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

EDITORAL 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:

CARDIOVASCULAR RISK FACTORS IN EGYPTIANS: NEW DATA FROM THE EGYPTIAN NATIONAL HYPERTENSION PROJECT

A number of cardiovascular risk factors have been linked to the development of atherosclerotic coronary artery disease, These include hypertension, cigarette smoking, hypercholesterolemia, obesity, diabetes mellitus, increased low-density lipoprotein cholesterol, hypertriglyceridemia and low levels of high-density lipoprotein cholesterol.

The prevalence of these risk factors at a national level was not reported previously in Egypt During the recent meeting of the Egyptian Hypertension Society held in Cairo December 1996, some of the important prevalence figures were released. The information is needed for health planners and medical scientific community. It can possibly provide an explanation for the observed increase in the incidence of coronary artery disease in our country. One of the objectives of the Egyptian NHP was to collect data about the prevalence and distribution of these risk factors among Egyptians. The data were original and outline for the first time the magnitude of the cardiovascular risk factors in our nation.

The information was collected from a representative sample distributed in 21 sampling locations in six Egyptian governorates that represent all Egyptian geographic regions and socioeconomic groups. The sample consisted of 1559 hypertensives and 754 normotensives. Women were more common, 57% of hypertensives and 58.6% of normotensives. The mean age of hypertensives was 54.4 years and of normotensives was 43.8 years.

Blood samples were collected after 12 hours fasting. Hypercholesterolemia (serum cholesterol >240 mg%) was more prevalent in hypertensive men and women (13.4% and 20.4% respectively) as compared to normotensive men and women (7.1% and 10.6% respectively). Elevated LDL-cholesterol level (>160 mg%) was more common in hypertensives compared to normotensives (15.2% and 23.5% in hypertensive men and women respectively Vs 9% and 11.1 % in normotensive men and women).

Diabetes mellitus (fasting blood sugar >140 mg %) was present in 11% of hyperensive males and 16% of hypertensive females compared to 4.2% and 6.1% in normotensive males and females respectively. Current cigarette smoking was more common in male normotensives than hypertensives (43.3% vs 35.7%).

cigarette smoking was rare in Egyptian women both hypertensive and normotensive (2.3% and 1.6% respectively). Prevalence of cigarette smoking was not influenced by age. Cholesterol and blood sugar levels were higher in all age decades in hypertensives compared to normotensives. Obesity, hypercholesterolemia and diabetes mellitus were more prevalent in Egyptians living in urban areas in comparison to those living in rural regions.

These data underscore the high prevalence rates of cardiovascular risk factors among Egyptians specially hypertensive individuals. The information should alert our health policy planners and medical community to start taking preventive and control measures. The Egyptian Hypertension Society, through its public and physician education programs should play a pivotal role in helping health promotion in our country.

The recently published Egyptian Hypertension Society booklet prepared by the Egyptian Hypertension Society working group on Guidelines for the Management of Hypertension in Egypt contains a number of recommendations directed to government organizations, public, drug and food industry. These recommendations if followed might help decrease the magnitude of the hypertension problem in our community.

The public education programs prepared by the Egyptian Hypertension Society will address in addition to the question of hypertension, methods to control other cardiovascular risk factors namely cigarette smoking, obesity and hypercholesterolemia. Control of these cardiovascular risk factors have proved effective in decreasing the incidence of atherosclerotic coronary artery disease over the past two decades in some western countries.

M. Mohsen Ibrahim, MD
Professor and chairman of the Cardiology
Department-Cairo University.
Principal Investigator the Egyptian National Hypertension Project

Editorial

WHITE COAT HYPERTENSION
Dr Zeinab Ashour, M.D
Lecturer in Cardiology, Cairo University

What is white coat hypertension? This elusive term has gained some attention in the last few years. Perhaps the simplest definition of it is the one proposed by Verdecchia and Porcellati as "co-existence of normal ambulatory or self measured blood pressure with persistently elevated clinical blood pressure" That a patient's blood pressure may rise at the sight of his/her doctor has been recognized a very long time ago, so much so that it is really surprising that this phenomenon has come into the spotlight only recently.

