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Shah SS, Gwini SM, Stowasser M, Reid CM, Young MJ, Fuller PJ, Yang J. A Randomized trial assessing Efficacy and safety of Mineralocorticoid receptor Antagonist therapy compared to Standard antihypertensive Therapy in hypErtension with low Renin (REMASTER): rationale and study design. J Hum Hypertens 2024; 38:663-668. [PMID: 39026100 PMCID: PMC11387186 DOI: 10.1038/s41371-024-00931-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2024] [Revised: 06/12/2024] [Accepted: 07/03/2024] [Indexed: 07/20/2024]
Abstract
Low-renin hypertension affects 1 in 4 people with hypertension, but the optimal management of this condition is not known. We hypothesize that a large proportion of people with low-renin hypertension is mediated by excess mineralocorticoid receptor (MR) activation and that targeted treatment with an MR antagonist (MRA) will be beneficial. This randomized, single-blinded, titration-to-effect aims to investigate whether targeted treatment in low-renin hypertension with MRA is better compared to standard antihypertensives in terms of blood pressure control and end-organ protection. Adults with hypertension, who are treatment naïve or are receiving up to two antihypertensive agents and have a low direct renin concentration <10 mU/L will be included. Participants with severe hypertension, a secondary cause of hypertension, pregnant, breastfeeding, with moderate-severe cardiovascular and chronic kidney disease, or on medications that confound interpretation of the plasma direct renin or aldosterone concentrations will be excluded. Eligible participants will be randomized 1:1 to either MRA therapy (spironolactone) or standard anti-hypertensive therapy (perindopril+/- amlodipine) for 48 weeks. Anti-hypertensives will be up-titrated every 12 weeks until target blood pressure is achieved. The primary objective will be to determine the total defined daily dose of antihypertensives required to achieve the target blood pressure and change in mean clinic systolic blood pressure at week 48. Current hypertension guidelines do not have specific recommendations for the choice of anti-hypertensive medications for people with low-renin hypertension. The results of this trial could guide future hypertension guidelines.
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Affiliation(s)
- Sonali S Shah
- Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Clayton, VIC, Australia
- Department of Endocrinology, Monash Health, Clayton, VIC, Australia
- Department of Molecular and Translational Science, Monash University, Clayton, VIC, Australia
| | - Stella May Gwini
- Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Clayton, VIC, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Michael Stowasser
- Endocrine Hypertension Research Centre, University of Queensland Diamantina Institute, Princess Alexandra Hospital, Woolloongabba, QLD, Australia
| | - Christopher M Reid
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Morag J Young
- Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Clayton, VIC, Australia
| | - Peter J Fuller
- Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Clayton, VIC, Australia
- Department of Endocrinology, Monash Health, Clayton, VIC, Australia
- Department of Molecular and Translational Science, Monash University, Clayton, VIC, Australia
| | - Jun Yang
- Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Clayton, VIC, Australia.
- Department of Endocrinology, Monash Health, Clayton, VIC, Australia.
- Department of Molecular and Translational Science, Monash University, Clayton, VIC, Australia.
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McEvoy JW, McCarthy CP, Bruno RM, Brouwers S, Canavan MD, Ceconi C, Christodorescu RM, Daskalopoulou SS, Ferro CJ, Gerdts E, Hanssen H, Harris J, Lauder L, McManus RJ, Molloy GJ, Rahimi K, Regitz-Zagrosek V, Rossi GP, Sandset EC, Scheenaerts B, Staessen JA, Uchmanowicz I, Volterrani M, Touyz RM. 2024 ESC Guidelines for the management of elevated blood pressure and hypertension. Eur Heart J 2024:ehae178. [PMID: 39210715 DOI: 10.1093/eurheartj/ehae178] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/04/2024] Open
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Durán CE, Bustamante M, Barbosa M, Useche EM, Triviño J, Sandoval L, Moncayo PA, Rivas AM, Zapata JS, Hernández Quintero JD, Meza S, Bolaños JS, Schweineberg J, Mesa L, Posada JG. Evaluation of aldosterone to direct renin ratio, low renin and related Phenotypes in Afro-Colombian patients with apparent treatment resistant hypertension. Sci Rep 2024; 14:18091. [PMID: 39103362 PMCID: PMC11300880 DOI: 10.1038/s41598-024-67261-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 07/09/2024] [Indexed: 08/07/2024] Open
Abstract
Apparent resistant hypertension (aTRH) is a significant public health issue. Once low adherence to antihypertensive treatment has been ruled out and true resistant hypertension is diagnosed, aldosterone-direct-renin-ratio (ADRR) aids in the screening of an aldosterone-producing adenoma (APA) and primary aldosteronism (PA). Once PA and other secondary causes have been ruled out, the values of aldosterone and renin allow patients to be classified into phenotypes such as low renin hypertension (LRH), Liddle's-like (LLph), and primary hyperaldosteronism (PAph). These classifications could aid in the treatment decision-making process. However, optimal cut-off points for these classifications remain uncertain. This study aims to assess the prevalence of these phenotypes and the behavior of different cut-offs of the ADRR in an Afro-Colombian population with apparent resistant hypertension, as well to describe their sodium consumption. Afro-descendant individuals 18 years of age or older, diagnosed with resistant hypertension and attending to a primary care center in Colombia were recruited as volunteers. As part of the study, their plasma renin concentration (PRC) and plasma aldosterone concentration (PAC) were measured. The phenotypes were categorized into three groups based on multiple cut-off points from different authors: low renin and low aldosterone phenotype (LLph), low renin and high aldosterone phenotype (PAph), and high renin and high aldosterone phenotype, referred to as the renal phenotype (Rph). The prevalence of ADRR values exceeding the cut-off and phenotypes were calculated. A linear regression model was derived to assess the effect of sodium consumption with PAC, PRC and ADRR. A total of 88 patients with aTRH were included. Adherence to at least 3 antihypertensive medications was 62.5%. The median age was 56 years (IQR 48-60), 44% were female, and 20% had diabetes. The study found that the prevalence of ADRR values exceeding the cut-off ranged from 4.5 to 23%, while low-renin hypertension (LRH) varied from 15 to 74%, Rph was found in approximately 30 to 34% of patients, PAph in 30 to 51%, and the LLph in 15 to 41%, respectively, depending on the specific cut-off value by different authors. Notably, sodium consumption was associated with lower aldosterone (β - 0.15, 95% CI [- 0.27, - 0.03]) and renin concentrations (β - 0.75, 95% CI [- 1.5, - 0.02]), but ADRR showed no significant association with sodium consumption. There were no significant differences in prevalences between the groups taking < 3 vs ≥ 3 antihypertensive medications. Altered aldosterone-direct-renin-ratio, low renin hypertension, Liddle's-like, and primary hyperaldosteronism are prevalent phenotypes in patients within Afro-Colombian patients with apparent treatment-Resistant hypertension.
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Affiliation(s)
- C E Durán
- Servicio de Nefrología, Fundación Valle del Lili, Carrera 98 No.18-49, 760032, Cali, Colombia
- Facultad de Ciencias de la Salud, Universidad Icesi, Calle 18 # 122-135, Cali, Colombia
| | - M Bustamante
- Facultad de Ciencias de la Salud, Universidad Icesi, Calle 18 # 122-135, Cali, Colombia
| | - M Barbosa
- Centro de Investigaciones Clínicas (CIC), Fundación Valle del Lili, Carrera 98 No.18-49, Valle del Cauca, 760032, Cali, Colombia
- Facultad de Ciencias de la Salud, Universidad Icesi, Calle 18 # 122-135, Cali, Colombia
| | - E M Useche
- Centro de Investigaciones Clínicas (CIC), Fundación Valle del Lili, Carrera 98 No.18-49, Valle del Cauca, 760032, Cali, Colombia
| | - J Triviño
- Centro de Investigaciones Clínicas (CIC), Fundación Valle del Lili, Carrera 98 No.18-49, Valle del Cauca, 760032, Cali, Colombia.
| | - L Sandoval
- Centro de Investigaciones Clínicas (CIC), Fundación Valle del Lili, Carrera 98 No.18-49, Valle del Cauca, 760032, Cali, Colombia
| | - P A Moncayo
- Centro de Investigaciones Clínicas (CIC), Fundación Valle del Lili, Carrera 98 No.18-49, Valle del Cauca, 760032, Cali, Colombia
| | - A M Rivas
- Centro de Investigaciones Clínicas (CIC), Fundación Valle del Lili, Carrera 98 No.18-49, Valle del Cauca, 760032, Cali, Colombia
| | - J S Zapata
- Facultad de Ciencias de la Salud, Universidad Icesi, Calle 18 # 122-135, Cali, Colombia
| | | | - S Meza
- Facultad de Ciencias de la Salud, Universidad Icesi, Calle 18 # 122-135, Cali, Colombia
| | - J S Bolaños
- Facultad de Ciencias de la Salud, Universidad Icesi, Calle 18 # 122-135, Cali, Colombia
| | - J Schweineberg
- Servicio de Nefrología, Fundación Valle del Lili, Carrera 98 No.18-49, 760032, Cali, Colombia
- Facultad de Ciencias de la Salud, Universidad Icesi, Calle 18 # 122-135, Cali, Colombia
| | - L Mesa
- Servicio de Nefrología, Fundación Valle del Lili, Carrera 98 No.18-49, 760032, Cali, Colombia
- Facultad de Ciencias de la Salud, Universidad Icesi, Calle 18 # 122-135, Cali, Colombia
| | - J G Posada
- Servicio de Nefrología, Fundación Valle del Lili, Carrera 98 No.18-49, 760032, Cali, Colombia
- Facultad de Ciencias de la Salud, Universidad Icesi, Calle 18 # 122-135, Cali, Colombia
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Shah SS, Libianto R, Gwini SM, Rusell G, Young MJ, Fuller PJ, Yang J. Prevalence and Characteristics of Low-renin Hypertension in a Primary Care Population. J Endocr Soc 2024; 8:bvae113. [PMID: 38957654 PMCID: PMC11215789 DOI: 10.1210/jendso/bvae113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2024] [Indexed: 07/04/2024] Open
Abstract
Introduction Low-renin hypertension is an underrecognized subtype of hypertension with specific treatment options. This study aims to identify the prevalence in primary care and to compare patient characteristics to those with normal-renin hypertension and primary aldosteronism (PA). Methods In a cohort study, patients with treatment-naïve hypertension were screened for PA with plasma aldosterone and direct renin concentrations. Patients with an elevated aldosterone-to-renin ratio [≥70 pmol/mU (≥2.5 ng/dL:mU/L)] underwent confirmatory testing. All screened patients were then classified as having (1) normal-renin hypertension, (2) low-renin hypertension (direct renin concentration <10mU/L (plasma renin activity ∼<1 ng/mL/hour) and not meeting the criteria for PA), or (3) confirmed PA. Results Of the 261 patients, 69 (26.4%) had low-renin hypertension, 136 (51.9%) had normal renin hypertension, and 47 (18.0%) had PA. Patients with low-renin hypertension were older and more likely to be female compared to normal-renin hypertension (57.1 ± 12.8 years vs 51.8 ± 14.0 years, P < .05 and 68.1% vs 49.3%, P < .05, respectively) but similar to PA (53.5 ± 11.5 years and 55.3%). However, in an adjusted binomial logistic regression, there was no association between increasing age or sex and low-renin hypertension. The median aldosterone concentration was lower compared to patients with normal-renin hypertension and PA: 279 pmol/L (216-355) vs 320 pmol/L (231-472), P < .05 and 419 pmol/L (360-530), P < .001. Conclusion At least a quarter of treatment-naïve hypertensive patients in primary care had a low direct renin concentration but did not meet the criteria for PA. Patient characteristics were similar, aside from a lower aldosterone concentration compared to patients with normal-renin hypertension and PA. Further research is needed to understand the underlying pathophysiology of low-renin hypertension and the optimal first-line treatment.
