Refractory hypertension

Lee K, Melinosky C, Cacciola J, Bodock M, Guanci M, Rordorf G, Badjatia N. Hypertonic sahne therapy for intracranial hypertension refractory to mannitol. Neurology 2005 64 S305. 

Inhalation of aerosolized iloprost is being tested in patients with severe primary or secondary pulmonary hypertension refractory to conventional therapy. The aim is to produce predominantly pulmonary vasodilatation without significant systemic effects. In an uncontrolled series of 19 patients, the most common adverse effects of inhaled iloprost were coughing, nausea, edema, and thoracic pain (4). In most patients, these effects were transient and rarely required a change in therapy. 

FIGURE 6 Bedside monitor recording of systemic artery pressure (SAP) and pulmonary artery pressure (PAP) in a 7-month-old child with postoperative pulmonary hypertension refractory to treatment, including hyperventilation with oxygen, anesthesia, alkalosis, nitroprus-side, prostaglandin E, and acetylcholine. Administration of 80-ppm inhaled nitric oxide produced an immediate reduction in PAP, with little effect on SAP. 

McCord RW, LaCoite WS. Hypertension refractory to methyldopa in a disulfiram-treated patient. Ctin Res (1984) 32,923A. 

Suarez JI, Qureshi AI, Bhardwaj A, Williams MA, Schnitzer MS, Mirski M, Hanley DF, Ulatowski JA. Treatment of refractory intracranial hypertension with 23.4% saline. Crit Care Med 1998 26(6) 1118-1122. 

Hyperventilation to 25-30 mmHg for brief periods may be considered in refractory intracranial hypertension ° Effect limited to 24 h... 

Cyclosporine is a cyclic polypeptide immunosuppressant typically used to prevent organ rejection in transplant patients. Its use is restricted to patients with fulminant or refractory symptoms in patients with active IBD. Significant toxicides associated with cyclosporine are nephrotoxicity, risk of infection, seizures, hypertension, and liver function test abnormalities.1,13,14... 

MAO Is have not been evaluated systematically for treatment of PD under the current diagnostic classification and generally are reserved for patients who are refractory to other treatments.48,49 MAOIs have significant side effects that limit adherence. Additionally, patients must adhere to dietary restriction of tyramine and avoid sympathomimetic drugs to avoid hypertensive crisis. 

Cyclosporine reduces production of cytokines involved in T-cell activation and has direct effects on B cells, macrophages, bone, and cartilage cells. Its onset appears to be 1 to 3 months. Important toxicities at doses of 1 to 10 mg/kg/day include hypertension, hyperglycemia, nephrotoxicity, tremor, GI intolerance, hirsutism, and gingival hyperplasia. Cyclosporine should be reserved for patients refractory to or intolerant of other DMARDs. It should be avoided in patients with current or past malignancy, uncontrolled hypertension, renal dysfunction, immunodeficiency, low white blood cell or platelet counts, or elevated Ever function tests. 

General note In resistant (refractory) hypertension centrally acting agents (selective and non-selective) and alpha-blockers may be required to control BR... 

Sodium nitroprusside is used in the management of hypertensive crisis. Although it is effective in every form of hypertension because of its relatively favorable effect on cardiac performance, sodium nitroprusside has special importance in the treatment of severe hypertension with acute myocardial infarction or left ventricular failure. Because the drug reduces preload (by venodila-tion) and after load (by arteriolar dilation), it improves ventricular performance and in fact is sometimes used in patients with refractory heart failure, even in the absence of hypertension. 

Unlabeled Uses Cardiopulmonary bypass surgery hemodialysis pulmonary hypertension associated with acute respiratory distress syndrome, systemic lupus erythematosus, or congenital heart disease refractory CHF severe community-acquired pneumonia... 

A 78-year-old man became short of breath. He had been taking rosiglitazone 8 mg/day for 6 months. He had renal insufficiency, atrial fibrillation, hypertension, and congestive heart failure, with pitting edema and bilateral pleural effusions. He was refractory to intravenous furosemide and metolazone. Withdrawal of rosiglitazone and administration of bumetanide gave a net fluid output of 9.5 litres and the edema resolved. 

A 61-year-old man with coronary artery stenosis became hypotensive during elective surgery, refractory to ephedrine (cumulative dose of 36 mg over 45 minutes). Immediately after terlipressin 1 mg, he developed hypertension and bradycardia, with evidence of myocardial ischemia. 

Augustyniak RA, Thomas GD, Victor RG, Zhang W. Nitric oxide pathway as new drug targets for refractory hypertension. Curr Pharm Des. 2005 11 3307-3315. 

High risk defer resumption of sexual activity until cardiological assessment and treatment Unstable or refractory angina Increased risk of Ml Uncontrolled hypertension... 

In addition, currently the investigation of patients with refractory hypertension associated with end-stage renal disease are continuing to confirm the efficacy and safety of renal denervation by Ardian Inc (NCT00664638) [61], Catheter-based renal denervation has been reported as an effective and safe, without serious adverse events, treatment to reduce blod pressure in 45 patients with resistant hypertension for 12 months in a multicenter trial [62, 63],... 

The role of the sympathetic nervous system in renal injury, end-stage renal disease, and renovascular hypertension are discussed through a literature review accompanying sympathetic nerve mechanisms in hypertension and obesity. Relevant studies of sympathetic nerve activity and 32-adrenoceptor polymorphism might contribute to the onset and maintenance of renal injury in healthy subjects and in patients with chronic heart failure and cardiovascular events in ESRD patients. A better understanding of the relationships of sympathetic nerve activity with renal injury might help clinical implications (treatment) for renal injury in hypertensive patients and hypertension in patients with ESRD. Recently, the role of denervation of renal sympathetic nerve in refractory hypertension has been examined and showed its efficacy in humans. The outcome from the study have not been established, but a number of animal studies show theoretical benefits for those patients in the acute phase. Further studies are needed to clarify the relationships between the sympathetic nerve activity and renal injury. 

Clinical Trials.gov. A service of the U.S. National Institute of Health. Renal denervation in refractory hypertension. http //clinicaltrials.gov/ct2/show/ NCT00664638 spons=%22Ardian+Inc%22andspons ex=Yandrank=3... 

---