Second International Symposium on Hypertension Translational Medicine in Hypertension November 18 21, 2010 Osijek, Croatia Croatian Hungarian Young Investigator Conference November 17 18, 2010 Pécs, Hungary / Osijek, Croatia
www.isho2010.mefos.hr www.hdh.hr
Organized by
Croatian Society of Hypertension Hungarian Hypertension Society
University of Josip Juraj Strossmayer School of Medicine
University of Zagreb School of Medicine
University of Pécs
Endorsed by
European Society of Hypertension
Chairpersons
Ines Drenjančević Ákos Koller Istvan Kiss Bojan Jelaković
updated 8.11.2010
DEAR COLLEAGUES, GUESTS AND FRIENDS, It is our privilege and honour to cordially invite you to participate on the Second International Symposium on Hypertension Translational Medicine in Hypertension.
This symposium is following the very successful first one that took place in 2006, in Osijek, Croatia with participants from 10 European countries and United States www.congress.mefos.hr.
The main aim of those meetings is to bridge between the scientific research, innovations, new ideas and technologies with clinical everyday medical practice.
Our goal is to integrate research inputs from the basic science, epidemiology and clinical practice to optimize patient care and preventive measures what may improve hypertension control but also attenuate hypertension prevalence.
This meeting is jointly organized by the Croatian Society of Hypertension, Hungarian Hypertension Society, Schools of Medicine University of Josip Juraj Strossmayer and University of Zagreb, and by University of Pecs. It is endorsed by the European Society of Hypertension.
Apart from the State of the Art Lectures, we will give opportunity to young scientists and physicians to present original papers as short oral presentations. Even more, as a Pre Symposium we will organize Croatian Hungarian Young Investigator Conference in Pécs and Osijek.
As at the main ESH meetings, moderated poster session will be very important area for discussions.
Several satellite symposia will be organized by drug industry where some specific treatment approaches will be presented and discussed.
Without any doubt this meeting will serve as a bridge not only between basic science, epidemiology and clinical work, but also between different countries from this part of Europe.
Symposium will take place in Osijek, picturesque historic city situated on the right bank of the Drava River, 25 km upstream from its mouth into the river of Danube. The region of Croatia (Slavonia and Baranja) has been inhabited since Neolithic and Roman times (Mursa). Osijek is known by its unique baroque part of the city called Tvrdja (18th century), and by beautiful Secession style buildings in the centre of the town.
You are warmly welcomed and we are looking forward seeing you in Osijek at this fruitful scientific event but also at cultural and social activities!
Ines Drenjančević Bojan Jelaković Istvan Kiss Ákos Koller CHAIRPERSON Ines Drenjančević (Croatia), Ákos Koller (Hungary), Istvan Kiss (Hungary) Bojan Jelaković (Croatia)
ORGANIZING COMMITTEE Ines Drenjančević, Rudika Gmajnić, Bojan Jelaković, Jerko Barbić,Tina Katić, Sandra Karanović, Ákos Koller, Jelena Kos, Slavica Kvolik, Mario Laganović, Mirjana Mihalić, Ivan Pećin, Milan Potkonjak, Vedran Premužić, Romana Samovojska, Miroslav Tišljar, Vedrana Vizjak, Lada Zibar, Marijana Živko
SCIENTIFIC COMMITTEE
Rok Acceto, Slovenia Dragan Lović, Serbia Jana Brguljan, Slovenia Zoka Milan, United Kingdom Renata Cifkova, Czech Rep Davor Miličić, Croatia Nada Čikeš, Croatia Judith Nagy, Hungary Ines Drenjančević, Croatia Krzysztof Narkiewicz, Poland Csaba Farsang, Hungary Peter Nilsson, Sweden Rudika Gmajnić, Croatia Mary Pat Kunert, USA Janos Hamar, Hungary Draško Pavlović, Croatia Bojan Jelakovic, Croatia Shane A. Phillips, USA Stevo Julius, USA Željko Reiner, Croatia Franz Kehl, Germany Vesna Stojanov, Serbia Istvan Kiss, Hungary Katarina Šakić, Croatia Ákos Koller, Hungary Aleksandar Včev, Croatia Duško Kuzmanić, Croatia Istvan Wittmann, Hungary Julian H. Lombard, USA
MAIN TOPICS
• Refresh course: Physiology and pathophysiology of blood pressure regulation • Integration and mechanisms in hypertension • Epidemiology • Blood Pressure and Heart Rate • Preventive medicine and control of hypertension (CRASH, SALT, Live under 140/90) • Treatment modalities in Croatia and Hungary: similarities and differences • Croatian and Hungarian Young Investigators Conference on Hypertension
IMPORTANT DATES
• Abstract deadline: June 15, 2010 , extended until September 6, 2010 • Abstract confirmation: September 15, 2010 • Early bird registration: September 15, 2010 ABSTRACT SUMBISSION Electronic submission only. More information at the Symposium web site www.isho2010.mefos.hr
REGISTRATION FEE Early bird : 150 €; Late : 200 €
Participants Amount Early bird (untill September 15 th , 2010) 150 € Late (after September 15 th , 2010) 200 € Residents 50 € PhD students 50 € Accompanying persons 50 € Exhibitors and sponsors 50 € Medical students, fellows, nurses no fee PhD students presenters no fee Invited speakers no fee
Registration Fee does not include Gala Dinner on 20th of November 2010.
Bank account: 2360000 1101214818; Call number: 268 78
OIB: 60192951611
During registration on site all participants should provide Bank money transfer statement.
Registration fee for participants include
• Admission to all scientific sessions and exhibition • Meetings bag, final program and abstract book • Certification of attendance • Coffee and refreshment during breaks • Working lunch • Welcome reception and concert • Registration fee for accompanying persons includes: • Welcome reception and concert • Gala dinner on 20 th of November is not included in registration fee
V E N U E
• November 17, Wendesday 2 nd Department of Internal Medicine, 7624 Pécs, Pacsirta u. 1, Hungary • November 18, Thursday Restaurant "Galija", Osijek Croatian National Theatre, Osijek • November 19, Friday November 21, Sunday Hotel Osijek, Osijek, Šamačka 4, Croatia
ACCOMODATION
• Hotel Osijek, www.hotelosijek.hr ; Hotel Waldinger, Osijek, www.waldinger.hr ; Maksimilijan Rooms, Osijek, www.maksimilian.hr ; Hotel Central, Osijek, www.hotel central os.hr ; Mursa Hotel, Osijek, www.zug.hr ; OFFICIAL LANGUAGE
• English
YOUNG INVESTIGATOR AWARD The three distinguished physicians and basic scientists younger than 35 years who will present results of own research in hypertension.
INFORMATION ON CONFERENCE
Secretary of ISHO Zoran Balkić, b.sc.ee. email: [email protected] Mobile: + 385 91 224 60 52 Fax: + 385 31 512 833 Prof. Ákos Koller PTE ÁOK Kórélettani és Gerontológiai Intézet 7624 Pécs, Szigeti út 12. email: [email protected] Tel: 72/536 246 Fax: 72/536 247
Secretary of the Croatian Society of Hypertension
Mario Laganović, M.D. M.Sc. email:[email protected], www.hdh.hr
Treasurer of the Croatian Society of Hypertension Ivan Pećin, M.D. email: [email protected], www.hdh.hr
PROFESSIONAL ORGANIZER Gold Tours Travel Agency email: goldtours@gold tours.com, www.gold tours.com Preradovićeva 4/1, HR – 10000 Zagreb, Croatia Phone: +385 1 4856 500 Fax: +385 1 4856 930
REGISTRATION DESK AND INFO
Hotel Osijek
• November 17 18:00 20:30 • November 18 08:00 20:30 • November 19 08:00 20:00 • November 20 08:00 20:00 • November 21 08:00 12:30 PROGRAM AT GLANCE
November 17, Wednesday November 18, Thursday November 19, Friday November 20, November 21, Sunday Saturday
University of Pecs, Pecs, University J.J. University J.J. University J.J. University J.J. Hungary Strossmayer, Osijek, Strossmayer, Osijek, Strossmayer, Osijek, Strossmayer, Osijek, Croatia Croatia Croatia Croatia Venue: 2nd Department of Internal Medicine, Venue: Restaurant Venue: Hotel Osijek Venue: Hotel Osijek Venue: Hotel Osijek Pécs, Hungary "Galija", Osijek, Croatia
9:30 11:40 11:00 17:00 8:30 10:10 8:30 9:30 8:30 9:50 Croatian Hungarian Croatian Hungarian Session 1 Session 5 Session 10 Young Investigator Young Investigator Epidemiology Blood pressure Secondary Hypertension Conference Conference measurements
9:50 10:30 9:30 10:25 Session 6 State of the Art Lecture Prevention and control
11:40 12:45 10:10 10:30 10:25 10:45 10:30 11:00 Lunch Coffee break Coffee break Coffee break
12:45 14:30 10:30 12:00 10:45 12:10 11:00 12:00 Croatian Hungarian Symposium Society of Session 7 Sponsored Symposium Young Investigator Nureses in Hypertension and Conference Hypertension surgery Session 2 14:30 15:30 Role of the Lunch Sympathetic Nervous System in Hypertension
12:00 13:00 12:10 13:10 12:00 13:00 Sponsored Symposium Sponsored Symposium Session 11 15:30 19:00 Hypertension and Heart Social program and Visiting Pécs 13:00 Young Investigator Awards 13:00 14:00 13:10 14:10 Lunch Lunch
14:00 15:40 14:10 15:25 13:15 Session 3 Session 8 Closing remarks Aging and Gender Integration and
mechanisms in hypertension 2
19:00 21:30 15:40 16:30 15:25 15:55 Dinner & Accommodation Attended Poster Attended Poster in Pécs Session Session
16:30 17:40 15:55 17:25 Session 4 Session 9 Integration and Integration and mechanism in mechanism in hypertension 1 hypertension 3
17:40 18:30 17:25 18:25 Sponsored Symposium Sponsored symposium Venue: Croatian National Theatre Osijek
18:00 21:30 20:30 Social Program 20:00 Gala Dinner Opening lectures Opening ceremony SPONSORS AND EXHIBITORS
Organizing committee would cordially thank to all sponsors for their generous help. We appreciate this very much especially in these very hard economic days.
General sponsor
• Abbott Laboratoires
Golden sponsors
• GlaxoSmithKline
• Sanofi Aventis
• Servier Pharma
Silver sponsors
• Krka Farma
• Pliva
Bronze sponsor
• Berlin Chemie
Other sponsors and exibitors
• Novartis
• Pfizer
• Belupo
• Sandoz Lek
• Merck d.o.o.
• Bayer pharma d.o.o.
• Medikor
• PERIMAED AB
• UpToDate CROATIAN HUNGARIAN YOUNG INVESTIGATOR CONFERENCE
Moderators: I. Drenjančević, A. Koller, J. Hamar, P. Légrády, B. Jelaković
November 17, Wednesday University of Pécs, Hungary
Venue : 2 nd Department of Internal Medicine, Pécs, Hungary Croatian and Hungarian Young Investigator Conference
09:30 10:15 Registration 10:15 10:35 A. Koller (Hun) Opening and Introduction A. Miseta, Dean, Med School, Univ. of Pécs, (Hun) L. Pancirov, Consul General of Croatia M. Kovács (Hun), President of the Hungarian Croatian Friendship Society
Chairs: I. Wittmann, B. Jelaković, P. Legrady 10:35 10:55 R. de Châtel (Hun) Diuretics in hypertension are they really obsolete? 10:55 11:15 I. Drenjančević (Cro) The role of renin angiotensin system in maintaining vascular reactivity – the methodological approach 11:15 11:30 A. Koller (Hun) Effect of high blood pressure on vasomotor functions 11:30 11:40 R. Ménesi, Zs. Sodium sensitive hypertension, the effectiveness of salt Lelovics, I. Kovács, F. restriction László (Hun)
11:40 12:45 Lunch
Chairs: R. de Châtel, I. Drenjančević, J. Hamar 12:45 13:05 I. Wittmann (Hun) Effect of smoking on vasomotor functions 13:05 13:25 L. Czopf (Hun) Hypertension and heart disease 13:25 13:45 P. Degrell (Hun) Detection of AT1 receptors in the kidney 13:45 14:00 E. Kicsindi (Hun) International grants for early stage researchers 14:00 14:20 S. Vikić Topić (Cro) How to prepare and apply for joint projects? 14:20 14:30 Closing remarks
14:30 15:30 Lunch 15:30 19:00 Social program and Visiting Pécs, the European Cultural Capital 2010 19:00 Dinner & Accommodation in Pécs
November 18, Thursday Restaurant "Galija", Osijek, Croatia Croatian and Hungarian Young Investigator Conference Session 1 Chairs: P. Legrady, P. Cseplo, V. Premužić, S. Karanović
11:00 11:10 M. Fištrek (Cro) Inflammation and hypertension 11:10 11:20 M. Solymar (Hun) Comparison of antioxidant effects of H2S and SOD in isolated small veins 11:20 11:30 M. Krstić (Cro) Hypertension in Children 11:30 11:40 Z. Vamos (Hun) Aging dependent changes in angiotensin II induced contractions of isolated rat carotid arteries 11:40 11:50 Zs. E. Mikolas(Hun) Effects of erythropoietin on glucose metabolism 11:50 12:00 Z. Miovski (Cro) Arterial hypertension and peripheral arterial disease 12:00 12:10 D. Bajcsi (Hun) Investigation of parameters of blood vessels with the finometer device in diabetic and non diabetic hypertensive patients
12:10 12:30 Coffee break
Session 1 Chairs: D. Bajcsi, Z. Vamos, V. Vizjak, M. Fištrek
12:30 12:40 K. Magyar (Hun) Poly(ADP ribose)polymearase inhibition reduces vascular remodeling in a chronic hypertension model 12:40 12:50 P. Legrady (Hun) Changes of the baroreflex sensitivity and plasma norepinephrine after neurosurgical decompression of the medulla oblongata on the left side in hypertensive woman 12:50 13:00 S. Karanović (Cro) Heart rate in prehypertension 13:00 13:10 P. Cseplo (Hun) Modelling of vasomotor effects of hemorrhagic stroke in isolated rat cerebral arteries 13:10 13:20 F. Džubur (Cro) Diagnostic algorithms in incidentalomas 13:20 13:30 Discussion
13:30 14:30 Buffet Lunch
November 18, Thursday Restaurant "Galija", Osijek, Croatia Croatian and Hungarian Young Investigator Conference Session 2 Chairs: T. Horváth , O. Cseprekál, K. Selthofer Relatić, T. Katić
14:30 14:40 Ž. Dika (Cro) Epidemiology of hypertension 14:40 14:50 I. A. Szijjarto (Hun) Does oxidative stress affect the vasoactive effect of insulin? 14:50 15:00 D. Buljubašić (Cro) Urinary protein/creatinine ratio in controlled and uncontrolled hypertension 15:00 15:10 I. Fejes (Hun) Retrospective analysis of two year data of resistant hypertensive patients with and without neurosurgical microvascular decompression 15:10 15:20 K. Selthofer Relatić Correlation between leptin and adiponectin in hypertensive (Cro) overweight patients 15:20 15:30 V. Vizjak (Cro) Correlation between Adipose Tissue Distribution and Sympathetic Nervous System Activation in Hypertensive Patients
15:30 15:40 Coffee break
Chairs: Ž. Dika, I. Fejes, A. Szijjarto, F. Džubur 15:40 15:50 O. Cseprekál (Hun) The method of distance measurement and torso length influences the relationship of pulse wave velocity to cardiovascular mortality 15:50 16:00 V. Premužić (Cro) Central blood pressure and pulse wave velocity 16:00 16:10 T. Horváth (Hun) Lack of relation between endothelial function and carotid artery stiffness in young, healthy male subjects 16:10 16:20 A. Čavka (Cro) The effects of high salt diet on tissue perfusion in young female 16:20 16:30 R. Samovojska (Cro) Importance of salt reduction 16:30 16:40 M. Živko (Cro) How to organize an outpatient hypertensive clinic 16:40 16:50 T. Katić (Cro) How to improve patients awareness 16:50 17:00 A. Koller (Hun) Discussion and closing remarks I. Drenjančević (Cro)
SECOND INTERNATIONAL SYMPOSIUM ON HYPERTENSION Translational Medicine in Hypertension
November 18, Thursday Croatian National Theatre, Osijek
18:00 18:30 Welcome drink 18:30 19:00 Opening lectures Chairs: I. Drenjančević, A. Koller, I. Kiss, B. Jelaković 19:00 19:30 N. Čikeš (Cro) Translation medicine – new era in medicine 19:30 20:00 G. Parati (Ita) High Care Translational medicine at high altitude Movie about research in Himalaya
20:00 Opening Ceremony and Welcome Reception
November 19, Friday Hotel Osijek, Osijek, Croatia Session 1 Epidemiology Chairs: I. Kiss, V. Žerjavić Hrabak, G. Parati
08:30 08:50 I. Kiss (Hun) Pharmacological treatment of hypertension – Guideline and practice in Hungary 2005 2010 08:50 09:10 C. Farsang (Hun) Diagnosis and control rates of hypertension in Europe 09:10 09:30 V. Žerjavić Epidemiology of cardiovascular diseases and hypertension in Hrabak(Cro) Croatia 09:30 09:50 J. Brguljan (Slo), Prehypertension in Slovenia and Croatia B. Jelaković (Cro) 09:50 10:10 J. Nagy (Hun) Cerebrovascular diseases in chronic kidney disease with and without hypertension
10:10 10:30 Coffee break Visit exhibitors
Session 2 Role of the Sympathetic Nervous System in Hypertension Chairs: S. Julius, A. Šmalcelj, J. Brguljan
10:30 10:50 H. Rupp (Ger) Sympathetic overactivity – pathophysiological link between hypertension, diabetes, coronary heart disease, stroke, and kidney disease 10:50 11:20 S. Julius (USA) Heart rate as neglected cardiovascular risk factor 11:20 11:40 G. Parati (Italy) Blood pressure and heart rate variability as biomarkers of sympathetic derangements 11:40 12:00 A. Šmalcelj (Cro) How to block sympathetic overdrive in clinical practice ?
12:00 13:00 Sponsored symposium Abbott 13:00 14:00 Lunch Visit exhibitors
Session 3 Aging and gender Chairs: J. Lombardt, A. Koller, D. Pavlović
14:00 14:30 P. Nilsson (Swe) Biology of telomeres and early vascular aging 14:30 15:00 M. P. Kunert (USA) Estrogens, high salt diet and vascular reactivity 15:00 15:20 G. Masszi (Hun) Hypertension in women 15:20 15:40 M. Laganović (Cro) Low birth weight and risk for hypertension and renal damage
15:40 16:30 Attended Poster Chairs: I. Drenjančević, S. Komoly Session (with some cheese, wine and fruits)
Session 4 Integration and mechanisms in hypertension 1 Chairs: P. Nilsson, Lj. Banfić, M. Laganović
16:30 17:00 J. H. Lombard (USA) Dietary Salt Intake, Endothelial Function, and Vascular Oxidant Stress: Parallel Lessons from Humans and Animals. 17:00 17:20 D. Verbanac (Cro) Mediterranean Diet – is it only myth? Could we make it alive? 17:20 17:40 D. Pavlović (Cro) Vitamin D and Hypertension
17:40 18:30 Sponsored symposium Sanofi November 20, Saturday Hotel Osijek, Osijek, Croatia Session 5 Blood pressure measurements Chairs: R. Gmajnić, Cs. Farsang, D. Miličić
08:30 08:50 P. Dolenc (Slo) Home and ambulatory blood pressure measurements 08:50 09:05 M. Illyés (Hun) How to assess arterial stiffness and to obtain clinically relevant data? 09:05 09:15 V. Premužić (Cro) Pulse wave velocity in endemic nephropathy 09:15 09:30 K. Farkas (Hun) Ankle brachial index Session 6 Prevention and control Chairs: K. Farkas, D. Počanić, I. Kiss
09:30 09:40 I. Pećin (Cro) CRASH – Croatian Action on Salt and Health 09:40 10:00 E. Martos (Hun) National Program for Salt in Hungary 10:00 10:15 D. Miličić (Cro) Acute coronary syndrome program in Croatia 10:15 10:25 D. Buljubašić (Cro) Impact of emotional intelligence on the regulation of hypertension 10:25 10:45 Coffee break Visit exhibitors Session 7 Hypertension in serious conditions Chair: K. Šakić, S. Komoly, I. Wittmann
10:45 11:05 Z. Milan (UK) Blood pressure regulation and control pre, during and after surgery 11:05 11:20 S. Kvolik (Cro) Blood pressure patterns, hypertension and perioperative blood pressure management 11:20 11:35 K. Šakić (Cro) A new look at an perioperative hypertension 11:35 11:50 F. Kehl (Ger) Organ protection by volatile anesthetics 11:50 12:10 S. Komoly (Hun) Acute hypertensive encephalopathy versus compensatory increase of blood pressure in acute stroke compensatory increase of blood pressure in acute stroke 12:10 13:10 Sponsored symposium Abbott Laboratories 13:10 14:10 Lunch Visit exhibitors Session 8 Integration and mechanisms in hypertension 2 Chairs T. Bačun, J. Hamar, P. Kunert
14:10 14:30 S. A. Phillips (USA) Microcirculation, blood pressure and physical exercise 14:30 14:40 I. Drenjančević (Cro) Oxygen as a physiological stimulus 14:40 14:55 A. Koller (Hun) Dynamic behaviour of AT1 receptors: role of oxidative stress 14:55 15:10 D. Počanić (Cro) How to assess and how to block RAAS in clinical practice ? 15:10 15:25 Ž. Dujić (Cro) Cardiopulmonary effects of breath hold diving 15:25 16:15 Attended Poster Chairs: M. Laganović, J. Nagy Session (with some cheese, wine and fruits) Session 9 Integration and mechanisms in hypertension 3 Chairs :Ž. Reiner, S. A. Phillips, V. Stojanov
16:15 16:35 I. Wittmann (Hun) Subclinical organ damage, endogenous ouabain and oxidative stress in hypertensive patients 16:35 16:45 D. Lović (Serb) Oubain, salt and hypertension 16:45 17:00 M. Boban (Cro) Acute oxidative stress, vascular function and uric acid 17:00 17:30 Ž. Reiner (Cro) Combination antilipid therapy today and tomorrow 17:30 17:45 M. Klobučić (Cro) Pleiotrophic effects of statins 17:45 18:45 Sponsored symposium Galaxo 20:00 Gala dinner November 21, Sunday Hotel Osijek, Osijek, Croatia Session 10 Secondary Hypertension Chairs: J. Nagy, R. Steiner
08:30 08:50 T. Kovacs (Hun) The role of kidney in Physiology and Pathophysiology of Blood Pressure 08:50 09:20 R. Acceto (Slo) Renovascular hypertension 09:20 09:50 D. Kuzmanić (Cro) Primary aldosteronism 09:50 10:30 State of the Art Chair: B. Jelaković, I. Štagljar (Can) Lecture Protein Networks Regulating Cell Signalling in human health and disease
10:30 11:00 Coffee break Visit exhibitors 11:00 12:00 Sponsored symposium Servier
Session 11 Hypertension and Heart Chairs: D. Kuzmanić, R. Acceto, J. Mirat
12:00 12:15 M. Čikeš (Cro) Cardiac remodelling and tissue Doppler 12:15 12:30 M. Kašner (Ger) Diastolic dysfunction 12:30 12:45 R. Steiner (Cro) Treatment of hypertensive heart disease 12:45 13:00 J. Mirat (Cro) Hypertension and Aortic Valvular Disease 13:00 Young Investigator Awards 13:15 Closing remarks
SIMPOZIJ MEDICINSKIH SESTARA U HIPERTENZIJI
19 Studeni 2010, Petak Hotel Osijek
10:30 Pozdravna riječ
Mirjana Mihalić , predsjednica Udruge
Ines Drenjančević , dopredsjednica Hrvatskog društva za hipertenziju
Predsjedavajuće: Mirjana Mihalić, Suzana Vidrih, Gordana Šantek Zlatar
10:45 11:00 Marina Colić, Suzana Vidrih
Zdravstvena njega bolesnika oboljelog od arterijske hipertenzije
11:00 11:15 Mirjana Mihalić
Renovaskularna hipertenzija – prikaz bolesnika
11:15 11:30 Vedran Premužić
Centralni arterijski tlak i pulsni val u kliničkoj praksi
11:30 11:45 Slavica Bošnjak, Branka Divčić, Ines Vidatić, Ruža Begić
Hipertenzija u djece i adolescenata
11:45 12:00 Gordana Šantek Zlatar Gabrijela Šimunić
Indikator kvalitete zdravstvene njege: sestrinska dokumentacija i kategorizacija pacijenata na odjelima Nefrologije i Neurologije, OB Koprivnica/ komparacija i analiza
12:00 – 13:00 Godišnja skupština Udruge medicinskih sestara u hipertenziji
HOTEL OSIJEK, HALL LEGEND
Hotel Osijek, ground level
A B S T R A C T S
(selected abstracts are also published in on-line issue of Kidney Blood Pressure Research)
PREVALENCE OF ARTERIAL HYPERTENSION AND OBESITY IN SEVEN YEAR OLD CHILDREN
Aberle N. 1, Kati ć M. 1, Tomac V. 1, Sarka J., Josipovi ć M. 1Pediatrics Clinic, Clinical Hospital Centre Osijek, Osijek, Croatia
Introduction: Hypertension is closely related with obesity in children because of bad diet and lack of physical activity. GOAL was to show prevalence of increased values of arterial blood pressure in 7 year old children and its relation with obesity and overweight.
Methods: The arterial blood pressure has been measured 3 times. Normal blood pressure: values at or lower than the 90th percentile. Blood pressure levels above the 90th percentile but lower than the 95th percentile are termed as prehypertension. Hypertension is defined as values of blood pressure at or above the 95th percentile for gender, age and height.
Nutritional status was calculated by the WHO classification criteria: overweight (85th and 95th pct.), obesity (BMI >95th pct.), underweight (BMI ≤ 5-10 pc)
Results: During our researh we have examineed 447 children by the age of 7 years old (range age was from 6.1 till 7.8). Proporition of boys and girls was almost equal (51,45%:48,55%). Elevated values of arterial blood pressure had 6,04% examinees (3,13% girls and 2,90% boys). Girls had statisticlly higher values of the arterial blood pressure than boys (p=0,13667). Prehypertension was registered in 3,58% and hypertension was detected in 2,46%. Obesity as a risk factor for hypertension was registered in 50 examiness (11,88%), 18% had hypertension. Overweight was detected in 64 examinees (14,31%), 12,5% had hypertension. Children with normal weight had hypertension in 2,9% and underweight children in 5,3%.
Conclusion: Obesity is a very important factor for developing hypertensia in children. In our research adipose and overweight children had significant higher values of arterial blood pressure than children with normal values of BMI.
Hypertension in childhood is a great risk for developing future cardiovascular disorders, with proper prevention we can prevent long-term consequences. HYPERTENSION AS THE MOST PREVALENT ETIOLOGICAL CONDITION IN CHRONIC AND TRANSITORY ATRIAL FIBRILLATION IN PATIENTS AT CANTON HOSPITAL ZENICA
Abdovi ć E.1, Abdovi ć S.2, Blaževi ć V1. 1Cantonal Hospital Zenica, Zenica, Bosnia and Herzegovina 2Referral Center for Pediatric Gastroenterology and Nutrition, Children's Hospital Zagreb, Croatia
Introduction: Atrial fibrillation (AF) is the most prevalent sustained cardiac arrhythmia in developed countries. It is a disease of the elderly and it is common in patients (pts) with structural heart disease. Hypertension, heart failure and valvular heart disease are predisposing factors to AF. Objectives: To evaluate predisposing factors for transitory and chronic AF.
Methods: From June 2000 to May 2010, 2760 consecutive pts with AF were studied during echocardiographic check-up. According to the 2-D transthoracic echocardiography, pts were divided into groups based on dominative underlying heart diseases. Electrocardiographically documented AF was subdivided into two groups: intermittent and chronic. Binary logistic regression was used to investigate relationship between gender, age, hypertension, diabetes and underlying heart diseases with the type of AF.
Results: The median age was 72 years, ranged between 16 and 95 years. Chronic AF was noted in 69.7% pts. The number of men and women with AF was about equal, 50.1% were men. Hypertensive heart disease (HHD) was the most common underlying heart disease (39.3%) followed by dilatative cardiomyopathy (DCM), 24.7%, coronary heart disease (CHD), 15.0% and valvular heart disease (VHD), 11.6%. Lone AF was diagnosed in only 27 pts, mostly in younger males (average age 47±9 years, men 62%). Hypertension and diabetes mellitus were found in 71.3% and 17.4% pts, respectively, primary in females. A significant frequency of transient AF was observed in younger pts, lone AF (OR=2.28, 95% CI=2.13-8.62) and in pts with hypertension regardless the presence of other concomitant heart diseases (OR=1.7, 95% CI=1.36-2.14). Chronic AF was more usual in older (OR=1.04, 95% CI=1.03-1.05), DCM (OR=2.04, 95% CI=1.31- 3.18) and VHD (OR=3.23, 95% CI=1.97-5.32).
Conclusion: HHD was by far the most prevalent associated medical condition. Chronic AF was predominant in groups with advanced cardiac remodeling such as DCM and VHD, mostly elderly. ARTERIAL HYPERTENSION IN PERITONEAL DIALYSIS PATIENTS
Altabas K. 1, Mihaljevi ć D. 2, Kova čevi ć Vojtušek I. 3, Jankovi č N. 4, Klari ć D. 5, Jaki ć M. 2, Čala K. 1, Pavlovi ć D. 1 1Sestre Milosrdnice University Hospital, Department of Nephrology and Dialysis, Zagreb, Croatia 2Department of Dialysis, Osijek University Hospital, Osijek, Croatia 3Department of Nephrology and Dialysis, Merkur University Hospital, Croatia 4Department of Nephrology and Dialysis, Sveti Duh University Hospital, Zagreb, Croatia 5Department of Nephrology and Dialysis, Zadar General Hospital, Zadar, Croatia, [email protected]
Introduction: Arterial hypertension is seen in the majority of dialysis, i.e. haemodialysis and peritoneal dialysis patients.
Aim: The goal of present cross-sectional observation study was to investigate the prevalence of hypertension in peritoneal dialysis pts and the use of antihypertensive drugs.
Methods: Total of 5 dialysis centres were included in the study. Age, sex, peritoneal dialysis duration, systolic and diastolic blood pressure were recorded, as well as antihypertensive drugs used: beta-blockers (BB), calcium channel blockers (CCB), diuretics (D), angiotensin –converting enzyme inhibitors (ACEI), angiotensin II-receptor blockers (ARB), alfa-blockers (AB) and central acting drugs (CAD).
Results: Hypertension was defined as blood pressure > 13/90 mmHg or less if patients were on antihypertensive treatment.
Total of 98 (mean age 56,6 ± 12,1 years) patients were included in study. On continuous ambulatory peritoneal dialysis (CAPD) were 68 (69%) patients and 30 on automated peritoneal dialysis (APD). CAPD patients were on dialysis for 29,9 ± 24,5 months, and APD patients for 23,5 ± 14,6 months. Arterial hypertension was observed in 96, i.e. 97% of patients. The average blood pressure was 137,5 ± 13,3 systolic and 82,7 ± 8,4 mmHg diastolic. There was no difference between CAPD and APD patients.
The most often used antihypertensive drugs were CCB, in 53 patients (54%), after that BB in 39 (39,7%) of patients, ACEI in 36 (36,7%) of patients. ARB were used in 26 (26,5%) of patients,, CAD in 17 (17,3%) and AB in 12 ( 12,2%) of patients. The diuretics were used in 54 (55,1%) of patients. Two or three antihypertensive drugs were used in majority of patients.
Conclusion: The prevalence of arterial hypertension is very high in peritoneal dialysis patients. Management of hypertension in dialysis, i.e. peritoneal and haemodialysis patients is still a challenge for nephrologists. It is obvious that multidrug regiment is necessary.
INVESTIGATION OF PARAMETERS OF BLOOD VESSELS WITH THE FINOMETER DEVICE IN DIABETIC AND NON-DIABETIC HYPERTENSIVE PATIENTS
Bajcsi D., Légrády P., Fejes I.
1st Department of Internal Medicine, University of Szeged, Szeged, Hungary
Introduction: The condition of blood vessels as a cardiovascular risk factor and subclinical target organ damage have been subjected to intensive research.
Aim: We investigated the different parameters characteristic to blood vessels in diabetic and non-diabetic treated hypertensives.
Methods: Sixteen non-diabetic (HT, age: 53.44±1.96 yr, duration of HT: 5.75±1.15 yr), 12 T2DM (DMHT, age: 54.5±1.33 yr, duration of HT: 12.75±2.5 yr, duration of DM: 7.69±1.77 yr) treated hypertensives and 10 normotensive, normoglycaemic healthy control people (C, age: 49.7±2.22 yr) were investigated. We calculated the total systemic peripheral resistance (TPR), the ascending aorta characteristic impedance (Zao) and the total arterial compliance (Cwk) at the current diastolic pressure with the non-invasive Finometer device in resting supine position and after standing up. Further we calculated in supine position the arterial stiffness index (ASI) with the Cardiovision device. Cardiac autonomic neuropathy (CAN) was assessed by means of the five standard CV reflex tests.
Results: The fasting blood glucose was significantly higher only in diabetic patients. The group HT and DMHT did not differ significantly form group C by treated blood pressure values. All the patients group were CAN positive (CAN: C: 0.8±0.29, HT: 3.94±0.47, DMHT: 4.25±0.66). After standing up the TPR and the Zao values increased in all groups. In group DMHT the change of the TPR was the lowest and the change of the Zao was the biggest. Both in supine position and after standing up the the TPR was the highest in group HT and the lowest in group C. The Zao in both position also in group HT was the highest. Similarly the ASI too. After standing up the Cwk decreased in all groups, and in both position it was the lowest in group HT and the highest in group C.
Conclusion. The arterial stiffness is more expressed in diabetic hypertensives than in hypertension alone, which can be well characterized with the Finometer device.
ARTERY PLAQUE SCORE AND ARTERIAL HYPERTENSION
Buljan K. 1, Butkovi ć-Soldo S. 1, Pribi ć S. 2
1Clinical Hospital Centre Osijek, Osijek, Croatia
2Health Centre Osijek, Osijek, Croatia
Introduction: Atherosclerotic plaque is the primary pathomorphologic manifestation of atherosclerosis, where the thickness of intima and media, is 1,3mm and more. Ultrasonography of carotid arteries is an accessible and safe method in plaque detection. Plaque score (PlaS) is a sum of thicknesses of registered plaques in a precisely defined region of carotid arteries, and it is significant because of its correlation with some subtypes of cerebrovascular insult and some lesions of coronary arteries.
Aim: The aim of study is to identify the intensity of atherosclerotic plaque in a population of age 50 to 59, in dependance of presence of arterial hypertension or additional risk factor, from atherosclerosis risk factors category (hypercholesterolemia, diabetes, tobacco).
Methods: The study included 148 examinees (79 women, 69 men) from age 50 to 59. From the total number of participants, 66 of them had no risk factors (32 women, 34 men), and they were the control group. 28 participants had hypertension only (16 women, 12 men), while 53 examinees had at least one more major risk factor besides hypertension (31 women, 22 men).
Ultrasonic carotid arteries exam in B mode, was made with standard protocol.
Intensity of atherosclerotic disease of carotid arteries was evaluated with a modified PlaS in 6 categories (0-5).
Results: Control group had average plaque thickness of 0,75mm(men), and 0,18(women) (average PlaS 0,4 and 0,1). Participants with isolated hypertension had plaque thickness 2,58mm(men), and 2,47mm(women), (PlaS 1,3 for both), while those with additional risk factors measured 4,93mm(men), 3,11mm(women). Healthy participants had plaque in 18,2%, those with hypertension in 78,6%, while those with additional risk factors in 96,3%.
Conclusion: By using a noninvasive and accessible method of carotid ultrasonography, it is possible to detect the thickness of plaque, and in that way, to recognize the risk groups for atherosclerotic diseases.
INFLUENCE OF HIGH SALT DIET ON MICROVASCULAR REACTIVITY IN YOUNG HEALTHY FEMALE HUMAN SUBJECTS
Čavka A. 1, Grizelj I. 1, Begi ć I. 2, Jelakovi ć B. 3, H Lombard J. 4, Mihaljevi ć I. 5, Koller A. 6, Drenjancevic I. 1
1Department of Physiology and Immunology, School of Medicine Universty of Josip Juraj Strossmayer in Osijek, Osijek, Croatia
2Department of Internal Medicine, Clinical Hospital Center Osijek, Osijek, Croatia
3Department of Nephrology and Arterial Hypertension, University Hospital Center Zagreb, Zagreb, Croatia
4Department of Physiology, Medical College of Wisconsin, US
Clinical Institute of Nuclear Medicine and Radiation Protection, Hospital Centre Osijek, Osijek, Croatia
5Department of Physiology, New York Medical College, NY, US
6Department of Physiology and Immunology, School of Medicine Universty of Josip Juraj Strossmayer in Osijek, Osijek, Croatia
Introduction: Increase in salt intake significantly alters vascular reactivity to different physiological stimuli. However, the effects of high salt (HS) intake on microvascular endothelial response in healthy young people without pre-existing conditions such as diabetes and hypertension are still unknown.
Aim: The aim was to assess effects of acute salt loading on microvascular reactivity to reactive hyperemia in young healthy women, using non-invasive Laser Doppler Flowmetry (LDF). Circulating concentration of cell adhesion molecules (CAMs): ICAM, VCAM and E-selectin, as indicators of endothelial function were measured. Eleven normotensive women (21±3 years) were instructed to maintain a low-salt (LS) diet (less than 40 mmol Na/daily) during 7 days and simultaneously divided into HS group (N=5) (intake of 200 mmol Na/daily) or placebo group (N=6). LDF was performed before and after salt diet protocol as measurement of relative changes in blood flow after 1- and 2-minute occlusion.
Results: In the HS group there was a statistically significant decrease in microvascular reactivity after 1-minute occlusion (endothelium-dependant mechanisms) with no difference after a 2-minute occlusion (maximum dilation ability), before and after HS diet. Concentration of VCAM was significantly decreased after HS salt diet with no difference in concentrations of other CAMs. The increased urinary volume, decreased urinary sodium, and increased urinary potassium concentration in subjects on LS diet, and increased urinary sodium concentration in subjects on HS diet confirmed consistency of experimental protocol and subjects’ adherence to diet. Although plasma renin activity and serum aldosterone concentration decreased in HS diet and increased in women on LS diet, they didn’t reach statistical significance.
Conclusion: This study shows that even 1 week of HS intake may have negative effect on vascular reactivity, decreasing blood flow in reactive hyperemia by affecting endothelial function, as shown in decreased levels of VCAM. Increased number of subjects in further study is needed. VASOMOTOR EFFECTS OF HEMOLYSED BLOOD IN ISOLATED RAT CEREBRAL ARTERIES
Cseplo P. 1, Vamos Z., Toth P. 2, Hamar J. 3, Koller A. 4
1Department of Pathophysiology and Gerontology, University of Pecs, Faculty of Medicine, Pecs, Hungary
2Department of Physiology, New York Medical College, Valhalla, NY USA, United States
3University of Pecs, Faculty of Medicine, Dept. of Pathophysiology and Gerontology, Hungary
4University of Pecs, Faculty of Medicine, Dept. of Pathophysiology and Gerontology, Hungary, Department of Physiology, New York Medical College, Valhalla, NY USA
Introduction: Hemorrhagic stroke is followed by increased vascular resistance and thus reduced blood flow to the affected area. The underlying vasoconstrictor mechanisms have not yet been elucidated.
