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David A. Calhoun - One of the best experts on this subject based on the ideXlab platform.
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Resistant Hypertension and aldosteronism
Current Hypertension Reports, 2020Co-Authors: Eduardo Pimenta, David A. CalhounAbstract:Resistant Hypertension is defined as blood pressure that remains uncontrolled despite using at least three antihypertensive medications in effective doses, ideally including a diuretic. Stricter blood pressure goals, higher obesity rates, older age, and increased use of certain exogenous substances are related to an increasing prevalence of Resistant Hypertension. The evaluation of patients with Resistant Hypertension focuses on identifying contributing factors and secondary causes of Hypertension including hyperaldosteronism, obstructive sleep apnea, renal artery stenosis, and pheochromocytoma. Hyperaldosteronism is now recognized as the most common secondary cause and all patients with Resistant Hypertension should be screened with a plasma aldosterone-renin ratio even if the serum potassium level is normal. Treatment includes reversal of contributing factors, appropriate treatment of secondary causes, and use of effective multidrug regimens. Recent studies indicate that the addition of spironolactone to standard treatment regimens induces significant blood pressure reduction in patients with Resistant Hypertension.
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Characterization and treatment of Resistant Hypertension
Current Cardiology Reports, 2020Co-Authors: Roberto Pisoni, Mustafa I. Ahmed, David A. CalhounAbstract:Resistant Hypertension is a common medical problem. It carries a significantly increased risk of end-organ damage and cardiovascular events compared with more easily controlled Hypertension. Resistant Hypertension is most often related to isolated systolic Hypertension and is characterized by aldosterone excess and increased intravascular volume. Its diagnosis requires the exclusion of pseudoresistance. The etiology of Resistant Hypertension is almost always multifactorial. Common reversible contributing factors need to be identified and addressed. Secondary causes of Hypertension, such as primary aldosteronism, parenchymal and vascular kidney disease, and obstructive sleep apnea, require investigation and effective treatment if present. Therapy for Resistant Hypertension should be based on use of rational drug class combinations at optimal doses, with particular attention to adequate diuretic use. The addition of an aldosterone antagonist may further improve blood pressure control.
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Recent Advancements in the Treatment of Resistant Hypertension
Postgraduate Medicine, 2020Co-Authors: Donald Clark, David A. Calhoun, Jason L. Guichard, Mustafa I. AhmedAbstract:AbstractThe 2008 Scientific statement from the American Heart Association defined Resistant Hypertension as blood pressure remaining above goal (< 140/90 mm Hg for the general population and < 130/80 mm Hg for patients with diabetes or renal disease) despite the concurrent use of optimal doses of 3 antihypertensive agents of different classes, ideally including a diuretic. Since then, there has been increasing recognition and characterization of patients with Resistant Hypertension and development of treatment strategies to treat this high–risk population. The role of aldosterone in Resistant Hypertension has gained increasing recognition. In particular, there has been development of a strong body of evidence for the use of spironolactone as a highly effective antihypertensive agent. Furthermore, there is increasing evidence to link aldosterone with both Resistant Hypertension and obstructive sleep apnea, with preliminary studies suggesting that aldosterone antagonists may potentially be effective in trea...
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Prevalence of Apparent Treatment-Resistant Hypertension in the United States
Hypertension, 2019Co-Authors: Robert M. Carey, David A. Calhoun, Swati Sakhuja, Paul K. Whelton, Paul MuntnerAbstract:In 2018, the American Heart Association published a Scientific Statement on Resistant Hypertension. We compared the prevalence of apparent treatment-Resistant Hypertension (aTRH) among US adults as...
