Drug-resistant hypertension is defined as suboptimal blood pressure control despite the treatment with at least three blood pressure-lowering drugs. Up until now, choosing a 4th add-on drug in these patients has been a doctor’s subjective preference more than a scientifically sound decision. Well, these times are over because Bryan Williams and colleagues found out what you should do in these patients in the so-called REVERT-2 trial, which was published in the Lancet in September 2015. Watch the above video to learn all about it.
Everyone is fronts from a mastery again today we’re going to learn about drug resistant hypertension what it is and what you can do about it ready here we go these are the results of the so called pathway to trial it’s full title is spironolactone versus placebo bezoar pull all and docks a season to determine the optimal treatment for drug resistant hypertension
A randomized double-blind crossover trial by brian williams a tell the paper was published in september 2015 in the lancet so what is drug resistant hypertension it’s defined a sub optimal blood pressure control despite the treatment with at least three blood pressure lowering drugs the prevalence of drug resistant hypertension is estimated to be at least ten
Percent of treated hypertensive patients which would amount to a potential prevalence of about 100 million people worldwide so these authors are tackling a super-important problem the three drug classes that are commonly recommended as first second and third line treatments can be remembered by the three-letter sequence a cd a stands for angiotensin converting
Enzyme inhibitor or ace inhibitor or a as in angiotensin ii receptor blocker also called arp c stands for calcium channel blocker and d stands for thiazide or thighs it–like diuretic so the question is what should you do in a patient who despite receiving the maximum dose of these three classes is still hypertensive in other words what should be your fourth line
Treatment in this patient that was the question that was elegantly answered by these authors here’s how they did it they performed a multicenter trial in 14 hospitals throughout the uk patients were included if all of the following three criteria were present they had to be 18 to 79 years of age their systolic clinical blood pressure had to be 140 millimeters of
Mercury or higher or their home systolic blood pressure had to be 130 millimeters of mercury or higher and they have to be on a maximally tolerated dose of three antihypertensive drugs for at least three months so they ended up with the total number of three 135 patients then each of these study participants rotated through four cycles of one’s daily oral treatment
With two doses of spironolactone docs a season bazaar law and placebo when they were in the spironolactone cycle they received 25 milligrams for six weeks followed by fifty milligrams for another six weeks when they were in the duct sizes in cycle they received four milligrams for six weeks followed by eight milligrams for another six weeks and when they were in
The bazzara law cycle they received five milligrams for six weeks followed by ten milligrams for another six weeks and when they were in the placebo arm they simply received the placebo for 12 weeks what was actually randomized in this study was the sequence of these treatment cycles so they could go from spironolactone to dex a season to placebo and sopra law or
From docs a season followed by bezalel placebo and spironolactone or whatever other permutation you can think of both caregivers and patients were blinded to the treatment that was given during each cycle and here the results 58 percent of patients reached target blood pressure values when they weren’t sparano lactone 42% reached them when they were in doc’s a
Season 43% reached them when they were on b’s oprah law and 24% when they were in placebo the mean systolic blood pressures were 140 three point six millimeters of mercury in the placebo cycle 134 point nine millimeters of mercury in the spur on a lactone cycle 139 undocks aces in one thirty nine point four on bizzle paulo and for completeness sake let’s draw in the
95% confidence intervals for these values real quick so the difference between placebo and spironolactone was eight point seven millimeters of mercury p-value below 0.0001 the difference between spironolactone and ox a surgeon was 4.0 three millimeters of mercury p-value also below 0.0001 and the difference between spironolactone and basel prologue was four point
Four eight millimeters of mercury p-value also below 0.0001 so of all these drugs spironolactone was clearly the most effective fourth line drug when they speculated why that is the authors concluded that sodium retention might be the most common cause of drug resistant hypertension in most of our patients and as you probably know spironolactone leads to sodium
Excretion all active treatments were well tolerated with similarly low rates of adverse events notably this continuations due to renal impairment hyperkalemia and gynecomastia were not increased with sparano lactone relative to other treatments and placebo six patients developed a symptomatic serum potassium levels above six millimoles per liter when they were in
The sparano lactone cycle but none of them had any serious clinical consequences quite interesting wasn’t it if you want to learn more about potassium sparing diuretics and all the other classes of diuretics then make sure to check out our fluids and electrolytes masterclass which will turn you into an expert on the topic also absolutely make sure to download the
Infographic that comes with this video and which nicely summarizes all the key facts mentioned with that being said i wish you a great day have a great learning experience and i hope to talk to you soon
Transcribed from video
Spironolactone and drug-resistant hypertension – Video Review By Medmastery
