Importance of adherence in the management of hypertension / Importancia de la adherencia terapéutica en el manejo de la hipertensión

The WHO indicates that lack of adherence is a matter of the highest priority in Public Health, and is the main cause of not obtaining all the benefits that medications can provide; it is at the origin of medical and psychosocial complications; reduces quality of life; it increases the probability of the appearance of drug resistance and wastes healthcare resources.The no adherence prevalence in hypertension (HTN) ranges between 55.5% with self-reporting and 46.6% with pill counting, and treatment abandonment occurs in 18.5% of patients. The electronic prescription has been validated in HTN using MEMS as a comparison, with sensitivity of 87% and specificity of 93.7%, with an area under the curve of 0.903. In 2019, almost 10 million deaths were directly attributed to HTN. No other disease causes as high a number of deaths and has as high a projected increase in deaths as cardiovascular disease (CVD). By 2030, it is projected that more than 22 million people/year will die from CVD, almost 5 million more than in 2012. In a predictive model for a period of 10 years in five European countries (Italy, Germany, France, Spain and England), the potential savings of increasing adherence to antihypertensive treatment to 70% has been estimated at 332 million euros (80 million in the case of Spain). The use of fixed combinations of two or three drugs is a good method to reduce non-adherence. (AU)

La OMS indica que la falta de adherencia es una cuestión de máxima prioridad en salud pública, y es la principal causa de que no se obtengan todos los beneficios que los medicamentos pueden proporcionar; está en el origen de complicaciones médicas y psicosociales, reduce la calidad de vida, aumenta la probabilidad de aparición de resistencias a los fármacos y desperdicia recursos asistenciales.La prevalencia de la no adherencia en hipertensión (HTA) oscila entre el 55,5% con la autodeclaración, y el 46,6% con el recuento y el abandono del tratamiento se produce en el 18,5% de los pacientes.Se ha validado en HTA la receta electrónica utilizándose los MEMS como comparativo, con sensibilidad del 87% y especificidad del 93,7%, con un área bajo la curva de 0,903.Se contabilizan en 2019 casi 10 millones de muertes achacadas directamente a la HTA. Ninguna otra enfermedad causa un número tan elevado de muertes ni tiene un incremento proyectado de fallecimientos tan elevado como la enfermedad cardiovascular. Para 2030 se prevé que morirán más de 22 millones de personas/año por enfermedad cardiovascular, casi 5 millones más que en 2012. En un modelo predictivo para un período de 10 años en 5 países europeos (Italia, Alemania, Francia, España e Inglaterra) el ahorro potencial de aumentar la adherencia al tratamiento antihipertensivo al 70% se ha estimado en 332 millones de euros (80 millones en el caso de España). El uso de combinaciones fijas de 2 o de 3 fármacos es un buen método para reducir la no adherencia. (AU)

Importance of adherence in the management of hypertension.

The WHO indicates that lack of adherence is a matter of the highest priority in Public Health, and is the main cause of not obtaining all the benefits that medications can provide; it is at the origin of medical and psychosocial complications; reduces quality of life; it increases the probability of the appearance of drug resistance and wastes healthcare resources. The no adherence prevalence in hypertension (HTN) ranges between 55.5% with self-reporting and 46.6% with pill counting, and treatment abandonment occurs in 18.5% of patients. The electronic prescription has been validated in HTN using MEMS as a comparison, with sensitivity of 87% and specificity of 93.7%, with an area under the curve of 0.903. In 2019, almost 10 million deaths were directly attributed to HTN. No other disease causes as high a number of deaths and has as high a projected increase in deaths as cardiovascular disease (CVD). By 2030, it is projected that more than 22 million people/year will die from CVD, almost 5 million more than in 2012. In a predictive model for a period of 10 years in five European countries (Italy, Germany, France, Spain and England), the potential savings of increasing adherence to antihypertensive treatment to 70% has been estimated at 332 million euros (80 million in the case of Spain). The use of fixed combinations of two or three drugs is a good method to reduce non-adherence.

