Efectos de la administración temporalizada de fármacos antihipertensivos en pacientes con hipertensión arterial resistente

Abstract

Patients with resistant hypertension represent an important clinical problem due to their poor control, high prevalence of target organ damage, and the associated increase in cardiovascular risk. Therapeutic strategies in resistant hypertension currently include a sequential change of drugs or the synergic combination of new drugs. Most patients, however, receive all their drugs in a single morning dose. We have evaluated the impact on the circadian pattern of blood pressure (BP) of modifying the time of treatment without increasing the number of prescribed drugs. We studied 123 patients with resistant hypertension (73 men and 50 women), 59.9 (11.9) years of age, who were receiving 3 antihypertensive drugs in a single morning dose. Patients were randomly assigned to one of two groups according to the modification in their treatment strategy: a) Changing one of the drugs, but keeping all 3 in the morning. b) The same approach but prescribing one of the drugs to be taken at bedtime. Blood pressure was measured at 20-minute intervals from 07:00 to 23:00 hours and at 30-minute intervals at night for 48 consecutive hours at baseline and after 3 months of treatment with the new therapeutic scheme. There was a small and non-significant BP reduction when all drugs were still taken on awakening (p > 0.374). On baseline, only 22% of the patients in this group were dippers, and this percentage was further reduced to 15% after 3 months of therapy with all drugs on awakening. The blood pressure reduction was statistically significant (8.6 and 5.9 mmHg for systolic and diastolic blood pressure; p < 0.001) with one drug at bedtime. This effect was markedly larger in the nocturnal mean of blood pressure. Thus, while only 13% of the patients in this group were dippers at baseline, 53% were already dippers after 3 months of therapy. Results from this prospective trial indicate that, in patients with resistant hypertension, time of treatment may be more important for patient control and for the proper modeling of the circadian blood pressure pattern than just changing the drug combination.