Treatment Of Elevated Blood Pressure Research Articles

Documentation and treatment of hypertension: quality of care and missed opportunities in a family medicine resident clinic

BackgroundIn the USA, uncontrolled hypertension contributes to 1000 deaths a day. However, little is known about the quality of hypertension management in family medicine resident clinics.ObjectivesTo examine rates of documentation...

Regulation of Na+ excretion and arterial blood pressure by purinergic signalling intrinsic to the distal nephron: consequences and mechanisms.

Discretionary control of Na(+) excretion is a key component of the regulation of arterial blood pressure in mammals. Sodium excretion is fine-tuned in the aldosterone-sensitive distal nephron by the activity of the epithelial Na(+) channel (ENaC). Here, ENaC functions as a final effector of the renin-angiotensin-aldosterone system (RAAS) during negative feedback control of blood pressure. Mutations affecting ENaC activity and abnormal regulation of this channel affect blood pressure through pathological changes to Na(+) excretion. Recent evidence demonstrates that powerful signalling pathways function in parallel with the RAAS to modulate ENaC activity and blood pressure. An inclusive paradigm is emerging with respect to regulation of blood pressure where ENaC serves as a critical point of convergence for several important signalling systems that affect renal Na(+) excretion. A robust inhibitory purinergic signalling system intrinsic to the distal nephron dynamically regulates ENaC through paracrine ATP signalling via the metabotropic P2Y2 purinergic receptor to properly match urinary Na(+) excretion to dietary Na(+) intake. This enables blood pressure to be maintained within a normal range despite broad changes in dietary Na(+) consumption. Loss of purinergic inhibition of ENaC increases blood pressure by causing inappropriate Na(+) excretion. In contrast, stimulation of the P2Y2 receptor promotes natriuresis and a decrease in blood pressure. Such observations identify purinergic signalling in the distal nephron as possibly causative, when dysfunctional, for certain forms of elevated blood pressure, and as a possible therapeutic target for the treatment of elevated blood pressure particularly that associated with salt sensitivity.

Cerebral perfusion pressure in women with preeclampsia is elevated even after treatment of elevated blood pressure

Cerebral perfusion pressure (CPP) is elevated in preeclampsia, and may predispose to cerebrovascular complications and progression to eclampsia. We estimated zero flow pressure (ZFP) and CPP using simultaneously obtained arterial blood pressure and middle cerebral artery blood flow velocity in 10 women with preeclampsia, all treated with methyldopa with or without nifedipine, and 18 healthy pregnant controls. Mean ± SD ZFP was lower in women with preeclampsia than in controls (16.8 ± 10.9 vs. 31.7 ± 15.0 mmHg, p = 0.01) whereas CPP was considerably higher (82.3 ± 17.7 vs. 55.0 ± 11.7 mmHg, p < 0.001), as was the cerebral flow index (41.9 ± 18.0 vs. 25.6 ± 11.2, p = 0.02). There was a significant correlation between blood pressure and CPP in women with preeclampsia, but not in controls. Women with preeclampsia may have an increased cerebral perfusion due to a reduced ZFP and increased CPP despite treatment with antihypertensive medication. More rigorous antihypertensive therapy, aimed at reducing CPP, could result in a decrease in cerebral complications in women with preeclampsia.

Inflammation modulation and cardiovascular disease prevention

Heart disease and stroke represent the major burden of health worldwide and account for a staggering 17 million deaths yearly. This pandemic is, in great part preventable through simple and modifiable preventive measures such as smoking cessation, healthy eating, regular activity and weight loss. In patients with established atherosclerotic vascular disease, lipid lowering agent have had a major impact on reducing risk, along with pharmacological treatment of elevated blood pressure and the use of anti-thrombotic medication. Despite these advances, there remains a significant residual risk and newer approaches are required to decrease atherosclerosis. Innate and acquired immunity play a pivotal role in the initiation, progression and instability of the atherosclerotic plaque. The remarkable complexity of the immune system makes it difficult to target a single pathway for the prevention of cardiovascular disease. Nevertheless, recent data points to possible therapeutic targets that may decrease atherosclerosis, without increasing the risk of infection, decreasing immune surveillance for cancers and without undue toxicity. Here we discuss the clinical trials and registry data associated with the use of inflammation modulation and cardiovascular disease and the ongoing major clinical trial that may change the clinical medicine and preventive cardiology. The selective inhibition of interleukin 1β and the use of low-dose methotrexate are now undergoing large outcome-driven clinical trials to answer these questions.

