To assert today that the treatment of arterial hypertension is a solved problem is a mistake. There are still many poorly treated patients and many expectations regarding treatment.
In 10 to 20% of patients with arterial hypertension, there are still many expectations vis-à-vis the treatment. Hypertension is a disease that would affect one French person out of 3, yet only one patient out of 2 would be on target. This lack of treatment is linked either to high blood pressure figures, or to associated risk factors which make the objectives stricter and therefore more difficult to achieve, or to certain populations of patients who have different mechanisms of blood pressure regulation.
These 3 categories define “HTA difficult to treat” or “HTA resistant” to currently available drugs. Due to the importance of the number of regulatory mechanisms involved in hypertension, it would be necessary to have other drugs targeting pathways other than those currently involved.
Several types of hypertensives
All patients are not, in fact, equal in the face of the disease. Some will be satisfied with a single antihypertensive drug to be balanced. The majority, however, will need “polytherapy”, that is to say a combination of treatments. Indeed, the regulation of blood pressure is complex. Several systems are involved, those that regulate and those that counter-regulate, yet the treatments available today target at best a single regulatory pathway. Moreover, one never knows in advance which of these pathways is particularly active in a patient and they can change over time.
It is therefore clear today that the number of drugs needed to control hypertension is a marker of the severity of arterial hypertension. A person who needs 3 medications to control their high blood pressure is more likely to have great vessel disease than someone who only needs one medication. She will also often have other associated arterial risk factors such as diabetes or hypercholesterolemia, obesity. In addition, certain ethnic groups, such as people with black skin, have different regulatory pathways.
Treatment recommendations
When triple therapy is needed to treat hypertension, the treatment must include a renin-angiotensin system blocker, a calcium channel blocker and a thiazide diuretic or equivalent, excluding intolerance or particular contraindication to one of the molecules of these classes. If everyone already applied these recommendations, blood pressure control would be better and certain titration errors would be avoided. In some countries, these triple therapies have been made available in a single tablet.
In the event of failure of triple therapy, the question of poor follow-up of the treatment should be raised, and this is not always simple. Once compliance is validated, the second question to ask is that of the reality of this poor blood pressure control and at this stage this requires mandatory ambulatory blood pressure measurements or “tension holter”. These ambulatory measurements will provide information on nocturnal blood pressure, because if the pressure does not drop at night (“non-diper”), this will point to a sleep pathology, such as sleep apnea, or an endocrine disease. the origin of hypertension. Once these 2 questions have been validated, we can affirm the true resistance of hypertension and it concerns about 20% of patients treated with triple therapy and it will be necessary to make a detailed exploration.
A need for new drugs
This highlights the need to develop new anti-hypertensives in order to block new metabolic pathways involved in the complex process of arterial hypertension. Despite all the progress made, arterial hypertension remains a frequent disease which is not well controlled in one out of two cases. The risk of damage to the arteries and organs of the body requires stricter control of blood pressure figures.
Some forms of hypertension remain difficult to treat, or even frankly resistant to treatment. We need new anti-hypertensive treatments, for example those targeting central blood pressure regulation, or endothelin pathways…, and therefore with a different mechanism of action than those targeted by current treatments.
Saying today that the treatment of arterial hypertension is a solved problem is a mistake, a mistake that we risk paying dearly for in 15 to 20 years. Today, we still have one last step to take and for research to take place, we need a strong signal to develop other drugs than those currently available and which are on average more than 20 years old. .
Interview with Pr Jean-Jacques Mourad (CHU Avicenne, Bobigny)
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