Impact of Lipoprotein(a) Levels on Cardiovascular Risk Estimation.

INTRODUCTION: A new cardiovascular risk (CVR) calculator that incorporates Lipoprotein(a) [Lp(a)] levels has recently been designed. AIMS: To estimate CVR using the new score and to identify the reduction in low-density lipoprotein cholesterol (LDL-C) or systolic blood pressure (SBP) necessary to balance the risk attributable to Lp(a). METHODS: CVR throughout life and at 10 years was estimated with the new score in patients in primary prevention, both considering and not considering the value of Lp(a). When the estimated risk considering Lp(a) levels exceeded the baseline risk, the reduction in LDL-C levels or SBP necessary to balance the risk attributable to Lp(a) was calculated. RESULTS: In total, 671 patients (mean age 54.2 years, 47.2% women) were included. Globally, 22.7% of the population had high Lp(a) values (> 50 mg/dL or > 125 nmol/L). When calculating CVR throughout life and considering the Lp(a) value, the global risk increased in 66.7% of cases (median 19.3%). Similar results were observed when we assessed the 10-year risk. The risk associated with Lp(a) could be completely compensated by decreasing LDL-C (average 21 mg/dL) or SBP (average 6.3 mmHg) in 79.2% and 74.7% of cases, respectively. CONCLUSION: When calculating the CVR with the new score, two-thirds and one-third of the population were bidirectionally recategorized as 'up' or 'down,' respectively. The decrease in LDL-C or SBP mitigated the increased risk caused by Lp(a) levels across a substantial proportion of patients.

Impacto de la optimización del tratamiento hipolipemiante en el riesgo cardiovascular residual / Impact of Optimizing Lipid-Lowering Therapy on Residual Cardiovascular Risk

RESUMEN Introducción: el modelo SMART-REACH predice el riesgo de eventos cardiovasculares recurrentes. Objetivos: los objetivos de este estudio fueron: a) evaluar el riesgo residual en una población en prevención secundaria y niveles de colesterol asociado a lipoproteínas de baja densidad (C-LDL) fuera de meta; b) mediante un modelo de simulación, determinar el impacto de optimizar las terapias hipolipemiantes en términos de reducción del riesgo residual. Material y métodos: estudio transversal, descriptivo y multicéntrico. Se incluyeron consecutivamente pacientes con antecedentes cardiovasculares y un C-LDL mayor o igual que 55 mg/dL. El riesgo de eventos recurrentes (infarto agudo de miocardio, accidente cerebrovascular o muerte vascular) a 10 años y a lo largo de la vida se estimó utilizando el modelo SMART-REACH. Mediante una simulación, se optimizó el tratamiento hipolipemiante de cada paciente (utilizando estatinas, ezetimibe o inhibidores de proproteína convertasa subtilisina kexina tipo 9 [iPCSK9]), se estimó el descenso del C-LDL, se verificó el alcance del objetivo lipídico y se calculó la reducción del riesgo cardiovascular y el número necesario a tratar (NNT) correspondiente. Resultados: se incluyeron 187 pacientes (edad media 67,9 ± 9,3 años, 72,7% hombres). Los riesgos residuales calculados a 10 años y a lo largo de la vida fueron 37,1 ± 14,7% y 60,3 ± 10,7%, respectivamente. Globalmente, se pudo optimizar una sola estrategia farmacológica con estatinas, ezetimibe o un iPCSK9 en el 38,5%, el 11,5% y el 5,5% de la población, respectivamente. La optimización basada en dos tratamientos se realizó en el 27,5% (estatinas + ezetimibe), el 7,7% (estatinas + iPCSK9) y el 1,1% (ezetimibe + iPCSK9) de los casos. En 15 pacientes se optimizó el tratamiento considerando los tres fármacos. El 53,9% y el 62,9% de las acciones para optimizar el tratamiento mostraron un NNT menor que 30 para evitar un evento a 10 años o a lo largo de la vida, respectivamente. Conclusión: en este estudio, los pacientes con antecedentes cardiovasculares que no alcanzan la meta de C-LDL mostraron un riesgo residual considerable. La simulación mostró un importante margen para optimizar el tratamiento, con un impacto notable en el riesgo residual.

ABSTRACT Background: The SMART-REACH model predicts the risk or recurrent cardiovascular events. Objectives: The objectives of this study were: a) to evaluate the residual cardiovascular risk in a secondary prevention population with LDL-C levels above the recommended goal, using a simulation model; and b) to determine the impact of optimizing lipid-lowering therapies in terms of residual cardiovascular risk reduction. Methods: We conducted a cross-sectional, descriptive and multicenter study. Patient with a history of cardiovascular disease and a LDL-C ≥55 mg/dL were consecutively included. The 10-year and lifetime risk of recurrent events (myocardial infarction, stroke, or vascular death) were estimated using the SMART-REACH model. By means of a simulation, lipid-lowering treatment was optimized for each patient [using statins, ezetimibe and/or PCSK9 (PCSK9) inhibitors], with estimation of LDL-C reduction, checking if lipid-lowering goal was achieved and calculating the reduction in cardiovascular risk and the corresponding number needed to treat (NNT). Results: The cohort was made up of 187 patients; mean age was 67.9 ± 9.3 years and 72.7% were men. The calculated 10-year and lifetime residual risks were 37.1 ± 14.7% and 60.3 ± 10.7%, respectively. Overall, treatment was optimized with a single pharmacological strategy with statins, ezetimibe or PCSK9 inhibitor in 38.5%, 11.5% and 5.5% of the population, respectively. Optimization based on two treatments was performed in 27.5% (statins + ezetimibe), 7.7% (statins + PCSK9 inhibitor) and 1.1% (ezetimibe + PCSK9 inhibitor) of the cases. In 15 patients, treatment was optimized when the three drugs (statins + ezetimibe + PCSK9 inhibitor) were considered. Overall, 53.9% and 62.9% of the actions implemented to optimize treatment showed a 10-year or lifetime NNT < 30 to prevent an event, respectively. Conclusion: In this study, patients with a history of cardiovascular disease who do not reach LDL-C goal showed significant residual cardiovascular risk. The simulation model showed a significant margin for optimizing treatment, with a marked reduction in residual cardiovascular risk.

