Contemporary concepts of the medical therapy of portal hypertension under liver cirrhosis

Severe complications of liver cirrhosis are mostly related to portal hypertension. At the base of the pathogenesis of portal hypertension is the increase in hepatic vascular resistance to portal blood flow with subsequent development of hyperdynamic circulation, which, despite of the formation of collateral circulation, promotes progression of portal hypertension. An important role in its pathogenesis is played by the rearrangement of vascular bed and angiogenesis. As a result, strategic directions of the therapy of portal hypertension under liver cirrhosis include selectively decreasing hepatic vascular resistance with preserving or increasing portal blood flow, and correcting hyperdynamic circulation and pathological angiogenesis, while striving to reduce the hepatic venous pressure gradient to less than 12 mm Hg or 20% of the baseline. Over the last years, substantial progress in understanding the pathophysiological mechanisms of hemodynamic disorders under liver cirrhosis has resulted in the development of new drugs for their correction. Although the majority of them have so far been investigated only in animal experiments, as well as at the molecular and cellular level, it might be expected that the introduction of the new methods in clinical practice will increase the efficacy of the conservative approach to the prophylaxis and treatment of portal hypertension complications. The purpose of the review is to describe the known methods of portal hypertension pharmacotherapy and discuss the drugs that may affect the basic pathogenetic mechanisms of its development.

Antiangiogenic therapy for portal hypertension in liver cirrhosis: Current progress and perspectives

Developing medicines for hemodynamic disorders that are characteristic of cirrhosis of the liver is a relevant problem in modern hepatology. The increase in hepatic vascular resistance to portal blood flow and subsequent hyperdynamic circulation underlie portal hypertension(PH) and promote its progression, despite the formation of portosystemic collaterals. Angiogenesis and vascular bed restructurization play an important role in PH pathogenesis as well. In this regard, strategic directions in the therapy for PH in cirrhosis include selectively decreasing hepatic vascular resistance while preserving or increasing portal blood flow, and correcting hyperdynamic circulation and pathological angiogenesis. The aim of this review is to describe the mechanisms of angiogenesis in PH and the methods of antiangiogenic therapy. The Pub Med database, the Google Scholar retrieval system, and the reference lists from related articles were used to search for relevant publications. Articles corresponding to the aim of the review were selected for 2000-2017 using the keywords: "liver cirrhosis", "portal hypertension", "pathogenesis", "angiogenesis", and "antiangiogenic therapy". Antiangiogenic therapy for PH was the inclusion criterion. In this review, we have described angiogenesis inhibitors and their mechanism of action in relation to PH. Although most of them were studie donly in animal experiments, this selective therapy for abnormally growing newly formed vessels is pathogenetically reasonable to treat PH and associated complications.

Factors associated with intensification of antihypertensive drug therapy in patients with poorly controlled hypertension

Objective To assess antihypertensive management of older patients with poor blood pressure(BP)control.Methods Physicians,voluntary participating in the study,included six consecutive hypertensive patients during routine visits.Hypertension had to have been previously recognized and averaged office BP was>140 and/or>90 mmHg in spite of>6 weeks of antihypertensive therapy.The physicians completed a questionnaire on patients'history of cardiovascular(CV)risk factors,comorbidities,home BP monitoring,anthropometric data and the pharmacotherapy.Results Mean age of the 6462 patients was 61 years,7%were>80 years,51%were female.Mean士SD office BP values were 158士13/92土10 mmHg.The most commonly prescribed antihypertensive drugs were:diuretics(67%),ACE inhibitors(64%),calcium channel blockers(58%)and卩-blockers(54%),and their use increased with age.On monotherapy or dual therapy,43%of the patients and 40%had their latest treatment modification within six months.Home BP monitoring was a factor that accelerated the modification of the therapy.Older patients had to have less chance on faster modification of antihypertensive therapy in spite of presence of diabetes and higher systolic BP.Conclusions Our study suggests that a large number of outpatients with poor BP control receive suboptimal antihypertensive therapy,especially in primary care.In older patients,higher BP values in the office settings are more frequently accepted by physicians even in case of higher CV risk.Regular home BP monitoring hastens the decision to intensify of antihypertensive treatment.

