Prevalence and Clinical Characteristics of Isolated-Office and True Resistant Hypertension Determined by Ambulatory Blood Pressure Monitoring

Abstract

Hypertension is defined as resistant to treatment when a therapeutic plan including ≥3 hypertension medications failed to sufficiently lower systolic (SBP) and diastolic (DBP) blood pressures (BPs). Most individuals, including those under hypertension therapy, show a "white-coat" effect that could cause an overestimation of their real BP. The prevalence and clinical characteristics of "white-coat" or isolated-office resistant hypertension (RH) has always been evaluated by comparing clinic BP values with either daytime home BP measurements or the awake BP mean obtained from ambulatory monitoring (ABPM), therefore including patients with either normal or elevated asleep BP mean. Here, we investigated the impact of including asleep BP mean as a requirement for the definition of hypertension on the prevalence, clinical characteristics, and estimated cardiovascular (CVD) risk of isolated-office RH. This cross-sectional study evaluated 3042 patients treated with ≥3 hypertension medications and evaluated by 48-h ABPM (1707 men/1335 women), 64.2 ± 11.6 (mean ± SD) yrs of age, enrolled in the Hygia Project. Among the participants, 522 (17.2%) had true isolated-office RH (elevated clinic BP and controlled awake and asleep ambulatory BPs while treated with 3 hypertension medications), 260 (8.6%) had false isolated-office RH (elevated clinic BP, controlled awake SBP/DBP means, but elevated asleep SBP or DBP mean while treated with 3 hypertension medications), and the remaining 2260 (74.3%) had true RH (elevated awake or asleep SBP/DBP means while treated with 3 medications, or any patient treated with ≥4 medications). Patients with false, relative to those with true, isolated-office RH had higher prevalence of microalbuminuria and chronic kidney disease (CKD), significantly higher albumin/creatinine ratio (p < .001), significantly higher 48-h SBP/DBP means by 9.6/5.3 mm Hg (p < .001), significantly lower sleep-time relative SBP and DBP decline (p < .001), and significantly greater prevalence of a non-dipper BP profile (96.9% vs. 38.9%; p < .001). Additionally, the prevalence of the riser BP pattern, which is associated with highest CVD risk, was much greater, 40.4% vs. 5.0% (p < .001), among patients with false isolated-office RH. The estimated hazard ratio of CVD events, using a fully adjusted model including the significant confounding variables of sex, age, diabetes, chronic kidney disease, asleep SBP mean, and sleep-time relative SBP decline, was significantly greater for patients with false compared with those with true isolated-office RH (2.13 [95% confidence interval: 1.95-2.32]; p < .001). Patients with false isolated-office hypertension and true RH, however, were equivalent for the prevalence of obstructive sleep apnea, metabolic syndrome, obesity, diabetes, microalbuminuria, and chronic kidney disease, and they had an equivalent estimated hazard ratio of CVD events (1.04 [95% confidence interval: .97-1.12]; p = .265). Our findings document a significantly elevated prevalence of a blunted nighttime BP decline in pat...

Prevalence of True Therapeutic Inertia in Blood Pressure Control in an Academic Chronic Kidney Disease Clinic

“…It would be incorrect to classify these patients as experiencing TI. Home BP or ambulatory BP measurement may provide an answer in case of this uncertainty …”

Circadian disruption: New clinical perspective of disease pathology and basis for chronotherapeutic intervention

“…Altered circadian BP 24 h patterning, that is, attenuated sleep-time decline and sleep-time riser profiles, often presenting as nocturnal hypertension, are common in persons diagnosed with diabetes , renal disease (Mojón et al, 2013), resistant hypertension -hypertension resistant to SBP/DBP reduction to normal values after treatment with three or more medications (Ríos et al, 2013) -and who are elderly, particularly those ≥60 years of age (Hermida et al, 2013a). According to Fabbian et al (2013), such BP patterns are highly prevalent also in persons with severe hypertension, salt-sensitive essential hypertension, neurogenic hypertension, essential hypertension with left ventricular hypertrophy, gestational hypertension, toxemia of pregnancy, orthostatic autonomic failure, Shy-Drager syndrome, vascular and Alzheimer-type dementia, cerebral atrophy, cardiovascular disease, ischemic arterial disease, congestive heart failure, carotid endarterectomy, fatal familial insomnia, catecholamine-producing tumors, Cushing's and mineral corticoid excess syndromes including from exogenous glucocorticoid administration, Addison's disease, pseudohypoparathyroidism, sleep apnea, normotensive and hypertensive asthma, plus those treated with immunosuppressive medication following renal, liver and cardiac transplantation, and those treated with recombinant human erythropoietin therapy.…”

The possibility of resistant hypertension during the treatment of hypertensive patients

“…The prevalence and clinical characteristics of white coat or isolated office RH are usually determined by comparing clinic BP values with either daytime home BP measurements or awake BP mean values obtained from ABPM. 11 Thus, so-called RH might include patients with normal or elevated asleep BP mean values. 11 The authors of the latter study indicated that RH should be classified into isolated-office RH, masked RH and true RH, and also emphasized that ABPM should be regarded as a clinical requirement for the diagnosis of RH.…”

“…11 Thus, so-called RH might include patients with normal or elevated asleep BP mean values. 11 The authors of the latter study indicated that RH should be classified into isolated-office RH, masked RH and true RH, and also emphasized that ABPM should be regarded as a clinical requirement for the diagnosis of RH. 11 Therefore, when assessing patients with suspected RH, we should measure BP using ABPM, rather than with the conventional cuff methods used to determine clinic BP in order to differentiate it from white coat, isolated office and masked hypertension.…”