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Resistant Hypertension: An Update of Experimental and Clinical Findings
Hypertension, 2017Co-Authors: David A. CalhounAbstract:An estimated 10% to 30% of hypertensive patients can be considered to be Resistant to treatment defined as controlled or uncontrolled blood pressure (BP) with use of ≥4 medications, including a diuretic.1–4 A large number of cross-sectional and longitudinal studies have demonstrated that patients with treatment-Resistant Hypertension compared with patients with more easily controlled Hypertension have increased cardiovascular risk, including coronary artery disease, congestive heart failure, stroke, and chronic kidney disease (CKD). Since publication of the first Scientific Statement on the Diagnosis, Evaluation, and Treatment of Resistant Hypertension by the American Heart Association in 2008, which coincided with development of device-based strategies for treating Resistant Hypertension, Resistant Hypertension has become a major focus of intensive experimental and clinical investigation.1 In that context, this review highlights scientific advances specific for Resistant Hypertension that have occurred in the last 2 years, including important findings related to prognosis, medication adherence, clinical use of aldosterone antagonists, and application of device-based therapies. Multiple cross-sectional studies have related Resistant Hypertension to prevalent cardiovascular and renal diseases.2–8 Recent analyses have strengthened those associations with use of longitudinal or prospective assessments. From a secondary analysis of the ALLHAT (Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial) results, which included 1870 participants with Resistant Hypertension, Muntner et al9 reported that compared with study participants without Resistant Hypertension, participants with Resistant Hypertension had a 44%, 57%, 23%, 88%, 95%, and 30% higher risk of incident coronary heart disease, stroke, peripheral artery disease, heart failure, end-stage renal disease, and all-cause mortality, respectively, during the almost 5-year duration of the study after adjustment for multiple traditional risk factors, such as age, smoking, diabetes mellitus, and low-density lipoprotein cholesterol. Because of the ALLHAT study design, diuretic use in this analysis was not required to …
Paul Muntner - One of the best experts on this subject based on the ideXlab platform.
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Prevalence of Apparent Treatment-Resistant Hypertension in the United States
Hypertension, 2019Co-Authors: Robert M. Carey, David A. Calhoun, Swati Sakhuja, Paul K. Whelton, Paul MuntnerAbstract:In 2018, the American Heart Association published a Scientific Statement on Resistant Hypertension. We compared the prevalence of apparent treatment-Resistant Hypertension (aTRH) among US adults as...
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prevalence of apparent treatment Resistant Hypertension among individuals with ckd
Clinical Journal of The American Society of Nephrology, 2013Co-Authors: Rikki M Tanner, David A. Calhoun, Suzanne Oparil, Emmy K Bell, Barrett C Bowling, Orlando M Gutierrez, Marguerite R Irvin, Daniel T Lackland, David G Warnock, Paul MuntnerAbstract:Summary Background and objectives Apparent treatment-Resistant Hypertension is defined as systolic/diastolic BP≥140/90 mmHg with concurrent use of three or more antihypertensive medication classes or use of four or more antihypertensive medication classes regardless of BP level. Design, setting, participants, & measurements The prevalence of apparent treatment-Resistant Hypertension among Reasons for Geographic and Racial Differences in Stroke study participants treated for Hypertension ( n =10,700) was determined by level of estimated GFR and albumin-to-creatinine ratio, and correlates of apparent treatment-Resistant Hypertension among those participants with CKD were evaluated. CKD was defined as an albumin-to-creatinine ratio≥30 mg/g or estimated GFR 2 . Results The prevalence of apparent treatment-Resistant Hypertension was 15.8%, 24.9%, and 33.4% for those participants with estimated GFR≥60, 45–59, and 2 , respectively, and 12.1%, 20.8%, 27.7%, and 48.3% for albumin-to-creatinine ratio 2 , respectively, versus ≥60 ml/min per 1.73 m 2 and 1.54 (1.39 to 1.71), 1.76 (1.57 to 1.97), and 2.44 (2.12 to 2.81) for albumin-to-creatinine ratio levels of 10–29, 30–299, and ≥300 mg/g, respectively, versus albumin-to-creatinine ratio Conclusions This study highlights the high prevalence of apparent treatment-Resistant Hypertension among individuals with CKD.
William J. Elliott - One of the best experts on this subject based on the ideXlab platform.
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What Is the Prevalence of Resistant Hypertension in the United States
Current Opinion in Cardiology, 2012Co-Authors: Dustin R. Roberie, William J. ElliottAbstract:Resistant Hypertension, defined as blood pressure uncontrolled on three, or controlled with at least four, antihypertensive agents (including a diuretic), is associated with higher risk of secondary Hypertension, cardiovascular and renal events, and increased healthcare expenditures. Until recently, however, the prevalence of Resistant Hypertension in the United States (US) was based on clinical trial registries or pharmacy databases. Recent analyses of National Health and Nutrition Examination Survey (NHANES) data, drawn from representative samples of the adult, noninstitutionalized, civilian population, have estimated the prevalence of Resistant Hypertension at 8.9 ± 0.6% of the US hypertensive population in 2003-2008. A time-sequence comparison of NHANES data from 1998 through 2008 suggests that, unlike Hypertension, Resistant Hypertension is becoming more prevalent (e.g., 20.7% in 2005-2008), due to aging and increased obesity in the general population. Resistant Hypertension was more frequent in people who were older, obese, male, African American or nonblack Hispanic. In coming years, even if the prevalence of Hypertension remains stable, Resistant Hypertension is likely to increase, especially as the proportion of treated Hypertension increases. Because of increased use of healthcare resources, Resistant hypertensive patients should be identified early, and greater efforts made to control their blood pressures.
