Actualizaciones en HTA MARZO-ABRIL 2023

Novedades en hipertensión arterial y riesgo vascular: Marzo-Abril 2023:
Los próximos días 20 y 21 de abril de 2023 tendrá lugar la XIX Reunión de Riesgo Vascular en el Hotel Elba Madrid Alcalá (Madrid).
Los días 23-26 de Junio 2023 tendrá lugar en Milán el 32nd European Meeting on Hypertension and Cardiovascular Protection, organizado por la European Society of Hypertension.
Últimas publicaciones relevantes en el campo de la HTA:
El primer artículo contempla un tema relevante en nuestra práctica clínica en la atención al diagnóstico y manejo de algunos pacientes con Hipertension arterial supina, pero con hipotensión relevante, y que pueden sufrir caídas si intensificamos el tratamiento en base a la medida de la PA en decúbito supino. Aunque conlleva unos minutos de trabajo, en determinados sujetos : ancianos, diabetes evolucionada o pacientes con enfermedades neurológicas que se acompañan de disfunción del S.N. autonómico, como por ejemplo el Parkinson, es imprescindible la determinación de la PA tras 5 minutos de repos en decúbito y supino, y posteriormente tras 1-3 minutos en bipedestación.
Berettaa MV,  Milan VB, Hoffmeister MC, Rodrigues TC. Orthostatic hypotension, falls and in-hospital mortality among elderly patients with and without type 2 diabetes. J Hypertens 2023;41:388-392
RESUMEN
Objectives: To evaluate the association of falls and in hospital mortality
with the presence of orthostatic hypotension and type 2 diabetes mellitus (T2D). The study also aims to identify whether the orthostatic hypotension assessed at 1 min or at 3 min can predict falls and mortality, as a secondary objective to identify the predictors of fall during hospitalization.
Methods: We performed a prospective study with patients admitted to a university hospital. The risk of falls was assessed using the Morse questionnaire and the presence of falls was verified by the patient’s medical records during hospitalization. The orthostatic hypotension was determined by measuring blood pressure at three times, considering as orthostatic hypotension the reduction of at least 20mmHg in SBP or 10mmHg in DBP. In-hospital mortality was consulted in the medical records.
Results: Patients with orthostatic hypotension were slower on Timed Up and Go test (TUG) (12.26_3.16 vs. 16.08 _5.96 s, P ¼ 20 s) and presence of orthostatic hypotension. After adjustments, patients with T2D and orthostatic hypotension had a 2.7 times greater risk of in-hospital falls and 1.54 times greater odds of in-hospital mortality when compared with patients without T2D and orthostatic hypotension.
Conclusion: In this sample, sedentary patients and those with lower TUG had a higher risk of falls. The prevalence of falls was higher in patients with T2D. The association of T2D with orthostatic hypotension significantly increased both the risk of falls and the risk of in-hospital mortality.
El segundo artículo, publicado esta semana online en Lancet, los autores llevan a cabo un ensayo clínico abierto, pero con evolución a ciegas del end point final, para evaluar la efectividad de un programa de intervención especial llevada cabo por profesionales sanitarios no médicos, respecto a una intervención usual en sujetos hipertensos, en China. Los autores muestran que en el grupo de intervención especial se consiguió una significativa e importante reducción de la PA respecto al grupo con intervención usual. La diferencia neta entre ambos grupos fue de -23,1 para la PA sistólica y de -9,9 mm Hg para la PA diastólica) , así como una reducción signicativa  de la enfermedad cardiovascular y de la mortalidad.
He J, Ouyang N, Guo X, Sun G, Li Z, Mu J et al. Effectiveness of a non-physician community health-care provider-led intensive blood pressure intervention versus usual care on cardiovascular disease (CRHCP): an open-label, blinded-endpoint, cluster-randomised trial
SUMMARY
Background: Effectiveness of a non-physician community health-care provider-led intensive blood pressure intervention on cardiovascular disease has not been established. We aimed to test the effectiveness of such an intervention compared with usual care on risk of cardiovascular disease and all-cause death among individuals with hypertension.
Methods: In this open-label, blinded-endpoint, cluster-randomised trial, we recruited individuals aged at least 40 years with an untreated systolic blood pressure of at least 140 mm Hg or a diastolic blood pressure of at least 90 mm Hg (≥130 mm Hg and ≥80 mm Hg for those at high risk for cardiovascular disease or if currently taking antihypertensive medication). We randomly assigned (1:1) 326 villages to a non-physician community health-care provider-led intervention or usual care, stratified by provinces, counties, and townships. In the intervention group, trained non-physician community health-care providers initiated and titrated antihypertensive medications according to a simple stepped-care protocol to achieve a systolic blood pressure goal of less than 130 mm Hg and diastolic blood pressure goal of less than 80 mm Hg with supervision from primary care physicians. They also delivered discounted or free antihypertensive medications and health coaching for patients. The primary effectiveness outcome was a composite outcome of myocardial infarction, stroke, heart failure requiring hospitalisation, and cardiovascular disease death during the 36-month follow-up in the study participants. Safety was assessed every 6 months. This trial is registered with ClinicalTrials.gov, NCT03527719.
Findings : Between May 8 and Nov 28, 2018, we enrolled 163 villages per group with 33 995 participants. Over 36 months, the net group difference in systolic blood pressure reduction was –23∙1 mm Hg (95% CI –24∙4 to –21∙9; p<0∙0001) and in diastolic blood pressure reduction, it was –9∙9 mm Hg (–10∙6 to –9∙3; p<0∙0001). Fewer patients in the intervention group than the usual care group had a primary outcome (1∙62% vs 2∙40% per year; hazard ratio [HR] 0∙67, 95% CI 0∙61–0∙73; p<0∙0001). Secondary outcomes were also reduced in the intervention group: myocardial infarction (HR 0∙77, 95% CI 0∙60–0∙98; p=0∙037), stroke (0∙66, 0∙60–0∙73; p<0∙0001), heart failure (0∙58, 0∙42–0∙81; p=0∙0016), cardiovascular disease death (0∙70, 0∙58–0∙83; p<0∙0001), and all-cause death (0∙85, 0∙76–0∙95; p=0∙0037). The risk reduction of the primary outcome was consistent across subgroups of age, sex, education, antihypertensive medication use, and baseline cardiovascular disease risk. Hypotension was higher in the intervention than in the usual care group (1∙75% vs 0∙89%; p<0∙0001).
Interpretation: The non-physician community health-care provider-led intensive blood pressure intervention is effective in reducing cardiovascular disease and death.