Target organ complications and prognostic significance of alerting reaction: analysis from the Dallas Heart Study.

Objective: Noninvasive blood pressure (BP) measurement often triggers a transient rise in BP, known as an alerting reaction. However, the prevalence and prognostic significance of the alerting reaction has never been assessed in the general population.

Methods: We evaluated the association between the alerting reaction and left ventricular mass by MRI and urinary albumin-to-creatinine ratio in the Dallas Heart Study, a large population sample of 3069 individuals.

Primary aldosteronism: evidence against a second epidemic.

Primary aldosteronism is widely held to be the most common cause of identifiable (secondary) hypertension, reported to be present in 6-10% of all hypertensive patients. This belief reflects the widespread use of the aldosterone-to-renin ratio (ARR) as a screening test. Unfortunately, the ARR is often wrong, leading to even more expensive testing that is also often misleading but that may then lead to potentially harmful additional measures.

The diastolic J curve: alive and threatening.

The occurrence of additional cardiovascular events when the diastolic blood pressure is lowered below a critical level is referred to as "the diastolic J curve." Although the critical level of diastolic blood pressure where the J curve begins is not certain, increasingly strong evidence from prospective, controlled studies has confirmed the existence of such a J curve. With the likely addition of more patients who will be treated more vigorously, in particular, elderly subjects with isolated systolic hypertension, the potential for an increase in the number of adverse cardiovascular events must be considered and caution used to avoid too low a diastolic blood pressure.

Can treating the diastolic blood pressure below a certain value increase cardiovascular risk?

The appearance of cardiovascular events when the diastolic blood pressure is lowered to some critical level is referred to as a "J-curve." Extensive data document the presence of a J-curve appearing when the diastolic blood pressure is lowered by antihypertensive medication to a level below 65 mm Hg, particularly in patients with underlying coronary heart disease even if such disease has not been clinically evident. Caution is needed in the more intensive and widespread treatment of hypertensive patients to avoid a J-curve.

Primary aldosteronism: A contrarian view.

This paper provides evidence that primary aldosteronism is likely much less common than is believed by the other authors of this collection. The basis for this contrarian view is simple: there is no way to know the true prevalence of PA because of the uncertain validity of all of the diagnostic procedures used to find and characterize this disease. Moreover, even if these uncertainties are overcome, the eventual treatment of most who have PA can be provided without the need for extensive testing and expensive treatment.

Current diagnosis and treatment of primary aldosteronism.

Primary aldosteronism is more common than previously recognized but much less common than most experts in this arena have recently stated. The recognition of autonomous hyperaldosteronism is not difficult but the identification of the source of excess aldosterone requires a costly and difficult procedure. Most patients with hyperaldosteronism turn out to have bilateral adrenal hyperplasia for which medical therapy with an aldosterone blocker is indicated.

Prehypertension: is it relevant for nephrologists?

Prehypertension has been proposed as the diagnosis for the presence of blood pressures >120/80 mmHg but <140/90 mmHg. It covers more than 60 million people in the United States and nephrologists will increasingly be involved with them. This review describes its relevance to nephrologists.

Combination therapy for hypertension.

Two or more drugs are needed to control blood pressure in the majority of patients with hypertension. The most commonly used combinations include a diuretic; however, results of two large, controlled trials show that better cardiovascular protection is provided by a combination of a renin-angiotensin inhibitor and a long-acting calcium-channel blocker than combinations that include a diuretic.