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Lin S, Hsu YJ, Kim JS, Jackson JW, Segal JB. Predictive Factors of Apparent Treatment Resistant Hypertension Among Patients With Hypertension Identified Using Electronic Health Records. J Gen Intern Med 2024:10.1007/s11606-024-09068-z. [PMID: 39358502 DOI: 10.1007/s11606-024-09068-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2024] [Accepted: 09/20/2024] [Indexed: 10/04/2024]
Abstract
BACKGROUND Early identification of a patient with resistant hypertension (RH) enables quickly intensified treatment, short-interval follow-up, or perhaps case management to bring his or her blood pressure under control and reduce the risk of complications. OBJECTIVE To identify predictors of RH among individuals with newly diagnosed hypertension (HTN), while comparing different prediction models and techniques for managing missing covariates using electronic health records data. DESIGN Risk prediction study in a retrospective cohort. PARTICIPANTS Adult patients with incident HTN treated in any of the primary care clinics of one health system between April 2013 and December 2016. MAIN MEASURES Predicted risk of RH at the time of HTN identification and candidate predictors for variable selection in future model development. KEY RESULTS Among 26,953 individuals with incident HTN, 613 (2.3%) met criteria for RH after 4.7 months (interquartile range, 1.2-11.3). Variables selected by the least absolute shrinkage and selection operator (LASSO), included baseline systolic blood pressure (SBP) and its missing indicator (a dummy variable created if baseline SBP is absent), use of antihypertensive medication at the time of cohort entry, body mass index, and atherosclerosis risk. The random forest technique achieved the highest area under the curve (AUC) of 0.893 (95% CI, 0.881-0.904) and the best calibration with a calibration slope of 1.01. Complete case analysis is not a valuable option (AUC = 0.625). CONCLUSIONS Machine learning techniques and traditional logistic regression exhibited comparable levels of predictive performance after handling the missingness. We suggest that the variables identified by this study may be good candidates for clinical prediction models to alert clinicians to the need for short-interval follow up and more intensive early therapy for HTN.
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Affiliation(s)
- Shanshan Lin
- Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Yea-Jen Hsu
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Ji Soo Kim
- Division of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - John W Jackson
- Center for Drug Safety and Effectiveness, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Jodi B Segal
- Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
- Center for Drug Safety and Effectiveness, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA.
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
- Division of General Internal Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA.
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Schäfer AKC, Wallbach M, Schroer C, Lehnig LY, Lüders S, Hasenfuß G, Wachter R, Koziolek MJ. Effects of baroreflex activation therapy on cardiac function and morphology. ESC Heart Fail 2024; 11:3360-3367. [PMID: 38970313 PMCID: PMC11424325 DOI: 10.1002/ehf2.14940] [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: 11/16/2023] [Revised: 04/17/2024] [Accepted: 06/18/2024] [Indexed: 07/08/2024] Open
Abstract
AIMS Arterial hypertension (aHTN) plays a fundamental role in the pathogenesis and prognosis of heart failure with preserved ejection fraction (HFpEF). The risk of heart failure increases with therapy-resistant arterial hypertension (trHTN), defined as inadequate blood pressure (BP) control ≥140/90 mmHg despite taking ≥3 antihypertensive medications including a diuretic. This study investigates the effects of the BP lowering baroreflex activation therapy (BAT) on cardiac function and morphology in patients with trHTN with and without HFpEF. METHODS Sixty-four consecutive patients who had been diagnosed with trHTN and received BAT implantation between 2012 and 2016 were prospectively observed. Office BP, electrocardiographic and echocardiographic data were collected before and after BAT implantation. RESULTS Mean patients' age was 59.1 years, 46.9% were male, and mean body mass index (BMI) was 33.2 kg/m2. The prevalence of diabetes mellitus was 38.8%, atrial fibrillation was 12.2%, and chronic kidney disease (CKD) stage ≥3 was 40.8%. Twenty-eight patients had trHTN with HFpEF, and 21 patients had trHTN without HFpEF. Patients with HFpEF were significantly older (64.7 vs. 51.6 years, P < 0.0001), had a lower BMI (30.0 vs. 37.2 kg/m2, P < 0.0001), and suffered more often from CKD-stage ≥3 (64 vs. 20%, P = 0.0032). After BAT implantation, mean office BP dropped in patients with and without HFpEF (from 169 ± 5/86 ± 4 to 143 ± 4/77 ± 3 mmHg [P = 0.0019 for systolic BP and 0.0403 for diastolic BP] and from 170 ± 5/95 ± 4 to 149 ± 6/88 ± 5 mmHg [P = 0.0019 for systolic BP and 0.0763 for diastolic BP]), while a significant reduction of the intake of calcium-antagonists, α2-agonists and direct vasodilators, as well as a decrease in average dosage of ACE-inhibitors and α2-agonists could be seen. Within the study population, a decrease in heart rate from 74 ± 2 to 67 ± 2 min-1 (P = 0.0062) and lengthening of QRS-time from 96 ± 3 to 106 ± 4 ms (P = 0.0027) and QTc-duration from 422 ± 5 to 432 ± 5 ms (P = 0.0184) were detectable. The PQ duration was virtually unchanged. In patients without HF, no significant changes of echocardiographic parameters could be seen. In patients with HFpEF, posterior wall diameter decreased significantly from 14.0 ± 0.5 to 12.7 ± 0.3 mm (P = 0.0125), left ventricular mass (LVM) declined from 278.1 ± 15.8 to 243.9 ± 13.4 g (P = 0.0203), and e' lateral increased from 8.2 ± 0.4 to 9.0 ± 0.4 cm/s (P = 0.0471). CONCLUSIONS BAT reduced systolic and diastolic BP and was associated with morphological and functional improvement of HFpEF.
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Affiliation(s)
- Ann-Kathrin C Schäfer
- Department of Nephrology and Rheumatology, University Medical Centre, Göttingen, Germany
| | - Manuel Wallbach
- Department of Nephrology and Rheumatology, University Medical Centre, Göttingen, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site, Göttingen, Germany
| | - Charlotte Schroer
- Department of Nephrology and Rheumatology, University Medical Centre, Göttingen, Germany
| | - Luca-Yves Lehnig
- Department of Nephrology and Rheumatology, University Medical Centre, Göttingen, Germany
| | - Stephan Lüders
- Department of Nephrology and Rheumatology, University Medical Centre, Göttingen, Germany
- St. Josefs Hospital, Cloppenburg, Germany
| | - Gerhard Hasenfuß
- German Center for Cardiovascular Research (DZHK), Partner Site, Göttingen, Germany
- Department of Cardiology and Pulmonology, University Medical Centre, Göttingen, Germany
| | - Rolf Wachter
- German Center for Cardiovascular Research (DZHK), Partner Site, Göttingen, Germany
- Department of Cardiology and Pulmonology, University Medical Centre, Göttingen, Germany
| | - Michael J Koziolek
- Department of Nephrology and Rheumatology, University Medical Centre, Göttingen, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site, Göttingen, Germany
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Alshahawey M, Jafari E, Smith SM, McDonough CW. Characterizing apparent treatment resistant hypertension in the United States: insights from the All of Us Research Program. J Am Med Inform Assoc 2024:ocae227. [PMID: 39181122 DOI: 10.1093/jamia/ocae227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2024] [Revised: 07/29/2024] [Accepted: 08/13/2024] [Indexed: 08/27/2024] Open
Abstract
BACKGROUND Hypertension (HTN) remains a significant public health concern and the primary modifiable risk factor for cardiovascular disease, which is the leading cause of death in the United States. We applied our validated HTN computable phenotypes within the All of Us Research Program to uncover prevalence and characteristics of HTN and apparent treatment-resistant hypertension (aTRH) in United States. METHODS Within the All of Us Researcher Workbench, we built a retrospective cohort (January 1, 2008-July 1, 2023), identifying all adults with available age data, at least one blood pressure (BP) measurement, prescribed at least one antihypertensive medication, and with at least one SNOMED "Essential hypertension" diagnosis code. RESULTS We identified 99 461 participants with HTN who met the eligibility criteria. Following the application of our computable phenotypes, an overall population of 81 462 were further categorized to aTRH (14.4%), stable-controlled HTN (SCH) (39.5%), and Other HTN (46.1%). Compared to participants with SCH, participants with aTRH were older, more likely to be of Black or African American race, had higher levels of social deprivation, and a heightened prevalence of comorbidities such as hyperlipidemia and diabetes. Heart failure, chronic kidney disease, and diabetes were the comorbidities most strongly associated with aTRH. β-blockers were the most prescribed antihypertensive medication. At index date, the overall BP control rate was 62%. DISCUSSION AND CONCLUSION All of Us provides a unique opportunity to characterize HTN in the United States. Consistent findings from this study with our prior research highlight the interoperability of our computable phenotypes.
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Affiliation(s)
- Mona Alshahawey
- Department of Pharmacotherapy and Translational Research, Center for Pharmacogenomics and Precision Medicine, College of Pharmacy, University of Florida, Gainesville, FL 32610, United States
- Department of Clinical Pharmacy, College of Pharmacy, Ain Shams University, Cairo 11566, Egypt
| | - Eissa Jafari
- Department of Pharmacotherapy and Translational Research, Center for Pharmacogenomics and Precision Medicine, College of Pharmacy, University of Florida, Gainesville, FL 32610, United States
- Department of Pharmacy Practice, College of Pharmacy, Jazan University, Jazan 45142, Saudi Arabia
| | - Steven M Smith
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL 32610, United States
| | - Caitrin W McDonough
- Department of Pharmacotherapy and Translational Research, Center for Pharmacogenomics and Precision Medicine, College of Pharmacy, University of Florida, Gainesville, FL 32610, United States
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Shariati F, Tandan N, Lavie CJ. Resistant hypertension. Curr Opin Cardiol 2024; 39:266-272. [PMID: 38456513 DOI: 10.1097/hco.0000000000001134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/09/2024]
Abstract
PURPOSE OF REVIEW Resistant hypertension (RH) is characterized by persistently elevated blood pressure despite the concurrent use of three antihypertensive medications, including a diuretic, at optimal doses. This clinical phenomenon poses a significant burden on healthcare systems worldwide due to its association with increased cardiovascular disease morbidity and mortality. RECENT FINDINGS Ongoing studies on device-based treatment of RH, with aim to reduce sympathetic nervous system outflow, have shown promising evidence in management of RH which may in turn decrease the incidence of composite cardiovascular outcome faced by the affected population. SUMMARY This paper aims to provide a comprehensive overview of RH, and review some of the diagnostic and therapeutic approaches in management of RH.
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Affiliation(s)
- Farnoosh Shariati
- Ochsner Heart and Vascular Institute, Ochsner Clinical School - The University of Queensland School of Medicine, New Orleans, Louisiana, USA
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Bakris G, Lin P(P, Xu C, Chen C, Ashton V, Singhal M. Prediction of cardiovascular and renal risk among patients with apparent treatment-resistant hypertension in the United States using machine learning methods. J Clin Hypertens (Greenwich) 2024; 26:500-513. [PMID: 38523465 PMCID: PMC11088433 DOI: 10.1111/jch.14791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 02/08/2024] [Accepted: 02/11/2024] [Indexed: 03/26/2024]
Abstract
Apparent treatment-resistant hypertension (aTRH), defined as blood pressure (BP) that remains uncontrolled despite unconfirmed concurrent treatment with three antihypertensives, is associated with an increased risk of developing cardiovascular and renal complications compared with controlled hypertension. We aimed to identify the characteristics of aTRH patients with an elevated risk of major adverse cardiovascular events plus (MACE+; defined as stroke, myocardial infarction, or heart failure hospitalization) and end stage renal disease (ESRD). This retrospective cohort study included aTRH patients (BP ≥140/90 mmHg and taking ≥3 antihypertensives) from the United States-based Optum® de-identified Electronic Health Record dataset and used machine learning models to identify risk factors of MACE+ or ESRD. Patients had claims for ≥3 antihypertensive classes within 30 days between January 1, 2015 and June 30, 2021, and two office BP measures recorded 1-90 days apart within 30 days to 11 months after the index regimen date. Of a total 18 797 070 patients identified with any hypertension, 71 100 patients had aTRH. During the study period (mean 25.5 months), 4944 (7.0%) patients had a MACE+ and 2403 (3.4%) developed ESRD. In total, 22 risk factors were included in the MACE+ model and 16 in the ESRD model, and most were significantly associated with study outcomes. The risk factors with the largest impact on MACE+ risk were congestive heart failure, stages 4 and 5 chronic kidney disease (CKD), age ≥80 years, and living in the Southern region of the United States. The risk factors with the largest impact on ESRD risk, other than pre-existing CKD, were anemia, congestive heart failure, and type 2 diabetes. The overall study cohort had a 5-year predicted MACE+ risk of 13.4%; this risk was increased in those in the top 50% and 25% high-risk groups (21.2% and 29.5%, respectively). The overall study cohort had a predicted 5-year risk of ESRD of 6.8%, which was increased in the top 50% and 25% high-risk groups (10.9% and 17.1%, respectively). We conclude that risk models developed in our study can reliably identify patients with aTRH at risk of MACE+ and ESRD based on information available in electronic health records; such models may be used to identify aTRH patients at high risk of adverse outcomes who may benefit from novel treatment interventions.
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Affiliation(s)
| | | | - Chang Xu
- Janssen Scientific Affairs, LLCTitusvilleNew JerseyUSA
| | - Cindy Chen
- Janssen Scientific Affairs, LLCTitusvilleNew JerseyUSA
| | | | - Mukul Singhal
- Janssen Scientific Affairs, LLCTitusvilleNew JerseyUSA
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Song L, Yang H, Ning X, Ma Y, Xue A, Du Y, Lu Q, Liu Z, Wang X, Wang J. Sacubitril/valsartan reversal of left ventricular remodeling is associated with improved hemodynamics in resistant hypertension. Hellenic J Cardiol 2024:S1109-9666(24)00073-3. [PMID: 38582140 DOI: 10.1016/j.hjc.2024.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Revised: 02/06/2024] [Accepted: 03/23/2024] [Indexed: 04/08/2024] Open
Abstract
BACKGROUND Sacubitril/valsartan (S/V) has been shown to be an effective antihypertensive drug combination. However, its therapeutic effects on blood pressure (BP), hemodynamics, and left ventricular (LV) remodeling in resistant hypertension (RHTN) remain unclear. METHODS Eighty-six patients completed this self-control study, during which olmesartan was administered within the first 8 weeks (phase 1), followed by S/V within the second 8 weeks (phase 2), with nifedipine and hydrochlorothiazide taken as background medications. Office BP, echocardiography, and hemodynamics assessment using impedance cardiography were performed at baseline and at the eighth and sixteenth weeks. RESULTS The reduction in office BP was larger in phase 2 than in phase 1 (19.59/11.66 mmHg vs. 2.88/1.15 mmHg). Furthermore, the treatment in phase 2 provided greater reductions in systemic vascular resistance index (SVRI) and thoracic blood saturation ratio (TBR), with differences between the two phases of -226.59 (-1212.80 to 509.55) dyn·s/cm5/m2 and -0.02 (-0.04 to 0.02). Switching from olmesartan to S/V also significantly reduced E/E', LV mass index, LV end-diastolic volume index, and LV end-systolic volume index (all P < 0.05). Decreases in arterial stiffness, SVRI, and TBR were correlated with changes in indicators of LV remodeling (all P < 0.05). This correlation persisted even after adjusting for confounders including changes in BP. CONCLUSIONS Switching from olmesartan to S/V effectively lowered BP and reversed ventricular remodeling in RHTN. In addition, hemodynamic improvement was also observed. Changes in hemodynamics played an important role in reversing LV remodeling of S/V, and were independent of its antihypertensive effect.
