Monitorización ambulatoria de la presión arterial en adultos y población pediátrica. Una revisión narrativa / Ambulatory blood pressure monitoring, adult and pediatric population. A narrative review

La hipertensión arterial (HTA) se ha convertido en un factor de riesgo central para el desarrollo de enfermedades cardiovasculares (CV), lo que subraya la importancia de su diagnóstico preciso. Numerosos estudios han establecido una estrecha relación entre los valores elevados de la presión arterial sistólica (PAS) y diastólica (PAD) y un incremento en el riesgo de padecer algún evento cardiovascular (ECV). Tradicionalmente, las mediciones de la presión arterial (PA) realizadas en entornos clínicos han sido el principal método para diagnosticar y evaluar la HTA. No obstante, en los últimos años, se ha reconocido que las mediciones de la PA obtenidas fuera del ambiente clínico, mediante la automedida de la presión arterial (AMPA) y la monitorización ambulatoria de la presión arterial (MAPA), ofrecen una perspectiva más realista de la vida cotidiana de los pacientes y, por lo tanto, brindan resultados más fiables. Dada la evolución de los dispositivos médicos, los criterios diagnósticos y la creciente relevancia de componentes de la MAPA en la predicción de ECV, se requiere una actualización integral que sea práctica para la clínica. Esta revisión tiene como objetivo proporcionar una actualización de la MAPA, enfocándose en su importancia en la evaluación de la HTA. Además, se analizarán los umbrales diagnósticos, los distintos fenotipos según el ciclo circadiano y las recomendaciones en diferentes poblaciones, asimismo, se ofrecerán sugerencias concretas para la implementación efectiva de la MAPA en la práctica clínica, lo que permitirá a los profesionales de la salud tomar decisiones fundamentadas y mejorar la atención de sus pacientes.(AU)

Hypertension has become a central risk factor for the development of cardiovascular disease, underscoring the importance of its accurate diagnosis. Numerous studies have established a close relationship between elevated systolic (SBP) and diastolic (DBP) blood pressure and an increased risk of cardiovascular event (CVE). Traditionally, blood pressure (BP) measurements performed in clinical settings have been the main method for diagnosing and assessing hypertension. However, in recent years, it has been recognized that BP measurements obtained outside the clinical setting, using self-monitoring blood pressure (SMBP) and ambulatory blood pressure monitoring (ABPM), offer a more realistic perspective of patients’ daily lives and therefore provide more reliable results. Given the evolution of medical devices, diagnostic criteria, and the increasing relevance of certain components of ABPM in the prediction of adverse cardiovascular outcomes, a comprehensive update that is practical for daily clinical practice is required. The main objective of this article is to provide an updated review of ABPM, focusing on its importance in the evaluation of hypertension and its impact on public health in Colombia. In addition, it will discuss the implications of changes in diagnostic thresholds and provide concrete recommendations for the effective implementation of ABPM in clinical practice, allowing health professionals to make informed decisions and improve the care of their patients.(AU)

Single-pill combination for treatment of hypertension: Just a matter of practicality or is there a real clinical benefit?

Elevated blood pressure (BP) is the largest contributor to the incident cardiovascular disease worldwide. Despite explicit guideline recommendations for the diagnosis and management of hypertension, a large proportion of patients remain undiagnosed, untreated, or treated but uncontrolled. Inadequate BP control is associated with many complex factors including patient preference, physician's inertia, health systems disparities, and poor adherence to prescribed antihypertensive drug treatment. The primary driver for reduced cardiovascular morbidity and mortality is lowering of BP ''per se'' and not class effects of specific pharmacotherapies. The recent ESH guidelines recommend the use of four major classes of drugs including renin-angiotensin-aldosterone system (RAS) blockers (angiotensin receptor blockers (ARB) or angiotensin-converting enzyme inhibitors (ACEi)), calcium channel blockers (CCB), thiazide and thiazide-like diuretics, and betablockers. Initiation of treatment for hypertension with a two-drug regimen, preferably in a single pill combination (SPC), is recommended for most patients. Preferred combinations should comprise a RAS blocker (either an ACEi or an ARB) with a CCB or thiazide/thiazide-like diuretic. These strategies are supported by robust evidence that combination therapy produces greater BP reductions than monotherapy, reduces side effects of the individual components, improves therapeutic adherence and long-term persistence on treatment, and permits achievement of earlier BP control.

[Ambulatory blood pressure monitoring, adult and pediatric population. A narrative review]. / Monitorización ambulatoria de la presión arterial en adultos y población pediátrica. Una revisión narrativa.

