Prevalencia, diagnóstico, tratamiento y control de la hipertensión arterial en España. Resultados del estudio Di@bet.es / Prevalence, diagnosis, treatment, and control of hypertension in Spain. Results of the Di@bet.es Study

Introducción y objetivos: El Di@bet.es es un estudio nacional diseñado con el objetivo de estimar la prevalencia de diabetes mellitus y otros factores de riesgo cardiovascular en la población adulta española. Se presenta la prevalencia de hipertensión arterial y en qué grado se reconoce, se trata y se controla. Métodos: Se incluye una muestra de la población española con 5.048 adultos de edad ≥ 18 años. Se realizó un interrogatorio clínico y una exploración que incluyó 3 lecturas de presión arterial en reposo y sedestación para calcular la media de las 3 lecturas. Se definió hipertensión como presión arterial sistólica ≥ 140 mmHg y/o presión arterial diastólica ≥ 90 mmHg y/o en tratamiento farmacológico antihipertensivo. Resultados: El 42,6% de la población adulta española de edad ≥ 18 años es hipertensa, más los varones (49,9%) que las mujeres (37,1%). La prevalencia fue superior entre los prediabéticos (67,9%) y diabéticos (79,4%). El 37,4% de los hipertensos están sin diagnosticar, más los varones (43,3%) que las mujeres (31,5%). Toman tratamiento farmacológico el 88,3% de los hipertensos conocidos y solo el 30% tiene la presión arterial controlada, más las mujeres (24,9%) que los varones (16%). Conclusiones: La prevalencia de hipertensión en España es alta y un importante porcentaje de pacientes hipertensos aún están sin diagnosticar. La hipertensión se asoció con diabetes y prediabetes, y aunque el tratamiento farmacológico es cada vez más frecuente, no logra mejorar el grado de control, que continúa siendo bajo. Es importante desarrollar y promocionar campañas poblacionales de prevención, detección y tratamiento de la hipertensión arterial (AU)

Introduction and objectives: Di@bet.es is a national study designed to estimate the prevalence of diabetes mellitus and other cardiovascular risk factors in the Spanish adult population. The prevalence of hypertension and the degree to which it is recognized, treated, and controlled are described. Methods: The study included a sample of the Spanish population with 5048 adults aged ≥ 18 years. Patients were questioned and examined, with 3 blood pressure readings while seated and at rest to calculate the mean of the 3 readings. Hypertension was defined as systolic blood pressure ≥ 140 mmHg and/or diastolic blood pressure ≥ 90 mmHg and/or prescription for antihypertensive drug therapy. Results: Hypertension was found in 42.6% of the Spanish adult population aged ≥ 18 years and was more common among men (49.9%) than women (37.1%). The prevalence was higher among prediabetics (67.9%) and diabetics (79.4%). Undiagnosed hypertension was identified in 37.4% of patients and was more common in men (43.3%) than in women (31.5%). Among patients with known hypertension, 88.3% were receiving drug therapy. Well-controlled blood pressure was found in only 30% and was more common among women (24.9%) than men (16%). Conclusions: The prevalence of hypertension in Spain is high, and a considerable percentage of hypertensive patients have still not been diagnosed. Hypertension is associated with diabetes and prediabetes, and although drug therapy is increasingly common, the degree of control has not improved and remains low. Population campaigns should be developed and promoted for hypertension prevention, detection, and treatment (AU)

Prevalence, Diagnosis, Treatment, and Control of Hypertension in Spain. Results of the Di@bet.es Study.

