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

Research in nephrologic nuclear medicine is presently concentrated in two well-defined areas: interventional procedures and the use of mercaptoacetyltriglycine. The ongoing evaluation of mercaptoacetyltriglycine continues to be a source of interesting research activity, with the distribution volume and the extent of hepatic excretion remaining points of discussion. This tracer permits quantitative determination of renal function. As an imaging agent, mercaptoacetyltriglycine compares favorably with hippurate and with diethylenetriamine penta-acetic acid, particularly in evaluating renal insufficiency. Renal function studies obtained during pharmacologic or physiologic intervention dominate research in hypertension and obstructive uropathy. Angiotensin-converting enzyme inhibition improved the renographic detection of renovascular lesions. Interventional renography with angiotensin-converting enzyme inhibition or ergometric exercise were both capable of generating useful prognostic data on the posttherapy blood pressure response in patients with renovascular hypertension. Interventional diuretic renography with furosemide permits surgical intervention to be reserved for organs at immediate risk because the degree of obstruction and the extent of renal function compromise are easily recognized.
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PMID:Renal studies in nuclear medicine. 183 42

The goals in the treatment of hypertension have been outlined previously. The antihypertensive drugs should achieve as many of these criteria as possible. 1. Efficacious as monotherapy in more than 50% of all patients (demographics) 2. 24-hour blood pressure control during all activities 3. Once per day dosing 4. Hemodynamically logical and effective: reduces SVR, improves arterial compliance, preserves CO and maintains perfusion to all vital organs 5. Lack of tolerance or pseudotolerance: no reflex volume retention or stimulations of neurohumoral mechanisms 6. Favorable biochemical and metabolic effects 7. Reverses the structural, vascular smooth muscle, cardiac hypertrophy, LVH, and improves systemic and diastolic compliance, LV contractility and function, and reduces ventricular ectopy if present 8. Reduces all end-organ damage: cardiac, cerebrovascular, renal, retinal and large artery 9. Maintains normal hemodynamic response to aerobic and anerobic exercise 10. Low incidence of side effects and good quality of life 11. Good compliance with drug regimen 12. Good profile in concomitant diseases or problems The drugs that come closest to these characteristics include CCB, ACEI, CAA, and alpha blockers. All of these agents are effective as monotherapy and should be given as initial therapy to the maximum dose shown in Table 10 or until the advent of side effects, whichever occurs first. Combination therapy should be the next step, using the principal of go low, go slow, using additive or synergistic drug combinations. Therapy should be individualized using the subsets of hypertension approach: Diuretics in particular, especially high-dose diuretics, and BB to a lesser extent, should be reserved as second- or third-line drugs and used for specific indications and in the lowest dose possible to achieve clinical results. For example, diuretics would be reserved for volume overload states, systolic CHF, and volume-resistant hypertension. Beta blockers would be reserved for patients after a Q-wave myocardial infarction, those with obstructive angina, specific cardiac arrhythmias, and other like conditions. Long-term, prospective, clinical trials will be needed to confirm that CCB, ACEI, CAA, and alpha blockers reduce end-organ damage more effectively than diuretics, BB, direct vasodilators, and older antihypertensive drugs. Until then, one must rely on scientific evidence, discussed here, that strongly suggests that reduction in risk factors for end-organ damage will reduce the end-organ damage in heart, brain, kidney, and large arteries.
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PMID:Hypertension strategies for therapeutic intervention and prevention of end-organ damage. 194 95

Although dietary salt restriction is often valuable as sole or adjunctive therapy of hypertensive disorders, it is abundantly clear that hypertensive patients comprise a heterogeneous group with regard to salt sensitivity of blood pressure. This is apparent despite the many methodological obstacles to defining salt sensitivity in an individual patient. Currently, dietary trial is the only sure means of defining a given patient as responsive to salt restriction. Easily definable markers of salt sensitivity would allow appropriate targeting of this rather ponderous therapy. Promising leads include the assessment of membrane ion transporters such as sodium-lithium exchange and of the activity of the renin-angiotensin system, including the phenomenon of "non-modulating" hypertension and other volume regulatory hormones such as atrial natriuretic factor. Although less intensively studied than in hypertensive patients, the blood pressure response of normal subjects to salt restriction is also marked by great variability. Given the possibility of deleterious consequences of population-wide salt restriction for at least some people in a setting such as the United States, it seems imprudent to recommend such a policy before its proven worth has been demonstrated by clinical trial. Pending such evidence and the development of markers, salt restriction should be reserved for those in whom it is of demonstrated efficacy.
Hypertension 1991 Jan
PMID:Dietary salt and blood pressure. A perspective. 198 20

