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Although hypertension is usually not associated with physical symptoms, there is survey evidence that many patients, perhaps the majority, see this condition as a cause for worry and a threat to their overall health.[1-3] It is a reasonable assumption that these concerns are most manifest in patients whose blood pressures (BPs) are not well controlled. As well, there is evidence derived from psychological testing that people with hypertension experience reductions in quality of life that are proportional to their BP elevations.[4-6]

A recent study of attitudes in patients with self-described uncontrolled or treatment-resistant hypertension by Schmieder and colleagues[7] has established that these individuals carry a heavy emotional burden. The authors of this work reported the results of a survey conducted by the professional polling organization, Harris Interactive (New York). The survey questions had been designed in collaboration with a steering committee of hypertension experts (see 'Acknowledgments' Section for details). The work of Harris Interactive and the committee was supported by an unrestricted grant from Medtronic.

Overall, 4574 patients from the United States, Brazil, Japan, and several Western European countries with self-reported uncontrolled or treatment-resistant hypertension were surveyed. In response to the question: “How would you describe your current overall health?” more than half of the respondents chose “poor” or “fair” rather than “good” or “excellent.” In addition, they indicated a sense of pessimism about the probability of their BPs ever being controlled. All aspects of health appeared to be compromised by their hypertension, including a fear by many patients for their future well-being. Even personal and family relationships were found to be adversely affected.[7]

How Are These Emotional Responses Explained?

  1. Top of page
  2. How Are These Emotional Responses Explained?
  3. Treatment-Resistant Hypertension in Perspective
  4. Emotional Issues
  5. What Can Be Done?
  6. Acknowledgments
  7. References

It is noteworthy that the negative feelings associated with hypertension cross several domains of life. Studies using the well-established Psychological General Well-Being Index (PGWBI)[8] have assessed the effects of hypertension and its treatment on anxiety, depressed mood, positive well-being, self-control, and general health and vitality, and have shown that all these important domains can be adversely affected.[4, 5, 9]

The emotional impact of being diagnosed with hypertension is not surprising. For young or middle-aged adults, hypertension is often the first cardiovascular diagnosis they have personally encountered. When they then learn that high BP is associated with an increased risk of cardiovascular events such as strokes and heart attacks, there is a natural apprehension at this serious turn of events in their lives. Even worse, if treatment is unsuccessful in controlling their BP, these patients understandably might feel an even greater burden of anxiety.

In essence, the findings of Schmieder and coworkers[7] provide powerful documentation of what could have been anticipated. It is perhaps inevitable that since hypertension is so common, medical practitioners simply do not have the time to fully delve into the emotional reactions of their patients to this diagnosis.

It is also possible that there is a physiologic link between high BP and anxiety or other negative feelings. In a large community-based study of 2716 patients with stage 1 hypertension (140–159/90–99 mmHg), either untreated or uncontrolled on existing therapy, pharmacologic treatment was started or added in order to better manage the hypertension. The PGWBI was applied to all patients before the new therapy was initiated and again after 6 weeks. The new treatment provided a highly significant improvement across all the domains of this psychological instrument.[9] Remarkably, the changes in this index correlated closely with the reductions in BP achieved with the new therapy. Of note, the psychological testing was done before the patients had their end-of-study BPs checked, so the changes in these psychological measurements presumably occurred without patients knowing whether the treatment had been effective in controlling their BPs. Reports from other trials have similarly found a link between changes in the PGWBI and BP.[4, 5] These findings suggest that high BP, per se, independent of the patient's awareness of his or her condition, can affect important emotional characteristics. This interesting and clinically important relationship should be explored further.

Treatment-Resistant Hypertension in Perspective

  1. Top of page
  2. How Are These Emotional Responses Explained?
  3. Treatment-Resistant Hypertension in Perspective
  4. Emotional Issues
  5. What Can Be Done?
  6. Acknowledgments
  7. References

Treatment-resistant hypertension has received much attention in recent years, and a detailed statement by experts has been written to advise on its diagnosis and management.[10] The pathogenesis of resistant hypertension is not well understood. Although its definition remains arbitrary, the most frequently cited recommendation is that this condition be diagnosed if a patient's BP remains uncontrolled (usually above the target of <140/90 mmHg) despite taking 3 drugs (including a diuretic) at maximum tolerated doses.[10, 11] It should be emphasized that this definition is based on expert opinion rather than evidence from clinical trial or observational data. Even so, it provides a useful basis for identifying hypertensive patients who might require more intensive evaluation and treatment.

It is important to understand that people whose BP cannot be controlled with pharmacologic therapy are clearly at increased cardiovascular risk.[12] Although the recommended treatment target of <140/90 mmHg has not been established by rigorous randomized controlled trials, data from a number of studies associating achieved on-treatment BPs with cardiovascular, stroke, and renal outcomes have shown that patients with achieved BPs <140/90 mmHg have significantly fewer major events than those whose BPs remain above this benchmark.[13-16] These data notwithstanding, we have no direct evidence that patients who require additional drugs to achieve this goal, as compared with those who achieve it with initial therapy, actually improve their prognosis.[17] So, it is a tenable proposition that patients with so-called treatment-resistant hypertension do not simply have higher BPs, but rather have a fundamentally different form of vascular disease than those whose BPs can be controlled more easily.

