Enrique Rodilla

Long-Term Impact of Systolic Blood Pressure and Glycemia on the Development of Microalbuminuria in Essential Hypertension

The objective was to assess the temporal impact of factors related to the development of microalbuminuria during the follow-up of young adult normoalbuminurics with high-normal blood pressure or at stage 1 of essential hypertension. Prospective follow-up was conducted on 245 normoalbuminuric hypertensive subjects (mean age 40.9 years; 134 men; blood pressure 139.7/88.6 mm Hg; body mass index 28.5 kg/m2) never treated previously with antihypertensive drugs, with yearly urinary albumin excretion measurements, until the development of microalbuminuria. After enrollment, patients were placed on usual care including nonpharmacological treatment or with an antihypertensive drug regime to achieve a blood pressure of <135/85 mm Hg. Thirty subjects (12.2%) developed microalbuminuria after a mean follow-up of 29.9 months (range 12 to 144 months), 2.5 per 100 patients per year. Baseline urinary albumin excretion (hazard ratio, 1.07; P=0.006) and systolic blood pressure during the follow-up (hazard ratio, 1.03; P=0.008) were independent factors related to the follow-up urinary albumin excretion in a Cox proportional hazard model. A significant increase in the risk of developing microalbuminuria for urinary albumin excretion at baseline >15 mg per 24-hour systolic blood pressure >139 mm Hg and a positive trend in fasting glucose were observed in the univariate analyses. However, in the multivariate analysis, only the baseline urinary albumin excretion and the trend of fasting glucose were independently related to the risk of developing microalbuminuria. In mild hypertensives, the development of microalbuminuria was linked to insufficient blood pressure control and to a progressive increment of glucose values.

Importancia del síndrome metabólico en el control de la presión arterial y de la dislipemia

Fundamento y objetivo: Valorar la importancia del sindrome metabolico (SM) en el tratamiento y control de la hipertension y dislipemia. Pacientes y metodo: Estudio transversal de 1.320 pacientes hipertensos no diabeticos (634 mujeres y 686 varones) con una edad media (DE) de 58,1 (13,3) anos y con un indice de masa corporal de 29,8 (4,7) (kg/m2). El diagnostico de SM se establecio segun los criterios del NCEP-ATP III. Se considero con buen control de la presion arterial los que presentaban valores inferiores a 140/90 mmHg. Se calculo el riesgo coronario segun los criterios de Framingham y se clasifico en 3 grupos (bajo: inferior al 10%; intermedio: 10-20%; alto: superior al 20%). Se consideraron objetivos del tratamiento hipolipemiante los del ATP III, segun su grupo de riesgo. Resultados: Tenian SM 461 pacientes (35%), 246 varones (36%) y 215 mujeres (34%). Los pacientes con SM requerian mayor numero de farmacos que los pacientes sin SM para el tratamiento de la presion arterial (2,1 [1,3] frente a 1,7 [1,3]; p < 0,001), pero el grado de control de la hipertension fue similar en ambos grupos (el 53 frente al 52%; p = ns). Los pacientes con SM tenian mayor riesgo coronario global que los pacientes hipertensos sin SM (10,7 [8,3] frente a 7,9 [6,8]; p < 0,001) y cumplian menos los objetivos terapeuticos del colesterol ligado a lipoproteinas de baja densidad (el 57 frente al 74%; p < 0,001). En un analisis de regresion logistica, la presencia de SM se asocio de forma independiente, y controlando por la edad, a un 26% menos probabilidades de cumplir el doble objetivo (p < 0,001). Conclusiones: La existencia de un SM se asocia a mayor riesgo coronario, requerir mas farmacos antihipertensivos para el control de la presion arterial, menor control de los valores de colesterol ligado a lipoproteinas de baja densidad y un 26% menos posibilidades de cumplir ambos objetivos. Los pacientes con SM constituyen un objetivo prioritario en la prevencion cardiovascular.

