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Desai D, Nohria A, Sikora M, Anyanwu N, Caplan AS, Garshick M, Shapiro J, Lo Sicco KI. Examining blood pressure changes with spironolactone for alopecia: A retrospective analysis. J Am Acad Dermatol 2024:S0190-9622(24)02749-X. [PMID: 39197494 DOI: 10.1016/j.jaad.2024.07.1523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Revised: 07/02/2024] [Accepted: 07/31/2024] [Indexed: 09/01/2024]
Affiliation(s)
- Deesha Desai
- The Ronald O. Perelman Department of Dermatology, New York University Grossman School of Medicine, New York, New York; University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.
| | - Ambika Nohria
- The Ronald O. Perelman Department of Dermatology, New York University Grossman School of Medicine, New York, New York
| | - Michelle Sikora
- The Ronald O. Perelman Department of Dermatology, New York University Grossman School of Medicine, New York, New York; New York Medical College, Valhalla, New York
| | - Nnaemeka Anyanwu
- The Ronald O. Perelman Department of Dermatology, New York University Grossman School of Medicine, New York, New York
| | - Avrom S Caplan
- The Ronald O. Perelman Department of Dermatology, New York University Grossman School of Medicine, New York, New York
| | - Michael Garshick
- The Ronald O. Perelman Department of Dermatology, New York University Grossman School of Medicine, New York, New York; Leon H. Charney Division of Cardiology, New York University Grossman School of Medicine, New York, New York
| | - Jerry Shapiro
- The Ronald O. Perelman Department of Dermatology, New York University Grossman School of Medicine, New York, New York
| | - Kristen I Lo Sicco
- The Ronald O. Perelman Department of Dermatology, New York University Grossman School of Medicine, New York, New York
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Nardoianni G, Pala B, Scoccia A, Volpe M, Barbato E, Tocci G. Systematic Review Article: New Drug Strategies for Treating Resistant Hypertension-the Importance of a Mechanistic, Personalized Approach. High Blood Press Cardiovasc Prev 2024; 31:99-112. [PMID: 38616212 PMCID: PMC11043106 DOI: 10.1007/s40292-024-00634-4] [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: 02/03/2024] [Accepted: 03/03/2024] [Indexed: 04/16/2024] Open
Abstract
Resistant hypertension (RHT) is characterized by persistently high blood pressure (BP) levels above the widely recommended therapeutic targets of less than 140/90 mmHg office BP, despite life-style measures and optimal medical therapies, including at least three antihypertensive drug classes at maximum tolerated dose (one should be a diuretic). This condition is strongly related to hypertension-mediated organ damage and, mostly, high risk of hospitalization due to hypertension emergencies or acute cardiovascular events. Hypertension guidelines proposed a triple combination therapy based on renin angiotensin system blocking agent, a thiazide or thiazide-like diuretic, and a dihydropyridinic calcium-channel blocker, to almost all patients with RHT, who should also receive either a beta-blocker or a mineralocorticoid receptor antagonist, or both, depending on concomitant conditions and contraindications. Several other drugs may be attempted, when elevated BP levels persist in these RHT patients, although their added efficacy in lowering BP levels on top of optimal medical therapy is uncertain. Also, renal denervation has demonstrated to be a valid therapeutic alternative in RHT patients. More recently, novel drug classes and molecules have been tested in phase 2 randomised controlled clinical trials in patients with RHT on top of optimal medical therapy with at least 2-3 antihypertensive drugs. These novel drugs, which are orally administered and are able to antagonize different pathophysiological pathways, are represented by non-steroid mineralocorticorticoid receptor antagonists, selective aldosterone synthase inhibitors, and dual endothelin receptor antagonists, all of which have proven to reduce seated office and 24-h ambulatory systolic/diastolic BP levels. The main findings of randomized clinical trials performed with these drugs as well as their potential indications for the clinical management of RHT patients are summarised in this systematic review article.
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Affiliation(s)
- Giulia Nardoianni
- Division of Cardiology, Department of Clinical and Molecular Medicine, Faculty of Medicine and Psychology, University of Rome Sapienza, Sant'Andrea Hospital, Rome, Italy
| | - Barbara Pala
- Division of Cardiology, Department of Clinical and Molecular Medicine, Faculty of Medicine and Psychology, University of Rome Sapienza, Sant'Andrea Hospital, Rome, Italy
| | - Alessandra Scoccia
- Division of Cardiology, Department of Clinical and Molecular Medicine, Faculty of Medicine and Psychology, University of Rome Sapienza, Sant'Andrea Hospital, Rome, Italy
| | - Massimo Volpe
- Division of Cardiology, Department of Clinical and Molecular Medicine, Faculty of Medicine and Psychology, University of Rome Sapienza, Sant'Andrea Hospital, Rome, Italy
- IRCCS San Raffaele Pisana, Roma, Italy
| | - Emanuele Barbato
- Division of Cardiology, Department of Clinical and Molecular Medicine, Faculty of Medicine and Psychology, University of Rome Sapienza, Sant'Andrea Hospital, Rome, Italy
| | - Giuliano Tocci
- Division of Cardiology, Department of Clinical and Molecular Medicine, Faculty of Medicine and Psychology, University of Rome Sapienza, Sant'Andrea Hospital, Rome, Italy.
- Division of Cardiology, Faculty of Medicine and Psychology, Hypertension Unit, University of Rome Sapienza, Sant'Andrea Hospital, Rome, Italy.
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Tian Z, Vollmer Barbosa C, Lang H, Bauersachs J, Melk A, Schmidt BMW. Efficacy of pharmacological and interventional treatment for resistant hypertension: a network meta-analysis. Cardiovasc Res 2024; 120:108-119. [PMID: 37890022 DOI: 10.1093/cvr/cvad165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Revised: 07/20/2023] [Accepted: 09/23/2023] [Indexed: 10/29/2023] Open
Abstract
AIMS Resistant hypertension is associated with a high risk of cardiovascular disease, chronic kidney disease, and mortality. Yet, its management is challenging. This study aims to establish the comparative effectiveness of pharmacologic and interventional treatments by conducting a network meta-analysis. METHODS AND RESULTS MEDLINE, Cochrane Register of Controlled Trials, and Web of Science Core Collection were systematically searched in March 2022. Randomized controlled trials comparing treatment options for management of resistant hypertension were included. Outcomes were blood pressure (BP) changes, measured in the office and in 24 h ambulatory BP measurement. We applied a frequentist random effects model to perform a network meta-analysis combining placebo medication and sham procedure as the reference comparator. From 4771 records, 24 studies met the inclusion criteria with 3458 included patients in total. Twelve active treatment alternatives [spironolactone, doxazosin, β-blocker, clonidine, darusentan, guanfacine, various types of renal sympathetic denervation, lifestyle intervention, continuous positive airway pressure, and baroreflex activation therapy (BAT)] were analysed. Among all comparators, spironolactone had the highest ranking probability and was considered the most effective treatment to reduce office systolic blood pressure (sBP) [-13.30 mmHg (-17.89; -8.72); P < 0.0001] and 24 h sBP [-8.46 mmHg (-12.54; -4.38); P < 0.0001] in patients with resistant hypertension. Lifestyle interventions were the most effective non-pharmacological treatment, lowering office sBP by -7.26 mmHg (-13.73; -0.8), whereas BAT lowered office sBP by -7.0 (-18.59; 4.59). Renal denervation lowered office sBP by -5.64 mmHg (-12.95; 1.66) and -3.79 mmHg (-11.39; 3.8) depending on the type of the procedure. CONCLUSION Among all pharmacologic and interventional treatments, spironolactone is the most effective treatment in reducing BP in patients with resistant hypertension. More comparative trials and especially trials with long-term follow-up are needed. In the meanwhile, we have to conclude that a combination of spironolactone and lifestyle modification are the most effective treatments in resistant hypertension.