Hypertension has become a central risk factor for the development of cardiovascular disease, underscoring the importance of its accurate diagnosis. Numerous studies have established a close relationship between elevated systolic (SBP) and diastolic (DBP) blood pressure and an increased risk of cardiovascular event (CVE). Traditionally, blood pressure (BP) measurements performed in clinical settings have been the main method for diagnosing and assessing hypertension. However, in recent years, it has been recognized that BP measurements obtained outside the clinical setting, using self-monitoring blood pressure (SMBP) and ambulatory blood pressure monitoring (ABPM), offer a more realistic perspective of patients' daily lives and therefore provide more reliable results. Given the evolution of medical devices, diagnostic criteria, and the increasing relevance of certain components of ABPM in the prediction of adverse cardiovascular outcomes, a comprehensive update that is practical for daily clinical practice is required. The main objective of this article is to provide an updated review of ABPM, focusing on its importance in the evaluation of hypertension and its impact on public health in Colombia. In addition, it will discuss the implications of changes in diagnostic thresholds and provide concrete recommendations for the effective implementation of ABPM in clinical practice, allowing health professionals to make informed decisions and improve the care of their patients.

Abordaje terapéutico integral de la hipertensión arterial. Recomendaciones para Centroamérica y el Caribe / Comprehensive Therapeutic Approach to Hypertension. Recommendations for Central America and the Caribbean

Las guías clínicas latinoamericanas de hipertensión arterial (HTA), elaboradas a la medida de las necesidades de los países de Centro y Sudamérica deben ser aplicadas y conocidas por la mayoría de los médicos latinoamericanos. El conocimiento e implementación de las guías es uno de los mayores desafíos de las sociedades de hipertensión del área latinoamericana tales como la Sociedad Centroamericana y del Caribe de Hipertensión Arterial (SCCH), la Sociedad latinoamericana de Hipertensión (LASH) y La Sociedad Interamericana de Cardiología (SIAC). En el año 2020, la SIAC publicó su posicionamiento sobre las guías vigentes de hipertensión arterial debido a la necesidad de estandarizar la evaluación, diagnóstico, tratamiento y control de la HTA, estableciendo recomendaciones que deberían adoptarse en todos los países de América Latina, encaminadas a optimizar el manejo del riesgo cardiovascular y conseguir una mejora sustancial en la disminución de eventos y mortalidad cardiovascular. El presente documento pretender reforzar las propuestas de la guía LASH y el posicionamiento de la SIAC en relación con el abordaje terapéutico y recomendaciones de tratamiento farmacológico de la HTA, con la finalidad de que se logre un mejor control de HTA en el área Centroamericana y del Caribe y, consecuentemente, mejorar el pronóstico de las enfermedades cardiovasculares en el área. (AU)

Latin American hypertension guidelines, tailored to the needs of countries of Central and South America, should be applied and known by most Latin American physicians. The knowledge and implementation of the Guidelines is one of the greatest challenges of hypertension societies in Latin America such as the Central American and Caribbean Society of Arterial Hypertension (SCCH), the Latin American Society of Hypertension (LASH) and the Inter-American Society of Cardiology (SIAC). In 2020, the Inter-American Society of Cardiology (SIAC) published its position on the current Guidelines for Arterial Hypertension due to the need to standardize the evaluation, diagnosis, treatment and control of hypertension, establishing recommendations that should be adopted in all Latin American countries, aimed at optimizing the management of cardiovascular risk and achieving a substantial improvement in the reduction of cardiovascular events and mortality. This document intends to reinforce all proposals by the LASH guidelines and the position of the SIAC in relation to the therapeutic approach and pharmacological recommendations for patients with hypertension (HT), in order to achieve better HT control in the Central American and Caribbean area, and the consequently prognosis improvement of cardiovascular disease in the area. (AU)

How low should blood pressure be in patients with chronic coronary and cerebrovascular diseases.

Over the last three decades, there are an increasing number of investigators and meta-analyses focusing on the fact that lowering blood pressure levels below a critical point is no longer beneficial and possibly even deleterious. In recent years, several trials and meta-analyses assessing intensive blood pressure (BP) lowering found that intensive treatment and lower blood pressure levels are associated with a reduction in CV events and mortality. However, a careful examination of the results shows that current data are not easily applicable to the general hypertensive population. In addition, recommendations of different guidelines since 2017 so far suggest different BP levels regarding the systolic and diastolic thresholds to be achieved and maintained, particularly in specific clinical situations such as patients with coronary artery disease and stroke. The challenge is to better define the limits of intervention and to define phenotypes of patients who are particularly vulnerable to over-aggressive lowering of blood pressure. This article reviews the evidence, controversies and current state of knowledge regarding intensive BP lowering and the lower thresholds of BP to be achieved in patients with chronic coronary or cerebrovascular diseases.

