György Ábrahám

Neurovascular Pulsatile Compression and Neurosurgical Decompression of the Rostral Ventrolateral Medulla in Medically Resistant Hypertensive Patients

Background/Aims: In cases of severe primary hypertension not responding to conventional medical therapy, neurovascular pulsatile compression of the rostral ventrolateral medulla on the left side may be considered as an etiological factor in the hypertension. Through neurosurgical decompression, the blood pressure can be reduced in these cases, and the conventional medication can also become more effective. Methods:The authors retrospectively analysed the changes in the blood pressure and therapy of patients with or without neurosurgical decompression over a 2-year period. The 2-year data were available for 9 operated and 7 non-operated patients with neurovascular compression. The data of control examinations performed 1, 3, 6, 12 and 24 months after the intervention (or after MR-angiography in the non-operated cases) were analysed. Results: After the decompression, both the systolic and diastolic blood pressure decreased significantly and permanently in all cases, and there was an improved response to the medication. In the non-operated group, the blood pressure did not change significantly during the 2 years. Conclusion: In severe hypertension that does not respond to conventional therapy, neurosurgical decompression of the brain stem on the left side can guarantee a long-lasting blood pressure reduction and a better response to antihypertensive medication.

Increased Short-Term Beat-to-Beat QT Interval Variability in Patients with Impaired Glucose Tolerance

Prediabetic states and diabetes are important risk factors for cardiovascular morbidity and mortality. Determination of short-term QT interval variability (STVQT) is a non-invasive method for assessment of proarrhythmic risk. The aim of the study was to evaluate the STVQT in patients with impaired glucose tolerance (IGT). 18 IGT patients [age: 63 ± 11 years, body mass index (BMI): 31 ± 6 kg/m2, fasting glucose: 6.0 ± 0.4 mmol/l, 120 min postload glucose: 9.0 ± 1.0 mmol/l, hemoglobin A1c (HbA1c): 5.9 ± 0.4%; mean ± SD] and 18 healthy controls (age: 56 ± 9 years, BMI: 27 ± 5 kg/m2, fasting glucose: 5.2 ± 0.4 mmol/l, 120 min postload glucose: 5.5 ± 1.3 mmol/l, HbA1c: 5.4 ± 0.3%) were enrolled into the study. ECGs were recorded, processed, and analyzed off-line. The RR and QT intervals were expressed as the average of 30 consecutive beats, the temporal instability of beat-to-beat repolarization was characterized by calculating STVQT as follows: STVQT = Σ|QTn + 1 − QTn| (30x√2)−1. Autonomic function was assessed by means of standard cardiovascular reflex tests. There were no differences between IGT and control groups in QT (411 ± 43 vs 402 ± 39 ms) and QTc (431 ± 25 vs 424 ± 19 ms) intervals or QT dispersion (44 ± 13 vs 42 ± 17 ms). However, STVQT was significantly higher in IGT patients (5.0 ± 0.7 vs 3.7 ± 0.7, P < 0.0001). The elevated temporal STVQT in patients with IGT may be an early indicator of increased instability of cardiac repolarization during prediabetic conditions.

Observations of Changes of Blood Pressure Before and after Neurosurgical Decompression in Hypertensive Patients with Different Types of Neurovascular Compression of Brain Stem

Aims: The neurovascular pulsatile compression of the rostral ventrolateral medulla can be divided into different subtypes. The posterior inferior cerebellar artery and/or vertebral artery can compress either the rostral ventrolateral medulla or the cranial nerves IX and X or both and on left, right or both sides. Methods: It was retrospectively investigated whether the types of neurovascular compression can influence blood pressure values. Data from 13 resistant hypertensive patients after decompression were investigated. Results: Six patients had 2 compressions, two had only medulla compression, four had only nerve compression on the left side and one had 2 compressions on both sides. There was no correlation between the types of compression and the levels of blood pressure, either before or after the decompression. Both, systolic and diastolic blood pressures and pulse pressure also decreased in all cases after the decompression but the change was significant only in the group with 2 compressions on the left side. Conclusion: According to our data, in a severe hypertension not responding to conventional antihypertensive therapy, the surgical decompression of the brain stem independently of the types of neurovascular compression could guarantee a decrease of blood pressure and improved sensitivity to antihypertensive medication.

Cardiovascular autonomic neuropathy and glucose variability in patients with type 1 diabetes: Is there an association?