Not all patients who appear unresponsive to their antihypertensive drugs have treatment-resistant hypertension. A large study from Spain that used ambulatory BP monitoring concluded that about one third of patients with apparent treatment-resistant hypertension had normal BPs when measured outside of the clinic, ie, had white-coat hypertension.[18] As well, resistant hypertension can be the result of other causes, including secondary hypertension or the effects of commonly used noncardiovascular drugs, eg, nonsteroidal inflammatory agents or antidepressants, which can antagonize BP treatment. As an aid in diagnosing true treatment-resistant hypertension, the committee that helped develop the survey reported by Schmieder and associates has created an online site called Power Over Pressure (www.poweroverpressure.com), again supported by Medtronic, which provides a detailed algorithm to guide practitioners through the evaluation and management of patients who appear unresponsive to BP treatment.

Emotional Issues

  1. Top of page
  2. How Are These Emotional Responses Explained?
  3. Treatment-Resistant Hypertension in Perspective
  4. Emotional Issues
  5. What Can Be Done?
  6. Acknowledgments
  7. References

Another recent study provides interesting data that cast further light on the behavior of patients with apparent treatment resistant hypertension. In a group of patients diagnosed with treatment resistant hypertension, after excluding those who responded to intensified pharmacologic therapy or were found to have secondary hypertension, the investigators tested urine samples by liquid chromatography-mass spectrometry to check the adherence of patients to their treatment. Remarkably, over half of the patients were found to be taking fewer medications than they had been prescribed and some were taking no treatment at all.[19] This finding adds a highly interesting perspective to the findings of Schmieder and colleagues because it suggests that there are some patients who, despite the fear and anxiety caused by uncontrolled hypertension, are still reluctant to comply with their prescribed therapy.

Whether this behavior of hypertensive patients can be described as denial or by other psychological labels, it is obvious that some people have complex and seemingly illogical attitudes in dealing with their hypertension diagnosis. It is possible that this behavior is another manifestation, albeit difficult to explain, of the negative emotional responses described by the Harris survey[7] or suggested by the PGWBI studies.[4, 5, 9]

What Can Be Done?

  1. Top of page
  2. How Are These Emotional Responses Explained?
  3. Treatment-Resistant Hypertension in Perspective
  4. Emotional Issues
  5. What Can Be Done?
  6. Acknowledgments
  7. References

Most patients with resistant hypertension can be effectively treated, but even when following published recommendations[10] or consulting the online algorithm (www.poweroverpressure.com) for dealing with treatment-resistant hypertension, there will be patients whose BPs remain uncontrolled. We have learned from recent experience that the problem of treatment-resistant hypertension is not simply one of increased cardiovascular risk, serious as that may be. This condition is also associated with complex and troubling emotional issues that adversely influence the lives of affected patients on an ongoing basis.

Sustained uncontrolled hypertension, whatever its cause, cannot be ignored. Pointing fingers at health care providers for being insufficiently committed or knowledgeable in their use of therapeutics—sometimes termed “clinical inertia”—doesn't help. Nor is it constructive to point fingers at patients whose emotional and counterproductive reactions to their hypertension might be preventing a successful outcome of treatment. A wait-and-see approach to uncontrolled hypertension is not acceptable and clinicians must be prepared to take decisive action. No matter what treatments have been attempted, it becomes appropriate to seek help from hypertension specialists and to consider all available treatment interventions, pharmacologic or otherwise, which could mitigate the risk of patients experiencing serious cardiovascular disease outcomes.

Acknowledgments

  1. Top of page
  2. How Are These Emotional Responses Explained?
  3. Treatment-Resistant Hypertension in Perspective
  4. Emotional Issues
  5. What Can Be Done?
  6. Acknowledgments
  7. References

MAW disclosures: member of the speakers' bureau for Daiichi Sankyo, Forest Pharmaceuticals, and Takeda Pharmaceuticals. Serves as a consultant for Boehringer-Ingelheim, Daiichi Sankyo, Forest Pharmaceuticals, Takeda Pharmaceuticals, Medtronic, and Boston Scientific. SO disclosures: serves as a consultant to Bayer, Daiichi Sankyo Inc., Medtronic, Novartis, Pfizer, and Takeda, and receives research support from AstraZeneca AB, Duke University, Merck and Co., NHLBI, Novartis, Takeda, Daiichi Sankyo, Comprehensive Cardiovascular Center, Medtronic, and Vivus.

