Management Of Chronic Hypertension Research Articles

Nifedipine outperforms labetalol: A comparative analysis of hypertension management in black pregnancies

BackgroundNifedipine has previously exhibited superior efficacy to labetalol in managing hypertension in the non-pregnant Black population, establishing itself as a first-line treatment option. However, the unique challenges of hypertension during pregnancy, especially prevalent in Black individuals, remain underexplored in terms of effective medication choices. This gap highlights the need for targeted research on antihypertensive efficacy specifically within this population. ObjectiveThis study aims to evaluate the effectiveness of nifedipine versus labetalol in managing blood pressure in Black pregnancies. The primary measure is the mean systolic and diastolic blood pressure trajectories throughout pregnancy, determining the superiority of nifedipine in this context. Study designA retrospective cohort study was conducted at a multi-center institution in the metropolitan Detroit area, encompassing data from 1,235 Black pregnancies affected by chronic hypertension between 2015 and 2022. Mean blood pressure trajectories during pregnancy were fit by linear mixed effects model with a random intercept and time effect. ResultsPatients on nifedipine had an estimated 2.08 mmHg lower mean systolic and 1.60 mmHg lower mean diastolic blood pressure compared to those on labetalol, with significant p-values of 0.040 and 0.028. Additionally, nifedipine users were less likely to need increased doses, with an odds ratio of 0.28 (95 % CI: 0.19–0.40, p < 0.001) compared to labetalol users. ConclusionThis study provides compelling evidence that nifedipine outperforms labetalol in managing blood pressure during Black pregnancies. These findings suggest that the initiation of nifedipine should be considered in the management of chronic hypertension among Black pregnant individuals, offering a potentially more effective treatment option.

Chronic Hypertension in Pregnancy: A Lens Into Cardiovascular Disease Risk and Prevention.

Hypertension is a major, modifiable risk factor for cardiovascular disease (CVD) in the United States. Over the past decade, the prevalence of chronic hypertension (CHTN) during pregnancy has nearly doubled with persistent race- and place-based disparities. Blood pressure elevations are of particular concern during pregnancy given higher risk of maternal and fetal morbidity and mortality, as well as higher lifetime risk of CVD in birthing individuals with CHTN. When identified during pregnancy, CHTN can, therefore, serve as a lens into CVD risk, as well as a modifiable target to mitigate cardiovascular risk throughout the life course. Health services and public health interventions that equitably promote cardiovascular health during the peripartum period could have an important impact on preventing CHTN and reducing lifetime risk of CVD. This review will summarize the epidemiology and guidelines for the diagnosis and management of CHTN in pregnancy; describe the current evidence for associations between CHTN, adverse pregnancy outcomes, and CVD; and identify opportunities for peripartum care to equitably reduce hypertension and CVD risk throughout the life course.

Assessing maternal cardiac function by obstetricians: technique and reference ranges