As early as 1897, when Riva-Rocci published his dissertation about his invention of the mercury sphygmomanometer "La tecnica della sflgmomanometria", he mentioned that a patient's blood pressure may rise at the sight of a doctor. This however was forgotten till in 1940, Ayman and Goldshine reported differences in blood pressure values measured in the physician's office and the patient's home. The breakthrough came with Pickering in 1974.

He and his associates proved by intra-arterial blood pressure measurement that the patient's BP would rise shortly after the doctor entered the room. In 1984, the term "White Coat Hypertension" was coined by Kleinert(1). The wide spread attention this phenomenon gained, is probably due to the invention and subsequent popularity of non invasive ambulatory blood pressure monitors.

A lot more cases than previously assumed were recognized, and physicians started patting their patients on the shoulder with the comforting words" You are not really hypertensive, relax. No, you do not need to take any treatment". This is rather a dangerous stand to take, considering that most cases of white coat hypertension were diagnosed by ambulatory BP monitoring.

It is known that those monitored have some degree of error, that this error varies according to the quality and validation of the machine, and worse, that up to date, there is no clear cut consensus regarding normal values, (2,3). Yet a plethora of data was published about this phenomenon. Prevalence figures of white coat hypertension varied from 21-55% of hypertensives according to the normal values and methods of detection used in the different studies (2,3,4,5).

Investigators tried to explain the mechanism as increased cardiovascular reactivity, but this was elegantly disproved by Siegel and associates who showed that WCH and persistent Ht had similar BP responses to mental stress, and that contrary to expectations, WCH had lower BP responses to physical stress(2) Pickering tried to explain this as a form of conditioned reflex and called it an alerting reaction, noting that in his recordings the white coat induced rise in BP was not associated with a similar increase in heart vate (I).

While some investigator showed that the incidence of target organ damage in WCH was similar to that of normotensives, others showed that WCH shared some similarities with persistently hypertensive patients, such as higher body weight, higher left ventricular mass index, higher plasma triglyceride level, higher plasma insulin level, reduced HDL cholesterol level, higher plasma norepinephrine, and even a higher prevalence of microalbuminuria than the normotensive population.

All these parameters indicate that WCH is not benign. In most of the studies WCH took an intermediate position between persistently normal and persistently hypertensive individuals, no matter what parameter was examined. This indicates that" white coat hypertension should not be considered a separate entity, but rather, a low risk stratum of essential Hypertension(1) and that "patients with this condition are prone to develop hypertension over time".

Should white coat hypertension be treated? The answer to this question till now is not clear. Although the phenomenon is reproducible, its magnitude is not. The difference between self or ABPM measured and office measured BP varies from - 11 mmHg to 69 mmHg for systolic and from - 17 mmHg to 33 mmHg for diastolic readings, the most common being 26-32 mmHg for systolic readings and 3-8 mmHg diastolic readings. Yet the magnitude of the response is not the same for each visit and each patient.

Gosse et al in a retrospective study looked at the degree to which various anti-hypertensive drugs controlled the white coat response (6). Although this study has a lot of limitations, it paves the way for future investigation in this field. Meanwhile, it may be prudent to become old fashioned again and to treat patients according to their office blood pressure, and only to consider investigating for WCH if the patients complain of symptoms indicative of over treatment such as postural hypotension.

