[Profile of the patient who wants to quick smoking seen in the Primary Care and Specialized consultations in Spain]. / Perfil del paciente que quiere dejar de fumar atendido en consultas de Atención Primaria y especializada de España.

OBJECTIVE: To determine the profile of the smoker who wants to stop smoking. Subjects and methods. A cross-sectional, multicenter study was conducted in 1634 smokers attended by General Practitioners and Specialized Physicians in Spain who had expressed their desire to stop smoking when explicitly asked. Sociodemographic data, background of smoking and related consequences were collected. A descriptive statistical analysis was performed. RESULTS: 67.1% of patients were seen by General Practitioners. Mean age +/- standard deviation was 45.6 +/- 12.0 years old and mean age of onset of usual consumption was 20.6 +/- 7.0. Fifty-six percent of the population studied were men. Most (35.2%) had studied beyond high school and 76.4% were active workers. Seventy-one percent had previously tried to stop smoking (2.7+/- 3.0 mean attempts). Out of 39.2% smokers who had participated in some type of smoking cessation treatment the year before, 70.7% were on substitutive therapy with nicotine. At the time of the visit, 80% admitted they could not stop smoking by themselves. CONCLUSIONS: The profile of the smoker seen in Primary Care and Specialized Consultation in Spain who wants to quit smoking corresponds to a male subject in his 40's, with studies beyond high school, actively working who has made more that two previous attempts to stop smoking, mostly with substitutive therapy with nicotine and who currently believes he is not being able to achieve it by himself.

[Hypertensive crises: prevalence and clinical aspects]. / Crisis hipertensiva: prevalencia y aspectos clínicos.

OBJECTIVE: To analyze the prevalence and characteristics of patients with hypertensive crises and to know the clinical differences between patients with hypertensive urgencies and patients with hypertensive emergencies. PATIENTS AND METHODS: Three-months prospective study in which all patients attended at the Emergency Department with an hypertensive crisis (arterial blood pressure of at least 210/120 mmHg) were included. From each patient, a clinical history, physical examination, eye fundus examination, blood analysis, electrocardiogram, and a chest X-ray were obtained. RESULTS: A total of 118 patients were included in the study, representing 0.65% of all attended emergencies. Twenty-two percent of them had an emergency hypertensive crisis. Coronary heart disease was the most common cause for this emergency crisis. Hypertension was unknown to 12.7% of patients and 12.6% of patients aware of their condition were not taking any medication. Twenty-four percent of patients were diabetic. Patients with hypertensive emergencies had more involvement of target organs. Twenty-four percent of crises resolved with no therapy, and captopril was the most commonly used drug. CONCLUSIONS: Hypertensive crises accounted for 0.65% of attended emergencies at our institution. Coronary heart disease was the most common condition for hypertensive emergencies. Patients with hypertensive emergencies had a more severe involvement of target organs. Twenty four percent of crisis resolved with rest alone.

Crisis hipertensiva: prevalencia y aspectos clínicos / Hypertensive crises: prevalence and clinical aspects

Fundamento. Analizar la prevalencia y las características de los pacientes que sufren una crisis hipertensiva y conocer qué diferencias clínicas existen entre los pacientes con urgencia y con emergencia hipertensiva. Pacientes y métodos. Estudio prospectivo durante 3 meses en el que se incluyen todos los pacientes que acuden al servicio de Urgencias con una crisis hipertensiva (presión arterial 210/120 mmHg).Se realiza anamnesis, exploración física, funduscopia, analítica, electrocardiograma y radiografía de tórax. Resultados. Se incluyen 118 pacientes, que representan el 0,65 por ciento de los atendidos en el área de Medicina de Urgencias. El 22 por ciento presentaron una emergencia hipertensiva, siendo la cardiopatía isquémica la emergencia más frecuente. El 12,7 por ciento de los pacientes desconocía ser hipertenso y el 12,6 por ciento de los conocidos no recibían tratamiento farmacológico. El 23,7 por ciento de los pacientes era diabético. Los enfermos con emergencia hipertensiva presentaron una mayor afectación de los órganos diana. Un 23,9 por ciento de las urgencias hipertensivas no precisaron tratamiento farmacológico para su resolución. El fármaco más empleado fue el captopril por vía oral. Conclusiones. En nuestro estudio el 0,65 por ciento de las urgencias atendidas en el área de medicina fueron crisis hipertensivas. La emergencia hipertensiva más frecuente fue la cardiopatía isquémica. La afectación visceral fue más frecuente en los pacientes con emergencia hipertensiva. El 23,9 por ciento de las urgencias hipertensivas se resolvió únicamente con reposo. (AU)

