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Cestario EDES, Vilela-Martin JF, Cosenso-Martin LN, Rubio TA, Uyemura JRR, da Silva Lopes V, Fernandes LAB, Bonalume Tacito LH, Moreno Junior H, Yugar-Toledo JC. Effect of Sequential Nephron Blockade versus Dual Renin-Angiotensin System Blockade Plus Bisoprolol in the Treatment of Resistant Hypertension, a Randomized Controlled Trial (Resistant Hypertension on Treatment - ResHypOT). Vasc Health Risk Manag 2022; 18:867-878. [PMID: 36545494 PMCID: PMC9762262 DOI: 10.2147/vhrm.s383007] [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: 07/29/2022] [Accepted: 10/20/2022] [Indexed: 12/23/2022] Open
Abstract
Introduction Hypertension is the most important modifiable risk factor for cardiovascular disease and a leading public health concern. Objectives The primary aim was to compare sequential nephron blockade (SNB) versus dual renin-angiotensin system blockade (DRASB) plus bisoprolol in patients with resistant hypertension to observe reductions in systolic and diastolic blood pressure (SBP and DBP) levels after 20 weeks of treatment. Material and Methods This trial was an open-label, prospective, randomized, parallel-group, clinical study with optional drug up-titration. Participants were evaluated during five visits at 28-day intervals. Results The mean age was 55.5 years in the SNB and 58.4 years in the DRASB + bisoprolol group (p=NS). Significant office BP reductions were observed in both groups. SNB group, SBP decreased from 174.5±21.0 to 127.0±14.74 mmHg (p<0.0001), and DBP decreased from 105.3±15.5 to 78.11±9.28 mmHg (p<0.0001). DRASB group, SBP decreased from 178.4±21.08 to 134.4 ± 23.25 mmHg (p<0.0001) and DBP decreased from 102.7±11.07 to 77.33±13.75 mmHg (p<0.0001). Ambulatory blood pressure monitoring (ABPM) showed also significant SBP and DBP reductions in both groups (p<0.0001). Conclusion In patients with RHTN adherent to treatment, SNB and DRASB plus bisoprolol showed excellent therapeutic efficacy, although SNB was associated with earlier SBP reduction.
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Affiliation(s)
| | - Jose Fernando Vilela-Martin
- Hypertension Clinic, Internal Medicine Department, Medical School in São José Do Rio Preto (FAMERP), São Paulo, Brazil,Correspondence: Jose Fernando Vilela-Martin, Ave Brig Faria Lima 5416, Sao Jose do Rio Preto, São Paulo, SP, 15090-000, Brazil, Tel +55 17 32015727, Email
| | - Luciana Neves Cosenso-Martin
- Hypertension Clinic, Internal Medicine Department, Medical School in São José Do Rio Preto (FAMERP), São Paulo, Brazil
| | - Tatiane Azevedo Rubio
- Hypertension Clinic, Internal Medicine Department, Medical School in São José Do Rio Preto (FAMERP), São Paulo, Brazil
| | | | - Valquiria da Silva Lopes
- Hypertension Clinic, Internal Medicine Department, Medical School in São José Do Rio Preto (FAMERP), São Paulo, Brazil
| | | | - Lucia Helena Bonalume Tacito
- Endocrinology Division, Internal Medicine Department, Medical School in São José Rio Preto (FAMERP), São Paulo, Brazil
| | - Heitor Moreno Junior
- Cardiovascular Pharmacology Laboratory, Faculty of Medical Sciences, State University of Campinas (UNICAMP), São Paulo, Brazil
| | - Juan Carlos Yugar-Toledo
- Hypertension Clinic, Internal Medicine Department, Medical School in São José Do Rio Preto (FAMERP), São Paulo, Brazil
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Treatment-resistant hypertension assessed by home blood pressure monitoring: a new target for intervention? Hypertens Res 2021; 45:167-169. [PMID: 34789916 DOI: 10.1038/s41440-021-00801-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 10/20/2021] [Indexed: 12/23/2022]
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Francischetti EA, de Abreu VG, da Silva Figueiredo LF, Dezonne RS, Coutinho ESF. Effects of Blood Pressure Lowering Agents on Cardiovascular Outcomes in Weight Excess Patients: A Systematic Review and Meta-analysis. Am J Cardiovasc Drugs 2020; 20:447-470. [PMID: 31898196 DOI: 10.1007/s40256-019-00393-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Obesity hypertension is an ongoing pandemic. The first-line medications to treat this condition are still subject to debate. We compared diuretics, calcium-channel blockers (CCB), beta-blockers (BB), angiotensin-converting enzyme inhibitors (ACEI) and angiotensin receptor blockers (ARB) as an initial antihypertensive therapy for prevention of cardiovascular morbimortality of hypertensive individuals who are overweight or obese. METHODS We conducted a search of the literature for randomized clinical trials in which at least 50% of the participants were overweight or obese. The primary outcomes were all-cause mortality, cardiovascular mortality, acute myocardial infarction (MI), heart failure (HF), stroke, or end-stage renal disease. RESULTS Our search yielded 16 randomized studies. Comparisons of two classes of drugs with at least two studies indicated that (1) CCB and ACEI increased the risk of HF [relative risk (RR) = 2.26; 95% confidence interval (CI) 1.16-4.40] and stroke [hazard ratio (HR) = 1.13; 1.00-1.26]), respectively, compared to diuretics; and (2) CCB showed a reduction in stroke (HR = 0.77; 0.66-0.89) and total mortality (HR = 0.94; 0.87-1.01) compared to the BB atenolol. Comparisons of two classes of antihypertensive medications with only one study showed that the risk of MI was higher with ARB valsartan versus CCB (HR = 1.19; 95% CI 1.02-1.38, p = 0.02). In contrast, losartan lowered the risk of a composite cardiovascular outcome compared to atenolol (HR = 0.87; 95% CI 0.77-0.98, p = 0.02). CONCLUSIONS In hypertensive subjects with excess weight, diuretics are more effective for preventing HF and stroke than CCB and ACEI, respectively. CCB are a good first-line choice for prevention of cardiovascular disease, except HF.
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Abstract
Resistant hypertension (RHTN) is defined as uncontrolled blood pressure despite the use of ≥3 antihypertensive agents of different classes, including a diuretic, usually thiazide-like, a long-acting calcium channel blocker, and a blocker of the renin- angiotensin system, either an ACE (angiotensin-converting enzyme) inhibitor or an ARB (angiotensin receptor blocker), at maximal or maximally tolerated doses. Antihypertensive medication nonadherence and the white coat effect, defined as elevated blood pressure when measured in clinic but controlled when measured outside of clinic, must be excluded to make the diagnosis. RHTN is a high-risk phenotype, leading to increased all-cause mortality and cardiovascular disease outcomes. Healthy lifestyle habits are associated with reduced cardiovascular risk in patients with RHTN. Aldosterone excess is common in patients with RHTN, and addition of spironolactone or amiloride to the standard 3-drug antihypertensive regimen is effective at getting the blood pressure to goal in most of these patients. Refractory hypertension is defined as uncontrolled blood pressure despite use of ≥5 antihypertensive agents of different classes, including a long-acting thiazide-like diuretic and an MR (mineralocorticoid receptor) antagonist, at maximal or maximally tolerated doses. Fluid retention, mediated largely by aldosterone excess, is the predominant mechanism underlying RHTN, while patients with refractory hypertension typically exhibit increased sympathetic nervous system activity.
