The Rationale for Using Fixed-Dose Combination Therapy in the Management of Hypertension in Colombia: A Narrative Review.

Hypertension is a major risk factor for cardiovascular disease and the leading cause of death in Colombia. While the rate of hypertension awareness in Colombia is generally high, rates of treatment initiation, adherence, and blood pressure (BP) control are suboptimal. Major international hypertension guidelines recommend starting treatment with a combination of antihypertensive agents, and the use of a single-pill combination (SPC) to maximize adherence. In contrast, Colombian hypertension guidelines recommend starting treatment with diuretic monotherapy in most patients, and only initiating combination therapy in those with BP > 160/100 mmHg. Therefore, the aim of the current narrative review is to examine the rationale for using SPCs to treat hypertension in Colombia, in the context of the major issues for BP control there. There is evidence of widespread therapeutic inertia in hypertension management, particularly in primary care, in Colombia. Moreover, combination therapy, angiotensin-converting enzyme inhibitors, and long-acting calcium channel blockers, which are internationally recommended as first-line drug therapies, are underutilized there. Adherence to antihypertensive therapy is low in Colombia and may be enhanced by use of SPCs as well as better patient education and follow-up. While there are promising national initiatives to improve BP management, more needs to be done by individual physicians. Antihypertensive SPCs are available on the national essential medicines list and may help to overcome some of the problems with suboptimal adherence, therapeutic inertia, and low rates of BP control that contribute to the high cardiovascular death rate in Colombia.

Violence and aggression against nurses during the COVID-19 pandemic in Latin America. From the emerging leaders program of the Interamerican Society of Cardiology (SIAC).

INTRODUCTION: During the Coronavirus (COVID-19) pandemic, healthcare providers have overcome difficult experiences such as workplace violence. Nurses are particularly vulnerable to workplace violence. The objective of this study was to characterize violence and aggression against nurses during the COVID-19 pandemic in Latin America. METHODS: An electronic cross-sectional survey was conducted in 19 Latin American countries to characterize the frequency and type of violent actions against front-line healthcare providers. RESULTS: Of the original 3544 respondents, 16% were nurses (n = 567). The mean age was 39.7 ± 9.0 years and 79.6% (n = 2821) were women. In total, 69.8% (n = 2474) worked in public hospitals and 81.1% (n = 2874) reported working regularly with COVID-19 patients. Overall, about 68.6% (n = 2431) of nurses experienced at least one episode of workplace aggression during the pandemic. Nurses experienced weekly aggressions more frequently than other healthcare providers (45.5% versus 38.1%, p < .007). Nurses showed a trend of lower reporting rates against the acts of aggression suffered (p = .076). In addition, nurses were more likely to experience negative cognitive symptoms after aggressive acts (33.4% versus 27.8%, p = .028). However, nurses reported considering changing their work tasks less frequently compared to other healthcare providers after an assault event (p = .005). CONCLUSION: Workplace violence has been a frequent problem for all healthcare providers during COVID-19 pandemic in Latin America. Nurses were a particularly vulnerable subgroup, with higher rates of aggressions and cognitive symptoms and lower rate of complaints than other healthcare providers who suffered from workplace violence. It is imperative to develop strategies to protect this vulnerable group from aggressions during their tasks.

Blood pressure telemonitoring and telemedicine, a Latin America perspective.

PURPOSE: To share a Latin-American perspective of the use of telemedicine, together with blood pressure measurements outside the medical office, as a potential contribution to improving access to the health system, diagnosis, adherence, and persistence in hypertension treatment. MATERIAL AND METHODS: A document settled by a Writing Group of Mexico Hypertension Experts Group, Interamerican Society of Hypertension, Epidemiology and Cardiovascular Prevention Council of the Interamerican Society of Cardiology, and National Cardiologist Association of Mexico. RESULTS: In almost all Latin American countries, the health sector faces two fundamental challenges: (1) ensure equitable access to quality care services in a growing population that faces an increase in the prevalence of chronic diseases, and (2) optimise the growing costs of health services, maintaining equity, accessibility, universality, and quality. Telehealth proposes an innovative approach to patient management, especially for chronic conditions, intending to provide remote consultation, education, and follow-up to achieve measurements and goals. It is a tool that promises to improve access, empower the patient, and somehow influence their behaviour about lifestyle changes, improving prevention and reducing complications of hypertension. The clinical practitioner has seen increased evidence that the use of out-of-office blood pressure (BP) measurement and telemedicine are helpful tools to keep patients and physicians in contact and promote better pharmacological adherence and BP control. A survey carried out by medical and scientific institutions showed that practitioners are up-to-date with telemedicine, had internet access, and had hardware availability. CONCLUSIONS: A transcendent issue is the need to make the population aware of the benefits of taking blood pressure to avoid complications of hypertension, and in this scenario, promote the creation of teleconsultation mechanisms for the follow-up of patients diagnosed with hypertension.

What is the context?In almost all Latin American countries, the health sector faces two fundamental challenges: (1) ensure equitable access to quality care services in a growing population that faces an increase in the prevalence of chronic diseases, and (2) optimise the growing costs of health services, maintaining equity, accessibility, universality, and quality.What is new?Telehealth proposes an innovative approach to patient management, especially for chronic conditions, intending to provide remote consultation, education, and follow-up to achieve measurements and goals. It is a tool that promises to improve access, empower the patient, and somehow influence their behaviour about lifestyle changes, improving prevention and reducing complications of hypertension.What is the impact?Needs are always infinite, and resources are finite, so according to the World Health Organisation (WHO), advances in electronic, information, and communication technology point to more significant equity in the provision of services, considering the effectiveness, possibility of refining the rationalisation of health spending, and improving health care for remote populations.A transcendent issue is the need to make the population aware of the benefits of taking blood pressure to avoid complications of hypertension, and in this scenario, promote the creation of teleconsultation mechanisms for the follow-up of patients diagnosed with hypertension.

