Special Article - The management of resistant hypertension: A 2020 update

Trends in Obesity Prevalence Among Adults With Hypertension in the United States, 2001 to 2023

BACKGROUND

Obesity is a factor contributing to the occurrence of hypertension and a risk factor for adverse outcomes in populations with hypertension. The changes in the prevalence of obesity in populations with hypertension remain unclear. Investigating the changes in the prevalence of obesity in populations with hypertension can provide information for the treatment and management of hypertension.

METHODS

The clinical data from adults aged ≥20 years with hypertension were extracted from the National Health and Nutrition Examination Survey 2001 to 2023. The primary outcome was the prevalence of obesity (body mass index≥30 kg/m2). The trend in the prevalence of obesity among American adults with hypertension was evaluated via a trend test.

RESULTS

The age-standardized prevalence of obesity among populations with hypertension in America increased from 39.6% in 2001 to 55.4% in 2023 (P for trend<0.001). This trend was observed in men (35.4%-53.6%; P for trend<0.001) and women (45.6%-57.7%; P for trend<0.001) populations with hypertension. While the prevalence of grade II (35 kg/m2≤body mass index<40 kg/m2) and grade III obesity (body mass index≥40 kg/m2) increased significantly in both sexes, the prevalence of grade I obesity (30 kg/m2≤body mass index<35 kg/m2) increased significantly only in men (23.2%-30.0%; P for trend=0.003) and did not significantly change in women (22.2%-21.7%; P for trend=0.135).

CONCLUSIONS

The prevalence of obesity among American adults with hypertension increased from 2001 to 2023. In men, the prevalence of grades I, II, and III obesity increased. Among women, the prevalence of only grades II and III obesity increased.

Acute physical exercise and ambulatory blood pressure in resistant hypertension

OBJECTIVES

The effects of acute physical exercise in patients with resistant hypertension remain largely unexplored compared with hypertensive patients in general. We assessed the short-term effects of acute moderate-intensity (MICE) and high-intensity interval exercise (HIIE) on the clinic (BP) and 24-h ambulatory blood pressure (ABP) of patients with resistant hypertension.

METHODS

Using a crossover randomized controlled design, 10 participants (56 ± 7 years) with resistant hypertension performed three experimental sessions: MICE, HIIE, and control. MICE consisted of continuous treadmill exercise at an intensity of 3-4 metabolic equivalents of energy (METs) until completing 3 kcal/kg and was energy-matched to HIIE (which included six to eight intervals of 3 min duration at 6-7 METs interspersed with 1.5-min rests at 3 METs). In the control session, participants remained seated for 50 min. Flow-mediated vasodilation, autonomic nervous system balance (heart rate variability), exerkines [interleukin (IL)-6, IL-8, IL-15, vascular endothelial growth factor A, irisin, adiponectin, and angiopoietin] and 71 inflammatory-related proteins were also measured.

RESULTS

Compared with baseline, HIIE and MICE reduced clinic SBP immediately ( P  < 0.001 for both) and 90 min ( P  = 0.001 and P  = 0.041, respectively) postexercise. HIIE and MICE also reduced clinic DBP immediately postexercise ( P  = 0.003 and P  = 0.025). By contrast, no changes were found in the control session. On the other hand, no significant effects were noted for 24 h ABP measures or for the rest of variables.

CONCLUSION

Although in patients with resistant hypertension, acute aerobic exercise induces short-term reductions in clinic BP, this stimulus does not suffice to reduce 24 h ABP or to impact on potential biological mechanisms.

Applications and outcomes of implementing telemedicine for hypertension management in COVID-19 pandemic: A systematic review

INTRODUCTION

COVID-19 presented a significant challenge for patients with hypertension in terms of access to care. However, telemedicine offered the healthcare system opportunities that had previously been underutilized. Therefore, this study aims to systematically review the applications and outcomes of telemedicine for hypertension management during the COVID-19 pandemic.

