Current 4 - Black Patients with Apparent Treatment-Resistant Hypertension May be at Risk for Underutilizing Evidence-Based Pharmacologic Treatments

Summary

A review of historical data from several recent landmark clinical trials found that, when applying current treatment recommendations for apparent treatment-resistant hypertension (aTRH), very few Black patients were taking the optimal pharmacologic treatment. This suggests a significant opportunity to change the prescribed therapy for Black patients to match current evidence-based guidelines.

Resistant hypertension (RH) is defined by the American Heart Association (AHA) as above-goal blood pressure (BP) in a patient despite the use of ≥ 3 classes of antihypertensive medication or the use of ≥ 4 classes regardless of BP level.

The qualifying term, apparent treatment-resistant hypertension, is used when criteria for RH are met but pseudoresistance cannot be excluded due to factors such as white coat effect or medication nonadherence. A 2018 AHA Scientific Statement provided a comprehensive update on RH management, which includes evidence-based lifestyle interventions and preferential use of two antihypertensive classes: changing the preferred diuretic to a long-acting thiazide-like diuretic (chlorthalidone or indapamide) and adding a mineralocorticoid receptor antagonist (spironolactone or eplerenone).¹

A recent Hypertension² article analyzed data from the JHS (Jackson Heart Study)³ and RE-GARDS (Reasons for Geographic and Racial Differences in Stroke)⁴ studies, conducted prior to 2016, to determine if self-identified Black adults with aTRH in these large study populations had received the lifestyle and pharmacologic treatments recommended by the 2018 AHA Scientific Statement. The authors found that 28% of Black adults taking antihypertensive medication met criteria for RH, but were unable to entirely exclude pseudoresistance in the original studies; those patients were categorized as having aTRH. Less than 6% of the patients with aTRH reported taking a long-acting thiazide-like diuretic and < 10% reported taking a mineralocorticoid receptor antagonist.

The authors conclude that recommended pharmacologic and evidence-based lifestyle interventions for aTRH were underutilized, low use of the optimized regimen presents an opportunity to improve care, and “achieving higher rates of BP control among Black adults may have an important role in reducing disparities in hypertension-related morbidity and mortality.”

Sources

¹Carey RM, Calhoun DA, Bakris GL, et al. Resistant hypertension: detection, evaluation, and management: a scientific statement from the American Heart Association. Hypertension. 2018;72:e53–e90. doi:10.1161/HYP.0000000000000084.

²Langford AT, Akinyelure OP, Moore TL Jr, et al. Underutilization of treatment for black adults with apparent treatment-resistant hypertension: JHS and the REGARDS study. Hypertension. 2020;76(5):1600-1607. doi:10.1161/HYPERTENSIONAHA.120.14836.

³National Heart, Lung, and Blood Institute. Jackson Heart Study (JHS). https://www.nhlbi.nih.gov/science/jackson-heart-study-jhs. Updated 2020. Accessed October 26, 2020.

⁴Shimbo D, Levitan EB, Booth JN 3rd, et al. The contributions of unhealthy lifestyle factors to apparent resistant hypertension: findings from the Reasons for Geographic And Racial Differences in Stroke (REGARDS) study. J Hypertens. 2013;31:370–376. doi:10.1097/HJH.0b013e32835b6be7.