Abstract
BackgroundMost cases of hypertension can be effectively treated with lifestyle changes together with medications, but within this population lies a group with more difficult to treat hypertension—those with apparent treatment-resistant hypertension (aTRH). The American Heart Association and the UK National Institute for Health and Care Excellence have both highlighted the need for further research into the prognosis of patients with resistant hypertension, both apparent and true.MethodsIn 16 practices affiliated to a university research network, 646 patients had been identified with apparent treatment-resistant hypertension. To inform a planned full cohort study of these patients, we conducted a feasibility study within three practices to determine participation of practices and patients, availability of outcome measures and data collection times.ResultsAll three practices fully participated and 205/210 (98%) patients were followed up for a median of 23 months. Thirty-five outcome events of interest occurred—the most common was the new onset of retinopathy (9 cases). Eight percent (17/210) had the main composite outcome of death or serious incident cardiovascular event. Of the six patients who died, identification of cause of death was possible from practice records in five; the national General Register Office was successfully used for the final patient. There were 123 admissions, both day and overnight, recorded in 94 individual patients. Average manual systolic blood pressure measurements improved from baseline by 5 mmHg to 138 (SD 19) mmHg; diastolic remained the same at 75 (SD 12) mmHg. Average eGFR increased from 58.8 (SD17.4) to 66 (SD19.7) mls/min/1.73m2. The average time for data collection per patient was 12 mins.ConclusionsThis study demonstrates that the proposed methodology for a full cohort study within general practice of patients with apparent treatment hypertension is both acceptable to practices and feasible. An adequately powered subsequent follow-up study of the entire cohort appears possible.
Highlights
Most cases of hypertension can be effectively treated with lifestyle changes and/or medications, but within this population lies a group with more difficult to treat hypertension—those with treatment-resistant hypertension (TRH)
Doses should be the optimal tolerated doses for each particular medication, lifestyle issues should be addressed and white coat hypertension needs to be examined by ambulatory blood pressure monitoring (ABPM)
The American Heart Association [8] and the UK National Institute for Health and Care Excellence [9] have both highlighted the need for further high-quality prospective research into the prognosis of patients with resistant hypertension
Summary
Most cases of hypertension can be effectively treated with lifestyle changes together with medications, but within this population lies a group with more difficult to treat hypertension—those with apparent treatment-resistant hypertension (aTRH). Daugherty [5] provided the best evidence to date with an outcomebased study on the longitudinal assessment of a large cohort of patients with aTRH (n = 3960) She found a 50% increase in cardiovascular events (largely attributable to development of chronic kidney disease) compared to those whose blood pressure was controlled on three medications. This impressive study is a retrospective study of electronic insurance data with no assessment of ABPM or dosing and limited assessment of adherence. Irvin [7] in retrospectively comparing similar groups found no significant increased risk of stroke but an increased risk for mortality These studies, utilising large electronic databases, had large patient numbers but limited assessment of adherence, dosing and white coat hypertension.
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