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Scientific Highlights: 2016 Latin American conference on cardiometabolic diseases management: health emergencies in focus

Scientific Highlights: 2016 Latin American conference on cardiometabolic diseases management: health emergencies in focus
  • Cardiometabolic
    Endocrinology and metabolism
  • Diabetes
    Hypertension
    Thyroid disorder

Resource type

Publication

Usage

Practical

Diabetes and hypertension are reaching epidemic proportions in Central and South America, and elsewhere in the world. Both conditions are associated with progression to serious cardiovascular emergencies: indeed, hypertension has the highest global risk of premature death. The worldwide prevalence of diabetes continues to rise: people with diabetes are at heightened risk of developing comorbidities that reduce health-related quality of life and also increase the mortality risk. However, relatively cost-effective lifestyle measures alone can reduce the risk of even the most serious cardiometabolic comorbidities, in people at risk of, or diagnosed with, diabetes and hypertension. Optimum management of diabetes and hypertension was a key theme of this conference. Thyroid disorder, which is common in Latin America, due to iodine deficiency and genetic factors, was also featured. Click on the links below to read about each presentation:

Contents

  1. Diabetes, how do (and did) we get there?
  2. Lifestyle modifications to prevent diabetes: is it enough?
  3. Drugs for type 2 diabetes: which is better?
  4. Diabetes Management: how to choose the right drug?
  5. Gestational diabetes: when and how should pharmacological intervention be implemented?
  6. What is the role of new technologies in type 2 diabetes?
  7. Cardiometabolic implications of thyroid dysfunction
  8. Subclinical hypothyroidism: myths, presumptions and facts
  9. New perspectives in the diagnostic of thyroid nodules
  10. Autonomic dysfunction in diabetes: the hidden disease complicating blood pressure and heart rate control
  11. New developments from recent trials in hypertension & arterial stiffness
  12. High heart rate and cardiovascular risk in hypertension
  13. Is heart rate a target in hypertensive treatment?
  14. Blood pressure targets after SPRINT study: is it time for change?
  15. Are hypertension and obesity linked?
  16. Combination treatment: RAS blockers are not the only possibility
  17. The prevention of heart failure development in hypertension

Diabetes, how do (and did) we get there?

The global obesity epidemic is a key factor contributing to the diabetes pandemic: fat is an active endocrine organ, not just a depot, explained Professor John Kennedy Cruickshank (London, UK), and diabetes management must look beyond glycemic goals, at factors such as dyslipidemia. People with pre-diabetes or the metabolic syndrome are more likely to experience of cardiovascular events earlier than those who are not obese/overweight – and are more likely to die as a result of such events.

Therefore, the first goals for anyone with (or at risk of) diabetes and obesity is to achieve normoweight and increase physical activity. Modest, sustainable lifestyle interventions are cost- and clinically effective at preventing type 2 diabetes mellitus (T2DM) or at least delaying its development.

Oral antidiabetes therapy (e.g. metformin) and statin treatment, should be secondary actions, following lifestyle improvements.

It is also important for governments to consider introducing health taxes, to stop the ongoing rise in calorie intake (Figure 1) or improve adherence to healthy lifestyle interventions, added Professor Cruickshank.

 Figure 1: The rising consumption of grains and fats since 1970 largely accounts for increases in calorie intake (Source: Food and Agriculture Organization of the United Nations)

However, T2DM management should focus on cardiometabolic parameters beyond just glycemic goals, cautioned Professor Cruickshank. Metabolomics research findings suggest that the definition of T2DM should incorporate disturbed lipid metabolism and cardiovascular dysfunction prior to hyperglycemia development.

Lifestyle modifications to prevent diabetes: is it enough?

The individual who does not develop T2DM is spared the symptoms of hyperglycemia and hypoglycemia. He is also spared the burdens associated with antidiabetes therapy and glycemic control (such as daily glucose monitoring, surveillance for T2DM consequences and comorbidities). And he is spared the life burdens associated with being ‘diabetic’, such as finding it complicated and costly to obtain health or personal insurance.

Dr José Patricio Lopez-Jaramillo (Bucaramanga, Colombia) personalized the scenario of T2DM. A 40-year-old man diagnosed with T2DM is likely to see a reduction in life expectancy of ~11.6 years and a reduction in quality of life years of ~18.6.

However, stopping T2DM from developing will likely prevent eye, kidney and nerve disease; it also has the potential (albeit yet unproven) of reducing the incidence of cardiovascular disease, and the rate of cognitive decline.

