Vicente Pallarés

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.

Prevalencia de fibrilación auricular y uso de fármacos antitrombóticos en el paciente hipertenso ≥ 65 años. El registro FAPRES

INTRODUCTION AND OBJECTIVES Age and arterial hypertension are two of the main factors associated with atrial fibrillation and an increased risk of embolism. The objective of this study was to determine the prevalence of atrial fibrillation and the extent of antithrombotic use in hypertensive patients aged ≥65 years in the Spanish region of Valencia. METHODS Each study investigator enrolled the first three hypertensive patients aged ≥65 years who came for a consultation on the first day of each week for 5 weeks. Each patients risk factors, history of cardiovascular disease, CHADS(2) score and medical treatment were noted and an ECG was recorded. Data were analyzed centrally. A patient was regarded as having atrial fibrillation if it was observable on the ECG or reported in medical records. RESULTS The study included 1,028 hypertensive patients with a mean age of 72.8 years. Overall, 10.3% had atrial fibrillation: in 6.7%, it was observable on the ECG while 3.6% were in sinus rhythm but had a history of the condition. Factors associated with atrial fibrillation were age, alcohol intake, structural heart disease and glomerular filtration rate. In total, 76.2% of patients with ECG evidence of atrial fibrillation and a CHADS(2) score >1 were taking anticoagulants compared with 41.7% of those who had a history of the condition but were currently in sinus rhythm. CONCLUSIONS The prevalence of atrial fibrillation in our group of hypertensives was 10.3%; in 1.7%, it was previously undiagnosed. Antithrombotic use was high in patients with current atrial fibrillation, but lower in those who had experienced an episode previously.

Serum lipid profiles and their relationship to cardiovascular disease in the elderly: the PREV-ICTUS study.

ABSTRACT Objective: To assess the relationship between different serum lipid profiles and the prevalence of established cardiovascular disease (CVD) in an elderly population. Research design and methods: An analysis was undertaken of the PREV-ICTUS population-based study on Spanish subjects aged ≥ 60 years. The following definitions were used: abnormal LDL cholesterol (LDL-C): ≥ 130 mg/dl (≥ 3.3 mmol/L), or ≥ 100 mg/dl (≥ 2.5 mmol/L) in those with diabetes or CVD, or treatment with any hypolipidaemic drug; low HDL cholesterol (HDL-C): < 40 mg/dl (< 1 mmol/L) (men), or < 50 mg/dl (< 1.3 mmol/L) (women), and abnormal triglycerides (TG): ≥ 150 mg/dl (≥ 1.7 mmol/L) or treatment with fibrates. We defined eight groups: A (normal lipid profile), B (isolated abnormal LDL-C), C (isolated abnormal TG), D (isolated low HDL-C), E (abnormal LDL-C and HDL-C), F (abnormal LDL-C and TG), G (abnormal TG and HDL-C), H (abnormal LDL-C, HDL-C and TG). A multivariate analysis was performed to assess the relationship between each lipid profile and CVD. Results: A total of 6010 subjects (mean age 71.7 years, 53.5% women, 73.2% with hypertension, 29.2% with diabetes mellitus, 24.3% with CVD), were included in the analysis. LDL-C elevation was present in 78.1%, 23.3% had low HDL-C and 35.7% abnormal TG. Combined dyslipidaemias were frequent (40.3%). Odds ratios (95% confidence intervals) for CVD, compared with those with a normal lipid profile, were 2.07 (1.24–3.46) for abnormal HDL-C ( p = 0.005), 4.09 (3.10–5.39) for abnormal LDL-C; 6.41 (4.59–8.95) for abnormal LDL-C plus HDL-C, 5.33 (3.98–7.14) for abnormal LDL-C plus TG and 7.59 (5.51–10.5) for those with the three parameters altered (all p < 0.001). Compared with those with isolated LDL-C elevation, those with abnormal LDL-C plus HDL-C had 1.57 (1.30–1.97) higher odds of having CVD ( p < 0.001), the figures being 1.30 (1.11–1.53) for those with abnormal LDL-C plus TG and 1.86 (1.52–2.28) for those with abnormal LDL-C, TG plus HDL-C ( p < 0.001). Conclusions: Lipid abnormalities are frequent in the elderly, and are associated with the presence of CVD. Low HDL-C and/or abnormal TG levels, when added to abnormal LDL-C, are associated with a higher prevalence of CVD, suggesting the advisability of a comprehensive lipid evaluation and treatment earlier in life.

