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Objective Real-life management of patients with hypertension and chronic kidney disease (CKD) among European Society of Hypertension Excellence Centres (ESH-ECs) is unclear : we aimed to investigate it. Methods A survey was conducted in 2023. The questionnaire contained 64 questions asking ESH-ECs representatives to estimate how patients with CKD are managed. Results Overall, 88 ESH-ECS representatives from 27 countries participated. According to the responders, renin-angiotensin system (RAS) blockers, calcium-channel blockers and thiazides were often added when these medications were lacking in CKD patients, but physicians were more prone to initiate RAS blockers (90% [interquartile range: 70-95%]) than MRA (20% [10-30%]), SGLT2i (30% [20-50%]) or (GLP1-RA (10% [5-15%]). Despite treatment optimisation, 30% of responders indicated that hypertension remained uncontrolled (30% (15-40%) vs 18% [10%-25%]) in CKD and CKD patients, respectively). Hyperkalemia was the most frequent barrier to initiate RAS blockers, and dosage reduction was considered in 45% of responders when kalaemia was 5.5-5.9 mmol/L. Conclusions RAS blockers are initiated in most ESH-ECS in CKD patients, but MRA and SGLT2i initiations are less frequent. Hyperkalemia was the main barrier for initiation or adequate dosing of RAS blockade, and RAS blockers' dosage reduction was the usual management.

Arterial hypertension is one of the most prevalent diseases in the field of geriatrics and is also a risk factor for pathologies that frequently result in hospital admissions, such as heart failure and stroke. This article addresses both pharmacological and non-pharmacological diagnosis and treatment strategies, focusing on the role of frailty as a guiding principle in determining the most appropriate course of treatment, emphasizing patient-centred prescribing. Furthermore, the article reviews other frequent topics, such as polypharmacy and orthostatic hypotension. Moreover, a concise overview of the current evidence in geriatrics on ambulatory blood pressure monitoring and self-measurement of blood pressure will be provided. Furthermore, a brief summary of the underlying pathophysiology and current epidemiological trends is provided. This consensus is founded upon the initial premise that a comprehensive geriatric assessment should be conducted to ascertain whether a blood pressure reduction strategy could confer a net benefit for elderly patients while simultaneously avoiding an increase in the safety risks associated with these strategies and preventing a de-prescription due to ageism. This is particularly important given the significance of maintaining optimal blood pressure control to prevent related complications., (Copyright © 2024 The Author(s). Publicado por Elsevier España, S.L.U. All rights reserved.)

Arterial hypertension is a major risk factor for cardiovascular morbidity and mortality, and highly prevalent in older age, underscoring the importance of its appropriate management. The population is ageing at an increasing rate, with those aged 80+ years being the fastest growing population characterized by high heterogeneity in terms of functionality and autonomy. The prevalence of hypertension rises with increasing age, due to a significant increase in SBP largely as a result of age-related stiffening of the aorta and other large arteries, affecting almost 80% of those aged 80+ years. Appropriate management of blood pressure in this population is a priority for clinicians. Frailty is a condition characterized by marked vulnerability to adverse health outcomes and is common among older adults including those with hypertension. Hypertension increases frailty level and at the same time, individuals with increasing frailty present with more drug-related adverse effects meaning they are less tolerant to blood pressure lowering by medication. Thus, frailty is a factor that should be integrated when treating hypertension in this population. The European Society of Hypertension 2023 Guidelines on the management of Hypertension are the first international guidelines to integrate the concept of adapting blood pressure management in older adults according to their frailty/functionality level, and to propose practical tools for the application of this concept in the daily practice of physicians and other healthcare professionals. The present article prepared by the European Society of Hypertension Working Group on Hypertension in Older Adults aims to further address some important aspects mentioned concisely in the 2023 European Society of Hypertension guidelines, in order to help physicians and other healthcare professionals including those practicing in primary care. To this end, this study discusses 12 'hot questions' which are answered with the help of the 2023 European Society of Hypertension Guidelines. We hope the present article and Working Group's actions will contribute to understanding and applying the ideal management of hypertension in this most vulnerable population., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Resistant hypertension is a condition where blood pressure levels remain elevated above target despite changes in lifestyle and concurrent use of at least three antihypertensive agents, including a long-acting calcium channel blocker (CCB), a blocker of the renin-angiotensin system (ACE inhibitor or angiotensin receptor blocker) and a diuretic. To be diagnosed as resistant hypertension, maintaining adherence to therapy is required along with confirmation of blood pressure levels above target by out-of-office blood pressure measurements and exclusion of secondary causes of hypertension. The key management points of this condition include lifestyle changes such as reduced sodium and alcohol intake, regular physical activity, weight loss and discontinuation of substances that can interfere with blood pressure control. It is also recommended that current treatment be rationalised, including single pill combination treatment where antihypertensive drugs should be provided at the maximum tolerated dose. It is further recommended that current drugs be replaced with a more appropriate and less difficult treatment regimen based on the patient's age, ethnicity, comorbidities and risk of drug-drug interactions. The fourth line of treatment for patients with resistant hypertension should include mineralocorticoid receptor antagonists such as spironolactone, as demonstrated in the PATHWAY-2 trial and meta-analyses. Alternatives to spironolactone include amiloride, doxazosin, eplerenone, clonidine and beta-blockers, as well as any other antihypertensive drugs not already in use. New approaches under research are selective non-steroidal mineralocorticoid receptor antagonists such as finerenone, esaxerenone and ocedurenone, selective aldosterone synthase inhibitors such as baxdrostat, and dual endothelin antagonist aprocitentan., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: Real-life management of hypertensive patients with chronic kidney disease (CKD) is unclear., Methods: A survey was conducted in 2023 by the European Society of Hypertension (ESH) to assess management of CKD patients referred to ESH-Hypertension Excellence Centres (ESH-ECs) at first referral visit. The questionnaire contained 64 questions with which ESH-ECs representatives were asked to estimate preexisting CKD management quality., Results: Overall, 88 ESH-ECs from 27 countries participated (fully completed surveys: 66/88 [75.0%]). ESH-ECs reported that 28% (median, interquartile range: 15-50%) had preexisting CKD, with 10% of them (5-30%) previously referred to a nephrologist, while 30% (15-40%) had resistant hypertension. The reported rate of previous recent (<6 months) estimated glomerular filtration rate (eGFR) and urine albumin-creatinine ratio (UACR) testing were 80% (50-95%) and 30% (15-50%), respectively. The reported use of renin-angiotensin system blockers was 80% (70-90%). When a nephrologist was part of the ESH-EC teams the reported rates SGLT2 inhibitors (27.5% [20-40%] vs. 15% [10-25], P  = 0.003), GLP1-RA (10% [10-20%] vs. 5% [5-10%], P  = 0.003) and mineralocorticoid receptor antagonists (20% [10-30%] vs. 15% [10-20%], P  = 0.05) use were greater as compared to ESH-ECs without nephrologist participation. The rate of reported resistant hypertension, recent eGFR and UACR results and management of CKD patients prior to referral varied widely across countries., Conclusions: Our estimation indicates deficits regarding CKD screening, use of nephroprotective drugs and referral to nephrologists before referral to ESH-ECs but results varied widely across countries. This information can be used to build specific programs to improve care in hypertensives with CKD., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Elevated blood pressure (BP) is the largest contributor to the incident cardiovascular disease worldwide. Despite explicit guideline recommendations for the diagnosis and management of hypertension, a large proportion of patients remain undiagnosed, untreated, or treated but uncontrolled. Inadequate BP control is associated with many complex factors including patient preference, physician's inertia, health systems disparities, and poor adherence to prescribed antihypertensive drug treatment. The primary driver for reduced cardiovascular morbidity and mortality is lowering of BP ''per se'' and not class effects of specific pharmacotherapies. The recent ESH guidelines recommend the use of four major classes of drugs including renin-angiotensin-aldosterone system (RAS) blockers (angiotensin receptor blockers (ARB) or angiotensin-converting enzyme inhibitors (ACEi)), calcium channel blockers (CCB), thiazide and thiazide-like diuretics, and betablockers. Initiation of treatment for hypertension with a two-drug regimen, preferably in a single pill combination (SPC), is recommended for most patients. Preferred combinations should comprise a RAS blocker (either an ACEi or an ARB) with a CCB or thiazide/thiazide-like diuretic. These strategies are supported by robust evidence that combination therapy produces greater BP reductions than monotherapy, reduces side effects of the individual components, improves therapeutic adherence and long-term persistence on treatment, and permits achievement of earlier BP control., Competing Interests: Declaration of competing interest The authors declare they have no conflict of interest., (Copyright © 2024 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.)

