Factors associated with mortality due to SARS-CoV-2 in the population over 75 years of age in the Community of Madrid.

OBJECTIVE: Various studies have identified factors associated with risk of mortality in patients with SARS-CoV-2 infection. However, their sample size has often been limited and their results partially contradictory. This study evaluated factors associated with COVID-19 mortality in the population of Madrid over 75 years of age, in infected patients, and in hospitalized patients up to January 2021. PATIENTS AND METHODS: This population-based cohort study analyzed all residents of the Community of Madrid born before January 1, 1945 who were alive as of December 31, 2019. Demographic and clinical data were obtained from primary care electronic medical records (PC-Madrid), data on hospital admissions from the Conjunto Mínimo Básico de Datos (CMBD, Minimum Data Set), and data on mortality from the Índice Nacional de Defunciones (INDEF, National Death Index). Data on SARS-CoV-2 infection, hospitalization, and death were collected from March 1, 2020 to January 31, 2021. RESULTS: A total of 587,603 subjects were included in the cohort. Of them, 41,603 (7.1%) had confirmed SARS-CoV-2 infection, of which 22,362 (53.7% of the infected individuals) were hospitalized and 11,251 (27%) died. Male sex and age were the factors most closely associated with mortality, though many comorbidities also had an influence. The associations were stronger in the analysis of the total population than in the analysis of infected or hospitalized patients. Mortality among hospitalized patients was lower during the second wave (33.4%) than during the first wave (41.2%) of the pandemic. CONCLUSION: Age, sex, and numerous comorbidities are associated with risk of death due to COVID-19. Mortality in hospitalized patients declined notably after the first wave of the pandemic.

[Factors associated with mortality due to SARS-CoV-2 in the population over 75 years of age in the Community of Madrid]. / Factores asociados con la mortalidad por SARS-CoV-2 en la población mayor de 75 años de la Comunidad de Madrid.

Objective: Various studies have identified factors associated with risk of mortality in patients with SARS-CoV-2 infection. However, their sample size has often been limited and their results partially contradictory. This study evaluated factors associated with COVID-19 mortality in the population of Madrid over 75 years of age, in infected patients, and in hospitalized patients up to January 2021. Patients and methods: This population-based cohort study analyzed all residents of the Community of Madrid born before January 1, 1945 who were alive as of December 31, 2019. Demographic and clinical data were obtained from primary care electronic medical records (PC-Madrid), data on hospital admissions from the Conjunto Mínimo Básico de Datos (CMBD, Minimum Data Set), and data on mortality from the Índice Nacional de Defunciones (INDEF, National Death Index). Data on SARS-CoV-2 infection, hospitalization, and death were collected from March 1, 2020 to January 31, 2021. Results: A total of 587,603 subjects were included in the cohort. Of them, 41,603 (7.1%) had confirmed SARS-CoV-2 infection, of which 22,362 (53.7% of the infected individuals) were hospitalized and 11,251 (27%) died. Male sex and age were the factors most closely associated with mortality, though many comorbidities also had an influence. The associations were stronger in the analysis of the total population than in the analysis of infected or hospitalized patients. Mortality among hospitalized patients was lower during the second wave (33.4%) than during the first wave (41.2%) of the pandemic. Conclusion: Age, sex, and numerous comorbidities are associated with risk of death due to COVID-19. Mortality in hospitalized patients declined notably after the first wave of the pandemic.

Comprehensive management of risk factors in peripheral vascular disease. Expert consensus.

INTRODUCTION: There is currently a degree of divergence among the main clinical practice guidelines on the management of risk factors for peripheral arterial disease (PAD). This project aims to gain understanding of the management of PAD risk factors in clinical practice and to reach a multidisciplinary consensus on the strategies to be followed in order to optimize its identification, treatment, and follow-up. METHODOLOGY: A multidisciplinary consensus following the Delphi methodology. RESULTS: Professionals (n = 130) with extensive experience in PAD participated in this consultation. The results suggest that in order to optimize the control of risk factors, efforts should be aimed at: (1) promoting the involvement and awareness of all specialists in the identification of and screening for the disease; (2) guaranteeing the possibility of evaluating the ankle-brachial index (ABI) in all the medical specialties involved; (3) promoting strategies for patients to quit smoking through the use of drugs, programs, or referrals to specialized units; (4) promoting an appropriate Mediterranean-based diet and the prescription of daily exercise; (5) raising awareness of the importance of ensuring LDL cholesterol values below 70 mg/dL, especially in symptomatic but also in asymptomatic patients (<55 mg/dL following the publication of the ESC/EAS guide); (6) recommending the use of antiplatelet therapy in asymptomatic patients with diabetes mellitus (DM) and/or a pathological ABI; and (7) protocolizing the annual evaluation of ABI in high-risk patients. CONCLUSION: This document presents the 22 agreed-upon strategies which are intended to help professionals optimize multidisciplinary management of PAD risk factors.