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Affiliation(s)
- Sonali S Shah
- Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Clayton, Victoria 3168, Australia
- Department of Endocrinology, Monash Health, Clayton, Victoria 3168, Australia
- Department of Molecular and Translational Science, Monash University, Clayton, Victoria 3168, Australia
| | - Renata Libianto
- Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Clayton, Victoria 3168, Australia
- Department of Endocrinology, Monash Health, Clayton, Victoria 3168, Australia
| | - Stella May Gwini
- Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Clayton, Victoria 3168, Australia
- School of Public Health and Preventive Medicine, Monash University, Clayton, Victoria 3168, Australia
| | - Grant Rusell
- Department of General Practice, Monash University, Notting Hill, Victoria 3168, Australia
| | - Morag J Young
- Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Clayton, Victoria 3168, Australia
- Baker Heart and Diabetes Institute, Prahran, Victoria 3004, Australia
| | - Peter J Fuller
- Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Clayton, Victoria 3168, Australia
- Department of Endocrinology, Monash Health, Clayton, Victoria 3168, Australia
- Department of Molecular and Translational Science, Monash University, Clayton, Victoria 3168, Australia
| | - Jun Yang
- Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Clayton, Victoria 3168, Australia
- Department of Endocrinology, Monash Health, Clayton, Victoria 3168, Australia
- Department of Molecular and Translational Science, Monash University, Clayton, Victoria 3168, Australia
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Mehanna M, McDonough CW, Smith SM, Gong Y, Gums JG, Chapman AB, Johnson JA, Cooper‐DeHoff RM. Integrated metabolomics analysis reveals mechanistic insights into variability in blood pressure response to thiazide diuretics and beta blockers. Clin Transl Sci 2024; 17:e13816. [PMID: 38747311 PMCID: PMC11094670 DOI: 10.1111/cts.13816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 04/05/2024] [Accepted: 04/13/2024] [Indexed: 05/19/2024] Open
Abstract
Hypertensive patients with a higher proportion of genetic West African ancestry (%GWAA) have better blood pressure (BP) response to thiazide diuretics (TDs) and worse response to β-blockers (BBs) than those with lower %GWAA, associated with their lower plasma renin activity (PRA). TDs and BBs are suggested to reduce BP in the long term through vasodilation via incompletely understood mechanisms. This study aimed at identifying pathways underlying ancestral differences in PRA, which might reflect pathways underlying BP-lowering mechanisms of TDs and BBs. Among hypertensive participants enrolled in the Pharmacogenomics Evaluation of Antihypertensive Responses (PEAR) and PEAR-2 trials, we previously identified 8 metabolites associated with baseline PRA and 4 metabolic clusters (including 39 metabolites) that are different between those with GWAA <45% versus ≥45%. In the current study, using Ingenuity Pathway Analysis (IPA), we integrated these signals. Three overlapping metabolic signals within three significantly enriched pathways were identified as associated with both PRA and %GWAA: ceramide signaling, sphingosine 1- phosphate signaling, and endothelial nitric oxide synthase signaling. Literature indicates that the identified pathways are involved in the regulation of the Rho kinase cascade, production of the vasoactive agents nitric oxide, prostacyclin, thromboxane A2, and endothelin 1; the pathways proposed to underlie TD- and BB-induced vasodilatation. These findings may improve our understanding of the BP-lowering mechanisms of TDs and BBs. This might provide a possible step forward in personalizing antihypertensive therapy by identifying patients expected to have robust BP-lowering effects from these drugs.
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Affiliation(s)
- Mai Mehanna
- Center for Drug Evaluation and Research, Office of Translational Science, Office of Clinical Pharmacology, US Food and Drug AdministrationSilver SpringMarylandUSA
| | - Caitrin W. McDonough
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, College of PharmacyUniversity of FloridaGainesvilleFloridaUSA
| | - Steven M. Smith
- Department of Pharmaceutical Outcomes & Policy, College of PharmacyUniversity of FloridaGainesvilleFloridaUSA
| | - Yan Gong
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, College of PharmacyUniversity of FloridaGainesvilleFloridaUSA
| | - John G. Gums
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, College of PharmacyUniversity of FloridaGainesvilleFloridaUSA
| | | | | | - Rhonda M. Cooper‐DeHoff
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, College of PharmacyUniversity of FloridaGainesvilleFloridaUSA
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Hundemer GL, Leung AA, Kline GA, Brown JM, Turcu AF, Vaidya A. Biomarkers to Guide Medical Therapy in Primary Aldosteronism. Endocr Rev 2024; 45:69-94. [PMID: 37439256 PMCID: PMC10765164 DOI: 10.1210/endrev/bnad024] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 06/23/2023] [Accepted: 07/11/2023] [Indexed: 07/14/2023]
Abstract
Primary aldosteronism (PA) is an endocrinopathy characterized by dysregulated aldosterone production that occurs despite suppression of renin and angiotensin II, and that is non-suppressible by volume and sodium loading. The effectiveness of surgical adrenalectomy for patients with lateralizing PA is characterized by the attenuation of excess aldosterone production leading to blood pressure reduction, correction of hypokalemia, and increases in renin-biomarkers that collectively indicate a reversal of PA pathophysiology and restoration of normal physiology. Even though the vast majority of patients with PA will ultimately be treated medically rather than surgically, there is a lack of guidance on how to optimize medical therapy and on key metrics of success. Herein, we review the evidence justifying approaches to medical management of PA and biomarkers that reflect endocrine principles of restoring normal physiology. We review the current arsenal of medical therapies, including dietary sodium restriction, steroidal and nonsteroidal mineralocorticoid receptor antagonists, epithelial sodium channel inhibitors, and aldosterone synthase inhibitors. It is crucial that clinicians recognize that multimodal medical treatment for PA can be highly effective at reducing the risk for adverse cardiovascular and kidney outcomes when titrated with intention. The key biomarkers reflective of optimized medical therapy are unsurprisingly similar to the physiologic expectations following surgical adrenalectomy: control of blood pressure with the fewest number of antihypertensive agents, normalization of serum potassium without supplementation, and a rise in renin. Pragmatic approaches to achieve these objectives while mitigating adverse effects are reviewed.
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Affiliation(s)
- Gregory L Hundemer
- Department of Medicine, Division of Nephrology, University of Ottawa, Ottawa, ON K1H 8L6, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON K1H 8L6, Canada
| | - Alexander A Leung
- Department of Medicine, Division of Endocrinology and Metabolism, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 1N4, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 1N4, Canada
| | - Gregory A Kline
- Department of Medicine, Division of Endocrinology and Metabolism, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 1N4, Canada
| | - Jenifer M Brown
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Adina F Turcu
- Division of Metabolism, Endocrinology, and Diabetes, University of Michigan, Ann Arbor, MI 48109, USA
| | - Anand Vaidya
- Center for Adrenal Disorders, Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
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Sethi Y, Patel N, Kaka N, Kaiwan O, Kar J, Moinuddin A, Goel A, Chopra H, Cavalu S. Precision Medicine and the future of Cardiovascular Diseases: A Clinically Oriented Comprehensive Review. J Clin Med 2023; 12:1799. [PMID: 36902588 PMCID: PMC10003116 DOI: 10.3390/jcm12051799] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 02/17/2023] [Accepted: 02/20/2023] [Indexed: 02/26/2023] Open
Abstract
Cardiac diseases form the lion's share of the global disease burden, owing to the paradigm shift to non-infectious diseases from infectious ones. The prevalence of CVDs has nearly doubled, increasing from 271 million in 1990 to 523 million in 2019. Additionally, the global trend for the years lived with disability has doubled, increasing from 17.7 million to 34.4 million over the same period. The advent of precision medicine in cardiology has ignited new possibilities for individually personalized, integrative, and patient-centric approaches to disease prevention and treatment, incorporating the standard clinical data with advanced "omics". These data help with the phenotypically adjudicated individualization of treatment. The major objective of this review was to compile the evolving clinically relevant tools of precision medicine that can help with the evidence-based precise individualized management of cardiac diseases with the highest DALY. The field of cardiology is evolving to provide targeted therapy, which is crafted as per the "omics", involving genomics, transcriptomics, epigenomics, proteomics, metabolomics, and microbiomics, for deep phenotyping. Research for individualizing therapy in heart diseases with the highest DALY has helped identify novel genes, biomarkers, proteins, and technologies to aid early diagnosis and treatment. Precision medicine has helped in targeted management, allowing early diagnosis, timely precise intervention, and exposure to minimal side effects. Despite these great impacts, overcoming the barriers to implementing precision medicine requires addressing the economic, cultural, technical, and socio-political issues. Precision medicine is proposed to be the future of cardiovascular medicine and holds the potential for a more efficient and personalized approach to the management of cardiovascular diseases, contrary to the standardized blanket approach.
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Affiliation(s)
- Yashendra Sethi
- PearResearch, Dehradun 248001, India
- Department of Medicine, Government Doon Medical College, HNB Uttarakhand Medical Education University, Dehradun 248001, India
| | - Neil Patel
- PearResearch, Dehradun 248001, India
- Department of Medicine, GMERS Medical College, Himmatnagar 383001, India
| | - Nirja Kaka
- PearResearch, Dehradun 248001, India
- Department of Medicine, GMERS Medical College, Himmatnagar 383001, India
| | - Oroshay Kaiwan
- PearResearch, Dehradun 248001, India
- Department of Medicine, Northeast Ohio Medical University, Rootstown, OH 44272, USA
| | - Jill Kar
- PearResearch, Dehradun 248001, India
- Department of Medicine, Lady Hardinge Medical College, New Delhi 110001, India
| | - Arsalan Moinuddin
- Vascular Health Researcher, School of Sports and Exercise, University of Gloucestershire, Cheltenham GL50 4AZ, UK
| | - Ashish Goel
- Department of Medicine, Government Doon Medical College, HNB Uttarakhand Medical Education University, Dehradun 248001, India
| | - Hitesh Chopra
- Chitkara College of Pharmacy, Chitkara University, Punjab 140401, India
| | - Simona Cavalu
- Faculty of Medicine and Pharmacy, University of Oradea, P-ta 1 Decembrie 10, 410087 Oradea, Romania
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Etiological Diagnosis and Personalized Therapy for Hypertension: A Hypothesis of the REASOH Classification. J Pers Med 2023; 13:jpm13020261. [PMID: 36836495 PMCID: PMC9960440 DOI: 10.3390/jpm13020261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 01/08/2023] [Accepted: 01/28/2023] [Indexed: 01/31/2023] Open
Abstract
With the epidemic of risk factors such as unhealthy lifestyle, obesity and mental stress, the prevalence of hypertension continues to rise across the world. Although standardized treatment protocols simplify the selection of antihypertensive drugs and ensure therapeutic efficacy, the pathophysiological state of some patients remains, which may also lead to the development of other cardiovascular diseases. Thus, there is an urgent need to consider the pathogenesis and selection of antihypertensive drug for different type of hypertensive patients in the era of precision medicine. We proposed the REASOH classification, based on the etiology of hypertension, including renin-dependent hypertension, elderly-arteriosclerosis-based hypertension, sympathetic-active hypertension, secondary hypertension, salt-sensitive hypertension and hyperhomocysteinemia hypertension. The aim of this paper is to propose a hypothesis and provide a brief reference for the personalized treatment of hypertensive patients.
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Promise of Physiological Profiling to Prevent Stroke in People of African Ancestry: Prototyping Ghana. Curr Neurol Neurosci Rep 2022; 22:735-743. [PMID: 36181575 DOI: 10.1007/s11910-022-01239-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/25/2022] [Indexed: 01/27/2023]
Abstract
PURPOSE OF REVIEW Worldwide, compared to other racial/ethnic groups, individuals of African ancestry have an excessively higher burden of hypertension-related morbidities, especially stroke. Identifying modifiable biological targets that contribute to these disparities could improve global stroke outcomes. In this scoping review, we discuss how pathological perturbations in the renin-angiotensin-aldosterone pathways could be harnessed via physiological profiling for the purposes of improving blood pressure control for stroke prevention among people of African ancestry. RECENT FINDINGS Transcontinental comparative data from the USA and Ghana show that the prevalence of treatment-resistant hypertension among stroke survivors is 42.7% among indigenous Africans, 16.1% among African Americans, and 6.9% among non-Hispanic Whites, p < 0.0001. A multicenter clinical trial of patients without stroke in 3 African countries (Nigeria, Kenya, and South Africa) demonstrated that physiological profiling using plasma renin activity and aldosterone to individualize selection of antihypertensive medications compared with usual care resulted in better blood pressure control with fewer medications over 12 months. Among Ghanaian ischemic stroke survivors treated without renin-aldosterone profiling data, an analysis revealed that those with low renin phenotypes did not achieve any meaningful reduction in blood pressure over 12 months on 3-4 antihypertensive medications despite excellent adherence. For a polygenic condition such as hypertension, individualized therapy based on plasma renin-aldosterone-guided selection of therapy for uncontrolled BP following precision medicine principles may be a viable strategy for primary and secondary stroke prevention with the potential to reduce disparities in the poor outcomes of stroke disproportionately shared by individuals of African ancestry. A dedicated clinical trial to test this hypothesis is warranted.
