Hypertension Alternative Treatments

Hypertension Exercise Program

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Hypertension Exercise Program Summary


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Hypertension Introduction

Hypertension in children is reflected by the consistent readings of the systolic and or diastolic blood pressure at the level of or above the 95th percentile for age and sex. It may be primary or secondary. Fifty to 80 of secondary hypertension is caused by renal parenchymal disease therefore, infants and children with hypertension and adolescents with severe hypertension need to be evaluated for renal pathology. Hypertension in children is of particular concern because of its close association with adult hypertension. Children with increased blood pressure usually do not display any overt symptoms. Blood pressure determinations are a part of routine examination in children 3 years and older. Children under 3 who have been diagnosed with a heart condition are also screened for hypertension.

Antihypertensive Agents

Recently, losartan and olmesartan, antihypertensive drugs known to act through angiotensin receptor inhibition, have been shown to decrease AGE formation (191). Hydralazine, another antihypertensive agent whose effect does not involve the renin-angiotensin system, has AGE-inhibitory effects similar to those of low-dose olmesartan (192). The renoprotective effects shown by these drugs suggest that they derive not only from the drugs effect on lowering blood pressure and blocking angiotensin but also from reduced AGE formation (193).

DRG Category 134 Mean LOS 35 days Description Medical Hypertension

I I ypertension is a persistent or intermittent elevation of systolic arterial blood pressure above 140 mm Hg or diastolic pressure above 90 mm Hg. Normal blood pressure is considered a systolic pressure lower than 120 mm Hg and a diastolic pressure lower than 80 mm Hg. Prehyper-tension is considered a systolic pressure of 120 to 139 mm Hg and a diastolic pressure of 80 to 89 mm Hg. Stage 1 hypotension is considered a systolic pressure of 140 to 159 mm Hg and a diastolic pressure of 90 to 99 mm Hg. Stage 2 hypertension is considered a systolic pressure of more than 160 mm Hg and a diastolic pressure equal to or more than 100 mm Hg. Over 60 million Americans have hypertension, which results in significant economic and personal costs, including disability and an increased mortality rate. There has been a growing awareness of the long-term health consequences of hypertension in the last 4 decades. Between 1960 to the present, the awareness of hypertension increased from 53 to almost 90 ....

Diuretic Use In Essential Hypertension During Pregnancy

Hypertension in pregnancy represents a risk factor to the mother and fetus even in the absence of preeclampsia. Women with essential hypertension should continue taking their usual anti-hypertensive medications, including diuretics, during pregnancy. Angiotensin converting enzyme inhibitors are an exception and are contraindicated in pregnancy. In one study of women with essential hypertension, diuretics were stopped and the results compared to women who continued diuretic use throughout pregnancy. There was no difference in fetal survival or birth weight, although maternal plasma volume was found to increase only 18 in the diuretic-treated group compared with 36 in those in whom diuretic use was stopped 14 . In another study of pregnant women with severe essential hypertension, all anti-hypertensives, including diuretics, were stopped and only methyldopa given throughout pregnancy. Half of the women developed preeclampsia with reduction in renal function, one developed malignant...

The Nature Of Hypertension

Hypertension is a raised systemic arterial blood pressure (BP). However, BP is a continuously distributed variable and the numerical boundary between nor-motension and hypertension is arbitrary and is based on the increasing cardiovascular risk, in particular stroke, as BP rises (Fig. 1) 7 . A WHO-based classification of hypertension is shown in Table 1. Considering end-point trials of cardiovascular risk (more specifically, stroke), it is now widely accepted that maintaining BP below 140 90 mm Hg is beneficial and that a BP of > 140 90 mm Hg is therefore considered abnormal 10 . However, the level at which pharmacological treatment is used differs between Europe and North America. In North America patients with a diastolic BP of 85 mm Hg or greater are more likely to be given drug treatment to lower BP, but in Europe the criterion for starting antihypertensive drug therapy is approximately 10 mm Hg higher. An isolated numerical definition of hypertension of 140 90 mm Hg or more...

Mechanisms Of Hypertension

Siderable variation in sodium intake and level of BP. There is some evidence that subjects can be divided according to their BP response to sodium into those who are sodium-sensitive and those who are not. Thus, abnormal handling of sodium may be a factor in the etiology of hypertension in salt-sensitive individuals in terms of both enhanced renal absorption and vascular effects through impaired Na+ K+ ATPase activity. Inhibition of Na+ K+ ATPase by an endogenous digitalis-like factor in response to sodium-induced ECV expansion leads to an increase in cytosolic calcium in vascular smooth muscle, vasoconstriction, and increased peripheral vascular resistance (see Fig. 5) 2 . Patients with low plasma renin2 activity (blacks and elderly hypertensives) tend to be sodium-sensitive and their BP responds better to dietary sodium restriction 14 . The anion accompanying sodium may be critical in salt-induced hypertension. Studies in animals and humans have shown that salt-sensitive...

Treatment Of Hypertension

The goals of treatment are to reduce BP and the risk of cardiovascular events, but to minimize adverse effects and facilitate patient compliance. Treatment can be divided into nonpharmacological and pharmacological 11 . Both forms of therapy rely heavily on patient education and good communication between doctor and patient. Nonpharmacological measures have the advantages of minimal cost and lack of side-effects, although compliance is not necessarily better. Current generally agreed-upon recommendations are 11 (i) appropriate weight loss (ii) no tobacco and limited alcohol consumption (iii) regular moderate exercise (iv) modest sodium restriction (no added salt) (v) diet low in animal fat and high in vegetable fiber. More controversial advice includes dietary potassium, calcium and fish oil supplementation, and reduced stress and caffeine intake. If these recommendations are followed, a significant number of patients with mild hypertension can avoid drug therapy. Even if drug...

Use of Diuretics in the Treatment of Hypertension in Renal Impairment

Hypertension is a consequence of renal impairment and if untreated accelerates the decline in renal function to end-stage renal failure. Moreover, hyperlipidemia and glucose intolerance are more common in chronic renal failure, and cardiovascular morbidity and mortality are significantly increased, particularly in patients on dialysis in whom BP control is often difficult. The major cause of hypertension in renal failure is sodium retention and ECV expansion, so-called volume-dependent hypertension. Additional factors may include increased sympathetic nerve acuity, hyperparathyroidism, hypothyroidism, increased and decreased production and or action of endogenous vasoconstrictors (e.g., angiotensin II, endothelin, nitric oxide inhibitors), and vasodilators (e.g., prosta- cyclin and nitric oxide), respectively. Diuretics should be useful in this setting when there is still residual kidney function, but thiazide diuretics are usually ineffective when glomerular filtration rate is much...

Use of Diuretics in the Treatment of Hypertension in Pregnancy

Hypertension in pregnancy can be broadly divided into preexisting hypertension (chronic hypertension), hypertension of pregnancy (usually appearing within the first trimester, but can develop at any time) and preeclampsia eclampsia (occurring in the third trimester). Preeclampsia is characterized by hypertension, proteinuria, edema, and hyperuricemia, with or without associated liver dysfunction and coagulopathy (HELLP syndrome hemolysis, elevated liver enzymes, and low platelets). Eclampsia is diagnosed when hypertension is severe and convulsions occur. An early indication of developing hypertension in pregnancy is failure to observe the normal fall in BP during the first trimester. Patients with preexisting hypertension and hypertension of pregnancy are at increased risk of developing preeclampsia. While there is some debate about diuretic treatment of hypertension in pregnancy, because the plasma volume in pregnant women with hypertension is reduced compared with normotensive...

Management of Hypertension

Hypertension in chronic renal insufficiency has been shown to respond to treatment with loop diuretics, either given alone or in combination with thiazide diuretics. A number of authors report success with the combined use of furosemide and hydrochlorothiazide 3 ormetolazone 32 . Whether these agents exert their hypotensive effect exclusively by inducing natriuresis and are thereby useful in patients with advanced renal failure and in patients undergoing dialysis is a matter of controversy. Several investigators have found indapamide effective in lowering blood pressure in patients with chronic renal failure and in patients undergoing dialysis 1, 24 . These effects were thought to be mediated by reduction of the pressor response to norepinephrine and angiotensin II 24 . Others, however, using hydrochlorothiazide or metolazone in patients undergoing maintenance hemodialysis, affirm that a functioning kidney with the ability to respond to diuretics with a natriuresis is necessary for...

