Hypertensive complications of pregnancy: A clinical overview.

Hypertensive disorders in pregnancy are a worldwide health problem for women and their infants complicating up to 10% of pregnancies and associated with increased maternal and neonatal morbidity and mortality. In Europe, 2.3-3% of pregnancies are complicated by preeclampsia. Gestational diabetes, obesity, no previous or multiple births, maternal age less than 20 or greater than 35years old and thrombophilia can be some of the possible factors related to increased risk for hypertension in pregnancy. Complications of hypertension during pregnancy affect both mothers and their infants. Ambulatory blood pressure monitoring helps to distinguish true hypertension from the white coat as pregnant women with office abnormal values may have normal out of office blood pressure. Imbalance between proangiogenic and antiangiogenic factors in placenta may lead to endothelial dysfunction, vasoconstriction, activation of the coagulation system, and hemolysis. Carotid intima-media thickness, pulse wave velocity, augmentation index, and arterial wall tension were found to be significantly increased in women with preeclampsia compared to normotensive pregnant women. Uterine artery Doppler and serum biomarkers can be used to evaluate the probability of hypertension and complications during pregnancy, but further research in the field is needed. Lately, micro ribonucleic acids have also been the focus of research as potential biomarkers.

Success and failure of cardiovascular disease prevention in Czech Republic over the past 30 years. Czech part of the EUROASPIRE I-IV surveys.

Cardiovascular (CV) mortality was reduced more than 50 % in the Czech population at the turn of the century, due to an improvement of major CV risk factors in the general population, interventional procedures implemented into the treatment of acute coronary events, and new drugs (ACE inhibitors, statins etc.) for CV prevention (Czech MONICA and post-MONICA studies, 1985-2008). An insufficient level of preventive efforts is described in the Czech patients after acute coronary syndrome (Czech part of the EUROASPIRE studies, 1995-2013). Drug underdosing and wrong patients' compliance to life style and drug therapy recommendations represent two main reasons of this unsatisfactory situation. The residual vascular risk of patients with stable coronary heart disease (CHD) is still high due to a poor control of conventional risk factors on the one hand, and due to increasing weight and glucose metabolism abnormalities on the other hand. Patients with insulin resistance and glucose disorders have more frequently non LDL C dyslipidemia (atherogenic dyslipidemia), hypertriglyceridemic waist and high atherogenic index of plasma (AIP>0.24), i.e. markers of residual CV risk. Among others increased dose of statins and combined lipid modifying therapy should be implemented in patients with CHD, diabetes or metabolic syndrome.

A comparison of secondary prevention practice in poststroke and coronary heart disease patients.

OBJECTIVES: It is evident that patients with atherosclerotic vascular disease (AVD) benefit from appropriate secondary prevention. In clinical reality, the secondary prevention in AVD patients other than those with coronary heart disease (CHD) is often overlooked. Therefore, we compared the adherence to secondary prevention principles between poststroke and CHD patients. STUDY DESIGN: Descriptive (cross-sectional) study with prospective mortality follow-up. METHODS: We examined 1729 chronic patients with AVD (mean age 65.9 (±SD 9.6) years), 964 with CHD, and 765 poststroke (pooled data of Czech samples of EUROASPIRE III, IV, and the ESH stroke survey). The interview was performed 6-36 months after the coronary event/revascularization or the first ischemic stroke, while the mortality follow-up 5 years after this interview. RESULTS: Poststroke patients had a significantly higher risk of persistent smoking, blood pressure ≥140/90 mmHg and LDL ≥2.5 mmol/L than CHD patients [odds ratios adjusted for age, gender and survey were 1.63 (95% CI: 1.13-2.33), 1.38 (95% CI: 1.13-1.69) and 2.26 (95% CI: 1.84-2.78), respectively]. In contrast, poststroke patients showed a lower risk of inappropriate glucose control and hypertriglyceridemia [0.66 (95%CI: 0.54-0.82) and 0.74 (95%CI: 0.61-0.91), respectively]. The prescription rates of antiplatelets/anticoagulants, antihypertensives and statins were also significantly lower in poststroke than in CHD patients (89.4 vs 93.7, 85.9 vs 97.5, and 57.7 vs 89.8, respectively). Mortality analysis was performed in a subsample of 815 subjects interviewed in 2006/07. The 5-year all-cause mortality rates were 25.8% and 13.3% in poststroke and coronary patients, respectively (P = 0.0023); the hazard ratio for stroke adjusted for major risk factors was 1.85 (95% CI: 1.31-2.63). CONCLUSIONS: Compared to CHD patients, poststroke patients are strongly handicapped in terms of poor adherence to secondary prevention target, prescription of basic pharmacotherapies and mortality risk.

