Hypertension and its Impact on Cognitive Function

Hypertension and its Impact on Cognitive Function Hypertension; ePub 2016 Oct 10; Iadecola, et al

10-25-2016 The American Heart Association (AHA) has issued a scientific statement which examines the impact of hypertension on cognition to assess the state of the knowledge, to identify gaps, and to provide future directions. After a review of the literature, the study group concluded that there were insufficient data to make evidence-based recommendations but did report the following results:

• Hypertension disrupts the structure and function of cerebral blood vessels, leads to ischemic damage of white matter regions critical for cognitive function, and may promote Alzheimer pathology.

• There is strong evidence of a deleterious influence of midlife hypertension on late-life cognitive function.

• There is a cumulative effect of hypertension on cerebrovascular damage.

The authors concluded that treatment of hypertension may safeguard vascular and brain health.

Citation: Iadecola C, Yagge K, Biller J, et al. Impact of hypertension on cognitive function. A scientific Statement from the American Heart Association. [Published online ahead of print October 10, 2016]. Hypertension. doi:10.1161/HYP.0000000000000053.

Commentary: Dementia affects over 30 million people worldwide and two of the main risk factors for the development of dementia are advancing age and hypertension. Alzheimer’s disease and multi-infarct dementia often co-exist, with hypertension a major risk factor for small–vessel disease in the brain which leads to dementia. In addition, some research shows that hypertensive vasculopathy exacerbates the accumulation of beta-amyloid in the brain, possibly contributing to the development of Alzheimer’s dementia. This review concluded that there was moderately strong evidence that hypertension leads to a decline in function in the areas of the speed of processing and executive function. Hypertension is not consistently associated with a decline in memory, one of the hallmarks of Alzheimer’s. The authors conclude with two important points: 1) “There is substantial evidence that hypertension leads to cognitive impairment, an effect attributed to oxidative stress-driven cerebrovascular dysfunction and damage” and, 2) “It is unclear whether treatment prevents cognitive decline.” —Neil Skolnik, MD

Targeting Statin Treatment In Primary Prevention

Targeting Statin Treatment In Primary Prevention –The Biolmage Study by Axel F. Sigurdsson MD

Cholesterol-lowering medications are being prescribed to almost 30% of US adults aged 40 and over, most of these are statins drugs (1 ). The number increases with age, and approximately 48% of adults older than 75 are receiving such treatment.

It has been suggested that treating more older individuals with statins may prevent a substantial number of cardiovascular events, and that, if statins have no adverse effects on functional limitation or cognitive impairment, treating all elderly individuals will be cost-effective (2).

However, transforming public health targets into clinical practice is easier said than done because clinical medicine is an entirely different ball game, not least because of the human factor. Explaining to someone why taking a medication with potential side effects for the rest of his or her life is worthwhile is a difficult task. Furthermore, the situation gets more complicated if the treating physician realizes that many of those he manages to convince will not necessarily derive any benefit.

Three years ago the American College of Cardiology (ACC) and the American Heart Association (AHA) released new guidelines for cardiovascular risk assessment (3). Not unexpectedly, the debate on how to use statins in primary prevention took center stage.

Instead of using cholesterol levels to target treatment a new risk model was introduced, together with an online risk calculator (4). It was based on the assumption that a high level of evidence exists for the use of statin therapy in individuals with a ≥7.5% estimated 10-year atherosclerotic cardiovascular disease (ASCVD) risk. The threshold to initiate statin therapy was later supported by risk-benefit and cost-effectiveness analyses (5).

In other words, to decide if a healthy individual should be treated with a statin drug, clinicians are offered an online calculator to assess risk. If the calculator shows that the risk of a cardiovascular event is higher than 7.5% for the next 10 years, statin treatment should be recommended.

The risk calculator itself is relatively user-friendly (4). The variables that have to be entered are race, gender, age, total cholesterol, HDL cholesterol, and systolic blood pressure. Furthermore, whether the individual has diabetes, treatment for hypertension or is a smoker has to be filled in as well. When all this is done, the calculator will report the 10-year ASCVD risk.

