Spironolactone Versus Clonidine as a Fourth-Drug Therapy for Resistant Hypertension: The ReHOT Randomized Study (Resistant Hypertension Optimal Treatment)

Synopsis of the 2020 U.S. Department of Veterans Affairs/U.S. Department of Defense Clinical Practice Guideline: The Diagnosis and Management of Hypertension in the Primary Care Setting

DESCRIPTION

In January 2020, the U.S. Department of Veterans Affairs (VA) and the U.S. Department of Defense (DoD) approved a joint clinical practice guideline for the diagnosis and management of hypertension in the primary care setting.

METHODS

The VA/DoD Evidence-Based Practice Work Group convened a joint VA/DoD guideline development effort that included a multidisciplinary panel of practicing clinician stakeholders and conformed to the Institute of Medicine's tenets for trustworthy clinical practice guidelines. The guideline panel developed key questions in collaboration with the ECRI Institute, which systematically searched and evaluated the literature from 15 December 2013 to 25 March 2019 and developed and rated recommendations by using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system.

RECOMMENDATIONS

This synopsis summarizes key features of the guideline in several key areas: the measurement of blood pressure, the definition of hypertension, target treatment goals, and nonpharmacologic and pharmacologic treatment of essential and resistant hypertension.

Recent advances in managing primary hypertension

Hypertension remains a leading risk factor for cardiovascular mortality and morbidity globally despite the availability of effective and well-tolerated antihypertensive medications. Accumulating evidence suggests a more aggressive blood pressure regulation aimed at lower targets, particularly for selected patient groups. Our concepts of the optimal method for blood pressure measurement have radically changed, maintaining appropriate standard office measurements for initial assessment but relying on out-of-office measurement to better guide our decisions. Thorough risk stratification provides guidance in decision making; however, an individualized approach is highly recommended to prevent overtreatment. Undertreatment, on the other hand, remains a major concern and is mainly attributed to poor adherence and resistant or difficult-to-control forms of the disease. This review aims to present modern perspectives, novel treatment options, including innovative technological applications and developing interventional and pharmaceutical therapies, and the major concerns emerging from several years of research and epidemiological observations related to hypertension management.

Role of endothelial function determined by asymmetric dimethylarginine in the prediction of resistant hypertension: A subanalysis of ReHOT trial

The authors conducted a subanalysis of the ReHOT (Resistant Hypertension Optimal Treatment) study to evaluate the association between endothelial dysfunction and resistant hypertension in a population of patients treated in a staged fashion for hypertension. One hundred and three hypertensive patients were followed for 6 months and participated in seven visits (V0-V6) 28 days apart. There was a first phase (V0-V3) of antihypertensive adjustment with three drugs and determination of resistant hypertension and a second randomized phase (V3-V6) of treatment with a fourth drug (clonidine or spironolactone) in the hypertensive patients characterized as resistant. Of the 103 patients included, 86 (83.5%) underwent the randomization visit (V3), 71 were characterized as non-resistant hypertensives (82.5%), and 15 as resistant hypertensives (17.5%). Serum asymmetric dimethylarginine (ADMA) was shown to be an independent predictor of resistant hypertension after adjustment for multiple variables (OR: 11.42, 95% CI: 1.02-127.71, P = .048), and in addition, there was a reduction in blood pressure levels and ADMA values during follow-up with a positive correlation in both groups and a greater reduction in the group of resistant hypertensives. We demonstrated that ADMA was an independent predictor of resistant hypertension, and we observed that the improvement in blood pressure levels obtained with the treatment was proportional to the reduction in ADMA values, suggesting a complementary role of ADMA not only as a stratification tool for the occurrence of resistant hypertension, but also as a possible therapeutic target in this population.

Effects of Blood Pressure Lowering Agents on Cardiovascular Outcomes in Weight Excess Patients: A Systematic Review and Meta-analysis

BACKGROUND

Obesity hypertension is an ongoing pandemic. The first-line medications to treat this condition are still subject to debate. We compared diuretics, calcium-channel blockers (CCB), beta-blockers (BB), angiotensin-converting enzyme inhibitors (ACEI) and angiotensin receptor blockers (ARB) as an initial antihypertensive therapy for prevention of cardiovascular morbimortality of hypertensive individuals who are overweight or obese.

METHODS

We conducted a search of the literature for randomized clinical trials in which at least 50% of the participants were overweight or obese. The primary outcomes were all-cause mortality, cardiovascular mortality, acute myocardial infarction (MI), heart failure (HF), stroke, or end-stage renal disease.

RESULTS

Our search yielded 16 randomized studies. Comparisons of two classes of drugs with at least two studies indicated that (1) CCB and ACEI increased the risk of HF [relative risk (RR) = 2.26; 95% confidence interval (CI) 1.16-4.40] and stroke [hazard ratio (HR) = 1.13; 1.00-1.26]), respectively, compared to diuretics; and (2) CCB showed a reduction in stroke (HR = 0.77; 0.66-0.89) and total mortality (HR = 0.94; 0.87-1.01) compared to the BB atenolol. Comparisons of two classes of antihypertensive medications with only one study showed that the risk of MI was higher with ARB valsartan versus CCB (HR = 1.19; 95% CI 1.02-1.38, p = 0.02). In contrast, losartan lowered the risk of a composite cardiovascular outcome compared to atenolol (HR = 0.87; 95% CI 0.77-0.98, p = 0.02).

CONCLUSIONS

In hypertensive subjects with excess weight, diuretics are more effective for preventing HF and stroke than CCB and ACEI, respectively. CCB are a good first-line choice for prevention of cardiovascular disease, except HF.

