Helios Pardell

Pharmacoeconomic considerations in the management of hypertension.

Hypertension is highly prevalent in developed and developing countries (more than 30% of the adult population when a threshold value of 140/90mm Hg is selected). It constitutes one of the major cardiovascular risk factors and accounts for more than 5% of total deaths worldwide.The economic impact of hypertension is enormous, representing

Blood pressure reactivity to mental stress task as a determinant of sustained hypertension after 5 years of follow-up.

US23.74 billion in the US in 1995 and approximately

Determinants of left ventricular mass in untreated mildly hypertensive subjects: hospitalet study in mild hypertension.

US1685 million in Spain in 1994. Direct costs amount to more than 50% of the total costs of hypertension, and almost 70% of these are attributable to drug treatment. Furthermore, hypertensive patients use medical services 50% more than normotensive individuals, and hypertension represents one of the 3 leading causes of visits to primary healthcare centres.When considering the cost effectiveness of hypertension treatment, there is no doubt that it is cost effective in comparison with other interventions, although some controversies exist, mainly with respect to mild-to-moderate hypertension and to the long term versus short term benefits. The controversy about the absolute risk of hypertension influences the cost-effectiveness analysis.Because of the limitations of the available cost-effectiveness analyses, it is currently impossible to recommend the use of any particular antihypertensive drug for all patients with hypertension. Consequently, the choice of antihypertensive in any patient should be guided by clinical experience and the recommendations of the present international guidelines.

Cardiac Damage in Hypertensive Patients with Inverse White Coat Hypertension. Hospitalet Study

Previous studies have reported an increased risk of developing sustained hypertension (SH) in borderline or mildly hypertensive subjects showing an exaggerated response of blood pressure (BP) to mental stress. The aim of this study was to assess if the response of BP to mental stress tasks is an independent predictor of SH. A total of 89 patients with grade 1 hypertension, aged 18–64 years, 62% males, were included. The mean of follow-up was 5.3 years (s.d. 2.1 years). SH was defined as the development of grades 2–3 hypertension (Systolic BP≥160 mmHg or diastolic BP≥100 mmHg) or to be in antihypertensive treatment after follow-up. Two mental stress tasks: mental arithmetic stress task and a stressful interview (SI) were applied at entry. The subjects were classified as hyper-reactors when BP increase was greater than 35 mmHg for systolic BP or greater than 21 mmHg for diastolic BP, according to the results obtained previously in a normotensive control group. In the univariate analysis, the factors associated with the development of SH were age (P=0.0007), office diastolic BP (P=0.014) and hyper-reactivity of BP during a stressful interview (P=0.003). In the Cox regression model, after adjusting for gender, age, and office BP, the hyper-reactivity of BP during SI was an independent predictor of development of SH. In conclusion, the response of BP to mental stress tasks is useful in predicting SH in young and middle-aged subjects with grade 1 hypertension.

Sobre la acreditación de la formación médica continuada en España

The objectives of this cross-sectional study were to identify the determinants of left ventricular mass in untreated mildly hypertensive subjects at the Hypertension Unit, Department of Internal Medicine, Red Cross Hospital, Hospitalet de Llobregat, Barcelona, Spain. One hundred seventy-one untreated mildly hypertensive subjects, with a mean age of 41.1+/-11.8 years (from 18 to 65 years) were sequentially visited in our Unit; 54% were men. Echocardiographic measurements of good quality were obtained in 142 subjects (83%). Two-dimensional guided M-mode echocardiograms were used and left ventricular mass was estimated according to the Penn convention. Left ventricular mass (LVM) was analyzed as a continuous variable. In the bivariate analysis, the variables that significantly correlated with LVM were patients height (r = 0.42, P<.0005), weight (r = 0.47, P< or =.0005), heart rate (r = -0.22, P = .01), HDLc (r = -0.30, P = .002), hematocrit (r = -0.28, P = .001), urinary sodium excretion (r = 0.23, P = 0.012), and different measurements from the ambulatory blood pressure profile for 24 h. By means of multiple regression analysis, a maximum of 41.2% of LVM variability could be explained from the factors registered in our study. The final model included age, gender, patients weight, and diastolic night load from ambulatory blood pressure monitoring. When added to different models, weight and diastolic night load showed a similar strength in predicting left ventricular mass. In untreated patients with mild hypertension, traditional factors such as blood pressure levels explain a maximum of 41.2% of LVM variability. More knowledge is needed about factors that may alter cardiac morphology in the evolution of hypertensive patients.

