Actualización del concepto del bloqueo dual del sistema renina-angiotensina-aldosterona. ¿Una nueva opción terapéutica? / Update concept of the dual blocking of the renin-angiotensin-aldosteron system. A new therapeutic option?

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Estatinas en la prevención secundaria del ictus: nuevas evidencias del estudio SPARCL / Statins in the secondary prevention of stroke: New evidence from the SPARCL Study

Hasta fechas recientes había poca evidencia de que el tratamiento con estatinas fuera capaz de reducir el riesgo de recurrencia de ictus. El estudio SPARCL, publicado en 2006, fue el primer ensayo específicamente diseñado con esa finalidad. El SPARCL demostró que el tratamiento con atorvastatina 80mg/día reducía el riesgo de ictus recurrente en pacientes con ictus o AIT recientes. Posteriormente se han realizado varios análisis post hoc de diferentes subgrupos que no han revelado diferencias según la edad, sexo o tipo de ictus. Además, el estudio SPARCL ha ayudado a identificar a los pacientes que pueden tener un mayor beneficio: pacientes con estenosis carotídea, con reducción más intensa de lípidos, y aquellos que alcanzan niveles óptimos de cLDL, de cHDL, de triglicéridos y de presión arterial. También ha ayudado a identificar a aquellos pacientes que presentan un riesgo más alto de nuevos episodios vasculares. Es evidente que hay un antes y un después en la prevención del ictus desde la publicación del estudio SPARCL

Until recently there was little evidence that statin therapy reduced the risk of stroke recurrence. The SPARCL trial, published in 2006, was the first trial to show the benefits of statin therapy in preventing recurrent stroke. The SPARCL trial showed that treatment with atorvastatin 80mg/day reduced recurrent stroke in patients with a recent stroke or transient ischemic attack (TIA). Several post hoc analyses of different subgroups followed the SPARCL trial. They have not revealed any significant differences when patients were grouped by age, sex or type of stroke. The SPARCL trial has also helped to identify patients who may have a greater benefit from statins: Patients with carotid stenosis, with more intense lipid lowering, and those who achieve optimal levels of LDL-C, HDL-C, triglycerides, and blood pressure. The trial has also helped to identify individuals at high risk of new vascular events. Clearly there is a before and after in stroke prevention since the SPARCL trial was published

[Statins in the secondary prevention of stroke: New evidence from the SPARCL Study]. / Estatinas en la prevención secundaria del ictus: nuevas evidencias del estudio SPARCL.

Until recently there was little evidence that statin therapy reduced the risk of stroke recurrence. The SPARCL trial, published in 2006, was the first trial to show the benefits of statin therapy in preventing recurrent stroke. The SPARCL trial showed that treatment with atorvastatin 80mg/day reduced recurrent stroke in patients with a recent stroke or transient ischemic attack (TIA). Several post hoc analyses of different subgroups followed the SPARCL trial. They have not revealed any significant differences when patients were grouped by age, sex or type of stroke. The SPARCL trial has also helped to identify patients who may have a greater benefit from statins: Patients with carotid stenosis, with more intense lipid lowering, and those who achieve optimal levels of LDL-C, HDL-C, triglycerides, and blood pressure. The trial has also helped to identify individuals at high risk of new vascular events. Clearly there is a before and after in stroke prevention since the SPARCL trial was published.

El control estricto de la presión arterial tras un ictus isquémico se asocia con la aparición de episodios de hipotensión nocturna / Tight control of blood pressure after ischemic stroke is associated with nocturnal hypotension episodes

