Incidence and Prognosis of Resistant Hypertension in Hypertensive Patients

Abstract

Background Despite a recent American Heart Association (AHA) consensus statement emphasizing the importance of resistant hypertension, the incidence and prognosis of this condition is largely unknown. Methods and Results This retrospective cohort study in two integrated health plans included patients with incident hypertension started on treatment from 2002–2006. Patients were followed for the development of resistant hypertension based on AHA criteria of uncontrolled blood pressure despite use of three or more antihypertensive medications using medication fill and blood pressure measurement data. We determined incident cardiovascular events (death or incident myocardial infarction, heart failure, stroke or chronic kidney disease) in patients with and without resistant hypertension adjusting for patient and clinical characteristics. Among 205,750 patients with incident hypertension, 1.9% developed resistant hypertension within a median 1.5 years from initial treatment, or 0.7 cases per 100 person-years of follow-up. These patients were more often men, older, and had higher rates of diabetes compared with nonresistant patients. Over 3.8 years of median follow-up, cardiovascular event rates were significantly higher in those with resistant hypertension (unadjusted: 18.0% vs. 13.5%, p<0.001). After adjusting for patient and clinical characteristics, resistant hypertension was associated with a higher risk of cardiovascular events (HR 1.47, 95% CI 1.33–1.62). Conclusions Among patients with incident hypertension started on treatment, 1 in 50 patients developed resistant hypertension. Resistant hypertension patients had an increased risk of cardiovascular events supporting the need for greater efforts toward improving hypertension outcomes in this population.

Physician Underutilization of Effective Medications for Resistant Hypertension at Office Visits in the United States: NAMCS 2006–2010

“…3 Data from clinical trials suggest that the prevalence may be substantially higher and the incidence rate among all hypertensive adults has been reported at 1.9 % per year. 4 In 2008, the American Heart Association (AHA) published guidelines for treatment of resistant hypertension that included recommendations for optimal diuretic use (chlorthalidone as the preferred thiazide diuretic), adding an aldosterone antagonist as a fourth medication for uncontrolled BP, and using fixed-dose combination drugs. 3 According to these guidelines, most resistant hypertension patients should be treated with an appropriately dosed thiazide diuretic, calcium channel blocker (CCB), and an ACE inhibitor (ACE-I) or angiotensin receptor blocker (ARB) with aldosterone antagonists as the first choice for patients whose BP remains uncontrolled on optimal doses of ≥ 3 distinct classes of antihypertensive medications.…”

Prevalence and Clinical Characteristics of Refractory Hypertension

“…Several studies have observed a prevalence of around 12% to 14% of treated hypertensives 2, 3. Compared with subjects with controlled hypertension with 3 or less antihypertensive drugs, patients with RH more frequently have target organ damage4, 5 and a higher incidence of cardiovascular events 6. We have previously reported that more than one third of RH patients have normal 24‐hour BP (white‐coat RH) and they exhibit a better cardiovascular risk profile compared with those with elevated 24‐hour BP 2…”

Apparent Treatment-Resistant Hypertension and Chronic Kidney Disease: Another Cardiovascular-Renal Syndrome?

“…9 Notably, when the development of CKD was excluded, aTRH was no longer associated with an increased risk for adverse CV outcomes (adjusted hazard ratio 1.18; 95% CI 0.98-1.43, P ¼ .09). 9 Given the known link between BP and adverse CV outcomes, the Kaiser data suggest that either larger or higher risk cohorts of aTRH patients may be necessary to fully uncover the relationship between aTRH and CV outcomes.…”

“…More recently, large prospective cohort studies have investigated the incidence and prevalence of aTRH. Daugherty and colleagues 9 examined the incidence of aTRH among patients in the combined Kaiser Northern California and Kaiser Colorado databases. Among 205,750 newly diagnosed hypertensive patients, 1.9% were found to have aTRH, defined as uncontrolled BP on 3 or more antihypertensive medications or controlled BP on 4 or more antihypertensive medications, plus at least 80% medication adherence at 1.5 years of follow-up.…”

“…Among those taking 3 medications or more for at least 1 month, the prevalence of aTRH was 16.2%. 9 Given that medication noncompliance is likely the most common cause of pseudoresistance, the study by Daugherty 11 Thus, aTRH appears to affect about 12% of hypertensive adults, an estimated 8 million individuals in the United States.…”