Target Audience (click to view)
This activity is designed to meet the needs of physicians.
Learning Objectives(click to view)
Upon completion of the educational activity, participants should be able to:
- Explain the need for, and the outcomes of, a study that explored the prevalence, predictors, and impact on adverse cardiovascular outcomes of treatment-resistant hypertension among patients with coronary artery disease and hypertension.
Describe the implications of the study on medical practice and how they may apply them into their own practices.
Method of Participation(click to view)
Statements of credit will be awarded based on the participant reviewing monograph, correctly answer 2 out of 3 questions on the post test, completing and submitting an activity evaluation. A statement of credit will be available upon completion of an online evaluation/claimed credit form at www.akhcme.com/pwmay3. You must participate in the entire activity to receive credit. If you have questions about this CME/CE activity, please contact AKH Inc. at firstname.lastname@example.org.
Credit Available(click to view)
CME Credit Provided by AKH Inc., Advancing Knowledge in Healthcare
This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of AKH Inc., Advancing Knowledge in Healthcare and Physician’s Weekly’s. AKH Inc., Advancing Knowledge in Healthcare is accredited by the ACCME to provide continuing medical education for physicians.
AKH Inc., Advancing Knowledge in Healthcare designates this enduring activity for a maximum of 0.5 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Commercial Support(click to view)
There is no commercial support for this activity.
Disclosures(click to view)
It is the policy of AKH Inc. to ensure independence, balance, objectivity, scientific rigor, and integrity in all of its continuing education activities. The author must disclose to the participants any significant relationships with commercial interests whose products or devices may be mentioned in the activity or with the commercial supporter of this continuing education activity. Identified conflicts of interest are resolved by AKH prior to accreditation of the activity and may include any of or combination of the following: attestation to non-commercial content; notification of independent and certified CME/CE expectations; referral to National Author Initiative training; restriction of topic area or content; restriction to discussion of science only; amendment of content to eliminate discussion of device or technique; use of other author for discussion of recommendations; independent review against criteria ensuring evidence support recommendation; moderator review; and peer review.
Disclosure of Unlabeled Use & Investigational Product(click to view)
This educational activity may include discussion of uses of agents that are investigational and/or unapproved by the FDA. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.
Disclaimer(click to view)
This course is designed solely to provide the healthcare professional with information to assist in his/her practice and professional development and is not to be considered a diagnostic tool to replace professional advice or treatment. The course serves as a general guide to the healthcare professional, and therefore, cannot be considered as giving legal, nursing, medical, or other professional advice in specific cases. AKH Inc. specifically disclaim responsibility for any adverse consequences resulting directly or indirectly from information in the course, for undetected error, or through participant’s misunderstanding of the content.
Faculty & Credentials(click to view)
Christopher Cole- Senior Editor
Discloses no financial relationships with pharmaceutical or medical product manufacturers.
Dorothy Caputo, MA, BSN, RN- CE Director of Accreditation
Discloses no financial relationships with pharmaceutical or medical product manufacturers.
AKH planners and reviewers have no relevant financial relationships to disclose.
Take CME(click to view)
“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 of resistant HTN in people with CAD and the level of risk were important findings in our analysis,” says Dr. Cooper-DeHoff. “Our results confirm the findings of previous studies and extend them to patients with concomitant CAD and HTN who were well managed. Regardless of how resistant HTN is defined, the condition portends an increased risk of major cardiovascular outcomes, especially non-fatal stroke and mortality.”
With the exception of non-fatal stroke, adverse outcomes did not differ significantly in patients with resistant HTN when compared with those with uncontrolled HTN. The overall prevalence of resistant HTN increased as the number of risk factors increased, ranging from about 25% in participants with no risk factors to higher than 75% in participants with at least eight risk factors (Figure 2). The prevalence of resistant HTN was at least 50% in participants with five or more risk factors. In addition, female sex, increasing age, and BMI were associated with a classification of resistant HTN.
Risk factors for resistant HTN appear to be comparable in patients with HTN with and without established cardiovascular disease. This underscores the need to recognize patients with CAD who are at risk for resistant HTN, Dr. Cooper-DeHoff says. “Many clinicians do not believe in the concept of resistant HTN,” she says. “They may think the phenomenon relates to a lack of patient adherence to therapy. Others believe that resistant HTN results from physician inertia, in which the prescribing of medications or dose titration of these drugs is inadequate. Regardless of how or why these patients become classified with resistant HTN, our data show that these individuals have poor outcomes.”
Clinicians may want to consider alternate therapies, such as renal denervation, as they become available for patients with resistant HTN, says Dr. Cooper-DeHoff. “Particular attention should be paid to those with comorbid cardiovascular diseases, diabetes, and renal insufficiency,” she says. “These characteristics are associated with the greatest risk of developing resistant HTN.”
The findings also have important implications for future research, according to Dr. Cooper-DeHoff. “Within the same dataset from this analysis, we’re currently examining the genetic makeup of patients to spot genetic and pharmacogenetic predictors of resistant HTN,” she says. “This information may help us improve how we target specific drug therapies for patients early in the process of treating their HTN.”
Readings & Resources (click to view)
Smith SM, Gong Y, Handberg E, et al. Predictors and outcomes of resistant hypertension among patients with coronary artery disease and hypertension. J Hypertens. 2014;32:635-643. Available at: http://journals.lww.com/jhypertension/Fulltext/2014/03000/Predictors_and_outcomes_of_resistant_hypertension.24.aspx.
Calhoun DA, Jones D, Textor S, et al. Resistant hypertension: diagnosis, evaluation, and treatment. A scientific statement from the American Heart Association Professional Education Committee of the Council for High Blood Pressure Research. Hypertension. 2008;51:1403-1419.
Smith SM. Epidemiology, prognosis, and treatment of resistant hypertension. Pharmacotherapy. 2013;33:1071-1086.
Daugherty SL, Powers JD, Magid DJ, et al. Incidence and prognosis of resistant hypertension in hypertensive patients. Circulation. 2012;125:1635-1642.
Messerli FH, Mancia G, Conti CR, et al. Dogma disputed: can aggressively lowering blood pressure in hypertensive patients with coronary artery disease be dangerous? Ann Intern Med. 2006;144:884-893.
Weber MA, Julius S, Kjeldsen SE, et al. Cardiovascular outcomes in hypertensive patients: comparing single agent therapy with combination therapy. J Hypertens. 2012;30:2213-2222.