Complete Resolution Of Hypertension Research Articles

Abstract P301: Predicting Complete Resolution Of Hypertension After Adrenalectomy In Primary Aldosteronism: A Systematic Review And Meta-analysis Of Prognostic Models. Surgical Outcome of PRimary Aldosteronism progNostic mOdels (SOPRANO) Study

Background: Unilateral primary aldosteronism (PA) is the most common surgically curable form of hypertension, despite complete clinical success after adrenalectomy being far from certain. Several presurgical factors were associated with complete resolution of hypertension (CRH). However, it remains unclear which of the available prognostic models combining those factors can be used in clinical practice to predict blood pressure-related outcomes after surgery for PA. Objectives: To identify, describe and appraise all prognostic models developed to predict CRH, and meta-analyse their predictive performances. Methods: We searched MEDLINE, Embase, and Web of Science, for development and validation studies of prognostic models according to the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) statement. The quality assessment used adapted TRIPOD (Transparent Reporting of a multivariable prediction model for Individual Prognosis Or Diagnosis) and PROBAST (Prediction model Risk Of Bias ASsessment Tool) criteria. After selection, we extracted descriptive statistics and aggregated area under the receiver operator curve (AUC) using meta-analysis. Results: From 25 eligible studies, we identified 12 prognostic models used for predicting CRH after total adrenalectomy in PA. We report the results for three models that had available data from at least three external validation studies: the Primary Aldosteronism Surgical Outcome (PASO) score (AUC: 0.81; 95% confidence interval [CI]: 0.74–0.86; 95% predictive interval [PI]: 0.04–1.00), Utsumi nomogram (AUC: 0.79; 95% CI: 0.72–0.85; 95% PI: 0.03–1.00), and the Aldosteronoma Resolution Score (ARS) model (AUC: 0.77; 95% CI: 0.74–0.80; 95% PI: 0.59–0.86 for all studies and AUC: 0.80; 95% CI: 0.75–0.85; 95% PI: 0.57–0.93 for the studies with the same adrenal vein sampling-guided adrenalectomy rate compared to the models meta-analyzed). Conclusions: The PASO score, Utsumi nomogram, and ARS model showed good and comparable discrimination performance to predict CRH after unilateral adrenalectomy in PA. However, unlike the ARS model, the number of external validation studies for the PASO score and the Utsumi nomogram was relatively low to draw definite conclusions.

Surgery for Primary Aldosteronism in France From 2010 to 2020 - Results from the French-Speaking Association of Endocrine Surgery (AFCE): Eurocrine Study Group.

Describe the diagnostic workup and postoperative results for patients treated by adrenalectomy for primary aldosteronism in France from 2010 to 2020. Primary aldosteronism (PA) is the underlying cause of hypertension in 6% to 18% of patients. French and international guidelines recommend CT-scan and adrenal vein sampling as part of diagnostic workup to distinguish unilateral PA amenable to surgical treatment from bilateral PA that will require lifelong antialdosterone treatment.Adrenalectomy for unilateral primary aldosteronism has been associated with complete resolution of hypertension (no antihypertensive drugs and normal ambulatory blood pressure) in about one-third of patients and complete biological success in 94% of patients.These results are mainly based on retrospective studies with short follow-up and aggregated patients from various international high-volume centers. Here we report results from the French-Speaking Association of Endocrine Surgery (AFCE) using the Eurocrine® Database. Over 11 years, 385 patients from 10 medical centers were eligible for analysis, accounting for >40% of adrenalectomies performed in France for primary aldosteronism over the period.Preoperative workup was consistent with guidelines for 40% of patients. Complete clinical success (CCS) at the last follow-up was achieved in 32% of patients, and complete biological success was not sufficiently assessed.For patients with 2 follow-up visits, clinical results were not persistent at 1 year for one-fifth of patients.Factors associated with CCS on multivariate analysis were body mass index, duration of hypertension, and number of antihypertensive drugs. These results call for an improvement in thorough preoperative workup and long-term follow-up of patients (clinical and biological) to early manage hypertension and/or PA relapse.

