Secondary Hypertension: Clinical Presentation, Diagnosis, and Treatment
http://www.100md.com
《新英格兰医药杂志》
The introduction states that the aim of this book is to provide "the essential clinical, diagnostic and treatment aspects of secondary hypertension." These topics are covered by succinct and authoritative overviews that provide an agreeable balance between evidence-based medicine and skilled clinical experience.
(Figure)
Enlarged Disk with Some Papilledema in a Patient with Intracranial Hypertension.
By permission of the Wellcome Library, London.
Appropriately, the first two chapters deal with refractory and iatrogenic hypertension. Resistance to treatment, or the exclusion of obvious factors that could cause resistance, is among the most important reasons for starting diagnostic maneuvers to detect secondary forms of hypertension. Even though the two chapters overlap somewhat, they cover the most important problems, and the uncertainties in the definition of refractory hypertension simply reflect the present state of clinical practice. In my opinion, an experienced practitioner may make a diagnosis of refractory hypertension only after a patient has been treated with the right combination of three drugs for at least one month and after the possibilities of nonadherence to treatment and misleading blood-pressure measurements have been excluded.
Hypertension secondary to renal disease is also clearly described. The most controversial issue is the treatment of renovascular hypertension. The few randomized trials comparing revascularization with medical therapy are too small to serve as the basis for making a meaningful choice between the two treatments. In the absence of convincing trials, the good results obtained with angioplasty in fibromuscular dysplasia favor this treatment for renovascular hypertension as well. In the case of atherosclerotic renal-artery stenosis, the decision is more difficult. Clinical practice and anecdotal observation point to a subgroup of patients who may benefit from revascularization with stenting to reduce the progression of either renal-artery stenosis or renal failure (particularly when there is stenosis in both kidneys). The procedure may also be used to lower blood pressure in patients already receiving a multidrug combination or to treat patients with coronary heart disease, cardiac insufficiency, or hypertensive encephalopathy.
The clinical problems associated with disorders of the adrenal cortex receive a well-balanced review. I personally prefer magnetic resonance imaging over computed tomography for the detection of morphologic adrenal abnormalities and the use of eplerenone over spironolactone for the treatment of primary aldosteronism (to prevent the side effects of spironolactone). The ratio of plasma aldosterone to plasma renin activity, which is still not widely used in screening for primary aldosteronism, is thoroughly discussed. I particularly appreciated the chapter on nonprimary aldosteronism for its concise descriptions of all the monogenic or mendelian forms of hypertension. Patients with these forms of the disease share an abnormality in sodium transport across the renal tubuli. In the much more common "primary," or "essential," hypertension, subtle abnormalities in renal pathways for sodium transport may also be involved.
In patients who have paroxysmal hypertension, palpitations, nervousness, tremor, excessive sweating, pallor, or erythema (together or in various combinations), it is not easy to distinguish between pseudopheochromocytoma due to short-term activation of the sympathetic nervous system in response to stressful stimuli (of which not all patients are aware) and the much less frequent classic pheochromocytoma. The two chapters dealing with this problem are very well written, with discussions that are neat and to the point.
Careful clinical evaluation and simple algorithms are needed to avoid unnecessary tests to make the diagnosis of secondary forms of hypertension in children and adolescents. The chapter dealing with this topic is very useful, as is the one entitled "Sleep Apnea and Hypertension," which covers important aspects of the association between breathing disorders during sleep and hypertension, a connection that is not well recognized in clinical practice.
Since arterial hypertension affects about 30 percent of the people in industrialized countries, this book should be in the library of primary care physicians, internists, and specialists in nephrology, cardiology, and endocrinology.
Giuseppe Bianchi, M.D.
University Vita Salute San Raffaele
20132 Milan, Italy
bianchi.giuseppe@hsr.it((Clinical Hypertension an)
(Figure)
Enlarged Disk with Some Papilledema in a Patient with Intracranial Hypertension.
By permission of the Wellcome Library, London.
Appropriately, the first two chapters deal with refractory and iatrogenic hypertension. Resistance to treatment, or the exclusion of obvious factors that could cause resistance, is among the most important reasons for starting diagnostic maneuvers to detect secondary forms of hypertension. Even though the two chapters overlap somewhat, they cover the most important problems, and the uncertainties in the definition of refractory hypertension simply reflect the present state of clinical practice. In my opinion, an experienced practitioner may make a diagnosis of refractory hypertension only after a patient has been treated with the right combination of three drugs for at least one month and after the possibilities of nonadherence to treatment and misleading blood-pressure measurements have been excluded.
Hypertension secondary to renal disease is also clearly described. The most controversial issue is the treatment of renovascular hypertension. The few randomized trials comparing revascularization with medical therapy are too small to serve as the basis for making a meaningful choice between the two treatments. In the absence of convincing trials, the good results obtained with angioplasty in fibromuscular dysplasia favor this treatment for renovascular hypertension as well. In the case of atherosclerotic renal-artery stenosis, the decision is more difficult. Clinical practice and anecdotal observation point to a subgroup of patients who may benefit from revascularization with stenting to reduce the progression of either renal-artery stenosis or renal failure (particularly when there is stenosis in both kidneys). The procedure may also be used to lower blood pressure in patients already receiving a multidrug combination or to treat patients with coronary heart disease, cardiac insufficiency, or hypertensive encephalopathy.
The clinical problems associated with disorders of the adrenal cortex receive a well-balanced review. I personally prefer magnetic resonance imaging over computed tomography for the detection of morphologic adrenal abnormalities and the use of eplerenone over spironolactone for the treatment of primary aldosteronism (to prevent the side effects of spironolactone). The ratio of plasma aldosterone to plasma renin activity, which is still not widely used in screening for primary aldosteronism, is thoroughly discussed. I particularly appreciated the chapter on nonprimary aldosteronism for its concise descriptions of all the monogenic or mendelian forms of hypertension. Patients with these forms of the disease share an abnormality in sodium transport across the renal tubuli. In the much more common "primary," or "essential," hypertension, subtle abnormalities in renal pathways for sodium transport may also be involved.
In patients who have paroxysmal hypertension, palpitations, nervousness, tremor, excessive sweating, pallor, or erythema (together or in various combinations), it is not easy to distinguish between pseudopheochromocytoma due to short-term activation of the sympathetic nervous system in response to stressful stimuli (of which not all patients are aware) and the much less frequent classic pheochromocytoma. The two chapters dealing with this problem are very well written, with discussions that are neat and to the point.
Careful clinical evaluation and simple algorithms are needed to avoid unnecessary tests to make the diagnosis of secondary forms of hypertension in children and adolescents. The chapter dealing with this topic is very useful, as is the one entitled "Sleep Apnea and Hypertension," which covers important aspects of the association between breathing disorders during sleep and hypertension, a connection that is not well recognized in clinical practice.
Since arterial hypertension affects about 30 percent of the people in industrialized countries, this book should be in the library of primary care physicians, internists, and specialists in nephrology, cardiology, and endocrinology.
Giuseppe Bianchi, M.D.
University Vita Salute San Raffaele
20132 Milan, Italy
bianchi.giuseppe@hsr.it((Clinical Hypertension an)