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~~~~~~~~~~~~~~~~  M"  ;  P+sZCU 4  3@))=c6N3!Rl +; M.+ - =3a a      a  $" &r<dH  $'  2 8- v<B4 g ^  ?++D  -9! +"4   0VE #   $b$s#ڿE`"  $2$dSAwC b$*@tqeT ( b$ t40c"$/|i)_+b$b0#F"$;W[-LJ"$Qq_}yNqUf"$ҷbPs_PM$"$Ҳ_6d@tKh" t0e0e    A A5% 8c8c     ?A)BCD|E||S" 3@l䇣 ʚ;l8ʚ;g4FdFdv 0Pp@pP <4!d!d` 0L<4dddd` 0L <4dddd 0L&g4=d=dv 0.p poz0___PPT10 pp:___PPT9%hlp#$$$&-3.333z(? %O =6"s;Cul debe ser la cifra de PA meta en la diabetes mellitus?"<" fff<$(1   ( t Antecedentes   Las principales guas de prctica clnica recomiendan mantener las cifras de PA <130/80 mmHg en los diabticos. Hay pocos ensayos clnicos en los que se haya estudiado cules son las mejores cifras objetivo de la PA en estos pacientes.0PWu Objetivos   Estudiar el efecto de intentar llegar a unas cifras de PAS <120 mmHg sobre las enfermedades cardiovasculares en pacientes con diabetes mellitus tipo 2 de alto riesgo. ,?B v Diseo (1)  Ensayo clnico. Estudio ACCORD (Action to Control Cardiovascular Risk in Diabetes): 10.251 pacientes afectos de diabetes mellitus tipo 2 de alto riesgo de 77 centros de EEUU y Canad distribuidos aleatoriamente a recibir tratamiento intensivo o convencional para el control de la HbA1c. 4.733 fueron distribuidos tambin aleatoriamente a: tratamiento intensivo de la HTA (objetivo PAS<120 mmHg) o tratamiento convencional (objetivo PAS<140 mmHg).TPP4PnP14n 3 EE$50w Diseo (2)  Los criterios de inclusin: Ser diabtico tipo 2 con una HbA1c e"7,5% y: e"40 aos con enfermedad cardiovascular. e"55 aos con: aterosclerosis, albuminuria o HVI o e"2 factores de riesgo cardiovascular adicionales (dislipemia, HTA, tabaquismo u obesidad). Criterios de exclusin: otras enfermedades importantes, creatinina e"1,5 mg/dL o IMC>45. vHP6PPPCPH6  CP8 X  Diseo (3)  :Se visit a los pacientes cada 4 meses con todas las visitas adicionales necesarias para alcanzar las metas del tratamiento. Se dio libertad a los profesionales para elegir el tratamiento antihipertensivo que prefiriesen entre los grupos que se han mostrado tiles para prevenir las enfermedades cardiovasculares.; ; Diseo (4)  sVariable de resultado principal: ocurrencia de un evento cardiovascular mayor (muerte cardiovascular, infarto de miocardio o AVC). Variables secundarias: la anterior ms revascularizacin o ingreso por ICC, eventos coronarios mayores, mortalidad total, muerte o ingreso por ICC y componentes de la variable principal por separado. Anlisis por intencin de tratar. N0 Z0 Z#0 Z#xResultados (2)Resultados (3)Resultados (4)CLos pacientes del grupo de intervencin intensiva necesitaban una media de 3,5 frmacos frente a 2,2 en el grupo de intervencin estndar. Los pacientes del grupo de intervencin intensiva: presentaron ms efectos adversos relacionados con la medicacin antihipertensiva y tenan una filtracin glomerular estimada media inferior a los del grupo de intervencin estndar. No se apreciaron diferencias estadsticamente significativas en el porcentaje de pacientes que desarrollaron macroalbuminuria. Tampoco se encontraron diferencias importantes en los anlisis por subgrupos.BZZZ,( P ConclusionesLos autores concluyen que en los diabticos tipo 2 de alto riesgo fijarse una meta de PAS <120 mmHg no se traduce en un menor nmero de eventos cardiovasculares que una meta de PAS <140 mmHg. ,^V0Comentario (1)@Una proporcin significativa de los pacientes con diabetes mellitus son hipertensos (20-60%). La HTA aumenta el riesgo de que los pacientes presenten complicaciones tanto macro- como microvasculares. En varios ensayos clnicos se ha demostrado que la reduccin de la PA en pacientes con diabetes mellitus tipo 2 mejora el pronstico a largo plazo. Las principales guas de prctica clnica recomiendan que en los pacientes con diabetes mellitus el objetivo de PA a conseguir sea <130/80. Esta recomendacin se basa sobre todo en los resultados de los estudios HOT y UKPDS. APA: X_  ,VeComentario (2)"En el estudio UKPDS participaron 1.148 pacientes afectos