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#21 De: Jorge Did Nunez <jdid@infomed.sld.cu>
Enviado: Miércoles, 01 de Diciembre de 1999 11:38 a.m.
Asunto: Estratificacion de Riesgo / Risk stratification
Nota del moderador del Foro: debido a lo extenso del comentario del Dr. Did, el mismo sera fraccionado en varios mensajes.
Las figuras y tablas a las que alude, se refieren a las del trabajo original publicado en las paginas web del Congreso.
------------------------------------------------------------------------------
Parte final
Sobre su "idoneidad", mucho se ha discutido y todavia se habra de discutir.
Indudablemente, nos falta mucho por recorrer en la senda del camino que nos conduzca a una medicina basada en la evidencia. Es tarea de todos. Sin embargo, las recomendaciones de JNC VI pretenden aportar un enfoque practico y util para el medico de asistencia que se enfrenta cotidianamente al problema de salud que representa la Hipertension Arterial. Y para ello, parte de evidencias cientificas al tratar de agrupar a los pacientes en los Grupos de Riesgo definidos. Veamos solamente algunos ejemplos.
Cuando la retinopatia se incluye como lesion de organo diana, no se refiere a cualquiera de sus variantes de grado, sino a la presencia de exudados y hemorragias, con o sin papiledema. De mas esta referirse a la importancia que la visualizacion de los vasos retinianos tiene para juzgar sobre el estado morfologico y funcional de otros territorios vasculares altamente sensibles, que no son asequibles al examen clinico.
En los pacientes  con insuficiencia cardiaca congestiva se observa una proporcion del 10% de muerte o mas anualmente [1]. Los pacientes con historia de stroke o isquemia transitoria, presentan entre un 3 - 5% de riesgo de stroke anual [2] o mas, y el riesgo de otro evento cardiovascular mayor es, al menos, de un 5 % adicional. En aquellos con historia de infarto de miocardio o angina inestable, la incidencia de recurrencia anual de infarto o muerte por enfermedad cardio-coronaria, es del 4% o mayor [3], y el riesgo adicional de otro evento cardiovascular mayor es del 1 al 2%.
Las manifestaciones subclinicas de enfermedad cardiovascular en casos asintomaticos, tambien pueden constituir importantes predictores de riesgo futuro. Por ejemplo, un mayor promedio de eventos mayores cardiovasculares (con incremento porcentual anual) ocurre entre pacientes con disfuncion ventricular izquierda significativa [4], evidencia electrocardiografica de onda Q [5], o evidencia electrocardiografica de hipertrofia de ventriculo izquierdo [6]. La observacion ultrasonografica de hipertrofia de ventriculo izquierdo [7] o ateroesclerosis carotidea [8,9], se encuentra tambien asociada a un riesgo incrementado de enfermedad cardiovascular aguda.
En lo personal, a los efectos practicos y para el pronostico, preferiria disponer de una herramienta de clasificacion de riesgo que permitiera la
evaluacion cuantitativa de la situacion concreta de riesgo del paciente. En este sentido, resulta muy interesante la estrategia de cuantificacion de riesgo que recientemente emitieran, de forma conjunta, la WHO y la Sociedad Internacional de Hipertension, en la edicion correspodiente al 1999 de las guias de trabajo para el manejo de la hipertension arterial [10], sobre las cuales ya estamos trabajando.
Y mas aun, quizas lo mas deseable - sin abandonar la valoracion y control sistematico de los factores de riesgo que presentan los pacientes -, seria el desarrollo de estrategias que nos permitieran identificar  y evaluar individualmente, desde el nivel primario de salud, a los pacientes sin
enfermedad cardiovascular establecida, que fueran candidatos para una intervencion medica intensiva, ademas de poder generalizar el uso de los llamados ¨marcadores de riesgo cardiovascular¨, test de ateroesclerosis de indole no invasiva, medidores de calcificacion coronaria, etc. Esta
problematica ha sido objeto de analisis  y debate  en la 72 sesion de la Asociacion Americana del Corazon, durante los dias 3-9 de noviembre de
1999, conducida por el Dr Philip Greenland, y que estara disponible a partir de enero del 2000 en la revista Circulation y en el sitio Web de la AHA.
Un afectuoso saludo a todos
Dr. Jorge P. Did Nunez.
La Habana. Cuba.
jdid@infomed.sld.cu
Referencias:
1. The SOLVD Investigators. Effect of enalapril on survival in patients with reduced left ventricular ejection and cogestive failure. N Engl J Med 1991; 325:293-302.
2. UK-TIA Study Group. The United Kindom trasient ischemic attack (UK-TIA) aspririn trials : final results. J Neurol Neurosurg Psychiatry 1991; 54:1044-1054.
3. The LIPID Study Group. Prevention if Cardiovascular events and death with pravastatin in patients with coronary heart disease and a
broad range of initial colesterol levels. N Engl J Med 1998; 339:1349-1357.
4. The SOLVD Investigators. Effect of enalapril on mortality and the developedment of heart failure in asymptomatic patiens with reduced left ventricular ejection fractions. N Enl J Med 1992; 327:685-691.
5. Wong ND, Levy D, Kannel WB. Pronostic significace of the electrocardiogram after Q wave myocardial infaction: The Framinghan Study. Circulation 1990; 81:780-789.
6. MacMahon S, Collins G, Rautaharju P, Cutler J, Neaton J, Prineas R, et al. for the Multiple Risk Factor Intervention Trial Reseach Group. Electrocardiographic left ventricular hypertropy and effects of antihypertensive drug therapy in hypertensive participants in the Multiple Risk Factor Intervention Trial. Am J Cardiol 1989; 63:202-210.
7. Levy D, Garrison R, Savage D, Kannel W, Castelli W. Prognostic imiplicationof echocardiograhpically determined left ventricular mass in the Framinghan Heart Study. N Engl J Med 1990; 322:1561-1566.
8. Saloenen JT, Salonen R. Ultrasonographically assessed carotid morphology and the risk of coronary heart disease. Arterioscler
Thromb 1991; 11:1245-1249.
9. Zanchetti A,  Agabiti-Rosei E, Dal Palu C, Leone G, Magnani B, Pessina A, for the VHAS Investigators. The Verapamil in Hypertension and Atherosclerosis Study (VHAS): results of long- term randomized randomised treatment with either verapamil or chlorthalidone on carotid intima-media thicknex. J Hypertens 1998; 16:1667-1676.
10. 1999 World HealthOrganization-International Society of Hipertension Guidelines for the Management of Hypertension. Guidelines Subcommittee. J  Hypertens 1999; 17:905-918.

