Uncontrolled and resistant arterial hypertension: prevalence, methods of modification of therapy

Abstract

The management of patients with uncontrolled arterial hypertension in real clinical practice remains a difficult task, despite the impressive arsenal of  antihypertensive drugs. In most cases, correction of medical therapy and lifestyle modification in this group of patients can achieve success in treatment, but in some cases, the target levels of blood pressure (AH) cannot be achieved.Aim. To assess the incidence of true resistant arterial hypertension in patients with hypertension, to identify the main causes of uncontrolled hypertension and to determine the main methods of modification of therapy.Materials and methods. The study included 70 patients with uncontrolled hypertension who received antihypertensive therapy previously. All patients underwent office measurement of blood pressure at the initial visit and after correction of therapy, 24-hour blood pressure monitoring (ABPM) was performed. Correction of therapy included the prescription of a standard three-component regimen «RAAS blocker + calcium antagonist + thiazide diuretic». In case of failure to achieve     the target BP levels, the measurement of aldosterone/renin in the blood was carried out to exclude primary hyperaldosteronism (PHA). In all patients, the body mass index (BMI) was calculated, echocardiography was performed to determine the target organ damage, complete blood count, biochemical blood tests were performed (to detect existing kidney damage).Results. In 86% of patients, target BP levels were achieved through lifestyle modification (weight loss) and correction of previous therapy. In 24% of the study subjects, low adherence to therapy (non-compliance) due to polypharmacy was revealed, in connection with which patients were recommended to switch to    fixed combinations of drugs, which made it possible to significantly reduce blood pressure below 140/90 mm Hg. according to the results of ABPM in all patients.   In 8% of patients, amlodipine/lercanidipine was replaced with long-acting nifedipine, which also led to a decrease in blood pressure (−5,5 mm Hg mean blood pressure according to ABPM). In two cases, the diagnosis of PHA was established, the tumor form of this disease was excluded using computed tomography of the adrenal glands, and treatment with aldosterone antagonists was prescribed. In 10% of patients, the diagnosis of «Resistant arterial hypertension» was confirmed, spironolactone in low doses (25-50 mg), doxazosin 1 mg, moxonidine 0,4 mg, bisoprolol 5 mg were sequentially added to the treatment. Spironolactone and doxazosin showed similar efficacy (−7,1 mmHg and −6,9 mmHg in mean BP, respectively), moxonidine and bisoprolol were less effective (−4,8 and −5,2 mmHg,respectively). In two patients, the addition of spironolactone or doxazosin did not lead to the achievement of the target BP level, a loop diuretic (furosemide 40 mg) was added to the treatment.Conclusion. The incidence of resistant hypertension among patients in the study was 10%. All patients with uncontrolled hypertension, if it is impossible to achieve the target values of blood pressure, provided that the treatment is correctly prescribed, it is necessary to exclude symptomatic hypertension, in particular, PHA. In case of confirmation of true RAH, it is necessary to prescribe aldosterone antagonists (spironolactone) in small doses, and doxazosin is also acceptable.