Sandra J. Taler

2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults: Report From the Panel Members Appointed to the Eighth Joint National Committee (JNC 8)

Hypertension is the most common condition seen in primary care and leads to myocardial infarction, stroke, renal failure, and death if not detected early and treated appropriately. Patients want to be assured that blood pressure (BP) treatment will reduce their disease burden, while clinicians want guidance on hypertension management using the best scientific evidence. This report takes a rigorous, evidence-based approach to recommend treatment thresholds, goals, and medications in the management of hypertension in adults. Evidence was drawn from randomized controlled trials, which represent the gold standard for determining efficacy and effectiveness. Evidence quality and recommendations were graded based on their effect on important outcomes. There is strong evidence to support treating hypertensive persons aged 60 years or older to a BP goal of less than 150/90 mm Hg and hypertensive persons 30 through 59 years of age to a diastolic goal of less than 90 mm Hg; however, there is insufficient evidence in hypertensive persons younger than 60 years for a systolic goal, or in those younger than 30 years for a diastolic goal, so the panel recommends a BP of less than 140/90 mm Hg for those groups based on expert opinion. The same thresholds and goals are recommended for hypertensive adults with diabetes or nondiabetic chronic kidney disease (CKD) as for the general hypertensive population younger than 60 years. There is moderate evidence to support initiating drug treatment with an angiotensin-converting enzyme inhibitor, angiotensin receptor blocker, calcium channel blocker, or thiazide-type diuretic in the nonblack hypertensive population, including those with diabetes. In the black hypertensive population, including those with diabetes, a calcium channel blocker or thiazide-type diuretic is recommended as initial therapy. There is moderate evidence to support initial or add-on antihypertensive therapy with an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker in persons with CKD to improve kidney outcomes. Although this guideline provides evidence-based recommendations for the management of high BP and should meet the clinical needs of most patients, these recommendations are not a substitute for clinical judgment, and decisions about care must carefully consider and incorporate the clinical characteristics and circumstances of each individual patient.

Clinical practice guidelines for the management of hypertension in the community a statement by the American Society of Hypertension and the International Society of Hypertension.

Clinical Practice Guidelines for the Management of Hypertension in the Community A Statement by the American Society of Hypertension and the International Society of Hypertension

2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines

Glenn N. Levine, MD, FACC, FAHA, Chair Patrick T. O’Gara, MD, MACC, FAHA, Chair-Elect Jonathan L. Halperin, MD, FACC, FAHA, Immediate Past Chair Sana M. Al-Khatib, MD, MHS, FACC, FAHA Joshua A. Beckman, MD, MS, FAHA Kim K. Birtcher, MS, PharmD, AACC Biykem Bozkurt, MD, PhD, FACC, FAHA

Clinical practice guidelines for the management of hypertension in the community: a statement by the American Society of Hypertension and the International Society of Hypertension.

Michael A. Weber, MD; Ernesto L. Schiffrin, MD; William B. White, MD; Samuel Mann, MD; Lars H. Lindholm, MD; John G. Kenerson, MD; John M. Flack, MD; Barry L. Carter, Pharm D; Barry J. Materson, MD; C. Venkata S. Ram, MD; Debbie L. Cohen, MD; Jean-Claude Cadet, MD; Roger R. Jean-Charles, MD; Sandra Taler, MD; David Kountz, MD; Raymond R. Townsend, MD; John Chalmers, MD; Agustin J. Ramirez, MD; George L. Bakris, MD; Jiguang Wang, MD; Aletta E. Schutte, MD; John D. Bisognano, MD; Rhian M. Touyz, MD; Dominic Sica, MD; Stephen B. Harrap, MD

