Hypertension in Latin America: Current perspectives on trends and characteristics

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"apellidos" => "Ruilope" "email" => array:1 [ 0 => "ruilope@ad-hocbox.com" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "A.C.P." "apellidos" => "Chagas" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "c" "identificador" => "aff0015" ] ] ] 2 => array:3 [ "nombre" => "A.A." "apellidos" => "Brandão" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "d" "identificador" => "aff0020" ] ] ] 3 => array:3 [ "nombre" => "R." "apellidos" => "Gómez-Berroterán" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "e" "identificador" => "aff0025" ] ] ] 4 => array:3 [ "nombre" => "J.J.A." "apellidos" => "Alcalá" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "f" "identificador" => "aff0030" ] ] ] 5 => array:3 [ "nombre" => "J.V." 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Principe de Gales, 821, 09060-870 Santo André, SP, Brazil" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Department of Cardiology – Hypertension Unit, State University of Rio de Janeiro, Rio de Janeiro, Brazil" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Social Security, Hospital Dr. Domingo Luciani, Rio de Janeiro av. Municipio Sucre, Caracas 1073, Venezuela" "etiqueta" => "e" "identificador" => "aff0025" ] 5 => array:3 [ "entidad" => "“Hospital Dr. Domingo Luciani” – Institute Venezuelan of the Safe Social (IVSS), Caracas, Venezuela" "etiqueta" => "f" "identificador" => "aff0030" ] 6 => array:3 [ "entidad" => "Instituto Nacional de Cardiologia “Ignacio Chávez”, Mexico City, Mexico" "etiqueta" => "g" "identificador" => "aff0035" ] 7 => array:3 [ "entidad" => "Research and Education General Director, Grupo Angeles Servicios de Salud, Mexico City, Mexico" "etiqueta" => "h" "identificador" => "aff0040" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Hipertensión en América Latina: perspectivas actuales de las tendencias y características" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "Adapted from Ref. <a class="elsevierStyleCrossRef" href="#bib0315">24</a>." "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2184 "Ancho" => 2639 "Tamanyo" => 250585 ] ] "descripcion" => array:1 [ "en" => "Age-adjusted years of life lost (in thousands) for (a) CHD and (b) stroke among 19 selected countries in 2013." ] ] ] "textoCompleto" => "Hypertension in Latin America: prevalence, awareness and control rateHypertension is the most important risk factor contributing to the burden of cardiovascular disease, the leading cause of death in all Latin American countries.<a class="elsevierStyleCrossRefs" href="#bib0200">1,2</a> Up to 40% of the adult Latin American population is estimated to be affected by hypertension – similar to that in developed countries – although there are considerable variations between ethnic and racial groups, men and women, and different countries within the region. For example, the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil) showed that the adjusted prevalence of hypertension was highest amongst Blacks (49.2%) compared with Whites (30.3%) and Browns (38.2%).<a class="elsevierStyleCrossRef" href="#bib0210">3</a> Variations in hypertension prevalence within the same country also exist, which may be partly explained by regional differences in diet.<a class="elsevierStyleCrossRefs" href="#bib0215">4–6</a> Like elsewhere, hypertension increases with age in Latin America: data from Mexico City showed a sharp increase in the prevalence of treated hypertension from middle age (26% among 35–44 year olds) to elderly (59% among 75–84 year olds), with this increase being significantly greater in women than in men.<a class="elsevierStyleCrossRef" href="#bib0230">7</a>Moreover, as in other parts of the world, the low rates of awareness, treatment and control of hypertension in Latin America reveal the difficulty and inadequacy in managing this chronic disease on a population level.<a class="elsevierStyleCrossRefs" href="#bib0235">8–10</a> In a recent cross-sectional survey of around 7500 adults from four cities across Argentina, Chile and Uruguay, around 42.5% had hypertension and 32.5% had pre-hypertension.<a class="elsevierStyleCrossRef" href="#bib0250">11</a> Of this population, around 63.0% were aware of their disease, 48.7% were taking prescribed medications to lower their blood pressure (BP), but only 21.1% of all hypertensive patients, and 43.3% of treated hypertensive patients, had their BP controlled to target.<a class="elsevierStyleCrossRef" href="#bib0250">11</a> Similarly, the ELSA-Brasil study found a high proportion of uncontrolled hypertension among its cohort of more than 15,000 subjects recruited from universities and research institutions.<a class="elsevierStyleCrossRef" href="#bib0255">12</a> In total, 34% of ELSA-Brasil participants knew they had hypertension and 29% were taking BP medication; however, among those receiving treatment, 31% did not have controlled BP. Perhaps not surprisingly, controlled BP was more frequent in those with a higher education level (postgraduate).<a class="elsevierStyleCrossRef" href="#bib0210">3</a>There are many reasons for inadequate BP control, including poor treatment adherence, physician's inertia, patient's baseline cardiovascular risk, and poor adherence to guidelines by the treating physician. Regarding the last point, physicians’ criteria for diagnosing and determining high BP may be highly subjective, based on a ‘personal appreciation’, without much heed to criteria specified in regional and international management guidelines. In a recently published study by Ragot et al.,<a class="elsevierStyleCrossRef" href="#bib0260">13</a> the rates of controlled hypertension were evaluated in 2185 hypertensive adults across five countries, including Venezuela. Part of the study compared BP control rates, as determined by physicians’ perception, with BP control rates determined using the 2007 European Society of Hypertension/European Society of Cardiology (ESH/ESC) guideline criteria. There was a marked divergence between physicians’ assessment and that based on the guidelines, with doctors grossly overestimating the BP control rate: according to physicians, 72% of patients had controlled hypertension when, actually, according to ESH/ESC criteria, only 40% had controlled BP.<a class="elsevierStyleCrossRef" href="#bib0260">13</a> The study found that other important factors leading to inadequate BP control were the presence of high or very high cardiovascular risk; high salt intake; treatment non-adherence; lack of understanding of the treatment's importance; comorbidity; and depression.<a class="elsevierStyleCrossRef" href="#bib0260">13</a>Clinical relevance of BP variability in Latin American populationsFurthermore, in today's context, the optimal control of a person's BP should necessarily involve some attention to BP variability, particularly in at-risk individuals such as the elderly. This rationale is based on accumulating evidence which indicates that some BP variability parameters have significant prognostic value for cardiovascular and cerebrovascular outcomes.<a class="elsevierStyleCrossRefs" href="#bib0265">14,15</a> Although these data have been derived from post hoc analyses and observational studies, and evidence is sorely needed from prospective, randomized, controlled trials, they nevertheless suggest that more can be learned from looking beyond 24-h mean BP values alone.Short-term (within 24h) BP variability includes excessive morning BP surge and non-dipping or excessive dipping of night-time BP, while long-term BP variability includes visit-to-visit BP variability. In the seminal study by Kario et al.,<a class="elsevierStyleCrossRef" href="#bib0275">16</a> an excessive surge in morning BP was significantly associated with an increased risk of stroke in elderly Japanese patients with hypertension. Subsequently, this correlation between exaggerated morning BP surge and stroke and mortality has been consistently demonstrated,<a class="elsevierStyleCrossRef" href="#bib0280">17</a> including in a recent retrospective study of Brazilian patients.<a class="elsevierStyleCrossRef" href="#bib0285">18</a> In this study, analysis of ambulatory BP monitoring (ABPM) data from Brazilian hypertensive patients attending a single center in São Paulo showed that those with an exaggerated morning BP surge (morning systolic BP surge ≥41mmHg) had a significant – almost threefold – increase in the risk of death compared with patients who had a normal morning BP surge (<41mmHg).<a class="elsevierStyleCrossRef" href="#bib0285">18</a> Patients who had exaggerated morning systolic BP surge were more likely to be older, had a higher daytime systolic BP as well as higher systolic and diastolic BP dipping, and a lower night-time diastolic BP.In the first reported study of its kind in Latin America, researchers in Argentina retrospectively evaluated the difference in morning and evening BP (MEdiff), as measured by home BP monitoring (HBPM), in hypertensive outpatients living in Buenos Aires, and correlated MEdiff with independent determinants.<a class="elsevierStyleCrossRef" href="#bib0290">19</a> Older age, smoking, total cholesterol and use of calcium channel blockers were found to be independent determinants of the home-based MEdiff. Moreover, looking at the MEdiff BP profile, home diastolic BP was found to be significantly higher in the morning than in the evening for all patients apart from smokers. After excluding smokers from the cohort for further analysis, both home systolic BP and diastolic BP were significantly higher in the morning than in the evening. This result was interesting in that it aligned with data obtained from Northeast Asian hypertensive populations, but not with European study findings.Though limited in scope, these regional data highlight that BP variability may be an important factor to consider in the management of hypertension in Latin American patients as a means to improve cardiovascular and stroke outcomes. Undoubtedly, more extensive but selective use of HBPM and ABPM – i.e., facilitating the mapping of an individual's BP – would help to enhance the rate and accuracy of BP diagnosis and control, but the major drawback currently lies in the limited availability of these devices. Nevertheless, the uptake of ABPM in Brazilian clinical practice has steadily increased since the Brazilian Societies of Cardiology, Hypertension and Nephrology first published guidelines on its use in 1993, and specific training on ABPM was provided via professional courses across the country.<a class="elsevierStyleCrossRef" href="#bib0295">20</a>Consequences of hypertension in Latin America: cardiovascular disease and strokeIn Venezuela, data from the 2012 Annual Mortality Report published by the Ministry of Health showed that cardiac diseases accounted for 30,000 deaths per year; cancer accounted for 22,000 deaths per year, and stroke, 11,000 deaths per year. Thus, in Venezuela, 41,000 deaths per year, or an average of 112 deaths per day, can be attributed to cardiovascular disease and stroke. The recently updated Panorama of Mortality from Cardiovascular Disease in Brazil, a descriptive epidemiological study that analyzed data from the 437 health regions of Brazil, reported on the trends in age-adjusted rates of total cardiovascular mortality in adults from 2003 to 2012. Cardiovascular disease remained the leading cause of death: in 2012, it was responsible for 31% of all deaths in Brazil, with ischemic heart disease (IHD) and cerebrovascular diseases being the leading causes, accounting for 31% and 30% of these deaths, respectively. A similar picture can be found across Latin America, particularly in those countries with burgeoning economies. Furthermore, unlike in developed nations such as the USA, where cardiovascular mortality has declined through consistent efforts to reduce hypertension and other risk factors, cardiovascular mortality in Latin America is rising.