Utilidad de la monitorización ambulatoria de la presión arterial en el pronóstico de los pacientes con insuficiencia cardiaca

La hipertensió arterial és una de les principals causes de la insuficiència cardíaca. Atès que la monitorització ambulatòria de la pressió arterial ha demostrat ser un marcador pronòstic molt fiable de la malaltia cardiovascular en pacients hipertensos sense malaltia cardiovascular, i que les dades de MAPA, en pacients amb IC, són escassos, i provenen de sèries amb un nombre limitat de pacients, ens proposem estudiar les el valor pronòstic de la MAPA en pacients amb IC. La nostra hipòtesi és que la MAPA és el millor predictor de l'evolució de la insuficiència cardíaca i un factor de risc independent del pronòstic d'aquests pacients. Realitzem un estudi prospectiu a pacients amb ingrés previ per IC i en situació d'estabilitat clínica. Als pacients se'ls va realitzar una MAPA de 24h, es van recollir dades de filiació, de comorbiditats, de valoració geriàtrica, analítics i ecocardiogràfics. Així mateix es va fer un seguiment durant un any per determinar l'aparició de noves hospitalitzacions o mort durant un seguiment d'almenys un any. Es van incloure un total de 154 pacients, edat mitjana 76,77 anys, 55.2% dones. Un 76.32 presentaven IC FEP. Els resultats mostren que un patró no reductor s'associa a un pitjor pronòstic. L'anàlisi mitjançant regressió logística va demostrar que no és un factor, sinó únicament un marcador de mal pronòstic. Un 74.02 presentar patró no reductor amb major prevalença de dislipèmia com a única característica diferencial. Un 45,45%, HTAN amb una menor freqüència de DM i menor freqüència de HTA com a causa d'IC com a característica diferencial. El 50% presentava PA ben controlada, amb xifres més elevades d'urea i FC com característiques diferencials. En conclusió un patró no depressor a la MAPA és un marcador de mal pronòstic en pacients amb insuficiència cardíaca, però no és un factor de riscLa hipertensión arterial es una de las principales causas de la Insuficiencia cardiaca. Dado que la monitorización ambulatoria de la presión arterial ha demostrado ser un marcador pronóstico muy fiable de la enfermedad cardiovascular en pacientes hipertensos sin enfermedad cardiovascular, y que los datos de MAPA, en pacientes con IC, son escasos, y provienen de series con un número limitado de pacientes, nos proponemos estudiar las el valor pronóstico de la MAPA en pacientes con IC. Nuestra hipótesis es que la MAPA es el mejor predictor de la evolución de la insuficiencia cardiaca y un factor de riesgo independiente del pronóstico de estos pacientes. Realizamos un estudio prospectivo a pacientes con ingreso previo por IC y en situación de estabilidad clínica. A los pacientes se les realizo una MAPA de 24h, se recogieron datos de filiación, de comorbilidades, de valoración geriátrica, analíticos y ecocardiográficos. Asimismo se realizó un seguimiento durante un año para determinar la aparición de nuevas hospitalizaciones o muerte durante un seguimiento de al menos un año. Se incluyeron un total de 154 pacientes, edad media 76,77 años, 55.2% mujeres. Un 76.32 presentaban IC FEP. Los resultados muestran que un patrón no reductor se asocia a un peor pronóstico. El análisis mediante regresión logística demostró que no es un factor, sino únicamente un marcador de mal pronóstico. Un 74.02 presentó patrón no reductor con mayor prevalencia de dislipemia como única característica diferencial. Un 45,45%, HTAN con una menor frecuencia de DM y menor frecuencia de HTA como causa de IC como característica diferencial. El 50% presentaba PA bien controlada, con cifras más elevadas de urea y FC como características diferenciales. En conclusión un patrón no depresor en la MAPA es un marcador de mal pronóstico en pacientes con insuficiencia cardíaca, pero no es un factor de riesgoHypertension is a major cause of heart failure. Since ambulatory blood pressure monitoring has proven to be a very reliable prognostic marker of cardiovascular disease in hypertensive patients without cardiovascular disease, and its data in patients with heart failure are scarce, mostly coming from series with a limited number of patients, we propose to study the prognostic value of ABPM in patients with HF. Our hypothesis is that ABPM is a good predictor of outcome of heart failure and an independent risk factor for the prognosis of these patients. We performed a prospective study in clinically stable patients with previous hospitalization for heart failure. Patients underwent ABPM, and demographic, comorbidities, geriatric, analytical data and echocardiographic evaluation were collected. Follow up was also performed for a year to determine the emergence of new hospitalizations or death during follow up of at least one year. A total of 154 patients were included, with a mean age of 76.77 years, 55.2% women. A total of 76.32% had HF with preserved ejection fraction. The results show that a non-dipping pattern is associated with a worse prognosis. However, the logistic regression analysis showed that it is not a factor, but only a marker of poor prognosis. Non dipping pattern is present in 74.02%, with higher prevalence of dyslipidemia as the only distinguishing feature. Nocturnal HT is present in a 45.45%, with a lower frequency of DM and lower frequency of hypertension as a cause of the IC as a differentiating feature. Half of the patients with HF, in our study, presented well controlled PA, with higher levels of urea and FC as differential characteristics. In conclusion ABPM Non dipping pattern is a risk marker of worse prognosis in real life Heart failure patients but not a risk facto