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Affiliation(s)
- Zhejia Tian
- Department of Nephrology and Hypertension, Hannover Medical School, Carl-Neuberg-Straße 1, Hannover 30625, Germany
| | - Clara Vollmer Barbosa
- Department of Nephrology and Hypertension, Hannover Medical School, Carl-Neuberg-Straße 1, Hannover 30625, Germany
| | - Hannah Lang
- Department of Nephrology and Hypertension, Hannover Medical School, Carl-Neuberg-Straße 1, Hannover 30625, Germany
| | - Johann Bauersachs
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Anette Melk
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hannover, Germany
| | - Bernhard M W Schmidt
- Department of Nephrology and Hypertension, Hannover Medical School, Carl-Neuberg-Straße 1, Hannover 30625, Germany
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Ahmed M, Nudy M, Bussa R, Filippone EJ, Foy AJ. A systematic review and meta-analysis of all sham and placebo controlled trials for resistant hypertension. Eur J Intern Med 2023; 113:83-90. [PMID: 37150718 DOI: 10.1016/j.ejim.2023.04.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 04/12/2023] [Accepted: 04/26/2023] [Indexed: 05/09/2023]
Abstract
INTRODUCTION There is a lack of consensus regarding the best add on therapy for treatment of resistant hypertension (RH). This is likely secondary to a paucity of data on the comparative effectiveness of proposed therapies for RH. METHODS Placebo-controlled and sham-controlled randomized clinical trials testing therapies for the treatment of RH were included in this meta-analysis. Therapies with two or more studies were included as subgroups in this meta-analysis. The primary outcomes being tested were 24-hr systolic blood pressure (SBP) and office SBP. RESULTS Eight studies were identified that tested mineralocorticoid receptor antagonist (MRA) including 1,414 participants. The raw mean difference (RMD) between MRA and placebo control was statistically significant for 24-hour SBP (-10.56 mmHg; 95% confidence interval (CI) -12.82 to -8.30), 24-hour diastolic (DBP) (-5.48 mmHg; 95% CI -8.48 to -2.58), office SBP (-11.97 mmHg; 95% CI -16.41 to -7.54), and office DBP (-4.14 mmHg; 95% CI -5.62 to -2.65). Six studies were identified that tested renal denervation (RD) including 989 participants. The RMD between RD and sham control was not statistically significant for 24-hour SBP (-1.84 mmHg; 95% CI -3.92 to 0.24), 24-hour DBP (-0.66 mmHg; 95% CI -1.85 to 0.54), office SBP (-1.57 mmHg; 95% CI -6.04 to 2.89), and office DBP (-1.49 mmHg; 95% CI -3.52 to 0.55). Four studies were identified that tested endothelin receptor antagonists (ERA) including 1,193 participants. The raw mean difference (RMD) between ERA and placebo control was statistically significant for 24-hr systolic (SBP) (-7.02 mmHg; 95% CI -9.15 to -4.90, 24-hr diastolic (DBP) (-6.22 mmHg; 95% CI -7.61 to -4.82), office SBP (-5.84 mmHg; 95% CI -10.08 to -1.60), and office DBP (-3.73 mmHg; 95% CI -5.87 to -1.59). DISCUSSION MRA lowers BP in patients with RH more than RD, which seems to have little to no effect in RH. ERAs lead to a statistically significant reduction in BP but the confidence in efficacy is limited due to the low number of studies and differences in trial population. Individual factors and their impact on treatment response in RH should be investigated in future research.
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Affiliation(s)
- Mohammad Ahmed
- Penn State Hershey Medical Center, Department of Internal Medicine, United States
| | - Matthew Nudy
- Penn State Hershey Medical Center, Heart and Vascular Institute, Division of Cardiology, United States
| | - Rahul Bussa
- Penn State Hershey Medical Center, Department of Internal Medicine, United States
| | - Edward J Filippone
- Thomas Jefferson University Hospitals, Division of Nephrology, United States
| | - Andrew J Foy
- Penn State Hershey Medical Center, Heart and Vascular Institute, Division of Cardiology, United States.
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Galceran I, Vázquez S, Crespo M, Pascual J, Oliveras A. Hypertensive mediated organ damage evolution in resistant hypertension patients after adding spironolactone. Nefrologia 2023; 43:309-315. [PMID: 36564229 DOI: 10.1016/j.nefroe.2022.12.002] [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: 03/05/2021] [Accepted: 12/28/2021] [Indexed: 06/17/2023] Open
Abstract
INTRODUCTION Resistant hypertension (RH) represents an important multi-organic impact and increases the morbi-mortality. We aimed to evaluate the evolution of hypertensive mediated organ damage in patients with RH after adding spironolactone. MATERIAL AND METHODS Retrospective study of 58 patients with RH who started spironolactone (12.5-25mg daily). Office blood pressure, 24-h ambulatory blood pressure monitoring (24h-ABPM), urine albumin-to-creatinine ratio and echocardiographic parameters were analyzed prior to initiation of spironolactone and after 12 months of treatment. RESULTS Thirty-six percent of patients were women and mean age was 67.3±10.1 years. We observed a decrease in urine albumin-to-creatinine ratio (median [RIQ25-75]) of 27.0 (7.5-255.4) to 11.3 (3.1-37.8)mg/g, p=0.009. This was more relevant in patients with albuminuria grade A2 and A3: 371.2 (139.5-797.4) to 68.4 (26.5-186.5)mg/g, p=0.02. The echocardiographic changes were: posterior wall thickness: -1.0±0.4mm (p<0.001), interventricular septal thickness: -0.6±0.5mm (p=0.01), left ventricular (LV) mass index: -14.7±10.2g/m2 (p=0.006), LV remodeling index: -0.04±0.036 (p=0.03), without statistically significant changes in LV ejection fraction, LV end-diastolic diameter, LV end-systolic diameter, left atrial diameter, relationship between early ventricular filling wave and atrial contraction and LV filling pressure index. Systolic/diastolic office blood pressure decreased -12.5±4.9/-4.9±3.0mmHg, p<0.001. In 24h-ABPM, systolic and diastolic BP had a significant decrease in diurnal and nocturnal periods and 38.1% of patients presented a favorable change in the circadian pattern, p<0.001. CONCLUSIONS Adding spironolactone to patients with RH contributes to improve hypertensive mediated organ damage by reducing albuminuria levels and echocardiographic parameters of hypertensive heart disease.
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Affiliation(s)
- Isabel Galceran
- Servicio de Nefrología, Hospital del Mar, Universitat Autònoma de Barcelona, Barcelona, Spain; Institut Hospital del Mar d' Investigacions Mèdiques, Universitat Autònoma de Barcelona, Barcelona, Spain.
| | - Susana Vázquez
- Servicio de Nefrología, Hospital del Mar, Universitat Autònoma de Barcelona, Barcelona, Spain; Institut Hospital del Mar d' Investigacions Mèdiques, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Marta Crespo
- Servicio de Nefrología, Hospital del Mar, Universitat Autònoma de Barcelona, Barcelona, Spain; Institut Hospital del Mar d' Investigacions Mèdiques, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Julio Pascual
- Servicio de Nefrología, Hospital del Mar, Universitat Autònoma de Barcelona, Barcelona, Spain; Institut Hospital del Mar d' Investigacions Mèdiques, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Anna Oliveras
- Servicio de Nefrología, Hospital del Mar, Universitat Autònoma de Barcelona, Barcelona, Spain; Institut Hospital del Mar d' Investigacions Mèdiques, Universitat Autònoma de Barcelona, Barcelona, Spain
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McNally RJ, Farukh B, Chowienczyk PJ, Faconti L. Effect of diuretics on plasma aldosterone and potassium in primary hypertension: A systematic review and meta-analysis. Br J Clin Pharmacol 2022; 88:1964-1977. [PMID: 34820874 DOI: 10.1111/bcp.15156] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 11/01/2021] [Accepted: 11/13/2021] [Indexed: 12/18/2022] Open
Abstract
AIM By contrast with drugs inhibiting the renin-angiotensin-aldosterone system (RAAS), diuretics stimulate renin release by the kidneys. Although plasma aldosterone (PA) is thought to be mainly regulated by RAAS activity, serum potassium has been shown to be an important factor in animal models and humans. Here we perform a systematic review and meta-analysis of randomised controlled trials (RCT) in hypertension investigating the effects of diuretic therapy on PA and the correlation of change in PA with that of potassium and blood pressure (BP). METHODS Three databases were searched: MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials (CENTRAL). Titles were first screened by title and abstract for relevance before full-text articles were assessed for eligibility according to a predefined inclusion/exclusion criteria. RESULTS A total of 1139 articles were retrieved, of which 42 met the prespecified inclusion/exclusion criteria. The average standardised difference in mean PA was similar for all classes of diuretic: thiazide/thiazide-like 0.299 (95% confidence interval [CI] 0.150, 0.447), loop 0.927 (0.37, 1.49), MRA/potassium-sparing 0.265 (0.173, 0.357) and combination 0.466 (0.137, 0.796), Q = 6.33, P = .097. In subjects untreated with another antihypertensive, there was a significant relationship between change in PA and change in systolic BP but no relationship with the change in potassium. CONCLUSION In RCTs of diuretic therapy in hypertension, there is an increase in PA with all classes of diuretic and no significant between-class heterogeneity. Change in PA is not related with potassium but correlates with the change in BP in subjects untreated with another antihypertensive medication.
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Affiliation(s)
- Ryan J McNally
- Department of Clinical Pharmacology, King's College London British Heart Foundation Centre, London, UK
| | - Bushra Farukh
- Department of Clinical Pharmacology, King's College London British Heart Foundation Centre, London, UK
| | - Philip J Chowienczyk
- Department of Clinical Pharmacology, King's College London British Heart Foundation Centre, London, UK
| | - Luca Faconti
- Department of Clinical Pharmacology, King's College London British Heart Foundation Centre, London, UK
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Rethinking Resistant Hypertension. J Clin Med 2022; 11:jcm11051455. [PMID: 35268545 PMCID: PMC8911440 DOI: 10.3390/jcm11051455] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 02/18/2022] [Accepted: 02/25/2022] [Indexed: 02/07/2023] Open
Abstract
Resistant hypertension is common and known to be a risk factor for cardiovascular events, including stroke, myocardial infarction, heart failure, and cardiovascular mortality, as well as adverse renal events, including chronic kidney disease and end-stage kidney disease. This review will discuss the definition of resistant hypertension as well as the most recent evidence regarding its diagnosis, evaluation, and management. The issue of medication non-adherence and its association with apparent treatment-resistant hypertension will be addressed. Non-pharmacological interventions for the treatment of resistant hypertension will be reviewed. Particular emphasis will be placed on pharmacological interventions, highlighting the role of mineralocorticoid receptor antagonists and sodium-glucose cotransporter-2 inhibitors and device therapy, including renal denervation, baroreceptor activation or modulation, and central arteriovenous fistula creation.