Position statement on use of pharmacological combinations in a single pill for treatment of hypertension by Argentine Federation of Cardiology (FAC) and Argentine Society of Hypertension (SAHA).

The present document provides scientific evidence reviewed and analysed by a group of specialist clinicians in hypertension that aims to give an insight into a pharmacological strategy to improve blood pressure control. Evidence shows that most hypertensive patients will need at least two drugs to achieve blood pressure goals. There is ample evidence showing that treatment adherence is inversely related to the number of drugs taken. Observational studies show that use of drug combinations to initiate treatment reduces the time to reach the treatment goal and reduces CVD, especially with single pill combinations (SPCs). This work, based on recommendations of the Argentine Federation of Cardiology and Argentine Society of Hypertension as a reference, aims to review the more recent evidence on SPC, and to serve as guidelines for health professionals in their clinical practice and to the wider use of SPCs for the treatment of hypertension. Evidence from clinical trials on the effectiveness and adverse effects of using SPCs are provided. An analysis is also made of the main contributions of SPCs in special populations, e.g., elderly and diabetic patients, and its use in high risk and resistant hypertension. The effects of SPCs on hypertensive-mediated organ damage is also examined. Finally, we provide some aspects to consider when choosing treatments in the economic context of Latin-America for promoting the most efficient use of resources in a scarce environment and to provide quality information to decision makers to formulate safe, cost-effective, and patient-centered health policies. Finally, future perspectives and limitations in clinical practice are also discussed.

Diastolic dysfunction, hypertrophy and hypertension ventricular-arterial uncoupling treatment.

The aim of the study was to evaluate hypertension treatment effects on mechanical efficiency of the cardiovascular system and cardiac reverse remodeling in hypertensive patients. This is an observational prospective study, consecutive hypertension patients. Left ventricle mass index measured by Devereux 2D method and diastolic function following the Guidelines from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. Left ventricular end systolic elastance (Ees) was measured by Guarracino calculator, the effective arterial elastance (Ea) and ventricular-arterial coupling (VAC) measured by Sunagawa et al. single beat method adapted by Chen et al. in human ventricles. The sample was analyzed in quartiles (Q) according to VAC. Follow-up 2 years. In total, 288 patients, mean age 56.3 ± 12.5 years and 168 patients (58.3%) males. VAC increased from 0.303 ± 0.07 to 0.54 ± 0.25 (p < 0.005) in Q1 mainly due to a reduction in Ees from 5.25 ± 2.3 to 3.68 ± 0.25 mmHg/ml (p < 0.01), while Ea increased from 1.5 ± 0.53 to 1.64 ± 0.56 mmHg/ml (p = NS). The frequency of LVH was reduced from 31.9 to 10.8% in Q1 (p < 0.025). The frequency of normal diastolic function increased from 75 to 94.6% (p < 0.01) in Q1, from 78.7 to 100% in Q2 (p < 0.005), from 87.1 to 100% (p < 0.025) in Q3 and from 88.7 to 100% (0,025) in Q4. Patients with the worst ventricular-arterial uncoupling were the most benefited from hypertension treatment. Regression of left ventricular hypertrophy was observed only in the group of patients with the worst ventricular-arterial uncoupling, while improvement in diastolic function was demonstrated in all quartiles of patients.

The Attitudes of Physicians Toward Guideline Recommendations for the Management of Dyslipidemia in Clinical Practice - The VIPFARMA ISCP Project.

The aim of this study was to explore the different attitudes of physicians regarding international recommendations for the management of dyslipidemia in routine medical practice. Seven clusters of questions were designed to characterize the surveyed population. Eight hundred ninety-eight physicians answered the survey, 68.3% cardiologists and 40.0% had specialties related to cardiovascular prevention. 29.6% of physicians supported LDL goals above 70 mg/dL in secondary prevention. Acceptance of values lower than 70 mg/dL was associated with greater levels of continuing education (OR 0.64, 95% CI 0.45-0.91; P = 0.014), specialization in preventive cardiology (OR 0.49, 95% CI 0.28-0.88; P = 0.017) or diabetology (OR 0.48, 95% CI 0.24-0.98; P = 0.043). A less aggressive attitude toward the achievement of guideline goals were observed in physicians who considered LDL values higher than 70 mg/dL as the goal in secondary prevention. One-third of physicians in the survey do not follow goals recommended by international guidelines.

Blood pressure telemonitoring and telemedicine for hypertension management-positions, expectations and feasibility of Latin-American practitioners. SURVEY carried out by several cardiology and hypertension societies of the Americas.

