SEA 2024 Standards for Global Control of Vascular Risk. / Estándares de la Sociedad Española de Arteriosclerosis 2024 para el control global del riesgo vascular.

One of the objectives of the Spanish Society of Arteriosclerosis is to contribute to the knowledge, prevention and treatment of vascular diseases, which are the leading cause of death in Spain and entail a high degree of disability and health expenditure. Atherosclerosis is a multifactorial disease and its prevention requires a global approach that takes into account the associated risk factors. This document summarises the current evidence and includes recommendations for patients with established vascular disease or at high vascular risk: it reviews the symptoms and signs to evaluate, the laboratory and imaging procedures to request routinely or in special situations, and includes the estimation of vascular risk, diagnostic criteria for entities that are vascular risk factors, and general and specific recommendations for their treatment. Finally, it presents aspects that are not usually referenced in the literature, such as the organisation of a vascular risk consultation.

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

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

Indications of PCSK9 inhibitors in clinical practice. Recommendations of the Spanish Sociey of Arteriosclerosis (SEA), 2019. / Indicaciones de los inhibidores de PCSK9 en la práctica clínica. Recomendaciones de la Sociedad Española de Arteriosclerosis (SEA), 2019.

A group of experts convened by the Spanish Society of Arteriosclerosis (SEA) has been in charge of updating the SEA document on the indications of PCSK9 inhibitors (PCSK9i) in clinical practice that was published in 2016. This update is justified by the fact that the data from clinical trials carried out on a large scale with PCSK9i have shown that in addition to their high potency to lower atherogenic cholesterol, they reduce the risk of atherosclerotic cardiovascular disease, both in patients with stable disease, and with recent disease, and with a high degree of security. This update provides the recommendations and level of evidence for the prescription of iPCSK9 in patients with homozygous and heterozygous familial hypercholesterolemia, with atherosclerotic cardiovascular disease, and in primary prevention in patients with very high cardiovascular risk. These recommendations have been established taking into account the concentration of LDL-C, the clinical situation of the patient, the additional risk factors and the cost-effectiveness of their use.

Standards for global cardiovascular risk management arteriosclerosis. / Estándares SEA 2019 para el control global del riesgo cardiovascular.

One of the main goals of the Spanish Society of Arteriosclerosis is to contribute to a wider and greater knowledge of vascular disease, its prevention and treatment. Cardiovascular diseases are the leading cause of death in our country and also lead to a high degree of disability and health expenditure. Arteriosclerosis is a multifactorial disease, this is why its prevention requires a global approach that takes into account the different risk factors with which it is associated. Thus, this document summarizes the current level of knowledge and integrates recommendations and procedures to be followed for patients with established cardiovascular disease or high vascular risk. Specifically, this document reviews the main symptoms and signs to be evaluated during the clinical visit, the laboratory and imaging procedures to be routinely requested or those in special situations. It also includes the estimation of vascular risk, the diagnostic criteria of the different entities that are cardiovascular risk factors, and presents general and specific recommendations for the treatment of the different cardiovascular risk factors and their final objectives. Finally, the document includes aspects that are not often mentioned in the literature, such as the organisation of a vascular risk consultation.

Type and doses of oral anticoagulants and adherence to anticoagulant treatment in elderly patients with atrial fibrillation: the ESPARTA study.

AIM: To analyze the use of oral anticoagulants in elderly patients with atrial fibrillation in clinical practice. PATIENTS & METHODS: Cross-sectional and multicenter study performed in atrial fibrillation patients ≥75 years treated with oral anticoagulants ≥3 months. RESULTS: 837 patients (83.0 ± 5.0 years; CHA2DS2-VASc 5.0 ± 1.4; HAS-BLED 2.1 ± 0.9; 70.8% vitamin K antagonists; 29.2% direct oral anticoagulants [DOACs]) were included. Poor adherence was observed in 27.9% of patients. Higher scores in the Pfeiffer's test and FRAIL scale were associated with poorer adherence. Among patients treated with DOACs, 62.3% received the lower doses. Having high CHADS2 score and being older were associated with the use of low doses. CONCLUSION: 28% of patients had a poor adherence to anticoagulant treatment. 62% of patients were treated with the lower doses of DOACs.

Consensus document for the use of the Polypill in the secondary prevention of cardiovascular disease. / Documento de consenso del uso clínico de la Polypill en la prevención secundaria del riesgo cardiovascular.

