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Common Secondary Causes of Resistant Hypertension and Rational for Treatment

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      Abstract

      Resistant hypertension is defined as uncontrolled blood pressure despite the use of three antihypertensive drugs, including a diuretic, in optimal doses. Treatment resistance can be attributed to poor adherence to antihypertensive drugs, excessive salt intake, physician inertia, inappropriate or inadequate medication, and secondary hypertension. Drug-induced hypertension, obstructive sleep apnoea, primary aldosteronism, and chronic kidney disease represent the most common secondary causes of resistant hypertension. Several drugs can induce or exacerbate pre-existing hypertension, with non-steroidal anti-inflammatory drugs being the most common due to their wide use. Obstructive sleep apnoea and primary aldosteronism are frequently encountered in patients with resistant hypertension and require expert management. Hypertension is commonly found in patients with chronic kidney disease and is frequently resistant to treatment, while the management of renovascular hypertension remains controversial. A step-by-step approach of patients with resistant hypertension is proposed at the end of this review paper.

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      Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure.

      The National High Blood Pressure Education Program presents the complete Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Like its predecessors, the purpose is to provide an evidence-based approach to the prevention and management of hypertension. The key messages of this report are these: in those older than age 50, systolic blood pressure (BP) of greater than 140 mm Hg is a more important cardiovascular disease (CVD) risk factor than diastolic BP; beginning at 115/75 mm Hg, CVD risk doubles for each increment of 20/10 mm Hg; those who are normotensive at 55 years of age will have a 90% lifetime risk of developing hypertension; prehypertensive individuals (systolic BP 120-139 mm Hg or diastolic BP 80-89 mm Hg) require health-promoting lifestyle modifications to prevent the progressive rise in blood pressure and CVD; for uncomplicated hypertension, thiazide diuretic should be used in drug treatment for most, either alone or combined with drugs from other classes; this report delineates specific high-risk conditions that are compelling indications for the use of other antihypertensive drug classes (angiotensin-converting enzyme inhibitors, angiotensin-receptor blockers, beta-blockers, calcium channel blockers); two or more antihypertensive medications will be required to achieve goal BP (<140/90 mm Hg, or <130/80 mm Hg) for patients with diabetes and chronic kidney disease; for patients whose BP is more than 20 mm Hg above the systolic BP goal or more than 10 mm Hg above the diastolic BP goal, initiation of therapy using two agents, one of which usually will be a thiazide diuretic, should be considered; regardless of therapy or care, hypertension will be controlled only if patients are motivated to stay on their treatment plan. Positive experiences, trust in the clinician, and empathy improve patient motivation and satisfaction. This report serves as a guide, and the committee continues to recognize that the responsible physician's judgment remains paramount.
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        Bevacizumab plus irinotecan, fluorouracil, and leucovorin for metastatic colorectal cancer.

        Bevacizumab, a monoclonal antibody against vascular endothelial growth factor, has shown promising preclinical and clinical activity against metastatic colorectal cancer, particularly in combination with chemotherapy. Of 813 patients with previously untreated metastatic colorectal cancer, we randomly assigned 402 to receive irinotecan, bolus fluorouracil, and leucovorin (IFL) plus bevacizumab (5 mg per kilogram of body weight every two weeks) and 411 to receive IFL plus placebo. The primary end point was overall survival. Secondary end points were progression-free survival, the response rate, the duration of the response, safety, and the quality of life. The median duration of survival was 20.3 months in the group given IFL plus bevacizumab, as compared with 15.6 months in the group given IFL plus placebo, corresponding to a hazard ratio for death of 0.66 (P<0.001). The median duration of progression-free survival was 10.6 months in the group given IFL plus bevacizumab, as compared with 6.2 months in the group given IFL plus placebo (hazard ratio for disease progression, 0.54; P<0.001); the corresponding rates of response were 44.8 percent and 34.8 percent (P=0.004). The median duration of the response was 10.4 months in the group given IFL plus bevacizumab, as compared with 7.1 months in the group given IFL plus placebo (hazard ratio for progression, 0.62; P=0.001). Grade 3 hypertension was more common during treatment with IFL plus bevacizumab than with IFL plus placebo (11.0 percent vs. 2.3 percent) but was easily managed. The addition of bevacizumab to fluorouracil-based combination chemotherapy results in statistically significant and clinically meaningful improvement in survival among patients with metastatic colorectal cancer. Copyright 2004 Massachusetts Medical Society
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          Global burden of hypertension: analysis of worldwide data.

          Reliable information about the prevalence of hypertension in different world regions is essential to the development of national and international health policies for prevention and control of this condition. We aimed to pool data from different regions of the world to estimate the overall prevalence and absolute burden of hypertension in 2000, and to estimate the global burden in 2025. We searched the published literature from Jan 1, 1980, to Dec 31, 2002, using MEDLINE, supplemented by a manual search of bibliographies of retrieved articles. We included studies that reported sex-specific and age-specific prevalence of hypertension in representative population samples. All data were obtained independently by two investigators with a standardised protocol and data-collection form. Overall, 26.4% (95% CI 26.0-26.8%) of the adult population in 2000 had hypertension (26.6% of men [26.0-27.2%] and 26.1% of women [25.5-26.6%]), and 29.2% (28.8-29.7%) were projected to have this condition by 2025 (29.0% of men [28.6-29.4%] and 29.5% of women [29.1-29.9%]). The estimated total number of adults with hypertension in 2000 was 972 million (957-987 million); 333 million (329-336 million) in economically developed countries and 639 million (625-654 million) in economically developing countries. The number of adults with hypertension in 2025 was predicted to increase by about 60% to a total of 1.56 billion (1.54-1.58 billion). Hypertension is an important public-health challenge worldwide. Prevention, detection, treatment, and control of this condition should receive high priority.
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            Author and article information

            Affiliations
            1Veterans Affairs Medical Center, George Washington University, VAMC 50 Irving Street NW, Washington, DC 20422, USA
            2Veterans Affairs Medical Center, Georgetown University, Washington, DC 20422, USA
            Author notes

            Academic Editor: Konstantinos Tsioufis

            Journal
            Int J Hypertens
            IJHT
            International Journal of Hypertension
            SAGE-Hindawi Access to Research
            2090-0392
            2011
            2 March 2011
            : 2011
            3057025
            21423678
            10.4061/2011/236239
            Copyright © 2011 Charles Faselis et al.

            This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

            Categories
            Review Article

            Cardiovascular Medicine

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