Discontinuation Of Antihypertensive Treatment Research Articles

Effects of the discontinuation of antihypertensive treatment on neuropsychiatric symptoms and quality of life in nursing home residents with dementia (DANTON): a multicentre, open-label, blinded-outcome, randomised controlled trial.

Based on observational studies and randomised controlled trials (RCTs), the benefit-harm balance of antihypertensive treatment in older adults with dementia is unclear. To assess whether discontinuing antihypertensive treatment reduces neuropsychiatric symptoms (NPSs) and maintains quality of life (QoL) in nursing home residents with dementia. Open-label, blinded-outcome RCT. Randomisation 1:1, stratified by nursing home organisation and baseline NPS. Trial registration: NL7365. Dutch long-term care residents with moderate-to-severe dementia and systolic blood pressure (SBP) ≤160mmHg during antihypertensive treatment. Exclusion criteria included heart failure NYHA-class-III/IV, recent cardiovascular events/procedures or life expectancy <4months (planned sample size n = 492). Co-primary outcomes NPS (Neuropsychiatric Inventory-Nursing Home [NPI-NH]) and QoL (Qualidem) at 16weeks. From 9 November 2018 to 4 May 2021, 205 participants (median age 85.8 [IQR 79.6-89.5] years; 79.5% female; median SBP 134 [IQR 123-146] mmHg) were randomised to either antihypertensive treatment discontinuation (n = 101) or usual care (n = 104). Safety concerns, combined with lacking benefits, prompted the data safety and monitoring board to advice a premature cessation of randomisation. At 16-week follow-up, no significant differences were found between groups for NPI-NH (adjusted mean difference 1.6 [95% CI -2.3 to 5.6]; P = 0.42) or Qualidem (adjusted mean difference - 2.5 [95% CI -6.0 to 1.0]; P = 0.15). Serious adverse events (SAEs) occurred in 36% (discontinuation) and 24% (usual care) of the participants (adjusted hazard ratio 1.65 [95% CI 0.98-2.79]). All 32-week outcomes favoured usual care. Halfway through this study, a non-significant increased SAE risk associated with discontinuing antihypertensive treatment was observed, and an associated interim analysis showed that significant worthwhile health gain for discontinuation of antihypertensive treatment was unlikely. This unbeneficial benefit-harm balance shows that discontinuation of antihypertensive treatment in this context does not appear to be either safe or beneficial enough to be recommended in older adults with dementia.

Arterial hypertension in acute stroke. Current therapeutical indications

Acute stroke (the first hours after its onset) is accompanied in over 70% of cases by rapid and significant increases in blood pressure, above normal values. The acute or reactive hypertensive response occurs both in patients with a history of hypertension and in normotensive patients. The greatly increased BP values, not controlled therapeutically, can be followed by the increase in the volume of the cerebral infarct and hemorrhagic transformation or the expansion of the hematoma and the increase in intracerebral pressure, respectively in ischemic or hemorrhagic stroke. This paper especially refers to the therapeutic control of hypertension in various situations (conditions): 1. Laboratory emergencies; 2. Hospital treatment with out thrombolytics or thrombolysis; 3. Endovascular treatment in acute stroke; 4. BP control in hemorrhagic stroke; 5. Continuation or discontinuation of antihypertensive treatment. The updated recommendations for the treatment of HTN in acute stroke result from clinical studies and recommendations of the recent ESO and AHA/ASA Guidelines.

THE DANTON STUDY - DISCONTINUATION OF ANTIHYPERTENSIVE TREATMENT IN OLDER PEOPLE WITH DEMENTIA LIVING IN A NURSING HOME: RESULTS OF A RANDOMIZED CONTROLLED TRIAL