Papel del sistema renina-angiotensina en el embarazo y la preeclampsia / Role of the renin-angiotensin system in pregnancy and preeclampsia

El sistema renina-angiotensina (SRA) es una cascada hormonal que regula presión arterial, electrólitos y balance hídrico. La angiotensinaII (AII) ejerce sus efectos a través de los receptores AT1 y AT2. El AT1 se encuentra en el sincitiotrofoblasto; el AT2 predomina durante el desarrollo fetal y su estimulación inhibe el crecimiento celular, aumenta la apoptosis, causa vasodilatación y regula el desarrollo del tejido fetal. Existe además un SRA en la placenta, y la generación local de AII es responsable de la activación de los receptores AT1 del trofoblasto. En el embarazo normal, concomitantemente con reducción de los niveles de presión arterial, se produce un aumento del SRA circulante, pero la presión arterial no sube porque existe refractariedad a la AII, cosa que no ocurre en la preeclampsia. Revisamos la función del SRA en el embarazo normal y en la preeclampsia

The renin-angiotensin system (ARS) is a hormonal cascade that regulates blood pressure, electrolytes and water balance. AngiotensinII (AII) exerts its effects through the AT1 and AT2 receptors. AT1 is found in the syncytiotrophoblast, AT2 predominates during foetal development and its stimulation inhibits cell growth, increases apoptosis, causes vasodilation and regulates the development of foetal tissue. There is also an SRA in the placenta. The local generation of AII is responsible for the activation of AT1 receptors in the trophoblast. In normal pregnancy, concomitantly with reduction of blood pressure the circulating RAS increases, but blood pressure does not rise due to AII refractoriness, which does not occur in preeclampsia. We review the role of the SRA in normal pregnancy and preeclampsia

[Role of the renin-angiotensin system in pregnancy and preeclampsia]. / Papel del sistema renina-angiotensina en el embarazo y la preeclampsia.

The renin-angiotensin system (ARS) is a hormonal cascade that regulates blood pressure, electrolytes and water balance. AngiotensinII (AII) exerts its effects through the AT1 and AT2 receptors. AT1 is found in the syncytiotrophoblast, AT2 predominates during foetal development and its stimulation inhibits cell growth, increases apoptosis, causes vasodilation and regulates the development of foetal tissue. There is also an SRA in the placenta. The local generation of AII is responsible for the activation of AT1 receptors in the trophoblast. In normal pregnancy, concomitantly with reduction of blood pressure the circulating RAS increases, but blood pressure does not rise due to AII refractoriness, which does not occur in preeclampsia. We review the role of the SRA in normal pregnancy and preeclampsia.

Experiencia inicial con catéter multielectrodo en denervación renal. ¿Una técnica que ha vuelto para quedarse? / Initial experience with a multi-electrode catheter in renal denervation. A technique that has come back to stay?

No disponible

Documento de la Sociedad Española de Hipertensión-Liga Española para la Lucha contra la Hipertensión Arterial (SEH-LELHA) sobre las guías ACC/AHA 2017 de hipertensión arterial / Spanish Society of Hypertension position statement on the 2017 ACC/AHA hypertension guidelines

El American College of Cardiology (ACC) y la American Heart Association (AHA) han publicado recientemente la guía para la prevención, detección, evaluación y tratamiento de la hipertensión arterial (HTA) en adultos. El punto más controvertido es el umbral diagnóstico de 130/80 mmHg, lo cual conlleva diagnosticar HTA en un gran número de personas previamente consideradas no hipertensas. La presión arterial (PA) se clasifica como normal (sistólica < 120 y diastólica 80 mmHg), elevada (120-129 y < 80 mmHg), grado 1 (130-139 o 80-89 mmHg) y grado 2 (≥ 140 o ≥ 90 mmHg). Se recomienda la medida de PA fuera de la consulta para confirmar el diagnóstico de HTA o para aumentar el tratamiento. En la toma de decisiones sería determinante el riesgo cardiovascular (RCV), ya que precisarían tratamiento farmacológico personas con HTA grado 1 con riesgo a 10 años de enfermedad cardiovascular aterosclerótica ≥ 10% y aquellas con enfermedad cardiovascular establecida, enfermedad renal crónica y diabetes, siendo el resto susceptibles de medidas no farmacológicas hasta umbrales de 140/90 mmHg. Dichas recomendaciones permitirían a los sujetos con HTA grado 1 y alto RCV beneficiarse de terapias farmacológicas y podrían mejorar las intervenciones no farmacológicas en todos los sujetos. Sin embargo, habría que ser cauteloso ya que sin poder garantizar una toma correcta de PA, ni el cálculo sistemático del RCV, la aplicación de dichos criterios podría sobrestimar el diagnóstico de HTA y suponer un sobretratamiento innecesario. Las guías son recomendaciones, no imposiciones, y el abordaje y manejo de la PA debe ser individualizado, basado en decisiones clínicas, preferencias de los pacientes y en un balance adecuado del beneficio y riesgo al establecer los diferentes objetivos de PA