Rationale and methods of the cardiometabolic valencian study (escarval-risk) for validation of risk scales in mediterranean patients with hypertension, diabetes or dyslipidemia

BackgroundThe Escarval-Risk study aims to validate cardiovascular risk scales in patients with hypertension, diabetes or dyslipidemia living in the Valencia Community, a European Mediterranean region, based on data from an electronic health recording system comparing predicted events with observed during 5 years follow-up study.Methods/DesignA cohort prospective 5 years follow-up study has been designed including 25000 patients with hypertension, diabetes and/or dyslipidemia attended in usual clinical practice. All information is registered in a unique electronic health recording system (ABUCASIS) that is the usual way to register clinical practice in the Valencian Health System (primary and secondary care). The system covers about 95% of population (near 5 million people). The system is linked with database of mortality register, hospital withdrawals, prescriptions and assurance databases in which each individual have a unique identification number. Diagnoses in clinical practice are always registered based on IDC-9. Occurrence of CV disease was the main outcomes of interest. Risk survival analysis methods will be applied to estimate the cumulative incidence of developing CV events over time.DiscussionThe Escarval-Risk study will provide information to validate different cardiovascular risk scales in patients with hypertension, diabetes or dyslipidemia from a low risk Mediterranean Region, the Valencia Community.

La troponina T como posible marcador del daño miocárdico menor. Su aplicación en el miocardio aturdido y en la isquemia silente

Introduccion y objetivos La necesidad de disponer de marcadores bioquimicos mas precoces y de mayor especificidad y sensibilidad para la deteccion del infarto agudo de miocardio ha impulsado la continua evaluacion de metodos alternativos a la isoenzima MB de la creatincinasa (CK-MB). Nuestro objetivo ha sido conocer la utilidad de las determinaciones de la troponina T (TnT), frente a otros marcadores, para detectar procesos de isquemia transitoria en ausencia de necrosis. Metodos Se ha utilizado un modelo canino experimental de isquemias muy breves y repetidas (series I y II), y un modelo de isquemia unica de 15 min de duracion, y 60 min de reperfusion (serie III). En la serie I el oclusor coronario se situo en la zona proximal de la arteria coronaria descendente anterior (DA), y en las series II y III en la zona distal de la DA. Las muestras de plasma se han obtenido de sangre venosa periferica (SVP) y coronaria (SVC), en distintas fases del estudio. Las concentraciones de adenosina, TnT, CK y CK-MB se determinaron por procedimientos bioquimicos. Se estudiaron los parametros de funcion regional y general, y se realizo un estudio anatomopatologico para conocer el tamano del area de riesgo. Resultados En la serie I se produjo hipocinesia que persistio 10 dias, y en las series II y III la funcion regional se habia recuperado a las 24 h. Las concentraciones de CK y CK-MB aumentaron ya significativamente tras la apertura del torax (p Conclusiones La troponina T se eleva en ausencia de necrosis, preferentemente cuando los episodios isquemicos son prolongados.

Is there a predictive profile for clinical inertia in hypertensive patients? An observational, cross-sectional, multicentre study.

