Resistant and refractory hypertension: two sides of the same disease? / Hipertensão resistente e refratária: duas faces de uma mesma doença?

Abstract Refractory hypertension (RfH) is an extreme phenotype of resistant hypertension (RH), being considered an uncontrolled blood pressure besides the use of 5 or more antihypertensive medications, including a long-acting thiazide diuretic and a mineralocorticoid antagonist. RH is common, with 10-20% of the general hypertensives, and its associated with renin angiotensin aldosterone system hyperactivity and excess fluid retention. RfH comprises 5-8% of the RH and seems to be influenced by increased sympathetic activity. RH patients are older and more obese than general hypertensives. It is strongly associated with diabetes, obstructive sleep apnea, and hyperaldosteronism status. RfH is more frequent in women, younger patients and Afro-americans compared to RFs. Both are associated with increased albuminuria, left ventricular hypertrophy, chronic kidney diseases, stroke, and cardiovascular diseases. The magnitude of the white-coat effect seems to be higher among RH patients. Intensification of diuretic therapy is indicated in RH, while in RfH, therapy failure imposes new treatment alternatives such as the use of sympatholytic therapies. In conclusion, both RH and RfH constitute challenges in clinical practice and should be addressed as distinct clinical entities by trained professionals who are capable to identify comorbidities and provide specific, diversified, and individualized treatment.

Resumo A Hipertensão Arterial Refratária (HARf) representa um fenótipo extremo da hipertensão arterial resistente (HAR), sendo considerada a falência ao tratamento apesar do uso de 5 ou mais classes de anti-hipertensivos, incluindo um diurético tiazídico de longa ação e um antagonista mineralocorticoide. A HAR é comum (10-20%) entre os hipertensos em geral, sendo decorrente de hiperatividade do Sistema Renina Angiotensina Aldosterona e retenção hidrossalina. Aqueles com HARf correspondem a 5-8% dos resistentes e parecem sofrer maior influência catecolaminérgica. Os resistentes tendem a ter maior idade, ao sobrepeso e à obesidade. Comorbidades incluem diabetes, apneia obstrutiva do sono e status de hiperaldosteronismo. Refratários são afro-americanos em maior proporção, mais jovens e, predominantemente, mulheres. Ambos são fortemente associados à elevada albuminúria, HVE, doenças cardio e cerebrovasculares, além da doença renal crônica. O fenômeno do jaleco branco parece ser mais evidente nos resistentes. Quanto ao tratamento, a intensificação da terapia diurética está indicada nos resistentes, enquanto na HARf, a falência à terapia impôs novas alternativas de tratamento ("simpaticolíticas"). Em conclusão, tanto a HAR quanto a HARf constituem-se desafios na prática clínica e devem ser abordadas como entidades clínicas distintas por profissionais especialistas que identifiquem comorbidades e venham a prover um tratamento específico, diversificado e individualizado.

Dexmedetomidine: present and future directions / 대한마취과학회지

Dexmedetomidine is a potent, highly selective α-2 adrenoceptor agonist, with sedative, analgesic, anxiolytic, sympatholytic, and opioid-sparing properties. Dexmedetomidine induces a unique sedative response, which shows an easy transition from sleep to wakefulness, thus allowing a patient to be cooperative and communicative when stimulated. Dexmedetomidine may produce less delirium than other sedatives or even prevent delirium. The analgesic effect of dexmedetomidine is not strong; however, it can be administered as a useful analgesic adjuvant. As an anesthetic adjuvant, dexmedetomidine decreases the need for opioids, inhalational anesthetics, and intravenous anesthetics. The sympatholytic effect of dexmedetomidine may provide stable hemodynamics during the perioperative period. Dexmedetomidine-induced cooperative sedation with minimal respiratory depression provides safe and acceptable conditions during neurosurgical procedures in awake patients and awake fiberoptic intubation. Despite the lack of pediatric labelling, dexmedetomidine has been widely studied for pediatric use in various applications. Most adverse events associated with dexmedetomidine occur during or shortly after a loading infusion. There are some case reports of dexmedetomidine-related cardiac arrest following severe bradycardia. Some extended applications of dexmedetomidine discussed in this review are promising, but still limited, and further research is required. The pharmacological properties and possible adverse effects of dexmedetomidine should be well understood by the anesthesiologist prior to use. Moreover, it is necessary to select patients carefully and to determine the appropriate dosage of dexmedetomidine to ensure patient safety.

Prenatal management with digoxin and sotalol combination for fetal supraventricular tachycardia : Case report and review of literature.

