martes, 10 de marzo de 2015

5 cosas que un médico de familia debería saber en 2015

Resultado de imagen para hipertension arterial
Tomado de Lista Medfam

1. No hay beneficio en tratar la hipertensión leve (140-159 mm Hg de sistólica y/o 90-99 mm Hg de diastólica) con fármacos.

2. En general, la restricción de sodio de la dieta reduce la tensión arterial.

3. Para restringir el sodio, más útil que quitar el salero de la mesa es evitar comidas preparadas (conserva, precocinados de supermercado, etc.), muy ricas en sodio.

4. La ingesta de potasio tiende a hacer descender la tensión arterial.

5. En cuanto a los diuréticos, clortalidona e hidroclorotiazida son de similar eficacia, aunque con algo más de efectos secundarios de la primera.

Y, de propina, 6: para la diabetes, lo mejor la dieta mediterránea.


5 Things Every Family Physician Should Know in 2015

Frank J. Domino, MD
March 03, 2015Editor's Note: This article is derived from a lecture presented by Dr Domino at the American Academy of Family Physicians October 2014 conference.

Best Strategies for Treatment of Hypertension

Although much remains unknown about the best therapies for treatment of hypertension, an increasing body of evidence sheds light on some of the important questions.
Should we be treating patients with mild hypertension? A Cochrane review[1] analyzed four randomized controlled trials involving almost 9000 patients with mild hypertension (systolic blood pressure [SBP] 140-159 mm Hg and/or diastolic blood pressure [DBP] 90-99 mm Hg) and without cardiovascular disease (CVD) treated with antihypertensive therapy or placebo for an average of 4-5 years. The reviewers found no difference between treated and untreated individuals in the incidence of coronary heart disease, stroke, total cardiovascular (CV) events, and death. Furthermore, about 9% of patients treated with drugs discontinued treatment owing to adverse effects. The bottom line? Treating mild hypertension provides little prevention of CVD in the short term; use the least bothersome first-line agent as possible.
Is sodium restriction helpful? A meta-analysis[2] of 34 trials examining the effect of salt restriction on blood pressure (BP) found a mean reduction in SBP of 5.39 mm Hg and mean DBP reduction of 2.82 mm Hg. From a population viewpoint, these were deemed to be important reductions in BP and were found in both hypertensive and normotensive individuals, irrespective of sex and ethnic group. The investigators further speculated that the significant association between the reduction in 24-hour urinary sodium and the fall in SBP indicates that larger reductions in salt intake would lead to larger SBP reductions. There were small physiologic increases in renin activity, aldosterone, and noradrenaline. Renin increases the amount of angiotensinogen in the blood, which could increase BP; the release of aldosterone has the potential to increase both sodium retention and potassium secretion, which also could increase BP.
How low should sodium intake go? The 2010 Dietary Guidelines for Americans [3]recommend reducing daily sodium intake to less than 2300 mg for the general population and to 1500 mg among higher-risk groups including African Americans, adults aged 51 years and older, and those with hypertension, diabetes, or chronic kidney disease (CKD). However, a 2013 report[4] from the Institute of Medicine concluded that current evidence did not support this lower recommendation for some populations. So, at least for now, one size appears to fit all. The bottom line? Limiting the use of a salt shaker is unlikely to improve any short- or long-term outcomes. Instead, encourage patients to limit their intake of prepared foods (canned soups, store or restaurant prepared foods) that contain large amounts of hidden sodium.
Could potassium be the answer? A systematic review and meta-analysis[5] of 22 randomized controlled trials and 11 cohort studies examined the effects of potassium intake on BP, renal function, lipids, catecholamine concentrations, all-cause mortality, CVD, stroke, and coronary heart disease. Increased potassium intake reduced BP with no adverse effect on lipids, catecholamine concentrations, or renal function in adults. The highest intake of more than 4700 mg/day was associated with the largest SBP reduction. However, the average American consumes only 2640 mg/day.[6] The highest potassium concentrations are found in figs, molasses, seaweed, dates, prunes, tree nuts, avocados, bran cereal, wheat germ, and lima beans. Just one fourth of a teaspoon of Morton® salt substitute provides more potassium than such frequently cited food sources as bananas, oranges, potatoes, and spinach. The Office of Disease Prevention and Health Promotion in the Department of Health and Human Services provides an online table of foods ranked by mg of potassium per standard serving.
If you are going to treat, should you use chlorthalidone or hydrochlorothiazide? To try to better answer this question, an observational cohort study[7] of almost 30,000 individuals aged 65 years or older who had not had a hospitalization for major CV event in the previous year and were newly treated with chlorthalidone or hydrochlorothiazide was conducted in Canada. The investigators concluded that the risk for death or adverse CV events was similar and use of chlorthalidone in older adults was not associated with fewer adverse CV events or deaths compared with hydrochlorothiazide. The chlorthalidone group was, however, more likely to be hospitalized with hypokalemia (hazard ratio [HR], 3.06) or hyponatremia (HR, 1.68). And thanks to the Joint National Committee 8 (JNC 8), thiazides are not the only choice for first-line treatment.
What does JNC 8 say? In December 2013, the long-awaited adult hypertension management guidelines from JNC 8[8] were released to much fanfare and controversy. Some of the new recommendations include:
  • In patients aged 60 years or older, start treatment for SBP >150 mm Hg or DBP >90 mm Hg and treat to under those thresholds.
  • In patients aged 18-60 years, treatment initiation and goals should be 140/90 mm Hg.
  • The same goals apply to patients with diabetes or CKD.
  • In nonblack patients, initial treatment can be a thiazide-type diuretic, calcium channel blocker (CCB), angiotensin-converting-enzyme (ACE) inhibitor, or angiotensin receptor blocker (ARB).
  • For black patients, initial therapy should be a thiazide-type diuretic or CCB.
  • In patients aged 18 years or older with CKD, initial or add-on therapy should be an ACE inhibitor or ARB, regardless of race or diabetes status.

