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Rational Pharmacotherapy in Cardiology

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Treatment of Resistant Hypertension in Real Clinical Settings

https://doi.org/10.20996/1819-6446-2021-04-03

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Abstract

Background. Current guidelines describe in detail the approaches to the management of patients with resistant hypertension, however, in real clinical settings the number of non-rational and ineffective combinations of antihypertensive drugs used remains high.

Aim. To analyze the distribution of different combinations of antihypertensive drugs for the treatment of resistant hypertension and to estimate the proportion of non-rational combinations.

Methods. The retrospective analysis includes 117 outpatients with resistant hypertension. Resistant hypertension was defined as blood pressure that remains above goal despite concurrent use of three antihypertensive agents of different classes. Exclusion criteria was secondary hypertension. We defined rational combination as the standard combination (renin-angiotensin system [RAS] blocker + calcium-channel blocker [CCB] + diuretic) plus one of the group of reserve drugs (mineralocorticoid receptors antagonist [MRA], beta-blocker, alpha-blocker, agonist of imidazoline receptors [AIR]). Non-rational were considered combinations in which reserve drugs were used before the appointment of a triple combination of first-line drugs. Moreover, in a subgroup of non-rational therapy, situations were identified where such a combination was justified.

Results. The proportion of rational combinations was 58.9%, reasonably non-rational - 15.5%, unreasonably non-rational - 25.6%. Unreasonably non-rational combinations are distributed as follows: non-appointment of CCB - 12%, non-appointment of RAS-blockers - 8%, non-appointment of diuretics - 6%, use of RAS-blockers for hyperkalemia - 6%, administration of MRA without non-potassium-sparing diuretics - 5%, double blockade of RAS - 3%, other combinations - 7%. In addition to first-line drugs, beta-blockers (93.2%), loop diuretics (22.2%), AIR (21.4) were the most prescribable, while the proportion of MRA is only 15.4% of the entire sample.

Limitation: some patient's characteristics could be missed in case histories and some of the combinations could be falsely recognized as malpractice since the analysis was conducted retrospectively.

Conclusion. The proportion of the non-rational combinations for the treatment of resistant hypertension is high. Among the drugs of the reserve, the frequent use of beta-blockers and moxonidine and the inadequate administration of spironolactone are noteworthy. The problem of treatment strategy choice remains relevant in real clinical practice.

About the Authors

A. S. Maltseva
I.M. Sechenov First Moscow State Medical University (Sechenov University)
Russian Federation

Alexandra S. Maltseva

Moscow



A. E. Tsygankova
I.M. Sechenov First Moscow State Medical University (Sechenov University)
Russian Federation

Anna E. Tsygankova - eLibrary SPIN 6583-0476

Moscow



M. A. Gabitova
I.M. Sechenov First Moscow State Medical University (Sechenov University)
Russian Federation

Mariia A. Gabitova - eLibrary SPIN 4536-4690

Moscow



A. V. Rodionov
I.M. Sechenov First Moscow State Medical University (Sechenov University)
Russian Federation

Anton V. Rodionov - eLibrary SPIN 5063-0847

Moscow



V. V. Fomin
I.M. Sechenov First Moscow State Medical University (Sechenov University)
Russian Federation

Victor V. Fomin - eLibrary 8465-2747

Moscow



References

1. Muromtseva GA, Kontsevaya AV, Konstantinov VV, et al. The prevalence of non-infectious diseases risk factors in Russian population in 2012-2013 years. The results of ECVD-RF. Cardiovascular Therapy and Prevention. 2014;13(6):4-11 (In Russ.) DOI:10.15829/1728-8800-2014-6-4-11.

2. Williams B, Mancia G, Spiering W, et al. ESC Scientific Document Group.2018 ESC/ESH Guidelines for the management of arterial hypertension: The Task Force for the management of arterial hypertension of the European Society of Cardiology (ESC) and the European Society of Hypertension (ESH). Eur Heart J. 2018;39(33):3021-104. DOI:10.1093/eurheartj/ehy339.

3. Bohm M, Kario K, Kandzari DE, et al. SPYRAL HTN-OFF MED Pivotal Investigators. Efficacy of catheterbased renal denervation in the absence of antihypertensive medications (SPYRAL HTN-OFF MED Pivotal): a multicentre, randomised, sham-controlled trial. Lancet. 2020;395(10234):1444-51. DOI:10.1016/S0140-6736(20)30554-7.

