Objective. This study aimed to investigate improvements in inflammatory mediator levels in induced sputum and airway hyperresponsiveness (AHR) in cough variant asthma (CVA) during long-term inhaled corticosteroid (ICS) treatment. Patients and Methods. Patients with CVA (N = 35) and classic asthma (N = 26) and healthy subjects (N = 24) were recruited into this study. All patients were treated with budesonide (400 μg/day). Measurement of inflammatory mediators in induced sputum and PD20-FEV1 (the accumulated provocative dose resulting in a 20% decrease in FEV1) in histamine-challenged subjects was performed every three months after the start of medication. Interleukin- (IL-) 5 and IL-10 were assayed by ELISA, and the percentage of eosinophils was detected with Giemsa stain. Trends during the follow-up period were analyzed using a general linear model. Results. Inflammatory mediator levels in induced sputum and PD20-FEV1 in patients with CVA and classic asthma differed from those in the control group, although no differences were found in the two asthmatic groups. PD20-FEV1 significantly increased in CVA patients after ICS treatment for 3 months, while classic asthma patients exhibited a delayed change in AHR. After ICS treatment, levels of IL-5 and IL-10 as well as the percentage of eosinophils in the CVA group were altered at 3 months and 6 months, respectively. Accordingly, the level of inflammatory mediators in classic asthma changed more slowly. Conclusion. CVA has a greater improvement in airway inflammation and airway hyperresponsiveness (AHR) than classic asthma with respect to inhaled corticosteroid (ICS). Short-term ICS considerably reduces AHR although longer treatment is required for complete control of airway inflammation. Budesonide can also reduce the percentage of eosinophils in induced sputum in CVA patients. Furthermore, long-term ICS may prevent the development of classic asthma from CVA by reducing bronchial responsiveness [β [Cough variant asthma (CVA), a variant form of classic asthma that presents solely with a cough and responds to bronchodilator treatment, is considered to be the most common cause of chronic coughs . Severalsiveness . It is wsiveness . Interlesiveness . More reeness [β . 1 (the accumulated provocative dose resulting in a 20% decrease in FEV1) in response to histamine challenge were analyzed to evaluate the efficacy of ICS treatment over time in CVA patients compared with mild asthmatics. Nevertheless, the changes associated with the improvements in AHR and airway inflammation including regulatory markers in CVA responding to ICS treatment, particularly as compared with those in mild classic asthma, have not yet been elucidated. Moreover, the time course of these changes during treatment is not known. To our knowledge, this is the first study investigating the changes in cytokine levels and hyperresponsiveness during ICS treatment in CVA patients compared with classic asthma patients. In the present study, the levels of Th2-associated cytokines, IL-5 and “cytokine synthesis inhibitory factor” (IL-10), were analyzed. Eosinophils (EOS) in sputum and airway hyperresponsiveness were also determined in CVA patients during the period of ICS treatment. Changes in inflammatory markers and PD20-FEVThirty-five patients with CVA and 26 patients with mild classic asthma who were attending the respiratory medicine outpatient clinic of the Huashan Hospital were recruited into this study from November 2010 to May 2011. Twenty-four healthy subjects were simultaneously recruited as the control group. Mild asthma was diagnosed according to the Global Initiative for Asthma (GINA) guidelines  and CVA μg budesonide. The total follow-up period lasted for twelve months. Levels of IL-5 and IL-10, the percentage of EOS in induced sputum, and the value of PD20 were examined every 3 months after the medication. This study comprised a longitudinal comparison of the changes in airway inflammation and bronchial hyperresponsiveness in CVA and classic asthma patients to estimate the effect of ICS treatment.Prior to the study, all subjects were required to undergo pulmonary function tests, bronchial challenge to histamine, and examination of induced sputum. After participating in these tests, all patients were treated with a daily dose equivalent of 400 1 and forced vital capacity (FVC) were measured utilizing a computerized spirometer  according to the standardization criteria of the American Thoracic Society [1) was required to be 80% or more of the predicted value.FEV Society . To be e1 was measured by inhalation histamine challenge with different concentrations of histamine (0.03–7.8 mg/mL) delivered by the quantitative aerosol dosimeter of the APS system. Initially, baseline FEV1 was measured using a spirometer 2 minutes after inhalation of a control solution . Subjects inhaled a histamine aerosol from a nebulizer with tidal breathing whilst wearing a nose clip for 2 min. Total inhalations of each concentration were administered, and FEV1 was measured three minutes after each period of inhalation. The test was stopped in the event of a fall in baseline FEV1 of 20% compared with the control inhalation solution. PD20 was calculated as the provocative dose of histamine causing a 20% fall in FEV1. AHR was considered to be present in subjects with PD20 values less than 2.2 mg. Subjects received two puffs (200 μg) of salbutamol from a metered dose inhaler following the histamine challenge test.Bronchial responsiveness was tested using an aerodynamic particle sizer (APS) aerosol provocative system . PD20-FEVμm), and total leukocyte cell counts and cell viability were determined. Filtrates were centrifuged at 750 ×g for 10 min, and supernatants were aspirated and stored in eppendorf tubes at −80°C for IL-5 and IL-10 assays. Cell suspensions were adjusted to 1.0 × 106/mL and a sample (60 μL) was used for cytocentrifuge preparations. Slides were stained with Giemsa stain, and 400 differential nonsquamous cell counts were performed. Results were expressed as the percentage of eosinophils in the total nonsquamous cell count. Samples containing more than 30% squamous cells were excluded from the analysis.Sputum was induced with an aerosol of hypertonic saline solution according to a previously described protocol . CollectConcentrations of IL-5 and IL-10 in sputum supernatants were determined using a solid-phase sandwich enzyme-linked immunosorbent assay (ELISA) . The sensitivities of the assays as quoted by the manufacturer were 15 pg/mL and 10 pg/mL, respectively. P < 0.05 was considered statistically significant.Statistical analyses were performed using SPSS 17.0 for Windows. All data were expressed as the mean ± standard deviation (SD) or median (M) with the range. A general linear model was applied for comparison of the time course of sputum marker levels and PD20 before and after treatment in patients with CVA and asthma. A time course of repeated measurements was used to compare groups. Statistical significance identified between groups or time points by post hoc analysis was further analyzed by Bonferroni's tests. 1% predicted, FEV1/FVC, hemocytes, and atopy .Levels of inflammatory markers were improved to some extent in the two asthmatic groups following treatment with budesonide. However, the changes in inflammatory mediators in induced sputum differed between the two groups during the period of medication. At each time point, levels of inflammatory markers in the CVA group also differed from those in the classic asthma group  in sputum was lower in the CVA group compared with that in the classic asthma group after treatment. The EOS% significantly decreased after ICS treatment for 6 months in the CVA group, while a change was observed in the classic asthma group only after treatment for 12 months Figures , and 4.β [Cough variant asthma is essentially an occult phase of classic asthma that shares similarity in fundamental pathologic and pathophysiologic characteristics. Evidence suggests that an imbalance in Th1 and Th2 lymphocyte responses plays a critical role in the pathogenesis of chronic asthma . The potβ , 14, 15.β . The eff+ T-helper lymphocytes characterized by the production of the IL-17 family cytokines like IL-17A and IL-17F. Animal models of asthma denote that Th17 cells may promote Th2 immunity and exacerbate airway hyperresponsiveness [In this study, the basic level of IL-5 and percentage of eosinophils in CVA patients and mild asthmatics were clearly higher than those in the control group although no statistically significant differences were detected between the two asthmatic groups. IL-5, one of the most important Th2-associated cytokines, is critical for the survival, differentiation, proliferation, and maturation of eosinophils within the bone marrow. Activated eosinophils possess secondary granules containing four primary cationic proteins: major basic protein (MBP), eosinophil cationic protein (ECP), eosinophil-derived neurotoxin (EDN), and eosinophil peroxidase (EPO), all of which participate in the processes of airway inflammation . Increassiveness , 23. Addsiveness . Taken tsiveness . Apart fsiveness  reportedsiveness . In the We also observed a kind of immune modulator, the level of induced sputum IL-10 in the three studied groups. IL-10, an anti-inflammatory cytokine secreted predominantly by immune regulatory cells in the lung, inhibits the transcription of many proinflammatory cytokines and chemokines  Borish e1 of CVA significantly increased after budesonide treatment for only 3 months, and, furthermore, therapy continued for 12 months resulted in improved airway hyperresponsiveness such that it was detected only to an extremely mild degree. In contrast, the improvement in PD20-FEV1 observed in classic asthma was delayed and was only apparent after treatment for 9 months. It is postulated that these differences are due to thickening of the subbasement membrane in CVA patients compared with healthy controls, although the degree of thickening was less than that detected in classic asthma [In this study, the improvement of airway hyperresponsiveness in patients with CVA and classic asthma was also investigated. Challenge tests are an important measurement for diagnosis and evaluation of the severity of CVA. Histamine was used as the provocative agent in this study. In accordance with previous reports , the PD2c asthma . This maThere are certainly other antiasthma mediations such as cysteinyl leukotriene (cys-LT) receptor antagonists (LTRAs). LTRAs alleviate clinical symptoms and improve pulmonary function as well as airway inflammation in classic asthma , but monNevertheless, some limitations of our study should be noted. In the present study, we lack determining the changing trend of cough sensitivity in CVA under long-term ICS treatment. It might have affected the precise evaluation of the efficacy of ICS treatment. Actually, there is evidence that cough threshold did not change whether taking or not taking ICS . Thus weTo summarize, ICS treatment provides greater alleviation of Th2-associated allergic responses and repair of regulatory mediators in CVA than in classic asthma. The current study has indicated that airway hyperresponsiveness can be rapidly improved as a result of short-term ICS treatment, although complete control of airway inflammation requires longer-term ICS treatment. Further studies, including randomized placebo-controlled trials, are required to confirm the effective maintenance period and dose of ICS treatment in CVA.


