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Ching K, Houard X, Berenbaum F, Wen C. Hypertension meets osteoarthritis - revisiting the vascular aetiology hypothesis. Nat Rev Rheumatol 2021; 17:533-549. [PMID: 34316066 DOI: 10.1038/s41584-021-00650-x] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/23/2021] [Indexed: 02/07/2023]
Abstract
Osteoarthritis (OA) is a whole-joint disease characterized by subchondral bone perfusion abnormalities and neovascular invasion into the synovium and articular cartilage. In addition to local vascular disturbance, mounting evidence suggests a pivotal role for systemic vascular pathology in the aetiology of OA. This Review outlines the current understanding of the close relationship between high blood pressure (hypertension) and OA at the crossroads of epidemiology and molecular biology. As one of the most common comorbidities in patients with OA, hypertension can disrupt joint homeostasis both biophysically and biochemically. High blood pressure can increase intraosseous pressure and cause hypoxia, which in turn triggers subchondral bone and osteochondral junction remodelling. Furthermore, systemic activation of the renin-angiotensin and endothelin systems can affect the Wnt-β-catenin signalling pathway locally to govern joint disease. The intimate relationship between hypertension and OA indicates that endothelium-targeted strategies, including re-purposed FDA-approved antihypertensive drugs, could be useful in the treatment of OA.
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Affiliation(s)
- Karen Ching
- Department of Biomedical Engineering, The Hong Kong Polytechnic University, Hung Hom, Hong Kong, China
| | - Xavier Houard
- Sorbonne Université, INSERM, Centre de Recherche Saint-Antoine, Paris, France
| | - Francis Berenbaum
- Sorbonne Université, INSERM, Centre de Recherche Saint-Antoine, Paris, France
- Department of Rheumatology, Sorbonne Université, Saint-Antoine Hospital, Paris, France
| | - Chunyi Wen
- Department of Biomedical Engineering, The Hong Kong Polytechnic University, Hung Hom, Hong Kong, China.
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Yeşiltepe A, Dizdar OS, Gorkem H, Dondurmacı E, Ozkan E, Koç A, Oguz Baktır A, Gunal AI. Maintenance of negative fluid balance can improve endothelial and cardiac functions in primary hypertensive patients. Clin Exp Hypertens 2017; 39:579-586. [PMID: 28613081 DOI: 10.1080/10641963.2017.1291663] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
PURPOSE The issue of unidentified volume expansion is well recognized as a cause for resistance to antihypertensive therapy. The aim of study is to identify contribution of negative fluid balance to hypertension control and impact on endothelial and cardiac functions among primary hypertensive patients who do not have kidney failure. MATERIALS AND METHODS This is a prospective interventional study with one-year follow-up. Preceded by volume status measurements were performed by a body composition monitor (BCM), the patients were put on ambulatory blood pressure monitoring for 24 hours. Then, echocardiographic assessments and flow-mediated dilation (FMD) and carotid intima-media thickness (CIMT) measurements were completed. Patients in one of the two groups were kept negative hydrated during trial with diuretic treatment. RESULTS At the end of one-year follow-up, patients in negative hydrated group were found to have significantly lower CIMT, left ventricle mass index, left ventricular end-diastolic diameter, mean systolic and diastolic BP, non-dipper patient ratio, and higher FMD. In negatively hydrated group, target organ damage significantly reduced during trial. CONCLUSIONS The significance of negative hydration status with respect to blood pressure control, endothelial and cardiac functions within primary hypertensive patients who do not suffer from kidney failure has been demonstrated.
