Abstract-We aimed to estimate the prevalence of resistant hypertension through both office and ambulatory blood pressure monitoring in a large cohort of treated hypertensive patients from the Spanish Ambulatory Blood Pressure Monitoring Registry. In addition, we also compared clinical features of patients with true or white-coat-resistant hypertension. In December 2009, we identified 68 045 treated patients with complete information for this analysis. Among them, 8295 (12.2% of the database) had resistant hypertension (office blood pressure Ն140 and/or 90 mm Hg while being treated with Ն3 antihypertensive drugs, 1 of them being a diuretic). After ambulatory blood pressure monitoring, 62.5% of patients were classified as true resistant hypertensives, the remaining 37.5% having white-coat resistance. The former group was younger, more frequently men, with a longer duration of hypertension and a worse cardiovascular risk profile. The group included larger proportions of smokers, diabetics, target organ damage (including left ventricular hypertrophy, impaired renal function, and microalbuminuria), and documented cardiovascular disease. Moreover, true resistant hypertensives exhibited in a greater proportion a riser pattern (22% versus 18%; PϽ0.001). In conclusion, this study first reports the prevalence of resistant hypertension in a large cohort of patients in usual daily practice. Resistant hypertension is present in 12% of the treated hypertensive population, but among them more than one third have normal ambulatory blood pressure. A worse risk profile is associated with true resistant hypertension, but this association is weak, thus making it necessary to assess ambulatory blood pressure monitoring for a correct diagnosis and management. (Hypertension. 2011;57:898-902.) • Online Data Supplement Key Words: resistant hypertension Ⅲ ambulatory blood pressure monitoring Ⅲ circadian pattern Ⅲ cardiovascular risk R esistant hypertension (RH) is defined as office blood pressure (BP) that remains above goal despite the concurrent use of 3 antihypertensive agents, at full doses, one of them being a diuretic. Although the prevalence of RH largely depends on the setting explored, this condition is of clinical importance, because it is associated with an impaired prognosis. 1 The definition of RH is based on office measurements. However, the use of ambulatory BP monitoring (ABPM) has allowed for the recognition of the white-coat effect as being responsible for a proportion of resistant hypertensive patients. It is estimated that approximately one third of patients with suspected RH indeed have white-coat or isolated office RH, showing normal daytime or 24-hour ABPM values. [2][3][4] Elevated ABPM values in patients with RH are associated with a higher prevalence of target organ damage 4,5 and increased incidence of future cardiovascular events. 6 -8 However, these data come from relatively small populations attended in single referral units, whereas there is lack of data coming from large hypertensive populations representi...

Resistant hypertension is associated with obesity, longer hypertension duration and kidney and cardiac damage. Ambulatory blood pressure monitoring reveals that white-coat hypertension is common among resistant hypertensive patients, as well as is masked hypertension among apparently controlled patients.

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BackgroundWe aimed to estimate the prevalence of refractory hypertension (RfH) and to determine the clinical differences between these patients and resistant hypertensives (RH). Secondly, we assessed the prevalence of white‐coat RfH and clinical differences between true‐ and white‐coat RfH patients.Methods and ResultsThe present analysis was conducted on the Spanish Ambulatory Blood Pressure Monitoring Registry database containing 70 997 treated hypertensive patients. RH and RfH were defined by the presence of elevated office blood pressure (≥140 and/or 90 mm Hg) in patients treated with at least 3 (RH) and 5 (RfH) antihypertensive drugs. White‐coat RfH was defined by RfH with normal (<130/80 mm Hg) 24‐hour blood pressure. A total of 11.972 (16.9%) patients fulfilled the standard criteria of RH, and 955 (1.4%) were considered as having RfH. Compared with RH patients, those with RfH were younger, more frequently male, and after adjusting for age and sex, had increased prevalence of target organ damage, and previous cardiovascular disease. The prevalence of white coat RfH was lower than white‐coat RH (26.7% versus 37.1%, P<0.001). White‐coat RfH, in comparison with those with true RfH, showed a lower prevalence of both left ventricular hypertrophy (22% versus 29.7%; P=0.018) and microalbuminuria (28.3% versus 42.9%; P=0.047).ConclusionsThe prevalence of RfH was low and these patients had a greater cardiovascular risk profile compared with RH. One out of 4 patients with RfH have normal 24‐hour blood pressure and less target organ damage, thus indicating the important role of ambulatory blood pressure monitoring in guiding antihypertensive therapy in difficult‐to‐treat patients.