Sedentary behavior is a risk factor for higher exercise blood pressure independent of moderate-to-vigorous physical activity (MVPA) in young subjects

Background: Intravenous (IV) hydralazine is frequently used for the treatment of elevated blood pressure (BP) in hospitalized children. Its safety and efficacy has not been examined. Methods: A retrospective chart review of IV hydralazine use in hospitalized children (birth to 17 years) over a 3-year period. Demographic data, adverse effects (AE), and BP and heart rate (HR) prior to and after each first dose were collected. Results: Included were 110 admissions; 77 children received the recommended dose. Mean age was 8.5 5.4 years, 33% were male, and 32.5% were white. Pre-dose systolic and diastolic BP indexes were 1.3 and 1.2, respectively. Median systolic and diastolic BP reduction was 8.5% and 11.5%, respectively. Sixteen (21%) achieved systolic or diastolic BP reduction by 25%. Eight (10.3%) achieved BP <95 percentile for age, sex, and height after one dose. Seven (9%) had documented AE. HR increased by a median of 3.5%. In multivariable models examining percent change in systolic and diastolic BP, male gender was significantly associated with change in systolic BP. Conclusions: In hospitalized children in this study, 21% achieved a reduction of systolic or diastolic BP by 25%. IV hydralazine was well tolerated.

The efficacy and safety of intravenous hydralazine for the treatment of hypertension in the hospitalized child

Intravenous (IV) hydralazine is frequently used for the treatment of elevated blood pressure (BP) in hospitalized children. Its safety and efficacy have not been examined. This is a retrospective chart review of IV hydralazine use in hospitalized children (birth to 17 years) over a 3-year period. Demographic data and data on adverse effects (AE), BP, and heart rate (HR) prior to and after each first dose were collected. The patient cohort comprised 110 children admitted to the hospital during the study period, of whom 77 received the recommended dose. Mean age of the children was 8.5 ± 5.4 years; 33 % were male, and 32.5 % were white. Pre-dose systolic and diastolic BP indexes were 1.3 and 1.2, respectively. The median reduction in systolic and diastolic BP was 8.5 and 11.5 %, respectively. Sixteen (21 %) children achieved a 25 % reduction in systolic or diastolic BP, and BP increased in 30 % of patients; 10 % of children had a BP of <95th percentile for age, sex, and height after one dose. Seven (9 %) children had a documented AE. HR increased by a median of 3.5 %. In the multivariable models examining percentage change in systolic and diastolic BP, male gender was significantly associated with a change in systolic BP. In hospitalized children, IV hydralazine was well tolerated, BP response was variable, and 21 % of the patients achieved a ≥25 % reduction of systolic or diastolic BP. Further studies are needed to compare the safety and efficacy of IV hydralazine to other short-acting antihypertensive agents.

Azilsartan alone and in combination for the treatment of hypertension &ndash; clinical utility and patient considerations

