Prevalence and Comorbidities of Resistant Hypertension: A Collaborative Population-Based Observational Study

Prevalence and associated risk factors of resistant hypertension among Chinese hypertensive patients in primary care setting

INTRODUCTION

Hypertension (HT) is a major public health problem globally, and it is the commonest chronic disease with a prevalence of 27% among people aged 15 years or above in Hong Kong. There is emerging literature confirmed that patients with resistant hypertension (RHT) give its increased risk for adverse clinical outcomes and higher rate of documented target organ damage. This study aims to identify the prevalence of RHT among Chinese hypertensive patients managed in public primary care setting of Hong Kong and exploring its associated risk factors.

METHODOLOGY

This is a cross-sectional descriptive study. Chinese hypertensive patients aged 30 or above with regular follow-up between 1st July 2019 and 30th June 2020 in 10 public primary care clinics under the Hospital Authority of Hong Kong were included. Demographic data, clinical parameters and drug profile of patients were retrieved from its computerized record system. The prevalence of RHT was identified and the associated risk factors of RHT were explored by multivariate logistic regression analysis.

RESULTS

Among the 538 sampled Chinese hypertensive patients, the mean age was 67.4 ± 11.5 years old, and 51.9% were female. The mean duration of hypertension was 10.1 ± 6.4 years, with a mean systolic and diastolic blood pressure of 128.8 ± 12.3 and 72.9 ± 10.8 mmHg respectively. 40 out of 538 patients were found to have RHT, giving an overall prevalence of 7.43%. Four factors were found to be associated with increased risk of RHT, in ascending order of odds ratio: duration of hypertension (OR 1.08), male gender (OR 2.72), comorbid with type 2 diabetes mellitus (T2DM, OR 2.99), and congestive heart failure (CHF, OR 5.39).

CONCLUSION

The prevalence of RHT among Chinese hypertensive patients in primary care setting of Hong Kong is 7.43%. RHT is more common in male patients, patients with longer duration of hypertension, concomitant T2DM and CHF. Clinicians should be vigilant when managing these groups of patients and provide aggressive treatment and close monitoring.

Resistant Hypertension and Related Outcomes in a Cohort of Patients with Cardiorenal Multimorbidity Hospitalized in an Internal Medicine Ward

INTRODUCTION

Resistant hypertension (RH) is characterized by the failure to reach a goal blood pressure despite the administration of three medications at maximally tolerated doses, one of which being a diuretic. RH can be observed in a variety of clinical conditions, such as heart failure and reduced renal function and may confer high cardiovascular risk.

AIM

To evaluate the prevalence of RH and its association with clinical outcomes; the primary outcome was in-hospital mortality and the composite outcome was all-cause of mortality and morbidity in a cohort of patients with cardiorenal multimorbidity hospitalized in an internal medicine ward.

METHODS

We conducted a retrospective analysis of consecutive hypertensive patients with cardiorenal multimorbidity. The composite outcome incorporated all-cause of in-hospital mortality and occurrence of sepsis, pulmonary embolism, acute coronary syndrome, stroke and renal replacement therapy.

RESULTS

We collected data in 141 inpatients with a mean age of 77 years ± 10 (males 65.9 %), estimated glomerular filtration rate of 34 ± 18.6 ml/min with length of stay of 17 ± 12 days. The prevalence of RH was 52.4%. In-hospital mortality was observed in 24 patients (17%) and the composite outcome occurred in 87 patients (61.7%) and among these 74 (85.1%) were patients with RH. Free survival for composite outcome was significantly higher in patients without RH than patients with RH (log rank 7.52, p = 0.006). Resistant hypertension was a risk factor for composite outcome [HR 1.857(C.I. 1.170-2.946, p = 0.009)].

CONCLUSION

In patients with cardiorenal multimorbidity there is a high proportion of RH that represents a risk factor for composite outcome but not for in-hospital mortality.

Hypertension, uncontrolled hypertension and resistant hypertension: prevalence, comorbidities and prescribed medications in 228,406 adults resident in urban areas. A population-based observational study

Although hypertension is the leading cause of cardiovascular disease and premature death worldwide, it remains difficult to control. The prevalence of uncontrolled and resistant hypertension (RH) may be underestimated and can reach up to 50% of all hypertensive patients. The aim of this observational study was to analyze the prevalence of hypertension, uncontrolled hypertension and RH, and their associations with risk factors or diseases in a large cohort of patients referred to primary care physician. In a population of 228406 adults, we only collected data from people with a diagnosis of arterial hypertension for a total of 43,526 patients. For this purpose, we used the MySQL database, run by Azalea.NET, built on the medical records of 150 General Practitioners (GPs). Patient data included sex, age, blood pressure (BP) values, number of antihypertensive drugs and presence of major cardiovascular comorbidities. We classified patients with RH as those treated with 3 different antihypertensive agents, with recorded BP ≥ 140/90 mmHg, or patients taking ≥ 4 medications. The prevalence of hypertension was 19.06%, that of resistant hypertension was 2.46% of the whole population and 20.85% of the hypertensive group. Thirteen thousand hundred, forty-six patients (30.20% of the hypertensive group) had uncontrolled BP (≥ 140/90 mmHg), whereas 16,577 patients did not have BP measurements done in the last 2 years (38.09% of the hypertensive group). Patients with uncontrolled BP were mainly female, used less drugs and showed a lower prevalence of all major cardiovascular comorbidities, except for diabetes. Instead, patients with RH had a significantly higher prevalence of all considered comorbidities compared to those without RH. Our results evidence that a broad number of patients with hypertension, especially those without comorbidities or with a low number of antihypertensive drugs, do not achieve adequate BP control. To improve the clinical management of these patients it is very important to increase the collaboration between GPs and clinical specialists of hypertension.

