Characteristics, drug combinations and dosages of primary care patients with uncontrolled ambulatory blood pressure and high medication adherence

Abstract

Most studies on the prevalence and determinants of resistant hypertension (RH) do not account for white coat hypertension, medication non-adherence, or use of suboptimal treatment dosages. We studied the characteristics, drug combinations, and dosages of patients on at least three antihypertensives of different classes who had uncontrolled blood pressure on 24-hour ambulatory blood pressure monitoring and high medication adherence measured by electronic monitoring. The data were collected as part of the baseline measures of a hypertension control trial. Of 140 monitored primary care patients, all with uncontrolled office blood pressure, 69 (49%) were on at least three antihypertensives of different classes. Of these 69, 15 (22%) were controlled on ambulatory blood pressure monitoring, 20 (29%) were uncontrolled and non-adherent, leaving only 34 (49%) adherent to their medications and having uncontrolled ambulatory hypertension (uncontrolled RH). Thirty-one (91%) of the 34 uncontrolled RH patients were prescribed a diuretic, of which 24 were on hydrochlorothiazide 25 mg. Less than half of the patients on angiotensin-converting enzyme inhibitor, angiotensin receptor blocker, or calcium channel blocker were prescribed maximal doses of these agents. Half of the RH can be attributed to white coat effect and poor medication adherence, and all of the remaining patients were on apparently suboptimal drug combinations and/or dosages. Primary care physicians need to be educated regarding the optimal treatment of RH.

Refractory Hypertension

“…Such causes of pseudoresistance are common such that up to 50% of patients with apparent resistant hypertension may not be truly resistant to treatment. 19 …”

“…In contrast, a study by Grigoryan et al simultaneously determined the prevalence of poor adherence, white coat resistant hypertension, and under-treatment as causes of pseudo-resistant hypertension in the same cohort. 19 This study was a retrospective analysis of primary care patients with resistant hypertension who were participants in a study of determinants of blood pressure control that included electronic pill monitoring and ambulatory blood pressure measurement. Of the 69 patients analyzed, 22% had white coat resistant hypertension and 29% were non-adherent with their medications based on taking <80% of the prescribed doses.…”

“…Of the 69 patients analyzed, 22% had white coat resistant hypertension and 29% were non-adherent with their medications based on taking <80% of the prescribed doses. 19 Accordingly, only half of the patients could be classified has having true resistant hypertension based on being adequately adherent with their prescribed medications and having elevated ambulatory blood pressure levels. Further, none of these patients were optimally treated in that only a small number of them were receiving a maximum recommended dose of an angiotensin converting enzyme inhibitor, angiotensin receptor blocker, or calcium channel blocker, and none were receiving chlorthalidone or spironolactone.…”

Problem of resistant arterial hypertension in the family doctor practice

“…В опубликованном исследовании влияния гипер-тензии белого халата, плохой приверженности лече-нию и неоптимальной терапии у больных с псевдо-резистентностью авторы провели оценку пациентов, участвовавших в рандомизированном, многоцен-тровом исследовании, проводившемся для изучения клинической инертности и контроля АД [7]. Все-го 69 пациентов соответствовавших классическим критериям РАГ, были подвергнуты 24-часовому амбулаторному мониторированию АД и их привер-женность предписанному антигипертензивному ле-чению мониторировалась с помощью электронной системы.…”

“…У больных с хронической почечной недостаточно-стью (ХПН) (клиренс креатинина <30 мл/мин) пред-почтение должно отдаваться петлевым диуретикам [7,8].…”