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Buso G, Agabiti-Rosei C, Lemoli M, Corvini F, Muiesan ML. The Global Burden of Resistant Hypertension and Potential Treatment Options. Eur Cardiol 2024; 19:e07. [PMID: 38983582 PMCID: PMC11231817 DOI: 10.15420/ecr.2023.51] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 03/22/2024] [Indexed: 07/11/2024] Open
Abstract
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.
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Affiliation(s)
- Giacomo Buso
- Department of Clinical and Experimental Sciences, Division of Internal Medicine, ASST Spedali Civili Brescia, University of Brescia Brescia, Italy
- Lausanne University Hospital, University of Lausanne Lausanne, Switzerland
| | - Claudia Agabiti-Rosei
- Department of Clinical and Experimental Sciences, Division of Internal Medicine, ASST Spedali Civili Brescia, University of Brescia Brescia, Italy
| | - Matteo Lemoli
- Department of Clinical and Experimental Sciences, Division of Internal Medicine, ASST Spedali Civili Brescia, University of Brescia Brescia, Italy
| | - Federica Corvini
- Department of Clinical and Experimental Sciences, Division of Internal Medicine, ASST Spedali Civili Brescia, University of Brescia Brescia, Italy
| | - Maria Lorenza Muiesan
- Department of Clinical and Experimental Sciences, Division of Internal Medicine, ASST Spedali Civili Brescia, University of Brescia Brescia, Italy
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Flack JM, Buhnerkempe MG, Moore KT. Resistant Hypertension: Disease Burden and Emerging Treatment Options. Curr Hypertens Rep 2024; 26:183-199. [PMID: 38363454 DOI: 10.1007/s11906-023-01282-0] [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] [Accepted: 10/27/2023] [Indexed: 02/17/2024]
Abstract
PURPOSE OF REVIEW To define resistant hypertension (RHT), review its pathophysiology and disease burden, identify barriers to effective hypertension management, and to highlight emerging treatment options. RECENT FINDINGS RHT is defined as uncontrolled blood pressure (BP) ≥ 130/80 mm Hg despite concurrent prescription of ≥ 3 or ≥ 4 antihypertensive drugs in different classes or controlled BP despite prescription of ≥ to 4 drugs, at maximally tolerated doses, including a diuretic. BP is regulated by a complex interplay between the renin-angiotensin-aldosterone system, the sympathetic nervous system, the endothelin system, natriuretic peptides, the arterial vasculature, and the immune system; disruption of any of these can increase BP. RHT is disproportionately manifest in African Americans, older patients, and those with diabetes and/or chronic kidney disease (CKD). Amongst drug-treated hypertensives, only one-quarter have been treated intensively enough (prescribed > 2 drugs) to be considered for this diagnosis. New treatment strategies aimed at novel therapeutic targets include inhibition of sodium-glucose cotransporter 2, aminopeptidase A, aldosterone synthesis, phosphodiesterase 5, xanthine oxidase, and dopamine beta-hydroxylase, as well as soluble guanylate cyclase stimulation, nonsteroidal mineralocorticoid receptor antagonism, and dual endothelin receptor antagonism. The burden of RHT remains high. Better use of currently approved therapies and integrating emerging therapies are welcome additions to the therapeutic armamentarium for addressing needs in high-risk aTRH patients.
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Affiliation(s)
- John M Flack
- Department of Medicine, Division of General Internal Medicine, Hypertension Section, Southern Illinois University, Southern Illinois University School of Medicine, 801 North Rutledge Street, Carbondale, IL, 62702, USA.
| | - Michael G Buhnerkempe
- Department of Medicine and the Center for Clinical Research, Southern Illinois University, Carbondale, IL, USA
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Flack JM, Agarwal R, Anker SD, Pitt B, Ruilope LM, Rossing P, Adler SG, Fried L, Jamerson K, Toto R, Brinker M, Farjat AE, Kolkhof P, Lawatscheck R, Joseph A, Bakris GL. Finerenone in Black Patients With Type 2 Diabetes and CKD: A Post hoc Analysis of the Pooled FIDELIO-DKD and FIGARO-DKD Trials. Kidney Med 2023; 5:100730. [PMID: 38046911 PMCID: PMC10692708 DOI: 10.1016/j.xkme.2023.100730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2023] Open
Abstract
Rationale & Objective In FIDELITY, finerenone improved cardiorenal outcomes in patients with chronic kidney disease (CKD) and type 2 diabetes (T2D). This analysis explored the efficacy and safety of finerenone in Black patients. Study Design Subanalysis of randomized controlled trials. Setting & Participants Patients with T2D and CKD. Intervention Finerenone or placebo. Outcomes Composite of cardiovascular death, nonfatal myocardial infarction, nonfatal stroke, or hospitalization for heart failure; composite of kidney failure, sustained ≥57% estimated glomerular filtration rate (eGFR) decline from baseline maintained for ≥4 weeks, or renal death. Results Of the 13,026 patients, 522 (4.0%) self-identified as Black. Finerenone demonstrated similar effects on the cardiovascular composite outcome in Black (HR, 0.79 [95% CI, 0.51-1.24]) and non-Black patients (HR, 0.87 [95% CI, 0.79-0.96; P = 0.5 for interaction]). Kidney composite outcomes were consistent in Black (HR, 0.71 [95% CI, 0.43-1.16]) and non-Black patients (HR, 0.76 [95% CI, 0.66-0.88; P = 0.9 for interaction]). Finerenone reduced urine albumin-to-creatinine ratio by 40% at month 4 (least-squares mean treatment ratio, 0.60 [95% CI, 0.52-0.69; P < 0.001]) in Black patients and 32% at month 4 (least-squares mean treatment ratio, 0.68 [95% CI, 0.66-0.70; P < 0.001]) in non-Black patients, versus placebo. Chronic eGFR decline (month 4 to end-of-study) was slowed in Black and non-Black patients treated with finerenone versus placebo (between-group difference, 1.4 mL/min/1.73 m2 per year [95% CI, 0.33-2.44; P = 0.01] and 1.1 mL/min/1.73 m2 per year [95% CI, 0.89-1.28; P < 0.001], respectively). Safety outcomes were similar between subgroups. Limitations Small number of Black patients; analysis was not originally powered to determine an interaction effect based on Black race. Conclusions The efficacy and safety of finerenone appears consistent in Black and non-Black patients with CKD and T2D. Funding Bayer AG. Trial Registration ClinicalTrials.gov NCT02540993, NCT02545049. Plain-Language Summary Diabetes is a major cause of chronic kidney disease (CKD), affecting more Black adults than White adults. Most adults with CKD ultimately die from heart and vascular complications (eg, heart attack and stroke) rather than kidney failure. This analysis of 2 recent trials shows that the drug finerenone was beneficial for patients with diabetes and CKD. Along with reducing kidney function decline and protein in the urine, it also decreased heart and vascular issues and lowered blood pressure in both Black and non-Black adults with diabetes and CKD. These findings have promising implications for slowing the progression of CKD and protecting against cardiovascular problems in diverse populations.
