Un análisis de la situación actual de las especialidades médicas en Chile / The present situation of medical specialties in Chile

During the fifties and sixties, physicians were mostly prepared as general practitioners. However, the progress in scientific knowledge and the introduction of complex technologies required the training of specialists. A number of sub specialties have been progressively added to the four basic specialties, namely Internal Medicine, Pediatrics, Obstetrics and Gynecology and General Surgery. The Post Graduate Schools of the traditional universities devised courses and training periods to teach these sub specialties. The Association of Medicine Schools has been in charge of the accreditation of the new training centers. Since the training of new specialists required the collaboration of hospitals of the public National Health Service, there is a special commission that coordinates the relationships between teaching requirements and medical attention in these hospitals. There is still a controversy on the exact proportion of general practitioners and specialists that the country needs, the role of Family Practice and the role of prevention and health promotion

Perfil del hipertenso adulto mayor tratado / Morbidity and mortality of treated elderly hypertensive patients

Background: There is concern about the consequences that hypertension has on the well being and mortality of elderly people. Aim: To compare the morbidity and mortality of young and old treated hypertensive subjects. Material and methods: Retrospective analysis of hypertensive subjects treated and followed for a period of 10 ñ 9 years. Subjects that started treatment at an age of less than 65 years and those that started treatment after 65 years of age, were analyzed separately. The antihypertensive drugs used for treatment and blood pressure reduction were similar in both groups. Results: Subjects that started treatment after 65 years of age (157 females and 133 males) had lower serum cholesterol levels and a higher prevalence of end organ damage than their younger counterparts. Women over 65 had a higher body mass index than women of less than 65. Males over 65 years had a higher prevalence of diabetes than younger males. Mortality and complications of hypertension were higher in subjects that started treatment after 65 years of age. Conclusions: The higher mortality of subjects that start hypertensive treatment after 65 years of age, is indicative of the need to detect and treat hypertension at the earliest possible moment

Optimización de la reducción de la presión arterial en hipertensos esenciales / Optimization of antihypertensive treatment

Background: A blood pressure below or equal to 140/90 mmHg, the aim of antihypertensive treatment, is rarely achieved. Only 16 percent of patients controlled by our group reach this goal. Aim: To analyze the causes of suboptimal treatment and to assess the effects of an optimization of antihypertensive therapy. Patients and methods: A random sample of 160 patients was analyzed and followed during one year. Results: Sixty six patients (41 percent) had a normal blood pressure, maintained during the first three months of follow up. The main causes of suboptimal reduction of blood pressure in the remaining 94 patients were an incorrect prescription or dosage of medications in 37.5 percent, lack of compliance in 34 percent, insufficient delivery of medications by the health service in 24 percent and secondary effects of drugs in 5 percent. When these factors were corrected, blood pressure normalized in 41 of them. In other 37, a reduction of 5 mmHg or more in blood pressure, was obtained. The most frequent changes introduced were modifications in dosage and addition of a new medication. Therefore, in 90 percent of these patients, blood pressure was reduced or normalized. Conclusions: A correct identification of the cause of antihypertensive treatment failure is imperative. The correction of this cause leads to a further reduction in blood pressure in 90 percent of those subjects with suboptimal treatment

Morbimortalidad de la hipertensión arterial esencial tratada en un seguimiento de 26 años / Mortality and morbidity of treated essential arterial hypertension: a 26 years follow up