de diabetes tipo 2 e HTA. Fueron distribuidos aleatoriamente en dos grupos con diferentes metas de PA: estricto: <150/85 y cuidados habituales. Las medias de PA conseguidas en los dos grupos: 144/82 y 154/87 mmHg. En el grupo de control estricto: se apreciaron mejores resultados en todas las variables de resultado analizadas, slo alcanzaron la significacin estadstica las muertes relacionadas con la diabetes (no la mortalidad total), los AVC y las complicaciones microvasculares.hP+PhPP+h>gComentario (3)En el estudio HOT se distribuyeron aleatoriamente a ms de 18.000 pacientes hipertensos en tres grupos con diferentes metas de tratamiento (PAS d"90, d"85 y d"80 mmHg respectivamente). Las cifras medias alcanzadas fueron 85, 83 y 81 mmHg respectivamente. En el subgrupo de pacientes con diabetes, se observ una reduccin progresiva estadsticamente significativa en la mortalidad cardiovascular y en los eventos cardiovasculares en los grupos de tratamiento ms intensivo. P>"mCComentario (4)Los resultados del estudio ACCORD comentado en este resumen no demuestran ninguna ventaja significativa en la reduccin de la PAS por debajo de los 120 mmHg, dado que: los efectos beficiosos eran muy limitados (una tasa de incidencia de AVC ligeramente inferior) y se asociaba a una tasa de efectos adversos superior. Los autores argumentan en contra de la meta teraputica de PA <130/80, pero dado que esta no se encontraba entre las estudiadas, a la vista de los resultados del estudio HOT, puede resultar una meta adecuada. 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L8 @ @ @&   fɘ_ж_ж ?p<$0  L8 \ \ \<  c $޽h ? ̙33  ___PPT10 ..]0G+FDc ' t= @B D ' = @BA?%,( < +O%,( < +D ' =%(D' =%(D' =A@BBBB0B%(D' =1:Bvisible*o3>+B#style.visibility<* %(D' =A@BBBB0B%(D' =1:Bvisible*o3>+B#style.visibility<* a%(D' =A@BBBB0B%(D' =1:Bvisible*o3>+B#style.visibility<* a%(D' =A@BBBB0B%(D' =1:Bvisible*o3>+B#style.visibility<* T%(DA' =%(D' =%(D' =A@BBBB0B%(D' =1:Bvisible*o3>+B#style.visibility<* T%(+8+0+ 0 +` % @ p(   &  Bċ_ж_ж ?P Resultados (1)(>'(   8 @ @ @   HA 3? YP t 8 3$D0y  0 P p ,$D0 =Los dos grupos fueron parecidos: Edad media: 62 aos. Un 52% eran varones. IMC medio: 32 Fumadores: 13%. Antecedentes de enfermedades cardiovasculares: 34%. PA media 139/76. Duracin media de la diabetes: 10 aos. HbA1c media: 8,3%. Seguimiento medio: 5 aos. Se dispuso de los datos del 95% de los participantes. 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~~~~~~~~~~~~~~~~  M"  ;  P+sZCU 4  3@))=c6N3!Rl +; M.+ - =3a a      a  $" &r<dH  $'  2 8- v<B4 g ^  ?++D  -9! +"4   0VE #   $b$s#ڿE`"  "$75J -n 5+F2$dSAwC b$*@tqeT ( b$ t40c$b$b0#F"$;W[-LJ"$Qq_}yNqUf"$ҷbPs_PM$"$Ҳ_6d@tKh" t0e0e    A A5% 8c8c     ?A)BCD|E||S" 3@l䇣 ʚ;l8ʚ;g4FdFdv 0pPp@pP <4!d!d` 0,<4dddd` 0, <4dddd 0,&g4=d=dv 0p.p poz0___PPT10 pp:___PPT9%hlp#$$$&-3.333z(? %O =6"s;Cul debe ser la cifra de PA meta en la diabetes mellitus?"<" fff<$(1   ( t Antecedentes   Las principales guas de prctica clnica recomiendan mantener las cifras de PA <130/80 mmHg en los diabticos. Hay pocos ensayos clnicos en los que se haya estudiado cules son las mejores cifras objetivo de la PA en estos pacientes.0PWu Objetivos   Estudiar el efecto de intentar llegar a unas cifras de PAS <120 mmHg sobre las enfermedades cardiovasculares en pacientes con diabetes mellitus tipo 2 de alto riesgo. ,?B v Diseo (1)  Ensayo clnico. Estudio ACCORD (Action to Control Cardiovascular Risk in Diabetes): 10.251 pacientes afectos de diabetes mellitus tipo 2 de alto riesgo de 77 centros de EEUU y Canad distribuidos aleatoriamente a recibir tratamiento intensivo o convencional para el control de la HbA1c. 4.733 fueron distribuidos tambin aleatoriamente a: tratamiento intensivo de la HTA (objetivo PAS<120 mmHg) o tratamiento convencional (objetivo PAS<140 mmHg).TPP4PnP14n 3 EE$50w Diseo (2)  Los criterios de inclusin: Ser diabtico tipo 2 con una HbA1c e"7,5% y: e"40 aos con enfermedad cardiovascular. e"55 aos con: aterosclerosis, albuminuria o HVI