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Query: UMLS:C0038454 (stroke)
 147,016 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

The declining mortality due to coronary heart disease and stroke has been attributed in part to improved effectiveness and application of antihypertensive therapy and the successful identification and treatment of the population at risk. In striking contrast, end-stage renal disease (ESRD) attributed to hypertension has increased annually for the last decade and will probably worsen at least through the year 2000. Taken together, patients with diabetic nephropathy and patients with hypertensive renal disease account for the majority of new cases annually. The reasons for the striking dissociation between our success with coronary heart disease and stroke on the one hand and our inability to lessen the incidence of ESRD on the other remain to be clarified. Evidence reveals that all levels of untreated hypertension are associated with potentially declining renal function. Data from the Hypertension Detection and Follow-up Program and other studies suggest that antihypertensive treatment can prevent or retard development of progressive renal failure. Although the importance of blood pressure control is implicit, a theoretic framework based on data derived from experimental animal suggests that ACE-inhibitors and perhaps calcium antagonists may exert specific renoprotective effects beyond those achieved by blood pressure reduction per se. The results of recent long-term prospective studies are consistent with such a formulation. In view of the increasing importance of ACE-inhibitors and calcium antagonists in the antihypertensive armamentarium, additional prospective randomized studies are required to delineate further the effects of these agents on the progression of chronic renal insufficiency.
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PMID:Effects of ACE inhibitors and calcium antagonists on progression of chronic renal disease. 758 66

Patients with end-stage renal disease (ESRD) are known to have significantly reduced functional abilities, as measured by the Sickness Impact Profile (SIP). We investigated the clinical correlates with SIP scores in a cohort of patients with lesser degrees of renal dysfunction recruited from an academic general medicine practice (mean calculated creatinine clearance, 25 mL/min). Of 603 eligible patients with chronic renal insufficiency (CRI) defined as a serum creatinine greater than 1.5 mg/dL and a calculated creatinine clearance less than 50 mL/min on two occasions more than 6 months apart, 360 (60%) agreed to participate. These patients were primarily elderly (mean age, 69 years) black (83%), women (69.2%), with an average of 6 years of education and a household income of $400 to $800 per month; 92% had hypertension and 57% had diabetes. The SIP was administered in-home by trained interviewers. Independent variables included demographic data, education, income, and medications (via interviewers), vital signs taken by a renal nurse, and diagnostic test results and diagnoses from patient's computerized records. The total SIP score was the dependent variable, and its physical and psychosocial subscales were also investigated. Variables with univariate correlations with total SIP (P < 0.05) were included in a multiple regression analysis. All variables with a multivariable P value less than 0.10 were included in the final model. The mean SIP score was 24.5 +/- 15.6, higher than that found in patients on dialysis. Significant (P < 0.05) independent correlates with higher SIP scores (greater disability) were lower educational level and income, prior diagnoses of coronary artery disease and stroke, and lower serum albumin.(ABSTRACT TRUNCATED AT 250 WORDS)
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PMID:Clinical correlates of functional status in patients with chronic renal insufficiency. 843 Jun 76

Hypertension is common throughout the world and represents the single greatest risk factor for increasing cardiovascular mortality, cardiovascular morbidity and overall mortality. Diseases associated with hypertension are not only, in general, of a chronic disabling nature, but, in most instances, require frequent hospitalization, with expensive drug treatment and management. Stroke, coronary heart disease, congestive heart failure and chronic renal insufficiency represent the most commonly encountered corollaries of inadequately treated hypertension. Anti-hypertensive treatment is accompanied by a reduction of hypertension-related cardiovascular risk and a clearcut benefit in terms of reduced incidence of major cardiovascular complications of hypertension and overall mortality. This benefit has frequently been underestimated in many clinical trials. Attempts to improve the cost-benefit ratio have included the use of treatment strategies based upon 24-h control of blood pressure, since it has been demonstrated that hypertension-related end-organ damage correlates more closely with 24-h average blood pressure and with 24-h blood pressure variability than with blood pressure measured in the clinic. It is hoped that new anti-hypertensive agents, which smoothly reduce 24-h blood pressure profile, will further reduce the incidence of hypertension-related end-organ damage.
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PMID:Benefit and costs of anti-hypertensive treatment. 873 98