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Affiliation(s)
- Lixue Song
- Department of Cardiology, The Second Hospital of Shandong University, Jinan, Shandong, China
| | - Hongrui Yang
- Department of Cardiology, The Second Hospital of Shandong University, Jinan, Shandong, China
| | - Xiang Ning
- Department of Cardiology, The Second Hospital of Shandong University, Jinan, Shandong, China
| | - Yanyan Ma
- Department of Cardiology, The Second Hospital of Shandong University, Jinan, Shandong, China
| | - Aiying Xue
- Department of Cardiology, The Second Hospital of Shandong University, Jinan, Shandong, China
| | - Yimeng Du
- Department of Cardiology, The Second Hospital of Shandong University, Jinan, Shandong, China
| | - Qinghua Lu
- Department of Cardiology, The Second Hospital of Shandong University, Jinan, Shandong, China
| | - Zhendong Liu
- Cardio-Cerebrovascular Control and Research Center, Clinical and Basic Medical College, Shandong First Medical University, Jinan, Shandong, China
| | - Xin Wang
- Department of Cardiology, The Second Hospital of Shandong University, Jinan, Shandong, China.
| | - Juan Wang
- Department of Cardiology, The Second Hospital of Shandong University, Jinan, Shandong, China.
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Jafari E, Cooper-DeHoff RM, Effron MB, Hogan WR, McDonough CW. Characteristics and Predictors of Apparent Treatment-Resistant Hypertension in Real-World Populations Using Electronic Health Record-Based Data. Am J Hypertens 2024; 37:60-68. [PMID: 37712350 PMCID: PMC10724527 DOI: 10.1093/ajh/hpad084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Revised: 09/07/2023] [Accepted: 09/12/2023] [Indexed: 09/16/2023] Open
Abstract
BACKGROUND Apparent treatment-resistant hypertension (aTRH) is defined as uncontrolled blood pressure (BP) despite using ≥3 antihypertensive classes or controlled BP while using ≥4 antihypertensive classes. Patients with aTRH have a higher risk for adverse cardiovascular outcomes compared with patients with controlled hypertension (HTN). Although there have been prior reports on the prevalence, characteristics, and predictors of aTRH, these have been broadly derived from smaller datasets, randomized controlled trials, or closed healthcare systems. METHODS We extracted patients with HTN defined by ICD-9 and ICD-10 codes during 1/1/2015-12/31/2018, from 2 large electronic health record databases: the OneFlorida Data Trust (n = 223,384) and Research Action for Health Network (REACHnet) (n = 175,229). We applied our previously validated aTRH and stable controlled HTN computable phenotype algorithms and performed univariate and multivariate analyses to identify the prevalence, characteristics, and predictors of aTRH in these populations. RESULTS The prevalence of aTRH among patients with HTN in OneFlorida (16.7%) and REACHnet (11.3%) was similar to prior reports. Both populations had a significantly higher proportion of Black patients with aTRH compared with those with stable controlled HTN. aTRH in both populations shared similar significant predictors, including Black race, diabetes, heart failure, chronic kidney disease, cardiomegaly, and higher body mass index. In both populations, aTRH was significantly associated with similar comorbidities, when compared with stable controlled HTN. CONCLUSIONS In 2 large, diverse real-world populations, we observed similar comorbidities and predictors of aTRH as prior studies. In the future, these results may be used to improve healthcare professionals' understanding of aTRH predictors and associated comorbidities.
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Affiliation(s)
- Eissa Jafari
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, College of Pharmacy, University of Florida, Gainesville, Florida, USA
- Department of Pharmacy Practice, College of Pharmacy, Jazan University, Jazan, Saudi Arabia
| | - Rhonda M Cooper-DeHoff
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, College of Pharmacy, University of Florida, Gainesville, Florida, USA
- Division of Cardiovascular Medicine, Department of Medicine, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Mark B Effron
- John Ochsner Heart and Vascular Institute, The University of Queensland Ochsner Clinical School, New Orleans, Louisiana, USA
| | - William R Hogan
- Department of Health Outcomes and Biomedical Informatics, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Caitrin W McDonough
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, College of Pharmacy, University of Florida, Gainesville, Florida, USA
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Abstract
PURPOSE The current review is to describe the definition and prevalence of resistant arterial hypertension (RAH), the difference between refractory hypertension, patient characteristics and major risk factors for RAH, how RAH is diagnosed, prognosis and outcomes for patients. MATERIALS AND METHODS According to the WHO, approximately 1.28 billion adults aged 30-79 worldwide have arterial hypertension, and over 80% of them do not have blood pressure (BP) under control. RAH is defined as above-goal elevated BP despite the concurrent use of 3 or more classes of antihypertensive drugs, commonly including a long-acting calcium channel blocker, an inhibitor of the renin-angiotensin system (angiotensin-converting enzyme inhibitor or angiotensin receptor blocker), and a thiazide diuretic administered at maximum or maximally tolerated doses and at appropriate dosing frequency. RAH occurs in nearly 1 of 6 hypertensive patients. It often remains unrecognised mainly because patients are not prescribed ≥3 drugs at maximal doses despite uncontrolled BP. CONCLUSION RAH distinctly increases the risk of developing coronary artery disease, heart failure, stroke and chronic kidney disease and confers higher rates of major adverse cardiovascular events as well as increased all-cause mortality. Timely diagnosis and treatment of RAH may mitigate the associated risks and improve short and long-term prognosis.
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Ebinger JE, Gluckman TJ, Magraner J, Chiu ST, Rider D, Thomas C, Das SR, Ho PM, Shreenivas S, Bradley S. Characterization of Individuals With Apparent Resistant Hypertension Using Contemporary Guidelines: Insights From CV-QUIC. Hypertension 2023; 80:1845-1855. [PMID: 37357771 PMCID: PMC10524942 DOI: 10.1161/hypertensionaha.123.20894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 05/09/2023] [Indexed: 06/27/2023]
Abstract
BACKGROUND Apparent resistant hypertension (aRH) carries excess cardiovascular risk beyond nonresistant forms of hypertension; however, our understanding of this at-risk population, as defined by current US practice guidelines, is limited. Accordingly, we sought to evaluate the prevalence, clinical characteristics, and pharmacotherapeutic patterns of patients with aRH using contemporary blood pressure guidance. METHODS We classified patients at 3 large healthcare systems by hypertensive status using contemporary hypertension guidelines. We subsequently described the demographic and clinical characteristics of patients with aRH and compared these factors among hypertensive patients without aRH and between those with controlled and uncontrolled aRH. RESULTS A total of 2 420 468 patients were analyzed, of whom 1 343 489 (55.6%) were hypertensive according to contemporary guidelines. Among hypertensive patients, 11 992 (8.5%) met criteria for aRH, with nearly all assessed comorbid conditions, particularly diabetes and heart failure, being more common in those with aRH. When compared with patients with uncontrolled aRH, those with controlled aRH were more frequently prescribed a beta-blocker, diuretic, and nitrate, with the largest standardized difference observed for a mineralocorticoid receptor antagonist (35.4% versus 10.4%, Cohen D 0.62). Consistent findings were noted in sensitivity analyses using the blood pressure threshold of 140/90 mm Hg. CONCLUSIONS In an analysis of over 2.4 million individuals, a lower prevalence of aRH was observed than previously reported (12%-15%), but with a high burden of comorbidities. Identification of differences in pharmacotherapy between patients with controlled and uncontrolled aRH, particularly lower rates of mineralocorticoid receptor antagonist use, help define potential opportunities to improve care and lower cardiovascular risk.
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Affiliation(s)
- Joseph E. Ebinger
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Ty J Gluckman
- Center for Cardiovascular Analytics, Research and Data Science, Providence Heart Institute, Providence St. Joseph Health, Portland, Oregon, USA
| | - Jose Magraner
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Shih Ting Chiu
- Center for Cardiovascular Analytics, Research and Data Science, Providence Heart Institute, Providence St. Joseph Health, Portland, Oregon, USA
| | - Deanna Rider
- Providence Research Network, Missoula, Montana, USA
| | | | - Sandeep R Das
- University of Texas Southwestern Medical Center and Center for Innovation and Value at Parkland, Dallas, Texas, USA
| | - P Michael Ho
- University of Colorado School of Medicine, VA Eastern Colorado Health Care System, Aurora, Colorado, USA
| | - Satya Shreenivas
- Lindner Center for Research, The Christ Hospital, Cincinnati, Ohio, USA
| | - Steven Bradley
- Healthcare Delivery Innovation Center, Minneapolis Heart Institute, Minnesota, USA
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Champaneria MK, Patel RS, Oroszi TL. When blood pressure refuses to budge: exploring the complexity of resistant hypertension. Front Cardiovasc Med 2023; 10:1211199. [PMID: 37416924 PMCID: PMC10322223 DOI: 10.3389/fcvm.2023.1211199] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 05/25/2023] [Indexed: 07/08/2023] Open
Abstract
Resistant hypertension, defined as blood pressure that remains above goal despite using three or more antihypertensive medications, including a diuretic, affects a significant proportion of the hypertensive population and is associated with increased cardiovascular morbidity and mortality. Despite the availability of a wide range of pharmacological therapies, achieving optimal blood pressure control in patients with resistant hypertension remains a significant challenge. However, recent advances in the field have identified several promising treatment options, including spironolactone, mineralocorticoid receptor antagonists, and renal denervation. In addition, personalized management approaches based on genetic and other biomarkers may offer new opportunities to tailor therapy and improve outcomes. This review aims to provide an overview of the current state of knowledge regarding managing resistant hypertension, including the epidemiology, pathophysiology, and clinical implications of the condition, as well as the latest developments in therapeutic strategies and future prospects.
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Khalfallah M, Elsheikh A, Eissa A, Elnagar B. Prevalence, Predictors, and Outcomes of Resistant Hypertension in Egyptian Population. Glob Heart 2023; 18:31. [PMID: 37334401 PMCID: PMC10275134 DOI: 10.5334/gh.1211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 05/16/2023] [Indexed: 06/20/2023] Open
Abstract
Background Hypertension is a leading problem; it affects around thirty million adult Egyptians, according to the last national registry. The exact prevalence of resistant hypertension (RH) in Egypt wasn't spotted before. The purpose of this study was to determine the prevalence, predictors, and impact on adverse cardiovascular outcomes among adult Egyptians with RH. Methods The present study examined a cohort of 990 hypertensive patients who were divided into two groups based on their blood pressure control; group I (n = 842) patients who achieved blood pressure control and group II (n = 148) patients who met the RH definition criteria. All patients underwent a close follow-up for one year to evaluate the major cardiovascular events. Results The prevalence of RH was 14.9%. The main predictors impacting the cardiovascular outcomes of RH were advanced age (≥65 years), the presence of chronic kidney diseases, a BMI ≥ 30 kg/m2, and NSAID use. After one year of follow-up, the RH group displayed noticeably higher rates of major cardiovascular events, including new-onset atrial fibrillation (6.8% vs. 2.5%, P = 0.006), cerebral stroke (4.1% vs. 1.2%, P = 0.011), myocardial infarction (4.7% vs. 1.3%, P = 0.004), and acute heart failure (4.7% vs. 1.8%, P = 0.025). Conclusion The prevalence of RH in Egypt is moderately high. Patients with RH have a far higher risk of cardiovascular events than those whose blood pressure is within control.
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Affiliation(s)
- Mohamed Khalfallah
- Assistant professor of cardiovascular medicine, cardiovascular department, faculty of Medicine, Tanta University, EG
| | - Ayman Elsheikh
- Assistant professor of cardiovascular medicine, cardiovascular department, faculty of Medicine, Tanta University, EG
| | - Ahmad Eissa
- Lecturer of endocrinology, internal medicine department, faculty of Medicine, Tanta University, EG
| | - Basma Elnagar
- Lecturer of cardiovascular medicine, cardiovascular department, faculty of Medicine, Tanta University, EG
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Jafari E, Cooper-DeHoff RM, Effron MB, Hogan WR, McDonough CW. Characteristics and Predictors of Apparent Treatment Resistant Hypertension in Real-World Populations Using Electronic Health Record-Based Data. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.04.28.23289293. [PMID: 37205447 PMCID: PMC10187337 DOI: 10.1101/2023.04.28.23289293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
Background Apparent treatment-resistant hypertension (aTRH) is defined as uncontrolled blood pressure (BP) despite using ≥3 antihypertensive classes or controlled BP while using ≥4 antihypertensive classes. Patients with aTRH have a higher risk for adverse cardiovascular outcomes compared to patients with controlled hypertension. Although there have been prior reports on the prevalence, characteristics, and predictors of aTRH, these have been broadly derived from smaller datasets, randomized controlled trials, or closed healthcare systems. Methods We extracted patients with hypertension defined by ICD 9 and 10 codes during 1/1/2015-12/31/2018, from two large electronic health record databases: the OneFlorida Data Trust (n=223,384) and Research Action for Health Network (REACHnet) (n=175,229). We applied our previously validated aTRH and stable controlled hypertension (HTN) computable phenotype algorithms and performed univariate and multivariate analyses to identify the prevalence, characteristics, and predictors of aTRH in these real-world populations. Results The prevalence of aTRH in OneFlorida (16.7%) and REACHnet (11.3%) was similar to prior reports. Both populations had a significantly higher proportion of black patients with aTRH compared to those with stable controlled HTN. aTRH in both populations shared similar significant predictors, including black race, diabetes, heart failure, chronic kidney disease, cardiomegaly, and higher body mass index. In both populations, aTRH was significantly associated with similar comorbidities, when compared with stable controlled HTN. Conclusion In two large, diverse real-world populations, we observed similar comorbidities and predictors of aTRH as prior studies. In the future, these results may be used to improve healthcare professionals' understanding of aTRH predictors and associated comorbidities. Clinical Perspective What Is New?: Prior studies of apparent treatment resistant hypertension have focused on cohorts from smaller datasets, randomized controlled trials, or closed healthcare systems.We used validated computable phenotype algorithms for apparent treatment resistant hypertension and stable controlled hypertension to identify the prevalence, characteristics, and predictors of apparent treatment resistant hypertension in two large, diverse real-world populations.What Are the Clinical Implications?: Large, diverse real-world populations showed a similar prevalence of aTRH, 16.7% in OneFlorida and 11.3% in REACHnet, compared to those observed from other cohorts.Patients classified as apparent treatment resistant hypertension were significantly older and had a higher prevalence of comorbid conditions such as diabetes, dyslipidemia, coronary artery disease, heart failure with preserved ejection fraction, and chronic kidney disease stages 1-3.Within diverse, real-world populations, the strongest predictors for apparent treatment resistant hypertension were black race, higher body mass index, heart failure, chronic kidney disease, and diabetes.
