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La pandemia producida por el coronavirus SARS-CoV-2 (COVID-19) ha obligado, en muchos casos a sustituir la consulta presencial por la consulta telemática para reducir el riesgo de contagio asociado a la presencia de pacientes en los centros sanitarios. Este cambio puede representar una oportunidad para una comunicación diferente y más eficiente entre profesionales y pacientes, permitiendo mejorar la accesibilidad a la atención médica y un abordaje más sistemático e integral a los pacientes con hipertensión y riesgo cardiovascular. No obstante, se necesitan herramientas organizativas que faciliten la comunicación entre pacientes y profesionales, específicamente con intercambio de datos clínicos que favorezcan la monitorización remota de las variables asociadas a la hipertensión y riesgo cardiovascular (presión arterial, peso, talla, variables analíticas…) y permitan realizar un seguimiento adecuado en aspectos como la adherencia a los tratamientos, estilos de vida y factores de riesgo. Todo ello sería deseable que fuera realizado por equipos multidisciplinares, tanto de atención primaria como hospitalaria y farmacia comunitaria, con una coordinación adecuada del cuidado en este tipo de pacientes. Este documento de la Sociedad Española de Hipertensión-Liga Española para la Lucha contra la Hipertensión Arterial (SEH-LELHA) trata de dar las claves para mejorar la calidad asistencial de las consultas telemáticas de los pacientes con hipertensión y riesgo cardiovascular, proporcionar criterios básicos de atención telemática o presencial y sistematizar el contenido de estas. Así mismo se plantean los criterios de seguimiento por los diferentes profesionales.

Aim: The aim of the case-control study was to investigate if serum biomarkers indicative of vascular inflammation and endothelial dysfunction can predict the development of microalbuminuria in patients with diabetes mellitus type 2. Methods: Among participants enrolled in the ROADMAP (Randomized Olmesartan And Diabetes MicroAlbuminuria Prevention) and observational follow-up (OFU) studies, a panel of 15 serum biomarkers was quantified from samples obtained at initiation of the study and tested for associations with the development of new-onset microalbuminuria during follow-up. A case-control study was conducted with inclusion of 172 patients with microalbuminuria and 188 matched controls. Nonparametric inferential, nonlinear regression, mediation, and bootstrapping statistical methods were used for the analysis. Results: The median follow-up time was 37 months. At baseline, mean concentrations of C-X-C motif chemokine ligand 16 (CXCL-16), transforming growth factor (TGF)–β1 and angiopoietin-2 were higher in patients with subsequent microalbuminuria. In the multivariate analysis, after adjustment for age, sex, body mass index, glycated hemoglobin, duration of diabetes, low-density lipoprotein (LDL), smoking status, blood pressure, baseline urine albumin-to-creatinine ratio (UACR), estimated glomerular filtration rate (eGFR), time of follow-up and cardiovascular disease, CXCL-16 (odds ratio [OR] 2.60, 95% confidence interval [CI] 1.71–3.96), angiopoietin-2 (OR 1.50, 95% CI 1.14–1.98) and TGF-β1 (OR 1.03, 95% CI 1.01–1.04) remained significant predictors of new-onset microalbuminuria (P < 0.001). Inclusion of these biomarkers in conventional clinical risk models for prediction of microalbuminuria increased the area under the curve (AUC) from 0.638 to 0.760 (P < 0.001). Conclusion: In patients with type 2 diabetes, elevated plasma levels of CXCL-16, angiopoietin-2, and TGF-β1 are independently predictive of microalbuminuria. Thus, these serum markers improve renal risk models beyond established clinical risk factors. Keywords: albuminuria, atheromatosis, cardiovascular disease, diabetic kidney disease, inflammation

Introduction The selective, nonsteroidal mineralocorticoid receptor antagonist finerenone was investigated in FIDELIO-DKD in patients with CKD and T2D (NCT02540993). Sodium-glucose co-transporter-2 inhibitors (SGLT-2is) are recommended for CKD in T2D to reduce risk of CKD progression. We report a predefined exploratory analysis of patients by SGLT-2i use. Methods Patients (N=5674) with T2D, urine albumin-to-creatinine ratio (UACR) 30–5000 mg/g and estimated glomerular filtration rate (eGFR) 25– Results Of 5674 patients, 259 (4.6%) received SGLT-2i at baseline. Overall, finerenone significantly reduced the primary (time to kidney failure, sustained decrease in eGFR ≥40% from baseline, or renal death) and key secondary CV outcomes (time to CV death, nonfatal MI, nonfatal stroke, or hospitalization for heart failure) vs placebo (p=0.001 and p=0.03, respectively) with no effect on A1C. Results were consistent irrespective of SGLT-2i use at baseline for the primary and key secondary CV outcomes (interaction p-value 0.21 and 0.46, respectively). Reduction in UACR with finerenone was seen without SGLT-2i use (ratio of LS-means 0.68, 0.65–0.71; p Conclusion The benefits of finerenone on kidney and CV outcomes in patients with CKD and T2D appear consistent in the absence or presence of SGLT2i, with UACR improvement observed in patients already receiving SGLT-2i at baseline.

