Resistant Hypertension: Definition, Prevalence and Clinical Implications Judith H. Veis, MD, FACP Associate Director, Nephrology Medstar Washington Hospital Center

I/we have no real or apparent conflicts of interest to report. Judith H. Veis, MD I/we have no real or apparent conflicts of interest to report.

Definitions Uncontrolled Hypertension Blood pressures not at goal JNC 7: General goal < 140/<90 Specific populations < 130/<80 CKD, ASCVD, DM and CHF Causes Previously undiagnosed Hypertension Medication Non-adherence Resistant Hypertension

Definitions Resistant Hypertension Failure to achieve goal BP despite adherence to a 3 antihypertensive drug regimen. Controlled BP with 4 or more antihypertensive drugs. One of the agents is a diuretic. Drugs are optimally dosed.

Definitions Pseudo-Resistant Hypertension Inaccurate Measurement BP measures should be taken after a patient has been seated quietly in a chair with back supported for five minutes. Poor adherence to antihypertensive therapy.: Multiple medications. Frequent changes. Side effects. Cost!!! White coat effect. ‘Inadequate treatment regimen’.

Secondary causes of Resistant Hypertension Obstructive Sleep Apnea (OSA) is prevalent!! Obesity CKD Primary aldosteronism Renal artery stenosis Pheocromocytoma Cushing’s syndrome

Lifestyle factors. Dietary salt consumption: Alcohol consumption: Assessment of 24 hrs UNa excretion ( goal <100 meq/24 hrs). Alcohol consumption: Alcohol should be limited to 1 ounce/day in RH patients. Obesity

Drug-related causes of Resistant Hypertension NSAIDs Steroids Sympathomimetics Decongestants Weight Loss Meds Cocaine Oral Contraceptives Erythropoeitin Licorice Stimulants Methylphenidate Amphetamine Modanifil Calcineurin Inhibitors Herbal Meds Ephedra Ma huang Tricyclic antidepressants Pisoni et al; Curr Cardiol Rep. 2009 November; 11(6): 407-413

Persell et al; Hypertension. 2011; 57:1076-1080. Prevalence NHANES: National health and Nutrition Examination Survey Persell et al; Hypertension. 2011; 57:1076-1080.

Persell et al; Hypertension. 2011; 57:1076-1080. Risk Factors Persell et al; Hypertension. 2011; 57:1076-1080.

Clinical Implications of Resistant Hypertension Higher incidence Cardiovascular events, particularly stroke More LVH, carotid intimal thickening Progressive kidney disease NIDDM

Incidence and Prognosis of Resistant Hypertension Retrospective, 2 integrated health plans 2002-2006 RH defined as uncontrolled BP despite use of > 3 medications or controlled with > 4 meds Adherent if > 80% of meds filled Outcome measure Incident cardiovascular events Death, MI, CHF, stroke or CKD Daughtery et al. Circulation 2012

Incidence and Prognosis of Resistant Hypertension 205,750 patients with HTN 1.9% Resistant w/in 1.5 years of initial treatment Risks of RH Male, older age, more DM Over 3.8 years, significantly more cardiovascular events with RH 18.0% vs. 13.5%, p < 0.001 Adjusted for patient and clinic characteristics Hazard ratio for higher risk of CV events: 1.47 95% CI, 1.33 – 1.62 Daughtery et al. Circulation 2012

Incidence and Prognosis of Resistant Hypertension Daughtery et al. Circulation 2012

Cardiovascular Risk in Resistant HTN Comparison of true responders, masked resistant (normal clinic BP and high ambulatory BP), false resistant (high clinic and normal ambulatory BP) and true resistant 4.98 + 2.9 years follow-up Events: fatal/nonfatal MI, revascularization (CAD or PVD), CHF, stroke and ESRD Event-rate per 100 patient-yrs True Responders, n = 340, rate 0.87 Masked HTN, n = 126, rate 2.42 False Resistant, n = 146, rate 1.2 True Resistant , n = 130, rate 4.1 Pierdomenica et al, Am J HTN 2005

Cardiovascular Risk in Resistant HTN Pierdomenica et al, Am J HTN 2005

Conclusions Resistant Hypertension is defined as uncontrolled HTN with BP > 140/90 on > 3 meds or controlled on > 4 meds Exclude non-adherent patients Prevalence ranges from 1.9 – 8.9% of HTN patients Check for OSA in all patients and consider meds and other secondary causes Note from a nephrologist CONTROL VOLUME with DIURETICS Increased CV event rates occur compared to controlled hypertension