ABSTRACT
Hypertension is the most important risk factor for global disease burden. Detection and management of hypertension are considered as key issues for individual and public health, as adequate control of blood pressure levels markedly reduces morbidity and mortality associated with hypertension. Aims of these practice guidelines for the management of arterial hypertension of the Spanish Society of Hypertension include offering simplified schemes for diagnosis and treatment for daily practice, and strategies for public health promotion. The Spanish Society of Hypertension assumes the 2018 European guidelines for management of arterial hypertension developed by the European Society of Cardiology and the European Society of Hypertension, although relevant aspects of the 2017 American College of Cardiology/American Heart Association guidelines and the 2020 International Society of Hypertension guidelines are also commented. Hypertension is defined as a persistent elevation in office systolic blood pressure ≥ 140 and/or diastolic blood pressure ≥ 90 mmHg, and assessment of out-of-office blood pressure and global cardiovascular risk are considered of key importance for evaluation and management of hypertensive patients. The target for treated blood pressure should be < 130/80 for most patients. The treatment of hypertension involves lifestyle interventions and drug therapy. Most people with hypertension need more than one antihypertensive drug for adequate control, so initial therapy with two drugs, and single pill combinations are recommended for a wide majority of hypertensive patients.
Subject(s)
Antihypertensive Agents , Hypertension , Humans , Antihypertensive Agents/therapeutic use , Hypertension/diagnosis , Hypertension/drug therapy , Blood Pressure , Blood Pressure Monitoring, Ambulatory , Blood Pressure DeterminationABSTRACT
To substantially reduce the risk of hospitalization and death among subjects with heart failure (HF) and reduced left ventricular ejection fraction, it is necessary to make a comprehensive approach of the different neurohormonal systems that are implied in its etiopathogenesis, including not only sympathetic nervous system, and renin-angiotensin system, but also vasoactive peptides and sodium-glucose transport protein 2. The DAPA-HF trial demonstrated that the addition of dapagliflozin to the standard treatment in HF with reduced left ventricular ejection fraction, markedly decreases the risk of cardiovascular death, HF hospitalization and overall death. In addition, dapagliflozin improves functional class and quality of life. Importantly, the prognostic benefit starts early after initiating treatment with dapagliflozin, regardless baseline therapy or the presence of diabetes. All these evidences make dapagliflozin as one of the mainstays of treatment for the management of HF with reduced left ventricular ejection fraction.
Subject(s)
Heart Failure , Quality of Life , Benzhydryl Compounds , Glucosides , Heart Failure/drug therapy , Heart Failure/prevention & control , Humans , Stroke Volume , Ventricular Function, LeftABSTRACT
Despite traditional treatments, morbidity and mortality of patients with heart failure (HF) and reduced left ventricular ejection fraction remains unacceptably high. Traditionally, guidelines recommended a step by step approach in the management of this population. However, this approach could delay the prescription of some drugs with proven efficacy on morbidity and prognosis. As current HF guidelines recommend, an initial comprehensive approach with the aim of targeting all neurohormonal systems that are implied in the etiopathogenesis of HF seems necessary. The DAPA-HF trial demonstrated that dapagliflozin markedly reduces the risk of HF hospitalization, and also improves prognosis. Consequently, dapagliflozin should be considered as a first-line therapy in the management of these patients. On the other hand, primary care physicians are essential for the prevention and treatment of patients with HF and reduced left ventricular ejection fraction. As a result, it is mandatory that they know when and how dapagliflozin should be used. In this review, a practical approach for an appropriate use of this drug is provided.
Subject(s)
Heart Failure , Physicians, Primary Care , Benzhydryl Compounds , Glucosides , Heart Failure/drug therapy , Humans , Stroke Volume , Ventricular Function, LeftABSTRACT
Sodium-glucose transport protein 2 (SGLT2) inhibitors are a new class of oral hypoglycemic agents that increase urinary glucose excretion independently of insulin secretion, although an apparently simple mechanism, but with multiple metabolic effects. Dapagliflozin was the first SGLT2 inhibitor marketed in Europe in 2012 for the treatment of patients with type 2 diabetes, and consequently, with the greatest clinical experience. The results of different clinical trials and real-life studies have demonstrated its effectiveness in glycemic control, as they reduce glycosylated hemoglobin, while achieving a decrease in body weight and blood pressure, among others, providing a comprehensive metabolic protection.