[Comprehensive Therapeutic Approach to Hypertension. Recommendations for Central America and the Caribbean]. / Abordaje terapéutico integral de la hipertensión arterial. Recomendaciones para Centroamérica y el Caribe.

Latin American hypertension guidelines, tailored to the needs of countries of Central and South America, should be applied and known by most Latin American physicians. The knowledge and implementation of the Guidelines is one of the greatest challenges of hypertension societies in Latin America such as the Central American and Caribbean Society of Arterial Hypertension (SCCH), the Latin American Society of Hypertension (LASH) and the Inter-American Society of Cardiology (SIAC). In 2020, the Inter-American Society of Cardiology (SIAC) published its position on the current Guidelines for Arterial Hypertension due to the need to standardize the evaluation, diagnosis, treatment and control of hypertension, establishing recommendations that should be adopted in all Latin American countries, aimed at optimizing the management of cardiovascular risk and achieving a substantial improvement in the reduction of cardiovascular events and mortality. This document intends to reinforce all proposals by the LASH guidelines and the position of the SIAC in relation to the therapeutic approach and pharmacological recommendations for patients with hypertension (HT), in order to achieve better HT control in the Central American and Caribbean area, and the consequently prognosis improvement of cardiovascular disease in the area.

[2022 Practice guidelines for the management of arterial hypertension of the Spanish Society of Hypertension]. / Guía práctica sobre el diagnóstico y tratamiento de la hipertensión arterial en España, 2022. Sociedad Española de Hipertensión - Liga Española para la Lucha contra la Hipertensión Arterial (SEH-LELHA).

Hypertension is the most important risk factor for global disease burden. Detection and management of hypertension are considered as key issues for individual and public health, as adequate control of blood pressure levels markedly reduces morbidity and mortality associated with hypertension. Aims of these practice guidelines for the management of arterial hypertension of the Spanish Society of Hypertension include offering simplified schemes for diagnosis and treatment for daily practice, and strategies for public health promotion. The Spanish Society of Hypertension assumes the 2018 European guidelines for management of arterial hypertension developed by the European Society of Cardiology and the European Society of Hypertension, although relevant aspects of the 2017 American College of Cardiology/American Heart Association guidelines and the 2020 International Society of Hypertension guidelines are also commented. Hypertension is defined as a persistent elevation in office systolic blood pressure ≥ 140 and/or diastolic blood pressure ≥ 90 mmHg, and assessment of out-of-office blood pressure and global cardiovascular risk are considered of key importance for evaluation and management of hypertensive patients. The target for treated blood pressure should be < 130/80 for most patients. The treatment of hypertension involves lifestyle interventions and drug therapy. Most people with hypertension need more than one antihypertensive drug for adequate control, so initial therapy with two drugs, and single pill combinations are recommended for a wide majority of hypertensive patients.

Comentario del CEIPV a las nuevas Guías Europeas de Prevención Cardiovascular 2021 / Statement of the Spanish Interdisciplinary Vascular Prevention Committee on the updated European Guidelines on Cardiovascular Disease Prevention

Presentamos la adaptación española de las Guías Europeas de Prevención Cardiovascular 2021. En esta actualización además del abordaje individual, se pone mucho más énfasis en las políticas sanitarias como estrategia de prevención poblacional. Se recomienda el cálculo del riesgo vascular de manera sistemática a todas las personas adultas con algún factor de riesgo vascular. Los objetivos terapéuticos para el colesterol low density lipoprotein (LDL), la presión arterial y la glucemia no han cambiado respecto a las anteriores guías, pero se recomienda alcanzar estos objetivos de forma escalonada (etapas 1 y 2). Se recomienda llegar siempre hasta la etapa 2, y la intensificación del tratamiento dependerá del riesgo a los 10 años y de por vida, del beneficio del tratamiento, de las comorbilidades, de la fragilidad y de las preferencias de los pacientes. Las guías presentan por primera vez un nuevo modelo para calcular el riesgo Systematic Coronary Risk Evaluation-2 (SCORE2) y Systematic Coronary Risk Evaluation-2 Old person (SCORE2-OP) de morbimortalidad vascular en los próximos 10 años (infarto de miocardio, ictus y mortalidad vascular) en hombres y mujeres entre 40 y 89 años. Otra de las novedades sustanciales es el establecimiento de diferentes umbrales de riesgo dependiendo de la edad (< 50, 50-69 ≥ 70 años).Se presentan diferentes algoritmos de cálculo del riesgo vascular y tratamiento de los factores de riesgo vascular para personas aparentemente sanas, pacientes con diabetes y pacientes con enfermedad vascular aterosclerótica. Los pacientes con enfermedad renal crónica se considerarán de riesgo alto o muy alto según la tasa del filtrado glomerular y el cociente albúmina/creatinina. Se incluyen innovaciones en las recomendaciones sobre los estilos de vida, adaptadas a las recomendaciones del Ministerio de Sanidad, así como aspectos novedosos relacionados con el control de los lípidos, la presión arterial, la diabetes y la insuficiencia renal crónica.

