A new tool to assess retinal vessel caliber. Reliability and validity of measures and their relationship with cardiovascular risk.

OBJECTIVE: To analyze the reliability and validity of a semiautomated tool for assessing retinal vessel caliber and to describe the relationship of measures taken to cardiovascular risk and target organ damage. METHODS: A total of 210 patients aged 34-75 years were selected with retinography. Retinal photographs were digitized, and superior and inferior temporal vessels were measured in an area 0.5-1 disk diameter from the optic disc with semiautomated software [arteriole/venule index (AVIx) calculator]. AVIx was also estimated. Vascular damage was assessed using carotid intima-media thickness and pulse wave velocity, cardiac damage using Cornell voltage-duration product, renal damage using the glomerular filtration rate and microalbuminuria, and cardiovascular risk with the Framingham score. RESULTS: Interobserver intraclass correlation coefficient (ICC) ranged from 0.96 [95% confidence interval (CI) 0.94-0.97] to 0.99 (95% CI 0.98-0.99), and intraobserver ICC ranged from 0.97 (95% CI 0.94-0.98) to 0.99 (95% CI 0.99-0.99). In the Bland-Altman plot, the limit of interobserver agreement was -0.009 (0.066 to -0.086) in right AVIx and -0.001 (0.083 to -0.085) in left AVIx, whereas the limit of intraobserver agreement for overall AVIx was -0.005 (-0.057 to -0.047). Cardiovascular risk and albumin-creatinine ratio were higher in the first tertile of AVIx as compared with the other two (P < 0.05). In multiple regression, AVIx and venule caliber, but not artery caliber, behaved as predictors of cardiovascular risk and microalbuminuria. CONCLUSION: This tool showed a high intraobserver and interobserver reliability, and results of the validity analysis agree with those from large studies in estimation of cardiovascular risk and evaluation of target organ damage.

Cardiovascular risk assessment in hypertensive patients with tests recommended by the European Guidelines on Hypertension.

OBJECTIVE: To evaluate the usefulness of the diagnostic tests recommended by the European Society of Hypertension/Cardiology Guidelines (ESH-ESC 2007) in hypertensive patients classified as being at low or moderate risk, analyzing the change to high risk classification and the characteristics associated with such change. METHODS: A cross-sectional study was made in 391 patients aged between 30 and 80 years recently diagnosed with arterial hypertension in the Primary Care setting. The criteria of the 2007 ESH-ESC Guidelines were followed for the evaluation of risk factors, subclinical organ damage, cardiovascular disease and cardiovascular risk. In addition to the routine tests, echocardiography, carotid ultrasound, albumin/creatinine ratio, estimated glomerular filtration rate, ankle-brachial index, pulse wave velocity and retinography were used. We established four levels of testing performed for risk classification. RESULTS: Using the routine tests to evaluate risk (level 1), 218 (55.8%) patients were classified as being at high risk. Of the 173 patients classified as presenting low or moderate risk, the ankle-brachial index, albumin/creatinine ratio and glomerular filtration rate were determined (level 2), and 18 patients (10.4%) were classified as being at high risk. With echocardiography and carotid ultrasound (level 3), another 16 patients (10%) were raised to high risk. Finally, with pulse wave velocity and retinography (level 4), 10 additional patients (5%) were classified as presenting high risk. Patients with increased blood pressure, advanced age and women showed a 4.28-fold (95%CI: 2.01-9.16), 3.54-fold (95%CI: 1.61-7.77) and 1.36-fold (95%CI: 0.62-3.00) higher probability of being reclassified to high cardiovascular risk, respectively. CONCLUSIONS: With the non-routine tests, 25.4% of the low or moderate risk patients were reclassified as presenting high risk.

Relationship between ambulatory arterial stiffness index and subclinical target organ damage in hypertensive patients.

