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Zeng W, Tomlinson B. Options for patients with out-of-control blood pressure: after all avenues have been exhausted. Expert Rev Cardiovasc Ther 2024:1-12. [PMID: 39258872 DOI: 10.1080/14779072.2024.2401875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2024] [Accepted: 09/04/2024] [Indexed: 09/12/2024]
Abstract
INTRODUCTION Uncontrolled hypertension is the leading risk factor for global mortality. Most hypertensive patients can be controlled with standard medication combinations, but some may not respond adequately to ≥3 or even to ≥5 antihypertensive agents. AREAS COVERED In this review, we summarize the recent literature on difficult-to-treat hypertension identified by a Medline search, and we discuss the options for fourth line and subsequent therapy. EXPERT OPINION It is essential to confirm resistant hypertension with out-of-office blood pressure measurements and to consider lifestyle factors, adherence to medication and secondary causes of hypertension. When true resistant hypertension is confirmed and blood pressure is not controlled with an optimal triple combination, preferably as a fixed dose combination tablet, spironolactone is usually recommended as the fourth medication. Comorbid conditions should be treated as appropriate with sodium-glucose-cotransporter 2 inhibitors, glucagon-like peptide-1 receptor agonists, sacubitril-valsartan or finerenone. Renal denervation appears to be a useful addition to overcome some of the problems of medication adherence. The endothelin antagonist aprocitentan may be a final option in some countries. Of the drugs in development, the RNA based therapeutics that inhibit angiotensinogen synthesis appear to be some of the most promising.
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Affiliation(s)
- Weiwei Zeng
- Department of Pharmacy, Shenzhen Longgang Second People's Hospital, Shenzhen, China
| | - Brian Tomlinson
- Faculty of Medicine, Macau University of Science & Technology, Macau, China
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Chattranukulchai P, Roubsanthisuk W, Kunanon S, Kotruchin P, Satirapoj B, Wongpraparut N, Sunthornyothin S, Sukonthasarn A. Resistant hypertension: diagnosis, evaluation, and treatment a clinical consensus statement from the Thai hypertension society. Hypertens Res 2024; 47:2447-2455. [PMID: 39014113 PMCID: PMC11374717 DOI: 10.1038/s41440-024-01785-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Revised: 06/03/2024] [Accepted: 06/15/2024] [Indexed: 07/18/2024]
Abstract
Resistant hypertension (RH) includes hypertensive patients with uncontrolled blood pressure (BP) while receiving ≥3 BP-lowering medications or with controlled BP while receiving ≥4 BP-lowering medications. The exact prevalence of RH is challenging to quantify. However, a reasonable estimate of true RH is around 5% of the hypertensive population. Patients with RH have higher cardiovascular risk as compared with hypertensive patients in general. Standardized office BP measurement, confirmation of medical adherence, search for drug- or substance-induced BP elevation, and ambulatory or home BP monitoring are mandatory to exclude pseudoresistance. Appropriate further investigations, guided by clinical data, should be pursued to exclude possible secondary causes of hypertension. The management of RH includes the intensification of lifestyle interventions and the modification of antihypertensive drug regimens. The essential aspects of lifestyle modification include sodium restriction, body weight control, regular exercise, and healthy sleep. Step-by-step adjustment of the BP-lowering drugs based on the available evidence is proposed. The suitable choice of diuretics according to patients' renal function is presented. Sacubitril/valsartan can be carefully substituted for the prior renin-angiotensin system blockers, especially in those with heart failure with preserved ejection fraction. If BP remains uncontrolled, device therapy such as renal nerve denervation should be considered. Since device-based treatment is an invasive and costly procedure, it should be used only after careful and appropriate case selection. In real-world practice, the management of RH should be individualized depending on each patient's characteristics.
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Affiliation(s)
- Pairoj Chattranukulchai
- Division of Cardiovascular Medicine, Department of Medicine, Faculty of Medicine, King Chulalongkorn Memorial Hospital, Chulalongkorn University, Bangkok, Thailand
| | - Weranuj Roubsanthisuk
- Division of Hypertension, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.
| | - Sirisawat Kunanon
- Division of Hypertension, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Praew Kotruchin
- Department of Emergency Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Bancha Satirapoj
- Department of Internal Medicine, Phramongkutklao Hospital and College of Medicine, Bangkok, Thailand
| | - Nattawut Wongpraparut
- Division of Cardiology, Department of Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Sarat Sunthornyothin
- Division of Endocrinology and Metabolism, Department of Medicine, Faculty of Medicine, King Chulalongkorn Memorial Hospital, Chulalongkorn University, Bangkok, Thailand
| | - Apichard Sukonthasarn
- Department of Medicine, Cardiovascular Unit, Faculty of Medicine, Chiang Mai University, and Thai Hypertension Society, Bangkok, Thailand
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Parodi R, Brandani L, Romero C, Klein M. Resistant hypertension: Diagnosis, evaluation, and treatment practical approach. Eur J Intern Med 2024; 123:23-28. [PMID: 38228447 DOI: 10.1016/j.ejim.2023.12.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 12/24/2023] [Accepted: 12/29/2023] [Indexed: 01/18/2024]
Abstract
The term RH describes a subgroup of hypertensive patients whose BP is uncontrolled despite the use of at least three antihypertensive drugs in an appropriate combination at optimal or best tolerated doses. True RH is considered when appropriate lifestyle measures and treatment with optimal or best tolerated doses of three or more drugs (a thiazide/thiazide-like diuretic, plus renin-angiotensin system -RAS- blocker and a calcium channel blocker -CCB-) fail to lower office BP to <140/90 mmHg; besides the inadequate BP control should be confirmed by home blood pressure monitoring (HBPM) or 24-hour ambulatory; and evidence of adherence to therapy and exclusion of secondary causes of hypertension are required. RH patients are at a high risk of cardiovascular events and death. RH is associated with a higher prevalence of end-organ damage. When stricter criteria are applied, a reasonable estimate of the prevalence of true RH is 5 % of the total hypertensive population. The predominant hemodynamic pattern appears to be increased systemic vascular resistance and plasma volume with normal or even low cardiac output. We must rule out pseudo-resistance before diagnosing true drug resistance. RH is a therapeutic challenge, and its management includes lifestyle interventions, avoiding nonadherence to treatment, avoiding inertia, appropriate use of antihypertensive drugs based on current evidence, especially long-acting diuretics, and the addition of mineralocorticoid receptor antagonists. RCTs to identify the most protective medical therapy in RH are needed. A series of drugs in different stages of investigation could significantly impact RH treatment in the future.
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Affiliation(s)
- Roberto Parodi
- Rosario National University, Hospital Provincial del Centenario, Rosario, Argentina.
| | - Laura Brandani
- Favaloro Foundation University Hospital, Buenos Aires, Buenos Aires, Argentina
| | - César Romero
- Renal Division, Emory University School of Medicine, Atlanta, GA, USA
| | - Manuel Klein
- Argentina Society of Medicine, Buenos Aires, Argentina
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Azzam O, Nejad SH, Carnagarin R, Nolde JM, Galindo-Kiuchi M, Schlaich MP. Taming resistant hypertension: The promise of novel pharmacologic approaches and renal denervation. Br J Pharmacol 2024; 181:319-339. [PMID: 37715452 DOI: 10.1111/bph.16247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2023] [Revised: 08/11/2023] [Accepted: 09/02/2023] [Indexed: 09/17/2023] Open
Abstract
Resistant hypertension is associated with an exceedingly high cardiovascular risk and there remains an unmet therapeutic need driven by pathophysiologic pathways unaddressed by guideline-recommended therapy. While spironolactone is widely considered as the preferable fourth-line drug, its broad application is limited by its side effect profile, especially off-target steroid receptor-mediated effects and hyperkalaemia in at-risk subpopulations. Recent landmark trials have reported promising safety and efficacy results for a number of novel compounds targeting relevant pathophysiologic pathways that remain unopposed by contemporary drugs. These include the dual endothelin receptor antagonist, aprocitentan, the aldosterone synthase inhibitor, baxdrostat and the nonsteroidal mineralocorticoid receptor antagonist finerenone. Furthermore, the evidence base for consideration of catheter-based renal denervation as a safe and effective adjunct therapeutic approach across the clinical spectrum of hypertension has been further substantiated. This review will summarise the recently published evidence on novel antihypertensive drugs and renal denervation in the context of resistant hypertension.
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Affiliation(s)
- Omar Azzam
- Dobney Hypertension Centre, Medical School-Royal Perth Hospital Unit, Royal Perth Hospital Medical Research Foundation, The University of Western Australia, Perth, Western Australia, Australia
- Department of Nephrology, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Sayeh Heidari Nejad
- Dobney Hypertension Centre, Medical School-Royal Perth Hospital Unit, Royal Perth Hospital Medical Research Foundation, The University of Western Australia, Perth, Western Australia, Australia
| | - Revathy Carnagarin
- Dobney Hypertension Centre, Medical School-Royal Perth Hospital Unit, Royal Perth Hospital Medical Research Foundation, The University of Western Australia, Perth, Western Australia, Australia
| | - Janis M Nolde
- Dobney Hypertension Centre, Medical School-Royal Perth Hospital Unit, Royal Perth Hospital Medical Research Foundation, The University of Western Australia, Perth, Western Australia, Australia
| | - Marcio Galindo-Kiuchi
- Dobney Hypertension Centre, Medical School-Royal Perth Hospital Unit, Royal Perth Hospital Medical Research Foundation, The University of Western Australia, Perth, Western Australia, Australia
| | - Markus P Schlaich
- Dobney Hypertension Centre, Medical School-Royal Perth Hospital Unit, Royal Perth Hospital Medical Research Foundation, The University of Western Australia, Perth, Western Australia, Australia
- Department of Nephrology, Royal Perth Hospital, Perth, Western Australia, Australia
- Department of Cardiology, Royal Perth Hospital, Perth, Western Australia, Australia
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5
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Awosika A, Khan A, Adabanya U, Omole AE, Millis RM. Aldosterone Synthase Inhibitors and Dietary Interventions: A Combined Novel Approach for Prevention and Treatment of Cardiovascular Disease. Cureus 2023; 15:e36184. [PMID: 36937127 PMCID: PMC10016316 DOI: 10.7759/cureus.36184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/15/2023] [Indexed: 03/17/2023] Open
Abstract
Systemic hypertension (HTN) is the hallmark of cardiovascular disease and the forerunner of heart failure. These associations have been established over decades of research on essential HTN. Advancements in the treatment of patients diagnosed with HTN, consisting of alpha- or beta-adrenergic receptor blockers, calcium channel blockers, angiotensin-converting enzyme inhibitors, thiazide, or aldosterone receptor blockers known as anti-mineralocorticoids, in the presence or absence of low sodium salt diets, often fail to control blood pressure adequately to prevent morbidity and mortality. Low sodium diets have had limited success in controlling HTN because low sodium intake is associated with renin-angiotensin-aldosterone system upregulation. Therefore, upregulating aldosterone secretion, sodium, and water retention which, in turn, moves the blood pressure back toward the range of HTN dictated by the baroreceptor reset value, as a compensatory mechanism, especially in resistant HTN. These impediments to blood pressure control in HTN may have been effectively circumvented by the advent of a new class of drugs known as aldosterone synthase inhibitors, represented by baxdrostat. The mechanism of action of baxdrostat as an aldosterone synthase inhibitor demonstrates the inextricable linkage between sodium and blood pressure regulation. Theoretically, combining a low sodium diet with the activity of this aldosterone synthesis inhibitor should alleviate the adverse effect of renin-angiotensin-aldosterone system upregulation. Aldosterone synthesis inhibition should also decrease the oxidative stress and endothelial dysfunction associated with HTN, causing more endothelial nitric oxide synthesis, release, and vasorelaxation. To the best of our knowledge, this is the first systematic review to summarize evidence-based articles relevant to the use of a novel drug (aldosterone synthase inhibitor) in the treatment of HTN and cardiovascular disease. Making the current database of relevant information on baxdrostat and other aldosterone synthase inhibitors readily available will, no doubt, aid physicians and other medical practitioners in their decision-making about employing aldosterone synthase inhibitors in the treatment of patients.
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Affiliation(s)
- Ayoola Awosika
- College of Medicine, University of Illinois Chicago, Chicago, USA
| | - Anosh Khan
- Internal Medicine, Spartan Health Sciences University School of Medicine, Vieux Fort, LCA
| | | | - Adekunle E Omole
- Anatomical Sciences, American University of Antigua College of Medicine, Coolidge, ATG
| | - Richard M Millis
- Pathophysiology, American University of Antigua College of Medicine, Coolidge, ATG
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Agarwal R, Pitt B, Palmer BF, Kovesdy CP, Burgess E, Filippatos G, Małyszko J, Ruilope LM, Rossignol P, Rossing P, Pecoits-Filho R, Anker SD, Joseph A, Lawatscheck R, Wilson D, Gebel M, Bakris GL. A comparative post hoc analysis of finerenone and spironolactone in resistant hypertension in moderate-to-advanced chronic kidney disease. Clin Kidney J 2022; 16:293-302. [PMID: 36864892 PMCID: PMC9972517 DOI: 10.1093/ckj/sfac234] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Indexed: 11/13/2022] Open
Abstract
Background Mineralocorticoid receptor antagonists (MRAs) reduce systolic blood pressure (SBP) and increase serum potassium concentration ([K+]). This indirect comparison investigated any differences in SBP-lowering and hyperkalemia risk between finerenone, a nonsteroidal MRA, and the steroidal MRA spironolactone ± a potassium binder. Methods In FIDELITY (a pooled analysis of FIDELIO-DKD and FIGARO-DKD), a subgroup of patients with treatment-resistant hypertension (TRH) and chronic kidney disease meeting eligibility criteria of the AMBER trial were identified (FIDELITY-TRH). The main outcomes were mean change in SBP, incidence of serum [K+] ≥5.5 mmol/L and hyperkalemia-associated treatment discontinuation. Results at ∼17 weeks were compared with 12 weeks from AMBER. Results In 624 FIDELITY-TRH patients and 295 AMBER patients, the least squares mean change in SBP (mmHg) from baseline was -7.1 for finerenone and -1.3 for placebo {between-group difference -5.74 [95% confidence interval (CI) -7.99 to -3.49], P < .0001} versus -11.7 for spironolactone + patiromer and -10.8 for spironolactone + placebo [between-group difference -1.0 (95% CI -4.4-2.4), P = .58]. The incidence of serum [K+] ≥5.5 mmol/L was 12% for finerenone and 3% for placebo versus 35% with spironolactone + patiromer and 64% with spironolactone + placebo. Treatment discontinuation due to hyperkalemia was 0.3% for finerenone and 0% for placebo versus 7% for spironolactone + patiromer and 23% for spironolactone + placebo. Conclusions In patients with TRH and chronic kidney disease compared with spironolactone with or without patiromer, finerenone was associated with a lower SBP reduction and lower risk of hyperkalemia and treatment discontinuation.Trial Registration: AMBER (NCT03071263), FIDELIO-DKD (NCT02540993), FIGARO-DKD (NCT02545049).
