Abstract P125: Determining Patient and Provider Acceptance of Therapeutic Drug Monitoring to Improve Medication Adherence

Objective: Therapeutic drug monitoring (TDM) is the assessment of medication adherence by detection of a drug or its metabolites in blood or urine samples. TDM-guided feedback has been shown to improve medication adherence and subsequent blood pressure (BP) control in patients with resistant hypertension. Herein, we sought to evaluate the attitudes of patients with uncontrolled hypertension as well as their providers towards incorporating TDM in clinical practice.

Methods: We conducted a qualitative study consisting of in-depth, cognitive interviews in 10 patients seen in Parkland General Cardiology and Internal Medicine Clinics with uncontrolled hypertension. The patients were asked a series of 9 standardized questions to elicit their attitudes towards TDM use in the management of hypertension after informed consent. In addition, 10 providers, including faculty, trainees, and pharmacists, were also interviewed, using the same questionnaire to evaluate their attitudes of incorporating TDM in hypertension management.

Results: Of the patients interviewed, 90% (9 of 10) were supportive of TDM use in clinical practice. Similarly, 100% (10 of 10) of providers thought TDM was a good idea and should be used regularly. On subsequent questioning, 78% (7 of 9) of patients who felt TDM was a good idea expressed reservation that TDM could negatively impact the physician-patient relationship. Nonetheless, 86% (6 of 7) of these patients felt TDM could be a useful tool to identifying and solving non-adherence of antihypertensive drugs, if providers are mindful of patients’ unique circumstances. Amongst providers, 90% (9 of 10) felt TDM may negatively impact the physician-patient relationship, yet felt TDM could still be useful in addressing non-adherence.

Conclusion: TDM was found to be well accepted amongst patients and providers, though between 80-90% of patients and providers still had concerns that TDM could negatively impact the physician-patient relationship. However, the majority of patients and providers believed that TDM could be an effective tool in identifying and solving barriers to adherence, if the providers are sensitive to the patients’ specific needs. Our survey suggested feasibility of adopting TDM in improving medication adherence.

Abstract P136: Comparison of Pharmacy Refill Data With Therapeutic Drug Monitoring (TDM) in Assessing Non-Adherence to Cardiovascular Drugs in Patients With Uncontrolled Hypertension

Pharmacy refill data are frequently used to screen for medication non-adherence in clinical practice but its accuracy has not been validated against therapeutic drug monitoring (TDM) in patients with uncontrolled hypertension. Accordingly, we evaluated the accuracy of proportions of days covered (PDC) and medication possession ratio (MPR) in assessing non-adherence to cardiovascular medications against therapeutic drug monitoring (TDM) in patients with uncontrolled hypertension at outpatient clinics of Parkland Memorial Hospital. Patients who had blood pressure of >130/80 mmHg, were on ≥2 antihypertensive medications, and verbally reported full medication compliance were enrolled in the study after an informed consent. Plasma samples were obtained for measurement of 36 cardiovascular drugs including statins, using liquid chromatography mass spectrometry assay. Among 38 patients enrolled in our study, 21% (8/38 patients) were non-adherent to at least 1 antihypertensive medication, while 39% (12/31 patients) were non-adherent to statin drugs. The non-adherent patients were younger than the adherent patients (57.2±12.0 vs. 62.9±7.8, p=0.08), and were less likely to be African Americans (7/17 vs. 16/21, p<0.05). The non-adherent group to statin drugs had significantly higher LDL level than the adherent group (112±41 vs. 70±21 mg/dL, p<0.04). The adherent group to antihypertensive medications had similar blood pressures as the non-adherent group (145±12.8/82±9.8 vs.146±9.6/87±12.9 mmHg). The pharmacy refill data are available in 50% (19/38) of patients, and there was no significant correlation between PDC/MPR and TDM results (r 2 =0.15, p=0.11 for PDC; r 2 =0.15, p=0.16 for MPR). Using a threshold of < 80%, low PDC has a sensitivity of 100% and a specificity of 63% in detecting medication non-adherence when compared to TDM. Similar results were obtained for MPR: sensitivity of 100% and specificity of 65%. While medication refill data may be a sensitive screening tool for medication non-adherence, it has limited specificity and availability when compared to TDM. Thus, TDM constitutes a more efficient and reliable way to assess medication non-adherence, which is crucial in optimizing cardiovascular risk factors in this indigent population.