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Zekarias K, Tessier KM. Screening Rate for Primary Aldosteronism Among Patients With Apparent Treatment-Resistant Hypertension: Retrospective Analysis of Current Practice. Endocr Pract 2022; 28:271-275. [PMID: 34843971 PMCID: PMC8901447 DOI: 10.1016/j.eprac.2021.11.085] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 11/17/2021] [Accepted: 11/22/2021] [Indexed: 01/13/2023]
Abstract
OBJECTIVE Primary aldosteronism (PA) is the most common secondary cause of hypertension. Patients with PA experience significant cardiovascular and other complications compared with patients with primary hypertension with the same degree of blood pressure control as those with PA. Guidelines have recommended screening all patients with resistant hypertension for PA. The objective of this study was to assess the screening rate for PA among patients with apparent treatment-resistant hypertension and determine the rate of positive screening test result among the group screened. METHODS This was a retrospective chart review of electronic medical record data of all patients with hypertension aged ≥18 years within a single health system in Minnesota from September 2018 to September 2020. RESULTS Of 140 734 patients who were aged ≥18 years and had a diagnosis of hypertension, 18 908 (13.4%) met the criteria for apparent treatment-resistant hypertension after those with congestive heart failure were excluded. Only 795 (4.2%) patients with apparent treatment-resistant hypertension underwent screening for PA in our cohort. Of the 795 patients who underwent screening for PA, 134 (16.9%) had a positive screening test result. CONCLUSION The screening rate for PA among patients with resistant hypertension was low. Clinical and public health strategies directed at improving the screening rate for PA are vital.
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Affiliation(s)
- Kidmealem Zekarias
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota.
| | - Katelyn M Tessier
- Masonic Cancer Center, Biostatistics Core, University of Minnesota, Minneapolis, Minnesota
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Evolución de la lesión orgánica mediada por hipertensión en pacientes con hipertensión arterial resistente tras añadir espironolactona. Nefrologia 2022. [DOI: 10.1016/j.nefro.2021.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Kario K, Williams B. Nocturnal Hypertension and Heart Failure: Mechanisms, Evidence, and New Treatments. Hypertension 2021; 78:564-577. [PMID: 34225469 DOI: 10.1161/hypertensionaha.121.17440] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Heart failure (HF) is a common condition with an increasing prevalence. Despite a variety of evidence-based treatments for patients with HF with reduced ejection fraction, morbidity and mortality rates remain high. Furthermore, there are currently no treatments that have yet been shown to reduce complication and death rates in patients who have HF with preserved ejection fraction. Hypertension is a common comorbidity in patients with HF, contributing to disease development and prognosis. For example, hypertension is closely associated with the development of left ventricular hypertrophy, which an important precursor of HF. In particular, nighttime blood pressure (BP) appears to be an important, modifiable risk factor. Both nighttime BP and an abnormal circadian pattern of nighttime BP dipping have been shown to predict development of HF and the occurrence of cardiovascular events, independent of office BP. Key mechanisms for this association include sodium handling/salt sensitivity and increased sympathetic activation. These pathogenic mechanisms are targeted by several new treatment options, including sodium-glucose cotransporter 2 inhibitors, angiotensin receptor neprilysin inhibitors, mineralocorticoid receptor antagonists, and renal denervation. All of these could form part of antihypertensive strategies designed to control nighttime BP and contribute to the goal of achieving perfect 24-hour BP management. Nevertheless, additional research is needed to determine the effects of reducing nighttime BP and improving the circadian BP profile on the rate of HF, other cardiovascular events, and mortality.
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Affiliation(s)
- Kazuomi Kario
- From the Jichi Medical University School of Medicine, Tochigi, Japan (K.K.)
| | - Bryan Williams
- Institute of Cardiovascular Science, University College London and National Institute for Health Research University College London Biomedical Research Centre, United Kingdom (B.W.)
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Maltseva AS, Tsygankova AE, Gabitova MA, Rodionov AV, Fomin VV. Treatment of Resistant Hypertension in Real Clinical Settings. RATIONAL PHARMACOTHERAPY IN CARDIOLOGY 2021. [DOI: 10.20996/1819-6446-2021-04-03] [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
Background. Current guidelines describe in detail the approaches to the management of patients with resistant hypertension, however, in real clinical settings the number of non-rational and ineffective combinations of antihypertensive drugs used remains high.Aim. To analyze the distribution of different combinations of antihypertensive drugs for the treatment of resistant hypertension and to estimate the proportion of non-rational combinations.Methods. The retrospective analysis includes 117 outpatients with resistant hypertension. Resistant hypertension was defined as blood pressure that remains above goal despite concurrent use of three antihypertensive agents of different classes. Exclusion criteria was secondary hypertension. We defined rational combination as the standard combination (renin-angiotensin system [RAS] blocker + calcium-channel blocker [CCB] + diuretic) plus one of the group of reserve drugs (mineralocorticoid receptors antagonist [MRA], beta-blocker, alpha-blocker, agonist of imidazoline receptors [AIR]). Non-rational were considered combinations in which reserve drugs were used before the appointment of a triple combination of first-line drugs. Moreover, in a subgroup of non-rational therapy, situations were identified where such a combination was justified.Results. The proportion of rational combinations was 58.9%, reasonably non-rational - 15.5%, unreasonably non-rational - 25.6%. Unreasonably non-rational combinations are distributed as follows: non-appointment of CCB - 12%, non-appointment of RAS-blockers - 8%, non-appointment of diuretics - 6%, use of RAS-blockers for hyperkalemia - 6%, administration of MRA without non-potassium-sparing diuretics - 5%, double blockade of RAS - 3%, other combinations - 7%. In addition to first-line drugs, beta-blockers (93.2%), loop diuretics (22.2%), AIR (21.4) were the most prescribable, while the proportion of MRA is only 15.4% of the entire sample.Limitation: some patient's characteristics could be missed in case histories and some of the combinations could be falsely recognized as malpractice since the analysis was conducted retrospectively.Conclusion. The proportion of the non-rational combinations for the treatment of resistant hypertension is high. Among the drugs of the reserve, the frequent use of beta-blockers and moxonidine and the inadequate administration of spironolactone are noteworthy. The problem of treatment strategy choice remains relevant in real clinical practice.
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Affiliation(s)
- A. S. Maltseva
- I.M. Sechenov First Moscow State Medical University (Sechenov University)
| | - A. E. Tsygankova
- I.M. Sechenov First Moscow State Medical University (Sechenov University)
| | - M. A. Gabitova
- I.M. Sechenov First Moscow State Medical University (Sechenov University)
| | - A. V. Rodionov
- I.M. Sechenov First Moscow State Medical University (Sechenov University)
| | - V. V. Fomin
- I.M. Sechenov First Moscow State Medical University (Sechenov University)
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12
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Directly Measured Adherence to Treatment in Chronic Heart Failure: LEVEL-CHF Registry. Am J Med Sci 2021; 361:491-498. [PMID: 33781390 DOI: 10.1016/j.amjms.2020.12.004] [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: 04/10/2020] [Revised: 11/08/2020] [Accepted: 12/04/2020] [Indexed: 11/21/2022]
Abstract
BACKGROUND Currently, most available data on the medication adherence of patients with chronic heart failure are based on indirect methods. We examined the level of adherence to medical therapy using a direct method - serum drug level testing. METHODS We carried out a prospective single-centre registry of patients with chronic heart failure (LEVEL-CHF registry), in whom we analysed serum levels of the medications prescribed for the treatment of heart failure: angiotensin converting enzyme inhibitors, angiotensin receptor blockers, beta-blockers and mineralocorticoid receptor antagonists. We labelled a patient as non-adherent if at least one serum level of a prescribed drug was unmeasurable (below the detection limit). Patients with all tested drugs identifiable in serum were labelled as adherent. We enrolled 274 patients (208 men and 66 women) mean age 62 years. RESULTS 82.5% of patients were adherent and 17.5% non-adherent to prescribed medications. 3.6% were completely non-adherent without any detectable drugs in serum. Patients aged <60 years were more likely to be non-adherent than older patients (OR 2.15). No other clinical or laboratory parameters predicted non-adherence. CONCLUSIONS A significant proportion of outpatients with chronic heart failure were non-adherent to treatment when assessed by a direct method of serum drug level testing. Non-adherence was more likely in younger patients.
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Hunter PG, Chapman FA, Dhaun N. Hypertension: Current trends and future perspectives. Br J Clin Pharmacol 2021; 87:3721-3736. [PMID: 33733505 DOI: 10.1111/bcp.14825] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 02/18/2021] [Accepted: 02/27/2021] [Indexed: 12/18/2022] Open
Abstract
Hypertension is a significant and increasing global health issue. It is a leading cause of cardiovascular disease and premature death worldwide due to its effects on end organs, and through its associations with chronic kidney disease, diabetes mellitus and obesity. Despite current management strategies, many patients do not achieve adequate blood pressure (BP) control. Hypertension-related cardiovascular mortality rates are rising in tandem with the increasing global prevalence of chronic kidney disease, diabetes mellitus and obesity. Improving BP control must therefore be urgently prioritised. Strategies include utilising existing antihypertensive agents more effectively, and using treatments developed for co-existing conditions (such as sodium-glucose cotransporter 2 inhibitors for diabetes mellitus) that offer additional BP-lowering and cardiovascular benefits. Additionally, novel therapeutic agents that target alternative prohypertensive pathways and that offer broader cardiovascular protection are under development, including dual angiotensin receptor-neprilysin inhibitors. Nonpharmacological strategies such as immunotherapy are also being explored. Finally, advancing knowledge of the human genome and molecular modification technology may usher in an exciting new era of personalised medicine, with the potential to revolutionise the management of hypertension.
