Inercia terapéutica en pacientes hipertensos asistidos en atención primaria en España. Estudio Objetivo Kontrol / Objective KONTROL study: therapeutic inertia in hypertensive patients attended in primary care of Spain

ObjetivosConocer el grado de inercia terapéutica (IT) y determinar los factores asociados al paciente, médico y organización sanitaria en pacientes hipertensos asistidos en atención primaria (AP).DiseñoEstudio transversal y multicéntrico.EmplazamentoMuestra de Equipos de AP de toda España.ParticipantesEl estudio fue realizado entre médicos de AP mediante un cuestionario y registro clínico de 4 pacientes.Mediciones principalesSe calculó la IT para cada paciente (ITp) como la proporción de visitas en las que no se produce un cambio en la medicación cuando está indicado.ResultadosUn total de 543 médicos aportaron datos de 2.032 pacientes, que cumplían el requisito de indicación de cambio, en el 77,8% de los casos se actuó con IT. La ITp observada fue inexistente o baja para el 17,1% de los pacientes, intermedia para el 42% y alta para el 40,8%. Los factores, relativos a los pacientes, que más se asociaron con la ITp alta fueron la edad (p<0,001), diabetes (p<0,001), ictus (p<0,01), obesidad (p<0,01) y el nivel bajo de estudios (p<0,001). Ser mujer, tener menos de 45 años o más de 55, ser médico de familia con un programa de formación diferente al MIR y trabajar en el sector público aumentaron la probabilidad de ITp (p<0,001 para todos los supuestos).ConclusionesLos resultados del estudio indican que en 7 de cada 10 visitas realizadas por pacientes hipertensos en AP se produce IT. Existen diferencias importantes en función de las características clínicas de los pacientes, de los médicos y de las consultas(AU)

ObjectivesTo determine the level of therapeutic inertia (TI), and the factors associated to the patient, doctor and the health organisation, in hypertensive patients treated in Primary Care (PC).DesignCross-sectional, multicentre study.SettingA sample of PC Teams from all over Spain.ParticipantsThe study was conducted among PC doctors using a questionnaire and clinical records of 4 patients.Main measurementsThe TI was calculated for each patient (TIp) as the proportion of visits in which there was no change in medication when this was indicated.ResultsA total of 543 PC doctors provided data on 2,032 patients, who fulfilled the indication of a change in requirement. There was TI In 77.8% of cases. The TIp observed was non-existent or low for 17.1% of the patients, intermediate for 42% and high for 40.8%. For the patients, the factors most associated with TIp were, age (P<.001), diabetes (P<.001), stroke (P<.01), obesity (P<.01) and a low education level (P<.001). To be female, be less than 40years or more than 55years, to be a family doctor with a training program other than MIR and to work in the public sector increased the probability of TIp (P<.001 for all the assumptions).ConclusionsThe results of the study indicate that there is TI in 7 out every 10 visits made by hypertensive patients in Primary care. There are significant differences as regards the clinical characteristics of the patients and of the doctors(AU)

Morbidity and mortality among heart failure patients in Galicia, N.W. Spain: the GALICAP Study.

OBJECTIVE: Characterization of current morbidity and mortality among heart failure (HF) outpatients in Galicia (N.W. Spain), together with their main determinants. DESIGN: Prospective multicentre study involving 149 primary care physicians. SETTING: Primary care physicians selected randomly from among all (1959) primary care physicians in Galicia. PATIENTS: Clinical and epidemiological information for 1195 outpatients with HF were collected in 2006, with a mean follow-up of 6.5+/-1.5 months. MAIN OUTCOME MEASURES: Survival rates were calculated by Cox's proportional hazard model. RESULTS: Mean patient age was 76 years, 48% were male, 82% had a history of arterial hypertension, and 32% ischaemic cardiopathy. Echocardiography had been performed in 67%, showing preserved systolic function in 61%. Ninety-two (8%) died during follow-up [74 (80%) of them from cardiac causes], and 313 (29%) were re-admitted to hospital [230 (73%) of them for cardiac reasons]. Multivariate analysis identified the following independent predictors of cardiovascular death and/or readmission: ischaemic cardiopathy [hazard ratio (HR) 1.76, 95% confidence interval (CI) 1.29-4.40], stroke (HR 1.79, CI 1.18-2.73), oedema (HR 1.49, CI 1.10-2.03), anaemia (HR 1.66, CI 1.21-2.27), deteriorated systolic function (HR 1.62, CI 1.19-2.20), and previous cardiovascular admissions (HR 2.33, CI 1.67-3.24). Residence in the Barbanza district was identified as an independent predictor of survival free from cardiovascular admission (HR 0.56, CI 0.37-0.86). CONCLUSION: Morbidity and mortality are currently high among Galician HF patients, and their best single predictor is previous hospitalization for cardiovascular reasons.

