Hypertension, uncontrolled hypertension and resistant hypertension: prevalence, comorbidities and prescribed medications in 228,406 adults resident in urban areas. A population-based observational study

Management of drug-resistant hypertension as a heterogeneous disorder

Approximately 1.3 billion adults globally have hypertension, and are at higher risk of death associated with cardiovascular disease. Adjusted death rate primarily due to high blood pressure is 31.3 per 100,000. The prevalence of drug-resistant hypertension is estimated to be up to 20 % in hypertensive individuals, and is more common in those with chronic kidney disease and obstructive sleep apnea. It occurs in individuals on ≥3 antihypertensive drugs including a diuretic. The addition of spironolactone, as a fourth drug has been found at times to be effective in management of blood pressure. Other strategies include sequential nephron block (e.g., spironolactone + furosemide + amiloride), and use of drugs such as alpha2 agonists, endothelin antagonists, and nonsteroidal mineralocorticoid antagonists. Use of positive airway pressure and pharmacotherapy have been found to be of value in individuals with sleep apnea in lowering blood pressure. In contrast, baroreceptor stimulation and/or renal denervation combined with pharmacotherapy seem to offer little in a way of consistent efficacy of optimally lowering blood pressures. Remarkably, evidence in the literature strongly supports the view that life style changes including regular exercise and appropriate diet combined with pharmacotherapy can lead to positive outcomes in helping to significantly reduce blood pressure. There is also ample data in literature suggesting the non-compliance to antihypertensive medications as a significant barrier to lowering blood pressure in this group. Accordingly, education regarding pharmacotherapy, and appropriate exercise regimen, including changes to diet should underpin any strategy in the management of high blood pressure in this population.

Characterizing apparent treatment resistant hypertension in the United States: insights from the All of Us Research Program

BACKGROUND

Hypertension (HTN) remains a significant public health concern and the primary modifiable risk factor for cardiovascular disease, which is the leading cause of death in the United States. We applied our validated HTN computable phenotypes within the All of Us Research Program to uncover prevalence and characteristics of HTN and apparent treatment-resistant hypertension (aTRH) in United States.

METHODS

Within the All of Us Researcher Workbench, we built a retrospective cohort (January 1, 2008-July 1, 2023), identifying all adults with available age data, at least one blood pressure (BP) measurement, prescribed at least one antihypertensive medication, and with at least one SNOMED "Essential hypertension" diagnosis code.

RESULTS

We identified 99 461 participants with HTN who met the eligibility criteria. Following the application of our computable phenotypes, an overall population of 81 462 were further categorized to aTRH (14.4%), stable-controlled HTN (SCH) (39.5%), and Other HTN (46.1%). Compared to participants with SCH, participants with aTRH were older, more likely to be of Black or African American race, had higher levels of social deprivation, and a heightened prevalence of comorbidities such as hyperlipidemia and diabetes. Heart failure, chronic kidney disease, and diabetes were the comorbidities most strongly associated with aTRH. β-blockers were the most prescribed antihypertensive medication. At index date, the overall BP control rate was 62%.

DISCUSSION AND CONCLUSION

All of Us provides a unique opportunity to characterize HTN in the United States. Consistent findings from this study with our prior research highlight the interoperability of our computable phenotypes.

A review of novel endothelin antagonists and overview of non-steroidal mineralocorticoid antagonists for treating resistant hypertension: An update

Several agents are emerging from five different novel classes of antihypertensive medications. We will focus on endothelin antagonists and non-steroidal mineralocorticoid receptor antagonists. While several agents exist in this later class, only a couple have demonstrated superior efficacy in resistant hypertension management. Endothelin receptor antagonists are effective therapy for primary and resistant hypertension, but they are not widely used. This is due to side effects demonstrated in large clinical trials, specifically increased peripheral edema and worsening heart failure in some cases, as well as the availability of many alternative agents to manage blood pressure effectively. However, the relationship between endothelin and its close ties to hypertension is evolving. Recent pre-clinical work explores new applications of more selective endothelin receptor antagonists. They suggest that specific subtypes of hypertension may benefit more from endothelin receptor blockade than simply those with primary hypertension. We review this topic and other related data. Lastly, we also provide a brief overview of non-steroidal mineralocorticoid receptor antagonists as some in the class show promise as antihypertensive agents.

Potential of Current Direct Mechanical Testing Methods in Assessing Intraoperative Samples of Aortic Aneurysm Caused by Uncontrolled Arterial Hypertension

The aim of the study was to investigate the potential of direct mechanical testing methods in clinical practice to assess the strength and elastic-deformative characteristics of intraoperative samples of aortic arch aneurysm caused by uncontrolled arterial hypertension.

Materials and Methods

The study experimental material was the resected parts of the aortic aneurysm obtained during aneurysm replacement surgery in a patient with uncontrolled arterial hypertension. The direct mechanical testing methods such as instrumental indentation and uniaxial extension were used.

