Influence of angiotensin receptor and converting enzyme blockers therapy in the respiratory outcome of COVID-19 hospitalized patients / Influencia de la terapia con bloqueadores del receptor de angiotensina y de la enzima convertidora en el resultado respiratorio de pacientes hospitalizados por COVID-19

Objectives: COVID-19, caused by SARS-CoV-2, has spread around the world since 2019. In severe cases, COVID-19 can lead to hospitalization and death. Systemic arterial hypertension and other comorbidities are associated with serious COVID-19 infection. Literature is unclear whether antihypertensive therapy with angiotensin receptor blockers (ARBs) and angiotensin converting enzyme (ACE) inhibitors affect COVID-19 outcomes. We aim to assess whether ACEI/ARB therapy is a risk factor for worse respiratory outcomes related to COVID-19 in hospitalized patients. Methods: Retrospective study enrolling admitted COVID-19-diagnosed patients by RT-PCR at the Hospital Geral de Fortaleza, Brazil, during 2021. Patient medical records, sociodemographic, and clinical data were analyzed. Chest CT images were analyzed using CAD4COVID-CT/Thirona™ software. Results: A total of 294 patients took part in the study. A cut-off point of 66% of pulmonary involvement was found by ROC curve, with patients having higher risk of death and intubation and lower 60-day survival. Advanced age (RR 1.025, P=0.001) and intubation (RR 16.747, P<0.001) were significantly associated with a higher risk of death. Advanced age (RR 1.023, P=0.001) and the use of noninvasive ventilation (RR 1.548, P=0.037) were associated with a higher risk of intubation. Lung involvement (>66%) increased the risk of death by almost 2.5-fold (RR 2.439, P<0.001) and by more than 2.3-fold the risk of intubation (RR 2.317, P<0.001). Conclusions: Altogether, our findings suggest that ACEI or ARB therapy does not affect the risk of death and disease course during hospitalization.(AU)

Objetivos: La COVID-19, causada por el SARS-CoV-2, se ha extendido por todo el mundo desde 2019. En casos graves, la COVID-19 puede provocar hospitalización y muerte. La hipertensión arterial sistémica y otras comorbilidades se asocian con una infección grave por COVID-19. La literatura no está clara si la terapia antihipertensiva con bloqueadores de los receptores de angiotensina (BRA) e inhibidores de la enzima convertidora de angiotensina (ECA) afecta los resultados de la COVID-19. Nuestro objetivo fue evaluar si la terapia BRA/ECA es un factor de riesgo de peores resultados respiratorios relacionados con COVID-19 en pacientes hospitalizados. Métodos: Estudio retrospectivo que incluyó pacientes ingresados con diagnóstico de COVID-19 mediante RT-PCR en el Hospital General de Fortaleza, Brasil, durante 2021. Se analizaron las historias clínicas de los pacientes, datos sociodemográficos y clínicos. Las imágenes de TC de tórax se analizaron utilizando el software CAD4COVID-CT/ThironaTM. Resultados: Participaron en el estudio un total de 294 pacientes. Mediante curva ROC se encontró un punto de corte del 66% de afectación pulmonar, teniendo los pacientes mayor riesgo de muerte e intubación y menor supervivencia a 60 días. La edad avanzada (RR 1,025; P=0,001) y la intubación (RR 16,747; P<0,001) se asociaron significativamente con un mayor riesgo de muerte. La edad avanzada (RR 1,023; P=0,001) y el uso de ventilación no invasiva (RR 1,548; P=0,037) se asociaron con un mayor riesgo de intubación. La afectación pulmonar (>66%) aumentó el riesgo de muerte casi 2,5 veces (RR 2,439; P<0,001) y más de 2,3 veces el riesgo de intubación (RR 2,317, P<0,001). Conclusiones: Se concluyó que el tratamiento con BRA o ECA no afecta el riesgo de muerte y el curso de la enfermedad durante la hospitalización.(AU)

Influence of angiotensin receptor and converting enzyme blockers therapy in the respiratory outcome of COVID-19 hospitalized patients.

OBJECTIVES: COVID-19, caused by SARS-CoV-2, has spread around the world since 2019. In severe cases, COVID-19 can lead to hospitalization and death. Systemic arterial hypertension and other comorbidities are associated with serious COVID-19 infection. Literature is unclear whether antihypertensive therapy with angiotensin receptor blockers (ARBs) and angiotensin converting enzyme (ACE) inhibitors affect COVID-19 outcomes. We aim to assess whether ACEI/ARB therapy is a risk factor for worse respiratory outcomes related to COVID-19 in hospitalized patients. METHODS: Retrospective study enrolling admitted COVID-19-diagnosed patients by RT-PCR at the Hospital Geral de Fortaleza, Brazil, during 2021. Patient medical records, sociodemographic, and clinical data were analyzed. Chest CT images were analyzed using CAD4COVID-CT/Thirona™ software. RESULTS: A total of 294 patients took part in the study. A cut-off point of 66% of pulmonary involvement was found by ROC curve, with patients having higher risk of death and intubation and lower 60-day survival. Advanced age (RR 1.025, P=0.001) and intubation (RR 16.747, P<0.001) were significantly associated with a higher risk of death. Advanced age (RR 1.023, P=0.001) and the use of noninvasive ventilation (RR 1.548, P=0.037) were associated with a higher risk of intubation. Lung involvement (>66%) increased the risk of death by almost 2.5-fold (RR 2.439, P<0.001) and by more than 2.3-fold the risk of intubation (RR 2.317, P<0.001). CONCLUSIONS: Altogether, our findings suggest that ACEI or ARB therapy does not affect the risk of death and disease course during hospitalization.

Importancia de la hipertensión en pacientes con primer episodio de ictus isquémico: estudio retrospectivo de 20 años / Importance of hypertension in patients after the first stroke: retrospective cohort study

Antecedentes y objetivos: La hipertensión arterial (HTA) es un factor de riesgo clave para el ictus. Evaluamos si la importancia de la HTA sobre el riesgo de ictus isquémico ha aumentado en las últimas décadas. Métodos: Estudio retrospectivo de pacientes con ictus isquémico dados de alta en 3 hospitales de Sevilla (España), durante los periodos: 1999-2001, 2014-2016 y 2019-2020. Resultados: Se incluyeron 1.379 pacientes, 42,6% mujeres, edad media 69,1 (±11) años. La HTA fue el factor de riesgo vascular más prevalente en todos los periodos, con un aumento progresivo de pacientes hipertensos (65,9 vs. 69,6 vs. 74%; p=0,029). La HTA fue especialmente frecuente en pacientes≥80 años (73 vs. 81,9 vs. 85,2%; p=0,029). Al alta se utilizaron progresivamente más fármacos antihipertensivos (en el 65 vs. 85,1 vs. 90,2% de los pacientes; p=0,0001), con un claro aumento en el número de fármacos antihipertensivos utilizados (media 0,9±0,8 vs. 1,5±1 vs. 1,8±0,8 fármacos; p=0,0001). El uso de diuréticos (13,7-39,3-65,3%; p=0,0001), IECA (35,5-43,3-53,4%; p=0,0001) y bloqueadores de los receptores de angiotensina (12,2-24-32,4%; p=0,0001) aumentó progresivamente. Por el contrario, disminuyó el uso de antagonistas del calcio (24-19,9-13,7; p=0,0001). Conclusiones: En las últimas 2 décadas existe un mayor protagonismo de la HTA entre los pacientes con primer evento cerebrovascular isquémico. Es necesario un mayor y mejor control de la HTA para disminuir la enorme carga de la enfermedad cerebrovascular. (AU)

