Dynamic resistant hypertension patterns as predictors of cardiovascular morbidity: a 4-year prospective study. J Hypertens. 2014;32:415-422. [PMID: 24241057 DOI: 10.1097/hjh.0000000000000023]

Investigation and management of resistant hypertension: British and Irish Hypertension Society position statement

People living with resistant hypertension (RH) are at high risk of adverse cardiovascular events. The British and Irish Hypertension Society has identified suspected RH as a condition for which specialist guidance may improve rates of blood pressure control and help clinicians identify those individuals who may benefit from specialist review. In this position statement we provide a practical approach for the investigation and management of adults with RH. We highlight gaps in the current evidence and identify important future research questions. Our aim is to support the delivery of high-quality and consistent care to people living with RH across the UK and Ireland.

Predictive Factors of Apparent Treatment Resistant Hypertension Among Patients With Hypertension Identified Using Electronic Health Records

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.

Screening of serum markers in patients with resistant hypertension

Background

This study delves into the intricacies of resistant hypertension (RH), a prevalent yet enigmatic chronic cardiovascular ailment that is linked to a myriad of complications. Although its full pathogenesis is still shrouded in mystery, the field of proteomics offers a beacon of hope, with its potential to shed light on the proteins that orchestrate the tapestry of life. Harnessing the power of proteomics is essential for demystifying the pathogenesis of RH, enabling more precise diagnostics and treatments, and ultimately improving prognostic outcomes.

Methods

Our approach was to employ rigorous statistical analyses to home in on proteins with significant expression variances between our two cohorts. We complemented this with bioinformatics tools to unravel the intricate functions and pathways of these proteins. By synthesizing these insights with the clinical profiles of our patients, we were able to distill a set of definitive biomarkers with diagnostic potential. In our quest for clarity, we also embarked on a retrospective journey, amassing and scrutinizing clinical data from both RH and hypertension (HTN) patients. We crafted and rigorously assessed risk factor models to evaluate their diagnostic prowess.

Results

Our exploration spanned across 30 blood samples from RH patients and 20 from those grappling with HTN. Our inquiry yielded some compelling revelations: (1) RH patients showcased 29 unique proteins, in contrast to the 59 unique proteins found in HTN patients. A deeper dive into the proteomic data unveiled molecular functions predominantly tied to lipid metabolism, protein networking, and oxidative stress, with a spotlight on pathways such as cholesterol metabolism, coagulation, and the complement cascade. (2) By charting receiver operating characteristic curves and rigorously analyzing the proteomic data, we surfaced 11 proteins with notable diagnostic potential, tightly interwoven with clinical metrics.

Conclusion

Our research has pinpointed 11 proteins that stand as promising serum biomarkers, endowed with significant diagnostic value. This discovery marks a stride towards a more nuanced understanding and management of resistant hypertension.

Resistant hypertension: diagnosis, evaluation, and treatment a clinical consensus statement from the Thai hypertension society

Resistant hypertension (RH) includes hypertensive patients with uncontrolled blood pressure (BP) while receiving ≥3 BP-lowering medications or with controlled BP while receiving ≥4 BP-lowering medications. The exact prevalence of RH is challenging to quantify. However, a reasonable estimate of true RH is around 5% of the hypertensive population. Patients with RH have higher cardiovascular risk as compared with hypertensive patients in general. Standardized office BP measurement, confirmation of medical adherence, search for drug- or substance-induced BP elevation, and ambulatory or home BP monitoring are mandatory to exclude pseudoresistance. Appropriate further investigations, guided by clinical data, should be pursued to exclude possible secondary causes of hypertension. The management of RH includes the intensification of lifestyle interventions and the modification of antihypertensive drug regimens. The essential aspects of lifestyle modification include sodium restriction, body weight control, regular exercise, and healthy sleep. Step-by-step adjustment of the BP-lowering drugs based on the available evidence is proposed. The suitable choice of diuretics according to patients' renal function is presented. Sacubitril/valsartan can be carefully substituted for the prior renin-angiotensin system blockers, especially in those with heart failure with preserved ejection fraction. If BP remains uncontrolled, device therapy such as renal nerve denervation should be considered. Since device-based treatment is an invasive and costly procedure, it should be used only after careful and appropriate case selection. In real-world practice, the management of RH should be individualized depending on each patient's characteristics.

Long-term effect of obstructive sleep apnoea management on blood pressure in patients with resistant hypertension: the SARAH study

BACKGROUND

There is a close relationship between obstructive sleep apnoea (OSA) and resistant hypertension (RH). However, studies assessing the long-term effect of diagnosing and treating OSA on blood pressure (BP) control in these patients are lacking.

METHODS

To address this gap, we recruited 478 RH patients from hypertension units and followed them prospectively after they were screened for OSA through a sleep study. By performing 24-h ambulatory BP monitoring (ABPM) annually, the effect of OSA management was assessed.

RESULTS

The patients had a median (interquartile range (IQR)) age of 64.0 (57.2-69.0) years, 67% were males and most were nonsleepy, with a median (IQR) apnoea-hypopnoea index (AHI) of 15.8 (7.9-30.7) events·h-1. The median (IQR) follow-up time was 3.01 (2.93-3.12) years. At baseline, severe OSA was associated with uncontrolled BP, nocturnal hypertension and a nondipper circadian BP pattern. Moreover, these patients had higher BP values during follow-up than did patients in the other groups. However, among patients with moderate and severe OSA, the management of sleep disordered breathing, including the implementation of continuous positive airway pressure treatment, was associated with a reduction in 24-h ABPM parameters, especially night-time BP values, at the 1-year follow-up. These benefits were attenuated over time and only subjects with severe OSA maintained an ABPM night-time reduction at 3 years. Furthermore, clinical variables such as uncontrolled BP, sex and age showed a predictive value for the BP response at 1 year of follow-up.

