Control de la anticoagulación en pacientes con fibrilación auricular no valvular en práctica clínica de atención primaria en las diferentes comunidades autónomas. Estudio PAULA / Control of anticoagulation in patients with non-valvular atrial fibrillation in a primary care clinical practice setting in the different autonomous communities. PAULA study

Objetivos. Conocer las diferencias entre comunidades autónomas en el grado de control de los pacientes con fibrilación auricular no valvular, tratados con antagonistas de la vitamina K, incluidos en el estudio PAULA. Métodos. Estudio observacional retrospectivo/transversal. Participaron 139 investigadores de 99 centros de salud de todas las Comunidades Autónomas (excepto La Rioja). El grado de control se determinó mediante tiempo en rango terapéutico, por método directo (mal control<60%), y por Rosendaal (mal control<65%). Resultados. Fueron incluidos 1.524 pacientes. Se observaron pequeñas diferencias entre las características basales de los pacientes. Se apreciaron diferencias en el porcentaje de tiempo en rango terapéutico, según el método Rosendaal (media 69,0±17,7%), desde 78,1%±16,6 (País Vasco) a 61,5%±14 (Baleares), según método directo (media 63,2±17,9%), desde 73,6%±16,6 (País Vasco) al 57,5%±15,7 (Extremadura). Al comparar comunidades, donde el médico de familia asume de forma integral el control y no existen restricciones a la prescripción, el porcentaje de tiempo en rango terapéutico por el método directo fue 63,89 frente 60,95%, en las que sí existen (p=0,006), por Rosendaal, del 69,39% frente al 67,68% (p=0,1036). Conclusiones. Existen diferencias significativas en el grado de control entre comunidades siendo inadecuado en algunas. Comunidades donde el médico de familia asume la gestión integral de la anticoagulación, el tiempo en rango terapéutico es algo superior y muestra una tendencia favorable a mejor control. Estos hallazgos pueden tener implicación clínica, merecen una reflexión y un análisis específico (AU)

Aims. To determine the differences between regions in the level of control of patients with non-valvular atrial fibrillation treated with vitamin K antagonists, included in the PAULA study. Methods. Observational, and coss-sectional/retrospective study, including 139 Primary Care physicians from 99 Health Care centres in all autonomous communities (except La Rioja). Anticoagulation control was defined as the time in therapeutic range assessed by either the direct method (poor control <60%), or the Rosendaal method (poor control <65%). Results. A total of 1,524 patients were included. Small differences in baseline characteristics of the patients were observed. Differences in the percentage of time in therapeutic range were observed, according to the Rosendaal method (mean 69.0±17.7%), from 78.1%±16.6 (Basque Country) to 61.5±14% (Balearic Islands), by the direct method (mean 63.2±17.9%) from 73.6%±16.6 (Basque Country) to 57.5±15.7% (Extremadura). When comparing regions, in those where the Primary Care physicians assumed full control without restrictions on prescription, the percentage of time in therapeutic range by the direct method was 63.89 vs. 60.95% in those with restrictions (p=.006), by Rosendaal method, 69.39% compared with 67.68% (p=.1036). Conclusions. There are significant differences in the level of control between some regions are still inadequate. Regions in which the Primary Care physicians assumed the management of anticoagulation and without restrictions, time in therapeutic range was somewhat higher, and showed a favourable trend for better control. These findings may have clinical implications, and deserve consideration and specific analysis (AU)

[Control of anticoagulation in patients with non-valvular atrial fibrillation in a primary care clinical practice setting in the different autonomous communities. PAULA study]. / Control de la anticoagulación en pacientes con fibrilación auricular no valvular en práctica clínica de atención primaria en las diferentes comunidades autónomas. Estudio PAULA.

AIMS: To determine the differences between regions in the level of control of patients with non-valvular atrial fibrillation treated with vitamin K antagonists, included in the PAULA study. METHODS: Observational, and coss-sectional/retrospective study, including 139 Primary Care physicians from 99 Health Care centres in all autonomous communities (except La Rioja). Anticoagulation control was defined as the time in therapeutic range assessed by either the direct method (poor control <60%), or the Rosendaal method (poor control <65%). RESULTS: A total of 1,524 patients were included. Small differences in baseline characteristics of the patients were observed. Differences in the percentage of time in therapeutic range were observed, according to the Rosendaal method (mean 69.0±17.7%), from 78.1%±16.6 (Basque Country) to 61.5±14% (Balearic Islands), by the direct method (mean 63.2±17.9%) from 73.6%±16.6 (Basque Country) to 57.5±15.7% (Extremadura). When comparing regions, in those where the Primary Care physicians assumed full control without restrictions on prescription, the percentage of time in therapeutic range by the direct method was 63.89 vs. 60.95% in those with restrictions (p=.006), by Rosendaal method, 69.39% compared with 67.68% (p=.1036). CONCLUSIONS: There are significant differences in the level of control between some regions are still inadequate. Regions in which the Primary Care physicians assumed the management of anticoagulation and without restrictions, time in therapeutic range was somewhat higher, and showed a favourable trend for better control. These findings may have clinical implications, and deserve consideration and specific analysis.