References
1- Verdechia P; and Porcellati C (1995): White Coat Hypertension G Ital Cardiol Jul; 25 (7): 899.
2. Siegel, WC Blumenthal JA and Devine GW (1990): Physiological, Psychological and Behavioral Factors and White Coat Hypertension Hypertension; 16:140.
3. Palma Gamiz JL, Calderon Montero A (1995): The clinical Utility of the Automatic Ambulatory Recording of the Arterial Pressure in Diagnosis, Prognosis and Treatment of Hypertension. Rev Esp Cardiol; 48 Suppl 4:57.
4. Ashour Z., Rizk H. and Ibrahim M.M (1994): Daily Blood Pressure Load and Exercise Response in Hypertension Doctorate Thesis, Faculty of Medicine, Cairo University'.
5. Ocon Pujadas J and Mora Macia J (1993): White Coat Hypertension and Related Phenomena Drugs 46 Suppl 2:95.
6. Oosse, P, Boughaleb, P Egloff, P Lemetayer P and Clementy J. (1994): Clinical Significance of White Coat Hypertension Hypertension, 12 Suppl 8:S 43.

Currently a survey is being carried out at one of the Cairo University hospitals to evaluate the knowledge of residents and high institute nurses about blood pressure measurement.

The survey entails a questionnaire to be filled out by each resident as well as a practical test. So far 33 individuals have been examined and the study is still ongoing. Preliminary results show that none of the staff cared to explain the procedure to the patient and that most were unaware of the necessary precautions.

Only 40% were aware of the correct arm position, 90% of the correct cuff position, but over 90% checked for sleeve tightness, 80% used correct cuff size, 85% knew how to wrap it snugly, 97% used the diaphragm instead of the bell, 85% placed it properly over the brachial artery and finally only 24% attempted to recheck the blood pressure. Over 90% admitted they had never attended any training sessions. These preliminary results indicate marked deficiencies in the technique used by residents to measure blood pressure and the need for regular training sessions.

Abstracts of World Literature

Abstracts of World Literature

Forthcoming Research

FORMULATION OF BLOOD PRESSURE NORMS AND PERCENTILES FOR EGYPTIAN CHILDREN AND ADOLESCENTS

The need for measuring blood pressure in children and adolescents and discerning normal from elevated or reduced levels cannot be overemphasized. This is especially so when it is noticed that over the past 4 decades the etiology of hypertension in children and adolescents has slowly but significantly changed. Earlier in the 40's 80% of childhood hypertension was considered secondary to a cause lurking behind the elevated blood pressure.

With the passage of time essential hypertension started to be discovered much earlier than previously thought, so that by the mid 70's nearly 45% of hypertension in childhood was thought to be essential, with no causal etiologic agent. found. As hypertension has been found to be affected by race and colour, dietary habits and life style, as well as rural and urban factors, and as hypertension risk factors according to the NHP statistical analysis, have been found to be more common in certain geographic areas & populations, the norms for blood pressure measurement must consequently differ as well from one population to another. This is especially so when considering children and adolescents.

In general a child's blood pressure is considerated elevated if it is found to be above the 90 th centile for age and height on more than one occasion. The child is considered potentially hypertensive and needs investigation if his blood pressure is above the 90 th centile on 3 separate occasions over a 6 months' period.

He is considered definitely hypertensive and needs investigation and treatment if his blood pressure is above the 95 th centile from the outset. In defining childhood and adolescent hypertension in Egypt, it becomes mandatory therefore to draw up percentile charts for normal blood pressure and its variations, from the aboriginal population under scrutiny. 22 hospitals in different geographic areas of Egypt will recruit from its staff 3 physicians (paediatrician, cardiologist and paediatric cardiologist when possible) in addition to 3 nurses.

Each hospital will act as a nucleus for blood pressure measurement in its locality. A 1-2 week course on B.P. measurement similar to the one carried out by the EHS will be conducted for all the recruited staff. Infants and children attending the hospital as well as the pupils of 16 schools in the neighbouring areas will have their B.P. measured according to a set out protocol. Certain criteria have to be fulfilled for enlisting hospitals and schools for the study.

