Managing hypertension in chronic renal disease

Hypertension is very common in the elderly patient with renal insufficiency and may be primary or secondary to the kidney disease. In these patients, hypertension is usually associated with an increase in peripheral vascular resistance and salt sensitivity (the latter related to the degree of renal failure.) Therapy should be tailored to the individual patient, particularly when the elevated blood pressure and renal insufficiency are associated with other significant medical problems. Most of the drugs used in younger hypertensives may be used in the elderly patient with renal insufficiency, but in general, starting and maintenance doses should be lower because of the greater sensitivity due to age and/or the renal failure. The goal in the elderly hypertensive patient with renal failure is similar to that in other hypertensive patients: blood pressure should be brought to 140/90 mm Hg or lower. In the elderly patient with resistant hypertension or who manifests a decrease in kidney function as blood pressure is lowered, an effort must be made to look for associated renovascular disease.     

Renovascular hypertension in the elderly: Results of surgical management

This review summarizes our experience with the operative management of renovascular hypertension (RVH) in elderly patients (≥ 60 years of age). From 7/87 through 6/95,230 of 428 adult patients (54%) undergoing operation of renovascular hypertension at our center were in their seventh (153 patients), eighth (70 patients) or ninth (7 patients) decade of life (mean age: 68 years). There were 117 males and 113 females with blood pressures ranging from 280/190 to 178/90 (mean: 202/102 mmHg). One hundred and eighty patients (78%) had renal insufficiency (i.e., serum creatinine ≥ 1.3 mg/dl). One hundred and four patients (45 %) had severe insufficiency (i.e., serum creatinine ≥2.0 mg/dl), with 23 of these patients being dialysis dependent prior to operation. Two hundred and eighteen (95%) had evidence of organ specific atherosclerotic damage as manifested by cardiac disease (93%), cerebrovascular disease (38%) or renal insufficiency (78%). Operative management consisted of a unilateral procedure in 100 patients, bilateral procedures in 130 patients, including 26 nephrectomies. Simultaneous aortic replacement was performed in 95 patients (41%; 59 AAA and 36 occlusive disease). After surgery, there were 13 operative deaths (6%) and 13 renal artery repairs failed (4%). Hypertension was cured (9%) or improved (77%) in 86% of operative survivors. Renal function was improved in 43% and worsened in 15% of patients with nondialysis dependent renal insufficiency. Eighteen of twenty-three patients (78%) who were dialysis dependent before surgery were removed from dialysis following renal revascularization. On follow-up (mean: 29 months), we found that 28 patients died. Multivariate analysis demonstrated that preoperative congestive heart failure (p = 0.007) and increased serum creatinine (p = 0.001) were significant and independent predictors of death on follow-up. Estimated survival was significantly increased among patients with improved renal function after operation compared with patients unimproved. This review emphasizes the complexity of atherosclerosis in the elderly population presenting for operative management of renovascular hypertension. Despite the complexity of disease, our experience suggests that operative management is beneficial and can be accomplished with acceptable, albeit increased, risk in properly selected elderly patients. For elderly patients with renovascular disease in combination with renal insufficiency (i.e., ischemic nephropathy), improved renal function after operation may convey improved survival.     

Analysis of various etiologies of hypertension in patients hospitalized in the endocrinology division

