Long-term outcome of surgical revascularization in ischemic nephropathy: normalization of average decline in renal function.

OBJECTIVE: Renovascular disease may lead to ischemia of the nephrons and to fibrosis, which is generally considered to be irreversible and progressive. We investigated the potential of revascularization to recover and stabilize renal function in patients with ischemic nephropathy. METHODS: In a retrospective analysis of all our 61 patients with ischemic nephropathy who underwent treatment with surgical revascularization, we determined the long-term course of renal function decline with an estimated glomerular filtration rate (EGFR; Cockcroft and Gault formula). With the assumption of normal renal function at age 25 years, the preoperative slope of EGFR and the postoperative slope of EGFR were determined from the EGFR before surgery, at the short-term follow-up examination (on average, 8 months after surgery), and at the long-term follow-up examination (on average, at 47 months after surgery). These declines in renal function were compared with EGFR values in age-matched and sex-matched samples from a large cross-sectional population study. RESULTS: The overall surgical mortality rate amounted to 13.1%. Five patients became dialysis dependent-two with preexisting end-stage renal disease and three at later follow-up examination-and two patients, who before surgery were dialysis dependent, could be withdrawn from dialysis treatment. Shortly after the operation, the mean EGFR level had increased from 28.3 to 43.1 mL/min/1.73 m2 ( P <. 01). The rate of decline in renal function had decreased from an estimated -2.57 mL/min/1.73 m2/year before surgery (weighted mean: interquartile range, -2.71 to -1.98) to -0.66 mL/min/1.73 m2/year (weighted mean: interquartile range, -2.00 to -0.18) in the short-term interval to the long-term interval, which was even slightly better than the slope of -0.84 mL/min/1.73 m 2/year in the age-matched and sex-matched control population. CONCLUSION: Surgical revascularization in selected patients with renovascular disease and ischemic nephropathy restores renal function and makes the average long-term rate of decline in renal function equal to that of the general population. This indicates that in most patients a "point-of-no-return" has not yet been passed even though their renal function is already markedly impaired before surgery. Therefore, in well-selected patients with ischemic nephropathy, considerable improvement of renal function can be realized.

Issues for cardiovascular disease risk factor development in Europe.

A review of U.S. and European clinical trials and cardiovascular prevention studies indicates a strong relation among cardiovascular disease risk factors and between metabolic factors and health behaviors established in youth. Social and behavioral determinants of risk are best modified by strategies applied in schools, families, and whole communities to provide a firm base for primordial prevention of risk factor development. This is illustrated with results from a European intervention trial and from observational studies in the young.

[Current tasks and structure of the Council on Public Health]. / Huidige opdracht en structuur van de Hoge Gezondheidsraad.

The Council on Public Health (CPH) is a scientific council established in 1848 to assist the authorities in public and environmental health. The CPH has recently been restructurized mainly on the basis of changes in tasks related to obligations at the European level and to the integration of the National Council on Nutrition in the CPH. The CPH consists of 80 members; the CPH is subdivided in seven sections and one logistic unit. Several sections are further subdivided in subsections each of which deals with specific problems. The CPH is assisted by a scientific and an administrative secretariat. The activities of the CPH are illustrated with several examples of important subjects that were treated recently.

Autonomic imbalance in the recovery period after myocardial infarction.

The aim of the study was to evaluate the responses to autonomic function tests during the healing period of myocardial infarction (AMI). In 24 patients, at 2 and 6 weeks after the acute event, Valsalva manoeuvre, deep breathing at 6 breaths per min, isometric handgrip and cold pressor tests were performed. Responses of arterial blood pressure (BP) and heart rate (HR) were measured. At 2 weeks post AMI a significant decrease in parasympathetic tone was noted: HR reduction during deep breathing: 18.5 +/- 5.7 beats.min-1 for controls vs 9.7 +/- 2.6 beats.min-1 for AMI, P < 0.001. Systolic BP response to handgrip and cold pressor test was only slightly (non significantly) increased: 30.6 +/- 12.9 mmHg (controls) vs 40.0 +/- 20.5 mmHg (AMI) for the handgrip test and 13.8 +/- 8.1 mmHg vs 18.0 +/- 10.1 mmHg respectively for the cold pressor test. At 6 weeks post AMI, the response to the deep breathing test (15.9 +/- 5.6 beats.min-1) no longer significantly differed from that in controls. In contrast, the sympathetic stressor tests showed a significant increase in systolic BP response: 63.8 +/- 21.9 mmHg, P < 0.001 and 26.1 +/- 14.9 mmHg, P < 0.05, respectively for the handgrip and cold pressor tests. It appeared that infarct localization had no effect on autonomic function tests. There is evidence of autonomic imbalance both at 2 and 6 weeks after AMI, with a rapid but transient decrease in vagal activity and enhancement of orthosympathetic nervous tone; this was markedly more pronounced at 6 weeks post AMI despite treatment with beta-blocking agents in all patients.

