SURVIVAL AND MORTALITY IN MALIGNANT (GRADE IV) AND GRADE III HYPERTENSION

Malignant hypertension--improving prognosis in a rare disease

A follow-up was made of 69 patients diagnosed as having malignant hypertension during 1969--76, essential in 26, secondary in 39 and unclassified in 4. A clear male dominance was seen (41 men, 28 women), particularly in the group with essential hypertension (18 men, 8 women). The mortality in this series was less than in previously published series. Thus, the 5-year survival rate was 75% in the patients with essential and 72% in those with secondary hypertension. In part this was due to haemodialysis and renal transplantation. The importance of renal function at the time of diagnosis was evident in this study. In most patients with essential hypertension and serum creatinine levels below 300 mumol/l, renal function could be maintained or improved when antihypertensive treatment was instituted, whereas progression of the renal damage was seen in those with serum creatinine levels above 300 mumol/l in spite of antihypertensive treatment with 3 or more drugs. The incidence of new cases of malignant hypertension tended to decrease during the observation period, particularly as regards essential hypertension.

Underestimation of the true benefits of antihypertensive treatment: an assessment of some important sources of error

The treatment of arterial hypertension is based on results from several large prospective randomized intervention trials that demonstrated significant benefits from antihypertensive therapy in terms of reduced cardiovascular morbidity and mortality, mainly from strokes, but also from myocardial infarction, congestive heart failure and other vascular or renal complications. Nonetheless, it is obvious that such studies, for a number of reasons, underestimate the true benefit of lowering elevated arterial pressure. Active treatment given to patients allocated randomly to be administered placebo is an important factor, particularly since active treatment is given preferentially to the placebo patients with the highest risk. Recruitment of low-risk patients into studies is another reason for the underestimation of benefit. Moreover, significant loss of patients to follow-up plays a role. Two recent epidemiological surveys, in Framingham and Göteborg, showed markedly beneficial blood pressure-related changes in those populations, suggesting that the long-term effects of antihypertensive therapy may in fact have been underestimated by intervention studies

Trends in the incidence of end-stage renal failure due to hypertension and vascular disease in Australia, 1972-1991

BACKGROUND

Despite the known protective effects upon renal function of lowering blood pressure in primary chronic renal disease, diabetes and malignant hypertension, the number of patients entering dialysis and transplantation programmes with renal failure due to hypertension or vascular disease remains high.

AIMS

To analyse the trends in incidence of arteriopathic end-stage renal failure.

METHODS

Calculation of mean annual age- and sex-specific rates (by decade) and truncated age-standardised rates for entry into Australian end-stage renal failure programmes in the period 1972-1991. Statistical analysis by chi-squared test, assuming a Poisson distribution of cases.

RESULTS

End-stage renal failure attributed primarily to hypertension or vascular disease fell to less than half its former level over the period of observation in persons aged 15-54 years. This change has occurred only in the diagnostic category 'malignant hypertension'. Trends in persons aged 55 years and over are more difficult to analyse because of changing criteria for entry into renal failure programmes, but there has been no indication of any fall in incidence.

CONCLUSIONS

The aetiology and pathology of arteriopathic renal failure is diverse, with different patterns in young and old adults. The formerly common pathology in young adults is largely preventable by modern antihypertensive therapy, while arteriopathic renal disease in older persons is not.

Antihypertensive treatment in patients with a history of accelerated malignant hypertension, with special reference to clinical decision-making in changing treatment

Conditions under which patients with hypertension controlled by combined therapy may be able to be switched to monotherapy were investigated. Eleven patients with benign phase accelerated malignant hypertension had their long-term combination antihypertensive treatment withdrawn for 1 day in an attempt to determine factors contributing to individual variability in the extent of BP increase. Patients were divided into two groups according to BP on day 1: patients with DBP above 130 mmHg formed group A, and those with DBP below 130 mmHg formed group B. Group A patients were not controlled by monotherapy with manidipine, even at the maximal dose of 60 mg/day, while group B patients were satisfactorily controlled by manidipine 20 mg/day. Group A patients had renal dysfunction whereas those in group B did not. Thus, renal dysfunction appears to be the most important single factor in predicting whether long-term combination therapy may be reduced in patients with a history of accelerated malignant hypertension.

