Recent advances in the management of hypertension

Hypertension is a worldwide prevalent disease that leads to considerable morbidity and mortality. While its underlying basis of genetics and pathology as well as its complications are universally agreed upon, management of hypertension remains to be controversial. In this article, we will present clear evidence of the recent advances in the management of hypertension that include newer therapeutic agents replacing old strategies. Moreover, a suggested approach that is evidence based is provided to help in establishing agreement in line of therapy

Hypertension in Saudi Arabia

To determine the prevalence of hypertension among Saudis of both gender, between the ages of 30-70 years in rural as well as urban communities. This work is part of a major national study on Coronary Artery Disease in Saudis Study [CADISS]. This is a community-based study conducted by examining subjects in the age group of 30-70 years of selected households during a 5-year period between 1995 and 2000 in Saudi Arabia. Data were obtained from history using a validated questionnaire, and examination including measurement of blood pressure. The data were analyzed to provide prevalence of hypertension. Logistic regression was used to develop a risk assessment model for prevalence of hypertension. The total number of subjects included in the study was 17,230. The prevalence of hypertension was 26.1% in crude terms. For males, the prevalence of hypertension was 28.6%, while for females; the prevalence was significantly lower at 23.9% [p<0.001]. The urban population showed significantly higher prevalence of hypertension of 27.9%, compared to rural population's prevalence of 22.4% [p<0.001]. The prevalence of CAD among hypertensive patients was 8.2%, and 4.5% among normotensive subjects [p<0.001]. Increasing weight showed significant increase in prevalence of hypertension in a linear relationship. Hypertension is increasing in prevalence in KSA affecting more than one fourth of the adult Saudi population. We recommend aggressive management of hypertension as well as screening of adults for hypertension early to prevent its damaging consequences if left untreated. Public health awareness of simple measures, such as low salt diet, exercise, and avoiding obesity, to maintain normal arterial blood pressure need to be implemented by health care providers

Metabolic syndrome in Saudi Arabia

Metabolic syndrome [MS] is a well-established risk factor for the development of coronary artery disease [CAD]. We designed this study to obtain the prevalence of MS and each of its components in Saudi Arabia. This study is part of Coronary Artery Disease in Saudi Study [CADISS]. We conducted this community-based national epidemiological health survey by examining Saudi subjects in the age group of 30-70 years of selected households over a 5-year period between 1995 and 2000 in Saudi Arabia. We interviewed all subjects, examined and took measurements of their blood pressure, weight, height, waist circumference, as well as fasting samples of plasma glucose, triglycerides, and high-density lipoprotein [HDL] cholesterol. We obtained the prevalence of MS based on the presence of at least 3 of the following: abdominal obesity [waist circumference >102 cm [40 inch] in male and >88 cm [35 inch] in female], triglycerides >=150 mg/dl [1.69 mmol/L], HDL cholesterol <40 mg/dl [1.03 mmol/L] in male and <50 mg/dl [1.29 mmol/L] in female, blood pressure >=130/85 mm Hg, fasting glucose >=110 mg/dl [6.1 mmol/L] as defined by the Adult Treatment Panel [ATP] III in 2001. We included 17,293 subjects in this survey during the study period. The overall age-adjusted prevalence of MS in Saudi Arabia obtained from this study is 39.3%. Age adjusted prevalence in males is 37.2% and crude prevalence is 40.9% [95% confidence interval [CI] 39.8-42], while females have a higher prevalence of 42% and crude prevalence of 41.9% [95% CI 40.9-42.9]. Saudi subjects from urban areas have significantly higher prevalence of 44.1% [95% CI 43.2-45] compared to those living in rural areas of 35.6% [95% CI 34.3-36.7] [p<0.0001]. Low HDL affects 81.8% of females and 74.8% of males with MS leading all other factors, and it continued to be consistent in all different age groups. Metabolic syndrome is a risk factor for CAD, as the prevalence of CAD was higher among patients with MS [6.7%] compared to subjects without MS [4.6%] [p<0.0001]. The prevalence of MS is high in Saudi Arabia. Low HDL cholesterol plays a major role in the contribution to the MS in Saudi Arabia. Therefore, we recommend routine assessment for the components of MS in patients with CAD, furthermore, we encourage aggressive management of the MS for primary prevention of CAD, particularly, measures to increase HDL cholesterol

