Luis Alcocer

Latin American guidelines on hypertension. Latin American Expert Group.

Hypertension is a highly prevalent cardiovascular risk factor in the world and particularly overwhelming in low and middle-income countries. Recent reports from the WHO and the World Bank highlight the importance of chronic diseases such as hypertension as an obstacle to the achievement of good health status. It must be added that for most low and middle-income countries, deficient strategies of primary healthcare are the major obstacles for blood pressure control. Furthermore, the epidemiology of hypertension and related diseases, healthcare resources and priorities, the socioeconomic status of the population vary considerably in different countries and in different regions of individual countries. Considering the low rates of blood pressure control achieved in Latin America and the benefits that can be expected from an improved control, it was decided to invite specialists from different Latin American countries to analyze the regional situation and to provide a consensus document on detection, evaluation and treatment of hypertension that may prove to be cost-utility adequate. The recommendations here included are the result of preparatory documents by invited experts and a subsequent very active debate by different discussion panels, held during a 2-day sessions in Asuncion, Paraguay, in May 2008. Finally, in order to improve clinical practice, the publication of the guidelines should be followed by implementation of effective interventions capable of overcoming barriers (cognitive, behavioral and affective) preventing attitude changes in both physicians and patients.

Anti-Hypertensive Effect of Timolol, a New Beta-Blocking Agent (Double-Blind Study)

The anti-hypertensive effect of timolol maleate (MK-950) was evaluated in patients with mild or moderate hypertension, in a double-blind, randomized, placebo controlled clinical trial. The study was divided into a baseline placebo period, that lasted 9 weeks, during which documentation was made of the patients untreated diastolic blood pressure. A 9 week titration period followed the placebo period, at which time patients were randomly assigned to an MK-950 or matching placebo group; the titration period was devoted to finding out the optimal dose of MK-950 or its matching placebo. The titration period was followed by a 6 week maintenance period during which patients were maintained on their optimal MK-950 or placebo dose. Timolol is an effective anti-hypertensive drug and significantly reduces diastolic blood pressure. Its effect becomes apparent at the first week of treatment, and reaches maximum effectiveness at 4 weeks of treatment. The diastolic blood pressure in the timolol group remained consistently below 90 mm Hg and at the end of the study, the average diastolic blood pressure was: 88·57 ± 8·6 mm Hg (p > 0·001 in comparison with placebo). The average daily dose of timolol maleate was 31·10 ± 1·80 mg. MK-950 has a strong negative chronotropic effect, capable of reducing the resting heart rate by an average of 28·50 beats/min. No correlation could be established between heart rate and blood pressure lowering effect. Other than bradycardia, no important side-effects were observed.

Guías Latinoamericanas de Hipertensión Arterial

Ramiro A. Sanchez, Miryam Ayala, Hugo Baglivo, Carlos Velazquez, Guillermo Burlando, Oswaldo Kohlmann, Jorge Jimenez, Patricio Lopez Jaramillo, Ayrton Brandao, Gloria Valdes, Luis Alcocer, Mario Bendersky, Agustin Jose Ramirez, Alberto Zanchetti, de parte del Grupo Latinoamericano de Expertos.

Cardiovascular risk factors in a Mexican middle-class urban population: The Lindavista Study. Baseline data

INTRODUCTION AND OBJECTIVE The aim of this communication is to describe the cardiovascular risk factors affecting a Mexican urban middle-class population. METHODS A convenience sample of 2602 middle class urban subjects composed the cohort of the Lindavista Study, a prospective study aimed to determine if conventional cardiovascular risks factors have the same prognosis impact as in other populations. For the baseline data, several measurements were done: obesity indexes, smoking, blood pressure, fasting serum glucose, total cholesterol, HDL-c, LDL-c and triglycerides. This paper presents the basal values of this population, which represents a sample of the Mexican growing urban middle-class. RESULTS The mean age in the sample was 50 years; 59% were females. Around 50% of the entire group were overweighed, while around 24% were obese. 32% smoked; 32% were hypertensive with a 20% rate of controlled pressure. 6% had diabetes, and 14% had impaired fasting glucose; 66% had total cholesterol ≥ 200 mg/dL; 62% showed HDL-c levels<40 mg/dL; 52% triglycerides>150 mg/dL, and 34% levels of LDL-c ≥ 160 mg/dL. Half of the population studied had the metabolic syndrome. CONCLUSION These data show a population with a high-risk profile, secondary to the agglomeration of several cardiovascular risk factors.

