Correlation of tumor necrosis factor alpha, interleukin 6 and interleukin 10 with blood pressure, risk of preeclampsia and low birth weight in gestational diabetes.

Several pathophysiological mechanisms have been proposed in the development of pregnancy complications, including endothelial dysfunction, an inflammatory pathway and oxidative stress. The aim of the present study was to evaluate the correlation between proinflammatory cytokines TNF-alpha, IL-6 and dual cytokine IL-10 in the mother's peripheral blood and systolic blood pressure, risk of preeclampsia and low birth weight in gestational diabetes (GDM). We observed 40 women with GDM divided into a gestational hypertension group (n=20) and comparison group (n=20) with normal blood pressure. We found a significant positive correlation between TNF-alpha; IL-6; IL-10 levels and systolic blood pressure (SBP) in the second trimester (p<0.001; p<0.001; p<0.001); the third trimester (p<0.001; p<0.001; p<0.05). We also proved correlations for diastolic blood pressure (DBP) during the second; third trimester (p<0.001; p<0.001; p<0.001); (p<0.001; p<0.001; p<0.0015). We demonstrated a statistically significant positive association between high TNF-alpha group and preeclampsia risk in the third trimester (p=0.04). We also determined the negative correlation in the second trimester between birth weight and TNF-alpha; IL-6, IL-10 levels (p<0.05; p<0.001; p<0.001). To conclude, our data highlight the importance of cytokines TNF-alpha, IL-6 and IL-10 in blood pressure regulation. In addition, high levels of TNF-alpha have been associated with increased risk of preeclampsia. We found a significant negative correlation between levels of TNF-alpha, IL-6, IL-10 and birth weight.

Relation of IL-6, IL-13 and IL-15 gene polymorphisms to the rheumatoid factors, anti-CCP and other measures of rheumatoid arthritis activity.

The aim of the study was to examine the relation between polymorphisms and serum levels of selected cytokines (IL-6, IL-13 and IL-15), production of autoantibodies and factors describing rheumatoid arthritis (RA), such as DAS28 and Total Sharp Score. A total of 156 patients with RA according to the ACR criteria, and 200 control subjects were recruited into the study. The measurements of CRP, anti-CCP, the presence of rheumatoid factors (RFs), radiographs of both hands with calculation of Total Sharp Score (TSS) and DAS28 were obtained from all patients with RA. In total, five polymorphisms in genes coding cytokines (IL-6, IL-13 and IL-15) were detected. The levels of these selected cytokines were measured in serum using ELISA method. A significant difference in allele frequencies between patients with RA and controls was observed for IL-15 -267C/T polymorphism. A higher prevalence of heterozygote variants of IL-15 polymorphisms (14035A/T and -267C/T) in the RF IgG- and RF IgA-negative subgroups was observed. Furthermore, the association of polymorphisms in gene for IL-15 with circulating level of IL-15 (14035A/T and 367G/A) and with total RF and Ig-specific RFs (-267C/T) was found. The relation of IL-15 to RFs IgA, IgM, IgG and the measure of DAS28 was proved. The frequency of the T allele of the IL-13 polymorphism -1112C/T was higher in subgroup with faster progression of the disease (TSS/month ≥ 0.1). In conclusion, we present an association of IL-15 gene polymorphisms with the RFs including subtypes (RF, IgG, IgA) underlined by the relation of increased IL-15 levels in circulation to RFs.

[Use of natriuretic peptides in diagnosis of left ventricular hypertrophy in obese hypertensive patients with metabolic syndrome]. / Vyuzití natriuretických peptidu v dia-gnostice hypertrofie levé komory srdecní u obézních hypertoniku s metabolickým syndromem.

