[Results of 5 campaigns to detect previously unidentified cases of hypertension]

OBJECTIVE

To find the efficacy of two methods of detecting previously unknown hypertension--systematic taking of blood pressure (ST) and the Mobile Unit (MU)--and to evaluate the over-diagnosis of arterial hypertension (AHT) in crossover studies which only use epidemiological criteria (EC).

DESIGN

A descriptive study with population and opportunist strategies. An operative MU team attended commercial and work centres within the chosen area. ST looked for AHT in patients attending Health Centre clinics.

INTERVENTION

EC in screening, in line with WHO guidelines and clinical confirmation (CC) in the Health Centres.

SETTING

MU in the catchment areas of Novelda, Carrús and C. Jardin Health areas. ST in the San Miguel de Salinas and C. Jardin Health Centres.

PATIENTS

1654 people over 19 with the MU and 4138 through ST.

RESULTS

Both methods discovered more hypertension in men (MU p = 0.009 and ST p = 0.000) and in the 20 to 39 age group (MU p = 0.000 and ST p = 0.000). EC led to over-diagnosis (5.8% MU and 6.3% ST); greater in men (6.6% and 6.5%) and +/- 60 years old (8.7% and 7.5%). Positive predictive values obtained were 59.8% with MU and 47.4% with ST.

CONCLUSIONS

Both methods are useful ways of identifying people suffering hypertension: both young people and men. But CC is essential in order to make a real diagnosis of AHT. Out of every 10 people detected by using EC, only 5 were confirmed by ST and 6 by MU. This information must be borne in mind when evaluating the the prevalence of AHT in epidemiological studies.

[A four year study of therapeutical observation of patients with hypertension]

We attempt to quantify compliance with hypotension medication regimens in 620 patients with hypertension at the Centros de Salud (community health centers) of Novelda and Elche (in the province of Alicante) and to assess the impact of a mixed-strategy health education program. The method used to evaluate compliance is the self-communicated interview as indicated by Haynes-Sackett. The intervention consisted of individualized instruction, family support, educational leaflets, and written instructions. Among the results obtained, we emphasize the following. First, 64% completed the treatment as prescribed, 16% stopped taking the medication, and 20% followed the regimen in a sporadic fashion, lack of motivation and forgetfulness being the main reasons cited for the latter. Second, 27% of the patients with hypertension--among them, primarily young people and men--do not visit the center for monitoring. Third, the health education program is responsible for a significant increase in blood pressure measurements and in therapeutic compliance, also reducing the number of drop-outs. Fourth, 26% did not come to the unit at the end of the study period (four years) despite phone calls and house visits as reminders.

[Indicators of follow-up activities undertaken by an arterial hypertension unit over a 5 year period]

OBJECTIVE

To assess the efficacy and effectiveness of an AHT programme by means of indicators which analyse the coverage, results and attendance.

SETTING

AHT unit at the Health Centre in Novelda, Alicante.

DESIGN

A quasi-experimental design of internal comparison with temporal series. The years analysed were 1985, '87, '88 and '90. The following were assessed: support, therapeutic compliance, risk level, weight, monitoring, visits per year, therapy, risk factors.

PATIENTS

A cohort of 266 hypertense patients (175 women and 91 men).

MEASUREMENTS AND MAIN RESULTS

The Unit significantly increased the number of patients being monitored and treated (WHO 46.7% and JNC 9.1%), but never exceeded 60%. Serious risk was eliminated and moderate risk went down (27.7%). Visits to the Centre were reduced by 2.8 per year. Of risk factors, weight did not go down, but hypercholesterolaemia diminished by 48.4%, hypertriglyceridaemia by 9.8%, hyperglycaemia by 4.4%, hyperuricaemia by 7.9% and tobacco addiction by 19.9%.

CONCLUSIONS

These figures contain extremely interesting information. They reveal the achievements and difficulties of clinical practice and point to practical strategies.

[The benefits of auditing clinical histories. Our experience over 5 years]

OBJECTIVE

To evaluate how our clinical records (CR) are filled in and to observe the impact of measures taken to correct faults found over a five-year follow-up period.

DESIGN

Three descriptive studies (auditing methodologies) on representative samples of CR selected at random. Four quality indicators were fixed: internal communication (i.e. legibility and comprehensibility), external communication, manageability and the quality of the activity at attendances measured by the SOAP. The optimum standards (OS) were agreed by the team (technique of nominal group).

