Drug Therapy for Resistant Hypertension: Simplifying the Approach

Mann, Samuel J.

doi:10.1111/j.1751-7176.2010.00387.x

Cited by 43 publications

(30 citation statements)

References 79 publications

(135 reference statements)

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“…11) Previous reports revealed the ineffectiveness of an adequate dose of an ACE inhibitor/diuretic or ARB/diuretic combination in resistant hypertension. 11,13) Acelajado, et al reported that greater sympathetic output based on higher heart rates may be contributing to antihypertensive treatment failure in resistant hypertension. 14) However, few data from randomized trials are available to guide the choice of beta blockers for resistant hypertensive patients.…”

Section: Discussionmentioning

confidence: 99%

Effectiveness of the Direct Renin Inhibitor, Aliskiren, in Patients With Resistant Hypertension

Yoshitomi¹,

Kawanishi²,

Yamaguchi³

et al. 2013

Int. Heart J.

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SummaryCurrently there is no consensus regarding which add-on therapy to use in resistant hypertension. We have conducted an open observational study of the use of aliskiren in resistant hypertensive patients. Forty-three patients with resistant hypertension were included in the study. The inclusion criteria were as follows: 1) office blood pressure (BP) > 140/90 mmHg despite treatment with at least three or more antihypertensive drugs; 2) no prior therapy with aliskiren; and 3) no renal insufficiency. Follow-up BP was determined at 1 and 3 months. Baseline BP was 153 ± 12/79 ± 12 mmHg. After 3 months, systolic BP (SBP) and diastolic BP (DBP) dropped significantly: 140 ± 19/73 ± 13 mmHg (P < 0.0001). Twenty-one patients (49%) had an office BP < 140/90 mmHg, and these patients were assigned to the good BP control group. Another 22 were placed into the poor BP control group. BP reductions from baseline in the good BP control group (SBP/ DBP: 19 ± 11/8 ± 7 mmHg) were larger than those in the poor BP control group (5 ± 15/3 ± 9 mmHg, P < 0.05). Mean BP (MBP) values at baseline, 1, and 3 months were higher in the poor BP control group. There was no significant difference in pulse pressure at baseline between the 2 groups. In multivariate analysis, only MBP at baseline correlated with lack of BP control. Aliskiren administration to resistant hypertensive patients was effective in reducing BP. The present findings suggest aliskiren may be useful as a fourth-line or fifth-line treatment added to other drugs in the treatment of resistant hypertension. (Int Heart J 2013; 54: 88-92) Key words: Uncontrolled hypertension, Pulse pressure, Mean blood pressure A lthough various authors use different definitions, resistant hypertension is defined as blood pressure (BP) that requires the use of four or more antihypertensive agents, whether controlled or uncontrolled. 1) Approximately 30% of adults who have hypertension are unaware of their condition, and about half of patients receiving treatment in Japan do not achieve the modest goal of < 140 / 90 mmHg. 2) In the absence of a definitive study, clinical trials have been largely relied upon as surrogate opportunities to estimate the prevalence of resistant hypertension. The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) is likely the most relevant, in that it included a large and diverse cohort, and, per protocol, subjects were to have continued escalation of their treatment regimen as long as the BP remained elevated. At the end of the 5-year treatment period, uncontrolled hypertension was common in ALLHAT, with 34% of subjects never having achieved BP control and with 27% of subjects receiving ≥ 3 antihypertensive medications. 3) Data from a large, community-based study indicated that 12.7% of hypertensive patients were uncontrolled on three or more medications. 4) Recently, de la Sierra, et al presented analysis of data from their large registry of Spanish patients who had 24-hour ambulatory BP monitoring performed. 5) They gathered dat...

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Section: Discussionmentioning

confidence: 99%

Effectiveness of the Direct Renin Inhibitor, Aliskiren, in Patients With Resistant Hypertension

Yoshitomi¹,

Kawanishi²,

Yamaguchi³

et al. 2013

Int. Heart J.

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“…General algorithms have been proposed. One such interesting proposal advocates a mechanism-based, multiple-drug regimen targeting treatment at the three hypertensive mechanisms: sodium/volume, RAAS, and SNA [45]. Such a regimen starts with baseline treatment with a two-drug combination directed at sodium/volume and the RAAS.…”

Section: Combination Therapiesmentioning

confidence: 98%

Resistant Hypertension: Concepts and Approach to Management

Sander

Giles

2011

Curr Hypertens Rep

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Resistant hypertension (RH), defined simply, is blood pressure (BP) requiring the use of four or more antihypertensive agents, whether controlled or uncontrolled. RH is an increasingly common problem in elderly patients and may affect as many as 20% of the hypertensive population. Unfortunately, at least 30% of patients evaluated for RH are actually adequately controlled when more carefully assessed by home BP monitoring or ambulatory BP monitoring, thus representing a white coat effect. It is also essential to exclude pseudoresistance resulting from improper BP recording techniques or failure of the patient to adhere to the prescribed treatment regimen. Concurrent use of drugs that may interfere with prescribed antihypertensive agents, including many over the counter herbal preparations, must also be excluded. The underlying mechanisms principally driving true RH include pathophysiologic abnormalities of aldosterone signaling, sodium and water retention, excessive sympathetic nervous system activity, and obstructive sleep apnea. Appropriate treatment regimens will usually include an inhibitor of the renin-angiotensin-aldosterone system, a calcium channel blocker, and a diuretic. An aldosterone receptor blocker can be instituted at any step, and is very effective as a fourth drug. Beta-blockers can also be integrated into these treatment plans and may be especially helpful when excessive sympathetic nervous system activity is suspected. Novel device therapies that interrupt sympathetic nerve stimulation at the carotid sinus and kidney are under investigation, and may add entirely new directions in the management of RH. What is most important is that treatment regimens should be targeted to specific patient profiles.

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“…1. Algorithm of diagnosing resistant hypertension [10] A drug regimen should be based on combination therapy, taking into account the basic mechanisms conditioning arterial hypertension development, such as sodium metabolism/volemia, renin-angiotensin-aldosterone system (RAAS) and increased tension of the sympathetic nervous system [34]. Most clinical trials involved dual therapy, with particular emphasis on diuretic treatment [2].…”

Section: Treatment Of Resistant Hypertensionmentioning

confidence: 99%