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Hypertension and nephrology

SEPTEMBER 20, 2014

[Changes in prescribing practice of diuretics in the treatment of hypertension between 2007 and 2013 in the mirror of insurance data]

BARNA István, GYURCSÁNYI András

[Amongst diuretics, thiazides are the most commonly used antihypertensive agents. Due to their long-term effect, they are ideal for treatment of hypertension. Indapamide is a long-acting (half-life 14-16 hours) thiazide-like diuretic, which is effective in very small doses (1.25 to 5 mg). Indapamide mainly provides a forceful blood pressure lowering effect, by decreasing arteriolar and peripheral resistance due to its vasodilatative effect. Even in hypertensive, diabetic patients, indapamide does not affect the lipid metabolism or the carbohydrate metabolism. As an antihypertensive medicine, thiazide-type diuretics (only in small doses - 6.25- 12.5 mg hypothiazide, 12.5 mg chlorthalidone, 5 mg clopamide) can be the first choice, when dealing with essential hypertension disease without complications. They may also be used in monotherapy. When dealing with hypertension associated with old age or with isolated systolic hypertension, these products are recommended with “A” type evidence. For the treatment of left ventricular hypertrophy and post-stroke conditions associated with the treatment of hypertension, it is recommended to use indapamide in case of diabetes, furosemide and thiazide in case of a left ventricular dysfunction and heart failure, or a combination of these. When reviewing the national sales of mono-component diuretics between 2007 and 2013 in the National Health Insurance (OEP) database, we could see that the sales of hydrochlorothiazide, clopamide, and chlorthalidone decreased. In 2013 however, the sales of the latter experienced a turnover, which might indicate the activity of the followers of the new guideline. The use of diuretics with indapamide as their active substance increased. The prescription of diuretics used in a combination increased continuously between 2007 and 2010 and reached a monthly one million prescribed boxes. During the time in question, the use of products combined with hydrochlorothiazide (most products contain this agent) was the most dominant, but its share fell from 88% to 66% due to the growth of combinations containing the active ingredient indapamide. This is interesting because this combination is “unique” (perindopril + indapamide). During the period in question, only the prescription of this combination increased steadily. The use of diuretics is very important in antihypertensive therapy. If we compare the diuretics and their combinations to the recommendations, we can state that the treatment is done along the guidelines, or in other words the use of the metabolic neutral combination therapy is increasing.]

Hypertension and nephrology

MARCH 22, 2013

[Causes of and therapeutic opportunities in resistant hypertension]

SIMONYI Gábor, GENCSI Kristína

[Hypertension is an independent cardiovascular risk factor and one of the most frequent diseases in Hungary. In the treatment of hypertensive patients usually more than two drugs are needed for the appropriate blood pressure control. Resistant hypertension (RH) is defined when blood pressure remains above target value despite full doses of antihypertensive medications, which consist of at least three different classes of drugs including a diuretic administered in maximal doses. The frequency of RH can reach 20-30% among hypertensive patients. RH increases the cardiovascular risk because of the lack of target blood pressure. RH is multifactorial and it is important to exclude pseudo-resistant hypertension (e.g. poor compliance, white coat effect). In the background of RH we can find lifestyle factors (e.g. obesity, excessive salt intake, alcoholism, etc.) and a variety of drugs (e.g. non-steroids, corticosteroids, sympathomimetics). In the pathogenesis of RH the increased activity of the sympathetic nervous system has an important role. In the treatment of RH we should manage lifestyle factors and it is important to assess the drugs and diseases (e.g. sleep apnea, chronic kidney disease, diabetes mellitus) which may cause increased blood pressure. It is no exact recommendations for the treatment of RH. Therapy often consists of 4-5 various drugs in combination. An important role has the device therapy of RH in recent years (e.g. stimulation of the carotid baroreceptors and renal denervation) as well.]

Clinical Neuroscience

NOVEMBER 20, 2012

[Clinical experiences with Creutzfeldt-Jakob disease: three case studies]

SZŰCS Anna, VÁRALLYAY Péter, OSZTIE Éva, PAPP Erzsébet, SÓLYOM András, FINTA Lehel, VARGA Dániel, BARCS Gábor, HOLLÓ András, KAMONDI Anita

[The clinical picture, electroencephalographic, imaging and cerebrospinal fluid parameters as well as the molecular background of Creutzfeldt-Jakob disease have been well explored. The diagnostic criteria, offering clinicians a fair chance to identify these patients in vivo, have recently been updated. However, the diagnosis is still a challenge in everyday neurological routine. We report on three of our Creutzfeldt-Jakob patients for calling attention to the classical and the recently defined features of the disease. We conclude that based on the rapidly progressing neuropsychiatric syndrome Creutzfeldt-Jakob disease may be suspected; follow-up EEG may reveal the typical (pseudo)-periodic pattern with progressive deterioration of the background activity. In addition, diffusion-weighted brain MRI imaging (DWI) has high diagnostic value. Detection of 14-3-3 protein in the cerebrospinal fluid supports the in vivo diagnosis.]