ESHRE Guideline: management of women with premature ovarian insufficiency.

STUDY QUESTION: What is the optimal management of women with premature ovarian insufficiency (POI) based on the best available evidence in the literature? SUMMARY ANSWER: The guideline development group (GDG) formulated 99 recommendations answering 31 key questions on the diagnosis and treatment of women with POI. WHAT IS KNOWN ALREADY: NA. STUDY DESIGN, SIZE, DURATION: This guideline was produced by a multidisciplinary group of experts in the field using the methodology of the Manual for ESHRE Guideline Development, including a thorough systematic search of the literature, quality assessment of the included papers up to September 2014 and consensus within the guideline group on all recommendations. The GDG included a patient representative to ensure input from women with POI. After finalization of the draft, the European Society for Human Reproduction and Embryology (ESHRE) members and professional organizations were asked to review the guideline. PARTICIPANTS/MATERIALS, SETTING, METHODS: NA. MAIN RESULTS AND THE ROLE OF CHANCE: The guideline provides 17 recommendations on diagnosis and assessment of POI and 46 recommendations on the different sequelae of POI and their consequences for monitoring and treatment. Furthermore, 24 recommendations were formulated on hormone replacement therapy in women with POI, and two on alternative and complementary treatment. A chapter on puberty induction resulted in five recommendations. LIMITATIONS, REASONS FOR CAUTION: The main limitation of the guideline is that, due to the lack of data, many of the recommendations are based on expert opinion or indirect evidence from studies on post-menopausal women or women with Turner Syndrome. WIDER IMPLICATIONS OF THE FINDINGS: Despite the limitations, the guideline group is confident that this document will be able to guide health care professionals in providing the best practice for managing women with POI given current evidence. Furthermore, the guideline group has formulated research recommendations on the gaps in knowledge identified in the literature searches, in an attempt to stimulate research on the key issues in POI. STUDY FUNDING/COMPETING INTERESTS: The guideline was developed and funded by ESHRE, covering expenses associated with the guideline meetings, with the literature searches and with the implementation of the guideline. The guideline group members did not receive payment. Dr Davies reports non-financial support from Novo Nordisk, outside the submitted work; the other authors had nothing to disclose. TRIAL REGISTRATION NUMBER: NA.

Desphospho-uncarboxylated matrix Gla protein is associated with increased aortic stiffness in a general population.

