Prevalence, awareness, treatment and control of hypertension in rural and urban communities in Latin American countries

OBJECTIVES: The objective is to describe hypertension (HTN) prevalence, awareness, treatment and control in urban and rural communities in Latin America to inform public and policy-makers. METHODS: Cross-sectional analysis from urban (n = 111) and rural (n = 93) communities including 33 276 participants from six Latin American countries (Argentina, Brazil, Chile, Colombia, Peru and Uruguay)were included. HTN was defined as self-reported HTN on blood pressure (BP)medication or average BP over 140/90 mmHg, awareness as self-reported HTN, and controlled as those with BP under 140/90 mmHg. RESULTS: Mean age was 52 years,60% were Female and 32% belonged to rural communities. HTN prevalence was 44.0%, with the lowest rates in Peru (17.7%) and the highest rates in Brazil (52.5%)58.9% were aware of HTN diagnosis and 53.3% were receiving treatment. Prevalence of HTN were higher in urban (44.8%) than rural (42.1%) communities in all countries. Most participants who were aware of HTN were receiving medical treatment (90.5%), but only 37.6% of patients receiving medical treatment had their BP controlled (<140/<90 mmHg), with the rates being higher in urban (39.6%) than in rural (32.4%) communities. The rate of use of two or more drugs was low [36.4%, lowest in Argentina (29.6%) and highest in Brazil (44.6%)]. Statin use was low (12.3%), especially in rural areas (7.0%). Most modifiable risk factors were higher in people with HTN than people without HTN. CONCLUSION: HTN prevalence is high but BP control is low in Latin America, with marked differences between countries and between urban and rural settings. There is na urgent need for systematic approaches for better detection, treatment optimization and risk factor modification among those with HTN in Latin America.(AU)

Correlação da capacidade funcional com força muscular respiratória em pacientes na fila de espera do transplante cardíaco / Correlation of functional capacity with respiratory muscle strength in cardiac transplant waiting list patients

INTRODUÇÃO: Estudos mostram que pacientes com insuficiência cardíaca apresentam fraqueza muscular respiratória e que quase sempre está associado com capacidade funcional reduzida, piora na qualidade de vida e mau prognóstico. Identificar a correlação da capacidade funcional com a força muscular respiratória é importante para melhor tratamento dos pacientes que aguardam transplante cardíaco. OBJETIVO: Avaliar a correlação da capacidade funcional com força muscular respiratória em pacientes na fila de espera do transplante cardíaco. MÉTODOS: Foi realizado um estudo observacional com pacientes que estavam ativos na fila do transplante cardíaco, não hospitalizados. Para verificar capacidade funcional foi realizado o teste de caminhada de seis minutos. Para mensuração da força muscular respiratória foi utilizado o manovacuômetro analógico e os valores obtidos foram a pressão inspiratória máxima (PImáx), e a pressão expiratória máxima (PEmáx). Para a análise estatística dos dados, as variáveis quantitativas foram apresentadas pela média e desvio padrão ou mediana e intervalo interquartil. As variáveis categóricas foram apresentadas por números absolutos e porcentagens. Para verificar a correlação entre as variáveis quantitativas e qualitativas foi utilizado o teste de Spearman. O nível de significância adotado foi de 5%. RESULTADOS: Dos 16 pacientes que estavam ativos na fila do transplante cardíaco, 10 foram selecionados pois preenchiam os critérios de inclusão do estudo. A idade variou de 18 a 65 anos, média de 42,5 ± 17,85, 60% de homens, 80% com hipertensão arterial sistêmica, 40% com diabetes melitus e 70% com dislipidemia. O IMC apresentou uma mediana de 28,52 (20,80-31,30) kg/m². Os dados do teste de caminhada de seis minutos, os pacientes andaram em mediana 387 (240 ­ 457) metros. Para as variáveis da manovacuometria, os pacientes tiveram uma mediana de 48,50 cmH2O (29,75 ­ 91,25) da PImáx e os valores de PEmáx 51 cmH2O (31,25 ­ 81,50). Houve correlação significativa da distância percorrida no teste de caminhada de seis minutos com PImáx de [0,778 (p=0,008)] e com PEmáx de [0,771 (p=0,021)], sendo que quanto menor a distância percorrida no teste de caminhada, menor os valores de força muscular respiratória. CONCLUSÃO: Existe possivelmente uma correlação da distância percorrida no teste de caminhada com os valores de força muscular respiratória em pacientes pré-transplante. As hipóteses devem ser confirmadas por estudos longitudinais. (AU)