<a class="elsevierStyleCrossRef" href="#bib0300">21</a>A comparison of data from two longitudinal cohort studies – the Bambui Cohort Study of Ageing (Brazil) and the English Longitudinal Study of Ageing (ELSA) – exemplify the fact that mortality risk associated with hypertension in Latin America significantly exceeds that in developed nations.<a class="elsevierStyleCrossRef" href="#bib0305">22</a> In this analysis, the 6-year mortality risk attributable to smoking, hypertension and diabetes was compared between more than 3000 English and Brazilian patients with hypertension. One of the key findings was that the mortality rates and hazard ratios for mortality by hypertension in the Brazilian cohort were significantly higher than in the English cohort, and this difference was most pronounced in patients older than 75 years. Since the Bambui study purposefully recruited individuals with low income and level of schooling – a demographic very different to that in ELSA – the comparison of these two cohorts served also to highlight the impact of social or economic differences on hypertension and its outcomes.In terms of stroke, it is encouraging that stroke mortality in Brazil has improved in recent years. In 2011, data from the Brazilian Ministry of Health showed for the first time that the number of deaths due to coronary heart disease (CHD) exceeded that from stroke. Nevertheless, stroke is a neglected disease in Brazil and it cannot be overstated that the risk of premature death due to stroke in Brazil remains one of the highest in the world.<a class="elsevierStyleCrossRef" href="#bib0310">23</a> According to data from the 2013 Global Burden Disease report,<a class="elsevierStyleCrossRef" href="#bib0315">24</a> the years of life lost (YLL) due to premature death from CHD in Brazil was similar to that of other countries; however, the YLL from cerebrovascular disease in Brazil was significantly higher than the mean of most other countries (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).<a class="elsevierStyleCrossRef" href="#bib0315">24</a> Ultimately, the suboptimal control of risk factors for stroke, beginning with hypertension, represents a huge missed opportunity for primary prevention which, in Brazil, is tremendously felt in terms of morbidity, mortality and financial loss.<a class="elsevierStyleCrossRef" href="#bib0320">25</a><elsevierMultimedia ident="fig0005"></elsevierMultimedia>Hypertension and obesity are common comorbid risk factors for cardiovascular disease in Latin American populationsA recent review of literature from Latin American countries (Argentina, Bolivia, Brazil, Chile, Costa Rica, Colombia, Cuba, Ecuador, El Salvador, Honduras, Guatemala, Mexico, Nicaragua, Panama, Paraguay, Peru, Puerto Rico, Venezuela, Uruguay and Dominican Republic; N=7,192,262; 45 eligible studies) found that the most frequent cardiovascular risk factors in the region were, in order of most prevalent: arterial hypertension, overweight/obesity, diabetes and smoking.<a class="elsevierStyleCrossRef" href="#bib0325">26</a> Interestingly, the overall majority of cardiovascular risk factors were significantly more prevalent in women than in men; for the specific risk factors of overweight/obesity, physical inactivity, smoking and alcohol consumption, however, there was no difference between the sexes, underscoring the fact that detrimental lifestyle factors are indiscriminately affecting the Latin American population.Part of the INTERHEART Latin American study evaluated the risk factors contributing to a first acute myocardial infarction (MI) in matched controls from Argentina, Brazil, Colombia, Chile, Guatemala and Mexico.<a class="elsevierStyleCrossRef" href="#bib0330">27</a> This showed that abdominal obesity, abnormal lipids and smoking were associated with the highest population-attributable risks (PARs) of 48.5%, 40.8% and 38.4%, respectively (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).<a class="elsevierStyleCrossRef" href="#bib0330">27</a> Meanwhile, the more recent INTERSTROKE study determined that ten potentially modifiable risk factors (hypertension, physical inactivity, apolipoprotein (Apo)B/ApoA1 ratio, diet, waist-to-hip ratio, psychosocial factors, smoking, cardiac causes, alcohol consumption and type 2 diabetes) collectively accounted for 90% of the PARs of stroke, regardless of geographical region, ethnic group, sex and age, with hypertension being the most dominant.<a class="elsevierStyleCrossRef" href="#bib0335">28</a> There were, however, important regional variations in terms of the relative impact of most individual risk factors for stroke, which may partly explain the worldwide variations in frequency and case-mix of stroke. The most important message from INTERSTROKE was that stroke is a largely preventable disease: through the elimination of hypertension alone, stroke cases would be almost halved (reduced by 48%); with physical activity alone, by 36%; and with a healthier diet alone, by 19%.<a class="elsevierStyleCrossRef" href="#bib0335">28</a><elsevierMultimedia ident="tbl0005"></elsevierMultimedia>A closer look at obesity and physical inactivityIn Brazil, physical inactivity was found to account for 15% of all hospitalizations among patients with chronic non-communicable diseases, including IHD and diabetes, incurring annual costs exceeding US$730 million.<a class="elsevierStyleCrossRef" href="#bib0340">29</a> Furthermore, not only has the prevalence of obesity increased among Brazilian adults in recent years, but data indicate that this is also happening in children.<a class="elsevierStyleCrossRef" href="#bib0345">30</a> In a cross-sectional study of two population samples in Rio de Janeiro, in which the prevalence of obesity was compared between similar cohorts in 1986/1987 and in 2016, comprising more than 5000 schoolchildren aged 10–15 years, the prevalence of overweight/obesity levels was found to have almost doubled, from 17% in 1986 to 32% in 2016, and the prevalence of obesity trebled, from 6% to 18%.<a class="elsevierStyleCrossRef" href="#bib0345">30</a> Central obesity was present in 46% of the 2016 cohort, and 60% of these children did not take part in any physical activity. Worryingly, the rise in obesity rates was accompanied by an increased prevalence of isolated diastolic hypertension and systo-diastolic hypertension compared with 30 years before. Although the overall prevalence of hypertension declined in this period (from 11% to 8%), the researchers speculated whether this was an artifact of the different methods of BP measurement used, i.e., reflecting the difference between the auscultatory method used in 1986 and 1987, and the oscillometric method used in 2016.In Mexico, the National Health and Nutrition Survey compared data from 2012 with that from 2006, which showed a significant increase in the prevalence of physical inactivity among adults based on the World Health Organization definition (less than 150min per week of moderate physical activity, or 75min of vigorous activity, or their respective combination).<a class="elsevierStyleCrossRef" href="#bib0350">31</a> The increase in prevalence, from 13.4% in 2006 to 19.4% in 2012, represented an absolute increase of 6%, or relative increase of 44%. Individuals older than 60 years and those in the highest socioeconomic tertile were significantly more likely to be physically inactive, as were those who were obese. It has been previously estimated that physical inactivity may directly account for 6% of all CHD cases and 8% of all type 2 diabetes cases in Mexico.<a class="elsevierStyleCrossRef" href="#bib0355">32</a>Possible ‘characteristics’ of hypertension in Latin AmericaThus, compared with other populations, Latin Americans appear to have a predominance of the clustering of hypertension with diabetes and lipid abnormalities – often referred to as the metabolic syndrome.<a class="elsevierStyleCrossRef" href="#bib0360">33</a> The prevalence of the metabolic syndrome in Latin America currently ranges from 25% to 45% and it is increasing.<a class="elsevierStyleCrossRef" href="#bib0360">33</a> Another observation peculiar to Latin America is the high prevalence of arterial hypertension in children, adolescents and adults with nutritional stunting.<a class="elsevierStyleCrossRefs" href="#bib0360">33,34</a> Changes in the sympatho-adrenal and renin–angiotensin systems have also been reported in children small for their gestational age.<a class="elsevierStyleCrossRef" href="#bib0370">35</a> This evidence has led researchers to speculate whether environmental or epigenetic factors underlie or contribute to the apparent increased propensity and susceptibility of Latin Americans to the metabolic syndrome, hypertension and diabetes.<a class="elsevierStyleCrossRef" href="#bib0375">36</a> The hypothesis is that poor nutritional status in early life, and even in the fetal period, may have differential effects on cardiovascular and metabolic diseases manifesting in later life. The increased rates of hypertension, metabolic syndrome and type 2 diabetes observed in Latin America today may be due to the discrepancy between the nutritional environment during fetal and early life (‘fetal programming’), and the adult environment, in which substantial lifestyle changes have occurred due to socio-economic transition.<a class="elsevierStyleCrossRef" href="#bib0360">33</a> Though controversial, these limited, preliminary available data suggest that genes and environmental factors may contribute to a profile or ‘characteristic’ of hypertension that is particular to Latin American individuals, which warrants further study. Moreover, improved early nutrition and good eating habits sustained over the lifetime might particularly help to lower the risk of hypertension in Latin Americans.Primary prevention of hypertension and cardiovascular diseaseGiven that social and economic inequality in Latin America greatly restricts an individual's access to quality or individualized health care, primary prevention has never been more important as a key strategy for reducing the burden of hypertension and cardiovascular disease. In this setting, the media play an important role, as do frontline healthcare professionals, who are often the only source of reliable medical advice on lifestyle and diet,<a class="elsevierStyleCrossRef" href="#bib0380">37</a> and the first point of healthcare contact, for many patients. Population-wide public health campaigns have met with some success – the public policy against smoking in Brazil is one example<a class="elsevierStyleCrossRef" href="#bib0385">38</a> – but they have been largely limited in terms of time and resources invested. It is generally acknowledged among the Latin American medical community that, for these public health campaigns to make a greater, more tangible difference in changing lifestyle and behavior across populations, and to reap benefits in terms of improving disease outcomes in the long term, the investment in time and money needs to be far greater and sustained for considerably longer.ConclusionIf every person with hypertension knew their diagnosis and received proper treatment with at least one antihypertensive drug, it is very likely that cardiovascular disease would no longer be the leading cause of death in Latin America or, indeed, the rest of the world. Better and more timely control of hypertension in Latin America – taking into account the BP profile and ‘characteristics’ of the Latin American hypertensive patient – may go a long way to reducing the impact of this major cardiovascular risk factor. More knowledge of local epidemiological patterns of hypertension, derived