Characteristics of the phenotypes in prevalent and incident cases of heart failure in primary care: IBERICAN study.

BACKGROUND: The management in primary care (PC) of the patients with Heart Failure (HF) is different from the management hospital, in a special way compared to cardiology departments. OBJECTIVE: To define the characteristics in both phenotypes of HF in prevalent and incident cases of HF in patients recruited in a large PC sample. METHODS: We proposed a and longitudinal analyses, in patients of the IBERICAN cohort, that recruited 8,066 patients in the Spanish primary care system, with 15,488 patients-years of follow-up. Of them, 252 patients (3.1%) had diagnoses of HF. HF was classified according to the 2014 guidelines in two groups: HF with a reduced eject fraction or HFrEF (LVEF < 50%) and HF with preserved eject fraction or HFpEF (LVEF ≥ 50%). Recommended treatment was defined as the patient receiving drug treatment with Renin-Angiotensin-System (RAS) blockers with beta-blockers and, optionally, spironolactone. The incidence of new cases of HF was calculated in the 7,814 patients without HF in the inclusion visit. Finally, we analysed which variables associated the onset new cases and get the hazard ratio (HR) with the confidence interval at 95% ([95%CI]). Clinical trials register: NCT02261441 (02/05/2017). RESULTS: The HFpEF was the most frequent phenotype in prevalent cases (61.1%) and incident cases (73.9%). Patients with HFrEF had a higher prevalence of coronary heart disease (p = 0.008) and PAD (p = 0.028), and no statistically significant differences was observed in the therapeutic groups used between both groups. The incidence of HF was 12.8 cases/1000 inhabitants/year, 35.6% of them was diagnosed in PC. The renin-angiotensin system blockers were more used in PC (60%) and beta-blockers (100%) and spironolactone (60%) in hospital. The female sex showed a protective effect for incident cases (0.51 [0.28-0.92]); and AF (HR [95%CI]: 2.90 [1.51-5.54]), coronary heart disease (HR [95%CI]: 2.18 [1.19-4.00]) and hypertension (HR [95%CI]: 1.91 [1.00-3.64]) increased the risk of developing HF. CONCLUSIONS: HF phenotype more frequent and incident in PC was the HFpEF, but only one third of them are diagnosed in PC level. The female sex showed a protective effect and atrial fibrillation, ischaemic heart disease and hypertension increased the risk of develop HF.

Elevated pulse pressure and cardiovascular risk associated in Spanish population attended in primary care: IBERICAN study.

Introduction: Elevated pulse pressure (ePP) is an independent marker of cardiovascular risk (CVR) in people older than 60, and a functional marker of subclinical target organ damage (sTOD) which can predict cardiovascular events in patients with hypertension (HTN), regardless of sTOD. Objective: To evaluate the prevalence of ePP in adult population seen in primary care and its association with other vascular risk factors, sTOD and with cardiovascular disease (CVD). Materials and methods: Observational multicentre study conducted in Spain (8,066 patients, 54.5% women) from the prospective cohort study IBERICAN recruited in Primary Care. Pulse pressure (PP) was defined as the difference between the systolic blood pressure (SBP) and the diastolic blood pressure (DBP) ≥60 mmHg. Adjusted (for age and sex) ePP prevalence were determined. Bivariate and multivariate analyses of the possible variables associated with ePP were carried out. Results: The mean of PP was 52.35 mmHg, and was significantly higher (p < 0.001) in patients with HTN (56.58 vs. 48.45 mmHg) The prevalence of ePP adjusted for age and sex was 23.54% (25.40% men vs. 21.75% women; p < 0.0001). The ePP prevalence rates increased linearly with age (R2 = 0.979) and were significantly more frequent in population aged ≥65 than in population aged <65 (45.47% vs. 20.98%; p < 0.001). HTN, left ventricular hypertrophy, low estimated glomerular filtration rate, alcohol consumption, abdominal obesity, and CVD were independently associated with ePP. 66.27% of patients with ePP had a high or very high CVR, as compared with 36.57% of patients without ePP (OR: 3.41 [95% CI 3.08-3.77]). Conclusions: The ePP was present in a quarter of our sample, and it was increased with the age. Also, the ePP was more frequent in men, patients with HTN, other TOD (as left ventricular hypertrophy or low estimated glomerular filtration rate) and CVD; because of this, the ePP was associated a higher cardiovascular risk. In our opinion, the ePP is an importer risk marker and its early identification lets to improve better diagnostic and therapeutic management.

