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Rivier CA, Acosta JN, Leasure AC, Forman R, Sharma R, de Havenon A, Spatz ES, Inzucchi SE, Kernan WN, Falcone GJ, Sheth KN. Secondary Prevention in Patients With Stroke Versus Myocardial Infarction: Analysis of 2 National Cohorts. J Am Heart Assoc 2024; 13:e033322. [PMID: 38639369 PMCID: PMC11179946 DOI: 10.1161/jaha.123.033322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 03/12/2024] [Indexed: 04/20/2024]
Abstract
BACKGROUND The implementation of preventive therapies among patients with stroke remains inadequately explored, especially when compared with patients with myocardial infarction (MI), despite sharing similar vascular risk profiles. We tested the hypothesis that participants with a history of stroke have a worse cardiovascular prevention profile in comparison to participants with MI. METHODS AND RESULTS In cross-sectional analyses within the UK Biobank and All of Us Research Program, involving 14 760 (9193 strokes, 5567 MIs) and 7315 (2948 strokes, 4367 MIs) participants, respectively, we evaluated cardiovascular prevention profiles assessing low-density lipoprotein (<100 mg/dL), blood pressure (systolic, <140 mm Hg; and diastolic, <90 mm Hg), statin and antiplatelet use, and a cardiovascular prevention score that required meeting at least 3 of these criteria. The results revealed that, within the UK Biobank, patients with stroke had significantly lower odds of meeting all the preventive criteria compared with patients with MI: low-density lipoprotein control (odds ratio [OR], 0.73 [95% CI, 0.68-0.78]; P<0.001), blood pressure control (OR, 0.63 [95% CI, 0.59-0.68]; P<0.001), statin use (OR, 0.45 [95% CI, 0.42-0.48]; P<0.001), antiplatelet therapy use (OR, 0.30 [95% CI, 0.27-0.32]; P<0.001), and cardiovascular prevention score (OR, 0.42 [95% CI, 0.39-0.45]; P<0.001). Similar patterns were observed in the All of Us Research Program, with significant differences across all comparisons (P<0.05), and further analysis suggested that the odds of having a good cardiovascular prevention score were influenced by race and ethnicity as well as neighborhood deprivation levels (interaction P<0.05 in both cases). CONCLUSIONS In 2 independent national cohorts, patients with stroke showed poorer cardiovascular prevention profiles and lower adherence to guideline-directed therapies compared with patients with MI. These findings underscore the need to explore the reasons behind the underuse of secondary prevention in vulnerable stroke survivors.
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Affiliation(s)
- Cyprien A. Rivier
- Department of Neurology, Center for Brain and Mind HealthYale School of MedicineNew HavenCT
| | - Julian N. Acosta
- Department of Neurology, Center for Brain and Mind HealthYale School of MedicineNew HavenCT
| | | | - Rachel Forman
- Department of Neurology, Center for Brain and Mind HealthYale School of MedicineNew HavenCT
| | - Richa Sharma
- Department of Neurology, Center for Brain and Mind HealthYale School of MedicineNew HavenCT
| | - Adam de Havenon
- Department of Neurology, Center for Brain and Mind HealthYale School of MedicineNew HavenCT
| | - Erica S. Spatz
- Section of Cardiovascular MedicineYale School of MedicineNew HavenCT
| | | | - Walter N. Kernan
- Department of Internal MedicineYale School of MedicineNew HavenCT
| | - Guido J. Falcone
- Department of Neurology, Center for Brain and Mind HealthYale School of MedicineNew HavenCT
| | - Kevin N. Sheth
- Department of Neurology, Center for Brain and Mind HealthYale School of MedicineNew HavenCT
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Mostaza JM, Pintó X, Armario P, Masana L, Real JT, Valdivielso P, Arrobas-Velilla T, Baeza-Trinidad R, Calmarza P, Cebollada J, Civera-Andrés M, Cuende Melero JI, Díaz-Díaz JL, Espíldora-Hernández J, Fernández Pardo J, Guijarro C, Jericó C, Laclaustra M, Lahoz C, López-Miranda J, Martínez-Hervás S, Muñiz-Grijalvo O, Páramo JA, Pascual V, Pedro-Botet J, Pérez-Martínez P, Puzo J. SEA 2024 Standards for Global Control of Vascular Risk. CLINICA E INVESTIGACION EN ARTERIOSCLEROSIS : PUBLICACION OFICIAL DE LA SOCIEDAD ESPANOLA DE ARTERIOSCLEROSIS 2024; 36:133-194. [PMID: 38490888 DOI: 10.1016/j.arteri.2024.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Accepted: 02/03/2024] [Indexed: 03/17/2024]
Abstract
One of the objectives of the Spanish Society of Arteriosclerosis is to contribute to the knowledge, prevention and treatment of vascular diseases, which are the leading cause of death in Spain and entail a high degree of disability and health expenditure. Atherosclerosis is a multifactorial disease and its prevention requires a global approach that takes into account the associated risk factors. This document summarises the current evidence and includes recommendations for patients with established vascular disease or at high vascular risk: it reviews the symptoms and signs to evaluate, the laboratory and imaging procedures to request routinely or in special situations, and includes the estimation of vascular risk, diagnostic criteria for entities that are vascular risk factors, and general and specific recommendations for their treatment. Finally, it presents aspects that are not usually referenced in the literature, such as the organisation of a vascular risk consultation.
