Are lead, cadmium and mercury risk factors for resistant hypertension?

BACKGROUND: Lead (Pb), cadmium (Cd) and mercury (Hg) are toxic trace elements that represent a public health problem as risk factors for cardiovascular disease and hypertension (HT) and could also contribute to the development of resistant hypertension (rHT) AIMS: To compare the blood concentrations of Pb, Cd and Hg in subjects with resistant and non-resistant HT and to define whether there is a relationship between its levels and rHT. METHODS: Cross-sectional study. Subjects aged ≥ 21 to ≤ 80 years with a body mass index < 40 kg/m2 were recruited on a discretionary basis from October 2001 to October 2004 in a hypertension unit of a tertiary hospital amongst those sent to the hypertension unit by their family physician. Resistant hypertension was defined according to the American Heart Association (AHA) criteria. Whole blood concentrations of Cd, Pb and Hg were measured by electrothermal atomic absorption spectrometry. RESULTS: 46 out of 73 included subjects (63%) suffered from rHT. Blood Pb median: HT 3.9 (IQR 2.7-5.2) vs. rHT 3.6 (IQR 2.8-6.0) µg/dL (p=0.941). Blood Cd median: HT 0.07 (IQR 0.07-0.80) vs. rHT 0.30 (IQR 0.07-0.65) µg/L (p=0.681). Blood Hg median: HT 7.9 (IQR 5.8-12.9) vs. rHT 7.3 (IQR 4.6-13.3) µg/L (p=0.611). Considering the 75th percentile of each element (Pb: 5.55 µg/dL, Cd: 0.75 µg/L, Hg: 13.15 µg/L), a multiple logistic regression analysis (adjusted for age, BMI, diabetes mellitus, clearance of creatinine and only for Cd the smoking habit) showed an OR = 3.44 (0.84-14.10, p=0.086) for Pb, OR = 1.80 (0.39-8.24, p=0.451), for Cd and OR = 2.31 (0.59-9.14, p=0.232) for Hg. Moreover, the stratified analyses showed that men with Pb ≥5.55 µg/dL have a 14 times higher risk of suffering from rHT (p=0.026). Interestingly, a 9-fold increased risk was found for non-obese subjects with elevated Pb levels, above 5.55 µg/dL (p=0.029). Also in men, the probability of suffering from rHT was more than 7 times higher if Cd levels were ≥ 0.75 µg/L (p=0.076). Most smokers had higher Cd levels, with a high risk of suffering from rHT (ORa 12.6 (0.8-200.2), p=0.072). CONCLUSION: A higher blood Pb levels, defined by the 75th percentile (Pb ≥ 5.55 µg/dL), is associated with a greater risk of suffering from rHT and to a lesser extent in the case of Cd and Hg.

Laparoscopic adrenalectomy vs. radiofrequency ablation for the treatment of primary aldosteronism. A single center retrospective cohort analysis adjusted with propensity score.

BACKGROUND: Laparoscopic adrenalectomy (LA) is the gold standard treatment for unilateral primary aldosteronism. However, satisfactory results have also been published with radiofrequency ablation (RFA). The aim of this study was to compare LA and RFA for the treatment of primary aldosteronism. METHODS: A retrospective cohort study of the patients who underwent LA or RFA in a single center was performed. Morbidity and long-term effectiveness (cure rate and blood pressure control) were analyzed. A multivariate analysis with a propensity score was also performed. RESULTS: Thirty-four patients were included in the study, 24 in the LA group and 10 in the RFA group. Hypertension had been diagnosed a median of 12 years before the intervention. Hypertension was properly controlled before the intervention in 55.9% of the patients. Hypertensive crisis was more common during RFA (4.2% vs. 70.0%, p < 0.001), although no patient suffered any complication because of these crises. LA was longer (174.6 vs. 105.5 min, p = 0.001) and had a longer length of stay (median 2 vs 1 days, p < 0.001). No severe complications were observed in any of the patients. After a median follow-up of 46.2 months, more patients had hypertension cured and blood pressure controlled in the LA group (29.2% vs. 0%, p = 0.078 and 95.5% vs. 50.0%, p = 0.006, respectively). Also, patients in the LA group were taking less antihypertensive drugs (1.8 vs. 3.0, p = 0.054) or mineralocorticoid receptor antagonists (41.7% vs. 90.0%, p = 0.020). Multivariate analysis adjusted by propensity score showed that LA had an OR = 11.3 (p = 0.138) for hypertension cure and an OR = 55.1 (p = 0.040) for blood pressure control. CONCLUSIONS: Although RFA was a less invasive procedure than LA, hypertension was cured and blood pressure was properly controlled in more patients from the LA group. Patients who underwent LA were taking less antihypertensive drugs than patients who had undergone RFA.