Background and objectives: Hypertension (HT) is a key risk factor for stroke. We evaluated whether the importance of hypertension on the risk of ischemic stroke has increased in recent decades. Methods: Retrospective study of patients with ischemic stroke discharged from 3 hospitals in Seville (Spain), during the periods: 1999-2001, 2014-2016 and 2019-2020. Results: 1,379 patients were included, 42.6% women, mean age 69.1 (±11) years. HT was the most prevalent vascular risk factor in all periods, with a progressive increase in hypertensive patients (65.9% vs 69.6% vs 74%; P=.029). HT was especially frequent in patients≥80 years (73% vs 81.9% vs 85.2%; P=.029). At discharge, progressively more antihypertensive drugs were used (in 65% vs 85.1 vs 90.2% of patients; P=.0001), with a clear increase in the number of antihypertensive drugs used (mean 0.9±0.8 vs 1.5±1 vs 1.8±0.8 drugs, P=.0001). The use of diuretics (13.7%-39.3%-65.3%; p=0.0001), ACE inhibitors (35.5%-43.3%-53.4%; P=.0001) and angiotensin receptor blockers (12.2%-24%-32.4%; P=.0001) increased progressively. On the contrary, the use of calcium antagonists decreased (24%-19.9%-13.7%; P=.0001). Conclusions: In the last 2 decades there has been a greater role for HT among patients with their first ischemic cerebrovascular event. Greater and better control of HT is necessary to reduce the enormous burden of cerebrovascular disease. (AU)

[Importance of hypertension in patients after the first stroke: retrospective cohort study]. / Importancia de la hipertensión en pacientes con primer episodio de ictus isquémico: estudio retrospectivo de 20 años.

BACKGROUND AND OBJECTIVES: Hypertension (HT) is a key risk factor for stroke. We evaluated whether the importance of hypertension on the risk of ischemic stroke has increased in recent decades. METHODS: Retrospective study of patients with ischemic stroke discharged from 3 hospitals in Seville (Spain), during the periods: 1999-2001, 2014-2016 and 2019-2020. RESULTS: 1,379 patients were included, 42.6% women, mean age 69.1 (±11) years. HT was the most prevalent vascular risk factor in all periods, with a progressive increase in hypertensive patients (65.9% vs 69.6% vs 74%; P=.029). HT was especially frequent in patients≥80 years (73% vs 81.9% vs 85.2%; P=.029). At discharge, progressively more antihypertensive drugs were used (in 65% vs 85.1 vs 90.2% of patients; P=.0001), with a clear increase in the number of antihypertensive drugs used (mean 0.9±0.8 vs 1.5±1 vs 1.8±0.8 drugs, P=.0001). The use of diuretics (13.7%-39.3%-65.3%; p=0.0001), ACE inhibitors (35.5%-43.3%-53.4%; P=.0001) and angiotensin receptor blockers (12.2%-24%-32.4%; P=.0001) increased progressively. On the contrary, the use of calcium antagonists decreased (24%-19.9%-13.7%; P=.0001). CONCLUSIONS: In the last 2 decades there has been a greater role for HT among patients with their first ischemic cerebrovascular event. Greater and better control of HT is necessary to reduce the enormous burden of cerebrovascular disease.

Terapia farmacológica en la prevención secundaria del ictus isquémico en los muy ancianos: ¿ha mejorado en las últimas décadas? / Pharmacological therapy in the secondary prevention of ischemic stroke in the oldest-old patients: has it improved in recent decades?

Introduction Population aging has caused an increase in strokes in very elderly patients (VEP). We assess how secondary prevention of ischemic stroke has changed in VEP in recent decades. Method Retrospective study of discharges due to ischemic stroke in the Virgen Macarena, Virgen del Rocio and Valme hospitals in Seville (Spain), during the periods 1999–2001, 2014−16 and 2019−2020. VEP were considered those with ≥80 years. Result We studied 1806 patients, 349 (19.3%) were VEP. Over the years, VEPs have doubled (13.5% vs. 25.9% and 28% p = 0.0001) and age has increased (83.3 ± 3 vs. 84.1 ± 3 vs. 85.2 ± 4 p = 0.001). Comparing the periods, the VEPs have more hypertension (69.9% vs. 84.8% vs. 84.6%; p = 0.0001) and dyslipidemia (12% vs. 41.7% vs. 52.3%; p = 0.0001) and have prescribed more antihypertensives (69.1% vs. 86.7% vs. 92.3%; p = 0.0001), statins (5.3% vs. 78% vs. 81.5%; p = 0.0001) and anticoagulants (16.5% vs. 19.4% vs. 53.1%; p = 0.001), increasing the number of antihypertensives (1 ± 0.9 vs. 1.6 ± 0, 9 vs. 1.9 ± 0.8 drugs p = 0.0001), and high-intensity statins (2.3% vs. 42.7 vs. 69.2% p = 0.0001). Comparing the VEPs with the younger ones, there were no differences in antihypertensive treatment in any period, there were differences in antithrombotic treatment in the first period, and with statins the differences were maintained until the end. Conclusions In the last 20 years the number of VEPs has doubled, exceeding a quarter of the discharges. Although there is improvement in secondary stroke prevention in VEPs, there is room for improvement (AU)

Introducción El envejecimiento poblacional ha provocado un aumento de los ictus en los pacientes muy ancianos (PMA). Valoramos cómo ha cambiado la prevención secundaria del ictus isquémico en PMA en las últimas décadas. Método Estudio retrospectivo de las altas por ictus isquémico en los hospitales Virgen Macarena, Virgen del Rocío y Virgen de Valme de Sevilla (España), durante los períodos 1999-2001, 2014-2016 y 2019-2020. Se consideró PMA ≥ 80 años. Resultado Estudiamos a 1.806 pacientes, de los cuales 349 (19,3%) eran PMA. Con los años se han duplicado los PMA (13,5% vs. 25,9% y 28%; p = 0,0001) y aumentado la edad (83,3 ± 3 vs. 84,1 ± 3 vs. 85,2 ± 4; p = 0,001). Comparando los períodos, los PMA tienen más hipertensión (69,9 vs. 84,8% vs. 84,6%; p = 0,0001) y dislipidemia (12 vs. 41,7% vs. 52,3%; p = 0,0001) y tienen prescritos más antihipertensivos (69,1% vs. 86,7% vs. 92,3%; p = 0,0001), estatinas (5,3% vs. 78% vs. 81,5%; p = 0,0001) y anticoagulantes (16,5% vs. 19,4% vs. 53,1%; p = 0,001); también ha aumentado el número de antihipertensivos (1 ± 0,9 vs. 1,6 ± 0,9 vs. 1,9 ± 0,8 fármacos; p = 0,0001) y de estatinas de alta intensidad (2,3% vs. 42,7% vs. 69,2%; p = 0,0001). Comparando los PMA con pacientes más jóvenes, no hubo diferencias en el tratamiento antihipertensivo en ningún período, aunque sí hubo diferencias en el tratamiento antitrombótico en el primer período y con las estatinas las diferencias se mantuvieron hasta el final. Conclusiones En los últimos 20 años el número de PMA se ha duplicado y supera la cuarta parte de las altas. Aunque existe mejoría en la prevención secundaria del ictus en los PMA, existe margen de mejora (AU)

Adherencia al tratamiento y nivel de conocimiento en adultos con hipertensión arterial, Asunción 2022

Introducción: la adherencia al tratamiento y el nivel de conocimientos en pacientes con hipertensión arterial son factores claves para controlar esta afección y evitar complicaciones. Objetivos: determinar el grado de adherencia al tratamiento, el nivel de conocimientos y comorbilidades en pacientes con hipertensión arterial de un área urbana de Asunción, Paraguay, en 2022. Metodología: se aplicó un diseño observacional, descriptivo, transversal. Se incluyeron varones y mujeres mayores de 18 años, conocidos portadores de hipertensión arterial, que residen en el barrio Sajonia entre mayo y octubre del 2022. Los datos fueron obtenidos con entrevistas realizadas casa por casa. Se midieron variables demográficas, el nivel de adherencia con el cuestionario de Morisky Green y el de conocimientos sobre la enfermedad con el cuestionario de Batalla. La investigación fue aprobada por el Comité de ética de la Universidad Privada del Este, Paraguay. Resultados: participaron del estudio 425 sujetos, con predominio del sexo femenino (61,1%). La diabetes mellitus fue referida en 28,9% de los entrevistados. El cuestionario de Morisky Green detectó que 60% de los sujetos olvida de tomar su medicación, 25% no la toma en el horario indicado, 29% de la toma si se siente bien y 44% deja de tomarla si siente efectos indeseables. El cuestionario de Batalla halló 7% cree que la hipertensión arterial no es para toda la vida, 9% cree que la afección no se controla con dieta y medicación, y 5,8% no pudo referir al menos un órgano blanco. Conclusión: la adherencia al tratamiento de la hipertensión arterial y el nivel de conocimientos sobre esta afección no fue adecuada.

