High cardiovascular risk in Spanish workers.

BACKGROUND AND AIMS: To investigate the prevalence of high cardiovascular risk in the Spanish working population, and its distribution among different occupations and gender. METHODS AND RESULTS: Cross-sectional study of 309,955 workers (72.6% males, mean age 36.5 years, range 16-74 years), who underwent a routine medical check-up. Workers were classified as high, intermediate or low cardiovascular risk, according to the SCORE system. Workers with a relative risk greater than 4 were also considered as high-risk. The prevalence of high cardiovascular risk was 7.6% (95% CI 7.5-7.7) in males and 1.7% (95% CI 1.6-1.8) in females. After adjusting for age and gender, the prevalence of high cardiovascular risk was greater in workers from the Agriculture and Construction sectors than in those from Industry and Service sectors. The prevalence of high cardiovascular risk was higher in blue-collar than in white-collar occupations. CONCLUSIONS: A sizeable proportion of workers, especially blue-collar males, are at high cardiovascular risk. Knowledge of this risk for certain workers may serve as a basis for preventive strategies.

Effect of individualizing starting doses of a statin according to baseline LDL-cholesterol levels on achieving cholesterol targets: the achieve cholesterol targets fast with atorvastatin stratified titration (ACTFAST) study.

AIMS: To investigate whether selecting the starting dose of atorvastatin according to baseline and target (<2.6 mmol/L) LDL-cholesterol (LDL-C) values would allow high-risk subjects to achieve target LDL-C concentration within 12 weeks, with the initial dose or a single uptitration. METHODS AND RESULTS: Twelve-week, prospective, open-label trial that enrolled 2117 high-risk subjects (statin-free [SF] or statin-treated [ST]). Subjects with LDL-C >2.6 mmol/L (100mg/dL) but

Profiling risk from arrhythmic or hemodynamic death.

Congestive heart failure is increasing in prevalence and, despite recent advances in therapy, mortality remains high. Sudden cardiac death (SCD) represents a significant percentage of overall mortality, accounting for almost 1 in 2 deaths in patients with congestive heart failure. In patients with asymptomatic left ventricular dysfunction or mild degrees of functional impairement, overall annual mortality is low, although a significant portion of the deaths are sudden; on the other hand, in advanced heart failure annual mortality increases, but SCD contributes to it to a lesser degree. The mechanisms of SCD in heart failure are multiple, including ventricular tachycardia/ventricular fibrillation, bradyarrhythmias, electromechanical dissociation, acute coronary events, and thromboembolic events. Only a minority of patients with advanced heart failure or on the waiting list for heart transplant experience SCD as a consequence of ventricular tachycardia (VT) or ventricular fibrillation (VF). The availability of effective therapies to prevent sudden arrhythmic death, such as that provided by automatic implantable cardioverter defibrillators, may help to reduce the burden of SCD in congestive heart failure, but major efforts will be needed to identify the candidates who may benefit from this approach.

Does angina the week before protect against first myocardial infarction in elderly patients?

Mortality rates for coronary artery disease are greater in elderly patients. Although prodromal angina occurring shortly before an acute myocardial infarction (MI) has protective effects against ischemia, this effect has not been well documented in older patients. This study investigated whether angina 1 week before a first MI provides protection in this group of patients. A total of 290 consecutive elderly (>64 years old, n = 143) and adult patients (<65 years old, n = 147) with a first MI were examined to assess the effect of preceding angina on the short- and long-term prognosis. Elderly patients with a history of prodromal angina were less likely than those without angina to experience in-hospital death, heart failure, or the combined end point of in-hospital death and heart failure (6% vs 20.4%, p = 0.02; 10% vs 23.7%, p = 0.07; 14% vs 32.3%, p = 0.01, respectively). Left ventricular function was more frequently depressed (ejection fraction <40%) in elderly patients without (44.8%) than with (26%, p = 0.04) preinfarction angina, and the incidence of arrhythmias (complete heart block and ventricular fibrillation) was greater in the former group (16.1% vs 4%, p = 0.03). Multivariate analysis confirmed that the presence of preinfarction angina was an independent predictor of in-hospital death and heart failure in older patients (odds ratio 0.28, p = 0.009). The occurrence of angina 1 week before a first MI may confer protection against in-hospital adverse outcomes, and may preserve left ventricular function in older patients.

[Beta-blockers in cardiac insufficiency: should they always be considered in the therapeutic strategy? Arguments in favor]. / Betabloqueantes en la insuficiencia cardíaca: deben incluirse siempre en la estrategia terapéutica? Argumentos a favor.

