Adult interrupted aortic arch revealed by resistant arterial hypertension

Background The negative effect of arterial hypertension on renal function is well known. Until present, the detrimental effect of resistant arterial hypertension (RAH) on kidneys was not clearly defined. Purpose To assess the deterioration of renal function in patients with RAH in comparison to patients with non-resistant arterial hypertension (AH) during a long term follow-up. Methods We retrospectively reviewed records of 307 patients followed between May 2007 and January 2019 in an Hypertension Excellence Centre of a tertiary hospital. In all patients we assessed basic demographic characteristics, co-morbidities, laboratory findings, secondary causes of AH, medication, blood pressure including ambulatory blood pressure monitoring, studies and invasive procedures (CT, MRI, coronarography). We statistically evaluated differences in both groups and compared the decline of renal function. Results 160 patients had resistant and 147 patients non-resistant hypertension. Patients were followed for a mean of 6 years. Patients with RAH were older (58.1±10.8 years vs. 51±13 years), more frequently diabetics (39.3% vs. 8.7%), had more frequent exposure to diagnostic studies and invasive procedures (86,5% vs. 64%). Age at baseline visit and diabetes mellitus were established as statistically significant independent risk factors. Linear mixed effect model adjusted to age and diabetes demonstrated that patients with RAH have increased decline of renal function than patients with AH: patients with AH had mean increase of creatinine +0.24 μmol/l per year, while patients with RAH + 2.12 μmol/l per year (P=0.005). Similarly the decrease of eGFR in patients with AH was −0.66 compared to −1.5 mL/s/1.73 m2 per year in patients with RAH (P=0.005). Figures 1 and 2 show the difference in mean slope of creatinine and eGFR in patients with resistant and non-resistant hypertension (based on linear mixed effect models)). Conclusion Patients with resistant hypertension had faster decline of renal function in comparison to patients with non-resistant hypertension independently on age and diabetes. Further studies are needed to determine the key factors affecting renal function decline in both subgroups. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): University Hospital Olomouc, Palacky University Olomouc, Faculty of Medicine, Czech Republic

Background Systemic arterial hypertension (SAH) is a prevalent global condition associated with significant microvascular dysfunction. In some individuals, SAH progresses to resistant arterial hypertension (RAH), which carries a poorer prognosis than non-resistant arterial hypertension (NRAH). Purpose This study aimed to evaluate systemic microvascular function in patients with RAH, comparing them to individuals with NRAH and healthy controls (CTL). Methods The study involved 52 patients with RAH (mean age 57.8±7.3 years, 50% men), 35 patients with NRAH (mean age 54±9.4 years, 46% men), and 22 CTL individuals (mean age 56.2±7.3 years, 50% men). Individuals with diabetes were excluded. Microvascular function was assessed in the forearm skin using a laser speckle contrast imaging system. Microvascular blood flow was measured in arbitrary perfusion units (APU) and normalized by mean arterial pressure to calculate cutaneous vascular conductance (CVC, APU/mmHg). Endothelium-dependent vasodilation was evaluated via iontophoresis of acetylcholine (ACh), while endothelium-independent vasodilation was assessed using sodium nitroprusside (SNP), both applied through increasing microcurrents (dose-response curves of 30-180 μA). Post-occlusive reactive hyperemia (PORH) was measured following a 3-minute brachial artery occlusion, with pre- and post-occlusion values recorded. Results There were no significant differences between the groups in terms of age and sex. The areas under the curves (AUCs) for vasodilation induced by ACh were 66±8, 76±8, and 88±9 APU/s for RAH, NRAH, and CTL groups, respectively (Figure 1, P<0.0001). Similarly, the AUCs for SNP-induced vasodilation were 55±7, 62±6, and 70±6 APU/s in the respective groups (Figure 1, P<0.0001). Peak CVC values during PORH were 0.6±0.2, 0.7±0.2, and 0.9±0.2 APU/mmHg for RAH, NRAH, and CTL groups, respectively (Figure 2, P<0.0001). The delta values (peak minus baseline) during PORH were 0.3±0.1, 0.4±0.2, and 0.5±0.2 APU/mmHg for the same groups (Figure 2, P<0.0001). Conclusions Patients with RAH exhibited significantly greater impairments in both endothelium-dependent (ACh and PORH) and endothelium-independent (SNP) vasodilation compared to those with NRAH. These findings indicate that the progression from NRAH to RAH involves both functional (endothelial dysfunction) and structural (arteriolar remodeling) microvascular changes. The observed alterations contribute to increased vascular resistance and reduced vasodilatory capacity in RAH, highlighting the progressive nature of microvascular dysfunction in resistant hypertension. This study underscores the critical role of endothelial dysfunction and microvascular remodeling in the persistence and severity of RAH, suggesting their key involvement in its pathophysiology.FIGURE 1 FIGURE 2

