Diuretic treatment of the patient with diabetes and heart failure. Role of SGLT2 inhibitors and similarities with carbonic anhydrase inhibitors. / Tratamiento diurético del paciente con diabetes e insuficiencia cardiaca. El papel de los inhibidores de la SGLT2 y semejanzas con los inhibidores de la anhidrasa carbónica.

Sodium-glucose cotransporter-2 inhibitors have changed the concept of the effects that hypoglycemic drugs have on hearth failure (HF). For the first time, a therapeutic group has modified the evolution of HF. Its effect goes beyond glycemic control, and different theories have been postulated to justify this benefit. In the article we sent, we analyze the influence of the different pharmacological groups used in type 2 diabetes mellitus on HF, and we present the theory of the mechanism of action associated with the benefit of these drugs. In our opinion, this benefit in HF is secondary to its diuretic effect, specifically an effect very similar to carbon dioxide inhibitors. We think that our theory is novel, explains the mechanism of action and we have not found in the literature any article that explains the mechanism of action in such a precise way.

[Tight control of blood pressure after ischemic stroke is associated with nocturnal hypotension episodes]. / El control estricto de la presion arterial tras un ictus isquemico se asocia con la aparicion de episodios de hipotension nocturna.

AIM: To evaluate whether a tighter blood pressure (BP) control in patients with recent ischemic stroke is associated with the presence of nocturnal hypotension (NHP) episodes. PATIENTS AND METHODS: We included one hundred consecutive patients who had been discharged for ischemic stroke in the previous six months. To evaluate adequacy of BP control in these patients office BP and 24-h ambulatory BP monitoring values were used. RESULTS: We studied 63 males and 37 females; mean age was 69 ± 11 years. Sixty-eight lacunar and 32 non-lacunar strokes were included. Episodes of NHP were observed in 59 patients. Clinical hypertension was present in 34 patients. An abnormal pattern of circadian rhythm of BP was present in 72 subjects. Only 18 patients had BP within normal limits. Episodes of NHP were more frequent in subjects with good BP control versus patients with bad BP control: 88.8% and 52.4 % respectively (p = 0.007). The presence of NHP episodes was also inversely related to number of BP parameters altered (p = 0.001). CONCLUSIONS: Tight control of BP after ischemic stroke is associated with a high frequency of NHP episodes. It is likely that aggressively lowering BP levels within the normal range after an ischemic stroke may be not beneficial, particularly in elderly patients.

TITLE: El control estricto de la presion arterial tras un ictus isquemico se asocia con la aparicion de episodios de hipotension nocturna.Objetivo. Evaluar si un control mas estricto de la presion arterial (PA) en pacientes con ictus isquemico reciente se asocia con la presencia de episodios de hipotension nocturna (HPN). Pacientes y metodos. Se incluyeron 100 pacientes consecutivos que habian sido dados de alta por ictus isquemico en los seis meses previos. Para evaluar el buen control de la PA en estos pacientes, se utilizaron valores de la PA en consulta y monitorizacion ambulatoria de la PA de 24 horas. Resultados. Se estudiaron 63 varones y 37 mujeres; la media de edad fue de 69 ± 11 años. Se incluyeron 68 ictus lacunares y 32 no lacunares. Se observaron episodios de HPN en 59 pacientes. La hipertension clinica estuvo presente en 34 pacientes. Un patron anormal del ritmo circadiano de la PA estaba presente en 72 sujetos. Solo 18 pacientes tenian la PA dentro de limites normales. Los episodios de HPN fueron mas frecuentes en los pacientes con buen control de la PA en comparacion con los pacientes con mal control: 88,8% y 52,4%, respectivamente (p = 0,007). La presencia de episodios de HPN tambien estaba inversamente relacionada con el numero de parametros de PA alterados (p = 0,001). Conclusiones. El control estricto de la PA tras un ictus isquemico se asocia con una alta frecuencia de episodios de HPN. Es probable que una reduccion intensiva de los niveles de la PA dentro del rango de la normalidad tras un ictus isquemico pueda no ser beneficiosa, en particular en los pacientes ancianos.

