Pedro Aranda

Prevalence and Factors Associated With Circadian Blood Pressure Patterns in Hypertensive Patients

Ambulatory blood pressure (BP) monitoring has become useful in the diagnosis and management of hypertensive individuals. In addition to 24-hour values, the circadian variation of BP adds prognostic significance in predicting cardiovascular outcome. However, the magnitude of circadian BP patterns in large studies has hardly been noticed. Our aims were to determine the prevalence of circadian BP patterns and to assess clinical conditions associated with the nondipping status in groups of both treated and untreated hypertensive subjects, studied separately. Clinical data and 24-hour ambulatory BP monitoring were obtained from 42 947 hypertensive patients included in the Spanish Society of Hypertension Ambulatory Blood Pressure Monitoring Registry. They were 8384 previously untreated and 34 563 treated hypertensives. Twenty-four-hour ambulatory BP monitoring was performed with an oscillometric device (SpaceLabs 90207). A nondipping pattern was defined when nocturnal systolic BP dip was <10% of daytime systolic BP. The prevalence of nondipping was 41% in the untreated group and 53% in treated patients. In both groups, advanced age, obesity, diabetes mellitus, and overt cardiovascular or renal disease were associated with a blunted nocturnal BP decline (P<0.001). In treated patients, nondipping was associated with the use of a higher number of antihypertensive drugs but not with the time of the day at which antihypertensive drugs were administered. In conclusion, a blunted nocturnal BP dip (the nondipping pattern) is common in hypertensive patients. A clinical pattern of high cardiovascular risk is associated with nondipping, suggesting that the blunted nocturnal BP dip may be merely a marker of high cardiovascular risk.

Surgical Menopause Increases Salt Sensitivity of Blood Pressure

Salt sensitivity of blood pressure is associated with an elevated risk of developing hypertension (HTN) and is an independent risk factor for cardiovascular disease. The prevalence of HTN increases after menopause. The aim of this study was to investigate prospectively whether the loss of ovarian hormones increases the occurrence of salt sensitivity among healthy premenopausal women. We enrolled 40 normotensive, nondiabetic women (age 47.2±3.5), undergoing hysterectomy–oophorectomy for nonneoplastic processes and not on hormone replacement, to determine the effect of changes in sodium intake on blood pressure the day before and subsequently 4 months after surgical menopause. Salt loading was achieved using a 2-L normal saline infusion and salt depletion produced by 40 mg of intravenous furosemide. A decrease >10 mm Hg in systolic blood pressure between salt loading and salt depletion was used to define salt sensitivity. Before and after menopause, salt-sensitive women exhibited higher waist/hip and waist/thigh ratios (P<0.01). Although all of the women remained normotensive, the prevalence of salt sensitivity was significantly higher after surgical menopause (21 women; 52.5%) than before (9 women; 22.5%; P=0.01), because 12 (38.7%) salt-resistant women developed salt sensitivity after menopause. In summary, we demonstrated that the prevalence of salt sensitivity doubled as early as 4 months after surgical menopause, without an associated increase in blood pressure. Epidemiological studies indicate that development of HTN may not occur until 5 to 10 years after menopause. The loss of ovarian hormones may unmask a population of women prone to salt sensitivity who, with aging, would be at higher risk for the subsequent development of HTN and cardiovascular disease.

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.

Discrepancies between Office and Ambulatory Blood Pressure: Clinical Implications