Background: Treatment has a definitive impact on mortality in hypertension. The magnitude of blood pressure reduction, the type of drug used and the associated risk factors may modulate the effect of treatment on mortality. Aim: To report the effects of treatment of essential hypertension, in a cohort followed for up to 26 years. Patients and methods: A cohort of 1,172 essential hypertensive patients followed up to 26 years. Patients were treated with different antihypertensive drugs, alone or in combination (diuretics, beta blockers, calcium channel blockers and angiotensin converting enzyme inhibitors) according to international rules and consensus. Subjects were followed until death or loss from follow-up. Blood pressure reduction was aimed to obtain figures near 140/ 90 mm Hg. Causes of death and complications were obtained from hospital records, phone and death certificates. Survival was studied using life tables (Kaplan Meier method and intention to treat analysis) and Cox proportional hazard analysis. Results: Initial blood pressure dropped significantly from 181/109 to 154/92 mm Hg, p <0.001. Mean follow-up time was 10.6ñ6.1 years. There were 143 cardiovascular deaths, 142 acute myocardial infarctions, 101 strokes, 83 subjects had cardiac failure and 49 had renal failure. The observed rates were 0.92 percent per year for cardiovascular mortality, 1.36 percent per year for coronary heart disease, 0.94 percent per year for stroke. Conclusions: Our mortality rate is lower than that found in classical randomized studies but similar or slightly higher than the more recent ones. Morbidity rates were also very similar. Except for mortality rate, frequency of complications did not change in comparison to our previous report after 15 year of follow up. Aging did not seem to negatively influence mortality rates in adequately treated hypertensive patients

Factores predictores de riesgo de morbimortalidad en hipertensos esenciales seguidos 25 años / Risk factors for morbidity and mortality in subjects with essential hypertension, followed for 25 years

Background: Among hypertensive patients, other risk factors for mortality and morbidity, besides blood pressure, must be considered when therapeutic decisions are done. Aim: To assess the incidence and relevance of cardiovascular risk factors in a cohort of patients with essential hypertension. Material and methods: A cohort of 1.072 treated patients with essential hypertension was followed for a period up to 25 years. Four hundred eighty six were men and 586 were women, age ranged from 31 to 70 years. At entry, 56 percent of subjects did not have any organic complications associated to hypertension (stage I WHO criteria), 30 percent had mild alterations (Stage II) and 14 percent had major complications (myocardial infarction, stroke, heart failure or renal failure). Likewise, 43.8 percent had mild, 14.5 percent, moderate and 41.7 percent, severe hypertension. Patients were treated with monotherapy or combined therapy based on diuretics, beta blockers, calcium antagonists and angiotensin converting enzyme inhibitors. Goal of therapy was 140/90 mm Hg. Risk factors associated diseases and complications were registered carefully. Causes of death were obtained from hospital records and death certificates. Mortality was analyzed using life tables (intention to treat method included). Results: Blood pressure dropped significantly during follow up from a mean of 182/110 to 154/92 mm Hg. During follow up, 143 patients died and 429 complications (lethal or non lethal) were recorded. Twenty four percent of patients smoked, 24 percent reported alcohol intake, 56 percent had hypercholesterolemia, 11 percent were obese, 13 percent had diabetes and 3 percent had gout. The proportional hazard model showed that the existence of previous complications, the presence of more than 3 risk factors, and age over 60 and mean systolic and diastolic pressure during therapy, were independent and significant risk factors for mortality. Conclusions: The incidence of risk factors among our hypertensive patients is very similar to that of other national or international cohorts

Seguridad y eficacia de celiprolol en hipertensos con enfermedad pulmonar obstructiva crónica / Safety and efficacy of celiprolol in patients with chronic obstructive lung disease

Background: Third generation beta blockers have an intrinsic simpatico-mimetic activity and are cardioselective. Therefore, they should not have adverse bronchial effects and could even have a slight bronchodilator activity. Aim: To test the efficacy and safety of celiprolol in hypertensive patients with chronic obstructive lung disease. Patients and methods: Uncomplicated hypertensive patients with chronic obstructive lung disease received celiprolol during 12 weeks. They were subjected to monthly clinical assessment and ventilatory function was measured on the basal period and at the end of the trial. Results: During the study period, blood pressure fell significantly from 179ñ6/112ñ8 to 161ñ4,7/98ñ1.6 mmHg. No changes were observed in forced expiratory volume in 1 s or in forced expiratory flow between 25 and 75 percent of the vital capacity. No subjective changes in respiratory function were reported during the trial. Conclusions: No changes in ventilatory function were observed in these patients with chronic obstructive lung disease, treated with celiprolol during 12 weeks

Recomendaciones sobre el uso de la monitorización ambulatoria de presión arterial: documento de consenso de la Sociedad Chilena de Hipertensión / Recommendations for the use of continuous ambulatory blood pressure monitoring: consensus document of the chilean hypertension society

