La pandemia por la COVID-19: una oportunidad para cambiar la forma de atender a nuestros pacientes / The COVID-19 pandemic: an opportunity to change the way we care for our patients

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La investigación clínica: razón de ser de una Sociedad Científica / Clinical research: reason for being of a Scientific Society

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Características basales y manejo clínico de los primeros 3.000 pacientes incluidos en el estudio IBERICAN (Identificación de la población española de riesgo cardiovascular y renal) / Baseline characteristics and clinical management of the first 3.000 patients enrolled in the IBERICAN study (Identification of the Spanish population at cardiovascular and renal risk)

Objetivos. Determinar la prevalencia y la incidencia de los factores de riesgo cardiovascular en España, así como de los eventos cardiovasculares, en población adulta española asistida en atención primaria. Metodología. IBERICAN es un estudio longitudinal, observacional y multicéntrico en el que se están incluyendo pacientes de 18 a 85años atendidos en las consultas de atención primaria en España. La cohorte obtenida se seguirá anualmente durante al menos 5años. La muestra final estimada es de 7.000 pacientes. Se presentan las características basales del segundo corte (n=3.042). Resultados. La edad media de los sujetos incluidos es de 57,9±14,6años, y el 55,5% son mujeres. El 54,9% viven en un hábitat urbano, y el 57,3% tienen estudios primarios. El 50,3% tienen dislipidemia, el 47,4% hipertensión arterial, el 29,7% sedentarismo, el 28,2% obesidad abdominal y el 19% diabetes mellitus. El grado de control de hipertensión arterial, dislipidemia y diabetes mellitus tipo2 fue del 58,5, del 25,8 y del 75,9%, respectivamente. El 28,2% cumplen criterios de síndrome metabólico. El 15,6% de los pacientes presentaban una enfermedad cardiovascular previa. El 7,8% tienen antecedentes de cardiopatía isquémica, el 8,4% de filtrado glomerular (CKD-EPI) <60ml/min, el 9,6% de microalbuminuria, el 5,5% de fibrilación auricular, el 4,6% de ictus y el 2,9% de insuficiencia cardiaca. Conclusiones. A pesar de que la población atendida en atención primaria es relativamente joven, la elevada prevalencia de factores de riesgo, su mal control y la existencia de patología cardiovascular previa condicionarán el impacto en el pronóstico de la cohorte (AU)

Objectives. To determine the prevalence and incidence of cardiovascular risk factors in Spain, as well as cardiovascular events, in Spanish adult population attended in primary care. Methodology. IBERICAN is a longitudinal, observational, multicenter study in which patients aged 18 to 85years attended in primary care health center in Spain are being included. The obtained cohort will be followed annually for at least 5years. The estimated final sample is 7,000 patients. The baseline characteristics of the second cut (n=3,042) are presented. Results. The mean age of the subjects included is 57.9±14.6 years, and 55.5% are women. 54.9% live in urban habitat, and 57.3% have primary education. 50.3% had dyslipidemia, 47.4% hypertension, 29.7% physical inactivity, 28.2% abdominal obesity and 19% diabetes mellitus. The degree of control of hypertension, dyslipidemia and type2 diabetes was 58.5%, 25.8% and 75.9%. 28.2% have criteria for metabolic syndrome. 15.6% of patients had previous cardiovascular disease. 7.8% have a history of coronary heart disease, a glomerular filtration rate <60ml/min (CKD-EPI) 8.4%, microalbuminuria 9.6%, atrial fibrillation 5.5%, stroke 4.6%, and heart failure 2.9%. Conclusions. Although the population treated in primary care is relatively young, the high prevalence of risk factors, their poor control and the existence of previous cardiovascular disease will determine the impact on the prognosis of the cohort (AU)

[Baseline characteristics and clinical management of the first 3,000 patients enrolled in the IBERICAN study (Identification of the Spanish population at cardiovascular and renal risk)]. / Características basales y manejo clínico de los primeros 3.000 pacientes incluidos en el estudio IBERICAN (Identificación de la población española de riesgo cardiovascular y renal).