Congestive heart failure is an increasing cause of mortality among the aging population. The current management approaches have increased the survival of patients with congestive heart failure, although the mortality rate remains high. Thus, any effort to reduce mortality in this condition seems justified. Beta-adrenergic blocking agents have shown to improve functional class and the ventricular function of heart failure patients; the use of these agents should be considered in congestive heart failure patients unless an increase in mortality with betablockers can be demonstrated. In fact, beta-blockers reduce mortality, as the recent study of carvedilol has demonstrated. Therefore, beta adrenergic blocking agents should be incorporated into the strategies of management of patients with congestive heart failure.

[Ventricular geometry and heart failure]. / Geometría ventricular e insuficiencia cardíaca.

In the last years there has been an appreciation of the importance of left ventricular geometry. After a period, in the sixties and seventies, that the interest was focused on cardiac physiology and the left ventricular geometry role about this subject, new studies are available on clinical significance of normal or distorted left ventricular shape. New assessment methods of ventricular geometry have been described. The use of simple measurements to assess ventricular geometry has allowed to know the clinical value of the shape distortion in patients with heart failure. The suspicion that left ventricular shape change to sphericity has prognosis value, has raised the interest about this subject. Whether distortion of left ventricular shape is an even better parameter than cardiac function indices normally used is under consideration. Moreover, new surgical therapies have been developed in an attempt to improve the ventricular geometry and to get better clinical prognosis in patients with heart failure.

[Guideline 1. Diagnosis of heart failure and ventricular dysfunction]. / Guía 1. Diagnóstico de la insuficiencia cardíaca y la disfunción ventricular.

The criteria required for the diagnosis of the four clinical aspects of the congestive heart failure, that are needed for the correct management of patients are discussed: the diagnosis of the syndrome, mechanism (systolic or diastolic dysfunction), ethology and functional capacity. The "initial evaluation" of patients presenting with symptoms of heart failure is described to encourage an structured diagnostic approach and the cost/effective use of diagnostic methods.

[Guideline 6. Cardiogenic shock]. / Guía 6. Shock cardiogénico.

The criteria required for the clinical and hemodynamic diagnosis of cardiogenic shock are described. The management of shock is briefly reviewed.

[Guideline 7. Intensive treatment of unstable heart failure. Indications for heart transplantation]. / Guía 7. Tratamiento intensivo de la insuficiencia cardíaca inestable. Indicaciones del trasplante cardíaco.

Unstable heart failure is defined as class IV cardiac failure with symptoms that do not respond to empiric treatment, which causes hypotension, renal failure, hyponatremia and/or symptomatic ventricular arrhythmias. It may be reversible or refractory. Refractory or "end-stage" heart failure is an indication for heart transplant, provided that: a) all reversible ethiologic factors have been corrected; and b) aggressive treatment in the intensive care unit under hemodynamic monitoring has not been able to stabilize heart failure.

[Guideline 8. Guidelines for diagnosis and treatment of congestive heart failure and shock (DRG 127). Hospitalization criteria]. / Guía 8. Criterios de hospitalización.

The recommendations for hospital admission are discussed. The need to avoid needless hospitalizations is emphasized.

[Guideline 2. Etiologic diagnosis of heart insufficiency. Identification and treatment of reversible causes]. / Guía 2. Diagnóstico etiológico de la insuficiencia cardíaca. Identificación y tratamiento de las causas reversibles.

The clinical picture suggesting the etiologic diagnosis at the initial evaluation is described as well as the criteria and the diagnostic tests recommended to arrive to the definite diagnosis. Special emphasis is placed on the diagnosis of the reversible factors that may benefit from specific treatment.

[Guidelines for the diagnosis and management of heart failure and cardiogenic shock. Informe del Grupo de Trabajo de Insuficiencia Carddiacade la Sociedad Espanñola de Cardiología]. / Guías del diagnóstico, clasificación y tratamiento de la insuficiencia cardíaca y del shock cardiogénico. Informe del Grupo de Trabajo de Insuficiencia Cardíaca de la Sociedad Española de Cardiología.

Guidelines for the Diagnosis and Management of Heart Failure and Cardiogenic Shock have been developed by the Working Group on Heart Failure of the Spanish Society of Cardiology, in collaboration with other Scientific Sections and members of the society. The aim of this report is to promote a more consistent and effective clinical practice according to the principles of evidence based medicine or the recommendations widely accepted by the scientific community. At the same time the aim is to give guidance for epidemiological surveys, heart failure registers clinical assays and clinical quality assessment, and to contribute to cost containment. These twelve guidelines have been designed for doctors in general practice as well as specialists. Criteria for diagnosis and classification of heart failure (systolic and diastolic heart failure, left or right, acute or chronic) are defined. The more appropriate use of clinical or high technology laboratory studies are recommended as well as the most efficient strategies nowadays for the management of chronic stable, unstable or refractory heart failure, or acute heart failure and cardiogenic shock.