Effectiveness of mindfulness based cognitive therapy on weight loss, improvement of hypertension and attentional bias to eating cues in overweight people

Objectives:Prevalence rates of overweight and obesity are dramatically ever-increasing across the world.Therefore,this study was to evaluate the effect of mindfulness-based cognitive therapy(MBCT)on weight loss,hypertension,and attentional bias towards food cues in a group of women affected with this condition.Methods:A total of 45 participants were selected out of women referring to the Nutrition and Diet Therapy Clinic affiliated to Shahid Beheshti University of Medical Sciences,Iran,and then randomized into three groups of 15.The first experimental group was subjected to an energy-restricted diet therapy together with MBCT during 8 sessions,the second group took the diet therapy alone,and the third group received no intervention.Body mass index(BMI),hypertension,and attentional bias towards food cues were correspondingly evaluated before,at the end,and four weeks after the completion of the interventions.Results:The results of this study revealed that MBCT,along with diet therapy,had been significantly more effective in weight loss,decrease in BMI,lower systolic blood pressure(SBP),and attentional bias towards food cues compared with the diet therapy alone(P≤0.01).MBCT had no significant impact on the decline in diastolic blood pressure(DBP)in participants in the follow-up phase.Conclusion:This study demonstrated that MBCT along with the conventional diet therapy was more effective in weight loss,decrease in BMI,hypertension control,as well as attentional bias towards food cues than the diet therapy alone.

Transjugular intrahepatic portosystemic shunt and splenectomy are more effective than endoscopic therapy for recurrent variceal bleeding in patients with idiopathic noncirrhotic portal hypertension

BACKGROUND Transjugular intrahepatic portosystemic shunt(TIPS),splenectomy plus esophagogastric devascularization(SED)and endoscopic therapy+non-selectiveβ-blockers(ET+NSBB)are widely applied in secondary prevention of recurrent gastroesophageal variceal bleeding in patients with liver cirrhosis.These different treatments,however,have not been compared in patients with idiopathic noncirrhotic portal hypertension(INCPH).AIM To compare the outcomes of TIPS,SED and ET+NSBB in the control of variceal rebleeding in patients with INCPH.METHODS This retrospective study recruited patients from six centers across China.Demographic characteristics,baseline profiles and follow-up clinical outcomes were collected.Post-procedural clinical outcomes,including incidence of rebleeding,hepatic encephalopathy(HE),portal vein thrombosis(PVT)and mortality rates,were compared in the different groups.RESULTS In total,81 patients were recruited,with 28 receiving TIPS,26 SED,and 27 ET+NSBB.No significant differences in demographic and baseline characteristics were found among these three groups before the procedures.After treatment,blood ammonia was significantly higher in the TIPS group;hemoglobin level and platelet count were significantly higher in the SED group(P<0.01).Rebleeding rate was significantly higher in the ET+NSBB group(P<0.01).Mortality was 3.6%,3.8%and 14.8%in the TIPS,SED and ET+NSBB groups,respectively,with no significant differences(P=0.082).Logistic regression analysis showed that mortality was significantly correlated with rebleeding,HE,portal thrombosis and superior mesenteric vein thrombosis(P<0.05).CONCLUSION In patients with INCPH,TIPS and SED were more effective in controlling rebleeding than ET+NSBB,but survival rates were not significantly different among the three groups.Mortality was significantly correlated with rebleeding,HE and PVT.

