A multicentre, 12-week study of imidapril and candesartan cilexetil in patients with mild to moderate hypertension using ambulatory blood pressure monitoring.

BACKGROUND: Twenty-four-hour ambulatory blood pressure monitoring (ABPM) provides the most accurate efficacy assessment of an antihypertensive agent throughout a 24-hour dosing interval. The objective of this prospective, randomised, double-blind, parallel-group, multicentre study was to compare the antihypertensive efficacy of imidapril versus candesartan cilexetil using ABPM. METHODS: After screening and a single-blind, placebo run-in phase, ambulatory adult patients with mild to moderate hypertension (defined as a mean office sitting diastolic BP [DBP] and systolic BP [SBP], respectively, of 90-109 mm Hg and 140-179 mm Hg, and a mean ABPM DBP and SBP, respectively, of >or=80 mm Hg and >or=125 mm Hg) were randomised to once-daily treatment with imidapril or candesartan cilexetil for 12 weeks. ABPM was performed at baseline and at the end of the 12-week treatment period in 112 patients (imidapril group, n=55; candesartan cilexetil group, n=57). To achieve the target BP of

[Global treatment of cardiovascular risk in the hypertensive patient]. / Tratamiento global del riesgo cardiovascular en el paciente hipertenso.

During 2006, new evidence supporting the need to adopt a global approach to the treatment of cardiovascular risk in hypertensive patients has been reported. It is increasingly clear that it is not sufficient to aim for optimum blood pressure control, which in any case is not easy to achieve, and that it is essential to treat all cardiovascular risk factors by using drugs with proven benefits, even when those benefits are supplementary to the drug's principal effects. In addition, drugs that could have a detrimental effect or that are, merely, less beneficial should be avoided or kept as a last resort. This appears to have happened with atenolol, and with beta-blockers in general, which have been withdrawn as first-line treatment in the recommendations of some professional societies. To lower cardiovascular risk, it is essential to prevent the development of conditions like diabetes, which are known to have drastic effect on the patient's prognosis. Recently, the results of the DREAM study, which are discussed in detail in this article, have been reported. They could lead to a change in therapeutic strategy in patients who are expected to develop diabetes. In addition, this year has seen the publication of substantial data on a new antihypertensive agent, aliskiren, the first oral renin inhibitor. It is awaiting approval by the international medicine agencies (i.e., the FDA and the EMEA), but should provide a very promising tool in the difficult area of high blood pressure management. Despite numerous advances in the pharmacologic treatment of high blood pressure, control is very difficult to achieve, principally in the elderly, in whom the prevalence of hypertension is high. In these patients, social factors and difficulties with treatment compliance also have an influence and must be dealt with by public health measures aimed at improving blood pressure control.

Introducción: diabetología para cardiólogos / No disponible

No disponible

La diabetes mellitus entendida como una enfermedad cardiovascular de origen metabólico / Diabetes mellitus seen as a cardiovascular disease of metabolic origin

Según criterios de la Asociación Americana de Diabetes (ADA), la diabetes mellitus tipo 2 se considera una enfermedad cardiovascular de origen metabólico. El proceso se caracteriza por un trastorno metabólico generalizado en el que la hiperglucemia es el factor bioquímico dominante. En su etiopatogenia, en la que mecanismos genéticos y ambientales son clave, hay que considerar un mecanismo dual: por un lado, un estado de resistencia insulínica sostenido, y por otro, una insuficiencia secretora de las células beta pancreáticas. Ambas circunstancias coexisten en la mayoría de los casos. Para comprender la fisiopatología del proceso es necesario hacer referencia a 4 aspectos fundamentales: a) el hecho anatómico, por el que los vasos arteriales grandes y pequeños se ven involucrados en un proceso aterotrombótico que conduce a la enfermedad vascular generalizada (infarto de miocardio, ictus, pie diabético, neuropatía diabética, ceguera e insuficiencia renal crónica progresiva e irreversible; b) la base bioquímica, en la que una serie de factores, como la glucación no enzimática de proteínas específicas, las vías metabólicas alternativas de los polioles por la que se genera sorbitol a partir de la aldosa reductasa y los aumentos de diacilglicerol y proteincinasa C, transducen señales que modifican estructural y funcionalmente el endotelio, que es el punto por donde el proceso aterotrombótico se inicia y se mantiene; c) los trastornos procoagulatorios, que incrementan la adhesividad y agregabilidad plaquetaria, lo que aumenta la hipercoagulabilidad y disminuye la fibrinolisis, y d) el complejo factor inflamatorio, en el que intervienen numerosos componentes humorales y celulares (AU)