Introduction The oxidative stress associated with glucose variability might be responsible for neuronal damage while autonomic neuropathy (AN) has a detrimental effect on metabolism. The aim of the study was to find relationship between AN and GV in type 1 diabetic patients and to identify further factors that affect GV. Patients and methods Twenty type 1 diabetic patients were involved (age: 39.5 ± 3.4 years, duration of diabetes: 17.5 ± 2.5 years; HbA1c: 8.1 ± 0.2%, mean ± SE). AN was assessed by the cardiovascular reflex tests. The interstitial glucose levels were determined following insertion of a subcutaneous electrode during the continuous glucose monitoring (CGM) method on six consecutive days. GV was characterized by calculation of four parameters. Results SD of interstitial glucose values correlated positively with the overall AN score and the degree of the orthostatic reduction of systolic blood pressure (AN-score-SD ρ = 0.47, p < 0.05; orthostasis-SD: ρ = 0.51, p < 0.05). Mean absolute glucose (MAG) correlated with three parameters of AN (AN-score-MAG: ρ = 0.62, p < 0.01; 30/15 ratio-MAG: ρ = −0.50, p < 0.05; orthostasis-MAG: ρ = 0.59, p < 0.01). The HbA1c also correlated with two parameters of GV (HbA1c-continuous overlapping net glycemic action: ρ = 0.56, p < 0.05; HbA1c-MAG: ρ = 0.45, p < 0.05). The frequency of hypoglycemia did not exhibit any correlation with measures of GV. Conclusion Severity of glucose variability but not overall glucose load correlates with both parasympathetic and sympathetic dysfunctions in type 1 diabetes. Higher HbA1c is associated with more severe glucose variability. The observed correlation between increased glucose variability and the severity of AN necessitates the further exploration of this relationship.

Investigation of cardiac autonomic and peripheral sensory neuropathy in diabetic and nondiabetic patients with hypertension.

Peripheral sensory function and cardiac autonomic neuropathy were studied in 18 nondiabetic and 10 type-2 diabetic hypertensives compared with 11 healthy controls. All the patients were treated with antihypertensive drugs. Cardiac autonomic neuropathy using Ewing method was detected in all patient groups. The current perception threshold values on peroneal nerve at 250 Hz in nondiabetic group and at 250 Hz and at 5 Hz in diabetic group were found increased compared with the controls. In conclusion, so-called typical complications of diabetes can be observed in nondiabetic hypertensives also. Our data might support the essential role of vascular factors in the development of neuropathy.

Enyhe szövettani eltérések ellenére gyors progressziójú proliferativ glomerulonephritis monoklonális immunglobulin-G-depozitumokkal

Proliferative glomerulonephritis with monoclonal immunoglobulin G (IgG) deposits is characterized by granular deposits of monoclonal IgG; histologically it has typically a membranoproliferative or endocapillary pattern, and seen electronmicroscopically there are dense deposits without substructure. Here, we present the case of a 62-year-old Caucasian woman who was admitted with rapidly progressive kidney failure. The patients status, the laboratory and imaging examinations did not support prerenal, postrenal and - among the intrinsic causes - vascular and tubulointerstitial origin. The proteinuria and dysmorphic microhematuria suggested rapidly progressive glomerulonephritis. Tests for anti-neutrophil cytoplasmic antibodies, anti-glomerular basement membrane, antinuclear antibodies and cryoglobulins were negative, the C3 and C4 levels were normal. The biopsy evaluation diagnosed proliferative glomerulonephritis with monoclonal IgG deposits because of mesangial granular deposits of IgG3-kappa, C3, and C1q, and ultrastructurally electron-dense deposits (incidence in our adult native kidney biopsy series: 0.18%). 31 glomeruli were assessed histologically. 29 glomeruli displayed mild mesangial hypercellularity, 2 glomeruli were globally sclerotic. Crescents were not observed. Mild arteriolar hyalinosis, interstitial fibrosis and tubular atrophy accompanied the glomerular alterations. In the postbiopsy evaluation, paraprotein or multiple myeloma was not detected. Despite the mild histological findings, the kidney failure progressed, and hemodialysis had to be started two weeks after the biopsy. Steroids, cyclophosphamide and rituximab did not affect her kidney function, and she remained on hemodialysis during the follow-up of 39 months. This report presents for the first time proliferative glomerulonephritis with monoclonal IgG deposits as the possible cause of rapidly progressive nephritic syndrome in the absence of pronounced glomerular proliferative, sclerotic or tubulointerstitial lesions. Orv Hetil. 2018; 159(38): 1567-1572.Proliferative glomerulonephritis with monoclonal immunoglobulin G (IgG) deposits is characterized by granular deposits of monoclonal IgG; histologically it has typically a membranoproliferative or endocapillary pattern, and seen electronmicroscopically there are dense deposits without substructure. Here, we present the case of a 62-year-old Caucasian woman who was admitted with rapidly progressive kidney failure. The patients status, the laboratory and imaging examinations did not support prerenal, postrenal and - among the intrinsic causes - vascular and tubulointerstitial origin. The proteinuria and dysmorphic microhematuria suggested rapidly progressive glomerulonephritis. Tests for anti-neutrophil cytoplasmic antibodies, anti-glomerular basement membrane, antinuclear antibodies and cryoglobulins were negative, the C3 and C4 levels were normal. The biopsy evaluation diagnosed proliferative glomerulonephritis with monoclonal IgG deposits because of mesangial granular deposits of IgG3-kappa, C3, and C1q, and ultrastructurally electron-dense deposits (incidence in our adult native kidney biopsy series: 0.18%). 31 glomeruli were assessed histologically. 29 glomeruli displayed mild mesangial hypercellularity, 2 glomeruli were globally sclerotic. Crescents were not observed. Mild arteriolar hyalinosis, interstitial fibrosis and tubular atrophy accompanied the glomerular alterations. In the postbiopsy evaluation, paraprotein or multiple myeloma was not detected. Despite the mild histological findings, the kidney failure progressed, and hemodialysis had to be started two weeks after the biopsy. Steroids, cyclophosphamide and rituximab did not affect her kidney function, and she remained on hemodialysis during the follow-up of 39 months. This report presents for the first time proliferative glomerulonephritis with monoclonal IgG deposits as the possible cause of rapidly progressive nephritic syndrome in the absence of pronounced glomerular proliferative, sclerotic or tubulointerstitial lesions. Orv Hetil. 2018; 159(38): 1567-1572.

