Antihyperglycemic agents as novel natriuretic therapies in diabetic kidney disease.

While sodium-glucose cotransporter-2 (SGLT2) inhibitors have been used for the routine management of type 2 diabetes for several years, it is perhaps their natriuretic effects that are most important clinically. This natriuresis activates tubuloglomerular feedback, resulting in reduced glomerular hypertension and proteinuria, leading to renal protective effects in the EMPA-REG OUTCOME and CANVAS Program trials. In the cardiovascular system, it is likely that plasma volume contraction due to natriuresis in response to SGLT2 inhibition is at least in part responsible for the reduction in the risk of heart failure observed in these trials. We compare this mechanism of action with other antidiabetics. Importantly, other diuretic classes, including thiazide and loop diuretics, have not resulted in such robust clinical benefits in patients with type 2 diabetes, possibly because these older agents do not influence intraglomerular pressure directly. In contrast, SGLT2 inhibitors do have important physiological similarities with carbonic anhydrase inhibitors, which also act proximally, and have been shown to activate tubuloglomerular feedback.

Management of Cardiovascular Risk in the Non-alcoholic Fatty Liver Disease Setting.

Non-alcoholic fatty liver disease (NAFLD) is an overlooked and undetected pathology, which affects more than 32% of adults worldwide. NAFLD is becoming more common in Western industrialised countries, particularly in patients with central obesity, type 2 diabetes, dyslipidaemia and metabolic syndrome. Although NAFLD has traditionally been interpreted as a liver disease with a high risk of liver-related complications, NAFLD is an underappreciated and independent risk factor for atherosclerotic cardiovascular disease, which is the principal cause of death in patients with NAFLD. Treatment options to counteract both the progression and development of cardiovascular disease and NAFLD include lifestyle interventions, such as weight loss, increased physical activity and dietary modification, and optimal medical therapy of comorbid conditions; nevertheless, further studies are needed to define optimal treatment strategies for the prevention of both hepatic and cardiovascular complications of NAFLD.

Consensus document for lipid profile testing and reporting in Spanish clinical laboratories: what parameters should a basic lipid profile include?

Cardiovascular diseases (CVD) continue to be the main cause of death in our country. Adequate control of lipid metabolism disorders is a key challenge in cardiovascular prevention that is far from being achieved in real clinical practice. There is a great heterogeneity in the reports of lipid metabolism from Spanish clinical laboratories, which may contribute to its poor control. For this reason, a working group of the main scientific societies involved in the care of patients at vascular risk, has prepared this document with a consensus proposal on the determination of the basic lipid profile in cardiovascular prevention, recommendations for its realization and unification of criteria to incorporate the lipid control goals appropriate to the vascular risk of the patients in the laboratory reports.

Consensus document for lipid profile determination and reporting in Spanish clinical laboratories. What parameters should be included in a basic lipid profile? / Documento de consenso para la determinación e informe del perfil lipídico en laboratorios clínicos españoles: ¿Qué parámetros debe incluir un perfil lipídico básico?

Cardiovascular diseases (CVD) continue to be the main cause of death in our country. Adequate control of lipid metabolism disorders is a key challenge in cardiovascular prevention that is far from being achieved in real clinical practice. There is a great heterogeneity in the reports of lipid metabolism from Spanish clinical laboratories, which may contribute to its poor control. For this reason, a working group of the main scientific societies involved in the care of patients at vascular risk, has prepared this document with a consensus proposal on the determination of the basic lipid profile in cardiovascular prevention, recommendations for its realization and unification of criteria to incorporate the lipid control goals appropriate to the vascular risk of the patients in the laboratory reports.

Consensus document for lipid profile testing and reporting in Spanish clinical laboratories: What parameters should a basic lipid profile include?

Cardiovascular diseases (CVD) continue to be the main cause of death in our country. Adequate control of lipid metabolism disorders is a key challenge in cardiovascular prevention that is far from being achieved in real clinical practice. There is a great heterogeneity in the reports of lipid metabolism from Spanish clinical laboratories, which may contribute to its poor control. For this reason, a working group of the main scientific societies involved in the care of patients at vascular risk, has prepared this document with a consensus proposal on the determination of the basic lipid profile in cardiovascular prevention, recommendations for its realization and unification of criteria to incorporate the lipid control goals appropriate to the vascular risk of the patients in the laboratory reports.

Consensus document for lipid profile testing and reporting in Spanish clinical laboratories.

Cardiovascular diseases (CVD) continue to be the main cause of death in our country. Adequate control of lipid metabolism disorders is a key challenge in cardiovascular prevention that is far from being achieved in real clinical practice. There is a great heterogeneity in the reports of lipid metabolism from Spanish clinical laboratories, which may contribute to its poor control. For this reason, a working group of the main scientific societies involved in the care of patients at vascular risk, has prepared this document with a consensus proposal on the determination of the basic lipid profile in cardiovascular prevention, recommendations for its realization and unification of criteria to incorporate the lipid control goals appropriate to the vascular risk of the patients in the laboratory reports.