Objetivo. Evaluar si un control más estricto de la presión arterial (PA) en pacientes con ictus isquémico reciente se asocia con la presencia de episodios de hipotensión nocturna (HPN). Pacientes y métodos. Se incluyeron 100 pacientes consecutivos que habían sido dados de alta por ictus isquémico en los seis meses previos. Para evaluar el buen control de la PA en estos pacientes, se utilizaron valores de la PA en consulta y monitorización ambulatoria de la PA de 24 horas. Resultados. Se estudiaron 63 varones y 37 mujeres; la media de edad fue de 69 ± 11 años. Se incluyeron 68 ictus lacunares y 32 no lacunares. Se observaron episodios de HPN en 59 pacientes. La hipertensión clínica estuvo presente en 34 pacientes. Un patrón anormal del ritmo circadiano de la PA estaba presente en 72 sujetos. Sólo 18 pacientes tenían la PA dentro de límites normales. Los episodios de HPN fueron más frecuentes en los pacientes con buen control de la PA en comparación con los pacientes con mal control: 88,8% y 52,4%, respectivamente (p = 0,007). La presencia de episodios de HPN también estaba inversamente relacionada con el número de parámetros de PA alterados (p = 0,001). Conclusiones. El control estricto de la PA tras un ictus isquémico se asocia con una alta frecuencia de episodios de HPN. Es probable que una reducción intensiva de los niveles de la PA dentro del rango de la normalidad tras un ictus isquémico pueda no ser beneficiosa, en particular en los pacientes ancianos (AU)

Aim. To evaluate whether a tighter blood pressure (BP) control in patients with recent ischemic stroke is associated with the presence of nocturnal hypotension (NHP) episodes. Patients and methods. We included one hundred consecutive patients who had been discharged for ischemic stroke in the previous six months. To evaluate adequacy of BP control in these patients office BP and 24-h ambulatory BP monitoring values were used. Results. We studied 63 males and 37 females; mean age was 69 ± 11 years. Sixty-eight lacunar and 32 non-lacunar strokes were included. Episodes of NHP were observed in 59 patients. Clinical hypertension was present in 34 patients. An abnormal pattern of circadian rhythm of BP was present in 72 subjects. Only 18 patients had BP within normal limits. Episodes of NHP were more frequent in subjects with good BP control versus patients with bad BP control: 88.8% and 52.4 % respectively (p = 0.007). The presence of NHP episodes was also inversely related to number of BP parameters altered (p = 0.001). Conclusions. Tight control of BP after ischemic stroke is associated with a high frequency of NHP episodes. It is likely that aggressively lowering BP levels within the normal range after an ischemic stroke may be not beneficial, particularly in elderly patients (AU)

Nocturnal hypotension in patients after ischemic stroke: does it really matter?

BACKGROUND: We aimed to evaluate the presence of nocturnal hypotension (NHP) in ischemic stroke (IS) survivors using ambulatory blood pressure (BP) monitoring (ABPM). METHODS: We included fifty consecutive patients presenting at our outpatient clinic for review and who had been discharged for IS in the previous six months. 24-h ABPM was performed with Spacelab 90207 monitor. NHP episodes were considered those values on which the mean arterial pressure (MAP)<70mm Hg. Patients were divided into two groups according to the presence or absence of NHP. RESULTS: We studied 31 men and 19 women, mean age 68±11years. Episodes of NHP were observed in 21 patients (42%). There were no significant differences with regard to clinical characteristics between groups. With regard to BP, patients with NHP had significantly lower mean 24-hour BPs, mean daytime BPs and mean nighttime BPs. Dipper pattern occurred more often in patients with NHP, although differences were only statistically significant in the diastolic BP values. Mean office readings were 142±26/77±13mm Hg (149±26 versus 133±20; P=0.06; 82±12 versus 71±12; P=0.008). None of the patients showed office SBP <90mmHg and only four had office DBP <60mmHg. CONCLUSIONS: Episodes of NHP in patients with recent IS are common and difficult to detect with clinical cuff measurements. It is necessary to redefine the target BP levels in secondary stroke prevention, possibly because we are subjecting our patients to increased risk of NHP and cerebral hypoperfusion.

Ambulatory blood pressure monitoring in stroke survivors: do we really control our patients?

