Incidence Of Severe Hypertension Research Articles

THE RELATIONSHIP BETWEEN SMOKING BEHAVIOR AND HYPERTENSION INCIDENCE IN MALE ELDERLY IN RW 18 CIANGSANA VILLAGE, GUNUNG PUTRI DISTRICT, BOGOR

Someone who reaches the age of 60 years and over or can be called the elderly, the increasing age, various kinds of diseases appear, one of which is hypertension. One of the risk factors for hypertension that can be changed is smoking behavior. The effect of chemicals contained in cigarettes such as nicotine will spur an increase in heart rate and blood pressure to increase. This study aims to determine the relationship between smoking behavior and the incidence of hypertension in elderly men in RW 18 Ciangsana Village, Gunung Putri District, Bogor. Correlation descriptive research method. The population of this research is the elderly aged 60-74 years as many as 100 respondents. Samples were taken by purposive sampling technique as many as 80 respondents. Univariate and bivariate analysis technique used Chi-Square = 5%. The results showed that smoking behavior was strong (51.2%) and had an influence on the incidence of severe hypertension (30.0%). From the analysis results obtained p value 0.000 this value is smaller than = 5%. Then H0 is rejected. The conclusion is that there is a relationship between smoking behavior and the incidence of hypertension in elderly men in RW 18 Ciangsana Village, Gunung Putri District, Bogor. It is recommended that elderly people who smoke can reduce or stop smoking so that high blood pressure can become normal by diverting more positive activities.

Efficacy of bolus-dose epinephrine to manage hypotension in the prehospital setting.

Hypotension in the Emergency Department (ED) and the prehospital setting has been associated with significant morbidity and mortality. Limited literature exists exploring the utilization of intravenous (IV) bolus-dose epinephrine (BDE) by Emergency Medical Services (EMS). A retrospective review evaluated patients transported to an academic medical center who had received IV BDE by a single urban EMS system from 2016 to 2020. The primary outcome was to assess the influence IV BDE had on systolic blood pressure (SBP). Secondary objectives were to assess changes in heart rate (HR), the impact of dose variability on SBP, and the incidence of severe hypertension (SBP > 220 mmHg). A total of 55 patients who received 96 administrations of IV BDE were included in the analysis. The most common individual dose was 10 μg (76.0%) and 45.5% received multiple doses. The median weight-based dose of BDE was 0.14 μg/kg. A significant increase in SBP (median 14.0 mmHg) was noted among all patients following BDE administration compared with baseline (p < 0.001). No significant difference was found in HR following BDE compared with baseline (p = 0.375). Those that received a BDE dose >10 μg were noted to have a significantly greater rise in SBP than those that received 10 μg (30.0 mmHg vs. 11.0 mmHg; p = 0.022). Similarly, patients that received a dose ≥0.2 μg/kg had a significantly greater increase in SBP compared with those that received <0.2 μg/kg (30.0 mmHg vs. 10.0 mmHg; p = 0.048). There were no incidences of severe hypertension following therapy. The utilization of IV BDE in the prehospital setting for acute hypotension resulted in a significant rise in SBP. A dose-response relationship was noted both in terms of a flat-based dose and a weight-based dose, with higher doses yielding a greater change in SBP. Additional investigations are necessary to further explore the most appropriate dose of this agent in this setting and its influence, if any, on clinical outcomes.

Real-World Experience in Toxicity with Bevacizumab in Indian Cancer Patients.

Background Bevacizumab, a humanized monoclonal antibody, known to block the binding of all known vascular endothelial growth factor-A isomers to their receptors, is used in solid cancers, especially in advanced settings where its role is proven to be stronger than localized stages. Furthermore, various studies have suggested that adding bevacizumab to first-line standard therapy in advanced solid cancers, such as colorectal cancer, lung cancer, ovarian cancer, renal cancer, and breast cancer, significantly prolongs progression-free survival, overall survival, and response rates. However, this ability is limited and variable in cancer subtype. The toxicity profile of bevacizumab is outspread, ranging from mild gastrointestinal side effects, proteinuria to life-threatening hemorrhagic tendency, ischemic thromboembolism, and intestinal perforation. However, it has never been studied in Indian subset of patients till date. Materials and Methods We performed an institutional retrospective study of 41 patients with a pathologically proven ovarian, colorectal, lung, mesothelioma, melanoma, round cell tumors, and GBMs who received bevacizumab (2.5 mg/kg/week [5 mg/kg every 2 weeks or 7.5 mg/kg every 3 weeks]) with or without chemotherapy, between January 2016 and January 2019 at our center in North India. Results Forty-one patients, including 12 (29) advanced ovarian cancer, 12 (29) colon cancer, 10 (24) rectal cancer, 1 (2) appendicular cancer, 1 (2) mesothelioma, 1 (2) melanoma, 1 (2) desmoplastic round cell tumor, and 3 (7) GBM, were treated with bevacizumab. The incidence of arterial thrombus and hemorrhage was 2 and 10%, respectively, whereas venous thrombus and fistula were not seen and not related to age. No fatal adverse event was recorded. The global incidence of severe (grade 3/4) arterial hypertension (HTN) was 49%. It was safely managed in all cases, and no grade 4 (life-threatening complication) occurred. The incidence of severe HTN was significantly higher in elderly patients than in younger ones (72 vs. 40%), proteinuria was found to be more frequent in the younger age group as compared with older age group (7 vs. 3%). Also to note, the incidence of congestive heart failure and subacute intestinal obstruction was found in 5% of patients, wherein all four patients belonged to the older subgroup. Furthermore, Grade 3 hypersensitivity reaction was found in one patient in the younger subgroup which warranted immediate termination of bevacizumab.

