Relationship of arterial stiffness and baseline vascular burden with new lacunes and microbleeds: A longitudinal cohort study.

INTRODUCTION: Arterial stiffness may have a significant impact on the development of cerebral small vessel disease (cSVD). PATIENTS AND METHODS: We obtained pulse wave velocity (24-h PWV) by means of ambulatory blood pressure monitoring (ABPM) in patients with a recent small subcortical infarct (RSSI). Patients with known cardiac or arterial embolic sources were excluded. Lacunes, microbleeds, white matter hyperintensities and enlarged perivascular spaces at baseline were assessed in a brain MRI and included in a cSVD score. A follow-up MRI was obtained 2 years later and assessed for the appearance of new lacunes or microbleeds. We constructed both unadjusted and adjusted models, and subsequently selected the optimal models based on the area under the curve (AUC) of the predicted probabilities. RESULTS: Ninety-two patients (mean age 67.04 years, 69.6% men) were evaluated and 25 had new lacunes or microbleeds during follow-up. There was a strong correlation between 24-h PWV and age (r = 0.942, p < 0.001). cSVD was associated with new lacunes or microbleeds when adjusted by age, 24-h PWV, NT-proBNP and hypercholesterolemia (OR 2.453, CI95% 1.381-4.358). The models exhibiting the highest discrimination, as indicated by their area under the curve (AUC) values, were as follows: 1 (AUC 0.854) - Age, cSVD score, 24-h PWV, Hypercholesterolemia; 2 (AUC 0.852) - cSVD score, 24-h PWV, Hypercholesterolemia; and 3 (AUC 0.843) - Age, cSVD score, Hypercholesterolemia. CONCLUSIONS: cSVD score is a stronger predictor for cSVD progression than age or hemodynamic parameters in patients with a RSSI.

NT-proBNP, cerebral small vessel disease and cardiac function in patients with a recent lacunar infarct.

NT-proBNP is produced from both atria and ventricles and it is increased in patients with cardiac disease. NT-proBNP is also associated with cerebral small vessel disease(cSVD) but there are no studies that had carried out a systematic evaluation of cardiac function in this specific setting. We conducted a prospective observational study in 100 patients within 30 days after a recent lacunar infarct by means of brain MRI, 24 h ambulatory blood pressure monitoring, transthoracic echocardiography, and plasmatic NT-proBNP. Global cSVD burden was quantified using a validated visual score (0 to 4) and dichotomized into 2 groups (0-2 or 3-4). Age (73.8 vs 63.5 years) and NT-proBNP (156 vs 76 pg/ml) were increased in patients with SVD 3-4, while daytime augmentation index normalized for the heart rate of 75 bpm (AIx75) (22.5 vs 25.6%) was decreased. The proportion of patients with left atrial enlargement, left ventricular hypertrophy, or septal e' velocity <7 cm/s was not different between both groups. NT-proBNP was increased in patients with left atrial enlargement (126 vs 88 pg/ml). In multivariate analysis, age (OR 1.129 CI 95% 1.054-1.209), daytime AIx75 (OR 0.91 CI 95% 0.84-0.987,) and NT-proBNP (OR 1.007 CI 95% 1.001-1.012,) were independently associated with cSVD score 3-4. In conclusion, as well as in other patients with cSVD we found an association between NT-proBNP and cSVD. This association was independent of cardiac function.

Impact of an oral anticoagulation self-monitoring and self-management program in patients with mechanical heart valve prosthesis.

Objective: To analyze impact of implementation of an oral anticoagulation self-monitoring and self-management program among patients with mechanical valve prosthesis. Materials & methods: Observational and retrospective study performed in Hospital Moises Broggi, Barcelona, Spain. The program started on June 2019. The study compared 6-month period before and after the implementation of the program. Results: The study included 44 patients. There was a numerical increase of time in therapeutic range from 53.6 ± 21.3% to 57.1 ± 15.7% (p = 0.30). Proportion of patients with international normalized ratio (INR) >5 significantly decreased from 3.9 to 2.0% (p = 0.04). No significant differences were observed in thromboembolic or bleeding complications. Visits to emergency department decreased from (29.5 to 22.7%; p = 0.41). Conclusion: Oral anticoagulation self-monitoring and self-management program seems an appropriate approach that could provide additional benefits in selected patients with mechanical valve prosthesis.

