Por qué es importante lograr metas de hipertensión arterial sistémica... A propósito un caso clínico que inició como evento vascular cerebral isquémico / Why is it important to achieve the goals of treatment of hypertension.... About a case that began as ischemic stroke

Resumen La hipertensión arterial sistémica (HAS) es una de las condiciones más frecuentes que se ve en atención primaria de las enfermedades cardiovasculares y que tiene como consecuencias; dependiendo del "órgano blanco" que afecte, producir la cardiopatía isquémica, la vasculopatía cerebral o la nefropatía crónica. Dentro de la patogénesis de la HAS se encuentran implicados varios mecanismos fisiopatológicos; de los cuales actualmente, por señalar los más importantes y frecuentes, juegan un papel el incremento en los niveles de adrenalina, el sistema renina-angiotensina-aldosterona y en fecha reciente, mucho se menciona la participación de la resistencia a la insulina y la hiperinsulinemia. Dichos procesos conllevan un desequilibrio entre el tono simpático y el parasimpático, aunado a la hipersensibilidad por el sodio desencadenan uno de los mecanismos fisiopatogénicos de la HAS. Actualmente se define la HAS como el hallazgo de cifras de tensión arterial mayores a 140/90 mm Hg. Este es uno de los padecimientos que más afecta a la población mundial encontrando prevalencias en grupos etarios y de género de 45 al 55% en varones entre los 45 y 70 años y del 45 al 65% en mujeres de ese mismo grupo etario. En el 2013 se publicaron las guías clínicas más recientes para su tratamiento y las metas recomendadas, con lo que se ha logrado disminuir sus complicaciones y mortalidad; dentro de las que destacan enfermedades vasculares como la cardiopatía isquémica y la cerebral y renal. En el presente trabajo se comenta un caso clínico que ejemplifica las complicaciones secundarias en un diagnóstico tardío, el daño a "órgano blanco" por exposición a largo plazo y el inadecuado cumplimiento de las metas terapéuticas.

Abstract Systemic arterial hypertension (SAH) is one of the most common conditions seen in primary care of cardiovascular disease and whose consequences; depending on the "target organ" affecting produce ischemic heart disease, cerebral vascular disease or chronic kidney disease. In the pathogenesis of HAS are several physiopathological mechanisms involved; of which currently, to name the most important and frequent play a role in increasing adrenaline levels, the renin-angiotensin-aldosterone system and recently, much the participation of insulin resistance and hyperinsulinemia mentioned. These processes lead to an imbalance between the sympathetic and parasympathetic tone, coupled with hypersensitivity sodium trigger one of the pathophysiologic mechanisms of hypertension. SAH is currently defined as finding numbers of older blood pressure 140/90 mm Hg. This is one of the diseases that most affect the world population prevalences found in age and gender groups 45 to 55% in men between 45 and 70 years and 45 to 65% in women of the same age group. In 2013 most recent clinical guidelines for treatment and the recommended goals, which has managed to reduce its complications and mortality were published; among which include vascular diseases such as ischemic heart and brain and kidney. In this paper a case that exemplifies the secondary complications in late diagnosis, damage to "target organ" by long-term exposure and inadequate compliance with therapeutic goals discussed.

Hipertensión arterial sistémica en el embarazo / Hypertension and pregnancy

Increasing evidence indicates that hypertension in pregnancy is an under recognized risk factor for cardiovascular disease (CVD). Compared with women who have had normotensive pregnancies, those who are hypertensive during pregnancy are at greater risk of cardiovascular and cerebrovascular events and have a less favorable overall risk profile for CVD years after the affected pregnancies. One factor that might underlie this relationship is that hypertensive disorders of pregnancy (pre-eclampsia, in particular) and CVD share several common risk factors (e.g. obesity, diabetes mellitus and renal disease). Alternatively, hypertension in pregnancy could induce long-term metabolic and vascular abnormalities that might increase the overall risk of CVD later in life. In both cases, evidence regarding risk-reduction interventions specific to women who have had hypertensive pregnancies is lacking. While awaiting results of large-scale studies, hypertensive disorders of pregnancy should be screened for during assessment of a woman's overall risk profile for CVD. Women at high risk must be monitored closely for conventional risk factors that are common to both CVD and hypertensive disorders of pregnancy and treated according to current evidence-based national guidelines.

