Tomás Romero

Prevención cardiovascular estancada: tendencias alarmantes y barreras socioeconómicas persistentes

La prevalencia, creciente en la ultima decada, de los factores de riesgo cardiovascular en todo el mundo y el estancamiento de la reduccion de la mortalidad cardiovascular (dependiente de la enfermedad coronaria sobre todo) en adultos jovenes de baja posicion socioeconomica son tendencias alarmantes que indican que la disminucion de la mortalidad cardiovascular observada en los ultimos 50 anos podria estar llegando a su termino. La obesidad, que ha alcanzado proporciones epidemicas en el mundo, ocupa un lugar central en esta tendencia. La enfermedad coronaria se desarrolla a traves de un proceso que involucra multiples vias causales. La expresion de los factores de riesgo cardiovascular parece estar determinada por caracteristicas que incluyen desde el codigo genetico hasta factores socioeconomicos desfavorables. El control del riesgo cardiovascular hasta ahora se ha centrado predominantemente en el manejo farmacologico de factores de riesgo aislados, en detrimento de otros factores participantes, en especial los socioeconomicos. Estrategias mas efectivas en el control del riesgo cardiovascular tanto en individuos como en las poblaciones deberian considerar este complejo escenario, que incluye caracteristicas socioeconomicas como la educacion, los ingresos y el medio ambiente construido. Las tendencias desfavorables senaladas mas arriba enfatizan la necesidad de redirigir las actuales estrategias preventivas del riesgo cardiovascular.

Desigualdad educacional y socioeconómica como determinante de mortalidad en Chile: análisis de sobrevida en la cohorte del proyecto San Francisco

In thisprospective cohort study, a random sample of 920 subjects, living in San Francisco de Mostazal, Chile,aged more than 20 years (395 males) was examined for the first time in 1997-1999 and re-examinedin 2005-2006. All had information about economic household income and level of education. A Coxregression model was used to evaluate the association between mortality and socioeconomic measures.

Stagnant Cardiovascular Prevention: Alarming Trends and Persistent Socioeconomic Hurdles

Recently it has been suggested that the decline in cardiovascular mortality observed over the last 50 years may be coming to an end. This alarming trend, which has been noted mainly in younger adults from lower socioeconomic strata, may be linked to other changes, namely the increasing prevalence of modifiable risk factors, the most important of which is obesity. In contrast, our ability to predict cardiovascular risk continues to improve steadily, although it is unclear which will be its ability in designing more effective global preventive measures. Coronary heart disease appears to develop through multiple pathways, whose association with cardiovascular risk is mediated by complex processes involving numerous factors ranging from genetic predisposition to unfavorable socioeconomic circumstances. Although some attention has been paid to the latter, more effort has been put into controlling isolated risk factors. For example, numerous large studies have involved looking at the effect of singledrug therapies aimed at specific targets rather than examining more comprehensive approaches to managing multiple risk factors. In conclusion, an effective strategy for controlling modifiable risk factors in both individuals and populations must address this complex scenario and should consider significant socioeconomic factors such as education, income and the built environment. The unfavorable trend observed in cardiovascular health makes it essential that current preventive strategies are reassessed.

Control del Hipertenso, un desafío no resuelto: Avances logrados en Chile mediante el Programa de Salud Cardiovascular

El control de la presion arte-rial (PA) es fundamental en reducir la morbi-mor-talidad en hipertensos, pero con resultados hasta la fecha insatisfactorios en Chile y en paises de alto desarrollo socioeconomico. En Chile se ini-cio en 2002 el Programa de Salud Cardiovascular (PSCV) intentando mejorar el manejo de estos pa-cientes.

