New Approaches Emerge for Hard-to-Control Hypertension

Key takeaways:

• Uncontrolled and resistant hypertension are common and lead to cardiovascular events and death.
• Patients now have more treatment options than before, though additional progress is still needed.

BOSTON — Too many adults have uncontrolled or resistant hypertension, but more solutions are now available or are on the way, a speaker said at the Cardiometabolic Health Congress.

“If your patient needs four blood pressure medications to be controlled, they have resistant hypertension,” Naomi D.L. Fisher, MD, an endocrinologist, director of hypertension services at Brigham and Women’s Hospital and associate professor of medicine at Harvard Medical School, said during a presentation. “Why do we care? Because this group of patients carries the very highest cardiovascular risk. This is the No. 1 killer around the world. Hypertension beats everything else. It beats cholesterol, obesity, smoking, communicable diseases, pollution, anything you can think of. Hypertension affects one in every two adults, so we have to pay attention.”

For people with hypertension, the first three medication classes should be ACE inhibitors or angiotensin receptor blockers, calcium channel blockers and diuretics, Fisher said.

If a fourth drug is required, spironolactone is usually the preferred choice, although some men respond better to eplerenone, she said, adding that not every patient can tolerate all four of the most commonly used options.

After that, treatment should be tailored to the individual, and clinicians should look for a secondary cause of hypertension, such as primary aldosteronism, chronic kidney disease, renal artery stenosis or obstructive sleep apnea, Fisher said.

“If patients have a cardiac indication, that’s a reason to give a beta-blocker or a combined alpha/beta-blocker,” she said. “If patients have tachycardia, they may need a central alpha-agonist like clonidine or guanfacine. If they are not tachycardic, there is a list we have. Some of them are very old medications like minoxidil, which is incredibly effective but causes reflex tachycardia and edema. Amiloride was shown to be effective as a fourth-line therapy. Then there are alpha-agonists. The last two on the block are two new drugs after a very long time without any. We have aprocitentan (Tryvio, Idorsia), a dual endothelin receptor antagonist, and baxdrostat (Baxfendy, AstraZeneca), an aldosterone synthase inhibitor.”

The latter two drugs had pivotal trials showing they lowered blood pressure effectively in patients with resistant hypertension, and an FDA decision is expected soon on another aldosterone synthase inhibitor, lorundrostat (Mineralys Therapeutics), she said.

Device-based therapy is also an option for resistant hypertension, as renal denervation “has been proven effective across a wide range of hypertension severity,” Fisher said.

Renal denervation has been shown to reduce systolic blood pressure by as much as 10 mm Hg, which corresponds to a relative risk reduction of 13% for all-cause mortality, 17% for coronary heart disease, 20% for major adverse cardiovascular events, 27% for stroke and 28% for heart failure, she said.

“Ten million people are dying every year” from causes related to hypertension, Fisher said during the presentation. “We need innovation and we need it badly. We all have to work together.”

Sources/Disclosures

Source:

Fisher NDL. Session I: Cardiorenal/Hypertension. Presented at: Cardiometabolic Health Congress; Boston.

Disclosures: Fisher reports conducting research for Aktiia and Recor Medical and consulting, advising and/or speaking for Aqua, AstraZeneca, Bayer, BD, Boehringer Ingelheim, Eli Lilly, Fractyl, Novo Nordisk, Roche, Sparrow, Vertex, vTv and Zealand.

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