| E.H.S.
EXECUTIVE BOARD: President
: M. M. Ibrahim, MD
Vice President : H. E. Attia, MD
Secretary : H. Rizk, MD
Treasurer : W. El Aroussy, MD
Members :
A. M. Hassaballa, MD
S. El-Tobgy, MD
O. Khashaab, MD
M. M. Gomaa, MD
M. S. Mokhtar, MD
|
EDITORAL
COMMITTEE:
Editor
: M. Hamed, MD
Assistant Editors : A.M. El-Keiy, MD
A. El-Etriby, MD
M. El Ramly, MD
H. Gobran, MD
W. El Naggar, MD |
PRESIDENT'S
MESSAGE:
PHYSICIAN
EDUCATION-AN IMPORTANT GOAL OF THE SOCIETY
One
of the important goals of the Egyptian Hypertension
Society is to help improve the standard of medical service
in the community through physician education. For a
number of different reasons, the level of medical education
in our country is less than optimum and this is particularly
obvious in the area of hypertension. Deficient medical
curriculum and lack of hospital training generate physicians
who lack both the basic skills and elementary knowledge
in hypertension diagnosis and management.
The
Egyptian Hypertension Society, aware of these defects
started a National Physician Education Program which
includes the organization of teaching courses in different
parts of the country and the preparation and distribution
of educational teaching material. Two teaching courses
were organized, the first was in Port Said in April
and the second was in Alexandria in June of this year.
Each course consisted of formal lectures, practical
session, discussions, an evaluation test and certification.
Hypertension case studies were added to the program
in the Alexandria Meeting.
These
courses are directed to the general practitioner, internists
and junior staff, providing elementary and practical
knowledge in the field of hypertension. Subjects discussed
included definition of hypertension, laboratory evaluation,
modern antihypertensive therapy, indications and follow
up of pharmacological intervention, hypertensive emergencies
and patient compliance.
In
December 1995, the Society will organize its First Advanced
Course in Hypertension under the leadership of Prof.
M. Sherif Mokhtar and Prof. Hussein Rizk. This advanced
course will discuss modern trends in hypertension including
molecular biology, endocrinal hypertension, target organ
damage and difficult case studies. A distinguished international
faculty will participate and lecture at this meeting.
Another educational area is the printing by the Society
of a small booklet for physicians, detailing the recommended
steps for accurate Blood pressure measurement. This
booklet will be available in August 1995.
The
Society is also planning a number of policy and consensus
meetings in order to formulate general guidelines for
diagnosis and management of hypertension in Egyptians.
The first of these policy sessions will be held during
the coming December 1995 Meeting during the Advanced
Course.
Finally,
the current Egyptian Hypertension Society Newsletter
under the guidance of the Editor Prof. Mohamed Hamed
will help in the education program through publication
of editorials, review articles and abstracts of world
literature. These different activities underscore the
important role of the Society in improving the standard
of medical knowledge among Egyptian physicians.
M.
Mohsen Ibrahim, M.D.
Professor
of Cardiology - Cairo University
President of the Egyptian Hypertension Society
Editorial
ALTERED
VASCULAR INTEGRITY IN ESSENTIAL HYPERTENSION
By
EBTIHAG HAMDI, M.D.
Prof. of Cardiology, Alexandria University
Changes
in vascular integrity can have a causal role in initiating
and perpetuating the hypertensive state. This was shown
by recent studies demonstrating markedly increased release
of prostacyclin in early stages of hypertension, and
high endothelin concentrations in borderline hypertensive
men. It was also found that endothelial dysfunction
can be primary, as antihypertensive therapy does not
restore the impaired endothelial dependent vascular
relaxation in hypertensive patients contrary to animal
experiments, where normalisation of blood pressure can
restore such impairment.
Meanwhile,
increased shear forces created by elevated pressure
can induce endothelial changes in the form of dehiscence
and malfunction of endothelial cells. This is evidenced
in the veins, which are known to be less distensible
in hypertension, when they exhibit plaquing once subjected
to the high arterial pressure as in saphenous vein grafting
in coronary bypass surgery. Vascular wall changes, through
angiotensin II, comprise hypertrophy of smooth muscle
cell layer of large vessels with increased collagen.
Such structural changes, with subsequent vasoconstriction
and remodelling of resistant vessels, lead to increase
in resistance.
