[Cardiovascular preventive recommendations. PAPPS 2022 thematic updates. Working groups of the PAPPS]

The recommendations of the semFYC's Program for Preventive Activities and Health Promotion (PAPPS) for the prevention of cardiovascular diseases (CVD) are presented. The following sections are included: epidemiological review, where the current morbidity and mortality of CVD in Spain and its evolution as well as the main risk factors are described; cardiovascular (CV) risk and recommendations for the calculation of CV risk; main risk factors such as arterial hypertension, dyslipidemia and diabetes mellitus, describing the method for their diagnosis, therapeutic objectives and recommendations for lifestyle measures and pharmacological treatment; indications for antiplatelet therapy, and recommendations for screening of atrial fibrillation, and recommendations for management of chronic conditions. The quality of testing and the strength of the recommendation are included in the main recommendations.

Evaluation of the antihypertensive effect of nocturnal administration of acetylsalicylic acid: a cross-over randomized clinical trial

OBJECTIVE

Several studies have shown that evening intake of aspirin has antihypertensive effect in healthy adults, which has not been proven in patients with cardiovascular disease, who mostly take aspirin in the morning. We have evaluated the antihypertensive effect of bedtime administration of aspirin in patients with cardiovascular disease already treated for hypertension.

METHODS

This is a multicenter randomized triple-blind placebo-controlled crossover trial, with hypertensive patients treated with aspirin for secondary prevention. There was a baseline-randomized assignment to 2-month periods of bedtime aspirin (100 mg) first and morning-time aspirin later, or inversely, both periods separated by an open label 2-4 weeks period of morning-time aspirin. At the start and end of each treatment period, a 24-h ambulatory blood pressure monitoring was performed. The main outcome measure was mean 24-h blood pressure. The analyses were performed according to the intention-to-treat principle.

RESULTS

Overall, 225 patients were randomized. No significant differences were observed in ambulatory blood pressure by time of intake of usual low doses of aspirin. The mean SBP/DBP was 123.2/69.9 (95% CI 121.58-124.9/68.86-76.86) with bedtime administration and 122.4/68.8 (95% CI 120.76-124.01/67.85-69.83) with daytime administration (P = 0.3 and P = 0.23 for SBP and DBP, respectively).

CONCLUSION

Administering aspirin at bedtime rather than in the morning does not modify the 24-h ambulatory blood pressure in hypertensive patients in secondary cardiovascular prevention.The trial was registered with ClinicalTrials.gov (number NCT01741922).

Prevalence and clinical characteristics of white-coat hypertension based on different definition criteria in untreated and treated patients

BACKGROUND AND AIM

The prevalence and associated risks of white-coat hypertension (WCH) are still a matter of debate. We aimed to assess differences in prevalence and associated conditions of WCH defined on the basis of the normality of all daytime, night-time, and 24-h blood pressure (BP), only daytime, or only 24-h BP.

METHODS

We selected 115 708 patients (45 020 untreated and 70 688 treated) from the Spanish Ambulatory BP Monitoring Registry. WCH was estimated in patients with elevated office BP (≥140 and/or 90 mmHg) by using normal daytime (<135/85) BP, normal 24-h BP (<130/80), or normal daytime, night-time (<120/70) and 24-h BP. Demographic and clinical data (associated risk factors and organ damage) were compared among groups.

RESULTS

Prevalence of WCH was 41.3, 35.2, and 26.1% in untreated, and 45.8, 38.9, and 27.2% in treated patients with elevated office BP, by using the criteria of daytime, 24-h, or all ambulatory periods. Compared with the normotensive group, WCH defined by normal daytime, night-time, and 24-h BP did not significantly differ in terms of other cardiovascular risk factors or organ damage. In contrast, patients from other groups (either only normal daytime BP or 24-h BP) had significantly more prevalence of diabetes, dyslipidaemia, microalbuminuria, left ventricular hypertrophy, reduced renal function, and previous history of cardiovascular disease.

CONCLUSION

Prevalence of WCH is dependent on definition criteria. Only diagnostic criteria which considers the normality of all ambulatory periods identifies patients with cardiovascular risk similar to normotensive patients. These results support using such criteria for a more accurate definition of WCH.

[Primary care evaluation of the hypertensive patient management in specialized care after derivation (DERIVA-2 Study)]

Introducción

Estudiar la opinión del médico de atención primaria (MAP) de la información de los pacientes remitida desde el médico especialista en hipertensión arterial (MEHTA).

Diseño

Estudio observacional descriptivo.

Emplazamiento

Realizado a nivel nacional.

Participantes

Médicos de atención primaria que reciben hipertensos estudiados por MEHTA.

Métodos

Se utilizó el consenso de derivación de la SEH-LELHA, y una encuesta en la que se recogían en la visita basal las características demográficas, antropométricas, presión y causa de derivación; en la posderivación se añaden preguntas sobre: tiempo utilizado en estudiar al paciente, modificaciones del diagnóstico y fármacos. Además se preguntó sobre el tiempo en recibir respuesta y se pidió la valoración del informe que le remite el MEHTA.