Comparación entre el algoritmo de Framingham y el de SCORE en el cálculo del riesgo cardiovascular en sujetos de 40-65 años

Fundamento y objetivo En el presente trabajo se analizan las implicaciones terapeuticas que en la practica clinica habitual tiene el uso de los 2 modelos de calculo del riesgo cardiovascular, y se estudian las diferencias entre los individuos clasificados como de riesgo alto por cada sistema en una poblacion de hipertensos de 40 a 65 anos. Pacientes y metodo : Se incluyo a 929 pacientes sin diabetes ni antecedentes de enfermedad cardiovascular, con al menos un ano de seguimiento en nuestra Unidad de Hipertension y Riesgo Vascular. Se estimaron el riesgo de muerte cardiovascular a los 10 anos segun la funcion Systematic Coronary Risk Evaluation (SCORE) de la guia europea y el riesgo coronario a los 10 anos segun la funcion de Framingham, modificada por el tercer informe del National Cholesterol Education Program Expert Panel on Detection, Evaluation and Treatment of High Blood Cholesterol in Adults (NCEP-ATP-III). Se clasifico a los pacientes como de alto riesgo si su riesgo cardiovascular era del 5% o mayor y su riesgo coronario superior al 20%. Resultados El SCORE clasifico como de alto riesgo a un 4,1% de los pacientes, frente a un 2,5% segun Framingham. Solo un 0,2% de las mujeres fueron clasificadas como de alto riesgo por un sistema u otro, mientras que un 8,2% de los varones lo fueron por SCORE y un 4,8% por Framingham. Existia una baja concordancia entre los 2 sistemas. Solo un 1,5% de los varones se catalogo como de alto riesgo con los 2 sistemas, y ninguna mujer. Los pacientes clasificados como de alto riesgo por SCORE, pero no por Framingham, presentaban una edad superior, menos frecuencia de tabaquismo y mejor perfil lipidico que el grupo de pacientes clasificados de alto riesgo solo por Framingham. Segun las recomendaciones de NCEP-ATP-III, el tratamiento hipolipemiante estaria indicado en un 43% de los varones y un 28% de las mujeres, frente a un 28 y un 23%, respectivamente, segun la guia europea. Conclusiones A pesar de que la funcion SCORE, en comparacion con el algoritmo de Framingham, casi duplica el numero de pacientes de riesgo alto, el tratamiento hipolipemiante farmacologico estaria indicado en una menor proporcion de pacientes segun la guia europea que segun las recomendaciones del NCEP-ATP-III. Las diferencias son mas acusadas en varones.

Prognostic Value of Microalbuminuria During Antihypertensive Treatment in Essential Hypertension

Whether changes over time of urinary albumin excretion have prognostic value is a matter of discussion. The objective was to assess the prognostic value of changes in urinary albumin excretion over time in cardiovascular risk during antihypertensive treatment. Follow-up study of 2835 hypertensives in the absence of previous cardiovascular disease (mean age 55 years, 47% men, BP 138/80 mm Hg, 19.1% diabetics, and calibrated systemic coronary risk estimation 5 or >10.6%). Usual-care of antihypertensive treatment was implemented to maintain blood pressure <140/90 mm Hg. Urinary albumin excretion was assessed yearly, and the values were expressed as the creatinine ratio. Incidence of cardiovascular events, fatal and nonfatal, was recorded during the follow-up. During a median follow-up of 4.7 years (17 028 patients-year), 294 fatal and first nonfatal cardiovascular events were recorded (1.73 CVD per 100 patients/year). Independently of blood pressure, estimated glomerular filtration rate, level of cardiovascular risk, and antihypertensive treatment, microalbuminuria at baseline and at any time during the follow-up resulted in higher risk for events, hazard ratio (HR) 1.35 (95% confidence interval [CI], 1.08–1.79) and HR 1.49 (95% CI, 1.14–1.94), respectively. Likewise, development of microalbuminuria (HR 1.60; 95% CI, 1.04–2.46) or persistence from the beginning (1.53; 95% CI, 1.13–2.06) had a significantly higher rate of events than if remained normoalbuminuric (HR 1) or regress to normoalbuminuria (HR 1.37; 95% CI, 0.92–2.06) with an 18%, 18%, 8%, and 11% events, respectively, P<0.001. The study supports the value of urinary albumin excretion assessment as a prognostic factor for cardiovascular risk, but also opens the way to consider it as an intermediate objective in hypertension.