Aim: We hypothesized that hemolysed blood has substantial effects on the vasomotor tone and responses of isolated cerebral arteries.
Methods: The middle cerebral artery (MCA) and basilar artery (BA) from male rats were isolated, cannulated and placed in a pressure-myograph chamber The diameters of vessels were measured in the presence of 80 mmHg intraluminal pressure. The vasomotor function of the vessels was studied in response to administration of hemolysed blood (HB, 40 µL) Vasomotor responses of vessels to acetylcholine (ACh 10-4M), sodium nitroprusside (SNP 10-4M) and nifedipine (10- 6M) were obtained in control, in the presence of HB and after washout of HB. At the end of the experiments the passive diameters (PD) of vessels were determined in Ca2+-free Krebs solution.
Results: The active basal diameters of MCA and BA were 170+/-4,5 µm and 264+/-7,5 µm, respectively; whereas their PDs were 269+/-10 µm and 404+/-10 µm, respectively. HB reduced the basal diameter of both MCA and BA (MCA: to 143+/-4 µm, 84,1+/-4% of AD; BA: to 204+/-13 µm, 77+/-4% of AD). After washing out of HB, the diameters of MCA and BA were 187+/-7 µm and 284+9 µm, respectively. In control ACh, SNP and nifedipine elicited substantial dilations (16+/- 2%, 23+/-3% and 31+/-2%) of cerebral arteries. In contrast, presence of HB decreased the dilation to ACh, SNP and nifedipin (12+/-2%, 16/-+2%, 21+/-2%). After washout of HB dilations were 5+/-1%, 10+/-3%, 18+/-2%, respectively.
Conclusion: The present study suggests that the hemolysed blood has substantial vasoconstrictor effect and inhibits both endothelium-dependent and -independent dilator mechanisms. Elucidating the underlying mechanisms of extravasated hemolysed blood-induced vasomotor dysfunction could contribute to the proper treatment of patients with hemorrhagic stroke.
(Supported by OTKA K71591, K67984)
PREVALENCE, TREATMENT, CONTROL AND DISTRIBUTION OF HYPERTENSION IN ENDEMIC NEPHROPATHY
Dika Ž. 1, Pe ćin I. 2, Karanovi ć S. 1, Vukovi ć Lela I. 1, Premuži ć V. 1, Fištrek M. 1, Laganovi ć M. 1, Fodor Lj. 1, Kos J. 1, Željkovi ć- Vrki ć T. 1, Juri ć D., Cvitkovi ć A., Bitunjac M., Kuzmani ć D. 1, Jelakovi ć B. 1
1Department of Nephrology, Arterial Hypertension and Dialysis UHC Zagreb, School of Medicine University of Zagreb, Zagreb, Croatia
2Department of Metabolic Diseases, UHC Zagreb, School of Medicine University of Zagreb, Zagreb, Croatia
Aim: Hypertension (H) is not a characteristic of endemic nephropathy (EN) and occurs only at the advanced stages of the renal disease. The aim of the study was to determine prevalence, treatment, control and distribution of hypertension in EN.
Methods: In total 1138 adult farmers were inclu ded: 852 from Croatian EN villages (339 M and 513 W) and 286 from control village (112 M and 174 W). There were no gender nor age differences between these groups (p>0.05) The EN population was classified according to WHO criteria as diseased (D), suspected of having EN (S), at risk (R), and others (O). Blood pressure (BP) was measured four times by mercury sphygmomanometer following ESH guidelines, and the mean value was calculated. H was defined as BP >140/90 mmHg and/or administration of antihypertensives.
Results: The study showed no difference in H prevalence between EN villages and control village, with the prevalence being 50.58% vs. 44.31% (p=0.5271), both in M (51.87% vs. 42.57%, p=0.9114) and in W (50.55% vs. 50.41%, p=0.2305). H prevalence was the lowest in the „O“ group (M: 40.4%, W: 50.53%) and the highest in the „S“ group (M: 72.16%, W: 100%). However, subjects in the „S“ group were also the oldest (p<0.0001). However, no difference in BMI when compared to other EN groups was found (p>0.05). More W were treated in EN than in control villages (68.18 vs. 54.9 %; p=0.0173). Compared to the control villages, we found no differences in the control of all H patients (10.28% vs. 12.31 %; p=0.5036) or treated H patients (23.68% vs. 22%; p=0.759). Unlike the control villages, control of H among the overall EN hypertensive population was better in W than in M (16.67% vs.5.34%; p<0.0001) as well as in treated H (24.44% vs. 14.86%; p=0.1916).
Conclusion: The prevalence of H in EN villages did not significantly differ from the one in the control, non endemic villages. The higher-than-expected prevalence of H among persons in the “S” category is likely due to their being of older age. Compared to EN villages, the observed poorer control among W in the control villages might be explained by the lower number of treated H women (p=0.3764) and the higher number of obese ones (p<0.0001).
HYPERTENSION PROTECTIVE ALLELE OF TOLL-LIKE RECEPTOR 2 POLYMORPHIC GENE
Džumhur A. 1, Wagner J. 1, Zibar L. 2, Barbi ć J. 2
1Clinical Hospital Center Osijek, Osijek, Croatia
2Medical School Osijek, University J.J. Strossmayer Osijek, Croatia
Introduction: Low grade inflammation has been shown to play a central role in cardiovascular disease and hypertension. Toll like receptors (TLRs) are crucial molecules for activation of immune system. While single nucleotide polypeptides (SNPs) in TLR4 gene were associated with different cardiovascular diseases, less is known about TLR2 gene. We analyzed the distribution of TLR2 and TLR4 SNPs among hypertensive subjects from the case control study performed at our institution.
Methods: Hypertensive subjects were chosen from the case control study. In the patients group were 120 patients with an acute myocardial infarction. The control group consisted of 120 sex and age matched blood donors without records of coronary disease. In the both groups there were 84 hypertensive subjects. Following the approval of the study by the Medical Ethical Committee of the Clinical Hospital Center Osijek, all participants gave informed written consent. From The data regarding age, sex, blood pressure, diabetes and cigarette smoking were obtained the medical records. Genomic DNA was extracted from peripheral blood with DNA kit (Intron Biotechnology, Seul, S. Korea). SNPs on TLR2 gene rs3804100 and TLR4 gene rs4986790 were determined by Real time PCR with TaqMan probes obtained from Applied Biosystems .
Results: There were 59 smokers in the patients group (49%) and significantly less in the control group (only 24 vs. 20%, p<.001). Diabetes mellitus was not present in the control group. TLR2 TC rs3804100 allele was statistically significantly less frequent in the hypertensive patients (a protective allele).
Table: Distribution of SNPs in TLR2 and TLR4 genes in hypertensive subjects.
Number of hypertensive TLR4( rs4986790) TLR2 (rs3804100 ) subjects
AA AG GG Statistics TT TC CC Statistics 85 72 13 0 p=0.945 82 3 0 p=0.003
Conclusion: TLR2 TC allele of SNP rs3804100 might be protective against hypertension. However, TLR4 SNP rs4986790 was not associated with hypertension. Further research in other large population based studies is needed to confirm these findings.
CUMULATIVE INCIDENCE OF ARTERIAL HYPERTENSION IN NORMOTENSIVE SUBJECTS COHORTA
Erceg M. 1, Ivi čevi ć Uhernik A. 1, Kern J. 2, Vuleti ć S. 2
1Croatian National Institute of Public Health, Zagreb, Croatia
2“Andrija Štampar“ School of Public Health, School of Medicine, University of Zagreb, Zagreb, Croatia
Introduction: The public health significance of hypertension is the result of the finding that hypertension is an independent risk factor for cardiovascular diseases. The risk grows continually as the blood pressure surpasses the values considered normal.
Aim: To establish age and sex differences in cumulative incidence in normotensive subjects cohort.
Methods : From a sample of the Croatian Health Survey for 2003 a cohort was formed of normotensive subjects on whom the same survey was repeated in 2008. The arterial blood pressure was measred by mercury sphygmomanometer, with standard cuff. Values were read twice and used to compute the mean for every respondent. This second survey included a total of 1381 respondents. Criteria for inclusion into the group of subjects with elevated blood pressure were: statement on taking antihypertensive drugs, and/or average systolic pressure >140 mmHg, and/or average diastolic pressure >90 mmHg. Results were expressed as percentage points of the incidence of arterial hypertension and their 95%-confidence intervals (hereinafter referred to as 95%CI).
Results: In the male group, cumulative incidence of arterial hypertension was recorded at 36.9% (95%CI =32.1-41.6), while women had a corresponding rate of 33.0% (95%CI=30.1-36.0). The highest cumulative incidence was registered in the oldest age group (65+), with a rate of 58.3% (95% CI=47.8-68.9) in men, and 52.2% (95% CI=46.8-63.6) in women. The rate of 45-to-64-year-old men figured 35.5% (95%CI=28.3-42.7), their female counterparts 41.7% (95% CI=36.6- 46.8). The lowest incidence was documented between the ages of 18 and 44, in which group men had 25.9% (95% CI=18.7-31.1), and women 20.6% (95% CI=17.0-24.1).
Conclusion: Arterial hypertension incidence increased with age and no significant sex differences were noted within respective age groups. Further studies should concentrate on analyzing other risk factors correlated with newly diagnosed cases of arterial hypertension. Their detection is crucial for the planning and evaluation of prospective prevention programs.
DIAGNOSIS OF SUBCLINICAL ATHEROSCLEROSIS: ANKLE/BRACHIAL INDEX AS A SCREENING METHOD
Farkas K. 1, Járai Z. 2, Kolossváry E. 1, Kiss I. 3
1Department of Angiology of Internal Medicine, St. Imre Teaching Hospital, Budapest, Hungary
2First Department of Medicine, Semmelweis University, Budapest, Hungary
3Department of Nephrology of Internal Medicine, St. Imre Teaching Hospital, Budapest
Introduction: Epidemiological data have shown that patients with clinical, but also preclinical stages of peripheral arterial disease (PAD) are characterized by a high risk of cardiovascular mortality. PAD can already be diagnosed in asymptomatic stage, with a simple, noninvasive test, defining the ankle/brachial index (ABI). Low ABI is an indicator of increased cardiovascular risk in asymptomatic subjects.
Methods: In the ÉRV program of the Hungarian Society of Hypertension hypertensive patients were screened for the presence of peripheral PAD. Ankle/brachial index and major cardiovascular risk factors were recorded before the 5 years long prospective phase of the program. A total of 21 892 hypertensive men and women (9162 males; mean age: 61.45 years) who were attended at 55 hypertension outpatient clinics in Hungary, during a 17 month period, were included in the study.
Results: The prevalence of PAD defined by low ABI ( ≤0.9) was 14.0%. In the two blood pressure target group (140/90 mmHg and 130/80 mmHg) the ratio of patients with controlled blood pressure was 45% and 33%, respectively. The prevalence of PAD (ABI<=0.9) was 10.9% in the controlled and 16.1% in the uncontrolled group (p<0.0001). During the control visits a significant decrease of the blood pressure was observed.
Conclusion: The prevalence of PAD (low ABI value) is high in hypertensive patients. Uncontrolled hypertension increases the risk of PAD. The results indicate, that ABI screening is a simple and cost-effective method for the diagnosis of preclinical atherosclerosis, which may improve cardiovascular risk prediction.
INFLAMMATION AND PREHYPERTENSION
Fištrek M. 1, Karanovi ć S. 1, Vukovi ć Lela I. 1, Čapkun V. 2, Cvitkovi ć A. 3, Mileti ć-Medved M. 3, Čvoriš ćec D. 4, Bitunjac M. 5 , Kuzmani ć D. 1, Pe ćin I. 6, Laganovi ć M. 1, Kos J. 1, Dika Ž. 1, Jelakovi ć B. 1
1Universitiy Hospital Center Zagreb, University of Zagreb, School of Medicine, Croatia
2University hospital center Splt, Department of nuclear medicine, Split, Croatia
3Public Health Institute Brodsko-Posavska County, Slavonski Brod, Croatia
4University hospital center Zagreb, Clinical Institute of Laboratory Diagnosis, School of medicine Zagreb University
5General hospital “Dr Josip Ben čevi ć”, Slavonski Brod, Croatia
6University hospital center Zagreb, Department of metabolic diseases, Internal medicine clinic, School of medicine Zagreb University, Croatia
Introduction: Whether the inflammation is an initial event in the development of hypertension or a consequence of endothelial damage, and whether WBC might be a marker for it, is still an open question.
Aim: To evaluate the association between prehypertension status and inflammatory markers (white blood cells - WBC) in 816 subjects (350 men and 466 women).
Methods: After an extended questionnaire and clinical exam BP was measured following the ESH/ESC guidelines and subjects were classified in groups with optimal BP (OBP), normal BP (NBP), prehypertension (PH), stage 1, 2, 3 hypertension and isolated systolic hypertension (ISH). Fasting blood was drawn and WBC count, number of neutrophiles, lymphocytes and other WBC were determined. Subjects treated with anti-inflammatory drugs and antibiotics were excluded.
Results: In our group OBP, NBP, PH, strage 1, 2, 3 hypertension and ISH were diagnosed in 16.2%, 12.6%, 11.1%, 12.9%, 9.4%, 5.9% and 21.2% subjects, respectively. BP categories were significantly related to the WBC count (χ2=14,2; p=0,027). There was no significant difference in WBC count in PH group and we failed to find any differences in WBC count and neutrophiles between OBP vs. NBP vs. PH (p>0.05). However, we observed the difference between stage 3 vs. OB, NBP and PH (p=0.008, 0.002, 0.001, respectively) and stage 2 vs. PH (p=0.01). Similar results were observed with neutrophiles ( χ2=18,1; p=0,006), and again significant differences between stage 3 vs. OB, NBP, PH (p<0.01) were determined. There were no differences in lymphocytes and other WBC between BP categories (p>0.05).
Conclusion: WBC are related to BP values only in advanced phases of hypertension. There was no differences in WBC among subjects with OBP and PH, thus inflammation was not an apperant characteristic of prehypertension (although it seems to be important in advanced stages of hypertension) and/or that WBC are not very sensitive biomarker.
ENDOVASCULAR INTERVENTION EFFECTS IN PATIENTS WITH ATHEROSCLEROTIC RENOVASCULAR HYPERTENSION ON BRACHIAL AND CENTRAL BLOOD PRESSURE AND PULSE WAVE VELOCITY
Fodor Lj. 1, Premuži ć V. 1 , Perkov D. 2, Jelakovi ć B. 1,Kuzmanic D. 1
1Department of Nephrology and Arterial Hypertension, UHC Zagreb,
2Department of radiology, UHC Zagreb,
Background: Renovascular hypertension (RVH) is one of the most common forms of secondary hypertension. The aim was to analyze the effect of endovascular intervention in 14 patients (mean age 64.66 ± 11.27) with atherosclerotic RVH on PWV(pulse wave velocity) and the other traditional risk factors.
Methods: Arterial stiffness was determined by TensioMedTM arteriography. Peripheral BP was measured by Omron BP monitors. Ambulatory blood pressure measurement (ABPM) was done with the SpaceLabs 90207 device. In all patients were determined serum creatinine, glucose and lipid levels. All measurements were analyzed before and 6 months after endovascular interventions.
Results: The mean peripheral BP was165/93mmHg, and 146/83mmHg in control. The average ABPM was 122/78mmHg and 116/73mmHg in the control, and MAP (mean arterial pressure) 95.14 (± 17.04), and in control 90.78 (± 15.96). Augmentation index of brachial artery was 24.10 (± 13.29), and in control 21.07 (± 31.87). Aortic augmentation index was 29.20 ( ± 15.5), and in control 43.79 (± 17.42). PWV was 11.91 (± 4.6) m/s, and in control 20.19 (± 23.08) m/s. There was a statistically significant difference between man and woman in body height (165.83 vs. 177.37 cm), weight (72.5 vs.91.87 kg), as well as the level of triglycerides (1.36 vs. 2.4 mmol/L) and HDL cholesterol (1.67 vs. 1.01 mmol/L). These factors also were significantly different between patients with left sided renal artery stenosis compared to the right, and also left sided had elevated serum creatinine (129.5 µmol/L) compared to the right (88.71 µmol/L).
Conclusion: PWV was initially 11.91 (± 4.6) m/s and in control increased to 20.19 (± 23.08 ) m/s. Although, there were no statistical differences among some of the parameters (due to the small sample size), there were significant differences between body height, weight, tryglicerides and creatinine in relation to the localization of renal arterial stenosis. LACK OF RELATION BETWEEN ENDOTHELIAL FUNCTION AND CAROTID ARTERY STIFFNESS IN YOUNG, HEALTHY MALE SUBJECTS
Horváth T., Pintér A., Kollai M.
Institute of Human Physiology and Clinical Experimental Research, Semmelweis University, Budapest, Hungary
Introduction : The tonic relaxant influence of the endothelium on vascular smooth muscle, reducing stiffness of the vessel wall, has been established in muscular conduit arteries. Stiffening of arteries with advancing age and risk factor exposure predominantly involves the elastic aorta and carotid arteries. It is not known to what extent the stiffness of large elastic arteries is under endothelial control. This study was designed to investigate the relationship between endothelial function and stiffness of the carotid artery, a representative of central elastic arteries.
Methods : Conduit artery endothelial function was assessed in 30 subjects by measuring brachial artery flow mediated dilatation (FMD). Carotid artery elastic parameters were calculated from carotid pulse pressure measured by local tonometry and from pulsatile distension determined by echo wall-tracking. Systemic arterial stiffness was assessed by aorto-femoral pulse wave velocity (PWV). Relations between variables were determined by univariate correlation analysis.
Results : All measured values fell within age related normal ranges. FMD was inversely related to age and DBP (r = -0.49 and -0.48, respectively; p<0.01 for both). FMD was also significantly and inversely related to PWV (r = -0.46; p<0.05), but was not related to any parameter of carotid artery elasticity,
Conclusion : In healthy young male subjects carotid artery elasticity is not related to conduit artery endothelial function, suggesting that large elastic vessel function may not be significantly influenced by the endothelium.
HEART RATE IS RELATED TO DIASTOLIC BLOOD PRESSURE
Karanovi ć S. 1, Vukovi ć Lela I. 1, Premuži ć V. 1, Fištrek M. 1, Čapkun V. 2, Laganovi ć M. 1, Dika Ž. 1, Kos J. 1, Juri ć D. 1, Cvitkovi ć A. 3, Bitunjac M. 4, Pe ćin I. 5, Kuzmani ć D. 1, Reiner Ž. 5, Jelakovi ć B. 1
1Department of Nephrology, Arterial Hypertension and Dialysis UHC Zagreb, School of Medicine University of Zagreb, Croatia
2Department of nuclear medicine UHC Split, Split, Croatia
3 Public Health Institute County of Slavonski Brod, Slavonski Brod, Croatia
4General Hospital Dr Josip Ben čevi ć, Slavonski Brod, Croatia
5University hospital center Zagreb, Department of metabolic diseases, Internal medicine clinic, School of medicine Zagreb University, Croatia
Aim: Recent studies renewed, too often neglected, interest in association of heart rate (HR), hypertension and cardiovascular morbidity. Our aim was to investigate the relationship of HR and blood pressure (BP) in general population.
Methods: Out of 1375 subjects enrolled in the epidemiologic survey conducted in Croatian rural area, 495 untreated subjects (216 men and 279 women) were included into the study. Exclusion criteria were: antihypertensive therapy, acute illness, chronic terminal disease and serious disability, dementia and pregnancy. BP and HR were measured three times in a sitting position using OMRON device, and mean values were calculated. Subjects were classified into groups with optimal BP (<120/80 mmHg), prehypertension (120/80-140/90 mmHg) and hypertension (>140/90mmHg). HR values were divided into quartiles (I <69.5, II 69.6-76.5, III 76.6-85.5, IV >85.6).
Results: Median age of the whole group was 45 (range 19-90). Although statistical significance was not revealed regarding BP categories and quartiles of HR (p=0.365), lower values were observed in subjects with optimal BP compared to values obtained in the hypertensive group. Statistical significance in HR was found between prehypertensive and hypertensive groups (76.44±11.48, and 78.96±12.56, respectively; p=0.04). Linear regression analysis between HR and BP showed no significance (p=0.360). Significant correlation was found only between diastolic BP and HR (p=0.006) what was also confirmed by the multiple regression analysis (p=0.0073).
Conclusion: Signficant corellation between dyastolic BP and HR was found. Although we could not find statistical significance, our study suggest a trend of increased HR in hypertensive subjects comparing to those with prehypertension.
HYPERTENSION AND SALT INTAKE - PRELIMINARY RESULTS FROM STUDY OBTAINED IN UNDEVELOPED RURAL PART OF CROATIA
Keranovi ć A. 1, Draži ć I. 1, Gardijan B 1, Križan čić J. 1, Modri ć Ž. 1, Vrkljan AM 1., Sovi ć S 1., Vitale K 1, Jelakovi ć B. 2
1School of Medicine, School of Public Health „Andrija Štampar“University of Zagreb, Croatia
2Department of Nephrology and Arterial Hypertension, University Hospital Center Zagreb, Zagreb, Croatia
Introduction: Previous studies suggest that there is a high prevalence of hypertension in rural areas, as well as high salt consumption.
The aim: To determine prevalence of hypertension and awareness of harmful effects of salt on blood pressure and health.
Methods: Adult farmers from three villages in Sisa čko-moslava čka County (Central part of Croatia) were enrolled. After clinical exam, blood pressure was measured following ESH guidelines using Omron devices, and data on socioeconomic status, education level, medical and family history as well data on awareness of harmful effect of salt were obtained from questionnaire.
Results: In this pilot, preliminary study we have analyzed data obtained in 106 persons (57 W, 49 M). As generally in rural parts of Croatia, majority were of older ages: age group 44-65 25.7% and 33.3% men and women, respectively; age group 45-64 25.7% men and 33.3 % women, respectively; age group 65-84 62.9% men and 55.6% women, respectively. Hypertension was confirmed in 77.6% of men and 75.4% of women. Hypertension was newly diagnosed in 6 men (15.8%) and 10 women (23.5%). Majority of farmers are aware that salt intake is related to hypertension (71.4%), but also most of them did not know, what the main sources of salt in every day meals are (69%). We failed to find differences between hypertensive and normotensive subjects. Salt intake was above recommended values (5 gr NaCl/day) in all enrolled farmers.
Conclusion: Our pilot study confirmed previous results on high prevalence of hypertension in rural areas, as well as on high salt consumption. Awareness was poor as it is in other parts of Croatia. We hope that final results of our study will attract attention of national and local public health authorities to apply proper therapeutic measures. INTRAOPERATIVE BP OSCILLATIONS AND 24-HOUR DIPPING STATUS IN SURGICAL PATIENTS
Kristi ć M. 1, Mili čevi ć N. 1, Kristek J. 2, Krajinovi ć Z. 2, Pinoti ć K. 2, Vizjak V. 3, Kvolik S. 1
1 Clinical Hospital Centre Osijek, Department of anestesiology and intensive care, Croatia
2 Clinical Hospital Centre Osijek, Clinic of surgery, Croatia
3 Internal clinic, Clinical Hospital Centre Osijek, Croatia
Aim: Preoperative dipping status may be predictive for blood pressure (BP) oscillations during anesthesia. Searching PubMed database with search terms ‘anesthesia’ and ‘dipping status’ retrieved no one publication on this topic. In this prospective open study we compared 24-hour dipping status and intraoperative BP oscillations in a cohort of surgical patients.
Methods: Differences in the BP were studied in a group of 22 consecutive surgical patients, 65±7.8 years undergoing vascular surgery in general anesthesia with propofol, rocuronium and fentanyl. Continuous 24-hours preoperative BP values were recorded using Mobil-O-Graph portable device during the hospitalization and evaluated by specialist in hypertension. Patient categories were recognized as deeper with satisfactory BP control (group D, night-time BP< 15- 20% from baseline), non deeper (group ND, night-time BP< 15% from baseline) and non deeper with >15% of critical night time BP measurements ± 20% from baseline (group ED, extreme deeper). Perioperative BP values were recorded through invasive BP monitoring. Statistical analysis was performed using SPSS.
Results: Only 4/22 vascular patients had normal preoperative dipping status. The most pronounced oscillations were recorded during the night-time. An average of 17.8% of all night-time measurements was considered as critical. Dipping status significantly correlated with variability of systolic BP (SBP) during the nigh-time (p=0.33, r=0.64), whereas negative correlation was registered for dipping status and minimal day-time diastolic BP (p=0.009, r=0.74). Maximal 24-hour SBP was 163±14.4 mmHg, whereas maximal intraoperative SBP was registered after intubation (168.3±37mmHg, p=0.76, ns). A total number of 24-hour critical BP measurements significantly predicted intraoperative BP oscillations and maximal intraoperative BP, and (p<0.001). ED patient category (7/21) had enhanced perioperative BP oscillations as recorded by SBP standard deviation (awake BP SD in ED =39.5 mmHg vs. 19.7 in D group, p>0.05).
Conclusion: This study revealed that preoperative BP oscillations significantly correlate with that registered during anesthesia.
THE IMPACT OF INDIVIDUAL BLOOD PRESSURE COMPONENTS ON THE TYPE AND DEGREE OF THE LEFT VENTRICULAR HYPERTROPHY
Kunišek J. 1, Zaputovi ć L. 2, Žuvi ć Butorac M. 3, Kunišek L, Vu čkovi ć Rapai ć S 1
1Thalassotherapia Opatija, Croatia
2Clinical Hospital Center Rijeka, Department of Internal Medicine, Division of Cardiology, Croatia
3University of Rijeka, Technical Faculty, Rijeka,Croatia
Aim: We sought to determine which of the individual components of arterial pressure has the greatest impact on the shaping of left ventricular hypertrophy (LVH) pattern/degree .
Methods: The study included 192 patients (87 men), aged 43-80 years ( median 68 years) with LVH. The subjects were classified into three groups with regard to the type of hypertrophy (concentric, eccentric and asymmetric) and into three subgroups with regard to the degree of hypertrophy (mild, moderate and severe). After discontinuing all medications for a period of 48 hours, blood pressure was measured, electrocardiography, and echocardiography were performed. Antihypertensive drugs and the duration of previous treatment were taken into consideration. What was sought was the correlation between the systolic, diastolic, mean arterial pressure and pulse pressure on one side, and the LVH type/degree on the other.
Results: The pulse pressure was significantly greater in the case of concentric LVH, more so than in cases of eccentric and asymmetric LVH (p=0.029), the values of which were mutually identical. It rose with the LVH degree (not significantly, p=0.217). The systolic pressure has a similar tendency (p=0.177). The diastolic and mean arterial pressure were not significantly different, neither in regard to the type, nor the degree of LVH.
Conclusion: The pulse pressure has the strongest impact on the shaping of the LV geometry, particularly in the case of the concentric type. With the reduction of pulse pressure (primarily systolic pressure in elderly) we shall prevent the adverse (primarily concentric) remodelling of the left ventricle.
INFLUENCE OF METABOLIC SYNDROME ON CIRCADIAN BLOOD PRESSURE REGULATION IN NEWLY DIAGNOSED ESSENTIAL HYPERTENSIVES
Kos J., Laganovi ć M., Premuži ć V., Kuzmani ć D., Dika Ž., Željkovi ć Vrki ć T., Fištrek M., Fodor Lj., Ron čevi ć T., Jelakovi ć B.
University Hospital Center Zagreb, Department of Nephrology and Arterial Hypertension, Zagreb, Croatia
Introduction : Metabolic syndrome may affect circadian changes in blood pressure.
Aim: We aimed to assess a possible influence of metabolic syndrome (MS) on circadian blood pressure (BP) regulation in newly dignosed hypertensives.
Methods: In the study 103 previously untreated, otherwise healthy patients were included (60 M, 43 F, average age 37+9.1 years) with newly diagnosed essential hypertension (HT) without target organ damage and normal renal function. BP was measured using mercury sphygmomanometer and ambulatory BP monitor (ABPM). Body mass index (BMI), waist circumference(WC), fasting blood glucose(FPG), total cholesterol(TC), tryglicerides(TG), HDL cholesterol(HDL), GFR (MDRD) were determined in all patients. MS is defined according to modified ATP III criteria. Following ABPM parameters were analyzed: average 24 hour, daytime and nighttime values of BP; blood pressure load (BPL), dipper vs non-dipper status, BP variability and heart rate. Patients with white-coat hypertension vere excluded.
Results: MS was diagnosed in 30 % males and 16% females. We did not observe differences between non-MS and MS group for office BP, 24h ambulatory BP, daytime, nighttime BP, BPL, BP variability or heart rate in whole group or according to gender. We found increased PP in ABPM both in daytime (55,2+10,3 vs 47,9+7,4 p=0,002) and nighttime period (52,9+9,6 vs 47,6+7,9 p=0,024). We observed increased percentage of non-dippers (51,3 vs 25,0 % chi2 4,92 p= 0,026) in hypertensive group of patients with MS.
Conclusion: in patients with MS increased PP and subtle changes in circadian BP pattern were observed mainly influencing dipping status, which points toward increased CV risk already in the early phase of essential hypertension.
CHANGES OF THE BAROREFLEX-SENSITIVITY AND PLASMA NOREPINEPHRINE AFTER NEUROSURGICAL DECOMPRESSION OF THE MEDULLA OBLONGATA ON THE LEFT SIDE IN A HYPERTENSIVE WOMAN
Légrády P. 1, Fehértemplomi K. 1, Vörös E. 2, Bajcsi D. 1, Fejes I. 1, Barzó P. 3, Ábrahám G. 1
11st Department of Internal Medicine, University of Szeged, Szeged, Hungary
2Department of Radiology, University of Szeged, Szeged, Hungary
3Department of Neurosurgery, University of Szeged, Szeged, Hungary
Introduction: The baroreflex-sensitivity (BRS) is a good marker for the fast cardiovascular (CV) regulation and low BRS comes with hihger CV risk. We investigated the changes of BRS and plasma norepinephrine (NE) after microvascular decompression (MVD) in a case of a therapeutically resistant hypertensive woman with microvascular pulsatile compression (MPC) of the rostral ventrolateral medulla on the left side.
Methods: The 57 year old woman blood pressure (BP) could not be normalised with 11 folder antihypertensive medication. The continuous systolic BP and ECG data were recorded with the Finometer (FMS, Arnhem, Netherlands) device before and after the operation. We calculated the time-domain up- and down-BRS and the frequency-domain alpha-index in the low-frequency (aLF) and high-frequency (aHF) spectra both in resting supine position and after standing up. The NE was evaluated also before and after the MVD.
Results: The BRS values calculated by both method after the MVD increased not only in the supine position but after standing up. Before MVD: (supine vs. standing) upBRS 5.80 vs. 2.51, downBRS 5.49 vs. 3.82, aLF 3.67 vs. 2.61, aHF 3.70 vs. 2.01 [ms/mmHg]. After MVD: (supine vs. standing) upBRS 5.80 vs. 4.07, downBRS 10.5 vs. 7.48, aLF 7.51 vs. 3.89, aHF 6.68 vs. 4.68 [ms/mmHg]. The BP was normalised after the MVD with 5 folder drug combination. The NE significantly decreased after the MVD.
Conclusions: In resistant hypertension with MPC, the MVD results significant BP reduction and improving fast cardiovascular regulation.
DIETARY SALT INTAKE, ENDOTHELIAL FUNCTION, AND VASCULAR OXIDANT STRESS: PARALLEL LESSONS FROM HUMANS AND ANIMALS
Lombard H.J. 1, Durand M. 1, Priestley J. 1, Raffai G., Baer A., Drenjan čevi ć I. 2, Zhu J.
1Medical College of Wisconsin, Milwaukee Department of physiology, United States
2Department of Physiology and Immunology, School of Medicine Universty of Josip Juraj Strossmayer in Osijek, Osijek, Croatia
Introduction: There is growing evidence that elevated dietary salt intake can contribute to endothelial dysfunction and increased mortality in humans. Experimental animal models that recapitulate the effects of elevated dietary salt intake in humans can be tremendously valuable in elucidating the mechanisms of endothelial dysfunction in salt-sensitive hypertension.
Methods: The responses of arteries to multiple vasodilator stimuli were evaluated in isolated cannulated resistance arteries, in situ arterioles, and aortic rings. Nitric oxide (NO) availability and superoxide levels were assessed with using DAF-2 and DHE staining, respectively. Studies were conducted in normotensive rats and hamsters, Dahl salt sensitive (SS) rats, and in consomic and congenic rat strains having the Brown Norway (BN) renin allele substituted into the Dahl SS genetic background. Animals were fed either a low-salt (LS; 0.4% NaCl) or high salt (HS; 4% NaCl) diet.
Results: Vascular relaxation in response to multiple vasodilator stimuli was impaired in animals switched to HS diet, and in Dahl SS rats fed LS diet, which exhibit chronically low angiotensin II levels due to an inability to regulate their plasma renin activity normally. Impaired vascular relaxation was paralleled by reduced NO levels and elevated superoxide levels. Vascular relaxation could be restored by chronic i.v. infusion of a subpressor dose of angiotensin II and by antioxidant treatment. Substitution of the BN renin allele into the SS genetic background also restored salt-sensitive vascular relaxation.
Conclusions: The deleterious effects of elevated dietary salt intake and lower than normal levels of circulating angiotensin II have been demonstrated in multiple normotensive animals, and in genetic models of salt sensitive hypertension such as the Dahl SS rat. The availability of multiple experimental animal models promises to provide crucial insight into the effects of elevated dietary salt intake and the mechanisms of early cardiovascular dysfunction in salt- sensitive humans.
INVESTIGATION OF THE BAROREFLEX-SENSITIVITY IN DIFFERENT CARDIOVASCULAR DISEASES
Majtényi P., Légrády P., Bajcsi D., Ondrik Z., Fehértemplomi K., Fejes I., Farkas K., Ábrahám G.
1st Department of Internal Medicine, University of Szeged, Szeged, Hungary
Introduction: The risk for cardiovascular events is high in patients with decreased baroreflex-sensitivity (BRS).
Methods: We investigated the spontaneous BRS in significant carotid artery stenotic (CS, n=14, age: 68.0±9.9 yrs, BMI: 25.7±3.8 kg/ m2), diabetic (DHT, n=13, age: 56.0±5.1 yrs, duration of HT: 15.9±12.2 yrs, duration of DM: 11.2±7.1 yrs, BMI: 30.2±3.9 kg/m2) and non-diabetic hypertensive (HT, n=25, age: 55.4±7.0 yrs, duration of HT: 7.0±5.2 yrs, BMI: 28.6±3.8 kg/m2), haemodialysed (HD, n=23, age: 62.4±16.5 yrs, BMI: 26.6±3.6 kg/m2) patients and in healthy normotensives (C, n=13, age: 50.4±6.3 yrs, BMI: 26.7±3.5 kg/m2). The hypertensives in all groups were on combined drug treatment. Mean±SD are reported. The continuous BP and ECG data were recorded with the Finometer (FMS, Arnhem, Netherlands) device during 10 minutes long lying and after it 10 minutes long standing position. The data were analysed with the Nevrokard software. We calculated the up- and down-BRS by time-domain sequence method. In this work we attended to systolic BP. After stenting carotid artery data could be recorded only in lying position. After stenting the both way calculated BRS values increased in lying position.
Results: All the BRS values were the lowest in group HD in both positions (lying upBRS: 4.48±3.1, standing upBRS: 3.94±2.3, lying downBRS: 5.44±3.0, standing downBRS: 4.59±2.2 [ms/mmHg]). All the BRS values were higer in group HT compared to the other non-healthy groups (lying upBRS: 9.5±5.2, standing upBRS: 5.47±3.0, lying downBRS: 8.65±6.5, standing downBRS: 6.12±2.5 [ms/mmHg]). The spontaneous BRS increased after stenting and decreased after haemodialysis.
Conclusion: These data suggest the lonely hypertension has the lowest cardiovascular risk among different cardiovascular diseases. In any other or complicated cases the risk is higher.
INHIBITION OF POLY(ADP-RIBOSE)POLYMERASE REDUCES HYPERTENSION INDUCED VASCULAR REMODELING IN SPONTANEOUS HYPERTENSIVE RAT (SHR) MODEL
Magyar K. 1, Vamos Z. 1, Bruszt K. 1, Balogh A. 2, Kálai T. 3, Hideg K. 3, Seress L. 4, Sumegi B. 5, Koller A. 6, Halmosi R. 1, Tóth K. 1
1University of Pecs, Medical School 1st Department of Medicine, Hungary
2University of Pecs, Medical School Medical Biology3, Pecs, Hungary
3University of Pecs, Medical School Organic and Pharmacological Chemistry, Pecs, Hungary
4University of Pecs, Medical School Central Electron Microscope Laboratory, Pecs, Hungary
5University of Pecs, Medical School Department of Biochemistry and Medical Chemistry, Pecs, Hungary
6University of Pecs, Medical School Department of Pathophysiology and Gerontology, Pecs, Hungary
Introduction: Remodeling of large vessels and vasomotor dysfunction in resistance arteries are well known consequences of prolonged hypertension. Continuous elevated blood pressure triggers oxidative stress causing consequent poly(ADP-ribose) polymerase (PARP) activation.
Aim: Vasoprotective effect of L-2286 PARP inhibitor was assumed in spontaneously hypertensive rat (SHR) model.
Methods: Male 10-week-old SHR rats were divided into two groups: 1st group was treated with 5 mg/kg/day L-2286 orally for 32 weeks (SHR-L), 2nd received no treatment (SHR-C). Age-matched male CFY rats were used as normotensive controls (CFY). Intima-media thickness (IMT), arterial stiffness index (ASI), acetylcholine- (ACh) and Na- nitroprussid induced relaxation were measured in carotid arteries. Ultrastructural morphology of aortas, PARP and apoptosis inducing factor (AIF) activation were measured. Involved signal transduction proteins were analyzed by Western blotting.
Results: L-2286 did not influence blood pressure in SHR and CFY rats. At the beginning of the study IMT and ASI were similar both in SHR and CFY rats. However, at the end of the study IMT and ASI values were higher in SHR-C compared to CFY (IMT: CFY: 41±2 m, SHR: 78±5 m; ASI: CFY: 4.1±0.1, SHR: 5.8±0.3; p<0.01), and were decreased significantly by L-2286 (SHR-L: IMT: 63±1 m, ASI: 4.3±0.4; p<0.05). Relaxation of carotid arteries to ACh significantly increased in SHR-L compared to SHR-C (22.3±8% vs. 41±5%, p<0.05), but responses to SNP did not differ. In electron microscope images increased fibroblast activation with collagen overproduction and endothelial lesions were observed in aortas of SHR-C. In contrast in SHR-L decreased collagen content was noticed. L-2286 treatment enhanced the phosphorylation of Akt-1 (p<0.05), while phosphorylation of JNK and p38 MAPKs were significantly lower (p<0.05) in carotid arteries of SHR- L. Translocation of AIF was elevated in SHR-L and decreased in SHR-C.
