The Therapeutics of Resistant Hypertension

Volume 9, Issue 4

Happy Thanksgiving, everyone! In honor of the holiday, I thought it fitting that we discuss one of the most common conditions worldwide. Hypertension is still a leading contributor to cardiovascular mortality around the globe. Resistant hypertension (usually defined as refractory to three antihypertensive medications) is a dangerous condition that is difficult to treat. In this week’s issue of Talking Therapeutics, we explore recent evidence for two contributing factors to resistant hypertension.

Turkey Point 1: Hold the Salt

This topic felt too relevant not to discuss this week, as most of us will consume a month’s worth of salt in one sitting this Thanksgiving. Recent evidence has solidified the strong link between salt intake and hypertension.

Earlier this year, a group of researchers sought to clarify the dose-response effect of daily salt intake on blood pressure. They conducted a large network meta-analysis of 85 eligible trials with sodium intake ranging from 0.4 to 7.6 g/day and follow-up from 4 weeks to 36 months. The trials were conducted in participants with hypertension (n=65), without hypertension (n=11), or a combination (n=9).

Overall, the pooled data were compatible with an approximately linear relationship between achieved sodium intake and mean systolic as well as diastolic blood pressure, with no indication of a flattening of the curve at either the lowest or highest levels of sodium exposure. Results were similar for participants with or without hypertension, but the former group showed a steeper decrease in blood pressure after sodium reduction.

Turkey Point 2: Watch Those Offending Medications

Many medications can raise blood pressure, and use of these medications in patients with hypertension can lead to a resistant/refractory state.

Just this week, research published in the Journal of the American Medical Association evaluated the NHANES database to ascertain the presence and effect of medications known to increase blood pressure in a cohort of 27,599 adults. In total, 14.9% of US adults reported using medications that may cause elevated blood pressure, including 18.5% of adults with hypertension. The most reported classes were antidepressants (8.7%), prescription nonsteroidal anti-inflammatory drugs or NSAIDs (6.5%), steroids (1.9%), and estrogens (1.7%).

The use of medications that may raise blood pressure was associated with greater odds of uncontrolled hypertension among adults not concurrently taking antihypertensives (odds ratio, 1.24; 95% CI, 1.08-1.43) but not among patients concurrently taking antihypertensives. Also, the use of medications that may raise blood pressure was associated with greater use of antihypertensives among adults with controlled and uncontrolled hypertension, which suggests that discontinuation of the offending agents may facilitate deprescribing of antihypertensive drug therapy.