DEFINITIONS.ARTERIAL BLOOD PRESSURE CLASSIFICATION.Arterial Blood Pressure (ABP) is a complex physiological variable in regard to its
measure, behavior between BP taken in the same visit at the office and between these and
ABPM, chronobiology (different day time BP levels), evolution in time, meaning and
classification.
Not appropriate approach or analysis may be addressed without taking into account all the
BP characteristics that have demonstrated prognostic implications.
In order to arrive to the most comprehensive analysis, BP classification takes into
account the following characteristics:
A. Primary or Essential: Not clear causes may be identified. Multiple mechanisms may be
involved, obvious players and contributors, but no definitive cause.
B. Secondary: an identifiable cause is characterized.
.
- II. The sitting, supine, standing BP and/or ABPM value.
A. High arterial BP (HBP):
1. At the office: the average of the two systolic or diastolic sitting, supine,
standing BP are considered.
1. Office Supine SBP ≥140 mm Hg and/ or DPB ≥90 mmHg. 2. Diagnosis HBP: As single criteria in the abscence of ABPM. 2. Ambulatory BP Monitoring (ABPM):
1. 24 hrs: SBP ≥130; DBP ≥80 mmHg.
2. Awake (06:00-22:00): SBP ≥135; DBP ≥85 mmHg.
3. Night (22:00-06:00): SBP ≥125; DBP ≥70 mmHg.
3. Both at the office and ABPM always predominate ABPM:
1. HBP in ABPM at 24 hrs, awake or night time, regardless of the office BP. 2. Masked hypertension (MHBP): HBP AWAKE in the ABPM and NBP or LBP at the office.
B. Low BP (LBP) Since there are no clear limits in ABPM for LBP, only office
supine SBP and/or DBP will be considered.
SBP <90 DBP <60. C. Normal BP (NBP) > 90 SBP <140 > 60 DBP <90 White Coat Hypertension (WCHBP):
Normal BP AWAKE in the ABPM and HBP at the office.
D. NIGHT BP. 1. Night HBP: HBP at night in the ABPM. 2. Night NBP: NBP at night in the ABPM. 3. Night LBP: LBP at nigth in the ABPM .
- III. The BP orthostatic response (Supine minus Standing [SUPINE] and Sitting
minus Standing [SITTING], example: SUPINE OH, or SITTING OH)
A.
Orthostatic hypotension (OhypoT): Drop in BP upon standing.
- - 20 mmHg if SBP is normal.
B. Orthostatic Hypertension (OhyperT) Rise in SBP upon standing ≥20 mmHg. C. Orthostatic Normotension (ONT): No criteria for Ohypot or OhyperT. .
- IV. The circadian component of BP.
A. Normal Dipper (NDBP): average decrease of SBP between day and night time
greater than 10% and less than 20%
B. Extreme Dippers (EDBP): greater than 20% fall. C. Nondippers (NonDBP): less than 10% fall. D. Reverse dippers (RDBP): night time BP higher than daytime average. E. Abnormal early Morning BP Surge (BPS): A rise ≥50 mmHg.
.
- V. BP response to treatment (requires office BP and ABPM)
A.
True Control HBP (TCHBP): NBP at the office and the ABPM AWAKE. B. True Resistant HBP (TRHBP): HBP at the office and the ABPM AWAKE. C. False Control HBP (FCHBP): NBP at the office and HBP in the ABPM AWAKE. D. False Resistant HBP (FRHBP): HBP at the office and NBP in the ABPM AWAKE. Patients must be in the absence of medication for Essential hypotension
diagnosis and hypotension must be dismissed as a secondary manifestation of
another disease or other condition such as dehydration, medication causing
hypotension for other conditions or secondary dysautonomia.
There are 3 types of orthostatic hypotension Initial: in the first 30 sec.
after assuming the standing position Classic: It occurs between the 1st and 3rd
min. Late: It occurs between 5 and 45 min. later (no patients within this
category)
ESTIMATION OF TARGET-ORGAN DAMAGE Electrocardiogram, Doppler color
echocardiogram, creatinine and urinalysis, lipid and metabolic profile and
microalbuminuria are requested to the patients; carotid Doppler is also
requested in patients with suspect of disorder.