INTRODUCTION: Presence of left ventricular (LV) hypertrophy significantly increases cardiovascular risk in patients suffering from hypertension. Diagnostics of LV hypertrophy in hypertensive patients is not easy and there is still no method of enabling a simple and sufficiently sensitive dia-gnosis across a large patient population. The golden standard in LV hypertrophy diagnostics is echocardiography, and there are adverse opinions regarding the use of natriuretic peptides BNP and NT proBNP (NP) to diagnose LV hypertrophy. PATIENTS AND METHODS: We examined through echocardiography 173 hypertensive patients with signs of metabolic syndrome and a moderate increase in blood pressure (130- 159/ 85- 99 mm Hg) with an average age of 54.8 ± 13.54 years, i.e. 119 men and 54 women, who were divided into 2 groups; 1 with BMI > 30 (group A with a severe obesity) and the other without obesity, BMI < 30 (group B). Both groups were examined for BNP and NT proBNP levels. RESULTS: We found a positive correlation between NP and LVMi, both for BNP (r = 0.169; p = 0.033) and for NT proBNP (r = 0.240; p = 0.002). NT proBNP statistically significantly predicts the given LV hypertrophy LK in people with BMI < 30 but not in obese people (BMI > 30). CONCLUSION: Obese patients suffer from a higher occurrence of left ventricular hypertrophy and paradoxically a lower NP value than patients with a metabolic syndrome (MS) who are not obese. Natriuretic peptides have a limited diagnostic value when assessing left ventricular hypertrophy. They are only of value in patients who are not obese and whose kidney function and systolic myocardial function have not been impaired.

[Where is the treatment of hypertension heading?]. / Kam smeruje lécba hypertenze?

High normal blood pressure is defined as pressure of 130- 138/ 85- 89 mm Hg. The term prehypertension is used for systolic blood pressure of 120- 139 mm Hg and diastolic pressure of 80- 89 mm Hg. The question is whether blood pressure at those levels should be treated and if so, in which patients. Another question is, whether the therapy can affect the incidence of hypertension and cardiovascular complications.

[Adherence and persistence with a focus on the treatment of hypertensive patients]. / Adherence a perzistence se zamerením na lécbu hypertenzních pacientu

Insufficient adherence of patients to treatment is a serious problem and it is monitored most frequently in hypertensive patients. The possibilities of increasing adherence to longterm treatment include mainly the motivation and education of patients, simple dosage regimes, telephone consultations and involving the patient in the treatment process (self monitoring), but it also means providing information about the consequences of failure to adhere to the treatment process. Other possibilities can include new dosage forms which increase the biological availability of medicines, reduce the variability of absorption, and thus allow for achieving their more stable levels. It is possible to take advantage of fixed combinations which can improve adherence. Some new dosage forms simplify the therapy for patients and make it more pleasant. One of the latest innovations is for example, orodispersible dosage forms, which have been recently introduced in the therapy of arterial hypertension. In order to improve the adherence of patients to hypertension treatment it is necessary to use all means available adjusted to the individual needs of patients.

[Comparison of MRCP a ERCP in diagnosis of choledocholithiasis]. / Srovnání MRCP a ERCP v diagnostice choledocholitiázy.

INTRODUCTION: Choledocholithiasis is the most common cause of biliary obstruction. Each of the testing methods used in its diagnosis has its advantages and disadvantages. OBJECTIVE OF THE STUDY: The objective of this prospective study is to compare endoscopic retrograde cholangiopancreatography with magnetic resonance cholangiopancreatography in the diagnosis of choledocholithiasis on the basis of own experience and literature data. Set of patients and methodology: The set was studied from the beginning of 2007 to the end of 2012 (i.e. six years). The study assessed prospectively 45 patients (age range 28- 72 years) with symptoms of biliary obstruction, who first underwent magnetic resonance cholangiopancreatography and subsequently endoscopic retrograde cholangiopancreatography. RESULTS: The sensitivity, specificity and diagnostic accuracy of magnetic resonance cholangiopancreatography was lower, both in our set of patients and according to the literature data, compared to the endoscopic retrograde cholangiopancreatography (92%, 91% or 93 %). CONCLUSION: Considering the frequency of complications (in some cases serious ones) following endoscopic retrograde cholangiopancreatography, the magnetic resonance cholangiopancreatography is, in spite of its lower sensitivity, the method of choice in the diagnosis of choledocholithiasis by means of noninvasive methods, on the basis of which it is possible to refer the patients subsequently for therapeutic endoscopic retrograde cholangiopancreatography.

[Spondyloarthritides: current perspective on diagnosis and classification]. / Spondyloartritidy: aktuální pohled na diagnostiku a klasifikaci.

Spondyloarthritides (SpA) are a heterogeneous group of chronic inflammatory diseases with common clinical features and genetic basis. They primarily affect the axial skeleton, especially the sacroiliac joint, other localizations of the affection being peripheral joints and entheses -  typical of the group of spondyloarthritides. On the basis of the predominant affection of the axial or peripheral skeleton, they can be divided, according to the current classification criteria, into axial SpA and peripheral SpA. Apart from axial and peripheral articular manifestations, many patients also display extra articular manifestations, which can thus become an important diagnostic clue and also the first symptom of the disease. The most frequent of them are anterior uveitis, inflammatory bowel diseases, and psoriasis. Also the strong binding of spondyloarthritides to the positivity of HLA B27 antigen or a family history of the disease is important information which helps in the diagnosis. Comorbidities, the most common and important of which are cardiovascular diseases or osteoporosis and its consequences in the form of fractures, are an integral part of the issue of spondyloarthritides.

