Alexander Schirger

Cold pressor test as a predictor of hypertension.

To determine the usefulness of the cold pressor test as a predictor of hypertension, we compared the blood pressure recordings available from 142 patients in 1979 with readings obtained during performance of two cold pressor tests, the first in 1934 when these subjects were children, and the second in 1961. Forty-eight subjects were hyperreactors to the tests in either 1934 or 1961, and 94 were normoreactors. At last follow-up, blood pressures in 14 of the hyperreactors were between 140 and 160 mm Hg systolic or 90 and 100 mm Hg diastolic (Stratum 1) and in 20 exceeded 160 mm Hg systolic or 100 mm Hg diastolic (Stratum 2). Ten normoreactors had casual blood pressures in Stratum 1 and eight in Stratum 2. Hypertension had thus occurred in 71% of the hyperreactors and 19% of the normoreactors. Fifteen hyperreactors were receiving antihypertensive therapy, and this reduced the severity of the casual blood pressure elevation in most patients to Stratum 1. Antihypertensive therapy had been started in three normoreactors. The duration of follow-up, 45 years, and the mean age at follow-up, almost 57 years, were greater in this study than in any previously reported study. Early hyperreactivity was related to future hypertension in enough subjects to suggest that an abnormal response to an external cold stimulus may be useful as an indicator of future hypertension.

Outcomes of Atherosclerotic Renal Artery Stenosis Managed Without Revascularization

OBJECTIVE To determine how often patients with renal artery stenosis (RAS) managed without revascularization progress to accelerated hypertension and/or renal failure. PATIENTS AND METHODS We examined the outcomes of 68 patients (mean +/- SEM age, 71.8 +/- 0.9 years) with high-grade (>70%) RAS identified between 1989 and 1993 who were treated without renal revascularization for at least 6 months after angiography. The time to last follow-up averaged 38.9 +/- 2.8 months. Other vascular beds were affected in 66 of the 68 patients. End points were revascularization, nephrectomy, dialysis, or death. RESULTS The mean +/- SEM serum creatinine level rose from 1.4 +/- 0.1 to 2.0 +/- 0.2 mg/dL (P<.001). Mean +/- SEM blood pressure did not change (157 +/- 3/83+/-2 vs 155 +/- 3/79 +/- 2 mm Hg), but the need (mean +/- SEM) for medication increased from 1.6+/-0.1 to 1.9+/-0.1 drugs (P=.02). Four patients (5.8%) eventually underwent renal revascularization for refractory hypertension (1 patient), for progressive stenosis (1 patient), and during aortic reconstruction (2 patients). One additional patient underwent nephrectomy to improve blood pressure control. Five others (7.4%) developed end-stage renal disease (ESRD) for reasons other than progressive vascular disease, namely, diabetes (3 patients), atheroemboli (1 patient), and contrast toxicity without RAS progression (1 patient). In 1 further case, the reason for ESRD was unknown, and it may have been caused by vascular occlusion. During follow-up, 19 patients died of unrelated causes, including myocardial infarction and stroke. CONCLUSIONS These data indicate that antihypertensive medication requirements increased and renal function deteriorated modestly in a subset of patients with atherosclerotic RAS managed initially without vascular intervention. Many achieved stable blood pressure for many years. Deterioration of renal function and mortality risk were greatest in patients with bilateral stenosis or stenosis to a solitary functioning kidney. These results reinforce the need for meticulous follow-up for disease progression but underscore the role of competing risks and high mortality from other cardiovascular diseases, which primarily determine the outcomes in patients with RAS and widespread atherosclerotic disease.

Noninvasive evaluation of the swollen extremity: Experiences with 190 lymphoscintigraphic examinations

Lymphoscintigraphy (LS), performed with technetium 99m-labeled antimony trisulfide colloid (Cadema Medical Products, Inc., Middletown, N.Y.), was used as a noninvasive diagnostic examination to evaluate the lymphatic circulation in 190 extremities of 115 patients. Forty-six patients had primary lymphedema, 48 had secondary lymphedema, and 21 patients had other causes of limb swelling. To determine the value of LS in surgical decision making, preoperative and postoperative LS of 16 patients who underwent surgical repair of the lymphatic abnormality were studied separately. Semiquantitative evaluation of the lymphatic drainage and visual interpretation of the image patterns were reliable to differentiate lymphedema from edemas of other origin (sensitivity: 92%, specificity: 100%). Although certain image patterns were characteristic of either primary or secondary lymphedema, LS could not consistently differentiate between the two types. Episodes of cellulitis in lymphedema clearly delayed lymph transport. LS was helpful in patient selection and follow-up after lymphatic surgery, but it did not prove patency of lymphovenous anastomoses. It was diagnostic in the evaluation of lymphangiectasia and was used to document successful surgical treatment of reflux of chyle. LS is safe and reliable and has no side effects. It should replace contrast lymphangiography in the routine evaluation of the swollen extremity.

