Despite recommendations, patients with treatment-resistant hypertension rarely tested for primary al

December 28, 2020

Below please find summaries of new articles that will be published in the next issue of Annals of Internal Medicine. The summaries are not intended to substitute for the full articles as a source of information. This information is under strict embargo and by taking it into possession, media representatives are committing to the terms of the embargo not only on their own behalf, but also on behalf of the organization they represent.

1. Despite recommendations, patients with treatment-resistant hypertension rarely tested for primary aldosteronism
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A retrospective cohort study found that testing for primary aldosteronism in patients with treatment-resistent hypertension was rare and also associated with higher rates of evidence-based treatment and better longitudinal blood pressure control. The findings are published in Annals of Internal Medicine.

Primary aldosteronism is a common cause of secondary hypertension and is highly prevalent among patients with treatment-resistant hypertension. Primary aldosteronism is associated with a 4- to 12-fold increased risk for adverse cardiovascular events compared with primary hypertension and can be effectively treated with MRAs or surgery. Although clinical practice guidelines recommend aldosteronism screening for such patients, they may not be followed.

Researchers from the University of Pennsylvania Perelman School of Medicine, Stanford University, and University of Michigan reviewed data from the Veterans Health Administration (VHA) for more than 269,000 veterans with incident apparent treatment-resistant hypertension to evaluate testing rates for primary aldosteronism (plasma aldosterone-renin) and evidence-based hypertension management. Treatment-resistant hypertension was defined as either 2 blood pressures of at least 140 mm Hg (systolic) or 90 mm Hg (diastolic) at least 1 month apart during use of at least 3 antihypertensive agents (including a diuretic), or hypertension requiring at least 4 antihypertensive classes.

The data showed that fewer than 2% of patients with incident apparent treatment-resistant hypertension underwent guideline-recommended testing for primary aldosteronism. Testing rates ranged from 0% to 6% across medical centers and did not correlate to population size of patients with apparent treatment-resistant hypertension. Testing also was associated with higher rates of evidence-based treatment with mineralocorticoid receptor antagonist (MRAs) and better longitudinal blood pressure control. Testing rates also did not change meaningfully over nearly 2 decades of follow-up despite an increasing number of guidelines recommending testing for primary aldosteronism in this population. According to the researchers, these findings suggest an opportunity for the VHA to introduce innovative practices to educate providers about the importance of testing high-risk patients.

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For an embargoed PDF, please contact Lauren Evans at
To reach the corresponding author, Jordana B. Cohen, MD, MSCE, please contact Lauren Ingeno at

2. A stepped exercise program may improve symptoms of knee osteoarthritis
Summaries for Patients (Free):
URL goes live when the embargo lifts

An adaptive stepped approach to delivering exercise and physical therapy interventions for knee osteoarthritis improved pain and physical function compared with arthritis education alone in a randomized controlled trial. The findings are published in Annals of Internal Medicine.

Knee osteoarthritis is a common condition that may be painful and limit a person's activity level. Exercise with or without a physical therapist can help, but many patients do not exercise. A stepped care model that moves from exercises a patient can do on their own to in-person physical therapy might be an effective way to meet patients' needs.

Researchers from the Veterans Administration (VA) Health Care System randomly assigned 345 patients with painful knee osteoarthritis at two VA health care sites to an exercise program called STEP-KOA (stepped exercise program for patients with knee osteoarthritis) or to arthritis education. The STEP-KOA program consists of a 3-level intervention that progresses based on patient needs. If the internet-based exercise program in step 1 was not effective, the patient moved to step 2, 3 months of physical activity coaching calls twice per month. If pain still did not approve, the patient advanced to step 3, in-person physical therapy visits. The arthritis education group received educational materials via mail every 2 weeks. After 9 months, the researchers found that of the patients in the stepped exercise program, 65% progressed to step 2 and 35% went on to step 3. The stepped care group also showed greater improvement in pain and function levels compared with the group that received arthritis education only.

According to the researchers, this type of stepped care strategy could preserve health care resources and tailor programs to patients' needs. However, more work would be needed to increase patient engagement in such programs.

Media contacts:
For an embargoed PDF, please contact Lauren Evans at
To reach the corresponding author, Kelli D. Allen, PhD, please contact James Shahron at

American College of Physicians

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