Aborted sudden nocturnal cardiac death in young man with structurally nomal heart

Sudden cardiac death is a devastating event, particularly when it occurs to young, otherwise healthy individuals. We report here a young Burmese male who survived sudden cardiac death with structurally normal heart. His electrocardiogram revealed features consistent with Brugada syndrome. He was referred for intra-cardiac defibrillator implantation. In this article, in addition to the case presentation, a review of Brugada syndrome medical literature is also presented

Asymptomatic giant pulmonary artery aneurysm in an elderly male patient

Pulmonary artery aneurysm is rarely seen in clinical practice. It has been reported to develop in patients due to several underlying etiologies. However, the natural history is not yet defined, and management remains controversial. We report a case of giant main pulmonary artery aneurysm 6.06 cm in diameter in an asymptomatic 75-year-old male who has an incidental abnormal chest x-ray for preoperative evaluation as management of benign prostatic hypertrophy. The patient was managed conservatively. He was discharged home in good general condition to be followed up by echocardiography every 6 months. We conclude that pulmonary artery aneurysm can reach a massive size with no apparent symptoms. The treatment can therefore be conservative as no clear guidelines to support interventional management, particularly in the absence of pulmonary hypertension

Coronary artery disease in Suadi Arabia

Coronary artery disease [CAD] is a major public health problem worldwide. To our knowledge, there is no national data available from community based studies on prevalence of CAD in the Kingdom of Saudi Arabia [KSA]. Therefore, we designed this study with the objective to determine the prevalence of CAD among Saudis of both sexes, between the ages of 30-70-years in rural as well as urban communities. Further, to determine the prevalence and clinical pattern of the major modifiable risk factors for CAD among the same population. This work is part of a major national study on CAD in Saudis Study [CADISS]. This is a community based study conducted by examining subjects in the age group of 30-70-years of selected households during 5-year period between 1995 and 2000 in KSA. Data were obtained from history using a validated questionnaire, and electrocardiography. The data were analyzed to provide prevalence of CAD and risk assessment model. Nine hundred and forty-four subjects, out of 17232 were diagnosed to have CAD. Thus, the overall prevalence of CAD obtained from this study is 5.5% in KSA. The prevalence in males and females were 6.6% and 4.4% [P<0.0001]. Urban Saudis have a higher prevalence of 6.2% compared to rural Saudis of 4% [P<0.0001]. The following variables are found to be statistically significant risk factors in KSA: age, male gender, body mass index [BMI], hypertension, current smoking, fasting blood glucose, fasting cholesterol and triglycerides. The overall prevalence of CAD in KSA is 5.5%. A national prevention program at community level as well as high risk groups should be implemented sooner to prevent the expected epidemic of CAD that we are seeing, beginning. Measures are needed to change lifestyle and to address the management of the metabolic syndrome, to reduce modifiable risk factors for CAD. A longitudinal study is needed to demonstrate the importance of reducing modifiable risk factors for CAD in KSA

Management of acute myocardial infraction: do we follow guidelines applied in practice?