The Committee that participated in designing the survey[7] and wrote the algorithm for managing treatment-resistant hypertension (www.poweroverpressure.com) was composed of the following members, including the authors of this commentary: Brent M. Egan, Guido Grassi, Sverre E. Kjeldsen, Suzanne Oparil, Roland E. Schmieder, Michael A. Weber, and Jackson Wright.

References

  1. Top of page
  2. How Are These Emotional Responses Explained?
  3. Treatment-Resistant Hypertension in Perspective
  4. Emotional Issues
  5. What Can Be Done?
  6. Acknowledgments
  7. References
  • 1
    Oliveria SA, Chen RS, McCarthy BD, et al. Hypertension knowledge, awareness, and attitudes in a hypertensive population. J Gen Intern Med. 2005;20:219225.
  • 2
    Miller NH, Berra K, Long J. Hypertension 2008–awareness, understanding, and treatment of previously diagnosed hypertension in baby boomers and seniors: a survey conducted by Harris Interactive on behalf of the Preventive Cardiovascular Nurses Association. J Clin Hypertens. (Greenwich) 2010;12:328334.
  • 3
    Egan BM, Lackland DT, Cutler NE. Awareness, knowledge, and attitudes of older americans about high blood pressure: implications for health care policy, education, and research. Arch Intern Med. 2003;163:681687.
  • 4
    Wiklund I, Halling K, Rydén-Bergsten T, Fletcher A. Does lowering the blood pressure improve the mood? Quality-of-life results from the Hypertension Optimal Treatment (HOT) study. Blood Press. 1997;6:357364.
  • 5
    Weir MR, Prisant LM, Papademetriou V, et al. Antihypertensive therapy and quality of life. Influence of blood pressure reduction, adverse events, and prior antihypertensive therapy. Am J Hypertens. 1996;9:854859.
  • 6
    Bulpitt CJ. The effect of lowering blood pressure on quality of life. Curr Hypertens Rep. 2000;2:509.
  • 7
    Schmieder RE, Grassi G, Kjeldsen SE. Patients with treatment-resistant hypertension report increased stress and anxiety: a worldwide study. J Hypertens. 2013;31:610615.
  • 8
    Dupuy HJ. The psychological general well being. In: Wenger NK, Mattson ME, Furburg CD, et al, eds. Assessment of Quality of Life in Clinical Trials of Cardiovascular Therapies. New York, NY. LeJacq Publishing Inc; 1984:170183.
  • 9
    Weber MA, Bakris GL, Neutel JM, et al. Quality of life measured in a practice-based hypertension trial of an angiotensin receptor blocker. J Clin Hypertens (Greenwich). 2003;5:322329.
  • 10
    Calhoun DA, Jones D, Textor S, et al; American Heart Association Professional Education Committee. Resistant hypertension: diagnosis, evaluation, and treatment: a scientific statement from the American Heart Association Professional Education Committee of the Council for High Blood Pressure Research. Circulation. 2008;117:e510e526.
  • 11
    Chobanian AV, Bakris GL, Black HR, et al; Joint National Committee on Prevention; Detection, Evaluation, and Treatment of High Blood Pressure; National Heart, Lung, and Blood Institute; National High Blood Pressure Education Program Coordinating Committee. Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension. 2003;42:12061252.
  • 12
    Pierdomenico SD, Lapenna D, Bucci A, et al. Cardiovascular outcome in treated hypertensive patients with responder, masked, false resistant, and true resistant hypertension. Am J Hypertens. 2005;18:14221428.
  • 13
    Weber MA, Julius S, Kjeldsen SE, et al. Blood pressure dependent and independent effects of antihypertensive treatment on clinical events in the VALUE Trial. Lancet. 2004;19:363.
  • 14
    Sleight P, Redon J, Verdecchia P, et al; ONTARGET investigators. Prognostic value of blood pressure in patients with high vascular risk in the Ongoing Telmisartan Alone and in combination with Ramipril Global Endpoint Trial study. J Hypertens. 2009;27:13601369.
  • 15
    Cooper-DeHoff RM, Gong Y, Handberg EM, et al. Tight blood pressure control and cardiovascular outcomes among hypertensive patients with diabetes and coronary artery disease. JAMA. 2010;304:6168.
  • 16
    Weber MA, Bakris GL, Hester A, et al. Systolic blood pressure and cardiovascular outcomes during treatment of hypertension. Am J Med. 2013;126:501508.
  • 17
    Weber MA, Julius S, Kjeldsen SE, et al. Cardiovascular outcomes in hypertensive patients: comparing single-agent therapy with combination therapy. J Hypertens. 2012;30:22132222.
  • 18
    de la Sierra A, Segura J, Banegas JR, et al. Clinical features of 8295 patients with resistant hypertension classified on the basis of ambulatory blood pressure monitoring. Hypertension. 2011;57:898902.
  • 19
    Jung O, Gechter JL, Wunder C, et al. Resistant hypertension? Assessment of adherence by toxicological urine analysis. J Hypertens. 2013;31:766774.