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Affiliation(s)
- Paul G Hunter
- Department of Renal Medicine, Royal Infirmary of Edinburgh & University/BHF Centre for Cardiovascular Science, The Queen's Medical Research Institute, University of Edinburgh, UK
| | - Fiona A Chapman
- Department of Renal Medicine, Royal Infirmary of Edinburgh & University/BHF Centre for Cardiovascular Science, The Queen's Medical Research Institute, University of Edinburgh, UK
| | - Neeraj Dhaun
- Department of Renal Medicine, Royal Infirmary of Edinburgh & University/BHF Centre for Cardiovascular Science, The Queen's Medical Research Institute, University of Edinburgh, UK
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14
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Rodríguez-Sánchez E, Navarro-García JA, Aceves-Ripoll J, González-Lafuente L, Baldan-Martin M, de la Cuesta F, Alvarez-Llamas G, Barderas MG, Segura J, Ruilope LM, Ruiz-Hurtado G. Prediction of the early response to spironolactone in resistant hypertension by the combination of matrix metalloproteinase-9 activity and arterial stiffness parameters. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2020; 8:68-76. [PMID: 32663251 DOI: 10.1093/ehjcvp/pvaa086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 06/15/2020] [Accepted: 07/08/2020] [Indexed: 11/14/2022]
Abstract
AIMS The aim of present study was to determine whether arterial stiffness assessed with the biochemical parameter active matrix metalloproteinase (MMP)-9 and the clinical parameters pulse pressure (PP) and pulse wave velocity predicts the response to spironolactone in resistant hypertension (RH). METHODS AND RESULTS Ambulatory blood pressure (BP) and active MMP-9 (measured by zymography and ELISA) were measured at baseline, and patients were classified as having pseudo-RH or RH. Patients with RH received spironolactone and the response was determined after 8 weeks by ambulatory BP monitoring: those who achieved BP goals were considered controlled (CRH) and those who did not were considered uncontrolled (UCRH). Plasma active MMP-9 was significantly higher in patients with RH than with pseudo-RH, and correlated with 24-hour systolic BP and PP. Receiver operating characteristic analysis indicated that active MMP-9 could predict the response to spironolactone, and its combination with 24-hour PP and pulse wave velocity significantly improved this prediction. Moreover, plasma of patients with UCRH induced the MMP-9 expression pathway. CONCLUSION We propose active MMP-9 as a useful biomarker to identify patients with RH who will not respond to spironolactone. Combining MMP-9 activity with classical arterial stiffness parameters improves the prediction of the clinical response to spironolactone and might contribute to guide the most appropriate therapeutic decisions for patients with RH.
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Affiliation(s)
- Elena Rodríguez-Sánchez
- Cardiorenal Translational Laboratory, Institute of Research i + 12, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - José Alberto Navarro-García
- Cardiorenal Translational Laboratory, Institute of Research i + 12, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Jennifer Aceves-Ripoll
- Cardiorenal Translational Laboratory, Institute of Research i + 12, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Laura González-Lafuente
- Cardiorenal Translational Laboratory, Institute of Research i + 12, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Montserrat Baldan-Martin
- Department of Vascular Physiopathology, Hospital Nacional de Parapléjicos (HNP), SESCAM, Toledo, Spain
| | - Fernando de la Cuesta
- Department of Vascular Physiopathology, Hospital Nacional de Parapléjicos (HNP), SESCAM, Toledo, Spain
| | - Gloria Alvarez-Llamas
- Departament of Immunology, IIS-Fundación Jimenez Diaz-UAM, Madrid, Spain.,REDINREN, Madrid, Spain
| | - María G Barderas
- Department of Vascular Physiopathology, Hospital Nacional de Parapléjicos (HNP), SESCAM, Toledo, Spain
| | - Julián Segura
- Cardiorenal Translational Laboratory, Institute of Research i + 12, Hospital Universitario 12 de Octubre, Madrid, Spain.,Hypertension Unit, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Luis M Ruilope
- Cardiorenal Translational Laboratory, Institute of Research i + 12, Hospital Universitario 12 de Octubre, Madrid, Spain.,Hypertension Unit, Hospital Universitario 12 de Octubre, Madrid, Spain.,European University of Madrid, Madrid, Spain.,CIBER-CV, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Gema Ruiz-Hurtado
- Cardiorenal Translational Laboratory, Institute of Research i + 12, Hospital Universitario 12 de Octubre, Madrid, Spain.,Hypertension Unit, Hospital Universitario 12 de Octubre, Madrid, Spain.,CIBER-CV, Hospital Universitario 12 de Octubre, Madrid, Spain
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15
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Shuey M, Perkins B, Nian H, Yu C, Luther JM, Brown N. Retrospective cohort study to characterise the blood pressure response to spironolactone in patients with apparent therapy-resistant hypertension using electronic medical record data. BMJ Open 2020; 10:e033100. [PMID: 32461291 PMCID: PMC7259833 DOI: 10.1136/bmjopen-2019-033100] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
OBJECTIVE Identify blood pressure (BP) response to spironolactone in patients with apparent therapy-resistant hypertension (aTRH) using electronic medical records (EMRs) in order to estimate response in a real-world clinical setting. DESIGN Developed an algorithm to determine BP and electrolyte response to spironolactone for use in a retrospective cohort study. SETTING An academic medical centre in Nashville, Tennessee. POPULATION Patients with aTRH prescribed spironolactone. MAIN OUTCOME MEASURES Baseline BP and BP response, determined as the change in mean systolic BP (SBP) and diastolic BP (DBP) following spironolactone initiation. Additional response measures were serum sodium, potassium and creatinine, estimated glomerular filtration rate, haemoglobin A1c (HbA1c), glucose, high-density lipoprotein, low-density lipoprotein and triglycerides. Demographic characteristics included race, age, gender, body mass index (BMI), diabetes mellitus, chronic kidney disease stage 3, ischaemic heart disease and smoking. RESULTS The mean decreases in SBP and DBP were 8.1 and 3.4 mm Hg, consistent with clinical trial data. Using a mean decrease in SBP of 5 mm Hg or in DBP of 2 mm Hg to define 'responders', 30.3% of patients did not respond. In univariable analyses, responders had higher BMI, baseline SBP, DBP, sodium and HbA1c, and lower creatinine. In multivariable analysis, responders were older and had significantly higher BMI and baseline SBP and DBP, and lower potassium. Increases in potassium and creatinine following spironolactone were larger in responders. When BP was evaluated as a continuous variable, decreases in SBP and DBP correlated with baseline BP, decrease in sodium and increases in potassium and creatinine following spironolactone. The decrease in SBP was associated with decreasing glucose in European Americans. CONCLUSIONS We developed an algorithm to assess BP response to a commonly prescribed medication for aTRH using EMRs. Electrolyte changes associated with the BP response to spironolactone are consistent with its mechanism of action of blocking the mineralocorticoid receptor and decreasing epithelial sodium channel activity.
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Affiliation(s)
- Megan Shuey
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Bradley Perkins
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Hui Nian
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Chang Yu
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, United States
| | - James M Luther
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Nancy Brown
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
- Department of Medicine, Yale School of Medicine, New Haven, CT, United States
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16
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Hypertension Canada’s 2020 Evidence Review and Guidelines for the Management of Resistant Hypertension. Can J Cardiol 2020; 36:625-634. [DOI: 10.1016/j.cjca.2020.02.083] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 02/19/2020] [Accepted: 02/19/2020] [Indexed: 11/30/2022] Open
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17
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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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18
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Galceran I, Vázquez S, Durán X, Outón S, Pascual J, Oliveras A. Renal safety outcomes of spironolactone in patients with resistant hypertension. Nefrologia 2020; 40:414-420. [PMID: 31898989 DOI: 10.1016/j.nefro.2019.10.004] [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: 06/05/2019] [Revised: 09/18/2019] [Accepted: 10/20/2019] [Indexed: 10/25/2022] Open
Abstract
INTRODUCTION Resistant hypertension (RH) is a significant health problem with complex management. The aim of this study was to evaluate the risks and benefits of adding spironolactone to treat RH. MATERIAL AND METHODS In total, 216 patients with RH in whom spironolactone (12.5-25mg daily) was added as an antihypertensive were evaluated. One-hundred and twenty-five (125) were analysed retrospectively and 91 prospectively. Blood pressure (BP) and laboratory parameters (serum creatinine [sCrea], estimated glomerular filtration rate [eGFR] and serum potassium [sK]) were analysed at baseline and at 3-6-12 months after introducing spironolactone. RESULTS A change of systolic/diastolic BP (mean±standard deviation) of -10.9±2.7/-4.3±1.6mmHg at 3 months and -13.6±2.8/-6.0±1.6mmHg at 12 months; p<0.001 was observed. These values were confirmed with ambulatory-BP monitoring at 12 months. At 3 months, an increase in sCrea of 0.10±0.04mg/dl, a decrease in eGFR of -5.4±1.9ml/min/1.73m2 and an increase in sK of 0.3±0.1mmol/l; p<0.001 was observed for all cases. These changes were maintained after 12 months. There were no significant differences in changes of BP, sCrea, eGFR and sK between 3 and 12 months. Results of the retrospective and prospective cohorts separately were superimposable. In the prospective cohort, spironolactone was withdrawn in 9 patients (9.9%) because of adverse effects. CONCLUSIONS After 3 months with spironolactone, a decrease in BP associated with a decrease in the eGFR and an increase in sCrea and sK was observed. These changes were maintained at 12 months. Spironolactone is an effective and safe treatment for RH in patients with baseline eGFR ≥30ml/min/1.73m2.