PURPOSE: To assess the opinion of Latin-American physicians on remote blood pressure monitoring and telehealth for hypertension management. MATERIAL AND METHODS: Cross-sectional survey of physicians residing in Latin-America. The study was conducted by the Mexico Hypertension Experts Group, Interamerican Society of Hypertension, Interamerican Society of Cardiology Epidemiology and Cardiovascular Prevention Council, and National Cardiologist Association of Mexico. An online survey composed of 40 questions using Google Forms was distributed from 7 December 2021, to 3 February 2022. The survey was approved by the GREHTA Ethics Committee and participation was voluntary and anonymous. Multiple logistic regression models were constructed to identify the challenges of telehealth. RESULTS: 1753 physicians' responses were gathered. The responses came from physicians from different Latin-American countries, as follows: 24% from Mexico, 20.6% from Argentina, 14.7% from Colombia, 10.9% from Brazil, 8.7% from Venezuela, 8.2% from Guatemala and 3.2% from Paraguay. Responders with a high interest in carrying out their assistance task through remote telemonitoring reached 48.9% (821), while 43.6% are already currently conducting telemonitoring. A high number, 62%, claimed to need telemonitoring training. There is a direct relation between higher interest in telemonitoring and age, medical specialty, team working, residence in the biggest cities, expectations regarding telemedicine and reimbursement. CONCLUSIONS: Remote monitoring is feasible in Latin-America. General practitioners and specialists from bigger cities seem eager and are self-perceived as well-trained and experienced. Facilities and resources do not seem to be a challenge but training reinforcement and telemedicine promotion is necessary for those physicians less motivated.PLAIN LANGUAGE SUMMARYWhat is the context?Hypertension is one of the leading worldwide modifiable risk factors for premature death. Strong evidence supports that effective treatment of this condition results in a significant reduction of hard outcomes.Only 20%-30% of hypertensive patients are within the blood pressure targets recommended by guidelines in Latin-America. There is an urgent need to implement innovative strategies to reverse this alarming health situation.What is new?Latin-American physicians were highly predisposed to telemonitoring practice. This high motivation was not influenced by hardware or software availability, technological knowledge or experience, by volume of monthly consultations, or by area (private-public) where the care activity is carried out.This high motivation may be supported by the conviction that this practice could be very useful as a complement to face-to-face assistance and a highly effective tool to improve adherence even though respondents considered that just 10% of the patients would prefer telemonitoring over office consultation.What is the impact?Facilities and resources do not seem to be a challenge but training reinforcement and telemedicine promotion is necessary for those physicians less motivated. The general perception is that it is necessary to move forward to resolve legal gaps and financial aspects.Physicians must adapt to changes and develop new communication strategies in a world where the unrestricted access to teleinformation makes patients self-perceived as experts.

[Control of arterial hypertension: a pending issueControle da hipertensão arterial: um assunto inacabado]. / El control de la hipertensión arterial, una asignatura pendiente.

Adequate diagnosis, treatment, and control of arterial hypertension (AHT) continues to be a pending issue in the attempt to reduce the incidence of premature mortality and disability due to cardiovascular disease, which is a reality worldwide and in the region of the Americas in particular.Despite having adequate diagnostic algorithms and efficient treatment schemes, the gap between medical knowledge and reality reveals the great difficulty in ensuring that patients follow recommendations. Adherence to treatment is a great challenge and a proper understanding of its dimensions is essential when designing strategies to improve control of AHT.It is clear that part of the solution is having adequate information and disseminating it, but actions that guarantee implementation are no less important. That is why clinical practice guidelines that try to address this problem are welcome. The recent publication of the World Health Organization's guidance on arterial hypertension is a clear example of this type of initiative.Implementation programs are arguably one of the biggest challenges in contemporary medicine. The development of multimodal interventions aimed at improving response capacity at the first level of care and promoting the development of integrated health services networks appears to be the most appropriate way to achieve adequate control of AHT.Scientific societies clearly play an important role in these initiatives by providing support and coordinating interactions among the different actors involved.

O diagnóstico, tratamento e controle adequados da hipertensão arterial sistêmica (HAS) continua sendo uma questão pendente em nossa tentativa de reduzir a incidência de mortalidade cardiovascular prematura e a incapacidade. Essa é a realidade no nível mundial e, particularmente, na região das Américas.Apesar de algoritmos de diagnóstico adequados e esquemas de tratamento eficientes, a lacuna entre o conhecimento médico e a realidade nos mostra como é difícil que nossas recomendações sejam adotadas por nossos pacientes. A adesão representa um grande desafio, e uma compreensão adequada de suas dimensões é essencial ao se projetar estratégias para melhorar o controle da HAS.Claramente, a disponibilidade e a divulgação de informações adequadas é parte da solução, mas não menos importantes são as ações para garantir sua implementação. Portanto, acolhemos de bom grado as diretrizes de prática clínica que visam abordar esta questão. A recente publicação das diretrizes da Organização Mundial da Saúde sobre hipertensão arterial é um claro exemplo de tais iniciativas.Os programas de implementação são indiscutivelmente um dos maiores desafios da medicina contemporânea. O desenvolvimento de intervenções multimodais na atenção primária com o objetivo de melhorar sua resolutividade e promover o desenvolvimento de redes integradas de serviços de saúde parece ser a forma mais apropriada para atingir níveis adequados de controle da HAS.Estamos convencidos do importante papel que nossas sociedades científicas desempenham nestas iniciativas ao prestar apoio, suporte e articulação aos diferentes atores envolvidos.