INTRODUCTION AND OBJECTIVES: Di@bet.es is a national study designed to estimate the prevalence of diabetes mellitus and other cardiovascular risk factors in the Spanish adult population. The prevalence of hypertension and the degree to which it is recognized, treated, and controlled are described. METHODS: The study included a sample of the Spanish population with 5048 adults aged ≥ 18 years. Patients were questioned and examined, with 3 blood pressure readings while seated and at rest to calculate the mean of the 3 readings. Hypertension was defined as systolic blood pressure ≥ 140 mmHg and/or diastolic blood pressure ≥ 90 mmHg and/or prescription for antihypertensive drug therapy. RESULTS: Hypertension was found in 42.6% of the Spanish adult population aged ≥ 18 years and was more common among men (49.9%) than women (37.1%). The prevalence was higher among prediabetics (67.9%) and diabetics (79.4%). Undiagnosed hypertension was identified in 37.4% of patients and was more common in men (43.3%) than in women (31.5%). Among patients with known hypertension, 88.3% were receiving drug therapy. Well-controlled blood pressure was found in only 30% and was more common among women (24.9%) than men (16%). CONCLUSIONS: The prevalence of hypertension in Spain is high, and a considerable percentage of hypertensive patients have still not been diagnosed. Hypertension is associated with diabetes and prediabetes, and although drug therapy is increasingly common, the degree of control has not improved and remains low. Population campaigns should be developed and promoted for hypertension prevention, detection, and treatment.

Spanish Society of Nephrology document on KDIGO guidelines for the assessment and treatment of chronic kidney disease.

The new Kidney Disease: Improving Global Outcomes (KDIGO) international guidelines on chronic kidney disease (CKD) and the management of blood pressure (BP) in CKD patients are an update of the corresponding 2002 and 2004 KDOQI (Kidney Disease Outcomes Quality Initiative) guidelines. The documents aim to provide updated guidelines on the assessment, management and treatment of patients with CKD. The first guidelines retain the 2002 definition of CKD but present an improved prognosis classification. Furthermore, concepts about prognosis of CKD, recommendations for management of patients, and criteria for referral to the nephrologist have been updated. The second guideline retains the <130/80 mm Hg-goal for management of BP in patients with CKD presenting increased albuminuria or proteinuria (albumin-to-creatinine ratio 30-300 mg/g, and >300 mg/g, respectively) but recommends a less-strict goal of <140/90 mm Hg in patients with normoalbuminuria. The development of the guidelines followed a predetermined process in which the evidence available was reviewed and assessed. Recommendations on management and treatment are based on the systematic review of relevant studies. The GRADE system (Grading of Recommendations Assessment, Development and Evaluation) was used to assess the quality of evidence and issue the grade of recommendation. Areas of uncertainty are also discussed for the different aspects addressed.

Effect of dual blockade of the renin-angiotensin system on the progression of type 2 diabetic nephropathy: a randomized trial.

BACKGROUND: Blockade of the renin-angiotensin system with angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers has been shown to lessen the rate of decrease in glomerular filtration rate in patients with diabetic nephropathy. STUDY DESIGN: A multicenter open-label randomized controlled trial to compare the efficacy of combining the angiotensin-converting enzyme inhibitor lisinopril and the angiotensin II receptor blocker irbesartan with that of each drug in monotherapy (at both high and equipotent doses) in slowing the progression of type 2 diabetic nephropathy. SETTING & POPULATION: 133 patients with type 2 diabetic nephropathy (age, 66 ± 8 years; 76% men) from 17 centers in Spain. INTERVENTION: Patients were randomly assigned (1:1:2) to lisinopril (n = 35), irbesartan (n = 28), or the combination of both (n = 70). OUTCOMES: The primary composite outcome was a >50% increase in baseline serum creatinine level, end-stage renal disease, or death. RESULTS: Baseline values for mean estimated glomerular filtration rate and blood pressure were 49 ± 21 mL/min/1.73 m(2) and 153 ± 19/81 ± 11 mm Hg. Mean geometric baseline proteinuria was protein excretion of 1.32 (95% CI, 1.10-1.62) g/g creatinine. After a median follow-up of 32 months, 21 (30%) patients in the combination group, 10 (29%) in the lisinopril group, and 8 (29%) in the irbesartan group reached the primary outcome. HRs were 0.96 (95% CI, 0.44-2.05; P = 0.9) and 0.90 (95% CI, 0.39-2.02; P = 0.8) for the combination versus the lisinopril and irbesartan groups, respectively. There were no significant differences in proteinuria reduction or blood pressure control between groups. The number of adverse events, including hyperkalemia, was similar in all 3 groups. LIMITATIONS: The study was not double blind. The sample size studied was small. CONCLUSIONS: We were unable to show a benefit of the combination of lisinopril and irbesartan compared to either agent alone at optimal high doses on the risk of progression of type 2 diabetic nephropathy.

Cardiovascular risk in women attending primary care centres: baseline data of the EVA study.