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Affiliation(s)
- Ali Yeşiltepe
- a Department of Internal Medicine , Kayseri Training and Research Hospital , Kayseri , Turkey
| | - Oguzhan Sıtkı Dizdar
- b Department of Internal Medicine and Clinical Nutrition , Kayseri Training and Research Hospital , Kayseri , Turkey
| | - Hasan Gorkem
- a Department of Internal Medicine , Kayseri Training and Research Hospital , Kayseri , Turkey
| | - Engin Dondurmacı
- c Department of Cardiology , Kayseri Training and Research Hospital , Kayseri , Turkey
| | - Eyup Ozkan
- c Department of Cardiology , Kayseri Training and Research Hospital , Kayseri , Turkey
| | - Ali Koç
- d Department of Radiology , Kayseri Training and Research Hospital , Kayseri , Turkey
| | - Ahmet Oguz Baktır
- c Department of Cardiology , Kayseri Training and Research Hospital , Kayseri , Turkey
| | - Ali Ihsan Gunal
- e Department of Internal Medicine Division of Nephrology , Kayseri Training and Research Hospital , Kayseri , Turkey
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Sinnott SJ, Tomlinson LA, Root AA, Mathur R, Mansfield KE, Smeeth L, Douglas IJ. Comparative effectiveness of fourth-line anti-hypertensive agents in resistant hypertension: A systematic review and meta-analysis. Eur J Prev Cardiol 2016; 24:228-238. [DOI: 10.1177/2047487316675194] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Sarah-Jo Sinnott
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, UK
| | - Laurie A Tomlinson
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, UK
| | - Adrian A Root
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, UK
| | - Rohini Mathur
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, UK
| | - Kathryn E Mansfield
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, UK
| | - Liam Smeeth
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, UK
| | - Ian J Douglas
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, UK
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Rada MA, Galarza CR, Aparicio LS, Cuffaro PE, Piccinini JM, Alfie J, Morales MS, Barochiner J, Marin MJ, Waisman GD. Dependence of thoracic fluid content with anthropometric-geometric factors in impedance cardiography. Clin Exp Pharmacol Physiol 2016; 43:1151-1152. [PMID: 27514021 DOI: 10.1111/1440-1681.12631] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Revised: 07/27/2016] [Accepted: 08/09/2016] [Indexed: 12/01/2022]
Affiliation(s)
- Marcelo A Rada
- Hypertension Section, Internal Medicine Service, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina.
| | - Carlos R Galarza
- Hypertension Section, Internal Medicine Service, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Lucas S Aparicio
- Hypertension Section, Internal Medicine Service, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Paula E Cuffaro
- Hypertension Section, Internal Medicine Service, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | | | - José Alfie
- Hypertension Section, Internal Medicine Service, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Margarita S Morales
- Hypertension Section, Internal Medicine Service, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Jessica Barochiner
- Hypertension Section, Internal Medicine Service, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Marcos J Marin
- Hypertension Section, Internal Medicine Service, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Gabriel D Waisman
- Hypertension Section, Internal Medicine Service, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
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Abstract
Loop diuretics are not recommended in current hypertension guidelines largely due to the lack of outcome data. Nevertheless, they have been shown to lower blood pressure and to offer potential advantages over thiazide-type diuretics. Torsemide offers advantages of longer duration of action and once daily dosing (vs. furosemide and bumetanide) and more reliable bioavailability (vs. furosemide). Studies show that the previously employed high doses of thiazide-type diuretics lower BP more than furosemide. Loop diuretics appear to have a preferable side effect profile (less hyponatremia, hypokalemia, and possibly less glucose intolerance). Studies comparing efficacy and side effect profiles of loop diuretics with the lower, currently widely prescribed, thiazide doses are needed. Research is needed to fill gaps in knowledge and common misconceptions about loop diuretic use in hypertension and to determine their rightful place in the antihypertensive arsenal.
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Affiliation(s)
- Line Malha
- Department of Nephrology and Hypertension, Hypertension Center, NY Presbyterian Hospital-Weill Cornell Medicine, 424 E. 70th Street, New York, NY, 10021, USA
| | - Samuel J Mann
- Department of Nephrology and Hypertension, Hypertension Center, NY Presbyterian Hospital-Weill Cornell Medicine, 424 E. 70th Street, New York, NY, 10021, USA.
