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Resistant hypertension
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- 2. HYPERTENSION IN INDIA Anchala et al,J Hypertension 2014
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- 4. RESISTANT HYPERTENSION • Uncontrolled(>140/90 mm Hg) • office BP • Despite three antihypertensive drugs • In adequate doses and combinations • OR Controlled with 4 drugs • Including one diuretic • Long acting: Chlorthalidone/ spiranolactone • After 3 months follow up Calhoun et al. AHA/ACC. J Hypertension 2008
- 5. Magnitude of theproblem 10% of HTN are resistant
- 6. CAVEATS OF DEFINITION •Secondary causes? • What is ‘controlled’ BP? • OBP/ ABP/ HBP? • Accurate Measurements? • Which Anti-hypertensives? • what doses? • Which diuretics? • Adherence?
- 7. SECONDARY HYPERTENSION Faselis etal, Int J of HTN 2011
- 8. SPRINT SPRINT Research Group.NEJM 2015
- 9. NEW GOALS: AHAACC 2017
- 10. RESISTANT HYPERTENSION: DO NOTTRUST OFFICE BP ABPM MANDATORY. NICE 2014 Drawz et al. Am J Kidney Dis 2014
- 11. SPRECTRUM OF RESISTANT HYPERTENSION Muxfeldtet al. Hypertension Research 2013
- 12. Resistant HTN 12.2%True Resistant HTN 7.5% Sierra et al. Hypertension. 2011 WHO ARE GOING TO HAVE TRULY RESISTANT HYPERTENSION?
- 13. Muxfeldt et al.Hypertension Research 2013 RRESISTANT HTN 473 OFFICE BP<140/90 94 (20%) OFFICE BP>140/90 379 (80%) SUSTAINED CONTROLLED BP 58 (62%) MASKED HTN 36 (38%) TRUE RHTN 226 (60%) WHITE COAT HTN 153 (40%) 5 years of follow-up ABPM LONG TERM FOLLOW UP
- 14. ABPM: NEW TOOLIN BOX Muxfeldt et al. Hypertension Research 2013
- 15. ABPM • ABPM isa very important tool not only for diagnosis but also for treatment and follow up. • Office BP has a poor prognostic value than ABPM Muxfeldt et al. Hypertension Research 2013
- 16. J HOME STUDY (n=528) 17.8% 16.1% 23.5% 42.6% Highcholesterol Female Low BMI CAD Alcohol Obesity HCTZ RESISTANT HTN Home Blood Pressure Obara et al. J Hum Hypertens. 2008
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- 18. Inaccuracy of BPmeasurement Triage BP technique overestimated the prevalence of uncontrolled RHTN in approximately 33% of the patients Bhatt et al. J Am Soc Hypertens 2016
- 19. Adherence Factor Durand etal. Journal of Hypertension 2017 Adherence method Prevalence Prescription refill 31% Serum drug level 86% Pill counts 3% 24 studies. 68000 patients
- 20. Inadequate Therapy 44684 patientsof resistant HTN on 3 or more antihypertensive agents Egan et al. Hypertension 2012 Inadequate Therapy Prevalence Optimal diuretic 15% Recommended optimal dose 50% Optimal BP therapy in -Black -CKD -DM -CAD
- 21. Dosages of anti-hypertensives Johnston.Drugs 47 (4): 567-575, 1994
- 22. One antihypertensive atnight-time Harmida et al. Hypertension 2010. (n=250) Group of single morning dose: -nondipping pattern twofold higher -lower nocturnal fall of SBP and DBP 1306 true resistant hypertensives, those using at least one drug at bedtime: Better contol of ABP Better metabolic profile Less subclinical organ damage Muxfeldt et al. J Hypertens 2008.
