Numerical values and impact of hypertension in Spain.

In Spain, 33% of adults aged 30 to 79 years (10 million) were hypertensive in 2019. Among them, 68% were diagnosed, 57% received drug therapy, and effective therapeutic coverage (control) reached 33%. Both diagnosis and control show geographical and social disparities. Approximately 46 000 cardiovascular deaths per year are attributable to hypertension. In recent decades, the control of hypertension has increased, due to improvements in lifestyle measures and increased use of polytherapy, coinciding with a reduction in stroke mortality. There are several modifiable determinants of the lack of hypertension control: a) white-coat phenomenon affects 22% to 33% of treated individuals, partly due to the limited availability of ambulatory blood pressure monitoring (ABPM) (49%) and self-measured BP (SMBP) (78%); b) inadequate patient adherence to medication and healthy lifestyles (weight loss, the most effective measure, is the least used, ≈40%); and c) insufficient use of polytherapy (≈55%). The remaining challenges include: a) technological aspects, such as measuring BP with more accurate techniques (ABPM, SMBP) and using cardiovascular-risk estimation tools (eg, SCORE); b) clinical challenges, such as reducing therapeutic inertia (≈59%), involving patients in their own management (medication adherence, ≈62%) and effectively implementing clinical guidelines); and c) public health challenges, such as reducing the burden of obesity (≈24%), monitoring progress with updated surveys, and setting national BP control targets.

Safety and Efficacy of Botulinum Toxin in the Treatment of Self-Biting Behavior in Lesch-Nyhan Disease.

BACKGROUND: Lesch-Nyhan disease (LND) is a disease of purine metabolism linked to chromosome X due to the absence or near-absence of enzyme hypoxanthine-guanine phosphoribosyltransferase. Patients with LND have a compulsive autoaggressive behavior that consists of self-mutilation by biting. METHODS: The objective of this study was to explore the safety and efficacy of botulinum toxin (BoNT) injected into the masticatory muscles and biceps brachii to reduce self-mutilation in patients with LND. We retrospectively analyzed six patients with LND who were treated with BoNT to prevent automutilatory behavior. RESULTS: The patient ages when started on treatment with BoNT were 4, 4.5, 6.6, 7.9, 13.9, and 32.3 years. Patients received a mean number of injections of 20, ranging from 3 to 29, over a period that ranged from 1.5 to 7.1 years. The maximum total dose of Botox was 21.3 units/kg mean and the maximum total dose of Dysport was 37.5 units/kg mean. A total of 119 injections were performed. Of these 113 (95%) were partially or completely effective. Only three of 119 injections (2.5%) produced adverse effects. CONCLUSIONS: Botulinum toxin is useful and safe for the treatment of self-biting behavior in patients with LND.

Frequency and Prognosis of Treated Hypertensive Patients According to Prior and New Blood Pressure Goals.

United States and European guidelines have recommended new treatment goals for office blood pressure (BP). We examined 9784 hypertensives of the Spanish Ambulatory BP Monitoring (ABPM) registry with office BP treated to the prior goal (<140/90 mm Hg); and evaluated the frequency and all-cause mortality of 4 BP strata depending on whether or not they attained more conservative or new office BP goal (130-139/80-89 and <130/80 mm Hg, respectively) and whether or not BP was controlled according to ABPM criteria in the European and US guidelines (24-hour ambulatory BP <130/80 and <125/75 mm Hg, respectively). Whether achieving or not the new office BP goal, the total-mortality risk during a 5-year follow-up was only significantly higher than the reference (normal office BP and ABPM) when 24-hour ambulatory BP was above goal (hazard ratio from multivariable Cox models was in the range of 2.4-2.9; P<0.001). The frequency of patients achieving the new office BP goal was 34.4%, and the frequencies of those not achieving the ABPM goal were 31.6% and 53.7% using the 130/80 or the 125/75 ABPM goal, respectively. Mean office systolic BP was 129 mm Hg for patients not achieving the ABPM goal. In hypertensive patients controlled under prior office BP goal, the frequency of those achieving new office BP goal <130/80 was high, suggesting this goal can be attained. In addition, patients had a higher mortality risk only when ABPM was above goal despite having mean office systolic BP under control, a condition that was also common.

Home blood pressure vs. clinic blood pressure measurement-based follow up in type ii diabetics: Effect on 24-h ambulatory BP and albuminuria. Randomised trial. / Automedición en el domicilio frente a lectura de la presión arterial en la consulta en el seguimiento de diabéticos tipo ii: efecto sobre la presión arterial ambulatoria y la albuminuria. Estudio aleatorizado.

