Raquel Hernández del Rey

Ambulatory blood pressure monitoring in hypertensive patients with high cardiovascular risk: a cross-sectional analysis of a 20,000-patient database in Spain.

Objective To evaluate ambulatory blood pressure monitoring (ABPM) parameters in a broad sample of high-risk hypertensive patients. Methods The Spanish Society of Hypertension is developing a nationwide project in which more than 900 physicians send ABPM registries and corresponding clinical records to a central database via www.cardiorisc.com. Between June 2004 and July 2005 a 20 000-patient database was obtained; 17 219 were valid for analysis. Results We identified 6534 patients with high cardiovascular risk according to the 2003 European Society of Hypertension/European Society of Cardiology guidelines stratification score. Office blood pressure (BP) was 158.8/89.9 mmHg and 24-h BP was 135.8/77.0 mmHg. Patients with grade 3 BP in the office showed ambulatory systolic BP values less than 160 mmHg in more than 80%. A non-dipping pattern was observed in 3836 cases (58.7%), whereas this abnormality was present in 47.9% of patients with low-to-moderate risk [odds ratio (OR) 1.54; 95% confidence interval (CI) 1.45–1.64]. The prevalence of non-dippers was higher as ambulatory BP increased (≈ 70% when 24-h systolic BP > 155 mmHg) and was similar in both groups. At the lowest levels of BP (24-h systolic BP < 135 mmHg) a non-dipping pattern was more prevalent in high-risk cases (56.6 versus 45.7%; OR 1.51; 95% CI 1.40–1.64). Conclusion There was a remarkable discrepancy between office and ambulatory BP in high-risk hypertensive patients. The prevalence of a non-dipper BP pattern was almost 60%. In the lowest levels of ambulatory BP, high-risk patients showed a higher prevalence of non-dipping BP than lower-risk cases. These observations support the recommendation of a wider use of ABPM in high-risk hypertensive patients.

Clinical characteristics of isolated clinic hypertension.

Objective To analyze the clinical characteristics of patients with isolated clinic hypertension (ICH) compared with other hypertensive patients, and to evaluate the capacity of physicians to predict a diagnosis of ICH. Methods A cross-sectional, comparative multicenter descriptive study was made of 6176 hypertensive individuals without pharmacological treatment, subjected to ambulatory blood pressure monitoring (ABPM). In 2611 cases, ABPM was prescribed due to suspected ICH. The participants were consecutively selected in primary care centers and hospital hypertension units in all Spanish Autonomous Communities. ICH was defined by clinical blood pressure (BP) ≥ 140 mmHg (systolic) or ≥ 90 mmHg (diastolic), with diurnal ambulatory BP < 135 and < 85 mmHg (ICH1) or BP < 130 and < 80 mmHg (ICH2) or 24-h BP < 125 and < 80 mmHg (ICH3). Results ICH1, ICH2 and ICH3 criteria were met by 1807 (29.2%), 960 (15.5%) or 1133 (18.3%) subjects, respectively. Total sample mean age (SD) was 51.8 (14.1) years, and clinical BP 145.7 ± 17.3/89.3 ± 11.3 mmHg. Compared with the rest of the hypertensive individuals, the patients with ICH were predominantly female, of older age, with fewer smokers, and increased frequency of obesity. Moreover, they were more frequently nondippers, and with greater systolic BP in the office (P < 0.05), except when we used ICH3 criteria. The sensitivity and specificity of the physician predictions in relation to suspected ICH1, ICH2 and ICH3 were 48.7 and 60.4%, 52.9 and 59.7%, and 52.3 and 60.0%, respectively. Conclusions The prevalence of ICH is between 15 and 29%, depending on the defining criterion used. The 24-h ICH criteria are not affected by awake/sleep biases, and should be preferred. Clinical capacity for predicting ICH is low.

Pharmacoeconomic considerations in the management of hypertension.

Hypertension is highly prevalent in developed and developing countries (more than 30% of the adult population when a threshold value of 140/90mm Hg is selected). It constitutes one of the major cardiovascular risk factors and accounts for more than 5% of total deaths worldwide.The economic impact of hypertension is enormous, representing

Reproducibility of the circadian blood pressure pattern in 24-h versus 48-h recordings: the Spanish Ambulatory Blood Pressure Monitoring Registry.