Objective: The prevalence of arterial hypertension in adult men is 34% worldwide and 52% in Lithuania. This paper aims to provide an overview of the prevalence trends of arterial hypertension and its clinical forms in middle-aged Lithuanian men and to assess the risk profiles of the different groups. Methods: This retrospective research study collected data from 52,012 Lithuanian male patients. The study population consisted of men aged 40-55 who participated in the Lithuanian High Cardiovascular Risk Program between 2009 and 2019. Results: Of the 52,012 participants, 47.2% (n = 24,531) were men with arterial hypertension. The prevalence of arterial hypertension in Lithuanian men decreased between 2009 and 2019 (p < 0.001). Before the study visit, 12.6% (n = 6583) of men were unaware of their diagnosis, and 8.8% (n = 4555) of diagnosed cases were untreated. In addition, 2.6% (n = 1334) of the men had resistant arterial hypertension. Significant differences in most general characteristics were found between the groups with arterial hypertension. Waist circumference increased from 92.8 ± 10.7 cm in men without arterial hypertension to 109 ± 13.3 cm and in men with resistant arterial hypertension (p < 0.001), and mean triglyceride levels increased from 1.55 ± 1.22 mmol/L to 2.32 ± 1.82 mmol/L in these groups (p < 0.001). Obesity (63.6%), unhealthy diet (74.7%), physical inactivity (62.9%), and diabetes (25.2%) were more common in the group with resistant arterial hypertension than in all other groups (p < 0.001). Meanwhile, dyslipidaemia was the most common risk factor in all groups (from 83.2% in men without arterial hypertension to 92.6% in men with resistant hypertension). Conclusions: Almost half of middle-aged men had arterial hypertension, with prevalence decreasing from 2009 to 2019. Significant changes in cardiometabolic characteristics were observed in newly diagnosed cases of arterial hypertension. These changes are even more notable in men with resistant hypertension compared to a non-resistant form. Most cardiovascular risk factors were most prevalent in over 50% of resistant hypertension cases, with dyslipidaemia being the most common risk factor in the entire male sample.

Association between systemic microvascular dysfunction and resistant hypertension: Insights from a clinical observational study.

Objective: To establish the frequency of different forms of coronary artery disease (CAD) in patients with resistant arterial hypertension (AH). Methods: Based on the data from clinical and anamnestic studies and the results of electrocardiography (ECG), Holter ECG monitoring (HM-ECG), and bicycle ergometry (VEM), 370 young and middle-aged patients (WHO, 1965), the mean age 54.1±4, with primary AH were diagnosed with CAD according to the Canadian classification (World Health Organization (WHO), 1979; with additions by All-Union Cardiology Research Centre, 1995). With daily monitoring of blood pressure (BP) against the background of antihypertensive therapy (AHT), groups of patients with controlled (CAH; n=84) and resistant (RAH; n=286) arterial hypertension were identified. Results: It was found that in young and middle-aged patients with both CAH and RAH, the frequency of stable angina pectoris (SA) was the highest, mainly due to functional classes (FC) I-II; severe functional classes of SA, and unstable angina (UA) were markedly less frequent; less than a quarter of patients had a myocardial infarction (MI), mainly due to non-Q-wave MI (non-Q-MI). In patients with CAH and RAH FC I-II of SA were predominant (in 70.2% of patients with CAH and 34.3% with RAH; p=0.0001), while FC III-IV of SA were mainly observed against the background of RAH (21% vs. 5% in patients with CAH, p=0.0015). In patients of young and middle age, against the background of RAH, the frequency of UA (18.9%; p=0.0220) and the total number of MI (25.9%; p=0.0482) was higher, than in CAH, mainly due to Q-MI (11.2%; p=0.0360), indicating the severity of coronary insufficiency. The increase in non-Q-MI against the background of RAH was statistically insignificant (p=0.5191). Conclusion: The ratio of the frequency of different forms of CAD against the background of CAH and RAH was unidirectional. However, the overall frequency of severe forms of CAD (UA and MI, especially Q-MI) in patients with RAH significantly exceeded those in patients with CAH, which allowed us to consider RAH as a factor in the progressive course of CAD. Keywords: Coronary artery disease, stable angina, unstable angina, myocardial infarction, resistant arterial hypertension, young and middle age.

