Conference Coverage

Consider spironolactone in treatment-resistant hypertension



– More than one-third of patients with treatment-resistant hypertension in U.S. cardiology practices are eligible for preferential consideration of spironolactone as their fourth-line agent in accord with the practice-changing findings of the PATHWAY-2 trial, Lauren Thompson, MD, said at the annual meeting of the American College of Cardiology.

She presented a study that harnessed the ACC’s National Cardiovascular Data Registry PINNACLE Registry – the largest observational outpatient cardiovascular registry in the world – to assess the potential impact of PATHWAY-2 on the management of treatment-resistant hypertension (TRH) in U.S. cardiology practices. And as she discovered, the potential implications for daily practice are huge.

Dr. Lauren Thompson, a cardiology fellow at the University of Colorado Bruce Jancin/MDedge News

Dr. Lauren Thompson

PATHWAY-2 was a randomized, double-blind, crossover trial involving 314 U.K. patients with TRH despite treatment with maximally tolerated doses of three drugs: a diuretic, an ACE inhibitor or angiotensin receptor blocker, and a calcium channel blocker. Patients were randomized to rotate through 12 weeks of once-daily add-on therapy with spironolactone at 25-50 mg, bisoprolol at 5-10 mg, modified-release doxazosin at 4-8 mg, and placebo. All of the add-ons were similarly well tolerated, but spironolactone proved to be easily the most effective fourth drug for TRH (Lancet. 2015 Nov 21;386[10008]:2059-68).

Dr. Thompson, a cardiology fellow at the University of Colorado, Denver, identified 19,044 patients in the PINNACLE registry for 2013-2014 with TRH, defined as uncontrolled blood pressure despite use of drugs from three antihypertensive classes. Of these patients, 37% met the PATHWAY-2 enrollment criteria by virtue of already being on an ACE inhibitor or angiotensin receptor blocker, a calcium channel blocker, and a thiazide diuretic, but not spironolactone. This is the large subgroup which, on the basis of PATHWAY-2, should receive serious consideration of spironolactone as the fourth drug.

The most widely prescribed antihypertensive agents in PINNACLE registry patients with TRH were beta-blockers, in 87%; ACE inhibitors, in 72%; calcium channel blockers, in 71%; and thiazide diuretics, in 69%. Of note, 27% of patients with TRH were already on spironolactone.

Audience discussion centered around the uncertainties regarding treatment adherence in patients labeled as having TRH.

“I think sometimes clinicians are afraid to prescribe spironolactone in patients that they think might be nonadherent,” one cardiologist observed.

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