Successful Treatment with an Antihypertensive Drug Regimen Including Eplerenone in a Patient with Malignant Phase Hypertension with Renal Failure.

A 28-year-old man was referred to our hospital for the treatment of congestive heart failure and severe hypertension. The patient was diagnosed with malignant phase hypertension based on the presence of marked hypertension with left ventricular hypertrophy, exudate retinopathy, and renal failure. Intensive therapy for hypertension and heart failure with a combination of antihypertensive drugs including nitroglycerin, nifedipine, eplerenone and candesartan successfully lowered his blood pressure and further improved the renal function. Eplerenone could be one of the choices of antihypertensive drugs in combination therapy in patients with malignant phase hypertension with progressive heart and renal failure.

Usefulness of Intravenous Anesthesia Using a Target-controlled Infusion System with Local Anesthesia in Submuscular Breast Augmentation Surgery

BACKGROUND: Patients have anxiety and fear of complications due to general anesthesia. Through new instruments and local anesthetic drugs, a variety of anesthetic methods have been introduced. These methods keep hospital costs down and save time for patients. In particular, the target-controlled infusion (TCI) system maintains a relatively accurate level of plasma concentration, so the depth of anesthesia can be adjusted more easily. We conducted this study to examine whether intravenous anesthesia using the TCI system with propofol and remifentanil would be an effective method of anesthesia in breast augmentation. METHODS: This study recruited 100 patients who underwent breast augmentation surgery from February to August 2011. Intravenous anesthesia was performed with 10 mg/mL propofol and 50 microg/mL remifentanil simultaneously administered using two separate modules of a continuous computer-assisted TCI system. The average target concentration was set at 2 microg/mL and 2 ng/mL for propofol and remifentanil, respectively, and titrated against clinical effect and vital signs. Oxygen saturation, electrocardiography, and respiratory status were continuously measured during surgery. Blood pressure was measured at 5-minute intervals. Information collected includes total duration of surgery, dose of drugs administered during surgery, memory about surgery, and side effects. RESULTS: Intraoperatively, there was transient hypotension in two cases and hypoxia in three cases. However, there were no serious complications due to anesthesia such as respiratory difficulty, deep vein thrombosis, or malignant hypertension, for which an endotracheal intubation or reversal agent would have been needed. All the patients were discharged on the day of surgery and able to ambulate normally. CONCLUSIONS: Our results indicate that anesthetic methods, where the TCI of propofol and remifentanil is used, might replace general anesthesia with endotracheal intubation in breast augmentation surgery.

Resistant hypertension, secondary hypertension, and hypertensive crises: diagnostic evaluation and treatment.

Hypertension is a very common modifiable risk factor for cardiovascular morbidity and mortality. Patients with hypertension represent a diverse group. In addition to those with primary hypertension, there are patients whose hypertension is attributable to secondary causes, those with resistant hypertension, and patients who present with a hypertensive crisis. Secondary causes of hypertension account for less than 10% of cases of elevated blood pressure (BP), and screening for these causes is warranted if clinically indicated. Patients with resistant hypertension, whose BP remains uncontrolled in spite of use of 3 or more antihypertensive agents, are at increased cardiovascular risk compared with the general hypertensive population. After potentially correctible causes of uncontrolled BP (pseudoresistance, secondary causes, and intake of interfering substances) are eliminated, patients with true resistant hypertension are managed by encouraging therapeutic lifestyle changes and optimizing the antihypertensive regimen, whereby the clinician ensures that the medications are prescribed at optimal doses using drugs with complementary mechanisms of action, while adding an appropriate diuretic if there are no contraindications. Mineralocorticoid receptor antagonists are formidable add-on agents to the antihypertensive regimen, usually as a fourth drug, and are effective in reducing BP even in patients without biochemical evidence of aldosterone excess. In the setting of a hypertensive crisis, the BP has to be reduced within hours in the case of a hypertensive emergency (elevated BP with evidence of target organ damage) using parenteral agents, and within a few days if there is hypertensive urgency, using oral antihypertensive agents.

Classificação dos hipertensos na estratégia de saúde da família visando melhorar o acompanhamento e inclusão no Programa Remédio em Casa / Classficação of hypertension in the family health strategy to improve the monitoring and inclusion in the Program Home Remedy

A Hipertensão Arterial afeta órgãos alvos e está associada à doenças cardiovasculares quando relacionadas a fatores de riscos, existindo possibilidade de intervenção quanto a esta evolução com tratamento adequado. Iniciamos a classificação dos hipertensos para atuar no atendimento desses pacientes(AU)

Hypertensive crises.