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Zhu B, Liu Y, Zhou W, Du Y, Qi D, Wang C, Cheng Q, Zhang Y, Wang S, Gao C. Clinical characteristics and outcomes of Chinese patients with coronary heart disease and resistant hypertension. J Clin Hypertens (Greenwich) 2023; 25:350-359. [PMID: 36929173 PMCID: PMC10085807 DOI: 10.1111/jch.14651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Revised: 02/22/2023] [Accepted: 02/24/2023] [Indexed: 03/18/2023]
Abstract
There is currently few research on clinical characteristics and outcomes of coronary heart disease (CHD) with resistant hypertension in central region of China. This study aimed to assess the risk factors and outcomes of CHD and resistant hypertension in population of central region of China. A total of 1467 CHD patients with hypertension were included and considered to three groups according to blood pressure control: controlled group (blood pressure < 140/90 mmHg on three or less antihypertensive drugs); uncontrolled group (blood pressure ≥ 140/90 mmHg on two or less antihypertensive drugs); or resistant group (blood pressure ≥ 140/90 mmHg on three antihypertensive drugs or < 140/90 mmHg on at least four antihypertensive drugs including diuretic). The authors evaluated the clinical outcomes of three groups at 1-year follow-up. The prevalence of resistant hypertension was 21.8%. Significant adjusted associated factors of resistant hypertension included per unit changes body mass index (BMI, OR 1.12), and four categorical variable diagnosis by yes or no: heart failure (HF, OR 2.62), left ventricular hypertrophy (LVH, OR 2.83), diabetes (OR 1.55), and chronic kidney disease (CKD, OR 1.63). In multiple adjusted Cox regression analysis, patients in resistant group had a higher risk of the primary outcome (HR, 2.14 [95% CI, 1.47-3.11]; p < .001). Moreover, the risk of atherosclerotic cardiovascular disease (ASCVD) in patients with resistant hypertension is also significantly increased (HR, 2.11 [95% CI, 1.39-3.20]; p < .001). In conclusion, resistant hypertension was a quite common and high proportion finding in patients with CHD and hypertension in central region of China, and these patients have a worse clinical prognosis.
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Affiliation(s)
- Binbin Zhu
- Department of Cardiology, Zhengzhou University People's Hospital, Henan Provincial People's Hospital, Zhengzhou, China.,Henan Provincial Key Lab for Control of Coronary Heart Disease, Zhengzhou University Central China Fuwai Hospital, Zhengzhou, China
| | - Yahui Liu
- Department of Cardiology, Zhengzhou University People's Hospital, Henan Provincial People's Hospital, Zhengzhou, China.,Henan Provincial Key Lab for Control of Coronary Heart Disease, Zhengzhou University Central China Fuwai Hospital, Zhengzhou, China
| | - Weicen Zhou
- Henan Provincial Key Lab for Control of Coronary Heart Disease, Zhengzhou University Central China Fuwai Hospital, Zhengzhou, China
| | - Yao Du
- Henan Provincial Key Lab for Control of Coronary Heart Disease, Zhengzhou University Central China Fuwai Hospital, Zhengzhou, China
| | - Datun Qi
- Department of Cardiology, Zhengzhou University People's Hospital, Henan Provincial People's Hospital, Zhengzhou, China.,Henan Provincial Key Lab for Control of Coronary Heart Disease, Zhengzhou University Central China Fuwai Hospital, Zhengzhou, China
| | - Chenxu Wang
- Henan Provincial Key Lab for Control of Coronary Heart Disease, Zhengzhou University Central China Fuwai Hospital, Zhengzhou, China
| | - Qianqian Cheng
- Henan Provincial Key Lab for Control of Coronary Heart Disease, Zhengzhou University Central China Fuwai Hospital, Zhengzhou, China
| | - You Zhang
- Henan Provincial Key Lab for Control of Coronary Heart Disease, Zhengzhou University Central China Fuwai Hospital, Zhengzhou, China
| | - Shan Wang
- Henan Provincial Key Lab for Control of Coronary Heart Disease, Zhengzhou University Central China Fuwai Hospital, Zhengzhou, China
| | - Chuanyu Gao
- Department of Cardiology, Zhengzhou University People's Hospital, Henan Provincial People's Hospital, Zhengzhou, China.,Henan Provincial Key Lab for Control of Coronary Heart Disease, Zhengzhou University Central China Fuwai Hospital, Zhengzhou, China
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14
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Promise of Physiological Profiling to Prevent Stroke in People of African Ancestry: Prototyping Ghana. Curr Neurol Neurosci Rep 2022; 22:735-743. [PMID: 36181575 DOI: 10.1007/s11910-022-01239-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/25/2022] [Indexed: 01/27/2023]
Abstract
PURPOSE OF REVIEW Worldwide, compared to other racial/ethnic groups, individuals of African ancestry have an excessively higher burden of hypertension-related morbidities, especially stroke. Identifying modifiable biological targets that contribute to these disparities could improve global stroke outcomes. In this scoping review, we discuss how pathological perturbations in the renin-angiotensin-aldosterone pathways could be harnessed via physiological profiling for the purposes of improving blood pressure control for stroke prevention among people of African ancestry. RECENT FINDINGS Transcontinental comparative data from the USA and Ghana show that the prevalence of treatment-resistant hypertension among stroke survivors is 42.7% among indigenous Africans, 16.1% among African Americans, and 6.9% among non-Hispanic Whites, p < 0.0001. A multicenter clinical trial of patients without stroke in 3 African countries (Nigeria, Kenya, and South Africa) demonstrated that physiological profiling using plasma renin activity and aldosterone to individualize selection of antihypertensive medications compared with usual care resulted in better blood pressure control with fewer medications over 12 months. Among Ghanaian ischemic stroke survivors treated without renin-aldosterone profiling data, an analysis revealed that those with low renin phenotypes did not achieve any meaningful reduction in blood pressure over 12 months on 3-4 antihypertensive medications despite excellent adherence. For a polygenic condition such as hypertension, individualized therapy based on plasma renin-aldosterone-guided selection of therapy for uncontrolled BP following precision medicine principles may be a viable strategy for primary and secondary stroke prevention with the potential to reduce disparities in the poor outcomes of stroke disproportionately shared by individuals of African ancestry. A dedicated clinical trial to test this hypothesis is warranted.
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15
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Leiba A, Yekutiel N, Chodick G, Wortsman J, Angel-Korman A, Weinreb B. Resistant hypertension is associated with an increased cardiovascular risk compared to patients controlled on a similar multi-drug regimen. J Hum Hypertens 2022:10.1038/s41371-022-00749-y. [PMID: 35999382 DOI: 10.1038/s41371-022-00749-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 08/02/2022] [Accepted: 08/11/2022] [Indexed: 11/09/2022]
Abstract
The long-term risk associated with resistant hypertension compared to other phenotypes of hypertension is still unclear. We aimed to assess cardiovascular and renal outcomes over 10 years of follow-up of patients with uncontrolled resistant hypertension (uRH) compared to a similarly treated (≥ 3 medication classes including a diuretic) and adherent group whose blood pressure is under control. This retrospective cohort study utilized the computerized database of Maccabi Healthcare Services, a state-mandated health provider covering 25% of the Israeli population. Clinical outcomes were assessed using Cox regression multivariable analyses. A total of 1487 patients (50% males, mean age at baseline = 68.3 ± 10.4 years) were included in the uRH cohort and 1343 patients (50% males, 66.2 ± 10.6 years) in the controlled hypertension reference group (Controlled hypertension on multi drug regimen- CH-MDR). After adjusting for age, sex, BMI and patients' comorbidities, uRH was associated with a Hazard Ratio of 1.35 (95% CI: 1.08-1.69) for incidence of ischemic heart disease, 1.51 (1.06-2.16) for secondary cardiovascular events, and 1.36 (1.00-1.86) for risk of stroke or transient ischemic attack compared to the reference group. Patients with uRH were found to have more hospitalization days (mean, 4.2 vs. 3 days per year, p < 0.001), and more emergency room visits (83.3% vs. 77%, p < 0.001). Overall, uRH was associated with a 19% (95% CI 11% to 29%) increase in direct healthcare expenditures during the first year of follow-up. uRH is associated with a substantial increased risk of both cardiovascular and cerebrovascular events, when compared to similarly treated hypertensive patients whose blood pressure is under control.
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Affiliation(s)
- Adi Leiba
- Institute of Nephrology and Hypertension, Assuta Ashdod University Hospital, Faculty of Health Sciences, Ben Gurion University, Beer Sheva, Israel. .,Faculty of Health Sciences, Ben Gurion University of the Negev, Beer Sheba, Israel.
| | - Naama Yekutiel
- Maccabitech Institute for Research & Innovation, Maccabi Healthcare Services, Tel Aviv, Israel
| | - Gabriel Chodick
- Maccabitech Institute for Research & Innovation, Maccabi Healthcare Services, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Joshua Wortsman
- Maccabitech Institute for Research & Innovation, Maccabi Healthcare Services, Tel Aviv, Israel
| | - Avital Angel-Korman
- Institute of Nephrology and Hypertension, Assuta Ashdod University Hospital, Faculty of Health Sciences, Ben Gurion University, Beer Sheva, Israel.,Faculty of Health Sciences, Ben Gurion University of the Negev, Beer Sheba, Israel
| | - Baruch Weinreb
- Faculty of Health Sciences, Ben Gurion University of the Negev, Beer Sheba, Israel
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16
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Sarfo FS, Olasoji E, Banfill GP, Ovbiagele B, Simpkins AN. Apparent Treatment-Resistant Hypertension Among Stroke Survivors: A Transcontinental Study Assessing Impact of Race and Geography. Am J Hypertens 2022; 35:715-722. [PMID: 35366323 PMCID: PMC9340623 DOI: 10.1093/ajh/hpac046] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 03/09/2022] [Accepted: 04/01/2022] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Race and geographic differences in the prevalence and predictors of hypertension in stroke survivors have been reported, but apparent treatment-resistant hypertension (aTRH) among stroke survivors by race (African ancestry vs. non-Hispanic Caucasians) and by geography (continental Africa vs. the United States) are under studied. METHODS This is a cross-sectional study using ethically approved stroke registries from the University of Florida and the Kwame Nkrumah University of Science and Technology, Kumasi, Ghana. Univariate and multivariate regression was used to evaluate for differences in prevalence of aTRH and associations with clinical covariates. RESULTS Harmonized data were available for 3,365 stroke survivors of which 943 (28.0%) were indigenous Africans, 558 (16.6%) African Americans, and 1,864 (55.4%) non-Hispanic Caucasians with median ages (interquartile range) of 59 (49-68), 61 (55-72), and 70 (62-78) years, P < 0.0001. The overall frequency of aTRH was 18.5% (95% confidence interval [CI]: 17.2%-19.8%) with 42.7% (95% CI: 39.6%-46.0%) among indigenous Africans, 16.1% (95% CI: 13.2%-19.5%) among African Americans, and 6.9% (95% CI: 5.8%-8.2%) among non-Hispanic Caucasians, P < 0.0001. Five factors associated with aTRH: age, adjusted odds ratio (95% CI) of 0.99 (0.98-0.99), female sex 0.70 (0.56-0.87), cigarette smoking 1.98 (1.36-2.90), intracerebral hemorrhage 1.98 (1.57-2.48), and Black race namely indigenous Africans 4.42 (3.41-5.73) and African Americans 2.44 (1.81-3.29). CONCLUSIONS Future studies are needed to investigate the contribution of socioeconomic disparities in the prevalence aTRH in those with African Ancestry to explore the long-term impact, and evaluate effective therapeutic interventions in this subpopulation.
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Affiliation(s)
| | - Esther Olasoji
- Department of Neurology, University of Florida, Gainesville, Florida, USA
| | - Grant P Banfill
- Department of Neurology, University of Florida, Gainesville, Florida, USA
| | - Bruce Ovbiagele
- Department of Neurology, University of California, San Francisco, San Francisco, California, USA
| | - Alexis N Simpkins
- Department of Neurology, University of Florida, Gainesville, Florida, USA
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17
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Sarfo FS, Ovbiagele B. Key determinants of long-term post-stroke mortality in Ghana. J Neurol Sci 2022; 434:120123. [PMID: 34974202 PMCID: PMC8979649 DOI: 10.1016/j.jns.2021.120123] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Revised: 12/14/2021] [Accepted: 12/23/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Stroke affects a predominantly young to middle-aged population in Africa and is associated with poor outcomes. There are limited data on patient-level determinants of long-term stroke survival on the continent. PURPOSE To assess factors associated with long-term, all-cause mortality among stroke survivors in a Ghanaian medical system. METHODS We analyzed the dataset of clinical trial involving hypertensive stroke survivors (n = 60) who enrolled in a 9-month study primarily assessing the effect of an m-health intervention on blood pressure control. This was a single tertiary center study conducted in a Ghanaian medical center. Participants or relatives were contacted by a phone call to assess vital status 4.5 years after stroke onset. Demographic, psycho-social and vascular risk factors data were collected during the study. Cox proportional hazards regression modeling was used to assess the factors associated with death. RESULTS Among the study participants, long term information was obtainable on 58 of 60 (97%). After a median follow-up of 52 months [IQR: 48 to 53 months], 16 participants had died, resulting in a mortality rate of 27.6% (95% CI of 16.6% - 40.9%). Upon adjustment for confounders, the two factors independently associated with long-term mortality were resistant hypertension (Hazard Ratio 3.99; 95% CI: 1.29-12.37] and depression (Hazard Ratio 1.18; 95% CI: 1.05-1.31; per unit rise on the Hamilton Depression Scale). CONCLUSION In this convenience sample of recent stroke patients in Ghana, over a quarter had died within 5 years of index stroke onset. Resistant hypertension and depression may be modifiable therapeutic targets to improve outcomes in these patients.
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Affiliation(s)
- Fred Stephen Sarfo
- Department of Medicine, Kwame Nkrumah University of Science & Technology, Kumasi, Ghana; Department of Medicine, Komfo Anokye Teaching Hospital, Kumasi, Ghana.
| | - Bruce Ovbiagele
- Department of Neurology, University of California, San Francisco, USA
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18
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Wijkman MO, Malachias MVB, Claggett BL, Cheng S, Matsushita K, Shah AM, Jhund PS, Coresh J, Solomon SD, Vardeny O. Resistance to antihypertensive treatment and long-term risk: The Atherosclerosis Risk in Communities study. J Clin Hypertens (Greenwich) 2021; 23:1887-1896. [PMID: 34547175 PMCID: PMC8678845 DOI: 10.1111/jch.14269] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 04/28/2021] [Accepted: 05/05/2021] [Indexed: 01/13/2023]
Abstract
More stringent blood pressure (BP) goals have led to greater prevalence of apparent resistant hypertension (ARH), yet the long‐term prognostic impact of ARH diagnosed according to these goals in the general population remains unknown. We assessed the prognostic impact of ARH according to contemporary BP goals in 9612 participants of the Atherosclerosis Risk in Communities (ARIC) study without previous cardiovascular disease. ARH, defined as BP above goal (traditional goal <140/90 mmHg, more stringent goal <130/80 mmHg) despite the use of ≥3 antihypertensive drug classes or any BP with ≥4 antihypertensive drug classes (one of which was required to be a diuretic) was compared with controlled hypertension (BP at goal with 1‐3 antihypertensive drug classes). Cox regression models were adjusted for age, sex, race, study center, BMI, heart rate, smoking, eGFR, LDL, HDL, triglycerides, and diabetes. Using the traditional BP goal, 133 participants (3.8% of the treated) had ARH. If the more stringent BP goal was instead applied, 785 participants (22.6% of the treated) were reclassified from controlled hypertension to uncontrolled hypertension (n = 725) or to ARH (n = 60). Over a median follow‐up time of 19 years, ARH was associated with increased risk for a composite end point (all‐cause mortality, hospitalization for myocardial infarction, stroke, or heart failure) regardless of whether traditional (adjusted HR 1.50, 95% CI: 1.23‐1.82) or more stringent (adjusted HR 1.43, 95% CI: 1.20‐1.70) blood pressure goals were applied. We conclude that in patients free from cardiovascular disease, ARH predicted long‐term risk regardless of whether traditional or more stringent BP criteria were applied.