Abordaje clínico terapéutico del paciente adulto mayor con hipertensión arterial sistémica: recomendaciones para la práctica clínica / Therapeutic clinical approach for the elderly patient with hypertension: recommendations for clinical practice

The incidence of hypertension in the geriatric population is very high and is a significant determinant of cardiovascular risk in this group. The tendency for blood pressure to increase with age in westernized societies such as the United States may depend on environmental factors such as diet, stress, and inactivity. Our population tends to become more obese; to consume relatively greater amounts of sodium and lesser amounts of potassium, calcium, and magnesium; and to decrease exercising with increasing age. Senescent changes in the cardiovascular system leading to decreased vascular compliance and decreased baroreceptor sensitivity contribute not only to rising blood pressure but also to an impairment of postural reflexes and orthostatic hypotension. The hallmark of hypertension in the elderly is increased vascular resistance. Greater vascular reactivity in the elderly hypertensive patients may reflect decreased membrane sodium pump activity and decreased beta-adrenergic receptor activity as well as age-related structural changes. Treatment of diastolic hypertension in the elderly is associated with decreased cardiovascular morbidity and mortality. Although treatment of systolic hypertension may not decrease immediate cardiovascular mortality, it appears to decrease the incidence of stroke. The initial therapeutic approach to the elderly hypertensive patient should generally consist of a reduction in salt and caloric intake and an increase in aerobic exercise, i.e., walking. Drug therapy should be initiated with lower doses of medication with a special concern about orthostatic hypotension.

Hipertensión arterial sistémica en el niño y adolescente / Hypertension in children and adolescence

The epidemic of childhood obesity, the risk of developing left ventricular hypertrophy, and evidence of the early development of atherosclerosis in children would make the detection of and intervention in childhood hypertension important to reduce long-term health risks; however, supporting data are lacking. Secondary hypertension is more common in preadolescent children, with most cases caused by renal disease. Primary or essential hypertension is more common in adolescents and has multiple risk factors, including obesity and a family history of hypertension. Evaluation involves a through history and physical examination, laboratory tests, and specialized studies. Management is multifaceted. Nonpharmacologic treatments include weight reduction, exercise, and dietary modifications. Although the evidence of first line therapy for hypertension is still controversial, the recommendations for pharmacologic treatment are based on symptomatic hypertension, evidence of end-organ damage, stage 2 of hypertension, or stage 1 of hypertension unresponsive to lifestyle modifications, and hypertension with diabetes mellitus.

Elevación extrema de la presión arterial (crisis hipertensiva): recomendaciones para su abordaje clínico-terapéutico / Extreme elevation of the blood pressure (hypertensive crisis): recommendations for its clinical-therapeutic approach

From beginnings of last century the hypertensive emergency was defined as the association of acutely elevation from the arterial pressure and the appearance of damage to end organ. At present is recognized the effects of the hypertensive emergency, the aspects of its patophysiology in which are included phenomenon of vasomotricity and the participation of different substances with vasoactives properties. The clinical presentation includes not only the manifestations of the increase of the arterial pressure, the end organ damage too; for this reason the hypertensive emergency needs the immediate reduction of the arterial tension to prevent the damage to specific organs. The treatment in every case will have to be individualized, with a wide knowledge of the characteristics of every medicament to obtain the best results. The diagnosis and treatment of the hypertensive emergencies needs often of the attention of its complications if they have appeared and later, of a treatment of support for the arterial hypertension.