Statement of the Spanish Interdisciplinary Vascular Prevention Committee on the updated European Guidelines on Cardiovascular Disease Prevention. We present the Spanish adaptation of the 2021 European Guidelines on Cardiovascular Disease (CVD) prevention in clinical practice. The current guidelines besides the individual approach greatly emphasize on the importance of population level approaches to the prevention of cardiovascular diseases. Systematic global CVD risk assessment is recommended in individuals with any major vascular risk factor. Regarding LDL-Cholesterol, blood pressure, and glycemic control in patients with diabetes mellitus, goals and targets remain as recommended in previous guidelines. However, it is proposed a new, stepwise approach (Step 1 and 2) to treatment intensification as a tool to help physicians and patients pursue these targets in a way that fits patient profile. After Step 1, considering proceeding to the intensified goals of Step 2 is mandatory, and this intensification will be based on 10-year CVD risk, lifetime CVD risk and treatment benefit, comorbidities and patient preferences. The updated SCORE algorithm—SCORE2, SCORE-OP— is recommended in these guidelines, which estimates an individual's 10-year risk of fatal and non-fatal CVD events (myocardial infarction, stroke) in healthy men and women aged 40-89 years. Another new and important recommendation is the use of different categories of risk according different age groups (< 50, 50-69 ≥ 70 years). Different flow charts of CVD risk and risk factor treatment in apparently healthy persons, in patients with established atherosclerotic CVD, and in diabetic patients are recommended. Patients with chronic kidney disease are considered high risk or very high-risk patients according to the levels of glomerular filtration rate and albumin-to-creatinine ratio. [...]

[Statement of the Spanish Interdisciplinary Vascular Prevention Committee on the updated European Guidelines on Cardiovascular Disease Prevention]. / Comentario del CEIPV a las nuevas Guías Europeas de Prevención Cardiovascular 2021.

Statement of the Spanish Interdisciplinary Vascular Prevention Committee on the updated European Guidelines on Cardiovascular Disease Prevention. We present the Spanish adaptation of the 2021 European Guidelines on Cardiovascular Disease (CVD) prevention in clinical practice. The current guidelines besides the individual approach greatly emphasize on the importance of population level approaches to the prevention of cardiovascular diseases. Systematic global CVD risk assessment is recommended in individuals with any major vascular risk factor. Regarding LDL-Cholesterol, blood pressure, and glycemic control in patients with diabetes mellitus, goals and targets remain as recommended in previous guidelines. However, it is proposed a new, stepwise approach (Step 1 and 2) to treatment intensification as a tool to help physicians and patients pursue these targets in a way that fits patient profile. After Step 1, considering proceeding to the intensified goals of Step 2 is mandatory, and this intensification will be based on 10-year CVD risk, lifetime CVD risk and treatment benefit, comorbidities and patient preferences. The updated SCORE algorithm-SCORE2, SCORE-OP- is recommended in these guidelines, which estimates an individual's 10-year risk of fatal and non-fatal CVD events (myocardial infarction, stroke) in healthy men and women aged 40-89 years. Another new and important recommendation is the use of different categories of risk according different age groups (< 50, 50-69 ≥ 70 years). Different flow charts of CVD risk and risk factor treatment in apparently healthy persons, in patients with established atherosclerotic CVD, and in diabetic patients are recommended. Patients with chronic kidney disease are considered high risk or very high-risk patients according to the levels of glomerular filtration rate and albumin-to-creatinine ratio. New lifestyle recommendations adapted to the ones published by the Spanish Ministry of Health as well as recommendations focused on the management of lipids, blood pressure, diabetes and chronic renal failure are included.

Hypertension and heart failure with preserved ejection fraction. A past, present, and future relationship.

