Miguel Camafort

Hypertension and Mild Cognitive Impairment

The brain is an early target for organ damage due to high blood pressure. Hypertension is the major modifiable risk factor for stroke and small vessel disease. It has been suggested that cerebral microvascular disease contributes to vascular cognitive impairment. The mechanisms underlying hypertension-related cognitive changes are complex and not yet fully understood. Both high and, especially in the elderly, low blood pressure (BP) have been linked to cognitive decline and dementia. There is some evidence that antihypertensive drug treatment could play a role in the prevention of cognitive impairment through BP control. The BP levels that should be targeted to achieve optimal perfusion while preventing cognitive decline are still under debate.

Secondary Prevention of Arterial Disease in Very Elderly People: Results From a Prospective Registry (FRENA)

There is little information on the effectiveness of secondary prevention interventions in very elderly patients. In this article, the incidence of major cardiovascular events during a 12-month follow-up period in a series of consecutive patients with coronary, cerebrovascular, or peripheral artery disease is analyzed. As of October 2006, 1264 patients had been enrolled. Of these, 324 (26%) were ≥75 years of age. Their incidence rate of 22 events per 100 patient-years (95% CI, 17-28) was over 2-fold the 7.9 (95% CI, 6.2-10) found in those <75 years of age. Among them, only chronic heart failure and diabetes were independently associated with an increased risk for major events, whereas the use of angiotensin II antagonists was associated with a lower risk. Patients ≥75 years of age had an over 2-fold higher incidence of major cardiovascular events. The use of angiotensin II antagonists was associated with a lower risk.

Prevalence of masked hypertension and associated factors in normotensive healthcare workers.

Background and objectiveEvidence on the elevated cardiovascular risk associated with masked hypertension (MHT) is becoming stronger. Determining the prevalence of MHT in apparently healthy individuals may enable better risk stratification and management. MethodsThis was a cross-sectional study of normotensive healthcare workers recruited from 52 hypertension units. We included individuals aged at least 18 years with no known history of hypertension and office blood pressure (BP) less than 140/90 mmHg. MHT was defined as mean daytime ambulatory BP of at least 135/85 mmHg. ResultsOverall, 485 individuals (mean age 43.1 years, 55% women) were included. The prevalence of MHT was 23.9% [95% confidence interval (CI): 20.1–27.7]. The most prevalent associated cardiovascular risk factors in the total population were smoking (24.9%), dyslipidemia (16.4%), a family history of premature cardiovascular disease (15.9%), and obesity (7.4%). A total of 45.4% of individuals had a family history of hypertension. MHT was associated with male sex [odds ratio (OR) 1.722, 95% CI: 1.091–2.718] and prehypertension (OR 4.561, 95% CI: 2.880–7.222). In univariate analysis, the OR of the diagnosis of MHT increased by 2.3% per year of age. ConclusionThe prevalence of MHT in normotensive healthcare workers in Spain is almost 25%. Therefore, 24-h ambulatory BP monitoring should be routine in occupational health checks in health workers, especially men.

Prevalencia de hipertensión arterial enmascarada en una cohorte de pacientes hipertensos controlados en España

INTRODUCTION AND OBJECTIVE In recent years the evidence that masked hypertension is associated with a highest cardiovascular risk is well established. Knowing the prevalence of masked hypertension in our country will allow a better cardiovascular risk stratification and management of hypertensive patients, although the information is scant and heterogeneous. For this reason, the working group for the study of masked hypertension (ESTHEN) in Spain developed the present study with the objective to know the prevalence of masked hypertension in a cohort of hypertensive patients follows in several Hypertension Units in Spain. PATIENTS AND METHODS Prospective study of a cohort of hypertensive patients followed in 75 Hypertension Units in Spain. Eligible patients were hypertensive cases aged ≥ 18 years receiving antihypertensive drug treatment and showing an adequate BP control at the clinic (BP < 140/90 mmHg). Masked hypertension was defined when mean daytime BP ≥ 135/85 mmHg. RESULTS We analyzed data from 302 patients. Mean age was 56.2 years and 56% were male. Prevalence of masked hypertension was 48% (95%CI 42-53). The most prevalent accompanying risk factors were abdominal obesity (39.7%), smoking (24.2%), family with premature cardiovascular disease (22.5%), and diabetes (11.6%). Prevalence of left ventricular hypertrophy was 23.8%, and 22.2% of patients had established cardiovascular disease, and 6.3% had renal disease. Masked hypertension was related to the absence of established cardiovascular disease (OR 0.306, 95%CI 0.139-0.676) and to the proximity of the clinic BP levels to the control thresholds (0.901, 95%CI 0.842-0.963). The OR of masked hypertension diminished 10% for each mmHg below the threshold of control. CONCLUSIONS The prevalence of masked hypertension was approximately 50% in treated hypertensive patients. ABPM constitutes a basic tool for detection of this abnormality.