Increased arterial stiffness has been shown to predict cardiovascular risk in hypertensive patients. Our objective was to evaluate the relationship between the ambulatory arterial stiffness index (AASI) and subclinical organ damage (SOD). The design was a cross-sectional study. Subjects included 554 hypertensive patients with and without drug treatment (mean age 57±12 years, 60.6% men). The AASI was defined as 1 minus the regression slope of diastolic over systolic blood pressure (BP) readings obtained from 24-h recordings. Renal damage was evaluated on the basis of glomerular filtration rate (GFR) and microalbuminuria; vascular damage was measured by carotid intima-media thickness (IMT) and ankle/brachial index (ABI); and cardiac damage was evaluated on the basis of the Cornell voltage-duration product (VDP) and left ventricular mass index. The mean AASI was 0.38±0.07 (0.39±0.07 in treated patients and 0.37±0.06 in nontreated subjects). The AASI showed a positive correlation with IMT (r=0.417, P<0.001) and Cornell VDP (r=0.188, P<0.001), and a negative correlation with GFR (r=-0.205, P=0.001) and the ABI. The variables associated with the presence of SOD were AASI (odds ratio (OR)=3.89) and smoking (OR=1.55). The variables associated with IMT were smoking and waist circumference, whereas those associated with GFR were AASI, body mass index and waist circumference. In turn, smoking, total cholesterol and glycosylated hemoglobin A1c were associated with the ABI. Increased AASI implies a greater presence of SOD in primary hypertensive patients with or without BP-lowering drug treatment.

Pulse pressure and nocturnal fall in blood pressure are predictors of vascular, cardiac and renal target organ damage in hypertensive patients (LOD-RISK study).

OBJECTIVES: To analyse the relationship between various parameters derived from ambulatory blood pressure monitoring (ABPM) and vascular, cardiac and renal target organ damage. METHODS: A cross-sectional, descriptive study. It included 353 patients with short-term or recently diagnosed hypertension. PRIMARY MEASUREMENTS: ABPM, carotid intima-media thickness (IMT), Cornell voltage-duration product (Cornell VDP), glomerular filtration rate and albumin/creatinine ratio to assess vascular, cardiac and renal damage. RESULTS: Two hundred and twenty-three patients (63.2%) were males, aged 56.12+/-11.21 years. The nocturnal fall in blood pressure was 11.33+/-8.41, with a dipper pattern in 49.0% (173), nondipper in 30.3% (107), extreme dipper in 12.7% (45) and riser in 7.9% (28). The IMT was lower in the extreme dipper (0.716+/-0.096 mm) and better in the riser pattern (0.794+/-0.122 mm) (P<0.05). The Cornell VDP and albumin/creatinine ratio were higher in the riser pattern (1818.94+/-1798.63 mm/ms and 140.78+/-366.38 mg/g, respectively) than in the other patterns. In the multivariate analysis after adjusting for age, sex and antihypertensive treatment, with IMT as dependent variable the 24-h pulse pressure (beta = 0.003), with Cornell VDP the rest pulse pressure (beta = 12.04), and with the albumin/creatinine ratio the percentage of nocturnal fall in systolic blood pressure (beta = -3.59), the rest heart rate (beta = 1.83) and the standard deviation of 24-h systolic blood pressure (beta = 5.30) remain within the equation. CONCLUSION: The estimated pulse pressure with ABPM is a predictor of vascular and cardiac organ damage. The nocturnal fall and the standard deviation in 24-h systolic blood pressure measured with the ABPM is a predictor of renal damage.