Prognostic models to predict complete resolution of hypertension after adrenalectomy in primary aldosteronism: A systematic review and meta-analysis.

Complete resolution of hypertension (CRH) after adrenalectomy for primary aldosteronism is far from a certainty. Although several prognostic models have been proposed to predict outcome after adrenalectomy, studies have not clarified which of the available models can be used reliably in clinical practice.To identify, describe and appraise all prognostic models developed to predict CRH, and meta-analyse their predictive performances.We searched MEDLINE, Embaseand Web of Science for development and validation studies of prognostic models. After selection, we extracted descriptive statistics and aggregated area under the receiver operator curve (AUC) using meta-analysis.From 25 eligible studies, we identified 12 prognostic models used for predicting CRH after total adrenalectomy in primary aldosteronism. We report the results for 3models that had available data from at least 3external validation studies: the primary aldosteronism surgical outcome (PASO) score (AUC: 0.81; 95% confidence interval [CI]: 0.74-0.86; 95% predictive interval [PI]: 0.04-1.00), Utsumi nomogram (AUC: 0.79; 95% CI: 0.72-0.85; 95% PI: 0.03-1.00)and the aldosteronoma resolution score (ARS) model (AUC: 0.77; 95% CI: 0.74-0.80; 95% PI: 0.59-0.86 for all studies and AUC: 0.80; 95% CI: 0.75-0.85; 95% PI: 0.57-0.93 for the studies with the same adrenal vein sampling-guided adrenalectomy rate compared to the models meta-analysed).The PASO score, Utsumi nomogramand ARS model showed comparable discrimination performance to predict CRH in primary aldosteronism. Unlike the ARS model, the number of external validation studies for the PASO score and the Utsumi nomogram was relatively low to draw definite conclusions.

Assessment of performance of stratum-specific likelihood ratios of the aldosteronoma resolution score for predicting hypertension cure after adrenalectomy for primary aldosteronism: a systematic review and meta-analysis.

The Aldosteronoma Resolution Score (ARS) is the most studied scoring system for predicting the high likelihood of hypertension cure after adrenalectomy for unilateral primary aldosteronism (PA). However, the ARS's accuracy in PA patients worldwide is uncertain. We aimed to perform a meta-analysis of the accuracy, discrimination, and calibration of the ARS using stratum-specific likelihood ratios (SSLR) by organizing available data from cohort studies. We searched PubMed, Embase (Ovid), the Cochrane CENTRAL, Web of Science to November 2021 according to PRISMA statement. The quality assessment used adapted TRIPOD and PROBAST criteria. Thirteen studies comprising 2158 PA patients from North America (43%), Europe (32%), Asia (22%), and other continents, were included. The pooled estimate of the area under the receiver operating characteristic curve for all studies was 0.77 (95% CI: 0.73-0.81), and the ratio of the observed to expected complete resolution of hypertension (CRH) for all studies was 0.9 (95% CI: 0.8-1.0). The summary estimates of the SSLR for all studies were 0.31, 0.89, and 3.1, for the low (ARS 0-1), medium (ARS 2-3), and high-likelihood group (ARS 4-5) of CRH, respectively. However, substantial heterogeneity existed among studies. Follow-up period, and adrenalectomy AVS (adrenal vein sampling)-guided served as potential sources of heterogeneity for quantitative studies, which were measurement and reference standard for qualitative studies selection. In conclusion, in patients with unilateral PA, the ARS is currently an accurate prediction tool, the easiest and cheapest, for identifying long-term high likelihood of CRH after adrenalectomy, particularly when the adrenalectomy is AVS-guided.