Continuous ambulatory blood pressure monitoring is a diagnostic technique devised as a consequence of the great variations in blood pressure measurements. It allows multiple daily measurements, nocturnal monitoring, avoids the stress of blood pressure measurements, gives a picture of pressure behavior during 24 hours and reduces observer related errors. The equipment used must be accurate and validated using international protocols. Accepted indications for continuous ambulatory blood pressure monitoring are white coat hypertension, episodic hypertension, resistance to medications and assessment of symptoms or autonomic dysfunction. Other indications with less clear cut usefulness, are high risk cardiac, renal or pregnant patients and an accurate blood pressure control. We describe equipment calibration, elements that must be considered in the reports, result interpretation and conclusions. Normal blood pressure ranges for children and pregnant women are also reported

La hipertensión arterial mineralocorticoidea: ¿una nueva forma de hipertensión secundaria? / Mineralcorticoid hypertension: a new form of secondary hypertension?

There is a group of genetic alterations that are phenotypically related to mineralocorticoid hypertension. They include, among others, some forms of primary hyperaldosteronism and of hyporeninemic aldosteronism that can be specifically treated, thus becoming secondary forms of hypertension. These could account for 10 to 15 percent of cases of essential hypertension, but more studies are required to accept these figures. The screening for these forms of hypertension should be done measuring aldosterone levels and plasma renin activity. An aldosterone/plasma renin activity ratio over 25 should lead to the suspicion of the disease. However, the cost effectiveness of the widespread measurement of these parameters would be very low. Therefore it is mandatory to determine the epidemiological features of these diseases to perform a selective screening among subjects with essential hypertension

Avances en el tratamiento de la hipertensión arterial / Advances in the treatment of hypertension

This review describes the most recent advances in the treatment of essential hypertension, from non pharmacological measures and changes in lifestyles to new blood pressure lowering drugs. A blood pressure lower tha 130/80 mmHg, has been established as the new goal for optimal treatment. In the last two consensus a new range of blood pressure, denominated Òhigh normalÓ (130-139/85-89 mm Hg) has been incorporated. People with other cardiovascular risk factors and a blood pressure within this range, should be treated. The HOT study recently demonstrated that a reduction to less than 90 mmHg of diastolic pressure is associated with a reduction on cardiovascualr morbidity and mortality. The importance of the peak/valley relationship in the election of anti hypertensive medication is also reviewd

Efecto comparativo de policosanol con dos inhibidores de la HMG-CoA reductasa en el tratamiento de la hipercolesterolemia tipo II / Comparative effects of policosanol and two HMG-CoA reductase inhibitors on type II hypercholesterolemia

Background: Policosanol is a new cholesterol lowering agent derived from sugar cane. Aim: To compare the cholesterol lowering efficacy of policosanol with HMG CoA inhibitors. Patients and methods: Patients with a LDL cholesterol over 160 mg/dl were studied. If, after 6 weeks of diet, cholesterol persisted elevated, they were doubly blind randomized to receive policosanol 10 mg/day (55 patients), lovastatin 20 mg/day (26 patients) or simvastatin 10 mg/day (25 patients). Serum cholesterol was measured again after 8 weeks of therapy. Results: Initial demographic and laboratory data were similar among treatment groups. A 24 percent LDL cholesterol reduction was obtained with policosanol, compared with a 22 percent reduction with lovastatin and a 15 percent reduction with simvastatin. HDL cholesterol significantly increased in patients on policosanol and did not change in the other treatment groups. Adverse effects of policosanol were mild and unspecific. No changes in hepatic enzymes were observed. Conclusions: Policosanol is a safe and effective cholesterol reducing agent

Avances en el tratamiento de la hipertensión arterial / Advances in the treatment of arterial hypertension