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Lin M, Heizhati M, Gan L, Hong J, Wu T, Xiamili Z, Tong L, Lin Y, Li N. Higher plasma renin activity is associated with increased kidney damage risk in patients with hypertension and glucose metabolic disorders. J Clin Hypertens (Greenwich) 2022; 24:750-759. [PMID: 35522256 PMCID: PMC9180335 DOI: 10.1111/jch.14492] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Revised: 04/20/2022] [Accepted: 04/20/2022] [Indexed: 11/30/2022]
Abstract
The impact of renin on kidney remain unclear among hypertensives with glucose metabolic disorders (GMD). We aimed to evaluate the association between plasma renin activity (PRA) and kidney damage in hypertensive patients with GMD. Overall, 2033 inpatients with hypertension and GMD free of chronic kidney disease (CKD) at baseline were included. CKD was defined using estimated glomerular filtration rate (eGFR) and urine protein. PRA was treated as continuous variable, and also dichotomized as high (≥0.65) or low (< 0.65) groups. The association of PRA with incident CKD was evaluated using multivariable Cox model controlling for antihypertensive medications and baseline aldosterone, and traditional parameters. Subgroup and interaction analyses were performed to evaluate heterogeneity. During a median follow‐up of 31 months, 291 participants developed CKD. The incidence was higher in high‐renin group than that in low‐renin group (54.6 vs 36.6/1000 person‐years). Significant association was observed between PRA and incident CKD, and the association was mainly driven by an increased risk for proteinuria. Each standard deviation increment in log‐transformed PRA was associated with 16.7% increased risk of proteinuria (hazard ratio = 1.167, P = .03); compared with low‐renin group, there was 78.4% increased risk for high‐renin group (hazard ratio = 1.784, P = .001). Nonlinear associations were observed between PRA and kidney damage. Higher PRA is associated with greater risk of incident kidney damage, especially for positive proteinuria, in patients with coexistence of hypertension and diabetes, independent of aldosterone. In this patient population with high risk for kidney damage, PRA may serve as an important predictor.
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Affiliation(s)
- Mengyue Lin
- Hypertension Center of People's Hospital of Xinjiang Uygur Autonomous Region, Xinjiang Hypertension Institute; National Health Committee, Key Laboratory of Hypertension Clinical Research, Key Laboratory of Xinjiang Uygur Autonomous Region "Hypertension Research Laboratory", Xinjiang Clinical Medical Research Center for Hypertension (Cardio-Cerebrovascular) Diseases, Urumqi, China
| | - Mulalibieke Heizhati
- Hypertension Center of People's Hospital of Xinjiang Uygur Autonomous Region, Xinjiang Hypertension Institute; National Health Committee, Key Laboratory of Hypertension Clinical Research, Key Laboratory of Xinjiang Uygur Autonomous Region "Hypertension Research Laboratory", Xinjiang Clinical Medical Research Center for Hypertension (Cardio-Cerebrovascular) Diseases, Urumqi, China
| | - Lin Gan
- Hypertension Center of People's Hospital of Xinjiang Uygur Autonomous Region, Xinjiang Hypertension Institute; National Health Committee, Key Laboratory of Hypertension Clinical Research, Key Laboratory of Xinjiang Uygur Autonomous Region "Hypertension Research Laboratory", Xinjiang Clinical Medical Research Center for Hypertension (Cardio-Cerebrovascular) Diseases, Urumqi, China
| | - Jing Hong
- Hypertension Center of People's Hospital of Xinjiang Uygur Autonomous Region, Xinjiang Hypertension Institute; National Health Committee, Key Laboratory of Hypertension Clinical Research, Key Laboratory of Xinjiang Uygur Autonomous Region "Hypertension Research Laboratory", Xinjiang Clinical Medical Research Center for Hypertension (Cardio-Cerebrovascular) Diseases, Urumqi, China
| | - Ting Wu
- Hypertension Center of People's Hospital of Xinjiang Uygur Autonomous Region, Xinjiang Hypertension Institute; National Health Committee, Key Laboratory of Hypertension Clinical Research, Key Laboratory of Xinjiang Uygur Autonomous Region "Hypertension Research Laboratory", Xinjiang Clinical Medical Research Center for Hypertension (Cardio-Cerebrovascular) Diseases, Urumqi, China
| | - Zuhere Xiamili
- Hypertension Center of People's Hospital of Xinjiang Uygur Autonomous Region, Xinjiang Hypertension Institute; National Health Committee, Key Laboratory of Hypertension Clinical Research, Key Laboratory of Xinjiang Uygur Autonomous Region "Hypertension Research Laboratory", Xinjiang Clinical Medical Research Center for Hypertension (Cardio-Cerebrovascular) Diseases, Urumqi, China
| | - Ling Tong
- Hypertension Center of People's Hospital of Xinjiang Uygur Autonomous Region, Xinjiang Hypertension Institute; National Health Committee, Key Laboratory of Hypertension Clinical Research, Key Laboratory of Xinjiang Uygur Autonomous Region "Hypertension Research Laboratory", Xinjiang Clinical Medical Research Center for Hypertension (Cardio-Cerebrovascular) Diseases, Urumqi, China
| | - Yue Lin
- Hypertension Center of People's Hospital of Xinjiang Uygur Autonomous Region, Xinjiang Hypertension Institute; National Health Committee, Key Laboratory of Hypertension Clinical Research, Key Laboratory of Xinjiang Uygur Autonomous Region "Hypertension Research Laboratory", Xinjiang Clinical Medical Research Center for Hypertension (Cardio-Cerebrovascular) Diseases, Urumqi, China
| | - Nanfang Li
- Hypertension Center of People's Hospital of Xinjiang Uygur Autonomous Region, Xinjiang Hypertension Institute; National Health Committee, Key Laboratory of Hypertension Clinical Research, Key Laboratory of Xinjiang Uygur Autonomous Region "Hypertension Research Laboratory", Xinjiang Clinical Medical Research Center for Hypertension (Cardio-Cerebrovascular) Diseases, Urumqi, China
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Metabolomics Signature of Plasma Renin Activity and Linkage with Blood Pressure Response to Beta Blockers and Thiazide Diuretics in Hypertensive European American Patients. Metabolites 2021; 11:metabo11090645. [PMID: 34564461 PMCID: PMC8466669 DOI: 10.3390/metabo11090645] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2021] [Revised: 09/13/2021] [Accepted: 09/14/2021] [Indexed: 01/13/2023] Open
Abstract
Plasma renin activity (PRA) is a predictive biomarker of blood pressure (BP) response to antihypertensives in European–American hypertensive patients. We aimed to identify the metabolic signatures of baseline PRA and the linkages with BP response to β-blockers and thiazides. Using data from the Pharmacogenomic Evaluation of Antihypertensive Responses-2 (PEAR-2) trial, multivariable linear regression adjusting for age, sex and baseline systolic-BP (SBP) was performed on European–American individuals treated with metoprolol (n = 198) and chlorthalidone (n = 181), to test associations between 856 metabolites and baseline PRA. Metabolites with a false discovery rate (FDR) < 0.05 or p < 0.01 were tested for replication in 463 European–American individuals treated with atenolol or hydrochlorothiazide. Replicated metabolites were then tested for validation based on the directionality of association with BP response. Sixty-three metabolites were associated with baseline PRA, of which nine, including six lipids, were replicated. Of those replicated, two metabolites associated with higher baseline PRA were validated: caprate was associated with greater metoprolol SBP response (β = −1.7 ± 0.6, p = 0.006) and sphingosine-1-phosphate was associated with reduced hydrochlorothiazide SBP response (β = 7.6 ± 2.8, p = 0.007). These metabolites are clustered with metabolites involved in sphingolipid, phospholipid, and purine metabolic pathways. The identified metabolic signatures provide insights into the mechanisms underlying BP response.
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12
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Mahfoud F, Townsend RR, Kandzari DE, Kario K, Schmieder RE, Tsioufis K, Pocock S, David S, Patel K, Rao A, Walton A, Bloom JE, Weber T, Suppan M, Lauder L, Cohen SA, McKenna P, Fahy M, Böhm M, Weber MA. Changes in Plasma Renin Activity After Renal Artery Sympathetic Denervation. J Am Coll Cardiol 2021; 77:2909-2919. [PMID: 33957242 DOI: 10.1016/j.jacc.2021.04.044] [Citation(s) in RCA: 57] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 03/23/2021] [Accepted: 04/12/2021] [Indexed: 12/25/2022]
Abstract
BACKGROUND The renin-angiotensin-aldosterone system plays a key role in blood pressure (BP) regulation and is the target of several antihypertensive medications. Renal denervation (RDN) is thought to interrupt the sympathetic-mediated neurohormonal pathway as part of its mechanism of action to reduce BP. OBJECTIVES The purpose of this study was to evaluate plasma renin activity (PRA) and aldosterone before and after RDN and to assess whether these baseline neuroendocrine markers predict response to RDN. METHODS Analyses were conducted in patients with confirmed absence of antihypertensive medication. Aldosterone and PRA levels were compared at baseline and 3 months post-procedure for RDN and sham control groups. Patients in the SPYRAL HTN-OFF MED Pivotal trial were separated into 2 groups, those with baseline PRA ≥0.65 ng/ml/h (n = 110) versus <0.65 ng/ml/h (n = 116). Follow-up treatment differences between RDN and sham control groups were adjusted for baseline values using multivariable linear regression models. RESULTS Baseline PRA was similar between RDN and control groups (1.0 ± 1.1 ng/ml/h vs. 1.1 ± 1.1 ng/ml/h; p = 0.37). Change in PRA at 3 months from baseline was significantly greater for RDN compared with control subjects (-0.2 ± 1.0 ng/ml/h; p = 0.019 vs. 0.1 ± 0.9 ng/ml/h; p = 0.14), p = 0.001 for RDN versus control subjects, and similar differences were seen for aldosterone: RDN compared with control subjects (-1.2 ± 6.4 ng/dl; p = 0.04 vs. 0.4 ± 5.4 ng/dl; p = 0.40), p = 0.011. Treatment differences at 3 months in 24-h and office systolic blood pressure (SBP) for RDN versus control patients were significantly greater for patients with baseline PRA ≥0.65 ng/ml/h versus <0.65 ng/ml/h, despite similar baseline BP. Differences in office SBP changes according to baseline PRA were also observed earlier at 2 weeks post-RDN. CONCLUSIONS Plasma renin activity and aldosterone levels for RDN patients were significantly reduced at 3 months when compared with baseline as well as when compared with sham control. Higher baseline PRA levels were associated with a significantly greater reduction in office and 24-h SBP. (SPYRAL PIVOTAL - SPYRAL HTN-OFF MED Study; NCT02439749).
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Affiliation(s)
- Felix Mahfoud
- Klinik für Innere Medizin III, Universitätsklinikum des Saarlandes, Saarland University, Homburg/Saar, Germany.
| | - Raymond R Townsend
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - David E Kandzari
- Department of Interventional Cardiology, Piedmont Heart Institute, Atlanta, Georgia, USA
| | - Kazuomi Kario
- Department of Cardiovascular Medicine and Department of Sleep and Circadian Cardiology, Jichi Medical University School of Medicine, Tochigi, Japan
| | - Roland E Schmieder
- Department of Nephrology and Hypertension, Universitätsklinikum Erlangen, Erlangen, Germany
| | - Konstantinos Tsioufis
- Department of Cardiology, University of Athens, Hippocratio Hospital, Athens, Greece
| | - Stuart Pocock
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Shukri David
- Department of Cardiology, Providence Hospital, Southfield, Michigan, USA
| | - Kiritkumar Patel
- Department of Cardiology, Saint Joseph Mercy Oakland, Bloomfield Hills, Michigan, USA
| | - Anjani Rao
- Department of Cardiology, Saint Joseph Mercy Oakland, Bloomfield Hills, Michigan, USA
| | - Antony Walton
- Department of Cardiology, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Jason E Bloom
- Department of Cardiology, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Thomas Weber
- Department of Cardiology, Klinikum Wels-Grieskirchen, Wels, Austria
| | - Markus Suppan
- Department of Cardiology, Klinikum Wels-Grieskirchen, Wels, Austria
| | - Lucas Lauder
- Klinik für Innere Medizin III, Universitätsklinikum des Saarlandes, Saarland University, Homburg/Saar, Germany
| | - Sidney A Cohen
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Coronary and Renal Denervation Division, Medtronic PLC, Santa Rosa, California, USA
| | - Pamela McKenna
- Coronary and Renal Denervation Division, Medtronic PLC, Santa Rosa, California, USA
| | - Martin Fahy
- Coronary and Renal Denervation Division, Medtronic PLC, Santa Rosa, California, USA
| | - Michael Böhm
- Klinik für Innere Medizin III, Universitätsklinikum des Saarlandes, Saarland University, Homburg/Saar, Germany
| | - Michael A Weber
- Department of Medicine, SUNY Downstate College of Medicine, Brooklyn, New York, USA
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McNally RJ, Faconti L, Cecelja M, Farukh B, Floyd CN, Chowienczyk PJ. Effect of diuretics on plasma renin activity in primary hypertension: A systematic review and meta-analysis. Br J Clin Pharmacol 2021; 87:2189-2198. [PMID: 33085785 DOI: 10.1111/bcp.14597] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 07/14/2020] [Accepted: 09/30/2020] [Indexed: 11/27/2022] Open
Abstract
AIMS Plasma renin activity (PRA) is regarded as a marker of sodium and fluid homeostasis in patients with primary hypertension. Whether effects of diuretics on PRA differ according to class of diuretic, whether diuretics lead to a sustained increase in PRA, and whether changes in PRA relate to those in blood pressure (BP) is unknown. We performed a systematic review and meta-analysis of trials investigating the antihypertensive effects of diuretic therapy in which PRA and/or other biomarkers of fluid homeostasis were measured before and after treatment. METHODS Three databases were searched: MEDLINE, EMBASE and The Cochrane Central Register of Controlled Trials. Titles were firstly screened by title and abstract for relevancy before full-text articles were assessed for eligibility according to a predefined inclusion/exclusion criteria. RESULTS A total of 1684 articles were retrieved of which 61 met the prespecified inclusion/exclusion criteria. PRA was measured in 30/61 studies. Diuretics led to a sustained increase in PRA which was similar for different classes of diuretic (standardised mean difference [95% confidence interval] 0.481 [0.362, 0.601], 0.729 [0.181, 1.28], 0.541 [0.253, 0.830] and 0.548 [0.159, 0.937] for thiazide, loop, mineralocorticoid receptor antagonists/potassium-sparing and combination diuretics respectively, Q = 0.897, P = .826), and did not relate to the average decrease in blood pressure. CONCLUSION In antihypertensive drug trials, diuretics lead to a sustained increase in average PRA, which is similar across different classes of diuretic and unrelated to the average reduction in blood pressure.
