Complication Of Severe Hypertension Research Articles

Circulating microRNAs May Serve as Biomarkers for Hypertensive Emergency End-Organ Injuries and Address Underlying Pathways in an Animal Model.

There is an incomplete understanding of the underlying pathophysiology in hypertensive emergencies, where severely elevated blood pressure causes acute end-organ injuries, as opposed to the long-term manifestations of chronic hypertension. Furthermore, current biomarkers are unable to detect early end-organ injuries like hypertensive encephalopathy and renal thrombotic microangiopathy. We hypothesized that circulating microRNAs (c-miRs) could identify acute and chronic complications of severe hypertension, and that combinations of c-miRs could elucidate important pathways involved. We studied the diagnostic accuracy of 145 c-miRs in Dahl salt-sensitive rats fed either a low-salt (N = 20: 0.3% NaCl) or a high-salt (N = 60: 8% NaCl) diet. Subclinical hypertensive encephalopathy and thrombotic microangiopathy were diagnosed by histopathology. In addition, heart failure with preserved ejection fraction was evaluated with echocardiography and N-terminal pro-brain natriuretic peptide; and endothelial dysfunction was studied using acetylcholine-induced aorta ring relaxation. Systolic blood pressure increased severely in animals on a high-salt diet (high-salt 205 ± 20 mm Hg vs. low-salt 152 ± 18 mm Hg, p < 0.001). Partial least squares discriminant analysis revealed 68 c-miRs discriminating between animals with and without hypertensive emergency complications. Twenty-nine c-miRs were strongly associated with hypertensive encephalopathy, 24 c-miRs with thrombotic microangiopathy, 30 c-miRs with heart failure with preserved ejection fraction, and 28 c-miRs with endothelial dysfunction. Hypertensive encephalopathy, thrombotic microangiopathy and heart failure with preserved ejection fraction were associated with deviations in many of the same c-miRs, whereas endothelial dysfunction was associated with a different set of c-miRs. Several of these c-miRs demonstrated fair to good diagnostic accuracy for a composite outcome of hypertensive encephalopathy, thrombotic microangiopathy and heart failure with preserved ejection fraction in receiver-operating-curve analyses (area-under-curve 0.75–0.88). Target prediction revealed an enrichment of genes related to several pathways relevant for cardiovascular disease (e.g., mucin type O-glycan biosynthesis, MAPK, Wnt, Hippo, and TGF-beta signaling). C-miRs could potentially serve as biomarkers of severe hypertensive end-organ injuries and elucidate important pathways involved.

Refractory Hypertension in Infantile-Onset Denys-Drash Syndrome.

Denys-Drash syndrome is characterized by progressive nephropathy, gonadal dysgenesis, and Wilms tumor caused by a WT1 gene mutation. Infants with Denys-Drash syndrome frequently experience severe hypertension, but detailed clinical manifestations have yet to be clarified. Cases of infantile-onset Denys-Drash syndrome with severe hypertension at our hospital were retrospectively analyzed and the pathogenesis of hypertension was investigated. Six infants who received the diagnosis of Denys-Drash syndrome at the median age of 10 days (range: 2-182 days) were enrolled. Five infants had the complication of severe hypertension within a few days of diagnosis. All the patients showed rapid progression to end-stage renal disease and urgently required dialysis due to anuria/oliguria and hypervolemia with a median duration of 7.5 days (range: 0-17 days) on the day after diagnosis. Even under dialysis, all the patients continued to need antihypertensive treatment. Five patients underwent a preventive nephrectomy for Wilms tumor, and one patient underwent a nephrectomy due to progression to Wilms tumor. Two patients developed hypotension after a nephrectomy. The main causes of hypertension were hypervolemia in the predialysis stage, renin-associated hypertension in the dialysis stage, and multiple factors, including increased plasma catecholamine-associated hypertension in the postnephrectomy dialysis stage. At last the follow-up after bilateral nephrectomy, four of the five patients required antihypertensive treatment. Not all the patients showed target organ complications caused by hypertension. Severe hypertension is a common complication of infantile-onset Denys-Drash syndrome. The possibility of hypotension after nephrectomy should be considered in patients with Denys-Drash syndrome.

