-
Current Cardiology Reports Nov 2023To provide an update and review approaches to the treatment of resistant hypertension (RH) with a focus on emerging potential therapies. (Review)
Review
PURPOSE OF REVIEW
To provide an update and review approaches to the treatment of resistant hypertension (RH) with a focus on emerging potential therapies.
RECENT FINDINGS
Resistant hypertension is defined as a blood pressure that remains elevated above a patient's individualized target despite the concurrent use of 3 antihypertensive agents of different classes including a diuretic or use of 4 or more antihypertensive agents. Patients with RH have an increased risk of adverse cardiovascular and renal outcomes. Most RH is attributed to apparent RH and is not true RH. True RH is a diagnosis of exclusion after apparent RH has been excluded. Treatment of RH is challenging, and blood pressure goal is often difficult to achieve. Currently several new therapies have emerged with forthcoming data that provide promise for improved blood pressure control in those with resistant hypertension. Once RH has been diagnosed, patients should be on standardized therapy that includes agents from three different classes including a diuretic with addition in most cases of a mineralocorticoid as a fourth line agent. There are newer agents in development currently being studied in clinical trials including dual endothelin receptor antagonists and aldosterone synthase inhibitors that appear to be efficacious. Other approved medications including SGLT2 inhibitors and non-steroidal mineralocorticoids such as finerenone also need to be incorporated into treatment paradigms. Renal denervation with catheter based devices is another potential promising treatment option in this population.
Topics: Humans; Antihypertensive Agents; Hypertension; Blood Pressure; Kidney; Diuretics; Mineralocorticoid Receptor Antagonists
PubMed: 37755638
DOI: 10.1007/s11886-023-01966-8 -
Current Opinion in Cardiology Jul 2024Resistant hypertension (RH) is characterized by persistently elevated blood pressure despite the concurrent use of three antihypertensive medications, including a... (Review)
Review
PURPOSE OF REVIEW
Resistant hypertension (RH) is characterized by persistently elevated blood pressure despite the concurrent use of three antihypertensive medications, including a diuretic, at optimal doses. This clinical phenomenon poses a significant burden on healthcare systems worldwide due to its association with increased cardiovascular disease morbidity and mortality.
RECENT FINDINGS
Ongoing studies on device-based treatment of RH, with aim to reduce sympathetic nervous system outflow, have shown promising evidence in management of RH which may in turn decrease the incidence of composite cardiovascular outcome faced by the affected population.
SUMMARY
This paper aims to provide a comprehensive overview of RH, and review some of the diagnostic and therapeutic approaches in management of RH.
Topics: Humans; Hypertension; Antihypertensive Agents; Drug Resistance; Blood Pressure
PubMed: 38456513
DOI: 10.1097/HCO.0000000000001134 -
Hypertension Research : Official... Aug 2023The significance of hypertension management in older individuals is greatly influenced by factors other than chronological age, as they have diverse physical, mental,... (Review)
Review
The significance of hypertension management in older individuals is greatly influenced by factors other than chronological age, as they have diverse physical, mental, and social backgrounds. Differences in physical functions, between independence, frailty and dependence, have a great impact on antihypertensive therapy in the older population. While recent clinical trials support the significance of intensive antihypertensive therapy regardless of age, there is little evidence to positively support the significance of antihypertensive therapy for older patients with physical function requiring nursing care, and observational studies suggest that antihypertensive treatment may instead be harmful in these older patients. Therefore, frailty, the transitional state between independence and dependence with the need for nursing care, is conceivable to be the tipping point at which the balance of risks and benefits of antihypertensive treatment is converted. The increased risk of acute adverse outcome is another issue that complicates management in the practice of hypertension treatment in frail patients. Particularly, increased blood pressure variability manifested by orthostatic hypotension in frail patients can induce fall and fracture leading to disability shortly after initiation or modification of antihypertensive treatment. Future challenges to optimize the management of frail hypertensive patients include developing techniques to estimate treatment efficacy, identifying safe antihypertensive regimens that reduce the risk of falls, and establishing strategies to restore frail patients to robust health.