Medida simultánea de la presión arterial en ambos brazos. ¿ Qué aporta en el manejo y en la evaluación del riesgo vascular en el paciente hipertenso? / Simultaneous measurement of blood pressure in both arms. What does it contribute to the management and assessment of vascular risk in the hypertensive patient?

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Biomarkers levels and brachial and central blood pressure during the subacute phase of lacunar stroke and other ischemic stroke subtypes.

We aimed to evaluate brachial and central blood pressure (BP) estimates and biomarker levels in lacunar ischemic stroke (IS) and other IS subtypes (nonlacunar stroke). We studied 70 functionally independent subjects consecutively admitted to our institution after a first episode of IS. Subjects with previous heart failure were excluded. BP was measured at admission and during the subacute phase of stroke (5-7 days after stroke onset). Aortic pulse wave velocity (aPWV), augmentation index (AIx), and 24 h brachial and central BP (24h-ABPM) were measured by means of a Mobil-O-Graph device during the subacute phase of stroke. Determination of N-terminal prohormone of brain natriuretic peptide (NT-proBNP), urinary albumin excretion, and echocardiography were performed in all subjects. After adjusting for age and clinical severity, lacunar IS had significantly higher levels of BP at admission (systolic BP 173 ± 37 vs 153 ± 28 mmHg, p = 0.006; diastolic BP: 97 ± 21 vs 86 ± 16 mmHg, p = 0.035) and during the subacute phase of stroke (systolic BP 152 ± 23 vs 134 ± 19 mmHg, p = 0.001; diastolic BP: 84 ± 14 and 77 ± 10 mmHg, respectively; p = 0.038) but lower NT-proBNP levels (median: 36,277 vs 274 pg/mL, p = 0.009) than nonlacunar IS. Central BP, aPWV, and AIx were not different between lacunar and nonlacunar IS, neither the rate of target organ damage. In conclusion, patients with a first episode of lacunar IS have higher BP values at admission and during the subacute phase of stroke and lower levels of NT-proBNP, suggesting a closer relationship with hypertension of this IS subtype.

Association of Either Left Ventricular Hypertrophy or Diastolic Dysfunction With 24-Hour Central and Peripheral Blood Pressure.

BACKGROUND: Central blood pressure (BP) is considered as a better estimator of hypertension-associated risks than peripheral BP. We aimed to evaluate the association of 24-hour central BP, in comparison with 24-hour peripheral BP, with the presence of left ventricular hypertrophy (LVH), or diastolic dysfunction (DD). METHODS: The cross-sectional study consisted of 208 hypertensive patients, aged 57 ± 12 years, of which 34% were women. Office and 24-hour central and peripheral BP were measured by the oscillometric Mobil-O-Graph device. We performed echocardiography-Doppler measurements to calculate LVH and DD, defined as left atrium volume ≥34 ml/m2 or septal e' velocity <8 cm/s or lateral e' velocity <10 cm/s. RESULTS: Seventy-seven patients (37%) had LVH, and 110 patients (58%) had DD. Systolic and pulse BP estimates (office, 24-hour, daytime, and nighttime) were associated with the presence of LVH or DD, after adjustment for age, gender, and antihypertensive treatment, with higher odds ratios for ambulatory-derived values. The comparison between central and peripheral BP estimates did not reveal a statistically significant superiority of the former neither in multiple regression models with simultaneous adjustments nor in the comparison of areas under receiver-operating curves. Correlation coefficients of BP estimates with left ventricular mass, although numerically higher for central BP, did not significantly differ between central and peripheral BP. CONCLUSIONS: We have not found a significant better association of 24-hour central over peripheral BP, with hypertensive cardiac alterations, although due to the sample size, these results require further confirmation in order to assess the possible role of routine 24-hour central BP measurement.