Bilateral cortical blindness with Anton–Babinski syndrome in an elderly Nigerian woman: Challenges for tertiary prevention

Anton–Babinski syndrome (Anton's syndrome) is well described in the scientific literature even though it is a rare neurological condition. Most publications have highlighted the anatomy, neurophysiology, and pathology of visual anosognosia, which is the hallmark of the syndrome. We are not aware of any published report of cortical blindness with Anton's syndrome from Africa. We report a catastrophic complication of severe hypertension in an elderly Nigerian woman who was on follow-up for stroke, chronic heart failure, diabetes mellitus, and glaucoma. She developed bilateral cortical blindness with Anton's syndrome as a complication of severe hypertension, following 3 weeks of missed medications. This report highlights some challenges of tertiary prevention in this elderly woman without health insurance, who before becoming blind, had been largely dependent on family members' goodwill for her medical care.

Traitements antihypertenseurs et objectifs thérapeutiques de l’hypertension de la femme enceinte (HTA chronique préexistante, HTA gestationnelle) avant le sixième mois de grossesse

In the first 6months of pregnancy, the primary goal of antihypertensive treatment is to prevent the complications of severe hypertension. Initiation of antihypertensive drug treatment is recommended in pregnant women with severe hypertension (blood pressure>160/110mmHg). Initiation of antihypertensive drug treatment should also be considered in pregnant women at high cardiovascular risk (diabetes, chronic kidney disease, personal history of cardiovascular disease) with moderate hypertension (blood pressure between 140-159/90-109mmHg). A systolic blood pressure goal<160and a diastolic blood pressure goal between 85and 100mmHg is recommended in pregnancy. Labetalol, nifedipine, nicardipine and alphamethyldopa should be considered preferential antihypertensive drugs in pregnancy. Salt restriction, physical exercise and weight loss have not demonstrated any effect in the prevention of preeclampsia and serious maternal complications of hypertension.

Ischémie choroïdienne multifocale au cours de la toxémie gravidique : à propos de deux cas

Multifocal choroidal ischemia is a complication of severe hypertension, notably in preeclampsia. It is a rare phenomenon due to multiple choriocapillaris occlusions. We report the cases of two patients, age 28 and 32 years, 34 and 26 weeks since last menstrual period, respectively. The first had controlled preeclampsia under treatment. The second had developed Hemolysis, Elevated Liver enzymes, Low Platelet count (HELLP) syndrome complicated by in utero fetal death. Both patients reported visual loss. Comprehensive ophthalmological examination and fluorescein angiography confirmed the diagnosis of multifocal choroidal ischemia, in the acute stage in the first patient and cicatricial in the second. Acute choroidal ischemia is an ocular vascular syndrome which must be ruled out by systematic examination in any preeclamptic patient, so as to make the diagnosis and begin treatment early.

PP086. Severe hypertensive complications in pregnancy - Two years study (2011-2012).

There are major hypertensive disorders related to pregnancy-preeclampsia,eclampsia and HELLP syndrome. These women are at an increased risk for placental abruption,renal failure, cerebral hemorrhage,hepatic failure/rupture,pulmonary edema, DIC and of long-term cardiovascular disease. Study the incidence, risk factors, maternal/fetal outcome of hypertensive complications that determined Intensive Care Unit admission. A retrospective study of admissions in Intensive Care Unit for preeclampsia, HELLP syndrome and eclampsia in 2011-2012. There were 8 admissions in Intensive Care - 88% black women, average age was 20 years and all were nulliparous. 1 had an hypertension induced by pregnancy, but 63% had increased blood pressure in hospital admission. 50% had elevated liver enzymes, 25% proteinuria, 1 low platelet count and 1 had normal blood results. 50% of the admissions were due to eclampsia, 38% due to severe preeclampsia and 1 due to HELLP. Fetal/neonatal outcomes were prematurity in 25%, birth weight average was 2759g and none had apgar below 7. There was no fetal death. Vaginal delivery occurred in 25% and caesarian in 75%. Maternal complications were elevated blood pressure (75%), cardiorespiratory disorders (38%), encephalopathy (25%), renal disorder (13%) and convulsions (13%). There was no maternal death. The risk of adverse outcome increases with the severity of hypertension and organ damage. Early detection and appropriate management are essential.