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Affiliation(s)
| | - Bertram Pitt
- Department of Medicine, University of Michigan School of Medicine, Ann Arbor, MI, USA
| | - Biff F Palmer
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Csaba P Kovesdy
- Division of Nephrology, Department of Medicine, University of Tennessee, Health Science Center Memphis, TN, USA,Nephrology Section, Memphis VA Medical Center, Memphis, TN, USA
| | - Ellen Burgess
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Gerasimos Filippatos
- National and Kapodistrian University of Athens, School of Medicine, Department of Cardiology, Attikon University Hospital, Athens, Greece
| | - Jolanta Małyszko
- Department of Nephrology, Dialysis and Internal Medicine, Medical University of Warsaw, Warsaw, Poland
| | - Luis M Ruilope
- Cardiorenal Translational Laboratory and Hypertension Unit, Institute of Research imas12, Madrid, Spain,CIBER-CV, Hospital Universitario 12 de Octubre, Madrid, Spain,Faculty of Sport Sciences, European University of Madrid, Madrid, Spain
| | - Patrick Rossignol
- Université de Lorraine, Inserm, Centre d’Investigations Cliniques – Plurithématique 14-33, and Inserm U1116, CHRU Nancy, F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Nancy, France
| | - Peter Rossing
- Steno Diabetes Center Copenhagen, Herlev, Denmark,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Roberto Pecoits-Filho
- Arbor Research Collaborative for Health, Ann Arbor, MI, USA,School of Medicine, Pontificia Universidade Católica do Paraná, Curitiba, Brazil
| | - Stefan D Anker
- Department of Cardiology and Berlin Institute of Health Center for Regenerative Therapies, German Centre for Cardiovascular Research Partner Site Berlin, Charité Universitätsmedizin, Berlin, Germany
| | - Amer Joseph
- Cardiology and Nephrology Clinical Development, Bayer AG, Berlin, Germany
| | - Robert Lawatscheck
- Cardiology and Nephrology Clinical Development, Bayer AG, Berlin, Germany
| | - Daniel Wilson
- US Medical Affairs, Bayer US LLC Pharmaceuticals, Whippany, NJ, USA
| | - Martin Gebel
- Research and Development, Integrated Analysis Statistics, Bayer AG, Wuppertal, Germany
| | - George L Bakris
- Department of Medicine, University of Chicago Medicine, Chicago, IL, USA
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Safaryan AS, Nebieridze DV. Sympathetic hyperactivity in patients with hypertension: pathogenesis and treatment. Part II. КАРДИОВАСКУЛЯРНАЯ ТЕРАПИЯ И ПРОФИЛАКТИКА 2021. [DOI: 10.15829/1728-8800-2021-2845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
The second part of the review considers different classes of drugs affecting blood pressure in increased activity of the sympathetic nervous system. Additional possibilities are discussed on how to reduce the negative effect of sympathetic hyperactivity on cardiovascular system and improve the prognosis.
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Affiliation(s)
- A. S. Safaryan
- National Medical Research Center for Therapy and Preventive Medicine
| | - D. V. Nebieridze
- National Medical Research Center for Therapy and Preventive Medicine
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Chu L, Fuller M, Jervis K, Ciaccia A, Abitbol A. Prevalence of Chronic Kidney Disease in Type 2 Diabetes: The Canadian REgistry of Chronic Kidney Disease in Diabetes Outcomes (CREDO) Study. Clin Ther 2021; 43:1558-1573. [PMID: 34426012 DOI: 10.1016/j.clinthera.2021.07.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 07/08/2021] [Accepted: 07/15/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE Chronic kidney disease (CKD) in patients with type 2 diabetes (T2D) is associated with an elevated risk of end-stage kidney disease, cardiovascular disease (CVD), and death. As the breadth of treatment options for CKD in patients with T2D (CKD in T2D) continues to expand, an analysis of the current use of therapies and cardiovascular and kidney outcomes is necessary. The objectives of the study were to assess the prevalence of CKD in T2D among a contemporary cohort of patients, to describe patient characteristics and treatment patterns, and to examine health care practitioner rationale for initiating therapies. METHODS The study was a retrospective, observational study (module A) with a prospective component (module B). For module A, sociodemographic data, medical history, prescription information, and laboratory investigations for patients seen by an endocrinologist in 2019 were retrieved from the LMC Diabetes Registry. Module B included a subset of patients for health care practitioner surveys to understand rationale for administering angiotensin-converting enzyme inhibitors (ACEis) or angiotensin receptor blockers (ARBs), steroidal mineralocorticoid receptor antagonists (MRAs), sodium-glucose cotransporter 2 inhibitors (SGLT2is), and glucagon-like peptide 1 receptor agonists (GLP-1RAs). Descriptive analyses were conducted. FINDINGS The study included 14,873 patients (59% male). Mean patient age was 67 years, mean body mass index was 31 kg/m2, and mean glycosylated hemoglobin was 7.6%. Mean diabetes duration was 16 years. The prevalence of CKD in patients with T2D was 47.9%. Common comorbidities were hypertension (76%), dyslipidemia (71%), and obesity (51%). CVD was reported in 22%. The proportion of kidney medications and emerging therapies varied, with 76% of patients using an ACEi or ARB, 48% using an SGLT2i, 30% using a GLP-1RA, and 3% using a steroidal MRA. In module B, physicians identified that ACEis/ARBs, SGLT2is, GLP-1RAs, or steroidal MRAs were administered to primarily treat CKD in 33%, 12%, 0%, and 4% of the patients (n = 500), respectively. IMPLICATIONS These findings improved our understanding of the current landscape and treatment patterns of CKD inT2D and highlighted the importance of considering treatments that will provide a comprehensive strategy for cardiovascular and kidney risk protection. Despite the high prevalence of CKD and comorbidities reported in a large, Canadian T2D specialist population, ACEis/ARBs, SGLT2is, and GLP-1RAs were underused, especially considering recent clinical trial reports. The relative use of steroidal MRAs was expectedly low. With an immense burden of CKD progression and among patients with T2D, the use of treatments that provide a comprehensive strategy for kidney protection will transform the landscape of CKD in T2D. ClinicalTrials.gov identifier: NCT04445181.
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Affiliation(s)
- Lisa Chu
- LMC Diabetes & Endocrinology, Toronto, Ontario, Canada
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Laffin LJ, Bakris GL. Approach to Resistant Hypertension from Cardiology and Nephrology Standpoints: Tailoring Therapy. Cardiol Clin 2021; 39:377-387. [PMID: 34247751 DOI: 10.1016/j.ccl.2021.04.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Resistant hypertension is commonly encountered in primary care, cardiology, and nephrology clinics. In patients presenting for the evaluation of resistant hypertension, taking a thoughtful approach to excluding pseudoresistant hypertension or a secondary cause of hypertension is important. When a patient is deemed to have true resistant hypertension, following an evidence-based treatment approach while considering patient-specific comorbidities results not only in better blood pressure control but also better patient long-term adherence to lifestyle and pharmacologic interventions. This article details an approach to the diagnosis and treatment of resistant hypertension with special consideration for patients with preexisting renal and/or cardiovascular disease.
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Affiliation(s)
- Luke J Laffin
- Section of Preventive Cardiology and Rehabilitation, Department of Cardiovascular Medicine, Cleveland Clinic Foundation, 9500 Euclid Avenue, Mail code JB1, Cleveland, OH 44195, USA
| | - George L Bakris
- American Heart Association Comprehensive Hypertension Center, Section of Endocrinology, Diabetes and Metabolism, Department of Medicine, University of Chicago Medicine, 5841 S. Maryland Avenue, MC 1027, Chicago, IL 60637, USA.
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Special Article - The management of resistant hypertension: A 2020 update. Prog Cardiovasc Dis 2020; 63:662-670. [PMID: 32795462 DOI: 10.1016/j.pcad.2020.08.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 08/05/2020] [Indexed: 11/21/2022]
Abstract
Resistant hypertension (RH) induces higher morbidity and mortality due to cardiovascular disease and stroke than hypertension without treatment resistance. New guidelines define RH as blood pressure (BP) ≥130/80 mmHg in a patient taking ≥3 antihypertensive agents of different classes or BP <130/80 mmHg in a patient taking ≥4 antihypertensive drugs. According to the new definition, pseudo-resistance due to error in BP measurement, white coat effect and medication nonadherence must be excluded to make the diagnosis of RH. This 2020 update focuses on the lifestyle and antihypertensive drug management of RH and includes recent proof-of-principle trials of renal nerve ablation in hypertension. Stepwise evidence-based pharmacologic treatment of RH includes optimization of the 3-drug regimen, substitution of a thiazide-like for a thiazide diuretic and addition of a mineralocorticoid receptor antagonist as the fourth drug. Non-evidence-based recommendations include addition of a β-blocker as the fifth drug and switching to a minoxidil-based regimen as the final step in achieving BP control.
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Abstract
Resistant hypertension (RHTN) is defined as uncontrolled blood pressure despite the use of ≥3 antihypertensive agents of different classes, including a diuretic, usually thiazide-like, a long-acting calcium channel blocker, and a blocker of the renin- angiotensin system, either an ACE (angiotensin-converting enzyme) inhibitor or an ARB (angiotensin receptor blocker), at maximal or maximally tolerated doses. Antihypertensive medication nonadherence and the white coat effect, defined as elevated blood pressure when measured in clinic but controlled when measured outside of clinic, must be excluded to make the diagnosis. RHTN is a high-risk phenotype, leading to increased all-cause mortality and cardiovascular disease outcomes. Healthy lifestyle habits are associated with reduced cardiovascular risk in patients with RHTN. Aldosterone excess is common in patients with RHTN, and addition of spironolactone or amiloride to the standard 3-drug antihypertensive regimen is effective at getting the blood pressure to goal in most of these patients. Refractory hypertension is defined as uncontrolled blood pressure despite use of ≥5 antihypertensive agents of different classes, including a long-acting thiazide-like diuretic and an MR (mineralocorticoid receptor) antagonist, at maximal or maximally tolerated doses. Fluid retention, mediated largely by aldosterone excess, is the predominant mechanism underlying RHTN, while patients with refractory hypertension typically exhibit increased sympathetic nervous system activity.
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Affiliation(s)
- Maria Czarina Acelajado
- From the Department of Medicine, Division of Cardiovascular Disease, Vascular Biology and Hypertension Program, University of Alabama at Birmingham
| | - Zachary H Hughes
- From the Department of Medicine, Division of Cardiovascular Disease, Vascular Biology and Hypertension Program, University of Alabama at Birmingham
| | - Suzanne Oparil
- From the Department of Medicine, Division of Cardiovascular Disease, Vascular Biology and Hypertension Program, University of Alabama at Birmingham
| | - David A Calhoun
- From the Department of Medicine, Division of Cardiovascular Disease, Vascular Biology and Hypertension Program, University of Alabama at Birmingham
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Ito S, Itoh H, Rakugi H, Okuda Y, Yoshimura M, Yamakawa S. Double-Blind Randomized Phase 3 Study Comparing Esaxerenone (CS-3150) and Eplerenone in Patients With Essential Hypertension (ESAX-HTN Study). Hypertension 2019; 75:51-58. [PMID: 31786983 DOI: 10.1161/hypertensionaha.119.13569] [Citation(s) in RCA: 107] [Impact Index Per Article: 21.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Mineralocorticoid receptors (MRs) are implicated in the pathology of hypertension. MR blockers are recommended for the treatment of salt-sensitive or resistant hypertension. However, use of currently available MR blockers is limited by adverse events. This phase 3 multicenter, randomized, double-blind study compared the efficacy and safety of esaxerenone, a new selective nonsteroidal MR blocker, at 2.5 and 5 mg/day and eplerenone 50 mg/day in Japanese patients with essential hypertension. After a 4-week washout period, 1001 eligible adults with hypertension were randomized evenly to esaxerenone 2.5 or 5 mg/day or eplerenone 50 mg/day treatments, taken orally once daily for 12 weeks. Primary end points were changes in sitting systolic or diastolic blood pressure (BP) from baseline at the end of treatment. Esaxerenone 2.5 mg/day was noninferior to eplerenone for reductions in sitting and 24-hour BP. Reductions in BP with esaxerenone 5 mg/day were significantly greater than those with esaxerenone 2.5 mg/day. Changes in diurnal BP showed persistent 24-hour antihypertensive effects in all treatment groups. The proportions of patients achieving target sitting BP (<140/90 mm Hg) were 31.5%, 41.2%, and 27.5% with esaxerenone 2.5 and 5 mg/day and eplerenone 50 mg/day, respectively. Incidences of adverse events (all mild or moderate) were similar across treatment groups. These results indicate that esaxerenone is an effective and well-tolerated MR blocker in Japanese patients with essential hypertension, with BP-lowering activity at least equivalent to eplerenone. Clinical Trial Registration- URL: http://www.clinicaltrials.gov. Unique identifier: NCT02890173.
