Retinopatia hipertensiva - relação com o tempo de diagnóstico da hipertensão arterial sistêmica / Hypertensive retinopathy - relation with time of diagnosis of hypertension / Retinopatía hipertensiva - relación con el tiempo de diagnóstico de hipertensión arterial sistémica

Introdução: Hipertensão arterial sistêmica é uma condição em que a pressão do sangue contra as paredes das artérias é muito elevada. O olho, diretamente envolvido no aumento da resistência vascular periférica, é orgão-alvo quando a retinopatia hipertensiva se faz presente. O controle da hipertensão arterial sistêmica desempenha papel fundamental na evolução da retinopatia hipertensiva, considerando o tempo de duração e a idade dos pacientes. Fundoscopia é o exame mais importante para visualizar esses pequenos vasos, sendo possível detectar alterações e classificar a hipertensão arterial sistêmica para uma melhor conduta terapêutica. As alterações vasculares retinianas visualizadas no fundo do olho são classificadas na hipertensão arterial sistêmica em arterioescleróticas e hipertensivas. Objetivo: Identificar os principais fatores relacionados à retinopatia hipertensiva e a relação com o tempo de diagnóstico de hipertensão arterial sistêmica. Método: Estudo transversal, observacional e descritivo. Fundoscopia e Retinografia foram realizados em pacientes do ambulatório de oftalmologia de um hospital-escola no interior paulista, com diagnóstico de hipertensão arterial sistêmica, para avaliar o grau de comprometimento vascular retiniano. Resultados: Foram examinados 236 olhos de 118 pacientes, a maioria do sexo feminino (58,5%), com idade média de 61 anos. Questionados sobre o controle da sua hipertensão arterial sistêmica, as respostas obtidas foram: 48 pacientes (40,7%) souberam responder que sua pressão era controlada com medicação; 60 (50,9%) afirmaram descontrole da pressão sistêmica e 10 (8,4%) não souberam responder. Dos 103 pacientes (88%) que apresentaram alterações na Fundoscopia, 70% apresentaram alterações relacionadas a arteriosclerose e 76 (64%) relacionados à retinopatia hipertensiva. Dos pacientes com arteriosclerose, 74,7% apresentaram alteração no cruzamento arteriovenoso, enquanto os pacientes com retinopatia hipertensiva 51,3% apresentaram vasoconstrição arteriolar espástica. A abordagem terapêutica da HAS é baseada na tentativa de controle dos valores pressóricos e a adesão ao tratamento é um fator fundamental para o manejo de condições e a prevenção de complicações decorrentes delas. Conclusão: Os fatores diagnósticos relacionados à retinopatia hipertensiva foram: o tempo diagnóstico, as alterações vasculares de arterioloesclerose e o descontrole pressórico. As alterações na retinografia servem para auxiliar na gravidade de hipertensão arterial sistêmica bem como alertar e estimular à ter um melhor controle de PA. O envolvimento de toda a equipe de saúde também é necessário para uma visão multidisciplinar do problema, já que a adesão ao tratamento é importante no controle da hipertensão arterial sistêmica

Introduction: Systemic arterial hypertension is a condition in which blood pressure against the walls of the arteries is very high. The eye, directly involved in increasing peripheral vascular resistance, is the target organ when hypertensive retinopathy is present. The control of systemic arterial hypertension plays a fundamental role in the evolution of hypertensive retinopathy, considering the duration and age of the patients. Fundoscopy is the most important exam to visualize these small vessels, making it possible to detect changes and classify systemic arterial hypertension for better therapeutic management. Retinal vascular changes seen in the fundus of the eye are classified in systemic arterial hypertension into arteriosclerotic and hypertensive. Objective: To identify the main factors related to hypertensive retinopathy and the relationship with the time of diagnosis of systemic arterial hypertension. Method: Cross-sectional, observational and descriptive study. Fundoscopy and retinography were performed on patients at the ophthalmology outpatient clinic of a teaching hospital in the interior of São Paulo, diagnosed with systemic arterial hypertension, to assess the degree of retinal vascular compromise. Results: 236 eyes of 118 patients were examined, the majority of them female (58.5%), with a mean age of 61 years. When asked about the control of their systemic arterial hypertension, the answers obtained were: 48 patients (40.7%) were able to answer that their pressure was controlled with medication; 60 (50.9%) stated that they had uncontrolled systemic pressure and 10 (8.4%) were unable to answer. Of the 103 patients (88%) who presented changes on Fundoscopy, 70% presented changes related to arteriosclerosis and 76 (64%) related to hypertensive retinopathy. Of the patients with arteriosclerosis, 74.7% presented changes in arteriovenous crossing, while 51.3% of patients with hypertensive retinopathy presented spastic arteriolar vasoconstriction. The therapeutic approach to SAH is based on trying to control blood pressure values and adherence to treatment is a fundamental factor in managing conditions and preventing complications resulting from them. Conclusion: The diagnostic factors related to hypertensive retinopathy were: time of diagnosis, vascular alterations of arteriolosclerosis and lack of blood pressure control. Changes in retinography serve to help with the severity of systemic arterial hypertension as well as alert and encourage better BP control. The involvement of the entire healthcare team is also necessary for a multidisciplinary view of the problem, as adherence to treatment is important in controlling systemic arterial hypertension