Resistant Hypertension: Comparing Hemodynamic Management to Specialist Care

Although resistant hypertension affects a minority of all hypertensives, this group continues to experience disproportionately high cardiovascular event rates despite newer antihypertensive agents. Hypertension represents an imbalance of hemodynamic forces within the circulation, usually characterized by elevated systemic vascular resistance. We studied the utility of serial hemodynamic parameters in the selection and titration of antihypertensive medication in resistant hypertensive patients using highly reproducible noninvasive measurements by thoracic bioimpedance. Resistant hypertension patients (n=104) were randomized to drug selection based either on serial hemodynamic (HD) measurements and a predefined algorithm or on drug selection directed by a hypertension specialist (SC) in a 3-month intensive treatment program. Blood pressure was lowered by intensified drug therapy in both treatment groups (169±3/87±2 to 139±2/72±1 mm Hg HD versus 173±3/91±2 to 147±2/79±1 mm Hg SC, P <0.01 for systolic and diastolic BP), using similar numbers and intensity of antihypertensive medications. Blood pressures were reduced further for those treated according to hemodynamic measurements, resulting in improved control rates (56% HD versus 33% SC controlled to ≤140/90 mm Hg, P <0.05) and incremental reduction in systemic vascular resistance measurements. Although the number of patients taking diuretics did not differ between groups, final diuretic dosage was higher in the hemodynamic cohort. Our results demonstrate superior blood pressure control using a treatment algorithm and serial hemodynamic measurements compared with clinical judgment alone in a randomized prospective study. Our measurements of thoracic fluid volume support occult volume expansion as a mediator of antihypertensive drug resistance and use of impedance measurements to guide advancing diuretic dose and adjustment of multidrug antihypertensive treatment.

The association between age and nephrosclerosis on renal biopsy among healthy adults.

BACKGROUND Chronic kidney disease is common with older age and is characterized on renal biopsy by global glomerulosclerosis, tubular atrophy, interstitial fibrosis, and arteriosclerosis. OBJECTIVE To see whether the prevalence of these histologic abnormalities in the kidney increases with age in healthy adults and whether histologic findings are explained by age-related differences in kidney function or chronic kidney disease risk factors. DESIGN Cross-sectional study. SETTING Mayo Clinic, Rochester, Minnesota, from 1999 to 2009. PATIENTS 1203 adult living kidney donors. MEASUREMENTS Core-needle biopsy of the renal cortex obtained during surgical implantation of the kidney, and medical record data of kidney function and risk factors obtained before donation. RESULTS The prevalence of nephrosclerosis (> or =2 chronic histologic abnormalities) was 2.7% (95% CI, 1.1% to 6.7%) for patients aged 18 to 29 years, 16% (CI, 12% to 20%) for patients aged 30 to 39 years, 28% (CI, 24% to 32%) for patients aged 40 to 49 years, 44% (CI, 38% to 50%) for patients aged 50 to 59 years, 58% (CI, 47% to 67%) for patients aged 60 to 69 years, and 73% (CI, 43% to 90%) for patients aged 70 to 77 years. Adjustment for kidney function and risk factor covariates did not explain the age-related increase in the prevalence of nephrosclerosis. LIMITATION Kidney donors are selected for health and lack the spectrum or severity of renal pathologic findings in the general population. CONCLUSION Kidney function and chronic kidney disease risk factors do not explain the strong association between age and nephrosclerosis in healthy adults. PRIMARY FUNDING SOURCE National Institutes of Health, U.S. Public Health Service.

Cyclosporine-induced hypertension after transplantation

OBJECTIVE To describe the features and mechanisms of posttransplantation hypertension and suggest appropriate management of the disorder. DESIGN We review our own experience and reports from the literature on hypertension in cyclosporine A (CSA)-treated transplant recipients. RESULTS Soon after immunosuppression with CSA and corticosteroids, hypertension develops in most patients who undergo transplantation. The blood pressure increases, which are usually moderate, occur universally because of increased peripheral vascular resistance. Disturbances in circadian patterns of blood pressure lead to loss of the normal nocturnal decline, a feature that magnifies hypertensive target effects. Changes in blood pressure sometimes are severe and associated with rapidly developing target injury, including intracranial hemorrhage, left ventricular hypertrophy, and microangiopathic hemolysis. The complex mechanisms that underlie this disorder include alterations in vascular reactivity that cause widespread vasoconstriction. Vascular effects in the kidney lead to reduced glomerular filtration and impaired sodium excretion. Many of these changes affect local regulation of vascular tone, including stimulation of endothelin and suppression of vasodilating prostaglandins. Effective therapy includes use of vasodilating agents, often calcium channel blocking drugs. Caution must be exercised to avoid interfering with the disposition of CSA or aggravating adverse effects relative to kidney and electrolyte homeostasis. CONCLUSION Recognition and treatment of CSA-induced hypertension and vascular injury are important elements in managing the transplant recipient.