Cardiovascular disease is a chronic disorder which is usually already at an advanced stage when the first symptoms develop. The fact that the initial clinical presentation can be lethal or highly incapacitating emphasizes the need for primary and secondary prevention. It is estimated that the ratio of patients with good adherence to secondary prevention of cardiovascular disease is low and also decreases gradually over time. The Polypill for secondary prevention of cardiovascular disease is the first fixed-dose combination therapy of salicylic acid, atorvastatin and ramipril approved in Spain. The purpose of this consensus document was to define and recommend, through the evidence available in the literature and clinical expert opinion, the impact of treatment adherence in the secondary prevention of cardiovascular disease and the use of the Polypill in daily clinical practice as part of a global strategy including adjustments in patient lifestyle. A RAND/UCLA methodology based on scientific evidence, as well as the collective judgment and clinical expertise of an expert panel was used for this assessment. As a result, a final report of recommendations on the impact of the lack of adherence to treatment of secondary prevention of cardiovascular disease and the effect of using a Polypill in adherence of patients was produced. The recommendations included in this document have been addressed to all those specialists, cardiologists, internists and primary care physicians with competence in prescribing and monitoring patients with high and very high cardiovascular risks.

[LDL-cholesterol control in patients with genetic dyslipidemia followed up by Lipid and Vascular Risk Units of the Spanish Society of Arteriosclerosis]. / Control del colesterol-LDL en pacientes con dislipidemias genéticas seguidos en unidades de lípidos y riesgo vascular de la Sociedad Española de Arteriosclerosis.

OBJECTIVE: To evaluate low-density lipoprotein-cholesterol (LDLc) achieved in patients with genetic dyslipidemia treated during one year in Lipid and Vascular Risk Units (LVRU) of the Spanish Society of Arteriosclerosis (SSA). DESIGN: Observational, longitudinal, retrospective, multicenter national study that included consecutive patients of both sexes over 18 years of age referred due to dyslipidemia to LVRU of the SSA. Information was collected from medical records corresponding to two visits in the lipid unit. RESULTS: A total of 527 patients (mean age 48 years, 60.0% men) diagnosed with genetic dyslipidemia (241 with heterozygous familial hypercholesterolemia, and 286 with familial combined hyperlipidemia) were included. The mean follow-up was 12.9 months. In the last visit, 94% were taking statins, one third combined with ezetimibe, although only 41% were taking a high-intensity hypolipidemic treatment. Overall, 28.5% of patients attained an LDLc level<100 mg/dL, 35.8% decreased their LDLc by >50%, and 53.8% achieved one of the two. Predictors of target LDLc levels in the multivariate analysis were age, smoking habit and the presence of vascular disease. CONCLUSION: Over half of the patients with genetic dyslipidemia followed up by LVRU of SSA achieve LDLc objectives after one year of follow-up. The use of high-intensity hypolipidemic treatment could improve these results.

[Risk of pharmacological interactions due to the co-administration of statins and cytochrome P450 isoenzyme 3A4-metabolized drugs: multicentre, crossover study]. / Riesgo de interacciones farmacológicas por la coadministración de estatinas con fármacos metabolizados por la isoenzima 3A4 del citocromo P450: estudio epidemiológico, transversal y multicéntrico.

BACKGROUND AND OBJECTIVES: Statins are safe but have a significant potential for pharmacological interactions. The objective of the study was to evaluate the prevalence of potential interactions throughout the cytochrome P450 isoenzyme 3A4 (CYP3A4) system in a large sample of statin-treated subjects and to determine which factors, from the patient and the physician, were associated with a higher risk of interactions. PATIENTS AND METHODS: This is an observational, cross-over, population study that included 7,880 subjects treated with statins. Both data from patients and from the1,681 participating physicians were recorded and analyzed. RESULTS: Fifty-nine percent of the participants were receiving a statin metabolized by the CYP3A4, and 21.5% of all participants received a drug, different from a statin, metabolized by the CYP3A4. There were no differences in the frequency of utilization of statins metabolized or not by the CYP3A4 in relation to the simultaneous prescription of drugs metabolized by the same pathway (22 vs. 21%, respectively). Globally, 12.9% of all participants were at risk of an interaction. These patients were older, received a higher number of drugs and had more comorbidity. Sixty percent of the physicians mentioned that the possibility of an interaction greatly conditioned their selection of a particular statin. Likewise, 56% of them had software that alerted of possible interactions. These aspects, however, did not influence the number of patients at risk of interactions. CONCLUSION: The proportion of statin-treated patients at risk of interaction is elevated. Physicians do not usually pay attention to this possibility despite having available alert software and therapeutic alternatives.

