Jose Ramón Banegas

Background: In cognitive impairment and dementia, where biological functions are disrupted, nonlinear dynamics may reflect dysregulation of blood pressure (BP) that might not be captured by linear variability. We investigated whether nonlinear dynamics of 24‐hour BP variability are associated with cognitive impairment and dementia. Methods: We conducted a cross‐sectional analysis of 4854 participants from 3 population‐based studies. Raw 24‐hour ambulatory BP recordings were structured as time series to quantify nonlinear variability using sample entropy, detrended fluctuation analysis, and Poincaré measures. High entropy and Poincaré values with low detrended fluctuation analysis suggest irregular dynamics, whereas the opposite pattern indicates a predictable BP system. Neurological outcomes included Mini‐Mental State Examination, mild cognitive impairment (n=212), and dementia (n=111). Results: The mean age was 67.6±7.89 years (61.0% women). Higher 24‐hour systolic BP entropy and Poincaré measures were associated with lower Mini‐Mental State Examination; adjusted‐mean Mini‐Mental State Examination estimates ranged from −0.119 (95% CI, −0.184 to −0.053) to −0.035 (95% CI, −0.060 to −0.010). These measures were also associated with higher odds for prevalent mild cognitive impairment (odds ratios [OR] ≥1.41) and dementia (ORs ranged from 1.32 [95% CI, 1.08–1.60] to 2.36 [95% CI, 1.49–3.74]). Lower detrended fluctuation analysis was related to dementia (OR, 1.64 [95% CI, 1.01–2.68]). Sex, antihypertensive medication, and measures of linear variability did not modify the association between nonlinear variability and cognitive outcomes. Conclusions: Nonlinear 24‐hour BP dynamics were associated with cognitive impairment and dementia. Nonlinear patterns of irregular 24‐hour variability may represent a form of BP dysregulation relevant to dementia.

Objectives: This study evaluated the association of resting heart rate (RHR) with major adverse cardiovascular events (MACEs) and all-cause mortality among adults without prior cardiovascular disease, stratified by baseline burden of cardiovascular risk factors (CVRFs). Methods: This was a prospective cohort study in a random sample of the general population aged ≥18 years in southeastern Spain. RHR was measured using an electrocardiogram. CVRFs (sedentary or light-to-moderate physical activity, body-mass index ≥ 25 kg/m², non-HDL cholesterol ≥ 130 mg/dL, diabetes, hypertension, and smoking) were grouped in three clusters based on whether each subject has 0–2, 3, or ≥4 factors. During a mean 21.5-year follow-up, MACEs were collected and classified as all-cause mortality (outcome-1, n = 193 events) and combined cardiovascular morbidity and mortality (outcome-2, n = 291 events). Cox regression models were adjusted for multiple confounders. Results: The mean age of the participants (n = 1169) was 47.4 years (55.8% women). For every 10 bpm increase in RHR, the fully adjusted hazard ratio was 1.15 (95% CI: 1.03–1.28) for outcome-1 and 1.09 (1.00–1.20) for outcome-2. In the cluster with three CVRFs, the fully adjusted hazard ratios per 10 bpm RHR increase were 1.18 (95% CI 1.04–1.36) for outcome-1 and 1.15 (1.03–1.27) for outcome-2. In the clusters with 0–2 and ≥4 CVRFs, there were no statistically significant differences. Conclusions: RHR was independently associated with both cardiovascular events and all-cause mortality in the 3 CVRF cluster (intermediate cluster in terms of the burden of CVRFs), whose prognostic value may be clinically meaningful. These results highlight the importance of RHR and the comprehensive assessment of CVRFs in the primary prevention setting.