Professionals' and Patients' Perspectives on Criteria for Referring Hypertensive Patients to Comprehensive Medication Management Services in Public Primary Health Care

Patient prioritization in comprehensive medication management services allows coordinating care and guiding patients according to their clinical profile and their medication use. The aim of the study is to identify and describe factors that indicate the need for comprehensive medication management services among primary care hypertension patients within a public health system from the perspective of patients, pharmacists, nurses and physicians. A qualitative study was carried out with interviews with nurses, pharmacists and physicians (n = 20), and two focus groups with hypertensive patients (n = 12) at primary health care facilities and a public outdoor fitness area between January and February 2019 in Brazil. All interviews were transcribed and analyzed using the Atlas.ti^® software. The data analysis revealed the following factors indicative of the need to refer hypertension patients to a pharmacist: lifestyle habits, comorbidities, health care utilization and medication use. The issues identified and the information obtained from the qualitative research and compared with literature studies reviewed allowed defining dimensions that should be considered as an aid in the selection of uncontrolled hypertensive patients for comprehensive medication management services.

Lobar intracerebral hemorrhage and risk of subsequent uncontrolled blood pressure

BACKGROUND

Uncontrolled blood pressure (BP) in intracerebral hemorrhage (ICH) survivors is common and associated with adverse clinical outcomes. We investigated whether characteristics of the ICH itself were associated with uncontrolled BP at follow-up.

METHODS

Subjects were consecutive patients aged ⩾18 years with primary ICH enrolled in the prospective longitudinal ICH study at Massachusetts General Hospital between 1994 and 2015. We assessed the prevalence of uncontrolled BP (mean BP ⩾140/90 mmHg) 6 months after index event. We used multivariable logistic regression models to assess the effect of hematoma location, volume, and event year on uncontrolled BP.

RESULTS

Among 1492 survivors, ICH was lobar in 624 (42%), deep in 749 (50%), cerebellar in 119 (8%). Lobar ICH location was associated with increased risk for uncontrolled BP after 6 months (OR 1.35; 95% CI [1.08-1.69]). On average, lobar ICH survivors were treated with fewer antihypertensive drugs compared to the rest of the cohort: 2.1 ± 1.1 vs 2.5 ± 1.2 (p < 0.001) at baseline and 1.8 ± 1.2 vs. 2.4 ± 1.2 (p < 0.001) after 6 months follow-up. After adjustment for the number of antihypertensive drugs prescribed, the association of lobar ICH location with risk of uncontrolled BP was eliminated.

CONCLUSIONS

ICH survivors with lobar hemorrhage were more likely to have uncontrolled BP after 6 months follow-up. This appears to be a result of being prescribed fewer antihypertensive medications. Future treatment strategies should focus on aggressive BP control after ICH independent of hemorrhage location.

Purification, characterization, and preliminary serial crystallography diffraction advances structure determination of full-length human particulate guanylyl cyclase A receptor

Particulate Guanylyl Cyclase Receptor A (pGC-A) is a natriuretic peptide membrane receptor, playing a vital role in controlling cardiovascular, renal, and endocrine functions. The extracellular domain interacts with natriuretic peptides and triggers the intracellular guanylyl cyclase domain to convert GTP to cGMP. To effectively develop methods to regulate pGC-A, structural information on the full-length form is needed. However, structural data on the transmembrane and intracellular domains are lacking. This work presents expression and optimization using baculovirus, along with the first purification of functional full-length human pGC-A. In vitro assays revealed the pGC-A tetramer was functional in detergent micelle solution. Based on our purification results and previous findings that dimer formation is required for functionality, we propose a tetramer complex model with two functional subunits. Previous research suggested pGC-A signal transduction is an ATP-dependent, two-step mechanism. Our results show the binding ligand also moderately activates pGC-A, and ATP is not crucial for activation of guanylyl cyclase. Furthermore, crystallization of full-length pGC-A was achieved, toward determination of its structure. Needle-shaped crystals with 3 Å diffraction were observed by serial crystallography. This work paves the road for determination of the full-length pGC-A structure and provides new information on the signal transduction mechanism.