Pacientes na fila de espera do transplante cardíaco com capacidade funcional reduzida apresentam piora da função muscular na dinamometria / Patients in the heart transplant waiting list with reduced functional capacity show worsening of muscle function on dynamometry

INTRODUÇÃO: Estudos mostram que pacientes com insuficiência cardíaca apresentam fraqueza muscular periférica e que quase sempre está associado com capacidade funcional reduzida. Identificar a correlação da capacidade funcional com a força muscular periférica é importante para melhor tratamento dos pacientes que aguardam transplante cardíaco. OBJETIVO: Avaliar a correlação da capacidade funcional com força muscular periférica em pacientes na fila de espera do transplante cardíaco. MÉTODOS: Foi realizado um estudo observacional com pacientes que estavam ativos na fila do transplante cardíaco, não hospitalizados. Para verificar capacidade funcional foi realizado o teste de caminhada de seis minutos. Para mensurar a função muscular utilizamos um dinamômetro de preensão palmar da marca SAEHAN. O protocolo utilizado para aplicação do teste foi baseado na recomendação da American Society of Hand Therapists. Para a análise estatística dos dados, as variáveis quantitativas foram apresentadas pela média e desvio padrão ou mediana e intervalo interquartil. As variáveis categóricas foram apresentadas por números absolutos e porcentagens. Para verificar a correlação entre as variáveis quantitativas e qualitativas foi utilizado o teste de Spearman. O nível de significância adotado foi de 5%. RESULTADOS: Dos 16 pacientes que estavam ativos na fila do transplante cardíaco, 10 foram selecionados pois preenchiam os critérios de inclusão do estudo. A idade variou de 18 a 65 anos, média de 42,5 ± 17,85, 60% de homens, 80% com hipertensão arterial sistêmica (HAS), 40% com diabetes melitus (DM) e 70% com dislipidemia (DLP). O IMC apresentou uma mediana de 28,52 (20,80-31,30) kg/m². Os dados do teste de caminhada de seis minutos (TC6'), os pacientes andaram em mediana 387 (240 ­ 457) metros. O membro direito foi considerado dominante (100%), a mediana da preensão palmar do membro direito foi 24,65 (21,75 ­ 43,07) e o de membro superior esquerdo foi de 23,45 (16,37 ­ 34,45). Houve correlação da distância percorrida no teste de caminhada de seis minutos com força de preensão palmar [0,821 (p=0,004)] sendo que quanto menor a distância percorrida no teste de caminhada, menor o valor de força muscular periférica. CONCLUSÃO: Existe possivelmente uma correlação da distância percorrida no teste de caminhada com os valores de força muscular periférica em pacientes que estão na fila de espera do transplante cardíaco. As hipóteses devem ser confirmadas por estudos longitudinais. (AU)

Prevalence, awareness, treatment and control of hypertension in rural and urban communities in Latin American countries.