Resistant Hypertension in Chronic Kidney Disease (CKD): Prevalence, Treatment Particularities, and Research Agenda

PURPOSE OF REVIEW

To explore the prevalence, treatment particularities, and research agenda in the management of resistant hypertension among patients with chronic kidney disease (CKD).

RECENT FINDINGS

The prevalence of resistant hypertension is reported to be 2-3 times higher in patients with CKD than in the general hypertensive population. Based in part on the results of the PATHWAY-2 trial showing add-on spironolactone to be superior to placebo or active treatment with an α- or β-blocker in reducing BP, international guidelines recommend the use of spironolactone as fourth-line agent in pharmacotherapy of resistant hypertension. Despite the several-fold higher burden of resistant hypertension among patients with stage 3b-4 CKD, the use of spironolactone in this population has been restricted, mainly due to the risk of hyperkalemia. The recently reported AMBER trial showed that among patients with uncontrolled resistant hypertension and an estimated glomerular filtration rate of 25-45 ml/min/1.73m², the newer potassium-binder patiromer prevented the development of hyperkalemia and increased the proportion of participants who remained on add-on spironolactone over 12 weeks of follow-up. Administration of spironolactone was associated with a clinically meaningful reduction of 11-12 mmHg in unattended automated office systolic blood pressure (BP) over the course of the AMBER trial. Newer potassium-binding therapies overcome the barrier of hyperkalemia and facilitate the persistent use of spironolactone, which is an effective add-on therapy to control BP in patients with resistant hypertension and advanced CKD. Future trials are now warranted to explore whether this strategy confers benefits on "hard" clinical outcomes in this high-risk population.

Blood Pressure Control and Associated Factors in a Real-World Team-Based Care Center

BACKGROUND

Although team-based care is recommended for patients with hypertension, results of this intervention in a real-world setting are missing in the literature.

OBJECTIVE

To report the results of a real-world long-term team-based care for hypertensive patients we conducted this study.

METHODS

Data of hypertensive patients attending a multidisciplinary treatment center located in the Midwest region of Brazil in June 2017 with at least two follow-up visits were retrospectively assessed. Anthropometric, blood pressure (BP), follow-up time, pharmacological treatment, diabetes and lifestyle data were collected from the last visit to the service. BP values < 140 x 90 mmHg in non-diabetics and < 130 x 80 mmHg in diabetics were considered controlled. A logistic regression model was built to identify variables independently associated to BP control. Significance level adopted p < 0.05.

RESULTS

A total of 1,548 patients were included, with a mean follow-up time of 7.6 ± 7.1 years. Most patients were female (73.6%; n=1,139) with a mean age of 61.8 ±12.8 years. BP control rates in all the sample, and in non-diabetics and diabetics were 68%, 79%, and 37.9%, respectively. Diabetes was inversely associated with BP control (OR 0.16; 95%CI 0.12-0.20; p<0.001) while age ≥ 60 years (OR 1.48; 95%CI 1.15-1.91; p=0.003) and female sex (OR 1.38; 95%CI 1.05-1.82; p=0.020) were directly associated.

CONCLUSIONS

A BP control rate around 70% was found in patients attending a multidisciplinary team care center for hypertension. Focus on patients with diabetes, younger than 60 years and males should be given to further improve these results. (Arq Bras Cardiol. 2020; 115(2):174-181).

Clinical efficacy and safety of spironolactone in patients with resistant hypertension: A systematic review and meta-analysis

BACKGROUND

We conducted a meta-analysis to summarize all available evidence from randomized controlled trial studies regarding the clinical efficacy and safety of spironolactone in patients with resistant hypertension (RH) and provided a quantitative assessment.

METHODS

A systematic search of PubMed, Web of Science, Cochrane Library, Embase, and China National Knowledge Infrastructure (CNKI) databases through December 8, 2019, was performed. Randomized controlled trials randomized controlled trials meeting inclusion criteria were included to assess the effect of the addition of spironolactone on office blood pressure (BP), 24-hour ambulatory BP or adverse events in RH patients.

RESULTS

Twelve trials, which enrolled a total of 1655 patients, were included in this meta-analysis. In comparison with placebo, spironolactone significantly reduced office BP (office SBP, weighted mean difference [WMD] = -20.14, 95% CI = -31.17 to -9.12, P < .001; office DBP WMD = -5.73, 95% CI = -8.13 to -3.33, P < .001) and 24-hour ambulatory BP (ASBP, WMD = -10.31, 95% CI = -12.86 to -7.76, P < .001; ADBP, WMD = -3.94, 95% CI = -5.50 to -2.37, P < .001). Compared with alternative drugs, spironolactone treatment in RH patients significantly decreased 24-hour ambulatory BP (ASBP, WMD = -6.98, 95% CI = -12.66 to -1.30, P < .05; ADBP, WMD = -3.03, 95% CI = -5.21 to -0.85, P < .001).

CONCLUSION

This meta-analysis fully evaluated the antihypertensive effect of spironolactone compared with placebo, alternative drugs, renal nerve denervation and no treatment. Spironolactone can result in a substantial BP reduction in patients with RH at 3 months.

Bariatric Surgery for Resistant Hypertension: Working in Progress!

PURPOSE OF REVIEW

To discuss the recent evidence pointing the benefits of the bariatric surgery on blood pressure control in patients with obesity and hypertension. Particular focus is devoted to discuss the potential impact on resistant hypertension.

