Key result
Intensive blood pressure lowering (<120 mm Hg) using the updated definition resulted in a treatment-resistant hypertension incidence of 30.3 per 100 patient-years vs 9.7 with standard treatment.
Why the study?
Recent guidelines call for more intensive blood pressure lowering and a less-stringent definition of treatment-resistant hypertension, both of which may increase the occurrence of this high-risk phenotype.
Does an intensive blood pressure target combined with updated guidelines increase the incidence of treatment-resistant hypertension in patients without baseline TRH?
RCT (n=11,784)
Intensive (<120 mm Hg) or standard (<140 mm Hg) systolic BP target
Does an intensive blood pressure target combined with updated guidelines increase the incidence of treatment-resistant hypertension in patients without baseline TRH?
Absolute Event Rate: 30.3% vs 9.7%
Implementation of the 2017 hypertension guidelines with lower BP goals substantially increases the incidence and prevalence of treatment-resistant hypertension and treatment burden.
May heighten treatment burden with intensive BP targets; leaves open optimal TRH definitions in future trials.
Recent guidelines call for more intensive blood pressure (BP)-lowering and a less-stringent treatment-resistant hypertension (TRH) definition, both of which may increase the occurrence of this high-risk phenotype. We performed a post hoc analysis of 11 784 SPRINT and ACCORD-BP participants without baseline TRH, who were randomized to an intensive (<120 mm Hg) or standard (<140 mm Hg) systolic BP target. Incidence, prevalence, and predictors of TRH were compared using the updated definition (requiring ≥4 drugs to achieve BP < 130/80 mm Hg) during intensive treatment, vs the former definition (requiring ≥4 drugs to achieve BP < 140/90 mm Hg) during standard treatment. Incidence/prevalence of apparent refractory hypertension (RFH; uncontrolled BP despite ≥5 drugs) was similarly compared. Overall, 5702 and 6082 patients were included in the intensive and standard treatment cohorts, respectively. Crude TRH incidence using the updated definition under intensive treatment was 30.3 (95% CI, 29.3-31.4) per 100 patient-years, compared with 9.7 (95% CI, 9.2-10.2) using the prior definition under standard treatment. Point prevalence using the prior TRH definition at 1-year was 7.5% in SPRINT and 14% in ACCORD vs 22% and 36%, respectively, with the updated TRH definition. Significant predictors of incident TRH included number of baseline antihypertensive drugs, having diabetes, baseline systolic BP, and Black race. Incidence of apparent RFH was also significantly greater using the updated vs prior definition (4.5 vs 1.0 per 100 person-years). Implementation of the 2017 hypertension guideline, including lower BP goals for most individuals, is expected to substantially increase treatment burden and incident TRH among the hypertensive population.
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Smith et al. (2019) conducted an RCT in Hypertension (n=11,784). Intensive systolic BP target vs. Standard systolic BP target (<140 mm Hg) was evaluated on Incidence of treatment-resistant hypertension (TRH). Intensive blood pressure lowering (<120 mm Hg) using the updated definition resulted in a treatment-resistant hypertension incidence of 30.3 per 100 patient-years vs 9.7 with standard treatment.
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