Background: Primary aldosteronism is a nonsuppressible renin-independent aldosterone production that causes hypertension and cardiovascular disease.Objective: To characterize the prevalence of nonsuppressible renin-independent aldosterone production, as well as biochemically overt primary aldosteronism, in relation to blood pressure.
Iatrogenic colonoscopy perforation (ICP) is a severe complication that can occur during both diagnostic and therapeutic procedures. Although 45–60% of ICPs are diagnosed by the endoscopist while performing the colonoscopy, many ICPs are not immediately recognized but are instead suspected on the basis of clinical signs and symptoms that occur after the endoscopic procedure. There are three main therapeutic options for ICPs: endoscopic repair, conservative therapy, and surgery. The therapeutic approach must vary based on the setting of the diagnosis (intra- or post-colonoscopy), the type of ICP, the characteristics and general status of the patient, the operator’s level of experience, and surgical device availability.Although ICPs have been the focus of numerous publications, no guidelines have been created to standardize the management of ICPs. The aim of this article is to present the World Society of Emergency Surgery (WSES) guidelines for the management of ICP, which are intended to be used as a tool to promote global standards of care in case of ICP. These guidelines are not meant to substitute providers’ clinical judgment for individual patients, and they may need to be modified based on the medical team’s level of experience and the availability of local resources.
Background
The prevalence of pseudoresistant hypertension (HTN) due to inaccurate BP measurement remains unknown.
Methods
Triage BP measurements and measurements obtained at the same clinic visit by trained physicians were compared in consecutive adult patients referred for uncontrolled resistant HTN (RHTN). Triage BP measurements were taken by the clinic staff during normal intake procedures. BP measurements were obtained by trained physicians using the BpTRU device. The prevalence of uncontrolled RHTN and differences in BP measurements were compared.
Results
Of 130 patients with uncontrolled RHTN, 33.1% (n=43) were falsely identified as having uncontrolled RHTN based on triage BP measurements. The median (IQR) of differences in systolic BP between pseudoresistant and true resistant groups were 23 (17 – 33) mm Hg and 13 (6 – 21) mm Hg, respectively (P=0.0001). The median (IQR) of differences in diastolic BP between the two groups were 12 (7 – 18) mm Hg and 8 (4 – 11) mm Hg, respectively (P=0.001).
Conclusion
Triage BP technique overestimated the prevalence of uncontrolled RHTN in approximately 33% of the patients emphasizing the importance of obtaining accurate BP measurements.
Masked uncontrolled hypertension (MUCH) is defined as controlled automated office BP (AOBP <135/85 mmHg) in clinic in patients receiving antihypertensive medication(s), but uncontrolled BP out-of-clinic by 24-hour ambulatory blood pressure monitoring (ABPM; awake ≥135/85 mmHg).We hypothesized that MUCH patients have greater out-of-clinic sympathetic activity compared to true controlled hypertensives.
Patients being treated for hypertension were prospectively recruited after three or more consecutive clinic visits. All patients were evaluated by in-clinic AOBP, plasma catecholamines and spot-urine/plasma metanephrines. In addition, out-of-clinic 24-hr ABPM, 24-hr urinary for catecholamines and metanephrines was done.
Out of 237 patients recruited, 169 patients had controlled in-clinic BP of which 156 patients had completed ABPM. Seventy-four were true controlled hypertensives, i.e. controlled by clinic AOBP and by out-of-clinic ABPM. The remaining 82 were controlled by clinic AOBP, but uncontrolled during out-of-clinic ABPM, indicative of MUCH. After exclusion of 4 patients because of inadequate or lack of 24-hr urinary collections, 72 true controlled hypertensive and 80 MUCH patients were analyzed. MUCH patients had significantly higher out-of-clinic BP variability and lower heart rate variability compared to true controlled hypertensives as well as higher levels of out-of-clinic urinary catecholamines and metanephrines levels consistent with higher out-of-clinic sympathetic activity. In contrast, there was no difference in in-clinic plasma catecholamines and spot-urine/plasma levels of metanephrines between the two groups, consistent with similar levels of sympathetic activity while in clinic.
MUCH patients have evidence of heightened out-of-clinic sympathetic activity compared to true controlled hypertensives, which may contribute to the development of MUCH.
Refractory hypertension is a recently described phenotype of antihypertensive treatment failure defined as uncontrolled blood pressure (BP) despite the use of 5 or more different antihypertensive agents, including chlorthalidone and spironolactone. Recent studies indicate that refractory hypertension is uncommon, with a prevalence of approximately 5-10% of patients referred to a hypertension specialty clinic for uncontrolled hypertension. The prevalence of white coat effect i.e. uncontrolled automated office BP (AOBP) ≥135/85 mmHg and controlled out-of-office BP <135/85 mmHg by awake ambulatory BP monitor (ABPM) in hypertensive patients overall is approximately 30-40%. The prevalence of white coat effect among patients with refractory hypertension has not been previously reported.
In this prospective evaluation, consecutive patients referred to University of Alabama at Birmingham (UAB) Hypertension Clinic for uncontrolled hypertension were enrolled. Refractory hypertension was defined as uncontrolled AOBP ≥135/85 mmHg with use of 5 or more antihypertensive agents, including chlorthalidone and spironolactone. AOBP measurements were based on 6 serial readings, done automatically with use of a BpTRU device unobserved in clinic. Out-of-office BP measurements were done by 24-hr ABPM.
Thirty-four patients were diagnosed with refractory hypertension, of whom 31 had adequate ABPM readings. White coat effect was present in only two patients, or 6.5% of the 31 patients with refractory hypertension, suggesting that white coat effect is largely absent from patients with refractory hypertension. These findings suggest that white coat effect is not a common cause of apparent lack of BP control in patients failing maximal antihypertensive treatment.
Treatment recommendations for resistant hypertension are generally based on intensification of diuretic therapy, especially with combined use of chlorthalidone and spironolactone. Although fuller elucidation is needed, such an approach may not be appropriate for refractory hypertension, which instead, may require effective sympathetic inhibition, either with medications or device-based approaches.
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