Hipotensión nocturna en pacientes con ictus reciente / Nocturnal hypotension in patients with recent stroke

Introducción: El tratamiento de la hipertensión arterial constituye en la actualidad un pilar fundamental en las estrategias de prevención secundaria del ictus. No obstante, hoy en día no hay unanimidad en las cifras de presión arterial (PA) objetivo en prevención secundaria, y existe controversia sobre si el tratamiento antihipertensivo comprometería la perfusión cerebral de estos pacientes. El objetivo de este estudio es describir y analizar la presencia de hipotensión nocturna (HPN) en pacientes con ictus reciente a través del análisis de la monitorización ambulatoria de la PA (MAPA).Material y método: Cuarenta y ocho pacientes consecutivos que acudieron a revisión al cabo de 6 meses tras un ictus fueron incluidos en el estudio. La MAPA de 24 h se llevó a cabo mediante el monitor Spacelab 90207. Se consideraron episodios de HPN aquellos valores en los que la PAsistólica era menor de 100 mmHg. Posteriormente se compararon los pacientes con HPN frente a los que no la presentaron mediante el programa estadístico SSPS18,0. Resultados: Se estudiaron 30 varones y 18 mujeres, de edad media 68±11 años. En 26 pacientes, el 54,2%, se evidenciaron episodios de HPN. No existieron diferencias significativas entre las características demográficas, tipo de ictus y factores de riesgo entre ambos grupos (..) (AU)

Introduction: Treatment of arterial hypertension is currently a fundamental mainstay in secondary stroke prevention strategies. However, at present there is no unanimity regarding target blood pressure (BP) levels in secondary prevention. Furthermore, controversy exists on whether blood pressure lowering treatment would affect the cerebral perfusion of these patients. This study has aimed to describe and analyze the presence of nocturnal hypertension (NHT)in patients with recent stroke through the analysis of ambulatory blood pressure monitoring(ABPM).Material and method: Forty-eight consecutive patients who came for checkup 6 months after a stroke were enrolled in the study. The 24-hour ABPM was conducted using the Spacelab 90207monitor. Episodes of NHT were considered to be those in which the systolic BP was less than100 mm Hg. After, the patients with NHT were compared with those who did not have it using the SSPS 18.0 statistical program. Results: A total of 30 men and 18 women, mean age 68±11 years, were studied. Of the 26patients, evidence of NHT episodes was observed. There were no statistical differences between the demographic characteristics, type of stroke and risk factors between both groups. In relationship to the BP levels, patients with NHT had significantly lower mean 24 hour BP, mean PB with (..) (AU)

Abnormal blood pressure circadian rhythm in acute ischaemic stroke: are lacunar strokes really different?