OBJECTIVES: To determine the prevalence and incidence of cardiovascular risk factors in Spain, as well as cardiovascular events, in Spanish adult population attended in primary care. METHODOLOGY: IBERICAN is a longitudinal, observational, multicenter study in which patients aged 18 to 85years attended in primary care health center in Spain are being included. The obtained cohort will be followed annually for at least 5years. The estimated final sample is 7,000 patients. The baseline characteristics of the second cut (n=3,042) are presented. RESULTS: The mean age of the subjects included is 57.9±14.6 years, and 55.5% are women. 54.9% live in urban habitat, and 57.3% have primary education. 50.3% had dyslipidemia, 47.4% hypertension, 29.7% physical inactivity, 28.2% abdominal obesity and 19% diabetes mellitus. The degree of control of hypertension, dyslipidemia and type2 diabetes was 58.5%, 25.8% and 75.9%. 28.2% have criteria for metabolic syndrome. 15.6% of patients had previous cardiovascular disease. 7.8% have a history of coronary heart disease, a glomerular filtration rate <60ml/min (CKD-EPI) 8.4%, microalbuminuria 9.6%, atrial fibrillation 5.5%, stroke 4.6%, and heart failure 2.9%. CONCLUSIONS: Although the population treated in primary care is relatively young, the high prevalence of risk factors, their poor control and the existence of previous cardiovascular disease will determine the impact on the prognosis of the cohort.

Non-compliance and inertia in hypertensive Spaniards at high cardiovascular risk: CUMPLE study.

OBJECTIVE: To assess non-compliance (NC) and therapeutic inertia (TI) after 6 months of follow-up in hypertensive patients with poorly controlled blood pressure and high cardiovascular risk. RESEARCH DESIGN AND METHODS: Longitudinal, multicentre study; 3900 uncontrolled hypertensive patients were recruited from 585 primary healthcare centres. Tablets were counted during visits at baseline, 1, 3 and 6 months. A tablet count between 80-100% was considered as compliant. Multivariate logistic regression was performed to determine variables associated with NC and TI. RESULTS: A total of 3636 patients completed, mean age was 64.8 (SD 10.8) years, 53.7% being male. After one month, 61.8% (60.2-63.4) had uncontrolled blood pressure, 39.5% (37.9-41.1) were NC and 52.3% (50.2-54.4) had TI. At the end of follow-up, uncontrolled blood pressure was 34.6% (33.1-36.1) (p < 0.05), NC was 46.8% (45.2-48.4) (p < 0.05) and TI was 34.2% (31.6-36.8) (p < 0.05). The variable associated with NC was greatest number of antihypertensive treatments (OR 1.09, 95% CI 1.05-1.13, p < 0.001), and variables associated with TI were least number of antihypertensive drugs (OR 0.88, 95% CI 0.84-0.98, p < 0.001) and least number of diseases suffered (OR 0.95, 95% CI 0.92-0.98, p = 0.002). LIMITATIONS: Due to the complexity of measuring compliance, we have to assume measurement bias. CONCLUSIONS: Among uncontrolled hypertensive patients, after completing 6 months follow-up, approximately one out of two patients were NC and one out of three physicians committed TI.

La investigación como fuente de sostenibilidad del sistema sanitario en Atención Primaria / Research as a source of sustainability of the health system in primary care

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¿Los pacientes con alto riesgo vascular toman correctamente la medicación antihipertensiva? Estudio Cumple-MEMS / Do patients with high vascular risk take antihypertensive medication correctly? Cumple-MEMS study

