[Decreased glomerular filtration rate using the Cockckroft-Gault and MDRD formulas does not always predict cardiovascular morbidity and mortality in hypertensive primary care patients]. / El filtrado glomerular reducido según las fórmulas de Cockcroft-Gault y MDRD no siempre predice la morbimortalidad cardiovascular en los pacientes hipertensos atendidos en atención primaria.

BACKGROUND: A decrease in renal function is associated with cardiovascular morbidity and mortality. The aim of this study was to analyse the association of cardiovascular morbidity and mortality with baseline glomerular filtration rate (GFR), calculated according to the Cockcroft-Gault and MDRD formulas, with the incidence of major adverse cardiovascular events (MACEs) in a cohort of hypertensive individuals followed for 12 years. METHOD: We performed a prospective study of a random sample of 223 hypertensive patients free of MACEs, who were followed in an urban Primary Care Centre. GFR was estimated using both formulas. MACEs were considered as the onset of ischaemic heart disease, heart failure, heart attacks, peripheral vascular disease or cardiovascular death. Data were analysed using the life-table method and Cox regression modeling. RESULTS: The median follow-up was 10.7 (interquartile range, 6.5-12.1) years. Follow-up was completed in 191 participants (85.7%). The cumulative survival was 64.7% (95% Confidence Interval (CI), 57.9-71.6). The incidence of MACEs during the follow-up period was 3.6 (95% CI, 2.7-4.4) per 100 subject-years. The final multivariable model showed that the most predictive variables of MACEs in the study population were the presence of diabetes mellitus and the estimation of GFR ≥60 ml/min/1.73 m2 by MDRD equation. CONCLUSIONS: There was a relationship between the occurrence of MACEs and an estimated GFR by MDRD above 60 ml/min/1.73 m2 at study entry, inversely to what was expected. GFR estimated by the C-G formula was not associated with cardiovascular risk.

Right bundle branch block: Prevalence, incidence, and cardiovascular morbidity and mortality in the general population.

Background: Right bundle branch block (RBBB) is among the most common electrocardiographic abnormalities. Objectives: To establish the prevalence and incidence of RBBB in the general population without cardiovascular events (CVE) and whether RBBB increases cardiovascular morbidity and mortality compared with patients with a normal electrocardiogram (ECG). Methods: A historical study of two cohorts including 2981 patients from 29 primary health centres without baseline CVE. Cox (for CVE) and logistic (for cardiovascular factors) regression was used to assess their association with RBBB. Results: Of the patients (58% women; mean age 65.9), 92.2% had a normal ECG, 4.6% incomplete RBBB (iRBBB) and 3.2% complete RBBB (cRBBB). Mean follow-up was five years. Factors associated with appearance of cRBBB were male sex (HR = 3.8; 95%CI: 2.4-6.1) and age (HR = 1.05 per year; 95%CI: 1.03-1.08). In a univariate analysis, cRBBB was associated with an increase in all-cause mortality but only bifascicular block (BFB) was significant after adjusting for confounders. cRBBB tended to increase CVE but the results were not statistically significant. Presence of iRBBB was not associated with adverse outcomes. Patients with iRBBB who progressed to cRBBB showed a higher incidence of heart failure and chronic kidney disease. Conclusion: In this general population cohort with no CV disease, 8% had RBBB, with a higher prevalence among men and elderly patients. Although all-cause mortality and CVE tended to increase in the presence of cRBBB, only BFB showed a statistically significant association with cRBBB. Patients with iRBBB who progressed to cRBBB had a higher incidence of CVE. We detected no effect of iRBBB on morbidity and mortality.

[Determination of arm circumference for correct measurement of blood pressure. Results of an intervention study]. / La determinación del perímetro braquial para una adecuada medida de la presión arterial. Resultados de un estudio de intervención.

OBJECTIVE: To assess the effectiveness of an intervention to promote standardized arm circumference measurement as way to choose appropriate cuff size to measure blood pressure. PATIENTS AND METHODS: A before-after intervention study was performed in a basic health care area in Barcelona. Doctors, nurses and pharmacy staff participated by filling out an anonymous self-administered questionnaire pre- and post-intervention (3m). Variables included: demographics, type of professional, years since they finished their studies, availability of different cuff sizes, if arm circumference measurement were obtained or not, knowledge about the cutoff values for each cuff size and type of blood pressure monitor. INTERVENTION: The written results were given to the participants and presented in sessions. RESULTS: Pre- and post-intervention: 74.3 and 67.3% answered the questionnaires (P=ns), respectively. Determination of arm circumference varied from 1.3 to 19.1% (P=.009). A total of 37.3% and 44.1% declared that they had 2 or more available cuff sizes (P=ns). Knowledge about the correct measurement of the cuffs was 2.7 to 33.8% regarding the standard cuff size (P=.0198) and 0 to 23.5% for obese subjects (P<.05). When more than one cuff was available, reasons for the choice went from: «making a rough guess¼ or «when velcro stops sticking¼ before and after the intervention. All blood pressure devices in our primary health care center were electronic and automatic as were those of the 9 pharmacies. CONCLUSION: The intervention increased the determination of arm circumference prior to the reading of the blood pressure and the knowledge about the cutoff interval for standard and obese cuff size after intervention. There was greater availability of different sized cuffs. Despite this, the choice of the appropriate cuff size was not made based on arm circumference.