ARTERIAL HYPERTENSION TREATMENT. The treatment starts with a low-sodium diet
(by nutritionist whenever possible), increase in fruits and vegetables intake,
weight loss, aerobic exercise, stop smoking, and changes in lifestyle.
The pharmacological first step is the use of IECAs (ARA II if there is cough),
calcium channel blockers, the use of diuretics like the Hydrochlorothiazide
12.5mg (or up to 25mg). If there is orthostatic hypotension, it is considered
to start with Amlodipine. In those patients with tachyarrhythmia, heart failure
or coronary disease Beta blockers are chosen. Alpha blockers are the last step
therapy.
ESSENTIAL HYPOTENSION TREATMENT The treatment starts with the use of
non-pharmacological measures consisting of postural hygiene (avoid assuming the
standing position abruptly, avoid staying in the standing position for too
long), eat salty (10 g), drink more than 2 liters of water per day, do aerobic
exercises, and raise the head of the bed. If there is not improvement, the
patient can wear gradient tights up to the waist. Next step is start
Fludrocortisone 0.05 daily or every other day. The last step is Midodrine (from
5 to 20mg daily, distributed at 06:00, 10:00 and 14:00 hrs or when needed,
avoid it after 6:00 pm). Counterpressure maneuvers are recommended if there is
a threat of syncope.
ALLOSTASIS. For the effects of what is mentioned here, allostasis is defined as the ability
to maintain homeostasis through the neuroendocrine and immune response to the
stress of any type. There is experimental evidence, measuring the sympathetic
nerve activity during the mathematical stress with microneurography of the
peroneal nerve (muscle sympathetic nerve activity or MSNA) that the response
may be increasing, neutral or decreasing.
The alterations in blood pressure are considered objective, which may be the
result of strategies and different responses to stress (adaptability), through
the neuroendocrine system (mainly the sympathetic nervous system).
The following variables are evaluated to describe the Allostasis:
1. SYMPTOMS OF HYPOTENSION: postural dizziness, dizziness after squatting, dizziness
during childhood or adolescence (in elementary school, high school and occasionally
in college) during the mass, at public events, religious processions or military
parades. It is also taken into account the previous diagnosis of low pressure or
"hypoglycemia" (which in our culture mainly refers to symptoms of orthostatic
hypotension).
2. HISTORY OF NEURALLY MEDIATED SYNCOPE OR VASOVAGAL SYNCOPE diagnosed by the scores of
Calgary or Tilt-test; or vasovagal syncope (syncope caused by seeing blood, a
venipuncture or donating blood; pain, by seeing or speaking about dramatic things,
when coughing, swallowing, defecating, urinating, laughing, or other situations). If
these situations occur with significant dizziness or pre-syncope, but not syncope
itself, it is called vasovagal component.
3. BLOOD PRESSURE: Low BP.The allostasis is classified as:
1. Hypo-allostasis: presence of at least one of the followings:
1. Symptoms of hypotension and/or. 2. Neurally mediated syncope (clinical or at the tilt-test) or vasovagal syncope
and/or. 3. Hypotension at the office or at the tilt-test. 2. Normal-allostasis: normal blood pressure and no symptoms of hypotension, no neurally
mediated syncope or vasovagal syncope (spontaneous or induced in the tilt table
test) and no presence of hypotension. Include those who develop permanent
hypertension after 65 yo. After this age, structural components mainly in the
Windkessel vessels, may contribute more than the increased sympathetic tone to the
hypertension phenomenon. For end points analysis, patients developing Hypertension
after 65 yo are considered hypertensives in their BP group, but normal in the
adaptability.
3. Hyper-allostasis: Arterial hypertension starting before 66 yo, with no identifiable
cause, no symptoms of hypotension, no neurally mediated syncope or vasovagal
syncope.