Hypertension and nephrology

DECEMBER 22, 2011

[The importance of white-coat hypertension in adolescents]

LENGYEL Szabolcs, SZÁNTÓ Ildikó, KATONA Éva, PARAGH György, FÜLESDI Béla, PÁLL Dénes

[The importance of adolescent hypertension is that there is tight correlation between blood pressure data in adolescents and in adulthood. In case of sustained adolescent hypertension increase of the left ventricular mass and the intima-media thickness of the carotid artery is also detected. The prevalence of adolescent hypertension is about 1-4%. Among them 1-41% is the frequency of white-coat hypertension. Diagnosis can be set up with repeated measurements at home, or with ambulatory blood pressure monitoring. In the background of adolescent white-coat hypertension the increased sympathetic activity has outstanding importance, which causes endothel dysfunction and increased arterial stiffness. There are growing evidence, that adolescent white coat hypertension is not a harmless condition, because sustained hypertension can develop in the future. In its case risk survey, start of non-pharmacological treatment, and follow-up has major importance.]

LAM Extra for General Practicioners

DECEMBER 15, 2011

[ECG ARTEFACTS]

TOMCSÁNYI János, BEZZEG Péter

[The recognition of ECG artefacts is becoming increasingly important for physicians working in the field of internal medicine. At the same time, however, very little information about artefacts is published in either articles or textbooks. The authors provide a summary of the generation, types and recognition of ECG artefacts. The aim of the article is to draw the attention of clinicians to the dangers of this increasingly common phenomenon. Unrecognised artefacts can often prompt further (unnecessary) investigations and may result in establishing wrong diagnosis as well as erroneous treatment decisions.]

Lege Artis Medicinae

SEPTEMBER 20, 2011

[The use of carvedilol following invasive interventions]

KOVÁCS Imre

[The primary goals of the treatment of AMI are to rapidly open - either mechanically or by thrombolysis - the blocked blood vessel and to keep it open. Restarting of the blood flow in blocked vessels results in an increased load in volume, pressure and metabolism in the blood vessel's supply area, which triggers the activation of a pathophysiological cascade. Pathophysiological processes accompanying the opening of the blood vessel include activation of catecholamines, RAS and neutrophils and subsequent free radical production, and increases in the levels of proinflammatory citokines and intracellular CA levels, that is, the so called oxygen paradox. The above mentioned processes can be blocked by beta receptor blockers (BRB) as demonstrated by class I, type A evidence. A number of clinical studies have shown their clinical efficiency following PCI. The PAMI, StentPAMI, AirPAMI and CADILLAC studies have proved that BRBs decrease mortality and morbidity after the intervention. The third-generation BRB carvedilol, which acts as a beta and alpha blocker in patients with STEMI successfully treated with PCI, and is also a Ca-channel blocker and a free radical trap, is the firstchoice agent for both theoretical and clinical reasons. Animal studies have shown that carvedilol results in greater reductions in the levels of markers indicating postinfarction reperfusion and ventricular remodeling (MCP1, MMP2, TIMP2) compared with metoprolol. Animal studies have also showed that carvedilol is the most efficient BRB for preventing the damaging of gap junction structure in reperfusion, and for inhibiting the ventricular arrhythmias induced by reperfusion, through restoring connexin 43. The beneficial effect of this drug on the cardiovascular events and mortality following myocardial infarction have been demonstrated in a number of human studies with hard endpoints. The unique efficiency of carvedilol in vascular prevention following PCI has been demonstrated by the short-term and longterm efficiency of carvedilol-filled stents, compared with BMSE-filled stents. Information on the postintervention, long-term (3-year) efficiency of carvedilol in a large (N :7500) patient group is expected to be published in 2015 in the CAPITAL-RCT study coordinated by the University of Kyoto. In summary, the results of experimental and clinical studies on carvedilol have shown that within the BRB group, carvedilol is highly recommended for the prevention of oxygen paradox following successful PCI and preserving the myocardium.]

