Improving Care in Resistant Hypertension

Abstract

Resistant hypertension is an important clinical problem that is poorly studied and not well managed. The objective of this study was to identify factors associated with successful treatment of resistant hypertension in a specialty clinic. This was a retrospective observational study examining the medical records of patients seen at a specialty hypertension clinic at the University of Rochester, Rochester, New York, USA, in the year 2005. The records of 68 patients were reviewed. Those presenting with resistant hypertension (defined as BP > or =140/90mm Hg and receiving at least three antihypertensive medications, including a diuretic) were identified. Change in medication type and dosage, BP reduction, and percentage of patients at Joint National Committee (JNC)-7 goal were noted. Twenty-eight patients were included in the analysis. Mean age was 62.5 +/- 11.6 years, 54% were women, and mean presenting BP was 175.4 +/- 23.5/87.5 +/- 14.6mm Hg. After an average of 6.2 +/- 3.2 visits over a mean of 13.9 +/- 13.5 months, mean BP was reduced to 145.3 +/- 27.7/73.9 +/- 13.6mm Hg (paired t-test: p = 0.001 SBP, p = 0.0001 DBP), and 44.8% of the patients were at their JNC-7 goal. Change in the mean number of antihypertensive medications was not significantly different between the initial and final clinic visits (4.1 +/- 1.2 vs 4.2 +/- 1.0; p = 0.627). Combination pill use increased from four patients (14%) at initial visit to 19 (68%) at final visit. Numbers of patients treated with diuretics, beta-adrenoceptor antagonists, calcium channel antagonists (CCB), and minoxidil increased at the final clinic visit. Significant dose-related changes included the up-titration of CCBs to high doses, and the initiation of moderate doses of thiazide diuretics; mainly chlorthalidone (67% final visit vs 0% at initial visit). Patients referred to a specialty clinic for the control of resistant hypertension achieved significant reductions in BP with frequent visits, combination pills, and greater use and higher doses of CCBs and thiazide diuretics.