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It is really great to post the European Society of Cardiology/European Society of Hypertension Guidelines about Arterial Hypertension. Just presented at the 28 th European Meeting of HTN and cardiovascular protection held last June in Barcelona.
Such a great honor having been there when the guideline was publicly released for first time.
Guillermo (author of this blog)
Click below: It will start from minute 1.00 forward. Avancen el video hasta el minuto 1 y desde allí comienza.
“A man is as old as his arteries”
Vascular aging represents a progressive process involving biochemical, enzymatic, and cellular changes of the vascular tree.
In short, early vascular aging (EVA), is defined as a vascular damage inappropriate for age. Increased arterial stiffness, dilated elastic arteries of central type and impaired endothelial function are main aspects of this process.
EVA is common in patients with hypertension and increased burden of cardiovascular risk factors. Several studies have indicated that this process starts early in life and could be programmed during foetal life or influenced by adverse growth patterns in early postnatal life.
Determinants of EVA can be classified as prenatal and postnatal factors. Prenatal factors are related to mothers’ behavior regarding food, smoking, or alcohol consumption. Some of the genetic mutations from prenatal life seem to influence the development of EVA in children, by starting even from intrauterine life without having clinical or subclinical manifestations in childhood. Posnatal factors comprise the presence of known cardiovascular risk factors that might impact negatively over life speeding up the vascular aging.
Nowadays, the early recognition of the EVA process has become the target of many investigations seeking going ahead in the early identification of individuals at cardiovascular risk.
This is and will be the smartest way to act, it is time to detect the risk early in life. When it comes to cardiovascular risk, the earlier the better. Once the disease is in place, things may turn very unfavorable for the patient and often migh be late for an efective treatment.
Thus, we have another tool to work with, kowing how to use it is key.
1- Nilsson P, Boutouyrie P, Cunha P. Early vascular ageing in translation a: from laboratory investigations to clinical applications in cardiovascular prevention. J Hypertens. 2013;(31):1517–1526.
2- Rana S, Pugh PC, Katz E, et al. Independent effects of early-life experience and trait aggression on cardiovascular function. Am J Physiol Regul Integr Comp Physiol. 2016;311(2):R272–R286.
Whenever someone have asked me- What makes so difficult to approach and control arterial hypertension and its related health conditions?
My response is loud and clear: The complexity of the tangled skein we must deal with as health care providers.
The problem is that there is a growing number of risk factors with a very complex interrelation.
Nowadays, another has been summed up to the list: the screen time or in other words, the time spent on social media, video games, watching television, music videos, advertising, etc.
It is not a secret that is increasingly rare to see kids and adolescents playing games outdoor unless these are part of the school program they belong to. Children are no longer playing hide-and-seek outside or reading a good hard-cover book. Instead, they’ve dived into a world of constant digital media through television, mobile devices and video games.
According to the latest statistics about the topic: Continue reading “Long screen time and cardiovascular disease in children and adolescents. Social media and video games might be taking their toll.”
“It’s always further than it looks. It’s always taller than it looks. And it’s always harder than it looks.” – The 3 rules of mountaineering.
I must add, however, it’s possible.
Keep going through this blog further below.
The diagnosis of arterial hypertension has made it increasingly complex over time. It is no longer just to tell a patient “you suffer from arterial hypertension”. Nowadays, there are more abnormal blood pressure categories added to the list as prehypertension, “white-coat” hypertension and “masked” hypertension. No doubts, the complexity of the human been plays its role in all this (1)
Many patients have been said over years that they had “emotional hypertension” since her or his blood pressure (BP) at the medical office was elevated even after several BP readings at prudent intervals during the consultation, whereas at home blood pressure remained normal.
The abovementioned situation was overlooked by the medical community for a long time and there was a long-standing thinking that it was simply the result of patient’s stress arising from the patient-doctor encounter at the clinic. However, as time went by, the so-called white-coat effect was study in-depth and as a result, the “white-coat” hypertension term emerged (2)
Is it dangerous? Yes indeed, several investigations have shown that: Continue reading “(1-minute read) “Emotional” hypertension. Do not get mixed up. There is more on the table.”
Dedicated to Dental Department at the Cuban Hospital in Qatar.
After several years studying the subject of cardiovascular disease early in life and with some papers published recently about it (1-5) I can say that nowadays, as health care providers, we are facing several cardiovascular disease contributing risk factors (hypertension, obesity, smoking, unhealthy diet, etc.) which prompts a large burden on our shoulders as they keep leading to a long-lasting and quite steady worldwide prevalence of heart conditions, stroke, kidney failure, premature death and disability for the last 20 years. (6)
Even, children and adolescents are not spared from this. For instance, according to the latest European (7) and North American Guidelines about the subject (8), the prevalence of high blood pressure in children and adolescents ranges between 3 to 11 % and rises up to 40 % when obesity is in place as well.
The above mentioned is a known fact that unfortunately is ongoing with some ups and downs but continue to be a pending endeavor yet to be solved by the medical community. Thus, I do not want to dwell on it on this post.