BACKGROUND: A pathologically reduced or abolished circadian blood pressure variation has been described in acute stroke. However, studies on alterations of circadian blood pressure patterns after stroke and stroke subtypes are scarce. The objective of this study was to evaluate the changes in circadian blood pressure patterns in patients with acute ischaemic stroke and their relation to the stroke subtype. AIMS: We studied 98 consecutive patients who were admitted within 24 h after ischaemic stroke onset. All patients had a detailed clinical examination, laboratory studies and a CT scan study of the brain on admission. To study the circadian rhythm of blood pressure, a continuous blood pressure monitor (Spacelab 90217) was used. Patients were classified according to the percentage fall in the mean systolic blood pressure or diastolic blood pressure at night compared with during the day as: dippers (fall> or =10-20%); extreme dippers (> or =20%); nondipper (<10%); and reverse dippers (<0%, that is, an increase in the mean nocturnal blood pressure compared with the mean daytime blood pressure). Data were separated and analysed in two groups: lacunar and nonlacunar infarctions. Statistical testing was conducted using the SSPS 12.0. Methods We studied 60 males and 38 females, mean age: 70.5+/-11 years. The patient population consisted of 62 (63.2%) lacunar strokes and 36 (36.8%) nonlacunar strokes. Hypertension was the most common risk factor (67 patients, 68.3%). Other risk factors included hypercholesterolaemia (44 patients, 44.8%), diabetes mellitus (38 patients, 38.7%), smoking (24 patients, 24.8%) and atrial fibrillation (19 patients, 19.3%). The patients with lacunar strokes were predominantly men (P=0.037) and had a lower frequency of atrial fibrillation (P=0.016) as compared with nonlacunar stroke patients. In the acute phase, the mean systolic blood pressure was 136+/-20 mmHg and diastolic blood pressure was 78.7+/-11.8. Comparing stroke subtypes, there were no differences in 24-h systolic blood pressure and 24-h diastolic blood pressure between patients with lacunar and nonlacunar infarction. However, patients with lacunar infarction showed a mean decline in day-night systolic blood pressure and diastolic blood pressure of approximately 4 mmHg [systolic blood pressure: 3.9 (SD 10) mmHg, P=0.003; diastolic blood pressure 3.7 (SD 7) mmHg, P=0.0001] compared with nonlacunar strokes. Nonlacunar strokes showed a lack of 24-h nocturnal systolic blood pressure and diastolic blood pressure fall. The normal diurnal variation in systolic blood pressure was abolished in 87 (88.9%) patients, and the variation in diastolic blood pressure was abolished in 76 (77.5%) patients. On comparing lacunar and nonlacunar strokes, we found that the normal diurnal variation in systolic blood pressure was abolished in 53 (85.4%) lacunar strokes and in 34 (94.4%) nonlacunar strokes (P=nonsignificant). In terms of diurnal variation in diastolic blood pressure, it was abolished in 43 (69.3%) lacunar strokes and in 33 (91.6%) nonlacunar strokes (P=0.026). CONCLUSIONS: Our results show clear differences in the blood pressure circadian rhythm of acute ischaemic stroke between lacunar and nonlacunar infarctions by means of 24-h blood pressure monitoring. The magnitude of nocturnal systolic and diastolic blood pressure dip was significantly higher in lacunar strokes. Besides, patients with lacunar strokes presented a higher percentage of dipping patterns in the diastolic blood pressure circadian rhythm. Therefore, one should consider the ischaemic stroke subtype when deciding on the management of blood pressure in acute stroke.

La polipíldora en la prevención secundaria del ictus / Polypills in the secondary prevention of strokes

No disponible

No disponible

Conocimiento sobre el tratamiento de la hipertensión, hiperglucemia y antiagregación en la fase aguda del ictus por los médicos de atención primaria / Primary care physicians’ knowledge about treatment of platelet aggregation inhibition, hyperglycemia and hypertension in the acute phase of stroke

No disponible

[Current role of statins in the stroke prevention]. / Papel actual de las estatinas en la prevención del ictus.

The role of lipids in stroke has been a traditionally debated subject. Many studies have recently demonstrated that reduction of cholesterol levels is associated to a lower stroke incidence. At present, statins play an essential role in both primary as well as secondary stroke prevention. More knowledge on the use of statins in stroke in order to be able to apply it in the daily clinical practice is needed.

Papel actual de las estatinas en la prevención del ictus / Current role of statins in the stroke prevention

El papel de los lípidos en el ictus ha sido un tema tradicionalmente a debate. Numerosos estudios han demostrado recientemente que la reducción de los niveles de colesterol se asocia a una menor incidencia de ictus. En la actualidad las estatinas desempeñan un papel esencial en la prevención del ictus, tanto en prevención primaria como en secundaria. Es necesario tener un mejor conocimiento del uso de las estatinas en el ictus para así poder aplicarlo a la práctica clínica diaria

The role of lipids in stroke has been a traditionally debated subject. Many studies have recently demonstrated that reduction of cholesterol levels is associated to a lower stroke incidence. At present, statins play an essential role in both primary as well as secondary stroke prevention. More knowledge on the use of statins in stroke in order to be able to apply it in the daily clinical practice is needed

[Statins and cerebrovascular disease: new perspectives in stroke prevention]. / Estatinas y enfermedad cerebrovascular: nuevas perspectivas en la prevención del ictus.