Introduction: Adherence to treatment and level of knowledge in patients with arterial hypertension are key factors to control this condition and avoid complications. Objectives: To determine the degree of adherence to treatment, the level of knowledge and comorbidities in patients with arterial hypertension in an urban area of ​​Asunción, Paraguay, in 2022. Methodology: An observational, descriptive, cross-sectional design was applied. Men and women over 18 years of age, known carriers of arterial hypertension, residing in Sajonia neighborhood between May and October 2022, were included. The data were obtained through house-to-house interviews. Demographic variables, the level of adherence with the Morisky Green test and the level of knowledge about the disease with the Batalla test were measured. The research was approved by the Ethics Committee of the Universidad Privada del Este, Paraguay. Results: Four hundred twenty-five subjects participated in the study, predominantly female (61.1%). Diabetes mellitus was referred to by 28.9% of the interviewees. The Morisky Green test detected that 60% of the subjects forget to take their medication, 25% do not take it at the indicated time, 29% take it if they feel well, and 44% stop taking it if they feel undesirable effects. The Batalla test found that 7% believe that arterial hypertension is not for life, 9% believe that the condition is not controlled with diet and medication, and 5.8% could not refer to at least one target organ. Conclusion: Adherence to the treatment of arterial hypertension and the level of knowledge about this condition was not adequate.

Pharmacological therapy in the secondary prevention of ischemic stroke in the oldest-old patients: has it improved in recent decades?

INTRODUCTION: Population aging has caused an increase in strokes in very elderly patients (VEP). We assess how secondary prevention of ischemic stroke has changed in VEP in recent decades. METHOD: Retrospective study of discharges due to ischemic stroke in the Virgen Macarena, Virgen del Rocio and Valme hospitals in Seville (Spain), during the periods 1999-2001, 2014-16 and 2019-2020. VEP were considered those with ≥80 years. RESULT: We studied 1806 patients, 349 (19.3%) were VEP. Over the years, VEPs have doubled (13.5% vs. 25.9% and 28% p = 0.0001) and age has increased (83.3 ±â€¯3 vs. 84.1 ±â€¯3 vs. 85.2 ±â€¯4 p = 0.001). Comparing the periods, the VEPs have more hypertension (69.9% vs. 84.8% vs. 84.6%; p = 0.0001) and dyslipidemia (12% vs. 41.7% vs. 52.3%; p = 0.0001) and have prescribed more antihypertensives (69.1% vs. 86.7% vs. 92.3%; p = 0.0001), statins (5.3% vs. 78% vs. 81.5%; p = 0.0001) and anticoagulants (16.5% vs. 19.4% vs. 53.1%; p = 0.001), increasing the number of antihypertensives (1 ±â€¯0.9 vs. 1.6 ±â€¯0, 9 vs. 1.9 ±â€¯0.8 drugs p = 0.0001), and high-intensity statins (2.3% vs. 42.7 vs. 69.2% p = 0.0001). Comparing the VEPs with the younger ones, there were no differences in antihypertensive treatment in any period, there were differences in antithrombotic treatment in the first period, and with statins the differences were maintained until the end. CONCLUSIONS: In the last 20 years the number of VEPs has doubled, exceeding a quarter of the discharges. Although there is improvement in secondary stroke prevention in VEPs, there is room for improvement.

Manejo de crisis hipertensiva en cirugía maxilofacial. Reporte de caso clínico / Hypertensive crisis management in maxillofacial surgery. Clinical case report

Introducción: un aumento marcado de la tensión arterial puede llevar a una crisis hipertensiva, que consiste en una elevación considerable de la tensión arterial (>180 mmHg en sístole y >120 mmHg en diástole). De no ser tratada, puede llevar a la pérdida progresiva de la conciencia, así como provocar daños irreversibles a algún órgano blanco, por ejemplo, el hígado, el riñón o el cerebro. Se puede clasifcar en urgencia o emergencia hipertensiva. Así, una urgencia hipertensiva se presenta cuando el paciente cuenta con cifras elevadas en la tensión arterial sin provocar daño a un órgano blanco y, en contraparte, una emergencia hipertensiva cumple con las cifras que se mencionaron, pero incluye daño a un órgano blanco. Objetivo: presentar un caso clínico, en el cual, durante la extracción quirúrgica de una aguja fracturada, en el período transoperatorio, el paciente sufre síncope vasovagal, con un aumento marcado de la tensión arterial (179/119 mmHg). Conclusión: este fue un diagnóstico intraoperatorio de crisis hipertensiva y la paciente recibió un tratamiento médico temprano por parte del servicio de urgencias médicas, lo cual resultó en una evolución trans y postoperatoria adecuada.

A marked increase in blood pressure can lead to a hypertensive crisis, it can be classifed as an urgency or hypertensive emergency, which consists of a considerable increase in blood pressure (> 180 mmHg in systole and> 120 mmHg in diastole) and that, not being treated can lead to progressive loss of consciousness, as well as cause irreversible damage to the liver, kidney or brain. The objective of this article is to present a clinical case that during the surgical extraction of a fractured needle, in the intraoperative period the patient sufers vasovagal syncope, with a marked increase in blood pressure (179/119 mmHg), intraoperative diagnosis of crisis hypertensive, receiving early medical treatment from the emergency medical service, resulting in an adequate trans and postoperative evolution.

Trombosis de seno venoso en paciente en puerperio mediato. Reporte de caso / Venous sinus thrombosis in a patient during the immediate puerperium. Case report

Resumen ANTECEDENTES: La trombosis del seno venoso representa el 1% de los eventos vasculares cerebrales; su incidencia es de 5 casos por cada millón de habitantes y su mortalidad es del 10%. Los senos sagital superior y venoso transversal son los más afectados. El embarazo es un factor de riesgo especial pues la trombosis se registra en el 0.01% de las gestaciones. CASO CLÍNICO: Paciente de 40 años, primigesta, con embarazo gemelar bicorial biamniótico de 33.6 semanas. Se ingresó al servicio de Urgencias debido al diagnóstico de preeclampsia con criterios de severidad, con presión arterial de 160-100 mmHg y transaminasemia. Se le indicó tratamiento antihipertensivo y sulfato de magnesio intravenoso. Se decidió la finalización del embarazo por cesárea. Al cuarto día poscesárea tuvo disminución de la fuerza en ambos brazos, pérdida del tono muscular en los miembros pélvicos, cefalea holocraneana y alteración del estado de alerta (Glasgow de 14). Mediante resonancia magnética se evidenció la oclusión del seno longitudinal superior e isquemia en la región parieto occipital izquierda. Se le administraron anticoagulantes y analgésicos con los que evolucionó adecuadamente; se dio de alta sin complicaciones. CONCLUSIONES: La trombosis del seno venoso implica un reto cuando no se tiene una alta sospecha diagnóstica en pacientes con signos y síntomas neurológicos y, más aún, cuando se agregan factores de riesgo protrombóticos, como el embarazo y el puerperio. El diagnóstico oportuno brinda la oportunidad de iniciar el tratamiento adecuado y disminuir los síntomas y comorbilidades.

