[Resistant hypertension in the elderly]. / Rezistentná hypertenzia v starsom veku.

The issue of resistant hypertension is complex and from the clinical aspect very current, especially in the elderly. For the diagnosis of resistant hypertension in routine practice, ambulatory blood pressure monitoring is a proven method to distinguish it from the white coat hypertension. Fixed combinations of antihypertensive drugs helps to improve compliance not only in geriatric patients, but are also indicated in hypertensive patients with diabetes mellitus, metabolic syndrome, in patients with target organ damage, renal disease, coronary heart disease and post stroke conditions. Especially in the population of older hypertensive patients, listed diseases with polymorbidity are frequently present.

Epinephrine producing pheochromocytoma. Is the secretory pattern decisive for the clinical manifestation?

Adrenal incidentalomas are becoming a major clinical problem, due to increasingly frequent radiological examinations. We present two cases of patients referred to our department with a finding of an unsuspected adrenal mass. Both of them were normotensive and without symptomatology typical for pheochromocytoma. In one patient we found 20-times higher levels of epinephrine and 3-times higher levels of dopamine in 24-h urine, in the second patient there were 8-times higher levels of epinephrine alone. Norepinephrine in urine, as well as values of all adrenal cortical hormones were normal. The diagnosis of pheochromocytoma was confirmed in both cases by a 123I-metaiodobenzylguanidine (MIBG) scintigraphy. The patients underwent adrenalectomy, which was performed without complications. We conclude that levels of single catecholamines excreted are decisive for the clinical presentation of pheochromocytoma. Epinephrine producing pheochromocytoma is more often oligo- or asymptomatic. We stress the importance of a complete hormonal screening in every case of adrenal incidentaloma, with measuring levels of catecholamines and/or metanephrines.

Retrospective analysis of patients clinical manifestations before and after pheochromocytoma surgery.

MAIN PURPOSE: A retrospective analysis of presurgical clinical picture and blood pressures of 34 patients with histologically verified pheochromocytoma. Assessment of clinical state, blood pressure and prognosis in the course of patients control hospitalizations from 2001 to 2002. PATIENTS AND METHODS: The study was designed as a synoptic one, based on a retrospective analysis of 34 patients records with histologically verified pheochromocytoma (26 women and 8 men). Our assessments of clinical symptomatology, maximum paroxysmal hypertension values, average blood pressure values in patients with persistent arterial hypertension, arterial hypertension grade and circadian index were based on patients records. Patients epinephrectomies were followed during their control hospitalizations to assess their clinical state. Their blood pressures were evaluated by means of their circadian monitoring. RESULTS: From the 34 patients, 21 were diagnosed with solitary pheochromocytomas. The circadian index persistence analysis prior to the surgery was associated with circadian blood pressure monitoring in 21 patients. It was lost in 57% of patients. During their control hospitalization as many as 82% of patients preserved their circadian blood pressure variability with a more than 10% decrease in the night time, 5 patients did not preserve their circadian blood pressure variability. Seven from the original 34 patients died: Three of them died from their primary disease, one 63-year old man died from shock following tumour extirpation. The death of other 3 patients was not associated with their primary disease. CONCLUSION: Long-lasting survival of patients with pheochromocytoma after surgical treatment--except for those with malignant disease--was demonstrated. Although our assessment of the resulting treatment effects was positive, a long-term follow-up is inevitable because of a difficult pathologic-anatomical verification of the malignant nature of the disease as well as of the risk of tumour relapse assessment. (Tab. 1, Fig. 5, Ref 36.)

[Clinical conditions imitating pheochromocytoma in diagnostic practice]. / Klinické situácie imitujúce feochromocytóm v diagnostickej praxi.

Serious predominantly diastolic treatment-resistant hypertension with unstable blood pressure values draws first contact physician's attention to a possibility of pheochromocytoma, although in some periods of disease blood pressure values of a patient can be normal or only slightly elevated. Clinical picture is sometimes atypical, can be overlooked or lead to a wrong diagnosis. The author brings forward atypical cases where pheochromocytoma emulates different disease or diseases with clinical pictures similar to that of pheochromocytoma.

