Effective Treatment of Severe Hypertension

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/72801/1/j.1751-7117.1999.tb00186.x.pd

Metoprolol succinate therapy associated with erythema multiforme

Metoprolol succinate is a widely used medication for the management of hypertension, heart failure, and angina. We report the case of a 36-year-old woman who developed erythema multiforme after administration of a low dose of this drug. She also presented with pruritic burning pain throughout her body accompanied by chills. While erythema multiforme has been reported with carvedilol, this is the first observation of metoprolol succinate causing this and physicians should be aware of this potential, yet rare, side-effect

Hypertension in the very elderly: Brief review of management

This brief review discusses pharmacological management of hypertension in very elderly patients, a very powerful and rapidly growing subpopulation of patients. It is well known that age is the most powerful risk factor for death, cardiovascular death and hypertension. Blood pressure reduction is effective in preventing major vascular events including stroke and heart failure. However, earlier trials were inconclusive as to whether treatment of this age group is beneficial. One of these trials, subgroup meta-analysis (1999) which enrolled 1,670 patients in seven clinical trials, showed a 36% lower risk of stroke and a 39% lower risk of heart failure, but slightly increased all-cause mortality. More recently, however, data coming from the Hypertension In the Very Elderly Trial (HYVET) has resolved the clinical uncertainty about the relative benefits and risks of antihypertensive treatment in patients over 80 years old. HYVET studied a relatively healthy 3,845 patients, who were assigned to indapamide ± perindopril vs. placebo ± placebo. There was a significant reduction in cardiovascular morbidity and mortality. What was unexpected was that overall mortality reduced as well in actively treated individuals. No specific guidelines exist for hypertension management for this particular population. Data from clinical trials including HYVET favor thiazide diuretics, angiotensin converting enzyme inhibitors and calcium channel blockers for either mono-therapy or combination therapy for hypertension in the elderly

Allergic respiratory disease as a potential co-morbidity for hypertension

This article examines the relationships between allergic rhinitis and hypertension, chronic sinusitis and hypertension, and asthma and hypertension. Previous studies have demonstrated that men reporting seasonal or chronic rhinitis had on average a 3.5 mm Hg higher systolic blood pressure than those without allergic rhinitis. Proposed mechanisms to the relationship between allergic rhinitis and sinusitis with hypertension may lie in the pathway of obstructive sleep apnea via neurohumoral responses to hypoxemia. Asthmatics were 1.4 times more likely to have heart disease, and 1.3 times more likely to have high blood pressure, than non-asthmatics. The commonality of immunological dysfunction and inflammation between diseases of allergy and those mediated by hypertension and other vascular disorders may explain the correlations observed. Interestingly, obese individuals have higher levels of circulating IL-6, leptin and TNF-alpha skewing the immune system toward the allergen-reactive type 2 helper T-cell. This would mean that obese individuals were predisposed to diseases of chronic inflammation. The implications of allergic rhinitis, chronic sinusitis, and asthma deserve closer attention, especially into the possibility of co-morbidity for hypertension. Although associations between allergic diseases and hypertension have been reported, more studies need to be performed to elucidate the mechanisms behind such associations. (Cardiol J 2010; 17, 5: 443-447

Diffuse large B cell lymphoma presenting as a cardiac mass and odynophagia

Cardiac involvement as an initial presentation of malignant lymphoma is a rare occurrence. We describe the case of a 77-year-old man who had initially been diagnosed with a left atrial mass on an echocardiogram, presenting with progressive dyspnea, dysphagia, odynophagia and fevers. The cardiac mass had been managed as an outpatient with full anticoagulation for the suspicion of clot. On admission, cardiac magnetic resonance imaging revealed a large mediastinal mass invading the left atrium that originated from the oesophagus. A barium oesophagram revealed an apple core lesion involving the distal third of the oesophagus. A subsequent computed tomography scan demonstrated a large mediastinal soft tissue mass and paratracheal lymphadenopathy. A flexible upper endoscopy revealed an oesophageal mass that was approximately 10 cm in length, irregular at the margins, and with a very necrotic appearance. This was biopsied, revealing findings consistent with high grade diffuse large B cell lymphoma. This case illustrates lymphoma presenting with dyspnea, odynophagia and a left atrial mass. To our knowledge, there are no reported cases of diffuse large B cell lymphoma presenting as odynophagia and a cardiac mass

Calcium channel blockers, angiotensin receptor blockers, and angiotensin-converting enzyme inhibitors: Effectiveness in combination with diuretics or β-blockers for treating hypertension

This retrospective database analysis compared the effectiveness of dihydropyridine calcium channel blockers (DHPs), angiotensin-converting enzyme (ACE) inhibitors, and angiotensin receptor blockers (ARBs) added to diuretics or β-blockers. Adults with hypertension treated with diuretic or β-blocker monotherapy between 1998 and 2001 were identified from a large US electronic medical records database of primary care practices. Patients were required to have a baseline blood pressure (BP) ≥140/90 mmHg (≥130/80 mmHg for diabetes mellitus) and recorded BP measurements within 6 months before and 1–12 months following index date. Patients were matched 1:1:1 by propensity score to correct for differences in baseline characteristics. 1875 patients met study criteria and 660 (220 in each cohort) were matched based on propensity scores. Matched cohorts had no significant differences in baseline characteristics. Mean changes in systolic/diastolic BP were −17.5/−8.8, −15.7/−6.3, and −13.0/−8.0 mmHg with DHPs, ACE inhibitors, and ARBs, respectively. Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High BP 6/7 goal attainment for each regimen was 47.3%, 40.0%, and 32.2%, respectively. DHPs, ACE inhibitors, and ARBs improved BP when added to patients’ β-blocker or diuretic therapy. The greatest benefits were observed with DHPs, followed by ACE inhibitors, then ARBs

Ambulatory blood pressure monitoring: Is 24 hours necessary?

Background: The variability of blood pressure (BP) makes any single measurement a poor indicator of a patient’s true BP. Multiple studies have confirmed the superiority of ambulatory BP measurements over clinic BP measurements in predicting cardiovascular risk; however, this method presents the problem of patient acceptance as it causes frequent arm discomfort and sleep disturbance. We hypothesized that 6 h of daytime BP measurements would result in slightly higher BP readings, yet reveal similar clinical decision making when compared to24 h of BP measurements.Methods: The source for writing this article was a retrospective analysis of 30 patients who underwent ambulatory BP monitoring. Data obtained included: age, sex, ethnicity, baseline medical problems, medications, laboratory values, reason given for ordering 24-h ambulatory BP measurements, ambulatory BP measurements, and a subsequent decision to change medication.Results: The average BP of the 24-h measurements was 127/75 mm Hg and the average BP of the 6-h daytime measurements was 131/79 mm Hg (SD 15, p = 0.009). Twenty-six out of 30 patients were at goal or pre-hypertensive. Two out of 30 patients had stage 1 hypertension and 2 out of 30 patients had stage 2 hypertension. Thirteen out of 30 patients had nocturnal dipping. Twelve out of 30 patients had a change in medication, but those changes were not associated with the presence or absence of nocturnal dipping (p = 0.5) or other factors beyond mean BP.Conclusions: Although there was a statistically significant, 4 mm Hg systolic difference between 24-h and 6-h average BP readings, there was no evidence that this difference led to changes in clinical management. The presence or absence of nocturnal dipping was not associated with a change in medication. We conclude that 6-h daytime ambulatory BP measurements provide sufficient information to guide clinical decision making without the problems of patient acceptance, arm discomfort, and sleep disturbance associated with 24-h BP measurements