Despite being on antihypertensive medication, the patient's blood pressure remains in Stage II. What is the most likely explanation given?

• A. Salt restriction
• B. Diltiazem + Aleve elevates BP
• C. Noncompliance with meds
• D. Secondary hypertension

Answer: (B)

When blood pressure stays in Stage II despite being on antihypertensive medication, look for factors that blunt drug effects. Here, the combination of a calcium channel blocker (diltiazem) with an NSAID (naproxen, Aleve) is a classic explanation. NSAIDs can raise blood pressure by causing sodium and water retention in the kidneys. They inhibit prostaglandin synthesis, which normally helps dilate the afferent arteriole and promote natriuresis. With prostaglandin inhibition, you get less renal vasodilation and more fluid retention, which increases overall vascular resistance and blood volume. This counters the BP-lowering action of the calcium channel blocker, so blood pressure can remain elevated despite therapy.

Salt restriction would typically help lower BP, not sustain it. Noncompliance could cause high readings on meds but doesn’t specifically explain a drug interaction that elevates BP, and secondary hypertension would require additional clues. The key idea here is the NSAID and antihypertensive interaction driving resistant hypertension.