Hypertension is the leading risk factor for cardiovascular disease (CVD) worldwide. Despite the availability of effective antihypertensive medications, the control of hypertension at a global level is dismal, and consequently, the CVD burden continues to increase. In response, countries in Latin America and the Caribbean are implementing How to cite this article: DiPette DJ, Goughnour K, Zuniga E, et al. Standardized treatment to improve hypertension control in primary health care: The HEARTS in the Americas Initiative. J
<b><i>Introduction:</i></b> A new generation of hemodialysis (HD) membranes called medium cut-off (MCO) membranes possesses enhanced capacities for middle molecule clearance, which have been associated with adverse outcomes in this population. These improvements could potentially positively impact patient-reported outcomes (PROs). <b><i>Objective:</i></b> The objective of this study was to evaluate the impact of MCO membranes on PROs in a cohort of HD patients in Colombia. <b><i>Methods:</i></b> This was a prospective, multicenter, observational cohort study of 992 patients from 12 renal clinics in Colombia who were switched from high-flux HD to MCO therapy and observed for 12 months. Changes in Kidney Disease Quality of Life 36-Item Short Form Survey (KDQoL-SF36) domains, Dialysis Symptom Index (DSI), and restless legs syndrome (RLS) 12 months after switching to MCO membranes were compared with time on high-flux membranes. Repeated measures of ANOVA were used to evaluate changes in KDQoL-SF36 scores; severity scoring was used to assess DSI changes over time; Cochran’s Q test was used to evaluate changes in frequency of diagnostic criteria of RLS. <b><i>Results:</i></b> During 12 months of follow-up, 3 of 5 KDQoL-SF36 domains improved compared with baseline: symptoms (<i>p</i> < 0.0001), effects of kidney disease (<i>p</i> < 0.0001), and burden of kidney disease (<i>p</i> < 0.001). The proportion of patients diagnosed with RLS significantly decreased from 22.1% at baseline to 10% at 12 months (<i>p</i> < 0.0001). No significant differences in the number of symptoms (DSI, <i>p =</i> 0.1) were observed, although their severity decreased (<i>p</i> = 0.009). <b><i>Conclusions:</i></b> In conventional HD patients, the expanded clearance of large middle molecules with MCO-HD membranes was associated with higher health-related quality of life scores and a decrease in the prevalence of RLS.
Clinical guidelines for the treatment of patients with non‐ST‐segment elevation myocardial infarction (NSTEMI) recommend an invasive strategy with cardiac catheterization, revascularization when clinically appropriate, and initiation of dual antiplatelet therapy regardless of whether the patient receives revascularization. However, although patients with NSTEMI have a higher long‐term mortality risk than patients with ST‐segment elevation myocardial infarction (STEMI), they are often treated less aggressively; with those who have the highest ischemic risk often receiving the least aggressive treatment (the “treatment‐risk paradox”). Here, using evidence gathered from across the world, we examine some reasons behind the suboptimal treatment of patients with NSTEMI, and recommend approaches to address this issue in order to improve the standard of healthcare for this group of patients. The challenges for the treatment of patients with NSTEMI can be categorized into four “P” factors that contribute to poor clinical outcomes: patient characteristics being heterogeneous; physicians underestimating the high ischemic risk compared with bleeding risk; procedure availability; and policy within the healthcare system. To address these challenges, potential approaches include: developing guidelines and protocols that incorporate rigorous definitions of NSTEMI; risk assessment and integrated quality assessment measures; providing education to physicians on the management of long‐term cardiovascular risk in patients with NSTEMI; and making stents and antiplatelet therapies more accessible to patients.