Chronic Thromboembolic Pulmonary Hypertension And Other Pulmonary Hypertension

Chronic pulmonary hypertension occurs in about 5 of patients within 2 yr following the first PE. The pulmonary vascular tree is a unique high flow, low pressure system (normal systolic diastolic pressures 25 10 mmHg mean 15 mmHg), but a number of pathological states, including PE, can trigger a vicious cycle of structural changes within the pulmonary vasculature, resulting in chronic pulmonary hypertension. Chronic or recurrent PE can progressively obstruct the pulmonary vasculature, leading to clinical features of chronic pulmonary hypertension accompanied by signs of chronic cor pulmonale. Chronic thromboembolic pulmonary hypertension is present when the systolic and mean pulmonary artery pressures exceed 40 and 25 mmHg, respectively. Pulmonary hypertension of various etiologies (Table 2) can be categorized as mild, moderate, or severe based on PASPs measuring 40-45 mmHg, 46-60 mmHg, or more than 60 mmHg, respectively. Pulmonary hypertension is most reliably quantified by spectral...

Ejection Sound in Pulmonary Hypertension

Phonocardiogram Trace

Why is an ejection sound heard in pulmonary hypertension This high-frequency phonocardiogram and simultaneous carotid tracing is from a patient with severe pulmonary hypertension secondary to a VSD (Eisenmenger syndrome). Note that the pulmonary ejection (E J) sound does not diminish with inspiration. This high-frequency phonocardiogram and simultaneous carotid tracing is from a patient with severe pulmonary hypertension secondary to a VSD (Eisenmenger syndrome). Note that the pulmonary ejection (E J) sound does not diminish with inspiration. 2. How does an ejection sound heard in pulmonary hypertension differ from one heard in PS ANS In pulmonary hypertension the ejection sound is

Treatment Of Nocturnal Hypertension

Normal subjects have a diurnal variation in BP, with lower nocturnal BP. Patients with neurogenic OH have nocturnal hypertension. To minimize the problems of nocturnal hypertension, pressor medications should not be taken after 6 pm. The head of the bed should be elevated, resulting in lower intracranial BP. A nighttime snack with a glass of fluids (not coffee or tea) results in some postprandial hypotension, and can be used to increase fluid intake and decrease nocturnal hypertension. Patients who enjoy a glass of wine should drink it at this time for its vasodilator effect. Occasionally, it is not possible to control OH without marked nocturnal hypertension. For these patients, hydralazine (Apresoline), 25 mg, can be given at night. Because this drug has sodium-retaining properties, it is especially suitable. Alternatives include the angiotensin-converting enzyme inhibitor nifedipine (Procardia), 10 mg, or a nitroglycerin patch.

Modified Dandy Criteria for Idiopathic Intracranial Hypertension

Note the typical patient profile (typical patient see Table 13) of a young obese woman is not required by these criteria, although the presence of idiopathic intracranial hypertension in a child, man, or thin or elderly individual would now be classified as being an atypical case. (Adapted with permission from Friedman DI, Jacobson DM. Diagnostic criteria for idiopathic intracranial hypertension. Neurology 2002 59 1492-1495, and from Lippincott, Williams, and Wilkens.)

The S2 Split In Pulmonary Hypertension

What are the three general types of pulmonary hypertension ANS a. Hyperkinetic pulmonary hypertension, i.e., that due to excess volume flow, as in large left-to-right shunts. The pulmonary arterioles can dilate to accommodate up to three times the normal cardiac output before the pulmonary artery pressure must rise. b. Vasoactive pulmonary hypertension, i.e., that due primarily to pulmonary arteriolar constriction, as in response to either hypoxia or to a high left atrial pressure, as in patients with mitral stenosis (MS). c. Obstructive pulmonary hypertension, i.e., that due to fixed lumen obliteration, as with pulmonary emboli, or to narrowing, as with the endothelial and medial hypertrophy seen in some ASDs, PDAs, and VSDs with bidirectional shunting (Eisenmenger reaction), or with primary pulmonary hypertension. ANS Almost the entire pulmonary tree on both sides must be obstructed. If, however, pulmonary hypertension is already present due to previous disease, a further embolus to...


GARLIC In Alabama domestic medicine, garlic is taken, cooked, preferably fried, to reduce blood pressure (Browne). Actually it is still prescribed, chopped finely in milk, for arteriosclerosis, as well as for hypertension (Fluck). Like true garlic, wild garlic, or RAMSONS, as it is generally known, has been used for hypertension, either by eating the fresh leaves, or by drinking a tea made from the dried leaves (Fluck). Actually, all the Alliums can be used to reduce blood pressure, including SHALLOTS, and particularly ONIONS (Schauenberg & Paris). MADAGASCAR PERIWINKLE (Catheranthus roseus) is used in Haiti to bring down blood pressure (F Huxley), and that is one of its uses in Chinese medicine, too. A decoction of HAWS, was traditionally taken in Scotland instead of tea or coffee, as a medicine for high blood pressure (Kourennoff), for it helps to prevent arteriosclerosis (Beith). Haws, in various preparations, have been used for angina pectoris both in Russia (Kourennoff) and in...

Discharge And Home Healthcare Guidelines

Metabolic acidosis, a pH below 7.35, results from any nonpulmonary condition that leads to an excess of acids over bases. Renal patients with chronic acidemia may show signs of skeletal problems as calcium and phosphate are released from bone to help with the buffering of acids. Children with chronic acidosis may show signs of impaired growth. Metabolic alkalosis, a pH above 7.45, results from any nonpulmonary condition that leads to an excess of bases over acids. Metabolic alkalosis results from one of two mechanisms an excess of bases or a loss of acids. Patients with a history of congestive heart failure and hypertension, who are on sodium-restricted diets and diuretics, are at greatest risk for metabolic alkalosis. Metabolic alkalosis can also be caused by prolonged vomiting, hyperaldosteronism, and diuretic therapy.

Diagnoses And Diagnostic Criteria

The diagnosis of other conditions is based on the measurement of a specific attribute. For example, the diagnosis of hypertension is made when measurements of blood pressure are observed to exceed a certain threshold. For the diagnosis to be reliable, there must be consensus on where the threshold for defining hypertension lies. Diabetes is another condition where measurement of an attribute in this case blood glucose level is compared with a threshold value considered by consensus to be normal.

Modeling The Diagnostic Process And The Establishment Of Standardized Diagnostic Criteria

Diagnostic criteria are usually based on traditional teaching that may be influenced through time by the literature. The literature often reflects an informal distillation of diagnostic concepts held by clinical experts in the field. However, a few examples exist where an ad hoc declaration of diagnostic criteria for a condition have been widely accepted. For instance, the Jones criteria for the diagnosis of rheumatic fever, although revised intermittently (6), have been the accepted standard for the identification of this disease entity for more than 50 years (7). Other examples include the criteria used for the diagnosis of essential hypertension (8) and systemic lupus erythematosus (9,10).

How is the harm of a treatment documented

The high cost of an intervention may also be considered an adverse factor to patients and to society. Newer drugs with only incremental benefit are often much more expensive than older generic agents. Patient labeling can be an adverse effect of drug treatment itself. It has been reported that otherwise asymptomatic subjects who are placed on antihypertensive treatment develop various symptoms, since taking their medication serves as a reminder that they are not healthy.

Shortwavelength Automated Perimetry

Studies of patients with glaucoma or ocular hypertension suggest that motion perimetry might be more sensitive than conventional perimetry for nerve fiber bundle defects in these conditions (25-28). However, stimulus size and duration may be critical variables in determining the sensitivity of the technique (28). There is a similar suggestion of better sensitivity to arcuate defects in IIH (29), which may share with glaucoma a pathologic effect of increased pressure at the optic nerve head. Although there are some claims of immunity to the effects of refractive blur and cataracts, defocus does affect foveal motion thresholds in complex ways that depend on stimulus displacement and velocity (30).