Left ventricular hypertrophy (LVH) is an independent cardiovascular risk factor in patients with essential hypertension. The main objective of this study was to assess the echocardiographic prevalence of left ventricular hypertrophy in patients with hypertension, its risk factors and effect of antihypertensive drugs on its prevalence.A hospital based cross sectional study was conducted on 200 hypertensive patients on treatment in southwest Ethiopia. A pretested structured questionnaire was used to collect data from participants and their clinical records. Blood pressure and anthropometric measurements were taken according to recommended standards. Left ventricular mass was measured by transthoracic echocardiography. Associations between categorical variables were assessed using chi-square test and odds ratio with 95% confidence interval. Logistic regression model was done to identify risks factors of LVH. P values of < 0.05 were considered as statistically significant.2 respectively. The overall prevalence of LVH among these study subjects was 52%. Age ≥50 years , female gender , systolic blood pressure ≥140 mmHg , and duration of hypertension  were independent predictors of left ventricular hypertrophy. Angiotensin converting enzyme (ACE) inhibitors were the only antihypertensive drugs associated with lower risk of left ventricular hypertrophy .The mean age, systolic blood pressure, diastolic blood pressure and body mass index were 55.7 ± 11.3 years, 139.2 ± 7.7 mmHg, 89.2 ± 5.7 mmHg and 24.2 ± 3.4 Kg/mLeft ventricular hypertrophy was found to be highly prevalent in hypertensive patients in Ethiopia. ACE inhibitors were the only antihypertensive drugs associated with reduced risk of LVH. We thus recommend strategies to early detect and treat hypertension and to timely screen for LVH among patients with hypertension. Multicenter prospective studies in Africa settings would be ideal to identify the best antihypertensive agents in black Africans. Cardiovascular disease (CVD) is the leading cause of death globally resulting in about 30% of deaths annually. About half of CVD related deaths are attributable to hypertension, a disease strongly associated with overall cardiovascular risk .Long standing hypertension results in left ventricular hypertrophy (LVH), a preclinical cardiac damage that in the long run may lead to potentially life-threatening complications ,3. LVH iCardiac hypertrophy is a compensatory response to cardiac insult of any cause . It is tDespite these challenges, the pathophysiologic mechanisms of LVH appear to be well established now. LVH is a myocardial remodeling  that ensSecondary messengers that regulate nuclear transcription factors activity  are activated in response to the neurohormonal activation. The nuclear transcription factors modify the expression of hypertrophic genes ,23. NF-κThough different mechanisms interplay in the development of LVH, there is a consistent and independent interaction between hypertension and left ventricular mass (LVM) . HoweverApart from hypertension itself, different factors are believed to play a role in the development of LVH. Obesity, dyslipidemia, diabetes mellitus, smoking, old age and excessive alcohol intake are said to be positively correlated with the prevalence of LVH in hypertensive patients ,29-32.Studies regarding LVH and its sequel are scarce in Black Africans. Most prevalence data for hypertension and LVH as well as treatment recommendations are extrapolated from the findings in African Americans. The main aim of the current study is thus to assess the prevalence of left ventricular hypertrophy in Ethiopian hypertensive patients and role of ACE inhibitors in preventing LVH in patients with hypertension.This is a cross-sectional study conducted at the Jimma University Specialized Hospital (JUSH) between May and August 2012. JUSH is a referral hospital for around 15 million people in southwest Ethiopia. It is one of the few teaching hospitals in the country. It is located in Jimma town, 356 km south-west of the capital Addis Ababa. At the time of the study, there were around 1100 patients on active follow-up for hypertension at hypertension clinic of the hospital. The clinic runs once a week every Wednesday. The service is rendered by internists, medical residents and medical interns.Hypertensive patients coming for follow-up to the hospital were consecutively recruited based on the selection criteria and their willingness to participate in the study. Over a period of four months, complete data from the patient interview, physical examination, chart review and echocardiographic assessment was done in 200 hypertensive patients.Any adult hypertensive patient over 18 years of age coming to the clinic for follow up was enrolled for the study based on their willingness and consent.All hypertensive patients with heart failure were excluded from the study.The data were collected using a pre-tested structured questionnaire which was prepared specifically for this study. Patient interviews, BP and anthropometric measurements were done by nurses working in the clinic after one day of training. Chart review was done by medical residents. The questionnaire consisted of socio-demographic profiles; physical measurements  and clinical records for co-morbidities, duration of hypertension and the types of antihypertensive medications used. Blood pressure was measured with a sphygmomanometer. An average of three blood pressure measurements was taken to assess blood pressure control (the current and the last two visits). Height and weight were measured using a standard weighing scale and stadiometer respectively. These parameters were measured by patient standing straight without shoes and wearing only light clothes.0.8 * 1.04 ((PWTd cm + IVSTd cm + LVIDd cm)3– LVIDd3cm )) + 0.6 grams[2 for men and > 96 g/m2 for women [Transthoracic echocardiography was performed to measure parameters used to estimate left ventricular mass (LVM). M-mode tracing was done at the papillary muscle level of the left ventricle to measure posterior wall thickness in diastole (PWTd), interventricular septal wall thickness in diastole (IVSTd) and left ventricular internal diameter in diastole (LVIDd). Absolute LVM was calculated by the Devereux formula given as 0.6 grams. The LVMor women .Data were analyzed using SPSS version 20. The findings were expressed as mean ± standard deviation and/or percentages. Categorical variables were compared using Chi-square test and odds ratio with 95% confidence interval. A P-value of less than 0.05 was considered statistically significant. The logistic regression model was done to identify predictors/risks of left ventricular hypertrophy.Ethical clearance was obtained from Jimma university ethical review board. Informed written consent was obtained from every participant. The information collected from participants will remain confidential indefinitely. Patients with life threatening conditions were exempted from the study and were linked for appropriate care.A total of 200 hypertensive patients were included in the study of which 57% were women. The mean age of the participants was 55.7 ± 11.1 years with a range of 22 to78 years. Hundred forty-nine (74.5%) of them were older than 50 years. About 70% of them had hypertension for 10 years or more. The mean systolic blood pressure (SBP) and diastolic blood pressure (DBP) were 139.2 ± 7.7 mmHg and 89.2 ± 5.7 mmHg respectively (Table Thirty-nine (19.5%) of patients have been diagnosed with diabetes and were on glucose lowering agents , 28 of them had type 2 diabetes.None of the participants reported smoking or use of alcohol.2. Fifty-six (28%) of them were found to be overweight and 14 patients (7%) were classified as obese according to the standard classification of overweight as BMI ≥25 Kg/m2 and obesity as BMI ≥30 kg/m2 (Table The mean Body Mass Index (BMI) was 24.2 ± 3.4 Kg/mAll of the participants were taking some types of antihypertensive agents at the time of the study. About 57% of them were taking a combination of two or more antihypertensive drugs. The most commonly used drug was hydrochlorothiazide used in 53% of the participants as the only agent or in combination with others. About 42% of them were taking angiotensin converting enzyme (ACE) inhibitors alone or in combination with others. Beta-blocker (atenolol) alone or in combination with other agents was used by 38% of the participants. None of the patients were taking angiotensin receptor blockers (ARB) , interventricular septal wall thickness in diastole (IVSTd) and left ventricular internal diameter in diastole (LVIDd) were 1.28 ± 0.25, 1.38 ± 0.31and 3.93 ± 0.4 centimeters respectively. The mean calculated left ventricular mass from the three parameters according to the Devereux formula was 193.4 ± 60.6 grams. When indexed to BSA, it was 107.3 ± 33.6 g/m2 for men and >96 g/m2 for women was 52%. There was a significant difference in its prevalence between genders, 68.4% among women and 30.2% among men (p < 0.001)  were 50 years or older. A bivariate analysis showed that age ≥50 years was associated with the development of LVH   .Overall, 70 (35%) of the participants had BMI ≥25 Kg/mDiabetes was not found to be a significant predictor of LVH in this study. All of the 28 type 2 patients were taking oral glucose lowering agents as all type 1 patients were on insulin. However, neither the type of diabetes nor the treatment was associated with LVH.At the time of this study, about 60% of the participants had high blood pressure defined as SBP ≥ 140 mmHg and/or DBP ≥ 90 mmHg. Significant difference in prevalence of LVH was detected only when dichotomizing the high BP into SBP or DBP. Elevated systolic blood pressure was found to be an independent predictor of LVH in patients with hypertension, . However, a significant interaction between DBP and LVH was not seen (p = 0.258) Tables  and 4.About 70% of the participants reported that they had hypertension for 10 years or more. The prevalence of LVH in this group was 62.9% versus 26.7% in those who were less than 10 years since diagnoses. Adjusting for all potential risk factors, patients with longstanding hypertension (≥10 years) were 3.59 times more likely to develop LVH as compared to those with less than 10 years of hypertension   for those on ACE inhibitors Table .ACE inhibitors were used more widely in patients older than 50 years (66.4%) and in those with diabetes (82%). These agents were used less often (<50%) in other groups. The effect of ACE inhibitors on LVH was independent of these groupings. However, this effect vanished in those with high blood pressure (SBP ≥160).When we grouped antihypertensive agents to those with anti-remodeling effect (ACE inhibitors and beta-blockers) and non-anti-remodeling drugs (other groups), a positive trend towards anti-remodeling agents was seen though not statistically significant .Left ventricular hypertrophy, a preclinical cardiac damage, was found to be highly prevalent in Ethiopian hypertensive patients. Age, female gender, longstanding and systolic hypertension were found to be independent predictors for its occurrences. Use of ACE inhibitors was associated with decreased risk of LVH. This cross-sectional study from a single health facility in Africa may give clues to the effect of ACE inhibitors in the treatment of hypertension and their effect on LVH in black patients.LVH is an independent cardiovascular risk factor . Its preAge was found to be an independent risk factor for LVH in most studies ,8,35,36.Female gender was found to be an independent risk factor for LVH in hypertensive patients in our study with adjusted OR of 7.69. Different studies from around the world have shown that the gender effect on prevalence of LVH varies from population to population -39, whetThe presences of diabetes  and highUncontrolled systolic blood pressure ≥140 mmHg was associated with the development of left ventricular hypertrophy in this study. However, no correlation was found between diastolic blood pressure and the occurrence of LVH. These findings are consistent with results from other studies . The reaDuration of hypertension was found to be an independent predictor of left ventricular hypertrophy in our study which is consistent with most studies from around the world ,43.The fact that all