Conducta del médico ante el mal control de la hipertensión arterial. Aportaciones de los estudios PRESCAP 2002 y PRESCAP 2006 al conocimiento de la inercia terapéutica en España / Attitude of the physician towards poorly controlled arterial hypertension. Contributions of the PRESCAP 2002 and PRESCAP 2006 studies to knowledge on the therapeutic inertia in Spain

En España tan solo 4 de cada 10 hipertensos tratados con fármacos antihipertensivos que reciben asistencia sanitaria en Atención Primaria tienen bien controlada la PA. La inercia terapéutica está reconocida como una de las principales causas de mal control de la HTA y de otras enfermedades crónicas. Los PRESCAP fueron estudios tranversales y multicéntricos diseñados para estimación de prevalencias, que se realizaron en los años 2002 y 2006 con la misma metodolología en poblaciones similares asistidas en AP. Uno de los objetivos de ambos estudios fue analizar la conducta terapéutica del médico ante pacientes mal controlados (PA sistólica o diastólica ≥140 o ≥90mmHg, respectivamente, en población hipertensa en general, o PA≥130 o ≥80mmHg en pacientes con diabetes, nefropatía o enfermedad cardiovascular). El estudio PRESCAP 2002 mostró que el porcentaje de pacientes con inadecuado control de la PA en los que el médico modificó la pauta terapéutica fue del 18,3% (IC 95%: 17,5–19,1), siendo el cambio de fármaco la opción más elegida (47%), seguida de la combinación (34,7%) y del aumento de dosis (18,3%). En el estudio PRESCAP 2006 el médico modificó el tratamiento en el 30,4% (IC 95%: 29,2–31,6) de los sujetos mal controlados, resultando las acciones más frecuentemente llevadas a cabo la combinación con otro fármaco (46,3%), el incremento de dosis (26,1%) y la sustitución del antihipertensivo (22,8%). La percepción de buen control de la PA por parte del médico fue la variable que más se relacionó con la no modificación del tratamiento farmacológico. Aunque la conducta terapéutica del médico dista de ser idónea, nuestros resultados parecen indicar que se ha producido una mejora importante en la inercia terapéutica de los médicos de Atención Primaria ante los hipertensos mal controlados que siguen tratamiento farmacológico antihipertensivo (AU)

In Spain, only 4 out of 10 hypertensive patients treated with antihypertensive drugs who are attended in Primary Care (PC) have well-controlled blood pressure (BP). Therapeutic inertia (TI) is recognized as one of the main causes for poorly controlled arterial hypertension and other chronic diseases. The PRESCAPs were cross-sectional and multicenter studies designed to calculate prevalence. These studies were conducted in the years 2002 and 2006 using the same methodology in similar populations attended in PC. One of the purposes of both studies was to analyze the therapeutic attitude of the physician in regards to poorly-controlled patients (systolic or diastolic BP≥140 or ≥90mmHg, respectively, in hypertensive population in general, or BP PA≥130 or ≥80mmHg in patients with diabetes, nephropathy or cardiovascular disease). The PRESCAP 2002 study showed that the percentage of patients with inadequate control of PB in whom the physician changed the therapeutic regime was 18.3% (95% CI: 17.5–19.1), the change in the drug of choice being the action chosen the most (47%), followed by combination (34.7%) and dose increase (18.3%). In the PRESCAP 2006 study, the physician modified the treatment in 30.4% (95% CI: 29.2–31.6) of the poorly controlled subjects. The most frequently performed actions were combination with another drug (46.3%), dose increase (26.1%) and substitution of the antihypertensive drug (22.8%). Perception of good control of BP by the physician was the variable that was most related with the non-modification of the drug treatment. Although the therapeutic attitude of the physician is far from being the best, our results seem to indicate that there has been an important improvement in the therapeutic inertia of the primary care physicians in regards to poorly controlled hypertensive patients who follow a treatment with antihypertensive drugs (AU)

Evolución del control de la presión arterial en España en el período 2002–2006. Estudios PRESCAP / Evolution of the control of blood pressure in Spain in the period 2002–2006. PRESCAP Studies