Apparent Treatment-Resistant Hypertension Across the Spectrum of Heart Failure Phenotypes in the Swedish HF Registry

BACKGROUND

Hypertension is common in patients with heart failure (HF), but less is known about resistant hypertension.

OBJECTIVES

This study sought to investigate apparent treatment-resistant hypertension (aTRH) in patients with HF in the SwedeHF (Swedish Heart Failure Registry), across the spectrum of HF phenotypes (heart failure with reduced ejection fraction [HFrEF], heart failure with mildly reduced ejection fraction [HFmrEF], and heart failure with preserved ejection fraction [HFpEF]).

METHODS

aTRH was defined as systolic blood pressure ≥140 mm Hg (≥135 mm Hg in diabetes) despite treatment with an angiotensin-converting enzyme inhibitor, angiotensin receptor blocker, or sacubitril-valsartan, as well as a calcium-channel blocker and a diuretic; non-treatment-resistant hypertension (TRH) was defined as systolic blood pressure above these thresholds but not on the 3-drug combination; and normal blood pressure was defined as under these thresholds. In each left ventricular ejection fraction (LVEF) category, patient factors associated with aTRH and non-TRH and outcomes (HF hospitalization and cardiovascular death composite, its components, and all-cause death) according to hypertension category were examined.

RESULTS

Among 46,597 patients, aTRH was present in 2,693 (10%), 1,514 (14%), and 1,450 (17%) patients with HFrEF, HFmrEF, and HFpEF, respectively. Older age, obesity, diabetes, and kidney disease were associated with a greater likelihood of aTRH and non-TRH (vs normal blood pressure). Associations were generally similar irrespective of LVEF category. Compared with normal blood pressure, aTRH was associated with a lower adjusted risk of the composite outcome in HFrEF and HFmrEF (HR: 0.79 [95% CI: 0.74-0.85] and HR: 0.86 [95% CI: 0.77-0.96]) but not in HFpEF (HR: 0.93 [95% CI: 0.84-1.04]).

CONCLUSIONS

aTRH was most common in HFpEF and least common in HFrEF. Associated patient characteristics were similar irrespective of LVEF category. aTRH (vs normal blood pressure) was associated with a lower risk of first HF hospitalization or cardiovascular death in HFrEF and HFmrEF but not in HFpEF.

Relationship between the prognostic nutritional index and resistant hypertension in patients with essential hypertension

OBJECTIVES

Immune system activation plays a role in resistant hypertension (RHTN) pathogenesis. The clinical effect of the prognostic nutritional index (PNI) on patients with RHTN remains unclear. The aim of this study investigated the possible correlation between PNI and RHTN.

METHODS

In this cross-sectional study, we enrolled 180 adult subjects. In patients were classified into three groups according to their office and ambulatory blood pressure measurements (ABPM): RHTN (n = 60), controlled hypertension (CHTN, n = 60), and normotension-control (NT-C, n = 60). RHTN was defined as BP ≥140/90 mm Hg while taking ≥3 antihypertensive medications or BP <140/90 mm Hg while taking ≥4 medications. The PNI was calculated from the 10 x serum albumin (g/dL) + 0.005 x total lymphocyte count (/μL) formula.

RESULTS

Office and ABPM were significantly higher in patients with RHTN. Patients in the RHTN (46.1 ± 5.3) had significantly lower PNI than that in the CHTN (54.9 ± 6.7) (P = .032), and PNIs of both hypertensive groups were significantly lower than the NT-C group (P = .019, for both). The ROC curve analysis performed to assess the predictive value of PNI for RHTN and using 50.9 optimal cutoff value of PNI for RHTN gave a sensitivity of 77% and a specificity of 68.5% (AUC = 0.73, 95% CI 0.69-0.96).Multivariate analysis indicated diabetes, 24-h ABPM SBP, CRP, pill burden, and PNI (<51.6) as independent predictors of RHTN.

CONCLUSION

This study showed that the level of PNI was significantly lower in patients with RHTN compared to patients with CHTN. PNI is independently related to RHTN.

The Burden of Resistant Hypertension Across the World

PURPOSE OF REVIEW

Resistant hypertension (R-HTN) is related to worse cardiovascular, renal outcomes, and death compared to non R-HTN. We aimed to review the burden of R-HTN across the world, focusing on its prevalence, associated factors and outcomes, and the impact of treatment.

RECENT FINDINGS

R-HTN prevalence among hypertensive individuals varies around 10-20%, depending on the population and definition applied. R-HTN consistently relates to older age, chronic kidney disease, obesity, and obstructive sleep apnea - which are increasing in prevalence with global population aging. As such, R-HTN prevalence is also expected to rise. Infrequent use of ambulatory blood pressure monitoring to identify at higher risk individuals and poor adherence to treatment are still barriers in the approach of R-HTN. Available evidence suggests that 10-20% of patients with hypertension have R-HTN. However, the prevalence of true R-HTN using contemporaneous standardized definitions is still unknown. Novel strategies to address clinicians, patients and health system barriers to treatment inertia and adherence are fundamental to reduce the burden of R-HTN.