An atherosclerotic risk sheet, a BP sheet, and percentile charts for height and weight of Egyptian children (Abbassy et al) have all to be filled in for the study. The body mass index will then be computed. The normal B.P. range for each age and the mean for that age will then be computed. A line connecting the means at different ages will represent the 50 th centile. The upper limit for the age will represent the 95 th centile and the lower limit will represent the 5 th centile. Connecting these limits for the different ages will produce 2 curves one above and one below the curve of means. The same procedure will be repeated for both sexes.

EHS NEWS

* The symposium of the EHS on Hypertension in Special groups that was scheduled in Fayed on October 17 th, 1996 was changed to take place in Port-Said on the same date. It was attended by nearly all members of the EHS. The first session of the Meeting discussed hypertension in the Elderly and was chaired by Prof. Yehia Saad & Prof. Mahmoud El sherbeeny. In this session the physiology of aging and the changes that take place in the cardiovascular system with advancing age was discussed by Prof. Mohamed El Guindy.

This was followed by a discussion of the clinical characteristics of hypertension in the elderly by Prof. Hussein Rizk, and special problems met with in the elderly hypertensive patient by Prof. Adel Zaki. Finally the session was terminated by a discussion of the choice of anti hypertensive medication and the quality of life of the elderly hypertensive by Prof. Omar Khashaab.

The second session was devoted to the problems of Hypertension in Women and Adolescents and was chaired by Prof Aly Rarusy and Prof. Samir Abdel Kader. Dr. Wafaa El Aroussy started the session by a talk on the clinical and pathophysiologic characteristics of pregnancy induced hypertension. This was followed by a talk on how to treat hypertension in pregnancy by Prof. Fathy Maklady. Prof. Galal El-Said then discussed the predictors of hypertension in childhood and adolescence, and this was terminated by a talk on the clinical and laboratory evaluation of childhood and adolescent hypertension given by Prof Mohamed Hamed.

At lunch time a luncheon panel on resistant hypertension was haired by Prof. Mohsen Ibrahim, President of the EHS and the speakers at the panel were Prof. Abdel Moneim Hasaballah, Prof. Hamed Badr, Prof. Mokhtar Gomaa and Prof Omar Awaad. The third session was devoted to Neurogenic and White Coat Hypertension and was chaired by Prof Ahmad Badran and Prof Hassan Ezzeddine Attia.

Office (or white coat) hypertension was defined and discussed by Dr. Zeinab Ashour. This was followed by a talk on hypertension in the Panic Disorder syndrome delivered by Prof Sherif Mokhtar. Adrenergic mediated hypertension was then discussed by Prof Hassan Khalid Nagy. Finally a talk on the differential diagnosis of Paroxysmal hypertension given by Prof Khairy Abdel Dayem with concluding remarks by Prof Mohsen Ibrahim. The scientific sessions were then followed by a cruise at the harbour of Port-Said and the entrance to the Suez Canal on the invitation of the Governer of Port-Said and afternoon tea was served.

* The 2 nd Annual Meeting of the EHS took place on 18 th to 20 th December 1996 at the Marriott Hotel Gezira, Cairo, Egypt. The Organising Committee was chaired by Prof Khairy Abdel-Dayem, Vice Dean of Am Shams Faculty of Medicine, with the membership of Dr. Wafaa El Aroussy of Cairo University and Dr. Ahmed Abdel Rahman of Ain Shams University.

A very rich and attractive variety show was arranged specially and exclusively for the participants in the Meeting on the evening of December 19th at the Egyptian Opera House.

Guest speakers at the Meeting from all over the world were the following (titles reserved):

Salah Abdel Alim (U.S.A.) Kamal Ahmed (U.K.) Ove Anderson (Sweden) Lawrence Apple (U.S.A.) Kikuo Arakawa (Japan) Marc De Gasparo (Switzerland) Alessandro Desideri (Italy) David Hearse (U.K.) Paul Hugenholtz (Netherlands) Ahined Kissebah (U.S.A.)