This research aimed to analyze the clinical data of various etiologies of hypertension in patients hospitalized in the Endocrinology Division. The differences between essential and secondary hypertension were examined to provide a basis for clinical differential diagnosis. The data from all the inpatients with hypertension of unknown origin admitted in the Endocrinology Division of the First Affiliated Hospital of the Zhejiang University School of Medicine from January 2001 to May 2011 were reviewed. The patients were classified into either essential or secondary hypertensive groups. The differentiating parameters of these forms of hypertension were analyzed using the one-factor and multi-factor logistic regression analysis. A total of 1,001 cases were selected in which 346 cases (34.6%) were essential hypertensive and 655 cases (65.4%) were secondary hypertensive. Adrenal hypertension was the primary cause of secondary hypertension, followed by renal artery, central, psychogenic, and renal hypertension as well as others that have not been classified systematically. Using one-factor analysis, significant differences were found among duration of hypertension, age, the onset age, family history of hypertension, diastolic pressure on admission, Cushing syndrome, body mass index (BMI), urine protein, serum creatinine, orthostatic aldosterone, ratio of orthostatic aldosterone to renin activity, incidence of fatty liver displayed by type-B ultrasound, and computed tomography adrenal masses incidence (P < 0.05). Multi-factor regression analysis showed that family history of hypertension (OR = 7.196) and BMI above the normal range (OR = 15.124) were the independent factors that predicted essential hypertension, but failed to determine any other valid predictors of secondary causes except adrenal masses (OR = 10.114), orthostatic aldosterone value >200 pg/ml (OR = 9.742), and a ratio of orthostatic aldosterone and renin activity >40 (OR = 4.723).     

Prediction of primary vs secondary hypertension in children

Despite current guidelines, variability exists in the workup of hypertensive children due to physician preferences. The study evaluates primary vs secondary hypertension diagnosis from investigations routinely performed in hypertensive children. This retrospective study included children 5 to 19 years with primary and secondary hypertension. The proportions of abnormal laboratory and imaging tests were compared between primary and secondary hypertension groups. Risk factors for primary vs secondary hypertension were evaluated by logistic regression and likelihood function analysis. Patients with secondary hypertension were younger (5-12 years) and had a higher proportion of abnormal creatinine, renal ultrasound, and echocardiogram findings. There was no significant difference in abnormal results of thyroid function, urine catecholamines, plasma renin, and aldosterone. Abnormal renal ultrasound findings and age were predictors of secondary hypertension by regression and likelihood function analysis. Children aged 5 to 12 years with abnormal renal ultrasound findings and high diastolic blood pressures are at higher risk for secondary hypertension that requires detailed evaluation.     

高血压专科3706例住院继发性高血压患者病因构成分析

目的分析2012-2016年河南省人民医院高血压科住院高血压患者9439例中继发性高血压患者3706例病因分类及构成比较,为高血压防治提供病因学参考。方法采用回顾性研究方法,分析9439例住院高血压患者中3706例继发性高血压患者年龄、性别构成及病因分类。结果9439例住院高血压患者中原发性高血压占60.74%(5733例),继发性高血压占39.26%(3706例)。在继发性高血压患者中,心理因素性高血压例数最多(1175例,31.70%),其次例数较多的是阻塞性睡眠呼吸暂停低通气综合征(779例,21.02%)、原发性醛固酮增多症(728例,19.64%)、肾血管性高血压(702例,18.94%)。与原发性高血压患者相比,心理因素性高血压、原发性醛固酮增多症、肾血管性高血压、甲状腺功能减退症、青光眼患者年龄较大,心理因素性高血压、内分泌性继发性高血压的女性患者较多(P<0.05)。与原发性高血压患者相比,继发性高血压患者的年龄[(50.2±15.0)比(46.6±15.2)岁]较大、男性患者比例[54.6%(2024/3706)比64.5%(3695/5733)]较小(均P<0.05)。继发性高血压和原发性高血压患者中女性的平均年龄高于男性(P<0.05)。结论2012-2016年高血压住院患者中继发性高血压占39.26%,高于国内外文献报道。住院的高血压患者心理因素性高血压比例居于首位,阻塞性睡眠呼吸暂停低通气综合征、原发性醛固酮增多症、肾血管性高血压的比例也较高。年龄较大的高血压患者中也筛查出不少继发性高血压。     

The current role of surgical revascularization for combined renovascular hypertension and renal insufficiency.

The number of elderly patients presenting with the difficult combination of renovascular hypertension and deteriorating renal function is increasing. The majority of these patients have diffuse cardiovascular disease requiring careful preoperative evaluation and stabilization. Adequate control of hypertension and preservation of renal function frequently requires bilateral renal procedures in addition to aortic replacement in patients with significant aorto-iliac disease or aortic aneurysms. Early and late results continue to justify prompt surgical consultation and revascularization of patients with combined renovascular hypertension and renal insufficiency.     

