Description of antihypertensive use in patients with resistant hypertension prescribed four or more agents

Prescribing patterns of antihypertensive medications: A systematic review of literature between 2010 and 2020

Background

Hypertension has affected over 1.13 billion people worldwide in 2015 and it's one of the most preventable risk-factors for morbidity and mortality. Antihypertensives significantly reduce cardiovascular risks. Several studies on antihypertensives' prescribing patterns were conducted worldwide, and guidelines were developed on hypertension management. However, no systematic reviews were conducted globally to synthesize the evidence from these studies. This review aims to evaluate antihypertensives' prescription patterns, and adherence to international guidelines for hypertension management worldwide.

Methods

Full-text antihypertensives' prescribing patterns evaluation studies were included. Reviews, commentaries, guidelines, and editorials were excluded. Various databases were searched including PubMed, Embase, and others. Studies were limited to English only and to articles published from (01/01/2010) to (20/03/2020). Crowe Critical Appraisal Tool (CCAT) was used for quality assessment.

Results

The most commonly prescribed antihypertensives as monotherapy in adult patients with no comorbidities were ACEIs/ARBs (Angiotensin converting enzyme inhibitors/Angiotensin receptor blockers), followed by CCBs (Calcium channel blockers), and BBs (Beta Blockers). Most commonly prescribed dual combinations were thiazide diuretics+ACEIs/ARBs, BBs + CCBs and CCBs+ACEIs/ARBs. Among diabetic patients, the most common agents were ACEIs/ARBs. Among patients with heart diseases, CCBs were prescribed frequently. While patients with kidney diseases, CCBs and ARBs were most prescribed. Of the 40 studies included in the review, only four studies directly assessed the prescribing patterns of antihypertensives in adherence to clinical practice guidelines. And only two studies confirmed adherence to guidelines. Furthermore, the quality of the majority of studies was moderate (50%), while 25% of articles were reported as either high or low quality.

Conclusion

This review revealed that there are areas for improvement for prescribing practices of antihypertensives in concordance with the latest evidence and with clinical practice guidelines.

Resistant Hypertension in Patients With Type-2 Diabetes Mellitus: A Single-Center, Cross-Sectional Study

Background The prevalence of resistant hypertension in Saudi patients with type-2 diabetes mellitus (T2DM) has not been previously estimated. Therefore, our objective was to assess the prevalence and characteristics of resistant hypertensive patients with T2DM at King Abdulaziz Medical City, Jeddah, Saudi Arabia. Methods This cross-sectional study included patients with hypertension and T2DM who presented to our center in 2018. We examined 1960 patients with T2DM during the study period; 809 were hypertensives. We compared T2DM patients with controlled hypertension versus resistant hypertension. Results The prevalence of resistant hypertension in patients with T2DM was 137/809 (16.93%). The mean age was 66.38±10.80 years, and females presented 56% of the study population (n= 451). Obstructive sleep apnea (OSA; OR: 2.60 [1.15- 5.87]; P=0.02) and ischemic heart disease (IHD; OR: 3.01 [2.04- 4.45]; P˂0.001) were significantly associated with resistant hypertension. The most common medications used with resistant hypertension were calcium channel blockers (CCBs; 89.05%), β-blockers (76.64%), and angiotensin-2 receptor blockers (ARBs; 62.77%). Conclusions Resistant hypertension in patients with T2DM is common in Saudi Arabia. Resistant hypertension could be associated with OSA and IHD. Further studies are required to evaluate the temporal relationship between resistant hypertension and risk factors.

Medication Adherence and Treatment-Resistant Hypertension in Newly Treated Hypertensive Patients in the United Arab Emirates

(1) Background: The present study aimed to analyze medication adherence and its effect on blood pressure (BP) control and assess the prevalence of treatment-resistant hypertension (TRH) among newly treated hypertensive patients in the United Arab Emirates (UAE); (2) Methods: A retrospective chart review was conducted to evaluate 5308 naïve hypertensive adults registered for the treatment across Abu Dhabi Health Services (SEHA) clinics in Abu Dhabi in 2017. After collecting data regarding basic details and BP measurements, patients were followed up for six months. Patients who did not reach BP targets despite taking three or more antihypertensive medications were defined as TRH; (3) Results: The overall adherence to antihypertensive treatment was 42%. At 6-month, a significant reduction in BP was observed in patients adherent to medications (systolic: -4.5 mm Hg and diastolic: -5.9 mm Hg) than those who were nonadherent to antihypertensive therapy (1.15 mm Hg and 3.59 mm Hg). Among 189 patients using three or more antihypertensive medications for six months, only 34% (n = 64) were adherent to the treatment, and only 13.7% (n = 26) reached the BP target. The prevalence of TRH was 20.1%; (4) Conclusions: Medication adherence and BP control among the participants were suboptimal. The study shows a high prevalence of TRH among newly treated hypertensives in the UAE. More extraordinary efforts toward improving adherence to antihypertensive therapy and more focus toward BP control and TRH are urgently needed.

Antihypertensive drug use in resistant and nonresistant hypertension and in controlled and uncontrolled resistant hypertension

BACKGROUND AND AIM

Treatment-resistant hypertension (TRH) is associated with particular clinical features, nonadherence, and suboptimal treatment. We assessed possible associations of antihypertensive drug classes, specific agents inside each class, and types of combinations, with the presence of non-TRH vs. TRH, and with controlled vs. uncontrolled TRH.

METHODS

Comparisons were done in 14 264 patients treated with three drugs (non-TRH: 2988; TRH: 11 276) and in 6974 treated with at least four drugs (controlled TRH: 1383; uncontrolled TRH: 5591). Associations were adjusted for age, sex, and previous cardiovascular event.