Safety of non-steroidal anti-inflammatory drugs in postpartum period in women with hypertensive disorders of pregnancy: systematic review and meta-analysis.

To assess the effect of non-steroidal anti-inflammatory drugs (NSAIDs) on blood pressure when administered for postpartum analgesia in women with hypertensive disorders of pregnancy. MEDLINE, Scopus, CENTRAL, Clinicaltrials.gov and Google Scholar databases were searched systematically from inception to 5 December 2019 for studies evaluating the safety of postpartum NSAIDs in women with any gestational hypertensive disorder. Randomized controlled trials (RCTs) and cohort studies were eligible for inclusion. Case-control studies, case series and case reports were excluded. The primary outcomes of interest were the incidence of severe hypertension and systolic, diastolic and mean arterial blood pressure. Pooled estimates were obtained by fitting a random-effects statistical model. The quality of evidence was assessed according to Grading of Recommendations, Assessment, Development and Evaluations (GRADE) guidelines. Ten studies were included, comprising five RCTs and five retrospective cohort studies and involving a total of 1647 women. All studies were evaluated qualitatively and eight of them were included in the quantitative meta-analysis. Administration of NSAIDs was not associated with a significantly higher risk of severe postpartum hypertension (odds ratio, 1.52 (95% CI, 0.77-3.01)). Similarly, no significant differences were found in postpartum systolic blood pressure (mean difference (MD), -3.03 mmHg (95% CI, -6.21 to 0.15 mmHg)) and mean arterial pressure (MD, -0.38 mmHg (95% CI, -1.88 to 1.11 mmHg)) between women who received NSAIDs and those who did not, whereas postpartum diastolic blood pressure was marginally lower in women treated with NSAIDs (MD, -2.28 mmHg (95% CI, -4.44 to -0.13 mmHg)). The same effects were observed when studies with a large sample size, RCTs, women with severe pre-eclampsia and studies using ibuprofen as the study drug and acetaminophen as the control treatment were examined separately. The credibility of evidence was judged to be very low according to GRADE, owing to concerns about study limitations, inconsistency and imprecision. This meta-analysis suggests that postpartum administration of NSAIDs is not associated with elevated blood pressure in women with hypertensive disorders of pregnancy. However, the existing evidence is of very low quality, thus future large-scale RCTs are warranted to verify the safety of postpartum NSAIDs in this population. Copyright © 2020 ISUOG. Published by John Wiley & Sons Ltd.

Haplotype analysis of SERPINE1 gene: Risk for aneurysmal subarachnoid hemorrhage and clinical outcomes.

BackgroundAneurysmal subarachnoid hemorrhage (aSAH) has high fatality and permanent disability rates due to the severe damage to brain cells and inflammation. The SERPINE1 gene that encodes PAI‐1 for the regulation of tissue plasminogen activator is considered an important therapeutic target for aSAH.MethodsSix SNPs in the SERPINE1 gene (in order of rs2227631, rs1799889, rs6092, rs6090, rs2227684, rs7242) were investigated. Blood samples were genotyped with Taqman genotyping assays and pyrosequencing. The experiment‐wide statistically significant threshold for single marker analysis was set at p < 0.01 after evaluation of independent markers. Haplotype analysis was performed in Haplo.stats package with permutation tests. Bonferroni correction for multiple comparison in dominant, additive, and recessive model was applied.ResultsA total of 146 aSAH patients and 49 control subjects were involved in this study. The rs2227631 G allele is significant (p = 0.01) for aSAH compared to control. In aSAH group, haplotype analysis showed that G5GGGT homozygotes in recessive model were associated with delayed cerebral ischemia (p < 0.01, Odds Ratio = 5.14, 95% CI = 1.45–18.18), clinical vasospasm (p = 0.01, Odds Ratio = 4.58, 95% CI = 1.30–16.13), and longer intensive care unit stay (p = 0.01). By contrast, the G5GGAG carriers were associated with less incidence of cerebral edema (p < 0.01) and higher Glasgow Coma Scale (p < 0.01). The A4GGGT carriers were associated with less incidence of severe hypertension (>140/90) (p < 0.01).ConclusionThe results suggested an important regulatory role of the SERPINE1 gene polymorphism in clinical outcomes of aSAH.