Sustained fetal supraventricular tachycardia (SVT) with a heart rate of approximately 210 bpm may lead to increased atrial and venous pressures and congestive heart failure. There is no clear consensus regarding the best drug-treatment regimens for fetal SVT. However, considerable nonrandomized experience in the transmaternal treatment of fetal SVT is available with a number of antiarrhythmic agents. We report a case of fetal supraventricular tachyarrhythmia with hydrops detected at 32 weeks that was managed with combination of oral digoxin and sotalol and review management guidelines available in the literature.

The Effects of Lumbar Sympathetic Ganglion Block in the Patients with Spinal Stenosis and the Skin Temperature Changes according to the Contrast Spread Patterns

BACKGROUND: We hypothesized that if a fluoroscopic image of the lumbar sympathetic ganglion block (LSGB) showed the spread patterns of contrast at both the L2/3 and L4/5 disc areas, then this would demonstrate a more profound blockade effect because the spread patterns are close to sympathetic ganglia. In addition, we compared the effects of LSGB and transforaminal epidural steroid injection (TFESI) for the patients suffering with spinal stenosis. METHODS: Eighty patients were divided into two groups (Group S: the patients treated with TFESI, Group L: the patients treated with LSGB). The patients of group L were classified into three groups (groups A, B and, C) according to their contrast spread pattern. The preblock and postblock temperature difference between the ipsilateral and contralateral great toe (DT(pre), DT(post), degrees C), and the DTnet were calculated as follows. DT(net) = DT(post) - DT(pre). RESULTS: Both group showed a significant reduction of the visual analogue score (VAS) and the Oswestry disability index (ODI) score. Only the patients of group L showed a significant increase of their walking distance (WD). Group A showed the most significant changes in the DT(post) (6.1 +/- 1.2degrees C, P = 0.021), and the DTnet (6.0 +/- 1.0degrees C, p = 0.023), as compared to group C. CONCLUSIONS: LSGB showed a similar effect on the VAS, and ODI, and a significant effect, on WD, compared with TFESI. Group A showed a significant sympatholytic effect, as compared to group C.

effect of sympathetic antagonists on the antidepressant action of Alprazolam

Alprazolam is an anti-anxiety drug shown to be effective in the treatment of depression. In this study, the effect of sympathetic receptor antagonists on alprazolam-induced antidepressant action was studied using a mouse model of forced swimming behavioral despair. The interaction of three sympathetic receptor antagonists with benzodiazepines, which may impact the clinical use of alprazolam, was also studied. Behavioral despair was examined in six groups of albino mice. Drugs were administered intraperitoneally. The control group received only a single dose of 1% Tween 80. The second group received a single dose of alprazolam, and the third group received an antagonist followed by alprazolam. The fourth group was treated with imipramine, and the fifth group received an antagonist followed by imipramine. The sixth group was treated with a single dose of an antagonist alone [atenolol, a beta1-selective adrenoceptor antagonist; propranolol, a non selective [beta-adrenoceptor antagonist; and prazocin, an al-adrenoceptor antagonist]. Results confirmed the antidepressant action of alprazolam and imipramine. Prazocin treatment alone produced depression, but it significantly potentiated the antidepressant actions of imipramine and alprazolam. Atenolol alone produced an antidepressant effect and potentiated the antidepressant action of alprazolam. Propranolol treatment alone produced depression, and antagonized the effects of alprazolam and imipramine, even producing depression in combined treatments.In conclusion, our results reveal that alprazolam may produce antidepressant effects through the release of noradrenaline, which stimulates beta2 receptors to produce an antidepressant action. Imipramine may act by activating beta2 receptors by blocking or down-regulating beta1 receptors

Correction Upper Eyelid Retraction with Nasal Septal Cartilage-Mucosa Composite Graft

The retraction of the upper eyelid is associated with thyroid dysfunction, facial palsy, trauma, and overcorrection of ptosis and also occurs iatrogenically after eyelid or orbital surgery. In this condition, corneal exposure leads to discomfort, epiphora, and corneal irritation. Moreover increased showing of sclera above corneal limbus is considered one of cosmetic defect. Treatment modalities may be either medical or surgical. The medical treatments consists of control of thyroid dysfunction, steroid, sympatholytics. Many authors described surgical correction; recession of levator palpebral muscle or M ller muscle and graft matrix. The difficulties in surgical treatment consist of unpredictability of levator-M ller muscle manipulation, and healing of grafted material. Two patients have been operated with using of septal cartilage-mucosa composite graft. nasal septal cartilage-mucosa composite graft is autologous, firm, thin and harvested easily. The result was satisfactory functionally and aesthetically.