Hypertension
can produce intimal plaques (indirect risk) leading
to lumen narrowing of big arteries, while weakening
of the media (direct risk) can occur in certain arteries
e.g. cerebral arteries and aorta.
Coronary
Arteries:
The
coronary arteries can be involved either through increased
reactivity producing spasm, or through endothelial dysfunction
with atheroma formation. Atheroma can produce total
vasconstriction (1). Coronary syndromes are more common
in hypertensives with left ventricular hypertrophy showing
more aggravation of atherosclerosis, and a three fold
increase in incidence of silent myocardial infarction
which is more complicated and extensive. It was shown
that 20-30% of asymptomatic hypertensives have significant
coronary artery disease. With left ventricular hypertrophy,
there is an increase in coronary vascular resistance
and decreased coronary reserve.
An
upward shift of the lower range of coronary flow autoregulation
occurs, i.e. the point of exhaustion of coronary reserve
is shifted to a higher perfusion pressure making the
myocardium vulnerable to hypotensive responses. There
is also a loss of the normal flow-mediated dilatation.
Thirty-eight to fifty-five percent of sudden coronary
deaths occur in hypertensives, whereas the figures go
up to 40-68% if hypertrophy coexists.
Cerebral
Arteries:
Atherothrombotic
infarctions and their recurrence are more in hypertensives
than in normotensives, while intra cranial bleeding
correlates more with LV hypertrophy. It was also found
that 20% of cases with intracerebral hemorrhage are
hypertensives in contrast to 1 % being normotensive.
The function of the normal endothelium is crucial as
it limits the response to catecholamines, prevents atheroma
formation, and assures a balance between relaxants and
constrictors.
Shear
forces and the endothelium:
The
vessel wall is subjected to two primary hemodynamic
forces; the biaxial tensile stress and the fluid shear
stress. As a responsre to shear stress there is release
of ED RFs and endothelium dependent hyperpolarising
factor. There is also release of prostacyclin (PGI 2)
and the potent vasoconstrictor endothelin. The rate
of pinocytosis and rate of low density lipoprotein binding
and internalisation is also increased. Shear forces
have also an effect on the expression of growth factors.
Endothelium-dependent
vasodilatation:
This
can be triggered by acetylcholine, adrenergic receptor
agonists and calcitonin gene-related peptide. It can
also be flow mediated. The release of EDRFs is triggered
by shear stress, a number of autacoids as histamine,
bradykinin, noradrenaline, substance P, platelet products,
serotonin, thrombin and calcium ionophore A23187.
Nitric
Oxide (NO):
Its
release is possible by NO synthase, L-arginine, nitrates,
Nanitroprusside and bradykinin agonists. ACEI and Ca
antagonists can enhance its production (3). NO causes
relaxation of arteries, decreases inotropism, has favorable
effects on platelets and leucocytes, and decreases SMC
growth. Its inhibition results in increased blood pressure
in humans and in animals.
Endothelium-Derived
Hyperpolarising Factor (EDHF):
It
is a K-channel opener which tends to act mainly on smaller
blood vessels in contrast NO which is more active on
large arteries. Its release is controlled by cytosolic
calcium and is inhibited by calmodulin antagonists.
Mediation
of vascular contractions:
A
possible little role of endothelium- derived contracting
factor is postulated. Vasoconstriction can occur through
NO withdrawal, superoxide anions, endoperoxides, cyclooxygenase,
stretch, acetyl choline, serotonin, platelet products
and Ca ionophore A 23187. Endothelin-1 is enhanced by
thrombin, All, epinephrine, arginine vaso pressin, tumour
growth factor B, phorbolester, interleukin-1, and Ca
ionophore A 23187, while NO and prostacyclin are antagonists.
Endothelin-1 produces a potent long standing vasoconstriction
and potentiates the response to norepinephrine. It is
a positive inotropic substance that directly activates
Ca channels. It can also produce EDRF and prostacyclin
through endothelial activation.
Influence
of antihypertensive drugs on coronary events versus
cerebral strokes:
The
poor results of antihypertensives in diminishing the
incidence of coronary events may be due to failure to
reverse atherosclerosis, metabolic side effects of the
drugs, reduction of myocardial metabolic activity and
hence less vasodilating materials. Marked reduction
in blood pressure may disturb coronary autoregulation
especially in the presence of LVH.