Phosphate, the forgotten mineral in hypertension

PURPOSE OF REVIEW

The purpose of this study is to review the current literature related to the role of inorganic phosphate in the pathogenesis of hypertension.

RECENT FINDINGS

An increasing number of publications have revealed a detrimental role of inorganic phosphate, which is commonly used as a flavor enhancer or preservative in the processed food, in promoting hypertension in otherwise healthy individuals. Animal experimental data indicate that dietary phosphate excess engages multiple mechanisms that promote hypertension, including overactivation of the sympathetic nervous system, increased vascular stiffness, impaired endothelium-dependent vasodilation, as well as increased renal sodium absorption or renal injury. These effects may be explained by direct effects of high extracellular phosphate levels or increase in phosphaturic hormones such as fibroblast growth factor 23, or downregulation of klotho, a transmembrane protein expressed in multiple organs which possess antiaging property.

SUMMARY

Dietary phosphate, particularly inorganic phosphate, is an emerging risk factor for hypertension which is ubiquitous in the western diet. Large randomized clinical trials are needed to determine if lowering dietary phosphate content constitutes an effective nonpharmacologic intervention for prevention and treatment of hypertension.

Exaggerated pressor and sympathetic responses to stimulation of the mesencephalic locomotor region and exercise pressor reflex in type 2 diabetic rats

The cardiovascular responses to exercise are potentiated in patients with type 2 diabetes mellitus (T2DM). However, the underlying mechanisms causing this abnormality remain unknown. Central command (CC) and the exercise pressor reflex (EPR) are known to contribute significantly to cardiovascular control during exercise. Thus these neural signals are viable candidates for the generation of the abnormal circulatory regulation in this disease. We hypothesized that augmentations in CC as well as EPR function contribute to the heightened cardiovascular responses during exercise in T2DM. To test this hypothesis, changes in mean arterial pressure (MAP) and renal sympathetic nerve activity (RSNA) in response to electrical stimulation of mesencephalic locomotor region (MLR), a putative component of the central command pathway, and activation of the EPR, evoked by electrically induced hindlimb muscle contraction, were examined in decerebrate animals. Sprague-Dawley rats were given either a normal diet (control) or a high-fat diet (14-16 wk) in combination with two low doses (35 mg/kg week 1, 25 mg/kg week 2) of streptozotocin (T2DM). The changes in MAP and RSNA responses to MLR stimulation were significantly greater in T2DM compared with control (2,739 ± 123 vs. 1,298 ± 371 mmHg/s, 6,326 ± 1,621 vs. 1,390 ± 277%/s, respectively, P < 0.05). Similarly, pressor and sympathetic responses to activation of the EPR in diabetic animals were significantly augmented compared with control animals (436 ± 74 vs. 134 ± 44 mmHg/s, 645 ± 135 vs. 139 ± 65%/s, respectively, P < 0.05). These findings provide the first evidence that CC and the EPR may generate the exaggerated rise in sympathetic activity and blood pressure during exercise in T2DM.