At the moment, I am more interested on reflecting how these spotlighted main risk factors might be blindfolding us from seeing “little facts” that are having also an impact on the complex setting related with the development of cardiovascular disease and sadly are often overlooked.
In this light, there is one fact which is not as publicized as the main risk factors mentioned above which is critical my opinion. I am referring to the buccal hygiene and its links to cardiovascular disease.
To get started, it is worth mentioning that the surfaces of the human body are heavily colonized by a varied microbial ecosystem called the microbiota, in other words, this is a mixed community of microorganisms composed of bacteria, viruses, archaea, and eukaryotic microbes that coinhabit in our body . The gathering of those microbes and their genes is named the human microbiome and each person has a unique microbiome which varies along with our genetic background, age and life style (9)
As per the aim of this paper, I will point out at the oral microbiome, which is considered one of the most highly dynamic ecosystems in the human body.
According to the latest investigations, the estimated number of bacteria in the mouth is up to 100 billion and comprised nearly 700 identified bacterial species being the most prevalent Firmicutes and Proteobacteria, along with Bacteroidetes, Actinobacteria, and Fusobacteria (10)
Though, the oral microbiome is dynamic in terms of functioning, as ecosystem must be stable in its composition and structure. Any disruption in it leads to a state called dysbiosis.
Recently, multiple animal and human studies have examined the relationship between the oral microbiome disruption (dysbiosis) and blood pressure and have reported important insights explaining such links.
The most important proposed links to hypertension would be the following:
- Increasing sympathetic nervous system activity.
- Inflammation and endothelial dysfunction with vascular remodeling (11)
The above links, in turn are known triggering factors for high blood pressure through complex mechanisms beyond the scope of this article.
Now, I will lay out a question: How many time have you been asked by a doctor (no a dentist) in a clinic when feeling some cardiac-like symptoms about your buccal hygiene habits?
The response to this question will come later… Continue reading “Poor buccal hygiene might lead to an acute myocardial infarction. Time to make the difference.”
As we are settled in the Middle East now. I feel it is important to know about how good are dates for cardiovascular disease.
The concept of “predisease” arose in 1914 when Dr. William Rodman came up with the idea of intervening early on those patients having signs of a precancerous state. However, Rodman acknowledged that his thesis would be controversial when noted: “I am aware that the term precancerous can be objected by at least two reasons: first, not always there will be a precancerous state; second, if this state existed, it does not mean that cancer will develop”.
Nevertheless, with the goal in preventing the appearance of morbid events, predisease as category makes sense if the following three conditions are met: 1) individuals who fall into this category should be more likely to develop disease; 2) There must be a an intervention that when directed towards this individuals at risk be effective in reducing the risk of evolution to disease, and 3) the benefits of intervening on the pre-disease must exceed the risks. Currently, the state of predisease applies for various conditions: pre-diabetes, pre-hypertension, subclinical thyroid dysfunction or even individuals tested positive for human immunodeficiency virus. All these clinical situations involve an increased risk of developing the disease. Although the lapse of time for this to happen might be uncertain in most cases, lots of studies have shown that there can be several damages at molecular and cellular levels that might be impairing tissues and at the same time fueling the occurrence of the disease.
Then, I wonder, are the current and most used cut-off points in medical practice really reliable to advise a patient on whether he or she has an unhealthy condition?
In the author’s opinion, a fundamental limitation of the cut-off points is that their use on biological variables might be biased since there is not any reliable foundation to do so. However, we keep labeling individuals as healthy or sick based on them and it has been this way since a long time and probably will be until we consider the problem more comprehensibly and stop staying on shallow waters instead of going into the deep end.
I acknowledge that currently the decision-making process would be very weak without cut-off point to make decisions but we must be very cautious when giving an opinion based on them.
In addition, it is valid to say that most of the cut-off points we use in our day to day practice with patient are not autochthonous but they have been taken from guidelines, pathways, etc that have nothing to do with the population of patient we deal with.
Can you imagine what would it be like to use a cut-off points to determine if one individual living in the middle east had any health condition using cut-off points offered by health institutions based in Canada, USA or Asia? It sounds like nonsense, however we do it every day. Why? because we have never thought on it. Some time we simply use what we have been given or taught as the best evidence, but this evidence is far away from us in terms of ethnicity, genetics or socioeconomic status and these factors indeed could have been a significant statistical impact in the countries they were used when where pooled to yield certain cut-off figures, but it does not mean that can be widely used across regions and continents.
Accordingly, I think that each country’s medical society must dig deep and pull out its own cut-off points, otherwise we will continue to miss key elements when it comes to diagnosing in medicine.
In the end my dear colleagues, the autochthonous is and always will be the most consistent and reliable. To be enticed by names of medical associations with a well gained fame in terms of taking all they offered as the absolute truth can be deceptive. So, never fall into the “Band Wagon“ fallacy (if most people like them, then they must be okay)
On one next post, I will expose some examples of some steps taken on this.
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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.”