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Affiliation(s)
- Sadayoshi Ito
- From the Division of Nephrology, Endocrinology and Vascular Medicine, Department of Medicine, Tohoku University School of Medicine, Sendai, Japan (S.I.)
| | - Hiroshi Itoh
- Department of Endocrinology, Metabolism and Nephrology, Keio University, School of Medicine, Tokyo, Japan (H.I.)
| | - Hiromi Rakugi
- Department of Geriatric and General Medicine, Osaka University Graduate School of Medicine, Suita, Japan (H.R.)
| | - Yasuyuki Okuda
- Daiichi Sankyo Co., Ltd., Tokyo, Japan (Y.O., M.Y., S.Y.)
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Abstract
Primary aldosteronism (PA) is the most common form of secondary hypertension. In many cases, somatic mutations in ion channels and pumps within adrenal cells initiate the pathogenesis of PA, and this mechanism might explain why PA is so common and suggests that milder and evolving forms of PA must exist. Compared with primary hypertension, PA causes more end-organ damage and is associated with excess cardiovascular morbidity, including heart failure, stroke, nonfatal myocardial infarction, and atrial fibrillation. Screening is simple and readily available, and targeted therapy improves blood pressure control and mitigates cardiovascular morbidity. Despite these imperatives, screening rates for PA are low, and mineralocorticoid-receptor antagonists are underused for hypertension treatment. After the evidence for the prevalence of PA and its associated cardiovascular morbidity is summarized, a practical approach to PA screening, referral, and management is described. All physicians who treat hypertension should routinely screen appropriate patients for PA.
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Affiliation(s)
| | - Adina F Turcu
- Division of Metabolism, Endocrinology, and Diabetes (A.F.T., R.J.A.)
| | - Richard J Auchus
- Division of Metabolism, Endocrinology, and Diabetes (A.F.T., R.J.A.).,Department of Pharmacology (R.J.A.), University of Michigan, Ann Arbor
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Abstract
Recent guidelines on diagnosis and management of high blood pressure (BP) include substantial changes and several new concepts compared with previous guidelines. These are reviewed and their clinical implications are discussed in this article. The goal is to provide a practical reference to assist clinicians with up-to-date management of patients with high BP. Important issues include new diagnostic thresholds, out-of-office BP monitoring, intensified treatment goals, and a different approach to resistant hypertension. Finally, differences among guidelines, the persistent controversies that have led to them, and their implications for clinical practice are discussed.
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Affiliation(s)
| | - Robert D Brook
- University of Michigan, Ann Arbor, Michigan (J.B.B., R.D.B.)
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15
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Eplerenone Versus Spironolactone in Resistant Hypertension: an Efficacy and/or Cost or Just a Men’s Issue? Curr Hypertens Rep 2019; 21:22. [DOI: 10.1007/s11906-019-0924-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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16
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Abstract
PURPOSE OF REVIEW To review the most recent literature on current strategies for the treatment of hypertension associated with pediatric obesity. RECENT FINDINGS Over the last three decades, childhood and adolescent overweight and obesity prevalence in the USA has continued to rise. Unsurprisingly but rather disturbingly, this rising prevalence has been paralleled by an increase in cardiovascular disease (CVD) risk factors in childhood such as hypertension, dyslipidemia, and diabetes that become manifest earlier than previously reported. These childhood CVD risk factors are not only associated with target organ damage in childhood but also track into adulthood, increasing the risk of long-term CVD morbidity and mortality. There have been several mechanisms proposed to explain the role of obesity on the development of hypertension in childhood. However, central to the management of obesity-related hypertension is a multifaceted approach targeting lifestyle modifications and weight loss. Effective treatment often also requires a pharmacologic approach and rarely bariatric surgery.
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Abstract
PURPOSE OF REVIEW Emerging evidence suggests that multiple mechanisms may be responsible for the development of treatment-resistant hypertension (TRH). This review aims to summarize recent data on potential mechanisms of resistance and discuss current pharmacotherapeutic options available in the management of TRH. RECENT FINDINGS Excess sodium and fluid retention, increased activation of the renin-angiotensin-aldosterone system, and heightened activity of the sympathetic nervous system appear to play an important role in development of TRH. Emerging evidence also suggests a role for arterial stiffness and, potentially, gut dysbiosis. Therapeutic approaches for TRH should include diuretic optimization and the addition of aldosterone antagonists as the preferred fourth agent in most patients. Further therapeutic approaches may be guided by the suspected underlying mechanism of TRH in conjunction with other patient-specific factors. The pathophysiology of TRH is multifaceted; however, increasing evidence supports several mechanisms that may be targeted to improve blood pressure control among patients with TRH. Further studies are needed to determine whether such approaches may be more effective than usual care.
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Jalil F, White WB. A New Era of Renal Denervation Trials for Patients With Hypertension? Am J Kidney Dis 2018; 71:615-618. [PMID: 29352604 DOI: 10.1053/j.ajkd.2017.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Accepted: 11/08/2017] [Indexed: 11/11/2022]
Affiliation(s)
- Fatima Jalil
- The University of Connecticut School of Medicine, Farmington, CT
| | - William B White
- The University of Connecticut School of Medicine, Farmington, CT.
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Yugar-Toledo JC, Modolo R, de Faria AP, Moreno H. Managing resistant hypertension: focus on mineralocorticoid-receptor antagonists. Vasc Health Risk Manag 2017; 13:403-411. [PMID: 29081661 PMCID: PMC5652936 DOI: 10.2147/vhrm.s138599] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Mineralocorticoid-receptor antagonists (MRAs) have proven to be effective in some types of hypertension, especially in resistant hypertension (RHTN). In this phenotype of hypertension, the renin-angiotensin-aldosterone pathway plays an important role, with MRAs being especially effective in reducing blood pressure. In this review, we show the relevance of aldosterone in RHTN, as well as some clinical characteristics of this condition and the main concepts involving its pathophysiology and cardiovascular damage. We analyzed the mechanisms of action and clinical effects of two current MRAs - spironolactone and eplerenone - both of which are useful in RHTN, with special attention to the former. RHTN represents a significant minority (10%-15%) of hypertension cases. However, primary-care physicians, cardiologists, nephrologists, neurologists, and geriatricians face this health problem on a daily basis. MRAs are likely one of the best pharmacological options in RHTN patients; however, they are still underused.
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Affiliation(s)
| | - Rodrigo Modolo
- School of Medical Sciences, University of Campinas (UNICAMP), Campinas, Brazil
| | - Ana Paula de Faria
- School of Medical Sciences, University of Campinas (UNICAMP), Campinas, Brazil
| | - Heitor Moreno
- School of Medical Sciences, University of Campinas (UNICAMP), Campinas, Brazil
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Kino T, Ishigami T, Murata T, Doi H, Nakashima-Sasaki R, Chen L, Sugiyama M, Azushima K, Wakui H, Minegishi S, Tamura K. Eplerenone-Resistant Salt-Sensitive Hypertension in Nedd4-2 C2 KO Mice. Int J Mol Sci 2017; 18:ijms18061250. [PMID: 28604611 PMCID: PMC5486073 DOI: 10.3390/ijms18061250] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2017] [Revised: 05/29/2017] [Accepted: 06/07/2017] [Indexed: 12/25/2022] Open
Abstract
The epithelial sodium channel (ENaC) plays critical roles in maintaining fluid and electrolyte homeostasis and is located in the aldosterone-sensitive distal nephron (ASDN). We previously found that Nedd4-2 C2 knockout (KO) mice showed salt-sensitive hypertension with paradoxically enhanced ENaC gene expression in ASDN under high oral salt intake. Eplerenone (EPL), a selective aldosterone blocker, is a promising therapeutic option for resistant or/and salt-sensitive hypertension. We examined the effect of EPL on Nedd4-2 C2 KO mice with respect to blood pressure, metabolic parameters, and molecular level changes in ASDN under high oral salt intake. We found that EPL failed to reduce blood pressure in KO mice with high oral salt intake and upregulated ENaC expression in ASDN. Thus, salt-sensitive hypertension in Nedd4-2 C2 KO was EPL-resistant. Gene expression analyses of laser-captured specimens in ASDN suggested the presence of non-aldosterone-dependent activation of ENaC transcription in ASDN of Nedd4-2 C2 KO mice, which was abolished by amiloride treatment. Our results from Nedd4-2 C2 KO mice suggest that enhanced ENaC gene expression is critically involved in salt-sensitive hypertension under certain conditions of specific enzyme isoforms for their ubiquitination.
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Affiliation(s)
- Tabito Kino
- Department of Medical Science and Cardiorenal Medicine, Graduate School of Medicine, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama 236-0004, Japan.
| | - Tomoaki Ishigami
- Department of Medical Science and Cardiorenal Medicine, Graduate School of Medicine, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama 236-0004, Japan.
| | - Tsumugi Murata
- Department of Medical Science and Cardiorenal Medicine, Graduate School of Medicine, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama 236-0004, Japan.
| | - Hiroshi Doi
- Department of Medical Science and Cardiorenal Medicine, Graduate School of Medicine, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama 236-0004, Japan.
| | - Rie Nakashima-Sasaki
- Department of Medical Science and Cardiorenal Medicine, Graduate School of Medicine, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama 236-0004, Japan.
| | - Lin Chen
- Department of Medical Science and Cardiorenal Medicine, Graduate School of Medicine, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama 236-0004, Japan.
| | - Michiko Sugiyama
- Department of Medical Science and Cardiorenal Medicine, Graduate School of Medicine, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama 236-0004, Japan.
| | - Kengo Azushima
- Department of Medical Science and Cardiorenal Medicine, Graduate School of Medicine, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama 236-0004, Japan.
- Cardiovascular and Metabolic Disorders Program, Duke-NUS Medical School, 8 College Road, Singapore 169857, Singapore.
| | - Hiromichi Wakui
- Department of Medical Science and Cardiorenal Medicine, Graduate School of Medicine, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama 236-0004, Japan.
| | - Shintaro Minegishi
- Department of Medical Science and Cardiorenal Medicine, Graduate School of Medicine, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama 236-0004, Japan.
| | - Kouichi Tamura
- Department of Medical Science and Cardiorenal Medicine, Graduate School of Medicine, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama 236-0004, Japan.
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21
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Renal denervation in comparison with intensified pharmacotherapy in true resistant hypertension. J Hypertens 2017; 35:1093-1099. [DOI: 10.1097/hjh.0000000000001257] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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22
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Tam TSC, Wu MHY, Masson SC, Tsang MP, Stabler SN, Kinkade A, Tung A, Tejani AM. Eplerenone for hypertension. Cochrane Database Syst Rev 2017; 2:CD008996. [PMID: 28245343 PMCID: PMC6464701 DOI: 10.1002/14651858.cd008996.pub2] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Eplerenone is an aldosterone receptor blocker that is chemically derived from spironolactone. In Canada, it is indicated for use as adjunctive therapy to reduce mortality for heart failure patients with New York Heart Association (NYHA) class II systolic chronic heart failure and left ventricular systolic dysfunction. It is also used as adjunctive therapy for patients with heart failure following myocardial infarction. Additionally, it is indicated for the treatment of mild and moderate essential hypertension for patients who cannot be treated adequately with other agents. It is important to determine the clinical impact of all antihypertensive medications, including aldosterone antagonists, to support their continued use in essential hypertension. No previous systematic reviews have evaluated the effect of eplerenone on cardiovascular morbidity, mortality, and magnitude of blood pressure lowering in patients with hypertension. OBJECTIVES To assess the effects of eplerenone monotherapy versus placebo for primary hypertension in adults. Outcomes of interest were all-cause mortality, cardiovascular events (fatal or non-fatal myocardial infarction), cerebrovascular events (fatal or non fatal strokes), adverse events or withdrawals due to adverse events, and systolic and diastolic blood pressure. SEARCH METHODS We searched the Cochrane Hypertension Specialised Register, CENTRAL, MEDLINE, Embase, and two trials registers up to 3 March 2016. We handsearched references from retrieved studies to identify any studies missed in the initial search. We also searched for unpublished data by contacting the corresponding authors of the included studies and pharmaceutical companies involved in conducting studies on eplerenone monotherapy in primary hypertension. The search had no language restrictions. SELECTION CRITERIA We selected randomized placebo-controlled trials studying adult patients with primary hypertension. We excluded studies in people with secondary or gestational hypertension and studies where participants were receiving multiple antihypertensives. DATA COLLECTION AND ANALYSIS Three review authors independently reviewed the search results for studies meeting our criteria. Three review authors independently extracted data and assessed trial quality using a standardized data extraction form. A fourth independent review author resolved discrepancies or disagreements. We performed data extraction and synthesis using a standardized format on Covidence. We conducted data analysis using Review Manager 5. MAIN RESULTS A total of 1437 adult patients participated in the five randomized parallel group studies, with treatment durations ranging from 8 to 16 weeks. The daily doses of eplerenone ranged from 25 mg to 400 mg daily. Meta-analysis of these studies showed a reduction in systolic blood pressure of 9.21 mmHg (95% CI -11.08 to -7.34; I2 = 58%) and a reduction of diastolic pressure of 4.18 mmHg (95% CI -5.03 to -3.33; I2 = 0%) (moderate quality evidence).There may be a dose response effect for eplerenone in the reduction in systolic blood pressure at doses of 400 mg/day. However, this finding is uncertain, as it is based on a single included study with low quality evidence. Overall there does not appear to be a clinically important dose response in lowering systolic or diastolic blood pressure at eplerenone doses of 50 mg to 400 mg daily. There did not appear to be any differences in the number of patients who withdrew due to adverse events or the number of patients with at least one adverse event in the eplerenone group compared to placebo. However, only three of the five included studies reported adverse events. Most of the included studies were of moderate quality, as we judged multiple domains as being at unclear risk in the 'Risk of bias' assessment. AUTHORS' CONCLUSIONS Eplerenone 50 to 200 mg/day lowers blood pressure in people with primary hypertension by 9.21 mmHg systolic and 4.18 mmHg diastolic compared to placebo, with no difference of effect between doses of 50 mg/day to 200 mg/day. A dose of 25 mg/day did not produce a statistically significant reduction in systolic or diastolic blood pressure and there is insufficient evidence for doses above 200 mg/day. There is currently no available evidence to determine the effect of eplerenone on clinically meaningful outcomes such as mortality or morbidity in hypertensive patients. The evidence available on side effects is insufficient and of low quality, which makes it impossible to draw conclusions about potential harm associated with eplerenone treatment in hypertensive patients.