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Affiliation(s)
- José María Mostaza
- Servicio de Medicina Interna, Unidad de Lípidos y Arteriosclerosis, Hospital La Paz-Carlos III, Madrid, España.
| | - Xavier Pintó
- Unidad de Riesgo Vascular, Servicio de Medicina Interna, Hospital Universitario Bellvitge, Centro de Investigación Biomédica en Red, Fisiopatología de la Obesidad y Nutrición (CIBERobn), Fundación para la Investigación y Prevención de las Enfermedades Cardiovasculares (FIPEC), Universidad de Barcelona, Instituto de Investigación Biomédica de Bellvitge (IDIBELL), Barcelona, España
| | - Pedro Armario
- Servicio de Medicina Interna, Área de Atención Integrada de Riesgo Vascular, Complex Hospitalari Universitari Moisès Broggi, Consorci Sanitari Integral (CSI), Sant Joan Despí, Universidad de Barcelona, Barcelona, España
| | - Luis Masana
- Unidad de Medicina Vascular y Metabolismo (UVASMET), Institut d'Investigació Sanitària Pere Virgili (IISPV), Hospital Universitari Sant Joan de Reus, Centro de Investigación Biomédica en Red de Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Universitat Rovira i Virgili, Tarragona, España
| | - José T Real
- Servicio de Endocrinología y Nutrición, Hospital Clínico, Universidad de València, Valencia, España; Departamento de Medicina, Universidad de Valencia, Valencia, España; CIBER de Diabetes y Enfermedades Metabólicas (CIBERDEM), Instituto de Salud Carlos III (ISCIII), Madrid, España
| | - Pedro Valdivielso
- Unidad de Lípidos, Servicio de Medicina Interna, Hospital Universitario Virgen de la Victoria, Málaga, España; Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina (IBIMA-Bionand), Universidad de Málaga, Málaga, España
| | - Teresa Arrobas-Velilla
- Laboratorio de Nutrición y RCV, UGC de Bioquímica clínica, Hospital Virgen Macarena, Sevilla, España
| | | | - Pilar Calmarza
- Servicio de Bioquímica Clínica, Hospital Universitario Miguel Servet, Zaragoza, España; Centro de Investigación en Red en Enfermedades Cardiovasculares (CIBERCV), Instituto de Investigación Sanitaria (ISS) de Aragón, Universidad de Zaragoza, Zaragoza, España
| | - Jesús Cebollada
- Servicio de Medicina Interna, Hospital Clínico Universitario Lozano Blesa, Zaragoza, España
| | - Miguel Civera-Andrés
- Servicio de Endocrinología y Nutrición, Hospital Clínico, Universidad de València, Valencia, España; Departamento de Medicina, Universidad de Valencia, Valencia, España
| | - José I Cuende Melero
- Consulta de Riesgo Cardiovascular, Servicio de Medicina Interna, Complejo Asistencial Universitario de Palencia, Palencia, España
| | - José L Díaz-Díaz
- Sección de Medicina Interna, Unidad de Lípidos y Riesgo Cardiovascular, Hospital Abente y Lago Complejo Hospitalario Universitario A Coruña, La Coruña, España
| | - Javier Espíldora-Hernández
- Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina (IBIMA-Bionand), Universidad de Málaga, Málaga, España; Unidad de Lípidos y Unidad Asistencial de Hipertensión Arterial- Riesgo Vascular (HTA-RV), UGC Medicina Interna, Hospital Universitario Virgen de la Victoria, Málaga, España
| | - Jacinto Fernández Pardo
- Servicio de Medicina Interna, Hospital General Universitario Reina Sofía de Murcia, Universidad de Murcia, Murcia, España
| | - Carlos Guijarro
- Unidad de Medicina Interna, Hospital Universitario Fundación Alcorcón, Universidad Rey Juan Carlos, Alcorón, España
| | - Carles Jericó
- Servicio de Medicina Interna, Área de Atención Integrada de Riesgo Vascular, Complex Hospitalari Universitari Moisès Broggi, Consorci Sanitari Integral (CSI), Sant Joan Despí, Universidad de Barcelona, Barcelona, España
| | - Martín Laclaustra
- Centro de Investigación en Red en Enfermedades Cardiovasculares (CIBERCV), Instituto de Investigación Sanitaria (ISS) de Aragón, Universidad de Zaragoza, Zaragoza, España
| | - Carlos Lahoz
- Servicio de Medicina Interna, Unidad de Lípidos y Arteriosclerosis, Hospital La Paz-Carlos III, Madrid, España
| | - José López-Miranda
- Unidad de Lípidos y Arteriosclerosis, UGC de Medicina Interna, Hospital Universitario Reina Sofía, Córdoba, España; Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Universidad de Córdoba, Córdoba, España; CIBER Fisiopatología de la Obesidad y Nutrición (CIBEROBN), Instituto de Salud Carlos III (ISCIII), Madrid, España
| | - Sergio Martínez-Hervás
- Servicio de Endocrinología y Nutrición, Hospital Clínico, Universidad de València, Valencia, España; Departamento de Medicina, Universidad de Valencia, Valencia, España; CIBER de Diabetes y Enfermedades Metabólicas (CIBERDEM), Instituto de Salud Carlos III (ISCIII), Madrid, España
| | - Ovidio Muñiz-Grijalvo
- Servicio de Medicina Interna, UCERV, UCAMI, Hospital Virgen del Rocío de Sevilla, Sevilla, España
| | - José A Páramo
- Servicio de Hematología, Clínica Universidad de Navarra, Navarra, España; Laboratorio Aterotrombosis, CIMA, Universidad de Navarra, Pamplona, España
| | - Vicente Pascual
- Centro de Salud Palleter, Universidad CEU-Cardenal Herrera, Castellón, España
| | - Juan Pedro-Botet
- Unidad de Lípidos y Riesgo Vascular, Servicio de Endocrinología y Nutrición, Hospital del Mar, Universitat Autònoma de Barcelona, Barcelona, España
| | - Pablo Pérez-Martínez
