Open Journal Systems

EDITORIALS

Received: 15/10/2015

Accepted: 23/11/2015

Systemic arterial hypertension in México. A consensus to mitigate its comorbidities

Gilberto Pérez-Rodríguez^a

^aDirección General, Hospital de Cardiología, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Ciudad de México, México

Communication with: Gilberto Pérez-Rodríguez

Email: gilberto.perez@imss.gob.mx

Given that systemic arterial hypertension (SAH) is the most common illness presented by the adults who come to primary care in México, in this supplement a group of cardiologists, as well as other specialists, from the Instituto Mexicano del Seguro Social (IMSS) offer a systematic review, a critical analysis, and a national consensus of guidelines as a frame of reference to the daily clinical practice in order to mitigate SAH in México.

Keywords: Hypertension; Comorbidity; Evidence-based medicine

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Hypertension is the most common condition afflicting adults attending primary care; it often causes heart attack, stroke, kidney failure, and death if not detected on time and treated properly.

This systematic review for updating, critical analysis, and national consensus on guidelines regarding hypertension looks at the geo-demographic characteristics of the hypertensive population in Mexico and its environment with other common comorbidities; it represents an important effort by a group of cardiologists interested in the subject, belonging to the Hospital de Cardiología of the Centro Médico Nacional Siglo XXI of the Instituto Mexicano del Seguro Social. These cardiologists took on not only the systematic review, but also organized the national consensus using the Delphi method.

The concepts set forth here aim to support the framework of daily clinical practice and cover epidemiological, clinical, pathophysiological, and socio-medical basics. Our recommendations should not be taken dogmatically, rather the doctor’s knowledge and clinical judgment, and the individualization of each case, shall give greater relevance to these recommendations. Thus, although certain guidelines for drug treatment are suggested, one should not forget the idiosyncrasy of the person, the feasibility of the proposed scheme, and, above all, lifestyle changes.

The urgent need to specifically and practically address major public health problems in our country necessitates the participation of all health-related entities in Mexico.

Recently published national epidemiological data confirm and give alarming figures on the prevalence of key chronic diseases in adults (KCDA), also called chronic noncommunicable diseases. In general, we can say that the prevalence of all KCDA shows a significant percentage growth, especially when compared with the diseases that have been collected in the 1993 Encuesta Nacional de Enfermedades Crónicas (ENEC), in the 2000 ENSA, 2006 ENSANUT, or the 2012 ENSANUT.^1-3 A serious consequence of the increase in the prevalence of these KCDA is the exponential increase in the rate of complications, since they are already the leading cause of morbidity and mortality in adults over 20 in Mexico.³  

A major fraction of the health sector budget is undoubtedly mainly absorbed by the KCDA and their complications (e.g. atherosclerosis, hypertensive heart disease, atherosclerotic or ischemic heart disease, diabetes, obesity, chronic renal failure, heart failure, blindness, amputations, degenerative neuropsychiatric disorders, chronic obstructive pulmonary disease, cerebral vascular disease, and others). These complications are also the main generators of disability, since they incapacitate both the economically active group and the elderly population. The cost of care is in the multiple millions, and, as they are not curable ailments, only controllable, they usually require more medical care and drug treatment for life.

Therefore, experts were summoned from basic, clinical, and epidemiological areas of the Hospital de Cardiología of the Centro Médico Nacional Siglo XXI to participate in the scientific update for the detection, control, and treatment of hypertension (HT). A questionnaire with key questions was applied to more than 70 experts from all over the republic. A simple and practical approach was made for any doctor who sees people with HT, of course without sacrificing cutting-edge scientific knowledge. The purpose of this consensus was to assess the socio-medical and environmental context of the hypertensive population of Mexico.

The need for preventive measures is emphasized. For example, the importance of non-pharmacological management (nutrition, exercise, and lifestyle changes, which should ideally begin from a very early age) is crucial for the clinical prevention of any essential chronic adult disease, and hypertension is no exception:

only if measures of change are systematized in the lifestyle [that are] healthy and continuous, with the reinforcement and active participation by all agencies related to health and population education, and with the social commitment of all, we must confront in a real and preventive way the pandemic of chronic diseases.⁴

This new edition of the guidelines amplified the importance and information on this subject. Preventive cardiology should contribute to the multidisciplinary linkage.

Based primarily on national data and reports from the rest of the world, our own rating and risk stratification system was created for HT carriers, called HTM (Hypertension in Mexico), which aims to remind us that the approach to HT is and always will be multidisciplinary.

The expert committee was given the task of critically and thoroughly reviewing, under the principles of evidence-based medicine, the most prominent information offered by national and international medical literature, in order to adapt the concepts and guidelines for better control and treatment of HT in Mexico. One of the most important conclusions of this working group was recognize that HT is not an isolated entity, but must be addressed in the context of the prevalence and interaction with other KCDA, as well as other risk factors such as obesity, diabetes, dyslipidemia, and smoking, among others. We emphasize the urgent need to thoroughly address various cardiovascular risk factors, because regardless of sharing common pathophysiological mechanisms, their proper identification and control will undoubtedly affect the natural history of other combined risk factors. Of course the greater involvement of factors, the higher the cardiovascular risk; however, one should never ignore the specific weight that each has on overall cardiovascular risk. 

