Low rate of resistant hypertension in Chinese patients with hypertension: an analysis of the HOT-CHINA study

Triple Antihypertensive Medication Prediction Score After Intracerebral Hemorrhage (the TRICH Score)

BACKGROUND AND OBJECTIVES

Poor long-term blood pressure (BP) control due to undertreatment of hypertension is not uncommon after intracerebral hemorrhage (ICH). It heightens the risk of ICH recurrence and subsequent stroke, which is the highest within the first year. Promptly achieving BP targets would significantly reduce these risks. To accomplish this, upfront triple antihypertensive medications could be prescribed soon after ICH because many ICH survivors require ≥3 antihypertensives. However, not all would suit this approach, particularly those with cerebral amyloid angiopathy (CAA), where elevated admission BP may be due to acute hypertensive response rather than underlying hypertension. In addition, overtreatment and excessive BP lowering would cause more side effects and have been associated with increased mortality in older patients. Hence, to facilitate individualized treatment, we aimed to develop a score (TRICH) to predict the need for ≥3 antihypertensives at 3 months after ICH.

METHODS

We developed the score using data from the University of Hong Kong prospective ICH registry (2011-2022) and validated it in 3 hospitals (2020-2022) locally. Consecutive patients with spontaneous ICH who survived >90 days and had follow-up BP 3 months after ICH were included. Predictors for needing ≥3 antihypertensive medications at 3 months were identified using multivariate logistic regression, and the score was created using the β-coefficients.

RESULTS

The TRICH score was developed from 462 patients (mean age 66.6 ± 14.3 years, 60% male) and validated in 203 patients (mean age 66.3 ± 14.6 years, 62% male). The 9-point score (age younger than 60 years = 1, male = 1, ischemic heart disease = 1, admission estimated glomerular filtration rate <60 mL/min/1.73 m2 = 2, admission systolic BP 190-230 mm Hg = 2 while >230 mm Hg = 4) has a c-statistic (95% CI) of 0.79 (0.75-0.83) in the development cohort and 0.76 (0.69-0.82) in validation. A dichotomized score (≥3 points) predicted the need for ≥3 antihypertensives with 0.73 (95% CI 0.67-0.80) sensitivity and 0.76 (95% CI 0.70-0.81) specificity. The score performed better in patients with untreated/uncontrolled hypertension before ICH than in controlled patients (c-statistic [95% CI] 0.81 [0.77-0.86] vs 0.74 [0.69-0.80], p = 0.037) but showed no difference between patients with CAA and non-CAA patients.

DISCUSSION

The TRICH score identifies patients with ICH who need ≥3 antihypertensive medications 3 months after ICH with good discrimination ability. It may guide upfront triple antihypertensive prescription, but further research is warranted, particularly in non-Han Chinese populations.

Efficacy and safety of sympathetic mapping and ablation of renal nerves for the treatment of hypertension (SMART): 6-month follow-up of a randomised, controlled trial

Background

Previous trials of renal denervation (RDN) have been designed to investigate reduction of blood pressure (BP) as the primary efficacy endpoint using non-selective RDN without intraoperatively verified RDN success. It is an unmet clinical need to map renal nerves, selectively denervate renal sympathetic nerves, provide readouts for the interventionalists and avoid futile RDN. We aimed to examine the safety and efficacy of renal nerve mapping/selective renal denervation (msRDN) in patients with uncontrolled hypertension (HTN) and determine whether antihypertensive drug burden is reduced while office systolic BP (OSBP) is controlled to target level (＜140 mmHg).

