True Resistant Hypertension: Is it Possible to Be Recognized in the Office?

Muxfeldt, Elizabeth Silaid; Bloch, Kátia Vergetti; Nogueira, Armando da Rocha; Salles, Gil F.

doi:10.1016/j.amjhyper.2005.06.013

Cited by 91 publications

(102 citation statements)

References 21 publications

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“…Overall, our cross-sectional study, in agreement with the findings of some (16,17) but not all investigators (14,15), demonstrates that nondipping is a common finding in patients with RH. The novel findings of our study are the extraordinarily high prevalence of nocturnal hypertension and the increased prevalence of nocturnal BP rising (and a trend toward less extreme dipping) in subjects with RH.…”

Section: Discussionsupporting

confidence: 77%

“…In a study (22) of 62 healthy middle-aged men, the percentage fall in nocturnal mean arterial pressure was 15% and the proportion of nondippers was 13%. Using a standard definition of RH in a study of 313 such patients, Muxfeldt et al (17) found that the percentage fall in nocturnal systolic and diastolic BP was 7% and 10.5%, respectively, and the proportion of nondippers was 65.8%. However, 63% of the 184 white-coat resistant hypertensive patients in this study also had a nondipping pattern.…”

Section: Discussionmentioning

confidence: 99%

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Nocturnal blood pressure profiles among normotensive, controlled hypertensive and refractory hypertensive subjects

Friedman

Logan

2009

Canadian Journal of Cardiology

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R efractory hypertension (RH) is emerging as a significant and growing problem in managing hypertension. In a previous study (1), 11% of patients referred for uncontrolled hypertension were found to meet the criteria for RH. Not surprisingly, RH is associated with an increased risk of hypertensive target organ damage (2). Experts recommend 24 h ambulatory blood pressure monitoring (ABPM) to differentiate true RH from white-coat resistant hypertension (3). The test also provides information on nocturnal blood pressure (BP) and the means to assess its relationship with survival and the occurrence of cardiovascular and renal events, adjusted for daytime or 24 h BP (4-12). Several sleep BP pattern disturbances in normotensive (NT) and hypertensive subjects have been identified. A Japanese study (6) found a 20% increase in cardiovascular mortality for every 5% attenuation in nocturnal BP fall, independent of overall 24 h BP. In another study (13), a J-shaped curve of stroke incidence was found among extreme dippers (subjects with a 20% or greater fall in nocturnal BP) and nondippers, albeit from different causes, with risers (subjects with a paradoxical increase in nocturnal BP) having the worst cardiovascular prognosis. Recently, nighttime BP, independent of daytime level, was found to be a predictor of death and cardiovascular disease (12). Surprisingly, to date, little attention has been given to sleep BP patterns in subjects with RH, and the results in the existing literature conflict, at least in part, with the use of different definitions of the condition itself and methods to define the nighttime period (14-17).The present study was undertaken to determine whether sleep BP pattern disturbances are related to the presence or severity of hypertension. We used a widely accepted definition of RH and diaries BACKGROUND: Nocturnal blood pressure abnormalities are independently associated with an increased risk of death and cardiovascular disease. It is unclear, however, whether they are related to the presence or severity of hypertension. OBJECTIVES: To determine and compare the prevalence of sleep pattern disturbances in normotensive (NT) and hypertensive patients. METHODS:The present cross-sectional study assessed the nocturnal blood pressure profiles from 24 h ambulatory blood pressure monitoring of refractory hypertensive (RH) (n=26), controlled hypertensive (CH) (n=52) and NT (n=52) subjects who were matched for age, sex and body mass index. Results are expressed as mean ± SD or proportion, as appropriate. RESULTS: During sleep, the percentage fall in mean arterial pressure was 15.1±6.1% in the NT group, 11.5±7.0% in the CH group and 7.7±7.7% in the RH group (P<0.0001). The corresponding proportions of nondipping were 25.0%, 42.3% and 61.5%, respectively (P=0.006), and those of nocturnal hypertension were 9.6%, 23.1% and 84.6%, respectively (P<0.0001). All pairwise comparisons of nocturnal blood pressure fall were significant. The proportion of subjects in the RH group who experienced a rise in nocturnal blood ...

