Both Ambulatory Blood Pressure (ABP) recording and echocardiography provide some prognostic markers, however, their role in the routine management of hypertensive patients is not well defined. ABP correlates better with target organ damage than the casual office measurements. ABP is useful in the diagnosis of isolated office (white coat) hypertension and identifying a possible cause for resistance to antihypertensive drugs. Furthermore, ABP might help to decide when to initiate drug therapy in a subset of patients when there is a question about the need for drug intervention. Some symptomatic hypertensive patients are candidates for ABP studies in order to clarify the nature of their complaints. Finally, ABP is an important research tool for examining the effectiveness of a new antihypertensive drug. Although the procedure is easy with minimal discomfort to the patient, the large amount of data collected leaves in absence of consensus, a large number of unanswered questions. Which is more important, the average 24 hours systolic or diastolic pressure, the average day or night readings, the degree or absence of nocturnal dipping, the number of BP readings above a certain threshold and what is this threshold? White et a1(1) introduced the concept of daily BP load based upon the percentage of elevated readings during each time period using cut points of 140/90 mmHg for day time and 120/80 mmHg for night time readings. The same approach was used by Tsioufis et alt(2) in their recent study of the relation between ABP load with left ventricular geometry. Hypertensive patients were classified into four groups based upon the 24 hour SBP and DBP loads. Patients with the lowest load 24-h SBP and DBP loads <20% while in those with the highest loads the 24-hrs SBP and DBP load were 20.1-100%. This approach of categorizing hypertensive patients when compared with changes in left ventricular mass and geometry showed that the incidence of patients with normal LV geometry was significantly decreasing and the incidence of patients with concentric LV hypertrophy was significantly increasing as the degree of ABP load was increasing. Earlier echocardiographic studies showed that in hypertensive patients the pattern of concentric LV hypertrophy carries the worst prognosis(3).The study of Tsioufis et al has a number of practical implications. First, BP loads are better predictors of LV mass than mean 24-hour BP values. Second, in patients with mild hypertension when there is a question regarding initiating drug therapy, it seems reasonable to consider the percentage of abnormal ABP load value, level greater than 40% might be an acceptable threshold. Third, aggressive lowering of BP should be considered in high risk patients with high BP loads. Longitudinal studies are needed in order to support the prognostic value of ABP load and to define the threshold for initiating drug therapy.

M. Mohsen Ibrahlin, M.D.
Prof & Chairman, Department of Cardiovascular Medicine - Cairo
University. President of The Egyptian Hypertension Society.

THE PRESIDENT’S MESSAGE
AMBULATORY BLOOD PRESSURE AND LEFT VENTRICULAR
GEOMETRY

Both Ambulatory Blood Pressure (ABP) recording and echocardiography provide some prognostic markers, however, their role in the routine management of hypertensive patients is not well defined. ABP correlates better with target organ damage than the casual office measurements. ABP is useful in the diagnosis of isolated office (white coat) hypertension and identifying a possible cause for resistance to antihypertensive drugs. Furthermore, ABP might help to decide when to initiate drug therapy in a subset of patients when there is a question about the need for drug intervention. Some symptomatic hypertensive patients are candidates for ABP studies in order to clarify the nature of their complaints. Finally, ABP is an important research tool for examining the effectiveness of a new antihypertensive drug. Although the procedure is easy with minimal discomfort to the patient, the large amount of data collected leaves in absence of consensus, a large number of unanswered questions. Which is more important, the average 24 hours systolic or diastolic pressure, the average day or night readings, the degree or absence of nocturnal dipping, the number of BP readings above a certain threshold and what is this threshold? White et a1(1) introduced the concept of daily BP load based upon the percentage of elevated readings during each time period using cut points of 140/90 mmHg for day time and 120/80 mmHg for night time readings. The same approach was used by Tsioufis et alt(2) in their recent study of the relation between ABP load with left ventricular geometry. Hypertensive patients were classified into four groups based upon the 24 hour SBP and DBP loads. Patients with the lowest load 24-h SBP and DBP loads <20% while in those with the highest loads the 24-hrs SBP and DBP load were 20.1-100%. This approach of categorizing hypertensive patients when compared with changes in left ventricular mass and geometry showed that the incidence of patients with normal LV geometry was significantly decreasing and the incidence of patients with concentric LV hypertrophy was significantly increasing as the degree of ABP load was increasing. Earlier echocardiographic studies showed that in hypertensive patients the pattern of concentric LV hypertrophy carries the worst prognosis(3).The study of Tsioufis et al has a number of practical implications. First, BP loads are better predictors of LV mass than mean 24-hour BP values. Second, in patients with mild hypertension when there is a question regarding initiating drug therapy, it seems reasonable to consider the percentage of abnormal ABP load value, level greater than 40% might be an acceptable threshold. Third, aggressive lowering of BP should be considered in high risk patients with high BP loads. Longitudinal studies are needed in order to support the prognostic value of ABP load and to define the threshold for initiating drug therapy.