Gender differences in evidence-based pharmacological therapy for patients with stable coronary heart disease.

BACKGROUND: Women have a higher morbidity and mortality than men after an acute coronary event. We analyzed the prescription rates of evidence-based pharmacological therapies for patients with stable coronary heart disease and whether there were any differences with respect to gender. DESIGN: This cross-sectional study evaluated 8817 patients, 26.3% women, receiving attention from 1799 family doctors in primary care centers (PCC) throughout Spain, and who had had a coronary event requiring hospitalization in the previous 6 months to 10 years. RESULTS: Mean age was 65.4 years and a mean time-lapse since hospitalization of 37.4 months. In the overall population, prescription medications were: antiplatelet drugs in 80.5% of patients, 79% statins, 66% blockers of the angiotensin-renin system (BARS) and 47% beta-blockers. Males received less cardiovascular disease medications than females (4.3+/-1.5 versus 4.6+/-1.6, respectively; p<0.001), but when adjusted for risk factors the significance was lost (p=0.231). Following adjustment for risk factors and for co-morbidities, the use of diuretics was significantly higher in women while beta-blockers and statins were higher in men. The triple combination of antithrombotics, beta-blockers and statins was used in 41.4% (43.8% males versus 34.6% females; p<0.001) while 24.3% used this triple combination plus a BARS; without significant difference between the genders. CONCLUSIONS: An important percentage of patients with stable coronary disease, particularly women, attended-to in primary care do not receive medications that have been shown to decrease the morbido-mortality of cardiovascular disease.

[Occult chronic kidney disease in patients with stable coronary heart disease]. / Insuficiencia renal crónica oculta en pacientes con enfermedad coronaria estable.

BACKGROUND AND OBJECTIVE: Chronic kidney disease (CKD) increases cardiovascular risk mainly in subjects with coronary heart disease. The aim of this study was to evaluate the prevalence of occult CKD (OCKD) in stable coronary heart disease patients and to study the factors associated in order to improve its detection. PATIENTS AND METHOD: Cross sectional study of 7,884 patients who had had a coronary event requiring hospitalization in the previous 6 months to 10 years. Glomerular filtration rate was estimated by means of the Modification of Diet in Renal Disease (MDRD) study equation. CKD was defined as a glomerular filtration rate lower than 60 ml/min/1.73 m(2), and OCKD when, in addition, serum creatinine was < 133 mmol/l in men and < 124 mmol/l in women. RESULTS: The mean age was 65.3 years, 73.7% male and 22.4% had CKD, 68.3% of them with normal serum creatinine. In subjects with OCKD the prevalence of risk factors and cardiovascular diseases associated was intermediate between subjects without CKD and subjects with CKD and high serum creatinine. Age, female sex, hypertension, diabetes, heart failure, cerebrovascular disease and peripheral artery disease were significantly and independently associated with OCKD in the multivariate analysis. CONCLUSIONS: Almost one in 4 subjects with stable coronary heart disease had CKD, most of them with normal serum creatinine, mainly women and older patients.

Insuficiencia renal crónica oculta en pacientes con enfermedad coronaria estable / Occult chronic kidney disease in patients with stable coronary heart disease

FUNDAMENTO Y OBJETIVO: La presencia de insuficiencia renal crónica (IRC) aumenta el riesgo de enfermedadcardiovascular, especialmente en los pacientes con enfermedad coronaria. El objetivode este estudio ha sido examinar la prevalencia de IRC oculta (IRCO) en pacientes con enfermedadcoronaria estable e investigar los factores asociados a ella para favorecer su detección.PACIENTES Y MÉTODO: Se ha realizado un estudio transversal en el que participaron 7.884 sujetosque habían ingresado por un episodio coronario entre 6 meses y 10 años antes. Se calculó elfiltrado glomerular según la ecuación abreviada del estudio Modification of Diet in Renal Disease(MDRD). Se consideró IRC cuando el filtrado glomerular era menor de 60 ml/min/1,73 m2 eIRCO cuando además la creatinina sérica era inferior a 133 mmol/l en varones y a 124 mmol/len mujeres.RESULTADOS: La edad media de la población estudiada era 65,3 años y el 73,7% eran varones.Presentaba IRC un 22,4%, de los que el 68,3% tenía cifras de creatinina normales. En los pacientescon IRCO la prevalencia de factores de riesgo y enfermedades cardiovasculares asociadasera intermedia entre aquellos sin IRC y entre los que presentaban IRC con creatinina elevada.La edad, el sexo femenino, la presencia de hipertensión arterial, diabetes, insuficienciacardíaca, enfermedad cerebrovascular y enfermedad arterial periférica se asociaron de manerasignificativa e independiente con la presencia de IRCO en el análisis multivariante.CONCLUSIONES: Casi uno de cada 4 pacientes con enfermedad coronaria estable presenta IRC, lamayoría de ellos con creatinina normal, siendo especialmente frecuente en las mujeres y con elaumento de la edad

