Renal Function, Albumin-Creatinine Ratio and Pulse Wave Velocity Predict Silent Coronary Artery Disease and Renal Outcome in Type 2 Diabetic and Prediabetic Subjects.

INTRODUCTION: Silent coronary heart disease is frequently undetected in type 2 diabetes mellitus (DM2) and pre-diabetes determined by glucose intolerance (GI). Pulse wave velocity (PWV) and albumin-creatinine ratio (ACR) have been considered markers of cardiovascular mortality, coronary heart disease and chronic renal failure. AIM: To evaluate the incidence of coronary artery disease (CAD) and the relationship between urinary albumin-creatinine ratio, glomerular filtration rate (GFR) and PWV in type 2 DM with silent CAD. METHODS: We analyzed 92 individuals (44 male), 49 (60±7y) type 2 DM non-insulin dependents and 43 prediabetics (43±4y), with Grade I-II hypertension and no symptoms of CAD. All type 2 DM patients were under antidiabetic treatment with A1C hemoglobin between 5.5 and 6.5%. Every patient underwent a myocardial perfusion SPECT scan. In those subjects with ischemic patterns, coronary angiography was performed. In addition, PWV, glomerular filtration rate, and ACR were evaluated. STATISTICS: mean±SEM, and ANOVA among groups. RESULTS: 48.59% of DM2 and 25.58% of GI patients had silent coronary artery had silent coronary artery disease and higher ACR, PWV and reduced GFR. Higher ACR and PWV and reduced GFR. DM2 and GI showed a negative relationship between GFR and ACR. Moreover, this relation was also observed in different levels of GFR (>60 ml/min and <60ml.min (p<0.05) in patients with CAD, suggesting a cardio-renal interaction in DM2. CONCLUSION: Higher PWV, lower GFR and ACR predict the incidence of CAD in DM2. Dysglycemic individuals also represent a group of higher risk for coronary artery disease with similar predictors as in DM2. Diabetic and prediabetics still develop renal microalbuminuria. Thus, PWV seems to represent a reliable marker of renal impairment and coronary artery disease.

Recommendations for home blood pressure monitoring in Latin American countries: A Latin American Society of Hypertension position paper.

Out-of-office blood pressure (BP) monitoring appears to be a very useful approach to hypertension management insofar it allows to obtain multiple measurements in the usual environment of each individual, allows the detection of hypertension phenotypes, such as white-coat and masked hypertension, and appears to have superior prognostic value than the conventional office BP measurements. Out-of-office BP can be obtained through either home or ambulatory monitoring, which provide complementary and not identical information. Home BP monitoring yields BP values self-measured in subjects' usual living environment; it is an essential method for the evaluation of almost all untreated and treated subjects with suspected or diagnosed hypertension, best if combined with telemonitoring facilities, also allowing long-term monitoring. There is also increasing evidence that home BP monitoring improves long-term hypertension control rates by improving patients' adherence to prescribed treatment. In Latin American Countries, it is widely available, being relatively inexpensive, and well accepted by patients. Current US, Canadian, Japanese, and European guidelines recommend out-of-office BP monitoring to confirm and refine the diagnosis of hypertension.

Ambulatory blood pressure monitoring over 24 h: A Latin American Society of Hypertension position paper-accessibility, clinical use and cost effectiveness of ABPM in Latin America in year 2020.

Accurate office blood pressure measurement remains crucial in the diagnosis and management of hypertension worldwide, including Latin America (LA). Office blood pressure (OBP) measurement is still the leading technique in LA for screening and diagnosis of hypertension, monitoring of treatment, and long-term follow-up. Despite this, due to the increasing awareness of the limitations affecting OBP and to the accumulating evidence on the importance of ambulatory BP monitoring (ABPM), as a complement of OBP in the clinical approach to the hypertensive patient, a progressively greater attention has been paid worldwide to the information on daytime and nighttime BP patterns offered by 24-h ABPM in the diagnostic, prognostic, and therapeutic management of hypertension. In LA countries, most of the Scientific Societies of Hypertension and/or Cardiology have issued guidelines for hypertension care, and most of them include a special section on ABPM. Also, full guidelines on ABPM are available. However, despite the available evidence on the advantages of ABPM for the diagnosis and management of hypertension in LA, availability of ABPM is often restricted to cities with large population, and access to this technology by lower-income patients is sometimes limited by its excessive cost. The authors hope that this document might stimulate health authorities in each LA Country, as well as in other countries in the world, to regulate ABPM access and to widen the range of patients able to access the benefits of this technique.

Serum Uric Acid Elevation is Associated to Arterial Stiffness in Hypertensive Patients with Metabolic Disturbances.

