Influence of target organ lesion detection (assessment of microalbuminuria and echocardiogram) in cardiovascular risk stratification and treatment of untreated hypertensive patients

Cardiovascular risk profile of young hypertensive patients: the OPENJOVEN study

Background: Knowledge of the hypertensive patient’s characteristics is an important aspect to improve its clinical handling. Because of the burden that the patients of advanced age suppose in primary care, few data exist about the youngest patient's cardiovascular profile.

Objective: To describe the cardiovascular profile of the young hypertensive patient (<55 years) in primary care in Spain.

Design and methods: Cross-sectional multicentre study that was carried out in centres of primary care of the whole Spanish territory. At total of 2108 doctors participated and 6815 patients diagnosed with high blood pressure were included. We used a survey of risk factors, subclinical organ damage, and cardiovascular or renal established disease according to the European Society of Hypertension and the European Society of Cardiology 2007 guidelines to evaluate the cardiovascular risk.

Results: Of the hypertensive patients, 5.8% did have not another cardiovascular risk factor (CVRF), 23.2% had one risk factor associated with high blood pressure, 32.8% two, 24.7% three, 11.3% four, and 2.3% had five risk factors. The most prevalent cardiovascular risk factor was dyslipidaemia, found in 80.4% (37.9% with treatment), followed by abdominal obesity, in 45.9% of the hypertensive patients. The prevalence of metabolic syndrome was 44.4%. The cardiovascular risk was average in 0.2% of the sample, low in 5%, moderate in 26.1%, high in 47.3%, and very high in 21.4%.

Conclusions: Our study demonstrates that newly diagnosed young hypertensive patients have an intense association of CVRF and a high cardiovascular risk.

Effectiveness of an Interventional Program to Improve Blood Pressure Control in Hypertensive Patients at High Risk for Developing Heart Failure: HEROIC study

The Efectividad de un Programa de Intervención en el Control de la Presión Arterial de los Hipertensos en Riesgo de Desarrollar Insuficiencia Cardiaca (HEROIC) study was designed to assess whether an educational program for primary care physicians could improve blood pressure (BP) control in hypertensive patients at high risk for developing heart failure. The program contained a combination of educational training (live group sessions or online training) and information feedback. Two hundred twenty-six physicians completed the program and provided valid data in 2489 patients before and 2168 after 1 year. There was a small but significant reduction of -1.1 mm Hg (P=.009) in systolic BP and a higher proportion of patients achieved their BP target (13.6% vs 15.6%, P=.055). Thus, the authors concluded that there was a slight improvement in BP control after the educational program, but this change was not sufficient to avoid development of heart failure. More complex and intensive programs are needed for this type of prevention.

Protein and albumin-to-creatinine ratios in random urines accurately predict 24 h protein and albumin loss in patients with kidney disease

BACKGROUND

Random urine protein-to-creatinine (PCR) and albumin-to-creatinine (ACR) ratios have been proposed as alternatives to 24 h urine measurements to simplify sample collection and overcome errors. The aim of this study was to examine the ability of PCR and ACR to predict urinary 24 h protein and albumin loss, respectively, in patients with kidney disease, and determine the most appropriate time of collection.

METHODS

Eighty-three patients were recruited from a renal outpatient clinic. In a 24 h period, each collected an early-morning urine (EMU), second and third voids, and the remaining urine passed that day. PCR and ACR were determined in random urines and compared with the 24 h loss of protein and albumin, respectively.

RESULTS

For all patients, median (range) 24 h urine protein and albumin losses were 220 (30-15600) and 60 (<8-10,557) mg, respectively. Ratios derived from each of three random urines correlated well with 24 h protein or albumin loss (Spearman's r(s) > 0.87, P < 0.0001). Receiver operator characteristic (ROC) curve analysis showed PCR accurately predicted both an abnormal 24 h urine protein > or =150 mg/24 h (areas under curves [AUC] 0.90-0.92) and significant proteinuria above 300 mg/24 h (AUC between 0.97 and 1.00). ACR accurately predicted both an abnormal 24 h urine albumin > or =30 mg/24 h (AUC 0.98 to 0.99) and frank albuminuria at > or =300 mg/24 h or > or =700 mg/24 h (AUC between 0.99 and 1.00). EMU and random urines performed equally well in predicting proteinuria and albuminuria from PCR and ACR, respectively.

CONCLUSIONS

By careful choice of cut-offs, both PCR and ACR can be used in patients with kidney disease to rule in or rule out abnormal 24 h losses of protein and albumin. EMU and, importantly, random samples can be used as surrogates for 24 h urine collections.