of our study participants were nonsmokers and nonalcoholic was merely a chance occurrence. This can also be explained by the fact that the prevalence of smoking in Ethiopia is low, 3.3% in the general population and 0.5% for women  who madeAs LVH is a cardiac remodeling problem ,13, we tIn addition to this, recent studies have also casted doubts on the benefits of these drugs among black patients . Such evAnother explanation for the lack of effect of beta-blockers in our study may be due to the fact that most (56%) of the patients on these agents had high SBP (≥160 mmHg). In these patients, beta-blockers were used as additional antihypertensive agents after blood pressure control became difficult with original one or two types of antihypertensive drugs. It should also be reminded here that the benefit of beta-blockers on regression of LVH and uncomplicated hypertension is becoming questionable . In addiThe effect of ACE inhibitors on LVH also vanished in those with SBP ≥ 160 mmHg. This is contrary to the fact that ACE inhibitors induce left ventricular hypertrophy regression, independent of changes in blood pressure . Cross-sEven though this study has come up with such important findings, there are important limitations worth mentioning here. First of all, the relatively small sample size might have contributed to the inability to detect the effect of certain risk factors for LVH. For example none of the participants reported a history of smoking or alcohol use. On the other hand, other potential risk factors for LVH like dyslipidemia, anemia and renal dysfunction were not assessed making an assessment of risk factors incomplete. Finally, as all of the participants were those on pharmacological treatment for hypertension, it may not be generalizable for all patients with hypertension in the country.Left ventricular hypertrophy was found to be highly prevalent in Ethiopian hypertensive patients where BP control is suboptimal. Older age, female gender, longstanding and systolic hypertension were independent predictors of LVH. ACE inhibitor use on the other hand has been associated with lower risk of this complication. Taking these results and observations into consideration, we thus recommend early screening of hypertensive patients for LVH with either echocardiography or electrocardiography based on availability. Besides, we urge health care providers and policymakers to improve standards of care for hypertensive patients by optimizing BP control and working on those modifiable risk factors of LVH.Last but not least, we recommend a large scale multicenter study to substantiate the findings in this research.The authors declare that there is no conflict of interest associated with this research work.GNJ designed the study, developed the instruments, supervised data collection, analyzed the data and wrote the manuscript. EKG participated in study design, instrument development, data analysis and writing of manuscript. WG participated in study design and instrument development, took part in data collection and editing manuscript. All authors read and approved the final manuscript.


Endothelial dysfunction is found in hypertensive patients and may serve as a prognostic marker of future cardiovascular events. Endothelial function can be assessed noninvasively by flow-mediated vasodilation (FMD). The goal of this paper is to summarize comprehensively the clinical trials that investigated the effects of antihypertensive drugs on endothelial function assessed by FMD in hypertensive patients. A PubMed-based search found 38 clinical trial papers published from January 1999 to June 2011. Significant improvement of FMD after antihypertensive treatment was shown in 43 of 71 interventions . Angiotensin II receptor blockers and angiotensin converting enzyme inhibitors appeared to improve FMD more than other drug types. Antihypertensive treatment can improve endothelial dysfunction when assessed by FMD, although there are conflicting data that require further research. Atherosclerotic risk factors such as hypertension (HTN), diabetes mellitus, dyslipidemia, obesity, and smoking cause endothelial dysfunction –5. EndotThe evaluation of endothelial function is available as a predictor of cardiovascular events and as a surrogate marker for early atherosclerosis –3, 7, 8.HTN is prevalent worldwide and one of the most important risk factors for atherosclerotic disease , 12. TheGuidelines for the ultrasound assessment of endothelial-dependent FMD of the brachial artery have been established . There aFMD is assessed in a subject's right arm in the supine position in a quiet, temperature-controlled room. The brachial artery is imaged above the antecubital fossa in the longitudinal plane using B-mode ultrasound, and the diameter of the brachial artery is measured continuously. A cuff is placed either around the forearm or above the antecubital fossa. After a baseline, resting image is acquired, arterial occlusion is induced by cuff inflation to a pressure above the systolic pressure, typically to at least 50 mmHg above systolic pressure for 5 minutes. When the cuff is released, FMD is calculated as the maximum percent increase in the diameter during hyperemia compared with the baseline diameter.Several studies were reviewed that investigated changes in FMD due to treatment in hypertensive patients. We selected 38 papers published from January 1999 to June 2011 using a PubMed-based search engine. The keywords used in the search were “flow-mediated vasodilation” and “hypertension”, and the original articles were eligible. The appropriateness of all papers identified by the search was confirmed by two experts. When the trial designs of 38 clinical trial papers were classified by the method of Zaza et al. , there wn = 9) and the ARB losartan  on endothelial function in hypertensive patients [n = 31; irbesartan 150–300 mg/day, n = 30; candesartan 8–16 mg/day, n = 31) for 2 months, and the change in FMD was compared among the three groups. ARB therapy significantly improved FMD with no differences among the three groups [n = 46) [G-monomethyl-L-arginine to block NO synthase was greater with the high than with the low dose [n = 22) did not change FMD as much as treatment with the ARB telmisartan  for 24 weeks [Medications that block the renin-angiotensin-aldosterone system (RAAS) include angiotensin converting enzyme inhibitors (ACEIs) and angiotensin II receptor blockers (ARBs). These agents are effective in lowering blood pressure and result in organ protection that is effective for clinical conditions such as heart failure , 54, chrpatients . Six mone groups . The oth[n = 46) . While blow dose . In anot24 weeks , valsart24 weeks ), and alThe protective effect of CCBs on cardiovascular disease in hypertensive patients has been established in several large-scale clinical trials , 57. Howβ-blockers have also an established role in cardioprotection [β-blockers, nebivolol is a selective β-1 adrenergic receptor antagonist and induces endothelial-dependent vasodilation [n = 20) with atenolol , a traditional selective β-1 adrenergic receptor blocker without vasodilating properties, on FMD in hypertensive patients [otection , 54, 58.dilation . One RCTpatients . At 4 wepatients , 43; hown = 28), the ARB telmisartan , the CCB, nifedipine , the CCB amlodipine , the β-blocker atenolol , and the β-blocker nebivolol  on FMD [Several RCTs compared three or more types of antihypertensive drugs , 29, 49.) on FMD . Interesn = 400) with HTN and impaired FMD received 6 months of antihypertensive therapy (the choice of the antihypertensive drug used was at the discretion of the study investigators) and then were followed-up for a mean period of 67 months. After 6 months of treatment, 250 women showed significantly improved FMD, and this group had significantly fewer cardiovascular events compared with the group without improved FMD (there were no deaths from cardiac causes during the study period) [Furthermore, there was one study that examined the significance of FMD as a prognostic marker of cardiovascular events. Postmenopausal women ( period) .n = 172) were divided into a low- and high-FMD group based on the median level of FMD and were followed for 95 months [A prospective study showed the relationship between a low level of FMD and cardiovascular events  . Hyperte5 months . The inc5 months .Given the overall data, antihypertensive treatment can improve endothelial dysfunction when assessed by FMD. The results of clinical trials showing the effects of different drug types on change in FMD are summarized in n = 42, mean age = 43) [Although discrepant results among trials remain to be resolved, they may have been due to differences in the characteristics of patients, the experimental design , the sample size (relating to the study power) and statistical methodology, and measurement issues  –63. A prge = 43) . Patientge = 43) , 63.n = 13, 4 weeks on each drug) compared the effects of losartan (100 mg/day) and atenolol (100 mg/day) on FMD and the levels of 8-isoprostane, a marker of oxidative stress [n = 15), ramipril , or atenolol  for 8 weeks, there was a similar improvement in FMD, but only zofenopril significantly reduced plasma hydroperoxides, 8-isoprostanes, oxidized-LDL, and adhesion molecules [Endothelial dysfunction is generally caused by a reduction of endothelium-derived relaxing factors (EDRFs) such as NO, failure of smooth muscle cells to respond to EDRF, activation of the RAAS, and production of vasoconstrictors such as endothelin –5. Thesee stress . Losartae stress . In hypeolecules . Other tolecules , 51, 52.Angiotensin II causes vasoconstriction and increases the production of reactive oxygen species (ROS) by activating NADH/NADPH oxidase through the angiotensin II type 1 receptor , 67. ARBACEIs block the RAAS and augment prostaglandins and the kallikrein-kinin system, and these effects lead to a decrease in blood pressure , 69. ACECCBs have antihypertensive effects that are mediated through the relaxation of vascular smooth muscle cells, and antioxidative effects that are mediated through an increased release of NO , 72.β-blockers have scavenging activity for ROS, and these effects are possibly useful in preventing oxidative damage in HTN [β-blockers was not as great as that observed with other antihypertensive agents. Nebivolol, which is associated with NO-induced vasodilation, improved endothelial function more than other β-blockers.e in HTN . HoweverAtherosclerotic risk factors such as diabetes mellitus and dyslipidemia also affect endothelial function, similar to HTN. These risk factors are often observed in patients with HTN. While the effects of these risk factors on FMD should be considered, specific trials for patients with diabetes mellitus or dyslipidemia were not included among the studies cited in the present paper.HTN is a major atherosclerotic risk factor, and antihypertensive treatment protects against future cardiovascular events. The evaluation of endothelial function can be useful in the risk assessment of hypertensive patients treated with antihypertensive drugs. However, larger clinical trials that include morbidity and mortality as outcome variables are needed to further establish FMD as a prognostic marker in hypertensive patients. The influence of other atherosclerotic risk factors and confounding factors  on FMD in hypertensive patients should also be evaluated in future studies that attempt to establish the prognostic value of FMD. Furthermore, future studies should examine the association between the reduction in blood pressure and the improvement in FMD. In addition, changes in FMD should be compared with sonographical findings of carotid arteries, ankle brachial index, and pulse wave velocity, which have already been widely adopted as noninvasive methods to evaluate atherosclerosis.The improvement of FMD in hypertensive patients is expected to slow the progression of atherosclerosis and improve long-term outcomes in these patients. The results of many but not all clinical trials suggest that there is a significant effect of antihypertensive therapy on FMD. ARBs and ACEIs appeared to improve FMD relative to other drug types. Antihypertensive treatment can generally improve endothelial dysfunction as assessed by FMD, although further research is needed.


