[High cardiovascular risk due to inadequate control of risk factors in Spanish hypertensive patients seen in the Spanish primary care]. / Alto riesgo cardiovascular por el inadecuado control de los factores de riesgo de hipertensos españoles en Atención Primaria en España.

INTRODUCTION: Cardiovascular diseases are the main cause of morbidity-mortality in Spain. Hypertension and the other cardiovascular factors are important in the pathophysiological basis of this fact. Control of the main risk factors in treated hypertensives was evaluated in this study. PATIENTS AND METHODS: Multicenter study in hypertensive patients treated in Primary Care. Blood pressure, cardiovascular risk factors as well as registered target organ damage and clinical diseases were measured. Finally, global cardiovascular risk was calculated. RESULTS: Only 17.3% of pharmacologically treated hypertensives were controlled (3.9% of diabetic patients). LDL-cholesterol control deteriorated as the patient's cardiovascular risk pattern increased (90.4% in low risk and 19.9% in high-very high risk). High levels of serum creatinine were detected in 8.3%, microalbuminuria being positive in 15.6%, with 20.8% ventricular hypertrophy. A total of 31% of the patients were diabetic, 59.8% of them having HbA1c > or = 6.5%. Global CV risk was high very high in many subjects (65.4%) when European Society of Hypertension-European Society of Cardiology (ESH-ESC) guidelines were used. This percentage was 3.6% when the Spanish-validated Framingham score was used. CONCLUSIONS: Blood pressure control as well as main cardiovascular risk factors is poor in this population. Considering this fact plus the number of target organ damage, the global risk is high in many patients according to the European guidelines. Guidelines that do not consider target organ damage do not estimate adequately the risk of this uncontrolled population. This conclusion could explain the clinical tendency of many doctors when attending uncontrolled patients.

Alto riesgo cardiovascular por el inadecuado control de los factores de riesgo de hipertensos españoles en Atención Primaria en España / High cardiovascular risk due to inadequate control of risk factors in spanish hypertensive patients seen in the spanish Primary Care

Introducción. Las enfermedades cardiovasculares constituyen la causa principal de muerte en España. En su génesis son importantes la hipertensión y otros factores de riesgo. En este estudio se ha valorado el control de los principales componentes de riesgo en hipertensos tratados. Pacientes y métodos. Estudio multicéntrico en hipertensos de Atención Primaria. Se determinaron presiones arteriales, factores de riesgo cardiovascular, lesiones de órganos diana y patologías asociadas calculándose el riesgo cardiovascular global. Resultados. El 17,3% de los hipertensos (3,9% en diabéticos) tenían la presión arterial controlada. El control del colesterol ligado a lipoproteínas de baja densidad empeoró a medida que aumentaba el riesgo (90,4% en riesgo bajo y 19,94% en pacientes de alto/muy alto). El 8,3% tenían creatinina elevada, 15,6% microalbuminuria positiva, 20,8% hipertrofia ventricular. El 31% tenía diabetes y un 59,8% de ellos HbA1c ≥ 6,5%. Según la guía European Society of Hypertension-European Society of Cardiology (ESH-ESC) el riesgo cardiovascular era alto/muy alto en el 65,4%. Según las tablas de Framingham adaptadas a España este porcentaje era 3,6%. Conclusiones. El grado de control de presiones y otros factores de riesgo cardiovascular fue bajo. La elevada prevalencia de lesión de órgano diana determinó que el riesgo cardiovascular fuera elevado/muy elevado en la mayoría de sujetos según la guía europea, que tiene en cuenta todos estos factores. Las guías que no consideran la lesión orgánica infraestiman el riesgo de estos hipertensos deficientemente controlados y ello podría contribuir a la inercia médica ante la falta de control de los factores de riesgo

Introduction. Cardiovascular diseases are the main cause of morbidity-mortality in Spain. Hypertension and the other cardiovascular factors are important in the pathophysiological basis of this fact. Control of the main risk factors in treated hypertensives was evaluated in this study. Patients and methods. Multicenter study in hypertensive patients treated in Primary Care. Blood pressure, cardiovascular risk factors as well as registered target organ damage and clinical diseases were measured. Finally, global cardiovascular risk was calculated. Results. Only 17.3% of pharmacologically treated hypertensives were controlled (3.9% of diabetic patients). LDL-cholesterol control deteriorated as the patient's cardiovascular risk pattern increased (90.4% in low risk and 19.9% in high-very high risk). High levels of serum creatinine were detected in 8.3%, microalbuminuria being positive in 15.6%, with 20.8% ventricular hypertrophy. A total of 31% of the patients were diabetic, 59.8% of them having HbA1c ≥ 6.5%. Global CV risk was high very high in many subjects (65.4%) when European Society of Hypertension-European Society of Cardiology (ESH-ESC) guidelines were used. This percentage was 3.6% when the Spanish-validated Framingham score was used. Conclusions. Blood pressure control as well as main cardiovascular risk factors is poor in this population. Considering this fact plus the number of target organ damage, the global risk is high in many patients according to the European guidelines. Guidelines that do not consider target organ damage do not estimate adequately the risk of this uncontrolled population. This conclusion could explain the clinical tendency of many doctors when attending uncontrolled patients

High prevalence of secondary hypertension and insulin resistance in patients with refractory hypertension.

