Characterization of Individuals With Apparent Resistant Hypertension Using Contemporary Guidelines: Insights From CV-QUIC

Abstract

Background: Apparent resistant hypertension (aRH) carries excess cardiovascular risk beyond nonresistant forms of hypertension; however, our understanding of this at-risk population, as defined by current US practice guidelines, is limited. Accordingly, we sought to evaluate the prevalence, clinical characteristics, and pharmacotherapeutic patterns of patients with aRH using contemporary blood pressure guidance.

Methods: We classified patients at 3 large healthcare systems by hypertensive status using contemporary hypertension guidelines. We subsequently described the demographic and clinical characteristics of patients with aRH and compared these factors among hypertensive patients without aRH and between those with controlled and uncontrolled aRH.

Results: A total of 2 420 468 patients were analyzed, of whom 1 343 489 (55.6%) were hypertensive according to contemporary guidelines. Among hypertensive patients, 11 992 (8.5%) met criteria for aRH, with nearly all assessed comorbid conditions, particularly diabetes and heart failure, being more common in those with aRH. When compared with patients with uncontrolled aRH, those with controlled aRH were more frequently prescribed a beta-blocker, diuretic, and nitrate, with the largest standardized difference observed for a mineralocorticoid receptor antagonist (35.4% versus 10.4%, Cohen D 0.62). Consistent findings were noted in sensitivity analyses using the blood pressure threshold of 140/90 mm Hg.

Conclusions: In an analysis of over 2.4 million individuals, a lower prevalence of aRH was observed than previously reported (12%-15%), but with a high burden of comorbidities. Identification of differences in pharmacotherapy between patients with controlled and uncontrolled aRH, particularly lower rates of mineralocorticoid receptor antagonist use, help define potential opportunities to improve care and lower cardiovascular risk.

Keywords: angiotensin-converting enzyme; blood pressure; electronic health record; epidemiology; hypertension.

Figure 1.

Flow diagram of patient hypertensive classification.

Figure 2.

Standardized mean differences in race and clinical comorbidities between non-resistant and apparent resistant hypertension patients. Numbers over bars represent Cohen’s D comparing controlled/uncontrolled hypertensive and apparent resistant hypertensive patients. aRH; apparent resistant hypertension

Figure 3.

Antihypertensive class prescription overall and by control status among patients with apparent resistant hypertension following sequential exclusion of comorbid conditions. Numbers over bars represent Cohen’s D comparing controlled and uncontrolled apparent resistant hypertensive patients. aRH; apparent resistant hypertension