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Estrategias para un control eficaz de la hipertensión arterial en España. Documento de consenso

Blood pressure (BP) control is inadequate among treated hypertensive patients in Spain. Control rates are lower than 40% of all treated patients and the cause of this problem is multifactorial. Despite the fact that possible solutions to this problem have been repeatedly suggested by expert groups along the last 10 years, BP control rates are still low. This fact have a negative impact on cardiovascular morbidity and mortality of patients with hypertension. The aim of the present document has been to achieve a consensus on effective specific measures in order to improve hypertension control rates in Spain. These measures involve health care professionals (physicians, nurses, pharmaceutics), health care authorities and patients. The document summarizes the consensus conference of several scientific societies involved in cardiovascular medicine in five group of measures: a) improvement of the methodology of office BP measurement; b) improvement of compliance to treatment by patients; c) clarification of pressure targets to be achieved in hypertensive patients; d) optimization of life style modifications and pharmacological treatment of hypertension; and e) continuous medical education. The document emphasize life style changes as a crucial aspect to be implemented in all patients. These changes have a beneficial impact on pressure reduction, contribute to a better control of associated cardiovascular risk factors, and increase the effectiveness of antihypertensive drugs. Health care professionals should base their clinical practice on the recommendations of guidelines in order to modify their therapeutic attitudes in patients whose targets have not been achieved.

Estrategias para un control eficaz de la hipertensión arterial en España. Documento de Consenso

ducir la morbimortalidad cardiovascular asociada a las cifras elevadas de presion arterial (PA). Para alcanzarlo es preciso aplicar una serie de medidas encaminadas tanto a reducir la PA como a minimizar el impacto de otros posibles factores de riesgo cardiovascular asociados . Practicamente todas las guias nacionales e internacionales coinciden en que el objetivo terapeutico para todos los pacientes con hipertension arterial (HTA) esencial mayores de 18 anos de edad es lograr un descenso de la PA, estable y sostenido, a menos de 140 mmHg de presion arterial sistolica (PAS) y de 90 mmHg de presion arterial diastolica (PAD). Ademas, muchas de ellas senalan la conveniencia de alcanzar la PA optima y estabilizarla a valores del orden de 120/80 mmHg o inferiores en la poblacion de hipertensos con menos de 60 anos. Finalmente, todas las recomendaciones indican con firmeza reducir la PA a menos de 130/80 mmHg para los pacientes diabeticos o con enfermedad cardiovascular establecida, y a menos de 125/75 mmHg para los pacientes con insuficiencia renal y proteinuria superior a 1 g/24 horas. En cualquier caso, el objetivo de mantener a los hipertensos tratados por debajo de los 140/90 mmHg esta universalmente aceptado. No se conoce con precision el efecto real del tratamiento antihipertensivo sobre la poblacion espanola de pacientes hipertensos, aunque los datos disponibles considerados en su conjunto apuntan a tasas de control de PA entre el 13% y el 39%. Esta amplia variacion obedece a factores de diversa indole tales como: a) utilizacion de distintos criterios de control a lo largo del tiempo (160/95 mmHg frente a 140/90 mmHg); b) utilizacion en algunos estudios de muestras de pequeno tamano no representativas de la poblacion hipertensa; c) diferentes ambitos de los estudios (poblacion general, Atencion Primaria, Unidades de Hipertension, etc.); d) comparacion de pacientes procedentes de areas geograficas con distinta prevalencia de HTA que impide extrapolar los datos al conjunto del territorio nacional; e) heterogeneidad metodologica en la medicion de la PA, y f) descripcion de tasas de control respecto del grupo de hipertensos tratados o del total de hipertensos detectados. Con los criterios generales de control utilizados en la actualidad (PA < 140/90 mmHg), mucho mas estrictos que los recomendados antigua-

Lack of association between ACE gene polymorphism and left ventricular hypertrophy in essential hypertension.

The possible association between the insertion/deletion (I/D) polymorphism of the angiotensin I converting enzyme (ACE) gene and left ventricular hypertrophy (LVH) was investigated in a group of essential hypertensive patients. Seventy-one essential hypertensive patients (35 men and 36 women), aged 51 ± 1 years, were genotyped by PCR for the I/D polymorphism of the ACE gene. Cardiac morphology and function were assessed by means of M-mode echocardiography. The relative frequencies of the three genotypes, DD, DI, and II, were respectively: 24%, 55%, and 21%. Mean values of left ventricular mass index were 145, 144, and 150 g/m2 for DD, DI, and II genotypes, without significant differences among them (P = 0.82). Likewise, the prevalence of LVH (76%, 64%, and 87%) was not significantly different among the three genotypes (P = 0.23). We conclude that the ACE gene I/D polymorphism is not associated with LVH in essential hypertension.

