EHS EXECUTIVE BOARD:
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Editorial Committee
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| President :
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M. M.Ibrahim, MD |
Editor
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M.Hamed.MD |
| Vice President
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H.E.Attaia,MD |
Assistant
Editor : |
A.m.El-Keiy,MD |
| Secretary : |
H.H.Rizk,MD |
|
O.Nayel,MD |
| Treasurer :
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W.El-Aroussy,MD |
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F.El-Demedrdash,MD |
| Members : |
A.M.Hassaballah,MD |
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M.Hassanein,MD |
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M.M.Gomaa,MD |
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Abdel Fattah,MD |
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F.A.Maklady,MD |
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Z.Ashour,MD |
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S.El-Tobgy-MD |
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O. EL-Khashaab,MD |
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Coronary artery disease (CAD) are closely
linked to hypertension.They constitute the main cause
of disability,morbidity and mortality in hypertensive
patients. On the other hand epidemiologic studies revealed
that hypertension is a major risk factor for CAD .Furthermore,CAD
are predicated to be the main techniques,drugs and therapeutic
interventions that are introduced in the management
of coronary patients. for these reasons, the EHS organized
a working group on CAD with the objective of writing
a practical manual.targeted to the internists and cardiologists
and contains the Guidelines.
The book is expected to be available before the end
of this year ,it consists of four sections covering
the diagnosis and management of the different coronary
syndromes.including values and limitations of the commonly
used diagnostic procedures,drugs and interventions in
the treatment of coronary patients.special resuscitation
in his everyday handling of the coronary patients.stress
has been given to practical questions such as clinical
evaluation of chest pain,how to predict the need for
hospitalization,the role of ECG-Stress testing, the
values and limitation of coronary angiography and other
imaging techniques, management of acute coronary syndromes
with a detailed chapter on acute myocardial infarction.
This is the second book produce by the
EHS, the first book was published two years ago consisting
of a brief review and guidelines for the management
of hypertension in Egypt, The success of this firs book,which
became an important source of information for many of
the practicing physicians was an important factor behind
the idea of writing a new practical manual about CAD
these two books fit within the educational goals of
the EHS and are available at no coast to all Egyptian
physicians.the production and printing of both books
was through the generous support of the Egyptian drug
industry,namely,Hoechst Marion Roussel And Merck Sharp
& Dhome-Egypt.
These two books were the result of collaboration
of a number of Egyptian experts from different Universities
and will help the Egyptian practitioner to catch with
the rapid developments in the fields of hypertension
and coronary Artery Disease.
M.Mohsen Ibrahim, MD
Prof. & Chairman Department of Cardiovascular Medicine-Cairo
University
president of the Egyptian Hypertension ,Society
THE PRESIDENTS MESSAGE
THE PRESIDENTS
MESSAGE
CORONARY ARTERY DISEASE
EHS GUIDELINES
Coronary artery disease (CAD) are closely
linked to hypertension.They constitute the main cause
of disability,morbidity and mortality in hypertensive
patients. On the other hand epidemiologic studies revealed
that hypertension is a major risk factor for CAD .Furthermore,CAD
are predicated to be the main techniques,drugs and therapeutic
interventions that are introduced in the management
of coronary patients. for these reasons, the EHS organized
a working group on CAD with the objective of writing
a practical manual.targeted to the internists and cardiologists
and contains the Guidelines.
The book is expected to be available before the end
of this year ,it consists of four sections covering
the diagnosis and management of the different coronary
syndromes.including values and limitations of the commonly
used diagnostic procedures,drugs and interventions in
the treatment of coronary patients.special resuscitation
in his everyday handling of the coronary patients.stress
has been given to practical questions such as clinical
evaluation of chest pain,how to predict the need for
hospitalization,the role of ECG-Stress testing, the
values and limitation of coronary angiography and other
imaging techniques, management of acute coronary syndromes
with a detailed chapter on acute myocardial infarction.
This is the second book produce by the
EHS, the first book was published two years ago consisting
of a brief review and guidelines for the management
of hypertension in Egypt, The success of this firs book,which
became an important source of information for many of
the practicing physicians was an important factor behind
the idea of writing a new practical manual about CAD
these two books fit within the educational goals of
the EHS and are available at no coast to all Egyptian
physicians.the production and printing of both books
was through the generous support of the Egyptian drug
industry,namely,Hoechst Marion Roussel And Merck Sharp
& Dhome-Egypt.