RESULTS

In both groups of patients treated with three or with at least four drugs, aldosterone antagonists among drug classes [adjusted odds ratio (OR): 1.82 and 1.41, respectively], and ramipril (OR: 1.28 and 1.30), olmesartan (OR: 1.31 and 1.37), and amlodipine (OR: 1.11 and 1.41) inside each class were significantly associated with blood pressure control (non-TRH or controlled TRH). In patients treated with three drugs, non-TRH was also associated with the use of chlorthalidone (OR: 1.50) and bisoprolol (OR: 1.19), whereas in patients treated with at least four drugs, controlled TRH was significantly associated with the triple combination of a renin-angiotensin system blocker, a calcium channel blocker, and a diuretic (OR: 1.17).

CONCLUSION

The use of aldosterone antagonists is associated with blood pressure control in patients treated with three or more drugs. Similar results are observed with specific agents inside each class, being ramipril, olmesartan, chlorthalidone, amlodipine, and bisoprolol those exhibiting significant results. An increased use of these drugs might probably reduce the burden of TRH.

Resistant Hypertension: Diagnosis and Management

Resistant hypertension is defined as high blood pressure requiring 3 or more medications for adequate control or controlled blood pressure requiring 4 or more medications. Considering the growing prevalence of hypertension and the strong link with cardiovascular disease, it is vital to understand the causes and treatment of resistant hypertension. This review article starts with an overview of the prevalence and little-known pathophysiology of resistant hypertension. Afterward, we discuss the evaluation and management of suspected secondary resistant hypertension in 2 broad categories: pseudoresistant hypertension and true resistant hypertension. Strategies for the identification and management of pseudoresistant hypertension are addressed. In addition, causes of true resistant hypertension, such as obstructive sleep apnea, primary aldosteronism, and renal artery stenosis, are examined along with their respective treatments. Finally, treatment of resistant hypertension is reviewed including pharmacologic treatments and novel procedural interventions for resistant hypertension. Overall, the review hopes to provide practitioners with a cohesive approach for the diagnosis and treatment of resistant hypertension.

Medication adherence and treatment-resistant hypertension: a review

Nonadherence is a common reason for treatment failure and treatment resistance. No matter how it is defined, it is a major issue in the management of chronic illnesses. There are numerous methods to assess adherence, each with its own strengths and weaknesses; however, no single method is considered the best. Nonadherence is common in patients with hypertension, and it is present in a large proportion of patients with uncontrolled blood pressure taking three or more antihypertensive agents. Availability of procedure-based treatment options for these patients has shed further light on this important issue with development of new methods to assess adherence. There is, however, no consensus on the management of nonadherence, which reflects the complex interplay of factors responsible for it.

Predicting the risk of apparent treatment-resistant hypertension: a longitudinal, cohort study in an urban hypertension referral clinic

Apparent treatment-resistant hypertension (aTRH) is associated with higher prevalence of secondary hypertension, greater risk for adverse pressure-related clinical outcomes, and influences diagnostic and therapeutic decision-making. We previously showed that cross-sectional prevalence estimates of aTRH are lower than its true prevalence as patients with uncontrolled hypertension undergoing intensification/optimization of therapy will, over time, increasingly satisfy diagnostic criteria for aTRH. aTRH was assessed in an urban referral hypertension clinic using a 140/90 mm Hg goal blood pressure target in 745 patients with uncontrolled blood pressure, who were predominately African-American (86%) and female (65%). Analyses were stratified according to existing prescription of diuretic at initial visit. Risk for aTRH was estimated using logistic regression with patient characteristics at index visit as predictors. Among those prescribed diuretics, 84/363 developed aTRH; the risk score discriminated well (area under the receiver operating curve = 0.77, bootstrapped 95% CI [0.71, 0.81]). In patients not prescribed a diuretic, 44/382 developed aTRH, and the risk score showed a significantly better discriminative ability (area under the receiver operating curve = 0.82 [0.76, 0.87]; P < .001). In the diuretic and nondiuretic cohorts, 145/363 and 290/382 of patients had estimated risks for development of aTRH <15%. Of these low-risk patients, 139/145 and 278/290 did not develop aTRH (negative predictive value, diuretics - 0.94 [0.91, 0.98], no diuretics - 0.95 [0.93, 0.97]). We created a novel clinical score that discriminates well between those who will and will not develop aTRH, especially among those without existing diuretic prescriptions. Irrespective of baseline diuretic treatment status, a low-risk score had very high negative predictive value.

A comprehensive review of an unmet public health issue: resistant hypertension

Resistant hypertension is an intractable problem to patients and physicians. In recent decades, a substantial amount of basic and epidemiological studies provide us a vast number of valuable evidence and information about this once elusive disease. Better understanding about this entity could help physicians improve diagnostic and therapeutic accuracy. In present review, therefore, we first will detail the definition and diagnosis of resistant hypertension between cardiology societies, and followed by the information of prevalence of resistant hypertension around the world, and then briefly discuss currently used different nomenclature of resistant hypertension, and finally present diagnostic and therapeutic strategies of resistant hypertension.

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

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

Trends in Antihypertensive Medication Use Among US Patients With Resistant Hypertension, 2008 to 2014

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.