Health perception in menopausal women.

AIM: The aim of this study is to find whether the worsening of health perception was related to the menopausal (MNP) state or to its negative consequences on cardiometabolic risk factors (CMRF) and the presence of depression/anxiety. METHODS: In this study, 2,562 women, 1,357 (53%) MNP and 1,205 (47%) non-MNP, were analyzed. Blood pressure, heart rate, body mass index, waist circumference, and depression/anxiety screening using the Hospital Depression/Anxiety Scale (HADS) were measured. We collected a blood sample in fasting state for glycemia, total cholesterol, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol and triglycerides. Logistic regression models were fitted with a backward method from the potentially confusing variables of the menopause study groups. RESULTS: Age 49.4 (±15.9) years; 10.1% belonged to semi-rural population; 87.5% had children. Regarding the educational level, 22.1% had <5 years of education, 31.3% had between 6 and 7 years, 33.4% had between 8 and 12 years, and 13.2% had >12 years of education. The prevalence of CMRF was significantly higher in MNP women, except for smoking. We did not find any differences in the prevalence of depression or anxiety between MNP and non-MNP women. Health was perceived as worse among MNP women (P<0.05) and patients over 45 years of age than patients younger than 45 years. We found a relationship between the negative health perception with metabolic syndrome, depression, and anxiety, having children, smoking, residing in rural area, and low educational level; nevertheless, it is not correlative with MNP status. CONCLUSION: Perceived health should be viewed as a multifaceted condition related to social circumstances, and various symptoms in women, including menopause symptoms, but not with MNP state itself.

Effect of intensive multifactorial treatment on vascular progenitor cells in hypertensive patients.

BACKGROUND: Most hypertensive patients, despite a proper control of their cardiovascular risk factors, have cardiovascular complications, evidencing the importance of controlling and/or reversing target-organ damage. In this sense, endothelial dysfunction has been associated with the presence of cardiovascular risk factors and related cardiovascular outcomes. Since hypertension often clusters with other risk factors such as dyslipemia, diabetes and obesity, in this study we have investigated the effect of intensive multifactorial treatment on circulating vascular progenitor cell levels on high-risk hypertensive patients. DESIGN: We included108 hypertensive patients receiving intensive multifactorial pharmacologic treatment and dietary recommendations targeting blood pressure, dyslipemia, hyperglycemia and weight for 12 months. After the treatment period, blood samples were collected and circulating levels of endothelial (CD34+/KDR+, CD34+/VE-cadherin+) and smooth muscle (CD14+/endoglin+) progenitor cells were identified by flow cytometry. Additionally, plasma concentration of vascular endothelial growth factor (VEGF) was determined by ELISA. RESULTS: Most hypertensive patients (61±12 years, 47% men) showed cardiovascular parameters within normal ranges at baseline. Moreover, body mass index and the majority of the biochemical parameters (systolic and diastolic blood pressure, fasting glucose, total cholesterol, HDL-c, LDL-c, creatinine and hs-CRP) significantly decreased overtime. After 12 months of intensive treatment, CD34+/KDR+ and CD14+/endoglin+ levels did not change, but CD34+/VE-cadherin+ cells increased significantly at month 12 [0.9(0.05-0.14)% vs 0.05(0.02-0.09)% P<0.05]. However, VEGF plasma concentration decreased significantly overtime [89.1(53.9-218.7) vs [66.2(47.5-104.6) pg/mL, P<0.05]. CONCLUSIONS: Long-term intensive treatment in hypertensive patients further improves cardiovascular risk and increases circulating EPCs, suggesting that these cells could be a therapeutic target.

[Primary care evaluation of the hypertensive patient management in specialized care after derivation (DERIVA-2 Study)]. / Valoración desde atención primaria del manejo del hipertenso en atención especializada (estudio DERIVA-DOS).