Introducción: La hipertensión arterial sistémica es una condición en la que la presión arterial contra las paredes de las arterias es muy alta. El ojo, directamente implicado en el aumento de la resistencia vascular periférica, es el órgano diana cuando hay retinopatía hipertensiva. El control de la hipertensión arterial sistémica juega un papel fundamental en la evolución de la retinopatía hipertensiva, considerando la duración y edad de los pacientes. La fundoscopia es el examen más importante para visualizar estos pequeños vasos, permitiendo detectar cambios y clasificar la hipertensión arterial sistémica para un mejor manejo terapéutico. Los cambios vasculares retinianos observados en el fondo del ojo se clasifican en la hipertensión arterial sistémica en arteriosclerótica e hipertensiva. Objetivo: Identificar los principales factores relacionados con la retinopatía hipertensiva y la relación con el momento del diagnóstico de la hipertensión arterial sistémica. Método: Estudio transversal, observacional y descriptivo. Se realizaron fundoscopia y retinografía a pacientes del ambulatorio de oftalmología de un hospital universitario del interior de São Paulo, diagnosticados con hipertensión arterial sistémica, para evaluar el grado de compromiso vascular retiniano. Resultados: Se examinaron 236 ojos de 118 pacientes, la mayoría del sexo femenino (58,5%), con una edad media de 61 años. Al preguntarles sobre el control de su hipertensión arterial sistémica, las respuestas obtenidas fueron: 48 pacientes (40,7%) pudieron responder que su presión estaba controlada con medicamentos; 60 (50,9%) afirmaron tener presión sistémica descontrolada y 10 (8,4%) no supieron responder. De los 103 pacientes (88%) que presentaron cambios en la fundoscopia, el 70% presentó cambios relacionados con arteriosclerosis y 76 (64%) relacionados con retinopatía hipertensiva. De los pacientes con arteriosclerosis, el 74,7% presentó cambios en el cruce arteriovenoso, mientras que el 51,3% de los pacientes con retinopatía hipertensiva presentaron vasoconstricción arteriolar espástica. El abordaje terapéutico de la HAS se basa en intentar controlar los valores de presión arterial y la adherencia al tratamiento es un factor fundamental para el manejo de las afecciones y la prevención de complicaciones derivadas de las mismas. Conclusión: Los factores diagnósticos relacionados con la retinopatía hipertensiva fueron: momento del diagnóstico, alteraciones vasculares de la arteriolosclerosis y falta de control de la presión arterial. Los cambios en la retinografía sirven para ayudar con la gravedad de la hipertensión arterial sistémica, así como para alertar y fomentar un mejor control de la PA. También es necesaria la implicación de todo el equipo sanitario para una visión multidisciplinar del problema, ya que la adherencia al tratamiento es importante en el control de la hipertensión arterial sistémica

Alteraciones retinianas detectadas por screening con cámara retinal no midriática y derivación a oftalmología en una población de alto riesgo cardiovascular / Retinal alterations detected by non-mydriatic retinal camera screening and referral to ophthalmology in a population with high cardiovascular risk

Objetivo Describir las principales alteraciones retinianas detectadas por screening con cámara retinal no midriática y evaluar los factores relacionados con la derivación a oftalmología en una población de alto riesgo cardiovascular en Palmira, Colombia. Materiales y métodos Estudio observacional de tipo transversal, con 11.983 registros fotográficos de pacientes con hipertensión y diabetes mellitus del programa de enfermedades crónicas de Gesencro S.A.S. entre 2018 y 2020. Se evaluaron con regresión logística los factores de riesgo relacionados con la derivación a oftalmología y se obtuvieron los odds ratios (OR) crudos y ajustados. Resultados Se analizaron 11.880 registros; la edad media fue de 67,7±12años, y el 69,5% fueron mujeres. Entre las alteraciones retinianas se encontraron pacientes con retinopatía diabética clasificada como más que leve (10%) y gradoI de retinopatía hipertensiva (54,9% ojo derecho, 51,9% ojo izquierdo). También se identificó edema macular (15%). Solo 2.069 (17,4%) pacientes requirieron derivación a oftalmología; el 81,3% requirieron control a 1año y el 1,3% a los 6meses. En el análisis multivariado los factores de riesgo que se relacionaron con la probabilidad para ser derivados fueron: el género masculino, la edad mayor o igual a 60años, la hemoglobina glucosilada (HbA1c) fuera de metas, la enfermedad renal crónica avanzada y la razón microalbúmina-creatinina moderada a severamente elevada. Conclusión Este estudio permitió determinar la importancia que tiene el screening con cámara retinal no midriática en pacientes de alto riesgo cardiovascular para detectar alteraciones retinianas y evaluar factores de riesgo asociados con derivación a oftalmología. El documentar tempranamente el compromiso ocular en estos pacientes podría prevenir y evitar la discapacidad visual y la ceguera (AU)

Objective To describe the main retinal alterations detected by non-mydriatic retinal camera screening and to evaluate factors related to referral to ophthalmology in a population at high cardiovascular risk in Palmira, Colombia. Materials and methods Cross-sectional observational study, which included 11,983 photographic imaging records of patients with hypertension and diabetes mellitus from Gesencro's S.A.S. comprehensive chronic disease care program between 2018 and 2020. Risk factors associated to referral to ophthalmology were evaluated with logistic regression, and crude and adjusted ORs (odds ratios) were obtained. Results A total of 11,880 records were analyzed; 67.7±12years old, and 69.5% were women. Among the retinal alterations were patients with diabetic retinopathy classified as more than mild in 10% and gradeI hypertensive retinopathy in 54.9% right eye, 51.9% left eye. Macular edema was also identified. Only 2069 patients (17.4%) required referral to ophthalmology, and for imaging control 82.6%. In the multivariate analysis, the risk factors associated with the probability of being referred were male gender, age 60years and older, glycosylated hemoglobin out-of-target, advanced chronic kidney disease and the microalbumin-to-creatinine ratio moderate to severely elevated. Conclusion This study makes it possible to determine the importance of screening with a non-mydriatic retinal camera in patients at high cardiovascular risk to detect retinal abnormalities and assess risk factors associated with referral to ophthalmology. Early documentation of ocular compromise in these patients could prevent and avoid visual impairment and blindness (AU)

El fondo de ojo, una ventana a la microvasculatura del paciente hipertenso / The fundus, a window to microvasculature in hypertensive patients

Introducción: La hipertensión arterial constituye una de las enfermedades más frecuentes en la población general. En la actualidad llega a una prevalencia global del 30 al 45 %. La microcirculación retiniana puede considerarse como una representación anatómica de las características fisiológicas y funcionales de la circulación coronaria y cerebral. Objetivos: Profundizar en la relación existente entre los niveles de presión arterial y el daño del órgano diana, específicamente a través del fondo de ojo, así como de las posibles complicaciones oftalmológicas derivadas de la hipertensión arterial, y la comparación de algunas de las clasificaciones existentes sobre los cambios oftalmológicos que esta provoca. Métodos: Se emplearon los métodos de análisis-síntesis y análisis bibliográfico y documental. Los motores de búsqueda utilizados fueron: Google y Google Académico, y las bases de datos Hinari, SciELO Cuba, Pubmed, entre otras. Conclusiones: La retinopatía hipertensiva es una de las complicaciones adversas de la hipertensión arterial aguda o crónica. Por su parte, las oclusiones venosas y la formación de macroaneurismas, constituyen otras de gran envergadura. Mientras más eficaz sea el diagnóstico y seguimiento de los pacientes hipertensos, menos recursos se necesitarán para su tratamiento, y se evitarán así las complicaciones de otros órganos diana como el cerebro y el riñón, lo que provocaría en los pacientes una mayor discapacidad.

