Monocyte chemoattractant protein-1 and hypertension: An overview

Background: The association between hypertension and cardiovascular disease (CVD) has been increasingly studied through early inflammatory biomarkers. The monocyte chemoattractant protein-1 (MCP-1) is the main chemokine implicated in the inflammatory endothelial process, attracting monocytes and macrophages to the atherosclerotic plaque. Methods: We reviewed the main observational studies that have analyzed serum MCP-1 in patients with hypertension regardless of CVD, relating them to target organ damage (TOD). Results: As endothelial dysfunction continues and TOD accumulates, MCP-1 has been perpetuated at higher levels. The relationship between this chemokine and the increase in comorbidities, such as chronic kidney disease, dyslipidaemia, diabetes, and coronary artery disease, became clearer from the observational studies. However, patients with such morbidities use medications with potential anti-inflammatory effects. Conclusion: There is no normal threshold of MCP-1 for the healthy population, nor a uniform curve pattern, due to a balance between genetic factors, age, gender, comorbidities, TOD, and anti-inflammatory effects of drugs. In fact, MCP-1 seems to have a promising role as a tool for further improvement in cardiovascular risk stratification, as prognostic studies have demonstrated an association with fatal and non-fatal cardiovascular outcomes, regardless of other clinical and laboratory predictors.(AU)

Antecedentes: Se ha venido estudiando con mayor frecuencia la asociación entre hipertensión y enfermedad cardiovascular a través de los biomarcadores inflamatorios tempranos. La proteína 1 quimioatrayente de monocitos (MCP-1) es la principal quimioquina implicada en el proceso inflamatorio endotelial, que atrae monocitos y macrófagos a la placa aterosclerótica. Métodos: Revisamos los principales estudios observacionales que han analizado la MCP-1 sérica en pacientes hipotensos independientemente de enfermedad cardiovascular, relacionándolos con el daño del órgano diana. Resultados: A medida que prosigue la disfunción endotelial, y se acumula daño en el órgano diana, MCP-1 se perpetúa a niveles mayores. La relación entre esta quimioquina y el incremento de las comorbilidades, tales como la enfermedad renal crónica, la dislipidemia, la diabetes y la enfermedad arterial coronaria se hizo más evidente a partir de los estudios observacionales. Sin embargo, los pacientes con dichas morbilidades utilizan medicaciones con efectos antiinflamatorios potenciales. Conclusión: No existe un umbral normal de MCP-1 para la población sana, ni un patrón de curva uniforme, debido al equilibrio entre factores genéticos, edad, sexo, comorbilidades, TOD y efectos antiinflamatorios de los fármacos. De hecho, MCP-1 parece tener un rol prometedor como herramienta de mejora futura de la estratificación del riesgo cardiovascular, ya que los estudios pronósticos han demostrado una asociación con los resultados cardiovasculares fatales y no fatales, independientemente de otros factores predictivos clínicos y de laboratorio.(AU)

Resistant hypertension and Morgagni hernia: The importance of nocturnal hypoxaemia

A 51-year-old woman consulted for resistant arterial hypertension despite adequate antihypertensive treatment. Physical examination and analytical study showed no relevant abnormalities, with pulse oximeter saturation of 95%. The study highlighted nocturnal respiratory polygraphy with data of mild intensity sleep apnoea syndrome, and severe nocturnal hypoxaemia (apnoea hypopnoea index per hours of sleep [AHI] 7.8; desaturation index per hour [ODI]: 12.6. Oxygen-medium saturation: 89%, minimum saturation: 72%. CT90: 34.2%). The chest X-ray showed elevation of the right hemidiaphragm, and the chest computed tomography (CT) revealed a Morgagni hernia with a maximum diameter of 20cm. After adjusting the antihypertensive treatment, the patient was referred to General Surgery for intervention. The onset of resistant hypertension secondary to severe nocturnal hypoxemia from a large Morgagni hernia has not been previously described in the literature.(AU)

