Systematic review of motivational interventions to improve adherence to medication in patients with hypertension and meta-analysis / Revisión sistemática de intervenciones motivacionales para mejorar la adherencia a la medicación en pacientes con hipertensión y metanálisis

Introduction: Antihypertensive medication non-adherence is an important cause of poor control in hypertension. The role of motivational interventions to increase antihypertensive medication adherence remains unclear. Objective: To systematically review RCTs of motivational interventions for improving medication adherence in hypertension. Methods: EMBASE and Pubmed were searched from inception to February 2019 for RCTs of motivational interventions for improving medication adherence in hypertension vs. usual care. Inclusion criteria: RCTs with motivational intervention to improve medication adherence in adults with hypertension. A blinded review was conducted by 2 reviewers. Disagreements were resolved by consensus/a third reviewer. Data extraction and quality appraisal was performed using the risk of bias tool from cochrane collaboration. The meta-analyses of blood pressure control used random-effects models to report mean difference and 95% CIs. Primary outcome was medication adherence and second outcome was blood pressure control. Results: The search methodology yielded 10 studies comprising 1171 participants. Medication adherence improved significantly in 5 studies. We could not perform pool analysis for this outcome due to different measurements of medication adherence. Seven trials reported significant results regarding blood pressure control. On pooled analysis, motivational interventions were not significantly associated with a systolic blood pressure (mean difference, −0.06; 95% CI, −0.05 to 0.18; p=0.63; I2=0.0%) or diastolic blood pressure (mean difference, −0.11; 95% CI, −0.10 to 0.31; p=0.28; I2=23.8%) decrease or blood pressure control. (AU)

Introducción: La falta de adherencia a la terapia farmacológica es una de las principales razones del descontrol de la hipertensión arterial. Se desconoce el papel de las intervenciones motivacionales en el aumento de la adherencia. Objetivo: Realizar una revisión sistemática de ensayos clínicos aleatorizados (ECA) dirigidos a mejorar la adherencia a la medicación en hipertensión arterial. Métodos: Se buscaron ECA de intervenciones motivacionales vs. atención habitual en las bases de datos Embase y PubMed desde su inicio hasta febrero de 2019. Criterios de inclusión: ECA de intervenciones motivacionales para aumentar la adherencia a la terapia con medicamentos en adultos con hipertensión. Dos revisores realizaron una revisión ciega y sus desacuerdos se resolvieron por consenso/por un tercer revisor. La extracción de datos y la evaluación de la calidad se realizaron mediante la herramienta Cochrane de evaluación del riesgo de sesgo. El metaanálisis del control de la presión arterial utilizó modelos de efectos aleatorios para informar la diferencia en las medias y los intervalos de confianza de 95% (IC 95%). El outcome primario fue la adherencia a la medicación y el secundario fue el control de la presión arterial. Resultados: Se obtuvieron 10 estudios con 1.171 participantes. La adherencia mejoró significativamente en cinco estudios. No fue posible realizar un análisis agrupado de la adherencia debido al uso de diferentes medidas de cumplimiento. Siete estudios mostraron una diferencia significativa en el control de la presión arterial. En el análisis conjunto, las intervenciones motivacionales no se asociaron a una disminución significativa de la presión arterial sistólica (diferencia de medias, -0,06; IC 95%, -0,05-0,18; p=0,63; I2=0%) o de la presión arterial diastólica (diferencia de medias, -0,11; IC 95%, -0,10-0,31; p=0,28; I2=23,8%) o a mejora en control de la misma.(AU)

Association between blood pressure during vasopressor weaning and in-hospital survival: an analysis of vasopressor targets. / Relación entre la presión arterial durante el destete de fármacos vasopresores y la supervivencia hospitalaria: análisis de los valores objetivo del tratamiento vasopresor.