Allostasis scores (scores between 1 and 7 apply for hypo-allostasis only)
1. Only symptoms. 2. Only essential hypotension. 3. Only neurally mediated syncope. 4. 1 and 2. 5. 1 and 3. 6. 2 and 3. 7. 1, 2 and 3. 8. Normotensive. 9. Hypertensive. 10. The patient does not remember.Thus then, 3 groups of blood pressure are recognized at the moment of evaluating their
impact on the comorbidities:
1. Normotensive. 2. Hypotensive. 3. Hypertensive, that in turn can be:
1. Hypertensive since the admission. 2. Previously hypotensive. 3. Previously normotensive.METHODS.Cohort.
LABORATORY EXAMINATIONS.Complete blood count Basal glycemia and 2 hr post-load 75 g glucose Insulinaemia Glycated
hemoglobin Serum ferritin Thyroid stimulating hormone and sometimes free thyroxine Sodium
and serum potassium Uric acid Lipid profile Creatinine Basal serum cortisol and/or
post-Adrenocorticotropic hormone 24-hr urinary free cortisol Post-dexamethasone cortisol:
in those with high cortisol with not recognized cause Microalbuminuria Others depending
on the case, such as: 24-hr urine catecholamines (Epinephrine, Norepinephrine and
Metanephrines), gliadin antibodies, vanillylmandelic acid, parathyroid hormone, vitamin
B12, folic acid, ANAs, testosterone, creatinine clearance, antibodies against human
hemoglobin in stool, hypersensitive reactive C protein, 24-hrs urinary sodium, brain
natriuretic peptide, etc.
There is not a single laboratory to make the blood tests, so there are different values
of normality for some tests.
PHYSICAL EXAMINATION.ANTHROPOMETRIC MEASUREMENTS:
In every medical consultation, the patient is weighed wearing trousers or skirt. The
waist is measured at an equidistant level between the last rib and the iliac crest. The
hip is measured at the level of the greater trochanter. Finally, the size that appears in
the identity card of the patient, or the latest measurement is written down. After May
2016 measurements are taken in the office.
TAKING OF BLOOD PRESSURE:
It is performed using a mercury sphygmomanometer from Tycos brand (it is revised annually
in accordance with the current rules of the Ministry of Health), and it is controlled
that the mercury column falls to 2 mm per second.
The bracelet must cover approximately the 80% of the forearm. We have three sizes of
bracelets as needed, including a pediatric bracelet. This should be positioned at heart
level.
The appearance of the first sound and the disappearance of Korotkoff sounds are taken as
systolic and diastolic BP respectively.
About 6 BP measurements are taken, two on supine position and the second one after 5 min.
supine, this second supine value is the one used to calculate the BP drop upon standing.
Later, and having the bracelet previously inflated, the BP is taken immediately once the
up-right position is assumed (first 30 sec). Then, additional pressures are taken at the
first, second and third min.
Since November the 30th, 2017, two additional BPs will be taken in a seated position;
these will be taken at the beginning of the BP taking session. The patient will be seated
comfortably with their right arm resting at the heart level. The BPs, HRs, COs and SVRs
will be taken first after one minute of having the patient sit comfortably and then again
after two minutes. Later on, the patient will assume the first supine position and the
protocol continues as explained previously; however, the interval between the two BPs
taken at the supine position will be of one and three minutes.
Starting on January 2018, an immediate standing BP after seated position will be taking.
Invasive beat to beat BP taken was no longer used since March 2020 because the COVID-19
Pandemic. Few patients have been seen since then, BP is taken with mercury
sphygmomanometer always in sitting position and sometimes, in supine and standing
position.
The same process is fulfilled for the HR, taken in 15 sec. During the taking of blood
pressure neither the patient nor the doctor talk, and it is avoided making any comments
that might alter the patient psychologically, and potentially modify their BP levels. The
patient is asked to have an empty bladder and the Physician tries to support the
patient´s arm at the heart level in every position.
NON-INVASIVE BEAT TO BEAT BP MONITORING Non-invasive, beat to beat, BP monitoring and
Cardiac Output (CO) and Systemic Vascular Resistance (SVR) started to be used since May
2017 to measure BP, HR, CO, SVR. CNAP Monitor 500, CNSystems, is CE and FDA approved. It
is intended to be use in every consecutive patient.
Instructions:
1. Rings, bracelets, and wristwatches should be withdrawn from the right arm.
2. Fingers in the cuffs should not be bending since this could increase BP
artificially.
3. The arm will rest beside the body, relaxed.
4. When standing, the physician or person taking BP should take the patient´s right arm
and help him stand up in an attempt to decrease the arm´s movement and avoid
interference on the recording.
