Multiple Antihypertensive Medications Research Articles

Adrenal pheochromocytoma associated with transient hyperreninemia

We report a case of adrenal pheochromocytoma with transient hyperreninemia exceeding more than a hundred-fold of upper limit of normal range. The patient, a 61-year-old woman, was admitted due to recurrent episodes of angina and hypertensive urgency. Eight years before this admission, she was diagnosed to have a case of hypertension, and was found to have dyslipidemia and diabetes mellitus 2 and 1 year ago, respectively. During the past 2 years, fluctuation of blood pressure, ranging from 130 to 220 mm Hg in systole, were noted even after multiple anti-hypertensive medications were prescribed and paroxysmal attacks of hypertensive urgency with chest pain, sweating, headache, and tachycardia had brought her to our Emergency department for many times.

Antihypertensive Medication Use Among US Adults With Hypertension

High blood pressure can be controlled through existing antihypertensive drug therapy. This study examined trends in prescribed antihypertensive medication use among US adults with hypertension and compared drug utilization patterns with recommendations of the Sixth Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Persons aged > or =18 years from the National Health and Nutrition Examination Surveys were identified as hypertensive on the basis of either a blood pressure > or =140/90 mm Hg or self-reported current treatment for hypertension with a prescription medication. In 1999-2002, 62.9% of US hypertensive adults took a prescription antihypertensive medication compared with 57.3% during 1988-1994 (P<0.01). Men had the greatest increase in antihypertensive medication use (47.5%, 1988-1994 versus 57.9%, 1999-2002 [P<0.001]). In both surveys, antihypertensive medication use increased with age, was lower among men than among women, and was lower among Mexican Americans than among non-Hispanic whites and blacks. Multiple antihypertensive drug use increased from 29.1% to 35.8% (P<0.001). Polytherapy with a calcium channel blocker, beta-blocker, or angiotensin-converting enzyme inhibitor significantly increased by 30%, 42%, and 68%, respectively, whereas monotherapy with a diuretic or beta-blocker significantly decreased. For hypertensives with diabetes, congestive heart failure, or a prior heart attack, the utilization patterns closely followed the Sixth Joint National Committee guideline recommendations. Antihypertensive medication use and multiple antihypertensive medication use among US hypertensive adults increased over the past 10 years, but disparities by sociodemographic factors continue to exist.

Five-Year Follow-Up After Clinical Islet Transplantation

Islet transplantation can restore endogenous beta-cell function to subjects with type 1 diabetes. Sixty-five patients received an islet transplant in Edmonton as of 1 November 2004. Their mean age was 42.9 +/- 1.2 years, their mean duration of diabetes was 27.1 +/- 1.3 years, and 57% were women. The main indication was problematic hypoglycemia. Forty-four patients completed the islet transplant as defined by insulin independence, and three further patients received >16,000 islet equivalents (IE)/kg but remained on insulin and are deemed complete. Those who became insulin independent received a total of 799,912 +/- 30,220 IE (11,910 +/- 469 IE/kg). Five subjects became insulin independent after one transplant. Fifty-two patients had two transplants, and 11 subjects had three transplants. In the completed patients, 5-year follow-up reveals that the majority ( approximately 80%) have C-peptide present post-islet transplant, but only a minority ( approximately 10%) maintain insulin independence. The median duration of insulin independence was 15 months (interquartile range 6.2-25.5). The HbA(1c) (A1C) level was well controlled in those off insulin (6.4% [6.1-6.7]) and in those back on insulin but C-peptide positive (6.7% [5.9-7.5]) and higher in those who lost all graft function (9.0% [6.7-9.3]) (P < 0.05). Those who resumed insulin therapy did not appear more insulin resistant compared with those off insulin and required half their pretransplant daily dose of insulin but had a lower increment of C-peptide to a standard meal challenge (0.44 +/- 0.06 vs. 0.76 +/- 0.06 nmol/l, P < 0.001). The Hypoglycemic score and lability index both improved significantly posttransplant. In the 128 procedures performed, bleeding occurred in 15 and branch portal vein thrombosis in 5 subjects. Complications of immunosuppressive therapy included mouth ulcers, diarrhea, anemia, and ovarian cysts. Of the 47 completed patients, 4 required retinal laser photocoagulation or vitrectomy and 5 patients with microalbuminuria developed macroproteinuria. The need for multiple antihypertensive medications increased from 6% pretransplant to 42% posttransplant, while the use of statin therapy increased from 23 to 83% posttransplant. There was no change in the neurothesiometer scores pre- versus posttransplant. In conclusion, islet transplantation can relieve glucose instability and problems with hypoglycemia. C-peptide secretion was maintained in the majority of subjects for up to 5 years, although most reverted to using some insulin. The results, though promising, still point to the need for further progress in the availability of transplantable islets, improving islet engraftment, preserving islet function, and reducing toxic immunosuppression.