Nutritional Risk and Mortality at One Year for Elderly Patients Hospitalized with Nonvalvular Atrial Fibrillation. Nonavasc Registry.

OBJECTIVES: To determine whether nutritional risk is associated with the mortality of elderly patients hospitalized with nonvalvular atrial fibrillation (NVAF). DESIGN: Prospective, multicenter cohort study. SETTING: Internal medicine departments in Spain. PARTICIPANTS: Inpatients >75 years with NVAF. MEASUREMENTS: We measured the thrombotic and hemorrhagic risk at admission using the CHA2DS2-VASc and HAS-BLED scales, respectively, and the nutritional risk with the controlling nutritional status (CONUT) index. We established 4 degrees of nutritional risk: null (CONUT score 0-1 point), low (2-4 points), moderate (5-8 points) and high (9-12 points). We also conducted a 1-year follow-up. RESULTS: We included 449 patients, with a mean age of 85.2(5.2) years. The nutritional risk was null for 70(15.6%) patients, low for 206 45.9%), moderate for 152(33.8%) and high for 21(4.7%). At the end of one year, 177(39.4%) patients had died. The score on the CONUT index was higher for the deceased patients (4.6 vs. 3.6, p<0.001). The CONUT score (HR, 1.076; 95%CI 1.009-1.148; p=0.025), the Charlson index (HR, 1.080; 95%CI 1.017-1.148; p=0.013) and the presence of pressure ulcers (HR, 1.700; 95%CI 1.028-2.810; p=0.039) were independently associated with increased mortality at one year of follow-up. The prescription of oral anticoagulants at discharge was associated with lower mortality (HR, 0.440; 95%CI 0.304-0.638; p<0.001). CONCLUSIONS: More than a third of elderly patients hospitalized with NVAF have a moderate to high nutritional risk. These patients have greater mortality at the end of one year.

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.

Sarcopenia, frailty, cognitive impairment and mortality in elderly patients with non-valvular atrial fibrillation. / Sarcopenia, fragilidad, deterioro cognitivo y mortalidad en pacientes ancianos con fibrilación auricular no valvular.

OBJECTIVES: To determine the prevalence of sarcopenia, frailty and cognitive impairment in elderly patients with nonvalvular atrial fibrillation (NVAF) and the factors' influence on survival. METHODS: Prospective, multicentre cohort study of patients older than 75 years with NVAF hospitalised in internal medicine departments in Spain. For each patient, we recorded the creatinine, haemoglobin and platelet levels, the scores on the CHA2DS2-VASc and HAS-BLED scales and Charlson index, as well as the use of oral anticoagulants. We measured sarcopenia with the SARC-F scale, frailty with the FRAIL scale and cognitive impairment with the Short Portable Mental State Questionnaire. We also conducted a 1-year follow-up. RESULTS: The study included 596 patients with NVAF, with a mean age of 84.9 (SD: 5.2) years. Of these, 295 (49.5%) presented sarcopenia, 305 (51.2%) presented frailty, and 251 (42.1%) presented cognitive impairment. At the end of 1year, 226 (37.9%) patients had died. Mortality was greater for the patients with sarcopenia, frailty and cognitive impairment. In the multivariate analysis, sarcopenia (HR: 1.775; 95%CI: 1.270-2.481), age, comorbidity and a history of peripheral embolism were associated with increased mortality, and the use of oral anticoagulants at discharge (HR: 0.415; 95%CI: 0.307-0.560) was associated with lower mortality. CONCLUSIONS: Sarcopenia, frailty and cognitive impairment are very common in elderly patients with NVAF and are frequently associated. Sarcopenia was associated with increased mortality.