- Unidad de Lípidos y Arteriosclerosis, UGC de Medicina Interna, Hospital Universitario Reina Sofía, Córdoba, España; Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Universidad de Córdoba, Córdoba, España; CIBER Fisiopatología de la Obesidad y Nutrición (CIBEROBN), Instituto de Salud Carlos III (ISCIII), Madrid, España
| | - José Puzo
- Servicio de Bioquímica Clínica, Unidad de Lípidos, Hospital General Universitario San Jorge de Huesca, Huesca, España; Departamento de Medicina, Universidad de Zaragoza, Zaragoza, España
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Filippone EJ, Naccarelli GV, Foy AJ. Controversies in Hypertension V: Resistant and Refractory Hypertension. Am J Med 2024; 137:12-22. [PMID: 37832756 DOI: 10.1016/j.amjmed.2023.09.015] [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: 09/24/2023] [Accepted: 09/26/2023] [Indexed: 10/15/2023]
Abstract
Apparent resistant hypertension, defined as uncontrolled office blood pressure despite ≥ 3 antihypertensive medications including a diuretic or use of ≥ 4 medications regardless of blood pressure, occurs in ≤ 15% of treated hypertensives. Apparent refractory hypertension, defined as uncontrolled office pressure despite use of 5 or more medications including a diuretic, occurs in ≤ 10% of resistant cases. Both are associated with increased comorbidity and enhanced cardiovascular risk. To rule out pseudo-resistant or pseudo-refractory hypertension, employ guideline-based methodology for obtaining pressure, maximize the regimen, rule out white-coat effect, and assess adherence. True resistant hypertension is characterized by volume overload and aldosterone excess, refractory by enhanced sympathetic tone. Spironolactone is the preferred agent for resistance, with lower doses. Spironolactone, potassium binders, or both, are preferred if the estimated glomerular filtration rate is below 45. If significant albuminuria, finerenone is indicated. The optimal treatment of refractory hypertension is unclear, but sympathetic inhibition (α-β blockade, centrally acting sympathoinhibitors, or both) seems reasonable. Renal denervation has shown minimal benefit for resistance, but its role in refractory hypertension remains to be defined.
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Affiliation(s)
- Edward J Filippone
- Division of Nephrology, Department of Medicine, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pa.
| | - Gerald V Naccarelli
- Department of Medicine, Penn State University Heart and Vascular Institute, Penn State M.S. Hershey Medical Center and College of Medicine, Hershey, Pa
| | - Andrew J Foy
- Department of Medicine, Penn State University Heart and Vascular Institute, Penn State M.S. Hershey Medical Center and College of Medicine, Hershey, Pa
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Park S, Shin J, Ihm SH, Kim KI, Kim HL, Kim HC, Lee EM, Lee JH, Ahn SY, Cho EJ, Kim JH, Kang HT, Lee HY, Lee S, Kim W, Park JM. Resistant hypertension: consensus document from the Korean society of hypertension. Clin Hypertens 2023; 29:30. [PMID: 37908019 PMCID: PMC10619268 DOI: 10.1186/s40885-023-00255-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 10/09/2023] [Indexed: 11/02/2023] Open
Abstract
Although reports vary, the prevalence of true resistant hypertension and apparent treatment-resistant hypertension (aTRH) has been reported to be 10.3% and 14.7%, respectively. As there is a rapid increase in the prevalence of obesity, chronic kidney disease, and diabetes mellitus, factors that are associated with resistant hypertension, the prevalence of resistant hypertension is expected to rise as well. Frequently, patients with aTRH have pseudoresistant hypertension [aTRH due to white-coat uncontrolled hypertension (WUCH), drug underdosing, poor adherence, and inaccurate office blood pressure (BP) measurements]. As the prevalence of WUCH is high among patients with aTRH, the use of out-of-office BP measurements, both ambulatory blood pressure monitoring (ABPM) and home blood pressure monitoring (HBPM), is essential to exclude WUCH. Non-adherence is especially problematic, and methods to assess adherence remain limited and often not clinically feasible. Therefore, the use of HBPM and higher utilization of single-pill fixed-dose combination treatments should be emphasized to improve drug adherence. In addition, primary aldosteronism and symptomatic obstructive sleep apnea are quite common in patients with hypertension and more so in patients with resistant hypertension. Screening for these diseases is essential, as the treatment of these secondary causes may help control BP in patients who are otherwise difficult to treat. Finally, a proper drug regimen combined with lifestyle modifications is essential to control BP in these patients.
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Affiliation(s)
- Sungha Park
- Division of Cardiology, Severance Cardiovascular Hospital, Integrative Research Center for Cerebrovascular and Cardiovascular Diseases, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jinho Shin
- Division of Cardiology, Department of Internal Medicine, Hanyang University Seoul Hospital, Seoul, South Korea
| | - Sang Hyun Ihm
- Division of Cardiology, Department of Internal Medicine, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Bucheon, Republic of Korea.