OBJECTIVES: To analyze the association between blood pressure during vasopressor weaning and in-hospital mortality in patients admitted to an intensive care unit (ICU). MATERIAL AND METHODS: Observational retrospective single-center study including patient data registered in the Medical Information Mart for Intensive Care, version 4. The outcome was in-hospital mortality. We used restricted cubic spline (RCS) functions to analyze the associations between mortality and systolic and diastolic blood pressures and mean arterial pressure (SBP, DBP, and MAP, respectively) during weaning from vasopressors. The data was stratified a ccording t o SBP, DBP, and MAP, and sensitivity was assessed with Cox regression analysis. RESULTS: Data for 8294 patients were analyzed. The RCS functions showed that SBP, DBP, and MAP values had nonlinear U-shaped associations with in-hospital mortality. Patients were classified into the following subgroups according to points of intersection of SBP, DBP, and MAP reference values: SBP 110, 110-150, or >150 mmHg; DBP 60, 60-85, or >85 mmHg; and MAP 75, 75-110, or >110 mmHg. In the lowest blood pressure group the hazard ratio was 0.59 (95% CI, 0.52-0.66) for SBP in the 110-150 mmHg range; 0.62 (95% CI, 0.55-0.70) for DBP in the 60-85 mmHg range; and 0.64 (95% CI, 0.57-0.72) for MAP in the 75-110 mmHg range during weaning. The analysis of subgroups also indicated that blood pressures during weaning interacted with cerebral vascular disease and chronic obstructive pulmonary disease. CONCLUSION: Higher blood pressures during vasopressor weaning are associated with longer in-hospital survival in ICU patients. The optimum pressure ranges are SBP, 110-150 mmHg; DBP, 60-85 mmHg; and MAP, 75-110 mmHg. Blood pressures may behave differently according to diagnosis.

OBJETIVO: Analizar la relación entre la presión arterial (PA) durante el destete de fármacos vasopresores y la mortalidad intrahospitalaria en pacientes ingresados en una unidad de cuidados intensivos (UCI). METODO: Estudio de cohorte observacional, retrospectivo y unicéntrico. Incluyó pacientes del registro MIMIC-IV. La variable de resultado fue la mortalidad intrahospitalaria. Se utilizaron splines cúbicos restringidos (SCR) para estudiar la relación entre la PA durante el destete de los vasopresores [sistólica (DPAS), diastólica (DPAD), media (DPAM)] y la mortalidad. Los pacientes se clasificaron en diferentes subgrupos según sus cifras de DPAS, DPAD y DPAM. Se realizó un análisis de sensibilidad mediante regresión de Cox. RESULTADOS: Se analizaron 8.294 pacientes. El SCR mostró que DPAS, DPAD y DPAM tenían una relación no lineal, en forma de "U", con la mortalidad intrahospitalaria. Basándose en los puntos de intersección de los valores de referencia, los pacientes se clasificaron en los siguientes grupos: DPAS 110, 110-150 y > 150 mmHg; DPAD 60, 60-85 y > 85mmHg; y DPAM 75, 75-110 y > 110 mmHg. En comparación con el grupo de PA más baja, de DPAS entre 110-150 mmHg tenía una hazard ratio (HR) de 0,59 (IC 95% 0,52-0,66), DPAD entre 60-85 mmHg una HR de 0,62 (IC 95% 0,55-0,70) y DPAM entre 75-110 mmHg una HR de 0,64 (IC 95% 0,57-0,72). El análisis de subgrupos diagnósticos mostró que la PA durante el destete interactuaba con la enfermedad vascular cerebral y con la enfermedad pulmonar crónica. CONCLUSIONES: Valores altos de PA durante el destete de los fármacos vasopresores se asocian a una mayor supervivencia intrahospitalaria en pacientes ingresados en una UCI. Los valores óptimos son: DPAS 110-150 mmHg, DPAD 60-85 mmHg y DPAM 75-110 mmHg. La PA óptima puede ser diferente en función del diagnóstico del paciente.

Relación entre la presión arterial durante el destete de fármacos vasopresores y la supervivencia hospitalaria: análisis de los valores objetivo del tratamiento vasopresor / Association between blood pressure during vasopressor weaning and in-hospital survival: an analysis of vasopressor targets

Objetivos. Analizar la relación entre la presión arterial (PA) durante el destete de fármacos vasopresores y la mortalidad intrahospitalaria en pacientes ingresados en una unidad de cuidados intensivos (UCI).Método. Estudio de cohorte observacional, retrospectivo y unicéntrico. Incluyó pacientes del registro MIMIC-IV. La variable de resultado fue la mortalidad intrahospitalaria. Se utilizaron splines cúbicos restringidos (SCR) para estudiar la relación entre la PA durante el destete de los vasopresores [sistólica (DPAS), diastólica (DPAD), media (DPAM)] y lamortalidad. Los pacientes se clasificaron en diferentes subgrupos según sus cifras de DPAS, DPAD y DPAM. Se realizó un análisis de sensibilidad mediante regresión de Cox.Resultados. Se analizaron 8.294 pacientes. El SCR mostró que DPAS, DPAD y DPAM tenían una relación no lineal, en forma de “U”, con la mortalidad intrahospitalaria. Basándose en los puntos de intersección de los valores de referencia, los pacientes se clasificaron en los siguientes grupos: DPAS < 110, 110-150 y > 150 mmHg; DPAD < 60, 60-85 y > 85 mmHg; y DPAM < 75, 75-110 y > 110 mmHg. En comparación con el grupo de PA más baja, de DPAS entre 110-150 mmHg tenía una hazard ratio (HR) de 0,59 (IC 95% 0,52-0,66), DPAD entre 60-85 mmHg una HR de 0,62 (IC 95% 0,55-0,70) y DPAM entre 75-110 mmHg una HR de 0,64 (IC 95% 0,57-0,72). El análisis de subgrupos diagnósticos mostró que la PA durante el destete interactuaba con la enfermedad vascular cerebral y con la enfermedad pulmonar crónica.Conclusiones. Valores altos de PA durante el destete de los fármacos vasopresores se asocian a una mayor supervivencia intrahospitalaria en pacientes ingresados en una UCI. Los valores óptimos son: DPAS 110-150 mmHg, DPAD 60-85 mmHg y DPAM 75-110 mmHg. La PA óptima puede ser diferente en función del diagnóstico del paciente. (AU)