Physician-pharmacist collaboration versus usual care for treatment-resistant hypertension

Team-based care has been recommended for patients with treatment-resistant hypertension (TRH), but its efficacy in this setting is unknown. We compared a physician-pharmacist collaborative model (PPCM) to usual care in patients with TRH participating in the Collaboration Among Pharmacists and Physicians To Improve Outcomes Now study. At baseline, 169 patients (27% of Collaboration Among Pharmacists and Physicians To Improve Outcomes Now patients) had TRH: 111 received the PPCM intervention and 58 received usual care. Baseline characteristics were similar between treatment arms. After 9 months, adjusted mean systolic blood pressure was reduced by 7 mm Hg more with PPCM intervention than usual care (P = .036). Blood pressure control was 34.2% with PPCM versus 25.9% with usual care (adjusted odds ratio, 1.92; 95% confidence interval, 0.33-11.2). These findings suggest that team-based care in the primary care setting may be effective for TRH. Additional research is needed regarding the long-term impact of these models and to identify patients most likely to benefit from team-based interventions.

Quality of Life in Treatment-Resistant Hypertension

Treatment-resistant hypertension (TRH) is an increasingly common and clinically challenging hypertension phenotype associated with adverse impact on cardiovascular events and death. Recent evidence, although limited, suggests that TRH may also adversely affect health-related quality of life (HrQoL) and other patient-reported outcomes. However, the precise mechanisms for this link remain unknown. A number of recent studies focusing on both the general hypertensive population and those with TRH suggest that patient awareness of difficult-to-control blood pressure, chronically elevated blood pressure levels, and the use of aggressive medication regimens with attendant cumulative adverse effects may play significant roles. This review summarizes the existing literature on HrQoL in persons with TRH, highlights literature from the general hypertensive population with relevance to TRH, and discusses important remaining questions regarding HrQoL in persons with TRH.

Improvement in All-Cause Mortality With Blood Pressure Control in a Group of US Veterans With Drug-Resistant Hypertension

The current definition of drug-resistant hypertension includes patients with uncontrolled (URH) (taking ≥3 antihypertensive medications) and controlled hypertension (CRH; blood pressure [BP] ≤140/90 mm Hg) (taking ≥4 medications). The authors hypothesized that all-cause mortality is reduced when URH is controlled. Qualified patients followed at the Washington DC VA Medical Center were included. BPs were averaged for each year of follow-up. In 2006, among 2906 patients who met the criteria for drug-resistant hypertension, 628 had URH. During follow-up, 234 patients were controlled (group 1) and 394 patients remained uncontrolled (group 2). The mortality rate among patients with URH was 28% (110 of 394) and among patients with CRH was 13% (30 of 234), a 54% reduction (P<.01). Multivariate analysis identified independent predictors of mortality as uncontrolled HTN (hazard ratio, 2.5; 95% confidence interval, 1.67-3.75; P<.01), age (hazard ratio, 1.03; 95% confidence interval, 1.01-1.04; P<.01), and diabetes (hazard ratio, 1.46; 95% confidence interval, 1.04-2.05; P<.027). The authors conclude that controlling drug-resistant hypertension markedly reduces all-cause mortality.

Resistant hypertension in type 2 diabetes: prevalence and patients characteristics

BACKGROUND AND AIMS

Resistant hypertension is defined as failure to achieve blood pressure lower than 140/90 mmHg when using three antihypertensive agents or controlled blood pressure with four or more drugs. We aimed at assessing the prevalence of resistant hypertension and to describe a type 2 diabetes population with resistant hypertension.

METHODS

The retrospective observational study included (n=73) type 2 diabetes subjects with resistant hypertension selected from (n=728) subjects admitted to the Centre of Diabetes, Cluj, Romania.

RESULTS

The subjects (70% women) had a mean age of 65.0±8.9 yrs. and diabetes duration 11(6-19) yrs. Prevalence of resistant hypertension was 10%. Chronic diabetes complications and cardiovascular disease were present in 77% and 56% of subjects respectively. On admission, antihypertensive drugs used were: angiotensin-converting enzyme inhibitors or angiotensin II receptors blockers 93%, β-blockers 88%, diuretics 78%, calcium channels blockers 59%, adrenergic α-antagonists 11%. Systolic and diastolic blood pressure were lower in the last compared to first admission day. Diuretics and calcium channels blockers were the most frequently newly added antihypertensive agents.

CONCLUSION

Although the prevalence of resistant hypertension in type 2 diabetes did not differ from the general population, we observed that these patients had increased frequency of chronic diabetic complications. Angiotensin-converting enzyme inhibitors or angiotensin II receptors and β-blockers were the most used antihypertensive drugs, while the most frequently newly prescribed drugs were diuretics and calcium channel blockers.

Treatment resistant hypertension--investigation and conservative management

BACKGROUND

The introduction of invasive treatments, some of which are irreversible, for the entity called treatment-resistant hypertension (TRH) creates the need for a comprehensive discussion of the diagnostic evaluation that TRH requires and the available options for its conservative treatment.

METHOD

The pertinent literature is selectively reviewed in the light of the authors' longstanding clinical experience.

RESULTS

Our review of the literature suggests that the high prevalence of TRH in Germany (ca. 20%) can be nearly halved with the aid of more thorough diagnostic evaluation. Such an evaluation should include a review of the patient's antihypertensive drugs (adherence, daily dosing, concomitant medication), investigation for other vascular changes that might affect blood pressure measurement, and exclusion of white-coat hypertension, sleep apnea syndrome, and secondary rather than essential hypertension. As there have been no randomized trials of treatment for TRH, the physician confronted with such cases must devise treatments on the basis of observational data and pathophysiological reasoning (volume status considering renin levels, sympathetic blockade, vasodilatation). Such measures can presumably lower the number of truly treatment-resistant cases still further.

CONCLUSION

To save patients from preventable harm, patients should undergo a thorough diagnostic evaluation and-under close monitoring for side effects-conservative pharmacological and nonpharmacological treatments should be deployed before any invasive treatment is performed.