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Affiliation(s)
- Tina SC Tam
- Lower Mainland Pharmacy ServicesPharmacyVancouverBCCanada
| | - May HY Wu
- Lower Mainland Pharmacy ServicesSurrey Memorial Hospital PharmacySurreyBCCanada
| | - Sarah C Masson
- Fraser Health AuthorityPharmacy Services3938 Kincaid StBurnabyBCCanadaV5G 1V7
| | - Matthew P Tsang
- Fraser Health AuthorityPharmacy Services32900 Marshall RoadAbbotsfordBCCanadaV2S 0C2
| | - Sarah N Stabler
- Lower Mainland Pharmacy ServicesCardiac Clinics, Royal Columbian HospitalVancouverBCCanada
| | - Angus Kinkade
- Lower Mainland Pharmacy ServicesPharmacyVancouverBCCanada
| | - Anthony Tung
- Lower Mainland Pharmacy ServicesPharmacyVancouverBCCanada
| | - Aaron M Tejani
- University of British ColumbiaTherapeutics Initiative2176 Health Sciences MallVancouverBCCanadaV6T 1Z3
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Dudenbostel T, Calhoun DA. Use of Aldosterone Antagonists for Treatment of Uncontrolled Resistant Hypertension. Am J Hypertens 2017; 30:103-109. [PMID: 27609503 DOI: 10.1093/ajh/hpw105] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Revised: 07/19/2016] [Accepted: 08/18/2016] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Multiple studies indicate that primary aldosteronism (PA) is common in patients with resistant hypertension, with an estimated prevalence of approximately 20%. Additional studies suggest that beyond this 20% of patients with classical PA, there is a larger proportion of patients with lesser degrees of hyperaldosteronism which contributes even more broadly to antihypertensive treatment resistance. Given these observations, it is intuitive that use of aldosterone antagonists will provide antihypertensive benefit in patients with resistant hypertension and evidence of aldosterone excess. Intriguingly, however, are clinical findings demonstrating substantive benefit of aldosterone antagonists in patients with resistant hypertension, but without demonstrative evidence of hyperaldosteronism, that is, with seemingly normal or even low aldosterone levels. CONCLUSION Spironolactone is clearly established as the most effective fourth agent for treatment of uncontrolled resistant hypertension. Emerging observations suggest a further role of spironolactone for counteracting the effects of diet high in sodium, particularly in obese, hypertensive patients.
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Affiliation(s)
- Tanja Dudenbostel
- Vascular Biology and Hypertension Program, University of Alabama at Birmingham, Birmingham, Alabama, USA.
| | - David A Calhoun
- Vascular Biology and Hypertension Program, University of Alabama at Birmingham, Birmingham, Alabama, USA
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24
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Martell-Claros N, Abad-Cardiel M. ¿Qué posibilidades farmacológicas existen para tratar la hipertensión arterial resistente? HIPERTENSION Y RIESGO VASCULAR 2017; 34 Suppl 1:25-28. [DOI: 10.1016/s1889-1837(18)30060-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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25
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A meta-analysis of add-on use of spironolactone in patients with resistant hypertension. Int J Cardiol 2016; 233:113-117. [PMID: 28089457 DOI: 10.1016/j.ijcard.2016.12.158] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Revised: 11/15/2016] [Accepted: 12/20/2016] [Indexed: 12/18/2022]
Abstract
OBJECTIVE The efficacy of add-on use of spironolactone in patients with resistant hypertension has been investigated in several small studies. We performed this meta-analysis evaluating the efficacy of add-on use of spironolactone in these patients. METHODS We searched Pubmed, Web of Science, and Cochrane Central for all published studies evaluating add-on use of spironolactone in patients with resistant hypertension. Only randomized controlled trials determining antihypertensive effects of spironolactone were considered. RESULTS The antihypertensive effects were assessed in 869 patients included in 4 trials with a mean follow-up of 12±3weeks. The reduction of systolic blood pressure (SBP) and diastolic BP (DBP) in patients treated with spironolactone was greater than placebo (weighted mean differences (WMD) for SBP -16.67mmHg (95% confidence interval (CI), -27.54, -5.80), p<0.01; WMD for DBP -6.11mmHg (95% CI, -9.34, -2.88), p<0.001), respectively. The rates of serious adverse effects or patient withdrawals from the trials tended to be higher in patients treated with spironolactone than placebo (WMD for odds ratio 2.11 (95% CI, 0.98, 4.53), p=0.05). CONCLUSIONS This meta-analysis provides the evidence that add-on use of spironolactone in patients with resistant hypertension is effective in lowering SBP and DBP, suggesting an add-on use of spironolactone as fourth line therapy in patients with resistant hypertension.
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Abstract
Treatment resistant hypertension (TRH), defined as a blood pressure above goal despite treatment with optimally tolerated doses of 3 antihypertensive agents of different classes, ideally including a diuretic, remains a significant problem and its management an area of uncertainty for physicians. One hypothesis is that resistant hypertension is due to abnormal sodium retention, mediated by aldosterone breakthrough occurring despite blockade of the renin-angiotensin-aldosterone system with angiotensin converting enzyme inhibitors (ACEi) or angiotensin receptor blockers (ARB). Thus, there has been renewed interest in the use of mineralocorticoid receptor blockers (MRB) to treat this condition. This article critically evaluates new evidence supporting the use of MRB in TRH published in the last 3 years. We conclude that there is now sufficient evidence to recommend MRB, in particular spironolactone, as the first choice medication to treat this condition, and for its inclusion in future guidelines.
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Arai K, Morikawa Y, Ubukata N, Tsuruoka H, Homma T. CS-3150, a Novel Nonsteroidal Mineralocorticoid Receptor Antagonist, Shows Preventive and Therapeutic Effects On Renal Injury in Deoxycorticosterone Acetate/Salt-Induced Hypertensive Rats. J Pharmacol Exp Ther 2016; 358:548-57. [PMID: 27384074 DOI: 10.1124/jpet.116.234765] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Accepted: 06/30/2016] [Indexed: 11/22/2022] Open
Abstract
The present study was designed to assess both preventive and therapeutic effects of (S)-1-(2-Hydroxyethyl)-4-methyl-N-[4-(methylsulfonyl) phenyl]-5-[2-(trifluoromethyl) phenyl]-1H-pyrrole-3-carboxamide (CS-3150), a novel nonsteroidal mineralocorticoid receptor antagonist, on renal injury in deoxycorticosterone acetate (DOCA)/salt-induced hypertensive rats (DOCA rats). From 7 weeks of age, DOCA was subcutaneously administered once a week for 4 weeks to uninephrectomized rats fed a high-salt diet. In experiment 1, CS-3150 (0.3-3 mg/kg) was orally administered once a day for 4 weeks coincident with DOCA administration. In experiment 2, after establishment of renal injury by 4 weeks of DOCA/salt loading, CS-3150 (3 mg/kg) was orally administered once a day for 4 weeks with or without continuous DOCA administration. In experiment 1, DOCA/salt loading significantly increased systolic blood pressure (SBP), which was prevented by CS-3150 in a dose-dependent manner. Development of renal injury (proteinuria, renal hypertrophy, and histopathological changes in glomeruli and tubule) was also suppressed by CS-3150 with inhibition of mRNA expression of fibrosis, inflammation, and oxidative stress markers. In experiment 2, under continuous DOCA treatment, CS-3150 clearly ameliorated existing renal injury without lowering SBP, indicating that CS-3150 regressed renal injury independent of its antihypertensive action. Moreover, CS-3150 treatment in combination with withdrawal of DOCA showed further therapeutic effect on renal injury accompanied by reduction in SBP. These results demonstrate that CS-3150 not only prevents but also ameliorates hypertension and renal injury in DOCA rats. Therefore, CS-3150 could be a promising agent for the treatment of hypertension and renal disorders, and may have potential to promote regression of renal injury.
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Affiliation(s)
- Kiyoshi Arai
- End-Organ Disease Laboratories (K.A., N.U., T.H.), Rare Disease and LCM Laboratories (Y.M.), and Venture Science Laboratories (H.T.), Daiichi Sankyo Co., Ltd., Tokyo, Japan
| | - Yuka Morikawa
- End-Organ Disease Laboratories (K.A., N.U., T.H.), Rare Disease and LCM Laboratories (Y.M.), and Venture Science Laboratories (H.T.), Daiichi Sankyo Co., Ltd., Tokyo, Japan
| | - Naoko Ubukata
- End-Organ Disease Laboratories (K.A., N.U., T.H.), Rare Disease and LCM Laboratories (Y.M.), and Venture Science Laboratories (H.T.), Daiichi Sankyo Co., Ltd., Tokyo, Japan
| | - Hiroyuki Tsuruoka
- End-Organ Disease Laboratories (K.A., N.U., T.H.), Rare Disease and LCM Laboratories (Y.M.), and Venture Science Laboratories (H.T.), Daiichi Sankyo Co., Ltd., Tokyo, Japan
| | - Tsuyoshi Homma
- End-Organ Disease Laboratories (K.A., N.U., T.H.), Rare Disease and LCM Laboratories (Y.M.), and Venture Science Laboratories (H.T.), Daiichi Sankyo Co., Ltd., Tokyo, Japan
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28
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Du M, Pan C, Chen J, Song M, Zhu T, Hang T. A validated stability-indicating ultra performance liquid chromatography method for the determination of potential process-related impurities in eplerenone. J Sep Sci 2016; 39:2907-18. [DOI: 10.1002/jssc.201600324] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Revised: 04/18/2016] [Accepted: 05/24/2016] [Indexed: 11/07/2022]
Affiliation(s)
- Mingluo Du
- Department of Pharmaceutical Analysis; China Pharmaceutical University; Nanjing Jiangsu P. R. China
| | - Chunyan Pan
- Department of Pharmaceutical Analysis; China Pharmaceutical University; Nanjing Jiangsu P. R. China
| | - Jing Chen
- Department of Pharmaceutical Analysis; China Pharmaceutical University; Nanjing Jiangsu P. R. China
| | - Min Song
- Department of Pharmaceutical Analysis; China Pharmaceutical University; Nanjing Jiangsu P. R. China
| | - Tingting Zhu
- Department of Pharmaceutical Analysis; China Pharmaceutical University; Nanjing Jiangsu P. R. China
| | - Taijun Hang
- Department of Pharmaceutical Analysis; China Pharmaceutical University; Nanjing Jiangsu P. R. China
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Epstein M, Duprez DA. Resistant Hypertension and the Pivotal Role for Mineralocorticoid Receptor Antagonists: A Clinical Update 2016. Am J Med 2016; 129:661-6. [PMID: 26899747 DOI: 10.1016/j.amjmed.2016.01.039] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2016] [Revised: 01/29/2016] [Accepted: 01/29/2016] [Indexed: 01/12/2023]
Abstract
True resistant hypertension must be distinguished from apparent resistant hypertension, of which important causes include medication nonadherence, illicit drug use, and alcoholism. Ambulatory blood pressure monitoring should be considered to rule out white coat hypertension. The pathogenesis is multifactorial, but the 2 pivotal factors include volume excess and the myriad effects of aldosterone. Aldosterone increases vascular tone because of endothelial dysfunction and enhances the pressor response to catecholamines. It also plays a crucial role in vascular remodeling of small and large arteries. Aldosterone also promotes collagen synthesis, which leads to increased arterial stiffness and elevation of blood pressure. Because aldosterone has been demonstrated to modulate baroreflex resetting, in cases of severe hypertension, there would be fewer compensatory mechanisms available to offset the blood pressure elevation.
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Affiliation(s)
- Murray Epstein
- Division of Nephrology and Hypertension, University of Miami Miller School of Medicine, Fla.
| | - Daniel A Duprez
- Cardiovascular Division, Medical School, University of Minnesota, Minneapolis
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Eguchi K, Kabutoya T, Hoshide S, Ishikawa S, Kario K. Add-On Use of Eplerenone Is Effective for Lowering Home and Ambulatory Blood Pressure in Drug-Resistant Hypertension. J Clin Hypertens (Greenwich) 2016; 18:1250-1257. [DOI: 10.1111/jch.12860] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Revised: 04/23/2016] [Accepted: 04/29/2016] [Indexed: 12/22/2022]
Affiliation(s)
- Kazuo Eguchi
- Division of Cardiovascular Medicine; Department of Medicine; Jichi Medical University School of Medicine; Tochigi Japan
| | - Tomoyuki Kabutoya
- Division of Cardiovascular Medicine; Department of Medicine; Jichi Medical University School of Medicine; Tochigi Japan
| | - Satoshi Hoshide
- Division of Cardiovascular Medicine; Department of Medicine; Jichi Medical University School of Medicine; Tochigi Japan
| | - Shizukiyo Ishikawa
- Division of Community and Family Medicine; Department of Medicine; Jichi Medical University School of Medicine; Tochigi Japan
| | - Kazuomi Kario
- Division of Cardiovascular Medicine; Department of Medicine; Jichi Medical University School of Medicine; Tochigi Japan
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Abstract
Hypertension is a common problem in the diabetic population with estimates suggesting a prevalence exceeding 60%. Comorbid hypertension and diabetes mellitus are associated with high rates of macrovascular and microvascular complications. These two pathologies share overlapping risk factors, importantly central obesity. Treatment of hypertension is unequivocally beneficial and improves all-cause mortality, cardiovascular mortality, major cardiovascular events, and microvascular outcomes including nephropathy and retinopathy. Although controversial, current guidelines recommend a target blood pressure in the diabetic population of <140/90 mmHg, which is a similar target to that proposed for individuals without diabetes. Management of blood pressure in patients with diabetes includes both lifestyle modifications and pharmacological therapies. This article reviews the evidence for management of hypertension in patients with type 2 diabetes mellitus, and provides a recommended treatment strategy based on the available data.