The American College of Cardiology (ACC) and the American Heart Association (AHA) have recently published their guidelines for the prevention, detection, evaluation, and management of hypertension in adults. The most controversial issue is the classification threshold at 130/80mmHg, which will allow a large number of patients to be diagnosed as hypertensive who were previously considered normotensive. Blood pressure (BP) is considered normal (<120mmHg systolic and <80mmHg diastolic), elevated (120-129 and <80mmHg), stage 1 (130-139 or 80-89mmHg), and stage 2 (≥140 or ≥90mmHg). Out-of-office BP measurements are recommended to confirm the diagnosis of hypertension and for titration of BP-lowering medication. In management, cardiovascular risk would be determinant since those with grade 1 hypertension and an estimated 10-year risk of atherosclerotic cardiovascular disease ≥10%, and those with cardiovascular disease, chronic kidney disease and/or diabetes will require pharmacological treatment, the rest being susceptible to non-pharmacological treatment up to the 140/90mmHg threshold. These recommendations would allow patients with level 1 hypertension and high atherosclerotic cardiovascular disease to benefit from pharmacological therapies and all patients could also benefit from improved non-pharmacological therapies. However, this approach should be cautious because inadequate BP measurement and/or lack of systematic atherosclerotic cardiovascular disease calculation could lead to overestimation in diagnosing hypertension and to overtreatment. Guidelines are recommendations, not impositions, and the management of hypertension should be individualized, based on clinical decisions, preferences of the patients, and an adequate balance between benefits and risks

[Spanish Society of Hypertension position statement on the 2017 ACC/AHA hypertension guidelines]. / Documento de la Sociedad Española de Hipertensión-Liga Española para la Lucha contra la Hipertensión Arterial (SEH-LELHA) sobre las guías ACC/AHA 2017 de hipertensión arterial.

The American College of Cardiology (ACC) and the American Heart Association (AHA) have recently published their guidelines for the prevention, detection, evaluation, and management of hypertension in adults. The most controversial issue is the classification threshold at 130/80mmHg, which will allow a large number of patients to be diagnosed as hypertensive who were previously considered normotensive. Blood pressure (BP) is considered normal (<120mmHg systolic and <80mmHg diastolic), elevated (120-129 and <80mmHg), stage 1 (130-139 or 80-89mmHg), and stage 2 (≥140 or ≥90mmHg). Out-of-office BP measurements are recommended to confirm the diagnosis of hypertension and for titration of BP-lowering medication. In management, cardiovascular risk would be determinant since those with grade 1 hypertension and an estimated 10-year risk of atherosclerotic cardiovascular disease ≥10%, and those with cardiovascular disease, chronic kidney disease and/or diabetes will require pharmacological treatment, the rest being susceptible to non-pharmacological treatment up to the 140/90mmHg threshold. These recommendations would allow patients with level 1 hypertension and high atherosclerotic cardiovascular disease to benefit from pharmacological therapies and all patients could also benefit from improved non-pharmacological therapies. However, this approach should be cautious because inadequate BP measurement and/or lack of systematic atherosclerotic cardiovascular disease calculation could lead to overestimation in diagnosing hypertension and to overtreatment. Guidelines are recommendations, not impositions, and the management of hypertension should be individualized, based on clinical decisions, preferences of the patients, and an adequate balance between benefits and risks.

Trastornos hipertensivos en el embarazo: repercusión a largo plazo en la salud cardiovascular de la mujer / Hypertensive disorders during pregnancy: Cardiovascular long-term outcomes