Note from the Moderator of the Forum: due to the length of the commentary by Dr. Did, it will be divided in several messages.
The figures and tables he mentions, are included in his original work published in the Web pages of the Congress.
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Final part
About its "suitability", a lot has been argued, and will still be argued. Undoubtedly, we have a long way to go in the road that will lead us to an evidence based medicine. This is a task for everyone. However, the recommendations by JNC VI attempt to provide a practical and useful approach for the care physician, that faces daily the health problem that Blood Pressure represents. And for this, part of the scientific evidence when trying to gather the patients in the defined Risk Groups. Let us see only some examples.
When retinopathy is included as lesion of the target organ, this does not refer to any of its degree variants, but to the presence of exudates and  hemorrhages, with or without papilledema. Needless to mention the importance that visualization of retinal vessels have to assess the morphological and functional state of other vascular regions highly sensitive, that cannot be reached by the clinical examination.
In the patients with congestive heart failure, a proportion of a 10% of death or more, annually, is observed [1]. The patients with history of stroke or transitory ischemia, present between a 3-5% of risk of stroke annually [2] or more, and the risk of another major cardiovascular event is, at least, an additional 5%. In those with history of myocardial infarction or unstable angina, the incidence of yearly recurrence of infarction or death by cardio-coronary disease, is a 4% or more [3], and the additional risk of another major cardiovascular event is a 1 to 2%.
Subclinical manifestations of cardiovascular disease in asymptomatic cases, can also be important predictors of future risk. For instance, a greater ratio of major cardiovascular events (with yearly percentage increase) happens in patients with significant left ventricular dysfunction [4], electrocardiographic evidence of Q wave [5], or electrocardiographic evidence of hypertrophy of left ventricle [6]. Ultrasonographic observation of left ventricle hypertrophy [7] or carotid atherosclerosis [8,9], is also associated to an increased risk of severe cardiovascular disease.
Personally, for practicality and for prognosis, I would rather have a tool of classification of risk available, that would allow quantitative evaluation of the concrete risk situation of the patient. In this sense, the strategy of quantification of risk, recently issued by both the WHO and the International Society of Hypertension, in the issue corresponding to 1999 of the guidelines of work for the management of blood pressure [10], is very interesting, and we are already working on it.
Moreover, maybe what is most desirable -without giving up assessment and systematic control of risk factors that the patients present-, would be to develop strategies that would let us identify and assess individually, from the primary level of health, the patients without established cardiovascular disease, that would be candidates for an intensive medical intervention, besides of letting us generalize the use of the so called "markers of cardiovascular risk", test of atherosclerosis of a non invasive kind, coronary calcification measurement, etc. These situation has been analyzed and debated in the 72nd session of the American Heart Association, during days November 3-9, 1999, lead by Dr. Philip Greenland, and that will be available since January, 2000, in the Circulation Journal, and in the Web site of the AHA.
Warm regards,
Dr. Jorge P. Did Nunez.
La Habana. Cuba.
jdid@infomed.sld.cu
References:
1. The SOLVD Investigators. Effect of enalapril on survival in patients with reduced left ventricular ejection and cogestive failure. N Engl J Med 1991; 325:293-302.
2. UK-TIA Study Group. The United Kindom trasient ischemic attack (UK-TIA) aspririn trials : final results. J Neurol Neurosurg Psychiatry 1991; 54:1044-1054.
3. The LIPID Study Group. Prevention if Cardiovascular events and death with pravastatin in patients with coronary heart disease and a
broad range of initial colesterol levels. N Engl J Med 1998; 339:1349-1357.
4. The SOLVD Investigators. Effect of enalapril on mortalit and the developedment of heart failure in asymptomatic patiens with reduced left ventricular ejection fractions. N Enl J Med 1992; 327:685-691.
5. Wong ND, Levy D, Kannel WB. Pronostic significace of the electrocardiogram after Q wave myocardial infaction: The Framinghan Study. Circulation 1990; 81:780-789.
6. MacMahon S, Collins G, Rautaharju P, Cutler J, Neaton J, Prineas R, et al. for the Multiple Risk Factor Intervention Trial Reseach Group. Electrocardiographic left ventricular hypertropy and effects of antihypertensive drug therapy in hypertensive participants in the Multiple Risk Factor Intervention Trial. Am J Cardiol 1989; 63:202-210.
7. Levy D, Garrison R, Savage D, Kannel W, Castelli W. Prognostic imiplicationof echocardiograhpically determined left ventricular mass in the Framinghan Heart Study. N Engl J Med 1990; 322:1561-1566.
8. Saloenen JT, Salonen R. Ultrasonographically assessed carotid morphology and the risk of coronary heart disease. Arterioscler Thromb 1991; 11:1245-1249.
9. Zanchetti A,  Agabiti-Rosei E, Dal Palu C, Leone G, Magnani B, Pessina A, for the VHAS Investigators. The Verapamil in Hypertension and Atherosclerosis Study (VHAS): results of long- term randomized randomised treatment with either verapamil or chlorthalidone on carotid intima-media thicknex. J Hypertens 1998; 16:1667-1676.
10. 1999 World HealthOrganization-International Society of Hipertension Guidelines for the Management of Hypertension. Guidelines Subcommittee. J  Hypertens 1999; 17:905-918.

