highlights
nature publishing group
Tips from Kaiser Permanente show how PRA can enhance blood pressure control and cardiovascular disease prevention individuals with high PRA respond best to anti-renin agents. By assessing PRA, authors found that drug use and treatment results are not randomly distributed; both were inversely associated with PRA. This was true even for the common mismatch Medications 3.2
140
3
130
2.8
120
2.6
Number of medications
Systolic BP mm Hg
SBP 150
2.4
110 Q1
Q2
Q3
Q4
PRA quartiles
of anti-renin drugs, particularly β-blockers, in low-PRA patients. At the high-PRA end, most patients were receiving both a diuretic and a reninblocking agent. The PRA levels observed included heights never reached by untreated individuals. 3.0 ACEI/ARBs
2.9 2.8
distal diuretics
2.6
# meds Q2
2.7
# meds/person
85% # meds 80% 75% beta blockers 70% 65% 60% 55% CCBs 50% 45% 40% 35% Q1
Q3
Q4
2.5
PRA quartiles
These findings identify opportunities to improve blood pressure control and cardioprotection for both high- and low-PRA hypertension patients. At the
AMERICAN JOURNAL OF HYPERTENSION | VOLUME 25 NUMBER 3 | 275 | march 2012
low end, mismatch of drugs with PRA almost certainly led to inclusion—and perpetuation—of drugs that might have counteracted antivolume agents. PRAguided drug selection would almost certainly produce more efficient and better control. There may also have been a hazard with high-PRA individuals in whom blood pressure control was achieved at the possible cost of hemoconcentration. Sim et al. suggest that in such situations the elevated renin needed to sustain pressure might be accompanied by diminished tissue perfusion due to low blood volume. There is accumulating evidence that links in-treatment elevated PRA with increased cardiovascular disease mortality, for which compromised tissue perfusion may be responsible. Hypovolemia may be corrected by either reducing diuretic/anti-renin drugs or increasing sodium intake. The goal must be the best blood pressure control that can be achieved without sacrificing volume and therefore flow. In sum, the KPSC experience is consistent with the emerging recognition that optimal hypertension management demands more than blindly seeking a particular target number on the scale of a physical sign. Instead, both volume and pressure need to be fine-tuned in order to achieve vascular function that allows sufficient tissue perfusion. Therefore, assessment of PRA must become a component of conventional antihypertension care. See page 379
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The Kaiser Permanente Southern California (KPSC) health-care system’s more than 3 million enrollees reflect the diverse community it serves. In this issue, John Sim and colleagues in California and New York report on their analysis of more than 7,500 hypertension patients who had plasma renin activity (PRA) assessed while on treatment. Although KPSC’s blood pressure control rates far exceed the national averages, there were important concerns about patterns of care and some of its consequences. For example, more than 60% of the patients were receiving three or more drugs, and this was directly related to blood pressure. Treatment, in accordance with guidelines from KPSC and the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure, began with a diuretic, followed by a renin-blocking or -suppressing agent and, thereafter, additional unspecified drugs as needed. No provision was made for subtraction of ineffective drugs, much less pressor agents. Not surprisingly, mistreatment was addressed by increasing polypharmacy. This one-size-fits-all treatment algorithm assumes that hypertension is a homogeneous condition. In fact, the mechanisms by which hypertension are maintained are heterogeneous and can be identified via plasma renin activity (PRA). Low-PRA individuals respond best to antivolume diuretic agents and poorly to anti-renin agents, whereas