Subject(s)
Cardiovascular Diseases , Diabetes Mellitus, Type 2 , Sodium-Glucose Transporter 2 Inhibitors , Benzhydryl Compounds/adverse effects , Cardiovascular Diseases/epidemiology , Cardiovascular Diseases/etiology , Cardiovascular Diseases/prevention & control , Diabetes Mellitus, Type 2/drug therapy , Glucosides , Glycemic Control , Heart Disease Risk Factors , Humans , Hypoglycemic Agents , Risk FactorsABSTRACT
A pesar de los tratamientos actuales,la morbilidad y la mortalidad de los pacientes con insuficiencia cardiaca continúan siendo elevadas. El diagnóstico tardío, el tratamiento insuficiente de la insuficiencia cardiaca (por ejemplo no emplear los fármacos apropiados, prescribir dosis más bajas que las recomendadas, etc.) y la pobre coordinación entre los diferentes niveles asistenciales pueden explicar, al menos en parte, estos datos. El programa MICCAP se ha desarrollado con el objetivo de optimizar el manejo integrado de los pacientes con insuficiencia cardiaca entre atención primaria y cardiología, a través de la mejora en la coordinación entre ambos niveles asistenciales y la educación médica continuada, reforzando las habilidades diagnósticas y terapéuticas de los médicos de atención primaria en el campo de la insuficiencia cardiaca. En este manuscrito se resumen el racional y los objetivos del programa MICCAP
Despite current treatments, morbidity and mortality of patients with heart failure remain high. The late diagnosis of heart failure, the insufficient heart failure treatment (i.e. not using the appropriate drugs, prescribing lower doses of drugs than recommended, etc.), and a poor coordination between different health care levels, may explain, at least in part, these figures. The Management of Heart Failure in Cardiology and Primary Care (MICCAP) program has been developed with the aim of optimising the integrated management of patients with heart failure between Primary Care and Cardiology, through the improvement of coordination between both health care levels. This includes continuous medical education to reinforce the diagnostic and therapeutic skills of general practitioners in the field of heart failure. The rationale and objectives of the MICCAP program are summarised in this article
Subject(s)
Humans , Cardiology/organization & administration , Integrality in Health , Heart Failure/therapy , Primary Health Care/organization & administration , Clinical Competence , Cooperative Behavior , Education, Medical/methods , General Practitioners/organization & administration , General Practitioners/standards , Heart Failure/diagnosisABSTRACT
Despite current treatments, morbidity and mortality of patients with heart failure remain high. The late diagnosis of heart failure, the insufficient heart failure treatment (i.e. not using the appropriate drugs, prescribing lower doses of drugs than recommended, etc.), and a poor coordination between different health care levels, may explain, at least in part, these figures. The Management of Heart Failure in Cardiology and Primary Care (MICCAP) program has been developed with the aim of optimising the integrated management of patients with heart failure between Primary Care and Cardiology, through the improvement of coordination between both health care levels. This includes continuous medical education to reinforce the diagnostic and therapeutic skills of general practitioners in the field of heart failure. The rationale and objectives of the MICCAP program are summarised in this article.