BACKGROUND AND OBJETIVE: Chronic kidney disease (CKD) increases cardiovascular risk mainly insubjects with coronary heart disease. The aim of this study was to evaluate the prevalence ofoccult CKD (OCKD) in stable coronary heart disease patients and to study the factors associatedin order to improve its detection.PATIENTS AND METHOD: Cross sectional study of 7,884 patients who had had a coronary event requiringhospitalization in the previous 6 months to 10 years. Glomerular filtration rate was estimatedby means of the Modification of Diet in Renal Disease (MDRD) study equation. CKD wasdefined as a glomerular filtration rate lower than 60 ml/min/1.73 m2, and OCKD when, in addition,serum creatinine was < 133 mmol/l in men and < 124 mmol/l in women.RESULTS: The mean age was 65.3 years, 73.7% male and 22.4% had CKD, 68.3% of them withnormal serum creatinine. In subjects with OCKD the prevalence of risk factors and cardiovasculardiseases associated was intermediate between subjects without CKD and subjects with CKDand high serum creatinine. Age, female sex, hypertension, diabetes, heart failure, cerebrovasculardisease and peripheral artery disease were significantly and independently associatedwith OCKD in the multivariate analysis.CONCLUSIONS: Almost one in 4 subjects with stable coronary heart disease had CKD, most ofthem with normal serum creatinine, mainly women and older patients

Achievement of therapeutic goals and utilization of evidence-based cardiovascular therapies in coronary heart disease patients with chronic kidney disease.

To evaluate whether the presence of chronic kidney disease (CKD) influenced the rate of prescription of evidence-based cardiovascular preventive therapies and attainment of therapeutic goals in patients with stable coronary heart disease, 7,884 patients (mean age 65.4 years; 81.7% men; 22.4% with CKD) attended to in 1,799 primary-care centers and who had had a coronary event requiring hospitalization in the previous 6 months to 10 years were recruited. Glomerular filtration rate (GFR) was estimated using the MDRD Study equation. Results indicated that patients with CKD received more diuretics (47.6% vs 32.8%; p = 0.034), calcium channel blockers (29.3% vs 23.2%, p = 0.027); and blockers of the angiotensin-renin system (76.4% vs 65.3%; p <0.001). The lower prescription rate of antiaggregants, beta blockers, and statins in subjects with CKD did not reach statistical significance in multivariate analysis. A lower percentage of subjects with CKD achieved good control of blood pressure (39.2% vs 65.4%; p <0.001) and glycosylated hemoglobin (43.9% vs 53.4%; p <0.001) relative to patients without CKD. Only 11.8% of patients with CKD had optimum control of all risk factors. Using multivariate analysis, the presence of CKD was inversely related to the degree of risk-factor control, especially in groups with low GFR. In conclusion, patients with stable coronary heart disease and CKD attended to in primary-care centers had poorer control of coronary heart disease risk factors than those with normal GFR despite receiving a similar rate of prescription of evidence-based cardiovascular disease preventive therapies.

[Galician study of heart failure in primary care (GALICAP Study)]. / Estudio gallego de insuficiencia cardiaca en atención primaria (estudio GALICAP).

INTRODUCTION AND OBJECTIVES: Heart failure (HF) is an important public health concern. Our aim was to evaluate the characteristics of HF patients in Galicia, Spain. METHODS: This descriptive, cross-sectional, multicenter study involved 149 primary care physicians and recorded the characteristics of 1195 patients diagnosed with HF. RESULTS: Some 48% of patients were male, and their mean age was 76 years, though women were older (P<.001). Disease history included hypertension in 82%, hyperlipidemia in 47%, diabetes in 31%, atrial fibrillation in 49%, valvular disease in 35%, and ischemic heart disease in 32%. Mean systolic and diastolic blood pressures were 131 mm Hg and 76 mm Hg, respectively. Pressure was controlled (