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Affiliation(s)
- Maria Czarina Acelajado
- From the Department of Medicine, Division of Cardiovascular Disease, Vascular Biology and Hypertension Program, University of Alabama at Birmingham
| | - Zachary H Hughes
- From the Department of Medicine, Division of Cardiovascular Disease, Vascular Biology and Hypertension Program, University of Alabama at Birmingham
| | - Suzanne Oparil
- From the Department of Medicine, Division of Cardiovascular Disease, Vascular Biology and Hypertension Program, University of Alabama at Birmingham
| | - David A Calhoun
- From the Department of Medicine, Division of Cardiovascular Disease, Vascular Biology and Hypertension Program, University of Alabama at Birmingham
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Clemmer JS, Faulkner JL, Mullen AJ, Butler KR, Hester RL. Sex-specific responses to mineralocorticoid receptor antagonism in hypertensive African American males and females. Biol Sex Differ 2019; 10:24. [PMID: 31072402 PMCID: PMC6507140 DOI: 10.1186/s13293-019-0238-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Accepted: 04/16/2019] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND African Americans (AA) develop hypertension (HTN) at an earlier age, have a greater frequency and severity of HTN, and greater prevalence of uncontrolled HTN as compared to the white population. Mineralocorticoid antagonists have been shown to be very effective in treating uncontrolled HTN in both AA and white patients, but sex-specific responses are unclear. METHODS We evaluated the sex-specific impact of mineralocorticoid antagonism in an AA population. An AA cohort (n = 1483) from the Genetic Epidemiology Network of Arteriopathy study was stratified based on sex and whether they were taking spironolactone, a mineralocorticoid antagonist, in their antihypertensive regimen. RESULTS As compared to AA women not prescribed a mineralocorticoid antagonist, AA women taking spironolactone (n = 9) had lower systolic and diastolic blood pressure despite having a similar number of antihypertensive medications. The proportion of AA women with uncontrolled HTN was significantly less for patients taking spironolactone than for patients not prescribed spironolactone. Interestingly, none of these associations were found in the AA males or in white females. CONCLUSIONS Our data suggests that spironolactone is particularly effective in reducing blood pressure and controlling HTN in AA women. Further research into the impact of this therapy in this underserved and understudied minority is warranted.
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Affiliation(s)
- John S Clemmer
- Department of Physiology and Biophysics, Center for Computational Medicine, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS, 39216-4505, USA.
| | - Jessica L Faulkner
- Vascular Biology Center, Medical College of Georgia, Augusta University, Augusta, GA, 30912-5563, USA
| | - Alex J Mullen
- Department of Physiology and Biophysics, Center for Computational Medicine, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS, 39216-4505, USA
| | - Kenneth R Butler
- Department of Medicine, University of Mississippi Medical Center, Jackson, MS, 39216-4505, USA
| | - Robert L Hester
- Department of Physiology and Biophysics, Center for Computational Medicine, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS, 39216-4505, USA.,Department of Data Sciences, John D. Bower School of Population Health, University of Mississippi Medical Center, Jackson, MS, 39216-4505, USA
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Carnagarin R, Matthews V, Gregory C, Schlaich MP. Pharmacotherapeutic strategies for treating hypertension in patients with obesity. Expert Opin Pharmacother 2018; 19:643-651. [DOI: 10.1080/14656566.2018.1458092] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Revathy Carnagarin
- Dobney Hypertension Centre, School of Medicine, Royal Perth Hospital Unit, University of Western Australia, Perth, Australia
| | - Vance Matthews
- Dobney Hypertension Centre, School of Medicine, Royal Perth Hospital Unit, University of Western Australia, Perth, Australia
| | - Cynthia Gregory
- Dobney Hypertension Centre, School of Medicine, Royal Perth Hospital Unit, University of Western Australia, Perth, Australia
| | - Markus P. Schlaich
- Dobney Hypertension Centre, School of Medicine, Royal Perth Hospital Unit, University of Western Australia, Perth, Australia
- Department of Cardiology, Royal Perth Hospital, Perth, Australia
- Department of Nephrology, Royal Perth Hospital, Perth, Australia
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7
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Mineralocorticoid receptor antagonists: time of repositioning them in the treatment of arterial hypertension. J Hypertens 2018; 36:1015-1018. [PMID: 29578956 DOI: 10.1097/hjh.0000000000001686] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Dudenbostel T, Calhoun DA. Use of Aldosterone Antagonists for Treatment of Uncontrolled Resistant Hypertension. Am J Hypertens 2017; 30:103-109. [PMID: 27609503 DOI: 10.1093/ajh/hpw105] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Revised: 07/19/2016] [Accepted: 08/18/2016] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Multiple studies indicate that primary aldosteronism (PA) is common in patients with resistant hypertension, with an estimated prevalence of approximately 20%. Additional studies suggest that beyond this 20% of patients with classical PA, there is a larger proportion of patients with lesser degrees of hyperaldosteronism which contributes even more broadly to antihypertensive treatment resistance. Given these observations, it is intuitive that use of aldosterone antagonists will provide antihypertensive benefit in patients with resistant hypertension and evidence of aldosterone excess. Intriguingly, however, are clinical findings demonstrating substantive benefit of aldosterone antagonists in patients with resistant hypertension, but without demonstrative evidence of hyperaldosteronism, that is, with seemingly normal or even low aldosterone levels. CONCLUSION Spironolactone is clearly established as the most effective fourth agent for treatment of uncontrolled resistant hypertension. Emerging observations suggest a further role of spironolactone for counteracting the effects of diet high in sodium, particularly in obese, hypertensive patients.
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Affiliation(s)
- Tanja Dudenbostel
- Vascular Biology and Hypertension Program, University of Alabama at Birmingham, Birmingham, Alabama, USA.
| | - David A Calhoun
- Vascular Biology and Hypertension Program, University of Alabama at Birmingham, Birmingham, Alabama, USA
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Martell-Claros N, Abad-Cardiel M. ¿Qué posibilidades farmacológicas existen para tratar la hipertensión arterial resistente? HIPERTENSION Y RIESGO VASCULAR 2017; 34 Suppl 1:25-28. [DOI: 10.1016/s1889-1837(18)30060-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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A meta-analysis of add-on use of spironolactone in patients with resistant hypertension. Int J Cardiol 2016; 233:113-117. [PMID: 28089457 DOI: 10.1016/j.ijcard.2016.12.158] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Revised: 11/15/2016] [Accepted: 12/20/2016] [Indexed: 12/18/2022]
Abstract
OBJECTIVE The efficacy of add-on use of spironolactone in patients with resistant hypertension has been investigated in several small studies. We performed this meta-analysis evaluating the efficacy of add-on use of spironolactone in these patients. METHODS We searched Pubmed, Web of Science, and Cochrane Central for all published studies evaluating add-on use of spironolactone in patients with resistant hypertension. Only randomized controlled trials determining antihypertensive effects of spironolactone were considered. RESULTS The antihypertensive effects were assessed in 869 patients included in 4 trials with a mean follow-up of 12±3weeks. The reduction of systolic blood pressure (SBP) and diastolic BP (DBP) in patients treated with spironolactone was greater than placebo (weighted mean differences (WMD) for SBP -16.67mmHg (95% confidence interval (CI), -27.54, -5.80), p<0.01; WMD for DBP -6.11mmHg (95% CI, -9.34, -2.88), p<0.001), respectively. The rates of serious adverse effects or patient withdrawals from the trials tended to be higher in patients treated with spironolactone than placebo (WMD for odds ratio 2.11 (95% CI, 0.98, 4.53), p=0.05). CONCLUSIONS This meta-analysis provides the evidence that add-on use of spironolactone in patients with resistant hypertension is effective in lowering SBP and DBP, suggesting an add-on use of spironolactone as fourth line therapy in patients with resistant hypertension.