Heart failure with preserved ejection fraction (HFpEF) is an increasingly prevalent syndrome with high cardiovascular and non-cardiovascular morbidity and mortality. Hypertension (HT) is one of its major risk factors and participates in its origin, development, and prognosis. The guidelines do not set out specific treatments, as clinical trials show limitations. Hypertension control is fundamental in the prevention and treatment of HFpEF. The guidelines recommend renin-angiotensin system blockade as the mainstay of hypertension treatment in patients with HFpEF. Spironolactone and angiotensin receptor-neprilysin inhibitors are also recommended in some cases. There are also new treatments that are already indicated, such as sodium-glucose cotransporter-2 (SGLT2) inhibitors, and promising treatments such as finerenone. A phenotypic classification that allows for more targeted treatments and studies that cover pending issues are yet to be undertaken.

Hypertension and heart failure with preserved ejection fraction. A past, present, and future relationship

Heart failure with preserved ejection fraction (HFpEF) is an increasingly prevalent syndrome with high cardiovascular and non-cardiovascular morbidity and mortality. Hypertension (HT) is one of its major risk factors and participates in its origin, development, and prognosis. The guidelines do not set out specific treatments, as clinical trials show limitations. Hypertension control is fundamental in the prevention and treatment of HFpEF. The guidelines recommend renin–angiotensin system blockade as the mainstay of hypertension treatment in patients with HFpEF. Spironolactone and angiotensin receptor-neprilysin inhibitors are also recommended in some cases. There are also new treatments that are already indicated, such as sodium-glucose cotransporter-2 (SGLT2) inhibitors, and promising treatments such as finerenone. A phenotypic classification that allows for more targeted treatments and studies that cover pending issues are yet to be undertaken.(AU)

La insuficiencia cardiaca con fracción de eyección preservada (ICFEp) es un síndrome de prevalencia creciente con una gran morbilidad y mortalidad, tanto cardiovascular como por otras causas. La hipertensión arterial (HTA) es uno de sus principales factores de riesgo e interviene en su origen, desarrollo y pronóstico. Las guías no establecen tratamientos específicos, ya que los ensayos clínicos muestran limitaciones. El control de la presión arterial es fundamental en la prevención y tratamiento de la ICFEp. Las guías recomiendan el bloqueo del sistema renina-angiotensina como eje del tratamiento de la HTA en pacientes con ICFEp. Asimismo, se recomienda espironolactona y antagonistas del receptor de angiotensina e inhibidor de neprilisina en algunos casos. Existen además novedades ya indicadas, como los inhibidores del cotransportador-2 de sodio-glucosa (SGLT2), y prometedoras como la finerenona. Queda pendiente el desarrollo de una clasificación fenotípica que permita tratamientos más dirigidos y estudios que respondan a aspectos pendientes.(AU)

Registro Latinoamericano de monitorización ambulatoria de la presión arterial (MAPA-LATAM): una necesidad urgente / Latin-American Ambulatory Blood Pressure Registry (MAPA-LATAM): An urgent need

La hipertensión arterial (HTA) es el principal factor de riesgo de enfermedad cardiovascular. Aunque es un problema global, independiente de la situación económica, región, raza o cultura, los datos disponibles con respecto a Latinoamérica no son muy abundantes. Por otra parte, las guías clínicas enfatizan la importancia de obtener lecturas fiables de la presión arterial. Por ello, se recomienda el uso de la monitorización ambulatoria de la presión arterial (MAPA), que mejora su precisión y reproducibilidad, ayudando a un mejor diagnóstico, en la toma de decisiones terapéuticas, y representa una mejor estimación pronóstica que las medidas en consulta. Lamentablemente, no existe ningún registro prospectivo global de MAPA para toda Latinoamérica que analice la prevalencia de HTA, el grado de su conocimiento, su porcentaje de tratamiento y el grado de control. En consecuencia, los autores de este artículo consideran prioritaria su puesta en marcha (AU)

Hypertension (HT) is one of the main risk factors for cardiovascular disease. Although it is a global problem, independently of economic situation, region, race or culture, the data available on Latin America are limited. Clinical guidelines emphasise the importance of obtaining reliable blood pressure readings. For this reason, the use of ambulatory blood pressure monitoring (ABPM) is recommended. This improves precision and reproducibility, resulting in better diagnosing and therapeutic decision-making, and constitutes a better estimation of prognosis than office measurements. Unfortunately, there is no global prospective ABPM registry for all of Latin America that analyses HT prevalence, the level of knowledge about it, treatment percentage and the degree of control. Consequently, the authors of this article consider its implementation a priority (AU)

