RESUMEN
Severe hypertension (systolic blood pressure (BP) ⩾160 mm Hg) resistant to treatment with multiple antihypertensive medications, poses a serious challenge to therapeutic treatment. Catheter-based renal denervation (RDN) is being increasingly proposed and researched as a safe and effective method of treating this condition. This article evaluates the existing evidence on the effects of RDN on BP reduction and other conditions with increased sympathetic tone. Findings indicate that RDN is a safe and effective treatment for severe hypertension. Moreover, the antihypertensive response to RDN is sustained for up to 3 years of follow-up. RDN decreases office BP more than ambulatory BP, which may be explained by the white-coat effect that causes an increase in office BP. Findings indicate that although reinnervation may occur following RDN, it does not appear to attenuate or reverse the BP response over 24-36 months. There is also evidence that patients with milder forms of hypertension may benefit from RDN. Furthermore, there is emerging evidence that RDN may have a role in the treatment of heart failure, obstructive sleep apnea, insulin resistance, atrial fibrillation and hypertension associated with end-stage renal disease. Taking into account that resistant hypertension and other diseases associated with elevated sympathetic tone are associated with significant morbidity and mortality rates, RDN therapy may be expected to have a significant impact on public health.
Asunto(s)
Desnervación/métodos , Hipertensión/cirugía , Riñón/inervación , Cateterismo , Estudios de Seguimiento , Humanos , Hipertensión/fisiopatología , Riñón/fisiologíaRESUMEN
Systemic hypertension is a common disorder in clinical practice and causes significant morbidity and premature death. A small percentage (< 5%) of patients with hypertension may have renovascular hypertension. Strictly speaking, the term renovascular hypertension should be applied only when the blood pressure rises as a consequence of renal ischemia. Thus, the mere presence of renal artery stenosis is not synonymous with renovascular hypertension. Treatment strategies should be directed at ''renovascular hypertension'' rather than an anatomic renal artery stenosis (which may be discovered accidentally). Management of renal artery stenosis/renovascular hypertension is imprecise at best. This article discusses the patho-physiology of renovascular hypertension and how to approach a patient with renal artery stenosis.
Asunto(s)
Hipertensión Renovascular , Obstrucción de la Arteria Renal , Adulto , Angiografía , Angiografía de Substracción Digital , Angioplastia de Balón , Angiotensina II/fisiología , Inhibidores de la Enzima Convertidora de Angiotensina , Auscultación , Captopril , Diagnóstico Diferencial , Resistencia a Medicamentos , Femenino , Displasia Fibromuscular , Tasa de Filtración Glomerular , Humanos , Hipertensión Maligna/etiología , Hipertensión Renovascular/sangre , Hipertensión Renovascular/diagnóstico , Hipertensión Renovascular/diagnóstico por imagen , Hipertensión Renovascular/tratamiento farmacológico , Hipertensión Renovascular/fisiopatología , Isquemia/complicaciones , Riñón/irrigación sanguínea , Riñón/diagnóstico por imagen , Riñón/fisiopatología , Angiografía por Resonancia Magnética , Masculino , Persona de Mediana Edad , Examen Físico , Pronóstico , Renografía por Radioisótopo , Obstrucción de la Arteria Renal/sangre , Obstrucción de la Arteria Renal/complicaciones , Obstrucción de la Arteria Renal/diagnóstico , Obstrucción de la Arteria Renal/diagnóstico por imagen , Obstrucción de la Arteria Renal/patología , Obstrucción de la Arteria Renal/terapia , Renina/sangre , Sensibilidad y Especificidad , Tomografía Computarizada Espiral , Ultrasonografía DopplerRESUMEN
UNLABELLED: Despite successful therapies for chronic hypertension, hospital admissions for hypertensive emergency more than tripled between 1983 and 1992. OBJECTIVE: To examine the safety and efficacy of fenoldopam, the first antihypertensive with selective and specific action on vascular dopamine (DA1) receptors, in a clinical trial involving emergency department patients with true hypertensive emergencies. METHODS: Patients with a sustained diastolic blood pressure (DBP) of > or =120 mm Hg and evidence of target organ compromise were randomized in a double-blinded manner to one of four fixed doses of intravenous fenoldopam (0.01, 0.03, 0.1, or 0.3 microg/kg/min) for 24 hours. The primary endpoint was the magnitude of DBP reduction in each of the three higher-dose groups after four hours of fenoldopam treatment compared with the lowest-dose group. RESULTS: One hundred seven participants from 21 centers were enrolled, and 94 patients received fenoldopam. Evidence of acute target-organ damage included new renal dysfunction or hematuria (50%), acute congestive heart failure or myocardial ischemia (48%), and papilledema or grade III-IV hypertensive retinopathy (34%). The DBP decreased in a dose-dependent fashion, with significant differences between the 0.1- and 0.3-microg/kg/min groups compared with the lowest-dose group. Treatment was well tolerated, and there were no deaths or serious adverse events during follow-up, up to 48 hours. All patients were successfully transitioned to oral or transdermal antihypertensives with maintenance of blood pressure control. CONCLUSIONS: Fenoldopam safely and effectively lowers blood pressure in a dose-dependent manner in patients with hypertensive emergencies. Observations supporting potential risk factors for hypertensive emergency are discussed.
