Framingham risk score for prediction of cardiovascular diseases: a population-based study from southern Europe.

BACKGROUND: The question about what risk function should be used in primary prevention remains unanswered. The Framingham Study proposed a new algorithm based on three key ideas: use of the four risk factors with the most weight (cholesterol, blood pressure, diabetes and smoking), prediction of overall cardiovascular diseases and incorporating the concept of vascular age. The objective of this study was to apply this new function in a cohort of the general non Anglo-Saxon population, with a 10-year follow-up to determine its validity. METHODS: The cohort was studied in 1992-94 and again in 2004-06. The sample comprised 959 randomly-selected persons, aged 30-74 years, who were representative of the population of Albacete, Spain. At the first examination cycle, needed data for the new function were collected and at the second examination, data on all events were recorded during the follow-up period. Discrimination was studied with ROC curves. Comparisons of prediction models and reality in tertiles (Hosmer-Lemeshow) were performed, and the individual survival functions were calculated. RESULTS: The mean risks for women and men, respectively, were 11.3% and 19.7% and the areas under the ROC curve were 0.789 (95%CI, 0.716-0.863) and 0.780 (95%CI, 0.713-0.847) (P<0.001, both). Cardiovascular disease events occurred in the top risk tertiles. Of note were the negative predictive values in both sexes, and a good specificity in women (85.6%) and sensitivity in men (79.1%) when their risk for cardiovascular disease was high. This model overestimates the risk in older women and in middle-aged men. The cumulative probability of individual survival by tertiles was significant in both sexes (P<0.001). CONCLUSIONS: The results support the proposal for "reclassification" of Framingham. This study, with a few exceptions, passed the test of discrimination and calibration in a random sample of the general population from southern Europe.

[Association of insulin resistance to different anthropometric measures and cardiovascular risk factors in a non-diabetic population]. / Relación de la resistencia a la insulina con diferentes medidas antropométricas y factores de riesgo cardiovascular en una población no diabética.

BACKGROUND AND OBJECTIVE: Insulin resistance (IR) has been directly related to obesity, particularly central obesity, and to other cardiovascular risk factors (CVRFs). Direct IR quantification is difficult in clinical practice, and indirect methods such as HOMA (homeostasis model assessment) have therefore been developed. The aim of this study was to assess the association of IR, as measured by HOMA, with different anthropometric measures and some CVRFs. MATERIALS AND METHODS: A cross-sectional, observational study was carried out in a general population sample older than 18 years in the province of Albacete, Spain. Sample size was 678 subjects. Participants completed a survey and underwent physical examinations and laboratory tests. Obesity measures included body mass index, waist perimeter, and sagittal abdominal diameter. Data analysis was performed using SPSS 15.0 software. RESULTS: Mean values of obesity measures were higher in males as compared to females and increased with age. IR prevalence was 39.8%. All assessed anthropometric measures, decreased HDL (high density lipoprotein) cholesterol and increased non-HDL cholesterol were independently associated to the risk of IR. CONCLUSIONS: A clear association exists between different anthropometrical measures and IR in the general population. There is also an association between lipid profile cahnges and the risk of experiencing IR.

[Trends in prevalence of risk factors and global cardiovascular risk in general population of albacete, Spain (1992-94 a 2004-06)]. / Evolución de la prevalencia de los factores de riesgo y del riesgo cardiovascular global en población mayor de 18 años de la provincia de Albacete (1992-94 a 2004-06).

BACKGROUND: To establish strategies for prevention of cardiovascular disease implies to know its epidemiology and evolution in time. The objective of this study is to know the prevalence of risk factors and cardiovascular risk in two moments during the following of a grownup general population. METHODS: Study of cohorts, followed at random selected general population during 12 years (1992-94 to 2204-06). Two transversal studies were made, one at the beginning and the other one at the end of this follow-up. The population in this study was 18 years and older registered in the province of Albacete. Random sampling, stratified and two-stage. The sample size for the first cut was 2121 subjects and for second one 1577. One specific anamnesis was made, physical examination, measurement of blood pressure, electrocardiogram and extraction of venous blood. The studied variables were: age, sex, personal and familiar antecedents, risk factors and global cardiovascular risk. RESULTS: 1322 subjects went to the appointment for the first examination (mean age 48.2 years. 53.6% women) and 997 for the second (mean age 52.8 years. 56.7% women). Has Increased the prevalence of hypertension (32.7% to 41,2%), diabetes (9,8 to 11,4%), obesity (27,8 to 34,3%) and hypercolesterolemia (47,5 to 53,5%), whereas smokers have decreased (32,6 to 23,7%) and have handicapped the average values of arterial pressure (132/81 to 129/73 mmHg), glycaemia (100,8 to 92,8 mg/dl) and LDL-cholesterol (128,7 to 116,7 mg/dl) and also a lowering of cardiovascular risk with Framingham (10,8% to 8,2%) and Score (2,3% to 1,6%). CONCLUSIONS: In the last years an increasing prevalence of risk factors has been seen (hypertension, diabetes and hypercolesterolemia), a better control of them, and lower prevalence of smoking and cardiovascular risk in the population has also be seen.