Cardiovascular risk in women attending primary care centres: baseline data of the EVA study.

BACKGROUND: The purpose of this study was to determine the prevalence of hypertension, cardiovascular risk factors and target organ damage using baseline data from the EVA study. METHODS: EVA is a 5-year multicentre prospective study of women aged between 40 and 70 years attending primary care centres in a rural-urban area in the north of Spain. The recruitment period was between October 2009 and January 2010. The following variables were analysed: associated cardiovascular risk factors, target organ damage and cardiovascular or renal disease defined according to the 2007 European Society of Hypertension and the European Society of Cardiology Guidelines (2007 ESH/ESC 2007). Blood pressure <140/90 mmHg and <130/80 in diabetics were considered target blood pressure values. Cardiovascular risk was stratified according to the 2007 ESC-ESH guidelines. RESULTS: The study sample comprised of 903 women with a mean age of 59.6 ± 8 years. The prevalence of hypertension, Type 2 diabetes and dyslipidaemia was 45.6, 13.3 and 41.7%, respectively. Target organ damage affected 17.6% of women and manifested as microalbuminuria (1.8%), slight increase in plasma creatinine (1.6%) and left ventricular hypertrophy (2.9%). Overall, 9.3% had cardiovascular disease, 3.4% coronary heart disease, 1.8% heart failure, 1.8% peripheral artery disease and 1.4% renal disease; 2.2% of patients had experienced a stroke. The prevalence of cardiovascular risk factors in hypertensive women (HT) with respect to non-hypertensive women (NHT) was as follows: obesity 44.7 versus 18.9%, dyslipidaemia 48.8 versus 35.8% and Type 2 diabetes 21.8 versus 6.1%. The target organ damage was more prevalent in hypertensive women: 27.3 versus 9.4%. Cardiovascular disease was present in 14.8% of HT and 4.7% of NHT. High or very high cardiovascular risk affected 65.3% of HT and 26.9% of NHT. CONCLUSIONS: Four in 10 women attending primary care centres had a high or very high cardiovascular risk. Percentages of classic cardiovascular risk factors were higher in HT than in NHT and increased significantly with age. The most commonly used drugs were renin-angiotensin system blockers and diuretics.

Prevalence of Hyperuricemia and Its Association with Cardiovascular Risk Factors and Subclinical Target Organ Damage.

The role of uric acid levels in the cardiovascular continuum is not clear. Our objective is to analyze the prevalence of hyperuricemia (HU) and its association with cardiovascular risk factors (CVRF), subclinical target organ damage (sTOD), and cardiovascular diseases (CVD). We evaluated the prevalence of HU in 6.927 patients included in the baseline visit of the IBERICAN study. HU was defined as uric acid levels above 6 mg/dL in women, and 7 mg/dL in men. Using adjusted logistic regression models, the odds ratios were estimated according to CVRF, sTOD, and CVD. The prevalence of HU was 16.3%. The risk of HU was higher in patients with pathological glomerular filtration rate (aOR: 2.92), heart failure (HF) (aOR: 1.91), abdominal obesity (aOR: 1.80), hypertension (HTN) (aOR: 1.65), use of thiazides (aOR: 1.54), left ventricular hypertrophy (LVH) (aOR: 1.36), atrial fibrillation (AFIB) (aOR: 1.29), and albuminuria (aOR: 1.27). On the other hand, being female (aOR: 0.82) showed a reduced risk. The prevalence of HU was higher in men, in patients presenting CVRF such as HTN and abdominal obesity, and with co-existence of LVH, atrial fibrillation (AFIB), HF, and any form of kidney injury. These associations raise the possibility that HU forms part of the early stages of the cardiovascular continuum. This may influence its management in Primary Healthcare because the presence of HU could mean an increased CV risk in the patients.