Mujer de 51 años de edad que consultó por hipertensión arterial resistente, pese a tratamiento antihipertensivo adecuado. Presentaba una exploración y estudio analítico sin alteraciones relevantes, con saturación del 95% por pulsioximetría. En el estudio destacaba una poligrafía respiratoria nocturna con datos de síndrome de apnea del sueño de intensidad leve, e hipoxemia nocturna grave (índice de apneas hipopnea por horas de sueño [IAHH] 7,8; índice de desaturaciones por hora [IDH]: 12,6. Oxígeno-saturación media: 89%, saturación mínima: 72%. CT90: 34,2%). La radiografía de tórax mostró una elevación de hemidiafragma derecho, comprobándose en la tomografía computarizada (TC) torácica una hernia de Morgagni de 20 cm de diámetro máximo. Tras ajustar el tratamiento antihipertensivo, la paciente se derivó a cirugía general para su intervención. La aparición de hipertensión resistente secundaria a hipoxemia nocturna grave por una gran hernia de Morgagni no ha sido descrita previamente en la literatura.(AU)

Monocyte chemoattractant protein-1 and hypertension: An overview.

BACKGROUND: The association between hypertension and cardiovascular disease (CVD) has been increasingly studied through early inflammatory biomarkers. The monocyte chemoattractant protein-1 (MCP-1) is the main chemokine implicated in the inflammatory endothelial process, attracting monocytes and macrophages to the atherosclerotic plaque. METHODS: We reviewed the main observational studies that have analyzed serum MCP-1 in patients with hypertension regardless of CVD, relating them to target organ damage (TOD). RESULTS: As endothelial dysfunction continues and TOD accumulates, MCP-1 has been perpetuated at higher levels. The relationship between this chemokine and the increase in comorbidities, such as chronic kidney disease, dyslipidaemia, diabetes, and coronary artery disease, became clearer from the observational studies. However, patients with such morbidities use medications with potential anti-inflammatory effects. CONCLUSION: There is no normal threshold of MCP-1 for the healthy population, nor a uniform curve pattern, due to a balance between genetic factors, age, gender, comorbidities, TOD, and anti-inflammatory effects of drugs. In fact, MCP-1 seems to have a promising role as a tool for further improvement in cardiovascular risk stratification, as prognostic studies have demonstrated an association with fatal and non-fatal cardiovascular outcomes, regardless of other clinical and laboratory predictors.

Resistant hypertension and Morgagni hernia: The importance of nocturnal hypoxaemia.

A 51-year-old woman consulted for resistant arterial hypertension despite adequate antihypertensive treatment. Physical examination and analytical study showed no relevant abnormalities, with pulse oximeter saturation of 95%. The study highlighted nocturnal respiratory polygraphy with data of mild intensity sleep apnoea syndrome, and severe nocturnal hypoxaemia (apnoea hypopnoea index per hours of sleep [AHI] 7.8; desaturation index per hour [ODI]: 12.6. Oxygen-medium saturation: 89%, minimum saturation: 72%. CT90: 34.2%). The chest X-ray showed elevation of the right hemidiaphragm, and the chest computed tomography (CT) revealed a Morgagni hernia with a maximum diameter of 20cm. After adjusting the antihypertensive treatment, the patient was referred to General Surgery for intervention. The onset of resistant hypertension secondary to severe nocturnal hypoxemia from a large Morgagni hernia has not been previously described in the literature.

Long-term Effect of CPAP Treatment on Cardiovascular Events in Patients With Resistant Hypertension and Sleep Apnea. Data From the HIPARCO-2 Study / Efecto a largo plazo del tratamiento de la presión positiva continua en las vías respiratorias en eventos cardiovasculares en pacientes con hipertensión resistente y apnea del sueño. Datos del estudio HIPARCO-2