Abstract BACKGROUND: Venous sinus thrombosis accounts for 1% of cerebral vascular events; its incidence is 5 cases per million population and its mortality is 10%. The superior sagittal and transverse venous sinuses are the most affected. Pregnancy is a special risk factor since thrombosis is registered in 0.01% of pregnancies. CLINICAL CASE: A 40-year-old primigravida patient with a 33.6 week biamniotic twin pregnancy. She was admitted to the Emergency Department due to the diagnosis of preeclampsia with severity criteria, with blood pressure of 160-100 mmHg and transaminasemia. She was prescribed antihypertensive treatment and intravenous magnesium sulfate. It was decided to terminate the pregnancy by cesarean section. On the fourth post-cesarean day she had decreased strength in both arms, loss of muscle tone in the pelvic limbs, holocranial headache and altered alertness (Glasgow of 14). Magnetic resonance imaging showed occlusion of the superior longitudinal sinus and ischemia in the left parietooccipital region. He was administered anticoagulants and analgesics with which he evolved adequately; he was discharged without complications. CONCLUSIONS: Venous sinus thrombosis implies a challenge when there is no high diagnostic suspicion in patients with neurological signs and symptoms and, even more so, when prothrombotic risk factors are added, such as pregnancy and puerperium. Timely diagnosis provides the opportunity to initiate appropriate treatment and reduce symptoms and comorbidities.

Moving toward improved access to medicines and health technologies for cardiovascular disease / Avanzando para mejorar el acceso a los medicamentos y tecnologías sanitarias para las enfermedades cardiovasculares / Avançando para melhorar o acesso a medicamentos e tecnologias de saúde para as doenças cardiovasculares

ABSTRACT The objectives of this article are to describe the interventions carried out by the Strategic Fund of the Pan American Health Organization to facilitate access to and availability of antihypertensive medicines and devices for measuring blood pressure across the Region of the Americas as part of the HEARTS initiative, and to present the preliminary results of price analyses of antihypertensive medicines. The study methodology included a review of reports made by the Strategic Fund between 2019 and 2020, an evaluation of modalities of procurement, a review of the public procurement databases for five antihypertensive medicines, and a comparison with the price obtained by the Strategic Fund. Differences in price ranging from 20% to 99% were identified, indicating significant opportunities for savings. The study also presents interprogrammatic actions that can support the HEARTS initiative, such as the inclusion of antihypertensive medicines recommended by the World Health Organization, consolidation of regional demand and competitively-priced long-term agreements to manage the procurement of quality generic products, and the definition of technical specifications and regulatory requirements to support the procurement of devices to measure blood pressure. This mechanism will enable Member States to reduce their costs significantly, while extending treatment and diagnostic coverage to more people.

RESUMEN Los objetivos del presente artículo son describir las intervenciones realizadas por el Fondo Estratégico de Organización Panamericana de la Salud, para facilitar el acceso y disponibilidad de medicamentos antihipertensivos y dispositivos para la medición de la presión arterial a los países de la Región de las Américas en apoyo a la implementación de la Iniciativa HEARTS; y presentar los resultados preliminares de los análisis de los precios de los medicamentos antihipertensivos. La metodología del estudio incluyó la revisión de informes realizados por el Fondo Estratégico durante los años 2019-2020, la evaluación de las modalidades de adquisición y revisión de las bases de datos de compras públicas para 5 medicamentos antihipertensivos, y el análisis comparativo con el precio obtenido por el Fondo Estratégico. Se identificaron diferencias que oscilaron entre 20% y 99%, lo que evidencia oportunidades de ahorro significativas. Asimismo, se presentan las acciones interprogramáticas desarrolladas en apoyo a la Iniciativa HEARTS, entre las que se destacan la inclusión de medicamentos antihipertensivos recomendados por la Organización Mundial de la Salud; la consolidación de la demanda regional y el establecimiento de precios competitivos con acuerdos a largo plazo para gestionar la adquisición de productos genéricos de calidad; y la definición de especificaciones técnicas y requisitos regulatorios para apoyar con la adquisición de dispositivos para la medición de la presión arterial. A través de este mecanismo, los Estados Miembros pueden disminuir sus costos significativamente, extendiendo cobertura del tratamiento y diagnóstico a más personas.

RESUMO Os objetivos deste artigo são descrever as intervenções realizadas pelo Fundo Estratégico da Organização Pan-Americana da Saúde para facilitar o acesso e a disponibilidade de medicamentos anti-hipertensivos e aparelhos de medição de pressão arterial aos países da Região das Américas, em apoio à implementação da iniciativa HEARTS; e apresentar os resultados preliminares da análise dos preços dos medicamentos anti-hipertensivos. A metodologia do estudo incluiu a revisão de relatórios feitos pelo Fundo Estratégico durante os anos de 2019 e 2020, a avaliação das modalidades de aquisição e revisão dos dados de compras públicas de 5 medicamentos anti-hipertensivos e uma análise comparativa com o preço obtido pelo Fundo Estratégico. Foram identificadas diferenças que oscilaram entre 20% e 99%, o que evidencia oportunidades de economia significativas. Da mesma forma, são apresentadas as ações interprogramáticas desenvolvidas em apoio à iniciativa HEARTS, entre as quais se destacam a inclusão de medicamentos anti-hipertensivos recomendados pela Organização Mundial da Saúde; a consolidação da demanda regional e o estabelecimento de preços competitivos com acordos de longo prazo para gerenciar a aquisição de genéricos de qualidade; e a definição de especificações técnicas e requisitos regulatórios para subsidiar a aquisição de aparelhos de medição de pressão arterial. Por meio desse mecanismo, os Estados Membros podem reduzir seus custos significativamente, ampliando a cobertura de tratamento e diagnóstico para atingir mais pessoas.

Choque vasopléjico por envenenamiento con amlodipino y losartán

RESUMEN El choque vasodilatado o también llamado distributivo ocurre cuando las arteriolas presentan una pérdida de contractibilidad por diferentes mecanismos en donde la hipoxia y acidosis suelen ser los principales. La causa más común de este tipo de choque es la sepsis. Sin embargo, existen otras causas como las intoxicaciones con fármacos. Presentamos el manejo en la unidad de cuidados intensivos de un caso de intoxicación con fines de autoeliminación con dosis elevadas de antihipertensivos bloqueantes de canales calcio y antagonistas del receptor de angiotensina II, que requirió soporte hemodinámico y respiratorio.

ABSTRACT Vasodilated or also called distributive shock occurs when the arterioles present a loss of contractility due to different mechanisms in which hypoxia and acidosis are usually the main events. The most common cause of this type of shock is sepsis. However, there are other causes such as drug poisoning. We present the management in the intensive care unit of a case of poisoning for self-elimination purposes with high doses of antihypertensive calcium channel blockers and angiotensin II receptor antagonists, which required hemodynamic and respiratory support.

Desenvolvimento e validação de método analítico por CLAE para determinação simultânea de atorvastatina, losartana e metformina em formulações farmacêuticas magistrais

Objetivos: Desenvolver e validar um método analítico para a análise simultânea de atorvastatina (ATO), losartana (LOS) e metformina (MTF) em formulações farmacêuticas magistrais por CLAE. Método: O método foi desenvolvido empregando o cromatógrafo a líquido modelo Dionex® Ultimate 3000, acoplado ao detector de arranjo de diodos (DAD) e a validação se deu conforme compêndios de validação internacional e nacional. Os seguintes parâmetros foram analisados: linearidade, precisão, exatidão, robustez, seletividade, LD e LQ. A separação cromatográfica foi realizada na coluna Sigma-Aldrich® C18, fase móvel MeOH:H2O (78:22 v/v), pH 3,0 e vazão de 0,3 mL-min-1, modo isocrático. As detecções foram realizadas nos comprimentos de onda de 225 nm (LOS), 236 nm (MTF) e 246 nm (ATO). Resultados: O método foi linear, com coeficientes de correlação linear (r)> 0,99 para todos os fármacos, preciso (DPR entre medidas < 2 %), exato (recuperação entre 98-102 %). As variações propostas no estudo de robustez não tiveram influência significativa nos resultados, exceto a coluna cromatográfica. O método foi seletivo, pois os excipientes não interferiram nas análises. A sensibilidade do método foi demonstrada através da determinação teórica dos LD e LQ. Conclusão: Os resultados obtidos sugerem que o método cromatográfico desenvolvido e validado nessa pesquisa poderá ser empregado nas análises de rotina dos laboratórios de controle de qualidade de medicamentos contendo esses fármacos de forma isolada ou combinados em formulações farmacêuticas de uso oral.