Objective: Neuropsychiatric symptoms (NPS), such as apathy and agitation, are highly prevalent in nursing home (NH) residents with dementia. Literature suggests an association of both cerebral hypoperfusion and antihypertensive treatment (AHT) with NPS in patients with dementia. Therefore, we investigated whether discontinuation of AHT in NH residents with dementia reduces NPS and improves quality of life (QoL). Design and method: Randomized, single-blinded trial conducted in 26 Dutch NH organisations. Residents with moderate-severe dementia and a systolic blood pressure &lt; 160 mmHg during AHT were randomized in an intervention (semi-protocolized discontinuation) and control (continuation) group during a period of 8 months. Exclusion criteria were heart failure NYHA-class-III/IV, angina pectoris, a recent cardiovascular event/reperfusion procedure, or a life-expectancy &lt; 4 months. Co-primary endpoints were NPS (Neuropsychiatric Inventory-Nursing Home version) and QoL (Qualidem) at 4 months. Secondary endpoints include cognitive function, care dependency, general daily functioning and falls. Results: Between December 2018 and May 2021, 205 NH residents with dementia (median age 86 years-79.5% women) were randomized, of which 177 (86.3%) reached the primary endpoint at 4 months. During trial, 63 severe adverse events occurred in 61 residents. On advice of the Data Safety Monitoring Board, the study was preliminary finished in December 2021 due to futility based on the co-primary endpoints. Definitive results for all endpoints measured at 4 and 8 months follow-up will be available in April 2022. Conclusions: This is, to our knowledge, the largest AHT deprescription trial in NH residents with dementia. Based on preliminary results of this study, the benefits of deprescribing AHT in NH residents with dementia for reduction of NPS and improvement of QoL, are unclear and may not be without any potential risk.

Association of hypertension and antihypertensive treatment with COVID-19 mortality: a retrospective observational study.

AimsIt remains unknown whether the treatment of hypertension influences the mortality of patients diagnosed with coronavirus disease 2019 (COVID-19).Methods and resultsThis is a retrospective observational study of all patients admitted with COVID-19 to Huo Shen Shan Hospital. The hospital was dedicated solely to the treatment of COVID-19 in Wuhan, China. Hypertension and the treatments were stratified according to the medical history or medications administrated prior to the infection. Among 2877 hospitalized patients, 29.5% (850/2877) had a history of hypertension. After adjustment for confounders, patients with hypertension had a two-fold increase in the relative risk of mortality as compared with patients without hypertension [4.0% vs. 1.1%, adjusted hazard ratio (HR) 2.12, 95% confidence interval (CI) 1.17–3.82, P = 0.013]. Patients with a history of hypertension but without antihypertensive treatment (n = 140) were associated with a significantly higher risk of mortality compared with those with antihypertensive treatments (n = 730) (7.9% vs. 3.2%, adjusted HR 2.17, 95% CI 1.03–4.57, P = 0.041). The mortality rates were similar between the renin–angiotensin–aldosterone system (RAAS) inhibitor (4/183) and non-RAAS inhibitor (19/527) cohorts (2.2% vs. 3.6%, adjusted HR 0.85, 95% CI 0.28–2.58, P = 0.774). However, in a study-level meta-analysis of four studies, the result showed that patients with RAAS inhibitor use tend to have a lower risk of mortality (relative risk 0.65, 95% CI 0.45–0.94, P = 0.20).ConclusionWhile hypertension and the discontinuation of antihypertensive treatment are suspected to be related to increased risk of mortality, in this retrospective observational analysis, we did not detect any harm of RAAS inhibitors in patients infected with COVID-19. However, the results should be considered as exploratory and interpreted cautiously.

ANTIHYPERTENSIVE DRUG TREATMENT DISCONTINUATION IN PATIENTS UNDERGOING ORTHOPEDIC SURGERY. IS IT SAFE?