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Affiliation(s)
- Ryan J McNally
- Department of Clinical Pharmacology, King's College London British Heart Foundation Centre, St. Thomas' Hospital, London, UK
| | - Luca Faconti
- Department of Clinical Pharmacology, King's College London British Heart Foundation Centre, St. Thomas' Hospital, London, UK
| | - Marina Cecelja
- Department of Clinical Pharmacology, King's College London British Heart Foundation Centre, St. Thomas' Hospital, London, UK
| | - Bushra Farukh
- Department of Clinical Pharmacology, King's College London British Heart Foundation Centre, St. Thomas' Hospital, London, UK
| | - Christopher N Floyd
- Department of Clinical Pharmacology, King's College London British Heart Foundation Centre, St. Thomas' Hospital, London, UK
| | - Philip J Chowienczyk
- Department of Clinical Pharmacology, King's College London British Heart Foundation Centre, St. Thomas' Hospital, London, UK
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14
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Fay KS, Cohen DL. Resistant Hypertension in People With CKD: A Review. Am J Kidney Dis 2021; 77:110-121. [DOI: 10.1053/j.ajkd.2020.04.017] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Accepted: 04/17/2020] [Indexed: 01/23/2023]
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15
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Mehanna M, Chen YE, Gong Y, Handberg E, Roth B, De Leon J, Smith SM, Harrell JG, Cooper-DeHoff RM. Optimizing Precision of Hypertension Care to Maximize Blood Pressure Control: A Pilot Study Utilizing a Smartphone App to Incorporate Plasma Renin Activity Testing. Clin Transl Sci 2020; 14:617-624. [PMID: 33142006 PMCID: PMC7993275 DOI: 10.1111/cts.12922] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 10/17/2020] [Indexed: 12/13/2022] Open
Abstract
Only half of patients with hypertension (HTN) respond to any given antihypertensive medication. Heterogeneity in pathophysiologic pathways underlying HTN is a major contributor. Personalizing antihypertensive therapy could improve blood pressure (BP) reduction. The objective of this study was to assess the effect of pragmatic implementation of a personalized plasma renin activity (PRA)‐based smartphone app on improving BP reduction. Patients with untreated or treated but uncontrolled HTN were recruited. BP and PRA were measured at baseline with final BP measured at 6 months. Patient’s information was entered into the app and treatment recommendations were returned. Clinicians were at liberty to follow or disregard the app’s recommendations. BP levels and percent BP control among patients whose clinicians did and did not follow the app’s recommendations were compared using independent t‐test and Fisher’s exact test, respectively. Twenty‐nine European American patients were included (38% women) with mean age of 52 ± 9 years and median PRA of 1.3 ng/mL/hr (interquartile range 0.5–3.1 ng/mL/hr). Participants whose clinicians followed the app’s recommendations (n = 16, 55%) as compared with those whose clinicians did not (n = 13, 45%), had a greater reduction in 6‐month systolic BP (−15 ± 21 vs. −3 ± 21 mm Hg; adjusted‐P = 0.1) and diastolic BP (−8 ± 8 vs. −1 ± 8 mm Hg; adjusted‐P = 0.04). BP control at 6 months tended to be greater among patients whose clinicians accepted the app’s recommendations vs. those whose clinicians did not (63% vs. 23%, P = 0.06). This pilot study demonstrates that acceptance of the app’s recommendations was associated with a greater BP reduction. Future studies to confirm these pilot findings are warranted.
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Affiliation(s)
- Mai Mehanna
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Yiqing E Chen
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Yan Gong
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Eileen Handberg
- Department of Medicine, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Brittney Roth
- Department of Health Outcomes & Biomedical Informatics, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Jessica De Leon
- Division of Research & Graduate Programs, College of Medicine, Florida State University, Tallahassee, Florida, USA
| | - Steven M Smith
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Jonathan G Harrell
- Department of Community Health & Family Medicine, University of Florida, Gainesville, Florida, USA
| | - Rhonda M Cooper-DeHoff
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics, College of Pharmacy, University of Florida, Gainesville, Florida, USA
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Siaki LA, Lin V, Marshall R, Highley R. Feasibility of a Clinical Decision Support Tool to Manage Resistant Hypertension: Team-HTN, a Single-arm Pilot Study. Mil Med 2020; 186:e225-e233. [PMID: 33007059 DOI: 10.1093/milmed/usaa255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 02/19/2020] [Accepted: 07/31/2020] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Based on defining criteria, hypertension (HTN) affects 31% to 46% of the adult U.S. population and almost 20% of service members. Resistant HTN (rHTN) consumes significant resources, carries substantial morbidity and mortality risk and costs over $350 billion dollars annually. For multiple reasons, only 48.3% of people with HTN are controlled, e.g., undiagnosed secondary HTN, therapeutic or diagnostic inertia, and patient adherence. Our purpose was to determine the feasibility of a web-based clinical decision support tool (CDST) using a renin-aldosterone system (RAS) classification matrix and drug sequencing algorithm to assist providers with the diagnosis and management of uncontrolled HTN (rHTN). Outcomes were blood pressure (BP) rates of control, provider management time, and end-user satisfaction. METHODS This two-phase, prospective, non-randomized, single-arm, six-month pilot study was conducted in primary care clinics at a tertiary military medical center. Patients with uncontrolled HTN and primary care providers were recruited. Phase 1 patients checked their BP twice daily (AM and PM), three times weekly using a standardized arm cuff. Patients with rHTN were enrolled in phase 2. Phase 2 patients were managed virtually by providers using the CDST, the RAS classification matrix, and the drug sequencing algorithm which incorporated age, ethnicity, comorbidities, and renin/aldosterone levels. Medications were adjusted every 10 days until BP was at target, using virtual visits. RESULTS In total, 54 patients and 16 providers were consented. One transplant patient was disqualified, 29 met phase 2 criteria for rHTN, and 6 providers completed the study. In phase 1, 45% (n = 24) of patients were identified as having apparent uncontrolled HTN using peak diurnal blood pressure (pdBP) home readings. In phase 2 (n = 29), previously undetected RAS abnormalities were identified in 69% (n = 20) of patients. Blood pressure control rates improved from 0% to 23%, 47%, and 58% at 2, 4, and 6 months, respectively. Provider management time was reduced by 17%. Using home pdBP readings identified masked HTN in almost 20% of patients that would have been missed by a single daily AM or PM home BP measurement. Feasibility and satisfaction trends were favorable. CONCLUSIONS Despite significant morbidity, mortality, and existing guidelines, over half of hypertensive patients are uncontrolled. Our results suggest that this CDST used with pdBP monitoring is a feasible option to facilitate improved rates of control in rHTN, aid in overcoming therapeutic/diagnostic inertia, improve identification of secondary HTN, and potentially, access. Further research with this tool in a larger population is recommended.
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Affiliation(s)
- Leilani A Siaki
- Madigan Army Medical Center, 9040 Jackson Ave. Tacoma, WA 98431,
| | - Victor Lin
- Naval Medical Forces Pacific, 4170 Norman Scott Rd Suite 5, San Diego, CA 92136,
| | - Robert Marshall
- Madigan Army Medical Center, 9040 Jackson Ave. Tacoma, WA 98431,
| | - Robert Highley
- Analytics4Medicine (A4M), 11827 26 Ave SW, Burien, WA 98146, USA
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Zhang Y, Yang H, Wang R, Zhao F, Liu T, Zhang Y, Guo Z, Cong H. An Analysis of Medication Prescriptions for Hypertension in Urban and Rural Residents in Tianjin. Adv Ther 2020; 37:4414-4426. [PMID: 32857316 DOI: 10.1007/s12325-020-01475-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Indexed: 12/20/2022]
Abstract
INTRODUCTION This study aims to examine the medication prescriptions for hypertension in Tianjin. METHODS Patients with hypertension in Tianjin were enrolled in this study. The patients' ages ranged from 35 to 75 years. A questionnaire survey and physical examination were completed to collect clinical data. Thereafter, a statistical analysis of the medication prescriptions was conducted with different age groups and different grades of hypertension. RESULTS The results show that, in the total population, and for the young, middle-aged, and older groups, the proportions of single-drug use were 62.97%, 59.26%, 62.76%, and 63.49%, respectively, and the highest rate was for calcium channel blocker (CCB) use. The rates of the two drug classes were 24.51%, 29.63%, 25.13%, and 23.15%, respectively. The drug use rate of CCBs combined with angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor antagonists (ARBs) was the highest. The rates of the three drug classes were 4.08%, 4.94%, 4.36%, and 3.52%, respectively, and the highest was ACEI/ARB and CCB combined with diuretics. The rates of the four drug classes were low. Regarding the hypertension grade, in grade 1, grade 2, and grade 3, the rates of single-drug use were 63.53%, 62.69%, and 58.38%, respectively. The rates of the two drug classes were 24.62%, 23.97%, and 25.05%, while the rates of the three drug classes were 3.86%, 4.39%, and 5.34%, respectively. CONCLUSION The rate of single-drug use was high, and the rate of combined drug use in the youth group was slightly higher than in the middle-aged and older age groups. The combination of two drugs was common. In grades 2 and 3 hypertension, the rate of combined drug use remained low.
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18
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Mulerova T, Uchasova E, Ogarkov M, Barbarash O. Genetic forms and pathophysiology of essential arterial hypertension in minor indigenous peoples of Russia. BMC Cardiovasc Disord 2020; 20:169. [PMID: 32293282 PMCID: PMC7158150 DOI: 10.1186/s12872-020-01464-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 04/02/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To study the genetic forms and pathophysiology of arterial hypertension by evaluating plasma renin activity in the Shors, minor indigenous peoples inhabiting the south of Western Siberia. METHODS A single-stage study of indigenous (the Shors) and non-indigenous peoples living in the villages of Gornaya Shoria of the Kemerovo region in the south of Western Siberia was conducted in the period from 2013 to 2017. One thousand four hundred nine adults (901 Shors and 508 non-indigenous inhabitants) were recruited in the study using a continuous sampling plan. Arterial blood pressure was measured according to 2018 ESC/ESH guidelines for the management of arterial hypertension. All the respondents underwent clinical and instrumental examination. Plasma renin activity was determined by enzyme-linked immunoassay with the BRG kits (Germany). Polymorphisms of ACE (I/D, rs 4340), АGT (c.803 T > C, rs699), AGTR1 (А1166С, rs5186), ADRB1 (с.145A > G, Ser49Gly, rs1801252) and ADRA2B (I/D, rs 28,365,031) genes were tested using polymerase chain reaction. RESULTS Renin-dependent hypertensive patients prevailed in both ethnic groups (65.6% in the indigenous group vs. 89.8% in the non-indigenous group, p = 0.001). Prevalence of a volume-dependent AH was low in both groups (34.4% in the indigenous group vs. 10.2% in the non-indigenous group, р = 0.001). The D/D and Т/Т genotypes of the АСЕ [OR = 6.97; 95% CI (1.07-55.58)] and AGT [OR = 3.53; 95% CI (1.02-12.91)] genes were associated with the renin-dependent AH in the Shors. The C/C genotype of AGTR1 gene was found to predispose to the volume-dependent AH [OR = 5.25; 95% CI (1.03-27.89)]. The C/C genotype of AGTR1 gene was associated with moderate or high renin levels suggesting essential AH in the non-indigenous group [OR = 5.00; 95% CI (1.21-22.30), р = 0.029]. CONCLUSION An in-depth understanding of AH pathophysiology and its genetic forms ensures the optimal choice of blood pressure-lowering treatment and optimizes AH control.