A strong body of evidence has now coalesced indicating that some obstetrical syndromes may result from maladaptive responses of the maternal cardiovascular system. Longitudinal studies have shown that these changes are complex and present before the clinical recognition of preeclampsia and fetal growth restriction, suggesting that hemodynamic maladaptation may play an etiologic role in obstetrical complications. Chronic hypertension is one of the most frequent complications of pregnancy, and recent evidence suggests that control of mild hypertension in early pregnancy improves outcome. The management of chronic hypertension can be improved by understanding specific cardiovascular hemodynamic abnormalities such as increased cardiac output or increased systemic vascular resistance, which can respond to either beta or calcium channel blockers, depending on the hemodynamic findings. Evaluation of maternal cardiac function has not been previously available to obstetrical healthcare providers using diagnostic ultrasound equipment used for fetal evaluation. Obstetrical ultrasound machines may be configured for various probes (endovaginal, abdominal, 3D/4D, and cardiac). This study used a cardiac probe placed in the suprasternal notch to image and measure the descending aorta diameter and the velocity time integral using pulsed and continuous wave Doppler ultrasound in normal pregnant women between 11 and 39 weeks of gestation. These measurements were followed by computation of maternal left ventricular preload, afterload, contractility, and blood flow. This was a prospective cross-sectional study. A total of 400 pregnant women were recruited between 11 and 39 weeks of gestation. Imaging of the maternal aortic arch was performed by placing a cardiac probe in the suprasternal notch to identify the aortic arch using 2D and color Doppler ultrasound. The end-systolic diameter of the aorta was measured at the junction of the left subclavian artery with the descending aorta, which was followed by insonation of the descending aorta to obtain the Doppler waveform. Following insonation of the descending aorta, measurements of the aortic diameter, velocity time integral, ejection time, mean pressure gradient, heart rate, maternal weight and height, and systolic and diastolic blood pressures were entered into an Excel spreadsheet to compute the following: (1) preload measurements of stroke volume, stroke volume index, and stroke work index; (2) afterload measurements of systemic vascular resistance and the potential-to-kinetic energy ratio; (3) contractility measurements of inotropy and the Smith-Madigan inotropy index; and (4) blood flow measurements of cardiac output and the cardiac output index. Fractional polynomial regression analysis was performed for each of the above measurements using gestational age as the independent variable. The diastolic and mean arterial blood pressure decreased from 11 to 18 weeks of gestation and then increased until term. The afterload measurements demonstrated similar characteristics, as all values decreased from 11 weeks until the mid and late second trimester, after which all values increased until term. Changes in contractility demonstrated an increase from 11 weeks to 25 to 28 weeks, followed by a decline until term. Changes in blood flow demonstrated an increase from 11 to 27 weeks and then declined until term. The continuous wave Doppler values were greater than the pulsed Doppler values except for the contractility measurements. Examples of abnormal cardiac measurements were identified in pregnant patients with hypertension and fetal growth restriction. An Excel calculator was created to provide quick computation of z-score measurements and their corresponding centiles described in this study. The technique for evaluation of maternal cardiac function described in this study would allow screening of maternal left ventricular preload, afterload, contractility, and blood flow in the obstetrical clinical milieu once a cardiac probe is acquired for obstetrical ultrasound machines used for fetal evaluation. The above measurements would allow the clinician to select appropriate hypertensive medication on the basis of the results of the evaluation of the maternal left ventricle.

Society of Obstetricians and Gynaecologists Pakistan (SOGP) Hypertensive Disorders in Pregnancy Guidelines- 2022

The Society of Obstetricians &amp; Gynecologist Pakistan Hypertensive Disorders of Pregnancy (SOGP- HDP) guideline is evidence based practical clinical guide to the management of pregnant women with hypertension. It defines hypertension, preeclampsia &amp; severe hypertension, encourages measuring blood pressure (BP) accurately, preferably by automated/mercury blood pressure monitors. The guideline gives an approach to screening, risk prediction and prevention of preeclampsia and management of hypertensive disorders of pregnancy. The guideline emphasizes experienced team management approach and mandatory hospital protocols for the management of pregnant women with hypertension. The aim is to have locally tailored easy to follow protocols for preconception care, screening, prevention and management of women at risk of preeclampsia; management of chronic hypertension in pregnancy, antihypertensive therapy for severe and non-severe hypertension. In addition, it discusses post-partum management, contraception, follow-up, discusses risk of recurrence and long-term follow up for women with preeclampsia to mitigate future cardio-metabolic risks to maternal health associated with hypertensive disorders of pregnancy

Evaluation and Management of chronic Hypertension in Pregnancy

Chronic hypertension is present in 1-2% of pregnant women. Women with chronic hypertension are at an increased risk of maternal and perinatal complications when compared with normotensive women. It is not uncommon for the women with chronic hypertension to present first time during pregnancy and obstetricians are the first one to encounter them during antenatal checkup. Secondary hypertension is often unrecognised and misdiagnosed thus leading to improper treatment with significant risk to the mother and fetus. It is potentially treatable and timely recognition leads to excellent pregnancy outcome. It is important to look into the causes of chronic hypertension in pregnancy and do individualised management for best outcome.

Chronic Hypertension in Pregnancy

(Am J Obstet Gynecol. 2020;222:532–541) New guidelines for the management of chronic hypertension have been published in the last 3 years by the American College of Obstetricians and Gynecologists (ACOG), The American College of Cardiology (ACC), The American Heart Association (AHA), and the International Society for the Study of Hypertension in Pregnancy (ISSHP). The authors compiled this work to review the evidence supporting these new guidelines and to provide critiques on areas that need further research.