OBJECTIVES: The objective is to describe hypertension (HTN) prevalence, awareness, treatment and control in urban and rural communities in Latin America to inform public and policy-makers. METHODS: Cross-sectional analysis from urban (n = 111) and rural (n = 93) communities including 33 276 participants from six Latin American countries (Argentina, Brazil, Chile, Colombia, Peru and Uruguay) were included. HTN was defined as self-reported HTN on blood pressure (BP) medication or average BP over 140/90 mmHg, awareness as self-reported HTN, and controlled as those with BP under 140/90 mmHg. RESULTS: Mean age was 52 years, 60% were Female and 32% belonged to rural communities. HTN prevalence was 44.0%, with the lowest rates in Peru (17.7%) and the highest rates in Brazil (52.5%). 58.9% were aware of HTN diagnosis and 53.3% were receiving treatment. Prevalence of HTN were higher in urban (44.8%) than rural (42.1%) communities in all countries. Most participants who were aware of HTN were receiving medical treatment (90.5%), but only 37.6% of patients receiving medical treatment had their BP controlled (<140/<90 mmHg), with the rates being higher in urban (39.6%) than in rural (32.4%) communities. The rate of use of two or more drugs was low [36.4%, lowest in Argentina (29.6%) and highest in Brazil (44.6%)]. Statin use was low (12.3%), especially in rural areas (7.0%). Most modifiable risk factors were higher in people with HTN than people without HTN. CONCLUSION: HTN prevalence is high but BP control is low in Latin America, with marked differences between countries and between urban and rural settings. There is an urgent need for systematic approaches for better detection, treatment optimization and risk factor modification among those with HTN in Latin America.

Effects of trypanocidal treatment on echocardiographic parameters in chagas cardiomyopathy and prognostic value of wall motion score index: A BENEFIT trial echocardiographic substudy

Serial echocardiographic studies in chronic Chagas cardiomyopathy are scarce. The aims of this study were to evaluate whether therapy with benznidazole modifies the progression of cardiac impairment and to identify baseline echocardiographic parameters related to prognosis. METHODS: A prospective sub study was conducted in 1,508 patients with chronic Chagas cardiomyopathy randomized to benznidazole or placebo, who underwent two-dimensional echocardiography at enrollment, 2 years, and final follow-up (5.4 years). Left ventricular (LV) ejection fraction, LV wall motion score index (WMSI), indexed left atrial volume, and chamber dimensions were collected and correlated to all-cause death and a composite hard outcome using univariate and multivariate analyses. RESULTS: At enrollment, most patients had normal chamber dimensions, and 70.5% had preserved LV ejection fractions. During follow-up, all chamber dimensions increased similarly in both treatment arms. LV ejection fraction was comparably reduced (55.7 ± 12.7% to 52.1 ± 14.6% vs 56.3 ± 12.7% to 52.8 ± 14.1%) and LV WMSI similarly increased (1.31 ± 0.41 to 1.49 ± 0.03 and 1.27 ± 0.38 to 1.51 ± 0.03) for the benznidazole and placebo groups, respectively (P > .05). A higher baseline LV WMSI was identified in subjects who died compared with those alive at final echocardiography (1.76 ± 0.517 vs 1.271 ± 0.393, P < .0001). There was a significant (P < .0001) graded increase in the risk for the composite outcome with worsening LV WMSI (hazard ratios, 2.27 [95% CI, 1.69-3.06] and 6.42 [95% CI, 4.94-8.33]) and also of death (hazard ratios, 2.45 [95% CI, 1.62-3.71] and 8.99 [95% CI, 6.3-12.82]) for 1 < LV WMSI < 1.5 and LV WMSI > 1.5, respectively. Both LV WMSI and indexed left atrial volume remained independent predictors in multivariate analysis. CONCLUSIONS: Trypanocidal treatment had no effect on echocardiographic progression of chronic Chagas cardiomyopathy over 5.4 years. Despite normal global LV systolic function, regional wall motion abnormalities and indexed left atrial volume identified patients at higher risk for hard adverse clinical outcomes. Copyright © 2018 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved. KEYWORDS: Chagas cardiomyopathy; Echocardiography; Prognosis; Trypanocidal therapy. (AU)

Effects of Trypanocidal Treatment on Echocardiographic Parameters in Chagas Cardiomyopathy and Prognostic Value of Wall Motion Score Index: A BENEFIT Trial Echocardiographic Substudy.