Central blood pressure variability is increased in hypertensive patients with target organ damage.

We aimed to evaluate the association of aortic and brachial short-term blood pressure variability (BPV) with the presence of target organ damage (TOD) in hypertensive patients. One-hundred seventy-eight patients, aged 57 ± 12 years, 33% women were studied. TOD was defined by the presence of left ventricular hypertrophy on echocardiogram, microalbuminuria, reduced glomerular filtration rate, or increased aortic pulse wave velocity. Aortic and brachial BPV was assessed by 24-hour ambulatory BP monitoring (Mobil-O-Graph). TOD was present in 92 patients (51.7%). Compared to those without evidence of TOD, they had increased night-to-day ratios of systolic and diastolic BP (both aortic and brachial) and heart rate. They also had significant increased systolic BPV, as measured by both aortic and brachial daytime and 24-hours standard deviations and coefficients of variation, as well as for average real variability. Circadian patterns and short-term variability measures were very similar for aortic and brachial BP. We conclude that BPV is increased in hypertensive-related TOD. Aortic BPV does not add relevant information in comparison to brachial BPV.

Cuff-Based Oscillometric Central and Brachial Blood Pressures Obtained Through ABPM are Similarly Associated with Renal Organ Damage in Arterial Hypertension.

BACKGROUND/AIMS: Central blood pressure (BP) has been suggested to be a better estimator of hypertension-associated risks. We aimed to evaluate the association of 24-hour central BP, in comparison with 24-hour peripheral BP, with the presence of renal organ damage in hypertensive patients. METHODS: Brachial and central (calculated by an oscillometric system through brachial pulse wave analysis) office BP and ambulatory BP monitoring (ABPM) data and aortic pulse wave velocity (PWV) were measured in 208 hypertensive patients. Renal organ damage was evaluated by means of the albumin to creatinine ratio and the estimated glomerular filtration rate. RESULTS: Fifty-four patients (25.9%) were affected by renal organ damage, displaying either microalbuminuria (urinary albumin excretion ≥30 mg/g creatinine) or an estimated glomerular filtration rate (eGFR) <60 ml/min/1.73 m2. Compared to those without renal abnormalities, hypertensive patients with kidney damage had higher values of office brachial systolic BP (SBP) and pulse pressure (PP), and 24-h, daytime, and nighttime central and brachial SBP and PP. They also had a blunted nocturnal decrease in both central and brachial BP, and higher values of aortic PWV. After adjustment for age, gender, and antihypertensive treatment, only ABPM-derived BP estimates (both central and brachial) showed significant associations with the presence of renal damage. Odds ratios for central BP estimates were not significantly higher than those obtained for brachial BP. CONCLUSION: Compared with peripheral ABPM, cuff-based oscillometric central ABPM does not show a closer association with presence of renal organ damage in hypertensive patients. More studies, however, need to be done to better identify the role of central BP in clinical practice.

Prevalence and Clinical Characteristics of Refractory Hypertension.