Peripheral Facial Nerve Palsy in Severe Systemic Hypertension: A Systematic Review

Signs of nervous system dysfunction such as headache or convulsions often occur in severe systemic hypertension. Less recognized is the association between severe hypertension and peripheral facial nerve palsy. The aim of this study was to systematically review the literature on the association of peripheral facial palsy with severe hypertension. Systematic review of Medline, Embase, Web of Science, and Google Scholar from 1960 through December 2011 and report of two cases. The literature review revealed 24 cases to which we add two cases with severe hypertension and peripheral facial palsy. Twenty-three patients were children. Palsy was unilateral in 25 cases, bilateral in one case, and recurred in nine. The time between the first facial symptoms and diagnosis of hypertension was a median of 45 days (range, 0 days-2 years). In five case series addressing the complications of severe hypertension in children, 41 further cases of peripheral facial palsy were listed out of 860 patients (4.8%). The association between severe hypertension and peripheral facial palsy is mainly described in children. Arterial hypertension is diagnosed with a substantial delay. Outcome is favorable with adequate antihypertensive treatment. The pathophysiology is still debated.

Outcome at 4.5 years of children born after expectant management of early-onset hypertensive disorders of pregnancy

The objective of the study was to describe neurodevelopmental outcome at the age of 4.5 years in 216 children, born after expectant management of severe early-onset hypertensive complications of pregnancy. This was a prospective follow-up study until age 4.5 years from maternal admission onward. Developmental outcome measurements included child intelligence quotient and behavioral, motor, and neurological outcome. Abnormal composite outcome (perinatal mortality or abnormal developmental outcome) was studied in relation to gestational age (GA), birthweight (BW), and perinatal variables. Fetal and neonatal mortality was 9% and 8%, respectively. Of the 178 survivors, 149 (84%) were seen for follow-up. Mean GA was 31.4 weeks and 90% were born growth restricted. Abnormal developmental outcome occurred in 20% and abnormal composite outcome in 37%. Perinatal mortality or abnormal child development occurs in one third of pregnancies with early-onset and severe hypertensive complications and is highest in the lowest GA and BW ranges.

Renal Thrombotic Microangiopathies Induced by Severe Hypertension

Renal thrombotic microangiopathy (TMA) is an uncommon vascular complication of severe hypertension. Until now, its clinical-pathological characteristics and renal survival have been unclear. Twenty-one patients with biopsy-proven renal TMA and with severe or malignant hypertension were retrospectively studied. All the patients exhibited severe hypertension, with systolic blood pressure at 200-280 mmHg and diastolic pressure at 110-180 mmHg. No patients had hemorrhagic manifestations. Elevated lactate dehydrogenase and thrombocytopenia were found in 6 and 5 patients, respectively. Significant proteinuria (>3 g/day) was present in 2 patients and microscopic hematuria in 18 patients. All patients presented with renal insufficiency (creatinine 3.1+/-2.1 mg/dL). The level of von Willebrand factor:antigen (vWF:Ag) in patients was not significantly higher than that in the healthy subjects, while the ADAMTS13 (a disintegrin and metalloprotease, with thrombospondin-1-like domains) activity was not significantly lower than that in the healthy subjects. Renal histology showed a TMA involving preglomerular arterioles and/or interlobular arteries characterized by fibrin deposits and vascular wall sclerosis. Fibrin glomerular microthrombi were not observed in these patients. Four patients required hemodialysis upon admission for severe acute renal failure. On follow-up, 3 patients had recovered normal renal function and 14 had mild renal insufficiency (creatinine 1.8+/-0.3 mg/dL), while 4 patients still required persistent hemodialysis. In conclusion, compared with patients having hemolytic uremic syndrome/thrombocytopenic purpura, our patients showed a low incidence of thrombocytopenia and better renal outcome.

