[Show abstract][Hide abstract] ABSTRACT: Thrombolytic therapy with intravenous recombinant tissue plasminogen activator (rt-PA) improves outcome in patients with ischaemic stroke treated within 3 h of symptom onset, but its extended implementation is limited. A pilot study was designed to verify whether evaluation of patients with acute ischaemic stroke and their treatment with intravenous rt-PA in the emergency department (ED), followed by transportation to a semi-intensive stroke care unit, offers a safe and effective organisational solution to provide intravenous thrombolysis to acute stroke patients when a stroke unit (SU) is not available.
After checking for inclusion and exclusion criteria, ED doctors contacted the stroke team with a single page, located family members and urgently obtained computed tomography scan and laboratory tests. A stroke team investigator clinically assessed the patient, obtained written informed consent and supervised intravenous rt-PA in the ED. After treatment, the patient was transferred to the SU for rehabilitation and treatment of complications, under supervision of the same stroke team investigator.
52 patients were treated with intravenous rt-PA within 3 h of symptom onset. 20 patients (38%) improved neurologically after 24 h, the number increased to 30 (58%) after one week. At 3 months 22 patients had a favourable outcome (43%). The 3-month mortality rate was 12%. Symptomatic cerebral haemorrhage was observed in two patients (4%).
Intravenous rt-PA administration in the ED is an effective organisational solution for acute ischaemic stroke when an SU is not established.
Full-text · Article · Aug 2008 · Emergency Medicine Journal
[Show abstract][Hide abstract] ABSTRACT: Resistant hypertension is common in clinical practice. The aim of our study was to evaluate inappropriate aldosterone activity in causing resistance to antihypertensive therapy.
Among the patients consecutively evaluated for the first time between 1995 and 2001, we selected all those (n = 157) with an aldosterone-to-renin ratio (ARR) >or=25 (ng/dL)/(ng/mL/h), and plasma aldosterone >or=12 ng/dL. Eight patients with Conn adenoma were excluded from the study. Fifty-eight were diagnosed as idiopathic aldosteronism (IHA), the other 91 patients, who did not meet the criteria for primary aldosteronism, were operatively classified as aldosterone-associated hypertension (AAH). As a control group, we randomly chose 160 patients with essential hypertension and plasma aldosterone <12 ng/dL (EH). Antihypertensive treatment was given in accordance to World Health Organization Guidelines (1999). The study end point was blood pressure (BP) <140/90 mm Hg.
During follow-up (22 +/- 2 months), 24 (41.4%) patients with IHA, 35 (38.5%) with AAH, and 72 (54.0%) with EH reached the end point. According to survival analysis, AAH and IHA patients reached the end point in a smaller fraction and in a longer time compared with EH patients, with no difference between IHA and AAH. At the end of follow-up, IHA and AAH patients had higher diastolic BP than EH patients with no difference between IHA and AAH.
Patients with elevated aldosterone plasma levels develop resistant hypertension, even in the absence of clinically diagnosed primary aldosteronism. Their identification will allow a targeted therapy and a more effective BP reduction.
No preview · Article · May 2006 · American Journal of Hypertension
[Show abstract][Hide abstract] ABSTRACT: Hypertension is a common early finding after an acute ischemic stroke, even in previously normotensive patients. But its significance and proper management are a matter of debate, because of the lack of adequately powered randomized clinical trials. A close analysis of observational and interventional trials, published so far, fails to convince that an early antihypertensive therapy is needed and beneficial. During the first 24-48 hr after ischemic stroke, only blood pressure values repeatedly higher than 220/120 mmHg require antihypertensive treatment to keep blood pressure levels in the range of 180-220 mmHg systolic and 100-120 diastolic. Blood pressure reduction should be cautious with the aim of keeping the pressure at relatively high values (180/100-105 in previously hypertensive patients and 160-180/90-100 in previously normotensive patients). The usefulness of increasing blood pressure with vasopressive agents in selected patients with ischemic stroke deserves adequate testing with randomized clinical trials.
No preview · Article · Apr 2006 · Clinical and Experimental Hypertension
[Show abstract][Hide abstract] ABSTRACT: Resistant hypertension (blood pressure ≥140/90 mmHg on 3+ anthypertensive agents) is a common problem in clinical practice.
Several factors induce treatment resistance, especially unrecognized secondary hypertension. Aldosterone/renin ratio (ARR)
is an index for inappropriate aldosterone activity and it could be helpful to predict the response to anthypertensive agents.
Aim of our study was evaluate inappropriate aldosterone activity in causing resistance to anthypertensive therapy. Among the
patients from the Hypertension Outpatient Clinic that were consecutively evaluated for the first time between 1995 and 2001,
we selected all the patients (n=157) with aldosterone-associated hypertension (AAH, ARR (ng dL−1 / ng mL−1 h−1) >25, plasma aldosterone >12 ng/dL). 58 were diagnosed as idiopathic hyperaldosteronism (IHA, aldosterone after captopril
suppression test >15) and 91 as “high aldosterone hypertension” (HAH, aldosterone after captopril <15). Patients with Conn
adenoma (n=8) were excluded from the study. As a control group, we randomly chose 160 patients with essential hypertension
and plasma aldosterone <12 (EH). Anthypertensive treatment was given in accordance to WHO Guidelines (1999). The study end-point
was blood pressure <140/90 mmHg. At baseline, there was no significant difference between the AAH and EH group with respect
to age, BMI, systolic blood pressure, serum potassium, and creatinine. On the contrary, those with AAH had higher diastolic
blood pressure (104±1 vs 98±1 mmHg, p<0.001), serum sodium (142.1±0.2 vs 141.4±0.2 mEq/L, p<0.05), and lower serum uric acid
(4.09±0.03 vs 4.11±0.03 mg/dL, p<0.01) in comparison with EH group. During the follow-up (22±2 months), 59 (40%) patients
with AAH and 72 (54%) patients in EH group reached the end point. According to survival analysis the patients with AAH reached
the end-point in a smaller fraction and in a longer time compared with EH group, with no difference between IHA and HAH. At
the end of follow-up, diastolic blood pressure was higher in AAH group compared with EH group. In IHA, spironolactone-based
therapy was associated with a lower blood pressure at the end of follow-up in comparison with those without spironolactone.
Inappropriate aldosterone activity in HAH is a risk factor for resistance to anthypertensive agents and the benefits of spironolactone
is worth testing.
No preview · Article · May 2005 · American Journal of Hypertension