Presión arterial clínica y ambulatoria y su relación con el grosor íntima-media de carótida (LOD-RISK Study) / Outpatient blood pressure monitoring and its relationship with carotid intima-media thickness (LOD-RISK study )

Objetivo. Evaluar la relación entre la presión arterial y el perfil circadiano y el grosor de la íntima media de la carótida. Metodología. Estudio descriptivo transversal. Se evaluó a 284 pacientes con hipertensión en atención primaria, de los cuales el 62% eran varones, y tenían una edad media de 57,86 años. Mediciones: edad, sexo, presión arterial clínica, presión de pulso, monitorización ambulatoria de presión arterial y patrón circadiano. Se calculó el aumento del grosor de la capa íntima-media (GIM) de la carótida mediante ecografía con protocolo de 12 medidas, utilizando el grosor medio y máximo. Se considera patológico si el GMI medio > 0,9 mm o hay presencia de placas según la Guía Europea de Hipertensión de 2007. Resultados. La presión arterial clínica fue de 138,7/75,01 mmHg y la presión de pulso 50,6 mmHg. La presión arterial de 24 h fue de 122,9/76,3 mmHg; en actividad, 126,7/79,7 mmHg, y en descanso, 112,8/67 mmHg. El descenso nocturno fue del 10,8% en la presión arterial sistólica y del 15,8% en la diastólica, y la presión de pulso de 24 h fue de 46,7 mmHg en actividad, 46,9 mmHg, y en descanso, 45,8 mmHg. El 46,5% de los pacientes presenta patrón dipper; el 35,9%, non-dipper; el 10,9%, extreme dipper, y el 6,7%, riser. El GIM medio fue de 0,765 mm y el GIM máximo, 0,943 mm. Cuarenta y seis (16,2%) pacientes tenían GIM medio > 0,9 mm o placas. En el patrón riser, el GIM fue de 0,831 mm; en non-dipper, de 0,765 mm; en dipper, de 0,762 mm, y en extreme dipper, de 0,738 mm (p < 0,05).Encontramos correlación positiva (p < 0,05) entre GIM medio y máximo con presión arterial sistólica clínica (r = 0,27), presión de pulso (r = 0,38), presión arterial sistólica de 24 h (r = 0,26), en actividad (r = 0,24) y descanso (r = 0,28) y negativa con presión arterial díastólica de 24 h (r = –0,18) y en actividad (r = –0,21). Conclusiones. El GIM de carótida se correlaciona positivamente con la presión arterial sistólica y la presión de pulso, tanto clínica como ambulatoria, y negativamente con la presión arterial diastólica ambulatoria y con el descenso nocturno de la presión arterial. El patrón riser está asociado con GIM mayor y extreme dipper menor (AU)

Objective. To assess relationships between blood pressure and circadian pattern and carotid intima-media thickness (IMT). Methods. Cross-sectional study. We included 284 hypertensive patients evaluated in primary care. Men 62%, aged 57.86 years. Measurements: Age, sex, office blood pressure, pulse pressure, ambulatory monitoring blood pressure and circadian pattern. Intima-media thickness (IMT) by ultrasound with protocol of 12 measurements, using mean maximum values. It is considered pathological if IMT > 0.9 mm or presence of plaques in accordance with European hypertension guidelines 2007. Results. Office blood pressure was 138.7/75.01 mmHg and pulse pressure 50.6 mmHg. Blood pressure 24 hours was 122.9/76.3, in activity: 126.7/79.7 and at rest: 112.8/67 mmHg. Systolic decrease in blood pressure was 10.8% and diastolic 15.8%. pulse pressure 24 hours was 46.7 mmHg, in activity 46.9 mmHg and at rest 45.8 mmHg. Circadian pattern was: 46.5% dipper, 35.9% non-dipper, 10,9% extreme dipper and 6.7% riser. IMT mean value was 0.765 mm and mean maximum 0.943 mm. A total of 46 (16.2%) patients had IMT > 0.9 mm or plaque. IMT in riser was 0.831mm, non-dipper 0.765, dipper 0.762 and extreme dipper 0.738 mm (p < 9.05). We found a positive correlation (p < 9.05) between mean and maximum IMT with Office blood pressure (r = 0.27), pulse pressure (r = 0.38), systolic blood pressure 24 hours (r = 0.26), day (r = 0.24), night (r = 0.28) and a negative correlation with diastolic blood pressure 24 hours and daytime (r = –0.18, r = –0.21). Conclusions. Carotid intima-media thickness correlates positively with clinic and ambulatory systolic blood pressure and pulse pressure and negatively with diastolic blood pressure and decrease in night blood pressure. Riser pattern is associated with intima-media thickness higher and extreme dipper lower (AU)

[Cycles of improvement of the hypertensive patient's care: risk-cycle study]. / Los ciclos de mejora de calidad en la atención al paciente hipertenso: Ciclo-Risk Study.

