[2022 Practice guidelines for the management of arterial hypertension of the Spanish Society of Hypertension]. / Guía práctica sobre el diagnóstico y tratamiento de la hipertensión arterial en España, 2022. Sociedad Española de Hipertensión - Liga Española para la Lucha contra la Hipertensión Arterial (SEH-LELHA).

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.

2021 Spanish Society of Hypertension position statement about telemedicine / Documento de consenso sobre consulta telemática en hipertensión y riesgo vascular. Sociedad Española de Hipertensión-Liga Española para la Lucha contra la Hipertensión Arterial (SEH-LELHA)

The pandemic caused by coronavirus SARS-CoV-2 (COVID-19) has forced, in many cases, to replace face-to-face consultation with the telematic consultation, in order to reduce the risk of contagion associated with the presence of patients in health centres. This change may represent an opportunity for a different and more effective communication between professionals and patients, allowing better accessibility to medical care and more systematic and comprehensive approach to patients with hypertension and cardiovascular risk. However, organisational tools are needed to facilitate communication between patients and professionals, specifically with the exchange of clinical data by remote monitoring of variables associated with hypertension and cardiovascular risk (blood pressure, weight, height, blood tests…), and allow monitoring of adherence to treatments, lifestyles and risk factors. It would be desirable for this to be carried out by multidisciplinary teams, both from primary care, hospital and community pharmacy, with an adequate coordination of care. This document of the Spanish Society of Hypertension (SEH-LELHA) tries to give the keys to improve the quality of care of telematic consultations of patients with hypertension and cardiovascular risk, provide basic criteria of telematic or face to face attention and systematise their content. Likewise, the follow-up criteria are proposed by the different professionals. (AU)

La pandemia producida por el coronavirus SARS-CoV-2 (COVID-19) ha obligado, en muchos casos a sustituir la consulta presencial por la consulta telemática para reducir el riesgo de contagio asociado a la presencia de pacientes en los centros sanitarios. Este cambio puede representar una oportunidad para una comunicación diferente y más eficiente entre profesionales y pacientes, permitiendo mejorar la accesibilidad a la atención médica y un abordaje más sistemático e integral a los pacientes con hipertensión y riesgo cardiovascular. No obstante, se necesitan herramientas organizativas que faciliten la comunicación entre pacientes y profesionales, específicamente con intercambio de datos clínicos que favorezcan la monitorización remota de las variables asociadas a la hipertensión y riesgo cardiovascular (presión arterial, peso, talla, variables analíticas…) y permitan realizar un seguimiento adecuado en aspectos como la adherencia a los tratamientos, estilos de vida y factores de riesgo. Todo ello sería deseable que fuera realizado por equipos multidisciplinares, tanto de atención primaria como hospitalaria y farmacia comunitaria, con una coordinación adecuada del cuidado en este tipo de pacientes. Este documento de la Sociedad Española de Hipertensión-Liga Española para la Lucha contra la Hipertensión Arterial (SEH-LELHA) trata de dar las claves para mejorar la calidad asistencial de las consultas telemáticas de los pacientes con hipertensión y riesgo cardiovascular, proporcionar criterios básicos de atención telemática o presencial y sistematizar el contenido de estas. Así mismo se plantean los criterios de seguimiento por los diferentes profesionales. (AU)

2021 Spanish Society of Hypertension position statement about telemedicine.

The pandemic caused by coronavirus SARS-CoV-2 (COVID-19) has forced, in many cases, to replace face-to-face consultation with the telematic consultation, in order to reduce the risk of contagion associated with the presence of patients in health centres. This change may represent an opportunity for a different and more effective communication between professionals and patients, allowing better accessibility to medical care and more systematic and comprehensive approach to patients with hypertension and cardiovascular risk. However, organisational tools are needed to facilitate communication between patients and professionals, specifically with the exchange of clinical data by remote monitoring of variables associated with hypertension and cardiovascular risk (blood pressure, weight, height, blood tests…), and allow monitoring of adherence to treatments, lifestyles and risk factors. It would be desirable for this to be carried out by multidisciplinary teams, both from primary care, hospital and community pharmacy, with an adequate coordination of care. This document of the Spanish Society of Hypertension (SEH-LELHA) tries to give the keys to improve the quality of care of telematic consultations of patients with hypertension and cardiovascular risk, provide basic criteria of telematic or face to face attention and systematise their content. Likewise, the follow-up criteria are proposed by the different professionals.