BACKGROUND Recent trials have documented no benefit from small reductions in blood pressure measured in the clinical office. However, ambulatory blood pressure is a better predictor of cardiovascular events than office-based blood pressure. We assessed control of ambulatory blood pressure in treated hypertensive patients at high cardiovascular risk. METHODS We selected 4729 patients from the Spanish Ambulatory Blood Pressure Monitoring Registry. Patients were aged >/=55 years and presented with at least one of the following co-morbidities: coronary heart disease, stroke, and diabetes with end-organ damage. An average of 2 measures of blood pressure in the office was used for analyses. Also, 24-hour ambulatory blood pressure was recorded at 20-minute intervals with a SpaceLabs 90207 device. RESULTS Patients had a mean age of 69.6 (+/-8.2) years, and 60.8% of them were male. Average time from the diagnosis of hypertension to recruitment into the Registry was 10.9 (+/-8.4) years. Mean blood pressure in the office was 152.3/82.3 mm Hg, and mean 24-hour ambulatory blood pressure was 133.3/72.4 mm Hg. About 60% of patients with an office-pressure of 130-139/85-89 mm Hg, 42.4% with office-pressure of 140-159/90-99 mm Hg, and 23.3% with office-pressure > or =160/100 mm Hg were actually normotensive, according to 24-hour ambulatory blood pressure criteria (<130/80 mm Hg). CONCLUSION We suggest that the lack of benefit of antihypertensive therapy in some trials may partly be due to some patients having normal pressure at trial baseline. Ambulatory monitoring of blood pressure may allow for a better assessment of trial eligibility.

Hipertensión arterial y política de salud en España

José R. Banegas a,b, , Albert Jovell , Benjamı́n Abarca , Manuel Aguilar Diosdado , Luis Aguilera , Pedro Aranda , Vicente Bertoméu , Pedro Capilla , Pedro Conthe , Fernando De Álvaro , Antonio Fernández-Pro , Xavier Formiguera , Jesús Frı́as , Lucı́a Guerrero , José L. Llisterri , José M. Lobos , Juan F. Macı́as , Ángel L. Martı́n De Francisco , Jesús Millán , Juan C. Morales , Vicente Palomo , Alex Roca-Cusachs , Javier Román , Carlos Sanchis , Antonio Sarriá , Julián Segura , Álex De La Sierra , Luis Verde , Julio Zarco n y Luis M. Ruilope a,u a Asociación de la Sociedad Española de Hipertensión y Liga Española para la Lucha contra la Hipertensión Arterial b Universidad Autónoma de Madrid, CIBERESP (CIBER de Epidemiologı́a y Salud Pública), Madrid c Foro Español de Pacientes d Sociedad Española de Medicina General e Sociedad Española de Diabetes f Sociedad Española de Medicina de Familia y Comunitaria g Sociedad Española de Cardiologı́a h Consejo General de Colegios Oficiales de Farmacéuticos i Sociedad Española de Medicina Interna j Sociedad Española de Nefrologı́a en el Comité Español Interdisciplinario para la Prevención Cardiovascular k Sociedad Española para el Estudio de la Obesidad l Departamento de Farmacologı́a y Terapéutica, Universidad Autónoma de Madrid, Madrid m Asociación de Enfermerı́a de Hipertensión y Riesgo Cardiovascular (EHRICA) n Sociedad Española de Médicos de Atención Primaria o Comité Español Interdisciplinar de Prevención Cardiovascular (CEIP) p Sociedad Española de Geriatrı́a y Gerontologı́a q Sociedad Española de Nefrologı́a r Sociedad Española de Arteriosclerosis s Sociedad Española de Farmacéuticos de Atención Primaria t Ibermutuamur-Corporación Mutua-Proyectos Sanitarios u Agencia de Evaluación de Tecnologı́as Sanitarias. Instituto de Salud Carlos III, Madrid v Asociación para la Prevención del Riesgo Cardiovascular (PRECAR) x Sociedad Española de Directivos de Atención Primaria, España

Blood pressure control in patients with chronic renal insufficiency in Spain: a cross-sectional study.