Should All Elderly People Be Treated? What many of us found bizarre when testing the risk calculator was the strong influence of age. It turned out that all healthy individuals will automatically pass the 7.5% 10-year ASCVD risk threshold due to age alone, and thereby qualify for statin therapy, even if other risk factors are optimal. This will happen between age 63 and 71, depending on sex and ethnicity.

So, if we rely on the calculator, everybody will become eligible for statin treatment when they've reached a certain age, and everyone older than 70 will be on statins. Of course, this doesn't make sense. Many elderly individuals will never experience a cardiovascular event. Why should they be given a drug to prevent something that will never happen?

Giving someone the benefit of the doubt can hardly be regarded as good clinical practice. Although statins are by many experts considered to be relatively harmless, adverse effects do occur. The elderly may be more vulnerable to adverse events due to the presence of other diseases and concomitant medication. Furthermore, one of the most feared side effects of statins, functional limitation and cognitive impairment, may easily go undetected among the elderly (5).

So although universal treatment of the elderly may be cost effective, from the patient's and the clinician's perspective, such an approach is misguided if not unethical.

How Can We Identify Those Who Benefit (The Biolmage Study) Because the use of the risk calculator will lead to unnecessary treatment of a vast number of individuals with statin drugs, the next question inevitably is how we can detect those who truly are at increased risk. By doing so, overtreatment is less likely to occur as treatment will be targeted at only those who are likely to benefit.

One way to do this is to use noninvasive imaging of the coronary or the carotid arteries to detect individuals with subclinical atherosclerosis. Thus, the decision to treat with statins could be guided by the absence (do not treat) or presence (treat) of subclinical atherosclerosis.This hypothesis was tested in the Biolmage Study and recently presented in a paper published in the Journal of the American College of Cardiology (6).

The purpose of the study was to evaluate a more personalized approach to primary prevention with statins by adding a simple disease guided reclassification step after formal ACC/AHA recommended risk assessment. All study participants underwent CT scanning to determine the coronary artery calcium score (CAC) and carotid ultrasound imaging to detect and quantify carotid plaque.

Biolmage was a prospective observational cohort of men 55-80 years of age and women 60 to 80 years old without ASCVD at baseline examination between January 2008 and June 2009. Imaging was performed in 5.805 participants to detect the presence or absence of subclinical atherosclerosis. The mean age of the population was 69 years, and 56% were women.

It turned out that the vast majority of these participants (86%) was eligible for statin therapy because of an estimated 10-year ASCVD risk above 7.5%. However, among those individuals, 28% had no coronary artery calcium, and 20% had no carotid plaque.

There was a strong correlation between subclinical atherosclerosis and clinical events. Event rates were low in participants without subclinical atherosclerosis, including those with diabetes.

According to the authors of the paper, those without subclinical atherosclerosis should be down-classified to non-statin eligible, despite high 10-year ASCVD. The number needed to screen (NNS) to find one person with a CAC of zero was 2.6 among those with a 10-year ASCVD of 7.5-15%.

However, subclinical atherosclerosis was also found in participants with 10-year ASCVD risk below 7.5%. These individuals should be upgraded to statin eligible because of the increased risk associated with subclinical atherosclerosis. The NNS to find one person with a CAC > 100 among participants with 10-year ASCVD risk of <5% and 5% to 7.5% was 10 and 5.3 respectively.

The Take Home Message The recently published results from the Biolmage study may have several important implications for the practice of cardiovascular prevention.

The 2013 ACC/AHA guidelines support a universal treatment principle for the use of statins because everyone will qualify for treatment if they live long enough. Such an approach will likely lead to overtreatment and is unacceptable from the clinician's standpoint as well as from the patient's perspective.

The Biolmage data show that use of non-invasive imaging techniques to reveal the amount of coronary calcium or carotid plaque burden may be useful to reclassify patients as eligible or not eligible for statin treatment based on the presence or absence of subclinical atherosclerosis. In this elderly population assessing coronary artery calcium score (CAC) seemed to perform better than assessing carotid plaque burden.