SUMMARY Aims: To develop and validate an analytical method for the simultaneous analysis of atorvastatin (ATO), losartan (LOS), and metformin (MTF) in pharmaceutical compounding by HPLC. Method: The method was developed using a liquid chromatograph model Dionex® Ultimate 3000, coupled to a diode array detector (DAD), and validation was carried out according to international and national validation compendiums. The following parameters were analyzed: linearity, precision, accuracy, robustness, selectivity, LD, and LQ. Chromatographic separation was performed on a Sigma-Aldrich® C18 column, mobile phase MeOH:H2O (78:22 v/v), pH 3.0, and flow rate of 0.3 mL-min-1, isocratic mode. Detections were performed at 225 nm (LOS), 236 nm (MTF), and 246 nm (ATO) wavelengths. Results: The method was linear, with linear correlation coefficients (r)> 0.99 for all drugs, precise (DPR between measurements < 2 %), accurate recovery (between 98-102 %). The variations proposed in the robustness study had no significant influence on the results, except for the chromatographic column. The method was selective, as the excipients did not interfere in the analyses. The sensitivity of the method was demonstrated through the theoretical determination of LD and LQ. Conclusion: The results obtained suggest that the chromatographic method developed and validated in this research can be used in the routine analyzes of quality control laboratories of drugs containing these drugs alone or combined in pharmaceutical formulations for oral use.

Manifestaciones bucales en pacientes con medicación antihipertensiva / Oral manifestations in patients with antihypertensive medication

Objetivo: caracterizar las manifestaciones bucales en pacientes con medicación anti- hipertensiva que acuden al servicio estomatológico sur del municipio Morón, Ciego de Ávila, Cuba. Métodos: se realizó un estudio observacional, descriptivo, transversal, en el período enero 2019 a enero 2020. Se trabajó con la totalidad del universo, constituido por 162 pacientes. La información se recopiló de las historias clínicas estomatológicas individuales y de una ficha de recolección de datos creada por los autores de la investigación. Se estudiaron las variables grupo de edad, sexo, grupo de medicamentos antihipertensivos, dosis del medicamento, signos y síntomas clínicos, así como enfermedades bucales. Se utilizó estadística descriptiva (frecuencias absolutas y relativas porcentuales). Resultados: el 42,6 % representó el grupo de edad 35 a 59 años y el 53,7% al sexo femenino. Se observó que 88 pacientes (54,3 %) se encontraban medicados con inhibidores de la enzima convertidora de angiotensina; de ellos, 38 en su dosis mínima. La xerostomía estuvo presente en el 59,9 % de los casos. El 63,6 % presentó caries dental como enfermedad estomatológica. Conclusiones: existió predominio de la xerostomía y la caries dental en la mayoría de los pacientes.

Objective: To characterize the oral manifestations in patients with antihypertensive medication who attend the southern dental service of the Moron municipality, Ciego de Avila, Cuba. Method: An observational, descriptive, cross-sectional study was carried out in the period from January 2019 to January 2020. We worked with the entire universe which was made up of 162 patients. The information was collected from individual dental medical records and from a data collection form created by the authors of the research. The variables age group, sex, antihypertensive drug group, dose of antihypertensive drug, clinical signs and symptoms, and oral diseases were studied. Descriptive statistics were used (absolute and relative percentage frequencies). Results: 42,6 % represented the age group 35 to 59 years and 53,7 % the female sex. It was observed that 88 (54,3 %) patients were medicated with angiotensin converting enzyme inhibitors, 38 of them at their minimum dose. Xerostomia was present in 59,9% of the cases. 63,6 % presented dental caries as a dental disease. Conclusions: There was a predominance of xerostomia and dental caries in most of the patients.

Caracterización clínica de las crisis hipertensivas en pacientes adultos hospitalizados en el Hospital Nacional de Itauguá en 2021

RESUMEN Introducción: una crisis hipertensiva se define como una elevación aguda de la presión arterial superior a 180/120 mm Hg, pudiendo esto generar complicaciones en diferentes niveles fisiopatológicos como afectación del sistema nervioso central, cardiovascular, entre otros. Objetivos: caracterizar los aspectos clínicos de las crisis hipertensivas en pacientes internados en el Departamento de urgencias del Hospital Nacional de Itauguá. Métodos: estudio observacional, descriptivo con componente analítico, de corte transversal y prospectivo, realizado en el periodo de junio a noviembre del 2021. Se incluyeron pacientes con diagnóstico clínico de crisis hipertensiva definida por presión sistólica ≥ 180 mmHg y/o presión diastólica ≥120 mmHg. La investigación fue aprobada por el Comité de Ética de la Universidad Nacional de Itapúa. Resultados: se estudiaron 140 pacientes, cuya edad promedio fue 61 ± 14 años, con predominio masculino en 54,29%. Los valores promedios de cifras tensionales mayormente elevadas fueron la presión arterial sistólica (193,5 ± 15,2 mmHg) y la presión arterial diferencial (84,5 ± 17,75 mmHg). El motivo de consulta más frecuente fue la dificultad respiratoria (19,28%). A su vez, 113 (80,71%) pacientes tenían algún tipo de comorbilidad, predominando el sobrepeso en 61 casos. En 93 pacientes (66,43%) había tratamiento antihipertensivo irregular o abandono del mismo. El tratamiento inicial predominante fue la administración de enalaprilato EV (28,58%). En 91 pacientes (65%) se detectó daño de órgano blanco, prevaleciendo el accidente cerebrovascular (29,29%). Los factores que presentaron asociación estadísticamente significativa con presentar daño de órgano blanco fueron la comorbilidad (p 0,0033, OR: 3,52) y el tratamiento irregular o abandono del mismo (p 0,00007, OR: 4,35). Conclusión: se evidenció una alta frecuencia de emergencia hipertensiva, predominio marcado del tratamiento irregular o abandono del mismo. Mas de la mitad de los pacientes con crisis hipertensivas acuden con algún daño de órgano blanco, viéndose como principales factores de riesgo asociados la comorbilidad y el tratamiento irregular o abandono del mismo.

ABSTRACT Introduction: A hypertensive crisis is defined as an acute elevation of blood pressure greater than 180/120 mmHg, which can generate complications at different pathophysiological levels such as involvement of central nervous, cardiovascular systems, among others. Objectives: To characterize the clinical aspects of hypertensive crises in patients admitted to the Emergency Service of the Hospital Nacional o Itauguá. Methods: Prospective, cross-sectional, descriptive, observational study with an analytical component, carried out from June to November 2021. Patients with a clinical diagnosis of hypertensive crisis defined by systolic pressure ≥ 180 mmHg and/or diastolic pressure ≥ 120 mmHg were included. The research study was approved by the Ethics Committee of the National University of Itapúa. Results: One hundred forty patients were studied, whose mean age was 61±14 years, with male predominance (54.29%). The mean values ​​of the most elevated blood pressure values were systolic blood pressure (193.5±15.2 mmHg) and differential blood pressure (84.5± 17.75 mmHg). The most frequent reason for consultation was respiratory distress (19.28%). Some type of comorbidity was present in 113 patients (80.71%), with overweight predominating in 61 cases. In 93 patients (66.43%) there was irregular antihypertensive treatment or medication discontinuation. The predominant initial treatment was the administration of enalaprilat IV (28.58%). Target organ damage was detected in 91 patients (65%), with cerebrovascular accident prevailing (29.29%). The factors that presented a statistically significant association with presenting target organ damage were comorbidity (p = 0.0033, OR: 3.52) and irregular treatment or treatment discontinuation (p = 0.00007, OR: 4.35). Conclusion: A high frequency of hypertensive emergency, a marked predominance of irregular treatment or its discontinuation was evidenced. More than half of the patients with hypertensive crises consulted at the emergency service with some target organ damage, and with comorbidity and irregular treatment or medication discontinuation as the main associated risk factors.

