File Name: hypertension diagnosis and treatment .zip
Fourth, the guidelines put more emphasis on monitoring blood pressure at home and on team-based systems for managing hypertension. Ioannidis JPA.
- Pulmonary Hypertension (Guidelines on Diagnosis and Treatment of)
- Diagnosis and Treatment of Hypertension in the 2017 ACC/AHA Guidelines and in the Real World
Hypertension HTN or HT , also known as high blood pressure HBP , is a long-term medical condition in which the blood pressure in the arteries is persistently elevated. High blood pressure is classified as primary essential hypertension or secondary hypertension. Blood pressure is classified by two measurements, the systolic and diastolic pressures, which are the maximum and minimum pressures, respectively. Lifestyle changes and medications can lower blood pressure and decrease the risk of health complications. Hypertension is rarely accompanied by symptoms, and its identification is usually through screening , or when seeking healthcare for an unrelated problem.
The vast majority of hypertensive patients are never sought for a cause of their high blood pressure, i. This under detection explains why only a tiny percentage of hypertensive patients are ultimately diagnosed with a secondary form of arterial hypertension. The prevalence of these forms is, therefore, markedly underestimated, although, they can involve as many as one-third of the cases among referred patients and up to half of those with difficult to treat hypertension.
The early detection of a secondary form is crucial, because if diagnosed in a timely manner, these forms can be cured at long-term, and even when cure cannot be achieved, their diagnosis provides a better control of high blood pressure, and allows prevention of hypertension-mediated organ damage, and related cardiovascular complications. Even though specialized centers receive a selected cohort of patients, these figures indicate that the diagnosis of SH is probably missed in the majority of the patients.
Given the unprecedented progress made in the last decades in the understanding, screening, work-up, and management of SH, the purpose of this mini-review is to furnish concise updated information on the diagnosis and treatment of the most common forms of SH, which are summarized in Table 1.
For in depth information, the readers are referred to recent comprehensive reviews [ 6 , 7 ]. Table 2 reports the main clinical features of PA. When the PA patients were systematically subtyped by using adrenal vein sampling AVS , about two-thirds of them were found to have a unilateral form of PA, mainly an aldosterone-producing adenoma APA or, much more rarely, unilateral adrenal hyperplasia, while a bilateral form also known as idiopathic hyperaldosteronism was diagnosed in the remaining third [ 11 ].
Much rarer are unilateral aldosterone-producing carcinomas [ 16 ], and the familial forms FH due to germline mutations, which cause BAH [ 17 ] and include several types e. Figure 1 shows a simplified algorithm for the initial work-up of PA [ 9 ], which performed extremely well at our center. Briefly, the diagnosis of PA entails demonstration of low or undetectable renin levels and inappropriately high secretion of aldosterone. Considering this, in Hiramatsu et al. However, a major advancement in this field with profound implications for clinical practice has been the discovery that the mineralocorticoid receptor antagonists MRAs , which for decades were forbidden during the screening, can be prescribed during the screening of PA [ 21 ], and also when PA patients undergo subtype differentiation because they did not cause false negative ARR values during the screening, neither they precluded the diagnosis of unilateral PA by AVS [ 22 , 23 , 24 ].
Simplified algorithm for the work-up for primary aldosteronism. Moreover, in the largest and only study that followed these requirements, the captopril test was not shown to provide any diagnostic gain over the baseline ARR [ 26 ].
The use of confirmatory tests, such as the oral sodium loading test, the saline infusion test, the captopril challenge test, and the fludrocortisone plus salt loading test, remains controversial. They are based on the unproven premise that aldosterone secretion would be completely independent of renin and angiotensin II.
Moreover, studies that supported their use did not comply with the Standards for Reporting of Diagnostic Accuracy STARD requirement for validation for diagnostic tests [ 25 ].
Furthermore, the largest study that examined the captopril test and fulfilled these requirements—the AQUARR Study—failed to show any diagnostic gain of this confirmatory test over a carefully done ARR [ 26 ]. Thus, if the screening is properly performed and shows an ARR consistently elevated, i.