Gisbert Kober (Germany) Wolf Rafflendbeul (Gerrnany) Gordon Mclnnes (U.K.) Peter Meredith (U.K.) Pravin Shah (U.S.A.) Helmi Seraji (U.S.A.) Reynaud Timmers (U.K.) Adam Timmis (U.K.) Hugh Walter (U.K.) Alberto Zanchetti (Italy)

The Scientific program included symposia on current concepts in management of hypertension, chronic renal disease and hypertension, recent advances in antihypertensive therapy, hypertensive emergency management, diabetic nephropathy and hypertension, endocrine hypertension, hypotension and syncope, post-transplantation hypertension, essential hypertension.

State of the Art lectures included diastolic heart failure, stress and hypertension, value of controlled trials of medication, genetic basis of hypertension. Hypertension and hypertrophic myopathy, Ca channel Blockers in hypertension, effect of exercise ventricular hypertrophy and hypertension. A panel discussion on hyperlipidaemia in the hypertensive patient was also held.

Controversies discussed during the meeting were on non- pharmacologic versus pharmacologic therapy in mild hypertension, diuretics and/or Beta Blockers as first line therapy in mild and moderate cases, importance of the search for secondary causes of hypertension.

Most original communications delivered came under hypertension and C.A.D., drug therapy and complications of hypertension. Satellite symposia during the Meeting were organised by; * Bristol - Myers - Squibb - Step ahead in hypertension management.
* Glaxo - Wellcome - Update in Ca Channel Blockers.
* Ciba - Geigy - Benefits of angiotension II receptor antagonism.
* Zeneca: Issues in clinical management from hypertension to heart failure.
* Servier- Myocardial cytoprotection in CAD; role of Vastarel.

The speakers at the opening ceremony were Prof. Khairy Abdel Dayem for the Organising Committee, Prof. Mohsen Ibrahim President EHS, Ambassador Abdel - Raouf El-Reedy Former Ambassador to U.S.A. and finally HE Prof. Ismail Sallam, Minister of Public Health and Population. At the Gala Dinner which took place at the Marriot Ball Room on Friday 20 th December, six valuable prizes were awarded to the best orally presented communications by investigators under 40 years of age.

Five of these awards are presented by Knoll Pharmaceutical Company and one by the Board of the Egyptian Hypertension Society. The winners of these 6 prizes are as follows:

1st - Dr. Fatma Aboul Enein of Alexandria University and Dr. Khalid Dorgham of Ain-Shams University Each received LE:750 as 1 st prize.
3rd- Dr. Tarek Abdel Aziz (LE:500) of Ain-Shams University.
4th- Dr. Mervet Aboul-Maaty Nabih (LE: 500) of Ain-Shams University.
5th- Dr. Samuel Louis (LE:500) of Ain-Shams University.
6th- Dr. Mohamed Selim (LE:500) of Ain - Shams University

* The first continuing Medical Education Course (CME) on "High Blood Pressure: Its diagnosis and Management" held by the E.H.S. is due to take place on Sunday January 5 th, 1997, at the Conference Hall A of the New Kasr-El-Ainy Teaching Hospital at 9.00-15.00 his. The main aim of this course is to train young graduates especially house physicians and registrars in the proper

methods of blood pressure measurement, and its definition, as well as the basic knowledge in the diagnosis, and management of hypertension. The course director is Prof. Adel Zaky, of Cairo University. At the end of the course a multiple choice question examination will be sat for by the attendants enlisted in the course, to act as a feedback to the course organisers on its feasibility. A prize of LE 500 will be awarded to the best physician who scores the highest grades in both the practical sessions and the examination.

* The 4 th Annual Ramadan breakfast of the EHS is due to take place on the 24th January 1997, at the Ramses Hilton Hotel. The Breakfast is usually attended by all members of the Society whether Honorary, Founding or Ordinary Members and whether medical or non-medical members.

At this social gathering it is customary for the President of the EHS to give a report on the EHS activities and to introduce important new members of the EHS, to commend outstanding achievements, and to listen to the reports of the different sub- committee chairmen and the Treasurer of the EHS.

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