Comparative Epidemiology of Resistant Hypertension in Chronic Kidney Disease and the General Hypertensive Population

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

INTRODUCTION

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

Prevalence, Predictors, and Outcomes of Resistant Hypertension in Egyptian Population

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.

Novel Dual Endothelin Inhibitors in the Management of Resistant Hypertension

Resistant hypertension (RH) is defined as the failure to achieve blood pressure control despite using triple combination therapy with a renin-angiotensin system inhibitor (RAS-i), a calcium antagonist, and a diuretic. The endothelin (ET) system is implicated in the regulation of vascular tone, primarily through vasoconstriction, intervenes in cardiac contractility with inotropic effects, and contributes to water and sodium renal reabsorption. ET inhibitors, currently approved for the treatment of pulmonary hypertension, seem to be also useful for essential hypertension and RH as well. Studies into the development of new dual ET inhibitors, which inhibit both type A and B ET (ETA and ETB) receptors, present initial results of managing RH. Aprocitentan (ACT-132577) is a novel, orally active and well tolerated dual ET receptor antagonist, which has been examined in several experimental studies and clinical trials with promising results for RH control. The recent publication of the large PRECISION study in The Lancet journal provides further reassurance regarding the efficacy and safety of aprocitentan for RH, with the aim of overcoming unmet needs in the management of this difficult group of patients.

Assessment of a strategy combining ambulatory blood pressure, adherence monitoring and a standardised triple therapy in resistant hypertension

PURPOSE

Poor adherence to drug therapy and inadequate drug regimens are two frequent factors responsible for the poor blood pressure (BP) control observed in patients with apparent resistant hypertension. We evaluated the efficacy of an antihypertensive management strategy combining a standardised therapy with three long acting drugs and electronic monitoring of drug adherence in patients with apparent resistant hypertension.

MATERIALS AND METHODS

In this multicentric observational study, adult patients with residual hypertension on 24 h ambulatory BP monitoring (ABMP) despite the use of three or more antihypertensive drugs could be included. Olmesartan/amlodipine (40/10 mg, single pill fixed-dose combination) and chlorthalidone (25 mg) were prescribed for 3 months in two separated electronic pills boxes (EPB). The primary outcome was 24 h ambulatory systolic BP (SBP) control at 3 months, defined as mean SBP <130 mmHg.

RESULTS

We enrolled 48 patients (36.0% women) of whom 35 had complete EPB data. After 3 months, 52.1% of patients had 24 h SBP <130 mmHg. 24 h SBP decreased by respectively -9.1 ± 15.5 mmHg, -22.8 ± 30.6 mmHg and -27.7 ± 16.6 mmHg from the tertile with the lowest adherence to the tertile with the highest adherence to the single pill combination (p = 0.024). A similar trend was observed with tertiles of adherence to chlorthalidone. Adherence superior to 90% was associated with 24 h systolic and diastolic blood pressure control in multiple logistic regression analysis (odds ratio = 14.1 (95% confidence interval 1.1-173.3, p = 0.039).

CONCLUSIONS

A simplified standardised antihypertensive therapy combined with electronic monitoring of adherence normalises SBP in about half of patients with apparent resistant hypertension. Such combined management strategy enables identifying patients who need complementary investigations and those who rather need a long-term support of their adherence.

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

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

Krüppel-like factor 15 is a key suppressor of podocyte fibrosis under rotational force-driven pressure

Krüppel-like factor 15 (KLF15) is a well-known transcription factor associated with podocyte injury and fibrosis. Recently, hypertensive nephropathy was discovered to be closely related to podocyte injury and fibrosis. However, methods to stimulate hypertension in vitro are lacking. Here, we constructed an in vitro model mimicking hypertension using a rotational force device to identify the role of KLF15 in fibrosis due to mechanically induced hypertensive injury. First, we found that KLF15 expression was decreased in patients with hypertensive nephropathy. Then, an in vitro study of hypertension due to rotational force was conducted, and an increase in fibrosis markers and decrease in KLF15 levels were determined after application of 4 mmHg pressure in primary cultured human podocytes. KLF15 and tight junction protein levels increased with retinoic acid treatment. siRNA-mediated inhibition of KLF15 exacerbated pressure-induced fibrosis injury, and KLF15 expression after treatment with angiotensin II was similar to that observed after treatment with the blood pressure modeling device. Furthermore, the reduced KLF15 levels after mechanical pressure application were restored after the administration of an antihypertensive drug. KLF15 expression was also low in vivo. We confirmed the protective role of KLF15 in fibrosis using a mechanically induced in vitro model of hypertensive injury.