Transcatheter therapies for resistant hypertension: Clinical review

Resistant hypertension(RHTN) is a commonly encountered clinical problem and its management remains a challenging task for healthcare providers. The prevalence of true RHTN has been difficult to assess due to pseudoresistance and secondary hypertension. Atherosclerotic renal artery stenosis(RAS) has been associated as a secondary cause of RHTN. Initial studies had shown that angioplasty and stenting for RAS were a promising therapeutic option when added to optimal medical management. However, recent randomized controlled trials in larger populations have failed to show any such benefit. Sympathetic autonomic nervous system dysfunction is commonly noted in individuals with resistant hypertension. Surgical sympathectomy was the treatment of choice for malignant hypertension and it significantly improved mortality. However, postsurgical complications and the advent of antihypertensive drugs made this approach less desirable and it was eventually abandoned. Increasing prevalence of RHTN in recent decades has led to the emergence of minimally invasive interventions such as transcatheter renal denervation for better control of blood pressure. It is a minimally invasive procedure which uses radiofrequency energy for selective ablation of renal sympathetic nerves located in the adventitia of the renal artery. It is a quick procedure and has a short recovery time. Early studies in small population showed significant reduction in blood pressure. The most recent Symplicity HTN-3 study, which is the largest randomized control trial and the only one to use a sham procedure in controls, failed to show significant BP reduction at 6 mo.

Portal hypertension: Imaging of portosystemic collateral pathways and associated image-guided therapy

Portal hypertension is a common clinical syndrome, defined by a pathologic increase in the portal venous pressure. Increased resistance to portal blood flow, the primary factor in the pathophysiology of portal hypertension, is in part due to morphological changes occurring in chronic liver diseases. This results in rerouting of blood flow away from the liver through collateral pathways to low-pressure systemic veins. Through a variety of computed tomographic, sonographic, magnetic resonance imaging and angiographic examples, this article discusses the appearances and prevalence of both common and less common portosystemic collateral channels in the thorax and abdomen. A brief overview of established interventional radiologic techniques for treatment of portal hypertension will also be provided. Awareness of the various imaging manifestations of portal hypertension can be helpful for assessing overall prognosis and planning proper management.

TREATMENT OF 47 PATIENTS OF SENILE HYPERTENSION BY KANGLE MAGNETIC THERAPY

The authos used magnetic therapy to treat 47 patients with senile hypertensionand obtained a good therapeutic result with an effective rate of 80. 9%, 15 cases apparently improvedand 23 cases improved. The magnetic therapy is a mild treatment, but may produce a stable therapeu-tic effect without any side effect.

Clinical Effects of the Qi-acupuncture Therapy of TCM on Portal Hypertension

Objective:To explore the effective prevention and treatment of portal hypertension(PH).Methods:A total of 220 patients who came to our hospital from March 2015 to October 2018 were treated.They were randomly divided into the treatment group and the control group,each with 110 cases.Before treatment,there was no significant differences in age,sex,clinical symptoms,signs,laboratory tests and color Doppler ultrasound related examinations between the 2 groups(P>0.05).Among them,the treatment group on the basis of traditional Chinese and Western medicine treatment in our hospital,the Qi-acupuncture therapy of TCM was added.The extra meridian acupoints along with acupoints were selected.The control group received conventional treatment with traditional Chinese and Western medicine in our hospital.Results:There were significant differences in clinical symptoms,signs and chemistry between groups after treatment(P<0.01).There were significant differences in test,color ultrasound related examination and so on(P<0.01).Those in the treatment group was significantly better than the control group(P<0.01).Conclusion:On the basis of the Qi-acupuncture therapy of TCM,selecting extra meridian acupoint and acupoints can effectively treat PH.

The clinical features and effects with target therapy for post splenectomy pulmonary hypertension

Objective To analyze the clinical features and effects of target therapy of post splenectomy pulmonary hypertension, and improve the diagnosis and treatment of the disease.Methods Clinical data of 18 patients with post splenectomy pulmonary hypertension admitted to our hospital from October 2006 to March 2017 were systematically reviewed.