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Section: Discussionsupporting

confidence: 77%

Section: Discussionmentioning

confidence: 99%

Nocturnal blood pressure profiles among normotensive, controlled hypertensive and refractory hypertensive subjects

Friedman

Logan

2009

Canadian Journal of Cardiology

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“…These data are in line with the present study findings showing that despite the careful assessment of CBP in two study visits and after one pre-study visit more than one-third of subjects with CRH (36%) had low ABP (Figure 3). Another study by Muxfeldt et al 21 in 497 patients with RH in the clinic showed that those with elevated ABP (63%) had more severe target-organ damage (microalbuminuria and left ventricular hypertrophy) than those with low ABP. Redon et al 2 investigated the prognostic value of ABP compared with that of CBP in 86 subjects with RH in the clinic followed for 4 years and showed that subjects at the top tertile of ABP values had the worst cardiovascular prognosis.…”

Section: Discussionmentioning

confidence: 98%

Home versus ambulatory blood pressure monitoring in the diagnosis of clinic resistant and true resistant hypertension

et al. 2011

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Ambulatory blood pressure (ABP) monitoring is recommended as a standard method for the evaluation of resistant hypertension (RH). This study assessed the diagnostic value of home blood pressure (HBP) monitoring in RH. Subjects on stable treatment with X3 antihypertensive drugs were included. Clinic RH (CRH) was defined as elevated clinic blood pressure and true RH (TRH) as elevated ABP. The diagnosis of CRH was verified by ABP and HBP monitoring. The diagnostic value of HBP was assessed by taking ABP as reference method. Threshold for hypertension diagnosis was X135/85 mm Hg (systolic and/or diastolic) for HBP and awake ABP and X140/90 mm Hg for clinic blood pressure. Among 73 subjects on X3 antihypertensive drugs, 44 (60%) had CRH and 40 (55%) TRH. There was agreement between ABP and HBP in diagnosing CRH in 82% of the cases (26 subjects (59%) with CRH and 10 (23%) without CRH; kappa 0.59). Regarding the diagnosis of TRH, there was agreement between ABP and HBP in 74% of the cases (36 subjects (49%) with TRH and 18 (25%) without TRH; kappa 0.46). The sensitivity, specificity, and positive and negative predictive values of HBP in detecting CRH were 93%, 63%, and 81% and 83%, respectively, and TRH were 90%, 55%, and 71%, and 82%, respectively (ABP taken as reference method). These data suggest that HBP is a reliable alternative to ABP in the evaluation of RH. These methods are necessary in both uncontrolled and controlled subjects on triple therapy to detect the white coat phenomenon and also masked RH. Although the exact prevalence of RH is unknown, clinical trials suggest that it affects 20 --30% of participants 1 and is related with worse prognosis than subjects with controlled hypertension. 1,2 Studies have shown that a significant white-coat effect is as common in patients with RH as in the general hypertensive population, with prevalence ranging from 20 to 30%. 1,3 Furthermore, using only conventional clinic blood pressure (CBP) measurements as follow-up method, patients with masked RH 4 cannot be detected, antihypertensive treatment is not up-titrated and blood pressure (BP) control is not achieved. Several studies have shown that ambulatory BP (ABP) is superior to clinical measurements in predicting hypertension-induced target-organ damage and cardiovascular events in patients with RH. 2,5 Therefore, current guidelines recommend ABP monitoring as a standard method for the evaluation of RH. 1,6 Home BP (HBP) monitoring has also been shown to predict cardiovascular events better than clinical measurements 7,8 and several studies have reported similar ability of HBP with ABP in diagnosing white coat, masked and sustained hypertension. 9 Previous studies have also shown that HBP and ABP monitoring are interchangeable diagnostic methods, not only in untreated but also in treated hypertensives. 9 --11 However, in patients with RH, although the clinical utility of ABP has been documented, to date the usefulness of HBP monitoring has not been investigated.This study assessed the diagnostic value of HBP monitoring...

