Abstract
Introduction: Refractory hypertension is a phenotype of antihypertensive treatment failure defined as uncontrolled BP (> 135/85 mmHg) despite the use of five or more different antihypertensive agents, including long-acting thiazide like diuretic (chlorthalidone) and mineralocorticoid receptor antagonist (Spironolactone or Eplerenone). Recently white coat effect has been shown to be uncommon in patients with refractory hypertension. However, the degree of medication non-adherence, an important cause of apparent refractory hypertension, is unknown. Methods: In this prospective evaluation, 37 refractory hypertensive patients were recruited from the University of Alabama at Birmingham Hypertension Clinic after having uncontrolled BP at three or more clinic visits. All patients were evaluated by automated office BP (AOBP) with the BpTRU device, ambulatory BP monitoring (ABPM), and 24-hr urine collection to detect antihypertensive medication adherence by high-performance liquid chromatography-tandem mass spectrometry. Out of 34 patients who underwent ABPM monitoring, 30 (88%) patients were refractory hypertensive by AOBP and by ABPM. Of these, 27 patients had 24-hr urine collection for detection of prescribed antihypertensive medications or their metabolites. Results: Out of 27 patients, 11 (40.7%) patients had complete adherence with five or more antihypertensive medications, indicating true refractory hypertension. Ten (37.0%) patients were partially adherent, and 6 (22.2%) patients had total non-adherence to their antihypertensive medications. Conclusion: Of patients identified as having apparent refractory hypertension, 40% were adherent with at least 5 of their prescribed antihypertensive agents, confirming true refractory hypertension. The remaining 60% were partially or fully non-adherent. These results indicate that non-adherence is common in patients suspected of having refractory hypertension.
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