M. Mohsen Ibrahlin, M.D.
Prof & Chairman, Department of Cardiovascular Medicine - Cairo
University. President of The Egyptian Hypertension Society.

1. AM Heart 1989 118:182. 2.JHuman Hypert 1999, 13:677 3.NEng J Med 1990; 322:1561.

SCIENTIFIC NEWS

CONTENTS

Editorial

ARTERIAL PULSE WAVE VELOCITY
Yahia EL-Rakshy, MS, Ebtihag Hamdy, MD
Cardiology Unit, Faculty of Medicine, Alexandria University.

The pressure pulse generated by ventricular ejection is propagated throughout the arterial tree at a speed determined by elastic and geometric properties of the arterial wall, since the blood is incompressible. Thus, material properties of the arterial wall, its thickness, and the lumen diameter become the major determinants of pulse wave velocity (PWV).

PWV is calculated from measurement of pulse transit time and the distance traveled by the pulse between the two recording sites thus; PWV = Distance (meters)! Transit time (seconds). It is worth noting that, different signals can be used for measurement of PWV (Doppler, pressure, diameter), the most commonly used is the pressure signal recorded by a pressure transducer.

Previously, calculations of PWV was done manually (gold standard), but now it is automatically measured allowing real time on line assessment. The analysis of the determinants of aortic PWV in a large population showed that the two major determinants of PWV are age and systolic pressure as expressed in the formula: PWV m/s = 0.07 X systolic BP (mmHg) + 0.09 X age(y)-4.3

Carotid-femoral PWV is widely used to evaluate aortic distensibility because: pressure wave form can be easily recorded on these sites, the distance between these sites are large enough to allow an accurate calculation of time interval between successive waves and their PWV reflects arterial wall elasticity, which is widely related to that of the aorta.

The shape of arterial pressure waveform is determined by a forward wave that travels toward the periphery and a reflected wave that travels towards the heart. In the presence of optimal functional matching between the left ventricle and the vascular system, the reflected wave falls in the diastolic portion of central arterial waveform and generates a pressure increase that enhances coronary perfusion.

There is a qualitative association between the process of atherosclerosis and arterial rigidity; PWV studies indicate that hypertension contributes more than atherosclerosis to increased arterial stiffening with age. Thus, PWV depends on BP level ; the higher the pressure, the faster the speed of wave travel. Since PWV is related to wall elasticity, it become directly related to distending pressure.

Reduced carotid arterial compliance in nonoccluded arteries has been demonstrated in patients with coronary artery disease, in diabetic patients, and with high salt intake. A negative correlation was found between HDL-C and aortic PWV. But not with total plasma cholesterol. Reduced arterial compliance resulted in early return of reflected waves, so they reach the central circulation in late systole rather than in diastole, further augmenting systolic pressure. This phenomenon is associated with higher vascular impedance, an index of cardiac after load.

Quantitative information on the large arteries may be easily obtained by determination of PWV. This method enables one to evaluate indirectly arterial distensibility and stiffness. Reduced arterial distensibility contributes to disproportionate increase in systolic BP, and an increase in arterial PWV has also been shown to be associated with an increase in cardiovascular morbidity and mortality.