US23.74 billion in the US in 1995 and approximately

Gender Differences in Office and Ambulatory Control of Hypertension

US1685 million in Spain in 1994. Direct costs amount to more than 50% of the total costs of hypertension, and almost 70% of these are attributable to drug treatment. Furthermore, hypertensive patients use medical services 50% more than normotensive individuals, and hypertension represents one of the 3 leading causes of visits to primary healthcare centres.When considering the cost effectiveness of hypertension treatment, there is no doubt that it is cost effective in comparison with other interventions, although some controversies exist, mainly with respect to mild-to-moderate hypertension and to the long term versus short term benefits. The controversy about the absolute risk of hypertension influences the cost-effectiveness analysis.Because of the limitations of the available cost-effectiveness analyses, it is currently impossible to recommend the use of any particular antihypertensive drug for all patients with hypertension. Consequently, the choice of antihypertensive in any patient should be guided by clinical experience and the recommendations of the present international guidelines.

Determinants of left ventricular mass in untreated mildly hypertensive subjects: hospitalet study in mild hypertension.

Objectives To assess the reproducibility of the circadian blood pressure (BP) pattern over a 48-h period by comparing the first 24 h of ambulatory blood pressure monitoring (ABPM) with the following 24 h and with the mean over 48 h. Patients and methods Patients undergoing 48-h ABPM within the National ABPM Registry of the Spanish Society of Hypertension, based on 800 Spacelabs 90207 monitors distributed throughout Spain in hypertension units and primary healthcare centres, were included. Between June 2004 and September 2005, 611 valid 48-h ABPM recordings were obtained, 235 corresponded to patients without antihypertensive treatment. Results The percentages of patients classified as non-dipper for the first 24 h, the second 24 h and the 48-h average were 47, 50 and 48%, respectively. When the first and second 24-h periods were compared, 147 (24%) subjects switched from dipper (D) to non-dipper (ND) or vice-versa. When the first 24-h period was compared to the 48-h average, 66 (11%) subjects switched patterns. The proportions were similar separately for systolic blood pressure (SBP) and diastolic blood pressure (DBP) and between treated and untreated patients. In subjects with poor ABPM reproducibility, night-to-day ratios were of an intermediate value between those of subjects always classified as D or ND. Conclusion Categorization of D or ND based on a single 24-h ABPM is moderately reproducible, since one out of every five patients change profile over the following 24 h. Nevertheless, the use of 48-h ABPM in clinical practice should be assessed according to cost-effectiveness criteria. Night-to-day ratios may be helpful in identifying patients with a stable profile.

Agregación de factores de riesgo cardiovascular y de prevalencia de síndrome metabólico en personas con hipertensión arterial resistente

BACKGROUND Gender differences in hypertension control have not been explored fully. METHODS We studied 15,212 white men and 13,936 white women with treated hypertension who were drawn from the Spanish Ambulatory Blood Pressure Registry. For each participant, we obtained office blood pressure (BP) (average of 2 readings) and 24-hour ambulatory BP (average of measurements performed every 20 minutes during day and night). RESULTS Only 16.4% of women and 14.7% of men had both office (<140/90 mm Hg) and ambulatory (<130/80 mm Hg) BP controlled (P<.001). Women had a lower frequency of masked hypertension (office BP<140/90 mm Hg and ambulatory BP> or =130/80 mm Hg) than men (5.9% vs 7.9%, P<.001). Women had a higher frequency of isolated office hypertension (office BP> or =140/90 mm Hg and ambulatory BP<130/80 mm Hg) (32.5% vs 24.2%, P<.001). Although office BP control (office BP<140/90 mm Hg, regardless of ambulatory values) was similar in women and men (22.3% vs 22.6%, P=.542), ambulatory BP control (ambulatory BP<130/80 mm Hg, regardless of office values) was higher in women than in men (48.9% vs 38.9%, P<.001). After adjustment for age, number of antihypertensive drugs, hypertension duration, and risk factors, gender differences in BP control remained practically unchanged. CONCLUSION Ambulatory BP control was higher in women than in men. This may be due to the higher frequency of isolated office hypertension in women, and it is not explained by gender differences in other important clinical characteristics.