- Catholic Research Institute for Intractable Cardiovascular Disease, College of Medicine, The Catholic University of Korea, Bucheon St. Mary's Hospital327 Sosa-Ro, Wonmi-guGyunggi-do, Bucheon-si, 14647, Republic of Korea.
| | - Kwang-Il Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea
| | - Hack-Lyoung Kim
- Division of Cardiology, Department of Internal Medicine, Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
| | - Hyeon Chang Kim
- Department of Preventive Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Eun Mi Lee
- Division of Cardiology, Department of Internal Medicine, Wonkwang University Sanbon Hospital, Wonkwang University College of Medicine, Gunpo, Republic of Korea
| | - Jang Hoon Lee
- Department of Internal Medicine, Kyungpook National University Hospital, Daegu, South Korea
- School of Medicine, Kyungpook National University, Daegu, South Korea
| | - Shin Young Ahn
- Division of Nephrology, Department of Internal Medicine, Korea University Guro Hospital, Seoul, South Korea
| | - Eun Joo Cho
- Division of Cardiology, Department of Internal Medicine, The Catholic University of Korea, Seoul, Korea
| | - Ju Han Kim
- Department of Cardiovascular Medicine, Chonnam National University Hospital, Gwangju, Korea
| | - Hee-Taik Kang
- Department of Family Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hae-Young Lee
- Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Sunki Lee
- Hallym University, Dongtan Hospital, Gyeonggi-do, Korea
| | - Woohyeun Kim
- Division of Cardiology, Department of Internal Medicine, Hanyang University Seoul Hospital, Seoul, Korea
| | - Jong-Moo Park
- Department of Neurology, Uijeongbu Eulji Medical Center, Eulji University, Uijeongbu, South Korea
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Mesquita Bastos J, Ferraz L, Pereira FG, Lopes S. Systolic Blood Pressure and Pulse Pressure Are Predictors of Future Cardiovascular Events in Patients with True Resistant Hypertension. Diagnostics (Basel) 2023; 13:diagnostics13101817. [PMID: 37238300 DOI: 10.3390/diagnostics13101817] [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: 02/21/2023] [Revised: 05/13/2023] [Accepted: 05/15/2023] [Indexed: 05/28/2023] Open
Abstract
Given the increased risk of cardiovascular events associated with resistant hypertension, predictive cardiovascular prognosis is extremely important. Ambulatory blood pressure monitoring (ABPM) is mandatory for resistant hypertension diagnosis, but its use for prognosis is scarce. This observational longitudinal study included 258 patients (mean age of 60.4 ± 11.2 years; 61.2% male), who underwent 24 h ABPM in a hypertension unit from 1999 to 2019. The outcomes were global cardiovascular events (cerebrovascular, coronary, and other cardiovascular events). The mean follow-up period was 6.0 ± 5.0 years. Sixty-eight cardiovascular events (61 nonfatal) were recorded. Patients who experienced cardiovascular events were generally older, with higher rates of chronic kidney disease and prior cardiovascular events. The 24 h systolic blood pressure (hazard ratio 1.44; 95% CI 1.10-1.88), night systolic blood pressure (1.35; 95% CI 1.01-1.80), and 24 h pulse pressure (2.07; 95% CI 1.17-3.67) were independent predictors of global cardiovascular events. Multivariate Cox analysis revealed a higher risk of future cardiovascular events, particularly in patients with a 24 h daytime and nighttime pulse pressure > 60 mm Hg with respective hazard ratios of 1.95; 95% CI 1.01-3.45; 2.15; 95% CI 1.21-3.83 and 2.07; 95% CI 1.17-3.67. In conclusion, APBM is a fundamental tool not only for the diagnosis of resistant hypertension, but also for predicting future cardiovascular events.
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Affiliation(s)
- J Mesquita Bastos
- School of Health Sciences and Institute of Biomedicine-iBiMED, University of Aveiro, 3810-193 Aveiro, Portugal
- Cardiology Department, Centro Hospitalar do Baixo Vouga, 3810-164 Aveiro, Portugal
| | - Lisa Ferraz
- Internal Medicine Department, Centro Hospitalar do Baixo Vouga, 3810-164 Aveiro, Portugal
| | - Flávio G Pereira
- Internal Medicine Department, Centro Hospitalar do Baixo Vouga, 3810-164 Aveiro, Portugal
| | - Susana Lopes
- School of Health Sciences and Institute of Biomedicine-iBiMED, University of Aveiro, 3810-193 Aveiro, Portugal
- Polytechnic of Coimbra, ESTeSCoimbra Health School, Physiotherapy Department, 3040-854 Coimbra, Portugal
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Mehta ND, Battle SJ, DiPette DJ. Cardiac structure and function in resistant hypertension: The beneficial role of blood pressure control. J Clin Hypertens (Greenwich) 2023; 25:426-428. [PMID: 36861493 PMCID: PMC10184487 DOI: 10.1111/jch.14626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 12/13/2022] [Accepted: 12/14/2022] [Indexed: 03/03/2023]
Affiliation(s)
- Neil D Mehta
- Department of Internal Medicine, Prisma Health/University of South Carolina and University of South Carolina School of Medicine, Columbia, South Carolina, USA
| | - Sean J Battle
- Department of Internal Medicine, Prisma Health/University of South Carolina and University of South Carolina School of Medicine, Columbia, South Carolina, USA
| | - Donald J DiPette
- Department of Internal Medicine, University of South Carolina and University of South Carolina School of Medicine, Columbia, South Carolina, USA
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7
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The Effect of Renal Denervation on T Cells in Patients with Resistant Hypertension. Int J Mol Sci 2023; 24:ijms24032493. [PMID: 36768814 PMCID: PMC9917284 DOI: 10.3390/ijms24032493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Revised: 01/21/2023] [Accepted: 01/23/2023] [Indexed: 02/03/2023] Open
Abstract
(1) Background: Sympathetic overactivity is a major contributor to resistant hypertension (RH). According to animal studies, sympathetic overactivity increases immune responses, thereby aggravating hypertension and cardiovascular outcomes. Renal denervation (RDN) reduces sympathetic nerve activity in RH. Here, we investigate the effect of RDN on T-cell signatures in RH. (2) Methods: Systemic inflammation and T-cell subsets were analyzed in 17 healthy individuals and 30 patients with RH at baseline and 6 months after RDN. (3) Results: The patients with RH demonstrated higher levels of pro-inflammatory cytokines and higher frequencies of CD4+ effector memory (TEM), CD4+ effector memory residential (TEMRA) and CD8+ central memory (TCM) cells than the controls. After RDN, systolic automated office blood pressure (BP) decreased by -17.6 ± 18.9 mmHg. Greater BP reductions were associated with higher CD4+ TEM (r -0.421, p = 0.02) and CD8+ TCM (r -0.424, p = 0.02) frequencies at baseline. The RDN responders, that is, the patients with ≥10mmHg systolic BP reduction, showed reduced pro-inflammatory cytokine levels, whereas the non-responders had unchanged inflammatory activity and higher CD8+ TEMRA frequencies with increased cellular cytokine production. (4) Conclusions: The pro-inflammatory state of patients with RH is characterized by altered T-cell signatures, especially in non-responders. A detailed analysis of T cells might be useful in selecting patients for RDN.