These two books were the result of collaboration
of a number of Egyptian experts from different Universities
and will help the Egyptian practitioner to catch with
the rapid developments in the fields of hypertension
and coronary Artery Disease.
M.Mohsen
Ibrahim, MD
Prof. & Chairman Department of Cardiovascular Medicine-Cairo
University
president of the Egyptian Hypertension ,Society
Editorial
HYPERTENSION IN THE ELDERLY
OMAR AWAAD
Prof. cardiology ,faculty of medicine.
Ain shams University
There are two patterns of hypertension
in the elderly combined systolic and diastolic hypertension
and isolated systolic hypertension (ISH)> 65y their
prevalence change with age as evidenced in framingham
study ,where the types of HPT between age 70-79 were
(20% ISH & 50% borderline ISH). However this should
not be admixed with pseudohypertension [White coat effect
or artifactually elevated with modest lowering utilities
.in this situation measurements is better assessed by
finger recording.
The retrieved data ,from the so many
clinical trials conducted on elderly hypertensives[AUSTRALIAN.EWPHE,WARRENDER,SHEP,STOP-HT,MRC.STONE,..etc.]cleared
that risks of morbidity&morbidity is high specially
in those without treatment for 2 years also mortality
from CHD & stroke is much higher than in normal
population.in such a category the systolic pressure
[SBP] is more predictor of cardiovascular[CV] risk even
more in ISH where there is 1% increase in the rate of
mortality with each 1mm increase in SBP in the very
old>85y; lowest mortality was achieved at BP range
of [140-169/70-99].Moreover,in general,higher BP predisposes
to dementia (Alzheimer) the basic pathophysiological
mechanism of hypertension in the elderly is the loss
of distensiblity & elasticity in large arteries
with an increase in pulse wave velocity & an early
return of plus wave reflection in systoli with or without
a decrease in diastolic pressure[DBP]. the cardiac output,intravascular
filling, renal blood flow & PRA Decrease while PVR,
LV wall thickness and mass increase .if an abrupt increase
in SBP & DBP occurs , one should suspect atherosclerosis
&/or renovascular disease.
It is worth noting that postural hypotension
[A fall in SP of 20mm Hg after 1 min quite standing]
is common in elderly hypertensive. in SHEP the incidence
was 10 % at 1 min & 12% At 5 min 17% at either.
the prevalence is higher if rising from a supine position
,I.e the higher the basal SBP the greater the postural
fall observed the most common mechanism, for this
is ;venous pooling in the legs,autonomic insufficiency,reduction
in baroreceptor sensitivity, splanchnic blood of after
eating &/or shifts in the threshold of cerebral
autoregulation.
Therapeutic intervention to control
hypertension in the elderly proved of value in 13 randomized
controlled trials and 6 large high quality trials .
the conclusion from such trials is that; the morbidity
& mortality of the treated group where significantly
better I.e only 18 elderly hypertensive and 15 ISH patients
needed treatment for 5y to prevent CV events ,A number
of explanation for this greater benefit has been proposed
namely ;the elderly start with much higher risk and
smoke less [better response to antihypertensive ].Also
being more recent ,the drugs assessed in most of such
trials were those of greater cardioprotection. however
treatment with low-dose diuretics or B-blockers was
still claimed by some to be of benefit whether in diastolic
or ISh .However ,the disclaimers to the general agreement
of such trials argue that they may not accurately reflect
what can be accomplished in clinical practice and that
benefits may be lessened in the very old
(over age 80 ) and had been only shown in those using
diuretics or calcium channel blockers [CCBs],but not
B-blockers.
Yet at this juncture,one has to Admit
That only A small minority of elderly hypertensive are
being treated ,thought Treatment of this category Seems
The judicious decision as; millions of people over the
age 65 have hypertension [predominantly or purely systolic],
their risk are significant ,and the benefits of their
treatment have been documented so therapy of such patients
should be gentle & gradual due to their increases
risk and be more cautious in the very elderly>80y
for fear of increased mortality.
