Unexpected improvement of resistant hypertension in older adults: A red flag sign

IF 2.4 4区 医学 Q3 GERIATRICS & GERONTOLOGY
Ami Schattner MD
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Two such patients are briefly reported to suggest different mechanisms of this unusual, poorly-reported occurrence and its potentially urgent clinical significance in older adults.</p><p>A 92-year-old community-dwelling woman had a long history of primary isolated systolic hypertension and chronic obstructive pulmonary disease on budesonide inhaler treatment. The chronic obstructive pulmonary disease (Global Initiative for Chronic Obstructive Lung Disease 3 when last tested a few months prior) did not cause dyspnea on effort, as she was bedridden for most of the day, helped by a caretaker. She had never been hospitalized, and adhered to a low-salt diet and medications administered by her live-in caregiver, including candesartan 16 mg/day, amlodipine 10 mg/day, bisoprolol 5 mg/day and clonidine 0.3 mg b.i.d. (thiazides could not be tolerated due to hyponatremia). 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引用次数: 0

Abstract

Resistant hypertension is defined as failure to reach blood pressure (BP) targets despite the use of three classes of antihypertensive drugs, including a diuretic, at their maximal tolerated doses.1 A recent meta-analysis including 91 studies and >3 million patients with essential hypertension reported a prevalence of 10.3% for resistant hypertension, higher with advancing age or chronic kidney disease.2 The National Health and Nutrition Examination Surveys database also identified older age as a distinct risk factor for refractory hypertension.3 These patients pose a therapeutic challenge, because of their increased risk of major adverse cardiovascular events and end-organ damage.4 Thus, invasive treatments, such as renal denervation, had been tried, including among older adult patients, but remain under clinical trial.5, 6 In contrast, patients with longstanding resistant hypertension that suddenly spontaneously resolved are rarely encountered. Two such patients are briefly reported to suggest different mechanisms of this unusual, poorly-reported occurrence and its potentially urgent clinical significance in older adults.

A 92-year-old community-dwelling woman had a long history of primary isolated systolic hypertension and chronic obstructive pulmonary disease on budesonide inhaler treatment. The chronic obstructive pulmonary disease (Global Initiative for Chronic Obstructive Lung Disease 3 when last tested a few months prior) did not cause dyspnea on effort, as she was bedridden for most of the day, helped by a caretaker. She had never been hospitalized, and adhered to a low-salt diet and medications administered by her live-in caregiver, including candesartan 16 mg/day, amlodipine 10 mg/day, bisoprolol 5 mg/day and clonidine 0.3 mg b.i.d. (thiazides could not be tolerated due to hyponatremia). Nevertheless, frequent episodic asymptomatic BP recordings of >200/83 mmHg continued, confirmed by 24-h Holter monitoring. I was consulted after her son became concerned that her BP readings suddenly were “too good”: 130/80 mmHg, without peaks. She was found apathetic, and was referred immediately to the hospital where respiratory acidosis and hypercapnic respiratory failure was detected (pH 7.269, PCO2 95). There were no other contributing associated conditions, such as chest infection. She was intubated, admitted to the intensive care unit and later discharged home on non-invasive ventilation, resuming her full anti-hypertensive treatment shortly after.

A 76-year-old banker with a long history of primary hypertension and prediabetes (HbA1c 6.3%) was receiving valsartan 320 mg/day, disothiazide 25 mg/day, eplerenone 25 mg/day, bisoprolol 10 mg/day and metformin. Nevertheless, 24-h ambulatory blood pressure monitoring showed frequently abnormal BP (systolic 100%, diastolic 77% of the time). At home, values of 207/109 or 190/100 mmHg were not infrequently observed, despite adherence, low-salt diet and regular walking. He presented after his BP normalized, anxious to know why. The examination was unrewarding. Echocardiography, followed by thallium-201 myocardial perfusion scanning, showed that he had suffered a silent anteroseptal myocardial infarction, and ejection fraction (previously 60%) was down to 40%. As a banker, he practically moved from his car to the elevator to his office and reported no symptoms of heart failure. He subsequently had coronary angiography and stent placement, and was discharged on dual antiplatelets, high-dose statin, bisoprolol and sacubitril/valsartan. Two months later, hypertension again became a problem and full treatment resumed.