Increased sympathetic nerve activity in renovascular hypertension.

BACKGROUND: Increased sympathetic nerve activity may contribute to the progression of renovascular hypertension. Because previous results have been inconclusive, we investigated whether renovascular hypertensives show increased total and regional sympathetic nerve activity. METHODS AND RESULTS: Sixty-five patients underwent renal angiography and measurements of plasma renin activity and angiotensin II in conjunction with estimation of sympathetic nerve activity by means of radiotracer dilution and intraneural recordings of muscle sympathetic nerve activity (MSNA). Age-matched healthy subjects (n=15) were examined for comparison. Total body norepinephrine (NE) spillover, an index of overall sympathetic nerve activity, was increased by 100% and MSNA by 60% in the hypertensive patients compared with healthy subjects (P<0.01 for both). A subgroup of 24 patients with well-defined renovascular hypertension (cured or improved hypertension after renal angioplasty) showed similar increases in total body NE spillover compared with the group at large. Patients with arterial plasma renin activity and angiotensin II levels above median had higher values for total body NE spillover than patients below median (P<0.01). CONCLUSIONS: This study unequivocally demonstrates elevated sympathetic nerve activity in patients with renovascular hypertension. The adrenergic overactivity may contribute to the blood pressure elevation and perhaps also to the high cardiovascular mortality in renovascular hypertension.     

Reduced spontaneous baroreceptor sensitivity in patients with renovascular hypertension.

OBJECTIVE: Sympathetic nerve activity is increased in hypertensive patients with renal artery stenosis. Less is known about cardiac vagal function in these patients before and after renal angioplasty. The aim of the present study was to investigate cardiac baroreceptor reflex sensitivity together with total body noradrenaline (NA) spillover in hypertensive patients with renal artery stenosis before, and in some patients, 1 year after renal angioplasty. MATERIAL AND METHODS: Spontaneous baroreceptor reflex sensitivity and total body noradrenaline (NA) spillover were measured in patients with renovascular hypertension before intervention (n = 18), patients being cured/improved 1 year after renal angioplasty (n = 5) and age-matched healthy subjects (n = 25). RESULTS: Hypertensive patients with renal artery stenosis had higher total body NA spillover (4630 +/- 619 versus 3132 +/- 210 pmol/min, P < 0.05) and reduced cardiac baroreceptor reflex sensitivity (6.1 +/- 1.0 versus 10.7 +/- 1.0 ms/mmHg, P < 0.01) compared with healthy subjects. Similar results were obtained (before intervention) in a subgroup of patients (n = 9) with renovascular hypertension defined as cured/improved 1 year following renal angioplasty. Baroreceptor reflex sensitivity improved after renal angioplasty in a subset of patients showing good blood pressure control 1 year after intervention (6.4 +/- 0.7 to 9.4 +/- 1.7 ms/mmHg, P < 0.05). CONCLUSIONS: Patients with renovascular hypertension showed reduced cardiac baroreceptor reflex sensitivity and increased noradrenergic activity, which to some extent was reversed 1 year following successful renal angioplasty.     

How to diagnose,how to treat: renal artery stenosis-diagnosis and management

Renal artery stenosis is considered to be one of the more frequent causes of secondary arterial hypertension. Through its progression renal artery stenosis can cause renal insufficiency, uncontrolled hypertension, and increased cardiovascular morbidity. A thorough clinical examination and the presence of a typical abdominal bruit may provide helpful hints to identify hypertensive patients with possible renal artery stenosis. Testing for renovascular hypertension includes renal artery imaging, assessment of its functional significance, and evaluation for possible revascularization. Renal artery stenosis secondary to fibromuscular dysplasia should be mechanically corrected. For atherosclerotic renal artery stenosis, medical management can be attempted so long as it does not cause a decline of kidney function. In patients who are candidates for renovascular revascularization, surgical intervention can be helpful in improving blood pressure control and possibly halting the progression of renal failure. Randomized controlled trials comparing direct stenting with other surgical methods are necessary to define the best revascularization strategy in patients with renovascular hypertension. A careful follow-up study after renal artery revascularization should evaluate possible benefits in halting the deterioration of chronic renal insufficiency.     

