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Query: UMLS:C0020538 (hypertension)
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Pregnancies in women on dialysis and in women who have had renal transplant are no longer uncommon. Optimal obstetric outcomes require a multidisciplinary team approach, patient counseling, and clinicians who are knowledgeable and experienced in taking care of these patients. Counseling should begin before pregnancy, and all reproductive age women on dialysis and who have undergone renal transplant should receive family planning counseling. Preconceptional counseling should be provided to those patients who desire pregnancy. If the patient presents in early pregnancy, she should be informed about the maternal and fetal risks associated with her pregnancy. Prenatal care must include intensive surveillance for hypertension, preeclampsia, preterm labor, intrauterine growth restriction, anemia, infection, and renal allograft rejection. Aggressive treatment of complications is mandatory. There are limitations to our current knowledge about pregnancies in these patients. It is important for clinicians who provide care for these patients to be aware of these limitations when making obstetric management decisions. Cesarean section should be reserved for usual obstetric indications. Breast-feeding is not advised in patients taking cyclosporin or azathioprine. Transplant patients have unique gynecologic needs, so they should be encouraged to pursue follow-up gynecologic care after the pregnancy.
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PMID:Obstetric care for renal allograft recipients or for women treated with hemodialysis or peritoneal dialysis during pregnancy. 947 10

Cardiovascular mortality is the undisputed "hard endpoint" in hypertension intervention trials. Non-fatal myocardial infarction and stroke are frequently included in this category as well. For obvious reasons, such hard endpoints are not always realistic in relatively short-term (3-5 years) trials comprising patients with a relatively low absolute risk, such as mild hypertension. Nor are they directly applicable in the daily clinical routine care of hypertensive patients. In most situations intermediate endpoints are used as substitutes for the hard endpoints. These intermediate or substitute endpoints are sometimes referred to as surrogate endpoints. The most frequently used intermediate endpoint is blood pressure itself. It is also a most relevant substitute endpoint, being easy to measure and evaluate in routine clinical practice. Blood pressure is obviously a very strong predictor of cardiovascular risks, particularly as regards stroke. An ongoing large intervention trial in hypertension, the Hypertension Optimal Treatment (HOT) Study is specifically designed to evaluate the obtained level of treated blood pressure in relation to hard endpoints such as fatal and non-fatal stroke and myocardial infarction as well as other cardiovascular mortality. In view of the strong link between blood pressure and prognosis in hypertension, as demonstrated in several epidemiologic studies, it is disappointing to note that several recent reports show that only a minority of treated hypertensive patients are well controlled.
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PMID:Evaluation of endpoints in hypertension. 949 32

Nine-hundred-and-twenty-two hypertensive patients were included in a substudy to the Hypertension Optimal Treatment study, which aimed to investigate the impact on quality of life of lowering the pressure and of intensified therapy. Seven-hundred-and-eighty-one patients completed both baseline and follow-up questionnaires (intention-to-treat population), while 610 patients were included in a per protocol analysis. Patients were randomized to three diastolic BP levels (DBPs), i.e. < or =90 mmHg, < or =85 mmHg and < or =80 mmHg. Two self-administered validated questionnaires, the Psychological General Well-Being index and the Subjective Symptoms Assessment Profile (SSA-P) were completed at baseline and after 6 months. The lower the DBP achieved, the greater the improvement in well-being (p < 0.05). The increase in well-being from baseline to 6 months was significant in target groups < or =80 mmHg (p < 0.01) and < or =85 mmHg (p < 0.05). The SSA-P domains, cardiac symptoms and dizziness improved in all groups but the sex life score deteriorated in the < or =80 and < or =85 mmHg groups in male patients. In all target groups, headaches were reduced (p < 0.001), while swollen ankles (p < 0.001) and dry cough in the < or =80 mmHg group (p < 0.001) increased. Although more intensive antihypertensive therapy is associated with a slight increase in subjective symptoms, it is nonetheless still associated with improvements in patients' well-being.
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PMID:Does lowering the blood pressure improve the mood? Quality-of-life results from the Hypertension Optimal Treatment (HOT) study. 949 56

