Faculty Bibliography

Apparent treatment-resistant hypertension (aTRH) is defined as uncontrolled hypertension despite the use of >/=3 antihypertensive medication classes or controlled hypertension while treated with >/=4 antihypertensive medication classes. Although a high prevalence of aTRH has been reported, few data are available on its association with cardiovascular and renal outcomes. We analyzed data on 14 684 Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) participants to determine the association between aTRH (n=1870) with coronary heart disease, stroke, all-cause mortality, heart failure, peripheral artery disease, and end-stage renal disease. We defined aTRH as blood pressure not at goal (systolic/diastolic blood pressure >/=140/90 mm Hg) while taking >/=3 classes of antihypertensive medication or taking >/=4 classes of antihypertensive medication with blood pressure at goal during the year 2 ALLHAT study visit (1996-2000). Use of a diuretic was not required to meet the definition of aTRH. Follow-up occurred through 2002. The multivariable adjusted hazard ratios (95% confidence intervals) comparing participants with versus without aTRH were as follows: coronary heart disease (1.44 [1.18-1.76]), stroke (1.57 [1.18-2.08]), all-cause mortality (1.30 [1.11-1.52]), heart failure (1.88 [1.52-2.34]), peripheral artery disease (1.23 [0.85-1.79]), and end-stage renal disease (1.95 [1.11-3.41]). aTRH was also associated with the pooled outcomes of combined coronary heart disease (hazard ratio, 1.47; 95% confidence interval, 1.26-1.71) and combined cardiovascular disease (hazard ratio, 1.46; 95% confidence interval, 1.29-1.64). These results demonstrate that aTRH increases the risk for cardiovascular disease and end-stage renal disease. Studies are needed to identify approaches to prevent aTRH and reduce risk for adverse outcomes among individuals with aTRH.

OPINION STATEMENT: With the advent of noninvasive 24-hour ambulatory blood pressure monitoring (ABPM), clinicians have access to a wealth of individualized data for the hypertensive patient. This has led to a greater understanding of the pathophysiology of hypertension and its complications. This tool has provided more precise diagnostic criteria for hypertension and helped discover those with white coat and masked hypertension. Patterns noted on ABPM and correlated with outcomes have allowed for more accurate identification of patients at high risk of cardiovascular (CV) events, and have offered an additional prognostic tool. In addition, ABPM allows for the assessment of the efficacy and adequacy of blood pressure treatment. In the current paper, we will describe the essential components of ABPM, review the evidence detailing the prognostic information that can be derived from its use, highlight clinical scenarios wherein ABPM can offer invaluable diagnostic information, and describe applications of ABPM that evaluate the efficacy of treatment of the hypertensive patient.

Collaborations between physicians, particularly those in academic medicine, and industries that develop pharmaceutical products, medical devices, and diagnostic tests have led to substantial advances in patient care. At the same time, there is a strong awareness that these relationships, however beneficial they may be, should conform to established principles of ethical professional practice. Through a writing committee drawn from diverse disciplines across several institutions, the Association of Clinical Researchers and Educators (ACRE) has written a code of conduct to provide guidance to physicians in observing these principles. Our recommendations are not intended to be prescriptive or inflexible, but rather to be of assistance to physicians in making their own personal decisions on whether, or how, to be involved in research, education, or other collaborations with industry.

Abstract Background: Chronic kidney disease (CKD) is associated with increased risk of cardiovascular (CV) events and death. However, the effect of cardiorespiratory fitness on the CKD-mortality relationship remains unknown, particularly in women. Methods: We used Cox regression to estimate hazard ratios (HR) for the effect of kidney function and fitness on all-cause mortality in a prospective cohort of 5716 women free of CKD and CV disease symptoms. Serum creatinine (Cr) was used to estimate glomerular filtration rate (eGFR), and spot urine protein and maximal stress tests were performed at baseline. Results: Mean age at baseline was 52.5+/-10.8 years, and 86% of the sample was Caucasian. Mean Cr was 1.11+/-0.14 mg/dL, and mean eGFR was 53.7+/-8.3 mL/min/1.73 m(2) at baseline. The mean follow-up was 15.9+/-2.2 years, with 589 deaths identified. Cr <1.4 was associated with an HR of death of 1.59 (p=0.03). After adjustment for traditional CV risk factors and fitness, the risk of death decreased by 3% (p<0.001) for every mL/min/1.73 m(2) increase in eGFR. Compared to women with an eGFR <45 mL/min/1.73 m(2), the risk of death was reduced by 36% and 47%, for eGFR 45-59.9 mL/min/1.73 m(2) and eGFR >/=60 mL/min/1.73 m(2), respectively (p<0.001). At every level of eGFR, fitness remained an independent predictor of mortality, with the lowest level of fitness (<5 metabolic equivalents [METs]) at the highest risk of mortality regardless of eGFR level. Conclusions: Fitness remains an independent predictor of mortality regardless of eGFR. eGFR was a stronger predictor of mortality compared to Cr or the presence of proteinuria. These findings have important implications for clinical practice and health policy, as the level of cardiorespiratory fitness predicts risk of death in the presence of asymptomatic CKD.

J Clin Hypertens (Greenwich). 2012;00:00-00. (c)2012 Wiley Periodicals, Inc. In a prespecified subgroup analysis of a 12-week multinational, randomized, double-blind, parallel-group trial, self-identified Hispanic/Latino adult men and women with systolic blood pressure 160 mm Hg to 179 mm Hg received combination aliskiren/hydrochlorothiazide (HCT) 150/12.5 mg or aliskiren 150 mg (force-titrated to 300/25 mg and 300 mg, respectively, at week 1). At week 12, combination aliskiren/HCT provided greater reduction in mean sitting systolic blood pressure from baseline, the primary efficacy variable, compared with aliskiren monotherapy (-32.6 mm Hg vs -19.6 mm Hg; P<.0001). Differences in mean sitting diastolic blood pressure reductions followed a similar pattern (-13.5 mm Hg vs -7.1 mm Hg; P<.0001). Notable blood pressure reductions were evident at week 1 in both treatment groups, with near-maximal effects reached by week 8. Results were consistent regardless of country of residence. Both treatments were well tolerated. Aliskiren alone or in combination with HCT is safe and effective in Hispanic/Latino patients with stage 2 hypertension. Combination aliskiren/HCT produced greater blood pressure reductions than aliskiren monotherapy.