Renal Artery Stenosis: Diagnosis and Management

Renal artery stenosis is considered to be one of the more frequent causes of secondary arterial hypertension. Through its progression renal artery stenosis can cause renal insufficiency, uncontrolled hypertension, and increased cardiovascular morbidity. A thorough clinical examination and the presence of a typical abdominal bruit may provide helpful hints to identify hypertensive patients with possible renal artery stenosis. Testing for renovascular hypertension includes renal artery imaging, assessment of its functional significance, and evaluation for possible revascularization. Renal artery stenosis secondary to fibromuscular dysplasia should be mechanically corrected. For atherosclerotic renal artery stenosis, medical management can be attempted so long as it does not cause a decline of kidney function. In patients who are candidates for renovascular revascularization, surgical intervention can be helpful in improving blood pressure control and possibly halting the progression of renal failure. Randomized controlled trials comparing direct stenting with other surgical methods are necessary to define the best revascularization strategy in patients with renovascular hypertension. A careful follow-up study after renal artery revascularization should evaluate possible benefits in halting the deterioration of chronic renal insufficiency.     

Insulin resistance in secondary hypertension.

The insulin sensitivity of five essential hypertensive patients was compared to five patients with renovascular hypertension, five patients with primary hyperaldosteronism, and five normotensive subjects, using the euglycemic hyperinsulinemic clamp technique. Essential hypertensive patients had significantly lower insulin sensitivity than patients with hyperaldosteronism and renovascular hypertensive patients (P = .0066, P = .004, respectively). Hyperaldosteronism patients also had less insulin sensitivity than renovascular hypertensive patients (P = .016). A significant negative correlation was found between body mass index and insulin sensitivity index for essential hypertension patients only (r = -0.87, P less than .003). No such correlation was found in the secondary hypertension patients. The findings suggest a causal relationship between insulin resistance and the development of essential hypertension. Secondary hypertension, on the other hand, is not such an insulin resistant state.     

The evaluation of plasma dopamine beta-hydroxylase activity in essential and secondary hypertension

The relation of plasma dopamine beta-hydroxylase (DBH) activity to age was examined in normotensive and hypertensive subjects. Plasma DBH activity was the highest in the group of 25--34 years and gradually decreased with age. Plasma DBH activity was higher in the hypertensives than in the normotensives in all age groups, and the difference was significant between the groups of 45--54 and 55--64 years. Plasma DBH activity was increased in labile hypertension. Plasma DBH activity was higher in the group of essential hypertension with normal renal function than in that with reduced renal function. It was lower in the severe hypertensives than in the mild cases. Plasma DBH activity was also decreased in the hypertensive patients with cerebrovascular disorders. Plasma DBH activity was lower in the hypertensive patients with renal parenchymal diseases than those of essential hypertension with normal renal function. Plasma DBH activity was also decreased in primary aldosteronism, while it was increased in pheochromocytoma. These observations suggest that measurement of plasma DBH activity may be valuable in the differentiation of essential hypertension from the secondary forms of hypertension, and the evaluation of the hypertensive processes. To evaluate plasma DBH activity, it is important to consider its age-related changes.     