Diagnostic Thresholds for Blood Pressure Measured at Home in the Context of the 2017 Hypertension Guideline

Most guidelines have recommended lower home blood pressure (BP) threshold when clinic BP threshold of 140/90 mm Hg is used for diagnosis of hypertension. However, home BP thresholds to define hypertension have never been determined in the general population in the United States. We identified home BP thresholds for stage 1 (BP ≥130/80 mm Hg) hypertension using a regression-based approach in the DHS (Dallas Heart Study; n=5768) and the NCMH study (North Carolina Masked Hypertension; n=420). Home BP thresholds were also assessed using outcome-derived approach based on the composite of all-cause mortality or cardiovascular events in the DHS cohort. For this approach, BP thresholds were identified only for systolic BP because diastolic BP was not associated with the outcome. Among untreated participants, the regression-derived thresholds for home BP corresponding to clinic BP for stage 1 hypertension were 129/80 mm Hg in blacks, 130/80 mm Hg in whites, and 126/78 mm Hg in Hispanics, respectively. The results are similar in the North Carolina cohort. The 11-year composite cardiovascular and mortality events corresponding to clinic systolic BP >130 mm Hg were higher in blacks than in whites and Hispanics (13.3% versus 5.98% versus 5.52%, respectively). Using a race/ethnicity-specific composite outcome in the untreated DHS participants, the outcome-derived home systolic BP thresholds corresponding to stage 1 hypertension were 130 mm Hg in blacks, 129 mm Hg in whites, and 131 mm Hg in Hispanics, respectively. Our data based on both regression-derived and outcome approach support home BP threshold of 130/80 mm Hg for diagnosis of hypertension in blacks, whites, and Hispanics.

Prevalence of Apparent Treatment-Resistant Hypertension in the United States According to the 2017 High Blood Pressure Guideline

OBJECTIVE

To evaluate the prevalence of apparent treatment-resistant hypertension (aTR-hypertension) in US adults with treated hypertension by using the nationally representative National Health and Nutrition Examination Survey (NHANES).

PATIENTS AND METHODS

Nonpregnant US adults older than 20 years with a self-reported history of treated hypertension who had blood pressure measured in NHANES cycles 2007 to 2014 were included in this study. Study participants were stratified into 4 groups according to average blood pressure and antihypertensive medication use: well-controlled hypertension, undertreated hypertension, aTR-hypertension by the 2017 guideline, and aTR-hypertension by the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) guideline. National Health and Nutrition Examination Survey sample weights were used to estimate the national prevalence.

RESULTS

From 2007 to 2014, 5512 participants with treated hypertension representing 46.7 million people nationally were included. Compared with JNC 7 guideline criteria, application of the 2017 high blood pressure guideline criteria increased the prevalence of aTR-hypertension in US adults with treated hypertension from 12.0% to 15.95%, identifying an additional 1.85 million individuals with aTR-hypertension nationally. Individuals newly reclassified as having aTR-hypertension were younger. However, the prevalence of thiazide diuretic use remained less than 70%, and that of mineralocorticoid antagonist use remained less than 10% regardless of the guideline definition.

CONCLUSION

On the basis of the 2017 high blood pressure guideline, the prevalence of aTR-hypertension is 15.95% in US adults with treated hypertension. This represents an absolute increase of 4% (1.85 million additional individuals nationally) compared with the JNC 7 guideline definition, with a consistent increase across all subpopulations with treated hypertension.

Ambulatory pulse pressure, brain neuronal fiber integrity, and cerebral blood flow in older adults

Ambulatory blood pressure (ABP) reflects the end-organ vascular stress in daily life; however, its influence on brain neuronal fiber integrity and cerebral blood flow (CBF) remains unclear. The objective of this study was to determine the associations among ABP, white matter (WM) neuronal fiber integrity, and CBF in older adults. We tested 144 participants via ABP monitoring and diffusion tensor imaging. The total level and pulsatile indices of CBF were measured by phase-contrast MRI and transcranial Doppler, respectively. Neuropsychological assessment was conducted in 72 participants. Among ambulatory and office BP measures, elevated 24-h pulse pressure (PP) was associated with the greatest number of WM skeleton voxels with decreased fractional anisotropy (FA) and increased mean diffusivity (MD). Furthermore, these associations remained significant after adjusting for age, antihypertensive use, aortic stiffness, WM lesion volume, and office PP. Radial diffusivity (RD) was elevated in the regions with decreased FA, while axial diffusivity was unaltered. The reduction in diastolic index explained a significant proportion of the individual variability in FA, MD, and RD. Executive function performance was correlated with WM fiber integrity. These findings suggest that elevated ambulatory PP may deteriorate brain neuronal fiber integrity via reduction in diastolic index.

