Showing papers by "Luis M. Ruilope published in 2010"

European Society of Hypertension Practice Guidelines for home blood pressure monitoring

Abstract: Self-monitoring of blood pressure by patients at home (home blood pressure monitoring (HBPM)) is being increasingly used in many countries and is well accepted by hypertensive patients. Current hypertension guidelines have endorsed the use of HBPM in clinical practice as a useful adjunct to conventional office measurements. Recently, a detailed consensus document on HBPM was published by the European Society of Hypertension Working Group on Blood Pressure Monitoring. However, in daily practice, briefer documents summarizing the essential recommendations are needed. It is also accepted that the successful implementation of clinical guidelines in routine patient care is dependent on their acceptance by involvement of practising physicians. The present document, which provides concise and updated guidelines on the use of HBPM for practising physicians, was therefore prepared by including the comments and feedback of general practitioners.

Avosentan for Overt Diabetic Nephropathy

Abstract: In the short term, the endothelin antagonist avosentan reduces proteinuria, but whether this translates to protection from progressive loss of renal function is unknown. We examined the effects of avosentan on progression of overt diabetic nephropathy in a multicenter, multinational, double-blind, placebo-controlled trial. We randomly assigned 1392 participants with type 2 diabetes to oral avosentan (25 or 50 mg) or placebo in addition to continued angiotensin-converting enzyme inhibition and/or angiotensin receptor blockade. The composite primary outcome was the time to doubling of serum creatinine, ESRD, or death. Secondary outcomes included changes in albumin-to-creatinine ratio (ACR) and cardiovascular outcomes. We terminated the trial prematurely after a median follow-up of 4 months (maximum 16 months) because of an excess of cardiovascular events with avosentan. We did not detect a difference in the frequency of the primary outcome between groups. Avosentan significantly reduced ACR: In patients who were treated with avosentan 25 mg/d, 50 mg/d, and placebo, the median reduction in ACR was 44.3, 49.3, and 9.7%, respectively. Adverse events led to discontinuation of trial medication significantly more often for avosentan than for placebo (19.6 and 18.2 versus 11.5% for placebo), dominated by fluid overload and congestive heart failure; death occurred in 21 (4.6%; P = 0.225), 17 (3.6%; P = 0.194), and 12 (2.6%), respectively. In conclusion, avosentan reduces albuminuria when added to standard treatment in people with type 2 diabetes and overt nephropathy but induces significant fluid overload and congestive heart failure.

Long-term renal survival in malignant hypertension

Abstract: Background. Some studies have shown an improvement in the prognosis of patients with essential malignant hypertension (MHT), but data about long-term outcome and prognostic factors of these patients are scarce. Methods. We performed a single-centre retrospective analysis of 197 patients with MHT, diagnosed in the period 1974-2007. Results. Incidence of MHT remained stable along the different periods of the study. Renal damage at presentation was common (63% of patients) but renal function improved or remained stable after diagnosis in a majority of patients. The probability of renal survival was 84 and 72% after 5 and 10 years, respectively. Diagnosis during the first period (1974-85) of the study, previous chronic renal impairment, baseline renal function and proteinuria, presence of microhaematuria, systolic and diastolic blood pressure and proteinuria during follow-up were associated with an unfavourable outcome. By multivariate analysis, mean proteinuria during follow-up remained as the only significant risk factor (OR, 2.72; 95% CI, 1.59-4.64). Renal survival for patients with mean proteinuria <0.5 g/24 h was 100 and 95% after 5 and 10 years, respectively. The number of patients who improved or stabilized their renal function significantly increased in the second and third periods of the study (1987-2007). Conclusions. Renal survival in MHT has improved in recent years. Mean proteinuria during follow-up is a fundamental prognostic factor for renal survival.

Determinants of urinary albumin excretion within the normal range in patients with type 2 diabetes: the Randomised Olmesartan and Diabetes Microalbuminuria Prevention (ROADMAP) study

Abstract: Aims/hypothesis In contrast to microalbuminuric type 2 diabetic patients, the factors correlated with urinary albumin excretion are less well known in normoalbuminuric patients. This may be important because even within the normoalbuminuric range, higher rates of albuminuria are known to be associated with higher renal and cardiovascular risk.

Diurnal blood pressure variation, risk categories and antihypertensive treatment.

