LAM Extra for General Practicioners


WAGNER Gyula, AMMA Zoltán, JUHÁSZ László, KULCSÁR Katalin

DECEMBER 20, 2010

LAM Extra for General Practicioners - 2010;2(05)



Further articles in this publication

LAM Extra for General Practicioners

[Candesartan in Heart failure - Assessment of Reduction in Mortality and morbidity programme]


LAM Extra for General Practicioners



[Headache is one of the most common complaints in clinical practice. The International Headache Society’s current classification distinguishes two major categories of headache: primary and secondary (symptomatic) headache types. The former types, which account for the majority of headaches, are caused by a functional disorder in a structurally intact nervous system and are characterised by stereotypical attacks that resolve - in most cases - spontaneously after a certain period, the duration of which is characteristic for each headache type. The diagnosis of primary headaches is based on a detailed history of the attacks and negative results on a neurological examination. At the first presentation of the patient, it should be determined whether a potentially serious or life-threatening condition might be present, whether the type of the patient’s headache can be ascertained according to the IHS’s criteria, and what kind of examinations are needed to establish the correct diagnosis. A detailed history is the cornerstone of the diagnosis of primary headaches and it cannot be substituted by instrumental examinations. The use of imaging and other examination methods is necessary for the diagnosis of secondary headaches, but if the patient’s history and the results of the neurological investigation are fully consistent with a primary headache type, instrumental examinations are unlikely to provide any additional information. Although establishing the correct diagnosis is often time-consuming, it is necessary for the efficient treatment.]

LAM Extra for General Practicioners


BODA Zoltán

[A new era of anticoagulant therapy is approaching. No new oral anticoagulants have been introduced for seventy years. However, two large groups of anticoagulants (molecules with anti-FXa and anti-FIIa acitivity) are currently at advanced stages of clinical trials. This publication summarises the most important information on the mechanism of effect of the anti-FXa drug rivaroxaban. The possible advantages of the “direct” effect and the anti-FXa effect are emphasized. The most significant drug interactions of the new anticoagulant are also presented.]

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[Association between cyclothymic affective temperament and hypertension]


[Affective temperaments (cyclothymic, hypertymic, depressive, anxious, irritable) are stable parts of personality and after adolescent only their minor changes are detectable. Their connections with psychopathology is well-described; depressive temperament plays role in major depression, cyclothymic temperament in bipolar II disorder, while hyperthymic temperament in bipolar I disorder. Moreover, scientific data of the last decade suggest, that affective temperaments are also associated with somatic diseases. Cyclothymic temperament is supposed to have the closest connection with hypertension. The prevalence of hypertension is higher parallel with the presence of dominant cyclothymic affective temperament and in this condition the frequency of cardiovascular complications in hypertensive patients was also described to be higher. In chronic hypertensive patients cyclothymic temperament score is positively associated with systolic blood pressure and in women with the earlier development of hypertension. The background of these associations is probably based on the more prevalent presence of common risk factors (smoking, obesity, alcoholism) with more pronounced cyclothymic temperament. The scientific importance of the research of the associations of personality traits including affective temperaments with somatic disorders can help in the identification of higher risk patient subgroups.]

Lege Artis Medicinae

[Cardiovascular risk of non-steroidal antiinflammatory drugs]


[During the past decade, a number of original publications, reviews and metaanalyses were published on the cardiovascular safety of nonsteroidal antiinflammatory drugs (NSAIDs). As this group of medicines is among the most frequently used ones and many preparations are available over the counter, it seems to be prudent to summarise the most important results on the safety of these drugs, and underline their potentially harmful cardiovascular side effects. Nevertheless, it can also be emphasized that there are substantial differences between different compounds, and the cardiovascular risk does not depend on the ratio of COX-1/COX-2 selectivity. Cardiovascular risk can be increased by all NSAIDs with the possible exception of naproxen.]