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Affiliation(s)
- John M. Flack
- Department of Medicine, Division of General Internal Medicine, Hypertension Section Southern Illinois University School of Medicine, Illinois, IL
| | - Rajiv Agarwal
- Richard L. Roudebush VA Medical Center and Indiana University, Indianapolis, IN
| | - Stefan D. Anker
- Department of Cardiology (CVK) of German Heart Center Charité; Institute of Health Center for Regenerative Therapies (BCRT), German Centre for Cardiovascular Research (DZHK) partner site Berlin, Charité Universitätsmedizin, Berlin, Germany
| | - Bertram Pitt
- Department of Medicine, University of Michigan School of Medicine, Ann Arbor, MI
| | - Luis M. Ruilope
- Cardiorenal Translational Laboratory and Hypertension Unit, Institute of Research imas12, Madrid, Spain
- CIBER-CV, Hospital Universitario 12 de Octubre, Madrid, Spain
- Faculty of Sport Sciences, European University of Madrid, Madrid, Spain
| | - Peter Rossing
- Steno Diabetes Center Copenhagen, Gentofte, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Sharon G. Adler
- Division of Nephrology and Hypertension, Harbor-UCLA Medical Center, Torrance, CA
| | - Linda Fried
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Kenneth Jamerson
- Cardiology Clinic, University of Michigan, Ann Arbor, Michigan, MI
| | - Robert Toto
- Department of Internal Medicine, University of Texas Southwestern Medicine, Dallas, TX
| | - Meike Brinker
- Cardiology and Nephrology Clinical Development, Bayer AG, Wuppertal, Germany
| | - Alfredo E. Farjat
- Research and Development, Statistics and Data Insights, Bayer PLC, Reading, United Kingdom
| | - Peter Kolkhof
- Research and Development Cardiovascular Precision Medicines, Bayer AG, Wuppertal, Germany
| | - Robert Lawatscheck
- Cardiology and Nephrology Clinical Development, Bayer AG, Berlin, Germany
| | - Amer Joseph
- Cardiology and Nephrology Clinical Development, Bayer AG, Berlin, Germany
| | - George L. Bakris
- Department of Medicine, University of Chicago Medicine, Chicago, IL
| | - FIDELIO-DKD and FIGARO-DKD Investigators
- Department of Medicine, Division of General Internal Medicine, Hypertension Section Southern Illinois University School of Medicine, Illinois, IL
- Richard L. Roudebush VA Medical Center and Indiana University, Indianapolis, IN
- Department of Cardiology (CVK) of German Heart Center Charité; Institute of Health Center for Regenerative Therapies (BCRT), German Centre for Cardiovascular Research (DZHK) partner site Berlin, Charité Universitätsmedizin, Berlin, Germany
- Department of Medicine, University of Michigan School of Medicine, Ann Arbor, MI
- Cardiorenal Translational Laboratory and Hypertension Unit, Institute of Research imas12, Madrid, Spain
- CIBER-CV, Hospital Universitario 12 de Octubre, Madrid, Spain
- Faculty of Sport Sciences, European University of Madrid, Madrid, Spain
- Steno Diabetes Center Copenhagen, Gentofte, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Division of Nephrology and Hypertension, Harbor-UCLA Medical Center, Torrance, CA
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
- Cardiology Clinic, University of Michigan, Ann Arbor, Michigan, MI
- Department of Internal Medicine, University of Texas Southwestern Medicine, Dallas, TX
- Cardiology and Nephrology Clinical Development, Bayer AG, Wuppertal, Germany
- Research and Development, Statistics and Data Insights, Bayer PLC, Reading, United Kingdom
- Research and Development Cardiovascular Precision Medicines, Bayer AG, Wuppertal, Germany
- Cardiology and Nephrology Clinical Development, Bayer AG, Berlin, Germany
- Department of Medicine, University of Chicago Medicine, Chicago, IL
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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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Chen H, Zou Y, Leng X, Huang F, Huang R, Wijayabahu A, Chen X, Xu Y. Associations of blood lead, cadmium, and mercury with resistant hypertension among adults in NHANES, 1999-2018. Environ Health Prev Med 2023; 28:66. [PMID: 37914348 PMCID: PMC10636284 DOI: 10.1265/ehpm.23-00151] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 09/30/2023] [Indexed: 11/03/2023] Open
Abstract
BACKGROUND Resistant hypertension (RHTN), a clinically complex condition with profound health implications, necessitates considerable time and allocation of medical resources for effective management. Unraveling the environmental risk factors associated with RHTN may shed light on future interventional targets aimed at reducing its incidence. Exposure to heavy metal has been linked to an increased risk of hypertension, while the relationship with RHTN remains poorly understood. METHODS Using the 1999-2018 National Health and Nutrition Examination Survey (NHANES) data, we examined the association of blood lead (Pb), cadmium (Cd), and mercury (Hg) with RHTN using a multinomial logistic regression model. The combined effects of the metals and the contribution of each metal were assessed using a weighted quantile sum (WQS) analysis. RESULTS A total of 38281 participants were included in the analysis. Compared with no resistant hypertension (NRHTN), per 1 µg/dL increase in blood Pb concentration, the proportion of RHTN increased by 16% [adjusted odds ratio (aOR), 1.16; 95% confidence interval (CI) 1.01-1.32]. When analyzed by quartiles (Q), the aOR [95% CI] for Pd was 1.30[1.01,1.67] (Q4 vs. Q1); there was a significant dose-response relationship (p < 0.05). Likewise, as a continuous variable, each 1 µg/dL increase in blood Cd level was associated with a 13% increase in the proportion of RHTN (aOR: 1.13; 95%CI: [1.00,1.27]); when analyzed as quartile, aOR [95% CI] for Cd were 1.30[1.01,1.69] (Q3 vs. Q1), and 1.35[1.03,1.75] (Q4 vs. Q1); the dose-response relationship was significant (p < 0.05). WQS analysis showed a significant combined effects of Pb, Cd, and Hg on RHTN, with Pb as the highest weight (0.64), followed by Cd (0.25) and Hg (0.11). Stratified analysis indicated that the associations for the two heavy metals were significant for participants who were male, ≼ 60 years old, and with kidney dysfunction. CONCLUSION Findings of this study with national data provide new evidence regarding the role of environmental heavy metal exposure in RHTN. The prevention strategies aimed at reducing heavy metal exposure should particularly focus on Americans who are middle-aged, male, and afflicted with kidney dysfunction.
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Affiliation(s)
- Hao Chen
- Department of Occupational and Environmental Health, School of Public Health, Guangxi Medical University, Nanning, 530021, China
| | - Yunfeng Zou
- Department of Occupational and Environmental Health, School of Public Health, Guangxi Medical University, Nanning, 530021, China
| | - Xuebing Leng
- Department of Microbiology and Immunology, Miller School of Medicine, University of Miami, Miami, FL, US
| | - Feng Huang
- Department of Cardiology, The First Affiliated Hospital of Guangxi Medical University, Nanning, 530021, China
- Guangxi Key Laboratory of Precision Medicine in Cardio-Cerebrovascular Diseases, Nanning, 530021, China
- Guangxi Clinical Research Center for Cardio-Cerebrovascular Diseases, Nanning, 530021, China
| | - Rongjie Huang
- Department of Cardiology, The First Affiliated Hospital of Guangxi Medical University, Nanning, 530021, China
- Guangxi Key Laboratory of Precision Medicine in Cardio-Cerebrovascular Diseases, Nanning, 530021, China
- Guangxi Clinical Research Center for Cardio-Cerebrovascular Diseases, Nanning, 530021, China
| | - Akemi Wijayabahu
- Department of Epidemiology, University of Florida, Gainesville, Florida, USA
- Department of Environmental and Occupational Health, George Washington University, Washington, D.C., USA
| | - Xinguang Chen
- Global Health Institute, Xi’an Jiaotong University, Xi’an, 710020, China
| | - Yunan Xu
- Department of Medical Research, The First Affiliated Hospital of Guangxi Medical University, Nanning, 530021, China
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Kuzmin OB, Zhezha VV. Refractory Arterial Hypertension: Features of Neurohormonal and Water-salt Imbalanceand Approaches to Antihypertensive Drug Therapy. RATIONAL PHARMACOTHERAPY IN CARDIOLOGY 2022. [DOI: 10.20996/1819-6446-2022-08-14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Refractory arterial hypertension is characterized by a lack of control of target blood pressure, despite the prolonged use >5 antihypertensive drugs with different mechanisms of action, including longacting diuretic chlorthalidone and the mineralcorticoid receptor antagonists (spironolactone or eplerenone). The review presents the results of clinical studies devoted the elucidating peculiarities of the neurohormonal status and water-salt balance in such patients and developing new approaches to antihypertensive drug therapy based on them. According to these studies, individuals with refractory hypertension differ from patients with resistant hypertension with the higher of sympathetic nervous system activity and the absence of an increased of intrathoracic fluid volume, which indirectly indicates a significant decrease in the intravascular fluid volume. In this regard, the review focuses on the data obtained in assessing the clinical efficacy of sympatholytics clonidine and reserpine in patients with resistant and refractory hypertension, as well as renal sodium-glucose co-transporter type 2 inhibitors, which suppress the sympathetic nervous system activity and can be used to overcome refractory hypertension in patients with type 2 diabetes.