Our two older adult patients had longstanding primary hypertension that was resistant and poorly controlled over long, well-documented periods, despite adherence to multidrug treatment and lifestyle recommendations. Their sudden BP normalization under the same treatment was unexpected and, rightfully, caused concern. In case 1, it was due to severe respiratory acidosis in a patient with chronic obstructive pulmonary disease, and in the second, to a silent anterior wall myocardial infarction.

This presentation is rather unusual. As an ambulatory consultant in geriatric internal medicine and hypertension, I examine approximately 720 patients per year, and approximately 4:5 patients are hypertensive, with an estimated 15% of resistant primary hypertension. Over the past 5 years, I have encountered only these two cases of the “spontaneous” resolution of resistant hypertension, an estimated incidence of 0.11%/year of all resistant hypertension (0.56%/5 years).

Two different mechanisms were involved. In case 1, spontaneous resolution of poorly-controlled hypertension was secondary to the development of respiratory acidosis. In fact, it was its initial and presenting manifestation. Isolated myocardial muscle and excised heart studies have long shown that respiratory acidosis depresses myocardial contractility. Whole animal studies later elucidated the underlying mechanisms,7, 8 suggesting that the patient's beta-blockade (bisoprolol) and alpha-2-adrenoreceptor-agonists (clonidine) might have deprived her of important compensatory responses and led to further deterioration in myocardial contractility. Silent myocardial infarction as reported in case 2 is not uncommon, identified in 153 of 925 (16.5%) of screened people in a recent magnetic resonance imaging-based series.9 Diabetes or prediabetes confer significantly increased risk (OR 3.99, 95% CI 1.48–12.85), and increased susceptibility to subsequent myocardial infarction, congestive heart failure, stroke and death.9, 10 An unexpected improvement of resistant hypertension is another notable outcome, likely related to the loss of functioning myocardium and diminished cardiac output.

Thus, sudden BP normalization in older adult patients with longstanding, true resistant hypertension is a rare and potential red flag phenomenon that requires immediate attention, and may indicate diminished myocardial contractility and cardiac output.

The authors declare no conflict of interest.

老年人耐药性高血压的意外改善:警示信号。
整只动物的研究后来阐明了其基本机制,7、8 表明患者服用的β-受体阻滞剂(比索洛尔)和α-2-肾上腺素受体激动剂(氯尼丁)可能剥夺了她的重要代偿反应,导致心肌收缩力进一步恶化。病例 2 中报告的无症状心肌梗死并不罕见,在最近一系列基于磁共振成像的筛查中,925 人中有 153 人(16.5%)发现了无症状心肌梗死。9 糖尿病或糖尿病前期会显著增加风险(OR 3.99,95% CI 1.48-12.85),并增加随后发生心肌梗死、充血性心力衰竭、中风和死亡的可能性、10 耐药性高血压的意外改善是另一个值得注意的结果,可能与心肌功能丧失和心输出量减少有关。因此,长期存在真正耐药性高血压的老年患者突然血压正常化是一种罕见的潜在警示现象,需要立即引起注意,这可能表明心肌收缩力和心输出量减弱。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
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来源期刊
CiteScore
5.50
自引率
6.10%
发文量
189
审稿时长
4-8 weeks
期刊介绍: Geriatrics & Gerontology International is the official Journal of the Japan Geriatrics Society, reflecting the growing importance of the subject area in developed economies and their particular significance to a country like Japan with a large aging population. Geriatrics & Gerontology International is now an international publication with contributions from around the world and published four times per year.
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