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Affiliation(s)
- Magnus O Wijkman
- Cardiovascular Division, Brigham & Women's Hospital, Harvard Medical School, Boston, MA, USA.,Department of Internal Medicine and Department of Health, Medicine and Caring Sciences, Linköping University, Norrköping, Sweden
| | - Marcus V B Malachias
- Faculdade Ciências Médicas de Minas Gerais, Fundação Educacional Lucas Machado, Belo Horizonte, Brazil
| | - Brian L Claggett
- Cardiovascular Division, Brigham & Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Susan Cheng
- Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | | | - Amil M Shah
- Cardiovascular Division, Brigham & Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Pardeep S Jhund
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | | | - Scott D Solomon
- Cardiovascular Division, Brigham & Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Orly Vardeny
- Minneapolis VA Health Care System and University of Minnesota, Minneapolis, MN, USA
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Song SH, Kim YJ, Choi HS, Kim CS, Bae EH, Ahn C, Oh KH, Park SK, Lee KB, Sung S, Han SH, Ma SK, Kim SW. Persistent Resistant Hypertension Has Worse Renal Outcomes in Chronic Kidney Disease than that Resolved in Two Years: Results from the KNOW-CKD Study. J Clin Med 2021; 10:jcm10173998. [PMID: 34501446 PMCID: PMC8432533 DOI: 10.3390/jcm10173998] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 08/31/2021] [Accepted: 08/31/2021] [Indexed: 01/03/2023] Open
Abstract
Apparent treatment-resistant hypertension (ATRH) is closely related to chronic kidney disease (CKD); however, the long-term outcomes and the effects of improvement in ATRH in patients with CKD are not well understood. We evaluated the relationship between the persistence of ATRH and the progression of CKD. This cohort study enrolled 1921 patients with CKD. ATRH was defined as blood pressure above 140/90 mmHg and intake of three different types of antihypertensive agents, including diuretics, or intake of four or more different types of antihypertensive agents, regardless of blood pressure. We defined ATRH subgroups according to the ATRH status at the index year and two years later. The prevalence of ATRH at baseline was 14.0%. The presence of ATRH at both time points was an independent risk factor for end-point renal outcome (HR, 1.41; 95% CI, 1.04–1.92; p = 0.027). On the other hand, the presence of ATRH at any one of the time points was not statistically significant. In conclusion, persistent ATRH is more important for the prognosis of renal disease than the initial ATRH status. Continuous follow-up and appropriate treatment are important to improve the renal outcomes.
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Affiliation(s)
- Su-Hyun Song
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju 61469, Korea; (S.-H.S.); (Y.-J.K.); (H.-S.C.); (C.-S.K.); (E.-H.B.)
- Chonnam National Universitiy Hospital, Gwangju 61469, Korea
| | - Young-Jin Kim
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju 61469, Korea; (S.-H.S.); (Y.-J.K.); (H.-S.C.); (C.-S.K.); (E.-H.B.)
- Chonnam National Universitiy Hospital, Gwangju 61469, Korea
| | - Hong-Sang Choi
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju 61469, Korea; (S.-H.S.); (Y.-J.K.); (H.-S.C.); (C.-S.K.); (E.-H.B.)
- Chonnam National Universitiy Hospital, Gwangju 61469, Korea
| | - Chang-Seong Kim
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju 61469, Korea; (S.-H.S.); (Y.-J.K.); (H.-S.C.); (C.-S.K.); (E.-H.B.)
- Chonnam National Universitiy Hospital, Gwangju 61469, Korea
| | - Eun-Hui Bae
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju 61469, Korea; (S.-H.S.); (Y.-J.K.); (H.-S.C.); (C.-S.K.); (E.-H.B.)
- Chonnam National Universitiy Hospital, Gwangju 61469, Korea
| | - Curie Ahn
- Department of Internal Medicine, Seoul National University Hospital, Seoul 03080, Korea; (C.A.); (K.-H.O.)
| | - Kook-Hwan Oh
- Department of Internal Medicine, Seoul National University Hospital, Seoul 03080, Korea; (C.A.); (K.-H.O.)
| | - Sue-Kyung Park
- Department of Preventive Medicine, Seoul National University College of Medicine, Seoul 03080, Korea;
| | - Kyu-Beck Lee
- Department of Internal Medicine, Kangbuk Samsung Hospital, Seoul 03181, Korea;
| | - Suah Sung
- Department of Internal Medicine, Nowon Eulji Medical Center, Eulji University, Seoul 01830, Korea;
| | - Seung-Hyeok Han
- Department of Internal Medicine, College of medicine, Institute of Kidney Disease Research, Yonsei University, Seoul 03722, Korea;
| | - Seong-Kwon Ma
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju 61469, Korea; (S.-H.S.); (Y.-J.K.); (H.-S.C.); (C.-S.K.); (E.-H.B.)
- Chonnam National Universitiy Hospital, Gwangju 61469, Korea
- Correspondence: (S.-K.M.); (S.-W.K.); Tel.: +82-62-220-6271 (S.-W.K.); +82-62-220-6579 (S.-K.M.); Fax: +82-62-225-8578 (S.-W.K. & S.-K.M.)
| | - Soo-Wan Kim
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju 61469, Korea; (S.-H.S.); (Y.-J.K.); (H.-S.C.); (C.-S.K.); (E.-H.B.)
- Chonnam National Universitiy Hospital, Gwangju 61469, Korea
- Correspondence: (S.-K.M.); (S.-W.K.); Tel.: +82-62-220-6271 (S.-W.K.); +82-62-220-6579 (S.-K.M.); Fax: +82-62-225-8578 (S.-W.K. & S.-K.M.)
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20
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Kim S, Park JJ, Shin MS, Kwak CH, Lee BR, Park SJ, Lee HY, Kim SH, Kang SM, Yoo BS, Chung JW, Choi SW, Jo SH, Shin J, Choi DJ. Apparent treatment-resistant hypertension among ambulatory hypertensive patients: a cross-sectional study from 13 general hospitals. Korean J Intern Med 2021; 36:888-897. [PMID: 34092048 PMCID: PMC8273811 DOI: 10.3904/kjim.2019.361] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Accepted: 02/17/2020] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND/AIMS To examine the prevalence and clinical characteristics of apparent treatment-resistant hypertension among ambulatory hypertensive patients. METHODS We enrolled adult ambulatory hypertensive patients at 13 well-qualified general hospitals in Korea from January to June 2012. Apparent resistant hypertension was defined as an elevated blood pressure > 140/90 mmHg with the use of three antihypertensive agents, including diuretics, or ≥ 4 antihypertensives, regardless of the blood pressure. Controlled hypertension was defined as a blood pressure within the target using three antihypertensives, including diuretics. RESULTS Among 16,915 hypertensive patients, 1,172 (6.9%) had controlled hypertension, and 1,514 (8.9%) had apparent treatment-resistant hypertension. Patients with apparent treatment-resistant hypertension had an earlier onset of hypertension (56.8 years vs. 58.8 years, p = 0.007) and higher body mass index (26.3 kg/m2 vs. 24.9 kg/m2, p < 0.001) than those with controlled hypertension. Drug compliance did not differ between groups. In the multivariable analysis, earlier onset of hypertension (odds ratio [OR], 0.98; 95% confidence interval [CI], 0.97 to 0.99; p < 0.001) and the presence of comorbidities (OR, 2.06; 95% CI, 1.27 to 3.35; p < 0.001), such as diabetes mellitus, ischemic heart disease, heart failure, and chronic kidney disease, were independent predictors. Among the patients with apparent treatment-resistant hypertension, only 5.2% were receiving ≥ 2 antihypertensives at maximally tolerated doses. CONCLUSION Apparent treatment-resistant hypertension prevalence is 8.9% among ambulatory hypertensive patients in Korea. An earlier onset of hypertension and the presence of comorbidities are independent predictors. Optimization of medical treatment may reduce the rate of apparent treatment-resistant hypertension.
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Affiliation(s)
- Sehun Kim
- Division of Cardiology, Department of Internal Medicine, Hallym University Hangang Sacred Heart Hospital, Seoul,
Korea
| | - Jin Joo Park
- Cardiovascular Center, Seoul National University Bundang Hospital, Seongnam,
Korea
| | - Mi-Seung Shin
- Department of Cardiology, Gachon University Gil Medical Center, Incheon,
Korea
| | - Choong Hwan Kwak
- Division of Cardiology, Department of Internal Medicine, Gyeongsang National University Changwon Hospital, Changwon,
Korea
| | - Bong-Ryeol Lee
- Division of Cardiology, Department of Internal Medicine, Daegu Fatima Hospital, Daegu,
Korea
| | - Sung-Ji Park
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul,
Korea
| | - Hae-Young Lee
- Division of Cardiology, Department of Internal Medicine, Seoul National University Hospital, Seoul,
Korea
| | - Sang-Hyun Kim
- Division of Cardiology, Department of Internal Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul,
Korea
| | - Seok-Min Kang
- Division of Cardiology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul,
Korea
| | - Byung-Su Yoo
- Division of Cardiology, Department of Internal Medicine, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Joong-Wha Chung
- Division of Cardiology, Department of Internal Medicine, Chosun University Hospital, Gwangju,
Korea
| | - Si Wan Choi
- Division of Cardiology, Department of Internal Medicine, Chungnam National University Hospital, Daejeon,
Korea
| | - Sang-Ho Jo
- Division of Cardiology, Department of Internal Medicine, Hallym University Sacred Heart Hospital, Anyang,
Korea
| | - Jinho Shin
- Division of Cardiology, Department of Internal Medicine, Hanyang University Hospital, Seoul,
Korea
| | - Dong-Ju Choi
- Cardiovascular Center, Seoul National University Bundang Hospital, Seongnam,
Korea
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21
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Schäfer AK, Kuczera T, Wurm-Kuczera R, Müller D, Born E, Lipphardt M, Plüss M, Wallbach M, Koziolek M. Eligibility for Baroreflex Activation Therapy and medication adherence in patients with apparently resistant hypertension. J Clin Hypertens (Greenwich) 2021; 23:1363-1371. [PMID: 34101968 PMCID: PMC8678808 DOI: 10.1111/jch.14302] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Revised: 04/30/2021] [Accepted: 05/16/2021] [Indexed: 12/29/2022]
Abstract
Uncontrolled hypertension is a main risk factor for cardiovascular morbidity. Baroreflex activation therapy (BAT) is an effective therapy option addressing true resistant hypertension. We evaluated patients’ eligibility for BAT in a staged assessment as well as adherence to antihypertensive drug therapy. Therefore, we analyzed files of 345 patients, attending the hypertension clinic at University Medicine Göttingen. Additionally, gas chromatographic‐mass spectrometric urine analyses of selected individuals were performed evaluating their adherence. Most common cause for a revoked BAT recommendation was blood pressure (BP) control by drug adjustment (54.2%). Second leading cause was presence of secondary hypertension (31.6%). Patients to whom BAT was recommended (59 (17.1%)) were significantly more often male (67.8% vs. 43.3%, P = .0063), had a higher body mass index (31.8 ± 5.8 vs. 30.0 ± 5.7 kg/m², P = .0436), a higher systolic office (168.7 ± 24.7 vs. 147.7 ± 24.1 mmHg, P < .0001), and 24h ambulatory BP (155.0 ± 14.6 vs. 144.4 ± 16.8 mmHg, P = .0031), took more antihypertensive drugs (5.8 ± 1.3 vs. 4.4 ± 1.4, P < .0001), and suffered more often from numerous concomitant diseases. Eventually, 27 (7.8%) received a BAT system. In the toxicological analysis of 75 patients, mean adherence was 75.1%. 16 patients (21.3%) showed non‐adherence. Thus, only a small number of patients eventually received a BAT system, as treatable reasons for apparently resistant hypertension could be identified frequently. This study is—to our knowledge—the first report of a staged assessment of patients’ suitability for BAT and underlines the need for a careful examination and indication. Non‐adherence was proven to be a relevant issue concerning apparently resistant hypertension and therefore non‐eligibility for interventional antihypertensive therapy. We evaluated the eligibility for baroreflex activation therapy (BAT) of 345 patients, attending the hypertension clinic at University Medicine Göttingen. Patients’ drug adherence was investigated by 75 toxicological analyses. Most common cause for a revoked BAT recommendation was blood pressure control by drug adjustment. Eventually, only less patients (7.8%) received a BAT system. Patients receiving a BAT recommendation showed specific characteristics and suffered numerous comorbidities, leading to a high cardiovascular risk, and therefore seem to greatly benefit from BAT implantation. 21.3% of patients showed non‐adherence, proving non‐adherence to be a relevant issue.
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Affiliation(s)
- Ann-Kathrin Schäfer
- Department of Nephrology & Rheumatology, University Medical Centre, Göttingen, Germany
| | - Tim Kuczera
- Department of Nephrology & Rheumatology, University Medical Centre, Göttingen, Germany
| | - Rebecca Wurm-Kuczera
- Department of Hematology & Oncology, University Medical Centre, Göttingen, Germany
| | | | - Ellen Born
- Department of Nephrology & Rheumatology, University Medical Centre, Göttingen, Germany
| | - Mark Lipphardt
- Department of Nephrology & Rheumatology, University Medical Centre, Göttingen, Germany
| | - Marlene Plüss
- Department of Nephrology & Rheumatology, University Medical Centre, Göttingen, Germany
| | - Manuel Wallbach
- Department of Nephrology & Rheumatology, University Medical Centre, Göttingen, Germany
| | - Michael Koziolek
- Department of Nephrology & Rheumatology, University Medical Centre, Göttingen, Germany
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22
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Groenland EH, Bots ML, Asselbergs FW, de Borst GJ, Kappelle LJ, Visseren FLJ, Spiering W. Apparent treatment resistant hypertension and the risk of recurrent cardiovascular events and mortality in patients with established vascular disease. Int J Cardiol 2021; 334:135-141. [PMID: 33932429 DOI: 10.1016/j.ijcard.2021.04.047] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 04/13/2021] [Accepted: 04/26/2021] [Indexed: 10/21/2022]
Abstract
AIM To quantify the relation between apparent treatment resistant hypertension (aTRH) and the risk of recurrent major adverse cardiovascular events (MACE including stroke, myocardial infarction and vascular death) and mortality in patients with stable vascular disease. METHODS 7455 hypertensive patients with symptomatic vascular disease were included from the ongoing UCC-SMART cohort between 1996 and 2019. aTRH was defined as an office blood pressure ≥140/90 mmHg despite treatment with ≥3 antihypertensive drugs including a diuretic. Cox proportional hazard models were used to quantify the relation between aTRH and the risk of recurrent MACE and all-cause mortality. In addition, survival for patients with aTRH was assessed, taking competing risk of non-vascular mortality into account. RESULTS A total of 1557 MACE and 1882 deaths occurred during a median follow-up of 9.0 years (interquartile range 4.8-13.1 years). Compared to patients with non-aTRH, the 614 patients (8%) with aTRH were at increased risk of cardiovascular mortality (HR 1.27; 95% CI 1.03-1.56) and death from any cause (HR 1.25; 95% CI 1.07-1.45) but not recurrent MACE (HR 1.13; 95% CI 0.95-1.34). At the age of 50 years, patients with aTRH after a first cardiovascular event on average had a 6.4 year shorter median life expectancy free of recurrent MACE than patients with non-aTRH. CONCLUSION In hypertensive patients with clinically manifest vascular disease, aTRH is related to a higher risk of vascular death and death from any cause. Moreover, patients with aTRH after a first cardiovascular event have a 6.4 year shorter median life expectancy free of recurrent cardiovascular disease.
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Affiliation(s)
- Eline H Groenland
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Michiel L Bots
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Folkert W Asselbergs
- Department of Cardiology, Division Heart & Lungs, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands; Institute of Cardiovascular Science and Institute of Health Informatics, Faculty of Population Health Sciences, University College London, London, United Kingdom
| | - Gert J de Borst
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - L Jaap Kappelle
- Department of Neurology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Frank L J Visseren
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Wilko Spiering
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands.