Unilateral laparoscopic adrenalectomy is the best treatment that can be offered to PA patients with proven unilateral disease. This means that patients should be referred for AVS to be performed by an expert team in a specialized tertiary center before considering surgery. MRAs, such as spironolactone, canrenone potassium, potassium canrenoate, eplerenone, alone or in combination with other antihypertensive drugs, are recommended for those patients with BAH or not suitable for surgery.
MRAs are also indicated before adrenalectomy to control BP values and serum potassium levels [ 9 , 27 ]. A more in-depth discussion of the diagnostic work-up and treatment is available in the Italian Society of Arterial Hypertension SIIA practical guidelines [ 28 ].
Renovascular hypertension RVH defines a condition where renal artery occlusion or stenosis decreases renal perfusion pressure to levels that activates the renin—angiotensin—aldosterone system RAAS , thereby raising BP.
Its major causes are fibromuscular dysplasia FMD and atherosclerosis, which usually involve different cohorts of patients. FMD affects especially children and young-to-middle aged women [ 31 ], and is a systemic arterial disease. Atherosclerotic renovascular hypertension ATS-RVH is the most common form in older adults, predominantly men, with multiple risk factors. The increased renin synthesis aims at maintaining glomerular filtration rate GFR through a prominent constriction of the post-glomerular arterioles and via the elevation of systemic BP.
In the majority of the patients, however, at the time of diagnosis, the activation of the RAAS is no longer detectable for multiple reasons, as discussed elsewhere [ 32 ]. In fact, it has to be reckoned that stenosis of the renal arteries may be hemodynamically insignificant and can result from accelerated atherosclerosis in patients with primary HT. Hence, confirming the diagnosis of RVH is a challenging undertaking, as this can only be made retrospectively if revascularization results in the cure or improvement of HT [ 5 ].
For the reason just mentioned, the work-up of RVH, which has to be undertaken in a clinically selected high-risk population Table 4 and Fig. The latter comprise: 1 Duplex sonography with bilateral assessment of the most relevant indexes, e. The latter can be implemented with a simultaneous, unstimulated trans-lesional pressure gradient between the distal renal artery and the aorta measurement that has been suggested for determining the severity and hemodynamic significance of renal artery stenosis.
While there are no randomized clinical trials supporting the superiority of this approach in terms of outcome, its pitfalls are both theoretical and practical: positioning a catheter through a tight stenosis by itself creates a gradient, which can lead to an overestimation of the stenosis severity.
Moreover, in the presence of multiple lesions, as typically in FMD, estimation of pressure gradient can be challenging.
Finally, the measurement of the trans-lesional pressure gradient is not widely available, even in centers that perform a substantial number of percutaneous procedures for RVH.
In patients with ATS-RVH angioplasty should be performed with stenting, and there are compelling indications to undertake such treatment Table 5. However, it remains controversial if percutaneous transluminal renal angioplasty PTRA plus stenting is superior to an aggressive medical treatment in the patients without such compelling indications Class of Recommendation IIb, Level of Evidence C Fig. Owing to their common embryologic origin and clinical similarities, they are usually jointly defined as pheochromocytomas and paragangliomas, in short PPGLs.
On the whole, PPGLs are rare, as they comprise less than 0. In syndromic cases, the concurrence of physical signs see later should suggest the diagnosis Table 6 [ 36 , 37 , 38 ]. However, PPGLs occurring in the head and neck district are usually parasympathetic, and therefore do not secrete catecholamines. Syndromic PPGLs, including neurofibromatosis type 1, multiple endocrine neoplasia type 2, von Hippel-Lindau syndrome, renal cell carcinoma with SDHB mutation, Carney triad, and Carney-Stratakis syndrome, are rare and characterized by typical clinical phenotypes and associated comorbidities, which render the clinical suspicion quite obvious.
