Hypertension in Pregnancy: A Diagnostic and Therapeutic Overview.

Hypertensive disorders in pregnancy are associated with increased risk of maternal, fetal, and neonatal morbidity and mortality. It is important to distinguish between pre-existing (chronic) hypertension and gestational hypertension, developing after 20 weeks of gestation and usually resolving within 6 weeks postpartum. There is a consensus that systolic blood pressure ≥ 170 or diastolic blood pressure ≥ 110 mmHg is an emergency and hospitalization is indicated. The selection of the antihypertensive drug and its route of administration depend on the expected time of delivery. The current European guidelines recommend initiating drug treatment in pregnant women with persistent elevation of blood pressure ≥ 150/95 mmHg and at values > 140/90 mmHg in women with gestational hypertension (with or without proteinuria), with pre-existing hypertension with the superimposition of gestational hypertension, and with hypertension with subclinical organ damage or symptoms at any time during pregnancy. Methyldopa, labetalol, and calcium antagonists (the most data are available for nifedipine) are the drugs of choice. The results of the CHIPS and CHAP studies are likely to reduce the threshold for initiating treatment. Women with a history of hypertensive disorders in pregnancy, particularly those with pre-eclampsia, are at high risk of developing cardiovascular disease later in life. Obstetric history should become a part of the cardiovascular risk assessment in women.

Hot-Melt Extrusion of the Thermo-Sensitive Peptidomimetic Drug Enalapril Maleate.

The aim of this research was the production of extrudates for the treatment of hypertension and heart failure and the investigation of the degradation of the peptidomimetic drug enalapril maleate (EM) during hot-melt extrusion (HME). A fast HPLC method was developed to quantify enalapril maleate and possible degradation products. Screening experiments revealed that the diketopiperazine derivative (Impurity D) was the main degradation product. Hot-melt extrusion of enalapril maleate with the polymer Soluplus® enabled extrusion at 100 °C, whereas a formulation with the polymer Eudragit® E PO could be extruded at only 70 °C. Extrusion at 70 °C prevented thermal degradation. A stabilizing molecular interaction between enalapril maleate and Eudragit® E PO was identified via FT-IR spectroscopy. Dissolution studies were carried out to study the influence of the formulation on the dissolution behavior of enalapril maleate. These promising results can be transferred to other thermo-sensitive and peptidomimetic drugs to produce extrudates which can be used, for instance, as feedstock material for the production of patient-specific dosage forms via Fused Deposition Modeling (FDM) 3D printing.

Superior antihypertensive and cardioprotective effects of chlorthalidone compared with hydrochlorothiazide.

Diuretics are the most commonly used drugs for the treatment of hypertension, either alone or in combination with other antihypertensive drugs. Of all diuretics, hydrochlorothiazide (HCTZ) and chlorthalidone (CTD) are the most commonly used, with HCTZ being the most widely prescribed diuretic. Recent studies have shown that CTD is a better diuretic with superior antihypertensive effectiveness and cardiovascular protection. Although these diuretics are chemically, pharmacokinetically and pharmacodynamically different, CTD continues to be called a "thiazide-like" diuretic. The only common features they both share are a sulfhydryl group in their molecules and their common mechanism and site of diuretic action. In order to get a better understanding of the true pharmacologic actions as well as the benefits and risks of these diuretics, a MEDLINE search of the English language literature between 1964 and January 2021 was conducted, using the terms "diuretics", "hydrochlorothiazide", "chlorthalidone", "hypertension", "cardiovascular disease" and "treatment". From this search, 28 pertinent papers were selected and they will be discussed in this review together with collateral literature. The analysis of results revealed that CTD is superior to HCTZ in antihypertensive effectiveness and cardioprotection and should be the preferred diuretic for the treatment of hypertension.

Alexithymia: A facet of uncontrolled hypertension.