Augmentation index assessed in the proximal aorta is a means of quantifying the distensibility of the aorta through the effect of mechanical properties on the timing of the reflected pressure waves and hence of magnitude of augmentation of central pressure. This was measured with the use of radial artery applanation tonometry and a generalised transfer function. This new technique noted the dependence of augmentation index on heart rate, and the linear association between brachial and central BPs as assessed by the generalised transfer function.

Recently it was noted that for a given BP level, distensibility of the central arteries in hypertensive subjects may be altered as a function of various environmental and! or genetic factors that affect the composition of the extracellular matrix of the arterial wall.

BIBLIOGRAPHY:

ABSTRACTS OF WORLD LITERATURE
ELEVATED FASTING INSULIN PREDICTS INCIDENT HYPERTENSION: THE ARIC STUDY
Liese AD, Mayer-Davis U, Chain bless LE, Folsoin AR, Sharrett AR, Brancati FL , Heiss G

BACKGROUND: The prospective association of insulin and hypertension has been under debate in the context of the development of the insulin resistance or multiple metabolic syndrome. We examined the predictive associations of fasting serum insulin with incident hypertension occurring alone or as part of the multiple metabolic syndrome.
STUDY DESIGN & METHODS: Analyses were restricted to 5221 middle-aged participants of the Atherosclerosis Risk in Communities Study cohort who were free of component disorders of the multiple metabolic syndrome (hypertension; diabetes; high triglycerides and/or low HDL cholesterol (dyslipidaemias) at baseline.
RESULTS: A total of 1018 individuals developed hypertension, 80 1 in the absence of components of the metabolic syndrome and 217 in combination with diabetes or dyslipidaemias, between 1987 and 1993. Elevated fasting insulin (top quartile versus lowest quartile) was associated with overall incident hypertension in European Americans [hazard rate ratio (HRR) 2.0, 95% confidence interval (CI) 1.7-2.43 but the results were inconclusive in African Americans (HRR 1.3, 95% CI 0.9-1.8) after adjustment for age, gender and study centre. Among European Americans, body mass index and abdominal girth only partly explained the observed association. Elevated fasting insulin was more strongly predictive of hypertension occurring as a component of the multiple metabolic syndrome (HRR 2.4, 95% CI 1.5-3.9) than of hypertension occurring alone (HRR 1.3, 95% CI 1.01.7) adjusting statistically for age, gender, study centre, body mass index and abdominal girth.
CONCLUSION:The results are consistent with the concept of an aetiological heterogeneity for hypertension and may explain previously reported inconsistent findings on the association of insulin with incident hypertension.

Journal of Hypertension 1999 Aug; I 7(8):1169-1 177.

INCREASED SEVERITY OF MULTIFOCAL RENAL ARTERIAL FIBROMUSCULAR
DYSPLASIA IN SMOKERS.
Bofinger A; Hawley C; Fisher P; Daunt N; Stowasser M; Gordon R

Hypertension Unit, University of Queensland Department of Medicine, Greenslopes Private Hospital, Brisbane, Queensland, Australia.

Renal arterial fibromuscular dysplasia (FMD) is a significant cause of renovascular hypertension, especially in younger females. Tobacco constituents have been shown to stimulate proliferation and synthetic activity of cultured human vascular smooth muscle cells. We examined the relationship between smoking and severity of FMD in a group of 50 subjects with the multifocal form of renal arterial FMD. A detailed smoking history was obtained by interview, clinical data at diagnosis of FMD were obtained from medical records, and angiograms were reviewed. Clinical and angiographic features were compared between smokers and non-smokers. Twenty-four subjects were smokers. At the time of diagnosis of FMID, smokers were of younger mean age than non­smokers (38.7 years vs 48.9 years, P < 0.01), had a shorter median history of hypertension (1.5 years vs 8.5 years, P < 0.05), and had a higher prevalence of unilateral renal atrophy (67% vs 27%, P <0.01). The distribution of age at diagnosis of FMD was unimodal in non-smokers and bimodal, with a discrete group of younger subjects, in smokers. We conclude that cigarette smoking is associated with an earlier onset and increased severity of disease in a susceptible subgroup of patients predisposed to multifocal renal arterial FMD.