Methods

We conducted a randomized, prospective, multicenter, single-blinded, sham-controlled trial. The study combined two efficacy endpoints at 6 months as primary outcomes: The control rate of patients with OSBP ＜140 mmHg (non-inferior outcome) and change in the composite index of antihypertensive drugs (Drug Index) in the treatment versus Sham group (superior outcome). This design avoids confounding from excess drug-taking in the Sham group. Antihypertensive drug burden was assessed by a composite index constructed as: Class N (number of classes of antihypertensive drugs) × (sum of doses). 15 hospitals in China participated in the study and 220 patients were enrolled in a 1:1 ratio (msRDN vs Sham). The key inclusion criteria included: age (18-65 years old), history of essential HTN (at least 6 months), heart rate (≥70 bpm), OSBP (≥150 mmHg and ≤180 mmHg), ambulatory BP monitoring (ABPM, 24-h SBP ≥130 mmHg or daytime SBP ≥135 mmHg or nighttime SBP ≥120 mmHg), renal artery stenosis (＜50%) and renal function (eGFR ＞45 mL/min/1.73 m2). The catheter with both stimulation and ablation functions was inserted in the distal renal main artery. The RDN site (hot spot) was selected if SBP increased (≥5 mmHg) by intra-renal artery (RA) electrical stimulation; an adequate RDN was confirmed by repeated electronic stimulation if no increase in BP otherwise, a 2nd ablation was performed at the same site. At sites where there was decreased SBP (≥5 mmHg, cold spot) or no BP response (neutral spot) to stimulation, no ablation was performed. The mapping, ablation and confirmation procedure was repeated until the entire renal main artery had been tested then either treated or avoided. After msRDN, patients had to follow a predefined, vigorous drug titration regimen in order to achieve target OSBP (＜140 mmHg). Drug adherence was monitored by liquid chromatography-tandem mass spectrometry analysis using urine. This study is registered with ClinicalTrials.gov (NCT02761811) and 5-year follow-up is ongoing.

Findings

Between July 8, 2016 and February 23, 2022, 611 patients were consented, 220 patients were enrolled in the study who received standardized antihypertensive drug treatments (at least two drugs) for at least 28 days, presented OSBP ≥150 mmHg and ≤180 mmHg and met all inclusion and exclusion criteria. In left RA and right RA, mapped sites were 8.2 (3.0) and 8.0 (2.7), hot/ablated sites were 3.7 (1.4) and 4.0 (1.6), cold spots were 2.4 (2.6) and 2.0 (2.2), neutral spots were 2.0 (2.1) and 2.0 (2.1), respectively. Hot, cold and neutral spots was 48.0%, 27.5% and 24.4% of total mapped sites, respectively. At 6 M, the Control Rate of OSBP was comparable between msRDN and Sham group (95.4% vs 92.8%, p = 0.429), achieved non-inferiority margin -10% (2.69%; 95% CI -4.11%, 9.83%, p ＜ 0.001 for non-inferiority); the change in Drug Index was significantly lower in msRDN group compared to Sham group (4.37 (6.65) vs 7.61 (10.31), p = 0.010) and superior to Sham group (-3.25; 95% CI -5.56, -0.94, p = 0.003), indicating msRDN patients need significantly fewer drugs to control OSBP ＜140 mmHg. 24-hour ambulatory SBP decreased from 146.8 (13.9) mmHg by 10.8 (14.1) mmHg, and from 149.8 (12.8) mmHg by 10.0 (14.0) mmHg in msRDN and Sham groups, respectively (p < 0.001 from Baseline; p > 0.05 between groups). Safety profiles were comparable between msRDN and Sham groups, demonstrating the safety and efficacy of renal mapping/selective RDN to treat uncontrolled HTN.

Interpretation

The msRDN therapy achieved the goals of reducing the drug burden of HTN patients and controlling OSBP <140 mmHg, with only approximately four targeted ablations per renal main artery, much lower than in previous trials.

Funding

SyMap Medical (Suzhou), LTD, Suzhou, China.