The need for lifestyle modification
is one of the therapeutic objective, as enough data
is available to document its efficacy,so non drug therapy
should be applied before or instead of drug therapy
,dietary Na should be moderately restricted (100-120
mmo1/day) though its reduction is sometimes difficult
in the elderly.
Among drug treatment recommendations
that have been stated is; consider treatment for patients
up to age 80 with SBP>160/90 mm Hg.; the choice of
therapy should be individualized according to the presence
of concomitant conditions, first line therapy should
be low dose of diuretics,CCB and ACE Inhibitors can
be good alternatives and B-blockers are not the first
choice except in and ischaemics,other recommendations
suggest that; long action CCBs are an appropriate alternative
to diuretics and that home BP recording May be particularly
useful.
The golden therapeutic rule is ;start
with a lower dose better with (once-daily)smoothly working
preparation and watch out for drug interactions.
It is worth noting that the factors
that might contribute to the increased risk of pharmacological
treatment in the elderly are; the decrease in baroreceptor
activity [orthostatic hypotension].the impairment in
cerebral autoregulation [cerebral ischaemia with small
falls in BP],the decrease in intravascular volume [volume
depletion, hyponatraemia,],muscular weakness],the decrease
in existence of polypharmacy[drug accumulation ],the
existence of polypharmacy[drug interaction], and the
CNS changes [depression & confusion] and the CNS
changes [depression & confusion ].
Bibliography:
1- SHEP CO-operative research Group. prevention
of stroke by antihypertensive drug treatment in older
persons with isolated systolic hypertension. JAMA 1991;265:3255-3267.
2- MRC working party. Medical research council trial
of treatment of hypertension in older adults in the
elderly.BMJ 1992;304:405-412.
3-Mulrow CD, Cornall JA.herrera CR.,Hypertension in
the elderly .JAMA 1994;272;1932-38.
4-Coopola WGT.Whincup PH.walker M,Ebrahim S. identification
and management of stroke in older people . J Hum hypertension
1997;11:185-91.
5-Kaplan NM.(eds) clinical hypertension .7 Th.. eds.
Williams & Wilkins Awaverly company 1998;115-18,141.
6-Pascual J.Heart disease in older patients; the Practitioner.[EME]1999;10(1):25-29.
ABSTRACTS OF
WORLD LITERATURE
HYPERTENSION AND ITS TREATMENT IN THE NINDS rt-PA STROKE
TRIAL
Brott T et al.
Department of neurology , college of medicine,university
of Cincinnati, Bethesda,Cincinnati USA
Background : We examined the frequency,
course,and treatment of hypertension in the NINDS rt-PA
stroke trial.
Method: blood pressure (BP) was measured at the time
of admission ,at randomization ,and then 36 times during
the first 24 hours after randomization. patients with
a systolic BP of>185 mm Hg and a defined as hypertensive
before randomization, and those with a systolic BP of>105
mm Hg or a diastolic BP of> 105 mm Hg within the
first 24 hours after rawere defined as hypertensive
after randomization. standardized clinical assessments
were conducted at 24 hours and at 3 months .post association
of antihypertensive therapy with clinical outcomes
Result:of the 424 patients,121(19%) had hypertension
on admission and 372 (60%) had hypertension in the 24
hours after randomization .the use of antihypertensive
therapy before randomization (tPA 9%,placebo 29%) was
similar between placebo and tPA-treated patients NO.
adverse Effects of pre randomization antihypertensive
therapy on 3-month favorable outcome were detected for
either the placebo or tPA-treated Groups. for either
the placebo or tPA-treated groups .for placebo patients
with hypertension in the 24 hours after randomization
,clinical outcome measures were similar for those patients
who did and did not receive antihypertensive therapy
after randomization (p>0.26); antihypertensive therapy
was not associated with declines in BP (p=0.44) or with
abrupt declines (P=0.14), those tPA patients who were
hypertensive after randomization and received antihypertensive
therapy were less likely to have a favorable outcome
at 3 months (P<0.01) than those who were hypertensive
and did not receive antihypertensive therapyConclusion
:the frequency of hypertension and the use of antihypertensive
therapy were similar between the tPA and placebo group
in the NINDS rt-PA stroke Trial .in the placebo group,
antihypertensive therapy was not associated with less
favorable outcomes at 3 months; postrandomization antihypertensive
therapy was associated with less favorable outcomes
for the tPA patients who were hypertensive, however
,because of the nonrandomized post hoc comparisons leading
to type 1 errors,the significance of this observation
is unclear .careful attention to BP and gentle management
remain warranted for stroke patients treated with tPA..
stroke 1998;29:1504-1509.