Correspondence: Sylvia H Jackson Florida A&M University, College of Pharmacy and Pharmaceutical Sciences, 2050 Art Museum Drive, Suite 200, Jacksonville, FL 32207, USA Tel +1 904 391 3904 Fax +1 904 391 3915 Email sylvia.jackson@famu.edu Abstract: Hypertension is a common disease that leads to significant cardiovascular morbidity and mortality. Adequate blood pressure control is essential in preventing end organ complications. One of the most popular antihypertensive strategies for the treatment of elevated blood pressure is to attenuate the actions of the renin-angiotensin-aldosterone system. The agents include the angiotensin converting enzyme inhibitors, angiotensin II receptor blockers (ARBs), direct renin inhibitors, and aldosterone antagonists. The ARBs inhibit the action of angiotensin II by binding to the angiotensin II type 1 receptor. The inhibition of angiotensin II results in a dose dependent decrease in peripheral resistance, reduction in vascular smooth muscle contraction, and reduced synthesis of aldosterone in the kidneys. Azilsartan medoxomil is a highly selective ARB. It was approved by the US Food and Drug Administration in February 2011 for the treatment of hypertension in adults. It is the eighth ARB to be added to the market. This article will discuss the pharmacologic and clinical characteristics of azilsartan medoxomil to help differentiate it from other ARBs that are used for the management of hypertension.

Are there consequences of labeling patients with prehypertension? An experimental study of effects on blood pressure and quality of life

ObjectiveThe prehypertension classification was introduced to facilitate prevention efforts among patients at increased risk for hypertension. Although patients who have been told that they have hypertension report worse outcomes than unaware hypertensives, little is known about whether or not prehypertension labeling has negative effects. We evaluated the effects of labeling individuals with prehypertension on blood pressure and health-related quality of life three months later. MethodsOne hundred adults (aged 19 to 82 [mean=40.0] years; 54% women; 64% racial/ethnic minorities) with screening blood pressure in the prehypertensive range (120–139/80–89mmHg) and no history of diagnosis or treatment of elevated blood pressure were randomly assigned to either a “Labeled” group in which they were informed of their prehypertension, or an “Unlabeled” group in which they were not informed. Subjects underwent office blood pressure measurement, 24-hour ambulatory blood pressure monitoring and completed self-report questionnaires at baseline and at three months. ResultsMultilevel mixed effects regression analyses indicated that changes in the white coat effect, office blood pressure, mean daytime ambulatory blood pressure, and physical and mental health did not differ significantly between the two groups. Adjusting for age, sex, race/ethnicity and body mass index did not affect the results. ConclusionThese findings suggest that labeling patients with prehypertension does not have negative effects on blood pressure or quality of life. Additional research is needed to develop approaches to communicating with patients about their blood pressure that will maximize the clinical and public health impact of the prehypertension classification.

Hypertension in the elderly

IntroductionThere is a high prevalence of hypertension in the elderly, as evidenced by clinical and health behavioral policies. Still, there are uncertainties on the treatment of hypertension, especially treatment of the very elderly. These considerations have largely been ignored in clinical trials due to concern regarding contamination by other pathologies that are difficult to frame and manage.Methods We performed an effective and ample literature review and provided reflections on the Consensus Conference ACCF/AHA 2011 on the principle types of hypertension found in the elderly. We also considered the associated principle pathologies for various treatments and related organs.Discussion Even if the goal of treatment of elevated blood pressure in the elderly is same as in younger population, it is no longer certain that a target systolic blood pressure (SBP) &lt;140 mmHg should be persistently reached in the very elderly. It is important to note that for all studies these values have never been reached. In the treatment of isolated systolic hypertension (ISH) the preferred target is a SBP &gt;160 mmHg. Treating hypertension in the elderly and very elderly reduces the risk of stroke and heart failure, though the evidence is inconclusive for all-cause mortality.Conclusion Hypertension in the elderly is very common and needs to be treated with criteria that consider the patient's age, comorbidities, lifestyle and adherence. Above all, in the very elderly, therapeutic treatment should be personalized according to the above criteria. Where possible pharmaceutical therapy should be limited at the preference of healthy lifestyle changes (physical activity, diet, etc.).