ObjetivosDiscutir la evolución del grado de control de la presión arterial (PA) en una amplia muestra de pacientes hipertensos españoles durante el período 2002–2006.Material y métodosLos PRESCAP fueron estudios transversales y multicéntricos diseñados para la estimación de prevalencias, que se realizaron en los años 2002 y 2006 con la misma metodología en poblaciones similares asistidas en atención primaria (AP). Éstos incluyeron a pacientes ≥18 años diagnosticados de hipertensión arterial (HTA) que recibían tratamiento farmacológico antihipertensivo. Se consideró buen control de la HTA cuando la PA fue <140 y<90mmHg en general (<130 y<80mmHg en pacientes con diabetes, nefropatía o enfermedad cardiovascular). Se realizó estadística descriptiva y comparación de medias y porcentajes con el paquete SPSS versión 15.0.ResultadosSe incluyó a 12.754 pacientes (el 57,2% eran mujeres) con una edad media de 63,3±10,8 años en PRESCAP 2002 y a 10.520 pacientes (el 53,7% eran mujeres) con una edad media de 64,6±11,3 años en el PRESCAP 2006. En el año 2002 se observó un control de la PA sistólica (PAS) y de la PA diastólica (PAD) del 36,1% (intervalo de confianza del 95% [IC 95%]: 35,2–36,9) y en 2006 del 41,4% (IC 95%: 40,5–42,4). El porcentaje de pacientes diabéticos con PA controlada resultó del 9,1% (IC 95%: 8,0–10,2) en 2002 y del 15,1% (IC 95%: 13,8–16,5) en 2006.ResultadosEn el PRESCAP 2002 el 56,0% recibía monoterapia antihipertensiva, el 35,6% recibía combinaciones de dos fármacos y el 8,4% recibía tres o más fármacos, y en el PRESCAP 2006 estos porcentajes fueron del 44,4; el 41,1 y el 14,5%, respectivamente.Conclusiones(..) (AU)

ObjectivesDiscuss the evolution of blood pressure (BP) control grade in a large sample of Spanish hypertensive patients in the period of 2002–2006.Material and methodsThe PRESCAP were cross-sectional and multicenter studies designed to calculate prevalences that were conducted in 2002 and 2006 using the same methodology in similar populations attending in primary care (PC). They included patients ≥18 years diagnosed of high blood pressure (HBP) who received anti-hypertensive drug treatment. Good control of HBP was considered as BP<140 and<90mmHg in general (<130 and<80mmHg in patients with diabetes, nephropathy or cardiovascular disease). A descriptive statistical study and comparison of means and percentages with the SPSS version 15.0 were made.ResultsA total of 12,754 patients (57.2% women) with mean age of 63.3±10.8 years were included in PRESCAP 2002 and 10,520 (53.7% women) with a mean age of 64.6±11.3 years in PRESCAP 2006. In the year 2002, control of systolic BP (SBP) and diastolic BP (DB) of 36.1% (95% CI, 35.2–36.9) was observed and, in 2006, of 41.4% (95% CI, 40.5–42.4). The percentage of diabetic patients with controlled BP was 9.1% (95% CI, 8.0–10.2) in 2002 and 15.1% (95% CI, 13.8–16.5) in 2006.ResultsIn the PRESCAP 2002, 56.0% received antihypertensive monotherapy, 35.6% combinations of two drugs and 8.4% three or more drugs, and in the PRESCAP 2006 these percentages were 44.4%, 41.1% and 14.5%, respectively.ConclusionsThe control grade of HBP in Spain improved in the period of 2002–2006. The factors that may have had an influence in these results are the extensive amount of bibliography generated during this period on the need to achieve adequate control of BP and the change in the prescription profile of the PC physician, which indicates a greater percentage of combinations of antihypertensive drugs(AU)

[Evaluation of cardiovascular risk in the cross-sectional phase of the Mediterranean Study]. / Valoración del riesgo cardiovascular en la fase transversal del estudio Mediterránea.

INTRODUCTION AND OBJECTIVES: The Mediterranean study quantifies high cardiovascular risk (HCR), consistency between REGICOR (R) and low risk SCORE (LS) scales, altered blood pressure (ABP) values in hypercholesterolemia (HC) without any history of hypertension (HT), high total cholesterol (HTC) values with HT with no background of HC and cardiac and renal damage in hypertensive patients. PATIENTS AND METHODS: A national, cross-sectional and multicenter study was performed with the participation of 751 physicians. The physicians individually evaluated 7,973 patients with HT and 5,319 with HC. HCR was defined as over 10% with R and 5% with LS. Intra-class correlation coefficient (ICC) and Pearson coefficient (r) were calculated. The percentages of ABP and HTC were quantified. Creatinine (cr) value, glomerular filtration rate using Cockroft-Gault (CG), and prevalence of left ventricular hypertrophy (LVH) were analyzed. RESULTS: Regarding hypertensive patients: 17.3% HCR with R and 26.1% with LS. ICC = 0.222 (p < 0.0001), r = 0.61 (p < 0.0001), 64.7% HTC. There was no evaluation of LVH in 31.2% and a prevalence of 5.1%, prevalence of lesion and kidney failure (KF) of 4.7% and 1.6% respectively based on CR and 15.9% KF by CG. In HC patients, there was 21.1% of HCR with R and 21.5% with LS; ICC = 0.190 (p < 0.0001), r = 0.64 (p < 0.0001) and 33.7% ABP. CONCLUSIONS: The SCORE scale identifies more patients with HCR than the REGICOR one in HT patients and a similar amount in HC patients. Consistency between both scales is poor. A significant ABP/HTC was found. In HT patients, the patients who were not evaluated for LVH and the percentage of KF are important.