CONCLUSION

A favourable long-term decrease in BP was detected by diagnosing and treating OSA in a cohort of RH patients from hypertension units, but over time this decrease was only partially maintained in severe OSA patients.

The Global Burden of Resistant Hypertension and Potential Treatment Options

Resistant hypertension (RH) is defined as systolic blood pressure (SBP) or diastolic blood pressure (DBP) that remains .140 mmHg or .90 mmHg, respectively, despite an appropriate lifestyle and the use of optimal or maximally tolerated doses of a three-drug combination, including a diuretic. This definition encompasses the category of controlled RH, defined as the presence of blood pressure (BP) effectively controlled by four or more antihypertensive agents, as well as refractory hypertension, referred to as uncontrolled BP despite five or more drugs of different classes, including a diuretic. To confirm RH presence, various causes of pseudo-resistant hypertension (such as improper BP measurement techniques and poor medication adherence) and secondary hypertension must be ruled out. Inadequate BP control should be confirmed by out-of-office BP measurement. RH affects about 5% of the hypertensive population and is associated with increased cardiovascular morbidity and mortality. Once RH presence is confirmed, patient evaluation includes identification of contributing factors such as lifestyle issues or interfering drugs/substances and assessment of hypertension-mediated organ damage. Management of RH comprises lifestyle interventions and optimisation of current medication therapy. Additional drugs should be introduced sequentially if BP remains uncontrolled and renal denervation can be considered as an additional treatment option. However, achieving optimal BP control remains challenging in this setting. This review aims to provide an overview of RH, including its epidemiology, pathophysiology, diagnostic work-up, as well as the latest therapeutic developments.

Apparent Treatment-Resistant Hypertension in the First Year Associated With Cardiovascular Mortality in Peritoneal Dialysis Patients

BACKGROUND

Few reports have focused on the association between apparent treatment-resistant hypertension (aTRH) and cardiovascular (CV) mortality in peritoneal dialysis (PD) population, thus we conducted this retrospective cohort to explore it.

METHODS

This was a retrospective cohort study conducted from January 2011 to January 2020 with PD patients in 4 Chinese dialysis centers. aTRH was defined according to the American College of Cardiology and American Heart Association guidelines. aTRH duration was calculated as the total number of months when patients met the diagnostic criteria in the first PD year. The primary outcome was CV mortality, and the secondary outcomes were CV events, all-cause mortality, combined endpoint (all-cause mortality and transferred to hemodialysis [HD]), and PD withdrawal (all-cause mortality, transferred to HD, and kidney transplantation). Cox proportional hazards models were used to assess the association.

RESULTS

A total of 1,422 patients were finally included in the analysis. During a median follow-up period of 26 months, 83 (5.8%) PD patients incurred CV mortality. The prevalence of aTRH was 24.1%, 19.9%, and 24.6% at 0, 3, and 12 months after PD initiation, respectively. Overall, aTRH duration in the first PD year positively associated with CV mortality (per 3 months increment, adjusted hazards ratio [HR], 1.29; 95% confidence interval 1.10, 1.53; P = 0.002). After categorized, those with aTRH duration more than 6 months presented the highest adjusted HR of 2.92. Similar results were found for secondary outcomes, except for the CV event.

CONCLUSIONS

Longer aTRH duration in the first PD year is associated with higher CV mortality and worse long-term clinical outcomes. Larger studies are warranted to confirm these findings.

CLINICAL TRIALS REGISTRATION

There is no clinical trial registration for this retrospective study.

What is resistant arterial hypertension?

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.

A Need for Improvement in the Definition of Resistant Arterial Hypertension

With the medical and social importance of resistant arterial hypertension (HTN) in mind, we had three goals in this paper: to study the definitions of resistant HTN in the guidelines on the topic, to analyze them, and to suggest some improvements. We found (at least) eleven insufficiencies in the definition of resistant HTN: (1) different blood pressure (BP) values are used for diagnoses; (2) the number of BP measurements is not specified; (3) the time-frame for the definition is not obtained; (4) it fails to provide normal or target or controlled BP values; (5) secondary HTN is not currently defined as true resistant HTN, but as apparently treatment-resistant HTN; (6) the definition usually directly incorporates BP cut-offs for systolic BP (sBP) and diastolic BP (dBP) making the diagnosis temporary; (7) stress is not included in the exclusion strategy for resistant HTN; (8) there is potentially a need to introduce a category of recovered resistant HTN; (9) to what degree do healthy lifestyle measures have to be fulfilled to consider it as sufficient to change the diagnosis from "apparent treatment-resistant HTN" to the "resistant HTN"; (10) sBP values normal-for-the-age for 61 and 81 year old patients in some guidelines fulfill the criterion for resistant HTN; (11) it probably ought to read "In the absence of contraindications and compelling indications…" in the others. We believe that it is better to use the phrase "above the target BP" for the definition of (treatment) resistant HTN, because the whole story of resistant HTN is related to non-responders to antihypertensive treatment. Therefore, as we treat to target and not to normal values, it is appropriate to define resistant HTN as an insufficiency to reach the target BP values. Moreover, the definition of (treatment) resistant HTN should not be universal for every patient with HTN, but it should be age-related: (treatment) resistant HTN is elevated BP over the target/normal BP values. Using this modification, there will be no need to automatically change the definition of resistant HTN when we change the BP targets in the future.