INTRODUCTION: Proper control of blood pressure reduces the risk of developing cardiovascular and cerebrovascular complications in hypertensive people. However, this control remains mostly unsatisfactory. Although alexithymia has been associated with essential hypertension, no study has analysed the relationship between alexithymia and blood pressure control in drug-treated hypertension. This research aimed to analyse the presence and the characteristics of this relationship, considering both the pharmacological treatment and the achievement of adequate maintenance of blood pressure in a physiological range. METHOD: One thousand two hundred and forty-one people participated in the study. Eight hundred and ten were hypertensive patients, and four hundred and thirty-one were normotensive people. The Toronto Alexithymia Scale-20 was used to assess alexithymia. RESULTS: Results show that hypertensive people are more alexithymic than normotensive people. According to the presence of pharmacological treatment, treated hypertensive patients are more alexithymic than normotensive and not treated hypertensive patients. Considering the blood pressure control associated with the drug-therapy, people with uncontrolled hypertension are more alexithymic than normotensive and untreated hypertensive people. CONCLUSIONS: These findings confirm a relationship between alexithymia and essential arterial hypertension, but they also highlight that alexithymia appears to be associated with higher severity of hypertension. Alexithymia could be a facet of uncontrolled hypertension.

Treatment and Prevention of Hypertensive Disorders During Pregnancy.

This article reviews the pharmacology of the most commonly used antihypertensive medications during pregnancy; their mechanism of action; and the effects on the mother, the fetus, and lactation. Each class of antihypertensive pharmacologic agents have specific mechanisms of action by which they exert their antihypertensive effect. ß-Adrenoreceptor antagonists block these receptors in the peripheral circulation. Calcium channel blockers result in arterial vasodilation. α-Agonists inhibit vasoconstriction. Methyldopa is a centrally acting adrenoreceptor antagonist. Vasodilators have a direct effect on vascular smooth muscle. Diuretics decrease intravascular volume. Medications acting on the angiotensin pathway are avoided during pregnancy because of fetotoxic effects.

Prevalence, awareness, treatment and control of hypertension in the adult Polish population - Multi-center National Population Health Examination Surveys - WOBASZ studies.

INTRODUCTION: Hypertension is one of the main risk factors of cardiovascular diseases. The first aim of the study was to evaluate the prevalence, awareness and treatment of hypertension as well as treatment effectiveness (blood pressure < 140/90 mm Hg) in a representative sample of the Polish population over the age of 19, examined in the WOBASZ II program. The second aim was to assess the changes in these parameters between 2003-2005 (WOBASZ study) and 2013-2014 in adults aged 20-74. MATERIAL AND METHODS: Sampling was performed in three stages, stratified according to voivodeship (province), type of commune, and gender. Finally, the study included 6163 persons (3406 women and 2757 men) examined in the years 2013-2014 (aged ≥ 19 years). For comparison the data from 14 755 persons (7783 women and 6452 men aged 20-74 years) examined in the years 2003-2005 were used. RESULTS: In the years 2013-2014, the age-standardized prevalence of hypertension, awareness, treatment and control was 42.7%, 59.3%, 46.1%, and 23% respectively. In the last decade an increase in the prevalence of hypertension (relative ratio (RR) 1.12; 95% confidence interval (CI): 1.07-1.18), treatment (RR = 1.26; 95% CI: 1.17-1.36) and control (RR = 2.16; 95% CI: 1.9-12.45) was found. In contrast, the awareness decreased nonsignificantly (RR = 0.98; 95% CI: 0.92-1.05). CONCLUSIONS: The prevalence of hypertension in Poland is high, and increased by about 12% in 10 years. Although the number of treated patients and blood pressure control improved nearly twofold over the last decade, this is still below expectations. Efforts to improve the diagnosis and effective treatment of hypertension in Poland should still be intensified.

Patient-Centered Approach for Hypertension Management in End-Stage Kidney Disease: Art or Science?

Hypertension is present in most patients with end-stage kidney disease initiating dialysis and management of hypertension is a routine but challenging task in everyday dialysis care. End-stage kidney disease patients are uniquely heterogeneous individuals with significant variations in demographic characteristics, functional capacity, and presence of concomitant comorbid conditions and their severity. Therefore, these patients require personalized approaches in addressing not only hypertension but related illnesses, while also accounting for overall prognosis and projected longevity. There are only limited clinical trial data to guide individualized blood pressure management and current guidelines are based predominantly on observational evidence and expert opinions. Inthis review, we reflect on the shortcomings of peridialytic blood pressure recordings and discuss an important paradigm shift toward using out-of-dialysis blood pressure for evaluating hypertension control and for making treatment decisions. In addition, we provide our personal view on blood pressure goals and summarize nonpharmacologic and pharmacologic treatment options for individualized management of hypertension in end-stage kidney disease.

