Characterization of resistant hypertension: Association between resistant hypertension, aldosterone, and persistent intravascular volume expansion

Background: Resistant hypertension is a common clinical problem and greatly increases the risk of target organ damage. Methods: We evaluated the characteristics of 279 consecutive patients with resistant hypertension (uncontrolled despite the use of 3 antihypertensive agents) and 53 control subjects (with normotension or hypertension controlled by using ≤2 antihypertensive medications). Participants were prospectively examined for plasma aldosterone concentration, plasma renin activity, aldosterone to renin ratio, brain-type natriuretic peptide, atrial natriuretic peptide, and 24-hour urinary aldosterone (UAldo), cortisol, sodium, and potassium values while adhering to a routine diet. Results: Plasma aldosterone (P < .001), aldosterone to renin ratio (P < .001), 24-hour UAldo (P = .02), brain-type natriuretic peptide (P = .007), and atrial natriuretic peptide (P = .001) values were higher and plasma renin activity (P = .02) and serum potassium (P < .001) values were lower in patients with resistant hypertension vs controls. Of patients with resistant hypertension, men had significantly higher plasma aldosterone (P = .003), aldosterone to renin ratio (P = .02), 24-hour UAldo (P < .001), and urinary cortisol (P < .001) values than women. In univariate linear regression analysis, body mass index (P = .01), serum potassium (P < .001), urinary cortisol (P < .001), urinary sodium (P = .02), and urinary potassium (P < .001) values were correlated with 24-hour UAldo levels. Serum potassium (P = .001), urinary potassium (P < .001), and urinary sodium (P = .03) levels were predictors of 24-hour UAldo levels in multivariate modeling. Conclusions: Aldosterone levels are higher and there is evidence of intravascular volume expansion (higher brain-type and atrial natriuretic peptide levels) in patients with resistant hypertension vs controls. These differences are most pronounced in men. A significant correlation between 24-hour urinary aldosterone levels and cortisol excretion suggests that a common stimulus, such as corticotropin, may underlie the aldosterone excess in patients with resistant hypertension

Outcome in patients perceived as receiving excessive care across different ethical climates: a prospective study in 68 intensive care units in Europe and the USA

Purpose: Whether the quality of the ethical climate in the intensive care unit (ICU) improves the identification of patients receiving excessive care and affects patient outcomes is unknown. Methods: In this prospective observational study, perceptions of excessive care (PECs) by clinicians working in 68 ICUs in Europe and the USA were collected daily during a 28-day period. The quality of the ethical climate in the ICUs was assessed via a validated questionnaire. We compared the combined endpoint (death, not at home or poor quality of life at 1 year) of patients with PECs and the time from PECs until written treatment-limitation decisions (TLDs) and death across the four climates defined via cluster analysis. Results: Of the 4747 eligible clinicians, 2992 (63%) evaluated the ethical climate in their ICU. Of the 321 and 623 patients not admitted for monitoring only in ICUs with a good (n = 12, 18%) and poor (n = 24, 35%) climate, 36 (11%) and 74 (12%), respectively were identified with PECs by at least two clinicians. Of the 35 and 71 identified patients with an available combined endpoint, 100% (95% CI 90.0–1.00) and 85.9% (75.4–92.0) (P = 0.02) attained that endpoint. The risk of death (HR 1.88, 95% CI 1.20–2.92) or receiving a written TLD (HR 2.32, CI 1.11–4.85) in patients with PECs by at least two clinicians was higher in ICUs with a good climate than in those with a poor one. The differences between ICUs with an average climate, with (n = 12, 18%) or without (n = 20, 29%) nursing involvement at the end of life, and ICUs with a poor climate were less obvious but still in favour of the former. Conclusion: Enhancing the quality of the ethical climate in the ICU may improve both the identification of patients receiving excessive care and the decision-making process at the end of life

Similar prevalence of hyperaldosteronism in African American and white subjects with resistant hypertension

Purpose of the study was to test for racial differences in the prevalence of hyperaldosteronism in subjects with resistant hypertension. Consecutive subjects referred to the University of Alabama at Birmingham (UAB) hypertension clinic for resistant hypertension (uncontrolled blood pressure on 3 antihypertensive agents) were prospectively evaluated with a plasma aldosterone concentration (PAC), plasma renin activity (PRA), a 24-hr urine collection for aldosterone, cortisol, sodium and potassium during a normal diet. All subjects were on a stable antihypertensive regimen without use of potassium sparing diuretics. For results see the table. The prevalence of hyperaldosteronism on the basis of ARR 20 (29.6% vs. 31.1%) or using PR

Assessment of left atrial volume in resistant hypertension by cardiac magnetic resonance imaging

Introduction: Increased left atrial (LA) volumes are associated with impaired diastolic properties of the left ventricle (LV) and have been shown to predict cardiovascular events in a wide spectrum of patients. A relation between LA volume and aldosterone has been reported in idiopathic dilated cardiomyopathy, but this relationship has not been evaluated in resistant hypertensive subjects. Hypothesis: We hypothesized that patients with elevated plasma aldosterone concentration (PAC) have greater LA volumes. We compared LA volumes in normal subjects and mildly hypertensive patients (Controls) and patients with resistant hypertension. Methods: 71 patients (55 resistant hypertensive (51% male, age 57±12 y) and 16 Controls (62% men, age 54±11 y, p=ns) were studied. Clinic blood pressure (BP), plasma levels of B-type natriuretic peptide (BNP), PAC, plasma renin activity (PRA), serum cortisol, and 24 hour urinary aldosterone and sodium excretion were determined. Cardiac magnetic resonance imaging was performed in all patients and LA volumes were measured using a biplane length-area method and indexed for the body surface area. Results: Results are summarized in the Table. Resistant hypertensives had significantly higher systolic and diastolic BP compared to Controls. There was a trend towards higher PAC in hypertensives that did not reach statistical significance. BNP levels also were not different between the groups but we found a relationship between BNP and LA volume index (r=0.43, p=0.003). Hypertensives also exhibited increased LV mass and LA volume index compared to Controls. No relation between LA volume index and PAC was found. PRA, cortisol, and 24 hour urinary aldosterone and sodium excretion also had no relation to LA volume index. Conclusions: LA volume index is higher in resistant hypertension and shows positive correlation with BNP levels in all subjects but is not related to PAC in either the Control or Resistant hypertension groups