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23
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Hypertension Canada's 2020 Comprehensive Guidelines for the Prevention, Diagnosis, Risk Assessment, and Treatment of Hypertension in Adults and Children. Can J Cardiol 2021; 36:596-624. [PMID: 32389335 DOI: 10.1016/j.cjca.2020.02.086] [Citation(s) in RCA: 272] [Impact Index Per Article: 90.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 02/23/2020] [Accepted: 02/23/2020] [Indexed: 11/21/2022] Open
Abstract
Hypertension Canada's 2020 guidelines for the prevention, diagnosis, risk assessment, and treatment of hypertension in adults and children provide comprehensive, evidence-based guidance for health care professionals and patients. Hypertension Canada develops the guidelines using rigourous methodology, carefully mitigating the risk of bias in our process. All draft recommendations undergo critical review by expert methodologists without conflict to ensure quality. Our guideline panel is diverse, including multiple health professional groups (nurses, pharmacy, academics, and physicians), and worked in concert with experts in primary care and implementation to ensure optimal usability. The 2020 guidelines include new guidance on the management of resistant hypertension and the management of hypertension in women planning pregnancy.
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24
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Risk of fatal and nonfatal coronary heart disease and stroke events among adult patients with hypertension: basic Markov model inputs for evaluating cost-effectiveness of hypertension treatment: systematic review of cohort studies. JOURNAL OF PHARMACEUTICAL HEALTH SERVICES RESEARCH 2021. [DOI: 10.1093/jphsr/rmaa031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Abstract
Objectives
Hypertension is a risk factor for a number of vascular and cardiac complications. A Markov like simulation based on cardiovascular disease (CVD) policy model is being used for evaluating cost-effectiveness of hypertension treatment. Stroke, angina, myocardial infarction (MI), cardiac arrest and all-cause mortality were only included CVD outcome variables in the model. Therefore this systematic review was conducted to evaluate completeness of CVD policy model for evaluation of cost-effectiveness across different regions.
Key findings
Fourteen cohort studies involving a total of 1 674 773 hypertensive adult population and 499 226 adults with treatment resistant hypertension were included in this systematic review. Hypertension is clearly associated with coronary heart disease (CHD) and stroke mortality, unstable angina, stable angina, MI, heart failure (HF), sudden cardiac death, transient ischemic attack, ischemic stroke, sub-arachnoid hemorrhage, intracranial hemorrhage, peripheral arterial disease (PAD), and abdominal aortic aneurism (AAA). Lifetime risk of developing HF is higher among hypertensives across all ages, with slight variation among regions. Treatment resistant hypertension is associated with higher relative risk of developing major CVD events and mortality when compared with the non-resistant hypertension.
Summary
The CVD policy model can be used in most of the regions for evaluation of cost-effectiveness of hypertension treatment. However, hypertension is highly associated with HF in Latin America, Eastern Europe, and Sub-Saharan Africa. Therefore, it is important to consider HF in CVD policy model for evaluating cost-effectiveness of hypertension treatment in these regions. We do not suggest the inclusion of PAD and AAA in CVD policy model for evaluating cost-effectiveness of hypertension treatment due to lack of sufficient evidence. Researchers should consider the effect of treatment resistant hypertension either through including in the basic model or during setting the model assumptions.
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25
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Jorge-Galarza E, Martínez-Sánchez FD, Javier-Montiel CI, Medina-Urrutia AX, Posadas-Romero C, González-Salazar MC, Osorio-Alonso H, Arellano-Buendía AS, Juárez-Rojas JG. Control of blood pressure levels in patients with premature coronary artery disease: Results from the Genetics of Atherosclerotic Disease study. J Clin Hypertens (Greenwich) 2020; 22:1253-1262. [PMID: 32644257 DOI: 10.1111/jch.13942] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 05/11/2020] [Accepted: 05/29/2020] [Indexed: 01/19/2023]
Abstract
High blood pressure (BP) is the major cardiovascular-risk factor for coronary artery disease (CAD), principally in young patients who have an important and increasing socioeconomic burden. Despite the Seventh Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC-7), recommended BP target <140/90 mm Hg for patients with stable CAD, in 2017 the American College of Cardiology and the American Heart Association (ACC/AHA) updated BP target to <130/80 mm Hg. We aimed to analyze the prevalence of BP control in patients with premature CAD using both criteria. In addition, antihypertensive therapy, lifestyle, clinical, and sociodemographic characteristics of the patients were evaluated in order to identify factors associated with the achievement of BP targets. The present study included 1206 patients with CAD diagnosed before 55 and 65 years old in men and women, respectively. Sociodemographic, clinical, and biochemical data were collected. The results indicate that 85.6% and 77.5% of subjects with premature CAD achieved JNC-7 non-strict and ACC/AHA strict BP target, respectively. Consistently, number of antihypertensive drugs and hypertension duration >10 years were inversely associated with BP targets, whereas total physical activity and smoking were directly associated with BP targets, regardless of BP criteria. Considering that age, gender, and hypertension duration are non-modifiable cardiovascular-risk factors, our results highlight the need for more effective strategies focused on increase physical activity and smoking cessation in young patients with CAD. These healthier lifestyles changes should favor the BP target achievement and reduce the socioeconomic and clinical burden of premature CAD.
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Affiliation(s)
- Esteban Jorge-Galarza
- Department of Endocrinology, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico
| | | | - Cesar I Javier-Montiel
- Department of Endocrinology, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico
| | - Aida X Medina-Urrutia
- Department of Endocrinology, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico
| | - Carlos Posadas-Romero
- Department of Endocrinology, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico
| | - María C González-Salazar
- Department of Endocrinology, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico
| | - Horacio Osorio-Alonso
- Department of Cardio-Renal Physiopathology, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico
| | - Abraham S Arellano-Buendía
- Department of Cardio-Renal Physiopathology, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico
| | - Juan G Juárez-Rojas
- Department of Endocrinology, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico
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26
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Thomas G, Felts J, Brecklin CS, Chen J, Drawz PE, Lustigova E, Mehta R, Miller ER, Sozio SM, Weir MR, Xie D, Wang X, Rahman M. Apparent Treatment-Resistant Hypertension Assessed by Office and Ambulatory Blood Pressure in Chronic Kidney Disease-A Report from the Chronic Renal Insufficiency Cohort Study. ACTA ACUST UNITED AC 2020; 1:810-818. [PMID: 34308363 DOI: 10.34067/kid.0002072020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Background Apparent treatment-resistant hypertension is common in patients with CKD. Whether measurement of 24-hour ambulatory BP monitoring is valuable for risk-stratifying patients with resistant hypertension and CKD is unclear. Methods We analyzed data from the Chronic Renal Insufficiency Cohort study, a prospective study of participants (n=1186) with CKD. Office BP was measured using standardized protocols; ambulatory BP was measured using Spacelabs monitors. Apparent treatment-resistant hypertension was defined on the basis of office BP, ambulatory BP monitoring, and use of more than three antihypertensive medications. Outcomes were composite cardiovascular disease, kidney outcomes, and mortality. Groups were compared using Cox regression analyses with a control group of participants without apparent treatment-resistant hypertension. Results Of 475 participants with apparent treatment-resistant hypertension on the basis of office BP, 91.6% had apparent treatment-resistant hypertension confirmed by ambulatory BP monitoring. Unadjusted event rates of composite cardiovascular disease, kidney outcomes, and mortality were higher in participants with ambulatory BP monitoring-defined apparent treatment-resistant hypertension compared with participants without apparent treatment-resistant hypertension. In adjusted analyses, the risks of composite cardiovascular disease (hazard ratio, 1.27; 95% confidence interval [95% CI], 0.59 to 2.7), kidney outcomes (hazard ratio, 1.68; 95% CI, 0.88 to 3.21), and mortality (hazard ratio, 1.27; 95% CI, 0.5 to 3.25) were not statistically significantly higher in participants with ambulatory BP monitoring-defined apparent treatment-resistant hypertension compared with participants without apparent treatment-resistant hypertension. Conclusions In our study population with CKD, most patients with apparent treatment-resistant hypertension defined on the basis of office BP have apparent treatment-resistant hypertension confirmed by ambulatory BP monitoring. Although ABPM-defined apparent treatment-resistant hypertension was not independently associated with clinical outcomes, it identified participants at high risk for adverse clinical outcomes.
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Affiliation(s)
- George Thomas
- Department of Nephrology and Hypertension, Cleveland Clinic, Cleveland, Ohio
| | - Jesse Felts
- Department of Medicine, University Hospitals Cleveland Medical Center, Louis Stokes Cleveland Veterans Affairs Medical Center, Case Western Reserve University, Cleveland, Ohio
| | | | - Jing Chen
- Department of Medicine, Tulane School of Medicine, New Orleans, Louisiana
| | - Paul E Drawz
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Eva Lustigova
- Kaiser Permanente Medical Group, Pasadena, California
| | - Rupal Mehta
- Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.,Jesse Brown Veterans Affairs Medical Center, Chicago, Illinois
| | - Edgar R Miller
- Department of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Stephen M Sozio
- Department of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Matthew R Weir
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Dawei Xie
- Department of Biostatistics, Epidemiology and Informatics, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Xue Wang
- Department of Biostatistics, Epidemiology and Informatics, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Mahboob Rahman
- Department of Medicine, University Hospitals Cleveland Medical Center, Louis Stokes Cleveland Veterans Affairs Medical Center, Case Western Reserve University, Cleveland, Ohio
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27
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The global burden of hypertension exceeds 1.4 billion people: should a systolic blood pressure target below 130 become the universal standard? J Hypertens 2020; 37:1148-1153. [PMID: 30624370 DOI: 10.1097/hjh.0000000000002021] [Citation(s) in RCA: 80] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
: In 2010, 1.4 billion people globally had hypertension, with 14% controlled to systolic blood pressure (SBP, mmHg) below 140, which contributes to 18 million cardiovascular deaths annually. Recent hypertension guidelines endorsed SBP targets below 130 or lower for all or some hypertensive patients to reduce cardiovascular events (CVEs) more than the prior SBP target less than 140. In 2016, the Australian Guideline strongly recommended target SBP below 120 for adults at very high risk for CVE or aged above 75 years. In 2017 and 2018, the Canadian Guideline recommended automated office SBP (AOSBP) below 120 in adults at high risk and aged above 75 years (grade B). In 2017, the US Guideline recommended SBP below 130 for all adults (moderate-to-high risk class I; lower-risk grade IIb). In 2018, the European Guideline recommended SBP below 140 for all adults, and, if tolerated, a SBP range of 120-129 for adults aged below 65 years and 130-139 for adults aged at least 65 years (class I). The guidelines were variably influenced by Systolic blood PRessure INTervention trial and meta-analyses indicating fewer CVE when mean in-trial SBP was below 130 versus above 130. Clinicians considering lower SBP targets should be aware that: AOSBP preceded by 5-min rest is approximately 10-15 mmHg lower than usual office SBP; hypertensive patients with office SBP consistently versus intermittently below 140 have fewer CVE; benefits of mean office SBP or AOSBP below 120 remain unproven and could increase adverse events. Clinicians worldwide will do well to control SBP to below 140 in most hypertensive patients on most visits, which should lead to mean in-clinic SBP of 120-129.
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28
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Hypertension Canada’s 2020 Evidence Review and Guidelines for the Management of Resistant Hypertension. Can J Cardiol 2020; 36:625-634. [DOI: 10.1016/j.cjca.2020.02.083] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 02/19/2020] [Accepted: 02/19/2020] [Indexed: 11/30/2022] Open
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29
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Cai A, Siddiqui M, Judd EK, Oparil S, Calhoun DA. Aortic blood pressure and arterial stiffness in patients with controlled resistant and non-resistant hypertension. J Clin Hypertens (Greenwich) 2020; 22:167-173. [PMID: 32049430 DOI: 10.1111/jch.13826] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 01/11/2020] [Accepted: 01/16/2020] [Indexed: 11/27/2022]
Abstract
The purpose of the current study was to determine whether aortic blood pressure (BP) and arterial stiffness are greater in patients with controlled resistant hypertension (RHTN) than controlled non-resistant hypertension (non-RHTN) despite similar clinic BP level. Participants were recruited from University of Alabama at Birmingham (UAB) Hypertension Clinic. Controlled hypertension was defined as automated office BP measurement with BP < 135/85 mm Hg. A total of 141 participants were evaluated by pulse wave analysis (PWA) and carotid-femoral pulse wave velocity (cf-PWV). Among them, 75 patients had controlled RHTN with use of 4 or more antihypertensive medications and 56 patients had controlled non-RHTN with use of 3 or less antihypertensive medications. Compared to patients with controlled non-RHTN, those with controlled RHTN were more likely to be African American and had a higher prevalence of diabetes mellitus and congestive heart failure. The mean number of antihypertensive medications was greater in patients with controlled RHTN (4.4 ± 0.8 vs 2.3 ± 0.7, P < .001). Clinic brachial BP, aortic BP, augmentation pressure (AP), augmentation index normalized for heart rate of 75 beats per minute (AIx@75) and cf-PWV were similar in both groups. In summary, there was no significant difference in central BP or arterial stiffness between patients with controlled RHTN and controlled non-RHTN. These findings suggest that the higher residual cardiovascular risk observed in patients with RHTN after achieving BP control compared to patients with more easily controlled hypertension is not likely attributable to persistent differences in central BP and arterial stiffness.
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Affiliation(s)
- Anping Cai
- Vascular Biology and Hypertension Program, Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Mohammed Siddiqui
- Vascular Biology and Hypertension Program, Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Eric K Judd
- Division of Nephrology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Suzanne Oparil
- Vascular Biology and Hypertension Program, Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL, USA
| | - David A Calhoun
- Vascular Biology and Hypertension Program, Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL, USA
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30
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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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31
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Lamirault G, Artifoni M, Daniel M, Barber-Chamoux N, Nantes University Hospital Working Group On Hypertension. Resistant Hypertension: Novel Insights. Curr Hypertens Rev 2019; 16:61-72. [PMID: 31622203 DOI: 10.2174/1573402115666191011111402] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 09/05/2019] [Accepted: 09/12/2019] [Indexed: 12/27/2022]
Abstract
Hypertension is the most common chronic disease and the leading risk factor for disability and premature deaths in the world, accounting for more than 9 million deaths annually. Resistant hypertension is a particularly severe form of hypertension. It was described 50 years ago and since then has been a very active field of research. This review aims at summarizing the most recent findings on resistant hypertension. The recent concepts of apparent- and true-resistant hypertension have stimulated a more precise definition of resistant hypertension taking into account not only the accuracy of blood pressure measurement and pharmacological class of prescribed drugs but also patient adherence to drugs and life-style recommendations. Recent epidemiological studies have reported a 10% prevalence of resistant hypertension among hypertensive subjects and demonstrated the high cardiovascular risk of these patients. In addition, these studies identified subgroups of patients with even higher morbidity and mortality risk, probably requiring a more aggressive medical management. In the meantime, guidelines provided more standardized clinical work-up to identify potentially reversible causes for resistant hypertension such as secondary hypertension. The debate is however still ongoing on which would be the optimal method(s) to screen for non-adherence to hypertension therapy, recognized as the major cause for (pseudo)-resistance to treatment. Recent randomized clinical trials have demonstrated the strong benefit of anti-aldosterone drugs (mostly spironolocatone) as fourth-line therapies in resistant hypertension whereas clinical trials with device-based therapies displayed contrasting results. New trials with improved devices and more carefully selected patients with resistant hypertension are ongoing.