BAKGROUND AND OBJECTIVE: To compare the efficacy of two strategies of blood pressure (BP) measurement-based follow-up in hypertension and albuminuria control. PATIENTS AND METHODS: Multicentre, prospective, randomised, open trial with a parallel-group design. Nineteen primary care centres and a hospital clinic participated. Adult type 2 diabetics with systolic BP ≥140mmHg without relevant renal disease were randomised to one of two follow-up strategies: 1) standard follow up, with a clinic BP target <140/90mmHg and 2) self-monitoring home BP (SMHBP)-based follow up, with a BP target <135/85mmHg. Biochemical standard blood variables, albuminuria, and 24-h ambulatory BP monitoring were performed at entry, 12 and 24 months. The main outcome measurement was 24-h ambulatory systolic BP variation. Albuminuria change was analysed as a secondary outcome. RESULTS: 116 patients were analysed (mean age: 66.8 years). Mean systolic ambulatory 24- h BP change in two years was 3.9mmHg (95% CI 1.8-6.1). We did not find significant differences between both groups (p=0.706). Similarly, no differences were found when we compared other ambulatory BP values. Initial albuminuria was similar in both groups and did not significantly changed throughout the follow-up period. CONCLUSION: In type 2 diabetics without relevant nephropathy a SMHBP- based follow up was equivalent to a standard clinic-based BP follow up in BP and albuminuria control.

Atherosclerosis as a potential pitfall in the diagnosis of giant cell arteritis.

OBJECTIVES: To explore whether the increase in the intima-media thickness (IMT) in arteriosclerotic disease correlates with the increase in the IMT in temporal arteries (TAs) and if that could mimic the US GCA halo sign. METHODS: Consecutive patients ⩾50 years old with high vascular risk and without signs or symptoms of GCA were included. The carotid US IMT measurements were obtained using a standardized software radiofrequency-tracking technology. Colour Doppler US and grey-scale measurements of the IMT in the branches of both TAs were performed by a second sonographer using a 22 MHz probe. RESULTS: Forty patients were studied (28 men) with a mean age of 70.6 years. The carotid IMT exhibited significant correlation with the TA IMT. A carotid IMT >0.9 mm was associated with a temporal IMT >0.3 mm. Only one patient had an IMT >0.34 mm in two branches. CONCLUSIONS: Atherosclerotic disease with a carotid IMT >0.9 mm increases the TA IMT and might mimic the halo sign. As atherosclerosis is common in this age group, we propose a cut-off of TA IMT >0.34 mm in at least two branches to minimize false positives in a GCA diagnosis.

Clinic Versus Daytime Ambulatory Blood Pressure Difference in Hypertensive Patients: The Impact of Age and Clinic Blood Pressure.

Clinic blood pressure (BP) is usually higher than daytime ambulatory BP in hypertensive patients, but some recent studies have challenged this view, suggesting that this relationship is strongly influenced by age. We used the Spanish ambulatory BP monitoring cohort to examine differences between clinic and daytime BP by age among 104 639 adult hypertensive patients (office systolic/diastolic BP ≥140/90 mm Hg or treated) in usual primary-care practice, across the wide age spectrum. To assess the impact of age, cardiovascular variables, and clinic BP on the clinic-daytime BP differences, we built multivariable regression models of the average BP differences, white-coat hypertension (high clinic BP and normal daytime BP), and masked hypertension (normal clinic BP and high daytime BP). In most patients, mean clinic BP values were higher than daytime BP at all ages. Some 36.7% of patients had white-coat hypertension (amounting to 50% at clinic systolic BP of 140-159 mm Hg) and 3.9% had masked hypertension (amounting to 18% at clinic systolic BP of 130-139 mm Hg). Age explained 0.1% to 1.7% of the variance of quantitative or categorical BP differences (P<0.001). Cardiovascular variables explained an additional 1.6% to 3.4% of the variance (P<0.001). Finally, clinic BP generally explained ≥20% more of the variance (P<0.01). In this large study in usual clinical practice, clinic BP misclassified hypertension status in >40% of patients. This misclassification was not importantly influenced by age but was more evident in patients with borderline/grade 1 hypertension. These findings reinforce the importance of ambulatory BP monitoring for defining BP status in routine clinical practice.

Influence of immune activation and inflammatory response on cardiovascular risk associated with the human immunodeficiency virus.

