S. Sonkodi

Rosuvastatin and Cardiovascular Events in Patients Undergoing Hemodialysis

BACKGROUND Statins reduce the incidence of cardiovascular events in patients at high cardiovascular risk. However, a benefit of statins in such patients who are undergoing hemodialysis has not been proved. METHODS We conducted an international, multicenter, randomized, double-blind, prospective trial involving 2776 patients, 50 to 80 years of age, who were undergoing maintenance hemodialysis. We randomly assigned patients to receive rosuvastatin, 10 mg daily, or placebo. The combined primary end point was death from cardiovascular causes, nonfatal myocardial infarction, or nonfatal stroke. Secondary end points included death from all causes and individual cardiac and vascular events. RESULTS After 3 months, the mean reduction in low-density lipoprotein (LDL) cholesterol levels was 43% in patients receiving rosuvastatin, from a mean baseline level of 100 mg per deciliter (2.6 mmol per liter). During a median follow-up period of 3.8 years, 396 patients in the rosuvastatin group and 408 patients in the placebo group reached the primary end point (9.2 and 9.5 events per 100 patient-years, respectively; hazard ratio for the combined end point in the rosuvastatin group vs. the placebo group, 0.96; 95% confidence interval [CI], 0.84 to 1.11; P=0.59). Rosuvastatin had no effect on individual components of the primary end point. There was also no significant effect on all-cause mortality (13.5 vs. 14.0 events per 100 patient-years; hazard ratio, 0.96; 95% CI, 0.86 to 1.07; P=0.51). CONCLUSIONS In patients undergoing hemodialysis, the initiation of treatment with rosuvastatin lowered the LDL cholesterol level but had no significant effect on the composite primary end point of death from cardiovascular causes, nonfatal myocardial infarction, or nonfatal stroke. (ClinicalTrials.gov number, NCT00240331.)

Is interview a reliable method to verify the compliance with antihypertensive therapy? An international central-European study

Background Non-compliance with prescribed antihypertensive medication is an important contributor to the failure of antihypertensive therapy. Objective To assess the validity of a short questionnaire in the identification of non-compliant patients. Methods In three central-European countries, work-site screening for hypertension was conducted. Blood pressure was measured using an automatic electronic blood pressure measuring device (BpTRU). Respondents were interviewed by trained personnel and a short questionnaire focused on blood pressure awareness and treatment compliance was completed. Results A total of 2812 persons were screened: 841(29.9%) respondents were hypertensive, and out of these the total number of treated hypertensive subjects was 359 (42.6%). Mean systolic blood pressure and diastolic blood pressure were significantly lower in the compliant group than the non-compliant group (systolic blood pressure, 139.4 and 146.2 mmHg, respectively, P = 0.002; and diastolic blood pressure, 89.2 and 92.3 mmHg, respectively, P < 0.01). The non-compliant group was younger than the compliant group (mean age, 46.7 versus 48.9 years, respectively, P = 0.01). Females, patients on combined therapy and non-smokers were more compliant than males, those on mono-therapy and smokers (P = 0.01, P = 0.004 and P = 0.005, respectively). Conclusion Patients reporting strict compliance with prescribed drug therapy have significantly lower systolic blood pressure and diastolic blood pressure than those who admit even an occasional lapse in taking medication. A properly formulated questionnaire can identify non-compliant patients.

STRATEGIES FOR IMPROVEMENT OF AWARENESS, TREATMENT AND CONTROL OF HYPERTENSION: RESULTS OF A PANEL DISCUSSION

High blood pressure (BP) is a major risk factor for coronary heart disease, heart failure, stroke, chronic kidney disease, end stage renal disease, and a variety of other clinically important outcomes.1, 2, 3, 4 Results from the surveys described in this issue and elsewhere5 underscore a common finding that hypertension is both highly prevalent and insufficiently treated and controlled. Recognizing the differences in sampling and survey measurement techniques, the reported prevalence of hypertension (SBP/DBP ≥140/90 mmHg or treatment with antihypertensive medication) in adults exceeded 25% in all of the surveys reported in this issue. In Latvia, the prevalence of hypertension for 25–64-year-old adults in the general population was 46.1%.6 Control of hypertension with medication to an SBP/DBP <140/90 mmHg in the general population ranged from as low as 12% to a high of only 29%.7, 8, 9 Data from other parts of the world provide an equally distressing picture of what is (not) being accomplished in treatment and control of hypertension at the level of the general population.5, 10, 11 These data provide testimony to an urgent need for greater attention to the treatment and control of hypertension in populations around the world. This was the basis for a panel discussion at the International Society of Hypertension satellite conference The Epidemiology of Hypertension-Regional Differences in Treatment and Control. Panel participants included Drs P Whelton, S Sonkodi, DG Beevers, JG Fodor, H Elliot, R Cifkova, A Nissinen, A Javor, and there was active participation of other symposium attendees. The following summarizes key elements of the discussion and recommendations of the panel.