[Knowledge level of hypertensive patients about hypertension. Relationship between knowledge level and hypertension control]. / Estudio Conocimiento: grado de conocimiento sobre hipertensión arterial de nuestros pacientes. Relación con el nivel de control de la misma.

OBJECTIVE: To assess the knowledge of the hypertensive patients about their hypertension and their relation to its control. MATERIAL AND METHODS: Cross-sectional study among 400 hypertensive patients, all over 18 years, selected from 50 primary-care centres, who responded to an hypertension-related survey. Included variables were survey items, age, gender, educational level, professional occupation, blood pressure data and antihypertensive treatment. The obtained differences were analyzed using the chi-square test, Kruskal-Wallis, Wilcoxon, Anova and Bonferroni methods. RESULTS: There were 323 valid surveys. 52.9% of respondents were women, the average age: 65.4 years (SD: 11.2), 54.8% of them had primary education. 39.6% were aware of the objectives of systolic BP control. Only 19.6% having knowledge of those for diastolic BP control, with no differences between controlled and uncontrolled (systolic BP: 39% vs 38.1%, P=.887; diastolic BP: 19.2% vs 21%, P=.721). Over 70% knew about lifestyle changes, without significant differences between controlled and uncontrolled respondents. 82% of controlled respondents, and 79% of those uncontrolled, recognized the chronical nature of the treatment (P=.548), but 15.1% of the controlled respondents and 12.4% of uncontrolled respondents did not see the relation between the treatment and hypertension control (P=.525). 31.1% believed to be well-controlled, but in fact was not. CONCLUSIONS: Our patients doesn't know blood pressure targets of control. There isn't relationship between this knowledge and control of hypertension.

[Effectiveness of self-monitoring of blood pressure in white coat hypertension diagnosis. Rationale and design]. / Efectividad de la automedida de la presión arterial en el diagnóstico de la hipertensión clínica aislada. Justificación y diseño del estudio.

OBJECTIVE: To assess the effectiveness of blood pressure self-monitoring at home in front of 24-h blood pressure ambulatory measurement in isolated clinical hypertension diagnosis. DESIGN: Comparative study of repeated measurements of self-monitoring home BP and 24-h ambulatory BP measurement in a hypertensive patients sample. SETTING AND SUBJECTS TO STUDY: Mild-moderate essential hypertensive patients newly diagnosed or previously diagnosed in which suspect isolated clinical hypertension (BP>140/90 mm Hg in clinical setting repeatedly). It needs a sample of 182 hypertensive patients seen at urban primary health care. PRINCIPAL MEASUREMENTS: We compute the isolated clinical hypertension prevalence, the sensibility, specificity and positive and negative predictive values, with 95% confidence intervals. DISCUSSION: Prove the effectiveness of blood pressure self-monitoring at home in insolated clinical hypertension diagnosis, can involve an important cost saving for health care system as in hypertensive patient management (medicines and office visits), as in diagnosis equipment.

[The DISEHTAC II study: diagnosis and follow-up of hypertension in Catalonia. comparison with 1996 data]. / Estudio DISEHTAC II: diagnóstico y seguimiento de la hipertensión arterial en Cataluña. Comparación con los datos de 1996.