Objectives. To analyze the association between blood pressure during vasopressor weaning and in-hospital mortality in patients admitted to an intensive care unit (ICU).Methods. Observational retrospective single-center study including patient data registered in the Medical Information Mart for Intensive Care, version 4. The outcome was in-hospital mortality. We used restricted cubic spline (RCS) functions to analyze the associations between mortality and systolic and diastolic blood pressures and mean arterial pressure (SBP, DBP, and MAP, respectively) during weaning from vasopressors. The data was stratified according to SBP, DBP, and MAP, and sensitivity was assessed with Cox regression analysis.Results. Data for 8294 patients were analyzed. The RCS functions showed that SBP, DBP, and MAP values had nonlinear U-shaped associations with in-hospital mortality. Patients were classified into the following subgroups according to points of intersection of SBP, DBP, and MAP reference values: SBP <110, 110-150, or >150 mmHg; DBP <60, 60-85, or >85 mmHg; and MAP <75, 75-110, or >110 mmHg. In the lowest blood pressure group the hazard ratio was 0.59 (95% CI, 0.52-0.66) for SBP in the 110-150 mmHg range; 0.62 (95% CI, 0.55-0.70) for DBP in the 60-85 mmHg range; and 0.64 (95% CI, 0.57-0.72) for MAP in the 75-110 mmHg range during weaning. The analysis of subgroups also indicated that blood pressures during weaning interacted with cerebral vascular disease and chronic obstructive pulmonary disease.Conclusions. Higher blood pressures during vasopressor weaning are associated with longer in-hospital survival in ICU patients. The optimum pressure ranges are SBP, 110-150 mmHg; DBP, 60-85 mmHg; and MAP, 75-110 mmHg. Blood pressures may behave differently according to diagnosis. (AU)

Management of hypertension in the digital era: Perspectives and future directions / Gestión de la hipertensión en la era digital: perspectivas y direcciones futuras

Information and communication technology (ICT) have advanced remarkably in recent years. In the field of medicine, the problem of hypertension management seems especially well-suited to the application of novel methods. In patients with hypertension, it is important to assess blood pressure (BP) levels throughout the day and night, along with circadian BP variation, using out-of-office BP monitoring. ICT is an attractive tool to facilitate such monitoring and promises to change the current management of hypertension. The combination of self-telemonitoring of BP with lifestyle modification appears to be effective for strict BP control. ICT could be a solution to the challenging problem of nonadherence to antihypertensive medications and could reduce so-called clinical inertia in the treatment of hypertension. ICT approaches would be especially useful in geographically isolated areas or during natural disasters or complex health emergencies such as the ongoing coronavirus pandemic. However, it will be necessary to develop innovative ICT devices for easy and accurate BP measurement in a range of individuals, including the elderly, and to confirm their effectiveness in large scale clinical trials. ICT-based management of hypertension is expected to be pivotal for reducing the public-health burden of cardiovascular diseases and to be widely adopted in daily clinical practice in the future.

Las tecnologías de la información y la comunicación (TIC) han avanzado notablemente en los últimos años. En el campo de la medicina, el problema de la gestión de la hipertensión parece especialmente adecuado para la aplicación de métodos novedosos. En los pacientes con hipertensión, es importante evaluar los niveles de presión arterial (PA) a lo largo del día y de la noche, junto con la variación circadiana de la PA, mediante la monitorización de la PA fuera de la consulta. Las TIC son una herramienta atractiva para facilitar dicha monitorización y prometen cambiar el tratamiento actual de la hipertensión. La combinación de la autovigilancia de la PA con la modificación del estilo de vida parece ser eficaz para el control estricto de la PA. Las TIC podrían ser una solución al difícil problema de la falta de adherencia a la medicación antihipertensiva y podrían reducir la llamada inercia clínica en el tratamiento de la hipertensión. Los enfoques de las TIC serían especialmente útiles en zonas geográficamente aisladas o durante catástrofes naturales o emergencias sanitarias complejas como la actual pandemia de coronavirus. Sin embargo, será necesario desarrollar dispositivos TIC innovadores para medir la PA de forma fácil y precisa en una serie de individuos, incluidos los ancianos, y confirmar su eficacia en ensayos clínicos a gran escala. Se espera que la gestión de la hipertensión basada en las TIC sea fundamental para reducir la carga sanitaria de las enfermedades cardiovasculares y que se adopte ampliamente en la práctica clínica diaria en el futuro.