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Affiliation(s)
- Tatyana Mulerova
- Federal State Budgetary Institution “Research Institute for Complex Issues of Cardiovascular Diseases”, 6, Sosnoviy Blvd, 650002 Kemerovo, Russia
| | - Evgenya Uchasova
- Federal State Budgetary Institution “Research Institute for Complex Issues of Cardiovascular Diseases”, 6, Sosnoviy Blvd, 650002 Kemerovo, Russia
| | - Michael Ogarkov
- Federal State Budgetary Institution “Research Institute for Complex Issues of Cardiovascular Diseases”, 6, Sosnoviy Blvd, 650002 Kemerovo, Russia
| | - Olga Barbarash
- Federal State Budgetary Institution “Research Institute for Complex Issues of Cardiovascular Diseases”, 6, Sosnoviy Blvd, 650002 Kemerovo, Russia
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Hannah-Shmouni F, Gubbi S, Spence JD, Stratakis CA, Koch CA. Resistant Hypertension: A Clinical Perspective. Endocrinol Metab Clin North Am 2019; 48:811-828. [PMID: 31655778 DOI: 10.1016/j.ecl.2019.08.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Resistant hypertension is a common clinical entity, defined as suboptimal blood pressure response to multiple therapies after excluding medication nonadherence and secondary forms of hypertension. Patients with resistant hypertension generally share several comorbidities. Resistant hypertension is more common in individuals of African descent. Blood pressure should be optimized using multiple strategies, including lifestyle changes and single-pill combination therapies, with the aim of reducing cardiovascular events while reducing side effects from using antihypertensive therapy. A renin/aldosterone-based diagnostic and treatment approach will help tailor therapy. The use of mineralocorticoid receptor antagonists or amiloride as appropriate is favored.
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Affiliation(s)
- Fady Hannah-Shmouni
- Internal Medicine-Endocrinology, Hypertension and Metabolic Genetics, Section on Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, 10 Center Drive, MSC 1109, Bethesda, MD 20892, USA.
| | - Sriram Gubbi
- Diabetes, Endocrinology, and Obesity Branch, National Institute of Diabetes and Digestive and Kidney diseases, National Institutes of Health, 10 Center Drive, Bethesda, MD 20892, USA
| | - J David Spence
- Stroke Prevention and Atherosclerosis Research Centre, Robarts Research Institute, Western University, 1400 Western Road, London, ON N6G 2V4, Canada
| | - Constantine A Stratakis
- Internal Medicine-Endocrinology, Hypertension and Metabolic Genetics, Section on Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, 10 Center Drive, MSC 1109, Bethesda, MD 20892, USA
| | - Christian A Koch
- The University of Tennessee Health Science Center, 910 Madison Avenue, Memphis, TN 38163, USA
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Interpreting stimulated plasma renin and aldosterone to select physiologically individualized therapy for resistant hypertension: importance of the class of stimulating drugs. Hypertens Res 2019; 42:1971-1978. [DOI: 10.1038/s41440-019-0327-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Revised: 07/28/2019] [Accepted: 08/07/2019] [Indexed: 11/08/2022]
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Abstract
PURPOSE OF REVIEW To discuss the current definition as well as recommendations for diagnosis and treatment of resistant hypertension (RH) based on the 2018 American Heart Association (AHA) guidelines and recent literature. RECENT FINDINGS RH is defined as uncontrolled blood pressure (BP) on ≥ 3 anti-hypertensives, one of which should be a diuretic, prescribed at maximally tolerated doses and appropriate dosing frequency. The diagnosis of RH requires exclusion of white coat effect and medication non-adherence, underscoring the importance of out-of-office BP measurements. Secondary causes of hypertension must be excluded in all patients with RH. A step-wise approach to treatment focusing on lifestyle modifications and medication optimization can be effective in > 50% of the patients with RH. Device-based interventional therapies for RH are currently investigational. Out-of-office BP measurements are central to the diagnosis of RH. Medication optimization is successful in most patients. Further studies are needed to define the role of device-based interventions.
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Affiliation(s)
- Irene Chernova
- Yale School of Medicine/Section of Nephrology, New Haven, CT, USA
| | - Namrata Krishnan
- Yale School of Medicine/Section of Nephrology, New Haven, CT, USA. .,Veterans Affairs Medical Center, 950 Campbell Ave., West Haven, CT, 06516, USA.
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Mehanna M, Wang Z, Gong Y, McDonough CW, Beitelshees AL, Gums JG, Chapman AB, Schwartz GL, Bailey KR, Johnson JA, Turner ST, Cooper-DeHoff RM. Plasma Renin Activity Is a Predictive Biomarker of Blood Pressure Response in European but not in African Americans With Uncomplicated Hypertension. Am J Hypertens 2019; 32:668-675. [PMID: 30753254 PMCID: PMC6558666 DOI: 10.1093/ajh/hpz022] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 01/04/2019] [Accepted: 02/06/2019] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Interindividual variability in blood pressure (BP) response to antihypertensives has been reported. Although plasma renin activity (PRA) is a potential biomarker for personalizing antihypertensive therapy in European American (EA) and African American (AA) hypertensives, clinical utility of PRA-guided prescribing is incompletely understood. METHODS Using systematic-phased approach, PRA's clinical utility was assessed. After categorizing by baseline PRA, clinic systolic BP (SBP) responses to metoprolol and chlorthalidone were compared in 134 EAs and 102 AAs enrolled in the Pharmacogenomics Evaluation of Antihypertensive Responses-2 (PEAR-2) trial. Receiver operating characteristic (ROC) analysis was conducted in EAs. Data from PEAR-2 AAs were used to estimate an optimal PRA cut point using multivariable linear regression models. The derived cut point in AAs was tested in a meta-analysis of 2 independent AA cohorts, and its sensitivity and specificity were assessed. RESULTS EAs with PRA < 0.65 ng/ml/hour had a greater decrease in SBP to chlorthalidone than metoprolol (by -15.9 mm Hg, adjusted P < 0.0001), whereas those with PRA ≥ 0.65 ng/ml/hour had a greater decrease in SBP to metoprolol than chlorthalidone (by 3.3 mm Hg, adjusted P = 0.04). Area under ROC curve (0.69, P = 0.0001) showed that PRA can predict SBP response among EAs. However, we observed no association between PRA and SBP response in PEAR-2 AAs. Among independent AA cohorts, those with PRA ≥ 1.3 ng/ml/hour (PEAR-2-derived cut point) responded better to atenolol/candesartan than hydrochlorothiazide (meta-analysis P = 0.01). However, sensitivity of the derived cut point was 10%. CONCLUSIONS PRA at the previously established 0.60-0.65 ng/ml/hour cut point is an effective predictive biomarker of BP response in EAs. However, we were unable to identify PRA cut point that could be used to guide antihypertensive selection in AAs. TRIAL REGISTRATION NCT01203852, NCT00246519, NCT00005520.
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Affiliation(s)
- Mai Mehanna
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Zhiying Wang
- Human Genetics and Institute of Molecular Medicine, University of Texas Health Science Center, Houston, Texas, USA
| | - Yan Gong
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Caitrin W McDonough
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | | | - John G Gums
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Arlene B Chapman
- Department of Medicine, University of Chicago, Chicago, Illinois, USA
| | - Gary L Schwartz
- Department of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Kent R Bailey
- Department of Statistics, Mayo Clinic, Rochester, Minnesota, USA
| | - Julie A Johnson
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Stephen T Turner
- Department of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Rhonda M Cooper-DeHoff
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics, College of Pharmacy, University of Florida, Gainesville, Florida, USA
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Spence JD, Rayner BL. Hypertension in Blacks: Individualized Therapy Based on Renin/Aldosterone Phenotyping. Hypertension 2018; 72:263-269. [PMID: 29941519 DOI: 10.1161/hypertensionaha.118.11064] [Citation(s) in RCA: 75] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- J David Spence
- From the Stroke Prevention and Atherosclerosis Research Centre, Robarts Research Institute, Western University, London, Canada (J.D.S.)
| | - Brian L Rayner
- Division of Nephrology, University of Cape Town, Groote Schuur Hospital, South Africa (B.L.R.)
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Plasma renin activity to plasma aldosterone concentration ratio correlates with night-time and pulse pressures in essential hypertensive patients treated with angiotensin-converting enzyme inhibitors/AT1 blockers. J Hypertens 2018; 35:2315-2322. [PMID: 28614094 DOI: 10.1097/hjh.0000000000001438] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
OBJECTIVES Angiotensin-converting enzyme inhibitors (ACE-I) and AT1 blockers (ARB) are commonly used antihypertensive drugs, but several factors may affect their effectiveness. We evaluated the associations between ambulatory blood pressure (BP) monitoring (ABPM) parameters and plasma renin activity (PRA)-to-plasma aldosterone concentration (PAC) ratio (RAR) to test renin-angiotensin-aldosterone system inhibition in essential hypertensive patients treated with ACE-I or ARB for at least 12 months. METHODS We evaluated 194 consecutive patients referred to our Hypertension Centre. ABPM, PRA and PAC tests were performed without any changes in drug therapy. RAR, PRA and PAC tertiles were considered for the analyses. RESULTS Mean age: 57.4 ± 12.0 years; male prevalence: 63.9%. No differences between RAR tertiles regarding the use of ACE-I or ARB (P = 0.385), as well as the other antihypertensive drug classes, were found. A reduction of all ABPM values considered (24-h BP, daytime BP and night-time BP and 24-h pulse pressure (PP), daytime PP and night-time PP) and a better BP control were observed at increasing RAR tertiles, with an odds ratio = 0.12 to be not controlled during night-time period for patients in the third tertile compared with patients in the first tertile (P < 0.001). This association remained significant even after adjusting for 24-h BP control. All the associations were also confirmed for PRA tertiles, but not for PAC tertiles. CONCLUSION Higher RAR values indicate effective renin-angiotensin-aldosterone system inhibition and lower night-time and pulse pressures in real-life clinical practice. It could be a useful biomarker in the management of essential hypertensive patients treated with ACE-I or ARB.
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Spence JD. Controlling resistant hypertension. Stroke Vasc Neurol 2018; 3:69-75. [PMID: 30022799 PMCID: PMC6047342 DOI: 10.1136/svn-2017-000138] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Revised: 02/05/2018] [Accepted: 02/06/2018] [Indexed: 12/13/2022] Open
Abstract
Resistant hypertension (failure to achieve target blood pressures with three or more antihypertensive drugs including a diuretic) is an important and preventable cause of stroke. Hypertension is highly prevalent in China (>60% of persons above age 65), and only ~6% of hypertensives in China are controlled to target levels. Most strokes occur among persons with resistant hypertension; approximately half of strokes could be prevented by blood pressure control. Reasons for uncontrolled hypertension include (1) non-compliance; (2) consumption of substances that aggravated hypertension, such as excess salt, alcohol, licorice, decongestants and oral contraceptives; (3) therapeutic inertia (failure to intensify therapy when target blood pressures are not achieved); and (4) diagnostic inertia (failure to investigate the cause of resistant hypertension). In China, an additional factor is lack of availability of appropriate antihypertensive therapy in many healthcare settings. Sodium restriction in combination with a diet similar to the Cretan Mediterranean or the DASH (Dietary Approaches to Stop Hypertension) diet can lower blood pressure in proportion to the severity of hypertension. Physiologically individualised therapy for hypertension based on phenotyping by plasma renin activity and aldosterone can markedly improve blood pressure control. Renal hypertension (high renin/high aldosterone) is best treated with angiotensin receptor antagonists; primary aldosteronism (low renin/high aldosterone) is best treated with aldosterone antagonists (spironolactone or eplerenone); and hypertension due to overactivity of the renal epithelial sodium channel (low renin/low aldosterone; Liddle phenotype) is best treated with amiloride. The latter is far more common than most physicians suppose.
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Affiliation(s)
- J David Spence
- Stroke Prevention & Atherosclerosis Research Centre, Robarts Research Institute, Western University, London, Ontario, Canada
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Affiliation(s)
- Sandra J Taler
- From the Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
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27
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Affiliation(s)
- Omar Al Dhabyi
- Department of Medicine, ASH Comprehensive Hypertension Center, University of Chicago Medicine, Chicago, IL
| | - George L Bakris
- Department of Medicine, ASH Comprehensive Hypertension Center, University of Chicago Medicine, Chicago, IL
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Personalized medicine-a modern approach for the diagnosis and management of hypertension. Clin Sci (Lond) 2017; 131:2671-2685. [PMID: 29109301 PMCID: PMC5736921 DOI: 10.1042/cs20160407] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2017] [Revised: 09/22/2017] [Accepted: 09/25/2017] [Indexed: 12/15/2022]
Abstract
The main goal of treating hypertension is to reduce blood pressure to physiological levels and thereby prevent risk of cardiovascular disease and hypertension-associated target organ damage. Despite reductions in major risk factors and the availability of a plethora of effective antihypertensive drugs, the control of blood pressure to target values is still poor due to multiple factors including apparent drug resistance and lack of adherence. An explanation for this problem is related to the current reductionist and ‘trial-and-error’ approach in the management of hypertension, as we may oversimplify the complex nature of the disease and not pay enough attention to the heterogeneity of the pathophysiology and clinical presentation of the disorder. Taking into account specific risk factors, genetic phenotype, pharmacokinetic characteristics, and other particular features unique to each patient, would allow a personalized approach to managing the disease. Personalized medicine therefore represents the tailoring of medical approach and treatment to the individual characteristics of each patient and is expected to become the paradigm of future healthcare. The advancement of systems biology research and the rapid development of high-throughput technologies, as well as the characterization of different –omics, have contributed to a shift in modern biological and medical research from traditional hypothesis-driven designs toward data-driven studies and have facilitated the evolution of personalized or precision medicine for chronic diseases such as hypertension.