Several randomized clinical trials involving lifestyle changes in individuals at high risk of developing diabetes show that lifestyle interventions (diet modification, increased physical activity, increased muscle strength) prevent or delay T2DM onset:

  • Cumulative 6-year incidence of diabetes was significantly lower in the diet group (44%), the exercise group (41%), and the diet-plus exercise group (46%) than in the control group (67%) [Da Qing]
  • Risk reduction is directly proportional to the magnitude of lifestyle changes [Finnish Diabetes Prevention Study]

Key lifestyle intervention goals are summarized in Table 1.

Table 1: Lifestyle modifications to support people at risk of T2DM and its complications (adapted from DL Burnet et al, 2006)

Physical activity

Nutrition

150 min moderate-intensity exercise per week

Tailor physical activity to individual’s ability, interest

Walking suits most; cycling or water-based activities suit those with arthritis

Encourage increased activity in daily routines

Take the stairs, park further away, get off public transport one stop early

Previously inactive individuals begin with short amounts of exercise and gradually increase  duration/intensity

Set goals with the individual on the best way to accrue 150 min weekly: e.g. 30 min walking 5 days per week or 50 min walking 3 days per week

Make goals specific in time, amount and activity

Encourage self monitoring of activity (written records, pedometer, heart rate monitor)

Emphasize that total calories matter!

Goal: fat intake <25% of total calories, minimize intake of saturated fats, trans fats (red meat, deep-fried food, oils that are solid at room temperature)

Encourage portion size awareness

Read food labels to look for hidden sugars/fats

Increase dietary fiber to 20-30 g/day

Diet should be high in whole grains, fruits and vegetables, beans, and nuts

Goal-set with  individual on preferred initial dietary changes

Make goals specific in time, amount, type

Encourage self-monitoring (e.g. food diaries)

Encourage self-reward for meeting goals

Enlist family members to help with goals (if acceptable to patient)

Help patient to anticipate potential barriers to exercise (and solutions to such barriers)

Tell patient that relapse is normal; encourage them to think about what led to the relapse and how to overcome it next time

Arrange close follow-up

Drugs for type 2 diabetes: which is better?

In addition to lifestyle changes, pharmacological interventions should be considered in the following scenarios, explained Dr Leticia Schwerz Weinert (Porto Alegre, Brazil):

  • When lifestyle modifications fail
  • When participation in lifestyle modification is impossible
  • Previous history of gestational diabetes mellitus
  • Body mass index ≥ 35 kg/m²
  • Age < 60 years

The American Diabetes Association (ADA) advises that people at risk of developing T2DM should be monitored at least annually, including screening for modifiable risk factors for cardiovascular disease.

If pharmacological interventions are required for T2DM prevention, metformin (biguanide) remains the drug of choice, as recommended by the National Institute for Health and Care Excellence (NICE) and ADA. However, the Food and Drug Administration (FDA) considers its use for diabetes prevention to be off-label.

Metformin improves insulin sensitivity and reduces fasting or postprandial glucose levels; it also reduces the incidence of cardiovascular events in overweight people with diabetes.

There is less evidence for orlistat (reversible inhibitor of lipases) in T2DM prevention. Orlistat is recommended by NICE for obesity management in adults with BMI ≥ 28 kg/m². Again, its use for diabetes prevention is off-label. Orlistat therapy should be reviewed after 12 weeks and discontinued if there is < 5% body weight reduction.

Acarbose, thiazolidenediones, angiotensin II inhibitors or bariatric surgery are not recommended for T2DM prevention by any international or national guidelines. However, further studies are warranted, added Dr Schwerz Weinert.

Diabetes Management: how to choose the right drug?

Evidence supports a patient-centered approach to T2DM treatment that involves reviewing the algorithms for diabetes management and treatment. Treatment should be personalized, taking into account hyperglycemia and also multifactorial (and in particular cardiovascular) outcomes, said Dr Ernesto Maddaloni (Rome, Italy).

Several pathways and organs are involved in T2DM development; many drugs, with different mechanisms of action, are available to manage this complex condition and its comorbidities. However, having such varied options can present challenges for patient management and therapeutic decision making. Dr Maddaloni added that a smart approach to patient management is therefore required.

The therapeutic plan for T2DM starts with choosing the right glycemic target for the individual. ADA guidelines strongly suggest a personalized glycemic target. As shown by UKPDS, ACCORD, ADVANCE and VADT trials, individuals with newly diagnosed T2DM and without cardiovascular comorbidities likely benefit from tighter glycemic control.