Specific Test Panels for Patients With Heart Failure: Implementation and Use in the Spanish National Health System

[Abstract] Objectives. The use of specific test panels (STP) for heart failure (HF) could help improve the management of this condition. The purpose of this study is to gain an insight into the level of implementation of STPs in the management of HF in Spain and gather the opinions of experts, with a special focus on parameters related to iron metabolism. Methods. The opinions of experts in HF were gathered in three stages STAGE 1 as follows: level of implementation of STPs (n=40). STAGE 2: advantages and disadvantages of STPs (n=12). STAGE 3: level of agreement with the composition of three specific STPs for HF: initial evaluation panel, monitoring panel, and de novo panel (n=16). Results. In total, 62.5% of hospitals used STPs for the clinical management of HF, with no association found between the use of STPs and the level of health care (p=0.132) and location of the center (p=0.486) or the availability of a Heart Failure Unit in the center (p=0.737). According to experts, the use of STPs in clinical practice has more advantages than disadvantages (8 vs. 3), with a notable positive impact on diagnostics. Experts gave three motivations and found three limitations to the implementation of STPs. The composition of the three specific STPs for HF was viewed positively by experts. Conclusions. Although the experts interviewed advocate the use of diagnostic and monitoring STPs for HF, efforts are still necessary to achieve the standardization and homogenization of test panels for HF in Spanish hospitals

Ambulatory blood pressure monitoring in heart failure and serum sodium levels

Aims: To determine whether there are differences in blood pressure profile on dynamic assessment by ambulatory blood pressure monitoring (ABPM) according to serum sodium levels in stable heart failure patients.Methods: Data were collected from the Spanish National Registry on Ambulatory Blood Pressure Monitoring in Heart Failure (DICUMAP). Patients underwent ABPM by the oscillometric principle using a Spacelabs 90121 monitor. The sample was divided into three groups according to sodium levels and their clinical and laboratory data and echocardiographic findings were analyzed. Robust statistical methods were used to compare the groups in univariate and multivariate models.Results: A total of 175 patients (44.57% male) were analyzed. We found a predominance of anomalous circadian blood pressure profiles in all three groups, with a significantly higher percentage of risers in the lowest serum sodium group (p=0.05). In addition, in this group there were significant differences in mean 24-hour systolic blood pressure (SBP) (24-h SBP, p=0.05) and in mean daytime SBP (dSBP, p=0.008), with significant differences in nocturnal fall in SBP (p=0.05) and in diastolic blood pressure (p=0.005). In multivariate analysis a significant relationship was found between sodium levels and 24-h SBP (OR 0.97, 95% CI 0.95-0.99, p=0.01) and dSBP (OR 0.96, 95% CI 0.94-0.99, p=0.004).Conclusion: A relationship was found between lower sodium levels and lower systolic blood pressure, especially during waking hours, with a lower decline between daytime and night-timeblood pressure

TIMES TO ACT. Italian-Spanish-Polish-Uzbek Expert Forum Position Paper 2022. Dyslipidemia and arterial hypertension: The two most important and modifiable risk factors in clinical practice