Non-pharmacological therapy of TCM for the treatment of essential hypertension

Non-pharmacotogicat treatment is an important means to control hypertension, with many advantages such as tow cost, tess medication, stable btood pressure, tess compHcations, and improved prognosis. This article reviews the research progress of non-drug treatment of hypertension in Chinese medicine in the past five years, and evaluates traditional Chinese medicine such as TCM Qigong, Wuhuo opera, Ba Duanjin and Taijiquan, and Chinese medicine acupuncture, moxibustion, massage, apptication, acupoint embedding and other traditional Chinese medicine. The effect of external treatment in hypertension control provides guidance for non-drug therapy to control hypertension.

Clinical effect of four-dimensional therapy on patients with cervical hypertension

Objective:To research the effect of four-dimensional therapy on the clinical effect (symptoms, blood pressure, and pain degree), the changes of blood rheology and arterial (left vertebral artery (LVA), right vertebral artery (RVA), and basal artery (BA)) hemodynamics (average cerebral blood flow (Vm), resistance index (RI), pulsatility index (PI)) on patients with cervical hypertension. Method: Selecting 120 patients (Department of Orthopaedics, the second Affiliated Hospital to Liaoning University of Chinese Medicine, 2012.6-2018.10) with cervical hypertension, then they were divided into observation group (n=60) and control group (n=60). The control group were given enalapril meleate (amlodipine besylate) +conventional therapy (acupuncture treatment and massage), the observation group were given four-dimensional therapy on the basic of control group, they were treated 3 weeks. The primary endpoints were the changes from baseline to week 3 in the symptoms and function were scored using the Evaluation Scale for Cervical Vertigo, the secondary endpoints were changes from baseline to month 3 in the artery hemodynamics (Vm, RI, and PI) in the BA, LVA, blood rheology, and RVA. At last, assessing the pain degree through visual analog scale (VAS), measuring the blood pressure, and accessing the clinical effect.Results:The score of vertigo in the two groups had no statistical significance before treatment, the score of vertigo in the two groups were higher than pretherapy, and had statistical significance, and the score in the observation group were higher than control group, and had statistical significance. The hemodynamics (Vm, RI, and PI) in the artery (BA, LVA, and RVA) had no statistical significance in the two groups before treatment, and the hemodynamics (Vm) in the artery (BA, LVA, and RVA) were higher than pretherapy, and had statistical significance, the hemodynamics (Vm) in the artery (BA, LVA, and RVA) of observation group were higher than control group, and had statistical significance. The hemodynamics (RI and PI) in the artery (BA, LVA, and RVA) were lower than pretherapy, and had statistical significance, the the hemodynamics (Vm) in the artery (BA, LVA, and RVA) of observation group were lower than control group, and had statistical significance. The blood rheology had no statistical significance in the two groups before treatment, the blood rheology were lower than pretherapy, and had statistical significance, the blood rheology of observation group were lower than control group, and had statistical significance. The degree of VAS had no statistical significance in the two groups before treatment, the degree of VAS was lower than pretherapy, and had statistical significance, the degree of VAS of observation group were lower than control group, and had statistical significance. The blood pressure (systolic pressure and diastolic pressure) had no statistical significance in the two groups before treatment, the blood pressure (systolic pressure and diastolic pressure) were lower than pretherapy, and had statistical significance, the blood pressure (systolic pressure and diastolic pressure) of observation group were lower than control group, and had statistical significance, the clinical effect in the observation group were higher than control group, and had statistical significance.Conclusions:Giving four-dimensional therapy can improve the blood pressure and relieve the pain through improving blood rheology and hemodynamics in the artery in the patients with cervical hypertension.

Function prognosis promotion and relative factor analysis of subhypothermia therapy to hypertension cerebral hemorrhage patients

Objective To study the effect of sub-hypotherm ia on hypertension cerebral hemorrh age and content of serum endothelin(ET).Method87hypertension cerebral hemorrhage cases were divided into subhypothermia group and control group randoml y,patients in subhy-pothermia group received subhypoth ermia therapy in NICU 6hours after operation or hospitalization.We tested serum ET content with specific radioimmunoassay method 24hours,72hours and 3weeks after therapy,and compared them with control group.Result ET content of two groups increased apparently after 24hours,ET of subhypothermia group was lower than that of control group(P <0.01);it recovered 3weeks after therapy.Conclusion Subhypothermia techniques can appa rently improve prognosis of hyperte nsion cerebral hemorrhage patients,serum ET level may be one important index to evaluate severity of hypertension cerebral hemorrhage.