Work-site hypertension prevalence and control in three Central European Countries

Compared to Austria, cerebrovascular stroke (CVS) mortality is three times higher in Hungary, and twice as high in Slovakia. We hypothesized that this is due to better treatment and control of hypertension in Austria. To test this hypothesis, we carried out a cross-sectional survey of ‘blue collar’ employees on work sites in each of these countries. Blood pressure screening was carried out at three work sites in Austria, one in Hungary and one in Slovakia. A standardized protocol was followed in each of these countries. The Bp-TRUTM measuring instrument was used to provide accurate reproducible readings and eliminate interobserver error. After the exclusion of missing data and women, the study population included 323 males screened in Austria, 600 in Hungary, and 751 in Slovakia. The mean ages of the respondents ranged from 35 to 42 years. The prevalence of hypertension was 29% in Austria, 28% in Hungary and 40% in Slovakia. Of those identified as hypertensive, 73% in Austria, 45% in Hungary and 67% in Slovakia were newly diagnosed as a result of this screening. Of those treated for hypertension, 10% in Austria, 15% in Hungary and 5% in Slovakia were controlled. The differences in CVS mortality cannot be explained by better control of hypertension in Austria but indicate the involvement of other determinants.

High Prevalence of Prehypertension and Hypertension in a Working Population in Hungary

BACKGROUND Hungary has one of the highest mortality rates due to strokes among the European Union countries. As elevated blood pressure (BP) is the principal risk factor for strokes, we assessed BP levels, as well as awareness and treatment status of hypertension and prehypertension in a working population sample in Hungary. METHODS Worksite employees in Budapest and Szeged were screened for their BP using an automated BP measuring instrument (BpTRU). BpTRU readings of heart rate (HR) were also recorded. Respondents were classified as normotensives (NT), prehypertensives (PHTN) and hypertensives (HTN) according to their BP levels, as defined by the JNC 7 guidelines. Body height and body weight were measured and body mass index (BMI) was calculated. Self-reported information regarding smoking was collected. RESULTS In total, 2,012 respondents were recruited (1,000 white collar; 1,012 blue-collar workers), with a mean (±s.d.) age of 34.8 (±9.9) years. Of all respondents, 22.6% were identified as HTN and 39.8% as PHTN. Among HTN, 40% were unaware of their condition and only 18.5% were adequately treated. PHTN were similar in age as NT, but showed significantly higher HR. CONCLUSIONS A high proportion of relatively young and apparently healthy Hungarian employees were diagnosed with prehypertension and hypertension. Only a small proportion of HTN had their BP controlled. BMI and HR were significantly higher among individuals with prehypertension compared to NT. Whether the high rates of hypertension, prehypertension, and low levels of control explain the high stroke mortality and unfavorable cardiovascular disease (CVD) profile of Hungary needs further study.

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.

Changes in left ventricular mass during treatment with minoxidil and cilazapril in hypertensive patients with left ventricular hypertrophy

