The clinical characteristics of the 27 patients are presented in Table II. Seventeen had elevation of both office and home SBP, 5 had elevated office SBP without monitoring of home BP, and 5 had elevated home SBP with normal office SBP. At the initial visit, the mean office and home BP values were 150/89 mm Hg and 160/87 mm Hg, respectively. The initial office SBP was ≥160 mm Hg (≥150 mm Hg in patients with chronic kidney disease [CKD] or diabetes mellitus [DM]) in 10 of the 27 patients (Table III). Fourteen patients (52%) reported a history of adverse reactions to antihypertensive agents, with reactions to, on average, 2.2 drugs each.
The final office and home BP readings were 125.9±14.4/80.2±9.7 mm Hg and 134.8±12.9/80.2±11.6 mm Hg, respectively, representing a fall of 22.7/9.2 mm Hg and 25.0/6.9 mm Hg for each. Hypertension control was achieved in 24 patients (88.9%), including 16 of 17 patients (94%) with initial SBP <160 mm Hg (<150 mm Hg if CKD/DM) and 8 of 10 (80%) with an initial SBP ≥160 mm Hg (≥150 mm Hg in DM/CKD). Of the 24 patients who achieved BP control, 19 (79.2%) achieved the target BP by the first follow-up visit. The mean number of revisits was 4.3.
At the initial visit, patients were taking, on average, 4.1±1.4 drugs, and at the final visit, 4.4±1.4 drugs. Patients with initial SBP ≥160 mm Hg were taking more drugs than those with initial SBP 140 mm Hg to 159 mm Hg.
The frequency of use of each drug class at the initial and final visits is shown in Table IV. At the initial visit, 27 of 27 patients were taking a diuretic (by definition), 21 of 27 a β-blocker, 11 of 27 a calcium channel blocker (CCB), and 24 of 27 an ACE inhibitor, ARB, and/or DRI, including 7 who were taking drugs from 2 of the latter 3 drug classes. Only 2 were taking a potassium-sparing agent. Seven were taking an α-blocker (doxazosin, 5; prazosin, 2). Eleven were taking combined α-/β-blockade, including 5 who were taking labetalol or carvedilol, and 6 who were taking a separate α- and β-blocker. Seven were taking clonidine, and 5, a vasodilator (hydralazine, 2; minoxidil, 2; and both, 1).
Table IV. Preintervention and Postintervention Antihypertensive Drug Regimens
| ||Overall (N=27)||Initial SBP ≥160 mm Hg (n=10)|
|Thiazide or loop diuretic||26||27||10||10|
|ACE inhibitor, ARB, or DRI||24||23||8||9|
As shown in Table IV, the 2 drug classes most frequently added were potassium-sparing diuretics and α-blockers. The number taking a potassium-sparing diuretic increased from 2 (7.4%) to 15 (55.6%), and the number taking an α-blocker increased from 7 (25.9%) to 16 (59.3%). In contrast, there was no increase in the proportion taking a CCB, ARB, ACE inhibitor, DRI, or central α-agonist, with a trend toward less frequent use of CCBs and ACE inhibitors. Vasodilators were stopped in 4 of the 5 patients who were taking one at the initial visit, including both of the patients who were taking minoxidil. In no case was a DRI, vasodilator, or central α-agonist added, and combination ACE inhibitor/ARB therapy was not instituted in any.
Table V displays the interventions in the 24 patients in whom BP control was achieved. The diuretic regimen was modified in 13 of 24 (54.1%), an α- + β-blocker regimen was instituted or modified in 6 of 24 (25%), and both interventions were employed in 5 of 24 patients (20.8%). Thus, in successfully treated patients, option A (diuretic) was employed in 18 of 24 patients (75%) and option B (α- + β-blocker) in 11 of 24 patients (45.8%).
Table V. BP Outcomes and Treatment Options Employed
| ||All Patients||Patients With Initial SBP ≥160 mm Hg|
| Option A only: strengthen diuretic||13||54.1||5||62.5|
| Option B only: α-blocker+nonmetabolized β-blocker||6||25.0||1||12.5|
| Both option A+option B||5||20.8||2||25.0|
| Option A employed||18|| ||7|| |
| Option B employed||11|| ||3|| |
|BP not controlled||3||11.1||2||20.0|
Among the 18 patients whose diuretic regimen was modified, a loop or thiazide diuretic was added or strengthened in 10 and a potassium-sparing diuretic was added in 13 (spironolactone, 8; amiloride, 5). Thiazide or loop diuretic dose was increased in 4 patients, a thiazide diuretic was added to a K-sparing agent in 1, a thiazide diuretic was replaced by a loop diuretic in 3 patients, and a loop diuretic by a thiazide diuretic in 2 patients. At the final visit, 15 of the 24 patients were taking a K-sparing diuretic.
Among the 11 patients in whom an α- + β-blocker regimen was instituted or modified, an α-blocker was added to a previously prescribed β-blocker in 5 patients, both an α- and β-blocker were added in 1 patient, a β-blocker dose was increased in 1 patient, and a β-blocker whose bioavailability is vulnerable to first-pass hepatic metabolism was replaced with one whose bioavailablity is less affected in 6 patients. Among the 8 patients whose β-blocker regimen was modified, heart rate decreased from 72.9±11.6 beats per minute to 65.3±9.1 beats per minute (P=.1415).
The BP did not reach target in 3 patients. In 1, it was lowered from 170/100 mm Hg to 140/90 mm Hg (and subsequently normalized after extended follow-up). In another, it fell from 180/126 mm Hg to 135/95 mm Hg. The third patient, whose final BP was 155/100 mm Hg, had possible primary hyperaldosteronism, but was lost to follow-up before a definitive diagnosis could be made.