Resistant hypertension in 2017.

PURPOSE OF REVIEW: Hypertension (HTN) is a ubiquitous condition and cause for significant morbidity and mortality. Over 400 000 deaths in the United States are related to HTN every year, more than all the Americans who died through all of World War II. As many as half the patients with HTN in the United States have resistant HTN, a blood pressure greater than 140/90 mmHg despite three medications including a diuretic. It appears that the prevalence of HTN and resistant HTN is increasing over time. There is a dire need for newer therapies that may reduce or eliminate the need for multiple pharmacologic agents, thus helping with compliance and reducing the possibility of their adverse events. RECENT FINDINGS: The current review summarizes the techniques and results reported in recent studies utilizing renal denervation technologies from the original Symplicity Trials to newer multipolar electrodes being used for optimal denervation. We also report the early experience with noninvasive renal denervation. Endovascular carotid body stimulation is also being investigated for resistant HTN. Renovascular HTN remains an underlying cause for resistant HTN, and revascularization may prove to be an effective treatment for many of these patients. SUMMARY: A multipronged approach utilizing lifestyle modification, pharmacologic therapy and tailored endovascular treatments may be the algorithm to treat the growing cohort of resistant HTN. However, most of the endovascular treatments remain to be validated, and renal revascularization for renovascular HTN has been set back by recent studies that did not appear to target the real renovascular cohort.

Delayed Time to Peak Velocity Is Useful for Detecting Severe Aortic Stenosis.

BACKGROUND: Time to peak velocity (TPV) is an echocardiographic variable that can be easily measured and reflects a late peaking murmur, a classic physical finding suggesting severe aortic stenosis (AS). The aim of this study was to investigate the usefulness of TPV to evaluate AS severity. METHODS AND RESULTS: This study included 700 AS patients, whose aortic valve area (AVA) was <1.5 cm2, and 200 control patients. The TPV was defined as the time from aortic valve opening to when the flow velocity across the aortic valve reaches its peak. AS severity was classified as follows: High gradient severe AS, mean pressure gradient ≥40 mm Hg and AVA index (AVAI) <0.6 cm2/m2; Low gradient severe AS, mean pressure gradient <40 mm Hg, AVAI <0.6 cm2/m2, and dimensionless index <0.25; moderate AS, mean pressure gradient <40 mm Hg, AVAI ≥0.6 cm2/m2. The area under the receiver operating characteristic curve of TPV to predict high gradient severe AS was 0.94 (95% CI: 0.92-0.97, P<0.001). TPV was significantly delayed in low gradient severe AS compared with moderate AS both in patients with preserved (102±13 ms versus 83±13 ms, P<0.001) and with reduced ejection fraction (110±18 ms versus 88±13 ms, P<0.001). Delayed TPV was associated with increased all-cause mortality or need for aortic valve replacement after adjustment for confounders (hazard ratio for first quartile, reference is fourth quartile: 7.31, 95% CI 4.26-12.53, P<0.001). CONCLUSIONS: TPV is useful to evaluate AS severity and predict poor prognosis of AS patients.

Testosterone replacement and cardiovascular safety: no straight and narrow!

The past decade has seen a tremendous increase in the number of men treated for hypogonadism with the expectation of symptomatic benefit. However, the long-term cardiovascular safety of testosterone replacement remains unknown because retrospective studies of testosterone replacement have been inconsistent, and definitive, prospective, randomized studies are lacking. The purpose of this review is to critically appraise the studies on testosterone replacement and cardiovascular outcomes.