Incidence Of Resistant Hypertension Research Articles

A risk prediction nomogram for resistant hypertension in patients with obstructive sleep apnea

Patients with obstructive sleep apnea (OSA) are liable to have resistant hypertension (RH) associated with unfavorable cardiovascular events. It is of necessity to predict OSA patients who are susceptible to resistant hypertension. Hence, we conducted a retrospective study based on the clinical records of OSA patients admitted to Yixing Hospital Affiliated to Jiangsu University from January 2018 to December 2022. According to different time periods, patients diagnosed between January 2018 and December 2021 were included in the training set (n = 539) for modeling, and those diagnosed between January 2022 and December 2022 were enrolled into the validation set (n = 259) for further assessment. The incidence of RH in the training set and external validation set was comparable (P = 0.396). The related clinical data of patients enrolled were collected and analyzed through univariate analysis and least absolute shrinkage and selection operator (LASSO) logistic regression analysis to identify independent risk factors and construct a nomogram. Finally, five variables were confirmed as independent risk factors for OSA patients with RH, including smoking, heart disease, neck circumference, AHI and T90. The nomogram established on the basis of variables above was shown to have good discrimination and calibration in both the training set and validation set. Decision curve analysis indicated that the nomogram was useful for a majority of OSA patients. Therefore, our nomogram might be useful to identify OSA patients at high risk of developing RH and facilitate the individualized management of OSA patients in clinical practice.

Uncontrolled and resistant arterial hypertension: prevalence, methods of modification of therapy

The management of patients with uncontrolled arterial hypertension in real clinical practice remains a difficult task, despite the impressive arsenal of antihypertensive drugs. In most cases, correction of medical therapy and lifestyle modification in this group of patients can achieve success in treatment, but in some cases, the target levels of blood pressure (AH) cannot be achieved.Aim. To assess the incidence of true resistant arterial hypertension in patients with hypertension, to identify the main causes of uncontrolled hypertension and to determine the main methods of modification of therapy.Materials and methods. The study included 70 patients with uncontrolled hypertension who received antihypertensive therapy previously. All patients underwent office measurement of blood pressure at the initial visit and after correction of therapy, 24-hour blood pressure monitoring (ABPM) was performed. Correction of therapy included the prescription of a standard three-component regimen «RAAS blocker + calcium antagonist + thiazide diuretic». In case of failure to achieve the target BP levels, the measurement of aldosterone/renin in the blood was carried out to exclude primary hyperaldosteronism (PHA). In all patients, the body mass index (BMI) was calculated, echocardiography was performed to determine the target organ damage, complete blood count, biochemical blood tests were performed (to detect existing kidney damage).Results. In 86% of patients, target BP levels were achieved through lifestyle modification (weight loss) and correction of previous therapy. In 24% of the study subjects, low adherence to therapy (non-compliance) due to polypharmacy was revealed, in connection with which patients were recommended to switch to fixed combinations of drugs, which made it possible to significantly reduce blood pressure below 140/90 mm Hg. according to the results of ABPM in all patients. In 8% of patients, amlodipine/lercanidipine was replaced with long-acting nifedipine, which also led to a decrease in blood pressure (−5,5 mm Hg mean blood pressure according to ABPM). In two cases, the diagnosis of PHA was established, the tumor form of this disease was excluded using computed tomography of the adrenal glands, and treatment with aldosterone antagonists was prescribed. In 10% of patients, the diagnosis of «Resistant arterial hypertension» was confirmed, spironolactone in low doses (25-50 mg), doxazosin 1 mg, moxonidine 0,4 mg, bisoprolol 5 mg were sequentially added to the treatment. Spironolactone and doxazosin showed similar efficacy (−7,1 mmHg and −6,9 mmHg in mean BP, respectively), moxonidine and bisoprolol were less effective (−4,8 and −5,2 mmHg,respectively). In two patients, the addition of spironolactone or doxazosin did not lead to the achievement of the target BP level, a loop diuretic (furosemide 40 mg) was added to the treatment.Conclusion. The incidence of resistant hypertension among patients in the study was 10%. All patients with uncontrolled hypertension, if it is impossible to achieve the target values of blood pressure, provided that the treatment is correctly prescribed, it is necessary to exclude symptomatic hypertension, in particular, PHA. In case of confirmation of true RAH, it is necessary to prescribe aldosterone antagonists (spironolactone) in small doses, and doxazosin is also acceptable.