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Affiliation(s)
- Guillaume Lamirault
- l'institut du Thorax, INSERM, CNRS, UNIV Nantes, Nantes, France.,l'institut du Thorax, CHU Nantes, Service de Cardiologie, Nantes, France
| | | | - Mélanie Daniel
- Clinical Pharmacology Centre (INSERM CIC1505), CHU Clermont-Ferrand, France
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32
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Whelton PK, Carey RM, Aronow WS, Casey DE, Collins KJ, Dennison Himmelfarb C, DePalma SM, Gidding S, Jamerson KA, Jones DW, MacLaughlin EJ, Muntner P, Ovbiagele B, Smith SC, Spencer CC, Stafford RS, Taler SJ, Thomas RJ, Williams KA, Williamson JD, Wright JT. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation 2019; 138:e484-e594. [PMID: 30354654 DOI: 10.1161/cir.0000000000000596] [Citation(s) in RCA: 220] [Impact Index Per Article: 44.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Paul K Whelton
- American Society for Preventive Cardiology Representative. †ACC/AHA Representative. ‡Lay Volunteer/Patient Representative. §Preventive Cardiovascular Nurses Association Representative. ‖American Academy of Physician Assistants Representative. ¶Task Force Liaison. #Association of Black Cardiologists Representative. **American Pharmacists Association Representative. ††ACC/AHA Prevention Subcommittee Liaison. ‡‡American College of Preventive Medicine Representative. §§American Society of Hypertension Representative. ‖‖Task Force on Performance Measures Liaison. ¶¶American Geriatrics Society Representative. ##National Medical Association Representative
| | - Robert M Carey
- American Society for Preventive Cardiology Representative. †ACC/AHA Representative. ‡Lay Volunteer/Patient Representative. §Preventive Cardiovascular Nurses Association Representative. ‖American Academy of Physician Assistants Representative. ¶Task Force Liaison. #Association of Black Cardiologists Representative. **American Pharmacists Association Representative. ††ACC/AHA Prevention Subcommittee Liaison. ‡‡American College of Preventive Medicine Representative. §§American Society of Hypertension Representative. ‖‖Task Force on Performance Measures Liaison. ¶¶American Geriatrics Society Representative. ##National Medical Association Representative
| | - Wilbert S Aronow
- American Society for Preventive Cardiology Representative. †ACC/AHA Representative. ‡Lay Volunteer/Patient Representative. §Preventive Cardiovascular Nurses Association Representative. ‖American Academy of Physician Assistants Representative. ¶Task Force Liaison. #Association of Black Cardiologists Representative. **American Pharmacists Association Representative. ††ACC/AHA Prevention Subcommittee Liaison. ‡‡American College of Preventive Medicine Representative. §§American Society of Hypertension Representative. ‖‖Task Force on Performance Measures Liaison. ¶¶American Geriatrics Society Representative. ##National Medical Association Representative
| | - Donald E Casey
- American Society for Preventive Cardiology Representative. †ACC/AHA Representative. ‡Lay Volunteer/Patient Representative. §Preventive Cardiovascular Nurses Association Representative. ‖American Academy of Physician Assistants Representative. ¶Task Force Liaison. #Association of Black Cardiologists Representative. **American Pharmacists Association Representative. ††ACC/AHA Prevention Subcommittee Liaison. ‡‡American College of Preventive Medicine Representative. §§American Society of Hypertension Representative. ‖‖Task Force on Performance Measures Liaison. ¶¶American Geriatrics Society Representative. ##National Medical Association Representative
| | - Karen J Collins
- American Society for Preventive Cardiology Representative. †ACC/AHA Representative. ‡Lay Volunteer/Patient Representative. §Preventive Cardiovascular Nurses Association Representative. ‖American Academy of Physician Assistants Representative. ¶Task Force Liaison. #Association of Black Cardiologists Representative. **American Pharmacists Association Representative. ††ACC/AHA Prevention Subcommittee Liaison. ‡‡American College of Preventive Medicine Representative. §§American Society of Hypertension Representative. ‖‖Task Force on Performance Measures Liaison. ¶¶American Geriatrics Society Representative. ##National Medical Association Representative
| | - Cheryl Dennison Himmelfarb
- American Society for Preventive Cardiology Representative. †ACC/AHA Representative. ‡Lay Volunteer/Patient Representative. §Preventive Cardiovascular Nurses Association Representative. ‖American Academy of Physician Assistants Representative. ¶Task Force Liaison. #Association of Black Cardiologists Representative. **American Pharmacists Association Representative. ††ACC/AHA Prevention Subcommittee Liaison. ‡‡American College of Preventive Medicine Representative. §§American Society of Hypertension Representative. ‖‖Task Force on Performance Measures Liaison. ¶¶American Geriatrics Society Representative. ##National Medical Association Representative
| | - Sondra M DePalma
- American Society for Preventive Cardiology Representative. †ACC/AHA Representative. ‡Lay Volunteer/Patient Representative. §Preventive Cardiovascular Nurses Association Representative. ‖American Academy of Physician Assistants Representative. ¶Task Force Liaison. #Association of Black Cardiologists Representative. **American Pharmacists Association Representative. ††ACC/AHA Prevention Subcommittee Liaison. ‡‡American College of Preventive Medicine Representative. §§American Society of Hypertension Representative. ‖‖Task Force on Performance Measures Liaison. ¶¶American Geriatrics Society Representative. ##National Medical Association Representative
| | - Samuel Gidding
- American Society for Preventive Cardiology Representative. †ACC/AHA Representative. ‡Lay Volunteer/Patient Representative. §Preventive Cardiovascular Nurses Association Representative. ‖American Academy of Physician Assistants Representative. ¶Task Force Liaison. #Association of Black Cardiologists Representative. **American Pharmacists Association Representative. ††ACC/AHA Prevention Subcommittee Liaison. ‡‡American College of Preventive Medicine Representative. §§American Society of Hypertension Representative. ‖‖Task Force on Performance Measures Liaison. ¶¶American Geriatrics Society Representative. ##National Medical Association Representative
| | - Kenneth A Jamerson
- American Society for Preventive Cardiology Representative. †ACC/AHA Representative. ‡Lay Volunteer/Patient Representative. §Preventive Cardiovascular Nurses Association Representative. ‖American Academy of Physician Assistants Representative. ¶Task Force Liaison. #Association of Black Cardiologists Representative. **American Pharmacists Association Representative. ††ACC/AHA Prevention Subcommittee Liaison. ‡‡American College of Preventive Medicine Representative. §§American Society of Hypertension Representative. ‖‖Task Force on Performance Measures Liaison. ¶¶American Geriatrics Society Representative. ##National Medical Association Representative
| | - Daniel W Jones
- American Society for Preventive Cardiology Representative. †ACC/AHA Representative. ‡Lay Volunteer/Patient Representative. §Preventive Cardiovascular Nurses Association Representative. ‖American Academy of Physician Assistants Representative. ¶Task Force Liaison. #Association of Black Cardiologists Representative. **American Pharmacists Association Representative. ††ACC/AHA Prevention Subcommittee Liaison. ‡‡American College of Preventive Medicine Representative. §§American Society of Hypertension Representative. ‖‖Task Force on Performance Measures Liaison. ¶¶American Geriatrics Society Representative. ##National Medical Association Representative
| | - Eric J MacLaughlin
- American Society for Preventive Cardiology Representative. †ACC/AHA Representative. ‡Lay Volunteer/Patient Representative. §Preventive Cardiovascular Nurses Association Representative. ‖American Academy of Physician Assistants Representative. ¶Task Force Liaison. #Association of Black Cardiologists Representative. **American Pharmacists Association Representative. ††ACC/AHA Prevention Subcommittee Liaison. ‡‡American College of Preventive Medicine Representative. §§American Society of Hypertension Representative. ‖‖Task Force on Performance Measures Liaison. ¶¶American Geriatrics Society Representative. ##National Medical Association Representative
| | - Paul Muntner
- American Society for Preventive Cardiology Representative. †ACC/AHA Representative. ‡Lay Volunteer/Patient Representative. §Preventive Cardiovascular Nurses Association Representative. ‖American Academy of Physician Assistants Representative. ¶Task Force Liaison. #Association of Black Cardiologists Representative. **American Pharmacists Association Representative. ††ACC/AHA Prevention Subcommittee Liaison. ‡‡American College of Preventive Medicine Representative. §§American Society of Hypertension Representative. ‖‖Task Force on Performance Measures Liaison. ¶¶American Geriatrics Society Representative. ##National Medical Association Representative
| | - Bruce Ovbiagele
- American Society for Preventive Cardiology Representative. †ACC/AHA Representative. ‡Lay Volunteer/Patient Representative. §Preventive Cardiovascular Nurses Association Representative. ‖American Academy of Physician Assistants Representative. ¶Task Force Liaison. #Association of Black Cardiologists Representative. **American Pharmacists Association Representative. ††ACC/AHA Prevention Subcommittee Liaison. ‡‡American College of Preventive Medicine Representative. §§American Society of Hypertension Representative. ‖‖Task Force on Performance Measures Liaison. ¶¶American Geriatrics Society Representative. ##National Medical Association Representative
| | - Sidney C Smith
- American Society for Preventive Cardiology Representative. †ACC/AHA Representative. ‡Lay Volunteer/Patient Representative. §Preventive Cardiovascular Nurses Association Representative. ‖American Academy of Physician Assistants Representative. ¶Task Force Liaison. #Association of Black Cardiologists Representative. **American Pharmacists Association Representative. ††ACC/AHA Prevention Subcommittee Liaison. ‡‡American College of Preventive Medicine Representative. §§American Society of Hypertension Representative. ‖‖Task Force on Performance Measures Liaison. ¶¶American Geriatrics Society Representative. ##National Medical Association Representative
| | - Crystal C Spencer
- American Society for Preventive Cardiology Representative. †ACC/AHA Representative. ‡Lay Volunteer/Patient Representative. §Preventive Cardiovascular Nurses Association Representative. ‖American Academy of Physician Assistants Representative. ¶Task Force Liaison. #Association of Black Cardiologists Representative. **American Pharmacists Association Representative. ††ACC/AHA Prevention Subcommittee Liaison. ‡‡American College of Preventive Medicine Representative. §§American Society of Hypertension Representative. ‖‖Task Force on Performance Measures Liaison. ¶¶American Geriatrics Society Representative. ##National Medical Association Representative
| | - Randall S Stafford
- American Society for Preventive Cardiology Representative. †ACC/AHA Representative. ‡Lay Volunteer/Patient Representative. §Preventive Cardiovascular Nurses Association Representative. ‖American Academy of Physician Assistants Representative. ¶Task Force Liaison. #Association of Black Cardiologists Representative. **American Pharmacists Association Representative. ††ACC/AHA Prevention Subcommittee Liaison. ‡‡American College of Preventive Medicine Representative. §§American Society of Hypertension Representative. ‖‖Task Force on Performance Measures Liaison. ¶¶American Geriatrics Society Representative. ##National Medical Association Representative
| | - Sandra J Taler
- American Society for Preventive Cardiology Representative. †ACC/AHA Representative. ‡Lay Volunteer/Patient Representative. §Preventive Cardiovascular Nurses Association Representative. ‖American Academy of Physician Assistants Representative. ¶Task Force Liaison. #Association of Black Cardiologists Representative. **American Pharmacists Association Representative. ††ACC/AHA Prevention Subcommittee Liaison. ‡‡American College of Preventive Medicine Representative. §§American Society of Hypertension Representative. ‖‖Task Force on Performance Measures Liaison. ¶¶American Geriatrics Society Representative. ##National Medical Association Representative
| | - Randal J Thomas
- American Society for Preventive Cardiology Representative. †ACC/AHA Representative. ‡Lay Volunteer/Patient Representative. §Preventive Cardiovascular Nurses Association Representative. ‖American Academy of Physician Assistants Representative. ¶Task Force Liaison. #Association of Black Cardiologists Representative. **American Pharmacists Association Representative. ††ACC/AHA Prevention Subcommittee Liaison. ‡‡American College of Preventive Medicine Representative. §§American Society of Hypertension Representative. ‖‖Task Force on Performance Measures Liaison. ¶¶American Geriatrics Society Representative. ##National Medical Association Representative
| | - Kim A Williams
- American Society for Preventive Cardiology Representative. †ACC/AHA Representative. ‡Lay Volunteer/Patient Representative. §Preventive Cardiovascular Nurses Association Representative. ‖American Academy of Physician Assistants Representative. ¶Task Force Liaison. #Association of Black Cardiologists Representative. **American Pharmacists Association Representative. ††ACC/AHA Prevention Subcommittee Liaison. ‡‡American College of Preventive Medicine Representative. §§American Society of Hypertension Representative. ‖‖Task Force on Performance Measures Liaison. ¶¶American Geriatrics Society Representative. ##National Medical Association Representative
| | - Jeff D Williamson
- American Society for Preventive Cardiology Representative. †ACC/AHA Representative. ‡Lay Volunteer/Patient Representative. §Preventive Cardiovascular Nurses Association Representative. ‖American Academy of Physician Assistants Representative. ¶Task Force Liaison. #Association of Black Cardiologists Representative. **American Pharmacists Association Representative. ††ACC/AHA Prevention Subcommittee Liaison. ‡‡American College of Preventive Medicine Representative. §§American Society of Hypertension Representative. ‖‖Task Force on Performance Measures Liaison. ¶¶American Geriatrics Society Representative. ##National Medical Association Representative
| | - Jackson T Wright
- American Society for Preventive Cardiology Representative. †ACC/AHA Representative. ‡Lay Volunteer/Patient Representative. §Preventive Cardiovascular Nurses Association Representative. ‖American Academy of Physician Assistants Representative. ¶Task Force Liaison. #Association of Black Cardiologists Representative. **American Pharmacists Association Representative. ††ACC/AHA Prevention Subcommittee Liaison. ‡‡American College of Preventive Medicine Representative. §§American Society of Hypertension Representative. ‖‖Task Force on Performance Measures Liaison. ¶¶American Geriatrics Society Representative. ##National Medical Association Representative
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Carey RM, Calhoun DA, Bakris GL, Brook RD, Daugherty SL, Dennison-Himmelfarb CR, Egan BM, Flack JM, Gidding SS, Judd E, Lackland DT, Laffer CL, Newton-Cheh C, Smith SM, Taler SJ, Textor SC, Turan TN, White WB. Resistant Hypertension: Detection, Evaluation, and Management: A Scientific Statement From the American Heart Association. Hypertension 2019; 72:e53-e90. [PMID: 30354828 DOI: 10.1161/hyp.0000000000000084] [Citation(s) in RCA: 589] [Impact Index Per Article: 117.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Resistant hypertension (RH) is defined as above-goal elevated blood pressure (BP) in a patient despite the concurrent use of 3 antihypertensive drug classes, commonly including a long-acting calcium channel blocker, a blocker of the renin-angiotensin system (angiotensin-converting enzyme inhibitor or angiotensin receptor blocker), and a diuretic. The antihypertensive drugs should be administered at maximum or maximally tolerated daily doses. RH also includes patients whose BP achieves target values on ≥4 antihypertensive medications. The diagnosis of RH requires assurance of antihypertensive medication adherence and exclusion of the "white-coat effect" (office BP above goal but out-of-office BP at or below target). The importance of RH is underscored by the associated risk of adverse outcomes compared with non-RH. This article is an updated American Heart Association scientific statement on the detection, evaluation, and management of RH. Once antihypertensive medication adherence is confirmed and out-of-office BP recordings exclude a white-coat effect, evaluation includes identification of contributing lifestyle issues, detection of drugs interfering with antihypertensive medication effectiveness, screening for secondary hypertension, and assessment of target organ damage. Management of RH includes maximization of lifestyle interventions, use of long-acting thiazide-like diuretics (chlorthalidone or indapamide), addition of a mineralocorticoid receptor antagonist (spironolactone or eplerenone), and, if BP remains elevated, stepwise addition of antihypertensive drugs with complementary mechanisms of action to lower BP. If BP remains uncontrolled, referral to a hypertension specialist is advised.