Long-acting lacidipine versus short-acting nifedipine in the treatment of asymptomatic acute blood pressure increase

We compared antihypertensive efficacy and safety of a single administration of equipotent doses of lacidipine versus nifedipine in the hypertensive urgencies. Twenty-nine asymptomatic essential hypertensive patients (nine men, 20 women) with a mean age of 55.03+/-11.19 years and baseline diastolic blood pressure (DBP) of > or =120 mm Hg after resting 30 min, not taking antihypertensive drugs for the last 24 h, were randomized in a single-blind fashion to receive lacidipine, 4 mg (LCD, 15 patients) or short-acting nifedipine, 20 mg (NFD, 14 patients) in a single dose. Blood pressure (BP) and heart rate (HR) were taken every 30 min during the first 8 h and every 2 h until 24 h of follow-up. Baseline BP values were similar in the two groups (LCD, 222.5+/-32.8/124.6+/-8.4 mm Hg vs. NFD, 215.9+/-20.6/128+/-7.7 mm Hg; p = NS). Both drugs promoted a significant reduction of systolic blood pressure (SBP; 169.6+/-27.8 vs. 170.6+/-25.3 mm Hg) and diastolic blood pressure (DBP; 104.1+/-16 vs. 102.9+/-12.4 mm Hg) after 8 h. However, either SBP (165+/-27.3 vs. 190.6+/-18.2 mm Hg; p = 0.008) and DBP (99.9+/-12.3 vs. 117.2+/-11.4 mm Hg; p = 0.001) were significantly higher in the NFD group after 24-h dosing. Eleven patients in the LCD group had a decrease in BP >25% of the baseline value both 8 and 24 h after the dose. Although 10 patients showed the same response in the NFD group 8 h after the dose, only four patients maintained these values at 24 h. One patient treated with NFD had a transient cerebrovascular ischemic attack. No adverse effects were observed in the LCD group. We conclude that the long-acting calcium antagonist lacidipine was more effective than the short-acting nifedipine in both controlling BP and maintaining this BP reduction over 8 h in essential hypertensive patients with acute asymptomatic BP increase.

Prospective comparison of therapeutical attitudes in hypertensive type 2 diabetic patients uncontrolled on monotherapy. A randomized trial: the EDICTA study.

OBJECTIVE To compare the anti-hypertensive effect of combination therapy versus a single drug regimen schedule (dose-titration or switching to a different drug class) in type 2 diabetic hypertensive patients with inadequate blood pressure (BP) control on monotherapy. DESIGN Prospective, randomized, open-fashion, parallel study of two therapeutic strategies during an 8-week period. SETTING Primary care centers in Spain. PARTICIPANTS A total of 898 men and women with type 2 diabetes mellitus and hypertension, receiving antihypertensive treatment with one single drug and whose BP was > 140 and/or 90 mmHg. INTERVENTION Patients were randomized to a fixed combination therapy (verapamil 180 mg plus trandolapril 2 mg; Knoll AG, Ludwigshafen, Germany) or continued on a single drug regimen, either increasing the dose of the current drug or switching to a different drug class. MAIN OUTCOME MEASURE Absolute BP reduction in the two groups of treatment, and the percentage of normalized patients (< 140/90 mmHg) in each group. RESULTS The diastolic BP (DBP) decrease (5.6 mmHg) was significantly greater in patients treated with combination therapy, compared to patients on monotherapy (2.9 mmHg). The decrease in systolic BP (SBP) was not significantly different (11.1 versus 10.0 mmHg). In addition, a significantly higher number of patients treated with combination therapy (82% versus 74%) reached diastolic BP normalization (< 90 mmHg). CONCLUSIONS In type 2 hypertensive patients with uncontrolled BP despite anti-hypertensive monotherapy, the change to combination therapy was more effective in attaining DBP control than any monotherapy schedule (either increasing the dose or switching to another different drug class).