El tratamiento de la hipertensión arterial tiene por objetivos el reducir las cifras tensionales y disminuir la morbi-mortalidad de la afección. En los últimos años se ha agregado además el control de los factores de riesgo involucrados en los estilos de vida. La clasificación actualmente aceptada de las cifras tensionales arterial reconoce como valores óptimos < 120-80 mmHg; normales < 130-85; normales altos 130-139/85-90 mmHg y divide las hipertensiones en grado 1 (140-159/90-99 mmHg), grado 2 (160-179/100-109 mmHg) y grado 3 (> 180 >110 mmHg). Se destaca la importancia de las medidas terapéuticas no farmacológicas orientadas a modificar el estilo de vida (reducción de peso y del sedentarismo; disminución de ingesta de alcohol y sodio). Se enfatizan los avances realizados en el campo de los tratamientos farmacológicos, los que deben iniciarse en forma progresiva de acuerdo a la respuesta obtenida y a los efectos colaterales observados, siendo el ideal la administración de monoterapia en monodosis (una sola dosis diaria). Los fármacos actualmente disponibles se analizan por familias: diuréticos; betabloqueadores; bloqueadores adrenégicos alfa 1; antagonistas del calcio; inhibidores de la enzima de conversión de la angiotensina; bloqueadores de los receptores AT-1 de la angiotensina. Finalmente se presenta una estrategia terapéutica que se basa en los factores de riesgo y la severidad de la hipertensión

Nuevos estudios multicéntricos en hipertensión arterial / New multicentric studies in arterial hypertension

Prospective, randomized and long term multicentric studies, published since 1988, on the effects of pharmacological or non pharmacological treatment of hypertension are analyzed. Former studies, performed between 1967 and 1987, are devoted, in chronological order, to special populations or to forms of hypertension not sufficiently studied previously (elders and isolated systolic hypertension), using classical pharmacological treatments such as diuretics and beta blockers. Their results confirm the reduction in mortality obtained using such therapies. Ensuing studies, focused on the analysis of new drugs such as calcium antagonists and angiotensin converting enzyme inhibitors, also demonstrated a reduction in cardiovascular risk, even in severely damaged populations. Thereafter, meta analysis of new pharmacological treatments and of non pharmacological therapies such as sodium restriction, weight reduction, avoidance of alcohol intake, calcium and potassium supplementation have appeared. These studies have emphasized the importance of prevention through changes in lifestyles. Their positive, although modest results, encourage the assessment of long term preventive and therapeutic measures in hypertension

Influencia de factores de riesgo y terapia farmacológica en la mortalidad de hipertensos esenciales / Influence of pharmacological treatment and risk factors on mortality of hypertensive patients

Background: The V JNC consensus stated that although new antihypertensive agents, such as angiotensin converting enzyme inhibitors and calcium channel blockers, are considered safer drugs, there is no firm evidence from large controlled trials that these drugs are associated with a lower cardiovascular mortality. Aim: To study the association between cardiovascular risk factors, blood pressure levels, pharmacological treatment and mortality in a group of hypertensive patients followed at an hypertension outpatient clinic. Patients and methods: Patients with essential hypertension were treated with different antihypertensive medications, according to physicians criteria, and controlled until death or loss from follow up. Causes of death were obtained from hospital records and death certificates. Survival was analyzed using life tables, comparisons between groups of patients were done using chi square or a Cox's proportional hazards model. Results: Three hundred thirty nine hypertensive patients aged 33 to 80 years old were followed for a mean period of 9.8 ñ 4.9 years. Eighty six were treated with beta blockers, 64 with diuretics, 133 with calcium antagonists and 56 with ACE inhibitors. Blood pressure dropped similarly with all medications. During follow up, 79 patients died. Life table analysis showed that patients with a history of angina, diabetes or myocardial infarction had higher mortality rates. Similarly, patients treated with beta blockers and diuretics had higher mortality than patients treated with calcium antagonists or angiotensin converting enzyme inhibitors. The proportional hazards model showed that the effect of treatment modality persisted after correction for the other risk factors for mortality. Conclusions: In this series of hypertensive patients, those treated with beta blockers or diuretics had higher mortality rates than those receiving calcium channel antagonists or angiotensin converting enzyme inhibitors

La red asistencial de salud y el papel de los jefes de servicios clínicos en su gestión: un punto de vista desde el Hospital Clínico San Borja Arriarán / Health assistance net and the role of the clinical services chiefs in it management: a point of view under the San Borja Arriarán clinical hospital