Management of hypertension in the digital era: Perspectives and future directions.

Information and communication technology (ICT) have advanced remarkably in recent years. In the field of medicine, the problem of hypertension management seems especially well-suited to the application of novel methods. In patients with hypertension, it is important to assess blood pressure (BP) levels throughout the day and night, along with circadian BP variation, using out-of-office BP monitoring. ICT is an attractive tool to facilitate such monitoring and promises to change the current management of hypertension. The combination of self-telemonitoring of BP with lifestyle modification appears to be effective for strict BP control. ICT could be a solution to the challenging problem of nonadherence to antihypertensive medications and could reduce so-called clinical inertia in the treatment of hypertension. ICT approaches would be especially useful in geographically isolated areas or during natural disasters or complex health emergencies such as the ongoing coronavirus pandemic. However, it will be necessary to develop innovative ICT devices for easy and accurate BP measurement in a range of individuals, including the elderly, and to confirm their effectiveness in large scale clinical trials. ICT-based management of hypertension is expected to be pivotal for reducing the public-health burden of cardiovascular diseases and to be widely adopted in daily clinical practice in the future.

Caracterización de la prevalencia de la hipertensión arterial en Cuba en 2019 / Characterization of Arterial Hypertension Prevalence in Cuba in 2019

Introducción: La hipertensión arterial pudiera ser un elemento clave para la prevención de las enfermedades cardiovasculares, pues constituye su principal denominador común. Es el principal factor de riesgo, para la carga mundial de morbilidad y mortalidad. Objetivo: Caracterizar la prevalencia de hipertensión arterial en Cuba en el año 2019. Métodos: Se realizó un estudio ecológico. Se compararon las prevalencias de hipertensión arterial en las encuestas nacionales de factores de riesgo en los años 1995, 2001 y 2010 respecto a las de la dispensarización de esos años. Se tuvieron en cuenta las prevalencias totales de hipertensión arterial por grupos de edad y sexo, las de cada provincia y del municipio especial Isla de la Juventud. Los datos se procesaron de forma automatizada. Los resultados se expresaron en una tabla y gráficos. Resultados: Las prevalencias de hipertensión arterial encontradas en las encuestas nacionales de factores de riesgo superaron a las de la dispensarización en esos años. La prevalencia de hipertensión arterial se incrementó en la medida que lo hizo la edad. En el grupo de edad de 60 a 64 años, más del 75 por ciento de las personas resultaron hipertensas. En los de 25 a 59, de 65 y más y en el total predominaron las mujeres hipertensas. Conclusiones: Es preciso reducir la brecha entre los pacientes conocidos como hipertensos, dentro del sistema de salud y los que realmente son portadores de la enfermedad, conseguir el manejo adecuado de esta y con eso influir favorablemente en la morbilidad y mortalidad por enfermedades vasculares(AU)

Introduction: Hypertension could be a key element for the prevention of cardiovascular diseases, since it constitutes its main common denominator. It is the main risk factor for the global burden of morbidity and mortality. Objective: To characterize the prevalence of arterial hypertension in Cuba in 2019. Methods: An ecological study was carried out. The prevalence rates of arterial hypertension in the national surveys of risk factors in the years 1995, 2001 and 2010 were compared to those of the dispensarization carried out in those years. The total prevalence rates of arterial hypertension were taken into account by age groups and sex, considering also those of each province and of the special municipality of Isla de la Juventud. The data was processed automatically. The results were expressed in a table and in graphs. Results: The prevalence rates of arterial hypertension found in the national surveys of risk factors exceeded those of dispensarization in those years. The prevalence of hypertension increased with age. In the age group 60-64 years, more than 75 percent of people were hypertensive. In those aged 25-59, 65 and over, as well as in the total, hypertensive women predominated. Conclusions: It is necessary to reduce, within the health system, the gap between patients known as hypertensive and those who really are carriers of the disease, to achieve proper management of this and, thus, to have a favorable influence on morbidity and mortality from vascular diseases(AU)

[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.

