TRUE REFRACTORY HYPERTENSION IN 2023- LESSONS LEARNED FROM A NATIONAL REGISTRY OF 1.82 MILLION ADULTS

Abstract

Objective: Refractory hypertension (refHTN) is defined as blood pressure that remains uncontrolled on maximal therapy, which is defined as the use of 5 or more antihypertensive agents of different drug classes. We aimed to define the prevalence of apparent and true refHTN in a real life national registry of an Health Maintenance Organization (HMO). Design and method: In this real-life observational study we utilized the Maccabi Healthcare Services (MHS) database during 2023. Data includes pharmacy prescriptions and purchases. Apparent refHTN was defined as patients included in the Maccabi “Hypertension Registry” during 2023 and taking 5 different antihypertensive medications of different classes, of which four were from pre-specified groups (diuretics, CCB, RAAS inhibitors and MRAs). True refHTN (unlike apparent refHTN) was defined as being fully adherent to the antihypertensive medication regimen with at least 6 prescriptions and purchases (refills) during 2023 as well as blood pressure which was not optimally controlled during the year (less than 80% of blood pressure measurements equal or below the well-defined target of 130/80mmHg). Results: Out of 1,821,685 adult members of Maccabi HMO during 2023, 361,721 patients were defined as hypertensive patients (20%) and included in the registry. 0.5% (1750) of the hypertensive population were at some stage during 2023 on at least 5 anti-hypertensive medications (i.e., apparent refHTN). Of those only 264 patients (15%) were adherent to their medications during the whole year. Mean age was 71.3 years. Of the well adherent group, 205 patients (77%) were not optimally controlled and thus regarded as true refHTN. Therefore in total, true refHTN was evident in 0.056% of hypertensive population in Maccabi HMO. Conclusions: In an “optimal world” which lacks physician inertia, four medication regimen is prescribed (Diuretics, CCB, RAAS inhibitors and MRAs) and there is willingness to prescribe a fifth and a sixth medication, if needed (alpha blockers, beta blockers, central alpha-2 agonists or direct vasodilators). In the unlikely case of full adherence to all medications, true refHTN is extremely rare (0.056% of hypertensive patients). This suggests that most hypertensive patients can be well controlled using the current anti hypertensive armamentarium.