The situation of infection in the elderly in Spain: a multidisciplinary opinion document / Situación de la infección en el anciano: un documento multidisciplinar de opinión

Infection in the elderly is a huge issue whose treatment usually has partial and specific approaches. It is, moreover, one of the areas where intervention can have the most success in improving the quality of life of older patients. In an attempt to give the widest possible focus to this issue, the Health Sciences Foundation has convened experts from different areas to produce this position paper on Infection in the Elderly, so as to compare the opinions of expert doctors and nurses, pharmacists, journalists, representatives of elderly associations and concluding with the ethical aspects raised by the issue. The format is that of discussion of a series of pre-formulated questions that were discussed by all those present. We begin by discussing the concept of the elderly, the reasons for their predisposition to infection, the most frequent infections and their causes, and the workload and economic burden they place on society. We also considered whether we had the data to estimate the proportion of these infections that could be reduced by specific programmes, including vaccination programmes. In this context, the limited presence of this issue in the media, the position of scientific societies and patient associations on the issue and the ethical aspects raised by all this were discussed

La infección en los ancianos es un tema enorme que suele recibir enfoques muy específicos pero parciales. Además, es una de las áreas en las que la intervención podría tener más éxito para mejorar la calidad de vida de los pacientes mayores. En un intento de dar el mayor enfoque posible a este tema, la Fundación de Ciencias de la Salud ha convocado a expertos de diferentes áreas para elaborar este documento de opinión sobre la situación de la infección en los ancianos, tratando de comparar las opiniones de médicos expertos, enfermeras, farmacéuticos, periodistas, representantes de asociaciones de ancianos y terminando con los aspectos éticos que plantea el problema. El formato es el de la discusión de una serie de preguntas preformuladas que fueron discutidas entre todos los presentes. Empezamos discutiendo el concepto de "anciano", las razones de la predisposición a la infección, las infecciones más frecuentes y sus causas, y la carga laboral y económica que suponen para la sociedad. También preguntamos si teníamos datos para estimar la proporción de estas infecciones que podrían ser reducidas por programas específicos, incluyendo programas de vacunación. En este contexto, se discutió la baja presencia de este problema en los medios de comunicación, la posición de las asociaciones científicas y de pacientes sobre el problema y los aspectos éticos que todo esto plantea

Factors associated with discontinuing or not starting oral anticoagulant therapy in older hospitalized patients with non-valvular atrial fibrillation.

AIM: To determine the factors associated with discontinuing or not starting oral anticoagulation (OA) therapy in older patients with non-valvular atrial fibrillation (NVAF). METHODS: A prospective, multicenter cohort study was carried out of patients aged >75 years with NVAF hospitalized in internal medicine departments in Spain. For each patient, we recorded creatinine, hemoglobin and platelets levels, as well as CHA2DS2-VASc and HAS-BLED scores and the Charlson Comorbidity Index. We measured the ability to carry out basic activities of daily life with the Barthel Index, and the cognitive state with the Short Portable Mental Status questionnaire. RESULTS: We included 723 patients with NVAF, with a mean age of 84.8 years (SD 5.2 years); 390 (53.9%) of the patients were women. Before admission, 375 (51.9%) patients were treated with OA. Previously diagnosed NVAF (OR 4.099, 95% CI 1.824-9.211, P = 0.001), the number of errors in the Short Portable Mental Status questionnaire (OR 1.180, 95% CI 1.020-1.365, P = 0.026), peripheral arterial disease (OR 0.285, 95% CI 0.114-0.711, P = 0.007) and hemoglobin levels (OR 0.812, 95% CI 0.682-0.966, P = 0.019) were independently associated with not starting OA therapy at discharge. Of the 375 patients treated with OA at admission, 87 (23.2%) had their OA discontinued at discharge. The HAS-BLED score (OR 1.516, 95% CI 1.211-1.897, P < 0.001) and previous acute myocardial infarction (OR 0.327, 95% CI 0.121-0.883, P = 0.027) were associated with the discontinuation of OA. CONCLUSIONS: There are factors associated with discontinuing or not starting OA in older patients with NVAF, which often have no clinical justification. Geriatr Gerontol Int 2018; 18: 1219-1224.