Conclusions: Thus chronic inhibition of PARP delays vascular remodeling and improves endothelial dependent vasomotor function due to its effect on prosurvival and antiapoptotic signal transduction pathways.
Support: PTE ÁOK-KA 34039-21/2009, GVOP 3.2.1.-2004-04-0172/3.0
EFFECTS OF ERYTHROPOIETIN ON GLUCOSE METABOLISM
Zsóka Mikolás E. 1, Fisi V. 1, Cseh J. 1, Pap M. 2, Szijártó I.A. 1, Molnár G.A. 1, Bek ő V. 1, Wittmann I. 1
12nd Department of Internal Medicine and Nephrological Center, Hungary
2Department of Medical Biology, Hungary
Introduction: Erythropoietin (EPO) is a glycoprotein hormone, which regulates erythroid cell production. Recently several publications came out about non-erythroid effects of EPO - in central nervous system and breast cancer cells among others. Until now there is no reference for the presence of EPO-receptor on fat cells.
Aims: We aimed to make human measurements by using Continuous Glucose Monitoring System (CGMS) including two EPO-, and insulin-treated diabetic patients. We examined the effects of EPO on intracellular signal transduction and glucose-uptake in 3T3-L1 cells.
Methods: In the course of our human examinations we compared the postprandial glucose levels of the patients before and after subcutaneous EPO-injection. The glucose levels were measured with CGMS. We used deoxy-D-glucose isotope to measure the glucose-uptake of the cells under the effect of EPO. We examined the changes of Akt and Erk phosphorilation under the effect of EPO with Western blot method in 3T3-L1 cells.
Results: The postprandial glucose levels of the two patients were significantly lower after the EPO injection, than before it (p<0.05). In our isotope experiments we found a significant increase of glucose uptake adding 0.15ng/ml, 0.3 ng/ml and 0.625 ng/ml concentration of EPO (p<0.05). We detected significant phosphorilation increase of Erk and Akt under the effect of EPO with 5 minutes of treatment in 3T3-L1 cells (p<0.05).
Conclusion: EPO exerts physiological alterations in adipose tissue, which can explain the decrease of glucose level caused by the hormone. Our in vivo experiments in CFY rats are under way to detect the acute effects of EPO on blood glucose level.
SALT INTAKE IN THE CROATIAN ADULT POPULATION: IMPLICATIONS FOR THE PUBLIC HEALTH
Miškulin M. 1, Duman čić G. 1, Dumi ć A. 2, Ugar čić-Hardi Ž. 3, Pitlik N. 1
1Institute of Public Health for the Osijek-Baranja County, Osijek, Croatia; Medical School Osijek, Josip Juraj Strossmayer University Osijek, Osijek, Croatia
2General Practice, Osijek, Croatia
3Faculty of Food Technology in Osijek, Josip Juraj Strossmayer University of Osijek, Osijek, Croatia
Introduction: Excessive salt intake is the key factor in the epidemic of the pre-hypertension/ hypertension.
Aims: The aim of this study was to identify the amount and major food sources of dietary salt in the adult population from Eastern Croatia, and to assess the significance of salt intake from several foodstuffs presumed to be important sources of the 'hidden salt' in the daily diet. Methods: This cross-sectional epidemiological study was conducted during the June 2010 and had included 175 adult participants mean age 54.0±12.5 (range 20 to 89) years from the Osijek area; 49.1% (86/175) males and 50.9% (89/175) females. By the use of specially designed questionnaire demographic data and data concerning the potential nutritional sources of the 'hidden salt' in the daily diet were collected. The weight, height and blood pressure of each participant were measured. The values of the salt content in 23 breads, 42 bakery products and 31 different salty snacks available in Croatian market were established. The amount of salt consumed daily through the cooking, consumption of bread, bakery products and salty snacks as well as the overall daily salt consumption for each participant has been calculated. Results: The overall salt intake in observed population was 9.4±3.9 (range 3.2 to 24.7) grams of salt daily. Most (56.4%) dietary salt was from salt added in home cooking, around 29.8% was from daily consumption of bread, 12.8% was from daily consumption of various bakery products and only 0.7% from daily consumption of salty snacks.
Conclusions: To prevent and control prehypertension/hypertension and improve health, efforts to remove excess salt from the diets in the Eastern part of Croatia should focus on reducing salt in home cooking but also on reducing the amount of baked products in the daily diet of its inhabitants.
CEREBROVASCULAR DISEASES IN CHRONIC KIDNEY DISEASE WITH/ WITHOUT HYPERTENSION
Nagy J.
Second Department of Medicine and Nephrological Center, University of Pécs, Hungary
Introduction: The reason of the unfavorable life expectancy of patients with chronic kidney disease (CKD) is not only the development of end-stage renal failure but the frequent appearance of cardiovascular diseases (CVD). Chronic kidney damage itself is a cardiovascular risk state and the occurrence of CVD-associated diseases is significantly higher in chronic kidney failure.
Methods: Beside risk stratification and valid treatment of CVD (hypertension, diabetes mellitus, ischemic heart disease e.g.) we and the international nephrological community have left the cerebrovascular diseases of CKD patients out of consideration.
Results: Data from several studies show that up to 55% of patients suffering a stroke will die immediately, only 10% of stroke survivors can continue his/her profession, but the others will be permanently disabled. High blood pressure is a strong predictor of stroke and other CVD in most of the patients. In stroke risk reduction it is particularly important to reach the target blood pressure values. The main object of the „Live under 140/90 mmHg” program of the Hungarian Society of Hypertension is to familiarize with target blood pressure itself and how to reach target blood pressure.
Conclusion: In 2010, prevention, early diagnosis and management of stroke are the most important challenges of this program (The Brain Control Program). We think it is advisable to prepare and publish a clinical practice guideline in collaboration with stroke societies which is specific for CKD patients. This guideline would promote primary and secondary prevention of cerebrovascular diseases of CKD patients.
RELATION OF HYPERTENSION AND HELICOBACTER PYLORI INFECTION AS A RISKS FACTOR FOR ACUTE MYOCARDIAL INFARCTION
Naki ć D. 1, V čev A. 2, Patrk J. 1, Zekanovi ć D. 1 , Klarin I. 1
1General Hospital Zadar, Croatia
2School of Medicine, University J.J. Strossmayer in Osijek, Croatia
Introduction: there are several studies which showes association between low grade infections and developement of atherosclerosis and coronary heart disease including acute mycardial infarction (AMI). Hypertension is one of the main risk factors which prevalence is higher in patients with low socioeconomic status like a H.pylori infection.
Aim: find out is there a link between hypertension and H.pylori infection in the patients with AMI.
Methods: in this prospective study in one center, there was 100 patients with AMI undergoing coronary angiography. There was 67 men and 33 women, average age of 64.7 years, 56 had ST segment elevation (STEMI) and 44 were without ST segment elevation (nonSTEMI) myocardial infarction. Control group for prevalence of H. pylori infectiion consists 93 healthy individuals. H.pylori seropositivity was determined by enzyme link test Immulite.
Results: there was 77 % hypertonic patients with average values 144/ 88 mmHg, 52 % with grade I and 25 % with grade II hypertension according to the JNC VII classification. Investigate population were owerweight with average body mass index (BMI) 27.3 kg/m², smoking as a risk factor was present in 50 % patients, diabets in 59 % and hyperlipidaemia in 67 % . H.pylori infection was present in 29 % patients vs. 26 % in control group. Highest levels of systolic and diastolic blood pressure were in the group of hypertonic patients without H.pylori seropositivity compare to groups with hypertension and H.pylory seropositivity and group of normal blod pressure without H.pylori seropositivity. Highest levels of BMI were in group of hypertonic patients with H.pylori infection.
Conclusion: there was no association between H.pylori infection and hypertension as a contribute risks factor in the AMI ., association of obesity, hypertension and H.pylori infection is result of life style among the obese patients. Further studies are needed to clarify role of H. pylori infection with other risk factors in the acute myocardial infarction.
HYPERTENSION IN ELDERLY PATIENTS WITH A KIDNEY TRANSPLANT
Orlić L., Sladoje-Martinovi ć B., Vuksanovi ć-Mikuli čić S., Živ čić Ćosi ć S., Ra čki S.
Department of Nephrology and Dialysis, University Hospital Rijeka, Rijeka, Croatia
Introduction: A large number of patients today with terminal kidney failure are elderly. For a small number of these elderly patients a kidney transplant is a possible method of treatment for terminal kidney failure. Hypertension appears after a transplant among a large number of these patients because the risk of hypertension is higher among this age group of transplant patients.
Aim: The goal of this work was to investigate the prevalence of hypertension among kidney transplant patients above the age of 65 and to analyze anti-hypertension therapy.
Methods: The investigation included 27 patients, 15 male and 12 female, above the age of 65 who received a kidney transplant at the Clinical Hospital Center Rijeka. The average age of the patients was 71.2±5.6 years. The average time spent on dialysis before the transplant was 2.7±2.1 years. The amount of time that had passed since the transplant was 6.6±4.6 years. The average values of creatinine were 135±38.2 µmol/L.
Results: Of the number of patients analyzed, 25 had hypertension. Among all of the patients hypertension appeared within the first year after the transplant.
In the anti-hypertension therapy five patients were taking one antihypertensive drug, 14 patients were taking two drugs and six patients were taking three or more drugs. The most frequently taken medicine was a calcium channel blocker and beta blocker. Of the analyzed patients, 13 achieved the target values for blood pressure.
Conclusion: From the data acquired we can conclude that most older kidney transplant patients have hypertension. Also, in half of these patients the target values for blood pressure were achieved. The most frequently used anti- hypertensives among older patients were calcium channel blocker.
EFFECTS OF HYPERHOMOCYSTEINEMIA ON VARIOUS HEMORHEOLOGICAL PARAMETERS
Papp J. 1, Sándor B. 1, Tóth A. 1, Rába M., Vámos Z. 1, Kenyeres P., Koller A. 2, Tóth K. 1
1University of Pécs, 1st Department of Medicine, School of Medicine, Hungary, Hungary
2University of Pecs, Faculty of Medicine, Dept. of Pathophysiology and Gerontology, Hungary, Department of Physiology, New York Medical College, Valhalla, NY USA
Introduction: Previous in vitro and clinical studies have shown that hyperhomocysteinemia (HHcy) contributes to the development of several cardiovascular diseases and increased peripherial vascular resistance, thus hypertension. However, its effects on blood rheology are not very well known. Thus, the aim of the present study was to investigate the effects of HHcy on various hemorheological parameters.
Methods: Experiments were performed in a HHcy model of rats. For 6 weeks, animals received methionine (1g/kg body weight daily intake) in the drinking water known to increase serum level of homocysteine. Blood samples were taken from HHcy and control animals (n = 12, 12) and serum homocysteine level and hematocrit (Hct) were determined. After Hct standardization (40%), whole blood viscosity (WBV), plasma viscosity (PV), red blood cell (RBC) aggregation and deformability were measured using the Hevimet 40 capillary viscometer, the Myrenne RBC aggregometer and the LORCA.
Results: Serum homocysteine levels were elevated significantly in the animal group receiving supplemental methionine, when compared to the controls (6.4 ± 1.8 vs. 28.5 ± 23.9 mol/l; p<0.01). No significant difference was detected in Hct, WBV, PV and RBC deformability between the two groups. However, RBC aggregation, measured with the Myrenne, was significantly below the control values in rats receiving methionine supplementation (for M: 3.6 ± 1.4 vs. 1.7 ± 0.6; p <0.01; for M1: 8.1 ± 2.5 vs. 5.1 ± 1.7; p<0.01).
Conclusions: Although short-term HHcy did not affect most of the hemorheological parameters, it significantly decreased RBC aggregation. We assume that the reduced RBC aggregation compensates, at least in part, for the detrimental hemodynamic effects of HHcy. However, detrimental vascular effects of HHcy are not primarily due to the impairment of hemorheological parameters.
THE ROLE OF ACE GENE POLYMORPHISM ON EARLY CHANGES IN EPITHELIAL PROXIMAL TUBULE RENAL CELLS IN ENDEMIC (BALKAN) NEPHROPATHY
Pe ćin I. 1, Čvoriš ćec D.2, Mileti ć-Medved M. 3, Kova č-Pei ć A. 4, Cvitkovi ć A 3., Serti ć J 2., Leko N. 4, Vitale K 5., Jelakovi ć B. 6
1University hospital center Zagreb, Department of metabolic diseases, Internal medicine clinic, School of medicine Zagreb University, Croatia
2University hospital center Zagreb, Clinical Institute of Laboratory Diagnosis, School of medicine Zagreb University, Croatia
3Public Health Institute Brodsko-Posavska County, Slavonski Brod, Croatia
4General Hospital Dr Josip Ben čevi ć, Slavonski Brod, Croatia
5Andrija Stampar Institute of Public Health, Zagreb, Croatia
6Department of Nephrology and Arterial Hypertension, University Hospital Center Zagreb, Zagreb, Croatia
Introduction: Endemic nephropathy (EN) is a chronic tubulointerstitial nephritis with insidious clinical course. Tubular proteinuria and enzymuria are hallmarks of EN. The role of renin-angiotensin system (RAS) in EN has not yet been elucidated.
Aim: The aim of this study was to investigate the role of angiotensin-converting enzyme (ACE) gene polymorphism in EN focusing on the urinary N-acetyl-B-D-glucosaminidase (NAG) excretion.
Methods : 179 participants (122 women and 57 men) were stratified according to the modified WHO criteria: diseased (N=9), those at risk for EN (N=84), suspects of having EN (N=35), and others (N=51). After short questionnaire and clinical exam, blood and urine samples were taken for determination of serum creatinine, hemoglobin, low molecular weight proteins and NAG as well (as marker of proximal tubular cells early damage). ACE gene polymorphism was determined using PCR method.
Results: There were 58 (31.5%) DD, 78 (42.1%) ID and 43 (26.3%) II subjects. No differences in allele frequency and ACE genotypes were found between the subgroups (p>0.05). We failed to find connection between ACE genotype and blood pressure (p=0.125), serum creatinine (p=0.871), proteinuria (p=0.632), hemoglobin levels (p=0. 368) and markers of early proximal tubular cells damage (NAG as well (p=0.825).
Conclusion: Based on our results ACE gene polymorphism do not influence EN. It does not affect on early changes in proximal tubule cells. These results need to be confirmed in further studies on greater number of patients.
ENDOVASCULAR TREATMENT OF ATHEROSCLEROTIC RENAL ARTERY STENOSIS AND UNCONTROLLED HYPERTENSION: CHARACTERISTICS OF PATIENTS AND INTERVENTION
Perkov D. 1, Smiljani ć R. 1, Dobrota S. 1, Fodor Lj. 2, Premuži ć V. 2, Jelakovi ć B. 2, Štern Padovan R. 1
1Department of Diagnostic and Interventional Radiology, University Hospital Center Zagreb, University of Zagreb School of Medicine, Croatia
2Department of Internal Medicine, Division for Nephrology and Arterial Hypertension,University Hospital Center Zagreb, University of Zagreb School of Medicine
Aim: To present characteristics of patients and endovascular procedures in treatment of atherosclerotic renal artery stenosis (RAS) and uncontrolled arterial hypertension.
Methods: In the period between February 2009 and July 2010 we treated 22 patients (11 male and 11 female, mean age 64,66 ± 11,27 years) by method of percutaneous transluminal renal angioplasty/stent implantation (PTRA-S) due to hemodynamically significant atherosclerotic RAS and uncontrolled arterial hypertension. Arterial blood pressure was measured by 24-hour Holter. Aortic and periferal artery stiffness was measured non-invasive with Tensiomed Arteriograph device. Before PTRA-S, all the patients underwent color Doppler, MDCT of renal arteries and selective digital subtraction angiography (DSA) of renal arteries.
Results: In 22 patients we performed 26 endovascular interventions (23 implanted stents and 3 PTRAs) in 25 renal arteries. Out of 23 implanted stents, 22 were cobalt chromium renal stents, and only one was coronary bare metal stent (BMS). PTRA was performed with high-pressure renal balloon dilatation catheters. Average stenosis rate was 84,55 ± 11,20 % (range 68-95 %). Mean dilatation pressure of RAS was 12,71 ± 2,19 atm. All endovascular interventions were technically and hemodynamically successfull. There were no major complications and no periprocedural deaths. Mean systolic pressure before procedure was 165,21 ± 27,79 mmHg, an mean diastolic pressure was 93,57 ± 14,96 mmHg. Mean brachial augmentation index (Aix) value was 24,10 ± 13,29 %, and mean aortic puls wave velocity (PWV) was 11,91 ± 4,60 m/s.
Conclusion: Endovascular intervention (PTRA-S) in treatment of patients with atherosclerotic RAS and uncontrolled hypertension is technically successfull and safe. This method of treatment potentially allows better control of high blood pressure and reducing aortic and periferal artery stiffness.
MICROCIRCULATION, BLOOD PRESSURE AND PHYSICAL EXERCISE
Phillips S.
Departments of Physical Therapy and Medicine, University of Illinois at Chicago, United States
Introduction: Lifestyle interventions that involve exercise are commonly employed to prevent the development of cardiovascular disease. However, exercise-induced acute hypertension may increase reactive oxygen species (ROS) generation that scavenge nitric oxide (NO) and threaten vascular endothelial health. The situation is more complex in the microcirculation where NO participates less in vasodilation and ROS can play an important role in regulating vascular function when NO is reduced. Recent studies from our laboratory indicate that 1) conditioned subjects (EX) are protected from endothelial dysfunction in resistance arteries observed in sedentary (SED) subjects after acute weight lifting (WL) exercise and 2) the mechanism of maintained vasodilation to acetylcholine does not involve nitric oxide in EX subjects.
Methods: We studied healthy, lean SED and EX, who underwent blood pressure measurements during a single progressive 15 minute leg press WL session. Brachial artery flow- mediated vasodilation and nitroglycerin dilations were determined with ultrasound. Microvascular specimens were obtained with gluteal subcutaneous fat pad biopsies. Isolated microvessels from the same subjects were cannulated for vascular reactivity measurements to acetylcholine (ACh; 10-9- 10-4 M) pre and post WL. Superoxide and H2O2 production was assessed with hydroethidine and DCF fluorescence in isolated microvessels.
Results: Despite similar increases in arterial pressure, SED subjects have reduced ACh-dependent vasodilation after a brief strenuous WL session compared to EX subjects. The H2O2 scavenger PEG-catalase reduced DCF fluorescence and Ach-induced dilations post WL and had no effect on pre-WL. DCF fluorescence was increased in microvessels from EX subjects post WL. The mitochondrial electron transport chain inhibitor rotenone reduced dilations to ACh in resistance arteries.
Conclusions: These data indicate that H2O2 contributes to the maintained dilation in resistance arteries after exposure to exercise-induced hypertension. Future investigations will advance our understanding of the relationship between H2O2 from endothelium during exercise and resistance artery function.
THE CORRELATION OF ENDOTHELIN-1 AND NITRIC OXIDE WITH MEAN ARTERIAL PRESSURE DEPENDS ON THERAPY WITH ANGIOTENSIN-CONVERTING ENZYME INHIBITORS IN DIABETIC PATIENTS
Tomi ć M, Musa D., Pravdi ć D., Petrovi ć J., Markota I.
Clinical Hospital Mostar, Bosnia and Herzegovina
Introduction: Nitric oxide (NO) and endothelin-1 (ET-1) play an important role in modulation of vascular homeostasis. Recently, the role of NO and ET-1 in the pathogenesis of hypertension in diabetic patients has been proposed.
Aim: To investigate the changes in plasma and urine levels of NO and ET-1, and assess the association of NO and ET-1 with arterial hypertension in diabetic patients with or without therapy with angiotensin-converting enzyme inhibitors (ACEI).
Methods: 30 diabetic patients with diabetic nephrophaty, and 30 healthy control subjects were included. Blood pressure was measured with mercury sphingo-manometer. NO levels were determined in serum and urine by Griess reaction and ET-1 concentration was assessed by enzyme-linked immunosorbent assay (ELISA) using an ET-1 kit.
Results: The mean blood pressure was higher in diabetic patients (160/92 mmHg vs. 120/80 mm Hg, p<0.05). Concentration of ET-1 was tended to be higher (N.S.) in plasma and urine in diabetic patients as compared to control subjects (10.63 pg/mL vs. 8.10 pg/mL; plasma and 12.05 pg/mL vs. 9.66 pg/mL; urine). Plasma and urine concentrations of NO were also higher in diabetic patients (7.49 mol/L vs. 5.88 mol/L, p<0.05; plasma), and urine (13.61 mol/L vs. 11.02 mol/L, p=0.312). In diabetic patients receiving ACEI therapy the increase in plasma ET-1 level was associated with systolic blood pressure decline (R2=0.1474), and in those not receiving ACEI the increase in plasma ET-1 level was associated with an increase in systolic blood pressure (R2=0.4239). The patients on ACEI therapy had lower systolic and diastolic pressure with increasing concentrations of NO (R2=0.1402), while patients not receiving ACEI had an increase in both systolic and diastolic blood pressure with increasing plasma NO levels (R2=0.0111).
Conclusion: In summary, NO and ET-1 play a significant role in blood pressure regulation in diabetic patients. The correlation of ET-1 and NO with blood pressure depend on the presence or absence of ACEI therapy.
PULSE WAVE VELOCITY IN PATIENTS WITH ENDEMIC (BALKAN) NEPHROPATHY UNDERGOING HEMODIALYSIS
Premuži ć V. 1, Laganovi ć M. 1, Leko N. 2, Kova č-Pei ć A. 2, Teskera T 2, Čvorišćec D 3., Bitunjac M 2, Illyes M. 4, Pe ćin I. 5, Karanovi ć S. 1, Vukovi ć Lela I. 1, Jelakovi ć B. 1
1Department of Nephrology and Arterial Hypertension UHC Zagreb, School of Medicine University of Zagreb, Croatia
2General Hospital Dr Josip Ben čevi ć, Slavonski Brod, Croatia
3Laboratory for clinical diagnosis UHC Zagreb, School of Medicine University of Zagreb, Croatia
4TensioMed Ltd. Budapest, Hungary
5Department for Metabolic Diseases, UHC Zagreb, School of Medicine University of Zagreb, Croatia
Introduction: Although our recent results showed that prevalence of hypertension (H) in EN villages is not different comparing to other rural parts of Croatia, several decades ago it had been observed that blood pressure (BP) was normal in EN patients.
Aim: To determine arterial stiffness in EN patients undergoing hemodialysis HD.
Methods: In 81 HD patients (40 M, 41 W) (age 58.27 ± 15.15 vs. 65.63 ± 11.71) from Dialytic Unit, GH Slavonski Brod aortic pulse wave velocity (PWV) was measured by Tensiomed Arteriograph. Brachial BP was measured using Omron device following ESH/ECS guidelines. There were 23 (12 M, 11 W) EN and 58 (28 M 30 F) non EN patients (mean age 70.56 ±/5.94 vs. 58.60 ±/ 14.75, respectively; p=0.0003).
Results: There were no significant differences in brachial and aortic augmentation indexes (AIx) as well in aortic PWV between EN and non-EN patients. Mean brachial and aortic Aix were 13.36 ± 27.16 and 38.23 ± 11.52, while aortic PWV was 11.41 ± 2.05. Patients with higher AIx values had higher mean arterial pressure (MAP) (114.83 ± 15.24 vs. 101.41 ± 13.92, respectively; p=0.0017), pulse pressure (PP) (73.74 ± 17.38 vs. 55.41 ± 15.91, respectively; p=0.0002) and aortic systolic blood pressure (SBPAO) (169.82 ± 26.97 vs. 130.96 ± 22.00, respectively; p<0.001), while EN patients with higher Aix values had higher SBPAO values (163.56 ± 30.87 vs. 134.62 ± 13.31, respectively; p=0.029). EN patients with higher PWV values had higher BMI (24.33 ± 4.00 vs. 20.33 ± 2.38) and lower phosphates (1.90 ± 0.15 vs. 2.15 ± 0.24).
Conclusion: There was no differences between EN and non-EN patients undergoing dialysis, whereas we have found differences between patients with higher Aix and PWV values and the increasing arterial stiffness markers values with higher MAP,PP and SBPAO.
(Supported by grant of Ministry of Science Rep of Croatia 0108109)
A COMPARISON OF FREQUENCY OF ARTERIAL HYPERTENSION IN PATIENTS WITH ACUTE STROKE DURING FIVE-YEAR PERIOD IN OSIJEK AREA
Rostohar Bijeli ć B. 1., Bijeli ć N. 2, Hegeduš I. 3, Kadoji ć D. 3
1Scientific Research Unit, University Hospital Center Osijek, Osijek, Croatia
2School of Medicine Osijek, Josip Juraj Strossmayer University of Osijek, Osijek, Croatia
3Clinic of Neurology, University Hospital Center Osijek, Osijek, Croatia
Aim: To determine whether there exists a difference in frequency of hypertension and other risk factors in patients suffering from various types and subtypes of stroke (S) in years 2004 and 2009.
Methods: A group of 130 patients suffering from acute S in year 2004 was compared to a group of 100 patients with same disease in year 2009. In all patients, the diagnosis of S was determined using computed tomography of the brain, while other diagnostic procedures were performed as well. S was classified as hemorrhagic S (intracerebral hemorrhage and subarachnoid hemorrhage) and ischemic S which, according to TOAST classification, comprises large vessel S (LVS), small vessel S (SVS), cardioembolic S (CES), S of other determined etiology (OCS) and S of undetermined etiology (US).
Results: Average age of patients increased from 67.3 in year 2004 to 70.5 in year 2009. Share of male patients also increased. In year 2004 there were 7 patients for which the subtype of S could not be precisely determined, while in 2009 there were no such patients. Frequency of arterial hypertension, which is one of the most important risk factors for S increased from 78% in year 2004 to 83% in year 2009. There was some increase in frequency of diabetes and atrial fibrillation as well, while the frequency of hyperlipidemia, smoking and myocardiopathies decreased.
Conclusions: The research showed that arterial hypertension still is the most frequent and the most important risk factor for S. There is also high frequency of other common risk factors such as hyperlipidemia, diabetes, atrial fibrillation and smoking. All of this emphasizes the need for education and increased activity in the field of primary and secondary prevention of S.
DIFFERENT EFFECT OF IGA NEPHROPATHY AND POLYCYSTIC KIDNEY DISEASE ON ARTERIAL STIFFNESS
Sági B., Kés ői I., Tóth O.I., Vas T., Fazekas A., Kovács T., Wittmann I., Nagy J.
2nd Department of Internal Medicine and Nephrological Center, Hungary University of Pécs, Pécs, Hungary
Introduction: Renal function is a major predictor of cardiovascular disease. The effect of specific renal diseases on vascular function is unknown.
Methods: We studied 60 IgAN and 60 PKD patients with CKD stages 1-4. Fifty control patients had normal kidney function. We measured pulse wave velocity by digital volume pulse method and derived stiffness index (SIDVP). We investigated the effect of the two homogenous type of CKD on the arterial stiffness.
Results: PKD patients had an increased SIDVP compared to IgAN patients and controls (11.14 m/s, 9.66 m/s and 8.87 m/s, p<0.001) IgAN patients with CKD3-4 had significantly higher SIDVP, than controls (10.43 m/s and 9.15 m/s, p<0.05 CKD3-4 vs. controls), IgAN patients with CKD1-2 had not. In PKD both the CKD3-4 and CKD1-2 patients had higher SIDVP than controls (11.41 m/s and 10.95 m/s vs. 8.87 m/s, p<0.001). We found an inverse correlation between SIDVP and GFR in IgAN, but not in PKD.
Conclusion: In both PKD and in IgAN the arterial stiffness was increased comparing to controls. Arterial stiffening in PKD was independent from renal function and more pronounced than in IgAN. Vascular alterations are more severe and start earlier in PKD than in IgAN.
CORRELATION BETWEEN PLASMA LEPTIN AND ADIPONECTIN CONCENTRATIONS IN HYPERTENSIVE OVERWEIGHT PATIENTS
Selthofer-Relati ć K. 1, Radić R. 2, Steiner R. 1, Vizjak V. 1, Bošnjak I. 1
1Internal Clinic, Clinical Hospital Centre Osijek, Croatia
2School of Medicine, University J.J. Strossmayer in Osijek, Croatia
Introduction: Adipose tissue is biggest endocrine organ, which secretes numbers of adipokines, cytokines and chemokines. Leptin and adiponectin are part of complex neurohumoral system of adipokines who are involved in development of obesity-related cardiovascular diseases. Molecular mechanisms of their actions on development of the left ventricular hypertrophy are not clear yet.
Aim: To determine correlation of neurohumoral non-haemodynamic factors, leptin and adiponectin, in the same serum samples and their infuenze on development of the left ventricular hypertrophy.
Methods: The study included 80 hypertensive patients, divided into four groups according to sex and left ventricular hypertrophy, with body mass index 25-30 kg/m², regular renal fuction and regular glycaemia in the morning. Biochemical, anthropometric and cardiovascular determination were done to all examiners. Adiponectin concentration was determined by enzime immunoassay and leptin concentration by radioimmunoassay test.
Results: Overweight is characterized by higher plasma level of leptin and lower plasma level of adiponectin. Leptin and adiponectin concentrations did not correlate in the same serum samples. Also, leptin or adiponectin concentrations did not correlate with the left ventricular wall thickness, intraventricular septum and posterior wall.
Conclusion: Leptin and adiponectin present part of neurohumoral, non-haemodynamic system that contributes to development of obesity – related arterial hypertension and left ventricular hypertrophy. The major effect of higher leptin and lower adiponectin concentrations are probably achieved trought action on systemic haemodynamic factors (hypertension) and minor effect trought action on local non-haemodynamic factors (leptin and adiponectin receptors in the myocardium). Pathysiological mechanism of their actions are not understood yet. Also according to our results, we concluded that leptin and adiponectin concentrations are not in inversly-proportional relationship.
COMPARISON OF ANTIOXIDANT EFFECTS OF HYDROGEN SULPHIDE (H2S) AND SUPEROXIDE DISMUTASE (SOD) IN ISOLATED SMALL VEINS
Solymár M., Tanai E., Hamar J., Koller A.
Department of Pathophysiology and Gerontology, University of Pécs, Pécs, Hungary, Hungary
Introduction: Recent studies suggest that H 2S is a potent antioxidant that can improve the cardiovascular function.
Aim: Thus we aimed to compare the antioxidant properties of hydrogen sulphide (H 2S) to that of superoxide dismutase (SOD) on superoxide-induced vasomotor activity.
Methods: Small gracilis veins of Wistar rats were mounted in a myograph (Experimetria-WPI) filled with Krebs solution (37°C) and gassed with 95% O 2. A basal tone was established, then 60 mM KCl was used to induce pre-contraction. Then the vasomotor effects of the superoxide generator pyrogallol (10 -5 M) were measured. The chamber was washed out and the vessels were pre-contracted and incubated with SOD (120 U/ml). The contractions to pyrogallol were -5 obtained again. Subsequently, the effect of the H 2S donor NaHS (10 M) was measured.
Results: In small veins KCl elicited a substantial vasomotor tone (0.63 + 0.1 mN), which increased after pyrogallol administration (1.3 + 0.2 mN, p <0.05). In the presence of SOD the pyrogallol elicited contraction was significantly reduced (0.9 + 0.2 mN, p <0.05). In the presence of H 2S, the pyrogallol elicited contraction was similar to the control (1.3 + 0.2 mN). Also, SOD significantly decreased the KCl induced vasomotor tone (0.5 + 0.1 mN, p <0.05), whereas H 2S did not affect it (0.6 + 0.1 mN).
Conclusion: In the present study H 2S did not prevented the pyrogallol-induced contraction, whereas SOD significantly decreased it. These results suggest that the previously described antioxidant effects of H 2S are unlikely to be mediated by its direct interaction with superoxide.
(Supported by OTKA K71591 and K67984.)
CHRONIC HEMODIALYSIS PATIENTS' VIEW ON NORMAL BLOOD PRESSURE VALUES- IMPACT ON COMPLIANCE WITH ARTERIAL HYPERTENSION TREATMENT
Pandurovi ć T. 1, Špeh S. 1, Zibar L. 1, Stipani ć S. 2
1Medical School Osijek, University J.J. Strossmayer Osijek, Croatia
2University Hospital Centre Osijek, Osijek, Croatia
Introduction: Arterial hypertension (AH) is common among chronic hemodialysis (CHD) patients. It is associated with cardiovascular disease, which is highly responsible for morbidity and mortality within this population. We supposed that they frequently do not comply with the antihypertensive treatment, for the complex reasons, including their distored view on the normal blood pressure values.
Aim: We examined the hypothesis that CHD patients hold higher blood pressure (BP) values for normal with consecutive poor BP control.
Methods: 202 CHD patients (25 to 85 years, mean 64±13) answered questionnaire on maximal normal BP, compliance to antihypertensives and symptoms upon BP variations. Data on history and current AH control were taken from records. Optimal BP before hemodialysis session was considered less than 140/90 mmHg, mean arterial pressure (MAP) less than 107 mmHg, corresponding to high normal BP (guidelines ESH-ESC 2007).
Results: 57% of patients declared maximal acceptable systolic BP higher than 139 mmHg (median 150 mmHg, 140-180). More than a half would not take antihypertensives by BP lower than preferrd. Most of them report symptoms by lower BP. Only half of them had normal predialysis MAP below 107 mmHg. The year of AH diagnosis differed significantly from the year of beginning of treatment (p< 0.001). 17.3% initiated antihypertensive treatment delayed, even up to 40 years.
Conclusion: Chronic HD patients often consider normal BP higher than those recommended. Many of them had purely regulated AH. It might be, at least in part, due to insufficient compliance to the treatment with antihypertensives. Except for the ignorance, different view on normal BP could be attributed to symptoms related to BP below the preferred. They seem to be somehow adapted to the higher BP. The question remains whether this is a consequence of delayed AH treatment or inadequate guidelines for this particular population of patients.
INCREASES IN INTRALUMINAL FLOW ELICIT CONSTRICTIONS IN ISOLATED RAT MIDDLE CEREBRAL ARTERIES
Zsolt S. 1, Toth P. 2, Doczi T. 3, Koller A. 2
1Department of Pathophysiology and Gerontology, Medical School, University of Pécs, Hungary
21st Department of Pathophysiology and Gerontology, Medical School, University of Pécs, Hungary, 3, Department of Physiology, New York Medical College, Valhalla, NY, USA, Hungary
3 2nd Department of Neurosurgery, University of Pécs, Hungary, Hungary
Introduction: Changes in systemic pressure are accompanied with changes in intraluminal flow, as well.
Aim: Thus we hypothesized that – in addition to the pressure sensitive, myogenic mechanism - increases in intraluminal flow elicit constrictions of isolated cerebral arteries.
Methods: Middle cerebral arteries (MCA) were isolated from the brain of rats and studied in pressure-flow chamber. Changes in inner diameter were measured by a microangiometer to stepwise increases in intraluminal flow (at a constant intraluminal pressure of 80 mmHg). Intraluminal flow was established by increasing the pressure difference throughout the vessels ( ∆P = up to 5 or 60 mmHg). Also, the passive diameters of vessels (in Ca2+ free solution) were measured as a function of pressure and flow. From the data wall shear stress (WSS) was calculated and statistical analysis performed.
Results: MCA (basal diameter: 181±6 µm at 80 mmHg) maintained a constant diameter in the face of increasing intraluminal pressure in a range of 40-150 mmHg (~58% of passive diameter). Whereas, in the presence of constant intraluminal pressure of 80 mmHg increases in flow significantly constricted MCA (from 61±1.2 to 50±1.3% of passive diameter, p<0.05). Calculation of wall shear stress (WSS) also indicated that increases in flow elicited increases in WSS, which resulted in significant constrictions of MCA. The flow/WSS-induced constrictions significantly augmented pressure- induced constrictions in an additive manner.
Conclusion: In conclusion, we propose that constriction of cerebral arteries in response to increased flow has important physiological role in maintaining a relatively constant local cerebral blood flow and intracranial volume during increases in systemic blood pressure.
(Supported by: American Heart Association, AHA Founders Aff., 0855910D, Hungarian Nat. Sci. Res. Fund-OTKA K71591 and K67984).
THE METHOD OF DISTANCE MEASUREMENT AND TORSO LENGTH INFLUENCES THE RELATIONSHIP OF PULSE WAVE VELOCITY TO CARDIOVASCULAR MORTALITY
Cseprekál O. 1, Németh Z.K. 1, Studinger P. 1, Hadj Othmane T.E. 1, Nemcsik J. 2, Fekete B.C. 1, Deák G. 1, Egresits J. 2, Szathmári M. 1, Tislér A. 1
1 First Department of Medicine Semmelweis University, Budapest, Hungary
2Division of Angiology and Nephrology, Department of Medicine, St. Imre Teaching Hospital, Budapest, Hungary
Introduction: The method of estimating the distance traveled by the pulse wave, used in the calculation of pulse wave velocity (PWV), is not standardized.
Aim: Our objective was to assess whether different methods of distance measurement influenced the association of PWV to cardiovascular mortality in hemodialysis patients.
Methods: 98 chronic hemodialysis patients had their PWV measured using three methods for distance estimation; PWV1: sternal notch–femoral site minus sternal notch–carotid site, PWV2: carotid–femoral site, PWV3: carotid–femoral site minus sternal notch–carotid site. Carotid–femoral distance was used to approximate torso length. Patients were followed for a median of 30 (range 1-51) months and the association of PWV and cardiovascular mortality was assessed using survival analysis before and after stratification for torso length.
Results: The three methods resulted in significantly different PWV values (11.2 (3.3), 14.8 (4.2), 12.6 (3.7) m/s, respectively). During follow up 50 patients died, 32 of cardiovascular causes. In log-rank tests only PWV1 tertiles but not those of PWV2 or PWV3 were significantly related to outcome (p-values 0.017, 0.257, 0.138, respectively). In adjusted Cox proportional hazards regression only PWV1 was related to cardiovascular mortality (HR for 1m/s higher PWV 1.18[1.03-1.35], 1.10[0.99-1.21], 1,13[1.00-1.27], for the three PWVs respectively). In stratified analysis, however, among patients with below median torso length all three PWV values were related to outcome, while in patients with above median torso length neither PWV methods resulted in significant relationship to outcome.
Conclusion: PWV calculated using the sternal notch–femoral distance minus sternal notch–carotid distance provides the strongest relationship to cardiovascular mortality. Longer torso weakens the predictive value of PWV, possibly due to more tortuosity of the aorta hence more error introduced when using surface tape measurements.
DOES OXIDATIVE STRESS AFFECT THE VASOACTIVE EFFECT OF INSULIN?
Szijarto I.A. 1, Mérei Á. 1, Fisi V. 1, Fésüs G. 2, Cseh J. 1, Zsóka Mikolás E. 1, Molnár G.A. 1, Wittmann I. 1
1 2nd Department of Internal Medicine and Nephrological Center, Hungary
2 Heart Institute
Introduction: The amount of oxidative stress may be different in various blood vessels, which could affect their vasoactive function.
Aim: To measure the total amount of the free radical markers o- and m-Tyr (o+m-Tyr) in the walls of various blood vessels, furthermore to determine the vasoactive properties of these vessels.
