European expert consensus recommendations on the primary care use of direct oral anticoagulants in patients with venous thromboembolism.

BACKGROUND: Direct oral anticoagulants for the treatment of venous thromboembolism are supported by robust clinical trial evidence. Despite published guidance, general practitioners are faced with increasingly complex decisions and implementation remains sub-optimal in certain real-world scenarios. METHODS: A two stage formal consensus exercise was performed to formulate consensus statements and a summary guide, facilitating optimal management of direct oral anticoagulants in venous thromboembolism patients by generalist physicians across Europe. An online questionnaire distributed to a broad panel (Phase 1), followed by a virtual panel discussion by an expert group (Phase 2) were conducted. Phase 1 statements covered nine management domains, and were developed via a literature review and expert steering committee. Participants rated statements by their level of agreement. Phase 1 responses were collated and analysed prior to discussion and iterative refinement in Phase 2. RESULTS: In total 56 participants from across Europe responded to Phase 1. The majority had experience working as general practitioners. Consensus indicated that direct oral anticoagulants are the treatment of choice for managing patients with venous thromboembolism, at initiation and for extended treatment, with a review at three to six months to re-assess treatment effect and risk profile. Direct oral anticoagulant choice should be based on individual patient factors and include shared treatment choice between clinicians and patients; the only sub-group of patients requiring specific guidance are those with cancer. CONCLUSION: Results demonstrate an appreciation of best practices, but highlight challenges in clinical practice. The patient pathway and consensus recommendations provided, aim to highlight key considerations for general practice decision making, and aid optimal venous thromboembolism treatment.

[Cardiovascular risk factors and Primary Care: evaluation and intervention]. / Factores de riesgo cardiovascular y atención primaria: evaluación e intervención.

There is high prevalence of major cardiovascular risk factors (MCVRF) in Spain, equal or greater than the rest of the countries in Europe, with a tendency to increase, while the their control is in general sub-optimal. In the clinical setting, and in Primary Care clinics in particular, preventive activities and early detection (screening) of MCVRF that are well established by the scientific evidence should be carried out. Smoking should be tackled and treated with decisively, even more so in the context of the favourable current legislation. The measurement of risk factors makes it easy to take decisions in clinical practice, but should not be substituted for clinical judgement, given the limitation of the currently available calculation methods. The concept of overall focus on cardiovascular risks can obtain a reduction of the risk by the synergetic action on the different MCVRF in each individual case. The aim must be to reduce the probability of having a cardiovascular disease in the future, as well as the loss in quality of life, incapacity and associated mortality.

[Clinical profile and management patterns in outpatients with heart failure in Spain: INCA study]. / Perfil clínico y patrones de manejo en los pacientes con insuficiencia cardíaca atendidos ambulatoriamente en España: estudio INCA (Estudio Insuficiencia Cardíaca).

AIM: To assess clinical characteristics and treatment management of out-patients with chronic heart failure (CHF) in Spain. DESIGN: Cross-sectional study. LOCATION: Primary care (PC) centres and cardiology out-patient clinics. PATIENTS: CHF patients (all had an echocardiography performed). METHODS: Data were collected from consecutive patients who attended clinics (93 cardiologist and 415 PC physicians) with a diagnosis of CHF during June 2006. RESULTS: The study subjects were 2161 CHF patients (1412 PC; 749 Cardiology), with a mean age was 70.9+/-10.6 years and 55.62% were males. Patients followed up in cardiology were younger, the majority were male, had a better functional class, lower ejection fraction, and fewer co-morbidities than those followed up in PC. The most used treatments were drugs that block the renin-angiotensin system (ACEi or ARB) (89.4%) and diuretics (84.91%), followed by beta-blockers (43.96%). Blood pressure (< 130/80 mmHg) was controlled in 24.93% of the patients, and diabetes mellitus in 32.33% of the diabetics (HbA(1c)<6.5%). Both risk factors were significantly better in PC. CONCLUSIONS: The INCA results show different clinical characteristics between patients followed up in the two health care levels. The pharmacological treatment has improved since previous studies and is closer to that recommended in chronic heart failure guidelines. Nevertheless, blood pressure and diabetes mellitus control are still insufficient.