La preeclampsia es precedida por alteración de la función cardiovascular / Preeclampsia is Preceded by Cardiovascular Function Abnormalities

RESUMEN Introducción: La preeclampsia (PE) se acompaña de cambios en la función cardiovascular (FCV). Sin embargo, es desconocido si los cambios preceden y persisten a la manifestación clínica de PE. Objetivos: Evaluar las diferencias en la FCV, en la semana 22 de gestación (22sg) y un año posterior al parto (1app) en las pacientes que evolucionaron a la PE vs. a la normotensión (N). También, la asociación entre la FCV en 22sg y la evolución a PE. Material y métodos: Estudio prospectivo, que incluyó 260 primíparas normotensas. Se midió en la semana 22sg y a 1app: laboratorio de rutina, proteinuria de 24horas, presión arterial (PA). Por cardiografía por impedancia: índice cardíaco (IC) y de resistencia vascular sistémica (IRVS), velocidad de onda de pulso (VOP). Se formaron 3 grupos según la evolución a: PE, G1, HTA gestacional (HG) G2, y N, G3. Los resultados se presentan como media ± DS, ANOVA y test post hoc, p < 0,05. Resultados: 12 pacientes evolucionaron a PE, 18 a HG y 220 a N. El G1 presentó en los dos tiempos de medición, valores inferiores de IC y superiores de PA, IRP y VOP comparados al G3. El G2 presentó valores intermedios entre el G1 y el G3. La VOP y el IRP en la 22sg de gestación resultaron predictores de PE. Conclusiones: Las pacientes que evolucionaron a PE presentaron en fase temprana del embarazo diferente FCV respecto a las normotensas. El diagnóstico temprano de estos cambios contribuiría a predecir la PE y prevenir sus complicaciones.

ABSTRACT Background: Preeclampsia (PE) is associated with changes in cardiovascular function (CVF), but whether these changes precede and persist in the clinical phase of the disease is still unknown. Objectives: The aim of this study was to evaluate the differences in CVF during 22 weeks of gestation and one year after delivery in patients who developed PE vs. those with normotension (N). The association between CVF on 22 weeks of gestation and the development of PE was also analyzed. Methods: We conducted a prospective study including 260 normotensive primiparous women. Routine laboratory tests, 24-hour urine protein and blood pressure (BP) were measured on 22 weeks and one year after delivery. Cardiac index (CI) systemic vascular resistance index (SVRI) and pulse wave velocity (PWV) were measured by impedance cardiography. The population was divided into three groups according to the outcome during pregnancy: PE: G1, gestational hypertension (GH): G2 and normotension: G3. The results are presented as mean ± SD, ANOVA and post hoc test, p < 0.05. Results: Twelve patients evolved to PE, 18 to GH and 220 remained with N. In G1, CI was lower and BP, SVRI and PWV were higher than in G3 on 22 weeks and one year after delivery. In G2, values were always intermediate between G1 and G3. PWV and SVRI measured on 22 weeks resulted predictors of PE. Conclusions: Patients who developed PE had different CVF in the early stage of pregnancy than those with normotension. The early diagnosis of those changes could predict PE and thus contribute to prevent its complications.

Hipertensión matinal y comportamiento non-dipper en embarazadas con hipertensión de guardapolvo blanco / Morning Hypertension and Non-dipper Behavior in Pregnant Women with White Coat Syndrome

Introducción: La hipertensión de guardapolvo blanco (HGB) es común en el embarazo, aunque su evolución clínica durante la gestación se conoce poco. La hipertensión matinal y el comportamiento non-dipper, medidos por monitoreo ambulatorio de la presión arterial (MAPA), se asocian con mayor riesgo de eventos cardiovasculares; no obstante ello, son escasos los estudios en la gestación. Objetivos: El objetivo primario del estudio fue evaluar la hipertensión matinal y el comportamiento non-dipper en embarazadas con HGB versus un grupo control de normotensas. Se planteó como objetivo secundario evaluar si la HGB, la hipertensión matinal y el comportamiento non-dipper en el segundo trimestre del embarazo se relacionan con mayor hipertensión sostenida en el tercer trimestre. Material y métodos: Estudio prospectivo en el que se incluyeron 95 primigestas en la semana 20 de gestación, 50 con HGB y 45 normotensas como grupo control. Se registraron laboratorio de rutina, presión de consultorio y MAPA en la inclusión y a las 32 semanas de gestación. La hipertensión matinal y el comportamiento non-dipper se evaluaron por MAPA. Resultados: La edad, la glucemia y la presión diurna y nocturna por MAPA fueron similares en el examen basal en ambos grupos. Por el contrario, las pacientes con HGB presentaron valores significativamente superiores de hipertensión matinal y comportamiento non-dipper, lo cual se asoció en forma independiente con hipertensión sostenida en el tercer trimestre del embarazo. Conclusiones: Las gestantes con HGB en la semana 20 de embarazo presentaron mayor hipertensión matinal y comportamiento non-dipper y evolucionaron con más frecuencia a hipertensión sostenida que el grupo control de normotensas.

