Practical application of the ATOM study: Treatment efficacy of antihypertensive drugs in monotherapy or combination (ATOM metaanalysis according to PRISMA statement); tables for the use of antihypertensive drugs in monotherapy or combination.

BACKGROUND: The response to antihypertensive drugs is predictable. The absence of precise prescription recommendations to treat arterial hypertension (HT) lead to use drugs unable to reduce blood pressure (BP) to target values.We published ATOM study, in which we found significant differences in the ability to reduce BP between the different drugs.The objective of the study was to determine the expected decrease in blood pressure with the use of commercialized doses of the drugs commonly used in the treatment of HT in clinical practice, to avoid the use of drugs or combinations that even with the best response, are unable to obtain the necessary BP decrease to reach the goal. METHODS: The analysis was based on the results of the ATOM study. To convert the mean doses of the different drugs and combinations in commercialized doses, the conclusions of the study by Law et al have been applied. RESULTS: Based on the results, two tables were drawn, one for systolic BP and the other for diastolic BP, where the doses of the different drugs and combinations are classified according to the BP decrease that can be expected from them. In order to favor the use of the tables in clinical practice, the different drugs have been grouped in intervals of 10 millimeters of mercury (mmHg) for the decrease of the systolic BP and of 5 mmHg for the diastolic BP. CONCLUSIONS: Recommendations for the use of antihypertensive treatments should not be limited to pharmacological families. They should also consider differences between drugs or specific combinations. From the data of the ATOM study we have implemented tables that express the effect of the drugs commonly used in clinical practice and that should allow the clinicians to choose with care the treatment to use.

Individual socioeconomic factors conditioning cardiovascular disease risk.

BACKGROUND: Our objective is to ascertain whether the socioeconomic situation of individuals has an influence on the cardiovascular disease (CVD) risk estimation. METHODS: The subjects were part of VAMPAHICA study and had been recently diagnosed as hypertensive. The study subjects were seen in primary care centers, were aged between 15 and 75 years and have never been treated for hypertension (HT). Normotensive individuals were also included in the study sample. All individuals answered a questionnaire that included questions related to sociodemographic and socioeconomic variables as well as habit and lifestyle variables. Of a total of 424 individuals initially invited to answer the questionnaire, 388 finally did so. Due to missing data in the dependent variables, 304 individuals were included in the European Society of Hypertension (ESH) risk tables and 287 in the Systematic Coronary Risk Evaluation (SCORE) tables. The response variable CVD risk, which is a polytomic variable, was estimated using an ordered probit model. RESULTS: We found that individual's socioeconomic status, expressed mainly as their level of education, was an independent variable that had repercussions on the estimated CVD risk. This finding was more evident in the SCORE tables, and when risk was stratified according to the ESH tables the repercussions were only marginal. In particular, we found that individuals with only primary education had a 27% higher probability of CVD risk (> or =5%) in the SCORE tables, whereas individuals with a higher level of education had 50% less probability of high risk. CONCLUSIONS: The CVD risk estimation tables for the general population (SCORE) reflect the socioeconomic factor better than the CVD risk stratification tables for HT (ESH tables). Target organ damage (TOD) is an important factor for stratifying risk in the ESH tables; however, the SCORE tables do not take this into account. Therefore, socioeconomic factors may already be incorporated in the ESH tables through an intermediate variable, such as TOD.

Gender, socio-economic variables and target organ damage in new-diagnosed hypertensive patients.