[Evaluation and control of hypertensive diabetics seen in Primary Care centres in Spain. BRAND II study]. / Evaluación y control de los hipertensos diabéticos atendidos en centros de Atención Primaria de España. Estudio BRAND II.

OBJECTIVE: We aimed to verify the level of blood pressure and glucose control and treatment in hypertensive diabetics seen in Primary Care Centres in Spain. DESIGN: Descriptive study conducted on hypertensive diabetic patients who attended primary care centres for any reason. LOCATION: Primary Care centres throughout Spain. PARTICIPANTS: The study included 6,777 patients. MEASUREMENTS: Blood pressure, weight, height, waist circumference, blood analysis and treatment were recorded RESULTS: The mean age of the sample was 64.40 (11.50) years. Mean blood glucose was 141.8 (39) mg/dl, glycosylated haemoglobin was ≤7% in 45.9% of the sample, and blood pressure was under control (BP≤130/80 mmHg) in 9.8% of the patients studied. LDL Cholesterol was ≤100mg/dl in 25.3% of the sample. The drugs most used to control diabetes were; sulphonylureas 2259 patients (33.3%) and biguanides 3768 patients (55.6%). A total of 556 patients were on treatment with insulin, which represented 8.2% of the population studied. The drugs most used for hypertension were; diuretics in 3395 patients (50.1%) and angiotensin-converting enzyme inhibitors in 4053 patients (59.8%). CONCLUSIONS: A large proportion of hypertensive diabetics are insufficiently controlled.

Prevalence of chronic kidney disease and associated factors in the Spanish population attended in primary care: Results of the IBERICAN study. / Prevalencia de la enfermedad renal crónica y factores asociados en la población asistida en atención primaria de España: resultados del estudio IBERICAN.

OBJECTIVES: To determine the prevalence of chronic kidney disease (CKD) and the factors associated with impaired renal function in the population attended in primary care (PC). PATIENTS AND METHOD: Cross-sectional and multicentre study carried out in the baseline patients of the IBERICAN study (Identificación de la poBlación Española de RIesgo CArdiovascular y reNal). CKD was considered with an estimated glomerular filtration (eGF) <60ml/min/1.73 m2 or elevated albuminuria (≥ 30mg/g). According to the eGF, the CKD was classified in six stages (1, 2, 3a, 3b, 4 and 5) and according to albuminuria in three stages (A1 or normal / slightly increased, A2 or moderately increased and A3 or severely increased). The clinical characteristics and the relationship of CKD with the main cardiovascular risk factors (CVRF) and other variables of interest were analysed using unconditional logistic regression. RESULTS: 7,895 patients were included (mean age 57.9±14.8 years; 54.5% women). 14.4% (95% CI: 13.6-15.1) had CKD; 16.1% (95% CI: 14.9-17.3) in men and 12.9% (95% CI: 11.9-14.0) in women. A continuous increase of the prevalence was observed with age (24.8% in≥65 years) and with CVFR aggregation. The variables that were most associated with the probability of suffering CKD were left ventricular hypertrophy (OR: 1.95; p <.001), diabetes (OR: 1.58; P<.001) and hypertension (OR: 1.56; P<.001). CONCLUSIONS: Fourteen out of every 100 patients included in the IBERICAN study have CKD. The prevalence of CKD affects a quarter of patients ≥ 65 years and increases exponentially with the aggregation of FRCV.

Use of anthropometric measures to predict insulin resistance.

OBJECTIVE: Obesity is closely related to insulin-resistance (IR) but it is evaluated differently in the diverse definitions of the metabolic syndrome. The objective of this study was to verify the utility of different anthropometric measures to predict IR and to evaluate the best cut-off points. SUBJECTS AND METHOD: We performed a cross-sectional study of the general population aged 40 to 70 years old (n=2,143); a simple random sample of 305 non-diabetic persons was obtained. Sociodemographic data, physical examination and routine biochemical analysis with insulinemia were obtained. IR was defined by a HOMA index (Homeostasis Model Assessment) ≥2.9. To obtain the best variables to predict IR, a forward stepwise logistic regression was performed. Subsequently, a logistic equation was constructed and its predictive capacity was compared with the different anthropometric variables by the area under the ROC (receiver-operating characteristic) curve (AUC). The best cut-off points were established according to the Youden index. RESULTS: Body mass index (BMI) and the waist/hip ratio ×100 were entered into the model, but age, sex, waist, hip and body surface were not. The logistic equation found: p(RI)=1/1+exp{-[-14.295]-[0.234×IMC]-[0.07×(waist/hip×100)]} showed good adjustment, and the probability calculated on the basis of this equation showed the greatest AUC overall and in both sexes, followed in women by BMI and by waist measurement in men, but without significant differences. CONCLUSIONS: No significant differences were found between the BMI, waist or hip measurements and the logistic model to predict IR.