Se analizan los niveles de atención en las áreas de Salud de Chile, y en especial los problemas del nivel primario. Entre estos problemas se destacan: los" de naturaleza médica profesional; la administración municipal, que ha desmembrado la red de atención; y la insuficiencia de acciones de promoción basadas en el modelo biopsicosocial de la persona. Se examina la realidad de las relaciones entre el nivel primario y el secundario; el rol de los Centros de Diagnóstico y Tratamiento (CDT) y el de atención cerrada. Se concluye, sobre la base de la experiencia de los autores, que los jefes de servicios clínicos, o el profesor universitario, o ambos en el marco de un consejo técnico de la red deben planificar, supervisar y evaluar todos los niveles de la red local, incluyendo los consultorios o centros de salud y los CDT, con el objeto de entregar una atención médica integrada, continua y de calidad

Participación de los eicosanoides en el efecto protector cardiovascular del consumo de alcohol / Role of eicosanoids in the cardiovascular protective effect of alcohol consumption

Diversos estudios han asignado al consumo de alcohol un efecto protector cadiovascular que se manifiesta por una incidencia menor de enfermedad coronaria y desarrollo de aterosclerosis. Los mecanisos a través de los cuales el alcohol ejerce estos efectos no han sido aún dilucidados, habiéndose relacionado con una posible acción sobre los lípidos sanguíneos. Sin embargo, estudios recientes sugieren la participación de algunos eicosanoides en este efecto, particularmente la prostaciclina, un intenso antiagregante y vasodilatador, y el tromboxano, un potente agregante plaquetario y vasoconstrictor. En este estudio investigamos en ratas e individuos abstémicos y alcohólicos,el efecto del alcohol y sus metabolitos en la producción de prostaciclina, tromboxano y agregación plaquetaria, medidos por radioinmunoensayo. Los resultados obtenidos muestran que el etanol y su metabolito activo acetaldehido estimulan significativamente la producción vascular de prostaciclina. Además, el consumo de alcohol disminuyó en forma marcada la síntesis de tromboxano en las plaquetas y la agregación plaquetaria inducida por colágeno y trombina. Este último efecto se tradujo en un alargamiento del tiempo de sangría en los individuos alcohólicos. Estos resultados sugieren que los mecanismos responsables del efecto protector del alcohol son complejos y se relacionan no sólo con cambios en los lípidos sanguíneos, sino que también en la producción de prostaciclina, troboxano, agregación plaquetaria y reactividad vascular. Este conjunto de acciones explicaría el efecto protector cardiovascular asignado al consumo crónico de alcohol que se manifiesta por una incidencia disminuida de enfermedad coronaria y desarrollo de aterosclerosis

Estudio colaborativo chileno-argentino, para evaluar nifedipina OROS en hipertensos esenciales / Collaborative Chilean-Argentinean study of nifedipine GITS in patients with essential hypertension

Ocho centros chilenos y 5 argentinos evaluaron eficacia, tolerabilidad y seguridad de Nifedipina Oros en 355 hipertensos esenciales durante 8 semanas de tratamiento, previo placebo. 67 por ciento pacientes respondieron a 30, y 33 por ciento a 60 mg/día. El descenso de presión arterial fue 23/15 ñ 0.6/0.3 (ES) mmHg (p < 0,0001). Las variaciones de presión fueron similares en decúbito y de pie,sin causar diferencias en frecuencia cardíaca en ambas posiciones. La relación trough: peak (28:6-8 h) varió entre 0,91-0,95 con dosis inicial o de mantención. Ochenta y cuatro por ciento de hipertensos leves y 93 por ciento de moderados respondieron con decrementos de 10 o más mmHg; 59 por ciento alcanzaron normotensión. No se observaron respuestas significativamente diferentes según edad y terciles de Na urinario nocturno al ingreso. No hubo modificación de parámetros de laboratorio. 29 por ciento de los pacientes presentaron efectos colaterales durante tratamiento activo; en 65 por ciento únicos, en 63 por ciento leves y bien tolerados. Los más frecuentes al final del tratamiento fueron cefaleas (4,7 por ciento) y edema (2,6 por ciento). Once pacientes fueron retirados por efectos que interferían la vida habitual y 4 abandonaron control. Concluimos que Nifedipina GITS posee alta eficacia, similar para distintos grupos etáreos e ingesta de sodio, un efecto mantenido a lo largo de las 24 horas y efectos colaterales mayoritariamente leves y bien tolerados