[Role of the renin-angiotensin system in pregnancy and preeclampsia]. / Papel del sistema renina-angiotensina en el embarazo y la preeclampsia.

The renin-angiotensin system (ARS) is a hormonal cascade that regulates blood pressure, electrolytes and water balance. AngiotensinII (AII) exerts its effects through the AT1 and AT2 receptors. AT1 is found in the syncytiotrophoblast, AT2 predominates during foetal development and its stimulation inhibits cell growth, increases apoptosis, causes vasodilation and regulates the development of foetal tissue. There is also an SRA in the placenta. The local generation of AII is responsible for the activation of AT1 receptors in the trophoblast. In normal pregnancy, concomitantly with reduction of blood pressure the circulating RAS increases, but blood pressure does not rise due to AII refractoriness, which does not occur in preeclampsia. We review the role of the SRA in normal pregnancy and preeclampsia.

Epidemiological multicentre study on the education provided to patients with type 2 diabetes mellitus in the Spanish Health Care System. The Forma2 study.

PURPOSE: The purpose of the present study was to characterize the education that patients with type 2 diabetes mellitus receive, and to identify differences as regards the presence of insulin therapy or not. METHODS: This crossover, multicentre and descriptive study involved 1066 Spanish physicians who completed a questionnaire on Internet. RESULTS: The physicians that responded had a mean of 26.0 years of experience in healthcare, and mainly worked in a walk-in clinic in an urban area. Physicians rated the level of patient knowledge about their disease on a 5.0 point-scale. Fifty percent of them indicated that they spent between 15 and 30min in educating patients at the time of diagnosis. Previous control with HbA1c>9%, presence of microvascular complications, and a low socio-cultural level, were factors associated with spending more time in education. CONCLUSION: This is the first study designed to evaluate the education provided to patients with type 2 diabetes mellitus from Spain. The time spent and the individualization of the education are important factors associated with better long-term control of the disease, and thus with the effectiveness of the clinical management.

[Control of blood pressure by using an intelligent telephone application with feedback and competitiveness strategy. HTApp Control project]. / Control de la presión arterial mediante el uso de una aplicación para teléfono inteligente con estrategia de retroalimentación y competitividad. Proyecto Control HTApp.

INTRODUCTION AND OBJECTIVE: Arterial hypertension is a highly important cardiovascular risk factor, with low control percentages. New technologies can help to obtain a better control of this disease. The intention is to know if a mobile application can help achieve this goal. METHOD: A mobile phone application is used to give feedback to physicians with the aim of generate competitiveness in achieving objectives. The application could, at any time, determine the rate of controlled patients (<140/90mmHg) by each physician, and compare them with the mean number of the patients controlled by the group. The possible changes in the therapeutic attitude of physicians are also analysed and the differences in achieving objectives are compared based on specific characteristics of patients. RESULTS: The study included 220 patients aged 18-80 years, with mean blood pressure>140/90mmHg, despite medical treatment, tracked for 4 visits. At the end of the follow-up, 69.03% achieved good control, compared to 12.8% in the baseline study (P<.001), with no differences between gender (control of 68.6 and 69.29% of women and men, respectively), nor among the different levels of cardiovascular risk. CONCLUSIONS: The use of interactive tools that allow the dynamic process of feedback on the results fosters the motivation and improves the therapeutic inertia in the control of blood pressure.

[Hypertensive disorders during pregnancy: Cardiovascular long-term outcomes]. / Trastornos hipertensivos en el embarazo: repercusión a largo plazo en la salud cardiovascular de la mujer.