Baseline functional status as the strongest predictor of in-hospital mortality in elderly patients with non-valvular atrial fibrillation: Results of the NONAVASC registry.

OBJECTIVES: Atrial fibrillation (AF) has been associated with higher mortality. We aimed to identify the baseline predictors of in-hospital mortality among elderly patients with non-valvular AF (NVAF) hospitalised for any reason. METHODS: Observational, prospective and multicentre study was carried out on patients with NVAF over the age of 75, who had been admitted for any acute medical condition to Internal Medicine departments in Spain. RESULTS: We evaluated 804 patients with a mean age of 85±5.1years, of which 53.9% were females. During the hospitalization 10.1% (n=81) of the patients died. The patients who died were older, had a greater percentage of institutionalization, worse previous basic functional status (Barthel Index), worse cognitive performance at admission and greater proportion of frailty and sarcopenia. Logistic regression multivariate analysis identified that the strongest determinants of in-hospital mortality were the baseline functional status (Barthel Index) (OR for total dependency 4.73, 95% CI 2.32-9.63), and admissions for stroke (OR 3.55, 95% CI 1.41-8.90) and acute renal failure (OR 1.93, 95% CI 1.12-3.32). CONCLUSION: The overall in-hospital mortality of elderly patients with NVFA is high. Among all factors evaluated in the global geriatric assessment the baseline functional status was the strongest predictor for in-hospital mortality on this population.

Performance of the Finnish Diabetes Risk Score and a Simplified Finnish Diabetes Risk Score in a Community-Based, Cross-Sectional Programme for Screening of Undiagnosed Type 2 Diabetes Mellitus and Dysglycaemia in Madrid, Spain: The SPREDIA-2 Study.

AIM: To evaluate the performance of the Finnish Diabetes Risk Score (FINDRISC) and a simplified FINDRISC score (MADRISC) in screening for undiagnosed type 2 diabetes mellitus (UT2DM) and dysglycaemia. METHODS: A population-based, cross-sectional, descriptive study was carried out with participants with UT2DM, ranged between 45-74 years and lived in two districts in the north of metropolitan Madrid (Spain). The FINDRISC and MADRISC scores were evaluated using the area under the receiver operating characteristic curve method (ROC-AUC). Four different gold standards were used for UT2DM and any dysglycaemia, as follows: fasting plasma glucose (FPG), oral glucose tolerance test (OGTT), HbA1c, and OGTT or HbA1c. Dysglycaemia and UT2DM were defined according to American Diabetes Association criteria. RESULTS: The study population comprised 1,426 participants (832 females and 594 males) with a mean age of 62 years (SD = 6.1). When HbA1c or OGTT criteria were used, the prevalence of UT2DM was 7.4% (10.4% in men and 5.2% in women; p<0.01) and the FINDRISC ROC-AUC for UT2DM was 0.72 (95% CI, 0.69-0.74). The optimal cut-off point was ≥13 (sensitivity = 63.8%, specificity = 65.1%). The ROC-AUC of MADRISC was 0.76 (95% CI, 0.72-0.81) with ≥13 as the optimal cut-off point (sensitivity = 84.8%, specificity = 54.6%). FINDRISC score ≥12 for detecting any dysglycaemia offered the best cut-off point when HbA1c alone or OGTT and HbA1c were the criteria used. CONCLUSIONS: FINDRISC proved to be a useful instrument in screening for dysglycaemia and UT2DM. In the screening of UT2DM, the simplified MADRISC performed as well as FINDRISC.

Antithrombotic treatment in elderly patients with atrial fibrillation. / Tratamiento antitrombótico en el paciente anciano con fibrilación auricular.

Atrial fibrillation (AF) in the elderly is a complex condition due to the high number of frequently associated comorbidities, such as cardiovascular and kidney disease, cognitive disorders, falls and polypharmacy. Except when contraindicated, anticoagulation is necessary for preventing thromboembolic events in this population. Both vitamin K antagonists and direct oral anticoagulants (dabigatran, rivaroxaban and apixaban) are indicated in this context. Renal function should be closely monitored for this age group when these drugs are used. In recent years, various clinical practice guidelines have been published on patients with AF. The majority of these guidelines make specific recommendations on the clinical characteristics and treatment of elderly patients. In this update, we review the specific comments on the recommendations concerning antithrombotic treatment in elderly patients with nonvalvular AF.