Combination antihypertensive therapy in clinical practice. The analysis of 1254 consecutive patients with uncontrolled hypertension

The aim of the study was to analyze the clinical use of different types of combination therapy in a large sample of consecutive patients with uncontrolled hypertension referred to Hypertension Centre. We performed a retrospective analysis of combination antihypertensive therapy in 1254 consecutive patients with uncontrolled hypertension receiving at least triple-combination antihypertensive therapy. Among the most prescribed antihypertensive classes were renin-angiotensin blockers (96.8%), calcium channel blockers (82.5%), diuretics (82.0%), beta-blockers (73.0%), centrally acting drugs (56.0%) and urapidil (24.1%). Least prescribed were spironolactone (22.2%) and alpha-1-blockers (17.1%). Thiazide/thiazide-like diuretics were underdosed in more than two-thirds of patients. Furosemide was prescribed in 14.3% of patients treated with diuretics, while only indicated in 3.9%. Inappropriate combination therapy was found in 40.4% of patients. Controversial dual and higher blockade of renin-angiotensin system occurred in 25.2%. Incorrect use of a combination of two antihypertensive drugs with the similar mechanism of action was found in 28.1%, most commonly a combination of two drugs with central mechanism (13.5%). In conclusion, use of controversial or incorrect combinations of drugs in uncontrolled hypertension is common. Diuretics are frequently underdosed and spironolactone remains neglected in general practice. The improper combination of antihypertensive drugs may contribute to uncontrolled hypertension.

Systematic review and meta-analysis of the prevalence of resistant hypertension in treated hypertensive populations

BACKGROUND

Although treatment-resistant hypertension (RH) is a serious burden on population health, there exists uncertainty about its prevalence. Hence, the objectives of this work were to systematically review and critically appraise the literature and to conduct a meta-analysis on the prevalence of RH in treated hypertensive populations.

METHODS

PubMed, Cochrane Library, CRD York databases, and study bibliographies were systematically searched for observational and interventional studies that report disease frequency in adult populations. The pooled prevalence was obtained through random-effect modeling. Furthermore, quality assessment, publication bias diagnostics, meta-regression, subgroup analysis by sex, and sensitivity analysis were performed.

RESULTS

Out of 318 retrieved studies, 20 observational studies and 4 randomized control trials (RCTs) with a total population of 961,035 were included. The random-effect method for observational studies and RCTs yielded RH prevalence ratios of 13.72% (95% confidence interval (CI) = 11.19%-16.24%) and 16.32% (95% CI = 10.68%-21.95%), respectively. Yet, most studies were incapable of ruling out pseudo-resistance caused by white-coat effect, poor medication adherence, and suboptimal dosing. Differences in RH prevalence by sex were negligible. Meta-regression analysis showed that study-level characteristics had no statistically significant influence on RH prevalence. The inclusion of further studies in the sensitivity analysis concurred with the baseline results (13.19%; 95% CI = 10.89%-15.49%).

CONCLUSIONS

Researchers should enhance comparability of future empirical evidence through homogeneous methodologies and comparable baseline populations. This meta-analysis concludes that RH is a frequent phenomenon and further harmonization in terms of RH definition and measurement would be necessary to clearly distinguish true treatment resistance from pseudo-resistance.

Drug therapy for the patient with resistant hypertension

ABSTRACT 

Resistant hypertension is associated with high morbidity and mortality. Resistant hypertension is defined as blood pressure above targets despite treatment with at least three antihypertensive drugs in adequate dose and combination. Nonadherence is a frequent cause of uncontrolled hypertension and can be improved by providing fixed dose (of two or three agents) single pill combination. Triple combination of the most widely used antihypertensive agents (renin–angiotensin–aldosterone system antagonists, calcium channel blockers and diuretics) is a safe and effective therapy. Fourth line therapy is the use of an aldosterone antagonist. Renal denervation and baroreceptor stimulation can be considered in patients who remained uncontrolled despite optimal medical therapy.

Renal denervation after Symplicity HTN-3: an update

After three years of excessive confidence, overoptimistic expectations and performance of 15 to 20,000 renal denervation procedures in Europe, the failure of a single well-designed US trial—Symplicity HTN-3—to meet its primary efficacy endpoint has cast doubt on renal denervation as a whole. The use of a sound methodology, including randomisation and blinded endpoint assessment was enough to see the typical 25–30 mmHg systolic blood pressure decrease observed after renal denervation melt down to less than 3 mmHg, the rest being likely explained by Hawthorne and placebo effects, attenuation of white coat effect, regression to the mean and other physician and patient-related biases. The modest blood pressure benefit directly assignable to renal denervation should be balanced with unresolved safety issues, such as potentially increased risk of renal artery stenosis after the procedure (more than ten cases reported up to now, most of them in 2014), unclear long-term impact on renal function and lack of morbidity–mortality data. Accordingly, there is no doubt that renal denervation is not ready for clinical use. Still, renal denervation is supported by a strong rationale and is occasionally followed by major blood pressure responses in at-risk patients who may otherwise have remained uncontrolled. Upcoming research programmes should focus on identification of those few patients with truly resistant hypertension who may derive a substantial benefit from the technique, within the context of well-designed randomised trials and independent registries. While electrical stimulation of baroreceptors and other interventional treatments of hypertension are already “knocking at the door”, the premature and uncontrolled dissemination of renal denervation should remain an example of what should not be done, and trigger radical changes in evaluation processes of new devices by national and European health authorities.

Chinese herbal medicine for resistant hypertension: a systematic review

OBJECTIVES

This study aimed to summarise the current evidence from randomised control trials (RCTs) concerning treatment of patients with resistant hypertension with Chinese herbal medicine (CHM).