RECENT FINDINGS

Growing evidence suggest that bariatric surgery promotes not only a significant reduction in the anti-hypertensive medication while maintained blood pressure control but also a significant proportion of hypertension remission as compared to the usual care. In a sub-analysis of the GATEWAY trial using both office and 24-h ambulatory blood pressure monitoring, the prevalence of resistant hypertension significantly decreased after 12 months in the surgical group whereas the numbers remained stable in the control group. Despite the lack of robust evidence, preliminary findings underscore the strong need to explore the potential role of bariatric surgery on resistant hypertension in patients with obesity. This statement is justified not only for the burden of obesity in this scenario but also for the unmet demands in managing resistant hypertension appropriately by multiple drug-therapy or the lack of real utility of procedures like renal denervation and carotid baroreflex activation.

Contemporary and Future Concepts on Hypertension in African Americans: COVID-19 and Beyond

Background

Cardiovascular disease related mortality is the leading cause of death in the United States, with hypertension being the most prevalent and potent risk factor. For decades hypertension has disproportionately affected African Americans, who also have a higher burden of associated comorbidities including diabetes and heart failure.

Methods

Current literature including guideline reports and newer studies on hypertension in African Americans in PubMed were reviewed. We also reviewed newer publications on the relationship between COVID-19 and cardiovascular disease.

Findings

While APOL1 has been theorized in the epidemiology of hypertension, the increased prevalence and associated risks are primarily due to environmental and lifestyle factors. These factors include poor diet, adverse lifestyle, and social determinants. Hypertension control can be achieved by lifestyle modifications such as low sodium diet, weight loss, and adequate physical activity. When lifestyle modifications alone do not adequately control hypertension, a common occurrence among African Americans who suffer with greater prevalence of resistant hypertension, pharmacological intervention is indicated. The efficacy of renal denervation, and the use of sodium-glucose cotransporter 2 and aminopeptidase A inhibitors, have been studied for treatment of resistant hypertension. Furthermore, the recent COVID-19 crisis has been particularly devastating among African Americans who demonstrate increased incidence and poorer health outcomes related to the disease.

Conclusion

The disparities in outcomes, which are largely attributable to a greater prevalence of comorbidities such as hypertension and obesity, in addition to adverse environmental and socioeconomic factors, highlight the necessity of specialized clinical approaches and programs for African Americans to address longstanding barriers to equitable care.

Aldosterone receptor antagonists

Blocking the mineralocorticoid receptor (MR) is one of the most effective ways of reducing blood pressure in patients with resistant hypertension and improving cardiovascular prognosis in patients with heart failure with reduced ejection fraction and left ventricular dysfunction after myocardial infarction. Blockade of the biological effects of aldosterone has mostly been achieved with spironolactone and eplerenone, the two steroidal MR antagonists currently on the market. Development of new non-steroidal dihydropyridine-based third- and fourth-generation MR antagonists is ongoing. These antagonists are highly selective for the MR, but have no effect on the glucocorticoid, androgen, progesterone and estrogen receptors, in contrast with spironolactone.

Recent advances in understanding and managing resistant/refractory hypertension

The management of resistant hypertension presents several challenges in everyday clinical practice. During the past few years, several studies have been performed to identify efficient and safe pharmacological and non-pharmacological options for the management of such patients. The Spironolactone versus placebo, bisoprolol, and doxazosin to determine the optimal treatment for drug-resistant hypertension (PATHWAY-2) trial demonstrated significant benefits with the use of spinorolactone as a fourth-line drug for the treatment of resistant hypertension over doxazosin and bisoprolol. In addition, recent data support that spironolactone may demonstrate superiority over central acting drugs in such patients, as well. Based on the European guidelines, spironolactone is recommended as the fourth-line drug option, followed by amiloride, other diuretics, doxazosin, bisoprolol or clonidine.  Among several device-based approaches, renal sympathetic denervation had fallen into hibernation after the disappointing results of the Renal Denervation in Patients With Uncontrolled Hypertension (SYMPLICITY HTN) 3 trial. However, the technique re-emerged at the epicenter of the clinical and research interest after the favorable results of three sham-controlled studies, which facilitated novel catheters and techniques to perform the denervation. Significant results of iliac anastomosis on blood pressure levels have also been demonstrated. Nevertheless, the technique-related adverse events resulted in withdrawal of this interventional approach. Last, the sympatholytic properties of the carotid baroreceptor activation therapy were associated with significant blood pressure reductions in patients with resistant hypertension, which need to be verified in larger controlled trials. Currently device-based approaches are recommended only in the setting of clinical trials until more safety and efficacy data become available.

Managing Hypertension in the elderly: What's new?

Hypertension is the leading modifiable risk factor for cardiovascular events and mortality in the world. Hypertension is a major risk factor for cardiovascular events and mortality in the elderly. The 2017 American College of Cardiology/American Heart Association hypertension guidelines recommend treatment of noninstitutionalized ambulatory community-dwelling persons aged 65 years and older with an average systolic blood pressure of 130 ​mm Hg or higher or a diastolic blood pressure of 80 ​mm Hg or higher with lifestyle measures plus antihypertensive drug to lower the blood pressure to less than 130/80 ​mm Hg For elderly adults with hypertension and a high burden of comorbidities and limited life expectancy, clinical judgment, patient preference, and a team-based approach to assess risk/benefit is reasonable for decisions about the intensity of SBP lowering and the choice of antihypertensive drugs to use for treatment. Randomized clinical trials need to be performed in frail elderly patients with hypertension living in nursing homes. Elderly frail persons with prevalent and frequent falls, marked cognitive impairment, and multiple comorbidities requiring multiple antihypertensive drugs also need to be included in randomized clinical trials. Data on patients older than 85 years treated for hypertension are also sparse. These patients need clinical trial data. Finally, the effect of different antihypertensive drugs on clinical outcomes including serious adverse events needs to be investigated in elderly frail patients with hypertension and different comorbidities.

