[Endocrine hypertension in pregnancy]. / Hypertensions artérielles endocriniennes au cours de la grossesse.

Hypertension is a frequent complication of pregnancy and may compromise fetal and maternal outcome. Hypertension may be pregnancy-induced, essential or secondary to endocrine disorders. Most cases of endocrine hypertension are the consequence of adrenal diseases. Pheochromocytoma, hypercorticism, primary aldosteronism or glucocorticoid-remediable aldosteronism can be present or diagnosed at any term and may cause severe hypertension. The most hazardous form of endocrine hypertension during pregnancy is pheochromocytoma because it may involve paroxysmal arrhythmia and/or hypertension during labor. Clinical clues and biological tests are similar to those used in non-pregnant subjects. Tests for tumor location are limited to ultrasound and magnetic resonance scans in order to avoid maternal and fetal irradiation. Medication to prepare for pheochromocytoma surgery uses alpha- and beta-blockers. The timing of surgery depends on the term of pregnancy at the diagnosis of the tumor.

[Arterial hypertension secondary to curable causes in adults]. / Hypertensions artérielles secondaires à des causes curables chez l'adulte.

EXTENSIVE AND COSTLY INVESTIGATIONS: Are not warranted in the vast majority of hypertensive patients. Characteristics identifying the patients at risk for secondary hypertension can be used to define the small percentage of patients with hypertension who require more extensive diagnostic testing and management of their condition. Exposure to certain medicines, foods or drugs may cause reversible rises in blood pressure. Renovascular and adrenal diseases cause curable forms of hypertension. IN MANY CASES, THE PATIENT'S HISTORY: Examination and simple tests can detect such exposures and disorders. Checking for secondary hypertension is therefore an early step required for the management of all patients with hypertension, provided it is based on clinical signs and inexpensive tests. This primary screening cannot exclude the possibility of renovascular or adrenal disease in a small number of asymptomatic patients. The risk of missing a diagnosis is acceptable provided that blood pressure is normalized by non-specific antihypertensive treatment. However, more extensive etiologic investigation is required in patients who subsequently develop resistant hypertension. This secondary screening requires imaging and biochemical tests that are not required for primary screening. CORRECTION OF THE CAUSES: Of secondary forms of hypertension may restore blood pressure to normal. The patient's age affects the reversibility of renovascular and adrenal hypertension after etiologic treatment: the younger the patient, the higher the probability of blood pressure normalization.

[Revascularization of atherosclerotic stenosis of the renal artery. Indications and results]. / Revascularisation des sténoses athéroscléreuses de l'artère rénale. Indications et résultats.

RISKS: Atherosclerotic renal artery stenosis typically occurs in high risk patients with coexistent vascular disease elsewhere. Patients with atherosclerotic renal artery stenosis may develop progressive renal failure but have a much higher risk of dying with a stroke or a myocardial infarction than of progressing to end-stage renal disease. REVASCULARIZATION RESULTS: Recent controlled trials comparing medication to revascularization have shown that only a minority of such patients can expect hypertension cure, whereas trials designed to document the ability of revascularization to prevent progressive renal failure are not yet available. Percutaneous renal artery angioplasty is the first choice because it is simpler than and as effective as surgical reconstruction. INDICATIONS: Revascularization should be undertaken in patients with atherosclerotic renal artery stenosis and resistant hypertension or heart failure, and probably in those with rapidly deteriorating renal function or with an increase in plasma creatinine levels during angiotensin-converting enzyme inhibition. Older age, long history of hypertension and a kidney size less than 8 cm are associated with little chance of blood pressure improvement or kidney function recovery. PRACTICAL ATTITUDE: With or without revascularization, medical therapy using antihypertensive agents, statins and aspirin is necessary in almost all cases. Blood pressure and plasma creatinine concentration should be measured every three months. Kidney size and renal artery patency should be assessed yearly.

Is primary aldosteronism underdiagnosed in clinical practice?

1. Primary aldosteronism is a syndrome consisting of hypertension, suppressed renin activity or concentration and high aldosterone levels in plasma or urine. The main steps in diagnosis are the determination of renin and aldosterone levels, the demonstration of renin-aldosterone dissociation and discrimination between idiopathic hyperplasia and Conn's adenoma, with only Conn's adenoma amenable to surgery. 2. Patients with resistant hypertension and/or hypokalaemia should be screened for primary aldosteronism with simple, redundant hormonal tests. The aldosterone to renin ratio is a logical initial screening test, a high ratio demonstrating renin-aldosterone dissociation. Criteria for a high ratio should be determined in each laboratory. 3. In patients with documented primary aldosteronism, computed tomography scan and adrenal vein sampling help to distinguish between idiopathic hyperplasia and Conn's adenoma. 4. Patients with low renin hypertension, idiopathic hyperplasia and Conn's adenoma have overlapping values for plasma concentrations of potassium, renin and aldosterone and the aldosterone to renin ratio. Because primary aldosteronism subtypes are quantitative diseases, the true prevalence of primary aldosteronism cannot be defined. 5. The use of sensitive screening tests (e.g. aldosterone to renin ratio) gives a higher prevalence of diagnosed cases of primary aldosteronism, but not of surgically correctable forms. Therefore, there is no clinical evidence that primary aldosteronism is underdiagnosed. 6. There is a need for tests to predict the postoperative blood pressure outcome of surgery in subjects with Conn's adenoma.