Incremento matutino de la presión arterial en pacientes con ictus isquémico reciente: el factor olvidado / Morning blood pressure surge in patients with recent ischaemic stroke: the neglected factor

Introducción: Un incremento matutino de presión arterial (IMPA) elevado se asocia con la aparición de eventos cardiovasculares. Evaluamos la presencia de un IMPA elevado en pacientes con ictus isquémico reciente. Material y métodos: Se realizó un estudio casos-control. Se incluyeron 100 pacientes con un ictus isquémico en los 6 meses previos y 50 pacientes hipertensos sin enfermedad cardiovascular como controles. Resultados: Se estudiaron 61 ictus lacunares (LAC) y 39 no lacunares (NLAC). La edad media fue de 65±11 años, y 60 (40%) pacientes eran mujeres. El IMPA elevado estaba presente en el 9% de los ictus (en 5 LAC y 4 NLAC) y en el 8% de los controles (p no significativa [NS]), con un valor medio similar de IMPA en ambos grupos: 23,9±14mmHg y 24,9±15mmHg respectivamente (p=NS), aunque los pacientes controles presentaron una PA más alta en consulta (sistólica [p=0,008] y diastólica [p=0,0001]), PA sistólica de 24h (p=0,028) y PA sistólica diurna (p=0,022). Entre los pacientes con ictus, un IMPA elevado se asoció con enfermedad coronaria previa (p=0,005), con el patrón circadiano de PA (p=0,029), pero no con el tratamiento antihipertensivo prescrito. En el análisis multivariante, el IMPA elevado solo se asoció con enfermedad coronaria previa (p=0,001). Conclusiones: Aproximadamente uno de cada 10 pacientes con ictus isquémico reciente presenta un IMPA elevado. Se deberían implementar estrategias para la detección y tratamiento del IMPA tras un ictus.

Introduction: High morning BP surge (MBPS) has been associated with an increased risk of cardiovascular events. We evaluated the presence of a high MBPS in patients with recent ischaemic stroke. Material and methods: A case-control study was carried out. One hundred patients with an ischaemic stroke in the previous 6 months and fifty hypertensive patients without cardiovascular disease were included as controls. Results: 61 lacunar (LAC) and 39 non-lacunar (NLAC) strokes were studied. The mean age was 65±11 years, and 60 (40%) patients were women. High MBPS was present in 9% of strokes (in 5 LAC and 4 NLAC) and in 8% of controls (p not significant [NS]), with a similar mean value of MBPS in both groups: 23.9±14mmHg and 24.9±15mmHg respectively (p=NS), although the control patients had a higher office BP (systolic [p=.008] and diastolic [p=.0001]), 24h systolic BP (p=.028) and daytime systolic BP (p=.022). Among the stroke patients, high MBPS was associated with previous coronary heart disease (p=.005), circadian BP pattern (p=.029), but not with the type of antihypertensive treatment prescribed. In multivariate analysis, elevated MBPS was only associated with previous coronary artery disease (p=.001). Conclusions: Approximately one in ten patients with recent ischaemic stroke has a high MBPS. Strategies to detect and treat high MBPS after a stroke are needed.

[Morning blood pressure surge in patients with recent ischaemic stroke: the neglected factor]. / Incremento matutino de la presión arterial en pacientes con ictus isquémico reciente: el factor olvidado.

INTRODUCTION: High morning BP surge (MBPS) has been associated with an increased risk of cardiovascular events. We evaluated the presence of a high MBPS in patients with recent ischaemic stroke. MATERIAL AND METHODS: A case-control study was carried out. One hundred patients with an ischaemic stroke in the previous 6 months and fifty hypertensive patients without cardiovascular disease were included as controls. RESULTS: 61 lacunar (LAC) and 39 non-lacunar (NLAC) strokes were studied. The mean age was 65±11 years, and 60 (40%) patients were women. High MBPS was present in 9% of strokes (in 5 LAC and 4 NLAC) and in 8% of controls (p not significant [NS]), with a similar mean value of MBPS in both groups: 23.9±14mmHg and 24.9±15mmHg respectively (p=NS), although the control patients had a higher office BP (systolic [p=.008] and diastolic [p=.0001]), 24h systolic BP (p=.028) and daytime systolic BP (p=.022). Among the stroke patients, high MBPS was associated with previous coronary heart disease (p=.005), circadian BP pattern (p=.029), but not with the type of antihypertensive treatment prescribed. In multivariate analysis, elevated MBPS was only associated with previous coronary artery disease (p=.001). CONCLUSIONS: Approximately one in ten patients with recent ischaemic stroke has a high MBPS. Strategies to detect and treat high MBPS after a stroke are needed.