Efficacy of enhanced emergency department discharge for chronic hypertension management – Results of a randomized controlled trial

IntroductionAchieveBP is a randomized controlled trial (RCT) of an education intervention for patients with chronic hypertension who have uncontrolled blood pressure (BP) at discharge from an urban emergency department (ED). The study examined efficacy and moderators of an educational intervention in an RCT on BP control at 180-day post-intervention. MethodsParticipants were recruited from a single, urban ED and randomized to receive or not to receive hypertension education. To minimize potential bias, participants were all started on an evidence-based anti-hypertensive regimen and medications were dispensed directly to participants by the study team. Bivariate analysis was performed to examine differences in sociodemographic characteristics between patients achieving BP control and those who did not. Paired t-test was used to compare the difference of systolic and diastolic BP between baseline and 180 days post-discharge. Multiple logistic regression analysis examined interaction of covariates and intervention on achieving BP control. ResultsOne hundred and thirty-nine participants were randomized into the study. All were African-American with a mean age of 47.6 (SD = 10.8) years; 51% were male, 63% had smoked cigarettes and 15% had diabetes. A total of 66 patients completed the study (47.4%), 44 of whom (67%) achieved BP control. However, there was no difference in BP reduction or control between the two groups. Age and smoking status showed moderation effects on intervention efficacy. ConclusionDespite a neutral effect of our intervention, a high level of BP control was achieved overall, suggesting that the ED may be a viable location for efforts aimed at reducing the impact of chronic hypertension in predominantly African American communities.

A Multicenter, Cross-Sectional Quality Improvement Project: The Perioperative Implementation of a Hypertension Protocol by Anesthesiologists.

Hypertension is a common risk factor for cardiovascular morbidity and mortality, with a high prevalence in patients presenting for elective surgery. In limited resource environments, patients have poor access to primary care physicians, limiting the efficacy of lifestyle modification for the management of hypertension. In these circumstances, the perioperative period presents a unique opportunity for diagnosis and initiation and/or modification of pharmacotherapy of hypertension. Anesthesiologists are ideally placed to lead this aspect of perioperative medicine. The study objective was for anesthesiologists to identify patients at the preoperative visit with previously undiagnosed or poorly controlled chronic hypertension and follow a simple management algorithm. In collaboration with expert physicians, we designed and implemented an algorithm for the diagnosis and management of chronic hypertension. This was a multicenter, cross-sectional quality improvement project in 7 hospitals in the Western Cape, South Africa. On the day before scheduled elective surgery, adult in-patients had 2 sets of blood pressure (BP) readings taken, one by nurses and the other by anesthesiologists, using a noninvasive automated BP device. These were averaged on an electronic database, to diagnose hypertension. Patients with normal BP or well-controlled hypertension required no further management. Those with borderline BP received educational pamphlets. Patients with stage 1 or 2 hypertension were managed with medication according to the algorithm, starting 1 day postoperatively, and provided with educational pamphlets. Patients with stage 3 disease had their surgery postponed and were referred to a physician. The primary outcome was adherence by the anesthesiologist to the algorithm in the diagnosis and management of hypertension. An 80% adherence rate was considered successful implementation. The secondary outcome was the adherence to the algorithm at discharge. Two hundred ninety-eight patients were screened for hypertension. One hundred six patients were eligible for the quality improvement project. Thirty-seven (34.9%) had borderline BP readings, 43 (40.6%) had stage 1, 22 (20.8%) stage 2, and 4 (3.8%) stage 3 hypertension, respectively. The adherence rate by the anesthesiologist in initiating treatment according to the algorithm was 89 of 106 (84.0%; 95% confidence interval [CI, 77.0-91.0). There was full adherence to the algorithm in 59 of 106 (55.5%; 95% CI, 46.2-65.1) at the time of discharge from hospital. Anesthesiologists successfully implemented a quality improvement project for diagnosis and management of hypertension in the perioperative period. This has the potential to reduce the public health burden of hypertension in limited resource environments. Successful ongoing prescription and follow-up requires cooperation within a multidisciplinary team.

Hypertension Management in Emergency Departments.