2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines

Paul K. Whelton, MB, MD, MSc, FAHA, Chair, Writing Committee, Robert M. Carey, MD, FAHA, Vice Chair, Writing Committee, Wilbert S. Aronow, MD, FACC, FAHA, Writing Committee Member, Donald E. Casey, Jr., MD, MPH, MBA, FAHA, Writing Committee Member, Karen J. Collins, MBA, Writing Committee Member, Cheryl Dennison Himmelfarb, RN, ANP, PhD, FAHA, Writing Committee Member, Sondra M. DePalma, MHS, PA-C, CLS, AACC, Writing Committee Member, Samuel Gidding, MD, FACC, FAHA, Writing Committee Member, Kenneth A. Jamerson, MD, Writing Committee Member, Daniel W. Jones, MD, FAHA, Writing Committee Member, Eric J. MacLaughlin, PharmD, Writing Committee Member, Paul Muntner, PhD, FAHA, Writing Committee Member, Bruce Ovbiagele, MD, MSc, MAS, MBA, FAHA, Writing Committee Member, Sidney C. Smith, Jr., MD, MACC, FAHA, Writing Committee Member, Crystal C. Spencer, JD, Writing Committee Member, Randall S. Stafford, MD, PhD, Writing Committee Member, Sandra J. Taler, MD, FAHA, Writing Committee Member, Randal J. Thomas, MD, MS, FACC, FAHA, Writing Committee Member, Kim A. Williams, Sr., MD, MACC, FAHA, Writing Committee Member, Jeff D. Williamson, MD, MHS, Writing Committee Member, Jackson T. Wright, Jr., MD, PhD, FAHA, Writing Committee Member

Cyclosporin-induced hypertension. Incidence, pathogenesis and management

Blood pressure increases soon after administration of immunosuppressive regimens using cyclosporin. Characteristic vascular changes lead to systemic and renal vasoconstriction. Changes in blood pressure are commonly associated with disturbed circadian regulation and may promote the rapid development of target organ injury, including intracranial haemorrhage, left ventricular hypertrophy and microangiopathic haemolysis. The mechanisms underlying this disorder are complex and include altered vascular endothelial function. Vasodilators such as pro-stacyclin and nitric oxide are suppressed, whereas vasoconstrictors, including endothelin, are increased. Changes in the kidney include vasoconstriction, reduced glomerular filtration and sodium retention. Effective therapy depends upon rigorous blood pressure control by administration of vasodilating agents, with attention to potential interactions with cyclosporin.

Obesity in living kidney donors: clinical characteristics and outcomes in the era of laparoscopic donor nephrectomy.

Acceptance of obese individuals as living kidney donors is controversial related to possible increased risk for surgical complications and concern that obesity may contribute to long‐term renal disease. We retrospectively examined 553 consecutive hand‐assisted laparoscopic living kidney donations between October 1, 1999 and April 1, 2003. We stratified donors into quartiles by baseline body mass index (BMI) assessing perioperative complications and 6–12 months post‐donation metabolic and renal function. Compared to BMI <25 kg/m2, high BMI donors (≥35 kg/m2) had slightly longer operative times (mean increase 19 min), more overall perioperative complications (mostly minor wound complications), yet the same low rate of major surgical complications (conversion to open and re‐operation) and similar length‐of‐stay (2.3 vs. 2.4 days). At 6–12 months after donation (mean 11 months), renal function and microalbuminuria did not differ with BMI. These results suggest that laparoscopic donor nephrectomy is generally safe in selected obese donors and does not result in a high rate of major perioperative complications. Obese donors have higher baseline cardiovascular risk and warrant risk reduction for long‐term health. While early results are encouraging, we advocate careful study of obese donors and do not support their widespread use until longer follow‐up is available.