Knowledge of senior students in the definition, classification, and approaches to the treatment of arterial hypertension. Final results of the PHYSTARH project

Background. Arterial hypertension is a modifiable risk factor for the development of life-threatening cardiovascular complications. Early diagnosis and optimal treatment are the key to success in the fight against this pathology.
 Aim. To analyze the knowledge of senior medical students from different regions in the basic issues of hypertension.
 Materials and methods. The article presents the results of the first stage of the multicenter PHYSTARH study (the full name of the project is Physicians and undergraduates knowledge in arterial hypertension treatment). An anonymous questionnaire (pharmacoepidemiological survey) was conducted among 314 senior medical students from 6 cities of Russia and Ukraine.
 Results. The study revealed the average level of senior students knowledge. The average level of correct answers to the questions in the first part of the questionnaire was 49.4%. The minimum level of correct answers was obtained in the questions of determining hypertension by the value of home blood pressure monitoring, determining the degree of hypertension for a blood pressure of 140/110 mm Hg, the incidence of resistant hypertension, indications for drug correction of high normal blood pressure, the choice of the optimal class of drugs for initial antihypertensive therapy. The maximum level of correct answers was registered only for the question about the definition of hypertension.
 Conclusion. The results of the study indicate an insufficiently high level of students basic knowledge in the classification and treatment of hypertension.

Abstract P374: 24-h Blood Pressure Profile, Non-dipping Status And Incidence Of Resistant Hypertension In Patients Randomized To Bariatric Surgery Versus Medical Therapy: The Gateway Randomized Trial

Background: Bariatric surgery represents an effective strategy for office blood pressure (BP) reduction in obese hypertensive patients. However, no previous study evaluated the impact of bariatric surgery on 24-h BP profile, non-dipping status and incidence of resistant hypertension (RH). Methods: This is a sub-analysis of a randomized clinical trial including hypertensive patients with grade 1 and 2 obesity, aged 18 to 65 years, using at least 2 drugs at optimal doses or >2 at moderate doses. Patients were randomly allocated to either Roux-en-Y Gastric Bypass (RYGB) with medical therapy (MT) or MT alone for 12 months. We analyzed the 24-h BP profile, non-dipping status (defined by <10% of systolic BP reduction during sleep as compared to the daytime period) and RH incidence. Results: A total of 100 patients were included (76% female, age 43.8±9.2 years, BMI 36.9±2.7 Kg/m 2 ). The 24-h BP profile was similar at 12 months in both groups, but the RYGB group required less anti-hypertensive classes compared to the MT alone (Figure). The rate of non-dipping BP did not change significantly during the follow-up (RYGB: from 18/48 (37.5%) to 22/48 (45.8%); p=0.30; MT: from 16/33 (48.5%) to 15/33 (45.5%); p=0.80). In an exploratory analysis, the incidence of RH was similar at the baseline (RYGB 10% (5/50) and MT 16% (8/50); p=0.38). After 12 months, it changed significantly in the RYGB group: 0% (0/49) while remained stable in the MT group: 14.9% (7/47) (p<0.001). Conclusions: RYGB significantly reduced anti-hypertensive medications while promoting similar 24-h BP profile and non-dipping BP status compared to the MT alone. RYGB may be an attractive strategy to reduce RH incidence in obese patients.

Increased Lipoprotein-associated phospholipase A2 activity portends an increased risk of resistant hypertension.

BackgroundTo investigate the relationship between plasma lipoprotein-associated phospholipase A2 (Lp-PLA2) activity and incidence of resistant hypertension (RH).MethodsThis was a cross-sectional research. In essential, it was an observational design and collecting data on a population at a single point in time to evaluate the associations of studied variables. Totally 208 patients with arterial hypertension were enrolled. Baseline characteristics were collected and fasting venous blood were drawn for plasma Lp-PLA2 activity assessment. Twenty-four hour ambulatory blood pressure ambulatory (ABPM) was performed to diagnose RH. Initially, based on ABPM examination, all participants were divided into two groups, namely RH group and without RH group. And thereafter, in order to evaluate the effects of Lp-PLA2 activity on blood pressure, all participants were divided into low (< 225 nm/min/ml) and high (≥ 225 nm/min/ml) Lp-PLA2 activity groups based on the cut-off value of Lp-PLA2 activity. Comparisons were conducted between groups.ResultsForty two patients were diagnosed as RH. Compared to patients without RH, patients with RH were more elderly, had more males, smokers, longer duration of hypertension, higher plasma C-reactive protein (CRP) level and Lp-PLA2 activity (P < 0.05 for all comparisons). More RH patients treated with calcium channel blocker and diuretic, while less treated with angiotensin converting enzyme inhibitor, angiotensin receptor blocker and statins (P < 0.05 for all comparisons). Compared to low Lp-PLA2 group, the rate of RH was significantly higher in high Lp-PLA2 group (26.7 % versus 6.1 %, P < 0.05). Multivariate regression analysis revealed that after adjusted for age, gender, smoking, body mass index, hypertension duration, CRP, and anti-hypertensive drugs, association between Lp-PLA2 activity and RH remained significant, with odds ratio (OD) of 2.02 (95 % confidence interval, CI 1.85-2.06, P < 0.05). Nonetheless, the association was attenuated when further adjusted for statins, with OR of 1.81 (95 % CI 1.74-1.93, P < 0.05).ConclusionIncreased plasma Lp-PLA2 activity portends increased risk of RH, and statins may be beneficial to reduce incidence of RH in subjects with increased plasma Lp-PLA2 activity.

