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Sarafidis P.A.,University Hospital | Ruilope L.M.,Hypertension Unit
Kidney International

Over the past decades, aggressive control of blood pressure (BP) and blockade of the renin-angiotensin-aldosterone system (RAAS) were considered the cornerstones of treatment against progression of chronic kidney disease (CKD), following important background and clinical evidence on the associations of hypertension and RAAS activation with renal injury. To this end, previous recommendations included a BP target of <130/80 mm Hg for all individuals with CKD (and possibly <125/75 mm Hg for those with proteinuria >1 g/day), as well as use of angiotensin-converting-enzyme inhibitors and angiotensin receptor blockers as first-line therapy for hypertension in all CKD patients. However, long-term extensions of relevant clinical trials support a low-BP goal only for patients with proteinuria, whereas recent cardiovascular trials questioned the benefits of low systolic BP for diabetic patients, leading to more individualized recommendations. Furthermore, our previous knowledge of the specific renoprotective properties of RAAS blockers in patients with proteinuric CKD is now extended with data on the use of these agents in patients with less advanced nephropathy and/or absence of proteinuria, deriving mostly from subanalyses of cardiovascular trials. This review discusses previous and recent clinical evidence on the issues of BP reduction and RAAS blockade by type and stage of renal damage, aiming to aid clinicians in their treatment decisions for patients with CKD. © 2013 International Society of Nephrology. Source

Garcia-Donaire J.A.,Hypertension Unit
Fundamental & clinical pharmacology

Cardiovascular disease (CVD) is the most common cause of death in Western countries and will continue to be so in upcoming years. A close correlation has been demonstrated among CVD, stroke, ischemic heart disease, renal failure and a number of modifiable risk factors. As cardiovascular (CV) risk factors commonly co-exist, high-risk patients with hypertension, obesity and diabetes may well benefit from a multiple action combination of CV agents with synergistic efficacy. Control of blood pressure (BP) and the other CV risk factors is still far from the optimal rates and achievement of internationally accepted goals must be imperative. The benefits of achieving these goals, including significant reductions in CV morbidity and mortality, are well documented. Thus, a rigorous effort to improve BP goal attainment is required. Most of the patients will need two or more antihypertensives to achieve BP goal. Administering of two drugs in a single-dose formulation substantially improves patient compliance compared with separate agent administration. Fixed-dose combination therapy can offer potential advantages over individual agents, including increased efficacy, reduced incidence of adverse effects, lower healthcare costs and improved patient compliance through the use of a single medication administered once daily. Currently available fixed-dose agents include several combinations with complementary pharmacodynamic activity. Last, the polypill includes several CV acting agents that affects various CV risk factors and offers encouraging results, although more data are needed to strengthen the polypill concept, its efficacy and safety. Source

Ruilope L.M.,Hypertension Unit
Nature Reviews Cardiology

Elevated blood pressure (BP) is probably the most-important modifiable risk factor for cardiovascular disease (CVD). BP influences the development of CVD, even if levels of BP are well below the usual cut-off point that defines the presence of arterial hypertension. Adequate measurement of BP is the most-important requirement for the diagnosis and treatment of patients with suspected hypertension. The use of methodologies such as ambulatory and home BP monitoring have become powerful tools for defining the 'real' BP of patients, discarding the white-coat effect, and discovering masked hypertension. Early intervention with life-style changes and antihypertensive drugs is required to obtain the best outcome for the patient. In this sense, early use of combination antihypertensive drug therapy is recommended. The treatment of resistant hypertension-the type of elevated BP that is most difficult to control-has clearly improved over the past decade. Further studies are required to define how antihypertensive therapy should be used in the earliest stages of hypertension and for the treatment of patients with a mild-to-moderate increase in global cardiovascular risk. © 2012 Macmillan Publishers Limited. All rights reserved. Source

Savard S.,Hypertension Unit | Amar L.,Hypertension Unit | Amar L.,University of Paris Descartes | Plouin P.-F.,Hypertension Unit | And 3 more authors.

A higher risk of cardiovascular events has been reported in patients with primary aldosteronism (PA) than in otherwise similar patients with essential hypertension (EH). However, the evidence is limited by small sample size and potential confounding factors. We, therefore, compared the prevalence of cardiovascular events in 459 patients with PA diagnosed in our hypertension unit from 2001 to 2006 and 1290 controls with EH. PA cases and EH controls were individually matched for sex, age (±2 years), and office systolic blood pressure (±10 mm Hg). Patients with PA and EH differed significantly in duration of hypertension, serum potassium, plasma aldosterone and plasma renin concentrations, aldosterone-to-renin ratio, and urinary aldosterone concentration (P<0.001 for all comparisons). The prevalence of electrocardiographic and echocardiographic left ventricular hypertrophy was about twice higher in patients with PA even after adjustment for hypertension duration. PA patients also had a significantly higher prevalence of coronary artery disease (adjusted odds ratio, 1.9), nonfatal myocardial infarction (adjusted odds ratio, 2.6), heart failure (adjusted odds ratio, 2.9), and atrial fibrillation (adjusted odds ratio, 5.0). The risks associated with PA were similar across levels of serum potassium and plasma aldosterone. To conclude, patients with PA are more likely to have had a cardiovascular complication at diagnosis than otherwise similar patients with EH. Target organ damage and complications disproportionate to blood pressure should be considered as an additional argument for suspecting PA in a given individual and possibly for broadening the scope of screening at the population level. © 2013 American Heart Association, Inc. Source

Rossi G.P.,University of Padua | Auchus R.J.,University of Michigan | Brown M.,University of Cambridge | Lenders J.W.M.,Radboud University Nijmegen | And 5 more authors.

Adrenal venous sampling is recommended by current guidelines to identify surgically curable causes of hyperaldosteronism but remains markedly underused. Key factors contributing to the poor use of adrenal venous sampling include the prevailing perceptions that it is a technically challenging procedure, difficult to interpret, and can be complicated by adrenal vein rupture. In addition, the lack of uniformly accepted standards for the performance of adrenal venous sampling contributes to its limited use. Hence, an international panel of experts working at major referral centers was assembled to provide updated advice on how to perform and interpret adrenal venous sampling. To this end, they were asked to use the PICO (Patient or Problem, Intervention, Control or comparison, Outcome) strategy to gather relevant information from the literature and to rely on their own experience. The level of evidence/recommendation was provided according to American Heart Association gradings whenever possible. A consensus was reached on several key issues, including the selection and preparation of the patients for adrenal venous sampling, the procedure for its optimal performance, and the interpretation of its results for diagnostic purposes even in the most challenging cases. © 2013 American Heart Association, Inc. Source

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