5. The forearm is kept at the heart level.
6. A screen´s photography will be taken with the cellphone after every BP measure (8).
7. A label is placed on the recording just after the seating position and before
standing.
8. If the immediate standing BP taken shows a drop in the BP but systemic vascular
resistance (SVR) and cardiac output (CO) are those of the supine position then the
BP won´t be registered and a picture should be taken immediately SVR and CO are
recalculated.
9. If BP starts to rise, review that fingers in the cuff are straight.
10. If in doubt, make a manual measure of the BP.
11. BP and HR date along with SVR and CO will be introduced in the fields of the BP and
HR taken with the sphygmomanometer and usual physical examination. New fields were
created for SVR and CO.
12. The completed data is introduced as 3 attachment files for further analysis.
ELECTROCARDIOGRAM (HEWLETT PACKARD AND MORTARA) A careful reading of each plot is made in
which the HR, PR and cQT intervals, and QRS complex are recorded (automatic
measurements).
24 HOURS ECG MONITORING (HOLTER) It is specified the patient rhythm, if is under
medication that may affect the heart rate variability (HRV) and, it is recorded the name
and type of drug. The number of supraventricular and ventricular premature complexes are
counted.
The components of heart rate variability (HRV) allows calculating the sympathovagal
balance (SVB) in 24 hrs, in the day (06:00 to 22:00) and at night (22:00 to 6:00).
Low frequency (LF), high frequency (HF), very low frequency (VLF), Total power (TP) LF or
HF one = LF or HF x 100/ TP-VLF SVB = LFone/HFone.AMBULATORY BLOOD PRESSURE MONITORING (ABPM) The systolic and diastolic BP and HR are
registered in 24 hrs, in the day and at night, as in the 24-hr Holter monitoring. This
test is requested for all patients in order to define the presence of white coat
hypertension or masked hypertension and to define an effective treatment.
Morning surge in SBP: It results from the difference between the averages of SBP taken in
the first 2 hrs from awakening and the lower nighttime.
COLOR DOPPLER ECHOCARDIOGRAM AND/OR STRESS ECHOCARDIOGRAM It is made the measurement of
the heart and if the response to stress is positive or negative.
The ejection fraction (EF) is usually measured by the technique of Simpson or in a
qualitative way.
Body surface area = (weight x height / 36) X 1/2 Cardiac mass = 1.05 [(LVDD + SW + PW)3
- -
LVDD3] - 14 Cardiac mass index = cardiac mass / body surface area.
ABDOMINAL ULTRASOUND It is recorded the presence of fatty liver and abdominal aortic
aneurysm.UPPER GASTROINTESTINAL ENDOSCOPY AND COLONOSCOPY The main findings are recorded.CORONARY ANGIOGRAPHY Indication: For those who belong to the protocol and will indicate
it, it is tried that the indication belongs to a score between 7 and 9 (appropriate test
for a specific indication) of the recommendation of the working group aforementioned.
1. In patients with symptoms of acute coronary syndrome or positive test for myocardial
ischemia in individuals with moderate or high cardiovascular risk. 2. In patients with sustained ventricular tachyarrhythmias with unidentifiable cause
that stop spontaneously or require resuscitation. 3. In patients with left ventricular dysfunction at basal conditions (ejection fraction
<40%) and evidence of viability in the affected segments.
4. Evidence of new segmental alteration of motility of unknown etiology.
5. Suspected ischemic mitral regurgitation or interventricular septal defect.
6. Presence on the CT scan of lesions >50% on the left main trunk or other vessels, or
possibly obstructive lesions of debatable severity in symptomatic patients (when in
the left main trunk, also in asymptomatic patients)
It is classified according to the obstruction to coronary flow as follows:
- - Lesion <50%, non-obstructive (if not the left main trunk)
- Between 50-69%, intermediate lesion (if not the left main trunk)
- >70% or >50% of the left main trunk, it is a significant obstructive lesion.
It is
neither specified the number of affected vessels nor the vessel diameter.
ELECTROPHYSIOLOGICAL STUDY The patient must be in a fasting state and stop taking
medications that affect the study for at least 5 half-lives. It is made by puncturing the
right femoral vein, electro-catheters are placed in the high right atrium, in the bundle
of His and in the right ventricular apex. It is stimulated the double of the thresholds
to 3 cycle lengths (600, 500 and 430 ms) and three extra cycles, starting at 350 ms, and
with successive decreases of 10 ms until the refractory period is found.