Cholesterol and stroke: Roll of PCSK9 inhibitors. / Colesterol e ictus: papel de los inhibidores de la proproteína convertasa subtilisina/kexina tipo 9.

INTRODUCTION: Proprotein convertase subtilisin/kexin type 9 (PCSK9) plays an important role in the modulation of plasma levels of low density lipoprotein cholesterol (LDLC). PCSK9 binds to the LDL receptor (LDLR), disrupts its endocytic recycling itinerary and directs it to lysosomal degradation. Activation of PCSK9 can thus decrease the expression of LDLR in the liver and inhibit LDL uptake, which leads to hypercholesterolaemia. DEVELOPMENT: Currently we now know that different polymorphisms of PCSK9 are associated with the occurrence of ischaemic stroke. On the other hand, PCSK9 inhibitors prevent binding of PCSK9 to LDLR and inhibit degradation of LDLR, which results in increased hepatic uptake of LDL and lower LDL levels in blood. Different phase 2 and 3 studies, including OSLER and ODYSSEY LONG-TERM, have demonstrated the efficacy and safety of the new monoclonal antibodies against PCSK9 such as evolucumab and alirocumab, and the first exploratory analyses have shown evidence of their efficacy in decreasing vascular events, including stroke. CONCLUSIONS: Although few strokes have been reported by these studies, new ongoing trials examining the cardiovascular effects of evolucumab (FOURIER study), alirocumab (ODYSSEY OUTCOMES study), and bococizumab (SPIRE-1 and SPIRE-2 studies) will reveal the true potential of these drugs, particularly for the prevention of stroke.

[Carnitine deficiency myopathy: a case of late diagnosis]. / Miopatía por déficit de carnitina: un caso de diagnóstico tardío.

Myopathies caused by lipidic metabolism alterations are very infrequent. Carnitine deficiency-associated myopathies are included in this group. Two main types of carnitine deficiency syndromes have been delineated: a predominantly myopathic form, with normal serum and low muscle carnitine levels, and a systemic form, with encephalopathy, hepatic dysfunction, muscle weakness and low muscle, liver and serum carnitine levels. Both types have typical lipid stores in muscle biopsy. We describe the case of a myopathic form of carnitine deficiency. Due to the age of the patient, this is an unusual case, with an unfavourable evolution. Therapeutic measures used in these patients have included prednisone, carnitine replacement and a low-fat with medium chain tryglycerides and high-carbohydrate diet. However, in none of the patients responding to therapy, a significative increase in muscle carnitine has been demonstrated.

[Nosocomial urinary tract infections in patients with prolonged bladder catheterization: un unsolved problem]. / Infecciones urinarias nosocomiales en pacientes con sondaje vesical prolongado: un problema sin resolver.

Urinary tract infection (UTI) is the primary cause of hospitalary infection. We have prospectively studied during a 8-month period, 94 episodes of UTI in 61 patients with a mean age of 77 years and with a high percentage of vesical sounding (70.5%). The most frequent cause of sounding was urinary incontinence (74%) and in just 15% of all cases, there was a strict urological indication. The association fever/sounding was statistically significant (p < 0.05) and, when analyzing the prognosis factors, we observed that patients who had a significantly higher risk were those with vesical sounding (p < 0.05), fever equal to or higher than 38 degrees C and/or Pseudomonas aeruginosa isolated in their uroculture (p < 0.01). Among the microorganisms isolated, P. aeruginosa ranked in first place, followed by E. Coli. The most sensitive antibiotics in these patients were the aminoglycosides (tobramycin or gentamycin), cephtacidime and aztreonan. Finally, the percentage of coincidence between the microorganisms isolated in the uroculture and in the infections of other patients sharing the same room is significantly higher (p < 0.01) in patients with vesical sounding than in patients without it, suggesting a transmission role of the health staff.