Acute myocardial infarction [MI] is a major health problem with a substantial fatality and morbidity. The management of patients with acute MI has been addressed in major trials to improve the survival and enhance the quality of life of the patients. Numerous guidelines have been established for the management of such patients. The objective of this study is to determine whether the current practice in managing patients admitted with acute MI in a major community hospital in Riyadh is evidence based compliant. The data were collected from patients admitted to the Coronary Care Unit [CCU], Riyadh Medical Complex [RMC], Riyadh, Kingdom of Saudi Arabia, a 1500 bed community hospital, with a diagnosis of acute MI over one-year period [April 1999 to April 2000]. The administration of different therapeutic modalities upon admission as well as discharge medications was obtained. Patients outcome [all cause mortality] post treatment were collected. The data was analyzed and compared with the current guidelines. A total of 335 patients, 315 males [94%], were admitted to the CCU of RMC with a diagnosis of acute MI. Two hundred and seventy-one patients [80.9%] received thrombolytic therapy. Discharge medications were beta-blocker in 255 [76.1%], angiotensin converting enzyme inhibitors in 206 [61.5%], nitrates in 281 [83.9%], hypolipidemic agents in 15 patients [4.5%], and aspirin in all patients. The outcome of these patients obtained either alive or dead was 313 [93.4%] and 22 [6.6%] [p<0.00001]. The patients with acute MI received management compliant with evidence-based practice. However, more awareness to the use of angiotensin converting enzyme inhibitors as well as hypolipidemic agents is needed to provide maximum benefit to these patients. Moreover, national guidelines for the management of acute MI are needed for improvement of quality of care

Lack of associatin of coronary artery disease with H.pylori infection

It has been suggested from previous studies that there is an associated increased risk of coronary artery disease [CAD] in patients with Helicobacter pylori [H.pylori]. However, others dispute this. We therefore evaluated this hypothesis in a group of patients with confirmed H.pylori infection. A total of 158 patients with dyspeptic symptoms were evaluated by esophago-gastro-duodenoscopy [EGD] in King Khalid University Hospital in Riyadh, Kingdom of Saudi Arabia from May through to June 1997. Endoscopic biopsies and histology as well as culture and serology for H.pylori were obtained. In patients with confirmed H.pylori a further analysis was performed looking at associated [CAD] or known risk factors for CAD. Among the 158 patients who underwent EGD, 143 patients [90.5%] were found to have H.pylori either by culture, histology or serology, or both in a percentage of [31.5%] [77.6%] and [60.8%]. There was no evidence of CAD in this group of patients based on history, electrocardiogram [ECG], echocardiography, ECG stress test, dypiridamole thallium scan or coronary angiography. Other known risk factors for CAD were cigarette smoking [12.6%], diabetes mellitus [10.5%], hypertension [1.4%] and hyperlipidemia [2.8%]. Helicobacter pylori infection does not increase the risk of CAD, and should not be considered as an independent risk factor for CAD. Further, prospective large trial is needed to confirm our finding

Door to needle time in administering thrombolytic therapy for acute myocrdial infarction

Thrombolytic therapy is a standard treatment for patients presenting with acute myocardial infarction [MI]. Early administration of these agents is crucial for the outcome of management. This audit was conducted to evaluate the time between arrival to emergency department [ED] and the administration of thrombolysis [door to needle time]. Data was collected from patients admitted to the Coronary Care Unit of Riyadh Medical Complex [RMC], Riyadh, Kingdom of Saudi Arabia, a 1500-bed community hospital, with a diagnosis of acute MI and received thrombolytic therapy over a one-year period [April 1999 to April 2000]. The time between arrival to the ED to the time of administration of thrombolytic therapy was obtained as well as the time of onset of chest pain up to presentation to the hospital, and the outcome [all cause mortality] post treatment. A total of 271 patients [256 males] admitted to RMC with a diagnosis of acute MI received thrombolytic therapy over a one-year duration. The median door to needle time was 95 minutes. The median time of onset of chest pain to arrival to ED was 5 hours [300 minutes]. The outcome of these patients obtained either alive was 260 [96%] or dead was 11 [4%] [P < 0.00001]. The door to needle time was relatively similar to other centers. The delay in administering thrombolytic therapy should be reduced to a target of <70 minutes from onset of symptoms. Delay in presentation to the hospital was more important and factors contributing to this delay should be looked for and corrected. Another audit is needed to evaluate the implementation of these recommendations