La hipertensión en el embarazo (HE) produce daño materno y fetal, pero también puede suponer el inicio de alteraciones vasculares y metabólicas futuras. El riesgo relativo de padecer hipertensión crónica tras HE es de entre 2,3 y 11, y la probabilidad de desarrollo posterior de diabetes tipo2 se multiplica por un factor de 1,8. Las mujeres con historia previa de preeclampsia/eclampsia tienen doble riesgo de ictus y mayor frecuencia de arritmias y hospitalización por insuficiencia cardíaca. Asimismo, se observa un riesgo 10 veces mayor de enfermedad renal terminal a largo plazo. El riesgo relativo de muerte cardiovascular es 2,1 veces mayor que el del grupo sin problemas hipertensivos del embarazo, aunque en partos pretérmino asociados a hipertensión gestacional o hipertensión preexistente el riesgo es entre 4 y 7 veces superior. El periodo posparto supone una gran oportunidad para intervenir sobre los estilos de vida, la obesidad, hacer un diagnóstico temprano de HTA crónica y de DM y facilitar los tratamientos necesarios para prevenir complicaciones cardiovasculares de la mujer

Pregnancy-induced hypertension (PIH) induces maternal and fetal damage, but it can also be the beginning of future metabolic and vascular disorders. The relative risk of chronic hypertension after PIH is between 2.3 and 11, and the likelihood of subsequent development of type 2 diabetes is multiplied by 1.8. Women with prior preeclampsia/eclampsia have a twofold risk of stroke and a higher frequency of arrhythmias and hospitalization due to heart failure. Furthermore, a tenfold greater risk for long-term chronic kidney disease is observed as well. The relative risk of cardiovascular death is 2.1 times higher compared to the group without pregnancy-induced hypertension problems, although the risk is between 4 and 7 times higher in preterm birth associated with gestational hypertension or pre-existing hypertension The postpartum period is a great opportunity to intervene on lifestyle, obesity, make an early diagnosis of chronic hypertension and DM and provide the necessary treatments to prevent cardiovascular complications in women

La hipertensión arterial en la embarazada / Gestational hypertension

La preeclampsia es una enfermedad exclusiva de los humanos que complica entre el 3 y el 14% de las gestaciones en el mundo, de causa desconocida, aunque parte de una placentación deficiente que produce isquemia placentaria y ésta, liberación de factores antiangiogénicos y citocinas proinflamatorias. Se reconocen 2 cuadros la preeclampsia: temprana, que se asocia a eventos adversos maternos y fetales, y tardía, con baja afectación fetal y pronóstico materno-fetal más favorable. Como predictores se barajan: ácido úrico > 3,15 mg/dl como predictor de hipertensión gestacional en el primer trimestre y > 5,2 mg/dl de preeclampsia grave/eclampsia. La relación sFLT-1/PIGF (tirosincinasa-1 soluble/factor angiogénico de crecimiento placentario) > 85 es marcador de complicaciones del embarazo y un buen indicador que ayuda a la toma de decisiones. La hipertensión arterial durante el embarazo puede suponer el inicio de alteraciones vasculares y metabólicas futuras; de hecho la preeclampsia/eclampsia se considera un factor de riesgo específico en la mujer en algunas guías de riesgo cardiovascular

Preeclampsia (PE) is a disease unique to humans. PE complicates from 3 to 14% of pregnancies worldwide. Unknown cause yet, although part of poor placentation resulting placental ischemia release of proinflammatory cytokines and anti-angiogenic factors. Two PE types: early PE with maternal and fetal adverse events and late PE with low fetal involvement and more favorable maternal-fetal prognosis. As PE predictors being considered: increased uric acid of 3.15 mg/dl as a predictor of gestational hypertension in the first quarter and greater than 5.2 mg/dl for severe/eclampsia preeclampsia. The sFLT-1/PIGF (soluble FMS-like tyrosine kinase-1/angiogenic placental growth facto) ratio is above 85 is a marker of pregnancy complications and a good indicator that helps decision making. Hypertension in pregnancy can be the beginning of vascular and metabolic alterations future; indeed the PE/eclampsia is considered a specific risk factor in women in some guides cardiovascular risk

¿Qué posibilidades farmacológicas existen para tratar la hipertensión arterial resistente? / What are the pharmacological options for treating resistant hypertension?