The prevalence of resistant and undercontrolled hypertension among patients of a Hypertension Outpatient Clinic

Introduction. Around 57% of Hungarian hypertensive patients did not reach the goal blood pressure. According to an ESH Newsletter published in 2011, the prevalence of resistant hypertension is 2.9–43%. Objective. Analysing only the therapy of hypertensive patients of the Hypertension Outpatient Clinic of the University of Szeged, the authors wanted to answer following main questions: How many patients were therapeutically resistant according to the definition of resistant hypertension? How many patients were taking 3 or more antihypertensive drugs? How many of these patients reached target SBP values? How many drugs were usually used in combination therapy? Material and methods. Data were retrospectively collected from 01/01/2011 to 31/08/2011 from the electronic files of the hypertensive patients. Altogether 310 patients’ data were analysed, of all cases only one visit was taken into account. For those patients who visited the Clinic more than once during this period, only the first visit was considered. Means of two measurements were calculated. The goal SBP was 140 mmHg. Results. In this population, 234/310 (76%) patients had resistant hypertension according to the definition (158 ± 17/97 ± 8 mmHg). Three or more antihypertensive drugs were taken by 257/310 (83%) patients (136 ± 20 mmHg) and 134 of them (52% of 257 patients) reached the therapeutic goal. A fourfold combination of antihypertensive agents was the most frequent in this population. Conclusion. It is advised to use multiple drug combinations and it is recommended to spend enough time but not longer than necessary to find the most effective combination in every case.

Effect of left-sided brain stem decompression on blood pressure and short-term cardiovascular regulation in resistant hypertension

Effect of left-sided brain stem decompression on blood pressure and short-term cardiovascular regulation in resistant hypertension

Spontaneous baroreflex sensitivity and heart rate turbulence parameters: Parallel responses to orthostasis

Premature ventricular contractions (PVC-s) induce baroreflex mediated arterial pressure and heart rate fluctuations. PVC-related RR interval fluctuations detected on Holter ECG recordings could be characterized by the heart rate turbulence (HRT) parameters, including early post-extrasystolic acceleration, described by turbulence onset, and late deceleration, described by turbulence slope (TS). We have determined the increasing and decreasing spontaneous baroreflex sequence sensitivity (up- and down-BRS) parameters in supine and in upright position in 12 patients with VVI pacemaker while in sinus rhythm. Five–five premature ventricular pacemaker extrastmuli were also applied in both body positions and HRT parameters were calculated. Up- and down-BRS values showed a very close relationship with TS both in the supine (R = 0.94, P < 0.001 and R = 0.92, P < 0.001, respectively), and upright position (R = 0.96, P < 0.001, and R = 0.94, P < 0.001, respectively). The BRS indices decreased significantly upon tilting, which was paralleled by a significant decrease in TS (from 21.6 to 13.9 ms/cycle, P = 0.02). Our findings confirm the close association between TS and spontaneous BRS indices. The relationship is further supported by the similar postural behavior of these parameters. Our results suggest that the confounding effect of posture should be considered when analyzing Holter recordings.