Abstract: Ambulatory blood pressure (BP) monitoring is a useful tool aiding diagnostic and management decisions in patients with hypertension. Diurnal BP variation or circadian rhythm adds prognostic value to the absolute BP elevation. The Spanish ABPM Registry has collected information from >30 000 treated hypertensive patients attended by either primary care physicians or referral specialists. The analysis of BP diurnal variation has allowed the conclusion that nocturnal BP decline is related to the level of risk. Patients with blunted nocturnal dip frequently belong to high- or very high-risk categories and specifically are often older, obese, diabetics or with overt cardiovascular or renal disease. With respect to treatment, the non-dipper profile is more often observed in patients receiving several antihypertensive drug agents, but it does not correlate with the time of drug administration. Among patients receiving only one drug, non-dihydropyridine calcium channel blockers and alpha-blockers are associated with less nocturnal BP decline than other antihypertensive drug classes, even after adjusting for the level of risk.

Prevention of Microalbuminuria in Patients With Type 2 Diabetes: What Do We Know?

Abstract: Cardiovascular and chronic kidney disease are epidemic throughout industrialized societies. Diabetes leads to premature cardiovascular disease and is regarded by many as the most common etiological factor for chronic kidney disease. Because most studies of blood-pressure lowering agents in people with diabetes and hypertension have been conducted in individuals who already have some target organ damage, it is unclear whether earlier intervention could prevent or delay the onset of renal or systemic vascular disease. In early disease there is only a low possibility of observing cardiovascular or renal events; thus intervention trials in this population must rely on disease markers such as microalbuminuria. Accordingly, the authors review the evidence to support the use of microalbuminuria as a disease marker in diabetic patients based on its strong association with renal and cardiovascular events, and discuss recent trials that examine the impact of preventing or delaying the onset of microalbuminuria.

Isolated clinic hypertension: diagnostic criteria based on 24-h blood pressure definition.

Abstract: Objective The use of diagnostic criteria based on 24-h ambulatory blood pressure (BP) values could improve prognostic value by incorporating night BP, minimize biases and improve the diagnostic reproducibility of isolated clinic hypertension (ICH). We estimate the 24-h BP cut-off points that best discriminate and predict the two diagnostic thresholds of mean daytime BP for ICH (135/85 and 130/80 mmHg). Methods Cross-sectional, comparative, multicentre study in 6176 untreated hypertensive patients, whose BP was measured by ambulatory BP monitoring. ICH was defined with an office BP of ≥140/≥90 mmHg and a daytime BP of <135/<85 mmHg (ICH1) or <130/80 mmHg (ICH2). Sensitivity, specificity, positive likelihood ratio (LR+), odds ratio (OR), error rate, predictive values, κ values and 95% confidence interval were calculated for each possible cut-off point for ICH1 and ICH2. Results One thousand eight hundred and seven patients (29.2%) and 960 patients (15.5%) met ICH1 and ICH2 criteria, respectively. The 24-h BP cut-off points that best predict ICH1 and ICH2 are less than 132/82 mmHg (sensitivity: 93.6%, specificity: 94.3%, LR+: 16.6, OR: 1367.1, error rate: 5.9, κ 0.86) and less than 127/77 mmHg (sensitivity: 90.8%, specificity: 97.4%, LR+: 34.6, OR: 1041.5, error rate: 3.6,κ 0.86), respectively. These values achieved the best balance of sensitivity and specificity, together with the highest values of LR+ and OR and the lowest error rate. Conclusion The 24-h BP cut-off point that best predicts the daytime criterion of less than 135/85 and less than 130/80 mmHg are 132/82 and 127/77 mmHg, respectively. These 24-h cut-off points may add value to ambulatory blood pressure monitoring for both diagnostic and management future decisions.

How should we manage heart failure developing in patients already treated with angiotensin-converting enzyme inhibitors and beta-blockers for hypertension, diabetes or coronary disease?