Objective: High blood pressure levels represent a common reason for postponing a scheduled surgery and are usually based on in hospital blood pressure (BP) measurements. Stress and anxiety of surgery represents a significant factor that can influence BP levels. To confront office BP levels in the perioperative clinic with ambulatory BP (ABPM) measurement as well as cortisol levels, in order to evaluate the influence of stress and anxiety on BP levels, as well as to assess the variability of BP during surgery. Design and method: This was a prospective observational study enrolled 45 subjects underwent to a scheduled knee surgery. In all patients’ office BP (1 day before surgery), ABMP (12 hours before and 12 hours after surgery as well as plasma cortisol levels (1 hour before and 24 hours after surgery) were measured. In addition the magnitude of pain experienced before and after surgery was assessed by a questionnaire. In all patients, antihypertensive drug treatment was interrupted before surgery. Results: Forty five patients with mean age 73.8 ± 7.3 years were assessed. Mean office systolic BP (SBP) (138 ± 18 mmHg) while SBP at ABPM measurements 4 hours before, just before, during and just after the operation were (133 ± 18 mmHg p < 0.001, 136 ± 20 mmHg p < 0.05, 129 ± 19 mmHg p < 0.005 and 126 ± 24 mmHg mmHg p < 0.05 respectively) despite antihypertensive treatment discontinuation and despite the fact that pain as assessed by pain scale was greater after than before the operation (6.95 ± 2.2 vs 6.34 ± 2 p < 0.05). In addition, cortisol levels decreased significantly postoperatively as compared with operatively measures (10.3 ± 3.6 mcg/dL vs 14.0 ± 4.8 mcg/dL, p < 0.001). Interestingly, preoperative high BP levels were not associated with increased BP levels perioperativelly (p = ns). Conclusions: Preoperative discontinuation of antihypertensive drug treatment was not resulted into an increase of BP perioperativelly. Stress as expressed by cortisol levels is a significant determinant of increased BP levels before the operation.

Discontinuation of Antihypertensive Treatment in Elderly Patients and Cognitive Function-Reply.

Discontinuation of Antihypertensive Treatment in Elderly Patients and Cognitive Function-Reply.

Discontinuation of Antihypertensive Treatment in Elderly Patients and Cognitive Function.

Discontinuation of Antihypertensive Treatment in Elderly Patients and Cognitive Function.

Potential Benefits of Computer-Aided Detection for Cancer Identification and Treatment.

were not associated with the change in overall cognition compound scores (mean [standard error], -0.003 [0.10]; -0.06 [0.09]; and 0.05 [0.10], respectively; P = .29). The effect of the intervention was further explored by performing stratified analyses by median PP. In the 178 patients with a higher baseline PP (>64.8 mm Hg; ie, increased arterial stiffness), the discontinuation of antihypertensive treatment group did not differ from the continuation group in change in overall cognition compound score (difference, -0.07; 95% CI, −0.37 to 0.24;P = .68). Furthermore, analyses restricted to the discontinuation group (n = 180) showed that tertiles of the change in PP were not related to the change in overall cognition compound score (β = -0.10; 95% CI, −0.26 to 0.07; P = .24). A possible explanation for the absence of any association between PP and cognitive function in the DANTE study Leiden 1 is that persons with serious cardiovascular disease were excluded, resulting in a population with limited arterial stiffness. Also, several studies indicated that chronic kidney disease (CKD) is an independent predictor for cognitive impairment. 3 As estimated glomerular filtration rate was not assessed in the DANTE Study Leiden, 1 it was not possible to perform additional analyses regarding its association with cognitive function. Moreover, patients with CKD were excluded from participation, as discontinuation of antihypertensive treatment may have adverse effects on the progression of CKD. 4 Similarly, in other major trials 5 with cardiovascular interventions, patients with CKD are underrepresented despite the high prevalence of CKD in the general population and the growing need for high-quality evidence within this group.

Effect of discontinuation of antihypertensive medication on orthostatic hypotension in older persons with mild cognitive impairment: the DANTE Study Leiden

