[The PROPRESE trial: results of a new health care organizational model in primary care for patients with chronic coronary heart disease based on a multifactorial intervention]. / El estudio PROPRESE: resultados de un nuevo modelo organizativo en atención primaria para pacientes con cardiopatía isquémica crónica basado en una intervención multifactorial.

OBJECTIVE: Comparison of the results from the EUROASPIRE I to the EUROASPIRE III, in patients with coronary heart disease, shows that the prevalence of uncontrolled risk factors remains high. The aim of the study was to evaluate the effectiveness of a new multifactorial intervention in order to improve health care for chronic coronary heart disease patients in primary care. METHODS: In this randomized clinical trial with a 1-year follow-up period, we recruited patients with a diagnosis of coronary heart disease (145 for the intervention group and 1461 for the control group). An organizational intervention on the patient-professional relationship (centered on the Chronic Care Model, the Stanford Expert Patient Programme and the Kaiser Permanente model) and formative strategy for professionals were carried out. The main outcomes were smoking control, low-density lipoprotein cholesterol (LDL-C), systolic blood pressure (SBP) and diastolic blood pressure (DBP). A multivariate analysis was performed. RESULTS: The characteristics of patients were: age (68.4±11.8 years), male (71.6%), having diabetes mellitus (51.3%), dyslipidemia (68.5%), arterial hypertension (76.7%), non-smokers (76.1%); LDL-C < 100mg/dL (46.9%); SBP < 140mmHg (64.5%); DBP < 90 (91.2%). The multivariable analysis showed the risk of good control for intervention group to be: smoking, adjusted relative risk (aRR): 15.70 (95% confidence interval [95%CI], 4.2-58.7); P < .001; LDL-C, aRR: 2.98 (95%CI, 1.48-6.02); P < .002; SPB, aRR: 1.97 (95%CI, 1.21-3.23); P < .007, and DBP: aRR: 1.51 (95%CI, 0.65-3.50); P < .342. CONCLUSIONS: An intervention based on models for chronic patients focused in primary care and involving patients in medical decision making improves cardiovascular risk factors control (smoking, LDL-C and SBP). Chronic care strategies may be an efficacy tool to help clinicians to involve the patients with a diagnosis of CHD to reach better outcomes.

Opinions and perceptions of patients with cardiovascular disease on adherence: a qualitative study of focus groups.

BACKGROUND: Cardiovascular diseases are becoming more frequent throughout the world. Adherence to both pharmacological and non-pharmacological treatment, as well as lifestyles, is important for good management and control of the disease. This study aims to explore the opinions and perceptions of patients with ischemic heart disease on the difficulties associated with therapeutic adherence. METHODS: An interpretive phenomenological study was carried out using focus groups and one semi-structured interview. The MAXQDA qualitative data analysis program was used for inductive interpretation of the group discourses and interview. Data were coded, and these were grouped by categories and then consolidated under the main themes identified. RESULTS: Two in-person focus groups and one remote semi-structured interview were performed. Twelve participants (6 men and 6 women) from the Hospital de San Juan de Alicante participated, two of them being family companions . The main themes identified were aspects related to the individual, heart disease, drug treatment, and the perception of the health care system. CONCLUSIONS: Adhering to recommendations on healthy behaviors and taking prescribed medications for cardiovascular disease was important for most participants. However, they sometimes found polypharmacy difficult to manage, especially when they did not perceive the symptoms of their disease. Participants related the concept of fear to therapeutic adherence, believing that the latter increased with the former. The relationship with health professionals was described as optimal, but, nevertheless, the coordination of the health care system was seen as limited.

[Testosterone and coronary artery disease]. / Testosterona y enfermedad coronaria.