Abstract: An increasing number of patients in the community are being treated with angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs) and beta-blockers for hypertension, coronary disease or diabetic renal and vascular complications. Some of these patients will develop heart failure despite such treatment. Based on data from hypertension trials it can be estimated that approximately 5% of treated patients will develop heart failure over 5 years. It is unclear whether patients developing heart failure on and off ACE-inhibitors or beta-blockers, respectively, at the time of heart failure diagnosis have similar prognosis.Treatment options for patients developing heart failure while already treated with ACE inhibitors/ARBs and beta-blockers are very limited if current heart failure guidelines are followed. In this review possible strategies are outlined and important areas for research are identified. It is suggested that trials are designed specifically to address prognosis and treatment in this growing population.

Systolic pressure, diastolic pressure, or pulse pressure as a cardiovascular risk factor in renal disease.

Abstract: Chronic kidney disease is a leading global health problem with an increasing prevalence. Hypertension is present in most patients with chronic kidney disease, and hypertension-related nephrosclerosis is a top cause of progressive renal damage and end-stage renal disease. Systolic blood pressure (BP) and pulse pressure, together with nocturnal BP, are the most important factors favoring the progression of renal failure. Consequently, strict control of BP and other cardiovascular risk factors is required, including an adequate degree of suppression of the renin-angiotensin system in every patient.

Multiple action fixed combination. Present or future

Abstract: Cardiovascular disease (CVD) is the most common cause of death in Western countries and will continue to be so in upcoming years. A close correlation has been demonstrated among CVD, stroke, ischemic heart disease, renal failure and a number of modifiable risk factors. As cardiovascular (CV) risk factors commonly co-exist, high-risk patients with hypertension, obesity and diabetes may well benefit from a multiple action combination of CV agents with synergistic efficacy. Control of blood pressure (BP) and the other CV risk factors is still far from the optimal rates and achievement of internationally accepted goals must be imperative. The benefits of achieving these goals, including significant reductions in CV morbidity and mortality, are well documented. Thus, a rigorous effort to improve BP goal attainment is required. Most of the patients will need two or more antihypertensives to achieve BP goal. Administering of two drugs in a single-dose formulation substantially improves patient compliance compared with separate agent administration. Fixed-dose combination therapy can offer potential advantages over individual agents, including increased efficacy, reduced incidence of adverse effects, lower healthcare costs and improved patient compliance through the use of a single medication administered once daily. Currently available fixed-dose agents include several combinations with complementary pharmacodynamic activity. Last, the polypill includes several CV acting agents that affects various CV risk factors and offers encouraging results, although more data are needed to strengthen the polypill concept, its efficacy and safety.

Europejskie zalecenia dotycza̧ce leczenia nadciśnienia tȩtniczego: Stanowisko Europejskiego Towarzystwa Nadciśnienia Tȩtniczego 2009

Abstract: Adresy do korespondencji: Professor Giuseppe Mancia, Clinica Medica, University of Milan-Bicocca, San Gerardo Hospital, Via Pergolesi 33, 20052 Monza, Milan, Włochy tel.: +39 039 2333357; faks: +39 039 322274; e-mail: giuseppe.mancia@unimib.it Professor Stéphane Laurent, Department of Pharmacology and INSERM U970, European Hospital Georges Pompidou, Paris Descartes University, 20 rue Leblanc, 75015 Paris, Francja tel.: +33 1 56 09 39 91; faks: +33 1 56 09 39 92; e-mail: stephane.laurent@egp.ap-hop.-paris.fr

The Framingham risk score is valuable in Europeans

Abstract: The Framingham hypertension risk score developed in the US has been validated in a large group of London-based civil servants. The score is therefore a useful tool for estimating the short-term risk of developing hypertension in a European population.

Detection and treatment of resistant hypertension.

Abstract: The evaluation of patients with resistant hypertension should be directed toward confirming true treatment resistance, identifying the causes contributing to treatment resistance (including secondary causes of hypertension), and documenting target-organ damage. Treatment of resistant hypertension is aimed at reversing lifestyle factors contributing to treatment resistance, accurately diagnosing and appropriately treating secondary causes of hypertension, and effectively using multidrug regimens. Lifestyle changes, pharmacologic therapies, and nonpharmacologic therapies have all shown benefits in patients with resistant hypertension, but much additional knowledge is needed to better identify and treat these patients.

ARBs and ACEis together in the treatment of hypertension and its complications? current practical recommendations.