via a national registry for example, as has been established in countries like Brazil,<a class="elsevierStyleCrossRef" href="#bib0390">39</a> will provide more insight, and help to tailor and optimize management. In terms of public health initiatives and policy, we strongly advocate the need for institutional disease awareness campaigns, similar to those conducted for certain types of cancer, in order to motivate the population to measure their BP and consult the physician as soon as their values go outside of the normal range. We firmly believe that this is the way forward to reducing cardiovascular mortality in Latin America and worldwide.Ethical disclosuresProtection of human and animal subjectsThe authors declare that the procedures followed were in accordance with the regulations of the relevant clinical research ethics committee and with those of the Code of Ethics of the World Medical Association (Declaration of Helsinki).Confidentiality of dataThe authors declare that they have followed the protocols of their work center on the publication of patient data.Right to privacy and informed consentThe authors have obtained the written informed consent of the patients or subjects mentioned in the article. The corresponding author is in possession of this document.Conflicts of interestThe authors have served as speaker/advisors for Daiichi-Sankyo." "textoCompletoSecciones" => array:1 [ "secciones" => array:14 [ 0 => array:3 [ "identificador" => "xres790144" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec788404" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres790145" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec788405" "titulo" => "Palabras clave" ] 4 => array:3 [ "identificador" => "sec0005" "titulo" => "Hypertension in Latin America: prevalence, awareness and control rate" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0010" "titulo" => "Clinical relevance of BP variability in Latin American populations" ] ] ] 5 => array:2 [ "identificador" => "sec0015" "titulo" => "Consequences of hypertension in Latin America: cardiovascular disease and stroke" ] 6 => array:3 [ "identificador" => "sec0020" "titulo" => "Hypertension and obesity are common comorbid risk factors for cardiovascular disease in Latin American populations" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0025" "titulo" => "A closer look at obesity and physical inactivity" ] ] ] 7 => array:2 [ "identificador" => "sec0030" "titulo" => "Possible ‘characteristics’ of hypertension in Latin America" ] 8 => array:2 [ "identificador" => "sec0035" "titulo" => "Primary prevention of hypertension and cardiovascular disease" ] 9 => array:2 [ "identificador" => "sec0040" "titulo" => "Conclusion" ] 10 => array:3 [ "identificador" => "sec0045" "titulo" => "Ethical disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0050" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0055" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0060" "titulo" => "Right to privacy and informed consent" ] ] ] 11 => array:2 [ "identificador" => "sec0065" "titulo" => "Conflicts of interest" ] 12 => array:2 [ "identificador" => "xack264481" "titulo" => "Acknowledgements" ] 13 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2016-11-02" "fechaAceptado" => "2016-11-28" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec788404" "palabras" => array:9 [ 0 => "Hypertension" 1 => "Latin America" 2 => "Brazil" 3 => "Mexico" 4 => "Venezuela" 5 => "Cardiovascular disease" 6 => "Blood pressure control" 7 => "Lifestyle" 8 => "Obesity" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec788405" "palabras" => array:9 [ 0 => "Hipertensión" 1 => "América Latina" 2 => "Brasil" 3 => "México" 4 => "Venezuela" 5 => "Enfermedad cardiovascular" 6 => "Control de la tensión arterial" 7 => "Estilo de vida" 8 => "Obesidad" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "The region of Latin America, which includes Central America, the Caribbean and South America, is one that is rapidly developing. Signified by socio-economic growth, transition and development over the last few decades, living standards in countries like Brazil and Mexico have improved dramatically, including improvements in education and health care. An important marker of socio-economic change has been the epidemiological shift in disease burden. Cardiovascular disease is now the leading cause of death in Latin America, and the drop in prevalence of infectious diseases has been accompanied by a rise in non-communicable diseases. Hypertension is the major risk factor driving the cardiovascular disease continuum. In this article we aim to discuss the epidemiological and management trends and patterns in hypertension that may be specific or more common to Latin-American populations – what we term ‘Latin American characteristics’ of hypertension – via a review of the recent literature. Recognizing that there may be a specific profile of hypertension for Latin-American patients may help to improve their treatment, with the ultimate goal to reduce their cardiovascular risk. We focus somewhat on the countries of Brazil, Mexico and Venezuela, the experience of which may reflect other Latin American countries that currently have less published data regarding epidemiology and management practices." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "La región de América Latina, que incluye Centroamérica, el Caribe y Sudamérica, está atravesando una rápida evolución. Esto se refleja en el crecimiento socioeconómico, la transición y el desarrollo durante las últimas décadas; las condiciones de vida en países como Brasil o México han mejorado drásticamente, lo que incluye reformas educativas y sanitarias. Un marcador importante de cambio socioeconómico ha sido el giro epidemiológico en la carga que suponen las enfermedades. Los trastornos cardiovasculares son la principal causa de mortalidad en América Latina, y la reducción en la prevalencia de enfermedades infecciosas se ha visto acompañada de un aumento de las enfermedades no contagiosas. La hipertensión es el factor de riesgo que lidera la continuidad de las enfermedades cardiovasculares. En este artículo pretendemos analizar las tendencias y los patrones en materia de epidemiología y gestión de la hipertensión que podrían ser específicos o más comunes en la población latinoamericana –lo que hemos llamado «características latinoamericanas» de la hipertensión– por medio de una revisión de la literatura reciente. Reconocer que podría existir un perfil específico de hipertensión para los pacientes latinoamericanos podría mejorar su tratamiento, con el objetivo final de reducir su riesgo cardiovascular. Nos centramos levemente en los países de Brasil, México y Venezuela, cuyas experiencias podrían verse reflejadas en otros países de América Latina que en la actualidad disponen de menos datos publicados en lo que respecta a las prácticas de epidemiología y gestión." ] ] "multimedia" => array:2 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "Adapted from Ref. <a class="elsevierStyleCrossRef" href="#bib0315">24</a>." "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2184 "Ancho" => 2639 "Tamanyo" => 250585 ] ] "descripcion" => array:1 [ "en" => "Age-adjusted years of life lost (in thousands) for (a) CHD and (b) stroke among 19 selected countries in 2013." ] ] 1 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "ApoB/ApoA1, apolipoprotein (Apo)B/ApoA1 ratio; CI, confidence interval; IHD, ischemic heart disease; PAR, population-attributable risk.Adapted from Ref. <a class="elsevierStyleCrossRef" href="#bib0330">27</a>." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td-with-role" title="table-head ; entry_with_role_rowhead " align="left" valign="top" scope="col">Risk factor \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Controls (%)</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">PAR (95% CI)</th></tr><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">LA \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">IH-ROW \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">LA \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">IH-ROW \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">ApoB/ApoA1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">42.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">32 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">40.8 (30.3–52.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">44.2 (41.3–47.1) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Smoking \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">48.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">48.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">38.4 (32.8–44.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">35.3 (33.3–37.4) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Type 2 diabetes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12.9 (10.3–16.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12.2 (11.3–13.1) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hypertension \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">29.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">20.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">32.9 (28.7–37.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">22.0 (20.7–23.4) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Waist/hip ratio \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">48.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">31.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">48.5 (35.8–56.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">30.2 (27.4–33.2) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Depression \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">28.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4.7 (1.4–13.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8.4 (7.3–9.7) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Permanent stress \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">28.1 (18.5–40.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7.8 (4.6–13.1) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Regular exercise \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">22.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">18.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">28.0 (17.7–41.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">24.8 (20.6–29.6) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Alcohol \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">19.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−3.2 (−18 to 11.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">16.3 (12.7–20.6) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Daily consumption of fruits and vegetables \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">84.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">83.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6.9 (3.35–10.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4.1 (2.9–5.3) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">All combined \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">88.1 (82.3–93.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">85.1 (82.9–87.2) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1319870.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Comparison of Latin American (LA) INTERHEART population with INTERHEART-Rest of World (IH-ROW) population excluding LA: risk factors associated with IHD." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:39 [ 0 => array:3 [ "identificador" => "bib0200" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Hypertension prevention and control in Latin America and the Caribbean" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "P. 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Special article