Asunto(s)
Agonistas de Dopamina/administración & dosificación , Fenoldopam/administración & dosificación , Hipertensión Maligna/tratamiento farmacológico , Adulto , Anciano , Análisis de Varianza , Agonistas de Dopamina/efectos adversos , Relación Dosis-Respuesta a Droga , Método Doble Ciego , Esquema de Medicación , Tratamiento de Urgencia , Femenino , Fenoldopam/efectos adversos , Estudios de Seguimiento , Humanos , Hipertensión Maligna/diagnóstico , Infusiones Intravenosas , Masculino , Persona de Mediana Edad , Probabilidad , Estudios Prospectivos , Valores de Referencia , Índice de Severidad de la Enfermedad , Resultado del TratamientoAsunto(s)
Antihipertensivos/uso terapéutico , Hipertensión/tratamiento farmacológico , Bloqueadores de los Canales de Calcio/uso terapéutico , Enfermedades Cardiovasculares/prevención & control , Felodipino/uso terapéutico , Humanos , Estudios Multicéntricos como Asunto , Ensayos Clínicos Controlados Aleatorios como AsuntoRESUMEN
Systemic hypertension is common in patients with acute as well as with chronic renal diseases. Hypertension is an important factor that contributes to the progression of renal failure. Cardiovascular disease is the leading cause of death and disability in patients with chronic renal failure and in those receiving renal replacement therapy. The prevalence of hypertensive nephropathy remains unabated. Hypertension and chronic renal failure are closely interlinked and govern the morbidity and mortality in patients afflicted by these conditions. There is considerable hope that effective control of hypertension may retard the progression of renal disease. Although mere control of hypertension is of paramount importance, specific pharmacologic approaches may offer certain important renal advantages. Angiotensin-converting enzyme (ACE) inhibitors, by the virtue of their intrarenal effects, exert favorable consequences on the kidney function (and structure, to some extent), particularly in patients with diabetic nephropathy and hypertension. Both experimental and clinical studies have demonstrated the renoprotective effects of ACE inhibitors; these drugs slow down the progression of renal disease independent of their antihypertensive actions. More recently, angiotensin-receptor blockers have been shown to exert similar glomerular effects as ACE inhibitors. Preliminary clinical data also suggest a possible role for angiotensin-receptor blockers in the prevention of progression of renal failure. Therapeutic agents that inhibit the renin-angiotensin axis hold considerable promise in the management of patients with renal disease by slowing down the rate of decline in renal function.
Asunto(s)
Antagonistas de Receptores de Angiotensina , Inhibidores de la Enzima Convertidora de Angiotensina/uso terapéutico , Hipertensión/tratamiento farmacológico , Enfermedades Renales/prevención & control , Animales , Presión Sanguínea/efectos de los fármacos , Progresión de la Enfermedad , Humanos , Hipertensión/complicaciones , Hipertensión/metabolismo , Hipertensión/fisiopatología , Enfermedades Renales/complicaciones , Enfermedades Renales/fisiopatología , Pruebas de Función Renal , Sistema Renina-Angiotensina/efectos de los fármacos , Sistema Renina-Angiotensina/fisiologíaRESUMEN
Although renovascular hypertension is less common than primary hypertension, it is important for clinicians to recognize this clinical entity because of its distinct pathophysiology and specific therapy. It is estimated that about 5% of the overall hypertensive population have renovascular hypertension. Whereas most renovascular lesions are caused by atherosclerosis, stenosis due to fibrous dysplasia is an important disease. In children and young adults, fibromuscular dysplasia of the renal arteries is the most common cause of renovascular hypertension. This review deals with the pathology, clinical characteristics, diagnosis, and therapy of renovascular hypertension associated with fibromuscular dysplasias.