Increased cardiac sympathetic drive in renovascular hypertension

BACKGROUND : Patients with renovascular hypertension (RVH) have high cardiovascular mortality and morbidity. In these patients, overall sympathetic nerve activity is increased. It is unknown, however, whether this increase also involves the heart. OBJECTIVE : We tested the hypothesis that cardiac sympathetic activity is increased in patients with hypertension and renal artery stenosis. METHODS AND RESULTS : A total of 14 patients with hypertension were studied before angioplasty of angiographically identified renal artery stenosis. Nine out of 14 patients had renovascular hypertension proven at the 1-year follow-up visit. A total of 19 healthy subjects served as a control group. A right heart catheterization, including the positioning of a coronary sinus thermodilution catheter was performed for hemodynamic recordings and blood sampling. Using a radiotracer dilution technique with infusion of tritiated noradrenaline ([3H]NA) and adrenaline ([3H]A), fractional extraction and clearance were calculated. Total body and cardiac NA spillovers were used as indices of systemic and cardiac sympathetic nervous activity. The study group had normal left ventricular ejection fraction and cardiac pressures. Cardiac NA spillover was increased by 127% in the hypertensive patients compared with healthy subjects (200 +/- 53 versus 88 +/- 10 pmol/min in controls, P < 0.05). Total body NA spillover was similar in both groups. Cardiac fractional extraction of [3H]NA and [3H]A was decreased by 26 and 47%, respectively, compared with normotensive subjects (P < 0.01 for both). CONCLUSIONS : Patients with renovascular hypertension have altered cardiac sympathetic function with increased sympathetic drive and impaired catecholamine extraction. The increased cardiac sympathetic drive may have adverse long-term effects on prognosis in this patient group with high cardiovascular mortality.     

Similar prevalence of renovascular hypertension in selected blacks and whites

Renovascular hypertension is a potentially curable form of high blood pressure that is thought to be extremely rare among blacks. We demonstrate, however, that in a clinically selected population, the prevalence of renovascular hypertension is similar in blacks and whites. We prospectively evaluated 167 hypertensive subjects who had one or more clinical features known to be associated with renovascular hypertension. All subjects had captopril-stimulated peripheral renin measurements and conventional renal arteriography. All significant renal artery stenoses (greater than 50% luminal narrowing) were treated with percutaneous transluminal angioplasty or surgery. Renovascular hypertension was diagnosed if there was a blood pressure response to interventional therapy, according to the criteria established by the Cooperative Study of Renovascular Hypertension. Of the total group evaluated, 24% (39 of 167) had renal artery stenosis and 14% (23 of 167) had renovascular hypertension. Renal artery stenosis or occlusion was found in 27% (26 of 97) of whites and 19% (13 of 67) of blacks (p = 0.27). Renovascular hypertension was diagnosed in 18% (17 of 97) of whites and 9% (6 of 67) of blacks evaluated (p = 0.25). Renovascular hypertension was associated with severe or refractory hypertension and with smoking, but there were no racial differences in these associations. Blacks with renovascular hypertension tended to have low captopril-stimulated peripheral renin activity. We conclude that blacks with clinical features suggestive of renovascular hypertension should be evaluated with angiography. Captopril-stimulated plasma renin may not be useful in detecting blacks with renovascular hypertension, but this and other potential screening tests require further evaluation.     

Baroreflex control of muscle sympathetic nerve activity in borderline hypertension

Patients with borderline hypertension have exaggerated vascular responses to orthostatic stress produced by tilt or lower body negative pressure (LBNP). It has been suggested that 1) in the supine position, these patients have augmented activity of cardiopulmonary baroreceptors that exerts an increased restraint on sympathetic vasoconstrictor tone; 2) withdrawal of this augmented inhibitory baroreceptor activity during orthostatic stress elicits augmented reflex sympathetic vasoconstrictor outflow; and 3) augmented cardiopulmonary baroreceptor activity may be secondary to impaired arterial baroreflex mechanisms. To test these hypotheses, we recorded muscle sympathetic nerve activity from the peroneal nerve in seven borderline hypertensive subjects and seven age-, sex-, and weight-matched normotensive subjects during three levels of nonhypotensive LBNP and infusions of phenylephrine and nitroprusside. During LBNP, reductions of central venous pressure were similar in borderline hypertensive and normotensive subjects, and arterial pressure and heart rate values were unchanged. Increases of sympathetic nerve activity, however, were significantly greater in borderline hypertensive than in normotensive subjects at each level of LBNP, indicating an augmented gain of the cardiopulmonary baroreflex. To determine whether this augmentation is related to impairment of arterial baroreflexes, we measured changes of sympathetic nerve activity during increases and decreases of arterial pressure produced with infusions of intravenous phenylephrine and nitroprusside. Central venous pressure was held at control levels by LBNP during phenylephrine and saline infusion during nitroprusside. Changes of sympathetic nerve activity during alterations of arterial pressure were similar in borderline hypertensive and normotensive subjects. These data show that cardiopulmonary baroreflex control of SNA is augmented in borderline hypertensive subjects and that this augmentation does not result from an attenuation of the arterial baroreflex.     