[Baseline characteristics and clinical management of the first 3,000 patients enrolled in the IBERICAN study (Identification of the Spanish population at cardiovascular and renal risk)]. / Características basales y manejo clínico de los primeros 3.000 pacientes incluidos en el estudio IBERICAN (Identificación de la población española de riesgo cardiovascular y renal).

OBJECTIVES: To determine the prevalence and incidence of cardiovascular risk factors in Spain, as well as cardiovascular events, in Spanish adult population attended in primary care. METHODOLOGY: IBERICAN is a longitudinal, observational, multicenter study in which patients aged 18 to 85years attended in primary care health center in Spain are being included. The obtained cohort will be followed annually for at least 5years. The estimated final sample is 7,000 patients. The baseline characteristics of the second cut (n=3,042) are presented. RESULTS: The mean age of the subjects included is 57.9±14.6 years, and 55.5% are women. 54.9% live in urban habitat, and 57.3% have primary education. 50.3% had dyslipidemia, 47.4% hypertension, 29.7% physical inactivity, 28.2% abdominal obesity and 19% diabetes mellitus. The degree of control of hypertension, dyslipidemia and type2 diabetes was 58.5%, 25.8% and 75.9%. 28.2% have criteria for metabolic syndrome. 15.6% of patients had previous cardiovascular disease. 7.8% have a history of coronary heart disease, a glomerular filtration rate <60ml/min (CKD-EPI) 8.4%, microalbuminuria 9.6%, atrial fibrillation 5.5%, stroke 4.6%, and heart failure 2.9%. CONCLUSIONS: Although the population treated in primary care is relatively young, the high prevalence of risk factors, their poor control and the existence of previous cardiovascular disease will determine the impact on the prognosis of the cohort.

[Differences in the prevalence of metabolic syndrome according to the ATP-III and WHO definitions]. / Diferencias en la prevalencia del síndrome metabólico según las definiciones del ATP-III y la OMS.

BACKGROUND AND OBJECTIVE: The objective of the study is to know the prevalence of the metabolic syndrome (MS), as well as to know the differences in its prevalence according to the Adult Treatment Panel of the National Cholesterol Education Program (ATP-III) and World Health Organization (WHO) criteria. PATIENTS AND METHOD: Cross-sectional descriptive study performed in primary care in population of both sexes aged between 40 and 74 years. Variables studied were risk factors as well as each one of the components of MS, according to both definitions. RESULTS: We studied 358 patients, 161 (45%) men and 197 women. The prevalence of MS using the WHO criteria was 17.9% and according with the ATP-III criteria it was 23.5%. The prevalence increased with age and the body mass index. Both definitions agreed in the classification of MS in 80% of cases (kappa = 0.38). If we considered the definition of MS according to the WHO taken as the "gold standard", the ATP-III definition displays a sensitivity of 59.4%, specificity of 84.4% and negative predictive value of 90.5%. The agreement is greater in women and older than 60 years. CONCLUSIONS: The prevalence of MS is smaller with the WHO criteria. The agreement between both methods is scarce and the clinical application of the ATP-III criteria in primary care needs its homologation with clinic-epidemiological studies.

[Comparison of the SCORE and Framingham models in calculating high cardiovascular risk for a sample of males within the 45-65 age range in Asturias, Spain]. / Comparación de los modelos SCORE y Framinghan en el cálculo de alto riesgo cardiovascular para una muestra de varones de 45 y 65 años de Asturias.