BACKGROUND: Frequently we found deficiencies in the management of cardiovascular risk factors on hypertensive patients in primary care. OBJECTIVE: This study was to evaluate the effect of a quality improvement intervention in the care of cardiovascular risk factors in hypertensive patients. METHODS: Quality assurance study. Two health centres with fourteen family doctors. One centre (seven doctors) was assigned to receive a quality improvement intervention while the other centre was assigned the control group. 482 hypertensive patients were in the study group (64% females, mean age 61,4 years (SD 6,8)), and 360 were in the control group (63% females, mean age 60,7 (SD 7,4)). Quality improvement circles consisting of audit, feedback, training sessions, and guidelines discussion. Process criteria of hypertension control, blood pressure, weight, lipids, smoking, cardiovascular risk and antihypertensive drugs used were measurement before intervention and again one year later. RESULTS: The mean improvement in process criteria after the intervention was 5,3 percent points (CI95%:3,7-6,9). Systolic blood pressure was decreased by 3,5 mmHg(IC95%:1,6-5,3) and Diastolic blood pressure by 2,5 mmHg(IC95%:1,3-3,8). Adequate BP control was significantly increased in the intervention group (29,1% to 40,9%;p<0,01), while no effect was achieved in the control group. Absolute cardiovascular risk decreased (15,86 to14,34%, p<0.01) in the study group, with no changes in the control group. Absolute risk decreases 2,07(IC95%:1,21-2,93) and relative risk 0,25 (IC95%:0,14-0,35) percent points. CONCLUSION: The quality intervention was effective in improving the quality care process and decreased blood pressure and absolute and relative cardiovascular risk.

Los ciclos de mejora de calidad en la atención al paciente hipertenso. (Ciclo-Risk study) / quality circles improve on hypertensive patients care (Ciclo-risk study)

Fundamentos: Con frecuencia encontramos deficiencias en el manejo de los factores de riesgo en las personas hipertensas. El objetivo del estudio fue evaluar el efecto de una intervención de mejora de calidad en la atención a los factores de riesgo cardiovascular en personas hipertensas. Métodos: Estudio de mejora de calidad. Dos centros de salud y catorce médicos de familia. Un centro (siete médicos) se seleccionó para recibir una intervención de mejora de calidad y otro como grupo control. Se incluyó a 482 personas hipertensas en el grupo de estudio [64% mujeres, edad media 61,4 años (DS:6.8)] y 360 en el grupo control (63% mujeres, edad media 60,7 (DS:7.4)). La intervención consistió en una auditoria de historias clínicas con feedback, sesiones de entrenamiento y discusión de guías clínicas. Previamente a la intervención y un año después de la misma se evaluaron criterios de proceso de atención a personas hipertensas, presión arterial, peso, lípidos, tabaco, riesgo cardiovascular y fármacos antihipertensivos. Resultados: La mejora media en el proceso después de la intervención fue de 5,3 puntos porcentuales (CI95%:3,7-6,9). La presión arterial sistólica descendió 3,5 mmHg (IC95%:1,6-5,3) y la presión arterial diastólica 2,5 mmHg (IC95%:1,3-3,8). El control adecuado de la presión arterial se incrementó en el grupo de intervención (29,1% a 40,9%; p<0.01) y no hubo cambios en el grupo control. El riesgo cardiovascular descendió en el grupo de intervención (15,86 a 14,34%, P<0.01) y en el grupo control no varió. El riesgo absoluto descendió 2,07(IC95%:1,21-2,93) y el relativo 0,25 puntos porcentuales (IC95%:0,14-0,35). Conclusiones: La intervención fue efectiva en la mejora de calidad de atención al proceso asistencial al haber descendido la presión arterial y el riesgo cardiovascular, tanto absoluto como relativo (AU)