Características y tratamiento antitrombótico de los pacientes ancianos con fibrilación auricular no valvular hospitalizados en Medicina Interna. Registro NONAVASC / Antithrombotic treatment and characteristics of elderly patients with non-valvular atrial fibrillation hospitalized at Internal Medicine departments. NONAVASC registry

Introducción y objetivos. La prevalencia de fibrilación auricular no valvular (FANV) aumenta con la edad y se asocia a alta morbimortalidad. El objetivo principal fue conocer las características de los pacientes ancianos con FANV hospitalizados y los factores clínico-funcionales que determinan la estrategia antitrombótica utilizada. Pacientes y métodos. Estudio observacional, prospectivo, multicéntrico realizado en pacientes mayores de 75 años con FANV, hospitalizados por cualquier causa en Medicina Interna. Resultados. Se evaluaron 804 pacientes con una edad media de 85 años (rango: 75-101); el 53,9% fueron mujeres. La prevalencia de factores de riesgo y enfermedades vasculares fue elevada: hipertensión (87,6%), insuficiencia cardíaca (65,4%), cardiopatía isquémica (24,4%), enfermedad cerebrovascular (22,4%) e insuficiencia renal (45%). Entre los pacientes con diagnóstico previo al ingreso de FANV el 86,2% recibía tratamiento antitrombótico: anticoagulantes (59,7%), antiagregantes (AAG) (17,8%) y doble terapia (8,7%). Los factores asociados con la utilización del mismo fueron el antecedente de síndrome coronario agudo y la FANV de más de un año de evolución. Se asociaron con el uso de antiagregación la edad avanzada, la FANV de menos de un año de evolución, las puntuaciones superiores de HAS-BLED y el deterioro cognitivo grave. La fibrilación auricular permanente favorecía la prescripción de anticoagulantes. Conclusiones. Los pacientes mayores de 75 años con FANV hospitalizados en Medicina Interna tienen numerosas comorbilidades. El porcentaje de anticoagulación es escaso y un 18% recibe solo antiagregación, influyendo en su selección la edad, el tiempo de evolución de la fibrilación auricular y la gravedad del deterioro cognitivo (AU)

Background and objetives. The prevalence of non-valvular atrial fibrillation (NVAF) increases with the patient's age and is associated with high morbi-mortality rates. The main goal of this study was to describe the characteristics of hospitalized elderly patients with NVAF and to identify the clinical and functional factors which determine the use of different antithrombotic strategies. Patients and methods. Observational, prospective, multicentre study carried out on patients with NVAF over the age of 75, who had been admitted for any medical condition to Internal Medicine departments. Results. We evaluated 804 patients with a mean age of 85 years (range 75-101), of which 53.9% were females. The prevalence of risk factors and cardiovascular disease was high: hypertension (87.6%), heart failure (65.4%), ischemic cardiomyopathy (24.4%), cerebrovascular disease (22.4%) and chronic kidney disease (45%). Among those cases with previous diagnoses of NVAF, antithrombotic treatment was prescribed in 86.2% of patients: anticoagulants (59.7%), antiplatelet medication (17.8%) and double therapy (8.7%). The factors associated with the use of antithrombotic treatment were history of acute coronary syndrome and atrial fibrillation progression longer than one year. Older age, atrial fibrillation for less than one year, higher HAS-BLED scores and severe cognitive impairment were associated with the use of anti-platelet drugs. Permanent atrial fibrillation favoured the use of anticoagulants. Conclusions. Hospitalized patients older than 75 years old with NVAF showed numerous comorbidities. The percentage of anticoagulation was small and 18% received only anti-platelet therapy. The patient's age, atrial fibrillation's progression time and the severity of the cognitive impairment influenced this therapy choice (AU)

Changes in the expression of α1B-adrenoceptor in peripheral mononuclear cells correlates with blood pressure and plasmatic homocysteine.