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.

Renal Denervation: A Practical Guide for Health Professionals Managing Hypertension

Growing evidence demonstrates the suitability of renal denervation in a broad population of patients; however, questions remain over its suitability and practical implementation. Given the rapidity of emerging data, this has been a challenging field for potential adopters to navigate. The purpose of this article is twofold: to provide navigation through emerging clinical data and evolving guidance; and to provide physicians with practical, evidence-based advice for identifying eligible patients and providing appropriate management in the pre- and postintervention settings. Although many of these recommendations are based on existing published guidance documents, we reflect equally on our own experiences of using this technology.

Associated factors and hemodynamic characteristics of resistant hypertension in the elderly

The purpose of this study was to explore the associated factors and hemodynamic characteristics of resistant hypertension (RHTN) in the elderly. A total of 283 patients aged ≥60 years with hypertension were evaluated by the CNAP™ monitor. Among them, 240 patients were non-RHTN (controlled hypertension with use of three or fewer antihypertensive medications) and 43 patients were RHTN (uncontrolled hypertension despite the concurrent use of ≥3 antihypertensive drugs at optimized doses, including a diuretic, or achieving target blood pressure with the use of ≥4 antihypertensive medications). RHTN was associated with higher body mass index (BMI), longer hypertension duration, and coronary heart disease (p = .004, p < .001, and p = .042, respectively). The mean number of antihypertensive medications was greater in patients with RHTN (p < .001). Hemodynamic analysis revealed higher cardiac output in the RHTN group than in the non-RHTN group, while no difference was observed in systemic vascular resistance. Screening for secondary etiology showed that, among the 43 patients with RHTN, 8 (18.6%) had chronic kidney disease, 8 (18.6%) had obstructive sleep apnea, 4 (9.3%) had primary aldosteronism, 2 (4.7%) had renovascular disease. No significant differences were observed in the cardiac output and systemic vascular resistance values between different causes of RHTN. These findings suggest that higher body mass index, longer hypertension duration, and coronary heart disease emerged as the associated factors of RHTN in the elderly. RHTN is characterized by higher cardiac output. Screening for the possible secondary etiology of RHTN in the elderly patients is necessary and important.

Role of home blood pressure monitoring in resistant hypertension

The definition of resistant hypertension (RHT) has been updated to include failure to achieve target blood pressure (BP) despite treatment with ≥3 antihypertensive drugs, including diuretics, renin-angiotensin system blockers, and calcium channel blockers, prescribed at the maximum or maximally tolerated doses, or as success in achieving the target blood pressure but requiring ≥4 drugs. RHT is a major clinical problem, as it is associated with higher mortality and morbidity than non-RHT. Therefore, it is crucial to accurately identify RHT patients to effectively manage their disease. Out-of-clinic BP measurement, including home BP monitoring and ambulatory BP monitoring is gaining prominence for the diagnosis and management of RHT. Home BP monitoring is advantageous as it is feasibly repetitive, inexpensive, widely available, and because of its reproducibility over long periods. In addition, home BP monitoring has crucial advantage of allowing safe titration for the maximum or maximally tolerable dose, and for self-monitoring, thereby improving clinical inertia and nonadherence, and allowing true RHT to be more accurately identified.

Compliance to Multidisciplinary Lifestyle Intervention Decreases Blood Pressure in Patients with Resistant Hypertension: A Cross-Sectional Pilot Study

Hypertension is a common chronic medical condition. Treatment is not satisfactory in a significant proportion of patients with primary hypertension, despite the concurrent use of three or more medications with different mechanisms of action. Such treatment-resistant hypertension is a clinical challenge associated with poor prognosis and needs further investigation. The efficacy of lifestyle changes has not been established yet in patients with resistant hypertension, and educational efforts appear clinically irrelevant in patients who must achieve behavioral changes without supervision. A 6-month multidisciplinary pilot intervention enrolled 50 patients with established resistant hypertension. The aims were: (1) to examine whether intensive and supervised lifestyle changes contribute to decreasing blood pressure in this condition, and (2) to identify which components affect compliance and feasibility. The program provided intensive changes in nutrition, physical exercise, and control of sleep disturbances supervised by nutritionists, physiotherapists, and psychologists. Nurses and pharmacists followed up on adherence to the antihypertensive medication. The primary outcome was 24 h blood pressure control. Data in patients with full compliance (n = 30) indicate that lifestyle modifications in resistant hypertension significantly reduced 24 h both systolic and diastolic blood pressure (p < 0.01), body mass index (p < 0.01), medication burden (p = 0.04), improving physical fitness, and cardiovascular risk markers such as heart rate (p = 0.01) and augmentation index (p = 0.02). The adherence to the intervention was moderate, with an attrition rate of 12%. A modified version reducing visits and explorations will likely improve compliance and can be used to assess the long-term maintenance of these benefits in managing resistant hypertension by diverse healthcare providers.

