The value of ABPM and subclinical target organ damage parameters in diagnosis of resistant hypertension. / El valor de la MAPA y de los parámetros de lesión subclínica de órgano diana en el diagnóstico de hipertensión refractaria.

INTRODUCTION: We aimed to assess the effectiveness of ambulatory blood pressure monitoring (ABPM) and subclinical target organ damage parameters for diagnosis of resistant hypertension (RH). METHODS: We assessed demographic and anthropometric variables, the incidence of cardiovascular events and subclinical target organ damage (n=112). We also studied the relationship between these variables and the ABPM results. RESULTS: Of the 112 patients referred from primary care with a diagnosis of RH, 69 (61.6%) were confirmed by ABPM. We found statistically significant differences (P<.001) between patients with RH and pseudo-resistant hypertension in the appearance of subclinical target organ damage. A percentage of 84 of the patients had microalbuminuria: 66.25±30.7mg/dl); 44.9% had stage 3 chronic kidney disease: the average glomerular filtration was 59ml/min/1.73m2; and 56.5% had left ventricular hypertrophy on echocardiography. Fundoscopy revealed that 64% of the patients had hypertensive retinopathy. Three variables were associated with an increased HR risk: microalbuminuria, hypertensive retinopathy and left ventricular hypertrophy (OR 5.7, 6.2 and 11.2, respectively). CONCLUSIONS: This study shows that the systematic testing for target organ damage, particularly in terms of albuminuria, is a simple and inexpensive tool, with a high predictive value for RH (85%), which could be useful for prioritising patients who need ABPM.

[What are the pharmacological options for treating resistant hypertension?] / ¿Qué posibilidades farmacológicas existen para tratar la hipertensión arterial resistente?

When treating a patient with resistant hypertension therapy should be optimize in order to prescribe three antihypertensive drugs at full doses, being powerful drugs, having 24-hour coverage, and showing synergistic effects. Diuretic therapy is of special relevance. The fourth drug should be an aldosterone antagonists. In the case of intolerance, or when control is not achieved, drugs from other type of antihypertensive drugs should be, sometimes allowing adequate blood pressure control.

[Physician knowledge and attitudes on the clinical evaluation and treatment of resistant hypertension: The RESIST study]. / Conocimiento y actitudes sobre la evaluación clínica y el tratamiento de la hipertensión arterial resistente: Estudio RESIST.

BACKGROUND: Resistant hypertension (RH) is associated with a high risk of cardiovascular and renal complications. The purpose of this study was to assess the knowledge and attitudes of Primary Care physicians, general medicine doctors, and clinical cardiologists on the management of this condition. MATERIAL AND METHODS: A multicentre, descriptive, observational study based on an ad hoc questionnaire distributed to Primary Care physicians (n=1017) and general medicine physicians/clinical cardiologists (n=457). RESULTS: To establish the diagnosis of resistant hypertension, 69.1% of physicians confirm that systolic/diastolic blood pressure is above 140/90 mmHg, despite treatment. Furthermore, 64.9% only consider this diagnosis if the patient is treated with at least 3 medications, and 50.3% also requires that one of them is a thiazide diuretic (56.7% among specialists, P=.0004). To establish a definite diagnosis of true RH, 89.6% perform 24-h ambulatory blood pressure monitoring (93.3% of specialists, P=.0017), looking specifically for «white-coat¼ effect in 70.2% of cases. In addition, 79.3% verify that adherence to treatment is adequate. Between 87 and 95% of physicians indicate examinations to exclude causes of secondary hypertension. Up to 54.3% of physicians (71.3% specialists, P<.0001) consider adding a fourth drug and insisting on lifestyle interventions as a priority therapeutic measure. CONCLUSION: These data show that physician knowledge regarding the management of patients with RH is good. Interestingly, this knowledge is somewhat higher among specialists than among Primary Care physicians.

InnovaSEC in Action: Cost-effectiveness of Barostim in the Treatment of Refractory Hypertension in Spain.

INTRODUCTION AND OBJECTIVES: In Spain, 0.3% of patients with hypertension are refractory to conventional treatment. The complications resulting from deficient control of this condition can lead to poor quality of life for the patient and considerable health care costs. Barostim is an implantable device designed to lower blood pressure in these patients. The aim of this study was to analyze the cost-effectiveness of Barostim compared with drug therapy in hypertensive patients refractory to conventional treatment (at least 3 antihypertensive drugs, including 1 diuretic agent). METHODS: We used a Markov model adapted to the epidemiology of the Spanish population to simulate the natural history of a cohort of patients with refractory hypertension over their lifetime. Data on the effectiveness of the treatments studied were obtained from the literature, and data on costs were taken from hospital administrative databases and official sources. Deterministic and probabilistic sensitivity analyses were conducted. RESULTS: Barostim increased the number of quality-adjusted life years by 0.78 and reduced the number of hypertension-associated clinical events. The incremental cost-effectiveness ratio in a cohort of men reached 68 726 euros per year of quality-adjusted life. One of the main elements that makes this technology costly is the need for battery replacement. The results were robust. CONCLUSIONS: Barostim is not a cost-effective strategy for the treatment of refractory hypertension in Spain. The cost-effectiveness ratio could be improved by future reductions in the cost of the battery.