Renin Angiotensin System RAS

Hypertension has been identified as a major risk factor of microvascular complications leading to small vessel dysfunction, manifesting the state of diabetic retinopathy. In patients with diabetic retinopathy, tight control of blood pressure delays the progression of the disease and growing evidence suggests that RAS plays an important role in the regulation of blood pressure. The RAS is an enzymatic cascade in which angiotensinogen is the precursor of the angiotensin peptides. The cascade begins with the conversion of the inactive form of renin, prorenin, to active renin Satofuka S, 2009 . Renin converts angiotensinogen to angiotensin-1 (Ang I) which is further cleaved by angiotensin converting enzyme (ACE) to angiotensin-II (Ang II). Ang II is the main effector peptide of the RAS, acting primarily on two receptors, the angiotensin type I (AT-1) and angiotensin type 2 (AT22). Ang II is known to cause systemic and, local blood pressure via its constrictor effect by upregulation of...

Clinical Development Plan

In the pharmaceutical industry clinical development of a pharmaceutical entity starts with seeking alternatives or new drug therapies for an existing health problem (e.g., hypertension) or a newly identified health problem (e.g., AIDS). The health problem of interest may be related to virus, cardiovascular, cancer diseases, or other diseases. Once the health problem is selected or identified, whether it is worth developing an alternative or a new pharmaceutical entity for this particular disease is a critical development decision point. A clear decision point can increase the success of the project and consequently reduce the risk and cost. Suppose that it is decided to proceed with the development of a pharmaceutical

The Metabolic Syndrome in HIVinfected Individuals

The metabolic syndrome may be even more common in HIV-infected individuals there are many possible reasons. HIV infection on its own may exacerbate many of the manifestations of the metabolic syndrome, particularly elevation in serum triglycerides this was seen in HIV-infected individuals prior to the advent of antiretro-viral therapy. In addition, many HIV-infected individuals smoke (50 vs. 25 in the US population overall), and many HIV-infected individuals have hypertension. The metabolic syndrome may be exacerbated by some of the drugs used to treat HIV infection, including thymidine analog reverse transcriptase inhibitors and some protease inhibitors both tend to increase triglycerides and cholesterol, and may be associated with glucose intolerance.

HIV and Kidney Disease

HIV-associated nephropathy (HIV-AN) is directly caused by HIV infection and is the most common form of chronic renal disease in HIV-infected patients. Although this syndrome has been reported in all stages of HIV disease including acute infection, advanced immunosuppression is strongly associated with HIV-AN risk. In one study, 83 of HIV-infected patients with microscopic albuminuria who were biopsied, had HIV-AN. The prevalence of HIV-AN is variable among different ethnic and racial groups suggesting that there may be genetic determinants of the disease. Casanova et al. did not find HIV-AN on biopsies in 26 Italian HIV-positive patients with renal disease. Also, none of 26 HIV-infected positive individuals with proteinuria were found to have HIV-AN in a study from Thailand by Praditpornsilpa et al. The majority of patients in the U.S. who have HIV-AN are African-American males (more than 85 ). However, in one study on Ethiopian HIV patients, none of the patients fulfilled criteria...

Primary Nursing Diagnosis

Signs of withdrawal, such as irritability, anxiety, tremors, restlessness, confusion, mild hypertension (blood pressure > 140 90), tachycardia (heart rate > 100), and a low-grade fever (temperature > 100 F). Keeping the patient safe during the withdrawal process depends on managing the physiological changes, the signs and symptoms, and the appropriate drug protocols. The goal is to keep the patient mildly sedated or in a calm and tranquil state but still allow for easy arousal.

Gender Ethnicracial And Life Span Considerations

The onset of DAT may occur at any age but is rare before age 50 the average onset occurs after age 65. Approximately 3 of men and women ages 65 to 74 have AD, and some scientists note that about 50 of those age 85 and older may have AD. The prevalence of AD doubles every 5 years beyond age 65. More females than males have the disease. It is difficult to determine if there are racial and ethnic differences in the prevalence of AD. However, a unique issue for older black African Americans is that, contrasted with other ethnic racial groups, they are disproportionately affected by stroke, high blood pressure, and diabetes. These diseases can increase the risk of developing AD.

Phase Iiiii Clinical Trials

Phase II III trials are designed to study the efficacy and safety of a test drug. Unlike Phase I studies, subjects recruited in Phase II III studies are patients with the disease for which the drug is developed. Response variables considered in Phase II III studies are mainly efficacy and safety variables. For example, in a trial for the evaluation of hypertension (high blood pressure), the efficacy variables are blood pressure measurements. For an anti-infective trial, the response variables can be the proportion of subjects cured or time to cure for each subject. Phase II III studies are mostly designed with parallel treatment groups (in contrast to crossover). Hence, if a patient is randomized to receive treatment A, then this patient is to be treated with Drug A through out the whole study.

The Bottom Line on Fats

Dietary fat is a source of energy, but high-fat diets, especially diets high in saturated fat, increase the risk of gaining excessive amounts of weight and of developing diabetes, coronary artery disease, high blood pressure, and several types of cancer. This increased risk is the reason that health experts encourage us to reduce our intake of total and saturated fats by

Cardiac transplantation

Major complications, such as hypertension, accelerated atherosclerosis and osteoporosis. The detrimental effects of muscle weakness are responsible for a substantial part of the initial functional disturbance, and rehabilitation programmes should include resistance and weight-bearing activities as well as aerobic exercise. Kobashigawa, et al. (1999) found that when initiated early after cardiac transplantation, exercise training increased capacity for physical work in transplant patients.

Site and Mechanism of Diuretic Action

Diuretics are a diverse group of chemical compounds that share the ability to augment net renal sodium excretion. These agents are widely used in clinical medicine for the treatment of hypertension, pulmonary or cerebral edema, and other disorders that are characterized by the accumulation of fluid in the interstitial or extracellular compartments. Detailed discussions of the therapeutic use of diuretics can be found elsewhere in this text. The goal of the present chapter is to provide the reader with an understanding of the site and mechanisms of diuretic effects, with particular emphasis on recent insights into their cellular mechanisms of action and the molecular biology of the transport proteins that they inhibit.

Common symptoms in pregnancy

Heartburn is also a common symptom in pregnancy, but unlike constipation, occurs more frequently as the pregnancy progresses. It is estimated to complicate one-fifth of pregnancies in the first trimester rising to three quarters by the third trimester. It is due to the increasing pressure caused by the enlarging uterus combined with the hormonal changes that lead to gastro-oesophageal reflux. It is important to distinguish this symptom from the epigastric pain associated with pre-eclampsia which will usually be associated with hypertension and proteinuria. Symptoms can be improved by simple lifestyle modifications such as maintaining an upright posture especially after meals, lying propped up in bed, eating small frequent meals and avoiding fatty foods. Antacids (especially Gaviscon ), H2 receptor antagonists and proton-pump inhibitors are all effective, although it is recommended that the latter be used only when other treatments have failed because of its unproven safety in...

Ageing stress and the brain

Ageing of the brain is an important factor in overall ageing and mortality, and new insights have clarified the relationship between neuroregulation and ageing. First, neuronal loss in normal ageing is now known to be a minor change. Loss of synapses through dystrophic neuronal change is the hallmark of normal ageing. Second, similar dystrophic changes occur in the brain with chronic stress. In both instances, forebrain sites experience loss of synaptic input from brainstem regulatory nuclei. Third, functional ageing is attributed in part to lifetime stress, under the concept of 'allostatic load'. Being inseparable from the functions of appraising and responding to stress, the brain is an ultimate mediator of stress-related mortality, through hormonal changes that lead to proximate pathologies like hypertension, glucose intolerance, cardiovascular disease and immunological impairment. In chronic stress the brain shows clear allostatic compensations that lead to pathology....

Who should provide the antenatal care

A meta-analysis comparing pregnancy outcome in two groups of low-risk women, one with community-led antenatal care (midwife and general practitioner) and the other with hospital-led care did not show any differences in terms of preterm birth, Caesarean section, anaemia, antepartum haemorrhage, urinary tract infections and perinatal mortality. The first group had a lower rate of pregnancy-induced hypertension and pre-eclampsia which could reflect a lower incidence or lower detection 7 . Clear referral pathways need to be developed, however, that allow appropriate referral to specialists when either fetal or maternal problems are detected.

Diabetes And Circulatory Problems

What is it about diabetes that predisposes a person to atherosclerosis First, having high glucose levels for long periods can injure the cells lining the blood vessels, initiating the plaque buildup. Second, the high blood pressure and the elevated lipids frequently present in people with diabetes are known risk factors for plaque buildup. There are also other less well understood factors such as blood clotting factors and platelet function that are also altered in people with diabetes. Even though people with type 1 diabetes generally do not have high blood pressure and high cholesterol problems, they can develop heart disease after many years. This is especially likely to occur if they have diabetic kidney disease. Heart failure is more common in people with diabetes. Many times it occurs because of heart muscle damage following a heart attack. Long-standing high blood pressure associated with diabetes is also an important cause. It is now also recognized that high glucose levels...