Abnormal Na+-K+ ATPase kinetics in a subset of essential hypertensive patients

Abstract We have performed a kinetic analysis of the interaction of Na+‐K+ ATPase with internal Na+ in erythrocytes of 30 normotensive controls and 72 essential hypertensive patients. Neither the maximal rate of ouabain‐sensitive sodium efflux (Vmax) nor the internal Na+ content required for half‐maximal stimulation (K50%) were significantly different between normotensive and hypertensive patients. Nevertheless, using the 95% confidence limits of the K50% in the normotensive group as a cut‐off point, 13 (18·06%) essential hypertensive patients exhibited increased values of this parameter (29·16 ± 4·31 mmol l‐1 cells) revealing decreased affinity of Na+‐K+ ATPase for internal Na+ (Pump‐hypertensives). The Vmax was also higher in the Pump‘—’ subset (14·08 ± 4·85 mmol (1 cells h)‐1 vs. 6·92 ± 1·80; P = 0·0002) and 10 of these 13 hypertensives exhibited a Vmax above the upper end limit of 10·5 mmol (1 cells h)‐1, suggesting a compensatory effect. No differences were observed between the Pump ‘—’ subset and the remaining 59 hypertensives without Na+‐K+ pump abnormality when basal erythrocyte Na+ content and clinical parameters of hypertension were examined. Decreased apparent affinity of Na+‐K+ pump for internal Na+ present in 9–27% of essential hypertensives may be implicated in pathogenetic mechanisms of hypertension.

Comparative evaluation of the antihypertensive efficacy of once-daily amlodipine versus nitrendipine with 24-hour ambulatory blood pressure monitoring in essential hypertension.

Summary We compared the antihypertensive efficacy of once-daily amlodipine (AM) versus nitrendipine (NTR) by 24-h ambulatory blood pressure monitoring (24-h ABPM) in 32 patients with mild to moderate essential hypertension (EH). After a 2-week single-blind, placebo run-in period, patients were randomized in a double-blind, parallel fashion: 14 received AM 5 mg and 18 NTR 10 mg. After 2 weeks, dose was adjusted if necessary (AM 10 mg or NTR 20 mg) and continued for another 6-week period. At the end of the placebo period and during the last week of treatment, patients underwent 24-h ABPM. Initial office BP mean values were similar in both groups (169.8 ± 14/102.5 ± 6 vs. 167.1 ± 14/98.7 ± 5 mm Hg, respectively, p = NS). A comparable decrease in office mean values of systolic BP (SBP, −22.3 ± 13 vs. −19.1 ± 16 mm Hg) and diastolic BP (DBP, −12.0 ± 5 vs. −8.1 ±8 mm Hg) was observed. Nevertheless, 24-h ABPM mean values differed significantly between patients treated with AM or NTR with regard to 24-h SBP (120.0 ± 10 vs. 132.5 ± 1 mm Hg, p = 0.01). Moreover, the average decrease in 24-h SBP (-19.3 ± 6 vs. −5.2 ± 11 mm Hg, p = 0.0036) and 24-h DBP (-10.7 ± 4 vs. −3.7 ± 6 mm Hg, p = 0.0047) was higher in the AM group, with no changes in 24-h heart rate (HR). At equivalent once-daily dosage, AM was more effective than NTR in decreasing BP assessed by 24-h ABPM.

Automedida de la presión arterial. Documento de Consenso Español 2007

SEMERGEN. 2007;33(4):176-87 que se realiza de forma menos fiable y con un escaso cumplimiento de las recomendaciones aportadas por las diferentes guías nacionales e internacionales. Además, en los últimos años se han añadido a la medida tradicional en la consulta (medida clínica) otras metodologías cuyo uso va en constante incremento, tales como la monitorización ambulatoria de la PA de 24 horas (MAPA) y la automedida domiciliaria de la PA (AMPA). En este sentido cabe reflexionar sobre el hecho de que más de la mitad de los aparatos de medida de AMPA disponibles en España no han sido clínicamente validados. Por tanto, se hace necesario unificar criterios en este tipo de mediciones para que, con independencia del profesional que realiza su indicación, el aparataje y la metodología recomendada sean unitarios. Las sociedades científicas y los colegios profesionales tienen como una de sus misiones prioritarias la de actuar de vínculo entre la ciencia fundamental o aplicada y la práctica clínica diaria, facilitando la transmisión de los conocimientos y avances tecnológicos más relevantes. Esta monografía resume el trabajo de un grupo de expertos de diversas sociedades científicas y colegios profesionales cuyo nexo común es la prevención del riesgo cardiovascular. Este grupo aporta un documento de consenso en las indicaciones, normas de actuación y metodología de la AMPA por parte de los propios pacientes en su domicilio, que deseamos forme parte habitual de las recomendaciones de todos los profesionales a los que representan.