El control de la hipertensión arterial, una asignatura pendiente

[RESUMEN]. El adecuado diagnóstico, tratamiento y control de la hipertensión arterial (HTA) continúa siendo una asignatura pendiente en nuestro intento de reducir la incidencia de mortalidad cardiovascular prematura y discapacidades, siendo esta una realidad a nivel mundial y particularmente cierta en la región de las Américas. A pesar de contar con adecuados algoritmos diagnósticos y eficientes esquemas de tratamiento, la brecha entre el conocimiento médico y la realidad nos muestra la gran dificultad para que nuestras recomendaciones sean adoptadas por nuestros pacientes. La adherencia representa un gran desafío y la adecuada comprensión de sus dimensiones resulta básico al momento de diseñar estrategias para mejorar el control de la HTA. Es claro que disponer y diseminar información adecuada es una parte de la solución, pero no menos importante son las acciones que garanticen su implementación. Es por lo que damos la bienvenida a guías de práctica clínica que intenten abordar esta problemática. La reciente publicación de guía de la Organización Mundial de la Salud en hipertensión arterial es un claro ejemplo de este tipo de iniciativas. Los programas de implementación posiblemente sean uno de los mayores desafíos de la medicina contemporánea. El desarrollo de intervenciones multimodales en el primer nivel de atención con el objetivo de mejorar su capacidad resolutiva y promover el desarrollo de redes integradas de servicios de salud, impresiona ser el camino mas adecuado para alcanzar niveles adecuados de control de la HTA. Estamos convencidos del importante rol que nuestras sociedades científicas tienen con estas iniciativas dando apoyo, soporte y articulando la interacción con los diferentes actores involucrados.

[ABSTRACT]. Adequate diagnosis, treatment, and control of arterial hypertension (AHT) continues to be a pending issue in the attempt to reduce the incidence of premature mortality and disability due to cardiovascular disease, which is a reality worldwide and in the region of the Americas in particular. Despite having adequate diagnostic algorithms and efficient treatment schemes, the gap between medical knowledge and reality reveals the great difficulty in ensuring that patients follow recommendations. Adherence to treatment is a great challenge and a proper understanding of its dimensions is essential when designing strategies to improve control of AHT. It is clear that part of the solution is having adequate information and disseminating it, but actions that guarantee implementation are no less important. That is why clinical practice guidelines that try to address this problem are welcome. The recent publication of the World Health Organization's guidance on arterial hypertension is a clear example of this type of initiative. Implementation programs are arguably one of the biggest challenges in contemporary medicine. The development of multimodal interventions aimed at improving response capacity at the first level of care and promoting the development of integrated health services networks appears to be the most appropriate way to achieve adequate control of AHT. Scientific societies clearly play an important role in these initiatives by providing support and coordinating interactions among the different actors involved.

[RESUMO]. O diagnóstico, tratamento e controle adequados da hipertensão arterial sistêmica (HAS) continua sendo uma questão pendente em nossa tentativa de reduzir a incidência de mortalidade cardiovascular prematura e a incapacidade. Essa é a realidade no nível mundial e, particularmente, na região das Américas. Apesar de algoritmos de diagnóstico adequados e esquemas de tratamento eficientes, a lacuna entre o conhecimento médico e a realidade nos mostra como é difícil que nossas recomendações sejam adotadas por nossos pacientes. A adesão representa um grande desafio, e uma compreensão adequada de suas dimensões é essencial ao se projetar estratégias para melhorar o controle da HAS. Claramente, a disponibilidade e a divulgação de informações adequadas é parte da solução, mas não menos importantes são as ações para garantir sua implementação. Portanto, acolhemos de bom grado as diretrizes de prática clínica que visam abordar esta questão. A recente publicação das diretrizes da Organização Mundial da Saúde sobre hipertensão arterial é um claro exemplo de tais iniciativas. Os programas de implementação são indiscutivelmente um dos maiores desafios da medicina contemporânea. O desenvolvimento de intervenções multimodais na atenção primária com o objetivo de melhorar sua resolutividade e promover o desenvolvimento de redes integradas de serviços de saúde parece ser a forma mais apropriada para atingir níveis adequados de controle da HAS. Estamos convencidos do importante papel que nossas sociedades científicas desempenham nestas iniciativas ao prestar apoio, suporte e articulação aos diferentes atores envolvidos.

Ventricular-Arterial Uncoupling and Hypertension Mediated Diastolic Dysfunction.

INTRODUCTION: The increase in the pulsatile component of left ventricle afterload is suspected to cause a mismatch between the left ventricle (LV) and the vascular tree. AIM: To demonstrate that ventricular-arterial uncoupling is frequently present in the development of LV hypertrophy (H) and diastolic dysfunction (DD) in hypertension (HBP). METHODS: Observational study, HBP patients with ejection fraction > 54%. Conventional 2D echocardiography and tissue Doppler performed following imaging guidelines. LV end systolic elastance (Ees), the effective arterial elastance (Ea), and ventricular-arterial coupling (VAC) measured by Chen single beat method. RESULTS: 288 patients, mean age 56.3 ± 12.5 years and 168 patients (58.3%) males. Mean LV mass index was 87.2 ± 20.4 grs/m2 and frequency of LVH 20.1% (58 patients). The mean VAC was 0.54 ± 9.23. LV Stroke volume, stroke work and systolic stress were 46.2 ± 10.3 cc/m2, 91.4 ± 22.2 g-min/m2, and 57 ± 14.6 dynes/cm2 in quartile 1, and 33.5 ± 6.6 cc/m2, 65.5 ± 15.2 g-min/m2, and 77.8 ± 17.1 dynes/cm2, in quartile 4, respectively (p < 0.001). Peripheral resistance index was 3349 ± 1072 and 4410 ± 1143 dynes*s/cm-5/m2 quartiles 1 vs. 4 (p < 0.005). The frequency of LVH was 31.9% in quartile 1 and 11.3% in quartile 4 (p < 0.005) and LVH or DD was 37.5% and 12.7%, respectively (p < 0.001). CONCLUSIONS: Stroke volume and stroke work were significantly increased while systolic stress and peripheral resistance index were significantly reduced in patients with worst VAC. Ventricular-arterial uncoupling is mostly caused by an increase in Ees rather than by an elevation of Ea. LVH or DD are more frequent in the worst cases of ventricular-arterial uncoupling.