Ante un paciente con hipertensión arterial resistente se debe optimizar el tratamiento farmacológico, teniendo en cuenta que la definición de hipertensión arterial resistente conlleva el uso de 3 fármacos a dosis plenas, potentes, con cobertura de 24 h y cuya combinación sea sinérgica. De especial relevancia es el tratamiento diurético. Como cuarto fármaco, el uso de los antagonistas de aldosterona es casi obligado. En caso de intolerancia o de no conseguir un adecuado control, se debe recurrir a combinaciones con otras familias de fármacos menos usados, que en ocasiones permiten un adecuado control de estos pacientes

When treating a patient with resistant hypertension therapy should be optimize in order to prescribe three antihypertensive drugs at full doses, being powerful drugs, having 24-hour coverage, and showing synergistic effects. Diuretic therapy is of special relevance. The fourth drug should be an aldosterone antagonists. In the case of intolerance, or when control is not achieved, drugs from other type of antihypertensive drugs should be, sometimes allowing adequate blood pressure control

[Hypertensive disorders during pregnancy: Cardiovascular long-term outcomes]. / Trastornos hipertensivos en el embarazo: repercusión a largo plazo en la salud cardiovascular de la mujer.

Pregnancy-induced hypertension (PIH) induces maternal and fetal damage, but it can also be the beginning of future metabolic and vascular disorders. The relative risk of chronic hypertension after PIH is between 2.3 and 11, and the likelihood of subsequent development of type 2 diabetes is multiplied by 1.8. Women with prior preeclampsia/eclampsia have a twofold risk of stroke and a higher frequency of arrhythmias and hospitalization due to heart failure. Furthermore, a tenfold greater risk for long-term chronic kidney disease is observed as well. The relative risk of cardiovascular death is 2.1 times higher compared to the group without pregnancy-induced hypertension problems, although the risk is between 4 and 7 times higher in preterm birth associated with gestational hypertension or pre-existing hypertension The postpartum period is a great opportunity to intervene on lifestyle, obesity, make an early diagnosis of chronic hypertension and DM and provide the necessary treatments to prevent cardiovascular complications in women.

[Gestational hypertension]. / La hipertensión arterial en la embarazada.

Preeclampsia (PE) is a disease unique to humans. PE complicates from 3 to 14% of pregnancies worldwide. Unknown cause yet, although part of poor placentation resulting placental ischemia release of proinfammatory cytokines and anti-angiogenic factors. Two PE types: early PE with maternal and fetal adverse events and late PE with low fetal involvement and more favorable maternal-fetal prognosis. As PE predictors being considered: increased uric acid of 3.15 mg/dl as a predictor of gestational hypertension in the first quarter and greater than 5.2 mg/dl for severe/eclampsia preeclampsia. The sFLT-1/PIGF (soluble FMS-like tyrosine kinase-1/angioge nic placental growth facto) ratio is above 85 is a marker of pregnancy complications and a good indicator that helps decision making. Hypertension in pregnancy can be the beginning of vascular and metabolic alterations future; indeed the PE/eclampsia is considered a specific risk factor in women in some guides cardiovascular risk. © 2017 SEHLELHA. Published by Elsevier España, S.L.U. All rights reserved.

[What are the pharmacological options for treating resistant hypertension?] / ¿Qué posibilidades farmacológicas existen para tratar la hipertensión arterial resistente?

When treating a patient with resistant hypertension therapy should be optimize in order to prescribe three antihypertensive drugs at full doses, being powerful drugs, having 24-hour coverage, and showing synergistic effects. Diuretic therapy is of special relevance. The fourth drug should be an aldosterone antagonists. In the case of intolerance, or when control is not achieved, drugs from other type of antihypertensive drugs should be, sometimes allowing adequate blood pressure control.

Modification over time of pulse wave velocity parallel to changes in aortic BP, as well as in 24-h ambulatory brachial BP.

Arterial stiffness as assessed by carotid-femoral pulse wave velocity (cfPWV) is a marker of preclinical organ damage and a predictor of cardiovascular outcomes, independently of blood pressure (BP). However, limited evidence exists on the association between long-term variation (Δ) on aortic BP (aoBP) and ΔcfPWV. We aimed to evaluate the relationship of ΔBP with ΔcfPWV over time, as assessed by office and 24-h ambulatory peripheral BP, and aoBP. AoBP and cfPWV were evaluated in 209 hypertensive patients with either diabetes or metabolic syndrome by applanation tonometry (Sphygmocor) at baseline(b) and at 12 months of follow-up(fu). Peripheral BP was also determined by using validated oscillometric devices (office(o)-BP) and on an outpatient basis by using a validated (Spacelabs-90207) device (24-h ambulatory BP). ΔcfPWV over time was calculated as follows: ΔcfPWV=[(cfPWVfu-cfPWVb)/cfPWVb] × 100. ΔBP over time resulted from the same formula applied to BP values obtained with the three different measurement techniques. Correlations (Spearman 'Rho') between ΔBP and ΔcfPWV were calculated. Mean age was 62 years, 39% were female and 80% had type 2 diabetes. Baseline office brachial BP (mm Hg) was 143±20/82±12. Follow-up (12 months later) office brachial BP (mm Hg) was 136±20/79±12. ΔcfPWV correlated with ΔoSBP (Rho=0.212; P=0.002), Δ24-h SBP (Rho=0.254; P<0.001), Δdaytime SBP (Rho=0.232; P=0.001), Δnighttime SBP (Rho=0.320; P<0.001) and ΔaoSBP (Rho=0.320; P<0.001). A multiple linear regression analysis included the following independent variables: ΔoSBP, Δ24-h SBP, Δdaytime SBP, Δnighttime SBP and ΔaoSBP. ΔcfPWV was independently associated with Δ24-h SBP (ß-coefficient=0.195; P=0.012) and ΔaoSBP (ß-coefficient= 0.185; P=0.018). We conclude that changes in both 24-h SBP and aoSBP more accurately reflect changes in arterial stiffness than do office BP measurements.

