M.A. Prieto Díaz

Control de la presión arterial en una población hipertensa diabética asistida en atención primaria: Estudio PRESCAP-Diabetes 2010

OBJECTIVES To determine the level of blood pressure (BP) control in hypertensive diabetic patients treated in primary care and to determine the factors associated with poor control. MATERIAL AND METHODS A cross-sectional, multicentre study that enrolled hypertensive diabetics recruited by consecutive sampling by family doctors in Spain in June 2010. A mean BP of less than 140/90mmHg was considered as good control of arterial hypertension. The percentages of patients with<130/80mmHg PA, 140/80mmHg, and 140/85mmHg, respectively, were also determined. Sociodemographic, clinical, cardiovascular risk factors, and pharmacological treatments were recorded. RESULTS A total of 3,993 patients were enrolled (50.1% female) with a mean age (standard deviation) of 68.2 (10.2) years, of whom 73.9% received combination therapy. The figures showed good control of both blood pressure values (<140/90mmHg) in 56.4% (95% CI: 54.3 to 58.4) of the cases, with 58.5% (95% CI: 57.0-60.0) only in systolic BP, and 84.6% (95% CI, 83.2 to 85.8) only in diastolic BP. The variables with strongest association with poor control were the presence of albuminuria, elevated total cholesterol, physical inactivity, and not taking the medication on the day of the interview. CONCLUSIONS The PRESCAP-Diabetes 2010 study results indicate that 43.6% of diabetics with hypertension seen in primary care have a poorly controlled BP, in particular, systolic BP.

Conducta del médico de atención primaria ante el mal control de la hipertensión arterial. Estudio PRESCAP 2010

INTRODUCTION There is a need for more information on therapeutic inertia in blood pressure (BP) treatment. The purpose of this study was to determine the therapeutic behaviour and associated factors of Primary Care (PC) physicians on uncontrolled hypertensive patients. PATIENTS AND METHODS Cross-sectional multicentre study of patients with hypertension attending Spanish PC centres. Data was collected from patients (social-demographics, clinical status and treatment), as well as data from physicians (medical practice, background and therapeutic behaviour) were collected. Uncontrolled BP was considered when average BP values where ≥140/90mmHg. RESULTS A total of 12,961 patients (52.0% women) were included. The mean age was 66.3 (SD 11.4) years, and mean number of years from diagnosis of hypertension was 9.1 (6.7) years. Almost two-thirds (62.4%) of the patients were taking a combined blood pressure treatment, (44.2% with two drugs and 18.2% with three drugs, or more). An uncontrolled BP was observed in 38.9% (95% CI: 38.1-39.7) of patients. Treatment was changed by physicians in 41.8% (95% CI: 40.4-43.2) out of 5,036 uncontrolled patients. Adding another drug was the most frequent behaviour (55.6%). The physicians perception of good BP control in uncontrolled patients, together with the presence of combined blood pressure treatment, were the two variables most strongly associated with therapeutic inertia. CONCLUSIONS The Spanish PC Physician modified antihypertensive treatment in only 4 out of 10 uncontrolled patients. The physicians perception of good BP control was the variable most strongly associated with therapeutic inertia.

La presión de pulso como marcador de riesgo cardiovascular

La presion arterial de pulso ha sido considerada en los ultimos anos un factor de riesgo cardiovascular independiente y un marcador de mortalidad cardiovascular y total. Su valor pronostico en la poblacion hipertensa tratada ha sido menos estudiado. Objetivo Verificar el significado clinico y pronostico de la presion de pulso en una poblacion de hipertensos adultos vistos en Atencion Primaria. Metodos Se trata de un estudio descriptivo y transversal realizado con la totalidad de los enfermos hipertensos (n = 3.084) ya tratados, incluidos en la base de datos de 8 Centros de Salud de Asturias. Se analizaron los factores de riesgo clasicos y la patologia cardiovascular asociada. El estudio se realizo mediante la division en terciles de la presion de pulso. Resultados La edad media fue de 68 ± 12 anos, siendo mujeres el 67 % de la poblacion. Los terciles de la presion de pulso fueron: tercil 1≥51 mmHg (44 ± 6); tercil 2, 52-65 mmHg (59 ± 4); tercil 3,≤66 mmHg (78 ± 11). Los pacientes con presion de pulso mas elevada tuvieron edad mas avanzada (72,5 ± 10 frente a 63 ± 13; p Conclusion La presion de pulso en los pacientes hipertensos tratados se asocia directamente con la edad, el sexo femenino, niveles mas bajos de presion arterial (PA) diastolica, mas elevados de PA sistolica y con la presencia de diabetes. Ademas es un marcador de riesgo cardiovascular independiente.