DISCRIMINATION, CALIBRATION, AND STRATUM-SPECIFIC LIKELIHOOD RATIOS FOR THE ALDOSTERONOMA RESOLUTION SCORE: A META-ANALYSIS

Objective: The Aldosteronoma Resolution Score (ARS) is the most studied scoring system for predicting the high likelihood of complete resolution of hypertension (CRH) after adrenalectomy for primary aldosteronism (PA). We aimed to perform a meta-analysis of the accuracy, discrimination, and calibration of the ARS using a novel approach to calculation of stratum-specific likelihood ratios (SSLR). Design and method: We searched PubMed, Embase (Ovid), the Cochrane CENTRAL, Web of Science, the Bielefeld Academic Search Engine (BASE) to November 2021 according to the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) statement. The quality assessment used adapted TRIPOD (Transparent Reporting of a multivariable prediction model for Individual Prognosis Or Diagnosis) and PROBAST (Prediction model Risk Of Bias ASsessment Tool) criteria. Results: Thirteen studies comprising 2,158 PA patients from North America (43%), Europe (32%), Asia (22%), and other continents, were included. The pooled estimate of the area under the receiver operating characteristic curve for all studies was 0.77 (95% CI 0.73–0.81), and the ratio of the observed to expected CRH for all studies was 0.9 (95% CI 0.8–1.0). The summary estimates of the SSLR for all studies were 0.3, 0.9, and 3.1, for the low (ARS 0–1), medium (ARS 2–3), and high-likelihood group (ARS 4–5) of CRH, respectively. For studies with a mean follow-up closest to 6, 12, and 36 months, the likelihood ratios were 0.3, 0.8, and 2.6; 0.3, 0.7, and 3.9; and 0.3, 1.8, and 7.0, respectively. When we compared studies that had performed adrenal vein sampling (AVS) in at least 50% of the cohort (mean 77% vs. 38%), the ARS model’s accuracy doubled in the high-likelihood group (ARS 4–5) and tripled in the only study in which all patients were underwent AVS (Figure). Conclusions: In patients with unilateral PA, the ARS is currently the easiest, cheapest, and accurate prediction tool for identifying the long-term high likelihood of CRH after adrenalectomy, particularly when the adrenalectomy is AVS-guided.

Bilateral adrenal pheochromocytomas in a 14 year-old boy

Abstract Introduction Pheochromocytomas are catecholamine-secreting tumors arise from chromaffin cells of the adrenal medulla. Classical symptoms include palpitations, headaches, sweating and paroxysmal hypertension as a result of elevated catecolamine production. This case report aims to describe the clinical presentation, management and outcome of the phechromocytomas. Case A 14 year-old boy came with hypertensive crisis (blood pressure 220/140 mmHg), recurrent tension headache, excessive sweating, palpitation and weight loss during the last 1 year. Twenty four hour urinary catecholamine level was normal. Abdominal CT scan confirmed the suspicion of pheochromocytoma. After having preoperative treatment with nicardipine infusion, oral nifedipine and captopril, bilateral cortical sparing adrenalectomy was done. Nicardipine infusion was administered to maintain the blood pressure during surgery. Histopathology confirmed the diagnosis of adrenal pheochromocytoma Adrenocortical was preserved. Complete resolution of hypertension was achieved gradually after one month. Conclusion Pheochromocytomas is a rare disease which may lead to a life-threatening hypertension as a result of elevated catecolamine production. Initial recognition and appropriate management of pheochromocytomas are important. Preoperative management to normalize blood pressure followed by tumor removal has proved to be the ideal choice for good prognosis. Multidisciplinary team during preoperative, intraoperative and postoperative are required for successful outcome.

MP12-08 SURGICAL AND HEMODYNAMIC OUTCOMES IN PATIENTS UNDERGOING PHEOCHROMOCYTOMA AND PARAGANGLIOMA SURGERY: A PROSPECTIVE COHORT STUDY