α2A-Adrenoceptors Modulate Renal Sympathetic Neurotransmission and Protect against Hypertensive Kidney Disease

BACKGROUND

Increased nerve activity causes hypertension and kidney disease. Recent studies suggest that renal denervation reduces BP in patients with hypertension. Renal NE release is regulated by prejunctional α2A-adrenoceptors on sympathetic nerves, and α2A-adrenoceptors act as autoreceptors by binding endogenous NE to inhibit its own release. However, the role of α2A-adrenoceptors in the pathogenesis of hypertensive kidney disease is unknown.

METHODS

We investigated effects of α2A-adrenoceptor-regulated renal NE release on the development of angiotensin II-dependent hypertension and kidney disease. In uninephrectomized wild-type and α2A-adrenoceptor-knockout mice, we induced hypertensive kidney disease by infusing AngII for 28 days.

RESULTS

Urinary NE excretion and BP did not differ between normotensive α2A-adrenoceptor-knockout mice and wild-type mice at baseline. However, NE excretion increased during AngII treatment, with the knockout mice displaying NE levels that were significantly higher than those of wild-type mice. Accordingly, the α2A-adrenoceptor-knockout mice exhibited a systolic BP increase, which was about 40 mm Hg higher than that found in wild-type mice, and more extensive kidney damage. In isolated kidneys, AngII-enhanced renal nerve stimulation induced NE release and pressor responses to a greater extent in kidneys from α2A-adrenoceptor-knockout mice. Activation of specific sodium transporters accompanied the exaggerated hypertensive BP response in α2A-adrenoceptor-deficient kidneys. These effects depend on renal nerves, as demonstrated by reduced severity of AngII-mediated hypertension and improved kidney function observed in α2A-adrenoceptor-knockout mice after renal denervation.

CONCLUSIONS

Our findings reveal a protective role of prejunctional inhibitory α2A-adrenoceptors in pathophysiologic conditions with an activated renin-angiotensin system, such as hypertensive kidney disease, and support the concept of sympatholytic therapy as a treatment.

Managing the elderly patient with hypertension: current strategies, challenges, and considerations

Introduction: Hypertension is the leading modifiable risk factor for cardiovascular events and mortality in the world.Areas covered: An extensive literature review of articles and clinical trials on PUBMED on the topic of hypertension in the elderly from 1976 through January 2020 was conducted. This review article discusses clinical trials on treatment of hypertension in the elderly, the 2017 American College of Cardiology (ACC)/American Heart Association (AHA) hypertension guidelines, the 2018 European Society of Cardiology/European Society of Hypertension guidelines, and the treatment of hypertension and of resistant hypertension in the elderly.Expert opinion: The 2017 ACC/AHA hypertension guidelines recommend treatment of noninstitutionalized ambulatory community-dwelling adults aged 65 years and older with an average systolic blood pressure of 130 mm Hg or higher with lifestyle measures plus antihypertensive drug to lower the blood pressure to less than 130/80 mm Hg. For elderly adults with hypertension and a high burden of comorbidities and limited life expectancy, clinical judgment, patient preference, and a team-based approach to assess risk/benefit is reasonable for decisions about the intensity of SBP lowering and the choice of antihypertensive drugs to use for treatment.

Association of the genetic ancestry with resistant hypertension in the ReHOT (Resistant Hypertension Optimal Treatment) randomized study

Resistant hypertension (RH) is defined as uncontrolled blood pressure despite treatment with three or more antihypertensive medications, including, if tolerated, a diuretic in adequate doses. It has been widely known that race is associated with blood pressure control. However, intense debate persists as to whether this is solely explained by unadjusted socioeconomical variables or genetic variation. In this scenario, the main aim was to evaluate the association between genetic ancestry and resistant hypertension in a large sample from a multicenter trial of stage II hypertension, the ReHOT study. Samples from 1,358 patients were analyzed, of which 167 were defined as resistant hypertensive. Genetic ancestry was defined using a panel of 192 polymorphic markers. The genetic ancestry was similar in resistant (52.0% European, 36.7% African and 11.3% Amerindian) and nonresistant hypertensive patients (54.0% European, 34.4% African and 11.6% Amerindian) (p > 0.05). However, we observed a statistically suggestive association of African ancestry with resistant hypertension in brown patient group. In conclusion, increased African genetic ancestry was not associated with RH in Brazilian patients from a prospective randomized hypertension clinical trial.

Uncontrolled Arterial Hypertension: Kidney, Neurohormonal Imbalance, and Approaches to Antihypertensive Drug Therapy

Resistant and refractory arterial hypertensions are two distinct clinical phenotypes of uncontrolled arterial hypertension (AH), which differ in their sensitivity to antihypertensive drug therapy. The review presents data obtained in clinical studies devoted to elucidating the involvement of disorders of neurohormonal status and renal function in the formation of resistant and refractory arterial hypertension, to and the development of new approaches to increasing the effectiveness of antihypertensive therapy in these patient’s populations. The results of these studies have shown that in patients with uncontrolled arterial hypertension, despite prolonged intake ≥ 3 antihypertensive drugs with different mechanisms of action, including a diuretic, excess sodium reabsorption persists in the distal segments of nephron due to increased aldosterone activity and sympathetic nervous system hyperactivity. In this regard, special attention has been paid to the data of PATHWAY-2, PATHWAY-3 and ReHOT trials that in patients with resistant AH tested the clinical efficacy of spironolactone, amiloride, and antiadrenergic drugs bisoprolol, doxazosin and clonidine, suppressing activity of the sympathetic nervous system.