Pregnancy-induced hypertension (PIH) induces maternal and fetal damage, but it can also be the beginning of future metabolic and vascular disorders. The relative risk of chronic hypertension after PIH is between 2.3 and 11, and the likelihood of subsequent development of type 2 diabetes is multiplied by 1.8. Women with prior preeclampsia/eclampsia have a twofold risk of stroke and a higher frequency of arrhythmias and hospitalization due to heart failure. Furthermore, a tenfold greater risk for long-term chronic kidney disease is observed as well. The relative risk of cardiovascular death is 2.1 times higher compared to the group without pregnancy-induced hypertension problems, although the risk is between 4 and 7 times higher in preterm birth associated with gestational hypertension or pre-existing hypertension The postpartum period is a great opportunity to intervene on lifestyle, obesity, make an early diagnosis of chronic hypertension and DM and provide the necessary treatments to prevent cardiovascular complications in women.

[Circulating endothelial progenitor cell levels in treated hypertensive patients]. / Niveles de células progenitoras endoteliales circulantes en pacientes hipertensos tratados.

INTRODUCTION: Most optimally treated hypertensive patients still have an around 50% increased risk of any cardiovascular event, suggesting the possible existence of unidentified risk factors. In the last years there has been evidence of the essential role of circulating endothelial progenitor cells (EPCs) in the maintenance of endothelial integrity and function, increasing the interest in their involvement in cardiovascular disease. In this study, the circulating levels of EPCs and vascular endothelial growth factor (VEGF) are investigated in treated hypertensive patients with adequate control of blood pressure (BP). MATERIAL AND METHODS: Blood samples were collected from treated hypertensive patients with controlled BP. Plasma levels of EPCs CD34+/KDR+ and CD34+/VE-cadherin+ were quantified by flow cytometry. Plasma concentration of VEGF was determined by ELISA. A group of healthy subjects without cardiovascular risk factors was included as controls. RESULTS: A total of 108 hypertensive patients were included (61±12 years, 47.2% men) of which 82.4% showed BP<140/90 mmHg, 91.7% and 81.5% controlled diabetes (HbA1c <7%) and cLDL (<130 or 100 mg/dL), respectively, and 85.2% were non-smokers. Around 45% of them were obese. Although patients had cardiovascular parameters within normal ranges, they showed significantly lower levels of CD34+/KDR+ and CD34+/VE-cadherin+ compared with healthy control group, although plasma VEGF concentration was higher in patients than in controls. CONCLUSIONS: Despite an optimal treatment, hypertensive patients show a decreased number of circulating EPCs that could be, at least in part, responsible for their residual cardiovascular risk, suggesting that these cells could be a therapeutic target.

A review of renal, cardiovascular and mortality endpoints in antihypertensive trials in diabetic patients.

Renal disease is highly prevalent in people with type 2 diabetes, and co-existence with hypertension increases the risk of cardiac events and mortality. Despite many large randomized trials, controversies remain regarding optimal antihypertensive therapy in diabetic patients, including whether some classes of antihypertensive drugs have specific renal protective properties, and the relationships between renal, cardiovascular and mortality endpoints. In this article, we review landmark antihypertensive drug trials from the last two decades in patient populations composed, or including substantial proportions, of patients with type 2 diabetes. Several points emerge. Firstly, treatment effects can vary widely among different renal, cardiovascular and mortality endpoints. Secondly, combinations of antihypertensive drugs vary in their ability to prevent major renal and cardiovascular events, even if they produce similar reductions in blood pressure. Thirdly, simply adding further antihypertensive drugs may not improve outcomes, even if it produces further reductions in blood pressure. In most trials, a reduction in microalbuminuria was associated with evidence of renal protection, but further evidence is needed relating changes in proteinuria with cardiovascular risk. The study that aligns best with the current reappraisal of ESH guidelines, with regard to blood pressure goals, use of an adequate combination and simultaneously protecting the kidney and the cardiovascular system, is the ADVANCE study.