BACKGROUNDElevated blood pressure (BP) is pervasive among patients that visit emergency departments (EDs) for their care.METHODSIn this review article, we outline the current approach to the management of these individuals and highlight the crucial role emergency medicine clinicians play in reducing the morbidity associated with elevated BP.RESULTSWe highlight the critical importance of immediate treatment when elevated BP contributes to new or worsening end-organ injury but emphasize that such hypertensive emergencies are rare. For the vast majority of patients with elevated BP in the ED who do not have new or worsening end-organ injury from elevated BP, immediate BP reduction within the ED is not recommended or safe. Nonetheless, within weeks after an ED visit, there is a pressing need to improve the care of patients with elevated or previously undiagnosed hypertension. For many, it may be their only regular point of engagement with the healthcare system. To address this, we present novel perspectives that envision a new role for emergency medicine in chronic hypertension management—one that acknowledges the significant population-level gaps in BP control that contribute to disparities in cardiovascular disease and sets the stage for future changes in systems-based practice.CONCLUSIONSEmergency medicine plays a key and evolving role in reducing morbidity associated with elevated BP.

Pharmacokinetics of Amlodipine Besylate at Delivery and During Lactation

(Pregnancy Hypertens. 2018;11:77–80. Doi:10.1016/j.preghy.2018.01.002) The management of chronic hypertension, which affects ~5% of all US pregnancies, requires careful balance. While many drugs used to treat hypertension have been well-studied, there is a lack of options that have been adequately studied during pregnancy and lactation. Amlodipine is an ideal option for use in pregnancy due to its long half-life, infrequent dosing, low cost and positive side-effect profile, but more data are needed on its use in pregnant and lactating patients and whether it crosses the placenta. This study aimed to evaluate the pharmacokinetics of amlodipine besylate in a population of pregnant women during delivery and postpartum lactation.

Management of Chronic Hypertension Following Intracerebral Hemorrhage.

Acute blood pressure control after a cerebrovascular event is integral in the immediate care of these patients to preserve perfusion to ischemic areas and prevent intracerebral bleeding. The majority of patients with ischemic stroke or intracerebral hemorrhage (ICH) present with preexisting hypertension and therefore require a treatment plan after the acute phase. The presence of chronic hypertension after ICH has often been discussed as a modifiable risk factor for recurrent events. Clinical evidence is relatively lacking for clinicians to understand the extent of blood pressure lowering and the optimal agents to use in this setting. Limited data exist describing the long-term management of hypertension in patients after cerebrovascular events. This review provides nurses with a summary of the available literature on long-term blood pressure management to minimize the risk of secondary ICH and ischemic stroke. It focuses on oral antihypertensive medications available in the United States that may be utilized to manage chronic hypertension immediately after the postacute phase of care to lower blood pressure and to improve long-term outcomes.

New Evidence in the Management of Chronic Hypertension in Pregnancy

Chronic hypertension complicates 1% to 5% of all pregnancies, but debate continues regarding the benefits of lowering blood pressure in pregnancy as well as the optimal blood pressure targets. Women with chronic hypertension are at significant risk for maternal and fetal morbidity and mortality, yet it remains unclear whether antihypertensive treatment during pregnancy lowers these risks. Severe hypertension (systolic ≥ 160 mm Hg) should be treated, but there is considerable variability in the approach to mild-to-moderate hypertension (140-159/90-109 mm Hg). The recently published CHIPS (Control of Hypertension in Pregnancy Study) trial is an important effort to attempt to determine treatment goals in mild to moderate pregnancy hypertension. The risks and benefits of tight versus less tight control of blood pressure in nonproteinuric hypertensive women, most of whom had pre-existing hypertension, were evaluated. A main finding was an increased risk of severe hypertension (adjusted odds ratio, 1.8) when blood pressure was not tightly controlled. In this review, general management of chronic hypertension in pregnancy is discussed, including changes in treatment that may be appropriate in light of new clinical trial data.

SOMANZ guidelines for the management of hypertensive disorders of pregnancy 2014.