Telehealth with remote blood pressure monitoring for postpartum hypertension: A prospective single-cohort feasibility study.

Investigate feasibility of telehealth with remote blood pressure monitoring for management of hypertension in postpartum women at risk of severe hypertension after hospital discharge. In a single-center, prospective single-cohort feasibility study, women with hypertension in pregnancy participated in a postpartum telehealth intervention for blood pressure management after discharge. The primary feasibility outcome measures were recruitment and retention through 6 weeks postpartum. Secondary outcomes included the incidence of severe postpartum hypertension and/or need for blood pressure treatment after discharge, participant satisfaction, and 6-week hospital readmission. Participants received a tablet and equipment to transmit vital signs to a central monitoring site daily. Participants participated in telehealth or telephone visits with a nurse at 48 h and as needed. Among 1413 deliveries 263 (19%) women had hypertension in pregnancy and 55/124 (47%) of women approached were consented. The retention rate was 95%. Among study participants, the incidence of severe hypertension after discharge was 9 (16%). 29 (53%) of participants required treatment due to exacerbations in blood pressure after discharge, in which 9(16%) were severe. There were no hospital readmissions. Overall 39 (86%) participants were satisfied with the remote monitoring. Feasibility and participant satisfaction were demonstrated. The incidence of severe hypertension and need for blood pressure treatment after discharge and during 6 weeks postpartum was 16% and 53%. Our results indicate telehealth is a promising strategy for postpartum hypertension management to decrease maternal morbidity and hospital readmission.

Chronic hypertension: first-trimester blood pressure control and likelihood of severe hypertension, preeclampsia, and small for gestational age

There is extensive evidence that prepregnancy chronic hypertension is associated with a high risk of development of severe hypertension and preeclampsia and birth of small-for-gestational-age neonates. However, previous studies have not reported whether antihypertensive use, blood pressure control, or normalization of blood pressure during early pregnancy influences the rates of these pregnancy complications. The purpose of this study was to stratify women with prepregnancy chronic hypertension according to the use of antihypertensive medications and level of blood pressure control at the first hospital visit during the first trimester of pregnancy and to examine the rates of severe hypertension, preeclampsia, and birth of small-for-gestational-age neonates according to such stratification. We conducted a prospective study of 586 women with prepregnancy chronic hypertension, in the absence of renal or liver disease, that was booked at a dedicated clinic for the management of hypertension in pregnancy. The patients had singleton pregnancies and were subdivided according to findings in their first visit: group 1 (n=199), blood pressure <140/90 mm Hg without antihypertensive medication; group 2 (n=220), blood pressure <140/90 mm Hg with antihypertensive medication; and group 3 (n=167), systolic blood pressure ≥140 mm Hg and/or diastolic blood pressure ≥90 mm Hg, despite antihypertensive medication. In the subsequent management of these pregnancies, our policy was to maintain the blood pressure at 130-140/80-90 mm Hg with the use of antihypertensive medication; antihypertensive drugs werestopped if the blood pressure was persistently <130/80 mm Hg. Theoutcome measures were severe hypertension (systolic blood pressure ≥160 mm Hg and/or diastolic blood pressure ≥110 mm Hg), preterm and term preeclampsia (in addition to hypertension at least 1 of renal involvement, liver impairment, neurologic complications, or thrombocytopenia), and birth of small-for-gestational-age neonates (birthweight <5th percentile for gestational age). The incidence of these complications was compared in the 3 strata. The median gestational age at presentation was 10.0 weeks (interquartile range, 9.1-11.0 weeks). In groups 2 and 3, compared with group 1, there was a significantly higher body mass index, incidence of black racial origin, and history of preeclampsia in a previous pregnancy. There was a significant increase from group 1 to group 3 in the incidence of severe hypertension (10.6%, 22.2%, and 52.1%), preterm preeclampsia with onset at <37 weeks of gestation (7.0%, 15.9%, and 20.4%), and small for gestational age (13.1%, 17.7%, and 21.1%), but not term preeclampsia with onset at ≥37 weeks of gestation (9.5%, 9.1%, and 6.6%). In women with prepregnancy chronic hypertension, the rates of development of severe hypertension, preterm preeclampsia, and small for gestational age are related to the use of antihypertensive medications and the level of blood pressure control at the first hospital visit during the first trimester of pregnancy.

Blood pressure in adolescent patients with pre-eclampsia andeclampsia.