Efectos renales de los antagonistas del calcio / Renal effects of calcium antagonists

Los antagonistas del calcio son una familia de fármacos antihipertensivos que, ampliamente, han demostrado poseer una elevada eficacia, por lo que son empleados de forma generalizada. La prevención del deterioro de la función renal debe ser una prioridad en la evolución del paciente hipertenso, lo que resulta especialmente relevante debido a la creciente prevalencia de insuficiencia renal crónica en la población general. Los datos disponibles sobre función renal y tratamiento con antagonistas del calcio en pacientes hipertensos, tanto con función renal normal como con enfermedad renal establecida, demuestran que los antagonistas del calcio son fármacos efectivos que deben considerarse de forma preferente tanto en monoterapia como en combinación con otro fármaco con capacidad de inhibición del eje renina-angiotensina-aldosterona(AU)

Calcium antagonists are a family of antihypertensive drugs that have been widely shown to have high efficacy so they are widely used. Prevention of kidney function deterioration should be a priority in the course of the hypertensive patient. This is especially important due to the growing prevalence of chronic kidney failure in the general population. The data available on kidney function and treatment with calcium antagonists in hypertensive patients both with normal renal function as well as with established renal disease show that calcium antagonists are effective drugs that should be considered preferentially as single drug therapy as well as in combination with another drug with the capacity to inhibit the renin-angiotensin-aldosterone axis(AU)

Ventajas potenciales de aliskiren, el primer inhibidor de la renina / Potential advantages of aliskiren, the first renin inhibitor

A la hora de plantear el tratamiento más efi caz del paciente hipertensoresulta imprescindible lograr la inhibición óptima del sistema renina-angiotensina-aldosterona (SRAA), por ser una pieza clave como objetivofarmacológico en la prevención de la enfermedad vascular. El tratamientocon los inhibidores de la enzima conversora de la angiotensina (IECA)y los antagonistas de los receptores AT1 de la angiotensina II ha demostradoposeer un efecto antihipertensivo moderadamente efi caz, que setraduce en benefi cio en la morbilidad y mortalidad. Sin embargo, un grannúmero de pacientes hipertensos en todas las fases del continuum cardiovascularno logran alcanzar la prevención del desarrollo de lesiónorgánica y su posterior regresión para evitar la aparición de episodioscardiovasculares. En esta fase es especialmente importante el bloqueodel sistema renina-angiotensina para retrasar el desarrollo de un nuevoepisodio. La aparición de una nueva familia de antihipertensivos, los inhibidoresdirectos de la renina (IDR), cuyo representante es aliskiren, hagenerado una gran expectación, ya que cuentan con un creciente númerode evidencias que avalan su efi cacia antihipertensiva, tanto enmonoterapia como en combinación farmacológica, y ofrecen resultadosde buena tolerabilidad y perfi l de seguridad, además de datos benefi ciosos sobre protección orgánica(AU)

Optimal and most efficient antihipertensive therapy must achieve abest possible renin-angiotensin-aldosterone system inhibition. Thisstrategy is a key point as a therapeutic target in order to preventcardiovascular disease. Treatment with angiotensin converting enzymeinhibitors and angiotensin receptor blockers has shown to offeran appropriate blood pressure lowering effect, which translates incardiovascular mortality reduction. Nevertheless, a high population ofhypertensives included in each and every stage of the cardiovascularcontinuum does not attain prevention of the development of targetorgan damage and its latter regression in order to avoid cardiovascularevents. Appearance of a new family of antihipertensive drugs,direct renin inhibitors, as aliskiren, has aroused great interest due toits increasing number of evidences that endorses its antihipertensiveeffectiveness and organ protection, both in monotherapy and as apharmacological combination with a good tolerability and securityprofile(AU)

Importancia de la prevención de la fibrilación auricular en el paciente hipertenso / Importance of the prevention of atrial fibrillation in the hypertensive patient