High lipoprotein(a) (Lp(a)) levels are associated with an increased risk of arterial hypertension (AHT) and atherosclerotic cardiovascular disease. However, little is known about the detailed profile of AHT based on Lp(a) levels. This observational study focused on elucidating the relationship between Lp(a) concentrations and specific indices obtained from 24-h ambulatory blood pressure (BP) monitoring in hypertensive patients over 18 years of age. We gathered and analyzed data on BP indices along with demographic, epidemiological, clinical, and laboratory variables from 227 hypertensive patients, median age 56 years, including 127 women (56%). After comparing hypertensive patients with Lp(a) levels above and below 125 nmol/L, we found that a 10 mmHg increase in nocturnal systolic BP and all pulse pressure indices (24-h, daytime, and night-time) was associated with an increased risk of high Lp(a) levels by more than 20% and 40%, respectively. Similarly, each 10% increase in the area under the function over time of nocturnal diastolic BP dipping was associated with more than a 30% decrease in the odds of belonging to the elevated Lp(a) levels category. Additionally, Lp(a) levels above 125 nmol/L were associated with higher 24-h, daytime, and night-time systolic BP and pulse pressure load. The relationship between Lp(a) and AHT appears to extend beyond conventional BP measurements, which may be relevant given the prognostic implications of nocturnal BP and pulse pressure indices., (© 2024. The Author(s).)

Competing Interests: Conflict of interest: A.D.M.F., M.A.M.-G., and W.S.B. are consultants for Omron.

Hypertension has become a central risk factor for the development of cardiovascular disease, underscoring the importance of its accurate diagnosis. Numerous studies have established a close relationship between elevated systolic (SBP) and diastolic (DBP) blood pressure and an increased risk of cardiovascular event (CVE). Traditionally, blood pressure (BP) measurements performed in clinical settings have been the main method for diagnosing and assessing hypertension. However, in recent years, it has been recognized that BP measurements obtained outside the clinical setting, using self-monitoring blood pressure (SMBP) and ambulatory blood pressure monitoring (ABPM), offer a more realistic perspective of patients' daily lives and therefore provide more reliable results. Given the evolution of medical devices, diagnostic criteria, and the increasing relevance of certain components of ABPM in the prediction of adverse cardiovascular outcomes, a comprehensive update that is practical for daily clinical practice is required. The main objective of this article is to provide an updated review of ABPM, focusing on its importance in the evaluation of hypertension and its impact on public health in Colombia. In addition, it will discuss the implications of changes in diagnostic thresholds and provide concrete recommendations for the effective implementation of ABPM in clinical practice, allowing health professionals to make informed decisions and improve the care of their patients., (Copyright © 2024 SEH-LELHA. Publicado por Elsevier España, S.L.U. All rights reserved.)

Purpose of Review: Hypertension is a condition characterized by increased sympathetic activity and the autonomic nervous system. Resistant hypertension, a condition with a prevalence of 10% to 20% in the general hypertensive population, is more likely to experience poor outcomes and adverse cardiovascular events. Renal sympathetic denervation (RDN), a minimally invasive, catheter-based percutaneous intervention, has been considered for treating this condition. Clinical trials have used various catheters, such as the Symplicity Spyral catheter, Vessix Renal Denervation system, and Paradise endovascular ultrasound renal denervation system., Recent Findings: After the first randomized clinical trials examining the effectiveness and safety of RDN for lowering blood pressure in hypertensive patients, new clinical trials have used various catheters based on radiofrequency, such as the Spyral catheter, Vessix Renal Denervation system, or based on radiofrequency as the Paradise endovascular ultrasound renal denervation system. Positive results on this trials have shown that endovascular RDN (radiofrequency energy or high focused ultrasound energy) could be considered as a treatment option for uncontrolled resistant hypertension., Summary: Therefore, endovascular RDN (radiofrequency energy or high focused ultrasound energy) could be considered as a treatment option for uncontrolled resistant hypertension, which can be considered as an alternative to increasing medication. Nevertheless more data are needed, mainly in cardiovascular outcomes. RDN should be performed in experienced and specialized centers with a multidisciplinary team, and the benefits and risks of RDN should be addressed in a shared-decision-making process., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Heart failure (HF) is associated with a high morbidity and mortality burden. In light of more recent evidence, SGLT2 inhibitors are currently recommended as first-line therapy in managing patients with HF, regardless of ejection fraction, to reduce HF burden. The DAPA-HF and DELIVER trials, and particularly, the pooled analysis of both studies, have shown that dapagliflozin significantly reduces the risk of cardiovascular death, all-cause death, total HF hospitalizations, and MACE in the whole spectrum of HF, with sustained benefits over time. Recent data have shown that the full implementation of dapagliflozin in clinical practice would translate into a robust reduction in hospitalizations for HF and death in real-life populations. Many pathophysiological mechanisms have been involved in these benefits, particularly the positive effects of dapagliflozin on reversing cardiac (atrial and ventricular) remodeling, reducing cardiac fibrosis and inflammation, and improving endothelial dysfunction. In this manuscript, we reviewed from a practical point of view the role of dapagliflozin in the management of the whole spectrum of patients with HF.

Introduction: Hypertension (HT) remains the leading cause of death worldwide. In Brazil it is estimated that 35% of the adult population has HT and that about 20% of these have blood pressure values within the targets recommended for the reduction of cardiovascular risk. There are some data that point to different control rates in patients treated by cardiologists in public and private referral center and this is an important point to be investigated and discussed., Objective: To compare sociodemographic characteristics, body mass index (BMI), antihypertensive (AH) drugs, blood pressure (BP) and control rate in public (PURC) and private (PRRC) referral centers., Methodology: A cross-sectional multicenter study that analyzed data from hypertensive patients assisted by the PURC (one in Midwest Region and other in Northeast region) and PRRC (same distribution). Variables analyzed: sex, age, BMI, classes, number of AH used and mean values of systolic and diastolic BP by office measurement and home blood pressure measurement (HBPM). Uncontrolled hypertension (HT) phenotypes and BP control rates were assessed. Descriptive statistics and χ 2 tests or unpaired t -tests were performed. A significance level of p  < 0.05 was considered., Results: A predominantly female (58.9%) sample of 2.956 patients and a higher prevalence of obesity in PURC ( p  < 0.001) and overweight in PRRC ( p  < 0.001). The mean AH used was 2.9 ± 1.5 for PURC and 1.4 ± 0.7 for PRRC ( p  < 0.001). Mean systolic and diastolic BP values were higher in PURC as were rates of uncontrolled HT of 67.8% and 47.6% ( p  < 0.001) by office measurement and 60.4% and 35.3% ( p  < 0.001) by HBPM in PURC and PRRC, respectively., Conclusion: Patients with HT had a higher prevalence of obesity in the PURC and used almost twice as many AH drugs. BP control rates are worse in the PURC, on average 15.3 mmHg and 12.1 mmHg higher than in the PRRC by office measurement., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2023 Amorim, Vitorino, Feitosa, Santos, Bezerra, Lopes, Camafort, Coca, Sousa and Barroso.)

