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Observational Study
. 2016 Feb;67(2):387-96.
doi: 10.1161/HYPERTENSIONAHA.115.06487. Epub 2015 Dec 28.

Prevalence and Prognostic Significance of Apparent Treatment Resistant Hypertension in Chronic Kidney Disease: Report From the Chronic Renal Insufficiency Cohort Study

George Thomas  1 , Dawei Xie  1 , Hsiang-Yu Chen  1 , Amanda H Anderson  1 , Lawrence J Appel  1 , Shirisha Bodana  1 , Carolyn S Brecklin  1 , Paul Drawz  1 , John M Flack  1 , Edgar R Miller 3rd  1 , Susan P Steigerwalt  1 , Raymond R Townsend  1 , Matthew R Weir  1 , Jackson T Wright Jr  1 , Mahboob Rahman  1 ; CRIC Study Investigators
Collaborators, Affiliations
Observational Study

Prevalence and Prognostic Significance of Apparent Treatment Resistant Hypertension in Chronic Kidney Disease: Report From the Chronic Renal Insufficiency Cohort Study

George Thomas et al. Hypertension. 2016 Feb.

Abstract

The association between apparent treatment resistant hypertension (ATRH) and clinical outcomes is not well studied in chronic kidney disease. We analyzed data on 3367 hypertensive participants in the Chronic Renal Insufficiency Cohort (CRIC) to determine prevalence, associations, and clinical outcomes of ATRH in nondialysis chronic kidney disease patients. ATRH was defined as blood pressure ≥140/90 mm Hg on ≥3 antihypertensives, or use of ≥4 antihypertensives with blood pressure at goal at baseline visit. Prevalence of ATRH was 40.4%. Older age, male sex, black race, diabetes mellitus, and higher body mass index were independently associated with higher odds of having ATRH. Participants with ATRH had a higher risk of clinical events than participants without ATRH-composite of myocardial infarction, stroke, peripheral arterial disease, congestive heart failure (CHF), and all-cause mortality (hazard ratio [95% confidence interval], 1.38 [1.22-1.56]); renal events (1.28 [1.11-1.46]); CHF (1.66 [1.38-2.00]); and all-cause mortality (1.24 [1.06-1.45]). The subset of participants with ATRH and blood pressure at goal on ≥4 medications also had higher risk for composite of myocardial infarction, stroke, peripheral arterial disease, CHF, and all-cause mortality (hazard ratio [95% confidence interval], (1.30 [1.12-1.51]) and CHF (1.59 [1.28-1.99]) than those without ATRH. ATRH was associated with significantly higher risk for CHF and renal events only among those with estimated glomerular filtration rate ≥30 mL/min per 1.73 m(2). Our findings show that ATRH is common and associated with high risk of adverse outcomes in a cohort of patients with chronic kidney disease. This underscores the need for early identification and management of patients with ATRH and chronic kidney disease.

Keywords: antihypertensive agents; hypertension; hypertension resistant to conventional therapy; myocardial infarction; renal insufficiency, chronic.

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Conflict of interest statement

Conflict(s) of Interest/Disclosure(s)

John M. Flack: The Medicines Company (consultant), Medtronic (consultant and member of the steering committee for SYMPLICITY HTN 3), BackBeat Medical, Inc. (consultant)

Raymond R. Townsend: Medtronic (consultant)

Figures

Figure 1
Figure 1
Flow diagram of exclusion criteria applied to determine study population for final analysis
Figure 2
Figure 2
Prevalence of apparent treatment resistant hypertension (ATRH) by eGFR status
Figure 3
Figure 3
Figure 3A. Cumulative incidence of composite cardiovascular outcomes (Composite of MI, stroke, PAD, CHF) between patients with and without ATRH Figure 3B. Cumulative incidence of renal outcomes between patients with and without ATRH
Figure 4
Figure 4
Figure 4A. Hazard ratios (confidence intervals) for congestive heart failure in participants with or without ATRH in subgroups Figure 4B. Hazard ratios (confidence intervals) for renal outcomes in participants with or without ATRH in subgroups
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Comment in

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