Consensus document for the training of residents in cardiovascular risk. / Documento de consenso para la formación de residentes en riesgo vascular.

Vascular disease is currently a major health problem, not only for its high prevalence but also for the considerable morbidity, mortality and disability that it entails. Medical internists play a central role in diagnosing and treating vascular disease and controlling the cardiovascular risk factors (CRFs) that cause it. In fact, the clinical care of patients in cardiovascular risk units is a specific characteristic of an internist's field of action. This article contains the consensus document for the training of residents in CRFs. This proposal by the Cardiovascular Risk Workgroup of the Spanish Society of Internal Medicine emerged as a response by our Society to the specific need for training in CRFs. Implementing this proposal would provide an important benefit, not only for medical internists in training but also for society as a whole.

HbA1c measurement and relationship to incident stroke.

AIMS: To determine the proportion of people with diabetes who have HbA1c measured, what proportion achieve an HbA1c level of < 58 mmol/mol (7.5%), the frequency of testing and if there was any change in HbA1c level in the year before and the year after an incident stroke. METHODS: This study used the Secure Anonymised Information Linkage (SAIL) databank, which stores hospital data for the whole of Wales and ~ 65% of Welsh general practice records, to identify cases of stroke in patients with diabetes between 2000 and 2010. These were matched against patients with diabetes but without stroke disease. We assessed the frequency of HbA1c testing and change in HbA1c in the first year after stroke. Estimation was made of the proportion of patients achieving an HbA1c measurement ≤ 58 mmol/mol (7.5%). RESULTS: There were 1741 patients with diabetes and stroke. Of these, 1173 (67.4%) had their HbA1c checked before their stroke and 1137 (65.3%) after their stroke. In the control group of 16 838 patients with diabetes but no stroke, 8413 (49.9%) and 9288 (55.1%) had their HbA1c checked before and after the case-matched stroke date, respectively. In patients with diabetes and stroke, HbA1c fell from 61-56 mmol/mol (7.7-7.3%) after their stroke (P < 0.001). Before the study, 55.0% of patients with stroke had an HbA1c ≥ 58 mmol/mol compared with 65.2% of control patients, these figures were 62.5% and 65.3% after the stroke. CONCLUSIONS: The frequency of diabetes testing was higher in patients who had experienced a stroke before and after their incident stroke compared with control patients but did not increase after their stroke. Glucose control improved significantly in the year after a stroke.

Post-stroke depression: an update.

INTRODUCTION: Post-stroke depression (PSD) is the most common mood disorder following a stroke, and also the main factor limiting recovery and rehabilitation in stroke patients. In addition, it may increase mortality by up to ten times. DEVELOPMENT: PSD occurs in 1 in 3 stroke patients and more than half of all cases are neither diagnosed nor treated. Several mechanisms, including biological, behavioral, and social factors, are involved in its pathogenesis. Symptoms usually occur within the first three months after stroke (early onset PSD), and less frequently at a later time (late onset PSD). Symptoms resemble those of other types of depression, although there are some differences: PSD patients experience more sleep disturbances, vegetative symptoms, and social withdrawal. For PSD diagnosis, we recommended vigilance and use of specific diagnostic tools such as the Patient Health Questionnaire-2 (PHQ-2). The treatments of choice are selective serotonin reuptake inhibitors (SSRI). However, there are still many unanswered questions in the treatment of PSD, such as the best time to start treatment or the effects of antidepressants on cognition and motor function, among others. CONCLUSIONS: Neurologists play a pivotal role in the care and management of patients recovering from stroke. They must be familiar with methods for early detection and treatment of PSD, as this can facilitate a patient's functional recovery and social reintegration, and improve quality of life for patients and their families.

Importance of blood pressure monitoring in the acute phase of stroke. An update.

INTRODUCTION: The evaluation of blood pressure (BP) is essential in the acute phase of stroke. Although ambulatory blood pressure monitoring (ABPM) is a validated method for BP control, there are few studies assessing the usefulness of ABPM in the acute phase of stroke. DEVELOPMENT: A systematic review was carried out according to the PRISMA criteria in the PubMed/Medline and Scopus databases. Those articles that analysed the use of ABPM in the first days after suffering a stroke from 1992 to 2022 were selected. Those articles focused on the post-acute or sequelae phase of the stroke, with a sample size of less than 20 and those where the primary objective was different from the defined one. A total of 28 articles were included. CONCLUSIONS: The use of ABPM in patients with recent stroke demonstrates that the normal circadian profile of BP is altered in more than two-thirds of patients and that this will be fundamentally conditioned by the haemodynamic changes that occur on autoregulation of cerebral blood flow, the type of stroke or the response to treatment. Furthermore, these changes in BP have prognostic implications and are correlated with functional status, stroke recurrence and mortality, among others. However, although they continue to be a growing area of research, new studies are needed to clarify the real role of this technique in patients with acute stroke.