In this edition we have the participation of an external expert editor at the Hospital de Cardiología, who kindly coordinated the series of articles that are attached to this consensus, which have to do with special situations of patients with hypertension. The clinical approach to both suspected essential HT and secondary HT is amplified in a practical way, emphasizing women with menopause and hypertension in pregnancy. Some aspects of hypertensive emergencies and other special situations are also addressed. Recommendations for addressing children and adolescents appear for the first time in these guidelines.

Finally, I am infinitely grateful to the coordinators of these guidelines and to each and every one of those who enthusiastically participated either directly or indirectly in the achievement of these recommendations from the Hospital de Cardiología of the Centro Médico Nacional Siglo XXI. We integrated the results of major international studies such as JATOS,⁵ TROPHY,⁶ ALLHAT,⁷ PHARAO,⁸ COFFEE,⁹ ASCOT-BLA,¹⁰ and others, as well as some aspects from US, European, and Canadian guidelines.^11-14

Any reviews and comments on this consensus will be welcomed, as it will undoubtedly enrich and improve future work that we will update as required. Recently in the United States The National Heart Lung and Blood Institute issued a document recognizing that the primary focus should be on the reduction of overall cardiovascular risk, and the institute called for updating and further strengthening the guidelines on cholesterol (ATPIV), hypertension (JNC-8),¹² and obesity in adults, based on the impulse for an integrated approach; the same is suggested by recent European guidelines (2014).^13,14

References

1. Secretaría de Salud. Encuesta Nacional de Salud y Nutrición (ENSANUT) 2012. Cuernavaca, Morelos, México: Secretaría de Salud; 2012.
2. Velázquez-Monroy O, Rosas Peralta M, Lara Esqueda A, Pastelín Hernández G, Sánchez-Castillo C, Attie F et al. [Prevalence and interrelations of noncommunicable chronic diseases and cardiovascular risk factors in Mexico. Final outcomes from the National Health Survey 2000]. Arch Cardiol Mex. 2003;73(1):62-77.
3. Córdova Villalobos JA. Políticas Públicas en Salud para el Desarrollo de México. Academia Nacional de Medicina. 14 Febrero 2007.
4. Attie F, Rosas PM. Pasado, Presente y Futuro de la Cardiología. Academia Nacional de Medicina. 2005.
5. Jatos Group. Principal Results of the Japanese Trial to Assess Optimal Systolic Blood Pressure in Elderly Hypertensive Patients (JATOS). Hypertens Res. 2008;31:2115-27.
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7. ALLHAT collaborative research group. Major outcomes in High-risk hypertensive patients randomized to ACE inhibitor or Calcium channel blocker versus diuretic. The antihypertensive and lipid-lowering treatment to prevent heart attack trial (ALLHAT). JAMA. 2002;288(23):2981-96.
8. Pharao Study. 29th Annual Meeting. Fukuoka, Japan; 2006.
9. Williams B, Lacy PS, Thom SM, Cruickshank K, Stanton A, Collier D, et al. Differential impact of blood pressure-lowering drugs on central aortic pressure and clinical out-comes: principal results of the Conduit Artery Function Evaluation (CAFE) study. Circulation. 2006;113(9):1213-25.
10. Dahlof B, Sever PS, Poulter NR, Wedel H, Beevers DG, Caulfield M, et al; ASCOT Investigators. Prevention of cardiovascular events with an antihypertensive regimen of amlodipine adding perindopril as required versus atenolol adding bendroflumethiazide as required, in the Anglo Scandinavian Cardiac Outcomes Trial- Blood Pressure Lowering Arm (ASCOT-BPLA): a multicentre randomized controlled trial. Lancet. 2005 Sep 10-16;366(9489):895-906.
11. Campbell NRC, Tu K, Brant R, Duong-Hua M, McAlister FA. The Impact of the Canadian Hypertension Education Program on Antihypertensive Prescribing Trends for the Canadian Hypertension Education Program Outcomes Research Task Force. Hypertension. 2006;47:22-8.
12. James PA, Oparil S, Carter BL, Cushman WC, Dennison-Himmelfarb C, Handler J, et al. 2014 guide based on the evidence for the management of Arterial hypertension in adults report of the members of the panel appointed the whole Eighth National Committee (JNC 8) JAMA. 2014;311(5):507-20.
13. The Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). 2013 ESH/ESC Guidelines for the management of arterial hypertension. Journal of Hypertension. 2013,31:1281-357.
14. NICE clinical guideline 127. Clinical management of primary hypertension in adults. 2011; Available from: guidance.nice.org.uk/cg127.https://www.nice.org.uk/guidance/cg127/resources/guidance-hypertension-pdf

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