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Abstract
Purpose of Review To update on definition, diagnosis, prevalence, patient characteristics, pathophysiology, and treatment of refractory hypertension (RfHTN). Recent Findings Refractory hypertension (RfHTN) is defined as blood pressure (BP) that is uncontrolled despite using ≥ 5 antihypertensive medications of different classes, including a long-acting thiazide diuretic and a mineralocorticoid receptor antagonist (MRA) at maximal or maximally tolerated doses. This new phenotype is different from resistant hypertension (RHTN), defined as BP that is uncontrolled despite using ≥ 3 medications, commonly a long-acting calcium channel blocker (CCB), a blocker of the renin-angiotensin system (angiotensin-converting enzyme [ACE] inhibitor or angiotensin receptor blocker [ARB]), and a diuretic. The RHTN phenotype includes controlled RHTN, BP that is controlled on 4 or more medications. RfHTN is largely attributable to increased sympathetic activity, unlike RHTN, which is mainly due to increased intravascular fluid volume frequently caused by hyperaldosteronism and chronic excessive sodium ingestion. Compared to those with controlled RHTN, patients with RfHTN have a higher prevalence of target organ damage and do not have elevated aldosterone levels. Ongoing clinical trials are assessing the safety and efficacy of using devices to aid with BP control in patients with RfHTN. Summary RfHTN is a separate entity from RHTN and is generally attributable to increased sympathetic activity.
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Drawz PE, Beddhu S, Bignall ONR, Cohen JB, Flynn JT, Ku E, Rahman M, Thomas G, Weir MR, Whelton PK. KDOQI US Commentary on the 2021 KDIGO Clinical Practice Guideline for the Management of Blood Pressure in CKD. Am J Kidney Dis 2022; 79:311-327. [PMID: 35063302 DOI: 10.1053/j.ajkd.2021.09.013] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 09/26/2021] [Indexed: 12/13/2022]
Abstract
The Kidney Disease Outcomes Quality Initiative (KDOQI) convened a work group to review the 2021 KDIGO (Kidney Disease: Improving Global Outcomes) guideline for the management of blood pressure in chronic kidney disease (CKD). This commentary is the product of that work group and presents the recommendations and practice points from the KDIGO guideline in the context of US clinical practice. A critical addition to the KDIGO guideline is the recommendation for accurate assessment of blood pressure using standardized office blood pressure measurement. In the general adult population with CKD, KDIGO recommends a goal systolic blood pressure less than 120 mm Hg on the basis of results from the Systolic Blood Pressure Intervention Trial (SPRINT) and secondary analyses of the Action to Control Cardiovascular Risk in Diabetes-Blood Pressure (ACCORD-BP) trial. The KDOQI work group agreed with most of the recommendations while highlighting the weak evidence base especially for patients with diabetes and advanced CKD.
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Affiliation(s)
- Paul E Drawz
- Division of Nephrology and Hypertension, University of Minnesota, Minneapolis, Minnesota.
| | | | - O N Ray Bignall
- Department of Pediatrics, The Ohio State University College of Medicine, Division of Nephrology and Hypertension, Nationwide Children's Hospital, Columbus, Ohio
| | - Jordana B Cohen
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Joseph T Flynn
- Department of Pediatrics, University of Washington School of Medicine, Division of Nephrology, Seattle Children's Hospital, Seattle, Washington
| | - Elaine Ku
- University of California-San Francisco, San Francisco, California
| | - Mahboob Rahman
- University Hospitals Cleveland Medical Center, Case Western Reserve University, Louis Stokes Cleveland VA Medical Center Cleveland, Ohio
| | - George Thomas
- Department of Kidney Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Matthew R Weir
- Division of Nephrology, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Paul K Whelton
- Department of Epidemiology, Tulane University School of Public Health & Tropical Medicine, New Orleans, Louisiana
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Bacan G, Ribeiro-Silva A, Oliveira VAS, Cardoso CRL, Salles GF. Refractory Hypertension: a Narrative Systematic Review with Emphasis on Prognosis. Curr Hypertens Rep 2022; 24:95-106. [PMID: 35107787 DOI: 10.1007/s11906-022-01165-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/09/2021] [Indexed: 12/31/2022]
Abstract
PURPOSE OF REVIEW To perform a narrative systematic review on refractory hypertension (RfHT) with particular emphasis on prognosis. RECENT FINDINGS There were 37 articles on RfHT, 13 non-systematic reviews, and 24 original studies. RfHT, a recently described extreme phenotype of anti-hypertensive treatment failure, shall be defined as uncontrolled out-of-office blood pressure (BP) levels despite the use of at least 5 anti-hypertensive drugs, including a long-acting diuretic and a mineraloreceptor antagonist. Its prevalence ranges from 0.5 to 4.3% of general treated hypertensives and between 3.6 and 51.4% of patients with resistant hypertension (RHT). RfHT is associated with younger age, African ancestry, obesity, hypertension-mediated organ damage and clinical cardiovascular diseases, and with some comorbidities, such as diabetes and obstructive sleep apnea. Its physiopathological mechanisms probably involve sympathetic overactivity and not volume overload. Patients with RfHT have a worse prognosis than non-refractory RHT individuals, with higher risks of adverse cardiovascular and renal outcomes and of mortality. RfHT represents a rare but true extreme phenotype of anti-hypertensive treatment failure distinct from RHT and with a significantly worse prognosis. Identifying such individuals is important to tailor specific interventions.
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Affiliation(s)
- Giovanna Bacan
- Department of Internal Medicine, School of Medicine, Universidade Federal do Rio de Janeiro, Rua Croton, 72, Jacarepagua, Rio de Janeiro - RJ, CEP: 22750-240, Brazil
| | - Angélica Ribeiro-Silva
- Department of Internal Medicine, School of Medicine, Universidade Federal do Rio de Janeiro, Rua Croton, 72, Jacarepagua, Rio de Janeiro - RJ, CEP: 22750-240, Brazil
| | - Vinicius A S Oliveira
- Department of Internal Medicine, School of Medicine, Universidade Federal do Rio de Janeiro, Rua Croton, 72, Jacarepagua, Rio de Janeiro - RJ, CEP: 22750-240, Brazil
| | - Claudia R L Cardoso
- Department of Internal Medicine, School of Medicine, Universidade Federal do Rio de Janeiro, Rua Croton, 72, Jacarepagua, Rio de Janeiro - RJ, CEP: 22750-240, Brazil
| | - Gil F Salles
- Department of Internal Medicine, School of Medicine, Universidade Federal do Rio de Janeiro, Rua Croton, 72, Jacarepagua, Rio de Janeiro - RJ, CEP: 22750-240, Brazil.
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10
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Yoon M, You SC, Oh J, Lee CJ, Lee SH, Kang SM, Park S. Prevalence and prognosis of refractory hypertension diagnosed using ambulatory blood pressure measurements. Hypertens Res 2022; 45:1353-1362. [PMID: 35027714 DOI: 10.1038/s41440-021-00845-5] [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: 09/27/2021] [Revised: 12/07/2021] [Accepted: 12/09/2021] [Indexed: 11/09/2022]
Abstract
The prognosis of refractory hypertension is largely unknown due to its low prevalence. This study aimed to investigate the prognosis of refractory hypertension and compare it with those of resistant and nonresistant hypertension. We retrospectively analyzed the data of 16,284 participants with hypertension who underwent ambulatory blood pressure (BP) monitoring between 2012 and 2019 at a tertiary center. Uncontrolled BP was defined as a 24-h BP ≥ 130/80 mmHg as assessed by ambulatory BP monitoring. Resistant hypertension was defined as uncontrolled BP despite the use of three antihypertensive medications, including a diuretic or the use of ≥4 drugs regardless of BP control. Refractory hypertension was defined as uncontrolled BP despite the use of ≥5 antihypertensive medications. Among 16,284 patients with hypertension (mean age 59.2 ± 15.5 years, 52.7% men), 1501 (9.2%) and 150 (0.9%) patients had resistant and refractory hypertension, respectively. The prevalence of chronic kidney disease, end-stage renal disease, heart failure, previous stroke, left ventricular hypertrophy, and the riser/nondipper patterns of circadian BP rhythm progressively increased from patients with nonresistant hypertension to patients with resistant hypertension to patients with refractory hypertension. During a median follow-up of 3.9 years, the risk of cardiovascular mortality progressively increased from patients with nonresistant hypertension to patients with resistant hypertension (hazard ratio 1.62, 95% confidence interval 1.16-2.26) to patients with refractory hypertension (hazard ratio 5.22, 95% confidence interval 3.04-8.96). In conclusion, refractory hypertension, defined as uncontrolled ambulatory BP levels, was associated with a higher risk of all-cause and cardiovascular mortality than nonresistant or resistant hypertension.
