Apparent Treatment-resistant Hypertension Among Individuals with History of Stroke or Transient Ischemic Attack

Howard, Virginia J.; Tanner, Rikki M.; Anderson, Aaron; Irvin, Marguerite R.; Calhoun, David A.; Lackland, Daniel T.; Oparil, Suzanne; Muntner, Paul

doi:10.1016/j.amjmed.2015.02.008

Cited by 25 publications

(21 citation statements)

References 47 publications

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“…Another contributing factor is that many patients with hypertension are under-treated. A recent study showed that hypertension treatment after vascular events may be inadequate, and another study showed high rates of apparent treatment-resistant hypertension in TIA and stroke patients [18,19]. …”

Section: Discussionmentioning

confidence: 99%

Long-Term Risk of Stroke after Transient Ischemic Attack

Appelros

Berglund²,

Ström³

2016

Cerebrovasc Dis

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Background: In the absence of active management, the stroke risk after a transient ischemic attack (TIA) may be high. Almost 10 years ago, the results of the EXPRESS and SOS-TIA studies called for a more rapid management of TIA patients. The purpose of this study was to investigate the other stroke risks in the longer term, after the implementation of a more active approach to TIA. We also wanted to assess the predictive value of the ABCD2 score in this context. Methods: Riksstroke is the national stroke registry in Sweden. Data from Riksstroke's TIA module, and the national cause-of-death register, for the years 2011 and 2012 were used in this study. Stroke occurrence was monitored via Riksstroke. Cox's regression was used for risk evaluation. The predictive value of the ABCD2 score was assessed by calculating the area under the receiver operating characteristics curve. Results: A total of 15,068 TIA episodes occurred in 14,102 patients. The follow-up time varied between 0 and 819 days, with an average of 417 days. The mortality for all TIA patients during the follow-up time was 7.1%. Of the unique patients, 545 had one or more strokes (3.9%), corresponding to 34 events per 1,000 person years. Significant risk factors for stroke were: age, previous TIA, atrial fibrillation (AF), oral anticoagulant (OAC) treatment, hypertension treatment, and the ABCD2 items speech impairment, unilateral weakness, and diabetes mellitus. The ABCD2 score correlated with a subsequent stroke, but its predictive value was low. Conclusion: The risk of stroke is low after the acute phase of a TIA, probably lower than in previous studies. This may be due to better secondary prevention in recent years. Several risk factors predict stroke, notably hypertensive treatment, which may be inadequate; and AF, where OACs may be under-used. It is difficult to identify the role of the ABCD2 score in clinical practice.

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Section: Discussionmentioning

confidence: 99%

Long-Term Risk of Stroke after Transient Ischemic Attack

Appelros

Berglund²,

Ström³

2016

Cerebrovasc Dis

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Section: Data Collectionmentioning

confidence: 99%

“…17, 19, 20 In REGARDS, SBP and DBP were measured twice, 30 seconds apart, using an aneroid sphygmomanometer (American Diagnostic Corporation, Hauppauge, NY) after the participant had been seated for 5 minutes. 18, 20, 21 These measurements were averaged for analysis. In MESA, SBP and DBP were measured three times at 2 minute intervals using a Dinamap model Pro 100 automated oscillometric sphygmomanometer (GE Medical Systems Information Technologies, Inc., Milwaukee, Wisconsin) after participants rested for 5 minutes in a seated position.…”