To compare two bariatric surgical principles with regard to effects on blood pressure and salt intake.In most patients bariatric surgery induces a sustained weight loss and a reduced cardiovascular risk profile but the long-term effect on blood pressure is uncertain.Cohort study with data from the prospective, controlled Swedish Obese Subjects (SOS) study involving 480 primary health care centres and 25 surgical departments in Sweden. Obese patients treated with non-surgical methods  were compared to patients treated with gastric bypass  or purely restrictive procedures .P<0.05) and +170 ml (P<0.001) higher in GBP subjects than in weight-loss matched VBG/B subjects at the 2 y and 10 y follow-ups, respectively. Urinary output was linearly associated with blood pressure only after GBP and these patients consumed approximately 1 g salt per day more at the follow-ups than did VBG/B (P<0.01).At long-term follow-up (median 10 y) GBP was associated with lowered systolic (mean: −5.1 mm Hg) and diastolic pressure (−5.6 mmHg) differing significantly from both VBG/B  and Controls . Diurnal urinary output was +100 ml (The purely restrictive techniques VBG/B exerted a transient blood pressure lowering effect, whereas gastric bypass was associated with a sustained blood pressure reduction and an increased diuresis. The daily salt consumption was higher after gastric bypass than after restrictive bariatric surgery. The prevalence of obesity is dramatically increasing and associated morbidities such as myocardial infarction, stroke, cancer and diabetes are serious additional demands on health care providers Restrictive bariatric surgery refers to a narrowing of the stomach lumen by certain banding procedures and is represented in the present study by vertical banded gastroplasty or gastric banding (VBG/B). These procedures provide a resistance (‘restriction’) to food passage into the distal part of the stomach and excessive meal results in food retention in the gastric compartment oral to the band. Distension-sensitive afferent nerves in the wall of the proximal stomach, and presumably also in the esophagus, will then mediate sensations of discomfort and even pain that consequently motivates the individual to terminate food ingestion. However, also more subtle mechanisms may be involved. Early satiation and inter-meal satiety have recently been shown to be induced with well calibrated adjustable gastric bands giving only a briefly delayed bolus transit into the infraband stomach, thus without food retention. The satiety signalling in this case is ascribed to esophageal reinforced propulsive motility and compression of gastric vagal afferents at the level of the gastric band The present investigation is based on the SOS study, which compares obese patients undergoing bariatric surgery (n = 2010) with contemporaneously matched, non-operated obese control patients (n = 2037). The inclusion of study patients began 1987 and was continued until 2001. The design and selection of the study participants have been described in detail elsewhere Gastric bypass (GBP) patients, including the patients originally operated with GBP, but also patients converted from VBG/B to GBP, as well as subjects that were originally allocated to the control arm of the SOS study but had been treated with GBP during the study period, if the GBP operation had been performed at least 5 y prior to the 10 y follow-up visit; Vertical banded gastroplasty or gastric banding (VBG/B) patients, excluding those who had been converted to GBP but including control subjects in the SOS study that had been treated with VBG/B if performed at least 5 y prior to the 10 y follow-up; Non-operated control patients, including all subjects that were originally allocated to the control arm of the SOS study and had remained on conventional treatment. Subjects with bariatric constructions other than GBP and VBG/B were excluded from the analysis. With regard to blood pressure measurements, the follow-up rate was 92% in the GBP group and 92% in the VBG/B group at 2 y, and 68% vs. 74%, respectively, at the 10 y follow-up. The follow-up rate in the control group was 81% and 62% at 2 y and 10 y, respectively. Baseline characteristics for each study cohort are given in The SOS study subjects were sorted into the following three study cohorts . Urinary and serum creatinine was measured by enzymatic photometry . Twenty-four hour urinary excretions of sodium (U-Na+), potassium and creatinine were calculated from these data and the recorded 24 h urine output (U-Volume). The schedule, questionnaire, blood pressure and anthropometric measurements, and laboratory examinations were identical for GBP, VBG/B and control subjects.Systolic blood pressure and Korotkoff phase 5 diastolic blood pressure (after 15 min in the supine position), body weight and height were measured at each study visit. Use of blood pressure lowering medications (antihypertensives) was assessed with a questionnaire. A user of antihypertensives was defined as someone who, on a daily basis, took one or more medications included under the following codes: C02 (antihypertensives), C03 (diuretics), C07 (beta blocking agents), C08  or C09 (agents acting on the renin-angiotensin system) in the Anatomic Therapeutic Chemical (ATC) classification system. A user of diuretics was defined as someone who, on a daily basis, took a medication included under the ATC code: CO3 (diuretics). The subjects were instructed to collect urine over 24 h prior to the baseline examination, the 2 y follow-up visit and the 10 y follow-up visit, and to bring it to the examination site the next day. With regard to urine collections, the follow-up rate was 90% in the GBP group and 91% in the VBG/B group at 2 y, and 66% vs. 72%, respectively, at the 10 y follow-up. The follow-up rate in the control group was 81% and 61% at 2 y and 10 y, respectively. The volume of the urine was noted and a 200-mL sample was transferred to the Central Laboratory of Sahlgrenska University Hospital (accredited according to European Norm EN45001). Urinary and serum Nat test compared continuous variables at baseline, and the chi-square test was used for all comparisons of proportions. All changes over time were calculated as the difference between individual values at baseline and values at the 2 y and 10 y follow-up visits. Adjustments for baseline differences between the cohorts  are given in the text and figures, unless otherwise stated. Statistical significance was set at P<0.05. The statistical analyses were carried out using SPSS, version 18 .The Students  cohorts  & 2 wereWeight reduction following GBP was greater than after VBG/B, while non-surgical treatment was not associated with any significant effect .P<0.001) than in the control cohort (43%). At the 10 y visit, the proportion of patients using antihypertensives was significantly lower in the GBP group (35%) as compared to both the VBG/B  and the controls .After 2 y, the proportions of patients taking antihypertensives did not differ between the GBP (27%) and VBG/B (31%) cohorts. However, both these proportions were significantly lower  in absolute values were reduced in both the GBP and the VBG/B cohorts  after gastric bypass (Supporting information Changes in systolic and diastolic blood pressures (BP) were negatively associated with the change in diurnal urinary output (+) at the 2 y and 10 y follow-ups had decreased in the GBP and VBG/B cohorts and had increased slightly in the controls  intake could be calculated: GBP subjects were calculated to consume 1.1 g (0.4 to 1.9) and 1.2 g (0.6 to 1.8) more salt on a daily basis than did the VBG/B subjects with equal BMI changes 2 y and 10 y after surgery, respectively.A BMI reduction-adjusted quantitative analysis showed that the 24 h urinary excretion of sodium was +19 and +20 mmol higher in the GBP group than in the VBG/B group at the 2 y and 10 y follow-ups, respectively . BecauseSystolic and diastolic blood pressures were positively associated with salt intake in the VBG/B and control groups at 2 y and 10 y, respectively (data not shown). However, no associations between blood pressure changes and salt excretion were observed after GBP.ie. 8 to 10 y) are few and usually uncontrolled ad hoc-analysis based on the controlled prospective SOS study ie. dietary advice, life style changes, pharmacology etc) obese patients and those treated surgically with either GBP or VBG/B. Previously published meta-analyses have shown that a pharmacological reduction of diastolic pressure by 5 mm Hg considerably reduces the risks of stroke and ischemic heart disease per se is associated with a decrease in blood pressure mainly due to the improvement of renal sodium retention that is commonly associated to obesity Bariatric surgery was originally developed for weight reducing purposes. Today we know that these gastrointestinal interferences also markedly reduces the risk for cardiovascular disease as shown by an estimated 40% reduction in 10 y Framingham risk score Indeed, at the 2 y follow-up in the present study, the two bariatric surgery cohorts exhibited reduced BMI and a reduced arterial blood pressure compared to the non-operated controls. However, at the 10 y follow-up in VBG/B patients, blood pressure had returned near to preoperative levels despite a reduction in body weight. One explanation may be that an increased inclination for social interaction following weight reduction creates iterated situations with a psychosocial stimulation of the sympathetic nervous system, in turn increasing blood pressure per se (similar as after VBG/B), and a more long term mechanism unrelated to weight loss. This interpretation is supported by the present observation that arterial blood pressure was markedly more depressed after GBP than after VBG/B, already after a period of only 2 y. Actually, a weight-independent blood pressure reducing effect of GBP has previously been reported as early as week one postoperatively, thus before any significant weight loss In contrast to restrictive bariatric surgery, GBP was followed by a marked decrease in blood pressure also at the 10 y follow-up. This finding suggests that GBP interferes with blood pressure control via at least 2 principles: an initial transient blood pressure reduction related to weight loss In analysing diurnal urinary volumes, we found that the GBP patients excreted more urine per day than weight-matched patients treated with restrictive bariatric surgery. Furthermore, regression analysis demonstrated that changes in urinary output were linearly associated with blood pressure changes only in the GBP cohort Click here for additional data file.Figure S2Linear relationship between blood pressure changes and changes in BMI after gastric bypass surgery (GBP), after pure restrictive bariatric surgery (VBG/B) and in non‐operated obese controls at the 2 y and 10 y follow‐up visits. Regression lines and beta values (unadjusted) illustrate results of simple linear regression analysis, while adjusted beta values and P‐values are results of the multiple linear regression analysis adjusted for change in daily salt intake, as well as for sex, age and baseline BMI.(PDF)Click here for additional data file.Figure S3Linear relationship between blood pressure changes and changes in diurnal urinary output (U-Volume) after gastric bypass surgery (GBP), after pure restrictive bariatric surgery (VBG/B) and in non‐operated obese controls at the 2 y and 10 y follow-up visits. Regression lines and beta values (unadjusted) illustrate results of simple linear regression analysis, while adjusted beta values and P‐values are results of multiple linear regression analysis adjusted for both BMI change and change in daily salt intake, as well as for sex, age and baseline BMI.(PDF)Click here for additional data file.Table S1Urinary and serum variables in users and non-users of diuretics among obese controls at the baseline examination.(PDF)Click here for additional data file.Table S2Changes from baseline after vertical banded gastroplasty (VBG) and gastric banding at 2 and 10 years .(PDF)Click here for additional data file.


