Ethnic differences in blood pressure response to first and second-line antihypertensive therapies in patients randomized in the ASCOT Trial

Renin and prorenin as biomarkers in hypertension

PURPOSE OF REVIEW

This review examines the evidence that plasma renin and/or prorenin level may be used to guide therapy in hypertension and as an independent risk factor for future cardiovascular events.

RECENT FINDINGS

A large number of retrospective analyses of patient populations in clinical trials, in whom 'baseline' renin measurements were available, supports that high renin, but not high prorenin levels, are indicative of future cardiovascular disease and death, particularly in patients with kidney dysfunction and/or hypertension. The relationship is not affected by the use of renin-angiotensin system (RAS) blockers. High renin levels also tend to support the use of RAS inhibitors as first-choice antihypertensive agents. However, the added value of a renin measurement on top of traditional risk factors is modest, and the pressure response to RAS blockade, even in high-renin patients, varies widely.

SUMMARY

Measuring 'baseline' renin as a marker of future cardiovascular events or to determine the choice of drug is of limited value in an individual patient.

Differences in the classification of hypertensive controlled patient in primary care: Cross sectional study

Objectives

To examine differences in blood pressure control using the 2006 National Institute for Health and Clinical Excellence (NICE) guidelines and the 2007 Quality and Outcome Framework (QOF) standards.

Design

Cross-sectional study.

Setting

28 general practices located in Wandsworth, London.

Participants

Hypertensive patients aged 17 years and over.

Main outcomes measures

Percentage of hypertensive patients classified as a hypertensive controlled patient (HCP) by each standard.

Results

79.5% of patients were classified as a HCP by the QOF target and 60.7% by the NICE target. 93% and 14% of practices had more than 70% of patients classified as a HPC by using the QOF and NICE targets respectively. By applying the QOF target, men aged 45–64 years and 65 years and over had significantly higher probability of being classified as a HCP compared to those aged 17–44 years, OR 1.34 (1.08–.165) and OR 2.15 (1.61–2.87) respectively. Regardless of the target, for men the probability of being classified as a HCP increased with age.

Conclusion

Better achievement of blood pressure control targets is present when the less stringent QOF target is used. Men aged 65 years and over were more likely to be classified as a HCP. Greater consistency is needed between the clinical targets in QOF and NICE guidance.

Plasma renin activity-guided strategy for the management of hypertension

Despite the wide array of antihypertensive agents and the availability of national guidelines regarding treatment for hypertension, the disease remains uncontrolled in nearly 50% of affected patients. Furthermore, the number of patients with resistant hypertension continues to increase. For patients with resistant hypertension, the American Heart Association has advocated for clinical studies to determine appropriate pharmacologic treatment strategies. One proposed strategy involves ambulatory measurement of plasma renin activity (PRA) to guide the selection of antihypertensive therapy. Patients with low PRA would be prescribed natriuretic volume-mediated therapies (e.g., diuretics and calcium channel blockers), whereas those with high PRA would receive antirenin system therapies (e.g., β-blockers, angiotensin-converting enzyme inhibitors, and angiotensin II receptor blockers). This review focuses on the principles of PRA-guided therapy, its historical development, alternative approaches to classifying patients into categories of response to antihypertensive agents, and recent data supporting the use of plasma renin activity-guided hypertension management.