To compare variables among adolescent and adult patients diagnosed with severe pre-eclampsia or eclampsia. The present cross-sectional study enrolled patients with severe pre-eclampsia or eclampsia treated at an intensive care unit in Neiva, Colombia, between January 1 and November 30, 2014. Patients were stratified using age (younger than 20years [adolescents] and aged at least 20years [adults]) and patient variables were compared between groups. Maternal age, pregnancy duration at delivery, eclampsia, blood pressure, severe hypertension, maternal organ damage, HELLP syndrome, obstetric hemorrhage, laboratory findings, need for blood transfusion and fetal data were analyzed by group. There were 171 patients enrolled; 154 (90.1%) with severe pre-eclampsia and 17 (9.9%) with eclampsia. There were 46 (26.9%) adolescent patients and 125 (73.1%) adults, and 13 (28.3%) and 4 (3.2%) patients had eclampsia in the adolescent and adult groups, respectively (P=0.001). The systolic (P=0.081), diastolic (P=0.174), and mean (P=0.102) blood pressure did not differ significantly between the groups but were higher in the adult group. The incidence of severe hypertension was significantly higher among adult patients (P=0.037). The blood pressure used in defining pre-eclampsia and eclampsia should differ for adolescent patients in comparison with the rest of the population.

Impact of Antihypertensive Treatment on Maternal and Perinatal Outcomes in Pregnancy Complicated by Chronic Hypertension: ASystematic Review and Meta-Analysis.

BackgroundChronic hypertension complicates around 3% of all pregnancies. There is evidence that treating severe hypertension reduces maternal morbidity. This study aimed to systematically review randomized controlled trials of antihypertensive agents treating chronic hypertension in pregnancy to determine the effect of this intervention.Methods and ResultsMedline (via OVID), Embase (via OVID) and the Cochrane Trials Register were searched from their earliest entries until November 30, 2016. All randomized controlled trials evaluating antihypertensive treatments for chronic hypertension in pregnancy were included. Data were extracted and analyzed in Stata (version 14.1). Fifteen randomized controlled trials (1166 women) were identified for meta‐analysis. A clinically important reduction in the incidence of severe hypertension was seen with antihypertensive treatment versus no antihypertensive treatment/placebo (5 studies, 446 women; risk ratio 0.33, 95%CI 0.19‐0.56; I2 0.0%). There was no difference in the incidence of superimposed pre‐eclampsia (7 studies, 727 women; risk ratio 0.74, 95%CI 0.49‐1.11; I2 28.1%), stillbirth/neonatal death (4 studies, 667 women; risk ratio 0.37, 95%CI 0.11‐1.26; I2 0.0%), birth weight (7 studies, 802 women; weighted mean difference −60 g, 95%CI −200 to 80 g; I2 0.0%), or small for gestational age (4 studies, 369 women; risk ratio 1.01, 95%CI 0.53‐1.94; I2 0.0%) with antihypertensive treatment versus no treatment/placebo.ConclusionsAntihypertensive treatment reduces the risk of severe hypertension in pregnant women with chronic hypertension. A considerable paucity of data exists to guide choice of antihypertensive agent. Adequately powered head‐to‐head randomized controlled trials of commonly used antihypertensive agents are required to inform prescribing.

O65. Is there evidence to inform antihypertensive prescribing in pregnancy complicated by chronic hypertension: A systematic review

Introduction Chronic hypertension (CHT) complicates 1–5% of all pregnancies. The importance of optimising blood pressure control has been highlighted by the results of the Control of hypertension in pregnancy study. The frequency of severe hypertension in pregnancy directly affects maternal morbidity and mortality. Effective anti-hypertensive treatments (AHTs) for CHT in pregnancy that reduce this risk need to be identified. Objectives To perform a systematic review of randomised controlled trials (RCTs) in women with CHT in pregnancy to determine the incidence of severe hypertension with AHT use (vs. none) and by drug class, together with incidence of adverse maternal and fetal/neonatal outcomes. Method Medline (via OVID), Embase (via OVID) and the Cochrane Trials Register were searched from their earliest entries until 30.4.15. All RCTs evaluating AHTs for CHT in pregnancy were included. Additional data were found from references of papers identified from the original searches. Two review authors (LW and FCR) extracted and tabulated relevant data. Data were analysed in Stata 13.1 (StataCorp, College Station, Texas), using the metan suite of commands (Higgins et al. 2003). Where there was significant evidence of heterogeneity, the DerSimonian & Laird (1986) method was used. Results 10 RCTs of AHT vs other AHT or placebo/no AHT were identified for a pre-defined CHT cohort and an additional 5 RCTs reported outcomes for a CHT subgroup; all data were from studies completed prior to 2000. A clinically important reduction in the incidence of severe hypertension was seen with AHT use vs no AHT (4 studies, 244 women; risk ratio (RR) 0.37; 95% confidence interval (CI) 0.22 to 0.64; I 2 0.0%). Additionally two small studies reported incidence of severe hypertension when comparing β -blockers with methyldopa, but results are ambiguous (86 women; RR 0.85, CI 0.5 to 1.37; I 2 66.1%). There was no clear difference in the incidence of superimposed pre-eclampsia for women on AHTs vs no AHTs (6 studies, 525 women; RR 0.77, CI 0.50 to 1.18; I 2 37.3%). No significant difference in birthweight (g) was demonstrated with AHT treatment of CHT in pregnancy ( 7 studies, 731 women; weighted mean difference − 78.23; CI − 164.59 to 8.13; I 2 59.9%). Conclusion A considerable paucity of data exists from RCTs to guide AHT prescribing for CHT in pregnancy. Given the increasing incidence of CHT in pregnancy and that AHTs reduce the incidence of severe hypertension, head-to-head RCTs of the commonly used AHTs are urgently required to inform prescribing.