Does diabetic autonomic neuropathy influence the clinical manifestations of reflux esophagitis?

Diabetic autonomic neuropathy is a common complication of diabetes mellitus and affects every segment of the gastrointestinal tract. Gastrointestinal problems tend to be more common and severe in diabetics compared with the nondiabetic population. In the literature, the prevalence of reflux esophagitis is not known. The aim of this study was to analyze esophagoscopic findings, compare them with esophageal symptoms, and evaluate reflux esophagitis in relationship with autonomic neuropathy. We examined 54 diabetics (15 type 1, 39 type II), 28 males and 26 females, average age 55.4 (95% confidence intervals 52.1-58.8), with duration of diabetes more than 5 (average 15.0; 12.4-17.6) years. All patients completed a structured questionnaire. After overnight fasting, gastroesophageal endoscopy was performed in the morning to establish the presence of reflux esophagitis, using the Los Angeles classification. Cardiovascular autonomic neuropathy was diagnosed with the help of cardiovascular autonomic reflexes (deep breathing, active orthostasis, Valsalva's maneuver) and spectral analysis of heart rate variation. Endoscopic esophagitis was present in 22 (40.7%) diabetics and 10 of them (45 %) also complained of reflux symptoms. Sensitivity of symptoms was 45.5% and specificity was 72%. We found the presence of symptoms of reflux esophagitis in 21 (38.9%) diabetics, but of this group only 10 (47.6%) had endoscopic changes. Autonomic neuropathy was present in 29 patients, 16 (55%) of them had reflux esophagitis and 18 (62%) were positive for reflux symptoms. In the diabetics without autonomic neuropathy, esophagitis was noted in 6 (24%), which reflects a significant difference (p < 0.05). Reflux symptoms were present in 10 (40%) diabetics without autonomic neuropathy, and in comparison with patients who had autonomic neuropathy, the difference was not statistically significant. Thus, reflux eosophagitis is common in diabetic patients, with a prevalence of 40.7%. Reflux symptoms do not have a great diagnostic value in establishing reflux esophagitis. We confirmed a relationship between autonomic neuropathy and the clinical manifestations of reflux esophagitis, but no association with accompanying reflux symptoms. (Tab. 2, Ref. 27.)

Compliance and the therapeutic effect in patients with arterial hypertension.

OBJECTIVE AND METHOD: To analyse the therapeutic effect of treatment in patients monitored in our hypertension outpatient department and evaluation using questionnaires. To determine the influence of treatment effectiveness on the level of co-operation received from the patient. The effect of treatment was monitored by retrospective analysis of the medical records of 101 patients with essential hypertension. RESULTS: 1) Pharmacological treatment of essential hypertension led to the normalisation of blood pressure levels in 28 patients. The drop in pressure from 146/90 mmHg to 129/82 mmHg was statistically significant (p = 0.001). 2) Only 7 % of patients were fully compliant. A drop (6) in blood pressure was more marked in compliant patients (deltaBPs = 11 mmHg, deltaBPd=9 mmHg), compared with the group of non-compliant patients (deltaBPs = 3 mmHg, deltaBPd = -4 mmHg). 3) Patients have a low level of compliance in relation to non-medicamentous treatment. They are not willing to cut down their salt intake (37%), to stop smoking (12 %) and to reduce their weight (11%). CONCLUSION: The conducted study confirms the insufficient treatment of arterial hypertension, a better effect of treatment in the patients with 1st stage of arterial hypertension compared with the patients with a more serious stages, a fairly high percentage of non-compliant patients and a positive connection between patient's compliance and the reduction in blood pressure values. We would like to emphasise that long-term compensation of blood pressure is a key factor in preventing complications. The efficiency of treatment depends on regular blood pressure controls and intensive motivation of the patient to respect the therapeutic discipline. (Tab. 9, Fig. 1, Ref. 17.)

The Valsartan Antihypertensive Long-term Use Evaluation (VALUE) trial in Slovakia.