Trends in hypertension prevalence, awareness, treatment, and control among Polish adults 75 years and older during 2007-2014.

BACKGROUND: The aim of this study was to assess changes in the prevalence, awareness, and treatment of hypertension and its effectiveness between 2007 (WOBASZ Senior study) and 2013-2014 (WOBASZ II) in a sample of the Polish population over the age of 75 years. METHODS: Sampling had three stages, stratified according to voivodeships, type of community, and gen-der. Finally, the WOBASZ II study included 467 persons (290 women and 177 men). For a comparison of the data, 1096 persons (538 women and 554 men) examined in the WOBASZ Senior study were used. RESULTS: Systolic and diastolic blood pressures significantly decreased from 153.0 ± 23.9 mmHg to 142.9 ± 22.3 mmHg and from 85.2 ± 11.9 mmHg to 78.4 ± 11.3 mmHg, respectively, from 2007 to 2014 (p < 0.0001). Prevalence of hypertension among people included in WOBASZ studies slightly decreased from 83.8% to 77.9% (rate ratio [RR]: 0.95; 95% confidence interval [CI]: 0.78-1.16) in men, and from 75.4% to 71.8% (RR: 0.93; 95% CI: 0.8-1.09) in women. Hypertension awareness was improved from 59.2% to 72.9% (RR: 1.23; 95% CI: 0.97-1.56) in men, and from 74,8% to 93% (RR: 1.26; 95% CI: 1.01-1.58) in women. The proportion of men and women, with implemented hypertension treatment, increased from 48.4% to 61.1% (RR: 1.26; 95% CI: 1.01-1.58), and from 63.2% to 82.0% (RR: 1.3; 95% CI: 1.1-1.53), respectively. The effectiveness of the treatment was improved over two-fold, there was an increase from 10.3% to 26.8% (RR: 2.65; 95% CI: 1.81-3.89) in men, and from 13.8% to 33.5% in women (RR: 2.44; 95% CI: 1.81-3.3). CONCLUSIONS: The prevalence of hypertension in Polish seniors remains high, but has decreased slightly in the perspective of the last 7 years. Although treatment and control has improved over the last decade, it remains below expectations. Efforts to improve the diagnosis and effective treatment of hypertension in Polish seniors should be intensified.

Arterial hypertension in the elderly.

Hypertension is one of the most common problems at higher age and belongs to the most important cardiovascular risk factors. Subjects aged 65 years and more have typically isolated systolic hypertension with increased pulse pressure as a consequence of decreased elasticity of central arteries. With increasing age, the prevalence of cardiovascular/ renal diseases and diabetes is higher. Therefore, we use drugs that have cardiprotective effect and do not affect negatively concomitant diseases. Diuretics have the largest data from prospective studies, calcium channels blockers are suitable especially in isolated systolic hypertension, and ACE inhibitors tested in high-risk hypertensive patients, especially after stroke. The HYVET study showed that the risk of cardiovascular events and of heart failure is decreased with antihypertensive troroeatment also in subjects aged 80 years and more. Key words: hypertension in the elderly - isolated systolic hypertension - pulse pressure - treatment of hypertension.

AT2 Receptors: Potential Therapeutic Targets for Hypertension.

The renin-angiotensin system (RAS) is arguably the most important and best studied hormonal system in the control of blood pressure (BP) and the pathogenesis of hypertension. The RAS features its main effector angiotensin II (Ang II) acting via its 2 major receptors, angiotensin type-1(AT1R) and type-2 (AT2R). In general, AT2Rs oppose the detrimental actions of Ang II via AT1Rs. AT2R activation induces vasodilation and natriuresis, but its effects to lower BP in hypertension have not been as clear as anticipated. Recent studies, however, have demonstrated that acute and chronic AT2R stimulation can induce natriuresis and lower BP in the Ang II infusion model of experimental hypertension. AT2R activation induces receptor recruitment from intracellular sites to the apical plasma membranes of renal proximal tubule cells via a bradykinin, nitric oxide, and cyclic guanosine 3',5' monophosphate signaling pathway that results in internalization and inactivation of sodium (Na+) transporters Na+-H+ exchanger-3 and Na+/K+ATPase. These responses do not require the presence of concurrent AT1R blockade and are effective both in the prevention and reversal of hypertension. This review will address the role of AT2Rs in the control of BP and Na+ excretion and the case for these receptors as potential therapeutic targets for hypertension in humans.

