Masked Uncontrolled Hypertension Is Not Attributable to Medication Nonadherence

Abstract

Masked uncontrolled hypertension (MUCH) in treated hypertensive patients is defined as controlled automated office blood pressure (BP; <135/85 mm Hg) in-clinic but uncontrolled out-of-clinic BP by ambulatory BP monitoring (awake [daytime] readings ≥135/85 mm Hg or 24-hour readings ≥130/80 mm Hg). To determine whether MUCH is attributable to antihypertensive medication nonadherence. One hundred eighty-four enrolled patients were confirmed to have controlled office BP; of these, 167 patients were with adequate 24-hour ambulatory BP recordings. Of 167 patients, 86 were controlled by in-clinic BP assessment but had uncontrolled ambulatory awake BP, indicative of MUCH. The remaining 81 had controlled in-clinic and ambulatory awake BP, consistent with true controlled hypertension. After exclusion of 9 patients with missing 24-hour urine collections, antihypertensive medication adherence was determined based on the detection of urinary drugs or drug metabolites by high-performance liquid chromatography–tandem mass spectrometry. Of the 81 patients with MUCH, 69 (85.2%) were fully adherent and 12 (14.8%) were partially adherent (fewer medications detected than prescribed). Of the 77 patients with true controlled hypertension, 69 (89.6%) were fully adherent with prescribed antihypertensive medications and 8 (10.4%) were partially adherent. None of the patients in either group were fully nonadherent. There was no statistically significant difference in complete or partial adherence between the MUCH and true controlled groups ( P =0.403). Measurement of urinary drug and drug metabolite levels demonstrates a similarly high level of antihypertensive medication adherence in both MUCH and truly controlled hypertensive patients. These findings indicate that MUCH is not attributable to antihypertensive medication nonadherence.

Smoking and overweight associated with masked uncontrolled hypertension: a Hypertension Optimal Treatment (HOT) Sub-Study

“…However, it appears that when analyzing the presence of antihypertensive drugs or drug metabolites in urine samples, poor medication adherence did not explain the existence of MUCH [13][14]. It is more likely that MUCH is representing a form of hypertension that is worsening with time, and if no further intervention (adding more medication to gain BP control), there is transition from MUCH to established uncontrolled hypertension [11].…”

“…Terms like "white coat" hypertension for isolated elevation of BP in the office and "masked hypertension" for isolated elevation of BP out of the office, were previously reserved for people without antihypertensive treatment. But these terms are now also used for people who are treated for hypertension [11][12][13][14].…”

Twenty-Four-Hour Ambulatory Blood Pressure Monitoring

“…Poor medication adherence should be suspected in patients with masked hypertension, although there has not been a strong clinical correlation to suggest poor compliance as a major culprit. 38 It is recommended that these patients be treated with antihypertensive drugs to achieve normotension and decrease the risk for major cardiovascular events in the future. 7 , 39 , 40 …”

“…Poor medication adherence should be suspected in patients with masked hypertension, although there has not been a strong clinical correlation to suggest poor compliance as a major culprit. 38 It is recommended that these patients be treated with antihypertensive drugs to achieve normotension and decrease the risk for major cardiovascular events in the future. 7,39,40 Nocturnal blood pressure abnormalities, such as failure to decrease blood pressure during sleep (nondipping) or nocturnal high blood pressure, provide important information in studies on the association of 24-hour mean blood pressure with cardiovascular morbidity.…”

Hipertensão Mascarada: Qual O Verdadeiro Risco Cardiovascular?

“…11,19 A HMNC, por outro lado, poderia refletir simplesmente adesão inadequada ao regime terapêutico proposto, mas dados recentemente publicados, valendo-se de dosagem de concentrações urinárias de fármacos em pacientes com e sem HMNC não corroboraram esta impressão, ainda que alguns casos pudessem de fato resultar de adesão imprópria. 28 Ao contrário, um grande registro espanhol, ao documentar a presença de HMNC em 30% dos hipertensos tratados, encontrou importante associação com comorbidades tais como diabetes mellitus e doença renal crônica. 10 A medida da PA fora do ambiente ambulatorial padece da limitação imposta pela impossibilidade de obter registros durante o período de sono, quando é possível detectar padrões "non-dipper" ou "dipper reverso", reconhecidamente associados a pior prognóstico.…”