Human peripheral mononuclear cells (HPMC) have been suggested as a practical surrogate for myocardial or vascular cells. Present work analyses if changes in the expression of α1-adrenoceptors (ARs) in HPMC are related to the hypertensive state and its clinical consequences. Quantitative RT-PCR was employed to evaluate the mRNA levels of the three α1-ARs (α1A, α1B, α1D) in HPMC isolated from normotensive and hypertensive patients, and also in tissues from two animal models of hypertension: spontaneously hypertensive rats (SHR) and hypertension induced by chronic treatment with L-NAME. In patients, 24-h ambulatory blood pressure and serum biochemical profile were also recorded. We found that α1B-AR expression was higher in HPMC from hypertensive patients and correlated with blood pressure and plasmatic homocysteine. A rise in the α1B-AR expression in kidneys, but not in heart from hypertensive animal models was also found. α1D-AR did not change in HPMC, not in rat heart or kidney, but a significant correlation with plasmatic aldosterone was found. In conclusion, we have proved that α1-ARs mRNA expression in HPMC correlates with clinical variables and could be used as a potential biomarker in hypertensive patients.

Antithrombotic treatment and characteristics of elderly patients with non-valvular atrial fibrillation hospitalized at Internal Medicine departments. NONAVASC registry. / Características y tratamiento antitrombótico de los pacientes ancianos con fibrilación auricular no valvular hospitalizados en Medicina Interna. Registro NONAVASC.

BACKGROUND AND OBJETIVES: The prevalence of non-valvular atrial fibrillation (NVAF) increases with the patient's age and is associated with high morbi-mortality rates. The main goal of this study was to describe the characteristics of hospitalized elderly patients with NVAF and to identify the clinical and functional factors which determine the use of different antithrombotic strategies. PATIENTS AND METHODS: Observational, prospective, multicentre study carried out on patients with NVAF over the age of 75, who had been admitted for any medical condition to Internal Medicine departments. RESULTS: We evaluated 804 patients with a mean age of 85 years (range 75-101), of which 53.9% were females. The prevalence of risk factors and cardiovascular disease was high: hypertension (87.6%), heart failure (65.4%), ischemic cardiomyopathy (24.4%), cerebrovascular disease (22.4%) and chronic kidney disease (45%). Among those cases with previous diagnoses of NVAF, antithrombotic treatment was prescribed in 86.2% of patients: anticoagulants (59.7%), antiplatelet medication (17.8%) and double therapy (8.7%). The factors associated with the use of antithrombotic treatment were history of acute coronary syndrome and atrial fibrillation progression longer than one year. Older age, atrial fibrillation for less than one year, higher HAS-BLED scores and severe cognitive impairment were associated with the use of anti-platelet drugs. Permanent atrial fibrillation favoured the use of anticoagulants. CONCLUSIONS: Hospitalized patients older than 75 years old with NVAF showed numerous comorbidities. The percentage of anticoagulation was small and 18% received only anti-platelet therapy. The patient's age, atrial fibrillation's progression time and the severity of the cognitive impairment influenced this therapy choice.

Orthogeriatric care: improving patient outcomes.

Hip fractures are a very serious socio-economic problem in western countries. Since the 1950s, orthogeriatric units have introduced improvements in the care of geriatric patients admitted to hospital because of hip fractures. During this period, these units have reduced mean hospital stays, number of complications, and both in-hospital mortality and mortality over the middle term after hospital discharge, along with improvements in the quality of care and a reduction in costs. Likewise, a recent clinical trial has reported greater functional gains among the affected patients. Studies in this field have identified the prognostic factors present upon admission or manifesting themselves during admission and that increase the risk of patient mortality or disability. In addition, improved care afforded by orthogeriatric units has proved to reduce costs. Nevertheless, a number of management issues remain to be clarified, such as the optimum anesthetic, analgesic, and thromboprophylactic protocols; the type of diagnostic and therapeutic approach best suited to patients with cognitive problems; or the efficiency of the programs used in convalescence units or in home rehabilitation care. Randomized clinical trials are needed to consolidate the evidence in this regard.

ß2- and ß1-Adrenoceptor Expression Exhibits a Common Regulatory Pattern With GRK2 and GRK5 in Human and Animal Models of Cardiovascular Diseases.

