Manuel Luque

High prevalence of secondary hypertension and insulin resistance in patients with refractory hypertension.

Objective: To determine causes of treatment resistance in patients with refractory hypertension, and to estimate the prevalence of true resistant hypertension. Methods: We studied 50 consecutive patients referred with refractory hypertension after exclusion of hypokalemia and stenosis of the renal artery. Ambulatory blood pressure monitoring was performed in all patients to detect white-coat effect. The patients were hospitalized, antihypertensive drugs were withdrawn and a screening for secondary hypertension was performed. In addition, these patients, and a control group of essential hypertensives controlled with three antihypertensive drugs, underwent a OGTT with 75 g of glucose. Results: Primary normokaliemic hyperaldosteronism was diagnosed in seven patients. Two patients had a pheochromocytoma and six had white-coat effect. The 35 remaining patients with true resistant hypertension shown significant differences in serum insulin and HOMA IR when compared with the control group. Conclusions: These findings show that among normokaliemic treatment-resistant hypertension, the presence of hyperaldosteronism and pheochromocitoma is quite high. Moreover, treatment resistance in hypertensive patients appears to be associated with insulin resistance.

Influence of target organ lesion detection (assessment of microalbuminuria and echocardiogram) in cardiovascular risk stratification and treatment of untreated hypertensive patients

European guidelines indicate the importance of the evaluation of global cardiovascular risk (CVR) to determine the management of the hypertensive patients (EH). However, in primary care, the diagnostic work-up (PCD) only includes the metabolic risk factors. The aim of this study was to assess the importance of microalbuminuria (MA) and echocardiogram (ECHO) in the process of risk stratification, and the number of patients to be treated with drugs at diagnosis. In total, 155 nontreated EH were included in the study. Blood pressure, a lipid profile and plasma glucose (LG) were determined after an overnight fast. MA was evaluated with dipstick MICRALTEST, and in those patients with two positive results, it was measured again in two 24-h urine samples and was considered positive (MA+) if the average was >30 mg/24 h. Left ventricular mass index was calculated and values >125 g/m2 were considered as LV hypertrophy (LVH+). When the patients were stratified according to PCD, 22 had to be treated with drugs. When MA, ECHO and both tests used together were added to the risk evaluation, the number of patients to be treated were 42, 51 and 64, respectively (P<0.001 vs PCD). It is mainly in patients who have moderate cardiovascular risk that risk changes, whereas risk hardly changes in those having low and very high risk. In conclusion, in EH with moderate risk, measurement of MA, due to its easy availability and low cost, seems to be a cost effective screening test to avoid the underestimation of the CVR.

Características clínicas y manejo de pacientes hipertensos con diagnóstico de insuficiencia cardíaca en Atención Primaria en España. Estudio HICAP

Objetivos Conocer la proporcion de pacientes hipertensos con insuficiencia cardiaca y su manejo en Atencion Primaria. Metodos Estudio observacional, multicentrico, realizado en Atencion Primaria. La tecnica de seleccion de la muestra fue no probabilistica de seleccion de casos consecutivos, se incluyeron pacientes hipertensos con analitica y electrocardiograma realizados en los ultimos 6 meses. Resultados Participaron 1.288 medicos que incluyeron 6.719 pacientes, se consideraron validos 6.375. La proporcion de pacientes con diagnostico de insuficiencia cardiaca fue del 18,9%. En un 36,9% de los casos el diagnostico lo hizo Atencion Primaria y a un 57,5% de los pacientes se les habia hecho un ecocardiograma. Un 76,7% de los pacientes eran de clase funcional I-II y un 36,1% tenia disfuncion sistolica. En un 33,6% de los casos el seguimiento lo hacia solo Atencion Primaria. Un 77% de los pacientes no estaba tratado con bloqueadores beta y un 11% no tomaba farmacos bloqueadores del sistema renina-angiotensina. Conclusiones La proporcion de pacientes hipertensos con diagnostico de insuficiencia cardiaca es elevada, pero su manejo diagnostico y terapeutico no parece adecuado.