Abstract: Importance of the field: Arterial hypertension is highly prevalent in the general population. Its contribution to the development and evolution of cardiovascular and renal disease is well recognized. Angiotensin-converting enzyme inhibitors (ACEi) and angiotensin receptor blockers (ARB) have demonstrated favorable effects on cardiovascular and renal prognosis; however, some limitations have been described, for example angiotensin and aldosterone breakthrough. Areas covered in this review: This article describes several therapeutical strategies that can be administered with an ACEi or ARB, such as the direct renin inhibitors or the aldosterone receptor antagonists. What the reader will gain: The addition of an ACEi to an ARB or vice versa was initially considered as a way of obtaining a stronger suppression of the renin–angiotensin–aldosterone system (RAAS), but recent evidence has shown that the combination of the two classes of drugs does not seem to afford the expected increase in benefit. Take home mes...

¿Es posible conseguir una mayor reducción de la morbimortalidad cardiovascular en los pacientes ya tratados con bloqueadores del sistema renina-angiotensina?

Abstract: La enfermedad cardiovascular es un continuo que se inicia con la presencia de los factores de riesgo, prosigue con la aparicion de marcadores subclinicos de lesion organica, como la hipertrofia ventricular izquierda o la oligoalbuminuria, se manifiesta clinicamente con la aparicion de episodios agudos como el infarto de miocardio o el ictus y, en los supervivientes de estos episodios, concluye con la aparicion de disfuncion organica (insuficiencia cardiaca, demencia o insuficiencia renal), que conduce indefectiblemente a la muerte. Hoy en dia existe evidencia suficiente para indicar el tratamiento con inhibidores del sistema reninaangiotensina (SRA) en todos estos estadios evolutivos. Este tratamiento reduce la presion arterial y previene la aparicion de marcadores subclinicos como la oligoalbuminuria, reduce los episodios cardiovascualres y renales en pacientes con lesion subclinica y alarga la supervivencia en pacientes con enfermedad clinica o disfuncion organica. Estos argumentos han hecho de esta modalidad terapeutica la mas empleada tanto en Espana como en otros paises del entorno. No obstante, aun sin dudar del beneficio de la inhibicion del SRA, no es menos cierto que en el mejor de los casos la reduccion del riesgo no va mas alla de una tercera parte. Es decir, se puede reducir un 30% de los episodios y las muertes pero, a pesar de esto, la mayoria de los pacientes, aun tratados, van a seguir presentando episodios cardiovasculares y a morir debido a la progresion de la enfermedad. En estas circunstancias es necesario un planteamiento de futuro que explore las posibles formas de reducir aun mas el riesgo de estos pacientes. Obviamente, es posible que la participacion del SRA en la genesis del dano vascular sea solo una pequena parte de los multiples mecanismos que intervienen y, si esto es asi, los esfuerzos deberian encaminarse exclusivamente al control y al tratamiento de los otros factores de riesgo: optimizar el control de

Hypertension prevalence in health care staff and the rest of the working population: pp.19.263

Abstract: Objectives: To compare the prevalence of hypertension among health care professionals (HCP) and the rest of the workforce. Methods: Sample of 930,404 workers who attended a medical check up between May 2004 and December 2008. Of these 3688 were HCP (2200 nurses and 1448 physicians). Arterial hypertension (HTA) was defining as having blood pressure (BP) > 140/90 mmHg and / or previous diagnosed or treated hypertension. A bivariate analysis comparing the prevalence of hypertension among HCP with the rest of the working population was performed (chi-square test). The analysis was segmented by gender and age (<40 years vs = 40 years) to consider the potential confounding effect of these variables. Results: There were fewer differences than expected among HCP and the rest of the working population. Despite a tendency to find lower prevalence of hypertension among physicians, the differences found with the rest of the working population did not reach statistical significance (a = 0.05). However, altered levels of BP (BP> 140/90 mmHg) were lower in < 40 years male physicians, (12.7% vs. 17.7%, p = 0.02) and as well as = 40 years (35.1% vs. 42.2%, p = 0.02) than in the reference group of the remaining workforce, respectively. Regarding the group of nurses, only showed a lower prevalence of hypertension (3.8% vs. 5.1%, p = 0.03) and altered BP levels (3.5% vs. 4.8%; p = 0.02) among women younger than 40 years. Conclusions: Despite a tendency to find lower prevalence of hypertension among HCP, the differences between these and the rest of the working population are not so important as expected. Our data indicate the importance of assessing cardiovascular risk factors among HCP to design specific programs for this group responsible for monitoring BP.