DESIGN

Seven databases, including the Cochrane Library, PubMed, EMBASE, CNKI, VIP, CBM and Wanfang, were systematically searched from their inception to March 2014 for RCTs investigating treatment of resistant hypertension in which CHM was used either as a monotherapy or in combination with conventional medicine versus placebo, no intervention or conventional medicine.

RESULTS

Five trials containing 446 hypertensive patients were identified. The methodological quality of most trials was evaluated as generally low. All included trials compared CHM plus antihypertensive drugs with antihypertensive drugs alone for resistant hypertension. Formulations of CHM included tablet, decoction and injection. It was found that, compared with antihypertensive drugs alone, CHM (tablet) plus antihypertensive drugs resulted in clinically, but not statistically, significant reductions in systolic blood pressure (SBP; weighted mean difference (WMD)=-10.32 mm Hg; 95% CI -21.10 to 0.46; p=0.06) and diastolic blood pressure (DBP; WMD=-3.30 mm Hg; 95% CI -7.66 to 1.06; p=0.14). CHM (decoction) plus antihypertensive drugs also produced a clinically meaningful, but not statistically significant, reduction in SBP (WMD=-12.56 mm Hg; 95% CI -26.83 to 1.71; p=0.08), and did significantly decrease DBP (WMD=-7.89 mm Hg; 95% CI -11.74 to -4.04; p<0.0001). There were no significant differences in SBP (WMD=-3.50 mm Hg; 95% CI -8.95 to 1.95; p=0.21) and DBP (WMD=1.00 mm Hg; 95% CI -1.39 to 3.39; p=0.41) between CHM (injection) plus the antihypertensive drugs group and antihypertensive drugs alone. The safety of CHM remained uncertain.

CONCLUSIONS

No definite conclusions about the effectiveness and safety of CHM for resistant hypertension could be drawn. More rigorously designed trials are warranted.

Angiotensin II-induced endothelial dysfunction is temporally linked with increases in interleukin-6 and vascular macrophage accumulation

Angiotensin II (Ang II) is associated with vascular hypertrophy, endothelial dysfunction and activation of a number of inflammatory molecules, however the linear events involved in the development of hypertension and endothelial dysfunction produced in response to Ang II are not well defined. The goal of this study was to examine the dose- and temporal-dependent development of endothelial dysfunction in response to Ang II. Blood pressure and responses of carotid arteries were examined in control (C57Bl/6) mice and in mice infused with 50, 100, 200, 400, or 1000 ng/kg/min Ang II for either 14 or 28 Days. Infusion of Ang II was associated with graded and marked increases in systolic blood pressure and plasma Ang II concentrations. While low doses of Ang II (i.e., 50 and 100 ng/kg/min) had little to no effect on blood pressure or endothelial function, high doses of Ang II (e.g., 1000 ng/kg/min) were associated with large increases in arterial pressure and marked impairment of endothelial function. In contrast, intermediate doses of Ang II (200 and 400 ng/kg/min) while initially having no effect on systolic blood pressure were associated with significant increases in pressure over time. Despite increasing blood pressure, 200 ng/kg/min had no effect on endothelial function, whereas 400 ng/kg/min produced modest impairment on Day 14 and marked impairment of endothelial function on Day 28. The degree of endothelial dysfunction produced by 400 and 1000 ng/kg/min Ang II was reflective of parallel increases in plasma IL-6 levels and vascular macrophage content, suggesting that increases in arterial blood pressure precede the development of endothelial dysfunction. These findings are important as they demonstrate that along with increases in arterial pressure that increases in IL-6 and vascular macrophage accumulation correlate with the impairment of endothelial function produced by Ang II.

Non-interventional management of resistant hypertension

Hypertension is one of the most popular fields of research in modern medicine due to its high prevalence and its major impact on cardiovascular risk and consequently on global health. Indeed, about one third of individuals worldwide has hypertension and is under increased long-term risk of myocardial infarction, stroke or cardiovascular death. On the other hand, resistant hypertension, the “uncontrollable” part of arterial hypertension despite appropriate therapy, comprises a much greater menace since long-standing, high levels of blood pressure along with concomitant debilitating entities such as chronic kidney disease and diabetes mellitus create a prominent high cardiovascular risk milieu. However, despite the alarming consequences, resistant hypertension and its effective management still have not received proper scientific attention. Aspects like the exact prevalence and prognosis are yet to be clarified. In an effort to manage patients with resistant hypertension appropriately, clinical doctors are still racking their brains in order to find the best therapeutic algorithm and surmount the substantial difficulties in controlling this clinical entity. This review aims to shed light on the effective management of resistant hypertension and provide practical recommendations for clinicians dealing with such patients.

Prevalence and Factors Associated With Resistant Hypertension in a Large Health Maintenance Organization in Israel

Previous assessments of the prevalence of resistant hypertension (RH) in uncontrolled blood pressure (BP) have ranged from 3% to 30%. Using real-world data, our aim was to estimate the prevalence of RH in patients belonging to the Maccabi Healthcare Services, a 2-million-member health organization in Israel. From 2010 to 2011, all hypertensive patients with ≥2 recorded BP measurements during a minimum period of 6 months were identified. Patients were considered uncontrolled if their most recent BP during the study period and their mean systolic BP or diastolic BP during a preceding period of ≥6months were systolic BP ≥140 mm Hg or diastolic BP ≥90 mm Hg, or systolic BP ≥130 mm Hg or diastolic BP ≥80 mm Hg in chronic kidney disease or diabetes mellitus. Uncontrolled patients taking diuretics and ≥2 antihypertensive therapy classes at their maximal recommended dose were regarded as resistant hypertensives. A total of 172 432 patients were eligible for the study. Uncontrolled BP was found in 35.9% (n=65 710). Overall, 2.2% of the uncontrolled patients (n=1487) were resistant hypertensives. Patients with RH were characterized by a significantly ( P <0.01) older age, higher body mass index, and multicomorbidity (including dyslipidemia, diabetes mellitus, and impaired renal function) compared with patients with controlled hypertension receiving equivalent treatment. The results of this large population-based study indicate a substantially lower prevalence of RH than previously reported. Most patients with uncontrolled BP took less than the maximal recommended antihypertensive treatment.