Subject(s)
Cardiology/organization & administration , Delivery of Health Care, Integrated/organization & administration , Heart Failure/therapy , Primary Health Care/organization & administration , Clinical Competence , Cooperative Behavior , Education, Medical/methods , General Practitioners/organization & administration , General Practitioners/standards , Heart Failure/diagnosis , HumansABSTRACT
El objetivo del protocolo es conocer qué estudios deben solicitarse ante una anemia en un paciente con enfermedad renal crónica, el diagnóstico diferencial de la anemia renal, conocer y corregir otras anemias carenciales y los criterios de remisión del paciente anémico con enfermedad renal crónica a Nefrología u otras especialidades (AU)
The objective of this protocol is to know which test are needed to study an anaemia in a patient with chronic kidney disease, the differential diagnosis of renal anaemia, to know and correct other deficiency anaemias, and the criteria for referral to Nephrology or other specialties of the anaemic patient with chronic kidney disease (AU)
Subject(s)
Humans , Anemia/epidemiology , Renal Insufficiency, Chronic/complications , Glycated Hemoglobin/analysis , Practice Patterns, Physicians' , Renal Insufficiency, Chronic/physiopathology , Anemia/classification , Diagnosis, Differential , 16595/drug therapy , Iron Compounds/therapeutic useABSTRACT
The objective of this protocol is to know which test are needed to study an anaemia in a patient with chronic kidney disease, the differential diagnosis of renal anaemia, to know and correct other deficiency anaemias, and the criteria for referral to Nephrology or other specialties of the anaemic patient with chronic kidney disease.
Subject(s)
Anemia/etiology , Referral and Consultation , Renal Insufficiency, Chronic/complications , Anemia/diagnosis , Anemia/therapy , Diagnosis, Differential , HumansABSTRACT
BACKGROUND AND OBJECTIVES: Control of arterial blood pressure (BP) in hypertensive patients differs based on the evaluation procedure. This fact can be enhanced in subjects over 65 years of age. We have studied the degree of BP control with determinations in the office or ambulatory blood pressure monitoring (ABPM). METHODS: A multicenter, cross-sectional study was conducted in primary care (PC) and hypertension units in the Valencian Community. The first three hypertensive patients ≥ 65 years who attended the consultation on the first day of visits of the week of each investigator were included in the study. Cardiovascular risk factors, target organ damage and associated cardiovascular disease were recorded. Good clinical control values were defined as < 140/90 in the office and < 130/80 by ABPM for 24-hour according to 2007 ESH/ESC guidelines. RESULTS: A total of 1,028 hypertensive patients were included, 52.7% of whom were women, with a mean age of 72.6 years. Mean clinical BP was 146.7/81.1 mmHg and 24-hour ABPM 128.5/70.8 mmHg. Ninety-two percent of the patients were treated with antihypertensive drugs (35.6% monotherapy and 56.4% with combinations of two or more drugs). Good clinical control was found in 35.3% of cases (CI 95%: 32.4-38.2) and 50.9% (CI 95%: 47.8-54.0) (P < .001) had good control of 24-hour BP in ABPM. Male gender, personal background of heart disease and stroke were associated with good control of hypertension (P < .01) in 24-hour ABPM. CONCLUSIONS: In hypertensive patients over 65 years, and compared to the clinical determination of BP, the evaluation of ABMP showed a better proportion of controlled subjects. These findings support a wider use of ABPM to evaluate the control of BP in this population.