INTRODUCTION AND DEVELOPMENT: The role played by statins in the prevention of strokes has been subject to controversy for a long time, especially because no clear correlation between levels of cholesterol in serum and strokes has yet been established. Nevertheless, a number of randomised trials with statins and several meta-analyses that were carried out later have proved that statins lower the incidence of all kinds of strokes, with a 21% reduction in the relative risk. It has also been shown that this effect is essentially due to the degree to which LDL cholesterol (cholesterol linked to low-density lipoproteins) is reduced, which has a lowering effect on lipid levels. It has also been shown that statins have others beneficial effects apart from reducing cholesterol levels and that these may be independent of the subject's basal lipid levels. We are referring to the so-called pleiotropic effects, which include stabilisation of the atherosclerotic plaque, an antiinflammatory effect, an antithrombotic effect and enhanced vasomotor reactivity. CONCLUSION: The recent appearance of the results of the SPARCL (Stroke Prevention by Aggressive Reduction in Cholesterol Levels) study and the guidelines published by the American Heart Association and the Spanish Neurology Society, which grant statins a leading role in stroke prevention, both open up new horizons for the use of statins in cerebrovascular pathologies.

Estatinas y enfermedad cerebrovascular: nuevas perspectivas en la prevención del ictus / Statins and cerebrovascular disease: new perspectives in stroke prevention

Introducción y desarrollo. El papel de las estatinas en la prevención del ictus ha sido durante mucho tiempo tema de controversia, sobre todo porque la correlación entre los niveles séricos de colesterol e ictus no se ha establecido con claridad. No obstante, numerosos ensayos aleatorizados con estatinas y varios metaanálisis posteriores han demostrado que las estatinas disminuyen la incidencia de ictus de cualquier tipo, con una reducción de riesgo relativo del 21%, y este efecto se debe fundamentalmente al grado de reducción del colesterol LDL (colesterol ligado a lipoproteínas de baja densidad), con efecto hipolipemiante. También se ha demostrado que los beneficios de las estatinas van más allá de la reducción de los niveles de colesterol y que éstos pueden ser independientes de los niveles basales de lípidos del sujeto. Son los denominados efectos pleiotrópicos, entre los cuales se incluyen la estabilización de la placa aterosclerótica, el efecto antiinflamatorio, el efecto antitrombótico y la mejora de la reactividad vasomotora. Conclusión. La reciente aparición de los resultados del estudio SPARCL (Stroke Prevention by Aggressive Reduction in Cholesterol Levels), junto con la publicación de las guías de la American Heart Association y de la Sociedad Española de Neurología, que otorgan a las estatinas un papel principal en la prevención del ictus, abren nuevas perspectivas para el uso de las estatinas en la patología vasculocerebral

Introduction and development. The role played by statins in the prevention of strokes has been subject to controversy for a long time, especially because no clear correlation between levels of cholesterol in serum and strokes has yet been established. Nevertheless, a number of randomised trials with statins and several meta-analyses that were carried out later have proved that statins lower the incidence of all kinds of strokes, with a 21% reduction in the relative risk. It has also been shown that this effect is essentially due to the degree to which LDL cholesterol (cholesterol linked to low-density lipoproteins) is reduced, which has a lowering effect on lipid levels. It has also been shown that statins have others beneficial effects apart from reducing cholesterol levels and that these may be independent of the subject’s basal lipid levels. We are referring to the so-called pleiotropic effects, which include stabilisation of the atherosclerotic plaque, an antiinflammatory effect, an antithrombotic effect and enhanced vasomotor reactivity. Conclusion. The recent appearance of the results of the SPARCL (Stroke Prevention by Aggressive Reduction in Cholesterol Levels) study and the guidelines published by the American Heart Association and the Spanish Neurology Society, which grant statins a leading role in stroke prevention, both open up new horizons for the use of statins in cerebrovascular pathologies

[Neurologic manifestations of infective endocarditis: a diagnostic and prognostic challenge]. / Manifestaciones neurológicas de la endocarditis infecciosa: un reto diagnóstico y pronóstico.

INTRODUCTION: Infective endocarditis (IE) is an ongoing challenge in terms of excess morbidity and mortality. Neurologic complications occur in 20-40% of patients, and the brain is the main location of IE extracardiac complications. AIM: To analyse clinical characteristics of the neurologic complications found in patients with IE, focused on the diagnostic and prognostic aspects. PATIENTS AND METHODS: We studied retrospectively the cases of patients with IE admitted to the Hospital de Valme and Hospital de la Merced between 1998 and 2003. Laterly, patients with and without neurologic manifestations were compared. Sixty episodes of IE were evaluated. RESULTS: Neurological complications occurred in 12 patients (20%). The most frequent neurologic manifestation was unilateral hemi paresis, which occurred in seven cases (58.3%), three cases with acute confusional state (25%) and two patients developed meningitis (16.6%). Brain infarction was the most common lesion found in neuroimaging, in 6 patients (50%), followed by 2 cases (16.6%) of brain hemorrhage, and without significant findings in the cases left. Cases with neurologic complications had significantly higher mortality (p < 0.001) and higher frequency of negative blood culture (p < 0.001). CONCLUSIONS: Neurologic complications of IE are frequent during the evolution of the disease, and they still constitute a significant problem in clinical practice because they often are not accurately diagnosed and significantly increase patients' mortality.