Drugs
with favourable effects on the endothelium:
ACE
inhibitors can be beneficial as they decrease All production
and hence limit its hemodynamic stresses, while through
antagonising bradykinin degradation they can enhance
EDRF. They can also limit vascular hypertrophy in big
arteries with improvement of distensibility and remodelling.
Calcium antagonists have also favourable effects on
medial hypertrophy and hyper-reactivity with a decrease
in wall lumen ratio. They enhance EDRF release and improve
compliance. They also attenuate free radical formation
(2). Thus, the vascular endothelium plays an integral
role in the pathophysiologic disturbances of the hypertensive
state.
REFERENCES:
1.
Badawi H. (1992): Hypertension and ischemic heart disease
(Editorial). Egyptian Heart Journal 34:7.
2. Luscher TF, Yang, Z. W. Kiowski Linder, L. Dohi.
Y. (1992): Endothelin-induced vasoconstriction and calcium
antagonists. J. human Hypertension, 6 (suppl.2): 53.
3. Vanhoutte PM, Boulanger CM, Illiano SC, Nagao T,
Vidal M, MomboulijV. (1993): Endothelium-dependent effects
of converting-enzyme inhibitors. J. Cardiovasc Pharmacol.
22, (suppl 5)10.
4. Yanagisawa M, Kurihara H, Kimura S, Tomobe Y, Kobayashi
M, Mitsui T, et al. (1989): A novel potent vasoconstrictor
peptide produced by vascular endo thelial cells. Biochem
Biophys Res Commun, 161:859.
Ongoing
Research
HYPERTENSION
IN BLACK EGYPTIANS
RESULTS FROM THE EGYPTIAN NATIONAL
HYPERTENSION PROJECT (NHP)
Background:
Africans living in Western countries have high prevalence
and more severe degree of hypertension with early target
organ damage. Hypertension, however, is uncommon in
sub-saharan African blacks. The prevalence of hypertension
and the possible etiologic risk factors have not been
previously reported in black Egyptians.
Methods
and Population characteristics: Of 6733 subjects
(>25 ys) included in the NHP, there were 347 black
subjects. Their mean age was 48 ys, and 45.2% were males.
Most of them lived in Aswan governorate and the majority
(68.6%) were living in rural areas with poor sanitary
conditions. Illiteracy rate was 61.4% compared to 39.8%
in nonblack Egyptians and the majority belong to the
lower socioeconomic class. Unemployment, however, was
similar in blacks and nonblacks.
Prevalence
of hypertension: Hypertension was more prevalent
in black than nonblack Egyptians and more common in
females than males. Hypertension prevalence was similar
in urban and rural blacks. More severe hypertension
was encountered in blacks , 4.9% of blacks have DBP>
105 mmHg (2.9% in non blacks). The prevalence of hypertension
increases with age (6.5% between 25-34 ys and rises
to 73.6% between 65-74 ys). In blacks, 34.6% were aware
of being hypertensives, 18.1% were receiving treatment,
and only 2.4% were controlled (corresponding figures
for non blacks were 44.4%, 33%, 10.5%)
Hypertension
Risk Factors:
Obesity:
Egyptian blacks have lower BMI than non blacks. Obesity
was more common in black females than males. Obesity,
however, does not appear to play an important role.
Salt
Intake: 12 hrs urinary sodium excretion was high
in blacks than non blacks. However, there was no difference
between normotensives and hypertensives. Potassium excretion
was comparable in blacks and non blacks, normotensives
and hypertensives.
Education:
Hypertension was more prevalent in lower education groups
both blacks and non blacks.
Plasma
Insulin: p.2'st prandial plasma insulin levels were
higher in blacks than non blacks. The levels were higher
in hypertensive than nonhypertensive blacks. There was
no difference between non black hypertensives and normotensives.
Urinary schistosomiasis:
Positive history was present in 27.3% of normotensive
blacks and in 16.9% of normotensive non blacks and in
18.1% of hypertensive blacks and in 14% of hypertensive
non blacks.
Abstracts
of Local Literature
EFFECT
OF LEFT VENTRICULAR HYPERTROPHY ON ITS CONTRACTILE PERFORMANCE
IN HYPERTENSIVE PATENTS WITH END STAGE RENAL DISEASE
Gamal Aboul Nasr MD and
Adel Imam, MD
National Heart Institute, Cairo Egypt
Hypertension
(HTN) is a common clinical finding in patients (pts)
with end stage renal disease (ERD), while little is
known about development of left ventricular hypertrophy
(LVH) & its impact on LV systolic performance in
those pts. We studied 43 pts with ERD (24 Males and
19 females) with a mean age of 48 years (range 23-61)
using echocardiography. By defining HTN as BP of more
than 140/90 mmHg, 25 pts (58%) were found to have HTN
(group A), while the remaining 18 pts (42%) were normo
tensives (group B). Significant difference was found
between the two groups as regards systolic BP (180±21
mmHg in A vs 128±10 in B), diastolic BP (101±15 in A
vs 83±6 mmHg in B).