Prognostic Value of Masked Uncontrolled Hypertension

The prognostic relevance of masked uncontrolled hypertension (MUCH) is incompletely clear, and its global impact on cardiovascular outcomes and mortality has not been assessed. The aim of this study was to perform a meta-analysis on the prognostic value of MUCH. We searched for articles assessing outcome in patients with MUCH compared with those with controlled hypertension (CH) and reporting adjusted hazard ratio and 95% CI. We identified 6 studies using ambulatory blood pressure monitoring (12 610 patients with 933 events) and 5 using home blood pressure measurement (17 742 patients with 394 events). The global population included 30 352 patients who experienced 1327 events. Selected studies had cardiovascular outcomes and all-cause mortality as primary outcome, and the main result is a composite of these events. The overall adjusted hazard ratio was 1.80 (95% CI, 1.57-2.06) for MUCH versus CH. Subgroup meta-analysis showed that adjusted hazard ratio was 1.83 (95% CI, 1.52-2.21) in studies using ambulatory blood pressure monitoring and 1.75 (95% CI, 1.38-2.20) in those using home blood pressure measurement. Risk was significantly higher in MUCH than in CH independently of follow-up length and types of studied events. MUCH was at significantly higher risk than CH in all ethnic groups, but the highest hazard ratio was found in studies, including black patients. Risk of cardiovascular events and all-cause mortality is significantly higher in patients with MUCH than in those with CH. MUCH detected by ambulatory or home blood pressure measurement seems to convey similar prognostic information.

Rationale and methods for a multicenter clinical trial assessing exercise and intensive vascular risk reduction in preventing dementia (rrAD Study)

Alzheimer's Disease (AD) is an age-related disease with modifiable risk factors such as hypertension, hypercholesterolemia, obesity, and physical inactivity influencing the onset and progression. There is however, no direct evidence that reducing these risk factors prevents or slows AD. The Risk Reduction for Alzheimer's Disease (rrAD) trial is designed to study the independent and combined effects of intensive pharmacological control of blood pressure and cholesterol and exercise training on neurocognitive function. Six hundred and forty cognitively normal older adults age 60 to 85 years with hypertension and increased risk for dementia will be enrolled. Participants are randomized into one of four intervention group for two years: usual care, Intensive Reduction of Vascular Risk factors (IRVR) with blood pressure and cholesterol reduction, exercise training (EX), and IRVR+EX. Neurocognitive function is measured at baseline, 6, 12, 18, and 24 months; brain MRIs are obtained at baseline and 24 months. We hypothesize that both IRVR and EX will improve global cognitive function, while IRVR+EX will provide a greater benefit than either IRVR or EX alone. We also hypothesize that IRVR and EX will slow brain atrophy, improve brain structural and functional connectivity, and improve brain perfusion. Finally, we will explore the mechanisms by which study interventions impact neurocognition and brain. If rrAD interventions are shown to be safe, practical, and successful, our study will have a significant impact on reducing the risks of AD in older adults. NCT Registration: NCT02913664.

Antinuclear antibodies in the general population: positive association with inflammatory and vascular biomarkers but not traditional cardiovascular risk factors

OBJECTIVES

Patients with clinically evident autoimmune disease are at increased risk for premature cardiovascular disease (CVD). Markers of serological autoimmunity such as anti-nuclear antibodies (ANA) are found in approximately 25% of the general population. Yet, the vast majority will not develop clinical autoimmune disease. Serological autoimmunity is a risk factor for CVD death in individuals without autoimmune disease; however, the mechanisms mediating this excess CVD risk have not been elucidated.

