Descriptors: Hypertension – epidemiology, drug therapy, prevention and control; Croatia – epidemiology
Summary. Poor control of blood pressure (BP) is one of the main reasons for high cardiovascular mortality and morbidity. The aim of this study was to analyse control of BP in outpatient settings in four biggest towns in Croatia. The study included 412 medical doctors (GP) and 7031 middle-aged patients (62.9±11.5 years). Mean BP in treated patients was 162.9± 16.8/95.6±9.9 mmHg. There were no statistically significant differences in systolic (p=0.173) and diastolic (p=0.561) BP between men and women. In this group of patients only 8% achieved target BP values. In contrast, and surprisingly, 44.5% of medical doctors and 72% of patients were satisfied with obtained BP control. Higher percentage of male patients vs. female were satisfied with blood pressure control (81.9%:66.9%). BMI <25 was registered in 22.9% of hypertensive patients, and there was statistically significant difference in BMI between men and women (c2=56.769, p<0.001). In this study we found a statistically significant difference of hypertension in regard to BMI in both sexes (c2m=46.339, p<0.001; c2`=45.992, p=0.024). BMI was in correlation with severity of hypertension as well as with obtained treatment result. BMI was in correlation with the number of prescribed drugs. According to this, patients with BMI <25 were prescribed less drugs than those with BMI >30 (1.4:1,6 p=0.001). BP control in Croatia is, according to this study, very poor. The main reason for such situation is, beside obesity which determines the stage of hypertension and BP control in both sexes, insufficiently developed conscience in patients and doctors about the importance of stronger blood pressure control. The results indicate the necessity for the more intensive education of the population.

Descriptors: Antihypertensive agents – therapeutic use, adverse effects, pharmacology; Diabetes mellitus,
type 2 – chemically induced, physiopathology, complications; Hypertension – drug therapy, complications; Blood glucose – metabolism, drug effects
Summary. Arterial hypertension is frequently associated with type 2 diabetes mellitus, and both of these diseases are the major risk factors for cardiovascular complications. During the past few years, a number of large randomized clinical trials examined the frequency of new onset diabetes mellitus during administration of antihypertensive drugs. Application of ACE inhibitors or angiotensin receptor blockers reduces the risk for the onset of diabetes mellitus by 20–27%, and calcium channel blockers by 16%. Despite some uncertainties, novel studies have demonstrated an increased risk for cardiovascular complications related to new onset diabetes mellitus. The duration of patient monitoring is also an important factor, as the onset of diabetes-related complications is closely associated with the duration of this disease. Considering all above, the aim of preventing the onset of diabetes is to recognize patients with an increased risk. The risk factors include basal glycemia, positive family history for diabetes mellitus, obesity, metabolic syndrome, and some ethnic groups (South Asia, the Caribbeans). Therefore, increased-risk patients should be subjected to therapy with ACE inhibitor, angiotensin receptor blocker, or calcium channel blocker as the first drug of choice. For these patients, application of thiazides and beta blockers or the combination of these two drugs is not advantageous. However, such a view poses a dilemma whether thiazide diuretics should be the first choice in the treatment of hypertension.

Descriptors: Hypertension – complications, drug therapy; Arteriosclerosis – etiology, prevention and control; Antihypertensive agents – pharmacology, therapeutic use
Summary. Arterial hypertension is one of the leading causes of atherosclerosis. Many studies of antihypertensive drugs have been recently focused on prevention, stopping and if possible regression of atherosclerosis. Some antihypertensive drugs which are used in clinical practice have antiatherosclerotic effects besides their effects on the reduction of systemic blood pressure. Oxydative processes and oxygen free radicals participate in the pathogenesis of atherosclerosis. The concen- tration of oxygen free radicals is increased in patients with arterial hypertension. Antioxidant could neutralise oxygen free radicals. There are endogenous antioxidants like vitamin E, vitamin C etc. Some antihypertensive drugs have antioxidant properties and they could neutralise free oxygen radicals. These drugs are: calcium channel blockers, ACE-inhibitors, b-blocker carvedilol and blocker of a-receptors-doxazosine. Antiatherosclerotic effects of these drugs have been shown in experiments in vivo, in animals as well as in clinical studies. The results of the most important clinical studies will be presented in the following text.