Expectant Management of Severe Preeclampsia Remote From Term

Preeclampsia occurs in ∼2% to 12% of all pregnancies, and early severe preeclampsia accounts for ∼25% of all cases. The only known treatment for preeclampsia is delivery, yet an early preterm delivery increases the risk for adverse neonatal outcomes. This randomized, multicenter, parallel, open-label clinical trial was undertaken to determine whether expectant management of severe preeclampsia at less than 34 weeks’ gestation results in better perinatal outcomes compared with prompt delivery (PD) after steroid administration. Pregnant women with severe hypertensive disorders at 28 to 33 weeks’ gestation were randomly allocated to the PD or expectant management (EXM) group. Prompt delivery patients received glucocorticoid therapy followed by delivery in 24 to 72 hours. Patients in the EXM group were treated with glucocorticoid therapy followed by delivery only for specific maternal/fetal indications or reaching 34 weeks’ gestation. The primary outcome was perinatal mortality (fetal and neonatal death). Secondary outcomes were composite neonatal morbidities, neonatal birth data, and maternal morbidities and death. Of 267 women, the final cohort included 131 patients (138 births) in the EXM group and 133 (137 births) in the PD group. The 2 groups did not differ significantly in baseline characteristics. Reasons for delivery in the EXM group were uncontrollable blood pressure (40.4%), fetal compromise (29%), persistent symptoms (28.2%), reaching 34 weeks’ gestation (26.0%), and maternal complications (21.3%). Perinatal mortality rates were 9.4% in the PD group and 8.7% in the EXM group, not a significant difference. Composite neonatal morbidities were 56.4% in the PD group and 55.6% in the EXP group (relative risk, 1.01; 95% confidence interval, 0.81–1.26; P = 0.89). The PD group had lower birth weights at delivery (1543 ± 438 vs 1659 ± 509 g), but the EXM group had more small-for-gestational age infants (13 [9.4%] vs 30 [21.7%]; P = 0.005) and abruptio placentae (2 [1.5%] vs 10 [7.6%]; P = 0.01). Rates of total neonatal morbidity and mortality stratified by gestational age at randomization were 85% (63/75), 66.3% (65/98), and 36.2% (37/102), respectively, for 28 to 29 weeks, 30 to 31 weeks, and 32 to 33 weeks, with no significant differences between the PD and EXM groups. The average pregnancy prolongation in the EXM group was 10.3 ± 8 days compared with 2.2 ± 0.8 days in the PD group (P = 0.0001). No maternal deaths occurred. Oral antihypertensive medications to maintain blood pressure at less than 160/110 mm Hg were used in 61 women (46.5%) in the EXM group. No significant differences in perinatal mortality were noted between women with or without oral antihypertensive medications (7 [11.48%] vs 5 [7.14%]; P = 0.29). The incidence of severe hypertension was 41% and 38.6% in these 2 groups, respectively (P = 0.81). Five women in each oral antihypertensive group had abruptio placentae. Higher maternal morbidity (37.7% vs 14.3%; P = 0.02) was found in the EXM group receiving oral antihypertensive medications. The only curative treatment for severe preeclampsia is delivery of the fetus. At very early preterm, the consequences of neonatal prematurity must be weighed against potential maternal morbidity by prolonging gestation. The most important factors for improved neonatal outcome are gestational age on presentation, use of corticosteroids, and providing intensive neonatal care. Severe preeclampsia before 34 weeks should be managed with PD after corticoid administration.

Choosing outcomes in pregnancy research.