Limiting primary prevention with statins to those with CAC above zero could spare 1 in 4 elderly from taking life-long medication that will benefit only a few.

The question about how to use statin drugs in primary prevention illustrates a huge gap between public health targets and clinical medicine. From the public health perspective, extending the use of statins, particularly among the elderly may seem an attractive target, not least because of the possible cost-effectiveness. However, due to the risk of side effects and the fact that many of those treated will not derive any benefit, the clinician should not prescribe statin therapy unless there is a high likelihood of benefit. The Biolmage data may have opened the door to new practical tools making it easier for physicians to advise their patients on this thorny issue.

Axel F. Sigurdsson MD | October 17, 2016 at 9:42 am | Tags: atherosclerosis, Biomalge, cardiovascular disease, carotid plaque burden, coronary calcium score, coronary heart disease, statins | Categories: atherosclerosis, Carotid Intima Media Thickness (CIMT), coronary artery disease, Coronary calcification, Heart Disease, Risk factors, Statins | URL: http://www.docsopinion.com/?p=10334

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Effect of early treatment with ivabradine combined with beta-blockers versus beta-blockers alone in patients hospitalised with heart failure and reduced left ventricular ejection fraction (ETHIC-AHF)

Int J Cardiol. 2016 Apr 19;217:7-11. doi: 10.1016/j.ijcard.2016.04.136. [Epub ahead of print]

Effect of early treatment with ivabradine combined with beta-blockers versus beta-blockers alone in patients hospitalised with heart failure and reduced left ventricular ejection fraction (ETHIC-AHF): A randomised study.

Hidalgo FJ , Anguita M , Castillo JC , Rodríguez S , Pardo L , Durán E , Sánchez JJ ,
Ferreiro C , Pan M , Mesa D , Delgado M , Ruiz M .

OBJECTIVES Abstract To analyse the effect of
the early coadministration of ivabradine and beta-blockers (intervention group) versus beta-blockers alone (control group) in patients hospitalised with heart failure and reduced left ventricular ejection fraction (HFrEF).

METHODS A comparative,
randomised study was performed to compare the treatment strategies of beta-blockers alone versus ivabradine and beta-blockers starting 24hours after hospital admission, for acute HF in patients with an left ventricular ejection fraction (EF)<40%, sinus rhythm, and a heart rate (HR)>70bpm.

RESULTS A total of 71 patients were examined, 33 in the intervention group and 38 in the control group. No differences were observed with respect to their baseline characteristics or standard treatment at discharge. HR at 28days (64.3±7.5 vs. 70.3±9.3bpm, p=0.01) and at 4months (60.6±7.5 vs. 67.8±8bpm, p=0.004) after discharge were significantly lower in the intervention group. Significant differences were found with respect to the EF and brain natriuretic peptide levels at 4months. No differences in clinical events (rehospitalisation/death) were reported at 4months. No severe side effects attributable to the early administration of ivabradine were observed.

CONCLUSIONS:

The early coadministration of ivabradine and beta-blockers during hospital admission for acute HFrEF is feasible and safe, and it produces a significant decrease in HR at 28days and at 4months after hospital discharge. It also seemed to improve systolic function and functional and clinical parameters of HF patients at short-term.

Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

Beta-blocker; Heart failure;
KEYWORDS:
Heart rate; Ivabradine

Transcatheter PFO closure with GORE(®) septal occluder: early and mid-term clinical results.

Catheter Cardiovasc Interv. 2013 Nov 15;82(6):944-9. doi: 10.1002/ccd.25106. Epub 2013 Jul 30.
Transcatheter PFO closure with GORE(®) septal occluder: early and mid-term clinical results. Butera G , Saracino A, Danna P, Sganzerla P, Chessa M, Carminati M.

Abstract Transcatheter closure of patent foramen ovale (PFO) is a widespread procedure. However the "quest" for the ideal device is still ongoing. Here we present the procedural and early results of transcatheter closure of PFO with the GORE® Septal Occluder.