Interventricular
septum & posterior LV wall thickness in diastole
(1.57±0.3 cm in A vs 1 .2±0.3 & 12±0.4 in B respectively
(p<0.001 for both) LV mass index (293±89 gm/m2 in
A vs 186±46 in B p<0.01). However, both groups were
similar in LV internal dimensions in systole & diastole
(3.6±1.1 & 52±0.8 cm in A VS 3.4±0.8 & 5.1±
0.6 in B P=NS), LV% fractional shortening & ejection
fraction (27.7±9 & 53±15% in A VS 29±14 & 58±10
in B p=NS) as well as LV end systolic volume index (ESVI)
(39±27 mlIm2 in A VS 325± 17 in B; p=NS) and the ratio
of ESVI (2.2±0.9 in A VS 2.3±0.6 in B; p=NS).
These
results suggest that: 1) in hypertensive pts with ERD,
compensatory LVH is sufficeint to normalise wall stress
& maintain adequate forward flow similar to normotensive
pts. 2) concentric LVH in hypertensive pts with ERD
has no direct adverse effect on LV contractile performance
as assesed by the commonly used ejection phase or end
systolic indices.
(EHJ,
1995; 47:194)
RV
DIASTOLIC FUNCTIONS IN ESSENTIAL
HYPERTENSION
EI-Demerdash, F.M., Maaty
A.A., Shehab EI-Deen, M.B. Mansoura University Hospital
Department of Internal
Medicine,
(Cardiology Unit)
40
patients (pts), (36 males and 24 females) with essential
hypertension (EH) and with age rangeing from 35-55 years
as well as 15 normal age matched controls were subjected
to Doppler evaluation of right ventricular (RV) diastolic
function. Patients were subdivided into two groups according
to the echocardiographic criteria of left ventricular
hypertrophy (LVH); Group I included 20 patients with
LVH and group II included 20 patients without LVH.
Our
study revealed impaired RV diastolic function in patients
with EH this impairment was significantly higher in
group I when compared to group ll (p<0.001) The RVAWT
(right ventricular anterior wall thickness) increased
significantly in hypertensive patients, it was more
in group I when compared to group II. Also, our study
revealed significant increase in mean pulmonary artery
pressure in group I when compared to control group (p<0.001).
There
was a good positive correlation between RVAWT and IVST,
PLVWT, and LVM index in group with LVH and group without
LVH. These findings indicate that structural and functional
changes induced by EH are not limited to the left ventricle
but also involve the RV and pulmonary circulation.
(EHJ,
1995; 47:195)
LEFT
VENTRICULAR DIASTOLIC FUNCTION IN HYPERTENSIVE LEFT
VENTRICULAR HYPERTROPHY ECHODOPPLER VERSUS APEXCARDIOGRAPHIC
ASSESSMENT
Critical Care Centre,
Cairo University
The
diastolic function of left ventricle (LV) has been traditionally
assessed by the echo-Doppler technique in hypertensive
left ventricular hypertrophy (LVH). There has been recently
a renewed interest in the old technique of Apexcardiography
(ACG); a similarly non-invasive technique with less
need for special skills or expertise. In this study,
38 patients (35 males) with LVH due to mild hypertension
in 26, and moderate hypertension in 12, were subjected
to both techniques of Echo-Doppler and ACG in combination
with phonocardiography (PCG).In addition, 20 normal
males were included as controls.
Echo-Doppler
parameters included early filling wave (E-wave) velocity,
atrial filling wave (A-wave) velocity, A/E ratio, A-area
and A/E area ratio, where E and A areas represent the
time velocity intergrals of early and atrial filling
waves respectively. Other Echo-Doppler parameters studied
included: Acceleration time (from peak to end of E-wave),
average acceleration and deceleration of the early filling
phase (change of velocity per unit time), peak filling
rate (product of E-wave velocity multiplied by the mitral
valve cross-sectional area) and isovolumic relaxation
time (IRT-A2) calculated from aortic valve closure to
the beginning of the Doppler diastolic wave form of
the mitral flow.
