Is It True Resistant Hypertension? Find Out
Is It True Resistant Hypertension? Find Out
Hi. I'm Dr. Henry Black, Clinical Professor of Internal Medicine at the New York University School of Medicine, a member of the Center for the Prevention of Cardiovascular Disease at NYU, and Immediate Past President of the American Society of Hypertension. I have been interested in resistant hypertension or refractory hypertension for more than 20 years. When I had a specialty clinic in New Haven, I had patients referred to me whose blood pressures were out of control. We did a cohort study and found that the main difference required the adjusting of drugs, generally adding a diuretic or adjusting the diuretic used. I repeated this same study at Rush University in Chicago from 1993 to 2001. The findings were not that different. It was still the adjustment of medications that mattered, and these patients were defined as resistant by being on 3 drugs at appropriate doses, one of which was a diuretic. That was the definition that was used in both studies and is pretty much the definition that is used in the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. They have to be at goal. "Goal" was defined as less than 140/90 mm Hg. For diabetics and people with chronic renal disease, it has to be less than 130/80 mm Hg.
We rarely monitored ambulatory blood pressure for these patients. However, it was done once in a while and we would discover someone who had what I like to call "office resistance" -- not white-coat hypertension, because the patient is on treatment.
The Spaniards have really helped us out. They have been keeping records of ambulatory blood pressure monitoring in over 68,000 individuals, and they found that approximately 15% of the people studied had what was called resistant hypertension, based on office readings that were carefully collected. These were people taking 3 drugs at appropriate doses and who were not at goal, or 4 drugs regardless of whether the drugs were at appropriate doses.
Ambulatory blood pressure was monitored on all of these individuals, and they found that the patients could be broken down into 2 groups: About 62% of patients really had elevated blood pressures out of the office, and about 37% actually had blood pressures that were not elevated out of the office. They call these patients "white-coat resistants." I would call them "office hypertensives." The patients who had resistant hypertension had significantly higher blood pressures, especially at night. They had a higher average blood pressure as well, but that wasn't quite as clear. The nighttime readings for the office hypertensives were 122/70, as opposed to something considerably higher than that as seen in patients with true resistant hypertension. The drugs that were used were pretty much the same. The risks that the white-coat resistants had were more for target organ damage and diabetes, not necessarily lipid abnormalities. Prognosis was considerably worse for the true resistant hypertensives.
What the authors say is that monitoring ambulatory blood pressure on someone you consider having resistant hypertension is "mandatory." This is going to be a little difficult to do. These are not reimbursed. Not every office has access to that. Most hypertension specialists would have the ambulatory blood pressure monitoring capabilities. I think this is key, because we don't have to overtreat the people who don't have resistant hypertension out of the office, and we have to be particularly aggressive with the people who do.
I want to thank the team led by Luis Ruilope for this excellent look and for taking information that is not from a randomized trial but from an appropriate use of the database, giving us very important answers to questions that we pose. Thank you very much.
Hi. I'm Dr. Henry Black, Clinical Professor of Internal Medicine at the New York University School of Medicine, a member of the Center for the Prevention of Cardiovascular Disease at NYU, and Immediate Past President of the American Society of Hypertension. I have been interested in resistant hypertension or refractory hypertension for more than 20 years. When I had a specialty clinic in New Haven, I had patients referred to me whose blood pressures were out of control. We did a cohort study and found that the main difference required the adjusting of drugs, generally adding a diuretic or adjusting the diuretic used. I repeated this same study at Rush University in Chicago from 1993 to 2001. The findings were not that different. It was still the adjustment of medications that mattered, and these patients were defined as resistant by being on 3 drugs at appropriate doses, one of which was a diuretic. That was the definition that was used in both studies and is pretty much the definition that is used in the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. They have to be at goal. "Goal" was defined as less than 140/90 mm Hg. For diabetics and people with chronic renal disease, it has to be less than 130/80 mm Hg.
We rarely monitored ambulatory blood pressure for these patients. However, it was done once in a while and we would discover someone who had what I like to call "office resistance" -- not white-coat hypertension, because the patient is on treatment.
The Spaniards have really helped us out. They have been keeping records of ambulatory blood pressure monitoring in over 68,000 individuals, and they found that approximately 15% of the people studied had what was called resistant hypertension, based on office readings that were carefully collected. These were people taking 3 drugs at appropriate doses and who were not at goal, or 4 drugs regardless of whether the drugs were at appropriate doses.
Ambulatory blood pressure was monitored on all of these individuals, and they found that the patients could be broken down into 2 groups: About 62% of patients really had elevated blood pressures out of the office, and about 37% actually had blood pressures that were not elevated out of the office. They call these patients "white-coat resistants." I would call them "office hypertensives." The patients who had resistant hypertension had significantly higher blood pressures, especially at night. They had a higher average blood pressure as well, but that wasn't quite as clear. The nighttime readings for the office hypertensives were 122/70, as opposed to something considerably higher than that as seen in patients with true resistant hypertension. The drugs that were used were pretty much the same. The risks that the white-coat resistants had were more for target organ damage and diabetes, not necessarily lipid abnormalities. Prognosis was considerably worse for the true resistant hypertensives.
What the authors say is that monitoring ambulatory blood pressure on someone you consider having resistant hypertension is "mandatory." This is going to be a little difficult to do. These are not reimbursed. Not every office has access to that. Most hypertension specialists would have the ambulatory blood pressure monitoring capabilities. I think this is key, because we don't have to overtreat the people who don't have resistant hypertension out of the office, and we have to be particularly aggressive with the people who do.
I want to thank the team led by Luis Ruilope for this excellent look and for taking information that is not from a randomized trial but from an appropriate use of the database, giving us very important answers to questions that we pose. Thank you very much.