Cardiovascular news 2013/2014. / Novedades cardiovasculares 2013/2014.

During 2013 and the first months of 2014, numerous studies have been published in the cardiovascular field. New guidelines have appeared for managing arterial hypertension and reducing cardiovascular risk by lowering cholesterol levels. New data have emerged on the considerable lipid-lowering efficacy of monoclonal antibodies against PCSK-9, in contrast, however, to the clinical trials directed towards raising HDL-cholesterol with nicotinic acid, which have not shown a reduction in the rate of cardiovascular complications. In the field of hypertension, neither stent placement in patients with renovascular hypertension nor sympathetic denervation in patients with resistant hypertension has been shown to be effective in reducing blood pressure. In terms of antithrombotic treatment, the pharmacogenetic tests do not seem useful for maintaining patients anticoagulated with warfarin within the therapeutic range for longer periods. Moreover, there is increasing evidence that, for patients with coronary artery disease and atrial fibrillation, antiplatelet therapy adds no benefit to anticoagulation therapy and is associated with a greater risk of bleeding. Lastly, a Mediterranean diet could prevent the onset of diabetes, while bariatric surgery could be a reasonable option for improving the disease in patients with obesity. Many of these studies have immediate practice applications in daily clinical practice.

Atherogenic dyslipidemia: prevalence and management in lipid clinics. / Dislipemia aterogénica: prevalencia y control en las unidades de lípidos.

BACKGROUND AND OBJECTIVE: Atherogenic dyslipidemia, which is characterized by increased triglyceride levels and reduced HDL cholesterol levels, is underestimated and undertreated in clinical practice. We assessed its prevalence and the achievement of therapeutic objectives for HDL cholesterol and triglyceride levels in patients treated at lipid and vascular risk units in Spain. PATIENTS AND METHOD: This was an observational, longitudinal, retrospective, multicenter study performed in 14 autonomous Spanish communities that consecutively included 1828 patients aged ≥18 years who were referred for dyslipidemia and vascular risk to 43 lipid clinics accredited by the Spanish Society of Arteriosclerosis. We collected information from the medical records corresponding to 2 visits conducted during 2010 and 2011-12, respectively. RESULTS: Of the 1649 patients who had a lipid profile in the first visit (90.2%), 295 (17.9%) had atherogenic dyslipidemia. The factors associated with atherogenic dyslipidemia were excess weight/obesity, not taking hypolipidemic drugs (statins and/or fibrates), diabetes, myocardial infarction and previous heart failure. Of the 273 (92.5%) patients with atherogenic dyslipidemia that had a lipid profile in the last visit, 44 (16.1%) achieved the therapeutic objectives for HDL cholesterol and triglyceride levels. The predictors of therapeutic success were normal weight and normoglycemia. CONCLUSION: One of every 6 patients treated in lipid and vascular risk units had atherogenic dyslipidemia. The degree to which the therapeutic goals for HDL cholesterol and triglyceride levels were achieved in these patients was very low.

Metabolic syndrome in patients with peripheral arterial disease. / Síndrome metabólico en pacientes con enfermedad arterial periférica.

BACKGROUND AND OBJECTIVE: The prevalence of metabolic syndrome (MS) in patients with peripheral arterial disease (PAD) and coronary or cerebrovascular disease is increasing, but it is not known whether this association also exists in patients with isolated PAD. The aim of the current study was to assess the prevalence of MS in patients with PAD who had no coronary or cerebrovascular disease, the prescription rate of evidence-based cardiovascular therapies and the attainment of therapeutic goals in patients with PAD and with and without MS. PATIENTS AND METHODS: Multicenter, cross-sectional study of 3.934 patients aged ≥ 45 years with isolated PAD who were treated in primary care and specialized outpatient clinics during 2009. A diagnosis of PAD was reached for ankle brachial indices <0.9, a previous history of amputation or revascularization. RESULTS: In the overall population, the mean age was 67.6 years, 73.8% were males and 63% had MS (95% CI 61.5-64.3%). Patients with MS had a higher prevalence of cardiovascular risk factors and comorbidities, more severe PAD and higher prescription rate of evidence-based cardiovascular therapies. After adjusting for risk factors and comorbidity, there was a more frequent use of renin-angiotensin system blockers, beta-blockers, diuretics and statins among the patients with MS. A lower percentage of patients with MS achieved the therapeutic goals for blood pressure (22% vs. 41.5%, p<0.001). Similarly, a lower percentage of patients with diabetes achieved the glycated hemoglobin goals (44% vs. 53.1%, p<0.001), with no differences in LDL-cholesterol levels (29.8% vs. 39.1%, p=0.265). CONCLUSION: Patients with PAD have a high prevalence of MS. Patients with MS do not attain therapeutic goals as frequently as those without, despite taking more cardiovascular drugs.