INTRODUCTION: To know the opinion/evaluation of the primary care physicians (PCPH) of the received information about patients that were attended in specialized care (SC). DESIGN: Cross-sectional study. LOCATION: Performed nationwide in primary care centers. PARTICIPANTS: Researchers from the primary care network. METHODS: We used the SEH-LELHA derivation criteria guidelines, plus an ad hoc survey that included demographic and anthropometric data, blood pressure levels, and the main reason for derivation to SC at the baseline and final (post-derivation) visit. In addition, time deployed for the study of every patient, changes in diagnosis and treatment, type of follow-up, issues throughout the derivation process and assessment of the medical referred to the PCPH were evaluated. RESULTS: With participation of 578 researchers from primary, the study included 1715 patients aged 60.7±13.3years, 62.7% male. Patients were taking 2.3±1.2 (range 0-10) antihypertensive drugs pre-referral and 2.5±1.2 (0-9) after derivation. Blood pressure levels changed from 166±21.6 /97.7±12.6mmHg to 143±14.4 /85.5±10.5mmHg. The number of controlled patients (BP<140 and <90mmHg) increased from 5.8% to 32.2%. Time between pre- and post-derivation visit was 72±64days (median 57days, IQ26-99). The PCPH received a medical report in 80.3% of cases, 76.9% with an explanation of the results of the complementary tests, 75.8% with additional information or a reasoning of treatment and in 71% of cases information about the patient future management. 63% of PCPH were fully agreed with the management of the specialist, 29% agree and 2% strongly disagree. The derivation was evaluated as effective or very effective in 86% of patients and no effective in 9%. CONCLUSIONS: Communication between AE and SC in HTA is valued satisfactorily by MAP. However there is still room for improvement in the process.

[Evaluation of referral process of the hypertensive patient in Spain: DERIVA study]. / Análisis del proceso de derivación del paciente hipertenso en España: Estudio DERIVA.

INTRODUCTION: An adequate communication between levels of medical attention is the key point for optimal treatment and outcomes of the hypertensive population. AIMS: The aim of this study was to evaluate the adequacy of the hypertensive patients' derivation from Primary Care to Specialized Care. As secondary objectives, the information registered on the derivation report was assessed and concordance between derivation reason and final diagnosis was analysed. DESIGN: This is an observational, descriptive, multicentre study. SITE: Study conducted at the national level. PARTICIPANTS: Specialty Care Physicians receiving hypertensive patients referred from primary care. PRINCIPAL MEASUREMENTS: On the baseline visit, the specialist physicians assessed the quality of the derivation records and attended the patient. After the study, final diagnosis and treatment is suggested on the final visit. RESULTS: 1769 subjects were included, mean aged 62,4 (13,6) years, 45% female. Time of diagnosis of hypertension was 8,0 (7,7) years. More than the half of the derivation records contained very good information (5,4%; CI4,3-6,5) or sufficient (50,7%; CI48,4-53,0). In 7,1% (IC5,9-8,3) derivation cause was not specified. 74,7% of the derivations were considered as appropriate, though 30% were late. Concordance between derivation reasons and final diagnosis was low (kappa index 0,208). CONCLUSIONS: A quarter of the hypertensive population is unnecessary derived to Secondary Care and 30% of the appropriately derived was late. We should improve the interrelation of attention in the hypertension and cardiovascular area between the both attention levels.

Primary aldosteronism and its various clinical scenarios.

BACKGROUND: Primary aldosteronism is the most frequent endocrine cause of secondary hypertension. Aldosterone excess damages the cardiovascular system. OBJECTIVES: We compared biochemical; morphological, and cardiovascular risk differences among hypokalemic and normokalemic primary aldosteronism. We evaluated either both presentations correspond to two different entities or a unique disease in different evolutive stage. MATERIAL AND METHODS: This is a retrospective study including 157 patients with primary aldosteronism divided into two groups: typical presentation (serum potassium < 3.5 mmol/l, n = 87) and atypical presentation (serum potassium > 3.5 mmol/l, n = 70). RESULTS: The typical presentation group showed higher family background of ischemic heart disease (P = 0.028), plasmatic aldosterone levels (P = 0.001), and cardiovascular added risk (P = 0.013). Although kalemia was corrected in the hypokalemic group after specific treatment, typical presentation maintained lower levels. Predictors of typical presentation were the highest tertile of aldosterone level, baseline DBP, and a longer evolution of hypertension. Aldosterone serum levels increased along time in primary aldosteronism and it can be considered as the most discriminative factor for the type of presentation. CONCLUSION: Primary aldosteronism presentation along with normokalemia or hypokalemia could be the same disease at different evolution stages. Adequate detection of normokalemic primary aldosteronism deserves an early and intentional diagnostic attitude.