This guideline is an evidence based, practical clinical approach to the management of Hypertensive Disorders of Pregnancy. Since the previous SOMANZ guideline published in 2008, there has been significant international progress towards harmonisation of definitions in relation to both the diagnosis and management of preeclampsia and gestational hypertension. This reflects increasing knowledge of the pathophysiology of these conditions, as well as their clinical manifestations. In addition, the guideline includes the management of chronic hypertension in pregnancy, an approach to screening, advice regarding prevention of hypertensive disorders of pregnancy, and discussion of recurrence risks and long term risk to maternal health. The literature reviewed included the previous SOMANZ Hypertensive Disorders of Pregnancy guideline from 2008 and its reference list, plus all other published National and International Guidelines on this subject. Medline, Cochrane Database of Systematic Reviews (CDSR), Cochrane Central Registry of Controlled Trials (CCRCT), National Institute for Health and Care Excellence (NICE) Evidence Search, and Database of Abstracts and Reviews of Effects (DARE) were searched for literature published between January 2007 and March, 2014.

Management of chronic hypertension in pregnancy

Chronic hypertension is defined as an elevated blood pressure (BP) that predates conception or is detected before 20 weeks of gestation. It occurs in up to 5% of all pregnancies, and this incidence rate is increasing with the rising prevalence of women who conceive at an older age. Superimposed preeclampsia develops in about 25% of women with chronic hypertension and increases the risks of eclampsia, fetal intrauterine growth restriction, and stillbirth. The management of chronic hypertension remains controversial. According to systematic reviews and meta-analyses, antihypertensive agents are recommended to patients with severe hypertension (systolic BP ≥160 mmHg or diastolic BP ≥105 mmHg). They are not suggested for those with mild hypertension and no evidence of end-organ damage, however, due to the lack of evidence that pharmacologic treatment can improve perinatal outcomes in this population. The optimal BP target is a systolic BP of 120 to 160 mmHg and a diastolic BP of 80 to 105 mmHg. In antenatal care, fetal surveillance should be performed to detect abnormal fetal growth through regular ultrasonography examinations, and in those with fetal intrauterine growth restriction, umbilical arterial Doppler velocimetry should be used. In women at risk of preeclampsia, low-dose aspirin might reduce the possibility of its occurrence. Women with a hypertensive disorder during pregnancy are at increased risk of chronic hypertension, cardiovascular disease, and thromboembolism in later life; therefore, appropriate postnatal BP control and health interventions such as smoking cessation and obesity control should be proposed.

Hypertension Persisting after Pre-Eclampsia: A Prospective Cohort Study at Mulago Hospital, Uganda

BackgroundPre-eclampsia/eclampsia usually resolves after delivery but sometimes hypertension persists and cardiovascular disease develops later. Our objective was to determine the incidence and maternal socio-demographic and obstetric risk factors for persistence of hypertension in women with pre-eclampsia/eclampsia.MethodsThis was a prospective cohort study conducted from July 2009 to June 2011 at Mulago Hospital labour ward and postnatal clinics. We followed up 188 women admitted with pre-eclampsia/eclampsia until 3 months after delivery. Data was collected using interviewer-administered questionnaires, examination of participants and review of medical records. Stata (version12) software was used for data analysis. Univariable analysis was used to compute the relative risk of persistent hypertension at the 95% confidence level. This was followed by multivariable logistic regression analysis to determine factors independently associated with persistence of hypertension.Results64 (34%) out of the 188 women analysed had persistent hypertension three months after delivery. Maternal age, gestational age at delivery and parity were predictors of persistent hypertension. ConclusionThe proportion of women with pre-eclampsia/eclampsia at risk of persistent hypertension at three months after delivery was high, with nearly one of three mothers remaining hypertensive. Follow up of mothers who develop pre-eclampsia is important so that early diagnosis and management of chronic hypertension can be made to avoid long term morbidity and mortality.

