Miguel A. Sanchez-Zamorano

Factors associated with therapeutic inertia in hypertension: validation of a predictive model.

Objective To study factors associated with therapeutic inertia in treating hypertension and to develop a predictive model to estimate the probability of therapeutic inertia in a given medical consultation, based on variables related to the consultation, patient, physician, clinical characteristics, and level of care. Methods National, multicentre, observational, cross-sectional study in primary care and specialist (hospital) physicians who each completed a questionnaire on therapeutic inertia, provided professional data and collected clinical data on four patients. Therapeutic inertia was defined as a consultation in which treatment change was indicated (i.e., SBP ≥ 140 or DBP ≥ 90 mmHg in all patients; SBP ≥ 130 or DBP ≥ 80 in patients with diabetes or stroke), but did not occur. A predictive model was constructed and validated according to the factors associated with therapeutic inertia. Results Data were collected on 2595 patients and 13 792 visits. Therapeutic inertia occurred in 7546 (75%) of the 10 041 consultations in which treatment change was indicated. Factors associated with therapeutic inertia were primary care setting, male sex, older age, SPB and/or DBP values close to normal, treatment with more than one antihypertensive drug, treatment with an ARB II, and more than six visits/year. Physician characteristics did not weigh heavily in the association. The predictive model was valid internally and externally, with acceptable calibration, discrimination and reproducibility, and explained one-third of the variability in therapeutic inertia. Conclusion Although therapeutic inertia is frequent in the management of hypertension, the factors explaining it are not completely clear. Whereas some aspects of the consultations were associated with therapeutic inertia, physician characteristics were not a decisive factor.

Relationship between Ankle-Brachial Index and Chronic Kidney Disease in Hypertensive Patients with No Known Cardiovascular Disease

Both decreased GFR and albuminuria are associated with an elevated prevalence of peripheral artery disease. However, the combined effects of these alterations previously were not evaluated. Patients with hypertension and with no known vascular disease (n = 955; mean age 66 yr; 56% male) were selected from internal medicine outpatient clinics throughout Spain. Cardiovascular risk factors, urinary albumin excretion, and the ankle-brachial index (ABI) were assessed in all participants. GFR was estimated according to the Cockroft-Gault equation. Of the study population, 62% had diabetes, 23.8% had a GFR <60 ml/min per 1.73 m2, and 43.8% had albuminuria. The prevalence of ABI <0.9 was greater in patients with a GFR <60 ml/min per 1.73 m2 (37.4 versus 24.3%; P < 0.0001) and in those who had albuminuria (32.2 versus 23.3%; P = 0.001). In patients with both alterations, the prevalence of ABI <0.9 was 45.7%. Multivariate analysis indicated that the factors that were associated independently with low ABI were age (odds ratio [OR] 1.06; 95% confidence interval [CI] 1.03 to 1.08; P < 0.0001), triglyceride concentration (OR 1.003; 95% CI 1.001 to 1.005; P = 0.001), presence of albuminuria (OR 1.61; 95% CI 1.18 to 2.20; P = 0.003), smoking habit (OR 1.72; 95% CI 1.13 to 2.63; P = 0.012), and a GFR <60 ml/min per 1.73 m2 (OR 1.47; 95% CI 1.01 to 2.17; P = 0.049). In patients with hypertension and without known vascular disease, reduced GFR and albuminuria are associated independently with an ABI <0.9. Their combined presence characterizes a subgroup of the population who have an elevated prevalence of peripheral artery disease and could benefit from early diagnosis and treatment.

Sub-clinical vascular disease in type 2 diabetic subjects: relationship with chronic complications of diabetes and the presence of cardiovascular disease risk factors.