INTRODUCTION: Chronic serum uric acid elevation (SUA) is known to be induced by dyslipidemia, hypertension, inflammation, and insulin resistance. Therefore, it has been associated with higher risk for coronary artery disease and cardiovascular mortality. Also, increased levels of SUA have been associated with regional arterial stiffness, assessed by pulse wave velocity (PWV). AIMS: To evaluate the relationships of PWV, SUA and different metabolic parameters in essential hypertensive patients. MATERIAL AND METHODS: We evaluated 445 essential hypertensive patients, by measuring office blood pressure (BP), weight, height, and waist circumference. In each patient, blood samples were drawn for biochemical evaluations and 24h urine collection. Body Mass Index (BMI) and Glomerular Filtration Rate (GFR) were calculated. Carotid-Femoral PWV and Left Ventricular Mass Index (LVMI) were measured in all patients. RESULTS: All subjects (n=402), 242 males (55±0.9 yrs.; BMI: 28.9±0.3 Kg/m2) and 160 females (58±1 yrs.; BMI: 28.1±0.4 Kg/m2) had normal renal function. PWV values showed a significant association with SUA (p<0.001), Systolic BP (p<0.025) and LVMI (p<0.05). SUA showed a significant association, p<0.025: with BMI, Waist Circumference, and HDL-C; p<0.05: with Glycaemia at 120 min, Insulin at 120 min, TG, and LVMI; and p<0.001: with serum Creatinine. Backward Stepwise Regression showed that PWV could be predicted from SUA (p<0.001) and Systolic BP (p<0.05). BMI, Waist Circumference, DBP and HR did not significantly add to the ability of the equation to predict PWV. CONCLUSIONS: In this population of essential hypertensive patients, SUA was associated to increased arterial stiffness and to components of the Metabolic Syndrome. These results raise the possibility that a new approach to the role of SUA, linked to cardiovascular stratification, and a most appropriate treatment might be considered.

Clinical Perspective on Antihypertensive Drug Treatment in Adults With Grade 1 Hypertension and Low-to-Moderate Cardiovascular Risk: An International Expert Consultation.

Hypertension is a leading risk factor for disease burden globally. An unresolved question is whether grade 1 hypertension (140-159/90-99mmHg) with low (cardiovascular mortality <1% at 10 years) to moderate (cardiovascular mortality ≥1% and <5% at 10 years) absolute total cardiovascular risk (CVR) should be treated with antihypertensive agents. A virtual international consultation process was undertaken to summarize the opinions of select experts. After holistic analysis of all epidemiological, clinical, psychosocial, and public health elements, this consultation process reached the following consensus in hypertensive adults aged <80 years: (1) The question of whether drug treatment in grade 1 should be preceded by a period of some weeks or months during which only lifestyle measures are recommended cannot be evidence based, but the consensus opinion is to have a period of lifestyle alone reserved only to patients with grade 1 "isolated" hypertension (grade 1 uncomplicated hypertension with low absolute total CVR, and without other major CVR factors and risk modifiers). (2) The initiation of antihypertensive drug therapy in grade 1 hypertension with moderate absolute total CVR should not be delayed. (3) Men ≥55 years and women ≥60 years with uncomplicated grade 1 hypertension should automatically be classified within the moderate absolute total CVR category, even in the absence of other major CVR factors and risk modifiers. (4) Statins should be considered along with blood-pressure lowering therapy, irrespective of cholesterol levels, in patients with grade 1 hypertensive with moderate CVR.

Incretins and selective renal sodium-glucose co-transporter 2 inhibitors in hypertension and coronary heart disease.

Hyperglycemia is associated with an increased risk of cardiovascular disease, and the consequences of intensive therapy may depend on the mechanism of the anti-diabetic agent(s) used to achieve a tight control. In animal models, stable analogues of glucagon-like peptide-1 (GLP-1) were able to reduce body weight and blood pressure and also had favorable effects on ischemia following coronary reperfusion. In a similar way, dipeptidyl peptidase IV (DPP-IV) showed to have favorable effects in animal models of ischemia/reperfusion. This could be due to the fact that DPP-IV inhibitors were able to prevent the breakdown of GLP-1 and glucose-dependent insulinotropic polypeptide, but they also decreased the degradation of several vasoactive peptides. Preclinical data for GLP-1, its derivatives and inhibitors of the DPP-IV enzyme degradation suggests that these agents may be able to, besides controlling glycaemia, induce cardio-protective and vasodilator effects. Notwithstanding the many favorable cardiovascular effects of GLP-1/incretins reported in different studies, many questions remain unanswered due the limited number of studies in human beings that aim to examine the effects of GLP-1 on cardiovascular endpoints. For this reason, long-term trials searching for positive cardiovascular effects are now in process, such as the CAROLINA and CARMELINA trials, which are supported by small pilot studies performed in humans (and many more animal studies) with incretin-based therapies. On the other hand, selective renal sodium-glucose co-transporter 2 inhibitors were also evaluated in the prevention of cardiovascular outcomes in type 2 diabetes. However, it is quite early to draw conclusions, since data on cardiovascular outcomes and cardiovascular death are limited and long-term studies are still ongoing. In this review, we will analyze the mechanisms underlying the cardiovascular effects of incretins and, at the same time, we will present a critical position about the real value of these compounds in the cardiovascular system and its protection.