Background: White coat syndrome (WCS) is common during pregnancy, although little is known about its clinical outcome during gestation. Morning hypertension and the non-dipper behavior, measured by ambulatory blood pressure monitoring (ABPM), are associated with greater risk of cardiovascular events. However, there are few studies during pregnancy. Objectives: The primary aim of the study was to evaluate morning hypertension and the non-dipper behavior in pregnant women with WCS versus a control normotensive group. A secondary objective was to evaluate whether WCS, morning hypertension and the non-dipper behavior in the second trimester of pregnancy were associated with greater hypertension in the third trimester. Methods: This prospective study included 95 primiparae in the 20th week of gestation, 50 with WCS and 45 as normotensive control group. Routine lab tests, office blood pressure and ABPM at inclusion and in the 32th week of gestation were recorded. Morning hypertension and the non-dipper behavior were evaluated by ABPM. Results: Age, and baseline blood glucose level and daytime and nighttime blood pressure by ABPM were similar in both groups. Conversely, patients presenting WCS had significantly higher values of morning hypertension and non-dipper behavior, which were independently associated with sustained hypertension in the third trimester of pregnancy. Conclusions: Pregnant women with WCS in the 20th week of gestation presented greater morning hypertension and non-dipper behavior and progressed more frequently to sustained hypertension than the control normotensive group.

Hipertensión de guardapolvo blanco: evolución a hipertensión sostenida luego de 10 años de seguimiento / Progression of White Coat Hypertension to Sustained Hypertension After 10 Year Follow-up / Progression of White Coat Hypertension to Sustained Hypertension After 10 Year Follow-up

Introducción No obstante la amplia información en la bibliografía sobre la caracterización de la hipertensión de guardapolvo blanco (HGB), su evolución alejada es hasta el presente tema de controversia. Objetivo Evaluar la incidencia acumulada de hipertensión sostenida (HS) en hipertensos de guardapolvo blanco respecto de normotensos a los 10 años de su inclusión en el estudio. Material y métodos Se incorporaron en forma prospectiva 250 pacientes de ambos sexos, según los siguientes valores de presión de consultorio (PC) y de monitoreo ambulatorio de la presión arterial (MAPA) de 24 horas: Se conformaron dos grupos: 129 hipertensos de guardapolvo blanco y 121 normotensos, los cuales fueron evaluados nuevamente a los 10 años de seguimiento. Se midieron la glucemia, el perfil lipídico y el índice de masa ventricular izquierda (IMVI). Resultados Las variables edad, sexo, tabaquismo y glucemia de normotensos e hipertensos de guardapolvo blanco fueron similares en el examen basal. Los hipertensos de guardapolvo blanco, por el contrario, presentaron valores significativamente superiores en IMC, colesterol total, hipertrigliceridemia e IMVI. Cuarenta y ocho hipertensos de guardapolvo blanco y 21 normotensos originales evolucionaron a HS. La HGB se asoció en forma independiente con HS a los 10 años de seguimiento OR: 2,5 (IC 95% 1,2-4,2). Conclusión La evolución a hipertensión sostenida fue mayor en los hipertensos de guardapolvo blanco que en los normotensos.