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Akintunde A, Nondi J, Gogo K, Jones ESW, Rayner BL, Hackam DG, Spence JD. Physiological Phenotyping for Personalized Therapy of Uncontrolled Hypertension in Africa. Am J Hypertens 2017; 30:923-930. [PMID: 28472315 DOI: 10.1093/ajh/hpx066] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Accepted: 04/12/2017] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES African and African American hypertensives tend to retain salt and water, with lower levels of plasma renin and more resistant hypertension. We tested the hypothesis that physiological phenotyping with plasma renin and aldosterone would improve blood pressure control in uncontrolled hypertensives in Africa. METHODS Patients at hypertension clinics in Nigeria, Kenya, and South Africa with a systolic blood pressure >140 mm Hg or diastolic pressure > 90 mm Hg despite treatment were allocated to usual care (UC) vs. physiologically individualized care (PhysRx). Plasma renin activity and aldosterone were measured using ELISA kits. Patients were followed for 1 year; the primary outcome was the percentage of patients achieving blood pressure <140 mm Hg and diastolic <90 mm Hg. RESULTS Results are presented for the 94/105 participants who completed the study (42 UC, 52 PhysRx). Control of both systolic and diastolic pressures was obtained in 11.1% of UC vs. 50.0% of PhysRx (P = 0.0001). Systolic control was achieved in 13.9% of UC vs. 60.3% of PhysRx (P = 0.0001); diastolic control in 36.1% of UC vs. 67.2% of PhysRx, vs. (P = 0.003). Number of visits and total number of medications were not significantly different between treatment groups, but there were differences across the sites. There were important differences in prescription of amiloride as specified in the PhysRx algorithm. CONCLUSIONS Physiologically individualized therapy based on renin/aldosterone phenotyping significantly improved blood pressure control in a sample of African patients with uncontrolled hypertension. This approach should be tested in African American and other patients with resistant hypertension. Registered as ISRCTN69440037.
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Affiliation(s)
- Adeseye Akintunde
- Ladoke Akintola University of Technology Teaching Hospital, Ogbomoso, Oyo State, Nigeria
| | - Justus Nondi
- Department of Medicine, Egerton University, Nakuru, Kenya
| | - Kennedy Gogo
- Department of Medicine, Egerton University, Nakuru, Kenya
| | - Erika S W Jones
- Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Brian L Rayner
- Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Daniel G Hackam
- Departments of Medicine and Biostatistics and Epidemiology, Western University, London, ON, Canada
- Department of Neurology and Clinical Pharmacology, Stroke Prevention and Atherosclerosis Research Centre, Robarts Research Institute, Western University, London, ON, Canada
| | - J David Spence
- Department of Neurology and Clinical Pharmacology, Stroke Prevention and Atherosclerosis Research Centre, Robarts Research Institute, Western University, London, ON, Canada
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Furberg CD, Sealey JE, Blumenfeld JD. Unsuccessfully Treated Hypertension: A Major Public Health Problem With a Potential Solution. Am J Hypertens 2017; 30:857-860. [PMID: 28482060 DOI: 10.1093/ajh/hpx068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Accepted: 04/13/2017] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND About one-half of all hypertensive adults do not have their blood pressure controlled. They are often prescribed medications that conform to national guidelines but they continue to have elevated blood pressure. This public health problem might be improved by applying plasma renin guided therapy. RESULTS A contributor to the public health problem of unsuccessfully treated hypertension is that the circulating renin-angiotensin system (RAS) is not recognized in treatment guidelines as clinically relevant for the treatment of hypertension or as important as the body salt status for determining blood pressure levels. Another contributor to the problem is the lack of specificity in the package inserts for antihypertensive drugs. They do not specifically state under the heading "Indications" that RAS blockers are primarily most effective in hypertensive subjects with medium and high plasma renin levels; by contrast, natriuretic drugs are most effective in those with low plasma renin levels. METHODS Literature review. CONCLUSIONS To address the problem of unsuccessfully treated hypertension, we recommend that the "Indications" section of package inserts for antihypertensive drugs be more specific. The primary indication for RAS blockers ought to be hypertension with medium and high plasma renin levels, and natriuretic agents for those with low plasma renin levels. Similar language ought to be added to treatment guidelines. Additionally, 3 other reasons for lack of blood pressure control also need to be addressed-failure to prescribe antihypertensive drugs to hypertensive subjects, failure of patients to fill prescriptions, and low drug adherence.
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Affiliation(s)
- Curt D Furberg
- Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Jean E Sealey
- Department of Medicine, Weill Cornell Medical College, New York, New York, USA
| | - Jon D Blumenfeld
- Department of Medicine, Weill Cornell Medical College, New York, New York, USA
- The Rogosin Institute, New York, New York, USA
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Spence JD. Rational Medical Therapy Is the Key to Effective Cardiovascular Disease Prevention. Can J Cardiol 2017; 33:626-634. [DOI: 10.1016/j.cjca.2017.01.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2016] [Revised: 12/26/2016] [Accepted: 01/08/2017] [Indexed: 12/14/2022] Open
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Ghazi L, Drawz P. Advances in understanding the renin-angiotensin-aldosterone system (RAAS) in blood pressure control and recent pivotal trials of RAAS blockade in heart failure and diabetic nephropathy. F1000Res 2017; 6. [PMID: 28413612 PMCID: PMC5365219 DOI: 10.12688/f1000research.9692.1] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/13/2017] [Indexed: 12/11/2022] Open
Abstract
The renin-angiotensin-aldosterone system (RAAS) plays a fundamental role in the physiology of blood pressure control and the pathophysiology of hypertension (HTN) with effects on vascular tone, sodium retention, oxidative stress, fibrosis, sympathetic tone, and inflammation. Fortunately, RAAS blocking agents have been available to treat HTN since the 1970s and newer medications are being developed. In this review, we will (1) examine new anti-hypertensive medications affecting the RAAS, (2) evaluate recent studies that help provide a better understanding of which patients may be more likely to benefit from RAAS blockade, and (3) review three recent pivotal randomized trials that involve newer RAAS blocking agents and inform clinical practice.
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Affiliation(s)
- Lama Ghazi
- Division of Renal Disease and Hypertension, Department of Medicine, University of Minnesota, Minnesota, MN, USA
| | - Paul Drawz
- Division of Renal Disease and Hypertension, Department of Medicine, University of Minnesota, Minnesota, MN, USA
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Miller-Hodges E, Dominiczak AF, Jennings GLR, Oparil S, Batlle DC, Elijovich F, Basile JN, Laffer CL, Oliveras A, Dhaun N. Hypertension and Its Complications in a Young Man With Autoimmune Disease. Hypertension 2017; 69:536-544. [PMID: 28242716 DOI: 10.1161/hypertensionaha.117.09036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Eve Miller-Hodges
- From the University/British Heart Foundation Centre of Research Excellence, University of Edinburgh, United Kingdom (E.M.-H., N.D.); Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, United Kingdom (A.F.D.); Baker IDI Heart and Diabetes Institute, Melbourne, Australia (G.L.R.J.); Department of Medicine, Division of Cardiovascular Disease, University of Alabama at Birmingham (S.O.); Division of Nephrology and Hypertension, Northwestern University Feinberg School of Medicine, Chicago, IL (D.C.B.); Division of Clinical Pharmacology, Department of Medicine (F.E.) and Department of Medicine (C.L.L.), Vanderbilt University School of Medicine, Nashville, TN; Medical University of South Carolina, Charleston (J.N.B.); and Hypertension Unit, Nephrology Department, Hospital Universitari del Mar, Barcelona, Spain (A.O.)
| | - Anna F Dominiczak
- From the University/British Heart Foundation Centre of Research Excellence, University of Edinburgh, United Kingdom (E.M.-H., N.D.); Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, United Kingdom (A.F.D.); Baker IDI Heart and Diabetes Institute, Melbourne, Australia (G.L.R.J.); Department of Medicine, Division of Cardiovascular Disease, University of Alabama at Birmingham (S.O.); Division of Nephrology and Hypertension, Northwestern University Feinberg School of Medicine, Chicago, IL (D.C.B.); Division of Clinical Pharmacology, Department of Medicine (F.E.) and Department of Medicine (C.L.L.), Vanderbilt University School of Medicine, Nashville, TN; Medical University of South Carolina, Charleston (J.N.B.); and Hypertension Unit, Nephrology Department, Hospital Universitari del Mar, Barcelona, Spain (A.O.)
| | - Garry L R Jennings
- From the University/British Heart Foundation Centre of Research Excellence, University of Edinburgh, United Kingdom (E.M.-H., N.D.); Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, United Kingdom (A.F.D.); Baker IDI Heart and Diabetes Institute, Melbourne, Australia (G.L.R.J.); Department of Medicine, Division of Cardiovascular Disease, University of Alabama at Birmingham (S.O.); Division of Nephrology and Hypertension, Northwestern University Feinberg School of Medicine, Chicago, IL (D.C.B.); Division of Clinical Pharmacology, Department of Medicine (F.E.) and Department of Medicine (C.L.L.), Vanderbilt University School of Medicine, Nashville, TN; Medical University of South Carolina, Charleston (J.N.B.); and Hypertension Unit, Nephrology Department, Hospital Universitari del Mar, Barcelona, Spain (A.O.)
| | - Suzanne Oparil
- From the University/British Heart Foundation Centre of Research Excellence, University of Edinburgh, United Kingdom (E.M.-H., N.D.); Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, United Kingdom (A.F.D.); Baker IDI Heart and Diabetes Institute, Melbourne, Australia (G.L.R.J.); Department of Medicine, Division of Cardiovascular Disease, University of Alabama at Birmingham (S.O.); Division of Nephrology and Hypertension, Northwestern University Feinberg School of Medicine, Chicago, IL (D.C.B.); Division of Clinical Pharmacology, Department of Medicine (F.E.) and Department of Medicine (C.L.L.), Vanderbilt University School of Medicine, Nashville, TN; Medical University of South Carolina, Charleston (J.N.B.); and Hypertension Unit, Nephrology Department, Hospital Universitari del Mar, Barcelona, Spain (A.O.)
| | - Daniel C Batlle
- From the University/British Heart Foundation Centre of Research Excellence, University of Edinburgh, United Kingdom (E.M.-H., N.D.); Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, United Kingdom (A.F.D.); Baker IDI Heart and Diabetes Institute, Melbourne, Australia (G.L.R.J.); Department of Medicine, Division of Cardiovascular Disease, University of Alabama at Birmingham (S.O.); Division of Nephrology and Hypertension, Northwestern University Feinberg School of Medicine, Chicago, IL (D.C.B.); Division of Clinical Pharmacology, Department of Medicine (F.E.) and Department of Medicine (C.L.L.), Vanderbilt University School of Medicine, Nashville, TN; Medical University of South Carolina, Charleston (J.N.B.); and Hypertension Unit, Nephrology Department, Hospital Universitari del Mar, Barcelona, Spain (A.O.)
| | - Fernando Elijovich
- From the University/British Heart Foundation Centre of Research Excellence, University of Edinburgh, United Kingdom (E.M.-H., N.D.); Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, United Kingdom (A.F.D.); Baker IDI Heart and Diabetes Institute, Melbourne, Australia (G.L.R.J.); Department of Medicine, Division of Cardiovascular Disease, University of Alabama at Birmingham (S.O.); Division of Nephrology and Hypertension, Northwestern University Feinberg School of Medicine, Chicago, IL (D.C.B.); Division of Clinical Pharmacology, Department of Medicine (F.E.) and Department of Medicine (C.L.L.), Vanderbilt University School of Medicine, Nashville, TN; Medical University of South Carolina, Charleston (J.N.B.); and Hypertension Unit, Nephrology Department, Hospital Universitari del Mar, Barcelona, Spain (A.O.)
| | - Jan N Basile
- From the University/British Heart Foundation Centre of Research Excellence, University of Edinburgh, United Kingdom (E.M.-H., N.D.); Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, United Kingdom (A.F.D.); Baker IDI Heart and Diabetes Institute, Melbourne, Australia (G.L.R.J.); Department of Medicine, Division of Cardiovascular Disease, University of Alabama at Birmingham (S.O.); Division of Nephrology and Hypertension, Northwestern University Feinberg School of Medicine, Chicago, IL (D.C.B.); Division of Clinical Pharmacology, Department of Medicine (F.E.) and Department of Medicine (C.L.L.), Vanderbilt University School of Medicine, Nashville, TN; Medical University of South Carolina, Charleston (J.N.B.); and Hypertension Unit, Nephrology Department, Hospital Universitari del Mar, Barcelona, Spain (A.O.)
