Issue 1 - Issue 2

 

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 R. Barsoum, MD O. Khashaab, MD M.M. Gomaa,MD M.S.Mokhtar,MD

EDITORIAL COMMITTEE: Editor : M. Hamed, MD Assistant Editors : A. M. EI-Keiey, MD A. EI-Etriby, MD M.El Ramly,MD H. Gobran, MD W. El Naggar, MD

MESSAGE FROM THE PRESIDENT OF THE EGYPTIAN HYPERTENSION SOCIETY (LEAGUE):

Results from the Egyptian National Hypertension project (NHP) showed that Egypt has one of the highest prevalence rates of hypertension in the world. The weighted national estimate of the prevalence of hypertension in adult Egyptians is 26%. Furthermore, only 24% of hypertensives were receiving treatment, and 8% had their blood pressure controlled. The Egyptian Society of Cardiology concerned with preliminary results from the NHP approved in March 1992 a proposal presented by Dr. Mohsen Ibrahim, the principal investigator of the NHP, to establish the Egyptian Hypertension League (EHL) as a branch of the Egyptian Society of Cardiology.

A board of directors was elected in the same year. The goals of the League are: 1) To encourage research in the field of hypertension, 2) To develop hypertension education programs both for the public and the physicians. 3) To disseminate information about current trends in hypertension by organization of meetings, symposia and national conferences, 4) To plan and execute a nationwide campaign targeted to increase public awareness of the problem of hypertension, 5) To establish communication links with other national and international organizations and hypertension societies, help exchange information and encourage travel of scientists, speakers and young investigators.

A major accomplishment of the EHL was the organization of the First Pan Arab Conference on Hypertension in collaboration with the NHP and the US NHLBI. This conference was the first of its kind in the Arab world and Middle East with 950 participants from Egypt, Europe, USA and 14 Arab countries. The EHL also organized during December 7-9, 1994 its First National Scientific Meeting in the beautiful Red Sea resort city of Sharm El Sheikh-Egypt. To encourage young investigators, an award of 10.000 Egyptian pounds was given to the best works in the fields of clinical and of epidemiological hypertension research. The Founding Members of the Egyptian Hypertension League, approved in their recent meeting that it is time to recognize the League as an independent scientific organization under the name of the Egyptian Hypertension Society. A number of working groups and sub-Committees were established in order to fulfill the ambitious goals of the society.

These include the following Sub-Committees:
1. Membership & Credentials
2. Budget & Finance
3. Foreign & International Relations
4. Scientific Program
5. Media & Mass Communication
6. Publication-including the Egyptian Hypertension Newsletter.

M. Mohsen Ibrahim, M.D.
Professor of Cardiology-Cairo University
President of the Egyptian Hypertension League

Editorial

RETINOSCOPY AS AN INTEGRAL PART IN EVALUATING THE HYPERTENSIVE
BY
HASSAN H. KHALIL MD, PhD, FRCP, FACC
Prof. of Cardiology, Alexandria University

In an endeavor to encourage the practice of retinoscopy or fundoscopy, I shall try to emphasize the value of this process in the evaluation of hypertensive patients. The retinal arteries are the only vessels in the body that can be viewed with ease. Besides supplying the retina, they have the added importance of having a common origin with the cerebral arteries.

These arteries supply target organs of two extremely common diseases: Hypertension and Diabetes. An increase in systemic blood pressure would be directly reflected in increased capillary perfusion pressure were it not for the immediate homeostatic response of the retinal arteries. Narrowing of these vessels acts to insulate the capillary bed from the elevated arterial pressure.

ARTERIOSCLEROSIS:

In chronic hypertension the medial smooth muscle layer hypertrophies, later it becomes hyalinized with deposition of collagen. As the wall thickens the vessel takes on a burnished coppery luster, which later may become bright silver (Cu and Ag wiring). Interruption of the venous blood column at arterial crossings is early evidence of this process and the intensity of light reflex from these "old" arteries is increased.

COTTON-WOOL PATCHES:

These are almost always found within three disc diameters of the optic discs and have a feathery woolly character. lschaemia and oedema of the nerve fibre layer is almost certainly the cause of these spots, and their presence is usually indicative of severe hypertension.