Velocidad de la onda de pulso: relevancia de la edad en normotensión, hipertensión esencial e hipertensión limítrofe / Pulse Wave Velocity: Relevance of Age in Normotensive, Essential Hypertensive and Borderline Hypertensive Patients

Introducción: Se han descripto varios parámetros de medición del estado de la función arterial y, de ellos, la velocidad de la onda de pulso (VOP) es el único que permite una medición directa de la rigidez arterial. A medida que aumenta la edad del individuo se va produciendo una pérdida de la capacidad elástica, conocida como envejecimiento vascular, proceso este que estaría acelerado en los pacientes con hipertensión arterial. Objetivos: Normalizar por décadas los valores de la VOP en pacientes normotensos (NT), hipertensos esenciales (HT) e hipertensos limítrofes (LT) y diferenciar los efectos del envejecimiento sobre la VOP de los vinculados a la hipertensión arterial. Material y métodos: Se estudiaron 221 pacientes consecutivos, de ambos sexos, que fueron clasificados, por sus valores de presión arterial (PA), en tres grupos: NT (n = 120, 46 ± 13 años): PA < 135/85 mm Hg; HT (n = 60, 50 ± 13 años): PA > 140/90 mm Hg; y LT (n = 41, 47 ± 12 años): PA = 135-139/85-89 mm Hg. Posteriormente fueron divididos en cuatro grupos por edades: GI ≤ 39 años, GII = 40-49 años, GIII = 50-59 años y GIV > 60 años. La VOP se midió con transductores mecanográficos y cálculo computarizado. Se utilizaron las pruebas de ANOVA, de Newman-Keuls y de regresión lineal multivariada. Resultados: La VOP aumentó significativamente (p < 0,05) con la edad en todos los grupos etarios (m/seg): GI: NT (n = 42): 8,6 ± 1,1, HT (n = 16): 9,5 ± 1,3, LT (n = 10): 9,0 ± 0,5; GII: NT (n = 24): 9,5 ± 1,2, HT (n = 16): 10,7 ± 1,2, LT (n = 14): 9,8 ± 0,8; GIII: NT (n = 30): 10,3 ± 1,5, HT (n = 12): 12,1 ± 1,5, LT (n = 11): 11,0 ± 1,3; y GIV: NT (n = 24): 11,4 ± 1,8, HT (n = 16): 14,1 ± 2,4, LT (n = 6): 13,3 ± 1,1. Las ecuaciones de regresión halladas fueron: en NT, VOP = 0,08 × edad + 0,04 × presión arterial sistólica (PAS) + 1,07 (r = 0,71); en HT, VOP = 0,12 × edad + 0,06 × PAS - 2,51 (r = 0,81); y en LT, VOP = 0,10 × edad + 0,02 × PAS + 0,02 (r = 0,73) (p < 0,05). Conclusiones: La VOP aumentó con la edad, siendo el incremento mayor en HT para cada grupo etario. Los sujetos LT tuvieron valores intermedios entre los otros dos grupos. Ello sugiere un deterioro de la función arterial adicional inducido por la hipertensión arterial sobre el envejecimiento. Este efecto adicional puede estimarse con la ecuación de regresión obtenida para cada grupo.

