Abstract
More stringent blood pressure (BP) goals have led to greater prevalence of apparent resistant hypertension (ARH), yet the long‐term prognostic impact of ARH diagnosed according to these goals in the general population remains unknown. We assessed the prognostic impact of ARH according to contemporary BP goals in 9612 participants of the Atherosclerosis Risk in Communities (ARIC) study without previous cardiovascular disease. ARH, defined as BP above goal (traditional goal <140/90 mmHg, more stringent goal <130/80 mmHg) despite the use of ≥3 antihypertensive drug classes or any BP with ≥4 antihypertensive drug classes (one of which was required to be a diuretic) was compared with controlled hypertension (BP at goal with 1‐3 antihypertensive drug classes). Cox regression models were adjusted for age, sex, race, study center, BMI, heart rate, smoking, eGFR, LDL, HDL, triglycerides, and diabetes. Using the traditional BP goal, 133 participants (3.8% of the treated) had ARH. If the more stringent BP goal was instead applied, 785 participants (22.6% of the treated) were reclassified from controlled hypertension to uncontrolled hypertension (n = 725) or to ARH (n = 60). Over a median follow‐up time of 19 years, ARH was associated with increased risk for a composite end point (all‐cause mortality, hospitalization for myocardial infarction, stroke, or heart failure) regardless of whether traditional (adjusted HR 1.50, 95% CI: 1.23‐1.82) or more stringent (adjusted HR 1.43, 95% CI: 1.20‐1.70) blood pressure goals were applied. We conclude that in patients free from cardiovascular disease, ARH predicted long‐term risk regardless of whether traditional or more stringent BP criteria were applied.
Highlights
Elevated blood pressure (BP) is the most important risk factor for cardiovascular and renal death.[1]
Apparent resistant hypertension is associated with cardiovascular risk factors and with prevalent cardiovascular disease.7,9-23 Prospective studies have shown that apparent resistant hypertension” (ARH) is a marker of increased risk for cardiovascular morbidity and mortality across a wide range of patient populations.11-23 In 2018, the American College of Cardiology/American Heart Association guidelines lowered both the diagnostic threshold and the BP treatment goal for hypertension from 140/90 mmHg to 130/80 mmHg.[24]
We thereafter excluded 401 participants (Figure 1) who had incomplete baseline data for one or more of the following variables: body mass index (BMI), heart rate, smoking status, estimated glomerular filtration rate (eGFR), low-density lipoprotein (LDL), and high-density lipoprotein (HDL) cholesterol, TG, or prevalent diabetes status, and those who were of a race other than Black or White or who were non-White participants at the Minneapolis or Washington County Centers
Summary
Elevated blood pressure (BP) is the most important risk factor for cardiovascular and renal death.[1]. The cardiovascular prognosis in patients who change hypertension categories if the more stringent BP criteria are applied is not known. The aim of this analysis of a prospective observational study was to assess the prevalence and prognostic significance of ARH, diagnosed with either the traditional (BP≥140/90 mmHg) or the more stringent (BP≥130/80 mmHg) criteria, in a community-based cohort of persons without known cardiovascular disease. We explored the cardiovascular outcomes in participants who changed hypertension categories if the hypertension criteria were changed, and the prognostic significance of the number of antihypertensive drug classes used
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