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Sinnott SJ, Tomlinson LA, Root AA, Mathur R, Mansfield KE, Smeeth L, Douglas IJ. Comparative effectiveness of fourth-line anti-hypertensive agents in resistant hypertension: A systematic review and meta-analysis. Eur J Prev Cardiol 2016; 24:228-238. [DOI: 10.1177/2047487316675194] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Sarah-Jo Sinnott
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, UK
| | - Laurie A Tomlinson
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, UK
| | - Adrian A Root
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, UK
| | - Rohini Mathur
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, UK
| | - Kathryn E Mansfield
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, UK
| | - Liam Smeeth
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, UK
| | - Ian J Douglas
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, UK
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Rosa J, Zelinka T, Petrák O, Štrauch B, Holaj R, Widimský J. Should All Patients with Resistant Hypertension Receive Spironolactone? Curr Hypertens Rep 2016; 18:81. [PMID: 27787836 DOI: 10.1007/s11906-016-0690-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
- Ján Rosa
- 3rd Department of Medicine, Center for Hypertension, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic.
- Cardiocenter, University Hospital Královské Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic.
| | - Tomáš Zelinka
- 3rd Department of Medicine, Center for Hypertension, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Ondřej Petrák
- 3rd Department of Medicine, Center for Hypertension, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Branislav Štrauch
- 3rd Department of Medicine, Center for Hypertension, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Robert Holaj
- 3rd Department of Medicine, Center for Hypertension, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Jiří Widimský
- 3rd Department of Medicine, Center for Hypertension, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic
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Verdalles U, García de Vinuesa S, Goicoechea M, Macías N, Santos A, Perez de Jose A, Verde E, Yuste C, Luño J. Management of resistant hypertension: aldosterone antagonists or intensification of diuretic therapy? Nephrology (Carlton) 2016; 20:567-71. [PMID: 25818266 DOI: 10.1111/nep.12475] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/23/2015] [Indexed: 11/26/2022]
Abstract
OBJECTIVE No consensus has been established as to which is the best fourth-line agent in patients with resistant hypertension (RHT). The aim of the present study was to assess the effect of intensifying diuretic treatment with loop diuretic (furosemide) or aldosterone antagonist (spironolactone) on blood pressure (BP) control in RHT. METHODS The study population comprised 30 patients with RHT who were divided into two treatment arms. Fifteen patients received furosemide 40 mg/day and 15 patients received spironolactone 25 mg/day. Ambulatory BP monitoring was performed baseline, 3 and 6 months. RESULTS Baseline BP was 162 ± 8/90 ± 6 mmHg, 70% men, mean age 63.3 ± 9.1 years 56.1% diabetic and estimated glomerular filtration rate (eGFR) 55.8 ± 16.5 mL/min per 1.73 m(2) . There were no significant differences between groups at baseline in age, gender, percentage diabetics, eGFR, BP, number of antihypertensive drugs, or aldosterone levels. At 6 months, systolic BP decreased by 24 ± 9.2 mmHg (from 163.6 ± 8.6 to 139.6 ± 8.1 mmHg) in the spironolactone group, compared with 13.8 ± 2.8 mmHg (from 162 ± 7.9 to 148 ± 6.4 mmHg) in the furosemide group (P < 0.01). Diastolic BP fell 11 ± 8.1 mmHg in the spironolactone group compared with 5.2 ± 2.2 mmHg in the furosemide group (P < 0.01). Significant reduction in urinary albumin creatinine ratio (from 173 ± 268 to 14 ± 24 mg/g, P < 0.01) was observed in the spironolactone group at 6 months. Multiple regression analysis showed that only treatment with spironolactone was associated with control of BP < 140/90 mmHg at 6 months. No severe adverse events were recorded. CONCLUSION Spironolactone is more effective than furosemide for control of BP in RHT patients, with a positive added effect on albuminuria. Spironolactone is safe in patients with mild kidney impairment, although serum potassium should be closely monitored, especially in diabetics.
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Affiliation(s)
- Ursula Verdalles
- Department of Nephrology, Hospital General Universitario Gregorio Marañon, Madrid, Spain
| | | | - Marian Goicoechea
- Department of Nephrology, Hospital General Universitario Gregorio Marañon, Madrid, Spain
| | - Nicolas Macías
- Department of Nephrology, Hospital General Universitario Gregorio Marañon, Madrid, Spain
| | - Alba Santos
- Department of Nephrology, Hospital General Universitario Gregorio Marañon, Madrid, Spain
| | - Ana Perez de Jose
- Department of Nephrology, Hospital General Universitario Gregorio Marañon, Madrid, Spain
| | - Eduardo Verde
- Department of Nephrology, Hospital General Universitario Gregorio Marañon, Madrid, Spain
| | - Claudia Yuste
- Department of Nephrology, Hospital General Universitario Gregorio Marañon, Madrid, Spain
| | - Jose Luño
- Department of Nephrology, Hospital General Universitario Gregorio Marañon, Madrid, Spain
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Dahal K, Kunwar S, Rijal J, Alqatahni F, Panta R, Ishak N, Russell RP. The Effects of Aldosterone Antagonists in Patients With Resistant Hypertension: A Meta-Analysis of Randomized and Nonrandomized Studies. Am J Hypertens 2015; 28:1376-85. [PMID: 25801902 DOI: 10.1093/ajh/hpv031] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2015] [Accepted: 02/06/2015] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND A few studies have shown aldosterone antagonists (AA) to be effective therapy in patients with resistant hypertension (RH). We performed a meta-analysis of randomized and nonrandomized studies of AA in patients with RH. METHODS We searched PUBMED, EMBASE, and CENTRAL for studies on the use of AA in patients with RH. Meta-analysis was performed using random-effects model. The change in office and ambulatory blood pressures (BP), effects on biochemical profile, change in the number of antihypertensive agents, and adverse events were main outcomes. RESULTS We included 15 studies (3 randomized controlled trials, 1 nonrandomized comparative study, and 11 single-arm studies) with 1,204 total patients in the meta-analysis. In comparative studies, AA reduced systolic BP (SBP) by 24.26 mm Hg (95% CI: 8.65-39.87, P = 0.002) and diastolic BP (DBP) by 7.79 mm Hg (3.79-11.79, P = 0.0001). Similarly, AA reduced SBP by 22.74 mm Hg (18.21-27.27, P < 0.00001) and DBP by 10.49 mm Hg (8.85-12.13, P < 0.00001) in single-arm studies. AA resulted in significant change in serum electrolytes in single-arm studies but not in comparative studies. Significantly more adverse events were noted in single-arm studies but not in comparative studies. CONCLUSIONS On the basis of the current meta-analysis, we conclude that AA is safe and effective therapy in patients with RH.