Cardiovascular morbidity-mortality associated to ankle-brachial index in the general population.

BACKGROUND AND OBJECTIVES: Abnormal ankle-brachial index (ABI) is associated with a high risk of cardiovascular disease. This study has aimed to investigate the association between low ABI and risk of cardiovascular death in a general population attended in a primary care center. PATIENTS AND METHODS: A total of 1,361 volunteers aged between 60 and 79 years without any evidence of peripheral artery disease who attended a primary care center participated in the study. They underwent a complete physical examination, together with standard blood tests and ABI was determined. The participants were contacted by telephone 4 years later and asked about any cardiovascular problems for that period. Causes of death and hospitalization were confirmed in the medical records in the primary care center and/or hospital. RESULTS: Information was obtained about the clinical evolution of 1,300 participants (mean age 69.9 years, 38.2% men). Mean follow-up was 49.8 months. There were 13 cardiovascular death and 49 major cardiovascular events. Low ABI (<0.9) was associated with a significant higher risk of cardiovascular death (adjusted relative risk 6.83; 95% confidence interval 1.36-34.30, P=.020), and with a higher risk of major cardiovascular events (adjusted relative risk 2.42; 95% confidence interval 0.99-5.91, P=.051). High or uncompressible ABI was not associated with higher cardiovascular risk. CONCLUSIONS: A low ABI was associated with higher risk of cardiovascular death in the general population followed-up in a primary care center.

Predictive factors of achieving therapeutic goals of hypertriglyceridemia.

OBJECTIVES: The aim of this study was to ascertain the factors associated with non-achievement of triglyceride (TG) goals in a cohort of hypertriglyceridemic patients attending the lipid clinics of the Spanish Arteriosclerosis Society (LC-SAS). METHODS: Patients with high TG levels (>2.2 mmol/L; 200 mg/dL) were included in this multicenter, prospective, observational study and followed up for 1 year. The TG goal was ≤2.2 mmol/L (200 mg/dL). Main limitations of this study are that etiologic diagnosis of hypertriglyceridemia was not done under unified criteria and drug compliance was not evaluated. RESULTS: From 1394 patients initially included in the study, 929 (age range: 50 ± 12 years, 26% women) were followed up for 1 year; 523 patients (56%) failed to reach the TG target. These patients were younger, had a higher body mass index (BMI), were more frequently smokers, hypertensive and diabetic and had more severe dyslipidemia. They were also more sedentary, their diet was of poorer quality and they had higher alcohol consumption. The independent predictors of treatment failure were hypertriglyceridemia severity, low high density lipoprotein cholesterol (HDL-C), and high non-HDL-C, alcohol consumption and a raised BMI, while drug treatment had no predictive power. CONCLUSION: Independent predictors of failure to achieve hypertriglyceridemia treatment goals are inappropriate lifestyle, evidenced by insufficient weight loss, alcohol consumption and dyslipidemia severity.

Atherogenic dyslipidemia in patients with established coronary artery disease.