4. Bobrie G, Frank M, Azizi M, et al. Sequential nephron blockade versus sequential renin-angiotensin system blockade in resistant hypertension: a prospective, randomized, open blinded endpoint study. J Hypertens. 2012;30(8):1656-64. DOI:10.1097/HJH.0b013e3283551e98.

5. Vac^k J, Sedlak R, Jarkovsky J, et al. Effect of spironolactone in resistant arterial hypertension: a ran-domized, double-blind, placebo-controlled trial (ASPIRANT-EXT). Medicine (Baltimore). 2014;93(27):e162. DOI:10.1097/MD.0000000000000162.

6. Williams B, MacDonald TM, Morant S, et al. Spironolactone versus placebo, bisoprolol, and doxazosin to determine the optimal treatment for drug-resistant hypertension (PATHWAY-2): a randomised, double-blind, crossover trial. Lancet. 2015;386(10008):2059-68. DOI:10.1016/S0140-6736(15)00257-3.

7. Krieger EM, Drager LF, Giorgi DMA, et al. ReHOT Investigators. Spironolactone Versus Clonidine as a Fourth-Drug Therapy for Resistant Hypertension: The ReHOT Randomized Study (Resistant Hypertension Optimal Treatment). Hypertension. 2018;71(4):681-90. DOI:10.1161/HYPERTENSION-AHA.117.10662.

8. Carey RM, Calhoun DA, Bakris GL, et al. Resistant Hypertension: Detection, Evaluation, and Management: A Scientific Statement From the American Heart Association. Hypertension. 2018;72(5):e53- e90. DOI:10.1161/HYP.0000000000000084.

9. Manolis AA, Manolis TA, Melita H, Manolis AS. Eplerenone Versus Spironolactone in Resistant Hypertension: an Efficacy and/or Cost or Just a Men's Issue? Curr Hypertens Rep. 2019;21(3):22. DOI:10.1007/s11906-019-0924-0.

10. Dahlof B, Sever PS, Poulter NR, et al.; ASCOT Investigators. Prevention of cardiovascular events with an antihypertensive regimen of amlodipine adding perindopril as required versus atenolol adding bendroflumethiazide as required, in the Anglo-Scandinavian Cardiac Outcomes Trial-Blood Pressure Lowering Arm (ASCOT-BPLA): a multicenter randomized controlled trial. Lancet. 2005;366:895- 906. DOI:10.1016/S0140-6736(05)67185-1.

11. Sundstrom J, Arima H, Woodward M, et al. for the Blood Pressure Lowering Treatment Trialists' Collaboration. Blood pressure-lowering treatment based on cardiovascular risk: a meta-analysis of individual patient data. Lancet. 2014;384:591-8. DOI:10.1016/S0140-6736(14)61212-5.

12. ALLHAT Officers and Coordinators for the ALLHAT Collaborative Research Group. The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial.Major Outcomes in High-Risk Hypertensive Patients Randomized to Angiotensin-Converting Enzyme Inhibitor or Calcium Channel Blocker vs Diuretic The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). JAMA. 2002;288(23):2981-97. DOI:10.1001/jama.288.23.2981.

13. Cohn JN, Pfeffer MA, Rouleau J, et al.; MOXCON Investigators. Adverse mortality effect of central sympathetic inhibition with sustained-release moxonidine in patients with heart failure (MOXCON). Eur J Heart Fail. 2003;5(5):659-67. DOI:10.1016/S1388-9842(03)00163-6.

14. Martin U, Hill C, O'Mahony D. Use of moxonidine in elderly patients with resistant hypertension. J Clin Pharm Ther. 2005;30(5):433-7. DOI:10.1111/j.1365-2710.2005.00672.x.

15. ONTARGET Investigators, Yusuf S, Teo KK, Pogue J, et al. Telmisartan, ramipril, or both in patients at high risk for vascular events. N Engl J Med. 2008;358:1547-59. DOI:10.1056/NEJMoa0801317.

16. Fried LF, Emanuele N, Zhang JH, et al.; VA NEPHRON-D Investigators. Combined Angiotensin Inhibition for the Treatment of Diabetic Nephropathy. N Engl J Med. 2013;369:1892-1903. DOI:10.1056/NEJMoa1303154.


For citation:


Maltseva A.S., Tsygankova A.E., Gabitova M.A., Rodionov A.V., Fomin V.V. Treatment of Resistant Hypertension in Real Clinical Settings. Rational Pharmacotherapy in Cardiology. 2021;17(2):200-205. (In Russ.) https://doi.org/10.20996/1819-6446-2021-04-03

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ISSN 1819-6446 (Print)
ISSN 2225-3653 (Online)