Introducción y objetivos. Valorar el cumplimiento terapéutico del tratamiento con inhibidores del sistema renina-angiotensina (inhibidores de la enzima de conversión de la angiotensina o antagonistas de los receptores de la angiotensina II) en la hipertensión arterial no controlada de pacientes de alto riesgo vascular. Métodos. Estudio prospectivo, longitudinal y multicéntrico desarrollado en 102 centros de atención primaria españoles. Se incluyó a 808 hipertensos tratados con inhibidores del sistema renina-angiotensina (inhibidores de la enzima de conversión de la angiotensina o antagonistas de los receptores de la angiotensina II), no controlados y con alto riesgo vascular. Se realizaron cuatro visitas (inicial y tras 1, 3 y 6 meses). Se midió el cumplimiento mediante monitores electrónicos. Se calculó el porcentaje de cumplimiento medio, el porcentaje de cumplidores en general, cumplidores de una toma diaria, cumplidores en horario correcto y cobertura antihipertensiva. Se consideró cumplidor a aquel cuya tasa de cumplimiento estuviera entre el 80 y el 100%. Resultados. Finalizaron el estudio 701 pacientes (media de edad, 63,7±11,1 años). Las presiones arteriales sistólicas y diastólicas se redujeron significativamente (p<0,0001): 18,8 y 9,8mmHg respectivamente. Los controlados fueron el 70% (intervalo de confianza del 95%, 65,6-74,4%). Se observaron diferencias significativas con mayor control entre los cumplidores que entre los incumplidores (p<0,05). La media del porcentaje de dosis tomadas fue del 87,9% (intervalo de confianza del 95%, 84,8-91%) y la cobertura terapéutica, el 82,4% (intervalo de confianza del 95%, 78,7-86,1%). Fueron cumplidores en general el 73,3% (intervalo de confianza del 95%, 69-77,6%); de una toma diaria, el 52,8% (intervalo de confianza del 95%, 48-57,6%), y en horario correcto, el 46,5% (intervalo de confianza del 95%, 41,9-51,1%). El cumplimiento se asoció a menor número de fármacos prescritos y no estar diagnosticado de diabetes (p<0,001). Conclusiones. Entre los hipertensos de alto riesgo vascular, el incumplimiento fue muy alto, fundamentalmente cuando toman cinco o más comprimidos diarios (AU)

Introduction and objectives. To assess compliance with treatment inhibit the renin-angiotensin system (angiotensin-converting enzyme inhibitors or angiotensin receptor blockers) in uncontrolled hypertension in patients at high cardiovascular risk. Methods. Prospective, longitudinal, multicenter study, carried out in 102 Spanish primary care centers. We included 808 uncontrolled hypertensive patients treated with angiotensin-converting enzyme inhibitors or angiotensin receptor blockers who were at high vascular risk; 4 visits were conducted: baseline and 1, 3, and 6 months later. Compliance was measured by electronic monitors. We calculated the mean percentage compliance, the overall percentage of compliers, once-daily compliers, compliers with the prescribed time frame, and antihypertensive coverage. We considered a patient to be a complier when the percentage compliance was 80%-100%. Results. In all, 701 patients completed the study (mean age, 63.7 [11.1] years). The systolic and diastolic blood pressures decreased significantly (P<.0001) to 18.8mmHg and 9.8 mmHg, respectively. The control rate was 70% (95% confidence interval, 65.6%-74.4%) (P=.0001). The rate of control was significantly higher among compliers than noncompliers (P<.05). The mean percentage of doses taken was 87.9% (95% confidence interval, 84.8%-91%) and the mean therapeutic coverage was 82.4% (95% confidence interval, 78.7%-86.1%). Overall, 73.3% of the patients were compliers (95% confidence interval, 69%-77.6%), 52.8% (95% confidence interval, 48%-57.6%) were once-daily compliers, and 46.5% (95% confidence interval, 41.9%-51.1%) complied with the prescribed time frame. Noncompliance was associated with a higher number of drugs prescribed (P<.001). Conclusions. In hypertensive patients at high vascular risk, the rate of therapeutic noncompliance was very high, mainly when they took 5 or more pills daily (AU)

Prevalencia de enfermedad renal crónica en mujeres hipertensas de edad avanzada atendidas en atención primaria. Estudio MERICAP / Prevalence of chronic kidney disease in hypertensive aged women treated in primary care. MERICAP Study