METHOD

A structured search was conducted in accordance with PRISMA guidelines across multiple databases, including PubMed, Cochrane, Web of Science, and Scopus. The search was limited to studies published from December 2019 until May 2023, resulting in a total of 3727 studies. After quality appraisal using the CASP checklists version 2018, 29 articles were included in the final review. Data analysis was performed using thematic analysis.

RESULTS

Most of the studies reviewed had used the proprietary platforms (N = 14) and 11 studies had used public platforms such as social messengers or email. Also 9 studies relied on phone calls (N = 9) to record and transmit the clinical data. Some studies had applied two different approaches (proprietary/public platforms and phone). six articles (20.7%) focused only on hypertension control, while 23 articles (79.3%) examined hypertension as a comorbidity with other diseases. Also, the study identified 88 unique concepts, 15 initial themes, and six final themes for outcomes of using telemedicine for hypertension management during the COVID-19 pandemic. These themes include BP control, BP measurement and recording, medication management, mental health, care continuity and use and acceptance.

CONCLUSION

Telemedicine provides patients with hypertension with the opportunity to engage in medical consultations in a more convenient and comfortable manner, with the same validity as in-person visits. Telemedicine facilitates the creation of a connected network to support patients with high BP at any time and in any location. Limitations and issues may arise due to patients and healthcare staff's unfamiliarity with telemedicine. These issues can be resolved through the ongoing use and continuous feedback.

Compliance to Multidisciplinary Lifestyle Intervention Decreases Blood Pressure in Patients with Resistant Hypertension: A Cross-Sectional Pilot Study

Hypertension is a common chronic medical condition. Treatment is not satisfactory in a significant proportion of patients with primary hypertension, despite the concurrent use of three or more medications with different mechanisms of action. Such treatment-resistant hypertension is a clinical challenge associated with poor prognosis and needs further investigation. The efficacy of lifestyle changes has not been established yet in patients with resistant hypertension, and educational efforts appear clinically irrelevant in patients who must achieve behavioral changes without supervision. A 6-month multidisciplinary pilot intervention enrolled 50 patients with established resistant hypertension. The aims were: (1) to examine whether intensive and supervised lifestyle changes contribute to decreasing blood pressure in this condition, and (2) to identify which components affect compliance and feasibility. The program provided intensive changes in nutrition, physical exercise, and control of sleep disturbances supervised by nutritionists, physiotherapists, and psychologists. Nurses and pharmacists followed up on adherence to the antihypertensive medication. The primary outcome was 24 h blood pressure control. Data in patients with full compliance (n = 30) indicate that lifestyle modifications in resistant hypertension significantly reduced 24 h both systolic and diastolic blood pressure (p < 0.01), body mass index (p < 0.01), medication burden (p = 0.04), improving physical fitness, and cardiovascular risk markers such as heart rate (p = 0.01) and augmentation index (p = 0.02). The adherence to the intervention was moderate, with an attrition rate of 12%. A modified version reducing visits and explorations will likely improve compliance and can be used to assess the long-term maintenance of these benefits in managing resistant hypertension by diverse healthcare providers.

Beneficial Extracardiac Effects of Cardiovascular Medications

Cardiovascular diseases are the most common cause of death worldwide, with cardiovascular medications being amongst the most common medications prescribed. These medications have diverse effects on the heart, vascular system, as well as other tissues and organ systems. The extra cardiovascular effects have been found to be of use in the treatment of non-cardiovascular diseases and pathologies. Minoxidil is used to manage systemic hypertension with its well-known side effect of hirsutism used to treat alopecia and baldness. Sildenafil was originally investigated as a treatment option for systemic hypertension; however, its side effect of penile erection led to it being widely used for erectile dysfunction. Alpha-1 blockers such as terazosin are indicated to treat systemic hypertension but are more commonly used for benign prostatic hyperplasia and post-traumatic stress disorder. Beta blockers are the mainstay treatment for congestive heart failure and systemic hypertension but have been found useful to help in patients with intention tremors as well as prophylaxis of migraines. Similarly, calcium channel blockers are indicated in medical expulsion therapy for ureteric calculi in addition to their cardiovascular indications. Thiazides are commonly used for treating systemic hypertension and as diuretics. Thiazides can cause hypocalciuria and hypercalcemia. This side effect has led to thiazides being used to treat idiopathic hypercalciuria and associated nephrolithiasis. Spironolactone is commonly utilized in treating heart failure and as a diuretic for edema. It's well described anti-androgen side effects have been used for acne vulgaris and hirsutism in polycystic ovarian syndrome. This review article discusses how the various extracardiovascular effects of commonly used cardiovascular medications are put to use in managing non-cardiovascular conditions.

