Diferencias de género de la enfermedad cardiovascular y sus factores de riesgo asociados en especial referencia a la hipertensión y a la obesidad

Tesis doctoral inédita leída en la Universidad Autónoma de Madrid, Facultad de Medicina, Departamento de Medicina Preventiva y Salud Pública Y Microbiología. Fecha de lectura: 18-06-201

Valores de referencia y puntos de corte de leptina para identificar anormalidad cardiometabólica en la población española

Antecedentes y objetivo: Estimar los valores de referencia de leptina y calcular los puntos de corte de leptinemia que identifiquen anormalidad cardiometabólica en España. Métodos: Estudio transversal realizado de 2008 a 2010 sobre 11.540 individuos representativos de la población española ≥ 18 años. La información se obtuvo mediante examen físico estandarizado y las analíticas se realizaron en un laboratorio central. La leptinemia se midió por inmunoensayo enzimático. Se definió anormalidad cardiometabólica como la presencia de ≥ 2 de las siguientes anormalidades: presión arterial elevada; triglicéridos elevados; colesterol unido a lipoproteínas de alta densidad bajo; valores altos de resistencia a insulina según homeostasis model assessment; proteína C reactiva y glucosa elevada. Resultados: Los niveles de leptina fueron mayores en mujeres que en varones (media geométrica 21,9 ng/ml y 6,6 ng/ml, respectivamente, p<0.001) y aumentaban con la edad y el índice de masa corporal (p<0,001). La mediana fue 24,5 ng/ml en mujeres (rango intercuartílico P25-P75: 14,1-37,0) y 7,2 ng/ml en varones (P25-P75: 3,3-14,3). La leptinemia fue mayor en sujetos con obesidad general o abdominal, diabetes, hipertensión o síndrome metabólico (p<0.001 en todos los casos). Los valores de leptinemia que identificaron anormalidad cardiometabólica fueron 23,75 ng/ml en mujeres (área bajo la curva 0,722, 72,3% sensibilidad y 58,7% especificidad), y 6,45 ng/ml en varones (área bajo la curva 0,716, 71,4% sensibilidad y 60,2% especificidad). Conclusiones: Estos resultados facilitan la interpretación de los valores de leptinemia en estudios clínicos y poblacionales. La leptina tiene sensibilidad y especificidad moderadas para identificar anormalidad cardiometabólica en ambos sexosLos datos de este análisis proceden del estudio ENRICA, que fue financiado por Sanofi-Aventis. La financiación específica para este análisis procede de los proyectos FIS PI13/02321 y “Cátedra UAM de Epidemiología y Control del Riesgo Cardiovascular”, Madri

Short-term variability and nocturnal decline in ambulatory blood pressure in normotension, white-coat hypertension, masked hypertension and sustained hypertension: A population-based study of older individuals in Spain

Blood pressure (BP) variability and nocturnal decline in blood pressure are associated with cardiovascular outcomes. However, little is known about whether these indexes are associated with white-coat and masked hypertension. We performed a cross-sectional analysis of 1047 community-dwelling individuals aged ≥60 years in Spain in 2012. Three observer-measured home BPs and 24-h ambulatory blood pr essure monitoring (ABPM) were performed under standardized conditions. BP variability was defined as BP s.d. and coefficient of variation. Differences in BP variability and nocturnal BP decrease between groups were adjusted for sociodemographic and clinical covariates using generalized linear models. Of the cohort, 21.7% had white-coat hypertension, 7.0% had masked hypertension, 21.4% had sustained hypertension, and 49.9% were normotensive. Twenty-four hour, daytime and night-time systolic BP s.d. and coefficients of variation were significantly higher in subjects with white-coat hypertension than those with normotension (P &lt; 0.05) and were similar to subjects with sustained hypertension. In untreated subjects, 24-h but not daytime or night-time BP variability indexes were significantly higher in subjects with white-coat hypertension than in those with normotension (P &lt; 0.05). Percentage decrease in nocturnal systolic and diastolic BP was greatest in the white-coat hypertension group and lowest in the masked hypertension group in all patients and untreated patients (P &lt; 0.05). Lack of nocturnal decline in systolic blood pressure was observed in 70.2% of subjects with normotension, 57.8% of subjects with white-coat hypertension, 78.1% of subjects with masked hypertension, and 72.2% of subjects with sustained hypertension (P &lt; 0.001). In conclusion, 24-h BP variability was higher in subjects with white-coat hypertension and blunted nocturnal BP decrease was observed more frequently in subjects with masked hypertension. These findings may help to explain the reports of increased cardiovascular risk in patients with white-coat hypertension and poor prognosis in those with masked hypertension, highlighting the importance of ABPMStudy partially funded by FIS grant PI13/02321 and PI16/01460 (Instituto de Salud Carlos III and FEDER/FSE) and CIBERES