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#22 De: Gustavo Aronson <aronson@arnet.com.ar>
Enviado: Jueves, 02 de Diciembre de 1999 04:56 p.m.
Asunto: hta diureticos para la mayoria?/BP: diuretics for the majority?
Estimado Dr.Moderador de la Lista:
EL Dr. Alcala de San Juan, Argentina nos plantea un dilema socioeconomico en el tratamiento de la HTA: los diureticos son las drogas mas economicas para el tratamiento de esta enfermedad, pero mi impresion es que no pueden ser usados en todos; si son especialmente elegibles en pacientes hipertensos con insuficiencia cardiaca o algun grado de insuficiencia renal con edemas, las minidosis que postula el Dr Alcala probablemente Hidroclorotiazida 6,25 o 12,50mg o Clortalidona 25mg podrian ser dosis que no produzcan los efectos indeseables en el metabolismo de lipidos y alteraciones hidroelectroliticas asociadas en megatrials con aumento de la mortalidad total cardiovascular e inesperada cuando los diureticos fueron usados en dosis el doble o triple de altas. Por otra parte yo me pregunto si dosis bajas de diureticos son efectivas para bajar la presion arterial? Tal vez si consideramos que la presencia de la Hta leve representa el 70% de nuestros pacientes, si asociamos
como primer escalon del tratamiento al control estricto de la dieta hiposodica, ejercicios moderados, disminucion de peso y supresion de alcohol y cigarrillo podamos con dosis bajas de diureticos asociados o no a ahorradores de potasio, controlar la presion de esos pacientes. Por otro lado los diureticos a bajas dosis pienso tienen una especial utilidad para una especie de tratamiento de "pulsos", esto es cortos periodos de utilizacion en terapia combinada con otros antihipertensivos para tratamiento de esos "hipertensos Leves" que no siempre evolucionan como tales. Volvere a comunicarme con respecto a los pacientes gerontes y a lo que me parece importante en los protocolos clinicos de investigacion en Hta.
Cordialmente a todos.

