A GENERAL DESCRIPTION OF THE TREATMENT STRATEGY BASED ON V AND R CONCEPTS (REF:2-6)
About 60% of patients can be effectively treated long term with V or R monotherapy.
The first step is to find out if the pretreatment ambulatory PRA level is low (PRA < 0.65 ng/ml/hr: V patient) or not low (PRA > 0.65 ng/ml/hr: R patient).
V patients are volume expanded and need to start treatment with a natriuretic V drug (eg spironolactone 12.5 mg/day).
R patients have too much circulating renin and need to start treatment with an anti-renin system R drug (eg enalapril 5 mg/day).
But, the BP of some patients is not fully corrected with full dose monotherapy. A 2nd PRA test can then be used to determine if the reason is because of excess sodium-volume or excess renin.
VV patients are V patients who continue to have low PRA levels while taking a natriuretic drug, indicating that they remain overly volume expanded. They benefit from the addition of a 2nd V drug such as amlodipine (5-10 mg).
VR patients are also V patients, but their on-treatment PRA level increases into the medium range while taking a V drug. They benefit from the addition of an R drug such as enalapril 5 mg to curtail the excess R.
RV patients are R patients whose PRA level while taking an ACEI or ARB remains < 6.5 ng/ml/hr, indicating that PRA has been effectively blocked (ACEIs and ARBs block PRA by about 90%). RV patients are likely to benefit from the addition of a V drug, such as spironolactone 12.5 mg.
RR patients are R patients whose PRA level while taking an ACEI or ARB has increased to > 6.5 ng/ml/hr, indicating that PRA has not been effectively blocked. They are likely to benefit from the addition of a drug that suppresses renin secretion such as a beta blocker like bisoprolol 5 mg.