The measurement of conjugated metanephrines in h urine has been demonstrated to cause false positive test results, and thus free metanephrines should be preferred [ 38 ]. Imaging is recommended when the screening is positive e. A schematic algorithm suggested for diagnosis and treatment of hypertensive patients with suspected of pheochromocytoma and paraganglioma.
CT has been suggested as the first-choice imaging modality because of its excellent spatial resolution for thorax, abdomen, and pelvis.
If results remain elevated after repeating the measurement, the clonidine suppression test with detecting of plasma normetanephrine can be used. The gold-standard therapy for PPGLs is surgery for solitary or multiple tumors clustered in one area Fig. On history, excessive use of exogenous glucocorticoid leading to iatrogenic CS must be ruled out before considering screening tests, which are indicated in the following categories of hypertensives: 1 patients with unusual features, for example, osteoporosis at a young age; 2 patients with suggestive signs and symptoms Table 7 ; 3 adrenal incidentaloma compatible with adenoma [ 39 ].
The initial testing includes repeated at least twice measurements of h urine free cortisol, late-night salivary cortisol, and 1-mg overnight dexamethasone suppression test. For the 1-mg overnight dexamethasone suppression test, a normal response is a serum cortisol less than 1. Patients with ACTH-dependent CS should be evaluated in specialized tertiary referred centers by gadolinium-enhanced pituitary MRI, followed, when clinical, biochemical or radiological studies are discordant, by bilateral inferior petrosal sinus sampling.
In patients with contraindications to surgery, or with ectopic disease and persistent hypercortisolism, BP values are often difficult to control, and the most frequent causes of death are the CV complications.
In these patients and in those with persistent high BP after surgery, an association of multiple antihypertensive drugs, including renin—angiotensin—aldosterone system RAAS modulators i.
Its identification as the underlying cause of HT, followed by specific treatment, can render high BP responsive to treatment [ 44 ]. Fragmented, albeit rather consistent, evidence suggested that OSA can coexist with PA and that target treatment of the latter can ameliorate OSA [ 45 ]. However, results of a recent multicenter study seem to have challenged this view [ 46 ]; therefore, whether OSA is a presenting sign of PA or vice versa, remains somewhat controversial.
Nonetheless, there are no doubts that patients with difficult-to-treat HT should be screened for either condition because identification of one or both can allow to better control their high BP and improve their quality of life. Well recognized signs and symptoms Table 8 should lead to screen hypertensive patients for OSA [ 47 , 48 , 49 ].
In-laboratory full-night polysomnography is the diagnostic gold standard for OSA patients [ 48 , 49 ]. It allows to identify the severity of disease i. When unfeasible, the home sleep apnea testing can be used, particularly for uncomplicated adults with suspect of OSA Fig. Schematic algorithm summarizing the steps for recognition of obstructive sleep apnea and its diagnostic and therapeutic work-up.
The proper work-up of OSA patients varies according to individual features. The first steps are the lifestyle changes and sleep hygiene Fig.
The ENT specialist could also perform drug-induced sleep endoscopy examination that allows an accurate identification and correction of the obstruction [ 50 ]. In moderate-to-severe OSA i. Interestingly, recent data demonstrated a clinically significant improvement in PAP adherence and thereby improve symptom control in the treatment of OSA in adults with the use of telemonitoring intervention [ 51 ].
Only a few studies have evaluated the effects of antihypertensive agents on OSA. Their results were variable and statistical power was usually poor [ 47 ]. Growing evidence supports the role of high levels of plasma aldosterone in OSA that appear to contribute to poor control of BP values in these patients through peri-pharyngeal fluid retention [ 59 ]. By reducing parapharyngeal edema and upper airway obstruction, diuretics i.
Further studies are necessary to confirm this suggestion. A promising therapeutic strategy is the electrical stimulation of upper airway via hypoglossal nerve [ 62 , 63 ], but data on its effect on BP are still preliminary. Once a form of SH has been detected, knowledge of the underlying pathophysiology warrants a more rational and more effective treatment, which can allow to achieve long-term cure of arterial hypertension or a better control of the high BP values when cure is not accomplished.