Hipertensión arterial refractaria

La hipertensión arterial refractaria es aquella que no desciende por debajo de 140/90 mmHg en la consulta cuando el paciente está tomando tres fármacos antihipertensivos incluido un diurético. Su prevalencia se estima en torno a un 10. por ciento y supone un grave problema sanitario, pues conocemos que el riesgo cardiovascular del paciente hipertenso se relaciona con sus cifras de presión arterial. Existen varias causas que pueden provocar resistencia al tratamiento antihipertensivo. La más frecuente es el incumplimiento terapéutico por parte del paciente. Otras causas son un tratamiento no apropiado, la interferencia con otros fármacos o sustancias exógenas, la existencia de pseudorresistencia, la presencia de hipertensión secundaria a otra patología, y en los últimos años se ha incorporado a estas causas la presencia de determinados factores biológicos como la resistencia a la insulina. Ante un paciente con hipertensión arterial refractaria se descartarán estas causas, ya que cada una tiene un manejo específico. Si no se encuentra ninguna de ellas estaremos ante una hipertensión arterial verdaderamente resistente cuya prevalencia está en torno a un 3. por ciento. El conocimiento de los factores que pueden provocar la resistencia en estos pacientes servirá de guía para realizar las modificaciones terapéuticas más oportunas (AU)

Respuesta de la adición de doxazosina en hipertensos con hipertrofia benigna de próstata tratados con monoterapia

Objetivo. Evaluar la eficacia y tolerancia de la adición de doxazosina al tratamiento del hipertenso controlado con otros hipotensores que concomitante presenta prostatismo. Metodología. Estudio abierto, no comparativo, multicéntrico, observacional, prospectivo de farmacovigilancia, que se realizó en 2.363 pacientes varones, mayores de 40 años, ambulatorios, hipertensos, tratados con monoterapia antihipertensiva, con presión arterial diastólica (PAD) < 95 mmHg, susceptibles de ser tratados con doxazosina por presentar hipertrofia benigna de próstata (HBP) asociada a hipertensión (HTA). Se inició el tratamiento con una dosis de doxazosina de 1 mg/día, incrementándose a intervalos de dos semanas, a 2 mg/día y a 4 mg/día. La duración del estudio fue de catorce semanas. Se midió la presión arterial (PA) y la frecuencia cardíaca (FC) en cada una de las visitas. En la visita basal y en la visita tras catorce semanas de tratamiento se cuantificó la sintomatología de prostatismo con la Escala Internacional de Síntomas Prostáticos (I-PSS) y la valoración de calidad de vida del Comité de la Asociación Urológica Americana. Se determinó la incidencia de efectos adversos en función de la reducción de presión obtenida y de la edad de los sujetos. Resultados. En la cuarta visita, en que los pacientes tomaban 4 mg de doxazosina, la reducción de PA fue de 10,7 ñ 11,3/6,1 ñ 7,1 mmHg. Este descenso fue significativamente mayor para PAD en el grupo en tratamiento con betabloqueantes frente a los grupos tratados con calcioantagonistas o inhibidores de la enzima conversora de la angiotensina (IECA) y superior para presión sistólica en los pacientes tratados con diurético frente a los tratados con calcioantagonistas o IECA. La sintomatología de prostatismo se redujo desde 15 ñ 5,8 puntos hasta 7,9 ñ 4,3 puntos (p < 0,001) acompañada de una mejora de calidad de vida. La tolerancia fue muy buena, encontrando una incidencia de efectos adversos relacionados con doxazosina del 4,4 por ciento. Los pacientes que presentaron efectos adversos tenían mayor edad y sus presiones finales fueron menores. Conclusión. La doxazosina puede ser utilizada en pacientes con HTA + HBP tratados con otro fármaco antihipertensivo independientemente del control arterial, pues en caso de no control mostrará efecto sinérgico con casi todos los otros fármacos y en los pacientes normalizados no producirá reducciones de PA importantes y sí una mejoría sustantiva de la sintomatología prostática (AU)