The key points of this article are: (1) A hypertensive crisis is present when markedly elevated blood pressure is accompanied by progressive or impending acute target organ damage. (2) Most instances of very elevated blood pressure encountered in the office setting will not be crises and will not require acute reduction of blood pressure. (3) Hypertensive crises are largely preventable and often result from inadequate management of hypertension or poor adherence to therapy. (4) Effective triage of patients into categories of severe hypertension, hypertensive urgency, and hypertensive emergency through an expeditious history, examination, and testing should guide therapy. (5) Hypertensive urgency is managed with oral medications and usually on an outpatient basis; a hypertensive emergency warrants intensive care unit admission and parenteral therapy. (6) Ensuring adequate follow-up after treatment of very elevated blood pressure is a critical step that is often mishandled.

Hypertensive retinopathy associated with use of the ephedra-free weight-loss herbal supplement Hydroxycut.

The use of performance-enhancing and weight-loss supplements is prevalent in the United States, and over the past decade, there has been growing concern with regard to the safety and efficacy of these products. It is well documented that ephedra-based products are associated with adverse reactions, including serious cardiovascular and neurologic injuries. With new restrictions placed on such products, companies are now marketing caffeine-based ephedra-free herbal supplements. Less is known about the potential side effects of these products. We present the case of a 42-year-old, previously healthy man who developed malignant hypertension and hypertensive retinopathy while taking Hydroxycut, a caffeine-based ephedra-free supplement. To our knowledge, this is the first documented case of hypertensive retinopathy associated with the use of Hydroxycut. Given the lack of investigative studies in regard to their safety and efficacy, judicious care should be taken with the use of all herbal supplements, including those designated as ephedra-free.

Control of blood pressure and prevention of end-organ damage in patients with accelerated hypertension by combination with arotinolol and extended release nifedipine.

In patients with accelerated (malignant) hypertension, end-organ damage is the determinant factor for prognosis. Although recent advances in antihypertensive therapy have improved the outcome of patients with accelerated hypertension, the effectiveness of antihypertensive therapy still remains less convinced. In this study, we followed 13 patients clinically diagnosed with accelerated hypertension (defined as diastolic blood pressure > 130 mmHg, retinopathy with K-W IV and accelerated renal impairment) for 3 yr. One patient died due to acute myocardial infarction arising from poor compliance with antihypertensive therapy. One patient was maintained on hemodialysis for 3 yr. One patient was introduced for continuous ambulatory peritoneal dialysis (CAPD) for a year and then lived without dialysis therapy. The remaining 10 patients were followed for 3 yr. All patients were initially treated with intravenous administration of calcium antagonist for reduction of blood pressure, followed by hemodialysis therapy if needed. After stabilization of blood pressure, combination therapy with extended release nifedipine (40 to 80 mg daily) and arotinolol (20 mg daily) was started. The targets for blood pressure control were a systolic pressure of 135 mmHg and a diastolic pressure of 80 mmHg. If blood pressure control was unsatisfactory, guanabenz (2 to 4 mg before bedtime), a central acting drug, was added. At presentation, the mean diastolic blood pressure (mDBP) among the 10 remaining patients was 134 +/- 2 mmHg, the mean serum creatinine (mScr) was 4.5 +/- 0.7 mg/dl and the left ventricular mass index (LVMi) as measured by echocardiography was 150 +/- 9 g/m2. At 1 yr, the mDBP was reduced to 90 +/- 3 mmHg, the mScr to 2.9 +/- 0.9 mg/dl and the LVMi to 140 +/- 9 g/m2. At 3 yr, the mDBP was stabilized at 79 +/- 3 mmHg, the mScr maintained at 2.2 +/- 0.4 mg/dl, and the LVMi reduced to 128 +/- 9 g/m2. These results indicate that appropriate blood pressure control is important for improvement of renal impairment and cardiac damage in patients with accelerated hypertension. Moreover, combination therapy with arotinolol and extended release nifedipine may be beneficial for this purpose.

[Hypertensive crisis: definition, pathophysiology and treatment]. / Hypertensieve crisis: definitie, pathofysiologie en behandeling.

Hypertensive crises are currently subdivided into hypertensive emergencies and urgencies depending on the acuteness with which the elevated blood pressure has to be lowered. Malignant hypertension, defined as severe hypertension and a hypertensive fundus grade III or IV, can present itself as an emergency or an urgency. For a hypertensive emergency intravenously acting blood pressure lowering agents are almost always required, whereas an urgency can usually be treated with oral agents. In view of the danger of cerebral hypoperfusion, blood pressure reduction during the initial treatment phase of a hypertensive crisis should not be more than 20 to 25%. Agents that exert a controllable blood pressure lowering action are preferred. Controllable blood pressure lowering cannot be achieved with nifedipine capsules. The practice of biting and swallowing a nifedipine capsule for the treatment of a hypertensive crisis therefore is to be discouraged.