Residual cardiovascular risk, use of standard care treatments, and achievement of treatment goals in patients with cardiovascular disease.

Background: Residual risk management in patients with previous cardiovascular disease (CVD) is a relevant issue. Objectives: 1) to assess the residual risk of patients with CVD using the new scores developed to predict recurrent CVD events (SMART score/SMART-REACH model); 2) to determine the use of therapies with cardiovascular benefit and the achievement of therapeutic goals in patients with very high residual risk. Methods: A multicenter, descriptive, cross-sectional study was performed. Individuals over 18 years of age with CVD were included consecutively. The 10-year risk of recurrent events was estimated using the SMART score and the SMART-REACH model. A value ≥ 30% was considered "very high risk". Results: In total, 296 patients (mean age 68.2 ± 9.4 years, 75.7% men) were included. Globally, 32.43% and 64.53% of the population was classified as very high risk by the SMART score and the SMART-REACH model, respectively. Among patients classified as very high risk by the SMART score, 45.7% and 33.3% were treated with high-intensity statins and reached the goal of LDL-C <55 mg/dL, respectively. The results were similar when evaluating very high patients according to the SMART-REACH model (high-intensity statins: 59.7%; LDL-C <55 mg/dL: 43.9%). Few very high-risk patients with diabetes were receiving glucose-lowering drugs with demonstrated cardiovascular benefit. Conclusion: In this secondary prevention population, the residual risk was considerable. Underutilization of standard care treatments and failure to achieve therapeutic goals were evident even in subjects with very high residual risk.

Impact of COVID-19 vaccination in post-COVID cardiac complications.

BACKGROUND: After the acute infection, COVID-19 can produce cardiac complications as well as long-COVID persistent symptoms. Although vaccination against COVID-19 represented a clear reduction in both mortality and ICU admissions, there is very little information on whether this was accompanied by a decrease in the prevalence of post-COVID cardiac complications. The aim of this study was to analyze the relationship between COVID-19 vaccination and the prevalence of post-COVID cardiac injury assessed by echocardiogram, and long-COVID persistent cardiac symptoms. METHODS: All patients who consulted for post-COVID evaluation 14 days after discharge from acute illness were included. Patients with heart disease were excluded. The relationship between complete vaccination scheme (at least two doses applied with 14 days or more since the last dose) and pathological echocardiographic findings, as well as the relationship of vaccination with persistent long-COVID symptoms, were evaluated by multivariate analysis, adjusting for age, sex and clinical variables that would have shown significant differences in univariate analysis. RESULTS: From 1883 patients, 1070 patients (56.8%) suffered acute COVID-19 without a complete vaccination scheme. Vaccination was associated with lower prevalence of cardiac injury (1.35% versus 4.11%, adjusted OR 0.33; 95% CI 0.17-0.65, p=0.01). In addition, vaccinated group had a lower prevalence of persistent long-COVID symptoms compared to unvaccinated patients (10.7% versus 18.3%, adjusted OR 0.52; 95% CI 0.40-0.69, p<0.001). CONCLUSION: Vaccination against COVID-19 was associated with lower post-COVID cardiac complications and symptoms, reinforcing the importance of fully vaccinating the population.

[Statins and influenza mortality: systematic review and meta-analysis]. / Estatinas y mortalidad por influenza: revisión sistemática y meta-análisis.

BACKGROUND: Due to their anti-inflammatory properties, it has been suggested that the use of statins could influence the evolution of influenza virus infection. AIM: To evaluate the effect of statin therapy on mortality from influenza. METHODS: A meta-analysis that included studies evaluating the use of statins in patients with influenza and reporting data on mortality, after searching the PubMed/MEDLINE, Embase, and Cochrane Controlled Trials databases, was performed. A random effects model was applied. The risk of bias was analyzed and a sensitivity analysis was performed. RESULTS: Eight studies (10 independent cohorts), which included a total of 2,390,730 patients, were identified and eligible for analysis. A total of 1,146,995 subjects analyzed received statins, while 1,243,735 subjects were part of the control group. Statin therapy was associated with lower mortality (OR: 0.66; 95% CI: 0.51-0.85). The sensitivity analysis showed that the results were robust. CONCLUSION: Our data suggest that, in a population with influenza, the use of statins was associated with a significant reduction in mortality. These results must be confirmed in future clinical trials.

Estatinas y mortalidad por influenza: revisión sistemática y meta-análisis / Statins and influenza mortality: systematic review and meta-analysis

INTRODUCCIÓN: Debido a sus propiedades antiinflamatorias, se ha planteado que el uso de las estatinas podría influir en la evolución de la infección por el virus de influenza. OBJETIVO: Evaluar el efecto de la terapia con estatinas sobre la mortalidad por influenza. MATERIAL y MÉTODOS: Se realizó un meta-análisis que incluyó estudios que evaluaron el uso de estatinas en pacientes con influenza e informaron los datos sobre mortalidad, después de buscar en las bases de datos PubMed/MEDLINE, Embase y Cochrane Controlled Trials. Se aplicó un modelo de efectos aleatorios. Se analizó el riesgo de sesgos y se desarrolló un análisis de sensibilidad. RESULTADOS: Se identificaron y se consideraron elegibles para el análisis ocho estudios (diez cohortes independientes), que incluyeron un total de 2.390.730 de pacientes. Un total de 1.146.995 de sujetos analizados recibieron estatinas mientras que 1.243.735 de sujetos formaron parte del grupo control. La terapia con estatinas se asoció con una menor mortalidad (OR: 0,66; IC 95%: 0,51-0,85). El análisis de sensibilidad mostró que los resultados fueron robustos. CONCLUSIONES: Nuestros datos sugieren que, en una población con influenza, el uso de estatinas se asoció con una reducción significativa de la mortalidad. Estos resultados deben confirmarse en futuros ensayos clínicos.

