Plasma Renin Activity Testing to Guide Triple Antirenin System Drug Therapy in a Patient With Difficult-to-Treat Hypertension

OBJECTIVE: To report a case of difficult-to-treat hypertension ultimately managed with triple antirenin (anti-R) therapy using plasma renin activity (PRA) to guide medication selection. CASE SUMMARY: A 66-year-old white man was referred to the cardiology pharmacotherapy clinic for difficult-to-treat hypertension. His initial office blood pressure (BP) was 152/71 mm Hg on diltiazem and chlorthalidone. After a series of medication adjustments based on serial PRA measurements, the patient achieved his target BP with a regimen that included 3 anti-R angiotensin system medications: carvedilol, valsartan, and aliskiren. DISCUSSION: Despite continued progress in the understanding and advances in pharmacological therapy for hypertension, uncontrolled hypertension remains a major problem. The most common strategy to control hypertension is the stepped-care approach with progressive addition of medications to eventually reach BP goal. An alternative approach includes the use of PRA measurements to guide both the addition and removal of drugs in an attempt to effectively control BP. At times, this has the potential to result in a drug regimen that is incongruous with current guidelines and practice recommendations. However, if this results in more effective BP control with the same, or fewer, number of medications, it may represent a reasonable alternative. CONCLUSION: This case report illustrates a real-world application of PRA-guided therapeutics in a patient with difficult-to-treat hypertension. It highlights how a personalized approach can lead to BP control with a more streamlined regimen than would likely result if a stepped-care approach was used.