Subject(s)
Blood Pressure Determination/methods , Hypertension/diagnosis , Hypertension/therapy , Aged , Blood Pressure Monitoring, Ambulatory , Cross-Sectional Studies , Female , Humans , MaleABSTRACT
Antecedentes y objetivos. El control de la presión arterial (PA) en pacientes hipertensos difiere en función del procedimiento de valoración. Este hecho puede estar acentuado en los mayores de 65 años. Hemos examinado el grado de control de la PA con determinaciones en consulta y monitorización ambulatoria de la PA (MAPA). Metodología. Estudio transversal multicéntrico realizado en Atención Primaria y unidades de HTA de la Comunidad Valenciana. Se incluyeron los tres primeros pacientes hipertensos ≥ 65 años que acudieron a consulta el primer día de visita de la semana de cada investigador. Se registraron factores de riesgo cardiovascular, lesión de órgano diana y enfermedad cardiovascular. Se definió buen control clínico. Valores < 140/90 mmHg y buen control ambulatorio valores por MAPA en 24 horas < 130/80 mmHg. Resultados. Se incluyó a 1.028 pacientes, edad media 72,8 años (52,7% de mujeres). La PA clínica media fue de 146,7/81,1 mmHg y con MAPA de 24 horas 128,5/70,8 mmHg. El 92% de los pacientes estaba tratado con antihipertensivos (35,6% monoterapia y 56,4% con combinaciones de dos o más fármacos). El 35,3% (IC95%,32,4-38,2) presentó buen control clínico y un 50,9% (IC95%: 47,8-54,0). Buen control con MAPA (p < 0,001). El género masculino y los antecedentes personales de cardiopatía e ictus fueron los factores significativamente asociados al buen control de la PA (p < 0,01) con MAPA. Conclusiones. En los pacientes hipertensos mayores de 65 años y en comparación con las determinaciones clínicas de PA, la valoración con MAPA muestra una mayor proporción de sujetos controlados. Estos hallazgos sustentan un uso más amplio de la MAPA para valorar el control de la PA en esta población(AU)
Background and objectives. Control of arterial blood pressure (BP) in hypertensive patients differs based on the evaluation procedure. This fact can be enhanced in subjects over 65 years of age. We have studied the degree of BP control with determinations in the office or ambulatory blood pressure monitoring (ABPM). Methods. A multicenter, cross-sectional study was conducted in primary care (PC) and hypertension units in the Valencian Community. The first three hypertensive patients ≥ 65 years who attended the consultation on the first day of visits of the week of each investigator were included in the study. Cardiovascular risk factors, target organ damage and associated cardiovascular disease were recorded. Good clinical control values were defined as < 140/90 in the office and < 130/80 by ABPM for 24-hour according to 2007 ESH/ESC guidelines. Results. A total of 1,028 hypertensive patients were included, 52.7% of whom were women, with a mean age of 72.6 years. Mean clinical BP was 146.7/81.1 mmHg and 24-hour ABPM 128.5/70.8 mmHg. Ninety-two percent of the patients were treated with antihypertensive drugs (35.6% monotherapy and 56.4% with combinations of two or more drugs). Good clinical control was found in 35.3% of cases (CI 95%: 32.4-38.2) and 50.9% (CI 95%: 47.8-54.0) (P < .001) had good control of 24-hour BP in ABPM. Male gender, personal background of heart disease and stroke were associated with good control of hypertension (P < .01) in 24-hour ABPM. Conclusions. In hypertensive patients over 65 years, and compared to the clinical determination of BP, the evaluation of ABMP showed a better proportion of controlled subjects. These findings support a wider use of ABPM to evaluate the control of BP in this population(AU)
Subject(s)
Humans , Male , Female , Middle Aged , Hypertension/complications , Hypertension/diagnosis , Blood Pressure/physiology , Monitoring, Physiologic/methods , Monitoring, Physiologic/trends , Monitoring, Physiologic , Albuminuria/diagnosis , Risk Factors , 28599 , Primary Health Care , Cross-Sectional Studies , Informed ConsentABSTRACT
INTRODUCTION AND OBJECTIVES: The need for more specific, more sensitive and earlier biochemical markers of acute myocardial infarction, has led to the development of alternative methods to CK-MB). The aim of this work is to assess the usefulness of TnT measurement, in comparison with other markers for detecting transitory ischemic processes without necrosis in some experimental models. METHODS: The plasma levels of Troponine T, CK, CK-MB and adenosine were assessed as markers of ischemic myocardial injury. Two protocols were used: in Series I and II very brief (2 min ischemia with 3-min reperfusion) repeated (20 episodes) ischemias were induced, while Series III involved a single 15-min ischemia with a 60-min reperfusion. In Series I the coronary occlusor was placed close to the anterior descending coronary artery (AD); in Series II and III it was placed distally in the AD. Blood samples were taken from the peripheral vein (PVB) and corresponding coronary segment vein; in a basal situation, during ischemia, upon reperfusion, after 24 hours, and after 5 and 10 days. The plasma levels of adenosine, troponine T, CK and CK-MB as well as general and regional function parameters were measured. RESULTS: In Series I we observed hypokinesis that lasted 10 days, reaching its maximum on days 4-5. In Series II and III regional function was restored by 24 hours. CK and CK-MB showed similar behaviour; they rose significantly when the chest was opened (p < 0.05) reaching the highest value at 24 hours in all the series. Adenosine rose significantly only during reperfusion (p < 0.05). Troponine T increased after ischemia but not before, remained high for 5 days in all series (PVB). CONCLUSIONS: Troponine T rises in absence of necrosis, preferably when the ischemia is longer.