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Affiliation(s)
- Khagendra Dahal
- Department of Medicine, LRGHealthcare, Laconia, New Hampshire, USA;
| | - Sumit Kunwar
- Department of Medicine, LRGHealthcare, Laconia, New Hampshire, USA
| | - Jharendra Rijal
- Department of Medicine, Miriam Hospital, Brown University, Providence, Rhode Island, USA
| | - Fahad Alqatahni
- Department of Medicine, West Virginia School of Medicine, Morgantown, West Virginia, USA
| | - Raju Panta
- Department of Medicine, LRGHealthcare, Laconia, New Hampshire, USA
| | - Noshi Ishak
- Division of Nephrology, LRGHealthcare, Laconia, New Hampshire, USA
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Galve E, Martell-Claros N, Camafort-Babkowski M. [Renal denervation as treatment of resistant hypertension]. Med Clin (Barc) 2015; 145:131-5. [PMID: 25746610 DOI: 10.1016/j.medcli.2014.12.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2014] [Revised: 12/04/2014] [Accepted: 12/11/2014] [Indexed: 11/25/2022]
Affiliation(s)
- Enrique Galve
- Servicio de Cardiología, Hospital Vall d'Hebron, Barcelona, España.
| | | | - Miguel Camafort-Babkowski
- Departamento de Medicina Interna, Hospital Clínic, Instituto de Investigaciones Biomédicas August Pi i Sunyer (IDIBAPS), Universidad de Barcelona, Barcelona, España
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Drug therapy of apparent treatment-resistant hypertension: focus on mineralocorticoid receptor antagonists. Drugs 2015; 75:473-85. [PMID: 25787734 DOI: 10.1007/s40265-015-0372-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Apparent treatment-resistant hypertension (aTRH) is defined as blood pressure (BP) >140/90 mmHg despite three different antihypertensive drugs including a diuretic. aTRH is associated with an increased risk of cardiovascular events, including stroke, chronic renal failure, myocardial infarction, congestive heart failure, aortic aneurysm, atrial fibrillation, and sudden death. Preliminary studies of renal nerve ablation as a therapy to control aTRH were encouraging. However, these results were not confirmed by the Symplicity 3 trial. Therefore, attention has refocused on drug therapy. Secondary forms of hypertension and associated conditions such as obesity, sleep apnea, and primary aldosteronism are common in patients with aTRH. The pivotal role of aldosterone in the pathogenesis of aTRH in many cases is well recognized. For patients with aTRH, the Joint National Committee-8, the European Society of Hypertension, and a recent consensus conference recommend that a diuretic, ACE inhibitor, or angiotensin receptor blocker and calcium channel blocker combination be used to maximally tolerated doses before starting a 'fourth-line' drug such as a mineralocorticoid receptor (MR) antagonist. Although the best fourth-line drug for aTRH has not been extensively investigated, a number of studies summarized here show that an MR antagonist is effective in reducing BP when added to the standard multi-drug regimen.
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Combination antihypertensive therapy in clinical practice. The analysis of 1254 consecutive patients with uncontrolled hypertension. J Hum Hypertens 2015; 30:35-9. [PMID: 25833703 DOI: 10.1038/jhh.2015.24] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2014] [Revised: 02/01/2015] [Accepted: 02/17/2015] [Indexed: 11/08/2022]
Abstract
The aim of the study was to analyze the clinical use of different types of combination therapy in a large sample of consecutive patients with uncontrolled hypertension referred to Hypertension Centre. We performed a retrospective analysis of combination antihypertensive therapy in 1254 consecutive patients with uncontrolled hypertension receiving at least triple-combination antihypertensive therapy. Among the most prescribed antihypertensive classes were renin-angiotensin blockers (96.8%), calcium channel blockers (82.5%), diuretics (82.0%), beta-blockers (73.0%), centrally acting drugs (56.0%) and urapidil (24.1%). Least prescribed were spironolactone (22.2%) and alpha-1-blockers (17.1%). Thiazide/thiazide-like diuretics were underdosed in more than two-thirds of patients. Furosemide was prescribed in 14.3% of patients treated with diuretics, while only indicated in 3.9%. Inappropriate combination therapy was found in 40.4% of patients. Controversial dual and higher blockade of renin-angiotensin system occurred in 25.2%. Incorrect use of a combination of two antihypertensive drugs with the similar mechanism of action was found in 28.1%, most commonly a combination of two drugs with central mechanism (13.5%). In conclusion, use of controversial or incorrect combinations of drugs in uncontrolled hypertension is common. Diuretics are frequently underdosed and spironolactone remains neglected in general practice. The improper combination of antihypertensive drugs may contribute to uncontrolled hypertension.
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Adams M, Bellone JM, Wright BM, Rutecki GW. Evaluation and Pharmacologic Approach to Patients with Resistant Hypertension. Postgrad Med 2015; 124:74-82. [DOI: 10.3810/pgm.2012.01.2520] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Václavík J, Sedlák R, Jarkovský J, Kociánová E, Táborský M. Effect of spironolactone in resistant arterial hypertension: a randomized, double-blind, placebo-controlled trial (ASPIRANT-EXT). Medicine (Baltimore) 2014; 93:e162. [PMID: 25501057 PMCID: PMC4602792 DOI: 10.1097/md.0000000000000162] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
This study was designed to assess the effect of the addition of low-dose spironolactone on blood pressure (BP) in patients with resistant arterial hypertension. Patients with office systolic blood pressure (SBP) >140 mm Hg or diastolic blood pressure (DBP) >90 mm Hg despite treatment with at least 3 antihypertensive drugs, including a diuretic, were enrolled in this double-blind, placebo-controlled, multicentre trial. One hundred sixty-one patients in outpatient internal medicine departments of 6 hospitals in the Czech Republic were randomly assigned to receive 25 mg of spironolactone (N = 81) or a placebo (N = 80) once daily as an add-on to their antihypertensive medication, using simple randomization. This study was registered with ClinicalTrials.gov, number NCT00524615. A nalyses were done with 150 patients who finished the follow-up (74 in the spironolactone and 76 in the placebo group). At 8 weeks, BP values were decreased more by spironolactone, with differences in mean fall of SBP of -9.8, -13.0, -10.5, and -9.9 mm Hg (P < 0.001 for all) in daytime, nighttime, and 24-hour ambulatory BP monitoring and in the office. The respective DBP differences were -3.2, -6.4, -3.5, and -3.0 mm Hg (P = 0.013, P < 0.001, P = 0.005, and P = 0.003). Adverse events in both groups were comparable. The office SBP goal <14 mm Hg at 8 weeks was reached in 73% of patients using spironolactone and 41% using placebo (P = 0.001). Spironolactone in patients with resistant arterial hypertension leads to a significant decrease of both SBP and DBP and markedly improves BP control.
