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Low-renin status in therapy-resistant hypertension: a clue to efficient treatment
Ivar K Eide1, Peter A Torjesen, Anders Drolsum
1Department of Medicine, Ullevål University Hospital, Oslo, Norway. ivar.eide@tiscali.no
Objective:
Therapy resistance is an enduring problem in clinical hypertension. Our aims were to estimate: (1) the contribution of a low-renin status in therapy resistance; (2) whether such status could give a clue to more successful treatment; and (3) the contribution by adrenal cortical adenomas and by primary aldosteronism.
Setting:
Patients were referred from general and internal medicine practices following written invitations and included consecutively. Participants were examined and followed-up on an outpatient basis.
Design And Interventions:
Patients were divided according to renin status. Low-renin patients were treated with an aldosterone inhibitor in a prospective, randomized, placebo-controlled, double-blind, cross-over study.
Main Outcome Measures:
Prevalence of low-renin status in therapy resistance. Blood pressure and hormonal responses to specific treatment. Numbers of adrenocortical adenomas and primary aldosteronism.
Results:
In 90 treatment-resistant hypertensive, 67% had plasma renin activity (PRA) below 0.5 nmol/l per hour. Of the 60 low-renin patients, 38 were studied on a fixed combination of amiloride and hydrochlorothiazide. Three weeks' treatment reduced blood pressure by 31/15 mmHg compared to placebo (P < or = 0.0001). Serum aldosterone and plasma renin activity increased substantially during active treatment. Through the subsequent 6-12 months of open treatment, seven patients (18%) showing an escape phenomenon had their high blood pressure effectively treated by extra amiloride. Of the 60 low-renin patients, eight had adrenal adenoma.
Conclusion:
A low-renin status characterized two-thirds of patients with treatment-resistant hypertension, who could be treated efficiently by aldosterone inhibition. Patients with an escape phenomenon (18%) could effectively be treated by increasing the aldosterone inhibitor. Low-renin hypertensives had high prevalence of adrenocortical adenomas and primary aldosteronism.
Insights
Therapy-resistant hypertension is often linked to low-renin status. Aldosterone inhibition effectively treats these patients, with dose adjustments managing treatment escape. Low-renin hypertension also shows a high prevalence of adrenal adenomas and primary aldosteronism.
Area of Science:
- Endocrinology
- Cardiovascular Medicine
- Hypertension Research
Background:
- Therapy resistance is a significant challenge in managing clinical hypertension.
- Identifying underlying causes like low-renin status is crucial for effective treatment.
- Adrenal abnormalities, including adenomas and primary aldosteronism, are potential contributors.
Purpose of the Study:
- To determine the prevalence of low-renin status in therapy-resistant hypertension.
- To assess the efficacy of aldosterone inhibition in treating low-renin hypertension.
- To investigate the association between low-renin status and adrenal cortical adenomas or primary aldosteronism.
Main Methods:
- Patients with treatment-resistant hypertension were assessed for plasma renin activity (PRA).
- Low-renin patients were enrolled in a randomized, placebo-controlled, double-blind, cross-over study using an aldosterone inhibitor.
- Blood pressure and hormonal responses were monitored, along with the prevalence of adrenal adenomas and primary aldosteronism.
Main Results:
- Two-thirds (67%) of 90 treatment-resistant hypertensive patients exhibited low-renin status (PRA < 0.5 nmol/l/h).
- Aldosterone inhibition significantly reduced blood pressure by 31/15 mmHg compared to placebo in low-renin patients (P < 0.0001).
- Eight of the 60 low-renin patients had adrenal adenomas, and 18% experienced an escape phenomenon effectively managed by increasing aldosterone inhibitor dosage.
Conclusions:
- Low-renin status is a common characteristic of therapy-resistant hypertension and is responsive to aldosterone inhibition.
- Effective management of low-renin hypertension can be achieved through aldosterone inhibition, with dose adjustments for escape phenomena.
- A high prevalence of adrenal adenomas and primary aldosteronism exists among patients with low-renin, treatment-resistant hypertension.
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