To explore if genic expression of ß(1)- or ß(2)-adrenoceptors (ARs) exhibits a common regulatory pattern with G protein-coupled receptor kinase (GRK) 2, GRK3, or GRK5 expression, we determined messenger RNA levels for these genes in different tissues from human and animal models of cardiovascular disease. We measured genic expression by qRT polymerase chain reaction in the left and right ventricles or peripheral blood mononuclear cells from healthy (n = 21), hypertensive (n = 20), heart failure (n = 24), and heart transplanted patients (n = 17) or in left ventricle, peripheral blood mononuclear cells, and kidney from spontaneously hypertensive rats or L-N-methyl-arginine-induced hypertensive rats and their respective controls (n = 4-5). In diseased versus healthy subjects and rats, parallel changes in messenger RNA levels of GRK2 and ß(2)-AR or GRK5 and ß(1)-AR were observed in each territory. Therefore, without excluding other regulatory mechanisms, the parallelism observed suggests a common regulatory pattern for the ß(1)-AR/GRK5 and ß(2)-AR/GRK2 genes, which is independent of cellular type or pathology. This highlights the need to focus not only on GRKs but also on ß(1)- or ß(2)-AR changes to completely understand the involvement of ß-AR/GRK pathways in cardiovascular diseases.

Unanswered clinical questions in the management of cardiometabolic risk in the elderly: a statement of the Spanish Society of Internal Medicine.

BACKGROUND: Despite the progressive increase in life expectancy and the relationship between aging with multi-morbidities and the increased use of healthcare resources, current clinical practice guidelines (CPG) on cardiometabolic risk cannot be adequately applied to elderly subjects with multiple chronic conditions. Its management frequently becomes complicated by both, an excessive use of medications that may lead to overtreatment, drug interactions and increased toxicity, and errors in dosage and non-compliance. Concerned by this gap, the Spanish Society of Internal Medicine created a group of independent experts on cardiometabolic risk who discussed what they considered to be unanswered questions in the management of elderly patients. DISCUSSION: Current guidelines do not specifically address the problem of elderly with multiple chronic conditions. For this reason, the combined use of the limited available evidence, clinical experience and common sense, could all help us to address this unmet need. In very old people, life expectancy and functionality are the most important factors for guiding potential treatments. Their higher propensity to develop serious adverse events and their shorter lifespan could prevent them from obtaining the potential benefits of the interventions administered. SUMMARY: In this document, experts on cardiometabolic risk factors have established a number of consensual recommendations that have taken into account international guidelines and clinical experience, and have also considered the more effective use of healthcare resources. This document is intended to provide general recommendations for clinicians and to promote the effective use of procedures and medications.

Factores relacionados con la presencia de disfunción eréctil en pacientes con síndrome de apnea obstructiva del sueño / Factors related with the presence of erectile dysfunction in patients with obstructive sleep apnea

Fundamento y objetivo: El síndrome de apnea obstructiva del sueño (SAOS) puede contribuir al desarrollo de disfunción eréctil (DE) a través de múltiples mecanismos. El objetivo fue identificar los factores que están relacionados con la presencia de DE en estos pacientes. Pacientes y método: Estudio transversal en varones diagnosticados de SAOS. Se recogieron variables demográficas, índice de apneas-hipopneas (IAH), comorbilidad, fármacos, presión arterial, escala Epworth, exploración física, electrocardiograma, índice tobillo-brazo, analítica sanguínea y de orina. La presencia de DE se valoró mediante el cuestionario IIEF-5. Resultados: Se incluyeron 142 pacientes, con una edad media (desviación estándar) de 53 (11) años. La prevalencia de DE fue del 69%. Encontramos diferencias significativas en el IAH entre los pacientes con DE leve y grave (41 [21] frente a 63 [18]; p=0,023). La DE se asoció a la hipertensión arterial [HTA] (odds ratio [OR] 3,56; intervalo de confianza del 95% [IC 95%] 1,64-7,72), hipercolesterolemia (OR 7,19; IC 95% 2,39-21,68), diabetes mellitus tipo 2 (OR 3,07; IC 95% 1,02-9,48) y cardiopatía isquémica (OR 1,51; IC 95% 1,33-1,70), así como al tratamiento con antihipertensivos (OR 4,05; IC 95% 1,76-9,31), hipolipidemiantes (OR 9,71; IC 95% 2,21-22,72), antidiabéticos (OR 3,21; IC 95% 0,69-14,89), antiagregantes y anticoagulantes (OR 6,44; IC 95% 1,45-28,64). Tras el análisis de regresión logística, la DE se asoció con la edad (OR 1,11; IC 95% 1,05-1,16) y la hipercolesterolemia (OR 4,87; IC 95% 1,49-15,96). Conclusiones: Los pacientes con SAOS tienen una alta prevalencia de DE, principalmente en SAOS grave. Los factores que influyen en la presencia de la DE en pacientes con SAOS son fundamentalmente la edad y la hipercolesterolemia. Otros factores que pueden estar relacionados son la HTA, el mal control metabólico, la cardiopatía isquémica y el consumo de antihipertensivos, estatinas y antidiabéticos (AU)