Sildenafil citrate for erectile dysfunction in men receiving multiple antihypertensive agents: A randomized controlled trial

Erectile dysfunction (ED) is common among men taking antihypertensive drugs to control blood pressure. We evaluated the safety and efficacy of sildenafil citrate for treating ED in men taking multiple antihypertensive medications in a randomized, double-blind, placebo-controlled trial. A total of 568 men (> or =18 years) with ED and hypertension who were taking two or more antihypertensives were randomized to sildenafil (n = 281) or matching placebo (n = 287) for a 6-week double-blind trial followed by a 6-week open-label phase during which all patients received sildenafil. Primary efficacy variables were questions (Q) 3 and 4 (frequency of erections and penetration) of the International Index of Erectile Function (IIEF), and secondary efficacy variables were two global efficacy assessment (GEA) questions regarding improvement in erections and intercourse. A total of 562 men (mean age, 59 years) took > or =1 dose of study drug. At week 6, mean scores on both Q3 and Q4 improved significantly among sildenafil-treated compared with placebo-treated patients. In regard to Q3 and Q4 there were no differences between patients taking two and those taking three or more antihypertensive agents. In all, 71% and 69% of sildenafil-treated patients reported improved erections (GEA1) and intercourse (GEA2) compared with 18% and 20% of placebo-treated patients, respectively. By week 12, >80% of all patients (regardless of initial treatment group) had improved erections and intercourse. During double-blind treatment, 40% of sildenafil-treated and 25% of placebo-treated patients experienced adverse events; fewer than 2% in each group discontinued because of adverse events. Sildenafil was an effective and well tolerated treatment for ED in men receiving multiple antihypertensives. The results suggest that there were no additional safety risks associated with the use of sildenafil in these patients.

Diabetic nephropathy in African-American patients

Diabetic nephropathy (DN) is the number one cause of end-stage renal disease (ESRD) in the United States and is highly prevalent in African Americans. Since 1997, DN has been the number one cause of ESRD in African Americans. In African Americans, almost all DN is due to type 2 diabetes mellitus (T2DM), and nephropathy may affect female more than male patients. African Americans with T2DM are at increased risk for developing and having progression of DN. Glycemic control, development of albuminuria, family history of renal disease, and control of blood pressure are important risk factors for progression of DN. In addition, cigarette smoking, presence of hepatitis C, and use of thiazolinediones has an impact on renal survival in African Americans. Large vessel complications may be less frequent in African Americans with T2DM, when compared with white persons. Yet, cardiovascular disease and other microvascular complications are very common, and both are dependent on control of blood pressure. Achieving the recommended blood pressure of less than 130/80 mm Hg is essential but requires multiple antihypertensive medications, including an inhibitor of the renin-angiotensin system.

Identifying gaps between guidelines and clinical practice in the evaluation and treatment of patients with hypertension

Purpose Hypertension remains uncontrolled in the majority of affected patients despite treatment. Our goal was to identify specific action items in the Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC VI) guidelines that are not being translated into clinical practice. Methods We transformed the major JNC VI tables into a chart review instrument that was used to retrospectively analyze the medical records of 249 patients with newly diagnosed hypertension who had been followed for 18 months at one of six community-based primary care clinics. Results The practices of physicians deviated from the guidelines in several ways. Hypertension was staged initially on a single blood pressure recording in 85% (n = 212) of patients. No electrocardiogram was ordered for 89% (n = 221) of patients, while other mandatory laboratory tests were ordered for about 50%. After 18 months, 40% (72/179) of patients for whom prescription records were identified were still on monotherapy, and target blood pressure (<140/90 mm Hg) was achieved in only 33% (83/249) of patients. All of the 35 patients with diabetes received an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker, but only 1.7 medications were prescribed per patient at study end. Conclusion In this clinic system, staging of blood pressure with multiple measurements, thorough assessment of global cardiovascular risk, and titration of multiple antihypertensive medications to achieve blood pressure goal are components of the JNC VI guidelines that are not well translated into clinical practice. Overcoming these practice defects will require innovative multilevel interventions.