Terapia combinada de un antagonista de Ca++ y un inhibidor de la enzima convertidora de la angiotensina en hipertensión arterial esencial / Combined therapy with a calcium channel blocker and an ACE inhibitor in essential hypertension

La terapia combinada de un antagonista de Ca++ y un inhibidor de la enzima convertidora de la angiotensina, además de mejorar la tolerancia (menores dosis), permitiría mejor control de la PA por la acción amortiguadora que tienen los IECA sobre la estimulación del sistema RAA y del sistema simpático que ejercen los antagonistas del Ca++. Para estudiar la respuesta clínica a esta asociación, 84 hipertensos esenciales moderados (PAS entre 161-200 mmHg y PAD entre 114-120 mmHg) en etapas I-II OMS, fueron tratados con nifedipino 10 mg x 3 v. o enalapril 10 mg x 2 v. durante 3 ms. Cuarenta pac no lograron normotensión (< 140/90 mmHg), de los cuales 19 recibían enalaptil y 21, nifedipino, por lo que se les asoció el otro fármaco a dosis similar. Ambos grupos resultaron comparables en edad, sexo y niveles de la PA con monoterapia. La terapia combinada produjo desde el primer mes una nueva y significativa reducción de PA. Individualmente, 17 pac (42,5 por ciento) alcanzaron normotensión, 19 pac redujeron sus niveles de PAD entre 91 y 100 mmHg y sólo en 4 pac (10 por ciento) fracasó la combinación. Los efectos adversos fueron los clásicos para estas drogas: 33 por ciento con monoterapia y 20 por ciento con terapia combinada. Se concluye que en hipertensión esencial, de moderada a severa, la asociación de nifedipino y enalapril, a dosis moderadas, permite un control adecuado de la PA con menos efectos adversos

Eficacia clínica y aceptabilidad de ramipril en el tratamiento de la hipertensión arterial esencial etapas 1 y 2: resultados de un estudio multicéntrico / Clinical effectiveness and tolerance of ramipril in the treatment of essential arterial hypertension level 1 and 2: results of a multicentric study

One hundred eighty eight hyoertensive patients, aged 21 to 80 years old, coming from 4 Chilean hospitals were studied. Using an open non controlled design, they were treated with placebo for two weeks and with the active drug during eight weeks, in initial doses of 2.5 mg/day that were adjusted to 5 mg/day in diastolic blood pressure did not drop below 90 mm Hg or if its reduction was less than 10 mm Hg. During the active drug treatment period, systolic blood pressure decreased from 164.8ñ7.2 to 147.3ñ4.8 mm Hg. Diastolic blood pressure dropped from 102.3ñ3.1 to 87.8ñ3.0 mm Hg. Seventy percent of patients achieved a diastolic blood pressure of less than 90 mm Hg, 56.9 percent with 2.5 mg/day and 13.8 percent with 5 mg/day. Dizziness, cough and headache were the main adverse reactions, observed in 3.7, 3.2 and 2.1 percent of patients respectively. Adherence to treatment was 98 percent. There were no changes in laboratory values during the treatment period. Ramipril is effective and well tolerated in the treatment of essential hypertension

¿A qué niveles bajar la presión arterial en la hipertensión esencial para optimizar el resultado? / At what level should blood pressure be lowered in esential hypertension to optimized results?

Early studies of the seventies and eighties showed an inverse relationship between blood pressure reduction and incidence of complications and death. Afterwards, in the late eighties, some authors showed that reductions of diastolic blood pressure beyond 85 or 90 mm Hg increased coronary heart disease mortality (J shaped curve). Meta analyses and recent epidemiological studies have shown again that cardiovascular morbidity decreased along with reductions in diastolic blood pressure, if it is kept whithin normal limits (70-89 mm Hg). Cardiovascular mortality decreases significantly with blood pressure reductions of 7 to 8 mmHg. Some authors have suggested that diastolic blood pressure should be reduced to 85 mmHg or less in individuals with several cardiovascular risk factors, to obtain a better risk reduction. This hypothesis waits for confirmation from follow-up studies