Influencia de factores psicosociales en la adherencia al tratamiento farmacológico antihipertensivo: Resultados de una cohorte del Programa de Salud Cardiovascular de la Región Metropolitana, Chile

Background: Inadequate blood pressure control in hypertensive patients remains a persistent health problem in Chile and worldwide. Poor adherence to antihypertensive drug therapy is one of the frequently cited factors. Objectives: To determine the influence of psychosocial factors in the adherence to drug therapy in hypertensive patients followed through a Cardiovascular Health Program (CHP) that provides free access to primary care centers located in the Metropolitan Region of Santiago, Chile. Methods: Cross sectional study. A randomized sample of 513 hypertensive patients (30 to 68 years) was obtained from a universe of 1.484 patients. Adherence to treatment was determined by the Morisky-Green-Levine test. Demographic, socioeconomic and average values of blood pressure were recorded. Validated questionnaires were utilized to assess the patient-physician relationship, awareness of being hypertensive, patient perception of social support, family cohesion, patient self-health assessment and symptoms of emotional stress and depression. Results: The drug therapy adherence was 36.6%, higher in women (38.4% vs 28.9%; p<0.001). After multivariate analysis, absence of adherence was associated with male gender (OR: 1.76 [95% CI 1.21 – 2.56]), low education (OR: 1.72 [95% CI 1.18 to 2.53]), inadequate patient-physician relationship (OR: 1.56 [95% CI 1.13 to 2.27]), and high level of emotional stress and depression (OR: 1.93 [95% CI 1.27 to 2.94]). Conclusions: Our study highlights the influence of inadequate patient-physician relation, high level of emotional stress and depression, low education level and income and male gender in the lack of adherence to antihypertensive drug therapy in hypertensive patients followed throughout the CHP.

Evaluación del control de la presión arterial y la adherencia terapéutica en hipertensos seguidos en el Programa de Salud Cardiovascular (PSCV): Asociación con características clínicas, socioeconómicas y psicosociales

Muestra randomizada de 1.794 hiper-tensos seguidos por 1 ano en PSCV en Region Me-tropolitana. Se evaluo la asociacion de edad, sexo, educacion, ingreso familiar, Rx, diabetes, obesidad, tabaquismo, consumo problematico de alcohol y actividad fisica con el control de la PA (<140/90 mmHg) y adherencia. Ademas, en 600 pacientes, se evaluo la asociacion con estres emocional/depre -sion, relacion medico-paciente y apoyo social. Se obtuvieron Odds Ratio (OR) mediante analisis de regresion logistica multivariante.

Estatura, factores de riesgo cardiovascular y riesgo de mortalidad en adultos: Proyecto San Francisco, Chile

Resumen:Antecedentes: Una relacion inversa entre estatura y riesgo de mortalidad ha sido establecida en estudios prospectivos de paises desarrollados. Sin embargo, di-cha asociacion practicamente permanece inexplorada en sociedades latinoamericanas en rapida transicion economica y epidemiologica. Diseno: De un universo de 11.600 adultos vi-viendo en el centro urbano de Mostazal, Chile, se realizo un estudio de cohorte prospectivo de una muestra aleatoria ponderada de 795 sujetos segui-dos durante 8 anos. Metodo: Desde 1997 a 1999 se evaluo la estatura (percentiles 50 y 75 por sexo), hipertension, diabetes, dislipidemia, obesidad, tabaquismo, consumo de alco-hol y antecedentes hereditarios de enfermedad cardio-vascular. El riesgo relativo de mortalidad por cualquier causa fue estimado a traves de modelos de regresion de Cox ajustando por edad, sexo, factores de riesgo, educacion e ingreso. Resultados: Se observo una relacion inversa entre la estatura adulta y los factores de riesgo cardiovascu-lar. En el modelo completamente ajustado el riesgo de mortalidad por cualquier causa asociado a la estatura fue 0,75 (IC 95% 0,66 – 0,85; p tendencia <0,001). Los factores de riesgo cardiovascular tradicionales solo explicaron 22% de la asociacion inversa estable-cida entre estatura y mortalidad.

Modifiable cardiovascular risk factors: Which ones are we really modifying?