Latin American Consensus on management of residual cardiometabolic risk. A consensus paper prepared by the Latin American Academy for the Study of Lipids and Cardiometabolic Risk (ALALIP) endorsed by the Inter-American Society of Cardiology (IASC), the International Atherosclerosis Society (IAS), and the Pan-American College of Endothelium (PACE).

BACKGROUND: Hypertension, hyperglycemia, dyslipidemia, overweight, obesity, and tobacco (smoking, chewing, and vaping), together with a pro-inflammatory and procoagulant state, are the main risk factors related to atherosclerotic cardiovascular disease. OBJECTIVE AND METHODS: A group of experts from the Americas, based on their clinical expertise in cardiology, cardiovascular prevention, and cardiometabolic (CM) diseases, joined together to develop these practical recommendations for the optimal evaluation and treatment of residual CM risk factors in Latin America, using a modified Delphi methodology (details in electronic TSI) to generate a comprehensive CM risk reduction guideline, and through personalized medicine and patient-centered decision, considering the cost-benefit ratio The process was well defined to avoid conflicts of interest that could bias the discussion and recommendations. RESULTS: Residual risk reduction should consider therapeutic options adapted to specific patient needs, based on five treatment objectives: triglyceride-rich lipoproteins, inflammation, impaired glucose metabolism, high blood pressure, and prothrombotic status. Comprehensive control of all CM risk factors should be a priority to deal with this important public health problem and prevent premature deaths. The recommendations in this paper address the evidence-based treatment of CM risk and are intended for clinical application in Latin American countries.

Antecedentes: Un grupo de factores de riesgo cardiometabólicos (hipertensión, hiperglucemia, dislipidemia, sobrepeso, obesidad y tabaco (fumado, masticado, vaporizado), junto con un estado proinflamatorio y procoagulante, son los principales factores de riesgo relacionados con la enfermedad cardiovascular aterosclerótica. Objetivo y métodos: Basándose en su experiencia en cardiología, prevención cardiovascular y enfermedades cardiometabólicas, un grupo de expertos de las Américas se unió para desarrollar estas recomendaciones prácticas para la evaluación y tratamiento óptimos de los factores de riesgo cardiometabólicos residuales en América Latina, utilizando una metodología Delphi modificada con el objetivo de generar una guía integral de pautas para la reducción del riesgo cardiometabólico, mediante la medicina personalizada y la decisión centrada en el paciente teniendo en cuenta la relación costo-beneficio. El proceso fue bien definido para evitar conflictos de intereses que podrían sesgar la discusión y las recomendaciones. Resultados: La reducción del riesgo residual debe considerar opciones terapéuticas adaptadas a las necesidades específicas del paciente, basadas en 5 objetivos de tratamiento: lipoproteínas ricas en triglicéridos inflamación, metabolismo de la glucosa, presión arterial alta y estado protrombótico. El Control integral de todos los factores de riesgo cardiometabólicos debe ser una prioridad para hacer frente a este importante problema de salud pública y prevenir las muertes prematuras. Las recomendaciones de este documento abordan el tratamiento basado en evidencia del riesgo cardiometabólico y están destinadas a la aplicación clínica en los países de América Latina.

El control de la hipertensión arterial, una asignatura pendiente / Control of arterial hypertension: a pending issue / Controle da hipertensão arterial: um assunto inacabado

RESUMEN El adecuado diagnóstico, tratamiento y control de la hipertensión arterial (HTA) continúa siendo una asignatura pendiente en nuestro intento de reducir la incidencia de mortalidad cardiovascular prematura y discapacidades, siendo esta una realidad a nivel mundial y particularmente cierta en la región de las Américas. A pesar de contar con adecuados algoritmos diagnósticos y eficientes esquemas de tratamiento, la brecha entre el conocimiento médico y la realidad nos muestra la gran dificultad para que nuestras recomendaciones sean adoptadas por nuestros pacientes. La adherencia representa un gran desafío y la adecuada comprensión de sus dimensiones resulta básico al momento de diseñar estrategias para mejorar el control de la HTA. Es claro que disponer y diseminar información adecuada es una parte de la solución, pero no menos importante son las acciones que garanticen su implementación. Es por lo que damos la bienvenida a guías de práctica clínica que intenten abordar esta problemática. La reciente publicación de guía de la Organización Mundial de la Salud en hipertensión arterial es un claro ejemplo de este tipo de iniciativas. Los programas de implementación posiblemente sean uno de los mayores desafíos de la medicina contemporánea. El desarrollo de intervenciones multimodales en el primer nivel de atención con el objetivo de mejorar su capacidad resolutiva y promover el desarrollo de redes integradas de servicios de salud, impresiona ser el camino mas adecuado para alcanzar niveles adecuados de control de la HTA. Estamos convencidos del importante rol que nuestras sociedades científicas tienen con estas iniciativas dando apoyo, soporte y articulando la interacción con los diferentes actores involucrados.