BACKGROUND: Serial echocardiographic studies in chronic Chagas cardiomyopathy are scarce. The aims of this study were to evaluate whether therapy with benznidazole modifies the progression of cardiac impairment and to identify baseline echocardiographic parameters related to prognosis. METHODS: A prospective substudy was conducted in 1,508 patients with chronic Chagas cardiomyopathy randomized to benznidazole or placebo, who underwent two-dimensional echocardiography at enrollment, 2 years, and final follow-up (5.4 years). Left ventricular (LV) ejection fraction, LV wall motion score index (WMSI), indexed left atrial volume, and chamber dimensions were collected and correlated to all-cause death and a composite hard outcome using univariate and multivariate analyses. RESULTS: At enrollment, most patients had normal chamber dimensions, and 70.5% had preserved LV ejection fractions. During follow-up, all chamber dimensions increased similarly in both treatment arms. LV ejection fraction was comparably reduced (55.7 ± 12.7% to 52.1 ± 14.6% vs 56.3 ± 12.7% to 52.8 ± 14.1%) and LV WMSI similarly increased (1.31 ± 0.41 to 1.49 ± 0.03 and 1.27 ± 0.38 to 1.51 ± 0.03) for the benznidazole and placebo groups, respectively (P > .05). A higher baseline LV WMSI was identified in subjects who died compared with those alive at final echocardiography (1.76 ± 0.517 vs 1.271 ± 0.393, P < .0001). There was a significant (P < .0001) graded increase in the risk for the composite outcome with worsening LV WMSI (hazard ratios, 2.27 [95% CI, 1.69-3.06] and 6.42 [95% CI, 4.94-8.33]) and also of death (hazard ratios, 2.45 [95% CI, 1.62-3.71] and 8.99 [95% CI, 6.3-12.82]) for 1 < LV WMSI < 1.5 and LV WMSI > 1.5, respectively. Both LV WMSI and indexed left atrial volume remained independent predictors in multivariate analysis. CONCLUSIONS: Trypanocidal treatment had no effect on echocardiographic progression of chronic Chagas cardiomyopathy over 5.4 years. Despite normal global LV systolic function, regional wall motion abnormalities and indexed left atrial volume identified patients at higher risk for hard adverse clinical outcomes.

Challenges and Opportunities to Scale Up Cardiovascular Disease Secondary Prevention in Latin America and the Caribbean

Cardiovascular disease (CVD) is the leading cause of death throughout the world; however, a reduction of 21% (age-standardized cardiovascular mortality rates per 100,000 inhabitants) was observed between 1990 and 2010, with more substantial reductions in CVD mortality evident in high-income countries (w42% reduction in CVD deaths).

Independent predictors of effective blood pressure control in patients with hypertension on drug treatment in Brazil.

Population assessment of effective blood pressure (BP) control is fundamental for reducing the global burden of hypertension, especially in low- and middle-income countries. The authors evaluated the effectiveness of BP control and determined independent predictors associated with effective control among patients with hypertension on drug treatment in a large cross-sectional study performed in two metropolitan areas in Brazil's southeast region. A total of 43 647 patients taking antihypertensive treatment were identified. Less than half of the patients (40.9%) had controlled BP (systolic BP <140 mm Hg and diastolic BP <90 mm Hg). Independent predictors of BP control were age, eating fruit daily, physical activity, previous cardiovascular disease, male sex, diabetes mellitus, ethnicity, and obesity. Simple variables associated with BP control may be utilized for knowledge translation strategies aiming to reduce the burden of hypertension.