Prevención y tratamiento de la hipertensión arterial sistémica en el paciente con enfermedad arterial coronaria / Prevention and treatment of hypertension and coronary heart disease

The association between arterial systemic hypertension arterial coronary disease has been demonstrated by cumulated evidence of several epidemiological studies. Hypertension is an important independent risk factor for the development of coronary artery disease, vascular cerebral disease and nephropathy. Important advances exist in the knowledge of neurohumoral and hemodynamic factors that come together in the pathophysiology of the hypertension and in the development of coronary disease that allow to establish better strategies not only of treatment, but also of prevention, with the purpose of diminishing the cardiovascular mortality. The spectrum of the coronary artery disease secondary to atherosclerosis is wide and the strategies of treatment of hypertension must be adapted to each particular case. The treatment of both conditions needs of specific limits of agreement to the conditions of the patient and the form of presentation of each one of these disease.

Guías clínicas para la detección, prevención, diagnóstico y tratamiento de hipertensión arterial sistémica en México (2008) / Clinical guidelines for detection, prevention, diagnosis and treatment of systemic arterial hypertension in Mexico (2008)

The multidisciplinary Institutional Committee of experts in Systemic Arterial Hypertension from the National Institute of Cardiology [quot ]Ignacio Chávez[quot ] presents its update (2008) of [quot ]Guidelines and Recommendations[quot ] for the early detection, control, treatment and prevention of Hypertension. The boarding tries to be simple and realistic for all that physicians whom have to face the hypertensive population in their clinical practice. The information is based in the most recent scientific evidence. These guides are principally directed to hypertensive population of emergent countries like Mexico. It is emphasized preventive health measures, the importance of the no pharmacological actions, such as good nutrition, exercise and changes in life style, (which ideally it must begin from very early ages). [quot ]We suggest that the changes in the style of life must be vigorous, continuous and systematized, with a real reinforcing by part of all the organisms related to the health education for all population (federal and private social organisms). It is the most important way to confront and prevent this pandemic of chronic diseases[quot ]. In this new edition the authors amplifies the information and importance on the matter. The preventive cardiology must contribute in multidisciplinary entailment. Based mainly on national data and the international scientific publications, we developed our own system of classification and risk stratification for the carrying people with hypertension, Called HTM (Arterial Hypertension in Mexico) index. Its principal of purpose this index is to keep in mind that the current approach of hypertension must be always multidisciplinary. The institutional committee of experts reviewed with rigorous methodology under the principles of the evidence-based medicine, both, national and international medical literature, with the purpose of adapting the concepts and guidelines for a better control and treatment of hypertension in Mexico. This work group recognizes that hypertension is not an isolated disease; therefore its approach must be in the context of the prevalence and interaction with other cardiovascular risk factors such as obesity, diabetes, dislipidemia and smoking among others. The urgent necessity is emphasized to approach in a concatenated form the diverse cardiovascular risk factors, since independently of which they share common pathophysiological mechanisms, its suitable identification and cont

De la placa vulnerable solitaria, a la coronariopatía de múltiples vasos. De sus fundamentos, a las implicaciones terapéuticas modernas. Una realidad clínica en el espectro de los SICA / From the single vulnerable plaque, to the multiple complex coronary plaques. From their basis, to the modern therapeutic approach. A clinical reality in the spectrum of the acute coronary syndromes

