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 M. S. Mokhtar, MD S. EI-Tobgy, MD O. Khashaab, MD M. M. Gomaa, MD

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

PRESIDENT'S MESSAGE:

LESSONS FROM THE EGYPTIAN NATIONAL HYPERTENSION PROJECT (NHP)

The Egyptian NHP is the first National Hypertension Survey in a developing or an Arab country. It provides a large amount of data base not only about the prevalence of hypertension and hypertensive complications among Egyptians but also about hypertensive and cardiovascular risk factors.

The prevalence of hypercholesterolemia diabetes mellitus, obesity, cigarette smoking, salt intake and impaired glucose tolerance can now be defined in Egypt at the National level. As such as the Egyptian NHP can serve as a model for similar surveys in the Developing World. NHP was planned and executed by Egyptian scientists. Funding and support from USA underscored the value of international cooperation in public health research programs.

Most of the investigators of NHP had initially limited background in cardiovascular epidemiology but acquired a lot of experience during the three years of the survey. What we learned from this covers a wide range of information in design and execution of national surveys in developing countries. Good planning was the cornerstone in project success. A preparatory stage of ten months preceded the actual field operations.

During the period a number of activities were completed. These included recruitment of personnel - 64 persons were working for the project as part or full time, site preparation and purchase of different equipments, choice of survey areas and sample design, preparation questionnaire forms and other printed material, design ,training and certification of data collection staff, preparation of manual of operations and monthly plan of activities and finally conduction of three different pilot studies to test performance, logistics, response to questionnaires and to collect data for estimation of sample size.

Field survey was carried during the period December 1991 to May 1993. Data entry was completed at the beginning of 1994. Field operations which covered six Egyptian Governorates represented all geographic areas and socioeconomic classes. The sample design was a multistage probability sample of clusters of households in land-based segments.

Surveys were carried in 21 sampling locations according to a well defined time plan and included preparatory visits and establishment of local health centers. Home visits were carried out by data collection staff under the supervision of senior central office physicians to fill questionnaire forms and measure blood pressure four times.

The objectives of this phase were to identify hypertensive individuals and to collect data about the social demographic and environmental characteristics in the sample Dung a second phase of the survey, complete clinical evaluator including CG, echocardiogram and optic fundus examination were performed together with collection of blood and urine samples in hypertensive individuals and gender matched normotensives.

In order to make sure that the data we collect and report is accurate and free from bias and measurement errors, we developed a system of quality control measures. Quality control included activities carried during the preparatory stage, before and during field visits and at the time of data handling. It is not unexpected to face a number of difficulties during the planning and execution of a national survey of such extent and magnitude.

The important difficulties were due to lack of specialized infrastructure experienced in large scale epidemiologic studies and the absence of a similar experience from third world countries. The rind investigator and his senior staff had to develop everything from the beginning, to formulate questionnaire forms which required seven revisions and to put plans for field logistics tailored to the limited budget and limited pertise.

A second difficulty was to create and maintain interest and enthusiasm in the project staff specially the senior staff who were clinicians and were involved in areas outside their expertise.

What Is special about NHP?

NHP provides us for the first time with a national estimate of the magnitude of the problem of hypertension, its complications, and cardiovascular risk factors among Egyptians. The conduction of a large scale echocardiographic field survey was one of the special features of NHP. Substudies such as measuring skin colour reflectance and studying its relationship to blood pressure in a large population is another unique feature of the project.

The four blood pressure measurements, the sample design and the quality control procedures makes one feel confident in the information and data collected.

M. Mohsen Ibrahim, M.D.
Prof. of Cardiology - Cairo University
Principal Investigator of the National Hypertension Project
President of the Egyptian Hypertension Society

Editorial

CHILDHOOD HYPERTENSION
By
MOHAMED A. HAMED, MB, BCh; DCH; MD; FRCP (Glasg); FACC
Emeritus Professor of Paediatrics and Paediatric Cardiology Medical Academy and Maadi Hospital, Cairo, Egypt

The aetiology of hypertension in childhood has changed over the past four decades. Essential hypertension is now being seen more often in children owing to faulty dietary habits of excessive salt intake, increased consumption of high-caloric foods, in addition to blood pressure tracking, familial clustering as a result of consanguinous marriages and sedentary life style, coupled with early smoking habits, whether active or passive (5). The degree of severity of hypertension can give a clue as to whether a child is suffering from primary (when hypertension is mild) or secondary (when hypertension is severe).