Anticoagulación y fibrilación auricular no valvular. Introducción / No disponible

No disponible

Indicaciones de rivaroxabán en diferentes situaciones clínicas / Indications of rivaroxabán in distinct clinical situations

Rivaroxabán es un inhibidor oral directo y altamente selectivo del factor Xa de la coagulación. Los principales resultados del ROCKET-AF mostraron que en pacientes de alto riesgo con fibrilación auricular no valvular, rivaroxabán fue no inferior a la warfarina en la prevención del ictus o embolia sistémica, pero con un menor riesgo de intracraneales, fatales y en órgano crítico. Rivaroxabán ha demostrado ser eficaz y seguro en pacientes con insuficiencia renal, en pacientes ancianos, así como en aquellos con cardiopatía isquémica o ictus previo. Rivaroxabán se toma una sola vez al día. En comparación con los otros nuevos anticoagulantes orales (ACO), rivaroxabán puede proporcionar un mejor cumplimiento y adherencia al tratamiento y, en consecuencia, reducir el riesgo de ictus durante el seguimiento. Además, las interacciones con otros fármacos son escasas. Esto, junto con que es de una sola toma diaria, hace que rivaroxabán suponga una excelente alternativa para la prevención de los episodios tromboembólicos en los pacientes polimedicados con fibrilación auricular. En este manuscrito se revisa la evidencia disponible acerca de la eficacia y seguridad de rivaroxabán en los pacientes con fibrilación auricular en diferentes escenarios clínicos (AU)

Rivaroxaban is an oral highly selective direct factor Xa inhibitor. The main results of ROCKET-AF showed that in high risk patients with nonvalvular atrial fibrillation, rivaroxabán was noninferior to warfarin for the prevention of stroke or systemic embolism, but with lesser risk of intracranial and fatal bleeding. Remarkably, rivaroxaban has been proven to be effective and safe in patients with renal dysfunction, elderly patients as well as in those with ischemic heart disease or previous stroke . Rivaroxaban is taken only once daily. Compared with other new oral anticoagulants, this may provide better compliance and medication adherence and, consequently, a reduction in the risk of stroke during the follow-up. Moreover, the interactions with other drugs are low. This together with the once daily dose makes rivaroxabán an excellent alternative for the prevention of thromboembolic events in polymedicated patients with atrial fibrillation. This manuscript reviews the available evidence about the efficacy and safety of rivaroxabán in patients with atrial fibrillation in different clinical settings (AU)

[Medical conduct in primary care as regards blood pressure control. PRESCAP 2010 study]. / Conducta del médico de atención primaria ante el mal control de la hipertensión arterial. Estudio PRESCAP 2010.

INTRODUCTION: There is a need for more information on therapeutic inertia in blood pressure (BP) treatment. The purpose of this study was to determine the therapeutic behaviour and associated factors of Primary Care (PC) physicians on uncontrolled hypertensive patients. PATIENTS AND METHODS: Cross-sectional multicentre study of patients with hypertension attending Spanish PC centres. Data was collected from patients (social-demographics, clinical status and treatment), as well as data from physicians (medical practice, background and therapeutic behaviour) were collected. Uncontrolled BP was considered when average BP values where ≥140/90mmHg. RESULTS: A total of 12,961 patients (52.0% women) were included. The mean age was 66.3 (SD 11.4) years, and mean number of years from diagnosis of hypertension was 9.1 (6.7) years. Almost two-thirds (62.4%) of the patients were taking a combined blood pressure treatment, (44.2% with two drugs and 18.2% with three drugs, or more). An uncontrolled BP was observed in 38.9% (95% CI: 38.1-39.7) of patients. Treatment was changed by physicians in 41.8% (95% CI: 40.4-43.2) out of 5,036 uncontrolled patients. Adding another drug was the most frequent behaviour (55.6%). The physician's perception of good BP control in uncontrolled patients, together with the presence of combined blood pressure treatment, were the two variables most strongly associated with therapeutic inertia. CONCLUSIONS: The Spanish PC Physician modified antihypertensive treatment in only 4 out of 10 uncontrolled patients. The physician's perception of good BP control was the variable most strongly associated with therapeutic inertia.

Conducta del médico de atención primaria ante el mal control de la hipertensión arterial. Estudio PRESCAP 2010 / Medical conduct in Primary Care as regards blood pressure control. PRESCAP 2010 Study

Introducción. Es necesario tener mayor información sobre la inercia terapéutica en la hipertensión arterial (HTA). El objetivo de este estudio fue conocer la conducta del médico de atención primaria (AP) en pacientes hipertensos que presentan mal control de presión arterial (PA) y determinar los factores asociados. Pacientes y métodos. Estudio transversal y multicéntrico realizado en hipertensos asistidos en el ámbito de la AP española. Se registraron datos de los pacientes (sociodemográficos, clínicos y tratamiento) y médicos (asistenciales, formativos y conducta ante el mal control de PA). Se consideró mal control cuando el promedio de PA era >= 140/90mmHg. Resultados. Se incluyeron 12.961 hipertensos (52,0% mujeres), con una edad media de 66,3 (11,4) años y antigüedad media de la HTA de 9,1 (6,7) años. El 62,4% recibía terapia combinada (44,2%, 2 fármacos, y 18,2%, 3 o más). El 38,9% (IC 95%: 38,1-39,7) presentó mal control de PA. El médico modificó el tratamiento en el 41,8% (IC 95%: 40,4-43,2) de los 5.036 pacientes mal controlados. La conducta terapéutica más frecuente fue la asociación farmacológica (55,6%). La percepción por parte del médico de buen control de PA en el hipertenso mal controlado y la presencia de terapia combinada fueron las variables que mostraron mayor probabilidad de no modificar el tratamiento farmacológico. Conclusiones. El médico de AP modifica el tratamiento antihipertensivo en tan solo 4 de cada 10 hipertensos mal controlados. La percepción por parte del médico de buen control de PA es la variable que más incrementa la probabilidad de no modificar el tratamiento farmacológico (AU)

