Vicente Bertomeu Martínez

Actualización (2003) de las Guías de Práctica Clínica de la Sociedad Española de Cardiología en hipertensión arterial

Desde la elaboracion de las guias de practica clinica en hipertension arterial en enero del ano 2000 se han producido nuevas evidencias cientificas que hay que tener en cuenta en el ambito de la practica clinica. Es necesario realizar la evaluacion clinica del hipertenso mediante la estratificacion de su riesgo cardiovascular global, en la que los datos aportados por el electrocardiograma (ECG) y el analisis de orina (deteccion de excrecion urinaria de albumina) son de especial relevancia. Hasta la actualidad, los resultados de multiples estudios disponibles indican que en la hipertension arterial lo mas importante es normalizar los valores de la presion arterial, con un control mas estricto en los hipertensos de mayor riesgo (diabeticos, lesion de organo diana y enfermedad cardiovascular asociada). La individualizacion del tratamiento constituye la base de la eleccion de farmacos antihipertensivos. Sin embargo, debe tenerse en cuenta que los hipertensos con ciertas enfermedades asociadas obtienen un mayor beneficio de determinados grupos farmacologicos. Los hipertensos diabeticos o con hipertrofia ventricular izquierda parecen beneficiarse del bloqueo farmacologico del sistema renina-angiotensina y los pacientes con insuficiencia cardiaca deben recibir tratamiento combinado con inhibidores de la enzima de conversion de la angiotensina (IECA) y bloqueadores beta.

Variaciones estacionales en los ingresos por infarto agudo de miocardio. El estudio PRIMVAC

Introduccion y objetivos. Se ha descrito un aumento en la incidencia del infarto agudo de miocardio durante los meses frios. Se pretende averiguar si existe un ritmo estacional en los ingresos por infarto en las unidades coronarias y en su mortalidad, y determinar si la edad condiciona el efecto de los factores ambientales. Pacientes y metodo. A partir del registro PRIMVAC, se estudio a 8.400 pacientes ingresados consecutivamente por infarto agudo de miocardio desde enero de 1995 a diciembre de 1999 en 12 hospitales de la Comunidad Valenciana. Se analizo el ritmo estacional mediante el estudio de series temporales y la ecuacion de regresion Cosinor. El analisis de la influencia de la edad en los ingresos y la mortalidad se realizo mediante el test de la ?2. Resultados. El numero de ingresos por infarto agudo de miocardio aumento en invierno y disminuyo en verano. El pico maximo (acrofase) se produjo en invierno, con 2.183 casos (r2 = 0,91), concretamente en el mes de febrero, con 742 casos (r2 = 0,66). La edad condiciona las variaciones estacionales en el numero de ingresos (p = 0,006), con diferencias estadisticas a partir de los 65 anos. Las variaciones en la mortalidad no alcanzan significacion. Conclusiones. Existe un patron estacional en los ingresos por infarto agudo de miocardio, con un aumento en el numero de casos durante el invierno y un descenso durante el verano. La edad de los pacientes condiciona el efecto de los factores ambientales en el infarto. A partir de los 65 anos, los sujetos son mas sensibles a los mecanismos causantes del aumento de ingresos en invierno.

Heart Failure in Outpatients: Comorbidities and Management by Different Specialists. The EPISERVE Study

INTRODUCTION AND OBJECTIVES The aim of the EPISERVE study was to investigate the clinical characteristics of heart failure in outpatients and its diagnostic and therapeutic management by cardiology, internal medicine and primary care specialists. METHODS The study involved 507 physicians working in primary care (n=181, 36%), cardiology (n=172, 34%) or internal medicine (n=154, 30%) who treated 2249 consecutive outpatients with heart failure between June and November 2005. RESULTS The prevalence of heart failure was 2% in primary care, 17% in cardiology and 12% in internal medicine. Hypertension or coronary disease was the cause in more than 80% of cases. The prevalence of comorbidities was high: atrial fibrillation, 46%; diabetes, 38%; obesity, 64%; dyslipidemia, 60%; anemia, 27%; and renal failure, 7%. In 40% of cases, systolic function was preserved (i.e., left ventricular ejection fraction > or =45%). Echocardiographic and coronary angiographic studies were performed more frequently in patients seen in cardiology and in male patients. There were significant differences between men and women in pharmacologic treatment involving beta-blockers (55% vs. 44%, respectively; P< .001), diuretics (88% vs. 92%, respectively; P< .01) and statins (57% vs. 47%, respectively; P< .001). Only 20% of patients received the treatment recommended by clinical practice guidelines. The factors independently associated with appropriate treatment were being treated in cardiology, hypercholesterolemia, age and etiology. CONCLUSIONS The varied approaches of different specialists, the smaller effort put into diagnosis and therapy in women, and the low percentage of patients treated according to guidelines make it essential that an educational and multidisciplinary strategy should be developed for managing outpatients with heart failure.