SETTING

"Florida" Health Centre, Alicante.

PATIENTS AND OTHERS PARTICIPANTS

Periodic team meetings to analyse results and agree activities. In 1986, N of CR = 367; in 1988, 370; and in 1990, 372.

MAIN MEASUREMENTS AND RESULTS

During the follow-up period, the filling-in of all the variables, except the address, the test carried out and blood pressure, improved. But the following did not reach the OS: code, affiliation, origin, instruction, habits, allergies, working activity, socio-economic data, age and gender, family/personal background, test carried out, blood pressure and analytical data. The following all reached the OS: legibility, which went up from 88% to 96.5%, comprehensibility from 62 to 75.3%, external communication from 81 to 88.9%, manageability from 53 to 79.6% and SOAP from 62 to 82.5%.

CONCLUSIONS

Auditing allows the level of the filling-in of the CR to be measured. Deficiencies which appear to be due to the design of the record itself can be detected. The efficacy of corrective measures to improve records can also be assessed.

[Combined infarction: angiography and electrocardiographic diagnosis]

Combined infarction can be defined as the presence of ST segment elevation simultaneously in anterior and inferior leads. Their possible anatomical and physiopathological causes are suggested. Four cases of combined infarction, three of them in previously asymptomatic patients are presented, with their electrocardiographic and angiocoronarography patterns. Acute phase and 24 hours ECG ST changes are analysed and the possibility of an indirect approach to the angiographic diagnosis, is discussed.

[Ibopamine in the treatment of congestive heart failure. Multicenter follow-up study]

OBJECTIVE

To assess safety and efficacy of ibopamine, 200 mg TID, added to conventional treatment of congestive heart failure.

DESIGN

A prospective, longterm, open study over two years (1986-88). A multicenter trial.

SETTING

Outpatients of Departments of Internal Medicine of S. Francisco Xavier Hospital and Sta. Maria Hospital, and Departments of Cardiology of Sta. Cruz Hospital and Hospital Militar Principal, Lisbon.

PATIENTS AND METHODOLOGY

63 patients, 49 males from 34 to 80 years (m = 55.6 +/- 11.36) and 14 females from 41 to 80 years (m = 63 +/- 10.2), with congestive heart failure, NYHA class II in 52 patients (82.5%) and NYHA class III in 11 patients (17.5%) with a mean disease duration of 47.9 months entered into the study. Digoxin, diuretics, nitrates and antiarrhythmic drugs were allowed as concomitant therapy. Patients carried out clinical examination, ECG and laboratory tests monthly and X-Ray at the beginning and at the end of each year of the study.

RESULTS

42 patients completed one year of treatment and 20/42 continued for an additional year, 17 patients completed this second year of follow-up. From the 42 patients who completed the first year period, the NYHA class changed from II to I in 17/38 from II to III in 2/38 patients from III to II in 3/4 patients, and from III to IV in one patient. Twenty patients dropped during the first year of treatment. Six for non-compliance (less than 80% of the treatment). Two were submitted to cardiac valve surgery. Seven had cardiovascular clinical events: one ventricular tachycardia, one atrial fibrillation, one pulmonary edema, one patient had no therapeutic effect, two patients had anxiety and fatigue and one patient died suddenly. One diabetic patient had uncontrolled hyperglycemia. One patient had gastric ulcer. Two had nausea and vomiting. Dysrhythmia and nausea and vomiting were the only clinical events, considered, respectively, possibly related and related, to ibopamine. During the second year of treatment 9/11 patients were stabilized in NYHA class I and 6/9 in NYHA class II, one patient changed from class II to class I, and one patient changed from class I to class II of the NYHA. Three patients did not complete the second year of treatment; one due to abnormal creatininemia; one for probable pulmonary embolism with CHF worsening; the third died suddenly. None of these events was considered related to ibopamine. Heart rate, arterial pressure, laboratory values and cardiothoracic index did not vary over the two years of the study.

CONCLUSIONS

This has been the first study with data from patients treated with 200 mg TID of ibopamine during two years. Ibopamine has been shown to be a safe and useful drug added to conventional treatment of cardiac heart failure. Clinical events were few and well controlled after ibopamine interruption.