Eur Heart J. Secondary hypertension: current diagnosis and treatment. Int J Cardiol. Optimum and stepped care standardised antihypertensive treatment with or without renal denervation for resistant hypertension DENERHTN : a multicentre, open-label, randomised controlled trial.
Prevalence and outcome of drug-resistant hypertension in primary aldosteronism patients undergoing adrenal vein sampling. Eur J Prev Cardiol. In press. Secondary hypertension: the ways of management. Curr Vasc Pharmacol. Hirsch JS, Hong S. The demystification of secondary hypertension: diagnostic strategies and treatment algorithms. Curr Treat Options Cardiovasc Med. Secondary arterial hypertension: when, who, and how to screen?
Genetics, prevalence, screening and confirmation of primary aldosteronism. J Hypertens. Online ahead of print. Rossi GP. Primary aldosteronism: JACC state-of-the-art review. J Am Coll Cardiol.
Pulmonary Hypertension (Guidelines on Diagnosis and Treatment of)
The vast majority of hypertensive patients are never sought for a cause of their high blood pressure, i. This under detection explains why only a tiny percentage of hypertensive patients are ultimately diagnosed with a secondary form of arterial hypertension. The prevalence of these forms is, therefore, markedly underestimated, although, they can involve as many as one-third of the cases among referred patients and up to half of those with difficult to treat hypertension. The early detection of a secondary form is crucial, because if diagnosed in a timely manner, these forms can be cured at long-term, and even when cure cannot be achieved, their diagnosis provides a better control of high blood pressure, and allows prevention of hypertension-mediated organ damage, and related cardiovascular complications. Even though specialized centers receive a selected cohort of patients, these figures indicate that the diagnosis of SH is probably missed in the majority of the patients.
This means that one reading at your doctor's office is just that—a moment in time. An average of readings typically provides a more accurate picture of your blood pressure status. Your doctor may also order blood or urine tests if secondary hypertension is suspected. Blood Pressure Tests. A diagnosis of hypertension usually requires at least three elevated blood pressure readings taken at least one week apart.
Hypertension is a serious and common condition, the prevalence of which is set to rise given the increase in the ageing population, sedentary lifestyles and obesity. This article reviews the management of primary hypertension in adults, with reference to the National Institute for Health and Care Excellence guidelines. Diagnosis using clinic, ambulatory and home blood pressure BP monitoring, risk factors , BP targets, lifestyle advice, drug treatment and patient education are also discussed. Nursing Standard. Alternatively, you can purchase access to this article for the next seven days.
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Diagnosis and Treatment of Hypertension in the 2017 ACC/AHA Guidelines and in the Real World
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Наконец Беккер дошел до конца темного коридора и толкнул чуть приоткрытую дверь слева. Комната была пуста, если не считать старой изможденной женщины на койке, пытавшейся подсунуть под себя судно. Хорошенькое зрелище, - подумал Беккер. - Где, черт возьми, регистратура. За едва заметным изгибом коридора Беккер услышал голоса.
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Видите ли, я, честно говоря, очень спешу. - Он надеялся, что отказ представителю самого мощного разведывательного ведомства не слишком большая глупость с его стороны, но партия в сквош начиналась через сорок пять минут, а он дорожил своей репутацией: Дэвид Беккер никогда не опаздывает на партию в сквош… на лекцию - да, возможно, но на сквош -. - Постараюсь быть краткой, - улыбнулась Сьюзан Флетчер. - Пожалуйста.
Ни у кого не вызывало сомнений, что Стратмор любит свою страну. Он был известен среди сотрудников, он пользовался репутацией патриота и идеалиста… честного человека в мире, сотканном из лжи. За годы, прошедшие после появления в АНБ Сьюзан, Стратмор поднялся с поста начальника Отдела развития криптографии до второй по важности позиции во всем агентстве.