Three Italian centers participated in a registry and collected data from 122 consecutive patients undergoing PFO closure by using GSO device. Indication for closure was previous stroke or transient cerebral ischemia in 110 and migraine in 12 subjects.

The procedure was successful in all patients. The procedure was performed under general anesthesia, fluoroscopic, and trans-esophageal echocardiographic imaging in 80 subjects while it was performed with local anesthesia, fluoroscopic, and intracardiac echocardiographic monitoring in 42 subjects. Twenty patients received a 20 mm device, 70 patients received a 25 mm device, and 32 received a 30 mm device. Procedure and fluoroscopy times were 30 ± 20 and 5 ± 4 min, respectively. In three cases, the implanted device was retrieved because of unsatisfactory position. Four subjects (2.5%) experienced vascular complications. During a median follow-up of 9 months (range 1-18 months) seven patients experienced atrial arrhythmias and four of them required medical treatment. At six months follow-up, at chest X-ray in two cases there was evidence of fracture of two wires of the device. Devices were stable and no treatment was required. Moderate residual shunting was found in two patients at 6- and 12-months follow-up. No other complication occurred.

GORE® Septal Occluder is an easy, safe, and effective device in closing PFO.

© 2013 Wiley Periodicals, Inc.

Antibióticos macrólidos y riesgo cardiovascular

Antibióticos macrólidos y riesgo cardiovascular

Meta-análisis publicado en JACC y que repasa la posible relación entre la administración de antibióticos macrólidos y el riesgo de muerte súbita, taquicardias ventriculares, así como su potencial influencia con la mortalidad cardiovascular y de cualquier causa.

Antibióticos macrólidos y riesgo cardiovascular

Trabajo chino que incluyó estudios publicados entre 1966 y 2015, sin restricciones. Incluyeron aquellos trabajos en los que se estimaron riesgos relativos con sus intervalos de confianza. Así, los investigadores identificaron 33 estudios, con más de 20 millones de pacientes incluidos en total. 

Cuando se comparó los pacientes que tomaban macrólidos con aquellos que no lo hacían se objetivó un riesgo incrementado de taquiarritmias ventriculares o muerte súbita (Riesgo relativo de 2,42; intervalo de confianza95%: 1,61 a 3,63), significativo para ambos componentes de esta variable, muerte súbita (Riesgo relativo de 2,52; intervalo de confianza95%: 1,91 a 3,31) y taquicardias (Riesgo relativo de 1,31; intervalo de confianza95%: 1,06 a 1,62). En cambio, no se apreció relación con mortalidad global de todas las causas u otros eventos cardiovasculares.

Desglosando por antibióticos concretos, el riesgo relativo de muerte súbita o taquicardia ventricular fue de 3,4 para azitromicina, 2,16 claritromicina, y 3,61 eritromicina, respectivamente. No se observaron efectos cardiovasculares adversos en este sentido con roxitromicina. En resumen, el tratamiento con macrolidos en este meta-análisis se asoció con 118,1 muertes súbitas/taquicardias ventriculares o 38,2 muertes cardiovasculares adicionales por millón de tratamientos.

Interesante estudio que, sin embargo, adolece de muchas limitaciones evidentes, pues engloba decenas de estudios con diseños muy diferentes, en un periodo de tiempo muy amplio y no evalúa los pacientes a los que salva la vida o previene complicaciones de otro tipo el antibiótico. No obstante, supone una llamada de atención, sobre todo y más marcada probablemente en determinados enfermos de riesgo, para el uso de ciertos fármacos (aquí hay que incluir todos tipo de sustancias, de farmacia, herbolarios, etc.) que de ser necesarios deben emplearse con cautela y las precauciones adecuadas.