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Affiliation(s)
- Jan Václavík
- From the Department of Internal Medicine I-Cardiology, Faculty of Medicine and Dentistry, University Hospital Olomouc and Palacký University, Olomouc (JV, EK, MT); Department of Internal Medicine, Prostějov Hospital, Mathonova, Prostějov (RS); and Institute of Biostatistics and Analyses at the Faculty of Medicine and the Faculty of Science of the Masaryk University, Kamenice, Brno, Czech Republic (JJ)
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Mercier K, Smith H, Biederman J. Renin-angiotensin-aldosterone system inhibition: overview of the therapeutic use of angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, mineralocorticoid receptor antagonists, and direct renin inhibitors. Prim Care 2014; 41:765-78. [PMID: 25439533 DOI: 10.1016/j.pop.2014.08.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) therapy in hypertensive diabetic patients with macroalbuminuria, microalbuminuria, or normoalbuminuria has been repeatedly shown to improve cardiovascular mortality and reduce the decline in glomerular filtration rate. Renin-angiotensin-aldosterone system (RAAS) blockade in normotensive diabetic patients with normoalbuminuria or microalbuminuria cannot be advocated at present. Dual RAAS inhibition with ACE inhibitors plus ARBs or ACE inhibitors plus direct renin inhibitors has failed to improve cardiovascular or renal outcomes but has predisposed patients to serious adverse events.
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Affiliation(s)
- Kelly Mercier
- Botsford Hospital, 28050 Grand River Avenue, Farmington Hills, MI 48336, USA
| | - Holly Smith
- Garden City Hospital, 6245 N. Inkster Road, Garden City, MI 48135, USA
| | - Jason Biederman
- Garden City Hospital, 6245 N. Inkster Road, Garden City, MI 48135, USA; Hypertension Nephrology Associates, PC, 18302 Middlebelt Road, Livonia, MI 48152, USA.
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Rossi GP, Maiolino G. Mineralocorticoid receptor antagonism as an add-on treatment for resistant hypertension. Hypertens Res 2014; 37:1029-31. [PMID: 25231253 DOI: 10.1038/hr.2014.139] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Gian Paolo Rossi
- Department of Medicine-DIMED, University of Padua, Padova, Italy
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Burnier M, Wuerzner G. Ambulatory Blood Pressure and Adherence Monitoring: Diagnosing Pseudoresistant Hypertension. Semin Nephrol 2014; 34:498-505. [DOI: 10.1016/j.semnephrol.2014.08.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Effect of aldosterone antagonists on blood pressure in patients with resistant hypertension: a meta-analysis. J Hum Hypertens 2014; 29:159-66. [DOI: 10.1038/jhh.2014.64] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2014] [Revised: 06/14/2014] [Accepted: 06/30/2014] [Indexed: 11/09/2022]
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Treatment Strategies to Prevent Renal Damage in Hypertensive Children. Curr Hypertens Rep 2014; 16:423. [PMID: 24522942 PMCID: PMC3960483 DOI: 10.1007/s11906-014-0423-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Hypertension secondary to chronic kidney disease prevails in earlier childhood and obesity-related primary hypertension in adolescence. Both are associated with a high risk of renal and cardiovascular morbidity. In children with chronic kidney disease, uncontrolled hypertension may accelerate progression to end-stage renal disease before adulthood is reached and increase a child’s risk of cardiac death a thousand-fold. Obesity-related hypertension is a slow and silent killer, and though early markers of renal damage are recognized during childhood, end-stage renal disease is a risk in later life. Renal damage will be a formidable multiplier of cardiovascular risk for adults in whom obesity and hypertension tracks from childhood. Management options to prevent renal damage will vary for these different target groups. This review provides a summary of the available renoprotective strategies in order to aid physicians involved in the care of this challenging group of children.
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Armario P, Oliveras A, de la Sierra A. Resistant hypertension. Rev Clin Esp 2013. [DOI: 10.1016/j.rceng.2013.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Armario P, Oliveras A, de la Sierra A. Hipertensión arterial resistente. Rev Clin Esp 2013; 213:388-93. [DOI: 10.1016/j.rce.2013.05.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2013] [Accepted: 05/09/2013] [Indexed: 11/25/2022]
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Can we use mineralocorticoid receptor blockade in diabetic patients with resistant hypertension? Yes we can! But it may be a double-edged sword. J Hypertens 2013; 31:1948-51. [DOI: 10.1097/hjh.0b013e328364bcdf] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Oliveras A, de la Sierra A. Resistant hypertension: patient characteristics, risk factors, co-morbidities and outcomes. J Hum Hypertens 2013; 28:213-7. [PMID: 23985879 DOI: 10.1038/jhh.2013.77] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2013] [Accepted: 07/17/2013] [Indexed: 11/09/2022]
Abstract
Among the vast population of hypertensive subjects, between 10 and 15% do not achieve an adequate blood pressure (BP) control despite the use of at least three antihypertensive agents. This group, designated as having resistant hypertension (RH), represents one of the most important clinical challenges in hypertension evaluation and management. Resistant hypertensives are characterized by several clinical particularities, such as a longer history of hypertension, obesity and other accompanying factors, such as diabetes, left ventricular hypertrophy, albuminuria and renal dysfunction. In addition to other diagnostic and therapeutic maneuvers, such as excluding secondary hypertension, ensuring treatment adherence and optimizing therapeutic schemes, ambulatory BP monitoring (ABPM) is crucial in the clinical evaluation of patients with RH. ABPM distinguish between those with out-of-office BP elevation (true resistant hypertensives) and those having white-coat RH (WCRH; normalcy of 24-h BPs), the prevalence of the latter estimated in about one-third of the population with RH. True resistant hypertensives also exhibit more frequently other co-morbidities, more severe target organ damage and a worse cardiovascular prognosis, in comparison to those with WCRH. Some device-based therapies have recently been developed for treatment of RH. This requires a better characterization of a potential candidate population. A better knowledge of the clinical features of resistant hypertensive subjects, the confirmation of elevated BP values out of the doctor's office, and improvements in the search for secondary causes would help to select those candidates for newer therapies, once the pharmacological possibilities have been exhausted.