Resultados

Participaron 578 investigadores de AP que incluyeron 1.715 pacientes válidos. Edad 60,7 ± 13,3 años, varones 62,7%. En prederivación los pacientes tomaban 2,3 ± 1,2 fármacos antihipertensivos, y 2,5 ± 1,2 en posderivación; la presión arterial pasó de 166 ± 21.6 / 97,7 ± 12,6 mmHg a 143 ± 14,4 / 85,5 ± 10,5 mmHg. Los pacientes controlados (PA < 140 y < 90 mmHg) pasaron del 5,8 al 32,2%. El tiempo transcurrido entre la visita al hospital y la recepción del informe fue de 72 ± 64 días. Se realizó ampliación del estudio por parte del MEHTA en 1.250 casos (72,9%). El MAP médico de familia recibió informe reglado en el 80,3% de los casos. Globalmente, el 63% de los MAP están totalmente de acuerdo con la actuación del especialista, el 29% parcialmente de acuerdo y el 2% nada de acuerdo. La derivación se ha valorado mediante opinión subjetiva del MAP como efectiva o muy efectiva en el 86% de los pacientes y nada efectiva en el 9%.

Conclusiones

La comunicación entre niveles es clave en el cuidado de algunos pacientes hipertensos, como corresponde a una entidad crónica.

Hydration status, drug interactions, and determinants in a Spanish elderly population: a pilot study

Proper hydration is essential to maintain optimal health and well-being at all stages of life, especially for the elderly. Side effects of certain drugs that affect hydration status may compromise the health of the ancients, who also constitute the most vulnerable group. No studies have been carried out, to our knowledge, at the intersection of drugs and hydration status. Our study aimed to evaluate the effects of chronic use of certain drugs (diuretics, corticoids and metformin) in the hydration status of the elderly. Results were obtained from a cross-sectional study with 96 volunteers (65-93 years) selected based on their pharmacological treatment. It included a validated food and drink frequency questionnaire and water removal, dehydration signs and symptoms assessment and urine analysis. All data were analysed by age and sex. Water balance decreased with advanced age, especially in men's group. Results were confirmed by means of the evaluation of dehydration signs and symptoms and colorimetric and chemical analysis of urine. Correlations between consumption of corticoids and hydration status were found, with different signs depending on the administration route (Rho = 0.522 and Rho = - 0,522 for oral and pulmonary corticoids, respectively). Furthermore, correlations between diuretics (Rho = - 0.343, p < 0.05) and metformin (Rho = - 0.802, p < 0.01) consumption and different urine markers were determined. In conclusion, the predominant dehydration state of the volunteers of the study is affected by drugs consumption and their route of administration. Hence, there is an urgent need for monitorization of hydration status based on drugs consumption.

[Prevalence of polypharmacy among the population older than 65 years in Spain: Analysis of the 2006 and 2011/12 National Health Surveys]

INTRODUCTION

Polypharmacy in older people is the result of several inter-connected factors, and is very common despite the associated risks. Not many population-based studies have been conducted in Spain to ascertain the magnitude of polypharmacy in this population.

MATERIAL AND METHODS

A descriptive, cross-sectional study was conducted with individualised data for non-institutionalised older people (65 or older) of both sexes from the Spanish National Health Surveys (SNHS) 2006 (N=7,835) and 2011/12 (N=5,896). The prevalence of polypharmacy (use of 4 or more drugs within the 2 weeks preceding the survey) was ascertained for the 2 surveys used, as well as by sex and age groups. The prevalence of use of the different drug groups was also estimated in the elderly who used polypharmacy.

RESULTS

Polypharmacy occurred in about a third of the older people in the 2006 SNHS (32.54%), and was significantly higher in the 2011/12 SNHS (36.37%) (P<.05). In both surveys, the prevalence of polypharmacy was higher in women than men and among the older individuals (≥85 years) compared to the less old. The type of drugs most commonly used were analgesics (2006 SNHS: 71.93%, 2011/12 SNHS: 76.27%; P<.05), and antihypertensive drugs 2006 SNHS: 70.26%, 2011/12 SNHS: 78.10%; P<.05).

CONCLUSIONS

The magnitude of polypharmacy is considerable in older people and increasing over time. Further research on this issue is needed to identify those individuals who are at higher risk of using multiple drugs concomitantly.

[Evaluation of referral process of the hypertensive patient in Spain: DERIVA study]

INTRODUCTION

An adequate communication between levels of medical attention is the key point for optimal treatment and outcomes of the hypertensive population.

AIMS

The aim of this study was to evaluate the adequacy of the hypertensive patients' derivation from Primary Care to Specialized Care. As secondary objectives, the information registered on the derivation report was assessed and concordance between derivation reason and final diagnosis was analysed.

DESIGN

This is an observational, descriptive, multicentre study. SITE: Study conducted at the national level.

PARTICIPANTS

Specialty Care Physicians receiving hypertensive patients referred from primary care.

PRINCIPAL MEASUREMENTS

On the baseline visit, the specialist physicians assessed the quality of the derivation records and attended the patient. After the study, final diagnosis and treatment is suggested on the final visit.

RESULTS

1769 subjects were included, mean aged 62,4 (13,6) years, 45% female. Time of diagnosis of hypertension was 8,0 (7,7) years. More than the half of the derivation records contained very good information (5,4%; CI4,3-6,5) or sufficient (50,7%; CI48,4-53,0). In 7,1% (IC5,9-8,3) derivation cause was not specified. 74,7% of the derivations were considered as appropriate, though 30% were late. Concordance between derivation reasons and final diagnosis was low (kappa index 0,208).

CONCLUSIONS

A quarter of the hypertensive population is unnecessary derived to Secondary Care and 30% of the appropriately derived was late. We should improve the interrelation of attention in the hypertension and cardiovascular area between the both attention levels.

Resistant hypertension: do all definitions describe the same patients?