The enigma of resistant hypertension: from lifestyle changes and pharmacological treatment to renal denervation

Resistant hypertension consists in the failure to achieve effective control of blood pressure despite the use of at least three drugs, including a diuretic, at the maximum tolerated dosage. Despite the progress made in terms of improving awareness and effectiveness of the available therapeutic strategies, the percentage of patients with resistant hypertension represents up to 18% of the entire hypertensive population. The management of resistant hypertension includes the combination of different strategies from lifestyle changes to complex interventional procedures. Lifestyle interventions include reducing salt intake, weight loss, quitting smoking and alcohol consumption, and performing aerobic physical activity. With regard to drug therapy, international guidelines recommend the introduction of a mineralocorticoid receptor antagonist or, if not tolerated, of a loop diuretic, or of the beta-blocker bisoprolol, or of the alpha-blocker doxazosin. In the last few years, promising results have been obtained from studies that have evaluated the efficacy and safety of the denervation of the renal arteries by ablation. This procedure may constitute an increasingly widespread option for those patients suffering from resistant hypertension despite the use of different drug classes, or who are intolerant or poorly adherent to medical therapy.

Cardiovascular Prognosis in Drug-Resistant Hypertension Stratified by 24-Hour Ambulatory Blood Pressure: The JAMP Study

[Figure: see text].

Prevalence, predictors, and outcomes of both true- and pseudo-resistant hypertension in the action to control cardiovascular risk in diabetes trial: a cohort study

Resistant hypertension (RH) has been poorly studied due to the difficulty in distinguishing it from nonadherence-the exclusion of which is necessary to accurately diagnose RH. Therefore, little is known about the prevalence, predictors, and outcomes of true RH. We evaluated 1838 patients from the standard blood pressure (BP) arm of the Action to Control Cardiovascular Risk in Diabetes Trial. We classified patients into three groups: "true RH", "pseudo-RH" (i.e., patients with BP levels that would classify them as RH but who were non-adherent), and "other" (i.e., those who could not be classified as having "true RH" or "pseudo-RH"). We examined predictors of true and pseudo-RH and the relationship between true RH and the composite outcome of nonfatal MI, nonfatal stroke, or cardiovascular death. Among 1838 participants with complete information, 489 (26.6%) met the definition of true RH, and 94 (16.1%) RH patients had "pseudo-RH" on ≥1 visit over the first 12 months. Predictors of RH included: baseline SBP ≥ 160 mmHg (OR = 8.79; 95% CI: 5.70-13.68) and baseline SBP between 140-159 (OR = 2.91; 95% CI: 2.13-4.00) compared to SBP < 140, additional baseline BP medication (OR = 3.40; 95% CI: 2.83-4.11), macroalbuminuria (OR = 2.35; 95% CI: 1.50-3.67), CKD (OR = 1.53; 95% CI: 0.99-2.33), history of stroke (OR = 1.73; 95% CI: 1.04-2.82), and black race (OR = 1.39; 95% CI: 1.02-1.88); the cross-validated C-statistic was 0.80. "True RH" patients had a 65% increased hazard in composite outcome (HR = 1.65; 95% CI: 1.13-2.42). In conclusion, the majority of patients classified as having RH had "true RH," which was more common among those who are black, have macroalbuminuria, CKD, stroke, higher baseline SBP, and are taking more baseline antihypertensives. These patients are at increased risk for cardiovascular and mortality events.

Association of treatment-resistant hypertension defined by home blood pressure monitoring with cardiovascular outcome

In diagnosis of treatment-resistant hypertension (TRH), guidelines recommend out-of-office blood pressure (BP) measurements, ambulatory BP monitoring (ABPM) and home BP monitoring (HBPM). Although evidence of an association between ABPM-evaluated TRH and cardiovascular disease (CVD) prognosis has accumulated, data are sparse regarding HBPM-evaluated TRH. We investigated this issue using data from the nationwide practice-based J-HOP (Japan Morning-Surge Home BP) study, which recruited 4,261 outpatients (mean age 64.9 years; 46.8% men; 91.5% hypertensives) who underwent morning and evening HBPM for 14 days. During 6.2 ± 3.8 years (26,418 person-years) follow-up, 270 total CVDs (stroke, coronary artery disease, aortic dissection, and heart failure) occurred. The adjusted hazard ratio (HR) (95% CIs) of uncontrolled TRH, i.e., uncontrolled BP using 3 classes of medications including diuretics or ≥4 classes of medications, for total CVD risk compared to controlled BP using <3 classes were 2.02 (1.38-2.94) and 1.81 (1.23-2.65) in home BP of 135/85 mmHg and 130/80 mmHg, respectively. Additionally, patients with TRH defined by guidelines, i.e., uncontrolled BP using 3 classes of medications including diuretics or controlled/uncontrolled BP using ≥4 classes of medications, also had higher total CVD risk compared to non-TRH under all home BP criteria. Moreover, in patients with uncontrolled apparent-TRH, i.e., TRH defined by office BP, uncontrolled home BP (≥135/85 mmHg) was still associated with atherosclerotic CVD (CVDs except heart failure) risk (adjusted HR [95% CI], 2.38 [1.09-5.19]). This is the first study to demonstrate an independent association between TRH evaluated by HBPM and CVD outcomes.

Resistance to antihypertensive treatment and long-term risk: The Atherosclerosis Risk in Communities study

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.

Persistent Resistant Hypertension Has Worse Renal Outcomes in Chronic Kidney Disease than that Resolved in Two Years: Results from the KNOW-CKD Study

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.

The HIPARCO-2 study: long-term effect of continuous positive airway pressure on blood pressure in patients with resistant hypertension: a multicenter prospective study

INTRODUCTION

Short-term treatment with continuous positive airway pressure (CPAP) produces a clinically significant reduction in blood pressure (BP) in patients with obstructive sleep apnea (OSA) and resistant hypertension. However, it is unknown whether this effect continues over the long-term. Our objective was to assess the effect of long-term CPAP on BP in patients with OSA and resistant hypertension.