the relationship between antihypertensive medication and orthostatic hypotension in older persons remains ambiguous, due to conflicting observational evidence and lack of data of clinical trials. to assess the effect of discontinuation of antihypertensive medication on orthostatic hypotension in older persons with mild cognitive impairment. a total of 162 participants with orthostatic hypotension were selected from the Discontinuation of Antihypertensive Treatment in Elderly people (DANTE) Study. This randomised clinical trial included community-dwelling participants aged ≥75 years, with mild cognitive impairment, using antihypertensive medication and without serious cardiovascular disease. Participants were randomised to discontinuation or continuation of antihypertensive treatment (ratio 1:1). Orthostatic hypotension was defined as a drop of at least 20 mmHg in systolic blood pressure and/or 10 mmHg in diastolic blood pressure on standing from a seated position. Outcome was the absence of orthostatic hypotension at 4-month follow-up. Relative risks (RR) were calculated by intention-to-treat and per-protocol analyses. at follow-up, according to intention-to-treat analyses, of the 86 persons assigned to discontinuation of antihypertensive medication, 43 (50%) were free from orthostatic hypotension, compared with 29 (38%) of the 76 persons assigned to continuation of medication [RR 1.31 (95% confidence interval (CI) 0.92-1.87); P = 0.13]. Per-protocol analysis showed that recovery from orthostatic hypotension was significantly higher in persons who completely discontinued all antihypertensive medication (61%) compared with the continuation group (38%) [RR 1.60 (95% CI 1.10-2.31); P = 0.01]. in older persons with mild cognitive impairment and orthostatic hypotension receiving antihypertensive medication, discontinuation of antihypertensive medication may increase the probability of recovery from orthostatic hypotension.

Effect of Discontinuation of Antihypertensive Treatment in Elderly People on Cognitive Functioning--the DANTE Study Leiden: A Randomized Clinical Trial.

Observational studies indicate that lower blood pressure (BP) increases risk for cognitive decline in elderly individuals. Older persons are at risk for impaired cerebral autoregulation; lowering their BP may compromise cerebral blood flow and cognitive function. To assess whether discontinuation of antihypertensive treatment in older persons with mild cognitive deficits improves cognitive, psychological, and general daily functioning. A community-based randomized clinical trial with a blinded outcome assessment at the 16-week follow-up was performed at 128 general practices in the Netherlands. A total of 385 participants 75 years or older with mild cognitive deficits (Mini-Mental State Examination score, 21-27) without serious cardiovascular disease who received antihypertensive treatment were enrolled in the Discontinuation of Antihypertensive Treatment in Elderly People (DANTE) Study Leiden from June 26, 2011, through August 23, 2013 (follow-up, December 16, 2013). Intention-to-treat analyses were performed from January 20 through April 11, 2014. Discontinuation (n=199) vs continuation (n=186) of antihypertensive treatment (allocation ratio, 1:1). Change in the overall cognition compound score. Secondary outcomes included changes in scores on cognitive domains, the Geriatric Depression Scale-15, Apathy Scale, Groningen Activity Restriction Scale (functional status), and Cantril Ladder (quality of life). Compared with 176 participants undergoing analysis in the control (continuation) group, 180 in the intervention (discontinuation) group had a greater increase (95% CI) in systolic BP (difference, 7.36 [3.02 to 11.69] mm Hg; P=.001) and diastolic BP (difference, 2.63 [0.34 to 4.93] mm Hg; P=.03). The intervention group did not differ from the control group in change (95% CI) in overall cognition compound score (0.01 [-0.14 to 0.16] vs -0.01 [-0.16 to 0.14]; difference, 0.02 [-0.19 to 0.23]; P=.84). The intervention and control groups did not differ significantly in secondary outcomes, including differences (95% CIs) in change in compound scores of the 3 cognitive domains (executive function, -0.07 [-0.29 to 0.15; P=.52], memory, 0.08 [-0.12 to 0.29; P=.43], and psychomotor speed, -0.85 [-1.72 to 0.02; P=.06]), symptoms of apathy (0.17 [-0.65 to 0.99; P=.68]) and depression (0.14 [-0.20 to 0.48; P=.41]), functional status (-0.72 [-1.52 to 0.09; P=.08]), and quality-of-life score (-0.09 [-0.34 to 0.16; P=.46]). Adverse events were equally distributed. In older persons with mild cognitive deficits, discontinuation of antihypertensive treatment did not improve cognitive, psychological, or general daily functioning at the 16-week follow-up. trialregister.nl Identifier: NTR2829.