o e"2 factores de riesgo cardiovascular adicionales (dislipemia, HTA, tabaquismo u obesidad). Criterios de exclusin: otras enfermedades importantes, creatinina e"1,5 mg/dL o IMC>45. vHP6PPPCPH6  CP8 X  Diseo (3)  :Se visit a los pacientes cada 4 meses con todas las visitas adicionales necesarias para alcanzar las metas del tratamiento. Se dio libertad a los profesionales para elegir el tratamiento antihipertensivo que prefiriesen entre los grupos que se han mostrado tiles para prevenir las enfermedades cardiovasculares.; ; Diseo (4)  sVariable de resultado principal: ocurrencia de un evento cardiovascular mayor (muerte cardiovascular, infarto de miocardio o AVC). Variables secundarias: la anterior ms revascularizacin o ingreso por ICC, eventos coronarios mayores, mortalidad total, muerte o ingreso por ICC y componentes de la variable principal por separado. Anlisis por intencin de tratar. N0 Z0 Z#0 Z#xResultados (2)Resultados (3)Resultados (4)CLos pacientes del grupo de intervencin intensiva necesitaban una media de 3,5 frmacos frente a 2,2 en el grupo de intervencin estndar. Los pacientes del grupo de intervencin intensiva: presentaron ms efectos adversos relacionados con la medicacin antihipertensiva y tenan una filtracin glomerular estimada media inferior a los del grupo de intervencin estndar. No se apreciaron diferencias estadsticamente significativas en el porcentaje de pacientes que desarrollaron macroalbuminuria. Tampoco se encontraron diferencias importantes en los anlisis por subgrupos.BZZZ,( P ConclusionesLos autores concluyen que en los diabticos tipo 2 de alto riesgo fijarse una meta de PAS <120 mmHg no se traduce en un menor nmero de eventos cardiovasculares que una meta de PAS <140 mmHg. ,^V0Comentario (1)@Una proporcin significativa de los pacientes con diabetes mellitus son hipertensos (20-60%). La HTA aumenta el riesgo de que los pacientes presenten complicaciones tanto macro- como microvasculares. En varios ensayos clnicos se ha demostrado que la reduccin de la PA en pacientes con diabetes mellitus tipo 2 mejora el pronstico a largo plazo. Las principales guas de prctica clnica recomiendan que en los pacientes con diabetes mellitus el objetivo de PA a conseguir sea <130/80. Esta recomendacin se basa sobre todo en los resultados de los estudios HOT y UKPDS. APA: X_  ,VeComentario (2)"En el estudio UKPDS participaron 1.148 pacientes afectos de diabetes tipo 2 e HTA. Fueron distribuidos aleatoriamente en dos grupos con diferentes metas de PA: estricto: <150/85 y cuidados habituales. Las medias de PA conseguidas en los dos grupos: 144/82 y 154/87 mmHg. En el grupo de control estricto: se apreciaron mejores resultados en todas las variables de resultado analizadas, slo alcanzaron la significacin estadstica las muertes relacionadas con la diabetes (no la mortalidad total), los AVC y las complicaciones microvasculares.hP+PhPP+h>gComentario (3)En el estudio HOT se distribuyeron aleatoriamente a ms de 18.000 pacientes hipertensos en tres grupos con diferentes metas de tratamiento (PAS d"90, d"85 y d"80 mmHg respectiv   amente). Las cifras medias alcanzadas fueron 85, 83 y 81 mmHg respectivamente. En el subgrupo de pacientes con diabetes, se observ una reduccin progresiva estadsticamente significativa en la mortalidad cardiovascular y en los eventos cardiovasculares en los grupos de tratamiento ms intensivo. P>"mCComentario (4)Los resultados del estudio ACCORD comentado en este resumen no demuestran ninguna ventaja significativa en la reduccin de la PAS por debajo de los 120 mmHg, dado que: los efectos beficiosos eran muy limitados (una tasa de incidencia de AVC ligeramente inferior) y se asociaba a una tasa de efectos adversos superior. Los autores argumentan en contra de la meta teraputica de PA <130/80, pero dado que esta no se encontraba entre las estudiadas, a la vista de los resultados del estudio HOT, puede resultar una meta adecuada. 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