Renal protection with calcium antagonism in essential hypertension

The natural history of uncontrolled essential hypertension, with respect to renal function, is characterized by a progressive rise in renal vascular resistance, a progressive fall in effective renal plasma flow, and a progressive fall in glomerular filtration rate. Sustained effective antihypertensive therapy may reverse this pathophysiological sequence, preventing the development of arteriolar nephrosclerosis. It is unknown whether such a therapeutic benefit is a nonspecific response to controlling systemic hypertension, or is dependent on controlling both systemic and glomerular hypertension. Recent experimental evidence indicates that the control of systemic blood pressure may not necessarily be associated with control of glomerular capillary hypertension. The renal effects of calcium antagonists in essential hypertensive patients are only now being characterized. We have demonstrated that diltiazem, amlodipine, and nifedipine monotherapies enhance glomerular filtration rate and effective renal plasma flow, and lower renal vascular resistance. Although calcium antagonists attenuate the intrarenal effects of norepinephrine and angiotensin II, the precise mechanism(s) by which these drugs reverse the functional renal abnormalities in the essential hypertensive state, and by which they may attenuate the progression of hypertensive renal disease, are unknown. It is our hypothesis that renal protection requires normalization of both systemic and glomerular capillary pressure. Calcium antagonists have the ability to control systemic hypertension. If they can be demonstrated experimentally to reduce both pre- and post-glomerular capillary resistances (i.e. maintain a normal glomerular capillary pressure), they can be expected to provide long-term renal protection.     

Strategies for managing perioperative hypertension

Hypertension is a pervasive and growing health concern. The occurrence of hypertension due to systemic vasoconstriction in patients before, during, and after surgery is not uncommon and can have serious consequences with regard to outcomes. Careful evaluation prior to surgery to identify the underlying cause of hypertension is important in selecting the best treatment option. Preoperative treatment options include oral beta-adrenergic receptor blockers, alpha2-adrenergic receptor antagonists, and in the case of hypertensive emergencies, the fast-acting parenteral agents sodium nitroprusside, the intravenous beta-adrenergic receptor blocker esmolol, and nicardipine. Therapeutic options during and after surgery include sodium nitroprusside, esmolol, and nicardipine, among others.     

Treatment of elderly hypertension based on various hypertension management guidelines--comparison between European and American guidelines and Japanese guidelines

In civilized countries blood pressure is increased in association with age. Elderly population is lately increased both in Japan and Western countries and therefore elderly hypertensive patients are expected to increase. Recently, several guidelines and statements for the treatment of hypertension, such as JNC 7, 2003 ESH/ESC, 2003 WHO/ISH, and BSH IV, are reported in Western countries. In Japan, Japanese Society of Hypertension reported guidelines for management of hypertension in 2000 (JSH 2000) and JSH 2000 is now revised and a new version was published at the end of 2004 (JSH 2004). In this article, management of hypertension (when starts the treatment, target blood pressure level, and choice of drugs, etc) in the elderly is described based on these guidelines and statements.     

Concept and clinical character of hypertension in the elderly

Although blood pressure in the elderly was modulated by "physiological" changes due to aging, "pathological" changes in the elderly patients with essential hypertension cause to increase cardiovascular events and mortality. Hypertension in the elderly shows increase of pulse pressure, abnormal blood pressure daily profile and orthostatic hypotension. The importance of control of blood pressure in the elderly hypertensive patients is quite clear, however, the optimal blood pressure is still unclear. Very recently, clinical guideline of JSH 2004 by Japanese Society of Hypertension was published. We should try to control blood pressure in the elderly patients according to this guideline.     