Rationale and Design of Sympathetic Mapping/Ablation of Renal Nerves Trial (SMART) for the Treatment of Hypertension: a Prospective, Multicenter, Single-Blind, Randomized and Sham Procedure-Controlled Study

Renal denervation (RDN) is proposed as a durable and patient compliance independent treatment for hypertension. However, 20-30% non-responder after RDN treatment weakened the therapeutic effect, which may be due to blind ablation. The renal nerve mapping/selective ablation system developed by SyMap Medical Ltd (Suzhou), China, has the function of mapping renal sympathetic/parasympathetic nerve sites and selectively removing renal sympathetic nerves and is expected to meet the urgent unmet clinical need of targeted RDN. The "Sympathetic Mapping/Ablation of Renal Nerves Trial" (SMART) is a prospective, multicenter, randomized, single-blinded, sham procedure-controlled trial, to evaluate the safety and efficacy of targeted renal sympathetic denervation in patients with essential and uncontrolled hypertension. The study is the first clinical registry trial using a targeted RDN for the treatment of uncontrolled hypertension; the dual-endpoint design can answer the question of how many antihypertensive drugs can be reduced in patients after RDN. The trial is registered on clinicaltrials.gov NCT02761811.

Treatment resistant hypertension among ambulatory hypertensive patients: A cross sectional study

BACKGROUND

Treatment resistant hypertension(TRH) is detrimental risk of cardiovascular and premature deaths. Globally, the prevalence of resistant hypertension is inclining from time to time and it is yet to be determined in Ethiopia.

OBJECTIVE

To assess the prevalence of apparent TRH and its predictors among ambulatory hypertensive patients on follow up in hypertension clinic of Mekelle Hospital, Northern Ethiopia.

METHOD

A hospital based cross sectional study was conducted from Nov 25, 2018 to July 20, 2019, among 338 adult ambulatory hypertensive patients on follow up in Mekelle Hospital hypertension clinic. Hypertensive patient aged ≥18 years who were on regular follow up and taking antihypertensive medications for at least 6 months were included in the study. A simple random sampling technique was used to recruit the study patients.

RESULTS

A total of 338 adult ambulatory hypertensive patients were analysed. More than half, 182 (53.8%) patients were females and the average age of the patients was 58.9 ±11.5. Three hundred thirty-three (98.5%) patients had no family history of hypertension. Majority, 66.8% of the patients were on monotherapy. The prevalence of apparent TRH was calculated to be 8.6% [Confidence Interval = 0.056-0.116]. Patients with Body Mass Index(BMI) greater than 30[Adjusted Odds Ratio(AOR) = 12.1, 95%CI:2.00-73.19, p = 0.007] and longer duration of hypertension were the predictors of resistant hypertension.

CONCLUSION

Even if escalation of antihypertensive medications was not aggressive, apparent TRH was common in the study setting. Obesity (BMI greater than 30) and longer duration of hypertension since diagnosis were the predictors of TRH. Meticulous emphasis should be placed on to detect the prevalence of true hypertension resistance and future studies should discover the impact of aggressive antihypertensive medications scale up on the risks of TRH.

A comprehensive review of an unmet public health issue: resistant hypertension

Resistant hypertension is an intractable problem to patients and physicians. In recent decades, a substantial amount of basic and epidemiological studies provide us a vast number of valuable evidence and information about this once elusive disease. Better understanding about this entity could help physicians improve diagnostic and therapeutic accuracy. In present review, therefore, we first will detail the definition and diagnosis of resistant hypertension between cardiology societies, and followed by the information of prevalence of resistant hypertension around the world, and then briefly discuss currently used different nomenclature of resistant hypertension, and finally present diagnostic and therapeutic strategies of resistant hypertension.

Resistant hypertension in diabetes mellitus

Resistant hypertension in diabetes is associated with poor cardiovascular and renal outcomes. This brief review will examine the definitions and epidemiology of resistant hypertension and consider the differences between apparent resistant hypertension and truly resistant or refractory hypertension. It will review the role of the sympathetic nervous system in resistant hypertension. It will consider the relationship between obesity and leptin resistance and sympathetic signaling; the role of obstructive sleep apnea in resistant hypertension; and the role of aldosterone in resistant hypertension. It will conclude by mentioning briefly renal nerve ablation.