Die Diagnostik und Therapie des Schwangerschaftshochdruckes in Deutschland: Ergebnisse einer Umfrage an deutschen Frauenkliniken

Fragestellung: Wie ist der Standard von Diagnostik und Therapie hypertensiver Schwangerschaftserkrankungen an deutschen Frauenkliniken?

Interview with Raymond Gifford, Jr., MD. Interview by Marvin Moser.

It is appropriate that Raymond Gifford, Jr., MD, is considered an icon of hypertension. Dr. Gifford has been actively involved in research and treatment efforts in the field of hypertension for more than 45 years. He has been a strong voice in correcting the myths and misconceptions that prevailed in the 1940s and early 1950s about this disease. Dr. Gifford and other physicians at the Mayo Clinic were among the first to recognize that lowering blood pressure could reverse some of the complications of severe hypertension. They demonstrated that reducing blood pressure would help clear retinal hemorrhages, relieve symptoms of congestive heart failure, and at least temporarily reverse the syndrome of malignant hypertension. Later in his career, at the Cleveland Clinic where he was chairman of the Department of Hypertension and Nephrology for many years, Dr. Gifford worked with Irv Page, Harriet Dustan, Emanuel Bravo, Ed Frohlich, Bob Tarazi, and others on the causes of secondary hypertension. Dr. Gifford was involved in evaluating almost all of the antihypertensive drugs from the 1950s, including the peripheral and ganglion blocking agents, and did some of the early studies on diuretics. I have been fortunate to observe and interact with Dr. Gifford through many of these projects, at meetings and seminars, at the National Heart, Lung, and Blood Institute, and at quiet dinners. He possesses the unique ability to clarify an issue in one or two sentences that oftentimes will have been debated for hours. When Dr. Gifford speaks, people listen. I am always pleased when Dr. Gifford agrees with me; I know I must be right. In the following interview, Dr. Gifford minimizes his contributions, which extend far beyond his involvement in the National High Blood Pressure Education Program and his work at the Cleveland Clinic. Dr. Gifford is retired from practice and the Clinic, but remains a strong voice in the world of hypertension as a frequent speaker at national and international meetings where he always presents an unbiased, scientifically accurate point of view.

Spontaneous Sublingual Hematoma as a Complication of Severe Hypertension: First Report of a Case

We describe what we believe is the first reported case of a sublingual hematoma secondary to severe hypertension. The patient, a 77-year-old woman, experienced a spontaneous hematoma of the floor of the mouth, tongue, and sublingual space that eventually caused an airway obstruction. We performed an emergency tracheostomy under local anesthesia and then evacuated the hematoma through an incision along the floor of the mouth. The patient recovered uneventfully.

Hypertensive Encephalopathy

Hypertensive encephalopathy is a dramatic syndrome characterized by severe elevation of blood pressure, headache, visual disturbances, altered mental status, and convulsions. Although the syndrome is uncommon, to recognize and treat it promptly is important or the condition may prove to be fatal. Hypertensive encephalopathy should be distinguished from other cerebral complications of severe hypertension by obtaining careful history and performing thorough physical examination. The only definitive criterion for the diagnosis of this syndrome is its prompt response to therapy. If the patient's condition does not improve with hypotensive therapy, the physician should immediately search for alternate diagnoses. Potent drugs are available for prompt reduction of blood pressure. There are few medical emergencies in which the objective response to therapy is so strikingly apparent as in hypertensive encephalopathy.