Dear Dr. Moderator of the List:
Dr. Alcala from San Juan, Argentina, proposed to us a socioeconomic dilemma in treatment of BP: diuretics are the cheapest drugs for treatment of this disease, but my impression is that they cannot be used in everyone; the minidoses that Dr. Alcala poses are especially eligible in hypertensive patients with heart failure, or some degree of renal insufficiency with edemas, probably Hydrochlorothiazide 6.25 or 12.50mg, or Chlorthalidone 25mg, could be doses that do not produce the unwanted effects in metabolism of lipids and hydroelectric alterations associated  in megatrials with increase of total and unexpected cardiovascular mortality when diuretics were used in doses twice or thrice higher. On the other hand, I wonder if low doses of diuretics are effective to lower blood pressure? Maybe, if we consider that the presence of mild BP represent a 70% of our patients, if we associate as a first step of the treatment the strict control of hyposodic diet, moderated exercises, decrease of weight, and suppression of alcohol and cigarette, we could, with low doses of diuretics associated or not, to potassium savers, control the pressure of those patients. On the other hand, I think that the diuretics in low doses have a special usefulness for a kind of treatment of "pulses", this is in short periods of use in therapy combined with other antihypertensive agents for treatment of this "mild hypertensive patients" that do not always evolve as such. I will get in touch again about the elderly patients, and what I think is important in clinical protocols of research in BP.
Cordially,
Gustavo R. Aronson.
Rosario. Santa Fe. Argentina.