Hypertension in the elderly

Summary Introduction There is a high prevalence of hypertension in the elderly, as evidenced by clinical and health behavioral policies. Still, there are uncertainties on the treatment of hypertension, especially treatment of the very elderly. These considerations have largely been ignored in clinical trials due to concern regarding contamination by other pathologies that are difficult to frame and manage. Methods We performed an effective and ample literature review and provided reflections on the Consensus Conference ACCF/AHA 2011 on the principle types of hypertension found in the elderly. We also considered the associated principle pathologies for various treatments and related organs. Discussion Even if the goal of treatment of elevated blood pressure in the elderly is same as in younger population, it is no longer certain that a target systolic blood pressure (SBP) 160 mmHg. Treating hypertension in the elderly and very elderly reduces the risk of stroke and heart failure, though the evidence is inconclusive for all-cause mortality. Conclusion Hypertension in the elderly is very common and needs to be treated with criteria that consider the patient's age, comorbidities, lifestyle and adherence. Above all, in the very elderly, therapeutic treatment should be personalized according to the above criteria. Where possible pharmaceutical therapy should be limited at the preference of healthy lifestyle changes (physical activity, diet, etc.).

An Evidence-Based Review of Exercise and Metabolic Syndrome

An Evidence-Based Review of Exercise and Metabolic Syndrome

Implications of New Hypertension Guidelines in the United States

The American Heart Association Task Force released a scientific statement in 2007 for the treatment of hypertension in the prevention of coronary artery disease (CAD). These guidelines recommend more aggressive control of blood pressure (BP) among those at high risk for CAD: individuals with diabetes mellitus, chronic kidney disease, cardiovascular disease, congestive heart failure, or a 10-year Framingham risk score ≥10%. These individuals are advised to maintain a BP <130/80 mm Hg. We estimated the burden of uncontrolled BP among those at an increased risk of CAD using the updated task force guidelines. We used a cross-sectional analysis of National Health and Nutrition Examination Survey 2005-2008 participants. Participants were 24 989 adults aged 18 to 85 years. Using the old definition of hypertension (>140/90 mm Hg), 98 million (21%) Americans have hypertension. Using the updated guidelines, an additional 52 million (11%) American adults now have elevated BP requiring treatment, for a total of 150 million adults (32%). Adults with diabetes mellitus have the greatest population burden of uncontrolled BP (50.6 million), followed by adults with chronic kidney disease (43.7 million) and cardiovascular disease (43.3 million). Although individuals at a higher risk for CAD are more likely to be aware of their hypertension and to be taking antihypertension medication, they are less likely to have their BP under control. Additional efforts are needed in the treatment of elevated BP, especially among individuals with an increased risk of CAD.

Metabolic Syndrome and Heart Failure—The Risk, Paradox, and Treatment

The constellation of obesity, hypertension, dyslipidemia, and insulin resistance-together referred to as metabolic syndrome (MetS)-is increasing in prevalence in the American population and also worldwide. The individual components of MetS and MetS as a whole increase the risk of heart failure, cardiovascular mortality, and all-cause mortality. Despite this adverse association, numerous studies have documented an obesity paradox, in which overweight and obese people with established cardiovascular disease, including hypertension, coronary heart disease, heart failure, and peripheral arterial disease, have a better prognosis than patients who are not overweight or obese. Current treatment strategies for these patients include weight loss, control of blood pressure and cholesterol levels, and treatment of hyperglycemia. Because of increasing evidence for the obesity paradox, some physicians question whether obesity should be treated when it is associated with heart failure. Several studies have shown improvement in left ventricular function and decreased mortality and morbidity from heart failure with weight loss and treatment of elevated blood pressure, cholesterol, and hyperglycemia. The most reasonable approach at this time appears to be weight loss and exercise, lowering blood pressure to less than 130/80mmHg, low-density lipoprotein (LDL) cholesterol to less than 100mg/dL, and glycosylated hemoglobin levels to less than 7%.