Patients infected with the human immunodeficiency virus (HIV) have an increased cardiovascular risk. Although initially this increased risk was attributed to metabolic alterations associated with antiretroviral treatment, in recent years, the attention has been focused on the HIV disease itself. Inflammation, immune system activation, and endothelial dysfunction facilitated by HIV infection have been identified as key factors in the development and progression of atherosclerosis. In this review, we describe the epidemiology and pathogenesis of cardiovascular disease in patients with HIV infection and summarize the latest knowledge on the relationship between traditional and novel inflammatory, immune activation, and endothelial dysfunction biomarkers on the cardiovascular risk associated with HIV infection.

High prevalence of masked uncontrolled hypertension in people with treated hypertension.

AIM: There are limited data on the quality of treated blood pressure (BP) control during normal daily life, and in particular, the prevalence of 'masked uncontrolled hypertension' (MUCH) in people with treated and seemingly well-controlled BP is unknown. This is important because masked hypertension in 'treatment naïve' patients is associated with a high risk of cardiovascular events. We therefore conducted the first study to define the prevalence and characteristics of MUCH among a large sample of hypertensive patients in routine clinical practice in whom BP was treated and controlled to recommended clinic BP goals. METHODS AND RESULTS: We analysed data from the Spanish Society of Hypertension ambulatory blood pressure monitoring (ABPM) Registry and identified patients with treated and controlled BP according to current international guidelines (clinic BP <140/90 mmHg). Masked uncontrolled hypertension was diagnosed in these patients if despite controlled clinic BP, the mean 24-h ABPM average remained elevated (24-h systolic BP ≥130 mmHg and/or 24-h diastolic BP ≥80 mmHg). From 62 788 patients with treated BP in the Spanish registry, we identified 14 840 with treated and controlled clinic BP, of whom 4608 patients (31.1%) had MUCH according to 24-h ABPM criteria (mean age 59.4 years, 59.7% men). The prevalence of MUCH was significantly higher in males, patients with borderline clinic BP (130-9/80-9 mmHg), and patients at high cardiovascular risk (smokers, diabetes, obesity). Masked uncontrolled hypertension was most often because of poor control of nocturnal BP, with the proportion of patients in whom MUCH was solely attributable to an elevated nocturnal BP almost double that solely attributable to daytime BP elevation (24.3 vs. 12.9%, P < 0.001). CONCLUSION: The prevalence of masked suboptimal BP control in patients with treated and well-controlled clinic BP is high. Clinic BP monitoring alone is thus inadequate to optimize BP control because many patients have an elevated nocturnal BP. These findings suggest that ABPM should become more routine to confirm BP control, especially in higher risk groups and/or those with borderline control of clinic BP.

[Sugar and cardiovascular disease]. / Azúcar y enfermedades cardiovasculares.

Cardiovascular diseases are the leading cause of death in the Spanish population and may be a relationship between the prevalence of these and excessive sugar consumption. In recent years, researchers have focused on the properties of these nutrients. Although there are many studies examining this association, the results are not unanimous. In any case there is sufficient basis for designing public health strategies in order to reduce the consumption of sugary drinks as part of a healthy lifestyle. Therefore, the question we address is: sugar intake in abundant amounts, is associated with a higher risk of cardiovascular disease? We use as the focus of the discussion SAFO analysis model.

Las enfermedades cardiovasculares constituyen la principal causa de muerte en la población española y podría existir una relación entre la prevalencia de las mismas y el consumo excesivo de azúcar. En estos últimos años, los investigadores se han centrado en las propiedades de estos nutrientes. Aunque existen muchos estudios que analizan dicha asociación, los resultados no son unánimes. En cualquier caso, existe fundamento suficiente para diseñar estrategias de salud pública de cara a reducir el consumo de bebidas azucaradas, como parte de un estilo de vida saludable. Por lo tanto, la cuestión que abordamos es: ¿la ingesta de azúcar, en cuantía abundante, se asocia un mayor riesgo de padecer enfermedad cardiovascular? Para ello utilizamos como eje de la discusión el modelo de análisis DAFO.

Safety and efficacy of aliskiren/amlodipine/hydrochlorothiazide triple combination in patients with moderate to severe hypertension: a 54-week, open-label study.