The mildly hypertensive child is usually missed, but if followed up regularly with blood pressure measurement, he will be found to track, show familial clustering and become the essentially hypertensive adult (1).

Hypertension incidence in childhood is variable, and variations include diurnal as well as physiologic undulations, rest, exercise, sleep, meals, strong sensory stimuli, stress and emotion, extremes of temperature, posture, age, weight, height, sex and race (5). On the basis of age, height, weight and sex, percentile charts have been drawn to guide in the definition of childhood hypertension (3).
On this basis a child's blood pressure is considered:
1) elevated, if it is above the 90th centile on more than one occasion.
2) potentially hypertensive and needs investigation if above the 90th centile on 3 separate occasions over a 6 month's period.
3) definitely hypertensive and needs investigation and treatment if above the 95th centile from the outset Severe childhood hypertension is usually secondary and may be renal, reno-vascular, cardio-vascular, meta bolic, endocrine, neurologic, drug-related or miscellaneous.

The clinical evaluation of every child should include measuring his blood pressure. Special attention should be given to those showing a dark/turbid urine, obesity, a bruit over the loin, absent femoral pulses, or any patient whose blood pressure is above the 90th centile for age (1).

The laboratory evaluation is as important as the discovery that a child is hypertensive Four preliminary tests, viz, urinalysis, haemoglobin/haematocrit, blood chemistry (electrolytes, urea, creatinine and C02 content) and echo- cardiography can give a clue to the aetiology in the majority (2). If still in doubt abdominal Sonography, an intravenous pyelogram and plasma renin activity may further aid in this evaluation. From these preliminary investigations it is possible to categorise patients into 4 groups.

1) Renal disease
2) Non-renal disease
3) Reno-vascular disease
4) Essential hypertension

Further tests can then be planned accordingly.

In the management of childhood hypertension, if the blood pressure is above the 90th centile, measurement should be repeated over several visits. If the blood pressure is above the 95th centile and the patient is not obese, a diagnostic evaluation and non-pharmacologic therapy is indicated. This includes weight reduction, changes in diet, dynamic exercises and relaxation techniques.

Pharmaco logic therapy should be started immediately in children with severe hypertension accompanied by symptoms, but precipitous drops are to be avoided because of hypertension-related effects on the CNS (4).Recommendations of therapy have now changed with the availability of new drugs.

For severe hypertension the Calcium-channel blocker Nifedipine is now the drug of choice, and can be given to children of all ages and orally as well. Chronic anti-hypertensive therapy has been modified to include either an ACE inhibitor or a Calcium blocker as the initial drug. The stepwise approach with diuretics and Beta-blockers, etc., is still recommended in some patients, epecially diuretics in those with renal disease.

REFERENCES.

1. Hamed, MA. (1995): Hypertension in Children, Abstracts 1st Annual Meeting of EHS, Egypt. Heart J. (EHJ) 47: 212.
2. Ogborn, MR and Crocker, JFS, (1987): Investigation of Paediatric Hypertension: Use of a Tailored Protocol, Am. J. Dis. Child. 141:1205.
3. Rocchini, AP, (1984): Childhood Hypertension: Etiology, Diagnosis and Treatment, Ped. Clin. N. Amer. 31(6): 1259.
4. Sinaiko, AR, (1993): Pharmacologic Management of Childhood Hypertension, Ped. Clin. N. Amer. 40:195.
5. Voors, AW, Webber, LS and Berenson, ES, (1978): Epidemiology of Essential Hypertension in Youth: Implications for Clinical Practice, Ped. Cm. N. Amer. 25:15.

