Control de la hipertensión arterial por especialistas en Argentina (estudio charter)

Introducción: La proporción de hipertensos medicados que presentan adecuado control de su HTA es muy baja a nivel mundial, del orden del 32,5%. Objetivos: 1)determinar el grado de control de la HTA en hipertensos medicados, tratados en centros especializados de la República Argentina; 2) caracterizar a los pacientes atendidos en dichos centros respecto de su perfil de riesgo cardiovascular; analizar el número y tipo de antihipertensivos utilizados; determinar los factores asociados a un adecuado control de la presión arterial(PA). Metodología: estudio de corte transversal, en el que se incluyeron mayores de 18 años con diagnóstico establecido de hipertensión arterial, bajo tratamiento farmacológico, provenientes de 10 centros de referencia en HTA de la Argentina. En una única visita se midió la PA [3 lecturas] y se registraron variables antropométricas y demográficas, así como las características del tratamiento antihipertensivo. Se consideró adecuado control de la PA en consultorio a un promedio por debajo de 140/90 mmHg en 80 años. Se estimó el porcentaje del grado de control de la PA con su IC95% y se determinaron las variables independientemente asociadas con el adecuado control de la PA a través de un análisis de regresión logística multivariable. Resultados: se incluyeron 1146 pacientes. El promedio de edad fue de 63,5 (13,1) años, 42,8% varones, 19,7% diabéticos, 8,3% tabaquistas, 67,4% dislipidémicos, 8,1% con antecedentes de enfermedad coronaria y 6,7% con antecedentes de enfermedad cerebrovascular. La media de PA en consultorio fue de 135,3 (14,8)/ 80,8 (10) mmHg, siendo el porcentaje de adecuado control de la PA de 64,8% (IC95%: 62-67,6%). El consumo promedio de antihipertensivos fue de 2,1 (1) drogas por paciente (Figura 1). En la Tabla 1 se muestran las características de los sujetos con adecuado vs. inadecuado control de la PA. En el análisis multivariable, sólo el sexo femenino fue un predictor independiente de adecuado control (OR 1,33 [IC95% 1,02-1,72],p=0,04). Conclusiones: un 65% de los pacientes hipertensos tratados en centros especializados de la Argentina presentan adecuado control de PA, siendo esta cifra muy superior a la reportada en población general. Futuros estudios deberán definir estrategias para optimizar el control en centros no especializados.Fil: Marin, Marcos. Instituto Universidad Escuela de Medicina del Hospital Italiano; ArgentinaFil: Barochiner, Jessica. Instituto Universidad Escuela de Medicina del Hospital Italiano; ArgentinaFil: Rodriguez, Pablo. Instituto Cardiovascular de Buenos Aires; ArgentinaFil: Renna, Nicolas Federico. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Científico Tecnológico Conicet - Mendoza. Instituto de Medicina y Biología Experimental de Cuyo; Argentina. Universidad Nacional de Cuyo. Facultad de Ciencias Médicas. Cátedra de Fisiología Patológica; ArgentinaFil: Castellaro, Carlos. Sociedad Argentina de Hipertensión Arterial; ArgentinaFil: Espeche, Walter. Universidad Nacional de La Plata; ArgentinaFil: De Cerchio, Alejandro. Sociedad Argentina de Hipertensión Arterial; ArgentinaFil: Del Sueldo, Mildren. Sociedad Argentina de Hipertensión Arterial; ArgentinaFil: Visani, Sergio. Sociedad Argentina de Hipertensión Arterial; ArgentinaFil: Zilberman, Judith. Sociedad Argentina de Hipertensión Arterial; ArgentinaXXVI Congreso Argentino de Hipertensión ArterialMar del PlataArgentinaSociedad Argentina de Hipertensión Arteria

Determinants of the Morning-Evening Home Blood Pressure Difference in Treated Hypertensives: The HIBA-Home Study