[Combination for initial therapy in hypertension, is it useful?] / ¿Es útil el inicio de tratamiento con combinaciones antihipertensivas?

Hypertension represents the first cause of mortality worldwide because a leading role in development of cardiovascular and renal diseases. Evidence about the benefits of controlling hypertension is overwhelming, but adequate control of blood pressure is still poor even in high-income countries. At least one of 2 hypertensive patients suffers from uncontrolled blood pressure. Nearly 75% of hypertensive patients do not achieve adequate control with monotherapy. Strategies to improve control include avoiding inertia in initiating pharmacological treatment, prompt shift to combined therapy from monotherapy, initial treatment with a 2-drug combination, and use of fixed-dose combinations in a single pill. This review focuses in benefits of initiating treatment combining antihypertensive drugs.

Prevalence of Atherogenic Dyslipidemia in Spanish Hypertensive Patients and Its Relationship With Blood Pressure Control and Silent Organ Damage.

INTRODUCTION AND OBJECTIVES: To assess the prevalence of atherogenic dyslipidemia in hypertensive patients and its relationship with risk profile and blood pressure control. METHODS: The study included 24 351 hypertensive patients from the Spanish Ambulatory Blood Pressure Monitoring Registry. Atherogenic dyslipidemia was defined as the presence of hypertriglyceridemia (> 150mg/dL) and low levels of high-density lipoprotein cholesterol (< 40mg/dL in men and < 46mg/dL in women). Blood pressure control was assessed by office and ambulatory monitoring. RESULTS: Atherogenic dyslipidemia was present in 2705 patients (11.1%). Of these, 30% had hypertriglyceridemia and 21.7% had low levels of high-density lipoprotein cholesterol. Compared with patients without these risk factors, the former group were more often male (60% vs 52%), younger (57 years vs 59 years), had other risk factors and organ damage (microalbuminuria, reduced estimated glomerular filtration rate, and left ventricular hypertrophy), worse office, diurnal, and nocturnal blood pressure values (odds ratio 1.09, 1.06, and 1.10, respectively), and the lowest nocturnal blood pressure reduction (odds ratio=1.07), despite the greater use of antihypertensive drugs. CONCLUSIONS: Atherogenic dyslipidemia is present in more than 10% of hypertensive patients and is associated with other risk factors, organ damage, and poorer blood pressure control. Greater therapeutic effort is needed to reduce overall risk in these patients.

[Control of blood pressure in hypertensive patients on combination therapy]. / Control de la presión arterial en pacientes en tratamiento con terapia combinada.

BACKGROUND AND AIM: The impact of antihypertensive treatment on blood pressure (BP) control is fairly unknown. The aim of the study was to evaluate the degree of BP control and its relationship with treatment-related factors in hypertensive patients treated with 2 or 3 agents and attended in referral units. PATIENTS AND METHODS: We studied 1,337 hypertensive subjects (41% women) with a mean age (SD) of 63 (12) years, who were receiving 2 or 3 antihypertensive drugs. The degree of BP control was estimated in a single visit by the proportion of patients with BP below 140/90mmHg. RESULTS: BP was controlled in 767 patients (57%). Lack of BP control was related to older age (12% risk for each 10-year increase) and the presence of microalbuminuria (64% risk increase). In those treated with 2 agents, BP control was 61%, without differences between those treated with fixed-drug or free combinations. BP control in those treated with 3 agents was 55%, higher in those receiving 3 agents in a fixed-drug combination (68%) compared with those on 3 agents administered separately (52%; P=.025). Drug classes used in combinations did not influence the degree of BP control. CONCLUSIONS: The degree of BP control in patients treated with 2 or 3 agents is 57%. Microalbuminuria is related to a lack of BP control. In those receiving 3 agents, the use of fixed-drug combinations is associated with better BP control.

[Approach to hypertension in the older population]. / Abordaje de la hipertensión arterial en el paciente anciano.

Hypertension is one of the most frequent causes for seeking primary care attention and its prevalence increases with age, affecting 68% of people older than 60 years. Data indicate that the prevalence of hypertense individuals older than 65 years has increased from 48% in 2002 to 58% in 2010. High blood pressure is related to 1 out of every 2 deaths from cardiovascular causes in the Spanish population ≥ 50 years and causes 13.5% of premature deaths worldwide, both in persons with hypertension and in those with high-normal blood pressure. Although few clinical trials have been performed in the older population, especially in the very old, there is evidence that diastolic and systolic blood pressure control reduces cardiovascular morbidity and mortality in older hypertense individuals. Consequently, the updates of the various clinical practice guidelines continue to include among their objectives-with some nuances-good blood pressure control in this population group. The present article reviews new evidence on the approach to hypertension in the elderly, which has modified some of the recommendations made in the clinical practice guidelines of several scientific societies.