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#23 Degalcala.vwaisman@interredes.com.ar (Gustavo Alcala)
Enviado: Lunes, 6 de Diciembre de 1999 01:03
Asunto: hta diureticos para la mayoria?/BP: diuretics for the majority?
Los diureticos siguen siendo recomendados como drogas de primera linea principalmente por su eficacia, son tan buenos reduciendo la presion arterial como cualquier otra medicacion y numerosos ensayos clinicos aleatorizados, controlados con placebo con seguimiento a largo plazo mostraron que reducen la insuficiencia cardiaca, los accidentes cerebrovasculares fatales y no fatales, la hipertrofia ventricular izquierda y los eventos coronarios.
El segundo punto importante es la seguridad, a diferencia de los bloqueantes calcicos que luego de los estudios FACET y ABCD deberian ser puestos "en cuarentena" hasta que se aclare su efecto sobre los eventos cardiovasculares por lo menos en diabeticos.(Influences of educational interventions and adverse news about calcium- channel blockers on first-line prescribing of antihypertensive drugs to elderly people in British Columbia, Maclure M; Dormuth C; Naumann T; McCormack J; Rangno R; Whiteside C; Wright JM  Lancet 1998 Sep 19;352
(9132):943-8).
Se acuerdan ademas del mibefradil?
A menos que las nuevas drogas muestren ser considerablemente mejores es muy dificil justificar el incremento en el costo, pero los temas a tener en cuenta son la eficacia, seguridad, tolerabilidad y tambien el costo. No son "solo baratos". Seria importante desde el punto de vista epidemiologico averiguar que lugar ocupan dentro de las prescripciones como monodrogas en nuestros paises y comparar con estudios similares en Canada o paises europeos.

Diuretics go on being recommended as first line drugs, mostly due to their efficacy, they are so good lowering blood pressure as any other medication, and abundant randomized clinical trials, placebo controlled with follow up in long term, displayed that they reduce heart failure, fatal and non fatal strokes, left ventricular hypertrophy, and coronary events.
The second important item is safety, unlike calcium blockers that after the FACET, and ABCD studies, should be put in "quarantine" until its effect on the cardiovascular events at least in diabetics. (Influences of educational interventions and adverse news about calcium- channel blockers on first-line prescribing of antihypertensive drugs to elderly people in British Columbia, Maclure M; Dormuth C; Naumann T; McCormack J; Rangno R; Whiteside C; Wright JM Lancet 1998 Sep 19;352 (9132):943-8).
Moreover, do you remember mibefradil?
Unless new drugs prove to be quite better, is very hard to justify the increase in costs, but the topics to be considered are efficacy, safety, tolerance, and also cost. They are not "only cheap". It would be very important from the epidemiological point of view to find out the place they hold within prescriptions as monodrugs in our countries, and to compare them with similar studies in Canada or European countries.
Gustavo Alcala

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#24 De: Licy Yanes <licyyan@telemail.com.py>
Enviado: Domingo, 12 de Diciembre de 1999 17:06
Asunto: felicitaciones y VI JNC/Congratulations and VI JNC
Vuestro trabajo ha sido muy productivo para mi, soy residente de clinica medica, me gustaria si me podrian enviar el VI JNH. Gracias

Your job has been very productive for me, I am resident of clinical medicine, I would like to know if you could send me the VI JNH. Thanks.

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#25 De: Sergio Kuznicki <sergio.kuznicki@mail.roche.com.ar>
Enviado: Lunes, 17 de Enero de 2000 10:11
Asunto: Alfa metil dopa/Alpha methyldopa
Estimado colega:
En respuesta a la pregunta del Dr. Daniel Monteverde acerca de la alfametildopa: es una droga antihipertensiva que actúa a través de su metabolito, la alfa-metil-norepinefrina, que a su vez es un agonista de los receptores alfa-2 adrenérgicos centrales, con la consecuente inhibición de la descarga simpática. Esta acción en el sistema nervioso central tal vez sea la causa de su efecto adverso más conocido: la somnolencia.
La alfametildopa es una droga que actualmente se usa con amplitud en nuestro país para el tratamiento de la hipertensión en el embarazo, ya que no produce efectos deletéreos en el feto ni el recién nacido, por lo que puede suministrarse con tranquilidad durante todo el embarazo, incluso en la lactancia.
Lo saludo cordialmente