Asunto(s)
Displasia Fibromuscular/patología , Arteria Renal/patología , Biopsia , Diagnóstico Diferencial , Displasia Fibromuscular/complicaciones , Displasia Fibromuscular/diagnóstico por imagen , Humanos , Hipertensión Renovascular/complicaciones , Hipertensión Renovascular/diagnóstico , Pronóstico , Radiografía , Renografía por Radioisótopo , Arteria Renal/diagnóstico por imagen , Obstrucción de la Arteria Renal/diagnóstico , Obstrucción de la Arteria Renal/etiologíaRESUMEN
In the vast population of patients with established hypertension, there is a small group in whom the blood pressure elevation is caused by renal ischemia. These patients have renovascular hypertension, which can presently be diagnosed with greater precision than in the past. The exact prevalence of renovascular hypertension is not known and the diagnosis is probably missed in many patients. It is important to recognize this condition in clinical practice, because it is a correctable from of secondary hypertension and because it is a reversible cause of renal failure in some patients. Clinical identification of patients with renovascular hypertension has been so imprecise and complex that the very diagnostic quest for this condition has been questioned. However, it is well recognized that renovascular disease is a progressive disorder with serious sequelae if appropriate therapy is not rendered.
Asunto(s)
Hipertensión Renovascular , HumanosRESUMEN
A single-blind, run-in, randomized, double-blind, parallel-group, placebo-controlled comparison trial was conducted to assess the safety and efficacy of low-dose amlodipine 2.5 mg daily, low-dose benazepril 10 mg daily, and the combination of the two drugs at the same doses used once daily in patients (n = 401) with mild to moderate (stages I and II) systemic hypertension. Both monotherapy regimens were shown to significantly reduce both systolic and diastolic blood pressure compared with baseline placebo values, and the combination regimen was shown to be superior in lowering systolic and diastolic blood pressure when compared with either of the monotherapy regimens. The combination therapy also resulted in a greater percentage of patients having successful clinical response in mean sitting diastolic blood pressure. The amlodipine and benazepril regimen was also shown to be associated with a similar incidence of adverse experiences as the active monotherapy or placebo regimens, although the group given combination therapy appeared to have a lower incidence of edema than the group given amlodipine alone. Low-dose amlodipine (2.5 mg) plus benazepril (10 mg) provides greater blood-pressure-lowering efficacy than either monotherapy, and has an excellent safety profile.
Asunto(s)
Amlodipino/uso terapéutico , Inhibidores de la Enzima Convertidora de Angiotensina/uso terapéutico , Antihipertensivos/uso terapéutico , Benzazepinas/uso terapéutico , Bloqueadores de los Canales de Calcio/uso terapéutico , Hipertensión/tratamiento farmacológico , Adulto , Anciano , Amlodipino/efectos adversos , Inhibidores de la Enzima Convertidora de Angiotensina/efectos adversos , Antihipertensivos/efectos adversos , Benzazepinas/efectos adversos , Bloqueadores de los Canales de Calcio/efectos adversos , Quimioterapia Combinada , Femenino , Humanos , Masculino , Persona de Mediana EdadRESUMEN
A patient with a hypertensive crisis should be ideally treated in an intensive care unit. The choice of oral versus parenteral drug depends on the urgency of the situation, as well as the patient's general condition. The level to which the blood pressure should be lowered varies with the type of hypertensive crisis and should be individualized. The choice of parenteral drug is dictated by the clinical manifestations and concomitant medical problems associated with the hypertensive crisis. There is no predetermined level for the goal of therapy. Complications of therapy, mainly hypotension and ischemic brain damage, can occur in patients given multiple potent antihypertensive drugs in large doses without adequate monitoring. Such complications can be minimized by gentle lowering of blood pressure, careful surveillance, and individualization of therapy. A relatively asympatomatic patient who presents with severe hypertension, that is, a diastolic blood pressure 130 to 140 mm Hg, need not be treated with parenteral drugs. These patients should be managed on an individual basis, and the usual course would be to intensify or alter the previous antihypertensive therapy. Often, asymptomatic patients or those without an acute problem are unnecessarily subjected to immediate therapy. Acute alteration of the height of the mercury column does little good and may cause harm. A significant immediate change in the patient's blood pressure may be self-gratifying to the physician but is not indicated for most patients with asymptomatic severe hypertension. Indiscriminate use of therapeutic options such as nifedipine and furosemide should be discouraged strongly. Once the patient's condition is stable, one should evaluate the patient for possible factors that may have contributed to the dangerous elevation of blood pressure, such as nonadherence to prescribed therapy or the presence or progression of a secondary form of hypertension such as a renal artery stenosis. It is crucial to recognize not only what is a hypertensive crisis but also what is not an emergency.
