Resistant hypertension is a common clinical condition associated with higher rates of cardiovascular disease, kidney disease, and death. Among individuals with resistant hypertension, secondary causes of hypertension occur in about 20% of cases, but the rates of screening are unknown. We assessed the practice pattern of these guidelines in a major primary and tertiary care academic institution in Northern California. Using the electronic health record, we identified individuals between the years of 2008 and 2014 who were prescribed three separate classes of antihypertensive agents and had follow-up laboratory data within 24 months. We excluded individuals with known causes of secondary hypertension such as hyperaldosteronism, renal artery stenosis, fibromuscular dysplasia, adrenal disease, and end-stage renal disease. We also excluded individuals with diagnosed heart failure, who may have been prescribed selected medications for heart failure instead of hypertension. This cohort of 37,073 individuals with presumed resistant hypertension had a mean age of 58.5 years (SD 15.8), was 51.7% male, and 56.4% Caucasian, 6.3% Black, and 12.4% Asian. Among these individuals, only 520 had a serum aldosterone, and only 447 had both aldosterone and plasma renin activity levels measured. These data infer that the recommended initial screening tests for secondary causes of resistant hypertension - notably primary and secondary hyperaldosteronism - are conducted in only 1.2% of individuals. A detailed chart review of a representative sample of this cohort will be also be conducted. Thus far, these data suggest that there is significant under-screening of reversible causes of resistant hypertension. Furthermore, an electronic implementation strategy to prompt screening for secondary causes may be warranted to reduce blood pressure, optimize use of antihypertensive medications, and lower cardiovascular risk. A similar analysis will be performed in the Veterans Affairs database to evaluate screening rates in health-care delivery systems enriched with African Americans.
Carotid baroreceptor activation therapy for resistant hypertension and heart failure: a report of two cases
