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Cardiology Clinics Nov 2010Hypertension is a very common modifiable risk factor for cardiovascular morbidity and mortality. Patients with hypertension represent a diverse group. In addition to... (Comparative Study)
Comparative Study Review
Hypertension is a very common modifiable risk factor for cardiovascular morbidity and mortality. Patients with hypertension represent a diverse group. In addition to those with primary hypertension, there are patients whose hypertension is attributable to secondary causes, those with resistant hypertension, and patients who present with a hypertensive crisis. Secondary causes of hypertension account for less than 10% of cases of elevated blood pressure (BP), and screening for these causes is warranted if clinically indicated. Patients with resistant hypertension, whose BP remains uncontrolled in spite of use of 3 or more antihypertensive agents, are at increased cardiovascular risk compared with the general hypertensive population. After potentially correctible causes of uncontrolled BP (pseudoresistance, secondary causes, and intake of interfering substances) are eliminated, patients with true resistant hypertension are managed by encouraging therapeutic lifestyle changes and optimizing the antihypertensive regimen, whereby the clinician ensures that the medications are prescribed at optimal doses using drugs with complementary mechanisms of action, while adding an appropriate diuretic if there are no contraindications. Mineralocorticoid receptor antagonists are formidable add-on agents to the antihypertensive regimen, usually as a fourth drug, and are effective in reducing BP even in patients without biochemical evidence of aldosterone excess. In the setting of a hypertensive crisis, the BP has to be reduced within hours in the case of a hypertensive emergency (elevated BP with evidence of target organ damage) using parenteral agents, and within a few days if there is hypertensive urgency, using oral antihypertensive agents.
Topics: Antihypertensive Agents; Cardiovascular Diseases; Diagnosis, Differential; Diuretics; Dose-Response Relationship, Drug; Drug Administration Schedule; Drug Resistance; Drug Therapy, Combination; Humans; Hypertension; Hypertension, Malignant; Infusions, Intravenous; Infusions, Intraventricular; Risk Factors
PubMed: 20937447
DOI: 10.1016/j.ccl.2010.07.002 -
Journal of Human Hypertension Sep 1998This paper discusses the most significant aspects of secondary hypertension in older patients against the background of a rising proportion of elderly in the... (Review)
Review
This paper discusses the most significant aspects of secondary hypertension in older patients against the background of a rising proportion of elderly in the hypertensive population. Renal artery stenosis and pheochromocytoma are singled out as those causes of secondary hypertension which appear to be related to older age. The available data relevant to epidemiology of these conditions and age-dependent clinical characteristics are reviewed. Preservation of renal function in the elderly with renal artery stenosis is underlined as an important goal of therapy with revascularising techniques. It is proposed that screening for renal artery stenosis and pheochromocytoma may be equally important in the elderly as in the younger hypertensive patient.
Topics: Adrenal Gland Neoplasms; Aged; Arteriosclerosis; Cardiovascular Diseases; Female; Humans; Hypertension; Hypertension, Renovascular; Incidence; Male; Pheochromocytoma; Prognosis; Renal Artery Obstruction; Risk Assessment
PubMed: 9783488
DOI: 10.1038/sj.jhh.1000673 -
Journal of Human Hypertension Apr 2014Among the vast population of hypertensive subjects, between 10 and 15% do not achieve an adequate blood pressure (BP) control despite the use of at least three... (Review)
Review
Among the vast population of hypertensive subjects, between 10 and 15% do not achieve an adequate blood pressure (BP) control despite the use of at least three antihypertensive agents. This group, designated as having resistant hypertension (RH), represents one of the most important clinical challenges in hypertension evaluation and management. Resistant hypertensives are characterized by several clinical particularities, such as a longer history of hypertension, obesity and other accompanying factors, such as diabetes, left ventricular hypertrophy, albuminuria and renal dysfunction. In addition to other diagnostic and therapeutic maneuvers, such as excluding secondary hypertension, ensuring treatment adherence and optimizing therapeutic schemes, ambulatory BP monitoring (ABPM) is crucial in the clinical evaluation of patients with RH. ABPM distinguish between those with out-of-office BP elevation (true resistant hypertensives) and those having white-coat RH (WCRH; normalcy of 24-h BPs), the prevalence of the latter estimated in about one-third of the population with RH. True resistant hypertensives also exhibit more frequently other co-morbidities, more severe target organ damage and a worse cardiovascular prognosis, in comparison to those with WCRH. Some device-based therapies have recently been developed for treatment of RH. This requires a better characterization of a potential candidate population. A better knowledge of the clinical features of resistant hypertensive subjects, the confirmation of elevated BP values out of the doctor's office, and improvements in the search for secondary causes would help to select those candidates for newer therapies, once the pharmacological possibilities have been exhausted.