Introduction. There is a need for more information on therapeutic inertia in blood pressure (BP) treatment. The purpose of this study was to determine the therapeutic behaviour and associated factors of Primary Care (PC) physicians on uncontrolled hypertensive patients. Patients and methods. Cross-sectional multicentre study of patients with hypertension attending Spanish PC centres. Data was collected from patients (social-demographics, clinical status and treatment), as well as data from physicians (medical practice, background and therapeutic behaviour) were collected. Uncontrolled BP was considered when average BP values where >=140/90mmHg. Results. A total of 12,961 patients (52.0% women) were included. The mean age was 66.3 (SD 11.4) years, and mean number of years from diagnosis of hypertension was 9.1 (6.7) years. Almost two-thirds (62.4%) of the patients were taking a combined blood pressure treatment, (44.2% with two drugs and 18.2% with three drugs, or more). An uncontrolled BP was observed in 38.9% (95% CI: 38.1-39.7) of patients. Treatment was changed by physicians in 41.8% (95% CI: 40.4-43.2) out of 5,036 uncontrolled patients. Adding another drug was the most frequent behaviour (55.6%). The physician's perception of good BP control in uncontrolled patients, together with the presence of combined blood pressure treatment, were the two variables most strongly associated with therapeutic inertia. Conclusions. The Spanish PC Physician modified antihypertensive treatment in only 4 out of 10 uncontrolled patients. The physician's perception of good BP control was the variable most strongly associated with therapeutic inertia (AU)

Nuevas estrategias terapéuticas para la prevención del ictus en pacientes con fibrilación auricular: perspectiva desde atención primaria / New therapeutic strategies for stroke prevention in patients with atrial fibrillation: a perspective from Primary Care

La fibrilación auricular (FA) es la arritmia sostenida más frecuente, la que produce mayor número de ingresos hospitalarios y la principal causa de ictus de origen cardioembólico. Según recomiendan las guías de práctica clínica la estrategia terapéutica en la FA tiene como objetivos prioritarios, y no excluyentes, la corrección del trastorno del ritmo con reversión a ritmo sinusal, el control de la frecuencia cardiaca y la prevención de la tromboembolia. El tratamiento anticoagulante oral con warfarina o acenocumarol constituye la piedra angular para prevenir el ictus en pacientes con FA y ha sido el tratamiento de referencia durante más de medio siglo. Su uso en la práctica clínica, aunque está ampliamente reconocido, precisa una monitorización regular para mantener la dosis correcta, lo cual dificulta su aceptación por parte de pacientes y médicos. Los nuevos antitrombóticos orales sintéticos suponen un avance importante en la prevención del ictus y embolia sistémica de los pacientes con FA. Alguno de ellos, como es el caso de dabigatran, ha sido recientemente aprobado en EE.UU. y Canadá en la indicación de prevención de complicaciones tromboembólicas arteriales en pacientes con FA. Si se aprueba esta indicación en nuestro país, como es de esperar, el protagonismo del Sintrom® no durará mucho tiempo (AU)

Atrial fibrillation (AF) is the most common sustained arrhythmia, which leads to a higher number of hospital admissions and is the main cause of stroke of cardioembolic origin. According to the recommendations of the clinical practice guidelines, therapeutic strategy in AF has as its priority objectives, among others, the correction of the rhythm disorder with reversion, control of the heart rate, and prevention of thromboembolism. Anticoagulant treatment with warfarin or acenocoumarol is the keystone to the prevention of stroke in patients with AF, and has been the standard treatment for more than half a century. Their use in clinical practice, although it is widely unknown, requires regular monitoring to maintain the correct dose, which makes it difficult to be accepted by patients and doctors. The new oral synthetic anticoagulants are an important advance in the prevention of stroke and systemic embolism in patients with FA. Some of them, such as dabigatran, have recently been approved in the USA and Canada in the indication of arterial thromboembolic complications in patients with AF. If this indication, as is expected, is approved in our country, the importance of the role of coumarin derivatives (Sintrom®) will not last much longer (AU)

Control de la presión arterial en una población hipertensa diabética asistida en atención primaria. «Estudio PRESCAP-Diabetes» / Blood pressure control in a diabetic hypertensive population attended in primary care setting. “PRESCAP-Diabetes study”