Manifestaciones neurológicas de la endocarditis infecciosa: un reto diagnóstico y pronóstico / Neurologic manifestations of infective endocarditis: a diagnostic and prognostic challenge

Introducción. La endocarditis infecciosa (EI) es un reto médico actual debido a que todavía presenta gran morbimortalidad. Las complicaciones neurológicas aparecen en el 20-40% de los pacientes, y el cerebro es la principal localización de las complicaciones extracardíacas de las EI. Objetivo. Analizar las características clínicas de los pacientes con manifestaciones neurológicas debidas a EI, y centrarnos en los problemas diagnósticos y pronósticos que presentan. Pacientes y métodos. Se realizó un estudio retrospectivo de todos los pacientes diagnosticados de EI en los hospitales de Valme y de la Merced, entre los años 1998 y 2003. Posteriormente, se compararon los grupos de pacientes con EI y manifestaciones neurológicas con los que no las presentaron. Obtuvimos una muestra de 60 casos de EI. Resultados. Las manifestaciones neurológicas aparecieron en 12 pacientes (20%). La manifestación neurológica más frecuente fue la clínica focal en forma de hemiparesia en siete casos (58,3%); en tres casos apareció un síndrome confusional agudo (25%) y los dos pacientes restantes presentaron síndrome meníngeo. Los hallazgos de neuroimagen fueron: infartos isquémicos en seis casos (50%), seguidos de hemorragia cerebral en dos pacientes (16,6%), y no existieron hallazgos significativos en los restantes. Los pacientes con EI y manifestaciones neurológicas presentaron una mayor mortalidad (p < 0,001) y mayor frecuencia de hemocultivos negativos (p < 0,001) que los que no presentaban clínica neurológica. Conclusiones. Las complicaciones neurológicas de la EI son frecuentes durante la evolución de la enfermedad y todavía constituyen un grave problema en la clínica diaria por sus dificultades diagnósticas y elevada mortalidad

Introduction. Infective endocarditis (IE) is an ongoing challenge in terms of excess morbidity and mortality. Neurologic complications occur in 20-40% of patients, and the brain is the main location of IE extracardiac complications. Aim. To analyse clinical characteristics of the neurologic complications found in patients with IE, focused on the diagnostic and prognostic aspects. Patients and methods. We studied retrospectively the cases of patients with IE admitted to the Hospital de Valme and Hospital de la Merced between 1998 and 2003. Laterly, patients with and without neurologic manifestations were compared. Sixty episodes of IE were evaluated. Results. Neurological complications occurred in 12 patients (20%). The most frequent neurologic manifestation was unilateral hemi paresis, which occurred in seven cases (58.3%), three cases with acute confusional state (25%) and two patients developed meningitis (16.6%). Brain infarction was the most common lesion found in neuroimaging, in 6 patients (50%), followed by 2 cases (16.6%) of brain hemorrhage, and without significant findings in the cases left. Cases with neurologic complications had significantly higher mortality (p < 0.001) and higher frequency of negative blood culture (p < 0.001). Conclusions. Neurologic complications of IE are frequent during the evolution of the disease, and they still constitute a significant problem in clinical practice because they often are not accurately diagnosed and significantly increase patients’ mortality

Miastenia gravis en el anciano: experiencia de un hospital comarcal en una patología emergente / Myasthenia gravis in the elderly: a county hospital experience of an emerging disease