Hypertension in Latin America: Current perspectives on trends and characteristics

Hipertensión en América Latina: perspectivas actuales de las tendencias y características

L.M. Ruilopea,b,

Corresponding author

ruilope@ad-hocbox.com

Corresponding author.

, A.C.P. Chagasc, A.A. Brandãod, R. Gómez-Berroteráne, J.J.A. Alcaláf, J.V. Parisg, J.J.O. Cerdah

a “Cátedra UAM de Epidemiología y Control del Riesgo Cardiovascular”, Universidad Autónoma de Madrid, Spain

b Hypertension Unit, Institute of Research i+12: Hypertension and Cardiovascular Risk Group, Hospital Universitario 12 de Octubre & Department of Preventive Medicine and Public Health Universidad Autónoma de Madrid, Madrid, Spain

c Chief Cardiology Division, ABC Medical School, Av. Principe de Gales, 821, 09060-870 Santo André, SP, Brazil

d Department of Cardiology – Hypertension Unit, State University of Rio de Janeiro, Rio de Janeiro, Brazil

e Social Security, Hospital Dr. Domingo Luciani, Rio de Janeiro av. Municipio Sucre, Caracas 1073, Venezuela

f “Hospital Dr. Domingo Luciani” – Institute Venezuelan of the Safe Social (IVSS), Caracas, Venezuela

g Instituto Nacional de Cardiologia “Ignacio Chávez”, Mexico City, Mexico

h Research and Education General Director, Grupo Angeles Servicios de Salud, Mexico City, Mexico