BACKGROUND: We aim to evaluate prospectively the long-term changes of blood pressure (BP) in stroke survivors using ambulatory BP monitoring (ABPM) and compare them with the clinic conventional measurements. METHODS: We studied 101 patients who were admitted within 24h after stroke onset. To study the circadian rhythm of BP a continuous BP monitor (Spacelab 90207) was used. After six and twelve months follow-up a new ABPM was undertaken. Data were analyzed using the SSPS 12.0. RESULTS: We studied 62 males and 39 females, mean age: 70.9+/-10.7 years. We included 88 ischemic strokes and 13 hemorrhagic strokes. In the acute phase mean 24 h BPs were 136+/-19/78.6+/-11.4 mm Hg. The normal diurnal variation in BP was abolished in 88 (87.1%) patients. After six months, 74 patients were assessed. Mean office readings were 137.5+/-23.8/76.4+/-11.4 mm Hg, and high systolic BPs and diastolic BPs were found in 37% and 11% of the subjects respectively. ABPM revealed a mean BP of 118.5+/-20.1/70.3+/-8.6 (p<0.0001). In 57 (76.9%), the normal BP pattern remained abolished (p<0.001). After one year, 63 patients were assessed. Mean office readings were 130.8+/-26.3/77.6+/-9.3 mm Hg, and high systolic BPs and diastolic BPs were found in 23.8% and 10% of the subjects respectively. Mean 24 h BPs were 117+/-12.5/69.7+/-7.2 (p<0.001). The normal diurnal variation in BP was now abolished in 47 (74.6%) patients (p<0.001). CONCLUSION: Survivors of stroke, both hypertensive and non-hypertensive patients, present a chronic disruption of circadian rhythm of BP. Conventional clinical recordings are an unreliable method of controlling these patients and ABPM should be routinely performed in this population.

Statins in stroke prevention: what an internist should know.

Historically, the etiological link between hypercholesterolemia and stroke has been less clear than for coronary heart disease. The lack of association between cholesterol levels and stroke in most epidemiological and observational studies has brought about this controversy. Many recent, long-term clinical studies have confirmed that statin therapy results in a reduced risk of strokes, even in so-called "normocholesterolemic" patients. The magnitude of the effect is great. A large-scale analysis of more than 90,000 individuals showed that every 10% reduction in the concentration of LDL-cholesterol reduces the risk of stroke by 15.6%. The positive effect of statins on stroke depends mainly on LDL cholesterol reduction, but other non-lipid mechanisms, so-called "pleiotropic" effects, have been shown to play a role. This review seeks to summarize the role of statins in stroke prevention. Despite the fact that our understanding of the benefits of statins in stroke prevention is still evolving, we find marked room for improvement in stroke risk factor management. Internists must face this challenge and integrate this new knowledge into their daily clinical practice.

[Influence on white coat effect and heart rate of antihypertensive agents used at a urban health center]. / Influencia sobre el efecto de bata blanca y la frecuencia cardiaca de los fármacos antihipertensivos usados en un centro de salud urbano.

BACKGROUND: We name white coat effect (WCE) to the difference between the systolic arterial pressure (SAP)/diastolic AP (DAP) of consulting room and the ambulatory obtained one with ambulatory blood pressure monitoring (ABPM). In our work we analyzed by means of ABPM, the influence of the antihypertensive medicaments on the WCE and the cardiac frequency of use of the antihypertensive ones. DESIGN: Almost experimental study (with a period before and a period later) and descriptive. SETTING: Primary care. Urban health centre. PARTICIPANTS AND MAIN MEASUREMENTS: Studies of ABPM were realized to 70 hypertense essential patients with good control of the arterial pressure after pharmacological treatment before suspending the antihypertensive medication (phase 1) and to the 4 weeks of leaving the treatment (phase 2). RESULT: Or all 70 hypertense patients. 18 (26%) did not manage to carry out the second ABPM (unbalanced during the wash) that forced to re-introduce the antihypertensive medicaments. The WCE systolic and diastolic is significantly more raised in patient males in treatment with diuretics with regard to which they use other pharmacological groups. The CF is significantly more raised in patient women who do not take blockaders thread (they use another group) with regard to they take it. In the blockaders alpha the CF is significantly more raised in the women who use it with regard to that they use antihypertensive other one. Of all 52 patients who were realized double ABPM, WCE was significantly top in phase 1 that in 2. CONCLUSION: In hypertense controlled patients, the diuretics (in males) are the pharmacological group that of more significant way influences on WCE, them raising with regard to the patients who take antihypertensive other one, being in influence the opposite on CF. The women with blockaders thread present values of CF significantly lower than those who use another antihypertensive medication; happening the inverse thing the blockaders alpha. In our consulting room exists a inadequate use of the antihypertensive ones. The WCE is significantly mayor when is submitted to pharmacological treatment.