Background: There is some controversy about the effect of continuous positive airway pressure (CPAP) on the incidence of cardiovascular events (CVE). However, the incidence of CVE among patients with both obstructive sleep apnea (OSA) ans resistant hypertension (HR) has not been evaluated. Our objective was to analyze the long-term effect of CPAP treatment in patients with RH and OSA on the incidence of CVE.Methods: Multi-center, observational and prospective study of patients with moderate-severe OSA and RH. All the patients were followed up every 3•6 months and the CVE incidence was measured. Patients adherent to CPAP (at least 4h/day) were compared with those with not adherent or those who had not been prescribed CPAP.Results: Valid data were obtained from 163 patients with 64 CVE incidents. Treatment with CPAP was offered to 82%. After 58 months of follow-up, 58.3% of patients were adherent to CPAP. Patients not adherent to CPAP presented a non-significant increase in the total CVE incidence (HR:1.6; 95%CI: 0.96•2.7; p=0.07). A sensitivity analysis showed that patients not adherent to CPAP had a significant increase in the incidence of cerebrovascular events (HR: 3.1; CI95%: 1.07•15.1; p=0.041) and hypertensive crises (HR: 5.1; CI95%: 2.2•11.6; p=0.006), but the trend went in the opposite direction with respect to coronary events (HR: 0.22; CI95%: 0.05•1.02; p=0.053).Conclusions: In patients with RH and moderate-severe OSA, an uneffective treatment with CPAP showed a trend toward an increase in the incidence of CVE (particularly neurovascular events and hypertensive crises) without any changes with respect to coronary events. (AU)

Antecedentes: Existe cierta controversia sobre el efecto de la presión positiva continua en las vías respiratorias (CPAP) sobre la incidencia de eventos cardiovasculares (ECV). Sin embargo, no se ha evaluado la incidencia de ECV en los pacientes con apnea obstructiva del sueño (AOS) e hipertensión resistente (HR). Nuestro objetivo fue analizar el efecto a largo plazo del tratamiento con CPAP en pacientes con HR y AOS en la incidencia de ECV.Métodos: Estudio multicèc)ntrico, observacional y prospectivo de pacientes con AOS y HR. Cada paciente acudió a revisión cada 3-6 meses y se midió la incidencia de ECV. Se compararon los pacientes con buena adherencia a la CPAP (al menos 4h/día) con aquellos con mala adherencia o aquellos a quienes no se les había indicado la CPAP.Resultados: Se obtuvieron datos válidos de 163 pacientes con 64 eventos de ECV. Se ofreció tratamiento con CPAP al 82%. Despuèc)s de 58 meses de seguimiento, el 58,3% de los pacientes presentaron buena adherencia a la CPAP. Los pacientes con mala adherencia o sin prescripción de CPAP presentaron un aumento no significativo en la incidencia total de ECV (HR: 1,6; IC 95%: 0,96-2,7; p=0,07). Un análisis de sensibilidad mostró que los pacientes con mala adherencia a la CPAP tuvieron un aumento significativo en la incidencia de eventos cerebrovasculares (HR: 3,1; IC 95%: 1,07-15,1; p=0,041) y crisis hipertensivas (HR: 5,1; IC 95%: 2,2-11,6; p=0,006), pero la tendencia fue en la dirección opuesta con respecto a los eventos coronarios (HR: 0,22; IC 95%: 0,05-1,02; p=0,053).Conclusiones: En pacientes con HR y AOS moderada o grave, un tratamiento ineficaz con CPAP mostró una tendencia hacia un aumento en la incidencia de ECV (particularmente eventos neurovasculares y crisis hipertensivas), sin ningún cambio con respecto a los eventos coronarios. (AU)

Long-term Effect of CPAP Treatment on Cardiovascular Events in Patients With Resistant Hypertension and Sleep Apnea. Data From the HIPARCO-2 Study.