[Evaluation of cardiovascular risk in the longitudinal phase of the Mediterranean study]. / Valoración del riesgo cardiovascular en la fase longitudinal del estudio Mediterránea.

INTRODUCTION AND OBJECTIVES: There is little information on cardiovascular longitudinal studies. In Spanish patients with hypertension (AHT)) and/or hypercholesterolemia (HC), with poor initial control of blood pressure (BP) and/or total cholesterol (TC), incidence rate (IR), cumulative incidence (CI), relative risks (RR), survival curves (SC), therapeutic compliance (TC) were quantified and the Framingham-Anderson scale (FAS) was adjusted to our patients. PATIENTS AND METHODS: A total of 6,893 primary prevention patients with AHT and/or with HC were included in primary prevention, with an average of 1.22 years of follow-up. A total of 480 physicians participated. Incidence rate (IR), cumulative incidence (CIN), relative risks (RR), survival curves (SC) by Kaplan-Meier method, and therapeutic compliance (TCOM) by Haynes-Sackett self-reported questionnaire were calculated. The Framingham-Anderson scale (FAS) was validated with Pearson's correlation coefficient (r) and intraclass correlation index (ICI). RESULTS: CIN was 1.59% (1.31-1.90); the IR 1,321.6 cardiovascular events/ 100,000 patients/year (1,026.6-1,598.8). RRs with statistical significance were: age (p = 0.03). Blood pressure at the end of the study (p = 0.02), coronary background (p = 0.00), left ventricular hypertrophy (LVH) (p = 0.00), microalbuminuria (p = 0.02), CT >/= 250 mg/dl (p = 0.01), fasting glycemia (Gb) >/= 126 mg/dl (p = 0.00), creatinine >/= 1.2 mg/dl at the beginning (p = 0.00) and at the end of the study (p = 0.00), and poor compliance in HC patients (p = 0.00). SC have statistical significance (p < 0.05) for AHT background, fasting glucose >/= 126 mg/dl, target organ damage, and high cardiovascular risk with FAS scale. The adjusted FAS formula for global cardiovascular risk was (0.415 x FAS Risk%) + 0.517%, r = 0.9962 (p = 0.00) and ICI = 0.9969 (p < 0.0001). CONCLUSIONS: The equation for the FAS scale was adjusted for Spanish AHT/HC patients. Prognostic factors and SC were calculated. Benefit between TC and decrease of CVR in HC patients was quantified.

Valoración del riesgo cardiovascular en la fase longitudinal del estudio Mediterránea / Evaluation of cardiovascular risk in the longitudinal phase of the Mediterranean study

Introducción y objetivos. Es escasa la información de estudios cardiovasculares longitudinales. En hipertensos (HTA) y/o hipercolesterolémicos (HCL) españoles, con mal control inicial de la presión arterial (PA) y/o del colesterol total (CT) se cuantifica la tasa de incidencia (TI), la incidencia acumulada (IA), los riesgos relativos (RR), las curvas de supervivencia(CS), el cumplimiento terapéutico (CU) y se ajusta la escala de Framingham-Anderson (FA) a nuestro entorno. Pacientes y métodos. Se analizaron 6.893 HTA y/o HCL en prevención primaria que aportaronun promedio de 1,22 años de seguimiento. Participaron 480 médicos. Se calcularon: la TI, IA y los RR; el método de Kaplan-Meier para la CS; Haynes-Sackett adaptado para el CU; el ajuste de FA por la recta de los mínimos cuadrados, coeficiente de correlación de Pearson (r) e intraclase (cci).Resultados. La IA fue 1,59% (1,31-1,90); la TI de 1.321, 6 eventos cardiovasculares por100.000 pacientes/año (1.026,6-1.598,8). Los RR significativos fueron: edad (p = 0,03),PA final (p = 0,02), antecedentes coronarios (p = 0,00), hipertrofia ventricular izquierda(HVI) (p = 0,00), microalbuminuria (p = 0,02), CT ≥ 250 mg/dl al inicio (p = 0,01), glucemia basal (Gb) ≥ 126 mg/dl al inicio (p = 0,00), creatinina ≥ 1,2 mg/dl al inicio (p = 0,00) y fi nal (p =0,00), y no CU en HCL (p = 0,00). Las CS realizadas por antecedentes de HTAy/o HCL, existencia o no de Gb ≥ 126 mg/dl, existencia o no de lesión de órganos diana, y tener o no riesgo cardiovascular (RCV) alto con FA, fueron significativas (p < 0,05). El ajuste del FA para RCV global fue: (0,415 x Riesgo FA%) + 0,517%, obtuvo una r = 0,9962(p = 0,00) y un cci = 0,9969 (p < 0,0001).Conclusiones. Se ajustó la ecuación FA en nuestros pacientes, con datos propios. Se cuantificaron los factores pronósticos y CS. Se cuantificó un beneficio entre CU y disminución de RCV en HCL (AU)