Fundamento y objetivo: Se dispone de poca información sobre la prevalencia de enfermedad renal crónica (ERC) en atención primaria (AP). El objetivo del estudio ha sido determinar la prevalencia de ERC en mujeres hipertensas de 65 o más años de edad, y los factores asociados. Pacientes y método: Estudio transversal en hipertensas seleccionadas consecutivamente en AP de España. Se calculó el filtrado glomerular (FG) utilizando la fórmula de Modification of Diet in Renal Disease (MDRD), considerando ERC cuando la tasa de FG (TFG) era inferior a 60ml/min/1,73m2 y ERC oculta cuando la TFG era inferior a 60ml/min/1,73m2 con valores de creatinina<1,2mg/dl. Se recogieron datos demográficos, factores de riesgo y enfermedades cardiovasculares. Resultados: Se incluyeron 3.782 pacientes con una edad media (±DE) de 73,6 (6,1) años. El 53,4% (intervalo de confianza del 95% [IC 95%]: 51,8-55,0) presentaba una TFG<60ml/min/1,73m2 y un 25,7% (IC 95%: 26,3-29,1), ERC oculta. La prevalencia aumentó con la edad, siendo del 51% en las menores de 75 años y del 60,7% en las mayores de 84 (p<0,001). Las pacientes con ERC tenían, respecto a las pacientes sin ERC, mayor edad, presión arterial, dislipidemia, glucosa, lesión de órgano diana y más antecedentes de enfermedad cardiovascular (p<0,001). La presencia de ERC se asoció significativamente con cardiopatía (odds ratio [OR]: 1,9), hiperglucemia (OR: 1,6), hipertrigliceridemia (OR: 1,5) y presión arterial diastólica elevada (OR: 1,4). Conclusiones: Más de 5 de cada 10 mujeres hipertensas mayores de 64 años presentan ERC, y de estas casi la mitad tienen valores de creatinina normales (AU)

Background and objectives: Information about the prevalence of chronic kidney disease (CKD) in the population treated in primary care is scarce. The aim of this study was to assess the prevalence of CKD in Spanish hypertensive women aged 64 years or older, and to determine possible associated factors. Patients and method: Cross-sectional study including women with a diagnosis of hypertension selected by consecutive sampling in primary care. CKD was diagnosed when glomerular filtration rate was<60ml/min/1.73m2 (MDRD). We assessed sociodemographic and clinical data, cardiovascular risk factors, and the presence of cardiovascular disease. Results: The sample included 3782 women with a mean age of 73.6±6.1 years. CKD (glomerular filtration rate<60ml/min/1.73m2 was present in 53.4% (95% CI: 51.8-55.0). Masked CKD (serum creatinine<1.2mg/dl) was present in 25.7% (95% CI: 26.3-29.1). The prevalence increased with age (51% in those younger than 75 and 60.7% in women older than 84 (P<.001). With respect to those with normal renal function, hypertensive women having CKD were older, showed higher values of blood pressure, and had more frequently dyslipidemia, elevated plasma glucose, target organ damage and cardiovascular disease (P<.001). In a multivariate analysis, CKD was associated with coronary heart disease (OR: 1.9), hyperglycemia (OR: 1.6), hypertriglyceridemia (OR: 1.5), and elevated diastolic blood pressure (OR: 1.4). Conclusions: More than half of hypertensive women aged 64 years have CKD and of these about half have normal creatinine values (AU)

Do Patients With High Vascular Risk Take Antihypertensive Medication Correctly? Cumple-MEMS Study.

INTRODUCTION AND OBJECTIVES: To assess compliance with treatment inhibit the renin-angiotensin system (angiotensin-converting enzyme inhibitors or angiotensin receptor blockers) in uncontrolled hypertension in patients at high cardiovascular risk. METHODS: Prospective, longitudinal, multicenter study, carried out in 102 Spanish primary care centers. We included 808 uncontrolled hypertensive patients treated with angiotensin-converting enzyme inhibitors or angiotensin receptor blockers who were at high vascular risk; 4 visits were conducted: baseline and 1, 3, and 6 months later. Compliance was measured by electronic monitors. We calculated the mean percentage compliance, the overall percentage of compliers, once-daily compliers, compliers with the prescribed time frame, and antihypertensive coverage. We considered a patient to be a complier when the percentage compliance was 80%-100%. RESULTS: In all, 701 patients completed the study (mean age, 63.7 [11.1] years). The systolic and diastolic blood pressures decreased significantly (P<.0001) to 18.8 mmHg and 9.8 mmHg, respectively. The control rate was 70% (95% confidence interval, 65.6%-74.4%) (P=.0001). The rate of control was significantly higher among compliers than noncompliers (P<.05). The mean percentage of doses taken was 87.9% (95% confidence interval, 84.8%-91%) and the mean therapeutic coverage was 82.4% (95% confidence interval, 78.7%-86.1%). Overall, 73.3% of the patients were compliers (95% confidence interval, 69%-77.6%), 52.8% (95% confidence interval, 48%-57.6%) were once-daily compliers, and 46.5% (95% confidence interval, 41.9%-51.1%) complied with the prescribed time frame. Noncompliance was associated with a higher number of drugs prescribed (P<.001). CONCLUSIONS: In hypertensive patients at high vascular risk, the rate of therapeutic noncompliance was very high, mainly when they took 5 or more pills daily.