Sin financiación No data JCR 2018 0.129 SJR (2018) Q4, 297/365 Cardiology and Cardiovascular Medicine, 113/141 Internal Medicine No data IDR 2018 UEM

Background Recent trials investigating novel therapies in chronic kidney disease (CKD) and type 2 diabetes (T2D) include the randomized, placebo-controlled phase III FIDELIO-DKD and CREDENCE studies of finerenone (selective, nonsteroidal mineralocorticoid receptor antagonist) and canagliflozin (sodium-glucose co-transporter-2 inhibitor), respectively. This analysis investigated how differences in trial design between FIDELIO-DKD and CREDENCE influence the treatment effects of the two drugs. Methods This was a post hoc analysis of FIDELIO-DKD that included patients meeting the CKD inclusion criteria of the CREDENCE study (urine albumin-to-creatinine ratio >300–5000 mg/g and estimated glomerular filtration rate [eGFR] 30– Results Overall, 81.4% (4619/5674) of patients were eligible for this analysis; 2291 (49.6%) received finerenone and 2328 (50.4%) received placebo. The cardiorenal composite endpoint risk was significantly reduced by 26% with finerenone versus placebo (hazard ratio 0.74, 95% confidence interval 0.63–0.87; p=0.0003); after adjusting for history of heart failure, the risk was reduced by 28%. In CREDENCE, the cardiorenal endpoint risk reduction was 30% with canagliflozin versus placebo (see Figure for all results). Conclusion The results of this analysis highlight the pitfalls of direct comparisons between trials, and how subtle differences in patient eligibility criteria and endpoint definitions can lead to meaningful differences in outcomes. Both the FIDELIO-DKD and CREDENCE studies demonstrate cardiorenal benefits of a similar magnitude when these differences are considered.

Introduction Finerenone is a nonsteroidal mineralocorticoid receptor antagonist that significantly reduces risk of kidney and CV outcomes in patients with CKD and T2D. GLP-1RAs have also been shown to improve CV outcomes in patients with T2D. Mechanisms of action of finerenone and GLP-1RAs are largely independent but their combined effects are unknown. We report outcomes from the FIDELIO-DKD trial in patients by GLP-1RA treatment. Methods FIDELIO-DKD (NCT02540993) randomized 5734 patients with T2D (UACR 30–5000mg/g; eGFR 25– Results Of 5674 patients analyzed, 394 (6.9%) were treated with a GLP-1RA at baseline. There was no between-group interaction for primary kidney (HR 1.17, 95%CI 0.71–1.90 with GLP-1RA; HR 0.80, 95%CI 0.71–0.91 without GLP-1RA; P-interaction 0.15) or secondary CV outcomes (HR 1.02, 95%CI 0.60–1.74 with GLP-1RA; HR 0.85, 95%CI 0.73–0.98 without GLP-1RA; P-interaction 0.51). Reduction in UACR was independent of GLP-1RA use (ratio of LS-means 0.63, 95%CI 0.56–0.70 with GLP-1RA; 0.69, 95%CI 0.67–0.72 without GLP-1RA; P-interaction 0.20). Incidences of hyperkalemia events were similar in patients with and without GLP-1RA use. Conclusion Effects of finerenone on kidney and CV outcomes appear consistent irrespective of GLP-1RA use, with a potential additive benefit for UACR reduction.

Introduction and objectives: The purpose of this study was to investigate whether changes in cardiovascular risk (CVR) are associated with the length and cost of sickness absence. Methods: A prospective cohort of 179 186 participants was evaluated. Each participant's CVR (SCORE) was assessed on 2 consecutive medical examinations, approximately 1 year apart (365 90 days). Cardiovascular risk was categorized as < 4% or >= 4%, and participants were divided into 4 groups according to changes in their risk between the 2 assessments. After the second CVR estimate, a 1-year follow-up was carried out to assess sickness absence. Differences between the 4 groups in terms of the total count of sickness absence days during the follow-up period were tested using Poisson regression models. Results: After adjustment for covariates, participants who showed an improvement in CVR had a lower count of sickness absence days compared with both those who showed a worsening in risk and those who remained stable at >= 4% (RR, 0.91; 95%CI, 0.84-0.98). In comparison with participants whose CVR did not improve, more of the participants whose risk did improve had quit smoking (+17.2%; P

Acute heart failure (AHF) represents a clinical challenge as it encloses a heterogeneous group of syndromes (AHFS) with different pathophysiology, clinical presentations, prognosis and response to therapy. In the last 25years multiple therapeutic targets have been identified and numerous new drugs were evaluated but, up to now, all failed to demonstrate a consistent benefit on clinical outcomes. Moreover, a repeated finding has been the poor correlation between the encouraging results of preclinical and early clinical trials and the lack of effect on outcomes observed in phase III trials. We review several possible pharmacological reasons that may explain the lack of success to develop new drugs and the pharmacological challenges to overcome in the future to develop new more effective and safer drugs for the treatment of AHFS.

Pathway-2 is the first randomised, double-blind and crossover trial that compares spironolactone as a fourth drug with alfa-blocker, beta-blocker and placebo. This study shows that spironolactone is the drug with more possibilities of success for the management of patients with difficult-to-treat hypertension in patients with a combination of three drugs and poor control. The results validate the widespread treatment with mineralocorticoid receptor antagonists in resistant hypertension.