Low rate of resistant hypertension in Chinese patients with hypertension: an analysis of the HOT-CHINA study

Objective:

The rate of resistant hypertension in China is unknown. This is an analysis of resistant hypertension based on Hypertension Optimal Treatment Study in China.

Methods:

The study was conducted in 148 cities in mainland China from April 2001 to February 2002, which included 54 590 hypertensive patients (≥18 years of age), and used a five-step treatment programme. Patients not achieving blood pressure (BP) target (<140/90 mmHg) within 2 weeks received preplanned additional drugs. Resistant hypertension was defined in the participants with uncontrolled hypertension after 2 weeks of treatment on Step 5.

Results:

The rate of resistant hypertension was 1.9%. Patients with resistant hypertension were characterized by following features: higher male percentage (65.6 vs. 60.2%); younger age (59.51 ± 13.02 vs. 61.76 ± 12.27 years); higher BMI (24.8 ± 3.5 vs. 24.0 ± 3.4 kg/m²); longer disease course; higher fasting blood glucose (6.60 ± 2.69 vs. 5.99 ± 2.12 mmol/l); higher total cholesterol (5.67 ± 1.63 vs. 5.32 ± 1.24 mmol/l); higher triglycerides (2.15 ± 1.32 vs. 1.96 ± 1.09 mmol/l); and higher percentage of grade 3 hypertension (71.1 vs. 27.2%) (all P < 0.001). Patients with resistant hypertension also had a higher rate of metabolic syndrome (45.9 vs. 35.4%), diabetes mellitus (25.5 vs. 14.7%) and history of myocardial infarction (4.7 vs. 3.3%) or stroke (17.0 vs. 11.6%) (P < 0.001). Multivariate analyses revealed an association of resistant hypertension with younger age, higher BP, BMI, longer disease course, higher fasting blood glucose and total cholesterol (P < 0.05).

Conclusion:

Resistant hypertension in Chinese patients is associated with overweight/obesity, higher BP and metabolic syndrome. The rate of resistant hypertension in China, however, is much lower than previously reported. Another intriguing characteristic is the association of resistant hypertension with younger age.

The prevalence, incidence, prognosis, and associated conditions of resistant hypertension

Resistant hypertension is a relevant condition gaining special attention given its clinical and economic impact. Although the true prevalence is unknown, clinical trials and population-based studies have shown that it is a common clinical problem that likely will increase in incidence with an aging and more obese population. A complex interaction of various risk factors including lifestyle, associated conditions, and identifiable secondary causes can lead to uncontrolled hypertension. Important factors including improper blood pressure measuring technique, poor medication adherence, and the white coat phenomenon can lead to pseudoresistance, or a false impression of treatment resistance, which must be excluded. Patients with true resistant hypertension have a greater risk for developing adverse cardiovascular events compared with those with controlled blood pressure, leading to an unfavorable prognosis without adequate treatment. This article reviews the current understanding of the epidemiology of resistant hypertension.

Physician underutilization of effective medications for resistant hypertension at office visits in the United States: NAMCS 2006-2010

BACKGROUND

The American Heart Association (AHA) published guidelines for treatment of resistant hypertension in 2008 recommending use of thiazide diuretics (particularly chlorthalidone), aldosterone antagonists, and fixed-dose combination medications, but it is unclear the extent to which these guidelines are being followed.

OBJECTIVE

To describe trends in physician use of recommended medications for resistant hypertension and assess variations in medication use based on geography, physician specialty and patient characteristics.

DESIGN

Cross-sectional analysis using the National Ambulatory Medical Care Survey from 2006 to 2010.

STUDY SAMPLE

We analyzed visits of hypertension patients to family physicians, general internists, and cardiologists. Resistant hypertension was defined as concurrent use of ≥ 4 classes of blood pressure (BP) medications or elevated BP despite the use of ≥ 3 medications. Pregnant patients and visits with diagnosed heart failure or end-stage renal disease were excluded.

MAIN OUTCOME

Use of AHA-recommended medications for management of resistant hypertension.

RESULTS

Of 19,500 patient visits with hypertension, 1,567 or 7.1 % CI (6.6-7.7 %) met criteria for resistant hypertension. Thiazide diuretic use was reported in 58.9 % of visits pre-guidelines vs. 54.8 % post-guidelines (p = 0.37). Use of aldosterone antagonists was low and also did not change significantly after guideline publication (3.1 % vs. 4.5 %, p = 0.27). Fixed-dose combinations use was 42.0 % before and 37 % after guideline publication (p = 0.29). Each 10-year increase in patient age was associated with lower thiazide use (OR 0.87, CI 0.77-0.97), as was presence of comorbid ischemic heart disease (OR 0.62, CI 0.41-0.94). Medication use did not vary by geography or physician specialty.

CONCLUSION

Use of AHA-recommended medications for resistant hypertension remains low after publication of guidelines. Healthcare systems should encourage more frequent prescribing of these medications to improve care in this high-risk population.

Is chlorthalidone better than hydrochlorothiazide in reducing cardiovascular events in hypertensives?