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6
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Individualizing antihypertensive combination therapies: clinical and hemodynamic considerations. Curr Hypertens Rep 2015; 16:451. [PMID: 24806735 DOI: 10.1007/s11906-014-0451-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
While there are strong trial data to guide the selection of initial hypertension treatment choice and limited data to support second agent choice, beyond the first two agents, subsequent steps are empiric. As medications are added, the resulting polypharmacy may be complex, inefficient and poorly tolerated, resulting in low treatment adherence rates. The selection of antihypertensive drug therapy based on hemodynamic mechanisms is not new but became practical with the availability of noninvasive hemodynamic parameters using impedance cardiography. Individualized therapy based on hormonal or hemodynamic measurements can effectively control hypertension as shown in several small clinical trials. Hemodynamic measurements are obtained quickly, painlessly and can be used in a serial fashion to guide treatment adjustments. Current limitations relate to availability of the measurement device and personnel trained in its use, reimbursement for the measurements, expertise in interpretation of the measurements and systems to adjust medication and repeat measurements in a serial fashion until targets are attained. The potential utility of this approach increases with greater complexity of the medication regimen. Further studies are indicated and may advance options for individualized treatment of hypertensive patients.
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Slim HB, Black HR, Thompson PD. Older blood pressure medications-do they still have a place? Am J Cardiol 2011; 108:308-16. [PMID: 21550576 DOI: 10.1016/j.amjcard.2011.03.041] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2011] [Revised: 03/11/2011] [Accepted: 03/11/2011] [Indexed: 01/13/2023]
Abstract
Hypertension is a major risk factor for cardiovascular disease, but control of hypertension remains inadequate, often because of poor patient adherence to prescribed medical regimens that are viewed as poorly tolerated and expensive. Physicians have largely stopped using some older blood pressure medications in favor of newer agents, mostly because of a presumed more favorable side effect profile. The investigators reviewed the pharmacologic properties and the evidence supporting the effectiveness and tolerability of several older blood pressure drugs: sympatholytic agents such as reserpine, methyldopa, and clonidine; diuretics such as chlorthalidone, ethacrynic acid and spironolactone; the vasodilators hydralazine and minoxidil; and others. In conclusion, some of these drugs are well studied and represent alternatives for patients who cannot afford or tolerate newer medications.
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Affiliation(s)
- Hanna B Slim
- Cardiology, Hartford Hospital, Connecticut, USA.
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Faselis C, Doumas M, Papademetriou V. Common secondary causes of resistant hypertension and rational for treatment. Int J Hypertens 2011; 2011:236239. [PMID: 21423678 PMCID: PMC3057025 DOI: 10.4061/2011/236239] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2010] [Accepted: 01/11/2011] [Indexed: 12/20/2022] Open
Abstract
Resistant hypertension is defined as uncontrolled blood pressure despite the use of three antihypertensive drugs, including a diuretic, in optimal doses. Treatment resistance can be attributed to poor adherence to antihypertensive drugs, excessive salt intake, physician inertia, inappropriate or inadequate medication, and secondary hypertension. Drug-induced hypertension, obstructive sleep apnoea, primary aldosteronism, and chronic kidney disease represent the most common secondary causes of resistant hypertension. Several drugs can induce or exacerbate pre-existing hypertension, with non-steroidal anti-inflammatory drugs being the most common due to their wide use. Obstructive sleep apnoea and primary aldosteronism are frequently encountered in patients with resistant hypertension and require expert management. Hypertension is commonly found in patients with chronic kidney disease and is frequently resistant to treatment, while the management of renovascular hypertension remains controversial. A step-by-step approach of patients with resistant hypertension is proposed at the end of this review paper.
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Affiliation(s)
- Charles Faselis
- Veterans Affairs Medical Center, George Washington University, VAMC 50 Irving Street NW, Washington, DC 20422, USA
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Epstein M, Calhoun DA. The role of aldosterone in resistant hypertension: Implications for pathogenesis and therapy. Curr Hypertens Rep 2007; 9:98-105. [PMID: 17442219 DOI: 10.1007/s11906-007-0018-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Resistant hypertension constitutes an increasingly common medical disorder. Although the exact incidence is not precisely known, estimates derived from recent outcome studies emphasize that resistant hypertension is much more common than previously thought. A major advance in our understanding of its pathogenesis and management is the recent recognition of the importance of aldosterone excess or autonomy as an important mechanism for drug resistance in hypertension. Recent studies of the effects of aldosterone on vascular smooth muscle have delineated several extra-renal mechanisms whereby aldosterone produces hypertension primarily by its direct vasoconstrictor effects and by altering vascular compliance. Consequently, aldosterone blockade constitutes an effective intervention for treating resistant hypertension.
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Affiliation(s)
- Murray Epstein
- Professor of Medicine, Nephrology Section, VA Medical Center, Miami, FL 33125, USA.