La hipertensión arterial (HTA) es una patología altamente prevalente, asociándose su presencia a innumerables complicaciones, especialmente cardiovasculares. La fibrilación auricular ocupa un lugar destacado dentro de las manifestaciones de la cardiopatía hipertensiva. La fibrilación auricular es la arritmia cardíaca sostenida más frecuente. Aproximadamente el 70 % de los pacientes afectados se encuentran entre los 65 y 85 años. Los factores de riesgo relacionados con el desarrollo de fibrilación auricular son fundamentalmente la edad, la HTA, la diabetes, la obesidad, la hipertrofia ventricular izquierda y la presencia de enfermedad cardiovascular. La mortalidad en la fibrilación auricular es el doble cuando se la compara con las personas en ritmo sinusal. En la población española el riesgo de ictus aumenta de forma independiente en los pacientes con fibrilación auricular, con cifras de riesgo de 2 a 7 veces más elevadas. En los pacientes con insuficiencia cardíaca congestiva la incidencia de fibrilación auricular va del 15 % al 30 % y conlleva una mayor morbimortalidad y un incremento en el número de hospitalizaciones. El tratamiento agresivo de la HTA, principal factor de riesgo, puede invertir los cambios estructurales en el corazón y retardar o prevenir la ocurrencia de fibrilación auricular. Estudios recientes han demostrado el importante papel clínico de la inhibición del sistema renina-angiotensina-aldosterona en la prevención de la fibrilación auricular

Arterial hypertension is a highly prevalent disease, its presence being associated to numerous complications, especially cardiovascular one. Atrial fibrillation occupies an important place among the manifestations of hypertensive heart disease. Atrial fibrillation is the most frequent sustained cardiac arrhythmia. Approximately 70 % of the affected patients are between 65 and 85 years old. The risk factors related to the development of atrial fibrillation are fundamentally age, arterial hypertension, diabetes, obesity, left ventricular hypertrophy and the presence of cardiovascular disease. Mortality in atrial fibrillation is double when it is compared with those having sinus rhythm. In the Spanish population, the risk of stroke increases independently in patients with atrial fibrillation, the risk values being 2 to 7 times higher. In the patients with congestive heart failure the incidence of atrial fibrillation goes from 15 % to 30 %, and it entails a greater morbidity and mortality and an increase in the number of hospitalizations. Aggressive treatment of the arterial hypertension, the main risk factor, can invert the structural changes in the heart and slow down or prevent the occurrence of atrial fibrillation. Recent studies have demonstrated the important clinical role of inhibiting the renin angiotensin system in the prevention of atrial fibrillation

Influencia de la prediabetes en el pronóstico cardiovascular del paciente hipertenso / Influence of prediabetes in the cardiovascular prognosis of the hypertensive patient

Las diversas características de los pacientes que presentan un riesgo elevado de desarrollar diabetes mellitus han sido descritas de forma reciente, siendo las principales una concentración de glucosa sérica más elevada, índice de masa corporal aumentado, presión arterial sistólica elevada, una cifra de colesterol HDL bajo y la presencia de tratamiento antihipertensivo previo. Sin embargo, se sabe poco respecto al pronóstico a largo plazo de este grupo de pacientes, también denominados «prediabéticos». El estado prediabético ha sido definido por la presencia de intolerancia hidrocarbonada o glucemia anómala en ayunas. Las evidencias acumuladas sugieren que los individuos con hiperglucemia en rango no diabético (prediabéticos) presentan riesgo aumentado de enfermedades cardiovasculares. Esta revisión analiza la necesidad de reconocer de forma precoz a los pacientes hipertensos prediabéticos para desarrollar estrategias de protección cardiovascular y de esta forma disminuir las consecuencias de la precipitación del desarrollo de diabetes y sus efectos deletéreos cardiovasculares y renales

The different characteristics of patients who have an elevated risk of developing diabetes mellitus have recently been described, the main ones being higher serum glucose concentration, increased body mass index, elevated systolic blood pressure, low HDL-cholesterol value and presence of previous antihypertensive treatment. However, little is known about the long term prognosis of this group of patients, also called "prediabetics". The prediabetic state has been defined by the presence of hydrocarbonate intolerance of abnormal fasting glycemia. The accumulated evidence suggests that individuals with hyperglycemia in the non-diabetic range (prediabetics) have increased risk of cardiovascular diseases. This review analyzes the need to recognize prediabetic hypertensive patients early to develop cardiovascular protection strategies and, in this way, to decrease the consequences of the precipitation of the development of diabetes and its cardiovascular and renal harmful effects

Pregnancy in renal transplant recipients.