Objective Despite therapeutic advances, strict control of hypertension remains elusive in patients with chronic renal insufficiency (CRI). The present study was designed for assessment of control rates of blood pressure in patients with CRI. Secondary objectives included evaluation of the control rates of proteinuria and cardiovascular comorbidities. Methods A multicenter and cross-sectional survey of unselected patients with CRI attending outpatient nephrology clinics in Spain between April and September 2003 was performed. Results Fifty-two centers recruited 2501 patients with a mean age 64.8 years (65.7% men). The prevalence of previous cardiovascular disease was 55%. The two most prevalent renal diseases were vascular (38.9%) and diabetic nephropathy (20.1%). Blood pressure below 130/80 mmHg was observed in 435 patients (17.4%). A poor blood pressure control was associated with older age, greater proteinuria and higher low-density lipoprotein cholesterol levels. Proteinuria less than 0.5 g/day was observed in 1209 cases (48.3%). A total of 1899 patients (75.9%) were receiving drugs suppressing the activity of the renin–angiotensin system and 1048 patients (41.9%) were being treated with three or more antihypertensive drugs. Lipid-lowering agents and antiplatelet therapy were used in 49.3 and 38.1% of patients, respectively. Conclusions The control rate of blood pressure in patients with CRI is inadequate despite frequent use of combination therapy that most commonly included an angiotensin-converting enzyme inhibitor or an angiotensin receptor blocker. Greater emphasis should be made to increase the number and dose of antihypertensive drugs and the need for using a statin as well as antiplatelet therapy in order to improve renal and cardiovascular outcomes.

Abnormalities in ambulatory blood pressure monitoring in hypertensive patients with diabetes

Our aim was to assess the ambulatory blood pressure monitoring (ABPM) characteristics or patterns in hypertensive patients with diabetes compared with non-diabetic hypertensives. We performed a cross-sectional analysis of a 68 045 patient database from the Spanish Society of Hypertension ABPM Registry, a nation-wide network of >1200 primary-care physicians performing ABPM under standardized conditions in daily practice. We identified 12 600 (18.5%) hypertensive patients with diabetes. When compared with patients without diabetes, diabetic hypertensives exhibited higher systolic blood pressure (BP) levels in every ABPM period (daytime 135.4 vs. 131.8, and nighttime 126.0 vs. 121.0 mm Hg, P<0.001 for both) despite they were receiving more antihypertensive drugs (mean number 1.71 vs. 1.23, P<0.001). Consequently, diabetic patients suffered from lack of control of BP more frequently than non-diabetic subjects particularly during the night (65.5% vs. 57.4%, P<0.001). Prevalence of a non-dipping BP profile (64.2% vs. 51.6%, P<0.001) was higher in diabetic patients. In the other hand, prevalence of ‘white-coat’ hypertension in diabetic patients was 33.0%. We conclude that there was a remarkably high prevalence of alterations in ABPM in patients with diabetes. Abnormalities in systolic BP, particularly during the night, and in circadian BP pattern could be linked with the excess of BP-related cardiovascular risk of diabetes. A wider use of ABPM in diabetic patients should be considered.

Diferencias entre el control clínico y ambulatorio de la hipertensión arterial en pacientes muy ancianos. Proyecto CARDIORISC–MAPAPRES

BACKGROUND AND OBJECTIVE Hypertension is highly prevalent in the very elderly. We studied control rates of hypertension according to clinic blood pressure (BP) and ambulatory BP monitoring (ABPM) in treated hypertensives aged > or =80 years. PATIENTS AND METHOD Data came from the Spanish Society of Hypertension ABPM Registry (CARDIORISC - MAPAPRES project), which comprises a nation-wide network of more than 1,000 physicians sending standardized ABPM registries via web. Between June 2004 and April 2007 we obtained a 33.829-patient database. Control of hypertension was defined at the clinic when office BP was <140/90mmHg and at the ABPM when mean BP during the 24-h period was <130/80mmHg. RESULTS We identified 2,311 patients (6.8%) aged > or =80 years. Mean age (SD) was 83.1 (3.2) years and 63% were women. Control of clinic BP was observed in 21.5% of cases (95%CI: 19.1-23.9) and control of 24-h BP in ABPM was 42.1% (95%CI: 39.7-45.3). Prevalence of masked hypertension was 7.0% (95%CI: 6.0-8.0) and prevalence of office-resistant control (white coat) was 27.6% (95% CI: 25.7-29.4). Diabetes, kidney disease, and duration of hypertension were associated with lack of control in ABPM. CONCLUSIONS In very old hypertensives, control of clinic BP was 21.5% but ambulatory-based hypertension control was 42.1%. Physicians should be aware that the likelihood of misestimating BP control is high in these subjects. A wider use of ABPM in the elderly with hypertension should be considered.

