Resistant hypertension occurs in approximately 20-30 percent of individuals with high blood pressure and is a common problem faced by both primary care clinicians and specialists. John Szawaluk, MD, discusses treatment protocols and when a specialist referral is necessary.
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Treatment Protocols for Resistant Hypertension
Resistant hypertension is a common problem faced by both primary care clinicians and specialists. John Szawaluk, MD, discusses treatment protocols and when a specialist referral is necessary.
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Learn more about John Szawaluk, MD
John Szawaluk, MD
Dr. Szawaluk joined Ohio Heart and Vascular Center in 2002. As a non-invasive cardiologist, he specializes in clinical cardiology, hypertension, echocardiography stress testing and nuclear cardiology.Learn more about John Szawaluk, MD
Transcription:
Treatment Protocols for Resistant Hypertension
Melanie Cole: Resistant hypertension is a common problem faced by both primary care clinicians and specialists. My guest today is Dr. John Szawaluk. He's a noninvasive cardiologist with the Christ Hospital Health Network. Welcome to the show. Explain a little bit about resistant hypertension. What is it and how prevalent is it in the community?
Dr. John Szawaluk, MD: Resistant hypertension for the most part if you look in the literature is defined as a blood pressure of 140/90 on three or more medications or someone who’s controlled on more than four medications. It’s really difficult to get a good feel for what the exact number of resistant hypertensives are because of multiple factors and one of them being the definition and then adherence and other issues. In our clinic, I run a resistant hypertension clinic and I think our numbers parallel the national numbers. If you look at the number of hypertensives in the United States, I was estimated to be around 70 million Americans having hypertension. Recently, the new guidelines came out and changed the definition of hypertension and lowered if from 140/90 to 130/80. By virtue of doing that, the number of individuals with “hypertension” now is probably somewhere in the 100 million range. Intuitively, you would think that that’s going to increase the number of resistant hypertensives, but what I see and the literature that I look at, it’s really more in the 10%-15% range of resistant hypertensives. Those are people who have blood pressures of 140/90 on three or more medications or those who are controlled on four or more medications.
What are the causes? That’s a great question. There are genetic causes. We know that hypertension, in general, has a genetic component and that's really not very well defined, but there are also other risk factors that lead to hypertension in general and obviously resistant hypertension. That is obesity, individuals with sleep apnea, those who drink alcohol to excess -those are all risk factors for hypertension and resistant hypertension.
Melanie: Can someone hit a blood pressure plateau? Is there a point which you say they've been controlled with four medications or they're uncontrolled with three, and does it come to a point where this is really as high as we can let it get and then what?
Dr. Szawaluk: I think the other important thing one has to remember is if you use the new definition of hypertension, 130/80 for example, if you use that as your line in the sand to call someone hypertensive or not, does that mean that someone who has a blood pressure of 129/80 is not hypertensive and someone who’s 130/80 is? The important thing is it’s a continuum and you need to assess the individual’s total cardiovascular risk because not everyone with a blood pressure of 130/80 is created equal if you know what I mean. Those who have heart disease, those who are diabetic, those who have kidney disease – those individuals you need to be more aggressive with. It’s very difficult to put a line in the sand and that’s what I get concerned with when guidelines come out and it can confuse clinicians because it’s not cut and dried as ‘yes you are’ or ‘no you're not.’ It’s a continuum based on the individual’s risk.
Melanie: What a good point. Do you think some of it might be non-adherence to medicational intervention and protocol? Is there some way for you to gauge with your patients? Do you do an assessment?
Dr. Szawaluk: That’s a great question. Adherence is a huge issue and if you look nationally at the data for hypertension clinics, and our hypertension clinic mirrors that, we have about a 30% non-adherence rate. That means either individuals are not taking the medications as prescribed or not compliant with the follow-up visits to reevaluate them. What are the reasons for non-adherence? A big one is the cost of medications, although I think in general that is getting better, but that's still an issue. Another major issue with non-adherence is side effects from medications. There are individuals that really have issues that struggle with the side effects of the medications, therefore not taking medications as prescribed. You ask ‘is there a way to measure that?’ There is, but it’s very difficult. You can do urine tests to look to see if the drug is in the individual’s urine; however, those are costly and not all insurance plans pay for those and it’s difficult to do. The patient feels like they're being challenged. What we've done in a more simpler way is on occasion, we’ve actually had to call pharmacies and look to see if individuals have refilled medications. We found occasionally that there are still prescriptions sitting in the pharmacy, even though the individual says they take their medications. It’s a challenge and that’s something that’s going to be ongoing and just a fact of life.
