Effectiveness of chlorthalidone/amiloride versus losartan in patients with stage I hypertension and diabetes mellitus: results from the PREVER-treatment randomized controlled trial.

AIMS: To compare the blood pressure (BP)-lowering efficacy of a chlorthalidone/amiloride combination pill with losartan, during initial management of JNC 7 Stage I hypertension in patients with type 2 diabetes mellitus. METHODS: In an a priori subgroup analysis of a randomized, double-blind, controlled trial, volunteers aged 30-70 years, with stage I hypertension and diabetes mellitus, were randomized to 12.5/2.5 mg of chlorthalidone/amiloride (N = 47) or 50 mg of losartan (N = 50), and followed for 18 months in 21 clinical centers. If BP remained uncontrolled after three months, study medication dose was doubled, and if uncontrolled after six months, amlodipine (5 and 10 mg) and propranolol (40 and 80 mg BID) were added as open label drugs in a progressive fashion. RESULTS: Systolic BP decreased to a greater extent in participants allocated to diuretics compared to losartan (P < 0.001). After 18 months of follow-up, systolic BP was 128.4 ± 10.3 mmHg in the diuretic group versus 133.5 ± 8.0 in the losartan group (P < 0.01). In the diuretic group, 36 out of 43 participants (83.7%) had a JNC 7 normal BP, compared to 31/47 (66%) in the losartan group (P = 0.089). Serum cholesterol was higher in the diuretic arm at the end of the trial. Other biochemical parameters and reports of adverse events did not differ by treatment. CONCLUSIONS: Treatment of hypertension based on a combination of chlorthalidone and amiloride is more effective for BP lowering compared to losartan in patients with diabetes mellitus and hypertension. TRIAL REGISTRATION: Clinical trials registration number: NCT00971165.

Effectiveness of low-dose diuretics for blood pressure reduction to optimal values in prehypertension: a randomized clinical trial.

BACKGROUND: To determine the effectiveness of low-dose diuretic therapy to achieve an optimal level of blood pressure (BP) in adults with prehypertension. METHODS: The PREVER-prevention trial was a randomized, parallel, double-blinded, placebo-controlled trial, with 18 months of follow-up, conducted at 21 academic medical centers in Brazil. Of 1772 individuals evaluated for eligibility, 730 volunteers with prehypertension who were aged 30-70 years, and who did not reach optimal blood pressure after 3 months of lifestyle intervention, were randomized to a fixed association of chlorthalidone 12.5 mg and amiloride 2.5 mg or placebo once a day. The main outcomes were the percentage of participants who achieved an optimal level of BP. RESULTS: A total of 372 participants were randomly allocated to diuretics and 358 to placebo. After 18 months of treatment, optimal BP was noted in 25.6% of the diuretic group and 19.3% in the placebo group (P < 0.05). The mean net reduction in SBP and DBP for the diuretic group compared with placebo was 2.8 mmHg (95% CI 1.1 to 4.5) and 1.1 mmHg (95% CI -0.09 to 2.4), respectively. Most participants in the active treatment group (74.5%) and in the placebo group (80.7%) continued to have BP in the prehypertension range or progressed to hypertension. CONCLUSION: Low-dose diuretic therapy increased the probability of individuals with prehypertension to achieve optimal BP but most of those treated continued to have a BP in the prehypertension range or progressed to having overt hypertension.

Cognitive Alterations in Elderly Patients with Heart Failure'

Abstract Background: Among the various pathologies that affect the elderly, Heart Failure (HF) stands out. Recently, an attempt has been made to verify the existence of cognitive impairment associated with HF. Objectives: To compare the cognitive performance of elderly people with heart failure with that of age-matched individuals without this pathology. Check the existence of marked impairment in some cognitive functions in the clinical group. Methods: The sample consisted of 78 elderly people, whose inclusion criterion was the presence of HF and no HF (control group); age over 60 years, both sexes, and any level of education. The control group consisted of 37 individuals (with a median age of 68 years - Interquartile range of 12) and the HF group, with 41 individuals (with a median age of 67 years - Interquartile range of 11). The subjects were matched in terms of education level, with a predominance of elderly people with 0 to 4 years of education (65.9% in the Clinical Group and 59.5% in the Control Group). Eleven neuropsychological tests covering cognitive functions were used: attention, language, memory, mood, and executive function. Statistical analysis was performed using SPSS software, version 23, with a significance level of 5%. The Chi-square test and the Mann-Whitney test were applied. Results: The results showed significant differences between the groups, mainly in executive functions, which include the ability to plan, switch, and recall previously stored information. Conclusion: Our study showed differences between the cognitive performance of elderly people with HF and elderly people without HF. The main alteration was found in the so-called executive functions, attention, and memory.