BACKGROUND: Due to their anti-inflammatory properties, it has been suggested that the use of statins could influence the evolution of influenza virus infection. AIM: To evaluate the effect of statin therapy on mortality from influenza. METHODS: A meta-analysis that included studies evaluating the use of statins in patients with influenza and reporting data on mortality, after searching the PubMed/MEDLINE, Embase, and Cochrane Controlled Trials databases, was performed. A random effects model was applied. The risk of bias was analyzed and a sensitivity analysis was performed. RESULTS: Eight studies (10 independent cohorts), which included a total of 2,390,730 patients, were identified and eligible for analysis. A total of 1,146,995 subjects analyzed received statins, while 1,243,735 subjects were part of the control group. Statin therapy was associated with lower mortality (OR: 0.66; 95% CI: 0.51-0.85). The sensitivity analysis showed that the results were robust. CONCLUSION: Our data suggest that, in a population with influenza, the use of statins was associated with a significant reduction in mortality. These results must be confirmed in future clinical trials.

Injuria cardíaca post- COVID19 y su relación con la gravedad del cuadro agudo, los síntomas persistentes y la vacunación / Cardiac Injury after COVID-19 and its Association with the Severity of the Acute Presentation, Persistent Symptoms and Vaccination

RESUMEN Introducción: La infección por COVID-19 se asocia a compromiso cardiovascular en su etapa aguda. La información sobre el compromiso cardíaco post-COVID es muy heterogénea, y la indicación de realizar estudios de imágenes cardíacas de forma rutinaria es aún controvertida. Asimismo, no existe información actualizada sobre el efecto que produjo la vacunación masiva en la incidencia de la injuria cardíaca post-COVID. Objetivos: Analizar la prevalencia de injuria cardíaca mediante ecocardiograma luego de la infección por COVID-19 y su asociación con la gravedad del cuadro agudo y con los síntomas persistentes post-COVID. Como objetivo secundario se exploró la relación de la prevalencia de injuria cardíaca con el inicio de la campaña de vacunación contra COVID-19 en la República Argentina. Material y métodos: Estudio analítico, observacional, prospectivo y unicéntrico. Se incluyeron todos los pacientes consecutivos que consultaron para realizar evaluación post-COVID. Se realizó ecocardiograma transtorácico en todos los pacientes. Se consideró la fecha de inicio de la campaña de vacunación (29/12/2020) para el análisis de los subgrupos pre y post vacunación. Resultados: Se incluyeron los primeros 1000 pacientes que consultaron al centro desde el 01/09/2020 al 01/09/2021. Treinta y nueve (3,9%) presentaron hallazgos patológicos en el ecocardiograma compatibles con injuria post-COVID, incluyendo disfunción ventricular izquierda (2,8%), derrame pericárdico (0,5%) y trastorno de motilidad parietal (0,6%), no conocidos previamente. Los pacientes que padecieron cuadros de COVID-19 agudo moderados o graves presentaron mayor prevalencia de trastornos de motilidad parietal (2,9% versus 0,3%, p = 0,001) y derrame pericárdico (2,9% versus 0,14%, p = 0,001) en comparación con aquellos con cuadros asintomáticos o leves, y esta asociación se mantuvo al ajustar por factores de riesgo cardiovascular y edad (OR 6,7; IC 95% 1,05-42,2, p = 0,04 y OR 25,1; IC 95% 2,1-304,9, p = 0,01 respectivamente). El 19,3% de los pacientes referían síntomas persistentes en la consulta post-COVID; en estos pacientes se observó mayor evidencia de disfunción ventricular izquierda nueva (8,3% vs 2,4%, p<0,005); no obstante, dicha asociación perdió significancia en el análisis multivariado. Respecto a la relación de la injuria cardíaca con el inicio de la vacunación, los 330 pacientes que se realizaron estudios de control post-COVID previamente al inicio de la campaña presentaron mayor prevalencia de injuria que los 670 pacientes luego de esta fecha (6,3% vs 2,7%, p = 0,006). Esta relación se mantuvo en el análisis multivariado (OR 0,35; IC95% 0,17-0,69). Conclusión: La prevalencia de injuria cardíaca evaluada mediante ecocardiograma luego de la infección por COVID-19 fue de 3,9%. Se observó una asociación significativa e independiente entre cuadros iniciales de mayor gravedad y hallazgos patológicos en el ecocardiograma en la etapa post-COVID, no así con los síntomas persistentes. Los pacientes que consultaron luego del inicio de la campaña de vacunación en Argentina presentaron menos prevalencia de injuria cardíaca en comparación con los pacientes de la primera ola.

