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

Because of their efficacy and ease of use, oral contraceptives (OCs) have become the most widespread contraceptive in France and the world. OCs also have the advantages of reversibility and increasing safety and innocuity due to lower doses of ethinyl estradiol (EE) and improved progestins. The contraceptive effect of OCs depends primarily on suppression of ovulation, endometrial atrophy, and modifications in the cervical mucus rendering it inhospitable to sperm. The three major types of OCs are combined pills of either standard or low dose, sequential pills, and low-dose progestins. Higher dose progestins may also be used for contraception but they are usually reserved for treatment of uterine and mammary pathology. Standard-dose combined OCs contain 50 mcg of EE, while low-dose formulations contain 20-40 mcg. Combined pills are monophasic, biphasic, or triphasic. The advantages of combined OCs are their great efficacy and antigonadotropic power, which allows total steroid doses to be reduced. They may however cause cycle problems due to endometrial atrophy. The long-term administration of EE alone for the first cycle phase with sequential pills has been shown to increase risks of breast disorders, endometrial dysplasia and uterine cancer. Sequential pills are now used only for short-term treatment in specific indications. Low-dose progestins provide a low and continuous dose of progestin. Ovulation is not always inhibited, and persisting secretion of LH and FSH involves some follicular maturation. Contraceptive efficacy relies solely on local effects on the cervical mucus, endometrial atrophy, and decreased tubal motility. The failure rate and incidence of ectopic pregnancy are higher and cycle problems are frequent. The only advantage is the absence of estrogen for women with contraindications. The side effects of combined OCs may include alterations of glucose tolerance and of lipid profiles, increases of blood pressure, modifications in coagulation factors leading to increased thromboembolic risk proportional to the estrogen dose, and increased risk of biliary lithiasis and certain types of jaundice. Combined OCs have not been formally proven to increase risk of cervical cancer, and they are known to have protective effects against ovarian tumors. Most adolescents tolerate standard-dose combined OCs quite well. Low-dose combined pills or high-dose progestins may be appropriate for women over 40. Combined OCs are contraindicated in cases of hypertension, although low-dose progestins may be prescribed. Combined OCs are contraindicated for many diabetics and in all cases of hyperlipidemia and in smokers over 35.
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PMID:[Oral contraception]. 827 87

There is considerable evidence to suggest that the identification and treatment of dyslipidaemia will reduce the risk of premature CHD, i.e. before the age of 65. Diagnosis of the cause of raised plasma lipid levels will enable appropriate decisions to be taken with regard to management. The cornerstone of treatment is nutritional counselling and attention to other major risk factors for CHD, particularly smoking and hypertension. For a small percentage of patients with severe hyperlipidaemia drug therapy is indicated. Appropriate drug choices need to be made based on the particular lipid abnormality to be treated. In general those patients with clinical vascular disease are treated more aggressively than those where the aim is primary prevention. More research is needed to determine individual risk more precisely and to allow proper targeting of therapy. Genetic factors, qualitative changes in lipoproteins, lipoprotein (a), fibrinogen, and other coagulation and thrombotic factors are likely to be important in individual risk assessment. There is no doubt that more information is needed from prospective studies of lipid-lowering therapy in terms of risk benefit for affected individuals. Hopefully the major studies currently underway will fill some of the gaps in our knowledge. Until then aggressive therapy with drugs should be reserved for those at highest risk where the benefit is likely to be greatest.
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PMID:Management of hyperlipidaemia: guidelines of the British Hyperlipidaemia Association. 834 30