Background. The morning home blood pressure (BP) rise is a significant asymptomatic target organ damage predictor in hypertensives. Our aim was to evaluate determinants of home-based morning-evening difference (MEdiff) in Argentine patients. Methods. Treated hypertensive patients aged ≥18 years participated in a cross-sectional study, after performing home morning and evening BP measurement. MEdiff was morning minus evening home average results. Variables identified as relevant predictors were entered into a multivariable linear regression analysis model. Results. Three hundred sixty-seven medicated hypertensives were included. Mean age was 66.2 (14.5), BMI 28.1 (4.5), total cholesterol 4.89 (1.0) mmol/L, 65.9% women, 11.7% smokers, and 10.6% diabetics. Mean MEdiff was 1.1 (12.5) mmHg systolic and 2.3 (6.1) mmHg diastolic, respectively. Mean self-recorded BP was 131.5 (14.1) mmHg systolic and 73.8 (7.6) mmHg diastolic, respectively. Mean morning and evening home BPs were 133.1 (16.5) versus 132 (15.7) systolic and 75.8 (8.4) versus 73.5 (8.2) diastolic, respectively. Significant beta-coefficient values were found in systolic MEdiff for age and smoking and in diastolic MEdiff for age, smoking, total cholesterol, and calcium-channel blockers. Conclusions. In a cohort of Argentine medicated patients, older age, smoking, total cholesterol, and use of calcium channel blockers were independent determinants of home-based MEdiff

Cardiovascular end points and mortality are not closer associated with central than peripheral pulsatile blood pressure components

none32Pulsatile blood pressure (BP) confers cardiovascular risk. Whether associations of cardiovascular end points are tighter for central systolic BP (cSBP) than peripheral systolic BP (pSBP) or central pulse pressure (cPP) than peripheral pulse pressure (pPP) is uncertain. Among 5608 participants (54.1% women; mean age, 54.2 years) enrolled in nine studies, median follow-up was 4.1 years. cSBP and cPP, estimated tonometrically from the radial waveform, averaged 123.7 and 42.5 mm Hg, and pSBP and pPP 134.1 and 53.9 mm Hg. The primary composite cardiovascular end point occurred in 255 participants (4.5%). Across fourths of the cPP distribution, rates increased exponentially (4.1, 5.0, 7.3, and 22.0 per 1000 person-years) with comparable estimates for cSBP, pSBP, and pPP. The multivariable-adjusted hazard ratios, expressing the risk per 1-SD increment in BP, were 1.50 (95% CI, 1.33-1.70) for cSBP, 1.36 (95% CI, 1.19-1.54) for cPP, 1.49 (95% CI, 1.33-1.67) for pSBP, and 1.34 (95% CI, 1.19-1.51) for pPP (P<0.001). Further adjustment of cSBP and cPP, respectively, for pSBP and pPP, and vice versa, removed the significance of all hazard ratios. Adding cSBP, cPP, pSBP, pPP to a base model including covariables increased the model fit (P<0.001) with generalized R2 increments ranging from 0.37% to 0.74% but adding a second BP to a model including already one did not. Analyses of the secondary end points, including total mortality (204 deaths), coronary end points (109) and strokes (89), and various sensitivity analyses produced consistent results. In conclusion, associations of the primary and secondary end points with SBP and pulse pressure were not stronger if BP was measured centrally compared with peripherally.noneHuang, Qi-Fang; Aparicio, Lucas S; Thijs, Lutgarde; Wei, Fang-Fei; Melgarejo, Jesus D; Cheng, Yi-Bang; Sheng, Chang-Sheng; Yang, Wen-Yi; Gilis-Malinowska, Natasza; Boggia, José; Niiranen, Teemu J; Wojciechowska, Wiktoria; Stolarz-Skrzypek, Katarzyna; Barochiner, Jessica; Ackermann, Daniel; Tikhonoff, Valérie; Ponte, Belen; Pruijm, Menno; Casiglia, Edoardo; Narkiewicz, Krzysztof; Filipovský, Jan; Czarnecka, Danuta; Kawecka-Jaszcz, Kalina; Jula, Antti M; Bochud, Murielle; Vanassche, Thomas; Verhamme, Peter; Struijker-Boudier, Harry A J; Wang, Ji-Guang; Zhang, Zhen-Yu; Li, Yan; Staessen, Jan AHuang, Qi-Fang; Aparicio, Lucas S; Thijs, Lutgarde; Wei, Fang-Fei; Melgarejo, Jesus D; Cheng, Yi-Bang; Sheng, Chang-Sheng; Yang, Wen-Yi; Gilis-Malinowska, Natasza; Boggia, José; Niiranen, Teemu J; Wojciechowska, Wiktoria; Stolarz-Skrzypek, Katarzyna; Barochiner, Jessica; Ackermann, Daniel; Tikhonoff, Valérie; Ponte, Belen; Pruijm, Menno; Casiglia, Edoardo; Narkiewicz, Krzysztof; Filipovský, Jan; Czarnecka, Danuta; Kawecka-Jaszcz, Kalina; Jula, Antti M; Bochud, Murielle; Vanassche, Thomas; Verhamme, Peter; Struijker-Boudier, Harry A J; Wang, Ji-Guang; Zhang, Zhen-Yu; Li, Yan; Staessen, Jan