When asked to write an editorial on my personal experiences with pregnancy research, I accepted with enthusiasm but then found the task to be quite difficult. The topic is so broad that I struggled with the approach. Which of so many aspects should I touch on? There is the mastery of: the relevant published literature in pregnancy, the current relevant standard of care which must involve multidisciplinary collaboration, issues in internal medicine outside pregnancy as they apply to the relevant medical condition in pregnancy, choosing outcomes of relevance for both the mother and baby(ies), and then mobilization of a local team and international colleagues. Upon reflection, I decided to focus my comments on my struggles with outcomes that cover maternal, fetal and neonatal issues. Fetal and neonatal outcomes must also take into account the fact that women may deliver over a range of gestational ages. This will be true of any condition, pre-existing or gestational, that requires treatments for weeks or months before delivery. Important outcomes for the fetus before 20 weeks (e.g. miscarriage) are different from those of the very preterm baby (such as bronchopulmonary dysplasia). Chronic lung disease is not even possible for the baby born after 32 weeks’ gestation, and by definition, hypoxic–ischaemic encephalopathy and its devastating neurological implications can occur only at term. The absolute incidence of these adverse outcomes, however, is usually very low, even when the maternal condition in question (such as renal disease) is associated with substantially increased relative risks in pregnancy. As such, it is commonplace in perinatal research to study composite outcomes. This practice has been driven by the fact that outcomes of particular interest are devastating (e.g. maternal death) but not common enough to make feasible studies that examine these outcomes individually as their primary or secondary outcome. Combining these outcomes increases the anticipated incidence of the primary outcome and brings down the sample size. An example of this is the Pre-eclampsia Integrated Estimate of RiSk Score (PIERS), an outcome prediction model for adverse maternal outcomes in women admitted to hospital with preeclampsia. A Delphi consensus process was used to derive a composite outcome that covered concerns specifically related to the maternal central nervous, cardiorespiratory, haematological, hepatic and renal systems. 1 In a randomized controlled trial of treatment of gestational diabetes (versus standard care), the primary outcome was a composite of perinatal death, shoulder dystocia, bone fracture and/or nerve palsy. 2 Although combining multiple uncommon outcomes into a composite outcome is appealing from the perspective of sample size and feasibility, there are some serious concerns that arise. First, are the component outcomes of equal importance? The answer is ‘yes’ for a composite of neonatal morbidity associated with preterm birth, such a one or more of retinopathy of prematurity, necrotizing enterocolitis, bronchopulmonary dysplasia and/or severe brain injury. All of these morbidities are serious in the short-term and all have potential long-term implications. Clinicians and parents would wish to avoid each and every one of these outcomes. However, if component outcomes are not considered to be of equal importance, the results of a study may be driven by a less important but more common component. An example is the HYPITAT trial of induction of labour versus temporizing care for women who are at term and who have either gestational hypertension or non-severe preeclampsia. 3 The primary outcome was a composite of poor maternal outcome, defined as maternal mortality, maternal morbidity (eclampsia, HELLP syndrome, pulmonary oedema, thromboembolic disease and placental abruption), progression to severe hypertension or proteinuria and major postpartum haemorrhage (.1000 mL blood loss). Although induction of labour was associated with a lower incidence of the primary outcome (31% versus 44% among women allocated to expectant management), the results were driven by the between-group difference in the incidence of severe hypertension. Antihypertensives were used to treat only severe hypertension. Would induction of labour still be beneficial in settings where antihypertensives are used to treat non-severe hypertension? Second, could the study intervention cause the component outcomes within a composite to move in opposite directions? If so, the composite must be considered to be fatally flawed. This is the primary reason for not combining maternal and perinatal outcomes. For preeclampsia at ,34 weeks, delivery is always the best approach for the mother whose exposure to the preeclampsia process and its risks is therefore minimized, but delivery at early gestational ages may be associated with substantial neonatal mortality and morbidity.

Hypertension and the post-carotid endarterectomy cerebral hyperperfusion syndrome

Abstract Objective Cerebral hyperperfusion syndrome is a preventable cause of stroke after carotid endarterectomy (CEA). It manifests as headache, seizures, hemiparesis or coma due to raised intracranial pressure or intracerebral haemorrhage (ICH). There is currently no consensus on whether to control blood pressure, blood pressure thresholds associated with cerebral hyperperfusion syndrome, choice of anti-hypertensive agent(s) or duration of treatment. Method A systematic review of the PubMed database (1963–2010) was performed using appropriate search terms according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Results A total of 36 studies were identified as fitting a priori inclusion criteria. Following CEA, the incidence of severe hypertension was 19%, that of cerebral hyperperfusion 1% and ICH 0.5%. The postoperative mean systolic blood pressure of patients, who went on to develop cerebral hyperperfusion syndrome, was 164 mmHg (95% confidence interval (CI) 150–178 mmHg) and the cumulative incidence of cases rose appreciably above a postoperative systolic blood pressure of 150 mmHg. The mean systolic blood pressure of cerebral hyperperfusion cases was 189 mmHg (95% CI 183–196 mmHg) at presentation. The incidence of cerebral hyperperfusion in the first week was 92% with a median time to presentation of 5 days (interquartile range (IQR) 3–6 days). 36% of patients presented with seizures 31% with hemiparesis and 33% with both. The proportion of patients with severe hypertension was significantly higher in cases than in post-CEA controls (p Conclusion There is currently level-3 evidence for the prevention of ICH through control of postoperative blood pressure. From the available data, we suggest a definition for cerebral hyperperfusion syndrome, blood pressure thresholds, duration of monitoring and a postoperative blood pressure control strategy for validation in a prospective study. The implications of this are that one in five patients would need intravenous anti-hypertensives and home blood pressure monitoring for 1 week.

