Abstract
African Americans (AAs) have a high prevalence of hypertension and suffer a disproportionately
high risk for cardiovascular disease compared to whites. Apparent treatment-resistant
hypertension (aTRH) is a severe form of hypertension defined as requiring = 4 antihypertensive
medications to achieve blood pressure (BP) control. An estimated 9 million US adults have
aTRH. Given the rigorous clinical work-up needed to rule out pseudoresistance and therefore,
diagnose true TRH, the population prevalence of TRH is not known. We propose an ancillary
study to the Jackson Heart Study (JHS), a large prospective cohort of AA adults (n=5,306) that
will deeply phenotype participants with aTRH, ruling out pseudoresistance (i.e., inaccurate clinic
BP measurement, presence of a white coat effect, suboptimal antihypertensive therapy, and
poor medication adherence) and secondary causes of hypertension (i.e., primary aldosteronism,
obstructive sleep apnea, and kidney disease). The JHS provides a highly feasible setting for
the proposed study as it includes a large population of AAs with a high prevalence of
hypertension and extensive data collection as part of an upcoming fourth parent study visit,
which will facilitate the screening and recruitment of participants for our ancillary study. Based
on data collected during the fourth JHS exam, we will identify 400 participants with aTRH and
200 treatment-responsive controls. These participants will undergo a clinical evaluation for TRH
including assessment of existing ambulatory BP monitoring (ABPM) data to detect white coat
effect and urinalysis of antihypertensive drugs and metabolites to assess medication adherence.
Also, participants with aTRH will be compared to treatment responsive controls with respect to
secondary causes of hypertension and lifestyle factors. Clinical translation of the study findings
will be facilitated by an external panel of experts who co-authored the American Heart
Association 2018 Scientific Statement on Resistant Hypertension. Overall, the diagnosis and
treatment of TRH is limited by our understanding of pseudoresistance and other factors
underlying aTRH. The proposed study is urgently needed to more efficiently diagnose and
better treat this severe form of hypertension among African Americans.