OBJECTIVES: We described the baseline characteristics of a cohort of patients who are a part of a large prospective study and compared with those characteristics of patients enrolled globally. BACKGROUND: The Valsartan Antihypertensive Long-term Use Evaluation (VALUE) is a double-blind, randomized, multinational, multicenter, prospective, parallel group study. The primary objective of VALUE trial is to assess the effect of the angiotensin II (AT1 receptor) antagonist valsartan on the reduction of cardiac morbidity and mortality in patients 50 years of age or older with essential hypertension and a high risk of cardiovascular events. METHODS: A total of 15314 patients from 31 countries were randomized. In Slovakia 103 patients were randomized. We compared baseline characteristics of patients enrolled in Slovakia with those of patients enrolled globally. Statistic analysis was made with F-test, t-test, chi-square test and binomial test. RESULTS: The Slovak group had of fewer men (40.8%) and more patients of Caucasian race (99.0%). A higher proportion of patients treated for hypertension for at least three months was found in the Slovak group (99.0%), however the mean values of sitting systolic and sitting diastolic blood pressures remained similar in both groups. The value of serum creatinine >150 micromol/l did not occur in the Slovak group. The coronary heart disease was more prevalent in the Slovak group (77.7%) and the mean value of hemoglobin was lower in the Slovak group (138.0 g/l). CONCLUSIONS: The baseline characteristics of the 103 patients enrolled in VALUE trial in Slovakia indicate that the target population of patients with essential hypertension and a high risk of cardiovascular events was achieved. (Tab. 1, Fig. 6, Ref. 21.).

The effect of cardiovascular autonomic neuropathy on resting ECG in type 1 diabetic patients.

BACKGROUND: Cardiovascular autonomic neuropathy (CAN) is a common complication of diabetes mellitus. AIM: To assess the manifestations of CAN on ECG at rest. SUBJECTS AND METHODS: 100 type I diabetic patients, mean age 36.5 (range 17-62) years, mean duration of diabetes 14.6 (range 0-49) years were examined. The control group consisted of 88 healthy subjects, mean age 37 (range 15-65) years. Cardiovascular reflexes (respiration sinus arrhythmia, orthostatic test and Valsalva's maneuvre) were examined, and ECG at rest was analysed. RESULTS: In 35 (35%) diabetics CAN was established. In comparison to diabetic patients without neuropathy, patients with CAN had a higher heart rate (94, 89-99 vs. 79, 75-82 heart beats.min-1, p < 0.001), higher P wave voltage (0.13, 0.12-0.15 vs 0.11, 0.09-0.12 mV, p < 0.001), as well as QTc interval length (422, 410-433 vs 396, 388-404 ms, p < 0.001), but they had a lower voltage of R wave (0.83, 0.72-0.94 vs. 1.0, 0.91-1.09 mV, p < 0.05) and lower T wave voltage (0.18, 0.15-0.21 vs 0.23, 0.19-0.27 mV, p < 0.05). CONCLUSIONS: The higher voltage of P wave, lower voltage of T wave, shorter PQ interval and prolonged QTc interval with tachycardia may be the manifestation of relative sympatheticotonia. Lower R wave voltage and the prolonged QRS complex are the possible signs of cardiomyopathy. (Tab. 4, Ref. 31.)

Germline mutation of the RET proto-oncogene in members of Slovak families with multiple endocrine neoplasia 2.

Detection of mutations in RET proto-oncogene in Slovak families from different localities and of different ethnic origin with MEN 2 syndrome is reported. Despite the fact that the same mutation of RET oncogene was found in different family members, the latency period of tumor appearance and their pathogenicity differed substantially. In addition, also different phenotypes of the disease were expressed in various family members having the same RET gene mutation. The data indicate that the mechanism of MEN2 syndrome is not only due to the RET gene mutation, and strongly support the conclusion that additional genetic events are involved in the disease formation.

Passive smoking impairs endothelium-dependent relaxation of isolated rabbit arteries.