Conversely, patients with established cardiovascular (CV) comorbidities, older people and those with longer T2DM duration could be harmed if achieving tighter glycemic control is the focus.

As a general rule, focus on patient safety is paramount, especially in relation to the individual’s comorbidities (e.g. renal failure, heart failure, ischemic disease).

Lifestyle changes are the starting point for T2DM patients. If pharmacologic agents are required, unless contraindicated, metformin remains the first-line treatment. Several studies (UKPDS in primis) show that metformin treatment is associated with a sustained reduction in CV events.

Recently the EMPAREG and LEADER trials showed that empagliflozin and liraglutide, respectively, when added to metformin, further improve cardiovascular outcomes in people with T2DM.

Gestational diabetes: when and how should pharmacological intervention be implemented?

Gestational diabetes mellitus (GDM) is a common complication that is associated with adverse outcomes for the birth and immediate postnatal period. Dr Leticia Schwerz Weinert (Porto Alegre, Brazil) emphasized the importance of prompt diagnosis and individualized care.

Screening for GDM should be undertaken according to the mother’s individual risk factors or national universal testing strategies. Screening should occur at the first prenatal visit in women at heightened risk of GDM, defined as any of the following factors:

  • BMI >30 kg/m2
  • Previous macrosomic baby
  • Previous GDM
  • First-degree relatives with diabetes
  • High-risk ethnicity
  • Polycystic ovary syndrome
  • Advanced maternal age
  • Hypertension

At 24-28 weeks’ gestation, all pregnant women should be screened (Figure 2).

Figure 2 (A) One-step and (B) two-step strategies for GDM diagnosis

Dr Schwerz Weinert said that targets should be a fasting glucose <95mg/dl (1 h <140mg/dl; 2 h <120mg/dl). Diet (33-40% carbohydrate; 20% protein; 40% fat) and exercise are recommended for all GDM patients; no further intervention may be needed. However, pharmacological therapy is needed if glycemic targets are unmet after 1-2 weeks’ lifestyle modification.

The pharmacological options are:

  • Insulin (consider starting insulin immediately if hyperglycemia is severe at diagnosis)
    • Insulin analogues lispro, aspart and detemir (FDA pregnancy category B)
    • Insulin analogues glargine, degludec and glulisine (FDA pregnancy category C)
    • Therapy should be individualized:
      • Fasting hyperglycemia; intermediate-acting insulin
      • Post-prandial hyperglycemia; short-acting insulin
      • Educate about hypoglycemia
  • Metformin (FDA pregnancy category B)

What is the role of new technologies in type 2 diabetes?

Dr Schwerz Weinert said that targets should be a fasting glucose <95 mg/dl (1 h <140mg/dl; 2 h <120 mg/dl). Diet (33-40% carbohydrate; 20% protein; 40% fat) and exercise are recommended for all GDM patients; no further intervention may be needed. However, pharmacological therapy is needed if glycemic targets are unmet after 1-2 weeks’ lifestyle modification.

The pharmacological options are:

  • Insulin (consider starting insulin immediately if hyperglycemia is severe at diagnosis)
    • Insulin analogues lispro, aspart and detemir (FDA pregnancy category B)
    • Insulin analogues glargine, degludec and glulisine (FDA pregnancy category C)
    • Therapy should be individualized:
      • Fasting hyperglycemia; intermediate-acting insulin
      • Post-prandial hyperglycemia; short-acting insulin
      • Educate about hypoglycemia
  • Metformin (FDA pregnancy category B)

Table 2. CSII therapy, indications and contraindications in people with T2DM

Improvements in metabolic control are reported when CGM is used by people with T2DM. CGM provides daily information on blood glucose levels and helps patients to achieve treatment targets without increasing the risk of hypoglycemia.

Cardiometabolic implications of thyroid dysfunction

Thyroid hormones have direct effects on cardiac myocytes, vascular endothelium and vascular smooth muscle cells. Hypothyroidism is therefore associated with cardiovascular alterations that vary according to the degree of thyroid dysfunction and the patient’s age, explained Dr Gabriela Brenta (Buenos Aires, Argentina).

Cardiometabolic alterations that are observed in association with overt or subclinical hypothyroidism (SCH) include impaired cardiac contractility, arterial hypertension and dyslipidemia (Figure 3). Hypothyroidism is also associated with impaired peripheral resistance and arterial stiffness, which are implicated in hypertension development.