Device-Based Antihypertensive Therapy

Systemic hypertension represents a major cardiovascular epidemic in the developed and developing world. Projections to 2025 suggest that up to 50% of the adult populations of Western countries will meet standard guideline definitions of hypertension1 and thus will require therapeutic interventions, either nonpharmacological or pharmacological. Hypertension is also a component of many other major comorbidities contributing to cardiovascular disease burden. On the basis of this public health epidemic, maximizing the effectiveness of existing therapeutic strategies and broadening treatment choices available for patients and clinicians are priorities. Ideally, development of novel additional approaches would not only improve blood pressure control but also beneficially influence comorbid factors commonly associated with hypertension, such as metabolic syndrome and other related disorders. Polypharmacy strategies for the treatment of elevated blood pressure have identified populations of patients with “resistant hypertension.” This is variously defined as above target blood pressure despite ≥3 antihypertensive drug classes at maximal (or highest tolerated) doses including a diuretic.2 With the use of this definition, a considerable proportion of hypertensive patients meet such criteria. Such patients clearly need new therapeutic approaches to optimize blood pressure control. The promise of procedures or devices to improve the management of chronic diseases is not necessarily predicated on the failure of pharmaceutical strategies but rather on the potential of such novel approaches to selectively target organs or nerves without contending with the associated systemic effects of pharmaceutical strategies. In the case of hypertension therapy, inhibiting components of the sympathetic nervous system offers a unique opportunity to target the “neural” component of the neurohormonal axis. Combining novel drug-, device-, and procedure-based strategies with improved utilization of existing therapies (including appropriate attention to diet, exercise, and weight control) should result in a major positive public health impact on this cardiovascular epidemic. This review will focus on …

Lifestyle Intervention Strategies for the Prevention and Treatment of Hypertension: A Review

Hypertension (HTN) is an extraordinarily common progressive cardiovascular syndrome in the United States, afflicting approximately one third of the adult population. HTN is a powerful and unequivocal independent risk factor for cardiovascular and renal diseases, including coronary heart disease, stroke, and renal failure. Despite major advances in the understanding and treatment of HTN over the past several decades, the disease remains the most common primary diagnosis in the United States and is a major public health concern. Adoption of healthy lifestyle modifications has proven to be highly effective in both the prevention of new-onset HTN and in the treatment of those diagnosed with HTN. In view of the continuing epidemic of HTN and blood pressure (BP)—related diseases and the invaluable role of applying nonpharmacological therapy in the prevention and management of HTN, a review of current therapeutic lifestyle strategies appears warranted. This review will define 6 well-established nonpharmacological lifestyle modifications for preventing and managing HTN in addition to 3 novel lifestyle interventions that show promise as effective adjunct strategies for lowering BP. A healthy lifestyle prescription ideally comprising a number of these BP-lowering lifestyle intervention strategies should be dispensed by all primary care physicians for both the prevention and treatment of elevated BP, an action that would have major, positive public health ramifications.

Drug treatment of elevated blood pressure

The decision on when to start drugs for the treatment of elevated blood pressure should be determined by an individual's absolute risk of having an adverse cardiovascular event. The choice of drug depends on its safety and effectiveness and its indications and contraindications for individual patients. most patients will require two or more drugs to reach their target blood pressure. The main classes of antihypertensive drugs are equally effective at reducing blood pressure, but beta blockers are no longer recommended as first-line treatment for most patients.