Актуальність. Неконтрольований артеріальний тиск в осіб (АТ) пов’язаний із чотириразовим збільшенням ризику розвитку серцево-судинних подій порівняно з пацієнтами з АГ, які досягли цільового рівня АТ. Мета: оцінити загальну характеристику пацієнтів із резистентною АГ, які проходили стаціонарне лікування у відділенні симптоматичних гіпертензій ДУ «ННЦ «Інститут кардіології імені академіка М.Д. Стражеска» НАМН України», та визначити досягнення цільового рівня артеріального тиску в пацієнтів із резистентною АГ, які приймають 3 антигіпертензивні препарати та більше. Матеріали та методи. У дослідження було включено 1146 пацієнтів із резистентною АГ, які приймали 3 антигіпертензивні препарати та більше і лікувалися у відділенні симптоматичних гіпертензій ДУ «ННЦ «Інститут кардіології ім. акад. М.Д. Стражеска» НАМН України». Рівень офісного АТ при надходженні хворих у відділення при прийомі 3 антигіпертензивних препаратів і більше становив ≥ 140/90 мм рт.ст.: середній рівень систолічного (САТ)/діастолічного АТ (ДАТ) був 174,60 ± 0,64/100,50 ± 0,38 мм рт.ст. Пацієнтам проводили такі обстеження: вимірювання зросту та маси тіла, офісного АТ, добове моніторування артеріального тиску, ехокардіографічне дослідження, вимірювання швидкості поширення пульсової хвилі та центрального артеріального тиску, визначення нічного апное сну, загальний аналіз крові, біохімічний аналіз крові, визначення рівнів тиреотропного гормона, Т3, Т4, реніну крові, альдостерону крові та їх співвідношення, визначення метанефринів сечі, кортизолу. Результати. Серед пацієнтів із резистентною артеріальною гіпертензією жінок було більше, ніж чоловіків, — 62,7 проти 36,7 % відповідно. Серед них у 5 % була виявлена вторинна АГ, де в структурі переважну частку становили ренопаренхімна артеріальна гіпертензія, аденома наднирників із гіперальдостеронізмом та порушення функції щитоподібної залози з гіпотиреозом. У 16,6 % пацієнтів із резистентною АГ відмічався цукровий діабет 2-го типу, 15,8 % пацієнтів перенесли порушення мозкового кровообігу в анамнезі, де переважав ішемічний інсульт — 12,8 %. У пацієнтів, у яких не було досягнуто цільового САТ (31 %), спостерігались достовірно вищі показники АТ при надходженні в стаціонар. У них відмічались достовірно вищий рівень кортизолу крові (155,0 ± 44,0 нг/л проти 35,9 ± 20,8 нг/л), вищий індекс маси міокарда лівого шлуночка (147,50 ± 3,46 г/м2 проти 135,30 ± 1,74 г/м2), частіше спостерігались ожиріння (42,9 проти 37,5 %), аномалії розвитку нирок (2,7 проти 0,8 %), облітеруючий атеросклероз нижніх кінцівок (2,0 проти 0,2 %), структурні зміни наднирників (3,0 проти 1,2 %), нефропатія (1,3 проти 0,2 %), вищий ступінь серцевої недостатності (СН 2А стадії; 16,9 проти 8,5 %). Ступінь зниження офісного АТ серед пацієнтів, які приймали 3 антигіпертензивні препарати та більше, загалом становив для САТ 43,47 ± ± 0,65 мм рт.ст., для ДАТ — 20,33 ± 0,74 мм рт.ст., р &lt; 0,001 для обох значень. ДАТ між пацієнтами, які приймали 3 препарати та 4 препарати і більше, достовірно не відрізнявся та становив 19,88 і 20,81 мм рт.ст. відповідно, а офісний САТ достовірно більше знизився в пацієнтів, які приймали 4 препарати та більше, — на 45,78 мм рт.ст. порівняно з групою, яка приймала 3 препарати, — 41,3 мм рт.ст., р &lt; 0,001. Висновки. Вторинна артеріальна гіпертензія була виявлена в 5 % хворих із резистентною гіпертензією, в структурі найбільшу частку становили ренопаренхімна гіпертензія, аденома наднирників із гіперальдостеронізмом та порушення функції щитоподібної залози з гіпотиреозом.