Extracellular Fluid Volume Is an Independent Determinant of Uncontrolled and Resistant Hypertension in Chronic Kidney Disease: A NephroTest Cohort Study

Background

Hypertension is highly prevalent during chronic kidney disease (CKD) and, in turn, worsens CKD prognosis. We aimed to describe the determinants of uncontrolled and resistant hypertension during CKD.

Methods and Results

We analyzed baseline data from patients with CKD stage 1 to 5 (NephroTest cohort) who underwent thorough renal explorations, including measurements of glomerular filtration rate (clearance of ⁵¹Cr‐EDTA) and of extracellular water (volume of distribution of the tracer). Hypertension was defined as blood pressure (BP; average of 3 office measurements) ≥140/90 mm Hg or the use of antihypertensive drugs. In 2015 patients (mean age, 58.7±15.3 years; 67% men; mean glomerular filtration rate, 42±15 mL/min per 1.73 m²), prevalence of hypertension was 88%. Among hypertensive patients, 44% and 32% had uncontrolled (≥140/90 mm Hg) and resistant (uncontrolled BP despite 3 drugs, including a diuretic, or ≥4 drugs, including a diuretic, regardless of BP level) hypertension, respectively. In multivariable analysis, extracellular water, older age, higher albuminuria, diabetic nephropathy, and the absence of aldosterone blockers were independently associated with uncontrolled BP. Extracellular water, older age, lower glomerular filtration rate, higher albuminuria and body mass index, male sex, African origin, diabetes mellitus, and diabetic and glomerular nephropathies were associated with resistant hypertension.

Conclusions

In this large population of patients with CKD, a lower glomerular filtration rate, a higher body mass index, diabetic status, and African origin were associated with hypertension severity but not with BP control. Higher extracellular water, older age, and higher albuminuria were independent determinants of both resistant and uncontrolled hypertension during CKD. Our results advocate for the large use of diuretics in this population.

New Molecules for Treating Resistant Hypertension: a Clinical Perspective

PURPOSE OF REVIEW

To review the findings of trials evaluating pharmacological treatment approaches for hypertension in general, and resistant hypertension (RH) in particular, and propose future research and clinical directions.

RECENT FINDINGS

RH is defined as blood pressure (BP) that remains above target levels despite adherence to at least three antihypertensive medications, including a diuretic. Thus far, clinical trials of pharmacological approaches in RH have focused on older molecules, with spironolactone being demonstrated as the most efficacious fourth-line agent. However, the use of spironolactone in clinical practice is hampered by its side effect profile and the risk of hyperkalaemia in important RH subgroups, such as patients with moderate-severe chronic kidney disease (CKD). Clinical trials of new molecules targeting both well-established and more recently elucidated pathophysiologic mechanisms of hypertension offer a multitude of potential treatment avenues that warrant further evaluation in the context of RH. These include selective mineralocorticoid receptor antagonists (MRAs), aldosterone synthase inhibitors (ASIs), activators of the counterregulatory renin-angiotensin-system (RAS), vaccines, neprilysin inhibitors alone and in combined formulations, natriuretic peptide receptor agonists A (NPRA-A) agonists, vasoactive intestinal peptide (VIP) agonists, centrally acting aminopeptidase A (APA|) inhibitors, antimicrobial suppression of central sympathetic outflow (minocycline), dopamine β-hydroxylase (DβH) inhibitors and Na+/H+ Exchanger 3 (NHE3) inhibitors. There is a paucity of data from trials evaluating newer molecules for the treatment of RH. Emergent novel molecules for non-resistant forms of hypertension heighten the prospects of identifying new, effective and well-tolerated pharmacological approaches to RH. There is a glaring need to undertake RH-focused trials evaluating their efficacy and clinical applicability.

[Spironolactone in resistant essential hypertension]

Resistant hypertension is defined as uncontrolled blood pressure (BP) despite three antihypertensive agents including a diuretic (thiazide diuretic if renal function is normal or loop diuretic in case of chronic kidney disease with eGFR<30mL/min), a renin-angiotensin system blocker (ARB or ACEI) and a calcium channel blocker, at optimal doses. Resistance must be confirmed by out-of-office measurements (ambulatory blood pressure monitoring or home blood pressure monitoring) and patients should be asked about treatment compliance and excessive salt or alcohol intake. If the diagnosis of resistant hypertension is confirmed, the patient should be referred to a hypertension specialist to screen for secondary causes of hypertension as they are frequent in this context. If essential resistant hypertension is confirmed, the mineralocorticoid receptor antagonist, spironolactone, should be added (25 to 50mg daily). In the event of a contraindication to spironolactone, or if adverse effects occur, a beta-blocker, an alpha-blocker, or a centrally acting antihypertensive drug should be prescribed.

Myocardial global longitudinal strain: An early indicator of cardiac interstitial fibrosis modified by spironolactone, in a unique hypertensive rat model

OBJECTIVES

Is global longitudinal strain (GLS) a more accurate non-invasive measure of histological myocardial fibrosis than left ventricular ejection fraction (LVEF) in a hypertensive rodent model.

BACKGROUND

Hypertension results in left ventricular hypertrophy and cardiac dysfunction. Speckle-tracking echocardiography has emerged as a robust technique to evaluate cardiac function in humans compared with standard echocardiography. However, its use in animal studies is less clearly defined.

METHODS

Cyp1a1Ren2 transgenic rats were randomly assigned to three groups; normotensive, untreated hypertensive or hypertensive with daily administration of spironolactone (human equivalent dose of 50 mg/day). Cardiac function and interstitial fibrosis development were monitored for three months.