Cardiovascular diseases are the leading cause of mortality and morbidity in the Region of the Americas, and hypertension represents its main risk factor. However, population hypertension control rates in the Region are poor. Global Hearts is the World Health Organization's flagship initiative to reduce the burden of cardiovascular diseases. HEARTS in the Americas Initiative is its regional adaptation that seeks to be the cardiovascular disease risk management model, including hypertension and diabetes, in primary health care throughout the Americas by 2025. HEARTS in the Americas is being implemented in 22 countries and over 2 095 primary care centers. All implementing countries have defined their treatment protocols, and HEARTS in the Americas has supported continuous improvement. Because WHO recently released the 2021 Guideline for the Pharmacological Treatment of Hypertension in Adults and HEARTS in the Americas introduced the key drivers for hypertension control, the initiative generated a methodology to help countries update and strengthen their treatment protocols. This article describes the process of developing the treatment protocol appraisal checklist and defines the resulting clinical pathway. This tool can help countries and primary care centers to improve their protocols by identifying the improvement points and upgrading clinical pathways.
Background and Aims Uremic toxins which are retained in ESRD include small solutes to large middle molecules. Large middle molecules play significant roles in immune modulation and cardiovascular morbidity and mortality. Expanded hemodialysis (HDx) enabled by innovative medium cut-off (MCO) membrane more effectively removes large uremic toxins vs current dialytic therapies. Aims: To evaluate the efficacy of MCO dialyzer in large middle molecules removal and pre-dialysis albumin levels after 24 weeks of treatment. Method This was an exploratory, prospective observational, multicenter cohort study. Prevalent patients on HD therapy for at least 90 days at the Renal Care Services (RCS) were included between June 6, 2018, to June 14, 2018. Uremic toxins removal was evaluated by measuring the reduction ratio (RR) of free light chains (FLC) κ, λ, Interleukin (IL) 6, IL-10, β2 Microglobulin (β2 M) and fibroblastic factor 23 (FGF-23) at 12 weeks ( w) of treatment, as well as the change in predialysis midweek serum level of β2M, FGF-23, factor XIV activity, and VII at baseline, 12 w and 24 w of treatment. A mixed-model repeated measures analysis (MMRM) was performed to identify statistical differences over time Results The RR of κ-FLC, λ-FLC, β2 M, and FGF-23 at week 12 showed a reduction between 46-72%; while in IL-6 RR was not significantly changed (Table 2). Predialysis serum levels decreased for β2m, FLCs and IL-6 and FGF 23 (Table 3). The decrease in albumin was within 5% from baseline. Twenty-two adverse events (AEs) occurred during the follow-up period; No AEs during HDx were deemed related to MCO membrane use. Conclusion MCO dialyzers are safe and effective in removing large MMs and decrease in the uremic toxins levels.
ObjectivesThe utility of bedside inferior vena cava (IVC) ultrasound (US) in the diagnosis of heart failure (HF) is unclear. The aim of this study was to determine whether IVC parameters in patients with acute heart failure (AHF) are statistically different from those without HF.MethodsThe MEDLINE database of English‐language publications from 1966 to August 2018 was searched. Retrospective and prospective studies that included either IVC expiratory diameter (IVCexp) or IVC collapsibility index (IVC‐CI) values were collected in patients with and without HF. to determine whether there was a statistical difference in the IVC parameters between these groups.ResultsA total of 27 articles with a total of 1472 patients with AHF were included. The standard mean differences for the IVCexp and IVC‐CI for the control group versus the AHF group were found to be statistically significant (P < .0001). The combined mean IVCexp values were 15.11 mm (95% confidence interval [CI], 14.19–16.02 mm) for the control group and 20.26 mm (95% CI, 14.82–25.71 mm) for the AHF group. The combined mean IVC‐CI values were 61.6% (95% CI, 48.4%–74.7%) for the control group and 30.5% (95% CI, 26.4%–34.6%) for the AHF group.ConclusionsBedside IVC US showed that a statistically significant difference existed in the IVC parameters between patients with and without AHF. Based on mean calculations, an IVCexp of greater than 2.0 cm and an IVC‐CI of less than 30% are reasonable cutoffs to suggest that a patient with acute dyspnea is more likely to have AHF than a non‐AHF condition. Given the high degree of heterogeneity across the studies and the high risk of bias, larger randomized studies are warranted to explore the use of IVC US in patients with HF.
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