Matrix Gla protein (MGP), a natural inhibitor of calcification, strongly correlates with the extent of coronary calcification. Vitamin K is the essential cofactor for the activation of MGP. The nonphosphorylated-uncarboxylated isoform of MGP (dp-ucMGP) reflects the status of this vitamin. We investigated whether there is an association between dp-ucMGP and stiffness of elastic and muscular-type large arteries in a random sample from the general population. In a cross-sectional design, we analyzed 1087 subjects from the Czech post-MONICA study. Aortic and femoro-popliteal pulse wave velocities (PWVs) were measured using a Sphygmocor device. Dp-ucMGP concentrations were assessed in freshly frozen samples by enzyme-linked immunosorbent assay methods using the InaKtif MGP iSYS pre-commercial kit developed by IDS and VitaK. Aortic PWV significantly (P<0.0001) increased across the dp-ucMGP quartiles. After adjustment for all potential confounders, aortic PWV independently correlated with dp-ucMGP (with beta coefficient (s.d.) 11.61 (5.38) and P-value=0.031). In a categorized manner, subjects in the top quartile of dp-ucMGP (⩾ 671 pmol l(-1)) had a higher risk of elevated aortic PWV, with corresponding adjusted odds ratio (95% confidence interval) 1.73 (1.17-2.5). In contrast, no relation between dp-ucMGP and femoro-popliteal PWV was found. In conclusion, increased dp-ucMGP, which is a circulating biomarker of vitamin K status and vascular calcification, is independently associated with aortic stiffness, but not with stiffness of distal muscular-type arteries.

Association of intima-media thickness of carotid arteries with remnant lipoproteins in men and women.

The subclass of triglyceride-rich lipoproteins - remnant-like particles (RLP) seems to be strong and independent risk factor for cardiovascular disease. We evaluated the role of RLP and other risk factors (RF) with sonographically measured intima-media thickness of carotid arteries (IMT CCA) in a cohort of Czech population including women defined according to the time after menopause. We investigated relation of IMT CCA to age, weight, central obesity, plasma lipids including remnant-like particles cholesterol (RLP-C) and triglycerides (RLP-TG) in 136 men and 160 women. Using multiple linear regression analysis, significant association between IMT CCA and RLP-C was found in women 1-7 years after menopause. In the whole group of women, only age and fasting blood glucose were independently associated with IMT CCA. In men only age significantly correlated with IMT CCA. Significant decrease of all plasma lipids between 1988 and 1996 in men was detected, while in women significant increase in triglycerides and no change in non-HDL cholesterol was observed. RLP-C was the strongest independent RF for atherosclerosis in postmenopausal women but its association with IMT CCA was limited to several years after menopause. In conclusion, women changing reproductive status could be more sensitive to atherogenic impact of remnant lipoproteins.

Tobacco smoking strongly modifies the association of prothrombin G20210A with undetermined stroke: consecutive survivors and population-based controls.

OBJECTIVE: Due to contradictory results of previous studies evaluating the association between ischemic stroke (IS) and thrombophilic polymorphisms, their routine screening in IS patients, particularly those older than 60 years, is not recommended. We evaluated the differences in the distribution of rs6025 and rs1799963 polymorphisms according to IS subtypes and their interaction with smoking. METHODS: We conducted a case-control study of 423 hospital-based consecutive survivors of their first-ever IS and 614 population-based controls. Survivors (18-81 years) with IS documented by brain imagining were examined at a median of 16 months after the index event. The stroke subtype was categorized using the Causative Classification of Stroke System. Controls (50-75 years) were free of a history of stroke/TIA, coronary heart disease, and venous thromboembolism. RESULTS: Age- and gender-adjusted prevalence of individuals carrying at least one copy of the rs1799963A minor allele was 5.3% among stroke survivors (by subtypes: 3.1% in large artery atherosclerosis, 2.0% in cardio-aortic embolism, 2.4% in small artery occlusion, and 10.3% in undetermined stroke) vs. 2.4% among controls. In multinomial multivariate adjusted analysis, rs1799963 was exclusively associated with undetermined stroke (OR: 3.67; 95% CI: 1.52-8.85; p = 0.004). There was strong evidence of rs1799963 × smoking synergistic interaction (OR: 5.14; 95% CI: 1.65-16.01; p = 0.005). There was no association of rs6025 with IS in general, or with any subtype. CONCLUSIONS: In our consecutive IS survivors, carriage of the rs1799963A allele is associated with undetermined stroke. This effect appears to be confined to smokers.