Mortality and cardiovascular risk in vasculitis ANCA. Importance of hypertension and renal function. Experience from southern Spain.

BACKGROUND: Cardiovascular disease (CVD) is one of the principal causes of death in antineutrophil cytoplasmic antibody-(ANCA)-associated vasculitis (AAV). OBJECTIVES: To evaluate the mortality and it's causes and CVD and its vascular risk factors (VRFs) in AAV patients in Andalusia. METHODS: A multicenter cohort of 220 AAV patients followed-up from 1979 until June 2020 was studied in Andalussia, south of Spain. The information, including socio-demographic and clinical data was recorded retrospectively through chart review. Data was analysed using Chi2, ANOVA and Cox proportional hazards regresion as uni and multivariate test with a 95% confidence interval (CI). RESULTS: During a mean ± standard deviation follow-up of 96.79 ± 75.83 months, 51 patients died and 30 presented at least one CVE. Independent prognostic factors of mortality were age (HR 1.083, p=0.001) and baseline creatinine (HR 4.41, p=0.01). Independent prognostic factors of CVE were age [hazard ratio (HR) 1.042, p=0.005] and the presence of hypertension (HTN) six months after diagnosis (HR 4.641, p=0.01). HTN, diabetes and renal failure, all of these important VRFs, are more prevalent in AAV patients than it is described in matched general population. CONCLUSIONS: Age and baseline renal function, but not CVEs, are predictors of mortality and age and early HTN are independent predictors for having a CVE. CVD screening in AAV patients is demanded.

[Importance of hypertension in patients after the first stroke: retrospective cohort study]. / Importancia de la hipertensión en pacientes con primer episodio de ictus isquémico: estudio retrospectivo de 20 años.

BACKGROUND AND OBJECTIVES: Hypertension (HT) is a key risk factor for stroke. We evaluated whether the importance of hypertension on the risk of ischemic stroke has increased in recent decades. METHODS: Retrospective study of patients with ischemic stroke discharged from 3 hospitals in Seville (Spain), during the periods: 1999-2001, 2014-2016 and 2019-2020. RESULTS: 1,379 patients were included, 42.6% women, mean age 69.1 (±11) years. HT was the most prevalent vascular risk factor in all periods, with a progressive increase in hypertensive patients (65.9% vs 69.6% vs 74%; P=.029). HT was especially frequent in patients≥80 years (73% vs 81.9% vs 85.2%; P=.029). At discharge, progressively more antihypertensive drugs were used (in 65% vs 85.1 vs 90.2% of patients; P=.0001), with a clear increase in the number of antihypertensive drugs used (mean 0.9±0.8 vs 1.5±1 vs 1.8±0.8 drugs, P=.0001). The use of diuretics (13.7%-39.3%-65.3%; p=0.0001), ACE inhibitors (35.5%-43.3%-53.4%; P=.0001) and angiotensin receptor blockers (12.2%-24%-32.4%; P=.0001) increased progressively. On the contrary, the use of calcium antagonists decreased (24%-19.9%-13.7%; P=.0001). CONCLUSIONS: In the last 2 decades there has been a greater role for HT among patients with their first ischemic cerebrovascular event. Greater and better control of HT is necessary to reduce the enormous burden of cerebrovascular disease.

Pharmacological therapy in the secondary prevention of ischemic stroke in the oldest-old patients: has it improved in recent decades?