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Affiliation(s)
- Isabel Galceran
- Servicio de Nefrología, Hospital del Mar, Universitat Autònoma de Barcelona, Barcelona, España; Institut Hospital del Mar d' Investigacions Mèdiques, Universitat Autònoma de Barcelona, Barcelona, España.
| | - Susana Vázquez
- Servicio de Nefrología, Hospital del Mar, Universitat Autònoma de Barcelona, Barcelona, España; Institut Hospital del Mar d' Investigacions Mèdiques, Universitat Autònoma de Barcelona, Barcelona, España
| | - Xavier Durán
- Institut Hospital del Mar d' Investigacions Mèdiques, Universitat Autònoma de Barcelona, Barcelona, España
| | - Sara Outón
- Servicio de Nefrología, Hospital del Mar, Universitat Autònoma de Barcelona, Barcelona, España; Institut Hospital del Mar d' Investigacions Mèdiques, Universitat Autònoma de Barcelona, Barcelona, España
| | - Julio Pascual
- Servicio de Nefrología, Hospital del Mar, Universitat Autònoma de Barcelona, Barcelona, España; Institut Hospital del Mar d' Investigacions Mèdiques, Universitat Autònoma de Barcelona, Barcelona, España
| | - Anna Oliveras
- Servicio de Nefrología, Hospital del Mar, Universitat Autònoma de Barcelona, Barcelona, España; Institut Hospital del Mar d' Investigacions Mèdiques, Universitat Autònoma de Barcelona, Barcelona, España
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19
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Podzolkov VI, Bragina AE, Osadchiy KK. Resistant Hypertension: Questions and Contemporary Answers. RATIONAL PHARMACOTHERAPY IN CARDIOLOGY 2019. [DOI: 10.20996/1819-6446-2019-15-4-568-577] [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
The review presents the important problem of resistant hypertension. Its real prevalence is unknown. According to population studies and metaanalyzes of clinical studies, the prevalence of this most severe form of hypertension reaches 12-15% in the general population and 15-18% in clinical cohorts. Over the past decades, an increase in its frequency among patients with hypertension has been noted. Based on the results of large-scale studies, risk factors are detected that allow to assess the risk for the resistance to antihypertensive drugs. Adherence to ongoing antihypertensive therapy is crucial to addressing the issue of hypertension resistance; there are acceptable ways to evaluate it in clinical practice. The review discusses the most common mistakes in the choice of therapy, which can cause resistance to antihypertensive treatment, namely irrational drug combinations, insufficient dosage of the drug, and the use of non-prolonged forms of drugs. The latest recommendations for the diagnosis and treatment of hypertension, including its resistant form, are analyzed. The review contains a rationale based on the results of randomized clinical trials, the choice antihypertensive strategy in this variant of arterial hypertension. The importance of fixed combination antihypertensive drugs, as well as thiazine-like diuretics and amlodipine is stressed. The results of studies demonstrate the rational for the use of antimineralcorticoid drugs, namely spironolactone, for this category of patients. The authors offer an updated algorithm for the diagnosis and treatment of resistant hypertension, based on the sections of the latest clinical recommendations on this problem.
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Affiliation(s)
- V. I. Podzolkov
- I.M. Sechenov First Moscow State Medical University (Sechenov University)
| | - A. E. Bragina
- I.M. Sechenov First Moscow State Medical University (Sechenov University)
| | - K. K. Osadchiy
- I.M. Sechenov First Moscow State Medical University (Sechenov University)
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20
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Effect of mineralocorticoid antagonists on blood pressure lowering: overview and meta-analysis of randomized controlled trials in hypertension. J Hypertens 2019; 36:987-994. [PMID: 29356711 DOI: 10.1097/hjh.0000000000001671] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECTIVES Although mineralocorticoid antagonists (MRAs) have been proposed as effective fourth-line blood pressure (BP)-lowering agents in resistant hypertension, this effect in hypertension at-large is unclear. We evaluated whether MRAs-mediated BP lowering is both effective and safe against controls and whether the extent of BP lowering differs between resistant hypertension and nonresistant hypertension . METHODS We searched Medline and the Cochrane Collaboration Library databases from 1991 to mid-September 2017 for randomized controlled trials (RCTs), in which MRAs were compared with placebo or other active drugs. Main outcomes were SBP and DBP lowering and treatment-related discontinuations. Continuous outcome variables were pooled as mean difference and the categorical variables as risk ratios, both with 95% confidence interval (CI). The risk of bias was assessed by using the Cochrane collaboration tool. RESULTS We included 21 RCTs (2736 patients) of MRAs compared either with placebo or with active agents. Whenever all selected trials were analyzed together (MRAs versus controls), the resulting BP reduction was -7.6 (95% CI -10 to -5.3) mmHg for SBP and -2.5 (95% CI -4.2 to -0.8) mmHg for DBP, while limiting our analysis to MRAs versus placebo mean difference was increased by -2.1/-1.3 mmHg. We find no differential BP lowering between resistant hypertension and non-resistant hypertension. Treatment-related discontinuations were not different compared with either placebo or active comparators. CONCLUSION As the extent of BP lowering following treatment with MRAs in patients with and without resistant hypertension was similar and not accompanied by increased rate of treatment-related discontinuations compared with other active comparators, these agents may have a role in BP lowering in already treated hypertensive patients who did not reach target BP values.
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21
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Different effects of antihypertensive treatment on office and ambulatory blood pressure. J Hypertens 2019; 37:467-475. [DOI: 10.1097/hjh.0000000000001914] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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22
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Abstract
PURPOSE OF REVIEW To review the most recent literature on current strategies for the treatment of hypertension associated with pediatric obesity. RECENT FINDINGS Over the last three decades, childhood and adolescent overweight and obesity prevalence in the USA has continued to rise. Unsurprisingly but rather disturbingly, this rising prevalence has been paralleled by an increase in cardiovascular disease (CVD) risk factors in childhood such as hypertension, dyslipidemia, and diabetes that become manifest earlier than previously reported. These childhood CVD risk factors are not only associated with target organ damage in childhood but also track into adulthood, increasing the risk of long-term CVD morbidity and mortality. There have been several mechanisms proposed to explain the role of obesity on the development of hypertension in childhood. However, central to the management of obesity-related hypertension is a multifaceted approach targeting lifestyle modifications and weight loss. Effective treatment often also requires a pharmacologic approach and rarely bariatric surgery.
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23
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Martin-Lorenzo M, Martinez PJ, Baldan-Martin M, Lopez JA, Minguez P, Santiago-Hernandez A, Vazquez J, Segura J, Ruiz-Hurtado G, Vivanco F, Barderas MG, Ruilope LM, Alvarez-Llamas G. Urine Haptoglobin and Haptoglobin-Related Protein Predict Response to Spironolactone in Patients With Resistant Hypertension. Hypertension 2019; 73:794-802. [PMID: 30712426 DOI: 10.1161/hypertensionaha.118.12242] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Resistant hypertension prevalence is progressively increasing, and prolonged exposure to suboptimal blood pressure control results in higher cardiovascular risk and end-organ damage. Among various antihypertensive agents, spironolactone seems the most effective choice to treat resistant hypertension once triple therapy including a diuretic fails. However success in blood pressure control is not guaranteed, adverse effects are not negligible, and no clinical tools are available to predict patient's response. Complementary to our previous study of resistant hypertension metabolism, here we investigated urinary proteome changes with potential capacity to predict response to spironolactone. Twenty-nine resistant hypertensives were included. A prospective study was conducted and basal urine was collected before spironolactone administration. Patients were classified in responders or nonresponders in terms of blood pressure control. Protein quantitation was performed by liquid chromatography-mass spectrometry; ELISA and target mass spectrometry analysis were performed for confirmation. Among 3310 identified proteins, HP (haptoglobin) and HPR (haptoglobin-related protein) showed the most significant variations, with increased levels in nonresponders compared with responders before drug administration (variation rate, 5.98 and 7.83, respectively). Protein-coordinated responses were also evaluated by functional enrichment analysis, finding oxidative stress, chronic inflammatory response, blood coagulation, complement activation, and regulation of focal adhesions as physiopathological mechanisms in resistant hypertension. In conclusion, protein changes able to predict patients' response to spironolactone in basal urine were here identified for the first time. These data, once further confirmed, will support clinical decisions on patients' management while contributing to optimize the rate of control of resistant hypertensives with spironolactone.