Early predictors of gestational hypertension in a low-risk cohort. Results of a pilot study.

OBJECTIVE: To determine if the clinical or biochemical markers used in pregnancy can be applied as early predictors of gestational hypertension. DESIGN: Prospective cohort study. POPULATION: 315 pregnant women referred from the Prenatal Diagnosis Unit between weeks 10-13 of pregnancy and followed up to the childbirth. METHODS: Biomarkers were measured in serum specimens in the first and second trimester of pregnancy. Blood pressure (BP) was measured in the first, second and third trimester. RESULTS: The cumulative incidence of gestational hypertension was 6.01%. In the first trimester gestational hypertension predictors were uric acid greater than 3.15 mg/dl (P=0.01), BMI greater than 24 kg/m (P=0.003) SBP at least 120 mmHg (P=0.02) and DBP at least 71 mmHg (P=0.007). After applied multivariate analysis just uric acid and SBP were statistically significant. CONCLUSION: In our cohort of healthy pregnant women uric acid above 3.15 mg/dl and SBP at least 120 mmHg are consistent predictors of gestational hypertension in the first trimester. The most important implication of our study is the possibility to identify in the first trimester women at risk to develop gestational hypertension using available markers.

Association between urinary albumin excretion and both central and peripheral blood pressure in subjects with insulin resistance.

BACKGROUND: Central blood pressure (cBP) predicts cardiovascular events. Regarding subclinical organ damage, the relationship between urinary albumin excretion (UAE) and cBP is rather unknown. OBJECTIVE: We aimed to determine whether cBP is related to UAE, and if this relationship is stronger than that observed with peripheral blood pressure (pBP). METHODS: Three hundred and twenty-four hypertensives (61% men, aged 65 ±â€Š10 years) with insulin-resistance (77% diabetics; 23% nondiabetics with metabolic syndrome) were studied. Office pBP and cBP (radial applanation tonometry) were determined. UAE (albumin/creatinine) was averaged from three first-morning-void urine samples. Differences between patients with/without microalbuminuria, and the relationship between UAE and both pBP and cBP were analyzed. The strength of such relationship (cBP vs. pBP) was compared using a noninferiority test. RESULTS: Microalbuminuria was detected in 25% of all patients. After age-adjustment and sex-adjustment, both central and peripheral SBP and pulse pressure (PP) (mmHg) were higher in microalbuminurics than in normoalbuminurics [central SBP (cSBP): 130 ±â€Š20 vs. 124 ±â€Š19; peripheral (pSBP): 147 ±â€Š22 vs. 139 ±â€Š20; central pulse pressure (cPP): 52 ±â€Š15 vs. 47 ±â€Š14; peripheral pulse pressure (pPP): 67 ±â€Š16 vs. 62 ±â€Š16, P < 0.05 for all]. Partial correlation coefficients (age-adjusted and sex-adjusted) between blood pressure (BP) and UAE were 0.175 for cSBP, 0.143 for pSBP, 0.124 for cPP (P < 0.05 for all), and 0.092 for pPP (P = 0.117). Neither cBP nor pBP were superior to each other in their association with UAE or with microalbuminuria. Comparisons between cBP and pBP by means of noninferiority tests revealed no differences in the magnitude of correlation coefficients (P = 0.265 for SBP; P = 0.212 for PP), or differences in means between patients with/without microalbuminuria (P = 0.327 for SBP; P = 0.054 for PP). CONCLUSION: Although cBP is related with UAE, this relationship is not superior to that of office peripheral BP.

Hypertension caused by primary hyperaldosteronism: increased heart damage and cardiovascular risk.