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Management of Resistant Hypertension
Current Cardiovascular Risk Reports, 2011Co-Authors: William J. ElliottAbstract:“Resistant” Hypertension has been variously defined, but most authors accept a definition that includes a blood pressure ≥140/90 mm Hg after prescription of a diuretic and typically two other appropriately chosen antihypertensive drugs at near-maximal doses. Patients with Resistant Hypertension are of great public health importance because they have a high absolute cardiovascular and renal risk, greater health care expenditures, a higher prevalence of secondary Hypertension and target-organ damage, and are, by definition, more “difficult to control” than hypertensive patients who are controlled with only one or two medications. Centers that specialize in these patients report that more than 90% can be diagnosed with a specific cause of their treatment resistance, and more than 50% can be controlled in a relatively short time after an appropriate intervention. This article reviews the differential diagnosis, evaluation, and outcomes of treatment paradigms for such patients, and emphasizes the role of Hypertension specialists in their management.
George L Bakris - One of the best experts on this subject based on the ideXlab platform.
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the double challenge of Resistant Hypertension and chronic kidney disease
The Lancet, 2015Co-Authors: Patrick Rossignol, George L Bakris, Michel Azizi, Ziad A Massy, E Ritz, Adrian Covic, David Goldsmith, Gunnar H HeineAbstract:Summary Resistant Hypertension is defined as blood pressure above goal despite adherence to a combination of at least three optimally dosed antihypertensive medications, one of which is a diuretic. Chronic kidney disease is the most frequent of several patient factors or comorbidities associated with Resistant Hypertension. The prevalence of Resistant Hypertension is increased in patients with chronic kidney disease, while chronic kidney disease is associated with an impaired prognosis in patients with Resistant Hypertension. Recommended low-salt diet and triple antihypertensive drug regimens that include a diuretic, should be complemented by the sequential addition of other antihypertensive drugs. New therapeutic innovations for Resistant Hypertension, such as renal denervation and carotid barostimulation, are under investigation especially in patients with advanced chronic kidney disease. We discuss Resistant Hypertension in chronic kidney disease stages 3–5 (ie, patients with an estimated glomerular filtration rate below 60 mL/min per 1·73 m 2 and not on dialysis), in terms of worldwide epidemiology, outcomes, causes and pathophysiology, evidence-based treatment, and a call for action.
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detection evaluation and treatment of severe and Resistant Hypertension
Journal of The American Society of Hypertension, 2014Co-Authors: William B White, David A. Calhoun, John D. Bisognano, Rick J Turner, Domenic A Sica, Raymond R Townsend, Herbert D Aronow, Deepak L Bhatt, George L BakrisAbstract:Abstract The epidemiology, evaluation, and management of severe and Resistant Hypertension in the United States (US) are evolving. The American Society of Hypertension held a multi-disciplinary forum in October 2013 to review the available evidence related to the management of Resistant Hypertension with both drug and device therapies. There is strong evidence that Resistant Hypertension is an important clinical problem in the US and many other regions of the world. Complex drug therapy is effective in most of the patients with severe and Resistant Hypertension, but there are certain individuals who may be refractory to multiple-drug regimens or have adverse effects that make adherence to the regimen difficult. When secondary forms of Hypertension and pseudo-resistance, such as medication nonadherence, or white-coat Hypertension based on marked differences between clinic and 24-hour ambulatory blood pressure monitoring, have been excluded, the impact of device therapy is under evaluation through clinical trials in the US and from clinical practice registries in Europe and Australia. Clinical trial data have been obtained primarily in patients whose Resistant Hypertension is defined as systolic clinic blood pressures of ≥160 mm Hg (or ≥ 150 mm Hg in type 2 diabetes) despite pharmacologic treatment with at least three antihypertensive drugs (one of which is a thiazide or loop diuretic). Baroreceptor stimulation therapy has shown modest benefit in a moderately sized sham-controlled study in drug-Resistant Hypertension. Patients selected for renal denervation have typically been restricted to those with preserved kidney function (estimated glomerular filtration rate ≥ 45 mL/min/1.73 m 2 ). The first sham-controlled safety and efficacy trial for renal denervation (SYMPLICITY HTN-3) did not show benefit in this population when used in addition to an average of five antihypertensive medications. Analyses of controlled clinical trial data from future trials with novel designs will be of critical importance to determine the effectiveness of device therapy for patients with severe and Resistant Hypertension and will allow for proper determination of patient selection and whether it will be acceptable for clinical practice. At present, the focus on the management of severe and Resistant Hypertension will be through careful evaluation for pseudo-resistance and secondary forms of Hypertension, appropriate use of combination pharmacologic therapy, and greater utility of specialists in Hypertension.