Hypertension in Athletes and Active Populations.

Hypertension continues to be the most common cardiovascular disorder in the USA and worldwide. While generally considered a disorder of aging individuals, hypertension is more prevalent in athletes and the active population than is generally appreciated. The timely detection, diagnosis, and appropriate treatment of hypertension in athletes must focus on both adequately managing the disorder and ensuring safe participation in sport while not compromising exercise capacity. This publication focuses on appropriately diagnosing hypertension, treating hypertension in the athletic population, and suggesting follow-up and participation guidelines for athletes.

[New Aspects and Controversies in the Current European and American Hypertension Guidelines]. / Die aktuellen europäischen und amerikanischen Hypertonie-Leitlinien.

At the end of 2013, the long-awaited guidelines of the Eighth Joint National Committee (JNC8) were published. These guidelines developed nine specific recommendations for the management of arterial hypertension. The harmonization of blood pressure treatment thresholds and goals represents a convenient simplification for the practicing physician. However, the recommendations did not come without controversy. Especially the raise of the treatment goal in patients aged 60 years or older was criticized. In this and other aspects, the 2013 guidelines of the European Society of Cardiology and European Society of Hypertension (ESC/ESH 2013) share a different point of view. The article tries to summarize the different viewpoints and to provide an overview over the increasing number of hypertension guidelines.

Practical use of home blood pressure monitoring in chronic kidney disease.

Despite the availability of blood pressure (BP)-lowering medications and dietary education, hypertension is still poorly controlled in the chronic kidney disease (CKD) population. As glomerular filtration rate declines, the number of medications required to achieve BP targets increases, which may lead to reduced patient adherence and therapeutic inertia by the clinician. Home BP monitoring (HBPM) has emerged as a means of improving diagnostic accuracy, risk stratification, patient adherence, and therapeutic intervention. The definition of hypertension by HBPM is an average BP >135/85 mm Hg. Twelve readings over the course of 3-5 days are sufficient for clinical decision making. Diagnostic accuracy is especially important in the CKD population as approximately half of these patients have either white coat hypertension or masked hypertension. Preliminary data suggest that HBPM outperforms office BP monitoring in predicting progression to end-stage renal disease or death. When combined with additional support such as telemonitoring, medication titration, or behavioral therapy, HBPM results in a sustained improvement in BP control. HBPM must be adapted to provide information on the phenomena of nondipping (absence of nocturnal fall in BP) and reverse dipping (paradoxical increase in BP at night). These diurnal patterns are more prevalent in the CKD population and are important cardiovascular risk factors. Ambulatory BP monitoring provides nocturnal BP readings and unlike HBPM may be reimbursed by Medicare when certain criteria are met. Further studies are needed to determine whether HBPM is cost-effective in the current US healthcare system.

Temporal trends in management of hypertension among Israeli adults, 2002-2010: lesson from the Acute Coronary Syndromes Israeli Survey (ACSIS).

Our aim was to evaluate trends in blood pressure (BP) management and BP levels among patients admitted with acute coronary syndromes (ACS) over the past decade. The study population comprised 7658 ACS patients enrolled in the Acute Coronary Syndromes Israeli Survey (ACSIS) between 2002 and 2010. We compared patients' characteristics, admission systolic BP levels, and antihypertensive therapy between those hospitalized during the early (years: 2002-2004) and late (years: 2008-2010) periods. Among 7658 study participants, 4421 (58%) were hypertensive. Hypertensive patients presenting from 2008 to 2010 tended to exhibit lower BP levels (P < .001). The use of angiotensin converting enzyme inhibitors (ACEi)/angiotensin receptor blockers (ARB) and beta-blockers has increased over the years (P < .001 for both), whereas the use of diuretics and calcium antagonists has remained stable (P = .77 for both). The use of diuretics tended to increase in hypertensive subjects without prior cardiovascular disease (P = .05). In addition, the late period was characterized by a significant increase in the use of two or more antihypertensive agents (combination therapy) compared with the early period (57% vs 50%; P < .001). BP levels decreased among Israeli hypertensive patients presenting with ACS between 2002 and 2010, possibly due to increased use of ACEi/ARB, and combination therapies during this time period.