AbstractBackground: Some studies have described a large number of hypertensive patients who are followed by a primary care physician without achieving adequate blood pressure (BP) control but whose treatment nevertheless is not intensified. It is not known whether physicians are aware of this clinical inertia and what factors are associated with this problem. Objective: The aim of this study was to describe the factors associated with clinical inertia in hypertensive patients. Methods: This was an observational, cross-sectional, multicentre study conducted in a network of primary care centres and hospital hypertension units in Spain. Using a consecutive sampling approach, 512 physicians selected 5077 hypertensive patients in whom they suspected poor BP control after chart review. The main variables documented were BP control and cardiovascular risk according to European Society of Hypertension guidelines, changes in treatment after visit, type of treatment, and healthcare setting. A binomial logistic regression multivariate analysis, adjusted for physician, was performed. Results: Of the selected patients, 70.9% had poor BP control according to measurements taken in the physician’s office, and in 1499 (42.1%) of those poorly controlled patients, treatment was not intensified (clinical inertia). Factors associated with clinical inertia were as follows: being seen at a primary care centre (p<0.001), not having left ventricular hypertrophy (p<0.001) or microalbuminuria (p<0.001), taking fixed-dose (p=0.049) or free-dose (p=0.001) combination therapy, BP measured in other settings (nurse’s office, patient’s home) than the physician’s office (p=0.034) or the pharmacy (p=0.019), older age (p=0.032), and lower systolic (p<0.001) and diastolic (p<0.001) BP. Of the hypertensive patients with clinical inertia, 90.2% (95% CI 88.7, 91.7) had high cardiovascular risk. Conclusions: Clinical inertia was associated with a profile that included older age, lack of co-morbid conditions and being seen at a primary care centre.

Prevalence of Atrial Fibrillation and Use of Antithrombotics in Hypertensive Patients Aged ≥65 Years. The FAPRES Trial

INTRODUCTION AND OBJECTIVES Age and arterial hypertension are two of the main factors associated with atrial fibrillation and an increased risk of embolism. The objective of this study was to determine the prevalence of atrial fibrillation and the extent of antithrombotic use in hypertensive patients aged >or=65 years in the Spanish region of Valencia. METHODS Each study investigator enrolled the first three hypertensive patients aged >or=65 years who came for a consultation on the first day of each week for 5 weeks. Each patients risk factors, history of cardiovascular disease, CHADS2 score and medical treatment were noted and an ECG was recorded. Data were analyzed centrally. A patient was regarded as having atrial fibrillation if it was observable on the ECG or reported in medical records. RESULTS The study included 1,028 hypertensive patients with a mean age of 72.8 years. Overall, 10.3% had atrial fibrillation: in 6.7%, it was observable on the ECG while 3.6% were in sinus rhythm but had a history of the condition. Factors associated with atrial fibrillation were age, alcohol intake, structural heart disease and glomerular filtration rate. In total, 76.2% of patients with ECG evidence of atrial fibrillation and a CHADS2 score >1 were taking anticoagulants compared with 41.7% of those who had a history of the condition but were currently in sinus rhythm. CONCLUSIONS The prevalence of atrial fibrillation in our group of hypertensives was 10.3%; in 1.7%, it was previously undiagnosed. Antithrombotic use was high in patients with current atrial fibrillation, but lower in those who had experienced an episode previously.

Factors influencing pathological ankle-brachial index values along the chronic kidney disease spectrum: the NEFRONA study

Background: The ankle‐brachial index (ABI) is widely used to diagnose subclinical peripheral artery disease (PAD) in the general population, but data assessing its prevalence and related factors in different chronic kidney disease (CKD) stages are scarce. The aim of this study is to evaluate the prevalence and associated factors of pathological ABI values in CKD patients. Methods: NEFRONA is a multicentre prospective project that included 2445 CKD patients from 81 centres and 559 non‐CKD subjects from 9 primary care centres across Spain. A trained team collected clinical and laboratory data, performed vascular ultrasounds and measured the ABI. Results: PAD prevalence was higher in CKD than in controls (28.0 versus 12.3%, P < 0.001). Prevalence increased in more advanced CKD stages, due to more patients with an ABI ≥1.4, rather than ≤0.9. Diabetes was the only factor predicting both pathological values in all CKD stages. Age, female sex, carotid plaques, higher carotid intima‐media thickness, higher high‐sensitivity C‐reactive protein (hsCRP) and triglycerides, and lower 25‐hydroxi‐vitamin D were independently associated with an ABI ≤0.9. Higher phosphate and hsCRP, lower low‐density lipoprotein (LDL)‐cholesterol and dialysis were associated with an ABI ≥1.4. A stratified analysis showed different associated factors in each CKD stage, with phosphate being especially important in earlier CKD, and LDL‐cholesterol being an independent predictor only in Sage 5D CKD. Conclusions: Asymptomatic PAD is very prevalent in all CKD stages, but factors related to a low or high pathological ABI differ, revealing different pathogenic pathways. Diabetes, dyslipidaemia, inflammation and mineral‐bone disorders play a role in the appearance of PAD in CKD.

