Hypertension

ORLANDO -- A novel intravenous calcium channel blocker seems safe and at least as effective as one of the standard blood-pressure-lowering drug in cardiac surgery, a researcher said here.

WASHINGTON -- An observational study of 60,000 postmenopausal women found that about 40% have prehypertension, and that level of blood pressure was associated with a 58% higher risk of cardiovascular death than for normotensive women.

UTRECHT, The Netherlands -- Even if hypertension during pregnancy subsides after delivery, a risky postmenopausal second act may await, researchers reported.

BALTIMORE -- Eighteen million American men ages 20 or older have erectile dysfunction, generally attributed to the effects of diabetes, hypertension, or physical inactivity, researchers here reported.

An 80-year-old man presents to the emergency department (ED) with intermittent dyspnea and chest pain. He has hypertension and osteoarthritis but no known cardiac disease. Vital signs are normal. No jugular venous distention is noted. The lungs are clear with equal breath sounds, and the heart rate is regular, without murmurs, gallops, or rubs. The chest wall is not tender. No edema or asymmetry is evident in the extremities.

ABSTRACT: Angiotensin-converting enzyme (ACE) inhibitor therapy is recommended for all patients with heart failure (HF) and a reduced ejection fraction. It is generally initiated in the hospital at low doses as inotropic therapy is tapered. Angiotensin II receptor blockers may be a suitable alternative for patients who cannot tolerate ACE inhibitors. For patients who cannot tolerate either class of drug, a combination of hydralazine and a nitrate is recommended. ß-Blockers are first-line therapy for patients with current or previous symptoms of HF and reduced left ventricular function, as well as all patients hospitalized for HF. An aldosterone antagonist may be added to the regimen of patients with moderately severe to severe symptoms and reduced ejection fraction whose renal function and potassium concentration can be monitored.

In his recent editorial Putting Guidelines for Chronic Kidney Disease IntoPractice (CONSULTANT, October 2006, page 1295), Dr Gregory Ruteckidiscussed the results of a study that shows many clinicians fail to follow evidence-based guidelines for the management of chronic kidney disease(CKD), such as when to consult a nephrologist.1 A sampling of the feedbackwe received appears below, along with Dr Rutecki's responses.

During a routine diabetes follow-up visit, a 55-year-old man complains of increasing pain in his right groin and hip. He is also being treated for hypertension, and his body mass index is 28.

For several months, a 68-year-old man has had a highly pruritic rash on his lower legs. A similar rash recently arose on his trunk and arms. Treatment with a corticosteroid cream has been ineffective. The patient has diet-controlled diabetes and hypertension that is well controlled by medication.

PHILADELPHIA -- An aggressive approach to hypertension management in the U.S. has paid off in better blood pressure control than achieved in Europe, according to U.S. investigators.

CHICAGO -- Inhibitors of the renin-angiotensin system trumped calcium-channel-blockers, beta-blockers, and diuretics in preventing diabetes, according to a network meta-analysis of hypertension trials.

BALTIMORE -- The most vulnerable age for girls to initially put on too much weight is from nine to 12, and that may lead to high blood pressure and other cardiovascular risk factors, according to investigators here.

NEW YORK -- Pre-hypertension appears to increase the risk of developing an enlarged heart among teens and young adults, according to a study of American Indians.

MILAN, Italy -- An hour a week devoted by office workers to on-the-job stress management achieved small but significant improvements in both heart rate variability and arterial blood pressure after a year, researchers here reported.

On a warm August day, a 79-year-old man is hospitalized because of progressive lethargy over the past week. Previously, he was alert and able to converse. He has no chest pain, dyspnea, or cough. His history includes hypertension of unknown duration, chronic obstructive pulmonary disease, and a recent hospitalization for pneumonia.

For several days, a 38-year-old man has had an increasingly painful swelling behind the right knee. He runs several times a week. He has hypertension but no history of trauma or periods of inactivity, and no chest discomfort or shortness of breath. He drinks alcohol occasionally but does not use tobacco or illegal drugs.

To facilitate the assessment of jugular venous pressure, shine a beam of light tangentially across the skin overlying the jugular vein while the patient's neck muscles are relaxed.

Q:Is periodic laboratory monitoring recommended for patients withosteoarthritis who are receiving long-term cyclooxygenase-2 (COX-2)inhibitor therapy and who have no GI or renal symptoms? Similarly,is laboratory monitoring recommended for women who take a selectiveCOX-2 inhibitor to alleviate menstrual cramps (eg, rofecoxib, 50 mg/d,3 to 5 days per month)?--Sarita Salzberg, MDColumbus, Ohio

A pruritic rash under the left breast has bothered a 67-year-old woman forthe past month. She takes an antihypertensive and is otherwise healthy.

For 3 months, a 66-year-old retired man has had increasingweakness of the lower legs with stiffness,tingling, and numbness; worsening ataxia; anergia; andexertional dyspnea of insidious onset. He has lost 8 lb,and his appetite is poor. He denies fever, cough, chest orabdominal pain, paroxysmal nocturnal dyspnea, orthopnea,ankle swelling, bleeding disorders, hematemesis,melena, headache, vision problems, sciatica, joint pain,bladder or bowel dysfunction, and GI symptoms. He hasnocturia attributable to benign prostatic hypertrophy.

A 78-year-old widower with hypertension, type 2 diabetes, and hyperlipidemiais referred for a comprehensive geriatric assessment.His daughter is concerned about her father’s decline following her mother’s death a year ago.His memory seems to be deteriorating. His desk is cluttered with bills, but he refuses to lethis daughter help him or even look at his checkbook.

For the past week, a 16-year-old boy has had a progressively worsening dry, irritating cough; dyspnea on exertion; and intermittent fever and chills. During the past 24 hours, he has had no appetite and has vomited greenish material 3 or 4 times.

Q:How can I accurately determine when a patient’s hypertension isresistant to treatment-and what is the best approach to theevaluation?

Q:Under what circumstances is 24-hour ambulatoryblood pressure monitoring (ABPM) appropriate?

Q:Do evidence-based data support combination therapy with anangiotensin-converting enzyme (ACE) inhibitor and an angiotensin IIreceptor blocker (ARB)?