The study is made at basal conditions and in presence of Isoproterenol up to 4
micrograms/min; the sedation is obtained with Midazolam, administered 10 min. before
starting the measurements.
Sinus function tests: Sinoatrial conduction time (by Narula method), the sinus node
recovery time (SNRT) and the corrected sinus node recovery time (CSNRT)). For the SNRT,
it is stimulated to several cycle lengths for one min, with decreases of 100 ms up to 430
ms, and the longest pause is considered as the recovery time; if greater than 1500 ms is
considered abnormal.
The CSNRT is the result of SNRT minus the cycle length of the patient. It is considered
abnormal 500 ms or more (sensitivity of 85% and specificity of 90%). Additionally, at
five min, it is evaluated the response of the HR to the infusion of 3 micrograms of
Isoproterenol per min. (an increase of 25% from basal HR) and the intrinsic HR.
This latter is made by administering Atropine 0.04 mg/kg and propranolol 0.2 mg/kg, the
intrinsic HR is dependent on the age, and is calculated as follows:
118.1
- - (0.57 x age), for people under the age of 45 the value is adjusted +14% and for
people over the age of 45 +18%.
Indication:
1. In patients with syncope and ischemic heart disease, when the initial evaluation
suggests an arrhythmic cause.
2. In patients with syncope and bundle branch block, when the noninvasive evaluation
has not clarified the diagnosis.
3. When brief and sudden palpitations precede syncope, when the noninvasive evaluation
has not clarified the diagnosis.
4. In some cases of Brugada syndrome, arrhythmogenic right ventricular cardiomyopathy
and hypertrophic cardiomyopathy.
5. In high-risk patients in whom other methods have not clarified the diagnosis.
TILT TABLE TEST The patient is connected to the noninvasive BP beat to beat monitor.
(Task Force Monitor).
The patient must be fasting for at least 4 hrs; should stay 5 min. in supine position and
then is tilted at 60 degrees for 20 min. Then, it is administered 400 micrograms of
sublingual nitroglycerin for 20 min. more. The tilt table test (TTT) is considered
positive if the patient presents syncope or if the systolic blood pressure is lower than
60 mmHg. The hemodynamic variables, the HR variability, and the BP are written down for
those patients who have these values available.
Other diagnoses written down on the TTT are:
- - Postural orthostatic tachycardia syndrome (POTS):
- Inappropriate sinus tachycardia (IST): It is defined as a HR greater than 90 bpm in
supine position.
- - Orthostatic hypotension (OH):
Fall in the systolic BP ≥20 mmHg or in diastolic BP ≥10 mmHg, at any time of the TTT.
. Orthostatic Hypertension: rise in SBP ≥20 mmHg.
- - Asystole: Isoelectric line that last for more than 3 sec.
on the electrocardiogram
plot. The duration in sec. of the asystole is recorded.
- - Chronotropic incompetence (CI):
It refers to the inability of the heart to increase the HR more than 10% when standing up
within the first 10 min, and if the HR in supine <70 bpm.
Also, if this criterion is not
met but the HR to 60 degrees is lower than 65 bpm.
Indication:
Single syncope episode of unknown origin in high risk patients, or recurrent syncope in
absence of organic heart disease; or in presence of organic heart disease if cardiac
etiology was previously dismissed.
To show to the patient that he/she has this mechanism of syncope. To discriminate between
reflex and orthostatic syncope To differentiate syncope from epilepsy To diagnose
patients with recurrent unexpected falls To evaluate patients with recurrent syncope and
psychiatric disease Many patients referred by other colleagues already have the TTT.
CAROTID SINUS MASSAGE (CSM) It is made during the TTT.Contraindications for the accomplishment of the procedure:
1. History of cerebrovascular disease. 2. Acute myocardial infarction in the previous 3 months, or. 3. Presence of carotid bruit during the neck auscultation. The test consists of doing
pressure and circular movements during 10 sec. on each carotid sinus, allowing an
interval of 1 min. between both sides. The massage is made at 0 and 60 degrees tilt.
