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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...
Medical Simulation in Interventional Cardiology

Medical Simulation in Interventional Cardiology

Use of medical simulation has grown considerably over the past decade because it helps physicians overcome many training challenges, such as work-hour restrictions and the pace at which technology is evolving. According to John C. Messenger, MD, FSCAI, interventional cardiology is particularly well-suited for simulation. “These procedures are often complex,” he says. “The learning curves can be steep, and complications can be life-threatening. Simulation provides a safe arena to develop and refine skills that improve overall patient care. It’s especially helpful in interventional cardiology because of the field’s ever-changing technological and procedural environment.” A Call to Action In Catheterization and Cardiovascular Interventions, the Society for Cardiovascular Angiography and Interventions (SCAI) examined the current state of medical simulation in interventional cardiology. SCAI also issued recommendations for expanding and standardizing the use of this training technology by interventional cardiologists and fellows-in-training. “We need to increase use of medical simulation and accessibility to this training for highly complex procedures, such as structural heart interventions,” says Dr. Messenger, who chairs SCAI’s Simulation Committee. “Simulation can also improve training in areas where procedural volumes are low.” A key recommendation from SCAI is to integrate formal simulation programs into annual meetings and other training programs for fellows and practicing physicians. However, one of the major issues with integrating simulation is the high cost of simulators. “The key is for clinicians and simulation vendors to collaborate and find ways to alleviate the financial burden associated with simulation,” says Dr. Messenger. “Using simulation at annual meetings and establishing regional or central simulation centers could ease this burden.”   The key is for clinicians and simulation vendors to...
Data Standards for ACS & CAD

Data Standards for ACS & CAD

With the emergence of electronic health records (EHRs) and administrative and professional databases, it’s critical to facilitate clear communication and assure the accurate interchange of data and information. Clinical data standards are important for managing patients, assessing outcomes, and conducting research. Having a broad agreement on a common vocabulary and a standardized list of data elements helps lay the groundwork for future clinical registries and quality- improvement initiatives. It also can be used in the development of performance measures. An Important Update In 2013, the American College of Cardiology (ACC) and American Heart Association (AHA), in conjunction with 11 other organizations, developed a list of key data elements with standardized definitions for patients with acute coronary syndromes (ACS) and coronary artery disease (CAD). The document was published jointly in the Journal of the American College of Cardiology and Circulation. It updates information on elements specific to ACS that were released in 2001. CAD was added because of the overlap between the two conditions. The ACC/AHA publication listed key data elements and provided detailed definitions in seven categories, including demographics and admissions; history and risk factors; clinical presentation; diagnostic procedure; invasive therapeutic intervention; medications; and outcomes. The document is organized in tabular form to be a helpful tool for everyday use. Special attention is also given to important predictors of outcomes, including laboratory results and clinical presentation. This information should be mandatory reading for clinical investigators, quality assurance personnel, and research nurses. For cardiologists, the latest terminology and methods may seem obvious at first glance. However, even the most sophisticated practitioners can discover better ways to communicate and describe ambiguous...
Performance Measures for CAD & Hypertension

Performance Measures for CAD & Hypertension

During the past decade, there has been increased awareness of the need to improve the quality of care delivered to patients with coronary artery disease (CAD) and hypertension. In keeping consistent with this focus, the American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA) have developed guidelines and related performance measures that focus on these areas of care. In the July 12, 2011 issue of Circulation, the ACCF and AHA revised their original performance measures for adults with CAD and hypertension, which were developed in conjunction with the Physician Consortium for Performance Improvement (PCPI) and previously released in 2005. More Than a “Routine” Update for CAD & Hypertension With a general policy to revise performance measures no more than every 3 years, the AHA, ACCF, and PCPI had been working on revising the measurement sets for more than a year before they were published. “These new measurements represent a change in the science and methodology of how per­formance measures are typically developed,” says Joseph Drozda, Jr, MD, FACC, who co-chaired the PCPI panel. “The new mea­surements bring a focus on the outcomes of treatment rather than purely measures of process. We’re focusing on the things that make a difference and doing it in a way that will allow physicians to track their own per­formance in these key areas.” The 2011 ACCF/AHA performance measure sets consist of 10 total measures derived from several professional guidelines. It includes revisions to measures that were released in the 2005 document and five new measures (Table 1). “There are robust guidelines for CAD, supported by strong levels of evidence with respect...
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