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Calhoun DA. Low-Dose Aldosterone Blockade as a New Treatment Paradigm for Controlling Resistant Hypertension. J Clin Hypertens (Greenwich) 2007; 9:19-24. [PMID: 17215651 PMCID: PMC8109922 DOI: 10.1111/j.1524-6175.2007.06334.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Treatment of resistant hypertension requires confirmation of true resistance, diagnosis and treatment of secondary causes of hypertension, adoption of appropriate lifestyle modifications, and effective use of multidrug antihypertensive regimens. Excessive volume retention often underlies resistant hypertension, so diuretics are generally necessary to achieve blood pressure (BP) goals. Although treatment regimens consisting of 3 or more agents have not been systematically evaluated, the author has found a triple regimen consisting of a thiazide diuretic, a calcium channel blocker, and an angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) to be generally effective and well tolerated. Although hydrochlorothiazide is more widely used, chlorthalidone provides better BP reduction and should be preferentially used in patients with resistant hypertension, particularly if the patient remains uncontrolled on hydrochlorothiazide. Recent studies have demonstrated that low doses of aldosterone antagonists, when added to multidrug regimens that include a thiazide diuretic and an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker, provide significant additional BP reduction, seemingly exceeding what would be expected with addition of alternative classes of agents. The degree of BP reduction induced by aldosterone blockade has been similar in patients with and without evidence of aldosterone excess. Aldosterone antagonists are generally safe and well tolerated. The most common adverse effect of low-dose spironolactone has been breast tenderness, occurring in about 10% of men. Hyperkalemia is uncommon, but can occur, necessitating biochemical monitoring. Risk of hyperkalemia is increased in patients with chronic kidney disease or diabetes, elderly patients, and patients already receiving an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker.
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Affiliation(s)
- David A Calhoun
- Vascular Biology and Hypertension Program, University of Alabama Sleep/Wake Disorders Center, University of Alabama at Birmingham, USA.
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Affiliation(s)
- Domenic A. Sica
- From the Departments of Medicine and Pharmacology, Section of Clinical Pharmacology and Hypertension, Division of Nephrology, Virginia Commonwealth University, Richmond, VA
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Ménard J, Pascoe L. Can the dextroenantiomer of the aromatase inhibitor fadrozole be useful for clinical investigation of aldosterone-synthase inhibition? J Hypertens 2006; 24:993-7. [PMID: 16685193 DOI: 10.1097/01.hjh.0000226183.98439.b3] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The beneficial effects of spironolactone, eplerenone, amiloride and potassium in preventing cardiovascular damage in various experimental models of salt-induced hypertension can be dissociated from blood pressure effects, and have drawn attention to the direct genomic and non-genomic actions of aldosterone at the level of the vessels, the heart and the kidneys. Exposure to endogenous aldosterone could be decreased by direct and specific aldosterone-synthase inhibition. FAD 286A, the dextroenantiomer of the aromatase inhibitor fadrozole, might be a first candidate to investigate in humans, the physiological impact and therapeutic properties of aldosterone-synthase inhibition, especially in various forms of primary aldosteronism.
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Affiliation(s)
- Joël Ménard
- SPIM, Faculté de Médecine René Descartes, Paris, France.
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Abstract
Although the true prevalence of resistant hypertension is not known, it is likely that this condition will become increasingly common, driven by an aging population, obesity, nonadherence trends, and effects of target-organ disease. Current approaches focus on two goals: evaluation and correction of contributing causes, then selection of an effective drug regimen. Lifestyle factors contribute to resistance, particularly high sodium intake and weight gain. Secondary causes should be considered and corrected if feasible. Recent efforts have focused on the development of clinical pathways to guide treatment, based on plasma renin activity, aldosterone production, or hemodynamic measurements. The components of drug combinations beyond the second agent remain empiric. Although volume expansion plays a key role in drug resistance, clinical assessment of volume status is often difficult, frustrating efforts to achieve blood pressure control. Determination of the most effective approaches will require clinical trials using combination therapy.
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Affiliation(s)
- Sandra J Taler
- Division of Nephrology and Hypertension, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55905, USA.
