Variables associated with change in blood pressure control status after 1-year follow up in primary care: a retrospective analysis: the TAPAS study.

PURPOSE: This 1-year, retrospective, observational study assessed factors associated with changes in hypertension control status and differences in blood pressure (BP) management among general practitioners in Spain. METHODS: In 2009, 307 investigators from 260 primary care centres in Spain recruited the first four consecutive patients with hypertension that fit into one of four predefined cohorts: (1) uncontrolled BP at baseline and at a 1-year follow-up visit; (2) uncontrolled BP at baseline and good BP control at the 1-year follow-up visit; (3) good BP control at baseline and loss of BP control at the 1-year follow-up visit; and (4) good BP control at baseline and at the 1-year follow-up visit. RESULTS: A total of 1385 patients were included. Patients with poor BP and patients that lost BP control exhibited more cardiovascular risk factors. Although antihypertensive treatment was increased more markedly in these patients, this was not sufficient to attain/remain BP goals. Predictors for attaining BP control were no smoking, absence of diabetes, reduction in cholesterol, low baseline cholesterol, and no weight gain. Predictors for failing to maintain BP goals were weight gain, high baseline LDL cholesterol, and no reduction in fasting glucose. NSAID prescriptions increased markedly in patients that lost BP control compared to those that maintained BP control. CONCLUSION: Antihypertensive therapy should be intensified and healthy lifestyle changes should be emphasized, particularly weight control to improve BP control. Drugs that may increase BP levels, such as NSAIDs, should also be avoided.

Prevalence of abnormal urinary albumin excretion rate in hypertensive patients with impaired fasting glucose and its association with cardiovascular disease.

The prevalence and significance of microalbuminuria in hypertensive patients with impaired fasting glucose (IFG) has received very little attention. A total of 10,320 hypertensive patients who attended primary care centers were enrolled in this study, and the final analysis was done in 7625 patients: 1459 without IFG (plasma glucose <100 mg/dl), 3010 with IFG (plasma glucose > or =100 mg/dl and <126 mg/dl), and 3156 with type 2 diabetes (plasma glucose >126 mg/dl). Microalbuminuria was determined using the Micro Albustix reactive strip from Bayer (high urinary albumin excretion [UAE]: Albumin/creatinine ratio > or =3.4 mg/mmol). The proportion of patients with high UAE was 39.4, 48.3, and 65.6%, respectively, in the three groups (P < 0.01 for the trend). The differences in UAE between the group with IFG and the group with normal fasting glucose persisted after adjustment for age, gender, systolic BP, fasting plasma glucose, and cardiovascular comorbidity (odds ratio 1.74; 95% confidence interval 1.08 to 2.80). Hypertensive patients with IFG and high UAE showed a higher prevalence of ischemic heart disease, cardiac insufficiency, left ventricular hypertrophy, atrial fibrillation, and renal insufficiency than the group with normal UAE. Global prevalence of cardiovascular conditions was 30.4% in the group with high UAE compared with 21.4% in the group with normal UAE (odds ratio 1.60; 95% confidence interval 1.31 to 1.95). It is concluded that almost half of hypertensive patients with IFG have high UAE and a higher prevalence of associated cardiovascular involvement and renal insufficiency.

Urinary albumin excretion and glomerular filtration rate across the spectrum of glucose abnormalities in essential hypertension.

The objective of this study was to assess the relationship between urinary albumin excretion (UAE) and GF across the spectrum of the glucose metabolism abnormalities in a large population of patients with hypertension. The Microaluminuria en Pacientes con Glucemia Basal Alterada (MAGAL) is a multicenter, cross-sectional study that was carried out by 1723 primary care physicians. A total of 6227 patients with essential hypertension (in three groups: [1] normal fasting glucose <100 mg/dl, [2] impaired fasting glucose > or =100 to 126 mg/dl, and [3] type 2 diabetes) were analyzed in this substudy. GFR was estimated by using the Modification of Diet in Renal Disease (MDRD) abbreviated equation. A single first-morning urine albumin/creatinine ratio was measured using Bayer reagent strip Microalbustix, a semiquantitative method. Abnormal UAE was defined as an albumin/creatinine ratio > or =3.4 mg/mmol (equivalent to > or =30 mg/g). The prevalence of abnormal UAE, > or =3.4 mg/mmol, increased across the spectrum of glucose abnormalities: 39.7, 46.2, 48.6, and 65.6% for normoglycemic, low-range, and high-range impaired fasting glucose and diabetes, respectively. UAE was positively related to SBP (P = 0.003) and inversely to GFR (P < 0.001). Renal insufficiency (GFR <60 ml/min per 1.73 m2) was present in 21.8% of the patients, more frequently older patients, women, and those with diabetes. The factors that were related to renal insufficiency were UAE > or =3.4 mg/mmol (odds ratio 1.86; 95% confidence interval 1.60 to 2.17) and diabetes (odds ratio 1.62; 95% confidence interval 1.29 to 2.04). There is a close relationship between abnormal UAE and renal insufficiency in essential hypertension. This is more marked in patients with diabetes and moderate in patients with high-range impaired fasting glucose.

Cardiovascular risk factors in type 2 diabetic patients: multifactorial intervention in primary care.

BACKGROUND: Cardiovascular disease is the main cause of morbidity and mortality in patients with type 2 diabetes mellitus (DM). Intervention on cardiovascular risk factors (CVRF) is essential to obtain clinical results reducing the excess of cardiovascular risk (CVR) in these patients. METHODS: The objective of this study was to describe the association of type 2 DM with modifiable cardiovascular risk factors and the degree of control of these in a population of type 2 diabetics in attendance in primary care clinics, and also to establish prospectively whether an integral and multifactorial intervention on uncontrolled cardiovascular risk factors, carried out in conditions of routine clinical practice by applying an open protocol, could significantly reduce the estimated CVR according to the Framingham scale. The proposed intervention included both actions aimed at modifying habits, and pharmacologic intervention to achieve an optimum level of control in accordance with international recommendations for the objectives and treatment for type 2 diabetes. RESULTS: A total of 3466 patients with a mean age of 58 +/- 7.5 years were studied and followed-up for 1 year. Of these, 90.4% of patients had high blood pressure; 60.1% of men and 32.7% of women presented CVR >20% in 10 years according to the Framingham scale by categories. Intervention at 1 year of follow-up had achieved statistically significant reductions in blood pressure, glycated hemoglobin, and lipid levels, but not of patients' body weight. After 1 year of follow-up, 29% of males and 24% of women with a high CVR (>20%) at the start of the study presented reduced risk levels. CONCLUSION: The results of the study demonstrate that an integrated and multifactorial intervention in type 2 diabetic patients can achieve clinically significant reductions in CVR. However, conducted in effective conditions, it is not able to achieve optimum levels of control in spite of the initial proposal, possibly due to some degree of inertia in routine clinical practice.