Microsurgical lymphovenous anastomosis for treatment of lymphedema: A critical review

Lymphovenous anastomoses (LVA) offer ideal physiologic treatment for lymphedema, and our experimental data support late patency. Between Jan. 1, 1982, and April 1, 1986, 18 patients underwent operation for chronic lymphedema; LVA could be performed in 14 patients (10 women and four men). Six patients had secondary lymphedema of the upper extremity. One of eight patients with lymphedema of the lower extremity had filariasis, and seven had primary lymphedema. Mean follow-up was 36.6 months (range: 5 to 57 months). Limb circumference and volume, number of postoperative episodes of cellulitis, and lymphoscintigraphy were used to assess results. Improvement occurred in three upper extremities and two lower extremities. There was no change in five extremities, and in four patients the edema progressed. One patient with primary lymphedema and four of seven patients with secondary lymphedema improved. Only one of five patients benefited from one anastomosis; however, all patients with more than two anastomoses improved. Lymphoscintigraphy was performed in 10 patients. No lymphatic channel was visualized before operation in three patients, and at operation none was found. In four other patients lymph channels localized by lymphoscintigraphy were identified during operation. Significant improvement was documented by lymphoscintigraphy in one patient after operation, and this patient had permanent improvement 30 months later. Patients with primary lymphedema had disappointing results, but four of seven patients with secondary lymphedema benefited from LVA, especially if several anastomoses could be performed. Lymphoscintigraphy appears to be a suitable method of both identifying patent lymph channels before surgery and determining function of LVA after operation. However, presently objective data to prove the clinical efficacy of this operation are lacking.

Pharmacodynamics of midodrine, an antihypotensive agent

Midodrine is an orally active adrenergic agonist useful in the treatment of hypotension. We have investigated the pharmacodynamics of its active metabolite after oral midodrine therapy in nine patients with severe orthostatic hypotension. Peak plasma levels of the metabolite were reached in 60 to 90 minutes and ranged from 25 to 56 ng/ml. The mean values for distribution volume, plasma clearance, and t½were 4.0 L/kg, 23 ml/min/kg, and 2.1 hours, respectively. Heart rate increased after 5 to 10 mg doses and the increases were statistically significant (P < 0.05) at 120 minutes. An apparent increase in blood pressure was not statistically significant. The patients said that they felt better.

Orthostatic Hypotension as a Clue to Primary Systemic Amyloidosis

Data on 11 patients with orthostatic hypotension and primary systemic amyloidosis have been presented. Dizziness and light-headedness or syncope significantly hampered the involved patients. Three were incapacitated by orthostatic hypotension.Diarrhea, nausea, vomiting, and loss of weight were common, and adrenal insufficiency was seriously considered in the differential diagnosis of six of the 11 patients. Abnormal sweating was found in all six in whom this test was done.The drug 9-α-fluorohydrocortisone showed promise in symptomatic therapy of the condition. The possibility of primary systemic amyloidosis should be considered in the presence of orthostatic hypotension. Rectal biopsy and bone-marrow aspiration are recommended as initial biopsy procedures unless another organ suitable for biopsy is obviously involved.

Hypertension and renal artery stenosis: Serial observations on 54 patients treated medically

Medical treatment of hypertension was undertaken in 54 selected patients with arteriographically proved stenosis of the renal artery (32 with atheromatous and 22 with fibromuscular lesions). At follow‐up study (average, 20.3 months), 65 per cent of 49 surviving patients were normotensive on a regimen of common antihypertensive drugs in usual doses. There also was improvement in the hypertensive changes noted in the optic fundus. In 13 patients, additional cardiovascular episodes complicated the hypertensive disease and 5 of these patients had died. The frequent long duration of hypertension and frequent bilateral involvement of the renal arteries necessitate caution in recommending surgical treatment when: (1) the situation technically demands nephrectomy; (2) there are renovascular lesions in the absence of significant hypertension; (3) arteriographic and renal function data are discordant; and (4) there is associated severe symptomatic cardiovascular disease, old age, or other infirmities.