BACKGROUND AND AIMS: Patients with stable coronary heart disease (CHD) and atherogenic dyslipidemia (AD) have a high-risk of recurrence and are those who derive most benefit from treatment with lipid-lowering agents. The aim of this study was to examine the prevalence of AD in patients with stable coronary heart disease and to investigate associated factors. METHODS: Cross-sectional study involving 7823 subjects admitted for a coronary event between 6 months and 10 years previously. AD was considered to be the concurrent presence of low HDL-cholesterol (<1.03 mmol/L [40 mg/dL] in males, <1.29 mmol/L [50 mg/dL] in females) and elevated triglycerides (≥1.7 mmol/L [150 mg/dL]). RESULTS: Mean age was 65.3 (10.1) years, 73.6% were males and 80.3% were receiving treatment with statins. Low HDL-cholesterol was observed in 26.3% of the participants, 39.7% had elevated triglyceride concentration and 13.0% had AD. The percentage of AD in patients with criteria for metabolic syndrome was 30.9%. Factors associated directly and independently with the presence of AD in the multivariate analysis were female sex, history of coronary syndrome without ST elevation or coronary revascularization, presence of atrial fibrillation, body mass index, LDL-cholesterol, systolic blood pressure and blood glucose levels, while age and glomerular filtration rate were significantly and inversely associated with AD. CONCLUSION: A significant proportion of patients with coronary disease could benefit from interventions aimed at increasing HDL-cholesterol and reducing triglycerides.

[Prevalence of metabolic syndrome in patients with stable coronary disease: therapeutic objectives and utilization of cardiovascular drugs]. / Prevalencia de síndrome metabólico en pacientes con enfermedad coronaria estable: objetivos terapéuticos y utilización de fármacos cardiovasculares.

OBJECTIVE: The achievement of the therapeutic objectives in patients with ischemic heart disease and metabolic syndrome is unknown. This study has aimed to evaluate whether the prevalence of risk factors, the prescription rate of evidence-based cardiovascular therapies and the attainment of therapeutic goals differ in coronary patients with and without the metabolic syndrome (MS). METHODS: A multicenter, cross-sectional study carried out with the participation of 7,600 patients with stable coronary heart disease (mean age 65.3 years, 82% males, 37.7% with MS) attended in primary care. Data on drug prescription and goal attainment were extracted from clinical records. MS was defined according to the National Cholesterol Education Program (NCEP) criteria. RESULTS: Patients with MS had a higher prevalence of cardiovascular risk factors and cardiovascular disease. They also had a higher prescription rate of blood-pressure lowering drugs, statins and antidiabetic agents, without differences in the rate of use of antithrombotics and beta-blockers. After adjusting for cardiovascular risk factors and co-morbidity, only fibrates and angiotensin II receptor blockers were used more frequently in MS patients. A lower percentage of subjects with MS achieved therapeutic goals of LDL cholesterol (23.4% vs 27.7%, P<.001), blood pressure (29.1% vs 52.2%, P<.001) and, in diabetics, of glycated hemoglobin (54.7% vs 75.9%, P<.001). CONCLUSION: Patients with stable coronary disease and MS do not reach therapeutic objectives as frequently as those without MS, in spite of receiving a higher amount of cardiovascular drugs.

Management of physical health in patients with schizophrenia: international insights.

This international meeting discussed the management of physical health in patients with schizophrenia in several countries including France, Spain, Germany, the UK and Italy. Physical health parameters, including weight, blood pressure, blood glucose, lipids and standard biochemical assessments are measured in many patients at the first hospital consultation. These reveal physical disorders such as obesity, hypertension, dyslipidaemia, the metabolic syndrome, substance abuse, cardiovascular disease, extrapyramidal symptoms, sexual dysfunction and diabetes in substantial proportions of patients. Psychiatrists consider switching antipsychotic therapy if excessive sedation, extrapyramidal symptoms, unacceptable weight gain, hyperglycaemia or dyslipidaemia occur. In general, switching is more likely to be considered for symptomatic adverse events than for laboratory abnormalities. Switching is discouraged by limited knowledge of protocols, the absence of guidelines and fears of relapse or reduced treatment adherence. The physical health of patients with schizophrenia receives much less attention in the community setting than in the hospital setting. Improved guidelines, protocols, resources and support are needed to improve the physical health of patients in the community.

Prognostic value of the ankle-brachial index in elderly patients with a stable chronic cardiovascular event.