We evaluated the effect of chronic renal insufficiency (CRI) and commonly associated co-morbid conditions on the risk of adverse events (stroke, cardiac events, and death) within 30 days after carotid endarterectomy (CEA). Renal function of patients undergoing CEA from 1980 to 1994 was categorized as normal (creatinine < 1.5 mg/dl), mild CRI (creatinine 1.5-2.9 mg/dl), or severe CRI (creatinine > 2.9 mg/dl). Renal function, age, gender, indications for surgery, cardiac disease, chronic preoperative hypertension, diabetes mellitus, smoking history, severe perioperative hypertension or hypotension, intraoperative shunting, and patch closure of the carotid artery were evaluated for their influence on the incidence of adverse events within 30 days after surgery. The timing of postoperative stroke and mechanism of stroke was determined when possible. A total of 237 patients underwent 285 CEAs. No significant differences were found in demographic or clinical characteristics between patients with normal or abnormal renal function. Postoperative stroke and death occurred following three (43%) of seven CEAs in six patients with severe CRI, significantly greater than the 6% incidence of stroke and 1% mortality following 264 CEAs in 221 patients with normal renal function (p < 0.001 and p < 0.001, respectively). Of three patients with severe CRI suffering postoperative stroke, two had severe, difficult to control perioperative hypertension. Two patients with severe CRI who survived 30 days after operation suffered strokes 3 and 4 months postoperatively with one stroke-related death and another death not directly related to the stroke. One patient with severe CRI who survived CEA without stroke was alive 6 months after surgery. The 0% incidence of stroke and death following 14 CEAs in 10 patients with mild CRI was not significantly different from that in patients with normal renal function. Postoperative stroke was not associated with age, gender, history of cardiac disease, chronic preoperative hypertension, diabetes, smoking, or use of intraoperative shunts or patch closure. All three cardiac events occurred in diabetic patients, although they constituted only 26% of operations (p = 0.003). Other clinical characteristics were not associated with the occurrence of cardiac events. Patients with severe CRI are at significantly greater risk than others for postoperative stroke and death following CEA, possibly related to difficulty controlling severe perioperative hypertension. Age, gender, smoking, preoperative hypertension, diabetes, and known cardiac disease are not associated with an increased risk of postoperative stroke in any patient group. CEA can be justified only for carefully selected patients with severe CRI who have symptomatic carotid disease, acceptable operative risk factors, and a good long-term life expectancy. CEA in patients with mild CRI is associated with low risk, and these patients may be treated with the same consideration as patients with normal renal function.
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PMID:Is carotid endarterectomy justified in patients with severe chronic renal insufficiency? 918 64

Fosinopril is the prodrug of the active diacid ACE inhibitor fosinoprilat. In patients with heart failure, fosinopril reduces pulmonary capillary wedge pressure, mean arterial blood pressure, mean right atrial pressure and heart rate, and increases stroke volume index and cardiac index. The drug has compensatory dual elimination routes via renal and hepatic systems and accumulates to a lesser extent than enalapril and lisinopril in patients with chronic renal insufficiency with or without heart failure. Comparative studies of 3 or 6 months' duration with fosinopril 10 to 40 mg/day have demonstrated clinical efficacy significantly superior to that of placebo in patients with heart failure [mostly New York Heart Association (NYHA) functional class II or III]. Fosinopril treatment consistently increased exercise duration and improved heart failure symptoms in these patients. Significantly fewer fosinopril than placebo recipients withdrew or were hospitalised because of worsening heart failure. Additionally, significantly more fosinopril than placebo recipients showed improvement, and fewer patients had deteriorated, in terms of NYHA functional class. Fosinopril and enalapril showed similar clinical efficacy over 6 and 12 months' treatment in patients with NYHA functional class II to IV heart failure. As yet, there are no data showing a mortality benefit with fosinopril. Fosinopril was well tolerated in clinical trials in patients with heart failure. Dizziness (11.9 vs 5.4% for placebo), cough (9.7 vs 5.1%) and hypotension (4.4 vs 0.8%) were the most commonly reported adverse events. In 6- or 12-month comparative studies, fosinopril therapy was associated with a lower incidence of dizziness and hypotension, but a higher incidence of vertigo, than enalapril therapy. 0.8% of patients discontinued the drug because of cough, which occurred to a similar extent with fosinopril and enalapril. Thus, based on available clinical evidence, fosinopril is an effective and well tolerated option for the management of patients with heart failure. Although clinical data are limited, fosinopril may be especially useful in patients with renal or hepatic impairment.
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PMID:Fosinopril. A review of its pharmacology and clinical efficacy in the management of heart failure. 921 Oct 84