[Monocytosis is an independent risk marker for coronary artery disease]. / Monocitose é um marcador de risco independente para a doença arterial coronariana.

OBJECTIVES: Inflammation and activation of immune system cells play an important role in the pathogenesis of atherosclerosis. This study analyzes the white blood count, including neutrophils, eosinophils, lymphocytes, monocytes and basophils, of patients with chronic coronary artery disease (CAD) and acute myocardial infarction (AMI). METHODS: The white blood cell count was analyzed in 232 patients without diabetes between the ages of 15 and 88. One hundred and forty-two patients were angiographically diagnosed with CAD (57 with stable CAD and 85 with AMI) and compared to 90 control individuals. The control and CAD groups were similar in respect to age, body mass index, family history, smoking habits, hypertension, HDL and LDL (all variables with p > 0.25). RESULTS: The univariate analysis revealed a higher prevalence of leukocytosis in the CAD group, which in turn was higher in the AMI patients than the stable CAD patients. The same trend was observed for monocytes. However, the distribution of all other cells in the complete blood count (CBC) was similar. Multivariate analysis using the logistic regression method with the stepwise (all variables) and backward models (p < 0.25), showed that monocytosis was an independent variable for CAD and AMI. CONCLUSION: The number of monocytes, one of the most important components of the inflammatory process in the atherosclerosis plaque was an independent risk marker for CAD and AMI.

Ciprofibrate therapy in patients with hypertriglyceridemia and low high density lipoprotein (HDL)-cholesterol: greater reduction of non-HDL cholesterol in subjects with excess body weight (The CIPROAMLAT study).

BACKGROUND: Hypertriglyceridemia in combination with low HDL cholesterol levels is a risk factor for cardiovascular disease. Our objective was to evaluate the efficacy of ciprofibrate for the treatment of this form of dyslipidemia and to identify factors associated with better treatment response. METHODS: Multicenter, international, open-label study. Four hundred and thirty seven patients were included. The plasma lipid levels at inclusion were fasting triglyceride concentrations between 1.6-3.9 mM/l and HDL cholesterol < or = 1.05 mM/l for women and < or = 0.9 mM/l for men. The LDL cholesterol was below 4.2 mM/l. All patients received ciprofibrate 100 mg/d. Efficacy and safety parameters were assessed at baseline and at the end of the treatment. The primary efficacy parameter of the study was percentage change in triglycerides from baseline. RESULTS: After 4 months, plasma triglyceride concentrations were decreased by 44% (p < 0.001). HDL cholesterol concentrations were increased by 10% (p < 0.001). Non-HDL cholesterol was decreased by 19%. A greater HDL cholesterol response was observed in lean patients (body mass index < 25 kg/m2) compared to the rest of the population (8.2 vs 19.7%, p < 0.001). In contrast, cases with excess body weight had a larger decrease in non-HDL cholesterol levels (-20.8 vs -10.8%, p < 0.001). There were no significant complications resulting from treatment with ciprofibrate. CONCLUSIONS: Ciprofibrate is efficacious for the correction of hypertriglyceridemia / low HDL cholesterol. A greater decrease in non-HDL cholesterol was found among cases with excess body weight. The mechanism of action of ciprofibrate may be influenced by the pathophysiology of the disorder being treated.

A comparison between diuretics and angiotensin-receptor blocker agents in patients with stage I hypertension (PREVER-treatment trial): study protocol for a randomized double-blind controlled trial.