Estudio gallego de insuficiencia cardiaca en atención primaria (estudio GALICAP) / Galician study of heart failure in primary care (GALICAP study)

Introducción y objetivos. La insuficiencia cardiaca (IC) es un importante problema de salud en nuestro medio. Pretendemos conocer las características de estos pacientes en Galicia. Métodos. Estudio descriptivo, transversal, multicéntrico con la participación de 149 médicos de atención primaria, en el que se registraron las características de 1.195 pacientes diagnosticados de IC. Resultados. Un 48% de los pacientes eran varones con una edad media de 76 años, mayor en mujeres (p < 0,001). Presentaba antecedentes de hipertensión el 82%, de dislipidemia el 47%, de diabetes el 31%, de fibrilación auricular el 49%, de valvulopatía el 35% y de cardiopatía isquémica el 32%. Los valores medios de presión arterial sistólica y diastólica fueron, respectivamente, 131 y 76 mmHg, y estaban controlados (≤ 130/80 mmHg) en el 43% de pacientes. El 67% tiene un ecocardiograma, el 61% de ellos con una función sistólica preservada. Al 47% de los pacientes con IC se les realizó una coronariografía, porcentaje superior (p < 0,001) en varones. Los fármacos más prescritos fueron diuréticos (82%), inhibidores de la enzima de conversión de la angiotensina (IECA) (48%), antagonistas de los receptores de la angiotensina II (29%) y bloqueadores beta (27%). En los pacientes con función sistólica deprimida se prescriben más bloqueadores beta (p < 0,001), IECA (p < 0,01) y antialdosterónicos (p < 0,05). Durante el último año, el 57% de los pacientes estuvieron ingresados, el 45% de ellos por causa cardiovascular. Conclusiones. La IC con función sistólica preservada es la forma más prevalente en Galicia, que está mayoritariamente asociada con una presión arterial elevada siendo, su control limitado. En pacientes con cardiopatía isquémica, el sexo influye en la realización de coronariografía. La prescripción de fármacos no es óptima. Es necesario promover estrategias para mejorar el cuidado de estos pacientes (AU)

Introduction and objectives. Heart failure (HF) is an important public health concern. Our aim was to evaluate the characteristics of HF patients in Galicia, Spain. Methods. This descriptive, cross-sectional, multicenter study involved 149 primary care physicians and recorded the characteristics of 1195 patients diagnosed with HF. Results. Some 48% of patients were male, and their mean age was 76 years, though women were older (P<.001). Disease history included hypertension in 82%, hyperlipidemia in 47%, diabetes in 31%, atrial fibrillation in 49%, valvular disease in 35%, and ischemic heart disease in 32%. Mean systolic and diastolic blood pressures were 131 mm Hg and 76 mm Hg, respectively. Pressure was controlled (≤ 130/80 mm Hg) in 43% of patients. Overall, 67% underwent echocardiography, of whom 61% had preserved systolic function. Coronary angiography was performed in 47% of patients with ischemic heart disease, more frequently in males than females (P<.001). The most commonly prescribed drugs were diuretics (82%), angiotensin-converting enzyme (ACE) inhibitors (48%), angiotensin II receptor antagonists (29%), and beta-blockers (27%). Patients with depressed systolic function were more frequently prescribed beta-blockers (P<.001), ACE inhibitors (P<.01), and antialdosterones (P<.05). During the last year, 57% of patients had been admitted to hospital, of whom 45% were admitted for cardiovascular reasons. Conclusions. The most prevalent form of HF in Galicia was HF with preserved systolic function, which was mostly associated with high blood pressure due to poor control. In patients with ischemic heart disease, the use of coronary angiography was influenced by sex. Drug treatment was suboptimal. Intervention programs are required to improve care in these patients (AU)

Control de factores de riesgo coronario en prevención secundaria: estudio PRESENAP / Control of coronary risk factors in secondary prevention: PRESENAP study

