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Hypertension

The disease

The World Health Organization has estimated that high blood pressure causes 1 in every 8 deaths worldwide, making hypertension the third leading killer in the world. 1

A healthy blood pressure goal has a systolic reading below 140 mmHg, depending on the individual's health. Individuals who are unable to reach this goal, despite being on multiple blood pressure medications, are said to have “resistant hypertension". It is estimated that one in three people with high blood pressure has resistant hypertension.

When an individual has high blood pressure, small blood vessels can become damaged and less effective in supplying the body's vital organs (brain, heart and kidneys) with oxygen and nutrients. If an individual's systolic pressure is 160 mmHg, they face a four times greater risk of suffering a heart attack, stroke, or end stage kidney failure than an individual with normal blood pressure. 2

Autonomic imbalance plays a pivotal role in the etiology of hypertension. 3  Decreased parasympathetic and increased sympathetic tone increase peripheral vascular resistance, reduce renal blood flow, and increase sodium retention while impairing glucose handling and contributing to adverse cardiac and vascular remodelling.4

References:
1. The World Health Report 2012. World Health Organization; 2012:58. 2. Heart Disease and Stroke Statistics. American Heart Association, 2012 update. 3. Brook RD and Julius S. Autonomic imbalance, hypertension, and cardiovascular risk. Am J Hypertens (2000) 13 (S4): 112S-122S. 4. Bisognano JD et al. Baroreflex Activation Therapy Lowers Blood Pressure in Patients With Resistant Hypertension: Results From the Double-Blind, Randomized, Placebo-Controlled Rheos Pivotal Trial. JACC. 2011; 58: 7:765–773.

The need for better therapies

Polypharmacy and non-adherence make resistant hypertension a challenge 1

Polypharmacy in resistant hypertension
Treated with 3 or more antihypertensive medications. 1 The addition of a fourth or a fifth medication seldom provides any meaningful additional benefit.2

Managing comorbidities
The prevalence of chronic kidney disease or diabetes mellitus is higher in patients with resistant hypertension. 3 Co-morbidities can require additional medications.4

Multiple side effects
Up to 97% of patients who take antihypertensive medications experience drug side effects. 5

Non-adherence
Medication non-adherence * occurs in about 50% of newly treated hypertensive patients within the first year of treatment.5

Remain uncontrolled
Non-compliance increases the risk of uncontrolled hypertension about 5 times, as well as overall mortality, hospitalization rate and cost of care. 5

Increased risk of CV event
End-organ consequences include heart failure, stroke, ischemic heart disease and renal failure. 1

In patients who remain above risk factor target despite treatment with multiple medications, the benefit of intensifying treatment is unclear. 2

taking <80% of the number of prescribed pills
References:
1. Yaxley JP and Thambar SV. Resistant hypertension: an approach to management in primary care. J Family Med Prim Care. 2015 Apr-Jun; 4(2): 193–199. 2. Timbie JW et al. Diminishing Efficacy of Combination Therapy, Response-Heterogeneity, and Treatment Intolerance Limit the Attainability of Tight Risk Factor Control in Patients with Diabetes. Health Serv Res. 2010 Apr; 45(2): 437-456. 3. Bisognano JD et al. Baroreflex Activation Therapy Lowers Blood Pressure in Patients With Resistant Hypertension: Results From the Double-Blind, Randomized, Placebo-Controlled Rheos Pivotal Trial. JACC. 2011; 58: 7:765–773. 4. Long AN et al. The Comorbidities of Diabetes and Hypertension: Mechanisms and Approach to Target Organ Protection. J Clin Hypertens (Greenwich). 2011 April ; 13(4): 244–251. 5. Tedla YG and Bautista LE. Drug Side Effect Symptoms and Adherence to Antihypertensive Medication, Am J Hypertens. 2015 Dec 7. pii: hpv185. [Epub ahead of print].
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