BACKGROUND AND OBJECTIVES: Patients with polyvascular arterial disease have a greater risk of suffering a new atherothrombotic episode than those with involvement of only one vascular territory. We have studied the predictive prognostic value of the detection of non-diagnosed peripheral arterial disease, determined by measuring the ankle-brachial index in a population of elderly patients with stable chronic cardiac or cerebrovascular disease. METHODS: This was a multicenter, prospective cohort study with consecutive inclusion of patients between 65 and 85 years of age with a previous atherothrombotic event, but without previously established peripheral arterial disease. RESULTS: A total of 1096 patients were evaluated during 11.7 (+ or - 2.2) months of follow-up. An ankle-brachial index of < 0.9 was observed in 29.9% and > 1.4 in 6.9%. The detection of an ankle-brachial index < 0.9 was clearly associated with the presence of a combined primary event of cardiovascular death and non-fatal cardiovascular event [HR 1.99 (95% CI, 1.49-2.66; P < 0.001)]. There was also a significant relationship between ankle-brachial index > 1.4 and total (P = 0.001) or cardiovascular (P = 0.020) deaths. The predictive value of both ranges of the ankle-brachial index was maintained after adjusting for age, sex, diabetes mellitus, vascular territory, macroalbuminuria or glomerular filtration rate. CONCLUSIONS: The detection of non-diagnosed peripheral arterial disease in patients with stable coronary or cerebrovascular events identifies a very high risk population that might benefit from more intensive treatment.

Effect of apoE genotype on the hypolipidaemic response to pravastatin in an outpatient setting.

BACKGROUND: Considerable variability exists in the plasma lipid and lipoprotein response to statin treatment due, in part, to genetic factors. The gene for apolipoprotein E (ApoE) is polymorphic and the different genotypes modulate baseline lipid levels. The objective of the present study was to evaluate the effect of the apoE genotype on the lipoprotein response to pravastatin treatment in an outpatient population followed-up in several different clinics across Spain. Subjects and methods. Subjects (n=401; 56% female; mean age 57 years), who were hypercholesterolaemic despite a diet poor in saturated fat and cholesterol, were treated according to NCEP-ATP II guidelines. Plasma lipids and lipoproteins were measured centrally before and after 16 weeks of treatment with 20 mg day-1 of pravastatin. RESULTS: ApoE genotype distributions were 3.2% with varepsilon2/3, 73.1% with varepsilon3/3 and 22.4% with varepsilon3/4 or varepsilon4/4. ApoE genotype did not have any effect on baseline lipid levels except on triglycerides such that the carriers of the varepsilon2 allele had concentrations significantly greater than those subjects with varepsilon3/3 genotype and carriers of the varepsilon4 allele after adjustment for age, gender and body mass index (BMI) (P < 0.001). Once adjusted for age, gender, BMI and baseline lipid levels, the apoE polymorphism did not significantly influence the plasma lipid and lipoprotein response to pravastatin. CONCLUSION: ApoE genotype appears not to influence the hypolipidaemic effect of pravastatin in patients monitored in a general outpatient setting.

Pravastatin therapy increases procollagen I N-terminal propeptide (PINP), a marker of bone formation in post-menopausal women.

BACKGROUND: The aim of our study was to evaluate whether pravastatin treatment affected biochemical markers of bone turnover. METHODS: Thirty-six hypercholesterolemic post-menopausal women, not on hormonal replacement therapy, were selected from a population study evaluating factors affecting cholesterol response to pravastatin. After a 6-week period on a 30% fat diet, participants received treatment with 20 mg/day of pravastatin during a 16-week follow-up period. Pre- and post-treatment samples were analyzed for procollagen I aminoterminal peptide (PINP) and bone alkaline phosphatase (bAP) as markers of bone formation, carboxyterminal telopeptide of collagen I (CTX) as a marker of bone resorption, and procollagen III aminoterminal propeptide (PIIINP) as a marker of fibrogenesis. RESULTS: Total cholesterol decreased from 7.26+/-0.83 to 6.1+/-0.77 mmol/l with pravastatin treatment. PINP levels significantly increased (from 33.6+/-13 to 37.4+/-16, p=0.03) without changes in bAP or CTX. Individual changes in PINP correlated with individual reduction in cholesterol levels (r=0.337, p=0.04). There was no significant change in PIIINP concentration. CONCLUSIONS: Pravastatin treatment increased PINP levels, a marker of bone formation, in hypercholesterolemic, post-menopausal women, without affecting bone resorption. PIIINP concentration, a marker of liver fibrogenesis, was not affected by the treatment.