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Query: UMLS:C0018801 (heart failure)
 72,216 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

The aging kidney is characterized by a decrease in renal blood flow and glomerular filtration rate mainly due to glomerulosclerosis. Nevertheless, even in the presence of these changes, the kidney maintains its functionality until advanced age. However, there is a tendency towards greater renal vasoconstriction in the elderly as compared with young individuals. This occurs either in physiological circumstances such as physical exercise, or in disease manifestations, such as the effective circulatory volume depletion that develops, for example, in heart failure. This tendency may be secondary to the reduction of renal autacoid modulatory capacity, particularly at the vasodilating prostaglandin level. In an acute experimental model we could demonstrate that, in the healthy elderly, the renal response to adrenergic activation by mental stress is characterized by a prolonged and pronounced vasoconstriction. In addition to this, in elderly patients affected by isolated systolic hypertension, we demonstrated an impairment of renal hemodynamic and humoral adaptation capacity in response to adrenergic activation and blood pressure increase. In the presence of sudden blood pressure increase, the kidney of these patients responds with a passive vasodilation and a glomerular filtration rate increase without any activation of humoral modulatory substances. The impairment in renal adaptation capacity may predispose these patients to renal injury, particularly in the presence of the many hypertensive peaks which characterize everyday life of elderly individuals. In conclusion, these results show that renal adaptation capacity of elderly patients with isolated systolic hypertension is completely lost. Further studies will elucidate whether antihypertensive treatment per se, or specific classes of antihypertensive drugs, are able to revert this impairment.
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PMID:Changes in renal autacoids and hemodynamics associated with aging and isolated systolic hypertension. 1093 6

The goals of antihypertensive therapy are to lower blood pressure and prevent end-organ damage without side effects, which affect quality of life. The antihypertensive drugs, regardless of class, all lower blood pressure, but they vary in their mechanisms of action, side-effect profiles, suitability for patients with other comorbid conditions, and ability to protect against the long-term sequelae of hypertension. The Sixth Report of the Joint National Committee on Prevention, Evaluation, and Treatment of High Blood Pressure (JNC-VI) recommends diuretics and beta-blockers as first-line therapy for uncomplicated hypertension, with diuretics also being strongly preferred for patients with isolated systolic hypertension or hypertension and heart failure and beta-blockers being strongly preferred for patients who have had a myocardial infarction (MI) and those with hypertension and angina, atrial tachycardia, or atrial fibrillation. Because angiotensin-converting enzyme (ACE) inhibitors have been shown to be cardioprotective and renoprotective in patients with diabetes or impaired left ventricular (LV) function, the JNC-VI recommends them as first-line therapy in patients with diabetes with proteinuria, heart failure, and MI complicated by LV dysfunction. It recommends calcium channel blockers for hypertensive patients with angina, long-acting dihydropyridines for those with isolated systolic hypertension, and the nondihydropyridines for those with atrial tachycardia or fibrillation, diabetes, and proteinuria. The angiotensin II receptor blockers (ARBs) share many of the organ-protective effects of ACE inhibitors when studied in animal models. They are effective in lowering blood pressure and have a very benign side-effect profile; however, these agents have not been available long enough to ascertain their efficacy in protecting against long-term complications.
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PMID:Clinical overview of antihypertensive classes--clinically relevant differences: myths or facts? Based on a presentation by Alan H. Gradman, MD. 1097 60

Hypertension in women has received less attention than hypertension in men, and the major controlled trials of antihypertensive therapy have been carried out in populations made up predominantly of and have emphasised outcomes in men. Recently it has been recognised that women develop high blood pressure, particularly systolic hypertension, at an increased rate as they age, and that this age-related blood pressure increase is exaggerated by the menopause. The age-related rise in blood pressure, particularly systolic blood pressure and pulse pressure, contributes substantially to the age-related increase in risk of heart attack, heart failure, and stroke in middle-aged and elderly women. This article reviews aspects of hypertension epidemiology, pathophysiology, diagnosis and treatment that are important to women's health with particular emphasis on important concomitant cardiovascular disease risk factors such as type 2 diabetes and the menopause. The role of ovarian hormones and their withdrawal in the pathogenesis of hypertension and related target organ damage is considered, as are the results of drug treatment of high blood pressure in women. Blood pressure in pregnancy is discussed in a separate article by Broughton-Pipkin and Roberts.
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PMID:Hypertension in women. 1109 60