Utilidad pronóstica de las cifras ambulatorias de presión arterial en pacientes de edad avanzada con insuficiencia cardíaca. Resultados del estudio DICUMAP / Prognostic value of ambulatory blood pressure values in elderly patients with heart failure. Results of the DICUMAP study

Introducción La monitorización ambulatoria de la presión arterial (MAPA) ha demostrado la utilidad en la evaluación pronóstica de los pacientes hipertensos con insuficiencia cardíaca (IC) con o sin otras enfermedades cardiovasculares. El objetivo de este estudio consistió en determinar si la MAPA puede identificar a pacientes con IC con un peor pronóstico. Métodos y resultados Estudio multicéntrico prospectivo en el que se incluyeron pacientes ambulatorios y clínicamente estables con IC. Todos los pacientes se sometieron a una MAPA. Se incluyó un total de 154 pacientes de 17 centros. La edad media fue de 76,8 años (±8,3) y el 55,2% eran mujeres. En total, el 23,7% presentaba IC con fracción de eyección reducida (IC-FEr), el 68,2% se encontraba en la clase funcional II de la NYHA y el 19,5%, en la clase funcional III de la NYHA. Al cabo de un año de seguimiento se produjeron 13 (8,4%) muertes, 10 de ellas atribuidas a la IC. En 19 de los 29 pacientes que precisaron hospitalización, esta se debió a la IC. La presencia de un patrón no dipper de PA se asoció a un mayor riesgo de reingreso o muerte al año de seguimiento (25% frente al 5%; p=0,024). Según un análisis de regresión de Cox, una clase funcional más avanzada de la NYHA (razón de riesgos instantáneos, 3,51; IC del 95%, 1,70-7,26; p=0,001; comparación entre las clases III y II de la NYHA) y una mayor reducción nocturna proporcional de la PA diastólica (razón de riesgos instantáneos, 0,961; IC del 95%, 0,926-0,997; p=0,032 por cada reducción del 1% de la PA diastólica) se asociaron a muerte o reingreso al cabo de un año de manera independiente. Conclusiones En los pacientes de edad avanzada con IC crónica, un patrón no dipper de PA determinado mediante MAPA se asoció a un mayor riesgo de hospitalización y muerte por IC (AU)

Introduction Ambulatory blood pressure monitoring (ABPM) has demonstrated value in the prognostic assessment of hypertensive patients with heart failure (HF) with or without other cardiovascular diseases. The objective of this study was to evaluate whether ABPM can identify subjects with HF with a worse prognosis. Methods and results Prospective multicenter study that included clinically stable outpatients with HF. All patients underwent ABPM. A total of 154 patients from 17 centers were included. Their mean age was 76.8 years (±8.3) and 55.2% were female. In total, 23.7% had HF with a reduced ejection fraction (HFrEF), 68.2% were in NYHA functional class II, and 19.5% were in NYHA functional class III. At one year of follow up, there were 13 (8.4%) deaths, of which 10 were attributed to HF. Twenty-nine patients required hospitalization, of which 19 were due to HF. The presence of a non-dipper BP pattern was associated with an increased risk for readmission or death at one year of follow-up (25% vs. 5%; p=.024). According to a Cox regression analysis, more advanced NYHA functional class (hazard ratio 3.51; 95%CI 1.70-7.26; p=.001; for NYHA class III vs. II) and a higher proportional nocturnal reduction in diastolic BP (hazard ratio 0.961; 95%CI 0.926-0.997; p=.032 per 1% diastolic BP reduction) were independently associated with death or readmission at one year. Conclusion In older patients with chronic HF, a non-dipper BP pattern measured by ABPM was associated with a higher risk of hospitalization and death due to HF (AU)

Latin-American Ambulatory Blood Pressure Registry (MAPA-LATAM): An urgent need.

Hypertension (HT) is one of the main risk factors for cardiovascular disease (CVD). Although it is a global problem, independently of economic situation, region, race or culture, the data available on Latin America are limited. Clinical guidelines emphasise the importance of obtaining reliable blood pressure readings. For this reason, the use of ambulatory blood pressure monitoring (ABPM) is recommended. This improves precision and reproducibility, resulting in better diagnosing and therapeutic decision-making, and constitutes a better estimation of prognosis than office measurements. Unfortunately, there is no global prospective ABPM registry for all of Latin America that analyses HT prevalence, the level of knowledge about it, treatment percentage and the degree of control. Consequently, the authors of this article consider its implementation a priority.

