Last month, the research round-up provided you with an overview of three articles concerned with prescribing benzodiazepines. This month, we will review three articles around the management of hypertension. The first looks at recent medication advances in the management of resistant hypertension. The second article reviews treatment modalities in hypertensive heart failure. Finally, our third article deals with medication and guideline adherence in hypertension and hyperlipidaemia.
Approach to resistant hypertension: a review of recent pharmacological advances
This article, published in the journal Current Treatment Options in Cardiovascular Medicine, sought to provide an update on the current clinical and pharmacological management of resistant hypertension. This review of recent and published research by the authors focuses on new and novel pharmacological therapies in the treatment of raised blood pressure (BP).
The review begins with an overview of resistant hypertension, and diagnosis of such, as well as investigation of possible secondary causes before discussing traditional management approaches. The follow-on to this is a review of new medications, which includes non-steroidal mineralocorticoid receptor antagonists, dual endothelin receptor antagonists, aldosterone synthase inhibitors, and angiotensinogen synthesis inhibitors.
“ An aldosterone synthase inhibitor has shown a promising role in a phase II trial, but is still a drug requiring close monitoring in patients who have renal compromise ”
This is a small review due to the availability of trial data, but the authors highlight the promising results seen with some of these drugs, and that they may offer an enhanced efficacy and safety profile when compared to some conventional treatment options in this population of hypertensive patients.
Few specific drugs are mentioned, with the review concentrating on classes of drugs. Particular mentions of note include finerenone, a non-steroidal mineralocorticoid receptor antagonist that shows fewer safety concerns, especially in patients with a history of kidney failure; aprocitentan, a dual endothelin receptor antagonist with fewer theoretical adverse effects, which shows favourable outcomes, especially in patients with a high risk of hyperkalaemia; and baxdrostat, an aldosterone synthase inhibitor that has shown a promising role in a phase II trial, but is still a drug requiring close monitoring in patients who have renal compromise.
The authors are careful to say that this is not a recommendation to completely change treatment approaches, but that their findings highlight the need for further research to evaluate these therapies, and the need for longitudinal studies to elucidate long-term impact on cardiovascular health and other outcomes.
Comparing antihypertensive strategies in hypertensive emergencies with heart failure
This retrospective cohort study, published in the American Journal of Emergency Medicine, was intended to assess the primary outcome of the length of time required to achieve a 25% drop in systolic BP or a whole reached BP of <160/110 mmHg (guideline driven targets) of various treatment modalities to ascertain which, if any, were the most effective.
The study was performed at a single tertiary care centre and collected data between January 2019 and December 2021 from electronic patient chart records. The data was obtained by using ICD-10 diagnostic codes to search for eligible patient records showing heart failure exacerbation in patients with hypertensive crisis. Patients were categorised into four groups: only oral medications, IV bolus, continuous IV infusion, or both continuous IV infusion and IV bolus. After application of inclusion and exclusion criteria, 120 patient admission records were included for analysis.
The most common risk factor was hypertension, with 112 of the sample having this diagnosis. Other risk factors included smoking and variations of heart failure. The authors state that they believe this study is one of the largest of a group of patients with exclusively acute hypertensive heart failure. The data showed no significant differences in achieving the target BP among groups, but patients on continuous IV infusion reached target BP in the quickest time. They also noted that those with IV bolus administration spent less time in ICU, although they spent equivalent time in hospital overall.
They do state that, with no significant difference in rates of complications across groups, there is insufficient evidence to suggest use of continuous IV infusion over other modalities. Analysis also showed that acute kidney injury was the most common complication.
They conclude that patients with acute hypertensive heart failure were able to successfully meet guideline-driven blood pressure goals, regardless of choice of treatment modalities, and that their study could be used to guide management of acute hypertensive heart failure. They suggest that future studies should aim to assess long-term outcomes for each treatment modality.
Goal attainment, medication adherence and guideline adherence in the treatment of hypertension and dyslipidemia in Irish populations: a systematic review and meta-analysis
This systematic review article, published in the International Journal of Cardiology Cardiovascular Risk and Prevention, aimed to quantify levels of blood pressure goal achievement, medication adherence and prescriber guideline adherence for patients on lipid lowering drugs and antihypertensives, either as primary or secondary prevention of cardiovascular disease.
The study was to review adult patients in Ireland and used the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) 2020 checklist (Page et al, 2021). The review was carried out in 2024 and used robust systematic review principles to search for quantitative studies that met the criteria for analysis. After PRISMA screening and application of inclusion and exclusion criteria, 23 articles met the criteria. The studies included were cohort and cross-sectional studies.
The quality and bias assessment found that 15 were of fair quality and eight were of good quality. The review analysed all aims individually.
Goal achievement of BP and lipid targets varied across the included studies and meta-analysis used the random effects (mixed) model to generate statistical outcomes. The achievement of BP <140/90 mmHg was 56%. The achievement of LDL-C <1.8 mmol/L was 41% compared to 69% of people reported to have achieved the less stringent goal of LDL-C <3 mmol/L.
With regard to the medication adherence of the included patients, studies were varied with a coverage of community and in patient settings and the assessment of adherence was by self-reporting questionnaires. Pooled data showed a range of 27% and 92% adherence to prescribed regimens.
Guideline adherence by prescriber findings showed that not all patients who should be on lipid-lowering therapy are actually prescribed as per guidelines, and that choice of antihypertensive is not always in line with the guidelines; this is an area for action to improve patient outcomes.
With prescriber adherence being so low, the authors recommend the instigation of national studies to objectively examine this phenomenon, alongside patient adherence and treatment goal achievement to examine the relationship between the three areas.
They conclude that there is considerable scope to improve goal attainment in people at risk of cardiovascular disease progression, and optimisation of medication adherence and guideline adherence may be of significant benefit to these patients.
Conclusion
Hypertension is a global healthcare issue and a known risk factor for other major and debilitating conditions such as vascular dementia, stroke, heart failure, coronary artery disease and chronic kidney disease, among others. It can be primary in nature with no identifiable cause or secondary where a known underlying condition is responsible.
Primary (or essential) hypertension accounts for around 90% of diagnosed cases. Strategies in hypertension management depend on the severity of the condition, with diet and lifestyle advice for the least severe and the need for anti-hypertensive medication in a step-wise approach depending on severity and risk.
Medication guidelines and target blood pressures are available to assist with monitoring and ongoing care. It is clear from these and other areas of research that continued optimisation of medications and adherence is necessary to improve outcomes in this population of patients to benefit their long-term cardiovascular health and reduce the burden on healthcare systems.