Background and objective: Obstructive sleep apnea (OSA) syndrome can contribute to the development of erectile dysfunction (ED) through multiple mechanisms. The aim was to identify factors influencing the presence of ED in these patients. Patients and methods: Cross sectional study in men diagnosed with OSA by polysomnography. We obtained information about demographic variables, apnea-hypopnea index (AHI), comorbidity, blood pressure, drugs, Epworth Sleepiness Scale, physical examination, electrocardiogram, ankle-brachial index and blood and urine analysis. The presence of ED was assessed by questionnaire IIEF-5. Results: We included 142 patients, mean age was 53 (11) years. The prevalence of ED was 69%. We found significant differences in AHI between patients with mild and severe ED (41 [21] vs 63 [18], P=.023). ED was associated with hypertension (odds ratio [OR]=3.56 [1.64-7.72]), hypercholesterolemia (OR=7.19 [2.39-21.68]), diabetes mellitus type 2 (OR=3.07 [1.02-9.48]) and ischemic heart disease (OR=1.51 [1.33-1.70]); and treatment with antihypertensive (OR=4.05 [1.76-9.31)], lipid-lowering drugs (OR=9.71 [2.2-22.72]), anti-diabetic drugs (OR=3.21 [0.69-14.89]), antiplatelet and anticoagulant agents (OR=6.44 [1.45-28.64]). After logistic regression analysis, only age (OR=1.11 [1.05-1.16]) and hypercholesterolemia (OR=4.87 [1.49-15.96]) were associated with ED. Conclusions: Patients with OSA have a high prevalence of ED, mainly in severe OSA. Factors influencing the presence of ED in patients with OSA are primarily age and hypercholesterolemia. Other factors that may be related include hypertension, poor metabolic control, ischemic heart disease, and treatment with antihypertensive, lipid-lowering and anti-diabetic drugs (AU)

[Factors related with the presence of erectile dysfunction in patients with obstructive sleep apnea]. / Factores relacionados con la presencia de disfunción eréctil en pacientes con síndrome de apnea obstructiva del sueño.

BACKGROUND AND OBJECTIVE: Obstructive sleep apnea (OSA) syndrome can contribute to the development of erectile dysfunction (ED) through multiple mechanisms. The aim was to identify factors influencing the presence of ED in these patients. PATIENTS AND METHODS: Cross sectional study in men diagnosed with OSA by polysomnography. We obtained information about demographic variables, apnea-hypopnea index (AHI), comorbidity, blood pressure, drugs, Epworth Sleepiness Scale, physical examination, electrocardiogram, ankle-brachial index and blood and urine analysis. The presence of ED was assessed by questionnaire IIEF-5. RESULTS: We included 142 patients, mean age was 53 (11) years. The prevalence of ED was 69%. We found significant differences in AHI between patients with mild and severe ED (41 [21] vs 63 [18], P=.023). ED was associated with hypertension (odds ratio [OR]=3.56 [1.64-7.72]), hypercholesterolemia (OR=7.19 [2.39-21.68]), diabetes mellitus type 2 (OR=3.07 [1.02-9.48]) and ischemic heart disease (OR=1.51 [1.33-1.70]); and treatment with antihypertensive (OR=4.05 [1.76-9.31)], lipid-lowering drugs (OR=9.71 [2.2-22.72]), anti-diabetic drugs (OR=3.21 [0.69-14.89]), antiplatelet and anticoagulant agents (OR=6.44 [1.45-28.64]). After logistic regression analysis, only age (OR=1.11 [1.05-1.16]) and hypercholesterolemia (OR=4.87 [1.49-15.96]) were associated with ED. CONCLUSIONS: Patients with OSA have a high prevalence of ED, mainly in severe OSA. Factors influencing the presence of ED in patients with OSA are primarily age and hypercholesterolemia. Other factors that may be related include hypertension, poor metabolic control, ischemic heart disease, and treatment with antihypertensive, lipid-lowering and anti-diabetic drugs.

beta-Adrenoceptor and GRK3 expression in human lymphocytes is related to blood pressure and urinary albumin excretion.