The burden of cardiovascular disease: following the link from hypertension to myocardial infarction and heart failure

Cardiovascular disease (CVD) is an enormous health care burden in the United States (US) and is responsible for approximately 40% of all US deaths annually. Heart failure (HF) represents the final stage of the continuum of CVD and is increasing in incidence. Between 1970 and 2000, hospital discharges for HF in the US increased 145%. This trend appears to be related to rising life expectancy and the aging of the population. Once HF develops, the long-term prognosis continues to be dismal. Hypertension is a major risk factor for CVD and the most common risk factor for the development of HF. The results of clinical trials such as the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) have helped to clarify the importance of optimizing antihypertensive therapy to reduce CVD risks and development of HF. The trial also confirmed the need for multiple antihypertensive medications to reach recommended blood pressure (BP) goals in most patients. Aggressive lowering of BP is critical to help reduce the risk of CVD and help prevent the development of HF.

Determination of ambulatory blood pressure control in treated patients with controlled office blood pressures

Office blood pressure measurement is the standard for assessing blood pressure control. Many patients, however, take their antihypertensive medication in the morning, so they are likely to have their office blood pressure measured during the maximal antihypertensive effect. It is therefore unknown whether patients deemed by office blood pressure to be controlled do in fact have 24h blood pressure control. The objectives of this study were to determine blood pressure control, including blood pressure control while the patients were awake and during the first 6 hours after awakening, by ambulatory blood pressure monitoring (ABPM) in treated hypertensive patients deemed by office blood pressure measurements to be controlled. A total of 103 patients on a stable antihypertensive regimen and deemed to be controlled in terms of office blood pressure values (mean office blood pressure <140/90mmHg) were enrolled. Patients were stratified by cardiovascular risk status and the number of antihypertensive medications that they were taking. Seventy-eight out of 103 participants successfully completed ABPM. The mean ambulatory blood pressure was greater than 135/85mmHg and 140/90mmHg while awake for 37% (95% confidence interval [CI] 26-48%) and 23% (95% CI 14-32%) of all patients respectively. Forty-eight per cent (95% CI 33-63%) of patients taking monotherapy versus 25% (95% CI 11-39%) of patients on multiple antihypertensive medications were uncontrolled (P=0.039) using 135/85mmHg as the reference value. Thirty-one per cent (95% CI, 17-44%) of patients on monotherapy versus 14% (95% CI 3-25%) of patients on multiple antihypertensive medication were uncontrolled (P=0.064) using 140/90mmHg instead. These results demonstrate that a high number of patients deemed by office blood pressure to be under control do not have adequate blood pressure control based on ABPM.

Safety and Efficacy of a Mandatory Formulary Switch From Nifedipine GITS to Amlodipine

OBJECTIVE: To analyze retrospectively the effects on blood pressure (BP) control of a mandatory switch from nifedipine in the gastrointestinal therapeutic system (GITS) to amlodipine. DESIGN: Retrospective review of a randomized sample of medical records to assess the safety and efficacy of the medication change. All outpatient pharmacy prescriptions (n=525) had been converted over the course of a year by the patients' clinicians to amlodipine when the current refills for nifedipine GITS had expired. We reviewed a randomized sample of patients' medical records (n=182). SETTING: The Brockton/West Roxbury Veterans Administration Medical Center. PATIENTS: Patients on a stable dose of nifedipine GITS for three months or more before switching and on a stable dose of amlodipine for three months or more. MAIN OUTCOME MEASURES: The average of at least two outpatient BP measures was used as a measure of efficacy. RESULTS: Of the 86 patients who fulfilled the study criteria, 72 (84%) converted directly to amlodipine with no change in concomitant medications, and 14 had changes in concomitant medications related to BP response (seven had dose increases and seven neutral or decreased doses). In the 72 patients who were directly converted to amlodipine (all men, mean age 70 +/- 9 years), BP control did not change. Before the switch, BP averaged 140 +/- 14/77 +/- 9 mm Hg; after, it averaged 140 +/- 15/78 +/- 8 mm Hg (p=NS). After the switch, 22% of these patients were on monotherapy, 46% were taking one antihypertensive agent, and 32% were taking two or more antihypertensive medications; these percentages were similar to those when patients were taking nifedipine GITS. Similar BP responses were observed among patients 65 years of age (n=54). The mean dose of nifedipine GITS was 62 +/- 28 mg/d and of amlodipine 7.8 +/- 4 mg/d. Four patients discontinued amlodipine due to documented adverse events. CONCLUSION: A large group of patients, including older individuals and those on multiple antihypertensive medications, can be safely converted from nifedipine GITS to amlodipine. The medication switch resulted in identical BP control in the large majority of patients, infrequent concomitant medication changes, and few drug discontinuations.