- 23. Psuedo-Resistant HTN 50-50 Bhatt etal. J Am Soc Hypertens 2016 de la Sierra et al. Hypertension. 2011
- 24. Profile of Pseudo-resistantHTN Grigoryan et al. J Clin Hypertens 2013 Parameters Prevalence White coat HTN 22% Non Adherent 29% True resistant 49% Thiazide, frusemide 91% Chlorthalidone 0% Spiranolactone 0% CCB max dose 15% ACEI/ARB max dose 40%
- 25. Primary Hyperaldosteronaemia PFK score:U pH>7, Female Sex, K<3.5 Yamashita et al. Journal of Hypertension 2017
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- 27. PATHWAY 2 Home monitoringto exclude white coat HTN Directly observed therapy to ensure adherence Patients with eGFR <45 mL/min were excluded Included predominantly white Caucasians Williams et al, PATHWAY 2, Lancet 2015
- 28. Spironolactone was themost effective blood pressure-lowering agent throughout the distribution of baseline plasma renin but it was particularly effective in patients with lower renin Williams et al, PATHWAY 2, Lancet 2015
- 29. PATHWAY 3 Brown etal. PATHWAY 3. Lancet 2016
- 30. OGTT HBP K Combination of Amiloride-with-HCTZwas neutral for glucose and K+ and reduced BP by 3.4 mmHg more than twice the dose of each single diuretic
- 31. Chlorthalidone Pareek et al.J Am Coll Cardiol. 2016
- 32. White Coat HTN 15% Masked HTN25% True Resistant HTN 45% Controlled HTN 15% Outcome Daughtery et al. Circulation 2012 White coat HTN not so benign
- 33. ‘’Refractory’’ hypertension Refractory hypertensionwas defined as failure to achieve blood pressure control with treatment prescribed by hypertension experts at minimum of 3 follow-up visits during at least 6 months of care, receiving an 5 or more different antihypertensive medications. Acelajado et al. J Clin Hypertens 2012. University of Alabama at Birmingham Hypertension Clinic
- 34. Study Population (Resistant HTN) Definitionof RfH % of RfH Acelajado et al, 2012 retrospective analysis 304 patients University of Alabama at Birmingham Hypertension Clinic >5 drugs 10% Dudenbostel et al, 2015 700 patients Prospective analysis University of Alabama at Birmingham >5 drugs including, chlorthalidone and spironolactone 4% Modolo et al, 2015 116 patients cross-sectional analysis >5 drugs All of the refractory patients were receiving a diuretic and most were receiving spironolactone (76%). 31% Calhoun et al, 2014 REGARDS study n=30239 community-based cohort >5 drugs Diuretic use, including specifically chlorthalidone and spironolactone, was not required as part of the definition 3.6% Prevalence of Refractory HTN
- 35. Classification of HTN Asper number of drugs Dudenbosten et al. Hypertension 2016
- 36. ‘’Refractory’’ hypertension: Novel phenotype Armario etal. J Am Heart Assoc. 2017 Dudenbostel et al. J Nat Sci 2017 Risers are more common
- 37. Resistant vs RefractoryHTN Resistant HTN • Fluid dependent • Low renin • BNP high Refractory HTN • Not fluid dependent • High sympathetic tone • BNP low Dudenbostel et al. J Nat Sci 2017
- 38. RENAL ARTREY DENERVATION Bhatet al, BioMed Research International 2015
- 39. Response of Renalartrey denervation Favourable response in: High SBP (≥180 mm Hg), age <65 years, eGFR ≥60 mL/min/ m2 Bhat et al, BioMed Research International 2015
- 40. Baroreceptor Activation Therapy RheosPivotal Trial • 265 patients with resistant hypertension underwent surgical implantation. • One month after surgery, patients were randomly assigned to have BAT turned on immediately or to have BAT turned on six months later. • The patients were followed for at least 12 months Bakris et al. J of Am Soc of HTN 2012
- 41. RHEOS PIVOTAL 6 months Patientsreceiving BAT • Had a nonsignificantly larger decrease in systolic pressure • Significantly more likely to achieve a goal systolic pressure of 140 mmHg. 12 months • Mean reduction in systolic pressure in the BAT group was 25 mmHg • More than 80 % of these patients had at least a 10 mmHg decrease in systolic pressure Within one month of surgery 35 % of patients had serious adverse effects including facial nerve injury Bakris et al. J of Am Soc of HTN 2012
- 42. Central arteriovenous anastomosis Lateipsilateral venous stenosis in 29% patients ROX CONTROL HTN Lobo et al. Hypertension. 2017
- 43. Take Home Messages •ABPM mandatory for diagnosis and follow up. • HBPM is also suitable. Limitation is night-time BP. • One BP lowering drug at night time. • White Coat HTN is not benign. • Rule out secondary causes. OSA is commonest. • PFK score to decide utilization of Spiranolactone
- 44. Take Home Messages(Cont.) • Pseudo-resistance is 50%. Ensure 3A: accuracy, adherence, adequacy. Rule out NSAIDS/ OCP. • Chlorthalidone to start with. Add Spiranolactone when resistant. Ameloride+HCTZ is reasonable. • >5 drugs: Refractory HTN. High sympathetic activity. Thank You