Asunto(s)
Hipertensión/tratamiento farmacológico , Humanos , Hipertensión/complicaciones , Hipertensión Maligna/tratamiento farmacológicoRESUMEN
Renovascular hypertension is one of the more common causes of secondary hypertension. The true prevalence of this condition is not known, because only a selected few with hypertension are considered for thorough diagnostic work-up. The higher incidence figures come from centers with a special interest in this disease. The ability of a clinician to detect renovascular hypertension has improved substantially, thanks to the advances in radiology. The predominant mechanism of blood pressure elevation from renal ischemia is activation of the renin-angiotensin system. Clinically, the pathological lesions that cause renal artery stenosis are atherosclerosis and fibromuscular dysplasia; the former is typically seen in older men, and the latter is typically found in young women. Suspicion of the presence of renovascular disease should prompt the physician to obtain appropriate screening and confirmatory tests. Once diagnosed, the management of patients with renovascular hypertension requires a carefully planned multidisciplinary approach to offer the patient a best possible therapeutic option, with surgical revascularization or balloon angioplasty, or chronic medical therapy. However, these options are not mutually exclusive. The best long-term results are obtained with surgical therapy. Although balloon angioplasty is being increasingly used perhaps as the preferred initial therapeutic procedure for many patients with renal artery stenosis, long-term results comparable with surgery are not yet available. The ideal rational therapy for patients with renal artery stenosis is reperfusion of the ischemic kidney either by surgical correction or by balloon dilation. The aim is not only to improve the blood pressure control, but also to prevent and at times to reverse renal failure. Although effective antihypertensive drugs have become available, the role of medical management of renovascular hypertension is shrinking and should be limited to patients who have contraindications to or unwilling to undergo corrective procedures to relieve renal ischemia.
Asunto(s)
Hipertensión Renovascular , Angiografía , Angioplastia , Humanos , Hipertensión Renovascular/diagnóstico , Hipertensión Renovascular/fisiopatología , Hipertensión Renovascular/terapia , Obstrucción de la Arteria Renal/diagnóstico por imagen , Obstrucción de la Arteria Renal/patología , Obstrucción de la Arteria Renal/terapiaRESUMEN
Although a rare cause of secondary hypertension, timely recognition and management of pheochromocytoma are crucial to prevent serious complications that can result from this tumor. The cause of pheochromocytoma is unknown. It may be a component of a polyglandular endocrine disturbance or associated with other neuroectodermal tumors, but usually it is recognized as an isolated finding. Because of the variable clinical manifestations, proper diagnostic quest for pheochromocytoma depends on a high index of suspicion. Availability of biochemical assays for catecholamines and their metabolites has improved our ability to establish or exclude the diagnosis of pheochromocytoma in a suspected patient. However, before ordering the biochemical tests, it is important to be certain that the patient has not taken any drugs or substances that can lead to a spurious value. Confirmatory localization of pheochromocytoma has become a straightforward exercise owing to current radiological techniques. Blockade of the effects of catecholamines provides the pharmacological basis for medical treatment of pheochromocytoma. Surgical removal of the tumor is the treatment of choice for most patients with pheochromocytoma.