Descriptors: Hypertension – complications, drug therapy; Hypertensive encephalopathy – etiology, physiopathology, drug therapy; Cerebrovascular disorders – etiology, physiopathology, drug therapy; Antihypertensive agents – therapeutic use
Summary. Continuous brain blood supply in healthy individuals is warranted by brain autoregulation, the borders of which are not completely strict and can be changed as a part of dynamic physiological control. In acute neurological diseases like hypertensive encephalopathy, brain infarction, intracerebral hemorrhage and subarachnoid hemorrhage, a great attention should be paid to cerebral perfusion pressure preservation (which represents a difference between mean arterial pressure and intracranial pressure) when blood pressure is regulated. To preserve neurological function it is necessary to know anatomic and pathophysiological qualities of brain circulation and to approach the treatment of hypertension. In case of ishemic stroke hypertension should be reduced gradually, through several days, having in mind the distance of ischemic penumbra. The ideal antihypertensive for the reduction of hypertension in acute neurological diseases should have the following characteri- stics precise value and time control of blood pressure, not to have a rebound-phemonenon, not to cause the effect of exceed- ing with initially severe hypotension, not to have impact on heart muscle and not to worsen intracranial pressure. In everyday clinical work with these patients one should act according to the instructions for management of patients with stroke prepared by the Croatian Society for Neurovascular Disorders of the Croatian Medical Association and the Croatian Society for the Prevention of Stroke.

Descriptors: Hypertension – chemically induced, drug therapy; Immunosuppressive agents – adverse effects, therapeutic use; Kidney transplantation – adverse effects; Antihypertensive agents – therapeutic use; Postoperative complications – etiology
Summary. Cardiovascular disease (CVD) is the leading cause of death among renal transplant recipients. The prevalence and severity of CVD in renal transplant recipients are related to numerous factors, most shared with the general population and others specific to transplant recipients, including effects of kidney dysfunction and immunosuppressive drugs. Arterial hypertension is highly prevalent after renal transplantation and may contribute to the risk of cardiovascular disease and graft failure. Immunosuppressive drugs such as corticosteroids, cyclosporine and tacrolimus may be important contributing factors to post-transplant hypertension. Recent data suggest that renal transplant patients under tacrolimus-based therapy showed less arterial hypertension compared with cyclosporine treated patients. New immunosuppressive drugs, including mycophenolate mofetil and sirolimus, are not nephrotoxic, do not have any hypertensive effect and may permit several combinations that offer important alternatives to classical immunosuppressive regimens to reduce the incidence and clinical impact of arterial hypertension after renal transplantation. Other metabolic disorders, such as post-transplant dyslipidemia and diabetes have to be closely monitored and treated as soon as possible. Incidence of arterial hypertension after kidney transplantation may be reduced by early detection, proper adjustment of immunosuppressive protocols and aggressive treat- ment with lifestyle modification and potent antihypertensive drugs.

Descriptors: Kidney transplantation – adverse effects; Hypertension – etiology, drug therapy, epidemiology
Summary. Hypertension frequently occurs in patients with renal transplant. The aim of the present study was to determine the incidence, time of occurrence and hypertension severity following transplantation. A total of 78 patients (37 women and 41 men) mean age 49.9±12 years were included in the study. The post-transplant period amounted from 6 to 168 months. Prior to transplantation, hypertension was registered in14 patients (17.9%). Following transplantation hypertension was registered in 59 (75.6%). During the first post-transplant year hypertension occurred in 79% of patients, while in the period of one to three years in 13.5% and in 6.7% of patients with transplant performed three or more years earlier. Hypertension responsive to only one drug was found in 22%, and to two or more drugs in 25% of patients. The satisfactory blood pressure values were obtained in 78% of patients. The study reveals that hypertension in the majority of renal transplant patients develops during the first post-transplant year.