Figure 3: Associations between dyslipidemia and hypothyrioidism

Whereas observational studies show an increase in cardiac mortality in patients with SCH, particularly in those <65 years of age and with thyroid stimulating hormone (TSH) levels >7 mIU/l, guidelines differ on the best approach to levothyroxine treatment.

However, levothyroxine has been shown to improve cardiac contractility and lipid profiles in people with overt or SCH, in some observational trials, explained Dr Brenta. Recommendations are shown in Figure 4. She recommended a ‘start slow and go slow’ approach when treating patients at high cardiovascular risk. This typically involves an initial dose of 25 μg levothyroxine, with 25 μg increments every 3-4 weeks until total thyroid replacement is achieved.

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Figure 4. Recommendations for initiating therapy in patients with overt or SCH

Subclinical hypothyroidism: myths, presumptions and facts

Patients with serum TSH levels ≥10 mIU may be at significantly increased risk of developing overt hypothyroidism. SCH conveys a heightened risk of developing dyslipidemia or cardiovascular dysfunction, and experiencing heart failure (HF), cardiovascular events and related mortality. Together, explained Dr Bernadette Biondi (Naples, Italy), these risks might be considered sufficient for recommending levothyroxine therapy in people with SCH, with the belief that treating this condition may prevent cardiovascular disease development or reduce the risk of its progression.

The effects of levothyroxine treatment in patients with SCH vary depending on age (Figure 5). Guidelines do not show consensus in terms of treating mild SCH, or elderly people. Adequately powered studies are needed to establish whether treatment is beneficial in these groups. 

Dr Biondi outlined two large studies in progress. The Thyroid Hormone Replacement for Subclinical Hypothyroidism Trial (TRUST) is a multicenter, double-blind, placebo-controlled randomized trial that is recruiting 3000 older adults. The Institute for Evidence-Based Medicine in Old Age (IEMO) has started the 80-plus thyroid trial collaboration: this multicenter study in very elderly people is evaluating the effect of levothyroxine treatment.

Figure 5: Age-related recommendations for SCH treatment (Cooper and Biondi, 2012)

New perspectives in the diagnostic of thyroid nodules

Dr Gabriela Brenta (Buenos Aires, Argentina) presented case examples to illustrate the optimum approaches to diagnosing thyroid nodular disease.

The first step is to analyze functional thyroid status (to discount hyperthyroidism): TSH and free thyroxine (free T4) levels must be determined, and neck ultrasonography performed to define the location, dimensions and characteristics of each nodule.

Next, fine needle aspiration biopsy (FNAB) is required: its findings indicate whether patients should be monitored or referred for surgery. However, in ~20% of cases the cytology yield is indistinct. In such cases, various resources such as the analysis of suspicious ultrasound characteristics, molecular markers, elastography and core needle biopsy might help to clarify whether surgical referral is necessary.

Autonomic dysfunction in diabetes: the hidden disease complicating blood pressure and heart rate control

It is relatively easy to spot clinical indicators of cardiovascular autonomic neuropathy (CAN) in T2DM patients. By diagnosing CAN more consistently and effectively, Dr Vincenza Spallone (Rome, Italy) explained that we may be able to reduce its dangerous cardiometabolic burden. This, in turn may improve the prognosis for people with concomitant CAN and T2DM.

Diabetic autonomic neuropathy is a disorder of the autonomic nervous system in diabetes or pre-diabetes; CAN is determined easily, using several cardiovascular autonomic reflex tests.

CAN is a common yet largely unrecognized complication, with increasing prevalence in relation to patient age and diabetes duration. T2DM patients with autonomic dysfunction have a worse prognosis than other T2DM patients, particularly for increased CV and mortality risk.

Autonomic dysfunction starts before overt T2DM, affecting several cardiovascular functions and processes. Impaired autonomic reflexes may cause orthostatic hypotension, non-dipping blood pressure (BP) patterns and resting tachycardia. The latter has relevant implications for cardiovascular morbidity and mortality.

If CAN is identified in asymptomatic patients, risk can be stratified, clinical inertia can be addressed and treatments can be tailored. In symptomatic patients, tachycardia, non-dipping and orthostatic hypotension can be treated. Such clinical clues are easily detected and many can be treated using standard methods (Figure 6).