J Hum Hypertens 1999 Aug;13(8):517-20.

ABSTRACTS OF LOCAL LITERATURE

A MULTICENTRE RANDOMIZED COMPARATIVE STUDY ASSESSING THE EFFICACY AND
SAFETY OF AMLODIPINE VERSUS ISOSORBIDE MONO-NITRATE IN THE TREATMENT OF SYMPTOMATIC MYOCARDIAL ISCHAEMIA.

Rizk H*, Gharib S*,DiaaDardir M**, Kandil H* AbdEl Hamid M*, AbdAlaah M***, Khalid H****, Attia I***

Cardiology Department, Faculty of Medicine Cairo University,**National Heart Institute, ***Intensive care Unit, Matarya Hospital**** Intensive Care Unit, Faculty of Medicine, Cairo University, ***** Cardiology Department, Faculty of Medicine, Am Shams University.

Aim: We examined, in an open label multi-center study, the efficacy of Amlodipine, a 3rd generation dihydropyridine calcium channel blocker with negligible inotropic and chronotropic activity and high trough-to-peak ratio in relieving angina symptoms and prolonging treadmill exercise time in patients with stable effort angina as compared to long-acting iso-sorbide mono­nitrate[ISMN].
Methods: One hundred and twenty-three patients were randomized to receive Amlodipine 5 or 10 mg once daily[65(52.8%) patients] or ISMN 20 or 40 mg twice daily [58 or (45.2%) patients]. After a baseline symptom evaluation and exercise testing, the lower dose of each drug was started for 2 weeks and then doubled if no satisfactory relief of angina was observed. All patients were maintained on the adjusted dose for 4 weeks and then symptom evaluation and exercise testing were repeated. The two treatment groups were comparable regarding age, gender, number of anginal episodes/week, number of sublingual nitrate tablets consumed weekly, score of angina control, heart rate, systolic and diastolic blood pressure[BPI, total treadmill exercise time, maximal heart rate and BP reached, time to angina onset and time to ST segment depression.
Results: Both treatment lines improved symptoms markedly. However, am lodipine­treated patients had significantly fewer angina episodes/week [1.5 + 2.4 versus 3.6 ± 4.3, P<0.0l] and fewer sublingual nitrate pills consumed weekly [1.5 + 2.4 versus 3.1 ± 2.8, P<0.0 1] than those receiving ISM7N. Both drugs prolonged total treadmill exercise time .[from 7.6 + 3.0 mm. to 9.4 + 3.1 min. for amlodipine and from 8.1 ± 3.0 min to 10.7 + 10.4 min. for ISMN]. Neither treatment produced significant heart rate or blood pressure change. Severe adverse reactions leading to drug discontinuation were observed in 10.3% of patients on ISMN.
Conclusion: Compared to ISMN, the treatment of patients with chronic stable angina with Amlodipine resulted in fewer angina episodes, less sublingual nitrate consumption, comparable exercise tolerance, much less adverse reactions and no drug discontinuation.

Presented at the 4th Annual Meeting of the Egyptian Hypertension Society, Cairo, Egypt,. January 2000.

CIRCADIAN VARIATION IN THE ONSET OF ACUTE CORONARY ATTACKS IN
HYPERTENSIVE AND DIABETIC PATIENTS

YoussefM.M.A.; AbdelHamid M.E , Maaty A.., Khafagy M.A..
Faculty of Medicine, Mansoura University, Mansoura, Egypt..