Impact of ambulatory blood pressure monitoring on reclassification of hypertension prevalence and control in older people in Spain

This is the submitted version of the following article: Impact of ambulatory blood pressure monitoring on reclassification of hypertension prevalence and control in older people in Spain, Journal of Clinical Hypertension 17.6:453-61 which has been published in final form at http://dx.doi.org/10.1111/jch.12525. This article may be used for non-commercial purposes in accordance with the Wiley Self-Archiving Policy wiley.com/WileyCDA/Section/id- 820227.htmlAmbulatory blood pressure monitoring (ABPM) accurately classifies blood pressure (BP) status but its impact on the prevalence and control of hypertension is little known. The authors conducted a cross-sectional study in 2012 among 1047 individuals 60 years and older from the follow-up of a population cohort in Spain. Three casual BP measurements and 24-hour ABPM were performed under standardized conditions. Approximately 68.8% patients were hypertensive based on casual BP (≥140/90 mm Hg or current BP medication use) and 62.1% based on 24-hour ABPM (≥130/80 mm Hg or current BP medication use) (P=.009). The proportion of patients with treatment-eligible hypertension who met BP goals increased from 37.4% based on the casual BP target to 54.1% based on the 24-hour BP target (absolute difference, 16.7%; P<.01). These results were consistent across alternative BP thresholds. Therefore, compared with casual BP, 24-hour ABPM led to a reduction in the proportion of older patients recommended for hypertension treatment and a substantial increase in the proportion of those with hypertension controlData collection was funded by Fondo de Investigación Sanitaria (FIS) grants 09/1626 and 12/1166 (Ministry of Health of Spain) and by the ‘Cátedra UAM de Epidemiología y Control del Riesgo Cardiovascular’. Specific funding for this analysis was obtained from FIS grant PI13/02321

Medical students maintain their humanistic and patient‑centred vocation throughout Medicine Degree in Spain: a study based on narratives

Narrative medicine has great educational potential in the degree of medicine. This study explores for the frst time the use of narrative medicine in relation to longitudinal evolution of medical vocation for the same group of students. In the context of the Degree in Medicine at the Universidad Autónoma de Madrid (Spain), students wrote narratives about what it meant to them to be a doctor at the beginning and end of their studies. The narratives of 338 students of the academic years 2012/13– 2017/18 and 2013/14–2018/19 were analysed and compared. Students mostly pursued a degree in medicine on account of humanistic motivations, which are reinforced throughout their degree. In contrast, up to 10% of students reference to have experienced vocational crises and sufered frustration, with up to 25% of the references pertaining to having made signifcant sacrifces. Students maintain and evolve their humanistic, patient-centred vision throughout their degree studies, despite the difculties they appear to encounter. We suggest that eforts must be made to include more humanistic perspectives in the medical degree to keep this trend, which may improve both the educational experience created in universities and the health care given to patient

Key Factors for Optimal Care Models for Heart Failure: An Integrative and Multidisciplinary Approach