Topics: Aged; Humans; Antihypertensive Agents; Blood Pressure; Frail Elderly; Frailty; Hypertension; Hypotension, Orthostatic
PubMed: 37280259
DOI: 10.1038/s41440-023-01310-1 -
Hypertension (Dallas, Tex. : 1979) May 2024Elevated blood pressure is a well-established risk factor for age-related cognitive decline. Long linked to cognitive impairment on vascular bases, increasing evidence... (Review)
Review
Elevated blood pressure is a well-established risk factor for age-related cognitive decline. Long linked to cognitive impairment on vascular bases, increasing evidence suggests a potential association of hypertension with the neurodegenerative pathology underlying Alzheimer disease. Hypertension is well known to disrupt the structural and functional integrity of the cerebral vasculature. However, the mechanisms by which these alterations lead to brain damage, enhance Alzheimer pathology, and promote cognitive impairment remain to be established. Furthermore, critical questions concerning whether lowering blood pressure by antihypertensive medications prevents cognitive impairment have not been answered. Recent developments in neurovascular biology, brain imaging, and epidemiology, as well as new clinical trials, have provided insights into these critical issues. In particular, clinical and basic findings on the link between neurovascular dysfunction and the pathobiology of neurodegeneration have shed new light on the overlap between vascular and Alzheimer pathology. In this review, we will examine the progress made in the relationship between hypertension and cognitive impairment and, after a critical evaluation of the evidence, attempt to identify remaining knowledge gaps and future research directions that may advance our understanding of one of the leading health challenges of our time.
Topics: Humans; Alzheimer Disease; Hypertension; Cognitive Dysfunction; Brain; Antihypertensive Agents
PubMed: 38426329
DOI: 10.1161/HYPERTENSIONAHA.123.21356 -
American Heart Journal Dec 2023Atherosclerotic cardiovascular disease (ASCVD) is a prevalent chronic condition managed through pharmacotherapy targeting modifiable risk factors. However, ASCVD... (Review)
Review
Atherosclerotic cardiovascular disease (ASCVD) is a prevalent chronic condition managed through pharmacotherapy targeting modifiable risk factors. However, ASCVD patients often face poor medication adherence due to a high pill burden from multiple oral drugs, contributing to cardiovascular events. Recent evidence indicates that polypills combining antihypertensive and statin medications effectively control risk factors and improve adherence in various ASCVD risk patients. Randomized clinical trials demonstrate polypill efficacy in reducing major cardiovascular events, making them a convenient strategy for both established ASCVD patients and those without ASCVD. These positive results encourage the incorporation of polypills into comprehensive cardiovascular prevention programs, particularly for socio-economically vulnerable populations. Nevertheless, barriers remain, such as unclear regulatory approval pathways and physician hesitancy. Despite challenges, the benefits of fixed-dose combinations are evident and should be encouraged for secondary and primary prevention, especially in high-risk categories. Technological advancements could further support the successful integration of polypills in clinical practice. This review discusses the evidence, challenges, and perspectives of polypills, emphasizing their potential impact on cardiovascular disease management.
Topics: Humans; Cardiovascular Diseases; Drug Combinations; Antihypertensive Agents; Hydroxymethylglutaryl-CoA Reductase Inhibitors; Risk Factors; Secondary Prevention; Primary Prevention
PubMed: 37634656
DOI: 10.1016/j.ahj.2023.08.012 -
Pediatric Nephrology (Berlin, Germany) Jun 2024Diabetes mellitus, a disease that affects hundreds of millions of people worldwide, is increasing in prevalence in all age groups, including children and adolescents....
Diabetes mellitus, a disease that affects hundreds of millions of people worldwide, is increasing in prevalence in all age groups, including children and adolescents. Much of the morbidity and mortality associated with diabetes is closely related to hypertension, often coincident with diabetes. Comorbid hypertension and diabetes often worsen the outcomes of each other, likely rooted in some overlapping pathogenic mechanisms. In this educational review, we will discuss the shared pathophysiology of diabetes and hypertension, particularly in regard to inflammation and oxidative stress, the sympathetic nervous system, vascular remodeling, and the renin-angiotensin-aldosterone system (RAAS). We will also review current hypertension diagnosis and management guidelines from many international jurisdictions for both adult and paediatric populations in the setting of diabetes. Many of these guidelines highlight the use and utility of RAAS blockers in this clinical scenario; however, on review of the evidence for their use, several meta-analyses and systematic reviews fail to demonstrate superiority of RAAS blockers over other anti-hypertensive medications. Finally, we discuss several new anti-hypertensive medications, review their mechanisms of action, and highlight some of the evidence for their use in the setting of hypertension and diabetes.
