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Renal artery stenosis (RAS) is a common cause of secondary hypertension, with the activation of the renin-angiotensin-aldosterone system being the pathophysiologic hallmark of the disease. Renovascular hypertension, ischemic nephropathy, proteinuria, and flash pulmonary edema are the main clinical syndromes associated with RAS. The prevalence of RAS is on the rise, owing to an increasing prevalence of diabetes and atherosclerotic disease among our aging population. This rise in RAS prevalence poses major challenges for clinicians making diagnostic and treatment decisions. Although renal angioplasty is of proven benefit in fibromuscular dysplasia, randomized trials in atherosclerotic RAS have not shown any advantage for revascularization over medical therapy in terms of blood pressure control or renal function preservation. Angioplasty and surgical interventions should be reserved for patients with preserved kidney size and hemodynamically significant stenosis.
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PMID:Challenges in the diagnosis and management of renal artery stenosis. 1591 98

Pediatricians currently have improved understanding of how to best manage childhood hypertension. The goal of antihypertensive drug therapy in children with secondary hypertension is currently to reduce the blood pressure below the 90th centile. Most authors currently favor therapy with a blocker of the renin-angiotensin system (a converting enzyme inhibitor or an angiotensin II antagonist) or a calcium channel blocker. In patients with kidney disease and diabetes mellitus we generally advise therapy of hypertension with a blocker of the renin-angiotensin system especially in the presence of pathological proteinuria.
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PMID:[Childhood hypertension: current medical management]. 1596 31

34th Greek regimen, which was part of the NATO forces, provided medical services to the civilians of Kosovo. We studied epidemiologic data in the population of Kosovo regarding hypertension in order to determine the prevalence and characteristics of hypertension. 830 patients (281 - 33.86% male, 62 +/- 26 yrs and 549 - 66.14% female, 49 +/- 28 yrs) were examined for different diseases. We identified 254 (30.6%) patients with hypertension (188 female and 66 male). According to the international criteria used for the classification of the severity of hypertension, more than half of the patients (51.2%) had severe hypertension, 31.5% modest and 17.3% mild. Statistically significant relation between the severity of hypertension and age or sex was not found out. Increased BMI as well as the presence of proteinuria and rheumatic diseases were significantly related to the severity of the hypertension while the coexistent heart disease, diabetes mellitus and chronic obstructive pulmonary disease (COPD) wasn't. The use of non-steroid anti-inflammatory agents (NSAIDs) was related to the severity of hypertension with a borderline significance. 31.4% of the patients were on treatment with NSAIDs and/or cortisone because of rheumatic disease or obstructive pulmonary disease. Overfunction of the sympathetic system was present in 62.99%. The mean heart rate was greater in women (84/min) than in men (72/min). 28.35% of the patients had secondary hypertension, including the patients on a drug that can elevate the blood pressure and patients with increased activity of the sympathetic nervous system. So, 8.6% of the patients had usual causes of secondary hypertension and 19.6% hypertension secondary related to the use of NSAIDs or cortisone, or due to the increased activity of the sympathetic nervous system. Antihypertensive treatment was started in 248 patients, i.e. in all of them except the ones already on treatment having their blood pressure well controlled. For antihypertensive treatment beta-blockers or central adrenergic inhibitors either as monotherapy or in combination with other agents were used most frequently combined with diuretics and Ca antagonists and ACE inhibitors. In conclusion the diagnosis and treatment of hypertension in the population of Kosovo during the post war period had certain particularities.
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PMID:Epidemiologic characteristics of hypertension in the civilians of Kosovo after the war. 1596 52