Apexcardiographic
and phonocardiographic par ameters included: Apexcardiographic
A-wave duration, ratio of A-wave amplitude/total deflection
height (A/H ratio) ratio of rapid filling phase duration/total
diastolic duration (RFD/DD), isovolumic relaxation time
(IRT) and the corrected isovolumic relaxation time (IRTc).
Other ACG and PCG parameters studied included: P to
A-wave interval, S4 duration and P to S4 interval. Compared
to control subjects, Echo-Doppler criteria suggested
impairment of LV diastolic function in 63.15% of patients
with mild hypertension and 60.42% of those with moderate
hypertension versus 57.2% and 71% for both groups respectively
utilising ACG parameters.
In
conclusion: Impaired LV diastolic function due to
hypertensive LVH could be easily assessed by the simple
non-invasive technique of Apexcardiography. Comparsion
with Echo-Doppler technique revealed an almost equal
chance of diagnosing LV diastolic impairment using the
technique of Apexcardiography. This applied more significantly
to the moderately hypertensive LVH.
(EHJ,
1995; 47:197)
Forthcoming
Research
THE
EGYPTIAN MULTICENTER HYPERTENSION THERAPY PROJECT (EMHTP)
AIM
OF THE PROJECT:
1.
Set the standards for multi-center research in the field
of hypertension.
2. Test the efficacy and tolerability of different classes
of anti-hypertensive drugs.
3. Document the therapeutic advantage, or otherwise,
of ACE inhibitors and calcium channel blockers in terms
of prevention or delay of end organ damage in hypertensive
patients.
4. Establish, or otherwise, the cost-benefit justification
of some of the newer anti-hypertensive drugs.
GENERAL
FRAMEWORK:
The
project is composed of two phases:
A- Phase 1: aims at investigating the effect of
each of the following five drugs belonging to different
drug groups on the control of hypertension, as well
as their side ettect profile and patient compliance
in a population of patients with established mild to
moderate hypertension over a period of one year.
1.
chlorthalidone
2. Atenolol
3 Captopril
4 Methyl dopa
5. Nifodipine sustained release.
The
initial part of this phase will be a PILOT study that
aims at establishing the logistics and setting the standards
for the full scale multi-center trial. Six cardiology
centers (4 in Cairo and 2 in the Delta region) will
be invited to participate.
Each
center will recruit 50 patients with uncomplicated mild
to moderate hypertension (SBP> 140 mmHg & DBP:95-104
mmHg) Exclusion criteria include patients above 75 ys,
clinical heart failure, structural heart disease other
than concentric L.V.H., aortic aneurysm or dissection,
serious ventricular ectopy, history of syncope, significant
organ affections, pregnancy, lactation and history of
allergy to any of the trial drugs. All participants
are randomized to receive one of the above mentioned
five medications for a period of six months. The end
points for this part of the study are B.P. control (SB.P
< 160 & DBP <95) and/or side effects necessitating
drug withdrawal. B. Phase 11: aims at investigating
the effects using a long-acting ACE inhibitor (e.g.
enalapril, quinapril, ramipril) and a long acting primarily
vasodilator Ca channel blocker (e.g. amlodipine, nifedipine,
diltiazem) in a multi-center randomized controlled trial
against a standard antihpertensive regimen of proven
efficacy and acceptable side effect profile (e.g. atenolol
± low dose chorthalidone) in patients who could be treated
by any of these methods to examine differences in:
[a]
end organ status (kidney function, L V systolic &
diastolic function, muscle mass, myocardial ischemia,
carotid vertebral arterial changes and fundi).
[b] event rates (stroke, MI & renal failure) and
[c] Cardiovascular mortality by the end of a preset
trial time (3-5 years).
E.H.S
News & Calendar
*
Prof. Dr. Sherif EI-Tobgy has been nominated as a Member
of the Executive Board to replace Prof. Rashad Barsoum
in that capacity.
*
The Executive Board of the Egyptian Hypertension Society
in accordance with the stipulations in its Constitution
has extended Honorary Membership of the Society to a
distinguished faculty including high health authorities,
university staff, businessmen and media professionals.
The names of the faculty will be forthcoming in the
next issue of the Newsletter.
