Refractory and Resistant Hypertension: Antihypertensive Treatment Failure versus Treatment Resistance

Calhoun DA 대한심장학회 2016 Korean Circulation Journal Vol.46 No.5

Resistant hypertension has for many decades been defined as difficult-to-treat hypertension in order to identify patients who may benefit from special diagnostic and/or therapeutic considerations. Recently, the term “refractory hypertension” has been proposed as a novel phenotype of antihypertensive failure, that is, patients whose blood pressure cannot be controlled with maximal treatment. Early studies of this phenotype indicate that it is uncommon, affecting less than 5% of patients with resistant hypertension. Risk factors for refractory hypertension include obesity, diabetes, chronic kidney disease, and especially, being of African origin. Patients with refractory are at high cardiovascular risk based on increased rates of known heart disease, prior stroke, and prior episodes of congestive heart failure. Mechanisms of refractory hypertension need exploration, but early studies suggest a possible role of heightened sympathetic tone as evidenced by increased office and ambulatory heart rates and higher urinary excretion of norepinephrine compared to patients with controlled resistant hypertension. Important negative findings argue against refractory hypertension being fluid dependent as is typical of resistant hypertension, including aldosterone levels, dietary sodium intake, and brain natriuretic peptide levels being similar or even less than patients with resistant hypertension and the failure to control blood pressure with use of intensive diuretic therapy, including both a long-acting thiazide diuretic and a mineralocorticoid receptor antagonist. Further studies, especially longitudinal assessments, are needed to better characterize this extreme phenotype in terms of risk factors and outcomes and hopefully to identify effective treatment strategies.

Resistant hypertension: consensus document from the Korean society of hypertension

Park Sungha,Shin Jinho,임상현,김광일,Kim Hack-Lyoung,Kim Hyeon Chang,Lee Eun Mi,Lee Jang Hoon,Ahn Shin Young,Cho Eun Joo,Kim Ju Han,Kang Hee-Taik,Lee Hae-Young,Lee Sunki,Kim Woohyeun,Park Jong-Moo 대한고혈압학회 2023 Clinical Hypertension Vol.29 No.-

Although reports vary, the prevalence of true resistant hypertension and apparent treatment-resistant hypertension (aTRH) has been reported to be 10.3% and 14.7%, respectively. As there is a rapid increase in the prevalence of obesity, chronic kidney disease, and diabetes mellitus, factors that are associated with resistant hypertension, the prevalence of resistant hypertension is expected to rise as well. Frequently, patients with aTRH have pseudoresistant hypertension [aTRH due to white-coat uncontrolled hypertension (WUCH), drug underdosing, poor adherence, and inaccurate office blood pressure (BP) measurements]. As the prevalence of WUCH is high among patients with aTRH, the use of out-of-office BP measurements, both ambulatory blood pressure monitoring (ABPM) and home blood pressure monitoring (HBPM), is essential to exclude WUCH. Non-adherence is especially problematic, and methods to assess adherence remain limited and often not clinically feasible. Therefore, the use of HBPM and higher utilization of singlepill fixed-dose combination treatments should be emphasized to improve drug adherence. In addition, primary aldosteronism and symptomatic obstructive sleep apnea are quite common in patients with hypertension and more so in patients with resistant hypertension. Screening for these diseases is essential, as the treatment of these secondary causes may help control BP in patients who are otherwise difficult to treat. Finally, a proper drug regimen combined with lifestyle modifications is essential to control BP in these patients.

