SEA 2022 Standards for Global Control of Cardiovascular Risk. / Estándares SEA 2022 para el control global del riesgo cardiovascular.

One of the objectives of the Spanish Society of Arteriosclerosis is to contribute to better knowledge of vascular disease, its prevention and treatment. It is well known that cardiovascular diseases are the leading cause of death in our country and entail a high degree of disability and health care costs. Arteriosclerosis is a multifactorial disease and therefore its prevention requires a global approach that takes into account the different risk factors with which it is associated. Therefore, this document summarizes the current level of knowledge and includes recommendations and procedures to be followed in patients with established cardiovascular disease or at high vascular risk. Specifically, this document reviews the main symptoms and signs to be evaluated during the clinical visit, the laboratory and imaging procedures to be routinely requested or requested for those in special situations. It also includes vascular risk estimation, the diagnostic criteria of the different entities that are cardiovascular risk factors, and makes general and specific recommendations for the treatment of the different cardiovascular risk factors and their final objectives. Finally, the document includes aspects that are not usually referenced in the literature, such as the organization of a vascular risk consultation.

Albuminuria and polyvascular disease improve multivariate predictive models after an acute cardiovascular event. The AIRVAG cohort.

BACKGROUND AND AIMS: There is no consensus regarding risk stratification tools for secondary prevention in atherosclerotic cardiovascular disease. Our aim was to compare the discriminative performance of the Framingham, REGICOR, SCORE, and REACH risk functions and the Bohula-TIMI and SMART risk scores, as well as to assess the potential added value of other clinical variables for the prediction of recurrent events in patients with established vascular disease. METHODS: A cohort of 269 patients with established vascular disease (52.8% coronary, 32% cerebrovascular, 15.2% PAD) was included. The survival functions of risk groups (low/medium/high) according to commonly used cutoff points for each function/score were compared, and hazard ratios for each were estimated using Cox regression. We calculated Δ Harrell's C statistic, cat-NRI, and cNRI after adding new predictors to a base model including age, sex, total cholesterol, current smoking status, hypertension, and diabetes. RESULTS: After six years of follow-up (median 4.82 years), 61 events occurred (23%). High-risk groups had a higher risk of recurrent event: SMART (HR: 3.17 [1.55-6.5]), Framingham (HR: 3.08 [1.65-5.75]), REGICOR (HR: 2.71 [1.39-5.27]), SCORE (HR: 2.14 [1.01-4.5], REACH (HR: 5.74 [2.83-11.7]), B-TIMI (HR: 3.68 [0.88-15.3]). Polyvascular disease (three territories HR: 5.6 [2.2-14.25]), albuminuria (HR: 3.55 [2.06-6.11]), and heart failure (HR: 3.11 [1.34-7.25]) also increased risk. Discrimination (Harrell's C) was low but improved after adding albuminuria and polyvascular disease. Both variables also improved the performance of the base model (cNRI.326 [.036; .607]). CONCLUSIONS: The Framingham, REGICOR, SCORE, and REACH functions and the B-TIMI and SMART scores showed low yet similar performance in secondary prevention. Albuminuria and polyvascular disease improved the predictive performance of major classical cardiovascular risk factors.

Differential risk for COVID-19 in the first wave of the disease among Spaniards and migrants from different areas of the world living in Spain.

INTRODUCTION AND OBJECTIVES: Little is known regarding the relevance of racial/ethnic background to the risk for COVID-19 infection, particularly in Europe. We evaluated the risk of COVID-19 among migrants from different areas of the world within the context of universal free access to medical care. MATERIALS AND METHODS: We conducted a population-based cohort analysis of the cumulative incidence of PCR-confirmed COVID-19 among adult residents of Alcorcon (Spain) in the first wave of the disease up to April 25, 2020. RESULTS: The crude cumulative incidence among migrants (n = 20419) was higher than among Spaniards (n = 131599): 8.81 and 6.51 and per 1000 inhabitants, respectively (p <  .001), but differed by region of origin. As per a negative binomial regression adjusted for age and sex, relative risk (RR) for COVID-19 for individuals from Europe, Asia, or North Africa was not significantly different from Spaniards. In contrast, a markedly increased risk was found in people from Sub-Saharan Africa (RR 3.66, 95% confidence interval (CI) 1.42-9.41, p =  .007), the Caribbean (RR 6.35, 95% CI 3.83-10.55, p <  .001), and Latin America (RR 6.92, 95% CI 4.49-10.67, p <  .001). CONCLUSIONS: Migrants from Sub-Saharan Africa, the Caribbean, and Latin America exhibited increased risk for COVID-19 as compared to Spaniards or migrants from Europe, North Africa, or Asia. Our data suggest ethnic background may play a role in risk for COVID-19. Migrants from some areas of the world may merit closer attention for both clinical and epidemiological reasons.