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Kuzmin OB, Zhezha VV. Refractory Arterial Hypertension: Features of Neurohormonal and Water-salt Imbalanceand Approaches to Antihypertensive Drug Therapy. RATIONAL PHARMACOTHERAPY IN CARDIOLOGY 2022. [DOI: 10.20996/1819-6446-2022-08-14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Refractory arterial hypertension is characterized by a lack of control of target blood pressure, despite the prolonged use >5 antihypertensive drugs with different mechanisms of action, including longacting diuretic chlorthalidone and the mineralcorticoid receptor antagonists (spironolactone or eplerenone). The review presents the results of clinical studies devoted the elucidating peculiarities of the neurohormonal status and water-salt balance in such patients and developing new approaches to antihypertensive drug therapy based on them. According to these studies, individuals with refractory hypertension differ from patients with resistant hypertension with the higher of sympathetic nervous system activity and the absence of an increased of intrathoracic fluid volume, which indirectly indicates a significant decrease in the intravascular fluid volume. In this regard, the review focuses on the data obtained in assessing the clinical efficacy of sympatholytics clonidine and reserpine in patients with resistant and refractory hypertension, as well as renal sodium-glucose co-transporter type 2 inhibitors, which suppress the sympathetic nervous system activity and can be used to overcome refractory hypertension in patients with type 2 diabetes.
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Renal Denervation for Resistant Hypertension: A Concise Update on Treatment Options and the Latest Clinical Evidence. Cardiol Ther 2022; 11:385-392. [PMID: 35943714 PMCID: PMC9381663 DOI: 10.1007/s40119-022-00275-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 07/22/2022] [Indexed: 11/21/2022] Open
Abstract
Evidence from recent sham-controlled trials supports the use of endovascular renal denervation (RDN) to lower blood pressure in general as well as in treatment-resistant hypertension. According to recent studies, the effects of RDN are long lasting. Newer technologies using multipolar radiofrequency catheters and an additional ablation of the renal side branches as well as ultrasound with improved circumferential tissue penetration have made these advances possible. This has initiated a change of the perspective on RDN in clinical guidelines and has thereby set a cornerstone for a broader clinical application of RDN in the future.
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Zhang W, Deng G, Hu J, Yan R, Hu J, Fan J. Effects of Carvedilol on Blood Pressure, Blood Sugar, and Blood Lipids in Elderly Patients with Refractory Hypertension. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2022; 2022:7889024. [PMID: 35936366 PMCID: PMC9348927 DOI: 10.1155/2022/7889024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 06/15/2022] [Accepted: 06/20/2022] [Indexed: 11/17/2022]
Abstract
Refractory hypertension seriously affects the life safety of patients. To investigate the effect of carvedilol combined with conventional antihypertensive therapy on blood pressure, blood sugar, blood lipids, and cardiovascular and cerebrovascular complications in elderly patients with refractory hypertension, a total of 80 elderly patients with refractory hypertension who were admitted from June 2019 to September 2021 were selected as the retrospective research objects and divided into the observation group and the control group according to the random number table method, 40 cases in each group, and the control group received conventional antihypertensive therapy. On this basis, the observation group was treated with carvedilol, and the effects of blood pressure, blood sugar, blood lipids, and cardiovascular and cerebrovascular complications were analyzed in the two groups. After treatment, the systolic blood pressure, diastolic blood pressure, adrenal medulla (AM), and endothelin (ET) of the observation group were significantly lower than those of the control group, but the heart rate and NO of the observation group were significantly higher than those of the control group. After treatment, the fasting blood glucose, insulin, triacylglycerol (TG), cholesterol (CHO), and low-density lipoprotein (LDL-C) of the observation group were significantly higher than those of the control group, but the ISI and HDL-C of the observation group were significantly lower than those of the control group. After treatment, the levels of IL-1β, IL-6, TNF-α, UAER, BUN, and SCr in the observation group were significantly lower than those in the control group. The TC of the observation group was lower than that of the control group. Combination therapy has a remarkably stable, sustained, and safe antihypertensive effect on patients with refractory hypertension.