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Affiliation(s)
- Minjae Yoon
- Division of Cardiology, Severance Cardiovascular Hospital, Cardiovascular Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Seng Chan You
- Department of Preventive Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jaewon Oh
- Division of Cardiology, Severance Cardiovascular Hospital, Cardiovascular Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Chan Joo Lee
- Division of Cardiology, Severance Cardiovascular Hospital, Cardiovascular Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sang-Hak Lee
- Division of Cardiology, Severance Cardiovascular Hospital, Cardiovascular Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Seok-Min Kang
- Division of Cardiology, Severance Cardiovascular Hospital, Cardiovascular Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sungha Park
- Division of Cardiology, Severance Cardiovascular Hospital, Cardiovascular Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea.
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Angeli F, Reboldi G, Verdecchia P. African Ancestry and Uncontrolled Hypertension: Current Knowledge and Future Perspectives. Am J Hypertens 2021; 34:1255-1258. [PMID: 34543377 DOI: 10.1093/ajh/hpab148] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 09/16/2021] [Indexed: 01/09/2023] Open
Affiliation(s)
- Fabio Angeli
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
- Department of Medicine and Cardiopulmonary Rehabilitation, Maugeri Care and Research Institute, IRCCS Tradate, Varese, Italy
| | - Gianpaolo Reboldi
- Department of Medicine, and Centro di Ricerca Clinica e Traslazionale (CERICLET), University of Perugia, Perugia, Italy
| | - Paolo Verdecchia
- Fondazione Umbra Cuore e Ipertensione-ONLUS and Division of Cardiology, Hospital S. Maria della Misericordia, Perugia, Italy
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12
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Aksenova AV, Sivakova OA, Blinova NV, Danilov NM, Elfimova EM, Kisliak OA, Litvin AY, Oshchepkova EV, Fomin VV, Chikhladze NM, Shelkova GV, Chazova IE. Russian Medical Society for Arterial Hypertension expert consensus. Resistant hypertension: detection and management. TERAPEVT ARKH 2021; 93:1018-1029. [DOI: 10.26442/00403660.2021.09.201007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Accepted: 10/08/2021] [Indexed: 01/04/2023]
Abstract
The diagnosis of resistant arterial hypertension allows us to single out a separate group of patients in whom it is necessary to use special diagnostic methods and approaches to treatment. Elimination of reversible factors leading to the development of resistant arterial hypertension, such as non-adherence to therapy, inappropriate therapy, secondary forms of arterial hypertension, leads to an improvement in the patient's prognosis. Most patients with resistant hypertension should be evaluated to rule out primary aldosteronism, renal artery stenosis, chronic kidney disease, and obstructive sleep apnea. The algorithm for examining patients, recommendations for lifestyle changes and a step-by-step therapy plan can improve blood pressure control. It is optative to use the most simplified treatment regimen and long-acting combined drugs. For a separate category of patients, it is advisable to perform radiofrequency denervation of the renal arteries.
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Georgianos PI, Agarwal R. Hypertension in Chronic Kidney Disease (CKD): Diagnosis, Classification, and Therapeutic Targets. Am J Hypertens 2021; 34:318-326. [PMID: 33331853 DOI: 10.1093/ajh/hpaa209] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 12/04/2020] [Accepted: 12/14/2020] [Indexed: 12/20/2022] Open
Abstract
Blood pressure (BP) in the office is often recorded without standardization of the technique of measurement. When office BP measurement is performed with a research-grade methodology, it can inform better therapeutic decisions. The reference-standard method of ambulatory BP monitoring (ABPM) together with the assessment of BP in the office enables the identification of white-coat and masked hypertension, facilitating the stratification of cardiorenal risk. Compared with general population, the prevalence of resistant hypertension is 2- to 3-fold higher among patients with chronic kidney disease (CKD). The use of ABPM is mandatory in order to exclude the white-coat effect, a common cause of pseudoresistance, and confirm the diagnosis of true-resistant hypertension. After the premature termination of Systolic Blood Pressure Intervention Trial due to an impressive cardioprotective benefit of intensive BP-lowering, the 2017 American Heart Association/American College of Cardiology guideline reappraised the definition of hypertension and recommended a tighter BP target of <130/80 mm Hg for the majority of adults with a high cardiovascular risk profile, inclusive of patients with CKD. However, the benefit/risk ratio of intensive BP-lowering in particular subsets of patients with CKD (i.e., those with diabetes or more advanced CKD) continues to be debated. We explore the controversial issue of BP targets in CKD, providing a critical evaluation of the available clinical-trial evidence and guideline recommendations. We argue that the systolic BP target in CKD, if BP is measured correctly, should be <120 mm Hg.
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Affiliation(s)
- Panagiotis I Georgianos
- Section of Nephrology and Hypertension, 1st Department of Medicine, AHEPA Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Rajiv Agarwal
- Division of Nephrology, Department of Medicine, Indiana University School of Medicine and Richard L. Roudebush Veterans Administration Medical Center, Indianapolis, Indiana, USA
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15
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Ahmad S, Neubauer A, Cohen JB. Reconsidering α-Blockade for the Management of Hypertension in Patients With CKD. Am J Kidney Dis 2021; 77:172-174. [PMID: 33039175 PMCID: PMC7886005 DOI: 10.1053/j.ajkd.2020.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 08/27/2020] [Indexed: 11/11/2022]
Affiliation(s)
- Sarah Ahmad
- Renal-Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Adam Neubauer
- Department of Biology, University of Florida, Gainesville, FL
| | - Jordana B Cohen
- Renal-Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
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16
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Falkovskaya AY, Mordovin VF, Pekarskiy SE, Ripp TM, Manukyan MA, Lichikaki VA, Zyubanova IV, Sitkova ES, Gusakova AM, Ryabova TR. [Refractory and resistant hypertension in patients with type 2 diabetes mellitus: differences in metabolic profile and endothelial function]. TERAPEVT ARKH 2021; 93:49-58. [PMID: 33720626 DOI: 10.26442/00403660.2021.01.200593] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 02/25/2021] [Indexed: 11/22/2022]
Abstract
AIM To determine the prevalence of refractory hypertension (RfH) in patients with and without type 2 diabetes mellitus (DM), as well as to evaluate whether diabetic patients with RfH significant differ from those with uncontrolled resistant hypertension (RH) in clinical phenotype, metabolic profile and endothelial function. MATERIALS AND METHODS The study included 193 patients with RH: RH 74 patients with diabetes and 119 patients without DM. Uncontrolled RH and RfH were defined by the presence of uncontrolled blood pressure BP (140 and/or 90 mm Hg) despite the use of 3 but 5 antihypertensive drugs (for RH) and 5 antihypertensive drugs, including a mineralocorticoid receptor antagonist (for RfH). Clinical examination, lab tests were performed. Flow-mediated dilation (FMD) and vasoreactivity of middle cerebral artery (MCA) using both breath-holding and hyperventilation test were measured by high-resolution ultrasound. RESULTS The prevalence of refractory hypertension in patients with and without DM was similar (30% vs 28%, respectively). No differences in BP levels, data of echocardiography and clinical phenotype were found between the diabetic groups, but value of HOMA index, plasma resistin level and postprandial glycaemia were higher in patients with RfH. FMD and MCA reactivity to the breath-holding test were worse in patients with RfH, and they had a more pronounced vasoconstrictor response of MCA to the hyperventilation test compared to patients with RH. CONCLUSION The prevalence of RfH is the same in patients with and without diabetes. Diabetic patients with refractory hypertension have a more unfavorable metabolic profile and greater impairment of endothelial function than patients with uncontrolled resistant hypertension.
