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Hypertension is quite common in the elderly population. Isolated systolic hypertension and diastolic hypertension are associated with cardiovascular complications. Like younger patients, the elderly may have labile hypertension. On the other hand, pseudohypertension, auscultatory gap, and postural hypotension are peculiar to the elderly. Obesity, atherosclerosis, arteriosclerosis, baroreceptor insensitivity, decline in renal function, physical inactivity, and insomnia are factors that can lead to or aggravate hypertension in older patients. Secondary hypertension should be suspected if elevated blood pressure first appears late in life or becomes resistant to previously adequate treatment. Spontaneous hypokalemia can indicate primary aldosteronism. Elevation in the serum creatinine level of a patient taking an angiotensin-converting enzyme (ACE) inhibitor suggests bilateral renovascular hypertension. The goal of antihypertensive therapy is to prevent morbidity, disability, and death from complications and to maintain quality of life. Psychosocial factors may play an important role in controlling hypertension. Nonpharmacologic treatment, such as weight loss, salt restriction, and exercise, should always be tried prior to and in conjunction with medical therapy. Antihypertensive drugs often cause side effects and should be prescribed with caution. Always start with a low dose and gradually increase it if necessary. All drugs that reduce blood pressure in the younger individual also work in the elderly. ACE inhibitors and calcium blockers are particularly useful because of their low incidence of adverse effects.
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PMID:Hypertension in elderly patients. The special concerns in this growing population. 154 24

Metabolic disturbances such as hyperinsulinaemia, dislipoproteinaemia and glucose intolerance are often associated with essential hypertension and markedly affect cardiovascular morbidity in hypertensive patients. In order to shed some light on the prognostic significance of white coat hypertension (raised clinic and normal ambulatory blood pressure), we compared the metabolic profile in a group of white coat and sustained previously untreated hypertensives. We studied 84 newly detected hypertensive patients (49 men, 35 women, 47 +/- 8 years, range 28-59 years). Subjects with obesity (BMI > 30), NIDDM and target organ damage were excluded. Ambulatory blood pressure monitoring was performed by SpaceLabs 90207-31. Total cholesterol and triglycerides, LDL-cholesterol, HDL-cholesterol (HDL-C) and subclasses HDL2 and HDL3 cholesterol as well as apolipoprotein A1 and B were measured in fasting plasma. Glucose and insulin were determined in fasting and postload (glucose 75 g plasma. Twenty patients (24%, 8 men and 12 women) were classified as white coat hypertensives. No differences in age, BMI and waist to hip ratio were observed between white coat and sustained hypertensive patients. Plasma glucose and lipoprotein levels were similar in the two groups. Fasting and postload insulin levels were significantly lower in white coat hypertensives (fasting insulin 7.1 +/- 2.9 vs. 12 +/- 8.6 microU/ml, P < 0.02; insulin 120 minutes 48 +/- 27 vs. 65 +/- 41 microU/ml, P < 0.05); glucose/insulin rate was higher in white coat than in sustained hypertensive patients (15 +/- 7 vs. 11 +/- 7, P = 0.03).(ABSTRACT TRUNCATED AT 250 WORDS)
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PMID:Metabolic risk factors in white coat hypertensives. 793 8

More women than men eventually develop hypertension in the United States due to their higher numbers and longer longevity. The white coat hypertension is also more common in women. Alcohol, obesity and oral contraceptives are important causes of rise in blood pressure among women. On the other hand, hormone replacement therapy may decrease cardiovascular mortality in the postmenopausal woman. Women with left ventricular hypertrophy are at a greater risk of death than men. Fibromuscular hyperplasia and primary aldosteronism are more common as causes of secondary hypertension in women. Nonpharmacologic therapy, such as weight reduction, exercise, salt and alcohol reduction, should always be tried prior to medical treatment of hypertension and are very useful adjunctive measures in controlling hypertension. ACE inhibitors and angiotensin receptor blockers are contraindicated in pregnancy and should be avoided in women with childbearing potential. Hypertension remains a major public health problem among black women. Although the antihypertensive drug therapy seems to benefit white women the least, proportionately more of them comply with their antihypertensive therapy. Hypertension is the most common chronic medical condition requiring visits to the physicians, as well as prescription medications, in the United States. The epidemiology, clinical course, response to treatment and ultimate outcome of essential hypertension may vary with gender. More women than men eventually develop hypertension in the US due to their higher numbers and longer longevity.
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PMID:Hypertension in women. 1092 86