ARTERIAL HYPERTENSION: THE NATIONAL
PROGRAM OF ITS PREVENTION AND TREATMENT IN UKRAINE
Gorbos 1, Smyrnova 1,Svisclienko E,Sirenko Y
Ukrainian Research Institute of Cardiology,Kiev,Ukraine.
Arterial hypertension (AH) is one of
the commonest disease in Ukraine. About 5 million persons
with arterial hypertension were registered in 1997 Annually
,In the course of people's primary visits to medical-prophylactic
institutions almost 430000 patients with arterial hypertension
were identified .According to the data of the epidemiological
investigation ,there are nearly 13 million people with
arterial hypertension in the country. and in half of
them a border-line arterial hypertension is established.62.0%
of all patients are aware of arterial hypertension presence,
23% receive treatment with an effective outcome in only
12.8% of them.
An unfavorable epidemiological situation
with regard arterial hypertension and its complications
that has been established in Ukraine can be Drastically
improved provided that high arterial blood pressure
has properly controlled, however, the population is
inadequately instructed about arterial hypertension
and possibilities for prevention of its complications,
not all arterial hypertension patients are identified
as yet. the mercury sphygmomanometer is lacking the
arterial hypertension diagnosis and treatment leave
much to be desired in Ukraine the production of modern
antihypertensive drug,accessible and affordable,is still
at low level and dose not meet needs of the patients.
there do not exist mechanism encouraging people to maintain
and strengthen their heals. there is no state policy
aiming to formulate healthy life style. thus, arterial
hypertension constitutes a national social challenge
that requires state support and CO-ordinated efforts
of different ministries and departments, in this connection
the national and program for arterial hypertension prevention
and treatment in Ukraine has been worked out .the program
is focusing to reduce morbidity associated with arterial
hypertension coronary heart disease and cerebrovascular
diseases.presented in 26Th. Annual meeting of the Egyptian
Society of Cardiology , Cairo,Egypt.February 1999.
SODIUM REDUCTION &WEIGHT LOSS IN
THE TREATMENT OF HYPERTENSION IN OLDER PERSONS.
RANDOMIZED CONTROL TRIAL OF Nonpharmacologic INTERVENTIONS
IN THE ELDERLY [TONE]
WELTON PK,APPEL LJ,ESPELAND MD,APPLEGATE WB ,ETTINGER
WH,KOSTIS JB ,KUMANYKA S,LACY CR,
JOHNSON KC, FOLMAR S CULTER JA..
TONE Collaborative Research Group, New Orleans,USA
Context : Nonpharmacologic intervention
are frequency recommended for treatment of hypertension
in the elderly ,but there is a paucity of evidence from
randomized controlled trials in support of this recommendation.
objective : to determine whether weight loss or reduced
sodium intake is effective in the treatment of older
persons with hypertension.
Design : Randomized controlled trial.
Participants : A total of 875 men and women aged 60
to 80 years with systolic blood pressure lower than
145 mm Hg and diastolic blood pressure lower than 85
mm Hg while receiving treatment with a single antihypertensive
medication.
Setting : four academic health centers .
Intervention : The 585 obese participants were randomized
to reduce sodium intake, weight loss , both or usual
care, and the 390 nonobese participant were randomized
to reduce sodium intake or usual care withdrawal of
antihypertensive medication was attempted after 3 months
of intervention .
main Outcome Measure :Diagnosis of high blood pressure
at 1 or more follow-up visits,or treatment with antihypertensive
medication , or a cardiovascular event during follow-up
( range, 15-46 months;median,29 months ).