[Prevalence of chronic kidney disease in hypertensive aged women treated in primary care. MERICAP Study]. / Prevalencia de enfermedad renal crónica en mujeres hipertensas de edad avanzada atendidas en atención primaria. Estudio MERICAP.

BACKGROUND AND OBJECTIVES: Information about the prevalence of chronic kidney disease (CKD) in the population treated in primary care is scarce. The aim of this study was to assess the prevalence of CKD in Spanish hypertensive women aged 64 years or older, and to determine possible associated factors. PATIENTS AND METHOD: Cross-sectional study including women with a diagnosis of hypertension selected by consecutive sampling in primary care. CKD was diagnosed when glomerular filtration rate was<60 ml/min/1.73 m(2) (MDRD). We assessed sociodemographic and clinical data, cardiovascular risk factors, and the presence of cardiovascular disease. RESULTS: The sample included 3782 women with a mean age of 73.6 ± 6.1 years. CKD (glomerular filtration rate<60 ml/min/1.73 m(2) was present in 53.4% (95% CI: 51.8-55.0). Masked CKD (serum creatinine<1.2mg/dl) was present in 25.7% (95% CI: 26.3-29.1). The prevalence increased with age (51% in those younger than 75 and 60.7% in women older than 84 (P<.001). With respect to those with normal renal function, hypertensive women having CKD were older, showed higher values of blood pressure, and had more frequently dyslipidemia, elevated plasma glucose, target organ damage and cardiovascular disease (P<.001). In a multivariate analysis, CKD was associated with coronary heart disease (OR: 1.9), hyperglycemia (OR: 1.6), hypertriglyceridemia (OR: 1.5), and elevated diastolic blood pressure (OR: 1.4). CONCLUSIONS: More than half of hypertensive women aged 64 years have CKD and of these about half have normal creatinine values.

Inercia terapéutica en pacientes hipertensos asistidos en atención primaria en España. Estudio Objetivo Kontrol / Objective KONTROL study: therapeutic inertia in hypertensive patients attended in primary care of Spain

ObjetivosConocer el grado de inercia terapéutica (IT) y determinar los factores asociados al paciente, médico y organización sanitaria en pacientes hipertensos asistidos en atención primaria (AP).DiseñoEstudio transversal y multicéntrico.EmplazamentoMuestra de Equipos de AP de toda España.ParticipantesEl estudio fue realizado entre médicos de AP mediante un cuestionario y registro clínico de 4 pacientes.Mediciones principalesSe calculó la IT para cada paciente (ITp) como la proporción de visitas en las que no se produce un cambio en la medicación cuando está indicado.ResultadosUn total de 543 médicos aportaron datos de 2.032 pacientes, que cumplían el requisito de indicación de cambio, en el 77,8% de los casos se actuó con IT. La ITp observada fue inexistente o baja para el 17,1% de los pacientes, intermedia para el 42% y alta para el 40,8%. Los factores, relativos a los pacientes, que más se asociaron con la ITp alta fueron la edad (p<0,001), diabetes (p<0,001), ictus (p<0,01), obesidad (p<0,01) y el nivel bajo de estudios (p<0,001). Ser mujer, tener menos de 45 años o más de 55, ser médico de familia con un programa de formación diferente al MIR y trabajar en el sector público aumentaron la probabilidad de ITp (p<0,001 para todos los supuestos).ConclusionesLos resultados del estudio indican que en 7 de cada 10 visitas realizadas por pacientes hipertensos en AP se produce IT. Existen diferencias importantes en función de las características clínicas de los pacientes, de los médicos y de las consultas(AU)