Denervación renal percutánea mediante el uso de catéter con balón en pacientes con hipertensión arterial resistente / Percutaneous renal denervation using balloon catheter in patients with resistant hypertension

La hipertensión arterial afecta a más de 1.200 millones de personas en el mundo y constituye uno de los factores de riesgo más importantes en la incidencia del infarto agudo de miocardio y el accidente cerebrovascular. Solo el 35% de los pacientes hipertensos se encuentran con valores de la presión arterial (PA) controlados con el uso de medicamentos antihipertensivos. Surge una alternativa, la denervación renal como técnica invasiva, la cual ha demostrado disminuir significativamente los valores de la PA en pacientes con hipertensión arterial resistente, y aunque ha sido debatida y controvertida luego de la publicación del estudio SYMPLICITY HTN-3, en el que no se apreció reducción significativa de las cifras de la presión arterial utilizando el Monitoreo Ambulatorio de Presión Arterial (MAPA), como herramienta de evaluación, surgen muchos interrogantes por resolver sobre esta nueva técnica y su aplicación en el campo clínico. El objetivo del presente reporte es describir detalladamente dos casos de hipertensión arterial resistente, tratados mediante ablación con radiofrecuencia con el nuevo dispositivo Vessix® de la compañía Boston Scientific.

Hypertension affects more than 1,200 people in the world, and constitutes one of the most important risk factors for the incidence of acute myocardial infarction and cerebrovascular accident. Only 35% of hypertensive patients show controlled blood pressure (BP) values with the use of hypertensive drugs. Al alternative becomes available: renal denervation as an invasive technique. It has shown to significantly reduce the BP levels in patients with resistant hypertension, and though it was discussed and controversial after the publication of the SYMPLICITY HTN-3 trial, where no significant reduction of BP values using the ambulatory blood pressure monitoring (ABPM) was noted, many questions have yet to be answered regarding this new technique and its application in the clinical field. The motivation for this report is to accurately describe two cases of resistant hypertension treated with radiofrequency ablation with the new Vessix® device from the company Boston Scientific.

Reporte de un caso de coexistencia de feocromocitoma y adenoma cortical adrenal en un paciente con hipertensión severa / Report of a case of coexistence of pheochromocytoma and adrenal cortical adenoma in a patient with severe hypertension

Se reporta el caso de una paciente con hipertensión paroxística asociada a síntomas adrenérgicos, en quien se encontraron niveles elevados de metanefrinas totales en orina de 24 horas, hipopotasemia persistente y nódulo en la glándula suprarrenal. Fue llevada a cirugía en la que se identificaron dos masas suprarrenales, una con características histológicas de feocromocitoma y otra de adenoma suprarrenal.

We report the case of a female patient with paroxysmal hypertension associated with adrenergic symptoms. Elevated levels of total metanephrines in 24 hour urine were found, as well as persistent hypokalemia and a nodule in the adrenal gland. She was taken to surgery, and two adrenal masses were identified, one with histological characteristics of pheochromocytoma and another one of adrenal adenoma.

El control de la hipertensión arterial: un problema no resuelto / The high blood pressure control: A problem not solved

Motiva la redacción de este artículo el pobre control de la hipertensión arterial que se reporta en la mayoría de los países del mundo. Se aclararon los criterios que se siguen para considerar a un paciente hipertenso como controlado y se revisaron varios trabajos de investigación sobre prevalencia de hipertensión arterial y porcentaje de control en distintas poblaciones. Se expusieron las experiencias de los autores en la atención protocolizada de la hipertensión arterial refractaria como expresión de inadecuado control de esta afección y se señalaron las principales situaciones o causas que inciden en el pobre control de la enfermedad, tanto por parte del paciente como por parte del médico. Se insistió en la necesidad de que los sistemas de salud de los países den prioridad a la atención de la hipertensión arterial con la participación del propio paciente y la mayor preocupación por médicos e instituciones en garantizar la mejor y más efectiva atención a los casos con dificultades en el control de su afección

The aim of present paper is to analyze the poor control of high blood pressure reported in many countries at world scale. The criteria followed to consider that a patient be hypertensive and under control were clarified and some papers related to a research on the high blood pressure prevalence and the control percentage in different populations were reviewed. Author's experiences with the formalized care of refractory high blood pressure as expression of a inappropriate control of this affection designating the main situations or causes falling into the poor control of this disease by patient on the one hand and by physician by the other. We emphasize on the need that the health systems of the countries give priority to high blood pressure care with the involvement of patient and a greater preoccupation by the physicians and institutions to guarantee a better and more effective care to those cases with difficulties in the control of its affection

El control de la hipertensión arterial: un problema no resuelto / The high blood pressure control: A problem not solved

Motiva la redacción de este artículo el pobre control de la hipertensión arterial que se reporta en la mayoría de los países del mundo. Se aclararon los criterios que se siguen para considerar a un paciente hipertenso como controlado y se revisaron varios trabajos de investigación sobre prevalencia de hipertensión arterial y porcentaje de control en distintas poblaciones. Se expusieron las experiencias de los autores en la atención protocolizada de la hipertensión arterial refractaria como expresión de inadecuado control de esta afección y se señalaron las principales situaciones o causas que inciden en el pobre control de la enfermedad, tanto por parte del paciente como por parte del médico. Se insistió en la necesidad de que los sistemas de salud de los países den prioridad a la atención de la hipertensión arterial con la participación del propio paciente y la mayor preocupación por médicos e instituciones en garantizar la mejor y más efectiva atención a los casos con dificultades en el control de su afección(AU)

The aim of present paper is to analyze the poor control of high blood pressure reported in many countries at world scale. The criteria followed to consider that a patient be hypertensive and under control were clarified and some papers related to a research on the high blood pressure prevalence and the control percentage in different populations were reviewed. Author's experiences with the formalized care of refractory high blood pressure as expression of a inappropriate control of this affection designating the main situations or causes falling into the poor control of this disease by patient on the one hand and by physician by the other. We emphasize on the need that the health systems of the countries give priority to high blood pressure care with the involvement of patient and a greater preoccupation by the physicians and institutions to guarantee a better and more effective care to those cases with difficulties in the control of its affection(AU)