METHODS

The study included 161 patients diagnosed with both OSA [apnea--hypopnea index (AHI) ≥15] and resistant hypertension diagnosed via 24-hour ambulatory BP measurement (24-h ABPM), in whom a second analysis via 24-h ABPM was performed at the end of the follow-up.

RESULTS

Patients were followed up within 59 months [interquartile range (IQR): 44-70]. CPAP treatment was prescribed to 82% of the patients (70% with good adherence to CPAP defined as use of CPAP at least 4 h/night). A comparison between the adherent group and nonadherent group (including those with CPAP not prescribed) showed that CPAP adherents had a significant drop in the 24-h BP, both systolic [-3.9 mmHg; 95% confidence interval (CI): -8.1 to 0.3] and diastolic pressure (-3.5 mmHg [95% [CI]: -6.4-0.5]), with a higher magnitude during the night (-5.5 and -4.9 mmHg, respectively). The CPAP adherent group needed a mean of 1.1 less antihypertensive drugs (particularly spironolactone). Finally, there was a positive correlation between the drop in 24-h SBP and the hours of CPAP use (r = 0.24; P = 0.01).

CONCLUSION

Good adherence to long-term CPAP treatment largely succeeded in significantly reducing BP in those patients with OSA and resistant hypertension, despite the use of a lower number of antihypertensive drugs.

Prevalence and prognosis of the 2018 vs 2008 AHA definitions of apparent treatment-resistant hypertension in high-risk hypertension patients

Resistant hypertension was defined according to the 2008 scientific statement as office blood pressure ≥ 140/90 mm Hg and the 2018 scientific statement as office blood pressure ≥ 130/80 mm Hg. We investigated the prognostic significance of lowered blood pressure threshold for defining resistant hypertension in the 2018 American Heart Association scientific statement compared with that in the 2008 scientific statement. The participants of this prospective cohort were enrolled from December 2013 to November 2018. Major adverse cardiovascular events (MACEs) were defined as a composite of cardiovascular death, non-fatal myocardial infarction, non-fatal stroke, and heart failure hospitalization. Renal event was defined as a ≥ 50% decline in estimated glomerular filtration rate or progression to end-stage renal disease. A total of 206 patients among 2018 (10.2%) were diagnosed with resistant hypertension by the previous definition (≥140/90 mm Hg), and 276 patients among 2011 (13.7%) were diagnosed with resistant hypertension by the updated definition (≥130/80 mm Hg). During a median follow-up of 4.5 years, 33 MACEs (3.7 per 1000 patient-years) and 164 renal events (19.9 per 1000 patient-years) occurred in the study population. Treatment-resistant hypertension groups had a higher incidence rate of MACEs and renal events than the control groups. In multivariate Cox proportional hazards regression analysis, resistant hypertension by both definitions was significantly associated with increased risk of MACE and renal event. Both the previous and updated definitions of resistant hypertension were significant predictors of MACEs and renal events. This finding supports the adoption of the updated criteria for resistant hypertension in clinical practice.

Obesity predicts persistence of resistant hypertension after surgery in patients with primary aldosteronism

OBJECTIVE

Primary aldosteronism (PA) is considered a major cause of resistant hypertension (RHT). The prevalence of RHT has been recently reported to reach 18% in general hypertension. However, little is known about the prevalence and the outcomes after adrenalectomy of RHT in PA. Therefore, we aimed to clarify the prevalence and surgical outcomes in patients with both PA and RHT.

PATIENTS AND DESIGN

Among 550 patients who underwent adrenalectomy for unilateral PA in the Japan PA Study, RHT was defined as an uncontrolled blood pressure (≥140/90 mm Hg) despite treatment with at least any three antihypertensives or hypertension controlled with at least four drugs. Surgical outcome was assessed by the biochemical and clinical outcome.

RESULTS

Although 40 (7.3%) patients fulfilled the criteria for preoperative RHT, this should be underestimated because only 36% of patients with postoperative RHT were classified as having preoperative RHT. The prevalence of preoperative RHT was approximately 20% when estimated using the total number of patients with postoperative RHT and the ratio of postoperative RHT in patients with preoperative RHT. Although an improvement in hypertension was achieved in approximately 80% of patients with preoperative RHT, 20% of these exhibited persistent RHT. These patients were more obese than those for whom RHT improved after surgery. Notably, body mass index of ≥25 kg/m² was an independent predictor of postoperative RHT.

CONCLUSIONS

The prevalence of RHT in PA was lower than expected even with the adjustment for underestimation. Furthermore, obesity is an independent factor predicting the postoperative persistence of RHT.

Bariatric Surgery for Resistant Hypertension: Working in Progress!

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

Treatment resistant hypertension among ambulatory hypertensive patients: A cross sectional study

BACKGROUND

Treatment resistant hypertension(TRH) is detrimental risk of cardiovascular and premature deaths. Globally, the prevalence of resistant hypertension is inclining from time to time and it is yet to be determined in Ethiopia.

OBJECTIVE

To assess the prevalence of apparent TRH and its predictors among ambulatory hypertensive patients on follow up in hypertension clinic of Mekelle Hospital, Northern Ethiopia.

METHOD

A hospital based cross sectional study was conducted from Nov 25, 2018 to July 20, 2019, among 338 adult ambulatory hypertensive patients on follow up in Mekelle Hospital hypertension clinic. Hypertensive patient aged ≥18 years who were on regular follow up and taking antihypertensive medications for at least 6 months were included in the study. A simple random sampling technique was used to recruit the study patients.