Methods: The relative o+m-Tyr (o-Tyr+m-Tyr/Phe) content of the vascular wall were measured with high-performance liquid chromatography system (HPLC). In our experiments we measured the acute vasoactive effects of acetylcholine (ACh), insulin (INS) and sodium-nitroprusside (SNP) on aortic (Ao), mesenteric (Me) and femoral (Fe) arteries isolated from rats. The vessels were preconstricted by epinephrine with isometric myograph system.
Results: The highest oxidative stress was measured in the aortic wall, lower amount was detected in the mesenteric artery (o+m-Tyr: Ao vs. Me: 1.87±0.194 vs. 1.255±0.296, p ≤0.05). The o+m-Tyr extent of the femoral artery was significantly lower than in the aortic or mesenteric wall (Fe vs. Ao: 0.37±0.15 vs. 1.87±0.194; Fe vs. Me: 0.37±0.15 vs. 1.255±0.296, p ≤0.05). The EC50 value of ACh and INS was significantly different in every vessel, it was the highest in the aorta, followed by the mesenteric artery and it was the lowest in the femoral artery (log EC50: Ao vs. Me vs. Fe: ACh: - 4.101±0.35 vs. –6.01±0.078 vs. -7.183±0.102; INS: -0.2259±0.0815 vs. -1.018±0.087 vs. -1.304±0.038, p ≤0.05). The EC50 value of SNP was significantly higher in the aorta compared to the mesenteric and femoral artery (log EC50 SNP: Ao vs. Me: -8.648±0.185 vs. -9.909±0.192; Ao vs. Fe: -8.648±0.185 vs. -10.08±0.078, p ≤0.05), but there was no difference between the mesenteric and femoral artery (log EC50 SNP: Me vs. Fe: -9.909±0.192 vs. -10.08±0.078, p≤0.05).
Conclusion: The level of oxidative stress seems to be different along the arterial vascular tree, which could affect their vasomotor functions, such as the resonse to insulin.
MALIGNANT HYPERTENSION IN PATIENTS WITH RENAL DISEASES: SINGLE CENTRE EXPERIENCE
Tišljar M. 1, Kati ć T. 1, Horvati ć I. 1, Durlen I. 1, Boži ć B. 1, Galeši ć-Ljubanovi ć D. 2, Galeši ć K. 1
1 Department of Nephrology, University hospital Dubrava, Croatia
2 Department of Pathology, University hospital Dubrava, Croatia
Introduction:
Malignant hypertension (MH) is defined by severe hypertension (often ≥120 mmHg diastolic) occurring with retinopathy of grade III (flame haemorrhages) to grade IV (papilloedema). MH patients demand urgent referral for assessment and treatment in order to minimize end-organ damage and reduce the risk of life threatening events. In University hospital "Dubrava" we have identified 10 patients with MH and overt renal disease in the period from 2003. to 2010.
Methods:
After medical history and physical examination had been taken, routine blood biochemistry and urinalysis with 24-hour proteinuria were collected. Clinical and laboratory workup was expanded by 24-hour continuous blood pressure measurement, cardiac echosonography and retinal funduscopic examination. In order to determine the type of renal lesion, 16-gauge needle ultrasound guided kidney biopsy was performed.
Results: Average age of included patients (6 male, 4 female) was 42.4 years (range 26 to 68). Renal disorder was presented as nephrotic syndrome with azotaemia (3 patients), acute nephritic syndrome (5 patients) and chronic nephritic syndrome (2 patients), respectively. All patients had severe renal insufficiency with average serum creatinine level of 633.8 mol/L (range 200 to 1870 mol/L). Pathological proteinuria was found in all patients (2,63 gram/day in average) and 5 patients had erythrocyturia. In 7 patients retinal exudates and in 3 patients papilloedema were detected. In 2/3 of patients left ventricular hypertrophy was present. The most often pathohistological renal finding was thrombotic microangiopathy (5 patients) followed by chronic sclerosing glomerulonephritis (2 patients) and IgA glomerulonephritis, hypertensive nephropathy and an acute interstitial nephritis (each in 1 patient).
Conclusion: In presented study, in vast majority of patients, end-organ damage was already evolved with thrombotic microangiopathy as the most often kidney histological finding. In patients with MH and signs of renal disorder, kidney biopsy is a precious diagnostic tool which could significantly help clinician to make accurate diagnosis and apply adequate therapy.
ASSOCIATION OF HYPERTENSION WITH OVERWEIGHT AND WEIGHT GAIN - CROATIAN ADULT HEALTH SURVEY 2003-08
Ivi čevi ć Uhernik A. 1, Erceg M. 1, Vuleti ć S. 2
1Croatian National Institute of Public Health, Zagreb, Croatia
2 University of Zagreb, School of Medicine, Andrija Štampar School of Public Health, Croatia
Introduction: Objective of this study was to investigate association of long-term overweight status as well as of becoming overweight with hypertension.
Aim: Prevalence of hypertension in 2008 was calculated for 1,383 respondents which had normal blood pressure in 2003.
Results: Among men, 30.3% of respondents with normal BMI both in 2003 and 2008 developed hypertension by 2008, the same applies for 44.5% of respondents who were overweight both in 2003 and 2008 and for 26.0% of respondents who had normal BMI in 2003, but were overweight in 2008. Among women, 15.1% of respondents with normal BMI both in 2003 and 2008 developed hypertension by 2008, the same applies for 43.0% of respondents who were overweight both in 2003 and 2008 and for 37.5% of respondents who had normal BMI in 2003, but were overweight in 2008. For men being overweight both in 2003 and 2008 was associated with OR 1.70 for hypertension in 2008 (95% CI: 1.02-2.82) compared to men that maintained normal weight both in 2003 and 2008. Having normal weight in 2003 and being overweight in 2008 was not associated with increased OR for hypertension among men. For women being overweight both in 2003 and 2008 was associated with OR 3.39 for hypertension in 2008 (95% CI: 2.33-4.93), while having normal weight in 2003 and being overweight in 2008 was associated with OR 3.79 for hypertension in 2008 (95% CI: 2.45-5.87) compared to women that maintained normal weight both in 2003 and 2008.
Conclusion: For women both long-term overweight status and becoming overweight were significantly associated with development of hypertension, while for men this was true only for long-term overweight. Even recently becoming overweight (in last 5 years or even shorter period) can increase risk for hypertension among women. Long-term overweight status increases risk of hypertension among both sexes.
AGING DEPENDENT CHANGES IN ANGIOTENSIN II-INDUCED CONTRACTIONS OF ISOLATED RAT CAROTID ARTERIES
Vamos Z. 1, Cseplo P. 1, Koller A. 1, Toth P. 2, Degrell P. 3, Hamar J. 1
1Department of Pathophysiology and Gerontology, University of Pécs, Pécs, Hungary,, Hungary
2Department of Pathophysiology and Gerontology, University of Pécs, Pécs, Hungary - Department of Physiology, New York Medical College, Valhalla, NYC
32nd Department of Internal Medicine, University of Pécs, Pécs, Hungary.
Introduction: Angiotensin II (Ang II) is a potent vasoconstrictor and plays a crucial role in the regulation of blood pressure. In addition, Ang II has been shown to exhibit tachyphylaxis.
Aim: The potential aging-induced changes in Ang II and NE-induced vasomotor responses have not yet been explored. We hypothesized that aging induces changes in the magnitude of vasomotor responses to Ang II and NE.
Methods: Thus carotid arteries from newborn (8days: 8d), young (2month: 2m), adult (6m) and aged (12m and 24m) rats were isolated and placed in a wire myograph to measure changes in their isometric tension. Two dose response curves to Ang II and NE were obtained in a sequential manner (1.-, and 2.-administration (Adm)).
Results: Contractions of vessels to 1.-Adm of Ang II in 8d vessels were significantly less compared to those of 2m, 6m, 12m and 24m, which were similar in magnitude (1.4±0.2 and 5.2±0.6, 5.6±0.4, 5.2±0.5, 5.7±0.4 mN, respectively). Contractions of vessels to 2.-Adm of Ang II were significantly reduced in 2m, 6m, 12m and 24m vessels (4.4±0.5; 3.6±0.4; 1.9±0.4, 0.5±0.2 mN), whereas it didn’t change in vessels of 8d rats (1.28±0,2 mN). Contractions to 1.-Adm of NE increased to the age of 2m (8d: 0.7±0.3 and 2m: 6.9±0.7 mN), then it did not change (6m: 5.9±0.5, 12m: 5.7±0.9, 24m: 6.0±0.8mN). Compared to the 1.-Adm, contractions to 2.-Adm of NE did not change significantly (8d: 0.3±0.2mN, 2m: 6.4±0.8; 6m: 5.4±1.2, 12m: 5.0±1.7, 24m: 6.3±0.4mN). In summary, we have found that:1) Ang II-induced contraction increases with age, 2) repeated administration of Ang II elicits tachyphylaxis, which increases with age.
Conclusion: The data suggest that aging may induce specific changes in the functional availability of AT1-receptor, which could be due to altered internalization of its receptors, a finding that can have important clinical relevance. (Supported by OTKA K71591, K67984 és Am. Heart Assoc. Founders Aff. 0855910D)
MEDITERRANEAN DIET – DOES IT WORK? DOES IT EXIST?
Verbanac D.
Donatella Verbanac, University of Zagreb School of Medicine, Center for Translational and Clinical Research, Zagreb, Croatia
Introduction: We are witnessing a breakthrough of new dietary products, changing our dietary habits gradually, yet these are not always healthy. Lack of time, combined with a principle of saving money, accounts for the enormous popularity of fast food, prepared instantly and full of rich flavours, but very imbalanced concerning nutritional value. There is too much use of protein of animal origin, which are often a source of so called “bad” fats. Also, the vegetables consumed are often frozen or acidified, which does not comparable with fresh food. All of these are inevitably lead to negative consequences on people’s health, often resulting in metabolic disorders.
Methods: We are searching for “a salvage pathway” such as to follow a “Mediterranean diet”, which was first described in nutrition-related literature in the 1960s. There are several variants of the Mediterranean diet, but some common components can be identified: high consumption of olive oil; moderate wine consumption, especially red wine; high consumption of vegetables, fruits, legumes, and grains; high consumption of fish, particularly pilchard; moderate consumption of milk and dairy products, mostly in the form of cheese; and low consumption of meat and meat products.
Results: Growing evidence demonstrates that the Mediterranean diet is beneficial to health. This evidence is strongest for coronary heart disease, but it also applies to some forms of cancer and for the majority of chronic inflammatory diseases.
Should we approach the Mediterranean diet by examining the impact of a whole dietary culture rather than isolating single nutrients? Presumably the answer would be affirmative since the examination of single nutrients ignores the important and complex interactions between components of a diet.
Conclusion: Therefore, dietary recommendations to the population regarding the Mediterranean diet should include a whole-diet approach along with general life-style changes.
URINARY PROTEIN/CREATININE RATIO IN PATIENTS WITH REGULATED AND UNREGULATED ARTERIAL HYPERTENSION
Buljubaši ć D. 1, Vizjak V. 1, Ištvani ć T. 2, Peši ć S. 3
1Internal Clinic, Clinical Hospital Centre Osijek, Croatia
2Clinic for surgery, Clinical Hospital Centre Osijek, Croatia
3Department for radiology, Clinical Hospital Centre Osijek, Croatia
Introduction: Assesing target organ damage is crucial when treating patients with hypertension. One of the first signs of target organ damage is albuminuria and it is an indicator of kidney damage as well as an independent risk factor for development of chronic kidney disease and cardiovascular diseases. Instead of collecting 24 hour urine to quantify albuminuria, a urinary protein/creatinine ratio has been proved to be equally good in predicting cardiovascular risk.
Aim: The intention of this study was to show whether regulation of hypertension has any impact on urinary protein/creatinine ratio.
Methods: The research included 48 patients between the ages of 30 and 70 with pharmacologically treated arterial hypertension. They were divided into two groups, in the first one the patients whose blood pressure was lower than 140/90 mmHg (RH) and in the second patients whose blood pressure was equal or higher than 140/90 mmHg (NRH) measured during patients’ regular check-ups. Exclusion criteria were glucose intolerance and kidney disease. Data on number and type of antihypertensive medications that patients were taking on everyday basis were obtained as well as data on basic blood and urine analisys.
Results: There were 26 patients in RH group (18 women, 8 men) and 22 patients in NRH group (13 women, 9 men). There was no difference in duration of hypertension between the groups. Average protein/creatinine ratio was 79.55 mg/g creatinine in RH group and 71.46 mg/g creatinine in NRH group (p=0.481). A significant difference was found in type of antihypertensive medication between the groups – patients in RH group used more ACEIs and ARBs than those in NRH group (p=<0.001).
Conclusion: These results indicate that target organ damage measured by urinary protein/creatinine ratio is not dependent on regulation of hypertension, but the regulation of hypertension is most likely to be achieved when ACE inhibitors or ARBs are used as monotherapy or combined antihypertensive therapy.
CORRELATION BETWEEN ADIPOSE TISSUE DISTRIBUTION AND SYMPATHETIC NERVOUS SYSTEM ACTIVATION IN HYPERTENSIVE PATIENTS
Vizjak V 1, Buljubaši ć D 1, Radi ć R 2, Selthofer-Relati ć K 1, Šimundi ć T1, Bošnjak I 1, Jelakovi ć B 3
1Internal Clinic, Clinical Hospital Centre Osijek, Croatia
2School of Medicine, University J.J. Strossmayer in Osijek, Croatia
3University Hospital Center Zagreb, Department of Nephrology and Arterial Hypertension, Zagreb, Croatia
Introduction: It has not yet been clarified whether visceral or subcutaneous adipose tissue is responsible for excessive adipokine production which leads to hypertension and other metabolic disorders. We aimed to determine the correlation of each type of obesity (abdominal and peripheral) to sympathetic activation and its effect on blood pressure values and its variability.
Methods: The study included 18 patients with recently diagnosed essential arterial hypertension stage I. They were divided into groups regarding their body mass index (BMI). The following procedures were performed: sonographic visceral and subcutaneous adipose tissue measurement, 24 - hour ambulatory blood pressure monitoring and determination of catecholamines in plasma.
Results: 8 patients were lean (BMI < 25 kg/m2) and 10 were obese (BMI > 25 kg/m2). Mean waist/hip ratio was 0.91, and mean subcutaneous/visceral adipose tissue ratio was 0.94 and there were no significant differences between the groups regarding these ratios. Mean waist/hip ratio negatively correlated to mean subcutaneous/visceral adipose tissue ratio in both groups. Lean patients had significantly thinner subcutaneous adipose tissue compared to obese (16.33 and 23.08 respectively, p=0.023). There was a significant difference in adrenalin level between lean and obese patients (0.36 and 0.18 respectively, p=0.001). Plasma noradrenalin correlated positively to systolic blood pressure variability during 24 hours. Thickness of visceral adipose tissue correlated positively to diastolic blood pressure variability during the night. Subcutaneous/visceral adipose tissue ratio correlated positively to percentage of time that systolic blood pressure was above limits, and it negatively correlated to systolic blood pressure variability during the night.
Conclusion: This study indicates that there is a correlation between blood pressure values and adipose tissue thickness. Blood pressure variability is primarily related to visceral adipose tissue thickness but obviously subcutaneous/visceral adipose tissue ratio plays as important role in development of hypertension and that elevated level of catecholamines is not an inevitable determinant of stage I hypertension in overweight and obese patients.
IMPACT OF ANGIOTENSIN-CONVERTING ENZYME GENE POLYMORPHISM ON PROTEINURIA AND ARTERIAL HYPERTENSION
Živko M. 1, Galeši ć K. 2, Kušec R. 3
1General Hospital Virovitica, Croatia
2Department of Nephrology, University Hospital Dubrava, Zagreb, Croatia
3Department of Molecular Biology and Genetics, University Hospital Dubrava, Zagreb, Croatia
Introduction: Proteinuria is the hallmark of renal disease. Proteinuria has been shown to be tubulotoxic and directly contributes to renal deterioration. In essential hypertension the onset of de novo proteinuria is associated with faster rate of progression.
Aim: to investigated the relationship between ACE gene polymorphism and antiproteinuric effect of ACE inhibitors (ramipril) and to evaluate the possible association between I/D polymorphism and hypertension.
Methods : We recruited 66 patients (male 42, female 24) with overt proteinuria (urinary protein excretion over 500 mg/day). Before entry, previously used ACE inhibitors were withdrawn for at least one month and baseline proteinuria was measured. Patients were classified into three groups in accordance with ACE genotypes (17 DD; 35 ID; 14 II). They were treated with ramipril and prospectively followed up for one year. Various clinical parameters including age, body mass index (BMI), 24-h urine protein, creatinine, creatinine clearance (Ccr), systolic and diastolic blood pressure (SBP and DBP), mean arterial pressure (MAP) were measured in the pre- and post-treatment periods. The ACE gene insertion/ deletion (I/D) polymorphisms in intron 16 were determined by PCR.
Results: There were no significant differences in the clinical parameters such as age, gender, serum creatinine, Ccr, SBP, DBP, MAP, and daily urinary excretion of protein among three groups (p>0.05). ID genotype patients were found to have lower BMI (p=0.031). ACE inhibition significantly reduced proteinuria in all genotype groups (p<0.05). The percentage reductions of 24-h urinary excretion of protein were significantly different between the genotype groups (p=0.042) and for DD genotype were significantly greater than in ID (79.2+/-28.9% vs 49.2+/-64.8%, p=0.015). There was significant negative correlation between systolic blood pressure and percentage reductions of proteinuria (rs=-0.382; p=0.002).
Conclusion: ACE gene polymorphism might be a useful genetic marker for predicting the antiproteinuric effect of ACEI.
PULSE PRESSURE OR AMBULATORY ARTERIAL STIFFNESS INDEX- WHICH METHOD IS BETTER IN PREDICTING TARGET ORGAN DAMAGE?
Željkovi ć Vrki ć T., Laganovi ć M., Pe ćin I., Kuzmani ć D., Karanovi ć S., Vukovi ć Lela I., Premuži ć V., Ron čevi ć T., Fodor Lj., Fištrek M., Jelakovi ć B.
Department of Nephrology and Arterial Hypertension, University Hospital Centre Zagreb, School of Medicine University of Zagreb, Croatia
Background: Hypertension is the most important cardiovascular risk factor which causes target organ damage (TOD). Microalbuminuria (MA) and arterial stiffness (AS) are indicators of organ damage. In clinical practice there have often been used indirect methods for determining arterial stiffness. The older method is determination of pulse pressure (PP), and the novel is ambulatory arterial stiffness index (AASI) based on blood pressure (BP) values obtained during 24-h ambulatory blood pressure measurement (ABPM).
Aim: to determine the presence of TOD in our group of patients at the time of diagnosis. PP and AASI have been compared as assessment methods of organ damage.
Methods: We have included 103 subjects (60 men, 43 women, average age 37 ± 9.1 years) with newly diagnosed primary hypertension. Subjects were clinically examined. BP was measured using mercury sphygmomanometer and ABPM Spacelabs 90207. AASI was defined as 1 minus the regression slope of diastolic over systolic BP values obtained from ABPM. MA is defined as 30-300 mg 24h urine albumin excretion.
Results : There were no differences in age between man and woman but significant difference was observed in BMI (p=0.032). Also, significantly highest values of uric acid, triglycerides, homocysteine and 24-h natriuria were detected in man. AASI values were 0.373 ± 0.05 and were below the proposed cut-off values of 0.5 for younger subjects, respectively. The highest AASI values were observed in man and in subjects with highest body height, weight, heart rate and 24-h PP. Significant correlation was found between 24-h PP and MA (r=0.41, p=0.002). We failed to find association between AASI and MA.
Conclusion: PP and AASI can be a marker of AS but pulse pressure is more reliable marker of organ damage in the earliest phase of arterial hypertension. Definitive validation should await further studies with direct measurements of AS.
POLY(ADP-RIBOSE)POLYMEARASE INHIBITION REDUCES VASCULAR REMODELING IN A CHRONIC HYPERTENSION MODEL
Magyar K 1, Vamos Z 2, Bruszt K 1, Balogh A 3, Kálai T 4, Hideg K 4, Seress L 5, Sumegi B 6, Koller A 2, Halmosi R 1, Toth K 1.
11st Department of Medicine, University of Pecs, Medical School, Pecs, Hungary.
2Department of Pathophysiology and Gerontology, University of Pecs, Medical School, Pecs, Hungary.
3Medical Biology, University of Pecs, Medical School, Pecs, Hungary.
4Organic and Pharmacological Chemistry, University of Pecs, Medical School, Pecs, Hungary.
5Central Electron Microscope Laboratory, University of Pecs, Medical School, Pecs, Hungary.
6Department of Biochemistry and Medical Chemistry, University of Pecs, Medical School, Pecs, Hungary.
Introduction: Remodeling of large vessels and vasomotor dysfunction in resistance arteries are well known consequences of prolonged hypertension. Continuous elevated blood pressure triggers oxidative stress causing consequent poly(ADP-ribose) polymerase (PARP) activation.
Hypothesis: Vasoprotective effect of L-2286 PARP inhibitor was assumed in spontaneously hypertensive rat (SHR) model.
Methods: Male 10-week-old SHR rats were divided into two groups: 1 st group was treated with 5 mg/kg/day L-2286 orally for 32 weeks (SHR-L), 2 nd received no treatment (SHR-C). Age-matched male CFY rats were used as normotensive controls (CFY). Intima-media thickness (IMT), arterial stiffness index (ASI), acetylcholine- (ACh) and Na-nitroprussid induced relaxation were measured in carotid arteries. Ultrastructural morphology of aortas, PARP and apoptosis inducing factor (AIF) activation were measured. Involved signal transduction proteins were analyzed by Western blotting.
Results: L-2286 did not influence blood pressure in SHR and CFY rats. At the beginning of the study IMT and ASI were similar both in SHR and CFY rats. However, at the end of the study IMT and ASI values were higher in SHR-C compared to CFY (IMT: CFY: 41±2 m, SHR: 78±5 m; ASI: CFY: 4.1±0.1, SHR: 5.8±0.3; p<0.01), and were decreased significantly by L-2286 (SHR-L: IMT: 63±1 m, ASI: 4.3±0.4; p<0.05). Relaxation of carotid arteries to ACh significantly increased in SHR-L compared to SHR-C (22.3±8% vs. 41±5%, p<0.05), but responses to SNP did not differ. In electron microscope images increased fibroblast activation with collagen overproduction and endothelial lesions were observed in aortas of SHR-C. In contrast in SHR-L decreased collagen content was noticed. L-2286 treatment enhanced the phosphorylation of Akt-1 (p<0.05), while phosphorylation of JNK and p38 MAPKs were significantly lower (p<0.05) in carotid arteries of SHR- L. Translocation of AIF was elevated in SHR-L and decreased in SHR-C.
Conclusions: Our data suggest that chronic inhibition of PARP delays vascular remodeling and improves endothelial dependent vasomotor function due to its effect on prosurvival and antiapoptotic signal transduction pathways.
Support: PTE ÁOK-KA 34039-21/2009, GVOP 3.2.1.-2004-04-0172/3.0
RETROSPECTIVE ANALYSIS OF TWO YEAR DATA OF RESISTANT HYPERTENSIVE PATIENTS WITH AND WITHOUT NEUROSURGICAL MICROVASCULAR DECOMPRESSION
Fejes I. 1, Légrády P. 1, Bajcsi D. 1, Barzó P. 2, Vörös E. 3, Fehértemplomi K. 1, Majtényi P. 1, Ábrahám G 1.
11st Department of Internal Medicine, University of Szeged, Szeged, Hungary
2Department of Neurosurgery, University of Szeged, Szeged, Hungary
3Department of Radiology, University of Szeged, Szeged, Hungary
Introduction: The microvascular pulsatile compression (MVPC) of the rostral ventrolateral medulla (RVLM) on the left side may be considered as an etiological factor for hypertension. After neurosurgical microvascular decompression (MVD) the blood pressure (BP) and even antihypertensive medication were significantly reduced and the conventional medication became more effective.
Aim: The aim of our study was to analyse the data of BP of MVPC patients with and without MVD.
Methods: By our database the MR-angiography established MVPC on the left side in 44 hypertensives and 18 of them underwent the MVD. We could retrospectively analyze 2 year data of 9 operated (age: 43.7±3.0 ys, BMI: 28.5±1.6 kg/m2, duration of hypertension: 14.2±3.1 ys; mean±SEM) and 8 non-operated (age: 42.8±6.6 ys, BMI: 29.9±1.9 kg/m2, duration of hypertension: 6.2±2.5 ys; mean±SEM) patients. We analyzed the data of the control meetings at 1st, 3rd, 6th, 12th and 24th months after the intervention or after the MR-angiography in the non-operated cases.
Results: The type of MVPC described by the MR-angiography was confirmed by the intervention in all patients. Both the systolic and diastolic BP decreased significantly in all cases after the MVD and during the 2 years they were significantly lower than before the MVD. In the non-operated group the BP didn’t change significantly during the 2 years. The BP of the 2 groups didn’t differ significantly starting from the 1st month. The main values are presented in the table below:
BP0 BP1 BP3 BP6 BP12 BP24 op 211.1/115.6 *147.3/*90.8 *152.9/**99.2 *160.8/*97.2 *151.7/*93.6 *148/*95.8 nop †153.9/†87.0 141/87.0 158/93.6 143.2/83.2 152.4/83.7 131.6/76.4 op=operated, nop=non-operated, BP (mm Hg), *p<0.05 after MVD vs. before MVD,
**p<0.5 after MVD vs. before MVD, †p<0.05 nop vs. op
Conclusion: These results confirmed that in severe hypertension, which does not respond to conventional therapy, the neurosurgical MVD of the left sided RVLM could guarantee a long-lasting BP reduction and better sensitiveness for antihypertensive medication. HOW TO ORGANIZE AN OUTPATIENT CLINIC
Živko M. 1, Jelakovi ć B. 2
1General Hospital Virovitica, Croatia
2University hospital center Zagreb, Croatia
According to the EH-UH study results, prevalence of hypertension in Croatia is 37%, and in Virovitica-Podravina county is 43%. Unfortunately, control of hypertension in Croatia is still far from optimal. Obesity, physical inactivity and increased salt intake significantly contribute to high prevalence of hypertension and poor control.
Education of population and primary prevention should become the main stain in future.
Given the demographic shifts and needs of cost rationalization, it is of high priority to organize health care on the basis of ambulatory outpatients models.
The activity of this facility leads to a low rate of hospitalization as well as of cost reduction.
This paper is an attempt to outline possible strategies that could implemented in view of the ever decreasing meager resources.
Outpatient clinic of hypertension in the General Hospital Virovitica is a new organizational form of the institution between clinic and hospital for the provision of diagnostic and therapeutic outpatients care of patients. It is a working team composed of cardiologists, nephrologists, nurses and patients.
During the first visit after taking medical history using extended questionnaire (including salt awareness, smoking habits, drinking alcohol, physical actvity, self-blood pressure control and doctor s control of blood pressure, drugs) and detailed clinical exam including measuring height, weight and body mass index. Blood pressure is mesaured following ESH/ESC guidelines using Omron M6 device in seated position. Laboratory investigation performed in all patients included: ECG, RBC count, serum hemoglobin concentration, hematocrite, serum electrolytes, uric acid and creatinine, lipids, fasting blood glucose; urine sodium, potassium, albumin, creatinin is determined from 24h urine sample. We performed ambulatory blood pressure monitoring using CardioSoft-TONOPORT V device with oscilometric BP measuring. Aortic pulse wave velocity and augmentation index (parameters of arterial stffness that predicts cardiovascular mortality in hypertensive patients) are measured by Tensiomed Arteriograph. Others imagine techniques (fundoscopy, chest radiograph, abdominal and cardiac ultrasound, doppler of carotid and renal arteries, MSCT scan ) are performed in patients with suspected subclinical organ damages.
After obtaining all required findings during the examination, clasiffication of hypertension and stratification of total CV risk, we make decisions on treatment strategies (initiations of drugs treatment, use of combination treatment, blood pressure treshold and target for treatment) mainly depend on the initial level of risk. Patients are undergo control examination after 1,3, 6 and 12 months from beginning of treatments, after that only on indication primary medicine doctors, is recomended once yearly.
Basis of treatment is an education about hypertension, reducing daily salt intake and DASH diet provided by nurse who is very important member of working team in outpatient clinic. Active participation of patients, increasing the willingness and motivation to solve problems depends on quality of education. Nursing must meet this challenge by updating the attitudes of nurses and by improving their abilities and skills in developing and implementing planned patient education program.
In the area of chronic ambulatory illness it is well recognized that poor participation by patients in the treatment process greatly limits the potential benefits of effective medical technology. Patients contributions to treatments outcomes might be enhanced if medical care was oriented to consider patients as active participants in the treatment process, rather than as passive-obedient recipients of care. Findings indicate that patients adressed to the outpatients clinic of hypertension have their blood pressures under control and exhibit more positive cognitive and behavioral responses to illness- management.
The outpatient clinic promises many educational opportunities including more complete observation of chronic diseases, closer relationships between doctors, nurses and patients, and more apropriate forum for teaching preventive medicine and psychosocial aspect of disease.
It is a modern, economical and multidisciplinary treatment which significantly improves the quality of health care and requires enormous work and effort. Results are visible after a long time.
It will outline a step approach toward realignment and reengineering a viable health care system that is hopefully both cost effective and outcome oriented.
ACUTE OXIDATIVE STRESS, VASCULAR FUNCTION AND URIC ACID
Boban M.
Department of Pharmacology, University of Split School of Medicine, Split, Croatia, Croatia
Uric acid is an end-product of purine metabolism in humans in contrast to most other mammals that express urate oxidase, an enzyme responsible for further metabolism of uric acid to allantoin. Consequently, humans have plasma uric acid levels approximately 10 times higher than most other mammals indicating biological significance of uric acid in man. Indeed, uric acid is the most abundant aqueous antioxidant, accounting for up to 60% of plasma antioxidative capacity.
Chronic hyperuricemia, however, has been recognized as a cardiovascular risk factor, especially in patients with diabetes, hypertension, or heart failure. In spite of the strong association of plasma uric acid and cardiovascular diseases, a causative role of uric acid is not established. On the other side, acute hyperuricemia even at high concentrations and under different experimental conditions did not cause harmful cardiovascular effects in humans. On the contrary, it reduced exercise associated oxidative stress and protected endothelial function in patients with type 1 diabetes and regular smokers. In this presentation we discuss paradoxical associations of uric acid and present our results on protective effects of acute, moderate elevation of plasma uric acid against hyperoxia-induced oxidative stress and increase in arterial stiffness in healthy humans.
THE INFLUENCE OF ESTROGEN ON THE REACTIVITY OF SKELETAL MUSCLE ARTERIOLES TO INCREASED TISSUE OXYGEN IN SS AND SS13BN FEMALE RATS FED A LOW OR HIGH SALT DIET.
Kunert M.P.
University of Wisconsin-Milwaukee, College of Nursing
Introduction: Microvascular dysfunction, including alterations in endothelium and vascular smooth muscle, is a hallmark of many cardiovascular disorders and is characterized by an imbalance between the influence of vasodilating and vasoconstricting substances. It is likely that sex based differences in the microcirculation plays a role in the documented sexually dimorphic incidence, development and manifestation of these diseases. It has been demonstrated that high salt (HS) diets independent of affects on blood pressure can lead to alterations in arteriolar reactivity, for example an increase in arteriolar sensitivity to augmented tissue oxygen delivery. Since a HS diet differentially increases blood pressure in the male as compared to the female (F) SS and SS13BN rat, it is possible that estrogen plays a role in protecting against the salt induced vascular changes in structure and function.
Materials and Methods: Female F SS (Dahl Salt Sensitive, SS/JrHsdMcwi) or SS13BN (SS13BN/Mcwi) divided into the following 4 subgroups: a) intact, b) sham, c) ovariectomized (OVX), and d) ovariectomized with estrogen replacement (OVX +E). Each subgroup was divided by diet: LS (0.4% NaCl) or a HS (8.0% NaCl). The rats were OVX and estrogen replaced (or not). A telemetry transmitter for blood pressure measurement was implanted. Three days prior to the acute experiment the diet of half of the rats was changed to HS. On the day of the acute experiment a transverse arteriole in the spinotrapezius muscle was selected, allowed to equilibrate with 0% O2 in the superfusion solution, and then changes in arteriolar diameter to 21% O2 before and after the topical application of HET-0016, a selective inhibitor of 20-HETE production, (10µM) were measured.
Results: Data is preliminary. Will share at the meeting.
Conclusions: The importance of our studies is that we are evaluating the vascular influence of estrogen in a whole animal preparation in situ.
APPROACHES TO ADRENAL INCIDENTALOMAS
Džubur F 1, Kaštelan D 1 , Dušek T 1 , Kneževi ć N 2, Bareti ć M 1, Škori ć T 1, Aganovi ć I 1, Korši ć M 1
1Department of endocrinology, University Hospital Centre Zagreb, Zagreb, Croatia
2Department of endocrinology, University Hospital Centre Zagreb, Zagreb, Croatia
Clinically unapparent adrenal masses are incidentally detected after imaging studies conducted for reasons other than the evaluation of the adrenal glands.
Objective: It was the aim of this study to review and analyze clinical data on the diagnosis and management of patients with adrenal masses.
Patients and methods: Between 2007 and 2010, 264 patients admitted to our department with adrenal masses were reviewed. Incidence, clinical features, imaging technique findings, surgical approaches, morbidity and mortality, as well as pathological diagnoses were reported.
Results: The series comprised 91 males and 173 females (mean age 57.3 +/- 20.3 years). Left-sided masses were more common (59.4%), with a mean size of 3.9 +/- 2 cm. Both computed tomography and magnetic resonance imaging showed a high diagnostic yield (sensitivities of 98.9 and 100%, respectively). Open adrenalectomy was performed in 2 patients (3.75%), while a laparoscopic approach was employed in 51 patients (96.25%). Most of the excised masses were adenomas 25 (47%)-( 4 PA and 11 subclinical Cushing syndrome), pheochromocytomas 15 (28%), and carcinomas 6 (11%). Remaining tumors were metastatic melanoma, GIST, myelolipoma and simplex cyst.
Conclusions: Computed tomography is recommended as the first diagnostic modality to define and characterize adrenal masses along with endocrinological examination. Laparoscopic adrenalectomy is currently standard surgical management of adrenal masses.
REGULATION OF HYPERTENSION IN MANAGERIAL POPULATION
Pribi ć S. 1, Buljan K. 2, Gmajni ć R. 1
1Medical School Osijek, Osijek, Croatia
2Clinical Hospital Centre Osijek, Osijek, Croatia
Introduction: Managers are population affected by specific workplace conditions: stressful situations, responsibility, decision making, risks and interpersonal relationships.
Therefore, they have a specific approach to health preservation and therapy use.
Aim: To examine the possibility of motivating managers to proper use of prescribed antihypertensive therapy by employing various interventions.
Methods: We have established improper use of therapy and poor regulation of hypertension in a group of 123 managers treated for hypertension. We have managed to motivate those managers to behave more responsibly by using interventions such as educational material, discussions, SMS messages and e-mails.
Results: Following the interventions, 76% of the managers started using their therapy regularly, whereas only 56% of them used it regularly before the interventions. 18% used the therapy quite regularly (before 22%), 6% used it from time to time (before 10%) and 2% stopped using the therapy altogether (before 12%). In assessing the interventions it could be seen that the managers best responded to e-mails (42%), followed by SMS messages (36%) and discussions (18%) and, least of all, educational material (4%). 92% of managers are willing to finance the systems which would remind them to take their therapy.
Conclusion: It is possible to devise interventions adjusted for managerial population which would significantly influence their regular and continuous taking of antihypertensive therapy. Majority of managers support the idea of financing such interventions.
CHANGES OF THE BAROREFLEX-SENSITIVITY IN HEALTHY STUDENTS DURING SEMESTER AND EXAM PERIOD
Farkas K., Légrády P., Bajcsi D., Majtényi P., Fejes I., Fehértemplomi K., Ábrahám G. 1st Department of Internal Medicine, University of Szeged, Szeged, Hungary
The risk for cardiovascular events is more higher with lower baroreflex-sensitivity (BRS). We investigated the exam period’s effect as a stressor on blood pressure (BP) and pulse wave velocity (PWV) in the first serie (S1) and on BRS in the second one (S2).
We analysed data recorded in a semester and in an exam period of 34 (S1) and 53 (S2) healthy normotensive university students. We divided the students into optimal (O), normal, high-normal and hypertension groups by BP values. We used Arteriograf device to evaluate the PWV. The continuous systolic BP and ECG data were recorded with the Finometer. We calculated the time-domain up- and down-BRS and the frequency-domain alpha-index in the low-frequency (aLF) and high-frequency (aHF)) spectra both in resting supine position and after standing up. Mean±SD are reported.
In S1 in the exam period 10 students and in S2 11 students BP rised into a higher group. All the BRS values calculated in the exam period was significantly lower compared to the semester in the same positions. systolic BRS (ms/mmHg) diastolic BRS (ms/mmHg) lying standing lying standing
semester exam semester exam semester exam semester exam
upBRS 22.00± 15.3 16.92± 8.5 9.72± 3.2 7.95± 3.6 30.90± 14.5 24.79± 11.0 13.67± 4.5 10.99± 4.1 downBRS 22.30± 9.12 18.32± 7.9 9.43± 3.5 7.28± 3.1 28.20± 10.8 23.46± 9.4 13.15± 5.0 9.48± 4.2 allBRS 21.90± 10.9 17.40± 7.2 9.60± 3.2 7.57± 3.3 29.20± 11.7 24.30± 8.9 13.36± 4.4 10.14± 3.9 aLF 12.80± 6.1 9.54± 4.7 7.91± 3.7 6.58± 3.3 15.30± 6.7 11.86± 5.6 9.55± 4.3 7.96± 3.9 aHF 25.10± 13.0 17.00± 10.8 9.43± 4.4 8.36± 9.7 33.90± 13.7 22.20± 11.4 13.98± 7.2 10.30± 8.7
By our results just an exam period is an effective stressor to move the a cardiovascular parameters into the way of a higher risk even in healthy young people.
ADHERENCE IN PATIENTS TREATED FOR ARTERIAL HYPERTENSION IN ZAGREB, CROATIA
Čulig J. 1, Leppée M. 2, Boškovi ć M. 3, Eric M. 4
1School of Medicine Osijek, Pharmacology, Osijek, Croatia
2Andrija Stampar Institute of Public Health, Pharmacoepidemiology, Zagreb, Croatia
3Faculty of Pharmacy and Biochemistry, Zagreb, Croatia
4School of medicine Novi Sad, Department of anatomy, Novi Sad, Serbia
The aim of the study was to determine whether patient age influenced medication compliance and if so, to what extent. The study addressed medication compliance in general, compliance with antihypertensive therapy, and relations between these two groups. In addition to the reason for therapy prescription, the aim of the study was to establish whether patients considered it feasible for them to comply with their physician's instructions and whether they believed their therapy to be beneficial for their health. Hypertensive patients were compared with total study population according to age groups. The study was designed as a cross-sectional survey by use of a self-administered 33-item questionnaire. The study included 635 individuals collecting or buying drugs for the treatment of chronic diseases, with special reference to subjects taking antihypertensive agents (n=361). More than half (n=361; 56,9%) of 635 study subjects were on therapy for arterial hypertension and possibly for some other diseases. The great majority of study subjects stated forgetfulness as the main reason for skipping drug dosing, followed by not being at home and being short of the drug. Comparison of total study population and subjects treated for arterial hypertension according to age groups (compliant, noncompliant and all together) yielded no statistically significant difference. Based on the entire study we concluded that there was no difference in medication compliance between general patient population and patients receiving antihypertensive therapy and there was no correlation between medication compliance and age.