Evolución temporal del tratamiento de los pacientes con fibrilación auricular en un área sanitaria urbana

BACKGROUND AND OBJECTIVE To evaluate the adequacy of atrial fibrillation (AF) management 6 years after the establishment of a coordinated AF Unit. PATIENTS AND METHODS Patients with AF attended during 14 consecutive days in the Emergency Room, Internal Medicine, Neurology and Arrhythmia departments of a tertiary hospital, and 3 primary health care centers of the same urban health care area were included. Treatment for AF and its adequacy to current clinical guidelines, tests performed and knowledge about the arrhythmia were evaluated. Results were compared with a population of 239 patients treated 6 years earlier. RESULTS One hundred and sixty-eight patients were included. Knowledge of the arrhythmia improved. The adequacy of treatment (rate control, rhythm control and antithrombotic prophylaxis) remained at the same level as in the previous period in all areas. The adequacy of thromboprophylaxis was negatively associated with advanced age (P < .001) and positively associated with knowledge of arrhythmia (P = .026). CONCLUSION Treatment of AF in a coordinated health area remains appropriate 6 years after the establishment of a coordinated AF unit. Elderly patients are still poorly anticoagulated. Health education may improve this deficit.

Can the Treatment of Hypertension in the Middle-Aged Prevent Dementia in the Elderly?

Hypertension, one of the main risk factors for cardiovascular disease, is thought to play a crucial role in the pathophysiology of cognitive impairment. Studies have associated hypertension with subjective cognitive failures and objective cognitive decline. Subjective cognitive failures may reflect the early phase of a long pathological process leading to cognitive decline and dementia that has been associated with hypertension and other cardiovascular risk factors. The underlying cerebral structural change associated with cognitive decline may be a consequence of the cerebral small-vessel disease induced by high blood pressure and may be detected on magnetic resonance imaging as white matter hyperintensities, cerebral microbleeds, lacunar infarcts or enlarged perivascular spaces. The increasing interest in the relationship between hypertension and cognitive decline is based on the fact that blood pressure control in middle-aged subjects may delay or stop the progression of cognitive decline and reduce the risk of dementia in the elderly. Although more evidence is required, several studies on hypertension have shown a beneficial effect on the incidence of dementia.

Prevalence of masked uncontrolled hypertension according to the number of office blood pressure measurements

INTRODUCTION AND OBJECTIVES The reported prevalence of masked uncontrolled hypertension (MUCH) varies because many studies are not comparable as they use different measurement methodologies. To evaluate the influence of the number of office blood pressure readings on the prevalence of MUCH we conducted a cross-sectional, multicenter study in treated hypertensive patients. PATIENTS AND METHODS We carried out an observational, cross-sectional, multicenter study in 33 Spanish hospital-based hypertension units, involving 35 investigators and 12 Autonomous Communities. Six blood pressure readings and a 24-h ambulatory blood pressure monitoring were performed in treated hypertensive patients. The means of the first 3 readings (P123), the 2nd, 3rd and 4th readings (P234), the 3rd, 4th and 5th readings (P345) and the last 3 readings (P456) were compared with mean 24-h blood pressure. MUCH was defined as office blood pressure <140/90mmHg and 24-h blood pressure ≥130/80mmHg, considering the first 3 readings (MUCH123), the 2nd, 3rd and 4th readings (MUCH234), the 3rd, 4th and 5th readings (MUCH345) and the last 3 readings (MUCH456). RESULTS We included 498 hypertensive patients. Mean (standard deviation) office blood pressure measurements were: (P123) 141(18)/82(11); (P234) 139(17)/81(11); (P345) 138(17)/81(11) and (P456) 137(16)/80(10) mmHg. Mean 24-h blood pressure was 127(13.8)/75(9.5) mmHg. The correlation coefficients between ambulatory and office systolic/diastolic blood pressure were (P123):0.48/0.50; (P234):0.50/0.52; (P345):0.50/0.54; and (P456):0.50/0.55 (p<0.001, all). The prevalences of MUCH123, MUCH234, MUCH345 and MUCH456 were 14.5%, 18.9%, 19.5% and 21.1%, respectively. CONCLUSIONS The prevalence of MUCH diagnosis depends on the serial office blood pressure readings, being much higher for the last three blood pressure readings. Discarding the first and second office blood pressure measures seems to be the most accurate method for diagnosing MUCH.

