RESUMO
ABSTRACT: This manuscript is the result of the North American Neuroendocrine Tumor Society consensus conference on the medical management and surveillance of metastatic and unresectable pheochromocytoma and paraganglioma held on October 2 and 3, 2019. The panelists consisted of endocrinologists, medical oncologists, surgeons, radiologists/nuclear medicine physicians, nephrologists, pathologists, and radiation oncologists. The panelists performed a literature review on a series of questions regarding the medical management of metastatic and unresectable pheochromocytoma and paraganglioma as well as questions regarding surveillance after resection. The panelists voted on controversial topics, and final recommendations were sent to all panel members for final approval.
Assuntos
Neoplasias das Glândulas Suprarrenais/terapia , Tumores Neuroendócrinos/terapia , Paraganglioma/terapia , Feocromocitoma/terapia , Neoplasias das Glândulas Suprarrenais/diagnóstico , Humanos , Oncologia/métodos , Oncologia/normas , Metástase Neoplásica , Tumores Neuroendócrinos/diagnóstico , América do Norte , Paraganglioma/diagnóstico , Feocromocitoma/diagnóstico , Sociedades MédicasRESUMO
Resistant hypertension is common in the chronic kidney disease population and conveys increased risk for adverse cardiovascular outcomes and the development of kidney failure. Recently, the American College of Cardiology and American Heart Association published a revised scientific statement on the definition and management of resistant hypertension, which codified the long-debated differences between pseudoresistant hypertension and true resistant hypertension. We review this distinction and its importance to nephrologists, who frequently encounter patients for whom antihypertensive therapy fails due to difficulty adhering to complex multidrug regimens. Second, we discuss the evaluation of patients with resistant hypertension, including appropriate screening and diagnostic testing for causes of secondary hypertension. Third, we examine the management of established resistant hypertension, including medication optimization, recent clinical trials supporting lifestyle modifications, and the evidence behind the routine use of mineralocorticoid receptor antagonists. Special attention is given to the vital role of diuretics in the treatment of patients with chronic kidney disease. We propose an algorithm for the diagnosis and management of these cases. Finally, we briefly discuss the current state of antihypertensive device therapies, including kidney denervation and baroreceptor-directed therapies.
Assuntos
Anti-Hipertensivos/farmacologia , Hipertensão , Insuficiência Renal Crônica , Resistência a Medicamentos , Humanos , Hipertensão/complicações , Hipertensão/terapia , Conduta do Tratamento Medicamentoso , Insuficiência Renal Crônica/complicações , Insuficiência Renal Crônica/fisiopatologiaRESUMO
BACKGROUND: Obese patients may have unrecognized primary aldosteronism due to high rates of concomitant hypertension. We hypothesized that obesity impacts the diagnosis and management of patients with primary aldosteronism. METHODS: We conducted a retrospective analysis of all primary aldosteronism patients (n = 418) who underwent adrenal vein sampling (1997-2017). Patients were classified by body mass index as obese (body mass index ≥35) or nonobese (body mass index <35) and diagnostic evaluation was compared between groups. Within the operative cohort (n = 285), primary outcomes were changes in both blood pressure and antihypertensive medications after adrenalectomy. Secondary outcome was clinical resolution by Primary Aldosteronism Surgery Outcomes criteria. RESULTS: Thirty-five percent of patients were obese. Obese patients were more likely to be male (67.8% vs 56.1%, P = .025), somewhat younger (51.5 vs 54.4 years old, P < .012), and require more preoperative antihypertensive medications (6.7 vs 5.7, P = .04) than nonobese patients. Obese patients had lesser rates of radiologic evidence of adrenal tumors (68.4 vs 77.9%, P = .038) despite similar rates of lateralization on adrenal vein sampling. In the operative subset, obese patients had somewhat smaller tumors on final pathology (1.1 vs 1.5 cm, P = .014) but similar rates of complete and partial clinical resolution (P = 1.000). CONCLUSION: Obese primary aldosteronism patients have lesser rates of localization by imaging, likely due to smaller tumor size, however, experience similar benefit from adrenalectomy.
