Resistant Hypertension? Ask About Snoring
Resistant Hypertension? Ask About Snoring
Hi. I'm Dr. Henry Black. I'm a Clinical Professor of Internal Medicine at the New York University School of Medicine, member of the Center for the Prevention of Cardiovascular Disease, and Immediate Past President of the American Society of Hypertension.
Although we have developed better antihypertensive treatments and understand the value of spironolactone in dealing with patients with resistant hypertension, we still have a fair number of patients who are not getting to goal. The estimates depend on who you are talking to, but in our experience, both at New Haven and in Chicago, about 60% of patients referred to us are resistant to treatment and we can get about 60% of them to goal, leaving 40% who are still above goal.
More recent studies from Birmingham, Alabama, think that the addition of spironolactone reduces that 40% that we could not get to goal to about 10%. That is an enormous benefit of a therapy that we had not thought of as being valuable. But that still leaves 10% of maybe 70 million patients with hypertension who are not at goal; 7 million is not a small number.
So what have we not looked for? Secondary hypertension has always been thought to be a common reason for why individual patients do not respond to usual therapy. From studies that were done in the late 1980s, the late 1990s, and earlier in this decade, the concept that sleep apnea was a major contributor is becoming more and more evident. Two clinical centers in Brazil looked at their patients with resistant hypertension. They started with 161 patients and ended up with 125 patients with resistant hypertension. They did a thorough evaluation, including everything that you would usually do to see what the causes of resistant hypertension were, and determined how frequent secondary hypertension turned out to be.
About a third of the individuals that they considered resistant (ie, an average blood pressure of 176/107, ambulatory blood pressure 149/80s [diastolic range in the 80s], taking 6-7 medications) had a central hypertension that they could not locate or for which they could not find a secondary cause.
The most important finding was that about two thirds of those individuals had obstructive sleep apnea. We always thought it was there but were not sure how common it was and didn't routinely take everybody who qualified as patients with resistant hypertension. They used the JNC 7 definition, which is being on 3 appropriate drugs at appropriate doses, one of which is a diuretic, and still not being at goal.
The problem with identifying obstructive sleep apnea is that, other than continuous positive airway pressure, we don't really have a good therapy that is helpful. [The investigators] also looked at the individual predictors of resistant hypertension. It turned out that snoring was very important. How many of us ask every patient we see with hypertension whether they snore, or ask their partners and spouses whether they snore? That was an independent predictor of sleep apnea. Another predictor is a large neck. Obesity was important but tended to not be an independent predictor of outcomes.
I guess sleep labs have to get busy. We have to do ambulatory monitoring on patients with resistant hypertension to see if it is really elevated, and we also have to consider doing much more in the way of sleep. We also need a better way to treat sleep apnea, but that remains to be developed.
Thank you very much.
Hi. I'm Dr. Henry Black. I'm a Clinical Professor of Internal Medicine at the New York University School of Medicine, member of the Center for the Prevention of Cardiovascular Disease, and Immediate Past President of the American Society of Hypertension.
Although we have developed better antihypertensive treatments and understand the value of spironolactone in dealing with patients with resistant hypertension, we still have a fair number of patients who are not getting to goal. The estimates depend on who you are talking to, but in our experience, both at New Haven and in Chicago, about 60% of patients referred to us are resistant to treatment and we can get about 60% of them to goal, leaving 40% who are still above goal.
More recent studies from Birmingham, Alabama, think that the addition of spironolactone reduces that 40% that we could not get to goal to about 10%. That is an enormous benefit of a therapy that we had not thought of as being valuable. But that still leaves 10% of maybe 70 million patients with hypertension who are not at goal; 7 million is not a small number.
So what have we not looked for? Secondary hypertension has always been thought to be a common reason for why individual patients do not respond to usual therapy. From studies that were done in the late 1980s, the late 1990s, and earlier in this decade, the concept that sleep apnea was a major contributor is becoming more and more evident. Two clinical centers in Brazil looked at their patients with resistant hypertension. They started with 161 patients and ended up with 125 patients with resistant hypertension. They did a thorough evaluation, including everything that you would usually do to see what the causes of resistant hypertension were, and determined how frequent secondary hypertension turned out to be.
About a third of the individuals that they considered resistant (ie, an average blood pressure of 176/107, ambulatory blood pressure 149/80s [diastolic range in the 80s], taking 6-7 medications) had a central hypertension that they could not locate or for which they could not find a secondary cause.
The most important finding was that about two thirds of those individuals had obstructive sleep apnea. We always thought it was there but were not sure how common it was and didn't routinely take everybody who qualified as patients with resistant hypertension. They used the JNC 7 definition, which is being on 3 appropriate drugs at appropriate doses, one of which is a diuretic, and still not being at goal.
The problem with identifying obstructive sleep apnea is that, other than continuous positive airway pressure, we don't really have a good therapy that is helpful. [The investigators] also looked at the individual predictors of resistant hypertension. It turned out that snoring was very important. How many of us ask every patient we see with hypertension whether they snore, or ask their partners and spouses whether they snore? That was an independent predictor of sleep apnea. Another predictor is a large neck. Obesity was important but tended to not be an independent predictor of outcomes.
I guess sleep labs have to get busy. We have to do ambulatory monitoring on patients with resistant hypertension to see if it is really elevated, and we also have to consider doing much more in the way of sleep. We also need a better way to treat sleep apnea, but that remains to be developed.
Thank you very much.
Source...