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The American Heart Association (AHA) has issued updated recommendations for the diagnosis and management of resistant hypertension (RH), which lower the threshold to 130/80 mm Hg.
The document is the first revision since the AHA's initial scientific statement on hypertension in 2008, noted Robert M. Carey, MD, of the University of Virginia Health Sciences Center. in Charlottesville, and his colleagues.
The statement reflects the 2017 recommendations of the American College of Cardiology / AHA, which lower the AP thresholds for initiation of antihypertensive therapy in high-risk adults at> 130/80 mm Hg and goals. treatment up to <130/80 mm Hg.
Write in Hypertension, the authors noted that HR, which affects approximately 12 to 15% of people treated for high blood pressure, is defined as a BP that remains above the target of 130/80 mm Hg despite concomitant treatment with three antihypertensives of different classes, at maximum or maximum tolerated doses and at the appropriate dosing frequency.
Among the other major changes include the use of more specific diagnostic criteria for resistant hypertension, recognition of the importance of sleep duration and the quality of blood pressure control and treatment. Focus on dietary and physical habits to prevent and treat resistant hypertension.
African Americans, men, the elderly and obese people are most commonly affected and people with diabetes, peripheral arterial diseases and obstructive sleep apnea are also more exposed.
"Patients with hypertension are more likely to develop cardiovascular diseases such as heart attacks, heart failure and stroke, and their prognosis further deteriorates if they suffer from pain." resistant hypertension, "said Carey, chair of the drafting group. . "It is extremely important to lower blood pressure by any means possible, because study after study has shown the negative consequences of pressures that remain above the target level."
The recommendations describe the detection and management of various factors that mimic treatment-resistant hypertension, which should be excluded prior to the diagnosis of HR. These include poor treatment adherence (reported in 50% to 80% of patients treated for high BP); white coat effect (demonstrated not to contribute to cardiovascular risk); the inertia of treatment on the part of clinicians; as well as the side effects of a variety of over-the-counter or prescribed medications, lifestyle-related factors such as smoking and excessive drinking, and in some salt-sensitive subjects, unless of 2,400 mg / daily, the state guidelines).
Patients should also be screened for secondary hypertension, which may be related to primary aldosteronism (in approximately 20% of people with HR), or chronic kidney disease or stenosis of the kidneys. renal artery.
"Once all identifiable forms of hypertension, especially endocrine causes, have been excluded and the effects of the white coat effect (blood pressure at least 20/10 mm Hg at [ambulatory BP monitoring] Therapeutic measures to improve BP control in resistant hypertension can begin, "wrote the AHA team.
In addition to the regimen of three complementary antihypertensive drugs, usually a long-acting calcium channel blocker, an ACE inhibitor or an angiotensin receptor antagonist and a diuretic, the patient should consider switch from hydrochlorothiazide to chlorthalidone or indapamide, followed by the addition of a mineralocorticoid receptor antagonist (spironolactone or eplerenone). If AP remains high, the recommendation is to gradually add antihypertensive drugs with complementary mechanisms of action to reduce BP; If blood pressure remains uncontrolled, it is advisable to consult a specialist for hypertension.
"In addition to poor adherence to treatment … insufficient doses of medications are often prescribed – perhaps for fear of side effects," said John Bisognano, MD, president of the Ministry of Health. American Society of Hypertension. MedPage today.
Given the substantial increase in preventable kidney and heart disease, "more time and attention should be devoted to the management of side effects in these patients because they have everything to gain from an adequate and aggressive treatment of pills. combined and affordable medicines to the extent possible. "
In addition, he added, "Long-acting thiazide diuretics such as chlorthalidone and indapamide should be considered as basic treatments. [as they] provide an important treatment basis with which other drugs can work synergistically. "
"Although spironolactone, which has been shown to be extremely effective in patients with resistant hypertension, can cause hyperkalemia in a very small number of patients, it can often be offset by appropriate use of other diuretics, a drop in blood pressure that can even reduce a patient's cardiovascular risk by 50 %.The drug is cheap, but for patients who can not tolerate it, a new aldosterone antagonist, l & rsquo; Eplerenone, can offer a similar benefit.
Carey and his co-authors noted that the current approach to blood pressure control in HR treatment focuses on the addition or substitution of drugs or classes of drugs based on significant pharmacological principles. "Future research should seek to improve the personalized selection of antihypertensive drugs in patients with HR."
The AHA writing group also emphasized the need to develop approaches involving pharmacogenetics and pharmacogenomics and expand the classes of pharmacological agents.
Carey has reported research grants from the National Institutes of Health; other co-authors reported institutional support / relevant relationships with the industry.
1969-12-31T19: 00: 00-0500
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