Background The long-term outcome of white coat hypertension (WCH) is still controversial despite the broad information currently available. Objective To evaluate the cumulative incidence of sustained hypertension (SH) among patients with white coat hypertension compared to normotensive patients 10 years after being included in the study. Methods A total of 250 patients of both genders were prospectively included with the following office blood pressure (OBP) and 24- hour ambulatory blood pressure monitoring (ABPM) values: The patients were divided into two groups: 129 patients with WCH and 121 normotensive patients, and were evaluated after 10 years of follow-up. Glucose blood level, lipid profile and left ventricular mass index (LVMI) were measured. Results Age, gender, smoking habits and glucose blood level were similar at baseline among normotensive patients and patients with white coat hypertension. Yet, BMI, total cholesterol levels, lipid levels and LVMI were significantly greater in white-coat hypertensive patients. Sustained hypertension was developed by 48 patients with WCH and 21 normotensive patients. We found an independent association between WCH and SH at 10 years of follow-up OR: 2.5 (95% CI 1.2-4.2). Conclusion Progression to sustained hypertension was greater in patients with white coat hypertension compared to normotensive patients.

Acompanhamento a longo prazo de pacientes com indicação de desfibrilador implantável como prevenção primária de morte súbita / Long-term follow-up of patients with indication for a implantable defibrillator for primary prevention of death

FUNDAMENTO: Os recentes estudos MADIT II e SCD-HeFT levaram a uma expansão das indicações do uso profilático de cardiodesfibrilador implantável (CDI) em pacientes com grave disfunção ventricular esquerda. Essa terapia não foi totalmente adotada em nosso sistema de saúde, sobretudo em virtude de seu alto custo. OBJETIVO: Avaliar a taxa de mortalidade global de pacientes da nossa prática diária que têm o mesmo perfil dos participantes do estudo SCD-HeFT, estão recebendo tratamento clínico otimizado e não foram submetidos a implante de CDI, e comparar essa taxa com a do grupo de placebo do estudo SCD-HeFT. MÉTODOS: Foram incluídos neste estudo pacientes com o mesmo perfil dos participantes do estudo SCD-HeFT identificados a partir de prontuários médicos. A taxa de mortalidade global foi avaliada por contato telefônico. A análise estatística foi realizada com o teste t de Student, teste de Mann-Whitney ou teste de qui-quadrado, dependendo do tipo de variável. As taxas cumulativas de mortalidade foram calculadas de acordo com o método de Kaplan-Meier. RESULTADOS: Este estudo englobou 102 pacientes, 74 dos quais do sexo masculino. A mediana da idade foi 64 anos e a média da fração de ejeção, 25 por cento. Não encontramos diferenças entre os nossos pacientes e os pacientes do estudo SCD-HeFT em relação a essas três variáveis. Durante o período de acompanhamento de 19,6 meses, 21 pacientes morreram (20,6 por cento), contra 28,8 por cento do estudo SCD-HeFT. Essa diferença não foi estatisticamente significante (p = 0,08). CONCLUSÃO: Não houve diferença na taxa de mortalidade dos nossos pacientes e dos pacientes do grupo de placebo do estudo SCD-HeFT. Esses resultados indicam que a população do SCD-HeFT é representativa dos nossos pacientes.

BACKGROUND: Recent MADIT II and SCD-HeFT trials have led to an expansion of indications for use of prophylactic Implantable Cardioverter Defibrillator (ICD) in patients with severe left-ventricular impairment. This therapy has not been fully adopted in our health care system, mainly due to its high cost. OBJECTIVE: To assess total mortality of SCD-HeFT-like patients from our daily practice who are under stable, optimal medical treatment and who have not received an ICD; and to compare it to that of the placebo arm of the SCD-HeFT Trial. METHODS: SCD-HeFT-like patients identified from office medical records were included in our study. Total mortality was assessed by telephone contact. Statistical analysis was performed by Student's t-Test, Mann-Whitney Test or chi2 test, depending on the type of variable. Cumulative mortality rates were calculated according to the Kaplan-Meier method. RESULTS: Our study comprised 102 patients (seventy-four of which were men) with a median age of 64 years, and an overall median ejection fraction of 25 percent. We found no differences between our patients and SCD-HeFT patients across these 3 variables. Over a 19.6-month follow-up period, 21 patients died (20.6 percent) vs. 28.8 percent of the SCD-HeFT patients. This difference was not statistically significant (p = 0.08). CONCLUSION: SCD-HeFT-like patients from our practice had no difference in mortality rate than patients enrolled in the placebo arm of the SCD-HeFT trial. These results suggest that the SCD-HeFT population is representative of our patients.