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

Previous reports of the follow-up of patients with atrial fibrillation have been confusing because of the variety of clinical presentations, heterogeneity of underlying pathology, and the initiation of follow-up at various stages of the patient's disease. The Canadian Registry of Atrial Fibrillation (CARAF) is a non-interventional, follow-up study of patients enrolled at the time of their initial diagnosis with atrial fibrillation at seven Canadian centres. At baseline, a comprehensive database recorded clinical, laboratory, and echocardiographic variables. No specific intervention was initiated and care was left to the attending physicians. Follow-up was performed at 3 months, 1 year, then annually. Echocardiograms were repeated every 2 years. Recurrence of atrial fibrillation, medical intervention, stroke, death, and other significant events have been specifically recorded. To date, 967 patients have been enrolled. Seven hundred and sixty-seven patients have been followed for 1 year, 468 for 2 years, and 217 for 3 years. Several studies have been undertaken on these patients. One study compared the variables of patients who were symptomatic with those who were asymptomatic. This study demonstrated that symptoms were more likely to occur if the patient were younger, had high blood pressure and high ventricular response during atrial fibrillation, and were female. These all achieve statistical significance and a formula was developed to predict the probability of symptoms in different subgroups of patients. Antiarrhythmic drug use was evaluated. Sotalol and propafenone were the most commonly used drugs and their use increased when atrial fibrillation was recurrent. Many patients initially received no antiarrhythmic drugs. Trends suggest that therapy is more aggressive with recurrence of the arrhythmia. The prevalence of thyroid abnormalities was investigated utilizing sensitive TSH measurements. This showed that overt hyperthyroidism is rare (1%) but laboratory abnormalities and history of thyroid dysfunction occurred more frequently, in 19% of patients. Another study evaluated antithrombotic therapy. Factors known to increase stroke risk, including congestive heart failure, previous stroke, and large left atrium all increased the use of anticoagulants. Anticoagulants were used more frequently in patients over the age of 65 and in patients with recurrent or chronic atrial fibrillation. There was concern that hypertension, shown to be a high predictor of stroke, did not result in a significant use of warfarin. Aspirin use was common in patients not placed on anticoagulants. Further studies are being undertaken with the ultimate goal to utilize baseline data to predict clinical outcomes.
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PMID:Follow-up of atrial fibrillation: The initial experience of the Canadian Registry of Atrial Fibrillation. 880 39

Laparoscopic cholecystectomy is the standard method for surgical treatment of non-malignant gall bladder disease. Well tolerated in otherwise healthy patients, it remains however, questionable whether the laparoscopic procedure in patients with severe pre-existing morbidity is associated with a higher incidence of negative intraoperative events than open cholecystectomy. Therefore, the incidence of negative intraoperative events was prospectively investigated in a series of 1,367 patients (319 with open cholecystectomy and 1,048 with laparoscopic cholecystectomy) who were analysed for occurrence of events such as hypertension, hypotension, arrhythmia, unusual bleeding and transfusion requirement, regurgitation or aspiration of gastric content and respiratory disorders. For further analysis the patients undergoing each operative procedure were divided into two subgroups with either preoperative ASA physical status I and II or III and IV. The study groups were comparable in sex and age. There were no intraoperative deaths. The frequency of hypertension, hypotension or arrhythmia alone and in combination was similar in both groups. The need for intervention was significantly more frequent in ASA class I/II patients with laparoscopic cholecystectomy. Respiratory disorders were rare. There was a significantly higher incidence of postoperative ventilatory support in patients with conventional cholecystectomy. Transfusion was required significantly less often in patients with laparoscopic cholecystectomy (0.19% versus 15.36%). CO2-pneumoperitoneum led to severe circulatory alterations in 7 healthy patients. The most severe negative event was a cardiac arrest in 1 female patient who was successfully resuscitated without any sequelae. In ASA-class III and IV patients intraoperative negative events were equally frequent and independent of the procedure. Severe preoperative morbidity per se seems to be no contraindication for laparoscopic cholecystectomy.
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PMID:Preoperative morbidity and anaesthesia-related negative events in patients undergoing conventional or laparoscopic cholecystectomy. 884 27