RESULTS

The lower limit of normal LVEF was calculated to be 75%. After three months hypertensive animals (196±21 mmHg systolic blood pressure (SBP)) showed increased cardiac fibrosis (8.8±3.2% compared with 2.4±0.7% % in normals), reduced LVEF (from 81±2% to 67±7%) and impaired myocardial GLS (from -17±2% to -11±2) (all p<0.001). Myocardial GLS demonstrated a stronger correlation with cardiac interstitial fibrosis (r2 = 0.58, p<0.0001) than LVEF (r2 = 0.37, p<0.006). Spironolactone significantly blunted SBP elevation (184±15, p<0.01), slowed the progression of cardiac fibrosis (4.9±1.4%, p<0.001), reduced the decline in LVEF (72±4%, p<0.05) and the degree of impaired myocardial GLS (-13±1%, p<0.01) compared to hypertensive animals.

CONCLUSIONS

This study has demonstrated that, myocardial GLS is a more accurate non-invasive measure of histological myocardial fibrosis compared to standard echocardiography, in an animal model of both treated and untreated hypertension. Spironolactone blunted the progression of cardiac fibrosis and deterioration of myocardial GLS.

2018 Korean Society of Hypertension Guidelines for the management of hypertension: part II-diagnosis and treatment of hypertension

The standardized techniques of blood pressure (BP) measurement in the clinic are emphasized and it is recommended to replace the mercury sphygmomanometer by a non-mercury sphygmomanometer. Out-of-office BP measurement using home BP monitoring (HBPM) or ambulatory BP monitoring (ABPM) and even automated office BP (AOBP) are recommended to correctly measure the patient’s genuine BP. Hypertension (HTN) treatment should be individualized based on cardiovascular (CV) risk and the level of BP. Based on the recent clinical study data proving benefits of intensive BP lowering in the high risk patients, the revised guideline recommends the more intensive BP lowering in high risk patients including the elderly population. Lifestyle modifications, mostly low salt diet and weight reduction, are strongly recommended in the population with elevated BP and prehypertension and all hypertensive patients. In patients with BP higher than 160/100 mmHg or more than 20/10 mmHg above the target BP, two drugs can be prescribed in combination to maximize the antihypertensive effect and to achieve rapid BP control. Especially, single pill combination drugs have multiple benefits, including maximizing reduction of BP, minimizing adverse effects, increasing adherence, and preventing cardiovascular disease (CVD) and target organ damage.

Resistant Hypertension Management: Comparison of the 2017 American and 2018 European High Blood Pressure Guidelines

PURPOSE OF REVIEW

To compare European and American guidelines for the diagnosis, evaluation, and management of resistant hypertension.

RECENT FINDINGS

Resistant hypertension is defined as high blood pressure that remains above goal with the use of 3 or more antihypertensive agents, commonly a renin-angiotensin blocker (either an angiotensin-converting enzyme inhibitor or an angiotensin receptor blocker), a long-acting calcium channel blocker, and thiazide or thiazide-like diuretic. Resistant hypertension is common, with a recent analysis indicating that it affects approximately 17-19% of adult Americans with hypertension. Pseudocauses of apparent resistant hypertension, including inaccurate blood pressure measurement, white coat effect, undertreatment, and poor medication adherence, must be excluded in order to confirm true resistant hypertension. Evaluation of resistant hypertension requires identifying and treating secondary causes of hypertension, including obstructive sleep apnea, primary aldosteronism, and renal artery stenosis. Treatment of resistant hypertension includes a combined use of lifestyle modification and prescription of effective multiple-drug combinations. Preferential use of a long-acting thiazide-like diuretic, either chlorthalidone or indapamide, and a mineralocorticoid receptor blocker, most commonly spironolactone, is recommended if needed to achieve blood pressure control. Aside for small exceptions, European and American guidelines agree in terms of recommendations for diagnosing, evaluating, and treating resistant hypertension.

Hypertension

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.

Mineralocorticoid Receptor Antagonists in Essential and Resistant Hypertension

Background:

Mineralocorticoid receptor antagonists are a second-line class of antihypertensive drugs, which have been accounted for as the optimal add-on therapy in the triple algorithm for the management of resistant hypertension.

Objectives:

To assess the effects of mineralocorticoid receptor antagonists in the treatment of patients with essential hypertension and resistant hypertension.

Method:

We conducted a meticulous review of the literature and comprehensive identification of the clinical trials assessing the efficacy of mineralocorticoid receptor antagonists in individuals with primary and resistant hypertension.

Results:

MRAs have been thoroughly tested in several clinical studies in relevance to blood pressure lowering effects, over the last six decades. Accumulating data observed that MRAs resulted in a significant reduction in blood pressure level in patients with resistant hypertension. In addition, spironolactone was found to beneficially affect the management of resistant hypertension.

Conclusion:

Mineralocorticoid receptor antagonists exert a significant antihypertensive effect. Future welldesigned randomized controlled studies are greatly needed to address crucial clinical aspects in the field.