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“…Resistant hypertension may also be secondary to other medical conditions, most often chronic kidney disease or primary hyperaldosteronism as well as renovascular disease and obstructive sleep apnea (7). Low potassium and target organ damage, including albuminuria, retinopathy and left ventricular hypertrophy, were more frequent in those found to have true resistant hypertension compared with those with white coat hypertension (8).…”

Section: Etiology and Pathophysiologymentioning

confidence: 99%

Resistant hypertension

Tobe

Lewanczuk

2009

Canadian Journal of Cardiology

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R esistant hypertension is defined by a lack of response to therapy with three or more medications and is evidence of a more severe stage of hypertension, with over a fourfold greater risk of cardiovascular events compared with hypertensive patients achieving blood pressure targets (1). The Joint National Committee's recommendations on high blood pressure (2) define resistant hypertension as "the failure to reach goal blood pressure despite full doses of an appropriate 3 drug regimen including diuretics". The European Society of Hypertension definition (3) is "hypertension resistant or refractory to lifestyle measures and at least three medications, including a diuretic to lower blood pressure to target". These definitions are reasonable and would then be modified by the urgency to treat based on the actual stage of blood pressure, with higher stages indicating greater urgency to achieve control. The Canadian Hypertension Education Program (CHEP) has not developed a recommendation specific to resistant hypertension because of the lack of randomized controlled trials specific to treating the condition. Etiology and PathoPhysiologyThe main categories to consider for patients with resistant hypertension are presented in Table 1. Longstanding uncontrolled hypertension leading to resistant hypertension is most often the result of a drug regimen lacking a diuretic, or insufficient antihypertensive classes and dosages (4). Epstein (5) has described the common clinical characteristics of patients with resistant hypertension. These include obesity, diabetes, chronic kidney disease, black race, female sex and left ventricular hypertrophy. To these, Pickering (6) has added older age, and reviewed the literature associating each characteristic with arterial stiffness -a major component of arterial blood pressure. High blood pressure itself causes arterial stiffness and, if uncontrolled over time, it likely also leads to resistance to therapy. Conversely, there are anecdotal reports that over time (months to years), after blood pressure is brought to target, the dosage and number of antihypertensive agents can be reduced. Resistant hypertension may also be secondary to other medical conditions, most often chronic kidney disease or primary hyperaldosteronism as well as renovascular disease and obstructive sleep apnea (7). Low potassium and target organ damage, including albuminuria, retinopathy and left ventricular hypertrophy, were more frequent in those found to have true resistant hypertension compared with those with white coat hypertension (8).Nonadherence to therapy may be a much more common cause of resistant hypertension than appreciated, as reviewed by Park and Campese (9), who make the distinction between apparent resistance from lack of patient adherence as well as ineffective physician prescribing, versus true resistance. Clues to patient nonadherence are gathered by a careful patient history including a review of prescription refills. Other patient behaviours may lead to resistant hypertension. This includes taki...

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True Resistant Hypertension: Is it Possible to Be Recognized in the Office?

Abstract: True RH can be recognized in the office in selected RH patients. We propose a simple scoring system with these variables that can be used in clinical practice.

Cited by 91 publications

References 21 publications

Nocturnal blood pressure profiles among normotensive, controlled hypertensive and refractory hypertensive subjects

Nocturnal blood pressure profiles among normotensive, controlled hypertensive and refractory hypertensive subjects

Home versus ambulatory blood pressure monitoring in the diagnosis of clinic resistant and true resistant hypertension

Resistant hypertension

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