Cardiovascular risk profile and risk stratification of the hypertensive population attended by general practitioners and specialists in Spain. The CONTROLRISK study

The CONTROLRISK study was designed to determine the cardiovascular risk profile of the hypertensive population attended at primary care and specialist setting in Spain and to investigate whether physicians stratify the risk correctly, according to the 2003 European guidelines. A total of 8920 patients were recruited from primary care (n=4485) and specialist outpatient clinic (n=4435). The age criteria was 62.6+/-11.1 years; 51.6% were women. No differences were observed in the severity of hypertension. More than 85% presented other cardiovascular risk factors, similarly in both groups. Target organ damage (TOD) and associated clinical conditions (ACC) were more frequent in specialist setting (57.6 vs 34.3% and 39 vs 28.7%, both P<0.0001). The most common risk factor was age. The most frequently reported TOD was left ventricular hypertrophy (42.3 and 22.1%; P<0.0001). Ischemic heart disease was the most common ACC (21.5 vs 13.1%; P<0.0001). The risk profile was significantly higher in specialist population (75.1 vs 60.3% of patients belonged to high- or very high-risk groups). Specialists and primary care physicians stratified only 54.6 and 48% of their patients correctly, respectively (P<0.05). Both, specialists and general practitioners (GPs) strongly underestimated the risk. Very high-risk patients were adequately assessed only in 44.9% of cases by specialists and in 25.3% by GPs (P<0.001). More than half of the hypertensive patients attended by GPs in Spain belong to the high- or very high-risk groups. GPs and specialists tend to underestimate the cardiovascular risk in daily clinical practice, mainly in very high-risk patients.

[High cardiovascular risk due to inadequate control of risk factors in Spanish hypertensive patients seen in the Spanish primary care]

INTRODUCTION

Cardiovascular diseases are the main cause of morbidity-mortality in Spain. Hypertension and the other cardiovascular factors are important in the pathophysiological basis of this fact. Control of the main risk factors in treated hypertensives was evaluated in this study.

PATIENTS AND METHODS

Multicenter study in hypertensive patients treated in Primary Care. Blood pressure, cardiovascular risk factors as well as registered target organ damage and clinical diseases were measured. Finally, global cardiovascular risk was calculated.

RESULTS

Only 17.3% of pharmacologically treated hypertensives were controlled (3.9% of diabetic patients). LDL-cholesterol control deteriorated as the patient's cardiovascular risk pattern increased (90.4% in low risk and 19.9% in high-very high risk). High levels of serum creatinine were detected in 8.3%, microalbuminuria being positive in 15.6%, with 20.8% ventricular hypertrophy. A total of 31% of the patients were diabetic, 59.8% of them having HbA1c > or = 6.5%. Global CV risk was high very high in many subjects (65.4%) when European Society of Hypertension-European Society of Cardiology (ESH-ESC) guidelines were used. This percentage was 3.6% when the Spanish-validated Framingham score was used.

CONCLUSIONS

Blood pressure control as well as main cardiovascular risk factors is poor in this population. Considering this fact plus the number of target organ damage, the global risk is high in many patients according to the European guidelines. Guidelines that do not consider target organ damage do not estimate adequately the risk of this uncontrolled population. This conclusion could explain the clinical tendency of many doctors when attending uncontrolled patients.

Assessment of metabolic profile in a clinical setting

PURPOSE OF REVIEW

The metabolic syndrome, a clustering of abnormalities such as hyperglycemia, insulin resistance, hypertension, dyslipidemia, and central obesity, is a principal risk factor for cardiovascular disease, the leading cause of morbidity and mortality in the Western world. There are several definitions of the metabolic syndrome, all aiming at including as many persons at risk as possible. The assessment and, hence, the identification of such persons in a clinical setting is of utmost importance.

RECENT FINDINGS

Clinicians should document the presence of central obesity, assessed by waist circumference measurement or determination of body composition using dual X-ray absorptiometry or measurement of visceral fat using computed tomography or magnetic resonance imaging. The presence of dyslipidemia, insulin resistance, and arterial hypertension constitutes the full profile of the metabolic syndrome. Nevertheless, elevated uric acid levels or presence of nonalcoholic fatty liver, or the diagnosis of the polycystic ovary syndrome in women of reproductive age, all are reflected in high risk of later occurrence of the full metabolic syndrome and atherosclerotic cardiovascular disease.

SUMMARY

Although no unified definition for the metabolic syndrome exists, it is important to identify persons at risk, in order to reduce the resultant high morbidity and mortality rates.

C-reactive protein and echocardiography have little impact on risk stratification in never-treated hypertensive patients

The aim of this study was to assess the contribution of increased concentrations of high-sensitivity C-reactive protein (hsCRP) and echocardiography to risk stratification according to the 2003 European guidelines for the management of arterial hypertension in patients with untreated hypertension. A total of 207 consecutive medical outpatients with untreated hypertension were included. History and clinical examination, electrocardiography, laboratory analyses including the measurement of hsCRP and echocardiography were performed in all patients. Patients were classified into four risk groups with and without using echocardiography and hsCRP concentrations of at least 10 mg/l according to the 2003 guidelines for the management of hypertension. The majority of the 207 patients (81%) were at moderate or high cardiovascular risk before adding echocardiography and/or hsCRP to the risk stratification process. When echocardiography was included, only three patients were reclassified from the moderate added risk to the high added risk group. Adding hsCRP concentrations of at least 10 mg/l had no impact on risk stratification. Using an hsCRP cutoff level of 3 mg/l, one patient was at moderate instead of low added risk, eight patients were at high instead of moderate added risk and one patient was at very high instead of high added risk. We conclude that hsCRP at the proposed cutoff level of 10 mg/l has no impact on risk stratification in outpatients with untreated hypertension. An hsCRP cutoff level of 3 mg/l may be more suitable for risk stratification. Finally, our data suggest that depending on the population studied, there is minimal impact of echocardiography on risk stratification.