Hypertension and lipid disorders are two of the main cardiovascular risk factors. Both risk factors — if detected early enough — can be controlled and treated with modern, effective drugs, devoid of significant side effects, available in four countries as different as Italy, Spain, Poland, and Uzbekistan. The aim herein, was to develop this TIMES TO ACT consensus to raise the awareness of the available options of the modern and intensified dyslipidemia and arterial hypertension treatments. The subsequent paragraphs involves consensus and discussion of the deleterious effects of COVID-19 in the cardiovascular field, the high prevalence of hypertension and lipid disorders in our countries and the most important reasons for poor control of these two factors. Subsequently proposed, are currently the most efficient and safe therapeutic options in treating dyslipidemia and arterial hypertension, focusing on the benefits of single-pill combination (SPCs) in both conditions. An accelerated algorithm is proposed to start the treatment with a PCSK9 inhibitor, if the target low-density-lipoprotein values have not been reached. As most patients with hypertension and lipid disorders present with multiple comorbidities, discussed are the possibilities of using new SPCs, combining modern drugs from different therapeutic groups, which mode of action does not confirm the “class effect”. We believe our consensus strongly advocates the need to search for patients with cardiovascular risk factors and intensify their lipid-lowering and antihypertensive treatment based on SPCs will improve the control of these two basic cardiovascular risk factors in Italy, Spain, Poland and Uzbekistan

Dyslipidemias: a pending challenge in cardiovascular prevention. Consensus document from CEIPC/SEA Committee

Documento presentado en el XXXI Congreso Nacional de la Sociedad Española de Medicina Interna (SEMI). Oviedo, 18 de noviembre de 2010.En España, donde la enfermedad cardiovascular (ECV) es la primera causa de muerte, aproximadamente el 20% de los adultos presentan hipercolesterolemia, de los cuales sólo el 12% estarían controlados. El abordaje de las dislipemias debe realizarse en un contexto más amplio, mediante acciones encaminadas a reducir el riesgo cardiovascular (RCV). La medición del RCV facilita la toma de decisiones, pero no puede sustituir al juicio clínico, dadas las limitaciones de los métodos de cálculo disponibles. Este documento, elaborado por el Comité Español Interdisciplinar de Prevención Cardiovascular, a iniciativa de la Sociedad Española de Arteriosclerosis, describe las principales iniciativas en prevención cardiovascular de administraciones sanitarias y sociedades científicas, y el papel que juegan en ellas los profesionales sanitarios. Además de apoyar las iniciativas en marcha, se propone la puesta en marcha de una estrategia nacional de prevención cardiovascular, centrada en la modificación de estilos de vida (prevención del tabaquismo y promoción de la alimentación saludable y la actividad física) mediante acciones en todos los ámbitos. A nivel poblacional, la regulación de la publicidad alimentaria, la eliminación de los ácidos grasos trans y la reducción de azúcares añadidos en la cadena alimentaria constituyen intervenciones viables y coste-efectivas para ayudar a controlar las dislipemias y reducir el RCV. En el ámbito sanitario, se propone reducir las barreras para la aplicación de las guías, mejorar la formación de los profesionales en modificación de estilos de vida e incorporar la valoración del RCV entre los indicadores de calidad de la asistencia. Las sociedades científicas son responsables de colaborar con la administración y contribuir a la generación del conocimiento, su transmisión y su aplicación. Finalmente, está en manos de los profesionales evaluar al paciente dislipémico en el contexto del RCV, promover estilos de vida saludables y hacer un uso eficiente del arsenal terapéutico disponible. In Spain, where cardiovascular disease (CVD) is the leading cause of death, hypercholesterolemia, one of the most prevalent risk factors in adults, is poorly controlled. Dyslipidemia should not be approached in isolation, but in the context of overall cardiovascular risk (CVR). Measurement of CVR facilitates decision making, but should not be the only tool nor should it take the place of clinical judgment, given the limitations of the available calculation methods. This document, prepared by the Interdisciplinary Spanish Committee on Cardiovascular Prevention, at the proposal of the Spanish Society of Arteriosclerosis, reviews the cardiovascular prevention activities of the regional health authorities, scientific societies and medical professionals. An initiation of a national strategy on cardiovascular prevention is proposed based on lifestyle modification (healthy diet, physical activity and smoking cessation) through actions in different settings. At the population level, regulation of food advertising, elimination of trans fats and reduction of added sugar are feasible and cost-effective interventions to help control dyslipidemias and reduce CVR. In the health setting, it is proposed to facilitate the application of guidelines, improve training for medical professionals, and include CVR assessment among the quality indicators. Scientific societies should collaborate with the health authorities and contribute to the generation and transmission of knowledge. Finally, it is in the hands of professionals to apply the concept of CVR, promote healthy lifestyles, and make efficient use of available pharmacological treatments

Statement of the Spanish Interdisciplinary Cardiovascular Prevention Committee (CEIPC ) on the 2012 European Cardiovascular Prevention Guidelines

