Abstract-The role of spironolactone in resistant hypertension management is unclear. The aim of this prospective trial was to evaluate the antihypertensive effect of spironolactone in patients with true resistant hypertension diagnosed by ambulatory blood pressure monitoring. A total of 175 patients had clinical and complementary exams obtained at baseline and received spironolactone in doses of 25 to 100 mg/d. A second ambulatory blood pressure monitoring was performed after a median interval of 7 months. Paired Student t test was used to assess differences in blood pressure before and during spironolactone administration, and multivariate analysis adjusted for age, sex, and number of antihypertensive drugs to assess the predictors of blood pressure fall. There were mean reductions of 16 and 9 mm Hg, respectively, in 24-hour systolic and diastolic blood pressures (95% CIs: 13 to 18 and 7 to 10 mm Hg; PϽ0.001). Office systolic blood pressure and diastolic blood pressure also decreased (14 and 7 mm Hg). Controlled ambulatory blood pressure was reached in 48% of patients. Factors associated with better response were higher waist circumference, lower aortic pulse wave velocity, and lower serum potassium. No association with plasma aldosterone or aldosterone:renin ratio was found. Adverse effects were observed in 13 patients (7.4%). A third ambulatory blood pressure monitoring performed in 78 patients after a median of 15 months confirmed the persistence of the spironolactone effect. In conclusion, spironolactone administration to true resistant hypertensive patients is safe and effective in decreasing blood pressure, especially in those with abdominal obesity and lower arterial stiffness. Its addition to an antihypertensive regimen as the fourth or fifth drug is recommended. (Hypertension. 2010;55:147-152.)Key Words: ambulatory blood pressure monitoring Ⅲ resistant hypertension Ⅲ spironolactone R esistant hypertension (RH) is a common clinical condition defined as the failure to control office blood pressure (BP) despite a treatment with Ն3 different classes of antihypertensive drugs in optimal dosages, ideally including a diuretic. 1 Previous surveys have shown prevalence ranges from 10% to Ϸ30%. 1 Although there is no consensus about the better therapeutic scheme for resistant hypertensive patients, in general, diuretics, angiotensin-blocking agents, calciumchannel blockers, and ␤-blockers are used as the first-line choices. However, there is a lack of evidence about the optimal choice of a fourth-or fifth-line antihypertensive drug, and in this context there has been increasing interest in the role of aldosterone antagonists, particularly spironolactone.The efficacy and safety of spironolactone in reducing BP were demonstrated Ͼ2 decades ago. 2 Over the past 15 years, after many reports had suggested that primary hyperaldosteronism is probably more common than it was regarded previously, 3,4 several studies have been dedicated to evaluate the spironolactone effect in patients with refractoriness to treatment, mo...

Abstract-The relation between left ventricular hypertrophy (LVH) and unfavorable cardiovascular prognosis may involve systemic inflammation and endothelial dysfunction/damage. The aim of this study was to investigate in a cross-sectional design the relationships of LVH with C-reactive protein (CRP) levels (a marker of systemic low-grade inflammation) and with microalbuminuria (a marker of glomerular endothelial damage) in 705 patients with resistant hypertension. At baseline, all were submitted to a laboratory evaluation including 24-hour urinary albumin excretion, 2D echocardiogram, and 24-hour ambulatory blood pressure monitoring. A total of 463 patients also had high-sensitivity CRP levels determined. LVH was defined as an indexed left ventricular mass Ͼ110 g/m 2 in women and Ͼ125 g/m 2 in men. Microalbuminuria was evaluated in 3 categories: low normal (Ͻ15 mg/24 hours), high normal (between 15 and 29 mg/24 hours), and abnormal (between 30 and 299 mg/24 hours). CRP was dichotomized at the median value (3.7 mg/L). Associations with LVH were examined after adjustment for all of the potential confounders by multivariate logistic regression. A total of 534 patients (75.7%) had LVH. After full adjustment, both abnormal microalbuminuria (odds ratio: 1.97; 95% CI: 1.04 to 3.73) and high CRP (OR: 1.76; 95% CI: 1.06 to 2.93) were independently associated with LVH occurrence. The high-normal albuminuria was associated with a borderline significant 46% increased chance of having LVH. Furthermore, the association between high CRP and LVH was observed exclusively in the subgroup with normal albuminuria. In conclusion, both systemic inflammation and endothelial damage were associated with LVH occurrence. These relationships offer insight into the pathophysiological mechanisms linking LVH to atherosclerosis and to increased cardiovascular morbidity and mortality. Key Words: cardiovascular risk Ⅲ C-reactive protein Ⅲ left ventricular hypertrophy Ⅲ microalbuminuria L eft ventricular hypertrophy (LVH) is a hypertensive target organ damage strongly predictive of future cardiovascular morbidity and mortality. 1 However, the pathophysiologic mechanisms underlying the evolution from LVH to cardiovascular event development are still unclear, but they may involve accelerated atherosclerosis 2 because of systemic inflammation and endothelial dysfunction. 3 C-reactive protein (CRP), a marker of chronic low-grade systemic inflammation, is a predictor of untoward cardiovascular prognosis, beyond traditional risk factors, in different populations. 4 Also, its levels are generally elevated in patients with hypertension, 5 and high CRP may even precede and predict the development of arterial hypertension. 6 Similarly, microalbuminuria (MA), a slight elevation of urinary albumin excretion rate (UAER), reflects endothelial dysfunction/damage at the glomerulus and possibly also systemically 7 and is a risk marker for renal damage and cardiovascular morbidity/mortality in diabetic patients, 8 in hypertensive individuals, 9 and in general popul...

In order to demonstrate how DEA modeling can be helpful for hospital performance assessments conducted in compliance with Brazil's Teaching Hospital Policy, a case study is presented of 31 general hospitals linked to Federal Universities. It considers data on assistance, teaching and research and the use of the IDEAL (Interactive Data Envelopment Analysis Laboratory) software as a tool for assessing their efficiency. Developed in Brazil, this unique software provides a three-dimensional view of the productivity frontier, for easier exploratory analyses and selection of pertinent variables, with a better understanding of the outputs of the model (multiplier and envelope) for specialists and decision-makers. As an example, a University Hospital benchmark is presented through outputs that take structural and regional input differences into consideration. This modeling also indicates the changes required in the inefficient units (alterations to input and/or /output vectors), setting forth recommendations on public financing based on quality/efficiency.