ABSTRACT Adequate diagnosis, treatment, and control of arterial hypertension (AHT) continues to be a pending issue in the attempt to reduce the incidence of premature mortality and disability due to cardiovascular disease, which is a reality worldwide and in the region of the Americas in particular. Despite having adequate diagnostic algorithms and efficient treatment schemes, the gap between medical knowledge and reality reveals the great difficulty in ensuring that patients follow recommendations. Adherence to treatment is a great challenge and a proper understanding of its dimensions is essential when designing strategies to improve control of AHT. It is clear that part of the solution is having adequate information and disseminating it, but actions that guarantee implementation are no less important. That is why clinical practice guidelines that try to address this problem are welcome. The recent publication of the World Health Organization's guidance on arterial hypertension is a clear example of this type of initiative. Implementation programs are arguably one of the biggest challenges in contemporary medicine. The development of multimodal interventions aimed at improving response capacity at the first level of care and promoting the development of integrated health services networks appears to be the most appropriate way to achieve adequate control of AHT. Scientific societies clearly play an important role in these initiatives by providing support and coordinating interactions among the different actors involved.

RESUMO O diagnóstico, tratamento e controle adequados da hipertensão arterial sistêmica (HAS) continua sendo uma questão pendente em nossa tentativa de reduzir a incidência de mortalidade cardiovascular prematura e a incapacidade. Essa é a realidade no nível mundial e, particularmente, na região das Américas. Apesar de algoritmos de diagnóstico adequados e esquemas de tratamento eficientes, a lacuna entre o conhecimento médico e a realidade nos mostra como é difícil que nossas recomendações sejam adotadas por nossos pacientes. A adesão representa um grande desafio, e uma compreensão adequada de suas dimensões é essencial ao se projetar estratégias para melhorar o controle da HAS. Claramente, a disponibilidade e a divulgação de informações adequadas é parte da solução, mas não menos importantes são as ações para garantir sua implementação. Portanto, acolhemos de bom grado as diretrizes de prática clínica que visam abordar esta questão. A recente publicação das diretrizes da Organização Mundial da Saúde sobre hipertensão arterial é um claro exemplo de tais iniciativas. Os programas de implementação são indiscutivelmente um dos maiores desafios da medicina contemporânea. O desenvolvimento de intervenções multimodais na atenção primária com o objetivo de melhorar sua resolutividade e promover o desenvolvimento de redes integradas de serviços de saúde parece ser a forma mais apropriada para atingir níveis adequados de controle da HAS. Estamos convencidos do importante papel que nossas sociedades científicas desempenham nestas iniciativas ao prestar apoio, suporte e articulação aos diferentes atores envolvidos.

Influenza Vaccination for the Prevention of Cardiovascular Disease in the Americas: Consensus document of the Inter-American Society of Cardiology and the Word Heart Federation.

Background: Cardiovascular mortality is decreasing but remains the leading cause of death world-wide. Respiratory infections such as influenza significantly contribute to morbidity and mortality in patients with cardiovascular disease. Despite of proven benefits, influenza vaccination is not fully implemented, especially in Latin America. Objective: The aim was to develop a regional consensus with recommendations regarding influenza vaccination and cardiovascular disease. Methods: A multidisciplinary team composed by experts in the management and prevention of cardiovascular disease from the Americas, convened by the Inter-American Society of Cardiology (IASC) and the World Heart Federation (WHF), participated in the process and the formulation of statements. The modified RAND/UCLA methodology was used. This document was supported by a grant from the WHF. Results: An extensive literature search was divided into seven questions, and a total of 23 conclusions and 29 recommendations were achieved. There was no disagreement among experts in the conclusions or recommendations. Conclusions: There is a strong correlation between influenza and cardiovascular events. Influenza vaccination is not only safe and a proven strategy to reduce cardiovascular events, but it is also cost saving. We found several barriers for its global implementation and potential strategies to overcome them.

Management of Dyslipidaemia in Real-world Clinical Practice: Rationale and Design of the VIPFARMA ISCP Project.

Dyslipidaemia plays a major role in the pathogenesis of atherosclerosis. Every year, scientific institutions publish cardiovascular prevention guidelines with updated goals and recommendations based on new evidence. However, medical barriers exist that make achieving these goals difficult and gaps between guidelines and best daily clinical practice still persist. The International Society of Cardiovascular Pharmacotherapy designed the Surveillance of Prescription Drugs in the Real World Project (VIPFARMA ISCP), a survey for physicians who manage lipid disorders in high-risk patients. Seven clusters of questions will be analysed comprising demographics, institution profile, access to continuing medical education, clinical practice profile, attitude regarding use of statins, knowledge regarding proprotein convertase subtilisin/kexin type 9 inhibitors and attitudes regarding medical decisions about triglycerides. The present study will be the first part of a larger programme and aims to shed light on barriers between lipid-lowering drug therapy recommendations in the 2019 European Society of Cardiology guidelines and clinical practice in different countries.

Considerations and Guidance for the Structure, Organisation, and Operation of Cardiometabolic Prevention Units: A Consensus Statement of the Inter-American Society of Cardiology.