The aim of the present study was to examine the effect of prolonged passive smoking (lasting 3 weeks) on plasma catecholamine levels and reactivity of isolated rabbit arteries. Plasma noradrenaline, adrenaline and dopamine levels were determined radioenzymatically. Isolated rings of the thoracic aorta and carotid artery were suspended in organ chambers and connected to a force transducer for the recording of isometric tension. Plasma noradrenaline levels were found to be significantly elevated in rabbits subjected to passive smoking for 3 weeks. Plasma adrenaline and dopamine levels were not changed. Transmural nerve stimulation of arterial rings evoked frequency-dependent contractions. Prolonged passive smoking did not affect neurogenic contractions of the arteries tested. On the other hand, endothelium-dependent relaxations of phenylephrine-precontracted arteries were significantly impaired. Furthermore, hypertrophy of the left ventricle was observed. In conclusion, passive smoking impairs endothelium-dependent relaxations but not neurogenic contractions of systemic arteries. The impaired relaxations of arteries may be, at least in part, mediated through the degradation of released nitric oxide by superoxide anions derived from cigarette smoke.

[Long-term treatment of combined hyperlipidemia with a combination of fluvastatin and fenofibrate]. / Dlouhodobá lécba kombinované hyperlipidémie kombinací fluvastatinu s fenofibrátem.

The long-term efficacy and safety of fluvastatin monotherapy was compared with that of the combination of fluvastatin and fenofibrate in 104 patients with coronary heart disease and combined hyperlipidemia in an open, randomised, parallel group, clinical study of 78 weeks duration. Combined hyperlipidemia was defined as LDL-cholesterol 4.1 mmol/l and higher and triglycerides between 2.5 and 4.5 mmol/l after 8 weeks of dietary intervention. The patients were treated with either fluvastatin 40 mg daily or with the combination of fluvastatin (20 mg daily) and micronized fenofibrate 200 mg daily. Mean values of total and LDL-cholesterol decreased by 19.3% and 29.7% respectively after fluvastatin treatment and by 21.5% and 29.1% respectively after the combination of fluvastatin and fenofibrate treatment. The differences between the treated groups were not significant. Mean values of HDL-cholesterol increased significantly more after the combination of fluvastatin and fenofibrate than after fluvastatin monotherapy (26% vs. 9.9%). The mean values of triglycerides decreased significantly more after the combination treatment than after fluvastatin monotherapy (-40.2% vs. -19.7%). The treatment in both groups was well tolerated and no signs of myopathy were observed in any patient. The study was discontinued in 1 patient due to the increase of liver enzymes. The most frequently observed side effects were minor gastrointestinal symptoms, which were more frequent in patients treated by the combination of fluvastatin and fenofibrate. Thus our results demonstrate that the combination of fluvastatin and fenofibrate is an effective and safe treatment option for patients with coronary heart disease and mild to moderate combined hyperlipidemia if a more radical lowering of triglycerides and increase of HDL-cholesterol is desired.

[The role of home pressure monitoring in the treatment hypertension in the practice of general medicine]. / Prínos domácího merení tlaku k lécbe hypertenze v praxi vseobecných lékaru.