METHODS

We examined associations of ANA with traditional cardiovascular risk factors, inflammatory mediators, and vascular biomarkers in the Dallas Heart Study - a large, representative multiethnic population-based cohort. Plasma ANA were measured by enzyme linked immunosorbent assay in 3,488 Dallas Heart Study participants aged 30 to 65 years who do not have known rheumatologic disease. Associations of ANA with demographic characteristics, cardiovascular risk factors, and biomarkers were assessed using univariable and multivariable linear regression.

RESULTS

Factors independently associated with higher ANA include female sex, African-American race/ethnicity, soluble intracellular adhesion molecule-1, soluble CD40 ligand, chemokine CXCL-2, and Cystatin C (p<0.05 for each). ANA was not associated with traditional cardiovascular risk factors, high sensitivity C-reactive protein, coronary artery calcium scores, or aortic wall thickness.

CONCLUSION

ANA are associated with inflammatory mediators and biomarkers of vascular activation, but not with traditional cardiovascular risk factors in a multiethnic population-based cohort. These findings suggest that the cardiovascular risk associated with ANA may involve pathways distinct from traditional risk factors and include dysregulation of endothelial cells and the immune system.

Abstract 031: Thresholds for Defining Home Blood Pressure Elevation Among US adults

Background: Most hypertension guidelines have recommended lower home than clinic BP thresholds based on epidemiological studies conducted in non-US populations. However, diagnostic thresholds to define home BP elevation have never been determined in the general population in the United States.

Methods: We analyzed data from 2 US cohorts with home and clinic BP data in the same participants, the Dallas Heart Study (DHS, n=5,768) and the North Carolina Masked Hypertension study (NCMH, n = 420). Home BP thresholds for stage 1 (BP ≥ 130/80 mmHg) and stage 2 hypertension (BP ≥ 140/90 mmHg) were identified using a regression-based approach in both cohorts and an outcome-derived approach in the DHS cohort. The composite of all-cause mortality or a cardiovascular disease (CVD) event was used in the outcome-derived approach. For this approach, BP thresholds were identified only for systolic BP (SBP) as clinic diastolic BP (DBP) was not associated with the outcome.

Results: Among untreated participants in DHS, the regression-derived thresholds for home BP corresponding to clinic BP for stage 1 and stage 2 hypertension were 130/81 and 137/88 mmHg in blacks and 127/79 and 135/86 mmHg in nonblacks, respectively. The results are virtually identical in the NCMH cohort. The 11-year composite CVD and mortality events corresponding to stage 1 (clinic SBP ≥ 130) and stage 2 (clinic SBP ≥ 140 mmHg) were higher in untreated blacks than untreated non-blacks [13.3 (11.06-15.54) and 17.59 (14.8-20.37)% vs. 6.78 (5.17-8.39) and 9.86 (6.94-12.77)%, respectively]. Using a race/ethnicity-specific composite outcome, the outcome-derived thresholds from the DHS for home SBP corresponding to stage 1 and stage 2

hypertension were 131 and 140 mmHg in untreated blacks and 130 and 139 mmHg in untreated nonblacks, respectively.

Conclusions: Based on the regression-derived approach, we found home BP thresholds for stage 1 and 2 hypertension from both cohorts to be similar to the current ACC/AHA guidelines. The outcome-derived approach also identified similar home SBP thresholds for stage 1 hypertension but slightly higher home SBP thresholds for stage 2 hypertension than recommended guidelines.

Abstract P117: Blood Pressure Outcomes in Patients With Primary Aldosteronism after Adrenalectomy versus Medical Management in Relation to the New 2017 ACC/AHA Blood Pressure Guidelines

Objective: Investigate blood pressure (BP) outcomes in primary aldosteronism (PA) patients following adrenalectomy or medical therapy in the context of the lower BP target goal and threshold proposed by the 2017 ACC/AHA blood pressure guidelines.