INTRODUCTION AND OBJECTIVES: To identify risk factors, including aortic calcification, for persistent hypertension in primary aldosteronism (PA) patients who underwent laparoscopic adrenalectomies. METHODS: Between October 2000 and October 2015, we performed consecutive 101 laparoscopic adrenalectomies for unilateral PA patients. Of those, 95 patients who had at least one year follow-up periods were included. The patients were divided into two groups based on whether they had normal blood pressure without antihypertensive medications (resolved group) or still required medications (unresolved group) at one year after surgery. Variables included age, gender, body mass index, history of hypertension, dosage of antihypertensive medication score, presence of type 2 diabetes, subclinical Cushing syndrome, preoperative renal function, aldosteronoma resolution score (ARS), and abdominal calcification index (ACI). Univariate and multivariate logistic regression analyses were used to assess independent risk factors for persistent hypertension one year after surgery. RESULTS: The complete resolution of hypertension without antihypertensive medication one year after adrenalectomy was 36/95 (38%). Preoperative antihypertensive medication score, systolic blood pressure, ACI were significantly higher, and ARS were significantly lower in the unresolved group than in the resolved group. Using multivariate logistic regression analysis, independent risk factors significantly correlating with persistent hypertension one year after surgery were ARS and ACI. CONCLUSIONS: Adrenalectomy improved blood pressure and the need for antihypertensive medications, whereas ARS and ACI were potential independent risk factors for persistent hypertension one year after adrenalectomy.

Laparoscopic Revision of Banded Roux-En-Y Gastric Bypass: Pouch Resizing and Redo of Gastrojejunal Anastomosis for Ring Migration and Pouch Dilation

Introduction: The Roux-en-Y gastric bypass (RYGB) is a surgical procedure to induce and maintain weight loss. It was first reported for the treatment of obesity in 1967.1 Since then, this surgery has undergone many modifications, such as the placement of a silastic ring around the gastroenterostomy site.2 This procedure, known as banded RYGB, was performed to restrict the rate of emptying of the pouch. Some patients develop serious ring-related complications, such as nausea, vomiting, regurgitation, and even malnutrition, requiring revision of their bariatric operation.3 The stenosis due to the ring migration leads to gastric pouch dilation and weight regain after distal obstruction resolution. A pouch resizing may be necessary to prevent obesity relapse. We present a video of a revisional laparoscopic surgery for the treatment of ring migration with gastric pouch dilation. Materials and Methods: A 48-year-old female with hypertension and type 2 diabetes underwent open-banded RYGB in 2007. The maximum weight was 119 kg (body mass index [BMI] = 44 kg/m2). The patient remained with stable weight until 2012. After 5 years of surgery, the patient weighed 62.1 kg (BMI = 23 kg/m2) with complete resolution of hypertension and diabetes. However, the patient started presenting gastroesophageal reflux symptoms, postprandial vomiting, and progressive weight loss. Seven years after surgery, the patient weighed 55 kg (BMI = 20.7 kg/m2). The patient was subjected to investigation. Endoscopy revealed Los Angeles grade C esophagitis and stenosis of the gastrojejunal anastomosis, upper gastrointestinal contrast study demonstrated ring migration, and computed tomography showed pouch volumetry of 110 mL. The patient underwent multiple upper endoscopies with dilations without substantive relief of symptoms. Laparoscopic approach was performed with gastrojejunostomy resection along with the ring, pouch resizing, and redo of gastrojejunal anastomosis within a 210 minutes procedure. Results: The postoperative period was uneventful. The patient started with fasting at postoperative day 1, presented good liquid diet acceptance, and had hospital discharged 4 days after surgery. No early complication was observed. After 2 years, the patient is without gastroesophageal reflux and no weight regain. Conclusion: Ring migration along with pouch dilation after banded RYGB can be safely managed through laparoscopic gastrojejunostomy resection and pouch resizing with immediate and long-term symptomatic improvement. This video was presented at the IFSO Congress 2014 in Montreal, Canada. No competing financial interests exist. Runtime of video: 4 mins 58 secs