The IOP lowering effect was statistically significant at 20 h, favoring timolol as compared to dorzolamide (1.4 ± 2.4 vs. 0.2 ± 2.1 mmHg), (p < 0.05). Dorzolamide add-on therapy showed smaller IOP (2.0 ± 1.4), SPP (13.3 ± 7.9), systolic BP (13.5 ± 8.7) and diastolic BP (8.4 ± 5.4) fluctuations as compared to both latanoprost baseline or timolol add-on therapies. Higher difference between morning and evening BP was correlated to decreased evening CRA EDV in the timolol group . With increased MAP in the morning or evening hours, we found increased evening OA RI in timolol add-on group . Higher MAP fluctuations were related to impaired RBF parameters during evening hours-decreased CRA EDV , increased CRA RI  and tSPCA RI  in the dorzolamide group and increased nSPCA RI  in the timolol add-on group. OPP fluctuations correlated with increased nSPCA RI  in the timolol group. OPP fluctuations were not related to IOP fluctuations in both add-on therapies (p < 0.05). Conclusions: Both dorzolamide and timolol add-on therapies lowered IOP in a statistically significant fashion dorzolamide add-on therapy showed lower fluctuations in IOP, SPP and BP. Higher variability of daytime OPP led to impaired RBF parameters in the evening.Objective: To compare the effects of dorzolamide and timolol add-on therapy in open-angle glaucoma (OAG) patients previously treated with prostaglandin analogue (Pg), by evaluating fluctuations in the intraocular (IOP), blood (BP), ocular perfusion pressures (OPP) and retrobulbar blood flow (RBF) parameters. Methods: 35 OAG patients (35 eyes), 31 women (88.6%) age 63.3 (8.9) years were evaluated in a 3 month randomized, cross-over, single-masked study. During the experiments BP, heart rate, IOP and OPP were assessed 4 times per day (8–12–16–20 h). RBF was measured twice per day (8–20 h) using Color Doppler imaging in the ophthalmic (OA), central retinal (CRA), nasal (nSPCA) and temporal (tSPCA) posterior ciliary arteries. In each vessel, peak systolic velocity (PSV) and end-diastolic velocity (EDV) were assessed and vascular resistance (RI) calculated. Results: Both add-on therapies lowered IOP in a statistically significant manner from 15.7 ± 2.4 mmHg at latanoprost baseline to 14.9 ± 2.2 mmHg using dorzolamide ( Several large, multicenter, randomized clinical trials have shown that in many cases glaucoma continues to progress, despite maintaining target intraocular pressure (IOP) ,2 The coNon-IOP factors such as lower systolic ocular perfusion pressure (OPP), reduced OBF, cardiovascular disease, low systolic blood pressure (BP) have been identified as risk factors for primary GON. The Beaver Dam study reported a positive correlation between systolic BP and IOP . EvidencOur current knowledge of the vascular anatomy and physiology has increased over the past decade allowing us to identify the regional vascular beds involved in glaucoma. Imaging technologies allow non-invasive assessment of the ocular circulation. et al. analyzed 24-hour IOP and BP changes with different medications, but ocular blood flow parameters were not analyzed [It is still debated if changes in OBF are a consequence of IOP changes or represent a primary physiological response. Quaranta analyzed . Some stanalyzed  and is manalyzed . Ocular analyzed . Althouganalyzed . It is tThe main idea of our study was to analyse whether dorzolamide add-on therapy is statistically different from timolol treatment, whether fluctuations in IOP, OPP, BP are linked to impaired ocular blood flow in OAG patients and whether fluctuations of OPP are related with the IOP fluctuations.To compare the dorzolamide and timolol add-on effect in patients already treated with the prostaglandin analogue (Pg) latanoprost, evaluating IOP, BP, OPP and retrobulbar blood flow fluctuation parameters.Forty OAG patients were recruited into the randomized, cross-over, single-centre masked 3 month study. All study procedures were carried out according to the Declaration of Helsinki, and the study protocol was approved by the Kaunas Universisty of Medicine Review Board. For the objectivity of data the Reading Center Glaucoma Research and Diagnostic Center, Indiana University School of Medicine (USA) served as the double blind reading center site and analyzed all blood flow and perfusion data along with study coordination. Study sample calculation was based on previous studies  and testBest corrected visual acuity (LogMar test), perimetry  tests were carried out at the begining and at the end of study period. Reliable visual field test defined as a false positive error of less than 15%, a false negative error of less than 15% and a fixation loss less than 20%. Mean deviation (MD) and pattern standard deviation (PSD) were used for visual field data analysis.BP, heart rate, IOP, ocular perfusion pressure (OPP) calculated as 2/3 of mean arterial blood pressure minus IOP; diastolic perfusion pressure (DPP) calculated as diastolic blood pressure minus IOP; systolic perfusion pressure (SPP) calculated as systolic blood pressure minus IOP were analysed 4 times per day (8–12–16–20 h).Color Doppler imaging  for measurements of blood flow in the ophthalmic (OA), central retinal (CRA), nasal (nSPCA) and temporal (tSPCA) short posterior ciliary arteries was carried out twice daily at 8 and 20 h. In each vessel, peak systolic velocity (PSV) and end diastolic velocity (EDV) were determined, Pourcelot’s resistive index was calculated (RI = (PSV-EDV)/PSV). Both eyes were examined, the study eye was chosen randomly using a randomization table. Patients were instructed to avoid caffeine intake, smoking, and exercise for 2 h prior to study visit.®, Merck & Co. Inc.) add-on b.i.d.  and group B receiving topical timolol 0.5%  b.i.d. A randomization table was used to randomize eligible patients. Examinations after add-on therapy were carried out after 1 month of treatment. Patients were washed out 4 weeks, receiving only Pg analogue  monotherapy and a second set of baseline II parameters were obtained. Patients previously having received dorzolamide were signed for timolol and vice versa. After 4 weeks of patient masked treatment the second set of add-on treatments was evaluated.At the time of enrollment all subjects were receiving binocular Pg analogue  monotherapy and rated as subcompensated IOP by refering ophthalmologist. Before the study glaucoma was defined by elevated IOP > 21 mmHg, optic nerve disc cupping and retinal nerve fibber loss charicteristic of glaucoma, presence of visual field defects in perimetry charicteristic of glaucoma, open angles on gonioscopy. After baseline latanoprost measurements, patients were randomly assigned to add-on treatment group A or B (20 patients in each group): group A receiving topical dorzolamide 2%  for continuous variables. Mann-Whitney’s nonparametric test was used when the assumption of the data normality was rejected. The two way ANOVA with the Bonferroni adjustment was performed calculating exact probabilities and considering comparison significant if the p-value was less than 0.05 Changes in individual parameters were examined by paired Student’s t-test. Fluctuations of IOP, BP, OPP and ocular blood flow were modeled using a nonlinear least square dual harmonic regression procedure, studying the mean value, the highest and lowest value and the amplitude of each rhythm. Based on statistical mediana patients were divided into two groups for comparison: younger than 65 and 65 years and older; patients with period of illness ≥ and < than 5 years; patients using ≥ and < than 2 systemic medications.p < 0.05 was considered significant.Association between categorical variables or abnormally distributed continuous variables was assessed by Spearman’s correlation. There was no statistically significant diffference between baseline 1 and baseline 2 measurements, therefore basaline 1 was used for all statistical anglysis. The level of significance Forty OAG patients were recruited, but five patients (12.5%) withdrew from the study due to difficulties attending all study visits. Data from the remaining 35 OAG patients (88.6% women) who finished all study procedures were included for analysis. Patient characteristics are provided in p < 0.001) and to 14.2 ± 1.9 mmHg using timolol (p < 0.001). At 20 h the IOP lowering effect was statistically significant, favoring timolol as compared to dorzolamide   . Analysip > 0.05; t test).Mean RBF velocities and resistive indices in different treatment groups are shown in p < 0.05) in RBF parameters between patients younger than 65 (N = 17) and older than 65 (N = 18).Changes in diurnal CDI parameters between different patient groups are shown in p < 0.05; t test). By adding timolol OA RI decreased by 0.02 ± 0.05 in younger and increased by 0.02 ± 0.05 in older patients (p < 0.05). Patients younger than 65 years had statistically significant decreased morning OA RI from 0.79 ± 0.07 to 0.76 ± 0.08 in dorzolamide add-on therapy group . Patients older than 65 years had increased OA RI in the evening during both add-on therapies (0.77 ± 0.04 to 0.80 ± 0.05), (p < 0.05). Older patients group had bigger fluctuations in systolic BP, OPP, SPP and MAP with dorzolamide and timolol comparing to younger patients, but the difference when using dorzolamide was statistically significant . Patients with periods of illness of less than 5 years had lower fluctuations in OPP with dorzolamide add-on therapy, while patients with longer period of illness had lower fluctuations with timolol add-on therapy.Diurnal latanoprost baseline RI parameters of OA, CRA, tSPCA, nSPCA were lower in patients receiving glaucoma treatment less than 5 years (N = 17), compared with patients receiving more than 5 years of glaucoma treatment (N = 18), but a statistically significant difference was seen only in CRA and tSPCA RI (p < 0.05).Patients using less than two systemic medications (N = 18) had better OA, CRA, tSPCA, nSPCA RI diurnal latanoprost baseline parameters than patients using more than two medications (N = 17), but the differences were not statistically significant (p < 0.05). Most patients were on different systemic antihypertensive treatment receiving on average 2.3 (1.9) medications per day (p = 0.01). With increased MAP in the morning or evening hours, we found increased evening OA RI in timolol add-on group . Higher MAP fluctuations were related to impaired RBF parameters during evening hours-decreased CRA EDV , increased CRA RI  and tSPCA RI  in the dorzolamide group and increased nSPCA RI  in the timolol add-on group. OPP fluctuations correlated with increased nSPCA RI  in the timolol group. OPP fluctuations were not related to IOP fluctuations in both add-on therapies (p < 0.05), but were related to BP fluctuations (Figures There were no statistically significant differences in mean BP parameters between treatment groups ( per day . Dorzolavs. timolol in patients already treated with latanoprost we found that both drugs statistically significantly