According to American Diabetes Association criteria, type-2 diabetes mellitus is regarded as a cardiovascular disease of metabolic origin. The condition is characterized by a general metabolic disturbance in which hyperglycemia is the dominant biochemical factor. Both genetic and environmental factors play key roles in its pathogenesis, which involves two central mechanisms. On the one hand, there is a chronic state of insulin resistance and, on the other, insufficient insulin is secreted from pancreatic beta cells. In the majority of patients, both of these features coexist. An understanding of disease pathophysiology requires knowledge of four fundamental factors: a) the anatomical process in which large and small arterial vessels are affected by atherothrombosis, which leads to systemic vascular disease that can involve myocardial infarction, stroke, peripheral vascular disease, diabetic neuropathy, blindness, and chronic irreversible progressive renal failure; b) underlying biochemical processes in which a series of phenomena, such as non-enzymatic glycosylation by particular proteins, alternative polyol metabolic pathways in which aldose reductase catalyzes sorbitol production and diacylglycerol and protein kinase-C levels are increased, activate signal transduction pathways that modify the functional and structural properties of the endothelium, thereby initiating and maintaining the atherothrombotic process; c) coagulation disorders that increase platelet adhesion and aggregability, raise hypercoagulability, and decrease fibrinolysis, and d) complex inflammatory processes involving numerous humoral and cellular elements (AU)

Tratamiento global del riesgo cardiovascular en el paciente hipertenso / Global treatment of cardiovascular risk in the hypertensive patient

A lo largo del año 2006 han aparecido nuevas evidencias sobre la necesidad del tratamiento global del riesgo cardiovascular en el paciente hipertenso. Cada vez es mayor la certeza de que no basta con buscar un óptimo control de las cifras de presión arterial, lo que además no es fácil lograr, sino que es imprescindible tratar todos los factores de riesgo cardiovascular mediante la utilización de los fármacos de demostrado beneficio, incluso más allá de sus efectos principales, y evitando, o dejando para último recurso, los que puedan resultar perjudiciales o, simplemente, menos beneficiosos, como parece ser el caso de atenolol (extensivo a los bloqueadores beta en general), que ya ha sido retirado de la primera línea de tratamiento en las recomendaciones de algunas sociedades científicas. En la reducción del riesgo es fundamental la prevención de algunas enfermedades como la diabetes, que sabemos ensombrece de forma alarmante el pronóstico de nuestros pacientes. Recientemente hemos conocido los resultados del estudio DREAM, que se analizarán con detalle en este artículo y que pueden suponer un cambio en la estrategia terapéutica de los pacientes en los que es previsible la aparición de diabetes. También a lo largo del presente año hemos recibido amplia información sobre un nuevo fármaco antihipertensivo, aliskiren, primer inhibidor de la renina disponible por vía oral. Pendiente de aprobación por las agencias internacionales de medicamentos (Food and Drug Administration [FDA] y Agencia Europea de Evaluación de Medicamentos [EMEA]), es una herramienta muy prometedora en el difícil control de la hipertensión arterial. A pesar de todos los avances en el tratamiento farmacológico de la hipertensión arterial, persiste un escaso control de las cifras tensionales, sobre todo en los pacientes de mayor edad, en los que la prevalencia es más elevada. En estos pacientes influyen también factores sociales y la dificultad en el cumplimiento terapéutico, que precisan medidas sociosanitarias dirigidas a mejorar su control