Twenty-four-hour ambulatory heart rate and organ damage in primary hypertension

Abstract Background: The relationship between basal heart rate (HR) and the occurrence of myocardial ischemia, sudden death, cardiovascular mortality have been described. Therefore, further studies are warranted to evaluate the behaviour of heart rate in different scenarios. We sought to determine whether ambulatory heart rate is associated with the presence of target organ damage (TOD) in hypertensive patients. Patients and Methods: Crossectional study of essential hypertensive patients in whom a twenty-four hour ambulatory blood pressure monitoring (ABPM) was performed. The relationship between TOD and 24 hour ambulatory heart rate (HR) was analyzed. Results: Five hundred and sixty-six patients with arterial hypertension were included (55.8% male, mean age 59.9 ± 14.2 years). 15% were smokers, 62.2% had dyslipidemia, 18.4% diabetes mellitus. Heart rate values were higher during activity as compared to the resting period (72.8 vs 63.3 bpm, p < 0.001). Heart rate, in both periods, was not associated with the presence of TOD. Nevertheless, the patients with nocturnal HR ?65 bpm have high risk and a high prevalence of TOD. This relationship was also present in multivariate analysis (HR 2.41; CI 95% 1.41–4.11; p=0.001). Conclusion: An elevated nocturnal HR, ?65 bpm, obtained with ABPM registry, is associated with the presence of TOD in hypertensive patients. ABPM is a powerful tool for hypertensive patients not only to monitor BP control but also to obtain information on HR which may provide additional information about current and future cardiovascular risk.

Renal function and attributable risk of death and cardiovascular hospitalization in patients with cardiovascular risk factors from a registry-based cohort: the Estudio Cardiovascular Valencia-risk study

Background: Information about the attributable risk associated with renal dysfunction in patients with cardiovascular risk factors is lacking. Objective: We aimed to estimate the attributable risk associated with chronic kidney disease Epidemiology Collaboration-estimated glomerular filtration rate (eGFR), for all-cause mortality, and cardiovascular hospitalization. Design, setting, and participants: Prospective study of study participants with cardiovascular risk factors in 2008–2012. We included 52 007 cardiovascular disease-free men and women aged 30 years or older with hypertension, diabetes, or dyslipidemia, who underwent routine health examinations in primary care. Results: A total of 6639 (12.8%) patients had eGFR below 60 ml/min per 1.73 m2 and among them 1782 (3.4%) had 45 ml/min per 1.73 m2 or lower. During an average follow-up time of 3.2 years, 54.12 deaths, 99.98 coronary heart disease (CHD) hospitalizations, and 90.64 stroke hospitalizations/10 000 person-years were recorded. The population attributable risks associated with having a GFR lower than 60 ml/min per 1.73 m2 were 6.9% (95% confidence interval = 2.07, 10.65) for all-cause mortality, 6.8% (4.3, 9.4) for CHD hospitalization, and 4.1% (1.02, 7.00) for stroke hospitalization. Participants with increasing number of cardiovascular risk factors displayed increasing population attributable risks associated to a GFR less than 60 ml/min per 1.73 m2 for all-cause mortality and CHD (P heterogeneity 0.002 and 0.05, respectively). Conclusion: In a large general practice cohort of patients with cardiovascular disease risk factors, decreasing eGFR levels were associated with additional attributed risk of mortality and cardiovascular disease. Our findings underscore that intensified efforts are needed to reduce the cardiovascular disease burden associated to chronic kidney disease.