Niveles de células progenitoras endoteliales circulantes en pacientes hipertensos tratados / Circulating endothelial progenitor cell levels in treated hypertensive patients

Introducción: Muchos pacientes hipertensos óptimamente tratados de sus factores de riesgo cardiovascular (FRCV) siguen presentando complicaciones cardiovasculares. Las células progenitoras endoteliales (CPE) han demostrado ser fundamentales para la reparación del daño endotelial en tejidos isquémicos. Por ello, hemos estudiado los niveles de CPE y del factor de crecimiento del endotelio vascular (VEGF) en pacientes hipertensos en tratamiento con buen control de la presión arterial (PA). Material y métodos: Se recogió una muestra de sangre de pacientes hipertensos tratados que presentaban unas cifras de PA adecuadas para los objetivos individuales. Los niveles plásticos de CPE CD34+/KDR+ y CD34+/VE-cadherina+ se midieron mediante citometría de flujo. La concentración de VEGF se cuantificó mediante ELISA. Como controles se incluyó un grupo de sujetos sin FRCV tradicionales. Resultados: Hemos incluido 108 pacientes (61 ± 12 años, 47,2% hombres), de los cuales un 82,4% presentaba PA < 140/90 mmHg, un 91,7% control de la diabetes (HbA1c < 7%), el 81,5% cLDL < 130 o 100 mg/dl y el 85,2% no fumaba, aunque el 45,4% presentaba obesidad (IMC ≥ 30 kg/m2). A pesar de que, en conjunto, sus parámetros bioquímicos no diferían de los del grupo control, los pacientes hipertensos presentaban una disminución significativa de los niveles plasmáticos de células CD34+/KDR+ y CD34+/VE-cadherina+, aunque la concentración plasmática de VEGF era significativamente mayor en los pacientes hipertensos que en los sujetos control. Conclusiones: Los pacientes hipertensos tratados muestran una disminución significativa de los niveles plasmáticos de CPE que podría ser responsable, al menos en parte, del riesgo residual que presentan estos pacientes, sugiriéndose que las CPE podrían ser una importante diana terapéutica

Introduction: Most optimally treated hypertensive patients still have an around 50% increased risk of any cardiovascular event, suggesting the possible existence of unidentified risk factors. In the last years there has been evidence of the essential role of circulating endothelial progenitor cells (EPCs) in the maintenance of endothelial integrity and function, increasing the interest in their involvement in cardiovascular disease. In this study, the circulating levels of EPCs and vascular endothelial growth factor (VEGF) are investigated in treated hypertensive patients with adequate control of blood pressure (BP). Material and methods: Blood samples were collected from treated hypertensive patients with controlled BP. Plasma levels of EPCs CD34+/KDR+ and CD34+/VE-cadherin+ were quantified by flow cytometry. Plasma concentration of VEGF was determined by ELISA. A group of healthy subjects without cardiovascular risk factors was included as controls. Results: A total of 108 hypertensive patients were included (61±12 years, 47.2% men) of which 82.4% showed BP < 140/90 mmHg, 91.7% and 81.5% controlled diabetes (HbA1c <7%) and cLDL (<130 or 100 mg/dL), respectively, and 85.2% were non-smokers. Around 45% of them were obese. Although patients had cardiovascular parameters within normal ranges, they showed significantly lower levels of CD34+/KDR+ and CD34+/VE-cadherin+ compared with healthy control group, although plasma VEGF concentration was higher in patients than in controls. Conclusions: Despite an optimal treatment, hypertensive patients show a decreased number of circulating EPCs that could be, at least in part, responsible for their residual cardiovascular risk, suggesting that these cells could be a therapeutic target

[Circulating endothelial progenitor cell levels in treated hypertensive patients]. / Niveles de células progenitoras endoteliales circulantes en pacientes hipertensos tratados.