BACKGROUND: The purpose of this study was to determine the prevalence of hypertension, cardiovascular risk factors and target organ damage using baseline data from the EVA study. METHODS: EVA is a 5-year multicentre prospective study of women aged between 40 and 70 years attending primary care centres in a rural-urban area in the north of Spain. The recruitment period was between October 2009 and January 2010. The following variables were analysed: associated cardiovascular risk factors, target organ damage and cardiovascular or renal disease defined according to the 2007 European Society of Hypertension and the European Society of Cardiology Guidelines (2007 ESH/ESC 2007). Blood pressure <140/90 mmHg and <130/80 in diabetics were considered target blood pressure values. Cardiovascular risk was stratified according to the 2007 ESC-ESH guidelines. RESULTS: The study sample comprised of 903 women with a mean age of 59.6 ± 8 years. The prevalence of hypertension, Type 2 diabetes and dyslipidaemia was 45.6, 13.3 and 41.7%, respectively. Target organ damage affected 17.6% of women and manifested as microalbuminuria (1.8%), slight increase in plasma creatinine (1.6%) and left ventricular hypertrophy (2.9%). Overall, 9.3% had cardiovascular disease, 3.4% coronary heart disease, 1.8% heart failure, 1.8% peripheral artery disease and 1.4% renal disease; 2.2% of patients had experienced a stroke. The prevalence of cardiovascular risk factors in hypertensive women (HT) with respect to non-hypertensive women (NHT) was as follows: obesity 44.7 versus 18.9%, dyslipidaemia 48.8 versus 35.8% and Type 2 diabetes 21.8 versus 6.1%. The target organ damage was more prevalent in hypertensive women: 27.3 versus 9.4%. Cardiovascular disease was present in 14.8% of HT and 4.7% of NHT. High or very high cardiovascular risk affected 65.3% of HT and 26.9% of NHT. CONCLUSIONS: Four in 10 women attending primary care centres had a high or very high cardiovascular risk. Percentages of classic cardiovascular risk factors were higher in HT than in NHT and increased significantly with age. The most commonly used drugs were renin-angiotensin system blockers and diuretics.

Spontaneous remission of nephrotic syndrome in idiopathic membranous nephropathy.

Spontaneous remission is a well known characteristic of idiopathic membranous nephropathy, but contemporary studies describing predictors of remission and long-term outcomes are lacking. We conducted a retrospective, multicenter cohort study of 328 patients with nephrotic syndrome resulting from idiopathic membranous nephropathy that initially received conservative therapy. Spontaneous remission occurred in 104 (32%) patients: proteinuria progressively declined after diagnosis until remission of disease at 14.7 +/- 11.4 months. Although spontaneous remission was more frequent with lower levels of baseline proteinuria, it also frequently occurred in patients with massive proteinuria: 26% among those with baseline proteinuria 8 to 12 g/24 h and 22% among those with proteinuria >12 g/24 h. Baseline serum creatinine and proteinuria, treatment with angiotensin-converting enzyme inhibitors or angiotensin receptor antagonists, and a >50% decline of proteinuria from baseline during the first year of follow-up were significant independent predictors for spontaneous remission. Only six patients (5.7%) experienced a relapse of nephrotic syndrome. The incidence of death and ESRD were significantly lower among patients with spontaneous remission. In conclusion, spontaneous remission is common among patients with nephrotic syndrome resulting from membranous nephropathy and carries a favorable long-term outcome with a low incidence of relapse. A decrease in proteinuria >50% from baseline during the first year predicts spontaneous remission.

Bloqueo del sistema renina-angiotensina-aldosterona en hipertensión arterial, diabetes y nefropatía / Blockade of the renin-angiotensin-aldosterone system in arterial hypertension, diabetes and nephropathy