The purpose of the present study was to determine the relationship between body mass index (BMI) and parameters derived from 24-hour ambulatory blood pressure monitoring including mean 24-hour daytime and nighttime systolic and diastolic blood pressures, 24-hour daytime and nighttime pulse pressure, mean 24-hour daytime and nighttime heart rate, dipping and nondipping status. 3216 outpatient subjects who visited our hypertension center and were never treated with antihypertensive medication underwent 24-hour blood pressure monitoring. BMI was significantly correlated with clinic systolic and diastolic blood pressures. Significant correlations were also found between BMI and mean 24-hour daytime and nighttime systolic blood pressure, 24-hour daytime and nighttime pulse pressure, and mean 24-hour daytime and nighttime heart rate. In multivariate regression analysis, clinic systolic, diastolic blood pressure, mean 24-hour systolic blood pressure, 24-hour pulse pressure, and high-density lipoprotein were independently correlated with BMI. The incidence of white coat hypertension was higher in overweight and obese patients than in normal weight subjects. Confirmed ambulatory blood pressure hypertension was also found to be higher in overweight and obese individuals compared with normal weight subjects. Our data also highlight the higher incidence of nondipping status in obesity. These findings suggest that obese patients had increased ambulatory blood pressure parameters and altered circadian blood pressure rhythm with increased prevalence of nondipping status.
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PMID:Impact of obesity on 24-hour ambulatory blood pressure and hypertension. 1595 6

The incidence of resistant hypertension remains to be clarified. In this article, three categories of resistance are distinguished: resistant patient, resistant clinician and refractory hypertension. Inadequate compliance, which in case of antihypertensive treatment means taking fewer doses of medications than prescribed, remains a significant cause of poor blood pressure control. Among most frequent physician-related causes of resistant hypertension, there are measurement errors, pseudohypertension, white coat hypertension and therapy errors. Careful elimination of patient- and physician-related reasons of inadequate blood pressure control should lead to the diagnosis of truly resistant hypertension. One of the causes of refractory hypertension may be concomitant use of other medications that are known to reduce antihypertensive effect of main drugs. Resistance may be associated with increased intravascular volume or fluid overload or with sympathetic activation. Modifiable contributing factors responsible for resistant hypertension include obesity often coexisting with insulin resistance and metabolic syndrome as well as excessive alcohol use and cigarette smoking. Another potential cause of refractory hypertension is the presence of secondary hypertension. Certain therapeutic modifications are essential in resistant hypertension.
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PMID:Resistant hypertension. 1642 42

Prevalence of pediatric hypertension has increased with the onset of obesity epidemic. Early detection and treatment of childhood hypertension is important due to its link with atherosclerosis in adult life. Accurate measurement of blood pressure is the key for the management and physicians should make effort to rule out the possibility of anxiety associated and white coat hypertension before the final diagnosis of hypertension. Secondary hypertension is more common in children as compared to adults but essential hypertension is also common in older children and adolescents. The younger children with severe hypertension are more likely to have secondary hypertension. Non-pharmacologic treatment should be tried before instituting the pharmacologic treatment, unless patient is symptomatic and has severe hypertension.
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PMID:Management of childhood hypertension: a guide for primary care physicians. 1719 Apr 13

Resistant hypertension is defined as failure to achieve goal blood pressure despite adherence to 3 different antihypertensive medications, one of which must be a diuretic. True resistant hypertension must be distinguished by apparent resistant hypertension, of which an important cause is medication nonadherence, which can be recognized through a variety of monitoring strategies and may be improved through better patient education. A thorough history and examination should focus on evaluating for associated factors such as medication and illicit drug use, alcoholism, obesity, and obstructive sleep apnea. Further evaluation to differentiate apparent resistant hypertension from true resistant hypertension should include consideration of ambulatory blood pressure monitoring to rule out white coat hypertension. Routine laboratory work will reveal chronic kidney disease, which is the most common associated factor in resistant hypertension. Secondary or identifiable causes of resistant hypertension include primary aldosteronism, renovascular disease, and pheochromocytoma. Diagnostic evaluation for identifiable causes should be tailored for each patient and guided by signs and symptoms, as well as risks and benefits.
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PMID:Clinical characteristics of resistant hypertension: the importance of compliance and the role of diagnostic evaluation in delineating pathogenesis. 1721 49