BACKGROUND: There is some controversy about the effect of continuous positive airway pressure (CPAP) on the incidence of cardiovascular events (CVE). However, the incidence of CVE among patients with both obstructive sleep apnea (OSA) ans resistant hypertension (HR) has not been evaluated. Our objective was to analyze the long-term effect of CPAP treatment in patients with RH and OSA on the incidence of CVE. METHODS: Multi-center, observational and prospective study of patients with moderate-severe OSA and RH. All the patients were followed up every 3-6 months and the CVE incidence was measured. Patients adherent to CPAP (at least 4h/day) were compared with those with not adherent or those who had not been prescribed CPAP. RESULTS: Valid data were obtained from 163 patients with 64 CVE incidents. Treatment with CPAP was offered to 82%. After 58 months of follow-up, 58.3% of patients were adherent to CPAP. Patients not adherent to CPAP presented a non-significant increase in the total CVE incidence (HR:1.6; 95%CI: 0.96-2.7; p=0.07). A sensitivity analysis showed that patients not adherent to CPAP had a significant increase in the incidence of cerebrovascular events (HR: 3.1; CI95%: 1.07-15.1; p=0.041) and hypertensive crises (HR: 5.1; CI95%: 2.2-11.6; p=0.006), but the trend went in the opposite direction with respect to coronary events (HR: 0.22; CI95%: 0.05-1.02; p=0.053). CONCLUSIONS: In patients with RH and moderate-severe OSA, an uneffective treatment with CPAP showed a trend toward an increase in the incidence of CVE (particularly neurovascular events and hypertensive crises) without any changes with respect to coronary events.

Chronic kidney disease progression in patients with resistant hypertension subject to 2 therapeutic strategies: Intensification with loop diuretics vs aldosterone antagonists. / Progresión de la enfermedad renal crónica en pacientes con hipertensión resistente sometidos a 2 estrategias terapéuticas: intensificación con diuréticos de asa vs. antagonistas de la aldosterona.

INTRODUCTION: Actualy, there are few data about glomerular filtration rate (eGFR) drop in patients with resistant hypertension and how diferent therapies can modify chronic kidney disease progression (CKD). OBJECTIVE: To evaluate CKD progression in patients with resistant hypertension undergoing 2diferent therapies: treatment with spironolactone or furosemide. METHODS: We included 30 patients (21M, 9W) with a mean age of 66.3±9.1 years, eGFR 55.8±16.5ml/min/1.73 m2, SBP 162.8±8.2 and DBP 90.2±6.2mmHg: 15 patients received spironolactone and 15 furosemide and we followed up them a median of 32 months (28-41). RESULTS: The mean annual eGFR decrease was -2.8±5.4ml/min/1.73 m2. In spironolactone group was -2.1±4.8ml/min/1.73 m2 and in furosemide group was -3.2±5.6ml/min/1.73 m2, P<0.01. In patients received spironolactone, SBP decreased 23±9mmHg and in furosemide group decreased 16±3mmHg, P<.01. DBP decreased 10±8mmHg and 6±2mmHg, respectively (P<.01). Treatment with spironolactone reduced albuminuria from a serum albumin/creatine ratio of 210 (121-385) mg/g to 65 (45-120) mg/g at the end of follow-up, P<.01. There were no significant changes in the albumin/creatinine ratio in the furosemide group. The slower drop in kidney function was associated with lower SBP (P=.04), higher GFR (P=.01), lower albuminuria (P=.01), not diabetes mellitus (P=.01) and treatment with spironolactone (P=.02). Treatment with spironolactone (OR 2.13, IC 1.89-2.29) and lower albuminuria (OR 0.98, CI 0.97-0.99) maintain their independent predictive power in a multivariate model. CONCLUSION: Treatment with spironolactone is more effective reducing BP and albuminuria in patients with resistant hypertension compared with furosemide and it is associated with a slower progression of CKD in the long term follow up.

Hipertensión resistente en un paciente con aldosteroninsmo primario. Una presentación clínica inusual

En este reporte se presenta el caso de una paciente con hipertensión resistente que requería triple terapia antihipertensiva. Presentaba episodios súbitos de hipertensión, de predominio nocturno, cefalea, disnea, palpitaciones, dolor precordial, y se documentó ultrasonográficamente una masa suprarrenal izquierda. Estas manifestaciones clínicas podrían corresponder a hipertensión endocrina debida a feocromocitoma. No obstante, las pruebas de laboratorio mostraron hipocalemia, elevación de la aldosterona plasmática y supresión de la actividad de renina plasmática. Estos resultados fueron consistentes con aldosteronismo primario. Con la resección laparoscópica del adenoma suprarrenal, se normalizaron las cifras tensionales y las concentraciones de aldosterona y actividad de renina plasmática.