Descriptors: Hypertension – etiology, physiopathology, drug therapy; Kidney failure, chronic – therapy, complications; Antihypertensive agents – therapeutic use; Renal dialysis – adverse effects
Summary. Arterial hypertension is one of the most frequent causes of chronic kidney failure but also one of most frequent complications in patients on long-term haemodialysis. The aim of this work is to investigate the prevalence of arterial hyper- tension in long-term haemodialysis patients, and methods for treating it. A total of 168 patients (86 women and 82 men aver- age age 62.9±12.9 years) from three dialysis centers were included in this study. Arterial hypertension was defined as blood pressure immediately before hemodialysis >140/90 mmHg or less if the patient has been on anti-hypertensive therapy. Before the beginning of a long-term hemodialysis program arterial hypertension was registered in 139 (81%) patients. The patients were on haemodialysis 52.5±45.17 months. All patients were dialyzed three times per week, an average of 11.7 hours per week (9 to 13.5 hours). Body weight of the patients was 68.4±15.8 kg, and weight gain between dialysis treatments was 2.9±1.1 kg. Arterial hypertension was recorded in 141 patients (84%), i.e. average blood pressure before haemodialysis in all patients was 157.3±17.3/85.2±8 mmHg. The average blood pressure of the remaining patients was 132.6±8.2/ 78.3±10.3 mmHg. The patients were treated with a variety of anti-hypertensive drugs. Thirty-seven patients were on monotherapy, while the others were on combined treatment (2–4 antihypertensive drugs). The most frequently used antihypertensive drugs were calcium channel blockers (95 patients, or 67%), ACE inhibitors (47 patients, or 33%), b-blockers (29 patients, or 20%), angiotensin II receptor blockers and a-blockers (25 patients, or 17%), diuretics (11 patients, or seven percent), and nine patients (6%) received central agents or drugs wich acted like an a+b blocker. Preven- tion and treatment of arterial hypertension is a special problem for haemodialysis patients. Unfortunately, there are still no guidelines for the optimal method of measuring blood pressure in these patients, or optimal values of arterial blood pressure, the first drug of choice or optimal combination of therapies. Perhaps because of this cardiovascular morbidity and mortality among these patients is high.

Descriptors: Adrenal gland neoplasms – surgery, pathology; Adrenalectomy – methods; Laparoscopy
Summary. Introduction: Laparoscopy is now a widely used method for removal of functioning and non-functioning adrenal tumors. This paper reports our experience in laparoscopic transperitoneal removal of functioning adrenal tumors including pheochromocytoma, Cushing's disease and aldosteronoma. Methods: Between May 2001 and April 2006, 29 patients under- went laparoscopic adrenalectomy for pheochromocytoma. In 37 patients (10 patients with bilateral adrenalectomy) adre- nalectomy was performed for Cushing's disease, while 28 patients had aldosteronoma. In 2 patients adrenalectomy was performed for virilizing adenoma. Results: All laparoscopic adrenalectomies were finished successfully, and no open surgery was necessary. Major postoperative complications were not observed. Mean hospital stay was 3 days. No patient required blood transfusion. Conclusions: Laparoscopic adrenalectomy for functioning adrenal tumors proved a safe and minimally invasive procedure. Laparoscopic adrenalectomy, in comparison with open surgery, has numerous advantages, including a shorter length of stay, shorter time to return to preoperative level of activity, better cosmetic effect, and decrease in postoperative pain.

Descriptors: Hypertension, renovascular – diagnosis, etiology; Arteriosclerosis – complications; Renal artery obstruction – complications, etiology; Fibromuscular dysplasia – complications; Hypertension – diagnosis
Summary. The aim of our study was to show the value of comparing clinical parameters in patients with renovascular hypertension (RVH) and essential hypertension (EH). We examined the differences between renovascular hypertension patients with atherosclerosis (ATH) and those with fibromuscular dysplasia (FMD). The diagnosis of renovascular hyper- tension was established on the basis of renal angiography finding, which also defined the type of stenosis (ATH or FMD). Our patient group included 108 patients with atherosclerotic RVH (46 male / 62 female, median age 53 yrs), 16 patients with FMD (3 male / 13 female, median age 49 yrs), and 106 patients with EH (61 male / 45 female, median age 38 yrs). In com- parison with patients with EH, patients with atherosclerotic RVH were found to be more frequently of female gender with lower body weight and height, older, and more frequently on therapy with antihypertensives. Their hypertension was of later onset and more severe stage. All those differences were statistically significant (P<0.05). When analysis by genders was performed, women were more frequently smokers and had higher serum cholesterol levels, which is an explanation for higher proportion of female gender in atherosclerotic RVH patients. In patients with fibromuscular dysplasia a higher proportion of female gender was also present, but in comparison with ATH patients their hypertension was more often of a less than 5 years duration and they had lower serum creatinine and triglyceride levels. Our results are in agreement with the results of other authors who showed clinical parameters to be useful in screening of patients for further diagnostic procedure. This stresses the importance of good history, physical examination and well-chosen laboratory tests. They can't clearly establish or exclude the diagnosis of renovascular hypertension, but this approach could more easily point out those hyper- tensive patients who require a thorough work-up. Clinical parameters could furthermore help in determining the type of treatment of RVH.