[An analysis of the referrals of primary care physicians to a hospital hypertension unit]. / Análisis de la derivación de médicos de atención primaria a una unidad de hipertensión hospitalaria.

OBJECTIVES: To describe the referral of hypertense patients from primary care to a hospital arterial hypertension unit, the quality of the information sent and the profile of the referred patients. DESIGN: A descriptive crossover study. SETTING: The Hospital Clínico of San Carlos in Madrid. PATIENTS AND OTHER PARTICIPANTS: A simple random sample of 368 clinical records belonging to patients attended at the unit over the last 3 years. MEASUREMENTS AND MAIN RESULTS: 54.6% of patients were referred from primary care. 48.9% of the interclinical (IC) notes were high-quality, with 28.7% acceptable. 36.8% of referrals were considered incorrect, 30.3% because of false unresponsiveness to treatment. Good or acceptable IC notes were associated with 94.1% of correct referrals and only 65.4% of incorrect referrals. CONCLUSIONS: A high proportion of referrals which were incorrect by the consensus criteria were detected and were caused by inadequate or insufficient medical treatment. There was a statistically significant relationship found between correct referrals and the quality of information sent in the IC note.

[Effect of suppression of apnea on arterial pressure and plasma catecholamines in normotensive patients with sleep apnea]. / Efecto de la supresión de las apneas sobre la presión arterial y catecolaminas plasmáticas en normotensos con apnea del sueño.

BACKGROUND: The association of high blood pressure (HBP) and the sleep apnea syndrome (SPS) and the beneficial effect of SAS treatment on HBP are well known. The direct effect of the continuous nocturnal administration of positive air pressure (CPAP) on blood pressure is not, however, well known. The aim of this study was to evaluate the blood pressure (BP), plasma catecholamines (PC) and urinary derivatives of catecholamines (UDC) in 17 normotensive subjects (4 females; age 49 +/- 11 years) with SAS, prior to and after correction of apnea with CPAP. METHODS: Twenty-four hour outpatient registry of blood pressure (OPRBP) and after nocturnal polysomnography were performed both basal and during CPAP administration for two nights. Urine was collected over these 24 hour period for measurement of UDC. At 7 hours a blood sample was collected for measurement of PC. RESULTS: SAS was corrected by CPAP in all the patients with a reduction in mean BP (24 h: 87 +/- 6 vs 84 +/- 6 mmHg, p < 0.05, diurnal, 90 +/- 6 vs 87 +/- 6 mmHg, p < 0.05, nocturnal, 84 +/- 6 vs 82 +/- 7 mmHg, NS) and the percentage of diastolic BP > 90 mmHg (24 h: 10 +/- 7 mmHg vs 6.5 +/- 6 mmHg, p < 0.01, diurnal, 15 +/- 10 vs 10 +/- 10 mmHg, p < 0.05, nocturnal 5.2 vs 5 vs 3 +/- 4 mmHg, p < 0.05). The plasma catecholamines tended to reduce, although not significantly, without changes of urinary metabolites. CONCLUSIONS: There is a significant decrease in blood pressure with the administration of continuous positive air pressure even in normotensive patients. An early correction of sleep apnea syndrome may reduce the high prevalence of hypertension associated with this syndrome.

[Treatment of essential arterial hypertension with hypercholesterolemia. Effects of an alpha-adrenergic blocker and an inhibitor of the angiotensin converting enzyme]. / Tratamiento de la hipertensión arterial esencial con hipercolesterolemia. Efectos de un bloqueador alfaadrenérgico y un inhibidor de la enzima conversiva de la angiotensina.

