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1.
J Intern Med ; 294(3): 251-268, 2023 09.
Artigo em Inglês | MEDLINE | ID: mdl-37401044

RESUMO

The clinical and economic burden of hypertension is high and continues to increase globally. Uncontrolled hypertension has severe but avoidable long-term consequences, including cardiovascular diseases, which are among the most burdensome and most preventable conditions in Europe. Yet, despite clear guidelines on screening, diagnosis and management of hypertension, a large proportion of patients remain undiagnosed or undertreated. Low adherence and persistence are common, exacerbating the issue of poor blood pressure (BP) control. Although current guidelines provide clear direction, implementation is hampered by barriers at the patient-, physician- and healthcare system levels. Underestimation of the impact of uncontrolled hypertension and limited health literacy lead to low adherence and persistence among patients, treatment inertia among physicians and a lack of decisive healthcare system action. Many options to improve BP control are available or under investigation. Patients would benefit from targeted health education, improved BP measurement, individualized treatment or simplified treatment regimens through single-pill combinations. For physicians, increasing awareness of the burden of hypertension, as well as offering training on monitoring and optimal management and provision of the necessary time to collaboratively engage with patients would be useful. Healthcare systems should establish nationwide strategies for hypertension screening and management. Furthermore, there is an unmet need to implement more comprehensive BP measurements to optimize management. In conclusion, an integrative, patient-focused, multimodal multidisciplinary approach to the management of hypertension by clinicians, payers and policymakers, involving patients, is required to achieve long-term improvements in population health and cost-efficiency for healthcare systems.


Assuntos
Anti-Hipertensivos , Hipertensão , Humanos , Pressão Sanguínea , Anti-Hipertensivos/uso terapêutico , Estresse Financeiro , Hipertensão/diagnóstico , Hipertensão/prevenção & controle , Quimioterapia Combinada
2.
Hipertens Riesgo Vasc ; 37(2): 78-81, 2020.
Artigo em Espanhol | MEDLINE | ID: mdl-31542309

RESUMO

Therapeutic inertia is defined as the failure to take therapeutic decisions, such as initiating, adding or increasing the dose of a drug during patient follow-up, despite there being an indication to do so. It is currently considered that therapeutic inertia is a considerable impediment to achieving adequate control of hypertension, and this has implications for the prognosis of the disease. Therapeutic inertia might be due to various factors involving physicians, patients and the health system. Many studies have attempted to find determinants for therapeutic inertia in hypertension and to explain the reasons why health professionals in charge of treatment are failing to make the appropriate modifications to therapy. The many reasons for therapeutic inertia on the part of physicians include the various cognitive and affective biases that influence clinical reasoning and decision-making during healthcare activity in doctors' surgeries. Identifying and recognising these cognitive and affective biases could be important for planning educational strategies for health professionals. This requires a multi-dimensional approach, including knowledge beyond that observed in terms of insufficient information and updating on the disease, and starting to analyse and consider other reasons. Preventing therapeutic inertia should be made a priority along with other important measures to control hypertension and minimise its consequences.


Assuntos
Tomada de Decisão Clínica , Atenção à Saúde/organização & administração , Hipertensão/terapia , Médicos/psicologia , Viés , Cognição , Humanos , Médicos/organização & administração
4.
Appl Health Econ Health Policy ; 11(5): 531-42, 2013 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-24078223