Contemporary clinical and laboratory data have challenged our classical concepts of the pathogenesis of the acute coronary syndromes [ACS]. Indeed, several independent lines of clinical evidence have supported that the critical stenoses cause only a fraction of the ACS. Acute myocardial infarction is believed to be caused by rupture of a vulnerable coronary-artery plaque that appears as a single lesion on angiography. However, plaque instability might be caused by pathophysiologic processes, such as inflammation, that exert adverse effects throughout the coronary vasculature and therefore result in multiple unstable lesions. Recent studies have demonstrated that ruptured or vulnerable plaques exist not only at the culprit lesion but also in the whole coronary artery in some ACS patients. It has also been reported that a ruptured plaque at the culprit lesion is associated with elevated C- reactive protein and other inflammatory markers, which indeed indicate a poor prognosis in patients with ACS. Also, multiple plaque rupture is associated with systemic inflammation, and patients with multiple plaque rupture can be expected to show a poor prognosis. Therefore some ACS patients [20-40%] may harbor multiple complex coronary plaques that are associated with adverse clinical outcomes. It should be accepted that this ACS population represent a part of the spectrum of the ACS, and in particular in this group of patients treatment should focus not only on the stabilization of the culprit site but also warrants a broader approach to systemic stabilization of the arteries. However, recurrent cardiovascular events in this population still remain unacceptably high, indicating that plaque rupture or vulnerability of multiple plaques is a current challenge in the management of ACS patients.

De la placa vulnerable solitaria, a la coronariopatía de multiples vasos. De sus fundamentos, a las implicaciones terapéuticas modernas. Una realidad clínica en el espectro de los SICA / From the single vulnerable plaque, to the multiple complex coronary plaques. From their basis, to the modern therapeutic approach. A clinical reality in the spectrum of the acute coronary syndromes

Contemporary clinical and laboratory data have challenged our classical concepts of the pathogenesis of the acute coronary syndromes [ACS]. Indeed, several independent lines of clinical evidence have supported that the critical stenoses cause only a fraction of the ACS. Acute myocardial infarction is believed to be caused by rupture of a vulnerable coronary-artery plaque that appears as a single lesion on angiography. However, plaque instability might be caused by pathophysiologic processes, such as inflammation, that exert adverse effects throughout the coronary vasculature and therefore result in multiple unstable lesions. Recent studies have demonstrated that ruptured or vulnerable plaques exist not only at the culprit lesion but also in the whole coronary artery in some ACS patients. It has also been reported that a ruptured plaque at the culprit lesion is associated with elevated C- reactive protein and other inflammatory markers, which indeed indicate a poor prognosis in patients with ACS. Also, multiple plaque rupture is associated with systemic inflammation, and patients with multiple plaque rupture can be expected to show a poor prognosis. Therefore some ACS patients [20-40%] may harbor multiple complex coronary plaques that are associated with adverse clinical outcomes. It should be accepted that this ACS population represent a part of the spectrum of the ACS, and in particular in this group of patients treatment should focus not only on the stabilization of the culprit site but also warrants a broader approach to systemic stabilization of the arteries. However, recurrent cardiovascular events in this population still remain unacceptably high, indicating that plaque rupture or vulnerability of multiple plaques is a current challenge in the management of ACS patients.

Registro electrocardiográfico continuo durante el primer salto en paracaídas / Electrocardiographic recording of the first parachute jump

Mediante registro electrocardiográfico continuo, se estudio el comportamiento del ritmo cardiaco en 13 individuos jóvenes aparentemente sanos, miembros del club de paracaidismo de la Universidad Nacional Autónoma de México, durante su primer salto en paracaidas; 12 del sexo masculino (92.3%) y una mujer (7.6%) con edad promedio de 22.8 años. Dos semanas antes del salto se ralizó historia clínica completa, electrocardiograma de 12 derivaciones y prueba de esfuerzo. Para el registro electrocardiográfico se utilizaron grabadoras Holter de dos derivaciones que se colocaron 30 minutos antes de abordar la avioneta y se obtuvieron registros de aproximadamente una hora. La frecuencia cardiaca promedio se calculó en las siguientes fases: dos semanas antes de la maniobra (64.5 lat/min), durante la prueba de esfuerzo (143.3 lat/min), antes de abordar la avioneta (112.8 lat/min), durante la caída (170 lat/min) y durante el aterrizaje (122.8 lat/min) y se compararon por medio de la desviación estándar, el valor predictivo (p) y los límites de confianza. La diferencia entre cada una de las fases fue estadísticamente significativo con p < 0.001. En todos los casos el ritmo cardiaco fue calificado como taquicardia sinusal, y en 6 casos (43.6%) se observaron 22 episodios de disminución súbita de al frecuencia cardiaca. No se presentaron trastornos graves del ritmo ni la conducción cardiaca. En nueve casos se registro el nivel de catecolaminas urinarias inmediatamente después del salto (x 51.2 ug/100 ml) y dos semanas (x56.0 ug/100 ml), sin encontrar diferencia estadísticamente significativa. Se concluyó que el estrés intenso de duración limitada, no es capaz de provocar alteraciones graves del ritmo cardiaco en sujetos jóvenes aparentemente sanos. Las características del estuido permiten clasificarlo como longitudinal, descriptivo, experimental y prolectivo

