Greminger P

Fibromuscular Hyperplasia: Extension of the Disease and Therapeutic Outcome

92 patients with fibromuscular hyperplasia (FMH) seen at the University Hospital Zurich were studied. Renovascular FMH was the most frequent manifestation of the disease (89%). FMH of the cerebral arteries was seen in 26%. The intestinal and subclavian arteries were involved in 9% each and the iliac arteries in 5% of the patients. In 2 patients each FMH of the abdominal aorta or the coronary arteries, respectively, was found. 26% of the patients had systemic disease with involvement of 2 or more arteries. Half of the patients with bilateral renovascular disease showed additional extrarenal FMH. All patients with renovascular FMH were hypertensive (mean blood pressure 194 +/- 34/119 +/- 18 mm Hg). Surgery, percutaneous transluminal angioplasty (PTA) and medical therapy were equally effective in controlling blood pressure. The cure rates were 52% in patients undergoing surgery and 50% in those treated with PTA. The complication rate, however, was higher with surgery (11%) than with PTA (3%). 62% of the patients treated medically were normotensive. Major side effects occurred in 4.8%. The outcome of curative interventions (surgery or PTA) was influenced by the extension of FMH. In unilateral disease the cure rate was significantly higher (62%) than in systemic FMH (28%; p less than 0.03). Patients with strict bilateral disease were cured in 50%. We conclude: (a) PTA seems to be the treatment of choice in renovascular FMH because of a high cure and a low complication rate and (b) the outcome of curative interventions seems markedly influenced by the extension of FMH in these patients.

Long-term experience in percutaneous transluminal dilatation of renal artery stenosis

Percutaneous transluminal dilatation was attempted in 65 patients with renovascular hypertension. In five cases (8 percent), percutaneous transluminal dilatation could not be performed for technical reasons. In the remaining 60 patients (35 with atherosclerotic stenosis and 25 with fibromuscular dysplasia), both mean systolic and diastolic pressure fell immediately after percutaneous transluminal dilatation and remained significantly lower for a period of up to five years. Cure rates after a mean control period of 21.6 months were higher in patients with fibromuscular dysplasia (50 percent) than in those with atherosclerotic stenosis (29 percent). Improvement of blood pressure was observed in 32 percent of patients with fibromuscular dysplasia and in 48 percent of patients with atherosclerotic stenosis. Follow-up angiography in 33 cases showed occlusion of the dilated artery in two patients and recurrence of slight renal artery stenosis in nine patients. Successful redilatation could be performed in five of these cases. Furthermore, renal vein renin determinations were only of limited diagnostic or prognostic value. These results document the good long-term effect of percutaneous transluminal dilatation in patients with renal artery stenosis. Percutaneous transluminal dilatation should, therefore, be the favored procedure in patients with renovascular hypertension.

Acute and Chronic Effects of the Angiotensin-Converting Enzyme Inhibitor Captopril in Severe Hypertension

Abstract In this study the acute and chronic effect of the converting enzyme inhibitor captopril was investigated in a relatively large number of patients (acute: n = 78, chronic: n = 67) with various forms of severe hypertension, the majority of cases being resistant to a standardized triple therapy (100 mg of hydrochlorothiazide or 80 to 500 mg of furosemide, 320 mg of propranolol and 200 mg of hydralazine). Up to an observed period of 240 minutes, a single oral dose of 25 mg of captopril led to a significant and marked decrease in systolic and diastolic blood pressure. The acute antihypertensive effect of captopril was more pronounced in patients with renovascular than in those with essential or renal parenchymal hypertension. Similar differences among the three groups of patients were also observed during chronic treatment. Over a period of 18 months, patients with renovascular hypertension showed both a more pronounced decrease in mean diastolic blood pressure values and a significantly higher percentage of cases with excellent blood pressure control (diastolic blood pressure 95 mm Hg or less). Under long-term conditions, about 90 percent of all patients required a diuretic and a substantial percentage also needed propranolol as a third drug. Positive correlations between pretreatment plasma renin activity levels and captopril-induced blood pressure reduction were found under acute conditions only. The most frequent side effects were skin manifestations, taste disturbances, dizziness and unproductive cough. Serious adverse effects were rare and included one case of leukopenia and one of the nephrotic syndrome, both being reversible after withdrawal of captopril. Our results demonstrate that captopril is a very potent blood pressure lowering agent in severe hypertension especially in cases of renovascular hypertension. However, currently the potential risk of serious side effects should induce the physician to reserve this drug for those patients with truly resistant hypertension.