[Distribution of lipoprotein associated phospholipase A2 in Czech population and its interaction with conventional cardiovascular risk]. / Distribuce s lipoproteiny asociované fosfolipázy A2 v ceské populaci a její interakce s konvencním kardiovaskulárním rizikem.

INTRODUCTION: Lipoprotein associated phospholipase A2 (Lp PLA2) represent new cardiovascular risk factor and potential treatment target. We aimed to analyze the epidemiological situation of this factor in Czech population. METHODS AND RESULTS: The study population consisted from 1 962 subjects, a random samples of general population (postMONICA study), and from patients with manifest coronary or cerebrovascular disease (Czech samples of EUROASPIRE III survey). Lp PLA2 activity was estimated using commercial kits by diaDexus Inc. in frozen samples. Increased activity (by definition, i.e. > 195 nmol/ min/ ml) was observed in 21.1 % of sample, no apparent difference between subject with and without manifest vascular disease was found. Males showed higher Lp PLA2 activity, than females (179.6 vs 146, resp., p < 0.0001), while no substantial increase with age was observed. Taking Lp PLA2 activity > 195 as dependent variable, following independent variables entered the multiple logistic regression: male gender [with odds ratio 4.26 (3.26- 5.58)], low HDL cholesterol (i.e. < 1.0 mmol/ l in males or < 1.2 mmol/ l in females) [3.49 (2.62- 4.64)], LDLcholesterol > 2.5 mmol/ l [6.95 (4.79- 10.07)] and lipid  lowering treatment [0.59 (0.44- 0.79)]. In subject without manifest vascular disease, 6.3 % of them showed co incidence of markedly increased Lp PLA2 activity with high conventional risk (SCORE > 10 %). Expanding this group by intermediate risk subjects (ie. with Lp PLA2 activity 152- 194 and/ or SCORE 5- 9.9 %) leads to increase of this prevalence to 28.9 % of primary prevention subjects. CONCLUSION: Increased Lp PLA2 activity is in Czech population highly prevalent and with exception of lipid parameters, generally independent from conventional cardiovascular risk. However, up to 29 % of subject in primary prevention amalgamate increased Lp PLA2 activity with high conventional cardiovascular risk.

[Opinion of the Czech Atherosclerosis Society's committee (CSAT) on the ESC/EAS guidelines related to the diagnostics and treatment of dyslipidemias issued in 2011]. / Stanovisko výboru CSAT k doporucením ESC/EAS pro diagnostiku a lécbu dyslipidemií z roku 2011.

This position statement of the Executive Committee of the Czech Society for Atherosclerosis (CSAT) summarizes the most important aspects and novelties of the latest European guidelines for the management of dyslipidemia. In particular the position statement comments on: cardiovascular risk stratification, indications for plasma lipid and lipoprotein levels assessment as well as target lipid values, evaluation of current options for both lifestyle and pharmacological treatment of lipid metabolism disorders and, also, recommendation for laboratory monitoring of patients treated with lipid lowering agents. The statement deals with actual concepts of management of dyslipiemia in everyday practice, e.g. therapy of dyslipidemia in special patients´ groups. This statement does not replace the latest guidelines but focuses on the changes from the former guidelines for dyslipidemia management, published by CSAT in 2007.

Relation of central and brachial blood pressure to left ventricular hypertrophy. The Czech Post-MONICA Study.