Management of the Hypertensive Patient Who Smokes

Background: Few studies have assessed the relationship between ambulatory blood pressure (BP) and cardiac damage in essential hypertensive patients with inverse white coat hypertension (IWCH). Objectives: To determine the frequency of IWCH in untreated grade 1–2 hypertension and to assess possible differences in cardiac damage among patients with IWCH, white coat hypertension (WCH) and the rest of patients with grade 1–2 hypertension. Patients and Methods: Two hundred and eleven patients with grade 1–2 hypertension were sequentially included. A good quality 24-h ambulatory BP monitoring was obtained in 204 patients (age: 41 ± 12 years, 56% males). IWCH was defined as a daytime systolic and/or diastolic BP higher than diagnostic office systolic and/or diastolic BP, respectively. WCH was defined as a daytime BP < 135/85 mmHg. A good quality echocardiogram was obtained in 174 patients. We considered left ventricular hypertrophy a left ventricular mass index (LVMI) ≥ 125 g/m2. Results: We found IWCH in 29 subjects (14%), and WCH in 68 (33%). Office BP in patients with IWCH was in an intermediate position between WCH and the rest of grade 1–2 hypertension patients. The IWCH patients showed 24-h, daytime and night-time BP higher than the other groups. Left ventricular mass was significantly greater in patients with IWCH than in the other grade 1–2 hypertension patients after adjusting for age, gender, body mass index, smoking and office BP (regression coefficient 28.14, 95%CI: 7.36–48.91). Conclusion: IWCH is independently associated with higher values of left ventricular mass in patients with grade 1–2 hypertension.

Actions Implemented to Improve Hypertension Control in Spain

1. En ella pueden identificarse las tres grandes areas operativas del sistema (analisis de necesidades, provision y acreditacion) y sus cinco subsistemas (educativo, cognitivo, tecnologico, humano y organizativo). Cada una de las areas y subsistemas ofrece un interes particular y presenta distintos grados de desarrollo en los diversos paises, en funcion de su situacion sociopolitica y del consiguiente marco de regulacion de la profesion medica. De todos estos ambitos o componentes del sistema de FMC, el de la acreditacion es, sin duda, el que mas controversia genera en todo el mundo, no solo por sus dificultades metodologicas intrinsecas sino, muy especialmente, por las repercusiones derivadas. Esta controversia es particularmente viva en Espana en los momentos actuales, por diversas razones, como han apuntado varios autores 2-11

Pathogénie et épidémiologie de l'hypertension artérielle

Smoking and arterial hypertension are highly prevalent at the community level. While the coexistence of both risk factors is less frequent, the potentiation of cardiovascular risk when both are present makes the association highly relevant in terms of a preventive approach.There are many interrelationships between smoking and high blood pressure at the clinical, epidemiological and pathophysiological levels. Those demonstrable links compel us to review the usual explanation of the influence of smoking on blood pressure.Pharmacological treatment of the hypertensive patient who smokes must be adapted to the patients risk profile, using the most efficacious antihypertensive agents. With the exception of nonselective β-blockers, all the available anti-hypertensive drugs can be prescribed.Minimal intervention and nicotine replacement constitute the most well tested interventions in helping smokers to quit their habit. Nicotine replacement is currently a well tolerated intervention, even in patients with cardiovascular disease.

Doctors in Spain An old country, old and new structures, and a new future

Hypertension prevalence is estimated at approximately 30% of the adult population in Spain, using the 140/90 mm Hg cutoff. This represents a heavy public health burden when compared with other European countries, although the direct cost per person is one of the lowest in Europe. The programs implemented regionally since 1985 are presented here. As a result of them, a decade later the number of hypertensives with controlled blood pressure has increased from 10% in 1986 to 13% in 1995, and cerebrovascular mortality has steadily decreased.

¿Qué opinan los médicos sobre la formación continuada, la evaluación de la competencia y la recertificación?: Resultados de las encuestas del I Congreso de la Profesión Médica de Cataluña

