Hypertension

A 57-year-old man requests an extensive medical evaluation as part of a transition in the ownership of his business. He is generally healthy, although he reports that his capacity for physical exertion has diminished over the past several years. He denies chest pain with effort, dyspnea at night or on exertion, cough, and sputum production.

ABSTRACT: Patients who experience an acute myocardial infarction (MI) are at very high risk for recurrent cardiovascular events. Both site-supervised and home-based cardiac rehabilitation programs can effectively reduce all-cause and cardiovascular mortality. Start risk factor reduction as soon as possible; pharmacotherapy is best initiated while patients are still in the hospital. All patients who have had an MI should receive aspirin, an angiotensin-converting enzyme inhibitor, and a ß-blocker, unless these agents are contraindicated or are not tolerated. Prescribe aggressive lipid-lowering therapy to bring patients' low-density lipoprotein cholesterol levels to below 70 mg/dL. For smokers, quitting is the single most important change they can make to reduce future risk of MI.

What is "normal" blood pressure (BP)? Is it different from optimal BP?

For several months, a 52-year-old woman has had burning discomfort in the region of her lower sternum and frequent acid/sour sensations in her throat; the symptoms are usually associated with burping after meals and recumbency.

COLOGNE, Germany -- Chocolate, the ultimate comfort food, has won another health vote of confidence, a reduction in blood pressure. Tea -- black or green -- did not.

MONTRÉAL -- Restless legs syndrome may boost nocturnal blood pressure and exacerbate cardiovascular disease risks, particularly among older patients, investigators here suggested.

Among patients in whom angioedema developed while they were being treated with an ARB, 50% had previously had a similar reaction to angiotensin-converting enzyme (ACE) inhibitors, according to one report.

Numerous randomized trials have evaluated antihypertensive regimens in various settings, including those complicated by at least one other vascular disorder. Among these trials are the Modification of Diet in Renal Disease (MDRD) Study in hypertensive patients with kidney disease; the Comparison of AMlodipine versus Enalapril to Limit Occurrences of Thrombosis (CAMELOT) Study and the INternational VErapamil-trandolapril STudy (INVEST) in patients with hypertension and coronary disease; and the Perindopril pROtection aGainst REcurrence of Stroke Study (PROGRESS) in hypertensive patients who have had a stroke.

NEW ORLEANS -- Torcetrapib, an investigational cholesteryl ester transfer protein (CTEP) that spikes HDLs but boosts blood pressure, may have proatherogenic effects, according to results from a pair of ultrasound studies.

UTRECHT, The Netherlands -- Coffee for women, and its effect on their blood pressure, is an exception to the maxim that moderation in all things is a good approach to life, contend researchers here.

DALLAS -- Pre-participation cardiovascular evaluation of young competitive athletes to rule out Marfan syndrome, murmur, aortic coarctation, and hypertension could reduce the risk of sudden death, contend new guidelines.

ROCKVILLE, Md. -- The FDA said today it has approved aliskiren (Tektuma), the first oral direct renin inhibitor for treatment of hypertension.

**Until the 1990s, hypertension was largely defined using only the criterion of elevated DBP. However, with the aging and increased longevity of the population, the incidence of predominantly systolic hypertension is on the rise. Isolated systolic hypertension (ISH) is now the most common subtype of hypertension in American adults. The third National Health and Nutrition Examination Survey (NHANES III, 1988-1991) reported that 75% of persons with hypertension were 50 years or older and that about 80% of those untreated or inadequately treated had ISH.1

Although the definition of orthostatic hypotension requires that the significant drop in blood pressure observed on standing be sustained for 3 minutes (which provides evidence of true autonomic failure), clinicians who use this as a diagnostic criterion may be doing many patients a disservice. Most people who fall as a result of a drop in blood pressure do so on arising, as they get up from a bed or chair. Moreover, many hip fractures caused by falls occur in patients who experience a drop in blood pressure on standing. If patients can stand for 3 minutes without wavering or falling, their body is accommodating well.