RESUMO

BACKGROUND: A clinical­genetic function (Cardio inCode®) was generated using genetic variants associated with coronary heart disease (CHD), but not with classical CHD risk factors, to achieve a more precise estimation of the CHD risk of individuals by incorporating genetics into risk equations [Framingham and REGICOR (Registre Gironí del Cor)]. OBJECTIVE: The objective of this study was to conduct an economic analysis of the CHD risk assessment with Cardio inCode®, which incorporates the patient's genetic risk into the functions of REGICOR and Framingham, compared with the standard method (using only the functions). METHODS: A Markov model was developed with seven states of health (low CHD risk, moderate CHD risk, high CHD risk, CHD event, recurrent CHD, chronic CHD, and death). The reclassification of CHD risk derived from genetic information and transition probabilities between states was obtained from a validation study conducted in cohorts of REGICOR (Spain) and Framingham (USA). It was assumed that patients classified as at moderate risk by the standard method were the best candidates to test the risk reclassification with Cardio inCode®. The utilities and costs (€; year 2011 values) of Markov states were obtained from the literature and Spanish sources. The analysis was performed from the perspective of the Spanish National Health System, for a life expectancy of 82 years in Spain. An annual discount rate of 3.5 % for costs and benefits was applied. RESULTS: For a Cardio inCode® price of €400, the cost per QALY gained compared with the standard method [incremental cost-effectiveness ratio (ICER)] would be €12,969 and €21,385 in REGICOR and Framingham cohorts, respectively. The threshold price of Cardio inCode® to reach the ICER threshold generally accepted in Spain (€30,000/QALY) would range between €668 and €836. The greatest benefit occurred in the subgroup of patients with moderate­high risk, with a high-risk reclassification of 22.8 % and 12 % of patients and an ICER of €1,652/QALY and €5,884/QALY in the REGICOR and Framingham cohorts, respectively. Sensitivity analyses confirmed the stability of the study results. CONCLUSIONS: Cardio inCode® is a cost-effective risk score option in CHD risk assessment compared with the standard method.


Assuntos
Doença das Coronárias/economia , Medição de Risco/economia , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Doença das Coronárias/etiologia , Doença das Coronárias/genética , Análise Custo-Benefício/economia , Feminino , Predisposição Genética para Doença , Humanos , Masculino , Cadeias de Markov , Pessoa de Meia-Idade , Probabilidade , Medição de Risco/métodos , Espanha/epidemiologia
5.
J Hum Hypertens ; 16(4): 255-60, 2002 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-11967719

RESUMO

The existence of a heterogeneous blood pressure (BP) response to salt intake, a phenomenon known as salt sensitivity, has increasingly become a subject of clinical hypertension research, and has important clinical and prognostic implications. However, two different methodologies are currently used to diagnose salt sensitivity. The aim of the present study was to compare the BP response to intravenous sodium load and depletion on the one hand, and to changes in dietary salt intake on the other, in order to assess salt sensitivity in a group of essential hypertensive patients. Twenty-nine essential hypertensives underwent two different procedures separated by 1 month: a dietary test consisting of a 2-week period of low (20 mmol/day) and high (260 mmol/day) salt intakes, and an intravenous test consisting of a 2 litre saline load over a 4-h period, followed by 1 day of low (20 mmol) salt intake and furosemide (40 mg/8 h orally) administration. BP was registered at the end of every period using 24-h ambulatory BP monitoring. In the whole group of hypertensive patients studied, both low salt intake and furosemide administration significantly (P < 0.01) decreased mean BP. Correlation coefficients of BP changes obtained using the two methodologies were between 0.3 and 0.4. Moreover, coefficients of agreement between the oral and the intravenous tests, using several cut points for BP changes, were systematically below 0.5, thus indicating a misclassification of salt sensitivity greater than 50%, depending on the method used. None of the cut points for BP changes during furosemide administration showed a good combination of sensitivity and specificity compared with changes in response to low dietary salt. The present results indicate that the diagnosis of salt-sensitive hypertension should be based on the BP response to changes in dietary salt intake, while BP response to saline and furosemide administration leads to a systematic misclassification of more than 50% of patients, even using different cutpoints for changes in BP.