Why are clinical trials unreliable for the detection of rare adverse events

When a new compound intended for chronic or life-long use is introduced into the market, approximately a few hundred patients will have been treated for one year or longer. If the agent is an inhaled steroid for treatment of asthma, a lipid-lowering statin, or an antihypertensive drug, one can assume that the medications will be prescribed for longer than one year, maybe even for decades. Thus, one could legitimately question whether the one-year experience with the compound is adequate to predict drug safety over 5, 10, or up to 30 years. Many serious adverse events may take several years to become apparent. For example, it may take more than a decade of tobacco use to cause lung cancer. A safety profile based on limited drug exposure is inadequate and can be very misleading.

Clinical Significance And Clinical Equivalence

The magnitude of a clinically significant difference varies. In practice, no precise definition exists for the clinically significant difference, which depends on the disease, indication, therapeutic area, class of drugs, and primary efficacy and safety endpoints. For example, for antidepressant agents (e.g., Serzone), a change from a baseline of 8 in the Hamilton depression (Ham-D) scale or a 50 reduction from baseline in the Hamilton depression (Ham-D) scale with a baseline score over 20 may be considered of clinical importance. For antimicrobial agents (e.g., Cefil), a 15 reduction in bacteriologic eradication rate could be considered a significant improvement. Similarly, we could also consider a reduction of 10 mm Hg in sitting diastolic blood pressure as clinically significant for ACE inhibitor agents in treating hypertensive patients. The examples of clinical significance on antidepressant or antihypertensive agents are those of individual clinical significance, which can be...

Central Nervous System Cerebrovascular Accidents

Faecal incontinence may affect up to 40 of subjects immediately following a stroke, with a frequency of up to 15 of those who survive 3 years. It is associated with a higher mortality and greater likelihood of need for long-term (institutional) care (exceeding dementia as a reason for requesting nursing home placement). In the immediate poststroke period, incontinence has been shown to be associated with female gender, a history of previous stroke, and comorbidity of other disabling diseases, especially diabetes mellitus and hypertension. The cerebral lesions in those with incontinence are significantly more often a haemorrhage, larger in size, and more often involved the cerebral cortex than those without faecal incontinence 26 . The pathophysiology of urinary incontinence following a stroke has been categorised into three main mechanisms disruption of neuromicturition pathways, stroke-related cognitive and language deficits and concurrent neuropathy and medication use. Presumably,...

Why clinical trials have a limited value for detection of unexpected adverse events

Even very obvious adverse effects may be difficult to recognize if they are truly unexpected. Today we know that as many as 15-20 of users of ACE inhibitors develop dry cough, but it took several years after marketing of these drugs to establish this link. Why would anyone expect a potent class of drugs used for treatment of hypertension and congestive heart failure to cause cough

Lessons from Mutations in the Epithelial Na Channel SCNN Found in Human Disease

Mutations in the human ENaC subunit genes result in inherited diseases characterized by either gain-of-function or loss-of-function of the epithelial Na+ channel in distal convoluted tubules and collecting duct. Mutations causing overactivity of the Na+ channel result in NaCl retention and hypertension (Liddle's syndrome), whereas other mutations leading to reduction or loss of channel activity result in renal salt wasting and hyperkalemic acidosis (pseu-dohypoaldosteronism type I). These experiments of nature provide convinc Liddle's syndrome is an uncommon cause of familial hypertension that is transmitted in an autosomal dominant pattern. The syndrome is characterized by a defect in renal distal tubular sodium handling, resulting in excessive sodium absorption and concomitant potassium wasting and hypokalemia resembling primary aldosteronism. Serum and urine aldosterone concentrations are, however, low. Rapidly following the molecular cloning of SNCC (1A, IB, and IG) genes, it was...

Statistical Considerations

For a clinical trial, it is recognized that it is impossible to address all questions with one trial. Therefore, it is important to identify the primary and secondary response variables that will be used to address the scientific and or medical questions of interest. The response variables (or clinical endpoints) are usually chosen at the outset, since they are needed to fulfill the study objectives. Once the response variables are chosen, the possible outcomes of treatment are defined, and those showing efficacy and safety are clearly indicated. In practice, it is suggested that the selected clinical endpoints be validated (reliable and reproducible), widely available, understandable, and accepted. For example, in an antibiotic trial the outcome might be defined as cure, cure with relapse, or treatment failure, and the response variables may be pyrexia, dysuria, and frequency of urination. The criteria for the evaluation of a cure could be that all signs or symptoms of urinary tract...

John M Walker Series Editor

Chemosensitivity Volume 2, In Vivo Models, Imaging, and Molecular Regulators, edited by Rosalyn D. Blumethal, 2005 110. Chemosensitivity Volume 1, In Vitro Assays, edited by Rosalyn D. Blumethal, 2005 109. Adoptive Immunotherapy Methods and Protocols, edited by Burkhard Ludewig and Matthias W. Hoffman, 2005 108. Hypertension Methods and Protocols, edited by J r me P. Fennell and Andrew H. Baker, 2005 107. Human Cell Culture Protocols, Second

The heart and circulation

Lung expansion and oxygenation are thus essential to the circulatory changes at birth, allowing both a fall in pulmonary vascular resistance and the closure of the ductus arteriosus. Situations of impaired respiratory function are frequently associated with pulmonary hypertension leading to a physiological right to left shunt and exacerbation of hypoxaemia. This is evident in respiratory distress syndrome when the pulmonary artery pressure is high, and in conditions such as meconium aspiration or diaphragmatic hernia persistence of the fetal circulatory pattern is the major clinical problem.

Following Sequential Fields

More difficult is the issue of progression of the original defect. Is a nasal step or arcuate defect worsening in a patient with idio-pathic intracranial hypertension or glaucoma Therapeutic decisions often hinge on such questions. One must consider all the factors, whether a global reduction from some other irrelevant factor is creating a pseudo-progression, and whether the patient's current or past performance was too unreliable and variable on which to rely. In situations of uncertainty it is best to have the patient return for another perimetric examination or two. Continued persistence or consistent progression over several fields is less likely to be due to inter-test variability than one-time discrepancy between a single pair of fields.

Generalization Of Controlled Randomized Trials

Note that the current conduct of clinical trials is to compare the difference in distributions of the clinical responses observed from patients under a test therapy and a standard (or reference) therapy or a placebo. This concept is referred to as population efficacy (or safety). Suppose that the distribution of a clinical response can be adequately described by a normal probability distribution. Then the population efficacy can be assessed through the comparison of the first two moments of the distributions between the test and the reference therapies. This is because a normal distribution is uniquely determined by its first two moments. The comparison of the first moment of the efficacy endpoints for the two therapies is usually referred to as average efficacy, while the comparison of the second moments is called the variability of efficacy. To provide a better understanding of average efficacy and variability of efficacy, the comparison in averages and variabilities are illustrated...

Abnormalities of the V Wave

Why will a high mid-diastolic pressure of pulmonary hypertension or stenosis have a high V wave ANS Pulmonary hypertension or stenosis thickens the RV, thus raising the diastolic pressures. If there is a high pressure in this common atrioventricular (AV) chamber throughout diastole, then when the tricuspid valve is closed during systole the atrial V wave rises from a baseline that is higher than normal.

Is it perhaps time for CR professionals to look at current practice of risk stratification and to consider how risky

Account of the individuals' other health behaviour and motivational risk factors. This is an issue which often leads to confusion, particularly where in primary prevention the focus is on lifestyle issues like smoking and the recognised risk markers for CHD, e.g. hypertension. Box 2.1 poses this question.

Gastrointestinal disorders

Herniation of the abdominal contents into the hemithorax leads to severe respiratory difficulties with persistent pulmonary hypertension. Most cases present with respiratory distress and cyanosis at birth. Essential early management is the passage of a large bore nasogastric tube into the stomach to prevent gaseous distension, ventilation and rapid transfer to intensive care. All these infants require tertiary level intensive care, with access to sophisticated mechanical ventilation and modern vasodilator therapy such as nitric oxide. Surgery is delayed until the infant's respiratory status has been stabilized. Survival depends on the degree of underlying pulmonary hypoplasia and the presence of associated congenital anomalies such as cardiac defects. Long-term complications include persistent gastro-oesophageal reflux and respiratory problem neurodevelopmental problems can develop if neonatal hypoxia was severe.