Noodle consumption is positively associated with incident hypertension in middle-aged and older Korean women

BACKGROUND/OBJECTIVES

This study examined the association between refined grain consumption by subtype and the incidence of hypertension from the Korean Genome and Epidemiology Study data.

SUBJECTS/METHODS

In total, 5,018 participants (2,439 men and 2,579 women) from 40 to 69 years without hypertension were recruited at the beginning (2001–2002). Blood pressure and antihypertensive medication use were assessed biennially for the incidence of hypertension during the 8-year follow-up period (2009–2010). Hypertension was diagnosed as systolic blood pressure ≥ 140 mmHg or diastolic blood pressure ≥ 90 mmHg or antihypertensive medication use. Dietary intake including refined grains was assessed by a food frequency questionnaire at baseline and the follow-up (2005–2006). A multivariate Cox proportional hazard model was used to examine hazard ratios (HRs) and 95% confidence intervals (CIs) for incident hypertension according to refined-grain consumption.

RESULTS

A total of 1,377 cases of hypertension (710 men and 667 women) were newly ascertained. Frequent noodle consumers (≥ 5 servings/week) among the women had a 2.3-fold higher risk of hypertension than infrequent noodle consumers after adjustment for potential confounders (HR = 2.31, 95% CI = 1.33–4.01, P for trend = 0.0001). However, no significant association was found among the men. The intake of other refined grain products such as white rice and breads was not associated with the incidence of hypertension.

CONCLUSIONS

Frequent noodle consumption was positively associated with a risk of incident hypertension in South Korean women.

Global prevalence of resistant hypertension: a meta-analysis of data from 3.2 million patients

OBJECTIVE

We conducted the first systematic review and meta-analysis to estimate the specific prevalence of apparent treatment-resistant, pseudo-resistant and true-resistant hypertension among treated patients with hypertension globally.

METHODS

We conducted a search in PubMed, EMBASE, Web of Science and Global Index Medicus to identify articles published from inception to 30 September 2017, and searched the reference list of retrieved articles. We used a random-effects model to estimate the prevalence of resistant hypertension across studies and heterogeneity was assessed via the χ² test on Cochran's Q statistic.

RESULTS

We included 91 studies published between 1991 and 2017 reporting data of a pooled sample of 3 207 911 patients with hypertension on antihypertensive drugs globally. Most of the studies (n=64, 70%) only used office blood pressure (BP) measurement. In the general, population of treated patients with hypertension, the prevalence of true-resistant, apparent treatment-resistant and pseudo-resistant hypertension were 10.3% (95% CI 7.6% to 13.2%), 14.7% (95% CI 13.1% to 16.3%) and 10.3% (95% CI 6.0% to 15.5%). The prevalence of true-resistant hypertension was 22.9% (95% CI 19.1% to 27.0%), 56.0% (95% CI 52.7% to 59.3%) and 12.3% (95% CI 1.7% to 30.5%) in chronic kidney disease, renal transplant and elderly patients, respectively.

CONCLUSIONS

This study shows a high prevalence of true-resistant hypertension. This prevalence is lower than that of apparent treatment-resistant hypertension, demonstrating the importance to exclude causes of pseudo-resistant hypertension including white-coat hypertension with the use of ambulatory BP measurement. The burden of resistant hypertension is highest in patients with chronic kidney disease. New treatments for resistant hypertension are highly needed, considering the disastrous complications of the disease.

Association between Fruit and Vegetable Consumption and Risk of Hypertension in Middle-Aged and Older Korean Adults

BACKGROUND

High fruit and vegetable (F/V) intake may be beneficial for hypertension prevention. However, a prospective association has not been investigated in a Korean population, and differences exist between typical diets in Korea and those of Western populations.

OBJECTIVE

The aim of this prospective study was to investigate the association between F/V intake and risk of incident hypertension in middle-aged and older Korean adults using the data from the Korean Genome and Epidemiology Study (KoGES).