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Affiliation(s)
- A Y Falkovskaya
- Cardiology Research Institute, Tomsk National Research Medical Center
| | - V F Mordovin
- Cardiology Research Institute, Tomsk National Research Medical Center
| | - S E Pekarskiy
- Cardiology Research Institute, Tomsk National Research Medical Center
| | - T M Ripp
- Cardiology Research Institute, Tomsk National Research Medical Center
| | - M A Manukyan
- Cardiology Research Institute, Tomsk National Research Medical Center
| | - V A Lichikaki
- Cardiology Research Institute, Tomsk National Research Medical Center
| | - I V Zyubanova
- Cardiology Research Institute, Tomsk National Research Medical Center
| | - E S Sitkova
- Cardiology Research Institute, Tomsk National Research Medical Center
| | - A M Gusakova
- Cardiology Research Institute, Tomsk National Research Medical Center
| | - T R Ryabova
- Cardiology Research Institute, Tomsk National Research Medical Center
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17
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Affiliation(s)
- Rajiv Agarwal
- Division of Nephrology, Department of Medicine, Indiana University School of Medicine and Richard L. Roudebush Veterans Administration Medical Center, IN
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Shin J, Chia Y, Heo R, Kario K, Turana Y, Chen C, Hoshide S, Fujiwara T, Nagai M, Siddique S, Sison J, Tay JC, Wang T, Park S, Sogunuru GP, Minh HV, Li Y. Current status of adherence interventions in hypertension management in Asian countries: A report from the HOPE Asia Network. J Clin Hypertens (Greenwich) 2020; 23:584-594. [PMID: 33350024 PMCID: PMC8029547 DOI: 10.1111/jch.14104] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 10/26/2020] [Accepted: 10/27/2020] [Indexed: 11/29/2022]
Abstract
Adherence continues to be the major hurdle in hypertension management. Since the early 2000s, systematic approaches have been emphasized to tackle multi-dimensional issues specific for each regional setting. However, there is little data regarding implementation of adherence interventions in Asian countries. Eleven hypertension experts from eight Asian countries answered questionnaires regarding the use of adherence interventions according to 11 theoretical domain frameworks by Allemann et al. A four-point Likert scale: Often, Sometimes, Seldom, and Never used was administered. Responses to 97 items from 11 domains excluding three irrelevant items were collected. "Often-used" interventions accounted for 5/9 for education, 1/8 for skills, 1/2 for social/professional role and identity, 1/1 for belief about capabilities, 0/3 for belief about consequences, 2/4 for intentions, 2/9 for memory, attention, and decision process, 11/20 for environmental context and resources, 0/2 for social influences, 0/2 for emotion, and 2/2 for behavioral regulation. Most of them are dependent on conventional resources. Most of "Never used" intervention were the adherence interventions related to multidisciplinary subspecialties or formal training for behavioral therapy. For adherence interventions recommended by 2018 ESC/ESH hypertension guidelines, only 1 in 7 patient level interventions was "Often used." In conclusion, conventional or physician level interventions such as education, counseling, and prescription have been well implemented but multidisciplinary interventions and patient or health system level interventions are in need of better implementation in Asian countries.
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Affiliation(s)
- Jinho Shin
- Division of CardiologyDepartment of Internal MedicineHanyang University Medical CenterSeoulSouth Korea
| | - Yook‐Chin Chia
- Department of Medical SciencesSchool of Healthcare and Medical SciencesSunway UniversityBandar SunwayMalaysia
- Department of Primary Care MedicineFaculty of MedicineUniversity of MalayaKuala LumpurMalaysia
| | - Ran Heo
- Division of CardiologyDepartment of Internal MedicineHanyang University Medical CenterSeoulSouth Korea
| | - Kazuomi Kario
- Division of Cardiovascular MedicineDepartment of MedicineJichi Medical University School of MedicineTochigiJapan
| | - Yuda Turana
- School of Medicine and Health SciencesAtma Jaya Catholic University of IndonesiaJakartaIndonesia
| | - Chen‐Huan Chen
- Institute of Public Health and Community Medicine Research CenterNational Yang‐Ming University School of MedicineTaipeiTaiwan
| | - Satoshi Hoshide
- Division of Cardiovascular MedicineDepartment of MedicineJichi Medical University School of MedicineTochigiJapan
| | - Takeshi Fujiwara
- Division of Cardiovascular MedicineDepartment of MedicineJichi Medical University School of MedicineTochigiJapan
| | - Michiaki Nagai
- Department of Internal Medicine, General Medicine and CardiologyHiroshima City Asa HospitalHiroshimaJapan
| | | | - Jorge Sison
- Cardiology SectionDepartment of MedicineMedical Center ManilaManilaPhilippines
| | - Jam Chin Tay
- Department of General MedicineTan Tock Seng HospitalSingaporeSingapore
| | - Tzung‐Dau Wang
- Department of Internal MedicineNational Taiwan University College of MedicineTaipei CityTaiwan
| | - Sungha Park
- Division of Cardiology SeoulCardiovascular HospitalYonsei Health SystemSeoulSouth Korea
| | - Guru Prasad Sogunuru
- MIOT International Hospital ChennaiChennaiIndia
- College of Medical Sciences BharatpurKathmandu UniversityDhulikhelNepal
| | - Huynh Van Minh
- Department of Internal MedicineUniversity of Medicine and PharmacyHue UniversityHue CityVietnam
| | - Yan Li
- Department of HypertensionThe Shanghai Institute of HypertensionRuijin HospitalShanghai Jiaotong University School of MedicineShanghaiChina
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Buhnerkempe MG, Prakash V, Botchway A, Adekola B, Cohen JB, Rahman M, Weir MR, Ricardo AC, Flack JM. Adverse Health Outcomes Associated With Refractory and Treatment-Resistant Hypertension in the Chronic Renal Insufficiency Cohort. Hypertension 2020; 77:72-81. [PMID: 33161774 DOI: 10.1161/hypertensionaha.120.15064] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Refractory hypertension (RfH) is a severe phenotype of antihypertension treatment failure. Treatment-resistant hypertension (TRH), a less severe form of difficult-to-treat hypertension, has been associated with significantly worse health outcomes. However, no studies currently show how health outcomes may worsen upon progression to RfH. RfH and TRH were studied in 3147 hypertensive participants in the CRIC (Chronic Renal Insufficiency Cohort study). The hypertensive phenotype (ie, no TRH or RfH, TRH, or RfH) was identified at the baseline visit, and health outcomes were monitored at subsequent visits. Outcome risk was compared using Cox proportional hazards models with time-varying covariates. A total of 136 (4.3%) individuals were identified with RfH at baseline. After adjusting for participant characteristics, individuals with RfH had increased risk for the composite renal outcome across all study years (50% decline in estimated glomerular filtration rate or end-stage renal disease; hazard ratio for study years 0-10=1.73 [95% CI, 1.42-2.11]) and the composite cardiovascular disease outcome during later study years (stroke, myocardial infarction, or congestive heart failure; hazard ratio for study years 0-3=1.25 [0.91-1.73], for study years 3-6=1.50 [0.97-2.32]), and for study years 6-10=2.72 [1.47-5.01]) when compared with individuals with TRH. There was no significant difference in all-cause mortality between those with refractory versus TRH. We provide the first evidence that RfH is associated with worse long-term health outcomes compared with TRH.
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Affiliation(s)
- Michael G Buhnerkempe
- From the Department of Internal Medicine (M.G.B., A.B.), Southern Illinois University School of Medicine, Springfield, IL
- Center for Clinical Research (M.G.B., A.B.), Southern Illinois University School of Medicine, Springfield, IL
| | - Vivek Prakash
- Division of General Internal Medicine, Hypertension Section, Department of Internal Medicine (V.P., B.A., J.M.F.), Southern Illinois University School of Medicine, Springfield, IL
| | - Albert Botchway
- From the Department of Internal Medicine (M.G.B., A.B.), Southern Illinois University School of Medicine, Springfield, IL
- Center for Clinical Research (M.G.B., A.B.), Southern Illinois University School of Medicine, Springfield, IL
| | - Bemi Adekola
- Division of General Internal Medicine, Hypertension Section, Department of Internal Medicine (V.P., B.A., J.M.F.), Southern Illinois University School of Medicine, Springfield, IL
| | - Jordana B Cohen
- Renal-Electrolyte and Hypertension Division (J.B.C.)