Aldosteronoma resolution score predicts long-term resolution of hypertension

The Aldosteronoma Resolution Score (ARS) takes into consideration four, readily available, preoperative clinical parameters in predicting the likelihood of resolution of hypertension in patients 6 months after undergoing unilateral adrenalectomy for aldosterone-producing adenoma (APA). We sought to determine the durability of this predictive model after 1 year. Sixty patients who underwent unilateral adrenalectomy for APA at a single institution between 2004 and 2013 were reviewed retrospectively. Patients who were normotensive without any antihypertensive medication requirement at greater than 1-year follow-up were considered to have complete resolution of hypertension. Forty-seven patients had data available for analysis. Median follow-up was 1,135 days (371-3,202). Forty-five percent of patients had complete resolution, 45% had improvement, and 10% had no improvement in hypertension. Applying the ARS, we found there was complete resolution of hypertension in 73% of patients with ARS 4-5, 53% of patients with ARS 2-3, and 24% of patients with ARS 0-1 compared with 75% (P = .9), 46% (P = .66), and 28% (P = .76), respectively, in the original cohort used to create the ARS. Most patients (90%) have long-term improvement or complete resolution of hypertension after unilateral adrenalectomy for APA. The ARS predicts accurately a patient's likelihood of complete resolution of hypertension beyond 1 year.

A single-step approach to the diagnosis of primary hyperaldosteronism: filling a true void or burdening the bottleneck of adrenal vein sampling?

In the present issue of The Journal of Clinical Hypertension, Kline and colleagues propose a fundamental change in the diagnostic workup of patients evaluated for potential primary hyperaldosteronism (PH). Traditionally, the diagnosis of PH is predominantly considered in the presence of hypertension with hypokalemia; severe or resistant hypertension; adrenal incidentaloma, particularly when associated with hypertension; and hypertension of early onset, especially in the context of familial hypertension with early cerebrovascular events. That screening for PH should be initiated by the determination of the Aldosterone-Renin Ratio (ARR) is now widely recommended. A high ARR is followed by one of several confirmatory forms of testing, all of which are based on the principle that contrary to physiological control of aldosterone secretion, autonomous aldosterone secretion cannot be properly turned off in response to salt/volume loading or acute reduction in circulating angiotensin II. Although the need for confirmatory testing is widely accepted, views on the most adequate procedure vary. Reflecting this area of disagreement, the Endocrine Society’s guidelines endorse the use of one of several forms of tests: the oral sodium loading test, saline infusion test, fludrocortisone suppression test, or the captopril challenge test. In principle, only individuals with evidence of autonomous aldosterone secretion in any of these tests are presumed to have “true PH” and are thus referred for further evaluation, including computed tomography (CT) or magnetic resonance imaging scans, followed by adrenal venous sampling (AVS). Individuals with unilateral disease, mostly aldosterone-producing adenoma, are usually referred for surgery and are likely to benefit from adrenalectomy, whereas patients with bilateral adrenal hyperplasia are treated medically. In their present article, Kline and coworkers challenge the need for confirmatory testing and offer an alternative single-step, ARR-based approach to the diagnosis of PH, to be directly followed, when a preset critical ARR is surpassed, by adrenal imaging and AVS. Because of the inconsistent performance of the confirmatory tests, the authors abandoned this phase altogether. Having accumulated considerable experience with this approach, this group now submits evidence from a single referral center that a systematic omission of confirmatory testing has virtually no discernible impact on the clinical outcome of patients evaluated for PH. In the course of 6 years (2005–2011), Kline and associates evaluated 83 hypertensive patients whose initial ARR exceeded 550 pmol/L irrespective of their medication status. Patients with resistant hypertension and normal ARR were re-evaluated after the withdrawal of all medications known to affect aldosterone and/or plasma renin activity (PRA) and maintained on doxazocin and either nifedipine or diltiazem, supplemented, when needed, only by oral potassium-containing tablets. In all, 83 patients whose ARR exceeded 550 pmol/L were considered to have PH. All were referred for adrenal CT and AVS, using a protocol in which adrenal vein aldosterone was measured both before and after the administration of 250 lg of cosyntropin (a synthetic derivative of adrenocorticotropic hormone [ACTH]). Patients whose post-ACTH interadrenal aldosterone/cortisol ratio gradient was higher than 3 were considered to have unilateral disease. In terms of outcome, AVS was technically successful in 80 of 83 (96%) of the patients and an unequivocal AVS-based lateralization was established in 48 patients. Notably, 88% of the lateralized patients had a congruent CT finding, whereas unilateral anomalous CT adrenal was seen in <34% of patients with nonlateralization. Of the 48 lateralized patients, 8 refused surgery. With a median follow-up of 8 months, approximately one third of the operated patients had complete resolution of hypertension; approximately 60% had improvement in blood pressure, whereas only marginal improvement was seen in 2 patients (~5%). The latter patients turned out to have a known contralateral mass identified on CT prior to surgery. Are these data convincing enough to reconsider the traditional “first screen, then confirm/exclude” biphasic approach to the diagnosis of PH and possibly reduce it to a single-step ARR-based strategy? There are 4 fundamental questions that require elucidation before such modification can be contemplated. First, is the cohort treated here representative of the patient population assessed for PH at large? Apparently not, on several accounts: the population base from which the patients were referred for evaluation was not presented in Kline’s report. Referrals to a single center inherently reflect uncharacterized population specifics such as ethnic distribution, salt consumption, referring physicians’ perception of “resistant hypertension,” and access to specialists and/or credible laboratory services. Although not explicitly stated, Kline and colleagues *The first two authors contributed qually to this manuscript.