Methods: A retrospective study was conducted in patients with confirmed diagnosis of PA who were referred to Hypertension clinic at the University of Texas Southwestern between January 2009 and August 2017. Presence of PA was confirmed using previously recommended cutoff values of urinary aldosterone greater than 12 mcg/2h for the oral salt loading test and serum aldosterone greater than 10 ng/dL after intravenous saline suppression test. Patients were categorized into adrenalectomy or medical therapy groups. The average BP and number of anti-hypertensives were compared between the two groups at each clinic visit. Hypertension cure rate of PA patients undergoing adrenalectomy was compared using the JNC8 threshold BP of 140/90 mmHg versus the 2017 ACC/AHA threshold BP of 130/80 mmHg.

Results: Forty-nine patients were found to have PA. Twenty-two patients had an adrenalectomy, twenty-seven patients were started on a mineralocorticoid antagonist. The adrenalectomy subgroup required a fewer number of anti-hypertensives at the last follow-up visit (p=0.0004) compared to the medically treated group. Systolic BP reduced similarly from the baseline visit to the last visit in the adrenalectomy group compared to the medical therapy group (from 151.3 +/- 5.7 to 134.3 +/- 4.5 mmHg vs. 149 +/- 4.1 to 134.7 +/- 4.1 mmHg, p < 0.01 for visit and p=0.5 for group). Thirteen percent (3 of 23) of adrenalectomy patients achieved cure based on the previous JNC8 guidelines, whereas only 8.7% (2 of 23) achieved cure based on the current guidelines.

Conclusion: Adrenalectomy is more efficacious than medical management in reducing the number of anti-hypertensives needed for BP control. The percentage of patients who achieved cure following adrenalectomy decreased when defined by the 2017 ACC/AHA guidelines.

Hyposialylated IgG activates endothelial IgG receptor FcγRIIB to promote obesity-induced insulin resistance

Type 2 diabetes mellitus (T2DM) is a common complication of obesity. Here, we have shown that activation of the IgG receptor FcγRIIB in endothelium by hyposialylated IgG plays an important role in obesity-induced insulin resistance. Despite becoming obese on a high-fat diet (HFD), mice lacking FcγRIIB globally or selectively in endothelium were protected from insulin resistance as a result of the preservation of insulin delivery to skeletal muscle and resulting maintenance of muscle glucose disposal. IgG transfer in IgG-deficient mice implicated IgG as the pathogenetic ligand for endothelial FcγRIIB in obesity-induced insulin resistance. Moreover, IgG transferred from patients with T2DM but not from metabolically healthy subjects caused insulin resistance in IgG-deficient mice via FcγRIIB, indicating that similar processes may be operative in T2DM in humans. Mechanistically, the activation of FcγRIIB by IgG from obese mice impaired endothelial cell insulin transcytosis in culture and in vivo. These effects were attributed to hyposialylation of the Fc glycan, and IgG from T2DM patients was also hyposialylated. In HFD-fed mice, supplementation with the sialic acid precursor N-acetyl-D-mannosamine restored IgG sialylation and preserved insulin sensitivity without affecting weight gain. Thus, IgG sialylation and endothelial FcγRIIB may represent promising therapeutic targets to sever the link between obesity and T2DM.

Abstract 089: A Simple Algorithm Identifies Hypertensive Patients Who Benefit From Intensive Blood Pressure Lowering

Background: Large randomized trials have provided inconsistent evidence regarding the benefit of intensive BP lowering in hypertensive patients. Identifying which patients derive a higher net benefit is essential in informing clinical decision-making.

Objectives: To assess whether stratification by cardiovascular disease (CVD) risk will identify patients with a more favorable risk/benefit profile for intensive BP lowering.