24 hour ambulatory blood pressure variability and cardiac parasympathetic function 2 and 6 weeks after acute myocardial infarction.

The aim of the study was to assess non-invasively circadian blood pressure rhythm as well as the influence of parasympathetic function 2 and 6 weeks after acute myocardial infarction treated with beta-blocking agents. Twenty-four patients with uncomplicated first myocardial infarction, and aged less than 60 years, underwent ambulatory blood pressure recordings every 15 min during the day (0900-2100 h) and every 30 min during the night (2100-0900 h), 2 and 6 weeks after infarction. The deep breathing test (6 breaths/min) was performed on each occasion. Normal circadian blood pressure rhythm was maintained with a nocturnal decline of 10 to 15%. Both for systolic and diastolic blood pressure a moderate increase was obtained after 6 weeks (107.8 +/- 9.2 mmHg vs. 111.8 +/- 10.3 mmHg; NS and 64.9 +/- 4.5 mmHg vs. 68.8 +/- 6.5 mmHg; p < 0.05). The respective blood pressure variations were significantly higher at that time (10.0 +/- 2.4 mmHg vs. 13.6 +/- 4.2 mmHg; p < 0.001 and 7.9 +/- 1.7 mmHg vs. 11.7 +/- 3.5 mmHg, p < 0.001). There was a close correlation (r = 0.60, p < 0.005) between 24-h diastolic blood pressure variability and the results of the parasympathetic function test (deep breathing) 2 weeks after infarction. We conclude that the circadian blood pressure rhythm persists after acute myocardial infarction. The correlation between blood pressure variability and parasympathetic function early after infarction suggests a role for vagal control in post-infarction blood pressure variability.

Physical fitness does not reflect physical activity patterns in middle-aged workers.

Questionnaires and a sub-maximal exercise test were used to assess occupational and leisure time physical activity as well as physical fitness in a standardized prospective study in 2,565 Belgian and Slovakian middle-aged healthy workers. Less than 5% of the subjects engaged in strenuous work requiring an energy expenditure above 31.5 kJ.min-1. One-third of the Belgians and 50% of the Slovakians reported no heavy leisure time activity during the preceding 12 months. Physical fitness, defined as the workload at heart rate 150 beats.min-1 (standardized for body weight), was significantly higher in Slovakians as compared to Belgians (1.52 +/- 0.28 W.kg-1 and 1.48 +/- 0.28 W.kg-1; P less than 0.001). Occupational physical activity in Belgians and heavy leisure time activity in Slovakians were independently related to fitness levels. However, each activity score explained less than 1% of the variance of physical fitness. We conclude that in these mainly sedentary, middle-aged subjects, fitness levels are independent from the usual physical activity patterns.

Double-blind, randomized, placebo-controlled study of molsidomine in patients with stable effort angina receiving beta-blocker therapy with atenolol.

A randomized, double-blind, placebo-controlled trial was performed in 12 patients with chronic and stable effort angina to study the antianginal and anti-ischemic actions of a single dose of molsidomine in addition to long-term therapy with a long-acting beta-adrenergic blocker (100 mg of atenolol daily). Efficacy was assessed by means of objective endpoints obtained by computer-assisted exercise testing. The mean exercise time to produce angina improved significantly from 330 +/- 38 seconds (mean +/- SEM) in patients after administration of atenolol and placebo to 420 +/- 36 seconds after administration of atenolol and molsidomine. Similar significant improvements were seen in ST segment changes at an identical exercise duration, in maximal heart rate, and in maximal exercise duration. The increased anginal threshold and the reduced ischemic changes were not explained by changes in the rate-pressure product at submaximal levels. Thus molsidomine showed antianginal and anti-ischemic efficacy in the treatment of stable effort angina additional to the effect of long-term therapy with beta-adrenergic blockers.

Prevalence of left ventricular hypertrophy in middle-aged men according to various ECG-VCG techniques.

The prevalence rates of left ventricular hypertrophy (LVH) were studied in a middle-aged male working population using the Minnesota code, an automated processing of the orthogonal leads, and the Pipberger program. These various methods resulted in significant differences in prevalence rates. The odds ratios and relative differences were calculated for each method in subgroups according to the presence or absence of personal antecedents of arterial hypertension. For detecting LVH, the orthogonal criteria are superior to the other methods. The concordances between methods are low overall, leaving the question open as to the independent prognostic value of each method.

Prognostic value of exercise testing: a 6-year follow-up in post-myocardial infarction patients.

The predictive value of a symptom-limited exercise test was studied over a 6-year period in 112 men, who had survived a myocardial infarct. The test was performed within 3 months after the infarct. Among clinical variables, only a history of a previous myocardial infarct seems to bear some prognostic importance. Among the exercise parameters, the development of a ST-segment depression of greater than or equal to 2.0 mm at low effort and the maximal exercise parameters were indicative of future mortality and non-fatal recurrent infarction.