Plasma Renin test-guided drug treatment algorithm for correcting patients with treated but uncontrolled hypertension: a randomized controlled trial.

BACKGROUND: Undefined pathophysiologic mechanisms likely contribute to unsuccessful antihypertensive drug therapy. The renin test-guided therapeutic (RTGT) algorithm is based on the concept that, irrespective of current drug treatments, subnormal plasma renin activity (PRA) (<0.65 ng/ml/h) indicates sodium-volume excess "V" hypertension, whereas values >or=0.65 indicate renin-angiotensin vasoconstriction excess "R" hypertension. METHODS: The RTGT algorithm was applied to treated, uncontrolled hypertensives and compared to clinical hypertension specialists' care (CHSC) without access to PRA. RTGT protocol: "V" patients received natriuretic anti-"V" drugs (diuretics, spironolactone, calcium antagonists, or alpha(1)-blockers) while withdrawing antirenin "R" drugs (converting enzyme inhibitors, angiotensin receptor antagonists, or beta-blockers). Converse strategies were applied to "R" patients. Eighty-four ambulatory hypertensives were randomized and 77 qualified for the intention-to-treat analysis including 38 in RTGT (63.9 +/- 1.8 years; baseline blood pressure (BP) 157.0 +/- 2.6/87.1 +/- 2.0 mm Hg; PRA 5.8 +/- 1.6; 3.1 +/- 0.3 antihypertensive drugs) and 39 in CHSC (58.0 +/- 2.0 years; BP 153.6 +/- 2.3/91.9 +/- 2.0; PRA 4.6 +/- 1.1; 2.7 +/- 0.2 drugs). RESULTS: BP was controlled in 28/38 (74% (RTGT)) vs. 23/39 (59% (CHSC)), P = 0.17, falling to 127.9 +/- 2.3/73.1 +/- 1.8 vs. 134.0 +/- 2.8/79.8 +/- 1.9 mm Hg, respectively. Systolic BP (SBP) fell more with RTGT (-29.1 +/- 3.2 vs. -19.2 +/- 3.2 mm Hg, P = 0.03), whereas diastolic BP (DBP) declined similarly (P = 0.32). Although final antihypertensive drug numbers were similar (3.1 +/- 0.2 (RTGT) vs. 3.0 +/- 0.3 (CHSC), P = 0.73) in "V" patients, 60% (RTGT) vs. 11% (CHSC) of "R" drugs were withdrawn and BP medications were reduced (-0.5 +/- 0.3 vs. +0.7 +/- 0.3, P = 0.01). CONCLUSIONS: In treated but uncontrolled hypertension, RTGT improves control and lowers BP equally well or better than CHSC, indicating that RTGT provides a reasonable strategy for correcting treated but uncontrolled hypertension.

Ethnic differences in the treatment and control of hypertension in patients with diabetes.

Among diabetic hypertensive patients, ethnic differences in blood pressure control and outcomes have been attributed in part to greater reluctance of providers to prescribe combination antihypertensive regimens to African Americans than to Caucasians. African Americans purportedly receive fewer angiotensin-converting enzyme inhibitors (ACEIs) and/or angiotensin receptor blockers (ARBs), which reduce target organ complications. To assess these issues, cross-sectional data were analyzed from 19,864 diabetic hypertensives from 62 primary care clinics. Among diabetic hypertensives, African Americans (N=6230) were less likely than Caucasians (N=8041) to have blood pressure (BP) <130/80 mm Hg at their last clinic visit (23.1% [23.0%-23.2%] vs. 30.7% [30.6%-30.9%]) despite a greater number of prescriptions for antihypertensive medications (2.67 [2.63-2.70] vs. 2.23 [2.20-2.26]). African Americans were more likely than Caucasians to have an ACEI and/or ARB prescribed and to receive prescriptions for at least two antihypertensive medications that included an ACEI or ARB (64.1% [63.8%-64.4%] vs. 53.1% [52.8%-53.4%]). Among diabetic hypertensives, African Americans are less likely than Caucasians to attain BP <130/80 mm Hg, despite receiving more antihypertensive medication prescriptions. African Americans receive more ACEIs and/or ARBs than Caucasians for target organ protection and/or BP control. The data suggest provider prescribing patterns are not a major contributor to ethnic differences in BP control and outcomes in diabetic hypertensives.