In this report we present a case of a patient with resistant hypertension treated with triple antihypertensive medication. The patient suffered of sudden episodes of nocturnal hypertension, headache, dyspnoea, palpitations, precordial pain and a left suprarenal mass was found in the abdominal ultrasound. These findings suggested endocrine hypertension due to pheochromocytoma.However, the laboratory tests showed hypokalemia, high plasma aldosterone concentrations and suppressed plasma renin activity. This results were consistent with primary aldosteronism. After the laparoscopic removal of the suprarenal adenoma blood pressure, plasma aldosterone concentrations and plasma renine activity returned to normal.

[Resistant hypertension: An update]. / Hipertensión resistente: puesta al día.

An estimated 10% to 20% of hypertensive patients could be considered resistant to treatment (RH). These are patients who are not controlled using three drugs, at the maximum tolerated doses, including a diuretic, as well as those with high blood pressure controlled using four or more drugs. The term is used to identify patients that might benefit from special diagnostic and/or therapeutic consideration. The term 'refractory hypertension' has recently been proposed as a novel phenotype of antihypertensive failure. It refers to patients whose blood pressure cannot be controlled with maximum treatment. The first studies of this phenotype indicate that it is rare and affects less than 5% of patients with RH. Adherence to or compliance with medical treatment is key to defining resistant hypertension. Closer attention has been paid to clinical and experimental research since the first scientific statement for the diagnosis, assessment and treatment of RH from the American Heart Association, and in the European guidelines, was published in 2008. This review will set out the concepts relating to prevalence, prognosis and compliance and cover the latest developments on this subject.

Rationale and Methodology of the SARAH Trial: Long-Term Cardiovascular Outcomes in Patients With Resistant Hypertension and Obstructive Sleep Apnea.

INTRODUCTION: Patients with resistant hypertension (RH) have a high risk of developing cardiovascular events; therefore, new therapeutic approaches to better control blood pressure may be useful in improving cardiovascular outcomes. The prevalence of obstructive sleep apnea (OSA) is very high among patients with RH. Continuous positive airway pressure (CPAP) has been shown to be an effective treatment for reducing blood pressure in patients with RH. Nevertheless, the long-term effect of CPAP treatment on cardiovascular outcomes has not been explored. The main objective of the SARAH study is to assess the impact of OSA and its treatment on cardiovascular outcomes (morbidity and mortality) in patients with RH. METHODS: This study is a multi-center, prospective, observational cohort study. A total of 1371 patients with RH will be enrolled in the study and followed once a year for five years. At inclusion, ambulatory blood pressure monitoring (ABPM) and a sleep study will be performed in all subjects. Socio-demographic, clinical and cardiovascular variables will be collected at baseline and follow-up. Subsequently, subjects with OSA will be managed according to local standard practice. Based on the OSA diagnosis and its treatment, three cohorts of subjects with RH will be defined: non-OSA, treated OSA and non-treated OSA. CONCLUSIONS: This study will contribute to elucidating the long-term impact of OSA treatments on blood pressure control and cardiovascular outcomes in patients with RH. These results will contribute to improve the cardiovascular prognosis of patients with RH.

Resistant Hypertension: A Clinical Case / Hipertensión resistente: un caso clínico / Hipertensão resistente: um caso clínico

Abstract Introduction: Secondary hypertension corresponds to 15 % of the causes of arterial hypertension, and among them, primary hyperaldosteronism presents a variable incidence of about 3 % in hypertensive patients. It has a slightly higher prevalence in women, between 30 and 60 years, and is usually unilateral. Case presentation: The authors describe the clinical case of a patient, followed by a severe hypertension medicated with four antihypertensive drugs for tension stabilization, maintaining systolic arterial tensions superior to 170 mmHg. In the aetiological study of hypertension, analytical alterations suggested hyperaldosteronism and a nodular lesion was detected in the left adrenal gland. The patient was submitted to surgery and excision of the lesion was done with histological confirmation of the diagnosis of corticomedullary adenoma of the adrenal gland. The patient presented improvement of the tension profile, with need to suspend two of the four antihypertensive drugs and to reduce the dose of the remaining ones. Conclusion: A tumor of the adrenal cortex producing aldosterone is the main cause of primary hyperaldosteronism and should always be excluded when the presence of difficult to control, severe hypertension is detected, since the standard treatment is surgical, leading to a stabilization of the tension pattern after a few months.