Section: Data Collectionmentioning

confidence: 99%

Incident Cardiovascular Disease Among Adults With Blood Pressure <140/90 mm Hg

et al. 2017

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Background Data from before the 2000s indicate the majority of incident cardiovascular disease (CVD) events occur among US adults with systolic and diastolic blood pressure (SBP/DBP)≥140/90 mmHg. Over the past several decades, BP declined and hypertension control has improved. Methods We estimated the percentage of incident CVD events that occur at SBP/DBP<140/90 mmHg in a pooled analysis of three contemporary US cohorts: the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study, the Multi-Ethnic Study of Atherosclerosis (MESA), and the Jackson Heart Study (JHS) (n=31,856; REGARDS=21,208; MESA=6,779; JHS=3,869). Baseline study visits were conducted in 2003–2007 for REGARDS, 2000–2002 for MESA, and 2000–2004 for JHS. BP was measured by trained staff using standardized methods. Antihypertensive medication use was self-reported. The primary outcome was incident CVD, defined by the first occurrence of fatal or non-fatal stroke, non-fatal myocardial infarction, fatal coronary heart disease, or heart failure. Events were adjudicated in each study. Results Over a mean follow-up of 7.7 years, 2,584 participants had incident CVD events. Overall, 63.0% (95%CI: 54.9%–71.1%) of events occurred in participants with SBP/DBP<140/90 mmHg; 58.4% (95%CI: 47.7%–69.2%) and 68.1% (95%CI: 60.1%–76.0%) among those taking and not taking antihypertensive medication, respectively. The majority of events occurred in participants with SBP/DBP<140/90 mmHg among those <65 years (66.7% 95%CI: 60.5%–73.0%) and ≥65 years (60.3% 95%CI: 51.0%–69.5%), women (61.4%; 95%CI: 49.9%–72.9%) and men (63.8%; 95%CI: 58.4%–69.1%), and for whites (68.7%; 95%CI: 66.1%–71.3%), blacks (59.0%; 95%CI: 49.5%-68.6%), Hispanics (52.7% 95%CI: 45.1%–60.4%) and Chinese-Americans (58.5%; 95%CI: 45.2%–71.8%). Among participants taking antihypertensive medication with SBP/DBP<140/90 mmHg, 76.6% (95% CI: 75.8%–77.5%) were eligible for statin treatment but only 33.2% (95%CI: 32.1%–34.3%) were taking one and 19.5% (95%CI: 18.5%–20.5%) met the Systolic Blood Pressure Intervention Trial eligibility criteria and may benefit from a SBP target goal of 120 mmHg. Conclusions While higher BP levels are associated with increased CVD risk, in the modern era, the majority of incident CVD events occur in US adults with SBP/DBP<140/90 mmHg. Although absolute risk and cost-effectiveness should be considered, additional CVD risk reduction measures for adults with SBP/DBP<140/90 mmHg at high risk for CVD may be warranted.

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“…17,18 In persons with HTN, the prevalence of AF has been reported to be higher among those with uncontrolled HTN compared to controlled HTN. 8 Antihypertensive medications such as beta-blockers and angiotensin converting enzyme inhibitors (ACE-I) are associated with decreased AF risk.…”

Section: Introductionmentioning

confidence: 99%

Is there an association between the prevalence of atrial fibrillation and severity and control of hypertension? The REasons for Geographic And Racial Differences in Stroke study

Bhatt

Gamboa

Safford

et al. 2016

Journal of the American Society of Hypertension

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Background The association of atrial fibrillation (AF) with the severity and control of hypertension (HTN) remains unclear. Methods We analyzed data from the national biracial cohort of REasons for Geographic And Racial Differences in Stroke (REGARDS) study. The AF prevalence ratios were estimated and full multi-variable adjustment included demographics, risk factors, medication adherence, HTN duration and antihypertensive medication classes. Results Of the 30,018 study participants (8.6% with AF), 4,386 had normotension (4.3% with AF), 5,916 had prehypertension (4.3 with AF%), 12,294 had controlled HTN (11.2% with AF), 5,587 had uncontrolled HTN (8.1% with AF), 547 had controlled apparent treatment resistant hypertension (aTRH) (19.2% with AF), and 1288 had uncontrolled aTRH (15.5% with AF). Compared with normotension, the AF prevalence ratios for prehypertension, controlled HTN, uncontrolled HTN, controlled aTRH and uncontrolled aTRH groups in fully adjusted model were 1.01 (95% CI 0.84 – 1.21), 1.42 (1.18 – 1.71), 1.37 (1.14 – 1.65), 1.17 (0.86 – 1.58) and 1.42 (1.10 – 1.84) respectively (p < 0.001). Conclusion The prevalence of AF was similar among persons with HTN regardless of BP level and antihypertensive treatment resistance.

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Apparent Treatment-resistant Hypertension Among Individuals with History of Stroke or Transient Ischemic Attack

Cited by 25 publications

References 47 publications

Long-Term Risk of Stroke after Transient Ischemic Attack

Long-Term Risk of Stroke after Transient Ischemic Attack

Incident Cardiovascular Disease Among Adults With Blood Pressure <140/90 mm Hg

Is there an association between the prevalence of atrial fibrillation and severity and control of hypertension? The REasons for Geographic And Racial Differences in Stroke study

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