A personalised approach is vital for managing patients with difficult-to-control hypertension
PCR Honorary Chairman Jean Marco explains the value of using a personalised medicine approach in patients with difficult-to-control hypertension and discusses the potential role of genetics in such an approach.
> How many patients have difficult-to-control hypertension and what are the potential reasons for this condition?
Despite the use of medications with proven efficacy in randomised clinical trials and efforts to apply evidence-based therapies, less than 30% of treated hypertensive patients have
normalised blood pressure levels. There are several reasons why hypertension can be difficult to control - the patient may not be receiving optimum medical therapy; they may not be adhering to their treatment regimen; they may have an underlying atypical pathophysiology for the hypertension; or they may have genetic traits that make them prone to having difficult-to-control hypertension.
> How can the number of patients with difficult-to-control hypertension be reduced?
The Resistant Hypertension Course (RHC) team proposes a personalised medicine approach to understand why an individual patient is not responding to prescribed therapies. We suggest using a step-by-step checklist approach for each individual patient presenting with difficult-to-control hypertension. The aims of such an approach are to:
- Estimate the cardiovascular risk profile of a patient, including examining the possibility that they have inherited traits for cardiovascular disease, through appropriate interviews, clinical and biological investigations
- Detect all potentially curable causes of hypertension by systematic interviews, key biological tests and non-invasive imaging
- Obtain adequate readings for both office and home blood pressure levels
- Develop a step-by-step process for optimising treatment measures
- Determine the potential application of new therapies targeting the sympathetic nervous system (i.e. renal denervation).
> Do you advocate personalised medicine over evidence- based medicine?
I strongly believe that personalised medicine for each individual, integrating patient’s particularities and critical thought on available scientific data, is superior to the application of evidence-based medicine. The concept of evidence-based medicine relies on results of randomised trials, which means it is based on a population of highly selected patients. The nature of these populations (i.e. not representative of some patients seen in clinical practice) explains why there is a gap between the results achieved in clinical trials and those achieved in daily practice.
> Can you expand further as to why an evidence-based medicine approach does not produce results in clinical practice?
The possible explanation includes poor understanding of the need to adapt the data for patients in clinical practice (and how these data should be adapted). For example, some people might be ignorant of the fact that some patients may not respond to diuretics or to other forms of treatment and ignorant of how to identify these non-responding patients.
> You mentioned that examining inherited traits could play a role in understanding why a patient may have difficult-to-control hypertension. Can you expand on that?
Results from the Human Genome project and Genome-Wide Association Study (GWAS) have provided a new insight into how we understand hypertension, the individual risks for coronary artery disease, and the relationship between genetic traits and the likelihood of responding to angiotensin II receptor blockers and/or diuretics. Therefore, in the future, the integration of genetic risk score and the classical risk factors scores could help implement the concept of individualised medicine more accurately by indicating which patients are at high or intermediate risk of cardiovascular events. In these patients, we could then use “aggressive” therapies for hypertension and low-density lipoprotein cholesterol. However, to achieve this, we need more research into how we integrate data from the Human Genome project and GWAS into developing pharmacological or device based therapies.
> A goal of RHC is for delegates to share information. In the context of personalised medicine, why is this important?
Sharing (good or bad) experiences with an open mind and without fear of criticism is the basis of adult learning and is the heart of education.
> What have you personally learnt about personalised medicine from discussions at conferences?
I have found that sharing and listening to experiences about the management of individual patients with difficult-to-control hypertension is the most productive method of learning.