[Endoscopic retrograde cholangiography with a single-balloon enteroscope in patients with Roux-en-Y hepatico jejunal anastomosis]. / Endoskopická retrográdní cholangiografie pomocí jednobalónkového enteroskopu u pacientu s Roux-Y hepatikojejunoanastomózou.

AIMS OF THE STUDY: The aim of this retrospective study was to evaluate our experience with using a single-balloon enetroscope for diagnostic and therapeutic endoscopic retrograde cholangiography (ERC) in patients with Roux-en-Y hepatico jejunal anastomosis (HJA). Due to the considerably changed anatomic circumstances after the surgery, ERC is, in comparison to the standard endoscopic retrograde cholangiopancraeaticography (ERCP), significantly more difficult to perform. PATIENT SAMPLE AND METHODOLOGY: The sample was followed up from January 2009 to September 2011. The study retrospectively reviewed 14 patients with Roux-en-Y HJA with symptoms of biliary obstruction. A total of 21 ERCs were performed in these 14 Roux-en-Y HJA patients using the single-balloon videoenetroscope Olympus SIF Q 180. RESULTS: Diagnostic ERC cannulation was successful in 11 of the 14 patients (79% success rate for the diagnostic ERC). One of the 11 patients had a normal finding on the ERC. The remaining 10 patients had a pathological finding on ERC that, in one patient (cystic dilatation of bile duct), was subsequently managed surgically. Endoscopic treatment was initiated in the remaining 9 patients (HJA stenosis in 4, choledocholithiasis in 2 and concurrent HJA stenosis and choledocholithiasis in 3) immediately after the diagnostic ERC; the surgery was successful in 8 of the 9 patients (89% success rate for the therapeutic ERC). The performed endoscopic therapeutic procedures included: balloon dilatation of HJA stenosis 9 times (6 patients), choledocholithiasis extraction - 5 times (5 patients), biliary plastic stent placement - 5 times (3 patients), removal of biliary stents placed by us - 5 times (3 patients). We did not observe any complications in our sample of 14 patients. CONCLUSIONS: ERC using a single-balloon enteroscope in patients with Roux-Y HJA is significantly more difficult than the standard ERCP due to different post-surgical anatomy. In our sample of patients, we achieved 79% success rate for the diagnostic ERC and 89% success rate for the therapeutic ERC. Additional time should be allowed for the individual procedures. Furthermore, the presence of an anaesthesiologist during these operations (deep analgosedation) is essential. This is a technically very demanding technique that, however, is effective and safe and importantly extends the options available for the management of biliary pathologies in these patients.

[The importance of antihypertensive therapy in subclinical brain damage]. / Význam antihypertenzní lécby u subklinického poskození mozku.

Older patients are often affected by impaired cognitive function and high blood pressure. Damage to microcirculation of the brain is closely related to changes in large vessels. High blood pressure and vascular stiffness might lead to a damage in microcirculation of the brain and, consequently, to worsening of the patient's cognitive function and dementia. We discuss early diagnosis of subclinical brain damage using magnetic resonance and its preventive management with antihypertensive therapy.

[Hypertension and cardiovascular complications of chronic renal failure]. / Hypertenze a kardiovaskulární komplikace thronického selhání ledvin.

Chronic renal failure is associated with a significant cardiovascular risk due to an increased incidence of cardiovascular risk factors (hypertension, diabetes mellitus, dyslipidemia). Cardiovascular mortality is due to an increased incidence of left ventricular hypertrophy, ischemic heart disease and chronic heart failure. Management focuses on risk factors, mainly high blood pressure in patients with mild to moderate chronic kidney disease, but it often fails in patients with chronic kidney failure.

[The efficacy and safety of moxonidine in patients with metabolic syndrome (the O.B.E.Z.I.T.A. trial)]. / Ucinnost a bezpecnost podávání moxonidinu u pacientu s metabolickým syndromem (klinické hodnocení O.B.E.Z.I.T.A.).