Assuntos
Pressão Sanguínea/efeitos dos fármacos , Hipersensibilidade/diagnóstico , Hipertensão/diagnóstico , Cloreto de Sódio na Dieta/farmacologia , Administração Oral , Pressão Sanguínea/fisiologia , Monitorização Ambulatorial da Pressão Arterial , Feminino , Humanos , Hipersensibilidade/fisiopatologia , Hipertensão/fisiopatologia , Infusões Intravenosas , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Sensibilidade e Especificidade , Cloreto de Sódio na Dieta/administração & dosagem , Fatores de Tempo
6.
Hypertension ; 33(2): 653-7, 1999 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-10024322

RESUMO

Several studies have shown that cessation of alcohol drinking reduces blood pressure (BP). However, attempts to reproduce these findings by ambulatory BP monitoring (ABPM) have shown inconsistent results. The aim of the present study was to assess the effect of 1 month of proven abstinence from alcohol on the 24-hour BP profile in heavy alcohol drinkers. Forty-two men who were heavy drinkers (>100 g of pure ethanol per day) were consecutively admitted to a general ward for voluntary alcohol detoxification. On the day of admission, they received a total dose of 2 g/kg of ethanol diluted in orange juice in 5 divided doses, and a 24-hour ABPM was performed. A new 24-hour BP monitoring in the same environmental conditions was performed after 1 month of proven alcohol abstinence while the subjects were receiving the same amount of fluid but without the addition of alcohol. After 1 month of proven alcohol abstinence, BP and heart rate (HR) significantly decreased. The reduction was 7.2 mm Hg for 24-hour systolic BP (SBP) (95% CI, 4.5 to 9.9), 6.6 mm Hg for 24-hour diastolic BP (DBP) (95% CI, 4.2 to 9.0), and 7.9 bpm for HR (95% CI, 5.1 to 10.7). The proportion of alcoholic patients considered hypertensive on the basis of 24-hour BP criteria (daytime SBP >/=135 mm Hg or daytime DBP >/=85 mm Hg) fell from 42% during alcohol drinking to 12% after 1 month of complete abstinence. Abstinence did not modify either the long-term BP variability, assessed by SD of 24-hour BP, or its circadian profile. We conclude that abstinence in heavy alcohol drinkers significantly reduces BP assessed by 24-hour ABPM and that this reduction is clinically relevant. These results show that heavy alcohol consumption has an important effect on BP, and thus cessation of alcohol consumption must be recommended as a priority for hypertensive alcohol drinkers.


Assuntos
Consumo de Bebidas Alcoólicas/efeitos adversos , Pressão Sanguínea/efeitos dos fármacos , Temperança , Adulto , Pressão Sanguínea/fisiologia , Monitorização Ambulatorial da Pressão Arterial , Frequência Cardíaca , Humanos , Masculino , Pessoa de Meia-Idade , Síndrome de Abstinência a Substâncias
7.
Am J Hypertens ; 8(10 Pt 1): 970-7, 1995 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-8845078

RESUMO

We used ambulatory blood pressure monitoring (ABPM) in the assessment of salt sensitivity in 40 essential hypertensive patients, comparing 24-h mean blood pressure during 7 days of low salt (20 mmol NaCl/day) and high salt (260 mmol NaCl/day) intake. Salt sensitivity was diagnosed in 18 essential hypertensive patients (45%), each of them showing a significant increase in mean blood pressure (P < .05) from low to high salt diet. Salt-sensitive patients exhibited a high-salt-dependent increase in all blood pressure parameters including 24-h systolic, mean, diastolic blood pressure, blood pressure load, area under the curve, and awake and asleep blood pressure values. These patients exhibited a nondipper profile on both low-salt and high-salt diets. Salt-resistant patients (55%) showed a decrease in awake, and an increase in asleep blood pressure values after high salt intake, thus tending to flatten the circadian blood pressure profile. We conclude that ABPM is a useful method to assess salt sensitivity. In salt-resistant patients high salt intake induces a significant increase in asleep blood pressure with no significant changes in 24-h blood pressure, promoting a flattened blood pressure curve and tending to transform a dipper into a nondipper profile, which could have important implications in end-organ damage.


Assuntos
Monitorização Ambulatorial da Pressão Arterial , Pressão Sanguínea/efeitos dos fármacos , Ritmo Circadiano , Hipertensão/fisiopatologia , Cloreto de Sódio/farmacologia , Adulto , Idoso , Dieta Hipossódica , Resistência a Medicamentos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade
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