Resistant hypertension (RH) is defined as blood pressure (BP) that remains ⩾140 and/or 90 mm Hg despite therapy with ⩾3 full-dose antihypertensive drugs (classical definition=CD). A definition proposed subsequently (new definition=ND) includes patients requiring ⩾4 drugs irrespective of BP values. We aimed to evaluate whether both definitions characterize the same kind of patients.One hundred and twenty-four consecutively attended patients with RH were classified into two groups according to their BP control: 66 patients had non-controlled BP (all those who met the CD criteria plus a few patients who met the ND criteria); 58 patients had controlled BP (all with RH according to the ND). Clinical, laboratory and office BP data were recorded. RH patients with non-controlled BP were more frequently diabetic (72% vs 49%), and had higher plasmatic glucose (149 vs 130 mg dl(-1)), cholesterol (179 vs 164 mg dl(-1)), low-density lipoprotein (LDL)-cholesterol (107 vs 95 mg dl(-1)) and triglyceride (169 vs 137 mg dl(-1)) levels; P<0.05 for all comparisons. In multivariate logistic regression analysis, the variables that independently associated with non-controlled BP were diabetes (P=0.001) and higher LDL-cholesterol (P=0.007).We conclude that, although both cohorts of patients are phenotypically quite similar, uncontrolled RH patients have higher prevalence of diabetes mellitus and higher LDL-cholesterol levels than controlled RH patients.

A cardiovascular educational intervention for primary care professionals in Spain: positive impact in a quasi-experimental study

BACKGROUND

Routine general practice data collection can help identify patients at risk of cardiovascular disease.

AIM

To determine whether a training programme for primary care professionals improves the recording of cardiovascular disease risk factors in electronic health records.

DESIGN AND SETTING

A quasi-experimental study without random assignment of professionals. This was an educational intervention study, consisting of an online-classroom 1-year training programme, and carried out in the Valencian community in Spain.

METHOD

The prevalence rates of recording of cardiovascular factors (recorded every 6 months over a 4-year period) were compared between intervention and control group. Clinical relevance was calculated by absolute risk reduction (ARR), relative risk reduction (RRR), and number of patients needed-to-attend (NNA), to avoid under-recording, with their 95% confidence intervals (CIs). Linear regression models were used for each of the variables.

RESULTS

Of the 941 professionals initially registered, 78.1% completed the programme. The ARR ranged from 1.87% (95% CI = 1.79 to 1.94) in the diagnosis of diabetes to 15.27% (95% CI = 15.14 to 15.40) in the recording of basal blood glucose. The NNA ranged from 7 in blood pressure, cholesterol, and blood glucose recording to 54 in the diagnosis of diabetes. The RRR ranged from 26.7% in the diagnosis of diabetes to 177.1% in the recording of the Systematic Coronary Risk Evaluation (SCORE). The rates of change were greater in the intervention group and the differences were significant for recording of cholesterol (P<0.001), basal blood glucose (P<0.001), smoking (P<0.001), alcohol (P<0.001), microalbuminuria (P = 0.001), abdominal circumference (P<0.001), and SCORE (P<0.001).

CONCLUSION

The education programme had a beneficial effect at the end of the follow-up that was significant and clinically relevant.

Prevalence of Atherogenic Dyslipidemia in Spanish Hypertensive Patients and Its Relationship With Blood Pressure Control and Silent Organ Damage

INTRODUCTION AND OBJECTIVES

To assess the prevalence of atherogenic dyslipidemia in hypertensive patients and its relationship with risk profile and blood pressure control.

METHODS

The study included 24 351 hypertensive patients from the Spanish Ambulatory Blood Pressure Monitoring Registry. Atherogenic dyslipidemia was defined as the presence of hypertriglyceridemia (> 150mg/dL) and low levels of high-density lipoprotein cholesterol (< 40mg/dL in men and < 46mg/dL in women). Blood pressure control was assessed by office and ambulatory monitoring.

RESULTS

Atherogenic dyslipidemia was present in 2705 patients (11.1%). Of these, 30% had hypertriglyceridemia and 21.7% had low levels of high-density lipoprotein cholesterol. Compared with patients without these risk factors, the former group were more often male (60% vs 52%), younger (57 years vs 59 years), had other risk factors and organ damage (microalbuminuria, reduced estimated glomerular filtration rate, and left ventricular hypertrophy), worse office, diurnal, and nocturnal blood pressure values (odds ratio 1.09, 1.06, and 1.10, respectively), and the lowest nocturnal blood pressure reduction (odds ratio=1.07), despite the greater use of antihypertensive drugs.

CONCLUSIONS

Atherogenic dyslipidemia is present in more than 10% of hypertensive patients and is associated with other risk factors, organ damage, and poorer blood pressure control. Greater therapeutic effort is needed to reduce overall risk in these patients.

[Familial combined hyperlipidemia: consensus document]

Familial combined hyperlipidemia (FCH) is a frequent disorder associated with premature coronary artery disease. It is transmitted in an autosomal dominant manner, although there is not a unique gene involved. The diagnosis is performed using clinical criteria, and variability in lipid phenotype and family history of hyperlipidemia are necessaries. Frequently, the disorder is associated with type2 diabetes mellitus, arterial hypertension and central obesity. Patients with FCH are considered as high cardiovascular risk and the lipid target is an LDL-cholesterol <100mg/dL, and <70mg/dL if cardiovascular disease or type 2 diabetes are present. Patients with FCH require lipid lowering treatment using potent statins and sometimes, combined lipid-lowering treatment. Identification and management of other cardiovascular risk factors as type 2 diabetes and hypertension are fundamental to reduce cardiovascular disease burden. This document gives recommendations for the diagnosis and global treatment of patients with FCH directed to specialists and general practitioners.