Resumen Introduccion Las vesiculas extracelulares (EV) son liberadas al torrente circulatorio por determinados tipos celulares a consecuencia de procesos de transporte, activacion o muerte celular. El recuento de EV circulantes de origen plaquetario y endotelial ha demostrado tener un importante papel como biomarcador de riesgo cardiovascular. Por lo tanto, el proteoma de estas EV podria reflejar los procesos celulares subyacentes en pacientes con hipertension arterial y albuminuria. Material y metodos El contenido proteico de las EV circulantes se ha analizado mediante cromatografia liquida acoplada a espectrometria de masas. Las EV han sido aisladas mediante un protocolo de ultracentrifugacion optimizado para evitar la contaminacion de proteinas del plasma. La pureza de la fraccion aislada ha sido verificada mediante microscopia electronica y confocal, y por citometria de flujo. Resultados En este estudio mostramos un metodo de gran rendimiento y pureza para obtener extractos proteicos de EV circulantes de pacientes hipertensos con/sin albuminuria para analisis proteomico. Ademas, aportamos el proteoma de referencia de EV de estos pacientes, compuesto por 2.463 proteinas, y demostramos que las proteinas transportadas por estas vesiculas estan relacionadas con procesos cruciales involucrados en el riesgo cardiovascular asociado. Conclusion El proteoma de las EV circulantes constituye una interesante fuente de indicadores para la evaluacion de procesos relacionados con el riesgo cardiovascular en pacientes hipertensos con bloqueo del sistema renina-angiotensina.

The maintenance of an adequate blood pressure (BP) control during the life-time in the general population still constitutes the most relevant challenge in the prevention of cardiovascular disease and new goals are considered in clinical practice [1,2]. This must be accompanied by the adequate management of the associated risk factors and comorbidities that so frequently accompany the elevation in BP. It is well established that the joint effect of genetic component and inadequate life-style underlie the progressive increase in BP. Sin financiación 3.229 JCR (2019) Q2, 55/138 Cardiac & Cardiovascular Systems 1.082 SJR (2019) Q1, 82/362 Cardiology and Cardiovascular Medicine No data IDR 2019 UEM

Background High albuminuria is a strong predictor of development of cardiovascular events in hypertensive patients. The search for predictors identifying patients at risk of developing high albuminuria or presenting a more rapid progression in this parameter may represent an effective strategy for adequate intervention and better outcome. Methods and results Initially we investigated 24 patients presenting with normoalbuminuria, de novo albuminuria and sustained albuminuria. Plasma proteomics disclosed an upregulation of ceruloplasmin (CP), haptoglobin (HP) and alpha 1-acid glycoprotein (ORM1) that in a second step were selected for validation using turbidimetry assay in a cohort of 105 subjects. The validation showed that HP and ORM1 proteins were increased in patients presenting with very high albuminuria and potential irreversible kidney damage. CP and HP correlated positively with albuminuria values in normoalbuminuric patients. Finally, the levels of ORM1 and CP were increased in patients who progressed in their levels of albuminuria. Conclusions Our findings show that these proteins may potentially be useful for predicting the development of high albuminuria and to monitor renal damage.

Enrique Galve *, Nieves Martell-Claros b,2 y Miguel Camafort-Babkowski , en nombre del Grupo de consenso espanol sobre la denervacion renal a Servicio de Cardiologia, Hospital Vall d’Hebron, Barcelona, Espana Unidad de Hipertension, Hospital Clinico San Carlos, Madrid, Espana Departamento de Medicina Interna, Hospital Clinic, Instituto de Investigaciones Biomedicas August Pi i Sunyer (IDIBAPS), Universidad de Barcelona, Barcelona, Espana

Resumen Introduccion y objetivos La guia para el manejo y el tratamiento de las dislipemias del American College of Cardiology/American Heart Association estadounidense y la del National Institute for Health and Clinical Excellence britanico recomiendan cambios importantes, como la supresion de los objetivos terapeuticos o la utilizacion de unas tablas de riesgo nuevas. Este estudio pretende evaluar el impacto de utilizar estas nuevas guias en comparacion con lo que supone la aplicacion de la guia europea. Metodos Estudio de tipo observacional realizado en trabajadores espanoles. Se incluyo a todos los trabajadores reconocidos por la Sociedad de Prevencion de Ibermutuamur durante el ano 2011 y cuyo riesgo cardiovascular era evaluable. De cada sujeto, se calculo el riesgo cardiovascular utilizando las tablas Systematic Coronary Risk Evaluation para paises de bajo riesgo y las tablas recomendadas por las guias estadounidense y britanica. Resultados Se incluyo a 258.676 trabajadores (el 68,2% varones; media de edad, 39,3 anos). Segun las tablas Systematic Coronary Risk Evaluation, el 3,74% de la poblacion resulto ser de alto riesgo, mientras que segun las tablas britanicas eran el 6,85% y segun las tablas estadounidenses, el 20,83%. Se deberia tratar a mas de 20.558 trabajadores si se sigue la guia estadounidense, 13.322 con la britanica y 2.612 siguiendo las recomendaciones de las sociedades europeas. Con la guia estadounidense, el coste diario de estatinas se multiplicaria casi por 8. Conclusiones La nuevas recomendaciones supondrian identificar a mas pacientes de alto riesgo y tratar con hipolipemiantes a mas poblacion que con las recomendaciones europeas, lo que aumentaria los costes.