Respiratory, muscular, and overall perceptions of effort: the influence of hypoxia and muscle mass

Overall, respiratory and peripheral muscular perceptions of exercise have been examined in 16 subjects (eight men and eight women), each performing four types of exercise (two-leg, one-leg, arm + shoulder, and arm ergometry) under both normoxic and hypoxic (12% oxygen) conditions. Subjects could distinguish ratings for the three types of sensation. Both overall and peripheral muscular perceptions associated with a given oxygen intake or power output increased more than respiratory perceptions as the volume of active muscle was decreased. Hypoxia tended to increase both overall and respiratory perceptions for a given absolute oxygen consumption. Cross-modal comparisons suggested an average overall RPE of close to 13 units at 70% of a task and environment-specific peak oxygen intake, irrespective of exercise conditions, but the SD of individual responses varied by at least +/- 2 units about this average. Peripheral muscular sensations dominated small muscle tasks, but the peripheral muscular RPE became relatively consistent when related to external work rate per liter of active muscle. Respiratory perceptions provided some guide to the intensity of physical activity with a given mode of exercise and fixed environmental conditions. However, if respiratory RPE is used to "fine-tune" cross-modal exercise prescriptions, account must be taken of the distorting influence of active muscle volume and of hypoxia.

[Contribution of the electrocardiogram to the diagnosis of localization and extension of coronary lesions in patients with acute myocardial infarct]

With the purpose of evaluating the contribution of the ECG to the localization and extension of coronary artery lesions, 85 patients with the first acute myocardial infarction treated with thrombolysis, 79 males and 6 females (mean age 53.9 years), were studied, and the ECG changes at 3.5 and 24 hours correlated with the coronary angiographic findings before discharge. Patients were divided in two groups--Group A with anterior infarction (48 pts) and Group B with inferior infarction (37 pts).

RESULTS

A) Returning of the ST downslope to baseline in inferior and anterior leads, respectively in anterior and inferior infarction at 24 h ECG, excluded associated LAD or RCA/CX lesions with a sensitivity (S) of 93% and 87% and aspecificity (E) of 60% and 58%, with a positive predictive value (PPV) of 62% and 77% and a negative predictive value of 86% and 85% respectively. All patients with anterior infarction had LAD stenosis. B) ST upslope bigger than 5 mm in V2-V3 or its presence in D-I or aVL associated to any precordial leads, diagnosed proximal LAD lesions with S of 82% and 73% and E of 75% and 73% respectively. The left axis deviation was present in 6 of 7 patients and pointed to proximal lesion. C) In Group B patients, RCA lesion was related to ST downslope in D-I, S = 77%, E = 37.5%, PVV = 80% and NPV = 33.5%, and the proximal localization (ratio between ST downslope in V2 and ST upslope in aVF) inferior to 0.5 mm with S and NPV = 80% and E and PPV = 100%. The presence of an isoelectrical ST in D-I in association with ST upslope in V5-V6 is related to CX with S and NPV = 100%, E = 85% and PPV = 25%. In conclusion, these results suggest that a careful analysis of ECG changes in patients with first acute myocardial infarction, can provide important information regarding the infarct related artery, localization of the stenosis and the presence of associated coronary artery disease, with implications in the risk stratification before hospital discharge.

[Cardiovascular risk factors in the working population of Alicante]

The aim of the present study was to evaluate the prevalence of certain cardiovascular risk factors in the population of Asepeyo-Elche. The study sample was a working population of 697 persons (71.8% males and 28.2% females) with ages ranging from 15 to 65 years (mean age 34.7 +/- 13.2 years), seen during the first 6 months of 1990 in the health care center of Asepeyo-Elche. The evaluated cardiovascular risk factors and their prevalence rates were: hypertension (14.2%), hypercholesterolemia (18.5%), smoking (52.5%), hyperglycemia (3.5%), obesity (28.2%) and sedentariness (80.3%). We conclude that in our working population the prevalence rates of some cardiovascular risk factors are high and that intervention programs to modify the diet and lifestyle are mandatory to prevent the pathogenetic consequences of these factors.

[Computerized precordial mapping--the Mapcard system]

A computerized Data Acquisition System conceived and built by LNETI/DEE in cooperation with Department of Cardiology of Hospital Santa Cruz, and its application to processing and representation of cardiac precordial maps (MAPCARD SYSTEM), was described. A description was made about the evolution on cardiac maps, their main areas of interest, pointing to future ways. With this economic and easy to use system, important perspectives of hospital utilization are opened, in the fields of non invasive diagnostic and clinical research technics.