BACKGROUND: Hypertension and hypercholesterolemia are frequently associated with this leading to considerable cardiovascular risk. METHODS: An open parallel randomized study was performed in which the effects of doxazosin, an alpha-adrenergic blocker and enalapril, an inhibitor of the angiotensin converting enzyme were compared in 70 patients with essential high blood pressure and plasma cholesterol levels greater than 240 mg/dl. Following 2-4 weeks of placebo administration the patients were randomly treated with one of the two drugs. When required doses were increased and hydrochlorothiazide added until blood pressure lower than 160/95 mmHg was achieved. After this period the patients were observed for a minimum of 8 weeks. The mean length of the study was of 22 weeks. RESULTS: Both drugs significantly reduced blood pressure without modifying cardiac frequency. Doxazosin tended to favorably modify the lipid profile of the plasma while enalapril significantly reduced the levels of cholesterol, lipids and high density lipoproteins (HDL). Upon termination of the study the total HDL/cholesterol index increased 8.6% in those treated with doxazosin and decreased 5.5% in those receiving enalapril (p < 0.05). CONCLUSIONS: Although doxazosin and enalapril are potent antihypertensive drugs, the effects on plasma lipid obtained with doxazosin indicate that a reduction in cardiovascular risk was achieved with this drug in the patients included in this study.

[Sleep apnea in arterial hypertension]. / Apnea del sueño en la hipertensión arterial.

BACKGROUND: The sleep apnea syndrome (SAS) and high blood pressure (HBP) present multiple relations. Apnea culminates with an increase in arterial pressure, and a high percentage of apneic patients have HBP. It has also been reported that SAS is more frequent among hypertensive patients than among the general population. METHODS: In the present study 91 essential hypertensive individuals were studied by a questionnaire and polygraphic study of night sleep, to establish the prevalence of SAS among hypertensive subjects and the predictive value of the clinical questionnaire. RESULTS: The prevalence of SAS in HBP was 8.8%. The greatest predictive value was found for the presence of respiratory pauses every night and throughout the night. The risk factor of greatest association was cigarette smoking and the greatest organic repercussion was observed in renal function. CONCLUSIONS: An increase in the prevalence of sleep apnea syndrome was found among essential hypertensive subjects, thus leading this syndrome to be suggested as a risk factor of high blood pressure. The question as to whether the patients present daily pauses between snores and throughout the entire night is suggestive and implies confirmation by polygraphic study of night sleep.

The J-curve. The importance of gradual reduction of blood pressure.

Even if the treatment goal in hypertension is 'the lower the better', it is obvious that blood pressure (BP) cannot be reduced without reaching a point at which organ perfusion may become compromised and where mortality and morbidity will increase rather than decrease. In 1979, a 5-fold increase in myocardial infarction among patients whose diastolic BP was reduced to below 95mm Hg was reported. In 1987, these results were confirmed, and a J-shaped relationship between diastolic BP and death from myocardial infarction in those patients with evidence of ischaemic heart disease at entry into the trial was shown. In recent years, several studies have demonstrated this J-shaped curve with a J-point between 85 and 91mm Hg. However, all the data were obtained in retrospective analyses of a small number of patients and prospective properly designed studies are necessary before changing our treatment criteria. The Behandla Blodtryck Battre Study fulfils these criteria and preliminary results demonstrate that it is possible to achieve a further reduction in BP in well controlled hypertensive patients without increasing the incidence of side effects.

Cardiovascular effects of antihypertensive drugs--involvement in the therapeutic choice.

