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Management of Hypertension in Heart Failure
Published in Andreas P. Kalogeropoulos, Hal A. Skopicki, Javed Butler, Heart Failure, 2023
Jesse Kane, Clive Goulbourne, Hal A. Skopicki
Refractory hypertension should signal the need for agents that may target additional pathways. The PATHWAY2 study suggested a beneficial role of the mineralocorticoid antagonist spironolactone (compared with placebo, bisoprolol, and doxazosin) in improving cardiovascular outcomes in drug-resistant hypertension.54 More patients achieved controlled (<130/80 mmHg) BP with spironolactone, whereas eplerenone also effectively improved BP55 and was as effective as amlodipine in lowering systolic BP and pulse pressure in older patients with hypertension and widened pulse pressure.56
Pediatric Renovascular Hypertension: 132 Primary and 30 Secondary Operations in 97 Children
Published in Juan Carlos Jimenez, Samuel Eric Wilson, 50 Landmark Papers Every Vascular and Endovascular Surgeon Should Know, 2020
Juan Carlos Jimenez, Samuel Eric Wilson
Study Impact This contemporary report serves as the largest single institution experience with the surgical management of secondary renovascular hypertension in children, encompassing 132 primary operations and 30 secondary operations in nearly 100 pediatric patients. The authors carefully qualify refractory hypertension and identify themes in age- and gender-related disease patterns. Specifically, gender differences were most notable in the 21 boys and 11 girls with coexisting aortic disease. Vascular anatomy is similarly carefully qualified with the authors reporting ostial stenoses affected all 35 patients with concurrent abdominal aortic narrowings, often with a “gross hourglass appearance,” while extraparenchymal segmental renal artery stenosis affected only 13 children as isolated lesions and five children with existing main renal artery disease. Histopathology reported consistent complex medial and perimedial dysplastic disease complicated with secondary intimal fibroplasia accounting for all but a few of the renal artery stenoses in this series. Concurrent aortic and splanchnic disease was common.
Management of Hypertension by the Hypertension Specialist and the Hypertension Excellence Centres
Published in Giuseppe Mancia, Guido Grassi, Konstantinos P. Tsioufis, Anna F. Dominiczak, Enrico Agabiti Rosei, Manual of Hypertension of the European Society of Hypertension, 2019
Hypertensives with refractory hypertension, those with severe or difficult-to-control hypertension, suspicion of secondary forms of hypertension and patients who are noncompliant should be referred to a hospital hypertension specialist who has access to other experts and facilities for various laboratory and imaging investigations. Usually, hospital hypertension specialists work in ESH Excellence Centres of Hypertension. Evaluation and treatment of difficult-to-treat hypertensives, secondary forms of hypertension and resistant hypertensives are the main tasks of the hospital hypertensive specialist. The multidisciplinary approach is important as many (the majority of) patients have clusters of chronic diseases that are not efficiently addressed by disease-specific management strategies (1–7,10). For instance, patients with resistant hypertension frequently have obesity, sleep apnoea syndrome, chronic kidney disease or high salt intake; some have cognitive dysfunction or dementia, while others are noncompliant. Various hypertension specialists should be part of the team, including either interventional cardiologists or radiologists. However, they also should be involved in education of patients and be engaged in all other activities at the global and national level. Hypertension specialists must work on better communication between hospital specialists and general practitioners, and shared care should be introduced and encouraged (Figure 36.1) (6).
Clinical characteristics of concurrent primary aldosteronism and renal artery stenosis: A retrospective case–control study
Published in Clinical and Experimental Hypertension, 2021
Xu Meng, Yan-Kun Yang, Yue-Hua Li, Peng Fan, Ying Zhang, Kun-Qi Yang, Hai-Ying Wu, Xiong-Jing Jiang, Jun Cai, Xian-Liang Zhou
PA and RAS are common causes of refractory hypertension. Although PA and RAS have similar clinical manifestations, diagnosis is straightforward with proper assessment procedures. A confirmed diagnosis is essential in controlling BP, improving outcomes, and reducing complication and mortality rates for patients with secondary hypertension. However, a considerable number of patients have more than one primary disease, such as those with PA with RAS. In these patients, hypertension may be resistant despite treatment for one of the primary conditions. Resistant hypertension after successful PTRA or PTRAS is frequently attributable to restenosis or other secondary factors such as chronic renal dysfunction. Pizzolo et al. suggested that PA might be an important secondary factor leading to postoperative hypertension after renal angioplasty with or without stenting (11). Seven (14%) RAS patients were diagnosed with PA after successful endovascular treatment, in their study, which is similar to the incidence rate of PA for all-cause secondary hypertension (3–5).
Predictors of blood pressure control in patients with resistant hypertension after intensive management in two expert centres: the Brussels-Torino experience
Published in Blood Pressure, 2019
Marco Pappaccogli, Silvia Di Monaco, Coralie M.G. Georges, Géraldine Petit, Elisabetta Eula, Sabrina Ritscher, Jean-Philippe Lengelé, Elvira Fanelli, Francesca Severino, Jean Renkin, Valeria Avataneo, Pierre Wallemacq, Stefan W. Toennes, Philippe de Timary, Franco Rabbia, Alexandre Persu
First, our results underline the difficulty to reach BP control in patients with resistant hypertension, irrespective of the expert centre involved or the treatments used. In order to reach BP control in patients with RHTN, current guidelines recommend to implement diuretic treatment by increasing the existing diuretic dosage, or shifting to a more effective one (such as chlorthalidone or indapamide), and by adding as a fourth-line treatment a mineralocorticoid receptor antagonist (MRA) [1–2]. In agreement with these recommendations, in our bi-centric cohort we documented a marked increase in the prescription of spironolactone from baseline to follow-up (from 34% to 48%, p-value <0.001). Though clearly insufficient, a proportion of ∼50% of patients on aldosterone antagonists is higher than that achieved in most resistant hypertension trials and registries [18–21]. In a subset of patients characterized by particularly severe, refractory hypertension (21%), renal denervation was performed. Still, despite intensive attempts to improve BP treatment and use of exceptional therapies, three quarters of the patients remained uncontrolled at the end of follow-up.
Impact of psychological profile on drug adherence and drug resistance in patients with apparently treatment-resistant hypertension
Published in Blood Pressure, 2018
Géraldine Petit, Elena Berra, Coralie M.G. Georges, Arnaud Capron, Qi-Fang Huang, Marilucy Lopez-Sublet, Franco Rabbia, Jan A. Staessen, Pierre Wallemacq, Philippe de Timary, Alexandre Persu
The strengths of our interdisciplinary work include (i) careful exploration of consecutive patients with refractory hypertension, a rare subset of hypertensive patients [35]; (ii) evaluation of adherence using LC-MS/MS in the urine, which is considered as a gold standard in patients with aTRH [4,5]; (iii) evaluation of the degree of treatment resistance using on-treatment 24-hour ambulatory BP adjusted for drug adherence, thus limiting the impact of white-coat effect and patient- and physician related biases; and (iv) use of a wide array of carefully chosen and validated questionnaires to evaluate psychological profile of aTRH patients.