[Differential risk for COVID-19 in the first wave of the disease among Spaniards and migrants from different areas of the world living in Spain]. / Riesgo de COVID-19 en españoles y migrantes de distintas zonas del mundo residentes en España en la primera oleada de la enfermedad.

INTRODUCTION AND OBJECTIVES: Little is known regarding the relevance of racial/ethnic background to the risk for COVID-19 infection, particularly in Europe. We evaluated the risk of COVID-19 among migrants from different areas of the world within the context of universal free access to medical care. MATERIAL AND METHODS: We conducted a population-based cohort analysis of the cumulative incidence of PCR-confirmed COVID-19 among adult residents of Alcorcon (Spain) in the first wave of the disease up to April 25, 2020. RESULTS: The crude cumulative incidence among migrants (n = 20,419) was higher than among Spaniards (n = 131,599): 8.81 and 6.51 and per 1,000 inhabitants, respectively (p < .001), but differed by region of origin. As per a negative binomial regression adjusted for age and sex, relative risk (RR) for COVID-19 for individuals from Europe, Asia, or North Africa was not significantly different from Spaniards. In contrast, a markedly increased risk was found for people from Sub-Saharan Africa (RR 3.66, 95% confidence interval (CI) 1.42-9.41, p = .007), the Caribbean (RR 6.35, 95% CI 3.83-10.55, p < .001), and Latin America (RR 6.92, 95% CI 4.49-10.67, p < .001). CONCLUSIONS: Migrants from Sub-Saharan Africa, the Caribbean, and Latin America exhibited increased risk for COVID-19 as compared to Spaniards or migrants from Europe, North Africa, or Asia. Our data suggest that the ethnic background may play a role in risk for COVID-19. Migrants from some areas of the world may merit closer attention for both clinical and epidemiological reasons.

Differential risk for COVID-19 in the first wave of the disease among Spaniards and migrants from different areas of the world living in Spain. / Riesgo de COVID-19 en españoles y migrantes de distintas zonas del mundo residentes en España en la primera oleada de la enfermedad.

INTRODUCTION AND OBJECTIVES: Little is known regarding the relevance of racial/ethnic background to the risk for COVID-19 infection, particularly in Europe. We evaluated the risk of COVID-19 among migrants from different areas of the world within the context of universal free access to medical care. MATERIAL AND METHODS: We conducted a population-based cohort analysis of the cumulative incidence of PCR-confirmed COVID-19 among adult residents of Alcorcon (Spain) in the first wave of the disease up to April 25, 2020. RESULTS: The crude cumulative incidence among migrants (n=20,419) was higher than among Spaniards (n=131,599): 8.81 and 6.51 and per 1,000 inhabitants, respectively (p<.001), but differed by region of origin. As per a negative binomial regression adjusted for age and sex, relative risk (RR) for COVID-19 for individuals from Europe, Asia, or North Africa was not significantly different from Spaniards. In contrast, a markedly increased risk was found for people from Sub-Saharan Africa (RR 3.66, 95% confidence interval (CI) 1.42-9.41, p=.007), the Caribbean (RR 6.35, 95% CI 3.83-10.55, p<.001), and Latin America (RR 6.92, 95% CI 4.49-10.67, p<.001). CONCLUSIONS: Migrants from Sub-Saharan Africa, the Caribbean, and Latin America exhibited increased risk for COVID-19 as compared to Spaniards or migrants from Europe, North Africa, or Asia. Our data suggest that the ethnic background may play a role in risk for COVID-19. Migrants from some areas of the world may merit closer attention for both clinical and epidemiological reasons.

PCSK9 inhibitors: Ratification of the role of LDL cholesterol in cardiovascular prevention. Towards a convergence of European and North American prevention guidelines? / Inhibidores de PCSK9: ratificación del papel del colesterol LDL en prevención cardiovascular. ¿Hacia la convergencia en las guías de prevención europeas y norteamericanas?

The epidemiological association of cholesterol associated with low density lipoproteins (LDL-c) levels and the development of atherosclerotic vascular disease has been ratified by mendelian randomization studies. Paradoxically, the success of statins led to the underestimation of other lipid-lowering therapies and even the measurement of LDL-c. Recent studies show that the reduction of LDL-c to extraordinarily low levels through absorption inhibition, and, in a particularly intensive manner, with monoclonal antibodies against pro-protein convertase subtilisine Kesine 9 (PCSK9) continues to offer cardiovascular protection. However, the high cost and limited experience with PCSK-9 inhibitors advised a prudent use of them. An appropriate selection of patients most likely to benefit from treatment with PCSK9 inhibitors emerges as the basis for a consensus of international guidelines: the combination of a high absolute vascular risk and a greater expected benefit by the starting LDL-c levels.