Introduction: arterial hypertension is one the most frequent diseases in general population. Nowadays, it reaches a global prevalence of 30 to 45 %. Retinal microcirculation can be considered as an anatomical representation of the physiological and functional characteristics of the coronary and cerebral circulation. Objectives: to delve into the relationship between blood pressure levels and target organ damage, specifically through the fundus, as well as the possible ophthalmological complications derived from arterial hypertension, and the comparison of some of the existing classifications on the ophthalmological changes that it causes. Methods: analysis - synthesis and bibliographic- documentary analyses were the used methods. Google and Google Scholar as well as Hinari, SciELO Cuba, Pubmed and others databases were the search engines. Conclusions: hypertensive retinopathy is one of the adverse complications of acute or chronic arterial hypertension. On the other hand, venous occlusions and the formation of macroaneurysms constitute other serious ones to consider. The more effective the diagnosis and follow-up of hypertensive patients, the fewer resources will be needed for their treatment, thus avoiding complications in other target organs such as the brain and kidney, which would cause greater disability in patients.

[Retinal alterations detected by non-mydriatic retinal camera screening and referral to ophthalmology in a population with high cardiovascular risk]. / Alteraciones retinianas detectadas por screening con cámara retinal no midriática y derivación a oftalmología en una población de alto riesgo cardiovascular.

OBJECTIVE: To describe the main retinal alterations detected by non-mydriatic retinal camera screening and to evaluate factors related to referral to ophthalmology in a population at high cardiovascular risk in Palmira, Colombia. MATERIALS AND METHODS: Cross-sectional observational study, which included 11,983 photographic imaging records of patients with hypertension and diabetes mellitus from Gesencro's S.A.S. comprehensive chronic disease care program between 2018 and 2020. Risk factors associated to referral to ophthalmology were evaluated with logistic regression, and crude and adjusted ORs (odds ratios) were obtained. RESULTS: A total of 11,880 records were analyzed; 67.7±12years old, and 69.5% were women. Among the retinal alterations were patients with diabetic retinopathy classified as more than mild in 10% and gradeI hypertensive retinopathy in 54.9% right eye, 51.9% left eye. Macular edema was also identified. Only 2069 patients (17.4%) required referral to ophthalmology, and for imaging control 82.6%. In the multivariate analysis, the risk factors associated with the probability of being referred were male gender, age 60years and older, glycosylated hemoglobin out-of-target, advanced chronic kidney disease and the microalbumin-to-creatinine ratio moderate to severely elevated. CONCLUSION: This study makes it possible to determine the importance of screening with a non-mydriatic retinal camera in patients at high cardiovascular risk to detect retinal abnormalities and assess risk factors associated with referral to ophthalmology. Early documentation of ocular compromise in these patients could prevent and avoid visual impairment and blindness.

Severe bilateral visual loss as the first sign of IgA nephropathy / Perda visual bilateral grave como o primeiro sinal da nefropatia por IgA

ABSTRACT We describe a case of a 33-years-old woman who presents with severe acute bilateral visual loss secondary to massive exudative hypertensive maculopathy as the first sign of immunoglobulin A nephropathy. The patient's ophthalmic examination showed bilateral cotton-wool spots, flame-shaped retinal hemorrhages, diffuse narrow arterioles, optic disk edema, and exudative maculopathy. Systemic workup demonstrated a systolic and diastolic blood pressure of 240 mmHg and 160 mmHg, respectively, proteinuria, and hematuria, suggesting kidney disease as the causative condition. A kidney biopsy confirmed immunoglobulin A nephropathy. She was treated with systemic corticosteroids, antihypertensive drugs, and a single bilateral intravitreal injection of aflibercept. There was a prompt resolution of macular edema and vision improvement. Our case draws attention to the fact that severe bilateral visual loss can be the first sign of severe hypertension. Secondary causes, such as immunoglobulin A nephropathy, should be ruled out.

RESUMO Nosso objetivo é descrever uma paciente de 33 anos de idade, com perda visual bilateral grave por maculopatia hipertensiva exsudativa como o primeiro sinal da nefropatia por imunoglobulina A. A fundoscopia revelou a presença de manchas algodonosas, hemorragias em chama-de-vela, estreitamento arteriolar difuso, edema de disco óptico e maculopatia exsudativa bilateral. A pressão arterial sistólica foi de 240mmHg e a diastólica de 160 mmHg associado a proteinúria e hematúria, sugerindo a presença de doença renal. A biópsia renal confirmou a nefropatia por imunoglobulina A. A paciente foi tratada como corticoide sistêmico, drogas anti-hipertensivas e uma única dose intravítrea de Aflibercept em ambos os olhos. Houve rápida melhora do edema macular e da acuidade visual. Nosso caso chama a atenção para o fato de que a perda visual bilateral grave pode ser a primeira apresentação de uma doença hipertensiva sistêmica. Causas secundárias como a nefropatia por imunoglobulina A devem ser afastadas.

Impacto de la retinopatía hipertensiva asociada a cardiopatías coronarias

Introducción: La asociación entre la retinopatía hipertensiva y cardiopatías coronarias es un tema de una larga controversia. La retinopatía hipertensiva ha sido definida como un predictor de mortalidad y morbilidad en pacientes hipertensos desde hace mucho tiempo. Además, estudios recientes han demostrado que la microvasculatura retiniana refleja la patología en los pequeños vasos sistémicos, incluida la microcirculación coronaria. Objetivos: El objetivo fue realizar una revisión sistemática y un análisis cualitativo y cuantitativo mediante un metanálisis para determinar la asociación entre la retinopatía hipertensiva y cardiopatías coronarias. Métodos: Se realizó la búsqueda sistemática de estudios relacionados con el tema. La fuente de búsqueda fue PubMed y Google Scholar. La revisión sistemática y meta-análisis se desarrollaron con las pautas Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA). Resultados: Se demostró que existe una asociación entre la retinopatía hipertensiva y la enfermedad de la arteria coronaria. (P=0,01; RR 1,29; IC 95 %: 1,06 a 1,56), se evaluó la hipertrofia ventricular izquierda como desenlace, se encontró un efecto estadísticamente significativo que asocia a la retinopatía hipertensiva con la hipertrofia ventricular izquierda (p=0,03; RR: 1,71; IC 95 %: 1,31 a 2,24). Conclusiones: Se encontró asociación entre retinopatía hipertensiva y las cardiopatías coronarias más frecuentes (Enfermedad coronaria e HVI).