Hypertensive patients are at an increased risk of developing cerebrovascular and cardiovascular disease. Treatment has resulted in a substantial reduction in cerebrovascular deaths but not in cardiovascular mortality. As the number of deaths from myocardial infarction exceeds the sum of all other hypertension-related mortalities, these results are disappointing. The hypothesis that metabolic side effects of many antihypertensive drugs offset the potential benefit of decreasing blood pressure is of particular interest. In established hypertension there is an increase in total peripheral resistance. Long-term therapy with diuretics decreases vascular resistance. This is also evident with dihydropyridine calcium antagonists, vasodilators, angiotensin-converting enzyme inhibitors and alpha blockers. In patients with hypertension, an increased wall to lumen ratio occurs in resistance vessels where mechanisms such as smooth muscle hypertrophy and increased amounts of elastin and collagen are present. In small resistance vessels, long-term antihypertensive therapy has a positive effect, but the effect in large arteries is variable.

[Arterial hypertension in special situations: mild, systolic and in pregnancy]. / Hipertensión arterial en situaciones especiales: leve, sistólica y del embarazo.

Mild hypertension is very common, 50% of hypertensives being with their diastolic BP between 90 and 104 mmHg. Many large studies, especially HDFP, had shown not only the deleterious cardiovascular effects of mild hypertension but also the benefits obtained with the therapy. The non-pharmacological approach should be the first step in the treatment of mild hypertension. Isolated systolic hypertension have a high prevalence in the elderly, increasing the cardiovascular morbidity and mortality. Sodium restriction and, if necessary, vasodilators increasing the arterial compliance seem to be the logical approach to treat isolated systolic hypertension. Finally, eclampsia is the most serious complication of pregnancy - induced hypertension. The treatment with bed rest and either betablockers or methyldopa is beneficial. If eclampsia occurs hydralazine, magnesium sulphate or nifedipine should be used.

Calcium intake, calcium excretion and blood pressure in adolescents in the upper decile of the distribution: the Torrejon study.

We studied, by dietary recall, the calcium and magnesium intake in 1109 adolescents aged 14-18 years; from 128 we collected a 24-h urine sample to determine electrolyte excretion. Subjects with blood pressure greater than 90th percentile (211) did not consume less calcium or magnesium than those with blood pressure less than 50th (597). Urinary calcium excretion tended to be higher in the adolescents with the highest blood pressure, the difference being statistically significant in males. Urinary sodium excretion also tended to be higher in those adolescents with blood pressure above the 90th percentile than in those with blood pressure below the 50th percentile, the differences being statistically significant in females. A positive significant correlation was found between systolic blood pressure and both calcium and sodium excretion. Our results suggest that hypercalciuria is present in the early phase of hypertension and demonstrate that adolescents at high risk of developing hypertension consume the same amounts of calcium and magnesium as those with low blood pressure.

Acute antihypertensive effect of nifedipine on high and low salt diet.

To examine the influence of sodium balance in the acute response to nifedipine, we studied 10 untreated essential hypertensive patients aged 29 to 43 years. Blood pressure was recorded with the patients fasting and lying in the supine position, and 10 mg nifedipine was administered sublingually. Blood pressure was recorded again 3 h after nifedipine. Patients were studied after 1 week on both their unrestricted usual diet (NaU 206 +/- 29 mmol/day) and a low salt diet (NaU 66 +/- 8 mmol/day). The maximum hypotensive effect of nifedipine was observed at 90 min. The decrease of blood pressure tended to be greater and longer on high salt than low salt diet. Our results suggest that the acute antihypertensive effect of nifedipine is enhanced by sodium administration.

Relationship of blood pressure levels to height, weight and sodium and potassium excretion in Spanish children.

To study the distribution of blood pressure (BP) in children we measured the BP of 1928 children (aged 6-14 years) living in Torrejón de Ardoz, Spain. Of these, 441 children, representative of all ages, supplied a 24-h urine sample from which sodium and potassium were determined. There was a progressive rise in systolic BP of 1.8 mmHg and in diastolic BP of 0.8 mmHg per year of age. The correlations between BP, height and weight were positive and almost always statistically significant. Sodium excretion varied from 159 +/- 30 mmol/day at 6-7 years to 170 +/- 40 mmol/day at 13-14 years. There was a positive correlation between BP and sodium excretion which was statistically significant for diastolic BP in girls aged 6-7 years (P < 0.01) and for systolic BP in boys aged 10-12 (P < 0.05) and 13-14 (P < 0.01) years.