Hypertension in the Elderly

In our aging society, most of the elderly aged >65 years are affected by systolic hypertension (HTN) [blood pressure (BP) >140 mmHg], which constitutes a major risk factor for organ damage and cardiovascular (CV) events. Management of HTN in the elderly represents a therapeutic dilemma because HTN trials had upper age limits or did not present age-specific results. However, the HYVET trial documented that therapy is beneficial even in those >80 years. In the elderly, systolic BP and pulse pressure emerge as potent risk factors for CV events. In the past an empiric formula "100+age" was used to estimate appropriate systolic BP. Diastolic BP is more important in younger people <50 years.Hypertension in the elderly is due to increased stiffness and pulse wave velocity of the great arteries with earlier return of reflected waves, causing high systolic BP, low diastolic BP, increased myocardial oxygen demand with higher peripheral resistance and limited organ perfusion. Furthermore, decreased renal function contributes to HTN through volume expansion, increased intracellular sodium, reduced Na-Ca exchange; K+ excretion is limited and plasma aldosterone is low, so that the elderly are prone to drug-induced hyperkalemia. Autonomic dysfunction and venous insufficiency contribute to orthostatic hypotension, resulting in falls, syncope, CV events or orthostatic hypotension. Secondary HTN should also be considered, including renal artery stenosis, obstructive sleep apnea, primary aldosteronism, hyper- or hypo-thyroidism, tobacco, alcoholism, caffeine, use of no-steroidal anti-inflammatory drugs, glucocorticoids, sex hormones... (excerpt

Interventional Therapies for Resistant Hypertension

Resistant hypertension represents a major health problem despite the plethora of antihypertensive drugs. Activation of the sympathetic nervous system is considered to be the basis of its pathogenesis. Two novel invasive therapeutic strategies for the treatment of resistant hypertension have recently emerged, namely catheter based renal sympathetic denervation and carotid baroreceptor stimulation. Both are effective in reducing elevated blood pressure values and display a good tolerability profile without the occurrence of any major untoward effect

Indications for Renal Artery Stenting

Renal artery stenosis (RAS) is a relatively common condition in the elderly, especially in the setting of concomitant vascular disease in other anatomical sites and is most often of atheromatous origin. Rarely is it encountered in young women as a result of fibromuscular dysplasia. RAS is considered responsible for refractory or accelerated hypertension, progressive loss of renal function and deterioration of patients??? cardiovascular status, with episodes of angina or pulmonary oedema disproportional to the extent of coronary artery disease and left ventricle functional capacity, dominating the clinical presentation. This article summarizes the pathophysio logical implications and diagnostic methods and attempts a review of the current literature on indications and efficacy of the available therapeutic options for RAS, focusing on interventional treatment. Renal artery stenosis (RAS) is most commonly due to atherosclerosis (???90%) or fibromuscular dysplasia (10%) and rarely to extrinsic compression, neurofibromatosis type I or Williams syndrome. Fibromuscular dysplasia predominates in young women (30-50 years old), is a nonatherosclerotic, noninflammatory vascular disease that causes stenosis in medium and small arteries, most commonly involving the distal 2/3 of the renal artery and carotid arteries. Atherosclerotic renal artery stenosis is usually encountered in males over 55 years old and often occurs at the ostium or the proximal 2 cm of the artery. [1,2] Refractory hypertension, progressive renal function deterioration and recurrent episodes of decompensated heart failure or flash pulmonary oedema are the most common clinical manifestations of the disease Both conservative and interventional treatment have been proposed and applied with comparable efficacy, as far as atherosclerotic disease is concerned and thus certain controversies have arisen regarding the treatment of choice.[3

Bifocal Right Ventricular Pacing: Alternative to Biventricular Pacing for Cardiac Resynchronization Therapy?

A 59-year-old patient with dilated cardiomyopathy, severe systolic left ventricular dysfunction and drug-refractory advanced heart failure (New York Heart Association-NYHA class III-IV symptoms) and prior history of mitral valve replacement was scheduled for implantation of a biventricular pacing system (cardiac resynchronization therapy-defibrillator or CRT-D device). The coronary sinus was cannulated after some effort and a venous coronary angiogram was performed. Although a posterolateral cardiac venous branch was identified to accommodate the left ventricular pacing lead, placement of the lead in this tributary was accompanied by phrenic nerve stimulation, which could not be remedied by moving to more proximal positions where the lead could not be stabilized. Having no other option except for sending the patient to surgery for epicardial lead placement, albeit most difficult and high-risk procedure due to prior history of cardiac surgery, we attempted bifocal right ventricular pacing by placing the composite pacing-defibrillating lead at a low septal position and the left ventricular lead at a very high right ventricular (RV) outflow tract position. The procedure was otherwise uncomplicated and the patient’s post-procedural course remained uneventful. The patient had a good clinical response to this type of bifocal RV pacing over the subsequent days and months with amelioration of his dyspneic symptoms and improvement of his quality of life. At the three-year follow-up he remains in NYHA class II category