The role of thoracic epidural analgesia in cardiac surgery

It is suggested that TEA improves the myocardial metabolic supply and demand relationship and thereby affords myocardial protection. This is supported by a reduction in myocardial stunning and infarct size in animal models and by improved perioperative hemodynamic stability and reduced markers of ischemic injury in clinical studies. Other beneficial effects include reliable stress response attenuation with a reduction in postoperative analgesia resulting in improved pulmonary function following cardiac surgery. It is furthermore clear that to achieve improved outcome, it is essential that the use of TEA be extended well into the postoperative period as an analgesic component of a multimodal postoperative approach, which should also include such things as early enteral feeding and mobilization. However, because of the potential risk of epidural hematoma, with possible permanent neurological injury, it is essential that the use of TEA be justified through studies showing improved outcomes (e.g., reduced major myocardial events and improved graft patency). This will require large, well-designed multicenter clinical trials and an international registry for complications. Until then, it is essential that epidural anesthesia during cardiac surgery be used cautiously, following recommended guidelines

Hipertensäo arterial / High blood pressure

Os autores inicialmente apresentam dados de consensos nacionais e internacionais sobre os valores normais da pressäo arterial, conceituando a hipertensäo arterial de acordo com os critérios atuais para o diagnóstico preciso da doença, considerando a distribuíçäo dos valores tensionais na populaçäo geral e as lesöes da hipertensäo arterial sobre os órgäos-alvo, bem como os fatores de risco cardiovascular associados. O tratamento näo farmacológico deve ser aplicado a todos os pacientes, com base na modificaçäo do estilo de vida a fim de reduzir ou eliminar os fatores de risco para a hipertensäo arterial e para as doenças cardiovasculares, incluindo a reduçäo do peso corporal, diminuíçäo da ingestäo de sódio, aumento da ingestäo de potássio, reduçäo de bebidas alcoólicas, realizaçäo de exercícios físicos, abandono do tabagismo, controle das dislipidemias e do diabetes e evitar o uso de drogas que possam aumentar a pressäo arterial. No tratamento farmacológico, os autores tecem comentários sobre a monoterapia e as associaçöes, apresentando o grupo de agentes utilizados: diuréticos, simpatolíticos (incluindo beta-bloqueadores), bloqueadores dos canais de cálcio, inibidores da enzima conversora da angiotensina, antagonistas dos receptores da angiotensina; mensionam os agentes de cada grupo, salientando as açöes farmacológicas, principais características, efeitos adversos, benefícios e detalhes sobre a utilizaçäo desses agentes na prática clínica.(au)

Clonidina venosa no controle da hipertensäo arterial perioperatória em cirurgias de catarata: estudo retrospectivo / Intravenou clonidine to control perioperative arterial hypertension in cataract surgeries: a retrospective study

Justificativa e objetivos: a clonidina é um delta2 agonista de açäo central que diminui o tônus simpático proporcionando maior estabilidade hemodinâmica no per-operatório. O objetivo deste estudo foi avaliar o emprego da clonidina, por via venosa, no tratamento de crise hipertensivas no per-operatório de cirurgia de catarata, verificando sua eficácia e adequaçäo. Método: o estudo envolveu levantamento retrospectivo dos casos de crises hipertensivas tratadas com clonidina, por via venosa, no per-operatório de cirugias de catarata nos meses de junho, julho e agosto de 1999 no Hospital de Clínicas de Ribeiräo Preto, totalizando 76 pacientes. Através de revisäo das fichas anestésicas, de recuperaçäo pós-anestésica e de enfermagem, foram verificados dados demográficos, doenças associadas, classificaçäo do estado físico (ASA), medicaçöes em uso, tempo e condiçöes da alta anestésica, bem como parâmetros hemodinâmicos antes e após a administraçäo de clonidina. Considerou-se crise hipertensiva a PAS maior qie 170 mmHg e hipotensäo como PAS menor que 110 mmHg. Resultados: após a administraçäo de clonidina houve queda significativa da PAS nos tempos 15, 30, 45 e 60 minutos quando comparados com os níveis durante a crise hipertensiva. A clonidina controlou a pressäo arterial em 95 por cento dos pacientes, com baixa incidência de hipotensäo arterial (2,3 por cento) e outras complicaçöes. O tempo de alta näo foi prolongado com o uso da clonidina. Conclusöes: Os resultados mostraram a eficácia, adequaçäo e segurança da clonidina no tratamento de crises hipertensivas durante cirurgia de catarata

Expression of natriuretic peptide mRNAs in isoproterenol-induced cardiac hypertrophy in rats

We examined the expression of atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP) mRNAs upon isoproterenol (Iso)-induced cardiac hypertrophy in rats. Then, we tried to investigate the effects of sympatholytics to see if they can modulate the expression of ANP and BNP. In this study, RT-PCR technique was used to characterize the expression of ANP and BNP in right atrium (RA) and left ventricle (LV) of the hypertrophied rat heart. Histologic findings indicated that stimulation of beta-adrenoceptors with Iso for 5 days was sufficient to induce cardiac hypertrophy in rats. A continuous stimulation with Iso for 7 days resulted in an increase of the ANP and BNP expression in the LV and BNP expression in the RA. The increased expressions of ANP and BNP in the LV were slightly inhibited, and the increased expressions of BNP in the RA were markedly inhibited by a continuous treatment with propranolol, metoprolol, and clonidine for 7 days. Overall, our data present a differential expression of the natriuretic peptides in Iso-induced cardiac hypertrophy, and that the mechanisms involved in this differential ANP and BNP gene expression could be mediated via sympathetic nervous system.