Introduction and objectives: There is little information on cardiovascular longitudinal studies. In Spanish patients with hypertension (AHT)) and/or hypercholesterolemia (HC), with poor initial control of blood pressure (BP) and/or total cholesterol (TC), incidence rate (IR), cumulative incidence (CI), relative risks (RR), survival curves (SC), therapeutic compliance (TC) were quantified and the Framingham-Anderson scale (FAS) was adjusted to our patients. Patients and Methods: A total of 6,893 primary prevention patients with AHT and/or with HC were included in primary prevention, with an average of 1.22 years of follow-up. A total of 480 physicians participated. Incidence rate (IR), cumulative incidence (CIN), relative risks (RR), survival curves (SC) by Kaplan-Meier method, and therapeutic compliance (TCOM) by Haynes-Sackett self-reported questionnaire were calculated. The Framingham-Anderson scale (FAS) was validated with Pearson's correlation coefficient (r) and intraclass correlation index (ICI). Results: CIN was 1.59% (1.31-1.90); the IR 1,321.6 cardiovascular events/ 100,000 patients/year (1,026.6-1,598.8). RRs with statistical significance were: age (p=0.03). Blood pressure at the end of the study (p=0.02), coronary background (p=0.00), left ventricular hypertrophy (LVH) (p=0.00), microalbuminuria (p=0.02), CT≥250mg/dl (p=0.01), fasting glycemia (Gb)≥126mg/dl (p=0.00), creatinine≥1.2mg/dl at the beginning (p=0.00) and at the end of the study (p=0.00), and poor compliance in HC patients (p=0.00). SC have statistical significance (p<0.05) for AHT background, fasting glucose≥126mg/dl, target organ damage, and high cardiovascular risk with FAS scale. The adjusted FAS formula for global cardiovascular risk was (0.415 x FAS Risk%) + 0.517%, r=0.9962 (p=0.00) and ICI=0.9969 (p<0.0001). Conclusions: The equation for the FAS scale was adjusted for Spanish AHT/HC patients. Prognostic factors and SC were calculated. Benefitbetween TC and decrease of CVR in HC patients was quantified (AU)

[Primary care physicians behaviour on hypertensive patients with poor blood pressure control. The PRESCAP 2006 study]. / Conducta del médico de Atención Primaria ante el mal control de los pacientes hipertensos. Estudio PRESCAP 2006.

INTRODUCTION: There is little information available on Therapeutic Inertia in Primary Care (PC). This study aimed to know the therapeutic behavior of the physician for uncontrolled hypertensive patients. PATIENTS AND METHODS: Cross-sectional, multicenter study that included hypertensive patients of both genders, under pharmacological treatment who were recruited consecutively in the PC out-patient clinic in all of Spain. Social-demographic, clinical and treatment data were recorded, as well as the motives for eventual therapeutic modification. Adequate BP control was considered when BP values were below 140/90 mmHg in general, and below 130/80 mmHg in diabetes, renal insufficiency or cardiovascular disease. RESULTS: A total of 10,520 patients (53.7% women) were included with average age of 64.6 (11.3 years). Of these, 44.4% the patients were receiving monotherapy and 55.6% were treated with combined therapy (two drugs 41.2%, three drugs 11.7%, and more than three 2.8%). Uncontrolled hypertension was found in 58.6% (95% CI. 57.6-59.5) of the patients. Treatment was modified by physicians in 30.4% (95% CI. 29.2-31.6) of the uncontrolled patients, combination with another drug being the most frequent behavior (46.3%), followed by dose increase (26.1%), and antihypertensive drug switch (22.8%). The perception of the physician of good BP control was the factor most associated with not modifying the treatment in uncontrolled patients. CONCLUSIONS: Study results showed that the PC physician modified antihypertensive treatment in only 3 out of 10 uncontrolled patients. When treatment modification was made, association of drugs was the most frequent behavior.