Converting enzyme inhibitors and calcium antagonists in the long-term treatment of hypertension in chronic renal failure

Hypertension contributes to the inexorable decline of renal function in patients with chronic renal impairment. Studies on the long-term use of converting enzyme inhibitors and calcium antagonists in the treatment of hypertension in patients with chronic renal failure are hereby reviewed. The data demonstrate that converting enzyme inhibitors are effective antihypertensives in diabetic nephropathy and other forms of chronic renal failure. Furthermore, the results suggest that long-term treatment with captopril may slow the progression of renal impairment in diabetic nephropathy, whereas the data are inconclusive for non-diabetic nephropathies. A reduction of proteinuria or albuminuria was also observed in most trials during long-term converting enzyme inhibition. Treatment with calcium antagonists also led to effective blood pressure control in hypertensive patients with renal disease. However, the very limited data in humans suggest no consistent beneficial effect on kidney function or proteinuria. More controlled studies are necessary to determine the relative efficacy and safety of converting enzyme inhibitors and calcium antagonists in comparison with "standard antihypertensives" in long-term antihypertensive treatment of patients with various forms of chronic renal failure.     

Calcium antagonists and atherosclerosis protection in hypertension

Calcium antagonists are effective in hypertensive patients of all ethnic groups, irrespective of age, dietary salt intake, salt-sensitivity status or plasma renin activity profile. Some prospective studies show that the calcium antagonists, nifedipine GITS and nitrendipine, reduce cardiovascular morbidity and mortality at least to the same extent as the diuretics. Other prospective studies are in progress to evaluate the effect of calcium antagonists on cardiovascular morbidity and mortality, and the progression of atherosclerosis in hypertensive patients. Calcium antagonists, especially the highly lipophilic amlodipine, lacidipine and nisoldipine, are shown to possess antioxidant properties. These drugs reduce the oxidation of LDL and its influx into the arterial wall, and reduce atherosclerotic lesions in animals. Platelet production of malondialdehyde, a marker of oxygen free radical formation, is suppressed by amlodipine, lacidipine or nifedipine in hypertensive patients. New evidence from long-term clinical trials of calcium antagonists indicates that these drugs can reduce the rate of progression of atherosclerosis in hypertensive and coronary heart disease patients. In the Regression Growth Evaluation Statin Study (REGRESS), co-administration of calcium antagonist, amlodipine or nifedipine with pravasatin caused a significant reduction in the appearance of new angiographic lesions. In the Verapamil in Hypertension and Atherosclerosis Study (VHAS), verapamil was more effective than chlorthalidone in promoting regression of thicker carotid lesions in parallel with a reduction in the incidence of cardiovascular events. In the Prospective Randomized Evaluation of the Vascular Effects of Norvasc Trial (PREVENT), amlodipine slowed the progression of early coronary atherosclerosis in patients with coronary artery disease. In a subprotocol of the Intervention as a Goal in the Hypertension Treatment (INSIGHT) study, nifedipine GITS significantly decreased intima-media thickness as compared to co-amilozide (hydrochlorothiazide + amiloride). Preliminary results of the European Lacidipine Study on Atherosclerosis (ELSA) show that lacidipine reduced the intima-media thickness progression rate as compared to atenolol. Thus, selective calcium antagonists are potential antiatherosclerotic agents.     

Hypoxic therapy of arterial hypertension in patients with different variability of arterial pressure

Sixty two patients with essential hypertension stage II were divided into two groups. 32 patients of group 1 received combined therapy including a course of inhalations of gas hypoxic mixture containing 10% oxygen and conventional medication (ACE inhibitors, beta-blockers, calcium antagonists, diuretics). 30 patients of group 2 (controls) were given medication alone. 24-h monitoring of arterial pressure (AP) and echocardiography suggested that high AP variability (APV) in hypertensive subjects leads to more significant changes in left ventricular and atrial structure and function typical for hypertensive heart. In high VAP, its night values are subnormal while daytime values are high in patients on combined medication and hypoxic therapy. The patients on standard medication had significantly low VAP at night while their daytime VAP tended to decrease. VAP positively correlated with hypertensive load. In high VAP hypoxic and drug therapies are less effective.     

A rational approach to the treatment of hypertension in special populations.