MICROCOCCAL BACTEREMIA WITHOUT ENDOCARDITIS: CLINICAL DATA AND THERAPEUTIC CONSIDERATIONS IN 109 CASES

Excerpt Infections caused byMicrococcus pyogenesvar.aureus(Staphylococcus pyogenes aureus)continue to offer a major therapeutic challenge. Micrococci appear to possess an almost singular ability to...

Verapamil and 24-hour ambulatory blood pressure monitoring in essential hypertension

The antihypertensive effects of oral regular and slow-release verapamil, a calcium-channel blocking agent, were evaluated in 22 patients with mild to moderate hypertension (sitting diastolic blood pressure [DBP] 95 to 112 mm Hg). The dose required to control blood pressure varied from 80 to 120 mg, 3 times a day. All patients received regular verapamil for a further 3 to 4 months, when systolic blood pressure (SBP) and DBP had risen from the end of the open-label phase. During a double-blind phase patients were randomly assigned to continue the same dose of regular verapamil, 3 times a day, or an equivalent daily dose of sustained-release verapamil (240 to 360 mg once a day). Seven of the 11 patients on regular and 3 of the 11 on sustained-release verapamil were also taking diuretics. This antihypertensive program was continued for at least 4 weeks. During the efficacy period, 24-hour ambulatory blood pressure monitoring was carried out. Mean 24-hour SBP and DBP were 133 +/- 20 and 89 +/- 13 mm Hg, respectively, on regular and 131 +/- 22 and 87 +/- 12 mm Hg, respectively, on sustained-release verapamil. There were no statistically significant differences noted between the 2 groups. Mean SBP and DBP varied similarly during awake and sleep hours with both formulations of verapamil. With regular verapamil, SBP was 139 +/- 18 and 124 +/- 20 mm Hg and DBP 92 +/- 11 and 84 +/- 13 mm Hg during awake and sleep hours, respectively; with sustained release, SBP was 138 +/- 21 and 122 +/- 22 mm Hg and DBP 92 +/- 10 and 80 +/- 10 mm Hg during awake and sleep hours, respectively. Heart rate fell during the entry period and continued during the entire study period. No other adverse effects were noted during the double-blind phase. In summary, verapamil is an effective antihypertensive medication and can be administered once a day as a sustained-release preparation; it is most useful in patients in whom adrenergic blocking drugs are indicated.

Revisiting the role of nephrectomy for advanced renovascular disease

BACKGROUND Despite the advances in antihypertensive therapy and renal revascularization, there remains a group of patients in whom renovascular disease leads to renal atrophy and treatment-resistant hypertension. METHODS We performed an observational cohort study in which we reviewed blood pressures, renal function, and predictors of response in 74 patients who underwent nephrectomy of a small kidney for uncontrolled hypertension between 1990 and 2000. RESULTS The median age of the patients was 65 years; 43 (58%) were women. Thirty-five patients (47%) underwent nephrectomy as part of combined revascularization of the contralateral kidney. Associated atherosclerotic diseases were common (28% to 49%), as were prior renal revascularization (21 [28%]) and hypertensive urgency/emergencies (23 [31%]). The mean (+/- SD) long axis of the affected kidney was 8 +/- 2 cm, and the mean function of the kidney (based on radioisotope renography) was 12% +/- 11% of total renal function. The average systolic blood pressure fell from 168 +/- 19 mm Hg to 136 +/- 18 mm Hg (P <0.0001) and diastolic blood pressure declined from 88 +/- 10 mm Hg to 76 +/- 9 mm Hg (P <0.0001) at the most recent available clinic visit (mean follow-up, 4.1 +/- 2.6 years). In addition, the number of antihypertensive medications decreased from 3.2 +/- 1.1 to 2.2 +/- 1.5 (P <0.0001). Renal function remained stable. Results were similar (preoperative blood pressure of 165/88 mm Hg taking three medications to 137/77 mm Hg taking two medications) among the 39 patients who had a nephrectomy without contralateral revascularization. CONCLUSION Our results suggest that in selected patients with resistant hypertension and renal artery disease that has resulted in atrophic kidneys with reduced function, nephrectomy can improve blood pressure control without further loss in overall renal function.