[Resumen] Introducción y objetivos. La insuficiencia cardiaca (IC) supone un reto para los sistemas sanitarios que se puede responder a través del desarrollo de modelos integrales de atención. Un grupo multidisciplinar de expertos reflexionó sobre los factores clave para avanzar en el desarrollo de este tipo de modelos, planteando una hoja de ruta dirigida a todos los agentes (administraciones, gestores y profesionales sanitarios). Métodos. Se conformó un panel Delphi multidisciplinar integrado por un comité asesor de 15 expertos y un panel adicional de 31 expertos. A través de una revisión bibliográfica sistemática y entrevistas individuales semiestructuradas se realizó un diagnóstico e identificación de retos y áreas de mejora a lo largo del proceso asistencial. El panel Delphi consensuó y priorizó los factores clave con la metodología Delphi Rand/UCLA, valorando su adecuación y necesidad. Resultados. Tras 2 rondas de valoración Delphi se consensuó una propuesta de 7 retos y 75 factores clave para el desarrollo de modelos integrados para la IC. Los 25 factores clave considerados altamente prioritarios se relacionan con la necesidad de una mayor coordinación y planificación a nivel de gestión sanitaria, el abordaje integral durante la hospitalización y la implantación de medidas de continuidad y coordinación asistencial, garantizando que se cubren las necesidades específicas de diferentes perfiles de pacientes. Conclusiones. La propuesta y priorización de acciones para avanzar en modelos de atención integral a la IC debe surgir de reflexiones multidisciplinares y multinivel que incluyan la visión de los pacientes y cuidadores.[Abstract] Introduction and objectives. Heart failure (HF) is a challenge for health systems that can be responded through the development of comprehensive care models. A multidisciplinary group of experts reflected on the key factors that could facilitate the development of this type of models, proposing a roadmap aimed at all agents (politicians, managers, administrators, and health professional). Methods. A multidisciplinary Delphi panel was formed, made up of an advisory committee of 15 experts and an additional panel of 31 experts. After a systematic bibliographic review and semi-structured individual interviews, a diagnosis and identification of challenges and areas for improvement were made throughout the healthcare process. The Delphi panel agreed and prioritized the key factors applying Delphi Rand/UCLA methodology, assessing their appropriateness and need. Results. After 2 rounds of Delphi assessment, a proposal of 7 challenges and 75 key factors was agreed upon for the development of integrated models for HF. The 25 key factors considered high priority are related to the need for greater coordination and planning at the health management level, the comprehensive approach during hospitalization and the implementation of measures of continuity and care coordination, ensuring that the specific needs of different patient profiles. Conclusions. The proposal and prioritization of actions to advance in models of comprehensive care for HF must arise from multidisciplinary and multilevel reflections that include the vision of patients and caregivers.El proyecto MAIC ha sido financiado por Boehringer Ingelheim Españ

May Measurement Month 2018: a pragmatic global screening campaign to raise awareness of blood pressure by the International Society of Hypertension

Aims Raised blood pressure (BP) is the biggest contributor to mortality and disease burden worldwide and fewer than half of those with hypertension are aware of it. May Measurement Month (MMM) is a global campaign set up in 2017, to raise awareness of high BP and as a pragmatic solution to a lack of formal screening worldwide. The 2018 campaign was expanded, aiming to include more participants and countries. Methods and results Eighty-nine countries participated in MMM 2018. Volunteers (≥18 years) were recruited through opportunistic sampling at a variety of screening sites. Each participant had three BP measurements and completed a questionnaire on demographic, lifestyle, and environmental factors. Hypertension was defined as a systolic BP ≥140 mmHg or diastolic BP ≥90 mmHg, or taking antihypertensive medication. In total, 74.9% of screenees provided three BP readings. Multiple imputation using chained equations was used to impute missing readings. 1 504 963 individuals (mean age 45.3 years; 52.4% female) were screened. After multiple imputation, 502 079 (33.4%) individuals had hypertension, of whom 59.5% were aware of their diagnosis and 55.3% were taking antihypertensive medication. Of those on medication, 60.0% were controlled and of all hypertensives, 33.2% were controlled. We detected 224 285 individuals with untreated hypertension and 111 214 individuals with inadequately treated (systolic BP ≥ 140 mmHg or diastolic BP ≥ 90 mmHg) hypertension. Conclusion May Measurement Month expanded significantly compared with 2017, including more participants in more countries. The campaign identified over 335 000 adults with untreated or inadequately treated hypertension. In the absence of systematic screening programmes, MMM was effective at raising awareness at least among these individuals at risk

Position statement on ambulatory blood pressure monitoring (ABPM) by the Spanish Society of Hypertension (2019)