Background: Among the various parameters used to describe arterial function, pulse wave velocity (PWV) is the only one allowing direct measurement of arterial stiffness. Loss of arterial elastic capacity with increasing age, a process known as vascular aging, is enhanced in hypertensive patients. Objectives: The aim of this study was to normalize PWV in normotensive (NT), essential hypertensive (HT) and borderline hypertensive (BL) patients and differentiate the effects of aging on PWV from those associated to hypertension. Methods: A total of 221 consecutive male and female patients were included in the study. They were classified into three groups according to their blood pressure (BP) values: NT (n=120, 46±13 years): BP<135/85 mmHg; HT (n=60, 50±13 years): BP>140/90 mmHg; and BL (n=41, 47±12 years): BP=135-139/85-89 mmHg. They were then stratified into four groups according to age: GI≤39 years, GII=40-49 years, GIII=50-60 years and GIV>60 years. Mechanographic transducers and computerized calculation were used to measure PWV. Data analysis was performed using ANOVA, Newman-Keuls, and multivariate linear regression tests. Results: Pulse wave velocity increased with age in all age groups (p<0.05). Mean PWV (m/s) in G1 was: NT (n=42): 8.6±1.1, HT (n=16): 9.5±1.3, BL (n=10): 9.0±0.5; in GII: NT (n=24): 9.5±1.2, HT (n=16): 10.7±1.2, BL (n=14): 9.8±0.8; in GIII: NT (n=30): 10.3±1.5, HT (n=12): 12.1±1.5, BL (n=11): 11.0±1.3; and in GIV: NT (n=24): 11.4±1.8, HT (n=16): 14.1±2.4, BL (n=6): 13.3±1.1. Regression equations were: for NT, PWV=0.08 × age+0.04 × systolic blood pressure (SBP)+1.07 (r=0.71); for HT, PWV=0.12 × age+0.06 × SBP-2.51 (r=0.81); and for BL, PWV=0.10 × age+0.02 × SBP+0.02 (r=0.73) (p<0.05). Conclusions: Pulse wave velocity increased with age, and was higher in HT patients for each age group. Borderline hypertensive patients presented intermediate values between the other two groups. These results suggest additional vascular impairment induced by hypertension over that of aging. This surplus effect could be estimated from the regression equation obtained for each group.

[Latin American consensus on hypertension in patients with diabetes type 2 and metabolic syndrome]. / Consenso latino-americano de hipertensão em pacientes com diabetes tipo 2 e síndrome metabólica.

The present document has been prepared by a group of experts, members of cardiology, endocrinology, internal medicine, nephrology and diabetes societies of Latin American countries, to serve as a guide to physicians taking care of patients with diabetes, hypertension and comorbidities or complications of both conditions. Although the concept of metabolic syndrome is currently disputed, the higher prevalence in Latin America of that cluster of metabolic alterations has suggested that metabolic syndrome is a useful nosography entity in the context of Latin American medicine. Therefore, in the present document, particular attention is paid to this syndrome in order to alert physicians on a particular high-risk population, usually underestimated and undertreated. These recommendations result from presentations and debates by discussion panels during a 2-day conference held in Bucaramanga, in October 2012, and all the participants have approved the final conclusions. The authors acknowledge that the publication and diffusion of guidelines do not suffice to achieve the recommended changes in diagnostic or therapeutic strategies, and plan suitable interventions overcoming knowledge, attitude and behavioural barriers, preventing both physicians and patients from effectively adhering to guideline recommendations.

Consenso latino-americano de hipertensão em pacientes com diabetes tipo 2 e síndrome metabólica / Latin American consensus on hypertension in patients with diabetes type 2 and metabolic syndrome

O presente documento foi preparado por um grupo de especialistas, membros das Sociedades de Cardiologia, Endocrinologia, Medicina Interna, Nefrologia e Diabetes dos países da América Latina, para que sirva de diretriz para médicos que cuidam de pacientes com diabetes, hipertensão e fatores de risco concomitantes ou complicações de ambas as condições. Embora o conceito de síndrome metabólica seja atualmente muito discutido, a alta prevalência na América Latina do conjunto de alterações metabólicas que a compõem sugere que a síndrome metabólica é uma entidade nosográfica útil no contexto da medicina latino-americana. Devido a isso, no presente documento presta-se especial atenção a essa síndrome com a finalidade de alertar aos médicos sobre uma população particularmente de alto risco, que, por ser subestimada, não é tratada de forma adequada para os fatores de risco que constituem a síndrome metabólica. As recomendações deste documento são o resultado de apresentações e debates que ocorreram durante um encontro de dois dias em Bucaramanga (Colômbia), em outubro de 2012. Todos os participantes aprovaram as decisões finais. Os autores reconhecem que a publicação e difusão das diretrizes não serão suficientes para alcançar as mudanças recomendadas tanto em estratégias diagnósticas como terapêuticas, por isso programaram intervenções que permitirão identificar as barreiras do conhecimento, as atitudes e comportamento, o que permitirá tanto aos médicos como aos pacientes uma adequada adesão às recomendações sugeridas nestas diretrizes. Arq Bras Endocrinol Metab. 2014;58(3):205-25.

The present document has been prepared by a group of experts, members of cardiology, endocrinology, internal medicine, nephrology and diabetes societies of Latin American countries, to serve as a guide to physicians taking care of patients with diabetes, hypertension and comorbidities or complications of both conditions. Although the concept of metabolic syndrome is currently disputed, the higher prevalence in Latin America of that cluster of metabolic alterations has suggested that metabolic syndrome is a useful nosography entity in the context of Latin American medicine. Therefore, in the present document, particular attention is paid to this syndrome in order to alert physicians on a particular high-risk population, usually underestimated and undertreated. These recommendations result from presentations and debates by discussion panels during a 2-day conference held in Bucaramanga, in October 2012, and all the participants have approved the final conclusions. The authors acknowledge that the publication and diffusion of guidelines do not suffice to achieve the recommended changes in diagnostic or therapeutic strategies, and plan suitable interventions overcoming knowledge, attitude and behavioural barriers, preventing both physicians and patients from effectively adhering to guideline recommendations. Arq Bras Endocrinol Metab. 2014;58(3):205-25.