El bloqueo del sistema renina-angiotensina con fármacos inhibidores de la enzima de conversión de la angiotensina o con antagonistas de los receptores de la angiotensina II ha demostrado su efectividad en hipertensos con y sin enfermedad cardiovascular previa. También en normotensos con alto riesgo vascular. Como además tienen efecto antiproteinúrico, se estima que estos agentes deben ocupar el primer escalón terapéutico en los pacientes con nefropatía diabética incipiente o establecida. Asimismo son agentes de primera línea en los casos de nefropatía no diabética con proteinuria > 0,5 g/24 h. Los estudios comparativos entre inhibidores de la enzima de conversión de angiotensina y los antagonistas de los receptores tipo 1 de la angiotensina II parecen mostrar una efectividad similar, con mejor tolerabilidad de estos últimos. En pacientes con nefropatía, la combinación de ambos agentes muestra una mayor capacidad antiproteinúrica que la monoterapia, aunque se desconoce si este efecto es independiente de una mayor reducción de la presión arterial (AU)

Blockade of the renin-angiotensin system with angiotensin-converting enzyme (ACE) inhibitors or angiotensin-II receptor antagonists has proved effective in hypertensive individuals with or without cardiovascular disease and also in normotensive individuals at a high cardiovascular risk. Moreover, due to their additional antiproteinuric effects, these drugs could also provide first-line therapy for patients with incipient or established diabetic nephropathy. Similarly, they could be the drugs of first choice in patients with non-diabetic nephropathy and a 24-hour urinary protein excretion >0.5 g. Comparative studies of ACE inhibitors and angiotensin-II type-1 receptor antagonists have shown that they appear to have a similar efficacy though the latter drugs are better tolerated. In patients with nephropathy, combinations of these two classes of drug have been found to have a greater antiproteinuric effect than monotherapy. However, it is not known whether this effect is independent of the greater reduction in blood pressure (AU)

Blood pressure control in patients with chronic renal insufficiency in Spain: a cross-sectional study.

OBJECTIVE: Despite therapeutic advances, strict control of hypertension remains elusive in patients with chronic renal insufficiency (CRI). The present study was designed for assessment of control rates of blood pressure in patients with CRI. Secondary objectives included evaluation of the control rates of proteinuria and cardiovascular comorbidities. METHODS: A multicenter and cross-sectional survey of unselected patients with CRI attending outpatient nephrology clinics in Spain between April and September 2003 was performed. RESULTS: Fifty-two centers recruited 2501 patients with a mean age 64.8 years (65.7% men). The prevalence of previous cardiovascular disease was 55%. The two most prevalent renal diseases were vascular (38.9%) and diabetic nephropathy (20.1%). Blood pressure below 130/80 mmHg was observed in 435 patients (17.4%). A poor blood pressure control was associated with older age, greater proteinuria and higher low-density lipoprotein cholesterol levels. Proteinuria less than 0.5 g/day was observed in 1209 cases (48.3%). A total of 1899 patients (75.9%) were receiving drugs suppressing the activity of the renin-angiotensin system and 1048 patients (41.9%) were being treated with three or more antihypertensive drugs. Lipid-lowering agents and antiplatelet therapy were used in 49.3 and 38.1% of patients, respectively. CONCLUSIONS: The control rate of blood pressure in patients with CRI is inadequate despite frequent use of combination therapy that most commonly included an angiotensin-converting enzyme inhibitor or an angiotensin receptor blocker. Greater emphasis should be made to increase the number and dose of antihypertensive drugs and the need for using a statin as well as antiplatelet therapy in order to improve renal and cardiovascular outcomes.

Systemic and glomerular hypertension and progression of chronic renal disease: the dilemma of nephrosclerosis.

The link between the kidney and hypertension has been considered a villain-victim relationship. High blood pressure levels are a well-recognized feature in chronic renal disease, but the ability of mild-to-moderate hypertension to produce renal insufficiency has been questioned. Nephrosclerosis, benign nephrosclerosis, and hypertensive kidney disease are terms that clinicians use when renal damage is thought to be secondary to essential hypertension. Many cases of end-stage renal disease are ascribed to so-called benign nephrosclerosis. This entity could actually be a primary renal disease affecting the preglomerular microvasculature, perhaps genetically mediated and ethnically influenced, and showing a heterogeneous clinical expression. African Americans suffer from nephrosclerosis more frequently than Caucasians. Nephrosclerosis affecting Caucasians seems to show a less aggressive pattern and could represent early age-related renal sclerosis. The risk of end-stage renal disease is increased when atherosclerotic lesions in large renal arteries coexist. Age, systolic blood pressure, proteinuria, and concomitant cardiovascular disease are well-known promoters of renal failure. A multifactorial strategy, including antihypertensive and antiproteinuric drugs, and lipid-lowering and anti-platelet agents, could improve cardiovascular and renal outcomes in patients with nephrosclerosis.

