Pharmacotherapy for hypertension-induced left ventricular hypertrophy.

BACKGROUND: Hypertension is the leading preventable risk factor for cardiovascular disease and premature death worldwide. One of the clinical effects of hypertension is left ventricular hypertrophy (LVH), a process of cardiac remodelling. It is estimated that over 30% of people with hypertension also suffer from LVH, although the prevalence rates vary according to the LVH diagnostic criteria. Severity of LVH is associated with a higher prevalence of cardiovascular disease and an increased risk of death. The role of antihypertensives in the regression of left ventricular mass has been extensively studied. However, uncertainty exists regarding the role of antihypertensive therapy compared to placebo in the morbidity and mortality of individuals with hypertension-induced LVH. OBJECTIVES: To assess the effect of antihypertensive pharmacotherapy compared to placebo or no treatment on morbidity and mortality of adults with hypertension-induced LVH. SEARCH METHODS: Cochrane Hypertension's Information Specialist searched the following databases for studies: Cochrane Hypertension Specialised Register (to 26 September 2020), the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library; 2020, Issue 9), Ovid MEDLINE (1946 to 22 September 2020), and Ovid Embase (1974 to 22 September 2020). We searched the World Health Organization International Clinical Trials Registry Platform and the ClinicalTrials.gov for ongoing trials. We also searched Epistemonikos (to 19 February 2021), LILACS BIREME (to 19 February 2021), and Clarivate Web of Science (to 26 February 2021), and contacted authors and funders of the identified trials to obtain additional information and individual participant data. There were no language restrictions. SELECTION CRITERIA: Randomised controlled trials (RCTs) with at least 12 months' follow-up comparing antihypertensive pharmacological therapy (monotherapy or in combination) with placebo or no treatment in adults (18 years of age or older) with hypertension-induced LVH were eligible for inclusion. The trials must have analysed at least one primary outcome (all-cause mortality, cardiovascular events, or total serious adverse events) to be considered for inclusion. DATA COLLECTION AND ANALYSIS: Two review authors screened the search results, with any disagreements resolved by consensus amongst all review authors. Two review authors carried out the data extraction and analyses. We assessed risk of bias of the included studies following Cochrane methodology. We used the GRADE approach to assess the certainty of the body of evidence. MAIN RESULTS: We included three multicentre RCTs. We selected 930 participants from the included studies for the analyses, with a mean follow-up of 3.8 years (range 3.5 to 4.3 years). All of the included trials performed an intention-to-treat analysis. We obtained evidence for the review by identifying the population of interest from the trials' total samples. None of the trials provided information on the cause of LVH. The intervention varied amongst the included trials: hydrochlorothiazide plus triamterene with the possibility of adding alpha methyldopa, spironolactone, or olmesartan. Placebo was administered to participants in the control arm in two trials, whereas participants in the control arm of the remaining trial did not receive any add-on treatment. The evidence is very uncertain regarding the effect of additional antihypertensive pharmacological therapy compared to placebo or no treatment on mortality (14.3% intervention versus 13.6% control; risk ratio (RR) 1.02, 95% confidence interval (CI) 0.74 to 1.40; 3 studies; 930 participants; very low-certainty evidence); cardiovascular events (12.6% intervention versus 11.5% control; RR 1.09, 95% CI 0.77 to 1.55; 3 studies; 930 participants; very low-certainty evidence); and hospitalisation for heart failure (10.7% intervention versus 12.5% control; RR 0.82, 95% CI 0.57 to 1.17; 2 studies; 915 participants; very low-certainty evidence). Although both arms yielded similar results for total serious adverse events (48.9% intervention versus 48.1% control; RR 1.02, 95% CI 0.89 to 1.16; 3 studies; 930 participants; very low-certainty evidence) and total adverse events (68.3% intervention versus 67.2% control; RR 1.07, 95% CI 0.86 to 1.34; 2 studies; 915 participants), the incidence of withdrawal due to adverse events may be significantly higher with antihypertensive drug therapy (15.2% intervention versus 4.9% control; RR 3.09, 95% CI 1.69 to 5.66; 1 study; 522 participants; very low-certainty evidence). Sensitivity analyses limited to blinded trials, trials with low risk of bias in core domains, and trials with no funding from the pharmaceutical industry did not change the results of the main analyses. Limited evidence on the change in left ventricular mass index prevented us from drawing any firm conclusions. AUTHORS' CONCLUSIONS: We are uncertain about the effects of adding additional antihypertensive drug therapy on the morbidity and mortality of participants with LVH and hypertension compared to placebo. Although the incidence of serious adverse events was similar between study arms, additional antihypertensive therapy may be associated with more withdrawals due to adverse events. Limited and low-certainty evidence requires that caution be used when interpreting the findings. High-quality clinical trials addressing the effect of antihypertensives on clinically relevant variables and carried out specifically in individuals with hypertension-induced LVH are warranted.