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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Hypertension in Latin America&#58; prevalence&#44; awareness and control rate</span><p id="par0005" class="elsevierStylePara elsevierViewall">Hypertension is the most important risk factor contributing to the burden of cardiovascular disease&#44; the leading cause of death in all Latin American countries&#46;<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">1&#44;2</span></a> Up to 40&#37; of the adult Latin American population is estimated to be affected by hypertension &#8211; similar to that in developed countries &#8211; although there are considerable variations between ethnic and racial groups&#44; men and women&#44; and different countries within the region&#46; For example&#44; the Brazilian Longitudinal Study of Adult Health &#40;ELSA-Brasil&#41; showed that the adjusted prevalence of hypertension was highest amongst Blacks &#40;49&#46;2&#37;&#41; compared with Whites &#40;30&#46;3&#37;&#41; and Browns &#40;38&#46;2&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">3</span></a> Variations in hypertension prevalence within the same country also exist&#44; which may be partly explained by regional differences in diet&#46;<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">4&#8211;6</span></a> Like elsewhere&#44; hypertension increases with age in Latin America&#58; data from Mexico City showed a sharp increase in the prevalence of treated hypertension from middle age &#40;26&#37; among 35&#8211;44 year olds&#41; to elderly &#40;59&#37; among 75&#8211;84 year olds&#41;&#44; with this increase being significantly greater in women than in men&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">7</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Moreover&#44; as in other parts of the world&#44; the low rates of awareness&#44; treatment and control of hypertension in Latin America reveal the difficulty and inadequacy in managing this chronic disease on a population level&#46;<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">8&#8211;10</span></a> In a recent cross-sectional survey of around 7500 adults from four cities across Argentina&#44; Chile and Uruguay&#44; around 42&#46;5&#37; had hypertension and 32&#46;5&#37; had pre-hypertension&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">11</span></a> Of this population&#44; around 63&#46;0&#37; were aware of their disease&#44; 48&#46;7&#37; were taking prescribed medications to lower their blood pressure &#40;BP&#41;&#44; but only 21&#46;1&#37; of all hypertensive patients&#44; and 43&#46;3&#37; of treated hypertensive patients&#44; had their BP controlled to target&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">11</span></a> Similarly&#44; the ELSA-Brasil study found a high proportion of uncontrolled hypertension among its cohort of more than 15&#44;000 subjects recruited from universities and research institutions&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">12</span></a> In total&#44; 34&#37; of ELSA-Brasil participants knew they had hypertension and 29&#37; were taking BP medication&#59; however&#44; among those receiving treatment&#44; 31&#37; did not have controlled BP&#46; Perhaps not surprisingly&#44; controlled BP was more frequent in those with a higher education level &#40;postgraduate&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">There are many reasons for inadequate BP control&#44; including poor treatment adherence&#44; physician&#39;s inertia&#44; patient&#39;s baseline cardiovascular risk&#44; and poor adherence to guidelines by the treating physician&#46; Regarding the last point&#44; physicians&#8217; criteria for diagnosing and determining high BP may be highly subjective&#44; based on a &#8216;personal appreciation&#8217;&#44; without much heed to criteria specified in regional and international management guidelines&#46; In a recently published study by Ragot et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">13</span></a> the rates of controlled hypertension were evaluated in 2185 hypertensive adults across five countries&#44; including Venezuela&#46; Part of the study compared BP control rates&#44; as determined by physicians&#8217; perception&#44; with BP control rates determined using the 2007 European Society of Hypertension&#47;European Society of Cardiology &#40;ESH&#47;ESC&#41; guideline criteria&#46; There was a marked divergence between physicians&#8217; assessment and that based on the guidelines&#44; with doctors grossly overestimating the BP control rate&#58; according to physicians&#44; 72&#37; of patients had controlled hypertension when&#44; actually&#44; according to ESH&#47;ESC criteria&#44; only 40&#37; had controlled BP&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">13</span></a> The study found that other important factors leading to inadequate BP control were the presence of high or very high cardiovascular risk&#59; high salt intake&#59; treatment non-adherence&#59; lack of understanding of the treatment&#39;s importance&#59; comorbidity&#59; and depression&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">13</span></a></p><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Clinical relevance of BP variability in Latin American populations</span><p id="par0020" class="elsevierStylePara elsevierViewall">Furthermore&#44; in today&#39;s context&#44; the optimal control of a person&#39;s BP should necessarily involve some attention to BP variability&#44; particularly in at-risk individuals such as the elderly&#46; This rationale is based on accumulating evidence which indicates that some BP variability parameters have significant prognostic value for cardiovascular and cerebrovascular outcomes&#46;<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">14&#44;15</span></a> Although these data have been derived from post hoc analyses and observational studies&#44; and evidence is sorely needed from prospective&#44; randomized&#44; controlled trials&#44; they nevertheless suggest that more can be learned from looking beyond 24-h mean BP values alone&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Short-term &#40;within 24<span class="elsevierStyleHsp" style=""></span>h&#41; BP variability includes excessive morning BP surge and non-dipping or excessive dipping of night-time BP&#44; while long-term BP variability includes visit-to-visit BP variability&#46; In the seminal study by Kario et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">16</span></a> an excessive surge in morning BP was significantly associated with an increased risk of stroke in elderly Japanese patients with hypertension&#46; Subsequently&#44; this correlation between exaggerated morning BP surge and stroke and mortality has been consistently demonstrated&#44;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">17</span></a> including in a recent retrospective study of Brazilian patients&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">18</span></a> In this study&#44; analysis of ambulatory BP monitoring &#40;ABPM&#41; data from Brazilian hypertensive patients attending a single center in S&#227;o Paulo showed that those with an exaggerated morning BP surge &#40;morning systolic BP surge &#8805;41<span class="elsevierStyleHsp" style=""></span>mmHg&#41; had a significant &#8211; almost threefold &#8211; increase in the risk of death compared with patients who had a normal morning BP surge &#40;&#60;41<span class="elsevierStyleHsp" style=""></span>mmHg&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">18</span></a> Patients who had exaggerated morning systolic BP surge were more likely to be older&#44; had a higher daytime systolic BP as well as higher systolic and diastolic BP dipping&#44; and a lower night-time diastolic BP&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">In the first reported study of its kind in Latin America&#44; researchers in Argentina retrospectively evaluated the difference in morning and evening BP &#40;MEdiff&#41;&#44; as measured by home BP monitoring &#40;HBPM&#41;&#44; in hypertensive outpatients living in Buenos Aires&#44; and correlated MEdiff with independent determinants&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">19</span></a> Older age&#44; smoking&#44; total cholesterol and use of calcium channel blockers were found to be independent determinants of the home-based MEdiff&#46; Moreover&#44; looking at the MEdiff BP profile&#44; home diastolic BP was found to be significantly higher in the morning than in the evening for all patients apart from smokers&#46; After excluding smokers from the cohort for further analysis&#44; both home systolic BP and diastolic BP were significantly higher in the morning than in the evening&#46; This result was interesting in that it aligned with data obtained from Northeast Asian hypertensive populations&#44; but not with European study findings&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Though limited in scope&#44; these regional data highlight that BP variability may be an important factor to consider in the management of hypertension in Latin American patients as a means to improve cardiovascular and stroke outcomes&#46; Undoubtedly&#44; more extensive but selective use of HBPM and ABPM &#8211; i&#46;e&#46;&#44; facilitating the mapping of an individual&#39;s BP &#8211; would help to enhance the rate and accuracy of BP diagnosis and control&#44; but the major drawback currently lies in the limited availability of these devices&#46; Nevertheless&#44; the uptake of ABPM in Brazilian clinical practice has steadily increased since the Brazilian Societies of Cardiology&#44; Hypertension and Nephrology first published guidelines on its use in 1993&#44; and specific training on ABPM was provided via professional courses across the country&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">20</span></a></p></span></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Consequences of hypertension in Latin America&#58; cardiovascular disease and stroke</span><p id="par0040" class="elsevierStylePara elsevierViewall">In Venezuela&#44; data from the 2012 Annual Mortality