Clinical features of fetal growth restriction complicated later by preeclampsia

To assess the maternal and perinatal outcome of preeclampsia with fetal growth restriction (FGR) and to assess the risk factors of FGR complicated later by preeclampsia. A cohort of women with preeclampsia and/or FGR (n = 306) were retrospectively reviewed. First, the maternal and perinatal outcome were compared between preeclampsia with FGR (n = 37) and preeclampsia without FGR (n = 96). Second, the clinical findings of FGR followed later by preeclampsia (n = 24) were compared to FGR without preeclampsia (n = 149). The incidence of severe hypertension and critical maternal complications in women with preeclampsia with FGR was significantly higher than in those with preeclampsia without FGR. In women diagnosed with FGR, 13.8% (24/173) developed preeclampsia later. In this group, FGR was diagnosed at 28.8 gestational weeks, which was then complicated by preeclampsia at a mean of 32.6 gestational weeks, and delivered at 33.3 gestational weeks. The diagnosis of FGR was earlier and the incidence of proteinuria at entry was more common in women with FGR complicated later by preeclampsia than in those with FGR without preeclampsia (45.8% vs 4.7%; P < 0.001). Preeclampsia with FGR is severe condition which can possibly adversely affect the maternal condition. About 15% of all mothers diagnosed with FGR developed preeclampsia afterwards; therefore, those with FGR are considered to be candidates for close monitoring for the clinical manifestation of preeclampsia, and those with early-onset FGR with proteinuria may represent a high-risk group for preeclampsia.

Effect of Recombinant Human Erythropoietin Therapy on Blood Pressure in Hemodialysis Patients

The Canadian Erythropoietin Study Group conducted a randomized, placebo-controlled trial to examine the effect of human recombinant erythropoietin on the treatment of anemia in 118 hemodialysis patients. The effectiveness of therapy on hemoglobin concentration and quality of life has been reported elsewhere. Herein is reported the effect of erythropoietin therapy on blood pressure. Patients receiving erythropoietin had a significant increase in diastolic blood pressure (DBP; p = 0.001) and required increased antihypertensive medication. There was no difference in the incidence of severe hypertension (DBP > 110 mm Hg or hypertension-related seizure) between placebo-treated patients (13%) and those receiving erythropoietin (14%). The development of severe hypertension in erythropoietin-treated patients was associated with a history of receiving antihypertensive medication or having native kidneys in situ. In the first 5 weeks of the study, there was a correlation between the change in hemoglobin concentration and the change in DBP (r = 0.42, p < 0.001). Although erythropoietin therapy was associated with a significant increase in DBP, there was no difference between placebo- and erythropoietin-treated patients with respect to severe hypertension or hypertension-related seizures.

Opioid Analgesics in Anesthesia

In this article, an attempt has been made to review the use of receptor stimulating pure agonist opioids in anesthesia, especially in patients with cardiovascular disease. Particular emphasis has been placed on the use of opioids in high doses to produce anesthesia, techniques that recently have become popular in cardiovascular anesthesia. A major benefit of opioid anesthesia is the cardiovascular stability obtained during induction and throughout operation, even in patients with severely impaired cardiac function. There is a considerable body of evidence to support this claim when fentanyl is used. Anesthetic doses of morphine are associated with a higher incidence of cardiovascular disturbances and other problems, and, therefore, more attention to detail is required in order to achieve adequate anesthesia and hemodynamic stability. Although other opioids have been used as sole or principal agents in anesthesia for cardiovascular surgery, none have gained widespread acceptance. Meperidine, for example, which is widely used in lower (nonanesthetic) doses as a supplement to nitrous oxide in cardiac and noncardiac surgery, has proved unsuitable because of severe hemodynamic disturbances when high doses are given. However, initial reports concerning two of the newer agonist opioids, sufentanil and alfentanil, suggest that they may prove to be suitable alternatives and perhaps provide advantages over morphine and fentanyl in patients with or without cardiovascular disease. Although cardiovascular stability usually can be assured in the chronically sick cardiac patient with opioid anesthesia, this is not always so with the healthier patient, particularly those presenting for coronary artery surgery. A frequently occurring problem in these patients is hypertension during or after sternotomy, which can result in myocardial ischemia and infarction. The incidence of severe hypertension (increases in systolic blood pressure greater than 20% of control values) can be reduced drastically by increasing the dose of opioid, e.g., up to 140 micrograms/kg of fentanyl. However, despite such large doses, some patients will continue to need treatment with vasodilators, inhalation anesthetics, or other supplements at certain periods during cardiovascular operations. The use of very large doses of opioids also will prolong postoperative respiratory depression. High doses of opioids can reduce or prevent the hormonal and metabolic responses to the stress of surgery. However, even very large doses of fentanyl or its newer analogues do not prevent marked increases in plasma catecholamine concentrations in response to cardiopulmonary bypass.(ABSTRACT TRUNCATED AT 400 WORDS)

Combined use of prazosin and beta-blockers in hypertension.