INTRODUCTION: Population aging has caused an increase in strokes in very elderly patients (VEP). We assess how secondary prevention of ischemic stroke has changed in VEP in recent decades. METHOD: Retrospective study of discharges due to ischemic stroke in the Virgen Macarena, Virgen del Rocio and Valme hospitals in Seville (Spain), during the periods 1999-2001, 2014-16 and 2019-2020. VEP were considered those with ≥80 years. RESULT: We studied 1806 patients, 349 (19.3%) were VEP. Over the years, VEPs have doubled (13.5% vs. 25.9% and 28% p = 0.0001) and age has increased (83.3 ±â€¯3 vs. 84.1 ±â€¯3 vs. 85.2 ±â€¯4 p = 0.001). Comparing the periods, the VEPs have more hypertension (69.9% vs. 84.8% vs. 84.6%; p = 0.0001) and dyslipidemia (12% vs. 41.7% vs. 52.3%; p = 0.0001) and have prescribed more antihypertensives (69.1% vs. 86.7% vs. 92.3%; p = 0.0001), statins (5.3% vs. 78% vs. 81.5%; p = 0.0001) and anticoagulants (16.5% vs. 19.4% vs. 53.1%; p = 0.001), increasing the number of antihypertensives (1 ±â€¯0.9 vs. 1.6 ±â€¯0, 9 vs. 1.9 ±â€¯0.8 drugs p = 0.0001), and high-intensity statins (2.3% vs. 42.7 vs. 69.2% p = 0.0001). Comparing the VEPs with the younger ones, there were no differences in antihypertensive treatment in any period, there were differences in antithrombotic treatment in the first period, and with statins the differences were maintained until the end. CONCLUSIONS: In the last 20 years the number of VEPs has doubled, exceeding a quarter of the discharges. Although there is improvement in secondary stroke prevention in VEPs, there is room for improvement.

Trends in the use of statins after ischaemic stroke: Have clinical practices changed?

INTRODUCTION: The role of statins after ischaemic stroke changed with the publication of the SPARCL study in 2006. We analyse how this has influenced the prescription of statins in this patient population. METHODS: We conducted a retrospective study of patients discharged with ischaemic stroke at the Virgen Macarena, Virgen del Rocío, and Valme hospitals in Seville (Spain) over two periods: 1999-2001 and 2014-2016. RESULTS: The study included 1575 patients: 661 (42%) were women and mean age (standard deviation) was 69 (10) years. Patients from the later period are older (68 [10] vs 71 [11]; P = .0001); include a higher proportion of women; and present higher rates of dyslipidaemia, hypertension, and diabetes. At discharge, statins were used in 18.7% of patients (vs 86.9% in the first period; P = .0001), with high-intensity statins prescribed in 11.1% of cases (vs 54.4%; P = .0001). In both periods, atorvastatin was the most commonly prescribed statin (80 mg: 6% vs 42.7%; 40 mg: 5.1% vs 11.1%). In the first period, the use of statins and high-intensity statins was correlated with hypercholesterolaemia, and inversely correlated with age. In the second period, statin use was correlated with hypertension and hypercholesterolaemia, and high-intensity statin use was correlated with ischaemic heart disease and inversely correlated with age. CONCLUSION: There has been a clear change in the prescription of statins to patients with ischaemic stroke at discharge. However, many patients remain undertreated and the use of these drugs needs to be optimised.

Resistant hypertension and Morgagni hernia: The importance of nocturnal hypoxaemia.

A 51-year-old woman consulted for resistant arterial hypertension despite adequate antihypertensive treatment. Physical examination and analytical study showed no relevant abnormalities, with pulse oximeter saturation of 95%. The study highlighted nocturnal respiratory polygraphy with data of mild intensity sleep apnoea syndrome, and severe nocturnal hypoxaemia (apnoea hypopnoea index per hours of sleep [AHI] 7.8; desaturation index per hour [ODI]: 12.6. Oxygen-medium saturation: 89%, minimum saturation: 72%. CT90: 34.2%). The chest X-ray showed elevation of the right hemidiaphragm, and the chest computed tomography (CT) revealed a Morgagni hernia with a maximum diameter of 20cm. After adjusting the antihypertensive treatment, the patient was referred to General Surgery for intervention. The onset of resistant hypertension secondary to severe nocturnal hypoxemia from a large Morgagni hernia has not been previously described in the literature.

[Morning blood pressure surge in patients with recent ischaemic stroke: the neglected factor]. / Incremento matutino de la presión arterial en pacientes con ictus isquémico reciente: el factor olvidado.