Pheochromocytoma is an unusual but potentially devastating tumor. Although a high index of suspicion is necessary, the likelihood of a pheochromocytoma is lower in the absence of the typical symptoms and findings. Nonetheless, screening must be broadened to include patients with a lower risk of the disease, such as those with resistant or labile hypertension who are minimally symptomatic. Extensive diagnostic evaluations should be reserved for those whose clinical or laboratory findings are more suggestive. Symptoms in a group of patients in whom a pheochromocytoma was seriously considered but excluded overlap symptoms in patients with a pheochromocytoma. Certain symptoms are useful: flushing to suggest a non-pheochromocytoma illness; visual symptoms, flank pain, and pallor to suggest that a pheochromocytoma is more likely. Combinations of symptoms can be of value: 2 or more symptoms from the triad of headache, palpitations, and diaphoresis were present in the majority of pheochromocytoma patients, but in a smaller number of non-pheochromocytoma patients. The presence of the entire triad is more specific, but less sensitive. New hypertension, or hypertension associated with unexplained orthostatic hypotension, are suggestive of an underlying pheochromocytoma. Twenty-four-hour urine studies are consistently abnormal in patients with a pheochromocytoma, but are also elevated in a significant proportion of non-pheochromocytoma patients. Values greater then 1.5-2-fold above the upper limit of normal are very suggestive that a pheochromocytoma is present, and warrant a more intensive subsequent evaluation. Imaging studies are reliable in the diagnosis of pheochromocytoma, and can help to confirm or exclude the disease. Patients with a higher clinical likelihood and any elevated urinary testing, or with a lower clinical likelihood and persistently and/or significantly elevated urinary testing, should have imaging studies performed. This combination of clinical screening, 24-hour urinary testing, and imaging studies is a useful and reliable approach to patients suspected of harboring a pheochromocytoma.
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PMID:A simplified diagnostic approach to pheochromocytoma. A review of the literature and report of one institution's experience. 198 66

Spontaneous hepatic rupture secondary to severe pregnancy-induced hypertension is associated with a high rate of maternal and fetal mortality. Numerous types of surgical management have been described, but a uniform surgical approach has not been accepted. The purpose of this review was to examine modes of surgical therapy reported in the literature since 1976, as well as the 11-year experience at our institution. Twenty-eight cases were extracted from the literature and seven more were identified at our institution. The incidence in our population was one per 45,145 live births. Among 27 cases managed by packing and drainage, an 82% overall survival was achieved, whereas only 25% of eight patients undergoing hepatic lobectomy survived (P = .006). Hepatic hemorrhage with persistent hypotension unresponsive to blood products should be managed by evacuating the hematoma, packing the damaged liver, and draining the operative site. More aggressive surgical techniques, such as hepatic artery ligation or hepatic lobectomy, should be reserved for refractory cases.
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PMID:Spontaneous rupture of liver during pregnancy: current therapy. 198 75

Women on regular dialysis are usually infertile, but contraception should not be neglected. Pregnancy is invariably complicated and poses excessive risks, with an uncertain and low chance of success. Even when therapeutic abortion is excluded, the live birth outcome at best is 19%. Renal transplantation usually reverses abnormal reproductive function and comprehensive pre-pregnancy counseling is essential, with discussion of all implications, including the harsh realities of long-term maternal survival. In this survey of 2,309 pregnancies in 1,594 women, therapeutic abortion was undertaken in 27% of conceptions and the spontaneous abortion rate was 13%. Of the conceptions that continued beyond the first trimester, 92% ended successfully. In most, renal function was augmented in pregnancy, with transient deterioration in late pregnancy (with or without proteinuria). Permanent renal impairment occurred in 15% of pregnancies. There was a 30% chance of developing hypertension, preeclampsia or both. Preterm delivery occurred in 50%, and intrauterine growth retardation in 25% of pregnancies. Despite its pelvic location, the transplanted kidney rarely produced dystocia and was not injured during vaginal delivery. Cesarean section should be reserved for obstetric reasons only. Neonatal complications include respiratory distress syndrome, leukopenia, thrombocytopenia, adrenocortical insufficiency, and infection. No predominant or frequent developmental abnormalities have been described and data on infancy and childhood are encouraging. For the future more work is needed to improve pre-pregnancy assessment criteria, to understand the mechanisms of gestational renal dysfunction and proteinuria, to assess the side effects and implications of immunosuppression in pregnancy, and to elucidate the remote effects of pregnancy on both renal prognosis and the offspring.
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PMID:Dialysis, transplantation, and pregnancy. 195 48