Objetivos: Conocer el grado de control de la PA en una amplia muestra de pacientes hipertensos diabéticos atendidos en atención primaria, y determinar los factores asociados al mal control tensional. Material y métodos: Estudio transversal y multicéntrico que incluyó a hipertensos diabéticos de 18 años o más, reclutados mediante muestreo consecutivo por médicos de familia de toda España. La medida de PA se realizó siguiendo normas estandarizadas, calculándose la media aritmética de al menos 2 tomas sucesivas separadas entre sí 2 minutos. Se consideró buen control de la HTA al promedio de PA inferior a 140/90mmHg según recomienda la European Society Hypertension (ESH 2009). Se evaluó igualmente el porcentaje de pacientes con PA por debajo de 130/80mmHg (ESH 2007 y American Diabetes Association 2010). Se registraron datos sociodemográficos, clínicos, factores de riesgo cardiovascular, trastornos clínicos asociados y tratamientos farmacológicos. Resultados: Se incluyeron a 2.752 pacientes (55,6% mujeres) con una edad media de 67,1 (9,8) años. El 64,3% presentaba dislipemia, 61,8% sedentarismo, 46,5% obesidad, 41,2% antecedentes de ECV y el 16,0% tabaquismo. El 66,1% recibía terapia combinada (2 fármacos 43,5%, 3 fármacos17,9% y 4 fármacos o más 4,7%). Siguiendo las recomendaciones de 2009 el 47,3% (IC 95%: 45,4–49,2) presentó buen control de PAS y PAD, 50,2% (IC 95%: 48,3–52,1) solo de PAS y el 79,8% (IC 95%: 78,3–81,3) únicamente de PAD; considerando los criterios de 2007 el 15,1% (IC 95%: 13,8–16,4) mostró buen control de PAS y PAD, 22,5% (IC 95%: 20,9–24,1) de PAS y el 38,2% (IC 95%: 36,4–40,0) de PAD. La obesidad, el sedentarismo y no haber tomado la medicación el día de la visita fueron los factores que más se asociaron al mal control de la HTA (χ2 de Wald; p<0,01)...(AU)

Objectives: To know the grade of blood pressure (BP) control in a large sample of diabetic hypertensive patients attended in Primary Care (PC) and to determine the factors associated to poor blood pressure control. Material and methods: A cross-sectional and multicenter study that included diabetic hypertensive subjects of 18 years or older, recruited by consecutive sampling by family doctors throughout Spain. The measurement of BP was performed following standardized guidelines, calculating the arithmetic mean of at least two successive measurements separated by two minutes. Good control of arterial hypertension (AHT) was considered to be the average of BP lower than 140/90mmHg as recommended by the European Society Hypertension (ESH 2009). The percentage of patients with BP below 130/80mmHg (ESH 2007 and American Diabetes Association 2010) was also evaluated. Socio-demographic, clinical data, cardiovascular risk factors, associated clinical disorders and drug treatments were also recorded. Results: A total of 2752 patients (55.6% women) with a mean (SD) age of 67.1 (9.8) years were included. Of these, 64.3% presented dyslipidemia, 61.8% sedentary life style, 46.5% obesity, 41.2% background of cardiovascular disease and 16.0% smoked. A total of 66.1% received combined therapy (two drugs 43.5%, three 17.9% and four or more 4.7%). Following the 2009 recommendations, 47.3% (95% CI: 45.4–49.2) had good control of the systolic BP (SBP) and diastolic BP (DBP), 50.2% (95% CI: 48.3–52.1) only of the SBP and 79.8% (95% CI: 78.3–81.3) only of DBP. Considering the 2007 criteria, 15.1% (95% CI: 13.8–16.4) showed good control of SBP and DBP, 22.5% (95% CI: 20.9–24.1) of SBP and 38.2% (95% CI: 36.4–40.0) of DBP. Obesity, sedentary life, and not having taken the medication on the day of the visit were the factors that were most associated to the poor control of AHT (Wald χ2; p<0.01)...(AU)

Utilidad de la terapia combinada en la prevención y tratamiento de la enfermedad cardiovascular / Utility of combined therapy in the prevention and treatment of the cardiovascular disease

ResumenAunque el control de la presión arterial es crucial en los pacientes con HTA, las actuales gruías de práctica clínica recomiendan que el objetivo del tratamiento en esta población no se debería limitar a reducir las cifras de presión arterial, sino que debería ir encaminado además a reducir el riesgo cardiovascular global. Los datos actuales sugieren que las tasas de control tanto de la presión arterial como del colesterol LDL, 2 de los principales factores de riesgo cardiovascular, son bajos, tanto en atención primaria como en las consultas del especialista. Ensayos clínicos como el Anglo-Scandanavian Cardiac Outcomes Trial, han demostrado que el tratamiento basado en un abordaje multifactorial de los diferentes factores de riesgo cardiovascular, reduce eficazmente la morbimortalidad cardiovascular.ResumenEl objetivo de esta revisión fue realizar una actualización de los conocimientos existentes sobre el tratamiento combinado de los distintos factores de riesgo en la población hipertensa(AU)

Although blood pressure control is crucial in patients with hypertension, current clinical practice guidelines recommend that the goal of treatment should be aimed at not only reducing blood pressure values but decreasing global cardiovascular risk. Available data suggest that blood pressure and LDL-cholesterol control rates, two of the most common cardiovascular risk factors, are low, not only in the primary care setting but also in specialists setting. Clinical trials, such as the Anglo-Scandanavian Cardiac Outcomes Trial (ASCOT), have demonstrated that the integration of a multifactorial approach through the treatment of different risk factors effectively reduces the risk of cardiovascular morbidity and mortality.AbstractThe aim of this review was to update the current knowledge about the combined therapy of different risk factors in the hypertensive population(AU)

