Vivencio Barrios Alonso

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.

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.

Control de la presión arterial en la población hipertensa española asistida en Atención Primaria. Estudio PRESCAP 2010

BACKGROUND AND OBJECTIVE This study was aimed at determining the degree of blood pressure (BP) control in hypertensive patients attended in primary care (PC) settings. PATIENTS AND METHOD Cross-sectional, multicenter study. Hypertensive patients ≥18 years under antihypertensive treatment attended in Spanish PC settings were included. BP control was regarded as optimum when BP values were <140/90mmHg in general population and <130/80mmHg in patients with diabetes, chronic renal disease or cardiovascular disease. BP control was also calculated for all patients when it was <140/90mmHg. RESULTS A total of 12,961 hypertensive patients (52.0% women) with a mean age of 66.3 (±11.4) years were included. A percentage of 46.3 (95% CI: 45.4-47.1) presented good systolic BP and diastolic BP control; 61.1% (IC 95%: 60.2-61.9) of patients presented good BP control<140/90. A percentage of 63.6% was treated with combination therapy (44.1% with 2 drugs, 19.5% with 3 or more). BP control was significantly higher in evening measurements (50.4%) than in morning measurements (45.1%), and in patients who had taken the treatment before the visit (47.9%) compared with those who had not (30.5%). Factors such as not taking the medication before the visit, heavy alcohol consumption and dyslipemia were the risk factors mostly associated with a poor BP control (P<.001). CONCLUSIONS Five out of 10 hypertensive patients treated in PC settings have an optimal BP control. The degree of control of arterial hypertension has improved with respect to the PRESCAP 2006 study.

Impacto de la presencia de enfermedad cardiovascular en el control de presión arterial y lípidos en la población hipertensa asistida en atención primaria

Objetivos. Determinar el impacto de la enfermedad cardiovascular (ECV) (insuficiencia cardiaca, cardiopatia isquemica, enfermedad cerebrovascular, insuficiencia renal y arteriopatia periferica) en el control de la presion arterial (PA) y del colesterol de las lipoproteinas de baja densidad (cLDL) en una poblacion de pacientes hipertensos. Diseno. Se analizo al subgrupo de pacientes incluidos en el estudio PRESCOT (estudio transversal de sujetos hipertensos asistidos en atencion primaria). Emplazamiento. En el estudio participaron 2.000 medicos de atencion primaria, en Espana. Participantes. Se analizo a 12.954 pacientes (el 50,1%, varones; media de edad, 62,1 ± 10,7 anos). Se considero buen control de PA cifras < 140/90 mmHg (< 130/80 mmHg en diabeticos), y de cLDL, los establecidos por ATP III para cada grupo de riesgo. Resultados. Del total de pacientes incluidos, 3.294 (25,43%) tenian ECV establecida (media de edad, 66,0 ± 10,2 anos; el 56,3%, varones). El 82,2% de los pacientes con ECV eran dislipemicos, y el 45,6%, diabeticos (frente al 72,3 y el 23,9%, respectivamente, del grupo de pacientes sin ECV; p < 0,0001). Los pacientes con ECV tomaban mas antihipertensivos (el 55,7 frente al 30,4% tomaban 2 o mas farmacos; p < 0,001) y mas hipolipemiantes (el 67,6 frente al 55,4%; p < 0,001) que los pacientes sin ECV. La PA se controlo en el 25,3% de los pacientes con ECV frente al 26,7% (p = 0,095), y el cLDL en el 13,3 frente al 40,2% (p < 0,001). El 7% de los pacientes con ECV tenian bien controlados ambos parametros frente al 18,7% (p < 0,001). Los principales factores relacionados con el mal control de PA fueron la diabetes (odds ratio [OR] = 1,20; intervalo de confianza [IC] del 95%, 1,10-1,30), el sedentarismo (OR = 1,19; IC del 95%, 1,11-1,29) y el sexo femenino (OR = 1,12; IC del 95%, 1,02-1,23), entre otros, mientras que para el control del cLDL, los antecedentes familiares de ECV (OR = 1,34; IC del 95%, 1,24-1,46), el sedentarismo (OR = 1,28; IC del 95%, 1,18-1,39) y la diabetes (OR = 1,15; IC del 95%, 1,06-1,26), entre otros. Conclusiones. El control de la PA y del cLDL es muy pobre en la poblacion hipertensa con ECV. Unicamente el 7% tienen ambos parametros bien controlados.

