Prognostic value of masked uncontrolled apparent resistant hypertension detected through home blood pressure monitoring

Abstract

Objective: Resistant hypertension carries a poor prognosis and current guidelines recommend the exclusion of the white-coat phenomenon for proper diagnosis. However, guidelines do not focus on patients treated with at least three drugs whose blood pressure (BP) is controlled at the office but elevated out of it. We aimed at determining whether this masked uncontrolled apparent resistant hypertension (MUCRH) detected through home blood pressure monitoring (HBPM) has prognostic value for fatal and nonfatal events in these hypertensive patients. Methods: Hypertensive patients treated with at least three drugs who performed a baseline HBPM between 2008 and 2015 were followed to register the occurrence of total mortality, cardiovascular mortality, and fatal and nonfatal cardiac and cerebrovascular events. MUCRH was defined as office blood pressure less than 140/90 mmHg and home BP at least 135 and/or 85 mmHg. Multivariable Cox proportional hazard models were adjusted to determine the independent prognostic value of MUCRH for the events of interest. Results: We included 470 patients, 35.5% male, mean age 71.9 years, and treated with 3.3 antihypertensive drugs on average. Among study population, 15.5% had MUCRH (33.3% when considering only patients with adequate BP control at the office). Median follow-up was 6.7 years. In multivariable models, MUCRH was an independent predictor for cardiovascular mortality and cerebrovascular events: hazard ratio 4.9 (95% CI 1.2–19.9, P = 0.03) and 5.1 (95% CI 1.5–16.9, P = 0.01), respectively. Conclusion: MUCRH is not rare and is independently associated with cardiovascular morbidity and mortality. The systematic monitoring of intensively treated individuals through HBPM would be useful for the detection of patients at increased risk of events.

Prognostic value of non‐resistant and resistant masked uncontrolled hypertension detected by ambulatory blood pressure monitoring

“…In our population, moreover, patients were about 10 years younger, a higher prevalence of men was observed in the RMUCH group, prevalence of diabetes and previous events was lower, and antihypertensive drug class distribution tended to be different in both patients with CH and in those with RMUCH. When single components of the composite endpoint were analyzed separately in our study, the same trend of all events was observed, though direct comparison with previous study 19 is difficult because of different definition and evaluation of events. Some differences between our study and previous one 19 could be partly explained by the above‐mentioned characteristics.…”

“…When single components of the composite endpoint were analyzed separately in our study, the same trend of all events was observed, though direct comparison with previous study 19 is difficult because of different definition and evaluation of events. Some differences between our study and previous one 19 could be partly explained by the above‐mentioned characteristics. In any case, results of both studies are essentially in line emphasizing the prognostic relevance of RMUCH.…”

“…19 During a mean follow-up of 6.7 years, patients with RMUCH were at higher risk of cardiovascular mortality (HR 4.9, 95% CI 1.2-19.9, P = .03) and of fatal and nonfatal cerebrovascular events (HR 5.1, 95% CI 1.5-16.9, P = .01) when compared to individuals with CH. 19 At variance with the previous study, 19 we used ambulatory BP monitoring to define study groups, included patients with NRMUCH and RMUCH and evaluated a composite cardiovascular endpoint. In our population, moreover, patients were about 10 years younger, a higher prevalence of men was observed in the RMUCH group, prevalence of diabetes and previous events was lower, and antihypertensive drug class distribution tended to be different in both patients with CH and in those with RMUCH.…”

“… 19 Barochiner and colleagues, by using home BP recording, studied 470 treated hypertensive patients who were receiving at least three antihypertensive drugs. 19 Among individuals with controlled clinic BP, about one‐third had RMUCH. 19 During a mean follow‐up of 6.7 years, patients with RMUCH were at higher risk of cardiovascular mortality (HR 4.9, 95% CI 1.2–19.9, P = .03) and of fatal and nonfatal cerebrovascular events (HR 5.1, 95% CI 1.5–16.9, P = .01) when compared to individuals with CH.…”

“…At variance with the previous study, 19 we used ambulatory BP monitoring to define study groups, included patients with NRMUCH and RMUCH and evaluated a composite cardiovascular endpoint. In our population, moreover, patients were about 10 years younger, a higher prevalence of men was observed in the RMUCH group, prevalence of diabetes and previous events was lower, and antihypertensive drug class distribution tended to be different in both patients with CH and in those with RMUCH.…”