Dear colleague:
In response to the question by Dr. Daniel Monteverde about alphamethyldopa: it is an anti-hypertensive drug that acts through its metabolite, the alpha-methyl-norepinephrine, that in turn is an antagonist to central adrenergic alpha-2receptors, with the consequent inhibition of sympathetic discharge. This action in the central nervous system may be the cause of its best known adverse effect: somnolence.
Alphamethyldopa is a drug that currently is used widely in our country for the treatment of hypertension in pregnancy, since it does not produce deleterious effects in the fetus or the newly born baby, consequently it can be administered safely during all pregnancy, even during lactation.
Cordially,
Dr. Sergio Kuznicki - Argentina

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#26 De: Hernan Gomez Llambi <hgllambi@roche.com.ar>
Enviado: Jueves, 27 de Enero de 2000 13:04
Asunto: Ateneo para  discutir/Athenaeum for discussion
Envio un caso clinico en capitulos para que entre todos podamos discutirlo, y opinen.
Paciente femenina de 46 anios que consulta por primera vez a los 30 anios en el tercer trimestre de su embarazo por cifras de tension arterial (TA) elevadas.
Es tratada con alfa metil dopa, el parto es con cesarea y no presenta complicaciones fetales ni personales. A su alta post parto queda con cifras de TA limites: 140/90, recibiendo alfa metil dopa durante 2 anios.
A posteriori en los controles en 1990 - 1991, sin medicacion, esta siempre normotensa. Mas tarde, sintomatica, no se controla hasta el 27 de diciembre de 1999.
Tres dias previos a la consulta refiere malestar general constatandose 160/105. Se automedica con 20 mg de furosemida. El dia de la consulta persisten los síntomas referidos y se constata 250/150, 80 latidos p. min. Su Ecg revela hipertrofia ventricular izquierda con trastornos secundarios de la repolarizacion; su fondo de ojo es grado 2, no presenta soplos abdominales y el resto del examen físico es normal.
Aquí comienza la discusion.
Es de remarcar que la paciente por dificultades personales no se puede internar. Tomando en cuenta esta situacion:
1) conducta en esta emergencia hipertensiva.
2) diagnostico presuntivo.
3)que medicacion le darian y que estudios iniciales le pedirian.
Con esto me parece que podriamos iniciar una ronda de discusion en capitulos, de forma tal que voy relatando lo que hicimos nosotros
y los resultados que fuimos obteniendo y asi una nueva ronda de discusion hasta el final. En sintesis es un ateneo en capítulos continuados; les parece buena la idea?

I send a clinical case in chapters, so that we can discuss it between all of us, and for you to express your opinion.
Female patient, 46 years old, that consults for the first time when she was 30, in the third trimester of her pregnancy due to high values of blood pressure (BP).
She is treated with alpha methyldopa, the delivery was carried out through cesarean, and she did not present personal of fetal complications. At the time of discharge after delivery, she remains with boundary values of BP: 140/90, receiving alpha methyldopa for 2 years.
Later, in the controls in 1990-1991, without medication, her pressure was always normal. Afterwards, she becomes symptomatic, and does not control herself until December 27th, 1999.
Three days prior to consultation, she tells about general malaise, displaying 160/105. She self-medicates with 20mg of furosemide.
On the day of consultation, the mentioned symptoms persist, and we verify 250/150, 80bpm. Her ECG reveals left ventricular hypertrophy with secondary disorders of repolarization; eye fundus is degree 2, she does not present abdominal murmurs, and the rest of the physical examination is normal.
Here the discussion begins.
We have to point out that the patient, could not be admitted due to personal problems. Taking into account this situation:
1) management in this hypertensive emergency
2) presumable diagnosis
3) what medication would you administer, and what initial studies would you request
I think that with this we can begin a discussion in chapters, in such a way that I will tell what we did, and the results that we obtained, and so on until the final discussion. Summarizing, this is an athenaeum in successive chapters; do you think this is a good idea?
Dr. Hernan Gomez Llambi