Inibidores do sistema simpático / Sympathetic system inhibitors

Nesta breve revisão, discutimos o uso terapêutico de uma grande família de anti-hipertensivos: os inibidores do sistema nervoso simpático. Essa família de hipotensores consiste basicamente dos alfa2-agonistas, os beta-bloqueadores, os bloqueadores dos receptores alfa 1 e o mais novo membro, a moxonidina, considerado um alfa2-agonista de segunda geração. Além das ações anti-hipertensiva, também discutimos outros aspectos farmacológicos dessas drogas, o que poderá ajudar os clínicos a tratar condições co-mórbidas.

Influencia de la rehabilitacion cardiaca en pacientes con infarto del miocardio bajo tratamiento con betabloqueadores / Influence of cardiac rehabilitation in patients with myocardial infarction treated with betablockers

Para precisar si el estado de betabloqueo adrenergico atenua el grado de entrenamiento fisico en pacientes que han sufrido un infarto agudo del miocardio, se estudiaron 111 pacientes de ambos sexos, con una media de 49,8 anos, divididos en 2 grupos: grupo 1 (sin tratamiento betabloqueador) y grupo 2 (bajo tratamiento betabloqueador). Se les realizaron 3 pruebas ergometricas en bicilceta electrica a los 3,6 y 12 meses de estar incorporados a un programa de entrenamiento fisico. No se encontraron diferencias significativas en las variables que no son influidas directamente por los betabloqueadores en ambos grupos: media del consumo de oxigeno valor medio de la capacidad funcional, tiempo de ejercicio y potencia media. Se concluye que los pacientes infartados y tratados con betabloqueadores pueden beneficiarse cuando son incorporados a un Programa de Rehabilitacion Cardiovascular Integral

Bloqueio regional intra-venoso com guanetidina / Regional intravenous block with guanetidin

Demonstra-se a utilidade prática do bloqueio regional intra-venoso com Guanetidina em oito pacientes com dor; salienta-se a simplicidade de execuçäo, segurança, maior conforto e menor invasividade

Reversäo de midríase medicamentosa com ouso do Cloridato de Dapiprazole / Drug induced mydriasis reversal by dapiprazole

Cinquenta pacientes, submetidos à midríase para investigaçäo clínico-oftalmológica, foram estudados para acompanhamento da reversäo da dilataçäo pupilar com o uso do Cloridrato de Dapiprazole, um alfa-bloqueador existente no mercado internacional. Em aproximadamente 60 por cento do número dos casos, näo foram obtidos resultados significativos na reversäo da midríase medicamentosa com a droga pesquisada. Foram analisadas no trabalho algumas hipóteses que justificariam este resultado

Hipertensión arterial en niños / Arterial hypertension in children

La hipertensión arterial es un síndrome caracterizado por aumento persistente de la tensión arterial. La frecuencia en niños oscila entre 1 y 3 por ciento. Puede ser primaria o secundaria y de éstas, casi siempre debida a enfermedades renales. Se describen los métodos y la técnica de medición de la presión en niños, las cifras de normalidad y de acuerdo a ellas la clasificación de la hipertensión. La etiología es muy variada. Se describen guías clínicas y de auxiliares de diagnóstico para efectuar el diagnóstico etiológico. En relación al tratamiento, se insiste en la importancia del tratamiento etiológico, de las medidas generales para el control de la tensión arterial, de los medicamentos antihipertensivos y de la elección de los mismos de acuerdo al tipo de hipertensión arterial.

Anestésico para rinoseptoplastia / Anesthesia for rhinoseptoplasty

A 25 pacientes de uno y otro sexo y en buenas condiciones generales, se les hizo rinoseptoplastía bajo anestesia general balanceada e hipotensión controlada inducida con 2.4 mcg/kg de peso/minuto de nitroprusiato de sodio, previa administración de 1 mg/kg de peso de propanolol. La técnica permite un flujo sanguíneo periférico adecuado y no se hicieron aparentes signos de complicaciones neurológicas, cardiocirculatorias o metabólicas. Se describen los diferentes procedimientos anestésicos para el manejo de este grupo de pacientes y las consecuencias que conlleva la infiltración de catecolaminas exógenas y la liberación de sustancias vasoactivas endógenas