- Department of Biostatistics, Epidemiology, and Informatics (J.B.C.), Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Mahboob Rahman
- Division of Nephrology, Department of Medicine, Case Western Reserve University, Cleveland, OH (M.R.)
| | - Matthew R Weir
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD (M.R.W.)
| | - Ana C Ricardo
- Division of Nephrology, Department of Medicine, University of Illinois at Chicago, Chicago, IL (A.C.R.)
| | - John M Flack
- Center for Clinical Research (M.G.B., A.B.), Southern Illinois University School of Medicine, Springfield, IL
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20
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Langford AT, Akinyelure OP, Moore TL, Howard G, Min YI, Hillegass WB, Bress AP, Tajeu GS, Butler M, Jaeger BC, Yano Y, Shimbo D, Ogedegbe G, Calhoun D, Booth JN, Muntner P. Underutilization of Treatment for Black Adults With Apparent Treatment-Resistant Hypertension: JHS and the REGARDS Study. Hypertension 2020; 76:1600-1607. [PMID: 32924633 PMCID: PMC7685176 DOI: 10.1161/hypertensionaha.120.14836] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Accepted: 07/20/2020] [Indexed: 01/26/2023]
Abstract
Resistant hypertension, defined as blood pressure levels above goal while taking ≥3 classes of antihypertensive medication or ≥4 classes regardless of blood pressure level, is associated with increased cardiovascular disease risk. The 2018 American Heart Association Scientific Statement on Resistant Hypertension recommends healthy lifestyle habits and thiazide-like diuretics and mineralocorticoid receptor antagonists for adults with resistant hypertension. The term apparent treatment-resistant hypertension (aTRH) is used when pseudoresistance cannot be excluded. We estimated the use of healthy lifestyle factors and recommended antihypertensive medication classes among US Black adults with aTRH. Data were pooled for Black participants in the JHS (Jackson Heart Study) in 2009 to 2013 (n=2496) and the REGARDS study (Reasons for Geographic and Racial Differences in Stroke) in 2013 to 2016 (n=3786). Outcomes included lifestyle factors (not smoking, not consuming alcohol, ≥75 minutes of vigorous-intensity or ≥150 minutes of moderate or vigorous physical activity per week, and body mass index <25 kg/m2) and recommended antihypertensive medications (thiazide-like diuretics and mineralocorticoid receptor antagonists). Overall, 28.3% of participants who reported taking antihypertensive medication had aTRH. Among participants with aTRH, 14.5% and 1.2% had ideal levels of 3 and 4 of the lifestyle factors, respectively. Also, 5.9% of participants with aTRH reported taking a thiazide-like diuretic, and 9.8% reported taking a mineralocorticoid receptor antagonist. In conclusion, evidence-based lifestyle factors and recommended pharmacological treatment are underutilized in Black adults with aTRH. Increased use of lifestyle recommendations and antihypertensive medication classes specifically recommended for aTRH may improve blood pressure control and reduce cardiovascular disease-related morbidity and mortality among US Black adults. Graphic Abstract A graphic abstract is available for this article.
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Affiliation(s)
- Aisha T Langford
- From the Department of Population Health, NYU School of Medicine (A.T.L., M.B., G.O.)
- Departments of Epidemiology (O.P.A., T.L.M., J.N.B., P.M.), University of Alabama at Birmingham
- Departments of Biostatistics (G.H., B.C.J.), University of Alabama at Birmingham
- Departments of Medicine (D.C.), University of Alabama at Birmingham
- Departments of Data Science (Y.-I.M., W.B.H.), University of Mississippi Medical Center, Jackson
- Departments of Medicine (Y.-I.M., W.B.H.), University of Mississippi Medical Center, Jackson
- Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City (A.P.B.)
- Department of Health Services Administration and Policy, Temple University, Philadelphia, PA (G.S.T.)
- Department of Family Medicine and Community Health, Duke University School of Medicine, Durham, NC (Y.Y.)
- and Department of Medicine, Columbia Hypertension Center, Columbia University Medical Center, New York, NY (D.S.)
- CTI Clinical Trials and Consulting Services, Inc., Covington, KY (J.N.B.)
| | - Oluwasegun P Akinyelure
- From the Department of Population Health, NYU School of Medicine (A.T.L., M.B., G.O.)
- Departments of Epidemiology (O.P.A., T.L.M., J.N.B., P.M.), University of Alabama at Birmingham
- Departments of Biostatistics (G.H., B.C.J.), University of Alabama at Birmingham
- Departments of Medicine (D.C.), University of Alabama at Birmingham
- Departments of Data Science (Y.-I.M., W.B.H.), University of Mississippi Medical Center, Jackson
- Departments of Medicine (Y.-I.M., W.B.H.), University of Mississippi Medical Center, Jackson
- Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City (A.P.B.)
- Department of Health Services Administration and Policy, Temple University, Philadelphia, PA (G.S.T.)
- Department of Family Medicine and Community Health, Duke University School of Medicine, Durham, NC (Y.Y.)
- and Department of Medicine, Columbia Hypertension Center, Columbia University Medical Center, New York, NY (D.S.)
- CTI Clinical Trials and Consulting Services, Inc., Covington, KY (J.N.B.)
| | - Tony L Moore
- From the Department of Population Health, NYU School of Medicine (A.T.L., M.B., G.O.)
- Departments of Epidemiology (O.P.A., T.L.M., J.N.B., P.M.), University of Alabama at Birmingham
- Departments of Biostatistics (G.H., B.C.J.), University of Alabama at Birmingham
- Departments of Medicine (D.C.), University of Alabama at Birmingham
- Departments of Data Science (Y.-I.M., W.B.H.), University of Mississippi Medical Center, Jackson
- Departments of Medicine (Y.-I.M., W.B.H.), University of Mississippi Medical Center, Jackson
- Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City (A.P.B.)
- Department of Health Services Administration and Policy, Temple University, Philadelphia, PA (G.S.T.)
- Department of Family Medicine and Community Health, Duke University School of Medicine, Durham, NC (Y.Y.)
- and Department of Medicine, Columbia Hypertension Center, Columbia University Medical Center, New York, NY (D.S.)
- CTI Clinical Trials and Consulting Services, Inc., Covington, KY (J.N.B.)
| | - George Howard
- From the Department of Population Health, NYU School of Medicine (A.T.L., M.B., G.O.)
- Departments of Epidemiology (O.P.A., T.L.M., J.N.B., P.M.), University of Alabama at Birmingham
- Departments of Biostatistics (G.H., B.C.J.), University of Alabama at Birmingham
- Departments of Medicine (D.C.), University of Alabama at Birmingham
- Departments of Data Science (Y.-I.M., W.B.H.), University of Mississippi Medical Center, Jackson
- Departments of Medicine (Y.-I.M., W.B.H.), University of Mississippi Medical Center, Jackson
- Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City (A.P.B.)
- Department of Health Services Administration and Policy, Temple University, Philadelphia, PA (G.S.T.)
- Department of Family Medicine and Community Health, Duke University School of Medicine, Durham, NC (Y.Y.)
- and Department of Medicine, Columbia Hypertension Center, Columbia University Medical Center, New York, NY (D.S.)
- CTI Clinical Trials and Consulting Services, Inc., Covington, KY (J.N.B.)
| | - Yuan-I Min
- From the Department of Population Health, NYU School of Medicine (A.T.L., M.B., G.O.)
- Departments of Epidemiology (O.P.A., T.L.M., J.N.B., P.M.), University of Alabama at Birmingham
- Departments of Biostatistics (G.H., B.C.J.), University of Alabama at Birmingham
- Departments of Medicine (D.C.), University of Alabama at Birmingham
- Departments of Data Science (Y.-I.M., W.B.H.), University of Mississippi Medical Center, Jackson
- Departments of Medicine (Y.-I.M., W.B.H.), University of Mississippi Medical Center, Jackson
- Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City (A.P.B.)
- Department of Health Services Administration and Policy, Temple University, Philadelphia, PA (G.S.T.)
- Department of Family Medicine and Community Health, Duke University School of Medicine, Durham, NC (Y.Y.)
- and Department of Medicine, Columbia Hypertension Center, Columbia University Medical Center, New York, NY (D.S.)
- CTI Clinical Trials and Consulting Services, Inc., Covington, KY (J.N.B.)
| | - William B Hillegass
- From the Department of Population Health, NYU School of Medicine (A.T.L., M.B., G.O.)