Effectiveness and Tolerability of Fixed-Dose Combination Enalapril plus Nitrendipine in Hypertensive Patients

AbstractBackground and objective: Monotherapy with any class of antihypertensive drug effectively controls blood pressure (BP) in only about 50% of patients. Consequently, the majority of patients with hypertension require combined therapy with two or more medications. This study aimed to evaluate the effectiveness (systolic BP [SBP]/diastolic BP [DBP] control) and tolerability of the fixed-dose combination enalapril/nitrendipine 10mg/20mg administered as a single daily dose in hypertensive patients. Methods: This was a post-authorization, multicentre, prospective, observational study conducted in primary care with a 3-month follow-up. Patients throughout Spain with uncontrolled hypertension (≥ 140/90 mmHg for patients without diabetes mellitus, or ≥130/85 mmHg for patients with diabetes) on monotherapy or with any combination other than enalapril + nitrendipine, or who were unable to tolerate their previous antihypertensive therapy, were recruited. Change from previous to study treatment was according to usual clinical practice. BP was measured once after 5 minutes of rest in the sitting position. Therapeutic response was defined as follows: ‘controlled’ meant controlled BP (< 140/90 mmHg for nondiabetic patients, or < 130/85 mmHg for diabetic patients); ‘response’ meant controlled BP, or a decrease in SBP of ≥20mmHg and in DBP of ≥10mmHg. The main laboratory test parameters were documented at baseline and after 3 months. Patients aged >65 years, with diabetes, with isolated systolic hypertension (ISH; SBP ≥140mmHg for patients without diabetes, SBP ≥130mmHg for patients with diabetes) and who were obese (body mass index [BMI] ≥30 kg/m2) were analysed separately. Results: Of 6537 patients included, 5010 and 6354 patients were assessed in effectiveness and tolerability analyses, respectively. In the tolerability analysis population, there were 3023 men (47.6%) and 3321 women (52.4%). The mean (±SD)age of the tolerability analysis group was 62.8 (±10.7) years. A total of 71.1% of the patients presented at least one clinical cardiovascular risk factor other than hypertension, with the most frequent being dyslipidaemia (42.3%), obesity (29.2%) and diabetes (23.9%). After 3 months of treatment, SBP and DBP showed mean (±SD) decreases of 26.5 (± 14.4)mmHg and 14.9 (±9.0) mmHg, respectively, and 73.0% of patients responded to treatment while 40.9% achieved BP control (70.8%/36.1% in 2658 patients aged >65 years; 61.7%/46.8% in 1521 patients with diabetes; 55.3%/44.2% in 731 patients with ISH; 72.0%/36.4% in 1762 obese patients). Adverse events were reported in 10.8% of patients (n=689). During the follow-up period, ten patients died and seven patients had serious adverse events; in no case was a causal relationship attributed to the study product. Conclusions: The rate of SBP/DBP control achieved demonstrates the effectiveness of the fixed-dose enalapril/nitrendipine 10mg/20mg combination administered as a single daily dose in patients with essential hypertension not adequately controlled with monotherapy or with any combination other than enalapril + nitrendipine. The proportion and type of adverse events reported were as expected and have already been described for both components of the enalapril/nitrendipine 10mg/20mg combination. These results confirm the effectiveness of a strategy based on a fixed-dose enalapril/nitrendipine 10 mg/20 mg combination in reducing BP and achieving BP control goals.

Hipertrofia ventricular izquierda por electrocardiograma o ecocardiograma y complicaciones cardiovasculares en hipertensos tratados de la Comunidad Autónoma de Madrid. Estudio MAVI-HTA*

Objetivos Evaluar la prevalencia de hipertrofia ventricular izquierda electrocardiografica (hvi-ecg) y ecocardiografica (hvi-eco) en pacientes hipertensos en la comunidad de madrid, y su relacion con la enfermedad cardiovascular (ecv) establecida. Pacientes y metodos Estudio epidemiologico, transversal y multicentrico en centros de Atencion Primaria de la Comunidad Autonoma de Madrid. Se incluyeron pacientes hipertensos de edad ≥50 anos. Se recogieron datos demograficos, antropometricos, de presion arterial, factores de riesgo y enfermedades cardiovasculares. La HVI-ECG se evaluo con los criterios de voltaje de Cornell y Sokolow-Lyon, y la HVIECO mediante la masa ventricular izquierda (MVI) utilizando la formula de Devereux. Resultados En 620 pacientes evaluables, 71 presentaron HVI-ECG (prevalencia del 11,5%, similar en varones [10,6%] y en mujeres [12,1%; p=0,565], sin asociacion con la edad). En 580 pacientes con ecocardiograma, la prevalencia de HVI-ECO (MVI indexada por la superficie corporal ≥125 g/m2 [varones] y ≥110 g/m2 [mujeres]) fue de 56,4%, mayor en mujeres (66,6% frente a 42,4% en hombres; p Conclusiones La prevalencia de HVI-ECG fue del 11,5%, mientras que por ECO ascendio a 56,4%, y esta se asocio a una prevalencia de ECV tres veces superior. Determinados pacientes hipertensos podrian beneficiarse del ecocardiograma en la valoracion del riesgo cardiovascular.

