RESUMO
Confirmation of medication adherence is a challenge in clinical practice and essential for the accurate diagnosis of resistant hypertension. Although it is well established that drug adherence is critical for controlling blood pressure, there are still difficulties applying a simple, inexpensive, and reliable assessment of adherence in the clinical setting. We aimed to test a simple method to assess adherence in resistant hypertensive (RH) patients. A pilot study with normotensives or mild/moderate hypertensive subjects was performed to provide a fluorescence cutoff point for adherence. After that, 21 patients referred to the Resistant Hypertension Clinic had triamterene prescribed and were monitored for a 30-day period. We conducted two unannounced randomly selected home visits for urine collection to test drug intake that day. Office, home and 24-hour ambulatory blood pressure, biochemical data, and the 8-item Morisky Medication Adherence Scale (MMAS-8) were systematically acquired. According to adherence indicated by urine fluorescence, subjects were divided into adherent and nonadherent groups. We found 57% of nonadherence. No differences were found between groups regarding baseline characteristics or prescribed medications; Kappa's test showed concordance between adherence through MMAS-8 items and fluorescence (kappa = 0.61; 95% confidence interval: 0.28-0.94; P = .005). Nonadherent patients had higher office (81 ± 11 vs. 73 ± 6 mm Hg, P = .03), 24-hour ambulatory blood pressure monitoring (75 ± 9 vs. 66 ± 7 mm Hg, P = .01), and home blood pressure measurement (77 ± 9 vs. 67 ± 8 mm Hg, P = .01) diastolic blood pressure than their counterparts. Nonadherence to antihypertensive therapy is high in patients with RH, even when assessed in clinics specialized in this condition. Fluorometry to detect a drug in the urine of RH patients is safe, easy, and reliable method to assess adherence.
Assuntos
Anti-Hipertensivos/uso terapêutico , Vasoespasmo Coronário/tratamento farmacológico , Vasoespasmo Coronário/psicologia , Diuréticos/uso terapêutico , Hipertensão/tratamento farmacológico , Hipertensão/psicologia , Adesão à Medicação , Idoso , Anti-Hipertensivos/administração & dosagem , Anti-Hipertensivos/urina , Determinação da Pressão Arterial , Monitorização Ambulatorial da Pressão Arterial , Vasoespasmo Coronário/urina , Diuréticos/administração & dosagem , Diuréticos/urina , Estudos de Viabilidade , Feminino , Fluorometria , Humanos , Hipertensão/urina , Masculino , Pessoa de Meia-Idade , Projetos Piloto , Sensibilidade e Especificidade , Triantereno/administração & dosagem , Triantereno/uso terapêutico , Triantereno/urinaRESUMO
Resistant hypertension, a complex multifactorial hypertensive disease, is triggered by genetic and environmental factors and involves multiple physiological pathways. Single genetic variants may not reveal significant associations with resistant hypertension because their effects may be dependent on gene-gene or gene-environment interactions. We examined the interaction of angiotensin I-converting enzyme (ACE), angiotensinogen (AGT), and endothelial nitric oxide synthase (NOS3) polymorphisms with environmental factors (gender, age, body mass index, glycemia, total cholesterol, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, triglycerides, estimated glomerular filtration rate, and urinary sodium excretion) in 70 resistant, 80 well-controlled hypertensive patients, and 70 normotensive controls. All subjects were genotyped for ACE insertion/deletion (rs1799752); AGT M235T (rs699), and NOS3 Glu298Asp (rs 1799983). Multifactorial associations were tested using two statistical methods: the traditional parametric method (adjusted logistic regression analysis) and gene-gene and gene-environment interactions evaluated by multifactor dimensionality reduction analyses. While adjusted logistic regression found no significant association between the studied polymorphisms and controlled or resistant hypertension, the multifactor dimensionality reduction analyses showed that carriers of the AGT 235T allele were at increased risk for resistant hypertension, especially if they were older than 50 years. The AGT 235T allele constituted an independent risk factor for resistant hypertension.
Assuntos
Angiotensinogênio/genética , Resistência a Medicamentos/genética , Loci Gênicos/genética , Hipertensão/genética , Óxido Nítrico Sintase Tipo III/genética , Peptidil Dipeptidase A/genética , Polimorfismo Genético , Estudos de Casos e Controles , Meio Ambiente , Feminino , Frequência do Gene , Marcadores Genéticos/genética , Genótipo , Humanos , Hipertensão/tratamento farmacológico , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Redução Dimensional com Múltiplos Fatores , Fatores de RiscoRESUMO
Obstructive sleep apnea, aldosterone excess, and resistant hypertension are common comorbidities
nervous system activation, sodium retention, reninangiotensin-aldosterone system stimulation, endothelial dysfunction, and increased production of
reactive oxidative species may be contributing factors. Patients diagnosed with this triad should
be treated with low-salt diet, weight-loss counseling, and continuous positive airway pressure, as
well as aggressive antihypertensive therapy, usually with multiple agents, including a mineralocorticoid
receptor antagonist. Patients with aldosteroneproducing adenoma may require adrenalectomy.