BACKGROUND: The Spanish Interdisciplinary Committee for Cardiovascular Prevention has recently drafted a consensus for adapting the European Cardiovascular Prevention Guide to the Spanish population, using SCORE as the risk-calculation method. This study is aimed as ascertaining the differences involved in changing over from the Framingham to the SCORE criterion in the classification of males within the high-risk group. METHODS: Descriptive cross-sectional study conducted in primary care. A total of 379 males within the 45-65 age range, corresponding to four (4) groups from general practitioners from three healthcare centers in the Principality of Asturias. MAIN MEASUREMENTS: calculation of the cardiovascular risk and high-risk prevalence by the conventional Framingham method and according to SCORE. High-risk prevalence curve estimated by logic regression. RESULTS: The high-risk prevalence according to the Framingham equation was 24% (CI95%=19.9-28.7) and was 17.9% (CI95%=14.3-22.3) for SCORE, the difference being statistically significant (p=0.02). The SCORE model shows lower prevalences among subjects under age 60 and higher for those over age 60. Among male smokers, SCORE shows lower prevalences among individuals under 58 years of age, the high-risk males with Framingham and low-risk with SCORE being younger, smokers and having lower average blood pressure figures and moderate cholesterol figures. CONCLUSIONS: On applying the SCORE model, we classify fewer males as high-risk, especially among those under 58 years of age who are smokers having moderate cholesterol figures than when the Framingham scale is used.

[Guidelines for the management of hypertension]. / Guías en el manejo de la hipertensión.

In the last year, several scientific societies have published guidelines for the management of arterial hypertension. In Spain, two clinical practice guidelines have had a strong impact and have been closely followed in the last few years: the first is the Guideline of the National Heart, Lung and Blood Institute, although their last report (JNC 7) was published in 2003; the second is the clinical practice guideline for the management of arterial hypertension of the European Society of Cardiology (ESC) and the European Society of Hypertension (ESH), whose latest version was published in 2007, although an update was published in 2009. A new ESC/ESH document, published in 2013, adopts a mainly educational stance, closely rooted in clinical practice. Many of the recommendations maintain the same criteria as previous guidelines. However, the new publication shows greater rigor and contains major contributions such as specification of the level of evidence and grade of recommendation for each recommendation, which was lacking in the previous guidelines of these societies. The document is both practical and easy to consult, consisting of 17 tables, 5 figures and 18 blocks of recommendations. The JNC 8 report, however, has a single objective: to respond to three questions that are considered a priority and which refer exclusively to drug therapy. Nine recommendations are made relating to these three questions.

[Measurement of blood pressure in consultation and automated mesurement (BPTru(®)) to evaluate the white coat effect]. / Medida de la presión arterial en consulta y automatizada (BPTru®) para evaluar el efecto de bata blanca.

BACKGROUND AND OBJECTIVE: White coat effect (WCE) is one of the main bias that can affect office blood pressure (BP) measurement. Therefore, it is a factor must be considered in hypertensives to avoid mistakes in diagnosis and/or treatment. Employment of automated office BP (AOBP) devices could diminish that effect. METHODS: Two studies were designed with the objective of evaluating differences between routinely office and AOBP measurements. WCE was also assessed. First, the TRUE-ESP study included normotensive and hypertensive patients attending specialized consultations at Cardiology, Nephrology, Internal Medicine, Endocrinology and Family Practice. Second, the TRUE-HTA study included hypertensives attending a protocoled Hypertension Unit, with a trained staff. RESULTS: TRUE-ESP study included 300 patients, 76% being hypertensives. A significant difference between office BP and AOBP measurement (SBP/DBP 9.8±11.6/3.4±7.9 mmHg, P<.001) was observed. Percentage of patients gathering WCE criteria was 27.7%. TRUE-HTA study included 101 hypertensive patients. A significant difference between office BP and AOBP measurement (SBP/DBP 5.7±9.3/2.1±5.3 mmHg, P<.001) and activity period-ABPM (SBP/DBP 8.5±6.7/3.5±2.5 mmHg, P<.001) was observed. Percentage of WCE patients was 32.1%. CONCLUSIONS: Use of AOBP devices can contribute to decrease WCE and to improve accuracy of office BP measurement.