Prognostic value of ambulatory blood pressure values in elderly patients with heart failure. Results of the DICUMAP study.

INTRODUCTION: Ambulatory blood pressure monitoring (ABPM) has demonstrated value in the prognostic assessment of hypertensive patients with heart failure (HF) with or without other cardiovascular diseases. The objective of this study was to evaluate whether ABPM can identify subjects with HF with a worse prognosis. METHODS AND RESULTS: Prospective multicenter study that included clinically stable outpatients with HF. All patients underwent ABPM. A total of 154 patients from 17 centers were included. Their mean age was 76.8 years (± 8.3) and 55.2% were female. In total, 23.7% had HF with a reduced ejection fraction (HFrEF), 68.2% were in NYHA functional class II, and 19.5% were in NYHA functional class III. At one year of follow up, there were 13 (8.4%) deaths, of which 10 were attributed to HF. Twenty-nine patients required hospitalization, of which 19 were due to HF. The presence of a non-dipper BP pattern was associated with an increased risk for readmission or death at one year of follow-up (25% vs. 5%; p=.024). According to a Cox regression analysis, more advanced NYHA functional class (hazard ratio 3.51; 95% CI 1.70-7.26; p=.001; for NYHA class III vs. II) and a higher proportional nocturnal reduction in diastolic BP (hazard ratio 0.961; 95%CI 0.926-0.997; p=.032 per 1% diastolic BP reduction) were independently associated with death or readmission at one year. CONCLUSION: In older patients with chronic HF, a non-dipper BP pattern measured by ABPM was associated with a higher risk of hospitalization and death due to HF.

Nutritional Risk and Mortality at One Year for Elderly Patients Hospitalized with Nonvalvular Atrial Fibrillation. Nonavasc Registry.

OBJECTIVES: To determine whether nutritional risk is associated with the mortality of elderly patients hospitalized with nonvalvular atrial fibrillation (NVAF). DESIGN: Prospective, multicenter cohort study. SETTING: Internal medicine departments in Spain. PARTICIPANTS: Inpatients >75 years with NVAF. MEASUREMENTS: We measured the thrombotic and hemorrhagic risk at admission using the CHA2DS2-VASc and HAS-BLED scales, respectively, and the nutritional risk with the controlling nutritional status (CONUT) index. We established 4 degrees of nutritional risk: null (CONUT score 0-1 point), low (2-4 points), moderate (5-8 points) and high (9-12 points). We also conducted a 1-year follow-up. RESULTS: We included 449 patients, with a mean age of 85.2(5.2) years. The nutritional risk was null for 70(15.6%) patients, low for 206 45.9%), moderate for 152(33.8%) and high for 21(4.7%). At the end of one year, 177(39.4%) patients had died. The score on the CONUT index was higher for the deceased patients (4.6 vs. 3.6, p<0.001). The CONUT score (HR, 1.076; 95%CI 1.009-1.148; p=0.025), the Charlson index (HR, 1.080; 95%CI 1.017-1.148; p=0.013) and the presence of pressure ulcers (HR, 1.700; 95%CI 1.028-2.810; p=0.039) were independently associated with increased mortality at one year of follow-up. The prescription of oral anticoagulants at discharge was associated with lower mortality (HR, 0.440; 95%CI 0.304-0.638; p<0.001). CONCLUSIONS: More than a third of elderly patients hospitalized with NVAF have a moderate to high nutritional risk. These patients have greater mortality at the end of one year.

Inhibidores de PCSK9: ratificación del papel del colesterol LDL en prevención cardiovascular. ¿Hacia la convergencia en las guías de prevención europeas y norteamericanas? / PCSK9 inhibitors: ratification of the role of LDL cholesterol in cardiovascular prevention. Towards a convergence of European and North American prevention guidelines?

La asociación epidemiológica entre los niveles de colesterol asociado a lipoproteínas de baja densidad (c-LDL) y el desarrollo de enfermedad vascular aterosclerosa ha sido ratificada mediante estudios de aleatorización mendeliana. Paradójicamente, el éxito de las estatinas condujo a minusvalorar otros tratamientos hipolipidemiantes e incluso la medición del c-LDL. Estudios recientes muestran que la reducción del c-LDL hasta niveles extraordinariamente bajos mediante inhibidores de la absorción y, de modo especialmente intenso, con los anticuerpos monoclonales anti proproteína convertasa subtilisina kexina 9 (PCSK9) continúa ofreciendo protección cardiovascular. Sin embargo, el elevado coste y la limitada experiencia con los inhibidores de PCSK-9 aconsejan un uso prudente de los mismos. Una selección adecuada de los pacientes que más se pueden beneficiar del tratamiento con inhibidores de vPCSK9 emerge como base de consenso de las guías internacionales: la combinación de un elevado riesgo vascular absoluto y un mayor beneficio esperable por los niveles de c-LDL de partida

