Hypertension Journal

1.REVIEW ARTICLE

Cardiovascular Disease in Patients with Chronic Kidney Disease

Peter A. McCullough, Aaron Y. Kluger
[Year:2019] [Month:January-March] [Volume:5 ] [Number:1] [Pages No:25-31] [No. of Hits: 524]
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  • [Abstract]
  • [DOI : [DOI : 10.15713/ins.johtn.0146]]

ABSTRACT

Kidney and cardiovascular diseases are strongly associated due to the connections between the heart and the kidneys; kidney disease may even be seen as a cardiovascular risk. The Chronic Kidney Disease (CKD) Prognosis Consortium showed that CKD severity was related to cardiovascular death risk, among other factors. When reduced estimated glomerular filtration rate and albuminuria - both biomarkers for declining renal function - are present in a patient, the rate of cardiovascular events increases significantly. Kidney and heart diseases are linked with regard to coronary atherosclerosis, myocardial disease, valvular calcification, and atrial and ventricular arrhythmias. CKD and end-stage renal disease (ESRD) patients with coronary atherosclerosis frequently have accentuated calcification; many CKD-related factors accelerate the calcification process. These may include traditional risk factors such as hypertension or diabetes, as well as non-traditional risk factors such as uremia, anemia, and increased coagulation proteins. This is also associated with more stable lesions, often leading to episodes of silent and symptomatic coronary ischemia in these patients. CKD is linked to heart failure by accentuating pressure overload, volume overload, and cardiomyopathy, the three major pathophysiologic mechanisms causing left ventricle failure. Hemodialysis itself may lead to myocardial disease through ‘myocardial stunning,’ in which episodes of hypotension during hemodialysis cause transient wall motion abnormalities, worsening survival overtime. Short daily hemodialysis in the home setting may be associated with improved outcomes. CKD and ESRD patients often experience accelerated aortic valvular and mitral annular calcification and fibrosis. These patients should receive echocardiography during care, to evaluate for valve disease severity as well as the left ventricular systolic and diastolic function. Finally, CKD patients have many of the myocardial and hemodynamic factors of arrhythmia. 62% of cardiac deaths in the United States Renal Data System database are due to arrhythmias. CKD and ESRD patients should receive individualized treatment and frequent monitoring due to the increased risk of adverse events and iatrogenic death in this patient population. One option is to form hybrid ‘cardionephrology’ teams comprised cardiologists and nephrologists. This will optimize care for cardiorenal patients and boost interest in the nephrology field, which is presently lagging.

Key words: Chronic kidney disease, atherosclerosis, heart failure, aortic valve, mitral valve, arrhythmia, sudden death

How to cite this article: McCullough PA, Kluger AY. Cardiovascular Disease in Patients with Chronic Kidney Disease. Hypertens 2019;5(1): 25-31.

Source of support: Nil,

Conflict of interest: None

Received: 25-02-18;

Accepted: 02-03-18

2.REVIEW ARTICLE

Statin Update: Intolerance, Benefit, and Beyond

Aaron Y. Kluger, Kristen M. Tecson, Sivakumar Sudhakaran, Jun Zhang, Peter A. McCullough
[Year:2019] [Month:January-March] [Volume:5 ] [Number:1] [Pages No:2-7] [No. of Hits: 517]
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  • [Abstract]
  • [DOI : [DOI : 10.15713/ins.johtn.0141]]