Abstracts of Local Literature

RV DIASTOLIC FUNCTIONS IN ESSENTIAL HYPERTENSION
El-Demerdash, F.M.; Maaty A.A.; Shehab EI-Deen, M.B. Mansoura University Hospital Department of Internal Medicine, (Cardiology Unit).

40 patients (pts), (16 males and 24 females) with essential hypertension (EH) and with age ranging 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 impaimment was significantly higher in group I when compared to group II (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 ventricule but also involve the RV and pulmonary circulation.

EHJ, FEB'95, 47:195

RACIAL DIFFERENCES IN LEFT VENTRICULAR MASS AMONG HYPERTENSIVE EGYPTIANS
Sherif M. Helmy, M. Mohsen Ibrahim, Saiwa M. Guindy, Sameh S. Zaghloul, Wael Abdel Aal, Amal Khalifa- For the Egyptian National Hypertension Project (NHP) investigators, Cairo University - Egypt, Johns Hopkins, NHLBI, USA.

Background: Black patients from western communities tend to have heavier hearts than comparable white men at any level of arterial pressure (AP). It is not clear whether differences are secondary to genetic predisposition or to unfavorable environmental factors in the west.

Objectives: compare changes in left ventricular mass (LVM) in hypertensive non black (NB) and black (B) Egyptians living in the same environment.

Methods: The study is a part of a nationwide cross sectional survey of hypertension and its complications in Egyptians (NHP). AP (mmHg-average 4 readings), resting heart rate (HR-b/mm). 12-hs urinary Na excretion (mmol/12hs) and echocardiographic LV measurements were obtained from the records of 103 B and 1108 NB hypertensives (SBP> 140, DBP > 90 mmHg) who were not on treatment, and were. age and gender matched. In B, age was 56 years, males 39%. In NB, age was 54 years, males 43.4% LVM was corrected for BSA: LVM index (LVMI).

Results: SBP, DBP, HR, urinary Na and LVMI were as follows in B and NB respectively: 1 62±25 (mean±SD) vs 155±29 mmHg*, 93±25 Vs, 90±50 mmoI/12 hrs, 89±25 VS 94±29 gm/m2. LV end diastolic dimension was larger in NB (47±6 VS 44±5 mm*). Septal and wall thickness were similar in both groups, the LVMI was little higher in both NB males and females 98±30 VS 94±31 and 88±25 VS 84±24 gm/m respectively. (*P<0.001).

Conclusion: Black hypertensive Egyptians have similar or a less increase in LVMI as compared with non blacks inspite of having higher levels of SBP and urinary Na excretion. Data do not support the notion that black race is at specially higher risk of developing LVH.

(EHJ Feb'95 47:199)

THE CARDIOVASCULAR RISK PROFILE OF HYPERTENSIVE & NORMOTENSIVE EGYPTIANS
Hussien H. Rizk. MD For the NHP investigators

The NHP database made possible the comparison of prevalence of certain cardiovascular risk factors [Smoking behaviour, hypercholesterolemia, diabetes mellitus, obesity. body fat distribution and a family history of cardiovascular disease] in hypertensive versus normotensive populations matched for gender and urban/rueal distribution. Participants in phase II of the National Egyptian hypertension project [i.e. detailed clinical & laboratory study of all hypertensive subjects and a matched cohort of normotensives] constituted the material for this comparative study.

Methods: To compare hypertensive & normotensives, data tabulation was performed separating patients to hypertensives & normotensives, then each category was further divided to males & females then further to urban & rural. Thus 8 subgroups were analyzed for the prevalence of individual risk factors. Pooling of all hypertensives against all normotensives was sometimes done.

To examine the relation of the level of BP to the prevalence of individual risk factors, subjects were first grouped by BP level using the grading system adopted by the fifth report of the joint National Committee on Hypertension [JNC V]. Then at each category subjects were divided to males & females, then to urban & rural, yielding 20 subgroups in all.