Resumen Introducción: la hipertensión secundaria corresponde al 15 % de las causas de hipertensión arterial, y entre ellas, el hiperaldosteronismo primario presenta una incidencia variable de sobre 3 % en pacientes hipertensos. Tiene una prevalencia ligeramente mayor en mujeres, entre 30 y 60 años, y generalmente es unilateral. Presentación del caso: los autores describen el caso clínico de un paciente, seguido por una hipertensión resistente medicada con cuatro fármacos antihipertensivos para la estabilización de la tensión, con mantenimiento de las tensiones arteriales sistólicas superiores a 170 mmHg. Las alteraciones analíticas en el estudio etiológico de la hipertensión sugirieron hiperaldosteronismo y una lesión nodular en la glándula suprarrenal izquierda. El paciente fue sometido a cirugía y se realizó la escisión de la lesión con confirmación histológica del diagnóstico de adenoma corticomedular de la glándula suprarrenal. El paciente presentó una mejora en el perfil de tensión, con la necesidad de suspender dos de los cuatro fármacos antihipertensivos y reducir la dosis de los restantes. Discusión: un tumor de la corteza suprarrenal que produce la aldosterona es la principal causa de hiperaldosteronismo primario y siempre debe excluirse cuando se presenta hipertensión grave, difícil de controlar, ya que el tratamiento estándar es quirúrgico y conduce a una estabilización del patrón de tensión después de unos meses.

Resumo Introdução: a hipertensão secundária corresponde ao 15 % das causas de hipertensão arterial, e entre elas, o hiperaldosteronismo primário apresenta uma incidência variável de sobre 3 % em pacientes hipertensos. Tem uma prevalência ligeiramente maior em mulheres, entre 30-60 anos, e geralmente é unilateral. Apresentação do caso: os autores descrevem o caso clínico de um paciente, seguido por uma hipertensão resistente medicada com quatro fármacos anti-hipertensivos para a estabilização da tensão, com manutenção das tensões arteriais sistólicas a 170 mmHg. As alterações analíticas no estudo etiológico da hipertensão sugeriram hiperaldosteronismo e uma lesão nodular na glândula suprarrenal esquerda. O paciente foi submetido a cirurgia e se realizou a incisão da lesão com confirmação histológica do diagnóstico de adenoma córtico-medular da glândula suprarrenal. O paciente apresentou uma melhora no perfil de tensão, com a necessidade de suspender dois dos quatro fármacos anti-hipertensivos e reduzir a dose dos restantes. Discussão: um tumor do córtex suprarrenal que produz a aldosterona é a principal causa de hiperaldosteronismo primário e sempre deve excluir-se quando se apresenta hipertensão grave, difícil de controlar, pois o tratamento standard é cirúrgico e conduz a uma estabilização do patrão de tensão depois de uns meses.

Misdiagnosis of resistant hypertension: Real frequency of true resistant hypertension in patients with suspected resistance to treatment. / Diagnóstico erróneo de la hipertensión resistente: frecuencia real de la hipertensión resistente en los pacientes con sospecha de resistencia al tratamiento.

INTRODUCTION: Resistant hypertension(RH) has been defined as failure to control office blood pressure (BP) despite the use of≥3 different antihypertensive agents at optimal doses, including, ideally, a diuretic. Apparent RH, defines patients with an incorrect diagnosis of RH due to different causes. The objective was to determine whether most patients with RH in fact have apparent but not true RH. PATIENTS AND METHODS: Observational study involving 93 patients with suspected RH, being 60 patients finally included. Screening for secondary causes of hypertension was perfomed. True RH was defined as office BP>140/90mmHg despite full doses of 3 antihypertensive drugs including a diuretic. RESULTS: Mean age 63.7±9.8years, 68.3%were male. Office BP 154.3±14.4/84.4±13.7mmHg. Of the 60 patients, 23.3% had white coat effect, 3.3% didn't have a diuretic and 8.3% were non-adherent-to-treatment. Accordingly, 58.3% were classified as true RH. Spironolactone was added in 62.5% of patients of whom 78.4% achieved ambulatory BP control. DISCUSSION: Almost half of the patients with suspected RH were not really true RH. We provide more evidence of excess of fluid retention as an underlying cause of lack of BP control in patients with RH, reinforce the relevant paper of spironolactone for the management in those patients.