Results :The combined outcome measure was less frequent
among those assigned Vs not assigned to reduced sodium
intake (relative hazard ratio.0.69;95% confidence interval
[C1],0.59-0.81;P<001 ) and , in obese participants
,among those assigned Vs not assigned to weight loss
(relative hazard ratio, 0.70; 95% C1,0.57-0.87;P<.001
) .relative to usual care, hazard ratio among the obese
participants were 0.60 (95% C1, 0.45-0.80;P<.001>
for reduced sodium intake alone, 0.64 (95% C1 , 0.49-0.85;
P=.002 ) for weight lose alone , and 0.47 (95% C1 ,
0.35-0.64; P<.001 ) for Reduced sodium intake and
weight loss combined . the frequency of cardiovascular
events during follow-up was similar in each of the treatment
group
Conclusion : Reduced sodium intake and weight loss constitute
a feasible, effective and save Nonpharmacologic therapy
of hypertension in older persons.
JAMA 1998,279;839-846.
ABSTRACT OF LOCAL
LITERATURE
ECHOCARDIOGRAPHY FINDINGS IN HYPERTENSIVE EGYPTIANS
RESULTS FROM THE EGYPTIAN NATIONAL HYPERTENSION PROJECT
(NHP)
Helmy SM,Gharib S,Sharaf Y ,Ibrahim MM Department
of Cardiology,faculty of Medicine, Cairo University.
Background : inspite of the well recognized
role of echocardiography in defining LV changes yet
there is lack of survey studies utilizing this technique
this resulted in the limited data available about the
effect of elevated blood pressure on LV structure and
function among large populations specially the untreated
and uncomplicated case
Objectives : 1) to study the prevalence of different
cardiac diseases as diagnosed by echocardiography in
a nation wide survey study including hypertensive and
normotensive population , 2 ) to study changes in IN
structure and function in hypertensive Egyptians
Patient population : Among 2313 cases surveyed in phase
11 of the Egyptian NHP, 1559 were hypertensive ( BP>
140/90 mmHg or receiving antihypertensive medications
) and 754 were gendermatched normotensive Echocardiography
was attempted on all individuals those with limited
image quality (90%) were excluded , different cardiac
disease (5.8% ) pericardial disease (1.2% ) regional
wall motion abnormalities (5.9%) cardiomyopathies (1.2%)
,and other cardiac disease (1.8%).
results : the prevalence of different cardiac disease
was less in normotensives (N) compared to hypertensives
(H) as follows: significant valvular heart Disease in
2.8% of N Vs 7.4% of H;pericardial disease in 0.6% of
N Vs 1.6% of H; regional wall motion abnormalities in
3.4% of N Vs 7.2% of H; cardiomyopathy in 0.1 Tc of
N Vs 0.8% of H;and others cardiac disease in 0.4% of
N Vs 2.5% of h the remaining population (n=1796,77.6%;751
N and 1145 H) was further studied for the prevalence
of LV hypertrophy and changes in LV geometry. Of those
4.8% had LV hypertrophy ;1.2% of N and 6.9 of H Prevalence
of normal LV (Nr), Concentric remodeling (CR) , concentric
hypertrophy (CH) and Eccentric Hypertrophy (EH) was
as follows; Total : 1796 [N : 651 & H:1145 ] -NR
: 88.6 % [N:96.6% & H:84.1%]-CR : 6.5%[N : 2.1%
& H: 9.0%-CH :3.6%[n : 0.19% & h: 5.1%] -EH
:1.3% [N :03 % & H : 1.8%].
Conclusion : results of echocardiographic survey study
of hypertensive Egyptian revealed a higher prevalence
of different cardiac involvement of compared to normotensives.
the prevalence of cardiac involvement was (15.9) with
LV Concentric hypertrophy is the least encountered presented
at 3rd scientific meeting of the Egyptian hypertension
society,port said ,Egypt ,December 1998.
IMPACT OF HYPERTENSIVE LVH ON QT DISPERSION
: A COMPARISON BETWEEN ECHO EVIDENCE AND ELECTROCARDIOGRAPHIC
EVIDENCE OF HYPERTROPHY
El Ashry MM,Attia H,Fahmy M.
Cardiology Department , Faculty of Medicine ,Ain shams
University.