- Departments of Epidemiology (O.P.A., T.L.M., J.N.B., P.M.), University of Alabama at Birmingham
- Departments of Biostatistics (G.H., B.C.J.), University of Alabama at Birmingham
- Departments of Medicine (D.C.), University of Alabama at Birmingham
- Departments of Data Science (Y.-I.M., W.B.H.), University of Mississippi Medical Center, Jackson
- Departments of Medicine (Y.-I.M., W.B.H.), University of Mississippi Medical Center, Jackson
- Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City (A.P.B.)
- Department of Health Services Administration and Policy, Temple University, Philadelphia, PA (G.S.T.)
- Department of Family Medicine and Community Health, Duke University School of Medicine, Durham, NC (Y.Y.)
- and Department of Medicine, Columbia Hypertension Center, Columbia University Medical Center, New York, NY (D.S.)
- CTI Clinical Trials and Consulting Services, Inc., Covington, KY (J.N.B.)
| | - Adam P Bress
- From the Department of Population Health, NYU School of Medicine (A.T.L., M.B., G.O.)
- Departments of Epidemiology (O.P.A., T.L.M., J.N.B., P.M.), University of Alabama at Birmingham
- Departments of Biostatistics (G.H., B.C.J.), University of Alabama at Birmingham
- Departments of Medicine (D.C.), University of Alabama at Birmingham
- Departments of Data Science (Y.-I.M., W.B.H.), University of Mississippi Medical Center, Jackson
- Departments of Medicine (Y.-I.M., W.B.H.), University of Mississippi Medical Center, Jackson
- Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City (A.P.B.)
- Department of Health Services Administration and Policy, Temple University, Philadelphia, PA (G.S.T.)
- Department of Family Medicine and Community Health, Duke University School of Medicine, Durham, NC (Y.Y.)
- and Department of Medicine, Columbia Hypertension Center, Columbia University Medical Center, New York, NY (D.S.)
- CTI Clinical Trials and Consulting Services, Inc., Covington, KY (J.N.B.)
| | - Gabriel S Tajeu
- From the Department of Population Health, NYU School of Medicine (A.T.L., M.B., G.O.)
- Departments of Epidemiology (O.P.A., T.L.M., J.N.B., P.M.), University of Alabama at Birmingham
- Departments of Biostatistics (G.H., B.C.J.), University of Alabama at Birmingham
- Departments of Medicine (D.C.), University of Alabama at Birmingham
- Departments of Data Science (Y.-I.M., W.B.H.), University of Mississippi Medical Center, Jackson
- Departments of Medicine (Y.-I.M., W.B.H.), University of Mississippi Medical Center, Jackson
- Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City (A.P.B.)
- Department of Health Services Administration and Policy, Temple University, Philadelphia, PA (G.S.T.)
- Department of Family Medicine and Community Health, Duke University School of Medicine, Durham, NC (Y.Y.)
- and Department of Medicine, Columbia Hypertension Center, Columbia University Medical Center, New York, NY (D.S.)
- CTI Clinical Trials and Consulting Services, Inc., Covington, KY (J.N.B.)
| | - Mark Butler
- From the Department of Population Health, NYU School of Medicine (A.T.L., M.B., G.O.)
- Departments of Epidemiology (O.P.A., T.L.M., J.N.B., P.M.), University of Alabama at Birmingham
- Departments of Biostatistics (G.H., B.C.J.), University of Alabama at Birmingham
- Departments of Medicine (D.C.), University of Alabama at Birmingham
- Departments of Data Science (Y.-I.M., W.B.H.), University of Mississippi Medical Center, Jackson
- Departments of Medicine (Y.-I.M., W.B.H.), University of Mississippi Medical Center, Jackson
- Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City (A.P.B.)
- Department of Health Services Administration and Policy, Temple University, Philadelphia, PA (G.S.T.)
- Department of Family Medicine and Community Health, Duke University School of Medicine, Durham, NC (Y.Y.)
- and Department of Medicine, Columbia Hypertension Center, Columbia University Medical Center, New York, NY (D.S.)
- CTI Clinical Trials and Consulting Services, Inc., Covington, KY (J.N.B.)
| | - Byron C Jaeger
- From the Department of Population Health, NYU School of Medicine (A.T.L., M.B., G.O.)
- Departments of Epidemiology (O.P.A., T.L.M., J.N.B., P.M.), University of Alabama at Birmingham
- Departments of Biostatistics (G.H., B.C.J.), University of Alabama at Birmingham
- Departments of Medicine (D.C.), University of Alabama at Birmingham
- Departments of Data Science (Y.-I.M., W.B.H.), University of Mississippi Medical Center, Jackson
- Departments of Medicine (Y.-I.M., W.B.H.), University of Mississippi Medical Center, Jackson
- Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City (A.P.B.)
- Department of Health Services Administration and Policy, Temple University, Philadelphia, PA (G.S.T.)
- Department of Family Medicine and Community Health, Duke University School of Medicine, Durham, NC (Y.Y.)
- and Department of Medicine, Columbia Hypertension Center, Columbia University Medical Center, New York, NY (D.S.)
- CTI Clinical Trials and Consulting Services, Inc., Covington, KY (J.N.B.)
| | - Yuichiro Yano
- From the Department of Population Health, NYU School of Medicine (A.T.L., M.B., G.O.)
- Departments of Epidemiology (O.P.A., T.L.M., J.N.B., P.M.), University of Alabama at Birmingham
- Departments of Biostatistics (G.H., B.C.J.), University of Alabama at Birmingham
- Departments of Medicine (D.C.), University of Alabama at Birmingham
- Departments of Data Science (Y.-I.M., W.B.H.), University of Mississippi Medical Center, Jackson
- Departments of Medicine (Y.-I.M., W.B.H.), University of Mississippi Medical Center, Jackson
- Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City (A.P.B.)
- Department of Health Services Administration and Policy, Temple University, Philadelphia, PA (G.S.T.)
- Department of Family Medicine and Community Health, Duke University School of Medicine, Durham, NC (Y.Y.)
- and Department of Medicine, Columbia Hypertension Center, Columbia University Medical Center, New York, NY (D.S.)
- CTI Clinical Trials and Consulting Services, Inc., Covington, KY (J.N.B.)
| | - Daichi Shimbo
- From the Department of Population Health, NYU School of Medicine (A.T.L., M.B., G.O.)
- Departments of Epidemiology (O.P.A., T.L.M., J.N.B., P.M.), University of Alabama at Birmingham
- Departments of Biostatistics (G.H., B.C.J.), University of Alabama at Birmingham
- Departments of Medicine (D.C.), University of Alabama at Birmingham
- Departments of Data Science (Y.-I.M., W.B.H.), University of Mississippi Medical Center, Jackson
- Departments of Medicine (Y.-I.M., W.B.H.), University of Mississippi Medical Center, Jackson
- Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City (A.P.B.)
- Department of Health Services Administration and Policy, Temple University, Philadelphia, PA (G.S.T.)
- Department of Family Medicine and Community Health, Duke University School of Medicine, Durham, NC (Y.Y.)
- and Department of Medicine, Columbia Hypertension Center, Columbia University Medical Center, New York, NY (D.S.)
- CTI Clinical Trials and Consulting Services, Inc., Covington, KY (J.N.B.)
| | - Gbenga Ogedegbe
- From the Department of Population Health, NYU School of Medicine (A.T.L., M.B., G.O.)
- Departments of Epidemiology (O.P.A., T.L.M., J.N.B., P.M.), University of Alabama at Birmingham
- Departments of Biostatistics (G.H., B.C.J.), University of Alabama at Birmingham
- Departments of Medicine (D.C.), University of Alabama at Birmingham
- Departments of Data Science (Y.-I.M., W.B.H.), University of Mississippi Medical Center, Jackson
- Departments of Medicine (Y.-I.M., W.B.H.), University of Mississippi Medical Center, Jackson
- Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City (A.P.B.)
- Department of Health Services Administration and Policy, Temple University, Philadelphia, PA (G.S.T.)
- Department of Family Medicine and Community Health, Duke University School of Medicine, Durham, NC (Y.Y.)
- and Department of Medicine, Columbia Hypertension Center, Columbia University Medical Center, New York, NY (D.S.)
- CTI Clinical Trials and Consulting Services, Inc., Covington, KY (J.N.B.)
| | - David Calhoun
- From the Department of Population Health, NYU School of Medicine (A.T.L., M.B., G.O.)