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Affiliation(s)
- Samuel Horr
- Cardiovascular Medicine Fellow, Cleveland Clinic Foundation, USA.
| | - Steven Nissen
- Cardiovascular Medicine Department Chair, Cleveland Clinic Foundation, USA.
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Briet M, Barhoumi T, Mian MOR, Coelho SC, Ouerd S, Rautureau Y, Coffman TM, Paradis P, Schiffrin EL. Aldosterone-Induced Vascular Remodeling and Endothelial Dysfunction Require Functional Angiotensin Type 1a Receptors. Hypertension 2016; 67:897-905. [PMID: 27045029 DOI: 10.1161/hypertensionaha.115.07074] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Accepted: 01/18/2016] [Indexed: 12/30/2022]
Abstract
We investigated the role of angiotensin type 1a receptors (AGTR1a) in vascular injury induced by aldosterone activation of mineralocorticoid receptors in Agtr1a(-/-) and wild-type (WT) mice infused with aldosterone for 14 days while receiving 1% NaCl in drinking water. Aldosterone increased systolic blood pressure (BP) by ≈30 mm Hg in WT mice and ≈50 mm Hg in Agtr1a(-/-) mice. Aldosterone induced aortic and small artery remodeling, impaired endothelium-dependent relaxation in WT mice, and enhanced fibronectin and collagen deposition and vascular inflammation. None of these vascular effects were observed in Agtr1a(-/-) mice. Aldosterone effects were prevented by the AGTR1 antagonist losartan in WT mice. In contrast to aldosterone, norepinephrine caused similar BP increase and mesenteric artery remodeling in WT and Agtr1a(-/-) mice. Agtr1a(-/-) mice infused with aldosterone did not increase sodium excretion in response to a sodium chloride challenge, suggesting that sodium retention could contribute to the exaggerated BP rise induced by aldosterone. Agtr1a(-/-) mice had decreased mesenteric artery expression of the calcium-activated potassium channel Kcnmb1, which may enhance myogenic tone and together with sodium retention, exacerbate BP responses to aldosterone/salt in Agtr1a(-/-) mice. We conclude that although aldosterone activation of mineralocorticoid receptors raises BP more in Agtr1a(-/-) mice, AGTR1a is required for mineralocorticoid receptor stimulation to induce vascular remodeling and inflammation and endothelial dysfunction.
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Affiliation(s)
- Marie Briet
- Lady Davis Institute for Medical Research, Sir Mortimer B. Davis-Jewish General Hospital, McGill University, Montreal, PQ, Canada.,Department of Medicine, Sir Mortimer B. Davis-Jewish General Hospital, McGill University, Montreal, PQ, Canada.,Division of Nephrology (T.M.C.), Department of Medicine, Duke University, Durham, NC
| | - Tlili Barhoumi
- Lady Davis Institute for Medical Research, Sir Mortimer B. Davis-Jewish General Hospital, McGill University, Montreal, PQ, Canada
| | - Muhammad Oneeb Rehman Mian
- Lady Davis Institute for Medical Research, Sir Mortimer B. Davis-Jewish General Hospital, McGill University, Montreal, PQ, Canada
| | - Suellen C Coelho
- Lady Davis Institute for Medical Research, Sir Mortimer B. Davis-Jewish General Hospital, McGill University, Montreal, PQ, Canada
| | - Sofiane Ouerd
- Lady Davis Institute for Medical Research, Sir Mortimer B. Davis-Jewish General Hospital, McGill University, Montreal, PQ, Canada
| | - Yohann Rautureau
- Lady Davis Institute for Medical Research, Sir Mortimer B. Davis-Jewish General Hospital, McGill University, Montreal, PQ, Canada
| | - Thomas M Coffman
- Division of Nephrology (T.M.C.), Department of Medicine, Duke University, Durham, NC
| | - Pierre Paradis
- Lady Davis Institute for Medical Research, Sir Mortimer B. Davis-Jewish General Hospital, McGill University, Montreal, PQ, Canada
| | - Ernesto L Schiffrin
- Lady Davis Institute for Medical Research, Sir Mortimer B. Davis-Jewish General Hospital, McGill University, Montreal, PQ, Canada.,Department of Medicine, Sir Mortimer B. Davis-Jewish General Hospital, McGill University, Montreal, PQ, Canada
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Roles of Aldosterone Receptor Antagonists in Heart Failure, Hypertension, and Chronic Kidney Disease. J Nurse Pract 2016. [DOI: 10.1016/j.nurpra.2015.10.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Dose doubling, relative potency, and dose equivalence of potassium-sparing diuretics affecting blood pressure and serum potassium. J Hypertens 2016; 34:11-9. [DOI: 10.1097/hjh.0000000000000762] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Rosa J, Widimský P, Waldauf P, Lambert L, Zelinka T, Táborský M, Branny M, Toušek P, Petrák O, Čurila K, Bednář F, Holaj R, Štrauch B, Václavík J, Nykl I, Krátká Z, Kociánová E, Jiravský O, Rappová G, Indra T, Widimský J. Role of Adding Spironolactone and Renal Denervation in True Resistant Hypertension: One-Year Outcomes of Randomized PRAGUE-15 Study. Hypertension 2015; 67:397-403. [PMID: 26693818 DOI: 10.1161/hypertensionaha.115.06526] [Citation(s) in RCA: 64] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Accepted: 11/09/2015] [Indexed: 01/28/2023]
Abstract
This randomized, multicenter study compared the relative efficacy of renal denervation (RDN) versus pharmacotherapy alone in patients with true resistant hypertension and assessed the effect of spironolactone addition. We present here the 12-month data. A total of 106 patients with true resistant hypertension were enrolled in this study: 52 patients were randomized to RDN and 54 patients to the spironolactone addition, with baseline systolic blood pressure of 159±17 and 155±17 mm Hg and average number of drugs 5.1 and 5.4, respectively. Twelve-month results are available in 101 patients. The intention-to-treat analysis found a comparable mean 24-hour systolic blood pressure decline of 6.4 mm Hg, P=0.001 in RDN versus 8.2 mm Hg, P=0.002 in the pharmacotherapy group. Per-protocol analysis revealed a significant difference of 24-hour systolic blood pressure decline between complete RDN (6.3 mm Hg, P=0.004) and the subgroup where spironolactone was added, and this continued within the 12 months (15 mm Hg, P= 0.003). Renal artery computed tomography angiograms before and after 1 year post-RDN did not reveal any relevant changes. This study shows that over a period of 12 months, RDN is safe, with no serious side effects and no major changes in the renal arteries. RDN in the settings of true resistant hypertension with confirmed compliance is not superior to intensified pharmacological treatment. Spironolactone addition (if tolerated) seems to be more effective in blood pressure reduction.
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Affiliation(s)
- Ján Rosa
- From the 3rd Department of Medicine, Center for Hypertension, General University Hospital and First Faculty of Medicine (J.R., T.Z., O.P., R.H., B.Š., Z.K., T.I., J.W. Jr), Cardiocentre, University Hospital Královské Vinohrady and Third Faculty of Medicine (J.R., P. Widimský, P. Toušek, K.Č., F.B.), Department of Anesthesiology, University Hospital Královské Vinohrady and Third Faculty of Medicine (P. Waldauf), and Department of Radiology, General University Hospital and First Faculty of Medicine (L.L.), Charles University, Prague, Czech Republic; Department of Internal Medicine I, University Hospital Olomouc, Czech Republic (M.T., J.V., E.K.); and Cardiocentre, Nemocnice Podlesí, Třinec, Czech Republic (M.B., I.N., O.J., G.R.).
| | - Petr Widimský
- From the 3rd Department of Medicine, Center for Hypertension, General University Hospital and First Faculty of Medicine (J.R., T.Z., O.P., R.H., B.Š., Z.K., T.I., J.W. Jr), Cardiocentre, University Hospital Královské Vinohrady and Third Faculty of Medicine (J.R., P. Widimský, P. Toušek, K.Č., F.B.), Department of Anesthesiology, University Hospital Královské Vinohrady and Third Faculty of Medicine (P. Waldauf), and Department of Radiology, General University Hospital and First Faculty of Medicine (L.L.), Charles University, Prague, Czech Republic; Department of Internal Medicine I, University Hospital Olomouc, Czech Republic (M.T., J.V., E.K.); and Cardiocentre, Nemocnice Podlesí, Třinec, Czech Republic (M.B., I.N., O.J., G.R.)
| | - Petr Waldauf
- From the 3rd Department of Medicine, Center for Hypertension, General University Hospital and First Faculty of Medicine (J.R., T.Z., O.P., R.H., B.Š., Z.K., T.I., J.W. Jr), Cardiocentre, University Hospital Královské Vinohrady and Third Faculty of Medicine (J.R., P. Widimský, P. Toušek, K.Č., F.B.), Department of Anesthesiology, University Hospital Královské Vinohrady and Third Faculty of Medicine (P. Waldauf), and Department of Radiology, General University Hospital and First Faculty of Medicine (L.L.), Charles University, Prague, Czech Republic; Department of Internal Medicine I, University Hospital Olomouc, Czech Republic (M.T., J.V., E.K.); and Cardiocentre, Nemocnice Podlesí, Třinec, Czech Republic (M.B., I.N., O.J., G.R.)
| | - Lukáš Lambert
- From the 3rd Department of Medicine, Center for Hypertension, General University Hospital and First Faculty of Medicine (J.R., T.Z., O.P., R.H., B.Š., Z.K., T.I., J.W. Jr), Cardiocentre, University Hospital Královské Vinohrady and Third Faculty of Medicine (J.R., P. Widimský, P. Toušek, K.Č., F.B.), Department of Anesthesiology, University Hospital Královské Vinohrady and Third Faculty of Medicine (P. Waldauf), and Department of Radiology, General University Hospital and First Faculty of Medicine (L.L.), Charles University, Prague, Czech Republic; Department of Internal Medicine I, University Hospital Olomouc, Czech Republic (M.T., J.V., E.K.); and Cardiocentre, Nemocnice Podlesí, Třinec, Czech Republic (M.B., I.N., O.J., G.R.)
| | - Tomáš Zelinka
- From the 3rd Department of Medicine, Center for Hypertension, General University Hospital and First Faculty of Medicine (J.R., T.Z., O.P., R.H., B.Š., Z.K., T.I., J.W. Jr), Cardiocentre, University Hospital Královské Vinohrady and Third Faculty of Medicine (J.R., P. Widimský, P. Toušek, K.Č., F.B.), Department of Anesthesiology, University Hospital Královské Vinohrady and Third Faculty of Medicine (P. Waldauf), and Department of Radiology, General University Hospital and First Faculty of Medicine (L.L.), Charles University, Prague, Czech Republic; Department of Internal Medicine I, University Hospital Olomouc, Czech Republic (M.T., J.V., E.K.); and Cardiocentre, Nemocnice Podlesí, Třinec, Czech Republic (M.B., I.N., O.J., G.R.)
| | - Miloš Táborský
- From the 3rd Department of Medicine, Center for Hypertension, General University Hospital and First Faculty of Medicine (J.R., T.Z., O.P., R.H., B.Š., Z.K., T.I., J.W. Jr), Cardiocentre, University Hospital Královské Vinohrady and Third Faculty of Medicine (J.R., P. Widimský, P. Toušek, K.Č., F.B.), Department of Anesthesiology, University Hospital Královské Vinohrady and Third Faculty of Medicine (P. Waldauf), and Department of Radiology, General University Hospital and First Faculty of Medicine (L.L.), Charles University, Prague, Czech Republic; Department of Internal Medicine I, University Hospital Olomouc, Czech Republic (M.T., J.V., E.K.); and Cardiocentre, Nemocnice Podlesí, Třinec, Czech Republic (M.B., I.N., O.J., G.R.)
| | - Marian Branny
- From the 3rd Department of Medicine, Center for Hypertension, General University Hospital and First Faculty of Medicine (J.R., T.Z., O.P., R.H., B.Š., Z.K., T.I., J.W. Jr), Cardiocentre, University Hospital Královské Vinohrady and Third Faculty of Medicine (J.R., P. Widimský, P. Toušek, K.Č., F.B.), Department of Anesthesiology, University Hospital Královské Vinohrady and Third Faculty of Medicine (P. Waldauf), and Department of Radiology, General University Hospital and First Faculty of Medicine (L.L.), Charles University, Prague, Czech Republic; Department of Internal Medicine I, University Hospital Olomouc, Czech Republic (M.T., J.V., E.K.); and Cardiocentre, Nemocnice Podlesí, Třinec, Czech Republic (M.B., I.N., O.J., G.R.)
| | - Petr Toušek
- From the 3rd Department of Medicine, Center for Hypertension, General University Hospital and First Faculty of Medicine (J.R., T.Z., O.P., R.H., B.Š., Z.K., T.I., J.W. Jr), Cardiocentre, University Hospital Královské Vinohrady and Third Faculty of Medicine (J.R., P. Widimský, P. Toušek, K.Č., F.B.), Department of Anesthesiology, University Hospital Královské Vinohrady and Third Faculty of Medicine (P. Waldauf), and Department of Radiology, General University Hospital and First Faculty of Medicine (L.L.), Charles University, Prague, Czech Republic; Department of Internal Medicine I, University Hospital Olomouc, Czech Republic (M.T., J.V., E.K.); and Cardiocentre, Nemocnice Podlesí, Třinec, Czech Republic (M.B., I.N., O.J., G.R.)