ABSTRACT Background: COVID-19 is associated with cardiovascular involvement in the acute phase. The information about cardiac involvement after COVID-19 is heterogeneous, and the indication to routinely perform cardiac imaging tests is still controversial. There is no updated information on the effect mass vaccination has on the incidence of cardiac injury after COVID-19. Objectives: The primary objective of this study was to evaluate the prevalence of cardiac injury after COVID-19 by transthoracic echocardiography and its association with the severity of the acute phase and with persistent symptoms after recovery. The secondary objective was to explore the association of the prevalence of cardiac injury with the beginning of the vaccination campaign against COVID-19 in Argentina. Methods: We conducted an observational, single-center, and retrospective study. All the consecutive patients who consulted for post-COVID-19 evaluation were included. All the patients underwent transthoracic echocardiography. The date the vaccination campaign started (12/29/2020) was considered the cut-off point for the analysis of the pre-vaccination and postvaccination subgroups. Results: The first 1000 patients who consulted in our center between 09/01/2020 and 09/01/2021 were included. Thirty-nine patients (3.9%) had new abnormal echocardiographic findings suggestive of cardiac injury after COVID-19, including left ventricular dysfunction (2.8%), pericardial effusion (0.5%), and wall motion abnormalities (0.6%). Patients with moderate or severe acute COVID-19 presented a higher prevalence of wall motion abnormalities (2.9% versus 0.3%, p= 0.001) and pericardial effusion (2.9% versus 0.14%, p = 0.001) compared to those with asymptomatic or mild COVID-19 and this association remained after adjusting for cardiovascular risk factors and age (OR 6.7, 95% CI 1.05-4.2, p = 0.04, and OR 25.1, 95% 2.1-304.9, p = 0.01 respectively). The percentage of patients who reported persistent symptoms during consultation after COVID-19 was 19.3%, and they had higher evidence of new left ventricular dysfunction (8.3% vs. 2.4%, p < 0.005); however, this association lost significance on multivariate analysis. When the association of cardiac injury with the start of vaccination was considered, the 330 patients who underwent post-COVID assessment before the vaccination campaign started had a higher prevalence of injury than the 670 patients evaluated after this date (6.3% vs. 2.7%, p = 0.006). and this association persisted on multivariate analysis (OR 0.35; 95%CI 0.17-0.69). Conclusion: The prevalence of cardiac injury assessed by echocardiography after COVID-19 was 3.9%. There was a significant and independent association between the severe initial presentations and the abnormal echocardiographic findings after COVID-19, but not with persistent symptoms. Patients who consulted after the vaccination campaign started in Argentina had a lower prevalence of cardiac injury compared with those patients in the first wave.

Compromiso cardíaco y su relación con la gravedad del cuadro agudo y los síntomas persistentes en la convalecencia de infección por COVID-19 / Cardiovascular Involvement and its Relationship with the Severity of the Acute Phase and Persistent Symptoms during Recovery from COVID-19 Infection

RESUMEN Introducción: La infección por COVID-19 se asocia a compromiso cardiovascular en su etapa aguda. La información sobre el compromiso cardíaco en la etapa de convalecencia de la enfermedad tanto en pacientes con y sin síntomas persistentes es limitada. Objetivos: 1. Analizar el compromiso cardíaco mediante ecocardiograma en la etapa de convalecencia de la enfermedad por COVID-19; 2. Explorar su asociación con: a) gravedad del cuadro agudo y b) persistencia de síntomas. Métodos: Estudio analítico, observacional, prospectivo y unicéntrico. Se incluyeron pacientes consecutivos que consultaron al centro para realizar evaluación post-COVID. Se realizó ecocardiograma Doppler color transtorácico en busca de hallazgos patológicos. Resultados: Se incluyeron 600 pacientes desde el 01/09/2020 al 01/05/2021. Veintinueve (4,8%) presentaron hallazgos patológicos en el ecocardiograma. Los pacientes con cuadros iniciales moderados o graves presentaron mayor prevalencia de trastornos de motilidad parietal (4,3% versus 0,5%, p = 0,02) y derrame pericárdico (4,3% versus 0,24%, p = 0,01) en comparación con aquellos con cuadros asintomáticos o leves. En el ajuste multivariado esta asociación no alcanzó significación estadística. El 28,6% de los pacientes referían síntomas persistentes, no observándose una asociación entre la presencia de los mismos y los hallazgos ecocardiográficos patológicos. Conclusión: La prevalencia de compromiso cardíaco evaluado mediante ecocardiograma en la etapa de convalecencia de la enfermedad por COVID-19 fue de 4,8%. Los pacientes con cuadros iniciales más graves presentaron más hallazgos patológicos. La significancia no se sostuvo en el análisis multivariado. Los síntomas persistentes no se asociaron a mayor compromiso cardíaco.

ABSTRACT Background: The acute phase of COVID-19 infection is associated with cardiovascular involvement, but there is limited information regarding this relationship in the recovery phase from this disease both in patients with or without persistent symptoms. Objectives: The aims of this study were: 1. To analyze cardiovascular involvement by echocardiography in the recovery phase from COVID-19 disease, and 2. To explore its association with: a) the severity of the acute phase and b) the presence of persistent symptoms. Methods: An analytical, observational, prospective and single-center study was carried out, including consecutive patients attending the center for post-COVID-19 evaluation who underwent a transthoracic color Doppler echocardiogram looking for pathological outcomes. Results: A total of 600 patients were included from September 1, 2020 to May 1, 2021, and 29 of these patients (4.8%) presented pathological findings in the echocardiogram. Patients with moderate or severe acute phase COVID-19 infection had a higher prevalence of wall motion disorders (4.3% vs. 0.5%, p=0.02) and pericardial effusion (4.3% vs. 0.24%, p=0.01) compared with those with asymptomatic or mild symptoms; however, after multivariate adjustment, this association did not reach statistical significance. In 28.6% of cases, patients reported persistent symptoms, with no evident association between their presence and pathological echocardiographic results. Conclusion: The prevalence of cardiovascular involvement evaluated by echocardiography was 4.8% in the recovery phase from COVID-19 disease. Patients with more severe initial clinical presentation exhibited more pathological findings, but the significance was not sustained in the multivariate analysis. Persistent symptoms were not associated with greater cardiovascular involvement.

Role of non-statin lipid-lowering therapy in coronary atherosclerosis regression: a meta-analysis and meta-regression.

