Why some people with very risky lifestyle and lots of risk factors can live longer than others free of risks? A long-standing question in medical practice.

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This is an excerpt of an article written by me submitted recently to be assessed for publication in a scientific journal that I would like to share with you.

In medical practice is common to find situations that might call into question any practitioner on the epidemiological component of cardiovascular disease (CVD).

How many times we assess patients with multiple cardiovascular risk factors (CRF) and poor adherence to the treatment and they never develop one expected disease resulting from these CRF. While at the other extreme, there are individuals without CRF and with an appropriate lifestyle who begin suffering from an “unexpected” acute or chronic heart disease.

Taking into account the above mentioned, this article attempts to answer the following question: which would be the wiser perspective to address the issue of cardiovascular risk in relation to causation in CVD? Continue reading “Why some people with very risky lifestyle and lots of risk factors can live longer than others free of risks? A long-standing question in medical practice.”

Red Bull beverage and high blood pressure in adolescents. Watch out ¡¡¡¡¡.

redThose who has drunk the energy beverage called Red Bull might be aware that its slogan since 1984 when it was first introduced into the Market is “Red Bull gives you wings”, meaning somehow that by consuming it you are freer.

To start with, briefly, I will tell you something that happened to me at my hospital in Cuba. It was a very exhausting day, and the last patient was a 16-aged male teenager who came in along with his parents which seemed to be very concerned for the lack of control of their child´s blood pressure despite the right measurements ordered to him over the past month when the diagnosis was made.

It was a moderate high blood pressure without known cardiovascular risk factors and all the tests indicated so far were within the normal range. The patient and his parents assured me that the non-pharmacological and pharmacological measurements are being carried out in good terms.

After a long chat where I could not find any insights related with this lack of blood pressure control, at last I asked him the following: Continue reading “Red Bull beverage and high blood pressure in adolescents. Watch out ¡¡¡¡¡.”

Arterial hypertension in children and adolescents in Qatar. Precision in diagnosis is a necessity.

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This is an excerpt of a scientific paper of my authorship I sent to Qatar Medical Journal for publication. References are not shown as the paper is on the approval process.

Where does Qatar stand approaching the issue of hypertension in children and adolescents?

The 2010 Global Burden of Disease Study’s profile of health status in Qatar found that non-communicable diseases, where HTN is included, are a significant cause of health issues in Qatar.

According to the revised literature the prevalence of HTN in children and adolescents in Qatar ranges from 10.5 % and can reach up to 45 % when accompanied by obesity  In the same geographic area, a large Iran-based CASPIAN-5 study has reported similar a prevalence of HTN of 11,5 %. Other countries in the Middle East do not differ on the average from these statistics.

Furthermore, a recent systematic review with meta-analysis pooling BP data from 122,053 adolescents in 55 studies, stated a prevalence of HTN of 11.2%.

All the studies carried out on children and adolescents stress the negative impact of the classic cardiovascular risk factors usually accompanying HTN as obesity, overweight and metabolic syndrome, a condition with a rapid growth and life-threatening consequences on the long term in the region

The aforementioned do not come as a surprise in Qatar since with the discovery of oil in the 70s there has been a substantial social and economic improvement in the country which has had pros and sadly cons as well. The economic rise-related downside has been principally reflected on the life style of children and adolescence which have experienced a large transition in regard with their eating habits, which are now very similar to Western countries where fast food has gained many followers among those in these groups of ages.

Hence, the incidence of cardiovascular risk factors in on the rise, where overweight, obesity and diabetes mellitus, among others, are quite prevalent with their well know deleterious consequences throughout life. In addition, scarce knowledge about food choices, lack of physical activity and common socialization-related eating , in our opinion, are playing a key role in perpetuating the prevalence of HTN at early stages of life (childhood and adolescence) in the country as well.

If this paper is published, we will post the complete publication on this blog.

Thanks.

Note. This editorial has been written by Dr. Guillermo Alberto Perez Fernandez, author of this blog, and reflects his personal opinion about the topic.

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Left Ventricular Hypertrophy in Pediatric Hypertension. When damage is at sight. 

img_2190-2This is an excerpt of a publication of mine sent to a peer review journal by me to be published.