Las guías europeas de prevención cardiovascular contemplan dos sistemas de evaluación de la evidencia (SEC y GRADE) y recomiendan combinar las estrategias poblacional y de alto riesgo, interviniendo en todas las etapas de la vida, con la dieta como piedra angular de la prevención. La valoración del RCV incorpora los niveles de HDL y los factores psicosociales, una categoría de muy alto riesgo y el concepto edad-riesgo. Se recomienda e luso de métodos cognitivo-conductuales (entrevistamotivadora, intervenciones psicológicas), aplicados por profesionales sanitarios, con la participación de familiares de los pacientes, para contrarrestar el estrés psicosocial y reducir el RCV mediante dietas saludables, entrenamiento físico, abandono del tabaco y cumplimiento terapéutico. También se requieren medidas de salud pública, como la prohibición de fumar en lugares públicos o eliminar los ácidos grasos trans de la cadena alimentaria. Otras novedades consisten en desestimar el tratamiento antiagregante en prevención primaria y la recomendación de mantener la PA dentro del rango13-139/80-85 mmHg en pacientes diabéticos o con RCV alto. Se destaca el bajo cumplimiento terapéutico observado, porque influye en el pronóstico de los pacientes y en los costes sanitarios. Para mejorar la prevención cardiovascular se precisa una verdadera alianza entre políticos, administraciones, asociaciones científicas y profesionales de la salud, fundaciones de salud, asociaciones de consumidores, pacientes y sus familias, que impulse las estrategias poblacional e individual, mediante el uso de toda la evidencia científica disponible, desde ensayos clínicos hasta estudios observacionales y modelo matemáticos para evaluar intervenciones a nivel poblacional, incluyendo análisis de coste-efectividadBased on the two main frameworks for evaluating scientific evidence—SEC and GRADE—European cardiovascular prevention guidelines recommend interventions across all life stages using a combination of population-based and high-risk strategies with diet as the cornerstone of prevention. The evaluation of cardiovascular risk (CVR) incorporates HDL level and psycho-social factors, a very high risk category, and the concept of age-risk. They also recommend cognitive-behavioural methods (e.g.,motivational interviewing, psychological interventions, led by health professionals and with the participation of the patient’s family, to counterbalance psychosocial stress and reduce CVR through the institution of positive habits such as a healthy diet, physical activity, smoking cessation, and adherence to treatment. Additionally, public health interventions—such as smoking ban in public areas or the elimination of trans fatty acids from the food chain—are also essential. Other innovations include abandoning antiplatelet therapy in primary prevention and the recommendation of maintaining blood pressure (BP) within the1 30-139/80-85 mmHg range in diabetic patients and individuals with high CVR. Finally ,due to the significant impact on patient progress and medical costs, special emphasisis given to the low therapeutic adherence levels observed . In sum ,improving cardiovascular prevention requires a true partnership among the political class, public administrations, scientific and professional associations, health foundations, consumer associations, patients and their families. Such partnership would promote population-based and individual strategies by taking advantage o the broad spectrum of scientific evidence available, from clinical trials to observational studies and mathematical models to evaluate population-based interventions, including cost-effectiveness analyse

Spanish adaptation of the 2016 European Guidelines on cardiovascular disease prevention in clinical practice

The VI European Guidelines for Cardiovascular Prevention recommend combining population and high-risk strategies with lifestyle changes as a cornerstone of prevention, and propose the SCORE function to quantify cardiovascular risk. The guidelines highlight disease specific interventions, and conditions as women, young people and ethnic minorities. Screening for subclinical atherosclerosis with noninvasive imaging techniques is not recommended. The guidelines distinguish four risk levels (very high, high, moderate and low) with therapeutic objectives for lipid control according to risk. Diabetes mellitus confers a high risk, except for subjects with type 2 diabetes with less than <10 years of evolution, without other risk factors or complications, or type 1 diabetes of short evolution without complications. The decision to start pharmacological treatment of arterial hypertension will depend on the blood pressure level and the cardiovascular risk, taking into account the lesion of target organs. The guidelines don't recommend antiplatelet drugs in primary prevention because of the increased bleeding risk. The low adherence to the medication requires simplified therapeutic regimes and to identify and combat its causes. The guidelines highlight the responsibility of health professionals to take an active role in advocating evidence-based interventions at the population level, and propose effective interventions, at individual and population level, to promote a healthy diet, the practice of physical activity, the cessation of smoking and the protection against alcohol abuse.S