Use of calcium channel blockers in cardiovascular risk reduction: issues in Latin America.

Cardiovascular disease (CVD) is a continuum that begins with the presence of several risk factors for CVD, including smoking, hypertension, obesity, diabetes mellitus, and high levels of cholesterol, and if unaddressed can result in premature death, ischemic heart disease, stroke, congestive heart failure, and end-stage renal disease. Hypertension is associated with a significant increase in cardiovascular (CV) morbidity and mortality, raising the risk of stroke, myocardial infarction, heart failure, kidney disease, and peripheral arterial disease. In Latin America, the prevalence of hypertension and other CV risk factors has become similar to that seen in more developed countries, increasing the proportion of the population at high risk for CVD and congestive heart failure; however, it is hypertension that is a key driving force behind CV risk in Latin America. Despite the existence of a wide range of antihypertensive agents, BP control and reductions in CV risk remain poor in Latin America and in Hispanics living in the US. Ethnic differences in treatment rates and disease awareness have been well documented. Studies have shown that calcium channel blockers (CCBs; calcium channel antagonists) are at least as effective in reducing BP and improving the CV risk profile as other classes of antihypertensive agents when administered as monotherapy. CCBs have also been shown to be effective when administered as part of combination therapy in both low- and high-risk hypertensive patients, suggesting that CCBs can easily be combined with other antihypertensive classes in order to achieve BP control and CV risk reduction. In patients with hypertension, coronary artery disease, and high cholesterol, CCBs have been associated with beneficial effects on a range of other aspects of the CV continuum, including the vasculature, coronary calcification, and progression of atherosclerosis. CCBs have also been shown to preserve renal function. Unlike diuretics and β-adrenoreceptor antagonists, CCBs are metabolically neutral, inducing minimal changes in serum lipids and decreasing the incidence of new-onset diabetes compared with other antihypertensive agents. CCBs are well tolerated when administered as monotherapy or combination therapy, with long-acting formulations minimizing adverse events even further compared with short-acting formulations. These characteristics make CCBs an attractive option for the treatment of hypertension and CV risk in Latin America, which remain significant health issues in this region.

Guidelines on the management of arterial hypertension and related comorbidities in Latin America

Univ Hosp, Hypertens & Metab Unit, Fdn Favaloro, Belgrano 1782 P 4, RA-1093 Buenos Aires, DF, Argentina

Applicability of the current hypertension guidelines in Latin America

Recent research has focused on the development of evidence-based guidelines that are intended to regulate the conduct of physicians in the diagnosis and control of hypertension, with the goal of achieving greater effectiveness and equity at the lowest possible cost. In Latin America, guidelines are available for the management of hypertension at three levels: national, regional and international. The national and regional Latin American and Caribbean (LAC) guidelines are in fact adaptations of the international guidelines. The potential benefit of applying guidelines developed in other regions to local healthcare decision making is that it will enable decision makers to take advantage of existing analyses and transfer or adapt them to their local contexts. However, this adaptation precludes the assessment of their generalizability and potential transferability. In addition, this region is characterized by wide socioeconomic differences between its inhabitants, both among and within nations. Therefore, new guidelines for the LAC region must include recommendations that are common to all hypertensive patients in the region. Moreover, we advocate the inclusion of a specific section that makes comprehensive recommendations and provides strategies for implementation according to the socioeconomic conditions of particular groups. In addition to developing guidelines that are truly applicable to the LAC region, it seems sensible to consider information that is specific to this region. Furthermore, developing evidence-based guidelines is not enough to affect positively the burden of disease caused by hypertension. Therefore, professional programs are required for the implementation of such guidelines as well as the auditing of their results. Achieving these ambitious goals will require collaborative efforts by many groups including policymakers, international organizations, healthcare providers, universities and society.