Dorothee Perloff

The Prognosis of Essential Hypertension Treated Conservatively

Four hundred thirty-nine consecutive patients (143 men and 296 women) with essential hypertension were followed on conservative therapy for a minimum of 5 years or until death. The initial blood pressure taken by a standard method and the presence and degree of vascular involvement at the time of registration were recorded on all patients. On the basis of these observations, each patient was classified in one of four classes of over-all hypertensive severity. At the end of the 5-year follow-up period, 161 patients were dead, 78 men and 83 women. The higher mortality among men was significant and was apparent after the first year of follow-up. A progressive rise in 5-year mortality was observed with increasing degrees of initial blood pressure elevation, fundal involvement, cardiac size by radiogram, and electrocardiographic evidence of left ventricular hypertrophy, as well as with progressively higher classification of over-all hypertensive severity. Patients with mild hypertension and minimal cardiovascular impairment (class I) had an 11 per cent 5-year mortality, while patients with malignant hypertension, renal failure, or congestive heart failure (class IV) had an 84 per cent 5-year mortality. Early deaths in patients with mild hypertension were found to be largely due to atherosclerotic complications or noncardiovascular causes. Possible explanations for long survivals in patients with advanced vascular involvement on initial examination are discussed. The increased mortality of men over women was attributed in part to greater severity of disease on initial registration and in part to a higher incidence of coronary atherosclerosis. The mortality in patients with headache, dizziness, and nervous tension was found to be a factor of the associated vascular complication rather than of the symptoms alone. Patients with clinical obesity were found to have a lower over-all mortality than patients who were not obese. The prognostic value of a standardized initial blood pressure measurement is stressed and is discussed in the light of previous work by Perera, Smirk, and Gilchrist. The prognostic data were presented as a framework against which the long-term treatment of mild and moderate hypertension can be tested.

Hypertension Secondary to Renal Artery Occlusive Disease

Historically, the awareness of renal artery narrowing as a curable cause of hypertension has evolved gradually, highlighted especially by Goldblatt and Poutasse. The increasing use of renal arteriography over the past 8 years in this hospital has yielded a total of 70 patients with renal artery abnormalities out of 110 hypertensive patients examined. In order to select the hypertensive patients most likely to have demonstrable arterial lesions, certain indications for arteriography were used. Most useful among these were the presence of an epigastric bruit, malignant hypertension, atheroselerosis of the abdominal aorta, and recent onset of hypertension. However, no one indication was always present in patients with lesions or always absent in those without abnormalities. Of the 70 patients with renal artery abnormalities, 54 were considered to represent sufficient renal artery stenosis to be potential candidates for surgical correction, while 16 had minor renal artery abnormalities. Atherosclerotic lesions occurred in 63 per cent of the patients with significant lesions, fibromuscular hyperplasia in 28 per cent, unilateral renal artery hypoplasia or atrophy in 7 per cent, and one case had embolic renal artery occlusion. Fifty-four per cent of all patients with significant lesions had bilateral disease. The patients with atherosclerotic lesions and those with fibromuscular hyperplasia differed markedly in sex distribution, age, and severity of hypertension. It is suggested that the retrograde transfemoral catheterization technic may be associated with fewer complications in patients without extensive occlusive atherosclerotic disease of the aorta, and iliac and femoral arteries. At operation the radiologic findings were confirmed in all but one patient. Corrective surgical procedures were performed in 38 patients, including nephrectomy, endarterectomy, segmental resection with reanastomosis, and splenorenal arterial shunt. Of the 31 patients who survived, 25 (81 per cent) had a postoperative fall in blood pressure, 14 to normal, in addition to improvement in clinical status. The follow-up period, however, is not yet sufficiently long to permit definite conclusions. Seven patients died; most of these had bilateral renal artery disease and extensive atherosclerosis of the cerebral and coronary arteries. Divided renal function studies were of limited diagnostic value because of the high incidence of bilateral lesions. In all patients with significant differences in renal sodium and water excretion, a postoperative fall in blood pressure occurred, but the same number of patients with equal bilateral excretion also had a fall in blood pressure. The importance of suspecting renal artery lesions in hypertensive patients regardless of age, severity of hypertension, or renal function is stressed. The question is discussed whether all patients with sustained hypertension should undergo arteriography. Although further studies to determine the true prevalence of occlusive renal artery lesions in the hypertensive population are in order, the fact that 50 per cent of our 110 patients had occlusive lesions and 60 per cent of the operated cases had a fall in blood pressure attests not only to the prevalence of the lesion but also to its potential curability.

Renal vascular hypertension, further experiences

Abstract During the period 1952 through 1964 a total of 525 hypertensive and 134 normotensive patients underwent renal arteriography at the University of California Medical Center. Of the hypertensive patients, 195 were found to have major (more than 50 per cent occlusive) arterial lesions (95 due to atherosclerosis, 70 due to fibromuscular hyperplasia, and 30 to other diseases). Of the normotensive patients, 7 per cent had major arterial stenotic lesions. The most useful indications for arteriography, considered the definitive method for diagnosing the presence of an anatomic lesion, included recent acceleration of hypertension, the presence of an epigastric bruit or arteriosclerosis obliterans, onset of hypertension after age 50, and disparity in kidney size and function demonstrated by intravenous pyelography or divided renal function study. A total of 122 patients underwent revascularization procedures or nephrectomy. A postoperative fall in blood pressure sustained for at least one year occurred in 56 per cent of the patients with atherosclerosis, 76 per cent of those with fibromuscular hyperplasia, and 70 per cent of those with miscellaneous renal arterial lesions. Of the patients operated upon, 37 per cent were “cured” by operation. The reasons for the operative failures were: (1) technical or mechanical problems arising from the extent and location of the stenotic lesions, and (2) lack of a clearly defined primary etiologic relationship between the arterial lesion and the hypertension. The need for operative management depends not only on the technical operability of the arterial lesion but also on the clinical condition and age of the patient, the severity and controllability of the hypertension, the presence of renal impairment, and the likelihood of “curing” the hypertension.