UNLABELLED: Elderly patients present testosterone deficit syndrome (TDS) in a prevalent manner. TDS is defined as a clinical and biochemical syndrome with total fasting testosterone below normal levels in two consecutive measurements. A significant relationship with comorbidities such as diabetes mellitus, obesity or metabolic syndrome has been observed in these patients. These latter are recognized risk factors of coronary artery disease (CAD) and arteriosclerosis. It seems logical to think that CAD is more frequent in patients with TDS, and it is supported on multiple works demonstrating the correlation of theses two pathologies. We intend to illustrate the management of patients with TDS and CAD presenting a clinical case and the recommended diagnostic and therapeutic approach. A Sixty-four year old male with hypertension, non-insulin dependent diabetes mellitus and obesity consulted for erectile dysfunction and diminished sexual desire. Fasting total testosterone and glycosylate hemoglobin were determined. IIEF-5 was 12, Erection hardness Score was 2 and IIEF item 12 1 point over 5. His total testosterone was 150 ng/dl, which was confirmed in a second test; HDL cholesterol level was 30 mg/dl. Interrogated again, the patient referred oppressive chest pain appearing after running 50 meters for the last three months that never happened in rest or with minor efforts. APPROACH: It is a patient with high cardiovascular risk and atypical chest pain so recommendation was given to consult a cardiologist. Stress test was performed. It was a submaximal, evaluable test (reached 80% of his maximum theoretical heart rate) stopped due to angina. Clinically and electrically it was positive at medium charge. Coronary angiogram was indicated showing a severe (85%percnt;%) lesion at the medial third of anterior descendant artery. Balloon angioplasty was performed and a 3.0 x 24 mm drug-coated stent was placed. Cardiologic treatment was prescribed as well as combination therapy for his erectile dysfunction and diminished libido with testosterone and a PDE 5 inhibitor.

[Measurement of triglycerides in capillary blood: validation against whole blood measurement]. / Concordancia entre la determinación de triglicéridos en sangre capilar y por el método tradicional.

BACKGROUND AND OBJECTIVE: Elevated plasma triglycerides (TG) are an independent cardiovascular risk factor and a part of metabolic and postprandial syndromes. Capillary analysis of TG would facilitate the recognition of those abnormalities. The aim of the present study was to assess the concordance between TG values measured in capillary (Accutrend GCT Roche Diagnostics) and total blood. PATIENTS AND METHODS: Total blood and capillary TG were analyzed in 50 subjects without cardiovascular disease. RESULTS: Mean capillary TG were higher than total blood TG (116.5mg/dl vs 86.0mg/dl; P<.001); a good correlation between both methods was obtained (r=0.95; P<.001). CONCLUSIONS: in this cohort of consecutive unselected subjects we found that capillary TG measurement correlates well with total blood analysis and that there are significant differences between men and women. We propose regression equations to estimate blood TG from capillary measurements: men: capillary TG X 0,837; women: capillary TG X 0,698.

Prevalence and outcomes of atrial fibrillation in a European healthcare area gained through the processing of a health information technology system.

INTRODUCTION: Today's healthcare policies rely heavily on data that has been gathered from multiple small studies in intrinsically varied populations. We sought to describe the prevalence, comorbidities and outcomes of atrial fibrillation (AF) in the population of a specific region where all healthcare centers have implemented a common information technology (IT) structure. METHODS: The total number of inhabitants was obtained from the healthcare area's IT system. Information pertaining to AF was derived from various datasets in the data warehouse of the Galician regional health service. RESULTS: In the healthcare area of Santiago de Compostela (n=383000), the diagnosis of AF was coded in 7990 (2.08%) individuals in 2013. Mean age was 76.83±10.5 years, mean CHA2DS2-VASc score was 3.5, 4056 (50.8%) were female and 72.6% were receiving oral anticoagulants. Up until December 31, 2015, 1361 patients died from all causes (17%), 478 (6%) of them in-hospital, with 30 deaths secondary to intracranial bleeding (0.4%) and 125 to stroke (1.6%). On multivariate analysis, age, gender, heart failure, diabetes, previous thromboembolic events and dementia were independently associated with all-cause mortality. Similarly, age, gender and previous thromboembolic events were associated with future thromboembolic events. Oral anticoagulation was found to be protective against mortality and thromboembolic events. CONCLUSIONS: In this study, we report for the first time the true prevalence of diagnosed AF and its clinical characteristics, treatment and prognosis in a Spanish healthcare area, based on the systematic integration of data available from a universally adopted health IT system within the region.

