El cumplimiento terapéutico en la hipertensión arterial en España, según la opinión de los médicos de familia. Proyecto Cumplex

ObjetivoEvaluar los conocimientos de los médicos sobre el cumplimiento farmacológico en general, su actitud ante éste y sus necesidades de formación.DiseñoEstudio descriptivo, transversal, mediante una encuesta.EmplazamientoCentros de atención primaria de España.ParticipantesParticiparon 3.834 médicos.Mediciones principalesDefinición de incumplimiento, incumplimiento observado en su consulta y el resto de España, métodos de medición, causas, asociación con fracaso terapéutico, eficacia y uso de estrategias para mejorarlo, y necesidad de formación.ResultadosEl 95,9% cumplimentó la encuesta. El 92% (intervalo de confianza [IC] del 95%, 91,1-92,9) define como incumplimiento la omisión por el paciente de 5-20% de las tomas. Un 32,4% (IC del 95%, 30,9-33,9) opinó que menos del 10% sería incumplidor, mientras que un 6,8% (IC del 95%, 6,0-7,6) opinaba que la tasa de incumplimiento en España era inferior al 10%. Los métodos de medición más usados son la respuesta del paciente (77,0%; IC del 9%, 75,7-78,4) y la propia experiencia (76,0%; IC del 95%, 74,6-77,4). El 50,7% cree que el incumplimiento está asociado con el fracaso terapéutico en más del 50%.La presencia de efectos adversos fue considerada una causa muy importante en el mayor porcentaje (81,9%). Las estrategias consideradas más eficaces y utilizadas son: empleo de fármacos en monodosis (84,3%; IC del 95, 83,1-85,5) y consulta de enfermería (84,9%; IC del 95%, 83,8-86,0). El 65,2% (IC del 95%, 63,7-66,7) no ha recibido formación durante la carrera y un 42% (IC del 95%; 40,4-43,6) considera necesario realizar alguna actividad formativa.ConclusionesUn alto porcentaje de medicos utiliza una definición incorrecta de cumplimiento y cree que otros medicos tienen más pacientes incumplidores. Se utilizan preferentemente métodos de medición no validados y se observa un déficit de formación.ObjectivesTo evaluate physicians’ knowledge of therapy compliance, their attitudes towards it and their training needs in this field.DesignTransversal, descriptive study using a questionnaire.SettingPrimary care centres in Spain.ParticipantsThree thousand and trirty four general practitioners.Main measurementsDefinition of non-compliance, non-compliance in their own consultations and in the rest of Spain, methods of measurement, causes, association with therapy failure, efficacy and use of compliance-enhancing strategies, and need for training.ResultsMost participants (92%; 95% CI, 91.1-92.9) defined non-compliance as patients’ failure to take 5%-20% of their pills. A total of 32.4% (95% CI, 30.9%-33.9%) of the physicians estimated that less than 10% of their patients were non-compliers, whereas 6.8% (95% CI, 6.0-7.6) thought this was also the rate in the rest of Spain. The preferred methods of measurement were patient response (77.0%; 75.7-78.4) and their own clinical experience (76.0%; 74.6-77.4). About half (50.7%) believed that lack of compliance was associated with therapy failure in more than 50% of cases. The presence of adverse side-effects was considered a very important cause of poor compliance by 81.9%. The most common and effective strategies were: use of single-dose drugs (84.3%; 83.1-85.5) and nursing support (84.9%; 83.8-86.0).Moreover, 65.2% (63.7-66.7) of the surveyed physicians had not received any education about compliance as medical students and 42% (40.4-43.6) said further training in compliance was needed.ConclusionsA high percentage of physicians define compliance incorrectly and believe that other doctors have more non-complying patients than they do. They tend to favour non-validated measuring methods and they lack training

Prognostic value of non-specific ST-T changes and left ventricular hypertrohpy electrocardiographic criteria in hypertensive patients: 16-year follow-up results from the MINACOR cohort