BACKGROUND: We aimed to estimate the prevalence of refractory hypertension (RfH) and to determine the clinical differences between these patients and resistant hypertensives (RH). Secondly, we assessed the prevalence of white-coat RfH and clinical differences between true- and white-coat RfH patients. METHODS AND RESULTS: The present analysis was conducted on the Spanish Ambulatory Blood Pressure Monitoring Registry database containing 70 997 treated hypertensive patients. RH and RfH were defined by the presence of elevated office blood pressure (≥140 and/or 90 mm Hg) in patients treated with at least 3 (RH) and 5 (RfH) antihypertensive drugs. White-coat RfH was defined by RfH with normal (<130/80 mm Hg) 24-hour blood pressure. A total of 11.972 (16.9%) patients fulfilled the standard criteria of RH, and 955 (1.4%) were considered as having RfH. Compared with RH patients, those with RfH were younger, more frequently male, and after adjusting for age and sex, had increased prevalence of target organ damage, and previous cardiovascular disease. The prevalence of white coat RfH was lower than white-coat RH (26.7% versus 37.1%, P<0.001). White-coat RfH, in comparison with those with true RfH, showed a lower prevalence of both left ventricular hypertrophy (22% versus 29.7%; P=0.018) and microalbuminuria (28.3% versus 42.9%; P=0.047). CONCLUSIONS: The prevalence of RfH was low and these patients had a greater cardiovascular risk profile compared with RH. One out of 4 patients with RfH have normal 24-hour blood pressure and less target organ damage, thus indicating the important role of ambulatory blood pressure monitoring in guiding antihypertensive therapy in difficult-to-treat patients.

Twenty-four-hour central blood pressure is not better associated with hypertensive target organ damage than 24-h peripheral blood pressure.

BACKGROUND AND AIM: Central blood pressure (BP) is increasingly considered as a better estimator of hypertension associated risks. We aimed to evaluate the association of 24-h central BP, in comparison with 24-h peripheral BP, with the presence of target organ damage (TOD). METHODS: Cross-sectional study of 208 hypertensive patients, aged 57 ±â€Š12 years, 34% women. Office (mean of 4 measurements) and 24-h central and peripheral BP were measured by the oscillometric Mobil-O-Graph device. TOD was assessed at cardiac (left ventricular hypertrophy by echocardiography), renal (reduction of glomerular filtration rate and/or microalbuminuria), and arterial (increased aortic pulse wave velocity) levels. RESULTS: A total of 107 patients (51.4%) had TOD (77, 35% patients left ventricular hypertrophy; 54, 25.9% renal abnormalities; and 40, 19.2% arterial stiffness). All SBP and pulse BP estimates (office, 24-h, daytime, and night-time) were associated with the presence of TOD, after adjustment for age, sex, and antihypertensive treatment, with higher odds ratios for ambulatory-derived values. Odds ratios for central and peripheral BP were similar for all office, 24-h, daytime, and night-time BP. After simultaneous adjustment, peripheral, but not central, 24-h and night-time SBP and pulse pressures were associated with the presence of TOD. CONCLUSION: TOD in hypertension is associated with BP elevation, independently of the type of measurement (office or ambulatory, central or peripheral). Central BP, even monitored during 24 h, is not better associated with TOD than peripheral BP. These results do not support a routine measurement of 24-h central BP.

[European study of ambulatory management of heart failure by cardiologists]. / Estudio europeo del tratamiento ambulatorio de la insuficiencia cardíaca realizado por cardiólogos.

INTRODUCTION AND OBJECTIVES: This cross-sectional study examined the overall clinical characteristics and management of 1252 outpatients with heart failure in 3 countries (Spain, France and Germany). MATERIAL AND METHOD: A standardized questionnaire was used to record demographic, diagnostic, clinical and treatment data for all patients seen on one day (26 April 2001) by 465 outpatient cardiologists. RESULTS: Men accounted for 62.1% of the patients in the population, and mean age of the patients was 68.3 years. In the twelve months prior to the study 78% of the patients consulted their physician at least once because of heart failure, and 36.2% had hospital admissions. Differences between the three countries were observed in reported causes of heart failure (alone or in combination) such as ischemic heart disease (France 40.7%, Germany 41.3%, Spain 26%, P<.0001) and hypertension (France 10.7%, Germany 16.7%, Spain 43.6%, P<.0001). How-ever the proportion of patients with prior myocardial infarction was very similar (France 63.7%, Germany 69.5%, Spain 65%, P=NS). Diuretics were not prescribed in 19.7% of the patients, ACE inhibitors were not prescribed in 27.9%, and beta blockers were not prescribed in 52.3%. CONCLUSIONS: The study provides further information on the consumption of large amounts of medical resources because of heart failure. The reported etiologies differed between countries. However, the proportion of patients with prior myocardial infarction was very similar. Treatment with ACE inhibitors and beta blockers was slightly more common than previously reported, although beta blockers continue to be underused.