It is considered a vasodilatory response if the systolic BP falls at least 50 mmHg,
and chronotropic response if an asystole last 3 or more sec. If this latter occurs,
it is expected the patient to recover and the carotid massage is repeated after
applying atropine 1 mg. If still positive for syncope it is considered a mixed
response to the CSM.
OTHER EXAMINATIONS These tests are requested as needed to clarify other findings. 1.
Computerized axial tomography of brain, heart 2. Brain or heart nuclear magnetic
resonance 3. Polysomnography 4. Meta-iodo-benzyl-guanidine 5. Carotid, renal and lower
limbs arterial Duplex 6. Heart or other structures biopsy 7. Others.DATABASE We have over 1100 variables in OpenClinica 3.13.UPDATING INFORMATION It is made through the consultations, phone calls or emails sent to
the patient email address. The patients should be contacted annually if possible.
Requested information:
1. Updating of telephone number, cell phone number and e-mail addresses. 2. Full treatment. 3. Patient is questioned about new family histories. 4. Patient is questioned about new comorbidities, when were they diagnosed and by whom,
following the existing comorbidities in the database.
5. Patient´s current weight and exercise. 6. Paraclinical laboratory tests.
COMORBIDITIES DIAGNOSTIC CRITERIA. 1. Depression:
The diagnosis is made by a psychiatrist and/or if the patient meets the criteria of
DSM
- IV. If there is difference between the psychiatric diagnosis and the DSM IV
criteria, the diagnosis made by the psychiatrist prevails.
2. Panic attack:
The diagnosis is made by a psychiatrist, the DSM IV criteria or both, the diagnosis
made by the psychiatrist prevails.
3. Fibromyalgia:
It is diagnosed by a rheumatologist.
4. Postural Orthostatic Tachycardia Syndrome (POTS), not associated with hypotension.:
- - Increase in the HR >30 bpm when standing up.
- - Increase in the HR >40 bpm when standing up, between 12 and 18 years old.
- - HR >120 bpm during the first 10 min.
of standing up. 5. Inappropriate sinus tachycardia:
It is the HR average during the 24-hr Holter monitoring >90 bpm, in absence of
secondary cause.
6. Coronary heart disease:
It is diagnosed by the ACS criteria or by the abnormal coronary angiogram.
7. Acute coronary syndrome (ACS):
It refers to clinical, enzymatic, electrocardiographic, echocardiographic or
angiographic findings, diagnosis of acute coronary disease. It should be dismissed
the cocaine abuse, Prinzmetal's angina and Takotsubo cardiomyopathy. This latter is
classified as such in a separate box.
8. Acute myocardial infarction (AMI):
Term used when there is evidence of myocardial tissue necrosis in the clinical
spectrum of myocardial ischemia.
Ischemic symptoms. New changes or presumed new in the ST segment and T wave, or a
new LBBB. Development of new Q waves on the ECG Evidence by images of loss of viable
myocardium, or the emergence of a segmental defect in the motility.
Identification of an intracoronary thrombus in an angiography or autopsy.
Criteria for prior myocardial infarction:
Pathological Q waves on the ECG, with or without symptoms, in absence of
non-ischemic causes.
Evidence by images of loss of viable myocardium, which is thinner and does not
contract, in absence of non-ischemic cause.
Pathological findings of a previous MI.
9. Cerebrovascular disease (CVD) or transient cerebral ischemia (TCI):
The TCI has traditionally been considered as a deficit lower than 24 hrs in duration, and
so it is considered in this protocol. Well-founded evidence suggests duration lower than
60 min, and no evidence of nerve damage proved by CT scan or MRI.
10. Atrial fibrillation: Baseline low amplitude oscillations with irregular rhythm on
the ECG or at Holter monitoring (30 sec)
11. Diabetes mellitus: Fasting glucose > 126 mgs/dl Occasional glucose > 200 mgs/dl with
symptoms Glucose load (75 g): > 200 at 2 hrs A1C > 6.5.
12. Cancer: It is diagnosed by an oncologist.
13. Systolic or diastolic heart failure: Patients should be symptomatic. It is
considered systolic if the ejection fraction is decreased, otherwise, it is
considered diastolic. In case of being diastolic, it should be dismissed other
causes of dyspnea, such as lung diseases.