La presión de pulso como marcador de riesgo cardiovascular en población anciana

Objetivo Verificar el significado clinico y el valor pronostico de la presion de pulso en poblacion general anciana. Diseno Estudio descriptivo transversal realizado entre junio y octubre de 2000, en el ambito de atencion primaria. Participantes De la poblacion de edad 3 60 anos (n = 8.026) de 16 cupos de seis centros de salud de Asturias se obtuvo una muestra aleatoria simple de 415 personas. Mediciones principales Se analizaron variables demograficas y factores de riesgo cardiovascular y se investigo la presencia de patologia cardiovascular asociada. El analisis se realizo mediante la division en terciles de la presion de pulso. Resultados Se incluyo a 338 personas (18,5% de perdidas), con una edad media de 73 ± 7 anos; el 64% eran mujeres. Las medias de la presion arterial sistolica (PAS) y diastolica (PAD) fueron 140 ± 18 y 80 ± 8 mmHg, respectivamente. Los terciles de presion de pulso fueron: tercil 1, £ 51 mmHg; tercil 2, 52–65 mmHg, y tercil 3, 3 66 mmHg. En relacion con el tercil 1, los del tercil 3 son mas viejos (p Conclusiones En poblacion general anciana la presion de pulso es un marcador de riesgo cardiovascular independiente.

Control de la anticoagulación en pacientes con fibrilación auricular no valvular en práctica clínica de atención primaria en las diferentes comunidades autónomas. Estudio PAULA

AIMS To determine the differences between regions in the level of control of patients with non-valvular atrial fibrillation treated with vitamin K antagonists, included in the PAULA study. METHODS Observational, and coss-sectional/retrospective study, including 139 Primary Care physicians from 99 Health Care centres in all autonomous communities (except La Rioja). Anticoagulation control was defined as the time in therapeutic range assessed by either the direct method (poor control <60%), or the Rosendaal method (poor control <65%). RESULTS A total of 1,524 patients were included. Small differences in baseline characteristics of the patients were observed. Differences in the percentage of time in therapeutic range were observed, according to the Rosendaal method (mean 69.0±17.7%), from 78.1%±16.6 (Basque Country) to 61.5±14% (Balearic Islands), by the direct method (mean 63.2±17.9%) from 73.6%±16.6 (Basque Country) to 57.5±15.7% (Extremadura). When comparing regions, in those where the Primary Care physicians assumed full control without restrictions on prescription, the percentage of time in therapeutic range by the direct method was 63.89 vs. 60.95% in those with restrictions (p=.006), by Rosendaal method, 69.39% compared with 67.68% (p=.1036). CONCLUSIONS There are significant differences in the level of control between some regions are still inadequate. Regions in which the Primary Care physicians assumed the management of anticoagulation and without restrictions, time in therapeutic range was somewhat higher, and showed a favourable trend for better control. These findings may have clinical implications, and deserve consideration and specific analysis.

Cuándo y por qué iniciar el tratamiento farmacológico con doble terapia

Hypertension is a syndrome in which, in addition to the elevation of blood pressure, there is micro-, macrovascular and kidney disease. Several mechanisms are interrelated in the physiopathology of hypertension, such as, the volume, renin-angiotensin system, and the sympathetic nervous system. These factors make it difficult to achieve blood pressure control with only a single drug. The vast majority of patients will require the combination of 2 or 3 drugs acting synergistically to increase the rate of response rate to treatment, and improve blood pressure control. Recent studies show that this blood pressure control must be achieved as soon as possible, with dual therapy being the first choice, particularly in high cardiovascular risk patients, and in patients who need greater reductions in blood pressure to achieve the goal.