Determinants of urinary albumin excretion reduction in essential hypertension: A long-term follow-up study.

Objective The objective of the present study was to assess factors related to long-term changes in urinary albumin excretion (UAE) of nondiabetic microalbuminuric (n = 252) or proteinuric hypertensive individuals (n = 58) in a prospective follow-up. Method After enrolment, patients were placed on usual care including nonpharmacological treatment and/or treatment with an antihypertensive drug regime to achieve blood pressure < 135/85 mmHg. Periodic UAE measurements were performed until regression or significant reduction (defined when UAE dropped > 50% from the initial values, plus reduction of UAE to < 30 mg/24 h for microalbuminuric patients and < 300 mg/24 h for proteinuric patients). Results Among the microalbuminuric patients, 113 (44.8%) significantly reduced UAE after a mean follow-up of 18 months (range 12–69 months), 20.3/100 patients per year. Among the proteinuric patients, 29 (50%) significantly reduced UAE after a mean follow-up of 25 months (range 12–51 months), 20.2/100 patients per year. The baseline glomerular filtration rate, diastolic blood pressure and fasting glucose during follow-up were independent factors related to the regression or significant reduction in a Cox proportional hazard model. Regression of UAE was independently related to initial estimated glomerular filtration rate ≤ 60 ml/min per 1.73 m2 (hazard ratio, 0.57; 95% confidence interval, 0.38–0.86; P = 0.001) and DBP ≥ 90 mmHg achieved during the follow-up (hazard ratio, 0.57; 95% confidence interval, 0.38–0.86; P = 0.001), even when adjusted for age, gender, body mass index, fasting glucose, presence of treatment at the beginning of the study and treatment with angiotensin-converting enzyme inhibitors or angiotensin receptor blockers during the follow-up. Conclusions The reduction of urinary albumin excretion was linked to the preserved glomerular filtration rate and to adequate blood pressure control.

OriginalesComparación entre el algoritmo de Framingham y el de SCORE en el cálculo del riesgo cardiovascular en sujetos de 40-65 añosCardiovascular risk by Framingham and SCORE in patients 40-65 years old

Fundamento y objetivo En el presente trabajo se analizan las implicaciones terapeuticas que en la practica clinica habitual tiene el uso de los 2 modelos de calculo del riesgo cardiovascular, y se estudian las diferencias entre los individuos clasificados como de riesgo alto por cada sistema en una poblacion de hipertensos de 40 a 65 anos. Pacientes y metodo : Se incluyo a 929 pacientes sin diabetes ni antecedentes de enfermedad cardiovascular, con al menos un ano de seguimiento en nuestra Unidad de Hipertension y Riesgo Vascular. Se estimaron el riesgo de muerte cardiovascular a los 10 anos segun la funcion Systematic Coronary Risk Evaluation (SCORE) de la guia europea y el riesgo coronario a los 10 anos segun la funcion de Framingham, modificada por el tercer informe del National Cholesterol Education Program Expert Panel on Detection, Evaluation and Treatment of High Blood Cholesterol in Adults (NCEP-ATP-III). Se clasifico a los pacientes como de alto riesgo si su riesgo cardiovascular era del 5% o mayor y su riesgo coronario superior al 20%. Resultados El SCORE clasifico como de alto riesgo a un 4,1% de los pacientes, frente a un 2,5% segun Framingham. Solo un 0,2% de las mujeres fueron clasificadas como de alto riesgo por un sistema u otro, mientras que un 8,2% de los varones lo fueron por SCORE y un 4,8% por Framingham. Existia una baja concordancia entre los 2 sistemas. Solo un 1,5% de los varones se catalogo como de alto riesgo con los 2 sistemas, y ninguna mujer. Los pacientes clasificados como de alto riesgo por SCORE, pero no por Framingham, presentaban una edad superior, menos frecuencia de tabaquismo y mejor perfil lipidico que el grupo de pacientes clasificados de alto riesgo solo por Framingham. Segun las recomendaciones de NCEP-ATP-III, el tratamiento hipolipemiante estaria indicado en un 43% de los varones y un 28% de las mujeres, frente a un 28 y un 23%, respectivamente, segun la guia europea. Conclusiones A pesar de que la funcion SCORE, en comparacion con el algoritmo de Framingham, casi duplica el numero de pacientes de riesgo alto, el tratamiento hipolipemiante farmacologico estaria indicado en una menor proporcion de pacientes segun la guia europea que segun las recomendaciones del NCEP-ATP-III. Las diferencias son mas acusadas en varones.