lowered IOP, favouring timolol, but IOP fluctuations during the day decreased only with dorzolamide. According to AGIS patients with IOP < 14 mmHg had very little change in visual field defect score [Evaluating add-on effects of dorzolamide As IOP therapies may influence ocular perfusion , it is vAccording to our results patients with shorter illness periods had better response to dorzolamide, resulting in lower fluctuations of OPP, while patients with longer glaucoma treatment had the same effect with timolol. One might hypothesise that for a better treatment effect prescribing drugs according to glaucoma illness period should be taken into account.et al. [et al. showed that addition of dorzolamide to timolol monotherapy decreases IOP and increases retinal blood flow in the superficial retinal vasculature in both glaucomatous and healthy patients. The combination of increased retinal blood flow with consistent oxygen saturation may potentially increase oxygen delivery to the retina [In our study a statistically significant difference was found between younger and older patients in diurnal OA RI changes in both add-on groups. Younger patients using dorzolamide were linked to decreased morning OA RI and had lower fluctuations in OPP, SPP, MAP. This suggests better response to ocular hypotensive drugs in younger patients, probably due to a better vascular autoregulation. Our study findings may be explained by the vasodilatative effect of dorzolamide. Dorzolamide hydrochloride is perhaps the most vasoactive topical glaucoma treatment and several studies have shown it to increase various measures of ocular blood flow parameters ,22,23,24et al.  found the retina .Our results showed that patients with shorter illness period or taking less systemic medications had lower baseline resistance indices, which results in better ocular blood flow and possibly indicates better glaucoma prognosis, even if some systemic drugs are thought to improve ocular circulation ,40,41. TPossible limitations of the current study are a short observation period and specific limitations in the imaging technology used to assess OBF. Larger scale studies with longer follow up, standardization of OBF measurement techniques are required to elicit a clear understanding of vascular risk factors in glaucoma progression. Both dorzolamide and timolol add-on therapies statistically significantly lowered IOP but dorzolamide add-on therapy showed lower fluctuations in IOP, SPP and BP. Higher variability of daytime OPP led to impaired RBF parameters in the evening. With a variety of pharmacological agents the paradigm for today is to safely and most potentially treat individual glaucoma patient seeking for potential benefits in ocular perfusion.


Evidence suggests that the workplace plays an important etiologic role in blood pressure (BP) alterations. Associations in female samples are controversial, and the domestic environment is hypothesized to be an important factor in this relationship. This study assessed the association between job strain and BP within a sample of female nursing workers, considering the potential role of domestic overload. A cross-sectional study was conducted in a group of 175 daytime workers who wore an ambulatory BP monitor for 24 h during a working day. Mean systolic and diastolic BP were calculated. Job strain was evaluated using the Demand-Control Model. Domestic overload was based on the level of responsibility in relation to four household tasks and on the number of beneficiaries. After adjustments no significant association between high job strain and BP was detected. Stratified analyses revealed that women exposed to both domestic overload and high job strain had higher systolic BP at home. These results indicate a possible interaction between domestic overload and job strain on BP levels and revealed the importance of domestic work, which is rarely considered in studies of female workers.  A significant number of studies have documented the association between exposure to a stressful psychosocial environment at work and cardiovascular diseases . SpecialThe job strain model represented a breakthrough in psychosocial work environment research. A number of studies have indicated that the psychosocial conditions of the work environment, especially the combination of high psychological demands and low decision latitude (job strain), associated with an increased risk of cardiovascular diseases . There iDespite the substantial increase in women participating in the labor market in recent decades, most publications on occupational health deal with men . This siet al. [Besides, a meta-analysis of ambulatory blood pressure studies revealed that associations of job strain with blood pressure elevation are stronger for men than for women . One shoet al.  found thet al. , is thatet al. , has rarConsidering the literature on this topic, several aspects call for more research on job strain and blood pressure with female groups, such as the small numbers of studies among women , less coThe present study aims to assess whether job strain is associated with 24 h ambulatory blood pressure measurements considering the potential role of domestic work in a sample of female nursing professionals.et al. [This cross-sectional study was conducted at a public hospital in the municipality of Rio de Janeiro, Southeastern Brazil, in 2009. A total of 175 female nursing workers were selected by convenience sampling from 550 eligible workers. We did not exclude subjects under antihypertensive treatment; the inclusion of those subjects was considered a feasible solution to reduce the selection bias produced by healthy worker effect, as suggested by Ohlin The questionnaire provided comprehensive information on professional (paid) work hours, domestic work hours, and questions on health and healthy habits. Trained interviewers were responsible for recording the information from participants. Interviewers underwent a training course that covered the aims of the study with particular emphasis on the procedures of monitoring. The Demand-Control questionnaire was self-filled. Contact with the study participants occurred during the first three hours of a regular working shift, which began at 7 a.m. Participants were invited to start the blood pressure monitoring procedures shortly after the interview. The 24 h blood pressure monitoring was conducted using a SpaceLabs ABPM .The devices were programmed to measure the arterial blood pressure every 30 minutes during day and night . Before i.e., work, home or sleep), position  and physical activity during waking hours at the end of each measurement in a diary. In case of desistence the participant was instructed to switch off the device and keep it in a safe place.Participants were asked to perform their regular activities at work and at home during the monitoring period, and not to detach the device until the next day. They were also asked to remain still and to keep their arm beside the body during cuff inflation and deflation. Subjects recorded their location  at work, (ii) at home and awake and (iii) at home sleeping. When fewer than five readings were obtained for each location, the corresponding average was treated as missing data. This procedure follows the recommendations of Schnall et al.  and Llab [et al. . et al. [Perceived stress at work was measured by the Swedish version of the Demand-Control Questionnaire  translat et al. . PsycholJob strain was computed through the quadrant approach by dichotomizing decision latitude and demand scores at the medians of the sample. Subjects who presented high demand and low decision latitude scores were classified into the high strain group. The reference (low strain) group was formed by individuals who reported low demand and high decision latitude. Do you have to do the same thing over and over again?) increased the alpha from 0.54 to 0.56 for decision latitude. In addition, results from previous studies showed low psychometric performance of this item for nursing teams [Cronbach alpha values were 0.70 for psychological demands and 0.54 for decision latitude for this sample. Further analysis showed that the removal of the item which refers to repetitive tasks . Smokers were defined as subjects who currently smoke or have smoked in the past. Alcohol use was measured by the consumption of alcohol drinks taken two weeks before the interview. Users of anti-hypertensive medication were those who reported making daily use of medication prescribed by a doctor. Coffee intake was defined by the median value of the sample distribution (≥250 mL/day). Oral contraceptive use was defined according to current usage. Work-related variables included extended professional work hours defined by the median value of the sample distribution (≥25 h/week) obtained by recall information corresponding to the week before the interview, professional category (nurses or nurses’ aides), social support at work, night work in the past and type of employment contract (permanent or temporary). Socio-demographic variables also included age, marital status, presence of children up to 14 years-old, family earnings and self-reported skin color.Relevant covariates associated with health and with work were considered in the present study. Leisure-time physical activity was measured by the number of hours per week. Body mass index was defined by self-reported weight (kg)/height  and the Pearson’s chi-square test. Only variables that were significantly associated with BP and also with job strain were included in multivariate models. Since these data do not present a normal distribution, natural logarithm (ln) transformations were performed for mean blood pressure throughout 24 h, at work, at home and during sleep. The multivariate analyses of variance (MANOVA) were used to test the association between systolic and diastolic ambulatory BP and job strain and also other risk factors for BP alteration. Analyses were carried out for the whole 24h-monitoring period and for the periods at work, at home, and during sleep. The multivariate model included adjustment for age, self-reported skin color, and use of anti-hypertensive medication. Additionally, the possible interaction between job strain and domestic overload in relation to the ambulatory BP was previously assessed by the general linear model. Based on that, statistical analyses were performed for the whole sample and also stratified by domestic overload. All analyses were conducted using SPSS v.19.0 .The sample included 175 people. However, the estimation of the mean blood pressure for some participants was not possible because there were no valid readings for some locations. The mean blood pressure at work could not be calculated for one participant. Similarly, the mean BP at home and during sleep could not be calculated for 15 and 20 participants, respectively. Thus, statistical analyses were performed for 174 participants using work ABP, for 160 participants