고혈압이 조절 안 되는 원인과 대책

박종훈 ( Chong Hun Park ) 대한내과학회 2009 대한내과학회지 Vol.76 No.4

어떤 고혈압 환자에서는 부작용 없이 목표 혈압에 도달하기 어려운 경우도 있을 수 있다. 그러나 단순히 고혈압 약물을 증량하기 전에 살펴보아야 할 요소와 단계가 있다. 혈압 측정 시 혈압이 정확하게 측정되었는지 백의 고혈압이나 백의 효과는 없는지 확인한다. 환자가 자신의 적정한 혈압조절과 유지를 위한 마음가짐을 가지고 있으며 치료에 적극적으로 참여하기 위해 의사와 의사소통이 잘되고 있는지 생각해보고 항고혈압 약물을 잘 복용하도록 한다. 약물요법뿐만 아니라 체중조절 식이염분의 제한, 알코올 절제와 같은 비약물 요법도 충분히 노력할 가치가 있음을 인식하도록 한다. 이차 고혈압의 원인이 되는 질환에 대한 병력청취와 이에 대한 진단검사를 한다. 혈압을 상승시킬 수 있는 약물을 같이 복용하고 있지 않은지 체크한다. 복합적인 다수의 항고혈압 약제를 복용 중에는 혈관확장제의 과다사용으로 인해 용적과부하 또는 교감신경계의 이차적 항진이 일어났는지 살펴보고 충분한 이뇨제 사용과 적절한 베타차단제를 사용한다. 이뇨제는 반감기, 작용기전, 신기능 상태를 고려하여 적절히 선택하고 알도스테론 차단제도 고려한다. 그러나 무엇보다도 필요한 요소는 환자의 혈압조절에 대한 순응도를 높이기 위한 전반적인 배려일 것이다. Resistant hypertension is defined as when the blood pressure cannot be reduced to below 140/90 mmHg in patients who are adhering to an adequate and appropriate triple drug regimen that includes a diuretic, in near full doses. Before changing or increasing the antihypertensive medication, several factors should be checked. A careful evaluation of the patient`s adherence to therapy and adequate measurement of blood pressure are needed to exclude pseudoresistance secondary to poor medical adherence or white coat hypertension. Patients should be asked regularly about medications or substances that could interfere with blood pressure control. Successful treatment requires the identification of causes and a reversal of life style factors contributing to treatment resistance. Diabetes, chronic kidney disease, nonsteroidal anti-inflammatory drugs, high salt intake, obesity, and alcohol abuse are frequent causes of uncontrolled hypertension in Korea. The diagnosis and appropriate treatment of secondary hypertension is also needed. When multiple medications are used, vasodilators are the most commonly used antihypertensive drugs that cause subsequent fluid retention or sympathetic tone elevation. Adequate, effective, and sufficient diuresis and catecholamine suppression are needed for patients who do not respond to several vasodilators. (Korean J Med 76:398-401, 2009)

Effect of Myoarchitectonic Spinolaminoplasty on Concurrent Hypertension in Patients With Cervical Spondylotic Myelopathy

Kazushige Itoki,Ryu Kurokawa,Tetsuro Shingo,Phyo Kim 대한척추신경외과학회 2018 Neurospine Vol.15 No.1

Objective: When treating patients with cervical spondylotic myelopathy (CSM), we often note amelioration in concomitant hypertension after surgery. To assess the effects of surgery and the mechanisms thereof, blood pressure (BP) and parasympathetic nervous activity were monitored prospectively in CSM patients undergoing surgery. Methods: Sixty-eight consecutive CSM patients who underwent surgery with myoarchitectonic spinolaminoplasty were enrolled. BP and electrocardiography were recorded preoperatively and at 1, 3, and 6 months postoperatively. Forty-six patients completed the scheduled follow-ups and were analyzed. Preoperatively, 17 had a mean BP higher than 100 mmHg (the HT group) and 12 had hypertension despite taking medication (the HT-refractory group). To evaluate alterations in parasympathetic function, the coefficient of variation of the RR interval (CVRR) was evaluated. Results: A significant BP reduction was observed in the HT group 6 months after surgery, but not in the normotensive group (n=29). The effect was more remarkable in the HT-refractory group. A transient BP increase at 1 and 3 months after surgery was observed in all groups. Comparisons were made between groups classified by age (over 65 years or younger than 60 years) and the presence or absence of an intramedullary hyperintense T2 signal on magnetic resonance imaging, but no significant differences were detected. Measurements of CVRR did not significantly differ between the groups over the course of follow-up. Conclusion: Hypertension coexisting with CSM can be ameliorated after surgical treatment. The effect is likely to be mediated by moderation of sympathetic activity, rather than parasympathetic activation. We believe that a combination of adequate decompression of the spinal cord and relief from musculoskeletal stresses effectuate this moderation.