Background: Non-specific electrocardiographic ST-T wave changes and voltage criteria for left ventricular hypertrophy (LVH) have been associated with cardiovascular morbidity and mortality. The aim of the cohort study was to evaluate the prognostic value of non-specific ST-T changes and LVH electrocardiographic criteria on cardiovascular events and mortality in hypertensive patients. Methods: A cohort study of 352 non-diabetic hypertensive patients, without associated cardiovascular disease, randomly selected from 1,780 hypertensive patients atte nded in a primary care center. An electrocardiogram was performed at the baseline visit (classified according to the Minnesota Code). Cardiovascular events and death from any cause during the follow-up period were evaluate d. A multivariate analysis adjusted for gender, age and cardiovascular risk factors was performed. Results: Data of 273 patients were analyzed: 58.2% women, age 44.1 (7.9) years, 27.8% smokers, blood pressure at baseline 142.7 (15.3)/89.3 (9.6) mmHg. During the 197. 5 (59.24) month follow-up, 62 patients (22.7%) had a cardiovascular event. On multivariate analysis, age, systolic blood pressure, incidence of diabetes, smoking and electrocardiographic LVH criteria (HR 2.66 [CI 95% 1.39 - 5.10]), were significantly a ssociated with cardiovascular events, but the presence of non-specific ST-T abnormali ties (HR 0.97 [CI 95% 0.49 -1. 90]) was not significantly associated with cardiovascular morbidity and mortality. Conclusions: Hypertensive patients with LVH electrocardiographic criteria have significantly higher cardiovascular mortality and morbidity, but non-specific electrocardiographic ST-T changes are not associated with cardiovascular morbidity and mortality. Keywords: Electrocardiogram, Cardiovascular events, Hypertension, Left ventricular hypertrophy, Major and minor electrocardiographic abnormalities, Repolarization electrocardiographic abnormalitie

Intervención no farmacológica como estrategia para favorecer el control de la hipertensión arterial y mejorar el cumplimiento antihipertensivo

ResumenObjetivoComprobar la eficacia de una intervención mediante una revista educacional en el cumplimiento antihipertensivo de la hipertensión arterial (HTA) no controlada.DiseñoEstudio clínico controlado, aleatorizado y multicéntrico.EmplazamientoOchenta y siete Centros de Salud de España.ParticipantesSe incluyeron 450 pacientes hipertensos diagnosticados de HTA no controlada.IntervenciónSe formaron 2 grupos con 225 individuos: a) grupo de intervención (GI), los que recibieron una revista educacional domiciliaria bimensual y b) grupo de control (GC), que tuvieron práctica clínica habitual.Mediciones principalesEl cumplimiento se midió mediante monitores electrónicos (MEMS-Aardex). Se calculó el porcentaje de cumplimiento, el porcentaje de cumplidores del total de dosis y de días en los que tomaba una dosis y el NNT (number needed to treat 'número de pacientes que es necesario tratar'). Se definió cumplidor un consumo del 80 al 110%. Se calculó la presión arterial media y los porcentajes de los controlados.ResultadosConcluyeron 393 individuos (edad: 62,4 años [desviación estándar de 11,6 años]), 196 pacientes del GI y 197 pacientes del GC. Ciento ochenta y cuatro eran varones (46,8%).Fueron cumplidores del total de las dosis tomadas el 83,2% en el GI (del 78 al 88,4%) y el 49,2% del GC (IC del 95%: del 42,2 al 56,2%) (p=0,0001) y fueron cumplidores diarios el 74% del GI (IC del 95%: del 67,9 al 80,1%) y el 42,6% del GC (IC del 95%: del 35,7 al 49,5%) (p=0,0001).El control de la HTA fue del 81,6% en el GI (IC del 95%: del 76,2 al 86,5%) y del 56,3% en el GC (IC del 95%: del 49,4 al 63,2%). El NNT con la intervención fue de 3,3 pacientes.ConclusionesEl incumplimiento del tratamiento fue muy alto. La revista educacional es una estrategia eficaz para disminuir el incumplimiento y mejorar el grado de control de la HTA.AbstractObjetiveTo evaluate the efficacy of an intervention by means of an educational magazine on treatment compliance in uncontrolled arterial hypertension (AHT).DesignControlled, randomised clinical trial.Setting87 primary care centres. Spain.ParticipantsA total of 450 patients with uncontrolled hypertension were included.InterventionTwo groups of 225 patients were formed: 1) Control group (CG): standard health intervention; 2) Intervention Group (IG): received a twice monthly educational magazine at home.Main measurementsCompliance was measured using the Medication Event Monitoring System (MEMS-Aardex). Compliance rate (CR) was recorded. Compliers were defined as individuals with a treatment compliance of 80–110%. The percentage of compliers, the mean percentage of doses taken and the percentage of patients taking the medication at the correct times were estimated. The mean blood pressures (BPs) and the percentage of controlled patientswere calculated. The number needed to treat (NNT) was calculated.ResultsA total of 393 individuals were evaluable (Age: 62.4 years), 196 in the IG and 197 in the CG. There were 83.2% (95% CI 78–88.4) and 49.2% (95% CI 42.2–56.2) (P=0.0001) of overall compliers in the IG and CG, respectively and 74% (95% CI: 67.9–80.1) and 42.6% (95% CI=35.7–49.5) (P=0.0001) of correct times compliers. A total of 81.6% (95% CI=76.2–86.5%)) were controlled in the IG and 56.3% (95% CI=49.4–63.2) in the CG. The NNT was 3.3 patients.ConclusionsTherapeutic non-compliance was very high. The educational magazine is an effective strategy to improve the compliance and degree of control of the AHT