High predictive accuracy of Aldosteronoma Resolution Score in Japanese patients with aldosterone-producing adenoma

Primary aldosteronism caused by aldosterone-producing adenoma is the most common curable cause of secondary hypertension, but despite resection, many patients continue to require antihypertensive medications to control their blood pressure postoperatively. The Aldosteronoma Resolution Score is a preoperative 4-item predictive model for the complete postoperative resolution of hypertension. Our aim was to validate the accuracy of this model in predicting postoperative resolution of hypertension in Japanese patients. The records of 91 Japanese patients who underwent unilateral adrenalectomy for aldosterone-producing adenoma were surveyed retrospectively. Patients were distributed into 2 groups according to whether blood pressure was normal without antihypertensive medications at 6 months postoperatively. Clinical and biochemical data were evaluated at baseline and after the 6-month follow-up. At 6 months, blood pressure had normalized in 45% of the patients without antihypertensive medications. Multivariate logistic regression analysis revealed that patients who had complete resolution of hypertension were significantly more likely to have been taking ≤2 antihypertensive medications preoperatively, have a duration of hypertension of <6 years, and be female. The predictive accuracy of the Aldosteronoma Resolution Score was assessed using the area under the curve of receiver operator characteristics analysis. The value of the area under the curve was 0.81. Our external validation revealed that the Aldosteronoma Resolution Score developed using Western data can identify accurately Japanese individuals with aldosterone-producing adenoma who are likely to have complete resolution of hypertension after adrenalectomy.

Management of Primary Aldosteronism: Its Complications and Their Outcomes After Treatment

Primary aldosteronism is the most common cause of secondary hypertension, accounting for about 10% of all forms of high blood pressure. Life-time pharmacological therapy is the treatment of choice for primary aldosteronism due to idiopathic adrenal hyperplasia (IHA), while adrenalectomy is effective in curing most patients with an aldosterone producing adenoma (APA). Far from being a benign form of hypertension, primary aldosteronism is characterized by the development of cardiovascular renal and metabolic complications, including left ventricular hypertrophy, myocardial infarction, atrial fibrillation and stroke, microalbuminuria, renal cysts as well as metabolic syndrome, glucose impairment and diabetes mellitus. We review recent clinical experience with the above mentioned complications and long-term outcomes of blood pressure normalization and cardiac, renal and gluco-metabolic complications in patients with primary aldosteronism, after medical treatment with mineralocorticoid receptor antagonists and surgical treatment. We conclude that removal of adrenal adenoma results in normalization of the renin-angiotensin-aldosterone system (RAAS) and of kalaemia and improvement of blood pressure levels in all patients. Complete resolution of hypertension is achieved in nearly half of treated patients. Moreover, unilateral adrenalectomy is the best treatment to have the regression of cardiovascular, renal and metabolic complications in patients with APA. On the other hand, targeted medical treatment with aldosterone antagonists improves blood pressure control and appears able to prevent the progression of cardiac and metabolic complications in patients with IHA.