HARD EXUDATES:

These are oedema residues that occur where the vessels become leaky. As the more watery component of the extravasation is absorbed, the lipid residues form hard, yellow waxy deposits. They may surround the leaky vessel in a circinate ring or may appear in the macula, radiating from the fovea as a macular "star". These exudates indicate a loss of vascular wall integrity and are associated with hypertension, diabetes, venous outflow obstruction and oedema.

RENTINAL HEMORRHAGE:

In advanced cases hemorrhage may occur in the inner retinal layers in a characteristic flame pattern.

PAPILLOEDEMA:

In severe accelerating hypertension the optic nerve head may become oedematous and is viewed as papilloedema.

GRADE	VASCULAR CRITERIA
Grade I	Mild to moderate narrowing of the retinal arteries with or without sclerosis.
Grade II	I + Cu or silver wiring Exaggerated light reflex
Grade III	II + Cotton wool patches, hard exudates and/or flame pattern hemorrhages
Grade IV	III + papilloedema

This grading system has been in widespread use and several studies suggest the degree of retinopathy and hence vascular changes to other target organs, is related to the severity and duration of hypertension. However, early elevations of B.P. may not affect the retinal vasculature, which should be reassuring to the patient. While the presence of sclerosis in an elderly subject may have a limited value. On the other hand, acute elevations of B.P. as in pheochromocytoma and eclampsia may be associated with papilloedema and non hemorrhagic reversible retinal detachment. In these cases retinoscopy may offer definitive diagnostic evidence. Naturally, interest in the retinal vasculature is shared between ophthalmologists and physicians.

During the last 25 years investigative ophthalmologists have achieved great advances in their studies of the retina and its vasculature.

LASER DOPPLER VELOCIMETRY:

Laser Doppler velocimetry was developed to determine the velocity of erythrocytes flowing in the retinal vessels by measuring the Doppler shift of the laser light scattered by moving red cells. At present, 25 years after its invention, the LDV technique has been refined and has produced a wide variety of clinically oriented re search. The fundamental principle of LDV is that a portion of the retinal vessels is illuminated by high mono chromatic laser light of frequency f. Light scattered by an erythrocyte moving within the vessel is shifted to frequency f. This shift is processed through an optical spectrometer then through a photomultiplier tube that will os cillate at the frequency of the laser shift. Laser Doppler velocimetry has been used to assess normal retinal blood flow as well as changes in duced by diseases and therapy, starting with Diabetes. Normal retinal blood flow is only 80 ± 18 uL/min. flow to the temporal side being 3 times that to the nasal side.

THE SCANNING LASER OPHTHALMOSCOPE:

Perhaps the most exciting laser diagnostic device to be introduced recently is the scanning laser opthalmoscope (SLO). This scanner used a laser to provide video images of the retina, retinal vessels and other intraocular structures. In 1991 Filzke and his associates were able to produce very highly magnified three dimensional images of the retinal vasculature including capillaries and cap illary flow. Another interesting example of progress in investigating the retinal vasculature is that of Jan Dancer and his associates who included ophthalmologists and physicians.

These workers reported a high level of RAS in the retinal pigment epithelium and choroid. They also found that Ang. II to I ratio was 3 times higher in the retinal pigment epithelium and choroid than in plasma. The function of the high level and ratio of Angiotensin II in the retina is not yet clear. It may regulate the retinal vascular tone. It would be interesting to find the level of RAS and Ang.

II to I ratio in hypertensive experimental animals as this may have a bearing on the therapeutic use of ACE inhibitors arid other antihypertensive agents. These are only two of the recent advances in clinically oriented research on retinal vasculature and ultrastructure. Such advances point to the need for further joint collaborative research between investigative ophthalmologists and cardiologists and underline the value of retinoscopy as an integral part in evaluating the hypertensive patient.

Abstracts of World Literature

REDUCTION IN BLOOD PRESSURE WITH A LOW SODIUM, HIGH POTASSIUM, HIGH MAGNESIUM SALT IN OLDER SUBJECTS WITH MILD TO MODERATE HYPERTENSION
BY
J M Geleijnse, J C M Witteman, A A A Bak, J H den
Breeijen, D E Grobbee

Objective: To examine the effect of a reduced sodium and increased potassium and magnesium intake on blood pressure.

Design: Randomised double blind placebo controlled trial.

Setting: General population of a suburb of Rotterdam.

Subjects: 100 men and women between 55 and 75 years of age with untreated mild to moderate hypertension.

Interventions: During 24 weeks the intervention group received a mineral salt (sodium: potassium: magnesium 8:6:1) and foods prepared with the mineral salt. Controls received common salt and foods.