Consenso latinoamericano de hipertensión en pacientes con diabetes tipo 2 y síndrome metabólico / Latin american consensus of hypertension in patients with type 2 diabetes and metabolic syndrome

Resumen El presente documento ha sido preparado por un grupo de expertos, miembros de las sociedades de cardiología, endocrinología, medicina interna, nefrología y diabetes de los países de América Latina, para que sirvan de guía a los médicos que cuidan a pacientes con diabetes, hipertensión y enfermedades concomitantes o complicaciones de ambas condiciones. Aunque el concepto de síndrome metabólico actualmente es discutido, la alta prevalencia en América Latina del conjunto de alteraciones metabólicas que lo conforman sugiere que el síndrome metabólico es una entidad nosográfica común en el contexto de la medicina latinoamericana. Por lo tanto, en el presente documento se presta especial atención a este síndrome con el fin de alertar a los médicos de una particular población de alto riesgo, en la que por lo general es subestimada y no se tratan en forma optima los factores de riego que constituyen el síndrome metabólico. Las presentes recomendaciones son el resultado de las presentaciones y los debates en los paneles de discusión durante una reunión de dos días celebrada en Bucaramanga en octubre de 2012. Todos los participantes han aprobado las conclusiones finales. Los autores reconocen que la publicación y difusión de las guías no serán suficientes para alcanzar los cambios recomendados tanto en las estrategias diagnósticas como terapéuticas, por lo que se ha programado intervenciones que permitan identificar las barreras del conocimiento, de las actitudes y de comportamiento, lo que permitirá tanto a los médicos como a los pacientes una adecuada adherencia a las recomendaciones de las guías. (Acta MedColomb 2013; 38: 154-172).

Abstract The present document has been prepared by a group of experts, members of cardiology, endocrinology, internal medicine, nephrology and diabetes societies of Latin American Countries, to serve as a guide to physicians taking care of patients with diabetes, hypertension and comorbidities or complications of both conditions. Although the concept of metabolic syndrome is currently disputed, the higher prevalence in Latin America of that cluster of metabolic alterations has suggested that metabolic syndrome is useful nosography entity in the context of Latin American medicine. Therefore, in the present document, particular attention is paid to this syndrome in order to alert physicians on a particular high- risk population, usually underestimated and undertreated. These recommendations results from presentation and debates by discussion panels during a 2-day conference held in Bucaramanga, in October 2012, and all the participants have approved the final conclusions. The authors acknowledge that the publication and diffusion of guidelines do not suffice to achieve the recommended changes in diagnostic or therapeutic strategies, and plan suitable interventions overcoming both physicians and patients from effectively adhering to guideline recommendations. (Acta Med Colomb 2013; 38: 154-172)).

Consenso latinommericano de hipertensión en pacentes con diabetes tipo 2 y sínndrome metabólico / Latin american consensus on hypertension in patients with type 2diabetes and meetabolic syndrome / Consenso latinoamericano de hipertensão em pacientes com diabetes tipo 2 e síndrome metabólico

El presente documento ha sido preparado por un grupo de expertos, miembros de las sociedades de cardiología, endocrinología, medicina interna, nefrología y diabetes de los países de América Latina, para que sirva de guía a los médicos que cuidan a pacientes con diabetes, hipertensión y enfermedades concomitantes o complicaciones de ambas condiciones. Aunque el concepto de síndrome metabólico actualmente es discutido, la alta prevalencia en América Latina del conjunto de alteraciones metabólicas que lo conforman sugiere que el síndrome metabólico es una entidad nosografías útil en el contexto de la medicina latinoamericana. Por lo tanto, en el presente documento se presta especial atención a este síndrome con el fin de alertar a los médicos de una particular población de alto riesgo, en la que por lo general se subestimada y no se trata en forma optima los factores de riego que constituyen el síndrome metabólico. Las presentes recomendaciones son el resultado de las presentaciones y los debates en los paneles de discusión durante una reunión de 2 días celebrada en Bucaramanga en octubre de 2012. Todos los participantes han aprobado las conclusiones finales. Los autores reconocen que la publicación y difusión de las guías no serán suficientes para alcanzar los cambios recomendados, tanto en las estrategias diagnósticas como terapéuticas, por lo que se ha programado intervenciones que permitan identificar las barreras del conocimiento, de las actitudes y de comportamiento, lo que permitirá tanto a los médicos como a los pacientes una adecuada adherencia a las recomendaciones de las guías.