[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.

Prevalence and characteristics of patients with resistant hypertension and chronic kidney disease. / Prevalencia y características de los pacientes con hipertensión arterial resistente y enfermedad renal crónica.

Resistant hypertension (RH) is a common problem in patients with chronic kidney disease (CKD). A decline in the glomerular filtration rate (GFR) and increased albuminuria are associated with RH; however, there are few published studies about the prevalence of this entity in patients with CKD. OBJECTIVE: To estimate the prevalence of RH in patients with different degrees of kidney disease and analyse the characteristics of this group of patients. METHODS: A total of 618 patients with hypertension and CKD stages i-iv were enrolled, of which 82 (13.3%) met the criteria for RH. RESULTS: RH prevalence increased significantly with age, the degree of CKD and albuminuria. The prevalence of RH was 3.2% in patients under 50 years, 13.8% between 50-79 years and peaked at 17.8% in patients older than 80 years. Renal function prevalence was 4, 15.8 and 18.1% in patients with an estimated glomerular filtration rate (GFR) of > 60, 30-59 and < 30ml/min/1.73 m2, respectively, and 8.9, 15.9 and 22.5% for a urine albumin to creatinine ratio (UACR) < 30, 30-299 and > 300mg/g respectively. In a logistic regression model, the characteristics associated with resistant hypertension were age, history of cardiovascular disease, GFR, albuminuria and diabetes mellitus. A total of 47.5% of patients with resistant hypertension had controlled BP (<140/90mmHg) with 4 or more antihypertensive drugs. These patients were younger, with better renal function, less albuminuria and received more aldosterone antagonists. CONCLUSION: RH prevalence increases with age, the degree of CKD and albuminuria. Strategies such as treatment with aldosterone receptor antagonists are associated with better blood pressure control in this group of patients, leading to reduced prevalence.

[PATHWAY-2 study. Vision of the family physician in the approach of resistant hypertension]. / Estudio PATHWAY-2. La visión del médico de familia en el abordaje de la hipertensión arterial resistente.

Resistant hypertension is a relatively prevalent condition in primary care that exceeds 7% of patients with hypertension assisted in the office and that implies a high cardiovascular risk due to its association with cardiovascular events. The PATHWAY-2 study has allowed to establish that spironolactone is the best possible alternative in the fourth line of treatment for most patients. It significantly simplifies the approach of these patients for primary care physicians.

[Primary hyperaldosteronism due to unilateral adrenal hyperplasia with surgical resolution]. / Hiperaldosteronismo primario por hiperplasia suprarrenal unilateral con resolución quirúrgica.

Unilateral adrenal hyperplasia is a rare cause of primary hyperaldosteronism (around a 3%) that has surgical treatment. A case of a patient with hypertension resistant to conventional therapy in treatment with 7 drugs who presented with primary hyperaldosteronism due to unilateral adrenal hyperplasia is presented. A left adrenalectomy was performed, and the patient had a good clinical response, with no need of any drug after 2 years of surgery. Unilateral adrenal hyperplasia is a different entity and it is not an asymmetric variant of the bilateral adrenal hyperplasia. In the study of patients with primary hyperaldosteronism and imaging tests with absence of adenoma is a diagnosis that must be considered before cataloguing patients with bilateral adrenal hyperplasia and start a medical treatment, because unilateral adrenal hyperplasia would have a surgical resolution.