Hypertension in blacks is usually characterized by low renin, expanded volume and sensitivity to salt. Diuretics are the preferred initial therapy, but response to calcium channel antagonists is also good. The blood pressure response to monotherapy with beta blockers or angiotensin-converting enzyme (ACE) inhibitors is blunted, but this effect is abolished with concomitant use of diuretics. The two major types of hypertension in older persons are isolated systolic hypertension and combined systolic and diastolic hypertension. Strong data support the treatment of combined hypertension in patients 60 to 79 years of age and isolated systolic hypertension in patients 60 to 96 years of age. Diuretics and long-acting dihydropyridine calcium channel antagonists are the recommended initial therapies for isolated systolic hypertension. More studies are necessary before recommendations can be made about the treatment of combined hypertension in patients 80 years of age and older.     

Management of hypertension in patients developing end-stage renal failure

The benefits of treating hypertension include preventing or delaying the progression of chronic renal failure, and reducing the cardiovascular complications of patients with renal disease. We examined how well hypertension had been managed in all 145 patients from a single health district who started dialysis during a 3-year period. Data relating to management of hypertension, including all blood pressure readings, were obtained from their general practice and hospital case notes. The anonymized data were reviewed by two independent assessors against a set of standards based on the British Hypertension Society guidelines. There was close agreement between the assessors. Complete records were obtained in 98.5% of cases. Of the 145 patients, 107 (76.4%) were hypertensive before developing end-stage renal failure. There were departures from standards in all categories of care: 24.3% in detection/diagnosis, 29% in investigation, 22.4% in referring to a nephrologist, and 17% in follow-up. The British Hypertension Society recommended standard for diastolic blood pressure of 90 mmHg was achieved in only 45%. In 32%, the assessors independently concluded that poor blood pressure control might have affected adversely the progression of renal failure. New methods of dealing with these problems are required and possible approaches are discussed.     

Managing hypertension using combination therapy

Combination therapy of hypertension with separate agents or a fixed-dose combination pill offers the potential to lower blood pressure more quickly, obtain target blood pressure, and decrease adverse effects. Antihypertensive agents from different classes may offset adverse reactions from each other, such as a diuretic decreasing edema occurring secondary to treatment with a calcium channel blocker. Most patients with hypertension require more than a single antihypertensive agent, particularly if they have comorbid conditions. Although the Joint National Committee guidelines recommend diuretic therapy as the initial pharmacologic agent for most patients with hypertension, the presence of "compelling indications" may prompt treatment with antihypertensive agents that demonstrate a particular benefit in primary or secondary prevention. Specific recommendations include treatment with angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, diuretics, beta blockers, or aldosterone antagonists for hypertensive patients with heart failure. For hypertensive patients with diabetes, recommended treatment includes diuretics, beta blockers, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and/or calcium channel blockers. Recommended treatment for hypertensive patients with increased risk of coronary disease includes a diuretic, beta blockers, angiotensin-converting enzyme inhibitors, and/or calcium channel blocker. The Joint National Committee guidelines recommend beta blockers, angiotensin-converting enzyme inhibitors, and aldosterone antagonists for hypertensive patients who are postmyocardial infarction; angiotensin-converting enzyme inhibitors and angiotensin receptor blockers for hypertensive patients with chronic kidney disease; and diuretic and angiotensin-converting enzyme inhibitors for recurrent stroke prevention in patients with hypertension.     

Secondary hypertension

In patients with hypertension and chronic renal parenchymal disease, BP should be controlled to 130/85 mmHg or lower (125/75 mmHg) in patients with proteinuria in excess of 1 g/day. Reducing dietary sodium (< 7 g/day) and protein (< 0.6-0.7 g/kg) helps control high BP and renal function in patients with renal insufficiency. As first antihypertensive drug, ACE inhibitors or long-acting Ca antagonists are recommended. In patients with renovascular hypertension, angioplasty is the first choice increasingly to be accompanied by stenting, and surgical revascularization is the next choice. As antihypertensive drugs, beta blockers, ACE inhibitors, and AII-receptor blockers are recommended. Hypertension accompanied by endocrine disease with adenoma or tumor is almost cured or improved by surgical removal. Spironolactone and Ca antagonists are used in patients with idiopathic aldosteronism (bilateral hyperplasia). Alpha and beta blockers are used in patients with pheochromocytoma during preoperative period.     