PURPOSE OF REVIEW

Hydrochlorthiazide (HCTZ) is the tenth most commonly prescribed drug in recent data. Although no head-to-head trials compare HCTZ with the uncommonly prescribed chlorthalidone (CTDN) in reducing cardiovascular events (CVEs), numerous other data are available.

RECENT FINDINGS

Head-to-head trials have shown CTDN's superiority in antihypertensive potency, particularly during the critical nighttime period (SBP difference 7.1 mmHg), due to the differences in duration of action (16-24 h for HCTZ versus 48-72 h for CTDN). In an observational cohort study, compared with HCTZ, CTDN was associated with lower left ventricular hypertrophy. In another observational cohort analysis (n = 12,866), the percentage risk reduction in CVEs from CTDN versus HCTZ was 21 [95% confidence interval (CI) 8-32], P = 0.002. In network meta-analyses of randomized trials (n = 50,946), CTDN was superior to HCTZ in reducing congestive heart failure and in reducing all CVEs: percentage risk reduction 21 (95% CI 12-28), P < 0.0001. A statistically significant reduction in CVEs by CTDN versus HCTZ persisted even when reduction in office SBP produced by the two diuretics was identical, further strengthening the case for CTDN.

SUMMARY

Direct and indirect evidence demonstrates that CTDN is superior to HCTZ in reducing CVEs and is congruent with the recent changes in the guidelines for hypertension management.

Diagnosis and treatment of resistant hypertension

Hypertension resistant to lifestyle interventions and antihypertensive medications is a common problem encountered by physicians in everyday practice. It is most often defined as a blood pressure remaining ≥ 140/90 mmHg despite the regular intake of at least three drugs lowering blood pressure by different mechanisms, one of them being a diuretic. It now appears justified to include, unless contraindicated or not tolerated, a blocker of the renin-angiotensin system and a calcium channel blocker in this drug regimen, not only to gain antihypertensive efficacy, but also to prevent or regress target organ damage and delay the development of cardiorenal complications. A non-negligible fraction of treatment-resistant hypertension have normal "out of office" blood pressures. Ambulatory blood pressure monitoring and/or home blood pressure recording should therefore be routinely performed to identify patients with true resistant hypertension, i.e. patients who are more likely to benefit from treatment intensification.

Management of patients with resistant hypertension: current treatment options

Resistant hypertension (RHTN) is an increasingly common clinical problem that is often heterogeneous in etiology, risk factors, and comorbidities. It is defined as uncontrolled blood pressure on optimal doses of three antihypertensive agents, ideally one being a diuretic. The definition also includes controlled hypertension with use of four or more antihypertensive agents. Recent observational studies have advanced the characterization of patients with RHTN. Patients with RHTN have higher rates of cardiovascular events and mortality compared with patients with more easily controlled hypertension. Secondary causes of hypertension, including obstructive sleep apnea, primary aldosteronism, renovascular disease, are common in patients with RHTN and often coexist in the same patient. In addition, RHTN is often complicated by metabolic abnormalities. Patients with RHTN require a thorough evaluation to confirm the diagnosis and optimize treatment, which typically includes a combination of lifestyle adjustments, and pharmacologic and interventional treatment. Combination therapy including a diuretic, a long-acting calcium channel blocker, an angiotensin-converting enzyme inhibitor, a beta blocker, and a mineralocorticoid receptor antagonist where warranted is the classic regimen for patients with treatment-resistant hypertension. Mineralocorticoid receptor antagonists like spironolactone or eplerenone have been shown to be efficacious in patients with RHTN, heart failure, chronic kidney disease, and primary aldosteronism. Novel interventional therapies, including baroreflex activation and renal denervation, have shown that both of these methods may be used to lower blood pressure safely, thereby providing exciting and promising new options to treat RHTN.

Characteristics, drug combinations and dosages of primary care patients with uncontrolled ambulatory blood pressure and high medication adherence

Most studies on the prevalence and determinants of resistant hypertension (RH) do not account for white coat hypertension, medication non-adherence, or use of suboptimal treatment dosages. We studied the characteristics, drug combinations, and dosages of patients on at least three antihypertensives of different classes who had uncontrolled blood pressure on 24-hour ambulatory blood pressure monitoring and high medication adherence measured by electronic monitoring. The data were collected as part of the baseline measures of a hypertension control trial. Of 140 monitored primary care patients, all with uncontrolled office blood pressure, 69 (49%) were on at least three antihypertensives of different classes. Of these 69, 15 (22%) were controlled on ambulatory blood pressure monitoring, 20 (29%) were uncontrolled and non-adherent, leaving only 34 (49%) adherent to their medications and having uncontrolled ambulatory hypertension (uncontrolled RH). Thirty-one (91%) of the 34 uncontrolled RH patients were prescribed a diuretic, of which 24 were on hydrochlorothiazide 25 mg. Less than half of the patients on angiotensin-converting enzyme inhibitor, angiotensin receptor blocker, or calcium channel blocker were prescribed maximal doses of these agents. Half of the RH can be attributed to white coat effect and poor medication adherence, and all of the remaining patients were on apparently suboptimal drug combinations and/or dosages. Primary care physicians need to be educated regarding the optimal treatment of RH.

Determinants of blood pressure reduction by eplerenone in uncontrolled hypertension

BACKGROUND

Add-on therapy with aldosterone receptor antagonists has been reported to lower blood pressure (BP) in patients with uncontrolled hypertension. We assessed potential predictors of this response.

METHODS

In essential hypertensive patients with uncontrolled BP, despite the use of at least two antihypertensives, plasma renin and aldosterone concentrations and the transtubular potassium gradient (TTKG) were measured. Patients were treated with eplerenone 50 mg daily on top of their own medication. The office and ambulatory BP response and biochemical changes were evaluated after 1 week and 3 months of treatment and 6 weeks after discontinuation. Potential predictors for the change in 24-h ambulatory BP were tested in a multivariate regression model.