ASSOCIATED LIPID AND RENAL DISTURBANCES IN HYPERTENSIVE ELDERLY PATIENTS: PP.23.453

Objective: The kidney is an important target of hypertension-induced organ damage. High cholesterol and triglyceride plasma levels have been demonstrated to be independent risk factors for progression of renal disease in humans. The aim of this study was to compare lipid metabolism parameters and renal function of hypertensive patients and a healthy control group. Design and Methods: Our study included a group of 69 elderly patients with arterial hypertension (mean age ± S.D.: 66 ± 12 years) and a healthy control group made of 76 elderly subjects (mean age ± S.D: 67 ± 11 years) hospitalized in the IVth Medical Clinic of University of Medicine and Pharmacy “Victor Babes” Timisoara in a two years period. Their blood pressure (BP), serum total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), high density lipoprotein cholesterol (HDL-C), triglycerides (TG), serum uric acid, creatinine and blood urea nitrogen (BUN) levels were compared using the t Student's test. Results: Compared to controls, hypertensive elderly patients had higher levels of serum uric acid (6.7 ± 1.51 mg/dL vs. 6.6 ± 1.31 mg/dL, p = 0.000166), creatinine (1.5 ± 0.309 mg/dL vs. 0.8 ± 0.18 mg/dL, p = 0.026), urea (48 ± 10.58 mg/dL vs. 45 ± 11.4 9 mg/dL, p < 0.05), TC (257 ± 45.37 mg/dL vs. 207 ± 51.89 mg/dL, p < 0.05), LDL-C (216 ± 52.27 mg/dL vs. 122 ± 57.09 mg/dL, p = 0.032) and HDL-C (66 ± 12.23 mg/dL vs. 32 ± 7.56, p < 0.05). TG in hypertensive patients (231 ± 71.96 mg/dL) were significantly higher (p = 0.0067) than in controls (135 ± 69.31 mg/dL). A good correlation (r = 0.066) was found between systolic blood pressure and LDL-cholesterol, despite therapy. Conclusions: In this study we have shown that dyslipidemia affects a substantial proportion of hypertensive patients. Management of arterial hypertension should therefore focus both on lowering blood pressure and correcting associated lipid disorders. Treatment of elevated blood pressure not only reduces cardiovascular morbidity and mortality, but also reduces the incidence of renal failure as a consequence of hypertension-induced damage.

A Pressing Headache

A Pressing Headache

Treatment of Hypertension in the Inpatient Setting: Use of Intravenous Labetalol and Hydralazine

Acute blood pressure elevations are commonly treated in hospitalized patients. There are no guidelines for appropriate practice and no evidence that such treatment is useful. The authors performed a retrospective review of medical and pharmacy records to determine how often intravenous hydralazine and labetalol are ordered and administered. During a 1-year study period, a total of 29,545 hospitalizations were recorded. The authors identified 2189 patients (7.4% of all patients) for whom 7242 orders were written for hydralazine as needed (10-20 mg per dose) and 5915 for labetalol (10-20 mg per dose). Ordered drugs were administered in 60.3% of patients, and the average number of doses administered was 5.3+/-8.2 (mean +/- SD) for hydralazine and 5.6+/-7.7 for labetalol. Hospital length of stay (LOS) for patients for whom hydralazine was ordered was 12.0+/-15.9 days for those who received at least 1 dose and 7.1+/-9.0 days for those who did not receive a dose (P<.001). For patients for whom labetalol was ordered, patients receiving at least 1 dose had an LOS of 11.8+/-16.1 days vs 7.9+/-10.4 days for those who did not receive a dose (P<.001). Treatment of elevated blood pressure in in-patients is a common practice. The authors suggest that evidence is needed to determine whether the practice is of benefit.

Emergency Department Control of Blood Pressure in Intracerebral Hemorrhage

Background: Early treatment of elevated blood pressure (BP) in patients presenting with spontaneous intracerebral hemorrhage (ICH) may decrease hematoma enlargement and lead to better neurologic outcome. Study Objective: To determine whether early BP control in patients with spontaneous ICH is both feasible and tolerated when initiated in the Emergency Department (ED). Methods: A single-center, prospective observational study in patients with spontaneous ICH was performed to evaluate a protocol to lower, and maintain for 24 h, the mean arterial pressure (MAP) to a range of 100–110 mm Hg within 120 min of arrival to the ED. An additional goal of placing a functional arterial line within 90 min was specified in our protocol. Hematoma volume, neurologic disability, adverse events, and in-hospital mortality were recorded. Results: A total of 22 patients were enrolled over a 1-year study period. The average time to achieve our target MAP after implementation of our protocol was 123 min (range 19–297 min). The average time to arterial line placement was 84 min (range 36–160 min). Overall, 77% of the patients tolerated the 24-h protocol. The in-hospital mortality rate in this group of patients was 41%. Conclusions: Adopting a protocol to reduce and maintain the MAP to a target of 100–110 mm Hg within 120 min of ED arrival was safe and well tolerated in patients presenting with spontaneous ICH. If future trials demonstrate a clinical benefit of early BP control in spontaneous ICH, EDs should implement similar protocols.