Hypertension and nephrology

OCTOBER 20, 2010

[The role of vitamin D receptor and the risk reducing effect of vitamin D receptor agonists in chronic kidney disease]

KISS István, KULCSÁR Imre, BARABÁS Noémi, KERKOVITS Lóránt

[Vitamin D3 is produced in the skin and is modified in the liver and kidney to the active metabolite form, 1,25-dyhydroxyvitamin D3 (calcitriol). Calcitriol binds to a nuclear receptor, the vitamin D receptor (VDR), and activates processes that bind to vitamin D. The classical effects of vitamin D receptor activator or agonist (VDRA) therapy for the treatment of secondary hyperparathyroidism in patients with chronic kidney disease primarily involves suppressive effects on the parathyroid gland, and regulation of calcium and phosphorus absorption in the intestine an mobilization in bone. Several VDR agonists have been developed for the treatment of osteoporosis, hyperparathyroidism secondary to chronic kidney disease (CKD), and psoriasis. Secondary hyperparathyroidism (SHPT) is a common and serious consequence of CKD. SHPT is a complex condition characterized by a decline in 1,25-dihidroxi vitamin D and consequent VDR activation, abnormalities in serum calcium and phosphorus levels, parathyroid gland hyperplasia, elevated parathyroid hormone (PTH) secretion, and systemic mineral and bone abnormalities. There are three classes of drug used for treatment of SHPT (non-selective and selective VDR activators, and calcimimetics). Observational studies in hemodialysis patients report improved cardiovascular and allcause survival among those received VDRA therapy compared with those not on VDRA therapy. The survival benefits of selective VDRA paricalcitol appear to be linked to "non classical" action of VDRA, possibly through VDRA-mediated modulation of gene expression. VRDAs are reported to have beneficial effects such as anti-inflammatory and antithrombotic effects, inhibition of vascular calcification and stiffening, inhibition of vascular smooth muscle cell proliferation, and regression of left ventricular hypertrophy. VDRA are also reported to negatively regulate the renin-angiotensin system, which plays a key role in hypertension, myocardial infarction and stroke. Data from epidemiological, preclinical and clinical studies have shown that vitamin D and/or 25(OH) vitamin D deficiency is associated with increased risk for cardiovascular disease (CVD). The selective VDR agonists are associated direct protective effects on glomerular architecture and antiproteinuric effects in response to renal damage. Emerging evidence suggest that VDR plays important roles in modulating cardiovascular, immunological, metabolic and other function. Paricalcitol may prove to have a substantial beneficial effect on cardiac disease and its outcome in patients with CKD.]

Lege Artis Medicinae

NOVEMBER 30, 2006

[METABOLIC APPROACH IN THE THERAPY OF LEFT VENTRICULAR DYSFUNCTION]

MÁRK László

[Coronary heart disease has traditionally been treated by haemodynamic agents including beta-blockers, calcium channel blockers and nitrates. Trimetazidine, which shifts myocardial energy metabolism from fatty acid oxidation towards glucose oxidation, thereby providing a more efficient oxygen utilization, represents a new, metabolic approach in the medical treatment of this condition. The present review gives an overview of recent studies on the beneficial effects of trimetazidine in severely or moderately impaired left ventricular function. In addition to the parameters that characterize left ventricular ejection function and the to the improvement of clinical symptoms, the beneficial effects of trimetazidine after coronary angioplasty and in the older age are also discussed. Treatment is safe and the efficacy is maintained in the long-term.]

Lege Artis Medicinae

MARCH 20, 2001

[Antiatherosclerotic effect of ACE inhibitor drugs]

CZURIGA István

[Based on animal and human research data, it is likely that renin-angiotensin-aldosteron system has an important role in the pathogenesis and progression of atherosclerosis. It has been demonstrated in several large clinical trials that ACE inhibitors reduce the risk of ischemic events in patients with left ventricular dysfunction. Whereas some benefits of ACE inhibitors may be related to the lowering of blood pressure, other specific effects on vasculature have also been proposed. ACE inhibitors appear to possess unique cardioprotective and vasculoprotective properties even for patients without hypertension or left ventricular dysfunction. Recent data suggest that most patient with atherosclerotic cardiovascular disease should be considered for ACE inhibitor therapy, unless they are intolerant or have contraindication for the drug. The goal of this article is to review the data from clinical trials that support the anti-atherosclerotic and antiischemic effects of ACE inhibitors.]