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CME: Treatment-Resistant Hypertension: Assessing Predictors & Outcomes

CME: Treatment-Resistant Hypertension: Assessing Predictors & Outcomes

“The topic of treatment-resistant HTN has gained attention in recent years,” says Rhonda M. Cooper-DeHoff, PharmD, MS, FAHA, FACC. “The condition increases long-term risk for poor outcomes, regardless of whether or not HTN is controlled or uncontrolled. Unfortunately, we’re lacking important data on the long-term effects of treatment-resistant HTN.” Coronary artery disease (CAD) is among the leading causes of mortality, and treatment-resistant HTN is more common in patients with CAD than without CAD. Little is known, however, about the impact that treatment-resistant HTN has on cardiovascular outcomes in patients with CAD. Such data may inform clinicians on strategies to aggressively manage risk factors. Identifying Predictors & Impact In the Journal of Hypertension, Dr. Cooper-DeHoff and colleagues published a study that described the prevalence, predictors, and impact on adverse cardiovascular outcomes of resistant HTN among patients with CAD and HTN. More than 17,000 study participants were divided into three groups according to achieved BP: 1) controlled (BP<140/90 mm Hg on three or fewer drugs); 2) uncontrolled (BP≥140/90 mm Hg on two or fewer drugs); or 3) resistant (BP≥140/90 mm Hg on three drugs or any patient on at least four drugs). “We found that resistant HTN occurred in 38% of patients with CAD and HTN,” says Dr. Cooper-DeHoff. “Those with resistant HTN were at increased risk for having poorer outcomes.” Several characteristics were associated with an increased risk of resistant HTN, including a history of heart failure, diabetes, and renal insufficiency, among others (Figure 1). Overall, 13 independent predictors of resistant HTN were identified. Many of these characteristics can be obtained noninvasively and help clinicians recognize these patients in the clinic. “The prevalence...
Treatment-Resistant Hypertension: Assessing Predictors & Outcomes

Treatment-Resistant Hypertension: Assessing Predictors & Outcomes

Treatment-resistant hypertension (HTN) has been defined in various ways in clinical research. Some definitions go so far as to say which medications should be used before classifying patients as having resistant HTN. Regardless of the definition, the overriding theme of treatment-resistant HTN is that it occurs when several anti-hypertensive drugs are needed to control blood pressure (BP). Studies suggest that treatment-resistant HTN is present in 20% to 30% of patients with HTN. Its prevalence has more than doubled over the past 25 years, and research has linked it to an increased risk of cardiovascular events when compared with patients without treatment-resistant HTN. “The topic of treatment-resistant HTN has gained attention in recent years,” says Rhonda M. Cooper-DeHoff, PharmD, MS, FAHA, FACC. “The condition increases long-term risk for poor outcomes, regardless of whether or not HTN is controlled or uncontrolled. Unfortunately, we’re lacking important data on the long-term effects of treatment-resistant HTN.” Coronary artery disease (CAD) is among the leading causes of mortality, and treatment-resistant HTN is more common in patients with CAD than without CAD. Little is known, however, about the impact that treatment-resistant HTN has on cardiovascular outcomes in patients with CAD. Such data may inform clinicians on strategies to aggressively manage risk factors. Identifying Predictors & Impact In the Journal of Hypertension, Dr. Cooper-DeHoff and colleagues published a study that described the prevalence, predictors, and impact on adverse cardiovascular outcomes of resistant HTN among patients with CAD and HTN. More than 17,000 study participants were divided into three groups according to achieved BP: 1) controlled (BP<140/90 mm Hg on three or fewer drugs); 2) uncontrolled (BP≥140/90 mm Hg on...