HYPERTENSION IN WOMEN
Masszi G.
Departement of cardiology, Bajcsy-Zsilinszky Hospital Budapest, Hungary
Cardiovascular disease is the leading cause of death among men and women.The cardiovascular risk of women reaches the men of same age after the menopause. Hypertension is one of the most powerful and prevalent contributor of atherosclerotic cardiovascular disease.High blood pressure affects more men than women until 55 years of age, but after 55 the percentage of women is higher.Estrogen deficiency has been linked to the rapid progression of cardiovascular risk of women after menopause. The biological background of protective effects of estrogen is not fully, but mainly understood yet.It may involve direct effects on blood vessels accompanied by systematic effects of the hormon. The main effect of these influences protects the cardiovascular system. AÍfter menopause, loss of this protection may unmask a population of women prone to hypertension. This lecture would like to focus on the clinical relevance,characterictics and therapy of postmenopausal hypertension.
INTRAOPERATIVE INVASIVE HAEMODYNAMIC MONITORING IN HYPERTENSIVE PATIENT
Zoka M.
St James's University Hospital, Leeds, United Kingdom
Traditional invasive haemodynamic monitoring is based on pulmonary artery catheter and trans-oesophageal echocardiography. The new developments in pulmonary artery catheter technology offer the opportunity to monitor right heart pressures and preload indices with variables such as RVEDV and RVEF that give a better reflection of preload status than the “old” filling pressures. This advanced approach has only been studied in liver transplantation. Trans esophageal echography is receiving growing attention because it allows direct visualisation of heart structure, shape and function. The PiCCO system measures transpulmonary thermodilution cardiac output, but to this it adds a preload index through intrathoracic blood volume measurement, and monitors lung function status through extravascular lung water. Uncalibrated less invasive cardiac output monitoring devices do not give reliably accurate information on cardiac output in the hyperdynamic conditions.
BILATERAL VS. UNILATERAL SPINAL ANESTHESIA FOR VARICOSE VEIN IN HYPERTENSIVE PATIENTS
Nesek Adam V. 1, Grizelj Stoj čić E. 1 , Mrši ć V. 2, Šaki ć K. 2 , Maldini B. 3 , Marki ć A. 1
1University Department of Anesthesiology, Resuscitation and Intensive Care, Clinical hospital Sveti Duh, Zagreb, Croatia
2Anesthesiology, Resuscitation and Intensive Care, Clinical hospital Sveti Duh, Zagreb, Croatia
3Department of Anesthesiology, Resuscitation and Intensive Care, University hospital Sestre milosrdnice, Zagreb Croatia
Objective: To compare unilateral with bilateral spinal anesthesia in hypertensive patients undergoing surgery for varicose vein according to hemodynamic change.
Materials and Methods: The study included 40 ASA II hypertensive patients allocated in two groups of 20 patients. Group S patients received spinal anesthesia with 3 ml hyperbaric 0.5% levobupivacaine (15 mg) and group US patients received unilateral spinal anaesthesia with hyperbaric spinal solution (0.5% levobupivacaine 5 mg +plus fentanyl 50 g and 1 ml of 10% glucose) ). We measured noninvasive mean arterial blood pressure and heart rate before spinal blockade and then after 5, 15, 30, and 45 minutes. We also recorded the onset of motor blockade and side-effects.
Results: Unilateral spinal anaesthesia is very effective in restricting the sympathetic block in hypertensive patients showed minimal hemodynamic changes following the technique.
Conclusion: Unilateral spinal anesthesia is effective in restricting the sympathetic block in hypertensive patients.
HYPERTENSIVE EMERGENCY - THE FIRST MANIFESTATION OF RENAL DISEASE IN CHILDREN AND ADOLESCENTS
Pal čić I., Batinica M., Delmis J.
Children's Hospital Zagreb, Department of Pediatrics, Nephrology Unit, Zagreb, Croatia
Introduction: Hypertensive emergency is a life-threatening condition, defined as severe hypertension complicated with acute target organ dysfunction (mainly neurological, renal or cardiac). It rarely occurs in childhood and most children and adolescents who presents with hypertensive crises symptoms has secondary hypertension, mainly of renal etiology.
Case reports: We present the cases of three children with severe hypertension of different renal etiology that presented with the characteristic features of hypertensive emergency. Case 1 is a 11-year-old girl with reflux nephropathy, who was admitted with blood pressure as high as 250/200 mmHg. She was lethargic, with headache, vomiting and a 3-month history of weight loss. Case 2 is a 13-year-old boy with renal artery stenosis, who presented with generalized tonic clonic seizures and markedly elevated blood pressure at 220/150 mmHg. Case 3 is a 9-year-old boy with chronic renal insufficiency of unexplained etiology and blood pressure as high as 220/135 mmHg. This patient, like two others, presented dominantly with symptoms of hypertensive encephalopathy - headache and visual impairment, as well as signs of renal damage. All three patients have documented hypertrophic cardiomyopathy (ECG and echo exam). They required multiple antihypertensive agents. In patient who had renal artery stenosis, removal of his dysplastic atrophic kidney failed to normalize his blood pressure.
Conclusion: We discuss the cases of unrecognized long standing hypertension, with progression to malignant hypertension, as the first manifestation of renal disease - two with renal parenchymal disorders and one with renovascular disease. It is underreported in children and purpose of the case report is to raise its awarness. This cases also raise the importance of routine carefully measurement of blood pressure in all paediatric patients.
VITAMIN D AND ARTERIAL HYPERTENSION
Pavlovi ć D.
Sestre Milosrdnice University Hospital, Department of Nephrology and Dialysis, Zagreb, Croatia
Vitamin D deficiency is very common, i.e. there is pandemic of vitamin D hypovitaminosis. The high prevalence of vitamin D deficiency and insufficiency is an important public health problem because hypovitaminosis D is an independent risk factor for total morbidity and mortality in the general population. Moreover, it is well known today that vitamin D, particularly active hormone calcitriol, is involved not only in calcium and phosphorus homeostasis but there are also many non-skeletal actions of vitamin D. Many cells express the vitamin D receptors, some of them also 1 -hydroxylase activity. Directly or indirectly, vitamin D is involved in the regulation of cellular proliferation, differentiation, apoptosis etc. Therefore, not surprisingly, vitamin D deficiency is associated not only with bone disease but also with many other diseases such as cancer, autoimmune diseases, skin and infection diseases and cardiovascular diseases.
The association between vitamin D levels and arterial hypertension has been assessed in several cross-sectional studies. The majority of these studies strongly support an inverse association between plasma vitamin D level and blood pressure, i.e. arterial hypertension. There is no doubt that cross-sectional studies have established an association between arterial hypertension and vitamin D levels but they have not been able to establish the causative links. Several years ago Li et al. demonstrated that vitamin D is a potent suppressor of renin activation. Until that time, there had been an accumulation of evidence, ranging from in vitro to in vivo data, demonstrating the links between vitamin D concentration and blood pressure through the effects on the renin-angiotensin-aldosterone system or calcium homeostasis, vasoprotective effects, or by the prevention of insulin resistance.
Unfortunately, until now only a few studies have investigated the potential benefit of vitamin D supplementation on blood pressure. It appears that vitamin D supplementation could have a beneficial effect on blood pressure. Indeed, one small feasibility study of systolic blood pressure reduction by calcitriol is very promising.
In conclusion, the data linking vitamin D status to arterial hypertension are promising, but we need more randomized, placebo-controlled trials to prove the effect of vitamin D supplementation on arterial hypertension.
VALUE OF ECHOCARDIOGRAPHIC ASSESSMENT OF DIASTOLIC DYSFUNCTION IN ARTERIAL HYPERTENSION
Perši ć V. 1, Jovanovi ć Ž. 2, Ruži ć A. 3
1Clinic for cardiovascular disease treatment, rehabilitation and prevention, Opatija, Medical Faculty Osijek, Osijek, Medical Faculty Rijeka, Rijeka, Croatia
2Medical Faculty Osijek, Osijek, Croatia
3Clinic for cardiovascular disease treatment, rehabilitation and prevention, Opatija, Medical Faculty Osijek, Medical Faculty Rijeka, Croatia
Objective: Uncontrolled hypertension can significantly contribute to left ventricular remodelling, increasing in left ventricular (LV) mass, and ultimately heart failure, which can be presented with preserved LV systolic function. When heart failure occurs in association with normal ejection fraction but with concomitant LV diastolic dysfunction, the term diastolic heart failure (DHF) has been used. In the past two decades, a significant progress in understanding the importance of diastolic function in clinical cardiology due primarily echocardiography, which is referred to had a central role. Assessment of diastolic function of LV has become an indispensable part of the routine echocardiographic examination, particularly in patients with symptoms of dyspnea or cardiac deterioration. Diastology has become a new scientific discipline, as well as medical skills, the study of diastolic period of cardiac cycle, from its genetic basis and developed the disease in various pathological conditions. The aim of this review is based on review of available scientific literature and analyses clinical diastolic heart failure in the hypertension as part of preventive strategies to improve treatment of the above conditions.
Methods: Review, analysis, integration and critical interpretation of available scientific sources, review and analysis of information from subject area to their understanding of the scientific basis and modalities of interpretation.
Results: Arterial hypertension is undoubtedly important precursor in systolic and diastolic heart failure. If DHF as a consequence of hypertension, control blood pressure can result in improvement of abnormal LV diastolic function, and thereby change the sequence in the natural progression of the DHF associated to hypertension.
Conclusion: According to available data, hypertension clearly shows a significant effect in the development of diastolic and systolic heart failure. The true extent, impact and prospects of interaction yet to be thoroughly investigated and the conclusions integrated into future strategies in hypertension treatment.
Literature:
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Bonnema DD, Baicu CF, Zile MR, Patophysiology of Diastolic Heart Failure: Relaxation and Stiffness, U: Klein AL, Garcia MJ. ed. Diastology: Clinical approach to diastolic heart failure. Philadelphia: Saunders Elsevier, 2008: 11-26.
Zile MR, Baicu CF, Gaasch HW. Diastolic Heart Failure - Abnormalities in Active Relaxation and Passive Stiffness of the Left Ventricle. N Engl J Med. 2004;350:1953-1959.
Redfield MM, et all. Burden of systolic and diastolic ventricular dysfunction in the community: appreciating the scope of the heart failure epidemic JAMA. 2003:8;289(2):194-202
Fischer M, Baessler A, Hense HW, Hengstenberg C, Muscholl M, Holmer S, Döring A, Broeckel U, Riegger G, Schunkert H. Prevalence of left ventricular diastolic dysfunction in the community: Results from a Doppler echocardiographic-based survey of a population sample Eur. Heart J. 2003: 24(4):320-328
Levy D, Larson MG, Vasan RS, Kannel WB, Ho KK: The progresion from hypertension to congestive heart failure. JAMA 1996: 275:1557-1762
Owan TE, Hodge DO, Herges RM, Jacobsen SJ, Roger VL, Redfield MM. Trends in prevalence and outcome of heart failure with preserved ejection fraction. N Engl J Med 2006;355:251-9.
IMPORTANCE OF SALT REDUCTION
Samovojska R.
GH "Dr. Tomislav Bardek", Koprivnica, Croatia
Salt is one of the most valuable substances available to man, with a definitive role in the human body and in food production. However, the continued use or indeed misuse of salt has led to adverse effects on health. Current high salt intakes have therefore been attributed to processed foods, accounting for 75-85 per cent of total salt intake. Such findings and associated health implications have prompted a call from health professionals and food researchers to reduce salt intake. A large number of epidemiologic, evolutionary and clinical studies have confirmed that table salt is a significant factor in determining the blood pressure (BP) level, and thereby in the prevalence of arterial hypertension (AH). It has been observed in epidemiologic studies that BP increases with age only if accompanied by excessive table salt intake. In addition to affecting BP, increased salt intake independently contributes to target organ damage. Correlation has also been observed between coronary artery disease, left ventricular hypertrophy, cerebrovascular insult, microalbuminuria. Table salt, i.e. NaCl, is directly involved in the process of atherothrombogenesis by changing the relation between vasoactive factors in the blood vessel wall, by affecting the expression of receptor for angiotensin II and, which is particularly important, by elevating platelet aggregability. From clinical and public health aspects, the data obtained in interventional studies are particularly important, as well as those that apparently confirm the benefit of restricting NaCl intake. This benefit is manifested not only in decreased BP and reduction in- cardiovascular morbidity and mortality, but also in improved total health as it is known that excessive table salt intake is also a risk factor for osteoporosis, nephrolithiasis, gastric and nasopharyngeal carcinoma, etc. National programmes for reducing salt intake Cosensus Action on Salt and Health (CASH) was launched in Great Britain several decades ago. It has achieved the most and should serve as an example and model for others. In 2005 this programme evolved into the World Action on Salt and Health (WASH). The mission of WASH is to achieve a reduction in dietary salt intake around the world from the current intake of 10-15g/day to the World Health Organisation (WHO) target of 5g/day.
An average reduction of 6 grams a day over the next decade could easily be achieved if the food industry acts. Through the fall in blood pressure that would ensue, this reduction in salt intake will have a large impact on reducing strokes by approximately 24% and heart attacks by 18%, as well as having other health benefits for the global population. A 6 gram reduction in salt intake would prevent 5.2 million incidents of cardiovascular diseases (CVD) a year, half of which are fatal.
The Trials of Hypertension Prevention (TOHP) study, which studied the effect of salt reduction on cardiovascular morbidity and mortality, gave the answer and solved all the dilemmas. It showed that even small reduction in salt intake of 3g NaCl results in 25% reduction of cardiovascular mortality after a follow up of 15 years.
According to the EU plan, salt intake should be also cut down, and salt content should be labelled on all food articles. In 2006, the First Croatian Congress on Hypertension announced Declaration of salt reducing programme in Croatia, and in 2007 at the 6th Croatian Congress on Atherosclerosis Croatian Action on Salt and Health (CRASH), and national programme for reducing salt intake were launched.
It is necessery to establis collaboration with food manufactures in order to reduce the content of salt in processed food and to achieve appropiate salt intake per day in accordance with recommendations.
Recommendations for healthy lifestyles includes providing choices for consumers interested in managing their salt intake to meet the prescribed goal of 2,300 mg/d of sodium per day. This kind of collaboration is based on bilateral interests which an result positive helth effects.
IMPACT OF EMOTIONAL INTELLIGENCE ON THE REGULATION OF ARTERIAL HYPERTENSION
Buljubaši ć D 1, Vizjak V. 1 , Barki ć J. 2, Buljubaši ć D. 3
1Internal clinic, Clinical Hospital Centre Osijek, Croatia
2Clinic for psychiatry, Clinical Hospital Centre Osijek, Croatia
3Department for clinical laboratory diagnostics, Clinical Hospital Centre Osijek, Croatia, Croatia
Several clinical trials have shown that anxiety was associated with development of incident coronary heart disease in initially healthy persons and other trials confirmed the connection between emotional stress and development of arterial hypertension.
The intention of this study is to determine whether there is a difference in emotional status between patients with regulated and unregulated arterial hypertension and whether emotional IQ influences regulation of hypertension and thus favours development of cardiovascular diseases.
The research included 48 patients between the ages of 30 and 70 with pharmacologically treated arterial hypertension. They were divided into two groups, in the first one the patients whose blood pressure was lower than 140/90 mmHg (RH) and in the second patients whose blood pressure was equal or higher than 140/90 mmHg (NRH) measured during patients’ regular check-ups. Data on number and type of antihypertensive medications that patients were taking on everyday basis were obtained. Patients completed a questionnaire which was analysed in order to evaluate their emotional status. Groups were statistically compared for any differences in their emotional status.
There were 26 patients in RH group (18 women, 8 men) and 22 patients in NRH group (13 women, 9 men). The results showed no differences in emotional intelligence, emotion perception, emotion expression and emotion management between the two groups of patients as well as no significant correlation between the number and type of antihypertensive medications that these patients were taking and their emotional status.
The influence of emotional status on hypertension and its regulation is still in the shadow of pharmacological treatment and this study emphasizes the importance of appropriate choice of antihypertensive agents and the importance of compliance with antihypertensive therapy in order to diminish the risk for cardiovascular diseases that are often associated with unregulated hypertension.
ISOLATED INTERRUPTED AORTIC ARCH IN AN ADULT – RARE CAUSE OF SECONDARY HYPERTENSION
Vrbanic L. 1, Mirat J. 1 , Galic E. 1 , Coric V. 2
1University »J. J. Strossmayer«, Osijek, School of Medicine Osijek, University Hospital »Sveti Duh«, Internal Medicine Clinic, Zagreb, Croatia, Croatia
2Department of Cardiac Surgery, University Hospital Centre Zagreb, Zagreb
Interrupted aortic arch (IAA) is a congenital defect characterized by loss of luminal continuity between the ascending and descending aorta. It is a rare malformation with an estimated incidence of perinatally diagnosed cases of 3 per million live births. The condition is considered extremely rare in adults. However, its true prevalence in this population is unknown. Although IAA causes secondary arterial hypertension, there is no mention of this abnormality in guidelines regarding differential diagnosis of secondary hypertension. Coarctation of the aorta, the most similar condition to IAA, has several clinical differences which should be taken into consideration when screening for causes of secondary hypertension. Here we describe a 60-years-old male patient who had a type A asymptomatic IAA. Although initially aortic coarctation was suspected, further invasive procedures revealed complete interruption of the aortic arch just distal to the origin of the left subclavian artery. The patient underwent surgical repair, followed by full recovery and near-normalization of blood pressure.
CIRCADIAN BLOOD PRESSURE, HYPERTENSION AND PERIOPERATIVE BLOOD PRESSURE MANAGEMENT
Kvolik S.
Clinical Hospital Centre Osijek, University JJ Strossmayer, School of Medicine, Osijek Croatia
Intraoperative blood pressure (BP) regulation is a result of both patient preoperative cardiovascular performance and anaesthetic management. Severe intraoperative hypotension and hypertension are recognized as risk factors that may significantly influence patients' outcome.
Throughout day time period BP corresponds to the sympathetic activity and has typical oscillations. During the periods of intensive physical activity or emotional distress BP may be significantly higher than observed during the rest. Contrary, a mild decrease in the BP is observed over the night-time periods. It usually accounts for 20% of daily values.
A surgical anaesthesia in a healthy patient reflects the same BP oscillations as observed during daytime activities: a mild decrease in the BP during the rest periods and intense oscillations during surgical or anaesthetic manoeuvres. A circadian BP values may approximately determine acceptable intraoperative BP limits.
Inadequate BP regulation resulting from patient's comorbidity may especially be observed in vascular patients, hyperthyroid patients, psychiatric patients etc. Those patients may not have normal dipping status, but may have severe BP rise or fall during anaesthesia, representing high- or very high-risk categories. They also may be candidates for additional diagnostics, perioperative drug therapies, and invasive BP monitoring.
The most important problems to be resolved during preoperative evaluation of hypertensive patient are: is patient's antihypertensive therapy appropriate, should some of drugs be discontinued or introduced during perioperative period, which BP values should be considered as acceptable, is particular patient at special risk, will elective surgery be delayed, and which anaesthetic technique will be chosen? Postoperative BP management must be considered, especially for the patients admitted to ICU.
Patient preoperative BP oscillations may add a new dimension to the intraoperative BP regulation. Patients with blunted dipping status during daytime activities and during anaesthesia must be carefully managed to decrease both postoperative cardiovascular and surgical complications.
GLOBAL CARDIOVASCULAR RISK IN NEWLY DIAGNOSED HYPERTENSION AND PREHYPERTENSION
Karanovi ć S. 1, Vukovi ć Lela I. 1 , Premuži ć V. 1 , Fištrek M 1, Čapkun V 2, Laganovi ć M 1, Dika Ž 1, Kos J 1, Juri ć D 3, Cvitkovi ć A3, Bitunjac M 4, Pe ćin I 5, Kuzmani ć D 1, Reiner Ž 5, Jelakovi ć B 1
1Department of Nephrology, Arterial Hypertension and Dialysis UHC Zagreb, School of Medicine University of Zagreb, Zagreb, Croatia
2Department of nuclear medicine UHC Split, Split, Croatia
3 Public Health Institute County of Slavonski Brod, Slavonski Brod, Croatia
4General Hospital Dr Josip Ben čevi ć, Slavonski Brod, Croatia
5Department of Metabolic Diseases, University Hospital Centre Zagreb, School of Medicine University of Zagreb, Croatia
Aim: To analyze the prevalence and cardiovascular risk factors of individuals with normal blood pressure (BP) and those with untreated hypertension in a cohort of subjects enrolled in an epidemiological survey performed in the continental rural part of Croatia.
Subjects and methods: Out of 1375 subjects enrolled in the survey, 495 (216 men and 279 women) were included into study. Exclusion criteria were: treated hypertension, acute illness, chronic terminal disease, pregnancy, usage of nonsteroid anti-inflammatory drugs or corticosteroids therapy, dementia and immobility. BP was measured three times in a sitting position using the OMRON device. Subjects were classified into groups with optimal BP (<120/80 mmHg), prehypertension (120/80-140/90 mmHg) and hypertension (>140/90mmHg). Height, weight, body mass index and waist circumference were determined. Fasting blood was analyzed for glucose (FBG) and lipid status..
Results: Optimal BP had 131 (26.4%), prehypertension 174 (35.2 %) and untreated hypertension 190 (38.4%) of enrolled persons. From 190 hypertensives, 19 were priory diagnosed but untreated, while the rest were newly diagnosed. Significant differences were observed in age, BMI, waist circumference, total cholesterol, LDL cholesterol, FBG, triglycerides (p<0,001) between newly diagnosed hypertensives and other two groups, while significant differences were observed between prehypertensives and those with optimal BP in all paramaters (p<0.001) beside FBG and triglycerides. There were no significant differences in HDL cholesterol values among groups (p=0.363).
Conclusion: Newly diagnosed hypertension was recognized in substantial number of subjects, already with significantly increased global cardiovascular risk. Significant number of prehypertensives was also identified. Prehypertensives were older, more obese with more frequently presented dyslipidemia than subjects with optimal BP.
ARTERIAL ELASTICITY
Miovski Z.
Department of Cardiovascular Diseases - University Hospital Center Zagreb, Zagreb, Croatia
Arterial elasticity is determined by number of factors including structural elements within the arterial wall, vascular smooth muscle tone and mean arterial pressure. Cardiovascular risk factors alter the integrity of arterial wall and arterial elasticity. Arterial stiffness attenuation may reflect the reduction of arterial wall damage, whereas blood pressure, blood glucose and lipids can be normalized in a few weeks by using antihypertensive, antidiabetic and lipid lowering drugs, leading to a strong reduction in cardiovascular risk scores, but without yet any improvement of atherosclerotic lesions and arterial stiffness, which requires a long lasting correction of biochemical abnormalities.
Assessment of the arterial wall health can predict future cardiovascular morbid events ( myocardial infarction, stroke, aortic syndromes, total mortality) and can evaluate effectiveness of medical therapy of cardiovascular disease. Identifying and treating preclinical cardiovascular disease has increased the need for finding suitable easy applied, noninvasive methods. The most common techniques are measuring intima media thickness (IMT) of arterial wall, and functional assessment of the arteries by measuring their elasticity or their influence on the arterial pressure waveform. Arterial elasticity can be measured using parameters such as beta index, pulse wave velocity, augmentation index.
PWV is the gold standard marker for measuring arterial stiffness. The velocity of arterial wave is predicted by the Moans- Korteweg equation,, where E is Young's modulus of the arterial wall, h is wall thickness, R is arterial radius at the end of diastole, and p is blood density. Equation relates the velocity of pulse wave travel in vessel to the distensibility of that vessel. In other words, the stiffer the vessel, the faster the PWV. The velocity of the wave is usually measured between two predefined sites of the arterial system. The arterial pulse wave is recorded at a proximal artery such as the common carotid, as well as at a distal artery such as the femoral. That is the most widely used method but is our Clinic the measurement was done only on common carotid artery, using software called e-Tracking developed by ALOKA witch calculates PWV from only one site of arterial bed.
Augmentation index is a marker of systemic arterial stiffness, is calculated from the shape of pulse wave. Near aortic root, the initial rise in pressure following LV ejection is rapidly superimposed with a reflected pressure wave returning from the periphery. Start of this reflected wave is visible on the measured waveform as an inflection point, which has been named the augmentation point. The augmentation index is a mathematical expression of the augmentation point, whereby the increment in pressure after the first systolic shoulder to the peak of the aortic pressure is calculated as a percentage of pulse pressure –Aix = (P2 – P1)/PP x 100. The augmentation index depends on the shape of the forward wave, which is influenced by LV outflow and the elasticity of vessel wall, as well as the timing of the reflected wave, a factor influenced by gender, height, reflected wave amplitude and vessel stiffness.
Beta index ( β) is stiffness parameter and is derived from a logarithmic transformation of the curvilinear relationship between pressure and diameter measured with ultrasonic probe over the artery. It is calculated using formula β = ln (Ps / Pd) / ( (Ds –Dd) / Dd ; Ps systolic pressure, Pd diastolic pressure, Ds systolic vessel diameter, Dd diastolic vessel diameter. The β value is higher when the vessel is stiffer.
In patients with essential hypertension, numerous studies have shoved a decrease in arterial stiffness with different pharmacological classes of antihypertensive drugs. ACE inhibitors, angiotensin II receptor blockers, aldosterone antagonists, calcium antagonist can beneficial y modify the arterial elasticity, independently of the effect on BP. Influence of beta blockers on arterial elasticity is still controversial, according to some studies they do not have effect, although new generation of beta blockers have more favorable affect on the vasculature because of their vasodilating property.
HYPERTENSION AND AORTIC VALVULAR DISEASE
Mirat J.
University »J.J.Strossmayer«, Osijek, School of Medicine Osijek, University Hospital Sveti Duh, Internal Medicine Clinic, Zagreb, Croatia
Hypertension in aortic valvular heart disease represents specific clinical problem which requires cautious approach and knowledge of pitfalls which may mask the real situations, mislead clinicians and bring them to wrong conclusions. Reduction of arterial compliance is common in patients with degenerative diseases which impair valves as well as peripheral vessels. Both processes independently contribute to damage left ventricular (LV) function. Hence, the LV is faced with double: valvular and arterial load. Symptoms correlate better with the total ventricular burden than with the routinely used parameters of transvalvular gradients and aortic valve area.
We elaborate some clinical settings of valvulo-arterial diseases:
1. Hypertension in symptomatic patients with mild or moderate aortic stenosis (AS). In these patients first step would be to treat hypertension and then to re-evaluate status.
2. Hypertension in asymptomatic patients with severe AS. Wait for symptoms strategy may result in some patients undergoing surgery too late, when myocardial impairment has become irreversible.
3. Hypertension in paradoxal low-flow, low-gradient severe AS¸ is characterised by a high degree of LV concentric remodelling, normal ejection fraction, reduced mid-wall shortening and higher level of LV global load. They have worse prognosis if treated medically only.
4. Hypertension in combined valvular heart diseases with AS.
Identification of these patients is very important because the consequence of reduction in cardiac output is the reduction of transvalvular gradients and a psudonormalization of peripheral blood pressure. Thus, AS and hypertension may appear less severe. In fact, these patients are at more advanced stage of disease and require a very aggressive approach.
For more comprehensive evaluation should be included other than routinely used indexes such as: systemic arterial compliance, vascular resistance, energy loss index and recently proposed valvuloarterial impedance as a new index of global LV hemodynamic load. INTRAOPERATIVE CONTROL OF BLOOD PRESSURE DURING THYREOIDECTOMY: OUR CURRENT CLINICAL PRACTICE
Goranovi ć T. 1, Šaki ć Zdrav čevi ć K. 1, Kova čevi ć M. 1, Mili ć M. 2, Pirkl I. 3, Šimunjak B. 3
1 Clinic of Anaesthesiology, Reanimatology and Intensive Care Medicine, Clinical Hospital Sveti Duh, Zagreb, Croatia
2 Clinic of Anaesthesiology, Reanimatology and Intensive Care Medicine, University Hospital Dubrava, Zagreb, Croatia
3 Department of Otorhinolaryngology, Clinical Hospital Sveti Duh, Zagreb, Croatia
Background: Intraoperative control of blood pressure during thyreoidectomy can be achieved by the use of different intravenous hypotensive drugs (e.g. nitrates, urapridile) or by the use of volatile anaesthetic drugs (e.g. isoflurane, sevoflurane). The choice of drugs depends on the clinical decision of an anaesthesiologist in charge. The aim of this study was to evaluate the clinical practice for the intraoperative control of blood pressure during thyreoidectomy in our Institution.
Patients and methods: We retrospectively reviewed the anaesthetic charts of 93 adult patients scheduled for thyreoidectomy in the Clinical Hospital “Sveti Duh” in Zagreb, at the Department of Otorhinolaryngology between January 2008 and January 2010. Demographic data and data on the technique used for the intraoperative control of blood pressure were collected and further analysed. The patients were divided into three groups: group A- intravenous hypotensive drugs; group B- volatile anaesthetics; group C- intravenous hyportensive drugs plus volatile anaesthetics.
Results: There was need for intraoperative antihypertensive intervention in 60% (n= 56) of the studied cases. Intravenous hypotensive drugs as the sole agent were used in 42.86% (n=24), volatile anaesthetics in 32.14% ( n=18), and the combination of intravenous drugs plus volatile anaesthetics in rest 25% (n=14). There was no statistical difference between the groups in age, sex, nor basic anaesthetic technique.
Conclusion: In our Institution anaesthesiologists prefer the use of intravenous hypotensive drugs for the intraoperative control of hypertension during thyreoidectomy.
THE EFFECTS OF ANALGESIA ON BLOOD-PRESSURE
Rados I.
Deparment of anaesthesiology and intensive care, Pain Units, University Hospital Osijek, Osijek
Abstract The effects of analgesia on the blood-pressure, either by classic analgetics (non-opiats and opiat analgesia) or adjuvants (anti-convulsants, anti-depresants, steroids) are still not satisfactory clear.
In clinical practice still not enough attetion is payed to the effects of NSAID on the blood preasure and heart rate, merely following cases of severe side-effects of the NSAID with a deadly outcome in the near past. NSAID lead to the decrease of the synthesis of prostaglandins. Prostaglandins play an important part in the modulation of the kidney and systematic vascular dilatation, glomerular filtration, tubular secretion of water and salt adrenergic neurotransmission and the renin- angiotensin-aldosterone system, all of wich lead to water and salt retention. As an adjuvant analgetic in treating neuropatic pain, some anti-depresants are used (amitryptiline, venlafaxine, duloxetine). Research have shown tha anti- depresants, in particular tricyclic anti-depresants cause an increase of blood-pressure with an augmented chance of hyper-tension. Although anti-depresants do not augment the levels of serotonim and dopamine to extreme levels, it is known that an increased level of dopamine and serotonin plays an important part in the increase in blood-pressure. These two compounda compounds are both known to affect the heart and blood vessels. Administered in concentrated doses, dopamine is used as an emergency drug to support (increase) blood pressure, f.e.. during surgery. To a lesser extent, the similar blood-pressure-raising effects of serotonin may increase how sensitive the heart and vessels are to effects of dopamine. Unlike the anti-depresants, the anti-convulsants also used as adjuvant analgetics in the treatment of neuropathy pain, may have a twofold effect on the blood-pressure if used in cases of chronic pain. With some patients they lead to hyper, and with some to hypo-tension. The effects of opioids lead to a wane in the blood-pressure when applied to cases with acute pain, and in cases of chronic pain it can lead to orthostatic hypotension. Steroids, often used as adjuvant analgetics may also lead to an rise in blood-pressure. Steroida, when taken over a short period of time or in small doses, have minimal effects on blood pressure. Prescribed over a long time or in high doses, steroids may casue high blood-pressure as a result.
Keywords nonsteroidal antiinflamatory drugs, antidepressants, anticonvulsants, steroids, blood pressure TREATMENT OF HYPERTENSIVE HEART DISEASE
Steiner R.
KBC Osijek, Internal clinic, Cardiology department, Osijek
Hypertension can lead to a variety of changes in the myocardial structure, coronary vasculature and conduction system of the heart. These changes can lead to the development of left ventricular hypertrophy, coronary artery disease, conduction system diseases, dysfunction of the myocardium, which manifest clinically as angina or myocardial infarction, cardiac arrhythmias and congestive heart failure.
Treatement of hypertensive heart disease (HHD) falls under two categories: treatment of the elevated blood prasure(BP) and treatment of HHD. BP goal should be less than 140/90 mm Hg or even less depending on comorbidity and target organ demage. Various treatment strategies include dietary modifications, regular aerobic exercise, weight loss and pharmacotherapy.
Treatment of hypertension and HHD involves: diuretics, beta-blockers and combined alpha/beta-blockers, calcium channel blockers(CCB), ACE inhibitors, ARBs and direct vasodilators such as hydralazine. There is trial evidence of outcome reduction for the combination antihypertensive drugs.
Treatement of hypertension and AP include β-blockers, CCB, ACEI/ARB, thiazide diuretics, nitrates, antiplatelet agents, lipid-lowering agents (lipid lowering and pleiotropic effects). Same drugs are used when ACS develops including other measures.
Goals of treatment of LVH and diastolic dysfunction are to optimaze BP control, normalize LV geometry and improve diastolic filling. ACE inhibitors, beta-blockers and nondihydropyridine CCB have been shown to improve echocardiographic parameters in symptomatic and asymptomatic diastolic dysfunction and the symptomatology of heart failure. Diuretics and sodium restriction should be used with caution because of detrimental effect of volume depletion. Aldosteron antagonists have benefitial effect on myocardial fibrosis.
Therapeutic chioce for hypertensive patients with LLVEF as many studies showed are beta-blockers despite their adverse metabolic efects, ACE I/ARB, diuretics and aldosteron antagonists.
Treatment of cardiac arrhythmias is based on class I, class II and class III antiarrythmic drugs, while the role of ACE I/ARB is not confirmed.
PERIOPERATIVE HYPERTENSION
Goranovi ć T. 1, Šaki ć Zdrav čevi ć K. 1
1 Clinic of Anaesthesiology, Reanimatology and Intensive Care Medicine, Clinical Hospital Sveti Duh, Zagreb, Croatia
Summary Perioperative arterial hypertension has been considered a significant risk factor for perioperative morbidity and mortality for a long time. Nowadays, due to the development of efficient antihypertensive drugs and techniques drugs, mortality and morbidity due to perioperative hypertensive has declined. However, clinicians still should pay great effort and care to provide adequate perioperative management of hypertensive patients. The issued current guidelines may provide help in routine clinical decision making.
It is generally well accepted that there is a close association of arterial hypertension and cardiovascular disease. As a result, there are significant changes in cerebral, coronary and renal vessels that promote acute or chronic organ failure. Exacerbation of patophysiological changes or a new precipitating factor can attribute to acute raise in arterial pressure and disasters such as aortic dissection, acute myocardial infarction, intracerebral bleeding and acute renal failure (1). Having in mind importance and prevalence of arterial pressure, numerous cardiac societies have issued guidelines and recommendations on arterial hypertension prevention and management. These guidelines have been regularly updated.
Perioperative arterial hypertension has been considered as a significant risk factor for a long time. Nowadays, this approach has been modified and mitigated. This change should be attributed to the application of different effective techniques and drugs for the control of arterial blood pressure. In addition, there is overall very delicate approach to arterial hypertension in preoperative patient assessment (2). Finally, there have been issued the guidelines of leading American and European specialists' societies on perioperative management, that provide a great help to clinicians in their clinical decision making (3, 4, 5).
A very positive example of strict perioperative arterial pressure control is the management of the patients with phaeochromocytoma. Phaeochromocytoma is a rare tumour secreting catecholamines. In the early days periopertive mortality in patients with pheochromocytoma was 50% (6), due to catecholaminic hypertensive crisis. Nowadays, it is the standardized rule to prepare the pheochormocytomic patients before each surgery type by using alpha- and beta- blockade drugs. Stabile and controlled arterial pressure during the oepraive procedure is assured using this approach. As a result, the perioperative mortality in these patients is near 0% (6).
This article will review the following: the clinical relevance of arterial hypertension in surgical patients; the associative risk of arterial hypertension and cardiovascular events perioperatively; the use of modern drugs and techniques for the arterial pressure control perioperatively; the current leading European and American societies' recommendations on hypertensive patients perioperatively ; special concerns about hypertension in pregnancy and phaeochromocytoma.
Definition, prevalence and aethyology of arterial hypertension in perioperative period
It can be expected to have the significant number of hypertensive patients in surgical patient population. This is based on the arterial hypertension prevalence in general population, the increase of aged population and the increase of aged patients be scheduled for surgeries. Hypertension classification has been proved to be significant for risk stratification in ambulatory patients ( 7). Last Joint National Committee (JNC) classification is based solely on systolic and diastolic arterial pressure readings. This classification could be applied in perioperative period because it offers simple stratification of patients into two categories: 1. the patients of low and immediate risk; 2. the patients of high risk. Table 1 shows the Sixth JNC classification. An anaesthesiologist is often called for the estimation of arterial blood readings. The patient can be positioned on a risk scale by using JNC classification. Unfortunately, the classification has some limitations too. By definition it refers to the average value of two or more measurements taken on two or more visits after initial screening. In real clinical settings, it is obvious that anaesthesiologists do not have so many occasions to check the values of arterial pressure ( 8).
Table 1. The sixth JNC classification Arterial pressure Systolic pressure- Diastolic pressure- category mmHg mmHg Optimal <120 <80 Normal 120 129 80 84 High normal 130-139 85- 89 Hypertension Stage 1 140-159 90-99 Stage 2 160-179 100-109 Stage 3 >=180 >=110
Therefore, anaesthesiologist often use the definition of intraoperative hypertension related to basic measured values. Intraoperative hypertension is the rise or decline of pressure (systolic, diastolic, mean) in ±25% of the base values (9).
Besides having pre-existing hypertension, there are other potential causes of hypertension during anaesthesia. Table 2 shows the commonest causes of hypertension during anaesthesia. ( 9). In the absence of pre-existing hypertension, the majority of instances of intraoperative hypertension are related to increased activity of the sympathetic nervous system. This may be associated with tachycardia and arrhythmias. The commonest causes of hypertension are inadequate analgesia, light anaesthesia, surgical stimulation of airway manipulation ( laryngoscopy, extubation). However, al instances of intraoperative hypertension must promply be excluded for awareness and malignant hypertermia.