Consensus document for lipid profile determination and reporting in Spanish clinical laboratories. What parameters should be included in a basic lipid profile?

Cardiovascular diseases (CVD) continue to be the main cause of death in our country. Adequate control of lipid metabolism disorders is a key challenge in cardiovascular prevention that is far from being achieved in real clinical practice. There is a great heterogeneity in the reports of lipid metabolism from Spanish clinical laboratories, which may contribute to its poor control. For this reason, a working group of the main scientific societies involved in the care of patients at vascular risk, has prepared this document with a consensus proposal on the determination of the basic lipid profile in cardiovascular prevention, recommendations for its realization and unification of criteria to incorporate the lipid control goals appropriate to the vascular risk of the patients in the laboratory reports.

Update on the management of hypertension for secondary stroke prevention.

High blood pressure (BP) is the strongest risk factor for stroke. It is estimated that almost 50% of strokes may be attributable to hypertension. Both diastolic and isolated systolic hypertension are important predictors of primary or recurrent strokes, and even minor decreases in BP can reduce the risk of stroke. While the primary prevention of stroke through the treatment of hypertension is well established, the issue of lowering BP after a stroke has been uncertain, particularly since this might worsen cerebral perfusion if autoregulation remains chronically damaged or severe carotid artery stenosis is present. Furthermore, there is substantial evidence to support BP lowering for prevention of a first stroke; however, few trials have focused on antihypertensive therapy for recurrent stroke prevention. In fact, currently, BP management in patients with strokes remains problematic, and questions such as the choice of antihypertensive drug and by how much to reduce BP are yet to be resolved. Recently, the American Heart Association and American Stroke Association published updated guidelines for recurrent stroke prevention, and new recommendations on BP management have been included. Our review presents the most recent evidence on the management of hypertension in patients who have had a stroke.

Echocardiographic assessment of hypertensive left ventricular hypertrophy in patients with acute ischemic stroke or transient ischemic attack.

BACKGROUND: Hypertensive left ventricular hypertrophy (HLVH) is a major risk factor for cardiovascular morbidity, mortality, and stroke. However, little is known about the importance of transthoracic echocardiography (TTE) in the assessment of HLVH in patients with acute ischemic stroke (AIS) or transient ischemic attack (TIA). METHODS: We studied 203 consecutive patients admitted to our hospital with AIS or TIA and who were referred for TTE over the last 4 years. We included 102 (50.2%) lacunar strokes, 76 (37.1%) nonlacunar strokes, and 25 (12.3%) TIAs. The mean age was 68.9 years (standard deviation ± 11) and 128 patients were male (63.1%). RESULTS: Hypertension was the most common risk factor (131 patients; 64.5%). HLVH was seen in 86 cases (42.3%), in 51.9% of patients with previous hypertension, and in 25% of patients without known hypertension. We found that neither stroke subtype nor any previous risk factor, with the exception of hypertension (P = .0001), were associated with HLVH. Patients with HLVH were younger (67 v 71 yrs; P = .013) and more frequently women (50.6% v 37.5%; P = .078). At discharge, patients with HLVH were more likely to receive antihypertensive treatment (97% v 80%; P = .009) and a higher average number of antihypertensive drugs (2.2 v 1.4; P = .0001). CONCLUSIONS: HLVH was common in patients with AIS or TIA. These individuals had an increased risk of stroke and needed a more intensive therapy. TTE should be carried out in all AIS and TIA patients in order to optimize the management of these patients.

Usefulness of point-of-care ultrasound for the evaluation of non-traumatic eye emergencies. / Utilidad de la ecografía clínica en la valoración de la patología ocular urgente no traumática.

The role of clinical ultrasound or Point-of-Care Ultrasound (POCUS) in patients with urgent pathology has expanded exponentially in recent years. With clinical ultrasound, physicians can make a quick assessment and decide how to act in time critical situations. Ocular ultrasound is one of the most recently developed applications. In patients with severe non-traumatic ocular pathology it has numerous clinically relevant uses: retinal detachment, occlusion of the central retinal artery or optic nerve pathologies, among others. The technique is widely available, easy to perform, and can provide information even when fundoscopy is impossible. In this review, we describe the bases of clinical ocular ultrasound, focusing on the management of the main non-traumatic urgent ophthalmological pathologies that the physician may face in their clinical practice.

Pharmacological management of post-stroke depression.