Estudio europeo del tratamiento ambulatorio de la insuficiencia cardíaca realizado por cardiólogos / European Study of Ambulatory Management of Heart Failure by Cardiologists

Introducción y objetivos. Se presentan los resultados globales de un estudio transversal que examina las características clínicas y el manejo de 1.252 pacientes ambulatorios diagnosticados de insuficiencia cardíaca (IC) en 3 países (España, Francia y Alemania). Material y método. Se estudiaron en un cuestionario estandarizado los datos demográficos, diagnósticos, clínicos y terapéuticos de todos los pacientes atendidos en consultorio en un mismo día (26 de abril de 2001) por 465 cardiólogos de práctica extrahospitalaria. Resultados. El 62,1% de los pacientes de la población total eran varones y la edad media fue de 68,3 años. Durante los 12 meses previos acudieron al menos a una visita médica justificada por IC el 78% de los pacientes, y se hospitalizó al 36,2%. Hubo diferencias entre los países respecto a la etiología reportada de IC (sola o en combinación): cardiopatía isquémica (Francia, el 40,7%; Alemania, el 41,3%, y España, el 26%; p < 0,0001) e hipertensión (Francia, el 10,7%; Alemania, el 16,7%, y España, el 43,6%; p < 0,0001), aunque la tasa de pacientes con infarto de miocardio previo era similar (Francia, el 63,7%; Alemania, el 69,5%, y España, el 65%; p = NS). En el 19,7% de los pacientes no se prescribieron diuréticos, en el 27,9% no se prescribieron inhibidores de la enzima de conversión de la angiotensina (IECA), y en el 52,3% no se prescribieron bloqueadores beta. Conclusiones. Este estudio proporciona información adicional respecto al gran consumo de recursos médicos de la insuficiencia cardíaca. La etiología reportada difiere entre los países, aunque la proporción de pacientes con antecedentes de infarto de miocardio es muy similar. El tratamiento con IECA y bloqueadores beta es ligeramente superior al descrito en trabajos previos, pero los bloqueadores beta siguen estando infrautilizados (AU)

Introduction and objectives. This cross-sectional study examined the overall clinical characteristics and management of 1252 outpatients with heart failure in 3 countries (Spain, France and Germany). Material and method. A standardized questionnaire was used to record demographic, diagnostic, clinical and treatment data for all patients seen on one day (26 April 2001) by 465 outpatient cardiologists. Results. Men accounted for 62.1% of the patients in the population, and mean age of the patients was 68.3 years. In the twelve months prior to the study 78% of the patients consulted their physician at least once because of heart failure, and 36.2% had hospital admissions. Differences between the three countries were observed in reported causes of heart failure (alone or in combination) such as ischemic heart disease (France 40.7%, Germany 41.3%, Spain 26%, P<.0001) and hypertension (France 10.7%, Germany 16.7%, Spain 43.6%, P<.0001). However the proportion of patients with prior myocardial infarction was very similar (France 63.7%, Germany 69.5%, Spain 65%, P=NS). Diuretics were not prescribed in 19.7% of the patients, ACE inhibitors were not prescribed in 27.9%, and beta blockers were not prescribed in 52.3%. Conclusions. The study provides further information on the consumption of large amounts of medical resources because of heart failure. The reported etiologies differed between countries. However, the proportion of patients with prior myocardial infarction was very similar. Treatment with ACE inhibitors and beta blockers was slightly more common than previously reported, although beta blockers continue to be underused (AU)

[Use of oral anticoagulants in patients discharged with atrial fibrillation in 2000]. / Utilización de anticoagulantes orales en pacientes con fibrilación auricular al alta hospitalaria en el año 2000.