The pathogenesis of arterial hypertension is more clearly understood today because of the availability of data enabling identification of a certain number of precipitating factors. From a genetic standpoint, hypertension would appear to be a multifactorial polygenic disorder with a tendency to interact with certain environmental factors. The latter are mainly related to lifestyle and are potentially modifiable. Obesity during childhood and adolescence is the main predictive factor for hypertension. It has been suggested that the underlying mechanism could well be hyperinsulinaemia, which induces hyperactivity of the sympathetic nervous system. The mechanisms of the relationship between hypertension and alcohol are still unclear. However, in many countries, excessive alcohol consumption has been reported to be a significant factor in the development of arterial hypertension. The negative effect of a sedentary lifestyle on blood pressure has been widely demonstrated. In addition, it has also been shown that regular physical exercise under aerobic conditions leads to a reduction in blood pressure levels. An excessive sodium intake is also responsible for inducing arterial hypertension through increases in cardiac output and effects on vascular reactivity and contractility. Similarly, restricting sodium intake leads to a reduction in blood pressure levels. Smoking--namely, certain components of tobacco smoke--would appear to have both short and long term effects on blood pressure. These contributing factors all have specific effects on cardiac output and peripheral resistance in individuals. At the community level, the impact of hypertension is particularly significant. Prevalence is strongly influenced by the type of population studied, although it is generally estimated that this disease affects between 10 and 20% of the adult population and is responsible for 5.8% of all deaths worldwide. The direct and indirect costs of the disease are particularly high and are generally considered to be underestimated since a significant proportion of cardiac disease and stroke should also be included in any cost estimates, giving extremely high final figures. Hypertension-related morbidity and mortality principally result from cardiovascular complications and approximately 35% of atherosclerotic cardiovascular events can be attributed to hypertension. The highest risks are associated with stroke (relative risk: 3.8) and congestive heart failure in individuals with hypertension, in whom the risk is quadrupled. With regard to risk for an individual, the higher the blood pressure the greater the risk for the patient. However, the situation is very different if the entire population is being considered. In this instance, the highest risk is associated with mild hypertension since this involves the largest proportion of the hypertensive population. Similarly, relative risk corresponds to a probability rate that applies to populations rather than individuals. In response to this contradiction, the concept of absolute risk was proposed and corresponds to the prevalence of the disease. The approach to hypertension treatment based on absolute risk has recently been proposed for use in clinical practice. It takes into account lesions of the target organ together with any other risk factors and thus integrates the notion of prevention which remains the principal approach to the problems encountered in the management of hypertension.RésuméLa pathogénie de l’hypertension artérielle (HTA) essentielle est mieux connue aujourd’hui grâce aux données récentes qui ont permis d’identifier d’une part, des facteurs génétiques et d’autre part, des facteurs environnementaux, notamment poids corporel, consommation d’alcool, exercice physique, tabagisme et consommation de sel ainsi que le régime alimentaire en général.Par ailleurs, le poids global de l’HTA est évalué en tenant compte de l’impact de cette maladie en termes de prévalence, de complications associées et de son coût social. En ce qui concerne les complications liées à l’hypertension, les auteurs présentent une réactualisation des données concernant les accidents vasculaires cérébraux, l’insuffisance cardiaque, les cardiopathies d’origine coronarienne et les artériopathies périphériques.Les risques individuels sont comparés aux risques collectifs et les risques relatifs aux risques absolus. Des propositions sont avancées quant à l’intérêt de leur utilisation en pratique clinique.AbstractThe pathogenesis of arterial hypertension is more clearly understood today because of the availability of data enabling identification of a certain number of precipitating factors. From a genetic standpoint, hypertension would appear to be a multifactorial polygenic disorder with a tendency to interact with certain environmental factors. The latter are mainly related to lifestyle and are potentially modifiable.Obesity during childhood and adolescence is the main predictive factor for hypertension. It has been suggested that the underlying mechanism could well be hyperinsulinaemia, which induces hyperactivity of the sympathetic nervous system.The mechanisms of the relationship between hypertension and alcohol are still unclear. However, in many countries, excessive alcohol consumption has been reported to be a significant factor in the development of arterial hypertension.The negative effect of a sedentary lifestyle on blood pressure has been widely demonstrated. In addition, it has also been shown that regular physical exercise under aerobic conditions leads to a reduction in blood pressure levels. An excessive sodium intake is also responsible for inducing arterial hypertension through increases in cardiac output and effects on vascular reactivity and contractility. Similarly, restricting sodium intake leads to a reduction in blood pressure levels.Smoking — namely, certain components of tobacco smoke — would appear to have both short and long term effects on blood pressure.These contributing factors all have specific effects on cardiac output and peripheral resistance in individuals.At the community level, the impact of hypertension is particularly significant. Prevalence is strongly influenced by the type of population studied, although it is generally estimated that this disease affects between 10 and 20% of the adult population and is responsible for 5.8% of all deaths worldwide. The direct and indirect costs of the disease are particularly high and are generally considered to be underestimated since a significant proportion of cardiac disease and stroke should also be included in any cost estimates, giving extremely high final figures.Hypertension-related morbidity and mortality principally result from cardiovascular complications and approximately 35% of atherosclerotic cardiovascular events can be attributed to hypertension. The highest risks are associated with stroke (relative risk: 3.8) and congestive heart failure in individuals with hypertension, in whom the risk is quadrupled.With regard to risk for an individual, the higher the blood pressure the greater the risk for the patient. However, the situation is very different if the entire population is being considered. In this instance, the highest risk is associated with mild hypertension since this involves the largest proportion of the hypertensive population.Similarly, relative risk corresponds to a probability rate that applies to populations rather than individuals. In response to this contradiction, the concept of absolute risk was proposed and corresponds to the prevalence of the disease.The approach to hypertension treatment based on absolute risk has recently been proposed for use in clinical practice. It takes into account lesions of the target organ together with any other risk factors and thus integrates the notion of prevention which remains the principal approach to the problems encountered in the management of hypertension.