[Changes in knowledge and carrying out the advance directives of patients admitted to internal medicine]. / Evolución del conocimiento y de la realización de instrucciones previas en los pacientes ingresados en medicina interna.

BACKGROUNDS: Advance directives (ADs), are documents in which patients express in advance that their wishes are fulfilled when they are unable to communicate them. It is unknown whether patients admitted to internal medicine are more aware of and make ADs. OBJECTIVE: To study the changes in the level of knowledge and implementation of AD among patients admitted to an internal medicine department of a hospital in Madrid since a specific regulation to implement them was introduced. PATIENTS AND METHODS: A survey was conducted among patients admitted to internal medicine in two periods: 2008 and 2010. RESULTS: A total of 206 surveys were analysed (84 in 2008 and 122 in 2010). The mean age of the patients was 76.8 years, and 51.5% were women. More than two-thirds (69.4%) had a co-morbidity. and 4.4% had a terminal illness, with no statistical differences between the periods. Only 5.3% knew what ADs are, 1 had implemented ADs, and 46.1%, once informed, would like to implement them. There were no differences between 2008 and 2010 as regards knowledge and implementation of AD. In 2010 there was a greater interest to implement them (would like to implement them: 52.5 vs 36.9%), although in 2010 less respondents believe that AD would change the attitude of the doctor (not change the attitude: 92.6 vs. 69%, P<.001). CONCLUSIONS: Knowledge and implementation of AD did not change significantly in the years following the regulation (from 2008-2010). In both periods, their knowledge and implementation are scarce.

Spasticity improvement in patients with relapsing-remitting multiple sclerosis switching from interferon-ß to glatiramer acetate: the Escala Study.

BACKGROUND: A recent pilot study suggested spasticity improvement during glatiramer acetate (GA) treatment in multiple sclerosis (MS) patients who previously received interferon-ß (IFN-ß). OBJECTIVE: To evaluate changes in spasticity in MS patients switching from IFN-ß to GA. METHODS: Observational, multicentre study in patients with relapsing-remitting MS (RRMS) and spasticity switching from IFN-ß to GA. The primary endpoint comprised changes on Penn Spasm Frequency Scale (PSFS), Modified Ashworth Scale (MAS), Adductor Tone Rating Scale (ATRS), and Global Pain Score (GPS) at months 3 and 6 after starting GA. RESULTS: Sixty-eight evaluable patients were included (mean age,41.7±9.5 years; female,70.6%; mean time from MS diagnosis to starting GA,7.6±5.7 years). Previous treatments were subcutaneous IFN-ß1a in 42.6% patients, intramuscular IFN-ß1a in 41.2% and IFN-ß1b in 32.4%, whose mean durations were 3.5±3.3, 2.7±2.5 and 4.4±3.6 years, respectively. Statistically significant reductions in mean scores on all spasticity measurements were observed from baseline to month 3 (PSFS, 1.7±0.9 vs 1.4±0.6, p<0.01; MAS, 0.7±0.5 vs 0.6±0.5, p<0.01; highest MAS score, 1.9±0.8 vs 1.7±0.8, p<0.01; ATRS, 1.6±0.6 vs 1.4±0.6, p<0.01; GPS, 29.4±22.1 vs 24.7±19.4, p<0.01) and from baseline to month 6 (PSFS, 1.7±0.9 vs 1.3±0.6, p<0.01; MAS, 0.7±0.5 vs 0.5±0.5, p<0.01; highest MAS score, 1.9±0.8 vs 1.5±0.9, p<0.01; ATRS, 1.6±0.6 vs 1.3±0.6, p<0.01; GPS, 29.4±22.1 vs 19.1±14.8, p<0.01). CONCLUSION: Spasticity improvement in terms of spasm frequency, muscle tone and pain can be noted after three months and prolonged for six months of GA treatment.

A simple prognostic score for risk assessment in patients with acute pancreatitis.

BACKGROUND: Acute pancreatitis (AP) is a common disease that poses potential serious problems. Its clinical course is often unpredictable. Identification of high risk patients enables early appropriate treatment. METHODS: We conducted a prospective study to develop a new prognostic method that can objectively and easily grade the severity of AP within the first 72 h of admission. The prediction rule was based on clinical and analytical parameters in 308 patients admitted in a community-based hospital. We validated the score in 193 additional patients in the same hospital. RESULTS: Independent prognostic factors related to poor prognosis were age >65 years, leucocytes >13,000/mm(3), albumin <2.5 mg/dL, calcium <8.5 mg/dL and reactive C protein >150 mg/dL. We assigned points to each of the independent factors for complicated AP in proportion to the regression coefficients. We defined three different risk groups according to the points obtained in the prediction rule. Low risk, 0 points (18% patients, 0% risk), moderate, 1-3 points (56% patients, 19% risk) and high, 4-6 points (26% patients, 73% risk). The sensitivity of this formula was 90% with specificity of 63%. The positive and negative predictive values were 50% and 94% respectively. CONCLUSIONS: Our simple prediction rule is an additional tool that may help physicians stratifying the severity of AP. Patients with high risk for complicated AP should be kept under close surveillance whereas low risk patients would not need special monitoring.