Seasonal variation of blood pressure (BP) is a topic in cardiology that has gained more attention throughout the years. Although it is extensively documented that BP increases in seasons coupled with lower temperatures, there are still many gaps in this knowledge field that need to be explored. Notably, seasonal variation of BP phenotypes, such as masked and white coat hypertension, and the impact of air pollution, latitude, and altitude on seasonal variation of BP are still poorly described in the literature, and the levels of the existing evidence are low. Therefore, further investigations on these topics are needed to provide robust evidence that can be used in clinical practice., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The handling editor PL-J declared a past co-authorship with the authors MC, AC., (© 2023 Barbosa, Farina, Basso, Camafort, Coca and Nadruz.)

We present the Spanish adaptation of the 2021 European Guidelines on Cardiovascular Disease (CVD) prevention in clinical practice. The current guidelines besides the individual approach greatly emphasize on the importance of population level approaches to the prevention of cardiovascular diseases. Systematic global CVD risk assessment is recommended in individuals with any major vascular risk factor. Regarding LDL-Cholesterol, blood pressure, and glycemic control in patients with diabetes mellitus, goals and targets remain as recommended in previous guidelines. However, it is proposed a new, stepwise approach (Step 1 and 2) to treatment intensification as a tool to help physicians and patients pursue these targets in a way that fits patient profile. After Step 1, considering proceeding to the intensified goals of Step 2 is mandatory, and this intensification will be based on 10-year CVD risk, lifetime CVD risk and treatment benefit, comorbidities and patient preferences. The updated SCORE algorithm-SCORE2, SCORE-OP- is recommended in these guidelines, which estimates an individual's 10-year risk of fatal and non-fatal CVD events (myocardial infarction, stroke) in healthy men and women aged 40-89 years. Another new and important recommendation is the use of different categories of risk according different age groups (< 50, 50-69, ≥70 years). Different flow charts of CVD risk and risk factor treatment in apparently healthy persons, in patients with established atherosclerotic CVD, and in diabetic patients are recommended. Patients with chronic kidney disease are considered high risk or very high-risk patients according to the levels of glomerular filtration rate and albumin-to-creatinine ratio. New lifestyle recommendations adapted to the ones published by the Spanish Ministry of Health as well as recommendations focused on the management of lipids, blood pressure, diabetes and chronic renal failure are included., (Copyright © 2023. Published by Elsevier España, S.L.U.)

Cuffless wearable devices are currently being developed for long-term monitoring of blood pressure (BP) in patients with hypertension and in apparently healthy people. This study evaluated the feasibility and measurement stability of smartwatch-based cuffless BP monitoring in real-world conditions. Users of the first smartwatch-based cuffless BP monitor approved in Korea (Samsung Galaxy Watch) were invited to upload their data from using the device for 4 weeks post calibration. A total of 760 participants (mean age 43.7 ± 11.9, 80.3% men) provided 35,797 BP readings (average monitoring 22 ± 4 days [SD]; average readings 47 ± 42 per participant [median 36]). Each participant obtained 1.5 ± 1.3 readings/day and 19.7% of the participants obtained measurements every day. BP showed considerable variability, mainly depending on the day and time of the measurement. There was a trend towards higher BP levels on Mondays than on other days of the week and on workdays than in weekends. BP readings taken between 00:00 and 04:00 tended to be the lowest, whereas those between 12:00 and 16:00 the highest. The average pre-post calibration error for systolic BP (difference in 7-day BP before and after calibration), was 6.8 ± 5.6 mmHg, and was increased with higher systolic BP levels before calibration. Smartwatch-based cuffless BP monitoring is feasible for out-of-office monitoring in the real-world setting. The stability of BP measurement post calibration and the standardization and optimal time interval for recalibration need further investigation., (© 2023. The Author(s), under exclusive licence to The Japanese Society of Hypertension.)

Triple therapy with lipid‑lowering, antihypertensive, and antiplatelet agents reduces the risk of recurrent cardiovascular fatal and nonfatal events, cardiovascular mortality, and total mortality in secondary prevention. In real life, however, effective implementation of these optimal treatments both in primary and secondary prevention is low, and thus their contribution to cardiovascular prevention is much lower than it could be, based on research data. One of the main barriers to the adequate implementation of these strategies is low adherence to the elevated number of pills, as adherence is adversely affected by the complexity of the prescribed treatment regimen, and can be considerably improved by treatment simplification. This review updates the findings provided by recent epidemiological and clinical studies favoring a polypill‑based approach to cardiovascular prevention. The increased prevalence of patients with multiple cardiovascular risk factors and comorbidities provides the rationale for a therapeutic strategy based on a combination of drugs against different risk factors in a single pill. Pharmacologic studies have demonstrated that different cardiovascular drugs can be combined in a single pill with no loss of their individual efficacy, and this favors adherence to and persistence of treatment, as well as multiple risk factor control. Recently, a randomized clinical trial SECURE (Secondary Prevention of Cardiovascular Disease in the Elderly) has shown a significant, 30% reduction in cardiovascular events, and a 33% reduction in cardiovascular death in patients after myocardial infarction treated with a polypill, as compared with usual care, thus supporting the polypill use as an integral part of any cardiovascular prevention strategy.

Over the last three decades, there are an increasing number of investigators and meta-analyses focusing on the fact that lowering blood pressure levels below a critical point is no longer beneficial and possibly even deleterious. In recent years, several trials and meta-analyses assessing intensive blood pressure (BP) lowering found that intensive treatment and lower blood pressure levels are associated with a reduction in CV events and mortality. However, a careful examination of the results shows that current data are not easily applicable to the general hypertensive population. In addition, recommendations of different guidelines since 2017 so far suggest different BP levels regarding the systolic and diastolic thresholds to be achieved and maintained, particularly in specific clinical situations such as patients with coronary artery disease and stroke. The challenge is to better define the limits of intervention and to define phenotypes of patients who are particularly vulnerable to over-aggressive lowering of blood pressure. This article reviews the evidence, controversies and current state of knowledge regarding intensive BP lowering and the lower thresholds of BP to be achieved in patients with chronic coronary or cerebrovascular diseases., Competing Interests: Declaration of Competing Interest None declared., (Copyright © 2023 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.)

The heart failure (HF) guideline's purpose is to assist medical professionals while treating patients with HF in accordance with the best current research. Many cases of HF are both, avoidable and treatable thanks to scientific trials. Management is, therefore, based on lifestyle changes, also called non-pharmacological treatment. These, based on lifestyle changes, should be recommended in every patient at risk for HF or with diagnosed of HF, but evidence in itself is scarce. DASH Diet could be clearly beneficial while Mediterranean diet doesn't have enough evidence at the present moment. Smoking should be stopped, and excessive amounts of alcohol drinking avoided, but there is no clinical trial nor registry performed on these aspects. A moderate salt restriction is better than a strict reduction. Exercise and cardiac rehabilitation are beneficial but there are no clear recommendations about type, duration, etc. Most of the evidence that we have in HF patients with obesity is contradictory. Finally, due to the high number of aged frail patients in HF lifestyle changes should be individualized, but again available data is scant. Therefore, due to the lack of current evidence, these gaps need to be considered and need new efforts on investigation in the next future., Competing Interests: Conflict of Interest: The authors have no financial conflicts of interest., (Copyright © 2023. Korean Society of Heart Failure.)