Subject(s)
Myocardial Stunning/diagnosis , Troponin T/blood , Adenosine/blood , Animals , Biomarkers , Creatine Kinase/blood , DogsABSTRACT
The effects of needle bevel orientation and cerebrospinal fluid (CSF) pressure on dural displacement and force required to penetrate cadaveric dura were studied using 40 samples. A constant hydrostatic pressure was applied to the subdural surface, either high or low, simulating the sitting and lateral positions. A 17-gauge Tuohy needle was advanced through the dura with the bevel oriented parallel or perpendicular to dural fibres. Travel distance and peak force at which dural penetration occurred were measured under both pressure conditions. The work required to produce dural penetration was calculated. Greater force and work were required to penetrate dura in the perpendicular orientation (P < 0.05), regardless of the subdural pressure exerted. Dural displacement was similar under both pressure conditions.
Subject(s)
Cerebrospinal Fluid Pressure/physiology , Dura Mater/anatomy & histology , Needles , Spinal Puncture/instrumentation , Adult , Aged , Cadaver , Humans , Hydrostatic Pressure , Injections, Epidural/methods , Middle Aged , PostureABSTRACT
Epidural steroid injections are commonly used in the treatment of low back pain and radiculopathy based on their antiinflammatory and analgesic benefits. However, steroids are known to affect collagen synthesis, material strength, and tissue healing. The purpose of this study was to assess the effects of serial epidural steroid injections on the material properties of the lumbar dura mater. Serial epidural steroid injections of saline or methylprednisolone at 2-week intervals were performed in three paired groups of canines; a separate noninjected group was used as controls. Postmortem, dural sample testing to failure and histologic analysis was performed. Mechanical failure testing revealed no clinically significant change in the transverse dorsal dura tensile strength between all saline-injected, steroid-injected, or noninjected controls. Histologic analysis demonstrated no overt disruption of collagen matrix organization; however, electron microscopy demonstrated a significant decrease in the number of intracytoplasmic mitochondria of dural fibroblasts in steroid-injected animals, suggesting a metabolic inhibitory effect within steroid-injected dura mater. In the clinical time frame of this study, serial epidural steroid injections appeared to produce no significant material or matrix changes in the lumbar dura.
Subject(s)
Analgesia, Epidural/adverse effects , Anti-Inflammatory Agents/toxicity , Dura Mater/drug effects , Injections, Spinal/adverse effects , Methylprednisolone/toxicity , Analgesia, Epidural/methods , Animals , Dogs , Drug Administration Schedule , Dura Mater/cytology , Fibroblasts/drug effects , Fibroblasts/ultrastructure , Mitochondria/ultrastructure , Stress, Mechanical , Tensile StrengthABSTRACT
OBJECTIVE: To analyze whether nitroglycerin and nifedipine can reduce myocardial stunning due to very brief, repeated coronary ischemias. MATERIAL AND METHODS: In 33 anaesthetized and open chest dogs, the lengthening and shortening fractions were analyzed with ultrasonic crystals in the ischemic and control myocardial areas. Twenty repeated coronary occlusions of 2 minutes each, with a recovery time of 3 minutes between each occlusion, were induced. At the beginning of the experiment, nitroglycerin (0.3 mg i.v. and 80 micrograms/kg/min perfusion) was administered in series A (n = 8), nifedipine (5 mu/kg i.v. and 1 microgram/kg/min perfusion) in series B (n = 9). The results were compared with control results (n = 16) without drugs. RESULTS: Changes in the shortening fraction of the ischemic area during coronary occlusions were similar in all three series; after the last occlusion the shortening fraction in the control series was -14.9% with respect to basal values, -14.6% in series A and -16.6% in series B. Sixty minutes after the last ischemia, the shortening fraction impairment in respect to the basal values was larger in the control series (-18.9%) and in series A (-16.9%). In series B there was recovery (-13.5%) (p < 0.05 vs control series). CONCLUSIONS: Our study indicates that nitroglycerin does not seem to have cardioprotective effects against brief, repeated ischemia. However, nifedipine decreases postischemic dysfunction due to this model of ischemia, probably by avoiding the intracellular Ca overload produced during cardiac ischemia.