Fertility is restored after renal transplantation when good function is achieved. Our aim was to describe the gestations of our transplanted patients, analyzing outcomes and complications as well as long-term evolution of renal function. From 1976 to 2004, 43 gestations occurred in 35 renal transplanted women: their mean age was 31.7 +/- 4.06 years, with a mean time from the transplant to pregnancy of 4.32 years (0.4-13). At conception, all showed normal renal function (SCr 1.05 +/- 0.2 mg/dL). There were 19 abortions (43.8%), 9 of them spontaneous (21%) and 10 therapeutic (six cases for noncompliance with described criteria of European Best Practice Guidelines for Renal Transplantation, especially pregnancy less than 6 months after transplantation). Excluding these six cases of therapeutic abortions, 24 successful pregnancies occurred in 37 women (65.7%), although eight (29.1%) had premature delivery with live fetuses. Arterial hypertension was the most frequently complication (64%). Preeclampsia occurred in nine (37.5%) pregnancies, with proteinuria in five and only two with mild renal function deterioration. The majority of patients received cyclosporine (n = 20) or tacrolimus (n = 19). Since 1996, mycophenolate mofetil and sirolimus were stopped before conception. Birth weight was lower than 2500 g in 33.3% of pregnancies. Every newborn baby was healthy. Afterward, of the 24 patients with successfully pregnancy, 21 (87.5%) have functioning renal transplants at 53.2 months. After delivery, all currently show good renal function (SCr 1.16 +/- 0.35 mg/dL, CrCl 91 +/- 28.45 mL/m). In conclusion, pregnancy in our renal transplant women shows a success rate of 65.6%. However, complications related to arterial hypertension such as preeclampsia are frequent. The incidence of spontaneous abortions was similar to other series (21%). Long-term graft survival does not seem to be negatively affected by pregnancy.

Tacrolimus as basic immunosuppression in pregnancy after renal transplantation. A single-center experience.

Renal transplantation restores fertility within an average of 6 months, so women of childbearing age are able to consider pregnancy. Successful pregnancies have been reported in recent years under different immunosuppressive regimens, but the optimal treatment to achieve the maximum safety for both the mother and fetus remains unclear. Tacrolimus has been demonstrated to provide long-term immunosuppression and prevent rejection in most renal transplants. It seems safe, but experience is limited compared with cyclosporine. We report our experience highlighting the high rate of successful pregnancies attained in women treated with tacrolimus as the basic immunosuppressant and advised of recommendations to achieve a healthy newborn. Renal function was preserved during the pregnancy. The puerperal period and the rate of gestation-related difficulties appeared similar to that of the general population.

[Relapsing nephrotic syndrome in a diabetic patient with minimal change]. / Síndrome nefrótico recidivante por lesiones mínimas en un paciente diabético.

Although nondiabetic nephropathies are common among type 2 diabetic patients, very few cases of minimal change nephrotic syndrome have been reported in diabetic patients. We describe a type 2 diabetic patient that rapidly developed a nephrotic syndrome accompanied by a mild worsening of renal function. Proteinuria was negative one year before and no signs of diabetic retinopathy were found. Renal biopsy established the diagnosis of minimal change disease. Steroid treatment induced a complete remission of nephrotic syndrome and recovery of normal renal function. However, massive proteinuria relapsed two years later. A second cycle of steroids was followed by a disappearance of proteinuria, but a third bout of nephrotic syndrome was observed 6 months later. An 8-weeks cycle of steroids plus chlorambucil induced a complete and persistent remission. Throughout a five-year follow up, no relapse of the nephrotic syndrome was observed and microalbuminuria is negative.