Melanie: What do you think you can do or let other physicians know how do you deal with all of these issues? If this is continuing to be a problem and as those guidelines have changed, now there are more people with general hypertension, maybe not necessarily resistant hypertension – that number may or may not stay the same, but what do you want other physicians to know about treatment protocols now as we've looked at all these different avenues? What do you want other physicians to take away from this?
Dr. Szawaluk: I think going back to the guidelines, in general, the guidelines are very good. They give a nice outline of how to approach someone with hypertension. Our initial drug therapy really consists of three drugs, an ACE inhibitor or an angiotensin receptor blocker, a calcium blocker and a diuretic. If someone is unsuccessful on those three medications, there's a stepwise addition to guidelines discussing what to add on after that. These patients can be very labor intensive and in addition to medical therapy, you need to look for things like sleep apnea, secondary causes like hyperaldosteronism, which is more common than we think, diet and lifestyle modifications should not be ignored and they can be very helpful, and it’s sometimes a challenge to get individuals to buy into that. At our clinic, we spent a lot of time with the patients. At our first visit, it’s usually an hour or so going through the medical part and then the lifestyle part. We've had a lot of success with the dash diet, which is a low sodium-based diet to treat hypertension, and once patients start to see some improvement and some success, it’s easier to buy into. This is very difficult for a lot of physicians to handle on a routine office visit. They don’t have the time, they're inundated with many other patients and that’s where the hypertension clinics really can come in and help these patients and get them on track and refer them back to their prescribing physician. I think that’s the model that we need to look at to these more specialized clinics at least to get a handle on the issue and then refer back to the primary doctor for long-term care.
Melanie: As you're doing this combination therapy of lifestyle and medicational invention, are you seeing that some of the reversible causes are being taken care of and then narrowing it down? Summarize what you're seeing and what you would like to see in the future.
Dr. Szawaluk: In general, we've had very good success with using this model, a multidisciplinary type approach to treating hypertension, and of course there are some outliers that are still not successful and that’s where ongoing research and hypertension trials come into play. We’re involved in a couple of trials at the Christ Hospital, device trials that treat hypertension, and some of these individuals may or may not meet the criteria for these trials and I think that’s something that’s going to be ongoing. There's a lot of trials in the United States and Europe that are looking at device-based therapy for hypertension and these can be very successful in that resistant group that can't either tolerate medications or we just can't get their blood pressure to go on five or six medications, although I will say that this group is really quite small. Device-based therapy for hypertension is really more of a niche therapy, but certainly a real option. I think that’s where the specialty-based hypertension clinics come into play and can play a significant role.
Melanie: Thank you so much for being with us today. What great information. You're listening to Expert Insights, Physician Views and News with the Christ Hospital Network. More information on Dr. Szawaluk and all of the Christ Hospital physicians is available at tchpconnect.org. That’s tchpconnect.org. This is Melanie Cole. Thanks so much for listening.
Treatment Protocols for Resistant Hypertension
Melanie Cole: Resistant hypertension is a common problem faced by both primary care clinicians and specialists. My guest today is Dr. John Szawaluk. He's a noninvasive cardiologist with the Christ Hospital Health Network. Welcome to the show. Explain a little bit about resistant hypertension. What is it and how prevalent is it in the community?
Dr. John Szawaluk, MD: Resistant hypertension for the most part if you look in the literature is defined as a blood pressure of 140/90 on three or more medications or someone who’s controlled on more than four medications. It’s really difficult to get a good feel for what the exact number of resistant hypertensives are because of multiple factors and one of them being the definition and then adherence and other issues. In our clinic, I run a resistant hypertension clinic and I think our numbers parallel the national numbers. If you look at the number of hypertensives in the United States, I was estimated to be around 70 million Americans having hypertension. Recently, the new guidelines came out and changed the definition of hypertension and lowered if from 140/90 to 130/80. By virtue of doing that, the number of individuals with “hypertension” now is probably somewhere in the 100 million range. Intuitively, you would think that that’s going to increase the number of resistant hypertensives, but what I see and the literature that I look at, it’s really more in the 10%-15% range of resistant hypertensives. Those are people who have blood pressures of 140/90 on three or more medications or those who are controlled on four or more medications.
What are the causes? That’s a great question. There are genetic causes. We know that hypertension, in general, has a genetic component and that's really not very well defined, but there are also other risk factors that lead to hypertension in general and obviously resistant hypertension. That is obesity, individuals with sleep apnea, those who drink alcohol to excess -those are all risk factors for hypertension and resistant hypertension.
Melanie: Can someone hit a blood pressure plateau? Is there a point which you say they've been controlled with four medications or they're uncontrolled with three, and does it come to a point where this is really as high as we can let it get and then what?