Latin American hypertension guidelines, tailored to the needs of countries of Central and South America, should be applied and known by most Latin American physicians. The knowledge and implementation of the Guidelines is one of the greatest challenges of hypertension societies in Latin America such as the Central American and Caribbean Society of Arterial Hypertension (SCCH), the Latin American Society of Hypertension (LASH) and the Inter-American Society of Cardiology (SIAC). In 2020, the Inter-American Society of Cardiology (SIAC) published its position on the current Guidelines for Arterial Hypertension due to the need to standardize the evaluation, diagnosis, treatment and control of hypertension, establishing recommendations that should be adopted in all Latin American countries, aimed at optimizing the management of cardiovascular risk and achieving a substantial improvement in the reduction of cardiovascular events and mortality. This document intends to reinforce all proposals by the LASH guidelines and the position of the SIAC in relation to the therapeutic approach and pharmacological recommendations for patients with hypertension (HT), in order to achieve better HT control in the Central American and Caribbean area, and the consequently prognosis improvement of cardiovascular disease in the area., (Copyright © 2022 SEH-LELHA. Publicado por Elsevier España, S.L.U. All rights reserved.)

Hypertension is the most important risk factor for global disease burden. Detection and management of hypertension are considered as key issues for individual and public health, as adequate control of blood pressure levels markedly reduces morbidity and mortality associated with hypertension. Aims of these practice guidelines for the management of arterial hypertension of the Spanish Society of Hypertension include offering simplified schemes for diagnosis and treatment for daily practice, and strategies for public health promotion. The Spanish Society of Hypertension assumes the 2018 European guidelines for management of arterial hypertension developed by the European Society of Cardiology and the European Society of Hypertension, although relevant aspects of the 2017 American College of Cardiology/American Heart Association guidelines and the 2020 International Society of Hypertension guidelines are also commented. Hypertension is defined as a persistent elevation in office systolic blood pressure ≥ 140 and/or diastolic blood pressure ≥ 90 mmHg, and assessment of out-of-office blood pressure and global cardiovascular risk are considered of key importance for evaluation and management of hypertensive patients. The target for treated blood pressure should be < 130/80 for most patients. The treatment of hypertension involves lifestyle interventions and drug therapy. Most people with hypertension need more than one antihypertensive drug for adequate control, so initial therapy with two drugs, and single pill combinations are recommended for a wide majority of hypertensive patients., (Copyright © 2022 SEH-LELHA. Publicado por Elsevier España, S.L.U. All rights reserved.)

We present the Spanish adaptation of the 2021 European Guidelines on Cardiovascular Disease Prevention in Clinical Practice. The current guidelines besides the individual approach greatly emphasize on the importance of population level approaches to the prevention of cardiovascular diseases. Systematic global cardiovascular disease risk assessment is recommended in individuals with any major vascular risk factor. Regarding LDL-cholesterol, blood pressure, and glycemic control in patients with diabetes mellitus, goals and targets remain as recommended in previous guidelines. However, it is proposed a new, stepwise approach (steps 1 and 2) to treatment intensification as a tool to help physicians and patients pursue these targets in a way that fits patient profile. After step 1, considering proceeding to the intensified goals of step 2 is mandatory, and this intensification will be based on 10-year cardiovascular disease risk, lifetime cardiovascular disease risk and treatment benefit, comorbidities and patient preferences. The updated SCORE algorithm ?SCORE2, SCORE2-OP? is recommended in these guidelines, which estimates an individual's 10-year risk of fatal and non-fatal cardiovascular disease events (myocardial infarction, stroke) in healthy men and women aged 40-89 years. Another new and important recommendation is the use of different categories of risk according to different age groups (<50, 50-69, ≥70 years). Different flow charts of cardiovascular disease risk and risk factor treatment in apparently healthy persons, in patients with established atherosclerotic cardiovascular disease, and in diabetic patients are recommended. Patients with chronic kidney disease are considered high risk or very high-risk patients according to the levels of glomerular filtration rate and albumin-to-creatinine ratio. New lifestyle recommendations adapted to the ones published by the Spanish Ministry of Health as well as recommendations focused on the management of lipids, blood pressure, diabetes and chronic renal failure are included., (Copyright © 2022 Sociedad Española de Arteriosclerosis. Publicado por Elsevier España, S.L.U. All rights reserved.)

Background: Arterial hypertension is facing some changes in the last years. Its prevalence is increasing in elderly subjects. This growing prevalence is due to longer survival of the population worldwide, among other factors. On the other hand, recent guidelines have insisted in the relevance of out of office blood pressure measurements, to improve diagnostic and management of hypertension. Therefore, elderly subjects with hypertension could benefit from out of office blood pressure measurements, like ambulatory blood pressure measurements; nevertheless, there are very few or no specific recommendations regarding this., Aim: In this review, we will gather the most important information about this subject., Results: As hypertension in the elderly has some specific characteristics related to aging of the cardiovascular system, the most important aspect could be that these characteristics make ambulatory blood pressure measurement suitable for its use in elderly. Among those a higher prevalence of white coat hypertension, white coat phenomenon, and a higher nocturnal blood pressure and higher prevalence of nondipper and riser pattern, represent aspects that should be considered for better diagnostic and an improved management., Conclusion: As the prevalence of hypertension will grow in the next years, more studies specifically directed to this subject are needed., (© 2022. The Author(s).)

Age is associated with increased cardiovascular risk factors and cardiovascular disease, which constitutes the leading cause of morbidity and mortality in elderly population. In this text we thoroughly review current evidence regarding the impact on cardiovascular disease of the most important cardiovascular risk factors, especially prevalent and common in the elderly population. Diagnosis and treatment approaches are also addressed, also highlighting the importance of adequate primary and secondary prevention and management. Also, the relationship between cardiovascular disease and some comorbidities and geriatric conditions, such as frailty, particularly common in the elderly, is reviewed, together with some other issues, less often addressed but closely related to ageing, such as genetics, structural and electrical heart changes and oxidative stress. All such questions are of great importance in the comprehensive approach of risk factors and cardiovascular disease in the elderly., Competing Interests: The authors declare no conflict of interest. Manuel Martínez-Sellés is serving as one of the Editorial Board members/Guest editors of this journal. We declare that Manuel Martínez-Sellés had no involvement in the peer review of this article and has no access to information regarding its peer review. Full responsibility for the editorial process for this article was delegated to Ichiro Wakabayashi, Klaus Groschner and Brian Tomlinson., (Copyright: © 2022 The Author(s). Published by IMR Press.)