White coat hypertension in centenarians

BACKGROUND: To study white coat (WC) hypertension in centenarians, a cross-sectional surveillance was carried out on Uygurs, a long-lived population in China. METHODS: Twenty-four-hour ambulatory blood pressure (BP) monitoring (ABPM) was performed in 33 centenarians (age range, 100 to 113 years) and compared with 100 elderly subjects (age range, 65 to 70 years). All subjects were clinically healthy and capable of self-care. Subjects had no history, signs, or symptoms of cardiovascular disease and were receiving no medical treatments. Office BP, 24-h mean, daytime and night-time BP, pulse pressure, heart rate, standard deviation (SD), and coefficient of variation (CV) of the same variables were extracted from ABPM. The WC effect was defined as the difference between mean office and daytime BP. RESULTS: Centenarians demonstrated higher prevalence of WC hypertension, compared to elderly group (15% vs. 5%). The WC effect was also greater in centenarians than in elderly subjects, and was more marked for systolic BP than for diastolic BP and heart rate. The WC effect for systolic BP was positively correlated with both SD (r = 0.45, P < .01) and CV (r = 0.55, P < .01) for 24-h systolic BP in centenarians, but not in elderly subjects. CONCLUSIONS: Prevalence of WC hypertension was greater in centenarians than in elderly subjects. The WC effect and BP variation may be increased in centenarians. Previously observed higher BPs seen in very elderly individuals might be explained by the greater impact of WC hypertension.     

Prospective study on the prevalence of secondary hypertension among hypertensive patients visiting a general outpatient clinic in Japan.

Secondary hypertension (SH) including endocrine hypertension has been reported to be uncommon. We estimated the prevalence of SH among hypertensive patients. We prospectively studied 1,020 hypertensive patients. As an initial screening, we measured plasma aldosterone concentration, plasma renin activity, serum cortisol concentration and plasma catecholamine concentration and conducted abdominal ultrasonography (US). As a secondary screening, we performed furosemide plus upright test, captopril renography, dexamethasone suppression test, 24-h urine catecholamine measurement and abdominal CT. Finally, primary aldosteronism with the exception of idiopathic hyperaldosteronism, pheochromocytoma, and Cushing's syndrome were diagnosed by histopathological examination of surgical specimens. Idiopathic hyperaldosteronism was clinically diagnosed by adrenocorticotrophic hormone (ACTH)-stimulated adrenal venous sampling and renovascular hypertension by renal arteriography. There were 61 patients with primary aldosteronism, 5 with renovascular hypertension, 11 with Cushing's syndrome, 10 with preclinical Cushing's syndrome and 6 with pheochromocytoma, and the prevalence of SH was 9.1% among 1,020 hypertensive patients. In 76 (82%) of 93 patients with SH, hypertension was cured or improved after unilateral adrenalectomy, transsphenoidal pituitary adenectomy or percutaneous transluminal angioplasty. With the exception of US and CT, all initial and secondary screening tests were found to be sensitive and specific for differentiating SH from essential hypertension (EH). In conclusion, the measurement of various hormone concentrations was very sensitive for ruling out SH--a condition for which, in the present study, there were few specific signs or symptoms--while CT and US examinations were not always useful for differentiating SH from EH. The prevalence of curable SH among hypertensive subjects was higher in this study, which was conducted by our simple method of screening tests, than in previous reports. Hypertensive patients should be screened for SH and the underlying disease treated appropriately to avoid long-term use of antihypertensive drugs and risks of atherosclerotic complications.     