14. Chronic fatigue syndrome or idiopathic chronic fatigue: Persistent or chronic
fatigue, clinically evaluated, unexplained, which lasts for 6 or more consecutive
months, of recent onset, not explained by exercising, not improved substantially
with rest and that produces a substantial reduction in previous levels of
occupational, social, educational and personal activities.
The patient must have 4 of the following symptoms, which must have persisted or be
recurrent for 6 or more consecutive months of illness, and must have not been preceded by
fatigue: a) self-reporting of poor short-term memory or decreased ability to concentrate,
as severe as to alter the previous functional ability, b) dry throat, c) armpit and
cervical adenopathies, d) muscle pain, joint pain without redness, deformity or swelling,
de-novo headache, e) unrefreshing sleep, and malaise post exercise that lasts more than
24 hrs.
15. Syncope: It refers to the transient loss of consciousness secondary to cerebral
hypoperfusion, characterized by sudden onset, short duration, and spontaneous and
complete recovery.
16. Vasovagal syncope Emotion mediated syncope or orthostatic stress, usually preceded
by autonomic activation prodromes (diaphoresis, pallor, nausea). It includes
situational syncope and carotid sinus hypersensitivity.
PSYCHO BIOTYPE EVALUATION.Design to study in depth the Psycho Biotype hypothesis. It consist of consecutive
patients of each BP group to whom the following test are apply:
1. Big Five Questionary (BFQ) for personality.
2. Modified Coping Scale (Scale of modified coping strategies)
3. Zung questionary for depression and anxiety. 4. MINI in those patients with moderate or severe depression and/or anxiety at the Zung
questionary, apply by a psychiatrist.GENERAL OBJECTIVE To demonstrate if the essential arterial BP group and/or the
adaptability are clinically important and try to identify the mechanism involve.
SPECIFIC OBJECTIVES To demonstrate that the three groups of blood pressure differ in the
numbers taken as much in the doctor's office as in the ambulatory BP monitoring.
To inquire what variables are different between the groups of BP. To inquire which
comorbidities are more associated with each group of blood pressure and evaluate whether
the differences persist after a multivariate analysis. The same will be done with the
adaptability groups.
To provide hypotheses or evidences to explain the findings of the study.
DESIGN OF THE STUDY This is an observational, analytic, cohort type study that aims to
compare the differences between groups of patients classified according to their BP
numbers and their adaptability.
To this end, variables of the clinical, paraclinical, imaging and comorbidities profile
will be evaluated.
The database is designed to be flexible. It allows choosing different conditions in
different variables. The diagnoses have 3 options: No, New and Old. It is recorded the
date of the physical examinations, the diagnoses and the paraclinical results to ensure
accuracy in the calculation of the age and the relationship between the different
variables during the analysis.
The reports will be of prevalence (cross-sectional) and incidence (cohort). To evaluate
the significance between the groups of blood pressure depending on morbidities and other
variables, it is used a generalized linear model by adjusting the effect of the response
variable based on the age, gender and tension group in all cases. In some cases, and when
the response variable requires it, it is added the body mass index (BMI). When the
response variable is qualitative, it is used a logit link function and it is obtained the
corresponding Odds ratio with confidence intervals to 95%; while if the variable is
quantitative it is used the identity function. Finally, the multiple comparison test of
Tukey-Kramer is made in order to compare the groups of tension with a significance level
of 0.05.
To evaluate the relationship between the blood pressure groups and the comorbidities, and
other variables, the free events survival rates among participants using a Kaplan Meir
survival curves, adjusted for age and other related variables.
For the diagnosis of coronary disease, it was used a generalized linear model in which
was evaluated the adjustment of the effect in the groups of tension by age, gender, and
body mass index (BMI), diabetes mellitus (DM), systolic and diastolic blood pressure in
supine, total cholesterol, HDL cholesterol, smoking, and blood pressure group. Variables
were selected by the method of Backward maintaining in the model those variables with a
significance level of 0.05.
LIMITATIONS:
1. Because patients were recruited at the doctor's office, some of them may decide not
to take the required tests or decide not to come back.
2. Some insurance companies may not provide some test, like the Ambulatory blood
pressure monitoring.
3. The attending practitioner may be busy with too much work and has not available time
to see the patients opportunely.
4. The blood tests can be done at different sites and by different operators.
5. Black population is not represented in this sample.