RESULTS

A total of 338 adult ambulatory hypertensive patients were analysed. More than half, 182 (53.8%) patients were females and the average age of the patients was 58.9 ±11.5. Three hundred thirty-three (98.5%) patients had no family history of hypertension. Majority, 66.8% of the patients were on monotherapy. The prevalence of apparent TRH was calculated to be 8.6% [Confidence Interval = 0.056-0.116]. Patients with Body Mass Index(BMI) greater than 30[Adjusted Odds Ratio(AOR) = 12.1, 95%CI:2.00-73.19, p = 0.007] and longer duration of hypertension were the predictors of resistant hypertension.

CONCLUSION

Even if escalation of antihypertensive medications was not aggressive, apparent TRH was common in the study setting. Obesity (BMI greater than 30) and longer duration of hypertension since diagnosis were the predictors of TRH. Meticulous emphasis should be placed on to detect the prevalence of true hypertension resistance and future studies should discover the impact of aggressive antihypertensive medications scale up on the risks of TRH.

Copeptin Levels in Patients With Treatment-Resistant Hypertension Before and 6 Months After Renal Denervation

BACKGROUND

Copeptin, the C-terminal peptide of provasopressin, is released from the neurohypophysis and reflects the activity of the hormone arginine vasopressin in patients with hypertension. Elevated copeptin levels are associated with increased cardiovascular and all-cause mortality. The aim of this study is to compare copeptin levels in patients with treatment-resistant hypertension (TRH) before and 6 months after renal denervation (RDN).

METHODS

Copeptin was measured in 34 patients with TRH and 30 patients with primary hypertension stage 1 or 2 (HT). In addition, copeptin levels were measured in patients with TRH at 6-month follow-up visit after RDN. RDN was performed by an experienced interventionalist applying at least 4 ablations longitudinally and rotationally within the lengths of each renal artery to cover a full 4-quadrant ablation.

RESULTS

In patients with TRH 24-hour ambulatory blood pressure (BP) decreased from 154 ± 15/87 ± 12 mm Hg to 146 ± 13/83 ± 7.9 mm Hg after RDN (systolic: P = 0.001, diastolic: P = 0.034). There was no significant change in copeptin levels in these 34 patients with TRH before vs. 6 months after RDN (median 8.4 [interquartile range 3.6-14] vs. 8.5 [4.5-13] pmol/l, P = 0.334). Patients with TRH had higher copeptin levels (P = 0.024) than patients with HT (24-hour ambulatory BP: 142 ± 11/91 ± 8.3 mm Hg, copeptin: 4.2 [2.8-6.3] pmol/l).

CONCLUSION

Patients with TRH showed 2-fold higher copeptin levels than patients with HT. RDN did not lead to any change of copeptin levels in patients with TRH 6 months after procedure despite significant fall in BP.

CLINICAL TRIAL REGISTRATION

NCT01318395, NCT01687725.

Baroreflex Activation Therapy for Resistant Hypertension and Heart Failure

Hypertension and heart failure are important contributors to global morbidity and mortality. Despite therapeutic lifestyle and pharmacological measures, a significant proportion of people with hypertension do not reach treatment targets. Patients with resistant or poorly controlled hypertension are at significantly increased risk of cardiovascular events, including heart failure. Since dysfunction of the sympathetic nervous system appears to play a key role in the development and progression of both hypertension and heart failure, these patients may benefit from treatment modalities aimed at reducing sympathetic function. The purpose of this paper is to provide an overview of baroreflex activation therapy as a potential treatment strategy in patients with resistant hypertension or heart failure.

Long-term Effect of CPAP Treatment on Cardiovascular Events in Patients With Resistant Hypertension and Sleep Apnea. Data From the HIPARCO-2 Study

BACKGROUND

There is some controversy about the effect of continuous positive airway pressure (CPAP) on the incidence of cardiovascular events (CVE). However, the incidence of CVE among patients with both obstructive sleep apnea (OSA) ans resistant hypertension (HR) has not been evaluated. Our objective was to analyze the long-term effect of CPAP treatment in patients with RH and OSA on the incidence of CVE.

METHODS

Multi-center, observational and prospective study of patients with moderate-severe OSA and RH. All the patients were followed up every 3-6 months and the CVE incidence was measured. Patients adherent to CPAP (at least 4h/day) were compared with those with not adherent or those who had not been prescribed CPAP.

RESULTS

Valid data were obtained from 163 patients with 64 CVE incidents. Treatment with CPAP was offered to 82%. After 58 months of follow-up, 58.3% of patients were adherent to CPAP. Patients not adherent to CPAP presented a non-significant increase in the total CVE incidence (HR:1.6; 95%CI: 0.96-2.7; p=0.07). A sensitivity analysis showed that patients not adherent to CPAP had a significant increase in the incidence of cerebrovascular events (HR: 3.1; CI95%: 1.07-15.1; p=0.041) and hypertensive crises (HR: 5.1; CI95%: 2.2-11.6; p=0.006), but the trend went in the opposite direction with respect to coronary events (HR: 0.22; CI95%: 0.05-1.02; p=0.053).

CONCLUSIONS

In patients with RH and moderate-severe OSA, an uneffective treatment with CPAP showed a trend toward an increase in the incidence of CVE (particularly neurovascular events and hypertensive crises) without any changes with respect to coronary events.

Renal denervation: Alternative treatment options for hypertension?