INTRODUCTION: Most optimally treated hypertensive patients still have an around 50% increased risk of any cardiovascular event, suggesting the possible existence of unidentified risk factors. In the last years there has been evidence of the essential role of circulating endothelial progenitor cells (EPCs) in the maintenance of endothelial integrity and function, increasing the interest in their involvement in cardiovascular disease. In this study, the circulating levels of EPCs and vascular endothelial growth factor (VEGF) are investigated in treated hypertensive patients with adequate control of blood pressure (BP). MATERIAL AND METHODS: Blood samples were collected from treated hypertensive patients with controlled BP. Plasma levels of EPCs CD34+/KDR+ and CD34+/VE-cadherin+ were quantified by flow cytometry. Plasma concentration of VEGF was determined by ELISA. A group of healthy subjects without cardiovascular risk factors was included as controls. RESULTS: A total of 108 hypertensive patients were included (61±12 years, 47.2% men) of which 82.4% showed BP<140/90 mmHg, 91.7% and 81.5% controlled diabetes (HbA1c <7%) and cLDL (<130 or 100 mg/dL), respectively, and 85.2% were non-smokers. Around 45% of them were obese. Although patients had cardiovascular parameters within normal ranges, they showed significantly lower levels of CD34+/KDR+ and CD34+/VE-cadherin+ compared with healthy control group, although plasma VEGF concentration was higher in patients than in controls. CONCLUSIONS: Despite an optimal treatment, hypertensive patients show a decreased number of circulating EPCs that could be, at least in part, responsible for their residual cardiovascular risk, suggesting that these cells could be a therapeutic target.

Explorando el contexto del tratamiento antihipertensivo en Atención Primaria. Estudio SIMPLITENS / Exploring the context of antihypertensive treatment in primary care. The SIMPLITENS study

A pesar de la existencia de diferentes guías sobre el manejo de la hipertensión arterial y de los numerosos fármacos antihipertensivos disponibles, el grado de control de la hipertensión dista de ser óptimo, siendo muchas las razones que pueden explicar esta circunstancia. El objetivo del estudio SIMPLITENS fue describir la situación del tratamiento antihipertensivo en Atención Primaria en España con los objetivos secundarios de hacer un retrato de la actitud terapéutica de los médicos, identificar el papel de factores circunstanciales (administración, guías) sobre las decisiones terapéuticas y validar un modelo de simplificación del tratamiento. Se utilizó el método Delphi para investigaciones clínicas de RAND/UCLA. Participaron 140 médicos de Atención Primaria que manifestaron su grado de acuerdo o desacuerdo con 28 afirmaciones (13 sobre la actitud terapéutica frente a la hipertensión arterial, 9 sobre el impacto de los factores circunstanciales y 6 sobre un modelo simplificado de tratamiento) mediante una escala de cinco categorías. Se realizaron dos rondas y se consideró que había consenso cuando un 75% de los votos eran coincidentes. Hubo consenso sobre 12 cuestiones, 4 en primera y 8 en segunda ronda. Cuatro de las afirmaciones con consenso eran sobre la actitud terapéutica, 4 sobre los factores circunstanciales y 4 sobre la validación del modelo simplificado. A la vista de los resultados obtenidos, parece aconsejable diseñar acciones formativas sobre el tratamiento antihipertensivo, especialmente sobre las evidencias de eficacia de los distintos fármacos en monoterapia y combinación, sobre el contenido de las guías y sobre los criterios de selección del tratamiento en distintos grupos de pacientes