Background: Although the functions of the cardiovascular system and the processes which control them are complex, variations in specific cardiovascular parameters with time were already reported at the end of the 1 9th century. The understanding of this circadian rhythmicity may carry important pathophysiologic implications. Circadian variation of the acute coronary attacks has been reported in many studies with different observation. The aim of this study was to investigate the circadian pattern of acute coronary attacks in diabetic and hypertensive patients.
Methods: This study included 1080 patients with acute coronary attack who were admitted to coronary care unit of Mansoura University Hospital during the period 1996-1999. The studied patients were divided into four groups: Diabetics (205), hypertensives (248), diabetic hypertensives (207) and non diabetic non hypertensives (420). All patients were subjected to history taking, clinical examination, ECG,and laboratory investigations as blood glucose, lipogram, serum creatine kinase, renal, and liver function tests.
Results: In the 1080 patients with acute coronary attack, the time of symptom onset was recorded. An early morning peak between 6 AM and 12 noon was observed in the total patient population, diabetics, hypertensives, and in different subgroup of patients e. g those with anterior or other type myocardial infarction. Diabetics showed also a late evening peak between 6 PM and 12 midnight while hypertensive patients showed only the early morning peak. Modifying factors as gender, smoking, heavy dinner, and evening work do not affect the early morning peak, but smoking, heavy meals and evening work increase the incidence of late evening peak 6 PM - 12 midnight
Conclusion: The presence of two peaks indicated that two period of susceptibility may exist for some patients or that one set of patients in a subgroup has a morning and the other set has an evening period of susceptibility. The early morning peak in recorded in all groups of patients while the late evening peak is affected by some factors. Thus the circadian pattern of symptom onset of acute coronary attacks may be changed at least in part by presence of diabetes, hypertension and some modifying factors such as smoking and evening work.

Presented at the 27th Annual Congress of the Egyptian Society
of Cardiology, February 21 th - 25th, 2000. Cairo, Egypt.

PLASMA LEVEL OF HOMOCYSTEINE IN PATIENTS WITH ESSENTIAL ARTERIAL HYPERTENSION

Esmaeel EM., El-Badri M., Hassan MRA., Gomaa A
Internal Medicine & Biochemistry Departments, Benha Faculty of Medicine, Zagazig University, Egypt.

Background: There is no consensus about the association between arterial hypertension and homocysteine (Hcy), a vascular injuring amino acid found to be an independent risk factor in some cardiovascular disorders.
Methods and Results: In this study, plasma Hcy levels were assessed in 45 hypertensive patients classified into three equal groups with mild, moderate and severe hypertension, as well as in 15 healthy normotensive subjects by high performance liquid chromatographic method. Results showed statistically significant elevation in plasma Hcy mean values in hypertensive patients compared to normotensives (9.92 ± 0.3 vs 8.95 ± 0.26 nmol/mI, p < 0.01) and this elevation increased significantly with the increase in severity of hypertension ( mild: 9.54 + 0.1 5- moderate: 9.84±0.1 and severe:10.36 ± 0.2 nmol / ml) Significant positive correlation was noticed between plasma Hcy levels and each of age of patients (r -+ 0.322, p < 0.05) and stage of severity of Hypertension (r-±0.396, p< 0.01).
Conclusion : Plasma Hcy levels increased significantly in patients with essential arterial hypertension with a significant positive correlation between it and stage of severity of hypertension. The interrelationships between Hcy and hypertension became clear, it seems wise to recommend the estimation of plasma Hcy levels as a part of hypertension risk assessment, as well as the administration of Hcy lowering Vitamin B6, B 12 and folic acid to hypertensives hoping to improve the outcome of the disease.

Presented at the 4 World Congress of Echocardiography &
Vascular Ultrasound, Cairo-Egypt January 2000.

THE 3rd PAN-ARAB CONFERENCE PORTFOLIO; Abu Dhabi, February, 2000.

CURRENT STATUS OF HYPERTENSION IN KUWAIT
WAEL EL-RESHATD AL-BADER,
Artificial Kidney Center, Kuwait.

Hypertension is a major medical problem in Kuwait. The existing data from a nation wide study (1997) of non hospitalized patients (n--5233) show that the overall incidence of hypertension is 26.3% (males 28.3%, females 22.9 %). The incidence increases with age. Unawareness of hypertension is high (77%). The majority of patients (86%) have mild hypertension (diastolic blood pressure <110 mmHg). Higher proportion of hypertensives exists in diabetics after the age of 35 years as well as in obese patients. Family history, cardiovascular disease and smoking do not constitute risk factors for hypertension in Kuwait. Although B-blockers and diuretics are still the first line antihypertensives, there is a dramatic increase in the use of Angiotensin converting enzyme inhibitors and calcium channel blockers due to their added cardiovascular and renal protective effects. Hypertension constitutes the fourth cause for hospital admissions and the fourth leading cause for end-stage renal disease in Kuwait. However there is no decline in die death rate attributed to hypertension over the past 10 years (73.3 per 100,000 population). Strategies for the management of hypertension in Kuwait includes improving public awareness and strict monitoring of blood pressure with regular follow up by the treating physicians.