Objective: Arterial hypertension (AH) and its harmful effect on renal function is well known. Long term impact of resistant arterial hypertension (RAH) on renal function has not been evaluated yet. The aim of this study was to assess the long-term renal function decline in patients with RAH and non-resistant arterial hypertension. Design and method: We retrospectively reviewed records of 265 patients followed between May 2007 and January 2019 in an Hypertension Excellence Centre of a tertiary hospital. In all patients we assessed basic demographic characteristics, co-morbidities, laboratory findings, secondary causes of AH, medication, blood pressure including ambulatory blood pressure monitoring, studies and invasive procedures (CT, MRI, coronarography). We statistically evaluated differences in both groups and compared the decline of renal function. Results: 137 patients had resistant and 128 patients non-resistant hypertension. Patients were followed for a mean of 6 years (minimum 2 years, maximum 10,6 years). Decline of renal function occurred more frequently in in patients with RAH (74.5%) than patients with non-resistant AH (65.6%). During the first 4 years of follow-up, patients with RAH had higher mean annual eGFR decline (-2.45 ml/s/1.73m2) compared to patients with AH (-1.825 ml/s/1.73m2) (Table 1). Patients with RAH were older (58.1 ± 10.8 years vs. 51 ± 13 years), more frequently diabetics (39.3 % vs. 8.7 %), had more frequent exposure to diagnostic studies and invasive procedures (86,5% vs. 64%), and more patients with RAH underwent renal denervation (15.3% vs. 1.3%), all with P &lt; 0.001. Conclusions: Patients with resistant hypertension had faster decline of renal function in the course of first four years of follow-up in comparison to patients with non-resistant hypertension. The goal of the following studies will be to determine the key factors affecting renal function decline in both subgroups.

Individuals with resistant arterial hypertension are particularly at risk of developing target organ damage and cardiovascular events. The advanced echocardiography technique called myocardial work (MW), through the analysis of the left ventricular pressure-strain loop, is among the possibilities for evaluating these individuals. Our study was designed to describe the behavior of MW indices in individuals with resistant arterial hypertension (RH), controlled hypertension (CH), and normal arterial pressure (N). Seventy-one patients underwent Ambulatory Blood Pressure Monitoring (ABPM) and were characterized into three groups after a medical consult: RH (subjects with hypertension on four or more antihypertensive medications despite having controlled blood pressure); CH (subjects with hypertension on up to two antihypertensive medications); and N (individuals with normal ABPM; not using any medications). Echocardiographic analysis was performed using the Vivid E95 ultrasound system and blood pressure was measured at the time of the examination and subsequently used to determine myocardial work indices. RH demonstrated lower global work efficiency (GWE, mean=.95%; p=.005) and higher global wasted work (GWW, mean=114mm Hg%; p=.011) compared to other groups. Left ventricular mass measured by three-dimensional echocardiography, systolic wall stress, relative wall thickness and peak systolic dispersion were inversely correlated to GWE. No difference was observed between CH and N groups regarding MW indices. On multivariate analysis, only systolic wall stress remained as an independent predictor of GWE, when controlled by 3D mass index, relative wall thickness, peak systolic dispersion, and the hypertension group. Individuals with resistant hypertension have lower global work efficiency and higher global wasted work, compared to individuals with controlled hypertension and without arterial hypertension.