Risk Stratification by Cross-Classification of Central and Brachial Systolic Blood Pressure

Background: Whether cardiovascular risk is more tightly associated with central (cSBP) than brachial (bSBP) systolic pressure remains debated, because of their close correlation and uncertain thresholds to differentiate cSBP into normotension versus hypertension.Methods: In a person-level meta-analysis of the International Database of Central Arterial Properties for Risk Stratification (n=5576; 54.1% women; mean age 54.2 years), outcome-driven thresholds for cSBP were determined and whether the cross-classification of cSBP and bSBP improved risk stratification was explored. cSBP was tonometrically estimated from the radial pulse wave using SphygmoCor software.Results: Over 4.1 years (median), 255 composite cardiovascular end points occurred. In multivariable bootstrapped analyses, cSBP thresholds (in mm Hg) of 110.5 (95% CI, 109.1-111.8), 120.2 (119.4-121.0), 130.0 (129.6-130.3), and 149.5 (148.4-150.5) generated 5-year cardiovascular risks equivalent to the American College of Cardiology/American Heart Association bSBP thresholds of 120, 130, 140, and 160. Applying 120/130 mm Hg as cSBP/bSBP thresholds delineated concordant central and brachial normotension (43.1%) and hypertension (48.2%) versus isolated brachial hypertension (5.0%) and isolated central hypertension (3.7%). With concordant normotension as reference, the multivariable hazard ratios for the cardiovascular end point were 1.30 (95% CI, 0.58-2.94) for isolated brachial hypertension, 2.28 (1.21-4.30) for isolated central hypertension, and 2.02 (1.41-2.91) for concordant hypertension. The increased cardiovascular risk associated with isolated central and concordant hypertension was paralleled by cerebrovascular end points with hazard ratios of 3.71 (1.37-10.06) and 2.60 (1.35-5.00), respectively.Conclusions: Irrespective of the brachial blood pressure status, central hypertension increased cardiovascular and cerebrovascular risk indicating the importance of controlling central hypertension.</p

Opposing Age-Related Trends in Absolute and Relative Risk of Adverse Health Outcomes Associated With Out-of-Office Blood Pressure