BACKGROUND: Several studies have investigated the association between non-statin lipid-lowering therapy and regression of atherosclerosis. However, these studies were mostly small and their results were not always robust. The objectives were: (1) to define if a dual lipid-lowering therapy (statin + non-statin drugs) is associated with coronary atherosclerosis regression, estimated by intravascular ultrasound (IVUS); (2) to assess the association between dual lipid-lowering-induced changes in low density lipoprotein cholesterol (LDL-C) and non-high-density-lipoprotein cholesterol (non-HDL-C) levels and atherosclerosis regression. METHODS: A meta-analysis including trials of non-statin lipid-lowering therapy, reporting LDL-C, non-HDL-C and total atheroma volume (TAV) with a minimum of 6 months of follow-up was performed. The primary endpoint was defined as the change in TAV measured from baseline to follow-up, comparing groups of subjects on statins alone versus combination of statin and non-statin drugs. The random-effects model and meta-regression were performed. RESULTS: Eight eligible trials of non-statin lipid-lowering drugs (1759 patients) were included. Overall, the dual lipid-lowering therapy was associated with a significant reduction in TAV [- 4.0 mm3 (CI 95% -5.4 to - 2.6)]; I2 = 0%]. The findings were similar in the stratified analysis according to the lipid-lowering drug class (ezetimibe or PCSK9 inhibitors). In the meta-regression, a 10% decrease in LDL-C or non-HDL-C levels, was associated, respectively, with 1.0 mm3 and 1.1 mm3 regressions in TAV. CONCLUSION: These data suggests the addition of ezetimibe or PCSK9 inhibitors to statin therapy results in a significant regression of TAV. Reduction of coronary atherosclerosis observed with non-statin lipid-lowering therapy is associated to the degree of LDL-C and non-HDL-C lowering. Therefore, it seems reasonable to achieve lipid goals according to cardiovascular risk and regardless of the lipid-lowering strategy used (statin monotherapy or dual treatment).

Impact of the 2019 European Guidelines on Diabetes in Clinical Practice: Real and Simulated Analyses of Lipid Goals.

BACKGROUND: Recent European guidelines on diabetes, prediabetes, and cardiovascular disease developed for the European Society of Cardiology (ESC) in collaboration with the European Association for the Study of Diabetes (EASD) significantly changed some concepts on risk stratification, lipid goals, and recommendations for the use of lipid-lowering drugs. The objectives of this work were to describe the lipid-lowering treatment prescribed for patients with diabetes and to determine the percentage of patients that achieved the lipid goals recommended by the 2019 ESC/EASD Guidelines on Diabetes in real and simulated scenarios. METHODS: A multicenter, cross-sectional study was performed. Subjects >18 years with type 2 diabetes were included. The recommendations of the 2019 ESC/EASD Guidelines were followed. The real and simulated (ideal setting using adequate doses of statins ± ezetimibe) scenarios were analyzed. RESULTS: Overall, 528 patients were included. In total, 62.5% of patients received statins (17.1% high intensity). Most patients were stratified as "very high risk" (54.2%) or "high risk" (43.4%). Only 13.3% achieved the double lipid goal (LDL-C and non-HDL-C goals according to the risk categories). In the simulation analysis, the proportion of subjects that did not reach the therapeutic objective decreased in all risk strata, although a considerable proportion of subjects persisted outside the target. CONCLUSION: The difficulty of achieving lipid goals in diabetic patients was considerable when applying the new guidelines. The situation would improve if we optimized treatment, but the prescription of new lipid-lowering drugs could be limited by their high cost.

Metas lipídicas en pacientes diabéticos. Implicaciones clínicas luego de aplicar una nueva fórmula para el cálculo del colesterol-LDL / Lipid Goals in Diabetic Patients. Clinical Implications after Application of a New Formula for LDL-cholesterol Calculation

RESUMEN Introducción: Existen claras recomendaciones para el manejo lipídico en los diabéticos. Una nueva fórmula para el cálculo del C-LDL mejoraría la imprecisión de la fórmula de Friedewald. Objetivos: Analizar el uso de estatinas y el cumplimiento de las metas lipídicas en pacientes diabéticos, evaluando las consecuencias de aplicar una nueva fórmula para el cálculo del C-LDL. Métodos: Estudio descriptivo, transversal y multicéntrico. Se incluyeron diabéticos tipo 2 mayores de 18 años. El C-LDL se calculó con la fórmula clásica (Friedewald) y la nueva fórmula. Se siguieron las recomendaciones del documento de posición para el uso adecuado de estatinas (Sociedad Argentina de Cardiología). Resultados: Se incluyeron 528 pacientes. En prevención secundaria, el 77,2% recibió estatinas (23,4% alta intensidad). El 36,6% y el 36,0% alcanzaron la meta de C-LDL menor a 70 mg/dL y de C-noHDL inferior a 100 mg/dL, respectivamente. El 20,8% de los pacientes con un C-LDL menor de 70 mg/dL (Friedewald) salió de meta al aplicar la nueva fórmula. En los pacientes en prevención primaria con factores de riesgo o daño de órgano blanco, el 62,2% recibió estatinas (14,7% alta intensidad). El 20,9% y el 20,4% alcanzaron la meta de C-LDL menor a 70 mg/dL y de C-noHDL inferior a 100 mg/dL. El 27,7% de los pacientes con un C-LDL menor de 70 mg/dL (Friedewald) salió de meta al aplicar la nueva fórmula. A mayor nivel de triglicéridos, más pacientes salieron de meta de C-LDL con la nueva fórmula. Conclusión: El cumplimiento de las metas lipídicas y el uso adecuado de estatinas en esta población fue deficiente. Aplicar la nueva fórmula de C-LDL optimizó la evaluación de estos pacientes.