DESIGN

The KoGES is a large community-based cohort study of Korean adults aged 40 to 69 years, which began in May 2001. Questionnaires on demographic information and lifestyle factors were completed at baseline. Anthropometrics and biochemical measurements were conducted biennially. Fruit and vegetable consumption was assessed with a semiquantitative food frequency questionnaire. Hypertension was defined as a systolic blood pressure≥140 mm Hg or diastolic blood pressure ≥90 mm Hg.

PARTICIPANTS AND SETTING

A total of 4,257 participants (2,085 men, 2,172 women) without hypertension at baseline were evaluated.

MAIN OUTCOME MEASURES

The primary outcome was incident hypertension.

STATISTICAL ANALYSIS PERFORMED

Multivariate Cox proportional hazard models were used to examine hazard ratios (HRs) and 95% CIs for incident hypertension according to F/V consumption.

RESULTS

During the 8-year follow-up, 1,158 participants (606 men and 552 women) developed hypertension. Among men, frequent fruit consumers (≥4 servings/day) had a 56% lower risk of incident hypertension than did infrequent consumers (<1 serving/day) (HR=0.44, 95% CI=0.32 to 0.60, P for trend <0.0001). Among women, frequent fruit consumers had a 67% lower risk of incident hypertension than did infrequent consumers (HR=0.33, 95% CI=0.24 to 0.45, P for trend <0.0001), after adjustment for potential confounders. However, there was no association between vegetable consumption and risk of incident hypertension in either men or women.

CONCLUSION

A higher intake of fruit was prospectively associated with a lower risk of incident hypertension in middle-aged and older Korean adults, regardless of sex.

The highly neglected burden of resistant hypertension in Africa: a systematic review and meta-analysis

OBJECTIVE

The hypertension epidemic in Africa collectively with very low rates of blood pressure control may predict an incremented prevalence of resistant hypertension (RH) across the continent. The aim of this study was to determine the prevalence of RH and associated risk factors in Africa.

DATA SOURCES

We conducted a comprehensive search of electronic databases (PubMed, EMBASE, Africa Wide Information and Africa Index Medicus) completed by manual search of articles, regardless of language or publication date.

METHODS

We included studies which have reported the prevalence and/or risk factors for RH in Africa from inception to 19 May 2016. Forest plots were drawn to visualise the combined prevalence of RH and extent of statistical heterogeneity between studies.

RESULTS

Out of 259 retrieved studies, only 5 from Cameroon, Nigeria, Burkina Faso, Lesotho and Algeria with a total population of 4 068 patients were finally included in this review. There was no study from the Eastern part of Africa. Though the definition of RH was not similar across studies, its prevalence was respectively 11.7%, 4.9%, 14.6%, 14.3% and 19.0%, with an overall pooled prevalence of 12.1% (95% CI 8.0% to 17.7%). Potential risk factors were: non-compliance to treatment, ageing, male sex, dyslipidaemia, metabolic syndrome, previous cardiovascular events, physical inactivity and stress, but not excessive salt intake, alcohol and coffee ingestions. Moreover, diabetes, smoking, obesity and renal insufficiency yielded discrepant results.

CONCLUSIONS

There is a huge dearth of research on the epidemiology of RH in Africa. Thereby, an extensive study of RH prevalence and risk factors is still largely warranted to curtail the high and continuously increasing burden of hypertension across Africa.

Untreated, Uncontrolled, and Apparent Resistant Hypertension: Results of the German Health Examination Survey 2008-2011

The prevalence and associated factors of untreated, uncontrolled, and apparent-resistant hypertension (RH) in Germany are unknown. Based on European Society of Hypertension criteria, apparent RH was defined as blood pressure (BP) ≥140/90 mm Hg (≥140/85 mm Hg in diabetics) under treatment with three different classes of antihypertensive agents including a diuretic. Data from the German Health Examination Survey (2008-2011; n=7115, age 18-79 years) including standardized BP measurements and Anatomical Therapeutic Chemical-coded taken medications were analyzed. Among patients aware of their hypertensive status (n=2205), 37.9% were uncontrolled and, among those, 33.4% were untreated. Being aware and having untreated and uncontrolled BP was associated with male sex, young age, not having cardiovascular disease, not performing BP self-measurement, not being obese, and not smoking. Apparent RH occurred in 6.8% of treated aware hypertensive patients and was positively associated with having diabetes. The proportion of uncontrolled BP is still high. Not having "obvious risk factors" has become a risk itself for having untreated and uncontrolled hypertension.