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Affiliation(s)
- A Oliveras
- Department of Nephrology, Hospital del Mar, Barcelona, Spain
| | - A de la Sierra
- Department of Internal Medicine, Hospital Mutua Terrassa, University of Barcelona, Terrassa, Spain
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Yoshitomi Y, Kawanishi KI, Yamaguchi A, Sakurai SI, Minai K, Ishii T, Tarutani Y, Tsujibayashi T, Kaneki M, Saitou Y, Suwa S. Effectiveness of the direct renin inhibitor, aliskiren, in patients with resistant hypertension. Int Heart J 2013; 54:88-92. [PMID: 23676368 DOI: 10.1536/ihj.54.88] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Currently there is no consensus regarding which add-on therapy to use in resistant hypertension. We have conducted an open observational study of the use of aliskiren in resistant hypertensive patients. Forty-three patients with resistant hypertension were included in the study. The inclusion criteria were as follows: 1) office blood pressure (BP) > 140/90 mmHg despite treatment with at least three or more antihypertensive drugs; 2) no prior therapy with aliskiren; and 3) no renal insufficiency. Follow-up BP was determined at 1 and 3 months. Baseline BP was 153 ± 12/79 ± 12 mmHg. After 3 months, systolic BP (SBP) and diastolic BP (DBP) dropped significantly: 140 ± 19/73 ± 13 mmHg (P < 0.0001). Twenty-one patients (49%) had an office BP < 140/90 mmHg, and these patients were assigned to the good BP control group. Another 22 were placed into the poor BP control group. BP reductions from baseline in the good BP control group (SBP/ DBP: 19 ± 11/8 ± 7 mmHg) were larger than those in the poor BP control group (5 ± 15/3 ± 9 mmHg, P < 0.05). Mean BP (MBP) values at baseline, 1, and 3 months were higher in the poor BP control group. There was no significant difference in pulse pressure at baseline between the 2 groups. In multivariate analysis, only MBP at baseline correlated with lack of BP control. Aliskiren administration to resistant hypertensive patients was effective in reducing BP. The present findings suggest aliskiren may be useful as a fourth-line or fifth-line treatment added to other drugs in the treatment of resistant hypertension.
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Jansen PM, Frenkel WJ, van den Born BJH, de Bruijne ELE, Deinum J, Kerstens MN, Arnoldus JHA, Woittiez AJ, Wijbenga JAM, Zietse R, Danser AHJ, van den Meiracker AH. Determinants of blood pressure reduction by eplerenone in uncontrolled hypertension. J Hypertens 2013; 31:404-13. [PMID: 23249826 DOI: 10.1097/hjh.0b013e32835b71d6] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Add-on therapy with aldosterone receptor antagonists has been reported to lower blood pressure (BP) in patients with uncontrolled hypertension. We assessed potential predictors of this response. METHODS In essential hypertensive patients with uncontrolled BP, despite the use of at least two antihypertensives, plasma renin and aldosterone concentrations and the transtubular potassium gradient (TTKG) were measured. Patients were treated with eplerenone 50 mg daily on top of their own medication. The office and ambulatory BP response and biochemical changes were evaluated after 1 week and 3 months of treatment and 6 weeks after discontinuation. Potential predictors for the change in 24-h ambulatory BP were tested in a multivariate regression model. RESULTS One hundred and seventeen patients with a mean age of 50.5 ± 6.6 years were included. Office BP decreased from 149/91 to 142/87 mmHg (P < 0.001) and ambulatory BP from 141/87 to 132/83 mmHg after 3 months of treatment (P < 0.001). Six weeks after discontinuation of eplerenone, office and ambulatory BP measurements returned to baseline values. Treatment resulted in a small rise in serum potassium and creatinine, and a small decrease in the TTKG. In a multivariate model, neither renin, aldosterone, or their ratio, nor the TTKG predicted the BP response. Only baseline ambulatory SBP predicted the BP response, whereas the presence of left ventricular hypertrophy was associated with a smaller BP reduction. CONCLUSION Add-on therapy with eplerenone effectively lowers BP in patients with difficult-to-treat primary hypertension. This effect is unrelated to circulating renin-angiotensin-aldosterone system activity and renal mineralocorticoid receptor activity as assessed by the TTKG.
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Affiliation(s)
- Pieter M Jansen
- Department of Internal Medicine, Erasmus Medical Centre, Rotterdam, The Netherlands
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Guichard JL, Clark D, Calhoun DA, Ahmed MI. Aldosterone receptor antagonists: current perspectives and therapies. Vasc Health Risk Manag 2013; 9:321-31. [PMID: 23836977 PMCID: PMC3699348 DOI: 10.2147/vhrm.s33759] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Aldosterone is a downstream effector of angiotensin II in the renin-angiotensin-aldosterone system and binds to the mineralocorticoid receptor. The classical view of aldosterone primarily acting at the level of the kidneys to regulate plasma potassium and intravascular volume status is being supplemented by evidence of new "off-target" effects of aldosterone in other organ systems. The genomic effects of aldosterone are well known, but there is also evidence for non-genomic effects and these recently identified effects of aldosterone have required a revision in the traditional view of aldosterone's role in human health and disease. The aim of this article is to review the biological action of aldosterone and the mineralocorticoid receptor leading to subsequent physiologic and pathophysiologic effects involving the vasculature, central nervous system, heart, and kidneys. Furthermore, we outline current evidence evaluating the use of mineralocorticoid receptor antagonists in the treatment of primary aldosteronism, primary hypertension, resistant hypertension, obstructive sleep apnea, heart failure, and chronic kidney disease.
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Affiliation(s)
- Jason L Guichard
- University of Alabama at Birmingham, Department of Medicine, Division of Cardiovascular Disease, Birmingham, AL 35294-2041 , USA
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Abstract
Obesity is a global pandemic and with its rise, its associated co-morbidities are increasing in prevalence, particularly uncontrolled hypertension. Lifestyle changes should be an anchor for the management of obesity-related hypertension; however, they are difficult to sustain. Drug therapy is often necessary to achieve blood pressure control. Diuretics, inhibitors of the renin-angiotensin system, and dihydropyridine calcium channel blockers are often used as first trio, with subsequent additions of mineralocorticoid receptor antagonists and/or dual alpha/beta blocking agents. While a number of agents are currently available, 50 % of hypertensive patients remain uncontrolled. A number of novel drug and invasive therapies are in development and hold significant potential for the effective management of obesity-related hypertension.
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Smith SM. Epidemiology, Prognosis, and Treatment of Resistant Hypertension. Pharmacotherapy 2013; 33:1071-86. [DOI: 10.1002/phar.1297] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Affiliation(s)
- Steven M. Smith
- Department of Clinical Pharmacy; Skaggs School of Pharmacy and Pharmaceutical Sciences; University of Colorado; Aurora Colorado
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Vaclavik J, Sedlak R, Jarkovsky J, Kocianova E, Taborsky M. The effect of spironolactone in patients with resistant arterial hypertension in relation to baseline blood pressure and secondary causes of hypertension. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2013; 157:50-5. [DOI: 10.5507/bp.2012.078] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2012] [Indexed: 11/23/2022] Open
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Sequential nephron blockade versus sequential renin-angiotensin system blockade in resistant hypertension: a prospective, randomized, open blinded endpoint study. J Hypertens 2013; 30:1656-64. [PMID: 22728905 DOI: 10.1097/hjh.0b013e3283551e98] [Citation(s) in RCA: 100] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To compare two drug regimens to treat resistant hypertension. METHODS In a prospective, randomized, open blinded endpoint study, 167 patients with mean baseline daytime ambulatory blood pressure 135 mmHg or more and/or 85 mmHg or more, despite 4 weeks' treatment with irbesartan 300 mg/day, hydrochlorothiazide 12.5 mg/day and amlodipine 5 mg/day, were randomized to sequential nephron blockade (group 1, n = 85) or sequential renin-angiotensin system blockade (group 2, n = 82). First, spironolactone 25 mg/day in group 1 or ramipril 5 mg/day in group 2 were added for 4 weeks. Treatment was increased at weeks 4, 8 or 10 if home blood pressure was 135 mmHg or more and/or 85 mmHg or more by sequentially administering furosemide 20 mg/day, furosemide 40 mg/day and amiloride 5 mg/day in group 1, or ramipril 10 mg/day, bisoprolol 5 mg/day and bisoprolol 10 mg/day in group 2. The primary endpoint was change in systolic daytime ambulatory blood pressure at week 12. RESULTS At week 12, the mean between-group difference in daytime ambulatory blood pressure was 10/4 mmHg (95% confidence interval: 7-14/2-7; P < 0.001/P = 0.0014) in favour of the group 1. The blood pressure goal (daytime ambulatory blood pressure <135/85 mmHg) was achieved in 58% in the group 1 and 20% in the group 2 (P < 0.0001). Discontinuation for drug-related adverse events was low (group 1, n = 7; group 2, n = 6). CONCLUSION In patients with resistant hypertension, sequential nephron blockade induces a large and well tolerated reduction in blood pressure via a progressive increase in sodium depletion, and is more effective than sequential renin-angiotensin system blockade.