Obstructive sleep apnea (OSA) causes secondary hypertension. However, the reasons why the prevalence of hypertension among OSA patients varies widely (35-70%) are not clear. We sought to investigate the phenotypic characteristics of patients with and without hypertension among OSA patients who were matched for disease severity. We studied 152 OSA patients (76 normotensive and 76 hypertensive) diagnosed by polysomnography. Detailed phenotypic characteristics, including laboratorial analysis, were determined in all patients. Univariate analysis followed by multiple logistic regression analysis was used to identify variables that were independently associated with hypertension. The apnea-hypopnea index in normotensive and hypertensive patients was similar (48+/-26 and 48+/-26 events/h, respectively) as well as minimum arterial oxygen saturation (76+/-10 and 75+/-10%, respectively) and total sleep time with oxyhaemoglobin saturation <90% (25+/-25 and 28+/-26%, respectively). Hypertensive patients were older (57+/-11 vs 47+/-12 years; P<0.001), had a higher body mass index (BMI; 34+/-7 vs 30+/-5 kg/m(2); P<0.001), had a higher frequency of women (37 vs 8%; P<0.001), had a higher incidence of diabetes (25 vs 6%; P=0.002) and a higher family history of hypertension (75 vs 42%; P=0.01) than did the normotensive patients. Multiple logistic regression analysis indicated that age (P=0.004), familial history of hypertension (P=0.004), BMI (P=0.04) and female sex (P=0.03) were the independent variables associated with hypertension. We concluded that increasing age and BMI, familial history of hypertension as well as female gender are phenotypic characteristics associated with hypertension among OSA patients with similar disease severity.
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PMID:Phenotypic characteristics associated with hypertension in patients with obstructive sleep apnea. 1654 5

The development of a national database on normative blood pressure levels throughout childhood has contributed to the recognition of elevated blood pressure in children and adolescents. The epidemic of childhood obesity, the risk of developing left ventricular hypertrophy, and evidence of the early development of atherosclerosis in children would make the detection of and intervention in childhood hypertension important to reduce long-term health risks; however, supporting data are lacking. Secondary hypertension is more common in preadolescent children, with most cases caused by renal disease. Primary or essential hypertension is more common in adolescents and has multiple risk factors, including obesity and a family history of hypertension. Evaluation involves a thorough history and physical examination, laboratory tests, and specialized studies. Management is multifaceted. Nonpharmacologic treatments include weight reduction, exercise, and dietary modifications. Recommendations for pharmacologic treatment are based on symptomatic hypertension, evidence of end-organ damage, stage 2 hypertension, stage 1 hypertension unresponsive to lifestyle modifications, and hypertension with diabetes mellitus.
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PMID:Hypertension in children and adolescents. 1671 48

The following is a brief statement of the 2003 European Society of Hypertension (ESH)-European Society of Cardiology (ESC) guidelines for the management of arterial hypertension. The continuous relationship between the level of blood pressure and cardiovascular risk makes the definition of hypertension arbitrary. Since risk factors cluster in hypertensive individuals, risk stratification should be made and decision about the management should not be based on blood pressure alone, but also according to the presence or absence of other risk factors, target organ damage, diabetes, and cardiovascular or renal damage, as well as on other aspects of the patient's personal, medical and social situation. Blood pressure values measured in the doctor's office or the clinic should commonly be used as reference. Ambulatory blood pressure monitoring may have clinical value, when considerable variability of office blood pressure is found over the same or different visits, high office blood pressure is measured in subjects otherwise at low global cardiovascular risk, there is marked discrepancy between blood pressure values measured in the office and at home, resistance to drug treatment is suspected, or research is involved. Secondary hypertension should always be investigated. The primary goal of treatment of patient with high blood pressure is to achieve the maximum reduction in long-term total risk of cardiovascular morbidity and mortality. This requires treatment of all the reversible factors identified, including smoking, dislipidemia, or diabetes, and the appropriate management of associated clinical conditions, as well as treatment of the raised blood pressure per se. On the basis of current evidence from trials, it can be recommended that blood pressure, both systolic and diastolic, be intensively lowered at least below 140/90 mmHg and to definitely lower values, if tolerated, in all hypertensive patients, and below 130/80 mmHg in diabetics. Lifestyle measures should be instituted whenever appropriate in all patients, including subjects with high normal blood pressure and patients who require drug treatment. The purpose is to lower blood pressure and to control other risk factors and clinical conditions present. In most, if not all, hypertensive patients, therapy should be started gradually, and target blood pressure achieved progressively through several weeks. To reach target blood pressure, it is likely that a large proportion of patients will require combination therapy with more than one agent. The main benefits of antihypertensive therapy are due to lowering of blood pressure per se. There is also evidence that specific drug classes may differ in some effect or in special groups of patients. The choice of drugs will be influenced by many factors, including previous experience of the patient with antihypertensive agents, cost of drugs, risk profile, presence or absence of target organ damage, clinical cardiovascular or renal disease or diabetes, patient's preference.
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PMID:ESH-ESC guidelines for the management of hypertension. 1681 Apr 73