BACKGROUND: Cardiovascular disease is the leading cause of death in Brazil, and hypertension is its major risk factor. The benefit of its drug treatment to prevent major cardiovascular events was consistently demonstrated. Angiotensin-receptor blockers (ARB) have been the preferential drugs in the management of hypertension worldwide, despite the absence of any consistent evidence of advantage over older agents, and the concern that they may be associated with lower renal protection and risk for cancer. Diuretics are as efficacious as other agents, are well tolerated, have longer duration of action and low cost, but have been scarcely compared with ARBs. A study comparing diuretic and ARB is therefore warranted. METHODS/DESIGN: This is a randomized, double-blind, clinical trial, comparing the association of chlorthalidone and amiloride with losartan as first drug option in patients aged 30 to 70 years, with stage I hypertension. The primary outcomes will be variation of blood pressure by time, adverse events and development or worsening of microalbuminuria and of left ventricular hypertrophy in the EKG. The secondary outcomes will be fatal or non-fatal cardiovascular events: myocardial infarction, stroke, heart failure, evidence of new subclinical atherosclerosis and sudden death. The study will last 18 months. The sample size will be of 1200 participants for group in order to confer enough power to test for all primary outcomes. The project was approved by the Ethics committee of each participating institution. DISCUSSION: The putative pleiotropic effects of ARB agents, particularly renal protection, have been disputed, and they have been scarcely compared with diuretics in large clinical trials, despite that they have been at least as efficacious as newer agents in managing hypertension. Even if the null hypothesis is not rejected, the information will be useful for health care policy to treat hypertension in Brazil. CLINICAL TRIALS REGISTRATION NUMBER: ClinicalTrials.gov: NCT00971165.

Perfil da adesão dos usuários do programa HIPERDIA na Unidade Básica de Saúde da FamíliaDom Manoel Pestana Filho em Anápolis (GO) / Adhesion profile of HIPERDIA's program users in Basic Health Unit Family in Dom Manoel Pestana Filho at Anápolis (GO)

A hipertensão arterial sistêmica (HAS) bem como o diabetes mellitus (DM) configuram-se como doenças de grande impacto na sociedade brasileira. Este trabalho teve como objetivo identificar o perfil da adesão dos usuários do Sistema de Cadastramento e Acompanhamento de Hipertensos e Diabéticos (HIPERDIA) aos tratamentos farmacológicos e não farmacológicos na Unidade Básica de Saúde da Família (UBSF) Dom Manoel Pestana Filho. Trata-se de um estudo descritivo. Atécnica utilizada foi a observação direta extensiva por intermédio de questionário. A amostra foi não probabilística, formada por 79 usuários, por acessibilidade, não fazendo uso de forma aleatória de seleção. Apesquisa forneceu informações sobre hábitos de vida e adesão farmacológica e não farmacológica dos pacientes entrevistados. Concluiu-se por meio dos resultados obtidos que a maioria possui HAS e DM, predominando HAS dos tipos I e II. Não se pôde concluir se a adesão do paciente usuário do programa HIPERDIA na UBSF Dom Manoel Pestana Filho é ineficaz ou se a forma de mensuração é falha

The systemic arterial hypertension (SAH) and diabetes mellitus (DM) are characterized as high-impact diseases in Brazilian society. This work aims to identify the adhesion profile of HIPERDIA program's users to pharmacological and non-pharmacological treatments in Unit Basic Family Health Dom Manoel Pestana Filho. This is a descriptive study. The technique used was extensive direct observation through a questionnaire. The sample was non- probabilistic, formed by 79 users, accessibility, not making use of random selection basis. The survey provided information on the patients' habits interviewed and pharmacologic and non-pharmacological adhesion. It was concluded through the results that the majority has SAH and DM, SAH predominantly type I to II. And it can't be concluded whether the adhesion of HIPERDIA's users program in UBSF Dom Manoel Pestana Filho is ineffective or if the form of measurement is flawed.

Vascular calcifications seen on mammography: an independent factor indicating coronary artery disease.