OBJECTIVE: To determine causes of treatment resistance in patients with refractory hypertension, and to estimate the prevalence of true resistant hypertension. METHODS: We studied 50 consecutive patients referred with refractory hypertension after exclusion of hypokalemia and stenosis of the renal artery. Ambulatory blood pressure monitoring was performed in all patients to detect white-coat effect. The patients were hospitalized, antihypertensive drugs were withdrawn and a screening for secondary hypertension was performed. In addition, these patients, and a control group of essential hypertensives controlled with three antihypertensive drugs, underwent a OGTT with 75 g of glucose. RESULTS: Primary normokalemic hyperaldosteronism was diagnosed in seven patients. Two patients had a pheochromocytoma and six had white-coat effect. The 35 remaining patients with true resistant hypertension shown significant differences in serum insulin and HOMA IR when compared with the control group. CONCLUSIONS: These findings show that among normokalemic treatment-resistant hypertension, the presence of hyperaldosteronism and pheochromocytoma is quite high. Moreover, treatment resistance in hypertensive patients appears to be associated with insulin resistance.

Riesgo cardiovascular absoluto en hipertensos y su evolución con el tratamiento antihipertensivo / Absolute cardiovascular risk in hypertensive patients and evolution with antihypertensive treatment

El control de los factores de riesgo es la clave para la prevención primaria de las enfermedades cardiovasculares, por ello el concepto de riesgo cardiovascular absoluto debería ser la guía para iniciar el tratamiento antihipertensivo. El objetivo de este estudio fue calcular el riesgo cardiovascular absoluto para ictus y cardiopatía isquémica basal y tras un año de intervención médica en dos poblaciones de hipertensos: en asistencia primaria (CS) y en la Unidad de Hipertensión de referencia (UH). Material y métodos. Se realizó un estudio retrospectivo en el que se realizaron dos cortes transversales con un año de intervalo en los mismos pacientes. Utilizamos las tablas de predicción de riesgo del Framingham Heart Study, expresándolo como probabilidad porcentual de padecer incidente en 10 años. Se valoraron un total de 216 pacientes, 105 de la UH y 111 del CS. Resultados. Los pacientes de la UH presentan mayor riesgo absoluto basal tanto para ictus como para cardiopatía isquémica que los de CS. Con la práctica clínica habitual en el paciente hipertenso el riesgo de ictus se redujo significativamente en la UH (15,1 ñ 12,8 frente a 11,7 ñ 4,3, p < 0,05), pero no en el CS (11,7 ñ 10,5 frente a 9,6 ñ 7,9). La reducción del riesgo absoluto de cardiopatía isquémica fue significativa tanto en la UH como en el CS (19,4 ñ 12 frente a 16,5 ñ 12, p < 0,01 en la UH, y 18 ñ 10 frente a 14,8 ñ 9,5, p < 0,05 en CS). Conclusión. El tratamiento de la hipertensión arterial reduce los niveles de presión arterial y también el riesgo cardiovascular tanto en pacientes con riesgo menos elevado como son los del CS como en pacientes de mayor riesgo cardiovascular como son los remitidos a la UH. La utilización de un método de medida del riesgo es importante para conocer tanto el riesgo inicial del paciente y valorar la eficacia de la actuación médica (AU)

[An analysis of the referrals of primary care physicians to a hospital hypertension unit]. / Análisis de la derivación de médicos de atención primaria a una unidad de hipertensión hospitalaria.

OBJECTIVES: To describe the referral of hypertense patients from primary care to a hospital arterial hypertension unit, the quality of the information sent and the profile of the referred patients. DESIGN: A descriptive crossover study. SETTING: The Hospital Clínico of San Carlos in Madrid. PATIENTS AND OTHER PARTICIPANTS: A simple random sample of 368 clinical records belonging to patients attended at the unit over the last 3 years. MEASUREMENTS AND MAIN RESULTS: 54.6% of patients were referred from primary care. 48.9% of the interclinical (IC) notes were high-quality, with 28.7% acceptable. 36.8% of referrals were considered incorrect, 30.3% because of false unresponsiveness to treatment. Good or acceptable IC notes were associated with 94.1% of correct referrals and only 65.4% of incorrect referrals. CONCLUSIONS: A high proportion of referrals which were incorrect by the consensus criteria were detected and were caused by inadequate or insufficient medical treatment. There was a statistically significant relationship found between correct referrals and the quality of information sent in the IC note.