The epidemiological association of cholesterol associated with low density lipoproteins (LDL-c) levels and the development of atherosclerotic vascular disease has been ratified by mendelian randomization studies. Paradoxically, the success of statins led to the underestimation of other lipid-lowering therapies and even the measurement of LDL-c. Recent studies show that the reduction of LDL-c to extraordinarily low levels through absorption inhibition, and, in a particularly intensive manner, with monoclonal antibodies against pro-protein convertase subtilisine Kesine 9 (PCSK9) continues to offer cardiovascular protection. However, the high cost and limited experience with PCSK-9 inhibitors advised a prudent use of them. An appropriate selection of patients most likely to benefit from treatment with PCSK9 inhibitors emerges as the basis for a consensus of international guidelines: the combination of a high absolute vascular risk and a greater expected benefit by the starting LDL-c levels

Insuficiencia cardiaca y diabetes: la confrontación de dos grandes epidemias del siglo XXI / Heart failure and diabetes: The confrontation of two major epidemics of the 21st century

Existe una asociación bidireccional entre la insuficiencia cardiaca (IC) y la diabetes mellitus tipo 2 (DM2) que hace que la combinación de ambas enfermedades en un mismo paciente haya pasado a tener un incremento exponencial. Dicha combinación, parte de múltiples causas comunes que llevan a vías fisiopatológicas que resultan en un efecto deletéreo de la DM2 sobre la IC. La consecuencia clínica inevitable es que ante dicha situación el paciente presente peor clínica y peor pronóstico que el paciente con IC sin DM2. Por todo ello debemos tener en cuenta cómo tratar la DM2 en pacientes con IC, y cómo tratar la IC en pacientes con DM2. En esta revisión se hace hincapié en los últimos datos publicados al respecto

There is a bidirectional association between heart failure (HF) and type 2 diabetes mellitus (DM2), which has resulted in an exponential increase in the combination of the 2 diseases in a single patient. This combination is one of many common causes that lead to the pathophysiological pathways resulting in the deleterious effect of DM2 on HF. The inevitable clinical consequence is that, when faced with this situation, patients present worse symptoms and a poorer prognosis than patients with HF but without DM2. We should therefore consider how to treat DM2 in patients with HF and how to treat HF in patients with DM2. In this review, we highlight the latest published data on this issue

PCSK9 inhibitors: Ratification of the role of LDL cholesterol in cardiovascular prevention. Towards a convergence of European and North American prevention guidelines? / Inhibidores de PCSK9: ratificación del papel del colesterol LDL en prevención cardiovascular. ¿Hacia la convergencia en las guías de prevención europeas y norteamericanas?

The epidemiological association of cholesterol associated with low density lipoproteins (LDL-c) levels and the development of atherosclerotic vascular disease has been ratified by mendelian randomization studies. Paradoxically, the success of statins led to the underestimation of other lipid-lowering therapies and even the measurement of LDL-c. Recent studies show that the reduction of LDL-c to extraordinarily low levels through absorption inhibition, and, in a particularly intensive manner, with monoclonal antibodies against pro-protein convertase subtilisine Kesine 9 (PCSK9) continues to offer cardiovascular protection. However, the high cost and limited experience with PCSK-9 inhibitors advised a prudent use of them. An appropriate selection of patients most likely to benefit from treatment with PCSK9 inhibitors emerges as the basis for a consensus of international guidelines: the combination of a high absolute vascular risk and a greater expected benefit by the starting LDL-c levels.

Heart failure and diabetes: The confrontation of two major epidemics of the 21st century. / Insuficiencia cardiaca y diabetes: la confrontación de dos grandes epidemias del siglo xxi.

There is a bidirectional association between heart failure (HF) and type 2 diabetes mellitus (DM2), which has resulted in an exponential increase in the combination of the 2 diseases in a single patient. This combination is one of many common causes that lead to the pathophysiological pathways resulting in the deleterious effect of DM2 on HF. The inevitable clinical consequence is that, when faced with this situation, patients present worse symptoms and a poorer prognosis than patients with HF but without DM2. We should therefore consider how to treat DM2 in patients with HF and how to treat HF in patients with DM2. In this review, we highlight the latest published data on this issue.