Methods: We used patient-level data from two trials that tested intensive vs. standard BP lowering: SPRINT and ACCORD. Within SPRINT, we selected a subset of patients at extremes of major adverse cardiovascular event (MACE) rates to develop a decision-tree using recursive partitioning modeling. We then validated its predictive effects in the remaining ‘intermediate’ SPRINT subset (n=8,357) and externally in ACCORD (n=2,258).

Results: Recursive partitioning produced a three-variable decision-tree model consisting of age≥74 years, urinary albumin/creatinine ratio (UACR) ≥34, and history of clinical CVD. It classified 48.6% of SPRINT and 55.3% of ACCORD patients as “high-risk”. Compared with standard treatment, intensive BP lowering was associated with lower rates of MACE in this high-risk population in both SPRINT cross-validation data (HR=0.66, 95% CI 0.52-0.85) and ACCORD (HR=0.67, 95% CI 0.50-0.90), but not in the remaining low-risk patients (SPRINT: HR=0.83, 95% CI 0.56-1.25; ACCORD: HR=1.09, 95% CI 0.64-1.83). Additionally, intensive BP lowering did not confer an excess risk of serious adverse events in the high-risk group.

Conclusions: A simple risk prediction model consisting of age, UACR, and clinical CVD history successfully identified a subset of hypertensive patients who derived a more favorable risk/benefit profile for intensive BP lowering.

Mineralocorticoid receptor antagonists attenuate exaggerated exercise pressor reflex responses in hypertensive rats

Exaggerated heart rate (HR) and blood pressure responses to exercise in hypertension are mediated, in part, by overactivity of the exercise pressor reflex (EPR). The mechanisms underlying this EPR dysfunction have not been fully elucidated. Previous studies have shown that stimulation of mineralocorticoid receptors (MRs) with exogenous administration of aldosterone in normal, healthy rats reproduces the EPR overactivity characteristic of hypertensive animals. Conversely, the purpose of this study was to examine whether antagonizing MR with spironolactone (SPIR) or eplerenone (EPL) in decerebrated hypertensive rats ameliorates abnormal EPR function. Changes in mean arterial pressure (MAP) and HR induced by EPR or muscle mechanoreflex (a component of EPR) activation were assessed in normotensive Wistar-Kyoto rats and spontaneously hypertensive rats (SHRs) fed normal chow (NC) or a customized diet containing either SPIR or EPL for 3 wk. SHRs treated with SPIR or EPL had significantly attenuated MAP responses to EPR (NC: 45 ± 7 mmHg, SPIR: 26 ± 4 mmHg, and EPL: 24 ± 5 mmHg, P = 0.02) and mechanoreflex (NC: 34 ± 9 mmHg, SPIR: 17 ± 3 mmHg, and EPL: 15 ± 3 mmHg, P = 0.03) activation. SHRs treated with SPIR or EPL also showed significantly attenuated HR responses to EPR (NC: 17 ± 3 beats/min, SPIR: 9 ± 1 beats/min, and EPL: 9 ± 2 beats/min, P = 0.01) and mechanoreflex (NC: 15 ± 3 beats/min, SPIR: 6 ± 1 beats/min, and EPL: 7 ± 1 beats/min, P = 0.01) activation. Wistar-Kyoto rats treated with SPIR did not demonstrate significant differences in MAP or HR responses to EPR or mechanoreflex activation. The data suggest that antagonizing MRs may be an effective strategy for the treatment of EPR overactivity in hypertension.NEW & NOTEWORTHY Exaggerated cardiovascular responses to exercise in hypertensive patients are linked with overactive exercise pressor reflexes (EPRs). Administration of low-dose mineralocorticoid receptor antagonists (spironolactone or eplerenone) effectively ameliorates abnormal EPR function in hypertension. Effective treatment of EPR overactivity may reduce the cardiovascular risks associated with physical activity in hypertension.