Seasonal Variations in Admissions for Acute Myocardial Infarction. The PRIMVAC Study

Introduction and objectives. Some authors have described seasonal variations in the incidence of acute myocardial infarction. The aim of this study was to determine the existence of seasonal rhythms in admissions for acute myocardial infarction to coronary care units, and in mortality, and to analyze the influence of age on environmental factors. Patients and method. The study included a total of 8400 consecutive patients with acute myocardial infarction admitted to 12 coronary care units in the PRIMVAC registry from January 1995 to December 1999. Seasonal rhythms were analyzed with the time series method and the Cosinor regression equation. The influence of age was analyzed with the χ 2 test. Results. The total number of admissions increased in winter and decreased in summer. The highest peak (acrophase) occurred in winter, with 2183 cases (r 2 =0.91), specifically in February, with 742 cases (r2=0.66). The age of the patients conditioned seasonal variations (P=.006), and the influence was statistically significant for patients over 65 years of age. Changes in mortality with time did not reach statistical significance. Conclusions. A seasonal rhythm in admissions for acute myocardial infarction was found, with an increase in winter and a decrease in summer. Age conditioned the effect of environmental factors on acute myocardial infarction, and patients aged 65 years or older were more sensitive to mechanisms that led to increases in admissions in winter.

Valor del nivel de NTproBNP en población adulta extrahospitalaria

Introduction. The diagnosis of chronic heart failure (CHF) is based on demonstrating the cardiac origin of clinical manifestations. Echocardiography is the method of choice for the detection of left ventricular systolic dysfunction (LVSD). Brain natriuretic peptide (BNP) rises during LVSD. Objectives. To analyze the plasma concentration of Nterminal brain natriuretic propeptide (NTproBNP) in a general adult population in relation to different spontaneous circumstances and to study its capacity for identifying patients with LVSD. Methods. A cardiological examination was made and plasma NTproBNP levels were measured in a randomized group of 203 people (49-81 years old) from the Community of Valencia. Results. The average NTproBNP concentration was 52.2 ± 98.2 pmol/l. NTproBNP levels varied with age, gender and functional stage (NYHA). The highest NTproBNP values were observed in people who had previously suffered from acute pulmonary edema or who had an ejection fraction (EF) of less than 40%. There was also a significant elevation in patients with nocturnal dyspnea, orthopnea, atrial fibrillation, EF  50%, angina, and ankle edema. The best concentration of NTproBNP for differentiating EF  50% was 37.7 pmol/l, with 92% sensitivity and 68% specificity. Conclusions. The elevation of NTproBNP concentration indicates the cardiac origin of clinical manifestations and serves to select patients for echocardiographic examination. Low NTproBNP concentrations help to rule out LVSD.

Utilidad de la resonancia magnética en el estudio de la enfermedad endomiocárdica

Endomyocardial disease is a restrictive cardiomyopathy that includes Loffler endocarditis, which is characterized by hypereosinophilia, and endomyocardial fibrosis, which is not. Echocardiography enables cardiac function and anatomy to be assessed and the differential diagnosis of other causes of restrictive disease, but magnetic resonance imaging provides information about the tissue itself. Furthermore, paramagnetic contrast agents are useful in detecting myocardial abnormalities. We report three cases of endomyocardial disease and the typical findings of magnetic resonance imaging.

Empleo de fármacos antitrombóticos en pacientes hipertensos con fibrilación auricular crónica. Estudio CARDIOTENS 99

BACKGROUND: Our main goals were to know the actual degree of oral anticoagulation and antiaggregation in hypertensive patients with atrial fibrillation in the daily clinical practice in Spain and to analyze any differences between primary care physicians and cardiologists. PATIENTS AND METHOD: 32,051 outpatients attended the same day by 1,159 physicians (21% cardiologists) were prospectively included in a database taking into account a history of hypertension and atrial fibrillation, demographic data and ongoing treatments. RESULTS: Hypertension was detected in 10,555 patients and 999 of them had both hypertension and atrial fibrillation (9.46%: 435 males [44%] and 564 females [56%]). 53% patients were attended by primary care physicians and the rest by cardiologists. 33% of hypertensive patients with atrial fibrillation were on oral anticoagulation: 41% of them attended by cardiologists and 26% by primary care physicians (p 80 years-old) were found to receive less anticoagulants and more antiaggregants both in primary health-care and cardiology health-care.