飞行人员中高血压患者的认识误区以及护理对策

目的了解飞行人员对高血压病的认识误区,并提出护理对策。方法通过调查2008-01—2010-07在我院疗养的88例确诊为高血压的飞行人员,分析飞行人员的血压控制水平、服药情况及对疾病的认知情况。结果 48例血压控制在正常范围内,55例能规则服药,34例有不良嗜好。结论通过正确、及时的护理干预,纠正飞行人员的认识误区是高血压病治疗过程中至关重要的环节。     

中老年人群高血压与糖尿病及高血糖相关性分析

Background: Hypertension, diabetes are main risk factors of cardiovascular diseases. Many data shows: hypertension morbidity rate of diabetes patients is apparently higher than that of non diabetes people. In foreign country, hypertension morbidity rate of diabetes patients reaches 40% ～ 80% . In our country, survey of 220 thousand people in 1994 showed that hypertension morbidity rate of diabetes patients is 55.4% . insulin resistance is common pathogenetic foundation of hypertension and type 2 diabetes. In previous reports, there was little report on diabetes morbidity rate of hypertension patients.     

Nonpharmacological treatment of hypertension in diabetes mellitus

Hypertension may be partially or completely controlled by appropriate use of nondrug therapies. Because diabetic patients are so often hypertensive and because the same nondrug therapies effective for treatment of hypertension may also benefit the diabetes, the use of nondrug therapies is particularly important in these patients. Evidence about the effectiveness of various nondrug therapies is provided along with practical suggestions to improve patient adherence to them.     

Evaluation of therapy effectiveness in patients with hypertension using graded physical load

J. W. Franz graded exercise test (GET) was employed to examine healthy subjects, untreated patients with stage I and II essential hypertension and hypertensive subjects treated with hydrochlorthiazide, alpha-methyldopa, prazosine, dilthiazem resultant in normal resting values of blood pressure. Hydrochlorthiazide did not protect the patients from a pathological hypertensive response to GET, whereas alpha-methyldopa and prazosine furnish a physiological hypertensive response in much less number of patients and dilthiazem made possible normal response in the majority of treated patients. GET is suggested for assessing effectiveness of hypertension treatment and individual choice of antihypertensive drugs.     

Calcium antagonists in cardiovascular diseases--a valuable controversy, but unnecessary panic

Taking into consideration the available data in 1998, we believe that short-acting calcium antagonists should no longer be used in hypertensive patients. The practice of using oral or sublingual nifedipine in hypertensive emergency or pseudoemergency should be abandoned because it can lead to serious side effects such as syncope, myocardial infarction, stroke and even death. However, the use of a low dose of the long-acting formulations seems to be safe and promising in patients with essential hypertension. In the Hypertension Optimal Treatment (HOT) trial a calcium-antagonist based combination therapy reduced blood pressure by over 20 mmHg in most of the nearly 19,000 patients. Cardiovascular mortality in this study was with 3.8 per 1000 patient years clearlylower as compared to 6.5 per 1000 patient years reported in previous intervention trials. A long-acting dihydropyridine calcium antagonist was used in 78% of these patients. Clearly the calcium antagonists controversy was helpful in alerting physicians to the fact that hypertension remains a surrogate endpoint and that not all drugs that reduce blood pressure will reduce morbidity and mortality to the same extent. What was completely unnecessary, however, was the inappropriate news media coverage to the calcium blocker controversy that led to panic and confusion among patients and frustration among physicians. In this context we should perhaps remember the first rule in the treatment of Sir George Pickering: "Never frighten your patients."     