Cure and Improvement of Renovascular Hypertension after Percutaneous Transluminal Angioplasty of Renal Artery Stenosis

In the present study we report our long-term experience in 82 patients with renovascular hypertension (48 with atherosclerotic stenosis, 34 with fibromuscular dysplasia) who were followed up for a mean observation period of 23.6 months after percutaneous transluminal angioplasty (PTA) of renal artery stenosis. Our results show a highly significant decrease in mean systolic and diastolic blood pressure. Cure rates were slightly higher in patients with fibromuscular dysplasia (41% cured, 47% improved) than in those with atherosclerosis (23% cured, 54% improved). Kidney function significantly improved in patients with cure, remained stable in those with improvement and worsened in cases classified as unimproved. These results document the good long-term effect of PTA on blood pressure and kidney function in patients with renal artery stenosis.

Surgery, Transluminal Dilatation and Medical Therapy in the Management of Renovascular Hypertension

In the present retrospective study, the effect of various therapeutic procedures (surgery, percutaneous transluminal dilatation and antihypertensive drugs) was analyzed in 202 patients with renovascular hypertension. The results show that each of the three methods effectively lowers blood pressure. However, marked differences were observed in pretreatment clinical and laboratory data among the three groups. These differences were most probably caused by different selection criteria before submitting the patient to a given therapeutic regime. Our findings also demonstrate that on the basis of the present analysis a direct comparison between surgery, dilatation and medical therapy is not possible.

Swiss Hypertension and Risk Factor Program (SHARP): Cardiovascular risk factors management in patients with type 2 diabetes in Switzerland

The prevalence of hypertension in type 2 diabetics is high, though there is no published data for Switzerland. This prospective cohort survey determined the frequency of type 2 diabetes mellitus associated with hypertension from medical practitioners in Switzerland, and collected data on the diagnostic and therapeutic work‐up for cardiovascular risk patients. The Swiss Hypertension And Risk Factor Program (SHARP) is a two‐part survey: The first part, I‐SHARP, was a survey among 1040 Swiss physicians to assess what are the target blood pressure (BP) values and preferred treatment for their patients. The second part, SHARP, collected data from 20,956 patients treated on any of 5 consecutive days from 188 participating physicians. In I‐SHARP, target BP⩽135/85 mmHg, as recommended by the Swiss Society of Hypertension, was the goal for 25% of physicians for hypertensives, and for 60% for hypertensive diabetics; values >140/90 mmHg were targeted by 19% for hypertensives, respectively 9% for hypertensive diabetics. In SHARP, 30% of the 20,956 patients enrolled were hypertensive (as defined by the doctors) and 10% were diabetic (67% of whom were also hypertensive). Six per cent of known hypertensive patients and 4% of known hypertensive diabetics did not receive any antihypertensive treatment. Diabetes was not treated pharmacologically in 20% of diabetics. Proteinuria was not screened for in 45% of known hypertensives and in 29% of known hypertensive diabetics. In Switzerland, most physicians set target BP levels higher than recommended in published guidelines. In this country with easy access to medical care, high medical density and few financial constraints, appropriate detection and treatment for cardiovascular risk factors remain highly problematic.