[Is essential hypertension essentially metabolic?]. / La hipertensión arterial esencial, es esencialmente metabólica?

Hypertension is one of the most prevalent cardiovascular risk factors. Most of the cases are not due to secondary causes and are diagnosed as essential hypertension, although a common physiopathologic link underlies for diabetes and dyslipidemia that are usually present. Most hypertensive patients have also obesity and insulin resistance and this may be more than an epidemiologic association, but one of the main physiopathologic basis of essential hypertension.

[Consensus on objectives and action guidelines on low density lipoproteins-cholesterol control in very high risk cardiovascular patients]. / Consenso sobre los objetivos y pautas de actuación en el control del colesterol ligado a lipoproteínas de baja densidad en pacientes de muy alto riesgo cardiovascular.

INTRODUCTION: Cardiovascular disease is the leading cause of death in developed countries. Among cardiovascular disease risk factors one of the most relevant is low-density lipoprotein-associated cholesterol (LDL-c), but there is controversy about the methods used to control it. The aim was to obtain an expert opinion to clarify the most relevant issues regarding the control of dyslipidemia in very high cardiovascular risk patients. MATERIALS AND METHODS: A survey with 55 items, stratified into 4 blocks: LDL-c as a therapeutic target, therapeutic goals, causes of the failure to achieve LDL-c goals, and recommendations to optimize their achievement, was addressed to 41 specialists (Cardiology and Internal Medicine) using the Delphi method to achieve professional consensus criteria. RESULTS: A high consensus was reached among all items, in line with the European recommendations. The panelists considered that the goal of 70mg/dl for LDL-c for high cardiovascular disease risk (mainly vascular disease, diabetes mellitus, and renal failure), using combined treatment when necessary. Lack of adherence and therapeutic inertia were considered the main reasons for treatment failure. CONCLUSION: The Spanish experts show an elevated consensus with the European recommendations, confirming the LDL-c control target of <70mg/dl. The simplification of the guidelines and the combined treatment may favor an improvement the achievement of lipid target goals.

Challenges in Oral Lipid-lowering Therapy: Position Document of the Spanish Society of Cardiology.

Lipid-lowering therapy is one of the cornerstones of cardiovascular prevention and is one of the most effective strategies in the secondary prevention of ischemic heart disease. Nevertheless, the current treatment of lipid disorders, together with lifestyle changes, fails to achieve the targets recommended in clinical guidelines in a substantial proportion of patients. PCSK9 inhibitors have demonstrated safety and efficacy in the treatment of dyslipidemia. Due to their ability to reduce low-density lipoprotein cholesterol levels, these drugs have recently been approved for clinical use by Spanish regulatory agencies, with the aim of reducing cardiovascular risk in selected patient groups.

[Spanish Interdisciplinary Committee for Cardiovascular Disease Prevention and the Spanish Society of Cardiology position statement on dyslipidemia management. Differences between the European and American guidelines]. / Posicionamiento del comité español interdisciplinario de prevención cardiovascular y la sociedad española de cardiología en el tratamiento de las dislipemias. divergencia entre las guías europea y estadounidense.

The publication of the 2013 American College of Cardiology/American Heart Association guidelines on the treatment of high blood cholesterol has had a strong impact due to the paradigm shift in its recommendations. The Spanish Interdisciplinary Committee for Cardiovascular Disease Prevention and the Spanish Society of Cardiology reviewed this guideline and compared it with current European guidelines on cardiovascular prevention and dyslipidemia management. The most striking aspect of the American guideline is the elimination of the low-density lipoprotein cholesterol treat-to-target strategy and the adoption of a risk reduction strategy in 4 major statin benefit groups. In patients with established cardiovascular disease, both guidelines recommend a similar therapeutic strategy (high-dose potent statins). However, in primary prevention, the application of the American guidelines would substantially increase the number of persons, particularly older people, receiving statin therapy. The elimination of the cholesterol treat-to-target strategy, so strongly rooted in the scientific community, could have a negative impact on clinical practice, create a certain amount of confusion and uncertainty among professionals, and decrease follow-up and patient adherence. Thus, this article reaffirms the recommendations of the European guidelines. Although both guidelines have positive aspects, doubt remains regarding the concerns outlined above. In addition to using risk charts based on the native population, the messages of the European guideline are more appropriate to the Spanish setting and avoid the possible risk of overtreatment with statins in primary prevention. Full English text available from:www.revespcardiol.org/en.