Management of chronic hypertension during pregnancy with furosemide, amlodipine or aspirin: a pilot clinical trial

Objective: To determine the maternal and neonatal efficacy and safety with furosemide, amlodipine or aspirin in women with mild/moderate chronic hypertension during pregnancy.Methods: A pilot clinical trial was performed in a tertiary teaching hospital in Panama. Pregnant patients with mild/moderate chronic hypertension at ≤20 weeks of gestation were invited to take part in the study. Mild/moderate chronic hypertension was defined as a pregnancy with systolic blood pressure of 140–159 mmHg or diastolic blood pressure of 90–109 mmHg. Women in the furosemide group received 20 mg of furosemide oral each day, those in the amlodipine group received 5 mg of amlodipine oral each day and those in the aspirin group received 75 mg of orally-administered acetylsalicylic acid each day.Results: We enrolled 63 patients during the study period, 21 women were randomised to each group (aspirin, amlodipine and furosemide). We found no difference in maternal complications, pre-term births, mean birth weight or in the proportion of small for gestational age infants among treatment groups. Severe hypertension and aggregate pre-eclampsia were similar among treatment groups.Conclusion: This pilot trial demonstrates that both furosemide and amlodipine might have the same effect during pregnancy. However, a large clinical trial is necessary to prove this.

Abstract 19618: Effect of Electroanatomically Guided versus Conventional Renal Sympathetic Denervation on Radiation Exposure and Blood Pressure in the SAVE Trial

Introduction: SYMPLICITY -2 demonstrated that renal sympathetic denervation (RSDN) is effective in lowering blood pressure in patients with resistant hypertension. RSDN is typically performed using fluoroscopy. Our aim was to assess the clinical utility of electroanatomic mapping systems (EAM) on radiation exposure and treatment results in a prospective trial. Methods: Pre-specified analysis of outcomes in both the non-randomized Impact of Renal Sympathetic Denervation on Chronic Hypertension (SAVE) trial (n=10), and the randomized Renal Sympathetic Denervation for the Management of Chronic Hypertension (RELIEF) trial (n=10). Both trials enroll patients with refractory HTN, defined as BP≥140/90 mmHg despite treatment with at least 3 anti-HTN drugs. Patients in the SAVE cohort underwent catheter based RSDN using EAM (NavX, CARTO), and were compared with case-matched controls in the RELIEF trial who underwent RSDN using fluoroscopy. All patients underwent bilateral renal angiography prior to RSDN, resulting in radiation exposure. Blood pressure was measured at 1 month post-procedure in an office setting. Results: Radiation exposure was significantly reduced in the EAM group (39,175 ± 14,463 mGycm2 vs 61,209 ± 22,259 mGycm2, P=0.0172). Total procedure duration was comparable between the EAM group (77.0 ± 35.5 min) and conventional group (75.6 ± 33.8 min, P=0.8837). The SBP at 1 month (147 ± 11 vs 156 ± 19 mmHg, P=0.3662) and DBP at 1 month (91 ± 11 vs 88 ± 15 mmHg, P=0.6998) were similar between the EAM and conventional group. Conclusion: The use of electroanatomic mapping systems during RSDN significantly reduces radiation exposure, without increasing procedure duration.

Ambulatory Management of Chronic Hypertension in Pregnancy

Chronic hypertension in pregnancy is one of the most common medical diseases affecting pregnancy. It is associated with serious maternal and fetal complications, including superimposed pre-eclampsia, fetal growth restriction, premature delivery, placental abruption, and stillbirth. Baseline evaluation as early as possible is important to differentiate women with essential hypertension from those with severe hypertension, coexisting end-organ damage, and secondary causes of hypertension, as their risks of poor outcomes are increased. An optimal plan for maternal treatment and fetal surveillance can then be formulated. Coordination of care after delivery is important for long-term maternal health and future pregnancies.

Sertraline-Associated Hyponatremia and Subsequent Tolerability of Bupropion in an Elderly Woman