OBJECTIVE: The objective of our work was to analyze if changes in the expression of beta-adrenoceptors (beta-ARs) and G-protein-coupled receptor kinases (GRKs) in human lymphocytes - a practical surrogate for myocardial or vascular cells - are related to the hypertensive state and its clinical consequences. METHODS: Real-time quantitative RT-PCR was employed to evaluate the expression of the three beta-ARs (beta1, beta2, beta3) and three GRKs (GRK2, GRK3, GRK5) in human lymphocytes obtained from both normotensive and hypertensive patients, some of whom had been treated with blockers of the renin-angiotensin system. Office blood pressure, 24-h ambulatory blood pressure, urinary albumin excretion and serum biochemical profile were also recorded. RESULTS AND CONCLUSIONS: beta1-AR expression levels were higher in circulating lymphocytes from hypertensive patients (2-DeltaDeltaCt = 2.135 +/- 0.4252*, vs. control group), but this difference was not observed when these patients were treated with blockers of the renin-angiotensin system. beta1-AR levels directly correlated (r2 = 0.5711, P = 0.0185) with urinary albumin excretion in microalbuminuric patients, which relates alterations of this receptor to cardiovascular risk. An inverse correlation was observed between the expression levels of beta2-AR and diastolic blood pressure (r2 = 0.2078, P = 0.0031), suggesting that beta2-AR levels in lymphocytes mirror their expression in vascular cells, in which beta2-AR-mediated relaxation regulates vascular resistance. mRNA levels for GRK3 were inversely correlated with systolic and diastolic blood pressure (day, night and 24 h), which suggests a protective role for GRK3 in the regulation of human blood pressure, as supported by previous findings in transgenic mice.

[Prevalence of asymptomatic peripheral artery disease detected by the ankle-brachial index in patients with cardiovascular disease. MERITO II study]. / Prevalencia de enfermedad arterial periférica asintomática, estimada mediante el índice tobillo-brazo, en pacientes con enfermedad vascular. Estudio MERITO II.

BACKGROUND AND OBJECTIVE: Patients with polyvascular disease have an increased rate of cardiovascular events and death. Their identification would define a subgroup of the population at very high risk, who would be candidates to intensified preventive measures. The objective of the present study was to evaluate the prevalence of subclinical peripheral artery disease in subjects with a previous diagnosis of vascular disease in other territories. PATIENTS AND METHOD: Subjects with a coronary or a cerebrovascular event between 3 months and 5 years, and who were attended at internal medicine outpatient clinics from Spain were included in the study. All patients had a clinical history, a physical examination, a blood and urine analysis, and a measurement of the ankle-brachial index (ABI). RESULTS: A total of 1203 patients (64% males; mean age: 74.3 years), were included in the study. A previous coronary event was reported in 55.4% of the participants, cerebrovascular disease in 38%, and a clinical history of disease in both territories in 6.7%. The prevalence of a low ABI (< 0,9) was 33.8%, 32.4% and 53.9% for each group, respectively. In a multivariate analysis, factors associated with a low ABI were age, smoking habit, diabetes, a reduced glomerular filtration rate, systolic blood pressure and the presence of clinical disease in both territories upon inclusion. The sensitivity of both, the Edinburgh questionnaire and pulse palpation for detecting and ABI below 0.9, were low. CONCLUSIONS: Prevalence of a low ABI is elevated in asymptomatic patients with coronary or cerebrovascular disease, particularly if there are clinical manifestations in both territories.