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Effect of spironolactone in patients with resistant arterial hypertension in relation to age and sex: insights from the aspirant trial. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2012; 158:384-90. [PMID: 23235719 DOI: 10.5507/bp.2012.105] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2012] [Accepted: 11/27/2012] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND There are currently limited data on whether the effect of spironolactone in patients with resistant arterial hypertension depends on age and sex. METHODS Patients with an office systolic blood pressure (BP)>140 mmHg or diastolic BP>90 mmHg, despite treatment with at least 3 antihypertensive drugs including a diuretic, were randomly assigned to receive spironolactone or a placebo for 8 weeks in a double-blind, placebo-controlled, multicentre trial (ASPIRANT). RESULTS Analyses were done on 55 patients treated with spironolactone and 56 patients treated with placebo. Significant reductions of office systolic BP (-8.9±6.7 mmHg, P=0.012), 24-h ABPM systolic BP (-7.9±7.2 mmHg, P=0.032) and ABPM day-time systolic BP (-7.5±7.1 mmHg) after 8 weeks of spironolactone treatment, compared to placebo, were only observed in patients with a median age>62 years. The office and ABPM systolic BP reductions in patients aged ≤62 years and diastolic BP reductions by spironolactone in both age groups were not significant compared to placebo. Women tended to have a nonsignificantly higher reduction in systolic BP with spironolactone treatment, and there was no difference in diastolic BP reduction between women and men. CONCLUSIONS Spironolactone only leads to a reduction of systolic BP in older patients with resistant arterial hypertension aged >62 years, and is effective to a similar extent in men and women.
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Abstract
Resistant hypertension affects an estimated 10-15 million American adults and is increasing in prevalence. The etiology of resistant hypertension is almost always multifactorial, including obesity, older age, high dietary salt, chronic kidney disease, and aldosterone excess. Classical primary aldosteronism and lesser degrees of aldosterone excess, possibly originating from visceral adipocytes, contribute broadly to antihypertensive treatment resistance. Treatment of resistant hypertension is predicated on appropriate lifestyle changes and use of effective combinations of antihypertensive agents from different classes. Blockade of aldosterone with spironolactone has been shown to be particularly effective for treatment of resistant hypertension. The antihypertensive benefit of spironolactone is not limited to patients with demonstrable hyperaldosteronism but instead can be effective in resistant hypertensive patients regardless of aldosterone levels. Chlorthalidone is a potent, long-acting thiazide-like diuretic and should be used preferentially to treat resistant hypertension as it is superior to normally used doses of hydrochlorothiazide.
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Affiliation(s)
- David A Calhoun
- Vascular Biology and Hypertension Program, Sleep Disorders Clinic, University of Alabama at Birmingham, Birmingham, Alabama 35294-2180, USA.
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Paiva L, Cachulo MC, Providencia R, Barra S, Dinis P, Leitao-Marques A. Overview of resistant hypertension: A glimpse of the cardiologist's current standpoint. World J Cardiol 2012; 4:275-83. [PMID: 23024839 PMCID: PMC3460222 DOI: 10.4330/wjc.v4.i9.275] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2012] [Revised: 08/21/2012] [Accepted: 08/28/2012] [Indexed: 02/06/2023] Open
Abstract
Hypertension is a major risk factor for cardiovascular disease, resulting in increased incidence of cerebrovascular events, ischaemic heart disease, heart failure, and renal impairment. Thus, it is one of the most important preventable causes of premature morbidity and mortality. Despite current knowledge on the management of hypertension and the availability of several effective antihypertensive medications, uncontrolled hypertension remains a common and challenging clinical problem. Resistant hypertension is a complex condition with multiple contributing factors and overlapping comorbidities. Although there is limited hard evidence regarding resistant hypertension, our understanding of this condition has improved recently. This article will present an overview of resistant hypertension and highlight recent publications about this topic.
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Affiliation(s)
- Luis Paiva
- Luis Paiva, Maria Carmo Cachulo, Rui Providencia, Sergio Barra, Paulo Dinis, Antonio Leitao-Marques, Cardiology Department, Coimbra's Hospital and University Centre, 3041-801 Coimbra, Portugal
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Management of hypertension after kidney transplantation: a possible role for spironolactone? J Hypertens 2012; 30:830-1; author reply 831-2. [PMID: 22418913 DOI: 10.1097/hjh.0b013e328350e5c7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Ferdinand KC, Nasser SA. Improved Understanding and Innovative Approaches for an Aging Dilemma: Resistant Hypertension in Women with Existing Vascular Disease. CURRENT CARDIOVASCULAR RISK REPORTS 2012. [DOI: 10.1007/s12170-012-0252-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Clark D, Guichard JL, Calhoun DA, Ahmed MI. Recent advancements in the treatment of resistant hypertension. Postgrad Med 2012; 124:67-73. [PMID: 22314116 DOI: 10.3810/pgm.2012.01.2519] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The 2008 scientific statement from the American Heart Association defined resistant hypertension as blood pressure remaining above goal (< 140/90 mm Hg for the general population and < 130/80 mm Hg for patients with diabetes or renal disease) despite the concurrent use of optimal doses of 3 antihypertensive agents of different classes, ideally including a diuretic. Since then, there has been increasing recognition and characterization of patients with resistant hypertension and development of treatment strategies to treat this high-risk population. The role of aldosterone in resistant hypertension has gained increasing recognition. In particular, there has been development of a strong body of evidence for the use of spironolactone as a highly effective antihypertensive agent. Furthermore, there is increasing evidence to link aldosterone with both resistant hypertension and obstructive sleep apnea, with preliminary studies suggesting that aldosterone antagonists may potentially be effective in treating both conditions. Finally, recent work has directed increased attention toward novel invasive strategies for the treatment of resistant hypertension, specifically baroreflex activation therapy with carotid stimulation and percutaneous renal artery denervation. Initial randomized controlled trials have shown that both of these methods may be used to safely lower blood pressure, thereby providing exciting and promising new tools in the armamentarium of options to treat resistant hypertension.