ABSTRACT Background: There are clear recommendations for lipid management in diabetic patients. A new formula for the calculation of LDL-cholesterol (LDL-C) would improve the inaccuracy of the Friedewald formula. Objectives: The aim of this study was to analyze the use of statins and the fulfillment of lipid goals in diabetic patients, evaluating the consequences of applying a new formula for LDL-C calculation. Methods: This was a descriptive, cross-sectional, multicenter study including type 2 diabetic patients over 18 years of age. LDL-C was calculated using the classic Friedewald formula and the new formula. Recommendations of the position document for the appropriate use of statins from the Argentine Society of Cardiology were followed. Results: A total of 528 patients were included in the study. In secondary prevention, 77.2% of patients received statins (23.4% high-intensity statins) and 36.6% and 36.0% of these patients achieved the goals of LDL-C below 70% mg/dl and non-HDL-C below 100 mg/dl, respectively. In 20.8% of patients with LDL-C below 70 mg/dl according to the Friedewald formula, this goal was not attained when the new formula was applied. In primary prevention, 62.2% patients with risk factors or white organ damage received statins (14.7% high-intensity statins) and 20.9% and 20.4% achieved the goals of LDL-C below 70% mg/dl and non-HDL-C below 100 mg/dl. In 27.7% of patients with LDL-C below 70 mg/dl using the Friedewald formula, this goal was not reached when applying the new formula. More patients did not achieve the LDL-C goal with the new formula when the triglyceride level was higher. Conclusion: In this population, the appropriate use of statins and the fulfillment of lipid goals were poor. Applying the new LDL-C formula optimized the evaluation of these patients.

Impact of Lipid-Lowering Therapy on Mortality According to the Baseline Non-HDL Cholesterol Level: A Meta-Analysis.

INTRODUCTION: Previous report showed that more intensive lipid-lowering therapy was associated with less mortality when baseline LDL-C levels were > 100 mg/dL. Non-HDL-C is a better predictor of cardiovascular risk than simpler LDL-C. AIM: The objective of this meta-analysis was to define the impact of lipid-lowering therapy on the reduction of total and cardiovascular mortality by different baseline levels of non-HDL-C. METHODS: We performed a meta-analysis including randomized, controlled clinical trials of lipid-lowering therapy, reporting mortality with a minimum of 6 months of follow-up, searching in PubMed/Medline, EMBASE and Cochrane Clinical Trials databases. The random-effects model and meta-regression were performed. RESULTS: Twenty nine trials of lipid-lowering drugs, including 233,027 patients, were considered eligible for the analyses. According to the baseline non-HDL-C level, the results on cardiovascular mortality were: (1) ≥ 190 mg/dL: OR 0.63 (95% CI 0.53-0.76); (2) 160-189 mg/dL: OR 0.82 (95% CI 0.75-0.89); (3) 130-159 mg/dL: OR 0.71 (95% CI 0.52-0.98); (4) < 130 mg/dL: OR 0.95 (95% CI 0.87-1.05). When evaluating mortality from any cause, the results were the following: (1) ≥ 190 mg/dL: OR 0.70 (95% CI 0.61-0.82); (2) 160-189 mg/dL: OR 0.91 (95% CI 0.83-0.98); (3) 130-159 mg/dL; OR 0.88 (95% CI 0.77-1.00); (4) < 130 mg/dL: OR 0.98 (95% CI 0.91-1.06). The meta-regression analysis showed a significant association between baseline non-HDL-C and mortality. CONCLUSIONS: In these meta-analyses, lipid-lowering therapy was associated with reduction in the risk of all-cause and cardiovascular mortality when baseline non-HDL-C levels were above than 130 mg/dL.

Cardiovascular Risk Stratification in Patients with Metabolic Syndrome Without Diabetes or Cardiovascular Disease: Usefulness of Metabolic Syndrome Severity Score.

INTRODUCTION: The estimated cardiovascular risk determined by the different risk scores, could be heterogeneous in patients with metabolic syndrome without diabetes or vascular disease. This risk stratification could be improved by detecting subclinical carotid atheromatosis. AIMS: To estimate the cardiovascular risk measured by different scores in patients with metabolic syndrome and analyze its association with the presence of carotid plaque. METHODS: Non-diabetic patients with metabolic syndrome (Adult Treatment Panel III definition) without cardiovascular disease were enrolled. The Framingham score, the Reynolds score, the new score proposed by the 2013 ACC/AHA Guidelines and the Metabolic Syndrome Severity Calculator were calculated. Prevalence of carotid plaque was determined by ultrasound examination. A Receiver Operating Characteristic analysis was performed. RESULTS: A total of 238 patients were enrolled. Most patients were stratified as "low risk" by Framingham score (64%) and Reynolds score (70.1%). Using the 2013 ACC/AHA score, 45.3% of the population had a risk ≥7.5%. A significant correlation was found between classic scores but the agreement (concordance) was moderate. The correlation between classical scores and the Metabolic Syndrome Severity Calculator was poor. Overall, the prevalence of carotid plaque was 28.2%. The continuous metabolic syndrome score used in our study showed a good predictive power to detect carotid plaque (area under the curve 0.752). CONCLUSION: In this population, the calculated cardiovascular risk was heterogenic. The prevalence of carotid plaque was high. The Metabolic Syndrome Severity Calculator showed a good predictive power to detect carotid plaque.

