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Resistant Hypertension Predicts Mortality Outcomes in T2D

Dec 7, 2019
 
Editor: David L. Joffe, BSPharm, CDE, FACA

Author: Andrew Daoud, PharmD Candidate, Florida A&M University

Treatment-resistant hypertension and type 2 diabetes lead to both microvascular and macrovascular complications. 

A recently published study in Diabetes Care found that those patients with type 2 diabetes are at a higher risk of cardiovascular events and mortality when they also have apparent treatment resistant hypertension.

When a person has type 2 diabetes, his/her body cells are not able to respond to insulin as they are supposed to. Apparent treatment-resistant hypertension is uncontrolled blood pressure with the use of 3 antihypertensive classes regardless of medical level. In this study, patients who had type 2 diabetes were diagnosed with apparent treatment-resistant hypertension blood pressure levels during the first year, then follow up started. The patients then went through a 24-hour blood pressure monitoring where they were classified as controlled /white coat or true/uncontrolled hypertension.  Ambulatory blood pressure monitoring reduces the white coat hypertension effect where the blood pressure is elevated during the examination, which is a result of anxiety and nervousness caused by the clinical setting. The 24-hour blood pressure that patients underwent is ambulatory, where the patient is required to move around and live their normal daily life as it is being measured.

One of the major points to note is that ambulatory blood pressure monitoring reduces the effects of white coat hypertension. Patients with type 2 diabetes are at higher risks of cardiovascular events and mortality when they have apparent treatment-resistant hypertension.

Multivariate Cox analyses were used by the researchers to determine relationships between treatment-resistant hypertension diagnoses and the causes of cardiovascular mortality as well as the occurrence of microvascular and macrovascular complications. The analyses are used in medical research to analyze survival time data. It describes the relationship between incidences of an event, which is expressed by the hazard function. Microvascular complications occur due to the damage of small blood vessels, while macrovascular occur due to the damage of large blood vessels. Cardiovascular diseases like stroke and heart attack are some of the macrovascular complications, while diabetic nephropathy and retinopathy are microvascular complications. Cardiovascular mortality is attributed to heart failure, cardiac arrest, and infarction.

The traditional hypertension criteria revealed that 44.6% of patients had apparent treatment-resistant hypertension, while 2017 new criteria revealed that 50% of patients had apparent treatment-resistant hypertension. In traditional hypertension criteria, systolic blood pressure (SBP) ≥140 mm Hg while in new 2017 criteria SBP ≥130 mm Hg, DBP ≥80 mm Hg. One hundred seventy-seven patients had a cardiovascular event, 200 had a renal event, which is also known as deteriorated renal function, 156 had worsening retinopathy, 174 had worsening peripheral neuropathy, and 222 people died during the median follow up of 10 years. Cardiovascular events are incidences that cause damage to the heart. Deteriorated renal function is where the kidney is damaged and cannot function effectively. Retinopathy is damage to the retina of the eyes, which results in impaired vision and is normally caused by abnormal blood flow. Peripheral neuropathy is a condition where nerves carrying messages from the brain and the rest of the body get damaged. Hereditary disorders and diabetes are some of the causes of peripheral neuropathy.

Patients who had apparent treatment-resistant hypertension had high risks of cardiovascular and mortality outcomes compared to those who did not, and the hazard ratios ranged from 1.64 to 2.16 in multivariate-adjusted models with hazard ratios. The hazard ratio is comparing the probability of events in a group that is under treatment, which is then compared to the probability of events in a control group. Patients who had true treatment-resistant hypertension showed an increase in hazard ratios from 1.81-2.25 for cardiovascular event outcomes, cardiovascular mortality, and all-cause mortality. Renal outcomes of HR, 1.37-1.38, were also predicted on True treatment-resistant hypertension. Patients who had controlled resistant hypertension, which is also known as white-coat, were also at increased risks for mortality outcomes and cardiovascular outcomes with a hazard ratio of R, 1.33-1.86. The ratio was found to go down on patients who had true treatment-resistant hypertension and nonresistant hypertension.

This study had limitations, including: there was only single ambulatory BP reading for the diagnosis of white-coat/true treatment-resistant hypertension; and the small time lag between patients and ambulatory BP measurements, which caused inconveniences. The researchers of this study also wrote that the increased renal risks and cardiovascular risks could be reduced by interventional studies of intensive risk factor management to save as many patients as possible.

Practice Pearls:

  •  Patients with type 2 diabetes are at higher risks of cardiovascular events and mortality when they have apparent treatment-resistant hypertension
  • Microvascular complications occur due to the damage of small blood vessels, while macrovascular occur due to the damage of large blood vessels.
  • Patients who had controlled resistant hypertension, which is also known as white-coat, were also at increased risks for mortality outcomes and cardiovascular outcomes with a hazard ratio of R, 1.33-1.86.

 

Hannah Dellabella. Diagnosis of Treatment-Resistant Hypertension Predicts Mortality Outcomes in T2D. (2019). https://www.endocrinologyadvisor.com/home/topics/diabetes/type-2-diabetes/diagnosis-of-treatment-resistant-hypertension-predicts-mortality-outcomes-in-t2d/[24/11/2019]

Andrew Daoud, PharmD. Candidate of Florida Agricultural & Mechanical University School of Pharmacy