Central blood pressure (BP) has been shown to be a better predictor of target organ damage and cardiovascular events than brachial BP. Whether central BP is a better predictor of left ventricular hypertrophy (LVH) determined by electrocardiography (ECG) is not known. Radial applanation tonometry and ECG were performed in 728 subjects from the Czech Post-MONICA Study (a randomly selected 1% population sample). LVH was determined using the Sokolow-Lyon index and Cornell product; central pressure was derived from radial pulse. Of 657 subjects included in the analysis, 17 (9.4%) below 45 years and 43 (9%) over 45 years had LVH. In multiple linear regression analysis, the Sokolow-Lyon index in younger individuals was only associated with male sex and low BMI, with no association with BP found. In older individuals, LVH was associated with higher central and brachial BP. In separate binary logistic regression analyses adjusted for covariates, the odds ratio for central systolic pressure was higher than those for brachial systolic and pulse pressure in LVH prediction. Noninvasively determined central pressure in subjects over 45 years is more strongly related to ECG LVH than brachial pressure. This further supports a closer association of central pressure with target organ damage. Voltage criteria of LVH are not independently associated with central or brachial BP in younger individuals.

The association between low 25-hydroxyvitamin D and increased aortic stiffness.

There is accumulating evidence that vitamin D exerts important pathophysiological effects on cardiovascular system. Low vitamin D was associated with increased cardiovascular risk in several reports. We studied the association between vitamin D and arterial stiffness in a random sample of 560 subjects selected from general population. Arterial stiffness was measured as aortic pulse-wave velocity (PWV) using Sphygmocor device. Serum 25-hydroxyvitamin D (25(OH)D) was measured using commercial kits. We found a clear negative trend in aortic PWV among 25(OH)D quartiles. Subjects in the bottom 25(OH)D quartile (<20 ng ml(-1)) showed the highest aortic PWV (9.04 m s(-1)), compared with 2nd-4th quartile (8.07 m s(-1), 7.93 m s(-1) and 7.70 m s(-1), respectively; P for trend <0.0001). The association between 25(OH)D and aortic PWV remained significant after adjustment for age, gender and other potential confounders; subjects in the first 25(OH)D quartile had adjusted odds ratio 2.04 (1.26-3.30) for having aortic PWV ≥9 m s(-1) (top quartile) in multiple regression. In conclusion, we found a clear significant and independent negative association between 25(OH)D and aortic PWV. Subjects with lowest vitamin D status showed the highest arterial stiffness.

The association between subclinical atherosclerosis in carotid arteries and Connexin 37 gene polymorphism (1019C>T; Pro319Ser) in women.

AIM: The aim of our study was to evaluate a possible association between subclinical atherosclerosis in carotid arteries and the connexin 37 gene polymorphism (1019C>T; Pro319Ser) in a population of urban and rural women. METHODS: A 5% population sample of urban women aged 45-54 years (N.=896) and a 1% representative sample of rural women aged 33-72 years (N.=152) were examined using an identical protocol and genotyped for Cx37 gene polymorphism. The association between the Cx37 polymorphism and intima-media thickness in common carotid arteries measured by ultrasound (CIMT) was studied. RESULTS: We have found a different pattern of the effect of the Cx37 gene on CIMT with regard to fasting glycemia with significant interaction between fasting glycemia and Cx37 gene on CIMT (test for equality of slopes P<0.0001). In addition, we also detected potential threshold effect of fasting glycemia at the concentration of 5.5 mmol/L (ANCOVA; P=0.026). Carriers of TT genotype showed protection against subclinical atherosclerosis if their fasting glycemia was above 5.5 mmol/L. CONCLUSION: In women with higher fasting glycemia TT genotype of Cx37 polymorphism was protective against subclinical atherosclerosis. Therefore, the Cx37 gene may exert completely different effects in the artery wall, depending on glycemia.

A novel oscillometric device for peripheral arterial disease screening in everyday practice. The Czech-post MONICA study.