Adverse Cardiovascular Effects and Drug Interactions with Herbs

The herbs are plants or products of plants and despite their widespread promotion, their purity, efficacy and safety are often unknown. The healthcare professionals may be asked to give advice on the use of these products, in conjunction with other medications .Thus, they can potentially interact with the cardiovascular drugs with subsequent dramatic effects on the coagulation pathways and the platelets adhesion. The administration of the herbs in patients suffering from cardiovascular diseases should be done sparingly, with caution and with thorough knowledge of their possible interactions with the already prescribed drugs

Salt Controversy Stirred by “PURE” but Settled by “NUTRICODE”

Hypertension is a modifiable risk factor for cardiovascular disease and death. On a worldwide scale, it is estimated that over 1 billion adult individuals are afflicted by hypertension, and hypertension is responsible for over 9 million deaths annually. Among dietary strategies to counter this epidemic, principal role has been assigned to reducing dietary sodium which has been included in many guidelines for the treatment of hypertension and prevention of cardiovascular disease. However, recent studies have raised questions about potential harmful effects associated with low sodium intake. Ensuing the tumult stirred by these studies reporting on the role of salt intake restriction on blood pressure and cardiovascular mortality, we are herein providing a brief overview of the topic. Despite the “controversy’, the data appear compelling toward the need for reducing salt intake as one of the most cost-effective measures to control blood pressure and reduce cardiovascular disease worldwide at the population level

Indications for Renal Artery Stenting

Renal artery disease (RAD) is a relatively common condition in the elderly, especially in the setting of concomitant vascular disease in other anatomical sites and is most often of atheromatous origin. Rarely is it encountered in young women as a result of fibromuscular dysplasia. RAD with significant renal artery stenosis is considered responsible for refractory or accelerated hypertension, progressive loss of renal function and deterioration of patients’ cardiovascular status, with episodes of angina or pulmonary edema disproportional to the extent of coronary artery disease and left ventricle functional capacity, dominating the clinical presentation. This article summarizes the pathophysiological implications and diagnostic methods and attempts a review of the current literature on indications and efficacy of the available therapeutic options for renal artery stenosis, focusing on interventional treatment

Transesophageal Overdrive Pacing: A Simple and Versatile Tool

In the present case, a patient with atrial flutter failed drug conversion with use of intravenous amiodarone and before resorting to electrical cardioversion, transesophageal atrial overdrive pacing was proposed and performed as a bedside procedure with successful conversion of atrial flutter into sinus rhyth

Secondary Percutaneous Revascularization for Severe Unprotected Left Main Disease After Surgical Turndown

Patients with severe left main and/or multi-vessel coronary artery disease (CAD) and contraindications or extremely high risk for surgical revascularization that are subsequently referred for percutaneous coronary intervention (PCI) have been increasing in clinical practice. We present the case of a patient with a previous history of aortic valve replacement and coronary artery bypass grafting (CABG) hospitalized because of angina recurrence and a functional test with myocardial scintigraphy that showed extensive myocardial ischemia. The coronary angiogram revealed severe left main and two-vessel disease with totally occluded bypass grafts, while revascularization by re-do CABG was rejected. The patient was finally treated by a technically challenging high-risk unprotected left main PCI.   Rhythmos 2017;12(2):29-32

Κολπική Μαρμαρυγή και Σύνδρομο Brugada

Το σύνδρομο Brugada χαρακτηρίζεται από εικόνα RBBB, ανάσπαση του τμήματος ST στις απαγωγές V1-V3 του ΗΚΓ και από τάση για αιφνίδιο καρδιακό θάνατο. Πολλές μελέτες έχουν συνδέσει τη γενετική βάση του συνδρόμου με μεταλλάξεις σε γονίδια που κωδικοποιούν την α υπομονάδα του διαύλου Να+. Πιο πρόσφατες μελέτες το συσχετίζουν με μεταλλάξεις στα γονίδια των α και β υπομονάδων των διαύλων Ca2+ και στο γονίδιο του ομοιάζοντος στην αφυδρογονάση 1 της 3-φωσφορικής γλυκερόλης ενζύμου (glycerol-3-phosphate dehydrogenase1-like/GPD1L). Τα 4 αυτά γονίδια, από μακρού ταυτοποιηθέντα, έχουν εκτιμηθεί ως υπόλογα για το 28% περίπου του συνδρόμου Brugada. Έτσι, το 72% των περιπτώσεων παραμένει μη ταυτοποιημένο γονοτυπικά. Το χαρακτηριστικό γνώρισμα του συνδρόμου Brugada είναι οι επικίνδυνες για τη ζωή κοιλιακές αρρυθμίες. Το αρρυθμιογόνο υπόστρωμα του συνδρόμου μπορεί να μην περιορίζεται στο επίπεδο των κοιλιών... (excerpt