Nifedipine and arotinolol in combination for accelerated-malignant hypertension: results of one year follow-up.

The effects of a combined therapy with a calcium channel antagonist and alphabeta-blocker in patients with accelerated-malignant hypertension on blood pressure and renal function were examined. Thirteen patients presented with the clinical features of malignant hypertension (diastolic blood pressure >130 mmHg, retinal damage and progressive renal failure) at our hospital, over the 3 yr period from 1995 to 1997. These patients were treated with both a calcium antagonist, 60-80 mg/d dose of long acting nifedipine, and an alphabeta-blocker, 20 mg/d dose of arotinolol, for over 12 mo. At admission, the average blood pressure of the patients was 233+/-8/144+/-3 mmHg. The level of serum creatinine in these patients was 6.2+/-1.0 mg/dl. Intermittent hemodialysis therapy was introduced in 7 patients. Three days after treatment, blood pressure decreased to 162+/-4/102+/-4 mmHg. A month later, blood pressure decreased to 148+/-3/89+/-2 mmHg and serum creatinine levels were 3.6+/-0.4 mg/dl. Renal function in these patients improved, and they completely recovered from renal dysfunction, allowing withdrawal of haemodialysis therapy. One year later, the blood pressure in all of these patients was well controlled and no further renal deterioration was observed, except in one patient. Despite the reduction in blood pressure, one patient was on hemodialysis three times a week after 8 mo of treatment. From these finding, it is concluded that combination therapy with a calcium antagonist and alphabeta-blocker is effective in both the reduction of highly elevated blood pressure and protection of the kidneys, resulting in amelioration of accelerated-malignant hypertension.

Effect of coffee and cigarette smoking on the blood pressure of patients with accelerated (malignant) hypertension.

There is a strong association between cigarette smoking and accelerated hypertension. In mild hypertension smoking cigarettes has a distinct pressor effect and caffeine a small but more prolonged pressor action. Coffee and cigarette smoking together have an additive effect on blood pressure (BP). We have examined the interaction of cigarette smoking and drinking coffee on the BP of six patients who presented with accelerated hypertension (mean BP 240/140 mm Hg) and were heavy smokers and caffeine users. After initial control of the BP, the effects of smoking alone, coffee plus smoking, and placebo were examined in a balanced cross-over study. Baseline BP averaged 154/91 mm Hg and remained stable for 90 min after abstention from smoking and caffeine (placebo). Cigarette smoking without caffeine caused a modest rise in BP (mean 9/8 mm Hg), but the combination of coffee plus cigarette smoking caused a progressive increase in BP to an average 21/17 mm Hg (P < 0.05/P < 0.002) higher than placebo values. The effect of coffee was significantly additive to that of smoking alone. Smoking plus coffee ingestion shifted the BP from acceptable (155/94 mm Hg) to poor control (175/107 mm Hg). This pressor effect was observed despite treatment, and with amounts of caffeine and cigarettes which were in no way unusual for these patients. We propose that the association of cigarette smoking with accelerated hypertension may reflect an extreme pressor effect of combined smoking and caffeine use in some patients.

Avanços terapêuticos em cardiologia: parte 3; tratamento atual nas crises hipertensivas / Therapeutics advances in cardiology: part III; up-to-date treatment in hypertensive crises

Os autores mostram a importância da distinçäo nas crises hipertensivas entre emergências e urgências. Nas emergências, como é o caso da encefalopatia, o paciente deve ser hospitalizado e controlado em horas. Os portadores de urgência hipertensiva, como é o caso da hipertensäo maligna, podem ser tratados sem hospitalizaçäo, com controle até certo ponto lento. As drogas mais utilizadas säo o Nitroprussiato de Sódio, a Nifedipina, o Verapamil e o Labetalol. A sua incidência terá reduçäo crescente com o controle e a regularidade na administraçäo de drogas

A case of malignant hypertension and scleroderma after cosmetic surgery.

A 44-year-old woman with scleroderma-like skin lesions and malignant hypertension following mammoplasty is reported. Sclerotic change is an unusual finding for ordinary finding progressive systemic sclerosis. On admission, she had severe high-renin hypertension and progressive renal failure, suggesting scleroderma renal crisis. With intensive treatment for hypertension including angiotensin-converting enzyme inhibitor, the blood pressure was well controlled. It was then suggested that she had malignant hypertension due to scleroderma after silicone injection, or the so-called human adjuvant disease after cosmetic surgery.