[Familial combined hyperlipidemia: consensus document]

Familial combined hyperlipidemia (FCH) is a frequent disorder associated with premature coronary artery disease. It is transmitted in an autosomal dominant manner, although there is not a unique gene involved. The diagnosis is performed using clinical criteria, and variability in lipid phenotype and family history of hyperlipidemia are necessaries. Frequently, the disorder is associated with type2 diabetes mellitus, arterial hypertension and central obesity. Patients with FCH are considered as high cardiovascular risk and the lipid target is an LDL-cholesterol <100mg/dL, and <70mg/dL if cardiovascular disease or type 2 diabetes are present. Patients with FCH require lipid lowering treatment using potent statins and sometimes, combined lipid-lowering treatment. Identification and management of other cardiovascular risk factors as type 2 diabetes and hypertension are fundamental to reduce cardiovascular disease burden. This document gives recommendations for the diagnosis and global treatment of patients with FCH directed to specialists and general practitioners.

Derivation and validation of BOREAS, a risk score identifying candidates to develop cold-induced hypertension

INTRODUCTION

Blood pressure increases in cold periods, but its implications on prevalence of hypertension and on individual progression to hypertension remain unclear. Our aim was to develop a pre-screening test for identifying candidates to suffer hypertension only in cold months among non-hypertensive subjects.

METHODS

We included 95,277 subjects registered on a primary care database from Girona (Catalonia, Spain), with ≥ 3 blood pressure measures recorded between 2003 and 2009 and distributed in both cold (October-March) and warm (April-September) periods. We defined four blood pressure patterns depending on the presence of hypertension through these periods. A Cox model determined the risk to develop vascular events associated with blood pressure patterns. A logistic regression distinguished those nonhypertensive individuals who are more prone to suffer cold-induced hypertension. Validity was assessed on the basis of calibration (using Brier score) and discrimination (using the area under the receiver operating characteristics).

RESULTS

In cold months, the mean systolic blood pressure increased by 3.3 ± 0.1 mmHg and prevalence of hypertension increased by 8.2%. Cold-induced hypertension patients were at higher vascular events risk (Hazard ratio=1.44 [95% Confidence interval 1.15-1.81]), than nonhypertensive individuals. We identified age, diabetes, body mass index and prehypertension as the major contributing factors to cold-induced hypertension onset.

DISCUSSION

Hypertension follows a seasonal pattern in some individuals. We recommend screening for hypertension during the cold months, at least in those nonhypertensive individuals identified as cold-induced hypertensive by this assessment tool.

[Descriptive study of ambulatory blood pressure monitoring in the Primary Care Nursing clinic]

OBJECTIVE

To analyze the clinical characteristics and the circadian patterns of patients who received ambulatory blood pressure monitoring (ABPM) by a Primary Care Team.

METHOD

A descriptive, observational, cross-sectional study at community level. People older than 18 years on ABPM (2007-2011).

VARIABLES

demographic, cardiovascular disease, diabetes mellitus, cardiovascular risk factors, any type of arterial hypertension and circadian pattern. Intruments of measurement: 2 validated instruments with comparable results were used.

PROCEDURE

The instruments for ABPM were placed during the nursing visit. The instruments were then removed after 24h, and the data was retrieved and recorded in the computerized clinical history.

RESULTS

A total of 326 people were studied, with a mean age of 60.53±12.96 years, of whom 56.7% were male. According to ABPM the patient results showed that: 38.5% had «white coat» arterial hypertension, 36.2% were classified as poorly controlled arterial hypertension, 17.2% had masked hypertension, and 8% with isolated hypertension. Dipper circadian patterns were present in 39.6% of patients and non- dipper in 60.4%.

CONCLUSIONS

ABPM allows to Primary Health Care professionals to check the actual situation of the blood pressure over 24h and analyze the circadian pattern. In clinical practice this involves having a comprehensive care strategy on life style, as well as adherence to treatment.

Protocol for assessing the hypotensive effect of evening administration of acetylsalicylic acid: study protocol for a randomized, cross-over controlled trial

BACKGROUND

The objective of this study is to evaluate the antihypertensive effect of bedtime administration of low doses of aspirin in patients with treated hypertension and high cardiovascular risk on low-dose aspirin for secondary prevention, in order to optimize their usual treatment and reduce their cardiovascular risk.

METHODS/DESIGN

This is a prospective phase IV multicentre, randomised, triple-blind, placebo-controlled, cross-over clinical trial. We will include 258 individuals with hypertension treated with low-dose aspirin for secondary prevention. These patients will be randomly recruited, by approximately 40 primary care physicians collaborating in the study, mainly in the Guipúzcoa West, Bilbao and Barcelona areas. The 258 patients will be randomly allocated to treatments to create two comparable groups. In the first period, the intervention group will take aspirin at night and placebo in the morning, while the control group will take their aspirin in the morning and placebo in the evening for 2 months. After a washout period of 15 to 30 days, there will be a second 2-month period for which groups will swap treatments. Participants will undergo ambulatory blood pressure monitoring at baseline, at the end of first period and then again at the beginning and end of the second period. The main outcome measure is the change in mean blood pressure over 24 h, and as secondary outcomes we will also assess changes in systolic and diastolic blood pressure, during the day and night, and the relationship between them. Lastly, we will explore whether non-dipper patients convert into dippers with the intervention.