During 2006, new evidence supporting the need to adopt a global approach to the treatment of cardiovascular risk in hypertensive patients has been reported. It is increasingly clear that it is not sufficient to aim for optimum blood pressure control, which in any case is not easy to achieve, and that it is essential to treat all cardiovascular risk factors by using drugs with proven benefits, even when those benefits are supplementary to the drug's principal effects. In addition, drugs that could have a detrimental effect or that are, merely, less beneficial should be avoided or kept as a last resort. This appears to have happened with atenolol, and with beta-blockers in general, which have been withdrawn as first-line treatment in the recommendations of some professional societies. To lower cardiovascular risk, it is essential to prevent the development of conditions like diabetes, which are known to have drastic effect on the patient's prognosis. Recently, the results of the DREAM study, which are discussed in detail in this article, have been reported. They could lead to a change in therapeutic strategy in patients who are expected to develop diabetes. In addition, this year has seen the publication of substantial data on a new antihypertensive agent, aliskiren, the first oral renin inhibitor. It is awaiting approval by the international medicine agencies (i.e., the FDA and the EMEA), but should provide a very promising tool in the difficult area of high blood pressure management. Despite numerous advances in the pharmacologic treatment of high blood pressure, control is very difficult to achieve, principally in the elderly, in whom the prevalence of hypertension is high. In these patients, social factors and difficulties with treatment compliance also have an influence and must be dealt with by public health measures aimed at improving blood pressure control

Conocimiento y aplicación de las guías de práctica clínica sobre riesgo cardiovascular en las consultas generales y especializadas / Knowledge and Implementation of Cardiovascular Risk Clinical Practice Guidelines by General Practitioners and Specialists

Introducción y objetivos. Los pacientes de alto riesgo vascular alcanzan en escasa cuantía los objetivos de prevención que se indican en las directrices de las entidades profesionales. El objetivo del registro ACORISC fue analizar el grado de adecuación a las directrices de prevención por parte de un grupo de médicos de atención primaria y especialistas, así como sus resultados en los parámetros de riesgo. Métodos. Se registran de manera consecutiva los da- tos de 5.849 pacientes (65 años) con diabetes mellitus de tipo 2 o cardiopatía isquémica crónica visitados ambulatoriamente. Se encuestó a los 384 médicos participantes acerca de su conocimiento y aplicación de las directrices. Resultados. El 91% de los pacientes tenía, además, hipertensión arterial. Los médicos conocían y aplicaban prioritariamente las directrices dictadas por las sociedades profesionales más afines. El 14% de los tratamientos aplicados era incorrecto, la mitad de ellos antidiabéticos orales. En cambio, el 48% de los pacientes que precisarían un inhibidor de la enzima de conversión de la angiotensina según las guías no lo tomaba. Las cifras de control recomendadas de presión arterial, índice de masa corporal y colesterol se alcanzaron sólo en el 13, el 21 y el 39% de los pacientes, respectivamente. Conclusiones. El 75% de los parámetros de riesgo en pacientes diabéticos o con cardiopatía isquémica no están adecuadamente controlados por los médicos de atención primaria y los especialistas de acuerdo con las guías de práctica clínica vigentes. Es llamativamente alto el uso inadecuado de antidiabéticos orales (AU)

Introduction and objectives. Patients at a high risk of cardiovascular disease rarely achieve the preventive targets stipulated by the clinical practice guidelines published by professional bodies. The aims of the ACORISC registry were to determine the level of compliance with guidelines on prevention by general practitioners and specialists and to assess the findings in terms of risk factors. Methods. The study included 5849 consecutive patients (mean age 65 years) with type 2 diabetes or chronic ischemic heart disease who were seen as outpatients. In addition, 384 participating physicians were questioned on their knowledge and use of practice guidelines. Results. Overall, 91% of patients also had hypertension. Physicians tended to have better knowledge of and to implement guidelines published by the closest related professional bodies. Some 14% of treatment provided was inappropriate, half of which involved oral antidiabetics. Conversely, 48% of patients for whom guidelines recommended an angiotensin inhibitor did not receive one. The target figures for blood pressure, body mass index, and cholesterol were achieved in only 13%, 21% and 39% of patients, respectively. Conclusions. Overall, 75% of risk factors in patients with diabetes or chronic ischemic heart disease were not appropriately treated by general practitioners or specialists in accordance with current clinical practice guidelines. The inappropriate use of oral antidiabetics was particularly common (AU)

