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Brent M. Egan, Jan N. Basile, Shakaib U. Rehman, Phillip B. Davis, Curt H. Grob, Jessica Flynn Riehle, Christine A. Walters, Daniel T. Lackland, Carmen Merali, Jean E. Sealey, John H. Laragh, Plasma Renin Test–Guided Drug Treatment Algorithm for Correcting Patients With Treated but Uncontrolled Hypertension: A Randomized Controlled Trial, American Journal of Hypertension, Volume 22, Issue 7, July 2009, Pages 792–801, https://doi.org/10.1038/ajh.2009.63
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Abstract
Undefined pathophysiologic mechanisms likely contribute to unsuccessful antihypertensive drug therapy. The renin test–guided therapeutic (RTGT) algorithm is based on the concept that, irrespective of current drug treatments, subnormal plasma renin activity (PRA) (<0.65 ng/ml/h) indicates sodium-volume excess “V” hypertension, whereas values ≥0.65 indicate renin–angiotensin vasoconstriction excess “R” hypertension.
The RTGT algorithm was applied to treated, uncontrolled hypertensives and compared to clinical hypertension specialists' care (CHSC) without access to PRA. RTGT protocol: “V” patients received natriuretic anti-“V” drugs (diuretics, spironolactone, calcium antagonists, or α1-blockers) while withdrawing antirenin “R” drugs (converting enzyme inhibitors, angiotensin receptor antagonists, or β-blockers). Converse strategies were applied to “R” patients. Eighty-four ambulatory hypertensives were randomized and 77 qualified for the intention-to-treat analysis including 38 in RTGT (63.9 ± 1.8 years; baseline blood pressure (BP) 157.0 ± 2.6/87.1 ± 2.0 mm Hg; PRA 5.8 ± 1.6; 3.1 ± 0.3 antihypertensive drugs) and 39 in CHSC (58.0 ± 2.0 years; BP 153.6 ± 2.3/91.9 ± 2.0; PRA 4.6 ± 1.1; 2.7 ± 0.2 drugs).
BP was controlled in 28/38 (74% (RTGT)) vs. 23/39 (59% (CHSC)), P = 0.17, falling to 127.9 ± 2.3/73.1 ± 1.8 vs. 134.0 ± 2.8/79.8 ± 1.9 mm Hg, respectively. Systolic BP (SBP) fell more with RTGT (−29.1 ± 3.2 vs. −19.2 ± 3.2 mm Hg, P = 0.03), whereas diastolic BP (DBP) declined similarly (P = 0.32). Although final antihypertensive drug numbers were similar (3.1 ± 0.2 (RTGT) vs. 3.0 ± 0.3 (CHSC), P = 0.73) in “V” patients, 60% (RTGT) vs. 11% (CHSC) of “R” drugs were withdrawn and BP medications were reduced (−0.5 ± 0.3 vs. +0.7 ± 0.3, P = 0.01).
In treated but uncontrolled hypertension, RTGT improves control and lowers BP equally well or better than CHSC, indicating that RTGT provides a reasonable strategy for correcting treated but uncontrolled hypertension.