AIM OF THE STUDY: The aim of the study was to evaluate home blood pressure (BP) measurement using an OMRON HEM 706 device (including printout values) for the treatment of essential hypertension by a greater number of general practitioners and to establish the incidence of "white coat hypertension". METHODS: We compared home BP values, taken by the portable digital Omron HEM 706 device with casual BP values, measured during the course of a 6-month treatment of essential hypertension by the ACE inhibitor perindopril or a combination of perindopril and a diuretic (most frequently a low dose of hydrochlorothiazide) in 503 patients with mild to moderate essential hypertension. Czech and Slovak general practitioners participated in the study. Home BP measurement was performed by the patients always during the 4 days preceding the visit by the general practitioner. Home BP was measured twice daily, "trough" and "peak" values (in the morning before the use of drug and then between noon and 2.00 p.m.), each time twice. The OMRON device enables to print out the measured values. Casual hypertension was defined as casual BP 140/90 mmHg and higher, "home hypertension" was defined as a mean BP higher than 130/85 mm Hg from 8 home BP measurements performed during the last 2 days before the visit by the general practitioner higher than 130/85 mmHg. RESULTS: A significant decrease in both systolic and diastolic BP occurred during the treatment by perindopril or the combination of perindopril and a diuretic. The decrease in BP was observed both in the casual BP values and in the home BP values. Normalisation of the casual diastolic BP (diastolic BP lower than 90 mmHg) occurred in 59.3% of the patients after the first month of treatment, in 75.4% of the patients after 3 months of treatment, and in 78.5% of patients after 6 months of treatment. Only 2.1% of patients dropped out from the study due to side effects. These data demonstrated a very good efficacy and tolerance of perindopril. Only 62.6% of general practitioners showing interest in home BP measurement at the informative meetings joined the study and 14-19% of patients of the whole studied group did not use home BP at all. In general the interest of general practitioners and their patients observed in this study was less than that observed among the cardiologists in our previous study. The incidence of the "white coat phenomenon" was related to its definition, it increased when using a less strict definition and decreased during the course of therapy, in parallel to the normalisation of BP. Home BP values were significantly higher during the first 2 day of measurement then during the last 2 days of measurement (of the 4-days period). "White coat hypertension" could be observed in 9.4% of the group during the study. Home BP measurement also enabled to disclose "white coat normotension" defined as normal casual BP values and hypertensive home BP values. "White coat normotension" occurred at the end of the study in 26.3% of the patients. This relatively high number of patients with "white coat normotension" could be partly due to a short period of rest at home before taking home BP values. CONCLUSION: Home BP measurement was positively evaluated both by the general practitioners and patients. Home BP measurement provides better information about the efficacy of hypertension treatment and discloses "overtreatment" ("white coat hypertension") as well "undertreatment" ("white coat normotension"). It also increases the adherence of patients to the treatment of essential hypertension. The interest in home BP measuring was, however, less among the general practitioners and their patients than among the cardiologists and their patients (observed in a previous study).

Regression of left ventricular hypertrophy in hypertensive patients after 1 year of treatment with rilmenidine: a double-blind, randomized, controlled (versus nifedipine) study.

OBJECTIVE: To assess the effect of 1-year treatment with rilmenidine, an oxazoline compound that exerts its antihypertensive effects through binding to imidazoline receptors in the brainstem, on left ventricular hypertrophy (LVH) secondary to essential, mild-to-moderate hypertension [supine diastolic blood pressure (DBP)95-115 mmHg]. METHODS: We performed a double-blind, randomized, controlled (versus slow-release nifedipine) trial. Adjustment of treatment took place every month (M) between inclusion (MO) and an evaluation after 6 months (M6), then during M9 and after 1 year (M12) to achieve supine DBP values < or = 90 mmHg. Patients were dropped from our study if they had DBP> 95mmHg during two consecutive visits or DBP>115 mmHg on one occasion. The daily dosage of rilmenidine was 1 mg, and could be increased to 2 mg/day. The daily dosage of slow-release nifedipine was started from the beginning at the maximum dosage of 40 mg/day, so that there was no true adjustment of treatment despite the allocation of patients to a different unit in the case of DBP> 95 mmHg. The primary criterion was the change in left ventricular mass index (LVMI, g/m2), assessed by echocardiography, between MO and M12 for patients who completed the trial. RESULTS: After a 1-month placebo run-in period, 76 patients were selected and 73 were included (35 treated with rilmenidine and 38 treated with nifedipine). Fifteen patients withdrew from the study and two completed the study with a major deviation from protocol, leaving 56 patients (24 treated with rilmenidine and 32 treated with nifedipine) for a per-protocol analysis. Baseline demographic characteristics and history of arterial hypertension for the rilmenidine and nifedipine groups were similar, for included patients and for those taken into account for the per-protocol analysis. Between MO and M12, DBP in members of the per-protocol population was adequately controlled for those in the rilmenidine group (102.7+/-4.6 versus 88.5+/-7.1 mmHg, respectively) and for those in the nifedipine group (102.7+/-5.1 versus 85.6+/-79 mmHg, respectively). During MO, LVMI of patients in the rilmenidine group (176.9+/-41.3 g/m2) was slightly higher than that of patients in the nifedipine group (172.6+/-35.1 g/m2). During M12, LVMI was observed to have decreased both for patients in the rilmenidine group (to 154.8+/-40.2 g/m2, a decrease of 22.1+/-23.3 g/m2, P< 0.001) and for those in the nifedipine group (to 145.6+/-36.4 g/m2, a decrease of 26.9+/-29.5 g/m2, P< 0.001) but the difference between these two groups was not significant (P= 0.5). CONCLUSION: One-year treatment with a daily dosage of 1 or 2 mg rilmenidine achieves a significant reduction of left ventricular mass, which is not statistically different than that occurring with a daily dosage of 40 mg of slow-release nifedipine.