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Affiliation(s)
- Wen Zhang
- The First Hospital of Hunan University of Chinese Medicine, Department of Geriatrics, No. 95 Shaoshan Middle Road, Yuhua District, Changsha City, Hunan Province, China
| | - Guiming Deng
- The First Hospital of Hunan University of Chinese Medicine, Department of Geriatrics, No. 95 Shaoshan Middle Road, Yuhua District, Changsha City, Hunan Province, China
| | - Jia Hu
- Hunan University of Chinese Medicine, Graduate School, Xiangzui Road, Yuelu District, Changsha City, Hunan Province, China
| | - Ran Yan
- Hunan University of Chinese Medicine, School of Traditional Chinese Medicine, Xiangzui Road, Yuelu District, Changsha City, Hunan Province, China
| | - Junliu Hu
- Hunan University of Chinese Medicine, Graduate School, Xiangzui Road, Yuelu District, Changsha City, Hunan Province, China
| | - Jianmin Fan
- The First Hospital of Hunan University of Chinese Medicine, Department of Cardiovascular Diseases, No. 95 Shaoshan Middle Road, Yuhua District, Changsha City, Hunan Province, China
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11
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SEA 2022 Standards for Global Control of Cardiovascular Risk. CLINICA E INVESTIGACION EN ARTERIOSCLEROSIS : PUBLICACION OFICIAL DE LA SOCIEDAD ESPANOLA DE ARTERIOSCLEROSIS 2022; 34:130-179. [PMID: 35090775 DOI: 10.1016/j.arteri.2021.11.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 10/27/2021] [Accepted: 11/10/2021] [Indexed: 02/07/2023]
Abstract
One of the objectives of the Spanish Society of Arteriosclerosis is to contribute to better knowledge of vascular disease, its prevention and treatment. It is well known that cardiovascular diseases are the leading cause of death in our country and entail a high degree of disability and health care costs. Arteriosclerosis is a multifactorial disease and therefore its prevention requires a global approach that takes into account the different risk factors with which it is associated. Therefore, this document summarizes the current level of knowledge and includes recommendations and procedures to be followed in patients with established cardiovascular disease or at high vascular risk. Specifically, this document reviews the main symptoms and signs to be evaluated during the clinical visit, the laboratory and imaging procedures to be routinely requested or requested for those in special situations. It also includes vascular risk estimation, the diagnostic criteria of the different entities that are cardiovascular risk factors, and makes general and specific recommendations for the treatment of the different cardiovascular risk factors and their final objectives. Finally, the document includes aspects that are not usually referenced in the literature, such as the organization of a vascular risk consultation.
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Pio-Abreu A, Trani-Ferreira F, Silva GV, Bortolotto LA, Drager LF. Directly observed therapy for resistant/refractory hypertension diagnosis and blood pressure control. Heart 2022; 108:1952-1956. [PMID: 35444006 DOI: 10.1136/heartjnl-2022-320802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 04/04/2022] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To test the impact of directly observed therapy (DOT) at hospital for checking not only adherence/diagnosis in patients with resistant (RHTN) and refractory (RefHTN) hypertension but also blood pressure (BP) control after hospital discharge. METHODS During 2 years, Brazilian patients with clinical suspicion of RHTN/RefHTN after several attempts (≥3) to control BP in the outpatient setting were invited to perform DOT (including low-sodium diet and supervised medications intake) at the hospital. RHTN and RefHTN were categorised using standard definitions. After hospital discharge, we evaluated the BP values and the number of antihypertensive drugs prescribed by physicians who were not involved with the investigation. RESULTS We studied 83 patients clinically suspected for RHTN (31%) and RefHTN (69%) (mean age: 53 years; 76% female; systolic BP 177±28 mm Hg and diastolic BP 106±21 mm Hg; number of antihypertensive drugs: 5.3±1.3). DOT confirmed RHTN in 77%, whereas RefHTN was confirmed in only 32.5%. The number of antihypertensive drugs reduced to 4.5±1.3 and systolic/diastolic BP at hospital discharge reduced to 131±17 mm Hg/80±12 mm Hg. After hospital discharge, systolic BP remained significantly lower than the last outpatient visit prehospital admission (delta changes (95% CI): 1 month: -25.7 (-33.8 to -17.6) mm Hg; 7 months: -27.3 (-35.5 to -19.1) mm Hg) despite fewer number of antihypertensive classes (1 month: -1.01 (-1.36 to -0.67); 7 months: -0.77 (-1.11 to -0.42)). Similar reductions were observed for diastolic BP. CONCLUSIONS DOT at hospital is helpful not only in confirming/excluding RHTN/RefHTN phenotypes, but also in improving BP values and BP control and in reducing the need for antihypertensive drugs after hospital discharge.
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Affiliation(s)
- Andrea Pio-Abreu
- Unidade de Hipertensão, Disciplina de Nefrologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Fernanda Trani-Ferreira
- Unidade de Hipertensão, Disciplina de Nefrologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Giovanio V Silva
- Unidade de Hipertensão, Disciplina de Nefrologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Luiz A Bortolotto
- Unidade de Hipertensão, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Luciano F Drager
- Unidade de Hipertensão, Disciplina de Nefrologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil .,Unidade de Hipertensão, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
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Abstract
Purpose of Review To update on definition, diagnosis, prevalence, patient characteristics, pathophysiology, and treatment of refractory hypertension (RfHTN). Recent Findings Refractory hypertension (RfHTN) is defined as blood pressure (BP) that is uncontrolled despite using ≥ 5 antihypertensive medications of different classes, including a long-acting thiazide diuretic and a mineralocorticoid receptor antagonist (MRA) at maximal or maximally tolerated doses. This new phenotype is different from resistant hypertension (RHTN), defined as BP that is uncontrolled despite using ≥ 3 medications, commonly a long-acting calcium channel blocker (CCB), a blocker of the renin-angiotensin system (angiotensin-converting enzyme [ACE] inhibitor or angiotensin receptor blocker [ARB]), and a diuretic. The RHTN phenotype includes controlled RHTN, BP that is controlled on 4 or more medications. RfHTN is largely attributable to increased sympathetic activity, unlike RHTN, which is mainly due to increased intravascular fluid volume frequently caused by hyperaldosteronism and chronic excessive sodium ingestion. Compared to those with controlled RHTN, patients with RfHTN have a higher prevalence of target organ damage and do not have elevated aldosterone levels. Ongoing clinical trials are assessing the safety and efficacy of using devices to aid with BP control in patients with RfHTN. Summary RfHTN is a separate entity from RHTN and is generally attributable to increased sympathetic activity.