Objectives :This study sought to examine
whether the QT dispersion (QTD) was affected by left
ventricular hypertrophy (LVH) in Systemic Hypertension
and if there is any difference in the degree of QT dispersion
between patients with ( LVH) detected only by the Echocardiogran
( Echo ) & those with LVH detected by both Electrocardiogram
( ECG ) and ECHO.
Background : This study sought to examine whether the
QT dispersion ( QTD ) was affected by left ventricular
hypertrophy
( LVH ) in systemic hypertension and if there is any
difference in the degree of QT dispersion between patients
with ( LVH ) detected only by the Echocardiogran (Echo
) & those with LVH detected by both Electrocardiogram
( ECG ) and ECHO .
Background QT dispersion is a predictor of myocardial
unstability hypertensive subject QTD is due to anatomic
modification induced by LVH .these anatomic changes
have the same effect on arrhythmia substrate
Methods : Thirty consecutive newly diagnosed hypertensive
subject with hypertension ,not on treatment were age
and gender matched for LVH ( n=16 ) versus no LVH as
a control group ( n=14 ). LVH patients were diagnosed
by 12 lead surface ECG and /or by 2d Echo, divided into
2 groups : group 1 patients with LVH by Echo only (
n=7 ) ,group 11 .patients with LVH by Echo & ECG
(n=9 ) QTD was manually measured on 12 lead surface
ECG .A computerized channel Holter system was used to
study the average number of premature ventricular beats/minute
Results : QTD was significantly high in the whole study
population ( 96.33 +21.48 msec. )compared to those of
control group with no LVH (57.14 + 15.4 msec. ) (p=0.001
) . QTD was greater in patients of group 11 than those
group 1 ( p=0.004 ) the LVH evidenced by ECHO only septum
( 13.14 + 1.8 ) post wall ( 11.17 + 1.25 ) QTD (65.71
+ 21.4 ) , while LVH evidenced by ECG & ECHO septum
( 16.96 + 2.5 ) post wall (15.14 + 2.06 ) QTD ( 91.11
+ 11.6 ) .patients of group II had higher septal and
posterior wall thickness than those of 1 .premature
ventricular beats were more prevalent in group II with
a mean rate of ( 10.66 +0.7 ) beat/minute (p=0.0008
) VS (5.02 + 10.7 ) beat minute
( p=0.1 ) in Group I the frequency of ventricular arrhythmia's
was greater in patients with QTD ( n=17 patient )
Conclusions : QTD is greater in Hypertensive Subjects
particularly those with LVH evident by EGG and ECHO
( with greater LV .wall thickness ) tan that diagnosed
by ECHO only significant QTD is associated with higher
incidence of ventricular arrhythmia's hypertensive patients.
presented in the 26 Th. Annual Meeting of the Egyptian
Society of Cardiology ,Cairo,Egypt, February 1999.
AMBULATORY BLOOD
PRESSURE CHANGES DURING EPISODES OF SILENT ISCHAEMIA
Radwan W,Ragab
F,Salah M, Mowafi H,Mokhtar S.
Critical Care Dept, Faculty of Medicine ,Cairo University.
Background : Silence of ischaemia does
not speak of mildness and silent ischaemia ( SI ) is
expressed first as regional wall motion abnormalities
( detected by ECHO ) ,and then as ST segment depression
( by ECG ) before pain may be evoked . less well known
is the possible occurrence of altered autonomic function
which classically accompanies pain episodes, namely,
changes in blood pressure.
Methods : to address this issue ,we studies 22 pts with
Ischaemic heart disease ( 8 females and 14 males ,
mean age 45 + 8.4y ) with the diagnosis of unstable
angina pectoris in 15 pts and post infarction angina
in 7 pts with the purpose of recording BP changes during
Ischaemic episodes using 24 hour BP recording . Ambulatory
recording was periodically carried out for BP and continuously
for ECG ,BP was recorded every 15 minutes and a reading
was taken at the time of Ischaemic episodes detected
by ST depression .