| | - Cheryl L Laffer
- From the University/British Heart Foundation Centre of Research Excellence, University of Edinburgh, United Kingdom (E.M.-H., N.D.); Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, United Kingdom (A.F.D.); Baker IDI Heart and Diabetes Institute, Melbourne, Australia (G.L.R.J.); Department of Medicine, Division of Cardiovascular Disease, University of Alabama at Birmingham (S.O.); Division of Nephrology and Hypertension, Northwestern University Feinberg School of Medicine, Chicago, IL (D.C.B.); Division of Clinical Pharmacology, Department of Medicine (F.E.) and Department of Medicine (C.L.L.), Vanderbilt University School of Medicine, Nashville, TN; Medical University of South Carolina, Charleston (J.N.B.); and Hypertension Unit, Nephrology Department, Hospital Universitari del Mar, Barcelona, Spain (A.O.)
| | - Anna Oliveras
- From the University/British Heart Foundation Centre of Research Excellence, University of Edinburgh, United Kingdom (E.M.-H., N.D.); Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, United Kingdom (A.F.D.); Baker IDI Heart and Diabetes Institute, Melbourne, Australia (G.L.R.J.); Department of Medicine, Division of Cardiovascular Disease, University of Alabama at Birmingham (S.O.); Division of Nephrology and Hypertension, Northwestern University Feinberg School of Medicine, Chicago, IL (D.C.B.); Division of Clinical Pharmacology, Department of Medicine (F.E.) and Department of Medicine (C.L.L.), Vanderbilt University School of Medicine, Nashville, TN; Medical University of South Carolina, Charleston (J.N.B.); and Hypertension Unit, Nephrology Department, Hospital Universitari del Mar, Barcelona, Spain (A.O.)
| | - Neeraj Dhaun
- From the University/British Heart Foundation Centre of Research Excellence, University of Edinburgh, United Kingdom (E.M.-H., N.D.); Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, United Kingdom (A.F.D.); Baker IDI Heart and Diabetes Institute, Melbourne, Australia (G.L.R.J.); Department of Medicine, Division of Cardiovascular Disease, University of Alabama at Birmingham (S.O.); Division of Nephrology and Hypertension, Northwestern University Feinberg School of Medicine, Chicago, IL (D.C.B.); Division of Clinical Pharmacology, Department of Medicine (F.E.) and Department of Medicine (C.L.L.), Vanderbilt University School of Medicine, Nashville, TN; Medical University of South Carolina, Charleston (J.N.B.); and Hypertension Unit, Nephrology Department, Hospital Universitari del Mar, Barcelona, Spain (A.O.).
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Abstract
Loop diuretics are not recommended in current hypertension guidelines largely due to the lack of outcome data. Nevertheless, they have been shown to lower blood pressure and to offer potential advantages over thiazide-type diuretics. Torsemide offers advantages of longer duration of action and once daily dosing (vs. furosemide and bumetanide) and more reliable bioavailability (vs. furosemide). Studies show that the previously employed high doses of thiazide-type diuretics lower BP more than furosemide. Loop diuretics appear to have a preferable side effect profile (less hyponatremia, hypokalemia, and possibly less glucose intolerance). Studies comparing efficacy and side effect profiles of loop diuretics with the lower, currently widely prescribed, thiazide doses are needed. Research is needed to fill gaps in knowledge and common misconceptions about loop diuretic use in hypertension and to determine their rightful place in the antihypertensive arsenal.
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Affiliation(s)
- Line Malha
- Department of Nephrology and Hypertension, Hypertension Center, NY Presbyterian Hospital-Weill Cornell Medicine, 424 E. 70th Street, New York, NY, 10021, USA
| | - Samuel J Mann
- Department of Nephrology and Hypertension, Hypertension Center, NY Presbyterian Hospital-Weill Cornell Medicine, 424 E. 70th Street, New York, NY, 10021, USA.
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Egan BM, Kai B, Wagner CS, Henderson JH, Chandler AH, Sinopoli A. Blood Pressure Control Provides Less Cardiovascular Protection in Adults With Than Without Apparent Treatment-Resistant Hypertension. J Clin Hypertens (Greenwich) 2016; 18:817-24. [PMID: 26856795 PMCID: PMC5837039 DOI: 10.1111/jch.12773] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2015] [Revised: 11/23/2015] [Accepted: 11/23/2015] [Indexed: 01/13/2023]
Abstract
Hypertension control may offer less protection from incident cardiovascular disease (CVDi ) in adults with than without apparent treatment-resistant hypertension (aTRH), ie, blood pressure uncontrolled while taking three or more antihypertensive medications or controlled to <140/<90 mm Hg while taking four or more antihypertensive medications. Electronic health data were matched to health claims for 2006-2012. Patients with CVDi in 2006-2007 or with untreated hypertension were excluded, leaving 118,356 treated hypertensives, including 40,690 with aTRH, and 460,599 observation years. Blood pressure and medication number were determined by all clinic visit means from 2008 to CVDi or end of study. Primary outcome was first CVDi (stroke, coronary heart disease, heart failure) from hospital and emergency department claims. Controlling for age, race, sex, diabetes, chronic kidney disease, and statin use, hypertension control afforded less CVDi protection in patients with aTRH (hazard ratio, 0.87; 95% confidence interval, 0.82-0.93) than without aTRH (hazard ratio, 0.69; 95% confidence interval, 0.65-0.74; P<.001). Strategies beyond hypertension control may prevent more CVDi in patients with aTRH.
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Affiliation(s)
- Brent M. Egan
- Department of MedicineUniversity of South Carolina School of Medicine–GreenvilleGreenvilleSC
- Care Coordination InstituteGreenville Health SystemGreenvilleSC
| | - Bo Kai
- Department of MathematicsCollege of CharlestonCharlestonSC
| | - C. Shaun Wagner
- Care Coordination InstituteGreenville Health SystemGreenvilleSC
| | - Joseph H. Henderson
- Department of MedicineUniversity of South Carolina School of Medicine–GreenvilleGreenvilleSC
| | - Archie H. Chandler
- Department of MedicineUniversity of South Carolina School of Medicine–GreenvilleGreenvilleSC
| | - Angelo Sinopoli
- Department of MedicineUniversity of South Carolina School of Medicine–GreenvilleGreenvilleSC
- Care Coordination InstituteGreenville Health SystemGreenvilleSC
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Egan BM, Laken MA, Sutherland SE, Qanungo S, Fleming DO, Cook AG, Hester WH, Jones KW, Jebaily GC, Valainis GT, Way CF, Wright MB, Davis RA. Aldosterone Antagonists or Renin-Guided Therapy for Treatment-Resistant Hypertension: A Comparative Effectiveness Pilot Study in Primary Care. Am J Hypertens 2016; 29:976-83. [PMID: 27076600 DOI: 10.1093/ajh/hpw016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Accepted: 01/31/2016] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Uncontrolled treatment-resistant hypertension (TRH), i.e., blood pressure (BP, mm Hg) ≥140/≥90mm Hg in and out of office on ≥3 different BP medications at optimal doses, is common and has a poor prognosis. Aldosterone antagonist (AA) and renin-guided therapy (RGT) are effective strategies for improving BP control in TRH but have not been compared. METHODS A comparative effectiveness TRH pilot study of AA vs. RGT was conducted in 4 primary care clinics with 2 each randomized to AA or RGT. The primary outcome was change in clinic BP defined by means of 5 automated office BP values. Eighty-nine patients with apparent TRH were screened and 44 met criteria for true TRH. RESULTS Baseline characteristics of 20 patients in the AA (70% Black, 45% female, mean age: 57.4 years) and 24 patients in RGT (79% Black, 50% female, 57.8 years) arms were similar with baseline BP 162±5/90±3 vs. 153±3/84±3, respectively, P = 0.11/0.20. BP declined to 144±5/86±4 in AA vs. 132±4/75±3 in RGT, P = 0.07/0.01; BP was controlled to JNC7 (Seventh Joint National Committee Report) goal in 25% vs. 62.5%, respectively, P < 0.01. Although BP changes from baseline, the primary outcome, were not different (-17.6±5.1/-4.0±3.0 AA vs. -20.4±3.8/-9.7±2.0 RGT, P = 0.65/0.10.), more BP medications were added with AA than RGT (+0.9±0.1 vs. +0.4±0.1 per patient, P < 0.01). CONCLUSIONS In this TRH pilot study, AA and RGT lowered BP similarly, although fewer additional medications were required with RGT. A larger comparative effectiveness study could establish the utility of these treatment strategies for lowering BP of uncontrolled TRH patients in primary care.
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Affiliation(s)
- Brent M Egan
- Care Coordination Institute, Greenville Health System, Greenville, South Carolina, USA; University of South Carolina School of Medicine-Greenville, Greenville, South Carolina, USA;
| | - Marilyn A Laken
- College of Nursing, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Susan E Sutherland
- Care Coordination Institute, Greenville Health System, Greenville, South Carolina, USA
| | - Suparna Qanungo
- College of Nursing, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Douglas O Fleming
- Care Coordination Institute, Greenville Health System, Greenville, South Carolina, USA; University of South Carolina School of Medicine-Greenville, Greenville, South Carolina, USA
| | - Anne G Cook
- Department of Family Medicine, AnMed Health, Anderson, South Carolina, USA
| | - William H Hester
- Department of Family Medicine, McLeod Regional Medical Center, Florence, South Carolina, USA
| | - Kelly W Jones
- Department of Family Medicine, McLeod Regional Medical Center, Florence, South Carolina, USA
| | - Gerard C Jebaily
- Department of Family Medicine, McLeod Regional Medical Center, Florence, South Carolina, USA
| | | | - Charles F Way
- Family Diagnostic Associates, Holly Hill, South Carolina, USA
| | - Mary Beth Wright
- Department of Family Medicine, AnMed Health, Anderson, South Carolina, USA
| | - Robert A Davis
- Care Coordination Institute, Greenville Health System, Greenville, South Carolina, USA
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Bhandari SK, Batech M, Shi J, Jacobsen SJ, Sim JJ. Plasma renin activity and risk of cardiovascular and mortality outcomes among individuals with elevated and nonelevated blood pressure. Kidney Res Clin Pract 2016; 35:219-228. [PMID: 27957416 PMCID: PMC5142266 DOI: 10.1016/j.krcp.2016.07.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2016] [Revised: 07/16/2016] [Accepted: 07/20/2016] [Indexed: 02/05/2023] Open
Abstract
Background We sought to evaluate plasma renin activity (PRA) levels and risk of mortality and cardiovascular events among individuals with elevated blood pressure [systolic blood pressure (SBP) ≥ 140 mmHg] and those with controlled blood pressure (SBP < 140 mmHg) in a large diverse population. Methods A retrospective cohort study between January 1, 2007, and December 31, 2013, among adults (≥ 18 years) within an integrated health system was conducted. Subjects were categorized by SBP into 2 groups: SBP < 140 mmHg and SBP ≥ 140 mmHg and then further categorized into population-based PRA tertiles within each SBP group. Cox proportional hazard modeling was used to estimate hazard ratios for cardiovascular and mortality outcomes among tertiles of PRA levels. Results Among 6,331 subjects, 32.6% had SBP ≥ 140 mmHg. Multivariable hazard ratios and 95% confidence interval for PRA tertiles T2 and T3 compared to T1 in subjects with SBP ≥ 140 mmHg were 1.42 (0.99–2.03) and 1.61 (1.12–2.33) for ischemic heart events; 1.40 (0.93–2.10) and 2.23 (1.53–3.27) for congestive heart failure; 1.10 (0.73–1.68) and 1.06 (0.68–1.66) for cerebrovascular accident; 1.23 (0.94–1.59) and 1.43 (1.10–1.86) for combined cardiovascular events; and 1.39 (0.97–1.99) and 1.35 (0.92–1.97) for all-cause mortality, respectively. Among the SBP < 140 mmHg group, there was no relationship between PRA levels and outcomes. Conclusion Higher PRA levels demonstrated increased risk for ischemic heart events and congestive heart failure and a trend toward higher mortality among individuals with SBP ≥ 140 mmHg but not among those with SBP < 140 mmHg.
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Affiliation(s)
- Simran K Bhandari
- Division of Nephrology and Hypertension, Department of Internal Medicine, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA, USA
| | - Michael Batech
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Jiaxiao Shi
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Steven J Jacobsen
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - John J Sim
- Division of Nephrology and Hypertension, Department of Internal Medicine, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA, USA
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Byrd JB. Personalized medicine and treatment approaches in hypertension: current perspectives. Integr Blood Press Control 2016; 9:59-67. [PMID: 27103841 PMCID: PMC4827884 DOI: 10.2147/ibpc.s74320] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
In the US, hypertension affects one in three adults. Current guideline-based treatment of hypertension involves little diagnostic testing. A more personalized approach to the treatment of hypertension might be of use. Several methods of personalized treatment have been proposed and vetted to varying degrees. The purpose of this narrative review is to discuss the rationale for personalized therapy in hypertension, barriers to its development and implementation, some influential examples of proposed personalization measures, and a view of future efforts.