Over the past decades, aggressive control of blood pressure (BP) and blockade of the renin-angiotensin-aldosterone system (RAAS) were considered the cornerstones of treatment against progression of chronic kidney disease (CKD), following important background and clinical evidence on the associations of hypertension and RAAS activation with renal injury. To this end, previous recommendations included a BP target of130/80 mm Hg for all individuals with CKD (and possibly125/75 mm Hg for those with proteinuria1 g/day), as well as use of angiotensin-converting-enzyme inhibitors and angiotensin receptor blockers as first-line therapy for hypertension in all CKD patients. However, long-term extensions of relevant clinical trials support a low-BP goal only for patients with proteinuria, whereas recent cardiovascular trials questioned the benefits of low systolic BP for diabetic patients, leading to more individualized recommendations. Furthermore, our previous knowledge of the specific renoprotective properties of RAAS blockers in patients with proteinuric CKD is now extended with data on the use of these agents in patients with less advanced nephropathy and/or absence of proteinuria, deriving mostly from subanalyses of cardiovascular trials. This review discusses previous and recent clinical evidence on the issues of BP reduction and RAAS blockade by type and stage of renal damage, aiming to aid clinicians in their treatment decisions for patients with CKD.

Despite the high prevalence of hypertension and documented benefits of blood pressure (BP) control, >40% of patients with hypertension are not controlled. A majority of uncontrolled hypertensive patients receive two or more antihypertensive drugs. The current review examined the relationship between antihypertensive combination drug therapy, achievement of goal BP, and cardiovascular (CV) outcomes. Articles were selected from a PubMed search using a prespecified search strategy. Randomized, controlled clinical trials of adult human subjects published in English between January 1991 and January 2013 were included. From 2319 identified articles, 28 met inclusion criteria and contained a total of 226,877 subjects. There were seven placebo-controlled studies and 21 treatment comparator and combination therapy studies. The studies included in this review reported a positive association between the degree of BP lowering, number of medications, and CV outcomes. As combination therapy became available, it was increasingly utilized in clinical trials and enabled an increased proportion of patients to achieve a prespecified BP target. Adverse events with monotherapy and combination therapy were as anticipated for the specific classes of antihypertensive therapy. Although many patients reach BP goal, combination antihypertensive therapy is often needed to reach BP goal. Effective BP lowering has been shown to result in improvements in CV outcomes.

On Jan 14, 2018, during a tense final touchdown in a US National Football League playoff game, numerous Apple Watch users received an alert from their device telling them that they were having potentially harmful arrhythmias. Smartphones and wearable technology are increasingly used as public health tools because billions of people worldwide are digital users. In 2020, more than 6 billion people will have smartphone subscriptions. Clinicians and researchers can use these devices to effortlessly monitor patients' health and behaviour indicators in real time. Sin financiación 59.102 JCR (2018) Q1, 2/160 Medicine, General & Internal 15.871 SJR (2018) Q1, 5/2844 Medicine (miscellaneous) No data IDR 2018 UEM

Results from the GSR (Global Symplicity Registry) for patients treated with the Symplicity Spyral catheter on a limited cohort were presented previously. The current analysis presents data on safety and efficacy outcomes up to 3 years. GSR is a prospective, international registry of patients with

Catheter-based radiofrequency ablation technology to disrupt both efferent and afferent renal nerves has recently been introduced to clinical medicine after the demonstration of significant systolic and diastolic blood pressure reductions. Clinical trial data available thus far have been obtained primarily in patients with resistant hypertension, defined as standardized systolic clinic blood pressure ≥ 160 mm Hg (or ≥ 150 mm Hg in patients with type 2 diabetes) despite appropriate pharmacologic treatment with at least 3 antihypertensive drugs, including a diuretic agent. Accordingly, these criteria and blood pressure thresholds should be borne in mind when selecting patients for renal nerve ablation. Secondary forms of hypertension and pseudoresistance, such as nonadherence to medication, intolerance of medication, and white coat hypertension, should have been ruled out, and 24-h ambulatory blood pressure monitoring is mandatory in this context. Because there are theoretical concerns with regard to renal safety, selected patients should have preserved renal function, with an estimated glomerular filtration rate ≥ 45 ml/min/1.73 m(2). Optimal periprocedural management of volume status and medication regimens at specialized and experienced centers equipped with adequate infrastructure to cope with potential procedural complications will minimize potential patient risks. Long-term safety and efficacy data are limited to 3 years of follow-up in small patient cohorts, so efforts to monitor treated patients are crucial to define the long-term performance of the procedure. Although renal nerve ablation could have beneficial effects in other conditions characterized by elevated renal sympathetic nerve activity, its potential use for such indications should currently be limited to formal research studies of its safety and efficacy.