INTRODUCTION: High morning BP surge (MBPS) has been associated with an increased risk of cardiovascular events. We evaluated the presence of a high MBPS in patients with recent ischaemic stroke. MATERIAL AND METHODS: A case-control study was carried out. One hundred patients with an ischaemic stroke in the previous 6 months and fifty hypertensive patients without cardiovascular disease were included as controls. RESULTS: 61 lacunar (LAC) and 39 non-lacunar (NLAC) strokes were studied. The mean age was 65±11 years, and 60 (40%) patients were women. High MBPS was present in 9% of strokes (in 5 LAC and 4 NLAC) and in 8% of controls (p not significant [NS]), with a similar mean value of MBPS in both groups: 23.9±14mmHg and 24.9±15mmHg respectively (p=NS), although the control patients had a higher office BP (systolic [p=.008] and diastolic [p=.0001]), 24h systolic BP (p=.028) and daytime systolic BP (p=.022). Among the stroke patients, high MBPS was associated with previous coronary heart disease (p=.005), circadian BP pattern (p=.029), but not with the type of antihypertensive treatment prescribed. In multivariate analysis, elevated MBPS was only associated with previous coronary artery disease (p=.001). CONCLUSIONS: Approximately one in ten patients with recent ischaemic stroke has a high MBPS. Strategies to detect and treat high MBPS after a stroke are needed.

Utility of Doppler ultrasound for the study of ocular vascular disease.

Ocular vascular problems represent an emerging pathology within the activity of the internist. Ocular ultrasound is a widely used technique to evaluate a variety of eye conditions. Specifically, Doppler ultrasound of the ophthalmic vessels has become a very useful tool in diagnosing various eye diseases. Doppler ultrasound allows for examining blood flow in the eye even in the presence of eye opacities that impede viewing the posterior segment of the eye. In this review, we describe the principles and techniques of an ocular vascular Doppler ultrasound examination in clinical practice and provide a general approach to the ultrasound characteristics of the most important vascular eye disorders for internists. These include central retinal artery and vein occlusions, chronic retinal ischemic syndrome, anterior optic ischemic neuropathy, and diabetic retinopathy.

[Cardioembolic stroke]. / Ictus cardioembólico.

A 77-year old man who consulted due to left arm weakness and dysarthria. He reported having been diagnosed of high blood pressure and that he was taking enalapril/hydrochlorothiazide without adequate blood pressure control. He had smoked 2 packs of cigarettes a day and continues to smoke at present. He was admitted to the emergency service about 90 min after the onset of his symptoms. He did not report headache, nausea or vomiting. His BP was 182/104 mmHg, with irregular pulse at 88 beats per minute. The neurological examination revealed dysarthria, left homonymous hemianopsia, muscle weakness and hypoesthesia of the left limbs. How should this patient be evaluated and treated?

Trends in the use of statins after ischaemic stroke: Have clinical practices changed? / Tendencias en el uso de estatinas tras un ictus isquémico. ¿Hemos cambiado nuestra práctica clínica?

INTRODUCTION: The role of statins after ischaemic stroke changed with the publication of the SPARCL study in 2006. We analyse how this has influenced the prescription of statins in this patient population. METHODS: We conducted a retrospective study of patients discharged with ischaemic stroke at the Virgen Macarena, Virgen del Rocío, and Valme hospitals in Seville (Spain) over two periods: 1999-2001 and 2014-2016. RESULTS: The study included 1575 patients: 661 (42%) were women and mean age (standard deviation) was 69 (10) years. Patients from the later period are older (68 [10] vs 71 [11]; P=.0001); include a higher proportion of women; and present higher rates of dyslipidaemia, hypertension, and diabetes. At discharge, statins were used in 18.7% of patients (vs 86.9% in the first period; P=.0001), with high-intensity statins prescribed in 11.1% of cases (vs 54.4%; P=.0001). In both periods, atorvastatin was the most commonly prescribed statin (80mg: 6% vs 42.7%; 40mg: 5.1% vs 11.1%). In the first period, the use of statins and high-intensity statins was correlated with hypercholesterolaemia, and inversely correlated with age. In the second period, statin use was correlated with hypertension and hypercholesterolaemia, and high-intensity statin use was correlated with ischaemic heart disease and inversely correlated with age. CONCLUSION: There has been a clear change in the prescription of statins to patients with ischaemic stroke at discharge. However, many patients remain undertreated and the use of these drugs needs to be optimised.

Cholesterol and stroke: Roll of PCSK9 inhibitors. / Colesterol e ictus: papel de los inhibidores de la proproteína convertasa subtilisina/kexina tipo 9.