Introduction and Objectives: Hypertension is one of the main cardiovascular risk factors. An educational intervention, aimed at increasing or reinforcing the patient's knowledge, can contribute to better control of their blood pressure. Our goal was to evaluate the efficacy of a continuing therapeutic education versus an initial intervention in hypertensive patients., Methods: Experimental study of multicenter community intervention, through the application of a therapeutic education program in hypertension., Results: 980 patients on antihypertensive treatment were included, 490 in each group, with a mean age of 65 years, and 50% women, baseline mean SBP in both groups was136 mmHg. Regarding knowledge about hypertension, although a similar initial improvement was observed in both groups, at the end of the study, in the continuous intervention group (CIG) an average of 23.06 correct answers was observed, while in the Initial intervention group (IIG) the mean was 20.91, being the difference statistically significant (p < 0.001). At the end of the study, the mean SBP was 127.5 mmHg in the CIG and 136.57 mmHg in the IIG group. Likewise, a lower percentage of patients with a BMI ≥25 was observed in the CIG (78.2%) than in the IIG 82.6%, this difference being statistically significant (p < 0.001). This same effect was observed on the abdominal perimeter, observing an increased abdominal perimeter in 46.3% of the CIG compared to 68.8% in the IIG (p < 0.001). CONCLUSIóN: A continuous educational intervention increases the degree of knowledge about hypertension compared to an initial intervention. Likewise, this intervention is associated with an improvement in blood pressure, weight, body mass index and abdominal girth figures., (Copyright © 2021 Elsevier España, S.L.U. All rights reserved.)

Statement of the Spanish Interdisciplinary Vascular Prevention Committee on the updated European Guidelines on Cardiovascular Disease Prevention. We present the Spanish adaptation of the 2021 European Guidelines on Cardiovascular Disease (CVD) prevention in clinical practice. The current guidelines besides the individual approach greatly emphasize on the importance of population level approaches to the prevention of cardiovascular diseases. Systematic global CVD risk assessment is recommended in individuals with any major vascular risk factor. Regarding LDL-Cholesterol, blood pressure, and glycemic control in patients with diabetes mellitus, goals and targets remain as recommended in previous guidelines. However, it is proposed a new, stepwise approach (Step 1 and 2) to treatment intensification as a tool to help physicians and patients pursue these targets in a way that fits patient profile. After Step 1, considering proceeding to the intensified goals of Step 2 is mandatory, and this intensification will be based on 10-year CVD risk, lifetime CVD risk and treatment benefit, comorbidities and patient preferences. The updated SCORE algorithm-SCORE2, SCORE-OP- is recommended in these guidelines, which estimates an individual's 10-year risk of fatal and non-fatal CVD events (myocardial infarction, stroke) in healthy men and women aged 40-89 years. Another new and important recommendation is the use of different categories of risk according different age groups (< 50, 50-69 ≥ 70 years). Different flow charts of CVD risk and risk factor treatment in apparently healthy persons, in patients with established atherosclerotic CVD, and in diabetic patients are recommended. Patients with chronic kidney disease are considered high risk or very high-risk patients according to the levels of glomerular filtration rate and albumin-to-creatinine ratio. New lifestyle recommendations adapted to the ones published by the Spanish Ministry of Health as well as recommendations focused on the management of lipids, blood pressure, diabetes and chronic renal failure are included., (Copyright © 2022 SEH-LELHA. Publicado por Elsevier España, S.L.U. All rights reserved.)

We present the Spanish adaptation of the 2021 European Guidelines on Cardiovascular Disease (CVD) prevention in clinical practice. The current guidelines besides the individual approach greatly emphasize on the importance of population level approaches to the prevention of cardiovascular diseases. Systematic global CVD risk assessment is recommended in individuals with any major vascular risk factor. Regarding LDL-Cholesterol, blood pressure, and glycemic control in patients with diabetes mellitus, goals and targets remain as recommended in previous guidelines. However, it is proposed a new, stepwise approach (Step 1 and 2) to treatment intensification as a tool to help physicians and patients pursue these targets in a way that fits patient profile. After Step 1, considering proceeding to the intensified goals of Step 2 is mandatory, and this intensification will be based on 10-year CVD risk, lifetime CVD risk and treatment benefit, comorbidities and patient preferences. The updated SCORE algorithm (SCORE2, SCORE-OP) is recommended in these guidelines, which estimates an individual's 10-year risk of fatal and non-fatal CVD events (myocardial infarction, stroke) in healthy men and women aged 40-89 years. Another new and important recommendation is the use of different categories of risk according different age groups (<50, 50-69, >70 years). Different flow charts of CVD risk and risk factor treatment in apparently healthy persons, in patients with established atherosclerotic CVD, and in diabetic patients are recommended. Patients with chronic kidney disease are considered high risk or very high-risk patients according to the levels of glomerular filtration rate and albumin-to-creatinine ratio. New lifestyle recommendations adapted to the ones published by the Spanish Ministry of Health as well as recommendations focused on the management of lipids, blood pressure, diabetes and chronic renal failure are included.

Heart failure with preserved ejection fraction (HFpEF) is an increasingly prevalent syndrome with high cardiovascular and non-cardiovascular morbidity and mortality. Hypertension (HT) is one of its major risk factors and participates in its origin, development, and prognosis. The guidelines do not set out specific treatments, as clinical trials show limitations. Hypertension control is fundamental in the prevention and treatment of HFpEF. The guidelines recommend renin-angiotensin system blockade as the mainstay of hypertension treatment in patients with HFpEF. Spironolactone and angiotensin receptor-neprilysin inhibitors are also recommended in some cases. There are also new treatments that are already indicated, such as sodium-glucose cotransporter-2 (SGLT2) inhibitors, and promising treatments such as finerenone. A phenotypic classification that allows for more targeted treatments and studies that cover pending issues are yet to be undertaken., (Copyright © 2022 SEH-LELHA. Publicado por Elsevier España, S.L.U. All rights reserved.)

The incidence and prevalence of heart failure (HF) is increasing worldwide, leading to high morbidity and mortality. The global management of HF involves lifestyle changes in addition to pharmacological treatments. Changes include exercise and dietary recommendations, mainly salt and fluid restriction, but without any clear evidence. We conducted a systematic review to analyse the degree of evidence for these dietary recommendations in HF. Only randomized controlled trials (RCT), and observational studies in humans were selected. Studies were considered eligible if they included participants with HF and sodium and/or fluid restriction. Publications in languages other than English or Spanish were excluded. We included 15 studies related to sodium or fluid restriction. Nine RCT and six observational studies showed some improvements in symptoms and quality of life and a degree of reduction in new hospitalizations, but the results are based on limited population groups, applying different methodologies, and with different restriction goals. We found a lack of clear evidence of the benefits of sodium/fluid restriction in chronic HF. The evidence is limited to few studies with conflicting results. Randomized clinical trials are needed to fill this gap in our knowledge.

Hypertension (HT) is one of the main risk factors for cardiovascular disease (CVD). Although it is a global problem, independently of economic situation, region, race or culture, the data available on Latin America are limited. Clinical guidelines emphasise the importance of obtaining reliable blood pressure readings. For this reason, the use of ambulatory blood pressure monitoring (ABPM) is recommended. This improves precision and reproducibility, resulting in better diagnosing and therapeutic decision-making, and constitutes a better estimation of prognosis than office measurements. Unfortunately, there is no global prospective ABPM registry for all of Latin America that analyses HT prevalence, the level of knowledge about it, treatment percentage and the degree of control. Consequently, the authors of this article consider its implementation a priority., (Copyright © 2021 Elsevier España, S.L.U. and Sociedad Española de Medicina Interna (SEMI). All rights reserved.)