BACKGROUND We evaluated the association between a low ankle-brachial index (ABI), chronic complications of diabetes, and the presence of traditional cardiovascular disease risk factors in subjects with type 2 diabetes but without known cardiovascular disease. METHODS We included diabetic subjects (n=923; 52% male; age range 50-85 years) without clinical evidence of coronary, cerebrovascular, or peripheral artery disease (PAD). A history of nephropathy, retinopathy, or neuropathy was collected from the medical records. A 12-lead electrocardiogram and ABI measurements were conducted on all study participants. RESULTS The mean duration of diabetes was 9.6 years. Prevalence of a low ABI (<0.9) was 26.2%. Multivariate analysis indicated that factors significantly associated with a low ABI were age (OR: 1.06; 95%CI: 1.033-1.084; p<0.001), plasma triglyceride concentration (OR: 1.002; 95%CI: 1.001-1.004; p=0.006), duration of diabetes (OR: 1.029; 95%CI: 1.008-1.051; p=0.007), and smoking habit (OR: 1.755; 95%CI: 1.053-2.925; p=0.03). The presence of nephropathy, neuropathy, retinopathy, left ventricular hypertrophy, left bundle branch block, and atrial fibrillation were all associated with a low ABI, but only renal disease remained significant after adjusting for age, duration of diabetes, and cardiovascular risk factors. CONCLUSION A low ABI is highly prevalent in subjects with diabetes and is related to age, duration of diabetes, smoking habit, and hypertriglyceridemia. Although chronic complications are frequently associated with a low ABI, only renal damage is independently associated with peripheral artery disease.

Prevalencia de enfermedad arterial periférica asintomàtica, estimada mediante el índice tobillo-brazo, en pacientes con enfermedad vascular. Estudio MERITO II

Fundamento y objetivo Los pacientes con enfermedad arterial en varios territorios presentan una elevada tasa de complicaciones vasculares y de mortalidad. Su identificacion permitiria definir a un subgrupo de la poblacion de muy alto riesgo, candidatos a recibir medidas preventivas mas energicas. El objetivo del presente estudio ha sido estimar la prevalencia de enfermedad arterial periferica subclinica en personas con antecedentes de enfermedad vascular en otros territorios arteriales. Pacientes y metodo Se incluyo en el estudio a pacientes con historia de enfermedad coronaria y/o cerebrovascular entre los 3 meses y los 5 anos previos, atendidos en consultas de medicina interna repartidas por toda la geografia nacional. Se les realizaron anamnesis, exploracion fisica, analitica sanguinea y urinaria, y se les determino el indice tobillo-brazo (ITB). Resultados Se estudio a 1.203 pacientes (64% varones), con una edad media de 74,3 anos. El 55,4% tenia antecedentes de enfermedad coronaria, un 38% de enfermedad cerebrovascular y un 6,7% de afectacion en ambos territorios. La prevalencia de ITB bajo ( Conclusiones La prevalencia de un ITB bajo es elevada en pacientes asintomaticos con enfermedad coronaria o cerebrovascular, especialmente si presentan afectacion conjunta de ambos territorios.

Achievement of Therapeutic Goals and Utilization of Evidence-Based Cardiovascular Therapies in Coronary Heart Disease Patients With Chronic Kidney Disease

To evaluate whether the presence of chronic kidney disease (CKD) influenced the rate of prescription of evidence-based cardiovascular preventive therapies and attainment of therapeutic goals in patients with stable coronary heart disease, 7,884 patients (mean age 65.4 years; 81.7% men; 22.4% with CKD) attended to in 1,799 primary-care centers and who had had a coronary event requiring hospitalization in the previous 6 months to 10 years were recruited. Glomerular filtration rate (GFR) was estimated using the MDRD Study equation. Results indicated that patients with CKD received more diuretics (47.6% vs 32.8%; p = 0.034), calcium channel blockers (29.3% vs 23.2%, p = 0.027); and blockers of the angiotensin-renin system (76.4% vs 65.3%; p <0.001). The lower prescription rate of antiaggregants, beta blockers, and statins in subjects with CKD did not reach statistical significance in multivariate analysis. A lower percentage of subjects with CKD achieved good control of blood pressure (39.2% vs 65.4%; p <0.001) and glycosylated hemoglobin (43.9% vs 53.4%; p <0.001) relative to patients without CKD. Only 11.8% of patients with CKD had optimum control of all risk factors. Using multivariate analysis, the presence of CKD was inversely related to the degree of risk-factor control, especially in groups with low GFR. In conclusion, patients with stable coronary heart disease and CKD attended to in primary-care centers had poorer control of coronary heart disease risk factors than those with normal GFR despite receiving a similar rate of prescription of evidence-based cardiovascular disease preventive therapies.