Aortoiliac Occlusive Disease as a Cause of Allograft Kidney Dysfunction and Refractory Hypertension

오행진 고신대학교(의대) 고신대학교 의과대학 학술지 2019 고신대학교 의과대학 학술지 Vol.34 No.2

Aortoiliac occlusive disease (AIOD), especially proximal to the transplant artery, in kidney transplant patient activates the renin-angiotensin-aldosterone system by limiting graft renal perfusion and causes symptoms that can occur with transplant renal artery stenosis (TRAS) such as refractory hypertension, water retention, and graft renal dysfunction. Immediate clinical suspicion is difficult due to the nature of the progressive disease unlike TRAS. Herein, we present an interesting case of bilateral common iliac artery occlusion (AIOD, TASC II, type C) that manifested as uncontrolled blood pressure and decreased allograft function in a patient who had kidney transplant 17 years ago. The patient was successfully diagnosed with duplex scan, ankle-brachial index (ABI) and computed tomography angiography and treated with percutaneous luminal angioplasty and stent graft insertion.

β-blockers in advanced cirrhosis: More friend than enemy

( Ki Tae Yoon ),( Hongqun Liu ),( Samuel S. Lee ) 대한간학회 2021 Clinical and Molecular Hepatology(대한간학회지) Vol.27 No.3

Nonselective beta-adrenergic blocker (NSBB) therapy for the prevention of initial and recurrent gastrointestinal bleeding in cirrhotic patients with gastroesophageal varices has been used for the past four decades. NSBB therapy is considered the cornerstone of treatment for varices, and has become the standard of care. However, a 2010 study from the group that pioneered β-blocker therapy suggested a detrimental effect of NSBBs in decompensated cirrhosis, especially in patients with refractory ascites. Since then, numerous additional studies have incompletely resolved whether NSBBs are deleterious, although more recent evidence weighs against a harmful effect. The possibility of a “therapeutic window” has also been raised. We aimed to review the literature to analyze the pros and cons of using NSBBs in patients with cirrhosis, not only with respect to bleeding or mortality but also to other potential benefits and risks. β-blockers are highly effective in preventing first bleeding and recurrent bleeding. Furthermore, NSBBs improve congestion/ischemia of the gut mucosa, decrease intestinal permeability, and therefore indirectly alleviate systemic inflammation. β-blockers shorten the electrocardiographic prolonged QTc interval and may also decrease the incidence of hepatocellular carcinoma. On the other hand, the possibility of deleterious effects in cirrhosis has not been completely eliminated. NSBBs may be associated with an increased risk of portal vein thrombosis, although this could be correlational artifact. Overall, we conclude that β-blockers in cirrhosis are much more of a friend than enemy. (Clin Mol Hepatol 2021;27:425-436)

Ahmed Valve Implantation for Refractory Glaucoma following Pars Plana Vitrectomy

( Ji Won Hong ),( Gwang Ju Choi ) 대한안과학회 2005 Korean Journal of Ophthalmology Vol.19 No.4

A Case of Adrenal Lymphangiectatic Cyst Associated with Severe Hypertension

Ha Young Yang,Jun Ho Lee,Hye Ran Lee,Chan Ok Choi,Jang Pil Park,Tae Sun Jin,Sung Yoon Lee 대한내과학회 1990 The Korean Journal of Internal Medicine Vol.5 No.2