Objetivo: evidenciar el significativo incremento de la incidencia de miastenia gravis (MG) en la población anciana, así como conocer las particularidades del manejo de esta enfermedad en esos pacientes. Metodología: análisis retrospectivo de los casos de MG en pacientes mayores de 65 años atendidos en el hospital comarcal de la Merced de Osuna, Sevilla, durante los años 1995 a 2003.Resultados: obtuvimos una serie de 9 pacientes (5 varones y 4 mujeres) con una edad media de 77,6 (ñ 8,6) años y edad media de inicio de 68,1 (ñ 13,8) años. El tiempo medio de evolución era de 9,3 (ñ 11) años. Ocho pacientes (88,8 por ciento) presentaron MG de inicio tardío. Clínicamente 7 pacientes (77,7 por ciento) presentaron la forma ocular (grupo I) y 2 la generalizada (22,3 por ciento), uno leve (grupo IIa) y otro moderada (grupo IIb). Los síntomas oculares fueron las manifestaciones clínicas iniciales preponderantes (88,8 por ciento). Sólo uno de los pacientes presentó timoma. Los anticuerpos antirreceptores de acetilcolina (Ac-AchR) fueron positivos en todos los casos. Todos los pacientes recibieron tratamiento con piridostigmina, y en 5 pacientes (55,5 por ciento) se usaron además esteroides. No se produjo ninguna muerte, aunque en 3 enfermos (33,3 por ciento) los resultados del tratamiento fueron peores. Conclusiones: es necesario cambiar el concepto clásico de MG como patología del adulto joven y considerarla, como refleja nuestro estudio, como una patología emergente en la población anciana. Creemos que la MG es una enfermedad que debemos conocer, dado que la detección y el tratamiento precoces consiguen generalmente una mejoría física y funcional del paciente mayor (AU)

Influence of polymorphism (RFLP-sstI) at the apolipoprotein C-III gene locus on the lipoprotein metabolism and insulin resistance in essential hypertensive patients. Interaction between gender and genetic polymorphism.

BACKGROUND AND AIM: With respect to the general population, hypertensive patients show an increase in plasma total cholesterol and triglycerides, a decrease in HDL-cholesterol (HDLc) and a higher degree of insulin resistance. Apolipoprotein C-III (apo C-III) plays a regulatory role in the catabolism of triacylglycerol-rich lipoproteins. The S2 allele has been associated with elevated plasma triglycerides concentration, blood pressure and increased risk of myocardial infarction, all of which are characteristic of an insulin resistant state. The aim of this study was to investigate the SstI polymorphism of the apo C-III gene locus on the lipoprotein metabolism, apolipoproteins and basal glucose and insulin levels in essential hypertensive patients. We also examined the influence of the S1S2 allele on blood pressure and the interaction of the mutation at the apo C-III gene and the gender. METHODS AND RESULTS: We studied 104 essential hypertensive patients (59 males and 45 females) determining the carriers of the S2 allele of the genetic polymorphism in the apo C-III gene by polymerase chain reaction, lipoprotein metabolism by standard laboratory methods and ultracentrifugation, apolipoproteins A-I and B by immunoturbidimetry and basal glucose and insulin levels by enzymatic method and radioimmunoassay, respectively. The frequency for the carriers of the SstI minor allele S2 (S1S2 genotype) was 0.17. Patients with the rare S2 allele compared with those with S1S1 allele showed higher plasma triglycerides, total cholesterol and apo B (255.9 +/- 114.6 vs 135.8 +/- 89.1; 250.6 +/- 56.6 vs 214.8 +/- 47.9 and 128.7 +/- 34.8 vs 103.1 +/- 28.6 respectively). Furthermore, basal glucose, insulin levels in S2 allele, and the rate Tg-VLDL/HDLc were increased in the same group. Subgroup analysis revealed that the association between these polymorphism and lipoprotein metabolism, apolipoprotein and basal glucose and insulin levels occurred predominantly in females. A study on the effect of the interaction between this mutation with gender revealed an additive effect on changes in total triglycerides levels. However age, blood pressure and body mass index were similar in both groups of patients (S1S1 and S1S2 genotypes). CONCLUSIONS: These results provide evidence of interaction between gender and the Sst1 polymorphism of the apo C-III on lipoprotein metabolism and insulin resistance in essential hypertensive patients. However, the studied mutation does not contribute to blood pressure levels in essential hypertensive patients (crossover study).