S. Brian Penner

The 2013 Canadian Hypertension Education Program recommendations for blood pressure measurement, diagnosis, assessment of risk, prevention, and treatment of hypertension.

We updated the evidence-based recommendations for the diagnosis, assessment, prevention, and treatment of hypertension in adults for 2013. This years update includes 2 new recommendations. First, among nonhypertensive or stage 1 hypertensive individuals, the use of resistance or weight training exercise does not adversely influence blood pressure (BP) (Grade D). Thus, such patients need not avoid this type of exercise for fear of increasing BP. Second, and separately, for very elderly patients with isolated systolic hypertension (age 80 years or older), the target for systolic BP should be < 150 mm Hg (Grade C) rather than < 140 mm Hg as recommended for younger patients. We also discuss 2 additional topics at length (the pharmacological treatment of mild hypertension and the possibility of a diastolic J curve in hypertensive patients with coronary artery disease). In light of several methodological limitations, a recent systematic review of 4 trials in patients with stage 1 uncomplicated hypertension did not lead to changes in management recommendations. In addition, because of a lack of prospective randomized data assessing diastolic BP thresholds in patients with coronary artery disease and hypertension, no recommendation to set a selective diastolic cut point for such patients could be affirmed. However, both of these issues will be examined on an ongoing basis, in particular as new evidence emerges.

Antibiotic-Heparin Lock: In Vitro Antibiotic Stability Combined with Heparin in a Central Venous Catheter

Long‐term hemodialysis frequently requires vascular access through central venous catheters (CVCs). Infection related to these catheters is a significant complication. The use of an antibiotic‐heparin lock could decrease the risks associated with infected permanent catheters. As an initial step in developing an antibiotic‐heparin lock, we investigated the in vitro stability of antibiotic‐heparin combinations in CVCs. Initially, cefazolin, vancomycin, ceftazidime, ciprofloxacin 10 mg/ml each, and gentamicin 5 mg/ml were incubated separately in glass test tubes in the dark at 37°C for 72 hours. Samples were analyzed spectrophotometrically for stability at 24‐hour intervals. The procedure was repeated with the addition of heparin (final concentration 5000 U/ml in glass test tubes), and the combination was also examined in CVCs. High‐performance liquid chromatography analysis was conducted on the antibiotic‐heparin combinations at 72 hours to confirm the spectrophotometric results. Ciprofloxacin produced an immediate precipitate with the addition of heparin and was not analyzed further. Absorbance values decreased for all antibiotics, with the greatest decreases at 72 hours for cefazolin (27.4%), vancomycin (29.7%), ceftazidime (40.2%), and gentamicin (8%) when combined with heparin. These decreases were postulated to be secondary to adsorption of the antibiotics to the luminal surface of the catheters because submitting the catheters to ultrasound with 1% sodium bicarbonate and analyzing the resulting solution for absorbance revealed that some of the drug was recovered. Although free antibiotic in CVC solution was reduced, the concentration should be sufficient (approximately 5 mg/ml) to decrease the frequency of infections associated with CVCs. We conclude that the concentrations of vancomycin, ceftazidime, cefazolin, or gentamicin used in our study should be sufficient for an antibiotic‐heparin lock.

Dietary sodium and cardiovascular outcomes: A rational approach

Hypertension, the leading risk factor for mortality in the world, affects nearly one in four Canadians. There is substantive evidence that high dietary sodium contributes to hypertension. Animal studies consistently demonstrate increased blood pressure and cardiovascular morbidity and mortality with high dietary sodium intake. Evidence of the adverse health effects in humans associated with increased sodium intake is accumulating rapidly. Previously, limitations on sodium consumption were recommended only for those identifiable groups of people shown to be at higher risk. With the lifetime risk of developing hypertension being more than 90% in an average lifespan, the need for a population-based approach to reducing hypertension is clear. The present paper reviews the evidence of sodium and cardiovascular disease, resulting in the 2007 Canadian Hypertension Education Program recommendation of daily intake of less than 100 mmol of sodium in both normotensive and hypertensive adults.

Sodium excretion following central administration of an I1 imidazoline receptor agonist, moxonidine