using home ABP and for 155 participants using sleep ABP. The mean age was 46.1 years (standard deviation ± 11.9 years). A majority were married (53.7%), 40.8% reported being white and 59.2% reported being black or having a mixed background. With respect to family income, 51.4% of workers reported receiving more than USD 1,230 per month. Participants dedicated, on average, 20h/week (SD ± 15.4 h) to domestic work and 25.7 h/week (SD ± 12.9 h) to professional work. Among the 175 workers, 51 (29.1%) were nurses and 124 (70.9%) were nursing aides’. Most participants had only one job (67.4%) and were former night workers (72.4%). Only 23.4% practiced at least one hour of physical activity during the week, and 63.4% were overweight or obese. The sample was comprised of 32.4% of workers in active (high demand-high control) jobs, 30% in passive (low demand-low control) jobs, 22.9% in low strain (low demand-high control) jobs and 14.7% in high strain (high demand-low control) jobs.Non-white women, anti-hypertensive medication users and workers with domestic overload had higher systolic and diastolic blood pressure at work than their counterparts. Systolic blood pressure was also higher in women over 46 years compared to younger workers . vs. low) job stain and blood pressure (vs. low) job strain and home systolic blood pressure . Borderline significant associations for high (vs. low) job strain in the group with domestic overload were also observed for sleep systolic BP , 24 h diastolic BP , home diastolic BP  and sleep systolic BP .These findings suggest the existence of interaction between domestic overload and stress at work since much smaller (and non-significant) differences in mean BP due to high job strain were observed for workers with low domestic workload. The p-values of the interaction terms were <0.10 for 24 h and at home and >0.10 for work and sleep. Both active and passive groups were compared with the low strain group. No significant association was detected overall and in the two domestic overload groupsNo significant associations were found between high ; and limited objective variance in job characteristics . Also, the relatively small sample limited statistical power for observing associations, especially in subgroups. However, despite such biases and limited power, substantial associations were observed in the group exposed to both domestic overload and job strain. Workplace psychosocial stress was not significantly associated with ambulatory blood pressure in the whole group of workers. Only women exposed simultaneously to job strain and to domestic overload showed a significantly and substantially higher level of systolic blood pressure, suggesting an important interaction of domestic work and job strain. This result occurred despite the relatively small sample size, sample composition which included female workers taking anti-hypertensive medicine, and other study limitations.Evidence of the role of domestic work in the relationship between occupational stress and blood pressure levels may explain in part the greater inconsistency in results of studies with female samples when compared to those with male samples. The results of the present study encourage researchers to examine both the process of professional work and the domestic-family sphere when investigating female workers’ health. In sum, a gender approach is essential when considering health risks. It can be concluded that a fairer sharing of domestic responsibility and also the decrease of strain at work tend to improve the health status, thus preventing morbidity related to hypertension.


High blood pressure is common in acute stroke patients. Very high as well as very low blood pressure is associated with poor outcome. Spontaneous fall of blood pressure within the first few days after stroke was associated both with neurological improvement and impairment. Several randomized trials investigated the pharmacological reduction of blood pressure versus control. Most trials showed no significant difference in their primary outcome apart from the INWEST trial which found an increase of poor outcome when giving intravenous nimodipine. Nevertheless, useful information can be extracted from the published data to help guide the clinician's decision. Blood pressure should only be lowered when it is clearly elevated, and early after onset, reduction should be moderate but may be achieved rapidly. No clear recommendations can be given on the substances to use; however, care should be taken with intravenous calcium channel blockers and angiotensin receptor antagonists. Two ongoing randomized trials will help to solve the questions on blood pressure management in acute stroke. High blood pressure occurs in around 80% of patients with acute ischemic stroke  and usuaWhether this elevated blood pressure is a physiological and protective reaction or a side effect of a generalised stress reaction that is in fact harmful to the newly damaged brain and whether it should be lowered or not is yet to be answered. This problem is considered as “one of the major unresolved issues in acute stroke management” . AmericaThis article focuses on currently available data, the contraries of the results, and potential solutions. Several observational studies looked into the relationship of high initial blood pressure and outcome. A post hoc analysis of the International Stroke Trial found a U-shaped relationship between initial blood pressure and outcome, indicating that systolic blood pressure of around 140–180 mmHg is associated with best outcome .Patients with very low initial blood pressure had a higher incidence of heart failure and coronary heart disease. This might explain part of their worse outcome. The reason for poor outcome after initial high blood pressure seems more complex. High blood pressure after acute ischemic stroke causes brain edema , and braOne critique of those studies is that blood pressure was measured only on admission, usually several hours after stroke onset , 16, 17.Several observational studies looked into the prognosis of spontaneous change in blood pressure during the acute phase with divergent results. The Barcelona Downtown stroke registry found that early decrease of systolic blood pressure by 20–30% was associated with full recovery  . A decreThere might be a bias when looking into spontaneous decrease of blood pressure and correlating it to outcome. Rapid spontaneous decrease might reflect less severe stroke , recanalSeveral randomised controlled trials addressed the topic of blood pressure management in acute stroke see . The triBeta-blockers given within 48 hours after hemispheric stroke increased mortality (BEST) [nimodipine was investigated in several trials in the 1990s. A metaanalysis of nine trials showed a significant benefit from oral nimodipine versus placebo when given within 12 hours of symptom onset [y (BEST) . The treom onset . In contom onset . A correom onset . magnesium administered within 12 hours lowered systolic blood pressure by 4 mmHg and showed a trend towards improved outcome in all stroke patients . For the subgroup of patients with elevated blood pressure , improvement was significant  [Intravenous 61–0.99) . glyceryl trinitrate showed no significant difference in functional outcome [Smaller trials with  outcome , 27 but labetalol and lisinopril lead to a significant reduction in blood pressure as compared to the placebo group  (CHHIPS). Death and dependency at 3 months did not differ, but 3 months mortality was halved in the treatment group to 9,7% from 20,3% . The intervention was safe regarding early neurological outcome and serious adverse events [The early administration of e events .P = 0.045) [The COSSACS trial looked into the question whether previously taken antihypertensive agents should be stopped or continued in patients with acute stroke. The trial included patients within 48 hours from symptom onset. Continuing the medication reduced blood pressure significantly (13/8 mmHg lower at two weeks). No difference was seen in the primary outcome death or dependency at two weeks, but there was a significant functional improvement in the subgroup of patients with confirmed acute ischemic stroke  .candesartan to placebo within 30 hours after onset looking at a combined vascular endpoint. Blood pressure reduction was only moderate, and no significant differences in the endpoints were seen. A trend favouring placebo was noticed [Another trial (SCAST) compared A metaregression on actively lowered blood pressure in acute stroke including 9008 patients from randomized trials showed the lowest odds ratio  for death or dependency with a decrease of systolic blood pressure by 14 mmHg . Two Cochrane analyses concluded that there is insufficient evidence to evaluate the effect of blood pressure changes on outcome after acute stroke , 33.The management of blood pressure in acute ischemic stroke remains unclear due to divergent results of the studies. The effect of blood pressure management appears to differ in various patient populations. The effect might be dependent on level of initial blood pressure, time to treatment, stroke severity, and history of hypertension, as well as intensity of blood pressure lowering, substances used, and administration form . Some of the possible influences should be looked at in more detail.It is evident that lowering blood pressure of normotensive patients in acute stroke may lead to hypotensive events, thus deteriorating outcome. Therefore, blood pressure lowering should only be considered when it is elevated. The negative effect of the BEST trial might partly be explained by inclusion of normotensive patients with systolic blood pressure >100 mmHg . In a suThe earlier acute stroke treatment is initiated, the better the outcome . This seIt is agreed that a rapid and large decrease in blood pressure is dangerous for acute stroke patients. This opinion is largely based on the data from INWEST and some observational data , 20, 23.No clear answer can be given to this question as yet. Some trials included various classes , 29, andSeveral data showed that lowering blood pressure in acute ischemic stroke is safe in terms of early neurological deterioration and functional outcome –29, evenTrials looking at the effect of blood pressure reduction in the acute phase of stroke are heterogeneous in design, classes of antihypertensive agents, achieved blood pressure reduction, and influence on outcome. Although the guideline recommendation is not to lower blood pressure in the range up to 220/120 mmHg, there might be some neuroprotective effect of very early (first 7–10 hours after stroke) and rather moderate (10–20 mmHg) blood pressure lowering. Substance classes may differ in that respect, but care should be taken with intravenous calcium channel blockers and angiotensin receptor antagonists. Adequately powered, randomized trials, however, are urgently warranted to substantiate those speculations.


