Higher Statin Dose Helps Patients with Hard-to-Treat Hypertension

LOS ANGELES—Intensive lipid lowering with atorvastatin is associated with a significant decrease in cardiovascular events in patients with treatment-resistant hypertension, researchers reported at the American Heart Association Scientific Sessions 2012.

Sripal Bangalore, MD, Assistant Professor of Medicine at New York University School of Medicine, and colleagues elsewhere compared intensive lipid-lowering with atorvastatin 80 mg/day to standard lipid-lowering with atorvastatin 10 mg/day in patients with treatment-resistant hypertension who were enrolled in the randomized Treating to New Targets (TNT) trial. The TNT study examined the two strategies for use as  secondary prevention in 10,001 patients with stable coronary heart disease (CHD) and a low-density lipoprotein (LDL) cholesterol level below 130 mg/dL. Of the TNT cohort, 1,112 (11.1%) patients had treatment-resistant hypertension.

Up to 30% of hypertensive patients have treatment-resistant hypertension, Dr. Bangalore pointed out. Treatment-resistant hypertension is defined as blood pressure (BP) that remains above goal despite the concurrent use of three antihypertensive agents of different classes.  The definition also includes individuals whose BP is controlled with four or more agents. Patients with treatment-resistant hypertension are known to have a worse prognosis; for example, such patients are 77% more likely to have a non-fatal myocardial infarction and 41% more likely to die from any cause than patients without treatment-resistant hypertension.

New therapies including catheter-based radiofrequency ablation of the renal sympathetic nerves are being tested for this condition with a specific goal of reducing BP, he said.  While a focus on lowering BP is appropriate given the extremely high risk of cardiovascular events in this population, the effect of intensive lipid lowering on cardiovascular outcomes has not been known.

The primary outcome of the TNT trial was the composite of death from CHD, nonfatal non-procedure-related myocardial infarction, resuscitation after cardiac arrest, and fatal or nonfatal stroke. The median length of follow-up was 4.9 years. The analysis showed that intensive lipid-lowering therapy was associated with a significant 30% reduction in the risk of the primary outcome.

In addition, patients randomized to intensive lipid lowering had a significant 45% decreased risk of CHD-related death and a trend towards a reduction in all-cause mortality versus patients assigned to standard lipid-lowering.

Because the risk of stroke is largely dependent on BP control, intensive lipid lowering did not reduce stroke risk, Dr. Bangalore said.

He cautioned that the research involved a post-hoc analysis from a CHD population not specifically enrolled for the management of BP, so the results cannot be extrapolated to other populations.

“Given the exceedingly high cardiovascular morbidity and mortality in patients with treatment-resistant hypertension, intensive lipid-lowering with a statin should be considered in all such patients regardless of their blood pressure level,” he advised.

To improve BP control, he said clinicians may consider enrolling their patients in trials testing new pharmacologic agents and alternate therapies such as renal denervation.

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