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Affiliation(s)
- Marta Martin-Lorenzo
- From the Laboratory of Immunoallergy and Proteomics, Department of Immunology (M.M.-L., P.J.M., A.S.-H., G.A.-L.), IIS-Fundación Jiménez Díaz-UAM, Madrid, Spain
| | - Paula J Martinez
- From the Laboratory of Immunoallergy and Proteomics, Department of Immunology (M.M.-L., P.J.M., A.S.-H., G.A.-L.), IIS-Fundación Jiménez Díaz-UAM, Madrid, Spain
| | - Montserrat Baldan-Martin
- Department of Vascular Physiopathology, Hospital Nacional de Parapléjicos SESCAM, Toledo, Spain (M.B.-M., M.G.B.)
| | - Juan A Lopez
- Laboratory of Cardiovascular Proteomics CNIC, Madrid, Spain (J.A.L., J.V.)
| | - Pablo Minguez
- Department of Genetics (P.M.), IIS-Fundación Jiménez Díaz-UAM, Madrid, Spain
| | - Aranzazu Santiago-Hernandez
- From the Laboratory of Immunoallergy and Proteomics, Department of Immunology (M.M.-L., P.J.M., A.S.-H., G.A.-L.), IIS-Fundación Jiménez Díaz-UAM, Madrid, Spain
| | - Jesus Vazquez
- Laboratory of Cardiovascular Proteomics CNIC, Madrid, Spain (J.A.L., J.V.)
| | - Julian Segura
- Department of Nephrology, Hypertension Unit, Hospital Universitario 12 de Octubre, Madrid, Spain (J.S., L.M.R.)
| | - Gema Ruiz-Hurtado
- Cardiorenal Translational Laboratory, Instituto de Investigación I+12 Hospital Universitario 12 de Octubre/CIBER-CV, Madrid, Spain (G.R.-H., L.M.R.)
| | - Fernando Vivanco
- Department of Biochemistry and Molecular Biology, I Universidad Complutense, Madrid, Spain (F.V.)
| | - Maria G Barderas
- Department of Vascular Physiopathology, Hospital Nacional de Parapléjicos SESCAM, Toledo, Spain (M.B.-M., M.G.B.)
| | - Luis M Ruilope
- Department of Nephrology, Hypertension Unit, Hospital Universitario 12 de Octubre, Madrid, Spain (J.S., L.M.R.).,Cardiorenal Translational Laboratory, Instituto de Investigación I+12 Hospital Universitario 12 de Octubre/CIBER-CV, Madrid, Spain (G.R.-H., L.M.R.).,School of Doctoral Studies and Research, Universidad Europea de Madrid, Spain (L.M.R.)
| | - Gloria Alvarez-Llamas
- From the Laboratory of Immunoallergy and Proteomics, Department of Immunology (M.M.-L., P.J.M., A.S.-H., G.A.-L.), IIS-Fundación Jiménez Díaz-UAM, Madrid, Spain.,REDINREN, Madrid, Spain (G.A.-L.)
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24
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Abstract
Resistant hypertension (RH) is defined as blood pressure (BP) that remains above target levels despite adherence to at least three different antihypertensive medications, typically including a diuretic. Epidemiological studies estimate that RH is increasing in prevalence, and is associated with detrimental health outcomes. The pathophysiology underlying RH is complex, involving multiple, overlapping contributors including activation of the renin-angiotensin aldosterone system and the sympathetic nervous system, volume overload, endothelial dysfunction, behavioural and lifestyle factors. Hypertension guidelines currently recommend specific pharmacotherapy for 1st, 2nd and 3rd-line treatment, however no specific fourth-line pharmacotherapy is provided for those with RH. Rather, five different antihypertensive drug classes are generally suggested as possible alternatives, including: mineralocorticoid receptor antagonists, α1-adrenergic antagonists, α2-adrenergic agonists, β-blockers, and peripheral vasodilators. Each of these drug classes vary in their efficacy, tolerability and safety profile. This review summarises the available data on each of these drug classes as a potential fourth-line drug and reveals a lack of robust clinical evidence for preferred use of most of these classes in the setting of RH. Moreover, there is a lack of direct comparative trials that could assist in identifying a preferred fourth-line pharmacologic approach and in providing evidence for hypertensive guidelines for adequate treatment of RH.
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25
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Brandani L. Resistant hypertension: a therapeutic challenge. J Clin Hypertens (Greenwich) 2018; 20:76-78. [DOI: 10.1111/jch.13144] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
- Laura Brandani
- Prevention Department; Arterial Hypertension and Metabolic Unit; University Hospital of Favaloro Foundation; Favaloro University; Buenos Aires Argentina
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26
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Oliveras A, Armario P, Sans L, Clarà A, Vázquez S, Molina L, Pareja J, de la Sierra A, Pascual J. Organ damage changes in patients with resistant hypertension randomized to renal denervation or spironolactone: The DENERVHTA (Denervación en Hipertensión Arterial) study. J Clin Hypertens (Greenwich) 2018; 20:69-75. [DOI: 10.1111/jch.13156] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2017] [Revised: 08/02/2017] [Accepted: 08/14/2017] [Indexed: 11/29/2022]
Affiliation(s)
- Anna Oliveras
- Nephrology Department; Hospital del Mar; Barcelona Spain
- IMIM (Hospital del Mar Medical Research Institute); Barcelona Spain
- Universitat Autònoma de Barcelona; Barcelona Spain
| | - Pedro Armario
- Internal Medicine Department; Vascular Risk Area; Hospital Moisés Broggi; Consorci Sanitari Integral; University of Barcelona; Barcelona Spain
| | - Laia Sans
- Nephrology Department; Hospital del Mar; Barcelona Spain
- IMIM (Hospital del Mar Medical Research Institute); Barcelona Spain
| | - Albert Clarà
- IMIM (Hospital del Mar Medical Research Institute); Barcelona Spain
- Universitat Autònoma de Barcelona; Barcelona Spain
- Vascular Surgery Department; Hospital del Mar; Barcelona Spain
| | - Susana Vázquez
- Nephrology Department; Hospital del Mar; Barcelona Spain
- IMIM (Hospital del Mar Medical Research Institute); Barcelona Spain
| | - Luis Molina
- IMIM (Hospital del Mar Medical Research Institute); Barcelona Spain
- Universitat Autònoma de Barcelona; Barcelona Spain
- Cardiology Department; Hospital del Mar; Barcelona Spain
| | - Júlia Pareja
- Internal Medicine Department; Hospital de l'Esperit Sant; Santa Coloma de Gramenet Spain
| | - Alejandro de la Sierra
- Internal Medicine Department; Hospital Mútua Terrassa; University of Barcelona; Barcelona Spain
| | - Julio Pascual
- Nephrology Department; Hospital del Mar; Barcelona Spain
- IMIM (Hospital del Mar Medical Research Institute); Barcelona Spain
- Universitat Autònoma de Barcelona; Barcelona Spain
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27
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Tataru AP, Barry AR. A Systematic Review of Add-on Pharmacologic Therapy in the Treatment of Resistant Hypertension. Am J Cardiovasc Drugs 2017; 17:311-318. [PMID: 28349274 DOI: 10.1007/s40256-017-0224-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION The objective of this systematic review was to evaluate the efficacy and safety of add-on pharmacologic therapies in the treatment of resistant hypertension (RH), defined as blood pressure (BP) above target despite three antihypertensive agents. METHODS A systematic search was performed in MEDLINE, Embase, CENTRAL, CINAHL, ClinicalTrials.gov, and Google Scholar (inception to June 2016) to identify randomized controlled trials (RCTs) that compared any antihypertensive agent with control in patients with RH. Outcomes of interest included differences in BP, cardiovascular events, and serious adverse events. The Cochrane Collaboration's tool for assessing risk of bias in RCTs was used to evaluate the quality of the included trials. RESULTS Six RCTs were identified, including 749 participants. Four RCTs compared spironolactone with placebo and two used an active comparator. Four of the six studies did not report sufficient information regarding methods. A quantitative meta-analysis was not performed because of clinical heterogeneity among the RCTs. Compared with placebo, spironolactone reduced mean office BP by ~10 to 20 mmHg/~3 to 9 mmHg and home BP by ~10/4 mmHg. Compared with doxazosin or bisoprolol, spironolactone reduced clinic and home systolic BP, but not diastolic BP. Hyperkalemia occurred in ~3% of patients receiving spironolactone. Cardiovascular events were not consistently reported. All trials were limited by low enrollment, short follow-up, and inconsistent reporting of clinically meaningful outcomes and/or serious adverse events. CONCLUSIONS Spironolactone has the best evidence as add-on pharmacologic therapy in patients with RH, but data are limited.
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Makai P, IntHout J, Deinum J, Jenniskens K, Wilt GJVD. A Network Meta-Analysis of Clinical Management Strategies for Treatment-Resistant Hypertension: Making Optimal Use of the Evidence. J Gen Intern Med 2017; 32:921-930. [PMID: 28275946 PMCID: PMC5515781 DOI: 10.1007/s11606-017-4000-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2016] [Revised: 12/30/2016] [Accepted: 01/13/2017] [Indexed: 01/21/2023]
Abstract
BACKGROUND With the addition of surgical interventions to current medicinal treatments, it is increasingly challenging for clinicians to rationally choose among the various options for treating patients with apparent treatment-resistant hypertension (ATRHTN). This study aims to establish the comparative effectiveness of mineralocorticoid receptor antagonists (MRA), renal denervation (RDN), darusentan and central arteriovenous anastomosis (CAA) for patients with ATRHTN by performing a network meta-analysis. METHODS Data Sources: Studies from recent meta-analyses for RDN and placebo effect were supplemented with a systematic search for MRAs in ATRHTN in the Pubmed, EMBASE, CINAHL and Cochrane databases through November 2016. STUDY SELECTION Randomized controlled trials comparing treatment options for patients with ATRHTN. DATA EXTRACTION AND SYNTHESIS Data were extracted using predefined data extraction forms, including the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria. A Bayesian random effects model was used to conduct a network meta-analysis. Spironolactone was used as the main comparator. Main Outcomes and Measures: Reduction in 24-h ambulatory blood pressure measurement (ABPM). RESULTS Twenty articles met our inclusion criteria, and seven treatment alternatives were compared. Compared to MRA, CAA had the highest probability of being more effective, further reducing 24-h SBP (-4.8 mmHg [-13.0, 3.7]) and 24-h DBP (-9.7 mmHg [-18, -0.63]). This difference is likely to be clinically meaningful, with a probability of 78 and 96% at a threshold of a 2-mmHg reduction in blood pressure. CONCLUSIONS When compared to MRA as anchor, darusentan, CAA and RDN are not more effective in achieving a clinically significant reduction in ambulatory blood pressure in individuals with apparent treatment-resistant hypertension.