ABSTRACT: In patients with jaundice and normal liver function, the cause of hyperbilirubinemia is an isolated disorder of bilirubin metabolism. In patients with hyperbilirubinemia who have abnormal liver enzyme levels, hepatocellular disease must be differentiated from cholestatic liver injury. In general, if the cause of jaundice is global hepatocellular dysfunction, the serum alanine aminotransferase and aspartate aminotransferase levels will be predominantly elevated. If the cause is cholestasis, the serum alkaline phosphatase and gγ-glutamyl peptidase levels will be elevated. In most patients, imaging studies will be needed. The initial workup should include abdominal ultrasonography, which can identify dilated intrahepatic and extrahepatic biliary ducts as well as findings that may suggest cirrhosis or signs of portal hypertension, including splenomegaly and ascites.

BOSTON -- Daily use of over-the-counter analgesics -- including aspirin -- significantly increased the risk that men will develop new-onset hypertension, researchers here reported.

WALTHAM, Mass. -- Pulse pressure, the difference between systolic and diastolic pressures, may be a risk factor for the onset of atrial fibrillation independent of arterial pressure and other known factors, researchers said.

ORLANDO -- A novel intravenous calcium channel blocker seems safe and at least as effective as one of the standard blood-pressure-lowering drug in cardiac surgery, a researcher said here.

WASHINGTON -- An observational study of 60,000 postmenopausal women found that about 40% have prehypertension, and that level of blood pressure was associated with a 58% higher risk of cardiovascular death than for normotensive women.

UTRECHT, The Netherlands -- Even if hypertension during pregnancy subsides after delivery, a risky postmenopausal second act may await, researchers reported.

BALTIMORE -- Eighteen million American men ages 20 or older have erectile dysfunction, generally attributed to the effects of diabetes, hypertension, or physical inactivity, researchers here reported.

An 80-year-old man presents to the emergency department (ED) with intermittent dyspnea and chest pain. He has hypertension and osteoarthritis but no known cardiac disease. Vital signs are normal. No jugular venous distention is noted. The lungs are clear with equal breath sounds, and the heart rate is regular, without murmurs, gallops, or rubs. The chest wall is not tender. No edema or asymmetry is evident in the extremities.

ABSTRACT: Angiotensin-converting enzyme (ACE) inhibitor therapy is recommended for all patients with heart failure (HF) and a reduced ejection fraction. It is generally initiated in the hospital at low doses as inotropic therapy is tapered. Angiotensin II receptor blockers may be a suitable alternative for patients who cannot tolerate ACE inhibitors. For patients who cannot tolerate either class of drug, a combination of hydralazine and a nitrate is recommended. ß-Blockers are first-line therapy for patients with current or previous symptoms of HF and reduced left ventricular function, as well as all patients hospitalized for HF. An aldosterone antagonist may be added to the regimen of patients with moderately severe to severe symptoms and reduced ejection fraction whose renal function and potassium concentration can be monitored.

In his recent editorial Putting Guidelines for Chronic Kidney Disease IntoPractice (CONSULTANT, October 2006, page 1295), Dr Gregory Ruteckidiscussed the results of a study that shows many clinicians fail to follow evidence-based guidelines for the management of chronic kidney disease(CKD), such as when to consult a nephrologist.1 A sampling of the feedbackwe received appears below, along with Dr Rutecki's responses.

During a routine diabetes follow-up visit, a 55-year-old man complains of increasing pain in his right groin and hip. He is also being treated for hypertension, and his body mass index is 28.

For several months, a 68-year-old man has had a highly pruritic rash on his lower legs. A similar rash recently arose on his trunk and arms. Treatment with a corticosteroid cream has been ineffective. The patient has diet-controlled diabetes and hypertension that is well controlled by medication.

PHILADELPHIA -- An aggressive approach to hypertension management in the U.S. has paid off in better blood pressure control than achieved in Europe, according to U.S. investigators.

CHICAGO -- Inhibitors of the renin-angiotensin system trumped calcium-channel-blockers, beta-blockers, and diuretics in preventing diabetes, according to a network meta-analysis of hypertension trials.

BALTIMORE -- The most vulnerable age for girls to initially put on too much weight is from nine to 12, and that may lead to high blood pressure and other cardiovascular risk factors, according to investigators here.

NEW YORK -- Pre-hypertension appears to increase the risk of developing an enlarged heart among teens and young adults, according to a study of American Indians.