Treatment resistant hypertension and the incidence of cardiovascular disease and end-stage renal disease: results from the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) (original) (raw)

2014, Journal of the American Society of Hypertension

H ypertension is considered one of the most important risk factors for stroke, coronary heart disease (CHD), heart failure (HF), and end-stage renal disease (ESRD). 1,2 In a subset of patients with hypertension, blood pressure (BP) remains inadequately controlled despite the use of multiple classes of antihypertensive medication. The concept of resistant hypertension is familiar to many clinicians with one widely accepted definition provided in a scientific statement published by the American Heart Association in 2008. 3 In this statement, treatment-resistant hypertension (TRH) was defined as uncontrolled BP despite the use of ≥3 antihypertensive medication classes or controlled BP while treated with ≥4 antihypertensive medication classes. Ideally, one of these classes should be a diuretic. The concept of TRH was derived "to identify patients who are at high risk of having reversible causes of hypertension and patients who, because of persistently high BP levels, may benefit from special diagnostic and therapeutic considerations". 3 Using data from the 2005 to 2008 US National Health and Nutrition Examination Survey, Egan et al 4 estimated the prevalence of apparent TRH (aTRH) to be 11.8% among individuals Abstract-Apparent treatment-resistant hypertension (aTRH) is defined as uncontrolled hypertension despite the use of ≥3 antihypertensive medication classes or controlled hypertension while treated with ≥4 antihypertensive medication classes. Although a high prevalence of aTRH has been reported, few data are available on its association with cardiovascular and renal outcomes. We analyzed data on 14 684 Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) participants to determine the association between aTRH (n=1870) with coronary heart disease, stroke, allcause mortality, heart failure, peripheral artery disease, and end-stage renal disease. We defined aTRH as blood pressure not at goal (systolic/diastolic blood pressure ≥140/90 mm Hg) while taking ≥3 classes of antihypertensive medication or taking ≥4 classes of antihypertensive medication with blood pressure at goal during the year 2 ALLHAT study visit (1996-2000). Use of a diuretic was not required to meet the definition of aTRH. Follow-up occurred through 2002. The multivariable adjusted hazard ratios (95% confidence intervals) comparing participants with versus without aTRH were as follows: coronary heart disease (1.44 [1.18-1.76]), stroke (1.57 [1.18-2.08]), all-cause mortality (1.30 [1.11-1.52]), heart failure (1.88 [1.52-2.34]), peripheral artery disease (1.23 [0.85-1.79]), and end-stage renal disease (1.95 [1.11-3.41]). aTRH was also associated with the pooled outcomes of combined coronary heart disease (hazard ratio, 1.47; 95% confidence interval, 1.26-1.71) and combined cardiovascular disease (hazard ratio, 1.46; 95% confidence interval, 1.29-1.64). These results demonstrate that aTRH increases the risk for cardiovascular disease and end-stage renal disease. Studies are needed to identify approaches to prevent aTRH and reduce risk for adverse outcomes among individuals with aTRH. (Hypertension. 2014;64:1012-1021.) • Online Data Supplement