Results : out of 22 patients studied , 18 ( 27 % ) exhibited
episodes of silent ischaemia , 13 (59% ) did not show
ischaemia at one time or another , while only 4 (18%
) did not show ischaemia during recording. Systolic
BP average 144 + 20.09 mmHg , (range 120-, 180 ) during
silent ischaemia. 140 + 16.31 mmHg (rang 120-176) during
manifest Ischaemia versus 125.8+22.1 ( range 120 - 184
) with ischaemia free periods. diastolic BP ranged from
66 to 108 ( mean 82+10.83 ) mmHg during silent Ischaemic
episodes, from 47 to 112 (74.3+14.34) mmHg during Ischaemia
free episodes and from 54 to 107 (mean 81.61 +14.68
) mmHg during manifest Ischaemic .
Conclusion : Despite the limitations inherent to ambulatory
BP recording ,our data suggest that myocardial ischaemia
,whether manifest or silent ,is associated with an increase
in BP .Cause and effect relation between both are to
be elucidated , but the fact remains that BP is increased
in Silent ischaemia and adversely affected haemodynamics
would aggravate Ischaemic and set a viscous circle.
Presented at the 3rd Scientific meeting of the Egyptian
Hypertension Society, Port Said , Egypt, December 1998.
THERAPEUTIC AWARENESS NECESSITATES
:
Knowing that ,the recently introduced
,long acting non dihydropyridine Ca entry blocker [CCBs
],
Mibefradil : which blocks both the T [transient ] &
L [long ] type Ca channels ,bears life threatening drug-drug
interactions. The manufactures issued a warning letter
to physicians describing the supperssion of SA node
activity, occurring special in the elderly whom are
on concurrent B-blockers and emphasised that use of
the drug with digoxin, verapamil , diltiazem requires
great caution , Later on june 8th last year, the drug
was temporary vo luntary withdrawn by the manufact-urers
after the postmarketing surveillance had cleared that
the drug inhibits cytochrome P-450 enzyme CYP 3A4 and
interferes with the metabolism of at least 26 other
medicines. The dihydropyridine CCBs were not included
, yet since case reports unmasked the hazard of begining
with such group of CCBs in patients who are already
on mibefridil an B-blockers ,This has called the issue
of another warning supplement by June 12th this advises
a delay after discontinuation of miberfridil [half life
up to 25 hours ] to allow a prolonged washout period
of 7 days before considering begining B-blockers &
other CCBs THis period is to be increased to 14 days
in case of felopidine and timolol and is not required
in case of ACE inhibitors ,AT1 antagnoists & diuretics.
Due to such interactions, if myocardial depression or
hypotension issue high dose glucagon [5-10mg I.V. diluted
safer with or saline] to increase cAMP ,so as to enhance
a positive inotopic , dromotopic and chronotropic effects
is recommended .Repeated doses of Ca, vasopressors and
temporary pacing are often neccessary.
JAMA 1998;280:157-8
DIAGNOSTIC UTILITY IMPLIES :
Considering the pulse pressure a predictor of C.V. morbidity
& mortality, This was apparent in a french follow
up study conducted on 19,083 men aged 40-69 subjected
to routine examination .it was found that men whose
pluse pressure were greater than 65 mmHg had a three
fold increase in faftal coronary heart disease over
than those who had pulse pressure 45 mmHg or less .
this sinifites that pulse pressure is a good diagnostic
predictor. Thus, it is assumed that wilde pluse pressure
indicates indicates increased stiffness of larger arteries
and calls for aggressive therapy, it is proposed that
drugs that prevent or reverse sclerosis may be needed
in additition to the rational antihypertensives used
,
Hypertension 1997 ;3 (12):1410-5
EHS News & Calendar
EHS NEWS :
The annual Ramadan social gathering
was held last January at cairo sherton, New ideas to
expand the service of the society to the different governorates
was raised and will be organized by Prof ,Dr . Fathi
Maklady ,Public awareness and education at their social
gathering was also suggested.
The editorial committee of the News Letter of Egyptian
Society of Hypertension, is due to change in the coming
edition Prof. Dr.Mohsen Ibrahim has nominated Prof Dr.
Hassan Khaled Prof.of Cardiology Alexandria University
editor in chief and is whole heartily thanking Dr.Mohamed
Hamed the former editor for his executive elegant and
distinguished collaboration in making this News Letter
come to reality and progress throughout previous years.