Declaración ante los resultados del ensayo clínico Symplicity HTN 3. Grupo de estudio de la hipertensión arterial resistente / Position paper on the results of Symplicity HTN-3 trial. Grupo de estudio de la hipertensión arterial resistente

La denervación de las arterias renales ha sido una alternativa para el tratamiento de la hipertensión arterial resistente. Los estudios Symplicity HTN 1 y 2 mostraron en grupos pequeños y no controlados disminuciones de la presión sistólica hasta de 30 mm Hg. Este entusiasmo ha sido opacado por el estudio Symplicity HTN 3, ensayo clínico aleatorizado y controlado con un procedimiento placebo. Sorprendentemente, los resultados sugirieron que la denervación renal tuvo un efecto similar al del placebo, aunque en el análisis de subgrupos preespecificados los pacientes que no eran de raza negra, los menores de 65 años y los que tenían función renal normal tuvieron una reducción de la presión arterial sistólica estadísticamente significativa. Esta es una evaluación crítica de los resultados del Symplicity HTN 3 y propone posibles explicaciones para estos. Además, declara la postura de nuestro grupo y las acciones futuras.

Renal artery denervation has shown to be an effective treatment for resistant hypertension. Symplicity HTN 1 and 2 trials showed in small and uncontrolled groups, significant systolic blood pressure reductions down to 30 mm Hg. Symplicity HTN-3, a double blind, randomized, placebo controlled clinical trial shaded this initial enthusiasm. Surprisingly, their results showed that renal denervation has a similar effect to placebo. Pre-specified subgroup analysis showed that non-black race individuals, younger than 65 years and with normal renal function, had a statistically significant systolic blood pressure decrease. This manuscript critically appraises the Symplicity HTN-3 trial, proposing possible explanations for the results. Also declares our group position and future actions regarding renal denervation.

[Position paper on the results of Symplicity HTN-3 trial. Grupo de estudio de la hipertensión arterial resistente]. / Declaración ante los resultados del ensayo clínico Symplicity HTN 3. Grupo de estudio de la hipertensión arterial resistente.

Renal artery denervation has shown to be an effective treatment for resistant hypertension. Symplicity HTN 1 and 2 trials showed in small and uncontrolled groups, significant systolic blood pressure reductions down to 30 mm Hg. Symplicity HTN-3, a double blind, randomized, placebo controlled clinical trial shaded this initial enthusiasm. Surprisingly, their results showed that renal denervation has a similar effect to placebo. Pre-specified subgroup analysis showed that non-black race individuals, younger than 65 years and with normal renal function, had a statistically significant systolic blood pressure decrease. This manuscript critically appraises the Symplicity HTN-3 trial, proposing possible explanations for the results. Also declares our group position and future actions regarding renal denervation.

[Resistant arterial hypertension in Primary Care patients in Spain. PRESCAP Study 2010]. / Hipertensión arterial resistente en pacientes hipertensos atendidos en Atención Primaria de España. Estudio PRESCAP 2010.

OBJECTIVE: To determine the prevalence and clinical and epidemiological characteristics of Primary Care patients with resistant hypertension (RHT) in Spain. PATIENTS AND METHODS: A cross-sectional multicenter study was conducted on hypertensive patients aged 18 or over and seen in a Primary Care clinic. RHT was considered as the presence of uncontrolled blood pressure in patients treated with at least 3 drugs, one of which is a diuretic. RESULTS: Of the 12,961 hypertensive patients in the PRESCAP 2010 study, 962 (7.4%) fulfilled criteria for RHT, of whom 51% were women, and with a mean age (SD) 68.8 [11.4] years. Patients with RHT were older (68.80 [10.69] years vs. 66.06 [11.44] years, P<.001), had a higher prevalence of obesity (55.2 vs. 38.6%, P<.001), a higher waist circumference (103.90 [13.89] vs. 99.32 [13.69] cm, P<.001), and a higher prevalence of DM (48.3 vs. 29.5%, P<.001). The prevalence of target organ damage (73.0 vs. 61.4%, P<.001) and cardiovascular disease (46.7 vs. 26.8%, P<.001) were higher in patients with resistant hypertension. The multivariate analysis showed that the variables associated with resistant hypertension were the presence of cardiovascular disease, diabetes mellitus, sedentary life style, microalbuminuria, body mass index, duration of AHT, and triglycerides. CONCLUSIONS: The prevalence of RHT in Primary Care patients is related to inappropriate lifestyles, the presence of target organ damage, and cardiovascular disease.