Cardiovascular diseases (CVDs) remain the leading cause of death worldwide, particularly in low- and middle-income regions such as Latin America. This is because of the combination and interaction in different proportions of a high prevalence of cardiometabolic risk factors and socio-economic and cultural characteristics. This reality brings about the need to change paradigms to consistently and systematically boost cardiovascular prevention as the most cost-effective medium- to long-term strategy to reduce their prevalence in medium- and low-resource countries, not only in Latin America but also in other global regions. To achieve the therapeutic goals in various diseases, including CVD, the current literature demonstrates that the most effective way is to carry out the patient's diagnosis and treatment in multidisciplinary units. For this reason, the Inter American Society of Cardiology (IASC) proposes the creation of cardiometabolic prevention units (CMPUs) as a regional initiative exportable throughout the world to standardise cardiovascular prevention based on the best available evidence. This ensures homogeneity in the global management of cardiometabolic risk factors and access to quality medicine independently of the population's social situation. These guidelines, written by a panel of experts in cardiovascular prevention, defines what a CMPU is, its objectives and the minimum requirements for it, as well as proposing three categories and suggesting an operational scheme. It must be used as a guide for all individuals or centres that, aware of the need for multidisciplinary and standardised work, want to create a unit for the comprehensive management of cardiometabolic risk established as an international research network. Lastly, the document makes meaningful points on the determination of cardiovascular risk and its importance. These guidelines do not cover specific targets and therapeutic schemes, as these topics will be extensively discussed in another SIAC publication, namely a statement on residual cardiometabolic risk.

Medium to Long Term Follow-Up of Treated Hypertensive Mediated Heart Disease.

INTRODUCTION: Hypertensive mediated heart disease is the consequence of anatomical and functional changes in cardiovascular system. The benefits on left ventricular (LV) diastolic impairment and remodeling of hypertension treatment are well established. AIM: To evaluate LV structure, systolic and diastolic function of treated hypertensive patients on a medium to long term follow-up. METHODS: Prospectively observational cohort study. Hypertensive patients over 18 years, ultrasound evaluation of LV structure and diastolic and systolic function, follow-up at least once a year. Diastolic function assessed following recommendations of the American Society of Echocardiography and the European Association of Cardiovascular Imaging. RESULTS: 285 patients, mean follow up of 1731 ± 952 days. Sample mean age 56.3 ± 12.5 years, 166 patients (58.3%) were males. Baseline blood pressure 147.8 ± 19/86.8 ± 11 mm Hg, 5 years blood pressure 134.4 ± 15.7/79 ± 9 mm Hg (p < 0.005 SBP and p < 0.01 DBP). Baseline fixed dose combinations 115 patients (40.4%), follow-up 53.1% (p < 0.05). LV remodeling was detected in 88 patients (30.9%) vs. 30.1% at 5 years (p = NS). The frequency of an E/e' ratio > 14 was reduced from 38 patients (13.3%) to 3.6% (p < 0.001), e' septal velocity < 7 cm/sec or e' lateral velocity < 10 cm/sec was reduced from 38.6% (110 patients) to 19.3% (p < 0.001). Baseline normal diastolic function was detected in 85.6% (244 patients) and 94% at the end of the follow-up (p < 0.02). CONCLUSIONS: In this observational cohort followed by a mean of 5 years, the main benefit of hypertension treatment was the prevention or regression of diastolic dysfunction.

Ambulatory Patients with Cardiometabolic Disease and Without Evidence of COVID-19 During the Pandemic. The CorCOVID LATAM Study.

Background: SARS-CoV-2 pandemic has modified the cardiovascular care of ambulatory patients. The aim of this survey was to study changes in lifestyle habits, treatment adherence, and mental health status in patients with cardiometabolic disease, but no clinical evidence of COVID-19. Methods: A cross-sectional survey was conducted in ambulatory patients with cardiometabolic disease using paper/digital surveys. Variables investigated included socioeconomic status, physical activity, diet, tobacco use, alcohol intake, treatment discontinuation, and psychological symptoms. Results: A total of 4,216 patients (50.9% males, mean age 60.3 ± 15.3 years old) from 13 Spanish-speaking Latin American countries were enrolled. Among the study population, 46.4% of patients did not have contact with a healthcare provider, 31.5% reported access barriers to treatments and 17% discontinued some medication. Multivariate analysis showed that non-adherence to treatment was more prevalent in the secondary prevention group: peripheral vascular disease (OR 1.55, CI 1.08-2.24; p = 0.018), heart failure (OR 1.36, CI 1.05-1.75; p = 0.017), and coronary artery disease (OR 1.29 CI 1.04-1.60; p = 0.018). No physical activity was reported by 38% of patients. Only 15% of patients met minimum recommendations of physical activity (more than 150 minutes/week) and vegetable and fruit intake. Low/very low income (45.5%) was associated with a lower level of physical activity (p < 0.0001), less fruit and vegetables intake (p < 0.0001), more tobacco use (p < 0.001) and perception of depression (p < 0.001). Low educational level was also associated with the perception of depression (OR 1.46, CI 1.26-1.70; p < 0.01). Conclusions: Patients with cardiometabolic disease but without clinical evidence of COVID-19 showed significant medication non-adherence, especially in secondary prevention patients. Deterioration in lifestyle habits and appearance of depressive symptoms during the pandemic were frequent and related to socioeconomic status.

Psychological Impact of the Pandemic on Ambulatory Cardiometabolic Patients Without Evidence of SARS-CoV-2 Infection. The CorCOVID Latam Psy Study.

BACKGROUND: The COVID-19 pandemic's mental health consequences remain unknown. AIM: To assess the mental health status of ambulatory cardiometabolic patients during COVID-19 pandemic lockdown in Spanish speaking Latin American countries. METHODS: Cardiometabolic patients without COVID-19 evidence in 13 Latin American countries answered a survey between June 15th and July 15th, 2020. The Diagnosis Manual of Mental Disorders fifth edition was used to identify the presence of major depressive symptoms. RESULTS: The sample included 4216 patients, 1590 (37.71%; IC95% 36.24-39.19) were considered suffering major depression. Female gender, consuming ≥5 medications day, physical activity <100 minutes weekly, low fruits and vegetables intake, poor treatment adherence, reduced food consumption were independently associated to the presence of major depressive symptoms. CONCLUSIONS: The CorCOVID Latam Psy study showed that one-third of the Latin American Spanish speaking population is suffering from major depressive symptoms during the COVID-19 outbreak.

