[Classical nephroprotection: Renin angiotensin aldosterone system inhibitors]. / Nefroprotección clásica: inhibidores del sistema renina angiotensina aldosterona.

The role of the renin angiotensin aldosterone system (RAAS) in the pathophysiology of hypertension, cardiovascular disease and kidney disease has been known for years. RAAS inhibitors have been the mainstay of chronic kidney disease (CKD) treatment. Studies have shown that therapy with angiotensin-converting enzyme inhibitors (ACE inhibitors) or angiotensinII receptor blockers (ARBs) reduce the excretion of albuminuria and slow the progression of kidney disease in patients with and without diabetes. In clinical practice, RAAS inhibitors are recommended as the antihypertensive of choice in patients with CKD and albuminuria with or without diabetes. In addition, they have demonstrated cardiovascular benefits beyond blood pressure control. The use of RAAS inhibitors in non-proteinuric nephropathy and advanced CKD is not without controversy. Double blockade of the RAAS is contraindicated. On the other hand, it is essential to know how to titrate doses and avoid side effects, mainly hyperkalaemia.

[Failure Mode and Effects Analysis (FMEA) method applied to anticoagulation of patients with non-valvular atrial fibrillation]. / El método AMFE (Análisis Modal de Fallos y Efectos) aplicado a la anticoagulación de pacientes con fibrilación auricular no valvular.

OBJECTIVES: To contribute to the improvement of the process of anticoagulation in patients with nonvalvular atrial fibrillation (NVAF) through awareness and training activities for Primary Care Physicians. MATERIALS AND METHODS: A total of 38 focus groups, sequenced according to an adaptation of the Failure Mode and Effects Analysis (FMEA) method. Each meeting was driven by «brainstorming¼ methodology. The geographical representation was homogeneous, with a total of 482 national. physicians (444 Primary Care Physicians, and 38 cardiologists). The meetings were held between March 28 and June 20, 2017. RESULTS: The main unsafe actions that can lead to a haemorrhagic or thrombotic event are incorrect anticoagulation or lack of patient follow-up. These events are mainly caused by training deficiencies in the management of NVAF, or by not taking into account possible interactions with vitamin K antagonist drugs. The main recommendations to alleviate these failures were focused on a good follow-up of patients with NVAF, on creating or updating the protocols or clinical practice guidelines, and on promoting the continuous training of physicians who usually manage patients with non-valvular AF treated with oral anticoagulants. CONCLUSIONS: A significant percentage of patients with NVAF are not correctly anticoagulated. Specific actions are required to alleviate this problem. Among them, the importance of a general anticoagulation training was emphasised, and particularly, the use of direct oral anticoagulants.

[Design of a thromboprophylaxis care process in patients with atrial fibrillation]. / Diseño del proceso asistencial de profilaxis de la tromboembolia en pacientes con fibrilación auricular.

OBJECTIVE: To describe the milestones in the anticoagulant care process of atrial fibrillation patients (AF), as well as quality and safety indicators, in order to establish an integrated care process of these patients in the Community of Madrid. METHODS: A consensus conference technique was applied, with the participation of 21 professionals (seven in the Steering Group and 14 known experts), from the specialties of Emergency, Internal Medicine, Cardiology, Neurology, Haematology, Family Medicine, Nursing, and Quality. Hospitals and Primary Care were represented. Milestones, elements and barriers/limitations were agreed upon in the care process of anticoagulated AF patients. A minimum set of indicators were also defined to assess the quality of care. RESULTS: Four milestones (stratification of thromboembolism and bleeding risk, evaluation for anticoagulant treatment, follow-up of direct-acting oral anticoagulants, and follow-up of treatment with vitamin K antagonists) were identified. A total of 14 barriers/limitations were also prioritised. In total, six indicators were defined (two structural-related, two processes-related, and two outcomes-related). CONCLUSIONS: Milestones and critical activities, together with a set of indicators, have been agreed for the development of guidelines with which to achieve a better therapeutic approach for anticoagulated AF patients.

[Recommendations on the treatment of hypertension in the secondary prevention of ischemic stroke]. / Recomendaciones sobre el tratamiento de la hipertensión arterial en la prevención secundaria del ictus isquémico.

Stroke continues to be one of the leading causes of death and disability in the world. One of the main problems with a patient who has survived from a stroke is the possibility of developing a new vascular episode again. Hypertension is the modifiable vascular risk factor with the greatest impact for both primary prevention and stroke recurrence. The Group for the study of Hypertension and Brain (GEHYC) from the Spanish Society of Hypertension aims to spread the importance of strict control of blood pressure in order to prevent cerebrovascular diseases. In this article, this multidisciplinary Group reviews the latest evidence regarding antihypertensive treatment and secondary prevention of ischemic stroke.

[Management of heart failure in cardiology and primary care (MICCAP) program: Improving the management of patients with heart failure]. / Programa MICCAP (Manejo de la Insuficiencia Cardiaca en Cardiología y en Atención Primaria): mejorando el manejo del paciente con insuficiencia cardiaca.