| | - Ondřej Petrák
- From the 3rd Department of Medicine, Center for Hypertension, General University Hospital and First Faculty of Medicine (J.R., T.Z., O.P., R.H., B.Š., Z.K., T.I., J.W. Jr), Cardiocentre, University Hospital Královské Vinohrady and Third Faculty of Medicine (J.R., P. Widimský, P. Toušek, K.Č., F.B.), Department of Anesthesiology, University Hospital Královské Vinohrady and Third Faculty of Medicine (P. Waldauf), and Department of Radiology, General University Hospital and First Faculty of Medicine (L.L.), Charles University, Prague, Czech Republic; Department of Internal Medicine I, University Hospital Olomouc, Czech Republic (M.T., J.V., E.K.); and Cardiocentre, Nemocnice Podlesí, Třinec, Czech Republic (M.B., I.N., O.J., G.R.)
| | - Karol Čurila
- From the 3rd Department of Medicine, Center for Hypertension, General University Hospital and First Faculty of Medicine (J.R., T.Z., O.P., R.H., B.Š., Z.K., T.I., J.W. Jr), Cardiocentre, University Hospital Královské Vinohrady and Third Faculty of Medicine (J.R., P. Widimský, P. Toušek, K.Č., F.B.), Department of Anesthesiology, University Hospital Královské Vinohrady and Third Faculty of Medicine (P. Waldauf), and Department of Radiology, General University Hospital and First Faculty of Medicine (L.L.), Charles University, Prague, Czech Republic; Department of Internal Medicine I, University Hospital Olomouc, Czech Republic (M.T., J.V., E.K.); and Cardiocentre, Nemocnice Podlesí, Třinec, Czech Republic (M.B., I.N., O.J., G.R.)
| | - František Bednář
- From the 3rd Department of Medicine, Center for Hypertension, General University Hospital and First Faculty of Medicine (J.R., T.Z., O.P., R.H., B.Š., Z.K., T.I., J.W. Jr), Cardiocentre, University Hospital Královské Vinohrady and Third Faculty of Medicine (J.R., P. Widimský, P. Toušek, K.Č., F.B.), Department of Anesthesiology, University Hospital Královské Vinohrady and Third Faculty of Medicine (P. Waldauf), and Department of Radiology, General University Hospital and First Faculty of Medicine (L.L.), Charles University, Prague, Czech Republic; Department of Internal Medicine I, University Hospital Olomouc, Czech Republic (M.T., J.V., E.K.); and Cardiocentre, Nemocnice Podlesí, Třinec, Czech Republic (M.B., I.N., O.J., G.R.)
| | - Robert Holaj
- From the 3rd Department of Medicine, Center for Hypertension, General University Hospital and First Faculty of Medicine (J.R., T.Z., O.P., R.H., B.Š., Z.K., T.I., J.W. Jr), Cardiocentre, University Hospital Královské Vinohrady and Third Faculty of Medicine (J.R., P. Widimský, P. Toušek, K.Č., F.B.), Department of Anesthesiology, University Hospital Královské Vinohrady and Third Faculty of Medicine (P. Waldauf), and Department of Radiology, General University Hospital and First Faculty of Medicine (L.L.), Charles University, Prague, Czech Republic; Department of Internal Medicine I, University Hospital Olomouc, Czech Republic (M.T., J.V., E.K.); and Cardiocentre, Nemocnice Podlesí, Třinec, Czech Republic (M.B., I.N., O.J., G.R.)
| | - Branislav Štrauch
- From the 3rd Department of Medicine, Center for Hypertension, General University Hospital and First Faculty of Medicine (J.R., T.Z., O.P., R.H., B.Š., Z.K., T.I., J.W. Jr), Cardiocentre, University Hospital Královské Vinohrady and Third Faculty of Medicine (J.R., P. Widimský, P. Toušek, K.Č., F.B.), Department of Anesthesiology, University Hospital Královské Vinohrady and Third Faculty of Medicine (P. Waldauf), and Department of Radiology, General University Hospital and First Faculty of Medicine (L.L.), Charles University, Prague, Czech Republic; Department of Internal Medicine I, University Hospital Olomouc, Czech Republic (M.T., J.V., E.K.); and Cardiocentre, Nemocnice Podlesí, Třinec, Czech Republic (M.B., I.N., O.J., G.R.)
| | - Jan Václavík
- From the 3rd Department of Medicine, Center for Hypertension, General University Hospital and First Faculty of Medicine (J.R., T.Z., O.P., R.H., B.Š., Z.K., T.I., J.W. Jr), Cardiocentre, University Hospital Královské Vinohrady and Third Faculty of Medicine (J.R., P. Widimský, P. Toušek, K.Č., F.B.), Department of Anesthesiology, University Hospital Královské Vinohrady and Third Faculty of Medicine (P. Waldauf), and Department of Radiology, General University Hospital and First Faculty of Medicine (L.L.), Charles University, Prague, Czech Republic; Department of Internal Medicine I, University Hospital Olomouc, Czech Republic (M.T., J.V., E.K.); and Cardiocentre, Nemocnice Podlesí, Třinec, Czech Republic (M.B., I.N., O.J., G.R.)
| | - Igor Nykl
- From the 3rd Department of Medicine, Center for Hypertension, General University Hospital and First Faculty of Medicine (J.R., T.Z., O.P., R.H., B.Š., Z.K., T.I., J.W. Jr), Cardiocentre, University Hospital Královské Vinohrady and Third Faculty of Medicine (J.R., P. Widimský, P. Toušek, K.Č., F.B.), Department of Anesthesiology, University Hospital Královské Vinohrady and Third Faculty of Medicine (P. Waldauf), and Department of Radiology, General University Hospital and First Faculty of Medicine (L.L.), Charles University, Prague, Czech Republic; Department of Internal Medicine I, University Hospital Olomouc, Czech Republic (M.T., J.V., E.K.); and Cardiocentre, Nemocnice Podlesí, Třinec, Czech Republic (M.B., I.N., O.J., G.R.)
| | - Zuzana Krátká
- From the 3rd Department of Medicine, Center for Hypertension, General University Hospital and First Faculty of Medicine (J.R., T.Z., O.P., R.H., B.Š., Z.K., T.I., J.W. Jr), Cardiocentre, University Hospital Královské Vinohrady and Third Faculty of Medicine (J.R., P. Widimský, P. Toušek, K.Č., F.B.), Department of Anesthesiology, University Hospital Královské Vinohrady and Third Faculty of Medicine (P. Waldauf), and Department of Radiology, General University Hospital and First Faculty of Medicine (L.L.), Charles University, Prague, Czech Republic; Department of Internal Medicine I, University Hospital Olomouc, Czech Republic (M.T., J.V., E.K.); and Cardiocentre, Nemocnice Podlesí, Třinec, Czech Republic (M.B., I.N., O.J., G.R.)
| | - Eva Kociánová
- From the 3rd Department of Medicine, Center for Hypertension, General University Hospital and First Faculty of Medicine (J.R., T.Z., O.P., R.H., B.Š., Z.K., T.I., J.W. Jr), Cardiocentre, University Hospital Královské Vinohrady and Third Faculty of Medicine (J.R., P. Widimský, P. Toušek, K.Č., F.B.), Department of Anesthesiology, University Hospital Královské Vinohrady and Third Faculty of Medicine (P. Waldauf), and Department of Radiology, General University Hospital and First Faculty of Medicine (L.L.), Charles University, Prague, Czech Republic; Department of Internal Medicine I, University Hospital Olomouc, Czech Republic (M.T., J.V., E.K.); and Cardiocentre, Nemocnice Podlesí, Třinec, Czech Republic (M.B., I.N., O.J., G.R.)
| | - Otakar Jiravský
- From the 3rd Department of Medicine, Center for Hypertension, General University Hospital and First Faculty of Medicine (J.R., T.Z., O.P., R.H., B.Š., Z.K., T.I., J.W. Jr), Cardiocentre, University Hospital Královské Vinohrady and Third Faculty of Medicine (J.R., P. Widimský, P. Toušek, K.Č., F.B.), Department of Anesthesiology, University Hospital Královské Vinohrady and Third Faculty of Medicine (P. Waldauf), and Department of Radiology, General University Hospital and First Faculty of Medicine (L.L.), Charles University, Prague, Czech Republic; Department of Internal Medicine I, University Hospital Olomouc, Czech Republic (M.T., J.V., E.K.); and Cardiocentre, Nemocnice Podlesí, Třinec, Czech Republic (M.B., I.N., O.J., G.R.)
| | - Gabriela Rappová
- From the 3rd Department of Medicine, Center for Hypertension, General University Hospital and First Faculty of Medicine (J.R., T.Z., O.P., R.H., B.Š., Z.K., T.I., J.W. Jr), Cardiocentre, University Hospital Královské Vinohrady and Third Faculty of Medicine (J.R., P. Widimský, P. Toušek, K.Č., F.B.), Department of Anesthesiology, University Hospital Královské Vinohrady and Third Faculty of Medicine (P. Waldauf), and Department of Radiology, General University Hospital and First Faculty of Medicine (L.L.), Charles University, Prague, Czech Republic; Department of Internal Medicine I, University Hospital Olomouc, Czech Republic (M.T., J.V., E.K.); and Cardiocentre, Nemocnice Podlesí, Třinec, Czech Republic (M.B., I.N., O.J., G.R.)
| | - Tomáš Indra
- From the 3rd Department of Medicine, Center for Hypertension, General University Hospital and First Faculty of Medicine (J.R., T.Z., O.P., R.H., B.Š., Z.K., T.I., J.W. Jr), Cardiocentre, University Hospital Královské Vinohrady and Third Faculty of Medicine (J.R., P. Widimský, P. Toušek, K.Č., F.B.), Department of Anesthesiology, University Hospital Královské Vinohrady and Third Faculty of Medicine (P. Waldauf), and Department of Radiology, General University Hospital and First Faculty of Medicine (L.L.), Charles University, Prague, Czech Republic; Department of Internal Medicine I, University Hospital Olomouc, Czech Republic (M.T., J.V., E.K.); and Cardiocentre, Nemocnice Podlesí, Třinec, Czech Republic (M.B., I.N., O.J., G.R.)
| | - Jiří Widimský
- From the 3rd Department of Medicine, Center for Hypertension, General University Hospital and First Faculty of Medicine (J.R., T.Z., O.P., R.H., B.Š., Z.K., T.I., J.W. Jr), Cardiocentre, University Hospital Královské Vinohrady and Third Faculty of Medicine (J.R., P. Widimský, P. Toušek, K.Č., F.B.), Department of Anesthesiology, University Hospital Královské Vinohrady and Third Faculty of Medicine (P. Waldauf), and Department of Radiology, General University Hospital and First Faculty of Medicine (L.L.), Charles University, Prague, Czech Republic; Department of Internal Medicine I, University Hospital Olomouc, Czech Republic (M.T., J.V., E.K.); and Cardiocentre, Nemocnice Podlesí, Třinec, Czech Republic (M.B., I.N., O.J., G.R.)
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Arai K, Tsuruoka H, Homma T. CS-3150, a novel non-steroidal mineralocorticoid receptor antagonist, prevents hypertension and cardiorenal injury in Dahl salt-sensitive hypertensive rats. Eur J Pharmacol 2015; 769:266-73. [PMID: 26607463 DOI: 10.1016/j.ejphar.2015.11.028] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Revised: 11/13/2015] [Accepted: 11/18/2015] [Indexed: 11/19/2022]
Abstract
The present study was designed to evaluate the antihypertensive and cardiorenal protective effects of CS-3150, a novel non-steroidal mineralocorticoid receptor antagonist, in Dahl salt-sensitive hypertensive rats (DS rats), and to compare the effects with spironolactone and eplerenone. DS rats were fed a control diet (0.3% NaCl) or high salt diet (8% NaCl) from 7 weeks of age. CS-3150 (0.25-2mg/kg), spironolactone (10-100mg/kg) or eplerenone (10-100mg/kg) were orally administered once a day to DS rats fed a high salt diet for 7 weeks. The high salt diet significantly increased systolic blood pressure, which was prevented by treatment with CS-3150 in a dose-dependent manner with no hyperkalemia (>5.5mEq/L). The antihypertensive effect of CS-3150 (0.5mg/kg) was equivalent to that of spironolactone (100mg/kg) and eplerenone (100mg/kg). CS-3150 also suppressed proteinuria and renal hypertrophy induced by the high salt diet. Histopathological examination of kidneys showed that CS-3150 markedly ameliorated glomerulosclerosis, tubular injury and tubulointerstitial fibrosis. In addition, CS-3150 inhibited left ventricular hypertrophy and elevation of plasma brain natriuretic peptide level. In contrast, the cardiorenal protective effects of spironolactone or eplerenone were partial, and the dose-dependency was not clear, especially in eplerenone-treated rats. These results indicate that chronic treatment with CS-3150 exerts antihypertensive and cardiorenal protective effects in a DS hypertensive rat model, and its potency is much superior to that of spironolactone or eplerenone. Thus, CS-3150 could be a promising agent for the treatment of hypertension and cardiorenal disorders.