DISCUSSION

The goal of this research is to provide the scientific basis for indicating a change in the time of aspirin administration from morning to evening, by primary health practitioners, to improve the patient control of blood pressure and more effectively reduce their cardiovascular risk, by combining this hypotensive effect with the well-known anti-platelet effect of low-dose aspirin.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01741922.

[Blood pressure control in hospital units in Spain]

BACKGROUND AND OBJECTIVE

Blood pressure (BP) control has been extensively studied in patients attended in primary care but reports in the hospital setting, which includes referral units, are scarce. The aim was to evaluate the degree of BP control in hypertensive patients attended in referral units.

PATIENTS AND METHODS

We studied 1,550 hypertensive subjects (41.5% women) with a mean age of 64 (12) years, who were receiving antihypertensive drugs. The degree of BP control was estimated in a single visit by the proportion of patients with BP below 140/90 mm Hg.

RESULTS

BP was controlled in 653 patients (42%). In comparison, those whose BP was not controlled were more frequently women (odds ratio [OR] 1.57; 95% confidence interval [95%CI]: 1.23-1.99), obese (OR 1.28; 95%CI 1.00-1.63), smokers (OR 1.78; 95%CI 1.36-2.34), had left ventricular hypertrophy (OR 1.86; 95%CI 1.46-2.36) and elevated values of total serum cholesterol (OR 1.50; 95%CI 1.19-1.90) and triglycerides (OR 1.63; 95%CI 1.29-2.07). Therapeutical inertia was observed in 39% of uncontrolled patients. In a subgroup of patients who underwent ambulatory BP monitoring, discordance between measurements was only present in 23% (9.8 with isolated clinic hypertension and 13.1% with masked hypertension).

CONCLUSION

The degree of BP control in patients attended in referral units is estimated in 42% and has not been modified in the last decade. Although therapeutical effort and inertia have improved, this only compensates the increased risk and comorbidities of attended patients, making more difficult the control of BP values.

Treatment and blood pressure control in Spain during 2002-2010

OBJECTIVES

To examine the evolution of hypertension management and blood pressure (BP) control in Spain in the last decade across PRESCAP 2002, 2006 and 2010.

METHODS

The methodology of the three studies was the same. They were multicenter and cross-sectional surveys aimed to determine BP control rates in hypertensive patients in primary care in Spain during 2002, 2006 and 2010, respectively. In each study, patients at least 18 years, with an established diagnosis of hypertension were included. Adequate BP control was defined as BP less than 140/90 mmHg in the general population (<130/85 mmHg in PRESCAP 2002 and less than 130/80 mmHg in PRESCAP 2006 and PRESCAP 2010 for patients with diabetes, chronic kidney disease and cardiovascular disease).

RESULTS

A total of 12,754 patients (mean age 63.3 ± 10.8 years; 57.2% women), 10,520 patients (64.6 ± 11.3 years; 53.7% women) and 12,961 patients (66.3 ± 11.4; 52.0% women) were included in PRESCAP 2002, PRESCAP 2006 and PRESCAP 2010 studies respectively. With regard to BP control rates, 36.1% [95% confidence interval (CI) 35.2-36.9%], 41.4% (95% CI 40.5-42.4%) and 46.3% of patients (95% CI 45.4-47.1%) achieved BP goals in PRESCAP 2002, PRESCAP 2006 and PRESCAP 2010, respectively (P < 0.0001). In PRESCAP 2002, 56% of patients were on monotherapy, 35.6% were taking two drugs and 8.4% at least three drugs. In PRESCAP 2006 these numbers were 44.4, 41.1 and 14.5%, respectively, and in PRESCAP 2010 they were 36.4, 44.1 and 19.5%, respectively (P < 0.0001).

CONCLUSION

BP control rates have improved in Spain from 2002 to 2010. This may be related, at least in part, with the higher use of antihypertensive treatment, particularly combined therapy.

Effect of a pharmacist intervention in Spanish community pharmacies on blood pressure control in hypertensive patients

PURPOSE

The effect of a protocol-based pharmacist intervention on blood pressure (BP) control among treated hypertensive patients who use community pharmacies was studied.

METHODS

A quasi-experimental study with a control group was conducted at 13 community pharmacies in Jaén and Granada in Spain. Hypertensive patients over age 18 years who were receiving antihypertensive treatment were eligible for participation. The protocol-based intervention consisted of three components: (1) patient education about hypertension, (2) home blood pressure monitoring (HBPM), and (3) referral to a physician through personalized reports when necessary. The control group received the standard of care. BP control was assessed at the beginning and end of the study. Results Data were collected from 176 patients. In the intervention group (n = 87), significant baseline-to-endpoint reductions in systolic blood pressure (SBP) and diastolic blood pressure (DBP) were observed: 6.8 mm Hg (p < 0.001) and 2.1 mm Hg (p = 0.032), respectively. The changes in SBP and DBP in the intervention group at the end of the study were significantly greater than those in the control group (difference between adjusted mean change, 5.7 mm Hg for SBP [p = 0.001] and 2.6 mm Hg for DBP [p = 0.013]). The odds of achieving BP control in the intervention group was 2.46 times higher than in the control group (95% confidence interval, 1.15-5.24; p = 0.020).

CONCLUSION

A protocol-based community pharmacist intervention in combination with HBPM significantly reduced SBP and DBP and increased the percentage of patients with controlled BP compared with patients receiving the standard of care.

[The interarm blood pressure difference in the critically ill patient]

BACKGROUND AND OBJECTIVE

To evaluate the prevalence of a difference in systolic blood pressure (SBPd) ≥ 10 mmHg between arms in patients admitted in a Critical Care Unit and to examine the clinical characteristics associated with such blood pressure difference.