El fenómeno de Wenckebach en el paciente con infarto agudo del miocardio

Se estudiaron 1336 pacientes con diagnóstico de infarto agudo del miocardio (IAM); de ellos 198 (14.82%) tuvieron algún tipo de BAV y de estos, 67 pacientes presentaron fenómeno de Wenckbach (FW) que representa el 5.0% del total del grupo de IAM y el 33.83% de los enfermos con BAV. De los pacientes con FW, 53 eran hombres y 14 mujeres (4:1). Ingresaron por un primer IAM (77.51%) y por un segundo IAM (22.38%). La localización de IAM fue en 43.26% posteroinferior (PI) con extensión al V.D 36.0% (PI) 10.4% anterolateral (AL), 9.0% posterolateral (PL) y 1.4% lateral (L). El tiempo de aparición del FW con relación a la instalación de IAM fue en el 64.2% dentro de las 24 horas, y de 17.9% tanto para el grupo de 24-48 horas o de más 48 horas. El tiempo de duración del FW fue de menos de 24 horas en 43.3% de 24 a 48 horas en 19.4% y más de 48 horas en 25.4% y fue transitorio en 11.9%. El FW se presentó siempre con frecuencias cardiacas menores a 110x'. En 9 pacientes coincidió con bradicardia sinusal con 48 o 40. La duración de QRS fue de 80-90 msge en 91% y de 100-120 mseg en el 90%. El 4.47% tuvo BRDHH previo al FW. Hubo progresión del grado de BAV en 10.4% a Mobitz II y de 11.9% a BAV completo. La mortalidad fue de 5 pacientes. 3 del grupo segundo IAM y 2 con un primer IAM

Valores normales en México de las mediciones ecocardiográficas del corazón izquierdo / Normal value in Mexico of the echocardiographic measurements of the left side of the hearth

Se estudiaron las dimensiones ecocardiográficas modo M, siguiendo los criterios internacionales de medíción, de 274 sujetos sanos, residentes en la ciudad de México, para conocer las variantes en esta población. De sexo masculino 131 (47.8%), de sexo femenino 143(52.2%). La edad varió de 1 a 73 años, con predominio entre la tercera y quinta décadas de la vida. Se correlacionaron las mediciones con la edad, el peso y la superficie corporal (SC), con mejor proporción para esta última, por lo que se tomó como base del análisis, formando 6 subgrupos a partir de SC de 0.5 m2 e incremento de 0.4 m2 para cada subgrupo hasta el de 2.1 m2 o más. Se observó aumento proporcional a la SC de la excursión D-E de la válvula mitral, del diámetro anteroposterior, la excursión y la apertura de la aorta, así como del diámetro anteroposterior de la aurícula izquierda, de los diámetros diastólicos y sistólico finales del ventrículo izquierdo y de los espesores del septum interventricular (SIV) y de la pared posterior (PP). Las dimensiones encontradas fueron inferiores a las informadas en la literatura. Los valores de la velocidad media de acortamiento circunferencial (VMAC), de la fracción de acortamiento (FA) y las velocidades normalizadas (VN) del SIV y la PP fueron inversamente proporcionales a la SC. La VMAC y la VN con valores muy similares a los establecidos; en cambio la FA y la fracción de expulsión dieron valores superiores a los informados. El estudio permite conocer los valores normales para la población de la ciudad de México de acuerdo con su desarrollo somático y la altitud a la que vive (AU) )

