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Treatment-Resistant Hypertension and Outcomes Based on Randomized Treatment Group in ALLHAT.
Am J Med 2017; 130(4):439-448.e9AJ

Abstract

BACKGROUND

Although hypertension guidelines define treatment-resistant hypertension as blood pressure uncontrolled by ≥3 antihypertensive medications, including a diuretic, it is unknown whether patient prognosis differs when a diuretic is included.

METHODS

Participants in the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) were randomly assigned to first-step therapy with chlorthalidone, amlodipine, or lisinopril. At a Year 2 follow-up visit, those with average blood pressure ≥140 mm Hg systolic or ≥90 mm Hg diastolic on ≥3 antihypertensive medications, or blood pressure <140/90 mm Hg on ≥4 antihypertensive medications were identified as having apparent treatment-resistant hypertension. The prevalence of treatment-resistant hypertension and its association with ALLHAT primary (combined fatal coronary heart disease or nonfatal myocardial infarction) and secondary (all-cause mortality, stroke, heart failure, combined coronary heart disease, and combined cardiovascular disease) outcomes were identified for each treatment group.

RESULTS

Of participants assigned to chlorthalidone, amlodipine, or lisinopril, 9.6%, 11.4%, and 19.7%, respectively, had treatment-resistant hypertension. During mean follow-up of 2.9 years, primary outcome incidence was similar for those assigned to chlorthalidone compared with amlodipine or lisinopril (amlodipine- vs chlorthalidone-adjusted hazard ratio [HR] 0.86; 95% confidence interval [CI], 0.53-1.39; P = .53; lisinopril- vs chlorthalidone-adjusted HR = 1.06; 95% CI, 0.70-1.60; P = .78). Secondary outcome risks were similar for most comparisons except coronary revascularization, which was higher with amlodipine than with chlorthalidone (HR 1.86; 95% CI, 1.11-3.11; P = .02). An as-treated analysis based on diuretic use produced similar results.

CONCLUSIONS

In this study, which titrated medications to a goal, participants assigned to chlorthalidone were less likely to develop treatment-resistant hypertension. However, prognoses in those with treatment-resistant hypertension were similar across treatment groups.

Authors+Show Affiliations

Department of Medicine, New York University School of Medicine.Coordinating Center for Clinical Trials, The University of Texas School of Public Health, Houston. Electronic address: barry.r.davis@uth.tmc.edu.Memphis Veterans Affairs Medical Center, University of Tennessee College of Medicine.Coordinating Center for Clinical Trials, The University of Texas School of Public Health, Houston.Vascular Biology and Hypertension Program, University of Alabama, Birmingham.Vascular Biology and Hypertension Program, University of Alabama, Birmingham.Cardiovascular Institute, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ.Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, La.Department of Medicine, The University of Washington Medical Center, Seattle.Department of Medicine, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, Ohio.Department of Medicine, New York University School of Medicine.No affiliation info available

Pub Type(s)

Journal Article
Randomized Controlled Trial

Language

eng

PubMed ID

27984005

Citation

Bangalore, Sripal, et al. "Treatment-Resistant Hypertension and Outcomes Based On Randomized Treatment Group in ALLHAT." The American Journal of Medicine, vol. 130, no. 4, 2017, pp. 439-448.e9.
Bangalore S, Davis BR, Cushman WC, et al. Treatment-Resistant Hypertension and Outcomes Based on Randomized Treatment Group in ALLHAT. Am J Med. 2017;130(4):439-448.e9.
Bangalore, S., Davis, B. R., Cushman, W. C., Pressel, S. L., Muntner, P. M., Calhoun, D. A., ... Black, H. R. (2017). Treatment-Resistant Hypertension and Outcomes Based on Randomized Treatment Group in ALLHAT. The American Journal of Medicine, 130(4), pp. 439-448.e9. doi:10.1016/j.amjmed.2016.10.002.
Bangalore S, et al. Treatment-Resistant Hypertension and Outcomes Based On Randomized Treatment Group in ALLHAT. Am J Med. 2017;130(4):439-448.e9. PubMed PMID: 27984005.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Treatment-Resistant Hypertension and Outcomes Based on Randomized Treatment Group in ALLHAT. AU - Bangalore,Sripal, AU - Davis,Barry R, AU - Cushman,William C, AU - Pressel,Sara L, AU - Muntner,Paul M, AU - Calhoun,David A, AU - Kostis,John B, AU - Whelton,Paul K, AU - Probstfield,Jeffrey L, AU - Rahman,Mahboob, AU - Black,Henry R, AU - ,, Y1 - 2016/10/27/ PY - 2015/11/19/received PY - 2016/09/08/revised PY - 2016/10/10/accepted PY - 2016/12/17/pubmed PY - 2017/5/11/medline PY - 2016/12/17/entrez KW - Angiotensin-converting enzyme inhibitor KW - Calcium channel blocker KW - Diuretics KW - Hypertension KW - Resistance SP - 439 EP - 448.e9 JF - The American journal of medicine JO - Am. J. Med. VL - 130 IS - 4 N2 - BACKGROUND: Although hypertension guidelines define treatment-resistant hypertension as blood pressure uncontrolled by ≥3 antihypertensive medications, including a diuretic, it is unknown whether patient prognosis differs when a diuretic is included. METHODS: Participants in the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) were randomly assigned to first-step therapy with chlorthalidone, amlodipine, or lisinopril. At a Year 2 follow-up visit, those with average blood pressure ≥140 mm Hg systolic or ≥90 mm Hg diastolic on ≥3 antihypertensive medications, or blood pressure <140/90 mm Hg on ≥4 antihypertensive medications were identified as having apparent treatment-resistant hypertension. The prevalence of treatment-resistant hypertension and its association with ALLHAT primary (combined fatal coronary heart disease or nonfatal myocardial infarction) and secondary (all-cause mortality, stroke, heart failure, combined coronary heart disease, and combined cardiovascular disease) outcomes were identified for each treatment group. RESULTS: Of participants assigned to chlorthalidone, amlodipine, or lisinopril, 9.6%, 11.4%, and 19.7%, respectively, had treatment-resistant hypertension. During mean follow-up of 2.9 years, primary outcome incidence was similar for those assigned to chlorthalidone compared with amlodipine or lisinopril (amlodipine- vs chlorthalidone-adjusted hazard ratio [HR] 0.86; 95% confidence interval [CI], 0.53-1.39; P = .53; lisinopril- vs chlorthalidone-adjusted HR = 1.06; 95% CI, 0.70-1.60; P = .78). Secondary outcome risks were similar for most comparisons except coronary revascularization, which was higher with amlodipine than with chlorthalidone (HR 1.86; 95% CI, 1.11-3.11; P = .02). An as-treated analysis based on diuretic use produced similar results. CONCLUSIONS: In this study, which titrated medications to a goal, participants assigned to chlorthalidone were less likely to develop treatment-resistant hypertension. However, prognoses in those with treatment-resistant hypertension were similar across treatment groups. SN - 1555-7162 UR - https://www.unboundmedicine.com/medline/citation/27984005/Treatment_Resistant_Hypertension_and_Outcomes_Based_on_Randomized_Treatment_Group_in_ALLHAT_ L2 - https://linkinghub.elsevier.com/retrieve/pii/S0002-9343(16)31065-8 DB - PRIME DP - Unbound Medicine ER -