[Lower limb arterial disease and renal artery stenosis]. / Arteriopatía de las extremidades inferiores y estenosis de las arterias renales.

Peripheral arterial disease (PAD) refers to the atherosclerotic involvement of non-coronary and extracranial arteries, including visceral arteries, the aorta and its branches and the arteries of the limbs. PAD usually refers exclusively to atherosclerosis of the limbs (in particular the lower limbs). Age, male sex, smoking and diabetes, as well as hypertension and dyslipidemia, are the most relevant risk factors for the development of PAD. PAD is frequently associated with coronary heart disease and stroke. PAD patients have increased risk of developing cardiovascular complications (coronary disease, stroke) and total and cardiovascular mortality, even after adjustment by conventional risk factors. Despite this PAD exhibit a worse control of risk factors. This opens up an important opportunity to optimize their control, which can result in an improvement of the prognosis of patients with PAD. Ischemic nephropathy includes a constellation of disorders that are frequently associated: hypertension, renal failure and renal artery stenosis (RAS). RAS risk factors are similar to those of PAD. Recent studies have shown that renal revascularization is not associated with improvement in blood pressure control, preservation of renal function or reduction of cardiovascular events in most patients. Therefore, revascularization should be reserved for selected cases on an individual basis. In all cases, a strict control of vascular risk factors should be attempted.

[Clinical characteristics and in-hospital outcomes of patients with critical leg ischemia: ICEBERG Study]. / Características clínicas y evolución intrahospitalaria de los pacientes con isquemia crítica de miembros inferiores: estudio ICEBERG.

BACKGROUND AND OBJECTIVES: Critical leg ischemia (CLI) is a medical emergency with a high morbidity and mortality. Although its prognosis has improved during the last years, there are no data on its clinical characteristics, treatment and in-hospital prognosis in our country. PATIENTS AND METHOD: 671 patients (81% males, mean age 71.2 years) with atherosclerotic CLI, attended in 46 departments of vascular surgery were included in the study. RESULTS: Participants had a high prevalence of cardiovascular risk factors (72% hypertensive, 27% current smokers, 59% diabetics) and comorbidity (25% coronary heart disease, 18% cerebrovascular disease). 71% had a previous diagnosis of peripheral arterial disease. Upon admission, 71% were referred for revascularization, 5% for direct amputation and 24% for conservative treatment. During hospitalization 22 patients died and 49 were discharged with a major amputation. On multivariate analysis, the only factor associated with the risk of amputation was gangrenous lesions (OR 2.45; IC95% 1.22-4.92). Factors associated with mortality were the presence of chronic renal failure (OR 3.38; IC95% 1.36-8.39) and previous CLI (OR 0.20; IC95% 0.05-0.89). At discharge, 59% received lipid lowering drugs, 70% blood-pressure lowering medications and 85% antiplatelet drugs. CONCLUSION: CLI patients attended in Spanish vascular surgery departments have a low amputation rate and a low hospital mortality. However, and due to their high cardiovascular risk, it is necessary to improve the prescription rate of evidence-based cardiovascular prevention therapies at discharge.

[Clinical factors associated with inappropriate prescription of statins]. / Prescripción inadecuada de estatinas y factores clínicos asociados.

BACKGROUND AND OBJECTIVE: The aim of this study was to determine the percentage of subjects receiving statin treatment that was inappropriate and to evaluate the associated clinical factors. PATIENTS AND METHOD: A cross-sectional multi-centred study conducted across the Autonomous Regions of Spain. The appropriateness of prescription was based on the guidelines of the National Cholesterol Education Program-Adult Treatment Panel III (NCEP-ATP III) and the European Guidelines on Cardiovascular Disease Prevention. RESULTS: Of the 1,817 patients studied, 52.9% were male, the overall mean age was 59.4 years, 36% had cardiovascular disease and 32.7% had diabetes. In 90.8% of the population the prescription was correct according to at least one of the two guides being used, with a low concordance between them (kappa = 0.279). Almost 100% of subjects with cardiovascular disease or diabetes had an appropriate prescription. In primary prevention, 82.7% had an appropriate prescription according to at least one of the two guides used, but this percentage decreased to 20.7% when based on the European Guidelines. In multivariate analysis, there was agreement with both guides. The inappropriate prescription was directly, and significantly, associated with primary prevention and female gender, while being inversely related to age, smoking habit and LDL-cholesterol concentration. CONCLUSIONS: Most of the patients receiving statin treatment have an appropriate prescription, but the percentage of inappropriate prescription increases significantly in patients in primary prevention following European Guidelines.