[Blood pressure control in hospital units in Spain]. / Control de la presión arterial en unidades hospitalarias de referencia en España.

BACKGROUND AND OBJECTIVE: Blood pressure (BP) control has been extensively studied in patients attended in primary care but reports in the hospital setting, which includes referral units, are scarce. The aim was to evaluate the degree of BP control in hypertensive patients attended in referral units. PATIENTS AND METHODS: We studied 1,550 hypertensive subjects (41.5% women) with a mean age of 64 (12) years, who were receiving antihypertensive drugs. The degree of BP control was estimated in a single visit by the proportion of patients with BP below 140/90 mm Hg. RESULTS: BP was controlled in 653 patients (42%). In comparison, those whose BP was not controlled were more frequently women (odds ratio [OR] 1.57; 95% confidence interval [95%CI]: 1.23-1.99), obese (OR 1.28; 95%CI 1.00-1.63), smokers (OR 1.78; 95%CI 1.36-2.34), had left ventricular hypertrophy (OR 1.86; 95%CI 1.46-2.36) and elevated values of total serum cholesterol (OR 1.50; 95%CI 1.19-1.90) and triglycerides (OR 1.63; 95%CI 1.29-2.07). Therapeutical inertia was observed in 39% of uncontrolled patients. In a subgroup of patients who underwent ambulatory BP monitoring, discordance between measurements was only present in 23% (9.8 with isolated clinic hypertension and 13.1% with masked hypertension). CONCLUSION: The degree of BP control in patients attended in referral units is estimated in 42% and has not been modified in the last decade. Although therapeutical effort and inertia have improved, this only compensates the increased risk and comorbidities of attended patients, making more difficult the control of BP values.

Control del Hipertenso, un desafío no resuelto: avances logrados en Chile mediante el Programa de Salud Cardiovascular / Blood Pressure control in Hypertension, an unresolved challenge. Improvements achieved throughout the Chilean Cardiovascular Health Program

Antecedentes: El control de la presión arterial (PA) es fundamental en reducir la morbi-mor-talidad en hipertensos, pero con resultados hasta la fecha insatisfactorios en Chile y en países de alto desarrollo socioeconómico. En Chile se inició en 2002 el Programa de Salud Cardiovascular (PSCV) intentando mejorar el manejo de estos pacientes. Objetivos: Evaluar características sociodemográ-ficas, clínicas, antropométricas, psicosociales y de estilos de vida de un grupo de pacientes participantes en el PSCV, y la influencia de estos factores en el control de la PA. Métodos: Se obtuvo una muestra aleatoria de 525 pacientes (380 mujeres) de un universo de 1.533 hipertensos entre 30 y 68 años bajo seguimiento en el PSCV. Se registraron datos sociodemográficos, clínicos, antropométricos, psicosociales y de estilos de vida a través de evaluación clínica y cuestionarios validados. La PA fue medida utilizando un protocolo estándar por personal entrenado. El análisis estadístico incluyó la predicción del riesgo (Odds RATIO) de PA no controlada por las diversas características estudiadas. Resultados: El 47 por ciento de los pacientes logró una PA controlada (<140/90 mmHg). La presencia de diabetes mellitus (DM) fue documentada en el 38,5 por ciento. Factores predictores significativos de PA no controlada fueron DM, baja educación, inadecuada relación médico paciente y alto nivel de estrés emocional/depresión. Conclusiones: El PSCV ha logrado un avance importante en el control de la PA resaltando la influencia significativa de factores psicosociales. Sin embargo es preocupante la alta proporción de hipertensos diabéticos, su inferior control de PA, y la limitada captación de hombres al programa.