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Affiliation(s)
- Donald Clark
- Department of Medicine, Division of Cardiovascular Disease, Vascular Biology and Hypertension Program, University of Alabama at Birmingham, Birmingham, AL 35294-2041, USA
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Resistant hypertension and aldosterone: an update. Can J Cardiol 2012; 28:318-25. [PMID: 22521297 DOI: 10.1016/j.cjca.2012.03.010] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2011] [Revised: 03/16/2012] [Accepted: 03/18/2012] [Indexed: 11/21/2022] Open
Abstract
Resistant hypertension (RHTN) is defined as a blood pressure remaining above goal despite the concurrent use of 3 antihypertensive medications of different classes, including, ideally a diuretic. RHTN is an important health problem with a prevalence rate expected to increase as populations become older, more obese, and at higher risk of having diabetes and chronic kidney disease, all of which are important risk factors for development of RHTN. The role of aldosterone has gained increasing recognition as a significant contributor to antihypertensive treatment resistance. In prospective studies, the prevalence of primary aldosteronism (PA) has ranged from 14%-21% in patients with RHTN, which is considerably higher than in the general hypertensive population. Furthermore, marked antihypertensive effects are seen when mineralocorticoid antagonists are added to the treatment regimen of patients with RHTN, further supporting aldosterone excess as an important cause of RHTN. A close association exists between hyperaldosteronism, RHTN, and obstructive sleep apnea (OSA) based upon recent studies which indicate that OSA is worsened by aldosterone-mediated fluid retention. This interaction is supported by preliminary data which demonstrates improvement in OSA severity after treatment with spironolactone.
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Abstract
Resistant hypertension (RH), defined simply, is blood pressure (BP) requiring the use of four or more antihypertensive agents, whether controlled or uncontrolled. RH is an increasingly common problem in elderly patients and may affect as many as 20% of the hypertensive population. Unfortunately, at least 30% of patients evaluated for RH are actually adequately controlled when more carefully assessed by home BP monitoring or ambulatory BP monitoring, thus representing a white coat effect. It is also essential to exclude pseudoresistance resulting from improper BP recording techniques or failure of the patient to adhere to the prescribed treatment regimen. Concurrent use of drugs that may interfere with prescribed antihypertensive agents, including many over the counter herbal preparations, must also be excluded. The underlying mechanisms principally driving true RH include pathophysiologic abnormalities of aldosterone signaling, sodium and water retention, excessive sympathetic nervous system activity, and obstructive sleep apnea. Appropriate treatment regimens will usually include an inhibitor of the renin-angiotensin-aldosterone system, a calcium channel blocker, and a diuretic. An aldosterone receptor blocker can be instituted at any step, and is very effective as a fourth drug. Beta-blockers can also be integrated into these treatment plans and may be especially helpful when excessive sympathetic nervous system activity is suspected. Novel device therapies that interrupt sympathetic nerve stimulation at the carotid sinus and kidney are under investigation, and may add entirely new directions in the management of RH. What is most important is that treatment regimens should be targeted to specific patient profiles.
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Sica DA. What is the role of aldosterone excess in resistant hypertension and how should it be investigated and treated? Curr Cardiol Rep 2012; 13:520-6. [PMID: 21993610 DOI: 10.1007/s11886-011-0224-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Resistant hypertension has evolved as an important global health care problem. Primary aldosteronism is one of several potentially reversible causes of resistant hypertension. Primary aldosteronism can be effectively treated, when recognized, with a mineralocorticoid receptor antagonist, such as spironolactone and eplerenone. Each of these compounds can reduce blood pressure as monotherapy or when given with a range of other antihypertensive drug classes. These compounds have distinctive pharmacokinetic and pharmacodynamic patterns that require some forethought in their use before they are prescribed. However, as the use of mineralocorticoid-blocking agents has gradually increased, the hazards inherent to use of such drugs has become more apparent. Whereas the endocrine side effects of spironolactone are in most cases little more than a cosmetic annoyance, the potassium-sparing effects of both spironolactone and eplerenone can prove fatal if sufficient degrees of hyperkalemia develop. However, for most patients the risk of developing hyperkalemia in and of itself should not discourage the prudent clinician from bringing these compounds into play. Hyperkalemia should always be considered as a likelihood in any patient receiving one or the other of these medications. As such, steps should be taken to lessen the likelihood of it occurring if therapy is being contemplated with agents in this class.
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Affiliation(s)
- Domenic A Sica
- Medicine and Pharmacology, Clinical Pharmacology and Hypertension, Richmond, USA.
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Segura J, Cerezo C, Garcia-Donaire JA, Schmieder RE, Praga M, de la Sierra A, Ruilope LM. Validation of a therapeutic scheme for the treatment of resistant hypertension. ACTA ACUST UNITED AC 2011; 5:498-504. [DOI: 10.1016/j.jash.2011.08.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2011] [Revised: 08/01/2011] [Accepted: 08/03/2011] [Indexed: 11/24/2022]
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Hanselin MR, Saseen JJ, Allen RR, Marrs JC, Nair KV. Description of antihypertensive use in patients with resistant hypertension prescribed four or more agents. Hypertension 2011; 58:1008-13. [PMID: 22042809 DOI: 10.1161/hypertensionaha.111.180497] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Data describing the use of recommended antihypertensive agents in the resistant hypertension population are limited. Treatment recommendations for resistant hypertension include maximizing diuretic therapy by using chlorthalidone and/or adding an aldosterone antagonist. Additional recommendations include combining antihypertensive agents from different drug classes. This retrospective cohort study describes antihypertensive use in patients with resistant hypertension defined as the concurrent use of ≥4 antihypertensive agents. Claims data from the Medstat MarketScan Commercial Claims and Encounter database were used to identify patients with resistant hypertension based on International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) diagnosis codes and National Drug Codes between May 1, 2008 and June 30, 2009. Of the 5 442 410 patients with hypertension in the database, 140 126 met study criteria. The most frequently prescribed antihypertensive classes were angiotensin-converting enzyme inhibitors and/or angiotensin receptor blockers (96.2%), diuretics (93.2%), calcium channel blockers (83.6%), and β-blockers (80.0%). Only 3.0% and 5.9% of patients were on chlorthalidone or an aldosterone antagonist, respectively. A total of 15.6% of patients were treated with angiotensin-converting enzyme inhibitor plus angiotensin receptor blocker. Our findings demonstrate that frequently prescribed antihypertensive agents for the treatment of resistant hypertension included guideline-recommended first-line agents. However, evidence-based and recommended agents, such as chlorthalidone and aldosterone antagonists, were underused. Moreover, minimally efficacious combinations, such as an angiotensin-converting enzyme inhibitor with an angiotensin receptor blocker, were prescribed at higher rates than evidence-based and recommended agents.
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Affiliation(s)
- Michele R Hanselin
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, 12850 E Montview Blvd, V20-2126, Aurora, CO 80045, USA
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Management of Resistant Hypertension. CURRENT CARDIOVASCULAR RISK REPORTS 2011. [DOI: 10.1007/s12170-011-0194-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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