Objective. To evaluate the efficiency of radiofrequency denervation of the renal arteries in patients with resi-stant arterial hypertension during a three-year follow-up. Materials and methods. The study involved 40 patients with resistant arterial hypertension aged 27 to 70 years (mean age 54.91±9.77 years) while receiving three or more antihypertensive drugs (including diuretic) in optimal doses. The conditions for inclusion in the study were considered resistant arterial hypertension with blood pressure (BP)&gt;160/100 mm Hg, intact kidney function - glomerular filtration rate (MDRD)&gt;45 ml/min - and the absence of secondary hypertension. All patients had sympatic radiofrequency denervation of renal arteries; its efficiency later was estimated according to the clinical measurement and ambulatory blood pressure monitoring (ABPM). Results. The level of office BP reliably differed initially and after 3 years: DSBP -34.48±6.44 mm Hg (p=0.001), DDBP - 22.29 mm Hg (p=0.001). According to ABPM results, reliable dynamics of systolic blood pressure was not observed. The data of DBP at night were significantly lower after 36 months; DDBP was -5.37±9.77 mm Hg. Conclusions. A marked decrease in the data of office SBP and DBP was observed, which proves the long-term efficiency of radiofrequency denervation of the renal arteries in patients with resistant hypertension. Accor-ding to ABPM results after 36 months, a significant decrease was registered among the DBP indicators at night and daytime.

Objective In this study, we aimed to determine the prevalence and spectrum of secondary hypertension among patients with apparently resistant arterial hypertension (aRH) and to compare the rate of decline in estimated glomerular filtration rate (eGFR) between those with primary aldosteronism (PA) and true resistant arterial hypertension (RAH). Methods This retrospective cohort study involved 790 patients with aRH referred to a hypertension excellence centre. All patients fulfilled pharmacological criteria for aRH and underwent a screening protocol to evaluate secondary hypertension. We compared clinical and laboratory markers of patients with PA to those with RAH, with a median follow-up of 7 years. Results Secondary hypertension was identified in 213 patients (27%), with PA being the most common cause (17%), followed by renovascular hypertension (4.1%) and renal parenchymal disease (3.7%). Compared to RAH patients, those with PA had significantly fewer cardiovascular comorbidities. Patients with RAH exhibited a faster decline in renal function, specifically an additional 0.7 mL/min/1.73 m2 reduction per year (95% confidence interval: 0.05–1.35, p = .03), despite similar baseline eGFR and blood pressure (BP) control. In RAH, a continuous association between higher average 24-h systolic BP and a faster decline in renal function was observed. Conclusion Systematic screening in aRH reveals a high prevalence of secondary hypertension, particularly PA. Patients with RAH showed significantly worse renal outcomes compared to those with PA, with faster renal decline associated with higher BP within the RAH group, underscoring the need for early diagnosis and strict BP management.