ACE Inhibitors and Ang Ii Receptor Antagonists

Angiotensin antagonists represent a major category of antihypertensive agents that exert their influence by interfering with the multiplicity of actions of ANG II on the systemic circulation as well as on the kidney (Fig. 5). There are a large number of ACE inhibitors and a growing number of nonpeptide ANG II receptor antagonists. Of the two main classes of ANG II receptors, the AT receptor has been identified to be responsible for mediating most of the renal vascular and tubular effects. Thus, antagonists of AT receptors are now being used as antihypertensive agents and also enhance sodium excretion for any given level of arterial pressure. Specific renin inhibitors have also been used to reduce the formation of ANG I and II.

Early signs and symptoms

Physical findings in thyrotoxicosis may include hyperactivity, tachycardia or atrial fibrillation, systolic hypertension, warm, moist, smooth skin, stare and eyelid retraction, tremor, hyperreflexia, and muscle weakness (28). Goiter is not invariably present one study found that 37 of thyrotoxic patients over age 60 did not have thyroid enlargement (29). In Graves' disease, ophthalmologic findings may include exopthalmos, extraocular muscle dysfunction, periorbital edema, conjunctival chemosis and injection, and exposure keratitis (30). Pretibial myxedema is rarely seen in patients with Graves' disease and only when eye disease is also present.

Cerebrovascular Accident

In an embolic CVA, a clot is carried into the cerebral circulation, usually by the carotid arteries. Blockage of an intracerebral artery results in a localized cerebral infarction. Hemorrhagic CVA results from hypertension, rupture of an aneurysm, arteriovenous malformations, or bleeding disorder. Risk factors thought to cause blood vessel changes that cause vessel walls to be more susceptible to rupture and hemorrhage include elevated low-density lipoprotein (LDL) and lowered high-density lipoprotein (HDL) levels, cigarette smoking, and a sedentary lifestyle.

Systemic Hemodynamic Responses And Conclusions

Many patients receiving diuretic therapy are hypertensive and a long-term goal of the therapy is to achieve sustained reductions in arterial pressure to normo-tensive levels. Indeed, monotherapy with diuretics has long been shown to be an effective treatment for many hypertensive patients. In more resistant cases, combinations of either ACE inhibitors or calcium antagonists with a diuretic have been effective in treating resistant patients. While the antihypertensive mechanisms for agents that directly elicit vascular smooth muscle relaxation are readily apparent, it is more difficult to explain the prompt antihypertensive effects of diuretics that primarily inhibit epithelial transport and do not have much direct effect on vascular smooth muscle to decrease peripheral vascular resistance. Studies in anephric subjects have shown that the direct systemic vasodilatory responses of most diuretics are rather modest. In addition, the immediate effects on arterial pressure of diuretics are...

Ischaemic burden myocardial ischaemia

Those at greatest risk of exercise-induced ventricular fibrillation are individuals with significantly impaired left ventricular function namely those who have serious major myocardial damage, due either to a large infarct, multiple infarctions or other conditions affecting ventricular function, e.g. valve disease, myocarditis, hypertension and cardiomyopathy. There is a lack of recent evidence on the incidence of arrhythmic events during CR. In a study cited by Belardinelli (2003) a programme of exercise training for heart failure patients had only one episode of cardiac arrest in 16 years, i.e. 1 per 130000 patient hours. However, as Belardinelli (2003) suggests, the low incidence of arrhythmia, as with other complications, during CR is because exercise is safe if the exercise prescription is 'tailored to the patient's clinical picture and needs'.

Monitoring Blood Pressure

Blood pressure control is critical for the prevention of both microvascular and mac-rovascular complications of diabetes. The goal should be to have blood pressure measurements consistently below 130 80. Sometimes you may find that the blood pressure is high only when you see a doctor or when you see a particular doctor (a phenomenon called white-coat hypertension). If this is the case, ask to have your blood pressure measured when you see other doctors, or buy a home blood pressure machine and use those blood pressure measurements as a guide to treatment. Blood pressure is often easier to control than blood glucose levels, and controlling blood pressure is just as beneficial to your health. You doctor may not routinely recommend measuring blood pressure at home unless there is a suggestion that you have white-coat hypertension or symptoms that might be due to low or high blood pressure.

Surgical Liver Transplant

The first three types are the most commonly seen, accounting for 55 to 90 of cases of cirrhosis. Although each of these types has a different etiology, the clinical findings, including portal vein hypertension and eventual liver failure, are much the same (Box 2). Obstructed flow of blood leads to increased pressure in the portal vein (portal hypertension).

The Cyp Inhibition 421 Drug Drug Interactions

Drug-drug interaction mediated by CYPs are PK in nature as a result of a change in the metabolism of a drug by the coadministration of another. This result can occur by the induction of new protein synthesis, which accelerates drug metabolism and decrease the magnitude and duration of drug response, or from inhibition, which results in elevated plasma drug concentrations with increased potential for enhanced beneficial or, in most cases, adverse effect. The clinical significance of the enzyme inhibition is measured primarily by the extent to which the plasma level of the drug rises. If the plasma level remains within the therapeutic range, the interaction may not be a problem. If not, the interaction may become adverse as the serum level climbs into the toxic range. For example, felodipine and nifedipine are dihydro-pyridine calcium antagonists antihypertensive medication, which shows drug interaction with CYP3A4 inhibitor itraconazole. Concomitant use of itraconazole with felodipine...

Pharmacologic Highlights

Other Drugs Antihypertensives are also used since hypertension increases stress on damaged blood vessels. A direct vasodilating agent such as hydralazine or sodium nitroprusside may also be used. Angiotensin-converting enzyme inhibitors (ACEIs) are used to lower blood pressure.

Clinical Applications

In many cases, mutation detection can be used in choosing adequate healthcare, as some mutation positions are associated with the worst prognostic. Knowing the exact mutation position makes it possible to establish the prognostic prior to the disease development course and, based on this, to decide which one is the best therapy. Knowing the polymorphism makes it possible to associate some polymorphisms with hereditary complex disease traits for each different population for example, renin-angiotensin system polymorphisms are associated with high blood pressure in Japanese and African Ameri-can. 1U2

Right Ventricular Hypertrophy RVH

How does the left parasternal impulse caused by the RVH or pulmonary stenosis (PS) or pulmonary hypertension differ from normal ANS A palpable pulmonary artery movement is usually secondary to a dilated RV, as in ASD or primary pulmonary hypertension. The dilated pulmonary artery is best palpated in full held expiration, with the patient either supine or at various degrees of chest elevation. It is often better seen than palpated, and gentle pressure should be applied first. In patients with narrow anteroposterior diameters, a normal pulmonary trunk can sometimes be both visible and palpable.

Validation And Qualification

The primary distinction between biomarkers and surrogate endpoints is evidence. This is a point that has been highlighted by recent literature and also regulatory guidances. Many biomarker nomenclature systems categorize bio-markers according to their evidentiary status. For example, in AIDS research, one early nomenclature scheme includes (i) Type 0 markers of natural history, (ii) Type 1 markers that assess biologic activity, and (iii) Type 2 markers that act as surrogate endpoints for clinical outcome of therapy (14). In addition, selected FDA guidances emphasize the evidentiary status in biomarker classifications. For example, in the exposure-response guidance, the FDA indicates that biological marker (biomarker) refers to a variety of physiologic, pathologic, or anatomic measurements that are thought to relate to some aspect of normal or pathological biologic processes and these biomarkers include measurements that suggest the etiology of, the susceptibility to, or the progress...

Lowering RAGE expression

Several commonly used therapeutic agents showed effects on the reduction of RAGE expression in vascular endothelial cell thiazolidinediones (rosiglitazone and pioglitazone), calcium channel blocker (nifedipine), angiotensin II receptor blocker (telmisartan). Rosiglitazone and pioglitazone, kinds of thiazolidinediones, an anti-diabetic drug act by binding to peroxisome proliferator-activated receptors reduces basal and tumor necrosis factor-a stimulated expression of RAGE in cultured human umbilical vein endothelial cells. Decreased RAGE by thiazolidinediones results in subsequent inhibition of AGEs stimulated expression of pro-inflammatory protein (Marx et al., 2004). Nifedipine, a calcium channel blocker inhibits RAGE upregulation in AGEs treated human umbilical vein endothelial cells to reduce AGEs induced ROS production (Yamagishi & Takeuchi, 2004). Telmisartan, an angiotensin II receptor blocker inhibits RAGE expression in cultured human microvascular endothelial cells in vitro...

