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Gaddam, K. K. et al. Characterization of resistant hypertension: association between resistant hypertension, aldosterone, and persistent intravascular volume expansion. Arch. Intern. Med. 168, 1159-1164

Vascular Biology and Hypertension Program, University of Alabama at Birmingham, 933 19th St S, Community Health Services Bldg 115, Birmingham, AL 35294, USA.
Archives of internal medicine (Impact Factor: 13.25). 06/2008; 168(11):1159-64. DOI: 10.1001/archinte.168.11.1159
Source: PubMed

ABSTRACT Resistant hypertension is a common clinical problem and greatly increases the risk of target organ damage.
We evaluated the characteristics of 279 consecutive patients with resistant hypertension (uncontrolled despite the use of 3 antihypertensive agents) and 53 control subjects (with normotension or hypertension controlled by using <or=2 antihypertensive medications). Participants were prospectively examined for plasma aldosterone concentration, plasma renin activity, aldosterone to renin ratio, brain-type natriuretic peptide, atrial natriuretic peptide, and 24-hour urinary aldosterone (UAldo), cortisol, sodium, and potassium values while adhering to a routine diet.
Plasma aldosterone (P < .001), aldosterone to renin ratio (P < .001), 24-hour UAldo (P = .02), brain-type natriuretic peptide (P = .007), and atrial natriuretic peptide (P = .001) values were higher and plasma renin activity (P = .02) and serum potassium (P < .001) values were lower in patients with resistant hypertension vs controls. Of patients with resistant hypertension, men had significantly higher plasma aldosterone (P = .003), aldosterone to renin ratio (P = .02), 24-hour UAldo (P < .001), and urinary cortisol (P < .001) values than women. In univariate linear regression analysis, body mass index (P = .01), serum potassium (P < .001), urinary cortisol (P < .001), urinary sodium (P = .02), and urinary potassium (P < .001) values were correlated with 24-hour UAldo levels. Serum potassium (P = .001), urinary potassium (P < .001), and urinary sodium (P = .03) levels were predictors of 24-hour UAldo levels in multivariate modeling.
Aldosterone levels are higher and there is evidence of intravascular volume expansion (higher brain-type and atrial natriuretic peptide levels) in patients with resistant hypertension vs controls. These differences are most pronounced in men. A significant correlation between 24-hour urinary aldosterone levels and cortisol excretion suggests that a common stimulus, such as corticotropin, may underlie the aldosterone excess in patients with resistant hypertension.

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    • "Primary hyperaldosteronism presents in approximately 20% of patients with resistant hypertension.[29] In general, plasma renin activity (PRA) is very low or undetectable in patients with primary aldosteronism. "
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    ABSTRACT: Resistant hypertension in adolescents is increasing in frequency and is increasingly recognized as having significant short- and long-term health consequences. It may be seen in up to 30% of all hypertensive patients cared for. Adolescents with resistant hypertension are at higher cardiovascular (CV) risk due to a long history of severe hypertension complicated by other CV risk factors such as obesity. Common causes of resistant hypertension include primary aldosteronism, sleep apnea, diabetes and chronic kidney disease. Careful blood pressure (BP) measurement and thorough evaluation of patients with sustained BP elevation should make a possible early diagnosis of resistant hypertension. Successful treatment requires identification and reversal of life-style factors contributing to treatment resistant and diagnosis and appropriate treatment of causes of hypertension. Improved pharmacologic therapies may offer the potential for preventing or at least ameliorating early CV disease. This review highlights these and other important issues in the evaluation and management of adolescents with resistant hypertension and provides practical guidance to the practitioners involved in caring for such patients.
    International journal of preventive medicine 03/2014; 5(Suppl 1):S21-S24.
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    • "A further diuretic agent successfully tested in RH patients is spironolactone based on the finding that plasma aldosterone levels are higher in RH that in those with controlled hypertension [64]. Recently, ASPIRANT study, a randomized, controlled, double-blind study evaluated the antihypertensive effects of spironolactone in 117 patients with RH. "
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    ABSTRACT: Resistant hypertension (RH) is defined as blood pressure (BP) that remains above the target of less than 140/90 mmHg in the general population and 130/80 mmHg in people with diabetes mellitus or chronic kidney disease (CKD) in spite of the use of at least three full-dose antihypertensive drugs including a diuretic or as BP that reaches the target by means of four or more drugs. In CKD, RH is a common condition due to a combination of factors including sodium retention, increased activity of the renin-angiotensin system, and enhanced activity of the sympathetic nervous system. Before defining the hypertensive patient as resistant it is mandatory to exclude the so-called "pseudoresistance." This condition, which refers to the apparent failure to reach BP target in spite of an appropriate antihypertensive treatment, is mainly caused by white coat hypertension that is prevalent (30%) in CKD patients. Recently we have demonstrated that "true" RH represents an independent risk factor for renal and cardiovascular outcomes in CKD patients.
    04/2013; 2013:929183. DOI:10.1155/2013/929183
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    • "Large increases in ECF volume may arise if sodium intake is very high or reduction in GFR is severe (e.g., chronic kidney disease stage 4-5). Patients with resistant hypertension had higher brain natriuretic peptide (BNP) and atrial natriuretic peptide (ANP) levels confirming that they had increased intrathoracic blood volume [4]. Heart failure may aggravate sodium retention. "
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    ABSTRACT: Resistant hypertension is a failure to achieve goal BP (<140/90 mm Hg for the overall population and <130/80 mm Hg for those with diabetes mellitus or chronic kidney disease) in a patient who adheres to maximum tolerated doses of 3 antihypertensive drugs including a diuretic. The kidneys play a critical role in long-term regulation of blood pressure. Blunted pressure natriuresis, with resultant increase in extracellular fluid volume, is an important cause of resistant hypertension. Activation of the renin-angiotensin-aldosterone system, increased renal sympathetic nervous system activity and increased sodium reabsorption are important renal mechanisms. Successful treatment requires identification and reversal of lifestyle factors or drugs contributing to treatment resistance, diagnosis and appropriate treatment of secondary causes of hypertension, use of effective multidrug regimens and optimization of diuretic therapy. Since inappropriate renal salt retention underlies most cases of drug-resistant hypertension, the therapeutic focus should be on improving salt depleting therapy by assessing and, if necessary, reducing dietary salt intake, optimizing diuretic therapy, and adding a mineralocorticoid antagonist if there are no contraindications.
    03/2011; 2011:143471. DOI:10.4061/2011/143471
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