Main outcome measure: Change in blood pressure.

Results: Complete follow up was achieved for 97 of the 100 randomised subjects. Systolic blood pressure (mean of measurements at weeks 8,16, and 24) fell by 7-6 mm Hg (95% confidence interval 4.0 to 11.2) and diastolic blood pressure by 3.3 mm Hg (0.8 to 5.8) in the mineral salt group compared with the controls, with a 28% decrease in urinary sodium excretion. Twenty five weeks after the study the difference in blood pressure between the groups was no longer detectable.

Conclusion: Replacing common sodium salt by a low sodium, high potassium, high magnesium mineral salt could offer a valuable non-pharmacological approach to lowering blood pressure in older people with mild to moderate hypertension.

BMJ 1994;309:436-40

IMPORTANCE OF OBESITY AND AGE TO THE CARDIAC STRUCTURAL AND FUNCTIONAL EFFECTS OF HYPERTENSION
BY
John S. Gottdiener, MD, EACC, Domenic J. Reda, MS,
Barry J. Materson, MD, Barry M. Massie, MD, FACC, Aldo Notargiacomo, BS, Robert J. Hamburger, MD, David W. Williams, MS, William G. Henderson, PHD, for the Department of Veterans Affairs Cooperative Study Group on Antihypertensive Agents.
Washington, D.C.

Objectives: The purpose of this study was to determine the effects of obesity and its interaction with age, race and the magnitude of blood pressure elevation in a large cohort of patients with mild to moderate hypertension and a high prevalence of left ventricular hypertrophy.

Background: Obesity, race and age each have important effects on the incidence and severity of hypertension and may contribute to the effects of blood pressure elevation on the cardiac manifestations of hypertension.

Methods: Left ventricular structure and function were assessed with two-dimensional targeted M-mode echocardiography in 692 men with mild to moderate hypertension (average blood pressure 153/100 mm Hg), and the data were compared in relation to obesity (determined from body mass index), age, race, blood pressure, physical activity, plasma renin activity, urinary sodium excretion, hematocrit, heart rate and serum lipids.

Results: Left ventricular hypertrophy was common (63% with increased left ventricular mass, 22% with left ventricular hypertrophy on the electrocardiogram [ECG]). On multivariable regression analysis, body mass index was the strongest predictor of left ventricular mass and magnified the slope relation of blood pressure to left ventricular mass.

Despite a greater prevalence of ECG left ventricular hypertrophy in blacks (31%) than in whites(10%), left ventricular mass and echocardiographic prevalence of left ventricular hypertrophy did not differ by race. However, septal, posterior left ventricular and relative wall thickness were greater in black than in white men.

Conclusions: Obesity is the strongest clinical predictor of left ventricular mass and left ventricular hypertrophy in men, even in those with mild to moderate hypertension of sufficient severity to be associated with a high prevalence of left ventricular hypertrophy. Moreover, independent effects of systolic blood pressure on left ventricular mass are amplified by obesity. Although race does not affect left ventricular mass or the prevalence of left ventricular hypertrophy, black race is associated with greater relative wall thickness, itself a predictor of unfavorable cardiovascular outcome.

j Am Coil Cardiol 1994;24:1492-8

DOES EARLY NUTRITION IN INFANTS BORN BEFORE TERM PROGRAMME LATER BLOOD PRESSURE?
BY
A Lucas, R Morley

Objective: To test whether nutrition early in infants' development programmes later blood pressure and whether the reported relation between low birth weight and later high blood pressure is due to poor nutrition or growth before full term.

Design: Prospective randomisation of preterm infants to early diets differing greatly in nutrient content in four parallel multicentre trials, with blinded follow up 7.5-8 years later.

Setting: Neonatal units at Cambridge, lpswich, King's Lynn, Norwich, and Sheffield. Subjects: 758 children weighing under 1850 g at birth. Main outcome measure: Blood pressure at age of 7.5-8 years.

Results: There were major differences in nutrient intake from randomised diets (preterm formula v standard formula and preterm formula v donor breast milk; in each case with or without mother's milk), but follow up showed no differences in later blood pressure. Individual subjects showed large variation in protein and energy in takes and in growth performance, including degrees of growth failure seldom seen in-utero, but these factors were also unrelated to later blood pressure.

