Press "Enter" to skip to content

Tx Gaps for Resistant HTN Persist in Cardiac Rehab

NEW ORLEANS — More work needs to be done to get patients with apparent resistant hypertension referred to a hypertension specialist while they participate in cardiac rehabilitation, a study suggested.

The prevalence of resistant hypertension was up to 7% overall in 504 consecutive patients undergoing phase 2 rehab at the main campus of the Cleveland Clinic during 2012-2017, or 11% of the subgroup with hypertension, according to Luke Laffin, MD, medical director of cardiac rehabilitation at Cleveland Clinic.

Notably, within a year of cardiac rehab enrollment, only 14% of the resistant hypertension group had been seen by a hypertension specialist and another 6% prescribed a mineralocorticoid receptor antagonist (MRA) such as spironolactone (Aldactone), Laffin said at the American Heart Association annual Hypertension meeting.

In the end, hospitalizations within 2 years were more common among those with apparent treatment-resistant hypertension (66% vs 47%, P=0.036).

We need to do a better job treating resistant hypertension with evidence-based therapy, Laffin said.

“These patients with resistant hypertension can benefit from referral to a hypertension specialist. MRAs are now the standard of care in the management of these patients,” commented Rajiv Agarwal, MD, of Indiana University School of Medicine in Indianapolis, who was not involved in the study.

That said, these patients benefited from cardiac rehabilitation in the study, as they entered and left rehab with lower peak METs compared to those without resistant hypertension, but improved just as much — if not more — in average MET increase (33% vs 27%, P=0.56).

Laffin noted that phase 2 cardiac rehabilitation is an “intense program following a cardiac event or a cardiac intervention” that includes medical evaluation, exercise training and physical activity counseling, secondary prevention (nutritional counseling and weight management), psychosocial support, and education.

He defined resistant hypertension as blood pressure >130/80 mm Hg while the patient is on three antihypertensive medications (including a diuretic) or any patient taking four or more antihypertensives.

The 35 people in the study that fit this description tended to be older, were more likely to be black, had higher BMI, and were more likely to have type 2 diabetes. Surprisingly, they had the same 20% prevalence of chronic kidney disease as the rest of the cohort.

“Guidelines recommend that MRA be used when eGFR is >45 mL/min/1.73m2 and serum K is ≤4.5 mEq/L. It is possible that many patients may have been excluded because of high risk for hyperkalemia,” Agarwal suggested.

Laffin also cautioned that the patients in the retrospective study could only be said to have apparent treatment-resistant hypertension, however, because of one or more key pieces of information (medication dose, adherence, or out-of-office blood pressure) being missing from the dataset.

Laffin disclosed no relevant relationships with industry.

Agarwal disclosed relevant relationships with Relypsa and ZS Pharma.