Uso clínico de las estatinas y objetivos terapéuticos en relación con el riesgo cardiovascular

Fundamento y objetivo: El National Cholesterol Education program (NCEP) ha publicado las ultimas guias de tratamiento hipolipemiante, que amplian el numero de tratamientos farmacologicos respecto a anteriores guias. El objetivo de nuestro estudio es establecer el grado de cumplimiento de los objetivos terapeuticos establecidos por las guias terapeuticas recientemente publicadas. Pacientes y metodo: Estudio descriptivo transversal de pacientes que acudieron a una unidad de hipertension y riesgo cardiovascular. Se calculo el colesterol unido a lipoproteinas de baja densidad (cLDL) de cada uno y se definieron los valores considerados objetivos terapeuticos acordes con su riesgo coronario, siguiendo las indicaciones del NCEP-ATP III. Resultados: Se estudio a 1.811 pacientes (el 46% varones y el 54% mujeres), pertenecientes a tres categorias de riesgo definidas por el ATP III. El 35% de los pacientes pertenecia al grupo de mayor riesgo (grupo 1: riesgo coronario a los 10 anos superior al 20%). El 19% tenia un riesgo del 10-20% (grupo 2) y en el 46% el riesgo era inferior a 10% (grupo 3). El 58% de los pacientes cumplia los objetivos terapeuticos de cLDL: un 26% en el grupo 1, un 51% en el grupo 2 y el 86% del grupo 3 (p = 0,001). En el analisis de los factores que intervienen por conseguir el objetivo terapeutico, el tratamiento con estatinas obtuvo un resultado estadisticamente significativo solo en el grupo 1 de mayor riesgo coronario (odds ratio = 1,7; intervalo de confianza del 95%, 1,2-2,4; p = 0,007), pero no en los grupos de riesgo intermedio o bajo. El 41% de los pacientes del grupo 1 tenia valores de cLDL que requerian intervencion farmacologica (cLDL superior a 130 mg/dl) y no tomaba tratamiento. Conclusiones: En nuestro estudio, aunque el 58% de los pacientes alcanza los objetivos terapeuticos previstos, solo uno de cada 4 pacientes con alto riesgo coronario tiene valores de cLDL inferiores a 100 mg/dl. Estos datos indican que es necesario implementar el uso correcto de estatinas a las dosis eficaces en prevencion secundaria.

Effects of nebivolol and atenolol on central aortic pressure in hypertensive patients: a multicenter, randomized, double-blind study.

Abstract Introduction. The main objective was to compare the mean change in augmentation index of hypertensive patients treated with nebivolol or atenolol. Methods. Multicenter, double-blind randomized study conducted in six Spanish centers. We enrolled outpatients between the ages of 40 and 65 years with mild or moderate essential hypertension (systolic blood pressure, SBP ≥ 140 mmHg to ≤ 179 mmHg and diastolic blood pressure, DBP ≥ 90 mmHg to ≤ 109 mmHg after a 2-week run-in placebo period). Patients received nebivolol 5 mg or atenolol 50 mg once daily. At week 3, atenolol could be titrated up to 100 mg qd for non-responders. Additionally, patients not achieving normal blood pressure after 6 weeks could be treated with 25 mg hydrochlorothiazide. Follow-up visits were at 3, 6 and 10 weeks. Results. The final study population of 138 patients (58% men; median age 52.6 years, range 40–67 years) was randomized into two groups of 69 patients each. Baseline characteristics of the two groups were similar. At the screening visit, 69% presented with mild hypertension. Nebivolol modified the mean augmentation index to a lesser extent than atenolol after 10 weeks (mean difference 3.1%, 95% CI 0.55–5.69; p = 0.027). A higher proportion of patients in the atenolol group required a diuretic. Reductions in central aortic pressure and peripheral arterial pressure were similar for both treatment groups. Conclusions. The study confirms that nebivolol produces a less pronounced impact on augmentation index than atenolol.