Fe de errores de «Diferencias en el grado de control de la hipertensión arterial según métodos de medida en pacientes muy ancianos. Proyecto CARDIORISC – MAPAPRES»

Abstract: Fe de errores de )Diferencias en el grado de control de la hipertension arterial segun metodos de medida en pacientes muy ancianos. Proyecto CARDIORISC – MAPAPRES* Jose L. Llisterri , Francisco J. Alonso , Manuel Gorostidi , Cristina Sierra d, , Alejandro de la Sierra , Jose R. Banegas , Julian Segura , Javier Sobrino , Juan J. de la Cruz , Felipe Madruga , Pedro Aranda , Josep Redon , Luis M. Ruilope , en representacion de los investigadores del Proyecto CARDIORISC-MAPAPRES. Sociedad Espanola de Hipertension-Liga Espanola para la Lucha contra la Hipertension Arterial (SEH-LELHA) a Centro de Salud Joaquin Benlloch, Valencia, Espana b Centro de Salud Silleria, Toledo, Espana c Hospital San Agustin, Aviles, Asturias, Espana d Hospital Clinic, Barcelona, Espana e Hospital Mutua de Terrassa, Terrassa, Barcelona, Espana f Departamento de Medicina Preventiva y Salud Publica, Universidad Autonoma, Madrid, Espana g Hospital 12 de Octubre, Madrid, Espana h Fundacio Hospital de l’Esperit Sant, Santa Coloma de Gramanet, Barcelona, Espana i Hospital Geriatrico Virgen del Valle, Toledo, Espana j Hospital Carlos Haya, Malaga, Espana k Hospital Clinico, Valencia, Espana

Antihypertensive efficacy and tolerability oflercanidipine in daily clinical practice. The ELYPSE study

Abstract: Aim: Lercanidipine, a long-acting dihydropyridine with a good antihypertensive efficacy and tolerability. The aim of the ELYPSE trial was to determine the efficacy and tolerability of this medication in daily clinical practice. Methods: Patients with Stage 1-2 essential hypertension, in whom their physicians considered to prescribe a dihydropyridine, were administered lercanidipine 10 mg once daily, with a 3-month follow-up. The study included 9059 patients (mean age 63±11 years; 58% women, 60% over 60 years, 56% with Stage 2 hypertension, and 69% previously treated with other antihypertensive drugs). A subgroup of 1267 patients (14%) experienced adverse reactions, related to pre-administered antihypertensive therapy. Electronic case-report forms and a central Internet database were used for the data collection. Results: Baseline levels of blood pressure (BP) and heart rate (HR) were 160,1±10,2/95,6±6,6 mm Hg and 77,3±9,3 bpm, respectively. Significant reductions in both systolic and diastolic BP were attained at 1 month, with some additional reduction 2 months later. At 3 months, BP level was 141,4±11,3/83,1±6,9 mm Hg, and HR level was 75,2±8,2 bpm (p<0,001 vs. baseline). At the end of the study, 64% of the patients achieved the levels of diastolic BP <90 mm Hg, and BP control (<140/90 mm Hg) was attained in 32%. In the subgroup of diabetics (n=1269), adequate BP control (<130/85 mm Hg) was achieved only in 16,4%. The overall incidence of adverse events was 6,5%; the most frequent ones were headache (2,9%), ankle edema (1,2%), flushing (1,1%), and palpitations (0,6%). Withdrawal rate was <1%. The efficacy and tolerability of lercanidipine in the subgroup of patients included in the study due to adverse events of other antihypertensive drugs were similar to those in the whole study population. Conclusion: In this study, lercanidipine has demonstrated good efficacy and tolerability in daily clinical practice. These findings are consistent with the results of randomized controlled trials.

Recent advances in the management of hypertension.

Abstract: Recently, there have been several reports related to the adequacy of blood pressure (BP) control in high-risk hypertensive patients. These aspects have been reviewed in the recently published reappraisal of the European Society of Hypertension guidelines, and this short review comments on and briefly extends the discussion of this situation. In summary, a low BP goal when cardiorenal disease is advanced can be risky. However, attaining normal BP levels at earlier stages in the cardiorenal continuum is probably totally adequate.