Combination antihypertensive therapies are recommended to attain blood pressure (BP) targets especially in high-risk patients in whom rapid and pronounced BP control is essential. This 28- to 54-week, open-label, multicenter study evaluated the safety and efficacy of a triple combination, aliskiren with amlodipine and hydrochlorothiazide (HCTZ), in patients with moderate to severe hypertension. Following a washout period of up to 4 weeks, patients received aliskiren/HCTZ 300/12.5 mg for 1 week, followed by add-on amlodipine 5 mg for 1 week. Thereafter, the doses of amlodipine and HCTZ were doubled. The first 206 of 564 patients who completed 28 weeks of study continued for an additional 26 weeks. Safety was assessed by recording all adverse events. Efficacy variables included changes in BP from baseline to endpoint and BP control rate. Of 564 patients, 493 completed the study. Peripheral edema (9.4%), headache (5.7%), nasopharyngitis (4.1%), and bronchitis (3.7%) were reported frequently. Clinically significant reductions in mean sitting systolic BP/mean sitting diastolic BP from baseline (-34.2/-20.3 mm Hg and -37.3/-21.8 mm Hg at weeks 28 and 54, respectively) were observed. Corresponding BP control rates were 69.1% and 77.1%. The aliskiren/amlodipine/HCTZ combination in patients with moderate to severe hypertension was well tolerated and provided clinically significant BP reductions and effective BP control.

Knowledge of stroke warning symptoms and intended action in response to stroke in Spain: a nationwide population-based study.

BACKGROUND: Worldwide thrombolysis rates remain suboptimal. Ambulance transfer is associated with greater use of this time-dependent treatment. Information on public awareness of stroke symptoms is important for planning effective education programs to promote calling of emergency services for suspected stroke. However, there is a paucity of data on this subject in European countries. Our objectives were to explore the recognition of stroke symptoms, awareness of the need to activate the emergency medical services for acute stroke events, and the association between knowledge of warning symptoms and intent to call for an ambulance among a sample representative of the adult population of Spain. This is the largest study on this subject to date in Europe. METHODS: The data were taken from the Study on Nutrition and Cardiovascular Risk in Spain, a cross-sectional study conducted in a sample representative of the Spanish noninstitutionalized population aged ≥18 years in 2008-2010. Study participants were selected by multistage clustered random sampling. The households within each section were selected by random telephone dialing using the landline telephone directory as the sampling frame. Subjects in the households were selected proportionally to the distribution of the population of Spain by sex and age. The study included a computer-assisted telephone interview on stroke symptom knowledge and the first action to perform in a stroke event, based on the American Heart Association and American Stroke Association recommendations, and two home visits to perform a physical examination and to obtain blood samples. RESULTS: Among 11,827 adults, 7,711 (65.2%; 95% CI = 64.1-66.3) identified 4-6 stroke warning symptoms, considered as adequate knowledge. A total of 1,348 (11.4%) were unable to classify any of the symptoms correctly. In the multivariate analysis, higher education was significantly associated with better knowledge of symptoms, and age ≥65 years, fair/poor self-rated health, history of obesity and known diabetes were significantly associated with less knowledge of stroke symptoms. One in 5 individuals indicated they would do something other than calling for an ambulance if they thought someone was having a stroke. The number of specific stroke warning symptoms known was directly associated with the intent to call an ambulance in a stroke event (OR adjusted for sociodemographic and clinical variables = 1.06 per symptom, 95% CI = 1.03-1.09; p < 0.001). CONCLUSIONS: In this population-based study, stroke symptom knowledge was suboptimal and only modestly associated with the intent to call for an ambulance. Educational interventions are needed to link stroke recognition more strongly to an immediate need to call for an ambulance in order to increase stroke patients' access to thrombolysis.

Evaluation of the usefulness of a low-calorie diet with or without bread in the treatment of overweight/obesity.

BACKGROUND & AIMS: Despite the lack of scientific evidence, bread is one of the most restricted foods in popular hypocaloric diets. The aim of this study was to compare two nutrition strategies (with or without bread) designed to promote weight loss in overweight/obese women. METHODS: A clinical, prospective and randomised study in which 122 women >18 years, BMI ≥ 25 < 40 kg/m(2) were divided into two groups: intervention group (BREAD, n = 61) and control group (NO BREAD, n = 61). Both groups received a low-calorie diet (with or without bread), nutrition education and physical activity guidelines, and were monitored for 16 weeks. RESULTS: 104 women completed the study (48.4 ± 9 years, 29.8 ± 3.5 kg/m(2)). Anthropometric and biochemical markers improved after the intervention without significant differences between groups. BREAD group significantly increased total cereal consumption (3.2 ± 1.3 to 3.7 ± 0.5 servings/day, P < 0.05) and the percentage of energy from carbohydrates (41.2 ± 6.4 vs. 45.9 ± 5.0% P < 0.001) and reduced fat (39.0 ± 6.6 vs. 32.7 ± 5.1% P < 0.001). In contrast, NO BREAD group increased the discrepancy with recommended consumption. NO BREAD group had the most dropouts (21.3% vs. 6.6%, P < 0.05). CONCLUSION: The bread inclusion in a low-calorie diet designed for weight loss favoured a better evolution of dietetic parameters and greater compliance with the diet with fewer dropouts. Registered under ClinicalTrials.gov Identifier no. NCT01223989.