Prevalencia de enfermedad arterial periférica asintomática, estimada mediante el índice tobillo-brazo, en pacientes con enfermedad vascular. Estudio MERITO II / Prevalence of asymptomatic peripheral artery disease detected by the ankle-brachial index in patients with cardiovascular disease. MERITO II study

FUNDAMENTO Y OBJETIVO: Los pacientes con enfermedad arterial en varios territorios presentan unaelevada tasa de complicaciones vasculares y de mortalidad. Su identificación permitiría definir a unsubgrupo de la población de muy alto riesgo, candidatos a recibir medidas preventivas más enérgicas.El objetivo del presente estudio ha sido estimar la prevalencia de enfermedad arterial periféricasubclínica en personas con antecedentes de enfermedad vascular en otros territorios arteriales.PACIENTES Y MÉTODO: Se incluyó en el estudio a pacientes con historia de enfermedad coronaria y/ocerebrovascular entre los 3 meses y los 5 años previos, atendidos en consultas de medicina internarepartidas por toda la geografía nacional. Se les realizaron anamnesis, exploración física, analíticasanguínea y urinaria, y se les determinó el índice tobillo-brazo (ITB).RESULTADOS: Se estudió a 1.203 pacientes (64% varones), con una edad media de 74,3 años. El55,4% tenía antecedentes de enfermedad coronaria, un 38% de enfermedad cerebrovascular y un6,7% de afectación en ambos territorios. La prevalencia de ITB bajo (< 0,9) fue del 33,8, el 32,4y el 53,9% para cada grupo, respectivamente. En el análisis multivariante los factores que se asociaroncon un ITB bajo fueron la edad, el tabaquismo, la diabetes, una tasa reducida de filtradoglomerular, la presión arterial sistólica y el haber presentado afectación de ambos territorios vasculares.La sensibilidad del cuestionario de Edimburgo y de la palpación de pulsos para detectar lapresencia de un ITB inferior a 0,9 fue baja.CONCLUSIONES: La prevalencia de un ITB bajo es elevada en pacientes asintomáticos con enfermedadcoronaria o cerebrovascular, especialmente si presentan afectación conjunta de ambos territorios

BACKGROUND AND OBJECTIVE: Patients with polyvascular disease have an increased rate of cardiovascularevents and death. Their identification would define a subgroup of the population at very highrisk, who would be candidates to intensified preventive measures. The objective of the presentstudy was to evaluate the prevalence of subclinical peripheral artery disease in subjects with a previousdiagnosis of vascular disease in other territories.PATIENTS AND METHOD: Subjects with a coronary or a cerebrovascular event between 3 months and 5years, and who were attended at internal medicine outpatient clinics from Spain were included inthe study. All patients had a clinical history, a physical examination, a blood and urine analysis,and a measurement of the ankle-brachial index (ABI).RESULTS: A total of 1203 patients (64% males; mean age: 74.3 years), were included in the study. Aprevious coronary event was reported in 55.4% of the participants, cerebrovascular disease in 38%,and a clinical history of disease in both territories in 6.7%. The prevalence of a low ABI (< 0,9) was33.8%, 32.4% and 53.9% for each group, respectively. In a multivariate analysis, factors associatedwith a low ABI were age, smoking habit, diabetes, a reduced glomerular filtration rate, systolic bloodpressure and the presence of clinical disease in both territories upon inclusion. The sensitivity of both,the Edinburgh questionnaire and pulse palpation for detecting and ABI below 0.9, were low.CONCLUSIONS: Prevalence of a low ABI is elevated in asymptomatic patients with coronary or cerebrovasculardisease, particularly if there are clinical manifestations in both territories

Factors related to the occurrence of microalbuminuria during antihypertensive treatment in essential hypertension.