To the Editor: Although hyponatremia is a well-described adverse effect of antidepressant therapy,1 few reports have examined which antidepressant agents are safe after a patient experiences selective serotonin reuptake inhibitor (SSRI)–associated hyponatremia. We describe a case of sertraline-associated hyponatremia and the subsequent tolerability of bupropion in an elderly woman. Case report. Ms A, an 87-year-old thin, hypertensive woman with a history of dementia and major depressive disorder (diagnosed before the onset of dementia), was transferred from an assisted living facility to a geriatric psychiatry ward in December 2009 for management of 3 weeks of worsening physical aggression, depressed mood, anxiety, insomnia, and suicidal ideation. The admission physical examination and laboratory studies were unremarkable (including a serum sodium value of 140 mEq/L). The patient was diagnosed with a major depressive episode (using DSM-IV criteria), and sertraline therapy was initiated at 50 mg by mouth daily, and trazodone 50 mg was administered on 2 nights at bedtime to manage insomnia. Haloperidol was also given at 0.25 mg by mouth in the morning and 0.5 mg by mouth at night to manage the aggressive behaviors. The patient was also prescribed enalapril 5 mg by mouth daily and levothyroxine 112 μg by mouth daily for management of chronic hypertension and hypothyroidism. Four days later, the patient demonstrated inability to sustain attention, hypoarousal, and worsened disorientation. Laboratory evaluation revealed a serum sodium level of 126 mEq/L and plasma osmolality of 272 mOsm/kg, thyrotropin level of 4.64 uIU/mL, and urine specific gravity of 1.002 and osmolality of 655 mOsm/kg. Additionally, the patient was found to have acute cystitis. The patient was euvolemic and demonstrated laboratory evidence consistent with the syndrome of inappropriate antidiuresis. Sertraline was discontinued, fluids were restricted, and antibiotic therapy was prescribed. Bupropion immediate release was initiated the next day at 75 mg by mouth daily and then increased the following day to 75 mg by mouth twice daily. The patient's mental state improved, and electrolyte studies 6 days later revealed serum sodium and osmolality values of 135 mEq/L and 280 mOsm/kg, respectively. The suicidal ideation resolved and the other symptoms improved during the hospital course. The hyponatremia did not recur, and the patient was discharged to the assisted living facility. Jacob and Spinler1 reviewed all published material describing SSRI-associated hyponatremia and identified several patient characteristics (age greater than 65 years, woman, diuretic use, history of pneumonia, low body weight, low baseline sodium) commonly associated with development of hyponatremia. That review study was designed to identify patient characteristics associated with hyponatremia and did not address what agents may be safe for patients who experienced hyponatremia. During the initial clinical studies of bupropion, a norepinephrine and dopamine reuptake inhibitor, 1 group reported on a patient who experienced hyponatremia during imipramine monotherapy, then during bupropion monotherapy.2 Although 1 additional case described bupropion-associated hyponatremia,3 2 other case reports4,5 demonstrated the tolerability of bupropion in elderly patients who previously experienced antidepressant-associated hyponatremia. Our case is the third to demonstrate tolerability of bupropion in an elderly patient with SSRI-associated hyponatremia and suggests that bupropion may be a reasonable antidepressant choice for these patients.

Characteristics, practice patterns, and outcomes in patients with acute hypertension: European registry for Studying the Treatment of Acute hyperTension (Euro-STAT)

IntroductionAlthough effective strategies are available for the management of chronic hypertension, less is known about treating patients with acute, severe elevations in blood pressure. Using data from the European registry for Studying the Treatment of Acute hyperTension (Euro-STAT), we sought to evaluate 'real-life' management practices and outcomes in patients who received intravenous antihypertensive therapy to treat an episode of acute hypertension.MethodsEuro-STAT is a European, hospital-based, observational study of consecutive adult patients treated with intravenous antihypertensive therapy while in the emergency department, perioperative unit or ICU. Enrolment took place between 1 July and 15 October 2009 in 11 hospitals in 7 European countries (Austria, Belgium, Germany, Italy, Spain, Sweden and the United Kingdom).ResultsThe study population was composed of 791 consecutive patients (median age 69 years, 37% women). Median arterial blood pressure before treatment was 166 mmHg systolic blood pressure (IQR 141 to 190 mmHg) and 80 mmHg diastolic blood pressure (IQR 68 to 95). Nitroglycerine was the most commonly used antihypertensive treatment overall (40% of patients), followed by urapidil (21%), clonidine (16%) and furosemide (8%). Treatment was associated with hypotension in almost 10% of patients. Overall 30-day mortality was 4%, and new or worsening end-organ damage occurred in 19% of patients.ConclusionsHigh blood pressure requiring intravenous therapy is currently managed with a variety of agents in Europe, with those most commonly used being nitroglycerine, urapidil and clonidine. Patients with acute hypertension have substantial concomitant morbidity and mortality, and intravenous antihypertensive treatment is associated with hypotension in almost 10% of cases.