Assuntos
Humanos , Aldosterona , Hipertensão , Síndromes da Apneia do SonoRESUMO
Obstructive sleep apnea, aldosterone excess, and resistant hypertension are common comorbidities in obese patients. The mechanisms that link these conditions are not fully elucidated, but sympathetic nervous system activation, sodium retention, renin-angiotensin-aldosterone system stimulation, endothelial dysfunction, and increased production of reactive oxidative species may be contributing factors. Patients diagnosed with this triad should be treated with low-salt diet, weight-loss counseling, and continuous positive airway pressure, as well as aggressive antihypertensive therapy, usually with multiple agents, including a mineralocorticoid receptor antagonist. Patients with aldosterone-producing adenoma may require adrenalectomy.
Assuntos
Hiperaldosteronismo/complicações , Hipertensão/complicações , Obesidade/complicações , Apneia Obstrutiva do Sono/complicações , Adrenalectomia , Animais , Anti-Hipertensivos/uso terapêutico , Terapia Combinada , Pressão Positiva Contínua nas Vias Aéreas , Aconselhamento , Dieta Redutora , Dieta Hipossódica , Endotélio Vascular/fisiopatologia , Humanos , Hiperaldosteronismo/diagnóstico , Hiperaldosteronismo/fisiopatologia , Hiperaldosteronismo/terapia , Hipertensão/diagnóstico , Hipertensão/fisiopatologia , Hipertensão/terapia , Antagonistas de Receptores de Mineralocorticoides/uso terapêutico , Obesidade/fisiopatologia , Obesidade/terapia , Estresse Oxidativo , Sistema Renina-Angiotensina , Apneia Obstrutiva do Sono/diagnóstico , Apneia Obstrutiva do Sono/fisiopatologia , Apneia Obstrutiva do Sono/terapia , Sistema Nervoso Simpático/fisiopatologia , Resultado do TratamentoRESUMO
Obstructive sleep apnea, aldosterone excess, and resistant hypertension are common comorbidities in obese patients. The mechanisms that link these conditions are not fully elucidated, but sympathetic nervous system activation, sodium retention, reninangiotensin- aldosterone system stimulation, endothelial dysfunction, and increased production of reactive oxidative species may be contributing factors. Patients diagnosed with this triad should be treated with low-salt diet, weight-loss counseling, and continuous positive airway pressure, as well as aggressive antihypertensive therapy, usually with multiple agents, including a mineralocorticoid receptor antagonist. Patients with aldosteroneproducing adenoma may require adrenalectomy.
Assuntos
Aldosterona , Apneia Obstrutiva do Sono , Hipertensão , ObesidadeAssuntos
Hipertensão/etiologia , Monitorização Ambulatorial da Pressão Arterial/efeitos adversos , Anticoncepcionais Orais/efeitos adversos , Diuréticos/uso terapêutico , Resistência a Medicamentos , Humanos , Hiperaldosteronismo/complicações , Hipertensão/tratamento farmacológico , Erros de Medicação/efeitos adversos , Antagonistas de Receptores de Mineralocorticoides/uso terapêutico , Obesidade/complicações , Apneia Obstrutiva do Sono/complicações , Cloreto de Sódio na Dieta/efeitos adversos , Espironolactona/uso terapêutico , Recusa do Paciente ao TratamentoRESUMO
Resistant hypertension is defined as blood pressure that remains uncontrolled in spite of use of three or more antihypertensive medications in effective doses, usually including a diuretic. Stricter goals, higher obesity rates, increase in life expectance, and increased use of exogenous substances are related to an increasing prevalence of resistant hypertension. The evaluation of patients with resistant hypertension is focused on identifying contributing and secondary causes of hypertension, such as hyperaldosteronism, obstructive sleep apnea, renal parenchymal disease, renal artery stenosis, and pheochromocytoma. Hyperaldosteronism is now recognized as the most common cause of resistant hypertension and all patients with resistant hypertension should be screened with a plasma aldosterone/renin ratio even if the serum potassium levelis normal. Treatment includes removal of contributing factors, appropriate treatment of secondary causes, and useof effective multi-drug regimens. Recent studies indicate that the addition of spironolactone to standard treatment regimens induces significant BP reduction in patients with resistant hypertension.