Angiotensin II type 1 receptor blockade to control blood pressure in postmenopausal women: influence of hormone replacement therapy.

BACKGROUND: Hypertension is twice as common in postmenopausal than in premenopausal women. This study evaluated the effectiveness of a blockade of the renin-angiotensin-aldosterone system (RAAS) with candesartan cilexetil (CC) to control blood pressure (BP) in hypertensive menopausal women, and the influence of hormone replacement therapy (HRT). METHODS: This was designed as a prospective, open-label and non-comparative study. Included were 618 hypertensive menopausal women grade I/II according to the Sixth Report of the Joint National Committee (VI-JNC), with an average age 52+/-4.7 years (95% CI 52.3-53.0) and with a last menstrual period (LMP) at least one year before. BP was determined by measurement in four visits during six months of follow-up, according to the recommendations of the OMS/SIH. Optimal control of BP was considered as BP <140/90 mm Hg. RESULTS: A statistically significant decrease in systolic (SBP; 19.9+/-11.2) and diastolic (DBP; 11.5+/-7.3) blood pressure mm Hg values was observed (P<0.01). The control of BP increased significantly over time to 61.2% (P<0.01). In multivariate analysis, only age was associated with control of BP (beta= -0.062; P=0.004). Of the women not controlled in the second visit, 12.5 mg of hydrochlorothiazide (HCTZ) were added to 31.5% (N=122), with 80% more BP control achieved in visit 3 than in the non-supplement group (OR=1.8; 95% CI 1.04-3.05; P<0.03). One hundred and three (16.7%) patients were receiving HRT for 2.01+/-2.23 years (95% CI 1.55-2.46). HRT did not affect the control of BP. No severe adverse reactions were reported. CONCLUSIONS: Candesartan cilexetil significantly reduced SBP and DBP and increased control (61.2%) of BP in hypertensive menopausal women. Only age had an inverse association with control of BP. In this study, HRT did not affect the control of BP.

Losartan titration versus diuretic combination in type 2 diabetic patients.

METHODS: We compared the effects of Losartan dose titration to 100 mg versus the addition of 12.5 mg of hydrochlorothiazide, in 90 type 2 diabetic patients with microalbuminuria and blood pressure > 130/85 mmHg, receiving losartan 50 mg as initial treatment during 4 weeks. RESULTS: With the first dose of losartan, systolic (SBP) and diastolic blood pressure (DBP) decreased from 154.5 (152.1-157.5) to 144.4 (141.3-147.5) mmHg (P < 0.001) and from 91.1 (89.4-92.8) to 84.6 (82.8-86.4) mmHg (P < 0.001), with 20 patients attaining the expected goal blood pressure (< 130/85 mmHg); albuminuria decreased from 109.8 (90.5-133.3) to 83.5 (63.6-109.5) mg per 24 h (P = 0.006). Patients not attaining the target blood pressure were randomly allocated to titration or to the combination arm. After an additional 4 weeks, patients titrated exhibited a fall in SBP and DBP from 157.1 (152.7-161.5) to 142.1 (136.4-147.8) mmHg (P < 0.001) and from 92.4 (89.5-95.3) to 83.6 (81.1-86.1) mmHg (P < 0.001); albuminuria decreased from 136.3 (97.8-189.9) to 99.7 (69.3-143.4) mg per 24 h (P = 0.002). In the combination arm, there were similar reductions in SBP and DBP from 155.3 (151.5-159.1) to 139.1 (132.1-146.1) mmHg (P < 0.001) and from 92.1 (89.3-94.9) to 80.9 (77.4-84.4) mmHg (P < 0.001); while albuminuria fell from 107.7 (82.2-141.0) to 64.2 (45.9-89.9) mg per 24 h (P = 0.001). CONCLUSIONS: Losartan 50 mg was effective in reducing blood pressure and albuminuria in type 2 diabetic patients. When the blood pressure target was not reached, the two strategies tested seem to contribute similarly to further reductions in blood pressure and albuminuria.