Impact of abdominal obesity and ambulatory blood pressure in the diagnosis of left ventricular hypertrophy in never treated hypertensives.

BACKGROUND AND OBJECTIVES The principal objective was to assess the prevalence of left ventricular hypertrophy (LVH) in hypertensive, never treated patients, depending on adjustment for body surface or height. Secondary objectives were to determine geometric alterations of the left ventricle and to analyze the interdependence of hypertension and obesity to induce LVH. PATIENTS AND METHODS Cross-sectional study that included 750 patients (387 men) aged 47 (13, SD) years who underwent ambulatory blood pressure (ABPM) monitoring and echocardiography. RESULTS The prevalence of LVH was 40.4% (303 patients), adjusted for body surface area (BSA, LVHBSA), and 61.7% (463 patients), adjusted for height(2.7) (LVHheight(2.7)). In a multivariate logistic analysis, systolic BP24h, gender and presence of elevated microalbuminuria were associated with both LVHBSA and LVHheight(2.7). Increased waist circumference was the strongest independent predictor of LVHheight(2.7), but was not associated with LVHBSA. We found a significant interaction between abdominal obesity and systolic BP24h in LVHheight(2.7). Concentric remodelling seems to be the most prevalent alteration of left ventricular geometry in early stages of hypertension (37.5%). CONCLUSIONS The impact of obesity as predictor of LVH in never treated hypertensives is present only when left ventricular mass (LVM) is indexed to height(2.7). Obesity interacts with systolic BP24h in an additive but not merely synergistic manner. Systolic BP24h is the strongest determinant of LVH when indexed for BSA.

Relationship between increased arterial stiffness and other markers of target organ damage.

BACKGROUND AND OBJECTIVES The purpose of the present study was to assess the relationship of arterial stiffness with other markers of target organ damage, and the clinical factors related to it. PATIENTS AND METHODS Cross-sectional study that included 208 (115 men) never treated hypertensive, non-diabetic patients (mean age, 49+/-12 years). In addition to a full clinical study, 24h ambulatory blood pressure (BP), and determination of left ventricular hypertrophy (LVH) and microalbuminuria were performed. Clinical arterial stiffness was assessed by carotid-femoral pulse wave velocity (PWV) obtained with applanation tonometry (SphygmoCor-System). RESULTS PWV was 8.3 (7.3-9.9)m/s (median, interquartile range). Stepwise regression analysis revealed that age (beta=0.086, p<0.001), 24-h pulse pressure (beta=0.058, p<0.001), and low-density lipoprotein (LDL) cholesterol (beta=0.009, p<0.013) were independent determinants of PWV. PWV>12m/s (indicating target organ lesion) was present in only 16 (7.7%) patients, less frequent than LVH (28% of the patients) and microalbuminuria (16%). However, of the 16 patients with elevated PWV, 10 (62%) had neither LVH or microalbuminuria. In a logistic multivariate regression analysis the factors related to elevated PWV were age > or =45 in man and > or =55 in women (OR: 23.8, 95% CI: 2.7-195.5; p=0.004), LDL cholesterol > or =160mg/dl (OR: 10.6, 95% CI: 2.6-42.7; p=0.001) and increased 24-h pulse pressure > or =55mmHg (OR: 3.9, 95% CI: 1.2-12.9; p=0.03). CONCLUSIONS In untreated middle age hypertensives arterial stiffness assessed by PWV is less frequent than LVH or microalbuminuria. PWV is mainly related to age, LDL cholesterol, and pulse pressure values.