Severe hypertension developed secondary to renal artery stenosis in 11 of 229 children who received a renal allograft. Renal artery stenosis was suspected because of de novo development of hypertension or exacerbation of pre-existing hypertension, which was detected 1 to 24 months after transplantation. Selective renal angiography was performed 2 to 74 months after transplantation (mean 13 months). Follow-up was 1 to 8 years (mean 2.5 years). The stenosis involved the anastomosis in 5 patients and was distal to the anastomosis in 6. One graft had an arteriovenous malformation. Seven grafts were suitable for vessel dilation; percutaneous transluminal angioplasty was partially successful in 4 cases in which the stenosis occurred at the anastomosis. The remaining patients were treated with medical therapy alone and the grafts were not lost. Our findings suggest that strictures distal to the anastomosis rarely are amenable to percutaneous transluminal angioplasty and should be treated medically whenever possible. Strictures at the anastomosis respond to vessel dilation but antihypertensive medication also often is required. An operation should be reserved for patients who do not respond to these measures.
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PMID:Percutaneous transluminal angioplasty for transplant renal artery stenosis in children. 213 41

The diagnosis of atheromatous stenosis of the renal arteries has been greatly facilitated by the advances achieved in medical imaging: intravenous digital angiography, in particular, enables the renal arteries to be visualized in patients with progressive hypertension refractory to treatment and associated with renal impairment or symptomatic atheroma. However, the diagnosis of hypertension with renal stenosis is not synonymous with renovascular hypertension, the latter term being reserved to a disease that can be cured by a causal treatment. The diagnosis of imputation, inspired by experimental models, rests on exploration of the renal endocrine and excretory function upstream of the stenosis before and after blockade of the renin-angiotensin system by angiotensin-converting enzyme enzyme inhibitors. The exploration is made by urography, measurements of renin concentrations in the two renal veins and radioisotope scanning. The decision to operate or not is taken after comparing these renal data with such vascular data as influence of hypertension on the target organs and diffusion of the atheromatous disease to other territories. Treatment may be purely medical, but in most cases it includes a revascularization procedure, starting with transluminal dilatation: surgical revascularization is used only in difficult cases, in complete arterial obliteration and in failures of dilatation. Revascularization is not indicated when the stenosis has no systemic or local functional repercussions before or after blockade of the renin-angiotensin system.
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PMID:[Logical basis for the diagnosis of renovascular hypertension. Application to the treatment of atheromatous stenosis of the renal arteries]. 213 64

Left ventricular hypertrophy is a problem in itself in patients with hypertension. Hypertensives with left ventricular hypertrophy have a higher incidence of ventricular arrhythmias and sudden death. This article reviews the epidemiological evidence in favour of this association. Although the mechanism of ventricular arrhythmias in patients with left ventricular hypertrophy in unclear, several hypotheses have been suggested including cellular electrophysiological changes, alterations of the myocardial tissue and silent myocardial ischemia. The management of ventricular arrhythmias in hypertensive patients implies an effort to prevent left ventricular hypertrophy by early and aggressive treatment and a judicious choice of antihypertensive agents capable of reducing left ventricular hypertrophy. It is also important to avoid hypokalemia and other electrolytic disorders. Antiarrhythmic drugs should be reserved for symptomatic patients who do not respond to other preventive measures.
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PMID:[Ventricular arrhythmia in patients with hypertension and left ventricular hypertrophy]. 215 Apr 75

To further characterize the incidence and morbidity of recurrent carotid stenosis, we reviewed 184 consecutive carotid endarterectomies performed in a university hospital between August 1983 and January 1988, in patients followed after operation with serial duplex ultrasonography. Recurrent stenosis of greater than 50% diameter reduction developed in eleven arteries (6.0%) at a mean interval of 10.2 +/- 7.8 months. Three of the eleven (1.6% of the total) had associated transient ischemic attack, and none had strokes. Restenosis was significantly more frequent in diabetic patients than in nondiabetic patients (13.3% vs 4.5%; p less than 0.05); and among patients whose primary stenoses had been symptomatic compared to asymptomatic (11.0% vs 1.5%; p less than 0.02). No statistically significant association with restenosis could be established for gender, hypertension, or smoking. Completion angiography and/or Doppler spectral analysis had been performed, and results were normal at the primary operation in 10 of the 11 patients. Only six of 184 arteries (3.3%) had vein patch closure, but none of these restenosed. Uneventful reoperation with patch closure was performed in three patients with transient ischemic attacks and two with preocclusive restenoses. Lesions were myointimal hyperplasia in four and atheroma in one. Three of the unoperated restenoses have shown regression on duplex scanning, but a fourth progressed to asymptomatic occlusion. Carotid restenosis is uncommon, even without routine use of vein patch angioplasty. Reoperation should be reserved for patients with associated symptoms or greater than 80% restenosis.
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PMID:A rational approach to recurrent carotid stenosis. 218 14


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