ObjectivesTo determine the level of therapeutic inertia (TI), and the factors associated to the patient, doctor and the health organisation, in hypertensive patients treated in Primary Care (PC).DesignCross-sectional, multicentre study.SettingA sample of PC Teams from all over Spain.ParticipantsThe study was conducted among PC doctors using a questionnaire and clinical records of 4 patients.Main measurementsThe TI was calculated for each patient (TIp) as the proportion of visits in which there was no change in medication when this was indicated.ResultsA total of 543 PC doctors provided data on 2,032 patients, who fulfilled the indication of a change in requirement. There was TI In 77.8% of cases. The TIp observed was non-existent or low for 17.1% of the patients, intermediate for 42% and high for 40.8%. For the patients, the factors most associated with TIp were, age (P<.001), diabetes (P<.001), stroke (P<.01), obesity (P<.01) and a low education level (P<.001). To be female, be less than 40years or more than 55years, to be a family doctor with a training program other than MIR and to work in the public sector increased the probability of TIp (P<.001 for all the assumptions).ConclusionsThe results of the study indicate that there is TI in 7 out every 10 visits made by hypertensive patients in Primary care. There are significant differences as regards the clinical characteristics of the patients and of the doctors(AU)

Importancia de la detección temprana de la enfermedad renal crónica en grupos de riesgo / Importance of early detection of chronic kidney disease in risk groups

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Estudio “Objetivo Kontrol”: inercia terapéutica en hipertensión arterial. Diseño y metodología / “Kontrol Objective” Study: therapeutic inertia in arterial hypertension. Design and methodology

Introducción: En la actualidad, únicamente el 40% de los hipertensos tratados mantienen cifras tensionales dentro de los límites recomendados por las guías de práctica clínica. La inercia terapéutica (IT) es uno de los problemas para alcanzar un buen control de la presión arterial, y se desconoce en gran medida los factores que influyen en ella. Objetivos: elaborar y validar un cuestionario para medir la IT en el control de la HTA e identificar factores relacionados con la organización sanitaria que faciliten o prevengan la IT.Métodos: En la elaboración del cuestionario se utilizarán técnicas cualitativas (revisión de la literatura, informantes clave, grupos de discusión, análisis semiológico de la discusión y extracción de ítems). Posteriormente, mediante técnicas cuantitativas, se validará el cuestionario en un trabajo de campo, comparando la puntuación obtenida en el cuestionario con la medida directa de la IT obtenida a partir de las historias clínicas de pacientes (validez de criterio). Simultáneamente se identificarán factores asociados a la IT, en particular en aspectos del paciente, del médico, de enfermería y del tiempo dedicado a la consulta.Conclusiones: El producto principal de este estudio será un instrumento que ayude a medir el grado de IT del médico y a conocer qué factores del paciente, del médico y de su entorno contribuyen a producir en el médico la intención de actuar o no frente a un fracaso terapéutico. La principal limitación del estudio dependerá de en qué medida un test autoaplicable sobre conocimientos teóricos y juicios de valor sobre situaciones clínicas concretas pueda ser un reflejo fiable de la actuación clínica en circunstancias reales(AU)

Introduction: Only 40% of persons treated for arterial hypertension (AHT) currently maintain blood pressure levels within the limits recommended by clinical practice guidelines. Treatment inertia (TI) is one of the problems in achieving good blood pressure control, however the factors influencing TI are largely unknown.Objectives: To develop and validate a questionnaire to measure TI in controlling AHT and to identify factors related with the organization of healthcare that facilitate or prevent TI. Methods: Qualitative techniques (literature review, key informants, discussion groups, subsequent semiologic analysis of the discussion and extraction of items) were used in developing the questionnaire. Quantitative techniques were then used to validate the questionnaire in fieldwork, comparing the score obtained on the questionnaire with the direct measurement of TI obtained from clinical histories of patients (criterion validity). At the same time, factors associated with TI were identified, in particular, aspects related with the patient, physician, nursing staff and time devoted to the medical consultation.Conclusions: The main product of this study will be an instrument that helps to measure the physician’s degree of TI and to determine what factors related with the patient, physician and setting help produce the physician’s intention to act or not when faced with treatment failure. The main study limitation will depend on the extent to which a self-completed test on theoretical knowledge and value judgments about specific clinical situations can reliably reflect clinical actions in real circumstances(AU)

Papel de las nuevas combinaciones a dosis fijas en el tratamiento de la hipertensión arterial / Role of new drug combinations at fixed doses for the management of arterial hypertension

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