METHODS

Observational cross-sectional study. Two blood pressure measurements in each arm were carried out at unit admission. The firstly measured arm was chosen at random.

RESULTS

One-hundred and sixty-eight patients were studied, with a mean age of 61 (SD=16), 67.3% male and 45% with a previous hypertension diagnosis. On admission, 27.4% presented SBPd ≥ 10 mmHg. Among them, 54% had higher SBP in the right arm and 46% in the left one. A SBPd ≥ 10 mmHg was associated with a previous hypertension diagnosis (67.4 versus 36.9%; P<.001) and with reduced consciousness (76.1 versus 52.5%; P=.006).

CONCLUSIONS

Over a quarter of critically ill patients have a SBPd ≥ 10 mmHg between arms. This feature is associated with a previous hypertension diagnosis and reduced consciousness. It should be assessed in the future if the choice of a control arm would help improve patient's care as it would become a more accurate guide for hemodynamic management.

[Adherence to physical activity recommendations in a hypertensive primary care population]

OBJECTIVE

To determine the prevalence of adherence to physical activity recommendations in the hypertensive population of Lerida (Spain) attended in primary care and to identify related factors.

METHODS

A cross sectional study was carried out in hypertensive adults. The dependent variable was adherence to physical activity recommendations measured with the Minnesota Questionnaire. The independent variables were sociodemographic factors, the information received, and attitudes to physical activity.

RESULTS

A total of 786 hypertensive patients participated in this study; 53.9% were women and the mean age was 66.0±10.2 years. Adherence to recommendations was found in 64.3% (95% CI: 60.9-67.6); this percentage was 65.2% in men (95% CI: 60.2-70.0) and 63.4% in women (95% CI: 58.8-67.9). Greater adherence was associated with age in men and with residence in a rural area in women. In both genders, greater adherence was associated with unpaid work and with having a favorable attitude to physical activity. No association was observed with the number of recommendations received in the last 6 months.

CONCLUSIONS

More than half the hypertensive population adhered to physical activity recommendations. To improve physical activity levels, recommendations can be tailored to the attitudes of individual patients.

Clinical differences between resistant hypertensives and patients treated and controlled with three or less drugs

BACKGROUND AND AIM

Clinical characteristics of resistant hypertensive patients in comparison to controlled patients have not been fully investigated in large cohorts. The aim of the study was to evaluate clinical differences, target organ damage and ambulatory blood pressure monitoring in resistant hypertensive patients and patients controlled on three or less drugs.

METHODS

In December 2010, from the Spanish Ambulatory Blood Pressure Monitoring Registry, we identified 14 461 patients fulfilling criteria of resistant hypertension and 13 436 hypertensive patients controlled on three or less drugs. Clinical characteristics were compared between these two groups.

RESULTS

Compared to controlled patients, those having resistant hypertension were older, more obese and had longer hypertension duration. They also had more frequently diabetes, dyslipidemia, reduced renal function, microalbuminuria, left-ventricular hypertrophy and previous history of cardiovascular events. In multivariate analyses, hypertension duration, obesity, abdominal obesity, left-ventricular hypertrophy, reduced estimated glomerular filtration rate, and microalbuminuria were independently associated with resistant hypertension. Resistant hypertensive patients had higher ambulatory blood pressures, but differences between office and ambulatory blood pressure (white-coat effect) were also more pronounced in this group, revealing a proportion of 40% of patients with normal 24-h blood pressure. On the contrary, values of 24-h blood pressure above 130 and/or 80 mmHg (masked hypertension) were present in 31% of apparently controlled patients.

CONCLUSION

Resistant hypertension is associated with obesity, longer hypertension duration and kidney and cardiac damage. Ambulatory blood pressure monitoring reveals that white-coat hypertension is common among resistant hypertensive patients, as well as is masked hypertension among apparently controlled patients.

[Relationship of polymedication in controlling blood pressure: compliance, persistence, costs and incidence of new cardiovascular events]

BACKGROUND AND OBJECTIVE

To determine the relationship of polypharmacy on blood pressure (BP) control, compliance, persistence, the cost and incidence of cardiovascular events (CVD) in patients with moderate/severe hypertension.

PATIENTS AND METHODS

An observational multicenter retrospective study. We evaluated patients > 30 years who started a third antihypertensive treatment during 2004-2006. Depending on the number of chronic medications, we established 3 groups: regular consumption of 3-6 drugs, including between 7-10 and ≥ 11. Top-measures: sociodemographic, comorbidity, BP, compliance and persistence. For each group we determined the incidence of new CVD totals and total costs.

RESULTS

We evaluated 1,906 patients, 765 between 3-6 drugs, 624 between 7-10 and 517 in ≥ 11 (P<.001). Overage age: 69.4 years and 55.5% women. The group of 3-6 drugs showed better BP control (51.8 vs. 47.0 and 41.1%, P<.001), compliance (71.4 vs. 69.9 and 67.1%, P=.017), persistence (50.1 vs. 45.5 and 46.2%, P=.044) and lower incidence of CVD (12.2 vs. 19.7 and 30.2%, P<.001), respectively. The average/unit total costs was 3,369.1 vs. 4,362.1 and € 4,902.3 (P<.001). The presence of CVD was associated with therapy noncompliance (odds ratio [OR] 1.9, 95% confidence interval [95%CI] 1.1 to 3.6) and controlled by the lower BP control (OR 1.4 (95%CI 1.1-2.0) (P < .05). The use of antihypertensive fixed dose has greater compliance (72.8 vs. 68.2%), persistence (64.4 vs. 39.3%) and degree of BP control (52.6 vs. 43, 8%) (p<.001).