ABSTRACT

Statins (3-hydroxy-3-methyl-glutaryl-coenzyme A reductase inhibitors) comprise a class of lipid-lowering therapy (LLT) with demonstrated effects on reducing cholesterol synthesis so that less very low-density lipoprotein cholesterol (LDL-C) are secreted into plasma by the liver, ultimately reducing the concentration of plasma LDL-C. An additional effect of statins is upregulation of sterol regulatory element-binding protein 2, upregulation of this protein increases the density of LDL-receptors on the cell surface of hepatocytes and causes greater clearance of LDL-C. Therefore, because statins reduce the creation and increase the clearance of a family of atherogenic particles (particularly LDL-C), there is a clear biologic rationale for the reduction in atherosclerotic cardiovascular disease (ASCVD) events shown in multiple large-scale clinical trials. This makes statins well-suited as the base of therapy in the prevention and treatment of ASCVD. Real and perceived intolerance is the greatest detractor of statins from the potential public health benefits of broad-scale use. Up to one-third of patients who are prescribed statins fail to take them over the long-term and thus derive no benefit. About half of these patients have ‘perceived statin intolerance,’ in which they believe they have stain intolerance due to conflated chronic symptoms or concern for adverse effects. Randomized, placebo-controlled blinded trials including such patients demonstrate that approximately 85% can, in fact, tolerate a statin during the blinded period. The other half of the statin-intolerant population is believed to have ‘real statin-intolerance’ due to reproducible legitimate adverse effects such as myalgias, increases in hepatic transaminases, and malaise; there is a pharmacoepidemiologic explanation for this 15% of the patient population. The full public health benefit of statins can only be accomplished through improved patient education and public awareness. This paper will provide an update on statins and their position in clinical lipidology, especially given advances in other forms of LLT.

Key words: Cardiovascular death, intolerance, lipids, low-density lipoprotein cholesterol, myalgia, myocardial infarction, statin, stroke

How to cite this article: Kluger AY, Tecson KM, Sudhakaran S, Zhang J, McCullough PA. Statin update: Intolerance, benefit, and beyond. Hypertens 2019;5(1): 2-7.

Source of support: This work was partially funded by the Baylor Health Care System Foundation,

Conflict of interest: None

Received: 12-12-2018;

Accepted: 27-12-2018

3.REVIEW ARTICLE

Echocardiography in Hypertension

Prakash N. Nair
[Year:2019] [Month:January-March] [Volume:5 ] [Number:1] [Pages No:8-13] [No. of Hits: 732]
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  • [Abstract]
  • [DOI : [DOI : 10.15713/ins.johtn.0142]]

ABSTRACT

Hypertension (HTN) is a treatable risk factor for cardiovascular diseases. Accurate diagnosis of HTN along with the assessment of cardiovascular risk is essential for proper treatment in hypertensive patients. Echocardiography provides prognostic factors in HTN including left ventricular mass, systolic function, diastolic function, left atrial function, and size. Apart from routine echo methods, tissue Doppler, three-dimensional echo, and strain imaging are newer echo techniques in the evaluation of hypertensive patients. Familiarity with routine and newer echo parameters is helpful for risk stratification in HTN.

Key words: Left ventricular mass, echo parameters, cardiovascular risk

How to cite this article: Nair PN. Echocardiography in Hypertension. Hypertens 2019;5(1): 8-13.

Source of support: Nil,

Conflict of interest: None

Received: 23-11-2018;

Accepted: 05-01-2019

4.REVIEW ARTICLE

White-coat Hypertension

Lexy Vijayan
[Year:2019] [Month:January-March] [Volume:5 ] [Number:1] [Pages No:14-16] [No. of Hits: 525]
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  • [DOI : [DOI : 10.15713/ins.johtn.0143]]

ABSTRACT

The term white-coat hypertension (WCHT) comes from the reference to the white coats traditionally worn by the doctors. It is also called ‘isolated office or clinic hypertension.’ Thomas Pickering coined the term WCHT to denote individuals who were not on the treatment for hypertension but who had elevated office blood pressure and normal blood pressure measured at home or with ambulatory blood pressure monitor. When your blood pressure is taken at home, the systolic value can be 10 mmHg lower than it would be if taken by a doctor and 5 mm lower on the diastolic blood pressure value. For some people, the difference can be even greater. The traditional definition of WCHT is based, therefore, on an elevated office blood pressure with a normal blood pressure during the awake period with ambulatory blood pressure monitoring. The most recent European guidelines propose an alternative definition of WCHT, which encompasses subjects with office systolic/diastolic blood pressure readings of >140/90 mmHg and 24 h blood pressure <130/80 mmHg. This condition cannot be considered as innocent since it is associated with metabolic abnormalities as well as cardiac and vascular end-organ damage. Evidence has been provided that WCHT state is characterized by an increased risk of fatal and non-fatal cardiovascular (CV) events as compared to normotensive individuals. People with WCHT were more likely to be female young less obese and more recently diagnosed with hypertension. The purpose of the review is to provide new insights into the definition, characteristics, CV risk assessment, therapeutic implications, and all-cause mortality in patients with WCHT.