While efforts to identify the underlying mechanisms that lead to endovascular atherogenesis continue, the clinical management of the modifiable cardiovascular risk factors should depend on the most advantageous risk-benefit and cost-effective therapies. However these efforts probably will not have a significant impact in the population at risk unless an improvement in the socioeconomic factors of cardiovascular risk occurs. The ongoing global obesity epidemic reinforces the need for these changes. Public and privately sponsored programs and policies to improve education and access to health resources are important components of this process .

Clinical, Socioeconomic, and Psychosocial Factors Associated with Blood Pressure Control and Adherence: Results from a Multidisciplinary Cardiovascular National Program Providing Universal Coverage in a Developing Country

Background Limited information exists on blood pressure (BP) control factors and adherence to antihypertensive drug therapy (Rx) in developing countries. Methods Cross-sectional study in randomly selected 992 hypertensive patients under a Chilean national comprehensive Cardiovascular Health Program (CVHP). Association of education, income, diabetes, obesity, physical activity, psychosocial characteristics, smoking, and alcohol abuse with BP control and adherence were evaluated by multivariate logistic regression. Results BP control (<140/90 mmHg) was achieved in 63.1% of patients, with 38.4% adherent to Rx. Uncontrolled BP significantly associated with male sex (OR: 1.73 [95% CI 1.35-2.22]), low family income, high emotional-stress-depression score, body mass index, no adherence (OR: 1.83 [95% CI 1.44 - 2.32]), multiple Rx, baseline systolic BP value, and sedentary life style. Males (OR: 1.54 [95% CI 1.23 - 1.93]), low family income, high emotional stress-depression score (OR: 2.15 [95% CI 1.68 - 2.76]), low social support, and uncontrolled BP (OR: 1.52 [95% CI 1.22-1.90]) associated with no adherence. Conclusions Comparable BP control (63.1%) to higher-income societies was observed. Uncontrolled BP associated significantly to no adherence and both to male sex, socioeconomic, and psychosocial factors. Global low adherence (38.4%) and improved BP control and adherence in diabetics were noted.

Update on quality of care in Hispanics and other racial-ethnic groups in the United States discharged with the diagnosis of Acute Myocardial Infarction in 2013

BACKGROUND Disparities in Acute Myocardial Infarction (AMI) care and outcomes have been frequently reported in racial-ethnic minorities in the U.S. Some studies have attributed disparities in Hispanics and other minorities to lower quality of services at hospitals where they seek care. Current information from hospitals with large Hispanic representations and updated quality resources is needed. METHODS Retrospective observational study of 839 AMI patients discharged in 2013 from three Southern California Hospitals (A, B, C) with tertiary cardiac care level. Non-Hispanic Whites (NHW) and Hispanics (H) were the larger racial-ethnic groups (68.3%), and the comparison of these two groups constitutes the focus of the study. Mortality, 30day readmissions, medication/performance measures (PRx); aspirin, statins/anti-lipids, beta-blockers, ACEI/ARB for LV systolic dysfunction, <90min door-balloon time, and revascularization procedures were compared between hospitals, NHW and H, using Chi-squared tests (χ2), Odds Ratios (OR) with 95% confidence intervals (CI), and Z tests for proportions - independent groups. RESULTS No significant differences in hospital, 30day mortality, PRx or procedures were observed between NHW, H and other racial-ethnic minority groups, or hospitals. Hospital C had 47.3% H and Hospitals A+B 14.6% (p<0.001, effect size=0.430). AMI performance measures exceeded 2013 national rates across all facilities. NHW had more private/commercial insurance (52.5% vs. 25.4%, OR 3.24, 95% CI 2.19-4.80, p<0.001) than H. CONCLUSIONS Equitable access to quality hospital services in three Southern California hospitals offset previously reported disparities in AMI management in Hispanics. These results may not necessarily reflect the reality of AMI care for Hispanics in other U.S. regions.