CONCLUSIONS

Polypharmacy is associated with lower compliance and persistence to antihypertensive treatment, cardiovascular disease and increased health care costs.

Validation of diabetes mellitus and hypertension diagnosis in computerized medical records in primary health care

BACKGROUND

Computerized Clinical Records, which are incorporated in primary health care practice, have great potential for research. In order to use this information, data quality and reliability must be assessed to prevent compromising the validity of the results.The aim of this study is to validate the diagnosis of hypertension and diabetes mellitus in the computerized clinical records of primary health care, taking the diagnosis criteria established in the most prominently used clinical guidelines as the gold standard against which what measure the sensitivity, specificity, and determine the predictive values.The gold standard for diabetes mellitus was the diagnostic criteria established in 2003 American Diabetes Association Consensus Statement for diabetic subjects. The gold standard for hypertension was the diagnostic criteria established in the Joint National Committee published in 2003.

METHODS

A cross-sectional multicentre validation study of diabetes mellitus and hypertension diagnoses in computerized clinical records of primary health care was carried out. Diagnostic criteria from the most prominently clinical practice guidelines were considered for standard reference.Sensitivity, specificity, positive and negative predictive values, and global agreement (with kappa index), were calculated. Results were shown overall and stratified by sex and age groups.

RESULTS

The agreement for diabetes mellitus with the reference standard as determined by the guideline was almost perfect (κ=0.990), with a sensitivity of 99.53%, a specificity of 99.49%, a positive predictive value of 91.23% and a negative predictive value of 99.98%.Hypertension diagnosis showed substantial agreement with the reference standard as determined by the guideline (κ=0.778), the sensitivity was 85.22%, the specificity 96.95%, the positive predictive value 85.24%, and the negative predictive value was 96.95%. Sensitivity results were worse in patients who also had diabetes and in those aged 70 years or over.

CONCLUSIONS

Our results substantiate the validity of using diagnoses of diabetes and hypertension found within the computerized clinical records for epidemiologic studies.

[Suitability and performance of echocardiogram in primary care]

OBJECTIVE

The echocardiogram (ECC) is not available to all Spanish General Practitioners (GP) despite its proven benefits in prevalent diseases, such as hypertension and heart failure.

STUDY OBJECTIVE

To analyse the clinical adequacy of the application, performance, and diagnostic and therapeutic decisions of ECC indicated by the GP.

DESIGN

Descriptive, cross-sectional, retrospective, multicentre study.

SETTING

Primary care. Four health centres (HC).

PARTICIPANTS

A total of 684 patients over 18 years who had an ECC performed in 2006-2007.

MAIN MEASUREMENTS

A review of medical records and the ECC report. The socio-demographic variables, clinical and diagnostic performance were also evaluated.

RESULTS

The majority of patients (62.3%) were ≥ 65 years, of which 61.8% were female The most frequent reasons for performing ECC were (but not limited to): heart failure: 30%, suspected valvular disease: 26%; suspected cardiomyopathy: 24.3%. Adequacy of the ECC: 84% (95% CI: 81.09-86.7%) with differences by age (p=.02), HC teaching (p<.001), comorbidity (p<.001) and abnormal ECC (p<.001). A disease was found in 80% of ECC, with differences according to age (p<.001), comorbidity (p=0.02), cardiovascular risk factors (p<.001) and degree of appropriateness of ECC (p=.001). The most common findings (but not limited to) included: valvular heart disease (61.6%) left ventricular hypertrophy (43%) diastolic dysfunction (28.2%). The results of the ECC helped make decisions in 35.2%, with 17.1% referred to cardiology, 10.5% treatment change and 9.6% other tests.

CONCLUSIONS

We found that the application of ECC was highly appropriate. The results of ECC drive clinical decisions in a high percentage of cases. The ECC should be accessible to all GP.

Blood pressure control in hypertensive women aged 65 years or older in a primary care setting. MERICAP study

INTRODUCTION AND OBJECTIVES

The available information regarding blood pressure control in women is scarce. This study was aimed at assessing blood pressure control and predictors of a lack of blood pressure control in the primary care setting in a large sample of hypertensive women.

METHODS

Women aged 65 years or older with an established diagnosis of hypertension (≥ 6 months of evolution) were included in a cross-sectional, multicenter study. Blood pressure readings were taken following the current guidelines, and the value for each visit was the average of two separate measurements. Adequate blood pressure control was defined as < 140/90 mm Hg (< 130/80 mm Hg for diabetics).

RESULTS

A total of 4274 hypertensive women (mean age: 73.6 years [6.1 years]) were included in the study; blood pressure was controlled in 29.8% (95% confidence interval: 28.4%-31.1%) of the study population. Combined therapy was administered in 67.6% of patients (46.3% with 2 drugs and 21.7% with 3 or more drugs). The most common organ damage was left ventricular hypertrophy (33.8%) and the most common associated condition was heart failure (19%). Poor blood pressure control was more frequent in patients with more cardiovascular risk factors, organ damage, and associated clinical conditions (P<.01). A more recent hypertension diagnosis, LDL-cholesterol > 115 mg/dl, monotherapy, obesity, and hemoglobin A(1c) ≥ 7% were associated with a lack of blood pressure control (P < .0001).

CONCLUSIONS

Only 3 in 10 hypertensive women aged ≥ 65 years monitored daily in the primary care setting achieved their blood pressure goals. A recent diagnosis of hypertension was the main predictor of poor blood pressure control.