[Value of the ankle-brachial index in cardiovascular risk stratification of patients without known atherotrombotic disease. MERITO study]. / Modificación de la estratificación del riesgo vascular tras la determinación del índice tobillo-brazo en pacientes sin enfermedad arterial conocida. Estudio MERITO.

BACKGROUND AND OBJECTIVES: Peripheral arterial disease detected by measurement of ankle-brachial index enables the identification of asymptomatic patients with target organ damage. We have investigated the prevalence of peripheral arterial disease (ankle-brachial index < 0.9), and its potential clinical-therapeutic impact, in patients without known atherotrombotic disease from internal medicine practices. PATIENTS AND METHOD: It was a multicenter, cross-sectional, observational study. Outpatients aged 50 through 80 years, with either diabetes or a SCORE risk estimation of at least 3%, were enrolled. RESULTS: A total of 1,519 subjects (58% men) were evaluated, 917 with diabetes (61%). The mean age (standard deviation) was 66.2 (8.3) years. The prevalence of an ankle-brachial index < 0.9 was 26.19%. In multiple logistic regressions the risk factors associated to an ankle-brachial index < 0.9 were age, sedentary lifestyle, smoking, macroalbuminuria, and heart rate. There was a significant relationship between the ankle-brachial index and the SCORE risk estimation. With respect to the therapeutic aims of the patients with an ankle-brachial index < 0.9, only 21% were taking antiplatelet drugs, 26% showed low density lipoproteins-cholesterol values < 100 mg/dl (53% < 130 mg/dl), and 16% displayed recommended blood pressure levels. CONCLUSIONS: Measurement of ankle-brachial is useful to reclassify as high risk a significant proportion of patients without known previous atherotrombotic disease. The ankle-brachial index should be incorporated into routine cardiovascular evaluation, particularly in subjects with diabetes or a score risk assessment > or = 3%.

[Prevalence of an abnormal ankle-brachial index in relation to the cardiovascular risk estimated by the Framingham function]. / Prevalencia de un índice tobillo-brazo patológico según el riesgo cardiovascular calculado mediante la función de Framingham.

BACKGROUND AND OBJECTIVE: The measurement of the ankle-brachial index (ABI) is a straightforward method for the detection of atherosclerosis in the lower limbs. An abnormal ABI (< 0.9 or > 1.4) is associated with the development of cardiovascular disease and cardiovascular and all-cause mortality. Despite this, its measurement in clinical practice is underused. The objective of the present study was to evaluate the relation of the ABI with the cardiovascular risk determined by traditional risk functions in a population in primary prevention. PATIENTS AND METHOD: 1001 subjects without known cardiovascular disease attended in primary care were invited to participate in the study. Cardiovascular risk and ABI measurements were calculated in all participants. RESULTS: A low (< 0.9) ABI was found in a 3.8% of the participants, 3.9% females and 3.6% males. An abnormal ABI (< 0.9 or > 1.4) was found in 6.4% of all subjects, 5.2% females and 8.8% males. In a multivariable analysis age (OR = 1.09 for each year; 95% CI 1.03-1.15), smoking habit (OR = 2.96; 95% CI 1.51-5.80), HDL-cholesterol levels (OR = 0.98 for each mg/dl; 95% CI, 0.95-0.99) and hypertension (OR = 1.80; 95% CI, 1.05-3.06) were related with an abnormal ABI. Subjects were divided according to their risk stratification. The percentage of low, moderate and high risk individuals with an abnormal ABI was 2.6%, 8.7% and 14.9% respectively. CONCLUSIONS: In primary prevention, one in ten individuals with moderate risk and one in six individuals with high risk have an abnormal ABI. In these subjects there is an indication for intensive preventive strategies and antiagregation.