Trough-to-peak ratio and circadian blood pressure profile after treatment with once-daily extended-release diltiazem, 240 mg, in patients with mild-to-moderate essential hypertension

Once-daily diltiazem extended-release 240 mg (Lacerol-HTA Retard) was evaluated for safety, efficacy, and trough-to-peak ratio in a multicenter open study by using 24-h blood pressure (BP) monitoring in mild-to-moderate essential hypertension. After a 4-week washout period, 30 patients (17 men, 13 women) aged 25-76 years, showing a mean daytime diastolic BP (DBP) >90 mm Hg, were treated with diltiazem-ER, 240 mg, given once daily for 8 weeks. Ambulatory BP monitoring was obtained at the end of a 4-week placebo run-in period and during the last week of treatment. A significant reduction of the mean values of clinical BP [161.6 +/- 16.2 to 151.2 +/- 15.6 mm Hg; p < 0.01 for systolic BP (SBP); and 101.1 +/- 4.8 to 93.3 +/- 9.2 mm Hg; p < 0.001 for DBP] was observed at the end of treatment in the group of 30 patients, with no significant changes in heart rate (77.1 +/- 9.9 to 73.1 +/- 11.1 beats/min; p = NS). Likewise, mean values of 24-h SBP, DBP, SBP-load, and DBP-load were significantly reduced. In the group of 21 responders, the average reduction at peak was -18.6 +/- 12.9 mm Hg for SBP and -14.7 +/- 9.5 mm Hg for DBP. The residual effect at trough was -12.2 +/- 14.7 and -8.1 +/- 10 mm Hg, respectively. The trough-to-peak ratio was estimated as 0.66 for SBP and 0.55 for DBP. Long-term variability expressed as the mean standard deviation of BP for the 24-h period was reduced in responders (16.2 +/- 4.3 to 14.6 +/- 2.7 mm Hg for SBP; p = 0.0395; and 12.1 +/- 2.7 to 10.7 +/- 2.5 mm Hg for DBP; p = 0.0019), although no changes were observed in the variation coefficient (10.58-10.57% for SBP and 12.88-12.87% for DBP). We conclude that once-daily diltiazem-ER, 240 mg, was effective and well tolerated. Blood pressure was controlled over the entire period of 24 h, preserving the circadian profile and reducing long-term variability in responders. The significant reduction of both BP values and long-term variability may have implications involving protection from end-organ damage in essential hypertension.

Prevalence of masked uncontrolled hypertension according to the number of office blood pressure measurements

INTRODUCTION AND OBJECTIVES The reported prevalence of masked uncontrolled hypertension (MUCH) varies because many studies are not comparable as they use different measurement methodologies. To evaluate the influence of the number of office blood pressure readings on the prevalence of MUCH we conducted a cross-sectional, multicenter study in treated hypertensive patients. PATIENTS AND METHODS We carried out an observational, cross-sectional, multicenter study in 33 Spanish hospital-based hypertension units, involving 35 investigators and 12 Autonomous Communities. Six blood pressure readings and a 24-h ambulatory blood pressure monitoring were performed in treated hypertensive patients. The means of the first 3 readings (P123), the 2nd, 3rd and 4th readings (P234), the 3rd, 4th and 5th readings (P345) and the last 3 readings (P456) were compared with mean 24-h blood pressure. MUCH was defined as office blood pressure <140/90mmHg and 24-h blood pressure ≥130/80mmHg, considering the first 3 readings (MUCH123), the 2nd, 3rd and 4th readings (MUCH234), the 3rd, 4th and 5th readings (MUCH345) and the last 3 readings (MUCH456). RESULTS We included 498 hypertensive patients. Mean (standard deviation) office blood pressure measurements were: (P123) 141(18)/82(11); (P234) 139(17)/81(11); (P345) 138(17)/81(11) and (P456) 137(16)/80(10) mmHg. Mean 24-h blood pressure was 127(13.8)/75(9.5) mmHg. The correlation coefficients between ambulatory and office systolic/diastolic blood pressure were (P123):0.48/0.50; (P234):0.50/0.52; (P345):0.50/0.54; and (P456):0.50/0.55 (p<0.001, all). The prevalences of MUCH123, MUCH234, MUCH345 and MUCH456 were 14.5%, 18.9%, 19.5% and 21.1%, respectively. CONCLUSIONS The prevalence of MUCH diagnosis depends on the serial office blood pressure readings, being much higher for the last three blood pressure readings. Discarding the first and second office blood pressure measures seems to be the most accurate method for diagnosing MUCH.