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Affiliation(s)
- Peter Makai
- Department for Health Evidence, Health Technology Assessment Group, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands.
| | - Joanna IntHout
- Department for Health Evidence, Health Technology Assessment Group, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jaap Deinum
- Department for Health Evidence, Health Technology Assessment Group, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Kevin Jenniskens
- Julius Center, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Gert Jan van der Wilt
- Department for Health Evidence, Health Technology Assessment Group, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
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Liu L, Xu B, Ju Y. Addition of spironolactone in patients with resistant hypertension: A meta-analysis of randomized controlled trials. Clin Exp Hypertens 2017; 39:257-263. [DOI: 10.1080/10641963.2016.1246564] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Braam B, Taler SJ, Rahman M, Fillaus JA, Greco BA, Forman JP, Reisin E, Cohen DL, Saklayen MG, Hedayati SS. Recognition and Management of Resistant Hypertension. Clin J Am Soc Nephrol 2017; 12:524-535. [PMID: 27895136 PMCID: PMC5338706 DOI: 10.2215/cjn.06180616] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Despite improvements in hypertension awareness and treatment, 30%-60% of hypertensive patients do not achieve BP targets and subsequently remain at risk for target organ damage. This therapeutic gap is particularly important to nephrologists, who frequently encounter treatment-resistant hypertension in patients with CKD. Data are limited on how best to treat patients with CKD and resistant hypertension, because patients with CKD have historically been excluded from hypertension treatment trials. First, we propose a consistent definition of resistant hypertension as BP levels confirmed by both in-office and out-of-office measurements that exceed appropriate targets while the patient is receiving treatment with at least three antihypertensive medications, including a diuretic, at dosages optimized to provide maximum benefit in the absence of intolerable side effects. Second, we recommend that each patient undergo a standardized, stepwise evaluation to assess adherence to dietary and lifestyle modifications and antihypertensive medications to identify and reduce barriers and discontinue use of substances that may exacerbate hypertension. Patients in whom there is high clinical suspicion should be evaluated for potential secondary causes of hypertension. Evidence-based management of resistant hypertension is discussed with special considerations of the differences in approach to patients with and without CKD, including the specific roles of diuretics and mineralocorticoid receptor antagonists and the current place of emerging therapies, such as renal denervation and baroreceptor stimulation. We endorse use of such a systematic approach to improve recognition and care for this vulnerable patient group that is at high risk for future kidney and cardiovascular events.
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Affiliation(s)
- Branko Braam
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
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Optimizing Cardiovascular Care With Mineralocorticoid Receptor Antagonists. J Nurse Pract 2017. [DOI: 10.1016/j.nurpra.2016.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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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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Dudenbostel T, Calhoun DA. Effects of Spironolactone and Renal Denervation Treatment on Blood Pressure and Its Variability-Different Aspects of Hypertension Treatment. Am J Hypertens 2017; 30:12-15. [PMID: 27838625 DOI: 10.1093/ajh/hpw115] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Tanja Dudenbostel
- Vascular Biology and Hypertension Program, Cardiovascular Disease, Department of Medicine, University of Birmingham at Alabama, Birmingham, Alabama, USA.
| | - David A Calhoun
- Vascular Biology and Hypertension Program, Cardiovascular Disease, Department of Medicine, University of Birmingham at Alabama, Birmingham, Alabama, USA
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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: 37] [Impact Index Per Article: 4.6] [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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Abstract
Treatment resistant hypertension (TRH), defined as a blood pressure above goal despite treatment with optimally tolerated doses of 3 antihypertensive agents of different classes, ideally including a diuretic, remains a significant problem and its management an area of uncertainty for physicians. One hypothesis is that resistant hypertension is due to abnormal sodium retention, mediated by aldosterone breakthrough occurring despite blockade of the renin-angiotensin-aldosterone system with angiotensin converting enzyme inhibitors (ACEi) or angiotensin receptor blockers (ARB). Thus, there has been renewed interest in the use of mineralocorticoid receptor blockers (MRB) to treat this condition. This article critically evaluates new evidence supporting the use of MRB in TRH published in the last 3 years. We conclude that there is now sufficient evidence to recommend MRB, in particular spironolactone, as the first choice medication to treat this condition, and for its inclusion in future guidelines.
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Three drugs and still hypertensive: what's left? CANADIAN FAMILY PHYSICIAN MEDECIN DE FAMILLE CANADIEN 2016; 62:904. [PMID: 28661871 PMCID: PMC9844576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
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Prado JC, Ruilope LM, Segura J. [Benefits of spironolactone as the optimal treatment for drug resistant hypertension. Pathway-2 trial review]. HIPERTENSION Y RIESGO VASCULAR 2016; 33:150-154. [PMID: 27363610 DOI: 10.1016/j.hipert.2016.05.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Revised: 04/25/2016] [Accepted: 05/27/2016] [Indexed: 11/25/2022]
Abstract
Pathway-2 is the first randomised, double-blind and crossover trial that compares spironolactone as a fourth drug with alfa-blocker, beta-blocker and placebo. This study shows that spironolactone is the drug with more possibilities of success for the management of patients with difficult-to-treat hypertension in patients with a combination of three drugs and poor control. The results validate the widespread treatment with mineralocorticoid receptor antagonists in resistant hypertension.
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Affiliation(s)
- J C Prado
- Unidad de Hipertensión, Servicio de Nefrología, Hospital Universitario 12 de Octubre, Madrid, España.
| | - L M Ruilope
- Instituto de Investigación i+12, Hospital Universitario 12 de Octubre, Madrid, España
| | - J Segura
- Unidad de Hipertensión, Servicio de Nefrología, Hospital Universitario 12 de Octubre, Madrid, España
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Hwang AY, Dave C, Smith SM. Trends in Antihypertensive Medication Use Among US Patients With Resistant Hypertension, 2008 to 2014. Hypertension 2016; 68:1349-1354. [PMID: 27777360 DOI: 10.1161/hypertensionaha.116.08128] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Revised: 07/22/2016] [Accepted: 09/01/2016] [Indexed: 01/13/2023]
Abstract
Little is known of US trends in antihypertensive drug use for patients with treatment-resistant hypertension (TRH). We analyzed antihypertensive use among patients with TRH (treated with ≥4 antihypertensive drugs concurrently) from July 2008 through December 2014 using Marketscan administrative data. We included adults aged 18 to 65 years, with ≥6 months of continuous enrollment, a hypertension diagnosis, and ≥1 episode of overlapping use of ≥4 antihypertensive drugs; patients with heart failure were excluded. We identified 411 652 unique TRH episodes from 261 652 patients with a mean age of 55.9 years. From 2008 to 2014, we observed an increased prevalence, among TRH episodes, of β-blockers (+6.8% [79% to 85.8%]) and dihydropyridine calcium antagonists (+8.1% [69.1% to 77.2%]), and a decreased prevalence of angiotensin-converting enzyme inhibitors (-12.5% [60.4% to 47.9%]) and nondihydropyridine calcium antagonists (-5.0% [15% to 10%]). The prevalence of most other classes changed by <5% from 2008 to 2014. Thiazide diuretic use was largely unchanged from 2008 to 2014, with hydrochlorothiazide being by far the most prevalent thiazide diuretic; chlorthalidone use increased only modestly (+2.6% [3.8% to 6.4%]). Aldosterone antagonist use increased only modestly (+2.9% [7.3% to 10.2%]). Use of optimal regimens increased steadily (+13.8% [50.8% to 64.6%]) during the study period, whereas combined angiotensin-converting enzyme inhibitor/angiotensin receptor blocker use declined (-11.4% [17.7% to 6.3%]). Our results highlight the persistent infrequent use of recommended therapies in TRH, including spironolactone and chlorthalidone, and suggest a need for better efforts to increase the use of such approaches in light of recent evidence demonstrating their efficacy.
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Affiliation(s)
- Andrew Y Hwang
- From the Department of Pharmacotherapy and Translational Research (A.Y.H., S.M.S.) and Department of Pharmaceutical Outcomes and Policy (C.D.), College of Pharmacy, and Department of Community Health and Family Medicine, College of Medicine (A.Y.H., S.M.S.), University of Florida, Gainesville
| | - Chintan Dave
- From the Department of Pharmacotherapy and Translational Research (A.Y.H., S.M.S.) and Department of Pharmaceutical Outcomes and Policy (C.D.), College of Pharmacy, and Department of Community Health and Family Medicine, College of Medicine (A.Y.H., S.M.S.), University of Florida, Gainesville
| | - Steven M Smith
- From the Department of Pharmacotherapy and Translational Research (A.Y.H., S.M.S.) and Department of Pharmaceutical Outcomes and Policy (C.D.), College of Pharmacy, and Department of Community Health and Family Medicine, College of Medicine (A.Y.H., S.M.S.), University of Florida, Gainesville.