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Affiliation(s)
- Kiyoshi Arai
- Cardiovascular-Metabolics Research Laboratories, Daiichi Sankyo Co., Ltd., 1-2-58 Hiromachi, Shinagawa-ku, Tokyo 140-8710, Japan.
| | - Hiroyuki Tsuruoka
- Medicinal Chemistry Research Laboratories, Daiichi Sankyo Co., Ltd., 1-2-58 Hiromachi, Shinagawa-ku, Tokyo 140-8710, Japan
| | - Tsuyoshi Homma
- Cardiovascular-Metabolics Research Laboratories, Daiichi Sankyo Co., Ltd., 1-2-58 Hiromachi, Shinagawa-ku, Tokyo 140-8710, Japan
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Dahal K, Kunwar S, Rijal J, Alqatahni F, Panta R, Ishak N, Russell RP. The Effects of Aldosterone Antagonists in Patients With Resistant Hypertension: A Meta-Analysis of Randomized and Nonrandomized Studies. Am J Hypertens 2015; 28:1376-85. [PMID: 25801902 DOI: 10.1093/ajh/hpv031] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2015] [Accepted: 02/06/2015] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND A few studies have shown aldosterone antagonists (AA) to be effective therapy in patients with resistant hypertension (RH). We performed a meta-analysis of randomized and nonrandomized studies of AA in patients with RH. METHODS We searched PUBMED, EMBASE, and CENTRAL for studies on the use of AA in patients with RH. Meta-analysis was performed using random-effects model. The change in office and ambulatory blood pressures (BP), effects on biochemical profile, change in the number of antihypertensive agents, and adverse events were main outcomes. RESULTS We included 15 studies (3 randomized controlled trials, 1 nonrandomized comparative study, and 11 single-arm studies) with 1,204 total patients in the meta-analysis. In comparative studies, AA reduced systolic BP (SBP) by 24.26 mm Hg (95% CI: 8.65-39.87, P = 0.002) and diastolic BP (DBP) by 7.79 mm Hg (3.79-11.79, P = 0.0001). Similarly, AA reduced SBP by 22.74 mm Hg (18.21-27.27, P < 0.00001) and DBP by 10.49 mm Hg (8.85-12.13, P < 0.00001) in single-arm studies. AA resulted in significant change in serum electrolytes in single-arm studies but not in comparative studies. Significantly more adverse events were noted in single-arm studies but not in comparative studies. CONCLUSIONS On the basis of the current meta-analysis, we conclude that AA is safe and effective therapy in patients with RH.
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Affiliation(s)
- Khagendra Dahal
- Department of Medicine, LRGHealthcare, Laconia, New Hampshire, USA;
| | - Sumit Kunwar
- Department of Medicine, LRGHealthcare, Laconia, New Hampshire, USA
| | - Jharendra Rijal
- Department of Medicine, Miriam Hospital, Brown University, Providence, Rhode Island, USA
| | - Fahad Alqatahni
- Department of Medicine, West Virginia School of Medicine, Morgantown, West Virginia, USA
| | - Raju Panta
- Department of Medicine, LRGHealthcare, Laconia, New Hampshire, USA
| | - Noshi Ishak
- Division of Nephrology, LRGHealthcare, Laconia, New Hampshire, USA
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Huby AC, Belin De Chantemèle EJ. Reviving the use of aldosterone inhibitors in treating hypertension in obesity. Am J Physiol Regul Integr Comp Physiol 2015; 309:R1065-7. [PMID: 26157057 DOI: 10.1152/ajpregu.00133.2015] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Accepted: 07/08/2015] [Indexed: 11/22/2022]
Abstract
Obesity is a multifactorial disease associated with hypertension. In the obese population, the incidence of hypertension is high and resistant hypertension is commonly observed. Mechanisms to explain the resistance to current antihypertensive treatments are still poorly understood. Emerging knowledge of the role of aldosterone in controlling blood pressure in obesity may have therapeutic benefit. Mineralocorticoid receptor (MR) inhibitors are currently used as the fourth line of treatment. Clinical studies summarized in this short review suggest that MR antagonists have a strong efficacy in decreasing blood pressure in the hypertensive obese population and could be used as a primary antihypertensive in obesity.
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Affiliation(s)
- Anne-Cecile Huby
- Physiology Department, Medical College of Georgia, Georgia Regent University, Augusta, Georgia
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Mann SJ, Ernst ME. Personalizing the diuretic treatment of hypertension: the need for more clinical and research attention. Curr Hypertens Rep 2015; 17:542. [PMID: 25794956 DOI: 10.1007/s11906-015-0542-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Neither randomized controlled trials nor efforts to identify genetic markers have been helpful with regard to the goal of individualizing diuretic therapy in the treatment of hypertension, a goal that receives little clinical or research attention. This review will examine, and bring attention to, the considerable yet overlooked information relevant to individualizing diuretic therapy. It will bring attention to clinical, biochemical, and pharmacological clues that can be helpful in identifying who is likely to respond to a diuretic, who needs a stronger diuretic regimen, which diuretic to prescribe, and how to minimize adverse effects. New directions for clinical research aimed at individualizing use in hypertension will be explored. Research and clinical attention to the goal of individualizing diuretic treatment in hypertension need to be renewed, to help us achieve greater hypertension control with fewer adverse effects and lower costs.
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Affiliation(s)
- Samuel J Mann
- Division of Nephrology and Hypertension, NY Presbyterian Hospital-Weill Cornell Medical College, 424 East 70th St, New York, NY, 10021, USA,
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Václavík J, Sedlák R, Jarkovský J, Kociánová E, Táborský M. Effect of spironolactone in resistant arterial hypertension: a randomized, double-blind, placebo-controlled trial (ASPIRANT-EXT). Medicine (Baltimore) 2014; 93:e162. [PMID: 25501057 PMCID: PMC4602792 DOI: 10.1097/md.0000000000000162] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
This study was designed to assess the effect of the addition of low-dose spironolactone on blood pressure (BP) in patients with resistant arterial hypertension. Patients with office systolic blood pressure (SBP) >140 mm Hg or diastolic blood pressure (DBP) >90 mm Hg despite treatment with at least 3 antihypertensive drugs, including a diuretic, were enrolled in this double-blind, placebo-controlled, multicentre trial. One hundred sixty-one patients in outpatient internal medicine departments of 6 hospitals in the Czech Republic were randomly assigned to receive 25 mg of spironolactone (N = 81) or a placebo (N = 80) once daily as an add-on to their antihypertensive medication, using simple randomization. This study was registered with ClinicalTrials.gov, number NCT00524615. A nalyses were done with 150 patients who finished the follow-up (74 in the spironolactone and 76 in the placebo group). At 8 weeks, BP values were decreased more by spironolactone, with differences in mean fall of SBP of -9.8, -13.0, -10.5, and -9.9 mm Hg (P < 0.001 for all) in daytime, nighttime, and 24-hour ambulatory BP monitoring and in the office. The respective DBP differences were -3.2, -6.4, -3.5, and -3.0 mm Hg (P = 0.013, P < 0.001, P = 0.005, and P = 0.003). Adverse events in both groups were comparable. The office SBP goal <14 mm Hg at 8 weeks was reached in 73% of patients using spironolactone and 41% using placebo (P = 0.001). Spironolactone in patients with resistant arterial hypertension leads to a significant decrease of both SBP and DBP and markedly improves BP control.
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Affiliation(s)
- Jan Václavík
- From the Department of Internal Medicine I-Cardiology, Faculty of Medicine and Dentistry, University Hospital Olomouc and Palacký University, Olomouc (JV, EK, MT); Department of Internal Medicine, Prostějov Hospital, Mathonova, Prostějov (RS); and Institute of Biostatistics and Analyses at the Faculty of Medicine and the Faculty of Science of the Masaryk University, Kamenice, Brno, Czech Republic (JJ)
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Ferreira JP, Santos M, Almeida S, Marques I, Bettencourt P, Carvalho H. High-dose spironolactone changes renin and aldosterone levels in acutely decompensated heart failure. COR ET VASA 2014. [DOI: 10.1016/j.crvasa.2014.06.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Rosa J, Widimský P, Toušek P, Petrák O, Čurila K, Waldauf P, Bednář F, Zelinka T, Holaj R, Štrauch B, Šomlóová Z, Táborský M, Václavík J, Kociánová E, Branny M, Nykl I, Jiravský O, Widimský J. Randomized comparison of renal denervation versus intensified pharmacotherapy including spironolactone in true-resistant hypertension: six-month results from the Prague-15 study. Hypertension 2014; 65:407-13. [PMID: 25421981 DOI: 10.1161/hypertensionaha.114.04019] [Citation(s) in RCA: 156] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
This prospective, randomized, open-label multicenter trial evaluated the efficacy of catheter-based renal denervation (Symplicity, Medtronic) versus intensified pharmacological treatment including spironolactone (if tolerated) in patients with true-resistant hypertension. This was confirmed by 24-hour ambulatory blood pressure monitoring after excluding secondary hypertension and confirmation of adherence to therapy by measurement of plasma antihypertensive drug levels before enrollment. One-hundred six patients were randomized to renal denervation (n=52), or intensified pharmacological treatment (n=54) with baseline systolic blood pressure of 159±17 and 155±17 mm Hg and average number of drugs 5.1 and 5.4, respectively. A significant reduction in 24-hour average systolic blood pressure after 6 months (-8.6 [95% cofidence interval: -11.8, -5.3] mm Hg; P<0.001 in renal denervation versus -8.1 [95% cofidence interval: -12.7, -3.4] mm Hg; P=0.001 in pharmacological group) was observed, which was comparable in both groups. Similarly, a significant reduction in systolic office blood pressure (-12.4 [95% cofidence interval: -17.0, -7.8] mm Hg; P<0.001 in renal denervation versus -14.3 [95% cofidence interval: -19.7, -8.9] mm Hg; P<0.001 in pharmacological group) was present. Between-group differences in change were not significant. The average number of antihypertensive drugs used after 6 months was significantly higher in the pharmacological group (+0.3 drugs; P<0.001). A significant increase in serum creatinine and a parallel decrease of creatinine clearance were observed in the pharmacological group; between-group difference were borderline significant. The 6-month results of this study confirmed the safety of renal denervation. In conclusion, renal denervation achieved reduction of blood pressure comparable with intensified pharmacotherapy.
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Affiliation(s)
- Ján Rosa
- From the 3rd Department of Medicine, Centre for Hypertension, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic (J.R., O.P., T.Z., R.H., B.Š., Z.Š., J.W.); Cardiocentre, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic (J.R., P.W., P.T., K.Č., F.B.); Department of Anesthesiology, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic (P.W.); Department of Internal Medicine I, University Hospital Olomouc, Czech Republic (M.T., J.V., E.K.); and Cardiocentre, Nemocnice Podlesí, Třinec, Czech Republic (M.B., I.N., O.J.).
| | - Petr Widimský
- From the 3rd Department of Medicine, Centre for Hypertension, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic (J.R., O.P., T.Z., R.H., B.Š., Z.Š., J.W.); Cardiocentre, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic (J.R., P.W., P.T., K.Č., F.B.); Department of Anesthesiology, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic (P.W.); Department of Internal Medicine I, University Hospital Olomouc, Czech Republic (M.T., J.V., E.K.); and Cardiocentre, Nemocnice Podlesí, Třinec, Czech Republic (M.B., I.N., O.J.)
| | - Petr Toušek
- From the 3rd Department of Medicine, Centre for Hypertension, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic (J.R., O.P., T.Z., R.H., B.Š., Z.Š., J.W.); Cardiocentre, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic (J.R., P.W., P.T., K.Č., F.B.); Department of Anesthesiology, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic (P.W.); Department of Internal Medicine I, University Hospital Olomouc, Czech Republic (M.T., J.V., E.K.); and Cardiocentre, Nemocnice Podlesí, Třinec, Czech Republic (M.B., I.N., O.J.)
| | - Ondřej Petrák
- From the 3rd Department of Medicine, Centre for Hypertension, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic (J.R., O.P., T.Z., R.H., B.Š., Z.Š., J.W.); Cardiocentre, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic (J.R., P.W., P.T., K.Č., F.B.); Department of Anesthesiology, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic (P.W.); Department of Internal Medicine I, University Hospital Olomouc, Czech Republic (M.T., J.V., E.K.); and Cardiocentre, Nemocnice Podlesí, Třinec, Czech Republic (M.B., I.N., O.J.)
| | - Karol Čurila
- From the 3rd Department of Medicine, Centre for Hypertension, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic (J.R., O.P., T.Z., R.H., B.Š., Z.Š., J.W.); Cardiocentre, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic (J.R., P.W., P.T., K.Č., F.B.); Department of Anesthesiology, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic (P.W.); Department of Internal Medicine I, University Hospital Olomouc, Czech Republic (M.T., J.V., E.K.); and Cardiocentre, Nemocnice Podlesí, Třinec, Czech Republic (M.B., I.N., O.J.)
| | - Petr Waldauf
- From the 3rd Department of Medicine, Centre for Hypertension, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic (J.R., O.P., T.Z., R.H., B.Š., Z.Š., J.W.); Cardiocentre, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic (J.R., P.W., P.T., K.Č., F.B.); Department of Anesthesiology, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic (P.W.); Department of Internal Medicine I, University Hospital Olomouc, Czech Republic (M.T., J.V., E.K.); and Cardiocentre, Nemocnice Podlesí, Třinec, Czech Republic (M.B., I.N., O.J.)
| | - František Bednář
- From the 3rd Department of Medicine, Centre for Hypertension, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic (J.R., O.P., T.Z., R.H., B.Š., Z.Š., J.W.); Cardiocentre, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic (J.R., P.W., P.T., K.Č., F.B.); Department of Anesthesiology, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic (P.W.); Department of Internal Medicine I, University Hospital Olomouc, Czech Republic (M.T., J.V., E.K.); and Cardiocentre, Nemocnice Podlesí, Třinec, Czech Republic (M.B., I.N., O.J.)
| | - Tomáš Zelinka
- From the 3rd Department of Medicine, Centre for Hypertension, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic (J.R., O.P., T.Z., R.H., B.Š., Z.Š., J.W.); Cardiocentre, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic (J.R., P.W., P.T., K.Č., F.B.); Department of Anesthesiology, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic (P.W.); Department of Internal Medicine I, University Hospital Olomouc, Czech Republic (M.T., J.V., E.K.); and Cardiocentre, Nemocnice Podlesí, Třinec, Czech Republic (M.B., I.N., O.J.)