La medida de presión arterial (PA) en la clínica es el procedimiento más utilizado para el diagnóstico y tratamiento de la hipertensión arterial (HTA), pero presenta una considerable inexactitud debida, por un lado, a la propia variabilidad intrínseca de la PA y, por otro, a sesgos derivados de la técnica y condiciones de medida. Varios estudios han demostrado la superioridad pronóstica de la monitorización ambulatoria de la PA (MAPA), que además detecta la HTA de bata blanca, evitando sobrediagnósticos y sobretratamientos en numerosos casos, y la HTA enmascarada que, al contrario, tiene riesgo de infradetección e infratratamiento. La MAPA está reconocida como la técnica más apropiada para el diagnóstico y seguimiento de la HTA en la mayoría de las guías internacionales. El presente documento, tomando como referencia las recomendaciones de la Sociedad Europea de Hipertensión, tiene como objetivo revisar las evidencias sobre la MAPA, servir de guía a los profesionales sanitarios y fomentar la utilización de esta técnica en el diagnóstico y el seguimiento del paciente hipertenso. Se abordan el procedimiento, los requisitos necesarios para realizar una MAPA y sus indicaciones clínicas. También se analizan las principales aportaciones de la MAPA en el diagnóstico de los fenotipos de HTA de bata blanca y HTA enmascarada, los patrones de variabilidad a corto plazo de la PA, su utilidad en la HTA resistente y de alto riesgo, así como su papel en grupos especiales de población como ancianos, niños y embarazadas. Finalmente, se tratan aspectos sobre la situación actual del Registro español de MAPA y las perspectivas futuras en cuanto a investigación y generalización de la MAPA en la práctica clínica.Conventional blood pressure (BP) measurement in clinical practice is the most used procedure for the diagnosis and treatment of hypertension (HT), but is subject to considerable inaccuracies due to, on the one hand, the inherent variability of the BP itself and, on the other hand biases arising from the measurement technique and conditions, Some studies have demonstrated the prognosis superiority in the development of cardiovascular disease using ambulatory blood pressure monitoring (ABPM). It can also detect “white coat” hypertension, avoiding over-diagnosis and over-treatment in many cases, as well detecting of masked hypertension, avoiding under-detection and under-treatment. ABPM is recognised in the diagnosis and management of HT in most of international guidelines on hypertension. The present document, taking the recommendations of the European Society of Hypertension as a reference, aims to review the more recent evidence on ABPM, and to serve as guidelines for health professionals in their clinical practice and to encourage ABPM use in the diagnosis and follow-up of hypertensive subjects. Requirements, procedure, and clinical indications for using ABPM are provided. An analysis is also made of the main contributions of ABPM in the diagnosis of “white coat” and masked HT phenotypes, short term BP variability patterns, its use in high risk and resistant hypertension, as well as its the role in special population groups like children, pregnancy and elderly. Finally, some aspects about the current situation of the Spanish ABPM Registry and future perspectives in research and potential ABPM generalisation in clinical practice are also discussed.Sin financiaciónNo data JCR 20190.130 SJR (2019) Q4, 314/362 Cardiology and Cardiovascular Medicine, 109/139 Internal MedicineNo data IDR 2019UE

May Measurement Month 2018: An analysis of blood pressure screening results from Spain

Elevated blood pressure (BP) is the single most important contributing risk factor to the global disease burden, leading to over 10 million deaths each year. In Spain, hypertension (HTN) affects around 20% of the adult population and remains the greatest attributable cause of cardiovascular mortality. May Measurement Month (MMM) is a worldwide initiative aimed at increasing awareness of HTN and to improve the lack of screening programmes worldwide. An opportunistic cross-sectional survey of volunteers aged 18 and over was carried out in May 2018. Blood pressure measurement, the definition of HTN and statistical analysis followed the standard MMM protocol. Anthropometric data and responses to questionnaires on demographic, lifestyle, and environmental factors were obtained as additional information. Screening sites mainly in community pharmacies, universities, primary care centres, HTN units, and cardiovascular departments in hospitals were set up across Spain as part of this initiative. In total, 7646 individuals (63.5% female) were screened during MMM18. After multiple imputation, 40.0% had HTN, of whom 74.4% were aware of their diagnosis and 69.6% were taking antihypertensive medication. Of individuals not receiving antihypertensive medication, 16.9% were hypertensive. Of individuals receiving antihypertensive medication, 36.4% had uncontrolled BP. MMM18 almost doubled the number of participants of MMM17 and was the largest BP screening campaign ever undertaken in Spain, showing that in the absence of systematic screening programmes for HTN, MMM can identify a great number of individuals at risk, increasing their awareness and attracting the interest of the healthcare system in Spain.Sin financiación1.803 JCR (2020) Q4, 120/142 Cardiac & Cardiovascular Systems0.389 SJR (2020) Q3, 219/349 Cardiology and Cardiovascular MedicineNo data IDR 2020UE

