Outcomes of laparoscopic adrenalectomy for hyperaldosteronism.

BACKGROUND: Primary hyperaldosteronism is a frequent cause of resistant hypertension and is amenable to surgical intervention when caused by a unilateral aldosterone-producing adenoma. The aim of this study was to investigate the long-term results of laparoscopic adrenalectomy in the control of hypertension caused by primary hyperaldosteronism. METHODS: A prospective case series of patients undergoing laparoscopic adrenalectomy for hyperaldosteronism was studied. Blood pressure (BP), serum aldosterone levels, plasma renin activity, serum potassium and antihypertensive requirement were measured before and after adrenalectomy. RESULTS: Sixty-two patients with hyperaldosteronism underwent laparoscopic adrenalectomy in the period from December 1995 to August 2005. The median follow up was 59 months. There was a significant decrease in both systolic blood pressure and diastolic blood pressure at final follow up compared with that before operation. Systolic blood pressure decreased from 149 mmHg to 129 mmHg at final follow up (P < 0.0001). Diastolic blood pressure decreased from 89 mmHg to 80 mmHg (P < 0.0001). Antihypertensive requirement was decreased from an average of 2.6 separate medications preoperatively to 1.4 medications at final follow up (P < 0.0001). Serum aldosterone levels were significantly lower (698 (confidence interval 534-862) pg/mL vs 181 (confidence interval 139-225) pg/mL, P < 0.0001). Overall, 34% of patients had cure of hypertension and did not require any antihypertensive agent. A further 51% had improvement in BP control, whereas 5% had no change or had worsening hypertension. Multivariate regression analysis showed that age and gland size were independent factors predicting sustained hypertension after surgery. CONCLUSION: In appropriately selected patients with primary hyperaldosteronism, laparoscopic adrenalectomy is effective in improving long-term BP control. Larger adrenal gland size and older age at time of surgery are predictors of persisting hypertension.

Relationship between orthostatic hypotension and cognitive impairment in the elderly.

BACKGROUND AND PURPOSE: To determine the relationship between orthostatic hypotension (OH) and cognitive function in elderly subjects with memory complaints. METHODS: We studied the association between cognitive function and OH in 495 consecutive elderly outpatients attending a memory centre. Blood pressure (BP) was measured in a sitting and standing position. We examined cognitive function using a validated comprehensive battery of neuropsychological tests, the cognitive efficiency profile (CEP) assessing the main cognitive areas. Subjects were classified into 4 categories according to their cognitive status: normal cognitive function, mild cognitive impairment (MCI), Alzheimer's disease (AD) or vascular dementia (VaD). RESULTS: In this population, 76±8 years of age (women 72%), 18% had normal cognitive function, 28% had MCI, 47% AD, and 7% VaD. Hypertension was observed in 74% of patients. OH was present in 14% of subjects (n=69). After adjustment for age, education level, systolic BP, diastolic BP, weight, and antihypertensive drugs, subjects with OH had worse cognitive function than those without OH (CEP score 50±24 vs 56±22, p<0.05). Moreover, a significant relationship was observed between OH and cognitive status (normal cognitive function, MCI, AD, or VaD). OH was present in 22% in VaD subjects, 15% in AD subjects, 12% in MCI subjects and 4% in normal control subjects (p<0.01 for overall test). CONCLUSION: Our results showed an association between OH and cognitive impairment and emphasize the need for longitudinal studies designed to evaluate the nature of the relationship between OH and cognitive decline.

Definition of ambulatory blood pressure targets for diagnosis and treatment of hypertension in relation to clinic blood pressure: prospective cohort study.

BACKGROUND: Twenty-four hour ambulatory blood pressure thresholds have been defined for the diagnosis of mild hypertension but not for its treatment or for other blood pressure thresholds used in the diagnosis of moderate to severe hypertension. We aimed to derive age and sex related ambulatory blood pressure equivalents to clinic blood pressure thresholds for diagnosis and treatment of hypertension. METHODS: We collated 24 hour ambulatory blood pressure data, recorded with validated devices, from 11 centres across six Australian states (n=8575). We used least product regression to assess the relation between these measurements and clinic blood pressure measured by trained staff and in a smaller cohort by doctors (n=1693). RESULTS: Mean age of participants was 56 years (SD 15) with mean body mass index 28.9 (5.5) and mean clinic systolic/diastolic blood pressure 142/82 mm Hg (19/12); 4626 (54%) were women. Average clinic measurements by trained staff were 6/3 mm Hg higher than daytime ambulatory blood pressure and 10/5 mm Hg higher than 24 hour blood pressure, but 9/7 mm Hg lower than clinic values measured by doctors. Daytime ambulatory equivalents derived from trained staff clinic measurements were 4/3 mm Hg less than the 140/90 mm Hg clinic threshold (lower limit of grade 1 hypertension), 2/2 mm Hg less than the 130/80 mm Hg threshold (target upper limit for patients with associated conditions), and 1/1 mm Hg less than the 125/75 mm Hg threshold. Equivalents were 1/2 mm Hg lower for women and 3/1 mm Hg lower in older people compared with the combined group. CONCLUSIONS: Our study provides daytime ambulatory blood pressure thresholds that are slightly lower than equivalent clinic values. Clinic blood pressure measurements taken by doctors were considerably higher than those taken by trained staff and therefore gave inappropriate estimates of ambulatory thresholds. These results provide a framework for the diagnosis and management of hypertension using ambulatory blood pressure values.