Case Presentation:

A 32‐year‐old African American male was referred from a corrections facility with severe uncontrolled hypertension for 2 weeks despite being on a regimen of 7 antihypertensive medications. He complained of persistent bitemporal headaches and blurred vision, but he was otherwise asymptomatic. On presentation his blood pressure was 230/130 mmHg. His blood pressure was appropriately controlled with intravenous medications. When he was transitioned to oral medications, his blood pressure was in the range of 190‐230/100‐130 mmHg despite restarting multiple medications with different mechanisms of action. Basic metabolic panel and urinalysis were normal. Echocardiogram revealed normal chambers, normal ventricular wall motion, with LVEF of 60%‐65%. Renal ultrasound and abdominal MRI with angiography were unrevealing. Plasma aldosterone to renin ratio, 24‐hour urine calecholamines and metanephrines were all normal. Slit‐lamp examination showed no evidence of hypertensive retinopathy. These findings prompted a suspicion thai the patient was being surreptitiously noncompliant with his regimen. Thus, the palient was placed on observed treatment that included inspection of his oral cavity to confirm adherence. His regimen was revised, and minoxidil was discontinued. Several hours after starting directly observed treatment with a de‐escalated regimen, his systolic pressure dropped to 60 mmHg and he became oliguric. He developed acute kidney injury with a peak creatinine of 4.1 mg/dL. His medications were all discontinued, and he responded well to fluid resuscitation. A psychiatric evaluation was requested, and the patient was not found to have any suicidal intent. The patient was discharged back 1c the correctional facility on a simplified medication regimen with a directly observed treatment approach.


The approach to resistant hypertension requires investigation for the presence of secondary hypertension as well as identification of possible contributing factors. Medication compliance is easier to ascertain in the hospitalized patient. It is a known pitfall in practice that dosing regimens can be inappropriately escalated based on a mistaken assumption that the patient is compliant. This can have potentially deleterious consequences, which was illustrated in this case when directly observed treatment was instituted. Nonadherence may be the result of psychosocial factors, including secondary gain. Applicable to this particular case, research in medication compliance of correctional facility inmates has not expanded much beyond that of psychiatric medications. Further exploration of this topic is warranted.


Surreptitious noncompliance with medications must be considered in patients with resistant hypertensive urgency. Failure to recognize this may lead to potentially dangerous swings in blood pressure control. Directly observed treatment may be necessary in some patients.

Author Disclosure:

M. Wheaton, none; A. Shibani, none; A. Silver, none; D. Paje, none.