Renal Venous Renin Determinations in Renovascular Hypertension

To assess the diagnostic and prognostic value of renal venous renin levels in renovascular hypertension, 95 patients with severe unilateral renal artery stenosis were studied. Surgery (n = 52) or perc

Determinants of persistence in hypertensive patients treated with irbesartan: results of a postmarketing survey

BackgroundPersistence is a key factor for long-term blood pressure control, which is of high prognostic importance for patients at increased cardiovascular risk. Here we present the results of a post-marketing survey including 4769 hypertensive patients treated with irbesartan in 886 general practices in Switzerland. The goal of this survey was to evaluate the tolerance and the blood pressure lowering effect of irbesartan as well as the factors affecting persistence in a large unselected population.MethodsProspective observational survey conducted in general practices in all regions of Switzerland. Previously untreated and uncontrolled pre-treated patients were started with a daily dose of 150 mg irbesartan and followed up to 6 months.ResultsAfter an observation time slightly exceeding 4 months, the average reduction in systolic and diastolic blood pressure was 20 (95% confidence interval (CI) -19.6 to -20.7 mmHg) and 12 mmHg (95% CI -11.4 to -12.1 mmHg), respectively. At this time, 26% of patients had a blood pressure < 140/90 mmHg and 60% had a diastolic blood pressure < 90 mmHg. The drug was well tolerated with an incidence of adverse events (dizziness, headaches,...) of 8.0%. In this survey more than 80% of patients were still on irbesartan at 4 month. The most important factors predictive of persistence were the tolerability profile and the ability to achieve a blood pressure target ≤ 140/90 mmHg before visit 2. Patients who switched from a fixed combination treatment tended to discontinue irbesartan more often whereas those who abandoned the previous treatment because of cough (a class side effect of ACE-Inhibitors) were more persistent with irbesartan.ConclusionThe results of this survey confirm that irbesartan is effective, well tolerated and well accepted by patients, as indicated by the good persistence. This post-marketing survey also emphasizes the importance of the tolerability profile and of achieving an early control of blood pressure as positive predictors of persistence.

Adrenalectomy in Primary Aldosteronism: A Long-Term Follow-Up Study

The effect of unilateral adrenalectomy in primary aldosteronism was analyzed in 38 patients with unilateral adenoma, 12 cases with idiopathic bilateral hyperplasia and 1 patient suffering from an aldosterone-producing carcinoma. Responses to surgery differed markedly. In all 38 adenoma cases plasma aldosterone dropped to normal levels and remained within normal range during a mean follow-up period of 75 +/- 12 months. 23 (61%) of these patients became normotensive without medication and thus could be classified as definitely cured. 34% (13 patients) improved (normotensive under medical treatment) and only 2 cases (5%) remained hypertensive despite sufficient medical treatment. In the hyperplasia group, however, the effect of adrenalectomy was disappointing. None of these subjects showed a long-lasting normalization of aldosterone secretion. A temporary remission for no more than 3-4 months was achieved in only 3 patients. In a fourth case with macronodular hyperplasia, primary aldosteronism relapsed after a 6-year period of normal blood pressure and aldosterone values. Therefore, 6 years after adrenalectomy no hyperplasia patient was definitely cured in contrast to 61% of the adenoma cases. The problems in the management of hypertension in adrenal hyperplasia are furthermore documented by a poorer blood pressure control despite antihypertensive medication and a high rate of vascular complications. During the follow-up, 3 of 12 hyperplasia patients experienced a cerebrovascular event and 1 a myocardial infarction.

Primary aldosteronism: treatment with trilostane.

Trilostane, an inhibitor of the 3 beta-hydroxysteroid dehydrogenase enzyme system of steroid biosynthesis, was applied to 18 patients with primary aldosteronism (9 patients with adrenal adenoma, 9 patients with bilateral adrenal hyperplasia) for 12 weeks. A marked decrease in plasma aldosterone was observed during therapy combined with a reduction in blood pressure and a rise in serum potassium levels. Except for slight diarrhea in 4 patients, which did not require cessation of trilostane medication, no further side effects were observed. Trilostane proved to be an effective inhibitor of aldosterone biosynthesis and was found useful in the treatment of primary aldosteronism both in patients with adrenal adenoma and in those with bilateral adrenal hyperplasia.