Current and future strategies in the treatment of hypertension

Treatment of arterial hypertension is an important part of the medical care provided in industrialized countries today. Its rationale comes from large-scale intervention trials which have shown that lowering of elevated blood pressure reduces cardiovascular morbidity and mortality. Nevertheless, during the last few years it has been shown that treated hypertensive patients are still at an increased risk of cardiovascular morbidity and mortality compared with untreated normotensive subjects of the same age and sex. Possible explanations for this disappointing finding are that blood pressure has not been lowered to strictly normotensive levels; that some elements of the excess morbidity and mortality are not prevented by antihypertensive therapy, e.g., the part attributable to coronary artery disease; or that the drugs used may themselves have negative effects, e.g., on serum lipids, which may offset the positive effects of lowered blood pressure. It is desirable that antihypertensive treatment produces a reversal of hypertension-induced structural cardiovascular changes such as left ventricular hypertrophy or increased wall/lumen ratio in the precapillary blood vessels, but many of the current antihypertensive drug regimens have no effect on structural cardiovascular changes. Against this background it would appear logical to make renewed efforts to reduce blood pressure into the clearly normotensive range in an attempt to lower the excess risk demonstrable in treated hypertensive patients. It would also seem logical to use antihypertensive drugs that could also be expected to have positive effects on hypertension-induced structural cardiovascular changes.(ABSTRACT TRUNCATED AT 250 WORDS)

Malignant hypertension: aetiology and outcome in 83 patients

To evaluate the current pattern of aetiology and outcome in malignant hypertension, we reviewed all medical records of patients presenting between 1979 and 1985 who fulfilled WHO criteria for malignant hypertension. There were 83 patients, 43 males (52%) and 40 females (48%). Primary malignant hypertension was diagnosed in 17 cases (20%) and secondary lesions in 66 cases (80%). Overall one year survival was 94%, and 5 year survival 75%, which is similar to recent reports. Initial serum creatinine was a prognostic indicator.

Renal function as an indicator of prognosis in malignant essential hypertension

Renal function was evaluated in a group of 24 patients (21 men and 3 women, mean age 47 years) who had survived the malignant phase of hypertension during the period of 1969-1979. Five had grade III retinopathy (haemorrhages and exudates) and 19 had grade IV changes (papilloedema, FH IV) at diagnosis. Highest recorded blood pressure was 248 +/- 4/152 +/- 3 mmHg (mean +/- S.E.M.). Renal function rapidly deteriorated in 7 cases with progression to terminal uraemia. All patients in this group had a marked elevation in serum creatinine at diagnosis (448 +/- 105 mumol/l) and inadequate blood pressure control. Two of these 7 patients died and 5 underwent renal transplantation. The other 17 patients initially had serum creatinine less than or equal to 250 mumol/l (169 +/- 19 mumol/l-glomerular filtration rate (GFR) 51 +/- 7 ml/min). All except one were reinvestigated after a mean time of 6 years (range 6 months-11 years) with evaluation of blood pressure and determination of GFR by 51Cr-EDTA clearance. At follow-up their blood pressure was fairly well controlled (153 +/- 3/99 +/- 2 mmHg). Their GFR was 62 +/- 6 ml/min. Of the 11 patients in whom two GFR determinations were available (one initially and one at follow-up), six patients showed a marked increase in GFR while 5 patients showed only slight or no improvement in spite of fairly good blood pressure control. In malignant hypertension adequate antihypertensive treatment can lead to a pronounced improvement in GFR unless renal function has deteriorated gravely.

Studies on cerebrovascular stroke. I. Epidemiology of first-time strokes in persons under 70 years of age

The present investigation was carried out to study the incidence of new cerebrovascular strokes (cerebral haemorrhage, cerebral infarction and cerebral embolism) in people under the age of 70. SUCH INFORMATION HAS HITHERTO BEEN LACKING. The material comprises all cases from Uppsala county occurring between 1967 and 1971. The incidence was found to be 36/100,000 inhabitants. Of the total number of strokes, 25% were recurrences. During the period of study the incidence showed a moderate but significant decrease. It is assumed that this decrease is due to an extended and improved treatment of hypertension. It was observed that there were 6 females below 40 years of age. All had been on oral contraceptives at the time of the stroke. There was a high incidence of diabetes and symptoms of cardiovascular impairment (hypertension, transient ischaemic attack (TIA), cardiosclerotic disease) in the series. A high incidence of myocardial infarction was found among the parents of the cases of cerebral haemorrhage. A high incidence of strokes was found among the parents of those having cerebral infarctions.