Assuntos
Neoplasias das Glândulas Suprarrenais/diagnóstico , Adrenalectomia , Anti-Hipertensivos/administração & dosagem , Hiperaldosteronismo/diagnóstico , Hipertensão/terapia , Obesidade/complicações , Neoplasias das Glândulas Suprarrenais/complicações , Neoplasias das Glândulas Suprarrenais/epidemiologia , Neoplasias das Glândulas Suprarrenais/cirurgia , Glândulas Suprarrenais/diagnóstico por imagem , Glândulas Suprarrenais/patologia , Glândulas Suprarrenais/cirurgia , Adulto , Fatores Etários , Idoso , Pressão Sanguínea/efeitos dos fármacos , Índice de Massa Corporal , Feminino , Humanos , Hiperaldosteronismo/epidemiologia , Hiperaldosteronismo/etiologia , Hiperaldosteronismo/cirurgia , Hipertensão/etiologia , Masculino , Pessoa de Meia-Idade , Obesidade/epidemiologia , Estudos Retrospectivos , Fatores de Risco , Fatores Sexuais , Resultado do TratamentoAssuntos
Fibrilação Atrial/epidemiologia , Auscultação/instrumentação , Pressão Sanguínea/fisiologia , Hipertensão/epidemiologia , Idoso , Idoso de 80 Anos ou mais , Fibrilação Atrial/complicações , Fibrilação Atrial/fisiopatologia , Auscultação/normas , Determinação da Pressão Arterial/métodos , Humanos , Hipertensão/complicações , Incidência , Prevalência , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/prevenção & controle , Volume Sistólico/fisiologiaRESUMO
The authors conducted a study to assess the effects of yoga on blood pressure (BP). Patients were randomized to yoga (Blood Pressure Education Program [BPEP]), or a combined program (COMBO). Ambulatory BP was measured at baseline and at 12 and 24 weeks. Data are presented for all enrolled patients (n=137) and for completers only (n=90). Systolic BP (SBP) and diastolic BP (DBP) were significantly decreased within all groups at 12 and 24 weeks (P<.001) for enrolled patients and completers. SBP was significantly reduced in the yoga and COMBO groups as compared with the BPEP group at 12 weeks in all enrolled and completers. SBP differences were no longer significant at 24 weeks between groups in all enrolled patients; however, there was a greater reduction in SBP at 24 weeks in completers favoring BPEP over yoga. No differences in DBP between groups or in BP between the yoga and COMBO groups were present. The authors did not observe an additive benefit from combining yoga with BPEP measures. Reasons for this are unclear at this time. BP lowering with yoga, however, was similar to that achieved with lifestyle measures.
Assuntos
Pressão Sanguínea/fisiologia , Hipertensão/terapia , Adulto , Determinação da Pressão Arterial , Feminino , Humanos , Hipertensão/fisiopatologia , Estilo de Vida , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Resultado do Tratamento , YogaAssuntos
Pressão Sanguínea/efeitos dos fármacos , Doenças Cardiovasculares/prevenção & controle , Planejamento de Assistência ao Paciente/normas , Insuficiência Renal Crônica/prevenção & controle , Idoso , Idoso de 80 Anos ou mais , Pressão Sanguínea/fisiologia , Doenças Cardiovasculares/epidemiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , National Institutes of Health (U.S.)/organização & administração , Guias de Prática Clínica como Assunto , Prevenção Primária , Insuficiência Renal Crônica/epidemiologia , Medição de Risco , Sístole/efeitos dos fármacos , Sístole/fisiologia , Estados UnidosRESUMO
Symptoms of catecholamine excess or pseudopheochromocytoma can be clinically indistinguishable from pheochromocytoma. Patients usually present with paroxysmal or episodic hypertension and have a negative evaluation for pheochromocytoma. It is important to exclude other causes of catecholamine excess that can be induced by stress, autonomic dysfunction due to baroreflex failure, medications, and drugs. Patients with pseudopheochromocytoma appear to have an amplified cardiovascular responsiveness to catecholamines with enhanced sympathetic nervous stimulation. The exact mechanism is not well understood and increased secretion of dopamine, epinephrine, and norepinephrine, and their metabolites have been identified as potentiating this clinical scenario leading to differing hemodynamic presentations depending on which catecholamine is elevated. Management of this condition is often difficult and frustrating for both the physician and the patient. Most patients respond reasonably well to medications that reduce sympathetic nervous system activity. Anxiolytics, antidepressants, and psychotherapy also play an important role in managing these patients' symptoms.