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Bacan G, Ribeiro-Silva A, Oliveira VAS, Cardoso CRL, Salles GF. Refractory Hypertension: a Narrative Systematic Review with Emphasis on Prognosis. Curr Hypertens Rep 2022; 24:95-106. [PMID: 35107787 DOI: 10.1007/s11906-022-01165-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/09/2021] [Indexed: 12/31/2022]
Abstract
PURPOSE OF REVIEW To perform a narrative systematic review on refractory hypertension (RfHT) with particular emphasis on prognosis. RECENT FINDINGS There were 37 articles on RfHT, 13 non-systematic reviews, and 24 original studies. RfHT, a recently described extreme phenotype of anti-hypertensive treatment failure, shall be defined as uncontrolled out-of-office blood pressure (BP) levels despite the use of at least 5 anti-hypertensive drugs, including a long-acting diuretic and a mineraloreceptor antagonist. Its prevalence ranges from 0.5 to 4.3% of general treated hypertensives and between 3.6 and 51.4% of patients with resistant hypertension (RHT). RfHT is associated with younger age, African ancestry, obesity, hypertension-mediated organ damage and clinical cardiovascular diseases, and with some comorbidities, such as diabetes and obstructive sleep apnea. Its physiopathological mechanisms probably involve sympathetic overactivity and not volume overload. Patients with RfHT have a worse prognosis than non-refractory RHT individuals, with higher risks of adverse cardiovascular and renal outcomes and of mortality. RfHT represents a rare but true extreme phenotype of anti-hypertensive treatment failure distinct from RHT and with a significantly worse prognosis. Identifying such individuals is important to tailor specific interventions.
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Affiliation(s)
- Giovanna Bacan
- Department of Internal Medicine, School of Medicine, Universidade Federal do Rio de Janeiro, Rua Croton, 72, Jacarepagua, Rio de Janeiro - RJ, CEP: 22750-240, Brazil
| | - Angélica Ribeiro-Silva
- Department of Internal Medicine, School of Medicine, Universidade Federal do Rio de Janeiro, Rua Croton, 72, Jacarepagua, Rio de Janeiro - RJ, CEP: 22750-240, Brazil
| | - Vinicius A S Oliveira
- Department of Internal Medicine, School of Medicine, Universidade Federal do Rio de Janeiro, Rua Croton, 72, Jacarepagua, Rio de Janeiro - RJ, CEP: 22750-240, Brazil
| | - Claudia R L Cardoso
- Department of Internal Medicine, School of Medicine, Universidade Federal do Rio de Janeiro, Rua Croton, 72, Jacarepagua, Rio de Janeiro - RJ, CEP: 22750-240, Brazil
| | - Gil F Salles
- Department of Internal Medicine, School of Medicine, Universidade Federal do Rio de Janeiro, Rua Croton, 72, Jacarepagua, Rio de Janeiro - RJ, CEP: 22750-240, Brazil.
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Denisova AR, Solntseva TD, Zarmanbetova AS, Tkacheva AA, Sivakova OA, Chazova IЕ. The incidence of cardiovascular and cerebrovascular complications in patients with uncontrolled hypertension. TERAPEVT ARKH 2022; 94:94-99. [DOI: 10.26442/00403660.2022.01.201395] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Accepted: 03/12/2022] [Indexed: 11/22/2022]
Abstract
Aim. To assess the incidence of cardiovascular and cerebrovascular events in patients with controlled and uncontrolled hypertension, controlled resistant and uncontrolled resistant hypertension, refractory hypertension, and probably resistant and probably refractory hypertension.
Materials and methods. A telephone call was made to 256 patients with hypertension included in the database to assess the incidence of cardiovascular and cerebrovascular diseases. All responding patients were divided into 7 groups according to the classification of hypertension based on the achievement/non-achievement of target blood pressure values and the number of drugs taken (controlled and uncontrolled hypertension, controlled resistant and uncontrolled resistant hypertension, refractory hypertension, and probably resistant and probably refractory hypertension). The target blood pressure was considered to be less than 140/90 mm Hg. Patients not adhering to medication were not included in the analysis.
Results. The group of controlled hypertension included 146 (57%) patients out of 256, controlled resistant hypertension 36 (14%) patients, uncontrolled hypertension 6 (2.3%) patients, resistant uncontrolled hypertension 22 (8.6%) patients, refractory hypertension 31 (12.1%) patients. The group of probably resistant hypertension 6 (2.3%) patients, probably refractory hypertension 9 (3.5%) patients. Of the 28 events that occurred, 6 were attributed to coronary artery disease (including 3 acute myocardial infarction and 2 coronary artery stenting), 3 strokes, 6 episodes of transient ischemic attack and 10 new cases of atrial fibrillation, and 2 patients had sudden cardiac death. Significantly more often, patients with refractory hypertension developed any event compared with patients with controlled (38.7% versus 3.4%; p=0.005) and resistant hypertension (38.7% versus 13.6%; p=0.04). Also, patients from the group of probably refractory hypertension were more likely to develop events than patients with controlled hypertension (33.3% versus 3.4%; p=0.045). Patients with probably refractory hypertension significantly more often had a stroke than patients with controlled hypertension (22.2% versus 0%; p0.05), and patients with refractory hypertension significantly more often had a transient ischemic attack compared with patients from the group of controlled hypertension (12.9% versus 0.7%; p=0.03).