From an homogeneous population of 219 male medical students of La Plata University (20.9 +/- 1.6 years) who underwent a blood pressure screening, 34 were selected for measurements of left ventricular structure and function. Considering the JNC-V classification, samples from two groups were selected for comparisons: Optimal blood pressure (OBP) (21 males, 20.33 +/- 1.8 years) and Hypertensives stage I (H) (13 males, 20.85 +/- .66 years). The H showed values of body mass index (BMI) and heart rate (HR) higher than OBP (BMI OBP: 22.5 +/- 0.38 kg/m2, H: 24.26 +/- 0.84 kg/m2 -p < 0.04; HR OBP: 69.9 +/- 1.53 lat/min-H 80.5 +/- 3.58 lat/min -p < 0.03). Although the H were not reaching values of left ventricular mass index (LVMI) or septal (S) and posterior wall thickness to be considered hypertrophics, they were exceeding the OBP group (LVMI OBP: 89.6 +/- 3.33 g/m2, H: 124.5 +/- 6 g/m2 -p < 0.01; S OBP: 8.7 +/- 0.17 mm, H: 11.5 +/- 0.04 mm; P OBP: 7.9 +/- 0.18 mm, H: 10 +/- 0.13 mm -p < 0.01). Cardiac index (CI) was increased in H (OBP: 3.3 +/- 0.14 l/min/m2, H: 4.8 +/- 0.36 l/min/m2 -p < 0.01) supporting the existence of a hyperkinetic circulatory phase. OBP showed total peripheral resistance (TPR) higher than H group (OBP: 17 +/- 0.8 mmHg/l.min.m2, H: 13 +/- 1 mmHg/l.min.m2 -p < 0.008). Left ventricular (LV) systolic function indexes were not different in the two groups analyzed. The pattern of left ventricular late filling was however different between the two groups. The area of late diastolic flow (Area A) was lower in OBP (OBP: 2.64 +/- 0.09 cm2, H: 3.78 +/- 0.95 cm2 -p < 0.01) independently of HR value (adjusted mean OBP: 2.9 +/- 0.09 cm2, H: 3.52 +/- 0.95 cm2 -p < 0.01). The early filling fraction (EFF) was also detecting a significant shift to more prominent late diastolic filling in H (OBP 0.72 +/- 0.06%, H: 0.64 +/- 0.01% -p < 0.01) independently of HR values (adjusted mean PAO: 0.71 +/- 0.96%, H: 0.65 +/- 0.01% -p < 0.01). Healthy young males with hypertension stage I have similar LV systolic function, increased CI, LVMI, LV wall thickness, decreased TPR and evidence of impaired LV filling with shift of the pattern of filling to a late flow.
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PMID:[Left ventricular structure and function in young male students of La Plata University with stage I hypertension]. 953 28

CORRELATION BETWEEN BLOOD PRESSURE AND RISK OF CARDIOVASCULAR EVENTS: The goal of antihypertensive treatment is to reduce morbidity and mortality from cardiovascular disease associated with high blood pressure values. Epidemiological studies have demonstrated a direct correlation between the risk of stroke or coronary events and blood pressure values, and randomized controlled trials with antihypertensive drugs have shown that an average fall in diastolic blood pressure (DBP) of 5-6 mmHg [or in systolic blood pressure (SBP) of 10 mmHg] reduces the relative risk of cerebrovascular events by 40% and of coronary events by 15%. Thus, it would seem appropriate to achieve the maximum tolerated blood pressure reduction, although there is still no consensus on how far blood pressure should be lowered. PROBLEMS OF BLOOD PRESSURE CONTROL: Because the reduction in the absolute risk for a given level of blood pressure is higher in elderly patients and in those with multiple risk factors, the 1996 World Health Organization report recommends lowering blood pressure to below 140/90 mmHg in elderly patients, and suggests that it might be desirable to achieve blood pressure values of 120-130/80 mmHg in young patients with mild hypertension. Recent surveys in primary care centers in Spain show blood pressure control rates (blood pressure < 140/90 mmHg) ranging from 13 to 26%. These insufficient rates denote the particular difficulty of controlling SBP in an elderly population of patients with essential hypertension mainly treated in monotherapy schedules. The picture is similar in other developed countries. In a sample of 14,000 patients from Western European countries the Cardiomonitor survey showed control rates of 43% for DBP (< 90 mmHg) and 35% for SBP (< 140 mmHg). No more than 24% of treated hypertensive patients achieve the target (blood pressure < 140/90 mmHg) in the USA, and no more than 27% (DBP < 90 mmHg) in New Zealand. Preliminary reports from the Hypertension Optimal Treatment study indicate that in most patients combined therapy is required to achieve target blood pressure. Fixed combinations of synergistic antihypertensive drugs may help to improve both drug compliance and blood pressure control.
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PMID:Actual blood pressure control: are we doing things right? 953 97