INTRODUCTION AND OBJECTIVES: Primary hyperaldosteronism is the most common cause of secondary hypertension. Elevated aldosterone levels cause heart damage and increase cardiovascular morbidity and mortality. Early diagnosis could change the course of this entity. The objective of this report was to study the clinical characteristics, cardiac damage and cardiovascular risk associated with primary hyperaldosteronism. METHODS: We studied 157 patients with this diagnosis. We analyzed the reason for etiological investigation, and the routinely performed tests, including echocardiography. We used a cohort of 720 essential hypertensive patients followed in our unit for comparison. RESULTS: Compared with essential hypertensive patients, those with hyperaldosteronism were younger (56.9 [11.7] years vs 60 [14.4] years; P<.001), had higher blood pressure prior to the etiological diagnosis (136 [20.6] mmHg vs 156 [23.2] mmHg), more frequently had a family history of early cardiovascular disease (25.5% vs 2.2%; P<.001), and had a higher prevalence of concentric left ventricular hypertrophy (69% vs 25.7%) and higher cardiovascular risk. Specific treatment resulted in optimal control of systolic and diastolic blood pressures (from 150.7 [23.0] mmHg and 86.15 [14.07] mmHg to 12.69 [15.3] mmHg and 76.34 [9.7] mmHg, respectively). We suspected the presence of hyperaldosteronism because of resistant hypertension (33.1%), hypokalemia (38.2%), and hypertensive crises (12.7%). Only 4.6% of these patients had been referred from primary care with a suspected diagnosis of hyperaldosteronism. CONCLUSIONS: Hyperaldosteronism should be suspected in cases of resistant hypertension, hypokalemia and hypertensive crises. The diagnosis of hyperaldosteronism allows better blood pressure control. The most prevalent target organ damage is left ventricular hypertrophy.

Management of resistant arterial hypertension: role of spironolactone versus double blockade of the renin-angiotensin-aldosterone system.

BACKGROUND: Currently there is no consensus regarding which add-on therapy to use in resistant hypertension. This study was designed to compare two treatment options, spironolactone (SPR) versus dual blockade of the renin-angiotensin-aldosterone system (RAAS). METHODS: Forty-two patients with true resistant hypertension were included in the study. An open-label prospective crossover design was used to add a second RAAS blocker to previous treatment and then SPR following 1 month of wash-out. BP was measured in the office and by ambulatory blood pressure monitoring (ABPM). Changes in laboratory tests were also studied for both treatments. The predictive values of aldosterone-renin ratio (ARR) and serum potassium of determining the antihypertensive response were analyzed for both arms. RESULTS: Following the first stage of dual blockade, SBP dropped significantly both in office (reduction of 12.9 ± 19.2 mmHg)) and by ABPM (reduction of 7.1 ± 13.4 mmHg). Office DBP was unchanged but was significantly reduced as measured by ABPM (3.4 ± 6.2 mmHg). On SPR treatment, office BP was reduced 32.2 ± 20.6/10.9 ± 11.6 mmHg. By ABPM the reduction was 20.8 ± 14.6/8.8 ± 7.3 mmHg (P < 0.001). The BP control was achieved by 25.6% of patients in dual blockade and 53.8% in SPR with office blood pressure. By ABPM, 20.5% were controlled on dual blockade and up to 56.4% with SPR. Serum potassium was a weak inverse predictor of the blood pressure-lowering effect of SPR. CONCLUSION: SPR has a greater antihypertensive effect than dual blockade of the RAAS in resistant hypertension. SPR at daily doses of 25-50 mg shows a potent antihypertensive effect when added to prior regimes of single RAAS axis blockade in patients with resistant arterial hypertension.

[Hypertension due to persistent hypokalemia: a complex case]. / Hipertensión arterial secundaria con hipopotasemia persistente: un caso complejo.

High grade of suspect must be present to diagnose some of the multiple causes of secondary blood hypertension. In the literature, there are reports that describe the coincidence of 2 different aetiologies of secondary hypertension in one patient, but both of endocrine origin. This one is the first time that a case with simultaneity of fibromuscular dysplasia and hyperaldosteronism in the same patient is described. This is the case of a 40-year-sold hypertensive patient, with a normal previous study of secondary hypertension, which after presenting HELLP syndrome (hemolysis, elevated liver enzymes and low platelet count) during a pregnancy with foetal death was studied again to rule out a secondary aetiology for her hypertension. After various studies were performed the patient was diagnosed as having two secondary causes for her hypertension: primary hyperaldosteronism and fibromuscular dysplasia, and after a guided treatment, optimal control for blood pressure was attainted. With this clinical case we show the importance of the clinical suspicion and the need for perseverance in the diagnoses of secondary blood hypertension, and also the exclusivity of this case.