The Role of Obesity and Obstructive Sleep Apnea in the Pathogenesis and Treatment of Resistant Hypertension

The incidence of resistant hypertension, obesity, and obstructive sleep apnea (OSA), three highly prevalent conditions in the United States, is rising. Approximately one in three adults in the US has hypertension, and a significant proportion of these individuals have hypertension that is difficult to treat, or resistant. Obesity and OSA are well-established risk factors for resistant hypertension, a condition that portends significant cardiovascular risk. Awareness of the various mechanisms by which obesity and OSA impact systemic blood pressure is essential to better understand how best to effectively care for patients with resistant hypertension. In this review, we discuss the clinical and pathophysiologic associations between obesity, OSA, and resistant hypertension. Furthermore, we will explore the effect of continuous positive airway pressure therapy (CPAP) and other therapeutic interventions on blood pressure control in patients with resistant hypertension.Key Points• Obesity, obstructive sleep apnea, and resistant hypertension are highly prevalent conditions, with increasing overall incidence [1-3].• Both obesity and obstructive sleep apnea are independent risk factors for the development of resistant hypertension.• OSA is characterized by a physiologic cascade of collapse of the upper airway, which can lead to intermittent hypoxia, hypercapnia, significant negative intra-thoracic pressure, and increased SNS output.• Intermittent hypoxia leads to activation of the endothelin system [17, 18, 19•], which can lead to the development of resistant hypertension.• Intermittent hypoxia can lead to the over activation of the SNS, which can also contribute to the development of resistant hypertension [20, 21].• OSA leads to state of elevated adrenergic tone, which in turn may contribute to resistant hypertension [25-27].• OSA patients have a higher incidence of "non-dipping" of nocturnal systolic blood pressure, a marker of increased adrenergic tone. This potentially represents a risk factor for hypertensive end organ disease [31, 32].• The prevalence of OSA is significantly higher in patients predisposed to fluid accumulation: including kidney disease, heart failure and resistant hypertension [33].• Interventions (such as the daytime use of compression stocking) which reduce daytime lower extremity fluid accumulation can significantly reduce the severity of OSA, particularly in patients with comorbid resistant hypertension [35, 36].• CPAP therapy can significantly reduce blood pressure in patients with comorbid hypertension and OSA. The treatment effect is most pronounced in those with resistant hypertension and OSA [16••, 38-42].

Catheter-based Renal Sympathetic Denervation - Long-term Symplicity™ Renal Denervation Clinical Evidence, New Data and Future Perspectives.

Hypertension is one of the most prevalent chronic diseases worldwide and the incidence of resistant hypertension is increasing. Catheter-based renal denervation (RDN) offers a new approach to reaching blood pressure goals by targeting the renal nerves. The technique has demonstrated significant and sustained reductions in blood pressure (BP) in the Symplicity HTN-1 and Symplicity HTN-2 clinical trials. The Global SYMPLICITY Registry aims to demonstrate safety and effectiveness in a 'real-world' patient population. Real-world RDN experience has emphasised that patient selection is crucial to successful outcomes; a multidisciplinary referral network is recommended to increase awareness of the procedure and identify patients who are likely to respond best to RDN. Further advances in catheter technology have led to the development of the multi-electrode Symplicity Spyral™ multi-electrode catheter; preliminary data from the feasibility study using the Symplicity Spyral catheter indicate clinical efficacy and procedural safety with reduced procedure times. The Symplicity Spyral catheter is not yet commercially available. The indications of RDN may also expand beyond resistant hypertension - encouraging data have been seen in patients with moderate treatment resistant hypertension. Furthermore, RDN may be beneficial in other clinical states characterised by sympathetic nervous system overactivation including heart failure and chronic kidney disease. Additional data are needed to evaluate the efficacy of RDN in these disease states.