Different prognostic value of silent peripheral artery disease in type 2 diabetic and non-diabetic subjects with stable cardiovascular disease

OBJECTIVE ABI is a good predictor of morbidity and mortality in diabetic subjects with no known cardiovascular disease. However, its prognostic value in diabetic patients with prior coronary or cerebrovascular disease has not previously been evaluated. METHODS Multicenter, prospective study of 1 year of follow-up, in 1096 patients (73.6 years, 65% males, 45.4% with diabetes) with cardiovascular disease and without known peripheral arterial disease. The main outcome measure was the first occurrence of a major cardiovascular event (non-fatal acute coronary syndrome, non-fatal stroke, revascularization procedure, or cardiovascular death). Secondary endpoints included major cardiovascular events, cardiovascular death and death from any cause. RESULTS Prevalence of an abnormal ABI (<0.9 or >1.4) was 38.2% in diabetic and 26.8% in non-diabetic subjects. There were 150 major cardiovascular events (38.3/1000 person-years in diabetics vs. 30.6/1000 person-years in non-diabetics subjects, p=0.012) and 60 cardiovascular deaths (11.8/1000 person-years in diabetics vs. 10.7/1000 person-years in non-diabetics subjects, p=0.156). Patients with abnormal ABI had a higher rate of vascular complications. There was a significant interaction between ABI and diabetes. In non-diabetic patients, an abnormal ABI was associated with an increase risk of the primary endpoint (HR 2.71; 95% CI 1.54-4.76), cardiovascular mortality (HR 4.62; 95% CI 1.47-14.52) and total mortality (HR 2.80; 95% CI 1.08-7.27). These associations were not observed in patients with diabetes. CONCLUSION In patients with cardiovascular disease, ABI is a good predictor of risk of recurrent cardiovascular events and death, only in non-diabetic subjects.

Insuficiencia renal crónica oculta en pacientes con enfermedad coronaria estable

Fundamento y objetivo: La presencia de insuficiencia renal cronica (IRC) aumenta el riesgo de enfermedad cardiovascular, especialmente en los pacientes con enfermedad coronaria. El objetivo de este estudio ha sido examinar la prevalencia de IRC oculta (IRCO) en pacientes con enfermedad coronaria estable e investigar los factores asociados a ella para favorecer su deteccion. Pacientes y metodo: Se ha realizado un estudio transversal en el que participaron 7.884 sujetos que habian ingresado por un episodio coronario entre 6 meses y 10 anos antes. Se calculo el filtrado glomerular segun la ecuacion abreviada del estudio Modification of Diet in Renal Disease (MDRD). Se considero IRC cuando el filtrado glomerular era menor de 60 ml/min/1,73 m2 e IRCO cuando ademas la creatinina serica era inferior a 133 mmol/l en varones y a 124 mmol/l en mujeres. Resultados: La edad media de la poblacion estudiada era 65,3 anos y el 73,7% eran varones. Presentaba IRC un 22,4%, de los que el 68,3% tenia cifras de creatinina normales. En los pacientes con IRCO la prevalencia de factores de riesgo y enfermedades cardiovasculares asociadas era intermedia entre aquellos sin IRC y entre los que presentaban IRC con creatinina elevada. La edad, el sexo femenino, la presencia de hipertension arterial, diabetes, insuficiencia cardiaca, enfermedad cerebrovascular y enfermedad arterial periferica se asociaron de manera significativa e independiente con la presencia de IRCO en el analisis multivariante. Conclusiones: Casi uno de cada 4 pacientes con enfermedad coronaria estable presenta IRC, la mayoria de ellos con creatinina normal, siendo especialmente frecuente en las mujeres y con el aumento de la edad.

