Comparative Efficacy Of Antihypertensive Regimens In Patients With Resistant Hypertension: A Network Meta-analysis

Objectives: Since the number of therapies in resistant hypertension(RH)has been increasing,distinguishing therapies more preferable than others is an essential task for clinicians.Our network meta-analysis(NMA)was aimed at evaluating the efficacy of multiple antihypertensive regimens for resistant hypertension.Methods: Pub Med,Embase,and the Cochrane library were searched for related articles.The change of 24-h systolic blood pressure(SBP),24-h diastolic blood pressure(DBP),office SBP,and office DBP were considered as outcomes and displayed as weighted mean difference(WMD)and 95% credible intervals(95%CI).Both pairwise and network meta-analysis were conducted for evaluating the corresponding interventions.Besides,the surface under the cumulative ranking curve(SUCRA)was calculated to rank probabilities of various treatments.The node splitting method was adopted to calculate the inconsistency of the model.Additional analysis was carried out to identify potential confounding factors with a network meta-regression analysis.Results: A total of 27 eligible trials were included and 8 treatments were evaluated in this meta-analysis,including exercise(EXE),mineralocorticoid receptor antagonists(MRA),darusentan(DAR),renal denervation(RDN),central arteriovenous anastomosis(CAA),sham,placebo(PLA),no additional treatment(NOT).Concerning 24-h SBP,CAA,DAR,MRA,and RDN provided better efficacy than PLA(CAA:-13.0mm Hg [-25.0;-0.14];DAR:-7.5mm Hg [-13.0;-1.9];MRA:-8.9mm Hg [-13.0;-4.7];RDN:-7.7mm Hg [-14.0;-0.86]);CAA,DAR,MRA exhibited significantly improved 24-h DBP(CAA:-12.0mm Hg [-19.0;-4.8];DAR:-6.4mm Hg [-9.6;-3.4];MRA:-3.6mm Hg [-6.1;-1.3]);In terms of office SBP,only MRA had the significant superiority compared with placebo(MRA:-14.0mm Hg [-23.0;-5.0]);While CAA、MRA、RDN achieved better office DBP than placebo(CAA:-17.0mm Hg [-27.0;-5.8];MRA:-5.5mm Hg,[-8.7;-2.4];RDN:-6.0mm Hg [-11.0;-0.28]).When compared with MRA,superiority of other treatments was not demonstrated,only in 24-h DBP and office DBP,a modest benefit was observed in CAA(24-h DBP:-8.3mm Hg [-15.0;-1.6];office DBP:-11.0mm Hg [-21.0;-0.78]).According to SUCRA,CAA ranked highest in each outcome,and MRA ranked in the top three.There was only one closed-loop network containing RDN,MRA,PLA in all outcomes.No significant inconsistency was detected as all the P-value was higher than 0.05.The network meta-regression analysis of confounding factors showed that the evaluation of adherence had an effect on 24-h diastolic blood pressure(B:-9.59,-0.67),but no other confounding factors were found.Conclusion: MRA may be the most suitable therapy for its excellent efficiency in 24-h and office blood pressure.CAA ranked best but there was lack of statistical evidence.