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Query: UMLS:C0020538 (hypertension)
 170,190 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

Optimal management of abdominal aortic aneurysm (AAA) remains a challenging surgical problem. Over the last decade surgical and anesthetic improvements have provided perioperative mortality in the 2% range, when elective AAA repair was performed in single Institutions with large vascular experience. However, community- or national-based mortality rates for elective AAA surgery may be as high as 11% or more. Mortality rates associated with ruptured aneurysms remain as high as 90%. AAA prophylactic resection should be indicated when the risk of rupture exceeds the surgical risk. Although the risk of rupture correlates strongly with the diameter of the AAA, there is evidence that other factors can increase the rupture risk: hypertension, chronic pulmonary disease, aneurysm morphology, etc. Establishing a single threshold diameter for AAA repair appears naive. Moreover, AAA primarily affects older patients with other comorbidities that shorten life expectancy and increase perioperative risks: coronary artery disease, renal and pulmonary insufficiency, peripheral artery disease, etc. So that, proper management of individual AAA is based on balancing the perioperative risk, the risk of rupture, and life expectancy. In the subgroup of young healthy patients with additional risk factors for AAA rupture, elective repair at a smaller size (4 to 5.5 cm) may be beneficial if low surgical risk can be assured. In the last decade endovascular repair for AAA treatment has emerged. These less invasive endovascular techniques for AAA repair offer some advantages in terms of reduced patient stress, analgesic requirement, respiratory dysfunction, blood loss, need for intensive care and reduced hospitalization with an early technical success similar to that of open surgical treatment. However, there are no prospective, randomized studies evaluating endovascular treatment of AAA. Moreover, long-term results on the durability of these new techniques are needed to assess endovascular repair as an alternative treatment to prevent the risk of AAA rupture.
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PMID:Abdominal aortic aneurysms: current management. 1047 96

The aim of the HOT Study (Hypertension Optimal Treatment) was to determine the optimal diastolic blood pressure decrease and to assess the effect of the acetyl salicylic acid as a primary prevention on the cardiovascular morbidity and mortality in hypertensive patients. The HOT Study is an open, prospective, randomised, international trial with blinded end points. This study included 18,790 patients, 50 to 80 years old (mean 61.5 years) in 26 countries (1,574 patients in France) with a primary hypertension (100 < or = PAD < or = 115 mmHg). The patients were randomised in 3 target diastolic blood pressure: < or = 80 mmHg (n = 6,262), < or = 85 mmHg (n = 6,264), < or = 90 mmHg (n = 6,264). The felodipine LP, a long acting dihydropyridine, was selected as a first line therapy, other hypertension drugs combined if necessary. The lowest incidence of cardiovascular events was observed at a diastolic blood pressure level of 82.6 mmHg. There was no increased risk below this level even in the hypertensive patients with medical history of coronary heart disease or stroke. In the diabetic population, the diastolic blood pressure decrease from 90 to 80 reduced the incidence of the major cardiovascular events by 51%. The acetyl salicylic acid reduced the myocardial infarction risk in the blood pressure well-controlled population.
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PMID:[Effect of intensive antihypertensive treatment and of aspirin in a low dose in the hypertensive. The HOT (Hypertension Optimal Treatment) study]. 1048 68

Syndrome X and microvascular angina are a heterogenous group of diseases. Several medications, including angiotensin-converting enzyme inhibitors, beta-blockers, and calcium-channel blockers, have been reported to be successful in the treatment of microvascular angina. Control of hypertension and regression of left ventricular hypertrophy are important in controlling symptoms associated with this intriguing problem. The role of nitric oxide and the effects of L-arginine in the pathogenesis and treatment of hypertension and microvascular angina need to be elucidated. Optimal treatment will depend on the appropriate classification and diagnosis of chest pain in patients with hypertension and normal coronary angiograms.
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PMID:Treatment of the hypertensive patient with microvascular angina. 1050 Aug 98

The Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure defines hypertension as systolic blood pressure > or =140 mm Hg or diastolic blood pressure (DBP) > or =90 mm Hg. Evidence shows that even slightly elevated blood pressure significantly increases the risk of morbidity and mortality and only aggressive efforts to reduce blood pressure can significantly reduce this risk. In the recently completed Hypertension Optimal Treatment trial, patients were assigned to one of three target blood pressure groups, reflecting DBP goals of < or =90, < or =85, and < or =80 mm Hg. Aggressive antihypertensive treatment allowed more than 90% of patients to achieve goal DBP of < or =90 mm Hg. This study clearly showed that these defined goals could be safely met and even exceeded. Too few patients with hypertension receive the level of effective treatment achieved in clinical trials. Individuals with poorly controlled blood pressure are at significant risk for cardiovascular and cerebrovascular morbidity and mortality and represent a potentially substantial burden to the healthcare system. Setting appropriate blood pressure goals and working to meet them through aggressive antihypertensive treatment, with multiple agents if necessary, can reduce those risks.
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PMID:Optimal blood pressure: how low should we go? 1059 62