Gender differences in evidence-based pharmacological therapy for patients with stable coronary heart disease

BACKGROUND Women have a higher morbidity and mortality than men after an acute coronary event. We analyzed the prescription rates of evidence-based pharmacological therapies for patients with stable coronary heart disease and whether there were any differences with respect to gender. DESIGN This cross-sectional study evaluated 8817 patients, 26.3% women, receiving attention from 1799 family doctors in primary care centers (PCC) throughout Spain, and who had had a coronary event requiring hospitalization in the previous 6 months to 10 years. RESULTS Mean age was 65.4 years and a mean time-lapse since hospitalization of 37.4 months. In the overall population, prescription medications were: antiplatelet drugs in 80.5% of patients, 79% statins, 66% blockers of the angiotensin-renin system (BARS) and 47% beta-blockers. Males received less cardiovascular disease medications than females (4.3+/-1.5 versus 4.6+/-1.6, respectively; p<0.001), but when adjusted for risk factors the significance was lost (p=0.231). Following adjustment for risk factors and for co-morbidities, the use of diuretics was significantly higher in women while beta-blockers and statins were higher in men. The triple combination of antithrombotics, beta-blockers and statins was used in 41.4% (43.8% males versus 34.6% females; p<0.001) while 24.3% used this triple combination plus a BARS; without significant difference between the genders. CONCLUSIONS An important percentage of patients with stable coronary disease, particularly women, attended-to in primary care do not receive medications that have been shown to decrease the morbido-mortality of cardiovascular disease.

Thigh and buttock exertional pain for the diagnosis of peripheral arterial disease

OBJECTIVES To evaluate the prevalence of both non-calf intermittent claudication (IC) and classic IC in patients with no known atherosclerotic disease, and their accuracy to detect peripheral arterial disease (PAD). DESIGN Cross sectional, observational study conducted at 96 internal medicine services. MATERIALS AND METHODS 1487 outpatients with no known atherosclerotic disease, and either diabetes or a SCORE risk estimation of at least 3% were enrolled. IC was assessed using the Edinburgh Claudication Questionnaire and PAD was confirmed by an ankle-brachial index (ABI) <0.9. RESULTS Overall, 7.2% met criteria of classic and 5.8% of non-calf IC. PAD was diagnosed in 393 cases (26.4%). In these PAD patients, 17.8% exhibited classic and 13.2% non-calf IC. Both calf and non-calf IC had similar overall accuracy for detecting PAD. Considering both categories as a whole, the sensitivity of IC to predict a low ABI was 31% and the specificity 93%. CONCLUSIONS Non-calf IC is comparable to classic IC for the diagnosis of PAD in patients with no known arterial disease. The systematic implementation of Edinburgh Claudication Questionnaire could be a valuable call-to-action to improve clinical evaluation of PAD, bearing in mind that PAD detected by either non-calf or classic IC must be confirmed by ABI testing.

Factors associated with the discontinuation of evidence-based cardiovascular therapies in patients with stable coronary artery disease: a primary care perspective

Background To identify factors associated with the discontinuation of evidence-based cardiovascular therapies after hospital discharge for a coronary event. Design Cross-sectional study carried out between June and October 2004 in 1799 primary care centers throughout Spain. Patients and methods Eight thousand eight hundred and seventeen patients (73.7% males; 65.4 years) admitted for coronary disease causes in the past 6 months to 10 years and attending primary care postdischarge from hospital. Current medications, those prescribed at hospital discharge, and the development of adverse events, new risk factors, and comorbidities during follow-up, were collected from clinical records. Results After a median follow-up of 37.4 months, discontinuation rate of lipid-lowering agents, angiotensin renin system blockers, antiplatelet drugs, and β-blockers were 7.2, 9.1, 10, and 20%, respectively. Of these, 10.8, 16.5, 9.9, and 20.1%, respectively, were because of adverse events. Factors associated with the discontinuation of lipid-lowering agents were the development of hypertension and diabetes during the follow-up. Discontinuation of antiplatelet drug was associated with an earlier history, or with de-novo occurrence, of atrial fibrillation. Discontinuation of angiotensin renin system blockers was associated with the development of atrial fibrillation, diabetes and hypercholesterolemia, and discontinuation of β-blockers with de-novo appearance of peripheral artery disease, cerebrovascular disease, and heart failure. Conclusion In patients followed-up in primary care, the discontinuation rate of cardiovascular disease medications was low and was mainly related to the development of adverse events together with new risk factors and comorbidities arising after hospital discharge. Eur J Cardiovasc Prev Rehabil 16:34-38