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 147,016 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

The spectrum of disorders associated with an elevated blood pressure (BP) encompasses chronic uncomplicated hypertension and the hypertensive crises, including hypertensive urgencies and emergencies. Although these syndromes vary widely in their presentations, clinical courses, and outcomes they share pathophysiologic mechanisms and, consequently, therapeutic responses to specifically targeted antihypertensive drug types. Nevertheless, hypertensive crises are often treated with drugs which, in that setting are either unsafe or are of unsubstantiated efficacy. The purpose of this review is to examine the pathophysiology of commonly encountered hypertensive crises, including stroke, hypertensive encephalopathy, aortic dissection, acute pulmonary edema, and preeclampsia-eclampsia and to provide a rational approach to their treatment based upon relevant pathophysiologic and pharmacologic principles. Measurement of plasma renin activity (PRA) level often provides insight regarding pathophysiology and predicts efficacy of antihypertensive treatments in the individual patient. However, in hypertensive crises, drug therapy is initiated before the PRA level is known. Nevertheless, the renin-angiotensin dependence (R-type) or volume dependence (V-type) of hypertension can often be deduced by the BP response to drugs that interrupt the renin system (R-drugs) or that decrease body volume (V-drugs). Based upon these considerations, a treatment algorithm is provided to guide drug selection in patients presenting with a hypertensive crisis.
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PMID:Management of hypertensive crises: the scientific basis for treatment decisions. 1172 16

It is well-known that patients with terminal renal insufficiency are at increased risk for a future cardiovascular event. A relevant relationship also appears to apply to the early stages of renal insufficiency. The HOPE study has shown that the incidence of myocardial infarction, apoplexy and cardiovascular mortality in patients with incipient renal insufficiency is significantly raised. The study also found that the incidence of cardiovascular events is in direct proportion to the level of serum creatinine. Against this background, patients at risk can be readily identified. The HOPE study documents a considerable cardiovascular risk for patients with incipient renal insufficiency and concomitant uncomplicated hypertension, atherosclerosis or diabetes. In view of this, the use of ACE inhibitors in patients with moderate renal insufficiency should now be introduced. In the HOPE subjects, ramipril was found not only to lower the cardiovascular risk, but also to improve renal insufficiency.
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PMID:[Renal failure and cardiovascular risk. Increased borderline serum creatinine--a warning sign?]. 1177 Mar 72

Diuretics and beta-blockers are presently recommended as first-line therapy for the treatment of uncomplicated hypertension. JNC VII will probably consider ACE inhibitors worthy of this recommendation. In those at high risk for CHD or CHF, the initial use of an alpha-blocker or calcium antagonist will be recommended with caution. In those with systolic hypertension, who remain at increased risk of stroke, the initial use of CCB therapy continues to be supported by trial-based evidence. A diuretic, based on outcome-based trials, should be included in most regimens to lower the risk of ischemic stroke. Since most patients will require two or more drugs to control their blood pressure, the initial agent chosen will assume less importance for the practicing physician.
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PMID:Hypertension 2001: pearls for the clinician. 1178 Jun 73

Over the past decade, national and international guidelines have proposed beta-blockers to be used on an equal footing with diuretics for initial therapy of hypertension. This preferred status was supposedly based on evidence documenting a reduction in morbidity and mortality with beta-blocker therapy in hypertension. We systematically analyzed all available outcome studies and found no evidence that beta-blocker based therapy, despite lowering blood pressure, reduced the risk of heart attacks or strokes. Despite the inefficacy of beta-blockers, the incidence of adverse effects is substantial. In the MRC study, for every heart attack or stroke prevented, three patients withdrew from atenolol because of impotence, and another seven withdrew because of fatigue. Thus the risk/benefit ratio of beta-blockers is characterized by lack of efficacy and multiple adverse effects. Given that many thorough, prospective, randomized trials attest to efficacy and safety of diuretics, calcium antagonists, ACE inhibitors, and angiotensin receptor inhibitors, the time has come to admit that beta-blockers should no longer be considered appropriate for first-line therapy in uncomplicated hypertension.
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PMID:beta-Blockers in hypertension-the emperor has no clothes: an open letter to present and prospective drafters of new guidelines for the treatment of hypertension. 1455 68