INTRODUCTION AND OBJECTIVES: Although there is consensus about the use of oral anticoagulants to prevent thrombi and embolisms in most patients with atrial fibrillation, this treatment is underused in actual practice. Our objective was to determine and analyze the use of acenocoumarol in patients diagnosed as having atrial fibrillation at discharge. PATIENTS AND METHOD: Between January and July 2000, we retrospectively studied 501 consecutive patients with a diagnosis of atrial fibrillation. We recorded whether they were discharged with or without oral anticoagulation treatment. RESULTS: We identified 482 patients with at least one associated thromboembolic risk factor, who comprised the study population. Mean age was 79.3 years, and 33.3% of the patients were men. Forty-six percent were discharged with acenocoumarol, and 36.3% with platelet antiaggregants. Twenty-three percent had a known contraindication for acenoroumarol. Nearly 62% of the patients without contraindications for anticoagulation received treatment with acenocoumarol. Multivariate analysis showed that rheumatic mitral valve disease, previous stroke or thromboembolism and dilated left atrium were associated with a higher probability of receiving anticoagulant treatment. Age over 75 years was associated with a lower likelihood of receiving acenocoumarol. CONCLUSIONS: Oral anticoagulation was given in an inadequate proportion of patients who were discharged from a secondary-level hospital with atrial fibrillation and no contraindications. Rheumatic mitral valve disease, previous stroke or thromboembolism, and dilated left atrium were associated with a higher probability of anticoagulant treatment. Age over 75 years was related with less frequent use of this therapy.

Utilización de anticoagulantes orales en pacientes con fibrilación auricular al alta hospitalaria en el año 2000 / Use of oral anticoagulants in patients discharged with atrial fibrillation in 2000

Introducción y objetivos. Existe un amplio consenso sobre la utilización de dicumarínicos en pacientes con fibrilación auricular para prevenir eventos tromboembólicos, aunque su uso real es inadecuado. Nuestro objetivo es determinar y analizar su utilización en pacientes con fibrilación auricular al alta hospitalaria. Pacientes y método. Entre enero y julio de 2000 se estudió retrospectivamente a 501 pacientes consecutivos con el diagnóstico de fibrilación auricular. Se evaluó si recibieron o no anticoagulación oral. Resultados. Se identificó a 482 pacientes que tenían asociado al menos un factor de riesgo tromboembólico, los cuales constituyeron el grupo de pacientes a estudio. La edad media fue de 79,3 años y el 33,3 por ciento eran varones. El 46,5 por ciento de la muestra fue dada de alta con dicumarínicos y el 36,3 por ciento con antiagregantes. El 22,7 por ciento de la población presentaba contraindicación para recibir dicumarínicos. El 61,7 por ciento de los pacientes sin contraindicación para anticoagulación recibieron tratamiento con acenocumarol. En el análisis multivariado, los factores predictores de mayor probabilidad de recibir tratamiento anticoagulante fueron: valvulopatía mitral reumática, accidente cerebrovascular, embolia periférica, aurícula izquierda dilatada. La edad superior a 75 años se relacionaba con una menor probabilidad de recibir tratamiento con dicumarínicos. Conclusiones. El tratamiento anticoagulante oral se administró en una insuficiente proporción de pacientes con fibrilación auricular, sin contraindicaciones para recibir dicha terapia, que fueron dados de alta de un hospital de segundo nivel. La presencia de valvulopatía mitral reumática, accidente cerebrovascular, embolia periférica y aurícula izquierda dilatada es condición para un mayor uso de anticoagulación. La edad mayor de 75 años se relaciona con un menor uso (AU)

[Identification of factors responsible for oral over-anticoagulation in outpatients with heart disease]. / Identificación de factores responsables de anticoaguación oral excesiva en pacientes ambulatorios con cardiopatía.

