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Latin American Consensus on the management of hypertension in the patient with diabetes and the metabolic syndrome

López-Jaramillo, Patricioa; Barbosa, Eduardob; Molina, Dora I.c; Sanchez, Ramirod; Diaz, Margaritae; Camacho, Paul A.f; Lanas, Fernandog; Pasquel, Miguelh; Accini, José L.i; Ponte-Negretti, Carlos I.j; Alcocer, Luisk; Cobos, Leonardol; Wyss, Fernandom; Sebba-Barroso, Weimarn; Coca, Antonioo; Zanchetti, Albertop,* on behalf of the Latin American Society of Hypertension Consensus Expert Group

doi: 10.1097/HJH.0000000000002072
CONSENSUS DOCUMENT
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The prevalence of hypertension, type 2 diabetes mellitus (DM2) and the metabolic syndrome continues to increase in Latin America, while the rates of diagnosis, treatment and control of these disorders remain low. The frequency of the risk factors that constitute the metabolic syndrome and are associated with an increased risk of cardiovascular disease has not diminished since the publication of the previous consensus. This document discusses the socioeconomic, demographic, environmental and cultural characteristics of most associated Latin American countries and partially explains the lack of better results in improving clinical and public health actions that allow high morbidity and mortality rates caused by cardiovascular diseases and DM2 to be reduced through programs aligned with the so-called precision medicine, which should be predictive, preventive, personalized and participatory. The Consensus ratifies the diagnostic criteria expressed in the previous consensus to define hypertension and DM2 but, for the metabolic syndrome, and in the absence of evidence, the recommendation is to implement a cohort study that determines the abdominal perimeter value associated with hard outcomes, such as DM2 and CVD. Meanwhile, we recommend modifying the criterion to more than 94 cm in men and more than 84 cm in women according to WHO recommendations. We also recommend the carrying out of a study that identifies the situation of hypertension and DM2 in people of African ancestry who, in Latin America, exceed 75 million and whose epidemiology does not include solid studies. With respect to the proposed therapeutic targets, we recommended maintaining those defined in the previous consensus, but insisting that early pharmacological management of prediabetes with metformin should be introduced, as should the treatment of diabetic hypertensive patients with a combination therapy of two fixed-dose antihypertensive drugs and management with statins. To increase adherence, the use of different drugs combined in a single pill (polypill) is recommended. The simplification of the therapeutic regimen is accompanied by greater control of cardiovascular risk factors, both in primary and secondary prevention, and has been shown to be cost-effective. The consensus recommends the use of the currently available polypill combining an angiotensin-converting enzyme inhibitor, a statin and aspirin for secondary cardiovascular prevention and in patients with a high cardiovascular risk, such as hypertension patients with DM2.

aClinica de Síndrome Metabolico, Prediabetes y Diabetes, Direccion de Investigaciones FOSCAL y Facultad de Salud, Universidad de Santander (UDES), Bucaramanga, Colombia

bLiga de Combate a la Hipertensión de Porto Alegre, Brazil

cUniversidad de Caldas e IPS Médicos Internistas de Caldas, Manizales, Colombia

dHospital Universitario Fundacion Favaloro, Buenos Aires, Argentina

eClinica Platinium, Montevideo, Uruguay

fDireccion de Investigaciones FOSCAL y Facultad de Salud, Universidad Autonoma de Bucaramanga (UNAB), Bucaramanga, Colombia

gUniversidad de La Frontera, Temuco, Chile

hInstituto Médico Integral VIDA, Quito, Ecuador

iFundacion Hospital Universidad del Norte y Universidad Libre, Barranquilla, Colombia

jFundación Venezolana de Cardiología Preventiva, Caracas, Venezuela

kInstituto Mexicano de Salud Cardiovascular, Ciudad de Mexico, Mexico

lUnidad de Cardiologia, Hospital El Pino, Santiago, Chile

mServicios y Tecnologica Cardiovascular de Gautemala, S.A., Guatemala

nHypertension League, Federal University of Goias, Brazil

oHospital Clínico, Universidad de Barcelona, Spain

pIstituto Auxologico Italiano, IRCCS, and Università degli Studi of Milan, Italy

Correspondence to Professor Patricio López-Jaramillo, MD, PhD, Clinica de Síndrome Metabolico, Prediabetes y Diabetes, Direccion de Investigaciones FOSCAL y Facultad de Salud, Universidad de Santander (UDES), Bucaramanga, Colombia. Tel: + 57 7 679 7979 x6164; e-mail: jplopezj@gmail.com

Abbreviations: ACEI, angiotensin-converting enzyme inhibitor; AMI, acute myocardial infarction; ARB, angiotensin receptor blocker; BP, blood pressure; CAMDI, Central American Diabetes Initiative; CCB, calcium channel blocker; CI, confidence interval; CVD, cardiovascular disease; DIU, diuretic; DM2, type 2 diabetes mellitus; DOTA, Declaration of the Americas on Diabetes; IDF, International Diabetes Federation; LASH, Latin American Society of Hypertension; LATAM, Latin America; PAHO, Pan American Health Organization; PURE, The Prospective Urban Rural Epidemiology study; RAS, renin–angiotensin system; RCTs, randomized clinical trials; SLIM, Lifestyle Intervention on Postprandial Glucose Metabolism Study; SPC, single pill combination; UPF, ultra-processed foods; USA, United States of America

Received 10 December, 2018

Revised 22 December, 2018

Accepted 24 January, 2019

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