Hypertensive Retinopathy and Stroke (Page 706)
Despite the fact that high blood pressure has been established as one of the most important risk factors for stroke, it still remains impossible to predict among people with a high blood pressure who will develop a stroke. A retinal examination provides a noninvasive window to assess the presence of end-organ damage in people with hypertension (hypertensive retinopathy). However, it remains unclear whether a simplified hypertensive retinopathy classification may provide additional information on stroke risk in subjects with hypertension.
In this issue of Hypertension, Ong et al present data from the Atherosclerosis Risk in Communities (ARIC) Study showing that, using a simplified hypertensive retinopathy classification, stroke risk was elevated in patients with hypertension and without diabetes mellitus, who had mild, moderate, and severe retinopathy during a mean follow-up period of 13 years. In addition, even in subjects who were on medication with good blood pressure control at the time of retinal examination, risk of cerebral infarction was doubled in patients with mild retinopathy and nearly tripled in patients with moderate to severe retinopathy. This suggests that blood pressure monitoring and medication compliance may not be sufficient for stroke prevention and that a simplified retinal examination using digital fundus photography may be of additional value in predicting stroke risk in patients with hypertension.
BPV and Mortality (Page 698)
It is well recognized that blood pressure (BP) is inherently variable, and this BP variability (BPV) arises from complex interactions between extrinsic environmental and behavioral factors and intrinsic cardiovascular regulatory mechanisms. There is convincing evidence that short-term BPV (obtained from multiple BP measurements during a 24-hour period) predicts end-organ damage and cardiovascular events. However, the question of whether long-term visit-to-visit BPV (which potentially reflects a more diverse set of influences than short-term 24-hour BPV) also independently predicts clinical outcomes has received more attention recently. In real-world practice, BP tends to be measured at varying intervals, and treatment titration and adherence differ among patients; consequently, the association between BPV and risk and its use in clinical practice are unclear. In this issue of Hypertension, Hastie et al show a clear association between visit-to-visit BPV in a large hypertension cohort with 14 522 subjects and ≈100 000 person-years of follow-up. They show for the first time that visit-to-visit BPV calculated during different time periods (1, 4, 5, 9 years) of the patients’ clinical course is a predictor of mortality, independent of long-term average BP. More interestingly, they show an incremental risk with increasing variability even in individuals whose BPs are well controlled. These data extend the current knowledge of BPV and add real-world support to the monitoring of BPV in clinical practice to facilitate risk reduction.
Optimal Treatment in Resistant Hypertension (Page 691)
Approximately 30% of treated, uncontrolled patients with hypertension are prescribed ≥3 blood pressure (BP) medications. The term apparent treatment-resistant hypertension (aTRH) was selected as there are 4 groups of patients with aTRH.
Measurement artifacts, for example, office hypertension and inaccurate measurements; 30% to 50% of aTRH patients’ office resistance, documented by self or ambulatory BP monitoring, is associated with fewer cardiovascular events.
Suboptimal adherence affects 10% to 50% of patients.
Inadequate antihypertensive regimen. Patients can qualify for >1 of 1 to 3 medications.
True TRH was estimated in 30% to 50% of patients with aTRH.
Optimal regimens, defined as a diuretic and 2 other BP medication classes for uncontrolled aTRH and diuretic and 3 other classes for controlled aTRH with each medication at ≥50% of maximum recommended hypertension dose, were found in ≈50% of uncontrolled and 38% of controlled patients with aTRH. Implications of our report include the following:
More aTRH patients currently on suboptimal regimens that tolerate diuretics and ≥50% maximal doses could achieve control with an optimal 3 medication regimens.
More patients might attain control on a calcium channel blocker, renin–angiotensin system inhibitor, and diuretic. More controlled patients with aTRH received these 3 medications than uncontrolled patients with aTRH as recommended by NICE (National Institute for Health and Clinical Excellence) and ISHIB (International Society on Hypertension in Blacks).
Greater use of aldosterone antagonists and loop diuretics could improve BP control. Controlled patients with aTRH were more likely than uncontrolled patients with aTRH to receive aldosterone antagonists and loop diuretics.
Greater use of statins, lower low-density lipoprotein cholesterol, and single-pill antihypertensive medication combinations might improve BP control. These factors were independent predictors of BP control in patients with aTRH. Hypercholesterolemia is linked to more angiotensin receptors and greater pressor responses to angiotensin, which is improved with statin therapy. Single-pill combinations improve adherence and can improve BP control.
- © 2013 American Heart Association, Inc.