The objective of the study was to assess the factors related to the occurrence of microalbuminuria during the follow-up of a young adult group with essential hypertension that had not been previously treated. Normo-albuminuric essential hypertensives, <50 years old, who had not been previously treated with antihypertensive drugs and who did not have diabetes mellitus were included. After the initial evaluation, patients were treated using only nonpharmacological measures (n=62), beta-blockers (n=38), ACE inhibitors (n=64), calcium channel blockers (n=8), and several classes (n=15). Measurements were taken for office blood pressure, biochemical profile, and 24-hour urinary albumin excretion at the beginning of the study and were measured yearly during an average of 2.7+/-1.2 years of follow-up. Among the 187 patients included, 22 (11,7%) developed microalbuminuria (progressors, 4.4/100 patients/y). No differences were present between progressors and those who remained normo-albuminuric (nonprogressors) in terms of age, gender, body mass index, disease duration, blood pressure values, biochemical profile, familial history of diabetes or hypertension, smoking habits, or the presence of EKG left ventricular hypertrophy. The group with the lowest progression rate was the patients treated with ACE inhibitors (n=5; 2.9/100 patients/y), followed by the diet group (n=5; 3.3/100 patients/y) and the beta-blockers group (n=5; 4.1/100 patients/y). When we excluded patients treated with calcium channel blockers or those who changed over time between different classes of treatment, no significant differences in the incidence of microalbuminuria were observed among the groups. Progressors showed higher slopes of fasting glucose (4.78+/-11.4 versus 0.50+/-6.8 mg/y, P<0.02) and uric acid (0.58+/-0.93 versus 0.05+/-1.10 mg/y, P<0.03) compared with the slopes of nonprogressors. Both the slopes for glucose and systolic blood pressure over time were associated independently with the slope of the logarithm of urinary albumin excretion when adjusted for age, gender, and treatment groups. Cox proportional hazard model for progression of microalbuminuria showed that baseline urinary albumin excretion (risk ratio [RR]=1.06; confidence interval [CI] 95%, 1.01 to 1.11), slope for systolic blood pressure (RR=1.11; CI 95%, 1.03 to 1.20), and slope for glucose (RR=1.08; CI 95%, 1.03 to 1.14) were independently associated to the development of microalbuminuria. In conclusion, in a group of young adults with essential hypertension that had not been previously treated, the main factors influencing the occurrence of microalbuminuria during antihypertensive treatment were the values of microalbuminuria at baseline and the slopes for systolic blood pressure and fasting glucose.

Estudio de los factores relacionados con los cambios en la microalbuminuria durante el tratamiento antihipertensivo / Study of factors related with changes of microalbuminuria during antihypertensive treatment

Fundamento: Conocer los factores que determinan los cambios en la microalbuminuria (mAlb) durante el tratamiento antihipertensivo en pacientes con hipertensión arterial (HTA) esencial. Métodos: Se incluyeron 106 pacientes hipertensos esenciales (57 varones; edad media (DE) de 40,8 [6,6] años) no diabéticos y nunca tratados con fármacos antihipertensivos. Se determinaron valores de presión arterial, perfil bioquímico y excreción urinaria de albúmina (EUA) mediante inmunonefelometría en dos muestras de orina de 24 h. Los pacientes se asignaron al azar a recibir tratamiento, de forma que 53 pacientes se trataron con inhibidores de la enzima conversiva de la angiotensina (IECA), y 53 con bloqueadores beta (BB), manteniéndose durante 12 meses. En ambos grupos se añadió hidroclorotiazida cuando fue necesario para mantener cifras de presión arterial inferiores a 140/90 mmHg. Resultados: La EUA media fue de 32,1 (43,1) mg/24 h, 41 (39 por ciento) con mAlb > 30 mg/24 h. A los 12 meses se produjo un descenso significativo en la presión arterial sistólica (PAS) (-20,6 [18,03] mmHg, p < 0,001), presión arterial diastólica (PAD) (-14,18 [10,34] mmHg, p < 0,001) y un aumento de la glucemia (3,08 [11,07] mg/dl, p = 0,006). Los cambios en la EUA se relacionaron con los valores iniciales de EUA, y fueron independientes de la edad, sexo, PAD inicial, y cambios en la PAD. Aunque el descenso sobre la PAS y PAD no fue distinto en los pacientes tratados con IECA que con BB (PA media de -17,2 [10,9] frente a -14,8 [10,4] mmHg; p = NS), la EUA descendió significativamente sólo en el grupo de IECA (LogEUA: -0,203 [0,872] mg/24 h; p = 0,04). Adicionalmente, en los pacientes tratados con BB se produjo un aumento de glucemia (4,4 [12,3] mg/dl; p = 0,013) y ácido úrico (1,18 [4,18]; p = 0,031). Conclusiones: En pacientes con HTA esencial el descenso de la mAlb se relaciona principalmente con los valores basales de mAlb y con el tipo de tratamiento antihipertensivo, de forma que los IECA producen mayor descenso sobre la mAlb que los BB. (AU)