Despite the availability and use of effective methods for limiting infarct size with thrombolytic agents and primary angioplasty, patients experiencing a myocardial infarction (MI) are at increased risk for a second cardiac event in the post-MI period (e.g., reinfarction, heart failure, and sudden death). For this reason, postinfarction risk management is crucial. An extensive data base has firmly established the efficacy of beta blockers in reducing cardiovascular risk following acute MI. The full advantages of angiotensin-converting enzyme (ACE) inhibitors have only recently begun to emerge as the result of a growing understanding of the mechanisms of adverse outcomes following MI. The importance of lipid-lowering agents, in particular the "statins," should be considered in all post-MI patients, especially since recent studies have conclusively shown improved survival and reduced rates of MI and coronary artery bypass surgery in this population with this therapy. Aspirin is now considered a standard part of the early management of the acute infarct patient as well as for secondary prevention in post-MI patients. At present, chronic anticoagulation with warfarin should be reserved for selected patients. The nondihydropyridine calcium antagonists diltiazem and verapamil can be considered for post-MI use only in patients in whom beta blockers are contraindicated and who have preserved systolic function and/or those without clinical heart failure. In contrast, the dihydropyridine calcium antagonists, particularly nifedipine, have no role in secondary prevention. Although long-term benefits are minimal, nitrates continue to be useful in post-MI patients with residual ischemia (angina or silent ischemia), heart failure (systolic or diastolic), or postinfarction hypertension. Antiarrhythmic agents, except amiodarone, are relatively contraindicated in post-MI patients. Recent data show that vitamin E reduces the rate of nonfatal MI. Its role in cardiovascular death and overall mortality remains to be clarified. Despite their demonstrated value, agents used in secondary prevention generally appear to be underutilized. In addition, when pharmacologic therapies are administered for secondary prevention, they are often prescribed at lower doses than those tested and proved in trials. A greater appreciation for the efficacy and safety profiles of these agents could lead to more widespread use and more pronounced reductions in morbidity and mortality among post-MI patients.
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PMID:Pharmacologic therapies after myocardial infarction. 890 Mar 39

Normalbuminuric patients who have long-standing IDDM have a wide range of renal structure, from within normal limits to advanced lesions that overlap those of patients who have high levels of MA and border on those seen in patients who have overt DN. Patients who have low-level MA have reduced glomerular structure similar to that of patients who have NA. Low GFR, hypertension, or both can occur in patients who have NA or low-level MA and are associated with more advanced lesions. Patients who have MA and AER greater than 45 mg/24 hr have more advanced lesions than do patients with NA or low-level MA, but similar lesions are present in these patients whether AER is greater than or less than 100 mg/24 hr. Increasing AER in NA and MA patients who have long-standing IDDM is associated with GBM and mesangial expansion. A structural basis for MA cannot currently be deduced from studies of glomerular epithelial cell fine structure, capillary wall charge site analysis, or immunohistochemical studies of renal ECM composition. Hemodynamic adaptations to mesangial expansion and reduced filtration surface and, perhaps, hydraulic conductivity may accelerate glomerular damage, as expressed by increasing AER. Microalbuminuria derives its clinical utility in IDDM, as it identifies a population of patients at statistically increased risk of progression to overt DN by acting as a marker of already well-established DN lesions. Although MA is currently the best of the widely used indicators of DN risk, it is not precise. Therapies that reduce MA may ultimately slow or prevent progression toward ESRD, but this finding requires confirmation by demonstrating that a given treatment strategy can preserve GFR.
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PMID:Glomerular changes in normo- and microalbuminuric patients with long-standing insulin-dependent diabetes mellitus. 892 36