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Goodfriend TL, Calhoun DA. Resistant hypertension, obesity, sleep apnea, and aldosterone: theory and therapy. Hypertension 2004; 43:518-24. [PMID: 14732721 DOI: 10.1161/01.hyp.0000116223.97436.e5] [Citation(s) in RCA: 175] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Hypertension resistant to 2 antihypertensive drugs is more common among obese patients than among lean patients. The case we describe and the observations we report suggest that refractoriness among obese hypertensives is frequently caused by obstructive sleep apnea and/or inappropriately high plasma aldosterone levels. In other words, obese hypertensives may have sleep apnea, obese hypertensives without sleep apnea may have inappropriately elevated levels of plasma aldosterone, and a surprising number of obese patients with sleep apnea also have elevated levels of aldosterone. The mechanisms by which obesity and obstructive sleep apnea increase aldosterone levels and raise blood pressure are not understood, but sympathetic nervous system activation and production of nonclassical adrenal stimuli are two possibilities. Obstructive sleep apnea can be detected with a careful history and various sleep studies. Inappropriately elevated aldosterone levels can be detected by measuring the ratio of plasma aldosterone concentration to plasma renin activity. Successful treatment of these resistant hypertensives often can be achieved by devices that provide positive pressure to the upper airway to correct obstructive sleep apnea and by incorporating an aldosterone antagonist in the therapeutic regimen.
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Affiliation(s)
- Theodore L Goodfriend
- Research Service, William S. Middleton Memorial Veterans Hospital, 2500 Overlook Terrace, Madison, WI 53705, USA.
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Taler SJ, Textor SC, Augustine JE. Resistant hypertension: comparing hemodynamic management to specialist care. Hypertension 2002; 39:982-8. [PMID: 12019280 DOI: 10.1161/01.hyp.0000016176.16042.2f] [Citation(s) in RCA: 205] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Although resistant hypertension affects a minority of all hypertensives, this group continues to experience disproportionately high cardiovascular event rates despite newer antihypertensive agents. Hypertension represents an imbalance of hemodynamic forces within the circulation, usually characterized by elevated systemic vascular resistance. We studied the utility of serial hemodynamic parameters in the selection and titration of antihypertensive medication in resistant hypertensive patients using highly reproducible noninvasive measurements by thoracic bioimpedance. Resistant hypertension patients (n=104) were randomized to drug selection based either on serial hemodynamic (HD) measurements and a predefined algorithm or on drug selection directed by a hypertension specialist (SC) in a 3-month intensive treatment program. Blood pressure was lowered by intensified drug therapy in both treatment groups (169+/-3/87+/-2 to 139+/-2/72+/-1 mm Hg HD versus 173+/-3/91+/-2 to 147+/-2/79+/-1 mm Hg SC, P<0.01 for systolic and diastolic BP), using similar numbers and intensity of antihypertensive medications. Blood pressures were reduced further for those treated according to hemodynamic measurements, resulting in improved control rates (56% HD versus 33% SC controlled to </=140/90 mm Hg, P<0.05) and incremental reduction in systemic vascular resistance measurements. Although the number of patients taking diuretics did not differ between groups, final diuretic dosage was higher in the hemodynamic cohort. Our results demonstrate superior blood pressure control using a treatment algorithm and serial hemodynamic measurements compared with clinical judgment alone in a randomized prospective study. Our measurements of thoracic fluid volume support occult volume expansion as a mediator of antihypertensive drug resistance and use of impedance measurements to guide advancing diuretic dose and adjustment of multidrug antihypertensive treatment.
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Affiliation(s)
- Sandra J Taler
- Department of Medicine, Division of Hypertension and Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA.