Hipertensión arterial y riesgo cardiovascular en el año 2004 / Arterial Hypertension and Cardiovascular Risk in 2004

En la presente revisión se analizan los avances más relevantes publicados durante el último año en el campo de la hipertensión arterial (HTA), prestando un especial interés a los últimos ensayos clínicos que vienen a confirmar un concepto clásico ya conocido, en el que lo más importante en el tratamiento del paciente hipertenso es conseguir el control de las cifras de presión arterial y que, únicamente cuando ello se ha alcanzado, se ponen de manifiesto los efectos beneficiosos adicionales de determinados grupos terapéuticos antihipertensivos, como son los fármacos que bloquean el eje renina-angiotensina-aldosterona. Asimismo, se analiza la información pronóstica que nos aporta un procedimiento tan sencillo e incruento como es el índice tobillo-brazo en la valoración cardiovascular de los pacientes, sin olvidar la importancia creciente del hiperaldosteronismo primario como etiología de la HTA. Finalmente, se remarcan los aspectos más novedosos publicados respecto de la asociación entre la diabetes y la HTA y los efectos potenciales del bloqueo del receptor activador de la proliferación de peroxisomas gamma en la prevención cardiovascular (AU)

We review the latest and most relevant papers published this year about hypertension, focusing special interest in the clinical trials. All these studies reaffirm the classic topic that the main objective in a hypertensive patient is to achieve an accurate control of blood pressure. Anti hypertensive treatment with ACEIs or ARB, acting through the renin-angiotensin-aldosterone pathway shows beneficial effect only after lowering blood pressure. We also analyze the prognostic information provided by the ankle brachial index for cardiovascular assessment and the growing interest in the primary aldosteronism as a cause of hypertension. Finally, we remark the latest issues regarding the association between diabetes mellitus and hypertension and the effects of PPAR-γ blockers for the prevention of cardiovascular disease (AU)

[Diabetes mellitus in cardiology practice in Spain. Survey by the Working Group on Heart and Diabetes regarding the importance of diabetes mellitus in relation with other cardiovascular diseases]. / La diabetes mellitus en la práctica de la cardiología en España. Encuesta del Groupo de Trabajo de Corazón y Diabetes sobre la importancia de la diabetes mellitus en relación con las enfermedades cardiovasculares.

INTRODUCTION AND OBJECTIVES: Diabetes mellitus has been defined as a cardiovascular disease of metabolic origin. This article reports the results of a survey of cardiologists regarding their knowledge about this disease and their management of patients with diabetes in daily practice. METHODS: A survey was mailed to all 1840 cardiologists who were members of the Spanish Society of Cardiology, and responses were returned by 348 (18.9%). The survey consisted of 16 questions dealing with organizational and practical aspects of cardiological management for patients with diabetes. RESULTS: The creation of a Working Group on the Heart and Diabetes was judged necessary by 90.2% of the responders. Almost two thirds of the members felt their knowledge of diabetes and its treatment was inadequate, and 82.5% declared that cardiologists should be better able to treat patients with diabetes, since between 15% and 30% of the patients they see have this disease. With respect to secondary prevention, 65.8% of the cardiologists felt that medical care is much better for coronary patients than for patients with diabetes. Among the latter, angiotensin-inhibiting drugs, statins and aspirin are used for secondary prevention. CONCLUSIONS: Because of gaps in the cardiologist's knowledge of how to manage diabetes, the high prevalence of diabetes and its unquestionable impact on the cardiovascular system additional clinical training and educational efforts are needed. One potentially useful measure is the creation of a specific Working Group on the Heart and Diabetes.