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Clinical characteristics, antihypertensive medication use and blood pressure control among patients with treatment-resistant hypertension

the Survey of PatIents with treatment ResIstant hyperTension study

Carcel, Cheryla,b,c; Neal, Brucea,b,d; Oparil, Suzannee; Rogers, Krisa; Narkiewicz, Krzysztoff; Wang, Ji Guangg; Schiffrin, Ernesto L.h; Poulter, Neili; Azizi, Michelj,k,l; Chalmers, Johna,c

doi: 10.1097/HJH.0000000000002184

Objective: We evaluated the characteristics of patients with treatment-resistant hypertension (TRH) and the prevalence of TRH in a large multicountry sample of specialist tertiary centres.

Methods: The Survey of PatIents with treatment ResIstant hyperTension (SPIRIT) study was a retrospective review of medical records of patients seen at tertiary centres located in Western Europe, Eastern Europe, North America, South America, Australia and Asia. Data on demographics, medical history and medication use were extracted from medical records. Prevalence and incidence of TRH were based upon estimated catchment populations.

Results: On thousand, five hundred and fifty-five patients from 76 centres were included, mostly from centres that specialize in hypertension (55%), cardiology (11%) or nephrology (19%). Mean age was 64, 60% were men, 62% were Caucasian, 36% had chronic kidney disease, 41% had diabetes, 12% were smokers and 31% had a previous cardiovascular event. Daytime and night-time ambulatory blood pressure (BP) was the most frequently used measurement for diagnosis (82%). Ninety-five percent of patients were prescribed diuretics, 93% an inhibitor of the renin–angiotensin system, 86% a calcium channel blocker, 74% a beta-blocker and 36% an aldosterone antagonist. The overall estimated mean incidence of TRH was 5.8 per 100 000 per year (ranging between 2.3 and 14.0 across regions) and the corresponding estimated mean prevalence of TRH was 23.9 per 100 000 (ranging between 7.6 and 90.5 across regions).

Conclusion: Observed variation likely reflects real differences in patient characteristics and physician management practices across regions and specialities but may also reflect differences in patient selection and errors in estimation of catchment population across participating centres.

aThe George Institute for Global Health, University of New South Wales

bThe University of Sydney, Sydney Medical School

cRoyal Prince Alfred Hospital, Sydney, New South Wales, Australia

dDepartment of Epidemiology and Biostatistics, School of Public Health, Faculty of Medicine, Imperial College London, United Kingdom

eVascular Biology and Hypertension Program, Division of Cardiovascular Disease, Department of Medicine, School of Medicine, The University of Alabama at Birmingham, Birmingham, Alabama, USA

fDepartment of Hypertension and Diabetology, Medical University of Gdansk, Gdansk, Poland

gShanghai Key Laboratory of Hypertension, Department of Hypertension, Centre for Epidemiological Studies and Clinical Trials, The Shanghai Institute of Hypertension, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China

hLady Davis Institute and Department of Medicine, Jewish General Hospital, McGill University, Montreal, Quebec, Canada

iImperial Clinical Trials Unit, Imperial College London, London, UK

jUniversity Paris Descartes

kAssistance-Publique Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Hypertension Unit

lInstitut national de la santé et de la recherche médicale, Centre d’Investigation Clinique, Paris, France

Correspondence to Professor John Chalmers, MD, PhD, The George Institute for Global Health, Level 10, King George V Building, 83-117 Missenden Road, Camperdown, NSW 2050, Australia. E-mail:

Abbreviations: ABPM, ambulatory blood pressure measurement; ACE, angiotensin-converting enzyme; AHA, American Heart Association; AOBPM, automated office blood pressure measurement; ARB, angiotensin receptor blockers; BP, blood pressure; CCB, calcium channel blockers; CKD, chronic kidney disease; CVD, cardiovascular disease; HBPM, home BP measurement; OR, odds ratio; RAS, renin–angiotensin system; SPIRIT, Survey of PatIents with treatment ResIstant hyperTension; TRH, treatment-resistant hypertension

Received 14 December, 2018

Revised 16 May, 2019

Accepted 6 June, 2019

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