Enlaces:

J Am Coll Cardiol. - The Role of Macrolide Antibiotics in Increasing Cardiovascular Risk »

Comentario del Dr. Iván Núñez Gil licenciado en Medicina por la UCM de Madrid (Premio Extraordinario). Actualmente trabaja como cardiólogo intervencionista con interés en cuidados agudos cardiovasculares en el Hospital Clínico San Carlos de Madrid

Cancer Treatment Important for those at risk for or having heart disease

Assessing Patients Undergoing Cancer Treatment

Cleveland Clinic

Important for those at risk for or having heart disease

Apr. 9, 2015 / Heart & Vascular / Technology & Treatments

By Balaji Tamarappoo, MD, PhD

New chemotherapy agents have improved cancer survival, yet some may cause lasting damage to the heart. This is particularly concerning for patients who are at risk for or have existing heart disease. Although cardiotoxicity does not affect all patients, detecting problems early on provides the opportunity for proactive treatment. The goal is to help patients complete their cancer treatment without incurring damage to the heart.

Prior to starting chemotherapy, we advise obtaining an echocardiogram to determine baseline heart function. This will serve as a point of reference for any changes that may occur during or following completion of therapy.

Anthracyclines in general, and doxorubicin in particular, are among the most common chemotherapeutic agents known to be cardiotoxic. Cumulative doses of 400-500 mg per meter2 of body surface area can cause heart failure or cardiomyopathy at any time up to several years after treatment ends.

When a patient has received around 250 mg per meter2 of body surface area, we begin to become concerned about toxicity. We obtain a second echocardiogram at this point and compare it to the baseline echo. If all is well, the patient may continue treatment. If any abnormalities of heart function are seen, we may be able to add beta-blockers and ACE inhibitors to prevent further damage during treatment. This also provides an opportunity for the oncologist to consider alternative chemotherapy.

After treatment has been completed, we look again. If no disturbing changes have taken place, we have the patient return at one year. From this point on, a repeat echo is only necessary if the patient experiences symptoms of a heart problem.

Trastuzumab is an agent known to cause heart failure and arrhythmias during treatment. Although these side effects are reversible, and long-term effects are rare, they need to be addressed. The drug is usually given for one year, so echocardiograms at baseline, 6 months and end of treatment are advised. Treatment with tyrokinase inhibitors may cause hypertension that needs appropriate treatment.

Patients taking beta-blockers or ACE inhibitors may find that their oncologist discontinues these medications if they experience side effects from chemotherapy. It is wise to follow these patients closely to ensure the medications are restarted after the cancer has been addressed.

While chemotherapy agents can affect the heart muscle, radiation therapy tends to primarily affect the valves. Pre- and post-radiation echos are reasonable to evaluate valve function. If calcifications are seen, the patient should be followed every couple of years to monitor the development of valve disease.

Because heart damage can develop within the first year after therapy, and even several years after therapy, it is important for cancer patients to be followed by a cardiologist or cardio-oncologist, who can be alert for the development of symptoms including weakness, fatigue, swelling of the legs and feet, chest pain, arrhythmias or dizziness and provide immediate evaluation and early treatment, if needed.

A cardio-oncologist is also warranted when a patient with a prior history of cancer develops new cardiac problems or heart failure requiring advanced treatment.

Although echocardiography provides a cost-effective method of monitoring these patients, the addition of strain imaging provides a superior method of visualizing myocardial deformation. In the Cardio-Oncology Center at Cleveland Clinic, we are focusing our research on the value of strain imaging. Currently, we are assessing whether abnormal strain measurements on a clinically stable patient signify a bad prognosis later in life.

Government panel backs preventive statin use by adults 40 and over

(Reuters Health) - Aligning with heart health groups and other experts, a U.S. government-backed panel now suggests that adults as young as 40 without a previous heart attack or stroke may need to start on a low or moderate dose of cholesterol-lowering drugs.

People ages 40 to 75 with at least one risk factor for cardiovascular disease and a 10 percent or greater risk of heart attack or stroke over the next decade should take statin drugs, the U.S. Preventive Services Task Force recommends.