Results

It was shown that by the direct instrumental indentation it is possible to accurately assess and compare the stiffness of all three layers of the aortic wall. In this clinical case, the inner aorta layer was subject to the greatest atherosclerotic damage. In the media area, the values of this indicator were widely scattered, whereas the material was greatly dissected. By uniaxial extension method it is possible to obtain accurate parameters of the vascular wall strength, as well as to assess the stiffness, elasticity, and deformability of the intraoperatively resected aortic tissue. It was found that the aneurysm aortic wall, compared with the non-dilated aortic section, was characterized by a significantly lower strength in both longitudinal (by 4.25 times) and transverse (by 3.75 times) directions. In addition, aneurysm tissues demonstrated a significantly lower elasticity and deformability.

Conclusion

The study demonstrated the perspectives and options of using in clinical practice current methods of direct mechanical testing, which makes it possible to obtain more accurate indicators of the strength and elastic-deformative vascular characteristics, to clarify the pathophysiological mechanisms of cardiovascular accidents, and to justify the need for regular monitoring of vascular wall stiffness in clinical practice, in particular in patients with uncontrolled arterial hypertension.

The Global Burden of Resistant Hypertension and Potential Treatment Options

Resistant hypertension (RH) is defined as systolic blood pressure (SBP) or diastolic blood pressure (DBP) that remains .140 mmHg or .90 mmHg, respectively, despite an appropriate lifestyle and the use of optimal or maximally tolerated doses of a three-drug combination, including a diuretic. This definition encompasses the category of controlled RH, defined as the presence of blood pressure (BP) effectively controlled by four or more antihypertensive agents, as well as refractory hypertension, referred to as uncontrolled BP despite five or more drugs of different classes, including a diuretic. To confirm RH presence, various causes of pseudo-resistant hypertension (such as improper BP measurement techniques and poor medication adherence) and secondary hypertension must be ruled out. Inadequate BP control should be confirmed by out-of-office BP measurement. RH affects about 5% of the hypertensive population and is associated with increased cardiovascular morbidity and mortality. Once RH presence is confirmed, patient evaluation includes identification of contributing factors such as lifestyle issues or interfering drugs/substances and assessment of hypertension-mediated organ damage. Management of RH comprises lifestyle interventions and optimisation of current medication therapy. Additional drugs should be introduced sequentially if BP remains uncontrolled and renal denervation can be considered as an additional treatment option. However, achieving optimal BP control remains challenging in this setting. This review aims to provide an overview of RH, including its epidemiology, pathophysiology, diagnostic work-up, as well as the latest therapeutic developments.

Standard and New Echocardio Techniques, Such as Global Longitudinal Strain, to Monitor the Impact of Diets on Cardiovascular Diseases and Heart Function

"The Seven Countries Study", published in 1984, was the first study to find a correlation between diet and mortality related to cardiovascular diseases (CVDs). Since then, many investigations have addressed the relationship between type of diet, or specific nutrients, and CVDs. Based on these findings, some traditional dietary models, such as the Mediterranean or Nordic diet, are recommended to prevent CVDs. Meanwhile, new diets have been proposed for optimal nutrition therapy, for example, the Dietary Approaches to Stop Hypertension (DASH) and the Mediterranean-DASH Intervention Diet for Neurodegenerative Delay (MIND). The main outcomes evaluated after implementing these dietary models are as follows: CVD-related death; the development of specific CVDs, such as myocardial infarction and hypertension; or biochemical parameters related to CVDs, i.e., non-HDL cholesterol, C-reactive protein (CPR) and homocysteine. However, the early impact of diet on heart functionality is less evaluated. Recently, the echographic measurement of left ventricle (LV) deformation by global longitudinal strain (GLS) has been introduced as a novel marker of clinical and subclinical cardiac dysfunction. This technology allows a subclinical evaluation of heart functionality since, differently from the traditional evaluation of left ventricle ejection fraction (LVEF), it is capable of detecting early myocardial dysfunction. In this review, we analyzed the available studies that correlate dietetic regimens to cardiovascular diseases, focusing on the relevance of LV strain to detect subclinical myocardial alteration related to diet. Evidence is presented that DASH and MIND can have a positive impact on heart functionality and that myocardial strain is useful for early detection of diet-related changes in cardiac function.

Prevalence and risk factors associated with uncontrolled blood pressure in rural areas in Settat City, Morocco

Introduction

high blood pressure, commonly known as hypertension, is one of the most widespread chronic diseases in the world. It is a serious problem whose management is essential to maintain stable blood pressure levels in the short term, and to prevent neuro-cardio-vascular complications in the long term. This study aims firstly to explore the characteristics of uncontrolled blood pressure among patient´s residents of rural areas in Settat City, and secondly to determine its prevalence and identify associated risk factors.

Methods

this is a cross-sectional, descriptive, and analytical study which took place between March and August 2023, and targeted a population of hypertensive patients following up at primary healthcare facilities in rural areas in Settat City. A questionnaire was developed and evaluated to ensure its reliability before being administered to study participants, anthropometric measurements and blood pressure readings were also taken.