- Departments of Epidemiology (O.P.A., T.L.M., J.N.B., P.M.), University of Alabama at Birmingham
- Departments of Biostatistics (G.H., B.C.J.), University of Alabama at Birmingham
- Departments of Medicine (D.C.), University of Alabama at Birmingham
- Departments of Data Science (Y.-I.M., W.B.H.), University of Mississippi Medical Center, Jackson
- Departments of Medicine (Y.-I.M., W.B.H.), University of Mississippi Medical Center, Jackson
- Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City (A.P.B.)
- Department of Health Services Administration and Policy, Temple University, Philadelphia, PA (G.S.T.)
- Department of Family Medicine and Community Health, Duke University School of Medicine, Durham, NC (Y.Y.)
- and Department of Medicine, Columbia Hypertension Center, Columbia University Medical Center, New York, NY (D.S.)
- CTI Clinical Trials and Consulting Services, Inc., Covington, KY (J.N.B.)
| | - John N Booth
- From the Department of Population Health, NYU School of Medicine (A.T.L., M.B., G.O.)
- Departments of Epidemiology (O.P.A., T.L.M., J.N.B., P.M.), University of Alabama at Birmingham
- Departments of Biostatistics (G.H., B.C.J.), University of Alabama at Birmingham
- Departments of Medicine (D.C.), University of Alabama at Birmingham
- Departments of Data Science (Y.-I.M., W.B.H.), University of Mississippi Medical Center, Jackson
- Departments of Medicine (Y.-I.M., W.B.H.), University of Mississippi Medical Center, Jackson
- Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City (A.P.B.)
- Department of Health Services Administration and Policy, Temple University, Philadelphia, PA (G.S.T.)
- Department of Family Medicine and Community Health, Duke University School of Medicine, Durham, NC (Y.Y.)
- and Department of Medicine, Columbia Hypertension Center, Columbia University Medical Center, New York, NY (D.S.)
- CTI Clinical Trials and Consulting Services, Inc., Covington, KY (J.N.B.)
| | - Paul Muntner
- From the Department of Population Health, NYU School of Medicine (A.T.L., M.B., G.O.)
- Departments of Epidemiology (O.P.A., T.L.M., J.N.B., P.M.), University of Alabama at Birmingham
- Departments of Biostatistics (G.H., B.C.J.), University of Alabama at Birmingham
- Departments of Medicine (D.C.), University of Alabama at Birmingham
- Departments of Data Science (Y.-I.M., W.B.H.), University of Mississippi Medical Center, Jackson
- Departments of Medicine (Y.-I.M., W.B.H.), University of Mississippi Medical Center, Jackson
- Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City (A.P.B.)
- Department of Health Services Administration and Policy, Temple University, Philadelphia, PA (G.S.T.)
- Department of Family Medicine and Community Health, Duke University School of Medicine, Durham, NC (Y.Y.)
- and Department of Medicine, Columbia Hypertension Center, Columbia University Medical Center, New York, NY (D.S.)
- CTI Clinical Trials and Consulting Services, Inc., Covington, KY (J.N.B.)
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Georgianos PI, Agarwal R. Resistant Hypertension in Chronic Kidney Disease (CKD): Prevalence, Treatment Particularities, and Research Agenda. Curr Hypertens Rep 2020; 22:84. [PMID: 32880742 DOI: 10.1007/s11906-020-01081-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
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.
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Affiliation(s)
- Panagiotis I Georgianos
- Section of Nephrology and Hypertension, 1st Department of Medicine, AHEPA Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Rajiv Agarwal
- Division of Nephrology, Department of Medicine, Indiana University School of Medicine and Richard L. Roudebush Veterans Administration Medical Center, 1481 West 10th Street, Indianapolis, IN, USA.
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22
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Prevalence and clinical profile of refractory hypertension in a large cohort of patients with resistant hypertension. J Hum Hypertens 2020; 35:709-717. [PMID: 32868882 DOI: 10.1038/s41371-020-00406-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2020] [Revised: 07/18/2020] [Accepted: 08/18/2020] [Indexed: 11/08/2022]
Abstract
Refractory hypertension (RfHT) is an extreme phenotype of resistant hypertension (RHT) and is considered uncontrolled blood pressure (BP) despite the use of five or more antihypertensives. The objective of this study was to characterize the prevalence and clinical profile of RfHT patients in a historical cohort of patients with RHT at two different times: before and after the introduction of spironolactone. First, this cross-sectional study evaluated 1048 RHT patients (72.3% females, mean [SD] age: 61.2 [11.3] years) referred to a hypertension clinic (prespironolactone period). All patients were submitted to a standard protocol including clinical and complementary exams. Second, the analysis evaluated patients after the introduction of spironolactone (postspironolactone period). Statistical analysis included bivariate comparisons between patients with RHT and patients with RfHT and logistic regressions to assess the independent correlations of RfHT. A total of 146 patients (13.9%) remained refractory despite the use of at least five antihypertensives (prespironolactone period). After the introduction of spironolactone, the prevalence increased to 17.6%. For any criterion, RfHT patients were younger and more obese. In the initial period, current smoking and left ventricular hypertrophy were independently correlated with RfHT. Furthermore, after spironolactone use, RfHT patients had lower aortic stiffness and peripheral artery disease (PAD), pointing to a lower cardiovascular risk despite the lack of BP control. Younger age and lower prevalence of PAD correlated independently with RfHT. In conclusion, there was a high prevalence of RfHT, especially in younger and obese patients, and spironolactone use seemed to reduce cardiovascular risk despite the lack of BP control.
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Muxfeldt ES, Chedier B. Refractory hypertension: what do we know so far? J Hum Hypertens 2020; 35:181-183. [PMID: 32873873 DOI: 10.1038/s41371-020-00409-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 08/10/2020] [Accepted: 08/18/2020] [Indexed: 11/09/2022]
Affiliation(s)
- Elizabeth Silaid Muxfeldt
- Department of Internal Medicine, Hospital Universitário Clementino Fraga Filho, School of Medicine, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil.
| | - Bernardo Chedier
- Department of Internal Medicine, Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
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Cardoso CRL, Salles GF. Refractory Hypertension and Risks of Adverse Cardiovascular Events and Mortality in Patients With Resistant Hypertension: A Prospective Cohort Study. J Am Heart Assoc 2020; 9:e017634. [PMID: 32851922 PMCID: PMC7660786 DOI: 10.1161/jaha.120.017634] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Background The long‐term prognosis of refractory hypertension (RfHT), defined as failure to control blood pressure (BP) levels despite an antihypertensive treatment with ≥5 medications including a diuretic and mineraloreceptor antagonist, has never been evaluated. Methods and Results In a prospective cohort study with 1576 patients with resistant hypertension, patients were classified as refractory or nonrefractory based on uncontrolled clinic (or office) and ambulatory BPs during the first 2 years of follow‐up. Multivariate Cox analyses examined the associations between the diagnosis of RfHT and the occurrence of total cardiovascular events (CVEs), major adverse CVEs, and cardiovascular and all‐cause mortality, after adjustments for other risk factors. In total, 135 patients (8.6%) had RfHT by uncontrolled ambulatory BPs and 167 (10.6%) by uncontrolled clinic BPs. Over a median Follow‐Up of 8.9 years, 338 total CVEs occurred (288 major adverse CVEs, including 124 myocardial infarctions, and 96 strokes), and 331 patients died, 196 from cardiovascular causes. The diagnosis of RfHT, using either classification by clinic or ambulatory BPs, was associated with significantly higher risks of major adverse CVEs, cardiovascular mortality, and stroke incidence, with hazard ratios varying from 1.54 to 2.14 in relation to patients with resistant nonrefractory hypertension; however, the classification based on ambulatory BPs was better in identifying higher risk patients than the classification based on clinic BP levels. Conclusions Patients with RfHT, particularly when defined by uncontrolled ambulatory BP levels, had higher risks of major adverse CVEs and mortality in relation to patients with resistant but nonrefractory hypertension, supporting the concept of refractory hypertension as a true extreme phenotype of antihypertensive treatment failure.
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Affiliation(s)
- Claudia R L Cardoso
- Department of Internal Medicine School of Medicine University Hospital Clementino Fraga Filho Universidade Federal do Rio de Janeiro Brazil
| | - Gil F Salles
- Department of Internal Medicine School of Medicine University Hospital Clementino Fraga Filho Universidade Federal do Rio de Janeiro Brazil
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