OBJECTIVE: To evaluate the changes in the diagnosis and follow-up of hypertension, and in the evaluation of cardiovascular risk, in a population served by primary care centers in Catalonia (northeastern Spain). Management was evaluated with indicators published in the Guidelines for Hypertension for Primary Care (Guía de Hipertensión Arterial para la Atención Primaria). DESIGN: Multicenter, observational, before-after design (1996-2001). SETTING: Primary care. PARTICIPANTS: Twelve primary care centers chosen from among the 31 centers that took part in the DISEHTAC I study (1996), with a total of 990 patient records. MAIN MEASURES: We analyzed age, sex, date of diagnosis of hypertension, number of blood pressure measurements needed for diagnosis, use of the mean value of duplicate blood pressure determinations, values for all blood pressure measurements in 2001, blood pressure determinations during the preceding 6 months, screening for and diagnosis of diabetes, dyslipidemia, smoking, obesity, and left ventricular hypertrophy. RESULTS: Of the 171 new cases of hypertension, 16.7% were diagnosed from at least 3 duplicate blood pressure measurements or as a result of acute episodes of hypertension. About one third (32.4%) of the patients with hypertension had blood pressure values below 140 and 90 mm Hg (25.7% in 1996), and the difference between the 2 sets of survey results was statistically significant. In three fourths (75.4%) of the patients, blood pressure had been measured during the preceding 6 months; this percentage was not significantly different in comparison to the figure found in 1996. Screening to detect cardiovascular risk factors was done in 50.4% of the patients (63.1% in 1996). CONCLUSIONS: Follow-up for hypertension in Catalonia has improved notably since 1996, but there was no improvement in the diagnosis of risk factors or in the integral evaluation of cardiovascular risk.

[Diagnosis and follow-up of arterial hypertension: is the role of nursing staff relevant?]. / Diagnóstico y seguimiento de la hipertensión arterial: es relevante el papel del personal de enfermería?

OBJECTIVE: To determine the protagonism of the medical and nursing staff in the diagnosis and observation of hypertense patients in a primary care team. DESIGN: Cross-sectional descriptive study. SETTING: Urban primary care team. PARTICIPANTS: Two random samples, with 325 clinical histories, of the hypertense patients under observation in the centre in the years 1995 (N = 1992) and 1996 (N = 1994). MEASUREMENTS: The following variables were gathered on which professional had conducted the following: the blood pressure triple take (BPTT), physical examination (weight, height and peripheral pulses), request for further tests, health education on factors of cardiovascular risk (FCR), changes in life-style, anamnesis on side-effects in patients under medical treatment, and the number of attendances. The following details of patients were recorded: age and sex, body mass index, known time of hypertension evolution, blood pressure figures at the start and finish of the periods. MAIN RESULTS: 33 people in 1995 (10.2%; 95% CI, 6.8-13.4) and 8 people in 1996 (2.4%; 95% CI, 1-4.8) were diagnosed with hypertension. Average visits per professional in each year was 2.8 and 2.9 for nursing, and 1.5 and 1.8 for the doctor. There was a record of BPTT in 75.6% of cases, analysis request, ECG and full physical examination in 50.5% of cases, tackling CRF in 56.9%, recommendations on changes in life-style in 85.2%, and anamnesis on side-effects in 26.1%. It was basically nursing personnel who conducted BPTT (79.8% in 1996). 1995 saw greater CRF intervention by nursing staff (49.4%; 95% CI, 42.8-56.3) than by medical staff (15.3%; 95% CI, 10.3-19.9). In the second year the figures became 57.5% (95% CI, 50.9-64.2) against 12.3% (95% CI, 7.8-16.7). The interventions on life-style changes and anamnesis on possible side-effects were mainly conducted by nursing staff, at 66.2% (95% CI, 60.2-72.3) against doctors at 25.7% (95% CI, 20.2-31.3). CONCLUSIONS: The role of nursing staff is fundamental to the diagnosis and observance of hypertense patients in the primary care team.

[Validation of the quality of life questionnaire in arterial hypertension (HQALY) for its use in Spain. Relationship between clinical variables and quality of life. Investigator Group of the HQALY study]. / Validación del cuestionario de calidad de vida en hipertensión arterial (CHAL) para su uso en España. Relación entre variables clínicas y calidad de vida. Grupo de Investigadores del Estudio CHAL.

OBJECTIVE: To evaluate the measurement properties of the Hypertension Quality of Life (HQALY) questionnaire, under normal clinical practice conditions, and the relationship between quality of life and clinical variables in patients with hypertension. DESIGN: Observational, prospective and multi-centred study. SETTING: 92 primary care centres in Spain. PARTICIPANTS: 269 patients, of both sexes and over 17, with hypertension, stratified by age (18-44, 45-64 and over 64), sex and organic complaint. 106 individuals over 17 with normal tension were chosen at random. INTERVENTIONS: Intensification of treatment in hypertense patients. MEASUREMENTS: Administration of the HQALY and the EuroQol-5D at every attendance (patients, basal and at a month; controls, basal). In addition, at the basal attendance social-demographic and clinical features were recorded, and at the attendance at a month the clinical features and changes in health status. MAIN RESULTS: Mean time of administration was 28 (23) minutes. VALIDITY: factor analysis showed two dimensions, state of mind and somatic manifestations, which correlated most closely with the dimensions of anxiety/depression (0.64) and pain/discomfort (0.55) on the EQ-5D, respectively. HQALY scores were higher (worse quality of life) in patients than in controls without hypertension (p < 0.01). Reliability: intraclass correlation coefficient was 0.88 in state of mind and 0.76 in somatic manifestations. Cronbach's alpha was 0.96 and 0.89, respectively. Sensitivity: the "size of the effect" at a month from starting treatment for hypertension was 0.40. Hypertension for over 10 years, more organs affected, gravity and morbid obesity were associated with worse quality of life, especially in the state-of-mind dimension. Cardiac frequency correlated closer with state of mind than somatic manifestations. CONCLUSIONS: The HQALY is the first specific hypertension questionnaire developed in Spain which has been shown valid, reliable and sensitive to changes. However, the number of items on it must be reduced for routine use in clinical practice.