During the last decade, ambulatory blood pressure monitoring (ABPM) made a transition from a method reserved for clinical investigators to a technique considered useful by practicing physicians in assessing certain problems in hypertension. Recent recommendations of the National High Blood Pressure Education Program (NHBPEP) Working Group on Ambulatory Blood Pressure Monitoring suggested using ABPM for a number of clinical problems, including borderline hypertension without target organ damage, evaluation of drug resistance, and white-coat hypertension. We evaluated the clinical indications for ordering ABPM by Connecticut physicians both in hospital and community-based practices. Through specific questionnaires, the clinical indications used by referring physicians to order ABPM and their inclinations for future use of the methodology were assessed. Forty-seven of 70 physicians (65%) responded to the questionnaire, basing their answers on 237 patients. The majority of physicians were internists (57%) or cardiologists (25%). Leading indications for patient referral for ABPM included borderline hypertension (27%), assessment of drug therapy/BP control (25%), and possible white-coat hypertension (22%). Far fewer referrals were observed for severe hypertension or as a routine test for the diagnosis of hypertension. These data suggest that practicing physicians have become aware of the usefulness of ambulatory blood pressure recordings and are following the NHBPEP guidelines on referral for the study.
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PMID:Clinical usefulness of ambulatory blood pressure monitoring. 834 24

Therapy with angiotensin-converting enzyme (ACE) inhibitors was developed approximately 15 years ago as a novel therapeutic approach to hypertension. Although ACE inhibitor therapy was initially reserved for patients with severe hypertension, extensive clinical experience has broadened its use. These agents should now be considered as cornerstone therapy for patients with symptomatic heart failure and are of proved value in preventing the development of this syndrome. This article reviews the key studies that have documented the efficacy of ACE inhibitors in improving clinical outcome for patients with overt congestive heart failure, as well as for those with asymptomatic left ventricular dysfunction.
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PMID:Angiotensin-converting enzyme inhibition in congestive heart failure: benefit and perspective. 836 54

Questions persist about the management of postoperative chylothorax in infants and children. Our experience with postoperative chylothorax over the most recent decade (1980 to 1990) has been reviewed. The type and amount of drainage, data from cardiac catheterization and echocardiography, operative decisions and details, and eventual outcomes have been cataloged. All patients were initially treated with total gut rest, with operation reserved for unabated drainage. Chylothorax developed postoperatively in 15 infants and 11 children (18 with a cardiac procedure and 8 with a noncardiac procedure). The average age was 3.1 years. Spontaneous cessation and cure occurred in 19 (73.1%) of these 26 patients, with an average drainage duration of 11.9 days (range, 4 to 30 days). Those for whom operation was chosen drained preoperatively for an average of 29.2 days (range, 25 to 40 days). There were no deaths in either group. Complications were lymphopenia (2 patients) and fungal sepsis (1 patient). The amount of drainage per day was not significantly different between patients treated operatively and those treated nonoperatively. Failure of nonoperative management was associated with venous hypertension from increased right-sided cardiac pressures or central venous thrombosis (p < 0.05, Fisher's exact test). Presumably this increased pressure is transmitted to the lymphatic system. These patients should be identified early and considered for thoracic duct suture or pleuroperitoneal shunting.
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PMID:Management of pediatric postoperative chylothorax. 837 18

Severe neurologic illness and injury in children may occur in a wide range of clinical and environmental settings. The majority of children who sustain traumatic brain injury will achieve a good outcome if intensive care is directed toward preventing secondary injury. The most important aspect of care is ensuring adequate oxygenation, ventilation, and perfusion. Together with standard supportive care, the aggressive use of intraventricular pressure monitoring and CSF drainage to treat intracranial hypertension can attenuate or prevent continuing brain injury. Sustained hyperventilation, aggressive diuresis, hypothermia, and induction of barbiturate coma are reserved for children for whom the first tier of therapy is not effective.
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PMID:Critical care of children with acute brain injury. 854 Apr 36

Two pregnant patients presented with Takayasu's disease predominating in the major branches of the aorta. There was no extention below the diaphragm and no complications. One of the patients had Still's disease which is a predominantly cutaneous form without chronic arthritis. Both pregnancies were uneventful excepting dysgravidia in one case. Two eutrophic infants were born at term. The risk of Takayasu's arteritis associated with pregnancy, as reported in the literature, is mainly due to the consequences of arterial hypertension with pre-eclampsia (60%), heart failure and cerebral vascular events (5%). The major fetal risk is in utero death (2 to 5%), but intra-uterine growth retardation is more frequent (18%). The risk is greatest during the third trimester and during the perinatal period. Fetal involvement is greatest in sever cases and in those treated late. Prevention is based on the initial work-up to identify the disease and possible complications, programming pregnancies and increasing surveillance during periods of risk, defining the delivery route with cesarean section reserved for complications of arteritis (30%), and planned labour with instrumental extraction and epidural anaesthesia with control of the blood pressure. Still's disease has no particular consequence on pregnancy, although sequellae of chronic arthritis of the pelvis may have an impact on obstetrical technique. An association with Takayasu's disease is rare with only one case being reported in the literature; aetiopathology remains unknown.
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PMID:[Association of Takayasu's arteritis, pregnancy and Still's disease]. 856 84