Tabe 2. Cause of hypertension during anaesthesia ( 9)
Pre-existing Increased sympathic Drug overdose Other causes tone • Undiagnosed or • Inadequate • Vasoconstrictors • Hypervolaemia poorly controlled analgesia (norepinephrine, • Aoric cross-clamping hypertension phenylephrin) • Inadequate • Phaechromocytoma • Pregnancy induced anaesthesia • Inotropes (dobutamine) hypertension • Malignant • Hypoxaeia • Inotropes/ hypertermia • Withdrawal of • Airway Vasoconstrictors antihypertensive manipulaation (epinephrine, ephedrine) drugs • Hypercapnia • Ketamine • Ergometrine
Associative risk of arterial hypertension and cardiovascular events in perioperative period
Patophysiologically systolic hypertension increases myocardial work by increasing afterload and left ventricular wall tension. This is often associated with tachycardia that additionally increases myocardial oxygen demand, and causes increased risk for ischaemia and myocardial infarction. (9). In addition systolic hypertension increases surgical bleeding (10) and intracerebral bleeding ( 9).
In 1929 Spague et al. identified association of hypertension and cardiovascular risk in 75 hypertensive patients; one third of them died. Death cause was cardiovascular in 12 patients (11). After antihypertensive drugs induction and a series of investigations lead by Prys- Roberts et al. in the 70-ties in last century, (12,13,1,4,¸15) it was recommended to delay every surgical procedure in hypertensive patients if possible . This was done in order to give antihypertensive drugs extra time to start working , and with the thought that this would bring benefit to the patients and lowen the cardiac risk . Howell et al. performed a meta-analysis and showed that that cardiovascular odds risk was only 1.35, if perioperative hypertension existed. That was found to be significant statistically, but not clinically (8). Therefore, Howell et. al. recommended not to delay the surgical procedure on the basis of measured arterial pressure values. It was too little evidence to support association if systolic pressure on admission was less than 180 mmHg or diastolic less than 110 mmHg. The authors were not so clear when referring to the patients with the measured values above the mentioned. The patients with measured values above systolic 180 and diastolic 110 were prone to perioperative ischaemia, arrhythmias and cardiac liability. However, at that time there were not enough evidence to support the benefit in lowering cardiac risk if surgery postponed (8). Recent studies recommend very clearly that the surgery should be postponed in patients with Stage 2 hypertension and accompanying target organs damages or in patients with Stage 3 hypertension ( > 180/> 110 mm Hg) (5,16) .
In 2006 Aronson et al. showed that pulse pressure is a predictor for adverse perioperative renal, cerebral and mortality outcomes ( 7) . Similar results were obtained by Kenge et al. (17), who made an analysis to show association of basic arterial pressure values ( systolic, diastolic, pulse pressure, mean) and a proved 4.3 cardiovascular risk in the Action in Diabetes and Vascular Disease:Preterax and Diamicron-Modified Release Controlled Evaluation Study. The study included 11 140 patients.The authors proved systolic pressure and pulse pressure to be a strong predictors of cardiovascular risk in diabetic patients. Distolic pressure was a weak predictor (17). Kheterpal et al. performed analysis of 7740 surgeries (general, vascualar, urological) in a four-year period. The authors found 83 patients (1.1%) with adverse cardiac events (cardiac arrest, non-ST elevation myocardial infarction, Q-wave myocardial infarction, and new clinically significant cardiac dysrhythmia). Hypertension was among nine identified predictors of perioperative adverse cardic event in non-cardiac surgery (18).
Modern antihypertensive drugs and techniques in perioperative period
A number of agents and techniques are available to control blood pressure perioperatively (2). These include principally general (19) and regional anaesthetics, alpha(2)-adrenoceptor agonists, peripheral alpha(1)- and beta-adrenoceptor antagonists, dihydropyridine calcium channel antagonists, dopamine D(1A)-receptor agonists and nitric oxide donors (1, 2, 20). Recent years have seen important developments in the receptor selectivity of new compounds and in pharmacokinetics, particularly esterase metabolism. (2). The new drug, clevidipine, belongs to a third-generation of dihydropyridine calcium channel antagonists (21). It has evidenced favourable pharmacokinetics with short-acting and fast degradation via esterses, and is proved to be effective and safe in perioperative hypertension in preoperative, intraoperative and postoperative settings (22,23,24). Compared to nitroprusside and nitroglycerine, clevidipine was more effective in decreasing blood pressure during cardiac surgery ( 21,24,25).
Current guidelines on perioperative management of hypertensive patients
The common guidelines of European Cardiac Society (ECS) and European Society of Anaesthesiology (ESA) dedicate the whole separate chapter to the perioperative management of hypertensive patients. In general, arterial hypertension is not considered to be independent risk factor for cardiovascular risk in non-cardiac surgery. Preoperativaly, the patients with damaged target organs should be identified. There is no evidence to recommend one antihypertensive over another in perioperative settings (5). Hypertension should be treated according to ESC guidelines (26). It is recommended to administer perioperative beta-blockers in hypertensive patients with ischaemic heart disease. Antihypertensive drugs should be taken up to the morning of the surgery and respired promptly postoperatively. There is no evidence to delay Stage 1 and Stage 2 hypertension. In patients with Stage 3 hypertension (systolic pressure 180 and/or diastolic pressure 110) potential benefits of optimising arterial pressure should be weighted against potential risk of delaying surgery (5).
The 2007 guidelines of American Cardiac Society (ACS) are similar (3). Updated ACS guidelines 2009, referring to the chapter about beta-blockers, have been modified in accordance to the findings of POISE study (4). Hypertension during pregnancy
The hypertensive disorders of pregnancy include gestational hypertension and preeclampsia, both de novo and superimposed on chronic hypertension. These disorders occur frequently among pregnant woman and are important contributors to maternal and perinatal mortality and morbidity worldwide (27,28,29,30, 31). Because of short-term maternal risks, there is consensus that blood pressure should be treated when sustained at greater than or equal to 160 to 170 mm Hg systolic and/or 110 mm Hg diastolic (severe hypertenson) (29). A recent focus has been placed on systolic hypertension given the increased pulse pressure in these women. (32). There is no consensus regarding management of nonsevere hypertension, and randomized controlled trials involving just over 3000 women have not clarified the relative maternal and perinatal risks and benefits (29,32). Hypertensive disorders of pregnancy reflect endometrial endothelial dysfunction/abnormalities and systemic endothelial dysfunction, which might predict future cardiovascular disease in these young women, prompting early preventive measures. (30). Most commonly, severe hypertension is treated with parenteral labetalol or hydralazine, or oral nifedipine (32, 33,34). Though most recommended, there are recent opinions that magnesium-sulphate should not be relied on as an antihypertensive ( 32).
Phaeochromocytoma
Intraoperative complications of phaeochromocytoma come from hypertensive crisis and tachycardia as result of massive release of catecholamines (35). Current treatment and anaesthetic approach decreased the perioperative mortality from 50% to nearly 0% (6, 36). Alpha blockade is obligatory in all protocols (6, 35,36, 37). The other antihypertensive drugs are involved according to Institution’s protocol (36,37). Beta blocker are often applied (36,37). Recent papers published favourable outcomes in improving cardiovascular stability with using magnesium-sulphate and announced the possibility to use it as a promising agent in future for intraoperative management of phaeochromocytoma (6).
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SAŽECI PRIJAVLJENI NA HRVATSKOM JEZIKU
KONTROLA I ADEKVATNOST LIJE ČENJA ARTERIJSKE HIPERTENZIJE
Roši ć A., Pojski ć B., Mujari ć E., Mehinagi ć D., Čerim A., Badnjevi ć A., Bajrambaši ć E., Husi ć A., Omerovi ć J.
Kantonalna bolnica Zenica, Bosna i Hercegovina, Služba za unutrašnje bolesti -odjel kardiologija
Uvod: Nelije čena, ali i neadekvatno lije čena arterijska hipertenzija, predstavlja jedan od glavnih uzroka kardiovaskularnog morbiditeta i mortaliteta kao i cerebrovaskularnih incidenata.
Ispitanici i metode: Ura ñena je cross sectional studija, pri čemu je metodom slu čajnog odabira anketirano ukupno 249 pacijenata (104 muškarca i 145 žena) sa dijagnozom arterijske hipertenzije podijeljene prema ECHS na četiri kategorije (I, II, III stepen i izolirana sistolna hipertenzija). Korištenjem anketnog upitnika ispitane su varijable vezane za spol, dob pacijenta, trajanje hipertenzije, vrijeme uvo ñenja terapije po postavljanju dijagnoze, trajanje i redovno uzimanje terapije, broj i grupa antihipertenzivnih lijekova, visina krvnog pritiska prije i po zapo činjanju redovnog korištenja terapije kao i vrijednost tlaka u momentu anketiranja, te upoznatost pacijenata sa posljednicama neadekvatno lije čene arterijske hipertenzije. Podaci dobiveni anketiranjem analizirani su statisti čkim proogramom SPSS for Windows (vrsta 12.00) a korišten je Pearsonov hi-kvadrat test i Pearsonova korelaciona metoda za razliku razdioba nominalnih i ordinalnih podataka (statisti čka signifikantnost pri p<0.05).
Rezultati istraživanja: Naj češ će se radi o ispitanicima koji su na antihipertenzivnoj terapiji oko 5 godina. Prije uvo ñenja terapije najve ći broj ispitanika (34.1%) imao je III stepen hipertenzije, potom I te II stepen i izoliranu sistolnu hipertenziju. Oko 81% ispitanika redovno uzima preporu čenu terapiju i me ñu njima je signifikantno ve ći broj onih koji su prije redovnog uzimanja terapije imali III stepen HTA. Me ñu ispitanicima koji koriste terapiju duže od 10 godina prisutan je statisti čki signifikano ve ći broj žena, a one su prije uvo ñenja terapije imale više stepene HTA u odnosu na muškarce (p=0.042, p=0.029). Oko 73% pacijenata je starosne dobi izme ñu 40 i 70 godina. Mla ñi pacijenti su statisti čki signifikanto češ će uzimali jedan lijek u lije čenju HTA, ali su i zna čajno češ će imali niže stepene HTA prije lije čenja (p=0.007, p=0,028) te su bolje poznavali posljedice nelije čenog krvnog tlaka (p<0.001). Ispitanici koji duže znaju za arterijsku hipertenziju tako ñer statisti čki signifikantno duže koriste terapiju i češ će koriste više lijekova za regulaciju krvnog tlaka (p<0.001) ali poznavanje posljedica nelije čene hipertenzije nije zavisilo o trajanju hipertenzije. Skoro polovina ispitanika (48.2%) koristi jedan lijek u lije čenju hipertenzije, a njih 16.5% od ukupnog broja koristi tri ili više lijekova. ACE inhibitori najve ćim dijelom, a potom i beta adrenergi čki blokatori kao i antagonisti kalcija i diuretici, signifikantno češ će su dovodili do normalizacije krvnog tlaka (p<0,001). Oko 17.7% ispitanika je nezadovoljno preporu čenom terapijom a me ñu njima najviše je onih koji su prilikom uvo ñenja terapije imali III stepen HTA (p=0,034). Ispitanici koji su na dan anketiranja uzeli preporu čenu terapiju imali su signifikantno češ će normalan krvni pritisak ili I stepen hipertenzije (p<0.001).
Zaklju čci: Nakon uvo ñenja terapije skoro polovina ispitanika (46.6%) imalo je normalne vrijednosti krvnog pritiska. Ovakvi rezultati su mogu ći vjerovatno zbog toga što je ve ćina ovih pacijenata pod stalnim nadzorom ordinirajućih ljekara. Zabrinjavaju ći podatak je što čak 32.1% ispitanika nije poznavao nijednu posljedicu nelije čenog visokog tlaka. S obzirom na visok procenat pacijenata koji neredovno koristi preporu čenu terapiju a signifikantno češ ći normalan krvni pritisak u toku anketiranja kod pacijenata koji su na dan anketiranja uzeli svoje lijekove, name će se zaklju čak da adekvatnost lije čenja arterijske hipertenzije umnogome ovisi i od samih pacijenata i njihovog stava o bolesti i njenim posljedicama a na ljekarima je odgovornost stalne kontrole i nadzora sprovo ñenja odgovaraju će terapije.
PROMJENE NA AORTALNOM UŠ ĆU KOD HIPERTONI ČARA I UTICAJ PUŠENJA
Pojski ć B. 1, Roši ć A. 1 , Džankovi ć Maci ć A. 2, Husi ć A. 1 , Badnjevi ć A. 1 , Mehinagi ć D. 1
1Cantonal Hospital Zenica, Bosnia and Herzegovina
2General hospital " Abdulah nakaš" Sarajevo, Bosnia and Herzegovina
Hipertenzija je razlog pojave hipertenzivne kardiomiopatije, a veliki postotak hipertoni čara su i puša či. Pitanje je da li se ultrazvu čnim pregledom srca može odrediti težina hipertenzije.
Pacijenti i metode rada: Radjena je prospektivna kontrolirana studija sa 2 grupe pacijenata,ispitivana sa 100 hipertoni čara i kontrolna grupa 100 pacijenata bez hipertenzije.Pacijenti su podijeljeni u ispitivanoj grupu prema težini hipertenzije(HTA) na osnovu ESC vodi ča.Svim pacijentima je uradjen ehokardiografski nalaz, a u ovom radu je na činjen osvrt na pojavu aortalne fibroze, kalcifikata na aortalnoj valvuli, aortalne regurgitacije i veli čine aortalnog korijena u LAXu, a od faktora rizika pra ćena je pojava pušenja.Statisti čka obrada je uklju čivala procentualnu obradu, Hi kvadrat test, za p<0,01
Rezultati rada: Nije bilo signifikantne razlike u spolnoj i dobnoj skupini izmedju dvije grupe. U grupi hipertoni čara 21 pacijent je imao HTA I stepena, 59 HTA II stepena i 20 HTA III stepena.Fibroza aortalnih zalistaka je nadjena kod 37 pts HTA grupe, 11 pts u kontrolnoj grupi.Nadjena je značajna razlika u pojavi fibroze i kalcifikata na aortalnoj valvuli, aortalne regurgitacije te dilatacije aortalnog korijena izmedju kontrolne grupe i grupe hipertoni čara, kao i izmedju kontrolne grupe i HTA II i HTA III grupe.Nije bilo zna čajne razlike izmedju grupa HTA I i HTA II, a bila je izmedju HTA I i HTA III grupe samo za pojavu fibroze a ne i kalcifikata.HTA grupa je imala 53% puša ča, a kontrolna grupa 41%.Nije bilo signifikantne razlike u pojavi pušenja izmedju svih ispitivanih grupa, ali je bila signifikantna razlika izmedju pojave patološkog eho nalaza kod puša ča u odnosu na nalaz kod nepuša ča u obje grupe.
Zaklju čak: Patološke promjene na aortalnoj valvuli i po četnom dijelu ascendentne aorte su bile vezane za teže oblike hipertenzije.Pušenje je zna čajan faktor rizika za ovakve pojave kod hipertoni čara, te grani čno signifikantan kod pacijenata bez hipertenzije. U ovom radu patološke promjene na aortalnom zalisku su vezane za težinu hipertenzije kod nepuša ča, dok kod pacijenata bez hipertenzije promjene na aortalnom zalisku su bile signifikantno patološke kod puša ča. Pušenje se pokazalo kao zna čajan faktor rizika za aterosklerotske promjene i u odsustvu hipertenzije, te se kod puša ča ne može odrediti stepen hipertenzije na osnovu ultrazvu čnih promjena aortalnog korijena i zaliska.
REGULACIJA TVRDOKORNE ARTERIJSKE HIPERTENZIVNE KRIZE PRIMJENOM HLAPLJIVOG ANESTETIKA KOD KRITI ČNIH BOLESNIKA U JEDINICI INTENZIVNOG LIJE ČENJA
Ivi ć J, Ivi ć D , Tot O.K, Vu čini ć D, Došen G.
Odjel anestezije i intenzivnog lije čenja KBC Osijek
U jedinici intenzivnog lije čenja (JIL) susre ćemo bolesnike koji uz osnovnu bolest mogu razviti kratkotrajnu, ali tvrdokornu arterijsku hipertenziju (AH). Često su to bolesnici koji ve ć imaju u povijesti bolesti podatak o reguliranim ili nereguliranim vrijednostima povišenog arterijskog tlaka, ili je to o čekivana AH u sklopu kriti čnog stanja bolesnika. U bolesnika koji zahtijevaju invazivnu/neinvazivnu potporu strojne ventilacije tvrdokornu AH, koju nije mogu će kontrolirati raspoloživim parenteralnim antihipertenzivima, mogu će je regulirati primjenom hlapljivih anestetika primijenjenih uz pomo ć AnaConDa (ACD)sustava.
Sustav omogu ćuje dobro kontroliranu razinu dubine sedacije, brzo bu ñenje i predvidljivu ekstubaciju bolesnika uz zadovoljavaju ću hemodinamsku stabilnost.
Koriste ći inhalacijski anestetik izofluran kao krajnje sredstvo za kontrolu tvrdokorne AH u JIL uo čili smo da je jednostavno primjenjiv i nadasve u činkovit u okolnostima kad zakažu uobi čajeni postupci. Nismo uo čili zna čajnijih nuspojava.Vrijednosti jetrenih enzima i duši čnih metabolita mjereni 24 sata po isklju čivanju ACD nisu pokazali patološki otklon.
Porast vrijednosti γ-GT koji je zabilježen u trojice bolesnika možda je posljedica primjene hlapljivog anestetika, ali i ve ć prisutnog teškog stanja bolesnika ili primjene drugih i.v. lijekova, te ne možemo sa sigurnoš ću optužiti niti jedan od navedenih uzroka. Treba imati u vidu i činjenicu da je metaboli čka razgradnja isoflurana svega 0,2%. Tako ñer porast γ- GT ne korelira sa brojem sati provedenih na ACD sustavu.
Kako se radi o maloj skupini bolesnika ne možemo donijeti kona čne zaklju čke, ali iz dosadašnjih iskustava s lije čenjem tvrdokorne AH u kriti čnih bolesnika u JIL-u jasno je vidljivo da se može posti ći dobra kontrola sistoli čkog tlaka koji u daljnjem tijeku ne pokazuje tendenciju ponovnog rasta. Stoga smatramo da je ovaj na čin regulacije AH korisno primijeniti u slu čajevima tvrdokorne AH koju nije mogu će kontrolirati drugim terapijskim postupcima.
Reference: 1. Respir Care 2008; 53(10): 1295-1303 2. Crit Care Med 2008; 36: 801-806 3. Anesth Analg 2007 ; 104 :130-134 4. Pediatric Anesthesia Vol.15 Issue 10 October 2005 5. Artificial organs, Vol. 21, p 21-23, 1997. 6. Critical Care Clinics, Vol. 11, No. 4, 1995. 7. Crit Care Med 2004 Vol. 32, No.11 SAŽECI RADOVA PRIKAZANIH NA SIMPOZIJU UDRUGA MEDICI NSKIH SESTARA U HIPERTENZIJI
RENOVASKULARNA HIPERTENZIJA – PRIKAZ BOLESNIKA
Mihali ć M, Šušmak B, Grkavec A, dr. Fodor Lj.
Zavod za nefrologiju i arterijsku hipertenziju, Interna klinika, Klini čki bolni čki centar Zagreb
Klju čne rije či stenoza renalne arterije; renovaskularna hipertenzija; dijagnosti čki testovi; perkutana transluminalna angioplastika sa stentom/bez stenta
Renovaskularna hipertenzija je jedan od naj češ ćih uzroka sekundarnog oblika arterijske hipertenzije. Aterosklerotska stenoza renalne arterije nalazi se u 90% bolesnika s renovaskularnom hipertenzijom. Obi čno u tih bolesnika postoje i drugi znakovi difuzne vaskularne bolesti, koronarna i periferna vaskularna bolest, renalna insuficijencija, promjene abdominalne aorte. Tijek bolesti je uglavnom progresivan, a o čituje se pogoršanjem stenoze i smanjenjem bubrega. Potrebno je istaknuti da veli čina stenoze utje če i na preživljenje bolesnika, a glavni uzrok smrtnosti su kardiovaskularne bolesti. Kada na osnovi klini čkih pokazatelja postoji sumnja na stenozu renalne arterije, potrebno je dobiti uvid u funkcionalno stanje bubrega i anatomske promjene na krvnim žilama. U tu svrhu postoji niz morfoloških neinvazivnih pretraga. Nakon dijagnosti čke obrade kojom se postavi sumnja na hemodinamski zna čajnu stenozu jedne ili obje renalne arterije ( RA), potrebno je u činiti digitalnu suptrakcijsku angiografiju ( DSA) ,koja je krunska pretraga u postavljanju indikacije za endovaskularnu intervenciju sa ili bez implantacije stenta u RA.Ukoliko stenoza prikazana na DSA nije signifikantna ( ≥ 50%), nastaviti će se s medikamentoznom terapijom, uz daljnje redovne kontrole CD-om i kontrole laboratorijskih parametara bubrežne funkcije. Ciljevi lije čenja su regulacija krvnog tlaka, o čuvanje bubrežne funkcije i prevencija kardijalnih komplikacija.
INDIKATOR KVALITETE ZDRAVSTVENE NJEGE: SESTRINSKA DOKUMENTACIJA I KATEGORIZACIJA PACIJENATA NA ODJELIMA NEFROLOGIJE I NEUROLOGIJE OB KOPRIVNICA/ KOMPARACIJA I ANALIZA
Šantek-Zlatar G 1, Šimuni ć G 2.
1Odsjek za Nefrologiju i Endokrinologiju, Op ća bolnica „Dr.T.Bardek“ Koprivnica
2Jedinica djelatnosti za Neurologiju, Op ća bolnica „Dr.T.Bardek“ Koprivnica
U Op ćoj bolnici „Dr. T. Bardek“ Koprivnica 01.09.2002.g po čela je primjena sestrinske dokumentacije na svim odjelima bolnice. Dokumentaciju je osmislila radna grupa za izradu sestrinske dokumentacije pri bolni čkom Povjerenstvu za medicinsku dokumentaciju OB Koprivnica. Prije ovog datuma postojala je sporadi čna primjena dokumentacije na Internom odjelu zahvaljuju ći ambicioznosti i entuzijazmu nekolicine sestara.
Dokumentacija HKMS-a pruža sestrinstvu novu mogu ćnost, a to je kategorizacija pacijenata prema kritičnim čimbenicima koji su dokaz zahtjevnosti pacijenata za zdravstvenom njegom.
Ideja o projektu nastavka uvo ñenja sestrinske dokumentacije HKMS-a u bolnici na odjele nefrologije s endokrinologijom i neurologije te komparacija i analiza tih odjela kroz sestrinsku dokumentaciju na bazi kategorizacije pacijenata javila se po četkom 2009.g.
Na tim odjelima vrlo je složen i problemati čan profil pacijenata koji zahtijeva kompleksno, sustavno, dinami čno i fleksibilno provo ñenje zdravstvene njege kroz proces zdravstvene njege i dokumentiranje kroz sestrinsku dokumentaciju. Struktura i dinamika medicinsko-tehni čkih i dijagnosti čko-terapijskih intervencija kao i kompleksnost zdravstvene njege „školski“ su primjer i model u čenja procesa, pa su iz tog razloga ti odjeli izabrani za ovaj projekt.
Nakon niza edukacija kroz 2009. godinu za sve medicinske sestre koje rade na spomenutim odjelima, s projektom se po činje 1.12.2009. godine.
Nakon 3 mjeseca provo ñenja i implementacije dokumentacije napravljeno je istraživanje koje je dalo izvanredne rezultate, napravljena je evaluacija, komparacija i analiza zahtjevnosti i složenosti pacijenata za zdravstvenom njegom od strane voditelja projekta.
Sestrinska dokumentacija pruža sestrinstvu jednu novu dimenziju, a to je sestrinstvo-zdravstvena njega temeljena na dokazima. Medicinske sestre kroz dokumentaciju imaju dokaz o zahtjevnosti i potrebama pacijenata za zdravstvenom njegom koji su prikazani kroz kategorizaciju pacijenata po kriti čnim čimbenicima kategorizacije.
Postotak pacijenata raspore ñenih u pojedine kategorije Neuro/Nefro
60 52,8 52,35 50 40 I postotak 30 27,33 22,94 II 20 17,65 12,42 III 10 7,45 7,06 IV 0 NEURO NEFRO odjeli
Slika 1. Rezultati kategorizacije pacijenata na odjelima Neurologija/Nefrologija
Na temelju istraživanja došli smo do zaklju čaka o potrebi zapošljavanja medicinskih sestara na odjelima Nefrologije i Neurologije. Postoje ći broj sestara ne može zadovoljiti potrebe i zahtjeve pacijenata i pružiti kvalitetu zdravstvene njege koja se od njih o čekuje kako bi se zadovoljili standardi koje nam name će moderno sestrinstvo, napredak tehnologije u medicini i na kraju krajeva naš poslodavac.
HIPERTENZIJA U DJECE I ADOLESCENATA
Bošnjak S, Div čić B, Vidati ć I, Begi ć R.
Klinika za pedijatriju Klini čka bolnica „Sestre Milosrdnice“, Zagreb
Učestalost hipertenzije u djece,pogotovo u adolescenata je u stalnom porastu. Iako je uobi čajeno mišljenje da je hipertenzija u djece rijetka svakodnevni rad nam pokazuje suprotno. O hipertenziji u djece govorimo ako je prosje čan sistoli čki i / ili dijastoli čki krvni tlak>95 centile za dob, spol i tjelesnu visinu u tri odvojena mjerenja. Mjere lije čenja hipertenzije u djece i adolescenata su nefarmakološke (op će) i farmakološke (medikamentozne).
Dobrim provo ñenjem op ćih mjera i redovitim uzimanjem propisane medikamentozne terapije održavamo krvni tlak u normalnim vrijednostima i na taj na čin smanjujemo dugoro čno kardiovaskularni mortalitet i morbiditet. ZDRAVSTVENA NJEGA BOLESNIKA OBOLJELOG OD ARTERIJSKE HIPERTENZIJE
Coli ć M, Vidrih S.
Zavod za nefrologiju i dijalizu, Interna klinika, Klini čki bolni čki centar Rijeka
Klju čne rije či: Arterijska hipertenzija, zdravstvena njega, edukacija
Arterijska hipertenzija je stanje povišenog tlaka krvi u arterijama. Može biti znak, čimbenik rizika ili bolest. Naj češ će je čimbenik rizika za kardiovaskularne bolesti, cerebrovaskularni incident, pogoduje razvoju zatajivanja srca i kroni čne bubrežne bolesti. U ve ćini razvijenih zemalja arterijski se tlak u populaciji povisuje s dobi i s porastom tjelesne težine. Muškarci imaju više vrijednosti od žena. Arterijski tlak odre ñen je minutnim volumenom srca, perifernim otporom i volumenom krvi. Kada se javi poreme ćaj na bilo kojem od tih mehanizama dolazi do razvoja hipertenzije. Prema uzrocima razlikujemo primarnu i sekundarnu arterijsku hipertenziju. Najvažniji znak arterijske hipertenzije je izmjeren povišeni krvni tlak a naj češ ći simptomi su oni koji dolaze od strane ošte ćenih ciljnih organa. Otkrivanju uzroka hipertenzije prethodi niz osnovnih i proširenih dijagnosti čkih pretraga a lije čenje i prognoza ovise o etiologiji, edukaciji i suradljivosti bolesnika. Ciljevi zdravstvene njege su rano otkrivanje bolesti, snižavanje deficita znanja, promicanje razvoja plana lije čenja prihvatljivog za bolesnika i razumjevanje važnosti kontrole bolesti. Intervencije su usmjerene na procjenu znanja, pružanje informacija, indiciranje metoda modifikacije ponašanja, poticanje na aktivno sudjelovanje bolesnika i njegove obitelji u lije čenju. Sestrinski prioriteti su održati i poboljšati kardiovaskularno funkcioniranje i sprije čiti ili minimalizirati komplikacije.
HEALTH CARE OF PATIENTS WITH ARTERIAL HYPERTENSION
Coli ć M, Vidrih S.
Department of nephrology and dialysis, Internal clinic UHC Rijeka
Keywords: Arterial hypertension, health care, education
Hypertension is a condition of elevated blood pressure in the arteries. It may be a sign, a risk factor or disease. The most common risk factor for cardiovascular disease, cerebrovascular accident, helps the development of heart failure and chronic renal disease. In most developed countries in arterial blood pressure in the population increases with age and with higher body weight. Men have higher values than women. Arterial pressure was determined cardiac output, peripheral resistance and blood volume. When disorder arises at any of these mechanisms leads to the development of hypertension. According to differentiate causes of primary and secondary hypertension. The most important sign of hypertension is high blood pressure is measured and the most common symptoms are those that come from the damaged target organs. Discovering the causes of hypertension precedes a series of basic and enhanced diagnostic tests and treatment and prognosis depend on the etiology, patient education and compliance. The objectives of health care are early detection of disease, reducing the deficit of knowledge, promote the development of treatment plan acceptable to patients and understanding the importance of controlling the disease. Interventions aimed at assessing knowledge, providing information, indication of behavior modification methods, encouraging the active participation of patients and their families in treatment. Nurses priorities are to maintain and improve cardiovascular function and prevent or minimize complications. ZDRAVLJE I SOL
UVODNA RIJE Č UREDNICE TEME „ZDRAVLJE I SOL“
Vlasta Hrabak-Žerjavi ć
Hrvatski zavod za javno zdravstvo
Klju čne rije či: zdravlje, sol
Prema studiji Globalnog optere ćenja bolestima 80% smrtnosti u svijetu, a u Europi čak 86% smrtnosti, uzrokovano je kroni čnim nezaraznim bolestima. Svjetska zdravstvena organizacija 2005. godine zacrtala je kao globalni cilj u idu ćih 10 godina smanjiti smrtnost od kroni čnih nezaraznih bolesti svake godine za 2%, provode ći intervencije na individualnoj i populacijskoj razini. Na osnovi rezultata projekta Usporedne procjene rizika SZO cilj bi se moglo posti ći smanjenjem glavnih čimbenika rizika za nastanak ovih bolesti.
Jedan od vode ćih čimbenika rizika je hipertenzija. U Europi ona se nalazi na vrhu ljestvice uzroka dizabiliteta/onesposobljenosti s udjelom od 12,8% DALYs (disability – adjusted life years), a u Hrvatskoj je na drugom mjestu s udjelom od 13,8% u ukupnom dizabilitetu mjereno s DALYs. U nastanku hipertenzije zna čajnu ulogu ima suvremeni na čin života uklju čuju ći prekomjerni unos soli.
Stotinama tisu ća godina dnevni unos soli naših predaka iznosio je manje od 1 grama soli dnevno. Pred oko 5000 godina Kinezi su otkrili da sol može služiti za čuvanje hrane. Od tada je sol postala zna čajan gospodarski čimbenik. Njeno korištenje doseglo je vrhunac krajem 19. stolje ća. Pronalaskom čuvanja hrane u hladionicima i zamrziva čima unos soli se po čeo smanjivati. Me ñutim posljednjih desetlje ća korištenjem slane procesuirane hrane potrošnja soli se penje u ve ćini zemalja svijeta na razinu sli čnu onoj krajem 19. stolje ća. Istraživanja pokazuju da prosje čni dnevni unos soli iznosi 12-16 grama, a za normalno funkcioniranje organizma odrasle osobe potrebno je 4-6 grama soli dnevno.
Program smanjenja unosa soli s ciljem smanjenja razine krvnog tlaka zapo čeo je kasnih 70-ih u Sjevernoj Kareliji u Finskoj, a zatim se proširio na cijelu državu. Uklju čuje smanjenje koli čine natrija u prehrambenim proizvodima; obvezno deklariranje koli čine soli na svim prehrambenim proizvodima, koji su pridonosili pove ćanom unosu soli; uvo ñenje zdravstvenih upozorenja na takvim proizvodima, ali i oznaka za proizvode s malo soli; te bu ñenjem svijesti javnosti o štetnom djelovanju ve ćeg dnevnog unosa soli u organizam. Kroz tridesetak godina unos soli u populaciji Finske smanjen je za jednu tre ćinu, uz paralelno smanjenje i sistoli čkog i dijastoli čkog tlaka na populacijskoj razini za 10 mmHg kao i smanjenje smrtnosti od moždanog udara i koronarne bolesti (iako pritom ne treba zanemariti druge poduzete mjere intervencije). Sli čno uspješnim pokazali su se i nacionalni programi smanjenja unosa soli u Velikoj Britaniji i Japanu.
Niz epidemioloških i klini čkih studija pokazao je da je posljedica pove ćanog dnevnog unosa soli u organizam ne samo povišenje krvnog tlaka i pove ćanje rizika nastanka kardiovaskularnih nego i bubrežnih bolesti. Nadalje, indirektno unos soli doprinosi debljini ve ćom konzumacijom teku ćine. Povezuje ga se i s bubrežnim kamencima kao i osteoporozom, a vjerojatno je i zna čajan čimbenik rizika za rak želuca.
Studije intervencija na populacijskoj razini pokazale su da smanjenje unosa soli može smanjiti razinu krvnog tlaka populacije. Na osnovi meta analiza randomiziranih pokusa smanjenja unosa soli procjenjuje se da se smanjenjem unosa soli za 6 grama dnevno može smanjiti moždani udar za 24% i koronarnu bolest za 18%. Smanjenje unosa soli smatra se vrlo isplativom (cost-effective) mjerom. Prema Murray-u i sur. smanjenje unosa koli čine soli populacijskim pristupom, uklju čuju ći stimuliranje smanjenja soli u procesuiranim prehrambenim proizvodima, je u činkovit na čin smanjenja kardiovaskularnih bolesti i moglo bi smanjiti optere ćenje bolestima za 21 milijun DALYs godišnje na globalnoj razini.
Asaria i sur. napravili su procjenu u činka strategije smanjenja unosa soli i strategije nadzora nad duhana. Za desetgodišnje razdoblje (2006-2015) procijenili su da bi se primjenom strategije smanjenja unosa soli za 15% moglo sprije čiti 8,5 milijuna smrti, a primjenom četiri osnovna elementa Okvirne konvencije nadzora nad duhanom SZO 5,5 milijuna smrti od kroni čnih bolesti. U smanjenju smrtnosti kardiovaskularne bolesti sudjelovale bi s 75,6%, bolesti dišnog sustava s 15,4% i rak s 8,7%. Trošak bi u zemljama s niskim i nižim srednjih dohotkom iznosio 0,40 dolara po osobi godišnje, u zemljama s višim srednjim dohotkom 0,50-1,00 dolar po osobi godinšnje (razina 2005. godine). Navedene procjene govore o isplativosti ovakvog pristupa ali i mogu ćem doprinosu postizanja globalnog cilja smanjenja smrtnosti od kroni čnih bolesti. Na osnovi uspješnosti spomenutih nacionalnih programa smanjenja unosa soli 2005. godine izrasla je svjetska inicijativa WASH (World Action on Salt and Health). Hrvatska se pridružila ovim naporima i u listopadu 2006. godine na 1. kongresu Hrvatskog društva za hipertenziju prihva ćena je Deklaracija o važnosti zapo čimanja nacionalne kampanje za smanjenje konzumacije soli. Na 6. Hrvatskom kongresu o aterosklerozi u svibnju 2007. godine predstavljena je Hrvatska inicijativa za smanjenje prekomjernog unosa kuhinjske soli CRASH (Croatian Action on Salt and Health) čiji slogan je „Manje soli – više zdravlja“ kao i Nacionalni program smanjenja prekomjernog unosa kuhinjske soli. Program se provodi u organizaciji Akademije medicinskih znanosti Hrvatske, Hrvatskog društva za hipertenziju, Hrvatskog društva za aterosklerozu, Hrvatskog kardiološkog društva, Medicinskog fakulteta Sveu čilišta u Zagrebu i raznih udruga, a uz podršku Ministarstva zdravstva i socijalne skrbi. Cilj programa je smanjenje prekomjernog unosa kuhinjske soli mijenjanjem prehrambenih navika, na čina pripreme hrane i dosoljavanja hrane te smanjenjem koli čine soli u prehrambenim proizvodima, ali i uvo ñenjem deklariranja koli čina soli. Isto tako Hrvatska je i sudionik akcije Svjetske zdravstvene organizacije čiji cilj je utvr ñivanje razine unosa kuhinjske soli u europskim populacijama.
Literatura: 1. He FJ, Mac Gregor GA. Review. A comprehensive review on salt and health and current experience of worldwide salt reduction programmes. J Hum Hypertension 2009; 23:363-384. 2. Brown IJ, Tzoulaki I, Candeias V, Elliott P. Global Epidemiology. Salt intakes around the world:implications for public health. Int J Epidemiol 2009; 38:791-813. 3. Asaria P, Chisholm D, Mathers C, Ezzati M, Beaglehole R. Chronic disease prevetion: health effects and financial costs of strategies to reduce salt intake and control tobacco use. Lancet 2007; 370:2044-53. 4. Jelakovi ć B, Kai ć-Rak A, Mili čić D, Premuži ć V, Skupnjak B, Reiner Ž. Manje soli – više zdravlja. Hrvatska inicijativa za smanjnje prekomjernog unosa kuhinjske soli (CRASH). Lije č Vjesn 2009; 1341:87-92.
UNOS SOLI U ODRASLOJ POPULACIJI
Vedran Premužić1 , Inga Erceg 2 , Aleksandar Jovanovi ć3 , Željko Reiner 4 , Bojan Jelakovi ć1
1 Zavod za nefrologiju i arterijsku hipertenziju, KBC Zagreb i Medicinski fakultet Sveu čilišta u Zagrebu
2 Ambulanta Obiteljske Medicine Lasinje, Karlovac
3 Ambulanta Obiteljske Medicine, Dugave, Zagreb
4 Zavod za bolesti metabolizma, KBC Zagreb i Medicinski fakultet Sveu čilišta u Zagrebu
Klju čne rije či: kuhinjska sol, arterijska hipertenzija, proteinurija, epidemiologija, nacionalna akcija, arterijski tlak, natriurija
Key words : salt, arterial hypertension, proteinuria, epidemiology, national campaign, blood pressure, urine sodium
Uvod
Pretjeran unos kuhinjske soli je vrlo zna čajan čimbenik rizika za nastanak arterijske hipertenzije, moždani udar, hipertrofiju lijeve klijetke, proteinuriju, osteoporozu, nefrolitijazu i neke karcinome probavnog sustava. Unos soli je nadmašio dnevne potrebe našeg organizma u svim razvijenim zemljama te u onima u razvoju. Danas ne govorimo o unosu koji bi bio prihvatljiv (do 5 grama) ve ć o mnogo opasnijim koli činama (preko 10 grama, a ponegdje i još više). Često zaboravljamo kako opasnost ne leži samo u soljenci na stolu ve ć u gotovoj i polugotovoj hrani. I dok su neke zemlje krenule u smanjivanje unosa soli u svojoj populaciji te znaju koli činu njenog dnevnog unosa, mi u Hrvatskoj dosada nismo imali dostupne podatke, iako smo pretpostavljali da podaci nisu ohrabruju ći. U Velikoj Britaniji je potaknut veliki program (CASH) u cilju smanjenja prekomjernog unosa soli prije desetak godina te je postupno prerastao granice te zemlje te je postao svjetski (WASH). Velika Britanija je uspjela velikom akcijom u koju su bili vrlo aktivno uklju čeni mediji te prehrambena industrija (iako s mnogo otpora u po četku) u samo jednom desetlje ću smanjiti dnevni unos soli s 9.5 g na 8.6 g što je 10% sniženje cjelokupnog unosa, prera čunato u oko 19700 tona soli.