[Secondary prevention of myocardial infarction in Spain. The PREVERSE study]. / La prevención secundaria del infarto de miocardio en España. Estudio PREVESE.

INTRODUCTION AND OBJECTIVES: We present the results from the PREVESE Study, conducted in two phases: the first to identify the secondary prevention measurements recommended in Spain in patients who were discharged after a myocardial infarction; the second, 6 months later, to determine their evolution. METHODS: Data was collected from 1,242 patients in 39 hospitals. An analysis was made of the patients background, risk factors, working status, diagnostic procedures used during hospitalization, laboratory findings and drug therapy prescribed at discharge. At the second control, the risk factors status, diagnostic or assessment tests performed during the 6-month period, working status, mortality and cardiac events were revised. RESULTS: The previous history and risk factors studied showed a high risk profile among patients after myocardial infarction. Among the drug therapies prescribed at discharge the small percentage (6.7%) of lipid lowering prescriptions should be highlighted. An improvement in the risk factor profile was found at the six month checkup with a substantial reduction in the number of smokers, a very low number of hypertensives and an improvement in physical activity. There was no improvement in total-cholesterol levels. CONCLUSIONS: The implementation of preventive measures is not similar in all risk factors. An improvement is reached in prevention of smoking habit and hypertension, but not in the treatment of abnormal levels of hyperlipidemia.

[Pneumopericardium in an asthmatic patient. A case report and review of the bibliography]. / Neumopericardio en un paciente asmático. Descripción de un caso y revisión de la bibliografía.

Pneumopericardium is an uncommon but potentially serious condition of which leading cause is mechanical ventilation in infants suffering respiratory distress syndrome. In adults, however, the most common causes are iatrogenic in diagnostic and therapeutic procedures, as well as traumatic lesions. We describe a case of pneumopericardium in a teenager suffering an asthma crisis. A review of the literature is presented, stressing the most relevant findings of the physical examination and habitual laboratory tests.

[Large myxoma of the right atrium]. / Mixoma de gran tamaño en la aurícula derecha.

We describe the case of a patient in whom two-dimensional echocardiography, performed due to dissociated cholestasis and jugular ingurgitation, demonstrated a huge mass in the right atrium which prolapsed in the right ventricle. Intraoperative transesophageal echocardiography was performed to further assess the dimension and characteristics of the mass and to discard the involvement of associated structures. The patient underwent a cardiopulmonary bypass surgery and the mass (12 * 5 cm) was removed without complications. Histologic examination confirmed the diagnosis of myxoma. This case is of interest because of the size of the mass, and is centered in the diagnosis following clinical suspicion due to the pattern of dissociated cholestasis and jugular ingurgitation leading to surgery to prevent the potential embolic complications.

[Heart failure as the initial cardiac manifestation of Steinert's myotonic dystrophy]. / Insuficiencia cardíaca como manifestación cardiológica inicial de la distrofia miotónica de Steinert.

The relationship between neuromuscular diseases and the heart has been well known for many years. Cardiac lesions tend to involve the specialized conducting system. We report the case of a 36-year-old male diagnosed with Steinert's myotonic dystrophy whose initial cardiovascular symptom was heart failure and not symptoms related to alterations of the specialized conducting system.

[Creatine kinase increases after coronary interventions]. / Elevaciones de la creatincinasa tras intervencionismo coronario.