Report published by the Ministry of Health showed that cardiac diseases accounted for 30&#44;000 deaths per year&#59; cancer accounted for 22&#44;000 deaths per year&#44; and stroke&#44; 11&#44;000 deaths per year&#46; Thus&#44; in Venezuela&#44; 41&#44;000 deaths per year&#44; or an average of 112 deaths per day&#44; can be attributed to cardiovascular disease and stroke&#46; The recently updated Panorama of Mortality from Cardiovascular Disease in Brazil&#44; a descriptive epidemiological study that analyzed data from the 437 health regions of Brazil&#44; reported on the trends in age-adjusted rates of total cardiovascular mortality in adults from 2003 to 2012&#46; Cardiovascular disease remained the leading cause of death&#58; in 2012&#44; it was responsible for 31&#37; of all deaths in Brazil&#44; with ischemic heart disease &#40;IHD&#41; and cerebrovascular diseases being the leading causes&#44; accounting for 31&#37; and 30&#37; of these deaths&#44; respectively&#46; A similar picture can be found across Latin America&#44; particularly in those countries with burgeoning economies&#46; Furthermore&#44; unlike in developed nations such as the USA&#44; where cardiovascular mortality has declined through consistent efforts to reduce hypertension and other risk factors&#44; cardiovascular mortality in Latin America is rising&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">21</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">A comparison of data from two longitudinal cohort studies &#8211; the Bambui Cohort Study of Ageing &#40;Brazil&#41; and the English Longitudinal Study of Ageing &#40;ELSA&#41; &#8211; exemplify the fact that mortality risk associated with hypertension in Latin America significantly exceeds that in developed nations&#46;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">22</span></a> In this analysis&#44; the 6-year mortality risk attributable to smoking&#44; hypertension and diabetes was compared between more than 3000 English and Brazilian patients with hypertension&#46; One of the key findings was that the mortality rates and hazard ratios for mortality <span class="elsevierStyleItalic">by hypertension</span> in the Brazilian cohort were significantly higher than in the English cohort&#44; and this difference was most pronounced in patients older than 75 years&#46; Since the Bambui study purposefully recruited individuals with low income and level of schooling &#8211; a demographic very different to that in ELSA &#8211; the comparison of these two cohorts served also to highlight the impact of social or economic differences on hypertension and its outcomes&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">In terms of stroke&#44; it is encouraging that stroke mortality in Brazil has improved in recent years&#46; In 2011&#44; data from the Brazilian Ministry of Health showed for the first time that the number of deaths due to coronary heart disease &#40;CHD&#41; exceeded that from stroke&#46; Nevertheless&#44; stroke is a neglected disease in Brazil and it cannot be overstated that the risk of premature death due to stroke in Brazil remains one of the highest in the world&#46;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">23</span></a> According to data from the 2013 Global Burden Disease report&#44;<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">24</span></a> the years of life lost &#40;YLL&#41; due to premature death from CHD in Brazil was similar to that of other countries&#59; however&#44; the YLL from cerebrovascular disease in Brazil was significantly higher than the mean of most other countries &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">24</span></a> Ultimately&#44; the suboptimal control of risk factors for stroke&#44; beginning with hypertension&#44; represents a huge missed opportunity for primary prevention which&#44; in Brazil&#44; is tremendously felt in terms of morbidity&#44; mortality and financial loss&#46;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">25</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Hypertension and obesity are common comorbid risk factors for cardiovascular disease in Latin American populations</span><p id="par0055" class="elsevierStylePara elsevierViewall">A recent review of literature from Latin American countries &#40;Argentina&#44; Bolivia&#44; Brazil&#44; Chile&#44; Costa Rica&#44; Colombia&#44; Cuba&#44; Ecuador&#44; El Salvador&#44; Honduras&#44; Guatemala&#44; Mexico&#44; Nicaragua&#44; Panama&#44; Paraguay&#44; Peru&#44; Puerto Rico&#44; Venezuela&#44; Uruguay and Dominican Republic&#59; <span class="elsevierStyleItalic">N</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>7&#44;192&#44;262&#59; 45 eligible studies&#41; found that the most frequent cardiovascular risk factors in the region were&#44; in order of most prevalent&#58; arterial hypertension&#44; overweight&#47;obesity&#44; diabetes and smoking&#46;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">26</span></a> Interestingly&#44; the overall majority of cardiovascular risk factors were significantly more prevalent in women than in men&#59; for the specific risk factors of overweight&#47;obesity&#44; physical inactivity&#44; smoking and alcohol consumption&#44; however&#44; there was no difference between the sexes&#44; underscoring the fact that detrimental lifestyle factors are indiscriminately affecting the Latin American population&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Part of the INTERHEART Latin American study evaluated the risk factors contributing to a first acute myocardial infarction &#40;MI&#41; in matched controls from Argentina&#44; Brazil&#44; Colombia&#44; Chile&#44; Guatemala and Mexico&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">27</span></a> This showed that abdominal obesity&#44; abnormal lipids and smoking were associated with the highest population-attributable risks &#40;PARs&#41; of 48&#46;5&#37;&#44; 40&#46;8&#37; and 38&#46;4&#37;&#44; respectively &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">27</span></a> Meanwhile&#44; the more recent INTERSTROKE study determined that ten potentially modifiable risk factors &#40;hypertension&#44; physical inactivity&#44; apolipoprotein &#40;Apo&#41;B&#47;ApoA1 ratio&#44; diet&#44; waist-to-hip ratio&#44; psychosocial factors&#44; smoking&#44; cardiac causes&#44; alcohol consumption and type 2 diabetes&#41; collectively accounted for 90&#37; of the PARs of stroke&#44; regardless of geographical region&#44; ethnic group&#44; sex and age&#44; with hypertension being the most dominant&#46;<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">28</span></a> There were&#44; however&#44; important regional variations in terms of the relative impact of most individual risk factors for stroke&#44; which may partly explain the worldwide variations in frequency and case-mix of stroke&#46; The most important message from INTERSTROKE was that stroke is a largely preventable disease&#58; through the elimination of hypertension alone&#44; stroke cases would be almost halved &#40;reduced by 48&#37;&#41;&#59; with physical activity alone&#44; by 36&#37;&#59; and with a healthier diet alone&#44; by 19&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">28</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">A closer look at obesity and physical inactivity</span><p id="par0065" class="elsevierStylePara elsevierViewall">In Brazil&#44; physical inactivity was found to account for 15&#37; of all hospitalizations among patients with chronic non-communicable diseases&#44; including IHD and diabetes&#44; incurring annual costs exceeding US&#36;730 million&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">29</span></a> Furthermore&#44; not only has the prevalence of obesity increased among Brazilian adults in recent years&#44; but data indicate that this is also happening in children&#46;<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">30</span></a> In a cross-sectional study of two population samples in Rio de Janeiro&#44; in which the prevalence of obesity was compared between similar cohorts in 1986&#47;1987 and in 2016&#44; comprising more than 5000 schoolchildren aged 10&#8211;15 years&#44; the prevalence of overweight&#47;obesity levels was found to have almost doubled&#44; from 17&#37; in 1986 to 32&#37; in 2016&#44; and the prevalence of obesity trebled&#44; from 6&#37; to 18&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">30</span></a> Central obesity was present in 46&#37; of the 2016 cohort&#44; and 60&#37; of these children did not take part in any physical activity&#46; Worryingly&#44; the rise in obesity rates was accompanied by an increased prevalence of isolated diastolic hypertension and systo-diastolic hypertension compared with 30 years before&#46; Although the overall prevalence of hypertension declined in this period &#40;from 11&#37; to 8&#37;&#41;&#44; the researchers speculated whether this was an artifact of the different methods of BP measurement used&#44; i&#46;e&#46;&#44; reflecting the difference between the auscultatory method used in 1986 and 1987&#44; and the oscillometric method used in 2016&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">In Mexico&#44; the National Health and Nutrition Survey compared data from 2012 with that from 2006&#44; which showed a significant increase in the prevalence of physical inactivity among adults based on the World Health Organization definition &#40;less than 150<span class="elsevierStyleHsp" style=""></span>min per week of moderate physical activity&#44; or 75<span class="elsevierStyleHsp" style=""></span>min of vigorous activity&#44; or their respective combination&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">31</span></a> The increase in prevalence&#44; from 13&#46;4&#37; in 2006 to 19&#46;4&#37; in 2012&#44; represented an absolute increase of 6&#37;&#44; or relative increase of 44&#37;&#46; Individuals older than 60 years and those in the highest socioeconomic tertile were significantly more likely to be physically inactive&#44; as were those who were obese&#46; It has been previously estimated that physical inactivity may directly