Blood Pressure Is Not Associated With Cerebral Blood Flow in Older Persons.

Many studies showing a relation between low blood pressure (BP) and adverse health outcomes in older persons suggest that low BP gives rise to reduced cerebral blood flow (CBF). However, limited evidence is available about this association. Baseline data of 203 participants in the Discontinuation of Antihypertensive Treatment in the Elderly (DANTE) trial were used (mean age, 81 years, using antihypertensive medication and with mild cognitive deficits). BP, BP changes on standing, and CBF derived from pseudo-continuous arterial spin-labeling magnetic resonance imaging were assessed in all participants. In 102 participants who were randomly assigned to 4-month continuation (n=47) or discontinuation of antihypertensive treatment (n=55), BP and CBF change were evaluated at 4-month follow-up. Systolic and diastolic BP were not associated with CBF (B=-0.21, P=0.50 and B=-1.07, P=0.07), neither were mean arterial pressure, pulse pressure, and BP changes on standing. In subgroups of participants with small vessel-related cerebral pathologies, including high white matter hyperintensity volume, microbleeds, and lacunar infarcts, or in participants with lower cognition or diabetes mellitus, no association was found between any BP parameters and CBF. Furthermore, compared to the continuation group, CBF change at 4 months was not different in the discontinuation group (B=-0.12, P=0.23). Contrary to the notion that lower BP in old age is associated with decreased CBF, our data do not show this association in older persons using antihypertensive medication and with mild cognitive deficits. Also, this association was not present in subgroups of more vulnerable persons, reflected by small vessel-related cerebral pathologies, lower cognition, or diabetes mellitus.

Lower Blood Pressure and Gray Matter Integrity Loss in Older Persons.

In contrast to middle age, it is unclear whether blood pressure (BP) in older persons is associated with cerebral small vessel disease (cSVD). The authors evaluated the association of BP with signs of cSVD as well as gray and white matter integrity in older persons. In 220 participants aged 75 years and older from the Discontinuation of Antihypertensive Treatment in the Elderly (DANTE) study, cSVD was assessed with conventional magnetic resonance imaging, and microstructural integrity with diffusion tensor and magnetization transfer (MT) imaging. BP measures were not associated with cSVD. However, lower systolic and diastolic BP and mean arterial pressure were associated with decreased gray matter MT ratio peak height and MT ratio in cortical gray matter. Mean arterial pressure was also associated with increased gray matter diffusivity. A lower level of BP was especially associated with worse gray matter integrity. Results suggest that not only upper but preferably lower thresholds of BP values should be observed in older persons.

Lower Blood Pressure Is Associated With Smaller Subcortical Brain Volumes in Older Persons.

Both high and low blood pressure (BP) have been positively as well as negatively associated with brain volumes in a variety of populations. The objective of this study was to investigate whether BP is associated with cortical and subcortical brain volumes in older old persons with mild cognitive deficits. Within the Discontinuation of Antihypertensive Treatment in the Elderly trial, the cross-sectional relation of BP parameters with both cortical and subcortical brain volumes was investigated in 220 older old persons with mild cognitive deficits (43% men, mean age = 80.7 (SD = 4.1), median Mini-Mental State Examination score = 26 (interquartile range: 25-27)), using linear regression analysis. All analyses were adjusted for age, gender, volume of white matter hyperintensities, and duration of antihypertensive treatment. Brain volumes were determined on 3DT1-weighted brain magnetic resonance imaging scans. Lower systolic BP, diastolic BP, and mean arterial pressure (MAP) were significantly associated with lower volumes of thalamus and putamen (all P ≤ 0.01). In addition, lower MAP was also associated with reduced hippocampal volume (P = 0.035). There were no associations between any of the BP parameters with cortical gray matter or white matter volume. In an older population using antihypertensive medication with mild cognitive deficits, a lower BP, rather than a high BP is associated with reduced volumes of thalamus, putamen, and hippocampus.

Lower blood pressure and apathy coincide in older persons with poorer functional ability: the Discontinuation of Antihypertensive Treatment in Elderly People (DANTE) Study Leiden.