Efficacy of scraping therapy on blood pressure and sleep quality in stage Ⅰ and Ⅱ essential hypertension: A systematic review and meta-analysis

Background Scraping therapy is widely used in treating stage I and II essential hypertension in China.However,there has been no systematic evaluation of the efficacy of scraping therapy on blood pressure and sleep quality in stage I and II essential hypertension.Search strategy Seven electronic databases(PubMed,Scopus,Cochrane Library,Web of Science,EBSCO,China National Knowledge Infrastructure and Wanfang Data electronic databases)were searched from inception to December 2022.Based on the principle of combining subject words with text words,the search strategy was constructed around search terms for“scraping therapy,”“scraping,”“Guasha,”“Gua sha,”“hypertension,”and“high blood pressure”during the database searches.Inclusion criteria Randomized controlled trials(RCTs)were included if they recruited patients with stage I and II essential hypertension and included a scraping therapy intervention.The intervention group received antihypertensive drugs and scraping therapy,while the control group only took antihypertensive drugs.Data extraction and analysis Review Manager 5.4.0 and STATA 15.1 were used to enter all the relevant outcome variables to conduct the meta-analysis.The quality of the selected RCTs was assessed using the PEDro scale.The sensitivity analysis was carried out by iteratively excluding individual studies and repeating the analysis to determine the stability of the findings and identify any studies with greater influence on the outcome.Subgroup analysis was performed to find the source of heterogeneity.Funnel plots were used to evaluate the publication bias of included studies.Results Nine RCTs including 765 participants were selected.Meta-analysis showed that scraping therapy combined with medication had an advantage over the use of medication alone in lowering systolic blood pressure(mean difference[MD]=?5.09,95%confidence interval[CI]=?6.50 to?3.67,P<0.001)and diastolic blood pressure(MD=?2.66,95%CI=?3.17 to?2.14,P<0.001).Subgroup analysis showed that scraping therapy improved sleep quality in middle-aged patients with hypertension,but the efficacy was better in elderly patients(MD=?7.91,95%CI=?8.65 to?7.16,P<0.001)than in middle-aged patients(MD=?2.67,95%CI=?4.12 to?1.21,P=0.0003).Conclusion The available evidence indicates that scraping therapy has significant effects on patients with stage I and II hypertension,and it improves sleep quality for elderly patients with hypertension better than for middle-aged ones.Scraping therapy can be an adjunctive treatment for stage I and II essential hypertension.However,further high-quality studies are needed to verify its effectiveness and the best therapeutic strategies.

Potential impact of specific therapy on pregnant women with pulmonary arterial hypertension without cardiac shunt:a descriptive study in northern China

Background:Pregnancy in women with pulmonary arterial hypertension(PAH)is a fatal condition,despite the effectiveness of PAH-specific therapies.The coverage status and effect of specific therapies in pregnant patients with PAH without cardiac shunts in China remain unclear.To investigate this issue,we conducted a multicenter retrospective study in northern China.Methods:The study included 85 patients who were admitted to 4 clinical centers in Shandong Province between October 2010 and August 2020.Maternal endpoint events included(1)maternal death and/or(2)major adverse cardiac events,both occurring during pregnancy or within 6 weeks postpartum.Results:Although the overall mortality rate was encouraging(11.8%),the number of patients receiving PAH-specific therapies was extremely low(28.2%).Moreover,only 15.3%of patients received adequate duration of PAH-specific therapy(≥4 weeks)before delivery,and this subgroup showed the lowest major adverse cardiac events rate(7.7%)compared with that in the untreated(19.7%)and short-time treated groups(<4 weeks;54.5%).Conclusion:Pregnant patients with PAH without cardiac shunts face significantly increased mortality risks.Short-term PAH-specific therapy does not guarantee favorable maternal outcomes.Prepregnancy screening,early identification,and timely intervention are expected to improve maternal outcomes in pregnant women with PAH.