Since the publication in 1977 of the First American Task Force for the diagnosis, evaluation and treatment of high blood pressure (BP) in children and adolescents, updated in 1987, 1996 and more comprehensibly in 2004 (as Fourth Report) has been stressed out the importance of HTN related organ damage being, in this context, LVH a paradigm. Likewise, the latest European Society of HTN guidelines for the management of HTN in children and adolescents published in 2016 has highlighted the assessment of subclinical organ damage as an intermediate stage in the continuum of vascular disease as well, targeting predominantly LVH (2) Woroniecki and colleagues’ article (1) exposed the somehow puzzling issue when it comes to defining LVH in pediatric population on the basis of the existence of diverse criteria with pros and cons. These arguments are not new and have made very difficult over years to ascertain a reliable standardization of LVH definition at the early stages of life in children and adolescents suffering from HTN. Although, the authors of the article do not mention the connection of prehypertension with LVH, this association exists (3) and can trouble even more the things to decipher a definition of LVH for prehypertensive patients since the long-established studies that have reported the different formulas to define LVH in children and adolescents have been conducted on hypertensive individuals (2)

Unquestionably, the search for a definition of LVH in the context we are commenting here is complex with multiple answer and a solution far to be beheld to date; even though, the future might unfold some results especially with the American Heart Association’s SHIP-AHOY study, intended to evaluate blood pressure thresholds, ambulatory blood pressure, and metabolic phenotype that predicts hypertensive target organ damage. In addition, it is planned an update of the Fourth Report that would help with the necessary consensus on LVH (3)

In the meantime, according to our opinion, the appraisal of HTN induced LVH must get ahead of the simple quantification of left ventricular mass by focusing on the early diastolic alterations as regional mitral Ea, Aa and the E/Ea ratio by Tissue doppler imaging that precede the onset of LVH since this hypertrophy can be observed with the use of steroid, obesity, athletes, growth hormone use, etc., therefore can be reversible (4)

Those topics are not mentioned in Woroniecki and colleagues’ article (1) and might be key to increase consistency to the assessment of the HTN related cardiac organ damage in children and adolescents.

In the PESESCAD-HTA study we found diastolic abnormalities even in prehypertensive adolescents without LVH which makes it clear the relevance of targeting diastolic alterations on individuals prone to be hypertensive likely in the short term (5)

In short, the issue of LVH in pediatric populations remains challenging. The solution will lie on in undertaking large multinational studies in an attempt to find out a more reliable and matching approach to determine the cardiac organ damage that HTN entails in children and adolescents.

References

1- Woroniecki, Robert P, Andrew Kahnauth, Laurie E Panesar, and Katarina Supe-Markovina Left Ventricular Hypertrophy in Pediatric Hypertension: A Mini Review. Front. Pediatr (2017) 5:101.doi:10.3389/fped.2017.00101

2- Lurbe E, Agabiti-Rosei E, Cruickshank J, Dominiczak A, Erdine S, Hirth A, et al. 2016 European Society of Hypertension guidelines for the management of high blood pressure in children and adolescents. J Am Soc Hypert (2016); vol: 34 (10) pp: 1887-1920.

3- Sethna CB, Leisman DE. Left Ventricular Hypertrophy in Children with Hypertension: in Search of a Definition. Curr Hypertens Rep (2016) Aug;18(8):65. doi: 10.1007/s11906-016-0672-3.

4- Agu NC, McNiece Redwine K, Bell C, Garcia KM, Martin DS, Poffenbarger TS, et al. Detection of early diastolic alterations by tissue Doppler imaging in untreated childhood-onset essential hypertension. J Am Soc Hypertens (2014);8(5):303–11. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24685005.

5- Perez Fernandez GA, Grau Avalo R. Hypertensive heart disease in adolescence. preliminary results of the PESESCAD-HTA study. Hipertens y Riesgo Vasc (2012) ;29(3):75–85.

Thanks.

Note. This editorial has been written by Dr. Guillermo Alberto Perez Fernandez, author of this blog, and reflects his personal opinion about the topic.

Please rate this post

Escoge a los progenitores “sabiamente” y no serás hipertenso. ¿De quién es la culpa?

progValentín Fuster, uno de los padres de la cardiología moderna,  en la décimo sexta conferencia de Bethesda. EE.UU. en 1996, acerca del papel biológico de los factores de riesgo cardiovascular (FRC), emitió una interesante y no menos jocosa afirmación: “la mejor manera de evitar la aterosclerosis es “escoger” a los progenitores sabiamente”.