Results: Diabetes mellitus, plama cholesterol >240 mg/dl., body mass index > 31 Kg/m2 & a positive family history of cardiovascular disease were more prevalent among hypertensive than normotensive subjects. Smoking was slightly more common in normotensives.

The difference in prevalence of a positive FH of CVD was not significant in rural participants & insignificant in rural females. Both the waist/hip ratio & the waist circumference were significantly larger in hypertensives of all subgroups. The prevalence of obesity carried the most powerful correlation to the level of BP in both urban & rural males.

Conclusions: All cardiovascular risk factors are prevalent in adult Egyptians. Hypertension identifies a population with more prevalent obesity, truncal fat distribution, hypercholesterolemia & diabetes mellitus.

EHJ, Feb'95, 47: 207

Abstracts of World Literature

MORBIDITY AND MORTALITY IN HYPERTENSIVE ADULTS WITH A LOW ANKLE/ARM BLOOD PRESSURE INDEX
Anne B. Nawman, MD, MPH; Kim Sutton-Tyrrell, RN, Dr PH; Molly T. Vogt, PhD; Lewis H. Kuller, MD, DrPH

Objective.- To evaluate the relationship between the ankle/arm blood pressure index (AAI, the ratio of ankle to arm systolic blood pressure, a measure of peripheral arterial disease) and short-term cardiovascular morbidity and mortality in older adults with systolic hypertension.

Design.- Prospective cohort study, 1- to 2-year follow-up (mean, 16 months).

Setting.- Eleven of 16 field centers from the Systolic Hypertension in the Elderly Program.

Participants.- 1537 older men and women with systolic hypertension.

Main Outcome Measures.- All-cause mortality, coronary heart disease (CHD) mortality, cardiovascular disease (CVD) mortality, and CHD and CVD morbidity and mortality.

Results.- The AAI was measured at the 1989-1990 clinic examination and was 0.9 or less in 25.5% of 1537 participants. A low AAI was associated with most major CHD and CVD risk factors. In those with a low AAI (<0.9) compared with those with an AAI of more than 0.9, age- and sex-adjusted relative risks for mortality end points at follow-up were as follows: total mortality, 3.8 (950/0 confidence interval [Cl], 2.1 to 6.9); CHD mortality, 3.24 (95% Cl, 1.4 to 7.5); and CVD mortality, 3.7 (95% Cl, 1.8 to 7.7).

For CVD morbidity and mortality, the age- and sex-adjusted relative risk was 2.5 (95% Cl, 1.5 to 4.3). After adjustment for baseline CVD and other cardiovascular risk factors, the relative risk for total mortality was 4.1 (95% Cl, 2.0 to 8.3) and for CVD morbidity and mortality, 2.4 (95% Cl, 1.3 to 4.4). Results were similar when participants with clinical CVD at baseline were excluded.

Conclusion.- A low AAI appears to be an important predictor of morbidity and mortality among older adults with systolic hypertension.

(JAMA. 1993; 270:487-489)

PSYCHOLOGICAL PREDICTORS OF HYPERTENSION IN THE FRAMINGHAM STUDY IS THERE TENSION IN HYPERTENSION?
Jerome H. Markovitz, MD, MPH; Karen A. Matthews, PhD; William B. Kannel, MD; Janet L. Cobb, MPH; Ralph B. D'Agostino, PhD

Objective-To test the hypothesis that heightened anxiety, heightened anger intensity, and suppressed expression of anger increase the risk of hypertension, using the Framingham Heart Study.

Design- A cohort of men and women without evidence of hypertension at baseline were followed up for 18 to 20 years. Baseline measures of anxiety (tension), anger symptoms, and expression anger (anger-in and anger-out) were taken, along with biological and behavioral predictors of hypertension (initial systolic blood pressure, heart rate, relative weight, age, hematocrit, alcohol intake, smoking, education, and glucose intolerance).

Participants.- A total of 1123 initially normotensive persons (497 men, 626 women) were included. Analyses were stratified by age (45 to59 or> 60 years) and gender.

Main Outcome Measures.- Hypertension was defined as either taking medication for hypertension of blood pressures higher than 160/95 mmHg at a biennial examination.