Estimation of cardiovascular risk and detection of subclinical carotid atheromatosis in patients with diabetes without a history of cardiovascular disease

ABSTRACT Objectives Cardiovascular risk estimated by several scores in patients with diabetes mellitus without a cardiovascular disease history and the association with carotid atherosclerotic plaque (CAP) were the aims of this study. Materials and methods Cardiovascular risk was calculate using United Kingdom Prospective Diabetes Study (UKPDS) risk engine, Framingham risk score for cardiovascular (FSCV) and coronary disease (FSCD), and the new score (NS) proposed by the 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol. Ultrasound was used to assess CAP occurrence. A receiver operating characteristic (ROC) analysis was performed. Results One hundred seventy patients (mean age 61.4 ± 11 years, 58.8% men) were included. Average FSCV, FSCD and NS values were 33.6% ± 21%, 20.6% ± 12% and 24.8% ± 18%, respectively. According to the UKPDS score, average risk of coronary disease and stroke were 22.1% ± 16% and 14.3% ± 19% respectively. Comparing the risks estimated by the different scores a significant correlation was found. The prevalence of CAP was 51%, in patients with the higher scores this prevalence was increased. ROC analysis showed a good discrimination power between subjects with or without CAP. Conclusion The cardiovascular risk estimated was high but heterogenic. The prevalence of CAP increased according to the strata of risk. Understanding the relationship between CAP and scores could improve the risk estimation in subjects with diabetes.

Estimation of cardiovascular risk and detection of subclinical carotid atheromatosis in patients with diabetes without a history of cardiovascular disease.

OBJECTIVES: Cardiovascular risk estimated by several scores in patients with diabetes mellitus without a cardiovascular disease history and the association with carotid atherosclerotic plaque (CAP) were the aims of this study. MATERIALS AND METHODS: Cardiovascular risk was calculate using United Kingdom Prospective Diabetes Study (UKPDS) risk engine, Framingham risk score for cardiovascular (FSCV) and coronary disease (FSCD), and the new score (NS) proposed by the 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol. Ultrasound was used to assess CAP occurrence. A receiver operating characteristic (ROC) analysis was performed. RESULTS: One hundred seventy patients (mean age 61.4 ± 11 years, 58.8% men) were included. Average FSCV, FSCD and NS values were 33.6% ± 21%, 20.6% ± 12% and 24.8% ± 18%, respectively. According to the UKPDS score, average risk of coronary disease and stroke were 22.1% ± 16% and 14.3% ± 19% respectively. Comparing the risks estimated by the different scores a significant correlation was found. The prevalence of CAP was 51%, in patients with the higher scores this prevalence was increased. ROC analysis showed a good discrimination power between subjects with or without CAP. CONCLUSION: The cardiovascular risk estimated was high but heterogenic. The prevalence of CAP increased according to the strata of risk. Understanding the relationship between CAP and scores could improve the risk estimation in subjects with diabetes.

Association between triglyceride/HDL cholesterol ratio and carotid atherosclerosis in postmenopausal middle-aged women. / Asociación entre la razón triglicéridos/colesterol HDL y ateromatosis carotídea en mujeres posmenopáusicas de mediana edad.

BACKGROUND AND OBJECTIVE: The triglyceride/HDL cholesterol ratio, as a surrogate marker of insulin resistance, may be associated to presence of subclinical carotid atherosclerosis in postmenopausal women. The aim of this study was to explore this association. PATIENTS AND METHODS: Women (last menstrual period≥2 years) in primary prevention up to 65 years of age were recruited. Association between the triglyceride/HDL cholesterol (HDL-C) ratio and presence of carotid plaque, assessed by ultrasonography, was analyzed. ROC analysis was performed, determining the precision of this ratio to detect carotid plaque. RESULTS: A total of 332 women (age 57±5 years) were recruited. Triglyceride/HDL-C ratio was 2.35±1.6. Prevalence of carotid plaque was 29%. Women with carotid plaque had higher triglyceride/HDL-C ratios (3.33±1.96 vs. 2.1±1.2, P<.001) than women with no carotid plaque. A positive relationship was seen between quintiles of this ratio and prevalence of carotid plaque (p<.001). Regardless of other risk factors, women with higher triglyceride/HDL-C ratios were more likely to have carotid plaque (odds ratio 1.47, 95% confidence interval 1.20-1.79, P<.001). The area under the curve of the triglyceride/HDL-C ratio to detect carotid plaque was .71 (95% confidence interval .65 to .76), and the optimal cut-off point was 2.04. CONCLUSIONS: In postmenopausal women in primary prevention, insulin resistance, estimated from the triglyceride/HDL-C ratio, was independently associated to a greater probability of carotid plaque. A value of such ratio greater than 2 may be used for assessing cardiovascular risk in this particular group of women.

Cómo usan los pacientes Internet para la prevención cardiovascular / How Patients Use the Internet for Cardiovascular Prevention

Introducción: El uso de Internet y las redes sociales por parte de los pacientes en busca de información relacionada con la salud ha crecido en los últimos años. Desconocemos la utilización de estas herramientas en el contexto de la prevención cardiovascular en la Argentina. Objetivos: Analizar la utilización de Internet y las redes sociales en pacientes evaluados en el contexto de prevención cardiovascular, determinar las características de los sujetos que las utilizan, analizar la fiabilidad y utilidad percibida por los pacientes y describir el potencial impacto conductual. Material y métodos: Se encuestaron pacientes mayores de 18 años atendidos, en forma consecutiva, en 10 consultorios de cardiología con orientación en la prevención cardiovascular de la Ciudad de Buenos Aires y el Conurbano Bonaerense. De las encuestas entregadas, el 97% fueron completadas. Se recolectaron las características demográficas y clínicas de los participantes, excluyendo los sujetos con incapacidad para leer e interpretar un cuestionario. Resultados: Se incluyeron 1.135 pacientes (edad 49 ± 17 años). El 68%, 65% y 52% utilizaban Internet, correo electrónico o las redes sociales, respectivamente. El 58,2% buscó información relacionada con la salud. Los temas sobre prevención cardiovascular buscados con más frecuencia fueron alimentación (48%), actividad física (35%), medicación (32%), hipertensión (26%) y obesidad (25%). El 54,6% consideró que la información era confiable o muy confiable. Se observó interés en utilizar dichas herramientas para contactarse con el médico u otros pacientes. El 57,8% consideró que la red podría influir en su conducta. Tener menos de 50 años, atenderse en centros privados o tener más educación se asoció independientemente con una probabilidad mayor de buscar información sobre la salud. Conclusiones: En esta población, el uso de Internet en busca de información relacionada con la salud fue considerable. Los sujetos más jóvenes, más educados o atendidos en centros privados mostraron mayor probabilidad de buscar contenidos sobre la salud. El interés generado por estas herramientas permitiría utilizarlas en la atención de nuestros pacientes.