[Process indicators and result indicators in the control of arterial hypertension]. / Indicadores de proceso e indicadores de resultado en el control de la hipertensión arterial.

OBJECTIVE: To find whether better compliance with the indicators of procedure of a hypertension monitoring programme guarantees better control in the final blood pressure figures. DESIGN: Descriptive cross-sectional study. SETTING: Gòtic Area Health Centre, Barcelona. PATIENTS: Annual audit through random sampling of the computerised records of all the hypertense patients attended at the centre in each of 5 years (1992, n = 337; 1993, n = 318; 1994, n = 322; 1995, n = 325; 1996, n = 325). RESULTS: 1. Procedure indicators: complete physical examination took place in 1996 in only 12% of cases, proportion similar to at the start of the development of the programme (12.2%). Completion of at least two of the three records of protocols (complete physical examination, ECG and analysis) dropped during the period and did not cover half the patients. Screening of the various cardiovascular risk factors (CRF) increased markedly in the 1992-1995 period. 2. RESULTS INDICATORS: The proportion of patients under 66 with SP and DP < 140 and 99 mmHg went up from 23.2% in 1992 to 45.2% in 1996. In the over-65 age-group, it went from 58.9% in 1992 to 81.2% in 1996. CONCLUSIONS: The procedure indicators are still useful, in that they are necessary for designing a new hypertension programme. However, we must not forget that any health programme is designed in order to achieve good control and population impact (survival) results. The procedure is only an aid to reach these aims.

[Validation of a questionnaire for the diagnosis of urinary incontinence]. / Validación de un cuestionario para el diagnóstico de la incontinencia urinaria.

OBJECTIVE: To validate a questionnaire applied in the Primary Care (PC) clinic which enables urinary incontinence (UI) and its different types to be diagnosed. DESIGN: A descriptive crossover study. SETTING: A Urodynamics hospital out-patients clinic. PARTICIPANTS: Patients referred from PC to be tested for UI by Urodynamics. INTERVENTION: A self-filled questionnaire prior to the Urodynamics test to give a rough idea of the type of UI. Analysis of patients' characteristics and the internal validity of the questionnaire by comparing it with the Urodynamics test. MEASUREMENTS AND MAIN RESULTS: The sample was 59 men and 432 women. For the rough diagnosis of UI caused by straining in women, a five-question survey had a positive predictive value (PPV) of 77.2% for four affirmative replies, which went up to 83% if maximum exterior flow was included. For the UI group arising from anticholinergic treatment, a four-question survey had low PPV (57.6%), but this figure went up to 85.7% with a flowmeter. CONCLUSIONS: A questionnaire to study the type of UI, along with further tests, approached the aetiological diagnosis of incontinence in women. A Urodynamics study, however, always needs to be performed on men.

[Diagnosis and monitoring of hypertension in Catalonia. The DISEHTAC study]. / Diagnóstico y seguimiento de la hipertensión arterial en Cataluña. Estudio DISEHTAC.

OBJECTIVES: To evaluate the diagnosis, monitoring and control of hypertension in reformed primary care centres in Catalonia, on the basis of the evaluation indicators proposed in the primary care hypertension guidelines. DESIGN: Multi-centre cross-sectional descriptive study.Setting. Primary care.Participants. 31 reformed PCC in Catalonia. Randomised sampling of centres and hypertense patients (n = 2240). External audit. MEASUREMENTS AND MAIN RESULTS: a) Diagnosis indicator: in 19.4% of cases a triple double-take of blood pressure showed an average of = 140/90 mmHg. b) Monitoring indicator: 77.9% of patients had been seen for blood pressure in the previous 6 months. c) Indicator of degree of control of blood pressure: 38.8% of patients had pressure below the figures then recommended ((3/4) 65 < 140/90 mmHg, and > 65, < 160/95 mmHg). 25.7% of cases were found to have blood pressure figures < 140/90 mmHg. CONCLUSIONS: There was high compliance on the monitoring indicator. The degree of control of hypertense patients treated at reformed PCCs is still low.