Participant-level meta-analyses assessed the age-specific relevance of office blood pressure to cardiovascular complications, but this information is lacking for out-of-office blood pressure. At baseline, daytime ambulatory (n=12 624) or home (n=5297) blood pressure were measured in 17 921 participants (51.3% women; mean age, 54.2 years) from 17 population cohorts. Subsequently, mortality and cardiovascular events were recorded. Using multivariable Cox regression, floating absolute risk was computed across 4 age bands (80 years). Over 236 491 person-years, 3855 people died and 2942 cardiovascular events occurred. From levels as low as 110/65 mm Hg, risk log-linearly increased with higher out-of-office systolic/diastolic blood pressure. From the youngest to the oldest age group, rates expressed per 1000 person-years increased (P<0.001) from 4.4 (95% CI, 4.0-4.7) to 86.3 (76.1-96.5) for all-cause mortality and from 4.1 (3.9-4.6) to 59.8 (51.0-68.7) for cardiovascular events, whereas hazard ratios per 20-mm Hg increment in systolic out-of-office blood pressure decreased (P <= 0.0033) from 1.42 (1.19-1.69) to 1.09 (1.05-1.12) and from 1.70 (1.51-1.92) to 1.12 (1.07-1.17), respectively. These age-related trends were similar for out-of-office diastolic pressure and were generally consistent in both sexes and across ethnicities. In conclusion, adverse outcomes were directly associated with out-of-office blood pressure in adults. At young age, the absolute risk associated with out-of-office blood pressure was low, but relative risk high, whereas with advancing age relative risk decreased and absolute risk increased. These observations highlight the need of a lifecourse approach for the management of hypertension

Uncontrolled Hypertension is Associated with Postprandial Hypotension

Background: In a previous study that incorporated post-lunch measurements to the conventional scheme of home-based bloodpressure monitoring, we detected postprandial hypotension in about a quarter of hypertensive patients. The coexistence ofhypertension with hypotension poses a therapeutic dilemma, suggesting that the control of hypertension might attenuatepostprandial hypotension.Objectives: The aim of this study was to compare the postprandial change of systolic blood pressure, and the correspondingchronotropic response, associated to the control of hypertension.Methods: We prospectively evaluated 140 treated hypertensive patients, aged over 40 years, with home-based blood pressuremonitoring. The control of hypertension was based on the average morning and evening blood pressure, considering 135/85mmHg as cutoff value. Postprandial hypotension was defined as a drop in systolic blood pressure equal to or greater than 20mmHg with respect to the preprandial value in at least one of three lunches.Results: Postprandial hypotension was found in 13.2% (n=10) of patients with controlled hypertension and in 42.2% (n=27)with uncontrolled hypertension (p<0.001). After lunch, the average decrease of systolic blood pressure was 9.5±10.5 mmHg(6.4%±7.8%) in patients with uncontrolled hypertension and 3.2±7.8 mmHg (2.6%±6.5%) in those with controlled hypertension(p<0.001), with no significant difference in the chronotropic response. After stratifying the patients by hypertension control, the postprandial response of heart rate and systolic blood pressure showed a significant inverse correlation in controlledhypertensive patients (r=-0.24; p=0.035), and a not significant correlation in uncontrolled patients. On the multiplelinear regression analysis, lack of blood pressure control (beta=0.26, p=0.002) and female gender (beta=0.22; p<0.001) weresignificant predictors of a postprandial drop in systolic blood pressure, without a significant influence of age or number ofantihypertensive drugs.Conclusion: Lack of blood pressure control was associated with an abnormal postprandial circulatory response that predisposesto hypotension.Resumen Introducción En un estudio previo que incorporó mediciones post almuerzo al esquema convencional  de monitoreo domiciliario de presión arterial, hemos detectado hipotensión postprandial  en » ¼ de nuestros pacientes hipertensos. Objetivos En el presente estudio comparamos el cambio postprandial de la presión arterial sistólica, y la correspondiente respuesta cronotrópica, en relación al control de la hipertensión. Material y métodos Evaluamos prospectivamente con monitoreo domiciliario de presión arterial a 140 hipertensos tratados mayores de 40 años. El control de la hipertensión se basó en el promedio de presión arterial matinal y vespertina, tomando como valor de corte 135/85 mmHg. Se consideró hipotensión postprandial cuando la presión arterial sistólica disminuyó 20 mmHg ó más respecto del valor preprandial en al menos 1 de 3 almuerzos. Resultados Detectamos hipotensión postprandial, en el 13,2% (n = 10) de los hipertensos controlados y en el 42,2% (n = 27) de los no controlados (P< 0,001). Después de los almuerzos la presión arterial sistólica disminuyó en promedio 9,5±10,5 mmHg (6,4±7,8%) en los hipertensos no controlados y 3,2±7,8 mmHg (2,6±6,5 %) en los controlados (p < 0,001), sin diferencia significativa en la respuesta crontrópica.  El análisis de regresión lineal múltiple, confirmó que el delta postprandial de presión arterial sistólica se asoció significativamente con el control de la hipertensión (Beta = -0,26; P = 0,002) pero no con la edad. Al estratificar a los pacientes por el control de la hipertensión, se observó que la respuesta postprandial de la frecuencia cardíaca y de la presión arterial sistólica correlacionaron entre sí de manera inversa en los controlados (r = -0,42; P < 0,001), sin relación significativa en los no controlados. Conclusión La falta de control de la hipertensión se asoció a una anormal respuesta circulatoria postprandial que predispone a la hipotensión