Doctors may also consider prescribing the drugs for people in this age group with a 7.5 percent to 10 percent risk of heart attack or stroke based on the American Heart Association and American College of Cardiology risk calculator (www.cvriskcalculator.com).

"In addition to a healthy lifestyle, statins are useful for people at an elevated risk for cardiovascular disease," said Dr. Douglas Owens, of Stanford University in California and a member of the USPSTF.

Risk factors for cardiovascular disease include high total cholesterol or triglycerides - known as dyslipidemia, high blood pressure, diabetes and smoking. Ten-year risk of heart attack and stroke is calculated based on these and additional factors like sex and ancestry.

Heart disease, stroke and other cardiovascular diseases killed almost 787,000 people in the U.S in 2011, according to the American Heart Association.

Cholesterol, a type of fat in the blood, can build up in arteries and increase the risk of heart attacks, strokes and other cardiovascular problems. Statins lower cholesterol by blocking its production in the liver.

This is the first time the USPSTF is making a recommendation on the use of statins. It's based on analysis of existing data from 18 randomized controlled trials comparing statin use among people without previous heart attacks and strokes to people taking dummy pills or nothing at all.

Compared to those who are not on treatment, statin use was tied to a 17 percent reduced risk of death from any cause, and a 36 percent reduced risk of death from cardiovascular disease.

People taking statins were also 28 percent less likely to have strokes, 37 percent less likely to have heart attacks and 31 percent less likely to have other cardiovascular problems.

The benefits of statins were consistent in people with different risk factors, the panel found. And serious side effects like muscle or liver problems and diabetes were not significantly increased according to the analysis.

"We feel the benefits outweigh any potential harms," Owens told Reuters Health.

Owen also said, however, that people who have the highest cardiovascular risk will benefit the most from statins.

The new recommendation isn't surprising and is consistent with 2013 recommendations from the American Heart Association and American College of Cardiology, according to Dr. Sekar Kathiresan, who wasn't involved with the new recommendation but is director of preventive cardiology at Massachusetts General Hospital in Boston.

Those organizations recommended statins for people ages 40 to 75 with diabetes or a 7.5 percent or greater risk of heart attack or stroke over the next decade, people with a previous heart attack or stroke and young people with very high LDL ("bad") cholesterol.

Currently, 36 million Americans take statins, according to the USPSTF.

Cholesterol and Triglycerides Among Children

In another recommendation published online on Monday, the USPSTF proposed an update to its advice on testing children and teens for dyslipidemia, that is, high cholesterol level from any cause, including the inherited condition known as familial high cholesterol.

As it had in 2007, the panel said there is still not enough evidence to recommend for or against screening people younger than age 20 for either high cholesterol in general, which affects roughly seven of every 100 children and teens in the U.S., or familial hypercholesterolemia, which affects one in every 200 to 500 people across North America and Europe.

The statement is in line with the advice of the UK National Screening Committee and the American Academy of Family Physicians.

Owens said this is an area for future research, because it's an important topic.

"We’d say if you have concerns or any concern of elevated risk, it would be time to have a conversation with a child’s clinician," he said.

The panel also points out that the American Academy or Pediatrics (AAP) and the National Heart, Lung, and Blood Institute endorse universal screening for all children before ages nine and 11, and again between puberty and adulthood. Earlier testing is recommended for children at an increased risk of the condition.

"I actually tend to err on the side of AAP here, because it’s quite common and treatable," Kathiresan told Reuters Health.

"I think it’s appropriate for a national body to say we don’t have definitive evidence," he said, but he added that the problem is that finding the condition when a person is young is an incredible opportunity to modify risks in those people.

He said it's likely a discussion for a parent to have with their child's pediatrician.

Both recommendations are available for public comment on the USPSTF's website until January 25, 2016.

SOURCE: bit.ly/1euI2Rl U.S. Preventive Services Task Force, online December 21, 2015.

(Corrects paras 17 and 18 (after subhead) to clarify data on dyslipidemia in children.)