[Spanish interdisciplinary committee for cardiovascular disease prevention and the spanish society of cardiology position statement on dyslipidemia management. Differences between the European and american guidelines]. / Posicionamiento del Comité Español Interdisciplinario de Prevención Cardiovascular y la Sociedad Española de Cardiología en el tratamiento de las dislipemias. Divergencia entre las guías europea y estadounidense.

The publication of the 2013 American College of Cardiology/American Heart Association guidelines on the treatment of high blood cholesterol has had a strong impact due to the paradigm shift in its recommendations. The Spanish Interdisciplinary Committee for Cardiovascular Disease Prevention and the Spanish Society of Cardiology reviewed this guideline and compared it with current European guidelines on cardiovascular prevention and dyslipidemia management. The most striking aspect of the American guideline is the elimination of the low-density lipoprotein cholesterol treat-to-target strategy and the adoption of a risk reduction strategy in 4 major statin benefit groups. In patients with established cardiovascular disease, both guidelines recommend a similar therapeutic strategy (high-dose potent statins). However, in primary prevention, the application of the American guidelines would substantially increase the number of persons, particularly older people, receiving statin therapy. The elimination of the cholesterol treat-to-target strategy, so strongly rooted in the scientific community, could have a negative impact on clinical practice, create a certain amount of confusion and uncertainty among professionals, and decrease follow-up and patient adherence. Thus, this article reaffirms the recommendations of the European guidelines. Although both guidelines have positive aspects, doubt remains regarding the concerns outlined above. In addition to using risk charts based on the native population, the messages of the European guideline are more appropriate to the Spanish setting and avoid the possible risk of overtreatment with statins in primary prevention.

[Spanish Interdisciplinary Committee for Cardiovascular Disease Prevention and the Spanish Society of Cardiology Position Statement on Dyslipidemia Management. Differences Between the European and American Guidelines]. / Posicionamiento del Comité Español Interdisciplinario de Prevención Cardiovascular y la Sociedad Española de Cardiología en el tratamiento de las dislipemias. Divergencia entre las guías europea y estadounidense.

The publication of the 2013 American College of Cardiology/American Heart Association guidelines on the treatment of high blood cholesterol has had a strong impact due to the paradigm shift in its recommendations. The Spanish Interdisciplinary Committee for Cardiovascular Disease Prevention and the Spanish Society of Cardiology reviewed this guideline and compared it with current European guidelines on cardiovascular prevention and dyslipidemia management. The most striking aspect of the American guideline is the elimination of the low-density lipoprotein cholesterol treat-to-target strategy and the adoption of a risk reduction strategy in 4 major statin benefit groups. In patients with established cardiovascular disease, both guidelines recommend a similar therapeutic strategy (high-dose potent statins). However, in primary prevention, the application of the American guidelines would substantially increase the number of persons, particularly older people, receiving statin therapy. The elimination of the cholesterol treat-to-target strategy, so strongly rooted in the scientific community, could have a negative impact on clinical practice, create a certain amount of confusion and uncertainty among professionals, and decrease follow-up and patient adherence. Thus, this article reaffirms the recommendations of the European guidelines. Although both guidelines have positive aspects, doubt remains regarding the concerns outlined above. In addition to using risk charts based on the native population, the messages of the European guideline are more appropriate to the Spanish setting and avoid the possible risk of overtreatment with statins in primary prevention.

Spanish Interdisciplinary Committee for Cardiovascular Disease Prevention and the Spanish Society of Cardiology Position Statement on Dyslipidemia Management: differences between the European and American Guidelines.