CURRENT STATUS OF HYPERTENSION IN BAHRAIN
DR. ABDUL HAL AL AWADHI, M.D.
Salmaniya Medical Complex, Bahrain.

An elevated arterial pressure is probably one of the most important public health problem in Bahrain whereby the number of patients with hypertension and its complications are comparatively, high. And since hypertension is commonly asymptomatic, readily detectable, usually easily treatable disease which often leads to lethal complication if left untreated, thus it was of concern to implement extensive educational programs by private, governmental and international agencies in our community. As a merit of this, the number of untreated patients has become significantly reduced in Bahrain to level less than 20%. In this respect, 2 studies were conducted in Salmaniya Medical Complex [the biggest hospital in Bahrain, with 1000 bedded capacity and it is the territory referral hospital] to find out the incidence and the complications of hypertension in the year 1987-1989 and 1994. However a recent survey (1998) showed that the number of hypertensive patients is still increasing by double. In such a survey the systemic pressure of more than 140/90 was taken as the entry Criteria for the study. The age group ranged from 26 to 89 years. Comparative analysis of these studies have shown that even though the number of patients with hypertension has increased by 2 fold, there is a significant reduction in the incidence of complication related to hypertension

CHALLENGE YOURSELF!

A 44-years-old man was refereed for treatment of hypertension. He complained of easy fatigability and mild dyspnea on exertion but denied other cardiac symptoms.

Physical Examination: Vital signs; pulse; 90; BP; 170/100. Cardiac: PMI forceful in the fifth interspace 2 cm to the left of the mid-clavicular line; II/ VI short systolic ejection murmur to the left of the sternum.
Extremities: Femoral pulses present but diminished in strength.
Investigation; Chest radiography demonstrated notching of the ribs, indentation on one side and dilatation on the other side of the aorta. While Doppler interrogation demonstrated increased flow velocitry.

Question: What is the likely cause of the patient’s hypertension and easy fatigability?
Pick up the solution at CARDIOLOGY PEARLS on p. [7] of this issue.

PRACTICAL CONSIDERATIONS HYPERTENSIVE WOMEN
When your patient is pregnant;

Ask about her relevant pre-gestational history [stressing whether hypertension antedates pregnancy] then inquire about her gestation; whether nulliparous or multiparous, what is her gestational week, what are the ultrasound findings. Then proceed to ask for lab investigations focusing on; urine analysis , kidney and liver function tests, complete blood picture, coagulation . . .etc. This will help you in her categorization as being ; chronic hypertensive per Se, preeclampsia-eclampsia, preeclampsia superimposed upon chronic hypertension or transient hypertension.

This is important because hypertensive pregnant females n>’d utmost care. Hypertensive disorders during pregnancy are important causes of stillbirths, neonatal morbidity and mortality and maternal death, most of which is attributed to eclampsia. The potentially lethal complications then are notably; abruptio placentae, disseminated intravascular coagulation (DIC), cerebral hemorrhage, hepatic failure, and acute renal failure.

So, diagnose essential [chronic] hypertension, when blood pressure is; greater than 140/90 mm Fig and remains elevated (with or without therapy) below diastolic levels of 100 mm Hg (Korotkoff phase V)]and when exists prior to pregnancy, or, detected before the 20th week of gestation Land when persists beyond the 42nd day postpartum. Complications such as rnidtrimester loss, growth retardation, and abruption may occur. However it is worth noting, that women with essential hypertension often experience reductions in blood pressure during the first two trimesters; failure for this to occur is an unfavorable prognostic sign.