Outcomes in Diabetic Patients

An underlying question regarding the vascular protective effects of antihypertensive therapies is whether these effects are mediated via the reduction in BP or whether these drugs may provide additional effects. This issue has been addressed in a number of studies. Comparisons of antihypertensive therapies on cardiovascular outcomes in hypertensive patients with type 2 diabetes have been performed in several trials. In the United Kingdom Prospective Diabetes Study, the effects of tight and less tight BP control by the ACE inhibitor captopril or the -blocker atenolol were compared in patients with both hypertension and type 2 diabetes (9,93). This prospective study demonstrated that tight BP control was more effective than less tight control in reducing macrovascular endpoints, including stroke and deaths related to diabetes (9,93). Additionally, this study indicated that the ACE inhibitor and -blocker were equally effective in reducing cardiovascular outcomes. The Appropriate Blood...

Dysmetabolic Metabolic Syndrome Syndrome X

The original definition of syndrome X, by Reaven (20), emphasized insulin resistance. The dysmetabolic syndrome consists of insulin resistance in association with dyslipidemia, obesity (particularly with excess visceral fat), hypertension, and often IGT or type 2 diabetes. This constellation of abnormalities is associated with an accelerated onset of atherosclerosis (18,122). Patients with syndrome X have a 20-40 incidence of type 2 diabetes and probably an even greater association with IGT (123). The obesity in the abdomen tends to be deep or visceral adiposity, which is associated with accelerated atherosclerosis and coronary artery disease (104). The presence of visceral fat in this syndrome is an example of the fact that not all forms of obesity are functionally the same and that different forms can pose different health risks. Patients with fat distributed in subcutaneous regions around the gluteofemoral areas and upper abdomen are at much less risk for complications such as...

Description Medical Diabetes

Long-term complications such as disease of the large and small blood vessels lead to cardiovascular disease (coronary artery disease, peripheral vascular disease, hypertension), retinopa-thy, and renal failure. Diabetic patients also have nerve damage (neuropathy) that can affect the peripheral nerves, resulting in numbness and pain of the hands or feet.

Adult Dominant Polycystic Kidney Disease ADPKD

Co-morbidities associated with ADPKD can be numerous. Up to 50 of patients with ADPKD develop end-stage renal disease that necessitates hemodialysis or renal transplantation by the age of 60 (49). In addition, hypertension can develop in up to 50-70 of patients (50,51). The pathogenesis of hypertension in ADPKD patients is complex, but is thought to be derived from progressive intrarenal ischemia through physical compression by enlarging cysts, thus activating the renin-angiotensin-aldosterone pathway (48). Up to 60 of patients also have significant, chronic flank discomfort (52). The etiology of the pain is thought to derive from progressively increased tension on the sensory nerves of the renal capsule as cysts enlarge over time (53). Other potential causes of pain are cyst infection and hemorrhage, as well as nephrolithiasis (54).

Hypolipidemic 3thia Fatty Acids

In addition to lowering plasma TG, n-3 fatty acids (eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA)) are reported to have a number of additional beneficial effects on the cardiovascular system which include antihypertensive and antithrombotic actions.3-5 EPA and DHA are major fatty acid constituents of fish oil and it has been assumed that both EPA and DHA are responsible for its hypotriglyceridemic activity. However, growing evidence indicates that EPA and DHA may possess different hypolipidemic properties. We have reported that EPA is the fatty acid primarily responsible for the TG-lowering effect of fish oil (Table 1), but the mechanism underlying this hypotriglyceridemic effect has not yet been fully elucidated. Interestingly, however, we

Pressure and Hemodynamic Effects

The BP effects of Ang II are mediated via a combination of mechanisms including vasoconstriction, stimulation of renal tubular sodium resorption, and its effects on the central and sympathetic nervous tissues (100,101). Because hypertension exacerbates diabetic vascular complications (102), it is likely that the BP-lowering effects of ACE inhibitors are a major contributor to the reduction of vascular complications in diabetic patients with hypertension (9,93). However, there is growing evidence that ACE inhibitors may also provide beneficial vascular effects in diabetes in the absence of systemic hypertension. Several large studies have demonstrated that ACE inhibition can reduce renal, retinal, and cardiovascular complications in normotensive diabetic patients (1,5,8). Although a small reduction in systemic BP within the normotensive range may contribute to the vasoprotective effects of ACE inhibition, the magnitude of these effects is greater than that which would be predicted...

Shortterm Adaptations Postdiuretic Nacl Retention

Diuretic induced decrements in ECF volume have been shown to be associated with suppression of atrial natriuretic peptide secretion. These changes occur following diuretic administration in both normal individuals and in patients with nephrotic syndrome 16 , chronic glomerulonephritis, and essential hypertension. In some studies, atrial natriuretic peptide concentrations have declined before significant changes in extracellular or blood volume occur in these cases it has been suggested that furosemide-induced changes in venous capacitance may underlie the effect.

Congenital diaphragmatic hernia

Hypertension already established in fetal life. Open hysterotomy and surgical repair of the CDH proved to be very unsuccessful and was abandoned early. A number of techniques have been developed for the in utero management of CDH. These were primarily based on animal studies that showed that occlusion of the fetal trachea could improve pulmonary development by accumulation of pulmonary secretions. This led to the development and clinical use of reversible techniques for fetal tracheal occlusion. This could be achieved either by open hysterotomy and direct application of a removable external metal clip on the trachea or endoscopic neck dissection and tracheal clip application and morerecently by theuseof endoscopic bronchoscopy and placement of a tracheal balloon, which can be deflated in utero or at the time of delivery. However, a randomized trial performed by Harrison et al. 18 whose group had previously published most of the data on in utero therapy, comparing standard post-natal...

Other Neural Reflexes Involved With Blood Pressure Regulation

Another important consequence of increased filling of the right atrium and the resultant increase in right atrial pressure is the release of atrial natriuretic peptide (ANP) from the myocytes that bear this increased mechanical load. ANP acts on the peripheral vasculature and kidneys in a manner that favors a reduction in arterial blood pressure. The smooth muscle surrounding arterioles relax when exposed to ANP, resulting in a reduction in vascular resistance. ANP also diminishes the barrier function of endothelial cells lining capillaries and post-capillary venules, which favors a redistribution of plasma volume to the extravascular space. Natriuresis, diuresis, and a reduction in renin release are important responses of the kidney to ANP. The combined actions of ANP to cause vasodilation and reduce plasma volume account for the tendency of elevated plasma ANP levels to exert a hypotensive effect. ANP is metabolized by neutral endopeptidases (NEP) that are found in blood, the...

Solid Renal and Juxtarenal Lesions

Because of their biologically active nature, neuro-blastomas may secrete a significant amount of cate-cholamines and hence, patients may present with palpitations, tachycardia, hypertension, flushing, and sweating. Intractable diarrhea may result from the secretion of vasoactive intestinal peptide (VIP) (Gesundheit et al. 2004). Another unusual symptom is cerebel-lar ataxia and opsomyoclonus (dancing feet, dancing eyes myoclonic encephalopathy of infants). This syndrome is rare, of unknown etiology, and is usually associated with thoracic lesions (Bousvaros et al. 1986). Malaise, pain, and anemia may be the presenting complaint in up to 60 secondary to metastatic disease. bosis leads to vascular congestion and enlargement of the kidney and is marked clinically by hematuria, pro-teinuria, hypertension, and consumptive thrombocy-topenia. It is associated with dehydration, sepsis, maternal diabetes, birth asphyxia, and coagulopathies (Lowe et al. 2000). Doppler US is the best imaging...