The development of anemia is associated to poor prognosis in NKF/KDOQI stage 3 chronic kidney disease

BackgroundAnemia is a common condition in CKD that has been identified as a cardiovascular (CV) risk factor in end-stage renal disease, constituting a predictor of low survival. The aim of this study was to define the onset of anemia of renal origin and its association with the evolution of kidney disease and clinical outcomes in stage 3 CKD (CKD-3).MethodsThis epidemiological, prospective, multicenter, 3-year study included 439 CKD-3 patients. The origin of nephropathy and comorbidity (Charlson score: 3.2) were recorded. The clinical characteristics of patients that developed anemia according to EBPG guidelines were compared with those that did not, followed by multivariate logistic regression, Kaplan-Meier curves and ROC curves to investigate factors associated with the development of renal anemia.ResultsDuring the 36-month follow-up period, 50% reached CKD-4 or 5, and approximately 35% were diagnosed with anemia (85% of renal origin). The probability of developing renal anemia was 0.12, 0.20 and 0.25 at 1, 2 and 3 years, respectively. Patients that developed anemia were mainly men (72% anemic vs. 69% non-anemic). The mean age was 68 vs. 65.5 years and baseline proteinuria was 0.94 vs. 0.62 g/24h (anemic vs. non anemic, respectively). Baseline MDRD values were 36 vs. 40 mL/min and albumin 4.1 vs. 4.3 g/dL; reduction in MDRD was greater in those that developed anemia (6.8 vs. 1.6 mL/min/1.73 m2/3 years). These patients progressed earlier to CKD-4 or 5 (18 vs. 28 months), with a higher proportion of hospitalizations (31 vs. 16%), major CV events (16 vs. 7%), and higher mortality (10 vs. 6.6%) than those without anemia. Multivariate logistic regression indicated a significant association between baseline hemoglobin (OR=0.35; 95% CI: 0.24-0.28), glomerular filtration rate (OR=0.96; 95% CI: 0.93-0.99), female (OR=0.19; 95% CI: 0.10-0.40) and the development of renal anemia.ConclusionsRenal anemia is associated with a more rapid evolution to CKD-4, and a higher risk of CV events and hospitalization in non-dialysis-dependent CKD patients. This suggests that special attention should be paid to anemic CKD-3 patients.

Perception of health and understanding of cardiovascular risk among patients with recently diagnosed diabetes and/or metabolic syndrome.

Background: Cardiovascular (CV) disease mortality is increased in diabetes mellitus (DM) and metabolic syndrome (MS), conditions which share CV risk factors. Aim: The purpose of this study was to assess understanding of CV risk by patients with DM and/or MS diagnosed less than 1 year before and seen in primary care. Perception by these patients of their health state is also analysed. Design: A multicentre, observational study in subjects diagnosed with DM diagnosed less than 1 year before and/or with MS, in whom agreement between CV risk perceived by patients and assessed by physicians was analysed. Methods: Medical registry data and a survey of health status and perceived risk by patients and physicians. Agreement of patient perception of CV risk with perception of the physician in charge and with the CV risk established with clinical registry data was assessed. Self-perceived health status was also studied. Results: A total of 150 physicians recruited 681 patients (71.5% with DM and 28.5% with MS) aged 60.8 ± 10.8 years (55.8% males). Good or excellent health were reported by 41.3% and 0.9%, respectively. Inability to give an estimate of CV risk was found in 39.8%. Agreement between the CV risks perceived by patients and evaluated by chart was poor: kappa index 0.145 (95% CI 0.101–0.189), p < 0.001. Agreement between CV risk perceived by patients and clinical data in the medical registry was weak: kappa index 0.165 (95% CI 0.117–0.213), p < 0.001. Conclusions: Patients with recently diagnosed DM and/or with MS have a poor awareness of their CV risk and 42.2% of them think that they have good or excellent health.