The Hypertension Optimal Treatment Study is a prospective trial conducted in 26 countries. The aims are to (1) evaluate the relationship between three levels of target office diastolic blood pressure (BP) (< or = 80, < or = 85, or < or = 90 mm Hg) and cardiovascular morbidity and mortality in hypertensive patients and (2) examine the effects on cardiovascular morbidity and mortality of 75 mg aspirin daily versus placebo. A total of 19,193 patients between 50 and 80 years of age had been randomized by the end of April 1994. Treatment was initiated with felodipine 5 mg daily, and additional therapy was given in accordance with a set protocol. The present substudy of 926 patients performed in nine countries aimed to (1) compare home with office BP in a representative subsample of the HOT population after the titration of treatment was completed and (2) clarify whether the separation into the target groups could be expanded into the out-of-office setting. The differences between office and home measurements in diastolic BP of 0.2 mm Hg (SD, 9; 95% confidence interval, -0.36 to 0.81; P=.40) and systolic BP of 0.5 mm Hg (SD, 15; 95% confidence interval, -0.53 to 1.46; P=.21) were not significant. The group differences in home BP were 1.9 mm Hg (< or = 80 versus < or = 85) and 1.2 mm Hg (< or = 85 versus < or = 90) for diastolic BP (F=11.69; ANOVA, P<.0001) and 2.6 and 2.1 mm Hg for systolic BP (F=8.44, P=.0002). Thus, office and home BPs measured with the same semiautomatic device are comparable in treated hypertensive subjects in the HOT Study, and the separation into the target groups based on office readings prevails at home.
Hypertension 1998 Apr
PMID:Hypertension optimal treatment (HOT) study: home blood pressure in treated hypertensive subjects. 953 29

Calcium antagonists (CaAs) of the dihydropyridine type are widely used in the treatment of hypertension and other cardiovascular disorders. They are markedly effective in lowering elevated arterial pressure, and are well tolerated. Data from long-term intervention trials are emerging, which also show a beneficial effect on cardiovascular morbidity with the use of CaAs in the treatment of hypertension. The first such evidence was from the Shanghai Trial of Nifedipine in the Elderly (STONE), and, in February 1997, the Systolic Hypertension in Europe (Syst-Eur) trial was stopped prematurely because the active treatment, based on a CaA, was found to be significantly better than placebo in preventing cardiovascular disease. In addition, ongoing trials with dihydropyridine CaAs (e.g. the Hypertension Optimal Treatment [HOT] Study and the Swedish Trial in Old Patients with Hypertension-2 [STOP-2]) are close to termination. Final results are not yet available, but cardiovascular morbidity appears to be lower than expected in the HOT Study, suggesting a positive effect of the CaA-based therapeutic regimen. Claims of increased morbidity and mortality from the use of CaAs have been clearly refuted by the thorough scrutiny of all available data by a committee formed by the World Health Organization and the International Society of Hypertension. It can therefore be concluded that the available evidence on the use of dihydropyridine CaAs shows that these agents have a beneficial effect on morbidity. Whether this effect of CaAs is greater than that obtained with conventional therapies, such as diuretics and/or beta-blockers, will be shown by the STOP-2 Study, which is expected to be completed in 1998.
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PMID:Morbidity and mortality with dihydropyridines. 966 May 25

The goals of stable angina pectoris treatment are: (i) symptom relief and increase in angina-free walking time; and (ii) reduction of mortality and adverse outcome. Strategies used for plaque stabilisation resulting in a reduction in cardiovascular mortality and morbidity are: smoking cessation; aspirin (acetylsalicylic acid); blood pressure control; lipid lowering agents when low density lipoprotein cholesterol is elevated despite dietary therapy; coronary bypass surgery in patients with left main stem disease or triple vessel coronary disease and diminished left ventricular function; and use of estrogen in postmenopausal women. For symptom relief and to increase angina-free walking time, long acting nitrates, beta-blockers, calcium antagonists and potassium channel openers can be used. Drugs from these 3 classes are all effective when used optimally and choice of initial therapy should consider the presence of concomitant disease and underlying left ventricular function. However, none of the long acting nitrates provide continuous prophylaxis because nitrate tolerance develops during long term therapy. In patients with uncomplicated stable angina, nitrates, beta-blockers and calcium antagonists are all effective. Intermittent nitrate therapy is not associated with tolerance, but headache is a common adverse effect and the patient is unprotected at night and in the early hours of the morning. Concomitant treatment with a beta-blocker may be beneficial if the patient experiences withdrawal or early morning angina. For patients with stable angina and hypertension, therapy with a beta-blocker or a calcium antagonist rather than nitrate is indicated. beta-Blockers are preferred in patients who have had a myocardial infarction, or in those with a history of supraventricular tachyarrhythmias. beta-Blockers may produce excessive slowing of the heart rate, fatigue and bronchospasm in susceptible patients. Calcium antagonists are indicated as initial therapy when beta-blockers are either not tolerated or contraindicated. beta-Blockers and nondihydropyridine calcium antagonists should not be used in patients with sinus bradycardia and those with greater than first degree atrioventricular (AV) block because of the possibility of further slowing of heart rate and/or the development of high grade AV block. When monotherapy with one class is ineffective or associated with adverse effects, the patient should be switched to another class rather than given an additional drug. Optimal monotherapy is often as effective as combination therapy. If maximum monotherapy is only partially effective, a combination therapy which is not additive in terms of adverse effects should be chosen. Triple therapy may be deleterious and no more effective than dual therapy.
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PMID:Choosing the most appropriate treatment for stable angina. Safety considerations. 967 56