Impact of the Pandemic on NonInfected Cardiometabolic Patients: A Survey in Countries of Latin America-Rationale and Design of the CorCOVID LATAM Study.

BACKGROUND: The first case of coronavirus 2019 (COVID-19) in Latin America was detected on February 26th, 2020, in Brazil. Later, in June, the World Health Organization announced that the focus of the outbreak had shifted to Latin America, where countries already had poor control of indicators of noncommunicable diseases (NCDs). Concerns about coronavirus infection led to a reduced number of visits and hospitalizations in patients with NCDs, such as cardiovascular disease, diabetes, and cancer. There is a need to determine the impact of the COVID-19 pandemic on patients who have cardiometabolic diseases but do not have clinical evidence of COVID-19 infection. METHODS: The CorCOVID LATAM is a cross-sectional survey of ambulatory cardiometabolic patients with no history or evidence of COVID-19 infection. The study will be conducted by the Interamerican Society of Cardiology. An online survey composed of 38 questions using Google Forms will be distributed to patients of 13 Latin American Spanish-speaking countries from June 15th to July 15th, 2020. Data will be analyzed by country and regions. Seven clusters of questions will be analyzed: demographics, socioeconomic and educational level, cardiometabolic profile, lifestyle and habits, body-weight perception, medical follow-up and treatments, and psychological symptoms. RESULTS: Final results will be available upon completion of the study. CONCLUSIONS: The present study will provide answers regarding the impact of the COVID-19 pandemic on noninfected cardiometabolic patients. Data on this topic are scarce, as it is an unprecedented threat, without short-term solutions.

CONTEXTE: Le premier cas de maladie à coronavirus 2019 (COVID-19) en Amérique latine a été détecté le 26 février 2020 au Brésil. En juin, l'Organisation mondiale de la Santé a annoncé que le foyer de l'épidémie s'était déplacé en Amérique latine, où le suivi des indicateurs relatifs aux maladies non transmissibles est déjà déficient. Les préoccupations relatives à l'infection par le coronavirus ont entraîné une diminution du nombre de consultations et d'hospitalisations des patients atteints d'une maladie non transmissible, comme une ma-ladie cardiovasculaire, le diabète ou un cancer. Il est donc nécessaire d'évaluer l'incidence de la pandémie de COVID-19 chez les patients atteints d'une maladie cardiométabolique ne présentant aucun signe clinique d'une infection au virus de la COVID-19. MÉTHODOLOGIE: L'étude CorCOVID LATAM est une enquête transversale menée auprès des patients ambulatoires atteints d'une maladie cardiométabolique n'ayant pas d'antécédents d'infection au virus de la COVID-19 et ne présentant aucun signe d'une telle infection. L'étude est réalisée par la Société interaméricaine de cardiologie. Du 15 juin au 15 juillet 2020, on a demandé aux patients de 13 pays hispanophones d'Amérique latine de répondre à un questionnaire en ligne de 38 questions dans Google Forms. Les données seront analysées par pays et par région. Les réponses aux questions seront examinées selon sept grands thèmes : caractéristiques démographiques, caractéristiques socioéconomiques et niveau de scolarité, profil cardiométabolique, mode de vie et habitudes, perception quant au poids corporel, suivi et traitements médicaux et symptômes psychologiques. RÉSULTATS: Les résultats seront publiés à la fin de l'étude. CONCLUSIONS: L'étude fournira des renseignements sur l'incidence de la pandémie de COVID-19 chez les patients atteints d'une maladie cardiométabolique non infectés. Les données sur cette question sont rares, puisqu'il s'agit d'une menace sans précédent, à laquelle il n'existe de surcroît pas de solution à court terme.

Hypertensive Mediated Organ Damage and Hypertension Management. How to Assess Beneficial Effects of Antihypertensive Treatments?

The presence of hypertensive mediated organ damage is related to increased vascular risk and mortality and its prevention should be a therapeutic target and a surrogate marker of in/adequate blood pressure control. In old adult hypertensive patients the therapeutic target should be to prevent major cardiovascular events, but in young hypertensive subjects the focus should be pointed on preventing the development of hypertensive mediated organ damage, since most of the hard events are preceded by functional and structural tissues injury. Hypertension Guidelines of the European Society of Cardiology and European Society of Hypertension recognizes that some variables like electrocardiographic or echocardiographic left ventricle hypertrophy, chronic kidney disease or advance retinopathy, all considered as hypertensive mediated organ damage, may be modifiers of cardiovascular risk estimated by the SCORE system, and for that reason they should be screened in hypertensive patients. It is well known the problem of limited health systems financial resources in many low and even median income countries which precludes the possibilities of generalizing the search for hypertension mediated organ damage in all hypertensive patients. In these scenario the recommendation to perform a detailed screening should be critically evaluated. Some questions remained unanswered: the screening generalization of hypertensive mediated organ damage should modify the cardiovascular risk score of the patients, if its presence could modify the therapeutic approach, and as a consequence, if the treatment adjustment should prolong life expectancy and ameliorate the quality of life.