Prevalencia de la enfermedad renal crónica oculta en la población dislipémica asistida en atención primaria. Estudio LIPICAP.

BACKGROUND AND OBJECTIVE: Information about the prevalence of chronic kidney disease (CKD) in population treated in primary care (PC) is scarce. The aim of this study was to determine undetected CKD prevalence in dyslipidemic population measuring creatinine clearance according to the Cockcroft-Gault equation corrected for surface area. PATIENTS AND METHOD: Cross-sectional study including patients with diagnosis of dyslipidemia selected by consecutive sampling in PC. CKD was diagnosed when the glomerular filtration rate (GFR) was < 60 ml/min/1.73 m2. We assessed sociodemographic and clinical data, cardiovascular risk factors, coronary disease risk categories, dyslipidemia characteristics, functional CKD stage, and pharmacological treatments. RESULTS: The sample included 5,990 patients (50.2% women). The mean (standard deviation) age was 60.9 (11.1) years. The main reason for iclusion was hypercholesterolemia (65%), followed by mixed hyperlipidemia (26.4%), low high density lipoproteins (HDL)-cholesterol (4.9%) and hypertrigliceridemia (3.7%). According to the Cockcroft-Gault equation, CKD prevalence was 16.2% (95% confidence interval, 15.3-17.1) and it was significantly higher in women (22.7%) than in men (9.8%) (p < 0.0001). Patients with CKD were older compared with patients with normal GFR, and had higher systolic blood pressure, glucose and HDL-cholesterol (p < 0.001), as well as lower levels of total cholesterol, low density lipoproteins-cholesterol, and triglycerides (p < 0.01). The probability of presenting CKD was related to female gender, age, and lower body mass index. CONCLUSIONS: The LIPICAP study results indicate that almost 20% of PC dyslipidemic patients in Spain present undetected CKD when the GFR is measured according to the Cockcroft-Gault equation corrected for surface area.

Prevención de la fibrilación auricular en el paciente hipertenso

Un porcentaje importante de pacientes con hipertension arterial (HTA) tienen ademas fibrilacion auricular (FA). La presencia de HTA incrementa el riesgo de desarrollar FA, y la presencia de esta empeora el pronostico de los pacientes con HTA. La posibilidad de que algunos farmacos interfieran con las vias de transduccion especificas que facilitan la aparicion de FA resulta prometedora. Hasta la fecha, parece que el mecanismo mas efectivo es la inhibicion del sistema renina-angiotensina-aldosterona mediante la utilizacion de inhibidores de la enzima conversiva de la angiotensina (IECA) o antagonistas de los receptores de la angiotensina II (ARA-II). Este enfoque se encuentra actualmente bajo una activa investigacion. Algunos ensayos clinicos han evaluado la efectividad de estos farmacos en la prevencion de la FA. Los datos muestran que ambas clases de farmacos, IECA y ARA-II, parecen efectivos en la prevencion de la FA. Sin embargo, la falta de ensayos clinicos aleatorizados y doble ciego especificos limita su aplicacion, salvo que exista otra indicacion para su uso.

Comments on the 2016 ESC Guidelines for the Management of Atrial Fibrillation.

In line with the methodology recommended by the Guidelines Committee of the Spanish Society of Cardiology,1 the present article discusses the innovations and most controversial aspects of the recent guidelines for atrial fibrillation (AF).2 Notably, of 154 recommendations, only 23 (15%) have a level of evidence A and 80 (52%) a level of evidence B, confirming the need for further clinical research into this condition. Some of the most novel or relevant aspects of the guidelines are summarized in Table, in conjunction with some critical comments.