The present document has been prepared by a group of experts, members of cardiology, endocrinology, internal medicine, nephrology and diabetes societies of Latin American Countries, to serve as a guide to physicians taking care of patients with diabetes, hypertension and comorbidities or complications of both conditions. Although the concept of metabolic syndrome is currently disputed, the higher prevalence in Latin America of that cluster of metabolic alterations has suggested that metabolic syndrome is useful nosography entity in the context of Latin American medicine. Therefore, in the present document, particular attention is paid to this syndrome in order to alert physicians on a particular high- risk population, usually underestimated and undertreated. These recommendations results from presentation and debates by discussion panels during a 2-day conference held in Bucaramanga, in October 2012, and all the participants have approved the final conclusions. The authors acknowledge that the publication and diffusion of guidelines do not suffice to achieve the recommended changes in diagnostic or therapeutic strategies, and plan suitable interventions overcoming both physicians and patients from effectively adhering to guideline recommendations.

O presente documento tem sido preparado por um grupo de expertos, membros das sociedades de cardiologia, endocrinologia, medicina interna, nefrologiae diabetes dospaíses da América Latina, para que sirva de guia aos médicos que tomam conta de pacientes com diabetes, hipertensãoe enfermidades concomitantes ou complicaçõesdas duas condições. Porémoconceito de síndrome metabólico atualmente é discutido, a alta prevalênciana América Latina do conjunto de alterações metabólicas que o conformam,sugereque o síndrome metabólico é uma entidade nosográfica útil no contexto da medicina latino americana. Pelo tanto, no presente documento se presta especial atenção a este síndrome comofim de alertar aos médicos de una particular população de alto risco,a qual pelo geralé subestimada e não se trata em forma ótimaosfatores de risco que constituemo síndrome metabólico. As presentes recomendações sãoo resultado das apresentaçõeseos debates nos painéis de discussão durante una reunião de 2 dias celebrada em Bucaramanga em outubro de 2012. Todosos participantes têm aprovado as conclusões finais. Os autores reconhecem que a publicaçãoe difusão dos guias no serão suficientes para alcançar os câmbios recomendados tanto nas estratégiasdiagnósticas quanto terapêuticas, pelo que se têm programadointervenções que permitam identificar as barreiras do conhecimento, das atitudes e de comportamento, o que permitirá tanto aos médicos quanto aos pacientes una adequada aderênciaàs recomendações dos guias.

Consenso latinoamericano de hipertensión en pacientes con diabetes tipo 2 y síndrome metabólico / Latin american consensus on hypertension in patients with diabetes type 2 and metabolic syndrome

El presente documento ha sido preparado por un grupo de expertos, miembros de las sociedades de cardiología, endocrinología, medicina interna, nefrología y diabetes de los países de América Latina, para que sirvan de guía a los médicos que cuidan a pacientes con diabetes, hipertensión y enfermedades concomitantes o complicaciones de ambas condiciones. Aunque el concepto de síndrome metabólico actualmente es discutido, la alta prevalencia en América Latina del conjunto de alteraciones metabólicas que lo conforman sugiere que el síndrome metabólico es una entidad nosografías útil en el contexto de la medicina latinoamericana. Por lo tanto, en el presente documento se presta especial atención a este síndrome con el fin de alertar a los médicos de una particular población de alto riesgo, en la que por lo general se subestimada y no se trata en forma óptima los factores de riego que constituyen el síndrome metabólico. Las presentes recomendaciones son el resultado de las presentaciones y los debates en los paneles de discusión durante una reunión de 2 días celebrada en Bucaramanga en octubre de 2012. Todos los participantes han aprobado las conclusiones finales. Los autores reconocen que la publicación y difusión de las guías no serán suficientes para alcanzar los cambios recomendados tanto en las estrategias diagnósticas como terapéuticas, por lo que se ha programado intervenciones que permitan identificar las barreras del conocimiento, de las actitudes y de comportamiento, lo que permitirá tanto a los médicos como a los pacientes una adecuada adherencia a las recomendaciones de las guías(AU)

The present document has been prepared by a group of experts, members of cardiology, endocrinology, internal medicine, nephrology and diabetes societies of Latin American Countries, to serve as a guide to physicians taking care of patients with diabetes, hypertension and comorbidities or complications of both conditions. Although the concept of metabolic syndrome is currently disputed, the higher prevalence in Latin America of that cluster of metabolic alterations has suggested that metabolic syndrome is useful nosography entity in the context of Latin American medicine. Therefore, in the present document, particular attention is paid to this syndrome in order to alert physicians on a particular high- risk population, usually underestimated and undertreated. These recommendations results from presentation and debates by discussion panels during a 2-day conference held in Bucaramanga, in October 2012, and all the participants have approved the final conclusions. The authors acknowledge that the publication and diffusion of guidelines do not suffice to achieve the recommended changes in diagnostic or therapeutic strategies, and plan suitable interventions overcoming both physicians and patients from effectively adhering to guideline recommendations(AU)

Latin American consensus on hypertension in patients with diabetes type 2 and metabolic syndrome.