Evolución del control de la presión arterial en España en el período 2002–2006. Estudios PRESCAP / Evolution of the control of blood pressure in Spain in the period 2002–2006. PRESCAP Studies

ObjetivosDiscutir la evolución del grado de control de la presión arterial (PA) en una amplia muestra de pacientes hipertensos españoles durante el período 2002–2006.Material y métodosLos PRESCAP fueron estudios transversales y multicéntricos diseñados para la estimación de prevalencias, que se realizaron en los años 2002 y 2006 con la misma metodología en poblaciones similares asistidas en atención primaria (AP). Éstos incluyeron a pacientes ≥18 años diagnosticados de hipertensión arterial (HTA) que recibían tratamiento farmacológico antihipertensivo. Se consideró buen control de la HTA cuando la PA fue <140 y<90mmHg en general (<130 y<80mmHg en pacientes con diabetes, nefropatía o enfermedad cardiovascular). Se realizó estadística descriptiva y comparación de medias y porcentajes con el paquete SPSS versión 15.0.ResultadosSe incluyó a 12.754 pacientes (el 57,2% eran mujeres) con una edad media de 63,3±10,8 años en PRESCAP 2002 y a 10.520 pacientes (el 53,7% eran mujeres) con una edad media de 64,6±11,3 años en el PRESCAP 2006. En el año 2002 se observó un control de la PA sistólica (PAS) y de la PA diastólica (PAD) del 36,1% (intervalo de confianza del 95% [IC 95%]: 35,2–36,9) y en 2006 del 41,4% (IC 95%: 40,5–42,4). El porcentaje de pacientes diabéticos con PA controlada resultó del 9,1% (IC 95%: 8,0–10,2) en 2002 y del 15,1% (IC 95%: 13,8–16,5) en 2006.ResultadosEn el PRESCAP 2002 el 56,0% recibía monoterapia antihipertensiva, el 35,6% recibía combinaciones de dos fármacos y el 8,4% recibía tres o más fármacos, y en el PRESCAP 2006 estos porcentajes fueron del 44,4; el 41,1 y el 14,5%, respectivamente.Conclusiones(..) (AU)

ObjectivesDiscuss the evolution of blood pressure (BP) control grade in a large sample of Spanish hypertensive patients in the period of 2002–2006.Material and methodsThe PRESCAP were cross-sectional and multicenter studies designed to calculate prevalences that were conducted in 2002 and 2006 using the same methodology in similar populations attending in primary care (PC). They included patients ≥18 years diagnosed of high blood pressure (HBP) who received anti-hypertensive drug treatment. Good control of HBP was considered as BP<140 and<90mmHg in general (<130 and<80mmHg in patients with diabetes, nephropathy or cardiovascular disease). A descriptive statistical study and comparison of means and percentages with the SPSS version 15.0 were made.ResultsA total of 12,754 patients (57.2% women) with mean age of 63.3±10.8 years were included in PRESCAP 2002 and 10,520 (53.7% women) with a mean age of 64.6±11.3 years in PRESCAP 2006. In the year 2002, control of systolic BP (SBP) and diastolic BP (DB) of 36.1% (95% CI, 35.2–36.9) was observed and, in 2006, of 41.4% (95% CI, 40.5–42.4). The percentage of diabetic patients with controlled BP was 9.1% (95% CI, 8.0–10.2) in 2002 and 15.1% (95% CI, 13.8–16.5) in 2006.ResultsIn the PRESCAP 2002, 56.0% received antihypertensive monotherapy, 35.6% combinations of two drugs and 8.4% three or more drugs, and in the PRESCAP 2006 these percentages were 44.4%, 41.1% and 14.5%, respectively.ConclusionsThe control grade of HBP in Spain improved in the period of 2002–2006. The factors that may have had an influence in these results are the extensive amount of bibliography generated during this period on the need to achieve adequate control of BP and the change in the prescription profile of the PC physician, which indicates a greater percentage of combinations of antihypertensive drugs(AU)

[Primary care physicians behaviour on hypertensive patients with poor blood pressure control. The PRESCAP 2006 study]. / Conducta del médico de Atención Primaria ante el mal control de los pacientes hipertensos. Estudio PRESCAP 2006.

INTRODUCTION: There is little information available on Therapeutic Inertia in Primary Care (PC). This study aimed to know the therapeutic behavior of the physician for uncontrolled hypertensive patients. PATIENTS AND METHODS: Cross-sectional, multicenter study that included hypertensive patients of both genders, under pharmacological treatment who were recruited consecutively in the PC out-patient clinic in all of Spain. Social-demographic, clinical and treatment data were recorded, as well as the motives for eventual therapeutic modification. Adequate BP control was considered when BP values were below 140/90 mmHg in general, and below 130/80 mmHg in diabetes, renal insufficiency or cardiovascular disease. RESULTS: A total of 10,520 patients (53.7% women) were included with average age of 64.6 (11.3 years). Of these, 44.4% the patients were receiving monotherapy and 55.6% were treated with combined therapy (two drugs 41.2%, three drugs 11.7%, and more than three 2.8%). Uncontrolled hypertension was found in 58.6% (95% CI. 57.6-59.5) of the patients. Treatment was modified by physicians in 30.4% (95% CI. 29.2-31.6) of the uncontrolled patients, combination with another drug being the most frequent behavior (46.3%), followed by dose increase (26.1%), and antihypertensive drug switch (22.8%). The perception of the physician of good BP control was the factor most associated with not modifying the treatment in uncontrolled patients. CONCLUSIONS: Study results showed that the PC physician modified antihypertensive treatment in only 3 out of 10 uncontrolled patients. When treatment modification was made, association of drugs was the most frequent behavior.