ESTUDIO PATHWAY 2 HIPERTENSION REFRACTARIA ENFOQUE TERAPEUTICO

COMENTARIO del Dr. Juan Quiles

Hospital Universitario San Juan, Alicante

RESUMEN

La hipertensión arterial refractraria se ha definido de diversas formas, por regla general como el mal control de la presión arterial a pesar del tratamiento con tres fármacos antihipertensivos, uno de los cuales debe ser un diurético. Las guías NICE son más explícitas en su definición, ya que consideran refractaria a la hipertensión arterial que no se controla con la estrategia de tratamiento recomendada (A+C+D), consistente en la combinación de inhibidores del sistema renina angiotensina (IECA/ARAII), calcioantagonistas y diuréticos tiazídicos, a las dosis máximas o máximas toleradas. El tratamiento de la hipertensión arterial resistente se refiere por tanto a la cuarta línea de tratamiento utilizada con la combinación A+C+D, y la elección es empírica, ya que no se disponen de datos al respecto.

El estudio PATHWAY 2 es un estudio aleatorizado, doble ciego y controlado con placebo que compara el tratamiento con espironolactona (25-50 mg), doxazosina de liberación retardada (4-8 mg) y bisoprolol (5-10 mg), en toma única diaria en cuatro ciclos de tratamiento de forma ciega y con una secuencia aleatoria. Los ciclos se iniciaban con la dosis baja durante 6 semanas, con un incremento de la dosis durante las siguientes 6 semanas hasta completar 12 semanas de tratamiento. Entre los ciclos de tratamiento no había periodos de lavado. Se realizaron mediciones de la presión arterial sistólica media ambulatoria medida antes de la aleatorización y al final de las 6 y 12 semanas de cada ciclo de tratamiento.

Se incluyó a 335 pacientes con hipertensión resistente, con cifras basales de presión arterial de 147,6/84,2 mmHg. La evolución de las cifras de presión arterial con los tratamientos fue la siguiente:

Tratamiento PAS domiciliaria (mm Hg) Cambio desde basal (mm Hg)

Epironolactona 134,9 -12,8

Doxazosina 139,0 -8,7

Bisoprolol 139,4 -8,3

Placebo 143,6 -4,1

El tratamiento con espironolactona consiguió la mayor reducción de presión arterial, con mayor reducción incluso en la presión arterial clínica. Comparada con el bisoprolol y la doxazosina, la espironolactona consigue un descenso adicional de 4,26 mmHg respecto al conseguido por las otras dos medicaciones.

COMENTARIO

El estudio PATHWAY 2 es un estudio diseñado para determinar la mejor estrategia de tratamiento de la hipertensión arterial refractaria como cuarto escalón, tras el uso a dosis máximas toleradas de fármacos bloqueadores del sistema renina angiotensina, calcioantagonistas y diuréticos. En un diseño en el que se trata a los pacientes con varios tratamientos de cuarta línea de forma secuencial y aleatoria, se compararon las cifras de presión arterial domiciliaria alcanzadas con cada una de las alternativas y se comprobó que la estrategia más eficaz de tratamiento es la espironolactona, lo que la sitúa como fármaco de elección si no se alcanza un adecuado control de la presión arterial con el tratamiento A+C+D.

Los resultados de este estudio pueden modificar la definición de hipertensión refractaria, considerando como tal a la que no se controla con el tratamiento A+C+D junto con espironolactona.

Una desventaja de éste tratamiento son los posibles efectos secundarios, especialmente la ginecomastia que puede aparecer hasta en un 6% de varones tratados a largo plazo. La eplerenona es un fármaco similar, sin este efecto secundario. Sin embargo, su utilidad para el tratamiento de la hipertensión refractaria no se ha estudiado y por tanto no se puede recomendar.

BIBLIOGRAFÍA

Williams B et al. The principal results of the Prevention and Treatment of Hypertension With Algorithm-based Therapy (PATHWAY)—Optimal treatment of drug resistant hypertension—PATHWAY 2. European Society of Cardiology 2015 Congress. August 31, 2015; London, UK. Abstract 4137.