Hipertensión arterial resistente, más allá de un mal control de la presión arterial

Clásicamente se ha definido la hipertensión arterial refractaria o resistente (HTR) como aquella situación clı́nica en la que el paciente sigue presentando cifras elevadas de presión arterial (PA) en la consulta, a pesar de un correcto cumplimiento de un plan terapéutico que incluya necesariamente cambios adecuados en el estilo de vida y un tratamiento con dosis adecuadas de tres fármacos antihipertensivos con distintos mecanismos de acción, uno de los cuales debe ser un diurético. Recientemente, la ACC/AHA ha incluido otro elemento que define también refractariedad, además de lo ya descrito, en aquellos pacientes que aun presentando cifras de PA controladas, precisan de más de tres fármacos para su control. Esta definición operativa tiene como finalidad identificar desde un punto de vista práctico aquellos pacientes que pudieran beneficiarse de medidas diagnósticas y terapéuticas que no suelen aplicarse habitualmente a los pacientes hipertensos. Una aproximación diagnóstica adecuada puede conducir en estos casos a un diagnóstico y tratamiento mucho más apropiados, ya que nos permite identificar causas de HTR secundaria que son potencialmente reversibles con un tratamiento adecuado. Sin embargo, aun estando la definición basada en aspectos eminentemente prácticos, son obvias sus limitaciones. Ası́, por ejemplo, el número de fármacos necesarios para considerar una HTR es arbitrario, pues podrı́a también haberse considerado la inclusión de 4 o 5 fármacos con distinto mecanismo de acción a dosis más bajas. Por otra parte, son obvias las limitaciones implı́citas de basar la definición en cifras de PA medidas en la consulta. Todavı́a existen muchos aspectos desconocidos o controvertidos referentes a la HTR cuya importancia es muy relevante. Ası́, por ejemplo, la prevalencia real de la HTR es poco conocida. Un análisis transversal de los pacientes incluidos en el Framingham Heart Study mostró un buen control de la PA en pacientes hipertensos, definido como cifras de PA por debajo de 140/90 mmHg, en tan sólo

Baseline functional status as the strongest predictor of in-hospital mortality in elderly patients with non-valvular atrial fibrillation: Results of the NONAVASC registry

OBJECTIVES Atrial fibrillation (AF) has been associated with higher mortality. We aimed to identify the baseline predictors of in-hospital mortality among elderly patients with non-valvular AF (NVAF) hospitalised for any reason. METHODS Observational, prospective and multicentre study was carried out on patients with NVAF over the age of 75, who had been admitted for any acute medical condition to Internal Medicine departments in Spain. RESULTS We evaluated 804 patients with a mean age of 85±5.1years, of which 53.9% were females. During the hospitalization 10.1% (n=81) of the patients died. The patients who died were older, had a greater percentage of institutionalization, worse previous basic functional status (Barthel Index), worse cognitive performance at admission and greater proportion of frailty and sarcopenia. Logistic regression multivariate analysis identified that the strongest determinants of in-hospital mortality were the baseline functional status (Barthel Index) (OR for total dependency 4.73, 95% CI 2.32-9.63), and admissions for stroke (OR 3.55, 95% CI 1.41-8.90) and acute renal failure (OR 1.93, 95% CI 1.12-3.32). CONCLUSION The overall in-hospital mortality of elderly patients with NVFA is high. Among all factors evaluated in the global geriatric assessment the baseline functional status was the strongest predictor for in-hospital mortality on this population.

Circadian Blood Pressure Pattern and Cognitive Function in Middle-aged Essential Hypertensive Patients

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