Diferenças Raciais no Controle da Pressão Arterial em Usuários de Anti-Hipertensivos em Monoterapia: Resultados do Estudo ELSA-Brasil / Racial Differences in Blood Pressure Control from Users of Antihypertensive Monotherapy: Results from the ELSA-Brasil Study

Resumo Fundamento Aparentemente, a pior resposta a algumas classes de anti-hipertensivos, especialmente inibidores da enzima conversora da angiotensina e bloqueadores de receptor de angiotensina, pela população negra, explicaria, pelo menos parcialmente, o pior controle da hipertensão entre esses indivíduos. Entretanto, a maioria das evidências vêm de estudos norte-americanos. Objetivos Este estudo tem o objetivo de investigar a associação entre raça/cor da pele autorrelatadas e controle de PA em participantes do Estudo Longitudinal de Saúde do Adulto (ELSA-Brasil) utilizando várias classes de anti-hipertensivos em monoterapia. Métodos O estudo envolveu uma análise transversal, realizada com participantes da linha de base do ELSA-Brasil. O controle de pressão arterial foi a variável de resposta, participantes com valores de PA ≥140/90 mmHg foram considerados descontrolados em relação aos níveis de pressão arterial. A raça/cor da pele foi autorrelatada (branco, pardo, negro). Todos os participantes tiveram que responder perguntas sobre uso contínuo de medicamentos. A associação entre o controle de PA e raça/cor da pele foi estimada por regressão logística. O nível de significância adotado nesse estudo foi de 5%. Resultados Do total de 1.795 usuários de anti-hipertensivos em monoterapia na linha de base, 55,5% se declararam brancos, 27,9%, pardos e 16,7%, negros. Mesmo depois de padronizar em relação a variáveis de confusão, negros em uso de inibidores da enzima conversora de angiotensina (IECA), bloqueadores de receptor de angiotensina (BRA), diuréticos tiazídicos (DIU tiazídicos) e betabloqueadores (BB) in monoterapia tinham controle de pressão arterial pior em comparação a brancos. Conclusões Os resultados deste estudo sugerem que, nesta amostra de brasileiros adultos utilizando anti-hipertensivos em monoterapia, as diferenças de controle de pressão arterial entre os vários grupos raciais não são explicadas pela possível eficácia mais baixa dos IECA e BRA em indivíduos negros.

Abstract Background It seems that the worst response to some classes of antihypertensive drugs, especially angiotensin-converting enzyme inhibitors and angiotensin receptor blockers, on the part of the Black population, would at least partially explain the worse control of hypertension among these individuals. However, most of the evidence comes from American studies. Objectives This study aims to investigate the association between self-reported race/skin color and BP control in participants of the Longitudinal Study of Adult Health (ELSA-Brasil), using different classes of antihypertensive drugs in monotherapy. Methods The study involved a cross-sectional analysis, carried out with participants from the baseline of ELSA-Brasil. Blood pressure control was the response variable, participants with BP values ≥140/90 mmHg were considered out of control in relation to blood pressure levels. Race/skin color was self-reported (White, Brown, Black). All participants were asked about the continuous use of medication. Association between BP control and race/skin color was estimated through logistic regression. The level of significance adopted in this study was of 5%. Results Of the total of 1,795 users of antihypertensive drugs in monotherapy at baseline, 55.5% declared themselves White, 27.9% Brown, and 16.7% Black. Even after adjusting for confounding variables, Blacks using angiotensin converting enzyme inhibitors (ACEI), angiotensin receptor blocker (ARB), thiazide diuretics (thiazide DIU), and beta-blockers (BB) in monotherapy had worse blood pressure control compared to Whites. Conclusions Our results suggest that in this sample of Brazilian adults using antihypertensive drugs in monotherapy, the differences in blood pressure control between different racial groups are not explained by the possible lower effectiveness of ACEIs and ARBs in Black individuals.

Hipertensión arterial esencial: ¿cuál agente antihipertensivo elegir? / Essential hypertension: which antihypertensive agent to choose?

Resumen Introducción: La hipertensión arterial sistémica (HTA) constituye el principal factor de riesgo para morbilidad y mortalidad cardiovascular a nivel global, afecta a todas las edades, sin distinción de género y etnicidad. Su tratamiento continúa constituyendo un reto, dada la persistencia del pobre control, especialmente en países como Colombia. Objetivo: Mostrar la evidencia disponible respecto al tratamiento actualizado de la HTA y la elección certera de los agentes antihipertensivos acorde con la individualidad de cada paciente. Asimismo, consolidar y comparar el efecto hipotensor de cada agente antihipertensivo más usado. Metodología: Se realizó una búsqueda avanzada con los términos DeCS y MeSH: hipertensión, agentes antihipertensivos, hipertensión esencial y terapia combinada, en los motores de búsqueda PubMed, Clinical Key, Lilacs, Scielo. Un total de 109 artículos se seleccionaron para elaborar en la presente revisión de la literatura. Conclusiones: La individualización del manejo de la HTA lleva al reconocimiento de los distintos fenotipos, la presencia de complicaciones, el examen físico, el género y la raza como puntos fundamentales para elegir el agente antihipertensivo más adecuado que permita alcanzar las metas de control y propenda por la reducción y prevención de las complicaciones derivadas de un control no óptimo.

Abstract Introduction: Systemic arterial hypertension (HT) constitutes the main risk factor for cardiovascular morbidity and mortality at a global level, affecting all ages regardless of gender and ethnicity. Its treatment continues to be a challenge, given the persistence of poor control, especially in countries like Colombia. Objective: To show the available evidence regarding the updated treatments of HT and the correct choice of antihypertensive agents according to the individual needs of each patient. Likewise, to consolidate and compare the hypotensive effect of the most used antihypertensive agents. Methodology: An advanced search was carried out with the terms DeCS and MeSH: Hypertension, antihypertensive agents, Essential Hypertension and Combination Therapy through the search engines PubMed, Clinical Key, Lilacs, Scielo. A total of 109 articles were selected to prepare the present literature review. Conclusions: An individualized hypertension treatment plan leads to the recognition of the different phenotypes, the presence of complications, the gender, and race, which are fundamental aspects to consider when choosing the appropriate antihypertensive agents. These findings allow for the achievement of the desired blood pressure target and leads to reduction and prevention of complications derived from suboptimal control.

Os fatores sociodemográficos interferem na adesão aos anti-hipertensivos na atenção primária? Revisão integrativa / Do sociodemographic factors interfere with adherence to antihypertensive drugs in primary care? Integrative review

Este estudo teve por objetivo reunir evidências científicas sobre o papel dos fatores sociodemográficos na adesão aos anti-hipertensivos na Atenção Primária à Saúde (APS) no Brasil. Trata-se de uma revisão integrativa com estudos publicados entre 2015 e 2019 em periódicos nacionais. Foram incluídos artigos originais desenvolvidos com hipertensos usuários da APS no Brasil e foram excluídos artigos publicados fora do intervalo temporal citado, bem como revisões de literatura, e os que não tinham como foco os elementos de interesse nesta revisão. Foram selecionados 5 estudos que investigaram variáveis sociodemográficas no contexto da adesão a esta classe de medicamentos na APS. Embora alguns estudos tenham encontrado uma possível interferência de algumas variáveis sociodemográficas na adesão aos anti-hipertensivos na Atenção Básica, há, para cada uma dessas variáveis, resultados divergentes, mostrando que a dimensão sociodemográfica pode ou não interferir na adesão à medicação em um determinado grupo populacional. Nesse sentido, há também resultados sugestivos de que, com oferta efetiva de assistência aos usuários, tais variáveis parecem perderem capacidade de interferirem nesta adesão, em consonância com a hipótese de que características organizacionais dos serviços de saúde têm impacto muito maior na adesão do que diferenças sociodemográficas.