Background/Introduction Renal denervation (RDN) is an innovative procedure designed to regulate the renal sympathetic nervous system for the control of arterial hypertension (HTN). RDN emerges as an alternative for patients with resistant arterial hypertension. Despite this, the clinical efficacy of RDN is still not fully understood. Purpose Therefore, we aimed to compare the use of renal denervation versus sham procedure or pharmacological treatment in patients with resistant HTN. Methods We performed a systematic search of PubMed, Embase, Cochrane databases for randomized controlled trials (RCTs) comparing the use of renal denervation procedures and sham procedure or pharmacological treatment in patients with resistant HTN. Statistical analyses were performed using R Studio 4.3.2. Heterogeneity was examined with the Cochran Q test I² statistics. Mean difference (MD) with 95% CI were pooled across trials. P values of &amp;lt; 0.05 were considered statistically significant. The primary continuous outcomes of interest were change from baseline in systolic blood pressure (SBP), diastolic blood pressure (DBP) and serum creatinine. Results Twenty-one RCTs reporting data on 3345 patients were included in this meta-analysis. Among them, 2004 (59,91%) received renal denervation and 1341 (40,09%) received pharmacological treament or sham procedure. Follow-up ranged from 2 to 48 months. The mean age of patients between studies ranged from 50.7 to 65 years. Compared to control group, RDN significantly reduced Systolic Blood Pressure (SBP) (MD -3.53 mmHg; 95% CI -5.94 to -1.12; I2 = 74%) and Diastolic Blood Pressure (DBP) (MD -1.48 mmHg; 95% CI -2.56 to -0.40; I2 = 51%). Regarding serum creatinine (MD -2.51; 95% CI -7.90 to 2.87; I2 = 40%) there was no significant difference between RDN and control groups. Conclusion In this meta-analysis of RCTs of patients with resistant HTN, RDN was associated with a reduction in SBP and DBP compared to sham procedure or pharmacological treatment.

Introduction: Resistant arterial hypertension (RHT) is defined as poor controlled blood pressure (BP) despite optimal doses of three or more antihypertensive agents, including a diuretic. In the development of RHT, hyperactivity of sympathetic (SNS) and renin–angiotensin–aldosterone (SRAA) systems are involved, and SNS is a potent stimulator of vasoactive endothelin-1 (ET-1) peptide. Renal sympathetic denervation (RSD) through disrupting renal afferent and efferent nerves attenuates SNS activity.Material and methods: We carried out pilot study investigating the effect of RSD on BP and plasma ET-1 levels in consecutive 9 RHT patients (7 male and 2 female, mean age of 56 ± 13.3).Results: After 12 months of the RSD, we observed a significant reduction of BP office, 24-h ambulatory BP monitoring (ABPM) (p < 0.05, respectively), and “non-dipping” pattern (from 55% to 35%) (p < 0.05). Moreover, RSD significantly decreased plasma ET-1 levels in both renal artery (at right from 21.8 ± 4.1 to 16.8 ± 2.9 pg/ml; p = 0.004; at left from 22.1 ± 3.7 to 18.9 ± 3.3 pg/ml; p = 0.02). We observed positive correlations between plasma renal arteries ET-1 levels and systolic BP values at ABPM [Global-SBP (r = 0.58; p < 0.01), Diurnal-SBP (r = 0.51; p < 0.03) and Nocturnal-SBP (r = 0.58; p < 0.01), respectively].Discussion: Our data confirmed the positive effects of RSD on BP values in patients with RHT, and showed a possible physio-pathological role of ET-1.KEY MESSAGESRSD is associated to a significant reduction of plasma ET-1 levels, representing an useful tool into reduction of BP in RHT patients.

Aim To value the possible relationship between the intensity of neoangiogenesis in the aortic wall in patients with resistant arterial hypertension and the subsequent development of ischemic cerebral disorders in them over a three-year follow-up. Materials and methods This study comprised 36 patients with resistant hypertension, in whom the renal denervation was carried out. MRI of the brain and also with contrast enhancement of the aorta and kidneys were examined. MRI studies included T2 and T1 spin-echo MRI, and also coronal slices, with suppression of the signal from adipose tissue (TR=150 ms, TE = 4 ms), before and in 12–15 minutes after contrast-enhanced. The diameter and thickness of the wall of the descending aorta were measured. Index of the enhancement of the aortic wall was calculated as the ratio of intensities of the wall after, and before contrast-enhanced. 9 according to MRI data - developed an acute ischemic stroke during this period, and 27 had no cerebral circulation disorders. The control group consisted of individuals without hypertension (n=12). Results After renal denervation, the systolic blood pressure significantly decreased in all patients for more than 15 mm Hg. In groups of patients with ischemic stroke, and without it, the diameter of the aortic lumen at the level above the renal arteries was 22,1±2,4 mm and 22,8±2,7 mm, respectively; the aortic wall thickness was 3,9±0,7 mm and 3,7±0,8 mm. In control subjects without hypertension, the wall thickness was less than 2,7 mm (on average 2,2±0,4 mm), with an aortic diameter of 21,3±0,9. As to the index of enhancement (as a marker of neoangiogenesis intensity) in the control group, in everybody, the IE was &amp;lt;1,12. In patients with stroke within 3 years after renal denervation, IE = 2,12±0,31, and in patients without stroke IE = 1,66±0,19. The value of IE = 1,82 was the best for separating groups with and without stroke in the three years endpoint, as from the ROC analysis. Conclusion Contrast enhancement of the aortic wall in MRI is associated with the risk of brain ischemic stroke in patients with resistant arterial hypertension, even when blood pressure control is achieved by renal denervation. This makes it possible to predict the risk of stroke in these patients more reliably and encourages the inclusion of agents that reduce the activity of inflammation and pathological neoangiogenesis in the aortic wall, to the spectrum of antihypertensive therapy. Funding Acknowledgement Type of funding sources: None. Brain MRI T2WIMRI of the kidneys and aorta, T1WI