*
The First Issue (March 1995) of the Egyptian Hypertension
Society Newsletter has appeared in early April, and
was well received by both the Executive Board and Founding
Members, as well as Members of the Egyptian Society
of Cardiology and the Egyptian Medical Association.
The Executive Board has issued a word of thanks and
appreciation to the Editor and the Editorial Committee
of the Newsletter.
*
The Second Annual Meeting of the Egyptian Hypertension
Society will be held in Cairo in December 1996. Prof.
Mohamed Khairy Abdel-Dayem has been chosen by the Executive
Board as Chairman of the Organizing Committee for that
Meeting.
*
The committee for Media and Mass Communication of the
Society has issued a draft report with its plan for
the strategy of alerting both the public and the medical
profession to the dangers of hypertension and its sequelae.
The aim of the plan is to convey proper information
to physicians, medical students, patients and the laity
regarding hypertension. The report also suggests that
Members of the Hypertension Society and the mass media
including newspapers, TV & radio should all be utilized
to fulfill this aim. The report also suggests the recruitment
of health assistants and social workers to fill specified
jobs in this regard, even at a nominal honorarium.
*
The Teaching Course on Hypertension organized by the
Society and the Suez Canal Faculty of Medicine on April
13 th to 14 th 1995 in Port Said was very well received
and comprised the following subjects: Definition, Classification
and Methods of measurement of blood pressure; Clinical
Evaluation of the hypertensive patient; Laboratory Work-Up
of the hypertensive patient; Anti-hypertensive drugs
(part 1: diuretics, Beta-Blockers, sympatholytics),
(part 2: Calcium antagonists and ACE inhibitors); Hypertension
in special groups (pregnancy, elderly, children); risk
profile (non-pharmacologic management); Anti-hypertensive
therapy (when to treat? and how to monitor ?).
*
The 2 nd Teaching Course on Hypertension organised by
the EHS and Alexandria Faculty of Medicine was held
in Alexandria on June 1 st and 2 nd. The meeting was
very successful. It consisted of formal lectures, practical
sessions, discussions, an evaluation test and certification.
Also hypertension case studies were presented in addition
to the following subjects: definition of hypertension,
laboratory evaluation, modern anti-hypertensive therapy,
indications and follow-up of pharmacological interventions,
hypertensive emergencies and patient compliance.
*
An advanced Course in Hypertension is to be held by
the Egyptian Hypertension Society in Cairo from 13 th-15
th December, 1995. The course is intended for specialists
in the field of Medicine, Cardiology and Peadiatric
Cardiology. The course is under the chairmanship of
Prof. Sherif Mokhtar and Prof. Hussein Rizk and the
Secretary General is Dr. Hossam Kandil. For contacts
and correspondence with the Secretary General. P.O.
Box 136, Roda, Cairo, Egypt. Fax: 011 202 363 9895.
*
A Policy and Consensus Meeting will be held by the Egyptian
Hypertension Society in Aswan during the period from
Jan. 11th to 15th, 1996. A panel of Egyptian experts
has been selected to finalize the Society's policies
and guidelines for the management of hypertension in
Egypt. Working papers regarding all aspects of hypertension
will be prepared by the panelists and discussed at the
meeting.
*
A number of publications in the form of booklets have
been issued by the Society, some in Arabic and some
in English and are being distributed at present. One
booklet, sponsored by Zeneca Pharmaceuticals is headed
"What you should know about Blood Pressure".
Another booklet is a short resume of the main results
that have erupted from the Egyptian National Hypertension
Project.
CALENDAR
| Year |
Month |
Days |
Meeting |
Venue |
Correspondence |
| 1996 |
January |
25-27 |
21st
International Conference on Stroke and cerebral
circulation |
San
Antonio USA |
AHA,
Scentific and Corporate Meetings 7272 Greenville
Avenue, Dallas, TX75231, USA |
| 1996 |
January |
26-27 |
international
Workshop "Frontiers in Blood Pressure Measurement" |
Bad
Oeyenhausen Germany |
Dr.
Sigrid Glaichmann, Heart & Diabetes Center North
Rhine, Westphalia, P.O. Bcx 10036132503 Bad Oeyenhausen,
Germany. |
| 1996 |
February |
1-6 |
23rd
International Congress of Internal Medicine |
Manila
Philippine |
June
S. Aberilla Philippines The Society of Hypertension
Unit 33, Facilities Centre 548 Shaw Boulevard City
of Mandaluyong, Metro Manila Philippnes |