Documento de la Sociedad Española de Hipertensión-Liga Española para la Lucha contra la Hipertensión Arterial (SEH-LELHA) sobre las guías ACC/AHA 2017 de hipertensión arterial

El American College of Cardiology (ACC) y la American Heart Association (AHA) han publicado recientemente la guía para la prevención, detección, evaluación y tratamiento de la hipertensión arterial (HTA) en adultos. El punto más controvertido es el umbral diagnóstico de 130/80 mmHg, lo cual conlleva diagnosticar HTA en un gran número de personas previamente consideradas no hipertensas. La presión arterial (PA) se clasifica como normal (sistólica < 120 y diastólica 80 mmHg), elevada (120-129 y <80 mmHg), grado 1 (130-139 o 80-89 mmHg) y grado 2 (≥140 o ≥90 mmHg). Se recomienda la medida de PA fuera de la consulta para confirmar el diagnóstico de HTA o para aumentar el tratamiento. En la toma de decisiones sería determinante el riesgo cardiovascular (RCV), ya que precisarían tratamiento farmacológico personas con HTA grado 1 con riesgo a 10 años de enfermedad cardiovascular aterosclerótica ≥10% y aquellas con enfermedad cardiovascular establecida, enfermedad renal crónica y diabetes, siendo el resto susceptibles de medidas no farmacológicas hasta umbrales de 140/90 mmHg. Dichas recomendaciones permitirían a los sujetos con HTA grado 1 y alto RCV beneficiarse de terapias farmacológicas y podrían mejorar las intervenciones no farmacológicas en todos los sujetos. Sin embargo, habría que ser cauteloso ya que sin poder garantizar una toma correcta de PA, ni el cálculo sistemático del RCV, la aplicación de dichos criterios podría sobrestimar el diagnóstico de HTA y suponer un sobretratamiento innecesario. Las guías son recomendaciones, no imposiciones, y el abordaje y manejo de la PA debe ser individualizado, basado en decisiones clínicas, preferencias de los pacientes y en un balance adecuado del beneficio y riesgo al establecer los diferentes objetivos de PA.The American College of Cardiology (ACC) and the American Heart Association (AHA) have recently published their guidelines for the prevention, detection, evaluation, and management of hypertension in adults. The most controversial issue is the classification threshold at 130/80 mmHg, which will allow a large number of patients to be diagnosed as hypertensive who were previously considered normotensive. Blood pressure (BP) is considered normal (<120 mmHg systolic and <80 mmHg diastolic), elevated (120-129 and <80 mmHg), stage 1 (130-139 or 80-89 mmHg), and stage 2 (≥140 or ≥90 mmHg). Out-of-office BP measurements are recommended to confirm the diagnosis of hypertension and for titration of BP-lowering medication. In management, cardiovascular risk would be determinant since those with grade 1 hypertension and an estimated 10-year risk of atherosclerotic cardiovascular disease ≥10%, and those with cardiovascular disease, chronic kidney disease and/or diabetes will require pharmacological treatment, the rest being susceptible to non-pharmacological treatment up to the 140/90 mmHg threshold. These recommendations would allow patients with level 1 hypertension and high atherosclerotic cardiovascular disease to benefit from pharmacological therapies and all patients could also benefit from improved non-pharmacological therapies. However, this approach should be cautious because inadequate BP measurement and/or lack of systematic atherosclerotic cardiovascular disease calculation could lead to overestimation in diagnosing hypertension and to overtreatment. Guidelines are recommendations, not impositions, and the management of hypertension should be individualized, based on clinical decisions, preferences of the patients, and an adequate balance between benefits and risks.Sin financiaciónNo data JCR 20180.129 SJR (2018) Q4, 297/365 Cardiology and Cardiovascular Medicine, 113/141 Internal MedicineNo data IDR 2018UE