Topics: Aged; Antihypertensive Agents; Blood Pressure Monitoring, Ambulatory; Diabetes Complications; Drug Resistance; Female; Humans; Hypertension; Male; Middle Aged; Obesity; Prevalence; Risk Factors; Treatment Outcome
PubMed: 23985879
DOI: 10.1038/jhh.2013.77 -
International Journal of Cardiology Feb 2008Secondary hypertension affects a small but significant number of the hypertensive population and, unlike primary hypertension, is a potentially curable condition. The... (Review)
Review
Secondary hypertension affects a small but significant number of the hypertensive population and, unlike primary hypertension, is a potentially curable condition. The determinant for workup is dependent on the index of suspicion elicited during patient examination and treatment. Specific testing is available and must be balanced depending on the risk and cost of the workup and treatment with the benefits obtained if the secondary cause is eliminated. This article reviews common manifestations, workup, and the current treatments of the common causes of secondary hypertension.
Topics: Antihypertensive Agents; Diagnosis, Differential; Humans; Hypertension; Incidence; Prevalence; Risk Factors
PubMed: 17462751
DOI: 10.1016/j.ijcard.2007.01.119 -
EuroIntervention : Journal of EuroPCR... May 2013In the majority of hypertensive patients, no particular cause for abnormal blood pressure is evident (primary or essential hypertension). In contrast, in the minority of... (Review)
Review
In the majority of hypertensive patients, no particular cause for abnormal blood pressure is evident (primary or essential hypertension). In contrast, in the minority of patients with secondary hypertension a specific underlying cause is responsible for the elevated blood pressure. The prevalence of secondary hypertension is higher in patients with resistant hypertension than in the general hypertensive population and increases with age. The list of secondary forms of hypertension is long and prevalence of the individual causes of secondary hypertension varies. Hence, this review divides them into two categories: common causes and rare causes. If appropriately diagnosed and treated, patients with a secondary form of hypertension might be cured, or at least show an improvement in their blood pressure control. Consequently, screening for secondary causes of hypertension plays an essential part in the care of patients with arterial hypertension. If the basal work-up raises the suspicion of a secondary cause of hypertension, specific diagnostic procedures become necessary, some of which can be performed by primary care physicians, while others require specialist input.
Topics: Arterial Pressure; Humans; Hypertension; Predictive Value of Tests; Prevalence; Prognosis; Risk Factors
PubMed: 23732151
DOI: 10.4244/EIJV9SRA5 -
Cardiology Clinics May 2002Resistant hypertension, secondary hypertension, and hypertensive crises are uncommon but potentially dangerous forms of hypertension that are associated with an... (Review)
Review
Resistant hypertension, secondary hypertension, and hypertensive crises are uncommon but potentially dangerous forms of hypertension that are associated with an increased risk of complications such as myocardial infarction, heart failure, stroke, and renal failure. Appropriate diagnostic screening and selective drug or surgical management can reduce the risk of these complications dramatically. In compliant patients, resistant hypertension occurs most often in obese patients receiving inadequate diuretic therapy. In patients with clinical clues to the diagnosis, the best current screening test for renovascular hypertension is probably the ACE-inhibitor renal scintiscan. Angioplasty is considerably more successful in younger patients with fibrous dysplasia than in older patients with the atherosclerotic variety. Hypertensive crises are divided into BP urgencies and emergencies. In both settings, the reduction in BP should generally be gradual rather than abrupt, with no intent to acutely normalize the BP.
Topics: Drug Resistance; Humans; Hypertension; Recurrence; Risk Factors; Severity of Illness Index; Treatment Failure
PubMed: 12119801
DOI: 10.1016/s0733-8651(01)00004-2 -
Deutsche Medizinische Wochenschrift... Jan 2020The prevalence of arterial hypertension with its cardiovascular diseases like myocardial infarction, stroke, chronic kidney disease and peripheral artery disease is...
The prevalence of arterial hypertension with its cardiovascular diseases like myocardial infarction, stroke, chronic kidney disease and peripheral artery disease is increasing in our aging population. Despite numerous efficient and well-tolerated antihypertensive drugs more than eight million people die worldwide from the consequences of insufficiently controlled hypertension every year. One third of the german adult population suffers from high blood pressure. The fact that in only 50 % of hypertonic patients the blood pressure is on a string is even more disturbing. Several factors can counteract sufficient blood pressure control. This article should help to identify patients with possible secondary hypertension. It is certainly not decisive to request a broad screening for all hypertensive patients. A certain pre-selection of potential patients is mandatory. The most common types of secondary hypertension are discussed and the diagnostic and therapeutic pathways are specified.