[Prevalence of diabetes in an adult population in the region of Madrid (Spain). The Madrid Cardiovascular Risk study]. / Prevalencia de diabetes en una población adulta de Madrid (España). Estudio MADRIC (MADrid RIesgo Cardiovascular).

OBJECTIVE: To estimate the prevalence of diabetes mellitus and impaired fasting glycemia in an adult population living in Madrid (Spain). METHODS: In this cross-sectional, population-based survey, we studied 1,344 adults aged 31-70 years, randomly selected from the population living in 14 primary care districts of the Madrid region. All participants underwent a clinical evaluation that included a clinical interview, physical examination and fasting blood analysis (glycemia, cholesterol and triglyceride levels). The participants were considered to be diabetic if they had been previously diagnosed with diabetes by their general physician or had a fasting glycemia ≥ 126 mg/dl without a previous diabetes diagnosis. Impaired fasting glycemia was defined as fasting glycemia between 100mg/dl and 125 mg/dl in non-diabetic participants. RESULTS: The sex- and age-adjusted prevalence figures for diabetes and impaired fasting glucose were 6.6% (95% CI: 5.9-8.7) and 14.1% (95% CI: 12.1-15.8), respectively. A substantial proportion of diabetic patients [17.2% (95% CI: 10.9-23.5)] had not been previously diagnosed. The variables independently associated with diabetes were age, male gender, abdominal obesity and hypertension. CONCLUSIONS: Our prevalence figure for diabetes is similar to those reported in other Spanish regions. The high frequency of impaired fasting glucose is worrisome, particularly when combined with obesity, as this association confers a high risk for developing diabetes mellitus.

[Report of the editors, 2010]. / Informe de los Editores, 2010.

The Editors of the Rev Clin Esp inform herein on their editorial activity in the last year (November 2009 to October 2010) according to three different sections: (a) Objectives and achievements during 2010, (b) editorial activity, and (c) objectives for 2011. During 2010, we have updated the editorial algorithm (manuscript time lag). We have developed the "E-case reports" section and we have linked the abstracts of the Annual Congress of the Spanish Society of Internal Medicine (SEMI) to a journal supplement (electronically available). Since 2010, the subscribers have been able to receive all of the contents of the Rev Clin Esp on-line and to perform self-evaluations in order to obtain 1.7 credits per each journal issue (continuing education). In 2010 we handled 402 manuscripts (7.2% more than in 2009), 35% of which were accepted for publication. We asked 186 reviewers for their expert opinion, 75% of whom sent their reports in less than two weeks. The mean time needed to reach an editorial decision concerning original manuscripts ("accepted / rejected") was 44.5 days and for papers not sent to external reviewers 19.5 days. Collaboration with the work groups produced good results (2.4 published manuscripts per issue), but this could be improved if all the groups collaborated in all the journal sections. Our objectives for 2011 are to complete the renewal of the Rev Clin Esp scientific committee, in accordance with the SEMI Council, and to continue to proceed with the actions initiated to increase the journal impact factor. Rev Clim Esp is an open forum for all internal medicine specialists. Responsibility falls on all of us to collaborate in order to make our journal a little better day by day.

[Variant phenotype of Lesch-Nyhan syndrome]. / Fenotipo variante del síndrome de Lesch-Nyhan.

BACKGROUND AND OBJECTIVE: Lesch-Nyhan syndrome (LNS) and LNS variants are due to mutations in the HPRT1 gene causing HPRT enzymatic activity deficiency. We report a patient presenting a variant phenotype and a major genetic defect. The mutation has been previously reported as always associated with complete Lesch-Nyhan phenotype. PATIENT AND METHODS: We analyzed the presence of complete HPRT mRNA in this patient, in two patients with the complete Lesch Nyhan syndrome phenotype, and in control subjects. RESULTS: We found a minor amount of normal HPRT mRNA in the present patient but also in the two patients with splice mutation and the complete Lesch Nyhan syndrome phenotype. CONCLUSIONS: To our knowledge, this patient is the first report of a major genetic defect, with no detectable enzymatic activity, and a partial HPRT deficiency phenotype. Our results question the hypothesis of a normally spliced HPRT cDNA as the sole cause of the patient partial phenotype.