[Atherogenic and anti-atherogenic plasma lipoproteins modulate secretion of prostanoids by endothelial cells in vitro]. / Aterogénne a antiaterogénne lipoproteíny plazmy modulujú sekréciu prostanoidov endotelovou bunkou in vitro.

The authors present the evidence of atherogenic properties of VLDL and LDL potentiation on the model of endothelial cells-human umbilical vein endothelial cells, by preferable stimulation of the endothelial cell to thromboxane A1 production at in vitro conditions by atherogenic lipoproteins. The vasoconstrictive, thrombogenic and atherogenic effects of TXA2 are exerted on the vessel in this way. The ratio prostacycline/thromboxane, decisive for the maintenance of vascular homeostasis, is less than 1, this means the beneficial effect of prostacycline can not be applied. Protective, antiatherogenic effect of HDL and its subfractions HDL2 and HDL3/predominantly through their function in the reverse cholesterol transport from the periphery to the liver, antioxidative influence on LDL, as far as antiaggregation and fibrinolytic effects of HDL/is multiplied by the fact that HDL preferably stimulates the secretion of prostacycline by the endothelial cell. The ratio prostacycline/thromboxane A2 is higher than 1, that means beneficial vasodilative, antiaggregation and antiatherogenic effect of prostacycline on the vessel wall predominate. Quantitative evaluation of antiatherogenic effects of HDL subfractions (HDL2 and HDL3) revealed more significant antiatherogenic effect in HDL2 subfraction-in the sense of prostacycline secretion stimulation and exertion of its beneficial effects on the vessel. (Fig. 5, Ref. 33.)

A 5-year follow-up of preventive approach to patients with essential hypertension.

We examined the effect of a 4-5 week spa programme consisting of hypertension control education, physical education and smoking cessation on a long-term risk factor control. Two hundred and twenty hypertensive males underwent a 1 month training programme. At the end of the month, improvement had occurred in blood pressure (BP), heart rate (HR) exercise capacity, degree of obesity and serum cholesterol and triglycerides. At 5-year follow-up several parameters still showed improvement. The mean resting, exercise and recovery BP was lower than initial values as was the double product. The subjective and objective load tolerance during exercise had also improved. Half of the patients required less medication than initially to control their BP and in 80% of cases the BP was either the same or lower than initially. The mean heart size did not change from control values; 84% of patients felt that their general health improved. The mean triglyceride level was lower than at the start and the number of smokers had fallen from 33 to 21%. On the other hand several parameters showed disappointing results. The weight and serum cholesterol and risk factor score remained unchanged and mean resting HR actually increased. Only 10% were exercising regularly and 20% had a worsening of their BP. Thus intensive short term intervention studies may help reduce some cardiovascular risk factors temporarily but the long effect of this intervention in the control of risk factors is still limited.

Regression of left ventricular hypertrophy in patients with essential hypertension. Results of 6 month treatment with indapamide.