Resistant hypertension—its identification and epidemiology

Resistant hypertension is currently defined as the failure to achieve a goal blood pressure <140/90 mmHg in patients who are compliant with maximal tolerated doses of a minimum of three antihypertensive drugs, one of which must be a diuretic. The increasing prevalence of obesity and hypertension in the general population mean that this disorder has gained attention in the past decade. In the past 2 years, large-scale population-based studies such as the US National Health and Nutrition Examination Survey (NHANES) have specifically examined the prevalence and incidence of resistant hypertension, and associated risk factors. The findings suggest the prevalence of resistant hypertension is 8-12% of adult patients with hypertension (6-9 million people). The increasing prevalence of resistant hypertension contrasts with the improvement in blood pressure control rates during the same period. Studies also show that patients with resistant hypertension aged >55 years, of black ethnicity, with high BMI, diabetes or chronic kidney disease have an increased risk of cardiovascular events compared to nonresistant hypertensive patients. Analyses that exclude the effects of white-coat hypertension and pseudoresistant hypertension are also needed to clarify the epidemiology of true resistant hypertension.

Predictors of resistant hypertension in an unselected sample of an adult male population in Italy

Prevalence, incidence and predictors of resistant hypertension (RH), (defined as blood pressure persistently above goal in spite of the concurrent use of three antihypertensive agents of different classes) in the general population remain largely unknown. A complete database including anthropometric and biochemical data was collected in 1994-1995 (baseline examination) in 1,019 participants (mean age 51.8, range: 25-79 years) and again in 2002-2004 in 794 male participants of the Olivetti Heart Study (OHS) in southern Italy. The incidence of RH over the average follow-up time of 7.9 years was 4.8% (38/794) in the whole study population and 10.1% (31/307) among hypertensive participants. Basal blood pressure (systolic, diastolic or pulse pressure), cholesterol and urinary albumin/creatinine ratio (ACR) significantly predicted the risk of developing RH using a logistic regression model that also included age as covariates. If in the same model we added basal pharmacological treatment, the fractional excretion of sodium (FENa) also became a statistically significant predictor, and this last model explained nearly 25% of the risk of developing RH. In this unselected sample of an adult male population, ACR (an early marker of organ damage), an elevated FENa (a proxy for dietary sodium intake), cholesterol and a higher basal blood pressure level were independent predictors of RH.

Resistant Hypertension: Diagnosis, Evaluation, and Treatment

Resistant hypertension is a common clinical problem faced by both primary care clinicians and specialists. While the exact prevalence of resistant hypertension is unknown, clinical trials suggest that it is not rare, involving perhaps 20% to 30% of study participants. As older age and obesity are 2 of the strongest risk factors for uncontrolled hypertension, the incidence of resistant hypertension will likely increase as the population becomes more elderly and heavier. The prognosis of resistant hypertension is unknown, but cardiovascular risk is undoubtedly increased as patients often have a history of long-standing, severe hypertension complicated by multiple other cardiovascular risk factors such as obesity, sleep apnea, diabetes, and chronic kidney disease. The diagnosis of resistant hypertension requires use of good blood pressure technique to confirm persistently elevated blood pressure levels. Pseudoresistance, including lack of blood pressure control secondary to poor medication adherence or white coat hypertension, must be excluded. Resistant hypertension is almost always multifactorial in etiology. Successful treatment requires identification and reversal of lifestyle factors contributing to treatment resistance; diagnosis and appropriate treatment of secondary causes of hypertension; and use of effective multidrug regimens. As a subgroup, patients with resistant hypertension have not been widely studied. Observational assessments have allowed for identification of demographic and lifestyle characteristics associated with resistant hypertension, and the role of secondary causes of hypertension in promoting treatment resistance is well documented; however, identification of broader mechanisms of treatment resistance is lacking. In particular, attempts to elucidate potential genetic causes of resistant hypertension have been limited. Recommendations for the pharmacological treatment of resistant hypertension remain largely empiric due to the lack of systematic assessments of 3 or 4 drug combinations. Studies of resistant hypertension are limited by the high cardiovascular risk of patients within this subgroup, which generally precludes safe withdrawal of medications; the presence of multiple disease processes (eg, sleep apnea, diabetes, chronic kidney disease, atherosclerotic disease) and their associated medical therapies, which confound interpretation of study results; and the difficulty in enrolling large numbers of study participants. Expanding our understanding of the causes of resistant hypertension and thereby potentially allowing for more effective prevention and/or treatment will be essential to improve the long-term clinical management of this disorder.