Descriptors: Obesity – complications, epidemiology; Hypertension – complications, physiopathology; Abdominal fat; Blood pressure
Summary. Obesity significantly increases the risk for the occurrence of cardiovascular disease in patients with essential hypertension. The aim of the study was to assess the frequency of obesity, measured by different methods, in patients with essential hypertension, its effect on arterial pressure, and to determine the best correlation between indicators of obesity and arterial pressure. The study included 88 patients with essential hypertension, 32 males, mean age 59.4 (±10.4) years, and 56 females, mean age 62.9 (±8.8) years. Body weight (BW) and height (BH), waist circumference (WC), and body mass index (BMI) were measured for each subject. Arterial pressure was determined using mercury sphygmomanometer. Overweight patients were defined as those with BMI 25–29.9 kg/m2, while obese as those with 330 kg/m2. Abdominal obesity was assessed by WC. WC values exceeding 102 cm for men and 88 cm for women indicated obesity. Body measures of male patients were higher than those for women (BW 92.5(±14.5) vs 76.7(±11.5) p<0.001; BH 175.4(±7.4) vs 163.4(±5.8) p<0.001), significantly higher waist circumference values (102.4(±12.2) vs 94.1(±13.9) p=0.006), with no differences in age, BMI, and arterial pressure values (p>0.05). Also, no differences were observed in the number of uncontrolled hyperten- sive patients or number of overweight or obese patients (p>0.05). The number of obese patients did not differ significantly with regard to the various measurement methods employed (BMI: M 50%, F 37%; waist measurement: M 51%, F 54%). A significant difference was noted in arterial pressure values only in the male patient group on comparing patients with normal BW and obese patients (systolic blood pressure (SBP) 156(±22.5) vs 142(±6.4) p=0.04; diastolic blood pressure (DBP) 94(±11.6) vs 82.5(±6.4) p=0.05). The correlation between obesity indicators and arterial pressure was significant for WC only in the male group (SBP r=0.33, DBP r=0.35, p<0.05). The frequency of obesity does not differ with regard to the deter- mined obesity indicators. Obese men have higher risk for increased arterial pressure values. WC values correlate better with arterial pressure values as it is a more accurate indicator of abdominal obesity.

Descriptors: Endothelium, vascular – physiology, physiopathology; Hypertension – physiopathology; Atherosclerosis – physiopathology
Summary. Endothelium was »discovered« as a separate organ in the last decades of the previous century. For a long time endothelial cells were considered as a very passive monolayer of cells just covering the inner part of vascular walls. The role of these cells was thought to be only a mechanical barrier between circulating blood and vascular structures. Nowadays, after a series of biochemical and experimental studies, one can name endothelium as an organ, covering approximately 700 sqaure meters, weighing about 1.5 kilos in an average male with weight of 70 kg. Not only its quantity, but also its function is amazing. The most prominent and first well studied function of endothelial cells is vasodilatation and vasoconstriction. Normal cells, which are intact and in function produce regularly one of the most important protecting agent in circulation: NO. Normal endothelial cells produce NO as a result of higher blood pressure or growing demand for oxygen. It is produced from aminoacid L-arginine as a result of enzyme activity: endothelial NO synthetase (eNOS). Interleukins also can increase production of NO. NO has also antiinflammatory efects, helping in reparation and healing processes. Prostacyclins are the second most important vasodilating agent produced in endothelium. On the other hand, vasoconstriction is also mediated via endothelium. Endothelin 1, angiotensin II and thromboxan A are produced in vascular wall by endothelial cells, acting as op- ponent to NO. ACE system is very active inside those cells, with permanent local angiotensin II formation, that mostly act on vascular wall itself. Effects of such generated angiotensin II stimulate activation of VCAM molecules, starting adhesion of monocytes, their penetration in vascular wall and activation. Acivated macrophages get in contact with oxidized LDL particles already inside the vascular wall, producing foam cells. That is the very begining of atherosclerosis. All negative effects of excess of angiotensin II should be reduced by effective therapy with ACE inhibitors or AT antagonists. Today it seems more important to act on excess in endothelial AII in order to regulate not only blood pressure, but long-term devastat- ing effects on target organs, preventing atherosclerosis.

Descriptors: Blood pressure determination – instrumentation; Sphygmomanometers; Hypertension – diagnosis
Summary. Arterial blood pressure has been measured using mercury sphygmomanometer and auscultatory method for more than a hundred years. The results obtained by this measurement method make the basis of almost all conclusions related to pathogenesis, epidemiology and treatment of arterial hypertension. However, some deviations from ordinarily obtained data have been observed but are undoubtedly due to superficial approach to this simple method. A number of lesser faults can together result in an eventually inaccurate conclusion both regarding diagnosis and assessment of therapeutic effects. The aim of this short review article is to remind us of those little efforts needed to be done for improving the exactness of measurement in order to increase the accuracy of results. The ultimate consequence should be better care of patients with high blood pressure.