account for 6&#37; of all CHD cases and 8&#37; of all type 2 diabetes cases in Mexico&#46;<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">32</span></a></p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Possible &#8216;characteristics&#8217; of hypertension in Latin America</span><p id="par0075" class="elsevierStylePara elsevierViewall">Thus&#44; compared with other populations&#44; Latin Americans appear to have a predominance of the clustering of hypertension with diabetes and lipid abnormalities &#8211; often referred to as the metabolic syndrome&#46;<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">33</span></a> The prevalence of the metabolic syndrome in Latin America currently ranges from 25&#37; to 45&#37; and it is increasing&#46;<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">33</span></a> Another observation peculiar to Latin America is the high prevalence of arterial hypertension in children&#44; adolescents and adults with nutritional stunting&#46;<a class="elsevierStyleCrossRefs" href="#bib0360"><span class="elsevierStyleSup">33&#44;34</span></a> Changes in the sympatho-adrenal and renin&#8211;angiotensin systems have also been reported in children small for their gestational age&#46;<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">35</span></a> This evidence has led researchers to speculate whether environmental or epigenetic factors underlie or contribute to the apparent increased propensity and susceptibility of Latin Americans to the metabolic syndrome&#44; hypertension and diabetes&#46;<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">36</span></a> The hypothesis is that poor nutritional status in early life&#44; and even in the fetal period&#44; may have differential effects on cardiovascular and metabolic diseases manifesting in later life&#46; The increased rates of hypertension&#44; metabolic syndrome and type 2 diabetes observed in Latin America today may be due to the discrepancy between the nutritional environment during fetal and early life &#40;&#8216;fetal programming&#8217;&#41;&#44; and the adult environment&#44; in which substantial lifestyle changes have occurred due to socio-economic transition&#46;<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">33</span></a> Though controversial&#44; these limited&#44; preliminary available data suggest that genes and environmental factors may contribute to a profile or &#8216;characteristic&#8217; of hypertension that is particular to Latin American individuals&#44; which warrants further study&#46; Moreover&#44; improved early nutrition and good eating habits sustained over the lifetime might particularly help to lower the risk of hypertension in Latin Americans&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Primary prevention of hypertension and cardiovascular disease</span><p id="par0080" class="elsevierStylePara elsevierViewall">Given that social and economic inequality in Latin America greatly restricts an individual&#39;s access to quality or individualized health care&#44; primary prevention has never been more important as a key strategy for reducing the burden of hypertension and cardiovascular disease&#46; In this setting&#44; the media play an important role&#44; as do frontline healthcare professionals&#44; who are often the only source of reliable medical advice on lifestyle and diet&#44;<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">37</span></a> and the first point of healthcare contact&#44; for many patients&#46; Population-wide public health campaigns have met with some success &#8211; the public policy against smoking in Brazil is one example<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">38</span></a> &#8211; but they have been largely limited in terms of time and resources invested&#46; It is generally acknowledged among the Latin American medical community that&#44; for these public health campaigns to make a greater&#44; more tangible difference in changing lifestyle and behavior across populations&#44; and to reap benefits in terms of improving disease outcomes in the long term&#44; the investment in time and money needs to be far greater and sustained for considerably longer&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conclusion</span><p id="par0085" class="elsevierStylePara elsevierViewall">If every person with hypertension knew their diagnosis and received proper treatment with at least one antihypertensive drug&#44; it is very likely that cardiovascular disease would no longer be the leading cause of death in Latin America or&#44; indeed&#44; the rest of the world&#46; Better and more timely control of hypertension in Latin America &#8211; taking into account the BP profile and &#8216;characteristics&#8217; of the Latin American hypertensive patient &#8211; may go a long way to reducing the impact of this major cardiovascular risk factor&#46; More knowledge of local epidemiological patterns of hypertension&#44; derived via a national registry for example&#44; as has been established in countries like Brazil&#44;<a class="elsevierStyleCrossRef" href="#bib0390"><span class="elsevierStyleSup">39</span></a> will provide more insight&#44; and help to tailor and optimize management&#46; In terms of public health initiatives and policy&#44; we strongly advocate the need for institutional disease awareness campaigns&#44; similar to those conducted for certain types of cancer&#44; in order to motivate the population to measure their BP and consult the physician as soon as their values go outside of the normal range&#46; We firmly believe that this is the way forward to reducing cardiovascular mortality in Latin America and worldwide&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Ethical disclosures</span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Protection of human and animal subjects</span><p id="par0090" class="elsevierStylePara elsevierViewall">The authors declare that the procedures followed were in accordance with the regulations of the relevant clinical research ethics committee and with those of the Code of Ethics of the World Medical Association &#40;Declaration of Helsinki&#41;&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Confidentiality of data</span><p id="par0095" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their work center on the publication of patient data&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Right to privacy and informed consent</span><p id="par0100" class="elsevierStylePara elsevierViewall">The authors have obtained the written informed consent of the patients or subjects mentioned in the article&#46; The corresponding author is in possession of this document&#46;</p></span></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conflicts of interest</span><p id="par0105" class="elsevierStylePara elsevierViewall">The authors have served as speaker&#47;advisors for Daiichi-Sankyo&#46;</p></span></span>"
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          "titulo" => "Conflicts of interest"
        ]
        12 => array:2 [
          "identificador" => "xack264481"
          "titulo" => "Acknowledgements"
        ]
        13 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2016-11-02"
    "fechaAceptado" => "2016-11-28"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec788404"
          "palabras" => array:9 [
            0 => "Hypertension"
            1 => "Latin America"
            2 => "Brazil"
            3 => "Mexico"
            4 => "Venezuela"
            5 => "Cardiovascular disease"
            6 => "Blood pressure control"
            7 => "Lifestyle"
            8 => "Obesity"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec788405"
          "palabras" => array:9 [
            0 => "Hipertensi&#243;n"
            1 => "Am&#233;rica Latina"
            2 => "Brasil"
            3 => "M&#233;xico"
            4 => "Venezuela"
            5 => "Enfermedad cardiovascular"
            6 => "Control de la tensi&#243;n arterial"
            7 => "Estilo de vida"
            8 => "Obesidad"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The region of Latin America&#44; which includes Central America&#44; the Caribbean and South America&#44; is one that is rapidly developing&#46; Signified by socio-economic growth&#44; transition and development over the last few decades&#44; living standards in countries like Brazil and Mexico have improved dramatically&#44; including improvements in education and health care&#46; An important marker of socio-economic change has been the epidemiological shift in disease burden&#46; Cardiovascular disease is now the leading cause of death in Latin America&#44; and the drop in prevalence of infectious diseases has been accompanied by a rise in non-communicable diseases&#46; Hypertension is the major risk factor driving the cardiovascular disease continuum&#46; In this article we aim to discuss the epidemiological and management trends and patterns in hypertension that may be specific or more common to Latin-American populations &#8211; what we term &#8216;Latin American characteristics&#8217; of hypertension &#8211; via a review of the recent literature&#46; Recognizing that there may be a specific profile of hypertension for Latin-American patients may help to improve their treatment&#44; with the ultimate goal to reduce their cardiovascular risk&#46; We focus somewhat on the countries of Brazil&#44; Mexico and Venezuela&#44; the experience of which may reflect other Latin American countries that currently have less published data regarding epidemiology and management practices&#46;</p></span>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">La regi&#243;n de Am&#233;rica Latina&#44; que incluye Centroam&#233;rica&#44; el Caribe y Sudam&#233;rica&#44; est&#225; atravesando una r&#225;pida evoluci&#243;n&#46; Esto se refleja en el crecimiento socioecon&#243;mico&#44; la transici&#243;n y el desarrollo durante las &#250;ltimas d&#233;cadas&#59; las condiciones de vida en pa&#237;ses como Brasil o M&#233;xico han mejorado dr&#225;sticamente&#44; lo que incluye reformas educativas y sanitarias&#46; Un marcador importante de cambio socioecon&#243;mico ha sido el giro epidemiol&#243;gico en la carga que suponen las enfermedades&#46; Los trastornos cardiovasculares son la principal causa de mortalidad en Am&#233;rica Latina&#44; y la reducci&#243;n en la prevalencia de enfermedades infecciosas se ha visto acompa&#241;ada de un aumento de las enfermedades no contagiosas&#46; La hipertensi&#243;n es el factor de riesgo que lidera la continuidad de las enfermedades cardiovasculares&#46; En este art&#237;culo pretendemos analizar las tendencias y los patrones en materia de epidemiolog&#237;a y gesti&#243;n de la hipertensi&#243;n que podr&#237;an ser espec&#237;ficos o m&#225;s comunes en la poblaci&#243;n latinoamericana &#8211;lo que hemos llamado &#171;caracter&#237;sticas latinoamericanas&#187; de la hipertensi&#243;n&#8211; por medio de una revisi&#243;n de la literatura reciente&#46; Reconocer que podr&#237;a existir un perfil espec&#237;fico de hipertensi&#243;n para los pacientes latinoamericanos podr&#237;a mejorar su tratamiento&#44; con el objetivo final de reducir su riesgo cardiovascular&#46; Nos centramos levemente en los pa&#237;ses de Brasil&#44; M&#233;xico y Venezuela&#44; cuyas experiencias podr&#237;an verse reflejadas en otros pa&#237;ses de Am&#233;rica Latina que en la actualidad disponen de menos datos publicados en lo que respecta a las pr&#225;cticas de epidemiolog&#237;a y gesti&#243;n&#46;</p></span>"