Resumen Fundamento y objetivo El objetivo de este estudio de corte transversal fue comparar la prevalencia de lesion de organos diana (LOD) y de enfermedad cardiovascular (ECV) establecida en una cohorte de pacientes hipertensos no diabeticos con 3 o mas factores de riesgo cardiovascular (FRCV) frente a un grupo de hipertensos diabeticos tipo 2. Pacientes y metodo Se incluyeron 4.725 pacientes, 62% varones, con una edad media (DE) de 64 (12) anos, hipertensos diabeticos tipo 2, independientemente del numero de FRCV asociados (N = 2.608), o no diabeticos, en cuyo caso se requeria la presencia de 3 FRCV (N = 2.117). Se determino la prevalencia de ECV establecida (interrogatorio clinico) y de LOD (hipertrofia ventricular izquierda por electrocardiografia, microalbuminuria y filtrado glomerular estimado). Resultados Los pacientes hipertensos diabeticos tipo 2 presentaban una mayor edad y obesidad mas marcada. Asimismo, dichos pacientes mostraban mayores prevalencias de microalbuminuria y macroalbuminuria, insuficiencia renal, hipertrofia ventricular izquierda, placas de ateroma en arterias carotidas y ECV en comparacion con los hipertensos no diabeticos con 3 o mas FRCV. El analisis multivariante mostraba que el riesgo de presentar LOD o ECV previa se relacionaba de forma independiente con la presencia de diabetes. Conclusion Los pacientes hipertensos diabeticos tipo 2 presentan una mayor prevalencia de LOD y de ECV respecto a los pacientes hipertensos no diabeticos con 3 o mas FRCV. Aunque ambas situaciones se incluyen en el estrato de riesgo cardiovascular elevado, cabe esperar que los hipertensos diabeticos tengan una mayor incidencia de complicaciones cardiovasculares.

The kidney is involved in glucose homeostasis through three major mechanisms: renal gluconeogenesis, renal glucose consumption, and glucose reabsorption in the proximal tubule. Glucose reabsorption is one of the most important physiological functions of the kidney, allowing full recovery of filtered glucose, elimination of glucose from the urine, and prevention of calorie loss. Approximately 90% of the glucose is reabsorbed in the S1 segment of the proximal tubule, where glucose transporter-2 (GLUT2) and sodium-glucose transporter-2 (SGLT2) are located, while the remaining 10% is reabsorbed in the S3 segment by SGLT1 and GLUT1 transporters. In patients with hyperglycemia, the kidney continues to reabsorb glucose, thus maintaining hyperglycemia. Most of the renal glucose reabsorption is mediated by SGLT2. Several experimental and clinical studies suggest that pharmacological blockade of this transporter might be beneficial in the management of hyperglycemia in patients with type 2 diabetes.

The renin–angiotensin aldosterone system (RAAS) is central to the pathogenesis of cardiovascular disease. RAAS inhibition can reduce blood pressure, prevent target organ damage in hypertension and diabetes, and improve outcomes in patients with heart failure and/or myocardial infarction. This review presents the history of RAAS inhibition including a summary of key heart failure, myocardial infarction, hypertension and atrial fibrillation trials. Recent developments in RAAS inhibition are discussed including implementation and optimization of current drug therapies. Finally, ongoing clinical trials, opportunities for future trials and issues related to the barriers and approvability of novel RAAS inhibitors are highlighted.

Previous studies have examined control rates of office blood pressure (BP) in chronic kidney disease (CKD). However, recent evidence suggests major discrepancies between office and 24-hour BP values in hypertensive populations. This study examined concordance/discordance between office- and ambulatory-based BP control in a large cohort of patients with CKD.Cross-sectional.5,693 hypertensive individuals with CKD stages 1-5 from the Spanish ABPM (ambulatory BP monitoring) Registry.Thresholds of 140/90 and 130/80 mm Hg for office BP and 24-hour ambulatory BP, respectively. Age, sex, body mass index, waist circumference, hypertension duration, kidney measures, diabetes, dyslipidemia, target-organ damage, and cardiovascular comorbid conditions.Misclassification of BP control as "white-coat" hypertension (office BP ≥140/90 mm Hg, 24-hour BP130/80 mm Hg) or masked hypertension (office BP140/90 mm Hg, 24-hour BP ≥130/80 mm Hg).Standardized office-based BP and 24-hour ABPM.Mean age was 61.0 ± 13.9 (SD) years and 52.6% were men. The proportion with white-coat hypertension was 28.8% (36.8% of patients with office BP ≥140/90 mm Hg) and that of masked hypertension was 7.0% (but 32.1% of patients with office BP140/90 mm Hg). Female sex, aging, obesity, and target-organ damage were associated with white-coat hypertension; aging and obesity were associated with masked hypertension. Only 21.7% and 8.1% of the CKD population had office BP140/90 and130/80 mm Hg, respectively. In contrast, 43.5% of individuals had average 24-hour BP130/80 mm Hg.Cross-sectional design, longitudinal associations cannot be established.Misclassification of BP control at the office was observed in 1 of 3 hypertensive patients with CKD. Ambulatory-based control rates were far better than office-based rates. Nevertheless, the burden of uncontrolled ambulatory BP and misclassification of BP control at the office constitutes a call for wider use of ABPM to evaluate the success of hypertension treatment in patients with CKD.