Making Lifestyle Change Work for Patients With Diabetes

The Action for Health Diabetes (Look AHEAD) study[9] is a national, multicenter, randomized, controlled trial that is examining the long-term effects of an intensive lifestyle intervention program designed to achieve and maintain weight loss by reduced caloric intake and increased physical activity in more than 5000 overweight or obese patients with type 2 diabetes. Patients received weekly treatment with group and individual sessions for the first 6 months, with bimonthly sessions thereafter. The trial was stopped early at 9.6 years after finding that the intervention group had higher weight loss (8.6% vs 0.7% at 1 year; 6.0% vs 3.5% at study end) as well as larger reductions in glycated hemoglobin levels, greater initial improvements in fitness, and improved CV risk factors, except for low-density-lipoprotein cholesterol levels. However, the primary outcome of CV events was not affected. Does this mean that lifestyle intervention is not the answer? No. But it does mean that it may not be the only answer. Equally it is not an easy answer. The intensive intervention provided in this trial is not feasibly reproduced in a busy primary care setting. However, primary care is the best setting to provide smart, evidence-based weight loss suggestions and reinforce them at each visit. Recommendations should include:
  • Increase intake of vegetables and fruit but not fruit juice. A cohort study[10]conducted in Spain found a significant reduction in diabetes with every three servings per week, with the highest degree of fruit and vegetable intake associated with the lowest risk for weight gain (odds ratio [OR], 0.22).
  • Increase vegetable but not animal protein. A study[11] of 1730 employed white men aged 40-55 years found a statistically significant, positive association between animal protein intake and obesity; those in higher quartiles of vegetable protein intake had lower odds of being obese. The researchers calculated a relative risk (RR) for obesity of 4.62 in those at the highest quartile of animal protein intake; the comparable RR for those at the highest quartile of vegetable protein intake was 0.58.
  • Mediterranean diet beats low-fat diet. A randomized controlled trial[12] of 7000 patients at high CV risk but without CVD assigned participants to one of three diets: a Mediterranean diet supplemented with extra-virgin olive oil, a Mediterranean diet supplemented with mixed nuts, or a control diet (advice to reduce dietary fat). Patients were followed for a mean of 4.8 years. The Mediterranean diet, supplemented with either olive oil (approximately 4 tablespoons/day) or nuts (average of 3 servings/day), reduced the risk for major CV events. The unadjusted hazard ratios for both diets was 0.70 (95% CI, 0.53-0.91 for olive oil or 0.94 for nuts). Moreover, participants in the two Mediterranean-diet groups significantly increased weekly servings of fish (by 0.3 servings) and legumes (by 0.4 servings) in comparison with those in the control group.

What Else Should Family Physicians Know?

Happy Spitters Do Not Have a Disease

New guidelines[13] from the American Academy of Pediatrics released in 2013 emphasized what we all know—that gastroesophageal reflux (GER) is normal and does not require treatment beyond perhaps such lifestyle changes as feeding and positioning. GER with complications GER disease (GERD)—should likewise be treated with lifestyle changes. Medications should be reserved for children who do not respond to more conservative therapy. The guideline authors concluded: "Best practice involves both identifying children at risk for complications of GERD and reassuring parents of patients with physiologic GER who are not at risk for complications to avoid unnecessary diagnostic procedures or pharmacologic therapy."

SSRIs and Pregnancy

A cohort study[14] published in JAMA involving more than 30,000 women in Scandinavia with 1.6 million births (6054 stillbirths, 3609 neonatal deaths, and 1578 postneonatal deaths) concluded that selective serotonin reuptake inhibitor (SSRI) use was not associated with any of the following negative outcomes:
 Stillbirth: OR, 1.17 (confidence interval [CI], 0.96-1.41; = .12)
 Postneonatal death: OR, 1.34 (95% CI, 0.97-1.86; P = .08)
 Neonatal death: OR, 1.23 (95% CI, 0.96-1.57; P = .11)
Yes, women exposed to an SSRI presented with higher rates of stillbirth (4.62 vs 3.69 per 1000, P = .01) and postneonatal death (1.38 vs 0.96 per 1000, P = .03) than those who were not. However, these associations disappeared in multivariable models. Before you reach for your prescription pad, however, the results of another large, case control study[15] conducted in Sweden with approximately 1700 children with autism should be considered. After adjustment for potential confounders, in utero exposure to both SSRIs and nonselective monoamine reuptake inhibitors (tricyclic antidepressants) was associated with an increased risk for autism spectrum disorders (ASDs), particularly without intellectual disability. The study authors emphasized that it cannot be determined whether this association is causal or reflects the elevated risk for ASD in women with severe depression. Even if the association is causal, the use of these agents explained less than 1% of the cases of ASD in this cohort, and their use is unlikely to be a significant contributor to the rise in ASD. The researchers concluded that decisions about use of SSRIs during pregnancy must take into account other perinatal outcomes and the risks associated with maternal mental illness.

The Rise in Autism

An analysis of data[16] from the Nurses' Health Study II looked at 325 children with ASD matched with 22,000 control children. After adjustment for socioeconomic status and other potential confounders, the investigators concluded that the highest exposures to diesel, lead, manganese, mercury, methylene chloride, and overall metals were associated with increased risk for ASDs (OR, 1.5-2.0). The linear trend found in this study adds to existing evidence that maternal exposure to air pollution in the perinatal period may increase risk for ASD in children.

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