RESULTS

One hundred and seventeen patients with a mean age of 50.5 ± 6.6 years were included. Office BP decreased from 149/91 to 142/87 mmHg (P < 0.001) and ambulatory BP from 141/87 to 132/83 mmHg after 3 months of treatment (P < 0.001). Six weeks after discontinuation of eplerenone, office and ambulatory BP measurements returned to baseline values. Treatment resulted in a small rise in serum potassium and creatinine, and a small decrease in the TTKG. In a multivariate model, neither renin, aldosterone, or their ratio, nor the TTKG predicted the BP response. Only baseline ambulatory SBP predicted the BP response, whereas the presence of left ventricular hypertrophy was associated with a smaller BP reduction.

CONCLUSION

Add-on therapy with eplerenone effectively lowers BP in patients with difficult-to-treat primary hypertension. This effect is unrelated to circulating renin-angiotensin-aldosterone system activity and renal mineralocorticoid receptor activity as assessed by the TTKG.

Assessing factors related to the pharmacologic management of laryngeal diseases and disorders

OBJECTIVES/HYPOTHESIS

To examine how age, gender, comorbidity, geography, provider type, and laryngeal pathology influence the use of pharmacological treatment in managing patients with laryngeal disorders.

STUDY DESIGN

Retrospective analysis of data from a large, nationally representative, administrative, US claims database.

METHODS

Patients with a laryngeal disorder based on International Classification of Diseases, Ninth Revision, Clinical Modification codes from January 1, 2004 to December 31, 2008, seen as an outpatient by a primary care physician (PCP), otolaryngologist, or both and continuously enrolled for 12 months were included. Data regarding pharmacy claims, age, gender, geographic location, comorbid conditions, provider type, and laryngeal diagnosis were collected. To identify factors that influenced whether a patient received a medication or not, a logistic regression was performed.

RESULTS

Of almost 55 million individuals in the database, 258,705 had a laryngeal diagnosis 12 months post-index date follow-up and an outpatient encounter with a PCP, otolaryngologist, or both. A total of 135,973 (52.6%) unique patients, mean age 47.4 years (22.2 standard deviation [SD]), with 61.9% female, received a medication, and 122,732 (47.4%), mean age 47.4 years (19.8 SD), with 65.8% female, did not. Higher odds ratios for medication treatment were associated with PCPs versus otolaryngologists, acute laryngitis, the South region, and patients with comorbid conditions. Variable prescription patterns were also observed for age and gender.

CONCLUSIONS

Multiple factors are associated with the use of medical treatment for laryngeal disorders.

Prescribing Patterns of Primary Care Physicians and Otolaryngologists in the Management of Laryngeal Disorders

Objective

To examine how primary care physicians (PCPs) and otolaryngologists use proton pump inhibitors (PPIs), antibiotics, antihistamines, oral and inhaled steroids, and histamine 2 antagonists in the treatment of laryngeal disorders.

Study Design and Setting

Retrospective analysis of data from a large, national administrative US claims database.

Subjects and Methods

Patients with laryngeal disorders based on ICD-9-CM codes from January 1, 2004, to December 31, 2008, seen as an outpatient by a PCP, otolaryngologist, or both and continuously enrolled for 12 months were included. Pharmacy claims, age, gender, geographic location, comorbid conditions, provider type, and laryngeal diagnosis were collected. Random-effects logistic regression and multinomial logistic regression analyses were performed.

Results

Of approximately 55 million individuals, 135,973 had a laryngeal diagnosis, 12 months post–index date follow-up, and an outpatient encounter with a PCP, otolaryngologist, or both. Acute laryngitis was one of the most common reasons PCPs prescribed each medication class. Nonspecific dysphonia was the most common reason otolaryngologists prescribed each medication class. Patients seen by a PCP had a higher odds ratio for receiving an antibiotic and antihistamine, and patients seen by an otolaryngologist had a greater odds ratio for receiving a PPI and inhaled steroids. After adjusting for other variables in the model, the probability that a patient seen by a PCP would receive an antibiotic was .55 and a PPI .13. If seeing an otolaryngologist, it was .44 and .22, respectively.

Conclusion

Differences exist regarding the prescribing patterns of PCPs and otolaryngologists in treating patients with laryngeal disorders.

What is the prevalence of resistant hypertension in the United States?

PURPOSE OF REVIEW

Resistant hypertension, defined as blood pressure uncontrolled on three, or controlled with at least four, antihypertensive agents (including a diuretic), is associated with higher risk of secondary hypertension, cardiovascular and renal events, and increased healthcare expenditures. Until recently, however, the prevalence of resistant hypertension in the United States (US) was based on clinical trial registries or pharmacy databases.

RECENT FINDINGS

Recent analyses of National Health and Nutrition Examination Survey (NHANES) data, drawn from representative samples of the adult, noninstitutionalized, civilian population, have estimated the prevalence of resistant hypertension at 8.9  ±  0.6% of the US hypertensive population in 2003-2008. A time-sequence comparison of NHANES data from 1998 through 2008 suggests that, unlike hypertension, resistant hypertension is becoming more prevalent (e.g., 20.7% in 2005-2008), due to aging and increased obesity in the general population. Resistant hypertension was more frequent in people who were older, obese, male, African American or nonblack Hispanic.

SUMMARY

In coming years, even if the prevalence of hypertension remains stable, resistant hypertension is likely to increase, especially as the proportion of treated hypertension increases. Because of increased use of healthcare resources, resistant hypertensive patients should be identified early, and greater efforts made to control their blood pressures.