Independent predictors of effective blood pressure control in patients with hypertension on drug treatment in Brazil

Population assessment of effective blood pressure (BP) control is fundamental for reducing the global burden of hypertension, especially in low- and middle-income countries. The authors evaluated the effectiveness of BP control and determined independent predictors associated with effective control among patients with hypertension on drug treatment in a large cross-sectional study performed in two metropolitan areas in Brazil's southeast region. A total of 43 647 patients taking antihypertensive treatment were identified. Less than half of the patients (40.9%) had controlled BP (systolic BP <140 mm Hg and diastolic BP <90 mm Hg). Independent predictors of BP control were age, eating fruit daily, physical activity, previous cardiovascular disease, male sex, diabetes mellitus, ethnicity, and obesity. Simple variables associated with BP control may be utilized for knowledge translation strategies aiming to reduce the burden of hypertension...

Langerhans' cell histiocytosis with neurological injuries diagnosed from a single cutaneous lesion.

Histiocytoses are rare diseases caused by the proliferation of histiocytes. The pathogenesis remains unknown and the highest incidence occurs in pediatric patients. The clinical presentations can be varied, in multiple organs and systems, and the skin lesions are not always present. Evolution is unpredictable and treatment depends on the extent and severity of the disease. It is described the case of a patient with various neurological symptoms, extensively investigated, who had its was diagnosed with histiocytosis from a single skin lesion. This report highlights the importance of Dermatology in assisting the investigation of difficult cases in medical practice.

Langerhans' cell histiocytosis with neurological injuries diagnosed from a single cutaneous lesion

Abstract: Histiocytoses are rare diseases caused by the proliferation of histiocytes. The pathogenesis remains unknown and the highest incidence occurs in pediatric patients. The clinical presentations can be varied, in multiple organs and systems, and the skin lesions are not always present. Evolution is unpredictable and treatment depends on the extent and severity of the disease. It is described the case of a patient with various neurological symptoms, extensively investigated, who had its was diagnosed with histiocytosis from a single skin lesion. This report highlights the importance of Dermatology in assisting the investigation of difficult cases in medical practice.

Paracoccidioidomycosis with sarcoid-like lesions:a diagnostic challenge.

Clinical presentation of paracoccidioidomycosis (PCM) can be diverse. Morphology and quantity of skin lesions depends on interactions between host immunity and fungus virulence. Diagnosis can be a challenge considering that this fungus has low virulence and some individuals have immunity to microorganism, which results in well-marked granulomas without visible microorganisms. We report herein a clinical presentation of sarcoid-like PCM, initially diagnosed as tuberculoid leprosy. This rare type of PCM is often mistaken for other types of chronic granulomatous diseases. Diagnosis was confirmed after 4 years when a special stain analysis helped in the identification of the specific etiologic agent.

Paracoccidioidomycosis with sarcoid-like lesions: a diagnostic challenge

Abstract Clinical presentation of paracoccidioidomycosis (PCM) can be diverse. Morphology and quantity of skin lesions depends on interactions between host immunity and fungus virulence. Diagnosis can be a challenge considering that this fungus has low virulence and some individuals have immunity to microorganism, which results in well-marked granulomas without visible microorganisms. We report herein a clinical presentation of sarcoid-like PCM, initially diagnosed as tuberculoid leprosy. This rare type of PCM is often mistaken for other types of chronic granulomatous diseases. Diagnosis was confirmed after 4 years when a special stain analysis helped in the identification of the specific etiologic agent.

Secondary CV Prevention in South America in a Community Setting: The PURE Study.

