Acute Stress Cardiomyopathy: Heart of pheochromocytoma.

Stress cardiomyopathy (SCM) is a syndrome characterized by transient regional systolic dysfunction of the left ventricle in the absence of angiographic evidence of coronaropathy. This abnormality is associated with high levels of catecholamines. Stress cardiomyopathy is also called Takotsubo (TS) cardiomyopathy. Pheochromocytoma crisis can occur spontaneously or can be precipitated by manipulation of the tumor, trauma, certain medications or stress for example during non-adrenal surgery. The main drugs leading to pheochromocytoma crisis include D2 dopamine receptor antagonists, noncardioselective ß-adrenergic receptor blockers, tricyclic antidepressants and related neurotransmitter uptake blockers, sympathomimetics, certain peptide and steroid hormones and several agents used during induction of anesthesia. Patients can develop symptoms of heart failure associated with tachyarrhythmia, cardiogenic shock with hypotension and collapse, or apparent acute coronary syndromes. This review describes pathophysiology, epidemiology, diagnosis criteria and management of SCM.

[Spironolactone in resistant essential hypertension]. / HTA essentielle résistante : place de la spironolactone.

Resistant hypertension is defined as uncontrolled blood pressure (BP) despite three antihypertensive agents including a diuretic (thiazide diuretic if renal function is normal or loop diuretic in case of chronic kidney disease with eGFR<30mL/min), a renin-angiotensin system blocker (ARB or ACEI) and a calcium channel blocker, at optimal doses. Resistance must be confirmed by out-of-office measurements (ambulatory blood pressure monitoring or home blood pressure monitoring) and patients should be asked about treatment compliance and excessive salt or alcohol intake. If the diagnosis of resistant hypertension is confirmed, the patient should be referred to a hypertension specialist to screen for secondary causes of hypertension as they are frequent in this context. If essential resistant hypertension is confirmed, the mineralocorticoid receptor antagonist, spironolactone, should be added (25 to 50mg daily). In the event of a contraindication to spironolactone, or if adverse effects occur, a beta-blocker, an alpha-blocker, or a centrally acting antihypertensive drug should be prescribed.

[What is resistant hypertension and how to diagnose it?] / Qu'est-ce que l'hypertension artérielle résistante et comment l'objectiver ?

WHAT IS RESISTANT HYPERTENSION AND HOW TO DIAGNOSE IT?. High blood pressure is one of the leading factors influencing the cardiovascular risk. Despite current knowledge on the management of hypertension and the numerous antihypertensive drugs available, hypertension remains insufficiently controlled and part of these « uncontrolled ¼ patients meet the definition of resistant hypertension. Resistant hypertension is defined by the failure to achieve blood pressure target (office blood pressure smaller than 140/90 mm Hg) despite appropriate treatment with optimal doses of three antihypertensive drugs, ideally a combination of a renin angiotensin system blocker, a calcium channel blocker and a diuretic. Pseudoresistance should be excluded by using 24 h ambulatory blood pressure or home blood pressure measurements. The management of resistant hypertension includes the identification of lifestyle factors such as obesity, excessive alcohol and dietary sodium intake, volume overload, drug-induced hypertension and the screening of secondary forms of hypertension. The treatment associates lifestyle changes, reinforcement of adherence to treatment, discontinuation of interfering substances, association of antihypertensive drugs on top of the initial triple therapy, especially aldosterone antagonists (spironolactone) as fourth line treatment. Follow-up should be based on home blood pressure.

QU'EST-CE QUE L'HYPERTENSION ARTÉRIELLE RÉSISTANTE ET COMMENT L'OBJECTIVER ?. L'hypertension artérielle est l'un des principaux facteurs de risque cardiovasculaire. En dépit des nombreuses recommandations des sociétés savantes et du nombre important de classes d'antihypertenseurs disponibles, l'hypertension artérielle demeure insuffisamment contrôlée, et parmi les patients non contrôlés certains ont une hypertension résistante. L'hypertension artérielle résistante est caractérisée par la non-atteinte de la cible tensionnelle (mesure clinique plus petit que 140/90 mmHg) malgré une trithérapie à doses optimales comportant idéalement un bloqueur du système rénine-angiotensine, un antagoniste des canaux calciques et un diurétique thiazidique ou apparenté. On doit s'assurer de la réalité du niveau tensionnel (par mesure ambulatoire de la pression artérielle ou par automesure à domicile), de la bonne observance du traitement, de l'absence de prise de médicaments ou toxiques vasoactifs, de l'absence de cause méconnue. On doit aussi identifier les facteurs favorisant comme l'obésité, l'inactivité physique et la consommation excessive d'alcool et de sel. La conduite à tenir associe un renforcement des règles hygiéno-diététiques strictes, l'arrêt des substances hypertensives ou interférant avec l'efficacité des traitements antihypertenseurs, et l'ajout de différentes classes d'antihypertenseurs en sus de la trithérapie de base, en particulier la spironolactone à faible dose en quatrième ligne. Le suivi s'appuiera sur l'automesure à domicile.