The publication of the 2013 American College of Cardiology/American Heart Association guidelines on the treatment of high blood cholesterol has had a strong impact due to the paradigm shift in its recommendations. The Spanish Interdisciplinary Committee for Cardiovascular Disease Prevention and the Spanish Society of Cardiology reviewed this guideline and compared it with current European guidelines on cardiovascular prevention and dyslipidemia management. The most striking aspect of the American guideline is the elimination of the low-density lipoprotein cholesterol treat-to-target strategy and the adoption of a risk reduction strategy in 4 major statin benefit groups. In patients with established cardiovascular disease, both guidelines recommend a similar therapeutic strategy (high-dose potent statins). However, in primary prevention, the application of the American guidelines would substantially increase the number of persons, particularly older people, receiving statin therapy. The elimination of the cholesterol treat-to-target strategy, so strongly rooted in the scientific community, could have a negative impact on clinical practice, create a certain amount of confusion and uncertainty among professionals, and decrease follow-up and patient adherence. Thus, this article reaffirms the recommendations of the European guidelines. Although both guidelines have positive aspects, doubt remains regarding the concerns outlined above. In addition to using risk charts based on the native population, the messages of the European guideline are more appropriate to the Spanish setting and avoid the possible risk of overtreatment with statins in primary prevention.

[LDL cholesterol control in patients with very high cardiovascular risk. A simplified algorithm for achieving LDL cholesterol goals "in two steps"]. / Control del colesterol LDL en pacientes de muy alto riesgo vascular. Algoritmo simplificado para alcanzar objetivos de colesterol LDL "en dos pasos".

Reducing low density lipoprotein-cholesterol (LDL-c) is the main lipid goal of treatment for patients with very high cardiovascular risk. In these patients the therapeutic goal is to achieve a LDL-c lower than 70 mg/dL, as recommended by the guidelines for cardiovascular prevention commonly used in Spain and Europe. However, the degree of achieving these objectives in this group of patients is very low. This article describes the prevalence of the problem and the causes that motivate it. Recommendations and tools that can facilitate the design of an optimal treatment strategy for achieving the goals are also given. In addition, a new tool with a simple algorithm that can allow these very high risk patients to achieve the goals "in two-steps", i.e., with only two doctor check-ups, is presented.

Spanish Interdisciplinary Committee for Cardiovascular Disease Prevention and the Spanish Society of Cardiology position statement on dyslipidemia management. Differences between the European and American guidelines.

The publication of the 2013 American College of Cardiology/American Heart Association guidelines on the treatment of high blood cholesterol has had a strong impact due to the paradigm shift in its recommendations. The Spanish Interdisciplinary Committee for Cardiovascular Disease Prevention and the Spanish Society of Cardiology reviewed this guideline and compared it with current European guidelines on cardiovascular prevention and dyslipidemia management. The most striking aspect of the American guideline is the elimination of the low-density lipoprotein cholesterol treat-to-target strategy and the adoption of a risk reduction strategy in 4 major statin benefit groups. In patients with established cardiovascular disease, both guidelines recommend a similar therapeutic strategy (high-dose potent statins). However, in primary prevention, the application of the American guidelines would substantially increase the number of persons, particularly older people, receiving statin therapy. The elimination of the cholesterol treat-to-target strategy, so strongly rooted in the scientific community, could have a negative impact on clinical practice, create a certain amount of confusion and uncertainty among professionals, and decrease follow-up and patient adherence. Thus, this article reaffirms the recommendations of the European guidelines. Although both guidelines have positive aspects, doubt remains regarding the concerns outlined above. In addition to using risk charts based on the native population, the messages of the European guideline are more appropriate to the Spanish setting and avoid the possible risk of overtreatment with statins in primary prevention.

Clinical outcomes after intravascular ultrasound and fractional flow reserve assessment of intermediate coronary lesions. Propensity score matching of large cohorts from two institutions with a differential approach.

