Characterization of Individuals With Apparent Resistant Hypertension Using Contemporary Guidelines: Insights From CV-QUIC

Abstract

Background: Apparent resistant hypertension (aRH) carries excess cardiovascular risk beyond nonresistant forms of hypertension; however, our understanding of this at-risk population, as defined by current US practice guidelines, is limited. Accordingly, we sought to evaluate the prevalence, clinical characteristics, and pharmacotherapeutic patterns of patients with aRH using contemporary blood pressure guidance. Methods: We classified patients at 3 large healthcare systems by hypertensive status using contemporary hypertension guidelines. We subsequently described the demographic and clinical characteristics of patients with aRH and compared these factors among hypertensive patients without aRH and between those with controlled and uncontrolled aRH. Results: A total of 2 420 468 patients were analyzed, of whom 1 343 489 (55.6%) were hypertensive according to contemporary guidelines. Among hypertensive patients, 11 992 (8.5%) met criteria for aRH, with nearly all assessed comorbid conditions, particularly diabetes and heart failure, being more common in those with aRH. When compared with patients with uncontrolled aRH, those with controlled aRH were more frequently prescribed a beta-blocker, diuretic, and nitrate, with the largest standardized difference observed for a mineralocorticoid receptor antagonist (35.4% versus 10.4%, Cohen D 0.62). Consistent findings were noted in sensitivity analyses using the blood pressure threshold of 140/90 mm Hg. Conclusions: In an analysis of over 2.4 million individuals, a lower prevalence of aRH was observed than previously reported (12%–15%), but with a high burden of comorbidities. Identification of differences in pharmacotherapy between patients with controlled and uncontrolled aRH, particularly lower rates of mineralocorticoid receptor antagonist use, help define potential opportunities to improve care and lower cardiovascular risk.

Characteristics of Adults With Apparent Treatment Resistant Hypertension: Six Factors Impacting Prevalence—Editorial Commentary

“…Untreated and undertreated hypertension. In both the current study by Ebinger et al and in the Carey report, 1,9 patients were treated predominantly to a BP goal of <140/<90. In the current report, 1 for example, among 1 343 489 adults with hypertension, 883 693 had uncontrolled hypertension that was not aTRH.…”

“…In both the current study by Ebinger et al and in the Carey report, 1,9 patients were treated predominantly to a BP goal of <140/<90. In the current report, 1 for example, among 1 343 489 adults with hypertension, 883 693 had uncontrolled hypertension that was not aTRH. For this group, the mean number of antihypertensive medications was 0.53, which suggests that perhaps half were untreated and another substantial proportion was on monotherapy, with relatively few on combination therapy.…”

“…Medication reconciliation was an inclusion criterion in the current report 1 but not previous studies on the prevalence of aTRH. Medication data in the electronic health record system is often inaccurate and can adversely impact patient outcomes.…”

“…The current report combined subclasses of calcium channel blockers and diuretics, 1 which could reduce the prevalence of aTRH. Among those with aTRH, the mean number of medications was greater than the number of classes (3.68 versus 3.50), suggesting roughly 5% of this group was on combinations of antihypertensive medication subclasses.…”

“…In this issue of Hypertension , Ebinger et al provide important real-world clinical data on the prevalence of apparent treatment resistant hypertension (aTRH). 1 The authors combined electronic health record system data from 3 large health systems serving 2 420 468 adults with 2 or more outpatient visits that included both blood pressure (BP, mm Hg) values and medication reconciliation. Of the 1 343 489 adults with a diagnosis of hypertension, 113 992 (8.5%) met criteria for aTRH at a BP threshold of 130/80 and 8.3% at a BP threshold of 140/90.…”