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Treating hypertension in difficult settings

Meet the Experts session

  • A 53-year-old woman with difficult to control hypertension, presented by Y Uresin (Istanbul, TR) - Slides
  • A 72-year-old woman with hypertension and severe dyspnea on moderate exertion, presented by M Galderisi (Naples, IT) - Slides
  • What do the Guidelines say? Presented by V Sansoy (Istanbul, TR) - Slides

This session consisted of 2 case presentations followed by a panel discussion. The session was chaired by Dr. Sansoy (Turkey) and Dr. de la Sierra (Spain). Panellists were Dr. Schmieder (Germany), Dr. Uresin (Turkey) and Dr. Galderisi (Italy).

A 53-year-old woman with difficult to control hypertension

The first case was presented by Dr. Uresin. The patient was a woman 53 years old who had hypertension uncontrolled despite the use of 3 drugs, including an angiotensin receptor blocker, a calcium channel blocker and a thiazide diuretic. The patient had several comorbidities, including obesity, type 2 diabetes and osteoarthritis. She also had microalbuminuria. In addition to the 3-drug antihypertensive treatment, the patient was using atorvastatin, metformin, aspirin and consumed frequently other non-steroidal anti-inflammatory agents. Ambulatory blood pressure monitoring confirmed that blood pressure was elevated during the 24-hour period.

The panel discussion focused on several aspects regarding the management of resistant hypertension. The role of Ambulatory Blood Pressure Monitoring was discussed, aiming to differentiate between "true" and "white-coat" resistant hypertension, the latter a condition present in almost one third of such population. The confirmation of elevated ambulatory blood pressure is associated with more target organ damage, poorer prognosis and requires a more aggressive therapy. Another important aspect of the discussion referred to treatment compliance. Compliance is usually difficult to assess (no practical clinical tools have been developed), but the use of 3 antihypertensive agents, in addition to other pharmacological treatments for co-morbid conditions difficult treatment adherence. The possibility of using a 3-drug single pill fixed dose combination therapy for hypertension was emphasized by the panellists as possibly important to improve adherence. In addition, other lifestyle measures, and specifically reducing salt intake was considered important. Other aspects related to the case were the selection of a 4th antihypertensive agent. In these circumstances, the use of betablockers, direct renin inhibitors and aldosterone antagonists was discussed. Although betablockers are widely used by cardiologists, the persistence of microalbuminuria despite the use of valsartan supported the addition of alsikiren or spironolactone as the 4th drug, as both have demonstrated to reduce urinary albumin excretion in patients treated with other renin-angiotensin system blockers. Finally, the panel discussed the need for searching for secondary causes of hypertension. Importantly, the search for renovascular hypertension in a diabetic patient with long-standing essential hypertension was considered necessary.

A 72-year-old woman with hypertension and severe dyspnea on moderate exertion

Dr. Galderisi presented a female patient, 72 years old with long-standing hypertension that developed heart failure with preserved ejection fraction. Dr. Galderesi discussed the most important haemodynamic findings obtained in echo-doppler imaging and the rationale for using different treatments, including ACE inhibitors, new-generation betablockers, diuretics, and the role of other antihypertensive drugs, such as amlodipine in these patients.

The panel discussion emphasized several aspects of treatment, beginning by the fact that no evidence has been produced to prove of the benefit of different treatments in patients with heart failure and preserved ejection fraction. The panel admitted that treatments recommended for these patients derive from data obtained in patients with systolic heart failure. Two important things appeared in the discussion. Firstly, pathophysiological findings are in favour of using renin-angiotensin blockers, betablockers, and diuretics. Secondly, the most important prognostic factor in this group of patients is blood pressure, and blood pressure normalization drives the benefit of treatment. The discussion also concentrated on the ideal time to begin treatment with beta-blockers and the possibility of delaying this treatment until the symptoms of heart failure disappeared, and the advantages of beta-blockers with vasodilatory activity with respect to classical components of this group. It was admitted that no evidence was available for such selection. Finally, a general agreement was made on the need for treating these patients in order to improve their quality of life as no data on mortality was available.

What do the Guidelines say?

The session concluded with a short presentation from Dr. Sansoy, chairman, emphasizing the most important aspects of the discussion and the main recommendations contained in the guidelines.




Treating hypertension in difficult settings

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.