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#27 De: Moderador del Foro <edgardo@schapachnik.com.ar>
Enviado: Viernes, 28 de Enero de 2000 15:10
Asunto: Nifedipina: si o no?/Nifedipine: yes or not?
Mario Valdes, <mavs21@yahoo.com>, estudiante de quinto anio de Medicina de la Universidad de la Republica del Salvador pregunta a nuestro Foro acerca del uso de la nifedipina en una paciente de 82 anios que consulta por un episodio de epistaxis y en la cual se detectan cifras tensionales de 220/90
En su mail, Mario menciona varias drogas: verapamil, captopril, sobre las que recibio diferentes opiniones de sus tutores en la Universidad.
Asimismo seria interesante que los colegas opinen acerca de la "epistaxis", popularmente incluida entre las manifestaciones mas comunes de consulta por hipertension arterial
Cordialmente

Mario Valdes, <mavs21@yahoo.com>, student in the fifth year of Medicine School at the "Universidad de la Republica del Salvador", asks to our Forum about use of nifedipine in an 82-year-old patient that consulted due to an episode of epistaxis, and in whom pressure values of 220/90 were detected.
In his e-mail message, Mario mentions several drugs: verapamil, captopril, about which he received different opinions from his tutors at University.
Likewise, it would be interesting that the colleagues would express their opinion about the "epistaxis", popularly included among the most common manifestations in consult due to blood pressure.
Cordially,
Edgardo Schapachnik

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#28 De: Carlos E. Fullone cef@intramed.net.ar
Enviado: Domingo, 30 de Enero de 2000 11:20
Asunto: Ateneo para discutir/Athenaeum for discussion
Estimado colega: Ante todo, felicitaciones por la idea de la discusion de casos, con la cual todos aprenderemos.
Comenzando la misma, lo primero que me llama la atencion, es que haya quedado medicada con alfa metil dopa, durante dos anios, por una simple presion limitrofe. Creo que evidentemente, dicha presion era mas que limitrofe, y por ende, la HTA del embarazo no fue una eclampsia comun sino que se trataria de una hipertensa previa. Aqui la primera pregunta: ¿Controlo su embarazo desde su comienzo, como para poder afirmar la normotension o hipertension de los dos primeros trimestres?.
¿Que dosis de alfa metil dopa recibia durante aquellos dos anios?
La tercera cuestion, entre sus 30 anios y los actuales 46, se mencionan controles en los anios 90 y 91 (36 - 37 años edad de la paciente), ¿de que tipo de controles se trato?, y ¿Quien controlo la HTA?. Esto lo pregunto porque es sabido la mala calidad de los controles de rutina de TA, y lamentablemente la mala calidad de algunas atenciones de guardia o de medicos de obras sociales. Y de por si, se refieren problemas personales para internarse actualmente, por lo cual presupongo en 1990 y 1991, atenciones de poca confianza.
Con todas estas premisas de sospecha, haria el diagnostico de hipertension arterial secundaria, de larga data, con alteracion en el fondo de ojo, e hipertrofia cardiaca severa.
Creo que merece estudios etiologicos de su hipertension, por lo cual, si bien no puedo dejarla sin medicacion por las antedichas cifras demasiado elevadas, la medicaria con bloqueantes calcicos (amlodipina, e inmediatamente despues de obtener muestras sanguineas para determinacion de ionograma serico y urinario, agregaria al tratamiento un diuretico, via IV.
Indicaria reposo en su casa, dieta hiposodica estricta, proscripcion del consumo de alcohol o de cualquier droga, asi como de cualquier preparado magistral que tomase la paciente en forma habitual amlodipina 10 mg y lasix (furosemida) via oral como tratamiento de alta y nuevo control en 48 horas.
Como estudios complementarios, solicitaria Rutina, keratina, ionograma serico y en muestra de orina, Rx torax, y ecografia renal bilateral.
Si el ionograma basal es totalmente normal, ya pediria ac. vainillilmandelico y metanefrina urinaria para descartar feocromocitoma.
Saludos para todos.