Hypertension affects millions of Americans and has adverse long-term consequences increasing morbidity and mortality. Resistant hypertension (RH) continues to be difficult to treat with medications alone which may be associated with significant side effects. Alternate therapies have been evaluated for treating RH and renal denervation has been investigated extensively. We review the data from renal denervation trials and other novel technologies which are not FDA approved to date.

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

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

Resistant Hypertension: Novel Insights

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.

Apparent therapy-resistant hypertension as risk factor for the development of type 2 diabetes mellitus

OBJECTIVE

To evaluate whether the relationship between hypertension and type 2 diabetes mellitus (T2DM) is different for patients with uncontrolled hypertension, controlled hypertension or patients with apparent therapy-resistant hypertension (aTRH), compared with patients without hypertension.

METHODS

Using Cox proportional hazard models we evaluated the risk of new-onset T2DM in 8756 patients, at high risk for vascular disease. Hypertensive patients were subdivided according to blood pressure (BP) and use of BP-lowering drugs. BP ≥ 140/90 mmHg was defined as uncontrolled BP. aTRH was defined as uncontrolled BP despite being treated with at least three BP-lowering drugs including a diuretic, or the use at least four BP-lowering drugs irrespective of BP levels. Further analysis evaluated the risk of new-onset T2DM for patients with uncontrolled hypertension and for patients with aTRH, compared with patients with controlled hypertension and without hypertension, respectively.

RESULTS

Forty-five percent had controlled hypertension, 20% had uncontrolled hypertension, 5.7% had aTRH, and 29% were nonhypertensive. During a follow-up of 7.0 (interquartile range: 0-14) years there were 705 new cases of T2DM. Patients with hypertension had a 1.48 (95% confidence interval 1.22-1.80) times higher risk of new-onset T2DM than nonhypertensive patients. There was no significant difference in risk among different hypertension groups.

CONCLUSION

Patients at high risk for cardiovascular disease with hypertension have a 1.48 times higher risk of new-onset T2DM than nonhypertensive counterparts. The risk did not differ between patients with controlled hypertension, uncontrolled hypertension, or aTRH.

The prevalence and predictors of resistant hypertension in high-risk overweight and obese patients: A cross-sectional study based on the 2017 ACC/AHA guidelines

Obesity is significantly associated with uncontrolled blood pressure and resistant hypertension (RH). There are limited studies on the prevalence and determinants of RH in patients with higher body mass index (BMI) values. Since the hypertension guidelines changed in 2017, the prevalence of RH has become unknown and now is subject to be estimated by further studies. We conducted a cross-sectional study in an urban Federally Qualified Health Center in New York City aiming to estimate the prevalence of RH in high-risk overweight and obese patients based on the new hypertension definition, BP threshold ≥130/80 mm Hg, and also to describe the associated comorbid conditions in these patients. We identified 761 eligible high-risk overweight and obese subjects with hypertension between October 2017 and October 2018. Apparent treatment-RH was found in 13.6% among the entire study population. This represented 15.4% of those treated with BP-lowering agents. True RH confirmed with out-of-office elevated BP was found in 6.7% of the study population and 7.4% among patients treated with BP-lowering agents. Prevalence was higher with higher BMI values. Those with true RH were more likely to be black, to have diabetes mellitus requiring insulin, chronic kidney disease stage 3 or above and diastolic heart failure. In conclusion, obesity is significantly associated with RH and other significant metabolic comorbid conditions.

The Potential Role of Obstructive Sleep Apnoea in Refractory Hypertension

PURPOSE OF REVIEW

This review seeks to present an overview of the recently found association between refractory hypertension (RfH) and obstructive sleep apnoea (OSA).

RECENT FINDINGS

RfH was recently defined as an extreme phenotype of resistant hypertension characterized by the lack of blood pressure control despite using ≥ 5 antihypertensive drugs at optimal doses. Current data support that the pathophysiological pathway of both types of hypertension is different. The main mechanism involved in resistant hypertension is fluid retention whereas in the case of RfH is the sympathetic over-activity. OSA is now recognized as a cause of hypertension (especially in the case of difficult-to-treat hypertension). It seems that the biological mechanism linking OSA and arterial hypertension is the sympathetic over-activity related to the respiratory events (apnoeas and hypopnoeas) during the night. So, it is not surprising that, although the literature is scarce, some studies have found a very high prevalence of OSA and an excess of sympathetic activity in patients with RfH. Finally, a very recent study demonstrated that continuous positive airway pressure (CPAP) treatment, which controls sympathetic activation in OSA patients, achieves very significant reductions in blood pressure levels in RfH patients, even greater than in those with resistant (non-refractory) hypertension. The prevalence of OSA in patients with RfH is very high. CPAP treatment achieves a clinically significant reduction in blood pressure levels in those patients with RfH (especially in night readings). Patients with RfH must be sent to a sleep unit for a study.

Risk of resistant hypertension associated with restless legs syndrome and periodic limb movements during sleep: a study on 673 treated hypertensive individuals

OBJECTIVE

Given the limited data available in the literature, the aim of this study was to examine the risk of resistant hypertension (RHT) associated with restless legs syndrome (RLS) and periodic limb movements during sleep (PLMS) in a large sample of treated hypertensive individuals.

METHODS

Demographic and polysomnographic (PSG) data from 673 treated hypertensive individuals recruited from the research database of the sleep laboratory of Erasme Hospital were analysed. After exclusion of the main causes of pseudo-resistance and secondary hypertension, RHT status was defined by the presence of an uncontrolled hypertension despite treatment with at least three antihypertensive agents (including a diuretic) from different classes in correct combination and at the highest tolerated doses or by the presence of controlled hypertension requiring the use of at least four antihypertensive agents. Logistic regression analyses were conducted to examine the risk of RHT associated with RLS and PLMS in treated hypertensive individuals.