Prevención de la enfermedad cardiovascular en los pacientes diabéticos: ¿qué hay de nuevo? / No disponible

La diabetes mellitus (DM) constituye un problema socio--sanitario de primera magnitud que afecta en la actualidad a una población superior a los 200 millones de personas en todo el mundo. Es una enfermedad crónica, de rápido crecimiento, responsable de trastornos neurológicos, vasculares y microvasculares. Según recomiendan las guías de práctica clínica, la estrategia terapéutica en prevención primaria en laDM se debe de realizar sobre la base de un enfoque integral y multifactorial. El impacto del tratamiento integral en el paciente diabético ya ha sido valorado en algún estudio, en el que se ha observado que el tratamiento conjunto de la DM, hipertensión arterial (HTA) e hiperlipidemia, con objetivosde control estrictos y la administración de ácido acetilsalicílico, reduce significativamente las complicaciones vasculares de la enfermedad. Un reciente estudio muestra que una estrategia antihipertensiva basada en la combinación fija de perindopril-indapamida, comparada con placebo, consigue unareducción significativa de eventos cardiovasculares en una población diabética de alto riesgo cardiovascular ya tratada con otros fármacos para su DM, HTA, dislipidemia y/o enfermedad cardiovascular

Diabetes mellitus (DM) is a social-health care problem ofhigh importance that currently affects a population of more than 200 million persons worldwide. It is a chronic, rapidly growing disease that is responsible for neurological, vascular and microvascular disorders. According to the recommendation of the Practical Clinical Guide, the therapeutic strategyin primary prevention of DM should be made using an integral and multifactor approach. The impact of the integral treatment in the diabetic patient has already been evaluated in some study in which it was observed that the combined treatment of DM, arterial hypertension (AHT) and hyperlipidemia, with strict control objectives and the administration of acetylsalicylic acid, significantly reduces the vascular complications of the disease. A recent study shows that an antihypertensive strategy based on the fixed combination ofperindopril-indapamide, compared with placebo, achieves asignificant reduction in cardiovascular events in a high risk cardiovascular diabetic population already treated with other drugs for DM, AHT, dyslipidemia and/or cardiovascular disease

Prescripción de betabloqueantes en la insuficiencia cardíaca. Réplica / Prescription of beta blockers in heart failure. Reply

No disponible

La hipertensión arterial, ¿un estado de hipercoagulabilidad latente? / Arterial hypertension: is this a latent hypercoagulability condition?

No disponible

[Clinical characteristics of patients diagnosed of chronic heart failure attended in Primary Care. The CARDIOPRES study]. / Características clínicas de los pacientes diagnosticados de insuficiencia cardíaca crónica asistidos en Atención Primaria. Estudio CARDIOPRES.

INTRODUCTION: Scarce information is available on the clinical characteristics and risk factors of patients with chronic heart failure (CHF) attended in Primary Care (PC) setting. The aim of this study was to analyze the clinical characteristics of this population in PC. PATIENTS AND METHODS: Multicenter, cross-sectional study in patients with CHF, consecutively recruited by 232 physicians in PC. The collected data included sociodemographic, etiologic, clinical and therapeutic variables. RESULTS: Eight hundred forty seven (847) patients were included (age 73.0 +/- 9.6 years; 50.5% men). Of these, 84.3% had arterial hypertension (AHT), 59.2% hypercholesterolemia and 34.9% diabetes mellitus. The most frequent associated clinical disorders were ischemic heart disease (40.1%) and peripheral artery disease (28.6%). In 69.6% of the patients the physicians knew the type of dysfunction (32.4% systolic, 37.2% diastolic). The main etiologies of CHF were the hypertensive cardiomyopathy (75.0%) and ischemic heart disease (40.1%); the most frequent trigger factor was atrial fibrillation (43.9%). Loop diuretics (72.3%) and angiotensin-converting enzyme inhibitors (60.9%) were the treatments used most and 6.7% of the patients were receiving treatment with beta blockers. CONCLUSIONS: AHT appears to be primary cause of CHF in PC. Diastolic dysfunction is more frequent than the systolic one, and the PC physicians do not know the cause of the ventricular dysfunction in one third of the cases. Loop diuretics and angiotensin-converting enzyme inhibitors were the most frequently used in these patients; the use of beta blockers in CHF is very scarce in PC.