Despite the existence of several guidelines on the management of hypertension and the numerous antihypertensive agents available, hypertension control is far from optimal, for multiple reasons. The aim of the SIMPLITENS trial was to describe the situation of antihypertensive treatment in primary care in Spain. Secondary objectives were to describe the therapeutic approach in primary care physicians, identify the role of circumstantial factors (administration, guidelines) on therapeutic decisions, and to validate a treatment simplification model. We used the RAND-UCLA Delphi method for clinical research. Participants consisted of 140 primary care physicians who expressed their degree of agreement or disagreement with 28 statements (13 on the therapeutic approach to hypertension, 9 on the impact of circumstantial factors, and 6 on the treatment simplification model) through a 5-point scale. Two rounds were held and consensus was considered to be reached when 75% of the votes were in agreement. Consensus was reached on 12 statements, 4 in the first round and 8 in the second. Four of the statements achieving consensus were related to the therapeutic approach, 4 were related to circumstantial factors and 4 were related to the simplification model. The results obtained suggest that training strategies on antihypertensive treatment should be designed, especially on evidence of the effectiveness of the distinct agents, both as monotherapy and combination therapy, on the contents of guidelines, and on the criteria for treatment selection in distinct patient groups

Blood pressure control and cardiovascular risk among rural and urban population in Spain

Prevalence and control of hypertension seem to be influenced by population, geographical and psychosocial factors. Aims: To investigate if the places of residence (rural or urban) determine differences in both BP level (office and 24-hour ambulatory BP monitoring (ABPM)) and cardiovascular risk (CVR). We also assess if place of residence establishes differences regarding treatment of the cardiovascular risk patients. Methods: Data of 25,989 patients from the ABPM National Registry of the Spanish Society of Hypertension were analyzed. Out of them 80.8% (n = 20,998) were from urban settings and 19.2% (n = 4991) from rural settings. Date from subjects less than 65 years of age were analyzed in order to diminish the influence of residence changes following retirement. We measured office BP, 24 h ABPM, cardiovascular risk factors and CVR. Results: The percentage of patients with BP <140/90 mmHg in the office is higher in the urban group (23.4%) compared to their rural counterparts (21.4%) (p = 0.003). This fact lost its statistical significance when BP was measured by ABPM, showing controlled 46.1% in urban and 45.9% in rural settings. The masked hypertension was higher in urban (7.2%) than in rural settings (6.4%). White coat hypertension was more frequent in rural settings (31.6% versus 29.7%, p < 0.008). According to estimates of ESH-ESC 2007 guidelines, patients from the rural setting have a higher CVR. Conclusions: There are no differences in the hypertension control depending on place of residence when this is measured by ABPM. CVR is worse in the rural environment. This fact is linked to a higher level of obesity and its associated metabolic disorders

La prevalencia y el control de la hipertensión parecen estar influidos por factores demográficos, geográficos y psicosociales. Objetivos: Analizar si el lugar de residencia (rural o urbano) marca diferencias tanto en los valores de PA (en consulta y en monitorización ambulatoria de 24 horas [MAPA]) como en el riesgo cardiovascular (RCV). También evaluamos si el lugar de residencia conduce a diferencias en cuanto al tratamiento de pacientes con RCV. Métodos: Se analizaron los datos de 25.989 pacientes procedentes del Registro Nacional de MAPA de la Sociedad Española de Hipertensión. De ellos, el 80,8% (n = 20.998) procedían de zonas urbanas y el 19,2% (n = 4.991) de entornos rurales. Se analizó la fecha de los pacientes menores de 65 años para disminuir la influencia de los cambios de residencia tras la jubilación. Se midió la PA en consulta, la MAPA de 24 h, los factores de riesgo cardiovascular y el RCV. Resultados: El porcentaje de pacientes con PA < 140/90 mmHg en consulta era superior en el grupo urbano (23,4%) al compararse con sus contrapartes rurales (21,4%; p = 0,003). Este valor perdía su significación estadística cuando la PA se midió mediante MAPA, con una PA controlada del 46,1% en zonas urbanas y del 45,9% en zonas rurales. La hipertensión enmascarada fue mayor en las zonas urbanas (7,2%) que en las rurales (6,4%). La hipertensión de bata blanca era más frecuente en el medio rural (31,6 frente a 29,7%; p < 0,008). Según las estimaciones delas directrices de la ESH- ESC de 2007, los pacientes en las zonas rurales presentaban un mayo RCV. Conclusiones: No existen diferencias en el control de la hipertensión en función del lugar de residencia cuando esta se mide mediante MAPA. El RCV es superior en el entorno rural. Este hecho se vincula a un nivel más elevado de obesidad y a los trastornos metabólicos que ello conlleva