The goal of the treatment of hypertension is to reduce the risk of the cardiovascular complications--stroke, acute myocardial infarction, congestive heart failure and renal dysfunction--not just to lower an elevated blood pressure. There are no completed large long-term clinical trials of calcium antagonists--short-acting or long-acting--designed to assess their efficacy and safety in patients with hypertension. Two smaller trials of dihydropyridines have suggested that despite blood pressure control, there may be a paradoxical increase in cardiovascular complications. These adverse effects are similar to those reported from clinical trials of short-acting calcium antagonists in coronary patients. Due to concerns about their long-term safety, inadequate documentation of their long-term efficacy and their high cost, calcium antagonists should be reserved as third-line agents. If prescribed, they should be given in low doses, possibly in combination with another antihypertensive agent. Their use should be limited to patients who cannot tolerate the other proven agents such as diuretics and beta-blockers, and to those who are not controlled on these agents or those with relative or absolute contraindication to them.
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PMID:Should calcium antagonists be first line drugs in hypertension? 858 96

Ischemic nephropathy is defined as hypertension and a defect in renal function and/or loss of renal parenchyma caused by hemodynamic changes secondary to a renal artery stenosis. A work-up should be reserved for those patients considered candidates for intervention with percutaneous transluminal renal angioplasty (PTRA) or reconstructive surgery in whom there is hypertension with clinical features suggestive of ischemic nephropathy and/or a significant size disparity between the kidneys. Therefore, all patients suspected of ischemic nephropathy should undergo a renal ultrasound examination to quantitate renal size and a test of overall renal function (creatinine clearance or DTPA plasma disappearance). The diagnostic accuracy of functional tests for renovascular hypertension can be seriously impaired in the presence of renal insufficiency, and they have not been evaluated systematically in this clinical setting. Therefore, tests are reserved for those patients in whom the clinical clues of ischemic nephropathy are equivocal. Available evidence suggests that angiotensin-converting enzyme inhibitor (ACEI)-induced changes in the Hippuran or Mag3 renogram are predictive of reversible renovascular hypertension in the presence of renal insufficiency. Duplex ultrasound scanning of the renal arteries is an accurate method to identify renal artery stenosis in experienced hands. However, there is no quantitative information to judge the utility of noninvasive tests in predicting which patients with ischemic nephropathy will have an improvement in renal function after intervention.
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PMID:Ischemic nephropathy: noninvasive testing. 872 85

Renovascular disease is a frequent cause of severe hypertension in children and may result in significant morbidity or mortality. Most children presenting with renovascular hypertension have few if any symptoms, but devastating neurologic injury and congestive heart failure are still too often observed. Several new radiographic techniques have been used to detect renovascular lesions, but none has yet demonstrated consistently superior results when compared with intra-arterial digital subtraction angiography. Renal venous renin sampling, duplex ultrasonography, and captopril-enhanced renal scintigraphy may be useful diagnostic adjuncts. Therapeutic objectives include cure of hypertension and restoration or preservation of renal function. At many institutions, percutaneous transluminal angioplasty has become the treatment of choice for patients with renal transplant artery stenosis and discrete, nonostial stenoses caused by fibromuscular dysplasia. More extensive lesions generally respond well to surgical correction. Chronic pharmacologic therapy is reserved for patients who do not respond to angioplasty or in cases in which the location or extent of involvement of the renal arterial system precludes surgical revascularization. Nephrectomy is usually reserved for kidneys that have minuscule function of irreparable vascular anomalies. An individualized approach to therapy is increasingly emphasized.
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PMID:Pediatric renovascular hypertension. 872 6


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