Fundamento y objetivo: Evaluar el grado general de consecución de objetivos de control de los factores de riesgo en prevención secundaria de los pacientes que han tenido un episodio coronario y son seguidos en atención primaria. Pacientes y método: Estudio descriptivo, transversal y multicéntrico con inclusión mediante muestreo consecutivo de los primeros 5 pacientes que acudieron a consulta y habían tenido un episodio coronario en un período previo de 6 meses a 10 años. Los objetivos de control fueron: presión arterial < 140/90 mmHg en población general y < 130/85 mmHg en diabéticos, colesterol de las lipoproteínas de baja densidad (cLDL) < 100 mg/dl y no ser fumador. Resultados: Se incluyó a 8.817 pacientes (varones el 73,7%) con una media (desviación estándar) de edad de 65,4 (10,3) años. El 76,6% eran hipertensos; el 73,4%, dislipémicos, y el 32,7%, diabéticos. El 60,2% alcanzó el objetivo de presión arterial, el 26,3% alcanzó el objetivo de cLDL < 100 mg/dl y el 11,4% siguió fumando. Cumplió la totalidad de las recomendaciones el 16,4%. Los factores relacionados de forma independiente con un buen control fueron la menor edad, el sexo masculino, el ingreso por síndrome coronario agudo sin elevación del ST (odds ratio [OR] = 1,39; intervalo de confianza [IC] del 95%, 1,01-1,93; p = 0,04) o para revascularización (OR = 1,37; IC del 95%, 1,12-1,67; p = 0,002), tener enfermedad arterial periférica (OR = 1,43; IC del 95%, 1,11-1,84; p = 0,005) y que los objetivos planteados por los médicos fueran adecuados (OR = 1,90; IC del 95%, 1,48-2,44; p < 0,0001). El control fue peor en los pacientes hipertensos o dislipémicos. Conclusiones: El control general de los factores de riesgo en prevención secundaria de la enfermedad coronaria se consigue en 1 de cada 6 pacientes atendidos en atención primaria

Background and objective: Evaluate the overall achievement of goals in the control of risk factors in secondary prevention in patients who have suffered a coronary event and are followed up in primary care centers. Patients and method: Descriptive, transversal, multicenter study with sampling by consecutive inclusion of the first 5 patients attending the doctor's office who had suffered a coronary event 6 months to 10 years previously. The targets for control were: blood pressure < 140/90 mmHg in the general population and < 130/85 mmHg in diabetics; LDL-cholesterol < 100 mg/dl and no smoking habit. Results: 8,817 patients (73.7% males) were included, with a mean (SD) age of 65.4 (10.3) years; 76.6% were hypertensive, 73.4% dyslipidemic and 32.7% diabetics; 60.2% achieved target blood pressure; 26.3% achieved LDL-cholesterol <100 mg/dl and 11.4% continued smoking; 16.4% fulfilled all recommendations. Factors independently related with good control were a lower age, male sex, patients who had been admitted with acute coronary syndrome without ST elevation (OR = 1.39; CI 95%, 1.01-1.93; p = 0.04) or for revascularization (OR = 1.37; CI 95%; 1.12-1.67; p = 0.002), patients with peripheral arterial disease (OR = 1.43; CI 95%, 1.11-1.84; p = 0.005) and when the physicians proposed suitable objectives (OR = 1.90; CI 95%, 1.48-2.44; p < 0.0001). Control was poorer in hypertensive or dyslipidemic patients. Conclusions: Overall control of risk factors in secondary prevention of coronary disease is achieved in one in six patients attending primary care

[Control of coronary risk factors in secondary prevention: PRESENAP study]. / Control de factores de riesgo coronario en prevención secundaria: estudio PRESENAP.

BACKGROUND AND OBJECTIVE: Evaluate the overall achievement of goals in the control of risk factors in secondary prevention in patients who have suffered a coronary event and are followed up in primary care centers. PATIENTS AND METHOD: Descriptive, transversal, multicenter study with sampling by consecutive inclusion of the first 5 patients attending the doctor's office who had suffered a coronary event 6 months to 10 years previously. The targets for control were: blood pressure < 140/90 mmHg in the general population and < 130/85 mmHg in diabetics; LDL-cholesterol < 100 mg/dl and no smoking habit. RESULTS: 8,817 patients (73.7% males) were included, with a mean (SD) age of 65.4 (10.3) years; 76.6% were hypertensive, 73.4% dyslipidemic and 32.7% diabetics; 60.2% achieved target blood pressure; 26.3% achieved LDL-cholesterol <100 mg/dl and 11.4% continued smoking; 16.4% fulfilled all recommendations. Factors independently related with good control were a lower age, male sex, patients who had been admitted with acute coronary syndrome without ST elevation (OR = 1.39; CI 95%, 1.01-1.93; p = 0.04) or for revascularization (OR = 1.37; CI 95%; 1.12-1.67; p = 0.002), patients with peripheral arterial disease (OR = 1.43; CI 95%, 1.11-1.84; p = 0.005) and when the physicians proposed suitable objectives (OR = 1.90; CI 95%, 1.48-2.44; p < 0.0001). Control was poorer in hypertensive or dyslipidemic patients. CONCLUSIONS: Overall control of risk factors in secondary prevention of coronary disease is achieved in one in six patients attending primary care.