Achieving control of resistant hypertension: Not just the number of blood pressure medications

Resistant hypertension (RH) has a prevalence of around 12% and is associated with an increased risk of cardiovascular disease, progression to end-stage renal disease, and even mortality. In 2017, the American College of Cardiology and American Heart Association released updated guidelines that detail steps to ensure proper diagnosis of RH, including the exclusion of pseudoresistance. Lifestyle modifications, such as low salt diet and physical exercise, remain at the forefront of optimizing blood pressure control. Secondary causes of RH also need to be investigated, including screening for obstructive sleep apnea. Notably, the guidelines demonstrate a major change in medication management recommendations to include mineralocorticoid receptor antagonists. In addition to advances in medication optimization, there are several device-based therapies that have been showing efficacy in the treatment of RH. Renal denervation therapy has struggled to show efficacy for blood pressure control, but with a re-designed catheter device, it is once again being tested in clinical trials. Carotid baroreceptor activation therapy (BAT) via an implantable pulse generator has been shown to be effective in lowering blood pressure both acutely and in long-term follow up data, but there is some concern about the safety profile. Both a second-generation pulse generator and an endovascular implant are being tested in new clinical trials with hopes for improved safety profiles while maintaining therapeutic efficacy. Both renal denervation and carotid BAT need continued study before widespread clinical implementation. Central arteriovenous anastomosis has emerged as another possible therapy and is being actively explored. The ongoing pursuit of blood pressure control is a vital part of minimizing adverse patient outcomes. The future landscape appears hopeful for helping patients achieve blood pressure goals not only through the optimization of antihypertensive medications but also through device-based therapies in select individuals.

Personalized Medicine and the Treatment of Hypertension

PURPOSE OF REVIEW

The purpose of this review is to discuss the implications of personalized medicine for the treatment of hypertension, including resistant hypertension.

RECENT FINDINGS

We suggest a framework for the personalized treatment of hypertension based on the concept of a trade-off between simplicity and personalization. This framework is based on treatment strategies classified as low, medium, or high information burden personalization approaches. The extent to which a higher information burden is justified depends on the clinical scenario, particularly the ease with which the blood pressure can be controlled. A one-size-fits-many treatment strategy for hypertension is efficacious for most people; however, a more personalized approach could be useful in patients with subtypes of hypertension that do not respond as expected to treatment. Clinicians seeing patients with unusual hypertension phenotypes should be familiar with emerging trends in personalized treatment of hypertension.

Urine Haptoglobin and Haptoglobin-Related Protein Predict Response to Spironolactone in Patients With Resistant Hypertension

Resistant hypertension prevalence is progressively increasing, and prolonged exposure to suboptimal blood pressure control results in higher cardiovascular risk and end-organ damage. Among various antihypertensive agents, spironolactone seems the most effective choice to treat resistant hypertension once triple therapy including a diuretic fails. However success in blood pressure control is not guaranteed, adverse effects are not negligible, and no clinical tools are available to predict patient's response. Complementary to our previous study of resistant hypertension metabolism, here we investigated urinary proteome changes with potential capacity to predict response to spironolactone. Twenty-nine resistant hypertensives were included. A prospective study was conducted and basal urine was collected before spironolactone administration. Patients were classified in responders or nonresponders in terms of blood pressure control. Protein quantitation was performed by liquid chromatography-mass spectrometry; ELISA and target mass spectrometry analysis were performed for confirmation. Among 3310 identified proteins, HP (haptoglobin) and HPR (haptoglobin-related protein) showed the most significant variations, with increased levels in nonresponders compared with responders before drug administration (variation rate, 5.98 and 7.83, respectively). Protein-coordinated responses were also evaluated by functional enrichment analysis, finding oxidative stress, chronic inflammatory response, blood coagulation, complement activation, and regulation of focal adhesions as physiopathological mechanisms in resistant hypertension. In conclusion, protein changes able to predict patients' response to spironolactone in basal urine were here identified for the first time. These data, once further confirmed, will support clinical decisions on patients' management while contributing to optimize the rate of control of resistant hypertensives with spironolactone.

[European guidelines for the management of arterial hypertension 2018-what has changed?]

BACKGROUND

In November 2017, the latest American guidelines for the management of arterial hypertension were published. With these guidelines lowering the threshold for hypertension to 130/80 mm Hg, the latest European guidelines were expected with excitement.

OBJECTIVES

This article gives an overview on the European Society of Cardiology (ESC) and European Society of Hypertension (ESH) 2018 guidelines for the management of arterial hypertension, thereby identifying the most relevant changes in comparison to previous guidelines.

CURRENT DATA

The latest 2018 ESC/ESH guidelines adhere to the previous definition of hypertension, in which a blood pressure of 140/90 mm Hg is considered as threshold for diagnosis. In contrast, there was a change in blood pressure treatment target from below 140/90 to between 120-129/70-79 mm Hg in patients < 65 years if well tolerated. Among patients ≥ 65 years, a systolic blood pressure between 130 and 139 mm Hg is recommended, whereas a diastolic blood pressure between 70 and 79 mm Hg should be targeted. Additionally the guidelines recommend the use of fixed dose combinations as first choice instead of monotherapy to improve adherence. Interventional treatment strategies should only be applied in carefully selected patients at experienced centers and are not recommended outside of clinical studies and registers. Furthermore, the chapters regarding initiation of blood pressure-lowering therapy and clinical evaluation as well as management of hypertension emergencies have been outlined.

CONCLUSIONS

The latest European guidelines for the management of hypertension include several changes. One of the most important aspects is that-in contrast to the American guidelines-the threshold for diagnosis remains at 140/90 mm Hg, whereas treatment target range has been lowered by roughly 10 mm Hg and single pill fixed dose combinations are recommended.

Resistant and refractory hypertension: two sides of the same disease?