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Resistant Hypertension its identification and epidemiology
Nature Reviews Nephrology, 2013Co-Authors: Pantelis A. Sarafidis, Panagiotis I. Georgianos, George L BakrisAbstract:Resistant Hypertension is defined as failure to reach goal blood pressure in patients who are compliant with maximal doses of three antihypertensive drugs, one of which is a diuretic. Despite improvements in controlling blood pressure in the past decade, studies show the prevalence of Resistant Hypertension is increasing. In this Review, the authors define Resistant Hypertension and discuss current data on its prevalence, associated comorbidities and prognostic implications.
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Resistant Hypertension—its identification and epidemiology
Nature Reviews Nephrology, 2012Co-Authors: Pantelis A. Sarafidis, Panagiotis I. Georgianos, George L BakrisAbstract:Resistant Hypertension is defined as failure to reach goal blood pressure in patients who are compliant with maximal doses of three antihypertensive drugs, one of which is a diuretic. Despite improvements in controlling blood pressure in the past decade, studies show the prevalence of Resistant Hypertension is increasing. In this Review, the authors define Resistant Hypertension and discuss current data on its prevalence, associated comorbidities and prognostic implications.
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Resistant Hypertension an overview of evaluation and treatment
Journal of the American College of Cardiology, 2008Co-Authors: Pantelis A. Sarafidis, George L BakrisAbstract:Resistant Hypertension is defined as failure to achieve goal blood pressure (BP) when a patient adheres to the maximum tolerated doses of 3 antihypertensive drugs including a diuretic. Although the exact prevalence of Resistant Hypertension is currently unknown, indirect evidence from population studies and clinical trials suggests that it is a relatively common clinical problem. The prevalence of Resistant Hypertension is projected to increase, owing to the aging population and increasing trends in obesity, sleep apnea, and chronic kidney disease. Management of Resistant Hypertension must begin with a careful evaluation of the patient to confirm the diagnosis and exclude factors associated with “pseudo-resistance,” such as improper BP measurement technique, the white-coat effect, and poor patient adherence to life-style and/or antihypertensive medications. Education and reinforcement of life-style issues that affect BP, such as sodium restriction, reduction of alcohol intake, and weight loss if obese, are critical in treating Resistant Hypertension. Exclusion of preparations that contribute to true BP treatment resistance, such as nonsteroidal anti-inflammatory agents, cold preparations, and certain herbs, is also important. Lastly, BP control can only be achieved if an antihypertensive treatment regimen is used that focuses on the genesis of the Hypertension. An example is volume overload, a common but unappreciated cause of treatment resistance. Use of the appropriate dose and type of diuretic provides a solution to overcome treatment resistance in this instance.
Gunnar H Heine - One of the best experts on this subject based on the ideXlab platform.
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the double challenge of Resistant Hypertension and chronic kidney disease
The Lancet, 2015Co-Authors: Patrick Rossignol, George L Bakris, Michel Azizi, Ziad A Massy, E Ritz, Adrian Covic, David Goldsmith, Gunnar H HeineAbstract:Summary Resistant Hypertension is defined as blood pressure above goal despite adherence to a combination of at least three optimally dosed antihypertensive medications, one of which is a diuretic. Chronic kidney disease is the most frequent of several patient factors or comorbidities associated with Resistant Hypertension. The prevalence of Resistant Hypertension is increased in patients with chronic kidney disease, while chronic kidney disease is associated with an impaired prognosis in patients with Resistant Hypertension. Recommended low-salt diet and triple antihypertensive drug regimens that include a diuretic, should be complemented by the sequential addition of other antihypertensive drugs. New therapeutic innovations for Resistant Hypertension, such as renal denervation and carotid barostimulation, are under investigation especially in patients with advanced chronic kidney disease. We discuss Resistant Hypertension in chronic kidney disease stages 3–5 (ie, patients with an estimated glomerular filtration rate below 60 mL/min per 1·73 m 2 and not on dialysis), in terms of worldwide epidemiology, outcomes, causes and pathophysiology, evidence-based treatment, and a call for action.