Valor predictivo para muerte súbita de la extrasistolia ventricular repetitiva / Repetitive ventricular premature beats as predictors of sudden death

Con la intención de conocer el valor predictivo para muerte súbita (MS) de la extrasistolia ventricular repetitiva (E-VR), tanto en el cardiópata como en el sujeto sano, se estudiaron 452 pacientes mediante monitoreo electrocardiográfico continuo de 24 horas, cuantificando la mortalidad dentro de los 30 días posteriores a su elaboración. La EVR fué agrupada en: tipo A (extrasistolia ventricular pareada) y tipo B (extrasistolia ventricular multifocal y/o colgajos de taquicardia ventricular). En 74 casos de documentó insuficiencia cardiaca (ICCV) durante el seguimiento. Se contó con coronariografía en 92 casos. Eran cardiópatas 199 sujetos: 114 con infarto del miocardio (IM), 29 con angina de pecho (AP), 19 con cardiomiopatía congestiva (MCC); 14 con cardiopatía hipertensiva arterial sistémica (CHAS) y 23 con cardiopatía ateroesclerosa (CAE) con bloqueo de rama asintomáticos. Cuarenta cardiópatas (20%) tenían EVR, (26 del tipo A y 14 del tipo B), 12 tuvieron MS; 9 con (EVR) (18%) y 3 sin EVR (18%) y 3 sin EVR (2%). De los pacientes con (IM), 6 (14%) tuvieron EVR y de éstos 4 (25%) presentaron MS. Cuatro de los pacientes con (MCC) (25%) tuvieron MS, todos con EVR e ICCV. Dos de los pacientes con CHAS tuvieron MS, uno con EVR. De los pacientes con EVR tipo A, 5 (19%) y del tipo B, 4 (28%) tuvieron MS. De los pacientes con MS, 10 (83%) tuvieron ICCV durante el seguimiento. En 11 pacientes con (IM), coincidió ICCV y EVR; de ellos, 4 (26%) tuvieron MS. Los 3 pacientes sin EVR con MS correspondieron a: CAE, CHAS y AP. El 26% de los pacientes con MS tenían enfermedad coronaria trivascular, 5% dos vasos afectados y 11% un vaso. Ningún sujeto sano tuvo MS aunque 16 (6%) tuvieron EVR. En conclusión, el valor predictivo de la extrasistolia ventricular repetitiva es elevado para el caso de la muerte subita, sobre todo si vá en coincidencia con insuficiencia cardiaca congestiva, aún dentro de los 30 días posteriores a la realización del estudio

Valor predictivo de la extrasistolia ventricular en la prueba de esfuerzo y su relación con la magnitud del daño coronario / Predictive value of ventricular arrhytmias during stress testing on the presence and extent of coronary artery disease

El valor pronóstico que aportan las arritmias ventriculares asociadas con la prueba de esfuerzo fué evaluado en 115 pacientes sometidos a coronariografía y ventriculografía izquierda dentro de los 3 primeros meses después de la prueba de esfuerzo. En total 39 pacientes con arritmias ventriculares (al menos una extrasístole ventrícular, extrasístoles pareadas o taquicardia ventricular) tuvieron una alta prevalencia significativa de enfermedad coronaria, función ventricular anormal o múltiples vasos coronarios dañados, a diferencia de pacientes sin arritmias ventriculares (P <0.05). Este estudio demuestra que las arritmias ventriculares detectadas durante la prueba de esfuerzo están relacionadas con la magnitud de daño coronario, pero principalmente con la presencia de mala función ventricular