INTRODUCTION: Treatment with agents neutral to lipid metabolism but with a positive effect on glucose metabolism might significantly improve the long-term prognosis of patients with metabolic syndrome and hypertension. The aim of our non-interventional observational clinical study was to evaluate the safety of treatment with moxonidine and to assess changes to the metabolic syndrome-related laboratory parameters. MATERIALS AND METHODS: A total of 748 patients over 18 years of age (22-87; mean 59; median 60) were included in a 6-month evaluation (two 3-monthly study visits). There were slightly more female patients (n = 401, 54%) with metabolic syndrome (> or = 3 NCE ATP III risk factors) and poorly controlled hypertension. A standardized data collection form was used, blood pressure measurement was standardized as per the guidelines and laboratory samples were assessed in a certified laboratory. The study medication (moxonidine, Cynt) was prescribed to patients with newly diagnosed hypertension and/or patients with hypertension poorly controlled at an initial visit. RESULTS: The majority of patients (98.8%) completed the study. No adverse effects were reported during the study. Moxonidine was mostly prescribed as an add-on treatment to other antihypertensives (81.1% patients) due to the lack of efficacy of the present antihypertensive treatment. The most frequent dose was 0.4 mg/day as monotherapy (44.9% of patients) as well as add on treatment (59.8% of patients). A change to the treatment was performed in 142 (19.2%) of patients during the follow up visit and in 57 (7.7%) of patients during the last study visit. All parameters (blood pressure, body weight, waist circumference, total cholesterol, LDL- and HDL-cholesterol, triglycerides, glycaemia and pulse) have changed highly significantly (p < 0.001). CONCLUSION: Over the 6-month follow up, a highly significant change was observed to all monitored parameters. An addition of monoxidine (Cynt) to an existing treatment resulted not only in a reduction to blood pressure but also in highly significant changes to metabolic parameters without any significant modifications of the treatment. Treatment with monoxidine can be considered as metabolically neutral with an added value of positive effect on metabolic parameters. This is in line with the results of other studies.

[Hypertension in patients with diabetes mellitus]. / Hypertenze u patienta s diabetes mellitus.

Hypertension in patients with type 2 diabetes mellitus (DM) is one of the most frequent, most serious but treatable risk factors. The results of randomised studies clearly show the benefits of improved blood pressure control in type 2 DM patients but achievement of target blood pressure values in clinical practice remains a major problem. Type 2 DM, and primarily increased systolic blood pressure, significantly worsen patient prognosis with respect to microvascular as well as macrovascular complications. Recommendations by the European Society of Hypertension and the European Society of Cardiology emphasise the need for good diagnostics and effective management, predominantly using combination therapy. In 2009 a revision of recommendations for diagnostics and treatment of hypertension was issued that defines initiation of hypertension therapy in type 2 DM patients and target values and presents results of the most recent studies.

[The normalized smoothness index and parametric population RDH index of losartan in patients with newly diagnosed hypertension and metabolic syndrome]. / Normalizovaný smoothness index a parametrický populacní RDH index losartanu u pacientu s cerstve zjistenou hypertenzí a metabolickým syndromem.

INTRODUCTION: Ambulatory blood pressure monitoring provides an opportunity to evaluate 24-hour efficacy of once daily preparations. AIMS OF THE STUDY: To evaluate 24-hour efficacy of losartan in patients with newly diagnosed hypertension and metabolic syndrome using the parametric population RDH index and normalized smoothness index. PATIENT SAMPLE AND METHODOLOGY: Twenty seven patients with newly diagnosed hypertension and with metabolic syndrome, sufficiently responding to blood pressure therapy with losartan, assessed using sphygmomanometer. 18 men, 9 women, mean age of 48 years, body mass index of 32.6 kg.m(-2), before and after 1 year of therapy with losartan in the mean dose of 69 mg once a day. Blood pressure measured with sphygmomanometer and 24-hour ambulatory monitoring (SpaceLabs 90207) according to the European Society of Hypertension criteria. Hypertension was defined as sphygmomanometer-measured blood pressure values of more than or equal to 130 and/or 85 mm Hg. Fulfilment of at least 3 criteria of metabolic syndrome according to the definition by The Adult Treatment Panel III. RESULTS: The population normalized smoothness index of losartan (+/- standard error of the mean) was 1.10 +/- 0.13 for systolic pressure, 0.81 +/- 0.11 for diastolic pressure and 1.00 +/- 0.14 for mean arterial blood pressure. The parametric population RDH index of 24, 24, 0 for systolic pressure and 24, 24, 0 for diastolic pressure. CONCLUSION: Losartan at a mean dose of 69 mg once daily showed an adequate 24-hour efficacy in patients with newly diagnosed hypertension and metabolic syndrome responding to treatment when blood pressure was measured using sphygmomanometer and the effect expressed as the parametric population RDH index for systolic as well as diastolic pressure and when evaluating normalized smoothness index based on systolic blood pressure value and mean arterial pressure.