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Fernández Pinilla C, Rodríguez Cerrillo M. Hipertensión arterial refractaria. HIPERTENSION Y RIESGO VASCULAR 2000. [DOI: 10.1016/s1889-1837(00)71027-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Abstract
OBJECTIVES To study the prognosis in therapy-resistant hypertension (RH). DESIGN Patients with RH and age- and sex-matched responding hypertensives, were followed-up for a period of 7 years. SETTING All subjects were outpatients at a secondary referral centre for hypertension. SUBJECTS (i) Age < or = 65 years; (ii) no prior diagnosis of secondary hypertension; (iii) on antihypertensive triple-drug therapy of optimal dosage; (iv) diastolic blood pressure remaining 5 mmHg above their (age-related) target pressure; (v) no history of renal failure, heart failure, stroke or myocardial infarction; and (vi) no record of noncompliance. A total of 800 patients were screened. Thirty-six were finally included. For each study patient, two control patients were randomly selected. INTERVENTIONS Continuous efforts to optimize blood pressure control were made in all patients. MAIN OUTCOME MEASURES Transient ischaemic attack or stroke, myocardial infarction, congestive heart failure, renal failure, and death. Development of non-insulin-dependent diabetes mellitus (NIDDM). RESULTS At the end of the follow-up period, RH had a casual functional blood pressure 2/6 mmHg higher than the control hypertensives. RH exhibited an increased incidence of stroke (P < 0.05), renal insufficiency (P < 0.05) and NIDDM (P < 0.05). RH patients had an increased risk of suffering an event during the 7 years [odds ratio (OR) 2.71; P < 0.05]. CONCLUSIONS Resistance to antihypertensive therapy may persist even when therapy is aggressively applied in compliant patients. RH is associated to an increased risk of stroke and of target organ damage, foremost renal insufficiency. The apparent association between RH, obesity and NIDDM may imply that hyperinsulinaemia is involved in therapy resistance.
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Affiliation(s)
- H Isaksson
- Department of Cardiology, Söder Hospital Stockholm, Sweden
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Abstract
25 years have elapsed since the introduction of the first effective oral diuretic, chlorothiazide. Diuretics are now amongst the most widely prescribed drugs in clinical practice worldwide. Availability of these drugs has not only brought therapeutic benefit to countless numbers of patients but it has at the same time provided valuable research tools with which to investigate the functional behaviour of the kidney and other electrolyte-transporting tissues. Despite many remaining gaps in our knowledge of the biochemical processes involved in diuretic drug action, available compounds can be divided into 5 groups on the basis of their preferential effects on different segments of the nephron involved in tubular reabsorption of sodium chloride and water. Firstly, there is a heterogeneous group of chemicals that share the common property of powerful, short-lived diuretic effects that are complete within 4 to 6 hours. These agents act on the thick ascending limb of Henle's loop and are known as 'high ceiling' or 'loop' diuretics. The second group are the benzothiadiazines and their many related heterocyclic variants, all of which localise their effects to the early portion of the distal tubule. The third group comprises the potassium-sparing diuretics which act exclusively on the Na+-K+/H+ exchange mechanisms in the late distal tubule and cortical collecting duct. The action of drugs in groups 2 and 3 is prolonged to between 12 and 24 hours. The fourth group consists of diuretics that are chemically related to ethacrynic acid but have the unusual property of combining within the same molecule the property of saluresis and uricosuria. These compounds have actions, to different individual extents, in the proximal tubule, thick ascending limb, and early distal tubule and are known as 'polyvalent' diuretics. Finally, there is a mixed group of weak or adjunctive diuretics which includes the vasodilator xanthines such as aminophylline, and the osmotically active compounds such as mannitol. The metabolic consequences of continued diuretic usage are considered along with non-metabolic sequelae such as ototoxicity or interactions with other concurrent treatments. The relationships between the clinical benefits conferred and the potential harms generated by long term diuretic therapy are also discussed.
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Abstract
In a balanced single-blind placebo controlled study in six hypertensive patients treated with diuretic and beta-adrenoceptor blocker, a single oral dose of 10 mg pinacidil lowered blood pressure significantly, by a maximum of 26/13 mm Hg lying and 15/12 mm Hg standing at 3 h. The duration of action was less than 6 h. Chronic treatment of four patients (mean dose 20 mg twice daily for 3--7 weeks) lowered blood pressure by only 15/7 mm Hg. All four patients experienced side-effects of the type often observed during treatment with potent vasodilators. In the formulation studied pinacidil is unlikely to offer any advantage over the antihypertensive drugs currently available.
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Mackay A. Management of Intractable Hypertension. Med Chir Trans 1983. [DOI: 10.1177/014107688307600701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Mackay A. Management of intractable hypertension. J R Soc Med 1983; 76:537-9. [PMID: 6348281 PMCID: PMC1439103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
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