Secondary prevention of arteriosclerosis tries to inhibit progression of the atherosclerotic process. Therapeutic measures focus on modification of cardiovascular risk factors and antithrombotic treatment. Hypercholesterolemia is the main risk factor for coronary artery disease. The risk of a coronary event is correlated to the plasma cholesterol level. Lowering plasma cholesterol results in reduction of vascular morbidity and mortality. Cigarette smoking is the predominant risk factor for peripheral arterial occlusive disease (PAOD). Smoking cessation reduces progression of PAOD and lowers cardiovascular morbidity and mortality. The preventive effect of antihypertensive therapy in hypertensive patients is most pronounced for cerebrovascular events. Antihypertensive measures improve prognosis after stroke and myocardial infarction. The increased cardiovascular risk in diabetics is in part explained by hyperglycemia and hyperinsulinemia, but also depends on coexisting dyslipidemia and hypertension. Intensive treatment of elevated blood glucose levels, dyslipidemia and hypertension are important preventive measures. Aspirin is highly effective in secondary prevention of vascular events. For the coronary arteries, low-dose aspirin is well established. Whether low-dose aspirin is equally effective for reducing progression of arteriosclerosis in the cerebrovascular and in the peripheral vessels is questionable. Ticlopidine serves as an alternative to aspirin; however, neutropenia may occur, which requires supervision of the patient.
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PMID:[Secondary prevention of arteriosclerosis]. 892 4

Hypertensive disorders (gestational hypertension, preeclampsia, chronic hypertension, superimposed preeclampsia) are the most common medical complications of pregnancy and constitute a major cause of maternal and perinatal morbidity and mortality. Prediction of those women destined to develop preeclampsia remains elusive. The benefits of calcium supplementation for prevention of preeclampsia are encouraging; however, the definitive study is not yet complete. Aspirin therapy for high-risk has not been helpful; results of therapy for high-risk women are pending. More experience is being gained with antihypertensive therapy and expectant management in severe preeclampsia. Conservative management of severe preeclampsia, when performed in a tertiary care center, may benefit a select group of women and their fetuses.
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PMID:Hypertension in pregnancy: current concepts of preeclampsia. 904 50

We compared stroke severity, risk factors, and prognosis in patients with recurrent versus first-ever stroke. In the Copenhagen Stroke Study, we prospectively studied 1,138 unselected patients with acute stroke. Stroke was recurrent in 265 (23%) despite most of these patients being given prophylactic treatment prior to recurrence. Only 12% of patients with atrial fibrillation were receiving anticoagulant treatment prior to recurrence. In multivariate analysis, recurrence was more frequently associated with a history of TIA, atrial fibrillation, male gender, and hypertension, but not with age, daily alcohol consumption, smoking, diabetes, ischemic heart disease, serum cholesterol, or hematocrit. Mortality was almost doubled compared with patients with a first-ever stroke. In survivors, however, both neurologic and functional outcomes and the speed of recovery were, in general, similar in the two groups. Despite similar neurologic impairments, patients with recurrence contralateral to their first stroke had markedly more severe functional disability after completed rehabilitation than patients with ipsilateral recurrence, implying that the ability to compensate functionally is decreased in patients with contralateral recurrence. Our findings emphasize the importance of consistent anticoagulant treatment for stroke patients with atrial fibrillation and close blood pressure control in stroke patients with hypertension. Other prophylactic measures are needed in patients in whom ASA fails to prevent recurrence. Patients with recurrent stroke have a markedly higher mortality than patients with a first-ever stroke, but those who survive recover as well and as fast as patients with a first-ever stroke. However, if recurrence is contralateral to the first stroke, functional recovery is poorer.
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PMID:Stroke recurrence: predictors, severity, and prognosis. The Copenhagen Stroke Study. 910 73

Transesophageal echocardiography visualizes the left atrium, the left atrial appendage, thrombi and spontaneous echo contrast within them. The role of these findings as predictors for embolism in atrial fibrillation is unknown. We performed transesophageal echocardiography in 409 non-rheumatic atrial fibrillation outpatients (62 +/- 12 years, 36% female) with no recent (< 1 year) history of embolism. Patients with left atrial/appendage thrombi received oral anticoagulation, those without thrombi Aspirin. The patients were followed up over 2 years. Primary events were stroke, embolism and non stroke/embolism related deaths. Secondary events were initiation of anticoagulation in patients primarily assigned to Aspirin. Left atrial/appendage thrombi were diagnosed in 2.5%. They were associated with diabetes, heart failure and decreased left ventricular fractional shortening (p < 0.05 for each variable). Spontaneous echo contrast was diagnosed in 12%. It was associated with increased age, constant atrial fibrillation, hypertension, heart failure, valvular abnormalities and increased left atrial diameter (p < 0.05 for each variable). Increased left atrial appendage size was associated with constant atrial fibrillation, etiology of atrial fibrillation and valvular abnormalities (p < 0.05 for each variable). Follow-up was 25 +/- 7 months. 29 patients suffered a stroke, 33 further patients died of non stroke/embolism related causes. Secondary events occurred in 19 patients. Neither left atrial/appendage thrombi nor left atrial appendage size were predictors for embolism. Predictors for embolism were increased age (p = 0.003), hypertension (p = 0.01) and increased diastolic blood pressure (p = 0.04). In non-rheumatic atrial fibrillation outpatients with no recent history of embolism, transesophageal echocardiography is of limited value to assess embolic risk. Hypertension and increased diastolic blood pressure have been confirmed in their significance as clinical predictors for embolism.
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PMID:[Embolism in left-atrial thrombi (ELAT Study): are spontaneous echo contrast, thrombi in the left atrium/appendage and size of the left atrial appendage predictors of possible embolisms?]. 913 72