PURPOSE: Establish a relationship between vascular calcifications seen via mammography and coronary artery disease, estimate the risk ratios, and investigate the interrelationships between vascular calcification and other risk factors for coronary artery disease. MATERIALS AND METHODS: This was a case-control study consisting of 40 women with coronary artery disease in the case group and 40 women without any history of coronary artery disease in the control group who were matched according to age. The study was approved by the Institution's Research Ethics Committee (consent statement was obtained). Odds ratios and confidence intervals were calculated using univariate analysis. Interrelationships among other risk factors, such as arterial hypertension, dyslipidemia, smoking and diabetes mellitus, were calculated using multivariate analysis. A p <0.05 was considered to be significant for statistical analysis. RESULTS: The mean ages for the case and control groups were 64.65 years and 63.88 years, respectively. In multivariate analysis, the only variables related to coronary artery disease were Vascular calcification [OR 4.71 (CI 1.36-16.33) p=0.014], family history [OR 5.76 (CI 1.58-21.03) p=0.008] and arterial hypertension [OR 15.92 (CI 3.12-81.14) p=0.001]. Although smoking and diabetes are important variables in the pathogenesis of coronary artery disease, these factors did not show statistically significant associations in this sample. CONCLUSION: The presence of vascular calcifications seen via mammography was an independent risk factor for coronary artery disease, as were hypertension and a family history of coronary artery disease.

Vascular calcifications seen on mammography: an independent factor indicating coronary artery disease

PURPOSE: Establish a relationship between vascular calcifications seen via mammography and coronary artery disease, estimate the risk ratios, and investigate the interrelationships between vascular calcification and other risk factors for coronary artery disease. MATERIALS AND METHODS: This was a case-control study consisting of 40 women with coronary artery disease in the case group and 40 women without any history of coronary artery disease in the control group who were matched according to age. The study was approved by the Institution's Research Ethics Committee (consent statement was obtained). Odds ratios and confidence intervals were calculated using univariate analysis. Interrelationships among other risk factors, such as arterial hypertension, dyslipidemia, smoking and diabetes mellitus, were calculated using multivariate analysis. A p <0.05 was considered to be significant for statistical analysis. RESULTS: The mean ages for the case and control groups were 64.65 years and 63.88 years, respectively. In multivariate analysis, the only variables related to coronary artery disease were Vascular calcification [OR 4.71 (CI 1.36-16.33) p=0.014], family history [OR 5.76 (CI 1.58-21.03) p=0.008] and arterial hypertension [OR 15.92 (CI 3.12-81.14) p=0.001]. Although smoking and diabetes are important variables in the pathogenesis of coronary artery disease, these factors did not show statistically significant associations in this sample. CONCLUSION: The presence of vascular calcifications seen via mammography was an independent risk factor for coronary artery disease, as were hypertension and a family history of coronary artery disease.

Monocitose é um marcador de risco independente para a doença arterial coronariana / Monocytosis is an independent risk marker for coronary artery disease

OBJETIVOS: Inflamação e ativação das células do sistema imunológico têm participação importante na patogênese da aterosclerose. Este estudo analisa o leucograma que incluiu neutrófilos, eosinófilos, linfócitos, monócitos e basófilos dos pacientes com doença arterial coronariana (DAC) crônica e no infarto agudo do miocárdio (IAM). MÉTODOS: Analisamos o leucograma de 232 pacientes não-diabéticos, com idade entre 15 e 88 anos. A DAC estava presente em 142 pacientes (57 com DAC estável e 85 com IAM), diagnosticada angiograficamente, comparada a 90 indivíduos-controle. Os grupos controle e DAC foram comparáveis para a idade, índice de massa corpórea, antecedentes familiares, tabagismo, hipertensão, HDL e LDL (todas variáveis com p > 0,25). RESULTADOS: A análise univariada mostrou maior prevalência de leucocitose na DAC, sendo maior nos pacientes com IAM quando comparados com a DAC estável. O mesmo comportamento foi observado para os monócitos. Porém, a distribuição foi semelhante para as demais células do hemograma. A análise multivariada pelo método da regressão logística, utilizando-se os modelos stepwise (todas variáveis) e backward (p < 0,25), mostrou que a monocitose foi variável independente para DAC e para o IAM. CONCLUSÃO: O número de monócitos, um dos mais importantes componentes do processo inflamatório na placa aterosclerótica, foi um marcador de risco independente para a DAC e para o IAM.