1 Previously we have shown that an intrarenal infusion of moxonidine, an I1‐imidazoline receptor agonist, resulted in a natriuresis which was inhibited by intravenous idazoxan, a selective imidazoline receptor antagonist. Therefore we examined the effects on renal function of intracerebroventricular (i.c.v.) administration of moxonidine with or without i.c.v. idazoxan. 2 Seven days after unilateral nephrectomy, Sprague‐Dawley rats had i.c.v. cannulae implanted. Three days later the rats were anaesthetized (pentobarbitone), followed by cannulation of the jugular vein (fluid and drug administration), carotid artery (blood pressure) and the ureter (urine collection). 3 After a 45 min stabilization period, the effect of moxonidine was investigated by the i.c.v. administration of either isotonic saline or moxonidine (0.1, 0.3 or 1 nmol in isotonic saline) administered in 5 μl over 1 min. All doses of moxonidine resulted in an increase in urine flow with a concomitant increase in sodium excretion without affecting blood pressure. The highest dose of moxonidine (1 nmol) also increased free water clearance. 4 In a second series of experiments, the effects of idazoxan on the natriuretic response to i.c.v. moxonidine were determined. Moxonidine (0.3 nmol) again increased sodium and water excretion as compared to the i.c.v. saline control animals. Pretreatment with i.c.v. idazoxan (0.3 nmol), at a dose which alone failed to alter sodium and water excretion, completely attenuated the renal response to moxonidine. These results are consistent with central I1‐imidazoline receptors mediating a moxonidine‐induced increase in sodium and water excretion at doses that do not alter blood pressure.

The role of the peripheral sympathetic nervous system in the natriuresis following central administration of an I1 imidazoline agonist, moxonidine.

1 . Central administration of the I1‐imidazoline receptor agonist moxonidine increases sodium excretion without alteration of blood pressure. In the present study we determined whether this natriuretic action was mediated through a decrease in activity of the sympathetic nervous system, as has been reported for the antihypertensive action of this compound. Interruption of the sympathetic nervous system was achieved with prazosin (α‐adrenoceptor antagonist) and renal denervation. 2 . In pentobarbitone‐anaesthetized Sprague‐Dawley rats, intracerebroventricular (i.c.v.) injection of moxonidine alone increased urine volume and sodium excretion. Prazosin (0.15 mg kg−1, i.v.) alone decreased urine flow rate and sodium excretion as compared to the vehicle controls. In the presence of prazosin, i.c.v. injection of moxonidine failed to increase sodium excretion or urine volume as compared to animals which received the prazosin alone. 3 . The administration of moxonidine (i.c.v.) to sham renal‐denervated animals caused an increase in urine flow rate, urine sodium excretion, osmolar clearance and free water clearance. The increase in sodium excretion and osmolar clearance were completely attenuated in renal denervated rats, however, urine flow rate was still increased and this was secondary to the increase in free water clearance which remained intact. 4 . These results indicate the importance of an intact sympathetic nervous system in the renal response to i.c.v. moxonidine. Moreover, the differential antagonism of these interventions on solute and water excretion indicate that they may be mediated at two separate sites and/or receptors following i.c.v. moxonidine.

Peripheral and Central Imidazoline Receptor-Mediated Natriuresis in the Rata

On the basis of both radioligand and functional studies, the existence of a novel receptor that was unique from the alpha 2-adrenoceptor has become evident. Our initial studies contrasted the function of I1 imidazoline receptor agonists with that of purported alpha 2-adrenoceptor agonists in the kidney. The mechanism by which urine flow increased (osmolar vs free water clearance) as well as the effects of idazoxan, rauwolscine, a V2 vasopressin receptor antagonist, indomethacin pretreatment, and one-kidney one clip hypertension in rats were different following moxonidine when compared to an alpha 2-adrenoceptor agonist. This indicated two separate receptor systems. Subsequent studies determined that i.c.v. administration of moxonidine would also increase the urine flow rate by increasing osmolar clearance. This response to i.c.v. moxonidine differed from the response of an alpha 2-adrenoceptor agonist administered i.c.v.. Moreover, this effect of i.c.v. moxonidine was unique from that observed following the intrarenal infusion of moxonidine (Fig. 2). Denervation, intravenous prazosin, and i.c.v. idazoxan selectively blocked the effects of i.c.v. moxonidine. Intravenous idazoxan selectively blocked the response to intrarenal infusion of moxonidine. On the basis of the response to i.c.v. moxonidine in SH rats, the site(s) and/or receptor(s) responsible for blood pressure lowering were altered and those for increasing sodium excretion appear to be inactive. The significance of the findings in long-term regulation of blood pressure remain to be determined.

Imidazoline receptor mediated natriuresis: central and/or peripheral effect?