Resistant Hypertension: Diagnosis, Evaluation, and Treatment

Resistant hypertension is a common clinical problem faced by both primary care clinicians and specialists. While the exact prevalence of resistant hypertension is unknown, clinical trials suggest that it is not rare, involving perhaps 20% to 30% of study participants. As older age and obesity are 2 of the strongest risk factors for uncontrolled hypertension, the incidence of resistant hypertension will likely increase as the population becomes more elderly and heavier. The prognosis of resistant hypertension is unknown, but cardiovascular risk is undoubtedly increased as patients often have a history of long-standing, severe hypertension complicated by multiple other cardiovascular risk factors such as obesity, sleep apnea, diabetes, and chronic kidney disease. The diagnosis of resistant hypertension requires use of good blood pressure technique to confirm persistently elevated blood pressure levels. Pseudoresistance, including lack of blood pressure control secondary to poor medication adherence or white coat hypertension, must be excluded. Resistant hypertension is almost always multifactorial in etiology. Successful treatment requires identification and reversal of lifestyle factors contributing to treatment resistance; diagnosis and appropriate treatment of secondary causes of hypertension; and use of effective multidrug regimens. As a subgroup, patients with resistant hypertension have not been widely studied. Observational assessments have allowed for identification of demographic and lifestyle characteristics associated with resistant hypertension, and the role of secondary causes of hypertension in promoting treatment resistance is well documented; however, identification of broader mechanisms of treatment resistance is lacking. In particular, attempts to elucidate potential genetic causes of resistant hypertension have been limited. Recommendations for the pharmacological treatment of resistant hypertension remain largely empiric due to the lack of systematic assessments of 3 or 4 drug combinations. Studies of resistant hypertension are limited by the high cardiovascular risk of patients within this subgroup, which generally precludes safe withdrawal of medications; the presence of multiple disease processes (eg, sleep apnea, diabetes, chronic kidney disease, atherosclerotic disease) and their associated medical therapies, which confound interpretation of study results; and the difficulty in enrolling large numbers of study participants. Expanding our understanding of the causes of resistant hypertension and thereby potentially allowing for more effective prevention and/or treatment will be essential to improve the long-term clinical management of this disorder.

Resistant Hypertension: Diagnosis and Management

The incidence of resistant hypertension, the failure to reduce blood pressure below 140/90 mm Hg, despite the use of 3 antihypertensive medications at optimal doses including a diuretic, is estimated to be less than 5% of the hypertensive population. Resistant hypertension increases the risk of stroke, myocardial infarction, congestive heart failure, and renal failure. Evaluation of the patient with resistant hypertension should include 24-hour ambulatory blood pressure monitoring or home measurements and a limited search for secondary causes. Treatment should focus on optimizing the drug regimen in a logical way, based on the patient's comorbidities and tolerability. Long-acting, well-tolerated once-daily medications are preferred, and the regimen should include in sequence a diuretic, beta-blocker, angiotensin-converting enzyme/angiotensin receptor-blocker inhibitors, and a calcium-channel blocker. This article reviews the definitions and causes and provides specific recommendations for the evaluation and management of patients with this life-threatening condition.

Resistant hypertension

The incidence of resistant hypertension remains to be clarified. In this article, three categories of resistance are distinguished: resistant patient, resistant clinician and refractory hypertension. Inadequate compliance, which in case of antihypertensive treatment means taking fewer doses of medications than prescribed, remains a significant cause of poor blood pressure control. Among most frequent physician‐related causes of resistant hypertension, there are measurement errors, pseudohypertension, white coat hypertension and therapy errors. Careful elimination of patient‐ and physician‐related reasons of inadequate blood pressure control should lead to the diagnosis of truly resistant hypertension. One of the causes of refractory hypertension may be concomitant use of other medications that are known to reduce antihypertensive effect of main drugs. Resistance may be associated with increased intravascular volume or fluid overload or with sympathetic activation. Modifiable contributing factors responsible for resistant hypertension include obesity often coexisting with insulin resistance and metabolic syndrome as well as excessive alcohol use and cigarette smoking. Another potential cause of refractory hypertension is the presence of secondary hypertension. Certain therapeutic modifications are essential in resistant hypertension.