INTRODUCTION AND OBJECTIVES: Percutaneous revascularization has led to an important change in the treatment of patients with symptomatic ischemic heart disease in recent years. There is controversy concerning the incidence and prognostic significance of postprocedural increases in creatine kinase. The aim of this study was to assess the incidence of these elevations and the related factors and to observe the prognosis of patients with and without creatin kinase elevations. METHODS: We reviewed 447 patients in whom an angioplasty was done in our department from January 1997 to June 1998, excluding 138 patients with myocardial infarction in the previous four days or unsuccessful angioplasty. Creatine kinase was measured in all patients at 0, 4, 8 and 24 hours after angioplasty. We analyzed the incidence of elevated levels of creatine kinase following coronary surgery and the characteristics of the patients in comparison with a control group made up of patients who, at a similar time had undergone a similar angioplasty procedure including, a similar vessel and type of lesion, and equivalent left ventricular function but without elevated serum levels of creatine kinase. Major adverse coronary events were defined as: cardiac death, nonfatal myocardial infarction, new revascularization and unstable angina in which hospitalization was required. RESULTS: Out of 309 patients studied, an elevation in creatine kinase was observed in 24 patients (7.7%). Complications related to the procedure were found in 50% of these elevations, most of which involved side branch occlusion. There were no differences with respect to the demographical or anatomical characteristics of the lesions in the groups studied. During the follow-up of 9.5 months, complications were observed in 37.5% of the group of patients with elevated creatine kinase levels and in 20% of the control group, but this difference did not achieve statistical significance. CONCLUSIONS: Creatine kinase elevations are produced in 7.7% of the patients after coronary angioplasty. Complications related to the procedure were observed in 50% of the cases, most being side branch occlusion and no complications were seen in the remaining patients. Continuous measurement of creatine kinase after angioplasty shows a low sensitivity for detecting complications during follow-up. New, more sensitive and specific cardiac markers, such as troponin, could define this group of patients.

[Association between myocardial infarction and angiotensin converting enzyme gene polymorphism in young patients]. / Asociación entre polimorfismo inserción/deleción del gen codificador de la enzima conversiva de la angiotensina e infarto de miocardio en pacientes jóvenes.

BACKGROUND: Different studies have shown a relationship between an insertion-deletion polymorphism of the angiotensin converting enzyme (ACE) gene and the risk of ischemic heart disease, although there are no data on this association in the Spanish population. MATERIALS AND METHOD: We have studied three groups of patients: I, healthy volunteers (n = 56, mean age 36.20 +/- 4.20 years); II, patients having presented an acute myocardial infarction (MI) < or = 50 years (n = 59, mean age 42.30 +/- 5.30 years), and III, patients with MI over the age of 50 years (n = 60, mean age 66.36 +/- 9.47 years). In all patients the genotype ACE gen was determined by an assay based on the polymerase chain reaction. RESULTS: The distribution of the ACE genotype between the three groups were not significative. Comparing the ratio of DD/II-DI in groups II and III there were 26/33 versus 15/45 (p = 0.02864). There was no difference in the smoking, hypercholesterolemia and hypertension between groups II and III; there were only differences in familial history of ischemic heart disease; diabetes mellitus was more prevalent in the III group. A multivariate analysis showed that smoking familial history of ichemic heart disease, hypercholesterolemia and DD genotype were more prevalent in young patients (OR 3.92, 2.85, 2.36 and 1.77), whereas diabetes mellitus was more prevalent in the group of older patients. There were no differences in the ACE genotype with respect to infarct location or gender. CONCLUSIONS: In our population DD ACE genotype is associated with MI in young patients, although smoking, family history and hypercholesterolemia show a more powerful association.

Effect of atorvastatin on circulating hsCRP concentrations: a sub-study of the achieve cholesterol targets fast with atorvastatin stratified titration (ACTFAST) study.

BACKGROUND: Elevated C-reactive protein (CRP) concentration is a risk factor for cardiovascular events that may add prognostic information. Statin treatment is associated with significant reductions in CRP concentrations, which appear to be unrelated to the magnitude of LDL-cholesterol reduction. We investigated the effect of atorvastatin, across its dose range, on high sensitivity (hs)CRP in subjects at high cardiovascular risk. METHODS: ACTFAST was a 12 week, prospective, multicenter, open-label trial in which high-risk subjects were assigned a starting dose of atorvastatin (10, 20, 40 or 80 mg/d) based on LDL-C and status of statin use at screening (1345 statin-free [SF] and 772 previously statin-treated [ST]). RESULTS: At baseline, ST subjects had significantly lower hsCRP levels than SF subjects (ST group 2.31, 95% CI 2.15, 2.48 mg/L vs. SF group 3.16, 95% CI 2.98, 3.34 mg/L, p<0.05). In the SF group, atorvastatin 10 to 80 mg significantly (p<0.01) reduced hsCRP levels in a dose dependent-manner. In ST group, additional hsCRP reductions were observed over the statin used at baseline, which were not dose-dependent. Atorvastatin significantly decreased hsCRP concentrations in subjects with or without diabetes or the metabolic syndrome. CONCLUSIONS: Atorvastatin treatment at different doses, particularly 80 mg, significantly reduced hsCRP serum concentrations. This reduction was observed in both SF and ST groups and was independent of the presence of metabolic syndrome and/or diabetes. The beneficial effect of atorvastatin was evident at 6 weeks, supporting the practice of early introduction of higher doses of atorvastatin in high-risk patients.