Identification and treatment of hypertension should be an important focus of physicians caring for children. Ultimately, a link between hypertension in children and the risk of cardiovascular disease will be established. Further long-term studies are likely to show that morbidity and mortality will be decreased by the institution of treatment of hypertension in children. Additional risk factors such as obesity and lipid disorders should be sought and targeted for treatment as well. Lifestyle modifications are advised for all patients and can be tried solely for those with blood pressures between the 95th and 99th percentiles. Drug therapy is indicated in children with blood pressures greater than the 99th percentile, secondary hypertension, coexisting diabetes, left ventricular hypertrophy, or those who fail a trial of nonpharmacologic treatment. Children with white coat hypertension should not be treated with drugs. Children with renal artery stenosis and drug-refractory hypertension should be considered for percutaneous angioplasty or surgery depending on the anatomy of the lesion and operator experience. Children requiring multiple drug classes for control of blood pressure and older adolescents on one drug with renal artery lesions amenable to a percutaneous procedure may elect intervention in an attempt to reduce or eliminate drug therapy. Infants and children with hypertension due to native coarctation of the aorta should undergo surgical repair. Older children and adolescents with native coarctation should have surgical repair or percutaneous angioplasty/stenting. Hypertension secondary to recurrent coarctation is usually treated with a percutaneous intervention.
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PMID:Management of systemic hypertension in children and adolescents: an update. 1789 67

The aim of the present study was to determine if there is any association between white coat hypertension (WCH) and body mass index. The study was performed in two phases. In the first phase, we studied consecutive underweight patients, while in the second phase, age-matched consecutive normal weight, overweight, and obese cases were studied. Although we detected 61 cases in the underweight group with a mean age of 24.1 years, we could only detect 12 age-matched cases in the obesity group, and thus the obesity group was not used for comparison. When we looked at the prevalences of sustained normotension (NT), WCH, and HT in the groups, there were gradual and significant increases in the prevalences of WCH in addition to the gradual and significant decreases in the sustained NT from the underweight towards the normal weight and overweight groups. Eventually, only 31.5% of the overweight group had sustained NT, even though the mean age of the cases was very young. Due to the gradually increased prevalence of WCH from the underweight towards the normal weight and overweight groups, parallel to the already known increasing prevalences of HT, type 2 diabetes mellitus, hyperbetalipoproteinemia, dyslipidemia, and coronary heart disease and the very low prevalence of sustained NT among the overweight cases even in the early decades here, WCH should preferentially be accepted as an alarming sign of excess weight and many associated disorders in the future, rather than just being considered a predisposing factor of HT or atherosclerosis alone.
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PMID:Prevalence of white coat hypertension in underweight and overweight subjects. 1799 70

The prognostic significance of white coat hypertension (WCH) remains controversial. Consecutive patients (955 cases, 566 females) aged between 15 and 70 years were divided into 3 groups, those with sustained normotension (NT), WCH, and hypertension (HT), and the prevalences of obesity, impaired glucose tolerance (IGT) or type 2 diabetes mellitus (DM), coronary heart disease (CHD), and dyslipidemia were compared among the groups. Although the prevalences of all of the disorders showed significant progression from the sustained NT group towards the WCH and HT groups, the prevalence of dyslipidemia was significantly higher in the WCH group (P < 0.05 for all). Due to the gradually increased prevalences of obesity, IGT or DM, and CHD from the sustained NT group towards the WCH and HT groups and the highest prevalence of dyslipidemia in the WCH group, WCH should preferentially be accepted as an alarming sign of a deterioration in health rather than being a predisposing factor of HT or atherosclerosis alone. The significantly higher prevalence of dyslipidemia in the WCH group than in the HT group may be explained by the increased amount of adipose tissue in the HT cases, since the prevalence of obesity was the highest in the HT group. Thus, the high prevalence of WCH even in early decades may represent increased susceptibility to future weight gain, and dyslipidemia in patients with WCH may be a preliminary sign of obesity. Therefore, the management of WCH should focus on the prevention of dyslipidemia and excess weight gain.
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PMID:What is the relationship between white coat hypertension and dyslipidemia? 1836 67


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