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Fifth-line Antihypertensive Selection — EECC MCQ

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ModerateHypertension & Preventive CardiologyFifth-line Antihypertensive SelectionEECC

A 62-year-old man with resistant hypertension is taking amlodipine 10 mg, ramipril 10 mg, indapamide 2.5 mg, and spironolactone 50 mg. His BP remains 155/95 mmHg. Adherence is confirmed by urine drug testing. What is the next pharmacological step?

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Correct answer: B — Add a beta-blocker (bisoprolol) or alpha-blocker (doxazosin) as a fifth agent — the choice depends on resting HR (beta-blocker if elevated HR, alpha-blocker if normal HR or concurrent BPH); investigation for secondary causes should also be undertaken if not already done

The 2024 ESC Hypertension Guidelines treatment escalation beyond quadruple therapy: Step 1: dual SPC (ACEi/ARB + CCB or thiazide); Step 2: triple SPC; Step 3: add spironolactone 25-50 mg (PATHWAY-2 — most effective 4th agent); Step 4 (this patient): add 5th agent based on clinical profile: (1) beta-blocker (bisoprolol) — particularly if resting HR is elevated or concurrent angina/post-MI; (2) alpha-blocker (doxazosin) — particularly with concurrent BPH; (3) further diuretic (amiloride 10-20 mg, or loop diuretic if eGFR <30). ALSO: (1) confirm true resistance (adherence verified ✓, secondary causes excluded — renovascular disease, primary aldosteronism, phaeochromocytoma, Cushing, OSA, CKD, coarctation); (2) consider device therapy (renal denervation — Class IIb). NEVER combine ACEi + ARB (ONTARGET — no additional benefit, increased adverse events).

Reference: ESC (2024): Hypertension; PATHWAY-2