Conclusion: Extremes of nutritional intake and growth performance in preterm infants do not programme later blood pressure at 7.5-8 years of age. These findings do not support the hypothesis that high blood pressure has early nutritional origins.

We suggest that the long term rise in blood pres sure reported in individuals who had low birth weight (at full term) is not, as previously speculated, due to poor fetal nutrition or growth as such.

BHJ 1994;3O9:3

Ongoing Research

THE EGYPTIAN NATIONAL HYPERTENSION PROJECT (NHP)

As investment in health care is an integral part of economic and regional development, and as hypertension is a growing public health problem throughout the Middle East, a team of Egyptian scientists from Cairo University headed by Prof. Mohsen Ibrahim and American Scientists from U.S.A. put their heads together and formulated a co-operative research under the name of the" Egyptian National Hypertension Project (NHP)". The project aims to survey a sample of the Egyptian population for high blood pressure, to study the complications of hypertension in the community, and to explore the role of environmental, racial and demographic factors in the development of hypertension in Egypt.

The project is being executed by the Egyptian team of scientists headed by Prof. Ibrahim in collaboration with experts at both the National Heart, Lung and Blood Institute (NHLBI) and the Johns Hopkins University.

The project was phased in 3 stages:

I. National Hypertension Survey.
II. National Prevention and Control of Hypertension in Egypt.
(High Blood Pressure Education Program for Physicians and the Public).
III. Evaluation of progress and Impact of the Program.

Only phase I has been implemented to date. It started in April 1991 & was successfully completed in November 1993. It was jointly funded by both U.S.A. ID. and the Egyptian Ministry of Health. Preliminary data from the NHP (see also abstracts of local literature in the Newsletter) show that Egypt has one of the highest prevalence rates of hypertension in the world, and that about 10 million Egyptians are suffering from high blood pressure.

These findings coupled with the fact that hypertension is a major risk factor for stroke, heart disease, renal failure, disability and premature death raises great concern about the future health of the population of Egypt, and highlights the need for programs of prevention and control of high blood- pressure (phase II of the N.H.P.) As the data of the NHP are being analysed and unraveled, it is anticipated that this project will have major impacts on future health policies in Egypt, and also impacts on international health policies throughout the Arab World. It is also believed that the project will serve as a model for the detection and prevention of chronic disease in economically developing countries.

Forthcoming Research

THE EGYPTIAN MULTICENTER HYPERTENSION THERAPY TRIAL (E.M.H.T.T.)

The conflict between pharmaceutical firms in for warding their newer classes and generations of antihypertensive drugs has reached a serious stage of competition.

The reasons are:

1- That newer drugs are always more expensive than older ones. 2- That drug research has nearly always been funded by pharmaceutical industry and not by Academic Centers. 3- That firms marketing newer drugs have started to claim benefits for their products that go beyond blood pressure control viz., prevention or delay of end-organ damage, particularly relating to the early histologic changes in the myocardium, blood vessels and kidneys. 4- That such claimed benefits have never really been documented in a randomised controlled "drug-versus- drug" trial.
This competition has reached a stage where patients could be easily trapped into taking unjustified life long expensive medications, while they could have been equally well treated and controlled by less costly drugs. Such feud has prompted two eminent scientists at Cairo University viz., Prof. Mohamed Sherif Mokhtar, Head of the Critical Care Center and Dr. Hussein Rizk Assistant Prof. of Cardiology and Secretary-General of the E.H.S. 10 formulate an "Egyptian Multi-Center Hypertension Therapy Trial (E.M.H.T.T.)" which is to be discussed and amended at the coming bimonthly meeting of the E.H.S. in February 1995. At the Meeting of January 12th, it was decided to widen the scope of the E.M.H.T.T. to include 10 investigators from 10 different centers all over Egypt, with Prof. Mokhtar as the principle investigator for the project.

Two plans have been suggested for the execution of the Trial:

1- A simple comparative study of different antihypertensive medications used in Egypt in which the drugs will be compared for safety, efficacy, side-effects and patient compliance over 1 year. The effects of age, gender and BMI on the antihypertensive response will also be scrutinized.
2- An elaborate long-term study of 5 years duration comparing cheap versus expensive antihypertensives in terms of prevention or delay of end-organ damage in hypertensive patients and establishment of the cost- benefit justification of newer classes of antihypertensive drugs, as well as the morbidity and mortality of hypertension in Egyptian patients.
An estimate of 1500 patients is considered necessary to achieve statistical significance and a mean follow up period of 3-5 years with 6 monthly clinical and laboratory evaluation is equally deemed necessary for prognostication from the results of the trial. It is presumed that drug costs will be covered by the pharmaceutical manufacturers of the medications used at no cost to the project itself.