Left ventricular hypertrophy (LVH) is a major risk factor for cardiovascular morbidity in hypertensive patients. The effects of diuretics on LVH have raised controversies, but recent studies suggest that diuretics are able to reduce LVH in hypertensive patients, mainly through a reduction in ventricular diameter. The present multicenter open study was designed to test the effects of indapamide, a widely used nonthiazide diuretic, on LVH in patients with essential hypertension. Patients had to have mild-to-moderate essential hypertension (supine diastolic blood pressure [sDBP] 95 to 115 mm Hg) with echocardiographic evidence of LVH (left ventricular mass index [LVMI] > 130 g/m2 for men and > 110 g/m2 for women). After a 2 week placebo run-in period, eligible patients underwent a 6 month treatment with 2.5 mg indapamide daily. All echograms were performed by the same investigator before and after 6 months of indapamide. Clinical and biological acceptability and quality of life (visual analog scale) were also studied. One hundred and thirty patients were included in the study and 112 completed the trial. Indapamide induced a significant reduction i systolic and diastolic blood pressures. Indapamide induced a marked reduction in posterior wall thickness (from 12.1 +/- 2.0 to 11.2 +/- 1.6 mm) and in interventricular wall thickness (from 12.7 +/- 1.7 to 11.8 +/- 1.9 mm; each P < .001) and a slight decrease in left ventricular diameter (P = .049). This resulted in a 13% reduction in LVMI (from 161.9 +/- 37.9 to 140.7 +/- 33.8 g/m2, P < .001). Left ventricular fractional shortening remained unchanged. There was no significant relation between changes in LVMI and changes in systolic, diastolic, or mean blood pressure. No significant adverse clinical or biological effects were reported during the study. The increased score of the visual analog scale indicated that overall well-being was improved (P < .001). Our study indicates that indapamide, in addition to blood pressure control, is able to reduce LVH. This effect was achieved mainly through a reduction in wall thicknesses rather than in internal cavity diameter.

[Therapeutic approach in patients in hypertensive crisis]. / Terapeutický prístup k pacientovi s hypertenznou krízou.

The clinical picture of a hypertensive crisis is not determined only by the blood pressure reading but mainly by the associated symptoms of acute organ damage: neurological, cardiovascular and renal symptoms. The approach to the patient depends on the fact whether an emergency or urgent condition is involved. The authors review at first general principles of treatment of hypertensive crises. The analyze the therapeutic approach to different clinical conditions.

[Treatment of hypertension with a fixed combination of bopindolol and chlorthalidone (Sandoretic)]. / Lécba hypertenze fixní kombinací bopindololu a chlorthalidonu (Sandoretic).

A multicentric, prospective, 16-week open study evaluated the effectivity and tolerance of the fixed combination of the beta-blocking agent bopindolol with the diuretic chlorthalidone--Sandoretic in 81 patients with mild to moderate hypertension. The combination of these two drugs is appropriate, since both drugs have long-term effects. Sandoretic induced a decrease of the mean sitting initial systolic blood pressure of 162.5 +/- 16.5 mmHg to 134.2 +/- 12.8 mmHg at the end of the study, a decrease of 28.3 mmHg. Diastolic blood pressure decreased after 16 weeks of treatment from the initial value of 103.9 +/- 4.9 mmHg to 85.3 +/- 6.0, a decrease of 18.6 mmHg. Changes of the standing systolic and diastolic blood pressures were of similar magnitude. Sandoretic treatment led to a normalization of the diastolic blood pressure (90 mmHg and lower) in 80.3% of patients. In 49.4% of patients treatment with Sandoretic led even to a diastolic blood pressure of 85 mmHg and lower and 29.6% patients had at the end of treatment diastolic blood pressure 80 mmHg and lower. Tolerance of the drug was excellent in 75.3% patients. Sandoretic induced a mild, however, significant decrease of potassium plasma levels. The increase of the uric acid plasma level was also significant. Monitoring of potassium plasma levels is therefore necessary during the treatment with Sandoretic. In patients showing a decrease of the potassium plasma level, potassium sparing diuretic-amiloride should be added or the dosage of the drug should be halved.

[Problems posed by asymptomatic pheochromocytoma and malignant tumors of the adrenal medulla]. / Problèmes posés par les phéochromocytomes asymptomatiques et les formes malignes de tumeurs de la médullo-surrénale.

The authors analyse a group of 38 patients with a diagnosis of pheochromocytoma, in particular the topics of atypical symptomatology and malignancy. Three patients did not suffer from any subjective symptoms or other signs of pheochromocytoma ("incidentalomas"). Another three patients, although having giant tumours, only complained of atypical symptoms. Signs suspicious of malignancy were detected in 6 out of 38 patients. The authors recommend a practical approach to modern diagnostic and imaging tools for early primary diagnosis and for the early diagnosis of local recurrence and distant metastases.