Treating Hypertension: Opportunities Aplenty

Guidelines recommend that people with high blood pressure (BP) be prescribed medication and those on BP medications get a new one if their condition worsens or if BP control remains inadequate. It’s unclear how often these guidelines are followed on a national level. It’s likely that physicians are missing out on key opportunities to better control their patients’ high BP. Are Hypertension Guidelines Being Followed? In the September 24, 2012 Archives of Internal Medicine, my colleagues and I had a study published that analyzed new BP medication prescriptions for patients with uncontrolled hypertension. Using the National Ambulatory Medical Care Survey (NAMCS), we aimed to determine if physicians were following national recommendations and find out which factors influenced prescribing decisions. Data were reviewed on 16,473 visits between 2005 and 2009 for patients already diagnosed with high BP. Some patients were on BP medications, whereas others may have been told to bring their BP under control by other means, including lifestyle changes. “Empowering patients to discuss BP with their physicians may help us gain better control of the hypertension problem in the U.S.” According to our results, about 20% of the 7,153 visits by patients with uncontrolled hypertension— defined as 140/90 mm Hg and higher in the setting of a diagnosis of hypertension—resulted in new medications during doctors’ office visits. People with very high BP and those who specifically came to their doctor for hypertension were more likely to get a new prescription. Patients already on BP medications were less likely to get a new one. These factors remained highly significant in multivariable regression. Likelihood of New BP Medication Our findings...

Blood Pressure & End-Stage Renal Disease in Patients With CKD

Studies have shown that treating high blood pressure (BP) is one of the most important strategies to slowing the progression from chronic kidney disease (CKD) to end-stage renal disease (ESRD). Currently, a BP goal of less than 130/80 mm Hg is recommended for patients with CKD, a target lower than the goal recommended for people without CKD (less than 140/90 mm Hg). Despite the dissemination of clinical guidelines, meeting BP targets in people with CKD may be difficult in clinical practice. “The most recent evidence supporting the use of lower BP targets in people with CKD has been conflicting,” explains Carmen A. Peralta, MD, MAS. “The association of BP levels and ESRD risk in a large, national, community-based setting of persons with established CKD has not been well studied. In addition, some recent reports have found that higher pulse pressure and lower diastolic BP (DBP) may lead to adverse cardiovascular outcomes. This can make it especially challenging for clinicians to control BP aggressively in patients with CKD.” Associations Between BP and ESRD Few studies have investigated the association of each BP component with ESRD risk. In Archives of Internal Medicine, Dr. Peralta and colleagues had a study published that investigated the independent association of systolic BP (SBP) and DBP with ESRD risk in patients with CKD who participated in the Kidney Early Evaluation Program (KEEP), a nationwide kidney health screening program offered by the National Kidney Foundation. More than 16,000 patients in KEEP were studied in the analysis, all of whom had at least stage III CKD. “In the past, questions have been raised about the established BP targets...

More Patient Encounters Benefit Diabetes Care

As the epidemic of diabetes continues to grow, it’s becoming increasingly important for healthcare providers to find effective strategies to minimize microvascular and macrovascular complications associated with the disease. Unfortunately, many patients with diabetes do not have these disease components under control. Intriguing New Data In the Archives of Internal Medicine, my colleagues and I had a study published in which we retrospectively analyzed more than 26,000 patients with diabetes and hyperglycemia, hypertension, and/or hyperlipidemia who received care in primary care settings. We wanted to determine if diabetes control was improved with a greater frequency of patient encounters. A strong association between encounter frequency and A1C, blood pressure (BP), and LDL cholesterol control in patients with diabetes was observed (Table 1). Doubling the time between physician encounters was also found to increase median time to A1C, BP, and LDL cholesterol targets. More frequent opportunities for medication intensification are likely an important factor in our findings (Table 2). They may also likely improve medication adherence and increase opportunities for providers to offer lifestyle coaching or other education that can further enhance diabetes control. Potential for Great Benefits Considering that more frequent encounters in patients with diabetes would increase the demands on healthcare resources, increasing the frequency of encounters may require innovative approaches to delivering care. For example, medical homes may help coordinate the care of patients. In addition, some interactions could be accomplished through group visits, telephone, fax, email, or internet communications. Midlevel providers can also alleviate physician workloads without negatively affecting patient outcomes. Until guidelines provide more data or recommendations on how frequently patients with diabetes should be seen...
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