Women and minorities were underrepresented in trials demonstrating carotid endarterectomy (CEA) is superior to medical treatment for significant carotid stenosis. These trials also revealed that the benefit of CEA is largely determined by the incidence of operative complications. Our series of 429 CEAs reflects a more diverse population (41% women, 24% blacks). We questioned if outcome was related to race, gender or other factors. Stroke occurred after 4.9 per cent of operations, cardiac events after 3 per cent, and death after 2 per cent. No factors correlated with cardiac events. Diabetes, smoking, neurologic symptoms, shunting, and patch closure did not correlate with complications. Chronic renal insufficiency (CRI), emergent operation, and operation by neurosurgeons correlated with stroke. Black females (BF) had significantly more strokes than did others (16% versus 3%). More BF had CRI, but their higher complication rate persisted when CRI patients were excluded. More BF were hypertensive (98% versus 74%), but hypertension did not correlate with complications. However, severe acute perioperative hypertension was common in BF experiencing complications and may be related to the differences observed. These findings highlight the need for better understanding of racial and gender outcome differences after CEA in order to improve risks and allow modification of selection criteria for high risk groups.
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PMID:Racial and gender differences in outcome after carotid endarterectomy. 961 73

Chronic renal insufficiency (CRI) is often associated with cardiovascular disease; however, its underlying mechanisms are not completely understood. Therefore, in the present study, myocardial functions and metabolic changes were investigated using an animal model of CRI in subtotally nephrectomized rats. In addition, some other parameters, considered risk factors of cardiovascular diseases, were determined. Subtotal nephrectomy led to an elevation in blood pressure (144 +/- 2.8 vs 114 +/- 2.5 mm Hg), left ventricular hypertrophy (290 +/- 12 vs 200 +/- 40 mg/100 g b.w.), hypertriglyceridaemia (2.96 +/- 0.31 vs 0.77 +/- 0.07 mmol/l), and impaired glucose tolerance (AUC 836 +/- 12.4 vs 804 +/- 10.4 mmol x l(-1) x 120 min). Isolated perfused hearts of uraemic rats exhibited diminished basal functions (coronary and aortic flow, stroke volume) by 20-30% compared with the controls. Interestingly, the tolerance of isolated heart to global 20-min no-flow ischaemia was improved in uraemic rats. The most marked differences in heart function recovery during reperfusion concerned aortic flow (90 +/- 2.3 vs 66 +/- 10%) and stroke volume (97 +/- 2.7 vs 68 +/- 5.6% of pre-ischaemic values). Pre-ischaemic myocardial glycogen content was distinctly increased (by 50%) in uraemic rats compared with the controls.
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PMID:Effect of chronic renal insufficiency on the function and metabolic parameters of the isolated rat heart. 973 48