Physician Perception of Blood Pressure Control and Treatment Behavior in High-Risk Hypertensive Patients: A Cross-Sectional Study

Objective: We examined physician perception of blood pressure control and treatment behavior in patients with previous cardiovascular disease and uncontrolled hypertension as defined by European Guidelines. Methods: A cross-sectional study was conducted in which 321 primary care physicians throughout Spain consecutively studied 1,614 patients aged ≥18 years who had been diagnosed and treated for hypertension (blood pressure ≥140/90 mmHg), and had suffered a documented cardiovascular event. The mean value of three blood pressure measurements taken using standardized procedures was used for statistical analysis. Results: Mean blood pressure was 143.4/84.9 mmHg, and only 11.6% of these cardiovascular patients were controlled according to 2007 European Guidelines for Hypertension Management target of <130/80 mmHg. In 702 (49.2%) of the 1426 uncontrolled patients, antihypertensive medication was not changed, and in 480 (68.4%) of these cases this was due to the physicianś judgment that blood pressure was adequately controlled. In 320 (66.7%) of the latter patients, blood pressure was 130-139/80-89 mmHg. Blood pressure level was the main factor associated (inversely) with no change in treatment due to physician perception of adequate control, irrespective of sociodemographic and clinical factors. Conclusions: Physicians do not change antihypertensive treatment in many uncontrolled cardiovascular patients because they considered it unnecessary, especially when the BP values are only slightly above the guideline target. It is possible that the guidelines may be correct, but there is also the possibility that the care by the physicians is appropriate since BP <130/80 mmHg is hard to achieve, and recent reviews suggest there is insufficient evidence to support such a low BP targetFunding for this study was obtained from RECORDATI ESPAÑA, S.L through an unrestricted grant. Krista Lundelin has a ‘‘Rio Hortega’’ research training contract (Expediente CM10/00327) from the Ministry of Science and Innovation (Instituto de Salud Carlos III), Spain Governmen

Evaluation of the relationship between effervescent paracetamol and blood pressure: clinical trial

Background: Paracetamol's solubility is achieved by adding to the excipient sodium salts, either as bicarbonate, carbonate or citrate. As the relationship between salt and hypertension is well known, due to the sodium content it has raised a hypothesis that may interfere with the control of that risk factor. Therefore, the objective of this study is to evaluate the effect on blood pressure of effervescent paracetamol compared to non-effervescent, in hypertensive patients. Methods/Design: This is the protocol of a phase IV multicenter clinical trial, randomized, controlled, crossover, open, which will compare the effect of two different formulations of paracetamol (effervescent or non-effervescent) in the blood pressure of hypertensive patients, with a seven weeks follow up. 49 controlled hypertensive patients will be included (clinical BP lower than 150 and 95 mmHg, and lower than 135 mmHg and 85 mmHg in patients with diabetes or a history of cardiovascular event, and daytime ambulatory measurements lower than 140 and 90 mmHg) and mild to moderate pain (Visual Analog Scale between 1 and 4). The study was approved by the ethics committee of the Fundació Jordi Gol i Gurina and following standards of good clinical practice. The primary endpoint will be the variations in systolic BP in 24 h Ambulatory Blood Pressure Monitoring, considering significant differences 2 or more mmHg among those treated with non-effervescent and effervescent formulations. Intention-to-treat and per-protocol analysis will be held. Discussion: Despite the broad recommendation not to use effervescent drugs in patients with hypertension, there are relatively little studies that show exac tly this pressor effect due to sodium in salt that gives the effervescence of the product. This is the first clinical trial designed to study the effect of effervescence compared to the non-effervescent, in well-controlled hypertensive patients with mild to moderate pain, performed in routine clinical practic