Attainment of the regression of hypertension-associated left ventricular hypertrophy (LVH) seems to be a desirable goal of blood pressure (BP)-reducing therapy. Since antihypertensive drugs of differing types may exhibit markedly different abilities to modulate LVH, we examined the effects of the angiotensin-converting enzyme inhibitor cilazapril, and the potassium channel activator minoxidil, alone or in combination with each other, on the left ventricular mass (LVM) in patients with severe essential hypertension who had LVH detected by echocardiography. All patients received the same base therapy of bopindolol and guanfacine. After a run-in period, they were treated with: (1) cilazapril (n = 10); (2) minoxidil, combined with a diuretic (n = 10); or (3) both cilazapril and monoxidil (n = 6) for 12 months. The LVM index (LVMI; LVM per body surface area) was estimated every 3 months by means of echocardiography. Each kind of therapy decreased the arterial pressures to a similar degree. The 1-year treatment with the cilazapril-based regimen resulted in a significantly diminished LVMI (from a mean ± s.d. of 173 ± 38 to 152 ± 22 g/m2; P < 0.05). on the other hand, the minoxidil-based therapy led to a significant increase in lvmi (from 148 ± 19 to 170 ± 35 g/m2; P < 0.05). there were no significant lvmi changes in patients receiving the combined, cilazapril + minoxidil-based treatment (172 ± 34 vs the pretreatment 183 ± 54 g/m2). The results confirm that long-term treatment with cilazapril is effective both in reducing BP and in reducing LVM. In spite of yielding a satisfactory reduction of BP, minoxidil therapy, even in combination with a diuretic and a β -blocker, may lead to an aggravation of pre-existing LVH; this effect of minoxidil could be prevented by the simultaneous administration of cilazapril.

Hypertension screening in a salami factory: A worksite hypertension study

The prevalence, awareness and control of hypertension are important epidemiological research topics worldwide. The screening of hypertension in a workplace has some special aspects. We have screened the employees in a Hungarian salami factory (Pick Salami Factory, Szeged, Hungary) for hypertensives. In a cross-sectional survey, the blood pressure (BP) was measured with an instrument meeting accepted measuring principles (BP-TRUTM BP) and a questionnaire was filled. In all, 1012 factory workers were screened (600 male and 412 female) and 25.7% of the workers proved to be hypertensives. Of these, 61.5% of the hypertensive employees were aware that their BP is high. Among the treated hypertensives, 21.9% were controlled. These results suggest that the efficacy of the management of hypertension in Hungary cannot be solely responsible for the high cardiovascular morbidity and mortality. The improvement of the management of hypertension should decrease the cardiovascular risk in the hypertensive population. The worksite screening and follow-up of hypertension seem to be logical health service solutions. This has been proven to be cost-effective.

Membranous nephropathy accompanied by angiolymphoid hyperplasia of the skin

A 24-year-old female developed a painless swelling adjacent to the left ear. This was shown to be eosinophilic angiolymphoid hyperplasia (ALH). Three months later she developed a nephrotic syndrome. Renal biopsy revealed membranous nephropathy. This is the first non-Japanese case of dermal eosinophilic ALH and nephrotic syndrome; steroid treatment followed by surgical removal of the tumour resulted in complete remission in the renal lesion.

A cross-national comparative study of blood pressure levels and hypertension prevalence in Canada and Hungary

Purpose: Hungary has one of the highest cardiovascular (CV) mortality and stroke rates compared to other countries in Europe and North America. Data from two recent blood pressure (BP) screening projects in Hungary and Canada provided us with the opportunity to compare potential differences in the prevalence of hypertension between these countries. Methods: From the Ontario Blood Pressure Survey, 880 white Canadians between 20 and 62 years old with white-collar occupation were selected and compared with a total of 1000 Hungarian bank employees in the same age range. Identical methods were employed for CV risk factor screening and BP measurements using the BpTRU instrument. Hypertension was defined by elevated BP measurement (SBP ≥140 mmHg and/or DBP ≥90 mmHg) or current intake of antihypertensive medication. Results: Canadian participants were on average 10 years older with a higher rate of obesity, diabetes and high cholesterol. Smoking was more prevalent among Hungarians (29.4 vs. 22.5%, P < 0.001). Despite being younger, Hungarians exhibited significantly higher SBP (121.3 ± 4.3 vs. 111.6 ± 14.1, P < 0.001) and DBP (78.5 ± 10.5 vs. 70.8 ± 9.5, P < 0.001), which remained significant after adjustment for age and use of antihypertensive medication as well as sex and CV risk factors. Age-adjusted prevalence of hypertension was significantly higher and poorly controlled among Hungarians (P < 0.001). Conclusion: The increased prevalence of hypertension among young and middle-aged Hungarians compared with Canadians could represent an essential contributor to the high CV mortality and stroke rates in Hungary. BP awareness, treatment and control require improved medical attention and should be addressed early among young Hungarians.