The Aldosteronoma Resolution Score: Predicting Complete Resolution of Hypertension After Adrenalectomy for Aldosteronoma

The Aldosteronoma Resolution Score: Predicting Complete Resolution of Hypertension After Adrenalectomy for Aldosteronoma

Resolution of Systemic Hypertension after Laparoscopic Gastric Bypass

BackgroundHypertension is a well-recognized and treatable risk factor for coronary heart disease and is one of the most common comorbidities associated with obesity. The aim of this study was to characterize the clinical outcome of a cohort of patients with documented hypertension who underwent laparoscopic gastric bypass. MethodsNinety-five obese patients with documented hypertension and being treated with antihypertensive medication(s) underwent laparoscopic gastric bypass. Main outcome measures included length of hypertensive condition, changes in systolic and diastolic blood pressures, and changes in antihypertensive medication(s) at follow-up. ResultsThere were 69 (72%) females with a mean preoperative body mass index of 47 kg/m2. The mean duration of hypertension was 73 ± 70 months. The mean excess body weight loss at 12 months was 66%. The mean systolic blood pressure significantly decreased from 140 ± 17 mmHg preoperatively to 120 ± 18 mmHg at 12 months (p < 0.01). The mean diastolic blood pressure also significantly decreased from 80 ± 11 mmHg preoperatively to 71 ± 8 mmHg at 12 months (p < 0.01). At 12 months follow-up, 44 (46%) patients had complete resolution of hypertension while 18 (19%) patients had improvement. Patients with complete resolution had a shorter duration of disease as compared to patients without resolution (53 vs. 95 months, respectively, p = 0.01). ConclusionWeight loss associated with laparoscopic gastric bypass substantially improves and/or resolves hypertension in the majority of patients. Improvement of hypertension occurs as early as 1 month postoperatively and is more frequently in patients with a shorter preoperative duration of disease.

Good blood pressure control on antihypertensives, not only response to spironolactone, predicts improved outcome after adrenalectomy for aldosteronoma

Spironolactone is frequently used before adrenalectomy for hyperaldosteronism to control blood pressure. Response to spironolactone has been suggested to predict a better outcome. However, whether using other antihypertensive medications to control blood pressure predicts outcome remains unknown. We sought to determine the relationship between preoperative normalization of blood pressure with antihypertensive medications and response to adrenalectomy for hyperaldosteronism. A retrospective cohort study of 102 patients who underwent adrenalectomy for hyperaldosteronism at a tertiary medical center were included. Blood pressures were measured at first clinical presentation, preoperatively, postoperatively, and at 1 and 6 months postoperatively. The primary outcome measure was complete resolution of hypertension (blood pressure <140/90) without antihypertensive medications, versus incomplete resolution requiring antihypertensive medications. Hypertension resolved and medications were discontinued in 39% of patients. Hypertension resolved without medications in 53% of patients who were normotensive preoperatively versus 24% of patients who were hypertensive (P = .006). In contrast, hypertension resolved without medications in only 45% of patients who were normotensive on spironolactone preoperatively versus 34% of patients who were hypertensive (P = .38). Patients with good preoperative control of hypertension on antihypertensive medications, irrespective of response to spironolactone, are more likely to have complete resolution.

Complete Resolution of Hypertension after Decompression of Chiari I Malformation

The Chiari I malformation has not been previously linked to sustained hypertension. Other forms of medullary compression have, however, been shown to be associated with elevated arterial pressure. This association has been demonstrated through numerous studies that have implicated compression of the rostral ventrolateral medulla, usually by vascular structures, as a factor responsible for hypertension. We present a case of a young man with a 2-year history of hypertension who was found to have a Chiari I malformation. No other cause for hypertension was found. After subsequent surgical decompression, his hypertension resolved immediately. No other therapeutic options were activated. This is the first reported case linking Chiari I malformation and sustained hypertension. This case presents further evidence linking medullary compression and elevation of hemodynamic tone.