Esta revisión narrativa analiza la incorporación de la inteligencia artificial (IA) en las facultades de medicina (principalmente en España), sus aplicaciones educativas, y los retos éticos asociados, ilustrándolo con ejemplos como el desarrollo del razonamiento crítico y la inteligencia emocional. Nuestros resultados muestran que la integración de la IA en la formación médica de grado en España es limitada, aunque creciente, y la mayoría de los cursos ofrecidos son optativos, transversales y con carga lectiva reducida. Sin embargo, se observa un desarrollo sustancial en el posgrado, donde no obstante se identifica una carencia específica en programas orientados a la docencia médica con IA en comparación con las aplicaciones clínicas. Además, la integración en la formación médica de grado sigue siendo desigual entre los distintos países. El modelo español muestra una brecha estructural entre las necesidades clínicas y la formación de grado. La integración de la IA en la educación médica plantea pues desafíos estructurales, pedagógicos y éticos que exigen una planificación estratégica. Su adopción, impulsada en gran parte por actores tecnológicos, requiere un diseño educativo intencional basado en principios sólidos. La rigidez curricular dificulta su incorporación, aunque ofrece una oportunidad para reformas estructuradas. Es necesario garantizar un acceso equitativo y evitar desigualdades entre titulaciones, así como priorizar la formación en grado frente a una especialización precoz en posgrado, estandarizando competencias digitales mínimas en los planes de estudio troncales para garantizar que los futuros facultativos ejerzan con solvencia en entornos clínicos automatizados. La formación del profesorado y la creación de unidades de educación médica con competencias en IA son claves para una integración efectiva. Además, deben revisarse los sistemas de evaluación, centrando la atención en los procesos de aprendizaje. Finalmente, el papel del docente sigue siendo esencial como garante del pensamiento crítico, la ética y los valores profesionales.

Background: Central systolic blood pressure (cSBP) reflects the pressure experienced by vital organs and may be more closely related to hypertensive cardiac damage than brachial SBP. Twenty‐four–hour ambulatory blood pressure monitoring provides additional insight into cardiovascular load beyond office readings. This study investigated the association of 24‐hour cSBP, measured noninvasively with a validated device, with left ventricular mass index (LVMi) and LV hypertrophy. Methods: We analyzed data from 21 centers worldwide (n=2367; 45.5% women; mean age 49.5 years) participating in the International 24‐Hour Aortic Blood Pressure Consortium. Brachial and central 24‐hour SBPs were recorded using the Mobil‐O‐Graph device, calibrated by either systolic/diastolic (cSBP C1) or mean/diastolic (cSBP C2) pressure; LVMi was derived echocardiographically. BP phenotypes (normotension, isolated diastolic and systolic hypertension, and systolic‐diastolic hypertension) were based on 24‐hour brachial BPs, subdivided by cSBP. Results: LVMi correlated most strongly with 24‐hour cSBP C2 ( P P =0.0045 and <0.001, respectively), without interaction. Discordant classification occurred in 14.4% of participants and was linked to higher LVMi in normotension and lower LVMi in systolic‐diastolic hypertension. Conclusions: Twenty‐four–hour central SBP calibrated with oscillometric mean/diastolic pressure (cSBP C2), is more closely associated with LVMi and LV hypertrophy than brachial SBP. These findings highlight the potential clinical value of incorporating central pressure monitoring into risk assessment and hypertension management.

European hypertension guidelines recommend avoiding treatment targets of systolic blood pressure (BP) < 120 mmHg or diastolic BP < 70 mmHg. This study estimated the prevalence of these low BP levels and their associated factors in older treated patients with hypertension assessed at home, where BP measurement is increasingly common and useful for follow-up. Cross-sectional study of adults aged ≥ 65 years from the general population of Madrid in 2017. BP was calculated as the mean of the second and third standardized measurements. Among 1560 treated patients with hypertension (mean age, 72.1 years; 51.8% women), the prevalence of BP < 120/70 mmHg was 29% (95%CI, 26.8-31.3). In 36.4% of these cases, both systolic and diastolic BP were below target. The prevalence of BP < 120/70 mmHg was significantly higher in patients with (vs without) heart failure (51.1% vs 28.4%), atrial fibrillation (46.8% vs 27.1%), and antihypertensive polytherapy (≥ 3 drugs vs 1) (37.8% vs 27.8%), and in women (35.1% vs 22.5% in men). After adjustment for confounders, the odds ratios for low BP were: heart failure, 2.21; atrial fibrillation, 2.28; female sex, 1.73; and antihypertensive polytherapy, 1.53. One in 3 treated older patients with hypertension has home BP < 120/70 mmHg and shows a characteristic sociodemographic and clinical profile (female sex and higher prevalence of heart failure, atrial fibrillation, and antihypertensive polytherapy). These features may help identify patients at increased risk of having BP values below recommended targets. Full English text available from: www.revespcardiol.org/en.