Introduction: The association between hypertensive retinopathy and coronary heart disease is a subject of long-standing controversy. Hypertensive retinopathy has long been defined as a predictor of mortality and morbidity in hypertensive patients. In addition, recent studies have shown that the retinal microvasculature reflects pathology in small systemic vessels, including the coronary microcirculation. Objectives: The aim was to perform a systematic review and a qualitative and quantitative analysis by meta-analysis to determine the association between hypertensive retinopathy and coronary heart disease. Methods: A systematic search for studies related to the topic was performed. The search source was PubMed and Google Scholar. The systematic review and meta-analysis were developed using the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines. Results: An association between hypertensive retinopathy and coronary artery disease was demonstrated (P=0.01; RR 1.29; 95 % CI: 1.06 to 1.56), left ventricular hypertrophy was evaluated as an outcome, a statistically significant effect was found associating hypertensive retinopathy with left ventricular hypertrophy (P=0.03; RR: 1.71; 95 % CI: 1.31 to 2.24). Conclusions: An association was found between hypertensive retinopathy and the most frequent coronary heart diseases (coronary artery disease and LVH).

Hallazgos de la ecografía Doppler arterial oftálmica en pacientes con hipertensión arterial primaria / Ophthalmic Arterial Doppler Ultrasound Findings in Patients with Primary Arterial Hypertension

Objetivo: Determinar los hallazgos por ecografía Doppler arterial oftálmica en pacientes con hipertensión arterial primaria. Métodos: Se efectuó un estudio observacional descriptivo y transversal con 202 órbitas de 101 pacientes hipertensos, a los que se les realizó fondo de ojo para diagnóstico y gradación de la retinopatía hipertensiva. Por interrogatorio y examen físico se identificaron como factores de riesgo aterosclerótico el consumo excesivo de alcohol y la obesidad. Además, se les hizo ultrasonido orbitario y Doppler carotídeo, y solo en caso de resultar normales, se procedió a evaluar mediante ecografía Doppler las arterias oftálmicas. Resultados: Predominaron los hipertensos entre 40 y 60 años de edad, el sexo masculino, el color mestizo de piel, los casos sin retinopatía hipertensiva, y el grupo entre 10 y 20 años de diagnosticada la hipertensión. Se demostró un incremento de la velocidad del flujo y de la resistencia vascular a nivel de las arterias oftálmicas. En tanto, se evidenció asociación significativa de estos parámetros hemodinámicos con el envejecimiento y el tiempo de diagnóstico de la hipertensión. Sin embargo, no se comprobó asociación significativa con el sexo, el color de la piel, y la presencia o ausencia de obesidad, consumo excesivo de alcohol, y retinopatía hipertensiva independientemente de su gravedad. Conclusiones: La evaluación de las arterias oftálmicas mediante ecografía Doppler permite hacer un estudio y seguimiento más integral de los pacientes con hipertensión arterial primaria(AU)

Objective: To determine ophthalmic arterial Doppler ultrasound findings in patients with primary arterial hypertension. Methods: A descriptive and cross-sectional observational study was carried out with 202 orbits of 101 hypertensive patients, who underwent fundus examination for diagnosis and grading of hypertensive retinopathy. By interrogation and physical examination, excessive alcohol consumption and obesity were identified as atherosclerotic risk factors. In addition, orbital ultrasound and carotid Doppler were performed, and only if they were normal, the ophthalmic arteries were evaluated using Doppler ultrasound. Results: Hypertensive patients between 40 and 60 years of age, male, mixed skin color, cases without hypertensive retinopathy, and the group between 10 and 20 years after hypertension diagnosis predominated. An increase in flow velocity and vascular resistance at the level of the ophthalmic arteries was demonstrated. Meanwhile, a significant association of these hemodynamic parameters with aging and time of diagnosis of hypertension was evidenced. However, no significant association was found with gender, skin color, and the presence or absence of obesity, excessive alcohol consumption, and hypertensive retinopathy regardless of its severity. Conclusions: Evaluation of the ophthalmic arteries using Doppler ultrasound allows a more comprehensive study and follow-up of patients with primary arterial hypertension(AU)

Complicaciones vasculares en pacientes hipertensos jóvenes de un hospital de Paraguay

RESUMEN Introducción: la hipertensión arterial es una enfermedad que se caracteriza por la elevación sostenida de la presión arterial. Su aparición a temprana edad se ha duplicado en los últimos años, por lo que se espera un incremento de las complicaciones vasculares relacionadas a ella, como la manifestación de accidente cerebrovascular isquémico o hemorrágico, infarto agudo de miocardio, nefropatía hipertensiva, preeclampsia, eclampsia. Los factores de riesgos asociados de gran influencia como el antecedente patológico familiar entre otros se encuentran relacionados a su aparición. Objetivo: determinar las características clínicas de pacientes hipertensos menores de 50 años en el Hospital Nacional, Itauguá, Paraguay, en el periodo 2020-2021. Metodología: estudio observacional, descriptivo, retrospectivo de corte transversal, analítico que incluyo 150 pacientes con hipertensión arterial, de ambos sexos, menores de 50 años. Resultados: la edad media de la muestra fue 39 años, con rango entre 15-50 años, la mayoría provenía del área urbana, con nivel educativo secundario. Hubo predominio del sexo femenino (52%), sin embargo, las complicaciones vasculares fueron más frecuentes en el sexo masculino. Las complicaciones vasculares se detectaron en 89%, predominando el accidente cerebrovascular (26%), la retinopatía hipertensiva (24%) y la nefropatía de origen hipertensivo (22,6%). La mayoría de los pacientes presentaba factores de riesgo cardiovascular asociados, los principales fueron el sedentarismo y la diabetes mellitus tipo 2, así como el antecedente patológico familiar de hipertensión arterial. Conclusión: las principales complicaciones fueron el accidente cerebro vascular (26%), la retinopatía hipertensiva (24%) y la nefropatía de origen hipertensivo (22,6%). Se recomienda la detección precoz y el tratamiento oportuno de los hipertensos jóvenes.

