NEW YORK CITY, NY — A clinic dedicated specifically to the treatment of patients with resistant hypertension achieved significant reductions in systolic blood pressure compared with baseline values, and there was a trend toward a reduction in body weight and body-mass index[1].

The clinic, which includes a dietician, nurse practitioners, and physicians, including cardiologists and nephrologists, saw reductions in systolic blood pressure that were on par with the large reductions observed in the earlier, uncontrolled trials testing renal denervation.

Presenting the results of 109 patients treated at the specialized clinic between January 2012 and September 2013, Dr John Szawaluk (Ohio Heart and Vascular Center, Cincinnati), the senior investigator of the study and medical director of the Resistant Hypertension Clinic, said the work isn't particularly "sexy," but their approach is effective.

"When somebody is having a heart attack and the doctor comes into the hospital in the middle of night and puts in a stent, that's something that gets people's attention," Szawaluk told heartwire . "In the clinic, dealing with these hypertensive patients, with compliance, with side effects, it's not as sexy. It's in the trenches taking care of people, but that's what we got into this to do."

Large Reductions in Systolic Blood Pressure

The data, presented here at the American Society of Hypertension 2014 Annual Scientific Meeting , showed that patients referred to the clinic had a baseline systolic and diastolic blood pressure of 153.1/83.7 mm Hg. Approximately one-third of the patients were obese, nearly half had elevated cholesterol levels, and one in five had chronic kidney disease. Just over 25% of patients had underlying coronary artery disease.

After an average of three visits to the clinic, or approximately 3.5 months, systolic blood pressure was reduced to 130 mm Hg and diastolic blood pressure reduced to 75.1 mm Hg. Body weight was reduced from 94.5 kg to 91.4 kg, a reduction that did not achieve statistical significance. Body-mass index declined from 32.2 kg/m2 to 31.3 kg/m2, again a reduction that was not significant.

In terms of the typical treatment, most of the patients are taking at least four antihypertensive medications, sometimes as many as five. Szawaluk prescribes ACE inhibitors or angiotensin-receptor blockers (ARBs), calcium-channel blockers, and a diuretic (usually chlorthalidone). For a fourth medication, he'll frequently add spironolactone and usually take patients off atenolol.

What the Clinic Is Doing Well

Speaking with heartwire , Szawaluk said the patient will typically have a 60- to 90-minute first visit, including 20 to 25 minutes with the nurse practitioner, who determines what medications they are taking. In contrast, most patients might get only a brief 10- to 15-minute visit with their family physician. During the visit, the patient also receives comprehensive lifestyle advice, including help with reading food labels and recommendations on how to start increasing their daily physical-activity levels. In the clinic, patients are recommended to adhere to the DASH diet.

If there are other issues, such as sleep apnea, the resistant-hypertension team deals with that, too.

"What we've observed is that the lifestyle changes we recommend can be just as important as the medication changes we make," said Szawaluk. He added that some patients want to reduce the number of medications they take, and he tells them the only way they'll be able to do that will be by getting active and making significant changes to their diet.

The comprehensive team approach also tries to determine whether the patients have been taking their medication. In some instances, patients who are "resistant" to antihypertensive therapy simply haven't been adhering to therapy, because of side effects, cost, or other reasons. "Often we'll be assessing their medication and find out the patient can't afford it," said Szawaluk. In these cases, a switch to generics is made.

The clinic is not a money-making operation, said Szawaluk, and is supported by the Christ Hospital Health Network. While it is not in the black, the hospital is committed to the program because it's effective and helps prevent visits to the emergency department for uncontrolled hypertension.


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