Doctor checking blood pressure of a pregnant woman who may have hypertension or pre-eclampsia
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Treatment of apparent resistant hypertension (aRH) varies considerably, a new study finds. This form of high blood pressure requires more medication and medical management. These investigators learned that patients with well-managed aRH were more likely to be receiving a mineralocorticoid receptor antagonist, or MRA as part of their regimen. Such treatment was used in 34 percent of patients with controlled aRH, but only 11 percent of patients with uncontrolled forms of the condition.

 “… There are large differences in how providers treat high blood pressure, exemplifying a need to standardize care,” said Joseph Ebinger, MD, assistant professor of Cardiology in the Smidt Heart Institute and corresponding author of the study.

The study, led by investigators in the Smidt Heart Institute at Cedars-Sinai, was published today in Hypertension.

The team found that aRH prevalence was lower in a real-world sample than previously reported, but still relatively frequent—affecting nearly 1 in 10 hypertensive patients. A 2019 paper estimated that 10.3 million US adults had the condition. It was defined as “uncontrolled BP while taking ≥3 classes of antihypertensive medication or taking ≥4 classes of antihypertensive medication regardless of BP level.”

Hypertension can lead to stroke or heart attack, but medication usually keeps the condition at bay. It’s estimated that more than 700 million people worldwide have untreated hypertension.

These study findings were based on a unique design, which used clinically generated data from the electronic health records of three large, geographically diverse healthcare organizations. Of the 2,420,468 patients analyzed in the study, 55% were hypertensive. Of these hypertension patients, 8.5%, or 113,992 individuals, met criteria for aRH.

According to Ebinger, treating aRH can be just as tricky as diagnosing it. The “apparent” in apparent resistant hypertension stems from the fact that before diagnosis, medical professionals must first rule out other potential reasons for a patient’s blood pressure to be high.

These reasons might include medication non-adherence, inappropriate medication selection, or artificially elevated blood pressure in the doctor’s office—known as “white coat hypertension.”

“Large amounts of data tell us that patients with aRH, compared to those with non-resistant forms of hypertension, are at greatest risk for adverse cardiovascular events,” said Ebinger, director of Clinical Analytics in the Smidt Heart Institute. “Identifying these patients and possible causes for their elevated blood pressure is increasingly important.”

The takeaway, Ebinger says, is awareness—for both medical professionals and patients. He says providers should be mindful that if it’s taking four or more antihypertensive medications to control a patient’s blood pressure, they should consider evaluation for alternative causes of hypertension, or refer patients to a specialist.

Similarly, the researchers say, patients should lean on their medical providers to help them navigate the complex disease, including having a conversation around strategies for remembering to take their medication and addressing possible treatment side effects.

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