AIMS: Assessment of intermediate coronary lesions can be done with fractional flow reserve (FFR) and intravascular ultrasound (IVUS). There are no randomised trials and only a small registry from one centre is available but this is subject to important bias. We sought to evaluate the clinical outcomes of an FFR strategy compared with an IVUS strategy for intermediate lesion assessment. METHODS AND RESULTS: We compared the outcome of patients assessed with FFR and IVUS in two centres with a differential approach. After propensity score matching 400 pairs of patients were included. Revascularisation was done when FFR was <0.75 or minimum lumen area was <4 mm2 in vessels >3 mm, and <3.5 mm2 in vessels 2.5-3 mm, along with plaque burden >50%. After FFR and IVUS, 72% and 51.2% of lesions, respectively, were left untreated (p<0.001). At one and two years no significant differences in MACE-free survival were observed in overall groups (97.7% at one year and 93.1% at two years in the FFR group and 97.7% at one year and 95.6% at two years in the IVUS group; p=0.35) and among those with deferred intervention (97.9% at one year and 94.2% at two years in the FFR group and 96.5% at one year and 93.6% at two years in the IVUS group; p=0.7). CONCLUSIONS: IVUS and FFR may be safely used to defer revascularisation of intermediate lesions. IVUS induces a higher degree of revascularisation but much lower than previously reported and does not affect the clinical outcome.

[Advances in hypertension and diabetes]. / Temas de actualidad en hipertensión arterial y diabetes.

In the course of the last year, a number of important clinical trials on cardiovascular disease, principally in hypertensive and diabetic patients, have published their results. The findings, some of which were unexpected, have enabled us, in certain instances, to confirm what already we knew about controlling these risk factors, but they have also led to active discussion about well-established topics, such as: To what extent should blood pressure and glycemia levels be reduced in patients with cardiovascular disease? In addition, up-to-date information has become available about treating hypertension with new drugs or new combinations of existing drugs. This article contains a review of all these topics and also summarizes the findings of some observational studies carried out by the working group on hypertension of the Spanish Society of Cardiology that have been reported in the last year.

Prevalence of metabolic syndrome in heart transplant patients: role of previous cardiopathy and years since the procedure--the TRACA study.

BACKGROUND: Metabolic syndrome (MS) is a cluster of cardiovascular risk factors highly prevalent in patients with ischemic heart disease (IHD), the main etiologic cause for heart transplantation (HT). METHODS: Data for 111 HT patients of a single institution were collected. The assessment of MS was made, according to the ATP III criteria, when 3 of the following diagnostic criteria were present: waist circumference >102 cm (men) or >88 cm (women); triglycerides > or =150 mg/dl; HDL-cholesterol <40 mg/dl (men) or <50 mg/dl (women); blood pressure > or =130/85 mm Hg; and fasting glucose > or =110 mg/dl, or diabetes mellitus previously diagnosed. Renal function was assessed by glomerular filtration rate, as estimated by the MDRD abbreviated equation. RESULTS: Mean age of the 111 HT patients was 63.0 (11.0) years and 101 (91.0%) were men. The median time since transplant was 7.0 (3.0 to 13.0) years, and IHD was the primary cause for HT (56.8%). The prevalence of MS was 42.3% and was statistically higher in patients with IHD prior to HT (52.4% vs 27.2%; p = 0.007). Patients with MS were older but had the same time of follow-up since their HT. An analysis of the sample in tertiles of years since HT showed that MS was more prevalent in subjects who received HT due to IHD only in the lowest and highest tertile. Fifty-three patients (47.7%) had abdominal obesity, 47 (43.2%) were overweight and 22 (19.8%) were obese; most patients with abdominal obesity were diagnosed with MS (82.6%). Multivariate analysis showed a strong association between abdominal obesity and MS (odds ratio [OR] 6.2, 95% confidence interval [CI] 1.9 to 19.8), even after adjustment for body mass index, and also showed an independent association of MS with severe renal dysfunction (OR 9.8; p = 0.02). CONCLUSIONS: MS is highly prevalent in HT patients and abdominal obesity is the leading cause of this clustering. IHD status and time since HT are major determinants in the prevalence of MS in HT patients.