Características clínicas de los pacientes diagnosticados de insuficiencia cardíaca crónica asistidos en Atención Primaria. Estudio CARDIOPRES / Clinical characteristics of patients diagnosed of chronic heart failure attended in Primary Care. The CARDIOPRES study

Introducción. Se dispone de escasa información sobre las características clínicas de los pacientes con insuficiencia cardíaca crónica (ICC) asistidos en Atención Primaria (AP). El objetivo de este estudio fue analizar las características clínicas de estos enfermos en AP. Pacientes y métodos. Estudio multicéntrico y transversal realizado en pacientes con ICC reclutados consecutivamente por 232 médicos de AP. Se recogieron datos sociodemográficos, etiológicos, clínicos y terapéuticos. Resultados. Se incluyeron 847 pacientes (el 50,5% hombres) con una edad media de 73,0 ± 9,6 años. El 84,3% padecía hipertensión arterial (HTA), el 59,2% hipercolesterolemia y el 34,9% diabetes mellitus. Los trastornos clínicos asociados más frecuentes fueron la cardiopatía isquémica (40,1%) y la arteriopatía periférica (28,6%). En el 69,6% los médicos conocían el tipo de disfunción (el 32,4% sistólica; el 37,2% diastólica). Las principales causas de ICC fueron la cardiopatía hipertensiva (75,0%) y la cardiopatía isquémica (40,1%); el factor desencadenante más frecuente de la aparición de ICC fue la fibrilación auricular (43,9%). Los fármacos más utilizados en el tratamiento fueron los diuréticos de asa (72,3%) y los inhibidores de la enzima convertidora de la angiotensina (60,9%); el 6,7% de los pacientes recibía tratamiento con bloqueadores beta. Conclusiones. La principal causa de ICC en AP es la HTA, la disfunción diastólica es más frecuente que la sistólica y en una tercera parte de los casos el médico desconoce el tipo de disfunción. Diuréticos de asa e inhibidores de la enzima convertidora de la angiotensina son los fármacos más frecuentemente prescritos en estos pacientes; la prescripción de bloqueadores beta es muy pobre (AU)

Introduction. Scarce information is available on the clinical characteristics and risk factors of patients with chronic heart failure (CHF) attended in Primary Care (PC) setting. The aim of this study was to analyze the clinical characteristics of this population in PC. Patients and methods. Multicenter, cross-sectional study in patients with CHF, consecutively recruited by 232 physicians in PC. The collected data included sociodemographic, etiologic, clinical and therapeutic variables. Results. Eight hundred forty seven (847) patients were included (age 73.0 ± 9.6 years; 50.5% men). Of these, 84.3% had arterial hypertension (AHT), 59.2% hypercholesterolemia and 34.9% diabetes mellitus. The most frequent associated clinical disorders were ischemic heart disease (40.1%) and peripheral artery disease (28.6%). In 69.6% of the patients the physicians knew the type of dysfunction (32.4% systolic, 37.2% diastolic). The main etiologies of CHF were the hypertensive cardiomyopathy (75.0%) and ischemic heart disease (40.1%); the most frequent trigger factor was atrial fibrillation (43.9%). Loop diuretics (72.3%) and angiotensin-converting enzyme inhibitors (60.9%) were the treatments used most and 6.7% of the patients were receiving treatment with beta blockers. Conclusions. AHT appears to be primary cause of CHF in PC. Diastolic dysfunction is more frequent than the systolic one, and the PC physicians do not know the cause of the ventricular dysfunction in one third of the cases. Loop diuretics and angiotensin-converting enzyme inhibitors were the most frequently used in these patients; the use of beta blockers in CHF is very scarce in PC (AU)

Aplicación práctica de la lectura computarizada del electrocardiograma / Practical application of electrocardiogram computerization

El electrocardiograma (ECG) continúa siendo en el momento actual la exploración complementaria inicial e imprescindible en el paciente hipertenso. Es especialmente trascendente para el diagnóstico de la cardiopatía hipertensiva en todas sus vertientes, como son la hipertrofia ventricular izquierda, la cardiopatía isquémica y los trastornos del ritmo. Sin embargo, la correcta lectura del ECG del paciente hipertenso, a pesar de ser una actividad diaria, sigue siendo un reto para la mayoría de los médicos. Por ello desde finales del siglo pasado se han desarrollado programas informáticos que incorporados a los equipos de electrocardiografía puedan ayudar al médico en la interpretación del ECG. El rendimiento y la precisión de los diferentes programas han demostrado ser muy aceptables y en muchas ocasiones con una exactitud equivalente a la lectura realizada por expertos. La digitalización del ECG es especialmente interesante cuando, como en la mayoría de los casos, no se dispone de la opinión del experto en electrocardiografía, porque disminuye la carga de trabajo, reduce la variabilidad interintraobservador y, lo que es más importante, contribuye a mejorar la precisión diagnóstica. Además se ha mostrado extraordinariamente útil para poder aplicar en la práctica clínica los nuevos criterios electrocardiográficos descritos en los últimos años, y en especial los referidos a hipertrofia ventricular izquierda. Por ello, la lectura computarizada del ECG se presenta como una herramienta con un gran potencial presente y futuro porque, además de las ventajas que aporta su aplicación a la práctica diaria, puede desde el campo de la investigación aportar nueva información de gran importancia para el pronóstico y tratamiento del paciente hipertenso