First-in-human experience of preload regulation with percutaneous transluminal caval flow regulation in heart failure with reduced ejection fraction patients.

AIMS: This study aims to investigate the acute haemodynamic effects of percutaneous transluminal flow regulation (PTCR®) with an inferior vena cava regulator balloon in heart failure patients. Preload reduction in heart failure has been achieved with high potency diuretics. However, no study has been conducted in humans to assess the effect of inferior vena cava intermittent occlusion for preload reduction. METHODS AND RESULTS: Six patients were included in the study: four men (55 ± 6 years old) and two women (63 ± 4 years old). Baseline evaluations included Doppler echocardiogram, coronary angiogram, and right heart catheterization. Caval balloon was kept inflated for 30 min, and right catheterization and control echocardiogram were performed while the balloon was still inflated. The balloon was then deflated and removed. Right haemodynamic variables were evaluated before balloon insertion and with the inflated balloon. The mean right atrial pressure decreased by 42.59% (P = 0.005); systolic right ventricular pressure decreased by 30.19% (P < 0.003); mean pulmonary arterial pressure decreased by 25.33% (P < 0.043); mean pulmonary capillary wedge pressure decreased by 31.37% (P > 0.016); and cardiac output increased by 9.92% (P < 0.175). CONCLUSIONS: The haemodynamic and echocardiographic changes obtained in our study using PTCR® suggest that this innovative approach can play a beneficial role in the heart failure treatment.

Efficacy of indapamide SR compared with enalapril in elderly hypertensive patients with type 2 diabetes.

BACKGROUND: Blood pressure control is the main influential variable in reducing microalbuminuria in patients with type 2 diabetes. In this subanalysis of the Natrilix SR versus Enalapril Study in hypertensive Type 2 diabetics with micrOalbuminuRia (NESTOR) study, we have compared the effectiveness of indapamide sustained release (SR) and enalapril in reducing blood pressure and microalbuminuria in patients > or =65 years of age. METHODS: Of the 570 hypertensive patients with type 2 diabetes and persistent microalbuminuria in the NESTOR study, 187 (33%) individuals > or =65 years of age were included in this analysis. Of these, 95 patients received indapamide SR 1.5 mg and 92 patients received enalapril 10 mg, taken once daily in both cases. Adjunctive amlodipine and/or atenolol was added if required. RESULTS: The urinary albumin-to-creatinine ratio decreased by 46% in the indapamide SR group and 47% in the enalapril group. Noninferiority of indapamide SR over enalapril was demonstrated (P = .0236; 35% limit of noninferiority) with a ratio of 0.95 (95% CI: 0.68, 1.34). Mean arterial pressure decreased by 18 mm Hg and 15 mm Hg in the indapamide SR and the enalapril groups, respectively (P = .1136). The effects of both treatments seen in these elderly patients were similar to those observed in the main population, although the extent of the reduction in microalbuminuria was slightly higher. Both treatments were well tolerated, and no difference between groups was observed regarding glucose or lipid profiles. CONCLUSION: Indapamide SR is not less effective than enalapril in reducing microalbuminuria and blood pressure in patients aged >65 years of age with type 2 diabetes and hypertension.