Structural and functional changes in large and small arteries in hypertension, even at early stages, may affect one or several end organs such as the brain, heart, and kidneys, contributing to cardiovascular morbidity and mortality. Therefore, modern treatment strategies should not only target blood pressure (BP) reduction but also normalize vascular structure and function. The purpose of this article is to review the large body of evidence, from randomized double-blind clinical trials, that has been gathered in regard to the angiotensin-converting enzyme (ACE) inhibitor perindopril, demonstrating its efficacy in reducing BP, reversing abnormalities of vascular structure and function in patients with essential hypertension, and ultimately preventing cardiovascular events. At the site of small resistance arteries, long-term treatment with perindopril, but not atenolol, reduced arterial wall hypertrophy for a given BP reduction. The improvement in small artery function in response to structural changes is exemplified at the site of the coronary circulation. Perindopril increased coronary blood flow and coronary reserve, in parallel with the regression of periarteriolar and interstitial collagen of coronary arterioles. At the site of large arteries, long-term treatment with perindopril reduced carotid and radial artery wall hypertrophy, and reduced carotid artery internal diameter. In response to these structural changes, large artery function improved at the site of the carotid and brachial arteries, showing a higher arterial distensibility, and at the site of the coronary circulation, showing a normalized arterial dilation in response to a cold pressor test or an increase in blood flow. Moreover, in patients with end-stage renal disease, perindopril decreased pulse wave velocity independently of BP changes, resulting in a highly significant relative risk reduction in all-cause and cardiovascular mortality. The multifactorial antiatherosclerotic profile of perindopril suggests a beneficial effect not only in patients with uncomplicated hypertension but also in patients with established coronary heart disease or previous stroke, as exemplified by the EUropean trial on Reduction Of coronary events with Perindopril in stable coronary Artery disease (EUROPA) and the Perindopril pROtection aGainst REcurrent Stroke Study (PROGRESS).
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PMID:Evidence for benefits of perindopril in hypertension and its complications. 1612 52

Patients with the cardiometabolic syndrome (CMS) have an adverse cardiovascular risk factor profile, placing them at increased risk of stroke, coronary artery disease, chronic kidney disease, and type 2 diabetes mellitus. Although no specific treatments for CMS are available per se, prompt recognition and treatment of the individual components of the condition can prevent or delay the development of comorbidities. Primary care physicians are ideally positioned to identify patients with CMS and implement early intervention strategies. Hypertension contributes to many complications of CMS, and rigorous blood pressure control will help to delay or prevent end-organ vascular damage. Achieving blood pressure control to current guideline standards should be eagerly sought in the majority of patients through a combination of lifestyle modifications and appropriate pharmacologic therapy. Antihypertensive drug choice should be personalized, taking into account the CMS determinants present and any compelling indications for specific agents. As an initial approach, a thiazide diuretic is suitable for most cases of uncomplicated hypertension, although many patients will require additional antihypertensives from other classes to achieve their blood pressure goal. It is predicted that, due to the increase in unhealthy lifestyles, the prevalence of CMS will rise in the coming years. Therefore, by meeting the challenge of attaining and maintaining blood pressure control in patients with CMS, primary care physicians have the unique opportunity to markedly improve the health of the nation.
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PMID:Hypertension--a treatable component of the cardiometabolic syndrome: challenges for the primary care physician. 1641 36

Despite normal ejection fractions, patients who undergo heart transplantation (HT) have low peak aerobic capacity and reduced arterial compliance, suggesting "ventriculovascular uncoupling." To what extent this is related to post-transplantation hypertension versus the unique characteristics of the donor-recipient relation remains poorly understood. Echocardiograms were retrospectively reviewed from 126 normal subjects, 309 patients with uncomplicated hypertension (UH), and 58 consecutive patients with HT >1 year after the procedure who were stable without evidence of rejection. Left ventricular (LV) end-systolic elastance (Ees), a measure of LV systolic performance; effective arterial elastance (Ea), a measure of vascular stiffness; and Ea/Ees, a parameter describing ventriculovascular coupling, were obtained. Compared with normal subjects, tandem increases in Ea (+24% and +85%, all p values <0.0001) and Ees (+23% and +33%, all p values <0.0001) were observed in patients with UH and HT, respectively, with patients with HT having significantly higher values than those with UH (both p values <0.05). Although the Ea/Ees ratio remained similar between normal subjects and patients with UH, patients with HT exhibited increases in the Ea/Ees ratio (all p values <0.01) and reduced stroke volume indexes (-20% and -22%, respectively, all p values <0.05). These changes were associated with a doubling of LV concentric remodeling in patients with HT compared with those with UH (67% vs 34%, p <0.0001). In conclusion, HT is associated with increases in Ees, Ea, and the Ea/Ees ratio, suggesting ventriculovascular uncoupling and maximal LV stroke work. These aberrations, which determine cardiovascular performance in the setting of HT, are not simply explained by vascular age or post-transplantation hypertension but may adversely affect functional capacity.
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PMID:Comparison of cardiac and peripheral arterial stiffening and ventriculovascular uncoupling in patients with uncomplicated hypertension versus patients with hypertension after heart transplantation. 1695 Jan 86