The authors showed, in a spin-off study of SYST-EUR, that 24% of subjects with isolated systolic hypertension on conventional measurement were not hypertensive during ambulatory blood pressure monitoring. Moreover, in white coat hypertension, treatment had no effect either on the electrical signs of left ventricular hypertrophy or on the incidence of clinical events (cerebrovascular accident and global cardiovascular complications), contrary to what is observed in permanent systolic hypertension. These results raise question as to the diagnosis and treatment of isolated systolic hypertension in the elderly and prompt to a larger usage (if not systematic) of ambulatory blood pressure monitoring in this context. The importance of systolic blood pressure and pulsed pressure For different reasons, diastolic blood pressure was thought to be of greater prognostic significance, as the very large majority of clinical trials recruited on the basis of the value of their diastolic blood pressure alone demonstrate. In recent years, the importance of systolic blood pressure has been underlined in many studies and 3 trials have shown the unquestionable benefits of treatment of isolated hypertension. It would also appear that the pulse pressure, which reflects arterial compliance, has considerable prognostic value. In the absence of established manometric criteria and mostly of therapeutic trials, the practical use of the pulse pressure remains questionable. The interruption of the doxazosin arm of the ALLHAT trial The ALLHAT (Antihypertensive and Lipid Lowering Treatment to Prevent Heart Attack Trial) study showed a doubling of the morbidity from cardiac failure, a 19% excess of cerebrovascular events and 16% of angina pectoris in subjects treated with doxazosin compared with those treated with chlorthalidone. The differences in blood pressure with treatment were minimal and, a priori, unable to explain these results. Beyond the fact that alphablockers cannot be considered as first-line antihypertensive therapy, without doubt, the affirmation that lowering the blood pressure provides the same benefit irrespective of the antihypertensive agent used, probably needs to be reviewed.
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PMID:[The best in 2000 on arterial hypertension]. 1126 Aug 42

Over half of all people over the age of 65 in the U.S. have hypertension. In most cases this is diagnosed because of increased systolic blood pressure. It is now recognized that systolic blood pressure is more predictive of cardiovascular events than diastolic blood pressure; since these events are the major cause of death and disability in this population, current hypertension guidelines now emphasize more aggressive blood pressure criteria for both diagnosing and treating systolic hypertension. This process has been stimulated by evidence from large clinical trials that reducing systolic blood pressure improves survival and prevents strokes, heart failure, and other cardiovascular outcomes. The guidelines of both the Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC VI) and the World Health Organization-International Society of Hypertension (WHO-ISH) recommend that, regardless of age, hypertension can be diagnosed when the systolic blood pressure is greater than 140 mm Hg. The treatment target is less than 140 mm Hg, though in the presence of concomitant conditions like diabetes mellitus or cardiac or renal impairment, which are common findings in the elderly, even lower target levels may be justified. For patients with systolic blood pressures in the range 140 mm Hg-159 mm Hg but who are without other cardiovascular risk factors, it is not yet certain that aggressive treatment is warranted. New clinical trials are now addressing this question. So far, most experience with treating systolic hypertension in older persons has been with diuretics and calcium channel blockers. But growing evidence indicates that most antihypertensive drug classes are effective and that agents should be selected to best match the needs of individual patients. (c)2000 by CVRR, Inc.
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PMID:Hypertension in the Aging Patient: New Imperatives, New Options. 1141 33

Increasing attention has focused on the magnitude of hypertension in the elderly, with recent data indicating that it afflicts over 50% of people greater than 65 years of age. Recent studies have clearly demonstrated that treatment of isolated systolic and diastolic hypertension in older patients confers substantive protection against hypertension induced morbidity and mortality, to an extent greater than previously appreciated. The results of the recent Systolic Hypertension in Europe (Syst-Eur) trial have demonstrated a striking decrease in the occurrence of strokes, as well as heart failure and all cardiac events in the active treatment group. Because a long acting dihydropyridine calcium antagonist was used in the Syst-Eur trial, it is reasonable and appropriate to recommend a long acting calcium antagonist as one of the preferred agents in the management of isolated systolic hypertensive (ISH) patients. Recent attention has also focused on the importance of formulation and pharmacokinetics as a determinant of cardiovascular risk. It is clear that the newer slow release formulations and intrinsically long acting calcium antagonists are to be preferred. By virtue of their ability to attain more gradual and sustained plasma levels, they do not evoke reactive sympathetic activation. Concomitantly, such formulations should promote increased patient compliance and thereby favorably influence hypertension related morbidity and mortality. (c)2000 by CVRR, Inc.
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PMID:The Growing Role of Calcium Antagonists in Treating Hypertension in the Elderly. 1141 37

Hypertension as a risk factor for cardiac and cerebrovascular morbidity and mortality poses a major health problem for our increasingly elderly population. Recent trials have shown large reductions in stroke, heart failure, and coronary artery disease when elderly hypertensive patients are treated. These benefits are also seen in elderly patients with isolated systolic hypertension. The elderly patient with hypertension should be investigated and managed in a similar manner to their younger counterpart. Nonpharmacological measures, such as dietary salt and calorie restriction, regular exercise, cessation of smoking, and reduction of excess alcohol intake, should be recommended. If these are insufficient, pharmacological treatment should be tailored to the individual patient. Diuretics have been shown to improve outcome measures in the elderly. Other antihypertensive drugs may be added or substituted depending on the patient's blood pressure response to therapy and their comorbid conditions. If all elderly hypertensive patients were treated, a major reduction in cardiovascular and cerebrovascular mortality and morbidity would result. Consideration also needs to be given to nonpharmacological treatment, particularly salt restriction in older subjects where blood pressure is at the upper limit of normal, as this would also result in a major reduction in cardiovascular morbidity and mortality. (c) 2000 by CVRR, Inc.
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PMID:Hypertension in the Elderly. 1141 51