Equivalence of indapamide SR and enalapril on microalbuminuria reduction in hypertensive patients with type 2 diabetes: the NESTOR Study.

OBJECTIVES: To test whether microalbuminuria in patients with type 2 diabetes and hypertension is primarily dependent on the severity of hypertension, and to compare the effectiveness of two antihypertensive drugs with opposite effects on the renin-angiotensin system [the diuretic, indapamide sustained release (SR), and an angiotensin-converting enzyme inhibitor, enalapril] in reducing microalbuminuria. DESIGN: A multinational, multicentre, controlled, double-blind, double-dummy, randomized, two-parallel-groups study over 1 year. METHODS: After a 4-week placebo run-in period, 570 patients (ages 60.0 +/- 9.9 years, 64% men) with type 2 diabetes, essential hypertension [systolic blood pressure (SBP) 140-180 mmHg, and diastolic blood pressure (DBP) < 110 mmHg], and persistent microalbuminuria (20-200 microg/min) were allocated randomly to groups to receive indapamide SR 1.5 mg (n = 284) or enalapril 10 mg (n = 286) once a day. Amlodipine, atenolol, or both were added, if necessary, to achieve the target blood pressure of 140/85 mmHg. RESULTS: There was a significant reduction in the urinary albumin : creatinine ratio. Mean reductions were 35% [95% confidence interval (CI) 24 to 43] and 39% (95% CI 30 to 47%) in the indapamide SR and enalapril groups, respectively. Equivalence was demonstrated between the two groups [1.08 (95% CI 0.89 to 1.31%); P = 0.01]. The reductions in mean arterial pressure (MAP) were 16.6 +/- 9.0 mmHg for the indapamide SR group and 15.0 +/- 9.1 mmHg for the enalapril group (NS); the reduction in SBP was significantly greater (P = 0.0245 ) with indapamide SR. More than 50% of patients in each group required additional antihypertensive therapy, with no differences between groups. Both treatments were well tolerated. CONCLUSIONS: Indapamide-SR-based therapy is equivalent to enalapril-based therapy in reducing microalbuminuria with effective blood pressure reduction in patients with hypertension and type 2 diabetes.

Attributable risks for acute myocardial infarction in four countries of Latin America.

This multicenter case control study investigated, in four countries of America, the proportions of acute myocardial infarction (AMI) attributable to cholesterol, smoking, hypertension, body mass index, diabetes and family history of coronary heart disease (attributable risks, AR). AR were estimated using information from 1060 cases of AMI and 1071 controls from Argentina, 323 cases of AMI and 314 controls from Cuba, 200 cases of AMI and 200 controls from Mexico and 266 cases of AMI and 264 controls from Venezuela. AR were obtained from the prevalence of coronary risk factors in the cases and the corresponding Odds Ratio (OR) derived through appropriate multivariate models. The AR for AMI observed for hypercholesterolaemia were the following: Venezuela 27%, Mexico 3%, Cuba 30% and Argentina 36%; for diabetes: Venezuela 10%, Mexico 15%, Cuba 5% and Argentina 7% and for body mass Index: Venezuela 12%, Mexico 3%, Cuba 19% and Argentina 17%. The same risk factor may have a different attributable risk in different populations. Together, hypercholesterolaemia, hypertension, smoking, diabetes, body mass index and family history of coronary heart disease accounted for 76% of all cases of AMI in Venezuela, 70% in Mexico, 81% in Cuba and 79% in Argentina. The knowledge of attributable risks could have important implications for public health strategies, especially in those countries with limited health care resources.

Availability and characteristics of cardiovascular rehabilitation programs in South America.