Most children who are normal weight for height and otherwise healthy have risk factor levels associated with the absence of heart disease (ie, they do not smoke, do not have diabetes, are physically active, have low-density lipoprotein levels < 110 mg/dL, and have blood pressure < 120/80 mm Hg). However, by adolescence, the earliest lesions in the atherosclerotic process, fatty streaks and raised lesions, are present in the coronary arteries and the abdominal aorta. The severity of early atherogenesis is related to the coexistence of the major cardiovascular risk factors. Most commonly, the associated risk disturbances are mild: borderline hypertension, mild dyslipidemia, insulin resistance, overweight, physical inactivity, and initiation of tobacco use. Rarely, more severe risk factors are present: familial hypercholesterolemia (a genetic disorder of lipid metabolism), diabetes mellitus, secondary hypertension of long standing, or risk factors associated with chronic conditions such as end-stage renal disease. Thus, cardiovascular risk management in this age group has two components: primordial prevention (the prevention of the development of cardiovascular risk in the first place) and primary prevention (more aggressive treatment of identified risk factors in high-risk individuals either through behavioral or pharmacologic means). Trials beginning in adolescence of the primary prevention of atherosclerosis-related diseases have not been undertaken; thus, the decision to initiate pharmacologic management in high-risk adolescents requires careful thought.
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PMID:Cardiovascular risk factors in adolescents. 1703 66

Resistance to antihypertensive drugs is common in hypertensive patients with type 2 diabetes. This is unfortunate because hypertension is one of the most important risk factors for development of cardiovascular events, and the goal blood pressure level is set lower in diabetic subjects than in nondiabetic subjects. Previous outcome trials in diabetic subjects have mainly focused on end points such as microalbuminuria or the incidence of cardiovascular events rather than on reduction of blood pressure; some reports, however, have suggested mechanisms for the drug resistance. These include several clinical conditions known to be associated with difficulty in reducing blood pressure specifically in diabetes mellitus: change in the renin-angiotensin system and chymase, volume overload, central sympathetic hyperactivity, sleep apnea, secondary hypertension, pseudoresistance (white coat hypertension), and poor compliance related to subclinical depression. In this review, the authors focus on the mechanisms of resistance to antihypertensive therapy (particularly for monotherapy with either angiotensin-converting enzyme inhibitors or angiotensin II antagonists) in the treatment of diabetic hypertension.
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PMID:Why is blood pressure so hard to control in patients with type 2 diabetes? 1768 64

Identification and treatment of hypertension should be an important focus of physicians caring for children. Ultimately, a link between hypertension in children and the risk of cardiovascular disease will be established. Further long-term studies are likely to show that morbidity and mortality will be decreased by the institution of treatment of hypertension in children. Additional risk factors such as obesity and lipid disorders should be sought and targeted for treatment as well. Lifestyle modifications are advised for all patients and can be tried solely for those with blood pressures between the 95th and 99th percentiles. Drug therapy is indicated in children with blood pressures greater than the 99th percentile, secondary hypertension, coexisting diabetes, left ventricular hypertrophy, or those who fail a trial of nonpharmacologic treatment. Children with white coat hypertension should not be treated with drugs. Children with renal artery stenosis and drug-refractory hypertension should be considered for percutaneous angioplasty or surgery depending on the anatomy of the lesion and operator experience. Children requiring multiple drug classes for control of blood pressure and older adolescents on one drug with renal artery lesions amenable to a percutaneous procedure may elect intervention in an attempt to reduce or eliminate drug therapy. Infants and children with hypertension due to native coarctation of the aorta should undergo surgical repair. Older children and adolescents with native coarctation should have surgical repair or percutaneous angioplasty/stenting. Hypertension secondary to recurrent coarctation is usually treated with a percutaneous intervention.
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PMID:Management of systemic hypertension in children and adolescents: an update. 1789 67

Pheochromocytoma is a rare form of secondary hypertension and may be potentially lethal if left untreated. The classical symptoms are paroxysmal hypertension, headaches, palpitations and sweating. They are caused by sudden catecholamine release. Hyperglycemia is reported in some patients with pheochromocytoma but diabetic ketoacidosis is an extremely rare complication of pheochromocytoma with only four cases reported. We report a case of a young woman with pheochromocytoma manifested as diabetic ketoacidosis.
J Diabetes Complications
PMID:Pheochromocytoma presenting as diabetic ketoacidosis. 1841 69


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