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Clinical Neuroscience

MARCH 30, 2016

[The importance of anticoagulant therapy in patients with artial fibrillation in stroke prevention – summary of international data and novel therapeutic modalities]

MIROLOVICS Ágnes, PAPP Csaba, ZSUGA Judit, BERECZKI Dániel

[The most common cardiogenic cause of ischaemic stroke is atrial fibrillation which increases the probability of stroke five-fold and doubles case fatality. Based on international data the incidence of atrial fibrillation is approx. 2% however this rapidly increases with age. The necessity of using oral anticoagulants in the prevention of non-valvular atrial fibrillation related stroke is decided based on estimated stroke risk. The CHADS2 and the more predictive CHA2DS2-VASc scales are used for this purpose while the bleeding risk of patients treated with anticoagulant may be estimated by the HAS-BLED scoring scale. For decades oral anticoagulation meant using vitamin-K antagonists. Based on international data we can see that rate of anticoagulation is unacceptably low, furthermore most of the anticoagulated patients aren’t within the therapeutic range of INR (INR: 2-3). A lot of disadvantages of vitamin-K antagonists are known (e.g. food-drug interaction, need for regular coagulation monitoring, increased risk of bleeding), therefore compounds with new therapeutic target have been developed. The novel oral anticoagulants (NOAC) can be divided in two major subgroups: direct thrombin inhibitors (dabigatran etexilate) and Xa-factor inhibitors (rivaroxaban, apixaban, edoxaban). These products are administered in fix doses, they less frequently interact with other medications or food, and regular coagulation monitoring is not needed when using these drugs. Moreover several studies have shown that they are at least as effective in the prevention of ischaemic stroke than the vitamin-K antagonists, with no more haemorrhagic complications.]

Thrombosis management

APRIL 27, 2020

Hypertension and nephrology

MAY 10, 2019

[One-year persistence of fixed-dose combinations of angiotensin-converting enzyme inhibitor and calcium channel blocker in hypertensive patients]

SIMONYI Gábor, FERENCI Tamás, FINTA Ervin, IGAZ Iván, BALOGH Sándor, GASPARICS Roland, MEDVEGY Mihály

[Introduction: The most recent European guidelines for the treatment of hypertension suggest the use of renin-angiotensin-aldosterone system antagonists (RAAS inhibitors) and calcium channel blockers (CCBs) or diuretics fixed-dose combinations (FDCs) as the first therapeutic option. In antihypertensive therapy, the patient’s adherence is one of the most important factors in reducing unwanted cardiovascular events. Aim: Our aim was to assess the one-year persistence of angiotensin-converting enzyme inhibitor (ACEI) and CCB FDCs in hypertensive patients. Method: Authors have analysed the prescription database of the National Health Insurance Fund in Hungary on pharmacy claims between October 1, 2012 and September 30, 2013. Those patients were identified who filled prescriptions for FDCs of ACEI and CCBs prescribed for the first time for hypertensive patients and who had not re ceived similar drugs during the year before. Apparatus of survival analysis was used, where ‘survival’ was the time to abandon the medication. Results: 124,388 patients met the inclusion criteria. One-year persistence rate and hazard ratio (HR) of discontinua tion in patients with ramipril/amlodipine FDC was 54% (HR = 1.00, reference), perindopril/amlodipine 47% (HR = 1.30, p<0.0001), lisinopril/amlodipine 36% (HR = 1.79, p<0.0001), ramipril/felodipine 26% (HR = 2.28, p<0.0001) and trandolapril/verapamil 12% (HR = 4.13, p<0.0001). The average survival time of drug limited to 360 days was 270.2 days for ramipril/amlodipine FDC, 242.7 days for perindopril/amlodipine FDC, 211.2 days for lisinopril/amlodipine FDC, 186.3 days for ramipril/felodipine FDC and 125.7 days for trandolapril/verapamil FDC. Conclusions: The authors demonstrated that the one-year persistence of ACEI/CCB FDCs was significantly different in hypertensive patients. Ramipril/amlodipine FDC was more advantageous for patient adherence.]

Hypertension and nephrology

JUNE 10, 2018

[Antihypertensive effect of rilmenidine focusing on the Hungarian multicenter trial VERITAS]

FARSANG Csaba, FINTA Ervin

[Summary in the antihypertensive therapy, in addition to the RAS-blockers (ACE-inhibitors or ARBs), calcium antagonists and thizid-like diuretics, other antihypertensive drugs with different mechanisms of actions, such as the imidazoline I1 receptor agonists, are beneficially used. Several international and Hungarian studies showed the results of the effects of these agents. Authors emphasize the effects of the VERITAS study showing that in hypertensive patients the imidazoline I1 receptor agonist, rilmenidine significantly decreased the office blood pressure as well as the blood pressure measured by ambulatory blood pressure monitoring (ABPM). The white-coat reaction and left ventricular hypertrophy (LVH) were also decreased. In a separate study involving hypertensive subjects rilmenidine significantly increased baroreflex sensitivity. This effect may contribute - mainly during daytime - to the antihypertensive effect. Authors summarise the most important actions of rilmenidine, and the selected publications on the results of the Hungarian and international investigations.]

Lege Artis Medicinae

MAY 02, 2018

[Everyday practice of atrial fibrillation treatment]

KISS István, BENCZÚR Béla

[The clinical importance of atrial fibrillation - the most frequent arrhythmia - is derived from the fact that it means a 5-fold risk of stroke/systemic embolism which contributes to the increased cardiovascular morbidity/mortality. Long-term oral anticoagulant therapy is a cornerstone of stroke prevention in patients with atrial fibrillation. Until recently Vitamin-K antagonists were the only available therapeutic option but its everyday use has several limitations, eg. bleeding risk, narrow therapeutic range, drug and food interactions and the need of monthly INR-control. The advent of NOAC-s may prevent a lot of difficulties regarding VKA-treatment and lead to as efficacious as and safer therapy than VKAs. These benefits can help better adherence of patients to the anticoagulant therapy which is one of the most important element of more effective stroke prevention. NOACs can be used more safely both in real life and in special patient populations (eg. elderly, type 2 diabetes, chronic kidney injury) than VKAs so they can contribute to effective cardiovascular risk reduction.]