Renal disease is the cause of hypertension in about 5% of all hypertonics. Patients with renal hypertension are threatened by cardiovascular complications of hypertension even more frequently than patients with essential hypertension. Hypertension is moreover an important factor in the progression of renal insufficiency. In the pathogenesis of renal hypertension an important role is played by sodium and fluid retention and activation of the renin-angiotensin system. Progression of rental insufficiency can be retarded only by more strict control of hypertension than in patients with normal renal function. Optimal treatment is administration of angiotensin converting enzyme inhibitor which moreover in the majority of patients retards the progression of renal insufficiency more markedly than other antihypertensive drugs.
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PMID:[Hypertension in diseases of the kidney. Pathogenesis and therapy]. 974 35

Leptin levels in subjects with android obesity with the insulin resistance syndrome (syndrome X, 5H) are in general elevated, as compared with non-obese subjects and correlate with the BMI, with the percentage of body fat, WHR, IRI levels and sex (they are higher in women), as it is the case in the general population. In the elevated leptin level in syndrome 5H (association of hyperinsulinism, hyperglycaemia-NIDDM, hyperlipoproteinaemia with android obesity, arterial hypertension and hirsutism in females with the polycystic ovaries syndrome) participate in a significant way also elevated basal IRI and cortisol levels as well as an elevated postprandial IRI response during oGTT despite the fact that leptin and endothelin-1 levels do not rise significantly during oGTT despite hyperinsulinaemia. Leptin levels were however higher in men (liminally significant in women) with an hyperinsulinaemic response during oGTT, as compared with probands with a normal insulin response. Optimal insulin and glucocorticoid levels are the prerequisite for a rise of leptin because proadipocytes in vitro begin to produce leptin as soon as insulin is added to the medium and this effect is trebled, if cortisol is added. It appears that the insulin and leptin resistance in syndrome 5H are parallel phenomena which potentiate each other. Elevated insulin and cortisol levels maintain elevated leptin levels which in turn enhances the insulin resistance in muscles and at the same time has an impact on the IRI response to postprandial hyperglycaemia. In the background of this insulin and leptin resistance in the majority of subjects with the 5H syndrome there is apparently no actual molecular defect of the hormone and its receptors in target tissues but a possible defect in mechanisms of postreceptor transduction of the hormonal signal. In the hormonal resistance participate moreover also two general and non-specific mechanisms such as: 1. increased consumption or uptake of hormonal receptors by elevated levels of the appropriate hormone ("down regulation" phenomenon), 2. disorders of paracrine endothelial mechanisms of the vascular wall which determine via the control of the inflow in the regional microcirculation the availability of insulin, leptin and metabolic substrates to target tissues. Impaired vasodilatation reserves and the development of paradoxical vascular spasms in response to stimuli which normally cause vasodilatation (strain, administration of acetylcholine, histamine, ATP etc.) are constant, associated phenomena in hyperlipoproteinaemias, arterial hypertension and in type 2 diabetics. These phenomena are the syndrome of insulin resistance and syndrome 5H-X resp. Endothelin-1 levels assessed in the systemic circulation are however due to their short biological half-life and the paracrine action of endothelin-1 not sensitive markers of endothelial dysfunction in syndrome X.
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PMID:[Relation between levels of leptin, insulin and cortisol in persons with the 5H (X) syndrome]. 982 79


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