| | - Robert Holaj
- From the 3rd Department of Medicine, Centre for Hypertension, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic (J.R., O.P., T.Z., R.H., B.Š., Z.Š., J.W.); Cardiocentre, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic (J.R., P.W., P.T., K.Č., F.B.); Department of Anesthesiology, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic (P.W.); Department of Internal Medicine I, University Hospital Olomouc, Czech Republic (M.T., J.V., E.K.); and Cardiocentre, Nemocnice Podlesí, Třinec, Czech Republic (M.B., I.N., O.J.)
| | - Branislav Štrauch
- From the 3rd Department of Medicine, Centre for Hypertension, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic (J.R., O.P., T.Z., R.H., B.Š., Z.Š., J.W.); Cardiocentre, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic (J.R., P.W., P.T., K.Č., F.B.); Department of Anesthesiology, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic (P.W.); Department of Internal Medicine I, University Hospital Olomouc, Czech Republic (M.T., J.V., E.K.); and Cardiocentre, Nemocnice Podlesí, Třinec, Czech Republic (M.B., I.N., O.J.)
| | - Zuzana Šomlóová
- From the 3rd Department of Medicine, Centre for Hypertension, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic (J.R., O.P., T.Z., R.H., B.Š., Z.Š., J.W.); Cardiocentre, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic (J.R., P.W., P.T., K.Č., F.B.); Department of Anesthesiology, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic (P.W.); Department of Internal Medicine I, University Hospital Olomouc, Czech Republic (M.T., J.V., E.K.); and Cardiocentre, Nemocnice Podlesí, Třinec, Czech Republic (M.B., I.N., O.J.)
| | - Miloš Táborský
- From the 3rd Department of Medicine, Centre for Hypertension, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic (J.R., O.P., T.Z., R.H., B.Š., Z.Š., J.W.); Cardiocentre, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic (J.R., P.W., P.T., K.Č., F.B.); Department of Anesthesiology, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic (P.W.); Department of Internal Medicine I, University Hospital Olomouc, Czech Republic (M.T., J.V., E.K.); and Cardiocentre, Nemocnice Podlesí, Třinec, Czech Republic (M.B., I.N., O.J.)
| | - Jan Václavík
- From the 3rd Department of Medicine, Centre for Hypertension, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic (J.R., O.P., T.Z., R.H., B.Š., Z.Š., J.W.); Cardiocentre, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic (J.R., P.W., P.T., K.Č., F.B.); Department of Anesthesiology, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic (P.W.); Department of Internal Medicine I, University Hospital Olomouc, Czech Republic (M.T., J.V., E.K.); and Cardiocentre, Nemocnice Podlesí, Třinec, Czech Republic (M.B., I.N., O.J.)
| | - Eva Kociánová
- From the 3rd Department of Medicine, Centre for Hypertension, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic (J.R., O.P., T.Z., R.H., B.Š., Z.Š., J.W.); Cardiocentre, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic (J.R., P.W., P.T., K.Č., F.B.); Department of Anesthesiology, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic (P.W.); Department of Internal Medicine I, University Hospital Olomouc, Czech Republic (M.T., J.V., E.K.); and Cardiocentre, Nemocnice Podlesí, Třinec, Czech Republic (M.B., I.N., O.J.)
| | - Marian Branny
- From the 3rd Department of Medicine, Centre for Hypertension, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic (J.R., O.P., T.Z., R.H., B.Š., Z.Š., J.W.); Cardiocentre, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic (J.R., P.W., P.T., K.Č., F.B.); Department of Anesthesiology, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic (P.W.); Department of Internal Medicine I, University Hospital Olomouc, Czech Republic (M.T., J.V., E.K.); and Cardiocentre, Nemocnice Podlesí, Třinec, Czech Republic (M.B., I.N., O.J.)
| | - Igor Nykl
- From the 3rd Department of Medicine, Centre for Hypertension, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic (J.R., O.P., T.Z., R.H., B.Š., Z.Š., J.W.); Cardiocentre, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic (J.R., P.W., P.T., K.Č., F.B.); Department of Anesthesiology, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic (P.W.); Department of Internal Medicine I, University Hospital Olomouc, Czech Republic (M.T., J.V., E.K.); and Cardiocentre, Nemocnice Podlesí, Třinec, Czech Republic (M.B., I.N., O.J.)
| | - Otakar Jiravský
- From the 3rd Department of Medicine, Centre for Hypertension, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic (J.R., O.P., T.Z., R.H., B.Š., Z.Š., J.W.); Cardiocentre, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic (J.R., P.W., P.T., K.Č., F.B.); Department of Anesthesiology, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic (P.W.); Department of Internal Medicine I, University Hospital Olomouc, Czech Republic (M.T., J.V., E.K.); and Cardiocentre, Nemocnice Podlesí, Třinec, Czech Republic (M.B., I.N., O.J.)
| | - Jiří Widimský
- From the 3rd Department of Medicine, Centre for Hypertension, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic (J.R., O.P., T.Z., R.H., B.Š., Z.Š., J.W.); Cardiocentre, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic (J.R., P.W., P.T., K.Č., F.B.); Department of Anesthesiology, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic (P.W.); Department of Internal Medicine I, University Hospital Olomouc, Czech Republic (M.T., J.V., E.K.); and Cardiocentre, Nemocnice Podlesí, Třinec, Czech Republic (M.B., I.N., O.J.)
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Doumas M, Tsioufis C, Faselis C, Lazaridis A, Grassos H, Papademetriou V. Non-interventional management of resistant hypertension. World J Cardiol 2014; 6:1080-1090. [PMID: 25349652 PMCID: PMC4209434 DOI: 10.4330/wjc.v6.i10.1080] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2013] [Revised: 04/12/2014] [Accepted: 08/31/2014] [Indexed: 02/06/2023] Open
Abstract
Hypertension is one of the most popular fields of research in modern medicine due to its high prevalence and its major impact on cardiovascular risk and consequently on global health. Indeed, about one third of individuals worldwide has hypertension and is under increased long-term risk of myocardial infarction, stroke or cardiovascular death. On the other hand, resistant hypertension, the “uncontrollable” part of arterial hypertension despite appropriate therapy, comprises a much greater menace since long-standing, high levels of blood pressure along with concomitant debilitating entities such as chronic kidney disease and diabetes mellitus create a prominent high cardiovascular risk milieu. However, despite the alarming consequences, resistant hypertension and its effective management still have not received proper scientific attention. Aspects like the exact prevalence and prognosis are yet to be clarified. In an effort to manage patients with resistant hypertension appropriately, clinical doctors are still racking their brains in order to find the best therapeutic algorithm and surmount the substantial difficulties in controlling this clinical entity. This review aims to shed light on the effective management of resistant hypertension and provide practical recommendations for clinicians dealing with such patients.
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Pelliccia F, Rosano G, Patti G, Volterrani M, Greco C, Gaudio C. Efficacy and safety of mineralocorticoid receptors in mild to moderate arterial hypertension. Int J Cardiol 2014; 200:8-11. [PMID: 25466561 DOI: 10.1016/j.ijcard.2014.10.150] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2014] [Accepted: 10/20/2014] [Indexed: 11/16/2022]
Abstract
The mineralocorticoid receptor antagonists have been shown to have favourable safety and cost-effectiveness profiles across a broad range of clinical indications, including heart failure, primary aldosteronism and resistant hypertension. The clinical biology of the first aldosterone blocker, i.e. spironolactone, and its effects in several organ systems has been well elucidated from multiple studies. The range of adverse effects experienced with spironolactone has led to its modification and the consequent synthesis of eplerenone. Scientific evidence accumulated so far supports the role of eplerenone as first-choice drug in heart failure, with lower prevalence rates of sex-related adverse effects associated with eplerenone as compared to spironolactone. In Europe, eplerenone is currently marketed only in some countries and only with the indication of heart failure, whereas its clinical efficacy and safety in mild to moderate hypertension is said to be uncertain. A review of available scientific evidence, however, discloses that 11 randomized clinical trials assessing eplerenone in >3500 hypertensives have been reported so far. The results of these studies clearly show that eplerenone is an effective antihypertensive agent when used alone or in combination with other medications. In doses ranging from 25 to 100mg daily, eplerenone monotherapy results in a dose-dependent reduction in clinic blood pressure. As compared to placebo, eplerenone reduces significantly blood pressure from baseline. In general, 100mg daily eplerenone has a blood pressure lowering that is 50 to 75% that of spironolactone. Eplerenone results in a greater reduction in blood pressure as compared with losartan, and comparison between eplerenone and amlodipine shows that both treatments decrease systolic blood pressure to a similar extent but eplerenone is better tolerated. In conclusion, there is now evidence that eplerenone can play an important role in the treatment of mild to moderate arterial hypertension and therefore scientific experts and regulatory authorities should support its wider use in clinical practice worldwide.
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Affiliation(s)
| | - Giuseppe Rosano
- IRCCS San Raffaele Pisana, Rome, Italy; Cardiovascular and Cell Sciences Research Institute, St. George's, University of London, London, UK
| | | | | | - Cesare Greco
- Department 'Attilio Reale', Sapienza University, Rome, Italy
| | - Carlo Gaudio
- Department 'Attilio Reale', Sapienza University, Rome, Italy; Eleonora Lorillard Spencer Cenci Foundation, Rome, Italy
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Medication adherence and resistant hypertension. J Hum Hypertens 2014; 29:213-8. [PMID: 25209307 DOI: 10.1038/jhh.2014.73] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2014] [Revised: 06/27/2014] [Accepted: 07/14/2014] [Indexed: 01/06/2023]
Abstract
Non-adherence has been a major concern in the treatment of hypertension and is particularly important in understanding and intervening in patients who appear to have resistant hypertension. Relatively few studies have examined the role of non-adherence in resistant hypertension. This review will address issues related to measurement of adherence, adherence interventions and rates of non-adherence in general hypertensive populations and in patients classified as having resistant hypertension.
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Lother A, Moser M, Bode C, Feldman RD, Hein L. Mineralocorticoids in the heart and vasculature: new insights for old hormones. Annu Rev Pharmacol Toxicol 2014; 55:289-312. [PMID: 25251996 DOI: 10.1146/annurev-pharmtox-010814-124302] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
The mineralocorticoid aldosterone is a key regulator of water and electrolyte homeostasis. Numerous recent developments have advanced the field of mineralocorticoid pharmacology—namely, clinical trials have shown the beneficial effects of aldosterone antagonists in chronic heart failure and post-myocardial infarction treatment. Experimental studies using cell type-specific gene targeting of the mineralocorticoid receptor (MR) gene in mice have revealed the importance of extrarenal aldosterone signaling in cardiac myocytes, endothelial cells, vascular smooth cells, and macrophages. In addition, several molecular pathways involving signal transduction via the classical MR as well as the G protein-coupled receptor GPER mediate the diverse spectrum of effects of aldosterone on cells. This knowledge has initiated the development of new pharmacological ligands to specifically interfere with targets on different levels of aldosterone signaling. For example, aldosterone synthase inhibitors such as LCI699 and the novel nonsteroidal MR antagonist BAY 94-8862 have been tested in clinical trials. Interference with the interaction between MR and its coregulators seems to be a promising strategy toward the development of selective MR modulators.
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Affiliation(s)
- Achim Lother
- Heart Center, Department of Cardiology and Angiology I, University of Freiburg, 79106 Freiburg, Germany;
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Papanastasiou L, Markou A, Pappa T, Gouli A, Tsounas P, Fountoulakis S, Kounadi T, Tsiama V, Dasou A, Gryparis A, Samara C, Zografos G, Kaltsas G, Chrousos G, Piaditis G. Primary aldosteronism in hypertensive patients: clinical implications and target therapy. Eur J Clin Invest 2014; 44:697-706. [PMID: 24909545 DOI: 10.1111/eci.12286] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2013] [Accepted: 06/03/2014] [Indexed: 12/27/2022]
Abstract
BACKGROUND The prevalence of primary aldosteronism (PA) in hypertensive patients varies according to diagnostic testing and ascertained normal cut-offs. The aim of this case-control study was to confirm the high prevalence of PA in a large hypertensive population and evaluate the antihypertensive effect of mineralocorticoid receptor antagonists (MRA) treatment. MATERIAL AND METHODS We investigated 327 hypertensive and 90 matched normotensive subjects with normal adrenal imaging. Serum aldosterone (ALD), active renin (REN) levels and aldosterone/active renin (ALD/REN) ratio were measured before and after a combined sodium chloride, fludrocortisone and dexamethasone suppression test (FDST). Post-FDST values were compared to cut-offs obtained from controls (post-FDST ALD 2·96 ng/dL and post-FDST ALD/REN 0·93 ng/dL/μU/mL). PA patients received MRA treatment. RESULTS By applying the combination of post-FDST ALD levels and ALD/REN ratio, 28·7% of the hypertensive patients had PA. There was a positive, albeit weak, correlation between systolic (SBP) and diastolic blood pressure (DBP) and ALD levels and/or ALD/REN ratio after the FDST (P < 0·0001). SBP was associated with a post-FDST ALD of 3·24 ng/dL and ALD/REN ratio of 0·90 ng/dL/μU/mL, whereas post-FDST ALD had an inverse association at serum K+ values of less than 3·9 mEq/L. MRA treatment in 69 PA patients, resulted in a significant reduction in the maximum SBP and DBP values (28 ± 15 and 14 ± 7 mmHg, respectively, P < 0·0001). CONCLUSIONS Using the FDST, an increased prevalence of PA in hypertensives was observed. Α significant blood pressure lowering effect was obtained with MRA treatment, implying that these agents may be beneficial in a significant number of hypertensive patients.
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Affiliation(s)
- Labrini Papanastasiou
- Department of Endocrinology and Diabetes Center, 'G Gennimatas' General Hospital, Athens, Greece
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Effect of aldosterone antagonists on blood pressure in patients with resistant hypertension: a meta-analysis. J Hum Hypertens 2014; 29:159-66. [DOI: 10.1038/jhh.2014.64] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2014] [Revised: 06/14/2014] [Accepted: 06/30/2014] [Indexed: 11/09/2022]
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