Resumen Introduccion y objetivos La hipertension resistente es un problema clinico por la dificultad de su tratamiento y el aumento de morbimortalidad que conlleva. Se ha demostrado que la denervacion renal por cateter mejora el control de estos pacientes. Se describen los resultados de la creacion de una unidad multidisciplinaria para la implementacion de la denervacion renal en el tratamiento de la hipertension resistente. Metodos Un equipo compuesto por nefrologos y cardiologos diseno un protocolo para la seleccion, la intervencion y el seguimiento de los pacientes. Se incluyo a 197 pacientes con hipertension esencial mal controlada pese a la toma de tres o mas farmacos. A la tecnica de ablacion descrita, se anadio el soporte de un navegador basado en angiografia rotacional. Se comparo la presion arterial basal y tras el seguimiento utilizando el test de Wilcoxon para muestras apareadas. Resultados Se excluyo a 108 (55%) pacientes con hipertension seudorresistente. A los otros 89, se les administraron antialdosteronicos, a los que respondieron 60 pacientes (30%). Fueron candidatos a denervacion los 29 (15%) pacientes restantes. Se realizo ablacion a 11 pacientes, con una presion arterial de 164/99 mmHg, en tratamiento con 4,4 farmacos. Tras un seguimiento de 72 dias, las presiones arteriales sistolica y diastolica se redujeron en 25 mmHg (p = 0,02) y 10 mmHg (p = 0,06) respectivamente. En 10 pacientes (91%) se suspendio al menos un farmaco. Conclusiones La denervacion renal implementada mediante un programa multidisciplinario ofrece una mejora en la presion arterial similar a la de estudios previos, con mayor reduccion de farmacos antihipertensivos.

Cardiovascular clinical trials are increasingly conducted globally as a means to reduce costs, expedite timelines, provide broad applicability, and satisfy regulatory authorities. Potential problems with trial globalization include regional differences in patient characteristics, medical practice patterns, and health policies which may influence outcomes and limit generalizability. Moreover, concerns have been raised about ethical misconduct and unsatisfactory quality oversight in regions with less trial experience and infrastructure. This article reviews geographical differences in cardiovascular trials in heart failure, acute coronary syndromes, hypertension and atrial fibrillation. It also explores potential explanations for these differences and methods to standardize the presentation of trial results. This review is based on discussions between basic scientists and clinical trialists at the 8th Global Cardio Vascular Clinical Trialists Forum 2011 in Paris, France, from December 2 to 3.

La medicion automatica de la presion sanguinea en consulta (MAPSC) presenta importantes ventajas sobre la medicion manual de la presion arterial en consulta (MMPAC). La MAPSC requiere el uso de un esfigmomanometro totalmente automatico que registra multiples lecturas con el paciente en reposo y sin la presencia del clinico. Al seguir estos tres principios de la MAPSC, es posible obtener lecturas en consulta similares a las obtenidas en domicilio y con monitorizacion ambulatoria de la PA de 24 horas con el paciente despierto. Los tres metodos de medicion automatica de la PA definen la hipertension como una presion arterial?135/85mmHg. La correlacion entre la PA ambulatoria con el paciente despierto (un estandar de oro reconocido para la prediccion de futuros eventos cardiacos en relacion con el estado de la PA) y la MAPSC es mucho mayor que para la MMPAC rutinaria. La MAPSC elimina la hipertension de bata blanca y se correlaciona con el dano al organo diana de forma significativamente superior que la MMPAC rutinaria. Despues de 100 anos de medicion manual de la PA con el esfigmomanometro de mercurio, es hora de adoptar el uso de la MAPSC de forma rutinaria en la practica clinica a fin de lograr una evaluacion mas precisa de la PA del paciente y su riesgo cardiovascular futuro.

Patients with grade 2 or 3 hypertension may require high-dose combination therapy to achieve blood pressure (BP) targets in a timely manner.This study compared the effectiveness and tolerability of a single-pill combination (SPC) of telmisartan/hydrochlorothiazide 80/25 mg (T80/H25) with T80 monotherapy.In a Phase IV, multinational, randomized, double-blind, double-dummy, active-controlled, parallel-group trial, 894 patients with mean seated trough cuff systolic BP [SBP] ≥160 mm Hg and diastolic BP [DBP] ≥100 mm Hg were randomly assigned in a 2:1 ratio to receive T40/H12.5 SPC or telmisartan 40 mg monotherapy for 1 week before the dose was uptitrated to T80/H25 SPC or T80, respectively, administered for 6 weeks. The primary efficacy measure was the change from baseline in mean seated cuff trough SBP. Adverse events (AEs) were recorded.A total of 888 patients received treatment (294 and 594 patients in the T80/H25 and T80 groups, respectively) (mean age, 57.0 years; age ≥65 years, 25.7%; male, 53.8%; white, 68.0%); 61 patients prematurely discontinued. Mean baseline SBP/DBP values were 172.3/104.3 mm Hg (T80/H25) and 173.3/104.5 mm Hg (T80). After 7 weeks, SBP was changed by -37.0 and -28.5 mm Hg in the T80/H25 and T80 groups (P0.0001); DBP was changed by -18.6 and -15.4 mm Hg respectively (P0.0001). These differences were significant after 2 weeks at the higher dosage (P0.0001). BP target (SBP/DBP140/90 mm Hg) was achieved in 55.5% and 34.7% of patients in the T80/H25 and T80 groups (P0.0001). T80/H25 SPC and T80 had a similar frequency of overall AEs (16.0% vs 17.0%). The prevalences of treatment-related AEs with T80/H25 SPC and T80 were low (4.6% and 2.8%), as were the rates of AEs that led to discontinuation (1.0% and 2.8%).In these patients with grade 2 or 3 hypertension, initial therapy with T80/H25 was associated with a significantly greater reduction in mean seated cuff trough SBP compared with T80 alone, as well as with improved hypertension goal attainment rates. Both treatments appeared to be well tolerated.