To examine the association between blood pressure (BP) measures and symptoms of apathy and depression in older adults with various levels of functional ability. Cross-sectional study using baseline data from the Discontinuation of Antihypertensive Treatment in Elderly people (DANTE) Study Leiden. Primary care setting, the Netherlands. Community-dwelling individuals aged 75 and older (N = 430). Systolic BP (SBP), diastolic BP (DBP), and mean arterial pressure (MAP) were measured during home visits. Symptoms of apathy and depression were assessed using the Apathy Scale and the Geriatric Depression Scale (GDS-15), respectively. Stratified linear regression was performed in participants with better and worse functional ability according to the median of the Groningen Activity Restriction Scale. In participants with lower functional ability, each 10-mmHg lower SBP, DBP, and MAP was associated with higher Apathy Scale scores (0.63, 0.92, and 0.94 points, respectively, all P < .005) but not with GDS-15 scores. In participants with higher functional ability, BP measures were not associated with Apathy Scale or GDS-15 scores. In older participants with poorer functional ability, lower BP was associated with more symptoms of apathy but not depression.

Factors involved in the discontinuation of antihypertensive drug therapy: an analysis from real life data.

We have previously shown that in Italian region of Lombardy (about 10 million citizens), adherence to antihypertensive treatment is low, and that this is associated with a greater risk of hospitalization for cardiovascular events. In this study, we used a healthcare database to study the factors involved in discontinuation of antihypertensive drug prescriptions in real life. The analysis was restricted to 493 623 new users of antihypertensive drugs (no prescriptions in the previous 3 years) recruited in 2003, 2006 and 2009. Discontinuation was defined as lack of prescription renewal for at least 3 months. Each patient was followed at most for 1 year. The adjusted risk of treatment discontinuation depended on the type of initial antihypertensive treatment (diuretic monotherapy associated with higher risk) and it was lower in men (-17%) and older (-21 to -29%) patients, in patients with co-treatment with antidiabetic drugs, or hospitalization for cardiovascular or renal disease (-12 to -27%), but greater in patients under co-treatment with antidepressant drugs or hospitalization for concomitant pulmonary, rheumatic, neoplastic or neurological diseases (+9 to +32%). An unexpected relationship between discontinuation of treatment and density of the population of patient's residence, with a much greater discontinuation in metropolitan areas, was observed. In a real life setting, discontinuation of antihypertensive treatment is affected in an opposite direction by a large number of factors: type of antihypertensive treatment, co-treatments, clinical conditions and even demographic characteristics of the geographical area where the patient lives. Knowledge of these factors may help the effort to reduce this phenomenon.

Heterogeneity in antihypertensive treatment discontinuation between drugs belonging to the same class

Heterogeneity in antihypertensive treatment discontinuation between drugs belonging to the same class

Heterogeneity in antihypertensive treatment discontinuation between drugs belonging to the same class

Discontinuation of antihypertensive treatment is known to be different for different classes of antihypertensive drugs. No information is available on whether this phenomenon differs for drugs belonging to the same class. This is clinically relevant because treatment discontinuation is mainly responsible for poor blood pressure control in the antihypertensive population. We studied a large (n=131,472) cohort of patients aged 40-80 years who lived in Lombardy (Italy) and received their first antihypertensive drug prescription during 2005. Discontinuation was defined by the absence of any antihypertensive drug prescription during the 90-day period following the end of the latest prescription. Class-related and drug-related discontinuation rates were standardized according to the demographic and therapeutic structure of the entire cohort and expressed as number of patients who experienced discontinuation every 100 person-months. Standardized rates of discontinuation ranged from 6.2 to 24.4 events every 100 person-months for patients who started monotherapy with an angiotensin receptor antagonist and a diuretic, respectively. However, there was a significant heterogeneity between treatment discontinuation rates within each class and the heterogeneity differed between classes. The highest discontinuation rate was 13.9-fold for channel blockers, but only 1.7-fold for angiotensin receptor antagonists. Within this class, losartan showed a discontinuation rate significantly greater than that of the other angiotensin receptor antagonists whose discontinuation rate was similar. A significant heterogeneity also characterized initial treatment with fixed-dose combinations of different angiotensin-converting enzyme inhibitors or angiotensin receptor antagonists with a diuretic. Comparison of treatment discontinuation between antihypertensive drug classes masks the fact that this phenomenon is heterogeneous within any given class. This is relevant to calculations of the cost-benefit of treatment, which, thus, should be drug-based rather than class-based.