Hypertension and nephrology

OCTOBER 20, 2017

[Therapy of isolated systolic hypertension III.]

FARSANG Csaba

[In the elderly and very elderly (˃80 yrs), a wealth of data from large clinical trials are available, showing the necessity of treatment mostly with drug combinations - fix-combinations are preferred for increasing the adherence/persistence to therapy. Using diuretics, ACE-inhibitors/ARBs with calcium antagonists, and in special cases diuretics and beta blockers are also suggested by recent European guidelines (ESH, HSH). The target is <140 mmHg, but in octogenarians <150 mmHg. Some studies are pressing for even lower SBP (to around 120 mm Hg), but it seems to be wise to balance advantages/disadvantages, so the optimal SBP may be around 130 mmHg.]

Hypertension and nephrology

MAY 20, 2017

[Isolated systolic hypertension in children and young adults I.]

FARSANG Csaba

[Prevalence of the isolated increase in systolic blood pressure ≥140 mmHg with normal or low diastolic blood pressure ≤80 mmHg, is defined as isolated systolic hypertension. Its prevalence increases with age up to >90% in patients aged >90 years. Isolated systolic hypertension is also found in the young and the clinical significance of it is still debated. For the therapy, those drugs should be used which have a license for use in children: angiotensin converting enzyme inhibitors, angiotensin AT-1 receptor antagonists, calcium channel blockers beta-blockers and diuretics and their combinations. The young adults with isolated systolic hypertension had a much higher risk of dying from coronary heart disease or cardiovascular disease, then the normotensive individuals, and should be treated to normalise their blood pressure. In the elderly and very elderly (>80 yrs), a wealth of data from large clinical trials are available, showing the necessity of treatment mostly with drug combinations - fix-combinations are preferred for increasing the adherence / persistence to therapy. Using diuretics, ACE-inhibitors / ARBs with calcium antagonists, and when needed diuretics and beta-blockers are suggested by recent European guidelines. The target is <140 mmHg, but in octogenarians <150 mmHg. Some studies are pressing for even lower SBP (to around 120 mm Hg), but it seems to be wise to balance advantages / disadvantages, so the optimal SBP may be around 130 mmHg.]

Hypertension and nephrology

OCTOBER 20, 2016

[Lercanidipine in hypertension]

HERCZEG Béla

[Lercanidipine is a third generation DHP type calcium antagonist. It’s antihypertensive efficacy is proven using in monotherapy or combined treatment as well. The main advantage compared with the first and second generation DHP calcium antagonists is that fewer side effects, especially the much less common ankle oedema. Renal protective effect has proven by experimental and clinical studies, but in the future more prospective randomized studies should be supported this benefit. The drug is very useful for diabetes, obesity associated with hypertension due to the metabolic „neutrality”. The key of successful antihypertensive is the high level persistence. From this point of view the lercanidipine is a very useful factor during the treatment.]

Hypertension and nephrology

APRIL 10, 2016

[Rilmenidin - a versatile combination partner in the treatment of high blood pressure]

KÉKES Ede

[The rilmenidin as an imidazoline agonist drug strongly decreases the central sympathetic activity, release of renine and the RAS activity. Because of these advantageous properties the peripheral vascular resistance falls and the blood pressure is decreased. Today it is excellent tool for combination therapy. Useful especially in stress induced hypertension. The antihypertensive effects of ACE inhibitors sor calcium antagonists are increased by rilmenidine. This drug decreases the insuline resistance, it has a positive effect on the carbohydrate and fat metabolism, because it is useful as a complementary therapy in metabolic syndrome and diabetes mellitus of type II. It is useful in stress induced hypertension, and in menopause as well.]

Lege Artis Medicinae

DECEMBER 15, 2015

[Actual questions of the longterm anticoagulant therapy]

SAS Géza

[In the last few years we have witnessed some changes in the area of the chronic oral anticoagulant therapy. The nomenclature of the anticoagulant drugs has been modified and concern has arisen about the possible vascular calcification in patients on long-term warfarin therapy. Because of the novelty of the “new” anticoagulants (dabigatran etc.) has been lost, instead of their previous acronym (NOAC) the DOAC (direct oral anticoagulants) term has been accepted for their marking. Experimental and clinical data suggested that vitamin K-antagonists (VKA) in addition to the coagulation factors disturb the production of other proteins, too. By inhibiting the matrix Gla protein (MGP), the chronic warfarin therapy promotes the calcification in media of the arteries as it was shown in women participating in routine mammography. However, the clinical importance of this observation is dubious, because the incidence of acute coronary events is not increased in cases of warfarin therapy in patients with atrial fibrillation. Notwith­standing, in addition to the bleeding complications we have to take into account of the possible harmful vascular calcification, too, at the indication of chronic coumarin therapy. Therefore, this therapy should be applied only in proper cases, such as non-valvular atrial fibrillation with a high risk of ischaemic stroke or unprovoked venous thromboembolic disease with a high risk of recurrence. The results of the Swedish anticoagulant register show that the efficacy and safety of the well-managed coumarin therapy may be superior to the treatments with DOACs. However, DOACs are indispensable in certain cases in which a previous “probe” coumarin treatment is unfounded.]