ABSTRACT Introduction: Hypertension is a disease characterized by sustained elevation of blood pressure. Its appearance at an early age has doubled in recent years, therefore an increase in vascular complications related to it is expected, such as the manifestation of ischemic or hemorrhagic stroke, acute myocardial infarction, hypertensive nephropathy, preeclampsia, eclampsia. Associated risk factors of great influence, such as family pathological history, among others, are related to its appearance. Objective: To determine the clinical characteristics of hypertensive patients under 50 years of age at the Hospital Nacional of Itauguá, Paraguay, in the period 2020-2021. Methodology: Observational, descriptive, retrospective, cross-sectional, analytical study that included 150 male and female patients with arterial hypertension under 50 years of age. Results: The average age of the sample was 39 years, with a range between 15-50 years, the majority came from the urban area, and had secondary education level. There was a predominance of women (52%), however, vascular complications were more frequent in men. Vascular complications were detected in 89%, predominantly stroke (26%), hypertensive retinopathy (24%) and hypertensive nephropathy (22.6%). Most of the patients had associated cardiovascular risk factors, the main ones being sedentary lifestyle and type 2 diabetes mellitus, as well as a family pathological history of high blood pressure. Conclusion: The main complications were cerebrovascular accident (26%), hypertensive retinopathy (24%) and hypertensive nephropathy (22.6%). Early detection and timely treatment of young hypertensive patients is recommended.

Retinopatia hipertensiva maligna secundária a lúpus eritematoso sistêmico em adolescente / Malignant hypertensive retinopathy secondary to systemic lupus erythematous in adolescent

RESUMO O lúpus eritematoso sistêmico é uma doença que pode apresentar comprometimento oftalmológico geralmente benigno, sendo as alterações mais encontradas a síndrome do olho seco e a catarata. Nos pacientes com a doença estável, o dano oftalmológico parece estar relacionado ao tratamento sistêmico a longo prazo, o que enfatiza a importância do exame oftalmológico completo de rotina. Porém, quando a doença está em franca atividade e, em especial, quando há o envolvimento renal, deve-se iniciar o tratamento precoce com corticoterapia sistêmica e com medidas de suporte, para se evitarem repercussões mais complexas, como as crises hipertensivas que podem levar ao óbito.

ABSTRACT Systemic lupus erythematosus may present ophthalmological involvement, usually benign, and the most common changes are dry eye syndrome and cataract. In patients with stable disease, ophthalmologic damage appears to be related to long-term systemic treatment, emphasizing the importance of routine complete ophthalmologic examination. However, in full-blown disease, especially when there is renal involvement, early treatment should start with systemic steroid therapy and supportive measures, to avoid major repercussions, such as hypertensive crises that may lead to death.

[Reliability of retinography for the detection of hypertensive retinopathy in Primary Care]. / Fiabilidad de la retinografía para la detección de retinopatía hipertensiva en Atención Primaria.

OBJECTIVE: High blood pressure is one of the most prevalent diseases in general adult population. Its importance lies in the complications it causes in target organs such as kidney, heart, brain and eye. The aim of this work is to evaluate the agreement in the evaluation and interpretation of retinographies of hypertensive patients by family doctors and ophthalmologists. MATERIAL AND METHODS: This is a multicentric cross-sectional study in which 976 hypertensive patients from 50 to 70 years old were involved. They were participants of the «Investigating Silent Strokes in Hypertensives: a Magnetic Resonance Imaging Study¼ (ISSYS project) carried out in primary care centers of Barcelona and who agreed to undergo retinography. Six family physicians and 2 ophthalmologists evaluated the presence of retinal lesions through the Keith-Wagener-Barker criteria. RESULTS: The inter/intra-observer Kappa concordance of the evaluations was analyzed. The evaluation of the retinographies under the usual conditions of clinical practice obtained a high subjective component with slight and fair intra-observer concordance values in the Keith-Wagener-Barker criteria. Only the assessment of the microaneurysms showed a moderate concordance and the ratio artery/vein was the worst concordant. CONCLUSIONS: The evaluation of the retinographies in habitual conditions of clinical practice has a high subjective component that is reflected in slight and fair inter-intraobserver concordance values. The use of objective reading systems in the assessment of retinography in hypertensive patients would be useful.

Endothelial lesion and complement activation in patients with Scleroderma Renal Crisis / Lesão endotelial e ativação do complemento em pacientes com crise renal esclerodérmica

Abstract In kidney biopsies reviews, scleroderma renal crisis (SRC) is characterized by vascular endothelial injuries, C4d deposits on peritubular vessels, and acute and chronic injuries coexisting on the same biopsy. The clinical signs of thrombotic microangiopathy (TMA) are described in systemic sclerosis (SSc), nevertheless, it has not been related to acute injuries described on kidney biopsies. We report a case of SRC in a patient with scleroderma-dermatomyositis overlap syndrome, which also showed clinical and histopathological data of TMA. On fundus examination, a severe acute hypertensive retinopathy was found. The kidney biopsy showed severe endothelial damage with widening of mucoid cells at the level of the intima, focal concentric proliferation on most small arterioles, and C3, C4d, and IgM deposits along the capillary walls. The genetic study of complement only showed the presence of membrane cofactor protein (MCP) risk haplotypes, without other genetic complement disorders. We understand that in a patient with TMA and SSc, the kidney damage would be fundamentally endothelial and of an acute type; moreover, we would observe clear evidence of complement activation. Once further studies correlate clinical-analytical data with anatomopathological studies, it is likely that we will be forced to redefine the SRC concept, focusing on the relationship between acute endothelial damage and complement activation.