Background: The use of the Internet and social networks by patients seeking health-related information has grown in recent years. The application of these tools in the context of cardiovascular prevention in Argentina is unknown. Objectives: The aim of this study was to analyze the use of the Internet and social networks in patients evaluated in the context of cardiovascular prevention, determine the characteristics of subjects using them, analyze the reliability and usefulness perceived by patients and describe the potential behavioral impact. Methods: Patients over 18 years of age, consecutively attending 10 cardiology centers focusing on cardiovascular prevention of the City of Buenos Aires and suburban areas, were surveyed. In 97% of cases the surveys were completed by the patients. Participants’ demographic and clinical data were collected, excluding subjects with inability to read and interpret a questionnaire. Results: A total of 1,135 patients (age 49±17 years) were included in the study. Among them 68%, 65% and 52% used Internet, email or social networks, respectively, and 58.2% sought health-related information. The most searched-for topics were food (48%), physical activity (35%), medication (32%), hypertension (26%) and obesity (25%). Information was considered reliable or very reliable in 54.6% of cases, and interest was perceived in using these tools to contact the physician or other patients. In 57.8% of cases, patients felt that the network could influence their behavior. Characteristics such as less than 50 years of age, attending private healthcare centers or higher education were independently associated with a greater possibility of seeking health information. Conclusions: In this population, the Internet was significantly used to explore about health information. Younger subjects, with higher education and those attending private healthcare centers were more likely to seek health-related information. The interest generated by these tools could be used for patient care.

Association between LDL-C, Non HDL-C, and Apolipoprotein B Levels with Coronary Plaque Regression / Associação entre Níveis De LDL-C, Não-HDL-C E Apolipoproteína B com Regressão de Placa Coronariana

Previous reports have inferred a linear relationship between LDL-C and changes in coronary plaque volume (CPV) measured by intravascular ultrasound. However, these publications included a small number of studies and did not explore other lipid markers.

Estudos prévios sugerem uma relação linear entre o LDL-C e mudanças no volume de placa coronariana (VPC) medido por ultrassonografia intravascular. No entanto, estas publicações incluíram um número pequeno de estudos e não exploraram outros marcadores lipídicos.

Impact of a Meditation Program on Pulse-Wave Velocity, C-reactive Protein and Quality of life / Impacto de un programa de meditación sobre la velocidad de onda de pulso, la proteína C-reactiva y la calidad de vida

background: Although various studies refer to the effect of meditation on blood pressure (BP), its impact on other cardiovascular clinical variables is unknown. Objective: The aim of this study was to evaluate the effects of a meditation program on pulse wave velocity (PWV), quality of life and ultrasensitive C-reactive protein (us-CRP) in patients with ischemic heart disease or chronic heart failure. Methods: This was a randomized study with two groups of patients: a meditation group (M) and an active control group (AC) with cardiovascular health education, evaluating the difference between initial and final values at 12 weeks of B P, PWV, quality of life (assessed by the SF-36 questionnaire) and us-CRP. results: Thirty-five patients were included in the M group and 35 in the AC group; mean age was 61 years and 80% were men. Both groups had similar baseline characteristics, except for higher number of smokers and triglyceride levels in the M group. At 12 weeks, no significant differences were found for ∆PWV: +0.51 (±1.40) in AC and +0.19 (±1.53) in M (p=0.37). Conversely, ∆SF-36 was +0.79 (±7.58) in AC vs. +5.40 (±9.69) (p=0.03) in M, and ∆us-PCR was +1.17 (±2.9) in AC vs. -0.69 (±0.89) in M (p=0.02). Conclusions: A meditation program did not significantly modify PWV at 12 weeks. However, patients allocated to this intervention improved their quality of life and us-PCR was significantly reduced. Larger studies are required to confirm these findings and explore the mechanisms involved in this improvement.

Association between LDL-C, Non HDL-C, and Apolipoprotein B Levels with Coronary Plaque Regression.

BACKGROUND: Previous reports have inferred a linear relationship between LDL-C and changes in coronary plaque volume (CPV) measured by intravascular ultrasound. However, these publications included a small number of studies and did not explore other lipid markers. OBJECTIVE: To assess the association between changes in lipid markers and regression of CPV using published data. METHODS: We collected data from the control, placebo and intervention arms in studies that compared the effect of lipidlowering treatments on CPV, and from the placebo and control arms in studies that tested drugs that did not affect lipids. Baseline and final measurements of plaque volume, expressed in mm3, were extracted and the percentage changes after the interventions were calculated. Performing three linear regression analyses, we assessed the relationship between percentage and absolute changes in lipid markers and percentage variations in CPV. RESULTS: Twenty-seven studies were selected. Correlations between percentage changes in LDL-C, non-HDL-C, and apolipoprotein B (ApoB) and percentage changes in CPV were moderate (r = 0.48, r = 0.47, and r = 0.44, respectively). Correlations between absolute differences in LDL-C, non­HDL-C, and ApoB with percentage differences in CPV were stronger (r = 0.57, r = 0.52, and r = 0.79). The linear regression model showed a statistically significant association between a reduction in lipid markers and regression of plaque volume. CONCLUSION: A significant association between changes in different atherogenic particles and regression of CPV was observed. The absolute reduction in ApoB showed the strongest correlation with coronary plaque regression.