Pediatric hypertension: An update on a burning problem

A large number of adults worldwide suffer from essen-tial hypertension, and because blood pressures(BPs) tend to remain within the same percentiles throughout life, it has been postulated that hypertensive pressures can be tracked from childhood to adulthood. Thus, chil-dren with higher BPs are more likely to become hyper-tensive adults. These "pre-hypertensive" subjects can be identified by measuring arterial BP at a young age, and compared with age, gender and height-specific references. The majority of studies report that 1 to 5% of children and adolescents are hypertensive, defined as a BP > 95th percentile, with higher prevalence rates reported for some isolated geographic areas. However, the actual prevalence of hypertension in children and adolescents remains to be fully elucidated. In addition to these young "pre-hypertensive" subjects, there are also children and adolescents with a normal-high BP(90th-95th percentile). Early intervention may help pre-vent the development of essential hypertension as they age. An initial attempt should be made to lower their BP by non-pharmacologic measures, such as weight re-duction, aerobic physical exercise, and lowered sodium intake. A pharmacological treatment is usually needed should these measures fail to lower BP. The majority of antihypertensive drugs are not formulated for pediatricpatients, and have thus not been investigated in great detail. The purpose of this review is to provide an up-date concerning juvenile hypertension, and highlight recent developments in epidemiology, diagnostic meth-ods, and relevant therapies.

Clinical management of portopulmonary hypertension

BACKGROUND: Portopulmonary hypertension (PPH) is defined as the development of pulmonary arterial hypertension associated with increased pulmonary vascular resistance complicated by portal hypertension, with or without advanced hepatic disease. In spite of the relatively rare prevalence, the clinical implications of PPH are significant. It has high perioperative morbidity and mortality. This review is an update of current pathogenesis, diagnosis and therapy of PPH. DATA SOURCES: An English-language literature search was conducted using PubMed (1980-2006) on portopulmonary hypertension. RESULTS: Echocardiographically identified patients with elevated pulmonary artery systolic pressure (>50 mmHg) receive right heart catheterization. Epoprostenol (prostacyclin), a potent pulmonary and systemic vasodilator with anti-platelet aggregating activity, and bosentan, an endothelin receptor antagonist, have so far proven beneficial to patients with PPH. CONCLUSIONS: After an accurate diagnosis of PPH treatment should (at a minimum) focus on reduction of mean pulmonary arterial pressure to less than 35 mmHg prior to orthotopic liver transplantation. However, orthotopic liver transplantation currently remains the only therapy to resolve PPH.

Hypertensive-Nimodipine Therapy for Middle Cerebral Artery Vasospasm after Resection of Glioblastoma Multiforme: A Case Report and Literature Review

Delayed cerebral ischemia (DCI) due to post-brain tumor resection vasospasm is an often unrecognized yet debilitating complication. We present a patient with DCI after the resection of glioblastoma multiforme (GBM). To our knowledge, this is the first report on DCI after GBM resection. A 52-year-old female patient with headache for one month underwent subtotal resection of a left temporal GBM encasing the proximal middle cerebral artery (MCA). She was well during the immediate postoperative period but developed right upper limb dense monoparesis on postoperative day four with computed tomographic angiography confirming left MCA vasospasm. Symptoms were significantly alleviated with weeklong hypertensive therapy and nimodipine administration;however they recurred soon after cessation of treatment. A high index of clinical suspicion is needed for the diagnosis of post-tumor resection DCI. Any new postoperative neurological deficit that cannot be explained by hemorrhage, seizures or infection should be expeditiously investigated by angiography or transcranial Doppler sonography. Prompt initiation of hypertensive and nimodipine therapy can possibly reverse neurological deficit. Treatment should be guided by Doppler, angiographic or perfusion imaging studies and not by clinical improvement alone.