Effects of Lifestyle Modification on Patients With Resistant Hypertension: Results of the TRIUMPH Randomized Clinical Trial

BACKGROUND

Although lifestyle modifications generally are effective in lowering blood pressure (BP) among patients with unmedicated hypertension and in those treated with 1 or 2 antihypertensive agents, the value of exercise and diet for lowering BP in patients with resistant hypertension is unknown.

METHODS

One hundred forty patients with resistant hypertension (mean age, 63 years; 48% female; 59% Black; 31% with diabetes; 21% with chronic kidney disease) were randomly assigned to a 4-month program of lifestyle modification (C-LIFE [Center-Based Lifestyle Intervention]) including dietary counseling, behavioral weight management, and exercise, or a single counseling session providing SEPA (Standardized Education and Physician Advice). The primary end point was clinic systolic BP; secondary end points included 24-hour ambulatory BP and select cardiovascular disease biomarkers including baroreflex sensitivity to quantify the influence of the baroreflex on heart rate, high-frequency heart rate variability to assess vagally mediated modulation of heart rate, flow-mediated dilation to evaluate endothelial function, pulse wave velocity to assess arterial stiffness, and left ventricular mass to characterize left ventricular structure.

RESULTS

Between-group comparisons revealed that the reduction in clinic systolic BP was greater in C-LIFE (-12.5 [95% CI, -14.9 to -10.2] mm Hg) compared with SEPA(-7.1 [-95% CI, 10.4 to -3.7] mm Hg) (P=0.005); 24-hour ambulatory systolic BP also was reduced in C-LIFE (-7.0 [95% CI, -8.5 to -4.0] mm Hg), with no change in SEPA (-0.3 [95% CI, -4.0 to 3.4] mm Hg) (P=0.001). Compared with SEPA, C-LIFE resulted in greater improvements in resting baroreflex sensitivity (2.3 ms/mm Hg [95% CI, 1.3 to 3.3] versus -1.1 ms/mm Hg [95% CI, -2.5 to 0.3]; P<0.001), high-frequency heart rate variability (0.4 ln ms² [95% CI, 0.2 to 0.6] versus -0.2 ln ms² [95% CI, -0.5 to 0.1]; P<0.001), and flow-mediated dilation (0.3% [95% CI, -0.3 to 1.0] versus -1.4% [95% CI, -2.5 to -0.3]; P=0.022). There were no between-group differences in pulse wave velocity (P=0.958) or left ventricular mass (P=0.596).

CONCLUSIONS

Diet and exercise can lower BP in patients with resistant hypertension. A 4-month structured program of diet and exercise as adjunctive therapy delivered in a cardiac rehabilitation setting results in significant reductions in clinic and ambulatory BP and improvement in selected cardiovascular disease biomarkers. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02342808.

Russian Medical Society for Arterial Hypertension expert consensus. Resistant hypertension: detection and management

The diagnosis of resistant arterial hypertension allows us to single out a separate group of patients in whom it is necessary to use special diagnostic methods and approaches to treatment. Elimination of reversible factors leading to the development of resistant arterial hypertension, such as non-adherence to therapy, inappropriate therapy, secondary forms of arterial hypertension, leads to an improvement in the patient's prognosis. Most patients with resistant hypertension should be evaluated to rule out primary aldosteronism, renal artery stenosis, chronic kidney disease, and obstructive sleep apnea. The algorithm for examining patients, recommendations for lifestyle changes and a step-by-step therapy plan can improve blood pressure control. It is optative to use the most simplified treatment regimen and long-acting combined drugs. For a separate category of patients, it is advisable to perform radiofrequency denervation of the renal arteries.