Abstract-Microalbuminuria is a known marker of subclinical organ damage. Its prevalence is higher in patients with resistant hypertension than in subjects with blood pressure at goal. On the other hand, some patients with apparently well-controlled hypertension still have microalbuminuria. The current study aimed to determine the relationship between microalbuminuria and both office and 24-hour ambulatory blood pressure. A cohort of 356 patients (mean age 64Ϯ11 years; 40.2% females) with resistant hypertension (blood pressure Ն140 and/or 90 mm Hg despite treatment with Ն3 drugs, diuretic included) were selected from Spanish hypertension units. Patients with estimated glomerular filtration rate Ͻ30 mL/min/1.73 m 2 were excluded. All patients underwent clinical and demographic evaluation, complete laboratory analyses, and good technical-quality 24-hour ambulatory blood pressure monitoring. Urinary albumin/creatinine ratio was averaged from 3 first-morning void urine samples. Microalbuminuria (urinary albumin/creatinine ratio Ն2.5 mg/mmol in males or Ն3.5 mg/mmol in females) was detected in 46.6%, and impaired renal function (estimated glomerular filtration rate Ͻ60 mL/min/1.73 m 2 ) was detected in 26.8%. Bivariate analyses showed significant associations of microalbuminuria with older age, reduced estimated glomerular filtration rate, increased nighttime systolic blood pressure, and elevated daytime, nighttime, and 24-hour diastolic blood pressure. In a logistic regression analysis, after age and sex adjustment, elevated nighttime systolic blood pressure (multivariate odds ratio, 1.014 [95% CI, 1.001 to 1.026]; Pϭ0.029) and reduced estimated glomerular filtration rate (multivariate odds ratio, 2.79 [95% CI, 1.57 to 4.96]; Pϭ0.0005) were independently associated with the presence of microalbuminuria. We conclude that microalbuminuria is better associated with increased nighttime systolic blood pressure than with any other office and 24-hour ambulatory blood pressure monitoring parameters. Key Words: resistant hypertension Ⅲ microalbuminuria Ⅲ urinary albumin/creatinine ratio Ⅲ ambulatory blood pressure monitoring Ⅲ night-systolic blood pressure Ⅲ estimated glomerular filtration rate I n the last 2 decades, microalbuminuria has risen consistently as a reliable marker of subclinical target organ damage, both in diabetic and nondiabetic persons. [1][2][3][4][5][6][7] It has been shown that microalbuminuria is a risk factor with significant prognostic impact for both incident cardiovascular and renal diseases and for all cause-mortality 1-4,6,8 -17. Current guidelines for the detection, prevention, and treatment of high blood pressure (BP) and chronic kidney disease have, therefore, included microalbuminuria as a determinant of cardiovascular and renal risk. 18,19 There is also some evidence of the association of high urinary albumin excretion (UAE) with elevated BP in subjects with resistant hypertension. 20 Until now, 24-hour ambulatory BP monitoring (ABPM) has been the best-known tool to identify patients with true...

Resistant (or refractory) hypertension (RH) is a clinical diagnosis based on blood pressure (BP) office measurements. About one third of subjects with suspected RH have indeed pseudo-resistant hypertension and 24-h ambulatory-blood pressure-monitoring aids to precisely identify them. Our aim was to determine those clinical, laboratory or echocardiographic variables that may be associated with subjects with sustained hypertension (namely true RH). We carried out a cross-sectional analysis of 143 patients consecutively enrolled with the clinical diagnosis of RH. All patients underwent clinicaldemographic, laboratory evaluation, 2D-echocardiography and 24-h ambulatory-blood pressure-monitoring. Pseudoresistant hypertension or white-coat RH was defined if office BP was X140 and/or 90 mm Hg and 24-h BP o130/ 80 mm Hg. One-hundred and three (72%) patients had true RH and 40 (28%) patients had white-coat RH. True RH patients had significantly higher diabetes prevalence and higher office-systolic blood pressure (SBP) levels. Regarding target organ damage, left ventricular mass index (LVMI) and 24-h urinary albumin excretion (UAE) were also higher in true RH after adjustment for possible confounders (P ¼ 0.031 and P ¼ 0.012, respectively). In a logistic regression analysis, only office-SBP (multivariate OR (95%CI): 1.030 (1.003-1.057), P ¼ 0.030) and UAE (multivariate OR (95% CI): 2.376 (1.225-4.608), P ¼ 0.010) were independently associated with true RH. We conclude that true resistant hypertension is associated with silent target organ damage, especially UAE. In patients with suspected RH, assessment of 24 h ambulatory BP is the most accurate way to detect a population with high risk for target-organ damage.

We present the Spanish adaptation from the CEIPC of the European Guidelines on Cardiovascular Disease Prevention in Clinical Practice 2008. This guide recommends the SCORE model for risk evaluation. The aim is to prevent premature mortality and morbidity due to CVD by means of dealing with its related risk factors in clinical practice. The guide focuses on primary prevention and emphasizes the role of the nurses and primary care medical doctors in promoting a healthy life style, based on increasing physical activity, change dietary habits, and non smoking. The therapeutic goal is to achieve a Blood Pressure <140/90 mmHg, but among patients with diabetes, chronic kidney disease, or definite CVD, the objective is <130/80 mmHg. Serum cholesterol should be <200 mg/dl and cLDL <130 mg/dl, although among patients with CVD or diabetes, the objective is <100 mg/dl (80 mg/dl if feasible in very high-risk patients). Patients with type 2 diabetes and those with metabolic syndrome must lose weight and increase their physical activity, and drugs must be administered whenever applicable, with the objective guided by BMI -body mass index- and waist circumference. In diabetic type 2 patients, the objective is glycated haemoglobin <7%. Allowing people to know the guides and developing implementation programs, identifying barriers and seeking solutions for them, are priorities for the CEIPC in order to put the recommendations into practice.

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