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Smith SM, Gurka MJ, Winterstein AG, Pepine CJ, Cooper-DeHoff RM. Incidence, prevalence, and predictors of treatment-resistant hypertension with intensive blood pressure lowering. J Clin Hypertens (Greenwich) 2019; 21:825-834. [PMID: 31066177 DOI: 10.1111/jch.13550] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Revised: 04/01/2019] [Accepted: 04/11/2019] [Indexed: 12/31/2022]
Abstract
Recent guidelines call for more intensive blood pressure (BP)-lowering and a less-stringent treatment-resistant hypertension (TRH) definition, both of which may increase the occurrence of this high-risk phenotype. We performed a post hoc analysis of 11 784 SPRINT and ACCORD-BP participants without baseline TRH, who were randomized to an intensive (<120 mm Hg) or standard (<140 mm Hg) systolic BP target. Incidence, prevalence, and predictors of TRH were compared using the updated definition (requiring ≥4 drugs to achieve BP < 130/80 mm Hg) during intensive treatment, vs the former definition (requiring ≥4 drugs to achieve BP < 140/90 mm Hg) during standard treatment. Incidence/prevalence of apparent refractory hypertension (RFH; uncontrolled BP despite ≥5 drugs) was similarly compared. Overall, 5702 and 6082 patients were included in the intensive and standard treatment cohorts, respectively. Crude TRH incidence using the updated definition under intensive treatment was 30.3 (95% CI, 29.3-31.4) per 100 patient-years, compared with 9.7 (95% CI, 9.2-10.2) using the prior definition under standard treatment. Point prevalence using the prior TRH definition at 1-year was 7.5% in SPRINT and 14% in ACCORD vs 22% and 36%, respectively, with the updated TRH definition. Significant predictors of incident TRH included number of baseline antihypertensive drugs, having diabetes, baseline systolic BP, and Black race. Incidence of apparent RFH was also significantly greater using the updated vs prior definition (4.5 vs 1.0 per 100 person-years). Implementation of the 2017 hypertension guideline, including lower BP goals for most individuals, is expected to substantially increase treatment burden and incident TRH among the hypertensive population.
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Affiliation(s)
- Steven M Smith
- Department of Pharmacotherapy & Translational Research, College of Pharmacy, Gainesville, Florida
| | - Matthew J Gurka
- Department of Health Outcomes & Biomedical Informatics, College of Medicine, Gainesville, Florida
| | - Almut G Winterstein
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, Gainesville, Florida
| | - Carl J Pepine
- Division of Cardiovascular Medicine, Department of Medicine, College of Medicine, University of Florida, Gainesville, Florida
| | - Rhonda M Cooper-DeHoff
- Department of Pharmacotherapy & Translational Research, College of Pharmacy, Gainesville, Florida.,Division of Cardiovascular Medicine, Department of Medicine, College of Medicine, University of Florida, Gainesville, Florida
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35
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Solini A, Penno G, Orsi E, Bonora E, Fondelli C, Trevisan R, Vedovato M, Cavalot F, Lamacchia O, Baroni MG, Nicolucci A, Pugliese G. Is resistant hypertension an independent predictor of all-cause mortality in individuals with type 2 diabetes? A prospective cohort study. BMC Med 2019; 17:83. [PMID: 31023377 PMCID: PMC6482506 DOI: 10.1186/s12916-019-1313-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2018] [Accepted: 03/25/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Resistant hypertension is independently associated with an increased risk of death in the general hypertensive population. We assessed whether resistant hypertension is an independent predictor of all-cause mortality in individuals with type 2 diabetes from the Renal Insufficiency And Cardiovascular Events (RIACE) Italian Multicentre Study. METHODS On 31 October 2015, vital status information was retrieved for 15,656 of the 15,773 participants enrolled in 2006-2008. Based on baseline blood pressure (BP) values and treatment, participants were categorized as normotensive, untreated hypertensive, controlled hypertensive (i.e., on-target with < 3 drugs), uncontrolled hypertensive (i.e., not on-target with 1-2 drugs), or resistant hypertensive (i.e., uncontrolled with > 3 drugs or controlled with > 4 drugs). Kaplan-Meier and Cox proportional hazards regression analyses were used to assess the association with all-cause mortality. RESULTS Using the 130/80 mmHg targets for categorization, crude mortality rates and Kaplan-Meier estimates were highest among resistant hypertension participants, especially those with controlled resistant hypertension. As compared with resistant hypertension, risk for all-cause mortality was significantly lower for all the other groups, including individuals with controlled hypertension (hazard ratio 0.81 [95% confidence interval 0.74-0.89], P < 0.0001), but became progressively similar between resistant and controlled hypertension after adjustment for cardiovascular risk factors and complications/comorbidities. Also when compared with controlled resistant hypertension, mortality risk was significantly lower for all the other groups, including controlled hypertension, even after adjusting for cardiovascular risk factors (0.77 [0.63-0.95], P = 0.012), but not for complications/comorbidities (0.88 [0.72-1.08], P = 0.216). BP was well below target in the controlled hypertensive groups (resistant and non-resistant) and values < 120/70 mmHg were associated with an increased mortality risk. Results changed only partly when using the 140/90 mmHg targets for categorization. CONCLUSIONS In the RIACE cohort, at variance with the general hypertensive population, resistant hypertension did not predict death beyond target organ damage. Our findings may be explained by the high mortality risk conferred by type 2 diabetes and the low BP values observed in controlled hypertensive patients, which may mask risk associated with resistant hypertension. Less stringent BP goals may be preferable in high-risk patients with type 2 diabetes. TRIAL REGISTRATION ClinicalTrials.gov, NCT00715481 , retrospectively registered 15 July, 2008.
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Affiliation(s)
- Anna Solini
- Department of Surgical, Medical, Molecular and Critical Area Pathology, University of Pisa, Pisa, Italy
| | - Giuseppe Penno
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Emanuela Orsi
- Diabetes Unit, IRCCS "Cà Granda - Ospedale Maggiore Policlinico" Foundation, Milan, Italy
| | - Enzo Bonora
- Division of Endocrinology, Diabetes and Metabolism, University and Hospital Trust of Verona, Verona, Italy
| | | | - Roberto Trevisan
- Endocrinology and Diabetes Unit, Azienda Ospedaliera Papa Giovanni XXIII, Bergamo, Italy
| | - Monica Vedovato
- Department of Clinical and Experimental Medicine, University of Padua, Padua, Italy
| | - Franco Cavalot
- Department of Clinical and Biological Sciences, University of Turin, Orbassano, Italy
| | - Olga Lamacchia
- Department of Medical Sciences, University of Foggia, Foggia, Italy
| | - Marco G Baroni
- Unit of Endocrinology and Diabetes, Department of Medical Sciences, University of Cagliari, Cagliari, Italy.,Present Address: Department of Experimental Medicine, "La Sapienza" University, Rome, Italy
| | - Antonio Nicolucci
- Centre for Outcomes Research and Clinical Epidemiology (CORESEARCH), Pescara, Italy
| | - Giuseppe Pugliese
- Department of Clinical and Molecular Medicine, "La Sapienza" University, Via di Grottarossa, 1035-1039, 00189, Rome, Italy.
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Kaczmarski KR, Sozio SM, Chen J, Sang Y, Shafi T. Resistant hypertension and cardiovascular disease mortality in the US: results from the National Health and Nutrition Examination Survey (NHANES). BMC Nephrol 2019; 20:138. [PMID: 31023262 PMCID: PMC6485047 DOI: 10.1186/s12882-019-1315-0] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Accepted: 03/29/2019] [Indexed: 12/12/2022] Open
Abstract
Background Apparent treatment-resistant hypertension (aTRH) is a common condition associated with risk of cardiovascular events. However, the risk of cardiovascular mortality associated with aTRH in the US population is unknown. We aimed to assess the risk of cardiovascular disease (CVD) mortality associated with aTRH in the US population. Methods We analyzed data from 6357 adult hypertensive participants of the National Health and Nutrition Examination Survey (1988–1994 and 1999–2010) linked to the National Death Index. Based on presence of uncontrolled hypertension [blood pressure (BP) ≥140/90 mmHg] and the number of antihypertensives prescribed, we classified participants into the following groups: non-aTRH (BP < 140/90 mmHg and ≤ 3 antihypertensives); controlled aTRH (BP < 140/90 mmHg and ≥ 4 antihypertensives); and uncontrolled aTRH (BP ≥140/90 mmHg and ≥ 3 antihypertensives). Results Of the 6357 participants, 1522 had aTRH, representing a US prevalence of 7.6 million. Of the participants with aTRH, 432 had controlled aTRH and 1090 had uncontrolled aTRH. During follow-up (median 6 years), there were 550 CVD deaths. The cumulative incidence of CVD mortality was significantly higher in the aTRH group compared with non-aTRH group (log-rank p < 0.001). In fully adjusted models, aTRH was associated with a 47% higher risk of CVD mortality compared with the non-aTRH group [1.47 (1.1–1.96)]. Similar increase in risk of CVD mortality was noted across aTRH subgroups compared with the non-aTRH group: controlled aTRH [1.66 (1.03–2.68)] and uncontrolled aTRH [1.43 (1.05–1.94)]. Among non-aTRH subgroups, those on 3 antihypertensive medications had a 35% increased risk of CVD mortality than those on < 3 medications [1.35 (0.98–1.86)]. Conclusions aTRH is a common condition, affecting approximately 7.6 million Americans. Regardless of BP control, people with aTRH remain at a higher risk of cardiovascular outcomes. The risk of cardiovascular disease mortality remains high among those with controlled BP on 3 medications (non-aTRH) or ≥ 4 medications (controlled aTRH), groups not generally considered at high risk. Future risk reduction interventions should consider focusing on these high-risk groups. Electronic supplementary material The online version of this article (10.1186/s12882-019-1315-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Katerina R Kaczmarski
- Department of Medicine, Johns Hopkins University School of Medicine, 600 N. Wolfe St, Baltimore, MD, 21287, USA.
| | - Stephen M Sozio
- Department of Medicine, Johns Hopkins University School of Medicine, 600 N. Wolfe St, Baltimore, MD, 21287, USA.,Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Jingsha Chen
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, MD, USA.,Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Yingying Sang
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, MD, USA.,Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Tariq Shafi
- Department of Medicine, Johns Hopkins University School of Medicine, 600 N. Wolfe St, Baltimore, MD, 21287, USA.,Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, MD, USA.,Department of Medicine, University of Mississippi Medical Center, Jackson, MS, USA
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Hipertensión resistente: puesta al día. HIPERTENSION Y RIESGO VASCULAR 2019; 36:44-52. [DOI: 10.1016/j.hipert.2017.12.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Revised: 12/16/2017] [Accepted: 12/18/2017] [Indexed: 12/30/2022]
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Affiliation(s)
- Robert M Carey
- From the Department of Medicine, University of Virginia Health System, Charlottesville
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39
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Whelton PK, Carey RM, Aronow WS, Casey DE, Collins KJ, Dennison Himmelfarb C, DePalma SM, Gidding S, Jamerson KA, Jones DW, MacLaughlin EJ, Muntner P, Ovbiagele B, Smith SC, Spencer CC, Stafford RS, Taler SJ, Thomas RJ, Williams KA, Williamson JD, Wright JT. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension 2018. [DOI: 10.1161/hyp.0000000000000065 10.1016/j.jacc.2017.11.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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40
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Cardiovascular morbidity of severe resistant hypertension among treated uncontrolled hypertensives: a 4-year follow-up study. J Hum Hypertens 2018; 32:487-493. [PMID: 29713047 DOI: 10.1038/s41371-018-0065-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Revised: 11/13/2017] [Accepted: 03/19/2018] [Indexed: 12/13/2022]
Abstract
Data regarding the prognosis of resistant hypertension (RHTN) with respect to its severity is limited. We investigated the cardiovascular risk of severe RHTN in a prospective observational study. A cohort of 1700 hypertensive patient with treated uncontrolled HTN was followed for a mean period of 3.6 ± 1.8 years. At baseline, standard clinical and laboratory workup was performed, including testing for secondary causes of RHT where applicable. Three groups were identified depending on presence of RHTN (office-based uncontrolled HTN under at least three drugs including a diuretic) and levels of office systolic blood pressure (BP): 1187 patients (70%) without RHTN, 313 (18%) with not-severe RHTN (systolic BP < 160 mmHg) and 200 (12%) with severe RHTN (systolic BP ≥ 160 mmHg). Endpoint of interest was cardiovascular morbidity set as the composite of coronary heart disease and stroke. During follow-up, incidence rates of cardiovascular events per 1000 person-years were 7.1 cases in the non-RHTN group, 12.4 cases in the not-severe RHTN group and 18 cases in the severe RHTN group. Unadjusted analysis showed that compared to uncontrolled patients without RHTN, patients with not-severe RHTN exhibited a similar risk but patients with severe RHTN had a significantly higher risk, by 2.5 times (CI: 1.28-4.73, p = 0.007). Even after multivariate adjustment for established risk factors including BP levels and isolated systolic HTN, severe RHTN remained as an independent predictor of the cardiovascular outcome (OR: 2.30, CI: 1.00-5.29, p = 0.05). In conclusion, among treated yet uncontrolled hypertensive patients, severe RHTN exhibits a significantly higher cardiovascular risk indicating the need for prompt management.
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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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Brandani L. Resistant hypertension: a therapeutic challenge. J Clin Hypertens (Greenwich) 2018; 20:76-78. [DOI: 10.1111/jch.13144] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
- Laura Brandani
- Prevention Department; Arterial Hypertension and Metabolic Unit; University Hospital of Favaloro Foundation; Favaloro University; Buenos Aires Argentina
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43
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Apparent resistant hypertension and the risk of vascular events and mortality in patients with manifest vascular disease. J Hypertens 2018; 36:143-150. [DOI: 10.1097/hjh.0000000000001494] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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44
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Prkacin I, Vrdoljak P, Cavric G, Vazanic D, Pervan P, Adam VN. Resistant Hypertension and Cardiorenovascular Risk. BANTAO JOURNAL 2017. [DOI: 10.1515/bj-2017-0002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
Studies have documented independent contribution of sympathetic activation to the cardiovascular disease continuum. Hypertension is one of the leading modifiable factors. Most if not all the benefit of antihypertensive treatment depends on blood pressure lowering, regardless how it is obtained. Resistant hypertension is defined as blood pressure that remains uncontrolled in spite of the concurrent use of three antihypertensive drugs of different classes. Ideally, one of the three drugs should be a diuretic, and all drugs should be prescribed at optimal dose amounts. Poor adherence to antihypertensive therapy, undiscovered secondary causes (e.g. obstructive sleep apnea, primary aldosteronism, renal artery stenosis), and lifestyle factors (e.g. obesity, excessive sodium intake, heavy alcohol intake, various drug interactions) are the most common causes of resistant hypertension. Cardio(reno)vascular morbidity and mortality are significantly higher in resistant hypertensive than in general hypertensive population, as such patients are typically presented with a long-standing history of poorly controlled hypertension. Early diagnosis and treatment is needed to avoid further end-organ damage to prevent cardiorenovascular remodeling. Treatment strategy includes lifestyle changes, adding a mineralocorticoid receptor antagonist, treatment adherence in cardiovascular prevention and, in case of failure to control blood pressure, renal sympathetic denervation or baroreceptor activation therapy. The comparative outcomes in resistant hypertension deserve better understanding. In this review, the most current approaches to resistant hypertension and cardiovascular risk based on the available literature evidence will be discussed.