RESULTS

After adjustment for major confounding factors associated with RHT, multivariate logistic regression analysis revealed that frequent RLS (≥2 episodes/week) combined with PLMS index ≥26/h [odds ratio (OR) 2.20; 95% confidence interval (CI) 1.35-3.61, p = 0.021] was a significant risk factor of RHT in treated hypertensive individuals.

CONCLUSION

In treated hypertensive individuals, frequent RLS combined with PLMS index ≥26/h is associated with higher risk of RHT which suggests that this pathology may be a secondary cause of RHT (eg, obstructive sleep apnoea syndrome and insomnia with short sleep duration) justifying the establishment of effective treatments in this particular subpopulation.

Resistant Hypertension: Detection, Evaluation, and Management: A Scientific Statement From the American Heart Association

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.

Phase II randomized sham-controlled study of renal denervation for individuals with uncontrolled hypertension - WAVE IV

OBJECTIVES

The aim of this double-blind, randomized, sham-controlled study was to verify the blood pressure (BP)-lowering efficacy of externally delivered focused ultrasound for renal denervation (RDN).

BACKGROUND

Nonrandomized, first proof-of-concept study and experimental evidence suggested that noninvasive techniques of RDN emerged as an alternative approach of RDN to invasive technologies.

METHODS

WAVE IV, an international, randomized (1 : 1) sham-controlled, double-blind prospective clinical study, was prematurely stopped. Patients were enrolled if office BP was at least 160 mmHg and 24-h ambulatory BP was at least 135 mmHg, while taking three or more antihypertensive medications. The treatment consisted of bilateral RDN using therapeutic levels of ultrasound energy and the sham consisted of bilateral application of diagnostic levels of ultrasound energy.

RESULTS

In the 81 treated patients neither changes in office BP at 12 and 24 weeks, nor changes in 24-h ambulatory BP at 24-week follow-up visit differed between the two groups significantly. Of note, no safety signal was observed. Adherence analysis disclosed full adherence in 77% at baseline and 82% at 6 months' follow-up visit. Post hoc analysis revealed that stricter criteria for stabilization of BP at baseline were associated with a numerically greater change in 24-h ambulatory BP in the RDN group than in the sham group.

CONCLUSION

Our data did not prove that antihypertensive efficacy of the externally delivered focused ultrasound for RDN was greater than the sham effect. Stabilization of BP at baseline was identified as an important determinant of BP changes.

Application of a central iliac arteriovenous coupler device in severe treatment-resistant hypertension: a 3.5-year follow-up

OBJECTIVE

In patients with resistant hypertension, percutaneous placement of an iliac arteriovenous coupler device leads to a reduction of blood pressure (BP) via decreased total vascular resistance and improved arterial compliance. However, long-term efficacy and safety need to be further explored. We report on the first case of 3.5-year follow-up in a patient who underwent implantation of an iliac arteriovenous coupler device.

RESULTS

A patient with resistant hypertension was admitted to hospital. Despite treatment with six anti-hypertensive drugs, his BP was poorly controlled. Previously, he had undergone renal denervation, which did not cause a significant BP decrease. Therefore, an arteriovenous coupler device was implanted, leading to an immediate and significant BP decrease. The patient was discharged with an office BP of 122/71 mmHg. After 3 months, there was a sustained BP decrease (-14/9 mmHg), whereas later, it was fluctuant (office BP: 147-173/85-95 mmHg, ABPM: 153-166/81-94 mmHg) probably due to medication non-adherence confirmed by a urinary toxicological screening test. Follow-up right heart catheterization showed changes in hemodynamic parameters related to volume congestion, which were accompanied by progressive dyspnea and weight gain. This was controlled by an optimized diuretic therapy. Additionally, an invasive closure maneuver was performed, leading to an immediate BP increase after closure and a similar decrease after re-opening of the anastomosis, verifying its proper long-term function.

CONCLUSION

The implantation of an iliac arteriovenous coupler device appears to be a promising and effective method to decrease BP and therefore reduce cardiovascular risk in patients with severe, treatment-resistant hypertension.

The Use of Precision Medicine to Manage Obstructive Sleep Apnea Treatment in Patients with Resistant Hypertension: Current Evidence and Future Directions

PURPOSE OF REVIEW

The significant prevalence of resistant hypertension (RH) and the high cardiovascular risk of the population of patients with RH have indicated the necessity to identify its main causes. Among these, obstructive sleep apnea (OSA) is considered the most well-established cause.

RECENT FINDINGS

In recent years, several studies have shown a beneficial effect of continuous positive airway pressure (CPAP) treatment on blood pressure (BP), but this effect exhibits great variability. The diagnosis and management of OSA in patients with RH suggest a clinical option for a phenotype of patients for whom therapeutic strategies are limited to pharmaceutical therapy and renal denervation. However, the great variability in the CPAP response has increased the necessity to develop instruments to identify patients who could benefit from a treatment that reduces BP. Application of precision medicine to these patients should be considered as a first-line intervention to avoid the prescription of ineffective treatments and excessive consumption of pharmacological drugs that do not ameliorate the cardiovascular risk.

Cardiovascular morbidity of severe resistant hypertension among treated uncontrolled hypertensives: a 4-year follow-up study

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.