Vicente Giner Galvañ

Severe acute hepatitis related to hydroxychloroquine in a woman with mixed connective tissue disease.

Antimalarial drugs are used for the control of mild manifestations of autoimmune diseases due to their low toxicity. Hydroxychloroquine (HCQ), a α-hydroxylated derivative of chloroquine, is usually preferred because of its higher tolerability. Mild and unspecific gastrointestinal symptoms are the main secondary effects related to HCQ use. Less than 1% of subjects show liver enzyme increase, although the percentage can be as high as 50% in subjects with chronic liver disease. A woman with mixed connective tissue disease who developed a reversible acute hepatitis shortly after the initiation of low-dose HCQ is presented. Two previous cases of patients with acute liver failure have previously been published. All three cases have been reported in the absence of previous liver disease. It seems to be a dose-dependent, idiosyncratic, and molecule-specific toxic effect and must be considered, taking into account the potential bad prognosis.

Rigidez arterial en sujetos normotensos e hipertensos: frecuencia en farmacias comunitarias

BACKGROUND AND OBJECTIVE Arterial stiffness (AS) is a well-recognized target organ lesion. This study aims to determine: 1) the frequency of AS in community pharmacies; 2) if stiffened subjects identified by brachial oscillometry have more CV risk factors than normal subjects, and 3) the dependence of stiffness on using either age-adjusted values or a fixed threshold. PATIENTS AND METHOD Observational, cross-sectional study in 32 community pharmacies of the Valencia Community, between November/2015 and April/2016. Stiffness was as pulse wave velocity (PWV) measured with a semi-automatic, validated device (Mobil-O-Graph®, IEM), followed by a 10-item questionnaire. RESULTS Mean age of the 1,427 consecutive recruited patients was 56.6 years. Overall proportion of patients with AS was 17.4% with age-adjusted PWV (9.4% in normotensives, 28.3% in hypertensives). Multivariate logistic regression showed independent association of stiffness in normotensives with male gender, obesity, higher pulse pressure and heart rate, in hypertensives, with higher pulse pressure and lower age. AS was globally found in 20.5% of subjects, defining stiffness by PWV>10m/s (6.2% in normotensives, 40.2% in hypertensives). It was associated with higher age and pulse pressure in both groups. Concordance in classifying stiffness was 74.6%. CONCLUSIONS Frequency of AS varied between 17.4-20.5%. Age-adjusted stiffness is associated in normotensives with male gender, pulse pressure, obesity and heart rate, in hypertensives with pulse pressure and inversely to age. Stiffness by 10m/s is determined by higher pulse pressure and higher age. Both definitions of PWV are not interchangeable.

Inhibición directa de la renina y enfermedad cardiovascular. Más allá de la hipertensión

Resumen La evidencia acumulada en los ultimos anos muestra que en el manejo del paciente hipertenso no es suficiente con reducir las cifras de presion arterial, especialmente en los hipertensos de alto riesgo cardiovascular, pues en ellos persiste un riesgo residual muy considerable a pesar de la correcta implementacion del tratamiento farmacologico y de conseguir los objetivos de presion que recomiendan las guias clinicas internacionales. Por eso, en los ultimos anos se ha intentado probar los efectos beneficiosos de las distintas estrategias antihipertensivas mas alla de la mera reduccion de presion. Conseguir un bloqueo intenso del sistema renina-angiotensina-aldosterona (SRAA) aparece en el centro de tales estrategias en los pacientes con riesgo cardiometabolico. La existencia demostrada de fenomenos de escape de la aldosterona observados a pesar de la inhibicion de los distintos pasos de la cascada enzimatica del SRAA es la base para buscar estrategias de bloqueo mas intenso del SRAA interfiriendo simultaneamente la enzima de conversion de la angiotensina con sus inhibidores (IECA) y el receptor AT1 de la angiotensina II con los antagonistas de este (ARA). Sin embargo, el impacto negativo del bloqueo dual que en general tienen en los electrolitos y la funcion renal ha frenado su generalizacion. Por la importancia fisiopatologica de la renina como paso regulador inicial del SRAA y la reciente posibilidad de su inhibicion con aliskiren, el primer inhibidor directo de la renina, se han abierto nuevas expectativas de un efecto diferenciador, al menos en algunos pacientes como los diabeticos, en sus efectos beneficiosos comparados con el bloqueo tradicional con IECA, ARA o su combinacion. Este articulo revisa los datos disponibles hasta el momento sobre los posibles efectos pleotropicos de los IDR que acompanan a la reduccion de la presion arterial en pacientes hipertensos con distintas formas de enfermedad cardiovascular, particularmente aquellas con mayor actividad del sistema renina-angiotensina intracelular, como es el caso de la diabetes tipo 2.