Key words: Ambulatory blood pressure monitoring, white-coat hypertension, sustained HTN

How to cite this article: Vijayan L. White-coat Hypertension. Hypertens 2019;5(1): 14-16.

Source of support: Nil,

Conflict of interest: None

Received: 22-11-2018;

Accepted: 17-12-2018

5.REVIEW ARTICLE

Angiotensin-converting Enzyme Inhibitor Radionuclide Renogram – A Non-invasive Tool to Suspect Renovascular Hypertension

Sampath Santhosh, Prabhu Ethiraj, J. Jonathan Solomon, Rajalakshmi Rajasekar
[Year:2019] [Month:January-March] [Volume:5 ] [Number:1] [Pages No:17-20] [No. of Hits: 553]
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  • [DOI : [DOI : 10.15713/ins.johtn.0144]]

ABSTRACT

Renal hypoperfusion due to renal artery stenosis (RAS) activates the renin-angiotensin-aldosterone system, leading to an elevated blood pressure (BP) that constitutes renovascular hypertension (RVH). Differentiation between RVH and RAS is essential because RAS is quiet in many non-hypertensive elderly persons. Furthermore, RAS is an associated but non-causative finding in a number of hypertensive patients. Angiotensin-converting enzyme inhibitors (ACEIs) renogram helps to detect RAS as the cause of hypertension and predicts curability or improvement in hypertension after intervention. ACEI renogram is most cost effective if used primarily in patients with moderate-to-high risk of RVH that includes abrupt or severe hypertension, hypertension resistant to three-drug therapy, bruits in the abdomen or flank, unexplained azotemia or recurrent pulmonary edema in an elderly hypertensive patient, or worsening renal function during therapy with ACEIs. In this report, we describe how ACEI renogram helped in the management of a patient with refractory hypertension due to RAS.

Key words: ACE inhibitor, renogram, DTPA, renal artery stenosis, renovascular hypertension

How to cite this article: Santhosh S, Ethiraj P, Solomon JJ, Rajasekar R. Angiotensin-converting Enzyme Inhibitor Radionuclide Renogram - A Non-invasive Tool to Suspect Renovascular Hypertension. Hypertens 2019;5(1): 17-20.

Source of support: Nil,

Conflict of interest: None

Received: 21-05-2018;

Accepted: 12-12-2018

6.REVIEW ARTICLE

Common but Underrated – Are we Neglecting these Hypertensive Subsets in India?

Tiny Nair
[Year:2019] [Month:January-March] [Volume:5 ] [Number:1] [Pages No:21-24] [No. of Hits: 498]
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  • [Abstract]
  • [DOI : [DOI : 10.15713/ins.johtn.0145]]

ABSTRACT

Unusual subsets of hypertension need different strategies for detection, treatment and follow up. Isolated systolic hypertension of the young (ISH-Y), metabolic nocturnal hypertension (MNH) and white coat ‘Alarm’ are subsets which are found in India, but often go undetected. A detailed review of such unusual subsets.

Key words: Isolated Systolic hypertension, nocturnal hypertension, white coat hypertension

How to cite this article: Nair T. Common but Underrated - Are we Neglecting these Hypertensive Subsets in India?. Hypertens 2019;5(1): 21-24.