Think of transient hypertension, when mild to moderate pressure develops late in pregnancy, which returns to normal postpartum. It can also show in the first 24 hours postpartum without other signs of preeclampsia or preexisting hypertension. This condition is rather benign yet is often predictive of the eventual development of essential hypertension. If any uncertainty regarding the diagnosis exists, these patients should be managed as preeclamptics.

The most important of all is not to miss a case of preeclampsia. It is a disease peculiar to pregnancy, mainly in nulliparas, presents primarily after gestational week 20, but most frequently near term. it represents the greatest danger for the fetus and is associated with life-threatening maternal syndromes. The incidence is also unclear, but one estimate from an indigent population is calculated to be about 13 percent, and incidences ranging from 10 to 20 percent have been noted in nulliparous women. A major pathophysiological feature of this disease is a marked increase in peripheral resistance. This vasospasm is due, in part, to exaggerated vascular responsiveness to circulating Angiotensin II and catecholamines (and possibly an imbalance between thromboxane and prostacyclin production). Prior to intervention, cardiac output is often decreased, pulmonary capillary wedge pressure is normal or low, and intravascular volume is below that of normal pregnant women. Retinal hemorrhage, exudates, or papilledema are added diagnostic clinical criteria. Renal hemodynamics also decrease due, in part, to a characteristic morphological lesion in the glomerulus, and there may be increased vascular permeability leading to albumin loss from the intravascular space. Uteroplacental perfusion is often compromised, which may lead to fetal growth retardation. Laboratory signs helpful in the diagnosis, are presence of proteinuria [2.0 gm or more in 24 hours], elevated creatinine [>1.2 mg/dL], platelet count L<100,000 microliters], edema (especially if of recent and rapid onset), and any of the following: hemoconcentration, hypoalbuminemia, hepatic function and/or coagulation abnormalities, and increased urate levels. Predictive value of raised serum iron, low antithrombin Ill, and hypocalciuria are under investigation. It can lead to two life-threatening complications.The first is a rapidly developing syndrome characterized by microangiopathic hemolytic anemia and marked signs of liver dysfunction as well as coagulation changes. This variant, termed HELP (hemolysis elevated liver enzymes low platelet count), constitutes an emergency requiring prompt pregnancy termination. The second complication is progression of preeclampsia to a convulsive
phase termed eclampsia, which at one time was the major cause of cerebral bleeding and maternal mortality in this disorder, also an emergency that requires immediate termination of gestation.

Because the preeclamptic syndromes and essential hypertension comprise over three-quarters of the hypertensive disorders in pregnancy, therapeutic approach to control them is so important and will be raised in the forthcoming issue.

[NHBPEP] Working Group Report On High Blood Pressure In Pregnancy NiH Publication No. 9 1-3029.

6th report of Joint National Committee on Prevention, Detection, Evaluation and Treatment of HBP.NIH Publication No. 98-4080.

HYPERTENSION TRIAL SURPRISE:

The National Heart, Lung, and Blood Institute [NHLBI] has prematurely halted one arm of a major trial of hypertension drugs because patients taking one of the drugs-an &-drenergic blocker- did not fare as well as patient taking a more traditional diuretic. The main portion of the Antihypertensive and Lipid Lowering Treatment to Prevent Heart Attack Trial [ALLHAT] was designed to compare four classes of drugs: an o­adrenergic blocker [doxazocin], a calcium antagonist [Amlodipine], an Angiotensin converting enzyme inhibitor [lisinopril] and a diuretic [chlorthalidone].

The NHLBI canceled the doxazocin arm of the study after the trial’s data safety monitoring board discovered that study participants who were taking doxaszocin had 25% more cardiovascular events and were twice as likely to be hospitalized for congestive heart failure as those who were taking chlorthalidone. The two drugs were similarly effective in preventing heart attacks and in reducing the risk of death from all causes. Based on the new findings, the NHLBI advised patients with hypertension who now take an &-adrenergic blocker to consult with their physicians about a possible alternative.

JAMA, Middle East 2000; 10(6).

CARDIOLOGY PEARLS

Diagnosis: Coarctation of the aorta

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