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Reciente publicación nuestra en la Revista Cubana De Medicina General Integral (Volumen 34, Número 2 (2018): abril-junio) la cual desde hace algún tiempo presenta un proceso de evaluación por pares (Peer–reviewed) y se encuentra ya indexada en SCOPUS (the World largest abstract and citation database of peer-reviewed literature: scientific journals, books and conference proceedings). Tomado del Sitio Web.
Esperamos sus comentarios.
Nota. Este editorial ha sido escrito por el Dr. Guillermo Alberto Perez Fernandez (MD, PhD, FACC)
Como ha dicho Arthur Schopenhauer (1788-1860), “la opinión es como un péndulo y se rige por la misma ley física: si por un lado se aparta del centro de gravedad, debe recorrer la misma distancia en el lado opuesto y así sucesivamente. Solo después de cierto tiempo encuentra el punto en el cual permanece en descanso”. Esta ley del péndulo también se aplica al conocimiento científico.
En estos días se habla mucho de hipertensión arterial (HTA) en la comunidad médica. Primero fue el lanzamiento de las Guías Norteamericanas de HTA el pasado año 2017; luego la presentación de las Guías Europeas de HTA, hace solo tres meses en este 2018, emitiendo puntos de corte diferentes para diagnosticar HTA a los que habían proclamado las guías norteamericanas del 2017. Lo anterior ha esparcido una marea de opiniones entre seguidores y detractores de ambas guías.
El tema de los puntos de corte para diagnosticar enfermedades es complejo y tiene varias aristas.
Hace unos años expresé mi opinión sobre el tema, la que fue publicada.
En próximos posts de este blog estaremos debatiendo más a fondo sobre el diagnóstico de hipertensión arterial y hacia que parte del globo terráqueo “miramos” para diagnosticar HTA.
Para lo que gusten de las referencias, aquí les dejo el link a Medline.
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.
After several months of inactivity due to reasons beyond my control I am back again trying to do my hardest in the fight against arterial hypertension (HTN).
During this time I got the fortune of being designated as a Fellow of the American Colleague of Cardiology which fills me with pride and creates at the same time a new commitment in my medical practice (see video) striving to keep cardiovascular disease away and if this is true for adults, when is comes to adolescence or childhood is imperative.
Taking into account the above mentioned, I would like to make a point regarding the latest Clinical Practice Guideline for the Management of High Blood Pressure in Children and Adolescents just published at the end of last year 2017. Just three things I want to stress:
The authors of the Guideline continue to emphasize the importance of life style modifications in children and adolescents, which is something that at times is unfulfilled with many factors on the table taking turns. This will be a subject will go into later on a new post.
The matter of the early cardiac impairment related with hypertension from childhood is another important issue to look at.
Last but not least, a smart prevention by using a proper prediction since early in life is key.
These topics will be covered further in-depth.
I also want to add that the first HAMAD Corporation-approved investigation from the Cuban Hospital just kicked off this month and will enroll adolescent from all over Qatar (national reach) in order to go deeper over the matter.
Please keep awaiting more posts with new updates and details.
(Lead Investigator of the investigation related with HTN and adolescence approved by HAMAD Corporation)
1- New Clinical Practice Guideline for the Management of High Blood Pressure in Children and Adolescents. Flynn JT, Falkner BE. New Clinical Practice Guideline for the Management of High Blood Pressure in Children and Adolescents. Hypertension. 2017 Oct;70(4):683-686.
“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.
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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