Resumo Nas revisões de biópsias renais, a crise renal esclerodérmica (CRE) é caracterizada por lesões endoteliais vasculares, depósitos de C4d em vasos peritubulares e lesões agudas e crônicas que coexistem na mesma biópsia. Os sinais clínicos de microangiopatia trombótica (MAT) são descritos na esclerose sistêmica (ES); no entanto, não foram relacionados às lesões agudas descritas nas biópsias renais. Relatamos um caso de CRE em um paciente com síndrome de superposição de esclerodermia-dermatomiosite, que também apresentou dados clínicos e histopatológicos de MAT. No exame de fundo do olho, foi encontrada uma retinopatia hipertensiva aguda grave. A biópsia renal mostrou lesão endotelial grave com alargamento das células mucoides ao nível da íntima, proliferação concêntrica focal na maioria das pequenas arteríolas e depósitos de C3, C4d e IgM ao longo das paredes dos capilares. O estudo genético do complemento mostrou apenas a presença de haplótipos de risco da proteína cofator de membrana (PCM), sem outros distúrbios genéticos do complemento. Entendemos que em um paciente com MAT e ES, o dano renal seria fundamentalmente endotelial e do tipo agudo; além disso, observaríamos evidências claras de ativação do complemento. Uma vez que novos estudos correlacionam dados clínico-analíticos com estudos anatomopatológicos, é provável que sejamos forçados a redefinir o conceito de CRE, enfocando a relação entre dano endotelial agudo e ativação do complemento.

Hypertensive choroidopathy, retinopathy and optic neuropathy in renal transplantation failure. / Coroidopatía, retinopatía y neuropatía óptica hipertensiva en un paciente con fracaso de trasplante renal.

A 32 year-old man who presented with severe elevation of blood pressure after failure of kidney transplant. The patient had multiple serous retinal detachments, venous dilation, arteriolar narrowing, retinal haemorrhages, as well as optic disc oedema. Due to the impossibility of performing a fluorescein angiography, an angiotomography and en-face optical coherence tomography images were used to identify the vascular alterations in the retina, choroid, and choriocapillaris. Angiotomography and en face-optical coherence tomography mode images are very useful in cases where it is not possible to perform fluorescein angiography.

Optical coherence tomography angiography findings in malignant hypertensive retinopathy / Achados da angiografia por tomografia de coerência óptica na retinopatia hipertensiva maligna

ABSTRACT A 33-year-old male presented to our clinic with low vision in both eyes that started during the previous week. Visual acuity was 20/63 in the right eye and 20/50 in the left eye. Fundus examination revealed signs of hypertensive retinopathy; thus, a multidisciplinary approach was adopted for the diagnosis and treatment of this patient. We consulted the nephrology and cardiology departments on this case. Upon diagnosing malignant hypertension and renal failure, the patient was put on hemodialysis. His visual acuity was 20/20 at 6 months, whereas foveal assessment on optical coherence tomography angiography revealed neither marked superficial and deep capillary density loss and foveal avascular zone enlargement nor a decrease in disc flow and radial peripapillary capillary density. Early diagnosis and treatment of malignant hypertension are critical in preventing progression of end-organ damage including the eyes. Optical coherence tomography angiography may be useful in cases when fundus fluorescein angiography is relatively contraindicated (e.g., renal failure).

RESUMO Um homem de 33 anos apresentou-se à nossa clínica com baixa visão em ambos os olhos que começou uma semana antes. A acuidade visual foi de 20/63 no olho direito e 20/50 no olho esquerdo. O exame de fundo de olho revelou sinais de retinopatia hipertensiva; então, adotou-se uma abordagem multidisciplinar para o diagnóstico e tratamento desse paciente. Consultamos os departamentos de nefrologia e cardiologia neste caso. Ao diagnosticar hipertensão maligna e insuficiência renal, o paciente foi colocado em hemodiálise. Sua acuidade visual era 20/20 aos 6 meses, enquanto a avaliação foveal com angiotomografia de coerência óptica não revelou perda de densidade capilar superficial e profunda acentuada e aumento da zona avascular foveal nem uma diminuição no fluxo de disco e na densidade capilar peripapilar radial. O diagnóstico precoce e o tratamento da hipertensão maligna são fundamentais na preveção da progressão de danos nos órgãos-alvo, incluindo os olhos. A Angiografia por tomografia de coerência óptica pode ser útil nos casos em que a angiografia com fluoresceína do fundo de olho é relativamente contraindicada (por exemplo, insuficiência renal).

Relationship between nocturnal blood pressure profiles and the presence and severity of hypertensive retinopathy. / Relação entre o perfil tensional noturno e a prevalência e gravidade da retinopatia hipertensiva.

INTRODUCTION: Non-dipper and extreme dipper blood pressure (BP) profiles are associated with a worse cardiovascular prognosis. The relationship between nocturnal BP profile and hypertensive retinopathy (HR) is not fully established. AIM: To assess the association between the prevalence and severity of HR and nocturnal BP. METHODS: We prospectively studied hypertensive patients who underwent 24-hour ambulatory BP monitoring. The population was divided into two groups according to the presence or absence of lesions and compared according to baseline characteristics, nocturnal BP profile (dippers, non-dippers, inverted dippers/risers and extreme dippers) and mean nocturnal systolic (SBP) and diastolic (DBP) BP values. The presence and severity of HR were assessed using the Scheie classification. The relationship between nocturnal SBP and DBP values (and nocturnal BP profile) and the prevalence and severity of HR was determined. RESULTS: Forty-six patients (46% male, aged 63±12 years) were analyzed, of whom 91% (n=42) were under antihypertensive treatment. Seventy percent (n=33) had uncontrolled BP. HR was diagnosed in 83% (n=38). Patients with HR had higher mean systolic nocturnal BP (151±23 vs. 130±13 mmHg), p=0.008). Patients with greater HR severity (Scheie stage ≥2) had higher nocturnal BP (153±25 vs. 140±16 mmHg, p=0.04). There was no statistically significant association between DBP and nocturnal BP patterns and HR. CONCLUSIONS: The prevalence and severity of HR were associated with higher nocturnal SBP. No relationship was observed between nocturnal BP profile and the presence of HR.