Refractory hypertension (RfH) is an extreme phenotype of resistant hypertension (RH), being considered an uncontrolled blood pressure besides the use of 5 or more antihypertensive medications, including a long-acting thiazide diuretic and a mineralocorticoid antagonist. RH is common, with 10-20% of the general hypertensives, and its associated with renin angiotensin aldosterone system hyperactivity and excess fluid retention. RfH comprises 5-8% of the RH and seems to be influenced by increased sympathetic activity. RH patients are older and more obese than general hypertensives. It is strongly associated with diabetes, obstructive sleep apnea, and hyperaldosteronism status. RfH is more frequent in women, younger patients and Afro-americans compared to RFs. Both are associated with increased albuminuria, left ventricular hypertrophy, chronic kidney diseases, stroke, and cardiovascular diseases. The magnitude of the white-coat effect seems to be higher among RH patients. Intensification of diuretic therapy is indicated in RH, while in RfH, therapy failure imposes new treatment alternatives such as the use of sympatholytic therapies. In conclusion, both RH and RfH constitute challenges in clinical practice and should be addressed as distinct clinical entities by trained professionals who are capable to identify comorbidities and provide specific, diversified, and individualized treatment.

Does Obstructive Sleep Apnea Influence Blood Pressure and Arterial Stiffness in Response to Antihypertensive Treatment?

Untreated obstructive sleep apnea (OSA) is common in patients with hypertension and may impair blood pressure (BP) and target-organ damage responses to antihypertensive therapy. In this study, we recruited hypertensive patients who underwent treatment with a 30-day regimen of hydrochlorothiazide 25 mg plus enalapril (20 mg BID) or losartan (50 mg BID) and were assessed with a baseline clinical evaluation, polysomnography, 24-hour ambulatory BP monitoring, and carotid-femoral pulse wave velocity. All the examinations except for polysomnography were repeated at 6 and 18 months of follow-up. We studied 94 hypertensive patients (mean age, 55±9 years). The frequency of OSA was 55%. Compared with baseline, we did not observe significant differences between groups in 24-hour BP, daytime systolic and diastolic BPs, or night-time systolic BP at 6 and 18 months. The BP control rate at 24 hours (<130/80 mm Hg) was similar between the groups (baseline, 42.3% versus 45.2%; 6 months, 46.9% versus 57.5%; 18 months, 66.7% versus 61.5%). However, patients with OSA had higher night-time diastolic BP decrease than did the non-OSA group (6 months, -4.9±11.8 versus -0.3±10.3 mm Hg; 18 months, -6.7±11.1 versus -1.2±10.6 mm Hg; P=0.027). There were no differences in the number and class of antihypertensive medications prescribed during follow-up. In terms of arterial stiffness, patients with OSA had higher pulse wave velocity than did patients without OSA at baseline (10.3±1.9 versus 9.2±1.7 m/s; P=0.024), but both groups had similar decreases in pulse wave velocity during follow-up. In conclusion, with combined antihypertensive treatment aimed at controlling BP, hypertensive patients with OSA had similar 24-hour BP and arterial stiffness to those without OSA.

Resistant Hypertension: Time to Consider the Best Fifth Anti-Hypertensive Treatment

PURPOSE OF REVIEW

Resistant hypertension (RH) is a growing clinical condition worldwide associated with target-organ damage and poor prognosis compared to non-resistant counterparts. The purpose of this review is to perform a critical evaluation of preferable drug choices for managing RH highlighting the evidence that significant proportion of patients remained uncontrolled despite using four anti-hypertensive drugs.

RECENT FINDINGS

Until recently, the fourth drug therapy was main derived from personal opinion or small interventional studies. The recent data derived from two multicentric randomized trials, namely PATHWAY-2 and ReHOT, pointed spironolactone as the preferable fourth drug therapy in patients with confirmed RH as compared to bisoprolol and doxazosin (PATHWAY-2) as well as clonidine (ReHOT). However, significant proportion of patients (especially observed in ReHOT trial that used 24-h ambulatory blood pressure monitoring) did not achieve optimal blood pressure with the fourth drug. This finding underscores the need of new approaches and treatment options in this important research area. The current evidence pointed that significant proportion of RH patients are requiring more than four drugs for controlling BP. This statement is particularly true considering the new criteria proposed by the 2017 Guidelines for diagnosing RH (> 130 × 80 mmHg). New combinations, drugs, or treatments should be tested aiming to reduce the RH burden. Based on the aforementioned multicentric trials, we proposed the first five preferable anti-hypertensive classes in the overall context of RH.

Genetics of Resistant Hypertension: the Missing Heritability and Opportunities

PURPOSE OF THE REVIEW

Blood pressure regulation in humans has long been known to be a genetically determined trait. The identification of causal genetic modulators for this trait has been unfulfilling at the least. Despite the recent advances of genome-wide genetic studies, loci associated with hypertension or blood pressure still explain a very low percentage of the overall variation of blood pressure in the general population. This has precluded the translation of discoveries in the genetics of human hypertension to clinical use. Here, we propose the combined use of resistant hypertension as a trait for mapping genetic determinants in humans and the integration of new large-scale technologies to approach in model systems the multidimensional nature of the problem.

RECENT FINDINGS

New large-scale efforts in the genetic and genomic arenas are paving the way for an increased and granular understanding of genetic determinants of hypertension. New technologies for whole genome sequence and large-scale forward genetic screens can help prioritize gene and gene-pathways for downstream characterization and large-scale population studies, and guided pharmacological design can be used to drive discoveries to the translational application through better risk stratification and new therapeutic approaches. Although significant challenges remain in the mapping and identification of genetic determinants of hypertension, new large-scale technological approaches have been proposed to surpass some of the shortcomings that have limited progress in the area for the last three decades. The incorporation of these technologies to hypertension research may significantly help in the understanding of inter-individual blood pressure variation and the deployment of new phenotyping and treatment approaches for the condition.