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[Cardiovascular aging]


[The world population in both industrialized and developing countries is aging. The clinical and economic implications of this demographic shift are staggering because age is the most powerful risk factor for cardiovascular diseases. The incidence and prevalence of hypertension, coronary artery disease, congestive heart failure, and stroke increase steeply with advancing age. Although epidemiologic studies have discovered that some aspects of lifestyle and genetics are risk factors for these diseases, age, per se, confers the major risk. There is a continuum of age-related alterations of cardiovascular structure and function in healthy humans, however these alterations are not synonymous with diseases processes. Old age is not a disease. Although cardiovascular aging changes are considered “normative”, they lower the threshold for development of cardiovascular disease, and appear to influence the steep increases in hypertension, atherosclerosis, stroke, left ventricular hypertrophy, chronic heart failure, and atrial fibrillation with increasing age. Specific pathophysiologic mechanisms that underlie these diseases become superimposed on cardiac and vascular substrates that have been modified by an “aging process”, and the latter modulates disease occurrence and severity. Age-associated changes in cardiovascular structure and function become “partners” with pathophysiologic disease mechanisms, lifestyle, genetics, and other presently unknown factors in determining the threshold, severity, prognosis, and therapeutic response of cardiovascular disease in older persons. However, the role of specific age-associated changes in cardiovascular structure and function in such age-disease interactions has not been considered in most epidemiologic and clinical studies of cardiovascular disease. Quantitative information on age-associated alterations in cardiovascular structure and function in health is essential to unravel age-disease interactions and to target the specific characteristics of cardiovascular aging that render it such a major risk factor for cardiovascular diseases. Such information is also of practical value to differentiate between the limitations of an older person that relate to disease and those that might be expected, within limits, to accompany advancing age or a sedentary lifestyle.]

Hypertension and nephrology

[Hypertension and sexuality]

BARNA István

[Atherosclerosis is a phenomenon of natural aging and as part of it erectile dysfunction (ED) occurs. ED is further aggraveted by smoking, diabetes, atherogen dyslipidemia, obesity, systolic hypertension and vascular disesases (carotid, coronary and peripheral). The average incidence of ED is 19.2% but depending on age (between 30 and 80 years) the relative frequency is fairly different (from 2.3% to 53.5%). Appearence of ED might be the first warning sign of cardiovascular disease. The basis of the treatment of hypertensive males suffering from ED might be the cessation of smoking and quitting alcohol consumption. Optimalization of body weight includes low dietary fat and carbohydrate consumption. Concerning the antihypertensive treatment of males suffering from ED centrally acting agents, diuretics (except indapamide) and beta blockers (except carvedilol and nebivolol) should be omitted. Because of the neutral effect of calcium channel blockers and ACE inhibitors they can be safely administered. There is increasing evidence about ARBs that they have beneficial effect on erectile function and libido, too. If, testosterone production decreases hormone substitution - controlled by an urologist - can be recommended. Oral phosphodiesterase inhibitors (PDE5) can be safely administered even in hypertension. The incidence of sexual dysfunction (SD) among women between ages 40 and 80 is 47%. The most frequent cause in the background of decreased sexual desire among women are psychological, emotional and hormonal reasons or side effect of medication. Several studies proved the association of hypertension, high plasma cholesterol levels, smoking, vascular diseases and sexual dysfunction among women. Disturbance of local blood supply (clitoral, vaginal) is an early prognostic sign, too, like in males. Estrogen hormon replacement might alleviate these symptoms. In recent years sildenafil proved to be effective in several studies and ARBs improve libido, as well.]

Hypertension and nephrology

[Practical aspects of therapy by erythropoiesis stimulating agents in renal anaemia]

DEÁK György, HERSZÉNYI Eszter, AMBRUS Csaba, KISS István

[Prevalence of renal anaemia due to insufficient production of erythropoietin increases progressively in the course of renal function deterioration. Renal anaemia is treated by erythropoesis stimulating agents (ESA). Outcomes of randomized clinical trials have taught us to avoid the strategy of normalization of hemoglobin (HGB) levels by ESA therapy as it may increase the risk of cardiovascular events and mortality. The Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guideline for Anaemia published in 2012 recommends to start ESA therapy in the 90-100 g/l HGB range and suggests to keep HGB concentrations below 115 g/l. It is an inappropriate strategy to aim at normalizing hemoglobin (HGB) levels by ESA therapy because it may lead to progressive escalation of ESA doses even in the presence of diminished ESA responsiveness. High ESA doses and diseases causing ESA hyporesponsiveness eg. infections, chronic inflammation, malnutrition, insufficient dose of dialysis, severe hyperparathyroidism, iron deficiency are related to increased risk of mortality. KDIGO Clinical Practice Guideline for Anaemia emphasizes the importance of assessing and treating causes of ESA hyporesponsiveness, limits ESA dose escalation and recommends gradually changing ESA doses to avoid high amplitude HGB oscillation.]