This study aimed to gather scientific evidence on the role of sociodemographic factors in adherence to antihypertensive drugs in Primary Health Care (PHC)_in Brazil. This is an integrative review with studies published between 2015 and 2019 in national journals. Original studies developed with hypertensive PHC users in Brazil were included and articles published outside the time range were excluded, as well as literature reviews, and those that did not focus on the elements of interest of this review. A total of 5 studies that investigated sociodemographic variables in the context of adherence to this class of drugs in PHC were selected. Although some studies have found a possible interference of some sociodemographic variables in adherence to antihypertensive drugs in Primary Care, there are, for each of these variables, divergent results, showing that the sociodemographic dimension may or may not interfere with medication adherence in a given population group. In this sense, there are also results suggesting that, with effective provision of assistance to users, such variables seem to lose their interference capacity in user adherence, in line with the hypothesis that organizational characteristics of health services have a much greater impact on adherence than sociodemographic differences.

Developing population-based hypertension control programs / Creación de programas de control de la hipertensión basados en la población / Desenvolvimento de programas de controle da hipertensão de base populacional

ABSTRACT Hypertension remains the leading cause of cardiovascular disease globally despite the availability of safe and effective treatments. Unfortunately, many barriers exist to controlling hypertension, including a lack of effective screening and awareness, an inability to access treatment and challenges with its management when it is treated. Addressing these barriers is complex and requires engaging in a systematic and sustained approach across communities over time. This analysis aims to describe the key elements needed to create an effective delivery system for hypertension control. A successful system requires political will and supportive leadership at all levels of an organization, including at the point of care delivery (office or clinic), in the health care system, and at regional, state and national levels. Effective screening and outreach systems are necessary to identify individuals not previously diagnosed with hypertension, and a system for follow up and tracking is needed after people are diagnosed. Implementing simple protocols for treating hypertension can reduce confusion among providers and increase treatment efficiency. Ensuring easy access to safe, effective and affordable medications can increase blood pressure control and potentially decrease health care system costs. Task-sharing among members of the health care team can expand the services that are delivered. Finally, monitoring of and reporting on the performance of the health care team are needed to learn from those who are doing well, disseminate ideas to those in need of improvement and identify individual patients who need outreach or additional care. Successful large-scale hypertension programs in different settings share many of these key elements and serve as examples to improve systems of hypertension care delivery throughout the world.

RESUMEN A pesar de la disponibilidad de tratamientos seguros y efectivos, la hipertensión sigue siendo la principal causa de enfermedad cardiovascular a nivel mundial. Lamentablemente, el control de la hipertensión enfrenta muchos obstáculos, como la falta de detección y concientización efectivas, la incapacidad de acceder al tratamiento y los retos que plantea su manejo cuando se recibe tratamiento. Resulta complejo abordar estos obstáculos; se debe adoptar un enfoque sistemático y sostenido en todas las comunidades a lo largo del tiempo. El presente análisis tiene como objetivo describir los elementos clave necesarios para crear un sistema de atención eficaz para el control de la hipertensión. Un sistema adecuado precisa voluntad política y un liderazgo que brinde apoyo en todos los niveles de una organización, incluido el punto donde se presta la atención (consultorio o clínica), el sistema de atención de salud y a nivel regional, estatal y nacional. Se necesitan sistemas efectivos de detección y de alcance comunitario para encontrar a las personas sin diagnóstico previo de hipertensión, así como un sistema para el seguimiento y la localización una vez han sido diagnosticadas. La aplicación de protocolos simples para tratar la hipertensión puede reducir la confusión entre los proveedores y aumentar la eficiencia del tratamiento. Garantizar un acceso fácil a medicamentos seguros, efectivos y asequibles puede aumentar el control de la presión arterial y potencialmente disminuir los costos para el sistema de atención de salud. La distribución de tareas entre los miembros del equipo de atención de salud permite expandir los servicios que se prestan. Finalmente, es necesario dar seguimiento al desempeño del equipo de atención de salud y presentar información al respecto, a fin de aprender de las buenas prácticas, difundir ideas entre quienes necesitan mejorar y determinar a cuáles pacientes se debe llegar y cuáles necesitan atención adicional. Los programas de hipertensión a gran escala con buenos resultados en diferentes entornos comparten muchos de estos elementos clave y sirven como ejemplos para mejorar la atención de la hipertensión en todo el mundo.

RESUMO A hipertensão continua sendo a principal causa de doenças cardiovasculares no mundo, apesar da disponibilidade de tratamentos seguros e eficazes. Infelizmente, existem muitas barreiras para o controle da hipertensão, incluindo a falta de rastreamento e a conscientização eficazes, a incapacidade de acesso ao tratamento e desafios de conduta clínica quando ela é tratada. A abordagem dessas barreiras é complexa e requer um enfoque sistemático e sustentado em diferentes comunidades ao longo do tempo. Esta análise tem como objetivo descrever os elementos-chave necessários para criar um sistema eficaz de prestação de intervenções para o controle da hipertensão. Um sistema de sucesso requer vontade política e liderança que o apoie em todos os níveis de uma organização, inclusive no ponto da prestação de cuidados (consultório ou clínica), no sistema de saúde e nos níveis regional, estadual e nacional. Sistemas eficazes de triagem e acolhida são necessários para identificar indivíduos com hipertensão não diagnosticada, e um sistema de acompanhamento e rastreamento após o diagnóstico se faz igualmente necessário. A implementação de protocolos simples para o tratamento da hipertensão pode reduzir a confusão entre os profissionais de saúde e aumentar a eficiência do tratamento. Garantir o fácil acesso a medicamentos seguros, eficazes e acessíveis pode aumentar o controle da pressão arterial e potencialmente diminuir os custos do sistema de saúde. A divisão de tarefas entre os integrantes da equipe de saúde pode expandir os serviços prestados. Finalmente, é necessário monitorar e informar acerca do desempenho da equipe de saúde para aprender com aqueles que estão indo bem, disseminar ideias para aqueles que precisam melhorar e identificar pacientes individuais que precisam de ajuda ou cuidados adicionais. Programas bem-sucedidos de controle da hipertensão em larga escala em diferentes ambientes compartilham muitos desses elementos-chave e servem como exemplos para melhorar os sistemas de atenção à hipertensão em todo o mundo.

Avanzando para mejorar el acceso a los medicamentos y tecnologías sanitarias para las enfermedades cardiovasculares / Moving toward improved access to medicines and health technologies for cardiovascular disease / Avançando para melhorar o acesso a medicamentos e tecnologias de saúde para as doenças cardiovasculares

RESUMEN Los objetivos del presente artículo son describir las intervenciones realizadas por el Fondo Estratégico de Organización Panamericana de la Salud, para facilitar el acceso y disponibilidad de medicamentos antihipertensivos y dispositivos para la medición de la presión arterial a los países de la Región de las Américas en apoyo a la implementación de la Iniciativa HEARTS; y presentar los resultados preliminares de los análisis de los precios de los medicamentos antihipertensivos. La metodología del estudio incluyó la revisión de informes realizados por el Fondo Estratégico durante los años 2019-2020, la evaluación de las modalidades de adquisición y revisión de las bases de datos de compras públicas para 5 medicamentos antihipertensivos, y el análisis comparativo con el precio obtenido por el Fondo Estratégico. Se identificaron diferencias que oscilaron entre 20% y 99%, lo que evidencia oportunidades de ahorro significativas. Asimismo, se presentan las acciones interprogramáticas desarrolladas en apoyo a la Iniciativa HEARTS, entre las que se destacan la inclusión de medicamentos antihipertensivos recomendados por la Organización Mundial de la Salud; la consolidación de la demanda regional y el establecimiento de precios competitivos con acuerdos a largo plazo para gestionar la adquisición de productos genéricos de calidad; y la definición de especificaciones técnicas y requisitos regulatorios para apoyar con la adquisición de dispositivos para la medición de la presión arterial. A través de este mecanismo, los Estados Miembros pueden disminuir sus costos significativamente, extendiendo cobertura del tratamiento y diagnóstico a más personas.