BACKGROUND: Few studies have attempted to investigate the clinical course or identify factors responsible for excessive anticoagulation in patients with heart disease. OBJECTIVES: To determine the incidence of excessive anticoagulation in outpatients with heart disease treated with acenocoumarol, analyze the factors related with over-anticoagulation, and identify bleeding complications. PATIENTS AND METHOD: This 7-month prospective observational study included consecutive outpatients anticoagulated with acenocoumarol. They were seen in an anticoagulation unit. The high INR group of 55 over-anticoagulated patients had at least one test with INR > 5. The control group of 49 patients had INR results strictly within therapeutic range. RESULTS: A total of 3,683 INR determinations were made in 512 patients. Seventy-seven tests had an INR > 5 (a 2% overall incidence of high-INR). In the group of 55 INR < 5 patients, 31% had more than one INR determination > 5 during follow-up. Multivariate analysis identified four variables as independent predictors of over-anticoagulation: artificial heart valve, poor treatment compliance, addition of potentially interactive new drugs, and illness in the last month. The high-INR group patients had more bleeding episodes (21.8 vs 4.08%; p = 0.008), one of which was major. CONCLUSION: The incidence of excessive oral anticoagulation in our outpatient population was similar to that reported in other studies. Patients with INR > 5 had more total bleeding complications, mostly minor. It is recommended to proceed carefully with oral anticoagulant therapy in patients with an artificial heart valve, suspected poor treatment compliance, addition of potentially interactive new drugs, and illness in the last month.

Identificación de factores responsables de anticoagulación oral excesiva en pacientes ambulatorios con cardiopatía / Identification of factors responsible for oral overanticoagulation in outpatients with heart disease

Fundamento. Pocos estudios han examinado la evolución clínica o la identificación de los factores responsables del mal control de pacientes con cardiopatía que han recibido tratamiento anticoagulante. Objetivos. Determinar la incidencia de enfermos con un exceso de anticoagulación en una población de pacientes con cardiopatía tratados con dicumarínicos, analizar los factores relacionados con esta sobredosificación e identificar las complicaciones hemorrágicas. Pacientes y método. Se trata de un estudio observacional y prospectivo en pacientes con cardiopatía anticoagulados con acenocumarol, controlados ambulatoriamente y con un período de seguimiento de 7 meses. Incluía un grupo de estudio (n = 55), pacientes excesivamente anticoagulados (INR > 5), y un grupo control (n = 49): pacientes con INR estrictamente dentro del intervalo terapéutico Resultados. Se realizaron 3.683 determinaciones de INR en 512 pacientes. Se identificaron 77 tests con INR > 5, que corresponden al 2 per cent del total. En total fueron 55 pacientes con INR > 5, y el 31 per cent de ellos (17 pacientes) tuvo más de un test > 5 durante el período de estudio. El análisis multivariado identificó 4 variables predictoras independientes de excesiva anticoagulación: pacientes portadores de prótesis valvular mecánica, mal cumplimiento terapéutico, adición de nuevos fármacos con interferencia y enfermedad intercurrente en el último mes. Los pacientes con INR > 5 presentaron más hemorragias totales (21,8 frente a 4,08 per cent; p = 0,008). Sólo un paciente sufrió una hemorragia mayor. Conclusiones. La incidencia de excesiva anticoagulación en pacientes con cardiopatía controlados de modo ambulatorio es aceptable. Los pacientes con INR > 5 presentan una incidencia más elevada de hemorragias totales, la mayoría de las cuales es menor. Debe tenerse especial precaución cuando se realiza tratamiento anticoagulante a pacientes portadores de prótesis mecánicas, con nuevos fármacos añadidos que interfieran con la anticoagulación, con enfermedad intercurrente en el último mes y si hay sospecha de que exista un incorrecto cumplimiento (AU)