Asunto(s)
Neoplasias de las Glándulas Suprarrenales , Feocromocitoma , Neoplasias de las Glándulas Suprarrenales/complicaciones , Neoplasias de las Glándulas Suprarrenales/diagnóstico , Neoplasias de las Glándulas Suprarrenales/genética , Catecolaminas/sangre , Diagnóstico Diferencial , Humanos , Hipertensión/etiología , Hipertensión/terapia , Incidencia , Neoplasia Endocrina Múltiple , Feocromocitoma/complicaciones , Feocromocitoma/diagnóstico , Feocromocitoma/terapia , Cintigrafía , Tomografía Computarizada por Rayos XRESUMEN
The primary objective of this study was to compare the antihypertensive efficacy and safety of intravenously administered nicardipine with that of intravenous nitroprusside (SNP) in patients with severe hypertension. The study was conducted in 121 patients with severe hypertension (diastolic blood pressure [BP] > 120 mm Hg, or systolic BP > 200 mm Hg). Patients were randomized to receive intravenous nicardipine or SNP. Drugs were administered according to a predetermined dosing schedule for a 10 to 12 h period. Sixty-one patients were randomized to intravenous nicardipine and 60 to SNP. Pretreatment BP values for the nicardipine and SNP groups were 217/128 mm Hg and 219/128 mm Hg, respectively. Therapeutic response (diastolic BP < 100 mm Hg, or a decrease of > 15 mm Hg; systolic BP < 180 mm Hg, or a decrease of > 20 mm Hg) was achieved in 98% (60/61) of patients treated with nicardipine and 93% (56/60) of patients treated with SNP. The mean decreases in systolic and diastolic BP were 61 mm Hg and 40 mm Hg after 4 h of nicardipine, and 59 mm Hg and 38 mm Hg after 4 h of SNP. The mean increases in heart rate also were similar in both groups (nicardipine, 12 beats/min; SNP 10 beats/min). The mean numbers of dose adjustments per hour required to maintain the BP reductions were lower (P < .01) in the nicardipine-treated patients (0.5 +/- 0.1 times per hour) than in the SNP-treated patients (1.5 +/- 0.2 times per hour).(ABSTRACT TRUNCATED AT 250 WORDS)
Asunto(s)
Hipertensión/tratamiento farmacológico , Nicardipino/uso terapéutico , Nitroprusiato/uso terapéutico , Adulto , Presión Sanguínea/efectos de los fármacos , Relación Dosis-Respuesta a Droga , Femenino , Frecuencia Cardíaca/efectos de los fármacos , Humanos , Hipertensión/fisiopatología , Inyecciones Intravenosas , Masculino , Persona de Mediana Edad , Nicardipino/efectos adversos , Nitroprusiato/efectos adversos , Estudios Prospectivos , Factores de TiempoRESUMEN
In the final analysis of this study at Week 26, 26% of the patients randomized to receive amlodipine attained blood pressure control with amlodipine alone compared with 33% of the patients allocated to hydrochlorothiazide (HCTZ). Neither amlodipine nor HCTZ produced clinically significant changes in pulse rate or in the electrocardiogram. Amlodipine treatment did not appear to produce clinically significant changes in blood lipids; HCTZ, however, produced an increase in total plasma cholesterol (delta 22.9 +/- 8.6 mg/dl). The incidence of side effects and the rate of patient withdrawal in the amlodipine and HCTZ groups were comparable. As expected, HCTZ therapy caused well-recognized biochemical alterations in cholesterol and potassium levels, whereas amlodipine was metabolically neutral.
Asunto(s)
Amlodipino/uso terapéutico , Hidroclorotiazida/uso terapéutico , Hipertensión/tratamiento farmacológico , Adolescente , Adulto , Anciano , Amlodipino/administración & dosificación , Amlodipino/efectos adversos , Atenolol/administración & dosificación , Atenolol/efectos adversos , Atenolol/uso terapéutico , Presión Sanguínea/efectos de los fármacos , Colesterol/sangre , HDL-Colesterol/sangre , LDL-Colesterol/sangre , VLDL-Colesterol/sangre , Método Doble Ciego , Combinación de Medicamentos , Electrocardiografía/efectos de los fármacos , Femenino , Humanos , Hidroclorotiazida/administración & dosificación , Hidroclorotiazida/efectos adversos , Masculino , Persona de Mediana Edad , Pulso Arterial/efectos de los fármacos , Seguridad , Método Simple Ciego , Triglicéridos/sangreRESUMEN
The three most common causes--renal artery stenosis, pheochromocytoma, and primary aldosteronism--are reviewed, including uncomplicated screening procedures to select candidates for a more intensive workup. The first two conditions are usually corrected by angioplasty or surgery, whereas aldosteronism may require both surgical and medical therapy or medication alone.