Introduction: Ambulatory blood pressure monitoring (ABPM) has demonstrated value in the prognostic assessment of hypertensive patients with heart failure (HF) with or without other cardiovascular diseases. The objective of this study was to evaluate whether ABPM can identify subjects with HF with a worse prognosis., Methods and Results: Prospective multicenter study that included clinically stable outpatients with HF. All patients underwent ABPM. A total of 154 patients from 17 centers were included. Their mean age was 76.8 years (± 8.3) and 55.2% were female. In total, 23.7% had HF with a reduced ejection fraction (HFrEF), 68.2% were in NYHA functional class II, and 19.5% were in NYHA functional class III. At one year of follow up, there were 13 (8.4%) deaths, of which 10 were attributed to HF. Twenty-nine patients required hospitalization, of which 19 were due to HF. The presence of a non-dipper BP pattern was associated with an increased risk for readmission or death at one year of follow-up (25% vs. 5%; p=.024). According to a Cox regression analysis, more advanced NYHA functional class (hazard ratio 3.51; 95% CI 1.70-7.26; p=.001; for NYHA class III vs. II) and a higher proportional nocturnal reduction in diastolic BP (hazard ratio 0.961; 95%CI 0.926-0.997; p=.032 per 1% diastolic BP reduction) were independently associated with death or readmission at one year., Conclusion: In older patients with chronic HF, a non-dipper BP pattern measured by ABPM was associated with a higher risk of hospitalization and death due to HF., (Copyright © 2021 Elsevier España, S.L.U. and Sociedad Española de Medicina Interna (SEMI). All rights reserved.)

Hypertension constitutes a major risk factor for heart failure with preserved ejection fraction (HFpEF). HFpEF is a prevalent clinical syndrome with increased cardiovascular morbidity and mortality. Specific guideline-directed medical therapy (GDMT) for HFpEF is not established due to lack of positive outcome data from randomized controlled trials (RCTs) and limitations of available studies. Although available evidence is limited, control of blood pressure (BP) is widely regarded as central to the prevention and clinical care in HFpEF. Thus, in current guidelines including the 2018 European Society of Cardiology (ESC) and European Society of Hypertension (ESH) Guidelines, blockade of the renin-angiotensin system (RAS) with either angiotensin-converting enzyme inhibitors or angiotensin receptor blockers provides the backbone of BP-lowering therapy in hypertensive patients. Although superiority of RAS blockers has not been clearly shown in dedicated RCTs designed for HFpEF, we propose that this core drug treatment strategy is also applicable for hypertensive patients with HFpEF with the addition of some modifications. The latter apply to the use of spironolactone apart from the treatment of resistant hypertension and the use of the angiotensin receptor neprilysin inhibitor. In addition, novel agents such as sodium-glucose co-transporter-2 inhibitors, currently already indicated for high-risk patients with diabetes to reduce heart failure hospitalizations, and finerenone represent promising therapies and results from ongoing RCTs are eagerly awaited. The development of an effective and practical classification of HFpEF phenotypes and GDMT through dedicated high-quality RCTs are major unmet needs in hypertension research and calls for action., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Switching from boosted PIs to dolutegravir in virologically suppressed HIV-infected patients with high cardiovascular risk significantly decreased total cholesterol and other proatherogenic lipid fractions at 48 weeks. The impact of this strategy on subclinical cardiovascular disease is unknown., Methods: NEAT022 is a European, multicentre, open-label, randomized, non-inferiority trial. HIV-infected adults aged >50 years or with a Framingham score >10% were eligible if plasma HIV RNA was <50 copies/mL for >24 weeks on a boosted PI-based regimen. Patients were randomized 1:1 to switch from boosted PIs to dolutegravir or to continue on boosted PIs. Common carotid arteries intima-media thickness (CIMT) and pulse wave velocity (PWV) were measured following a standardized protocol in a subgroup of NEAT022 study participants at baseline and at Week 48., Results: One hundred and fifty-six patients participated in the ultrasonography and arterial stiffness substudies, respectively. In each substudy, population characteristics did not differ between arms and matched those of the main study. At 48 weeks, patients who switched to dolutegravir had lower mean progression of both right (+4 versus +14.6 μm) and left (-6.1 versus +1.6 μm) CIMT and also a smaller increase in mean PWV (+0.18 versus +0.39 m/s) than patients continuing on boosted PIs, although differences were not statistically significant. CIMT trends were consistent across Framingham score, age and country. Inconsistent effects were seen in arterial stiffness., Conclusions: Relative to continuing on boosted PIs, switching to dolutegravir in virologically suppressed patients with high cardiovascular risk showed consistent favourable although non-significant trends on CIMT progression at 48 weeks., (© The Author(s) 2020. Published by Oxford University Press on behalf of the British Society for Antimicrobial Chemotherapy. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

According to the last Hypertension guideline recommendations, it may be concluded that intensive BP lowering is only advisable in a subgroup of patients where there is a clear net benefit of targeting to lower BP goals. However, taking into account the relevance of correct BP measurement, estimates of the benefits versus the harm should be based on reliable office BP measurements and home BP measurements.There is still debate about which BP goals are optimal in reducing morbidity and mortality in uncomplicated hypertensives and in those with associated comorbidities. In recent years, trials and meta-analyses have assessed intensive BP lowering, with some success. However, a careful examination of the results shows that current data are not easily applicable to the general hypertensive population.This article reviews the evidence on and controversies about intensive BP lowering in general and in specific clinical situations, and the importance of obtaining reliable BP readings in patients with hypertension and comorbidities.

Hypertension and heart failure are common conditions in older people. Comorbidity, together with aging, is commonly associated with frailty, which is a cause of a worse prognosis, more hospitalizations, increased dependency, and mortality. Despite being increasingly common conditions, data on the prevalence and influence of frailty in hypertensive older patients with HF are lacking. This may be due to the multidimensional aspects of frailty and the differing tools used to evaluate it. Nevertheless, in clinical practice, it is common to see frail hypertensive patients with HF but the specific characteristics of this group of patients, including multimorbidity and frailty, and the lack of data from registries or randomized clinical trials make the diagnosis and management of these patients more difficult than in those of other ages. This review focuses on what is known and on where future investigations should focus in this common but unclear situation., (© 2020 Wiley Periodicals LLC.)

The epidemiological association of cholesterol associated with low density lipoproteins (LDL-c) levels and the development of atherosclerotic vascular disease has been ratified by mendelian randomization studies. Paradoxically, the success of statins led to the underestimation of other lipid-lowering therapies and even the measurement of LDL-c. Recent studies show that the reduction of LDL-c to extraordinarily low levels through absorption inhibition, and, in a particularly intensive manner, with monoclonal antibodies against pro-protein convertase subtilisine Kesine 9 (PCSK9) continues to offer cardiovascular protection. However, the high cost and limited experience with PCSK-9 inhibitors advised a prudent use of them. An appropriate selection of patients most likely to benefit from treatment with PCSK9 inhibitors emerges as the basis for a consensus of international guidelines: the combination of a high absolute vascular risk and a greater expected benefit by the starting LDL-c levels., (Copyright © 2019 Elsevier España, S.L.U. and Sociedad Española de Medicina Interna (SEMI). All rights reserved.)

There is a bidirectional association between heart failure (HF) and type 2 diabetes mellitus (DM2), which has resulted in an exponential increase in the combination of the 2 diseases in a single patient. This combination is one of many common causes that lead to the pathophysiological pathways resulting in the deleterious effect of DM2 on HF. The inevitable clinical consequence is that, when faced with this situation, patients present worse symptoms and a poorer prognosis than patients with HF but without DM2. We should therefore consider how to treat DM2 in patients with HF and how to treat HF in patients with DM2. In this review, we highlight the latest published data on this issue., (Copyright © 2019 Elsevier España, S.L.U. and Sociedad Española de Medicina Interna (SEMI). All rights reserved.)