AIM: Ankle brachial index (ABI) is a diagnostic tool for peripheral arterial disease (PAD) and a cardiovascular risk stratification tool. Despite this evidence and guidelines recommending its use in everyday practice, ABI is not widely used. Automatic ABI measurement may lower the barrier to incorporate ABI measurement into everyday practice. The aim of this study was to validate a novel automatic oscillometric ABI device (BOSO ABI) against a gold standard-Doppler device in an epidemiological setting. METHODS: In 839 patients from the Czech post-MONICA study (a randomly selected representative population sample aged over 25 years), mean age 54.3±13.8 years (47% of men), ABI measurement was performed using the BOSO ABI device and a handheld Doppler device in a random fashion. The two techniques were carried out by different investigators each blinded to the findings of the other. Analyses were conducted as proposed by Bland and Altman. RESULTS: The mean ABI difference between the two methods was 0.1±0.11, with 95% limits of agreement ranging from -0.11 to 0.30. The difference between Doppler and oscillometric ABI increased significantly with increasing mean ABI (r=0.29; P<0.001). When considering Doppler the gold standard, automated oscillometric measurement had a 76.9% sensitivity, 97.9% specificity, and 37% positive and 99.6% negative predictive values in diagnosing ABI <0.9. CONCLUSION: The BOSO ABI device cannot be used interchangeably for standard Doppler ABI measurement in diagnosing PAD. However, its high negative predictive value allows using it as a screening tool for PAD.

Why we are not able to find the coronary heart disease gene - apoE as an example.

The apoprotein E gene ranks among the most discussed candidate genes for cardiovascular disease. We studied whether the association between apoprotein E gene polymorphism and manifestation of acute coronary syndrome is modulated by the presence/absence of traditional cardiovascular risk factors. The population under study were 1066 patients (men under 65 years) admitted between 2006- 2009 to five coronary care units in Prague (GENetic DEtermination of Myocardial Infarction in Prague) and the control population (1066 age-matched men selected from the Czech population sample). The frequency of disadvantage genotype E4+ was significantly higher (P < 0.01) in acute coronary syndrome patients (22.38 %) than in controls (16.76 %). When the acute coronary syndrome group was step by step limited to non-smokers, non-diabetics and normotensive individuals, the odds ratio displayed a gradual increase from 1.35 (for the entire group) through 1.48 (non-smokers), 1.53 (non-smokers+non-diabetics) to 1.71 (non-smokers+non-diabetics+normotensives). The effect of the apoprotein E gene on the individual risk of acute coronary syndrome is nonhomogenous within the patient groups. This association of apoprotein E gene with acute coronary syndrome is strongly modified by the presence/absence of traditional cardiovascular factors of atherosclerosis in a high-risk Czech population.

An inverse association between serum leptin concentration and reported alcohol intake in patients with manifest vascular disease.

BACKGROUND/OBJECTIVES: It has been reported that alcohol stimulates appetite. We aimed to establish the association between leptin, as a major food intake regulating factor, and alcohol intake in patients with chronic manifest coronary artery or cerebrovascular disease. SUBJECTS/METHODS: A cross-sectional study of 820 subjects after acute coronary syndrome, coronary revascularization or after first ischemic stroke (the Czech part of EUROASPIRE III surveys). Leptin concentrations were evaluated among predefined categories of reported weekly alcohol intake: abstainers, light drinkers (up to 2 drinks weekly, 1-44 g of pure alcohol), mild regular drinkers (3-14 drinks weekly, 45-308 g) and moderate or heavy drinkers (more than 15 drinks, ≥ 309 g of alcohol). RESULTS: Leptin showed a clear negative trend among the alcohol intake categories. Mild regular drinkers showed significantly lower leptin levels (9.3(8.2) ng/ml) compared with abstainers (18.7(18.7) ng/ml, P<0.0001) and light occasional drinkers (14.2(17.8) ng/ml, P=0.00064). The negative association between leptin and alcohol intake as a dependent variable remained significant even after adjustment for potential confounders in multiple linear regression analysis (P=0.00032). CONCLUSIONS: Drinking of small amounts of alcohol was, in our setting, associated with decreased serum leptin concentration, with a possible benefit in terms of cardiovascular risk.

[Management of high blood pressure in children and adolescents: Recommendations of the European Society of hypertension]. / Manejo de la hipertensión arterial en niños y adolescentes: recomendaciones de la Sociedad Europea de Hipertensión.