Impaired glucose tolerance is a disease

Prevent or delay the progression of IGT to type 2 diabetes underscores the need for early diagnosis (1). The accelerated heart disease in IGT probably stems from the presence of insulin resistance and its associated metabolic syndrome, which are defined in Table 2 according to the NCEP ATP III report (1). Three of five elevated factors, which are easy to measure, constitute the metabolic syndrome. Certain components of the syndrome, such as low HDL, elevated triglycerides, and hypertension, are well-known risk factors for cardiovascular disease. Other components that are less commonly measured in the clinical setting, such as elevated small, dense LDL cholesterol (the moiety that is more susceptible to oxidation) and elevated levels of the prothrombotic factor plasminogen activator inhibitor-1 (PAI-1), correlate with cardiovascular events and mortality (19).

And Insulin Sensitivity

There is growing evidence that inhibition of the RAS system by either ACE inhibition or AT1 receptor antagonism can increase insulin sensitivity and glucose utilization. Studies using euglycemic hyperinsulinemic clamps have shown that ACE inhibitor treatment improves insulin sensitivity in most (136-140), but not all (141,142) individuals with hypertension, obesity, and or type 2 diabetes. Similarly, although ATI antagonism has been reported to improve muscle sympathetic nerve activity and insulin sensitivity in obese hypertensive subjects (143) and increase basal and insulin-stimulated glucose oxidation in normotensive individuals with type 1 diabetes (144), other clinical studies have not observed improvement on insulin sensitivity and glucose homeostasis following treatment with AT1 receptor antagonists (139,145,146).

As The Cause Of A Split S

A bicuspid aortic valve without stenosis. (Bicuspid valves may or may not become stenotic.) b. A stiff aortic valve, such as that occurring in AS or hypertension. Note Hypertension may stretch the aortic root, causing the cusps to become taut and therefore to open with a sharp sound. This phonocardiogram is from a 40-year-old woman with mild hypertension. The third component is probably an aortic ejection sound. This sounded simply like a widely split S1, probably because the T1 was too close to the Ml to be audible.

Peroxisome Proliferator Activated Receptory Key Regulator of Adipogenesis and Insulin Sensitivity

PPAR-y was first identified as a part of a transcriptional complex essential for the differentiation of adipocytes, a cell type in which PPAR-y is highly expressed and critically involved (6). Homozygous PPAR-y-deficient animals die at about day 10 in utero as a result of various abnormalities including cardiac malformations and absent white fat (7-9). PPAR-y is also involved in lipid metabolism, with target genes such as human menopausal gonadotropin coenzyme A synthetase and apolipoprotein (apo)-A-I (10,11). Chemical screening and subsequent studies led to the serendipitous discovery that thiazolidinediones (TZDs) were insulin sensitizers that lower glucose by binding to PPAR-y. Used clinically as antidiabetic agents, the TZD class includes pioglitazone (Actos) and rosiglitazone (formerly BRL49653, now Avandia) (12,13). Troglitazone (ReZulin) was withdrawn from the market because of idiosyncratic liver failure. Naturally occurring PPAR-y ligands have been proposed, although with...

Acute Renal Failure From Diuretic And Nsaid Administration

Acute renal failure has been reported in two healthy volunteers taking indomethacin and triamterene as part of a drug study, in one patient taking this combination, and recently in a man with mild hypertension taking ibuprofen and the combination of hydrochlorothiazide and triamterene who had been strenuously exercising. The latter individual underwent a renal biopsy which showed acute tubular necrosis (ATN). All patients subsequently recovered renal function in a time course consistent with ATN. Why these individuals developed ATN is unclear, but an idiosyncratic reaction to this combination of drugs or potentiation of physiologic reductions in renal blood flow induced by exercise has been proposed. Clinicians and patients should be aware of the potential risks from this drug combination.

What should the reader look for

The distribution of baseline prognostic factors among the study groups should be included in one of the early tables of a trial report. It is important for the reader to review this table to obtain a sense of group comparability. Group differences are very unusual in large trials. Therefore, it came as no surprise when the reported differences in both mean baseline systolic and diastolic blood pressures in the Captopril Prevention Project1 attracted a lot of attention.2 In this trial of about 11,000 hypertensive subjects, the 2-3 mm Hg difference suggested tampering with the randomization process. The probability that these differences were due to chance alone was less than one in a million.

Predisposing factors for anaphylaxis

Other factors that may predispose to severe disease are the use of medications that may interfere with the normal physiological response to an allergen, i.e. the epinephrine (formerly adrenaline) response. The typical drugs implicated are the cardiac drugs called angiotensin converting enzyme (ACE) inhibitors which inhibit the physiological angiotensin reaction to hypertension, and the more familiar beta blockers prescribed for ischaemic heart disease. The latter may inhibit the generation of a faster heartbeat to maintain organ profusion in the face of allergen-mediated fall in blood pressure.

Studies In Man Neurophysiological Changes

Deep white matter lesions (DWML) in type 2 diabetic patients (n 115) and age and sex-matched nondiabetic controls. The severity of DWML was assessed semi-quantitatively using the Scheltens scale (116), a scale that takes both the number and the size of the lesions into account. Boxes represent quartiles and median scores. The DWML score is significantly (p < 0.01) higher in the diabetic patients. After adjustment for the presence of hypertension (HT defined as a systolic blood pressure > 160 mmHg and or diastolic blood pressure > 95 mmHg and or self reported use of antihypertensive medication) the difference between the diabetic and nondiabetic group remains statistically significant. Data are derived from the Utrecht Diabetic Encephalopathy Study (54). Fig. 3. Deep white matter lesions (DWML) in type 2 diabetic patients (n 115) and age and sex-matched nondiabetic controls. The severity of DWML was assessed semi-quantitatively using the Scheltens scale (116), a scale...

Complications Of Albumin And Diuretic Combinations

Administration of albumin with diuretics may be associated with a number of complications. The most frequently reported problem is hypertension. The acute onset of hypertension of sufficient severity to require treatment is reported in between 10 and 46 of treatment courses with albumin and loop diuretics in some series 6, 14 . Additionally, over one-third of already hypertensive individuals will require upward adjustment of their medications to maintain blood pressure control during treatment with albumin and diuretics. Electrolyte abnormalities are also a commonly observed problem during administration of albumin and loop diuretics 4 . Hypokalemia develops in up to 40 of treatment courses while hypernatremia and metabolic alkalosis have been reported in 17 and 11 of treatment courses, respectively. The high sodium concentration of hyperoncotic albumin (130-160 mEq liter) undoubtedly contributes to the hypernatremia. Acute respiratory distress and congestive heart failure also occur...

Autonomic Dysreflexia

Autonomic dysreflexia is an acute syndrome characterized by abrupt onset of excessively high blood pressure caused by uncontrolled sympathetic nervous system discharge in patients with spinal cord injury (SCI). Au-tonomic dysreflexia is potentially life-threatening. The syndrome was first described by Head and Rid-doch in 1917 (Head and Riddoch 1917). In 1947, Gutt-mann and Whitteridge showed the effects of bladder distensions on the cardiovascular system (Guttmann and Whitteridge 1947). Autonomic dysreflexia is also known as autonomic hyperreflexia, paroxysmal neuro-genic hypertension, sympathetic hyperreflexia, and neurovegetative syndrome.

Epidemiology Pathophysiology and Clinical Features

In SCI patients, these higher inhibitory pathways are not intact and cannot reach the splanchnic bed, resulting in high blood pressure. As a parasympathetic reflex, the heart beat is also reduced (bradycardia). Typical clinical signs and symptoms are Sudden severe hypertension

Oral Dopamine Agonists

Dopamine has striking effects on cardiac and renal function in patients with congestive heart failure as outlined above. Additionally, alterations of endogenous dopamine production or metabolism may participate in the pathogenesis of hypertension. The fact that dopamine infusion leads to vasodilation and na-

Genetic Considerations

HF is a complex disease combining the actions of several genes with environmental factors. Many HF risk factors have genetic causes or are associated with genetic predispositions. These include hypertrophic cardiomyopathy (HCM) and dilated cardiomyopathy (DCM), coronary artery disease, myocardial infarction, and hypertension. Genetic polymorphisms of the renin-angiotensin-aldosterone system (RAAS) and sympathetic system have also been associated with susceptibility to and or mitigation of HF. Gene variants in the alpha-2c adrenoceptor and the alpha-1 adrenoceptor have been associated with a higher risk of HF among African Americans.