Asunto(s)
Hipertensión/etiología , Hipertensión/terapia , Neoplasias de las Glándulas Suprarrenales/complicaciones , Neoplasias de las Glándulas Suprarrenales/diagnóstico , Neoplasias de las Glándulas Suprarrenales/terapia , Humanos , Hiperaldosteronismo/complicaciones , Hiperaldosteronismo/diagnóstico , Hipertensión Renovascular/diagnóstico , Hipertensión Renovascular/terapia , Feocromocitoma/complicaciones , Feocromocitoma/diagnóstico , Feocromocitoma/terapia , Obstrucción de la Arteria Renal/complicaciones , Obstrucción de la Arteria Renal/diagnóstico , Obstrucción de la Arteria Renal/cirugíaAsunto(s)
Antagonistas Adrenérgicos alfa/uso terapéutico , Hipertrofia Ventricular Izquierda/tratamiento farmacológico , Prazosina/análogos & derivados , Animales , Arritmias Cardíacas/etiología , Presión Sanguínea/efectos de los fármacos , Hemodinámica , Humanos , Hipertensión/complicaciones , Hipertrofia Ventricular Izquierda/etiología , Modelos Biológicos , Prazosina/uso terapéuticoRESUMEN
The antihypertensive effects of drugs are partly determined by characteristics of the patients treated. A randomized, double-blind study used 24-hour ambulatory blood pressure (BP) monitoring to compare the effects of 2 beta blockers, bisoprolol (10 to 20 mg; n = 107) and atenolol (50 to 100 mg; n = 96), administered once daily in 4 population groups. After a 4-week placebo period, patients with an office diastolic BP between 95 and 114 mm Hg were stratified according to race and age, and were randomly assigned to treatment with bisoprolol or atenolol for 8 weeks. BP averages measured by automated monitoring for the 24-hour periods were compared between groups. In elderly patients, the reductions in both average 24-hour systolic and diastolic BP were greater with bisoprolol than with atenolol (13 +/- 3/13 +/- 1 mm Hg [n = 23] vs 4 +/- 2/6 +/- 1 mm Hg [n = 30]; p < 0.01). Similarly, bisoprolol produced greater reductions in average 24-hour diastolic BP than did atenolol in nonblack patients (16 +/- 2/12 +/- 1 mm Hg [n = 85] vs 12 +/- 2/9 +/- 1 mm Hg [n = 83]; p = 0.02). Bisoprolol and atenolol were similar in the black (10 +/- 5/9 +/- 3 mm Hg [n = 22] and 10 +/- 6/6 +/- 3 mm Hg [n = 13], respectively) and young (15 +/- 1/11 +/- 1 mm Hg [n = 84] and 16 +/- 2/10 +/- 1 mm Hg [n = 66], respectively) groups.(ABSTRACT TRUNCATED AT 250 WORDS)
Asunto(s)
Atenolol/uso terapéutico , Bisoprolol/uso terapéutico , Hipertensión/tratamiento farmacológico , Adulto , Factores de Edad , Anciano , Atención Ambulatoria , Población Negra , Presión Sanguínea , Método Doble Ciego , Femenino , Humanos , Hipertensión/etnología , Hipertensión/fisiopatología , Masculino , Persona de Mediana Edad , Monitoreo Fisiológico , Resultado del TratamientoRESUMEN
PURPOSE: This multicenter, double-blind, parallel group study assessed the usefulness of the ambulatory blood pressure monitoring (ABPM) technique in differentiating between the once-daily administration of the beta blockers bisoprolol (10 to 20 mg) and atenolol (50 to 100 mg) in terms of efficacy and duration of action. PATIENTS AND METHODS: The study population consisted of 659 patients with essential hypertension and an average office diastolic blood pressure (BP) between 95 and 115 mm Hg after 4 weeks of placebo treatment. Office BPs were recorded at the end of the 24-hour dosing interval (trough). ABPM was performed in 11 of the 28 institutions participating in this study in a total of 203 patients. These procedures were performed at the end of the placebo phase and again after 8 weeks of active treatment. RESULTS: With the use of conventionally measured office BPs, the two drugs significantly (p < 0.001) decreased trough systolic and diastolic BPs to a similar extent. By 24-hour monitoring, bisoprolol demonstrated a 33% greater reduction in whole-day average diastolic BP than did atenolol (11.6 +/- 0.7 mm Hg versus 8.7 +/- 0.8 mm Hg, p < 0.01). Significant treatment differences in systolic (p < 0.05) and diastolic (p < 0.01) BPs were also noted for bisoprolol compared with atenolol during the final 4 hours of the dosing interval (-13.2 +/- 1.5/-10.9 +/- 1.0 mm Hg versus -8.9 +/- 1.6/-7.3 +/- 1.1 mm Hg, respectively), and over the time period 6:00 AM to noon (-14.2 +/- 1.3/-11.5 +/- 0.9 mm Hg versus -9.9 +/- 1.4/-7.7 +/- 0.9 mm Hg). CONCLUSIONS: Whereas conventional BP measurements did not detect differences in the antihypertensive effects of the beta blockers bisoprolol and atenolol, ABPM revealed significant treatment differences in both the efficacy and duration of action of these two agents. These findings indicate the power of this technique to discriminate potentially important differences between apparently similar antihypertensive drugs.
