Ferdinand: New agents, devices ‘not enough’ to address hypertension care disparities
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Key takeaways:
- Undertreatment is the most common cause of resistant hypertension.
- Emerging agents may add to pharmacotherapeutic choices and renal denervation may improve BP control.
Promising new devices and emerging drug classes may improve BP control for some patients with difficult-to-treat hypertension, but clinicians must first address the structural inequities that impact access to care, according to a speaker.
The white/Black mortality gap in the United States is mainly driven by CVD and hypertension is the most potent and prevalent risk factor, Keith C. Ferdinand, MD, the Gerald S. Berenson Endowed Chair in Preventive Cardiology, professor of medicine in the John W. Deming Department of Medicine at Tulane University School of Medicine and a member of the Healio | Cardiology Today Editorial Board, said during a presentation at the World Congress on Insulin Resistance, Diabetes & Cardiovascular Disease. Data show lowering BP has a linear direct effect on decreasing CV events, Ferdinand said. Yet, even with multiple antihypertensive agents and new renal denervation devices now approved to lower BP, control remains poor, especially for people from underrepresented groups or those living in neighborhoods with fewer resources.
“It is not enough to have new devices and new tools. We have to address some of the structural barriers to care,” Ferdinand said. “The problem is not necessarily in terms of awareness or treatments, it is in [BP] control.”
Promising new agents, devices
Data show evidence-based lifestyle factors and recommended pharmacological treatments are underutilized, particularly for Black adults with apparent treatment-resistant hypertension, Ferdinand said. Data from the Jackson Health Study, published in Hypertension in 2020, show that among Black adults with apparent treatment-resistant hypertension, 14.5% had three ideal lifestyle factors and only 1.2% had four ideal lifestyle factors; 5.9% were taking chlorthalidone or indapamide; and 9.8% were taking spironolactone or eplerenone.
“We have tools that are available, but then in the observational data in the cohort that has a high degree of morbidity and mortality related to hypertension, those tools are not being utilized,” Ferdinand said. “Will the new and emerging therapeutic approaches described control hypertension and reduce disparities? Well, some of these agents may have some benefit, especially in Black patients.”
Ferdinand highlighted some emerging drug classes for difficult-to-treat and resistant hypertension, including an investigational subcutaneous RNA interference therapeutic, zilebesiran (Alnylam), shown in a phase 2 study to lower blood pressure at 3 months with sustained reduction to 6 months. Other agents in the pipeline include the aldosterone synthase inhibitors baxdrostat (Cincor Pharma/AstraZeneca) and lorundrostat (Mineralys), the endothelin receptor antagonist aprocitentan (Idorsia/Janssen), nonsteroidal mineralocorticoid receptor antagonists such as the recently FDA-approved finerenone (Kerendia, Bayer), dual angiotensin II receptor-neprilysin inhibitors (ARNI) and SGLT2 inhibitors.
In November, the FDA also approved two novel renal denervation devices — the Symplicity Spyral radiofrequency system (Medtronic) and the Paradise ultrasound system (ReCor Medical) — both with indications to reduce BP as an adjunctive treatment for people with hypertension for whom lifestyle modifications and antihypertensive medications do not adequately control BP.
“Renal nerve denervation will not eliminate the need for pharmacotherapy but it may be applied safely and may assist some of these patients in the future,” Ferdinand said.
Strategies to improve BP control
U.S. and international hypertension guidelines, scientific statements and policy statements recommend evidence-based approaches for hypertension management and improved BP control. However, published data suggest troubling trends with declining BP control after decades of steady improvements. The downward trend reflects a disconnect between professional recommendations and real-world practice, Ferdinand said.
“Implementation [of guideline recommendations] remains an issue to improve BP control, and we need to take certain steps,” Ferdinand said.
To improve hypertension treatment, clinicians must first ensure accurate BP measurements.
“We do a very poor job measuring a biomarker which is highly prevalent and highly potent,” Ferdinand said.
Other structural improvements include utilizing team-based care, implementing safe and effective physical activity for patients, and the use of standardized medication protocols with two or more antihypertensive medicines as a first step.
“Use combination therapy,” Ferdinand said. “In middle-aged and older patients, it is not about ‘my drug’ vs. ‘your drug.’ This is going to require a cocktail of two or more BP agents. This is especially true for Black adults, who tend to have more persistent and more poorly controlled hypertension.”
Ferdinand also said to reduce health care disparities, addressing social determinants of health can have a profound effect on hypertension, diabetes and other chronic conditions.
References:
- Abdalla M, et al. Hypertension. 2023;doi:10.1161/HYP.0000000000000232.
- Khan SS, et al. Circulation. 2023;doi:10.1161/CIR.0000000000001191.
- Khan SS, et al. Circulation. 2023;doi:10.1161/CIRCULATIONAHA.123.067626.
- Langford AT, et al. Hypertension. 2020;doi:10.1161/hypertensionaha.120.14836.
- Ndumele CE, et al. Circulation. 2023;doi:10.1161/CIR.0000000000001186.
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Ferdinand KC. Need for new agents to overcome health care disparity in hypertension. Presented at: World Congress on Insulin Resistance, Diabetes & Cardiovascular Disease; Dec. 7-9, 2023; Los Angeles.
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