Conclusion. Patients with refractory and probably refractory hypertension are significantly more likely to develop cardiovascular and cerebrovascular complications than patients with controlled hypertension.
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Yoon M, You SC, Oh J, Lee CJ, Lee SH, Kang SM, Park S. Prevalence and prognosis of refractory hypertension diagnosed using ambulatory blood pressure measurements. Hypertens Res 2022; 45:1353-1362. [PMID: 35027714 DOI: 10.1038/s41440-021-00845-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 12/07/2021] [Accepted: 12/09/2021] [Indexed: 11/09/2022]
Abstract
The prognosis of refractory hypertension is largely unknown due to its low prevalence. This study aimed to investigate the prognosis of refractory hypertension and compare it with those of resistant and nonresistant hypertension. We retrospectively analyzed the data of 16,284 participants with hypertension who underwent ambulatory blood pressure (BP) monitoring between 2012 and 2019 at a tertiary center. Uncontrolled BP was defined as a 24-h BP ≥ 130/80 mmHg as assessed by ambulatory BP monitoring. Resistant hypertension was defined as uncontrolled BP despite the use of three antihypertensive medications, including a diuretic or the use of ≥4 drugs regardless of BP control. Refractory hypertension was defined as uncontrolled BP despite the use of ≥5 antihypertensive medications. Among 16,284 patients with hypertension (mean age 59.2 ± 15.5 years, 52.7% men), 1501 (9.2%) and 150 (0.9%) patients had resistant and refractory hypertension, respectively. The prevalence of chronic kidney disease, end-stage renal disease, heart failure, previous stroke, left ventricular hypertrophy, and the riser/nondipper patterns of circadian BP rhythm progressively increased from patients with nonresistant hypertension to patients with resistant hypertension to patients with refractory hypertension. During a median follow-up of 3.9 years, the risk of cardiovascular mortality progressively increased from patients with nonresistant hypertension to patients with resistant hypertension (hazard ratio 1.62, 95% confidence interval 1.16-2.26) to patients with refractory hypertension (hazard ratio 5.22, 95% confidence interval 3.04-8.96). In conclusion, refractory hypertension, defined as uncontrolled ambulatory BP levels, was associated with a higher risk of all-cause and cardiovascular mortality than nonresistant or resistant hypertension.
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Affiliation(s)
- Minjae Yoon
- Division of Cardiology, Severance Cardiovascular Hospital, Cardiovascular Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Seng Chan You
- Department of Preventive Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jaewon Oh
- Division of Cardiology, Severance Cardiovascular Hospital, Cardiovascular Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Chan Joo Lee
- Division of Cardiology, Severance Cardiovascular Hospital, Cardiovascular Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sang-Hak Lee
- Division of Cardiology, Severance Cardiovascular Hospital, Cardiovascular Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Seok-Min Kang
- Division of Cardiology, Severance Cardiovascular Hospital, Cardiovascular Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sungha Park
- Division of Cardiology, Severance Cardiovascular Hospital, Cardiovascular Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea.
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Cardoso CRL, Salles GF. Refractory Hypertension and Risks of Adverse Cardiovascular Events and Mortality in Patients With Resistant Hypertension: A Prospective Cohort Study. J Am Heart Assoc 2020; 9:e017634. [PMID: 32851922 PMCID: PMC7660786 DOI: 10.1161/jaha.120.017634] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Background The long‐term prognosis of refractory hypertension (RfHT), defined as failure to control blood pressure (BP) levels despite an antihypertensive treatment with ≥5 medications including a diuretic and mineraloreceptor antagonist, has never been evaluated. Methods and Results In a prospective cohort study with 1576 patients with resistant hypertension, patients were classified as refractory or nonrefractory based on uncontrolled clinic (or office) and ambulatory BPs during the first 2 years of follow‐up. Multivariate Cox analyses examined the associations between the diagnosis of RfHT and the occurrence of total cardiovascular events (CVEs), major adverse CVEs, and cardiovascular and all‐cause mortality, after adjustments for other risk factors. In total, 135 patients (8.6%) had RfHT by uncontrolled ambulatory BPs and 167 (10.6%) by uncontrolled clinic BPs. Over a median Follow‐Up of 8.9 years, 338 total CVEs occurred (288 major adverse CVEs, including 124 myocardial infarctions, and 96 strokes), and 331 patients died, 196 from cardiovascular causes. The diagnosis of RfHT, using either classification by clinic or ambulatory BPs, was associated with significantly higher risks of major adverse CVEs, cardiovascular mortality, and stroke incidence, with hazard ratios varying from 1.54 to 2.14 in relation to patients with resistant nonrefractory hypertension; however, the classification based on ambulatory BPs was better in identifying higher risk patients than the classification based on clinic BP levels. Conclusions Patients with RfHT, particularly when defined by uncontrolled ambulatory BP levels, had higher risks of major adverse CVEs and mortality in relation to patients with resistant but nonrefractory hypertension, supporting the concept of refractory hypertension as a true extreme phenotype of antihypertensive treatment failure.
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Affiliation(s)
- Claudia R L Cardoso
- Department of Internal Medicine School of Medicine University Hospital Clementino Fraga Filho Universidade Federal do Rio de Janeiro Brazil
| | - Gil F Salles
- Department of Internal Medicine School of Medicine University Hospital Clementino Fraga Filho Universidade Federal do Rio de Janeiro Brazil
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