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Prevalencia y características de los pacientes con hipertensión arterial resistente y enfermedad renal crónica. Nefrologia 2016; 36:523-529. [DOI: 10.1016/j.nefro.2016.04.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2015] [Revised: 02/29/2016] [Accepted: 04/29/2016] [Indexed: 11/20/2022] Open
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Association between long-term prescription of aldosterone antagonist and the progression of heart failure with preserved ejection fraction in hypertensive patients. Int J Cardiol 2016; 220:56-60. [PMID: 27372043 DOI: 10.1016/j.ijcard.2016.06.190] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Accepted: 06/24/2016] [Indexed: 01/01/2023]
Abstract
BACKGROUND Hypertension complicated with left ventricular hypertrophy (LVH) and diastolic dysfunction is independently related to increasing risk of subsequent incident heart failure with preserved ejection fraction (HFpEF). This study was designed to evaluate the influences of long-term aldosterone antagonist prescription in these patients. METHODS Using a propensity score matching of 1:2 ratio, this retrospective claims database study compared spironolactone prescription (n=65) and non-spironolactone therapy (n=130) in hypertensive patients with LVH [left ventricular mass index (LVMI)>125g/m(2) for men and >110g/m(2) for women] and suspected diastolic dysfunction (E/E' ratio between 8 and 15) and without clinical signs or symptoms of heart failure. RESULTS With a median follow-up of 7.4years, the new-onset symptomatic HFpEF occurred in 3 of 65 patients in the spironolactone group and 21 of 130 patients in the non-spironolactone group (P=0.021). Spironolactone also generated more prominent improvement in diastolic function and LVH. And multivariate logistic regression model revealed that spironolactone prescription (OR 0.177, 95% CI: 0.045-0.687, P=0.012) was associated with a reduced risk of new onset of symptomatic HFpEF, and the elevation of LVMI (OR 1.053, 95% CI: 1.011-1.097, P=0.012) or E/E' (OR 1.280, 95% CI: 1.015-1.615, P=0.037) was associated with a high risk of new onset of symptomatic HFpEF. CONCLUSIONS Long-term aldosterone antagonist exposure was associated with protective effects in terms of the incidence of new-onset symptomatic HFpEF, LV diastolic dysfunction and LVH in hypertensive patients, which might be beneficial for the delay of HFpEF progression.
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Ghazi L, Dudenbostel T, Lin CP, Oparil S, Calhoun DA. Urinary sodium excretion predicts blood pressure response to spironolactone in patients with resistant hypertension independent of aldosterone status. J Hypertens 2016; 34:1005-10. [PMID: 26886564 PMCID: PMC5636624 DOI: 10.1097/hjh.0000000000000870] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
OBJECTIVE Resistant hypertension (RHTN), blood pressure (BP) at least 140/90 mmHg despite using at least three different medications, including a diuretic, is associated with high dietary sodium and hyperaldosteronism. Mineralocorticoid receptor antagonists are recommended for treatment of RHTN, however, BP response to these agents varies widely. In the current analysis, we assessed predictors of BP response to spironolactone in patients with RHTN. METHODS We retrospectively evaluated the BP response to adding spironolactone 12.5-25 mg to existing medications. A favorable BP response was defined as a reduction in SBP of at least 10 mmHg. Tested variables included baseline characteristics and biochemical parameters. RESULTS A total of 79 patients with RHTN were included in the analysis. Evaluated patients were more likely women (53.2%) and African-American (55.8%); were generally obese (76%) and were prescribed an average of four antihypertensive medications. Baseline SBP was 153.6 ± 22.3 mmHg; addition of spironolactone resulted in a mean reduction of 15.5 ± 20.7 mmHg. Patients with high urinary sodium excretion (≥200 mEq/24 h) had a significantly greater BP reduction compared with patients with normal excretion (<200 mEq/24 h) (P = 0.008). Multivariable analysis identified 24 h urinary sodium excretion as a significant predictor of BP response (P = 0.021) after controlling for potential confounders, including primary aldosteronism. CONCLUSION The antihypertensive effect of spironolactone is positively related to urinary sodium excretion regardless of aldosterone status. These findings suggest that mineralocorticoid receptor antagonists may be of preferential benefit in counteracting the BP effects of high dietary sodium.
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Affiliation(s)
- Lama Ghazi
- Department of Medicine and Cardiovascular Disease, Vascular Biology and Hypertension Program, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Tanja Dudenbostel
- Department of Medicine and Cardiovascular Disease, Vascular Biology and Hypertension Program, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Chee Paul Lin
- Center for Clinical and Translational Science, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Suzanne Oparil
- Department of Medicine and Cardiovascular Disease, Vascular Biology and Hypertension Program, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - David A. Calhoun
- Department of Medicine and Cardiovascular Disease, Vascular Biology and Hypertension Program, University of Alabama at Birmingham, Birmingham, Alabama, USA
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Wang C, Xiong B, Huang J. Efficacy and Safety of Spironolactone in Patients with Resistant Hypertension: A Meta-analysis of Randomised Controlled Trials. Heart Lung Circ 2016; 25:1021-30. [PMID: 27118266 DOI: 10.1016/j.hlc.2016.02.016] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Revised: 02/13/2016] [Accepted: 02/20/2016] [Indexed: 10/22/2022]
Abstract
BACKGROUND The treatment of resistant hypertension (RH) is challenging. Several observational studies have suggested that the addition of spironolactone to triple-drug therapy might have a promising anti-hypertensive effect on RH. To provide more definite evidence for the benefit of spironolactone, we performed a meta-analysis of randomised controlled trials (RCTs) to evaluate the efficacy and safety of spironolactone in RH patients. METHODS Articles were searched from PubMed, EMBASE and Cochrane Library. Randomised controlled trials investigating the effect of additional spironolactone on office blood pressure (BP), ambulatory BP or adverse events in RH patients were included for analysis. Then quality assessment, subgroup, sensitivity, and publication bias analyses were performed. RESULTS Five RCTs involving a total of 553 patients were eligible for inclusion. Compared with control therapies, additional spironolactone treatment in RH patients significantly decreased 24-h ambulatory systolic BP (ASBP, weight mean difference [WMD]= -10.50, 95% confidence interval [CI] = -12.30 to -8.71, P<0.001), 24-h ambulatory diastolic BP (ADBP, WMD = -4.09, 95% CI = -5.28 to -2.91, P<0.001), daytime ASBP (WMD = -10.20, 95% CI = -12.41 to -7.99, P<0.001), daytime ADBP (WMD = -4.14, 95% CI = -5.50 to -2.78, P<0.001), night-time ASBP (WMD = -10.02, 95% CI = -12.63 to -7.41), night-time ADBP (WMD=-3.21, 95% CI=-4.84 to -1.58, P<0.001), office systolic BP (WMD=-16.99, 95% CI=-25.04 to -8.95, P<0.001) and office diastolic BP (WMD=-6.18, 95% CI=-9.30 to -3.05, P<0.001). However, serum potassium might be slightly elevated by additional spironolactone (WMD=0.181, 95% CI=0.042 to 0.319, P=0.011). CONCLUSION Spironolactone combined with triple-drug therapy may be an effective and relatively safe strategy for the management of RH patients.
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Affiliation(s)
- Chunbin Wang
- Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Bo Xiong
- Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jing Huang
- Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China.
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Kaysin A, Mounsey A. PURLs: Resistant hypertension? Time to consider this fourth-line drug. THE JOURNAL OF FAMILY PRACTICE 2016; 65:266-268. [PMID: 27262250 PMCID: PMC4832049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
For most adults with resistant hypertension, spironolactone is superior to doxazosin and bisoprolol as an adjunct to triple therapy.
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Affiliation(s)
- Alexander Kaysin
- Department of Family Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Anne Mounsey
- Department of Family Medicine, University of North Carolina, Chapel Hill, NC, USA
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Carey RM. Resistant Hypertension: Mineralocorticoid Receptor Antagonist or Renal Denervation? Hypertension 2015; 67:278-80. [PMID: 26693820 DOI: 10.1161/hypertensionaha.115.06616] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Robert M Carey
- From the Division of Endocrinology and Metabolism, Department of Medicine, University of Virginia Health System, Charlottesville.
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Abstract
PURPOSE OF REVIEW The present review highlights recent investigations in the prior 18 months focusing on the role of dysregulated cortisol physiology in obesity as a potential modifiable mechanism in the pathogenesis of obesity-related cardiometabolic disorders. RECENT FINDINGS Given the clinical resemblance of obesity-related metabolic disorders with the Cushing's syndrome, new studies have investigated the intracellular regulation and metabolism of cortisol, new measurements of cortisol in scalp hair as a tool for long-term exposure to cortisol, and the cortisol-mineralocorticoid receptor pathway. Thus, current and future pharmacological interventions in obesity may include specific inhibition of steroidogenic and regulatory enzymes as well as antagonists of the mineralocorticoid and glucocorticoid receptors. SUMMARY The understanding of how adrenal function is challenged by the interplay of our genetic and environmental milieu has highlighted the importance of inappropriate cortisol regulation in cardiometabolic disorders. Increased adipose tissue in obesity is associated with hypothalamic-pituitary-adrenal axis overactivation, increased cortisol production at the local tissue level, and probably higher mineralocorticoid receptor activation in certain tissues.
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Affiliation(s)
- Rene Baudrand
- Department of Endocrinology, School Of Medicine, Pontificia Universidad Catolica De Chile, Santiago 8330074, Chile
- Director of the Endocrine Hypertension and Adrenal Disease Program, School Of Medicine, Pontificia Universidad Catolica De Chile, Santiago 8330074, Chile
| | - Anand Vaidya
- Center for Adrenal Disorders, Division of Endocrinology, Diabetes and Hypertension, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School. Boston, MA 02115, USA
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