An elevated total homocysteine (tHcy) plasma concentration is associated with increased morbidity and mortality due to cardiovascular disease in the general population and in patients with impaired renal function. The prevalence of hyperhomocysteinaemia (plasma levels above 15 micromol/l) in the general population is less than 5% and can be as high as 50% in patients with vascular disease. In patients with renal insufficiency, elevated tHcy plasma levels are detected in 50 - 100% of the patients. Total homocysteine plasma levels can be lowered or normalised by folic acid and/or vitamin B(6) and vitamin B(12) supplementation. In patients with advanced chronic renal insufficiency or end-stage renal disease, hyperhomocysteinaemia is partially resistant to folic acid or vitamin therapy. However, higher tHcy plasma levels may also reflect tissue damage and the increase in Hcy after an acute incident such as stroke or myocardial infarction may be necessary for tissue repair mechanisms. This implies, that lowering tHcy may even be harmful to some patients. Currently, prospective studies are underway to clarify whether folate supplementation, with or without additional other vitamins, improves cardiovascular disease morbidity and mortality in the general population, as well as in renal failure patients. While population-wide screening for and treatment of hyperhomocysteinaemia is generally not recommended, treatment of high risk patients may be considered.
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PMID:Therapeutic potential of total homocysteine-lowering drugs on cardiovascular disease. 1106 Aug 26

The number of patients who needs for dialysis therapy is increasing rapidly among the older population. Although control of hypertension can delay or arrest the progression of renal failure, there are lacking of studies about antihypertensive treatment of chronic renal failure in the elderly. We have studied the effects of treating hypertension with a calcium antagonist, benidipine, on renal function and blood pressure in 58 patients (mean age: 71 +/- 9) with hypertension and chronic renal insufficiency (the levels of creatinine ranging from 1.5 to 4.0 mg/dl). The underlying disease included glomerulopathies (in 33), diabetic nephropathy (in 15), and other causes (in 10). Forty two patients who had been treated with other antihypertensive drugs other than angiotensin converting enzyme (ACE) inhibitors, antihypertensive drugs were withdrawn 2 weeks before the entry. At the entry, patients should have sitting systolic blood pressure (SBP) of above 160 mmHg and diastolic blood pressure (DBP) of above 90 mmHg. In total, both SBP and DBP decreased from 169/95+/-12.5/8.9 to 148/81+/-16.1/8.0 mmHg (p<0.001) with remaining the serum creatinine levels from 2.2+/-0.8 vs 2.4+/-1.3 mg/dl (P>0.05). Retrospective analysis revealed that in 4 of 4 patients treated with benidipine and 2 of 3 patients with benidipine and ACE inhibitors with systolic blood pressure more than 160 mmHg at the end of the study, the levels of serum creatinine increased from 2.5+/-0.3 to 2.8+/-0.4 with significance (P<0.05). If systolic blood pressure was reduced less than 159 mmHg, 38 of 48 patients did not show any deterioration of renal function. Compared to the significance of SBP in preserving renal function, DBP did not associate with the changes in renal function. No patients died during the study. One patient had transient ischemic attack and one patient had stroke in benidipine treated group. One patient had angina pectoris in benidipine-ACE inhibitors treated group. The results of our trial seem to give some support for the idea that long-acting calcium antagonists such as benidipine are renoprotective through reduction of SBP in the elderly people with hypertension and chronic renal insufficiency. However, if systolic blood pressure was not reduced below 160 mmHg throughout a year, the substantial declines in renal function would be expected.
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PMID:Effects of calcium antagonist, benidipine, on the progression of chronic renal failure in the elderly: a 1-year follow-up. 1133 86

A large cohort of patients with Fabry disease is being studied to determine the natural history of the disease and how this relates to the specific mutation involved and the amount of residual alpha-galactosidase A activity. To date, we have investigated the progression of cerebral lesions and stroke, as identified by magnetic resonance imaging, and renal disease. Results have shown that cerebral lesions do not appear until 23 years of age, but are present in all patients by 55 years of age. The peak onset of proteinuria occurred in the fourth decade, and the peak onset of chronic renal insufficiency and end-stage renal disease occurred in the fifth decade of life. Renal outcome was related to the type of mutation and residual enzyme activity. Data from these studies in untreated patients will be important when assessing the long-term efficacy of enzyme replacement therapy.
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PMID:Natural history of Fabry disease in males: preliminary observations. 1175 74


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