Pacientes con retinopatía hipertensiva e indicios de lesiones en otros órganos diana / Patients with hypertensive retinopathy and signs of lesions in other target organs

Fundamento: la hipertensión arterial es una de las enfermedades crónicas más frecuentes en el mundo; su inadecuado manejo y control puede provocar daños en diferentes órganos diana.Objetivo: caracterizar aspectos clínicos en pacientes hipertensos con retinopatía hipertensiva, atendidos en el servicio de medicina interna del Hospital General Docente Dr. Ernesto Guevara de la Serna de Las Tunas, desde septiembre de 2014 a junio de 2016.Método: se realizó un estudio observacional descriptivo de corte transversal en pacientes hipertensos con retinopatía hipertensiva, ingresados en el servicio y durante el periodo de tiempo ya citados. El universo de estudio estuvo conformado por el total de estos pacientes y la muestra por los 118 diagnosticados en la investigación con algún grado de retinopatía hipertensiva. Se les realizó fondo de ojo, electrocardiograma y/o eco cardiograma, radiografía de tórax y evaluación de la función renal. Se utilizaron datos provenientes de las historias clínicas.Resultados: predominó el grupo de edades de 45-59 años con el 56,7 por ciento, 75 pacientes (63,5 por ciento) pertenecieron al sexo masculino, el 46,6 por ciento eran de piel negra. El 68,6 % fueron identificados con hipertensión en estadio II de la enfermedad y el 48,3 por ciento presentaron retinopatía hipertensiva de grado III, seguida de la de grado II en el 27,9 por ciento de los casos. La retinopatía hipertensiva fue más frecuente en pacientes con evolución de la hipertensión por más de 20 años, representando el 51,6 por ciento. El 57,6 por ciento manifestaron daño cardiovascular y el 42,3 por ciento daño renal.Conclusiones: se caracterizaron aspectos clínicos en pacientes hipertensos con retinopatía hipertensiva (AU)

Background: arterial hypertension is one of the most frequent chronic diseases in the world. Its inadequate management and control can cause damage to different target organs.Objective: to characterize the clinical manifestations in hypertensive patients with hypertensive retinopathy attended to at the service of internal medicine of Dr. Ernesto Guevara de la Serna” General Teaching Hospital of Las Tunas, from September 2014 to June 2016.Methods: an observational, descriptive and cross-sectional study was carried out in hypertensive patients with hypertensive retinopathy, admitted to the service and during the period herein mentioned. The universe was made up of the total of these patients and the sample included 118 patients diagnosed with a certain degree of hypertensive retinopathy during the period of the research. Ophthalmoscopy, electrocardiogram and/or echocardiogram and chest radiography were performed on the patients, the renal function was also assessed. The data used were taken from the medical records. Results: the 45 to 59 age group prevailed for 56, 7 percent; 75 patients (63, 5 percent) were males and 46,6 percent of the patients were black-skinned. 68, 6 percent of the patients were identified with stage II hypertension and 48, 3 percent presented III degree hypertensive retinopathy, followed by II degree hypertensive retinopathy in 27, 9 percent of the cases. Hypertensive retinopathy was more frequent in patients with a progress of hypertension for more than 20 years, representing 51, 6 percent. 57, 6 percent presented cardiovascular damage and 42, 3 percent presented renal damage.Conclusions: the clinical manifestations in hypertensive patients with hypertensive retinopathy were characterized (AU)

Medición de la microcirculación retiniana luego del tratamiento antihipertensivo / Measuring retinal circulation after antihypertensive treatment

Background and objective: With the development of image processing techniques, it has become possible to measure the changes in retinal vessels of hypertensive patients by means of eye fundus photographs. Patients and method: In this paper we aim to classify retinal vessels automatically into arterioles and venules. In order to do so, we have compared three different strategies based on the colour of the pixels in images through an analysis of 78 hypertensive patients' eye fundus images. The first strategy classifies all the vessels by applying a clustering algorithm. The second divides the retinal image into four quadrants and classifies the vessels that belong to the same quadrant independently from the rest of the vessels. The third strategy classifies the vessels by dividing the retinal image into four quadrants that are rotated inside the mentioned image. Results: The third strategy was the one that obtained the best results, since it minimizes the number of unclassified vessels. In the initially analysed set of 20 images, we correctly classified 86.53% of the vessels, and this percentage remains similar in a set of 58 images examined by three medical experts. This confirms the validity of the method that automatically calculates the arteriovenous ratio (AVR).Conclusion: Our results are an improvement on those previously described in the bibliography, reducing the number of non-classified vessels. Furthermore, the method entails low computational costs.

Fundamento y objetivo: El desarrollo de técnicas de procesado de imágenes ha devuelto interés para poder medir de una forma objetiva los cambios en la estructura microvascular del hipertenso a través de las fotografías digitales del fondo de ojo. Pacientes y método: Para clasificar de forma automática los vasos de la retina en arteriolas y vénulas, con una elevada precisión, hemos comparado tres estrategias diferentes basadas en la información del color de los pixeles de la imagen del fondo de ojo, analizando 78 imágenes de fondo de ojo de hipertensos. La primera estrategia clasificaría todos los vasos aplicando un algoritmo de agrupamiento. La segunda divide la retina en cuatro cuadrantes y clasifica los vasos que pertenecen al mismo cuadrante independientemente del resto de los vasos. La tercera estrategia clasifica los vasos dividiendo la retina en cuadrantes que son rotados. Resultados: La mejor estrategia resultó la tercera porque minimiza el error y el número de vasos no clasificados. La característica vectorial más determinante está basada en la media o la mediana del componente gris del espacio de color RGB. Para las 20 imágenes inicialmente analizadas hemos clasificado correctamente el 86.53% de los vasos, y este porcentaje permanece similar en el grupo de 58 imágenes examinadas por tres expertos, lo que confirma la validez del método, para el cálculo del índice arteriovenoso de forma automática. Conclusión: Nuestros resultados son superiores a los descritos previamente, reduciendo además el número de vasos no clasificados. Por otro lado, el costo computacional del método es bajo

Síndrome de encefalopatía posterior reversible con afectación del tronco cerebral y médula espinal y retinopatía hipertensiva grado IV / Posterior reversible encephalopathy syndrome with brain stem and spinal cord involvement and grade iv hypertensive retinopathy