Objectives: To determine whether nutritional risk is associated with the mortality of elderly patients hospitalized with nonvalvular atrial fibrillation (NVAF)., Design: Prospective, multicenter cohort study., Setting: Internal medicine departments in Spain., Participants: Inpatients >75 years with NVAF., Measurements: We measured the thrombotic and hemorrhagic risk at admission using the CHA2DS2-VASc and HAS-BLED scales, respectively, and the nutritional risk with the controlling nutritional status (CONUT) index. We established 4 degrees of nutritional risk: null (CONUT score 0-1 point), low (2-4 points), moderate (5-8 points) and high (9-12 points). We also conducted a 1-year follow-up., Results: We included 449 patients, with a mean age of 85.2(5.2) years. The nutritional risk was null for 70(15.6%) patients, low for 206 45.9%), moderate for 152(33.8%) and high for 21(4.7%). At the end of one year, 177(39.4%) patients had died. The score on the CONUT index was higher for the deceased patients (4.6 vs. 3.6, p<0.001). The CONUT score (HR, 1.076; 95%CI 1.009-1.148; p=0.025), the Charlson index (HR, 1.080; 95%CI 1.017-1.148; p=0.013) and the presence of pressure ulcers (HR, 1.700; 95%CI 1.028-2.810; p=0.039) were independently associated with increased mortality at one year of follow-up. The prescription of oral anticoagulants at discharge was associated with lower mortality (HR, 0.440; 95%CI 0.304-0.638; p<0.001)., Conclusions: More than a third of elderly patients hospitalized with NVAF have a moderate to high nutritional risk. These patients have greater mortality at the end of one year., Competing Interests: The authors declare that they have no conflict of interest. Aranzazu Arenas Miquélez has no conflict of interest. María Ángeles Calleja Requena has no conflict of interest. Alejandra Gullón has no conflict of interest. Antonio Pose Reino has no conflict of interest. Françesc Formiga has no conflict of interest. Miguel Camafort has no conflict of interest. José María Cepeda Rodrigo has no conflict of interest. José María Mostaza has no conflict of interest. Carmen Suárez Fernández has no conflict of interest. Jesús Díez-Manglano has no conflict of interest.

Large continental faults extend for thousands of kilometres to form boundaries between rigid tectonic blocks. These faults are associated with prominent topographic features and can produce large earthquakes. Here we show the first evidence of a major tectonic structure in its initial-stage, the Al-Idrissi Fault System (AIFS), in the Alboran Sea. Combining bathymetric and seismic reflection data, together with seismological analyses of the 2016 M w 6.4 earthquake offshore Morocco - the largest event ever recorded in the area - we unveil a 3D geometry for the AIFS. We report evidence of left-lateral strike-slip displacement, characterise the fault segmentation and demonstrate that AIFS is the source of the 2016 events. The occurrence of the M w 6.4 earthquake together with historical and instrumental events supports that the AIFS is currently growing through propagation and linkage of its segments. Thus, the AIFS provides a unique model of the inception and growth of a young plate boundary fault system.

Aim: Renal insufficiency is associated with medical complications in patients with non-valvular atrial fibrillation (NVAF). However, data for elderly patients are scarce. Thus, the main objectives of the present study were to analyze the characteristics of elderly patients with NVAF and acute or chronic renal disease, describe their management in real-life conditions, and detect factors associated with complications., Methods: The NONAVASC registry includes patients > 75 years with NVAF, hospitalized by any cause in 64 Spanish Internal Medicine departments. Patients were categorized into acute kidney injury (AKI), chronic kidney disease (CKD) or preserved renal function (PRF). All variables associated with in-hospital mortality with P < 0.10 in univariate analysis were included to develop a multivariate logistic-regression model., Results: The study included 804 patients (53.9% women), 352 (43.8%) of whom met diagnostic criteria for CKD. AKI was detected in 119 (14.8%) patients. AKI was associated with greater length of stay, higher mortality and an increased rate of patient transfer to nursing homes. After logistic-regression analysis, we found an association between mortality and AKI (OR 2.4, 95% CI 1.03-5.53; P = 0.045). The increase in creatinine values (OR 1.8, 95% CI 1.19-2.73; P = 0.005) and the decrease in albumin values (OR 2.0, 95% CI 1.05-3.73; P = 0.033) were also linked to mortality., Conclusions: Our study shows the relationship between AKI and creatinine value increase and a higher mortality in elderly patients with NVAF. In light of our findings, the detection of renal function impairment in these patients should alert physicians and consider them as high-risk patients.

Aim: To determine the factors associated with discontinuing or not starting oral anticoagulation (OA) therapy in older patients with non-valvular atrial fibrillation (NVAF)., Methods: A prospective, multicenter cohort study was carried out of patients aged >75 years with NVAF hospitalized in internal medicine departments in Spain. For each patient, we recorded creatinine, hemoglobin and platelets levels, as well as CHA2DS2-VASc and HAS-BLED scores and the Charlson Comorbidity Index. We measured the ability to carry out basic activities of daily life with the Barthel Index, and the cognitive state with the Short Portable Mental Status questionnaire., Results: We included 723 patients with NVAF, with a mean age of 84.8 years (SD 5.2 years); 390 (53.9%) of the patients were women. Before admission, 375 (51.9%) patients were treated with OA. Previously diagnosed NVAF (OR 4.099, 95% CI 1.824-9.211, P = 0.001), the number of errors in the Short Portable Mental Status questionnaire (OR 1.180, 95% CI 1.020-1.365, P = 0.026), peripheral arterial disease (OR 0.285, 95% CI 0.114-0.711, P = 0.007) and hemoglobin levels (OR 0.812, 95% CI 0.682-0.966, P = 0.019) were independently associated with not starting OA therapy at discharge. Of the 375 patients treated with OA at admission, 87 (23.2%) had their OA discontinued at discharge. The HAS-BLED score (OR 1.516, 95% CI 1.211-1.897, P < 0.001) and previous acute myocardial infarction (OR 0.327, 95% CI 0.121-0.883, P = 0.027) were associated with the discontinuation of OA., Conclusions: There are factors associated with discontinuing or not starting OA in older patients with NVAF, which often have no clinical justification. Geriatr Gerontol Int 2018; 18: 1219-1224., (© 2018 Japan Geriatrics Society.)

Introduction: Residual cardiovascular risk remains high in patients with atherosclerotic cardiovascular disease despite current antithrombotic therapy. On the other hand, patients with atrial fibrillation have an increased risk of myocardial infarction and cardiovascular death. As a result, a new antithrombotic approach appears necessary to reduce this risk. Areas covered: In this article, the role of rivaroxaban on vascular protection in patients with cardiovascular disease and/or atrial fibrillation was reviewed, with a particular focus, but not limited, on clinical trials. Expert commentary: Previous data have shown that factor Xa plays a key role in the etiopathogenesis of atherothrombosis. Experimental data suggest that rivaroxaban exhibits antiinflammatory and antioxidative stress properties, and may improve endothelial dysfunction. The COMPASS trial showed that among patients with stable atherosclerotic vascular disease, the addition of rivaroxaban 2.5 mg twice daily (vascular dose) to aspirin provided a higher cardiovascular protection than aspirin alone. In ROCKET-AF trial, compared with warfarin, rivaroxaban 20 mg once daily (15 mg if moderate renal dysfunction) (anticoagulant dose) was, at least, as effective as warfarin for the prevention of stroke or systemic embolism among patients with nonvalvular atrial fibrillation, with a trend toward a reduction in the risk of cardiovascular outcomes. All these data suggest that rivaroxaban might have a vascular protective effect beyond its stroke/systemic embolism preventive activity.

