medwireNews: Apparent treatment-resistant hypertension (aRHT) may help identify patients with type 2 diabetes who are at elevated cardiovascular risk, say researchers, but ambulatory blood pressure (BP) should still be performed for comprehensive risk stratification.
Their prospective follow-up of 646 patients with type 2 diabetes showed that the 288 patients with aRHT, who thereby failed to achieve office BP goals with either optimal doses of three different classes of antihypertensive medications or the use of four or more drugs, had a risk for cardiovascular events, cardiovascular death, and death from any cause that was increased between 1.64- and 2.16-fold compared with those without aRHT.
Overall, 177 participants experienced a cardiovascular event during a median follow-up of 10.3 years, 145 of whom had major adverse cardiovascular events, defined as nonfatal myocardial infarction or stroke or cardiovascular death.
There were 222 patients who died, 101 from cardiovascular causes, while 200 had a renal event, 156 had new or worsening retinopathy and 174 new or worsening peripheral neuropathy.
aRHT was predictive of all-cause mortality and all the macrovascular outcomes studied, whether it was defined using traditional criteria (≥140/90 mmHg for office BP) or using lower values recently proposed by the American College of Cardiology and American Heart Association (ACC/AHA) in 2017 (≥130/80 mmHg).
However, an aRHT diagnosis using either criterion did not predict the microvascular outcomes studied.
Re-classifying patients using 24-hour ambulatory BP monitoring as having true, uncontrolled RHT (≥130/80 mmHg or ≥125/75 mmHg) or white-coat, controlled RHT – in which it was uncontrolled in a medical setting but controlled under ambulatory conditions – improved risk stratification, however.
True RHT by either BP criterion predicted all macrovascular outcomes and all-cause mortality, with the likelihood of events raised between 1.81- and 2.25-fold compared with participants without RHT. Unlike aRHT, it was also significantly associated with adverse renal outcomes, with the risk increased between 1.37- and 1.38 fold.
White-coat RHT was also associated with an elevated risk of cardiovascular events and death, but this was intermediate between people with non-RHT and true RHT.
“The traditional and the new ACC/AHA BP cutoff values to define aRHT and true RHT were equivalent in terms of cardiovascular/renal and mortality risk prediction,” report Gil Salles (Universidade Federal do Rio de Janeiro, Brazil) and co-workers in Diabetes Care.
They conclude: “In patients with type 2 diabetes and aRHT, [ambulatory BP monitoring] not only allows better BP management, but also improves the stratification risk for cardiovascular/renal outcomes, and it should be regularly performed whenever clinically indicated.
“Interventional studies of intensive risk factor management in these high-risk patients are warranted to verify whether such increased cardiovascular and renal risks could be reduced.”
By Anita Chakraverty
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