Prevalencia y riesgo de desarrollar insuficiencia cardíaca en los hipertensos españoles atendidos en Atención Primaria. Estudio HICAP

Objetivos Conocer la proporcion de pacientes con insuficiencia cardiaca (IC) y con alto riesgo de desarrollarla entre los hipertensos atendidos en las consultas de Atencion Primaria (AP) en Espana. Metodos Estudio transversal y multicentrico en el que cada investigador incluyo datos de 5 hipertensos consecutivos que acudieron a su consulta y que contaban con una analitica y un electrocardiograma realizados en los ultimos 6 meses. Resultados Se recogieron datos validos de 6.375 hipertensos. La proporcion de pacientes con diagnostico de IC fue de 18,9% (intervalo de confianza al 95% [IC95%]: 17,97-19,90) y aumentaba progresivamente con la edad. De los pacientes que no habian sido previamente diagnosticados de IC, el 59,1% (IC95%: 57,7-60,5) presentaba un alto riesgo de desarrollar IC. El control de la presion arterial y otros factores de riesgo cardiovascular en estos pacientes «con alto riesgo» era insuficiente. Conclusion Los datos indican que la proporcion de hipertensos diagnosticados de IC y con alto riesgo de desarrollar la enfermedad es alta en AP. Se deberia mejorar el control de la presion arterial y otros factores de riesgo para intentar evitar el desarrollo de la IC en los hipertensos con alto riesgo.

Left Ventricular Geometric Patterns After 1 Year of Antihypertensive Treatment

Left ventricular hypertrophy increases the risk for cardiovascular target organ damage, myocardial infarction, and stroke. The authors assessed the patterns of ventricular adaptation in 107 essential hypertensives whose treatment had been withdrawn and its modification after 1 year of hypertension treatment. Blood pressure decreased from 158+17/96+12 mm Hg to 137+15/83+10 mm Hg (mean + SD; p<0.001); 45% of the patients (49 of 107) had their blood pressure controlled below 140 mm Hg and 90 mm Hg. Although a significant decrease of left ventricular mass index was found in the study, the percentage of patients with normal left ventricular geometry at the completion of the study increased by only 9% (27% to 36%, p>0.05). Left ventricular mass geometry improved in 31% of the patients, remained unaffected in 51%, and worsened in 18%. The data suggest that even while suboptimal antihypertensive treatment reduces left ventricular mass index, either left ventricular hypertrophy or concentric remodeling remains present in a significant number of patients at the end of a 1‐year treatment period. The authors conclude that these patients should be considered as a subgroup at high risk and should be treated more aggressively.

АНТИГИПЕРТЕНЗИВНАЯ ЭФФЕКТИВНОСТЬ И ПЕРЕНОСИМОСТЬ ЛЕРКАНИДИПИНА В УСЛОВИЯХ ПОВСЕДНЕВНОЙ КЛИНИЧЕСКОЙ ПРАКТИКИ. ИССЛЕДОВАНИЕ ELYPSE

Aim: Lercanidipine, a long-acting dihydropyridine with a good antihypertensive efficacy and tolerability. The aim of the ELYPSE trial was to determine the efficacy and tolerability of this medication in daily clinical practice. Methods: Patients with Stage 1-2 essential hypertension, in whom their physicians considered to prescribe a dihydropyridine, were administered lercanidipine 10 mg once daily, with a 3-month follow-up. The study included 9059 patients (mean age 63±11 years; 58% women, 60% over 60 years, 56% with Stage 2 hypertension, and 69% previously treated with other antihypertensive drugs). A subgroup of 1267 patients (14%) experienced adverse reactions, related to pre-administered antihypertensive therapy. Electronic case-report forms and a central Internet database were used for the data collection. Results: Baseline levels of blood pressure (BP) and heart rate (HR) were 160,1±10,2/95,6±6,6 mm Hg and 77,3±9,3 bpm, respectively. Significant reductions in both systolic and diastolic BP were attained at 1 month, with some additional reduction 2 months later. At 3 months, BP level was 141,4±11,3/83,1±6,9 mm Hg, and HR level was 75,2±8,2 bpm (p <130/85 mm Hg) was achieved only in 16,4%. The overall incidence of adverse events was 6,5%; the most frequent ones were headache (2,9%), ankle edema (1,2%), flushing (1,1%), and palpitations (0,6%). Withdrawal rate was<1%. The efficacy and tolerability of lercanidipine in the subgroup of patients included in the study due to adverse events of other antihypertensive drugs were similar to those in the whole study population. Conclusion: In this study, lercanidipine has demonstrated good efficacy and tolerability in daily clinical practice. These findings are consistent with the results of randomized controlled trials.