Despite current treatments, morbidity and mortality of patients with heart failure remain high. The late diagnosis of heart failure, the insufficient heart failure treatment (i.e. not using the appropriate drugs, prescribing lower doses of drugs than recommended, etc.), and a poor coordination between different health care levels, may explain, at least in part, these figures. The Management of Heart Failure in Cardiology and Primary Care (MICCAP) program has been developed with the aim of optimising the integrated management of patients with heart failure between Primary Care and Cardiology, through the improvement of coordination between both health care levels. This includes continuous medical education to reinforce the diagnostic and therapeutic skills of general practitioners in the field of heart failure. The rationale and objectives of the MICCAP program are summarised in this article.

[Anemia of chronic kidney disease: Protocol of study, management and referral to Nephrology]. / Anemia en la enfermedad renal crónica: protocolo de estudio, manejo y derivación a Nefrología.

The objective of this protocol is to know which test are needed to study an anaemia in a patient with chronic kidney disease, the differential diagnosis of renal anaemia, to know and correct other deficiency anaemias, and the criteria for referral to Nephrology or other specialties of the anaemic patient with chronic kidney disease.

Unnecessary overuse. Study of "inadvisable practices" for patients with atrial fibrillation. / Sobreutilización innecesaria. Estudio de los «no hacer¼ en pacientes con fibrilación auricular.

OBJECTIVE: To identify overuse (diagnostic, therapeutic and self-care practices that represent risks that outweigh the potential benefits) in patients with atrial fibrillation. METHOD: The study was based on qualitative research techniques. Using the "Metaplan" technique, we identified and ordered potentially inappropriate, ineffective and inefficient practices. By means of a consensus conference, we then established a number of "inadvisable practice" measures (relatively common practices that should be eliminated based on the scientific evidence or clinical experience). Professionals from the specialties of cardiology, haematology, neurology, internal medicine, family medicine and nursing participated in the consensus. RESULTS: We developed a catalogue of 19 "inadvisable practices" related to the diagnosis, treatment and care of anticoagulated patients that were inappropriate, had questionable effectiveness or were ineffective, as well as 13 beliefs or behaviours for anticoagulated patients that could result in injury or were useless or inefficient. CONCLUSION: The "inadvisable practices" approach helps identify practices that represent greater risks than benefits for patients. It seems appropriate to include algorithms in the clinical decision-making support systems that consider this information for the diagnosis, treatment and for home care. For this last case, recommendations have also been prepared that define specific contents for the healthcare education of these patients.

[Prevalence of kidney insufficiency in primary care population in Spain: EROCAP study]. / Prevalencia de insuficiencia renal en Centros de Atención Primaria en España: Estudio EROCAP.

This cross-sectional, multicenter study investigated the prevalence of chronic kidney disease and associated disorders, in an adult population sample (> 18 years old) attending Primary Care services in Spain. Estimated glomerular filtration rate (Modification Diet in Renal Disease equation) was used for analysis of kidney disease prevalence according to NFK-KDOQI (The National Kidney Foundation-Kidney Disease Outcomes Quality Initiative) stages. Data were collected on serum creatinine, other laboratory parameters blood pressure, and medical history of cardiovascular risk factors or disease (hypertension, dislypidemia, diabetes, congestive heart failure, coronary artery disease, stroke or peripheral arteriopathy) in 7,202 patients attending Primary Care Centers. 47.3% were males, mean age 60,6 +/- 14,3 years, BMI 28.2 +/- 5.3, with 27,6% overweight (27-30 kg/m2) and 32,1% obese (BMI>or=30 kg/m2), The prevalence of cardiovascular risks factors were: absence in 17.3%, one factor 26.9% two 31.2%, and 23.6% presented three or more The frequency of CV risk factors was: hypertension (66.7%), dyslipidemia (48%) and diabetes (31.5%). Congestive heart failure, coronary artery disease, stroke or peripheral vascular disease frequency was lower than 10% The prevalence of eGFR < 60 ml/min x 1.73 m2 was: stage 3 (30-59 ml/min/1.73 m2) 19.7%; stage 4 (15-29 ml/min/1.73 m2) 1.2%; stage 5 no dialysis (GFR < 15 ml/min) 0.4%. This prevalence increased with age in both sexes and 33,7% of patients attending Primary Care services over 70 years presented a eGFR < 60 ml/min. Of the total patients with eGFR < 60 ml/min 37.3% had normal serum creatinine levels. This study documents the substantial prevalence of significantly abnormal renal function among patients at Primary Care level. Early identification and appropriate nephrological management of these patients with renal disease is an important opportunity for an adequate prescription of drugs that interfere with renal function, to delay the progression of renal disease and modify CV risk factors.

La hipertensión arterial, un factor de riesgo que no sólo afecta a los hipertensos / Hypertension, a risk factor that does not only affect hypertense people

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