Mortality among adult patients admitted to the hospital on weekends.

BACKGROUND: Some reports have shown that the risk of death is higher for patients admitted on weekends than for patients who go into the hospital on weekdays. This study was conducted to assess what independent influence, if any, weekend admission might have on mortality in our hospital. METHODS: The clinical data of 35,993 adult (>14 years) patients admitted to the emergency department of Fundación Hospital Alcorcón from 1999 to 2003 were analyzed. We compared global mortality and mortality within the first 48 h according to whether the patients were admitted on the weekend or on a weekday. Elective admissions, critical care patients, children under 14 and births were not included. RESULTS: Global mortality was similar in both groups, but mortality within the first 48 h was higher for patients admitted on the weekend (OR 1.40, 95% CI 1.18-1.62, P<0.001), even after controlling for age, gender and comorbidity (weight of diagnosis-related group and Charlson comorbidity index). CONCLUSION: The risk of mortality within the first 48 h is higher for patients admitted on weekends than for patients admitted on a weekday.

Occult vascular lesions in patients with atherothrombotic events: the AIRVAG cohort.

OBJECTIVES: To determine clinical parameters that could predict occult vascular lesions (OVL) in patients with symptomatic atherosclerosis. PATIENTS AND METHODS: Prospective evaluation of 269 consecutive patients with symptomatic atherosclerosis (cerebral 32%, peripheral vascular 15%, and coronary 53%): complete laboratory, ultrasound exams (carotids, aorta, heart), ankle-brachial index. OVL were defined as: abdominal aortic aneurysm, carotid artery stenosis > 50%, or left ventricular segmental contraction abnormalities when affecting a different vascular bed from the symptomatic. Clinical predictors of OVL were evaluated by logistic regression analysis. RESULTS: OVL were found in 35 patients (13%): 12 abdominal aortic aneurysms, 21 carotid artery stenosis and 15 segmental left ventricular contraction abnormalities. OVL were associated with peripheral vascular disease (intermittent claudication or reduced ankle-brachial index), cigarette smoking, increased pulse pressure, microalbuminuria and hyperhomocysteinemia. By multivariate analysis, intermittent claudication (odds ratio 5.8; 95% CI 2.6-12.8) and microalbuminuria (OR 4.2; 95% CI 1.7-10.5) were strong independent predictors of OVL. Similar results were obtained when peripheral vascular disease was defined as reduced ankle-brachial index (OR 5.3; 95% CI 2.4-11.7). CONCLUSIONS: Clinical and subclinical peripheral vascular disease, as well as microalbuminuria are strong independent predictors of OVL in atherosclerotic patients. A screening study of OVL may be warranted in these patients.

Assessing clinical probability of organic disease in patients with involuntary weight loss: a simple score.

BACKGROUND: Involuntary weight loss (IWL) is a frequent complaint with a difficult diagnosis. Any one of a number of different diseases may be the source of the symptom. However, there is no universal clinical protocol that can help physicians study this complex syndrome. METHODS: In March 1998, we defined a diagnostic protocol for the study of IWL. IWL was defined as an involuntary and documented weight loss of at least 5% of the usual body weight in the previous 3 months. We analyzed 78 consecutive patients with IWL who came to our clinic between March 1998 and December 2000. RESULTS: An organic disease was found in 56% of cases; cancer, metabolic and digestive diseases were the most common entities. Psychiatric problems were found in 33% of cases. After extensive study, an idiopathic group of 11% was identified. The variables that were independently predictive of a final diagnosis of organic disease were: age>50 years (OR: 8.6, CI 95%: 1.7-43.6), psychiatric symptoms (OR: 0.2, CI 95%: 0.1-0.8), smoking (OR: 14.3, CI 95% 2.3-74), the presence of guide symptoms (OR: 8.0, CI 95%: 1.8-34.4), and anemia (OR: 3.1, CI 95%: 2.5-387). Sixteen percent of the patients died, more often those suffering from organic diseases. Based on multivariate regression coefficients, a clinical risk score was established. CONCLUSIONS: IWL is a complex and frequent syndrome with a 16% rate of mortality during the first year. A protocol based on clinical data can help in the management of IWL. Our clinical prediction rule may help physicians to identify those patients with IWL who are likely to have an underlying organic disease.