Technical Consideration in Management of Renovascular Hypertension in an Infant With Double Renal Arteries

Abstract Renovascular hypertension is a curable disease that has recently been recognized with increasing frequency. A renal scan in a 1-month-old hypertensive white male showed diminished function of the right kidney, and his peripheral vein renin was elevated. Multiple antihypertensive medications failed to control his hypertension, and right kidney function deteriorated. An arteriogram showed two stenotic renal arteries supplying the right kidney. The smaller inferior artery supplied 35% of the kidney. Selective vein renin levels were greater than 15,000 ng/dL on the right side. Technical considerations in the repair of this lesion included (1) midline transabdominal incision to expose the abdominal aorta and the inferior vena cava; (2) dissection of inferior vena cava (IVC) with division of selected lumbar veins; (3) full mobilization of right kidney and transsection of both renal arteries and the renal vein; (4) perfusion of kidney via each renal artery with cold Sach's solution after resection of arterial stenoses; (5) end-to-side microvascular anastomosis of the smaller (2 mm) renal artery to the main renal artery at the hilum with 10-0 nylon over in situ perfusion cannula; (6) renal artery passed under the IVC to the aorta; and (7) right kidney autotransplanted to a new site on the abdominal aorta with an end-to-side (5.0 mm) renal artery to the aorta and an end-to-side renal vein to IVC anastomosis. Following revascularization, perfusion was excellent and the blood pressure returned to normal. At 6 months follow-up, selective renal vein renins were normal and an arteriogram showed no stenosis. Meticulous dissection, cold perfusion, microvascular anastomosis, and autotransplantation salvaged this kidney and resolved the hypertension.

Technical consideration in management of renovascular hypertension in an infant with double renal arteries

Renovascular hypertension is a curable disease that has recently been recognized with increasing frequency. A renal scan in a 1-month-old hypertensive white male showed diminished function of the right kidney, and his peripheral vein renin was elevated. Multiple antihypertensive medications failed to control his hypertension, and right kidney function deteriorated. An arteriogram showed two stenotic renal arteries supplying the right kidney. The smaller inferior artery supplied 35% of the kidney. Selective vein renin levels were greater than 15,000 ng/dL on the right side. Technical considerations in the repair of this lesion included (1) midline transabdominal incision to expose the abdominal aorta and the inferior vena cava; (2) dissection of inferior vena cava (IVC) with division of selected lumbar veins; (3) full mobilization of right kidney and transsection of both renal arteries and the renal vein; (4) perfusion of kidney via each renal artery with cold Sach's solution after resection of arterial stenoses; (5) end-to-side microvascular anastomosis of the smaller (2 mm) renal artery to the main renal artery at the hilum with 10-0 nylon over in situ perfusion cannula; (6) renal artery passed under the IVC to the aorta; and (7) right kidney autotransplanted to a new site on the abdominal aorta with an end-to-side (5.0 mm) renal artery to the aorta and an end-to-side renal vein to IVC anastomosis. Following revascularization, perfusion was excellent and the blood pressure returned to normal. At 6 months follow-up, selective renal vein renins were normal and an arteriogram showed no stenosis. Meticulous dissection, cold perfusion, microvascular anastomosis, and autotransplantation salvaged this kidney and resolved the hypertension.

Pheochromocytoma – An Unusual Presentation – A Case Report

This case report is of a 50yrs old man who got admitted inBIRDEM Hospital in a state of unconsciousness for 5 hours.He is a known case of hypertension and diabetes mellitusfor the last 12 years and was on insulin. Hypoglycemia wasdetected, treated with intravenous glucose and the patientregained consciousness. On further query he complainedof repeated episodes of nausea, palpitation and sweatingfor the last 12 years. The episodes were initially labeled ashypoglycemia but blood sugar was never found inhypoglycemic range. The patient was on multipleantihypertensive medications but blood pressure wasuncontrolled. All the investigations were normal including24hrs urinary VMA, serum adrenalin and noradrenalinexcept ultrasonography of whole abdomen which showed amass measuring 72x 76 mm in left suprarenal region. Onenight the patient again developed palpitation, chestdiscomfort, severe headache and profuse sweating. Bloodpressure was recorded 240/160 mmHg. Blood sample wasdrawn for adrenalin, noradrenalin, 24hrs urine collectionwas done for VMA and was found very high. The patientwas diagnosed as having left adrenal pheochromocytoma.After controlling blood pressure and other preoperativepreparations left adrenalectomy was done. Histopathologyrevealed phaeochromocytoma. Per and postoperativeperiods were quite eventful. Blood pressure was normalwithout any antihypertensive drug during discharge. Thepatient was discharged with the advice to come for followup after 1 month.DOI: 10.3329/jbcps.v28i2.5371J Bangladesh Coll Phys Surg 2010; 28: 113-116