El síndrome de leucoencefalopatía posterior reversible se presenta con síntomas de edema cerebral e imágenes hiperintensas en las secuencias T2 y FLAIR en la resonancia magnética (RM) de cerebro. Las lesiones típicamente comprometen la región parietooccipital, aunque también pueden tener localizaciones atípicas. Presentamos el caso de una mujer de 33 años que consultó por trastornos visuales asociados con dolor de cabeza intenso e hipertensión grave (220/140 mmHg). El examen del fondo de ojo reveló retinopatía hipertensiva grado IV y la RM mostró lesiones hiperintensas en T2 y FLAIR a nivel centropontino, bulbo y médula espinal, las cuales regresaron tras el control sostenido de la presión arterial. (AU)

The posterior reversible leukoencephalopathy syndrome presents with symptoms of cerebral edema. On magnetic resonance imaging (MRI) of the brain, hyperintensities on T2 -weighted and FLAIR sequences typically affect the parietal-occipital region; however it may also have atypical locations. We report the case of a 33 year old patient with visual disturbances associated with intense headache and severe hypertension (220/140 mmHg). The Fundus examination revealed grade IV hypertensive retinopathy, and MRI showed hyperintense lesions in T2 and FLAIR affecting the pontine center, medulla and spinal cord, which regressed after sustain blood pressure control. (AU)

Um novo olhar da retinopatia hipertensiva: a aplicação prática de novas tecnologias / A new look at hypertensive retinopathy: the practical application of new technologies

O exame de fundo de olho tem importância histórica e mantém sua relevância nos dias atuais, por possibilitar de maneira não invasiva, observar e avaliar o “interior” do corpo humano, além de ser um importante marcador de lesão de órgão-alvo em hipertensos. O surgimento de tecnologias de aquisição de imagens digitais permitiu acessar o fundo de olho de maneira mais simples, com grande definição, muitas vezes não necessitando dilatação da pupila. Isso tornou a observação do fundo de olho, que outrora era realizada apenas por pessoas com treinamento especial, fosse feita com extrema facilidade e quase sem treinamento. Estas “facilidades” permitiram que inúmeros artigos científicos fossem realizados, estabelecendo características do fundo de olho como relevante marcador de lesão de órgão-alvo em hipertensos. A incorporação de tecnologias virtuais na prática da medicina facilitará o acesso dos pacientes, reduzirá custos e certamente irá revolucionar a relação médico-paciente nos próximos anos.

Eye fundus examination is of historical importance, and maintains its relevance nowadays, by enabling non-intrusive observation and evaluation “inside” the human body, as well as being an important marker of target organ damage in hypertensive patients. The emergence of technologies for digital image acquisition have enabled easier access to the eye fundus, with greater definition, and often without having to dilate the pupil. As a result, eye fundusexamination, once carried out only by people with special training, is now performed with extreme ease and almost no training. These “facilities” have led to numerous scientific articles, establishing the characteristics of the eye fundus as a relevant marker of target organ damage in hypertensive patients. The incorporation of virtual technologies into the practiceof medicine will facilitate patient access, reduce costs, and without doubt, revolutionize the doctor-patient relationship in the coming years.

El fondo de ojo en gestantes hipertensas / Funduscopy in hypertensive expectant mothers

Se realizó un estudio observacional descriptivo en 54 mujeres con diagnóstico de hipertensión, ingresadas en el servicio de ginecobstetricia del Hospital General Docente Dr Ernesto Guevara de la Serna de la provincia de Las Tunas, en el período comprendido entre enero de 2009 y julio de 2009; con la finalidad de caracterizar las alteraciones a nivel ocular mediante el fondo de ojo por la elevación de la tensión arterial. Se les aplicó un examen oftalmológico completo y se analizaron las variables edad, factores asociados generales y obstétricos, estadio de la retinopatía hipertensiva, cifras de tensión arterial diastólica, principales hallazgos fundoscópicos encontrados. La información se procesó a través de frecuencias absolutas, relativas y medias. Se encontró que predominó el grupo de edad de 20- 35 años; el control inadecuado del peso y la nuliparidad constituyeron los factores asociados más frecuentes. De los estadios de retinopatía hipertensiva el Grado I fue el de mayor número de pacientes. Las cifras de tensión arterial leve, la estrechez arteriolar y los signos de compresión arteria-vena prevalecieron (AU)

An observational descriptive study was carried out in 54 women diagnosed with hypertension and admitted in the gynecology and obstetrics service at Ernesto Guevara de la Serna Hospital from January, 2009 to July, 2009 in Las Tunas province, with the purpose of characterizing the alteration at the ocular level by means of the funduscopy as a consequence of the high blood pressure. A complete ophthalmological examination was made and the variables: age, general and obstetric associated risk factors, stage of the hypertensive retinopathy, numbers of diastolic pressure, and main funduscopy finds were analyzed. The information was processed by means of absolute, relative and average frequencies. The age group from 20 to 35 years old prevailed; inadequate weight control and nulliparity were the most frequent associated factors. Out of the hypertensive stages, grade I showed the highest figure of patients. The numbers of minor arterial tension, the arteriole narrowness and the signs of artery-vein compression prevailed (AU)

Emergências hipertensivas: epidemiologia, definição e classificação / Hypertensive emergencies: epidemiology, definition and classification

Embora vários termos tenham sido aplicados para hipertensão grave, tais como crise hipertensiva, emergências ou urgências, todos eles são caracterizados por elevações agudas da pressão arterial que podem estar associados com lesão de órgão-fim (crise hipertensiva). Práticas de tratamento variam consideravelmente por causa da falta de evidências que suportam o uso de um agente terapêutico em detrimento de outro. O objetivo desta revisão foi analisar a fisiopatologia das crises hipertensivas comumente encontradas, incluindo acidente vascular cerebral (AVC), encefalopatia hipertensiva, dissecção aórtica, edema pulmonar agudo e pré-eclâmpsia/eclâmpsia, e fornecer uma abordagem racional para o seu tratamento com base em princípios fisiopatológicos e farmacológicos relevantes.

Although various terms have been applied to severe hypertension, such as hypertensive crisis, emergencies, or urgencies, they are all characterized by acute elevations in blood pressure that may be associated with end-organ damage (hypertensive crisis). Treatment practices vary considerably to because of the lack of the evidence supporting the use of one therapeutic agent over another. The purpose of this review is to examine the pathophysiology of commonly encountered hypertensive crises, including stroke, hypertensive encephalopathy, aortic dissection, acute pulmonary edema and preeclampsia/eclampsia and to provide a rational approach to their treatment based upon relevant pathophysiologic and pharmacologic principles