Obesity is a significant risk factor for hypertension and the cardiovascular sequelae of hypertension. Weight loss has been shown to be effective in lowering blood pressure in overweight individuals. The purpose of this study was to show the impact of a weight loss intervention on overall medication requirements for obese, hypertensive patients. This was a substudy of the Hypertension Optimal Treatment (HOT) study. HOT study patients who had a body mass index > or =27 kg/m2 were randomized to receive either the weight loss intervention, which included dietary counseling and group support, or to serve as the control group. Patients' weights and number of medication steps (per HOT protocol) required to achieve target diastolic blood pressure were measured at 3, 6, 12, 18, 24, and 30 months. Patients in the weight loss group lost significantly more weight than the control group only at 6 months (-3.2+/-4.3 v. -1.8+/-2.7 kg [mean +/- SD] for weight loss group versus control, respectively, P = .05). The weight loss group tended to regain weight after the first 6 months of the study. However, patients in the weight loss group used a significantly fewer number of medication steps than the control group at all time intervals except 3 months. Weight loss appears to be a useful tool in blood pressure management in patients who require medication to control their blood pressure.
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PMID:The effect of weight loss intervention on antihypertensive medication requirements in the hypertension Optimal Treatment (HOT) study. 1061 79

The most difficult diagnosis in medicine is the diagnosis of hypertension. Since this label encompasses many maladies both known (secondary hypertension), and the unknown, the office recording of blood pressure alone will not suffice to warrant treatment with drugs right away. There are more than 6 major guidelines in the world about the rules of the game of drug therapy in hypertension. The present preoccupation with newer drugs as first line antihypertensive drugs would ruin any economy, if the exchequer is to foot the bill. The stress in drug treatment has been the step-care mode of drug therapy where one starts with one drug in small doses, building the dose gradually, adding the next drug to get cumulative power to lower the pressure. Since the early seventies, the need to step-down therapy is being stressed wherein the doctor starts cutting down the drugs and the dosage, once he achieves the desired blood pressure levels. Diuretics and beta-blockers should be the first choice when drugs are indicated, unless there are positive indications for other drugs, or the first line drugs are contra-indicated. Routine treatment with drugs is recommended by the American JNC for people with sustained blood pressure above 140/90 mm Hg, but the British recommendations put the cut off at the pressure level of 160/100 mm Hg. Indian patients respond to very small doses in the beginning. The Hypertension Optimal Treatment (HOT) study failed to demonstrate a significant difference between the 3 randomised target blood pressure groups for the majority of cardiovascular events, although it did prove the theoretical hypothesis, that more vigorous treatment could certainly bring down the measured blood pressure to greater extent in 90% of patients I Greater importance will be given in the future for the non-pharmacological approaches, as well as to baseline blood pressure values, at which drug treatment should be started.
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PMID:Principles of drug therapy in hypertension. 1065 11

Eclampsia is defined as the occurrence of seizures in pregnancy or within 10 days of delivery, accompanied by at least two of the following features documented within 24 hours of the seizure: hypertension, proteinuria, thrombocytopenia or raised aspartate amino transferase. Eclampsia complicates approximately one in 2,000 pregnancies in the United Kingdom and it remains one of the main causes of maternal death. Up to 38% of cases of eclampsia can occur without premonitory signs or symptoms of pre-eclampsia-that is, hypertension, proteinuria, and oedema. Only 38% of eclamptic seizures occur antepartum; 18% occur during labour and a further 44% occur postpartum. Rare cases of eclampsia have occurred over a week after delivery. Outcome is poor for mother and child. Almost one in 50 women suffering eclamptic seizures die, 23% will require ventilation and 35% will have at least one major complication including pulmonary oedema, renal failure, disseminated intravascular coagulation, HELLP syndrome, acute respiratory distress syndrome, stroke, or cardiac arrest. Stillbirth or neonatal death occurs in approximately one in 14 cases of eclampsia. Up to one third of eclamptic seizures occur out of hospital. For this reason, initial management may involve accident and emergency departments. Early involvement of senior obstetric staff is crucial. Optimal emergency management of seizures, hypertension, fluid balance and subsequent safe transfer is essential to minimise morbidity and mortality.
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PMID:Management of eclampsia in the accident and emergency department. 1065 82