Hipertensão arterial sistêmica / Systemic arterial hypertension

A hipertensão tem alta prevalência e é importante fator de risco cardiovascular. De fácil diagnóstico e tratamento, mas com poucos pacientes controlados. Após diagnosticada, a estratificação do risco cardiovascular associado vai indicar qual a melhor conduta terapêutica. O tratamento consiste em mudança do estilo de vida (restrição ao sal, manutenção do peso ideal, atividade física regular, maior ingestão de frutas, verduras e cereais e moderação na ingestão álcool). Caso necessário, será também iniciado o tratamento medicamentoso com qualquer uma das cinco classes de anti-hipertensivos disponíveis (diuréticos, beta-bloqueadores, antagonistas dos canais de cálcio, inibidores da enzima conversora da angiotensina ou bloqueadores dos receptores AT1 de angiotensina II). Os benefícios dependem mais do controle efetivo da pressão que do tipo de fármaco utilizado. Para que sejam alcançadas as metas de controle da pressão há a necessidade de atenção especial com a adesão ao tratamento que representa um grande desafio.

Desmitificando o uso de betabloqueadores no tratamento da hipertensão arterial sistêmica / Demystifying the use of beta-blockers in the treatment of systemic hypertension

O uso de betabloqueadores (BBs) no tratamento da hipertensão arterial (HAS) tem sofrido diversas mitificações quanto ao seu real benefício. Quatro principais pontos têm sido divulgados como "verdades": os BBs são considerados pelas diretrizes como fármacos de quarta linha; teriam uma ação hipotensora fraca em relação aos outros fármacos; trariam poucos benefícios na prática clínica sobre o prognóstico evolutivo de pacientes com HAS; e são de difícil manuseio, por apresentarem uma série de paraefeitos. Os BBs apresentam um importante papel no controle da HAS, com benefícios clínicos bem demonstrados e com paraefeitos facilmente evitáveis através do conhecimento do seu comportamento farmacológico

The use of beta-blockers (BBs) in the treatment of hypertension (HTN) has undergone several mystification regarding its real benefit. Four main points have been discloses as "truths": the BBs are considered as drugs by the guidelines of the fourth line; would have a weak hypotensive action in relation to other drugs; would bring little benefit in clinical practice on the prognostic evaluation of patients with hypertension; and are difficult to handle because they present a series of side-effects. BBs have an important role in the control of hypertension, with clinical benefits demonstrated and well side-effects easily preventable through knowledge of their pharmacological behavior

Adherencia a los tratamientos farmacológicos y no farmacológicos en personas con hipertensión arterial. Montería, 2010 / Adherence to pharmacological and non-pharmacological treatments in people with arterial hypertension. Monteria, 2010

El presente estudio tuvo como objetivo describir y analizar la adherencia a tratamientos farmacológicos y no farmacológicos en personas con hipertensión arterial, inscritas en el Programa de Control de una Empresa Social del Estado de baja complejidad en la ciudad de Montería. Se utilizó un diseño descriptivo transversal con abordaje cuantitativo que permitió describir la adherencia al tratamiento en una muestra aleatoria de 177 personas que asistieron al servicio de consulta externa a control de la hipertensión arterial, mediante el empleo del Instrumento Factores que influyen en la adherencia a tratamientos farmacológicos y no farmacológicos en pacientes con factores de riesgo de enfermedad cardiovascular de Bonilla y De Reales. Los resultados del estudio revelan que la mayor proporción de las personas que participaron en el estudio se encontraron en riesgo de no desarrollar comportamientos de adherencia al tratamiento farmacológico y no farmacológico, lo cual guarda relación con los factores socioeconómicos y relacionados con el proveedor. Los factores relacionados con la terapia y con el paciente reflejaron una situación de ventaja para la adherencia. La relación entre los 24 ítems del instrumento utilizado y la situación adherencia encontrada es lineal y en general la relación es fuerte con tendencia positiva. Se recomienda a los profesionales de enfermería continuar realizando investigaciones sobre el fenómeno de la adherencia al tratamiento en personas con riesgo cardiovascular con el propósito de contribuir al desarrollo disciplinar y por ende mejorar las prácticas de cuidado como un aporte a la solución del problema de altos índices de morbimortalidad por enfermedades cardiovasculares.