[Our experience with endoscopic drainage of pancreatic pseudocysts]. / Nase zkusenosti s endoskopickou drenázní lécbou pankreatických pseudocyst.

INTRODUCTION: The authors first provide and overview of the main knowledge on pancreatic pseudocysts. They discuss the individual types of pancreatic pseudocysts, their clinical picture, complications and diagnosis. As part of the differential diagnosis, they emphasise the need to distinguish pancreatic pseudocysts from cystic tumours and benign cysts. Special attention is then paid to various modalities of treatment of pancreatic pseudocysts. METHODS: The authors present their own results of endoscopic drainage of pancreatic pseudocysts, one of the key options in the treatment of this condition. RESULTS: A total of 33 patients (24 men and 9 women) were treated by endoscopic drainage between September 2007 and March 2009. Endoscopic drainage was performed transduodenally in 4 patients and via the transgastric route in 29 patients; 6 times with endosonographic device and with duodenoscope after endosonographic alignment in 27 patients. CONCLUSION: The authors conclude that endoscopic drainage is an effective method of treatment of pancreatic pseudocysts.

[Aortic pulse wave velocity in patients with metabolic syndrome and hypertension treated with sartans]. / Rychlost aortální pulzové vlny u nemocných s metabolickým syndromem a hypertenzí lécených sartany.

INTRODUCTION: The incidence of subclinical organ damage is higher in patients with hypertension (HT) and metabolic syndrome (MS). Increased aortic pulse wave velocity (PWV) is one the markers reflecting subclinical arterial damage. Treatment with sartans leads not only to a reduction of blood pressure but may also bring regression of the subclinical damage. Long-acting sartans (telmisartan) may be more effective than sartans with medium duration of action (losartan); the aim of this research was to compare the impact of hypertension therapy with losartan and telmisartan on aortic pulse wave velocity (Ao-PWV). METHODS: We examined 32 patients with HT and MS, 15 patients were treated with losartan 50 mg (group A) and 17 patients were treated with telmisartan 80 mg (group B). At the beginning and the end of the study, PWV was measured using the Complior method and 24-hour BP monitoring and biochemistry testing were carried out. RESULTS: Treatment with sartans led to a reduction in BP in both groups, daytime BPs/BPd declined by 11.5/9.0 mm Hg in group A and by 13.8/8.1 mm Hg in group B, respectively, and night time BP declined by 5.7/5.1 mm Hg in group A compared to 7.4/3.89 mm Hg in group B. Aortal pulse wave velocity declined by 1.94 m/s in group A (p < 0.001) and by 0.46 m/s in group B (p < 0.001), respectively. CONCLUSION: Treatment with losartan as well as telmisartan resulted in reduced values of BP and Ao-PWV. We did not prove a more significant effect of a long-acting sartan (telmisartan) compared to a sartan with a medium duration of action (losartan) on Ao-PWV reduction after 1 year of treatment.

[The normalized smoothness index and parametric population RDH index of telmisartane in patients with newly diagnosed hypertension and metabolic syndrome]. / Normalizovaný smoothness index a parametrický populacní RDH index telmisartanu u pacientu cerstve zjistenou hypertenzí a metabolickým syndromem.