The electrocardiogram (ECG) continues to be the initial and essential complementary examinations in the patient with high blood pressure. It is especially relevant in the diagnosis of hypertensive heart disease in all its varieties, such as left ventricle hypertrophy, ischemic heart disease and rhythm disorders. Although the ECG is a daily routine in the study of the patient with high blood pressure, it is still a matter of concern for most doctors. This is the reason why different computer programs have been developed to be adapted to the electrocardiographic monitors in order to help the doctor interpret the results. The results and accuracy of the different programs has been shown to be quite acceptable, often with an accuracy equals to that of the lecture made by experts. The computerization of the ECG is very interesting when, as occurs in many cases, there is no expert on ECG available, because it decreases the work load, reduces variability between different observers, and what is more important, helps to make the diagnostic accuracy higher. It has become very useful in the application of the new ECG criteria in the last years especially when it comes to left ventricle hypertrophy. This is the reason why ECG computerization becomes a major tool with great present and future potential, because it not only has the advantages from its application to the daily practice, but can supply new information of great importance in the prognosis and treatment of the patient with a high blood pressure in the research field (AU)

[Cardiac protection as priority strategy of cardiovascular prevention in high blood pressure]. / La protección cardíaca como estrategia prioritaria de prevención cardiovascular en hipertensión arterial.

Cardiac complications are the main cause of morbidity and mortality related with HBP in our setting and entail first magnitude human and social-health care consequences. Although the incidence of ACVA has decreased in recent decades, this has not occurred with the same intensity for cardiac complications, probably due to their multifactorial origin. Left ventricular hypertrophy, main etiologic responsible factor of hypertensive heart disease that includes heart failure, ischemic heart disease, arrhythmias and sudden death are found as nuclear element of the cardiac disease. Consequently, the magnitude, etiological diversity, vulnerability and social-health care implications grant the intervention on cardiac protection a priority role in the management of HBP and its complications.

[ARB II in chronic heart failure. Coincidences and divergences. Class effect?]. / ARA II en insuficiencia cardíaca crónica. Coincidencias y divergencias. Efecto de clase?

Although it is possible to suggest that the ACE inhibitor may have a certain class effect in regards to the benefits observed in the treatment of chronic heart failure, it does not seem reasonable that the same can be assumed in the case of ARB II. Morbidity-mortality studies in chronic heart failure have only been conducted with three of the seven ARB II presently commercialized in our country. These are losartan (ELITE II), valsartan (Val-HeFT) and candesartan (CHARM). The three studies have demonstrated the utility of these drugs, although with different nuances. In these clinical comments, we review the evidence available, stressing what effects could be common to all the ARB II, such as the prevention of diabetes or atrial fibrillation and what effects may only be attributable to some of these, at least up to now. However, new information of the already finished studies and some still on-going clinical trials may help us to know the effects of the ARB II in this disease more and better.

ARA II en insuficiencia cardíaca crónica. Coincidencias y divergencias. ¿Efecto de clase? / ARB II in chronic heart failure. Concidences and divergencies. Class effect?

Si bien se puede sugerir que los inhibidores de la enzima de conversión de la angiotensina (IECA) quizás presentan un cierto efecto de clase en cuanto a los beneficios observados en el tratamiento de la insuficiencia cardíaca crónica, no parece razonable que se pueda asumir lo mismo en el caso de los antagonistas de los receptores de angiotensina II (ARA II). Sólo con tres de los 7 ARA II comercializados actualmente en nuestro país se han realizado hasta la fecha estudios de morbimortalidad en insuficiencia cardíaca crónica: losartán (ELITE II), valsartán (Val-HeFT) y candesartán (CHARM). Los tres estudios han demostrado la utilidad de estos fármacos, aunque con diferentes matices. En este comentario clínico revisamos las evidencias disponibles, resaltando qué efectos podrían ser comunes a todos los ARA II, como la prevención de diabetes o de fibrilación auricular y qué efectos pueden ser atribuidos solo a algunos de éstos, al menos hasta ahora. No obstante, nueva información de los estudios ya finalizados y algunos ensayos clínicos aún en marcha pueden ayudarnos a conocer más y mejor sobre los efectos de los ARA II en esta patología

Although it is possible to suggest that the ACE inhibitor may have a certain class effect in regards to the benefits observed in the treatment of chronic heart failure, it does not seem reasonable that the same can be assumed in the case of ARB II. Morbidity-mortality studies in chronic heart failure have only been conducted with three of the seven ARB II presently commercialized in our country. These are losartan (ELITE II), valsartan (Val-HeFT) and candesartan (CHARM). The three studies have demonstrated the utility of these drugs, although with different nuances. In these clinical comments, we review the evidence available, stressing what effects could be common to all the ARB II, such as the prevention of diabetes or atrial fibrillation and what effects may only be attributable to some of these, at least up to now. However, new information of the already finished studies and some still on-going clinical trials may help us to know the effects of the ARB II in this disease more and betterAlthough it is possible to suggest that the ACE inhibitor may have a certain class effect in regards to the benefits observed in the treatment of chronic heart failure, it does not seem reasonable that the same can be assumed in the case of ARB II. Morbidity-mortality studies in chronic heart failure have only been conducted with three of the seven ARB II presently commercialized in our country. These are losartan (ELITE II), valsartan (Val-HeFT) and candesartan (CHARM). The three studies have demonstrated the utility of these drugs, although with different nuances. In these clinical comments, we review the evidence available, stressing what effects could be common to all the ARB II, such as the prevention of diabetes or atrial fibrillation and what effects may only be attributable to some of these, at least up to now. However, new information of the already finished studies and some still on-going clinical trials may help us to know the effects of the ARB II in this disease more and better