318 Williams’ syndrome: an unusual cause of neonatal coarctation

To determine the frequency, clinical profile and outcome of patients with Williams syndrome and neonatal coarctation. Among 135 reviewed patients less than 3months of age who underwent aortic coarctation repair in our institution between January 1996 and June 2007, Williams syndrome was found in 3 cases (2,2%). They presented with congestive heart failure and absent femoral pulses, the diagnostic being confirmed by echocardiography. One case had an associated small ventricular septal defect. The 3 patients were operated at a mean age and weight of 51.6±32.7days and 3.5±0.6kg, respectively. All had resection of the coarctation segment with end-to-end anastomosis, through left thoracotomy in 2 cases, and sternotomy under cardiopulmonary bypass with large patch enlargement of the aortic arch and ventricular septal defect closure in one. The diagnosis of Williams syndrome was confirmed postoperatively by FISH analysis. All patients remained hypertensive and presented with recoarctation 2, 2.3, and 14.3months after initial repair. Transcatheter balloon dilation was attempted with failure to proceed in one and partial success in 2 cases. All had redo surgery at 0.6, 1.2 and 10.9 years after initial repair with patch enlargement of the aorta in two cases and an extra-anatomic bypass in the third, with good results and discontinuation of antihypertensive treatment. Williams syndrome may present as neonatal coarctation and is characterized by more complex repair and recurrent aortic obstruction. Balloon dilation seems disappointing to treat successfully these recoarctations. Reoperations are often necessary with patch enlargement and/or exclusion of the stenotic aortic segment.

Implementation of new evidence into hypertension guidelines: the case of the ONTARGET and TRANSCEND trials

One major element of novelty of the 2007 European guidelines on hypertension refers to the concept of risk categorization, with the aim of obtaining a more precise definition of the hypertensive patient. This has lead to identification of different categories of cardiovascular risk, from the low to the very high. Studies performed in the past few years have shown that the very high risk category is quite common and it is not unusually accompanied by poor blood pressure control. Results of the ONgoing Telmisartan Alone and in combination with Ramipril Global Endpoint Trial (ONTARGET) and the Telmisartan Randomized AssessmeNt Study in ACEI iNtolerant subjects with cardiovascular Disease (TRANSCEND) have allowed us to better define the therapeutic approach to high-risk patients showing the favorable effects of either ramipril or telmisartan on blood pressure control and risk profile. Additionally, these studies have shown that discontinuation of antihypertensive treatment is not a rare phenomenon, which can be at least in part minimized by the use of drugs with a high tolerability profile, such as angiotensin II receptor blockers (ARBs), and more specifically telmisartan. This review article examines in depth the results of the two above-mentioned trials as well as their impact on guidelines on antihypertensive treatment.

Hipertensión arterial asociada a estenosis congénita unilateral de la unión pieloureteral

To report one case of hypertension in association with congenital unilateral stenosis of the ureteropelvic junction (UPJ).We describe the case of a 19- year-old male patient without urologic symptoms who was incidentally diagnosed of high blood pressure. Radiological tests showed right hydronephrosis suggestive UPJ stenosis. The insertion of a percutaneous nephrostomy allowed discontinuation of antihypertensive treatment. Dismembered pyeloplasty was indicated.Functional results were satisfactory. Blood pressure normalization without medical treatment was achieved.We emphasize the physiopathogenic connection between unilateral ureteral obstructive pathology, as the case, described and other entities not strictly urological, such as high blood pressure. We concur with other authors in the validity of conservative reconstructive surgery for these cases.