Background: Frequently we found deficiencies in the management of cardiovascular risk factors on hypertensive patients in primary care. Objective this study was to evaluate the effect of a quality improvement intervention in the care of cardiovascular risk factors in hypertensive patients. Methods: Quality assurance study. Two health centres with fourteen family doctors. One centre (seven doctors) was assigned to receive a quality improvement intervention while the other centre was assigned the control group. 482 hypertensive patients were in the study group (64% females, mean age 61,4 years (SD 6,8)), and 360 were in the control group (63% females, mean age 60,7 (SD 7,4)).Quality improvement circles consisting of audit, feedback, training sessions, and guidelines discussion. Process criteria of hypertension control, blood pressure, weight, lipids, smoking, cardiovascular risk and antihypertensive drugs used were measurement before intervention and again one year later. Results: The mean improvement in process criteria after the intervention was 5,3 percent points (CI95%:3,7-6,9). Systolic blood pressure was decreased by 3,5 mmHg(IC95%:1,6-5,3) and Diastolic blood pressure by 2,5 mmHg(IC95%:1,3-3,8). Adequate BP control was significantly increased in the intervention group (29,1% to 40,9%;p<0,01), while no effect was achieved in the control group. Absolute cardiovascular risk decreased (15,86 to14,34%, p<0.01) in the study group, with no changes in the control group. Absolute risk decreases 2,07(IC95%:1,21-2,93) and relative risk 0,25 (IC95%:0,14-0,35) percent points. Conclusion: The quality intervention was effective in improving the quality care process and decreased blood pressure and absolute and relative cardiovascular risk (AU)

[Cardiovascular risk of hypertensive people with long-range monitoring. The effect of aging (Ciclo Risk Study)]. / Riesgo cardiovascular del paciente hipertenso con seguimiento prolongado en atención primaria. El efecto del envejecimiento (Ciclo Risk Study).

BACKGROUND: The evolution of estimated cardiovascular risk can be for evaluating the effectiveness of the different treatment interventions which are carried out on patients with regular follow-up by family physicians. This study is aimed at evaluating the effect of aging on the evolution of cardiovascular risk among hypertensive patients with long-range Primary Care monitoring. METHODS: Longitudinal, descriptive study with monitoring of 842 hypertensive patients within the 34-70 age range at two primary care centers, with a quality improvement intervention (improvement cycle) during the last year at one of these centers. The main variables were age and gender, blood pressure, lipids, smoking habit, diabetes and cardiovascular risk (CVR) (Framingham-Wilson) in the real-life situation and considering the age constant in the first case, and the risk factors in the second, plus the relative risk. RESULTS: A drop was found in the systolic and diastolic blood pressure from 11.78 mmHg (95 IC: 10.51-13.05) and 8.83 mmHg (95 CI: 8.13-9.53), respectively, and LDL Cholesterol 15.94 mg/dl (95 CI: 11.77-20.12), a rise in HDL-Cholesterol of 7.53 mg/dl (95C1: 6.39-8.66), decreased smoking habit of 31% and an increase in diabetics. The Coronary risk decreased 1.40 percent points, Coronary risk with age constant decreased 3.84 (95 CI: 3.35-4.33), having increased with constant risk factors by 3.06(95 CI: 2.82-3.29). The Relative risk dropped from 2.50 to 1.85. CONCLUSIONS: Aging may mask the effect achieved by health care in the absolute cardiovascular risk check. The relative risk could be an alternative for monitoring the follow-up.