Recent studies have shown that beta-blockers in patients with hypertension is associated with an increased risk of cardiovascular events, in particular stroke, leading to headlines speculating the end of the beta-blocker era. The objective of this review is to critically examine the usefulness of beta-blockers in cardiovascular diseases. We reviewed the currently available evidence for the usefulness of beta-blockers in patients with hypertension and also assessed the efficacy of its use for other indications, like, chronic heart failure, stable angina, myocardial infarction, arrhythmias etc. The review of the currently available literature shows that for patients with uncomplicated hypertension, there is paucity of data or absence of evidence to support use of beta-blockers as monotherapy or as first line agent. Given the risk of stroke and numerous unacceptable adverse effects, the risk benefit ratio for beta-blockers is not acceptable for this indication. However, beta-blockers are very efficacious agents for the treatment of heart failure, certain types of arrhythmia, and post myocardial infarction. The various guideline committees should seriously reconsider their decision about their endorsement of beta-blockers as first line therapy for uncomplicated hypertension. However, this is applicable for hypertension and beta-blockers continue to be efficacious for other indications.
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PMID:How useful are beta-blockers in cardiovascular disease? 1716 85

For more than 3 decades, beta-blockers have been widely used in the treatment of hypertension and are still recommended as first-line agents by national and international guidelines. Recent meta-analyses indicate that, in patients with uncomplicated hypertension, compared with other antihypertensive agents, first-line therapy with beta-blockers was associated with an increased risk of stroke, especially in the elderly cohort with no benefit for the end points of all-cause mortality, cardiovascular morbidity, and mortality. In this review, we critically analyze the evidence supporting the use of beta-blockers in patients with hypertension and evaluate evidence for its role in other indications. The review of the currently available literature shows that in patients with uncomplicated hypertension, there is a paucity of data or absence of evidence to support use of beta-blockers as monotherapy or as first-line agents. Given the increased risk of stroke, their "pseudo-antihypertensive" efficacy (failure to lower central aortic pressure), lack of effect on regression of target end organ effects like left ventricular hypertrophy and endothelial dysfunction, and numerous adverse effects, the risk benefit ratio for beta-blockers is not acceptable for this indication. However, beta-blockers remain very efficacious agents for the treatment of heart failure, certain types of arrhythmia, hypertropic obstructive cardiomyopathy, and in patients with prior myocardial infarction.
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PMID:Cardiovascular protection using beta-blockers: a critical review of the evidence. 1822 66

Beta-blockers have long being used as first-line therapy for hypertension as their use had resulted in a reduction in cardiovascular morbidity and mortality in controlled clinical trials. A recent meta-analysis comparing beta-blockers to all other anti-hypertensive drugs taken together has found that stroke reduction was sub-optimal. Specifically, atenolol was associated with a 26% higher risk of stroke compared with other drugs. Several reasons may explain the less favourable outcomes with beta-blocker therapy. These include some adverse metabolic abnormalities such as dyslipidaemia and new-onset diabetes, and less effective reduction of central aortic compared with brachial blood pressure. Newer beta-blockers such as carvedilol or nebivolol are better tolerated. These beta-blockers have a vasodilating effect, which may beneficially affect systolic blood pressure in the aorta. Their long-term cardiovascular outcome in hypertension is still not known. Further studies would be required to show that stroke is adequately reduced by these newer beta-blockers. In conclusion, beta-blockers should not be the first drugs of choice in the management of uncomplicated hypertension. They may be used in addition to other antihypertensive agents to achieve blood pressure goals. However, in patients with angina pectoris, a previous myocardial infarction, heart failure and certain dysrhythmias, beta-blockers still play an important role.
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PMID:Should beta-blockers still be used as initial antihypertensive agents in uncomplicated hypertension? 1807 10


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