BACKGROUND: The ambulatory arterial stiffness index (AASI) is increasingly used in clinical research and practice. This individual-participant meta-analysis aims to consolidate the prognostic accuracy of AASI in the general population and to derive an end point–based AASI risk threshold. METHODS: In 12 558 individuals enrolled in 14 population studies (48.8% women; mean age, 59.3 years), AASI was derived by regressing 24-hour diastolic on systolic blood pressure (mm Hg/mm Hg). Using Cox regression, the risk-carrying AASI threshold was established by examining stepwise increasing AASI levels and by determining the AASI level, yielding a 10-year risk similar to an office systolic pressure of 140 mm Hg. RESULTS: Over 10.7 years (median), 3027 all-cause deaths and 2183 cardiovascular end points occurred. In all participants, multivariable-adjusted hazard ratios expressing the all-cause deaths and cardiovascular end point risk per 1-SD AASI increment were 1.08 (95% CI, 1.04–1.13) and 1.13 (95% CI, 1.07–1.18). In a randomly defined subset of 8189 individuals, the risk-carrying AASI thresholds converged to 0.50 with hazard ratios (≥0.50 versus <0.50) of 1.14 (95% CI, 1.04–1.26) for all-cause deaths and 1.13 (95% CI, 1.01–1.26) for cardiovascular end point. In the replication sample (n=4369), these hazard ratios were 1.13 (95% CI, 1.01–1.26) and 1.19 (95% CI, 1.04–1.35). AASI continuous or per threshold significantly improved model performance. Analyses of secondary end points and subgroups stratified by sex, age, hypertension status and treatment, history of cardiovascular disease, and nocturnal dipping were confirmatory. CONCLUSIONS: Over and beyond traditional risk factors, AASI improves risk stratification. Exceeding the risk-carrying 0.50 AASI threshold necessitates increased vigilance in managing risk factors before irreversible cardiovascular complications occur.

Background: The Planetary Health Diet (PHD) benefits health and the environment. However, its impact on healthy ageing, estimated by intrinsic capacity (IC), remains unexplored. Objective: To examine the association between adherence to a PHD Index (PHDI) and changes in IC in older adults. Methods: Data were collected from 2519 adults aged ≥60y from the Seniors-ENRICA-1 (2012–15) and 3273 aged ≥65y from the Seniors-ENRICA-2 (2017–19) Spanish cohorts. Food consumption was collected with a dietary history, and the PHDI was based on 15 food groups. IC was measured across six domains: cognition, psychology, vitality, hearing, vision and locomotion (ranged: 0–18, lower score equals better IC). Adjusted multinomial logistic regressions were used, and data from both cohorts were pooled. Results: Over a 2.6-year median follow-up, IC worsened for 32.0% of participants, improved for 27.7% and remained stable for 40.3%. Participants in the highest vs lowest tertile of adherence to the PHDI were more likely to improve vs worsen IC [relative risk ratio (RRR) 1.36; 95% confidence interval (95% CI) 1.05–1.77; P-trend = .021]. Higher PHDI scores were significantly associated with improvement vs worsening in the hearing domain (RRR 1.37; 95% CI 1.04–1.82; P-trend = .025). Higher adherence to PHDI’s recommendations regarding nuts (RRR 1.05; 95% CI 1.01–1.09) and starchy vegetables (RRR 1.09; 95% CI 1.01–1.17) were independently associated with improvement vs worsening IC. Conclusion: In these older-adult cohorts, higher adherence to the PHDI was associated with improvement in overall IC and in its hearing domain. Adherence to nuts and starchy vegetables recommendations was particularly beneficial.