By establishing the renal suppletion procedure, the patients with chronic renal failure also have an acceleration of arterial hypertension phenomena. The management of this situation calls for the understanding of the ethological mechanisms (hypervolemia by the reduction of Na excretion and high rennin secretion) and the adaptation of the therapeutic approach to every patient. An individualized dialysis prescription is imposed, taking into account the residual renal function and an anti–hypertension treatment, in which the role of the conversion enzyme inhibitors (ACE inhibitor) is intensely debated.  In the majority of cases, arterial hypertension (HT) becomes therapeutically controllable with the implementation of renal substitution treatment, the rest of them being candidates for double nephrectomy. The link between the debut of the arterial hypertension and chronichypertensive nephropathies has been noticed since 1836 along with the research made by Richard Bright. These demonstrated the appearance of a rise in pressure values simultaneously with the evolution of the renal illness. Severe HT, essential HT or other non–renal causes can functionally affect the otherwise healthy kidneys, by inducing nephroangiosclerosis . HT reprHT Causes:Chronic glomerulonephritisSystemic lupus erythematosusSystemic atherosclerosis with nephroangiosclerosisPolyarteritis nodossaDiabetic nephropathyPolycystosisAmyloidosisIn the majority of cases, dialysis patients develop terminal conditions of cardiovascular origin, associated with a history of arterial hypertension and advanced sclerosis. Recent studies have shown that there is no direct causality between mean arterial pressure and the survival rate; the left ventricular hypertrophy (LVH) incidence is increased in dialysis patients, and has a significant prognostic value–an important parameter for the monitoring, evaluation and evolution of the disease. Even if the pathogenesis of the LVH is of high variety , it has been shown that this can be limited by administering the correct treatment–the association of dialysis with personal drug therapy, that keeps the arterial pressure values within acceptable limits . It is aNighttime measurements have shown significant decreases of values because of an autonomically acquired deficiency with a late debut of the chronic renal insufficiency.There have been documented cases in dialysis, in which, although before the onset of the substitute treatment, the subjects did not present with HT, they developed high values afterwards. These come secondary to their failure to meet their imposed dietary routine, even from technical mistakes during the dialysis procedure like hyperosmolarity of the dialysis patient, inadequate trans–membrane pressure, or intravenous fluids during the dialysis.Several groups concerning the dialysis patients have been described based on the pathogenesis of the condition that can cross–link in some situations :Hypervolemia HT seems to be the most frequent cause of hypertension affecting these patients, and this happened due to the complete failure of renal functions; these debuts as a consequence of reestablishing the electrolyte balance, with the secondary expansion of the extracellular liquid volume and the rise of non–exchangeable Na.Table 1Therefore, along with the rise in water and Na intake, we observe a rise of the total plasma volume, cardiac output and peripheral vascular resistance, due to the local auto–regulation. These patients have shown low levels of rennin and angiotensin Ⅱ (ATII) values, compared with their volemic status.The optimum treatment for these forms is established as:Na intake restriction and the close supervision of liquid intake, correlated with the residual dieresis and non–detectable losses–an average of 10ml/kg/day.Lowering plasma Na concentration to 133–135 mEq/LDaily or three times a week dialysis until patient reaches ideal weight The attention in establishing the patient's ideal weight and the adaptation of dialysis recommendations may assure the correction of pressure values and their stabilityThis type of HT is an altogether different entity, which imposes differential diagnostic issues with the hypervolemia type, making it hard to be diagnosed independently because of the etiological cross–linkage: plasma rennin, ATII, aldosterone, and peripheral resistance are high, with a normal or low serum Na concentration and plasma volume.Clinically, this form of HT is a malignant development, hard to control, but often with a spectacular result after the administration of ACE inhibitors. For patients on dialysis with therapy–resistant HT, we could incriminate a hyperactivity of plasma rennin even after ultra–filtration and idea–weight adapted dialysis. The administration of ACE inhibitor therapy for these patients has lead to a net improvement of their HT status , neverthPhysiopathology studies have recorded paradoxical vascular reactions to any exceeding volemic homeostasis values. Furthermore, the therapeutic loss of salt by dialysis may be the source of ulterior activity of renal vasopressor mechanisms and the generating of HT phenomena hard to control.The balance between cardiac output and peripheral vascular resistance determines the arterial pressure. Most studies indicate that the cardiac output is normal or above, while extracellular liquid volume is relatively high in patients with chronic renal insufficiency (CRI); systemic vascular resistance is abnormally high relatively to cardiac output, this revealing a switch in the vascular control mechanism towards vasoconstriction. Therefore, patients with CRI show an increased adrenergic tonus and some highly stimulated rennin–angiotensin, endothelin and vasoactive prostaglandins systems. Another aspect observed in some situations is that of diminished nitric oxide (NO) production which reduces the vasodilatation potency.The link between renal perfusion pressure and salt excretion, which defines pressure natriuresis, has been an element of interest for many studies. In essential HT, a higher renal perfusion pressure is imposed in order to stabilize the sodium balance, but not the same thing happens in patients with renal parenchyma disease, where natriuresis is perturbed by the loss of renal tissue mass. The same effects are also noticed when dealing with endocrine dysfunctions which have an effect on salt excretion , or in the case of diminished renal blood flow and stenosis of the renal artery (Goldblatt kidneys) .The necessity to control arterial blood pressure in patients with terminal renal insufficiency and dialysis patients has imposed the detailed study of the sodium plasma levels in concordance with ultra–filtration. Gathered data include body weight, plasma rennin activity and arterial blood pressure (before and after the administration of ACE inhibitors), on a period of 11 days of treatment. Rigorous ultra–filtration has been performed on these patients set on a low Na diet, in order to obtain a negative Na balance. We have observed the increase in plasma rennin concentration, concomitant with sodium extraction, and the values for arterial pressure depends on rennin–ATII system, as we can see after the administration of the ACE inhibitor (captoprilum). In conclusion, the reduction of extracellular liquid volume and sodium plasma levels is essential for the establishing of an efficient control of arterial BP values in patients with CRI.The relevance of the interaction between sodium and rennin–angiotensin balance in malignant HT is revealed by a study made on a group of subjects with renal dysfunction and accelerated HT. Lowering the BP values after the administration of ACE inhibitors is abruptly altered after the infusion of saline solution, with the establishing of a positive Na balance and the reduced plasma rennin concentration. Administering a strong diuretic induces net sodium excretion, restimulates the rennin synthesis and reestablishes the sensibility to ACE inhibitor therapy. These observations establish the reciprocal relationship between the Na status and the level of circulating rennin.The latest studies made on dialysis patients who have over 8 years of treatment, have shown that there is no correlation between plasma rennin levels and diastolic BP. In the same time, these studies indicate that severe HT in dialysis patients is an account not only of the nigh plasma rennin activity and ATII generation and extraction, but also of the overlapping excess of salt and water , 8. TherAdapting the therapy by associating an adequate ultra–filtration and the administration of an anti–hypertensive medication based on ACE inhibitors, with a prolonged half time, associated or not with other categories of anti–hypertensive drugs, is the key in managing this type of HT.ACE inhibitors act directly by interfering with the rennin–angiotensin–aldosterone system, which makes their use become attractive in the therapy of dialysis patients. They are a class of anti–hypertensive drugs generally well tolerated, with low side effects like the lethargy–somnolence syndrome or other effects shown by anti–adrenergic and beta–blocker drugs. In dialysis patients, the level of prekalicreine is low and that if ACE is high; high plasma rennin activity may be correlated with the increase of aortic pressure. ATII accelerates LVH and that is why the use of ACE inhibitors may stop and even make LVH regress. ACE inhibitors are useful in congestive cardiac insufficiency by reducing the thirst sensation, which is characteristic for high plasma rennin levels, this limiting the weight–gain between dialysis procedures.The utilization of captoprilum, has been associated with side–effects like:Skin rashCoughLeucopenia or neutropeniaAcceleration of anemiaThis last effect has become notable after the association of ACE inhibitor therapy withthe diminishing of plasma erythropoietin (EPO) or with an increased degree of hemolysis. The explanation for this phenomenon may lie in the direct interference of ATII, with the transcription signal for EPO at a cellular level. ACE inhibitors reduce arterial blood pressure by lowering peripheral vascular resistance because of the blocked formation of ATII, but there are also other collateral mechanisms. That is why most cases require the administration of more than one class of anti–hypertensive drugs .In conclusion, the management of HT in dialysis patients is linked especially to the disease that causes chronic nephropathy, the substrate of the terminal renal insufficiency, the presence of co–orbidities, the evolution of HT before the start of renal substitution therapy and during dialysis therapyThe optimal attitude is that of continuous evaluation and monitoring of the patient, with the adaptation of therapy by accurately combining the recommendation for dialysis and anti–hypertensive medication, all this in order to reach the aimed arterial blood pressure values.