During early pregnancy, placentation occurs in a relatively hypoxic environment which is essential for appropriate embryonic development. Intervillous blood flow increases at around 10-12 weeks of gestation and results in exposure of the trophoblast to increased oxygen tension (PO2). Prior to this time, low oxygen appears to prevent trophoblast differentiation towards an invasive phenotype. In other mammalian systems, oxygen tension effects are mediated by hypoxia inducible factor-1 (HIF-1). We found that the ontogeny of HIF-1alpha subunit expression during the first trimester of gestation parallels that of transforming growth factor-beta3 (TGFbeta3), an inhibitor of early trophoblast differentiation. Expression of both molecules is high in early pregnancy and falls at around 10 weeks of gestation when placental PO2 levels are believed to increase. Antisense-induced inhibition of HIF-1alpha inhibited the expression of TGFbeta3, and stimulated extravillous trophoblast (EVT) outgrowth and invasion. Of clinical significance we found that TGFbeta3 expression was increased in pre-eclamptic placentae when compared to age-matched controls. Significantly, inhibition of TGFbeta3 by antisense oligonucleotides or antibodies restored the invasive capability to the trophoblast cells in pre-eclamptic explants. We speculate that if oxygen tension fails to increase, or trophoblasts do not detect this increase, HIF-1alpha and TGFbeta3 expression remain high, resulting in shallow trophoblast invasion and predisposing the pregnancy to pre-eclampsia. Effective fetal-maternal interactions during early placentation are critical for a successful pregnancy. Optimal placental perfusion requires the controlled invasion of trophoblast cells deep into the decidua to the spiral arteries. Trophoblast stem cells, also referred to as cytotrophoblast cells, reside in chorionic villi of two types, floating and anchoring villi. Floating villi, which represent the vast majority of chorionic villi, are bathed in maternal blood and primarily perform gas and nutrient exchange for the developing embryo. During early placentation, cytotrophoblast cells in the floating villi proliferate and differentiate by fusing to form the multinucleate syncytiotrophoblast layer. Cytotrophoblast cells in anchoring villi either fuse to form the syncytiotrophoblast layer, or break through the syncytium at selected sites and form multilayered columns of non-polarized extravillous trophoblast cells, which physically connect the embryo to the uterine wall (Figure 1). The extravillous trophoblast cells invade into the uterine wall as far as the first third of the myometrium and its associated spiral arteries, where they disrupt the endothelium and the smooth muscle layer and replace the vascular wall. This results in the conversion of the narrow calibre arteries into distended uteroplacental arteries, thereby increasing blood flow to the placenta and allowing an adequate supply of oxygen and nutrients to the growing fetus. The invasive activity of the extravillous trophoblast cells is at a maximum during the first trimester of gestation, peaking at around 10-12 weeks and declining thereafter. Insufficient invasion contributes to the development of pre-eclampsia, which often results in fetal intrauterine growth restriction, maternal hypertension and proteinuria. In contrast, unrestricted invasion is associated with premalignant conditions, such as invasive mole, and with malignant choriocarcinoma. Invading trophoblast cells undergo striking and rapid changes in cellular functions that are temporally and spatially regulated along the invasive pathway (Figure 1) (Cross, Werb and Fisher, 1994. The formation of the anchoring villi is accompanied by changes in synthesis and degradation of extracellular matrix proteins and their receptors, and changes in the spatial distribution of extracellular matrix proteins, as well as changes in the expression of adhesion molecules (Damsky, Fitzgerald and
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PMID:Oxygen and placental development during the first trimester: implications for the pathophysiology of pre-eclampsia. 1083 Nov 18

The earlier large multicentre trials in hypertensive patients addressed questions of whether mild to moderate hypertension should be treated and whether similar approaches would be effective in elderly hypertensive patients or those with isolated systolic hypertension. The research focus of recent trials has now shifted to how rather than whether such patients should be treated. Trials such as the Hypertension Optimal Treatment study attempted to discern optimal targets for long-term blood pressure control. Although unsuccessful in this primary aim, they have established the safety of aggressive blood pressure lowering to diastolic targets of less than 80 mmHg as well as the safety and efficacy of a calcium entry blocker as a first line antihypertensive approach. The Captopril Prevention Project study and Swedish Trial in Old Patients with Hypertension-2 trial focussed on whether there might be specific antiatherosclerotic advantages of the newer agents (angiotensin converting enzyme inhibitors and calcium entry blockers) over conventional therapy in comparison studies with beta blockers and diuretics. Similar efficacy for cardiovascular outcomes appears to be emerging for each of the major classes of drugs with the degree of blood pressure lowering of prime importance in cardiovascular disease prevention.
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PMID:Large multicentre hypertension trials. 1084 31

Blood pressure control is needed in order to attain a normalization of the increased cardiovascular risk present in the hypertensive population. However, we are far from obtaining the most effective control of blood pressure. A more aggressive attitude, in particular in high-risk patients, is required, together with an adequate selection of antihypertensive pharmacological therapies. In this sense combined therapy has to be more widely used in patients presenting with the characteristics detailed in the newly published mega-trials like the Hypertension Optimal Treatment study. An adequate selection of the components of combination could also be of interest through a better protective capacity mediated by blood pressure-independent effects.
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PMID:Do we effectively lower blood pressure? 1085 44


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