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Vol. 7. Núm. F.
Enfoque traslacional de la insuficiencia cardiaca: del gen al paciente y a la población
Páginas 22F-33F (Octubre 2007)
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Vol. 7. Núm. F.
Enfoque traslacional de la insuficiencia cardiaca: del gen al paciente y a la población
Páginas 22F-33F (Octubre 2007)
Enfoque traslacional de la insuficiencia cardiaca
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Papel del tratamiento antihipertensivo en la prevención de la insuficiencia cardiaca
Role of Antihypertensive Treatment in Heart Failure Prevention
Visitas
306
Eulàlia Roiga, Antonio Cocab,
Autor para correspondencia
acoca@clinic.ub.es

Correspondencia: Dr. A. Coca. Instituto de Medicina y Dermatología. Hospital Clínic. Villarroel, 170. 08046 Barcelona. España.
a Unidad de Insuficiencia Cardiaca y Trasplante. Instituto del Tórax. Hospital Clínic (IDIBAPS). Universidad de Barcelona. España
b Unidad de Hipertensión. Instituto de Medicina y Dermatología. Hospital Clínic (IDIBAPS). Universidad de Barcelona. España
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Los estudios de prevención primaria de la enfermedad cardiovascular en pacientes hipertensos han demostrado que el descenso sostenido de las cifras de presión sistólica y diastólica reduce la incidencia de cardiopatía isquémica, insuficiencia cardiaca (ICC), accidente cerebrovascular e insuficiencia renal, así como la mortalidad asociada a tales complicaciones en todas las razas, a cualquier edad y en ambos sexos. En prevención primaria de la ICC los diuréticos, los bloqueadores betaadrenérgicos (BB), los fármacos que bloquean el SRA, y sus combinaciones, son superiores a las estrategias basadas en calcioantagonistas.

En el tratamiento de la ICC secundaria a hipertensión arterial (HTA) es importante valorar los factores precipitantes, ya que evitar su aparición constituye una parte importante del tratamiento. Debe intentarse mantener el ritmo sinusal, y en presencia de AC x FA, mantener frecuencias cardiacas controladas es básico para evitar la aparición de ICC. No existen estudios farmacológicos que hayan analizado cuál es el mejor tratamiento de la ICC diastólica. Los IECAs y ARA II pueden ser útiles tanto por su efecto antihipertensivo como inductores de regresión de HVI. Los diuréticos deben administrarse cuando hay retención de líquidos. Los BB y algunos antagonistas del calcio que inducen bradicardia, un efecto deseable en estos pacientes, pueden ser de utilidad. El tratamiento del paciente hipertenso con disfunción ventricular izquierda no difiere del tratamiento de la ICC crónica recomendado en las Guías de Práctica Clínica de la ESC y del ACC/AHA. El tratamiento incluye IECAs y BB pues ambos han demostrado reducir la mortalidad de la ICC. Cuando hay contraindicación para los IECAs, deben prescribirse ARA II y cuando hay retención de líquidos deben administrarse diuréticos. Si persisten los síntomas, la digoxina suele ser beneficiosa. La espironolactona añadida a IECAs y BB ha demostrado mejorar la supervivencia de estos pacientes.

Palabras clave:
Hipertensión arterial
Insuficiencia cardiaca
Hipertrofia ventricular
IECAs
ARA II
Bloqueadores beta
Abreviaturas:
PA
HTA
PAS
PAD
ICC
IECAs
ARA II
BB
HSA
AC x FA
BB
ESH
ESC
STOP
MRC
HOT
SHEP
SYST-EUR
HDFP
EWPHE
ALLHAT
SYST-CHINA
SRA

Studies on the primary prevention of cardiovascular disease in hypertensive patients have shown that sustained reductions in systolic and diastolic pressure decrease the incidence of coronary heart disease, congestive heart failure (CHF), stroke, and kidney failure, as well as the mortality associated with these conditions, in all races and both sexes, irrespective of age. In the primary prevention of CHF, the use of diuretics, betablockers, rennin–angiotensin system blockers, and their combination is superior to treatment based on calcium channel blockers.

Important aspects of the treatment of CHF due to hypertension are identifying predisposing factors and preventing their appearance. Sinus rhythm should be maintained, though if atrial fibrillation is present, strict heart rate control is essential for preventing the development of CHF. To date, no study has investigated the best pharmacological treatment for diastolic heart failure. Angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor antagonists (ARA IIs) may be useful because they have antihypertensive effects and reverse left ventricular hypertrophy. If there is fluid retention, a diuretic should be administered. Betablockers and calcium channel blockers that induce bradycardia, a beneficial effect in these patients, may be useful. The treatment of patients with hypertension and left ventricular dysfunction is no different from that recommended for those with chronic heart failure by clinical guidelines from the European Society of Cardiology and the American College of Cardiology/ American Heart Association. Treatment includes the use of ACE inhibitors and beta-blockers since both have been shown to reduce mortality in CHF. When ACE inhibitors are contraindicated, ARA IIs should be prescribed, and when there is fluid retention, diuretics should be administered. If symptoms persist, digoxin may be beneficial. The addition of spironolactone to ACE inhibitors and beta-blockers has been shown to improve survival in these patients.

Key words:
Hypertension
Heart failure
Ventricular hypertrophy
Angiotensin-converting enzyme inhibitor
Angiotensin II receptor antagonist
Beta-blocker
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