Prognosis of patients with apparent treatment-resistant hypertension—a feasibility study

Background: Most cases of hypertension can be effectively treated with lifestyle changes together with medications, but within this population lies a group with more difficult to treat hypertension—those with apparent treatment-resistant hypertension (aTRH). The American Heart Association and the UK National Institute for Health and Care Excellence have both highlighted the need for further research into the prognosis of patients with resistant hypertension, both apparent and true. Methods: In 16 practices affiliated to a university research network, 646 patients had been identified with apparent treatment-resistant hypertension. To inform a planned full cohort study of these patients, we conducted a feasibility study within three practices to determine participation of practices and patients, availability of outcome measures and data collection times. Results: All three practices fully participated and 205/210 (98%) patients were followed up for a median of 23 months. Thirty-five outcome events of interest occurred—the most common was the new onset of retinopathy (9 cases). Eight percent (17/210) had the main composite outcome of death or serious incident cardiovascular event. Of the six patients who died, identification of cause of death was possible from practice records in five; the national General Register Office was successfully used for the final patient. There were 123 admissions, both day and overnight, recorded in 94 individual patients. Average manual systolic blood pressure measurements improved from baseline by 5 mmHg to 138 (SD 19) mmHg; diastolic remained the same at 75 (SD 12) mmHg. Average eGFR increased from 58.8 (SD17.4) to 66 (SD19.7) mls/min/1.73m2. The average time for data collection per patient was 12 mins. Conclusions: This study demonstrates that the proposed methodology for a full cohort study within general practice of patients with apparent treatment hypertension is both acceptable to practices and feasible. An adequately powered subsequent follow-up study of the entire cohort appears possible

Additional file 1: of Effectiveness and content analysis of interventions to enhance medication adherence in hypertension: a systematic review and meta-analysis protocol

A populated PRISMA-P checklist. (DOC 80 kb

Prevalence of treatment-resistant hypertension after considering pseudo-resistance and morbidity: a cross-sectional study in Irish primary care

Background To confirm treatment-resistant hypertension (TRH), ambulatory blood pressure measurement (ABPM) must exclude white-coat hypertension (WCH), three or more medications should be prescribed at the optimal doses tolerated, and non-adherence and lifestyle should be examined. Most previous studies have not adequately considered pseudo-resistance and merely provide an apparent TRH (aTRH) prevalence figure. Aim To conduct a cross-sectional study of the prevalence of aTRH in general practice, and then consider pseudo-resistance and morbidity. Design and setting With support, 16 practices ran an anatomical therapeutic chemical (ATC) drug search, identifying patients on any possible hypertensive medications, and then a search of individual patients' electronic records took place. Method ABPM was used to rule out WCH. The World Health Organization-defined daily dosing guidelines determined adequate dosing. Adherence was defined as whether patients requested nine or more repeat monthly prescriptions within the past year. Results Sixteen practices participated (n = 50 172), and 646 patients had aTRH. Dosing was adequate in 19% of patients, 84% were adherent to medications, as defined by prescription refill, and 43% had ever had an ABPM. Using a BP cut-off of 140/90 mmHg, the prevalence of aTRH was 9% (95% confidence interval [CI] = 9.0 to 10.0). Consideration of pseudo-resistance further reduced prevalence rates to 3% (95% CI = 3.0 to 4.0). Conclusion Reviewing individual patient records results in a lower estimate of prevalence of TRH than has been previously reported. Further consideration for individual patients of pseudo-resistance additionally lowers these estimates, and may be all that is required for management in the vast majority of cases

Relative weight for each cue for each participant and the <i>R</i>² for each regression model.

<p>Relative weight for each cue for each participant and the <i>R</i>² for each regression model.</p

James’ case history profile.

<p>James’ case history profile.</p

Measuring adherence to therapy in apparent treatment-resistant hypertension: a feasibility study in Irish primary care

BACKGROUND: Apparent treatment-resistant hypertension (aTRH) is defined as uncontrolled blood pressure (BP) in patients taking three or more antihypertensive medications. Some patients will have true treatment-resistant hypertension, some undiagnosed secondary hypertension, while others have pseudo-resistance. Pseudo-resistance occurs when non-adherence to medication, white-coat hypertension (WCH), lifestyle, and inadequate drug dosing are responsible for the poorly controlled BP. AIM: To examine the feasibility of establishing non-adherence to medication, for the first time in primary care, using mass spectrometry urine analysis. Operationalisation would be established by at least 50% of patients participating and 95% of samples being suitable for analysis. Clinical importance would be confirmed by >10% of patients being non-adherent. DESIGN AND SETTING: Eligible patients with aTRH (n = 453) in 15 university research-affiliated Irish general practices were invited to participate. METHOD: Participants underwent mass spectrometry urine analysis to test adherence and ambulatory BP monitoring (ABPM) to examine WCH. RESULTS: Of the eligible patients invited, 52% (n = 235) participated. All 235 urine samples (100%) were suitable for analysis: 174 (74%) patients were fully adherent, 56 (24%) partially adherent, and five (2%) fully non-adherent to therapy. A total of 206 patients also had ABPM, and in total 92 (45%) were categorised as pseudo-resistant. No significant associations were found between adherence status and patient characteristics or drug class. CONCLUSION: In patients with aTRH, the authors have established that it is feasible to examine non-adherence to medications using mass spectrometry urine analysis. One in four patients were found to be partially or fully non-adherent. Further research on how to incorporate this approach into individual patient consultations and its associated cost-effectiveness is now appropriate