Determinants of the Morning-Evening Home Blood Pressure Difference in Treated Hypertensives: The HIBA-Home Study

Background. The morning home blood pressure (BP) rise is a significant asymptomatic target organ damage predictor in hypertensives. Our aim was to evaluate determinants of home-based morning-evening difference (MEdiff) in Argentine patients. Methods. Treated hypertensive patients aged ≥18 years participated in a cross-sectional study, after performing home morning and evening BP measurement. MEdiff was morning minus evening home average results. Variables identified as relevant predictors were entered into a multivariable linear regression analysis model. Results. Three hundred sixty-seven medicated hypertensives were included. Mean age was 66.2 (14.5), BMI 28.1 (4.5), total cholesterol 4.89 (1.0) mmol/L, 65.9% women, 11.7% smokers, and 10.6% diabetics. Mean MEdiff was 1.1 (12.5) mmHg systolic and 2.3 (6.1) mmHg diastolic, respectively. Mean self-recorded BP was 131.5 (14.1) mmHg systolic and 73.8 (7.6) mmHg diastolic, respectively. Mean morning and evening home BPs were 133.1 (16.5) versus 132 (15.7) systolic and 75.8 (8.4) versus 73.5 (8.2) diastolic, respectively. Significant beta-coefficient values were found in systolic MEdiff for age and smoking and in diastolic MEdiff for age, smoking, total cholesterol, and calcium-channel blockers. Conclusions. In a cohort of Argentine medicated patients, older age, smoking, total cholesterol, and use of calcium channel blockers were independent determinants of home-based MEdiff

Hemodynamic characterization of hypertensive patients with an exaggerated orthostatic blood pressure variation

Exaggerated orthostatic blood pressure variation (EOV) is a poorly understood phenomenon related to high cardiovascular risk. We aimed to determine whether hypertensive patients with EOV have a distinct hemodynamic pattern, assessed through impedance cardiography. Methods: In treated hypertensive patients, we measured the cardiac index (CI), systemic vascular resistance index (SVRI), blood pressure (BP), and heart rate (HR) in the supine and standing (after 3 minutes) positions, defining three groups according to BP variation: 1) Normal orthostatic BP variation (NOV): standing systolic BP (stSBP)-supine systolic BP (suSBP) between −20 and 20 mmHg and standing diastolic BP (stDBP)-supine diastolic BP (suDBP) between −10 and 10 mmHg; 2) orthostatic hypotension (OHypo): stSBP-suSBP≤-20 or stDBP-suDBP≤-10 mmHg; 3) orthostatic hypertension (OHyper): stSBP-suSBP≥20 or stDBP-suDBP≥10 mmHg. We performed multivariable analyses to determine the association of hemodynamic variables with EOV. Results: We included 186 patients. Those with OHyper had lower suDBP and higher orthostatic SVRI variation compared to NOV. In multivariable analyses, orthostatic HR variation (OR = 1.06 (95%CI 1.01–1.13), p = 0.03) and orthostatic SVRI variation (OR = 1.16 (95%CI 1.06–1.28), p = 0.002) were independently related to OHyper. No variables were independently associated with OHypo. Conclusion: Patients with OHyper have a distinct hemodynamic pattern, with an exaggerated increase in SVRI and HR when standing