas G, Calle J, Taliercio J. Resistant hypertension: a stepwise approach. Cleve Clin J Med 2023; 90(2):115–125. doi:10.3949/ccjm.90a.22046
    
    [Abstract/FREE Full Text](http://www.ccjm.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NToiY2Nqb20iO3M6NToicmVzaWQiO3M6ODoiOTAvMi8xMTUiO3M6NDoiYXRvbSI7czoyMDoiL2Njam9tLzkwLzUvMjc0LmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==)