Background: Blood pressure (BP) control is a necessary requirement to reduce cardiovascular events and mortality in hypertensive patients, but so far results have been disappointing in Chile and also in countries with advanced socioeconomic development. Since 2002 a Cardiovascular Health Program (CHP) was launched in Chile attempting to improve the outcomes in these patients. Objectives: To assess the influence of sociodemo-graphic, clinical, anthropometric, psychosocial, lifestyle habits characteristics upon BP control (<140/90 mmHg) in a group of hypertensive patients referred to the CHP. Methods: A cross sectional study of a random sample of 525 hypertensive patients (380 women) obtained from a universe of 1,533 patients with ages ranging from 30 to 68 years was performed. Socio-demographic, clinical, anthropometric, psychosocial and lifestyle habits data were collected through clinical evaluation and validated questionnaires. Trai-ned personnel using standard protocols recorded BP. Adjusted ODDS RATIOS were used to assess theinfluence of different population characteristics upon blood pressure control . Results: A controlled BP (<140/90 mmHg) was achieved in 47 percent of patients, and 38.5 percent presented diabetes mellitus (DM). Significant predictors of uncontrolled BP (>140/90 mmHg) were DM, low education, unsatisfactory patient-physician relation, and high score of emotional stress /depression. Conclusions: In Chile the CHP has achieved an important progress in BP control in hypertensive patients. Psychosocial factors influenced significantly these results. It is concern the high proportion of diabetics in this hypertensive population and their unsatisfactory BP control. The lower proportion of men enrolled in the CHP needs additional analysis and corrective actions.

Control ambulatorio de la hipertensión arterial en pacientes con insuficiencia renal crónica no terminal / Ambulatory High Blood Pressure Control in Patients with Nonterminal Chronic Renal Failure

La hipertensión arterial es un importante factor de riesgo de progresión de las enfermedades renales crónicas y un predictor del desarrollo de la insuficiencia renal crónica terminal, por lo que existe consenso sobre la importancia de su adecuado control en estos pacientes. Se realizó un estudio prospectivo en 67 pacientes atendidos en la consulta de insuficiencia renal crónica del Hospital General Lucía Iñiguez Landín a quienes se les indicó el chequeo ambulatorio sistemático de la presión arterial en su área de salud. Se realizó una comparación entre los pacientes con y sin control ambulatorio de la presión arterial en cuanto a los factores seleccionados, el 74,63 por ciento de los pacientes no lograba buen control de esta forma. En el análisis univariado no hubo diferencia en cuanto al promedio de edad, sexo, etiología de la IRC, ocupación, índice de masa corporal, hábito de fumar, ingestión de bebidas alcohólicas, filtrado glomerular, cifras de colesterol, presencia de anemia y número de consultas recibidas. Hubo significación estadística en la escolaridad, que fue superior en los enfermos controlados, y en el promedio de hipotensores utilizados fue superior en el grupo sin control (2,34 vs 1,35). En el análisis multivariado no se encontró relación de los factores estudiados con el descontrol de la PA. Se concluyó que el descontrol de la presión arterial fue muy frecuente entre los pacientes estudiados y principalmente en los de menor escolaridad...(AU)

High blood pressure is an important risk factor for progression of chronic renal diseases and it can predict the development of terminal chronic renal failure, resulting very important its accurate control. A prospective study in 67 patients that were assisted at Lucia Iñiguez Hospital was carried out. The patients were instructed for ambulatory blood pressure checking. A comparison between patients with and without good ambulatory blood pressure control was done. Blood pressure control was not obtained in 74,63 por ciento of the patients; there was no difference in average age, gender, chronic renal failure etiology, occupation, body mass rate, cigarette smoking, alcohol consumption, glomerular filtration rate, cholesterol number, anemia and number of consultations. There was significant difference in relation with school level, which was higher in well controlled patients, and antihypertensive medication number that was higher in noncontrolled patients (2.34 vs. 1.35). There was no relationship between bad blood pressure control and studied factors, which was determined through a multivariable analysis. In conclusion, uncontrolled high blood pressure was very frequent in the studied patients, mainly in patients with lower school level...(AU)

Hipertensión arterial: respuesta inadecuada al tratamiento médico vs. paciente / Hypertension: inadequate response to the treatment physician vs. patient

Objetivo: Determinar las causas más comunes de una respuesta inadecuada al tratamiento antihipertensivo en nuestro medio, y qué porcentaje de la población hipertensa controla su presión con el tratamiento aplicado.Diseño del estudio: El presente es un estudio retroprospectivo, analítico, llevado a cabo en el Servicio de cardiología de la Consulta Externa del hospital Luis Vernaza de Guayaquil. La muestra fue de 100 pacientes hipertensos tratados en quienes se trató de determinar la eficacia del tratamiento antihipertensivo. De estos pacientes, a 30 no controlados se les realizó una encuesta para establecer la causa de su respuesta inadecuada al tratamiento.Resultados: Aproximadamente 60% de pacientes presentó un control eficaz de su presión arterial. Dentro de los no controlados se observó que la causa principal de la respuesta inadecuada al tratamiento fue la falta de sometimiento al mismo, (53,33%), y a su vez esta se debió en su mayor porcentaje al olvido y a los costos de la medicación (44% c/u), siendo pocos los casos de abandono por intolerancia al fármaco empleado.Conclusión: Con lo observado se estableció la necesidad de reducir esta falta de colaboración al tratamiento mediante un seguimiento más persistente e integral de los pacientes hipertensos, el que incluye educación del paciente sobre la importancia y consecuencias a corto, mediano y largo plazo de su enfermedad y los beneficios de la terapia.