Topics: Adult; Blood Pressure; Diagnosis, Differential; Germany; Humans; Hyperaldosteronism; Hypertension; Practice Guidelines as Topic; Sleep Apnea Syndromes; Treatment Failure
PubMed: 31958856
DOI: 10.1055/a-1031-0520 -
Internal Medicine Journal Oct 2023Resistant hypertension (RHT) is typically defined as blood pressure that remains above guideline-directed targets despite the use of three anti-hypertensives, usually... (Review)
Review
Resistant hypertension (RHT) is typically defined as blood pressure that remains above guideline-directed targets despite the use of three anti-hypertensives, usually including a diuretic, at optimal or maximally tolerated doses. It is generally estimated to affect 10-30% of those diagnosed with hypertension, though the true incidence might be lower after one factor in the prevalence of non-adherence. Risk factors for its development include diabetes, obesity and other adverse lifestyle factors, and a diagnosis of RHT confers a greater risk of adverse cardiovascular outcomes, such as stroke, heart failure and mortality. It is essential to exclude pseudoresistance and secondary hypertension and to ensure non-pharmacologic management is optimised prior to consideration of fourth-line anti-hypertensive agents or advanced interventions, such as device therapies. In this review, we will cover the different definitions of RHT, along with the importance of careful diagnosis and management strategies, and discuss newer agents and research needs.
Topics: Humans; Hypertension; Antihypertensive Agents; Blood Pressure; Diuretics; Risk Factors
PubMed: 37493367
DOI: 10.1111/imj.16189 -
American Journal of Hypertension Jan 2015The aim was to determine the proportions and correlates of essential hypertension among children in a tertiary pediatric hypertension clinic. (Observational Study)
Observational Study
BACKGROUND
The aim was to determine the proportions and correlates of essential hypertension among children in a tertiary pediatric hypertension clinic.
METHODS
We evaluated 423 consecutive children and collected demographic and clinical history by retrospective chart review.
RESULTS
We identified 275 (65%) hypertensive children (blood pressure >95th percentile per the "Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents") from 423 children referred to the clinic for history of elevated blood pressure. The remainder of the patients had normotension (11%), white coat hypertension (11%), prehypertension (10%), and pending diagnosis (3%). Among the 275 hypertensive children, 43% (n = 119; boys = 56%; median age = 12 years; range = 3-17 years) had essential hypertension and 57% (n = 156; boys = 66%; median age = 9 years; range = 0.08-19 years) had secondary hypertension. When compared with those with secondary hypertension, those with essential hypertension had a significantly older age at diagnosis (P = 0.0002), stronger family history of hypertension (94% vs. 68%; P < 0.0001), and lower prevalence of preterm birth (20% vs. 46%; P < 0.001). There was a bimodal distribution of age of diagnosis in those with secondary hypertension.
CONCLUSIONS
The phenotype of essential hypertension can present as early as 3 years of age and is the predominant form of hypertension in children after age of 6 years. Among children with hypertension, those with essential hypertension present at an older age, have a stronger family history of hypertension, and have lower prevalence of preterm birth.
Topics: Adolescent; Age Distribution; Age of Onset; Blood Pressure; Child; Child, Preschool; Female; Humans; Hypertension; Infant; Infant, Newborn; Male; Pedigree; Phenotype; Premature Birth; Prevalence; Retrospective Studies; Risk Factors; Tertiary Care Centers; Texas
PubMed: 24842390
DOI: 10.1093/ajh/hpu083 -
Ethnicity & Disease Nov 2015Treatment resistant hypertension (TRH) is defined by office blood pressure (BP) uncontrolled on ≥ 3 or controlled on ≥ 4 antihypertensive medications, preferably at... (Review)
Review
Treatment resistant hypertension (TRH) is defined by office blood pressure (BP) uncontrolled on ≥ 3 or controlled on ≥ 4 antihypertensive medications, preferably at optimal doses and including a diuretic. Apparent (a)TRH is used when optimal therapy, adherence, and measurement artifacts are unknown. Among treated hypertensives, ~30% of uncontrolled and 10% of controlled individuals have aTRH, with a higher prevalence in Blacks than other race-ethnicity groups. In ≥ 50% of aTRH patients, BP measurement artifacts ('office' TRH), suboptimal regimens, or suboptimal adherence are present, ie, pseudo-resistance. While patients with 'office' TRH have fewer cardiovascular events than those with 'true' TRH, no evidence confirms that patients with suboptimal regimens or adherence are spared. Averaging several office BPs obtained with an automated monitor can reduce 'office' TRH. Home or ambulatory BP monitoring can identify office resistance. Prescribing ≥ 3 different antihypertensive medication classes, eg, thiazide-type diuretic, renin-angiotensin blocker and calcium antagonist at ≥ 50% of maximum recommended doses reasonably defines optimal therapy. Intensifying diuretic therapy, eg, adding an aldosterone antagonist, is effective for many TRH patients who are volume expanded. Clinical information, hemodynamic and renin-guided therapeutics can inform other treatment options. Attention to adverse effects, medication costs, and pill burden can improve adherence and control. Patients with aTRH and suspected secondary hypertension should be evaluated. Interfering substances or medications should be discontinued. These approaches will identify or correct the problem in ~80% of aTRH patients. Referral to a hypertension specialist and newer therapeutic approaches are options for TRH patients who cannot take or do not respond to optimal therapy.
Topics: Antihypertensive Agents; Blood Pressure Monitoring, Ambulatory; Diuretics; Humans; Hypertension; Prevalence; Renin; United States
PubMed: 26674466
DOI: 10.18865/ed.25.4.495