The aim of this study was to assess the relationship between pulse pressure (PP) and the occurrence of heart failure (HF) in older persons with isolated systolic hypertension. Data from a prospective, multicenter, randomized, double-blind, placebo-controlled clinical trial were analyzed. A total of 4736 persons aged > or = 60 years with systolic blood pressure (SBP) between 160 and 219 mm Hg and diastolic blood pressure (DBP) < 90 mm Hg who participated in the Systolic Hypertension in the Elderly Program (SHEP) were studied. The main outcome measures were fatal and nonfatal HF. During 4.5 years average follow-up, fatal or nonfatal HF occurred in 160 of 4736 patients. The SBP, PP, and mean arterial pressure (MAP) were strong predictors of the development of HF (P < .0002). Cox proportional hazards regression using time-dependent covariates and controlling for MAP indicated that HF was inversely related to DBP (P = 0.002) and was directly related to pulse pressure (P = 0.002). Data were similar when patients who developed myocardial infarction during follow up were excluded. These data indicate that, in older persons with isolated systolic hypertension, high pulse pressure is associated with increased risk of heart failure independently of MAP and of the occurrence of acute myocardial infarction during follow-up.
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PMID:Association of increased pulse pressure with the development of heart failure in SHEP. Systolic Hypertension in the Elderly (SHEP) Cooperative Research Group. 1149 97

Atherosclerosis and coronary artery disease (CAD) are now the commonest sequelae of hypertension and all clinical manifestations of CAD occur in excess in persons with elevated blood pressure. Risk increases in relation to the extent of blood pressure elevation whether this is in the systolic or diastolic component, at any age and in either sex. Even isolated systolic hypertension increases cardiovascular risk. Elevated pressures are often accompanied by lipid abnormalities, hyperglycemia, elevated fibrinogen, obesity, and ECG abnormalities, all of which augment the risk. These risk factors associated with hypertension influence the coronary risk potential more than the nature of the blood pressure elevation. Although blood pressure makes an independent contribution to CAD, the risk at any level of pressure is markedly influenced by the cardiovascular risk profile. In mild to moderate hypertension in particular, the risk of CHD is concentrated in those who have impaired glucose tolerance, increased total/HDL ratio, ECG abnormalities, and smoke cigarettes. One or more of these associated risk factors also predisposes to other cardiovascular sequelae of hypertension, including stroke, peripheral vascular disease, and cardiac failure. The presence of organ involvement indicated by proteinuria, evidence of impaired ventricular function, or left ventricular hypertrophy greatly escalates the risk and usually indicates a compromised coronary circulation. Most myocardial infarctions and sudden deaths occur prior to the appearance of such evidence. Hypertensive risk assessment requires consideration of the multivariate risk profile because of the interdependence of the risk factors. The nature and urgency of treatment is better determined from such a risk profile than from the blood pressure parameters alone. Optimal preventive management of hypertension requires more than normalization of the blood pressure if coronary sequelae are to be avoided.
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PMID:Influence of multiple risk factors on the hazard of hypertension. 1152 37

Pulse pressure has been related to higher risk of cardiovascular events in older persons. Isolated systolic hypertension is common among the elderly and is accompanied by elevated pulse pressure. Treatment of isolated systolic hypertension may further increase pulse pressure if diastolic pressure is lowered to a greater extent than systolic pressure. Little is known regarding pulse pressure as a predictor of cardiovascular outcomes in elderly persons with isolated systolic hypertension, and the influence of treatment on the pulse pressure effect. We assessed the relation between pulse pressure, measured throughout the follow-up period, and the incidence of coronary heart disease (CHD), heart failure (HF), and stroke in 4,632 participants in the Systolic Hypertension in the Elderly Program, a 5-year randomized, placebo-controlled clinical trial of treatment of isolated systolic hypertension in older adults. In the treatment group, a 10-mm Hg increase in pulse pressure was associated with a statistically significant 32% increase in risk of HF and a 24% increase in risk of stroke after controlling for systolic blood pressure and other known risk factors, as well as with a 23% increase in risk of HF and a 19% increase in risk of stroke after controlling for diastolic blood pressure and other risk factors. Pulse pressure was not significantly associated with HF or stroke in the placebo group, nor with incidence of CHD in either the placebo or treatment group. These results suggest that pulse pressure is a useful marker of risk for HF and stroke among older adults being treated for isolated systolic hypertension.
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PMID:Pulse pressure and risk of cardiovascular events in the systolic hypertension in the elderly program. 1170 93


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