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Affiliation(s)
- Ingrid Prkacin
- Department of Internal Medicine, Merkur Clinical Hospital, Zagreb , Croatia
- University of Zagreb, School of Medicine, Zagreb , Croatia
| | - Petra Vrdoljak
- University of Zagreb, School of Medicine, Zagreb , Croatia
| | - Gordana Cavric
- Intensive Unit, Merkur Clinical Hospital, Zagreb , Croatia
| | - Damir Vazanic
- Croatian Institute of Emergency Medicine, Zagreb , Croatia
| | - Petra Pervan
- Public Health Centre Zagreb-Center, Zagreb , Croatia
| | - Visnja-Nesek Adam
- Department for Anesthesiology, Resuscitation and Intensive Care, University Hospital Sveti Duh, Zagreb; University of Osijek, School of Medicine Osijek , Croatia
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Whelton PK, Carey RM, Aronow WS, Casey DE, Collins KJ, Dennison Himmelfarb C, DePalma SM, Gidding S, Jamerson KA, Jones DW, MacLaughlin EJ, Muntner P, Ovbiagele B, Smith SC, Spencer CC, Stafford RS, Taler SJ, Thomas RJ, Williams KA, Williamson JD, Wright JT. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension 2017; 71:e13-e115. [PMID: 29133356 DOI: 10.1161/hyp.0000000000000065] [Citation(s) in RCA: 1577] [Impact Index Per Article: 225.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Whelton PK, Carey RM, Aronow WS, Casey DE, Collins KJ, Dennison Himmelfarb C, DePalma SM, Gidding S, Jamerson KA, Jones DW, MacLaughlin EJ, Muntner P, Ovbiagele B, Smith SC, Spencer CC, Stafford RS, Taler SJ, Thomas RJ, Williams KA, Williamson JD, Wright JT. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 2017; 71:e127-e248. [PMID: 29146535 DOI: 10.1016/j.jacc.2017.11.006] [Citation(s) in RCA: 3123] [Impact Index Per Article: 446.1] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Viazzi F, Piscitelli P, Ceriello A, Fioretto P, Giorda C, Guida P, Russo G, De Cosmo S, Pontremoli R. Resistant Hypertension, Time-Updated Blood Pressure Values and Renal Outcome in Type 2 Diabetes Mellitus. J Am Heart Assoc 2017; 6:JAHA.117.006745. [PMID: 28939716 PMCID: PMC5634309 DOI: 10.1161/jaha.117.006745] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Background Apparent treatment resistant hypertension (aTRH) is highly prevalent in patients with type 2 diabetes mellitus (T2D) and entails worse cardiovascular prognosis. The impact of aTRH and long‐term achievement of recommended blood pressure (BP) values on renal outcome remains largely unknown. We assessed the role of aTRH and BP on the development of chronic kidney disease in patients with T2D and hypertension in real‐life clinical practice. Methods and Results Clinical records from a total of 29 923 patients with T2D and hypertension, with normal baseline estimated glomerular filtration rate and regular visits during a 4‐year follow‐up, were retrieved and analyzed. The association between time‐updated BP control (ie, 75% of visits with BP <140/90 mm Hg) and the occurrence of estimated glomerular filtration rate <60 and/or a reduction ≥30% from baseline was assessed. At baseline, 17% of patients had aTRH. Over the 4‐year follow‐up, 19% developed low estimated glomerular filtration rate and 12% an estimated glomerular filtration rate reduction ≥30% from baseline. Patients with aTRH showed an increased risk of developing both renal outcomes (adjusted odds ratio, 1.31 and 1.43; P<0.001 respectively), as compared with those with non‐aTRH. No association was found between BP control and renal outcomes in non‐aTRH, whereas in aTRH, BP control was associated with a 30% (P=0.036) greater risk of developing the renal end points. Conclusions ATRH entails a worse renal prognosis in T2D with hypertension. BP control is not associated with a more‐favorable renal outcome in aTRH. The relationship between time‐updated BP and renal function seems to be J‐shaped, with optimal systolic BP values between 120 and 140 mm Hg.
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Affiliation(s)
- Francesca Viazzi
- Università degli Studi and IRCCS Azienda Ospedaliera Universitaria San Martino-IST, Genova, Italy
| | - Pamela Piscitelli
- Department of Medical Sciences, Scientific Institute "Casa Sollievo della Sofferenza", San Giovanni Rotondo (FG), Italy
| | - Antonio Ceriello
- Institut d'Investigacions Biomèdiques August Pii Sunyer (IDIBAPS) and Centro de Investigación Biomédicaen Red de Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Barcelona, Spain
- Department of Cardiovascular and Metabolic Diseases, IRCCS Gruppo Multimedica, Sesto San Giovanni Milano, Italy
| | | | - Carlo Giorda
- Diabetes and Metabolism Unit, ASL Turin 5, Chieri (TO), Italy
| | | | - Giuseppina Russo
- Department of Clinical and Experimental Medicine, University of Messina, Italy
| | - Salvatore De Cosmo
- Department of Medical Sciences, Scientific Institute "Casa Sollievo della Sofferenza", San Giovanni Rotondo (FG), Italy
| | - Roberto Pontremoli
- Università degli Studi and IRCCS Azienda Ospedaliera Universitaria San Martino-IST, Genova, Italy
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de Beus E, van der Sande NGC, Bots ML, Spiering W, Voskuil M, Visseren FLJ, Blankestijn PJ. Prevalence and clinical characteristics of apparent therapy-resistant hypertension in patients with cardiovascular disease: a cross-sectional cohort study in secondary care. BMJ Open 2017; 7:e016692. [PMID: 28882918 PMCID: PMC5589036 DOI: 10.1136/bmjopen-2017-016692] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVES Our aim was to investigate the prevalence of apparent therapy-resistant hypertension (aTRH) in patients with clinical manifest cardiovascular disease (CVD), and to study clinical characteristics related to aTRH in this population. SETTING The SMART (Second Manifestations of ARTerial disease) study is a large, single-centre cohort study in secondary care. PARTICIPANTS Office blood pressure (BP) at inclusion was used to evaluate BP control in 6191 hypertensive patients with clinical manifest (cardio)vascular disease. Therapy-resistant hypertension was defined as BP ≥140/90 mm Hg despite use of antihypertensive drugs from ≥3 drug classes including a diuretic or use of ≥4 antihypertensive drugs irrespective of BP. Logistic regression analysis was used to explore the relationship between clinical characteristics measured at baseline and presence of aTRH. RESULTS The prevalence of aTRH was 9.1% (95% CI 8.4 to 9.8). Prevalence increased with age and when albuminuria was present and was higher in patients with lower estimated glomerular filtration rate (eGFR). Presence of aTRH was related to diabetes, female sex, duration and multiple locations of vascular disease, body mass index and waist circumference. Carotid intima-media thickness was higher (0.99±0.28 vs 0.93±0.28 mm) and ankle-brachial index lower (1.07±0.20 vs 1.10±0.19) in patients with aTRH compared with patients without aTRH. CONCLUSION aTRH is prevalent in patients with clinical manifest CVD and is related to clinical factors known to be related with increased vascular risk, and with lower eGFR.
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Affiliation(s)
- Esther de Beus
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Michiel L Bots
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Wilko Spiering
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Michiel Voskuil
- Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Frank L J Visseren
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Peter J Blankestijn
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, The Netherlands
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Eikelis N, Hering D, Marusic P, Duval J, Hammond LJ, Walton AS, Lambert EA, Esler MD, Lambert GW, Schlaich MP. The Effect of Renal Denervation on Plasma Adipokine Profile in Patients with Treatment Resistant Hypertension. Front Physiol 2017; 8:369. [PMID: 28611687 PMCID: PMC5447749 DOI: 10.3389/fphys.2017.00369] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Accepted: 05/18/2017] [Indexed: 12/16/2022] Open
Abstract
Background: We previously demonstrated the effectiveness of renal denervation (RDN) to lower blood pressure (BP) at least partially via the reduction of sympathetic stimulation to the kidney. A number of adipocyte-derived factors are implicated in BP control in obesity. Aim: The aim of this study was to examine whether RDN may have salutary effects on the adipokine profile in patients with resistant hypertension (RH). Methods: Fifty seven patients with RH undergoing RDN program have been included in this study (65% males, age 60.8 ± 1.5 years, BMI 32.6 ± 0.7 kg/m2, mean ± SEM). Throughout the study, the patients were on an average of 4.5 ± 2.7 antihypertensive drugs. Automated seated office BP measurements and plasma concentrations of leptin, insulin, non-esterified fatty acids (NEFA), adiponectin and resistin were assessed at baseline and the 3 months after RDN. Results: There was a significant reduction in mean office systolic (168.75 ± 2.57 vs. 155.23 ± 3.17 mmHg, p < 0.001) and diastolic (90.68 ± 2.31 vs. 83.74 ± 2.36 mmHg, p < 0.001) BP 3 months after RDN. Body weight, plasma leptin and resistin levels and heart rate remained unchanged. Fasting insulin concentration significantly increased 3 months after the procedure (20.05 ± 1.46 vs. 29.70 ± 2.51 uU/ml, p = 0.002). There was a significant drop in circulating NEFA at follow up (1.01 ± 0.07 vs. 0.47 ± 0.04 mEq/l, p < 0.001). Adiponectin concentration was significantly higher after RDN (5,654 ± 800 vs. 6,644 ± 967 ng/ml, p = 0.024). Conclusions: This is the first study to demonstrate that RDN is associated with potentially beneficial effects on aspects of the adipokine profile. Increased adiponectin and reduced NEFA production may contribute to BP reduction via an effect on metabolic pathways. Clinical Trial Registration Number: NCT00483808, NCT00888433.
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Affiliation(s)
- Nina Eikelis
- Human Neurotransmitters and Neurovascular Hypertension and Kidney Disease Laboratories, Baker Heart and Diabetes InstituteMelbourne, VIC, Australia.,Iverson Health Innovation Research Institute, Swinburne University of TechnologyMelbourne, VIC, Australia
| | - Dagmara Hering
- Human Neurotransmitters and Neurovascular Hypertension and Kidney Disease Laboratories, Baker Heart and Diabetes InstituteMelbourne, VIC, Australia.,School of Medicine and Pharmacology - Royal Perth Hospital Unit, University of Western AustraliaPerth, WA, Australia
| | - Petra Marusic
- Human Neurotransmitters and Neurovascular Hypertension and Kidney Disease Laboratories, Baker Heart and Diabetes InstituteMelbourne, VIC, Australia.,School of Medicine and Pharmacology - Royal Perth Hospital Unit, University of Western AustraliaPerth, WA, Australia
| | - Jacqueline Duval
- Human Neurotransmitters and Neurovascular Hypertension and Kidney Disease Laboratories, Baker Heart and Diabetes InstituteMelbourne, VIC, Australia
| | - Louise J Hammond
- Human Neurotransmitters and Neurovascular Hypertension and Kidney Disease Laboratories, Baker Heart and Diabetes InstituteMelbourne, VIC, Australia
| | | | - Elisabeth A Lambert
- Human Neurotransmitters and Neurovascular Hypertension and Kidney Disease Laboratories, Baker Heart and Diabetes InstituteMelbourne, VIC, Australia.,Iverson Health Innovation Research Institute, Swinburne University of TechnologyMelbourne, VIC, Australia
| | - Murray D Esler
- Human Neurotransmitters and Neurovascular Hypertension and Kidney Disease Laboratories, Baker Heart and Diabetes InstituteMelbourne, VIC, Australia.,Heart Centre Alfred HospitalMelbourne, VIC, Australia
| | - Gavin W Lambert
- Human Neurotransmitters and Neurovascular Hypertension and Kidney Disease Laboratories, Baker Heart and Diabetes InstituteMelbourne, VIC, Australia.,Iverson Health Innovation Research Institute, Swinburne University of TechnologyMelbourne, VIC, Australia
| | - Markus P Schlaich
- Human Neurotransmitters and Neurovascular Hypertension and Kidney Disease Laboratories, Baker Heart and Diabetes InstituteMelbourne, VIC, Australia.,School of Medicine and Pharmacology - Royal Perth Hospital Unit, University of Western AustraliaPerth, WA, Australia.,Heart Centre Alfred HospitalMelbourne, VIC, Australia
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50
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Bangalore S, Davis BR, Cushman WC, Pressel SL, Muntner PM, Calhoun DA, Kostis JB, Whelton PK, Probstfield JL, Rahman M, Black HR. Treatment-Resistant Hypertension and Outcomes Based on Randomized Treatment Group in ALLHAT. Am J Med 2017; 130:439-448.e9. [PMID: 27984005 PMCID: PMC5362319 DOI: 10.1016/j.amjmed.2016.10.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Revised: 09/08/2016] [Accepted: 10/10/2016] [Indexed: 11/28/2022]
Abstract
BACKGROUND Although hypertension guidelines define treatment-resistant hypertension as blood pressure uncontrolled by ≥3 antihypertensive medications, including a diuretic, it is unknown whether patient prognosis differs when a diuretic is included. METHODS Participants in the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) were randomly assigned to first-step therapy with chlorthalidone, amlodipine, or lisinopril. At a Year 2 follow-up visit, those with average blood pressure ≥140 mm Hg systolic or ≥90 mm Hg diastolic on ≥3 antihypertensive medications, or blood pressure <140/90 mm Hg on ≥4 antihypertensive medications were identified as having apparent treatment-resistant hypertension. The prevalence of treatment-resistant hypertension and its association with ALLHAT primary (combined fatal coronary heart disease or nonfatal myocardial infarction) and secondary (all-cause mortality, stroke, heart failure, combined coronary heart disease, and combined cardiovascular disease) outcomes were identified for each treatment group. RESULTS Of participants assigned to chlorthalidone, amlodipine, or lisinopril, 9.6%, 11.4%, and 19.7%, respectively, had treatment-resistant hypertension. During mean follow-up of 2.9 years, primary outcome incidence was similar for those assigned to chlorthalidone compared with amlodipine or lisinopril (amlodipine- vs chlorthalidone-adjusted hazard ratio [HR] 0.86; 95% confidence interval [CI], 0.53-1.39; P = .53; lisinopril- vs chlorthalidone-adjusted HR = 1.06; 95% CI, 0.70-1.60; P = .78). Secondary outcome risks were similar for most comparisons except coronary revascularization, which was higher with amlodipine than with chlorthalidone (HR 1.86; 95% CI, 1.11-3.11; P = .02). An as-treated analysis based on diuretic use produced similar results. CONCLUSIONS In this study, which titrated medications to a goal, participants assigned to chlorthalidone were less likely to develop treatment-resistant hypertension. However, prognoses in those with treatment-resistant hypertension were similar across treatment groups.
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Affiliation(s)
| | - Barry R Davis
- Coordinating Center for Clinical Trials, The University of Texas School of Public Health, Houston.
| | - William C Cushman
- Memphis Veterans Affairs Medical Center, University of Tennessee College of Medicine
| | - Sara L Pressel
- Coordinating Center for Clinical Trials, The University of Texas School of Public Health, Houston
| | - Paul M Muntner
- Vascular Biology and Hypertension Program, University of Alabama, Birmingham
| | - David A Calhoun
- Vascular Biology and Hypertension Program, University of Alabama, Birmingham
| | - John B Kostis
- Cardiovascular Institute, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Paul K Whelton
- Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, La
| | | | - Mahboob Rahman
- Department of Medicine, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Henry R Black
- Department of Medicine, New York University School of Medicine
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