Perelman School of Medicine, University of Pennsylvania, and Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania (J.B.C.).
Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania (D.L.C., D.S.H.).
Ann Intern Med. 2021 Mar;174(3):289-297. doi: 10.7326/M20-4873. Epub 2020 Dec 29.
Primary aldosteronism is a common cause of treatment-resistant hypertension. However, evidence from local health systems suggests low rates of testing for primary aldosteronism.
To evaluate testing rates for primary aldosteronism and evidence-based hypertension management in patients with treatment-resistant hypertension.
Retrospective cohort study.
U.S. Veterans Health Administration.
Veterans with apparent treatment-resistant hypertension ( = 269 010) from 2000 to 2017, defined as either 2 blood pressures (BPs) of at least 140 mm Hg (systolic) or 90 mm Hg (diastolic) at least 1 month apart during use of 3 antihypertensive agents (including a diuretic), or hypertension requiring 4 antihypertensive classes.
Rates of primary aldosteronism testing (plasma aldosterone-renin) and the association of testing with evidence-based treatment using a mineralocorticoid receptor antagonist (MRA) and with longitudinal systolic BP.
4277 (1.6%) patients who were tested for primary aldosteronism were identified. An index visit with a nephrologist (hazard ratio [HR], 2.05 [95% CI, 1.66 to 2.52]) or an endocrinologist (HR, 2.48 [CI, 1.69 to 3.63]) was associated with a higher likelihood of testing compared with primary care. Testing was associated with a 4-fold higher likelihood of initiating MRA therapy (HR, 4.10 [CI, 3.68 to 4.55]) and with better BP control over time.
Predominantly male cohort, retrospective design, susceptibility of office BPs to misclassification, and lack of confirmatory testing for primary aldosteronism.
In a nationally distributed cohort of veterans with apparent treatment-resistant hypertension, testing for primary aldosteronism was rare and was associated with higher rates of evidence-based treatment with MRAs and better longitudinal BP control. The findings reinforce prior observations of low adherence to guideline-recommended practices in smaller health systems and underscore the urgent need for improved management of patients with treatment-resistant hypertension.
National Institutes of Health.
原发性醛固酮增多症是治疗抵抗性高血压的常见病因。然而，来自地方卫生系统的证据表明，原发性醛固酮增多症的检测率较低。
评估治疗抵抗性高血压患者中原发性醛固酮增多症的检测率和基于证据的高血压管理情况。
回顾性队列研究。
美国退伍军人健康管理局。
2000 年至 2017 年期间，有明显治疗抵抗性高血压的退伍军人（ = 269010 人），定义为在使用 3 种降压药（包括利尿剂）期间，至少间隔 1 个月至少有 2 次血压（BP）至少为 140 mm Hg（收缩压）或 90 mm Hg（舒张压），或需要 4 种降压药治疗的高血压。
检测原发性醛固酮增多症（血浆醛固酮-肾素）的比率以及检测与使用盐皮质激素受体拮抗剂（MRA）进行基于证据的治疗的相关性，以及与纵向收缩压的相关性。
确定了 4277 名（1.6%）接受原发性醛固酮增多症检测的患者。与初级保健相比，与肾病医生（风险比[HR]，2.05 [95%CI，1.66 至 2.52]）或内分泌科医生（HR，2.48 [CI，1.69 至 3.63]）就诊的指数就诊更有可能进行检测。检测与更有可能开始 MRA 治疗（HR，4.10 [CI，3.68 至 4.55]）和随着时间的推移更好地控制血压相关。
主要是男性队列、回顾性设计、诊室 BP 易发生分类错误以及缺乏原发性醛固酮增多症的确诊性检测。
在一个分布广泛的有明显治疗抵抗性高血压的退伍军人队列中，原发性醛固酮增多症的检测率很低，与使用 MRA 进行更高比例的基于证据的治疗以及更好的纵向血压控制相关。这些发现强化了先前在较小的卫生系统中观察到的低遵循指南推荐实践的情况，并强调了迫切需要改善治疗抵抗性高血压患者的管理。
美国国立卫生研究院。