Background and Aims: Hypertension is the predominant modifiable cardiovascular risk factor. This cohort study assessed the association of risk with the percentage of time that the ambulatory blood pressure (ABP) is within the target range (PTTR) proposed by the 2024 European Society of Cardiology (ESC) guidelines for blood pressure (BP) management. Methods: In a person-level meta-analysis of 14 230 individuals enrolled in 14 population cohorts, systolic and diastolic ABPs were combined to assess 24-h, daytime, and nighttime PTTR with thresholds for non-elevated ABP set at <115/65, <120/70, and <110/60 mmHg, respectively. Results: Median 24-h PTTR was 18% (interquartile range 5–33) corresponding to 4.3 h (1.2–7.9). Over 10.9 years (median), deaths (N = 3117) and cardiovascular endpoints (N = 2265) decreased across increasing 24-h PTTR quartiles from 21.3 to 16.1 and from 20.3 to 11.3 events per 1000 person-years. The standardized multivariable-adjusted hazard ratios for 24-h PTTR were 0.57 (95% confidence interval 0.46–0.71) for mortality and 0.30 (0.23–0.39) for cardiovascular endpoints. Analyses of daytime and nighttime ABP, cardiovascular mortality, coronary endpoints and stroke, and subgroups produced confirmatory results. The 2024 ESC non-elevated 24-h PTTR, compared with the 2018 ESC/European Society of Hypertension non-hypertensive 24-h PTTR, shortened the interval required to reduce relative risk for adverse outcomes from 60% to 18% (14.4–4.3 h). Office BP, compared with 24-h PTTR, misclassified most participants with regard to BP control. Conclusions: Longer time that ABP is within the 2024 ESC target range is associated with reduced adverse outcomes; PTTR derived from ABP refines risk prediction and compared with office BP avoids misclassification of individuals with regard to BP control.

Background: We assessed the association of adherence to the guidelines and subsequent changes over time in adherence with all-cause mortality. Methods: We used data from 3 518 and 3 273 older adults, aged 60–96 years at baseline, from Seniors-ENRICA 1 and 2 cohorts, respectively. Adherence to 24-hour movement guidelines was defined as ≥150 min/wk of moderate-to-vigorous physical activity (MVPA), sedentary behavior (SB) ≤8 h/d (including ≤3 h/d of recreational screen time), and 7–9 h/d of sleep if aged 18–64 years or 7–8 h/d if aged ≥65 years. All-cause mortality was ascertained up to January 31, 2024. Analyses were performed using Cox regression adjusted for the main confounders. Results: Of the 6 613 participants with complete data, 1 353 died during a mean follow-up of 10.1 (standard deviation [SD] = 4.0) years. Meeting MVPA (hazard ratio [HR] 0.73; 95% confidence interval [CI] 0.65–0.82), SB (HR 0.89; 95% CI 0.80–0.99), and sleep (HR 0.89; 95% CI 0.80–0.99) recommendations were associated with lower mortality. Also, we noticed a reduction in mortality in meeting MVPA combined with both SB (34%) and sleep (12%), sleep and SB combined (23%), and meeting all 24-hour movement guidelines (40%). Changes in meeting 24-hour movement guidelines occurred between a mean follow-up of 2.8 (0.6) years. Meeting 24-hour movement guidelines at baseline and follow-up is associated with lower mortality (HR 0.69; 95% CI 0.47–0.99), compared to not meet them at both examinations. Conclusions: This prospective cohort study underscores the critical impact of adhering to and maintaining adherence to the 24-hour movement guidelines in reducing mortality risk among older adults.