Riesgo cardiovascular del paciente hipertenso con seguimiento prolongado en Atención Primaria. El efecto del envejecimiento (Ciclo risk study) / Cardiovascular risk of hypertensive people with long-range monitoring. The effect of aging (Ciclo risk study)

Fundamento La evolución del riesgo cardiovascular estimado, puede servir para valorar la efectividad de las diferentes intervenciones terapéuticas que se realizan en pacientes con seguimiento habitual en las consultas del médico de familia. El objetivo de este trabajo es comparar diferentes sistemas de evaluación del efecto de las intervenciones preventivas en la evolución del riesgo coronario en el seguimiento a largo plazo de personas hipertensas en Atención Primaria. Métodos: Estudio descriptivo longitudinal con seguimiento de 8.42 pacientes hipertensos de 34 a 70 años durante 6 años en dos centros de atención primaria, con una intervención de mejora de calidad (ciclo de mejora) en el último año en uno de ellos. El seguimiento mínimo en atención primaria previo al inicio del estudio fue de dos años. Las variables principales fueron edad y sexo, presión arterial, lípidos, tabaquismo, diabetes y riesgo cardiovascular (RCV)(Framingham-Wilson) en la situación real y considerando constante la edad en el primer supuesto y los factores de riesgo en el segundo y el riesgo relativo. Resultados: Se encontró un descenso de la presión arterial sistólica y diastólica de 11,78 mmHg (IC95%:10,51-13,05) y 8,83 mmHg (IC95%:8,13-9,53) respectivamente y LDL-Colesterol 15,94 mg/dl (IC95%:11,77-20,12), un ascenso del HDLColesterol de 7,53 mg/dl (IC95:6,39-8,66), disminución del tabaquismo del 31% y un aumento de diabéticos. El riego coronario disminuyó 1,40(IC95%:0,87-1,93) puntos porcentuales, el RCV con edad constante descendió 3,84(IC95%:3,35-4,33) y con factores de riesgo constantes incrementó 3,06(IC95%:2,82- 3,29). El Riesgo relativo descendió de 2,50 a 1,85. Conclusiones: El envejecimiento puede enmascarar el efecto logrado por la atención sanitaria en el control del riesgo cardiovascular absoluto. El riesgo relativo podría ser una alternativa para monitorizar el seguimiento (AU)

Background: The evolution of estimated cardiovascular risk can be for evaluating the effectiveness of the different treatment interventions which are carried out on patients with regular follow-up by family physicians. This study is aimed at evaluating the effect of aging on the evolution of cardiovascular risk among hypertensive patients with long-range Primary Care monitoring. Methods: Longitudinal, descriptive study with monitoring of 842 hypertensive patients within the 34-70 age range at two primary care centers, with a quality improvement intervention (improvement cycle) during the last year at one of these centers. The main variables were age and gender, blood pressure, lipids, smoking habit, diabetes and cardiovascular risk (CVR) (Framingham-Wilson) in the real-life situation and considering the age constant in the first case, and the risk factors in the second, plus the relative risk. Results: A drop was found in the systolic and diastolic blood pressure from 11.78 mmHg (95 IC: 10.51-13.05) and 8.83 mmHg (95 CI: 8.13-9.53), respectively, and LDL Cholesterol 15.94 mg/dl (95 CI: 11.77-20.12), a rise in HDL-Cholesterol of 7.53 mg/dl (95CI: 6.39-8.66), decreased smoking habit of 31% and an increase in diabetics. The Coronary risk decreased 1.40 percent points, Coronary risk with age constant decreased 3.84 (95 CI: 3.35-4.33), having increased with constant risk factors by 3.06(95 CI: 2.82-3.29). The Relative risk dropped from 2.50 to 1.85. Conclusions: Aging may mask the effect achieved by health care in the absolute cardiovascular risk check. The relative risk could be an alternative for monitoring the follow-up (AU)