PURPOSE: Cardiac rehabilitation (CR) programs decrease morbidity and mortality rates in patients with coronary artery disease, the leading cause of death in Latin America. This study was carried out to assess the characteristics and current level of CR program implementation in South America. METHODS: We carried out a survey of CR programs that were identified using the directory of the South American Society of Cardiology and through an exhaustive search by the investigators. RESULTS: We identified 160 CR programs in 9 of the 10 countries represented in the South American Society of Cardiology and 116 of those responded to our survey. On the basis of survey results from the responding programs, we estimate that the availability of CR programs in South America is extremely low, approximately 1 CR program for every 2 319 312 inhabitants. These CR programs provided services to a median of 180 patients per year (interquartile range, 60-400) and were most commonly led by cardiologists (84%) and physical therapists (72%). Phases I, II, III, and IV CR were offered in 49%, 91%, 89%, and 56% of the centers, respectively. The most commonly perceived barrier to participation in a CR program was lack of referral from the cardiologist or primary care physician, as reported by 70% of the CR program directors. CONCLUSIONS: The number of CR programs in South America appears to be insufficient for a population with a high and growing burden of cardiovascular disease. In addition, there appears to be a significant need for standardization of CR program components and services in the region.

Modelo de gerencia participativa: Hospital Dr. Luis Gómez López / Management models participative: Hospital Dr. Luis Gómez López

Se realizó una investigación cuali-cuantitativa, de tipo descriptiva, con el objeto de describir y analizar el desarrollo de técnicas administrativas aplicadas al modelo de gerencia participativa del Hospital "Dr. Luis Gómez López", para determinar la percepción sobre el modelo, entre el personal que allí labora, enfocando una innovación en la gerencia del sector salud. Para ello, se diseñó un instrumento (cuestionario) que se aplicó a 110 individuos seleccionados por muestreo proporcional. Entre los resultados se encontró que el Hospital está iniciando un proceso de gerencia participativa, con cierto rasgo consultivo, en la que la búsqueda de alternativas ha tratado de superar las dificultades que presenta el modelo tradicional; de allí que contiene elementos que han permitido fortalecer la gestión al resaltar rasgos positivos que demuestran ventajas a este modelo. Este trabajo permitirá caracterizar la gerencia participativa de la Institución

Obesidad en el Estudio de la Salud Cardiovascular del Estado Lara (ESCEL), Venezuela 1987 y 1997 / Obesity in the Study of the Cardiovascular Health of the State Lara (ESCEL) Venezuela 1987 and 1997

En América Latina, la epidemiología de las enfermedades crónicas no transmisibles, incluyendo sus factores de riesgo, ha sido poco explorada. En particular la obesidad, un problema de salud pública mundial, no ha sido estudiada de manera sistemática en el Estado Lara, Venezuela. Se presentaron los resultados del "Estudio de Salud Cardiovascular del Estado Lara" (ESCEL), de corte transversal, con una muestra probalística, polietápica con representatividad de la población de 15 años y más, residente del Estado Lara, Venezuela, en 1987 y repetido en 1997, Se calculó el índice de masa corporal (IMC) como el peso en Kg dividido entre el cuadrado de la talla en metros. Se definió obesidad como IMC>30. Se calcularon las prevalencias en porcentaje según grupo etano y género. En ESCEL 1987 se encontraron 5272 personas y en ESCEL 1997 se encontraron 3707. La obesidad es un problema social y de salud pública. Su estudio presenta dificultades que se inician con su definición y llega hasta su correlación con mortalidad y morbilidad. La prevalencia de obesidad ha aumentado en esta población sobre todo en varones, pero se mantiene por debajo de otros países de América y España. Los resultados indican que se está a tiempo de intervenir para evitar la epidemia de obesidad que ha ocurrido en otros países de la región

Resultado inicial del programa de educación médica sobre colesterol en Venezuela / Initial results of the medical education program over cholesterol in Venezuela