The aim of the study as to ascertain whether gender and socio-economic variables can explain differences in the degree of severity of hypertension (HT) at the time of diagnosis. Patients were recently diagnosed and never-treated hypertensives, seen in primary care sites and aged 15-75. This study also included a cohort of normotensive patients. All individuals were invited to respond a questionnaire to collect socio-demographic and socio-economic data. Target organ damage (TOD) is considered a marker of severity. Three hundred and eighty-eight individuals responded to the questionnaire, 277 hypertensive, 111 normotensive. In an ordered probit model, the odds ratio of presenting with more than one TOD were: Aged >67 (OR=1.22; 1.06-1.38), being a smoker (OR=1.21; 1.02-1.40) or ex-smoker (OR=2.89; 1.27-4.51), primary school education (OR=2.17; 1.47-2.87), being male (OR=0.75; 0.59-0.90), being an agricultural worker (OR=0.03; 0.00-0.05) or a salaried professional (OR=0.96; 0.94-0.99). The results show differences in the severity of the HT in the initial assessment of the patient according to gender or other socio-economic variables. It is particularly important at the time of carrying out the diagnosis and the HT assessment.

Proportion of isolated clinical hypertension in primary care settings. Comparison of target organ damage in patients with isolated clinical hypertension and patients with sustained arterial hypertension.

The aim of this study was to determine the proportion of isolated clinical hypertension (ICH) in newly diagnosed hypertensive patients, and to compare the incidence of target organ damage (TOD) in ICH and sustained hypertension patients. Participants. In a multi-centre study involving 14 primary care centres in Girona, Spain, 140 researchers recruited 214 newly diagnosed hypertensive patients 15-75 years of age, without history of cardiovascular events. Period of study. 2004-6. Method. Self-blood pressure monitoring (SBPM) and ambulatory blood pressure monitoring (ABPM). Evaluation. Anamnesis including blood pressure, physical examination and analysis (creatinine, albumin/creatinine index), electrocardiogram (left ventricular hypertrophy) and retinography (fundus damage). Results. In 129 (60.3%) subjects with sustained hypertension and 85 (39.7%) with ICH, no significant differences were found relative to gender, age, body mass index or blood pressure (155/90 vs 154/90 mmHg, respectively). Cholesterol levels were significant differences between both groups (5.97 mmol/l in sustained hypertension vs 5.64 mmol/l in ICH, p = 0.029). The proportion of ICH was approximately 40%. TOD incidence in sustained hypertensives was similar to that of ICH patients.

Assessment of self-monitoring of blood pressure in the diagnosis of isolated clinic hypertension.

BACKGROUND: There are no studies assessing cardiovascular morbidity, morality in patients with isolated clinical hypertension (ICH) with self-blood pressure monitoring (SBPM). OBJECTIVES: To determine the value of SBPM in the diagnosis of ICH. METHODS: Cohort study. New hypertensive and normotensive patients 15-75 years, without cardiovascular events history. VARIABLES: Oriented anamnesis hypertension; blood pressure measurements (BP): clinical BP, SBPM and ambulatory BP monitoring (ABPM); evaluation of target organ damage (TOD); electrocardiogram; retinography and microalbuminuria (MA). RESULTS: One hundred and thirty-five patients, 95 hypertensive (62.1% males; mean age 59.08+/-16.8 years), 40 normotensive (37.5% males; mean are 56.32+/-10.22 years). BP measurements (mmHG) in normotensives vs hypertensives: clinical BP, 125.36/76.74 vs 149.81/87.86 mmHg (p<0.0001) and SPPM, 114.90/69.96 vs 142.06/86.31 (p<0.0001). Twenty-four-hour ABPM: 135.41/81/81.74. Prevalence of TOD in hypertensive: 23.10% left ventricular hypertrophy (LVH), sustained hypertension (SH): clinic BP, 149.88/86.34 vs 152.51/89.55 (p>0.10); SBPM: 147.895/88.95 vs 128.17/79 (p<0.0001) and ABPM, 141.72/88.22 vs 131.66/80 (p=0.053 for systolic). TOD in SH vs ICH: LVH, 24.6% vs 19.2% (p=0.814); exudates or haemorrhages, 7.7% vs 9.8% (p=0.580). The risk of an occurrence of any TOD in ICH patients is lower for 125/80 (OR=2.5). CONCLUSIONS: VAMPAHICA will provide information about value SBPM in the diagnosis of ICH. Advanced retinopathy is relative frequent in ICH patients. If TOD is accepted as a surrogate endpoint, the diagnostic values of ICH will be probably decreased.