Figure 6: Clinical diagnosis and standard treatment for CAN

The prevention strategy for autonomic dysfunction and CAN in people with T2DM likely involves both cardiometabolic and physical measures. Lifestyle modifications, tighter glycemic control and control of classical CV risk factors are necessary in people with CAN.

New developments from recent trials in hypertension & arterial stiffness

PATHWAY-2 study findings strongly support lowering SBP to <130 mmHg, with spironolactone emerging as the most effective antihypertensive (Table 3). Professor John Kennedy Cruickshank added that plasma renin showed an inverse correlation with the BP lowering effect of spironolactone.

Table 3. PATHWAY-2 showed the antihypertensive effects of spironolactone

PATHWAY-2 compared the BP reductions induced by different regimens (involving spironolactone, doxazosine, bisoprolol and placebo) in patients with well documented hypertension resistant to standard treatment (RAS blocker plus calcium antagonist plus diuretic).

In addition, the results of PATHWAY-3 indicate that amiloride plus hydrochlorothiazide is more effective than monotherapy for preventing glucose intolerance and improving control of blood pressure. In addition to the BP lowering effect, this combination does not affect plasma potassium levels.

Evidence is emerging that pulse way velocity (PWV), which is a marker of arterial stiffness, may be an effective and efficient method of reducing cardiovascular events (Figure 7). Early evidence suggests that it may be possible to change PVW independently of BP, said Professor Cruickshank.

Figure 7. Arterial biomarkers of small and large vascular events

High heart rate and cardiovascular risk in hypertension

A large body of evidence, including the Framingham study, demonstrates that increased heart rate is an independent cardiovascular risk factor in the general population and should be an important therapeutic target.

Dr Guido Grassi (Milan, Italy) described the association between heart rate and cardiovascular events:

  • Is present at all ages (even in subjects aged >70 years)
  • Takes place in patients with or without cardiovascular complications
  • Appears to be independent of other risk factors for atherosclerotic disease
  • Consistent as association between other “classic” risk factors and cardiovascular disease

Follow up studies have reported an association between heart rate, sudden death and acute coronary events that remained significant even after adjustment for age, body mass index, smoking, BP, lipid profile, diabetes and history of cardiovascular disease.

Interestingly, in these studies the predictive power of heart rate for fatal cardiovascular and non-cardiovascular events was often greater than that of hypertension and/or hypercholesterolemia, and manifested in ischemic heart disease, heart failure, hypertension and diabetes.

The possible favourable effects of antihypertensive drug-induced sympathoinhibition include:

  • Reduction in heart rate and myocardial oxygen demand
  • Reduction in BP variability
  • Reduction in insulin resistance
  • Organ protection and organ damage regression
  • Possible increase in trough : peak ratio and smoothness index?

Measures to help reduce a high heart rate can be nonpharmacologic (e.g. weight reduction, increased physical activity, sodium-restricted diet) or pharmacologic. Many drugs are associated with heart rate reductions, and the largest reductions are observed with beta blocker administration.

Is heart rate a target in hypertensive treatment?

Elevated heart rate (>80 bpm) is an independent risk factor for cardiovascular mortality in hypertensive patients. Furthermore, heart rate reduction is associated with a decrease in cardiovascular events. Despite such evidence, hypertension guidelines do not consider heart rate as a target of pharmacological cardiovascular treatment, said Dr Harry Struijker-Boudier, Maastricht (The Netherlands).

Although he noted that it is necessary for guidelines to be evidence based, lack of evidence should not be considered as evidence: it is conceivable that treating hypertension with drugs that also lower the heart rate may show benefits above and beyond the BP decrease. Thus the utilization of selective beta blockers might offer an adjunctive beneficial effect beyond BP reduction.

Tachycardia increases cardiovascular risk through sympathetic overactivity and by causing mechanical vascular and cardiac damage. Tachycardia amplifies the tensile stress in arteries. In the aorta it increases aortic pressure and pulse wave velocity, and causes reflected pulse waves. In arterioles it results in a thicker vessel wall, smaller lumen and blood pressure amplification.

Blood pressure targets after SPRINT study: is it time for changing?

The SPRINT study demonstrated the benefits of reducing systolic BP values to 120 mmHg, compared with the standard target of 130 mmHg. However Dr Stefano Taddei (Pisa, Italy) reminded participants that these findings cannot be applied to the general hypertensive population.

First, the beneficial effect was mainly driven by the reduction of progression to heart failure. No effect was observed on stroke, which is the cardiovascular event usually most sensitive to BP reduction.