Topics: Child; Humans; Adolescent; Antihypertensive Agents; Angiotensin-Converting Enzyme Inhibitors; Hypertension; Renin-Angiotensin System; Diabetes Mellitus
PubMed: 37831122
DOI: 10.1007/s00467-023-06163-x -
Hypertension (Dallas, Tex. : 1979) Nov 2023Hypertension and osteoporosis are common comorbidities among elderly individuals. Drug therapy has been widely used in clinical practice as the preferred... (Review)
Review
Hypertension and osteoporosis are common comorbidities among elderly individuals. Drug therapy has been widely used in clinical practice as the preferred antihypertensive treatment. Therefore, antihypertensive drugs have become some of the most commonly prescribed drugs in healthcare settings. However, antihypertensive drugs have different effects on bone metabolism. The results of animal and clinical studies on the effects of antihypertensive drugs on osteoporosis or fracture risk are controversial and have aroused widespread concern among clinicians. Recent studies found that angiotensin receptor blockers, selective β-adrenergic receptor blockers, and thiazide diuretics might improve bone trabecular number and bone mineral density by stimulating osteoblast differentiation, reducing osteoclast generation, and other mechanism. Furthermore, nonselective β-adrenergic receptor blockers and dihydropyridine calcium channel blockers were found to have no significant relationship with bone mineral density or bone strength, and α-adrenergic receptor blockers and loop diuretics might increase fracture risk by decreasing bone mineral density. This article aimed to review previous animal experiments, clinical studies, and meta-analyses focusing on the effects of different antihypertensive drugs on bone metabolism, and to provide a new approach for the prevention and treatment of osteoporosis.
Topics: Humans; Aged; Antihypertensive Agents; Angiotensin-Converting Enzyme Inhibitors; Calcium Channel Blockers; Hypertension; Adrenergic beta-Antagonists; Adrenergic alpha-Antagonists; Fractures, Bone; Osteoporosis; Receptors, Adrenergic, beta; Diuretics
PubMed: 37675564
DOI: 10.1161/HYPERTENSIONAHA.123.21648 -
Ugeskrift For Laeger Jun 2024Ongoing monitoring and targeted treatment are important to ensure the best blood-pressure control and thus prevent cardiovascular risks. In this review, we evaluate the... (Review)
Review
Ongoing monitoring and targeted treatment are important to ensure the best blood-pressure control and thus prevent cardiovascular risks. In this review, we evaluate the findings of four clinical studies investigating the effects of morning versus bedtime dosing of antihypertensives. In three out of four studies, overwhelming results were found favouring bedtime dosing. The same studies have been criticized for mechanistic implausible results and multiple study biases. No harmful effects were reported in relation to bedtime dosing. Thus, antihypertensives can be taken as it is most convenient for the patient.
Topics: Humans; Antihypertensive Agents; Hypertension; Drug Administration Schedule; Drug Chronotherapy; Blood Pressure
PubMed: 38903038
DOI: 10.61409/V11230700 -
Journal of the American College of... Nov 2023
Topics: Humans; Kidney; Hypertension; Denervation; Longitudinal Studies; Antihypertensive Agents; Blood Pressure; Sympathectomy; Treatment Outcome; Blood Pressure Monitoring, Ambulatory
PubMed: 37914511
DOI: 10.1016/j.jacc.2023.09.795 -
Internal Medicine Journal Oct 2023Resistant hypertension (RHT) is typically defined as blood pressure that remains above guideline-directed targets despite the use of three anti-hypertensives, usually... (Review)
Review
Resistant hypertension (RHT) is typically defined as blood pressure that remains above guideline-directed targets despite the use of three anti-hypertensives, usually including a diuretic, at optimal or maximally tolerated doses. It is generally estimated to affect 10-30% of those diagnosed with hypertension, though the true incidence might be lower after one factor in the prevalence of non-adherence. Risk factors for its development include diabetes, obesity and other adverse lifestyle factors, and a diagnosis of RHT confers a greater risk of adverse cardiovascular outcomes, such as stroke, heart failure and mortality. It is essential to exclude pseudoresistance and secondary hypertension and to ensure non-pharmacologic management is optimised prior to consideration of fourth-line anti-hypertensive agents or advanced interventions, such as device therapies. In this review, we will cover the different definitions of RHT, along with the importance of careful diagnosis and management strategies, and discuss newer agents and research needs.
Topics: Humans; Hypertension; Antihypertensive Agents; Blood Pressure; Diuretics; Risk Factors
PubMed: 37493367
DOI: 10.1111/imj.16189