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Affiliation(s)
- James Brian Byrd
- Division of Cardiovascular Medicine, Department of Medicine, University of Michigan, Ann Arbor, MI, USA
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Affiliation(s)
- Hillel Sternlicht
- Department of Medicine, ASH Comprehensive Hypertension Center, Section of Endocrinology, Diabetes and Metabolism, University of Chicago, Chicago, IL 60637, USA
| | - George L Bakris
- Department of Medicine, ASH Comprehensive Hypertension Center, Section of Endocrinology, Diabetes and Metabolism, University of Chicago, Chicago, IL 60637, USA.
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Abstract
Treatment resistant hypertension (TRH) is defined by office blood pressure (BP) uncontrolled on ≥ 3 or controlled on ≥ 4 antihypertensive medications, preferably at optimal doses and including a diuretic. Apparent (a)TRH is used when optimal therapy, adherence, and measurement artifacts are unknown. Among treated hypertensives, ~30% of uncontrolled and 10% of controlled individuals have aTRH, with a higher prevalence in Blacks than other race-ethnicity groups. In ≥ 50% of aTRH patients, BP measurement artifacts ('office' TRH), suboptimal regimens, or suboptimal adherence are present, ie, pseudo-resistance. While patients with 'office' TRH have fewer cardiovascular events than those with 'true' TRH, no evidence confirms that patients with suboptimal regimens or adherence are spared. Averaging several office BPs obtained with an automated monitor can reduce 'office' TRH. Home or ambulatory BP monitoring can identify office resistance. Prescribing ≥ 3 different antihypertensive medication classes, eg, thiazide-type diuretic, renin-angiotensin blocker and calcium antagonist at ≥ 50% of maximum recommended doses reasonably defines optimal therapy. Intensifying diuretic therapy, eg, adding an aldosterone antagonist, is effective for many TRH patients who are volume expanded. Clinical information, hemodynamic and renin-guided therapeutics can inform other treatment options. Attention to adverse effects, medication costs, and pill burden can improve adherence and control. Patients with aTRH and suspected secondary hypertension should be evaluated. Interfering substances or medications should be discontinued. These approaches will identify or correct the problem in ~80% of aTRH patients. Referral to a hypertension specialist and newer therapeutic approaches are options for TRH patients who cannot take or do not respond to optimal therapy.
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Abstract
More is known about the epidemiology of drug-resistant hypertension than particular pathogenic factors and pathways. Several recurring themes, however, seem evident on using insight from epidemiology and general knowledge of the pathophysiology of hypertension. Specifically, 4 main pathways converge on drug resistance including sodium handling, sympathetic nervous system activation, endothelial dysfunction, and arterial stiffness. These factors, and the various pathways and elements contributing to them, are reviewed. In addition to describing how these factors exert their individual influences on resistant hypertension, several examples of how interactions between these factors, particularly in the case of chronic kidney disease, are included. At the conclusion of this review some thoughts are offered on additional mechanisms and areas for potential research.
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Comparative risk of renal, cardiovascular, and mortality outcomes in controlled, uncontrolled resistant, and nonresistant hypertension. Kidney Int 2015; 88:622-32. [PMID: 25945406 PMCID: PMC4556588 DOI: 10.1038/ki.2015.142] [Citation(s) in RCA: 126] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2014] [Revised: 03/05/2015] [Accepted: 03/26/2015] [Indexed: 12/14/2022]
Abstract
We sought to compare the risk of end stage renal disease (ESRD), ischemic heart event (IHE), congestive heart failure (CHF), cerebrovascular accident (CVA), and all-cause mortality among 470,386 individuals with resistant and nonresistant hypertension (non-RH). Resistant hypertension (60,327 individuals) was sub-categorized into 2 groups; 23,104 patients with cRH (controlled on 4 or more medicines) and 37,223 patients with uRH (uncontrolled on 3 or more medicines) in a 5 year retrospective cohort study. Cox proportional hazard modeling was used to estimate hazard ratios adjusting for age, gender, race, body mass index, chronic kidney disease (CKD), and co-morbidities. Resistant hypertension (cRH and uRH) compared to non-RH, had multivariable adjusted hazard ratios (95% confidence intervals) of 1.32 (1.27–1.37), 1.24 (1.20–1.28), 1.46 (1.40–1.52), 1.14 (1.10–1.19), and 1.06 (1.03–1.08) for ESRD, IHE, CHF, CVA, and mortality, respectively. Comparison of uRH to cRH had hazard ratios of 1.25 (1.18–1.33), 1.04 (0.99–1.10), 0.94 (0.89–1.01), 1.23 (1.14–1.31), and 1.01 (0.97–1.05) for ESRD, IHE, CHF, CVA, and mortality, respectively. Males and Hispanics had greater risk for ESRD within all 3 cohorts. Resistant hypertension had greater risk for ESRD, IHE, CHF, CVA, and mortality. The risk of ESRD and CVA and were 25% and 23% greater, respectively, in uRH compared to cRH supporting the linkage between blood pressure and both outcomes.
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Weber F, Anlauf M. Treatment resistant hypertension--investigation and conservative management. DEUTSCHES ARZTEBLATT INTERNATIONAL 2015; 111:425-31. [PMID: 25008301 DOI: 10.3238/arztebl.2014.0425] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/27/2013] [Revised: 04/07/2014] [Accepted: 04/07/2014] [Indexed: 01/25/2023]
Abstract
BACKGROUND The introduction of invasive treatments, some of which are irreversible, for the entity called treatment-resistant hypertension (TRH) creates the need for a comprehensive discussion of the diagnostic evaluation that TRH requires and the available options for its conservative treatment. METHOD The pertinent literature is selectively reviewed in the light of the authors' longstanding clinical experience. RESULTS Our review of the literature suggests that the high prevalence of TRH in Germany (ca. 20%) can be nearly halved with the aid of more thorough diagnostic evaluation. Such an evaluation should include a review of the patient's antihypertensive drugs (adherence, daily dosing, concomitant medication), investigation for other vascular changes that might affect blood pressure measurement, and exclusion of white-coat hypertension, sleep apnea syndrome, and secondary rather than essential hypertension. As there have been no randomized trials of treatment for TRH, the physician confronted with such cases must devise treatments on the basis of observational data and pathophysiological reasoning (volume status considering renin levels, sympathetic blockade, vasodilatation). Such measures can presumably lower the number of truly treatment-resistant cases still further. CONCLUSION To save patients from preventable harm, patients should undergo a thorough diagnostic evaluation and-under close monitoring for side effects-conservative pharmacological and nonpharmacological treatments should be deployed before any invasive treatment is performed.
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Affiliation(s)
- Franz Weber
- St Walburga Hospital, Meschede, Private Practice at the Medical Care Center, Dialysis Center, Cuxhaven
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Mann SJ, Ernst ME. Personalizing the diuretic treatment of hypertension: the need for more clinical and research attention. Curr Hypertens Rep 2015; 17:542. [PMID: 25794956 DOI: 10.1007/s11906-015-0542-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Neither randomized controlled trials nor efforts to identify genetic markers have been helpful with regard to the goal of individualizing diuretic therapy in the treatment of hypertension, a goal that receives little clinical or research attention. This review will examine, and bring attention to, the considerable yet overlooked information relevant to individualizing diuretic therapy. It will bring attention to clinical, biochemical, and pharmacological clues that can be helpful in identifying who is likely to respond to a diuretic, who needs a stronger diuretic regimen, which diuretic to prescribe, and how to minimize adverse effects. New directions for clinical research aimed at individualizing use in hypertension will be explored. Research and clinical attention to the goal of individualizing diuretic treatment in hypertension need to be renewed, to help us achieve greater hypertension control with fewer adverse effects and lower costs.
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Affiliation(s)
- Samuel J Mann
- Division of Nephrology and Hypertension, NY Presbyterian Hospital-Weill Cornell Medical College, 424 East 70th St, New York, NY, 10021, USA,
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Individualizing antihypertensive combination therapies: clinical and hemodynamic considerations. Curr Hypertens Rep 2015; 16:451. [PMID: 24806735 DOI: 10.1007/s11906-014-0451-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
While there are strong trial data to guide the selection of initial hypertension treatment choice and limited data to support second agent choice, beyond the first two agents, subsequent steps are empiric. As medications are added, the resulting polypharmacy may be complex, inefficient and poorly tolerated, resulting in low treatment adherence rates. The selection of antihypertensive drug therapy based on hemodynamic mechanisms is not new but became practical with the availability of noninvasive hemodynamic parameters using impedance cardiography. Individualized therapy based on hormonal or hemodynamic measurements can effectively control hypertension as shown in several small clinical trials. Hemodynamic measurements are obtained quickly, painlessly and can be used in a serial fashion to guide treatment adjustments. Current limitations relate to availability of the measurement device and personnel trained in its use, reimbursement for the measurements, expertise in interpretation of the measurements and systems to adjust medication and repeat measurements in a serial fashion until targets are attained. The potential utility of this approach increases with greater complexity of the medication regimen. Further studies are indicated and may advance options for individualized treatment of hypertensive patients.
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Gonzalez MC, Cohen HW, Alderman MH. Pressor response to initial blood pressure monotherapy is associated with cardiovascular mortality. Am J Hypertens 2015; 28:232-8. [PMID: 25227515 DOI: 10.1093/ajh/hpu133] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND A paradoxical pressor systolic response to initial antihypertensive monotherapy has been observed in 8% of hypertensive patients. The long-term consequences of this finding are unknown. METHODS We included 945 hypertensive patients with baseline systolic blood pressure (SBP) ≥140mm Hg. A 4-week washout period free of antihypertensive drugs was allowed for those already on treatment at entry. Mortality outcomes were ascertained from the National Death Index. Subjects were categorized by SBP response into depressor (≥10mm Hg fall), nonresponder, and pressor (≥10mm Hg rise) categories. RESULTS There were 268 fatalities. Of these, 100 (37%) were from cardiovascular disease (CVD), of which 70 (70%) were due to coronary artery disease (CAD). A pressor response was associated with higher SBP at 1 year compared with the nonresponder or depressor response (141 vs. 136 vs. 136mm Hg). CVD mortality was greater in pressors than depressors (hazard ratio (HR) = 3.0; 95% confidence interval (CI) = 1.4-6.4; P = 0.004], as was CAD (HR = 3.1; 95% CI = 1.4-6.8; P < 0.01) and all-cause mortality (HR = 1.7; 95% CI = 1.1-2.6; P = 0.02), after adjusting for 1-year SBP and other possible confounders. CONCLUSIONS We found the incidence of a pressor response to monotherapy at 3 months was significantly, specifically, and independently associated with higher subsequent cardiovascular mortality.
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Affiliation(s)
- Maday C Gonzalez
- New York Presbyterian-Weill Cornell Medical Center, New York, New York;
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47
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Furberg CD, Alderman MH. JNC 8: shortcomings in process and treatment recommendations. Am J Hypertens 2014; 27:1443-5. [PMID: 25194154 DOI: 10.1093/ajh/hpu158] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Affiliation(s)
- Curt D Furberg
- Wake Forest School of Medicine, Division of Public Health Sciences, Winston-Salem, North Carolina
| | - Michael H Alderman
- Departments of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York.
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Padwal RS, Rabkin S, Khan N. Assessment and management of resistant hypertension. CMAJ 2014; 186:E689-97. [PMID: 25135921 DOI: 10.1503/cmaj.130764] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Affiliation(s)
- Raj S Padwal
- Department of Medicine (Padwal), University of Alberta, Edmonton, Alta.; Alberta Diabetes Institute (Padwal), Edmonton, Alta.; Division of Cardiology (Rabkin), Department of Medicine (Rabkin, Khan), University of British Columbia, Vancouver, BC; Center for Health Evaluation and Outcome Sciences (Khan), Vancouver, BC
| | - Simon Rabkin
- Department of Medicine (Padwal), University of Alberta, Edmonton, Alta.; Alberta Diabetes Institute (Padwal), Edmonton, Alta.; Division of Cardiology (Rabkin), Department of Medicine (Rabkin, Khan), University of British Columbia, Vancouver, BC; Center for Health Evaluation and Outcome Sciences (Khan), Vancouver, BC
| | - Nadia Khan
- Department of Medicine (Padwal), University of Alberta, Edmonton, Alta.; Alberta Diabetes Institute (Padwal), Edmonton, Alta.; Division of Cardiology (Rabkin), Department of Medicine (Rabkin, Khan), University of British Columbia, Vancouver, BC; Center for Health Evaluation and Outcome Sciences (Khan), Vancouver, BC
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Sealey JE. John H. Laragh, MD: clinician-scientist. Am J Hypertens 2014; 27:1019-23. [PMID: 25103936 PMCID: PMC4125340 DOI: 10.1093/ajh/hpu110] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2014] [Accepted: 05/06/2014] [Indexed: 11/29/2022] Open
Affiliation(s)
- Jean E Sealey
- Department of Medicine, Weill Cornell Medical College, New York.
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