Estrés, enfermedad cardiovascular e hipertensión arterial

The objectives of this cross-sectional study were to identify the determinants of left ventricular mass in untreated mildly hypertensive subjects at the Hypertension Unit, Department of Internal Medicine, Red Cross Hospital, Hospitalet de Llobregat, Barcelona, Spain. One hundred seventy-one untreated mildly hypertensive subjects, with a mean age of 41.1+/-11.8 years (from 18 to 65 years) were sequentially visited in our Unit; 54% were men. Echocardiographic measurements of good quality were obtained in 142 subjects (83%). Two-dimensional guided M-mode echocardiograms were used and left ventricular mass was estimated according to the Penn convention. Left ventricular mass (LVM) was analyzed as a continuous variable. In the bivariate analysis, the variables that significantly correlated with LVM were patients height (r = 0.42, P<.0005), weight (r = 0.47, P< or =.0005), heart rate (r = -0.22, P = .01), HDLc (r = -0.30, P = .002), hematocrit (r = -0.28, P = .001), urinary sodium excretion (r = 0.23, P = 0.012), and different measurements from the ambulatory blood pressure profile for 24 h. By means of multiple regression analysis, a maximum of 41.2% of LVM variability could be explained from the factors registered in our study. The final model included age, gender, patients weight, and diastolic night load from ambulatory blood pressure monitoring. When added to different models, weight and diastolic night load showed a similar strength in predicting left ventricular mass. In untreated patients with mild hypertension, traditional factors such as blood pressure levels explain a maximum of 41.2% of LVM variability. More knowledge is needed about factors that may alter cardiac morphology in the evolution of hypertensive patients.

Abnormalities of vascular function in resistant hypertension.

Fundamento y objetivo La hipertension arterial (HTA) resistente requiere un abordaje global del riesgo cardiovascular. El objetivo del presente estudio ha sido analizar la agregacion de factores de riesgo cardiovascular y la prevalencia de sindrome metabolico (SM) en una serie de sujetos con HTA resistente. Pacientes y metodo Se incluyo de forma secuencial a 115 personas con HTA resistente, definida como un valor de presion arterial (PA) en consulta de 140/90 mmHg o mayor en tratamiento con 3 farmacos, uno de ellos diuretico, durante un minimo de 2 meses en buenos cumplidores. Se aplico el protocolo de la Unidad de HTA: seguimiento de la PA de 24 h con un monitor Spacelabs 90202 o 90207, y ecocardiografia Doppler en modo M de buena calidad en 68 sujetos. Se considero HTA seudorresistente cuando los valores de PA media diurna eran menores de 135/85 mmHg. Resultados La edad media (desviacion estandar) fue de 61 (10) anos y 50 pacientes (44%) eran varones. El valor medio de la PA en consulta fue de 166/95 (16/9) mmHg, y el de la PA diurna de 141/83 (15/12) mmHg. Tenian antecedentes familiares de enfermedad cardiovascular 88 sujetos (76,5%), de obesidad 64 (56%), de hipercolesterolemia 43 (37%), de concentracion baja de colesterol unido a lipoproteinas de alta densidad 34 (30%), de sedentarismo 63 (55%) y de diabetes mellitus 32 (28%). La prevalencia de SM fue del 54%. Presentaban hipertrofia ventricular izquierda 49 pacientes (72%), lesiones de organo diana 70 (61%) y un trastorno clinico asociado 44 (38%). En 31 casos (27%) se observo HTA seudorresistente; no se encontraron diferencias significativas en las distintas variables con los resistentes verdaderos. Conclusiones Los pacientes con HTA resistente en la consulta, independientemente de que tengan la PA ambulatoria controlada, presentan un riesgo muy elevado de experimentar un episodio cardiovascular, dada la importante agregacion de factores de riesgo cardiovascular y la alta prevalencia de SM. El manejo de estos hipertensos requiere la optimizacion del tratamiento antihipertensivo, asi como medidas o programas especificos del tratamiento de la obesidad y del sedentarismo.

Blood pressure in the initial phase of acute ischaemic stroke: Evolution and its role as an independent prognosis factor at discharge and after 3 months of follow‐up

Estres y enfermedad cardiovascular Existe actualmente una amplia evidencia de que la aparicion de enfermedad cardiovascular en la poblacion general esta muy influida por factores psicosociales, los cuales pueden desempenar un papel tanto etiopatogenico como pronostico 1-3 . Aunque esta relacion podria explicarse por la interaccion de distintos factores dieteticos y diferencias en el estilo de vida, existe tambien alguna evidencia de que la exposicion al estres cronico podria tener alguna funcion. En estudios experimentales llevados a cabo en animales se ha observado que el estres psicosocial cronico podria conducir, a traves de una estimulacion del sistema nervioso autonomo, a una exacerbacion de la enfermedad coronaria, con disfuncion endotelial transitoria o incluso necrosis. Se definen como agentes estresantes aquellos estimulos externos o internos que provocan un incremento de la actividad fisiologica en algunos o en todos los individuos. En la bibliografia medica se han referido distintos factores estresantes como cambios en la vida, estres ocupacional, situaciones laborales de alta demanda y bajo control en la toma de decisiones, carencia de apoyo social y situaciones fisicas como temperaturas extremas o niveles elevados de ruido 4,5