Objetivo: Valorar el impacto de un año de educación médica continua sobre colesterol en la opinión de los médicos sobre los factores de riesgo y en que nivel de colesterol deberían iniciar tratamiento dietético o médico. Diseño: Encuesta elaborada bajo la forma de cuestionario anónimo cerrado con preguntas y respuestas de múltiple escogencia, la cual se realizaba como una muestra consecutiva. La encuesta se realizó en dos años consecutivos 1989 y 1990. Participantes: Médicos asistentes al Congreso Venezolano de Cardiología de 1989 en Barquisimeto y 1990 en Caracas. Mediciones: Se interrogaba al médico sobre el nivel sérico de colesterol en el cual iniciaba tratamiento con dieta y con medicamentos. Se consultaba sobre que factores consideraban eran importantes para el control de la enfermedad coronaria (factores de riesgo). Resultados: No se apreciaron diferencias e.s. entre el porcentaje de médicos que consideraban como factores de riesgo al colesterol, intolerancia glucosada, hipertensión arterial y habitos tabáquicos en 1989 y 1990. El nivel promedio para iniciar tratamiento médico fue de 228.7+/- 32 mgr por ciento en 1989 y de 213.11 +/_ 24.72 mgr por ciento en 1990 fue de 297.3 +/- 61.3 y en 1990 fue de 280.23 +/- 78.25 mgr por ciento. Conclusiones: Aún cuando se logró disminuir en forma significativa los niveles de colesterol para iniciar tratamiento dietético y médico, estos niveles aún están por encima de lo ideal y no se lograron cambios en el conocimiento de los factores de riesgo,por lo cual es necesario continuar e intensificar el programa de educación médica continua sobre colesterol y realizar un programa venezolano de educación de colesterol. La "hipótesis del colesterol" que relaciona el nivel sérico de colesterol con la ateroesclerosis y la incidencia de enfermedad arterial coronaria (EAC), ha sido ampliamente demostrada tanto en estudios experimentales, epidemiológicos, genéticos y clínicos. Los estudios de prevención primaria, tanto con dieta como con medicamentos han demostrado en forma general que una disminución del 1 por ciento en el nivel sérico de colesterol reduce en un 2 por ciento la incidencia de EAC. En base a estos conceptos es clara la importancia de que los médicos conozcan en forma adecuada el nivel de colesterol con el cual deberán iniciar tratamiento ya que de esta medida inicial va a depender la prevención de la EAC. En Venezuela las enfermedades cardiovasculares ocupan el primer lugar de mortalidad con 16.584 muertes en 1987, por lo cual es indispensable un manejo adecuado de los factores de riesgo por parte de los médicos junto con una campaña de divulgación de los mismos al público con el fin de lograr un mejor control y de esa forma realizar la verdadera medicina preventiva

Hipertension arterial en el anciano tratamiento prolongado con nifedipina / Hypertension arterial in order persons treatment with nifedipine

Treinta y dos pacientes ancianos con diagnóstico de hipertensión arterial (HTA), habitantes de cinco hogares para ancianos localizados en el Estado Lara Venezuela, finalizaron un programa de setenta semanas de duración para el control de la HTA con el calcioantagonista nifedipina LP. Al cumplir con los criterios de inclusión los pacientes se les prescribía 20mgr de nifedipina LP (monodosis). El tratamiento podía ser modificado de acuerdo a la respuesta clínica. Un paciente murió antes de finalizado el estudio por insuficiencia cardíaca congestiva. Finalizaron 31 pacientes de los cuales 19(61 por ciento) presentaban PAS menor de 160 mm de Hg, 8(26 por ciento) entre 160 y 180 mm de Hg, mientras que 4(13 por ciento) presentaban más de 180 mm de Hg. Por lo tanto en 27(87 por ciento) de los pacientes se logró el control satisfactorio o parcial de la PAS. Ocho pacientes (22.5 por ciento) sin tratamiento con drogas, 13(42 por ciento) con una dosis única diaria de nifedipina LP (20mgs), 5(16 por ciento) recibieron dos dosis de nifedipina LP al día (40mgs), un paciente recibió dos dosis de nifedipina LP al día (40mgs) más 200 mgs, de acebutolol dosis única. El resultado de este estudio provee información para el diseño e implementación de programas de control de hipertensión arterial en el anciano