Prevalencia de la hipertensión arterial sistólica aislada en una población mayor de 60 años

Objetivos Conocer la prevalencia de hipertension arterial y de hipertension arterial sistolica aislada, factores de riesgo cardiovascular y patologia cardiovascular asociada, asi como el tratamiento farmacologico utilizado y el grado de control obtenido en una poblacion mayor de 60 anos, asi como analizar las diferencias entre ambos grupos de hipertensos. Metodos Se trata de un estudio descriptivo y transversal realizado sobre una muestra aleatoria extraida de la totalidad de personas mayores de 60 anos (n = 8.026) de 16 cupos de 6 centros de salud de Asturias. Se analizaron los factores de riesgo clasicos, tratamiento farmacologico y la patologia cardiovascular asociada. Resultados Se estudio una muestra de 342 pacientes. La prevalencia de hipertension sistodiastolica fue del 40,4 % y la de hipertension sistolica aislada del 24,6% (el 38 % de todos los hipertensos) y no eran hipertensos el 35 %. Encontramos que los hipertensos sistolicos aislados presentaban una edad media superior (75 ± 7 frente a 72 ± 7 anos), una mayor presion arterial sistolica (149± 15 frente a 144 ± 16 mmHg) y una mayor diferencia de la presion de pulso (70 ± 14 frente a 61 ± 13 mmHg), asi como una mayor presencia de microalbuminuria (25,6% frente al 10 %) y de arteriopatia periferica (8,3 % frente al 2,2 %) respecto a los hipertensos sistodiastolicos. En estos, la diabetes y la obesidad alcanzaron mayor prevalencia (23 % frente al 12 % y 46 % frente al 41 %, respectivamente) que en los hipertensos sistolicos aislados. El tratamiento farmacologico se pauto en el 83 % de los pacientes con hipertension sistodiastolica y solo en el 56% de los del grupo de sistolica aislada, no habiendo diferencias entre los dos grupos en cuanto al uso de farmacos antihipertensivos, salvo en el grupo de los calcioantagonistas (44,7 % frente al 28,1 % en los sistodiastolicos).

Antagonistas de los receptores de la angiotensina II. Una revisión farmacoterapéutica

El tratamiento con farmacos inhibidores de la enzima de conversion de la angiotensina constituye en la actualidad una de las claves del manejo de la enfermedad cardiovascular y renal aunque ciertos efectos secundarios limitan su utilizacion. Los antagonistas de los receptores de la angiotensina II se presentan como una alternativa a los anteriores pero con un perfil de efectos secundarios mas favorable al del placebo. Las recomendaciones actuales del Joint National Committee y de la Organizacion Mundial de la Salud/Sociedad Internacional de Hipertension indican los antagonistas de los receptores de la angiotensina II en aquellos casos en que existe una indicacion especial de usar un inhibidor de la enzima de conversion de la angiotensina, pero un efecto secundario lo impide. Los datos de los estudios sobre la eficacia a largo plazo de los antagonistas de los receptores de la angiotensina II, como los procedentes de los ensayos recientemente publicados en pacientes con nefropatia diabetica o insuficiencia cardiaca congestiva, van estableciendo el papel de estos farmacos en el tratamiento de la enfermedad cardiovascular y renal.