Resumen Fundamento y objetivo El efecto de bata blanca (EBB) es uno de los principales sesgos que pueden modificar la medida de la presion arterial (PA) en consulta, por lo que se debe considerar para evitar errores diagnostico-terapeuticos en los pacientes hipertensos. La utilizacion de aparatos automatizados en consulta podria disminuir dicho efecto. Metodo Se disenaron 2 estudios con el objetivo de evaluar las diferencias entre la medida rutinaria en consulta y la obtenida por el aparato automatizado de medida de PA en consulta, BPTru ® , asi como su influencia en el EBB. El primero de los estudios, TRUE-ESP, incluyo pacientes normotensos e hipertensos atendidos en consultas especializadas de Cardiologia, Nefrologia, Medicina Interna, Endocrinologia y Medicina Familiar. El segundo, TRUE-HTA, incluyo pacientes hipertensos atendidos en una Unidad de HTA, protocolizada, con personal entrenado. Resultados El estudio TRUE-ESP incluyo 300 pacientes, 76% hipertensos. Se observo una diferencia significativa entre la medida clinica y la medida BPTru ® (media [DE] de PA sistolica/PA diastolica [PAS/PAD] de 9,8 [6,11]/3,4 [7,9] mmHg, p ® (media [DE] de PAS/PAD de 5,7 [3,9]/2,1 [3,5] mmHg, p Conclusiones El empleo de aparatos automatizados de medida de PA en consulta, como el BPTru ® , puede colaborar a disminuir el EBB y mejorar la precision de la medida de la PA en consulta.

On the 6th May 2017, a Kenyan distance runner ran the marathon in 2:00:25 at the Monza racetrack, Italy. Although Eliud Kipchoge's time marks the fastest marathon ever run, his performance cannot be considered an official world record (currently at 2:02:57) because he benefited from unusual advantages (eg, car drafting and rotating pacemakers, controversial running shoes). Yet, this astonishing performance suggests that a sub 2-hour marathon under official conditions might not be so far away and demonstrates the remarkable capacity of the human body, as exemplified by Kipchoge's ability to endure a gruelling training regime (>120 miles/week at ~2400 m) in typically warm climes, helping him achieve a performance previously considered impossible. Even more important are the lessons we can learn from a global health perspective.

Resumen Fundamento y objetivo La hipertension arterial refractaria o resistente (HTR) es frecuente en las unidades especializadas de hipertension arterial (HTA). El objetivo de este trabajo fue valorar la prevalencia de afectacion de organos diana y alteraciones metabolicas asociadas en una serie de pacientes con HTR que se incluyeron de forma consecutiva en el registro de HTR de la Sociedad Espanola de Hipertension/Liga Espanola para la Lucha contra la Hipertension arterial (SEH-LELHA). Pacientes y metodo Estudio epidemiologico, transversal, multicentrico, en condiciones de practica clinica habitual. La HTR fue definida como la persistencia de cifras de presion arterial (PA) sistolica ≥ 140 mmHg o PA diastolica ≥ 90 mmHg en pacientes tratados con al menos 3 farmacos, a dosis plenas, uno de ellos diuretico. Se recogieron los datos demograficos y antropometricos, la presencia de otros factores de riesgo y condiciones clinicas asociadas. A todos los sujetos se les practico una monitorizacion ambulatoria de la presion arterial durante 24 horas (MAPA). La afectacion de organos diana se determino mediante la realizacion de ecocardiograma, electrocardiograma basal y excrecion urinaria de albumina. Resultados Se incluyeron 513 sujetos con una edad media (DE) de 64 (11) anos; un 47% eran mujeres. Un 65,7% (intervalo de confianza del 95% [IC 95%] 61,6-69,9) tenian obesidad central, un 38,6% (IC 95% 34,4-42,8) presentaban diabetes mellitus y un 63,8% (IC 95% 59,4-67,9) sindrome metabolico. La prevalencia de hipertrofia ventricular izquierda medida ecocardiograficamente fue del 57,1% (IC 95% 50,8-63,5) y la de dilatacion de auricula izquierda del 10,0% (IC 95% 6,3-13,7). Se observo microalbuminuria en un 46,6% de los sujetos (IC 95% 41,4-51,8). Los pacientes con sindrome metabolico fueron significativamente mayores (media de 65,4 [11] frente a 62,5 [ 12] anos; p = 0,0052), presentaron una mayor prevalencia de diabetes (52,0 frente a 16,6%, p Conclusiones La prevalencia de alteraciones metabolicas y de afectacion de organos diana es muy elevada en los sujetos con HTR.

High blood pressure can be both a cause and a consequence of chronic kidney disease and will contribute to an unfavorable renal and cardiovascular (CV) prognosis. Both in the general population and in hypertensive patients, the presence of chronic kidney disease is associated with a high prevalence of CV disease. Elevated blood pressure and the amount of albumin present in urine are the 2 most relevant factors facilitating the progression of chronic kidney disease in hypertensive patients. Therapeutic attitudes that must be considered when chronic kidney disease is present include the simultaneous performance of CV and renal protection.