 

E.H.S News & Calendar

E.H.S. NEWS

1- The EHL is becoming an independent Society under the name of the "Egyptian Hypertension Society (EHS)." This decision has been approved by a majority vote of the founding Members in their meeting on January 12 th 1995. In this regard it was thought better to start the Newsletter with the name EHS rather than writing EHL and then having to change the name again in the next issue when the society is due to be recognized as such. The official office of the society will be for the time being at its current address with the N.H.P.
2- A number of non-medical members of the Society have been nominated for Honorary Membership at the Meeting of January 12th, and it was left to the President to contact them and acquire their approval. Their names will soon be forthcoming.
3- One of the salient accomplishments of the Egyptian Hypertension League was the organization of the 1st Pan-Arab conference on Hypertension in collaboration with the N.H.P. and the U.S. NHLBI. This conference was the first of its kind in the Arab World and the Middle East with 950 participants from Egypt, Europe, and 14 Arab countries. It took place at the Marriot Hotel, Cairo, Egypt on December 6-8th 1993.
4- The 1st National Scientific Meeting of the E.H.S. was organized during December 7-9 th, 1994 in the beautiful Red Sea Resort City of Sharm El Sheikh Egypt.
It was also attended by 750 participants who enjoyed both the valuable exchange of knowledge, ideas and innovative research, as well as the charm and beauty of the locality at Sharm El Sheikh.
5- The E.H.S. Executive Board and founding members decided to make a yearly Young Investigators Award to be presented to the best communication delivered during the Annual Scientific Meeting and has appointed an Awards Committee under the chairmanship of Prof. Hassan H. Khalil of Alexandria University, and membership of Prof. Khairy Abdel Dayem of Am-Shams University, Prof. Sherif Mokhtar of Cairo University and Prof. Mokhtar Gomaa of Azhar University. The 1994 Award of LE 10,000 was donated by Zeneca Pharmaceutical Company.
The following 2 young investigators were chosen by the Committee to share the Award:

Prof. Hassan H. Khalil

Prof. Khairy Abdel Dayem

Prof. M Sherif Mokhtar

Prof.M Mokhtar Gomaa

(a) Dr. Mahmoud El Badry for his communication entitled "Depolarization and Repolarization abnormal ities in left ventricular hypertrophy: prevalence and prognostic implications".
(b) Dr. Sherif M. Helmy for his communication entitled Racial differences in left ventricular mass among hypertensive Egyptians"
6- The 3rd Pan-Arab Conference on Hypertension for the year 1997 has had 2 offers for its accommodation, one from Tunisia (Prof. Ben Maiz) and the other from Morocco (Prof. Shraibi) both of whom have kindly volunteered to organize and host the Conference.
* The second Pan-Arab Conference is to be held in Beirut, Lebanon (see Forthcoming Meetings of the News letter).
7- The 2nd Scientific Meeting of the EHS is due to take place in Cairo in December 1996.
8- Regular 2 monthly scientific meetings are due to take place throughout 1996. A scoring system has been developed and member's opinions will be registered to assess the quality of the scientific presentation. The best presentation of the year will be acknowledged in January 1996 with a certificate of excellence in recognition.

CALENDAR

FORTHCOMING CONGRESSES, CONFERENCES AND SYMPOSIA

Year	Month	Days	Meeting	Venue	Correspondence
1995	April	24-28	Second Asian - Pacific Symposium on ACE Inhibition & Other Inhibitors of the Renin-Angiotensin System	Beijing, China	Gardiner-CaIdwell Communications Ltd, The Old Ribbon Mill, Pitt Street Macclesfield, SK 11, 7PT, Cheshire, UK
1995	June	9-12	7th European Meeting on Hypertension	Milan, Italy	Prof. A. Zanchetti Centro di Fisiologia Clinica eIpertensione-Universita di Milano Ospedale Maggiore Via F.Sforza, 35,20122 Milan, Italy
1995	July	23-26	2nd Pan- Arab Congress of Hyper tension	Beirut Lebanon	Dr. Adil E.Birbari American University of Beirut, Medical Center P.O. Box 1136044 Beirut, Lebanon