Update for 2014 on clinical cardiology, geriatric cardiology, and heart failure and transplantation.

In the present article, we review publications from the previous year in the following 3 areas: clinical cardiology, geriatric cardiology, and heart failure and transplantation. Among the new developments in clinical cardiology are several contributions from Spanish groups on tricuspid and aortic regurgitation, developments in atrial fibrillation, syncope, and the clinical characteristics of heart disease, as well as various studies on familial heart disease and chronic ischemic heart disease. In geriatric cardiology, the most relevant studies published in 2014 involve heart failure, degenerative aortic stenosis, and data on atrial fibrillation in the geriatric population. In heart failure and transplantation, the most noteworthy developments concern the importance of multidisciplinary units and patients with preserved systolic function. Other notable publications were those related to iron deficiency, new drugs, and new devices and biomarkers. Finally, we review studies on acute heart failure and transplantation, such as inotropic drugs and ventricular assist devices.

Antiagregación: resistencia a fármacos tradicionales y papel de los nuevos antiplaquetarios

Platelet aggregation plays a key role in the development of major cardiovascular events (MACE) related to atherothrombosis. Since the appearance of coronary stenting, the importance of measuring and modulating platelet activity has considerably increased in the scientific literature during the last decade. Double antiplatelet therapy with aspirin and clopidogrel administrated to stent carriers has widely demonstrated its efficacy in the prevention of MACE compared with aspirin alone. These benefits are also present when a conservatory approach is chosen for acute coronary syndrome management. However, there are an important number of patients who develop MACE despite optimal dual antiplatelet therapy, most likely related to an incomplete platelet activity inhibition. Many studies suggest an important inter-individual variability in the response to the drugs, maybe related, at least in part, to the use of different assessment techniques of platelet aggregation. Other authors suggest an incomplete platelet inhibition as a possible explanation for the presence of MACE in patients under optimal antiplatelet therapy. Resistance to usual drugs has become a clinically relevant issue that requires an individual approach where new antiplatelet agents, such as prasugrel or ticagrelor, could play an important role as stated in current consensus documents.

Prevalencia de enfermedad renal crónica en mujeres hipertensas de edad avanzada atendidas en atención primaria. Estudio MERICAP

BACKGROUND AND OBJECTIVES Information about the prevalence of chronic kidney disease (CKD) in the population treated in primary care is scarce. The aim of this study was to assess the prevalence of CKD in Spanish hypertensive women aged 64 years or older, and to determine possible associated factors. PATIENTS AND METHOD Cross-sectional study including women with a diagnosis of hypertension selected by consecutive sampling in primary care. CKD was diagnosed when glomerular filtration rate was<60 ml/min/1.73 m(2) (MDRD). We assessed sociodemographic and clinical data, cardiovascular risk factors, and the presence of cardiovascular disease. RESULTS The sample included 3782 women with a mean age of 73.6 ± 6.1 years. CKD (glomerular filtration rate<60 ml/min/1.73 m(2) was present in 53.4% (95% CI: 51.8-55.0). Masked CKD (serum creatinine<1.2mg/dl) was present in 25.7% (95% CI: 26.3-29.1). The prevalence increased with age (51% in those younger than 75 and 60.7% in women older than 84 (P<.001). With respect to those with normal renal function, hypertensive women having CKD were older, showed higher values of blood pressure, and had more frequently dyslipidemia, elevated plasma glucose, target organ damage and cardiovascular disease (P<.001). In a multivariate analysis, CKD was associated with coronary heart disease (OR: 1.9), hyperglycemia (OR: 1.6), hypertriglyceridemia (OR: 1.5), and elevated diastolic blood pressure (OR: 1.4). CONCLUSIONS More than half of hypertensive women aged 64 years have CKD and of these about half have normal creatinine values.