Hipertensión arterial y riesgo cardiovascular en el año 2004

En la presente revision se analizan los avances mas relevantes publicados durante el ultimo ano en el campo de la hipertension arterial (HTA), prestando un especial interes a los ultimos ensayos clinicos que vienen a confirmar un concepto clasico ya conocido, en el que lo mas importante en el tratamiento del paciente hipertenso es conseguir el control de las cifras de presion arterial y que, unicamente cuando ello se ha alcanzado, se ponen de manifiesto los efectos beneficiosos adicionales de determinados grupos terapeuticos antihipertensivos, como son los farmacos que bloquean el eje renina-angiotensina-aldosterona. Asimismo, se analiza la informacion pronostica que nos aporta un procedimiento tan sencillo e incruento como es el indice tobillo-brazo en la valoracion cardiovascular de los pacientes, sin olvidar la importancia creciente del hiperaldosteronismo primario como etiologia de la HTA. Finalmente, se remarcan los aspectos mas novedosos publicados respecto de la asociacion entre la diabetes y la HTA y los efectos potenciales del bloqueo del receptor activador de la proliferacion de peroxisomas gamma en la prevencion cardiovascular.

Metabolite profile of the tomato dwarf cultivar Micro‐Tom and comparative response to saline and nutritional stresses with regard to a commercial cultivar

BACKGROUND The dwarf tomato variety Micro-Tom has been used as a plant model for studies of plant development. However, its response to environmental and agricultural factors has not been well studied. This work studies the phytochemical content of Micro-Tom tomato and its comparative response to saline and nutritional (N, K and Ca) stresses with regard to a commercial variety. RESULTS The chromatographic profiles of Micro-Tom were similar to those of the commercial variety and the only differences appear to be the concentration of the components. In Micro-Tom, the concentrations of sugars and organic acids increased by salinity in a lesser extent than in Optima. Moreover, contrary to that observed in the commercial variety, phenolic compounds and vitamin C did not increase by salinity in the dwarf variety. However, both varieties increased similarly the concentrations of carotenoids under saline conditions. Finally, fruit yield and most primary and secondary metabolite concentrations in Micro-Tom were not affected by N, K or Ca limitation. CONCLUSIONS The mutations leading to the dwarf phenotype did not greatly alter the metabolite profiles but studies using Micro-Tom as a plant model should consider the lower capacity for sugars and organic acids under saline conditions and the greater tolerance to nutrient limitation of the dwarf variety.

Control of Cardiovascular Risk Factors in Revascularized Patients With Diabetes: A Subanalysis of the ICP-Bypass Study

INTRODUCTION AND OBJECTIVES Patients with type 2 diabetes and revascularized coronary disease are a group with very high cardiovascular risk that has been rarely studied. This ICP-Bypass substudy analyzes the clinical characteristics and risk factor control of these patients. METHODS The analysis selected patients with type 2 diabetes who had participated in an earlier multicenter, observational, cross-sectional study (ICP-Bypass) conducted in 2293 patients > 18 years of age who had undergone coronary surgery or percutaneous coronary intervention. Demographic and therapeutic variables, as well as clinical and analytical parameters, were collected and comparatively analyzed. RESULTS The mean age (standard deviation) of the 771 diabetic patients included in the analysis was 67.7 (9.6) years (71.4% men; mean time since revascularization, 3.5 years). Most (57.8%) were receiving treatment with oral hypoglycemics alone, whereas 30.4% were receiving insulin alone or in combination. The mean glycohemoglobin figure was 7.1% (in 70%,<7.5%); 74.8% had been diagnosed with dyslipidemia. Mean low-density lipoprotein cholesterol was 93.5 mg/dL (in 73%, > 70 mg/dL). Among these patients, 93.6% were receiving statins and 18.7% a statin combined with ezetimib. A total of 78.1% had been diagnosed with hypertension; systolic/diastolic blood pressure was < 130/80 mmHg in 52% and < 140/90 mmHg in 93%. CONCLUSIONS Cardiovascular risk and prevention may be improved in revascularized diabetic patients in Spain through further control of risk factors, particularly dyslipidemia. Patients with glycohemoglobin > 7.5% should be individually assessed in terms of glycemic targets.