People with Type 2 (non-insulin-dependent) diabetes mellitus die mainly from cardiovascular and cerebrovascular disease. Furthermore, the major burden of their symptoms arise from arterial disease, including peripheral vascular disease. However, management guidelines for Type 2 diabetes continue to focus on blood glucose control, which is only one of a number of arterial risk factors found with this type of diabetes. Clinically it is evident that blood glucose control continues to occupy centre-stage in the management of Type 2 diabetes as practised by many physicians. Even when arterial risk factors such as smoking or raised serum triglycerides are noted, their management is often relatively neglected. As part of the St Vincent Declaration Action Programme, a working group has sought consensus on the number and relative importance of arterial risk factors requiring management in quality diabetes care. The group seeks to assist those devising protocols and guidelines, records and quality systems, and those charged with directly advising and educating people with diabetes. Arterial risk factors that can be routinely identified and monitored, and modified by application of management protocols, include high blood pressure, high serum total and LDL cholesterol, low serum HDL cholesterol and raised serum triglycerides, poor blood glucose control, smoking, high body mass index and body fat distribution. Aspirin can modify hypercoagulability, but this is not easily monitored. Arterial risk factors that cannot be modified, but which have an impact on the intensity of management of other factors, include ethnic group, gender, and family history of arterial disease. Raised albumin excretion is an arterial risk factor and can be modified, but it is not clear whether this reduces cardiovascular risk. For many of the risk factors, levels of high, medium, and low risk can be set. These can be used, in consultation with the patient, to determine appropriate interventions and provide feedback on risk reduction resulting from successful management.
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PMID:A strategy for arterial risk assessment and management in type 2 (non-insulin-dependent) diabetes mellitus. European Arterial Risk Policy Group on behalf of the International Diabetes Federation European Region. 947 70

Desflurane has been reported to cause tachycardia and hypertension during induction of anaesthesia. The aim of this study was to determine the effects of desflurane on cerebral blood flow (CBF) velocity using transcranial Doppler ultrasonography in a setting that closely resembled usual clinical practice. In two groups (n = 9 in each) ASA Grade I or II patients, anaesthesia was induced with etomidate and vecuronium intravenously (i.v.), sufentanil (0.3 microgram kg-1 i.v.) was added in the second group. Patients were ventilated by facemask for 2 min before desflurane was administered in steps of 0.5 MAC min-1 until 1.5 MAC was reached and maintained for 7 min. Haemodynamic variables and CBF velocity in the middle cerebral artery (MCA) were monitored throughout the study period. In group 1 heart rate increased to 108 +/- 2 b.p.m. (37% increase) whereas MAP increased to 114 +/- 6 mmHg after administration of desflurane (33% increase). CBF velocity increased to 86 +/- 7 cm s-1 (69% increase). In group 2 no significant changes in systemic haemodynamic responses were measured after desflurane administration; however, CBF velocity increased to 73 +/- 5 cm s-1 (59% increase). The results indicate that desflurane increases CBF velocity concurrently with induction of tachycardia and hypertension. Although sufentanil and N2O attenuate the systemic haemodynamic alterations caused by desflurane, the CBF velocity increases. These data suggest that the abrupt addition of desflurane may have adverse consequences in patients at risk for intracranial hypertension.
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PMID:Administration of sufentanil and nitrous oxide blunts cardiovascular effects of desflurane but does not prevent an increase in middle cerebral artery blood flow velocity. 925 67


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