Multifocal White Matter Lesions

Hypertension and ischemic white matter lesions (leukokraurosis) Increases with age, and has also been seen with chronic hypertension. There are two types of ischemic white matter lesions Enlargement of these perivascular spaces with age and hypertension, associated with thinning, pallor and atrophy of the adjacent myelin, is called tat cribl

Current and future therapies

The limited success achieved with diet exercise coupled with the realization that obesity is a chronic disease requiring lifelong treatment has fueled the intense drive to develop an effective drug therapy. Unfortunately, this attempt has received a lot of negative press for a variety of reasons, ranging from the inappropriate use of thyroid hormone, diuretics, and addictive sympathomimetics to the withdrawal of fenfluramine dexfenfluramine owing to associated valvular heart disease and pulmonary hypertension (88,89). Although a few have questioned the wisdom of using pharmacologic agents to treat obesity (90), most health care professionals and experts in this field lament the lack of safe and effective drug(s) to complement lifestyle modifications (diet exercise). Despite the many challenges inherent in this enterprise, recent advances in the understanding of the mechanisms pathways that regulate modulate appetite and energy expenditure (albeit studied mostly in rodents) have...

Renal Hemodynamic Effects

Diuretics tend to increase renal blood flow acutely in normal subjects and patients with hypertension, probably through prostaglandin mediated pathways 15, 29 , Renal vascular resistance must fall substantially as renal perfusion pressure will fall due to the diuretic. Frusemide may also redistribute blood flow toward the renal cortex 15 . During longer term therapy RAAS activation, resulting in a preferential increase in efferent arteriolar tone, may reverse the direct pharmacological effect of the diuretics. Chronic diuretic administration and RAAS activation is probably mainly responsible for the reduction in renal blood flow characteristic of chronic heart failure 15 , In patients with heart failure, in the absence of an ACE inhibitor, acute administration of a diuretic has little overall effect on renal blood flow 15 . This probably reflects the overriding effect of concomitant RAAS activation.

Clinical Findings

Classical branching enzyme deficiency most frequently presents during the first few months of life, with hepatosplenomegaly and failure to thrive. Progressive liver cirrhosis, with portal hypertension, ascites, esopha-geal varices, and death, usually occurs before 5 years of age. However, there are patients who have survived without apparent progressive liver disease. The neuromuscular system may also be involved. Severe cardiomyopathy as the predominant symptom has also been reported. 20 The diagnosis of type IV is established by demonstration of abnormal glycogen (an amylopectin-like polysaccharide) and a deficiency of glycogen branching enzyme in liver, muscle, or fibroblasts.

Blood Flow Velocities And Pressures In The Renal Vasculature

As shown by the scanning electron micrograph in Fig. 1, the glomerular capillaries are supplied by the afferent arteriole. However, the blood that leaves the glomerulus does not flow out through a venule as in most capillary systems, but through a second resistance vessel, the efferent arteriole. Because of this arrangement, most of the total drop in pressure from the arterial to the venous side of the circulation is divided between the two arterioles, resulting in a higher blood pressure in the glomerular capillary network and a lower blood pressure in the peritubular capillary network. The distribution of the fall in hydrostatic pressure is given in Table 1.

Indications And Preoperative Assessment

The indications for HALN can include any scenario in which an open radical nephrectomy is warranted. The most common indications include nephrectomy for functional renal masses (renal cell carcinoma being the most common pathology), nonfunctioning kidneys, and renovascular hypertension. Hand-assisted techniques can also be applied to nephroureterectomy for live donor renal transplants and upper tract transitional cell carcinoma.

What is the usefulness of quality of life assessments

Quality of life measures can sometimes produce unexpected results. A study evaluated the effects of antihypertensive drug treatment on various aspects of well-being using interviews with the patients themselves, their spouses or significant others, and their physicians.2 The physicians reported no noticeable change in their patients' well-being, as blood pressure was usually controlled and the patients had not complained. In contrast, three-quarters of the spouses had noted moderate to severe deterioration in the patients' behaviors and attitudes. Adverse effects noted were a decline in energy and general activity, preoccupation with illness, changes in mood and memory, and reduced libido. Some patients admitted certain negative effects of treatment. In general, the effects of treatment on a person's well-being are best assessed by the patients themselves, or someone who knows them well, rather than by their physician. Despite a lack of consensus on the definition of HRQL and the...

Reninangiotensinaldosterone System And Effects On Electrolytes

Diuretic therapy is one of the principle causes of RAAS activation in heart failure and essential hypertension 23 . Renin release reflects not only volume depletion, but also sympathetic nervous system activation and direct, prosta-glandin-mediated, renal renin release. Increases in aldosterone, predominantly under the control of angiotensin II in these settings, may attenuate the natriuretic effect of diuretics and is the principal cause of hypokalemia in heart failure. RAAS activation also contributes to vasoconstriction and structural remodeling of the heart and vasculature in heart failure and, probably, hypertension. Neuroendocrine activation may contribute importantly to the morbidity and mortality associated with these conditions 11 .

Sympathetic Nervous System

Diuretics increase plasma noradrenaline in patients with hypertension, probably a baroreflex response to a tendency for plasma volume to fall acutely. In patients with untreated heart failure diuretics may reduce plasma noradrenaline though this has not been subject to controlled studies 6 , In patients treated with diuretics chronically sympathetic activity is generally increased and plasma noradrenaline rises further on administration of a diuretic 15 . ACE inhibitors can reduce basal sympathetic activity in heart failure and attenuate the acute increase in plasma noradrenaline observed after diuresis 15 ,

Renal Sodium And Water Handling

In patients with hypertension some studies have suggested that ACE inhibitors increase sodium excretion (net cumulative increased excretion of about 100 mmol over the first week 36 . This appears to be independent of sodium intake and renin activation. However, other studies have not observed a natriuretic effect 47 .

Clinical manifestation

Silvery blond hair occasional subtle pigmentary dilution of the skin and iris and hyperpigmentation in sun-exposed areas accelerated phase of the disease with fever, jaundice, hepatosplenomegaly, lymphaden-opathy, pancytopenia and generalized lym-phohistiocytic infiltrates of various organs including the central nervous system neurologic manifestations hyperreflexia, seizures, signs of intracranial hypertension, regression of developmental milestones,

Diabetes and fibrinolysis

Thus, people with type 2 diabetes exhibit a decreased fibrinolytic system capacity secondary to increased PAI-1 in blood. Similar derangements are evident in association with other states of insulin resistance and compensatory hyperinsulinemia in conditions such as obesity (94,95), hypertension (101), and the polycystic ovarian syndrome (100,102,103).

The Loudness Of The Opening Snap

The mitral valve may be too calcified for the bellies to snap to their maximal open position. (The S1 may still be loud.) b. Extremely low flow due to exceptional severity of the stenosis, secondary pulmonary hypertension, concomitant aortic or tricuspid valve disease, or myocardial dysfunction.

Techniques To Assess Microvascular Dysfunction And Their Limitations

Endothelial dysfunction, assessed at the macrocirculation, has been proven as an early marker of vascular complications in several diseases, including diabetes, dyslipi-demia, and hypertension. The development of techniques capable to measure the skin blood flow has also enabled the study of the vascular reactivity at the microcirculation level. More specifically, the noninvasive measurement of cutaneous blood perfusion can be performed by the laser Doppler.

Spontaneous Intracerebral Hemorrhage

Spontaneous intracerebral hemorrhage (ICH) accounts for approximately 10 of cases of stroke. Arterial hypertension is by far the most common cause of ICH other causes are the intracranial aneurysms, vascular malformation, bleeding diathesis, cerebral amyloidosis, brain tumors, vasculitis, or drug abuse.

Macrovascular Disease And Diabetes An Overview

As opposed to the clear influence of hyperglycemia in the development of microvas-cular complications in diabetes, hyperglycemia plays a less strong role in the development of macrovascular disease, in particular CAD, as shown by the UKPDS (10). Thus, the risk for macrovascular disease in diabetes seems to rely to a considerable degree on other associated abnormalities, such as hypertension, dyslipidemia, altered fibrinolysis, and obesity, all components of the insulin resistance syndrome (44). Endothelial dysfunction activation, detected in most of the clinical abnormalities associated to the insulin resistance syndrome, is now considered a precocious event in the clinical history of both micro- and macrovascular complications, contributing to the initiation and progression of the vascular damage in diabetes.

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Your heart pumps blood throughout your body using a network of tubing called arteries and capillaries which return the blood back to your heart via your veins. Blood pressure is the force of the blood pushing against the walls of your arteries as your heart beats.Learn more...

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