BACKGROUND: Recent trials have documented no benefit from small reductions in blood pressure measured in the clinical office. However, ambulatory blood pressure is a better predictor of cardiovascular events than office-based blood pressure. We assessed control of ambulatory blood pressure in treated hypertensive patients at high cardiovascular risk. METHODS: We selected 4729 patients from the Spanish Ambulatory Blood Pressure Monitoring Registry. Patients were aged >= 55 years and presented with at least one of the following co-morbidities: coronary heart disease, stroke, and diabetes with end-organ damage. An average of 2 measures of blood pressure in the office was used for analyses. Also, 24-hour ambulatory blood pressure was recorded at 20-minute intervals with a SpaceLabs 90207 device. RESULTS: Patients had a mean age of 69.6 (+/-8.2) years, and 60.8% of them were male. Average time from the diagnosis of hypertension to recruitment into the Registry was 10.9 (+/-8.4) years. Mean blood pressure in the office was 152.3/82.3 mm Hg, and mean 24-hour ambulatory blood pressure was 133.3/72.4 mm Hg. About 60% of patients with an office-pressure of 130-139/85-89 mm Hg, 42.4% with office-pressure of 140-159/90-99 mm Hg, and 23.3% with office-pressure >= 160/100 mm Hg were actually normotensive, according to 24-hour ambulatory blood pressure criteria (

Resumen Fundamento y objetivos La hipertension arterial (HTA) afecta a la mayoria de la poblacion muy anciana. El objetivo de este estudio fue estimar el grado de control de la HTA segun se registre la presion arterial (PA) en la consulta o por monitorizacion ambulatoria de PA (MAPA). Pacientes y metodo Estudio transversal y multicentrico sobre pacientes hipertensos de 80 o mas anos de edad con tratamiento farmacologico antihipertensivo incluidos en el proyecto CARDIORISC–MAPAPRES. Entre junio de 2004 y abril de 2007 se obtuvo una base de datos de 33.829 registros de MAPA que cumplieron estandares de calidad preestablecidos. Se definio como buen control clinico a valores de PA menores de 140/90 mmHg, y como buen control ambulatorio a valores de PA por MAPA en periodo de 24 h menores de 130/80 mmHg. Resultados Se identificaron 2.311 pacientes (6,8%) de 80 o mas anos de edad. La edad media fue de 83,1 anos (DE de 3,2) y un 63% fueron mujeres. El 21,5% (intervalo de confianza [IC] del 95%: 19,1–23,9) presento buen control clinico y un 42,1% (IC del 95%: 39,7–45,3) presento buen control ambulatorio (p Conclusiones Solo 2 de cada 10 pacientes muy ancianos hipertensos tuvieron controlada adecuadamente su HTA por medida casual. Sin embargo, practicamente el doble estaban controlados con el criterio de la MAPA. Estos hallazgos justifican un uso mas amplio de la MAPA en el paciente hipertenso de edad muy avanzada.

Jose R. Banegas a,b, , Albert Jovell , Benjamin Abarca , Manuel Aguilar Diosdado , Luis Aguilera , Pedro Aranda , Vicente Bertomeu , Pedro Capilla , Pedro Conthe , Fernando De Alvaro , Antonio Fernandez-Pro , Xavier Formiguera , Jesus Frias , Lucia Guerrero, Jose L. Llisterri , Jose M. Lobos , Juan F. Macias , Angel L. Martin De Francisco , Jesus Millan , Juan C. Morales , Vicente Palomo , Alex Roca-Cusachs , Javier Roman , Carlos Sanchis , Antonio Sarria , Julian Segura , Alex De La Sierra , Luis Verde , Julio Zarco n y Luis M. Ruilope a,u a Asociacion de la Sociedad Espanola de Hipertension y Liga Espanola para la Lucha contra la Hipertension Arterial b Universidad Autonoma de Madrid, CIBERESP (CIBER de Epidemiologia y Salud Publica), Madrid c Foro Espanol de Pacientes d Sociedad Espanola de Medicina General e Sociedad Espanola de Diabetes f Sociedad Espanola de Medicina de Familia y Comunitaria g Sociedad Espanola de Cardiologia h Consejo General de Colegios Oficiales de Farmaceuticos i Sociedad Espanola de Medicina Interna j Sociedad Espanola de Nefrologia en el Comite Espanol Interdisciplinario para la Prevencion Cardiovascular k Sociedad Espanola para el Estudio de la Obesidad l Departamento de Farmacologia y Terapeutica, Universidad Autonoma de Madrid, Madrid m Asociacion de Enfermeria de Hipertension y Riesgo Cardiovascular (EHRICA) n Sociedad Espanola de Medicos de Atencion Primaria o Comite Espanol Interdisciplinar de Prevencion Cardiovascular (CEIP) p Sociedad Espanola de Geriatria y Gerontologia q Sociedad Espanola de Nefrologia r Sociedad Espanola de Arteriosclerosis s Sociedad Espanola de Farmaceuticos de Atencion Primaria t Ibermutuamur-Corporacion Mutua-Proyectos Sanitarios u Agencia de Evaluacion de Tecnologias Sanitarias. Instituto de Salud Carlos III, Madrid v Asociacion para la Prevencion del Riesgo Cardiovascular (PRECAR) x Sociedad Espanola de Directivos de Atencion Primaria, Espana