Subject(s)
Calcium Channel Blockers/therapeutic use , Myocardial Stunning/drug therapy , Nifedipine/therapeutic use , Nitroglycerin/therapeutic use , Vasodilator Agents/therapeutic use , Analysis of Variance , Animals , Data Interpretation, Statistical , Dogs , Electrocardiography , Hemodynamics , Myocardial Ischemia/complications , Myocardial Ischemia/physiopathology , Myocardial Stunning/etiology , Myocardial Stunning/physiopathology , Time FactorsSubject(s)
Anal Canal/surgery , Fissure in Ano/surgery , Adult , Female , Humans , Male , Methods , Postoperative Complications/epidemiology , Retrospective Studies , Spain/epidemiologyABSTRACT
We describe the unintentional injection of a small amount of local anesthetic with steroids into the subdural space during an attempted lumbar epidural injection for low back pain. When small volumes of local anesthetic are injected into the subdural space, a patchy and unilateral block of greater magnitude than expected will result. When larger volumes of local anesthetic are injected, a massive motor and sensory block can occur due to the small confines of this space. Accidental subdural injection must be recognized early and treated appropriately to avoid serious complications, especially in an outpatient setting.
Subject(s)
Anesthesia, Epidural/adverse effects , Anesthetics, Local/adverse effects , Bupivacaine/adverse effects , Hypotension/etiology , Low Back Pain/therapy , Methylprednisolone/analogs & derivatives , Aged , Female , Humans , Hypotension/chemically induced , Injections, Epidural/adverse effects , Methylprednisolone/adverse effects , Methylprednisolone Acetate , Sensation/drug effects , Spondylolisthesis/complications , Subdural Space/anatomy & histologyABSTRACT
Determinants of dural defects subsequent to deliberate or accidental dural puncture include the equipment, techniques, and the inherent anatomic and biomechanical properties of dura mater. These properties were studied in specimens of human and canine lumbar dura mater in an attempt to delineate the structure of the tissue and to characterize its behavior in biomechanical terms. Human dura had a longitudinal orientation on gross appearance, and was confirmed microscopically to be composed of longitudinal lamella of collagen and elastin fibers. Longitudinal tensile strength and stiffness were greater than transverse tensile strength and stiffness, which is consistent with the dura's apparent anatomic structure and functional requirements. Additional biomechanical testing of the dura demonstrated the property of relaxation which is a characteristic of a viscoelastic material. Significant differences were observed between human and canine dural properties, suggesting limited value of this animal model. Integration of these observed anatomic and biomechanical properties of the lumbar dura provides a greater understanding of dural puncture and may explain previous and often confusing clinical and experimental findings.
Subject(s)
Dura Mater/anatomy & histology , Dura Mater/physiology , Adolescent , Adult , Aged , Aged, 80 and over , Animals , Biomechanical Phenomena , Child , Child, Preschool , Dogs , Female , Humans , In Vitro Techniques , Infant , Infant, Newborn , Lumbar Vertebrae , Male , Middle AgedABSTRACT
Headache is one of the most frequent complications of the subarachnoid puncture. Physiopathology and the different clinical factors involved in this type of headache are reviewed. The treatment is based in two types of procedures: those increasing cerebrospinal fluid production and those trying to decrease its leakage, like the epidural blood patch.