Secondly, in SPRINT, BP measurement was performed by an automatic device with no assistance from a doctor or nurse. Thus, these values are not comparable with the clinic BP measurements that have been used in other controlled clinical trials.

Finally diabetic patients were not enrolled in SPRINT.

Consequently, several issues remain unresolved, in relation to the definition of new BP targets after SPRINT:

  • What is more important: the BP target or the amount of BP reduction?
  • Are SPRINT results, at least in part, caused by different treatments in the two arms?
  • How is it possible to compare controlled clinical trials in hypertension characterized by the use of diferent techniques to measure BP values?
  • Can a single study drastically change guidelines – even considering the legal implications?

Until these questions are answered Dr Taddei advised clinicians to aim for BP values of <140/90 mmHg, ideally reaching ~130/80 mmHg. Lower values can be attained if the antihypertensive treatment is well tolerated and the patient remains compliant with the regimen.

Are hypertension and obesity linked?

A direct relationship exists between BMI and BP values (Figure 8). BMI is also associated with BP variability and left ventricular mass, said Dr Guido Grassi (Milan, Italy).

Figure 8. Relationships between body weight and hypertension

Weight loss is associated with BP reduction. Although bariatric surgery appears to offer more beneficial effects compared with diet alone, leading to improvements in left ventricular mass and function, few randomized studies have been able to confirm or refute its value. Available studies have limited follow-up and lack robust reporting of post-surgery events.

Dr Grassi cautioned that the cost effectiveness of bariatric surgery remains poorly determined and the weight-cycling phenomenon must not be overlooked, even following surgery.

Obesity is associated with increased sympathetic nervous system activity, and the simultaneous presence of obesity and sleep apnoea syndrome causes a more pronounced sympathetic activation than BMI alone. Sympathetic activation is implicated in the development of several cardiometabolic disorders (Figure 9).

Figure 9. Sympathetic activation and its association with cardiometabolic dysfunction

 

Combination treatment: RAS blockers are not the only possibility

Combination therapy is the cornerstone of antihypertensive treatment since it is associated with improvements in BP control and a reduction in cardiovascular events, advised Dr Stefano Taddei. Two-drug combinations involving agents with different, but complementary, mechanisms of action may be beneficial. When possible, guidelines recommend the utilization of fixes-dose combinations to improve compliance.

In addition to classical RAS-blocker based combinations, a new fixed-dose combination (bisoprolol plus amlodipine) is available in clinical practice (Figure 11; A and B). This dual regimen may be particularly suitable for treating patients with high heart rate, atrial fibrillation, aortic aneurysm and other conditions requiring beta-blocker based therapy.

Figure 10: Effects of fixed dose bisoprolol and amlodipine on (A) systolic and (B) diastolic BP

The prevention of heart failure development in hypertension

Heart failure remains the leading cause of death and re-hospitalization in cardiovascular medicine. A key objective is, therefore, to avoid reaching the endpoint of HF by dealing with the principal etiologies that produce alterations in ventricular function.

Dr Maria Juliana Rodriguez-Gonzalez (Bogota, Colombia) added that research is urgently needed to identify optimal tools for stratification of hypertensive patients and identification of those at heightened risk of HF, including patients who have low compliance to antihypertensive therapy (Figure 11).

Controlling hypertension avoids HF and preclinical diastolic dysfunction (PDD); it also avoids progression from PDD to HF with preserved ejection fraction, she explained.

Figure 11. Adherence to antihypertensive therapy and HF risk in clinical practice

Although HF has multiple etiologies, myocardial ischemia and hypertension are the most common causes. Several clinical trials have focused on all-cause mortality, cardiovascular mortality and strokes as main outcomes of hypertension.

Strategies to manage hypertension in order to prevent HF are crucial, starting with lifestyle changes. When patients show organ damage (including left ventricular hypertrophy, which may predict the developing of HF) most guidelines recommend the administration of RAS blockers and calcium antagonists.

Once HF has developed, hypertension guidelines recommend treatment with thiazide diuretics, certain beta blockers, ACE inhibitors or ARBs, and mineralocorticoid receptor antagonists. Such treatments should be initiated at doses appropriate for the degree of HF, then increased gradually to achieve target dose or maximum tolerated dose.

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Target audience
This programme is intended for general practitioners, Cardiologists, Endocrinologists, internists and all other healthcare professionals managing cardiometabolic diseases in Latin America
by Excemed
Cardiometabolic, Endocrinology and metabolism