ABSTRACT The objectives of this article are to describe the interventions carried out by the Strategic Fund of the Pan American Health Organization to facilitate access to and availability of antihypertensive drugs and devices for measuring blood pressure in the countries of the Region of the Americas, supporting implementation of the HEARTS initiative; and to present the preliminary results of price analyses of antihypertensive drugs. The study methodology included a review of reports made by the Strategic Fund during 2019-2020, evaluation of modalities of procurement, a review of the public procurement databases for five antihypertensive drugs, and a comparison with the price obtained by the Strategic Fund. Differences ranging from 20% to 99% were identified, indicating significant opportunities for savings. Interprogrammatic actions in support of the HEARTS initiative are also presented, such as the inclusion of antihypertensive drugs recommended by the World Health Organization; consolidation of regional demand and establishment of competitive prices with long-term agreements to manage the procurement of quality generic products; and the definition of technical specifications and regulatory requirements to support the procurement of devices to measure blood pressure. Through this mechanism, Member States can reduce their costs significantly, enabling them to extend treatment and diagnostic coverage to more people.

RESUMO Os objetivos deste artigo são descrever as intervenções realizadas pelo Fundo Estratégico da Organização Pan-Americana da Saúde para facilitar o acesso e a disponibilidade de medicamentos anti-hipertensivos e aparelhos de medição de pressão arterial aos países da Região das Américas, em apoio à implementação da iniciativa HEARTS; e apresentar os resultados preliminares da análise dos preços dos medicamentos anti-hipertensivos. A metodologia do estudo incluiu a revisão de relatórios feitos pelo Fundo Estratégico durante os anos de 2019 e 2020, a avaliação das modalidades de aquisição e revisão dos dados de compras públicas de 5 medicamentos anti-hipertensivos e uma análise comparativa com o preço obtido pelo Fundo Estratégico. Foram identificadas diferenças que oscilaram entre 20% e 99%, o que evidencia oportunidades de economia significativas. Da mesma forma, são apresentadas as ações interprogramáticas desenvolvidas em apoio à iniciativa HEARTS, entre as quais se destacam a inclusão de medicamentos anti-hipertensivos recomendados pela Organização Mundial da Saúde; a consolidação da demanda regional e o estabelecimento de preços competitivos com acordos de longo prazo para gerenciar a aquisição de genéricos de qualidade; e a definição de especificações técnicas e requisitos regulatórios para subsidiar a aquisição de aparelhos de medição de pressão arterial. Por meio desse mecanismo, os Estados Membros podem reduzir seus custos significativamente, ampliando a cobertura de tratamento e diagnóstico para atingir mais pessoas.

O Efeito Anti-Hipertensivo de Sauromatum Guttatum Mediado por Efeitos Vasorrelaxante e Depressivos Miocárdicos / Antihypertensive Activity of Sauromatum guttatum Mediated by Vasorelaxation and Myocardial Depressant Effects

Resumo Fundamento: A Sauromatum guttatum (S. guttatum) é utilizado no tratamento de doenças do sangue e supostamente tem atividade espasmolítica através da inibição dos canais de Ca2+. Objetivos: O objetivo deste estudo foi investigar o potencial anti-hipertensivo de S. guttatum em modelo de rato Sprague-Dawley (SD) com hipertensão induzida por dieta com alto teor de sal (HIDATS). Métodos: Ratos SD foram divididos em normotensos, hipertensos e grupos tratados com verapamil e S. guttatum. Extrato bruto de S. guttatum (Sg.B) (100, 150 e 300 mg/kg/dia) e verapamil (5, 10 e 15 mg/kg/dia) foram administrados por via oral junto com NaCl. Anéis aórticos e faixas do átrio direito de ratos normotensos foram utilizados para investigar os mecanismos subjacentes. O nível de significância estatística adotado foi de 5%. Resultados: A pressão arterial média diminuiu nos grupos hipertensos tratados com Sg.B e verapamil de forma dose-dependente (p <0,001). No estudo de reatividade vascular, a acetilcolina induziu relaxamentos com valor CE50 de 0,6 µg/mL (0,3-1,0) em ratos hipertensos tratados com Sg.B (300 mg/kg), sugerindo preservação endotelial. Em aorta isolada de rato normotenso, o Sg.B exibiu vasorrelaxamento com valor de CE50 de 0,15 mg/mL (0,10-0,20), após ablação por desnudamento endotelial ou pré-tratamento com L-NAME e atropina. O tratamento com Sg.B causou relaxamento contra contrações induzidas por K+ alto, como o verapamil. O Sg.B mostrou efeitos inotrópicos (82%) e cronotrópicos (56%) negativos em preparações isoladas atriais de ratos reduzidas com atropina. A avaliação fitoquímica indicou a presença de alcaloides, flavonoides e taninos. Conclusão: O S. guttatum possui efeito vasodilatador através da preservação da função endotelial, liberação de NO mediada pelo receptor muscarínico e inibição do movimento de Ca2+, enquanto o efeito depressor do miocárdio atrial pode estar ligado ao receptor muscarínico. Esses achados fornecem a base farmacológica para o uso do extrato de S. guttatum como um medicamento anti-hipertensivo.

Abstract Background: Sauromatum guttatum (S. guttatum) is used in the treatment of blood disorders and reportedly has a spasmolytic activity through Ca2+ channel inhibition. Objectives: The aim of this study was to investigate the antihypertensive potential of S. guttatum in high salt-induced hypertensive Sprague-Dawley (SD) rat model (HSHRs). Methods: SD rats were divided into normotensive, hypertensive, S. guttatum and verapamil treated groups. S. guttatum crude extract (Sg.Cr) (100, 150 and 300 mg/kg/day) and verapamil (5, 10 and 15 mg/kg/day) were administered orally along with NaCl. Aortic rings and right atrial strips from normotensive rats were used to investigate the underlying mechanisms. The level of statistical significance was set at 5%. Results: Mean arterial pressure decreased in the Sg.Cr and verapamil-treated hypertensive groups in a dose-dependent manner (p < 0.001). In the vascular reactivity study, acetylcholine induced relaxations with an EC50 value of 0.6 µg/mL (0.3-1.0) in Sg.Cr-treated hypertensive rats (300 mg/kg), suggesting endothelial preservation. In isolated normotensive rat aorta, Sg.Cr-treated rats showed vasorelaxation with an EC50 value of 0.15 mg/mL (0.10-0.20), ablated by endothelial denudation or pretreatment with L-NAME and atropine. Sg.Cr treatment caused relaxation against high K+-induced contractions, like verapamil. Sg.Cr showed negative inotropic (82%) and chronotropic effects (56%) in isolated rat atrial preparations reduced with atropine. The phytochemical investigation indicated presence of alkaloids, flavonoids and tannins. Conclusion: S. guttatum has a vasodilatory effect through endothelial function preservation, muscarinic receptor-mediated NO release and Ca2+ movement inhibition, while atrial myocardial depressant effect can be linked to the muscarinic receptor. These findings provide pharmacological base for using S. guttatum extract as an antihypertensive medication.