Results

four hundred hypertensive patients were surveyed, 53% (212) of whom had uncontrolled blood pressure, with a mean age of 56.94 (±13.10 years), and a marked female preponderance, illustrated by 72.3% (289) were female. The risk factors associated with uncontrolled blood pressure were: male gender (aOR: 2.53, 95% CI 1.13-5.65), monthly income (aOR: 5.64, 95% CI 3.04-10.46), diabetes (aOR: 3.16, 95% CI 1.77-5.63), monotherapy (aOR: 8.42, 95% CI 2.85-24.90), poor compliance with medication (aOR: 7.48, 95% CI 4.21-13.29), and stress (aOR: 2.22, 95% CI 1.14-4.33).

Conclusion

the level of blood pressure control was unsatisfactory in this population, underscoring the imperative of educating hypertensive patients about management measures and reinforcing the quality of primary health services.

Prevalence of uncontrolled hypertension and contributing factors in Ethiopia: a systematic review and meta-analysis

Background

Uncontrolled hypertension (HTN) is a major risk factor for cardiovascular and cerebrovascular disease. The prevalence of HTN in the Ethiopian adult population is almost 20%.This study aimed to determine the prevalence of uncontrolled HTN and its contributing factors among patients with HTN in Ethiopia undergoing treatment.

Methods

Electronic bibliographic databases such as PubMed, Google Scholar, Hinari (Research4Life), Embase, and Scopus were searched for original records in the English language that assessed HTN control in Ethiopia and were available before 29 June 2023. The data were extracted using a format prepared in Microsoft Excel and exported to the software STATA 17.0 for analysis. The study protocol was registered at PROSPERO with the reference number CRD42023440121.

Results

A total of 26 studies with 9,046 patients with HTN were included in the systematic review and meta-analysis, of which 11 studies were used to assess factors contributing to uncontrolled blood pressure (BP) in patients in Ethiopia. The estimated prevalence of uncontrolled HTN in the population of Ethiopia is 51% [95% confidence interval (CI), 42%-60%]. The subgroup analysis, based on the assessment tools, region, and follow-up period, revealed that the prevalence of uncontrolled BP was highest following the guidelines of the American Heart Association/American College of Cardiology (AHA/ACC) (89%; 95% CI: 87%-91%) and in Addis Ababa (58%; 95% CI: 40%-76%), and the lowest proportion of uncontrolled BP was in the 3-month follow-up period (34%; 95% CI: 29%-39%). The presence of diabetes mellitus showed the highest impact (pooled odds ratio: 5.19; CI: 1.41-19.11) for uncontrolled HTN. The univariate meta-regression method confirmed that the sample size, year of publication, and subgroups were not sources of heterogeneity in the pooled estimates. Egger's regression test did not indicate the presence of publication bias.

Conclusion

More than half of the hypertensive patients in Ethiopia have uncontrolled BP. Diabetes mellitus, advanced age, male sex, and the presence of comorbidities are among the factors contributing to uncontrolled HTN in Ethiopia. The concerned bodies working in this area should implement interventional strategies and recommendations that might be helpful in achieving optimal BP in hypertensive patients.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023440121, PROSPERO (CRD42023440121).

Resistant Hypertension and Related Outcomes in a Cohort of Patients with Cardiorenal Multimorbidity Hospitalized in an Internal Medicine Ward

INTRODUCTION

Resistant hypertension (RH) is characterized by the failure to reach a goal blood pressure despite the administration of three medications at maximally tolerated doses, one of which being a diuretic. RH can be observed in a variety of clinical conditions, such as heart failure and reduced renal function and may confer high cardiovascular risk.

AIM

To evaluate the prevalence of RH and its association with clinical outcomes; the primary outcome was in-hospital mortality and the composite outcome was all-cause of mortality and morbidity in a cohort of patients with cardiorenal multimorbidity hospitalized in an internal medicine ward.

METHODS

We conducted a retrospective analysis of consecutive hypertensive patients with cardiorenal multimorbidity. The composite outcome incorporated all-cause of in-hospital mortality and occurrence of sepsis, pulmonary embolism, acute coronary syndrome, stroke and renal replacement therapy.

RESULTS

We collected data in 141 inpatients with a mean age of 77 years ± 10 (males 65.9 %), estimated glomerular filtration rate of 34 ± 18.6 ml/min with length of stay of 17 ± 12 days. The prevalence of RH was 52.4%. In-hospital mortality was observed in 24 patients (17%) and the composite outcome occurred in 87 patients (61.7%) and among these 74 (85.1%) were patients with RH. Free survival for composite outcome was significantly higher in patients without RH than patients with RH (log rank 7.52, p = 0.006). Resistant hypertension was a risk factor for composite outcome [HR 1.857(C.I. 1.170-2.946, p = 0.009)].

CONCLUSION

In patients with cardiorenal multimorbidity there is a high proportion of RH that represents a risk factor for composite outcome but not for in-hospital mortality.