This study has as an aim to describe and analyze the adherence to nonpharmacological and pharmacological treatment on people with arterial hypertension, registered in the control program of a state social enterprise of low complexity at Monteria city. It was used a cross sectional descriptive design with quantitative approach that allowed to describe the adherence to the treatment in a randomize sample of 117 people that attended the outpatient service to arterial hypertension control, through the using the instrumental factors that has influence in the adherence of nonpharmacolocical and pharmacological treatment on patients with risk factors of cardiovascular illness of Bonilla and De Reales. The outcomes of the study disclose that in an upper proportion of people who participate in the research were found on risk of not developing behaviors of adherence to the nonpharmacological and pharmacological treatment, which keeps relation with socioeconomic factors and related with the supplier. The factors related to the therapy and with the patient, showed a situation of advantage for the adherence. The relationship between the 24 items of the used instrument and the adherence situation founded is lineal and in general the relationship is strong and with positive trend. It is recommended for the nursery professionals to continue doing researches about the phenomenon of treatment adherence on people with cardiovascular risk with the aim of contributing to the disciplinary development and therefore improving the practices of care as a contributing to the solution for the problem of high mortality index due to cardiovascular illness. The present study aimed to describe and analyze adherence to pharmacologic and non pharmacologic treatments in people with hypertension, enrolled in a control program of the State Social Enterprise of low complexity for the city of Montería.

Tratamento da hipertensäo arterial sistêmica com urapidil: estudo na hipertensäo leve e moderada com monitorizaçäo ambulatorial da pressäo arterial / Treatment of Arterial Hypertension with Urapidil. Study in Mild and Moderate Hypertension with Ambulotory Blood Pressure Monitoring

Objetivo - Estudar a eficácia e tolerabilidade de urapidil em pacientes portadores de hipertensäo arterial leve a moderada, com monitorizaçäo ambulatorial da pressäo arterial (MAPA). Métodos - Foram estudados 20 pacientes de ambulatório, com idades de 40 a 75 anos, ambos os sexos, com pressäo arterial diastólica (PAD) entre 90 a 115mmHg. Utilizou-se a PAD como critério de seguimento, medida com esfigmomanômetro de mercúrio; realizou-se a MAPA de 24h para observaçäo do comportamento pressórico no período. Após 15 dias de wash out foi administrado urapidil por via oral, iniciando com 60mg/dia, aumentando para 120mg/dia e, posteriormente, para 180mg/dia, durante 2 semanas para se obter o nível de controle desejado de PAD menor ou igual a 90mmHg, seguindo-se tratamento de mais 8 semanas. Realizaram-se exames laboratoriais, ECG, MAPA e avaliaçäo clínica no pré e pós-tratamento, com observaçöes clínicas a cada duas semanas. Resultados - Em 15 pacientes (75//) obteve-se o controle da PA segundo os critérios do protocolo (p < 0,001). Ocorreu diminuiçäo significativa da PAS e PAD em 90// dos pacientes. Dos 5 restantes (25//), em 3(15//) näo se obteve o controle da PA e em 2// (10//) o tratamento foi interrompido por efeitos colaterais näo controlados. Os efeitos colaterais masi freqüentes foram a tontura, mal-estar, náuseas mas 60// dos pacientes näo os apresentaram. A duraçäo dos efeitos colaterais, exceto em um paciente, näo ultrapassou os 30 dias. Näo foram observadas alteraçöes significantes nos exames laboratoriais, quando comparadas as fases de pré e pós-tratamento. A MAPA mostrou melhora do comportamento da hipertensäo, com manutençäo do ritmo circadiano da pressäo arterial. Conclusäo - O urapidil mostrou ser um anti-hipertensivo eficaz no tratmento de pacientes com hipertensäo arterial leve e moderada, com aceitável controle dos níveis pressáricos e sem alterar os parâmetros loboratoriais avaliados