Finska je uspjela zahvaljuju ći suradnji s prehrambenom industrijom smanjiti 20-25% koli činu soli u naj češ će kupovanim prehrambenim proizvodima (kruhu, mesu, siru i gotovoj hrani). Japanski znanstvenici su tako ñer krenuli u veliku akciju s time da su kao cilj uzeli 6 g dnevno kao maksimalno dopušteni unos soli u organizam. Mi smo se tako ñer uklju čili u svjetsku akciju te je 2007. predstavljena naša akcija CRASH ( Croatian Action on Salt and Health ). Jedan od naših ciljeva je odrediti koli činu soli u nasumi čnom i reprezentativnom uzorku naše populacije. Cilj je bio odrediti postoje li razlike u unosu kuhinjske soli izme ñu dvije skupine ispitanika, jedne iz ruralnog područja Karlova čke županije, a druge iz urbanog podru čja grada Zagreba, te postoje li razlike u životnim navikama te posljedi čno tome i prehrani i njenim popratnim simptomima.
Metode
U ovu pilot studiju smo uklju čili 93 odrasle osobe (46.32+-7.38 godina starosti) iz dvije ambulante op će medicine (jedna u ruralnom kraju, druga u gradu). Nakon uzete anamneze te ispunjenog upitnika o prehrani i životnim navikama (naj češ će konzumirana hrana, op ća informiranost o štetnosti soli, koli čina soli u prehrani, podaci o pušenju, popis lijekova), slijedio je fizikalni pregled bolesnika (dob, visina, težina, indeks tjelesne mase). Arterijski tlak (AT) je mjeren Omronovim tlakomjerom pridržavaju ći se ESH/ESC smjernica, u sjede ćem položaju. Iz 24 satnog urina su odre ñene vrijednosti natrija, kalija i kreatinina te je u činjena laboratorijska obrada (kompletna krvna slika, biokemijski podaci, sediment urina). Koli činu unijete soli u organizam smo odredili na temelju vrijednosti natriurije iz 24 satnog urina koju smo podijelili s nazivnikom 17.1 i na taj na čin smo dobili koli činu NaCl u gramima.
Rezultati
U cijeloj skupini ispitanika, natriurija je bila zna čajno viša u muškaraca (223.6+-74.0 vs. 177.3+-69.1, p=0.001). Zna čajna razlika izme ñu muškaraca i žena je bila vidljiva u urbanoj skupini bolesnika (p=0.02), ali ne i ruralnoj (p=0.052). Nije bilo vidljive razlike izme ñu urbane i ruralne skupine u vrijednostima natriurije (189.2+-57.9 vs. 212.2+-88.3, p=0.17). U samo 9 ispitanika je unos soli bio < 6g/dan dok je u 39% (36/92) unos soli bio > 12g/dan. Najviši zabilježen unos soli je bio 29.5g/dan. Opažena je zna čajna korelacija izme ñu unosa soli i sistoli čkog i dijastoli čkog arterijskog tlaka (r=0.21, p=0.06; r=0.26, p=0.02).
Zaklju čak
Prosje čan unos soli u op ćoj Hrvatskoj populaciji je 13.3+-4.3 g/dan za muškarce i 10.2+-4.2 g/dan za žene. To je uistinu zabrinjavaju ći podatak koji upozorava na prehrambene i životne navike naše nacije i ukazuje na potrebu organiziranog multidiscisplinarnog pristupa i napora koji će trebat uložiti ne samo medicinska struka i znanost nego i gospodarstvo (poglavito prehrambena industrija), a o čekuje se svesrdna pomo ć i suradnja medija. Ovi rezultati pokazuju izrazito djelovanje kuhinjske soli na povišenje arterijskog tlaka. Uskoro ćemo napraviti istraživanje o unosu soli u drugim regijama u Hrvatskoj no i bez toga možemo zaklju čiti na temelju prisutnih podataka kako bi smanjenje unosa kuhinjske soli trebao biti nacionalni prioritet. Zapo četa je edukacija stru čnjaka i populacije, program se provodi u organizaciji Akademije medicinskih znanosti Hrvatske te Hrvatskog društva za hipertenziju, Hrvatskog društva za aterosklerozu, Hrvatskoga kardiološkog društva i Medicinskog fakulteta Sveu čilišta u Zagrebu, kao i udruga medicinskih sestara, studenata i udruge bolesnika. Pregovori s prehrambenom industrijom su zapo četi, uklju čeni su Ceh Ugostitelja Hrvatske, Hrvatska agencija za hranu, a i tvrtke zadužene za suradnju s medijima. Ministarstvo zdravstva i socijalne skrbi poduprlo je ovaj nacionalni program, a uklju čeni smo i u akciju Svjetske zdravstvene organizacije kojoj je cilj upravo odrediti unos kuhinjske soli u europskim populacijama. Naravno da ne ćemo odmah susti ći zemlje koje su ispred nas, no cilj je probuditi svijest u naših gra ñana o opasnostima pretjeranog unosa kuhinjske soli kao i cijele prehrambene industrije. Moto programa je Manje soli-više zdravlja, čijoj se uspješnoj primjeni nadamo.
Izvedbu ovog rada potpomognulo je Ministarstvo Znanosti Republike Hrvatske (projekt br. 0108109) i projekt Svjetske Zdravstvene Organizacije u sklopu organiziranja unosa soli u Europi.
Kontakt:
Vedran Premuži ć Zavod za nefrologiju i arterijsku hipertenziju KBC Zagreb, Kišpati ćeva 12, 10 000, Zagreb, Hrvatska Tel: +385-1-23-88-592; Fax: +385-1-23-67-468 e-mail: [email protected]
POVE ĆAN UNOS KUHINJSKE SOLI UTJE ČE NA POJAVU KARCINOMA PROBAVNOG SUSTAVA
Vedran Premuži ć1, Željko Reiner 2, Bojan Jelakovi ć1
1 Zavod za nefrologiju i arterijsku hipertenziju, KBC Zagreb i Medicinski fakultet Sveu čilišta u Zagrebu
2 Zavod za bolesti metabolizma, KBC Zagreb i Medicinski fakultet Sveu čilišta u Zagrebu
Klju čne rije či: kuhinjska sol, karcinom želuca, probavni sustav, prehrambene navike, karcinom jednjaka, epidemiologija, arterijska hipertenzija, Helicobacter pylori
Uvod
Danas u modernoj medicini i znanosti govorimo o mnogim epidemijama, no nekako što zbog neprepoznavanja medija, a što zbog nas samih, zdravstvenih djelatnika, epidemija kardiovaskularne bolesti (KVB), koja je svakom idu ćom godinom sve opširnija i posljedi čno tome teže ju je sprije čiti, ostaje slabo prevenirana. Jedan od čimbenika koji djeluju na pove ćanje epidemije KVB je nepravilna, nezdrava i preobilna prehrana. Poznata je činjenica kako je prehrana vrlo bitan faktor zdravlja, te uz štetnost pove ćanog unosa masti, še ćera i kalorija op ćenito, vrlo je bitna i štetnost pove ćanog unosa kuhinjske soli u organizam. Odavno prepoznati javno-zdravstveni problem u svijetu je prekomjeran unos kuhinjske soli te je to navelo znanstvenike na poja čano istraživanje nepoželjnih u činaka soli na ljudski organizam. Shvatilo se koliko je važno smanjiti unos soli u organizam te koliko je važno djelovati preventivno, a ne lije čiti posljedice dugogodišnjeg prekomjernog unosa.
Čovjek je prošao evoluciju te odavno stekao prehrambene navike, no s vremenom (to čnije tisu ćama godina) su se promijenile normalne životne okolnosti. Iz prakti čno spartanskog života te prehranom koja je pokrivala “samo“ naše dnevne potrebe, a često ni toliko, prešli smo u vrijeme kada je hrana uistinu dostupna na svakom koraku, no problem više nije samo u koli čini hrane ve ć i u njenoj kakvo ći. Naš organizam je zadržao metaboli čke potrebe i navike koje su postojale u paleolitsko doba te se ne može nositi s današnjim zahtjevima koje mu svakodnevno zadajemo pretjeranom i nepravilnom prehranom. Jasno da ne smijemo zaboraviti utjecaj gena koji u nekih ljudi još uvijek djeluju dovoljno protektivno unato č današnjoj prehrani te kod njih ne dolazi do razvitka KVB bolesti. Postoje narodi kod kojih je u čestalost arterijske hipertenzije (AH) zna čajno niža nego u zapadnoj populaciji, to su narodi koji žive u divljini te kod kojih je prisutan manji dnevni unos soli, no ne možemo re ći kako oni ne doživljavaju stres, barem jedan njegov oblik, kojem smo mi izloženi u moderno ure ñenim rodovskim zajednicama. Kao što samo možemo pretpostaviti, lov i život na otvorenom koji ti narodi prakticiraju je sve samo ne idili čan i lagodan. Postoje jasne činjenice kako ljudska populacija, a posebice ˝zapadna˝, dnevnim unosom soli višestruko premašuje svoje fiziološke potrebe što naravno nije samo krivica ljudi ve ć i prehrambene industrije koja svoje proizvode pretjerano i nepotrebno za činjava i soli. Jasno je da pove ćan unos soli kao jednostavno pretjerano zasoljavanje hrane koju smo mi pripremili nije jedini problem, puno ve ći je konzumiranje gotove ili polugotove hrane kojom nažalost naši stolovi obiluju 1.
Zabrinjavaju će je kako ne znamo osnovne stvari o našim dnevnim namirnicama koje nismo nikad smatrali štetnima. Tako 1 kg kruha sadrži 5g NaCl što je ve ć gornja granica dnevnih potreba našeg organizma za natrijem, a kada pobrojimo sve namirnice koje smatramo neophodnima i dnevno potrebnima dolazimo do izuzetno visokih vrijednosti NaCl koji se ne može izlu čiti iz organizma te dovodi do opasnog strujnog kruga koji ubija s odlaganjem.
Štetnost pove ćanog unosa kuhinjske soli je prepoznata na više razina. Poznato je kako povisuje arterijski tlak (AT) i pove ćava prevalenciju AH koja je najvažniji, nezavisni čimbenika KV rizika. Uz to, nezavisno djeluje na ošte ćenje ciljnih organa (koronarna bolest, hipertrofija lijeve klijetke, cerebrovaskularni inzult, mikroalbuminurija) 1,2 . Kuhinjska sol je i čimbenik rizika za nefrolitijazu i osteoporozu.
Kad nabrajamo sve posljedice prekomjernog unosa kuhinjske soli često zaboravljamo pojavu karcinoma probavnog sustava. Znali smo kako je hrana razlog nastanka odre ñenih karcinoma, no nismo znali da je kuhinjska sol tako važan faktor rizika, a posebice nismo bili svjesni kako njen prekomjeran unos dovodi do toliko vrsta karcinoma probavnog sustava. Naj češ ća je pojava karcinoma želuca, no prekomjeran unos soli dovodi i do razvitka nazofaringealnog i kolorektalnog karcinoma te karcinoma jednjaka 1-3.
Navedeni karcinomi probavnog sustava su nastali kao posljedica konzumiranja prezasoljene hrane te uz nekoliko dodatnih faktora rizika dovode do pojave maligne bolesti i sve ve će smrtnosti, ne više samo u zemljama koje oduvijek imaju pove ćanu u čestalost karcinoma probavnog sustava (Japan, Kina) nego i u zemljama koje dosad nisu bilježile takve podatke 1. Karcinom želuca
Karcinom želuca je drugi naj češ ći uzrok smrti od karcinoma i četvrti naj češ ći karcinom u svijetu te je jasno kako je njegova prevencija jedna od postavki moderne medicine. Toj tezi pove ćan unos kuhinjske soli nikako ne pridonosi, naprotiv. Intersalt studija 3 je pokazala kako je viša u čestalost karcinoma želuca u populaciji gdje je prisutan ve ći unos kuhinjske soli. Dokazano je kako sva dosoljavana hrana ili u startu presoljena dovodi do pove ćanog rizika od nastanka karcinoma želuca 4,5 .
Hrana koja sadrži velike koli čine soli (procjena na temelju 24-satne natriurije) dovodi do iritacije želu čane sluznice i do pojavljivanja upale, a ako je ve ć prisutan ulkus na sluznici želuca ili duodenuma veća je šansa nastanka infekcije s Helicobacter pylori koja, znamo, često može dovesti do razvitka malignog procesa želuca 2,4 . Razne instant-juhe, suhomesnati proizvodi, pizza, žitne pahuljice i zasoljena riba je samo dio hrane koju unosimo u organizam a koja dovodi do opasnosti od razvitka karcinoma.
Tako ošte ćena sluznica želuca je podložna i drugim kancerogenim tvarima koje se nalaze u hrani (posebice dimljenoj i prženoj), te u nikotinskom dimu cigareta i alkoholu, uz nezdrav život i obilan stres kao dodatne faktore rizika.
Kontrola unosa soli je od presudne važnosti jer time smanjujemo u čestalost infekcije s H. pylori, a posljedi čno tome i učestalost karcinoma želuca.
Karcinom jednjaka
Karcinom jednjaka je osmi naj češ ći karcinom u svijetu, s naj češ ćim tipom, karcinomom plo častih stanica. Karakteriziran je velikom geografskom rasprostranjenoš ću, od isto čne Turske i sjevernog Afganistana preko centralne i isto čne Azije do južne Afrike i Južne
Amerike. U zapadnoj Europi najve ća u čestalost je u Francuskoj, Portugalu te sjevernoj Italiji. U zapadnim zemljama glavni faktori rizika su pušenje i alkohol te loša prehrana. U manje razvijenim zemljama je prisutan puno ve ći utjecaj loše prehrane, nedostatak svježeg vo ća i povr ća te minerala uz pove ćan unos soli hranom koja na sli čan na čin kao i u karcinomu želuca dovodi do razvitka karcinoma jednjaka 6. Kao dodatan problem u skriningu karcinoma jednjaka name će se kasna pojavnost simptoma te posljedi čno tome kasno otkrivanje i loša prognoza bolesti pa je još bitnije upoznati populaciju s opasnostima pretjerane konzumacije soli i nekvalitetno pripremljene hrane.
Kolorektalni karcinom
Nastanak kolorektalnog karcinoma se povezuje izme ñu ostalog i s pretjeranom konzumacijom konzervirane i dimljene hrane koja je u velikom broju slu čajeva preslana i preza činjena što je često zasluga i prehrambene industrije 7. To je vrsta karcinoma probavnog sustava koji se pojavljuje u starijoj životnoj dobi kada postoji slabljenje regulacijskih mehanizama u sluznici te uz dodatne faktore rizika koji dodatno poništavaju protekciju sluznice dolazi do u čestale pojavnosti te vrlo opasne novotvorine.
Nazofaringealni karcinom
Nazofaringealni karcinom nije toliko čest karcinom, no vrlo je važan jer je još jedan u nizu karcinoma probavnog sustava na čiju pove ćanu pojavnost djeluje pove ćan unos kuhinjske soli posebice ako je prisutan od djetinjstvu 7,8 . Iako je Epstein- Barr virus (EBV) glavni faktor rizika nastanka ovog karcinoma, postoje istraživanja koja dokazuju kako EBV udružen s pove ćanim unosom soli dovodi do još ve će u čestalosti pojavljivanja karcinoma 8. Tu se može povu ći paralela s na činom nastajanja karcinoma želuca te vidimo kako je udruženost djelovanja odre ñenog virusa ili štetnih agensa u hrani s pove ćanim unosom kuhinjske soli zna čajna i pomalo letalna. Za sve navedene karcinome vrijedi pravilo o udruženosti više faktora rizika no to ne umanjuje važnost i opasnost kuhinjske soli u našoj svakodnevnoj prehrani.
Zaklju čak
Kuhinjska sol nedvojbeno utje če na pojavu karcinoma probavnog sustava. Djeluje na sluznicu organa koja postaje podložnija štetnim agensima ili virusima koji onda dovode do razvitka karcinoma. Što je ve ći unos soli viša je i incidencija karcinoma probavnog sustava 2-4. Na žalost ne radi se samo o pojavi karcinoma jednog odre ñenog nego niza organa probavnog sustava. Štetnost prekomjernog unosa kuhinjske soli nije dovoljno poznata našem pu čanstvu te je potrebno razviti široku mrežu informiranja koja će ljudima ukazati na opasnost ne samo od zasoljavanja hrane nego još ve ću opasnost od gotove ili polugotove hrane koja ne odgovara standardima ili dnevnim potrebama unosa soli 1,2 . Tu je izuzetno bitno pokušati posti ći suradnju s prehrambenom industrijom te ozna čiti sve proizvode etiketama koje prosje čne konzumente upozoravaju na koli činu soli što je uspjelo nekim zapadnim zemljama kao Velikoj Britaniji i Finskoj koje su samo u nekoliko godina smanjile dnevnu koli činu soli u svojoj populaciji a posljedi čno tome i sve popratne negativne pojave prekomjernog unosa kuhinjske soli. Isto tako, sve posljedice prekomjernog unosa soli treba prevenirati, a ne lije čiti. Vrlo je važan skrining i kontrola bolesnika koji unose prekomjerne koli čine soli u organizam pomo ću 24-satne natriurije jer time smanjujemo u čestalost karcinoma probavnog sustava, a time naravno i smrtnost, u tom smjeru je krenuo i Nacionalni program za smanjenje prekomjernog unosa soli i CRASH ( Croatian Action on Salt and Health ) 9 .
Dužnost lije čnika je obavijestiti bolesnika o opasnosti, a pomo ću vladinih institucija i uz suradnju s ugostiteljima i proizvo ñačima hrane jasno ozna čiti na proizvodima koli činu NaCl kako bi konzumenti sami mogli odabrati odgovaraju ću namirnicu.
Literatura:
1. Jelakovi ć B, Premuži ć V, Skupnjak B, Reiner Ž. Kuhinjska sol – skriveni otrov u svakodnevnoj hrani. Lije č Vjes. 2009 Svi-Lip;131(5-6):161-2 2. He FJ, MacGregor GA. A comprehensive review on salt and health and current experience of worldwide salt reduction programmes. J Hum Hypertens. 2009;23(6):363-84 3. Joossens JV, Hill MJ, Elliott P i sur. Dietary salt, nitrate and stomach cancer mortality in 24 countries. European Cancer Prevention (ECP) and the INTERSALT Cooperative Research Group. Int J Epidemiol. 1996;25(3):494-504 4. Tsugane S. Salt, salted food intake, and risk of gastric cancer: epidemiologic evidence. Cancer Sci. 2005;96(1):1-6 5. Strumylaite L, Zickute J, Dudzevicius J i sur. Salt-preserved foods and risk of gastric cancer. Medicina (Kaunas). 2006;42(2):164-70. 6. Szumiło J. Epidemiology and risk factors of the esophageal squamous cell carcinoma. Pol Merkur Lekarski. 2009;26(151):82-5 7. Kev TJ, Schatzkin A, Willet WC i sur. Diet, nutrition and prevention of cancer. Public Health Nutr. 2004;7(1A):187- 200 8. Zheng X, Yan L, Nilsson B i sur. Epstein-Barr virus infection, salted fish and nasopharyngeal carcinoma. A case- control study in southern China. Acta Oncol. 1994;33(8):867-72 9. Jelakovi ć B, Kai ć-Rak A, Mili čić D i sur. Manje soli – više zdravlja. Hrvatska inicijativa za smanjenje prekomjernog unosa kuhinjske soli (CRASH). Lije č Vjes. 2009 Ožu-Tra;131(3-4):87-92
Kontakt: Vedran Premuži ć, Zavod za nefrologiju i arterijsku hipertenziju KBC zagreb Kišpati ćeva 12, 10 000, Zagreb, Hrvatska Tel: +385-1-23-88-592; Fax: +385-1-23-67-468 e-mail: [email protected]
UNOS SOLI U SEOSKOJ POPULACIJI U HRVATSKOJ – PROCJENA KORIŠTENJEM JEDNOKRATNO SKUPLJENOG UZORKA MOKRA ĆE
Živka Dika¹, Ivan Pe ćin², Anamarija Kova č Pei ć³, Bojan Jelakovi ć¹
¹Zavod za nefrologiju i arterijsku hiperteziju, Klinika za unutrašnje bolesti; KBC Zagreb, Medicinski fakultet Sveu čilišta u Zagrebu, Zagreb, Hrvatska
²Zavod za bolesti metabolizma, Klinika za unutrašnje bolesti KBC Zagreb, Medicinski fakultet Sveu čilišta u Zagrebu, Zagreb, Hrvatska
³Op ća bolnica „Dr. Josip Ben čevi ć“, Slavonski Brod, Hrvatska
Klju čne rije či: sol, natrij, natrijurija, kaliurija, 24h urin, seoska populacija
Uvod
Prekomjeran unos soli važan je i zna čajan čimbenik rizika za arterijsku hipertenziju, moždani udar, hipertrofiju lijeve klijetke, mikroalbuminuriju, bronhalnu astmu, osteoporozu, nefrolitijazu, i neke zlo ćudne tumore, kao što su rak želuca i nazofarinksa (1-12). Velik broj epidemioloških studija je pokazao da je unos soli danas u svijetu nekoliko puta viši od preporu čenih 5 g dnevno prema trenutno važe ćim smjernicama Svjetske Zdrastvne Organizacije (SZO) (13). Iz navedenog se name će potreba za nekim jednostanim, brzim i jefitinim metodama kojima bi se moglo procjeniti trenutno stanje unosa soli u nekoj populaciji. Dvadeset četiri satni (24h) urin zlatni je standard za odre ñivanje unosa soli (5,13,14). Me ñutim, ova je metoda neprakti čna i teško izvodiva u javnozdrastvenim i velikim epidemiološkim istraživanjima, kao i javnozdravstvenim aktivnostima usmjerenim na sniženje arterijskog tlaka u zajednici. Stoga su Tanaka i sur. (14) utvrdili metodu procjene dnevnog unosa natrija (soli) iz jednokratno skupljenog uzorka urina.
Cilj ovog istraživanja je bio procijena unosa soli u seoskoj populaciji kontinentalne Hrvatske pomo ću Tanaka- Kawasakijeve metode.
Metode
U istraživanju je sudjelovalo 1315 ispitanika, 739 žena i 576 muškaraca, iz pet sela kontinentalne Hrvatske. Ukupni odaziv u ovom istraživanju je bio 75.6%. Istraživanje se provodilo od vrata do vrata. Nakon uzimanja jednokratnog uzorka mokra će, anamnesti čkih podataka i klini čkog pregleda mjerili smo arterijski tlak vode ći se recentnim smjernicama ESH/ESC (15). Koristili smo poluautomatske Omron M6 tlakomjera če. Tako ñer smo mjerili i tjelesnu visinu, masu te opseg struka. (Tablica 1). Prosje čnu 24 satnu natriuriju (EUNa) i kaliuriju (EUK) izra čunali smo koriste ći se Kawasaki- Tanaka formulama u kojima X ozna čava koncetraciju natrija/kalija u mmol/L:
EUNa (mmol/dan) = 21.98 x XNa 0.392
EUK (mmol/dan) = 7.59 x XK 0.431
Unos soli (ENaClI) i natrija (ENaI) procijenili smo koriste ći sljede će formule:
ENaClI (g/dan) = EUNa /17.1; ENaI (g/dan) = EUNa x 23.
Rezultati
Nismo našli razlike u dobi izme ñu muškaraca i žena (53.6±16.9 vs. 55.5±17.3; p>0.05). Ipak, me ñu njima prate se razlike u visini, težini, indeksu tjelesne mase i opsegu struka (p<0.05). Sveukupna EUNa je 151,5 ± 26,8 mmol/dan, a ENaCl i ENa je 8,8 ± 1,5 g/dan i 3.4 ± 0.6 g/dan. EUNa, ENaClI, ENaI bila je viša u muškaraca nego u žena (155,0 ± 24.4 vs .150.28 ± 24,5, 9,06 ± 1,47 vs 8,76 ± 1.50, 3,56 ± 0,56 vs 3,44 ± 0,59). (Tablica 1) Tablica 1 Osnovne demografske osobine ispitanika žene muškarci N 739 576 Dob 55.5 (17.3) 53.6 (16.9) (godine) Tjelesna visina 163.9 (1.1) 175.8 (7.4) (cm) Tjelesna masa 72.2 (15.4) 83.4 (14.9) (kg) Opseg struka 93.5 (16.0) 99.2 (13.4) (cm) Sistoli čki AT 138.9 (25.0) 141.8 (29.0) (mmHg) Dijastoli čki AT 82.3 (12.5) 82.4 (5.7) (mmHg) Prosje čna 24h * 150.28 (24.5) 155.0 (24.4) natrijurija (mmol/d) Prosje čna 24h ** 38.8 (11.9) 41.1 (12.4) Kaliurija (mmol/d) Prosje čni unos soli† 8.76 (1.50) 9.06 (1.47) (g/d) Prosje čni unos natrija†† 3.44 (0.59) 3.56 (0.56) (g/d)______
Navedene vrijednosti su izražene kao srednja vrijednost ± standradna devijacija. N je broj ispitanika; * vrijednosti izra čunate prema formuli: EUNa (mmol/dan) = 21.98 x XNa 0.392 (X-koncentracija natrija u mmol/L); **vrijednosti izra čunate prema formuli: EUK (mmol/dan) = 7.59 x XK 0.431 (X-koncentracija kalija u mmol/L).
†vrijednosti izra čunate prema formuli: ENaClI (g/dan) = e24h Na izlu čivanje/17.1; ††vrijednosti izra čunate prema formuli: ENaI (g/dan) = e24h Na izlu čivanje x 23.
Rasprava
Unos soli u selima kontinentalne Hrvatske je 1.8 puta viši od preporu čenog SZO dnevnog unosa i ve ći je u mušakarac (13). Ovi podaci su u skladu s podacima ve ćine zapadnih zemalja u kojima se unos kre će oko 10g dnevno, dok u neikim isto čnoeuropskim zemaljam i aziji do 15 g/d (16). Postoji nekoliko metoda za procjenu unosa soli i kalija, od kojih se prikupljanje 24-satne mokra će smatra najpouzdanijom jer se najve ći dio natrija i kalija koju osoba unosi izlu čuje mokra ćom, osim u slu čajevima poja čanog gubitka putem gastrointestinalnog trakta ili ekscesivnom perspiracijom. (17). Me ñutim, ova metoda predstvalja zna čajno optre ćenje za ispitanike i teško je prikupiti potpune i precizne 24-satne uzorke mokra će. Postoje podaci prema kojima je udio neuspješno prikupljenih uzoraka ovom metodom oko 40% (18). Stoga, ova metoda nije prikladana za primjenu u javnozdrastvenoj praksi i ve ćim epidemološkim istraživanjima. Tanak i sur. su razvili jednostavnu metodu za procjenu 24-satne natrijurije i kaliurije iz slu čajnog jednokratnog uzorka mokra će. (14) Ova metoda se pokazala prikladnom za uspore ñivanje razli čitih skupina, populacija, i pra ćanja godišnjih kretanja me ñu pojedinim skupinama. Me ñutim, ova metoda nije prikladna za individulane procjene te je u tim slu čajevima potrebno korstiti druge metode, primjerice Kawasakijevu metodu procjene iz drugog jutarnjeg urina (19,20) ili iz 24-satne prikupljene mokra će(17).
U našem istraživanju tako ñer je na ñena uska povezanost unosa soli s indeksom tjelesne mase i vrijednostima arterijskog tlaka. Veliki broj epidemioloških i klini čkih istraživanja je pokazalo da kuhinjska sol izravno utje če na visinu AT, a time i na učestalost AH (1,2,4). Osim toga, kuhinjska sol pove ćava kardiovaskualrni rizik neovisno o AT djeluju ći na bitne procese ateroskleroze aktivacijom simpatikusa, smanjenom sintezom duši čnog oksida u endotelu, aktivacijom trombocita. Uz to, utje če na hipertrofiju glatke i sr čane muskulature, ali i na bubrežnu i sr čanu fibrozu (23,24). Osim toga, opisana je pove ćana u čestalost osteoporoze, bronhalne astme, nefrolitijaze, karcinoma želuca i nazofrainksa s prekomjernim unosom soli (9-12).
Novija intrervencijska istraživanja neupitno pokazala i potvrdila korist smanjenog unosa soli sniženjem ukupne i kardiovaskualrne smrtnosti i pobola (24-29). Mnoge studije su tako ñer pokazale da smanjeni unos soli je isplativiji (30-32) pa su pokrenuti i nacionalni programi za smanjenje prehrambene potrošnje soli u svijetu i u Hrvatskoj. Stoga, nužna je združena akcija svih ljudi, ponajviše javnozdrastvenih djelatnika i lije čnika, s ciljem dobivanja to čnih podataka o konzumiranju soli u Hrvatskoj mjerenjem koli čine natrijurije što se koristilo u ovom istraživanju, edukacije šire populacije o štetnosti prekomjernog unosa soli naro čito u pojedinim dobnim skupinama- starije osobe i djeca i to aktivnim uklju čivanjem vlade i prehrambene industrije u ovaj program za zdravije, neslanije sutra (33).
Literatura
1.Gleibermann L. Blood pressure and dietary salt in human populations. Ecol Food Nutr. 1973;1:143-56. 2. Cappuccio FP. Salt and cardiovascular disease. BMJ 2007;334:859-60.
3. Nagata C, Takatsuka N, Shimizu N, Shimizu H. Sodium intake and risk of death from stroke in Japanese men and women. Stroke 2004;35:1543-7.
4. Umesawa M, Iso H, Date C, Yamamoto A, Toyoshima H,Watanabe Y, et al. Relations between dietary sodium and potassium intakes and mortality from cardiovascular disease: the Japan collaborative cohort study for evaluation of cancer risks. Am J Clin Nutr 2008;88:195-202.
5. KupariM, Koskinen P, Virolainen J. Correlates of left ventricular mass in a population sample aged 36 to 37 years. Focus on lifestyle and salt intake. Circulation 1994;89:1041-50.
6. Verhave JC, Hillege HL, Burgerhof JG, Janssen WM, Gansevoort RT, Navis GJ, et al. Sodium intake affects urinary albumin excretion especially in overweight subjects. J InternMed 2004;256:324-30.
7. Antonios T, MacGregor G. Salt intake : potential deletirous effects excluding blood pressure. J Hum hypert 1995;9:511- 15.
8. Strumylaite l, Zickute J, Duzdevicius J, Dregval L. Salt-preserved foods and risk of gastric cancer. Medicina (Kaunas) 2006;42:164-70.
9. Martini LA, Cuppari L, Colugati FAB,. High sodium chloride intake is associated with low bone density in calcium stone- forming patinets. Clin Nephrol 2000;54:85-9.
9. Frasseto L, Curtis morris RJ, sellmayer DE, Sebastian A. Adverse effects of sodium chloride on bone in the aging human population resulting from habitual consumption of typical american diets. J Nutr 2008;138(2).419s-422S
10. Tsugane S. Salt , salted food inatek, and risk of gastric cancer: epidemiologc evidence. Cancer Sci 2005;95:1-6.
11.Sjodahl K, Jia C, vatten L et al. Salt and gastric adenocarcinoma: a population-based cohort study in Norway. Cancer Epidemiol Biomarkers Prev 2008,17:1997-2001.
12. Borghi L, Meschi T, Maggiore U, Prati B. Dietary therapy in idiopathic nephrolithiasis. Nutr rev 2006;64:301-12.
13. World Health Organization. Reducing salt intake in populations: report of a WHO forum and technical meeting. WHO, 2007:1-60.
14. Tanaka T, Okamura T, Miura K, Kadowaki T, Ueshima H, Nakagawa H et al. A simple method to estimate populational 24-h urinary sodium and potassium excretion using a casaul urine specimen. J Hum Hypert 2002;16:97-103.
15. 2007 Guidelines for the Management of Arterial Hypertension The Task Force for the Management of Arterial Hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC) J Hypertens. 2007;25:1105 -1187.
16. Strazzullo P, D’Elia L, Kandala NB, Cappuccio F. Salt intake, stroke, and cardiovascular disease: metaanalysis of prospective studies. BMJ 2009;339:b4567.
17. Holbrook JT et al. Sodium and potassium intake and balance in adults consuming self-selected diets. Am J Clin Nutr 1984;40:786-793.
18. Mori T et al. Health education using 24-hour urine colection. Nippon Koshu Eisei Zasshi 1987;34:282 (in Japanese (apstrakt)
19. Kawasaki T, Itoh K, Uezono K, Sasaki H. Estimation of 24-hour urinary sodium and potassium excretion from predicted value of 24-hour urinary creatinine excreation and fractional urine sodium/creatinine and potassium/ creatinine ratio. In: Seventh symopsium on Salt, Vol.2 Elsevier Science Publishers B.V.: Amsterdam, 1993, pp 257-262.
20. The INTERSALT Co-operative research group. INTERSALT STUDY. An international co-operative study on realtion of blood pressure to electrolyte excretion in populations. I. Design and methods. J Hypertens 1986;4:781-787.
21. Gow I, padfield P, Reid M, Stewart S, Edward C, williams B. High sodium intake increases platelet aggregation in normal females. J Hypert 1985;7:972-8.
22. Ferri C, Bellini C; desideri G, mazzocchi C, De Siati L, Santucci A. Elevated plasma and urinary endothelin-1 levels in human salt-sensitive hypertension. Clin Sci 1997;93:35-41. 23.Schmeiser R, Langenfield M, Friedrich A, Schobel H, Gatzka C, Weihprecht H. Angiotensin ii releated to sodium excretion modulates left ventricular structure in human essential hypertension. Circulation 1996; 94:1304-9.
24. Yu H, Barell L, Black M. Salt induced myocardial and renal fibrosis in normotensive and hypertensive rats. Circulation 1998;98:2621-8.
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26. He FJ, MacGregor GA. Effect of modest salt reduction on blood pressure: a meta-analysis of randomized trials. Implications for public health. J Hum Hypertens 2002;16:761-70.
27. AldermanMH, Cohen H, Madhavan S. Dietary sodium intake and mortality: the national health and nutrition examination survey (NHANES I). Lancet 1998;351:781-5.
28. He J,Ogden LG, Vupputuri S,Bazzano LA, Loria C, Whelton PK. Dietary sodium intake and subsequent risk of cardiovascular disease in overweight adults. JAMA 1999;282:2027-34.
29. Cook NR, Cutler JA, Obarzanek E, Buring JE, Rexrode KM, Kumanyika SK, et al. Long term effects of dietary sodium reduction on cardiovascular disease outcomes: observational follow-up of the trials of hypertension prevention (TOHP). BMJ 2007;33:885-8.
30. Selmer RM, Kristiansen IS, Haglerod A, Graff-Iversen S, Larson HK, Meyer HE, et al. Cost and health consequences of reducing the population intake of salt. J Epidemiol Community Health 2000;54:697-702.
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Kontakt:
Dr. Živka Dika,
Zavod za nefrologiju i arterijsku hipertenziju, KBC Zagreb, Kišpati ćeva 12, 10000 Zagreb; Tel. 385 1 2388 271
UNOS SOLI, METABOLI ČKI SINDROM I PRETILOST
(Hrvatska Nacionalna Kampanja za Smanjenje Unosa Kuhinjske Soli (CRASH))
Ivan Pe ćin¹, Željko Reiner¹, Bojan Jelakovi ć²
¹ Zavod za bolesti metabolizma, Klinika za unutrašnje bolesti KBC Zagreb, Medicinski fakultet Sveu čilišta u Zagrebu, Zagreb, Hrvatska
² Zavod za nefrologiju i arterijsku hiperteziju, Klinika za unutrašnje bolesti; KBC Zagreb, Medicinski fakultet Sveu čilišta u Zagrebu, Zagreb, Hrvatska
Klju čne rije či: sol, metaboli čki sindrom, pretilost
Uvod
Dobro je poznato kako je visok unos kuhinjske soli važan faktor rizika za bubrežne i kardiovaskularne bolesti. No svjesnost o navedenom nije još dosegla željenu razinu kako u op ćoj populaciji tako i u bolesnika koji boluju od navedenih bolesti. Metaboli čki sindrom i komponente koje ga čine (arterijska hipertenzija, intolerancija glukoze, dislipidemija, pretilost) važan je faktor rizika za nastanak kardiovaskularnih bolesti. Rezultati nekih recentnijih studija ukazuju kako su prekomjerna konzumacija kuhinjske soli i metaboli čki sindrom usko povezani. S obzirom na navedeno, ovom pilot studijom, koja je dio Nacionalnog programa za smanjenje unosa kuhinjske soli (CRASH-Croatian Action on Salt and Health), pokušali smo istražiti koliko je okviran unos soli u ispitivanoj populaciji te odrediti povezanost izme ñu unosa soli i metaboli čkog sindroma.
Ispitanici i metode
U ovu studiju uklju čili smo 93 randomiziranih ispitanika odrasle dobi (dob 46.32+/-7.38 godina) iz dvije ambulante obiteljske medicine (jedna seoska, druga gradska). Po uzimanju anamesti čkih podataka i klini čkog statusa(pregleda) uz pomo ć poluautomatskih tlakomjera ča marke OMRON(M6), a vode ći se recentnim smernicama ESH/ESC, izmjerene su tri vrijednosti arterijskog tlaka (koriste ći iste izra čunali smo srednju vrijednost arterijskog tlaka). Uzevši osnovne antropometrijske mjere (tjelesne visine i težine, te opsega struka), odredili smo indeks tjelesne mase (ITM). Iz 24 satnog urina odredili smo natriuriju (Nau), kaliuriju i kreatinin. Pri definiciji metaboli čkog sindroma vodili smo se recentnim smjernicama NCEP-ATP III (Centralna pretilost(opseg struka ≥ 102 cm (muškarci), ≥ 88 cm (žene)); dislipidemija: TG ≥ 1.695 mmol/L; HDL-C < 40 mg/dL (muškarci), < 50 mg/dL (žene); arterijski tlak ≥ 130/85 mmHg; glukoza na tašte ≥ 6.1 mmol/L.)
Rezultati
Metaboli čki sindrom(MS) dijagnosticiran je u 29/92 ispitanika(31.5%)(slika1.), (14/29 muškaraca i 15/37 žena). Uz razlike u svim sastavnicama metaboli čkog sindroma (uklju čuju ći arterijski tlak), zna čajne smo razlike našli me ñu potskupinama MS i ne-MS u dobi (p=0.005) i natriuriji (235.4±93.3 vs. 192.6±57.2; p=0.032)(slika 2.). Razlike u dobi i natriuriji na ñene su u žena no ne i u muškaraca. Na ñena je (u cijeloj skupini) i zna čajna povezanost (p<0.05) izme ñu natriurije i indeksa tjelesne mase, še ćera u krvi, uri čne kiseline, ukupnoga kolesterola, LDL kolesterola, triglicerida (r=0.32; 0.51; 0.35;0.53; 0.27;0.43, p<0.05). U muškaraca ta povezanost prati se izme ñu natriurije i opsega struka, uri čne kiseline, ukupnog kolesterola, LDL kolesterola, triglicerida (r=0.44;0.64;0.58;0.48;0.56, p<0.05), dok u žena povezanost je zna čajna za opseg struka i še ćer u krvi (r=0.44;0.38, p<0.05). 48 46 44 42 40 38 36 metaboli čki sindrom muškarci žene
Slika1. Metaboli čki sindrom dijagnosticiran u 31.5% ispitanika
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0 NaU 24h MS ne MS
Slika 2.Ispitanici sa metaboli čkim sindromom konzumiraju ve će koli čine soli. Iskazano u 24h-om natriurijom.