Objective: Approximately 3%of patients with resistant arterial hypertension are diagnosed with pheochromocytoma. On other hand, paragangliomas of the head and neck are rare, representing &lt;0,5% of all head and neck tumors. They arise in a number of locations along the carotid sheath. Design and method: Herein, we present the case of a 66-year-old Caucasian woman (BMI 29,3 kg/m2) with resistant arterial hypertension (BP 160-170/100-110 mmHg while taking antihypertensive drugs: valsartan 320 mg/day, hydrochlorothiazide 25 mg/day, amlodipin 10 mg/day) and episodic headaches. Over the last 5 years prior to presentation, she had resistant hypertension and each year normal urinary metanephrine level and CT scan of the abdomen. Results: At the presentation a tumor (4,6x3,6x2,9 cm) was detected by ultrasound in the left submandibular region and laboratory tests detected a normal plasma metanephrine level - 0,16 nmol/l (reference values &lt;0,36 nmol/l) and normal plasma 3-methoxytyramine level -&lt;0,06 nmol/l (reference values&lt;0,15 nmol/l) and increased plasma normetanephrine level - 3,25 nmol/l (reference values&lt;1,05 nmol/l. The tumor was surgically removed and a carotid paraganglioma was confirmed histologically. After surgery, patient's blood pressure is controlled (130/80 mmHg) by taking a fixed combination valsartan 80/hydrochlorothiazide 6,25 mg /day). Conclusions: Patients with resistant arterial hypertension should be screened for secondary hypertension, even if such screening has already been done in previous years.

There is currently limited data on which drug should be used to improve blood pressure (BP) control in patients with resistant hypertension. This study was designed to assess the effect of the addition of 25 mg of spironolactone on BP in patients with resistant arterial hypertension. Patients with office systolic BP >140 mm Hg or diastolic BP >90 mm Hg despite treatment with at least 3 antihypertensive drugs, including a diuretic, were enrolled in this double-blind, placebo-controlled, multicenter trial. One hundred seventeen patients were randomly assigned to receive spironolactone (n=59) or a placebo (n=58) as an add-on to their antihypertensive medication, by the method of simple randomization. Analyses were done with 111 patients (55 in the spironolactone and 56 in the placebo groups). At 8 weeks, the primary end points, a difference in mean fall of BP on daytime ambulatory BP monitoring (ABPM), between the groups was -5.4 mm Hg (95%CI -10.0; -0.8) for systolic BP (P=0.024) and -1.0 mm Hg (95% CI -4.0; 2.0) for diastolic BP (P=0.358). The APBM nighttime systolic, 24-hour ABPM systolic, and office systolic BP values were significantly decreased by spironolactone (difference of -8.6, -6.6, and -6.5 mm Hg; P=0=0.011, 0.004, and 0.011 [corrected]), whereas the fall of the respective diastolic BP values was not significant (-3.0, -1.0, and -2.5 mm Hg; P=0.079, 0.405, and 0.079). The adverse events in both groups were comparable. In conclusion, spironolactone is an effective drug for lowering systolic BP in patients with resistant arterial hypertension.