INTRODUCTION: Proprotein convertase subtilisin/kexin type 9 (PCSK9) plays an important role in the modulation of plasma levels of low density lipoprotein cholesterol (LDLC). PCSK9 binds to the LDL receptor (LDLR), disrupts its endocytic recycling itinerary and directs it to lysosomal degradation. Activation of PCSK9 can thus decrease the expression of LDLR in the liver and inhibit LDL uptake, which leads to hypercholesterolaemia. DEVELOPMENT: Currently we now know that different polymorphisms of PCSK9 are associated with the occurrence of ischaemic stroke. On the other hand, PCSK9 inhibitors prevent binding of PCSK9 to LDLR and inhibit degradation of LDLR, which results in increased hepatic uptake of LDL and lower LDL levels in blood. Different phase 2 and 3 studies, including OSLER and ODYSSEY LONG-TERM, have demonstrated the efficacy and safety of the new monoclonal antibodies against PCSK9 such as evolucumab and alirocumab, and the first exploratory analyses have shown evidence of their efficacy in decreasing vascular events, including stroke. CONCLUSIONS: Although few strokes have been reported by these studies, new ongoing trials examining the cardiovascular effects of evolucumab (FOURIER study), alirocumab (ODYSSEY OUTCOMES study), and bococizumab (SPIRE-1 and SPIRE-2 studies) will reveal the true potential of these drugs, particularly for the prevention of stroke.

Pulmonary embolism in very elderly patients. A diagnostic challenge. / Embolia pulmonar en los pacientes muy ancianos. Un reto diagnóstico.

BACKGROUND: Diagnosing pulmonary embolisms can be challenging, given that its presentation shares clinical manifestations with other conditions. For patients 80 years of age or older, the healthcare challenge increases due to associated comorbidity when compared with younger patients (<80 years). OBJECTIVE: The aim of our study was to report the incidence of pulmonary embolism in elderly patients in our setting and identify differences in the clinical manifestations, comorbidity and laboratory parameters between these 2 groups of patients. METHOD: We conducted a hospital-based, case-control study to review the pulmonary embolisms diagnosed in our centre using computed tomography pulmonary angiography between 2013 and 2016. RESULTS: The study included 413 patients, 124 of whom were 80 years of age or older, with a median age of 72 years (IQR, 58-81). The typical presentation triad was uncommon and showed no differences between subgroups. The main symptoms presented by these groups were dyspnoea (73.4% vs. 63.7% for the elderly and younger groups, respectively; P=.055), chest pain (26.6% vs. 39.5%; P=.013) and cough/haemoptysis (31.1% vs. 18.9%; P=.021). The elderly group had more comorbidity (4.88±2.55 vs. 2.89±2.85; P=.0001). CONCLUSION: Thirty percent of the pulmonary embolisms occurred in the elderly group. The typical presentation form was uncommon. We detected significant differences in individual symptoms, comorbidity and laboratory parameters compared with the younger patients.

[Recommendations on the treatment of hypertension in the secondary prevention of ischemic stroke]. / Recomendaciones sobre el tratamiento de la hipertensión arterial en la prevención secundaria del ictus isquémico.

Stroke continues to be one of the leading causes of death and disability in the world. One of the main problems with a patient who has survived from a stroke is the possibility of developing a new vascular episode again. Hypertension is the modifiable vascular risk factor with the greatest impact for both primary prevention and stroke recurrence. The Group for the study of Hypertension and Brain (GEHYC) from the Spanish Society of Hypertension aims to spread the importance of strict control of blood pressure in order to prevent cerebrovascular diseases. In this article, this multidisciplinary Group reviews the latest evidence regarding antihypertensive treatment and secondary prevention of ischemic stroke.

[Statins and cerebrovascular disease: new perspectives in stroke prevention]. / Estatinas y enfermedad cerebrovascular: nuevas perspectivas en la prevención del ictus.

INTRODUCTION AND DEVELOPMENT: The role played by statins in the prevention of strokes has been subject to controversy for a long time, especially because no clear correlation between levels of cholesterol in serum and strokes has yet been established. Nevertheless, a number of randomised trials with statins and several meta-analyses that were carried out later have proved that statins lower the incidence of all kinds of strokes, with a 21% reduction in the relative risk. It has also been shown that this effect is essentially due to the degree to which LDL cholesterol (cholesterol linked to low-density lipoproteins) is reduced, which has a lowering effect on lipid levels. It has also been shown that statins have others beneficial effects apart from reducing cholesterol levels and that these may be independent of the subject's basal lipid levels. We are referring to the so-called pleiotropic effects, which include stabilisation of the atherosclerotic plaque, an antiinflammatory effect, an antithrombotic effect and enhanced vasomotor reactivity. CONCLUSION: The recent appearance of the results of the SPARCL (Stroke Prevention by Aggressive Reduction in Cholesterol Levels) study and the guidelines published by the American Heart Association and the Spanish Neurology Society, which grant statins a leading role in stroke prevention, both open up new horizons for the use of statins in cerebrovascular pathologies.