Dear colleague:
First of all, congratulations for the idea of discussing cases, with which we are all going to learn.
To begin with, the first thing that attracts my attention, is that she remained under medication with alpha methyldopa during two years, for just a boundary pressure. I think that obviously, such pressure was more than boundary, and that therefore, the BP of pregnancy was not common eclampsia, instead it would be a previous hypertension. Here is the first question: Did you control her pregnancy from its very beginning, so as to be able to state normal pressure or hypertension in the two first trimesters?
What dose of alpha methyldopa did she receive along those two years?
The third question: between her 30 years and her current 46, you mention controls in years 90 and 91 (36 - 37 years of age for the patient): what kind of controls were these? And who controlled the BP? I ask this because it is known that routine controls for BP are of low quality, as well as regrettably, the poor quality of the treatment provided by some care units and physicians from medical care funds. And she mentioned personal problems to be admitted currently, then I suppose that in 1990 and 1991, the care was little reliable.
With all these premises of suspicion, I would diagnose secondary blood hypertension, evolving for a long time, with alteration in the eye fundus, and severe heart hypertrophy.
I think she should be done etiologic studies of her hypertension, therefore, although I cannot leave her without medication due to the mentioned values that are too high, I would medicate her with calcium blockers (amlopidine and immediately after obtaining blood samples to determine the serum and urine ionogram, I would add to the treatment a diuretic, intravenous via.
I would indicate her rest at her home, strict hyposodic diet, proscription of consumption of alcohol or any other drug, just as any other magistral preparation that the patient may take usually, amlopidine 10mg, and lasix (furosemide) orally as treatment after discharge, and new control after 48hs. As supplementary studies I would request routine, keratin, serum ionogram and in urine sample, thorax Rx, and bilateral renal ultrasound scan.
If the basal ionogram is completely normal, I would ask vainillilmandelic acid and urine metanephrine to dismiss pheochromocytoma.
Greetings for everyone,
Dr. Carlos E. Fullone cef@intramed.net.ar

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#29 De: hernan gomez llambi <hgllambi@roche.com.ar>
Enviado: Lunes, 31 de Enero de 2000 11:31
Asunto: Ateneo. Respuesta al Dr Fullone/Athenaeum. Reply to Dr. Fullone
Contesto a la atenta carta del Dr. Fullone
1) la paciente no tenia antecedentes de hipertension en los otros embarazos ni tampoco entre los embarazos.
2) la dosis de alfa metil dopa en el embarazo fue 1000 mg.
3) la dosis (a posteriori de su parto) de alfa metil dopa no se la puedo precisar con certeza pues el cardiologo que la atendia fallecio hace 5 anios. Quisiera aclararle que el cardiologo de cabecera durante el embarazo y en esos primeros dos anios era un brillante investigador y clinico cardiólogo argentino, el prof. Carlos Maria Taquini.
Con respecto a los controles de 1990 y 1991 fui yo personalmente quien tomo su seguimiento, y los valores de TA así como su ECG eran totalmente normales.
Tambien querria aclararle que la suspension de la alfa metil dopa fue autoprescripta por la paciente.
Atte

I reply the kind letter by Dr. Fullone
1) the patient had no history of hypertension in other pregnancies, or between pregnancies either.
2) the dose of alpha methyldopa during pregnancy was 1000mg.
3) I cannot tell you accurately the dose (after delivery) of alpha methyldopa, since the cardiologist that treated her died 5 years ago. I would like to clarify, that the family cardiologist during her pregnancy and these first two years was a brilliant Argentine researcher, and clinical cardiologist, Prof. Carlos Maria Taquini.
About the controls in 1990, and 1991, it was I myself who followed her up, and the values of BP, just as her ECG were completely normal.
I would also like to clarify that suspending alpha methyldopa was a self-prescription by the patient.
Sincerely,
Hernan Gomez LLambi

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Feb/02/2000