The ability of imidazoline agonists, such as moxonidine and rilmenidine, to lower blood pressure has been attributed to a central effect resulting in a decrease in peripheral sympathetic nerve activity. A similar decrease in sympathetic nerve activity to the kidney has been proposed to explain the increase in sodium excretion. The observed increase in sodium excretion following an intrarenal infusion of moxonidine or rilmenidine suggested the existence of a direct renal action. We therefore tested the hypothesis that direct renal infusions were acting at a central rather than a peripheral site. Thus, interventions which would decrease the natriuretic effects of central administered moxonidine would also block the effects of intrarenal administered moxonidine. Studies were performed in anesthetized Sprague-Dawley rats (280-320 g) which had undergone unilateral nephrectomy 7 to 10 days prior to the experiment. The interventions utilized resulted in minimal effects on blood pressure and creatinine clearance. Intracerebroventricular (icv) or intrarenal (ir) administration of moxonidine produced a significant increase in urine flow rate and sodium excretion. Intravenous (iv) prazosin was used to block the ability of the sympathetic nerves to alter sodium excretion secondary to alpha1-adrenoceptor stimulation. Prazosin prevented the natriuresis following icv moxonidine but only partially antagonized the effects of ir moxonidine. To determine if central imidazoline receptors mediated the effects of moxonidine, animals were pretreated with icv idazoxan. Following icv idazoxan, the effects of icv moxonidine were blocked, whereas the response to intrarenal moxonidine was only partially blocked. Peripheral (iv) administration of idazoxan blocked the actions of intrarenal moxonidine but left the response to icv moxonidine intact. Finally, chemical sympathectomy with reserpine did not alter the response to intrarenal moxonidine suggesting that this effect was independent of the sympathetic nervous system. In conclusion, these studies indicate the ability of central and peripheral moxonidine to increase urine flow rate through sodium excretion at two unique sites of action, one central and the other one peripheral, most conceivably within the kidney.

Conversion From Subcutaneous to Intravenous Erythropoietin in a Hemodialysis Population

The purpose of this study was to compare erythropoietin dosage requirements during subcutaneous versus intravenous administration in a hemodialysis population. Hemodialysis patients receiving subcutaneous epoetin alfa were switched to the intravenous route using a prospective, crossover design. Baseline anemia parameters were measured at months −2, −1, and 0 when patients were receiving subcutaneous dosing and compared to months 4, 5, and 6 after the switch to intravenous dosing. Ninety‐eight patients were enrolled into the study with an average age of 54.8 years. Over the course of the study, 34 patients were excluded from analysis, leaving 64 patients with complete hemoglobin and erythropoietin dosing data throughout the subcutaneous and intravenous evaluation periods. In these patients, the dose of erythropoietin increased significantly from the subcutaneous to the intravenous period (7567.7 to 10229.2 IU/wk). The conversion of hemodialysis patients from the subcutaneous to the intravenous route of administration significantly increased epoetin alfa dosage requirements.

Renal denervation altered the hemodynamic and renal effects following intracerebroventricular administration of the I1-imidazoline receptor agonist, rilmenidine, in pentobarbital anaesthetized rats

Previous studies have reported on the effects of intracerebroventricular (icv) administration of the I1-imidazoline receptor agonist moxonidine. In the present study, the relationship between increasing doses of the I1-agonist rilmenidine (administered icv) with blood pressure and renal function has been determined. Moreover, the importance of the renal nerves in this response have also been assessed. In pentobarbitone anesthetized rats, icv rilmenidine (30, 100, 300 nmol in 5 microliters) produced a dose related decrease in blood pressure and heart rate. Urine flow was not altered at the lower doses although at the highest dose (300 nmol) the increase approached significance (p = 0.06). Sodium excretion and osmolar clearance were not altered. Free water clearance was increased at 100 and 300 nmol rilmenidine (p < 0.05). Consistent with the above dose response studies, in sham denervated rats icv rilmenidine (300 nmol) decreased blood pressure and increased free water clearance. In rats having undergone renal denervation, baseline levels of urine flow rate, sodium excretion and osmolar clearance were increased. In these denervated rats, icv rilmenidine (300 nmol) failed to decrease blood pressure. Urine flow rate was increased with a decrease in sodium excretion and osmolar clearance. Free water clearance was increased. These results indicate the importance of the renal nerves in mediating the acute decrease in blood pressure following icv administration of the I1-imidazoline receptor agonist rilmenidine. The increase in free water clearance seen following icv rilmenidine appears to be mediated independent of the renal nerves. The changes associated with sodium excretion on the contrary are dependent on intact renal nerves.

Long-term captopril in young and old patients with mild hypertension.

The decrease in renal blood flow (RBF) observed in patients with hypertension can be increased with converting enzyme inhibition (CEI). It is unknown whether the decrease in RBF observed with age can also be increased with CEI. This study compared the short‐ and long‐term effects of captopril monotherapy in young (<50 years) and old (>65 years) hypertensive patients. Captopril effectively decreased blood pressure in both groups (diastolic blood pressure < 90 mm Hg), with the young patients requiring a lower dose (.7 mg/kg) than the elderly patients (1.2 mg/kg). Creatinine and para‐aminohippurate clearances were maintained in both groups, with a decrease in renal vascular resistance being observed in the younger patients. Serum aldosterone levels fell significantly after each dose of captopril at all phases of the study, with no change observed in plasma renin levels. Atrial natriuretic peptide (ANP) level was increased in the elderly patients receiving placebo (48.8 ± 8 pg/mL) when compared with the young subjects (24 ± 3.8 pg/mL). Captopril did not alter ANP levels in either group.