Combined use of prazosin and beta-blockers in a hypertension clinic over a 3-year period was surveyed by means of a computerized record system. Of the 1,250 patients in the clinic, 171 (14%) had been treated with this combination for periods averaging 17 months. Prazosin was administered with a beta 1-selective beta-blocker in 94 cases and with a beta 1 + beta 2-blocker in 100 cases; 23 patients had received treatment with both combinations. Diuretics were given in 86% of cases and other antihypertensive drugs in 19%. The population treated had a high incidence of severe hypertension, with initial diastolic pressure greater than 120 mm Hg in 38% and between 100 and 120 mm Hg in 50%. The percentage of patients with diastolic pressure less than 100 mm Hg was 12% initially and 79% at the end of the treatment period. Side effects necessitated withdrawal of therapy in 35 cases. These were referable in 19 cases to prazosin and in 16 to beta-blockers. Prazosin was found to be more effective in lowering blood pressure in combination with beta 1-blockers than with beta 1 + beta 2-blockers, although there were fewer severe side effects with beta 1-blockers.

BLOOD PRESSURE IN WOMEN TAKING ORAL CONTRACEPTIVES

In a Glasgow study of 15 women who had taken oral contraceptives (OCs) for 5 years systolic blood pressures had risen significantly after 1 year (p less than .05) and after 5 years the mean increase was 12.3 mg of Hg (p less than .01). Mean diastolic pressure showed a significant rise after 2 years (p less than .05) and had increased by 8.8 mm of Hg (p less than .01). In a control group of 10 women no significant changes in either systolic or diastolic pressure had occurred after 5 years (p greater than .1). Of 186 women who have now t aken OCs for 2 years systolic blood pressures have increased in 164 cas es (p less than .01) and diastolic pressures have increased in 150 cases (p less than .05). 60 control women have shown no significant changes (p greater than .01). In 8 instances women taking OCs have had increased systolic pressure of over 25 mm Hg the largest rise being 41 mm to a level of 168 mm. Diastolic blood pressures have risen to 94 and 98 mm of Hg in 2 women representing increases of 34 and 24 mm of Hg respectively. Clinical complications have not followed in any case. Other studies suggest that those who develop increased blood pressure after using OCs have conditions favoring spontaneous development of high blood pressure. This was not confirmed in the present study. The estrogen content of the compounds seems to be the cause of the blood pressure changes. Plasma angiotensin-2 was not related nor were concentrations of aldosterone cortisol DOC or total exchangeable sodium. Although the incidence of severe hypertension among OC users has been comparatively low such pressures should be recorded while these drugs are being used. In cases when hypertension follows use of these compounds therapy should be discontinued and other contraceptive measures substituted. In some cases hypotensive drugs may be needed.

Blood pressure in women taking oral contraceptives

In a Glasgow study of 15 women who had taken oral contraceptives (OCs) for 5 years systolic blood pressures had risen significantly after 1 year (p less than .05) and after 5 years the mean increase was 12.3 mg of Hg (p less than .01). Mean diastolic pressure showed a significant rise after 2 years (p less than .05) and had increased by 8.8 mm of Hg (p less than .01). In a control group of 10 women no significant changes in either systolic or diastolic pressure had occurred after 5 years (p greater than .1). Of 186 women who have now t aken OCs for 2 years systolic blood pressures have increased in 164 cas es (p less than .01) and diastolic pressures have increased in 150 cases (p less than .05). 60 control women have shown no significant changes (p greater than .01). In 8 instances women taking OCs have had increased systolic pressure of over 25 mm Hg the largest rise being 41 mm to a level of 168 mm. Diastolic blood pressures have risen to 94 and 98 mm of Hg in 2 women representing increases of 34 and 24 mm of Hg respectively. Clinical complications have not followed in any case. Other studies suggest that those who develop increased blood pressure after using OCs have conditions favoring spontaneous development of high blood pressure. This was not confirmed in the present study. The estrogen content of the compounds seems to be the cause of the blood pressure changes. Plasma angiotensin-2 was not related nor were concentrations of aldosterone cortisol DOC or total exchangeable sodium. Although the incidence of severe hypertension among OC users has been comparatively low such pressures should be recorded while these drugs are being used. In cases when hypertension follows use of these compounds therapy should be discontinued and other contraceptive measures substituted. In some cases hypotensive drugs may be needed.