The present document has been prepared by a group of experts, members of cardiology, endocrinology and diabetes societies of Latin American countries, to serve as a guide to physicians taking care of patients with diabetes, hypertension and comorbidities or complications of both conditions. Although the concept of 'metabolic syndrome' is currently disputed, the higher prevalence in Latin America of that cluster of metabolic alterations has suggested that 'metabolic syndrome' is a useful nosographic entity in the context of Latin American medicine. Therefore, in the present document, particular attention is paid to this syndrome in order to alert physicians on a particularly high-risk population, usually underestimated and undertreated. These recommendations result from presentations and debates by discussion panels during a 2-day conference held in Bucaramanga, in October 2012, and all the participants have approved the final conclusions. The authors acknowledge that the publication and diffusion of guidelines do not suffice to achieve the recommended changes in diagnostic or therapeutic strategies, and plan suitable interventions overcoming knowledge, attitude and behavioural barriers, preventing both physicians and patients from effectively adhering to guideline recommendations.

Secondary arterial hypertension: improvements in diagnosis and management in the last 10 years.

The diagnosis and management of secondary hypertension has improved in the last decade as a result of the advances in the acknowledgment of some physiopathologic mechanisms and mainly by the development of new diagnostic methods. Furthermore, the treatment of some types of secondary hypertension may be solved by noninvasive techniques. Hypertension of renal and renovascular origin, coarctation of the aorta, primary hyperaldosteronism, and adrenal medullary tumors are analyzed. The main results of some relevant studies on diagnostic and treatment of those diseases are presented. Also, some experimental methods are mentioned, taking into account the possibility of clinical use in the near future.

Arterial wall structure and dynamics in type 2 diabetes mellitus methodological aspects and pathophysiological findings.

Type 2 Diabetes Mellitus (DM), or adult-onset diabetes, is being considered as a new pandemic. Cardiovascular disease is the major cause of morbidity and mortality in type 2 DM, due to arterial structure and functional changes. Assessment of arterial structure and biomechanics, by non-invasive methods and parameters, can be used to detect early alterations related to DM. Three markers of vascular disease may help to a better evaluation of vascular dysfunction in type 2 DM patients: carotid intimamedia thickness (IMTc), arterial stiffness, assessed by pulse wave velocity (PWV), and endothelial function, evaluated through the brachial artery flow-mediated dilation (FMD). Among these parameters, IMTc is considered a marker of structural vessel wall properties, and arterial stiffness reflects functional wall properties. Endothelial function represents the arterial way to actively regulate its diameter (smooth muscle-dependent actions) and its visco-elastic properties (wall elasticity and viscosity). IMTc is increased in patients with type 2 DM and other independent risk factors, such as: age, hyperlipidemia and duration of DM. Subjects with DM have shown increased arterial stiffness. Type 2 DM is associated with reductions in FMD (endothelial dysfunction), which has already been reported to be inversely and strongly related to the extent of hyperglycemia. The underlying patho-physiological mechanisms are complex and remain to be fully elucidated. A complete understanding of the association between arterial alterations and early detection, and type 2 DM, may be critical for the primary prevention of DM-related macro-vascular disease.

Latin American guidelines on hypertension. Latin American Expert Group.

Hypertension is a highly prevalent cardiovascular risk factor in the world and particularly overwhelming in low and middle-income countries. Recent reports from the WHO and the World Bank highlight the importance of chronic diseases such as hypertension as an obstacle to the achievement of good health status. It must be added that for most low and middle-income countries, deficient strategies of primary healthcare are the major obstacles for blood pressure control. Furthermore, the epidemiology of hypertension and related diseases, healthcare resources and priorities, the socioeconomic status of the population vary considerably in different countries and in different regions of individual countries. Considering the low rates of blood pressure control achieved in Latin America and the benefits that can be expected from an improved control, it was decided to invite specialists from different Latin American countries to analyze the regional situation and to provide a consensus document on detection, evaluation and treatment of hypertension that may prove to be cost-utility adequate. The recommendations here included are the result of preparatory documents by invited experts and a subsequent very active debate by different discussion panels, held during a 2-day sessions in Asuncion, Paraguay, in May 2008. Finally, in order to improve clinical practice, the publication of the guidelines should be followed by implementation of effective interventions capable of overcoming barriers (cognitive, behavioral and affective) preventing attitude changes in both physicians and patients.