CALENDER:
|
World Hypertension League 18Th Council Conference
and
workshop on Hypertension in the Elderly |
May 7,1999
Buenos Aires,
Argentine. |
Dr.Patrick J.Mulrow,
Secretary General,
World Hypertension League Medical College of Ohio
,Po Box 10008 Toledo,OH 43699-0008,USA e-mail :
gmonhollen@mco.edu |
|
Fourteenth Annual Scientific Meeting of the American
Society of Hypertension |
May 16-19,1999
New York
USA |
American Society of
Hypertension 515
Madison Avenue ,Suite 1212 New York NY
10022,USA. |
|
Symposium on
"what is new in hypertension |
13th May ,1999
Cairo Sheraton. |
Contact : Mrs Amany
Kandeel
Tel (202)362 4803-Fax (202) 363 9895 |
A STEP AHEAD WITH PERINDOPRIL
A major challenge to meet when tempting to control a
hypertensive patient is the emergence of prehypertrophic
or the establishment of overt left ventricular hypertrophy
[LVH] as a segregated or consecutive entity to the existing
pressure constrain. Once exists, it becomes a notion
of warning to the treating physician that the spectrum
of hypertensive heart disease [HHD] is now on the roll
and that one should be cognizant of its morphological
and functional alterations so as to try and halt its
progression by every possible mean.
Focusing on how things evolve clears that with pressure
constrains the myocardial texture gets disturbed namely;
the myocytes, the intramyocardial coronaries and the
interstium. Thus myocytes hypertrophy and get encased
by endomysial fibrosis, that will enhance their stiffness
and increase their 02 perfusion distance, to induce
a state of localized hypoxia. This together with thickening
of the intramyocardial coronaries [by medial hypertrophy
& adventetial fibrosis] is abet to impair the coronary
vasodilator reserve and create a state of microvascular
angina. This aside the concomitant progression of perimysial
fibrosis and microscars in the interstitum, coupled
to the disturbed myocardial relaxation will all contribute
to the diastolic dysfunction clinically characteristic
to HHD.
If triggers recycling such initially adaptive profile
are not curtailed by an appropriate therapeutic utility,
a switch to the maladaptive pole of the continuum sets
in. Thus, the increase microtubular hyperpolarization
within hypertrophied myocytes, will alter their viscoelastic
properties and increase the load within them to impede
their shortening. Also the microischaemic environment
created by hypertrophy and fibrosis, will trigger myocyte
apoptosis; a scenario that ends up by overt heart failure
with or without ischaemic episodes.
This molecular understanding of HHD is abet to highlight
the importance of having an antihypertensive like perindopril,
that has much More to offer, than just a 24 hours pressure
control, specially when the point of concern is its
ability to improve the coronary reserve.
This has been justified in many studies, one of which
has assessed the one-year utility of perindopril in
hypertensive with microvascular angina pectoris. Results
revealed that maximal coronary blood flow was increased
by 54% and minimal coronary vascular resistance was
significantly decreased [when quantified using Argon
method at basal condition and after microvascular vasodilatation
with pyridamole]. The calculated coronary reserve increased
then by 67% while the left ventricular mass decreased
by 11%, signifying that this improvement is more than
expected for regression of LVH alone. This preferential
improvement in coronary microcirculation validates the
utility of perindopril in cutting some of the triggers
that switch HHD to the maladaptive end of the continuum.
Moreover, perindopril like other ACE inhibitors was
shown to regress interstial fibrosis in endomyocardial
biopsies from hypertensive patients with normal coronary
angiogram but with microvascular angina. This seems
likely to be linked to the ability of such group to
increase bradykinin that will trigger the release of
arachidonic acid metabolites; prostacyclin being the
one specified in particular to suppress collagen gene
expression experimentally, in cardiac fibroblasts.
Thus, a dug with potentialities, that can interplay
on collagen metabolism to reverse fibrosis and that
can improve the coronary reserve and the existing diastolic
dysfunction, will offer optimum cytoprotection, that
enables it to step ahead to encompass HHD before it
might deteriorate to it morbid end points.
References:
- Circulation 1998; 98: 3801.
- Circulation 1998; 98: 4154.
- AJH 1998; 11:879.
- Hypertension 1998; 32: 84.