Introduction: Post-stroke depression (PSD) is a common clinical problem affecting approximately one-third of stroke survivors. PSD is associated with poor functional outcome and higher morbidity and mortality rates. Currently, uncertainty remains regarding optimal pharmacological strategies for its prevention and treatment.Areas covered: This article reviews the state of the current literature on pharmacologic intervention strategies for PSD, providing a summary of the most recent evidence to support pharmacological treatment in PSD.Expert opinion: Experimental and clinical research have increased our knowledge on PSD, although unanswered questions still remain regarding the best time to begin treatment, the effect of the antidepressants in areas other than emotion, or their capability to reduce mortality in stroke patients, among others.Currently, though numerous trials and meta-analyses suggest that antidepressants are effective in treating PSD and guidelines recommend their use for PSD, in the daily clinical practice, only a minority of patients are properly assessed and treated. Therefore, though further evidence is needed to clarify the real role of antidepressants in patients with stroke, physicians and other healthcare professionals must be familiar with the pharmacological treatment of PSD, in order to improve the outcome and increase the quality of life of this vulnerable group of patients.

Usefulness of predictive models of pulmonary embolism. / Utilidad de los modelos predictivos de embolia pulmonar.

BACKGROUND: Faced with the suspicion of pulmonary embolism (PE), the guidelines recommend the use of clinical probability scales, measurement of D-dimer and, in certain cases, confirmation by pulmonary angiography by computed tomography (CTPA) or scintigraphy. Recently, it has been proposed to adjust the D-dimer according to age or use simpler scales (YEARS algorithm) for a better selection of patients. OBJECTIVE: To define the degree of application of the guidelines in our population and compare sensitivity, specificity and positive and negative predictive values of the different diagnostic models: Standard model (Wells 2 categories+D-dimer), Model adjusted for age (Wells 2 categories+D-dimer adjusted for age), YEARS algorithm. MATERIAL AND METHODS: A retrospective study of all patients who underwent APTC at our centre for the diagnosis of PE over one year. RESULTS: Of 618 cases (85.4% of initial APTC), 544 patients were included. A total of 113 EPs were diagnosed (20.8%). The degree of application of the standard model was very high (90.1%) and proved to have the best sensitivity and negative predictive value ratio (sensitivity=1.0, negative predictive value=1.0). The new models could reduce the number of scans (17, 3.2% model adjusted for age and 48, 8.8% model YEARS) with a risk of false negatives (2 PE [1.8%] undiagnosed respectively). CONCLUSIONS: The current diagnostic models for PE lead to a large number of unnecessary explorations. The new models could reduce the number of APTC although with a minimum risk of false negatives.

Bleeding risk assessment for stroke patients on antithrombotic therapy. / Evaluación del riesgo hemorrágico de la terapia antitrombótica en pacientes con ictus.

INTRODUCTION: After an ischemic cerebrovascular event the risk of new ischemic events is high, therefore antithrombotic therapy are indicated to prevent stroke recurrence. DISCUSSION: Despite its clear benefit, these therapies increase the risk of bleeding. Therefore, it is essential to identify high hemorrhagic risk patients. There are different predictive models of hemorrhage, in particular of intracranial hemorrhage, associated with the use of antiaggregants in patients who have presented an ischemic stroke or TIA, such as the CCSC, intracranial scales -B2LEED3S score or S2TOP-BLEED. However, though main international guidelines recommend the use of scales, in particular, the HAS-BLED score, to assess the risk of bleeding in anticoagulated patients, there is no specific recommendation in the case of the use of antiplatelet drugs. CONCLUSIONS: In this review we present the main models currently available for the prediction of bleeding of antithrombotic therapy in patients who have had a stroke or TIA.

Statins in Ischemic Stroke Prevention: What Have We Learned in the Post-SPARCL (The Stroke Prevention by Aggressive Reduction in Cholesterol Levels) Decade?

PURPOSE OF REVIEW: We describe the current status of lipid-lowering therapies for ischemic stroke prevention. The SPARCL trial published in 2006 has been a landmark study in vascular neurology. The trial demonstrated that high-dose atorvastatin prevents recurrent stroke, and led the AHA/ASA to recommend statin therapy for patients with stroke or TIA of atherosclerotic origin. RECENT FINDINGS: Recently, the J-STARS study demonstrated that therapy with low-dose pravastatin reduced atherothrombotic infarction incidence among patients with prior ischemic stroke. Besides, several trials have shown improved stroke outcomes with non-statin lipid-lowering medications: IMPROVE-IT with ezetimibe on top of simvastatin and PCSK9 inhibitors-FOURIER with evocolumab and ODYSSEY-OUTCOMES with alirocumab-on top of statin therapy. LDL-cholesterol remains the primary lipid treatment target for reduction of stroke risk. Randomized trials have shown that each reduction of 40 mg/dL in the level of LDL-cholesterol reduces the stroke risk by approximately one quarter, and further, reductions in LDL-cholesterol levels have shown to produce additional reductions in stroke risk. Currently, we have evidence of benefit for adding non-statin lipid-modifying therapies to statins to reduce stroke risk. Surely, these novel strategies to reduce residual lipidic risk will provide future benefits on stroke prevention.