Significance of arterial hypertension in geriatric prevention

In Germany for decades the assessment and treatment of patients with high blood pressure is not satisfactory. As in other industrial countries only approximately 50% of hypertensive men and 60% of hypertensive women are diagnosed. Arterial hypertension bears the known risks on heart and vascular system also in old age when often target organ damages are already present. A sufficient number of clinical studies proves risk reduction by blood pressure lowering treatment. According to the criteria of WHO in old age the same limits of normal blood pressure and the same stages of the disease are valid as in younger patients. The probability of cardiovascular complications increases with the height of blood pressure. As small increases of blood pressure are far more prevalent than very high blood pressure values the cumulative risk in populations is predominantly linked to mild hypertension. In elderly patients systolic blood pressure has a better predictive value than diastolic blood pressure. A short review is given of work up and treatment of hypertension in the elderly instructed by the Guidelines of the German Hypertension Society.     

Diagnosis and treatment of hypertension in children and adolescents

PURPOSE: To provide nurse practitioners (NPs) with updated information regarding the etiology, diagnosis, and treatment of childhood hypertension. DATA SOURCES: Extensive review of the scientific literature regarding hypertension, including the latest NIH recommendations. CONCLUSIONS: Hypertension affects more than 350,000 American children. While the majority of hypertension in early childhood occurs from secondary causes, the incidence of essential hypertension in later childhood and adolescence is rising, raising concerns as elevated pressures in childhood "track" into adulthood. Early detection and treatment of elevated childhood pressures represent important steps in reducing long-term cardiovascular risk. IMPLICATIONS FOR PRACTICE: NPs must be able to accurately differentiate between primary and secondary hypertension in childhood. Secondary hypertension requires prompt diagnosis and treatment, and controlling primary childhood hypertension has lifelong implications. Given the familial predisposition to hypertension, it is important for adult NPs to be aware of the risks faced by children of hypertensive patients.     

Licorice-induced hypertension: a case of pseudohyperaldosteronism due to jelly bean ingestion

Hypertension is one of the most common problems encountered in the primary care setting. Numerous secondary causes of hypertension exist and are potentially reversible. The ability to screen for such causes and manage them effectively may spare patients from prolonged medical therapy and hypertensive complications. Licorice can cause hypertension and hypokalemia due its effects on cortisol metabolism. We report a case of jelly bean ingestion that highlights the presentation, pathophysiology and management of licorice-induced hypertension.     

Central role of sodium in hypertension in diabetic subjects

The common association between diabetes mellitus and hypertension may be promoted by several mechanisms. Patients with insulin-dependent (type I) diabetes and prone to develop nephropathy often have a familial predisposition for essential hypertension, whereas normotensive healthy offspring of nondiabetic essential hypertensive parents tend to have a reduced insulin sensitivity and increased plasma insulin levels. Na+ retention occurs as a characteristic alteration in type I or non-insulin-dependent (type II) diabetes; exchangeable body Na+ (Naex) is increased by 10% on average. This abnormality develops in the uncomplicated stage of diabetes and differentiates diabetic from nondiabetic essential hypertensive subjects. Possible Na(+)- retaining mechanisms include increased glomerular filtration of glucose leading to enhanced proximal tubular Na(+)-glucose cotransport, hyperinsulinemia (which activates several tubular Na+ transporters), an extravascular shift of fluid with Na+, and, once it occurs, renal failure. The pathogenetic role of Na+ retention in diabetes-associated hypertension is supported by positive correlations between systolic or mean blood pressure and Naex and by normalization of blood pressure after removal of excess Na+ by diuretic treatment in hypertensive diabetic subjects. The latter may also have an enhanced sensitivity of blood pressure to Na+. Plasma levels of active renin, angiotensin II, aldosterone, and catecholamines are usually normal or low in metabolically stable type I or type II diabetes. However, an exaggerated vascular reactivity to norepinephrine and angiotensin II commonly occurs already at uncomplicated stages of type I or type II diabetes. This may be a manifestation of functional (i.e., intracellular electrolytes) and/or morphological (proliferation, narrowing, and stiffening) vasculopathy. Diabetes-associated Na+ retention, vasculopathy, and a presumably inherited predisposition for both diabetes and essential hypertension may represent important complementary factors favoring the frequent occurrence of hypertension in the diabetic population.