Proceedings from Duke Resistant Hypertension Think Tank - 31/05/14

Doi : 10.1016/j.ahj.2014.02.008

Sreekanth Vemulapalli, MD ^a, Jamy Ard, MD ^b, George L. Bakris, MD ^c, Deepak L. Bhatt, MD, MPH ^d, Alan S. Brown, MD ^e, William C. Cushman, MD ^f, Keith C. Ferdinand, MD ^g, John M. Flack, MD, MPH ^h, Jerome L. Fleg, MD ⁱ, Barry T. Katzen, MD ^j, John B. Kostis, MD ^k, Suzanne Oparil, MD ^l, Chet B. Patel, MD ^a,^m, Carl J. Pepine, MD ⁿ, Ileana L. Piña, MD, MPH ^o, Krishna J. Rocha-Singh, MD ^p, Raymond R. Townsend, MD ^q, Eric D. Peterson, MD, MPH ^a,^m, Robert M. Califf, MD ^a,^m, Manesh R. Patel, MD ^a,^m,^{^⁎}
^a Division of Cardiology, Duke University Medical Center, Durham, NC
^b Department of Epidemiology and Prevention, Wake Forest School of Medicine, Winston Salem, NC
^c Department of Medicine, Hypertensive Diseases Unit, University of Chicago, Pritzker School of Medicine, Chicago, IL
^d Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
^e Division of Cardiology, Advocate Lutheran General Hospital, Park Ridge, IL
^f Section of Preventive Medicine, Veterans Affairs Medical Center–Memphis, Memphis, TN
^g Tulane Heart and Vascular Institute and Tulane University School of Medicine, New Orleans, LA
^h Department of Medicine, Wayne State University, Detroit, MI
ⁱ Division of Cardiovascular Sciences, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD
^j Baptist Cardiac and Vascular Institute, Miami, FL
^k Department of Medicine, UMDNJ-RWJ Medical School, New Brunswick, NJ
^l Section of Vascular Biology and Hypertension, University of Alabama–Birmingham, Birmingham, AL
^m Duke Clinical Research Institute, Durham, NC
ⁿ Division of Cardiology, University of Florida, Gainesville, FL
^o Division of Cardiology, Montefiore Medical Center, New York, NY
^p Prairie Heart Institute at St John’s Hospital, Springfield, IL
^q Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA

^⁎Reprint requests: Manesh R. Patel, MD, Duke Clinical Research Institute, Duke University, 2400 Pratt St Durham, NC 27710.

Résumé

To identify patients at increased risk for cardiovascular outcomes, apparent treatment resistant hypertension (aTRH) is defined as having a blood pressure (BP) above goal despite the use of ≥3 antihypertensive therapies of different classes at maximally tolerated doses, ideally including a diuretic. In light of growing scientific interest in the treatment of this group, a multistakeholder think tank was convened to discuss the current state of knowledge, improve the care of these patients, and identify appropriate study populations for future observational and randomized trials in the field. Although recent epidemiologic studies in selected populations estimate that the prevalence of aTRH is 10% to 15% of hypertensive patients, further large-scale observational studies will be needed to better elucidate risk factors. To spur the development of therapies for aTRH, the development of an “aTRH” label for pharmacologic and device therapies with a developmental pathway including treatment added to the use of existing therapies is favored. Although demonstration of adequate BP lowering should be sufficient to gain Food and Drug Administration approval for therapies targeting aTRH, assessment of improvement in quality of life and cardiovascular outcomes is also desirable and considered in Centers for Medicare and Medicaid Services coverage decisions. Device trials under the aTRH label will need uniform and consistent processes for defining appropriate patient populations as well as postapproval registries assessing both long-term safety and duration of responses. Finally, patients with aTRH are likely to benefit from evaluation by a hypertension team to assure proper patient identification, diagnostic work-up, and therapeutic management before consideration of advanced or novel therapies to lower BP.

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