[PP.11.03] PREVALENCE AND CHARACTERISTICS OF THE PATIENTS WITH HYPERTENSION IN THE IBERICAN STUDY

Objective: The general aim of IBERICAN study is to know the prevalence and incidence of cardiovascular risk factors (CVRF) and cardiovascular and renal disease (CVD) in Spain. The aim of this abstract is to know the prevalence of hypertension and its relation with CVRF, subclinical organ damage (LOD) and CVD in the population of the IBERICAN Study. Design and method: The IBERICAN Study is a longitudinal, observational, and multicentric study with subjects between 18 to 85 years of age, recruited in Primary Care and who will be follow up at least 5 years. The final sample size is estimated in 7,000 patients. We show the baseline characteristics of the patients in the first visit (n = 3,042). We analyzed patients with hypertension and their association with the presence of CVRF (diabetes, dyslipidemia, smoking and obesity), LOD (left ventricular hypertrophy, glomerular filtration <60 ml/min and albuminuria) and CVD: ischemic heart disease, heart failure, stroke, peripheral arterial disease and nephropathy. Results: The mean age in the sample was 65.4 ± 11 years, 50.5% women. The prevalence of hypertension was 47,4% (n = 1,429), and their degree control was 58.5%. The prevalence of hypertension in men was higher than women: 52.9% vs 43%, P < 0.001. Every CVRF were more frequent in hypertensive patients: dyslipidemia 66.4% vs 35.9%, p < 0.001; diabetes 30.6% vs. 8.5%, p < 0.001; obesity 44.4% vs 22.5%, p < 0.001; smoker 13.5% vs. 22.7%, p < 0.001; sedentary lifestyle 34.3% vs. 25.5%, p < 0.001. Also, the LOD were more frequent with the hypertension: HVI 8.2% vs 1.4%, p < 0.001; GFR less than 60 ml/min 13.7% vs 8.2%, p < 0.05; albuminuria 13.4% vs. 5.6%, p < 0.001. Finally, the prevalence of cardiovascular disease was higher in hypertensive patients (21.6% vs 10.2%, p < 0.0001), ischemic heart disease (10.7% vs 5.3%, p < 0.001); stroke (6.5% vs 3%, p < 0.001); peripheral arterial disease (6.4% vs 2.5%, p < 0.0001) and heart failure (4.8% vs. 1.3%, p < 0.001). Conclusions: Patients with hypertension in Primary Care have higher prevalence of cardiovascular risk factors, subclinical organ injury and established cardiovascular disease. The degree of blood pressure control is clearly improved.

MICROALBUMINURIA AND CARDIOVASCULAR RISK IN HYPERTENSION PATIENTS, IS IT CORRELATED AT LOW LEVELS? ANNUAL EVOLUTION OF THE MAUASTUR STUDY: PP.30.181

Objective: To compare the relation between microalbuminuria, measured at level below guidelines recomendations, and cardiovascular risk in a prospective study. Methods: A descriptive, cross sectional study of a 5 years prospective study. Random selection of hypertensive patients attended in primary care. The following variables were analyzed: associated cardiovascular risk factors (CVRF), target organ damage (TOD), and associated clinical diseases (ACD). Blood pressure (BP) < 140/90 mm Hg and <130/80 mmHg in diabetics were considered as target blood pressure values. Cardiovascular risk (CVR) was stratified according to ESC-ESH 2007 guidelines. Threshold for MA level was defined as a ratio of albumin/creatinine > 5 mg/g (both males and females) in a isolated urine sample. We compare this level of MA <= 5 vs > 5 mg/g) with the presence of CVRF, TOD, ACD and CVR in the first year of follow-up. Results: 616 patients were selected, 322 men (52.3%); mean age 66 ± 10 years; systolic blood pressure (SBP) 144 ± 73mmHg; diastolic blood pressure (DBP) 83 ± 10mmHg; and body mass index (BMI) 29.8 ± 8 kg/m2). Classification of patients according their CVR was: low 12.5%, moderate 14.9%, high 57.3% very high 15.3%. 342 patients (55.5%) had MA (men 57.1%, women 53.7%). BP control was similar in patients with or without MA, 53.8% vs 46.2%, p = ns. The presence of MA correlated with smoke 71.4% vs 54.1%, p = 0.020, OR 2.11 (1.11–4.02); renal failure 69.8% vs 51.8%, p = 0.000, OR 2.15 (1.41–3.27) and slight increase in plasma creatinine 71.2% vs 54.1%, p = 0.018, OR 2.1 (1.12–3.90). MA was numerically more prevalent in the presence of ACD, 61.4% vs 54%. Patients with MA had higher prevalence of high or very high CVR, 76.9% vs 67.2%, p = 0.007, OR 1.62 (1.14–2.32). Conclusions: Level of MA higher than 5 mg/g, are associated with kidney TOD, and probably with ACD. This association is independent of the BP control. In our study, patients with MA >5 mg/g showed a higher cardiovascular risk profile with respect to patients with MA <5 mg/g.