Dr. Szawaluk: I think the other important thing one has to remember is if you use the new definition of hypertension, 130/80 for example, if you use that as your line in the sand to call someone hypertensive or not, does that mean that someone who has a blood pressure of 129/80 is not hypertensive and someone who’s 130/80 is? The important thing is it’s a continuum and you need to assess the individual’s total cardiovascular risk because not everyone with a blood pressure of 130/80 is created equal if you know what I mean. Those who have heart disease, those who are diabetic, those who have kidney disease – those individuals you need to be more aggressive with. It’s very difficult to put a line in the sand and that’s what I get concerned with when guidelines come out and it can confuse clinicians because it’s not cut and dried as ‘yes you are’ or ‘no you're not.’ It’s a continuum based on the individual’s risk.
Melanie: What a good point. Do you think some of it might be non-adherence to medicational intervention and protocol? Is there some way for you to gauge with your patients? Do you do an assessment?
Dr. Szawaluk: That’s a great question. Adherence is a huge issue and if you look nationally at the data for hypertension clinics, and our hypertension clinic mirrors that, we have about a 30% non-adherence rate. That means either individuals are not taking the medications as prescribed or not compliant with the follow-up visits to reevaluate them. What are the reasons for non-adherence? A big one is the cost of medications, although I think in general that is getting better, but that's still an issue. Another major issue with non-adherence is side effects from medications. There are individuals that really have issues that struggle with the side effects of the medications, therefore not taking medications as prescribed. You ask ‘is there a way to measure that?’ There is, but it’s very difficult. You can do urine tests to look to see if the drug is in the individual’s urine; however, those are costly and not all insurance plans pay for those and it’s difficult to do. The patient feels like they're being challenged. What we've done in a more simpler way is on occasion, we’ve actually had to call pharmacies and look to see if individuals have refilled medications. We found occasionally that there are still prescriptions sitting in the pharmacy, even though the individual says they take their medications. It’s a challenge and that’s something that’s going to be ongoing and just a fact of life.
Melanie: What do you think you can do or let other physicians know how do you deal with all of these issues? If this is continuing to be a problem and as those guidelines have changed, now there are more people with general hypertension, maybe not necessarily resistant hypertension – that number may or may not stay the same, but what do you want other physicians to know about treatment protocols now as we've looked at all these different avenues? What do you want other physicians to take away from this?
Dr. Szawaluk: I think going back to the guidelines, in general, the guidelines are very good. They give a nice outline of how to approach someone with hypertension. Our initial drug therapy really consists of three drugs, an ACE inhibitor or an angiotensin receptor blocker, a calcium blocker and a diuretic. If someone is unsuccessful on those three medications, there's a stepwise addition to guidelines discussing what to add on after that. These patients can be very labor intensive and in addition to medical therapy, you need to look for things like sleep apnea, secondary causes like hyperaldosteronism, which is more common than we think, diet and lifestyle modifications should not be ignored and they can be very helpful, and it’s sometimes a challenge to get individuals to buy into that. At our clinic, we spent a lot of time with the patients. At our first visit, it’s usually an hour or so going through the medical part and then the lifestyle part. We've had a lot of success with the dash diet, which is a low sodium-based diet to treat hypertension, and once patients start to see some improvement and some success, it’s easier to buy into. This is very difficult for a lot of physicians to handle on a routine office visit. They don’t have the time, they're inundated with many other patients and that’s where the hypertension clinics really can come in and help these patients and get them on track and refer them back to their prescribing physician. I think that’s the model that we need to look at to these more specialized clinics at least to get a handle on the issue and then refer back to the primary doctor for long-term care.
Melanie: As you're doing this combination therapy of lifestyle and medicational invention, are you seeing that some of the reversible causes are being taken care of and then narrowing it down? Summarize what you're seeing and what you would like to see in the future.
Dr. Szawaluk: In general, we've had very good success with using this model, a multidisciplinary type approach to treating hypertension, and of course there are some outliers that are still not successful and that’s where ongoing research and hypertension trials come into play. We’re involved in a couple of trials at the Christ Hospital, device trials that treat hypertension, and some of these individuals may or may not meet the criteria for these trials and I think that’s something that’s going to be ongoing. There's a lot of trials in the United States and Europe that are looking at device-based therapy for hypertension and these can be very successful in that resistant group that can't either tolerate medications or we just can't get their blood pressure to go on five or six medications, although I will say that this group is really quite small. Device-based therapy for hypertension is really more of a niche therapy, but certainly a real option. I think that’s where the specialty-based hypertension clinics come into play and can play a significant role.
Melanie: Thank you so much for being with us today. What great information. You're listening to Expert Insights, Physician Views and News with the Christ Hospital Network. More information on Dr. Szawaluk and all of the Christ Hospital physicians is available at tchpconnect.org. That’s tchpconnect.org. This is Melanie Cole. Thanks so much for listening.