Source of support: Nil,

Conflict of interest: None

Received: 21-11-2018;

Accepted: 05-12-2018

7.REVIEW ARTICLE

Resistant Hypertension: Overview

K. Krishnakumar
[Year:2019] [Month:January-March] [Volume:5 ] [Number:1] [Pages No:32-34] [No. of Hits: 705]
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  • [Abstract]
  • [DOI : [DOI : 10.15713/ins.johtn.0147]]

ABSTRACT

Resistant hypertension (RH) is defined as office blood pressures (BP) which is uncontrolled on ≥3 or controlled on ≥4 different classes of antihypertensive medications at optimal doses and preferably including a diuretic.
• RH is important as many patients in this subgroup have secondary causes of hypertension.
• Most important aspect of treatment in RH is to divide RH into true RH and pseudo-RH.
• Three factors, namely patient adherence, optimal dosing of antihypertensive medications, and out-of-office BP recordings, are important in classifying RH to true RH and pseudo-RH.
• Many RH patients are volume expanded and respond to intensified diuretic therapy, sodium restriction, dual calcium-channel blocker, or α-adrenoreceptor blocker. Plasma renin activity can be used for personalized therapy in RH.

Key words: Resistant hypertension, insulin resistance, artifacts, adherence, secondary hypertension, indapamide, valsartan, escalating diuretics, renin guided therapy

How to cite this article: Krishnakumar K. Resistant Hypertension: Overview. Hypertens 2019;5(1): 32-34.

Source of support: Nil,

Conflict of interest: None

Received: 10-10-2018;

Accepted: 01-12-2018

8.REVIEW ARTICLE

Select Considerations for Secondary Hypertension

Geetha M. Nair, Jigy Joseph
[Year:2019] [Month:January-March] [Volume:5 ] [Number:1] [Pages No:35-39] [No. of Hits: 527]
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  • [DOI : [DOI : 10.15713/ins.johtn.0148]]

ABSTRACT

Hypertension assumes a dominant position among chronic non-communicable diseases worldwide. Of this, secondary hypertension constitutes only 5-10% of the total disease burden. In routine clinical practice, physicians come across hypertensive cases which are ifficult to control despite optimal therapy. In this backdrop, the present paper reviews the less frequently encountered etiologies of hypertension which can pose difficulties to both the patient and treating clinician. This is classified as secondary hypertension and the major entities include renal parenchymal diseases, renovascular diseases, primary hyperaldosteronism, and sleep-disordered breathing. Among patients with resistant hypertension, investigations such as urine analysis, renal function tests, electrolytes, sonogram for kidneys, duplex ultrasound for renal artery stenosis, plasma aldosterone concentration/plasma renin activity (PAC/PRA) ratio, and sleep study may be done in serial manner depending on the individual patient to identify a secondary cause. Druginduced high blood pressure should also be addressed, especially in young ladies due to oral contraceptives pills and in chronic obstructive pulmonary disease patients on long-term steroids. Many a time, a proper evaluation and diagnosis can reduce the pill burden and long-term consequences of resistant hypertension.

Key words: Endocrine, renovascular, secondary hypertension, sleep disorder

How to cite this article: Nair GM, Joseph J. Select Considerations for Secondary Hypertension. Hypertens 2019;5(1): 35-39.

Source of support: Nil,

Conflict of interest: None

Received: 14-12-2018;

Accepted: 02-01-2019

9.EDITORIAL

Greetings from PRS Hospital, Trivandrum, Kerala, India

Tiny Nair
[Year:2019] [Month:January-March] [Volume:5 ] [Number:1] [Pages No:1] [No. of Hits: 488]
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ABSTRACT

Occupying only a small percentage of Indian landmass, Kerala has an exemplary record of quality health care, comparable to the ‘western’ standards! Life expectancy is the highest and infant mortality is lowest in the country.

How to cite this article: Nair T. Greetings from PRS hospital, Trivandrum, Kerala, India. Hypertens 2019. Hypertens 2019;5(1): 1.

Source of support: Nil

Conflict of interest: None