Objectives: The aim of the study was to assess changes in and factors associated with anatomical [carotid artery intima-media thickness (CIMT)] and functional (arterial stiffness) markers of subclinical cardiovascular disease progression in antiretroviral-naïve patients starting triple combination antiretroviral therapy containing contemporary protease inhibitors., Methods: This was a planned substudy of the ATADAR (Metabolic Effects of Atazanavir/Ritonavir Versus Darunavir/Ritonavir in Combination With Tenofovir/Emtricitabine in naïve HIV-1 Infected Patients) clinical trial (ClinicalTrials.gov identifier NCT01274780). ATADAR is a multicentre, randomized, open-label clinical trial comparing the effects of ritonavir-boosted atazanavir and darunavir, both with tenofovir/emtricitabine, in antiretroviral-naïve HIV-infected patients. Common CIMT and aortic augmentation index (AIx@75) were measured at baseline and after 12 months of follow-up. Antiretroviral treatment, traditional cardiovascular risk factors and HIV-related factors were assessed as potential predictors of CIMT and Aix@75 changes using linear regression analysis., Results: Thirty-three patients were included in this pilot study. While CIMT significantly increased in the pooled population [median (interquartile range (IQR)) 68 (-13, 128) μm; P = 0.0511], AIx@75 did not [median (IQR) 1 (-6, 5)%; P = 0.8964]. Patients on darunavir showed a trend to faster CIMT progression than those on atazanavir [median change (IQR) 117 (-2, 143) vs. -6 (-58, 89) μm, respectively; P = 0.0917]. However, after adjustment in the multivariate analysis, a higher baseline Framingham score was the only factor associated with CIMT progression (coefficient 16.02; 95% confidence interval -1.04, 33.08; P = 0.064). AIx@75 change was not associated with any baseline factor., Conclusions: CIMT was a more sensitive marker of subclinical vascular disease progression than arterial stiffness in antiretroviral-naïve patients starting antiretroviral therapy with contemporary protease inhibitors. Classical risk factors but not antiretroviral therapy were associated with faster CIMT progression., (© 2018 British HIV Association.)

The American College of Cardiology (ACC) and the American Heart Association (AHA) have recently published their guidelines for the prevention, detection, evaluation, and management of hypertension in adults. The most controversial issue is the classification threshold at 130/80mmHg, which will allow a large number of patients to be diagnosed as hypertensive who were previously considered normotensive. Blood pressure (BP) is considered normal (<120mmHg systolic and <80mmHg diastolic), elevated (120-129 and <80mmHg), stage 1 (130-139 or 80-89mmHg), and stage 2 (≥140 or ≥90mmHg). Out-of-office BP measurements are recommended to confirm the diagnosis of hypertension and for titration of BP-lowering medication. In management, cardiovascular risk would be determinant since those with grade 1 hypertension and an estimated 10-year risk of atherosclerotic cardiovascular disease ≥10%, and those with cardiovascular disease, chronic kidney disease and/or diabetes will require pharmacological treatment, the rest being susceptible to non-pharmacological treatment up to the 140/90mmHg threshold. These recommendations would allow patients with level 1 hypertension and high atherosclerotic cardiovascular disease to benefit from pharmacological therapies and all patients could also benefit from improved non-pharmacological therapies. However, this approach should be cautious because inadequate BP measurement and/or lack of systematic atherosclerotic cardiovascular disease calculation could lead to overestimation in diagnosing hypertension and to overtreatment. Guidelines are recommendations, not impositions, and the management of hypertension should be individualized, based on clinical decisions, preferences of the patients, and an adequate balance between benefits and risks., (Copyright © 2018 The Authors. Publicado por Elsevier España, S.L.U. All rights reserved.)

Alzheimer's disease (AD), the most common form of dementia, is a complex disease, the mechanisms of which are poorly understood. AD represents 70% of all dementia cases, affecting up to 50% of elderly persons aged 85 or older, with functional dependence, poor quality of life, institutionalization and mortality. Advanced age is the main risk factor of AD, that is why population ageing, due to life expectancy improvements, increases AD incidence and prevalence, as well as the economic, social, and emotional costs associated with this illness. Existing anti-AD drugs present some limitations, as they target specific downstream neurochemical abnormalities while the upstream underlying pathology continues unchecked. Chronic hypertension has been suggested as one of the largest modifiable risk factors for developing AD. At least 25% of all adults and more than 50% of those over 60 years of age have hypertension. Epidemiological studies have shown that hypertension is a risk factor for dementia and AD, but the association is complex. Some studies have demonstrated that antihypertensive drugs can reduce the risk of AD. This review focuses on current knowledge about the relationship between chronic hypertension and AD as well as antihypertensive treatment effect on AD pathogenesis and its clinical outcomes.

Introduction: Resistant hypertension(RH) has been defined as failure to control office blood pressure (BP) despite the use of≥3 different antihypertensive agents at optimal doses, including, ideally, a diuretic. Apparent RH, defines patients with an incorrect diagnosis of RH due to different causes. The objective was to determine whether most patients with RH in fact have apparent but not true RH., Patients and Methods: Observational study involving 93 patients with suspected RH, being 60 patients finally included. Screening for secondary causes of hypertension was perfomed. True RH was defined as office BP>140/90mmHg despite full doses of 3 antihypertensive drugs including a diuretic., Results: Mean age 63.7±9.8years, 68.3%were male. Office BP 154.3±14.4/84.4±13.7mmHg. Of the 60 patients, 23.3% had white coat effect, 3.3% didn't have a diuretic and 8.3% were non-adherent-to-treatment. Accordingly, 58.3% were classified as true RH. Spironolactone was added in 62.5% of patients of whom 78.4% achieved ambulatory BP control., Discussion: Almost half of the patients with suspected RH were not really true RH. We provide more evidence of excess of fluid retention as an underlying cause of lack of BP control in patients with RH, reinforce the relevant paper of spironolactone for the management in those patients., (Copyright © 2017 Elsevier España, S.L.U. All rights reserved.)

Objectives: Atrial fibrillation (AF) has been associated with higher mortality. We aimed to identify the baseline predictors of in-hospital mortality among elderly patients with non-valvular AF (NVAF) hospitalised for any reason., Methods: Observational, prospective and multicentre study was carried out on patients with NVAF over the age of 75, who had been admitted for any acute medical condition to Internal Medicine departments in Spain., Results: We evaluated 804 patients with a mean age of 85±5.1years, of which 53.9% were females. During the hospitalization 10.1% (n=81) of the patients died. The patients who died were older, had a greater percentage of institutionalization, worse previous basic functional status (Barthel Index), worse cognitive performance at admission and greater proportion of frailty and sarcopenia. Logistic regression multivariate analysis identified that the strongest determinants of in-hospital mortality were the baseline functional status (Barthel Index) (OR for total dependency 4.73, 95% CI 2.32-9.63), and admissions for stroke (OR 3.55, 95% CI 1.41-8.90) and acute renal failure (OR 1.93, 95% CI 1.12-3.32)., Conclusion: The overall in-hospital mortality of elderly patients with NVFA is high. Among all factors evaluated in the global geriatric assessment the baseline functional status was the strongest predictor for in-hospital mortality on this population., (Copyright © 2017 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.)