Results.- In univariate analyses, middle-aged men who went on to develop hypertension had greater baseline anxiety levels than men who remained normotensive (P=.04). Older hypertensive men had fewer anger symptoms at baseline (P=.04) and were less likely to hold their anger in (P=.01) than normotensives.

In multivariate Cox regression analysis including biological predictors, anxiety remained an independent predictor of hypertension in middle-aged men (P=.02). Among older men, anger symptoms and anger-in did not remain significant predictors in the multivariate analysis. Further analysis showed that only middle-aged men with very high levels of anxiety were at increased risk (relative risk, 2.19; 95% confidence interval, 1.22 to 3.94). No psychological variable predicted hypertension in middle-aged or older women in either univariate or multivariate analyses.

Conclusions.- The results indicate that among middle- aged men, but not women, anxiety levels are predictive of later incidence of hypertension.

(JAMA. 1993; 270: 2439-2443)

ASSESSMENT OF LEFT VENTRICULAR FUNCTION BY THE MIDWALL FRACTIONAL SHORTENING/END-SYSTOLIC STRESS RELATION IN HUMAN HYPERTENSION
Giovanni de Simon, MD, FACC, Richard B. Devereux, MD, FACC, Mary J. Roman, MD, FACC, Antonello Ganau, MD, Pier S. Saba, MD, Michael H.Alderman, MD, John H. Laragh, MD, FACC
New York, New York

Objectives. This study examined left ventricular performance in relatively unselected hypertensive patients by use of physiologically appropriate midwall shortening end- systolic stress relations.

Background. Supranormal left ventricular function has been reported in hypertensive patients, possibly due to an artifact of mismatching endocardial rather than midwall fractional shortening to mean left ventricular end-systolic stress.

Methods. Samples of 474 hypertensive patients (150 women, 324 men) and 140 normal subjects (68 women, 72 men) were drawn from a large urban employed population. The inverse relations (p< 0.0001) of both echocardiographic endocardial and midwall fractional shortening to end-systolic stress in normal subjects were used to calculate the ratios of observed to predicted endocardial and midwall fractional shortening in hypertensive patients.

Midwall shortening was calculated from an elliptic model, taking into account the epicardial migration of the midwall during systole.

Results. Use of midwall fractional shortening in hypertensive patients reduced the proportion of patients with function above the 95th percentile of normal from 22% to 4% (p<0.0001) and fractional shortening as a percent of predicted from 107% (p<0.001 vs. 100% in normotensive control subjects) to 95% (p<0.0001; p<0.001 vs. 101 % in normotensive control subjects).

Midwall shortening was below the 5th percentile of normal in 16% of hypertensive patients instead of 2% with endocardial shortening (p<0.0001): They tended to be older than other hypertensive patients and had concentric left ventricular hypertrophy. Among hypertensive patients, those with concentric left ventricular hypertrophy or remodeling had reduced midwall shortening as a percent of predicted from end-systolic stress (p<0.0001).

Conclusions. Use of the physiologically more appropriate mid-wall shortening/end-systolic stress relation 1) markedly reduces the proportion of hypertensive subjects identified as having high endocardial left ventricular function; and 2) identifies a substantial subgroup of patients with reduced left ventricular function who have concentric geometry of the left ventricle, a pattern associated with high cardiovascular risk.

(J Am CoIl Cardiol 1994; 33:1444-51)

EHS NEWS

* The President of the EHS arranged a meeting of a delegation from the Society to meet with his Excellency Prof . Ismail Sallam, The Minister of Health, briefing him about the Society's activities and asking the support of the Ministry for the National Hypertension Project and put before him some proposals for future research with emphasis on the Multi-Center Anti-Hypertensive Drug Trial.