Hypertension in children and adolescents has been gaining ground in cardiovascular medicine, mainly due to the advances made in several areas of pathophysiological and clinical research. These guidelines arose from the consensus reached by specialists in the detection and control of hypertension in children and adolescents. Furthermore, these guidelines are a compendium of scientific data and the extensive clinical experience it contains represents the most complete information that doctors, nurses and families should take into account when making decisions. These guidelines, which stress the importance of hypertension in children and adolescents, and its contribution to the current epidemic of cardiovascular disease, should act as a stimulus for governments to develop a global effort for the early detection and suitable treatment of high pressure in children and adolescents. J Hypertens 27:1719-1742 Q 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins.

The interaction of endothelial nitric oxide synthase polymorphism and current smoking in terms of increased arterial stiffness.

Nitric oxide belongs to the most important factors influencing structural and functional properties of vessel wall. Both genetic and environmental factors may influence its metabolism. The aim of this study was to explore whether two common polymorphisms of endothelial nitric synthase (eNOS) may, jointly with smoking, influence the stiffness of large arteries, quantified as pulse wave velocity (PWV). One hundred ninety four subjects free of manifest atherosclerotic disease or chronic pharmacotherapy were selected from population-based postMONICA study. PWV´s were measured using Sphygmocor® device between carotic and femoral arteries (aortic PWV) and between femoral and tibialis-posterior arteries (peripheral PWV). Two common polymorphisms, T786C and G894T, were assessed. Among current smokers, homo- or heterozygous carriers of T786C mutation showed significantly higher peripheral PWV than normal genotype carriers (14.0 vs 10.7 m/s, p<0.002); the same was true for the carriers of G894T mutation (13.9 vs 11.0 m/s, p<0.015). No differences were found in non-smokers, and neither of the eNOS polymorphisms influenced aortic PWV in our setting. In conclusion, genetically determined disorder of nitric oxide metabolism was associated with increased stiffness of peripheral, muscular-type arteries in generally healthy, untreated subjects, but only in the interaction with current smoking.

[Hypertension in pregnancy]. / Hypertenze v tehotenství.

The most important task of classification of hypertension in pregnancy is to establish whether hypertension predates pregnancy (so-called pre-existing hypertension) or whether this is pregnancy-induced hypertension (so-called gestational hypertension). Pre-existing hypertension is diagnosed either before pregnancy or within 20 weeks of gestation. Gestational hypertension is characterized by poor perfusion of several organs, and the elevated blood pressure (BP) represents usually only one of the characteristic features. Non-pharmacological treatment of hypertension should be considered in pregnant females with systolic BP 140-150 mm Hg or diastolic BP 90-99 mm Hg. Salt restriction or weight reduction is not recommended. Systolic BP > or = 170 or diastolic BP > or = 110 mm Hg in a pregnant woman should be regarded as an emergency requiring hospitalization. Drug treatment with intravenous labetalol, or oral methyldopa or nifedipine should be considered. The thresholds at which to initiate antihypertensive therapy is systolic BP of 140 mm Hg or diastolic BP of 90 mm Hg in women with gestational hypertension without proteinuria or in those with pre-existing hypertension before 28 weeks' gestation. Drug treatment is to be initiated at the same threshold levels in females with gestational hypertension and proteinuria or those presenting with symptoms at any time during the pregnancy, those with pre-existing hypertension in the presence of associated conditions or organ damage and, also, those with pre-existing hypertension and superimposed gestational hypertension. In other cases, it is recommended to institute antihypertensive medication at systolic BP of 150 mm Hg or diastolic BP of 95 mm Hg. For non-severe hypertension, methyldopa, labetalol, calcium-channel blockers should be considered the drugs of choice. ACE inhibitors and angiotensin II antagonists (AT1-blockers) are contraindicated in pregnancy.