Myocardial ultrasonic backscatter in hypertension: relation to aldosterone and endothelin

A disproportionate accumulation of fibrillar collagen is a characteristic feature of hypertensive heart disease, but the extent of myocardial fibrosis may differ in different models of hypertension. In experimental studies, aldosterone and endothelins emerge as important determinants of myocardial fibrosis. Changes in myocardial extracellular matrix and collagen deposition can be estimated noninvasively by analysis of the ultrasonic backscatter signal, which arises from tissue heterogeneity within the myocardium and describes myocardial texture. This study was designed to investigate the relations between myocardial integrated backscatter and circulating aldosterone and immunoreactive endothelin in human hypertension. The study population consisted of 56 subjects: 14 healthy normotensive volunteers and 42 hypertensive patients (14 with primary aldosteronism, 7 with renovascular hypertension, and 21 with essential hypertension). The patients with essential and secondary hypertension were matched for age, gender, body mass index, and blood pressure. Myocardial integrated backscatter at diastole was 19.8+/-2.0 and 20.8+/-2.9 decibels in normotensive control subjects and patients with essential hypertension and significantly higher in patients with primary aldosteronism (27.4+/-3.8 decibels, P<0.01) and renovascular hypertension (26.8+/-4.8 decibels, P<0.01). In the population as a whole, as well as in the hypertensive subpopulation, myocardial integrated backscatter was directly related to plasma aldosterone (r=0.73 and 0.71, P<0.01 for both) and immunoreactive endothelin (r=0.60 and 0.56, P<0.01 for both). The data of this study suggest that in human hypertension, circulating aldosterone and immunoreactive endothelin may induce alterations in left ventricular myocardial texture, possibly related to increased myocardial collagen content.     

Treatment of hypertension in the elderly

Investigation of preventive measures for hypertension and atherosclerosis is a geriatric medicine priority. While the causes of both isolated systolic hypertension and conventional systolic and diastolic hypertension in the elderly are well defined, the benefits of lowering blood pressure are not. Evidence to support the treatment of symptomatic hypertension is convincing for men 60 years of age; it is not for women in this age group. The need to treat hypertension, particularly isolated systolic hypertension in patients above 75 years old, is still not resolved. Isolated systolic hypertension in older patients is at least as strong a risk factor for cardiovascular disease as is diastolic hypertension. Ongoing trials may answer these questions; in the meantime, drug therapy in this group will vary widely. The elderly hypertensive is more likely than the younger hypertensive to have other diseases; diagnosis of these disorders is crucial. Hypertension arising de novo late in life warrants a search for underlying and possibly remedial causes. Antihypertensive drug therapy to relieve symptoms is difficult to justify, because most elderly hypertensive patients are asymptomatic; however, it has been shown to delay morbid and fatal complications of hypertension. Appropriate therapy for the elderly hypertensive must be individualized and should be associated with few or no side effects. The thiazides are the preferred diuretics for long-term treatment of hypertension in the elderly. Beta blockers are attractive because they are cardioprotective, counter the end organ effect of catecholamines and reduce angina; however, some decrease cardiac output, increase peripheral resistance, decrease renal blood flow and cause fatigue.(ABSTRACT TRUNCATED AT 250 WORDS)     

The captopril test for identification of renovascular hypertension: value and immediate adverse effects

Abstract. To develop a screening test for identification of renovascular hypertension, the blood pressure and plasma renin concentration responses to an oral test dose of captopril (6.25 mg) were studied in 47 hypertensive patients of mean age 61 years (range 34-85 years). Blood pressure was measured at 15-min intervals for 90 min after administration of captopril. Blood samples for plasma renin determination were drawn immediately before and 90 min after drug administration. Eleven patients had renal artery stenosis. The fall in diastolic blood pressure in these patients was greater, on average, than in patients with other forms of hypertension (30 mmHg vs. 14 mmHg, P < 0.01), as was the increase in plasma renin concentration (188 mU l^?1 vs. 2 mU l^?1, P < 0.01). This study demonstrates that the short-term captopril test is useful for distinguishing patients with renovascular disease from those with other forms of hypertension. During the test, 7 patients (15%) exhibited reversible cerebral symptoms. In two of these subjects digital subtraction angiography was performed, which revealed stenosis of the carotid artery. Consequently, it is suggested that captopril should not be used in patients with arteriosclerotic stenoses of the carotids.