Parámetors ecocardiográficos normales en una población industrial del estado Lara, Venezuela / Echocardiography normal values in an industrial population of Lara state, Venezuela

La ecocarfiografía-doppler es un método utilizado ampliamente en la valoración de la estructura y función del corazón y grandes vasos. Por su reciente introducción como herramienta diagnóstica, existen pocos trabajos nacionales cuyo objetivo sea el estableciemiento de valores de referencia en poblaciones normales seleccionadas. Presentamos el análisis de los parámetros ecocardiograficos en los 214 empleados aparentemente sanos pertenecientes a una empresa fundidora de metales del Estado Lara. Las variables analizadas en modo M y B fueron las siguientes: diámetro sistólico y diastólico del ventrículo izquierdo (VI), grosor de las paredes del VI, diámetro de la raíz aórtica y tamaño de la aurícular izquierda. Los parámetros estudiados por Doppler fueron la velocidad máxima de flujo mitral y tricuspídeo en diástole precoz y tardía, velocidad máxima de flujo pulmonar y aórtico. En base a estas medidas se calculó la masa del VI y su relaci 2n con otros parámetros corporales. Se calcularán los parámetros más utilizados de la función ventricular sistólica y diastólica

Propuesta para el ánalisis de la situación de salud según condiciones de vida de la población para el apoyo a la gestión en los niveles locales / Proposal for the analysis of population health situation based on living conditions

En este trabajo se describe una propuesta de análisis de la situación de salud según condiciones de vida de la población, desarrollada como apoyo a la gestión municipal en el campo de la salud. Dicha propuesta consiste en formar estratos de Barrio/Urbanizaciones con condiciones de vida semejantes, utilizando como indicadores: el porcentaje de viviendas sin agua, el porcentaje de viviendas que carecen de sistemas de disposición de excretas y el porcentaje de población mayor de 15 años que no lee ni escribe, información obtenida a través de informantes claves. Al interior de cada estrato se caracteriza la situación de salud, utilizando los indicadores disponibles en los sistemas de información existentes. La metodología descrita fue aplicada en los Municipios Iribarren y Palavecino del Estado Lara, Venezuela, donde se encontró que la proporción de nacimientos vivos de bajo peso, la mortalidad proporcional en menores de un año, el porcentaje de muertes por enfermedades transmisibles y específicamente por afecciones instestinales, así como la mortalidad por causas perinatales son mayores en el estrato de peores condiciones de vida, observándose relación entre la magnitud de estos indicadores y la magnitud de la pobreza

Attributable risks for acute myocardial infarction in four countries of Latin America

This multicenter case control study investigated, in four countries of America, the proportions of acute myocardial infarction (AMI) attributable to cholesterol, smoking, hypertension, body mass index, diabetes and family history of coronary heart disease (attributable risks, AR). AR were estimated using information from 1060 cases of AMI and 1071 controls from Argentina, 323 cases of AMI and 314 controls from Cuba, 200 cases of AMI and 200 controls from Mexico and 266 cases of AMI and 264 controls from Venezuela. AR were obtained from the prevalence of coronary risk factors in the cases and the corresponding Odds Ratio (OR) derived through appropriate multivariate models. The AR for AMI observed for hypercholesterolaemia were the following: Venezuela 27%, Mexico 3%, Cuba 30% and Argentina 36%; for diabetes: Venezuela 10%, Mexico 15%, Cuba 5% and Argentina 7% and for body mass Index: Venezuela 12%, Mexico 3%, Cuba 19% and Argentina 17%. The same risk factor may have a different attributable risk in different populations. Together, hypercholesterolaemia, hypertension, smoking, diabetes, body mass index and family history of coronary heart disease accounted for 76% of all cases of AMI in Venezuela, 70% in Mexico, 81% in Cuba and 79% in Argentina. The knowledge of attributable risks could have important implications for public health strategies, especially in those countries with limited health care resources.