Adverse Health Outcomes Associated With Refractory and Treatment-Resistant Hypertension in the Chronic Renal Insufficiency Cohort.

Refractory hypertension (RfH) is a severe phenotype of antihypertension treatment failure. Treatment-resistant hypertension (TRH), a less severe form of difficult-to-treat hypertension, has been associated with significantly worse health outcomes. However, no studies currently show how health outcomes may worsen upon progression to RfH. RfH and TRH were studied in 3147 hypertensive participants in the CRIC (Chronic Renal Insufficiency Cohort study). The hypertensive phenotype (ie, no TRH or RfH, TRH, or RfH) was identified at the baseline visit, and health outcomes were monitored at subsequent visits. Outcome risk was compared using Cox proportional hazards models with time-varying covariates. A total of 136 (4.3%) individuals were identified with RfH at baseline. After adjusting for participant characteristics, individuals with RfH had increased risk for the composite renal outcome across all study years (50% decline in estimated glomerular filtration rate or end-stage renal disease; hazard ratio for study years 0-10=1.73 [95% CI, 1.42-2.11]) and the composite cardiovascular disease outcome during later study years (stroke, myocardial infarction, or congestive heart failure; hazard ratio for study years 0-3=1.25 [0.91-1.73], for study years 3-6=1.50 [0.97-2.32]), and for study years 6-10=2.72 [1.47-5.01]) when compared with individuals with TRH. There was no significant difference in all-cause mortality between those with refractory versus TRH. We provide the first evidence that RfH is associated with worse long-term health outcomes compared with TRH.

Serious Adverse Events Cluster in Participants Experiencing the Primary Composite Cardiovascular Endpoint: A Post Hoc Analysis of the SPRINT Trial.

BACKGROUND: Intensively treated participants in the SPRINT study experienced fewer primary cardiovascular composite study endpoints (CVD events) and lower mortality, although 38% of participants experienced a serious adverse event (SAE). The relationship of SAEs with CVD events is unknown. METHODS: CVD events were defined as either myocardial infarction, acute coronary syndrome, decompensated heart failure, stroke, or death from cardiovascular causes. Cox models were utilized to understand the occurrence of SAEs with CVD events according to baseline atherosclerotic cardiovascular disease (ASCVD) risk. RESULTS: SAEs occurred in 96% of those experiencing a CVD event but only in 34% (P < 0.001) of those not experiencing a CVD event. Occurrence of SAEs monotonically increased across the range of baseline ASCVD risk being approximately twice as great in the highest compared with the lowest risk category. SAE occurrence was strongly associated with ASCVD risk but was similar within risk groups across treatment arms. In adjusted Cox models, experiencing a CVD event was the strongest predictor of SAEs in all risk groups. By the end of year 1, the hazard ratios for the low, middle, and high ASCVD risk tertiles, and baseline clinical CVD group were 2.56 (95% CI = 1.39-4.71); 2.52 (1.63-3.89); 3.61 (2.79-4.68); 1.86 (1.37-2.54), respectively-a trend observed in subsequent years until study end. Intensive treatment independently predicted SAEs only in the second ASVCD risk tertile. CONCLUSIONS: The occurrence of SAEs is multifactorial and mostly related to prerandomization patient characteristics, most prominently ASCVD risk, which, in turn, relates to in-study CVD events.

Blood pressure and the new ACC/AHA hypertension guidelines.

The ACC/AHA hypertension guidelines cover virtually all aspects of the diagnosis, evaluation, monitoring, secondary causes as well as drug and non-drug treatment of hypertension. Substantial and appropriate emphasis has been given to the strategies necessary for accurate measurement of blood pressure in any setting where valid blood pressure measurements are desired. Most "errors" made during blood pressure measurement bias readings upwards resulting in over-diagnosis of hypertension and, amongst those already on drug therapy, underestimating the true magnitude of blood pressure lowering resulting in over-treatment. Hypertension is diagnosed when blood pressure is consistently ≥130 and/or ≥80 mm Hg. However, the majority of patients with hypertension between 130-139/80-89 mm Hg (stage 1 hypertension) do not qualify for immediate drug therapy. The guideline breaks new ground with some of its recommendations. Absolute cardiovascular risk is utilized, for the first time, to determine high-risk status when BP 130-139/80-89 mm Hg (Stage 1 hypertension) and high-risk patient characteristics/co-morbidities are absent including age 65 and older, diabetes, chronic kidney disease, known cardiovascular disease; high-risk individuals initiate drug therapy when BP ≥ 130/80 mm Hg. The exception amongst high-risk individuals is for secondary stroke prevention in drug naïve individuals as drug therapy is initiated when blood pressure ≥140/90 mm Hg. Non-high risk individuals will initiate drug therapy when BP is ≥140/90 mm Hg. Irrespective of blood pressure threshold for initiation of drug therapy, the target BP is minimally <130/80 mm Hg in most. However, target BP is <130 systolic amongst those 65 and older as the committee made no recommendation for a DBP target. Treatment should be initiated with two drugs having complementary mechanisms of action when blood pressure is >20/10 mm Hg above goal.