      ]
    ]
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        "identificador" => "fig0005"
        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "fuente" => "Adapted from Ref&#46; <a class="elsevierStyleCrossRef" href="#bib0315">24</a>&#46;"
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Age-adjusted years of life lost &#40;in thousands&#41; for &#40;a&#41; CHD and &#40;b&#41; stroke among 19 selected countries in 2013&#46;</p>"
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        "identificador" => "tbl0005"
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">ApoB&#47;ApoA1&#44; apolipoprotein &#40;Apo&#41;B&#47;ApoA1 ratio&#59; CI&#44; confidence interval&#59; IHD&#44; ischemic heart disease&#59; PAR&#44; population-attributable risk&#46;</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Adapted from Ref&#46; <a class="elsevierStyleCrossRef" href="#bib0330">27</a>&#46;</p>"
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              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td-with-role" title="table-head ; entry_with_role_rowhead " align="left" valign="top" scope="col">Risk factor&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Controls &#40;&#37;&#41;</th><th class="td" title="table-head  " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">PAR &#40;95&#37; CI&#41;</th></tr><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">LA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">IH-ROW&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">LA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">IH-ROW&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">ApoB&#47;ApoA1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">42&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">32&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">40&#46;8 &#40;30&#46;3&#8211;52&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">44&#46;2 &#40;41&#46;3&#8211;47&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Smoking&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">48&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">48&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">38&#46;4 &#40;32&#46;8&#8211;44&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">35&#46;3 &#40;33&#46;3&#8211;37&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Type 2 diabetes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12&#46;9 &#40;10&#46;3&#8211;16&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12&#46;2 &#40;11&#46;3&#8211;13&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hypertension&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">29&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">20&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">32&#46;9 &#40;28&#46;7&#8211;37&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">22&#46;0 &#40;20&#46;7&#8211;23&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Waist&#47;hip ratio&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">48&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">31&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">48&#46;5 &#40;35&#46;8&#8211;56&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">30&#46;2 &#40;27&#46;4&#8211;33&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Depression&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">28&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;7 &#40;1&#46;4&#8211;13&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8&#46;4 &#40;7&#46;3&#8211;9&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Permanent stress&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">28&#46;1 &#40;18&#46;5&#8211;40&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&#46;8 &#40;4&#46;6&#8211;13&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Regular exercise&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">22&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">18&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">28&#46;0 &#40;17&#46;7&#8211;41&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">24&#46;8 &#40;20&#46;6&#8211;29&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Alcohol&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">19&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">11&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8722;3&#46;2 &#40;&#8722;18 to 11&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">16&#46;3 &#40;12&#46;7&#8211;20&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Daily consumption of fruits and vegetables&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">84&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">83&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6&#46;9 &#40;3&#46;35&#8211;10&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;1 &#40;2&#46;9&#8211;5&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">All combined&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">88&#46;1 &#40;82&#46;3&#8211;93&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">85&#46;1 &#40;82&#46;9&#8211;87&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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        "descripcion" => array:1 [
          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Comparison of Latin American &#40;LA&#41; INTERHEART population with INTERHEART-Rest of World &#40;IH-ROW&#41; population excluding LA&#58; risk factors associated with IHD&#46;</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:39 [
            0 => array:3 [
              "identificador" => "bib0200"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Hypertension prevention and control in Latin America and the Caribbean"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "P&#46; Ordunez"
                            1 => "R&#46; Martinez"
                            2 => "M&#46;L&#46; Niebylski"
                            3 => "N&#46;R&#46; Campbell"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "J Clin Hypertens"
                        "fecha" => "2015"
                        "volumen" => "17"
                        "paginaInicial" => "499"
                        "paginaFinal" => "502"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0205"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:1 [
                  "referenciaCompleta" => "Pan American Health Organization&#46; Deaths due to noncommunicable diseases in countries of the Americas&#44; regional mortality database 2014&#46; <a id="intr0005" class="elsevierStyleInterRef" href="http://www.paho.org/hq/index.php?option=com_content%26view=article%26id=5967%3A2011-non-communicable-diseases%26catid=2390%3Aregional-health-observatory-themes%26Itemid=2391%26lang=en">http&#58;&#47;&#47;www&#46;paho&#46;org&#47;hq&#47;index&#46;php&#63;option&#61;com&#95;content&#38;view&#61;article&#38;id&#61;5967&#37;3A2011-non-communicable-diseases&#38;catid&#61;2390&#37;3Aregional-health-observatory-themes&#38;Itemid&#61;2391&#10216;&#61;en</a> &#91;accessed 08&#46;09&#46;16&#93;&#46;"
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0210"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Prevalence&#44; awareness&#44; treatment and influence of socioeconomic variables on control of high blood pressure&#58; results of the ELSA-Brasil Study"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "D&#46; Chor"
                            1 => "A&#46;L&#46; Pinho Ribeiro"
                            2 => "M&#46; S&#225; Carvalho"
                            3 => "B&#46;B&#46; Duncan"
                            4 => "P&#46; Andrade Lotufo"
                            5 => "A&#46; Ara&#250;jo Nobre"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1371/journal.pone.0127382"
                      "Revista" => array:5 [
                        "tituloSerie" => "PLOS ONE"
                        "fecha" => "2015"
                        "volumen" => "10"
                        "paginaInicial" => "e0127382"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26102079"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib0215"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "CARMELA&#58; assessment of cardiovascular risk in seven Latin American cities"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "H&#46; Schargrodsky"
                            1 => "R&#46; Hernandez-Hernandez"
                            2 => "B&#46;M&#46; Champagne"
                            3 => "H&#46; Silva"
                            4 => "R&#46; Vinueza"
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Article information

ISSN: 18891837
Original language: English

DOI:10.1016/j.hipert.2016.11.005

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