COMMENTARY
American Society of Hypertension Scientific Statements Addressing Resistant Hypertension J. Rick Turner, BSc, PhD; John Lee, MD, PhD From the Cardiovascular Center of Excellence, Quintiles, Durham, NC
Resistant hypertension (RH) can be defined as blood pressure (BP) that remains above its target level despite the use of three or more antihypertensive medications at maximally tolerated doses (ideally, one being a diuretic) or BP requiring four or more drugs to achieve control.1 It is an important clinical problem in many global regions, including the United States.2 The American Society of Hypertension (ASH) therefore published two Scientific Statements addressing severe hypertension and RH. The first, published in October 2014,3 discussed the identification of patients with pseudo-RH vs true RH and the appropriate steps in determining the most suitable pharmacologic regimen for them. It then recommended pharmacologic treatment strategies for patients with true RH: in the hands of skilled hypertension specialists,4 pharmacologically appropriate, complex antihypertensive drug regimens are effective for the majority of patients with RH.3 However, it was recognized that certain individuals are refractory to even this sophisticated level of pharmacotherapy or experience adverse effects (including tolerability issues) that decrease adherence to prescribed regimens. The second Scientific Statement, published in May 2015,5 focused on pathways for moving forward the development of renal sympathetic denervation (RDN) in the United States as a potential complementary therapeutic option for the patients with true RH whose BP is not managed successfully via sophisticated pharmacologic therapy.
ASH SCIENTIFIC STATEMENT: “DETECTION, EVALUATION, AND TREATMENT OF SEVERE AND RESISTANT HYPERTENSION” This Scientific Statement provides a summary of presentations and discussions at a multidisciplinary forum sponsored by ASH held in October 2013.3 It discusses best practices for diagnostic assessment of patients with RH and reviews pharmacologic regimens that have been successful in the treatment of RH by hypertension specialists. Patients with apparent RH can often be categorized into two subgroups: those with pseudo-RH and those with true RH. Pseudo-RH comprises approximately half of all patients and includes those with suboptimal adherence to medication regimens and/or those with Address for correspondence: J. Rick Turner, BSc, PhD, Cardiovascular Center of Excellence, Quintiles, 4820 Emperor Boulevard, Durham, NC 27703 E-mail: [email protected] DOI: 10.1111/jch.12617
artefactual clinical BP measurements.6 When using the definition of an optimal drug treatment regimen of three or more medications with a diuretic and two or more of the medications each prescribed at 50% or more of the maximum recommended dose,7 suboptimal regimens account for approximately 50% of pseudo-RH. Patients with true RH, who comprise an estimated 30% to 50% of apparent RH patients, are at the highest risk for cardiovascular disease.8 Typically, multiple drugs of varying pharmacologic classes are required to achieve goal BP in patients with RH.9–11 One example of a previous set of prescribing guidelines is the 2008 American Heart Association Scientific Statement.12 Three key points were emphasized: maximize diuretic therapy, including the possible addition of a mineralocorticoid receptor agonist; combine agents with different mechanisms of action; and use more potent diuretics in patients with reduced glomerular filtration rates (GFRs; eg, 180 mm Hg SBP and/or >110 mm Hg diastolic BP) in the untreated state, moderately severe or severe kidney disease (estimated GFR
American Society of Hypertension Scientific Statements Addressing Resistant Hypertension J. Rick Turner, BSc, PhD; John Lee, MD, PhD From the Cardiovascular Center of Excellence, Quintiles, Durham, NC
Resistant hypertension (RH) can be defined as blood pressure (BP) that remains above its target level despite the use of three or more antihypertensive medications at maximally tolerated doses (ideally, one being a diuretic) or BP requiring four or more drugs to achieve control.1 It is an important clinical problem in many global regions, including the United States.2 The American Society of Hypertension (ASH) therefore published two Scientific Statements addressing severe hypertension and RH. The first, published in October 2014,3 discussed the identification of patients with pseudo-RH vs true RH and the appropriate steps in determining the most suitable pharmacologic regimen for them. It then recommended pharmacologic treatment strategies for patients with true RH: in the hands of skilled hypertension specialists,4 pharmacologically appropriate, complex antihypertensive drug regimens are effective for the majority of patients with RH.3 However, it was recognized that certain individuals are refractory to even this sophisticated level of pharmacotherapy or experience adverse effects (including tolerability issues) that decrease adherence to prescribed regimens. The second Scientific Statement, published in May 2015,5 focused on pathways for moving forward the development of renal sympathetic denervation (RDN) in the United States as a potential complementary therapeutic option for the patients with true RH whose BP is not managed successfully via sophisticated pharmacologic therapy.
ASH SCIENTIFIC STATEMENT: “DETECTION, EVALUATION, AND TREATMENT OF SEVERE AND RESISTANT HYPERTENSION” This Scientific Statement provides a summary of presentations and discussions at a multidisciplinary forum sponsored by ASH held in October 2013.3 It discusses best practices for diagnostic assessment of patients with RH and reviews pharmacologic regimens that have been successful in the treatment of RH by hypertension specialists. Patients with apparent RH can often be categorized into two subgroups: those with pseudo-RH and those with true RH. Pseudo-RH comprises approximately half of all patients and includes those with suboptimal adherence to medication regimens and/or those with Address for correspondence: J. Rick Turner, BSc, PhD, Cardiovascular Center of Excellence, Quintiles, 4820 Emperor Boulevard, Durham, NC 27703 E-mail: [email protected] DOI: 10.1111/jch.12617
artefactual clinical BP measurements.6 When using the definition of an optimal drug treatment regimen of three or more medications with a diuretic and two or more of the medications each prescribed at 50% or more of the maximum recommended dose,7 suboptimal regimens account for approximately 50% of pseudo-RH. Patients with true RH, who comprise an estimated 30% to 50% of apparent RH patients, are at the highest risk for cardiovascular disease.8 Typically, multiple drugs of varying pharmacologic classes are required to achieve goal BP in patients with RH.9–11 One example of a previous set of prescribing guidelines is the 2008 American Heart Association Scientific Statement.12 Three key points were emphasized: maximize diuretic therapy, including the possible addition of a mineralocorticoid receptor agonist; combine agents with different mechanisms of action; and use more potent diuretics in patients with reduced glomerular filtration rates (GFRs; eg, 180 mm Hg SBP and/or >110 mm Hg diastolic BP) in the untreated state, moderately severe or severe kidney disease (estimated GFR