INTRODUCTION: Ambulatory blood pressure monitoring provides an opportunity to evaluate 24-hour efficacy of once daily preparations. AIMS OF THE STUDY: To evaluate 24-hour efficacy of telmisartane in patients with newly diagnosed hypertension and metabolic syndrome using the parametric population RDH index and normalized smoothness index. PATIENT SAMPLE AND METHODOLOGY: Thirty newly diagnosed hypertonics with metabolic syndrome, sufficiently responding to blood pressure therapy with telmisartane, assessed using sphygmomanometer. Twenty six men, 4 women, mean age of 44 years, body mass index of 31.4 kg. m2, before and after 1 year of therapy. Blood pressure measured with sphygmomanometer and 24-hour ambulatory monitoring (SpaceLabs 90207) according to the criteria of the European Society of Hypertension. Hypertension was defined as sphygmomanometer-measured blood pressure values of more or equal to 130 and/or 85 mm Hg. Fulfilment of at least 3 criteria of metabolic syndrome according to the definition by The Adult Treatment Panel III. RESULTS: The population normalized smoothness index oftelmisartane (+/- standard error of the mean) of 1.00 +/- 0.11 for systolic pressure and 0.84 +/- 0.10 for diastolic pressure. The parametric population RDH index of 24, 24, 0 for systolic pressure and 22, 15, 1 for diastolic pressure. CONCLUSION: Telmisartane at a mean dose of 60 mg once daily showed an adequate 24-hour efficacy in patients with newly diagnosed hypertension and metabolic syndrome responding to treatment, when blood pressure was measured using sphygmomanometer and the effect expressed as the parametric population RDH index and normalized smoothness index based on systolic blood pressure value. We did not prove the full 24-hour efficacy when diastolic blood pressure was used to calculate both indexes.

[Evaluation of cardiovascular high risk population in specialist ambulatory care: ESA]. / Evaluation of cardiovascular high risk population in Specialists Ambulance: ESA.

BACKGROUND: Arterial hypertension is the most common CV disease in the Czech Republic with estimated prevalence 35% among population aged 25 to 64 years. Although serious public health problem with significant medical and economic consequences the treatment of HT is currently unsatisfactory. Only 18.4% of patients with arterial HT reach goal BP. There are several factors responsible for this fact, among them low compliance of patients, low dosages of antihypertensive drugs used and low usage of the combination of antihypertensive drugs. AIM: To obtain following data from the specialists ambulances (internists and cardiologists) regarding hypertensive patients: frequency of high risk hypertensive patients and proportion of patients with hypertension in whom BP is well controlled (target BP reached). Another goal of the study was to obtain data about pharmacological treatment of hypertensive patients. METHOD: National, multicenter, non-interventional, cross sectional, representative sample, one visit study. RESULTS: Data of 19,821 patients with primary hypertension visited office-based internists and cardiologists was analysed. The average age was 64 +/- 12 years (range 19-99 years), 53% was women. The mean blood pressure of entire population was 138.5 +/- 15.1/81.7 +/- 9.1 mm Hg. There were high proportion of patients with well controlled blood pressure (BP below 140/90 mm Hg)--48% of the patients. Among those with diabetes the proportion of well controlled patients was much lower--only 11% of the patients. Regarding other cardiovascular risk factors the most common was hyperlipidaemia--66% of the patients, following by diabetes and smoking with 29 and 14% of the patients respectively. 8,444 (43%) of the patients suffered from the coronary artery diseases, 2,251 (11%) patients have experienced stroke or TIA and 1,601 (8%) patients had peripheral artery disease. Regarding antihypertensive therapy, only 21% of the population was treated by monotherapy. The most common was the combination of ACE inhibitors plus beta-blockers or triple-combination of ACE inhibitors plus diuretics plus beta-blockers.

[Treatment of hypertension in patients with diabetes mellitus and lower limb ischemia]. / Lécba hypertenze u pacientu s diabetes mellitus a ischemickou chorobou dolních koncetin.

The impact of some types of antihypertensives on carbohydrate metabolism and their association with type 2 diabetes is well-known. In this respect, ACE inhibitors, AT1 blockers or I1 imidazoline agonists, known to improve insulin sensitivity, are the first line therapeutic choice. Metabolism-neutral calcium channel blockers, particularly the dihydropyridines, are the second in line of therapeutic options. On the other hand, beta-blockers and diuretics, thiazide in particular, exert negative effect on carbohydrate metabolism. Should their use be still desirable, e.g. due to co-morbidities, it is advisable to select cardio-selective beta-blockers or beta-blockers with ISA activity, since the effect of these agents on carbohydrate and lipid metabolism is less significant. Diuretics should then be used only in combination therapy and in small doses; potassium-sparing or metabolically neutral indapamide derivatives should be selected. The benefit of cardioprotectivity, gained from the treatment with cardioselective beta-blockers will, particularly in patients with ischemic heart disease, usually outweigh the risk of metabolic adverse effects. Combination therapy, using AT1 blockers or ACE inhibitors in combination with calcium channel blockers or diuretics, should be utilized to its full potential in order to ensure that target values are achieved. Recently completed studies provide the evidence to support this approach. Hypertension in patients with lower limb ischemia increases the already high cardiovascular risk in these patients. Blood pressure reduction as such is more important than a specific antihypertensive.