Telmisartan improves insulin resistance in high renin nonmodulating salt-sensitive hypertensives.

BACKGROUND: Nonmodulating (NMHT) is a high-renin subtype of salt sensitive hypertension, which additionally develops insulin resistance and oxidative stress. Conversely, modulating hypertensives (MHT) normally regulates renal hemodynamics after high sodium intake without metabolic impairment. We postulate that telmisartan, an angiotensin receptor blocker with partial peroxisome proliferators-activated receptorgamma partial agonist, may improve insulin resistance compared with ramipril, an angiotensin-converting enzyme inhibitor (ACEI) in NMHT. METHODS: We studied 18 NMTH (32 +/- 5y nine men, BMI 29 +/- 3 kg/m2) and 16 MHT (34 +/- 4, 10 men, BMI 28 +/- 5 kg/m2) before and after the crossover administration of ramipril 10 mg (3 months) or telmisartan 80 mg (3 months). In each patient studied we measured, before and after each treatment period, office blood pressure, glycemia and insulinemia before and 60 and 120 min after a glucose overload (75 g), total cholesterol, high-density lipoprotein and low-density lipoprotein fractions, triglycerides and highly sensitive C-protein-reactive protein. After that, HOMA-IR Index was calculated. RESULTS: Plasma renin activity was higher in NMHT 4.4 +/- 0.5 than MHT 2.6 +/- 0.9 ng.ml.h; P < 0.01. Blood pressure was similarly reduced either in MHT or NMHT by ramipril (MHT: from 159 +/- 10/102 +/- 4 to 142 +/- 6/93 +/- 3 mmHg, P < 0.05; NMHT: from 162 +/- 12/97 +/- 4 to 139 +/- 7/89 +/- 2 mmHg, P < 0.05) or telmisartan (MHT: from 154 +/- 8/96 +/- 5 to 137 +/- 6/88 +/- 4 mmHg, P < 0.05; NMHT: from 161 +/- 9/96 +/- 5 to 137 +/- 5/86 +/- 3 mmHg, P < 0.05). In NMHT, fasting glycemia (99 +/- 10 mg%) and insulinemia (16 +/- 4 microU%) and 120 min glycemia (110 +/- 2 mg%) and insulinemia (57 +/- 9 microU%) were higher than in MHT (fasting: 92 +/- 8 mg% and 9.2 +/- 2 mU%; 120 min: 95 +/- 5 and 21 +/- 5 microU%, P < 0.05). In MHT, after 3 months treatment with either ramipril or telmisartan no changes were found in fasting and 120 min glycemia and insulinemia. In NMHT, telmisartan, after 3 months treatment, significantly reduced fasting and 120 min insulinemia (fasting: 8.4 +/- 2, 120 min: 25 +/- 10 microU%; P < 0.01) compared either to basal values or ramipril treatment. Similarly, only in NMHT, compared with basal values and ramipril treatment, telmisartan improved the HOMA-IR index in both MHT (2.76 +/- 0.16 to 2.24 +/- 0.18, P < 0.05) and NMHT (from: 4.4 +/- 1 to 2.3 +/- 0.7) and triglyceride plasma levels (MHT: from 139 +/- 1.85 to 122 +/- 2.4 mg%, P < 0.05; NMHT: from: 223 +/- 12 to 146 +/- 10 mg%, P < 0.01). Finally, highly sensitive C-protein-reactive protein values were higher in NMHT (0.33 +/- 0.07 mg.dl) than in MHT (0.14 +/- 0.06 mg.dl; P < 0.01). Both treatments reduced highly sensitive C-protein-reactive protein in NMHT. (ramipril from 0.32 +/- 0.05 mg.dl to 0.26 +/- 0.06 m.dl (P < 0.05) and telmisartan from 0.34 +/- 0.05+/- to 0.20 +/- 0.05 mg.dl (P < 0.01). CONCLUSION: Our data suggest that the improvement of the insulin sensitivity by telmisartan, instead of a similar effect on blood pressure shown by both drugs, could be ascribed to the PPAR agonistic action of telmisartan. This opens an interesting therapeutic approach for patients with hypertension and altered glycemic metabolism.

Determinación no invasiva de aterosclerosis subclínica y estratificación del riesgo cardiovascular / Non invasive assessment of subclinical atherosclerosis and stratification of cardiovascular risk

At present, cardiovascular diseases are the most frequent cause of morbidity and mortality in the world. Atherosclerosis has an important roll in the pathophysiology of cardiovascular diseases, mainly on the ischemic cardiopathy...The incorporation of ultrasonic screening for non invasive detection of subclinical atherosclerosis would allow the identification of a higher numbe of patients at high risk for coronary event and recommended for primary prevention