Objective: To determine common causes of an inadequate response to the antihypertensive treatment in our environment and how many patients can control their blood pressure with their treatment.Study Design: This is a retro prospective study made in cardiology service of Luis Vernaza Hospital – Guayaquil, where we chose 100 hypertensive patients under treatment and tried to determine its efficacy. We chose those who were not controlling their pressure and tried to establish more common causes of their inadequate response to the treatment. Results: Approximately 60% of patients had an effective control of their blood pressure. In those who were not under control we found that the outstanding cause of an inadequate response to the treatment was the lack of adherence (53.33%) and at the same time this lack of adherence to the treatment was due to forgetting as much as medication expenses (44%) and there with few cases of withdrawal for intolerance to the drugConclusion: As we observed, it is necessary to reduce this lack of adherence to the treatment by means of a more aggressive and integral following of hypertensive patients, which should include education of the patient about the importance and short-term and long-term consequences and also the benefits of the treatment.

Influencia de las Endotelinas y el Factor Natriurético Auricular en la respuesta cardiovascular al NaCl hipertónico administrado en la región anteroventral del tercer ventrículo de la rata

La región anteroventral del tercer ventrículo (AV3V) es capaz de detectar la concentración sanguínea de NaCl y ajustar la función cardiovascular y renal en respuesta a la composición hidroelectrolítica del líquido extracelular. La microinyección de NaCl hipertónico en esta área cerebral induce un incremento de la actividad simpática que aumenta de la presión arterial; la frecuencia cardíaca y la función renal. Estos cambios pueden ser modulados por la administración central de antagonistas de receptores 5HT2 de serotonina y bloqueadores de los receptores AT1 de angiotensina o por la administración periférica de antagonistas alfa y beta de los receptores adrenérgicos. El papel de las endotelinas cerebrales y del factor natriurético auricular (FNA) en esta región cerebral no ha sido estudiado. Se evaluó la participación de los receptores para endotelinas cerebrales y del FNA en la respuesta cardiovascular al NaCl hipertónico 1,5 M (2myL) administrado en la región AV3V de ratas anestesiadas. La microinyección de NaCl 1,5 M en la región AV3V de ratas normotensas produjo un incremento de la presión arterial media en un máximo de 17,9 ± 2,2 mm de Hg (p<0,01). La microinyección previa de FNA a una dosis 5myg/2myL no alteró la presión arterial media (PAM) ni el efecto en la PAM inducidos por la microinyección de NaCl 1,5 M en AV3V. La administración previa del antagonista no selectivo de los receptores de endotelinas PD-142893 (3myg/2myL) no alteró la PAM basal pero redujo en 8,52 ± 1,20 mm de Hg (47,6%) el incremento de la presión arterial media inducido por el NaCl 1,5 M (p<0,01). Los resultados indican un papel modulador de las endotelinas en la respuesta cardiovascular al NaCl 1,5 M administrado en la región AV3V y ausencia de la participación del FNA en la respuesta cardiovascular simpática evocada por el NaCl.

Third ventricle anteroventral area (AV3V) is sensitive to changes in NaCl concentration and able to modify blood pressure and renal function in response to NaCl concentration. Hypertonic NaCl microinjections in AV3V induce a sympathetic cardiovascular response which increases blood pressure and heart rate; these changes can be modulated by central administration of 5HT2 and AT1 receptor blockers, and also by peripheral administration of alpha and beta adrenergic receptor antagonists. Influence of endothelin receptors (ETR) and atrial natriuretic factor (ANF) on sensitivity to NaCl has not been explored. Hypertonic 1,5 M NaCl (2 muL volume) microinjections in AV3V of normotensive anesthetized rats increased mean arterial blood pressure by 17,9 ± 2.2 mm Hg (p<0.01). ANF microinjections (5mug/2muL) in AV3V neither changed mean arterial blood pressure nor altered the hypertensive response to NaCl 1,5 M microinjection. Microinjection of PD 142893 into AV3V a non selective endothelin antagonist (3mug/2muL) did not modify basal blood pressure but reduced by 47,6% (p<0,01) the hypertensive response to 1,5 M NaCl injection. These results indicates a possible modulator effect of endothelin receptors in the NaCl centrally- evocated cardiovascular response to hypertonic NaCl injections in AV3V. Acute microinjection of ANF in this brain area seems not to be involved in the NaCl-evoked sympathetic cardiovascular response.