Asunto(s)
Atenolol/uso terapéutico , Bisoprolol/uso terapéutico , Monitores de Presión Sanguínea , Hipertensión/tratamiento farmacológico , Adulto , Anciano , Anciano de 80 o más Años , Atenolol/administración & dosificación , Atenolol/efectos adversos , Bisoprolol/administración & dosificación , Bisoprolol/efectos adversos , Presión Sanguínea/efectos de los fármacos , Determinación de la Presión Sanguínea , Diástole , Método Doble Ciego , Femenino , Frecuencia Cardíaca/efectos de los fármacos , Humanos , Masculino , Persona de Mediana Edad , Placebos , Método Simple Ciego , SístoleRESUMEN
Emerging consensus indicates that the goal of antihypertensive therapy is not merely a reduction in the level of systemic arterial blood pressure; rather, it is prevention of target organ damage and reversal of complications. Among the clinical consequences of hypertension, left ventricular hypertrophy (LVH) is a prominent manifestation. Initially the left ventricle (LV) hypertrophies as an adaptive physiological response to an increase in afterload. However, persistence of LVH can cause a number of cardiac complications. Reversal of LVH is, therefore, likely to be of immense therapeutic benefit. A number of clinical and experimental observations have shown a close correlation between level of adrenergic activity and the development of LVH; adrenergic blockade has been shown to cause regression of LVH. Recent studies have demonstrated that post-synaptic alpha-blockers cause a reduction of LV mass. Terazosin, by virtue of its long duration of action, may attenuate the pathologic adrenergic pathways in the myocardium. These observations suggest the possible role of adrenergic mechanisms in the complex multifactorial pathogenesis of LVH and suggest the therapeutic impact of alpha-adrenergic blockade in promoting regression of LVH.
Asunto(s)
Hipertensión/fisiopatología , Hipertrofia Ventricular Izquierda/etiología , Sistema Nervioso Simpático/fisiopatología , Antagonistas Adrenérgicos alfa/uso terapéutico , Antagonistas Adrenérgicos beta/uso terapéutico , Animales , Humanos , Hipertensión/tratamiento farmacológico , Hipertrofia Ventricular Izquierda/tratamiento farmacológicoRESUMEN
Renovascular disease represents an important dimension of hypertension. Although estimates vary regarding the exact prevalence of renovascular hypertension, it is being diagnosed with increasing frequency because of refined criteria for the workup and the availability of sensitive diagnostic tests. Two major pathologic entities--atherosclerosis and fibromuscular dysplasia--account for most cases of renovascular hypertension. Once the diagnosis and clinical significance of renal artery stenosis in a hypertensive patient are established, appropriate and specific therapy should be considered. The goal is not only to treat hypertension, but to preserve and restore renal function. Although antihypertensive drug therapy may lower the blood pressure, reperfusion of the kidney (surgical, angioplasty) is a desirable long-term objective in the management of patients with renovascular hypertension. With careful selection of therapeutic choices, we are now able to render optimal care to patients with renovascular hypertension.