BACKGROUND: Despite the availability of evidence-based therapies, there is no information on the use of medications for the secondary prevention of cardiovascular disease in urban and rural community settings in South America. OBJECTIVES: This study sought to assess the use, and its predictors, of effective secondary prevention therapies in individuals with a history of coronary heart disease (CHD) or stroke. METHODS: In the PURE (Prospective Urban Rural Epidemiological) study, we enrolled 24,713 individuals from South America ages 35 to 70 years from 97 rural and urban communities in Argentina, Brazil, Chile, and Colombia. We assessed the use of proven therapies with standardized questionnaires. We report estimates of drug use at national, community, and individual levels and the independent predictors of their utilization through a multivariable analysis model. RESULTS: Of 24,713 individuals, 910 had a self-reported CHD event (at a median of 5 years earlier) and 407 had stroke (6 years earlier). The proportions of individuals with CHD who received antiplatelet medications (30.1%), beta-blockers (34.2%), angiotensin-converting enzyme inhibitors, or angiotensin-receptor blockers (36.0%), or statins (18.0%) were low; with even lower proportions among stroke patients (antiplatelets 24.3%, angiotensin-converting enzyme inhibitors/angiotensin-receptor blockers 37.6%, statins 9.8%). A substantial proportion of patients did not receive any proven therapy (CHD 31%, stroke 54%). A minority of patients received either all 4 (4.1%) or 3 proven therapies (3.3%). Male sex, age >60 years, better education, more wealth, urban location, diabetes, and obesity were associated with higher rates of medication use. In a multivariable model, markers of wealth had the largest impact in secondary prevention. CONCLUSIONS: There are large gaps in the use of proven medications for secondary prevention of cardiovascular disease in South America. Strategies to improve the sustained use of these medications will likely reduce cardiovascular disease burden substantially.

Secondary CV Prevention in South America in a community setting: the PURE study

BACKGROUND: Despite the availability of evidence-based therapies, there is no information on the use of medications for the secondary prevention of cardiovascular disease in urban and rural community settings in South America. OBJECTIVES: This study sought to assess the use, and its predictors, of effective secondary prevention therapies in individuals with a history of coronary heart disease (CHD) or stroke.METHODS: In the PURE (Prospective Urban Rural Epidemiological) study, we enrolled 24,713 individuals from South America ages 35 to 70 years from 97 rural and urban communities in Argentina, Brazil, Chile, and Colombia. We assessed the use of proven therapies with standardized questionnaires. We report estimates of drug use at national, community, and individual levels and the independent predictors of their utilization through a multivariable analysis model. RESULTS:Of 24,713 individuals, 910 had a self-reported CHD event (at a median of 5 years earlier) and 407 had stroke (6 years earlier). The proportions of individuals with CHD who received antiplatelet medications (30.1%), beta-blockers (34.2%), angiotensin-converting enzyme inhibitors, or angiotensin-receptor blockers (36.0%), or statins (18.0%) were low; with even lower proportions among stroke patients (antiplatelets 24.3%, angiotensin-converting enzyme inhibitors/angiotensin-receptor blockers 37.6%, statins 9.8%). A substantial proportion of patients did not receive any proven therapy (CHD 31%, stroke 54%). A minority of patients received either all 4 (4.1%) or 3 proven therapies (3.3%). Male sex, age >60 years, better education, more wealth, urban location, diabetes, and obesity were associated with higher rates of medication use. In a multivariable model, markers of wealth had the largest impact in secondary prevention...

Importance of multidisciplinary approach in diagnosis of histoplasmosis.

A patient with systemic involvement, initially treated as tuberculosis, is presented in this report. There were only two painful subcutaneous nodules, from which we arrived at the correct diagnosis of histoplasmosis. The patient was attended by several experts in the fields of infectious diseases, nephrology and internal medicine, but the diagnosis was only possible after dermatological examination and skin biopsy. This case values multidisciplinary interaction between dermatologists and other medical areas for diagnosis of cases with atypical manifestations.

Importance of multidisciplinary approach in diagnosis of histoplasmosis

Abstract: A patient with systemic involvement, initially treated as tuberculosis, is presented in this report. There were only two painful subcutaneous nodules, from which we arrived at the correct diagnosis of histoplasmosis. The patient was attended by several experts in the fields of infectious diseases, nephrology and internal medicine, but the diagnosis was only possible after dermatological examination and skin biopsy. This case values multidisciplinary interaction between dermatologists and other medical areas for diagnosis of cases with atypical manifestations.