Según la literatura, los individuos con antecedentes patológicos familiares (APF) de FRC presentan cifras de presión arterial (PA) mayores que aquellos descendientes de familiares sin este riesgo; aseveración confirmada desde la edad pediátrica con tendencia a adquirir más relevancia posteriormente 1. Se plantea que cuando ambos padres son hipertensos, teóricamente el 50 % de los hijos heredará la condición; si uno solo lo es, la cifra desciende al 20 ó 30 %.

La contribución de la historia familiar de riesgo cardiovascular al exceso de riesgo es independiente del accionar de otros FRC y se ha relacionado con una serie de anormalidades, incluso desde la adolescencia, en individuos con APF de ECV, como son: hiperinsulinismo, resistencia a la insulina, intolerancia a la glucosa, disfunción endotelial, y alteraciones lipídicas y del metabolismo de las mitocondrias 1.

Solini y colaboradores 2, al medir las concentraciones séricas de selectina P, interleucina 6, metaloproteinasas 2 y 9 y el factor tisular inhibidor de las metaloproteinasas en sujetos con APF de ECV y sin este antecedente, llegan a la conclusión de que aquellos con una historia familiar positiva de ECV presentaron niveles de estas sustancias significativamente mayores, lo que sin dudas constituye un elemento indicativo de la presencia de aterosclerosis en los individuos con APF de ECV.

Vercoza y colaboradores 3 midieron por ultrasonografía de alta resolución el grosor de la íntima y la media de la arteria braquial entre niños en edad escolar, y encontraron asociaciones significativas entre dichos parámetros y la presencia de APF de ECV.

En opinión del autor, el presentar APF de ECV es un riesgo para el desarrollo de HTA; la distinción de cuál de los antecedentes es el más notable no es lo más significativo, si se tiene en cuenta que más del 50 % de los individuos poseen más de un APF de ECV; y que el patrón de herencia en este caso no es mendeliano, sino complejo. Lo trascendente aquí sería no dejar de pesquisar la existencia de una historia familiar de FRC.

Referencias Bibliográficas.

1-    Kones R. Recent advances in the management of chronic stable angina II. Anti-ischemic therapy, options for refractory angina, risk factor reduction, and revascularization. Vasc Health Risk Manag. 2010;6:749-74.

2-    A Solini, E Santini, A Passaro, S Madec and E Ferrannini. Family history of hypertension, anthropometric parameters and markers of early atherosclerosis in young healthy individuals. J Hum Hypertens 2009; 23:801–807.

3-    Verçoza AM, Baldisserotto M, de Los Santos CA, Poli-de-Figueiredo CE, d’Avila DO. Cardiovascular risk factors and carotid intima-media thickness in asymptomatic children. Pediatr Cardiol. 2009;30(8):1055-60.

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Cardiovascular disease and cancer. A madness?

images (1)Is it possible the existence of a bond between cardiovascular disease and cancer? This was one of the first questions aimed to my fellows at a briefing.

Really, I acknowledge that to figure a link is difficult. Yet, there is a connection. Different theories could explain such as relationship: Continue reading “Cardiovascular disease and cancer. A madness?”

The uncertain beginnings and the “why” of this blog.

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If you want to see the spanish translation click here.

Back in 1998. I was doing my Residence in General Medicine in Santa Clara. Villa Clara. Cuba, it was noon and I was set out to see my last patient. He was a 10-year-old boy brought to the clinic by his mother. He looked like a bit overweight and reported intermittent headache for more than two days. Upon taking medical history, the only positive complain was a frontal headache lasting about an hour with no other accompanying symptom.

At physical examination, there was nothing relevant, in my opinion, to point out. I must confess that I was somewhat bewildered about the cause of the headache. However, I explained to the mother that this pain could be the result of multiple causes while I was ordering a routine checkup. The patient was prescribed pain killers and I advised the mother that if something new raised to go the nearest health center. At the stage, the patient was ready to leave the office I came up with the idea to measure his blood pressure (BP) and to my surprise, he had 140 mmHg of systolic blood pressure with 95 mmHg of diastolic blood pressure. Undoubtedly, that was the cause of the persistent headache. I said to myself: “this patient is hypertensive and he is only 11 years old, what should I do?” Continue reading “The uncertain beginnings and the “why” of this blog.”