Aspectos psicológicos na prevenção da aterosclerose na infância e na adolescência / Psychological aspects of preventing atherosclerosis in children and adolescents

A aterosclerose na infância e na adolescência, freqüentemente associada à obesidade, tem sido o foco de estudos internacionais que procuram entender a sua ontogênese. Devido às graves conseqüências possíveis, a aterosclerose na infância e na adolescência não só demanda ações preventivas multidisciplinares capazes de reduzir os fatores de risco já amplamente identificados, como obesidade, hipercolesterolemia familiar, tabagismo e sedentarismo, dentre outros, mas também clama pelo controle de fatores não tão claramente identificados, mas que podem contribuir para a sua patogênese. Dentre as variáveis ainda pouco conhecidas, que poderiam estar envolvidas na ontogênese da aterosclerose, encontram-se os fatores psicológicos e o stress emocional. Neste artigo, os autores versam sobre os aspectos psicológicos envolvidos na prevenção da aterosclerose e enfatizam a necessidade de uma mudança acentuada de estilo de vida, tanto no que se relaciona às atividades físicas e nutricionais como também às relacionadas às medidas anti-stress. Hábitos inadequados utilizados como estratégias de enfrentamento do stress emocional excessivo, como comer em excesso, entre outros, devem ser objeto de medidas preventivas na infância e na adolescência, visando substituí-los por estratégias de coping adequadas que reduzam o risco envolvido. Profissionais da área da saúde devem estar alertas para esses fatores subjacentes que podem contribuir para o desenvolvimento da doença aterosclerótica. Este trabalho foi compilado durante as discussões para a elaboração das I Diretrizes de Prevenção da Aterosclerose na Infância e na Adolescência e serviu de base para as recomendações incluídas na seção denominada "Aspectos Psicológicos na Prevenção da Aterosclerose" das Diretrizes.

Childhood and adolescent atherosclerosis, frequently associated with obesity, has been the focus of international studies that try to understand its development. Given its serious consequences, childhood and adolescent atherosclerosis not only demands multidisciplinary preventive actions that are capable of reducing the already very well identified risk factors, such as obesity, smoking, inactivity and familial hypercholesterolemia - just to mention some - but also calls for the control of factors that have not been clearly identified but that can contribute to its pathogenesis. Psychological factors and emotional stress are among the variables that are not yet fully known but nevertheless could be involved in the development of atherosclerosis. In this article, the authors discuss the psychological aspects involved in the prevention of atherosclerosis and emphasize the need for a dramatic change in lifestyle, which includes changing the levels of physical activity and eating habits and finding ways to fight or avoid stress. Inadequate habits employed as strategies to cope with excessive emotional stress, such as binge eating and others, should be targeted for preventive actions in childhood and adolescence and substituted by adequate coping strategies that have lower levels of risk. Health care professionals need to be watchful for these additional factors that can contribute to the development of atherosclerotic disease. This work was compiled during the discussion phase of the "I Guideline for Preventing Atherosclerosis in Childhood and Adolescence" and served as the basis for the recommendations included in its "Psychological Aspects in Preventing Atherosclerosis" section.

Calcificações vasculares na mamografia: achado insignificante ou indicador de doenças crônicas? / Vascular calcifications on mammography: insignificant findings of indication of chronic diseases?

A mamografia é um exame complementar de grande importância para o rastreamento do câncer de mama, sendo recomendada prioritariamente para mulhres após os 50 anos. Essa faixa etária também está relacionada a um risco mais alto de desenvolvimento de doença cardiovascular, responsável por altos índices de morbimortalidade entre as mulheres. As calcificações vasculares mamária são freqüentemente vistas nas mamografias, porém ainda não se sabe claramente a patogênese entre as calcificações vasculares mamárias e as doenças coronarianas. Neste trabalho foi feita uma revisão mostrando a ligação epidemiológica existente entre doenças como coronariopatias e diabetes com as calcificações vasculares vistas à mamografia.

Mammography is of great importance for breast cancer screening and is mainly recommended for women older than 50 years old. This age group is also related to a larger risk of development of coronary diseases, which are responsible for the high morbidity and mortality rates among women. The mammary vascular calcifications are frequently seen in mammography, however, so far there is no clear evidence relating the pathogenesis of mammary vascular calcifications and coronary diseases. In this article a literature search was performed showing the epidemiological link between systemic diseases such as coronary diseases and diabetes with mammary vascular calcifications.