Zaklju čak
Iz rezultata naše pilot studije razabire se kako je unos soli viši u ispitanika sa metaboli čkim sindromom. Promatrana i prikazana povezanost izme ñu unosa soli i sastavnica metaboli čkog sindroma govori u prilog kako su o čito metaboli čki sindrom i povišen unos soli usko povezani. No isto tako prati se gotovo dva puta viši unos soli (oko12g/dan!) od preporu čenog u ispitanika koji ne spadaju u skupinu metaboli čkog sindroma. To nam ukazuje, a s obzirom na današnje spoznaje, da su to ispitanici koji su tako ñer pod pove ćanim rizikom za kardiovaskularne bolesti. Iako se za sada još ne uklapaju u klaster metaboli čkog sindroma oni su tako ñer pod povišenim rizikom, jer je poznato kako je unos soli „per se“ faktor rizika u pobolu od kardiovaskularnih bolesti. Bez obzira na neke razlike me ñu našim ispitanicima, a s obzirom na spol, potrebne su rigorozne promjene u čitavoj populaciji uz posebnu naznaku na što raniju prevenciju.
Kontakt:
Ivan Pe ćin, dr. med
Klini čki bolni čki centar Zagreb
Zavod za bolesti metabolizma
Tel: 01/2388-747
Mail: [email protected]
SOL U PREHRANI ŠKOLSKE DJECE
Antoinette Kai ć-Rak 1, Katica Antoni ć-Dega č2, Jasna Pucarin-Cvetkovi ć3, Inge Heim 4, Benedict Rak 5
¹Ured SZO u Hrvatskoj
²Hrvatski zavod za javno zdravstvo
³ŠNZ "Andrija Štampar", Medicinski fakultet Sveu čilišta u Zagrebu
4Poliklinika za prevenciju i rehabilitaciju kardiovaskularnih bolesti, Zagreb
5Medicinski fakultet Sveu čilišta u Zagrebu - student
Sažetak
Pove ćani unos soli u organizam predstavlja rizi čni čimbenik za razvoj kardiovaskularnih bolesti te pojavu hipertenzije ve ć u adolescentnoj dobi, kao i nastanak drugih kroni čnih nezaraznih bolesti.
U prevenciji kroni čnih nezaraznih bolesti prema preporukama Svjetske zdravstvene organizacije (SZO) dnevni unos soli ne bi smio biti ve ći od 5 g/dan (< 2g Na). U Hrvatskoj se procjenjuje da ukupni dnevni unos soli u populaciji školske djece iznosi oko 9 g/dan. Na temelju dosadašnjih rezultata istraživanja o prehrambenim navikama školske djece u razli čitim regijama u Hrvatskoj utvr ñeno je da postoje zna čajne razlike u u čestalosti potrošnje suhomesnatih proizvoda, mlijeka i mlije čnih proizvoda, namaza, svježeg vo ća i povr ća, dok nema zna čajnih razlika u konzumaciji slatkiša i grickalica Rezultati dosadašnjih ispitivanja mogu poslužiti kao temelj za ocjenu kvalitete prehrane i prehrambenog stanja školske populacije te bi se trebali uzeti u obzir prilikom donošenja odluka o potrebi provo ñenja javnozdravstvenih programa u skladu sa nacionalnom prehrambenom politikom i akcijskim planom za hranu i prehranu. Nadalje, izuzetno je važno poticati suradnju roditelja i škole na unapre ñenju prehrane u čenika te educirati djecu o važnosti pravilne prehrane kako kroz nastavne programe tako i na prakti čnim primjerima. Potrebno je usmjeriti aktivnosti prema suradnji sa prehrambenom industrijom u cilju smanjenja sadržaja soli tj. natrija u proizvodnom procesu te uvo ñenju zakonske regulative s ciljem ozna čavanja sadržaja natrija na deklaraciji proizvoda. Nužno je i provoditi zdravstveno odgojne mjere na podru čju promicanja pravilne prehrane, s ciljem da se smanji potrošnja onih industrijskih proizvoda bogatim natrijem kao i dodavanje soli tijekom pripreme i konzumacije obroka.
Klju čne rije či: sol, prehrana, školska djeca Uvod
Suvremeni na čin života zna čajno utje če na na čin prehrane. Pove ćana je potrošnja industrijski pripremljene hrane, a potrošnja hrane izvan doma je sve u čestalija. Djeca i mladež vrlo često konzumiraju namirnice i hranu pripremljenu u restoranima brze hrane. Takvi obroci uglavnom sadrže dosta masti, ugljikohidrata, še ćera i soli. a manje prehrambenih zaštitnih tvari pa za njih možemo re ći da su energetski bogati, ali biološki manje vrijedni. Upravo je školska dob djece razdoblje intenzivnog rasta i razvoja kada je od osobite važnosti osigurati djeci pravilnu prehranu. Pravilna prehrana u adolescentnoj dobi doprinosi postizanju potencijalnog rasta i optimalnom zdravlju te smanjuje rizik nastanka kroni čnih bolesti u odrasloj dobi (1, 2). Problem prevelikog unosa soli jedan je od vode ćih javnozdravstvenih problema i predstavlja izazov zdravstvenoj struci ali cjelokupnoj zajednici. Glavni izvori natrija u prehrani su industrijski proizvodi (77%), prirodni sadržaj natrija u namirnicama (12%), dosoljavanje tijekom konzumacije objeda (6%) i pripreme obroka kod ku će (5%) (3). Pri tome je nužno naglasiti i u čestalost konzumacije obroka izvan ku će.
U prevenciji kroni čnih nezaraznih bolesti prema preporukama Svjetske zdravstvene organizacije (SZO) dnevni unos soli ne bi smio biti ve ći od 5 g/dan (< 2g Na) (4). U Hrvatskoj se procjenjuje da ukupni dnevni unos soli u populaciji školske djece iznosi oko 9 g/dan. Pove ćani unos soli u organizam predstavlja rizi čni čimbenik za razvoj kardiovaskularnih bolesti te pojavu hipertenzije ve ć u adolescentnoj dobi, kao i nastanak drugih kroni čnih nezaraznih bolesti. Istraživanja prehrambenih navika školske djece u kontinentalnom i priobalnom podru čju RH kao i procjena dnevnog unosa soli provedena je primjenom metodologije u skladu sa EFCOVAL preporukama. U populaciji djece u dobi od 7-15 godina provedeno je ispitivanje prehrambenih navika upitnikom o u čestalosti potrošnje namirnica, dok je metodom ocjene potrošnje hrane u 24 sata procijenjen unos soli (natrija) u razli čitim regijama. Ispitivanje prehrambenih navika školske djece provedeno je me ñu u čenicima šestih i sedmih razreda osnovnih škola u kontinentalnom (Zagreb, Osijek, Kostajnica) i priobalnom podru čju (Rijeka). U svakoj školi ispitano je 24 u čenika (12 djevoj čica i 12 dje čaka), ukupno 96 učenika. Za izra čunavanje cjelodnevnog unosa energije, makro i mikro nutrijenata korišten je kompjutorski program "HRANA" koji se temelji na podacima nacionalne baze o sastavu namirnica i pi ća. Za procjenu prosje čnog dnevnog unosa soli korištena je formula NaCl=Na x 2,5. Analizom cjelodnevnih obroka školske populacije na ispitivanim podru čjima utvr ñen je prosje čni dnevni unos soli oko 9 grama (3,6 g Na) u prehrani školske djece (Tablica 1). Gotovo polovica (42-49%) konzumirane soli unese se konzumiranjem kruha i pekarskih proizvoda. U čestalost potrošnje suhomesnatih proizvoda (3-6 x tjedno) je zna čajna kako u kontinentalnom dijelu (65,6%) tako i u priobalnom podru čju (51,7%). Prehrambene navike tako ñer ukazuju i na u čestalost potrošnje slanih grickalica u školske djece u ispitivanim podru čjima. Istovremeno djeca u priobalnom podru čju češ će konzumiraju vo će, a rje ñe povr će u odnosu na djecu u kontinentalnom podru čju (Tablica 2) (5).
Tablica 1. Prosje čan dnevni unos energije, natrija, soli i kalija u cjelodnevnim obrocima školske djece u dobi od 7-15 godina*
SVAKI DAN 3-6 X 1-2 X 2-3 X ≤ 1 X % TJEDNO TJEDNO MJESE ČNO MJESE ČNO VRSTA NAMIRNICE % % % % dal kon dal kon dal kon dal kon dal kon Mlijeko, jogurt, kis. vrhnje 79,3 46,9 13,8 37,5 3,4 15,6 0 0 0 0 Sir (svježi, trapist, namaz) 37,9 3,1 48,2 31,3 10,3 50,0 0 9,4 3,4 6,2 Jaja 0 3,1 48,3 31,3 48,3 56,3 3,4 6,2 0 3,1 Meso i perad 6,8 3,1 65,6 59,4 27,6 37,5 0 0 0 0 Riba 0 0 17,2 3,1 51,7 68,8 17,2 15,6 13,8 12,5 Kobasice, naresci 17,2 9,4 51,7 65,6 24,1 18,8 3,4 6,2 3,4 0 Slanina 0 3,1 0 18,8 31,0 34,4 20,8 9,4 48,2 37,4 Pašteta 0 3,1 13,8 21,9 37,9 37,5 20,8 9,4 27,5 28,1 Namazi 24,1 12,5 51,7 62,5 17,2 21,9 3,4 3,1 3,4 0 Povr će: 6,8 21,9 75,9 53,1 10,5 18,8 3,4 0 3,4 6,2 lisnato korjenasto 3,4 6,2 27,7 40,6 37,9 46,9 13,8 0 17,2 6,2 ukiseljeno 0 0 3,4 3,1 48,3 56,3 17,2 6,2 31,1 34,4 Krumpir 17,2 15,6 72,4 71,8 10,4 12,6 0 0 0 0 Mahunarke 0 0 10,3 21,9 65,6 56,2 20,7 12,5 3,4 9,4 Tjestenina, riža 0,0 0 41,3 40,6 37,9 59,4 17,2 0 3,4 0 Kola či, keksi 20,8 18,8 34,5 46,8 31,0 31,3 10,3 3,1 3,4 0 Vo će svježe 72,4 40,6 27,6 40,6 0 12,5 0 3,1 0 3,1 Vo ćni sokovi: 13,8 18,8 34,5 21,9 24,1 21,9 0 3,1 27,4 34,4 prirodni Vo ćni sirupi 34,5 34,4 48,3 34,4 6,9 12,6 3,4 0 6,9 18,6 Vitaminski napici 10,3 12,5 31,0 28,1 24,1 25,0 10,5 3,1 24,1 31,3 Gazirana pi ća 6,8 3,1 13,8 31,3 37,9 43,8 24,1 6,2 17,2 15,6 Slatkiši 20,9 28,1 34,4 56,2 37,9 15,6 3,4 0 3,4 0 Grickalice 10,3 12,5 44,8 50,0 41,4 31,3 3,4 3,1 17,2 3,1 Sladoled 3,4 0 24,2 31,2 20,7 43,8 13,8 3,1 37,9 21,9
Izvor: HINEKA 2009; 24: 103.
Tablica 2. Učestalost potrošnje pojedinih namirnica u dalmatinskom i kontinentalnom podru čju RH - % školske djece
Na NaCl K Mjesto kcal (g) (g) (mg) OSIJEK/ JOSIPOVAC 2,443 3,727 9,3 2,792 RIJEKA 2,370 4,028 10,1 3,394 KOSTAJNICA 2,303 3,735 9,4 3,103 ZAGREB 2,244 2,732 6,8 3,110 Prosje čni dnevni unos 2,340 3,556 8,9 3,070 Raspon prosje čnog 6,8-10,1 2,244 -2,443 2,732 - 4,028 2,951 -3,394 dnevnog unosa
Izvor: HINEKA 2009; 24: 103
Rasprava Prehrambene navike, na čin pripreme hrane i dosoljavanje tijekom jela uzroci su prekomjernog unosa soli, pri čemu treba posebice istaknuti tzv. „prikrivene izvore soli“. Zna čajan izvor soli u našoj prehrani su industrijski obra ñene namirnice i hrana pripremljena u restoranima brze prehrane, kruh i drugi pekarski proizvodi, tjestenina, konzervirano vo će i povr će, suhomesnati proizvodi, sir, dehidrirane juhe, koncentrati, za čini, itd. (6-8). Na temelju dosadašnjih rezultata istraživanja o prehrambenim navikama školske djece u Hrvatskoj utvrdilo smo da postoje zna čajne razlike u u čestalosti potrošnje suhomesnatih proizvoda, mlijeka i mlije čnih proizvoda, namaza, svježeg vo ća i povr ća, dok nema zna čajnih razlika u konzumaciji slatkiša i grickalica (5). Osim obroka kod ku će i u školi djeca često konzumiraju namirnice koje sami kupuju. Takvi me ñuobroci uglavnom se svode na slatkiše, slane grickalice i zasla ñene napitke. Na žalost, propuštene obroke kod ku će ili u školi, djeca nadomještaju sendvi čima u bijelom pecivu, komadom pizze, hamburgerima, hot dogom, vru ćim krumpiri ćima i sli čno. Bez obzira radi li se o hrani iz restorana brze prehrane ili industrijski obra ñenim namirnicama poput grickalica, uglavnom može se re ći da se radi o namirnicama sa visokim sadržajem soli. U čenicima se često nude i namirnice iz automata u školi (slatkiši, grickalice, zasla ñeni napici). Odabir namirnica vrlo često ovisi o stavu prijatelja kao i agresivnim reklamama upu ćenim djeci. Imaju ći u vidu spomenute prehrambene navike, ne iznena ñuje činjenica da je ukupan dnevni unos soli u populaciji školske djece gotovo dvostruko viši u odnosu na preporu čene vrijednosti. Zaklju čci
Ovi rezultati ispitivanja mogu poslužiti kao temelj za ocjenu kvalitete prehrane i prehrambenog stanja školske populacije te bi se trebali uzeti u obzir prilikom donošenja odluka o potrebi provo ñenja javnozdravstvenih programa u skladu sa nacionalnom prehrambenom politikom i akcijskim planom za hranu i prehranu (9-11). Nadalje, izuzetno je važno poticati suradnju roditelja i škole na unapre ñenju prehrane u čenika te educirati djecu o važnosti pravilne prehrane kako kroz nastavne programe tako i na prakti čnim primjerima. Potrebno je usmjeriti aktivnosti prema suradnji sa prehrambenom industrijom u cilju smanjenja sadržaja soli tj. natrija u proizvodnom procesu te uvo ñenju zakonske regulative s ciljem ozna čavanja sadržaja natrija na deklaraciji proizvoda. Nužno je i provoditi zdravstveno odgojne mjere na podru čju promicanja pravilne prehrane, s ciljem da se smanji potrošnja onih industrijskih proizvoda bogatim natrijem kao i dodavanje soli tijekom pripreme i konzumacije obroka. Literatura
1. World Health Organization. Food and health in Europe: a new basis for action. Geneva: WHO, 2004. 2. The world health report 2002: Reducing risks, promoting healthy life. Geneva: WHO, 2002. 3. Mattes RD, Donnelly D. Relative contributions of dietary sodium sources. J Am Coll Nutr 1991; 10: 383-93. 4. World Health Organization. Reducing salt intake in populations. Report of a WHO Forum and Technical meeting. Geneva: WHO, 2007. 5. Antoinette Kai ć-Rak A, Pucarin-Cvetkovi ć J , Dega č Antoni ć K , Laido Z. Unos soli u prehrani školske djece u RH. HINEKA.2009; 24: 103. 6. Kai ć-Rak A, Antoni ć K. Tablice o sastavu namirnica i pi ća. Zavod za zaštitu zdravlja RH, 1990. 7. Hrvatski zdravstveno-statisti čki ljetopis za 2003.godinu. Zagreb: Hrvatski Zavod za javno zdravstvo; 2004: 343-8. 8. Antoni ć Dega č K, Kai ć-Rak A, Mesaroš-Kanjski E, Petrovi ć Z. Capak K. Stanje uhranjenosti i prehrambene navike školske djece u Hrvatskoj. Pediatr Croat 2004; 48: 9-15. 9. WHO Global Strategy on Diet, Physical Activity and Health. http://www.who.int/gb/ebwha/pdf_files/WHA57/A57_R17- en.pdf 10.Hrvatski zavod za javno zdravstvo. Prehrambene smjernice za djecu. Zagreb: Kratis; 2003. 11. Antoni ć Dega č K i suradnici. Hrvatska prehrambena politika. Zagreb: Hrvatski zavod za javno zdravstvo 1999.
Kontakt adresa:
Prof.dr.sc. A. Kai ć-Rak
Svjetska zdravstvena organizacija-Ured u RH
Radni čka cesta 41
10 000 Zagreb, Hrvatska
Tel: 01 23 29 618
Fax: 01 23 29619
E-mail: [email protected]
KOLI ČINA SOLI U HRVATSKIM PEKARSKIM PROIZVODIMA
Žaneta Ugar čić-Hardi 1, Gabrijela Duman čić2, Daliborka Koceva Komleni ć1, Marko Juki ć1
1Prehrambeno-tehnološki fakultet Osijek Sveu čilišta u Osijeku, F. Kuha ča 20, Osijek
2Zavod za javno zdravstvo osje čko-baranjske županije, F. Krežme 1, Osijek
Klju čne rije či: smanjenje unosa soli, pekarski proizvodi
Visoki krvni tlak je glavni uzro čni čimbenik sr čanih bolesti i moždanog udara, koji može biti uspješno smanjen redukcijom unosa natrija (preko kuhinjske soli) u prehrani. Unos soli za stanovništvo diljem Europe, pa tako i Hrvatske, je visok i premašuje koli čine potrebne za normalno funkcioniranje. Prosje čan unos soli u svijetu iznosi oko 10-13 g/dan, a u Hrvatskoj i više. Preporuke svjetske zdravstvene organizacije su 5-6 g/dan.
Kako unosimo sol?
Oko 20% ukupnog dnevnog unosa soli unosi se namirnicama koje sadrže sol (jaja, meso, riba i sl.). 15% soli se unosi naknadnim dosoljavanjem, a približno 70% soli unosi se putem gotovih namirnica u kojima ne znamo koliko soli sadrže. To je tzv. „skrivena sol“, a dolazi u pekarskim i mesnim proizvodima, sirevima, gotovim juhama i umacima, konzerviranom povr ću i dr. i naravno u jelima koja se poslužuju u ugostiteljskim objektima. Na taj unos soli putem prehrambenih proizvoda, tj. gotove i polugotove hrane pojedinac nema utjecaja, osim na na čin da ju prestane uzimati. Iz tih razloga u svijetu su pokrenute mnoge nacionalne akcije za smanjenjem unosa kuhinjske soli, u koje je uklju čena i prehrambena industrija.
Velika Britanija je prva zapo čela kampanju za smanjenje potrošnje kuhinjske soli 1994. godine s ciljem smanjenja unosa soli s tadašnjih 12-tak grama na 6 g do 2010. godine. Kasnije su se ovoj akciji pridružile i Irska, Nizozemska, Njema čka, Austrija, Danska, Francuska i Švicarska. Akcija je dobrovoljna, ali su mnogi proizvo ñači shvatili važnost ove inicijative i uklju čili se u velikom broju.
U Hrvatskoj je ova inicijativa pokrenuta na Prvom hrvatskom kongresu o hipertenziji (2006.), te je dobila potpunu potporu medicinskih stru čnjaka. Me ñutim, za provedbu ove inicijative neophodno je uklju čivanje prehrambene industrije. Proizvo ñači pekarskih proizvoda prvi su se uklju čili u ovu akciju o kojoj su dobili informacije na me ñunarodnom kongresu Brašno-Kruh '07, te na Festivalu kruha održanom u listopadu 2007. godine. Prema nekim istraživanjima unos kuhinjske soli preko kruha i pekarskih proizvoda iznosi od 25 do 30%. Ovaj udio je znatno pove ćan ponudom pekarskih proizvoda koji su još dodatno posipani solju (slika 1. i 2.). Najve ći potroša či takvih proizvoda (kifle, perece) je mla ña populacija, kod kojih se onda još od djetinjstva stvara navika na slani okus. Tako ñer treba spomenuti i druge pekarske proizvode, kao pite, burek, piroške s razli čitim nadjevima, koji su često preslani.
Slika 1. Pecivo premazano suspenzijom Slika 2. Pecivo posuto krupnom solju brašna i soli
Zašto se dodaje sol?
Primarna upotreba soli je poboljšanje okusa pekarskih proizvoda. Osim utjecaja na okus dodatak soli ima i tehnološki aspekt. Utje če na razvoj glutena, reologiju tijesta i brzinu fermentacije. Me ñutim, iako dodatak soli utje če na okus i tehnološka svojstva proizvoda, istraživanja pokazuju da bi se njegov dodatak u standardne pekarske proizvode mogao smanjiti do 25% bez zna čajnijeg utjecaja na kakvo ću proizvoda.
Koli čina dodane soli u pekarskim proizvodima se razlikuje u pojedinim zemljama i iznosi 1-2%. U Hrvatskoj iznosi ∼2%, što zna či da se dodaje 20 g soli na 1 kg brašna (=13 g/kg kruha, 5g natrija/kg kruha). Budu ći da udio soli u pekarskim proizvodima varira u zavisnosti od proizvo ñača i vrste proizvoda, potrebno je utvrditi stvarni udio soli u pekarskim proizvodima na hrvatskom tržištu. U tablicama 1, 2, 3, i 4 prikazani su rezultati analiza udjela soli u razli čitim vrstama kruha, pecivu, proizvodima s razli čitim nadjevima i pekarskim smjesama na podru čju Slavonije i Baranje. Tablica 1. Udio soli u razli čitim vrstama kruha
Udio soli Vrsta kruha (%) 1. Pšeni čni francuski kruh 1,75 2. Pšeni čna uskršnja pletenica 1,41 3. Kruh sovital 1,79 4. Pšeni čni vodeni kruh 1,49 5. Kruh krunovit 1,57 6. Kruh Drava vital 1,31 7. Obiteljski kruh 1,30 8. Samostansko sunce I 1,90 9. Samostansko sunce II 2,01 10. Bakina mješavina 1,01 11. Kruh s lukom 0,96 12. Corn baguette 1,76 13. Bijeli kruh s inulinom 1,29 14. Bijeli kruh extra 1,52 15. Bijela ciabatta 1,73 16. Bijeli kruh 1,58 17. Žur veknica 2,02 18. Bijeli kruh 1,58 19. Bijeli – Retfala 1,03 20. Bijeli – Plodine 2,05 21. Crni – Plodine 1,61 22. Baguette – Jug II 1,84 23. Vodeni kruh - Kruna 1,29 Srednja vrijednost 1,56
Tablica 2.Udio soli u pecivu
Udio soli (%) Uzorak Neslana Prsti ći Perec Štapi ć Kifla Slanac kifla 1. 4,76 3,04 5,98 2,04 2,28 2,10 2. 2,20 2,41 2,60 2,40 2,53 1,89 3. 2,08 2,14 2,51 2,34 4. 2,45 3,44 2,71 5. 2,17 4,57 6. 2,26 Srednja 2,73 2,98 3,70 2,37 2,41 2,00 vrijednost
Udio soli u pojedinim vrstama kruha varira od 0,96 do 2,05%, a prosje čni udio soli iznosi 1,56% što je previsoko (tablica 1). To zna či, ako se pojedu samo 2 šnite kruha dnevno ( ∼100 g) unese se 1,56 g soli, a kod slanog peciva i nadjevenih proizvoda taj udio je znatno ve ći (tablica 2 i 3). Npr., ako se konzumira 1 slana pereca ( ∼70 g) unese se 2,09 g soli, što iznosi 1/3 ukupno potrebne koli čine sol (6g).
Tablica 3. Udio soli u nadjevenim pekarskim proizvodima
Udio soli Vrsta kruha (%) 1. Puž – sir i šunka 1,60 2. Burek – meso 2,49 3. Preklopljena pizza 2,70 4. Burek – sir 2,44 5. Kifla – šunka i sir 1,88 6. Kukuruzna piroška – punjenje: pizza 1,29 7. Kifla – šunka 2,21 8. Kifla – sir 2,09 9. Piroška – sir 1,65 10. Piroška – hrenovka 1,75 11. Trokut – šunka i sir 2,92 12. Čamac – sir 1,80 13. Prsti ći – sir 1,78 14. Čamac – sir i hrenovka 2,14 15. Piroška- šunka i sir 1,82 16. Kifla s hrenovkom 1,69 17. Topli sendvi č 1,46 18. Piroška sa sirom – pohana 1,06 19. Sfrknuta kifla posuta sirom 2,06 20. Kroasan punjen šunkom 1,95 Srednja vrijednost 1,94
U današnje vrijeme za proizvodnju pojedinih pekarskih proizvoda postoje gotove smjese i koncentrati, koji sadrže brašno i odre ñene potrebne dodatke i dodaju se u iznosu od 10 do 50% u zamjes, a tako ñer sadrže visok udio natrija (tablica 4). 1 g soli odgovara koli čini od 400 mg natrija.
Tablica 4. Udio kalcija, natrija i kalija u gotovim smjesama za pekarstvo
Ca Na K Uzorak (mg/100 g) (mg/100 g) (mg/100 g) 1. 156,18 460,78 102,94 2. 179,35 484,34 489,24 3. 126,61 547,95 128,18 4. 121,37 1011,45 763,36 5. 142,26 108,99 664,44 Srednja 145,15 522,70 429,63 vrijednost
Plamena AAS, Perkin_Elmer b1100
Vrlo je važno promijeniti prehrambene navike potroša ča vezane uz konzumaciju soli, te su mnoge zemlje u svijetu postavile za cilj postupnu redukciju soli u pekarskim proizvodima, prvo za 10-15%, a zatim nakon odre ñenog vremenskog razdoblja do 25% (1,5 g/100 g brašna). Ovaj na čin redukcije soli u pekarskim proizvodima preporu čuje se kao model i hrvatskim pekarima.
Bilo bi poželjno uvesti obvezu obilježavanja proizvoda, tj. isticanje koli čine soli na deklaraciji, kako bi potroša či mogli sami izra čunati koli činu unosa soli. Prijeko je potrebno provesti edukaciju naše populacije, lije čnika i medicinskih sestara, kao i aktivno uklju čivanje prehrambene industrije i ugostiteljstva.
Obzirom na visoki udio soli koji se unosi preko pekarskih proizvoda pozivaju se i hrvatski pekari, kao i proizvo ñači gotovih smjesa za pekarske proizvode da se uklju če u ovu hvale vrijednu inicijativu i u svoj asortiman uvrste što više pekarskih proizvoda sa smanjenim udjelom soli, čime bi se doprinijelo dugoro čnoj prevenciji kardiovaskularnih bolesti.
Literatura: 1. Cauvain SP & Young LS (1998) Technology of Breadmaking. London: Blackie
Fisher MH, Aitken TR & Anderson JA (1949) Effects of mixing, salt and consistency on extensograms. Cereal Chemistry 26 , 81–97. 2. He H, Roach RR, Hoseney RC (1992) Effect of nonchaotropic salts on flour bread-making
properties. Cereal Chemistry 69 (4), 366–371. 3. Hlynka I (1962) Influence of temperature, speed of mixing, and salt on some rheological
properties of dough in the farinograph. Cereal Chemistry 39 , 286–303. 4. Linko P, Harkonen H, Linko YY (1984) Effects of sodium chloride in the processing of bread baked from what, rye and barley flours. Journal of Cereal Science 2 (1), 53–62. 5. Piet Slumier: Principles of Breadmaking, Amercan Association of Cereal Chemists, Inc. St. Paul, Minnesota, USA, 2005, 46-47. 6. B. Skupnjak: Inicijativa za nacionalnu kampanju smanjenja utroška soli, Hrvatski časopis za javno zdravstvo, Vol 3, Broj 10, 2007. 7. Nutzen und Möglichkeiten einer natriumreduzierten Ernährung, in: Forschung hilft dem Backgewerbe , Bundesforschungsanstalt für Getreide – und Kartoffelverarbeitung 1989. 10 – 23.
Kontakt :
Žaneta Ugar čić-Hardi
Prehrambeno-tehnološki fakultet Osijek, F. Kuha ča 20, 31000 Osijek
031/224-300
031/207-115 [email protected]
Chairperson ...... 4 Organizing committee ...... 4 Scientific committee...... 4 Main topics ...... 4 Important dates ...... 4 Abstract sumbission ...... 5 Registration fee ...... 5 Registration fee for participants include ...... 5 Venue ...... 5 Accomodation ...... 5 Official language ...... 6 Young investigator award...... 6 Information on conference...... 6 Secretary of ISHO ...... 6 Secretary of the Croatian Society of Hypertension ...... 6 Treasurer of the Croatian Society of Hypertension...... 6 Professional organizer...... 6 Registration desk and info...... 6 Program at Glance...... 7 Sponsors and exhibitors...... 8 General sponsor ...... 8 Golden sponsors...... 8 Silver sponsors...... 8 Bronze sponsor ...... 8 Other sponsors and exibitors ...... 8 Croatian Hungarian Young Investigator conference ...... 9 November 17, Wednesday University of Pécs, Hungary ...... 9 November 18, Thursday Restaurant "Galija", Osijek, Croatia ...... 10 November 18, Thursday Restaurant "Galija", Osijek, Croatia ...... 11 Second International Symposium on Hypertension ...... 12 November 18, Thursday Croatian National Theatre, Osijek ...... 12 November 19, Friday Hotel Osijek, Osijek, Croatia...... 13 November 20, Saturday Hotel Osijek, Osijek, Croatia...... 14 November 21, Sunday Hotel Osijek, Osijek, Croatia...... 15 Simpozij medicinskih sestara u hipertenziji ...... 16 19 Studeni 2010, Petak Hotel Osijek...... 16 Hotel Osijek, Hall legend ...... 17 Hotel Osijek, ground level ...... 17 Abstracts...... 18 Sažeci prijavljeni na hrvatskom jeziku...... 99 Sažeci radova prikazanih na simpoziju Udruga medicinskih sestara u hipertenziji...... 102 Zdravlje i sol...... 107
Abstracts...... 18 Prevalence of Arterial Hypertension and Obesity in Seven Year Old Children ...... 18 Hypertension as the most Prevalent Etiological Condition in Chronic and Transitory Atrial Fibrillation in Patients at Canton Hospital Zenica ...... 19 Arterial Hypertension in Peritoneal Dialysis Patients...... 20 Investigation of Parameters of Blood Vessels with the Finometer Device in Diabetic and Non Diabetic Hypertensive Patients ...... 21 Artery Plaque Score and Arterial Hypertension...... 22 Influence of High Salt Diet on Microvascular Reactivity in Young Healthy Female Human Subjects ...... 23 Vasomotor Effects of Hemolysed Blood in Isolated Rat Cerebral Arteries ...... 24 Prevalence, Treatment, Control and Distribution of Hypertension in Endemic Nephropathy ...... 25 Hypertension Protective Allele of Toll Like Receptor 2 Polymorphic Gene ...... 26 Cumulative Incidence of Arterial Hypertension in Normotensive Subjects Cohorta...... 27 Diagnosis of Subclinical Atherosclerosis: Ankle/Brachial Index as a Screening Method ...... 28 Inflammation and Prehypertension ...... 29 Endovascular Intervention Effects in Patients with Atherosclerotic Renovascular Hypertension on Brachial and Central Blood Pressure and Pulse Wave Velocity ...... 30 Lack of relation between endothelial function and carotid artery stiffness in young, healthy male subjects..... 31 Heart Rate is Related to Diastolic Blood Pressure...... 32 Hypertension and Salt Intake Preliminary Results from Study Obtained in Undeveloped Rural Part of Croatia . 33 Intraoperative BP oscillations and 24 hour dipping status in surgical patients ...... 34 The Impact of Individual Blood Pressure Components on the Type and Degree of the Left Ventricular Hypertrophy ...... 35 Influence of Metabolic Syndrome on Circadian Blood Pressure Regulation in Newly Diagnosed Essential Hypertensives ...... 36 Changes of the Baroreflex Sensitivity and Plasma Norepinephrine after Neurosurgical Decompression of the Medulla Oblongata on the Left Side in a Hypertensive Woman ...... 37 Dietary Salt Intake, Endothelial Function, and Vascular Oxidant Stress: Parallel Lessons from Humans and Animals...... 38 Investigation of the Baroreflex Sensitivity in Different Cardiovascular Diseases ...... 39 Inhibition of Poly(ADP Ribose)Polymerase Reduces Hypertension Induced Vascular Remodeling in Spontaneous Hypertensive Rat (SHR) Model ...... 40 Effects of Erythropoietin on Glucose Metabolism ...... 41 Salt Intake in the Croatian Adult Population: Implications for the Public Health ...... 42 Cerebrovascular diseases in chronic kidney disease with/ without hypertension ...... 43 Relation of Hypertension and Helicobacter Pylori Infection as a Risks Factor for Acute Myocardial Infarction ... 44 Hypertension in Elderly Patients with a Kidney Transplant ...... 45 Effects of Hyperhomocysteinemia on Various Hemorheological Parameters ...... 46 The Role of ACE Gene Polymorphism on Early Changes in Epithelial Proximal Tubule Renal Cells in Endemic (Balkan) Nephropathy ...... 47 Endovascular Treatment of Atherosclerotic Renal Artery Stenosis and Uncontrolled Hypertension: Characteristics of Patients and Intervention ...... 48 Microcirculation, Blood Pressure and Physical Exercise...... 49 The Correlation of Endothelin 1 and Nitric Oxide with Mean Arterial Pressure Depends on Therapy with Angiotensin Converting Enzyme Inhibitors in Diabetic Patients ...... 50 Pulse Wave Velocity in Patients with Endemic (Balkan) Nephropathy Undergoing Hemodialysis...... 51 A Comparison of Frequency of Arterial Hypertension in Patients with Acute Stroke During Five Year Period in Osijek Area ...... 52 Different Effect of Iga Nephropathy and Polycystic Kidney Disease on Arterial Stiffness...... 53 Correlation between plasma leptin and adiponectin concentrations in hypertensive overweight patients ...... 54 Comparison of Antioxidant Effects of Hydrogen Sulphide (H2S) and Superoxide Dismutase (SOD) in Isolated Small Veins...... 55 Chronic Hemodialysis Patients' View on Normal Blood Pressure Values Impact on Compliance with Arterial Hypertension Treatment ...... 56 Increases in Intraluminal Flow Elicit Constrictions in Isolated Rat Middle Cerebral Arteries...... 57 The Method of Distance Measurement and Torso Length Influences the Relationship of Pulse Wave Velocity to Cardiovascular Mortality ...... 58 Does Oxidative Stress Affect the Vasoactive Effect of Insulin? ...... 59 Malignant Hypertension in Patients with Renal Diseases: Single Centre Experience...... 60 Association of Hypertension with Overweight and Weight Gain Croatian Adult Health Survey 2003 08...... 61 Aging Dependent Changes in Angiotensin II Induced Contractions of Isolated Rat Carotid Arteries ...... 62 Mediterranean Diet – does it work? Does it exist? ...... 63 Urinary Protein/Creatinine Ratio in Patients with Regulated and Unregulated Arterial Hypertension...... 64 Correlation between Adipose Tissue Distribution and Sympathetic Nervous System Activation in Hypertensive Patients ...... 65 Impact of Angiotensin Converting Enzyme Gene Polymorphism on Proteinuria and Arterial Hypertension ...... 66 Pulse Pressure or Ambulatory Arterial Stiffness Index which Method is Better in Predicting Target Organ Damage? ...... 67 Poly(ADP ribose)polymearase inhibition reduces vascular remodeling in a chronic hypertension model ...... 68 Retrospective Analysis of Two Year Data of Resistant Hypertensive Patients with and without Neurosurgical Microvascular Decompression ...... 69 How to organize an outpatient clinic...... 70 Acute oxidative stress, vascular function and uric acid...... 71 The influence of estrogen on the reactivity of skeletal muscle arterioles to increased tissue oxygen in SS and SS13BN female rats fed a low or high salt diet...... 72 Approaches to Adrenal Incidentalomas...... 73 Regulation of Hypertension in Managerial Population ...... 74 Changes of the baroreflex sensitivity in healthy students during semester and exam period ...... 75 Adherence in Patients Treated for Arterial Hypertension in Zagreb, Croatia ...... 76 Hypertension in women ...... 77 Intraoperative invasive haemodynamic monitoring in hypertensive patient ...... 78 Bilateral vs. unilateral spinal anesthesia for varicose vein in hypertensive patients ...... 79 Hypertensive emergency the first manifestation of renal disease in children and adolescents ...... 80 Vitamin d and arterial hypertension ...... 81 Value of echocardiographic assessment of diastolic dysfunction in arterial hypertension ...... 82 Importance of salt reduction...... 83 Impact of emotional intelligence on the regulation of arterial hypertension...... 84 Isolated Interrupted Aortic Arch in an adult – rare cause of secondary hypertension ...... 85 Circadian blood pressure, hypertension and perioperative blood pressure management...... 86 Global cardiovascular risk in newly diagnosed hypertension and prehypertension ...... 87 Arterial elasticity...... 88 Hypertension and Aortic Valvular Disease ...... 89 Intraoperative control of blood pressure during thyreoidectomy: our current clinical practice ...... 90 The effects of analgesia on blood pressure ...... 91 Treatment of hypertensive heart disease...... 92 Perioperative hypertension...... 93 Sažeci prijavljeni na hrvatskom jeziku...... 99 Kontrola i adekvatnost liječenja arterijske hipertenzije ...... 99 Promjene na aortalnom ušću kod hipertoničara i uticaj pušenja ...... 100 Regulacija tvrdokorne arterijske hipertenzivne krize primjenom hlapljivog anestetika kod kritičnih bolesnika u jedinici intenzivnog liječenja ...... 101 Sažeci radova prikazanih na simpoziju Udruga medicinskih sestara u hipertenziji...... 102 Renovaskularna hipertenzija – prikaz bolesnika ...... 102 Indikator kvalitete zdravstvene njege: sestrinska dokumentacija i kategorizacija pacijenata na odjelima Nefrologije i Neurologije OB Koprivnica/ komparacija i analiza ...... 103 Hipertenzija u djece i adolescenata...... 104 Zdravstvena njega bolesnika oboljelog od arterijske hipertenzije...... 105 Health care of patients with arterial hypertension ...... 106 Zdravlje i sol...... 107 Uvodna riječ urednice teme „Zdravlje i sol“...... 107 Unos soli u odrasloj populaciji ...... 109 Povećan unos kuhinjske soli utječe na pojavu karcinoma probavnog sustava...... 111 Unos soli u seoskoj populaciji u Hrvatskoj – procjena korištenjem jednokratno skupljenog uzorka mokraće.... 114 Unos soli, metabolički sindrom i pretilost ...... 118 Sol u prehrani školske djece ...... 120 Količina soli u hrvatskim pekarskim proizvodima...... 123