Clinical features of 8295 patients with resistant hypertension classified on the basis of ambulatory blood pressure monitoring

We aimed to estimate the prevalence of resistant hypertension through both office and ambulatory blood pressure monitoring in a large cohort of treated hypertensive patients from the Spanish Ambulatory Blood Pressure Monitoring Registry. In addition, we also compared clinical features of patients with true or white-coat-resistant hypertension. In December 2009, we identified 68 045 treated patients with complete information for this analysis. Among them, 8295 (12.2% of the database) had resistant hypertension (office blood pressure ≥140 and/or 90 mm Hg while being treated with ≥3 antihypertensive drugs, 1 of them being a diuretic). After ambulatory blood pressure monitoring, 62.5% of patients were classified as true resistant hypertensives, the remaining 37.5% having white-coat resistance. The former group was younger, more frequently men, with a longer duration of hypertension and a worse cardiovascular risk profile. The group included larger proportions of smokers, diabetics, target organ damage (including left ventricular hypertrophy, impaired renal function, and microalbuminuria), and documented cardiovascular disease. Moreover, true resistant hypertensives exhibited in a greater proportion a riser pattern (22% versus 18%; P<0.001). In conclusion, this study first reports the prevalence of resistant hypertension in a large cohort of patients in usual daily practice. Resistant hypertension is present in 12% of the treated hypertensive population, but among them more than one third have normal ambulatory blood pressure. A worse risk profile is associated with true resistant hypertension, but this association is weak, thus making it necessary to assess ambulatory blood pressure monitoring for a correct diagnosis and management.

[Objective KONTROL study: therapeutic inertia in hypertensive patients attended in primary care of Spain]

OBJECTIVES

To determine the level of therapeutic inertia (TI), and the factors associated to the patient, doctor and the health organisation, in hypertensive patients treated in Primary Care (PC).

DESIGN

Cross-sectional, multicentre study.

SETTING

A sample of PC Teams from all over Spain.

PARTICIPANTS

The study was conducted among PC doctors using a questionnaire and clinical records of 4 patients.

MAIN MEASUREMENTS

The TI was calculated for each patient (TIp) as the proportion of visits in which there was no change in medication when this was indicated.

RESULTS

A total of 543 PC doctors provided data on 2,032 patients, who fulfilled the indication of a change in requirement. There was TI In 77.8% of cases. The TIp observed was non-existent or low for 17.1% of the patients, intermediate for 42% and high for 40.8%. For the patients, the factors most associated with TIp were, age (P<.001), diabetes (P<.001), stroke (P<.01), obesity (P<.01) and a low education level (P<.001). To be female, be less than 40 years or more than 55 years, to be a family doctor with a training program other than MIR and to work in the public sector increased the probability of TIp (P<.001 for all the assumptions).

CONCLUSIONS

The results of the study indicate that there is TI in 7 out every 10 visits made by hypertensive patients in Primary care. There are significant differences as regards the clinical characteristics of the patients and of the doctors.

Psychological Factors Associated with Poor Hypertension Control: Differences in Personality and Stress between Patients with Controlled and Uncontrolled Hypertension

Only one-third of patients with hypertension under pharmacological treatment achieve the recommended blood pressure goals. Psychological factors could partially account for poor hypertension control through the existence of personality traits related to treatment compliance (e.g., self-discipline, deliberation, impulsiveness), and the fact that stress and some personality traits (e.g., anxiety, depression, anger expression, Type A) are involved in the etiology of some hypertension cases. This study was aimed at examining the differences in personality and stress between patients taking antihypertensive medications with controlled and uncontrolled hypertension. Results revealed that after controlling sex, age, and traditional variables associated with poor hypertension control, the uncontrolled hypertension group showed higher scores on impulsiveness, depression, anger expression-out, and stress, with differences ranging between medium and large (Hedges' g effect size = 0.77 to 1.08). These results support the hypothesized relationship between psychological factors and poor hypertension control.

[Variations in antihypertensive drug utilization among primary care areas in the autonomous region of Valencia (Spain)]

OBJECTIVES

To estimate consumption of five subgroups of antihypertensive drugs by primary care areas and to analyze its variation.

METHODS

We performed an ecological, descriptive study of antihypertensive consumption in 239 primary care areas in the autonomous region of Valencia in 2005 followed by analysis of the variability observed. The 239 primary care areas were studied by descriptive analysis of dispensation [defined daily dose (DDD) per 1,000 inhabitants/day in pensioners (DDD/1000p/day) and in the active population (DDD/1000a/day)] and standardized consumption ratios. Small-area variation analysis was used to analyze the observed variability. Associations among dispensations of the distinct therapeutic subgroups were also analyzed.

RESULTS

Overall antihypertensive use in the autonomous region of Valencia in 2005 was 235.6DDD/1000/day. This consumption was concentrated in pensioners (800DDD/1000p/day vs. 73DDD/1000a/day). Consumption of antihypertensive subgroups oscillated from 442DDD/1000p/day for drugs with action on the renin-angiotensin system to 32DDD/1000p/day for doxazosin. The active population showed similar patterns. Variation in consumption was moderate, with coefficients of variation from 0.20 to 0.40 (slightly greater for the active population). Associations among dispensations of the different therapeutic subgroups were strong.

CONCLUSIONS

This study shows major variations in the overall consumption of antihypertensive drugs among primary care areas of the autonomous region of Valencia. These results suggest that variation may be associated with problems of underutilization in areas with lower consumption.