* The summer meeting of the Egyptian Hypertension Society took place in Alexandria on the 6 th and 7 th of of June, 1996 at the Palestine Hotel, Montazzah. The main theme of the Meeting was (The diabetes - Hypertension Connection) . The 1st session was on Epidemiology and pathophysiology and the following topics were discussed in the interim : Magnitude of the problem, environmental and genetic factors, insulin and hypertension, and the syndrome of hyperinsulinism. The 2 nd session dealt with cardiovascular involvement in the diabetic and hypertensive, and under this heading coronary artery disease and myocardial disease as well as peripheral vascular disease were discussed . Also a review of the mechanisms of early atherosclerosis con cluded the session.

The 3 rd session dealt with renal involvement in the diabetic and hypertension (Mechanisms and classification) as well as hypertension in diabetic nephropathy, and the prevention of renal damage of both hypertension and diabetes, as well as management of the complicated renal diabetic and hypertensive were discussed

The 4 th session dealt with therapy Non-pharmacologic, pharmcologic and glycemic control, and the recent advances in this field were all discussed.

* Meeting with the WHO Regional Representative took place with the president of the EHS. The two gentlemen discussed some WHO projects as well as prospective research of the EHS. In addition mutual cooperation between the two organizations was also discussed.

* A regional meeting in the Suez Canal area is due to take place on the 18 th and 19 th of October in Morgaan Touristic Village in Fayed . The theme of the Meeting will be discussion on hypertension in special groups

* Prof Mohsen Ibrahim President of the EHS has been chosen as a Member of the Board of Directors of the World Hypertension League.

* The EHS wishes to convey its deep appreciation and gratitude to the following honorable members of the Society and equally to Non-members interested in the Society's activities for their generous contributions to the society budget.

List No :1
1) Mr. Mohamed Mustafa Abou Ghaly
2) Mr. Takiyallah Mohamed Helmy
3) Mr. Mohy-EI-Din KhaliI Kandil
4) Mrs. Nadia Ahmed Fouad
5) Mr. Aly Dabbous
6) Mr. Ramy Lakah
7) Mr. Mustafa El Bahnasawy
8) Mr. Ahmed Aly Dabbous
9) Mr. Fikry Abdel Wahab
10) Mr. Ibrahim Wagdy Mohamed Abdel-Ghany
11) Mr. Salah Ahmed Abou Eita

List No 2
1) Diamtex Company
2) Suez Company for Textiles and clothing
3) Egyptian Company for Agencies and Service Stations
4) Mardayef Company for petrolium Services
5) Bazan Company foor Wood Work
6) Isis Touristic Organization
7) Pyramisa Company for Hotel and Touristic Villages.
8) Hassan Abou El Makarem Oompany
9) The Tripartite Organization for Industry and Commerce.
10) Nile Company for Exterior Trade.
11) Diabco Company for International Trade.
12) The International Company for Export and Import.
13) The Egyptian Sponge Company.
14) Americana Company for Marketing and Advertising.
15) The Egyptian Company for International Touristic Projects.
16) The Cairo Company for Poultry.

List No : 3
1) The Arab-International Bank.
2) The Egyptian Watany Bank.
3) The National Bank-Societe Generale.
4) The Egyptian - British Bank.
5) Misr International Bank.
6) Bank Misr (Orman Branch ).

* Prof. Mohsen Ibrahim, president of the EHS has been nominated to Membership of the programming Committee of the International Society of Hypertension.

CALENDAR

Year	Month	Days	Meeting	Venue	Correspondence
1996	November	15-16	5th Congress of the Polish Society of Hypertension.	Warsaw Poland	Prof. S.L.Rywik National Institute of Cardiology Dept. CVD Epideniology and prevention lpejska Str., 42,04-628 Warsaw, Poland
1996	December	5-7	10 th Congress of the Hypertension Society of Southern Africa.	Cape Town South Africa	Charleen Daries Hypertension Society of Southern Africa 1996 Congress P.O. Box 19070,Tygerberg 7505, South Africa.
1996	December	18-20	The 2 nd Meeting of the Egyptian Hypertension Society (EHS)	Cairo Egypt	Prof. Khairy Abdel-Dayem Chairman of the Organizing Commiffee.Vice Dean of the Faculty of Medicine Am Shams University, Cairo, Egypt.