Evolución de la prevalencia de los factories de riesgo y del riesgo cardiovascular global en población mayor de 18 añor de la provincia de Albacete (1992-94 a 2004-06) / Trends in prevalence of risk factors and global cardiovascular risk in general population of Albacete, Spain (1992-94 a 2004-06)

Fundamento: Establecer estrategias de prevención de la enfermedad cardiovascular implica conocer su epidemiología y evolución en el tiempo. El objetivo del estudio es conocer las prevalencias de los factores de riesgo y del riesgo cardiovascular en dos momentos de seguimiento de una población general adulta. Métodos: Dentro de un estudio longitudinal y prospectivo con población general seleccionada al azar seguida durante 12 años (1992-94 a 2004-2006) se hacen dos análisis trasversales al inicio y en el último corte de seguimiento. La población objeto de estudio fueron personas mayores de 18 años censadas en la provincia de Albacete. Muestreo aleatorio, estratificado y bietápico. Tamaño muestral 2.121 y 1.577 sujetos en cada uno de los cortes. Se hizo anamnesis, exploración física, medida de presión arterial, electrocardiograma y extracción de sangre venosa. Las variables estudiadas fueron: edad, sexo, antecedentes personales y familiares, factores de riesgo y riesgo cardiovascular global. Resultados: En el primer examen acudieron a la cita 1.322 sujetos (edad media 48,2 años. 53,6% mujeres) y 997 en el segundo (edad media 52,8 años. 56,7% mujeres). Hubo un aumento en la prevalencia de hipertensión (32,7% a 41,2%) diabetes mellitus (9,8 a 11,4%), obesidad (27,8 a 34,3%) e hipercolesterolemia (47,5 a 53,5%), una disminución de fumadores (32,6 a 23,7%), de valores medios de presión arterial (132/81 a 129/73 mmHg), glucemia (100,8 a 92,8 mg/dl) y col-LDL (128,7 a 116,7 mg/dl) y un descenso del riesgo cardiovascular con Framingham (10,8% a 8,2%) y Score (2,3% a 1,6%). Conclusiones: En los últimos años se observa un aumento en la prevalencia de factores de riesgo (hipertensión, diabetes e hipercolestrerolemia), un mejor control de los mismos, una menor prevalencia de fumadores y menor riesgo cardiovascular en la población(AU)

Background: To establish strategies for prevention of cardiovascular disease implies to know its epidemiology and evolution in time. The objective of this study is to know the prevalence of risk factors and cardiovascular risk in two moments during the following of a grownup general population. Methods: Study of cohorts, followed at random selected general population during 12 years (1992-94 to 2204-06). Two transversal studies were made, one at the beginning and the other one at the end of this followup. The population in this study was 18 years and older registered in the province of Albacete. andom sampling, stratified and two-stage. The sample size for the first cut was 2121 subjects and for second one 1577. One specific anamnesis was made, physical examination, measurement of blood pressure, electrocardiogram and extraction of venous blood. The studied variables were: age, sex, personal and familiar antecedents, risk factors and global cardiovascular risk. Results: 1322 subjects went to the appointment for the first examination (mean age 48.2 years. 53.6% women) and 997 for the second (mean age 52.8 years. 56.7% women). Has Increased the prevalence of hypertension (32.7% to 41,2%), diabetes (9,8 to 11,4%), obesity (27,8 to 34,3%) and hypercolesterolemia (47,5 to 53,5%), whereas smokers have decreased (32,6 to 23,7%) and have handicapped the average values of arterial pressure (132/81 to 129/73 mmHg), glycaemia (100,8 to 92,8 mg/dl) and LDL-cholesterol (128,7 to 116,7 mg/dl) and also a lowering of cardiovascular risk with Framingham (10,8% to 8,2%) and Score (2,3% to 1,6%). Conclusions: In the last years an increasing prevalence of risk factors has been seen (hypertension, diabetes and hypercolesterolemia), a better control of them, and lower prevalence of smoking and cardiovascular risk in the population has also be seen(AU)

Rotura de tendón aquíleo asociada a levofloxacino / Levofloxacin-related Achilles tendon rupture

El uso de fluorquinolonas y el riesgo asociado de tendinitis aquílea está bien documentado, pero su prescripción en la práctica clínica es común1,2. Presentamos el caso de un paciente con tendinitis aquilea y posterior rotura a los pocos días de haber finalizado el tratamiento con levofloxacino por infección respiratoria. El diagnóstico temprano y la suspensión del tratamiento son fundamentales porque se podría prevenir el riesgo de rotura del tendón3,4 (AU)

The use of fluoroquinolones and the associated risk of Achilles tendinitis is well-documented however this drug is commonly prescribed in clinical practice1,2. We describe a case of Achilles tendinitis and subsequent tendon rupture a few days after taking levofloxacin for a respiratory infection. Early diagnosis and treatment cessation are essential for preventing the risk of tendon rupture3,4 (AU)

Crisis Hipertensivas / Hypertensive crises

Las crisis hipertensivas constituyen un motivo frecuente de consulta en los servicios de urgencias.Aproximadamente un 1-2% de los pacientes hipertensos desarrollarán una crisis hipertensiva en algúnmomento de su vida. El presente trabajo pretende revisar las guías clínicas de referencia más actualesen el manejo de esta patología, con el fi n de poder plantear unas recomendaciones clínicas. El temade estudio suele estar incluido en los documentos de consenso que sobre el manejo de la hipertensiónarterial se han publicado, los cuales son muy similares en cuanto a contenidos y recomendaciones.Las guías clínicas evaluadas son muy similares en cuanto a contenidos y recomendaciones, incluyendocasi todas un apartado de introducción, clasifi cación, defi niciones, y manejo general, diferenciandoentre urgencias y emergencias hipertensivas dependiendo de la ausencia o presencia de lesión aguda de órganos diana de la hipertensión arterial.Son escasos los ensayos clínicos aleatorizados publicados que han comparado diferentes fármacoso estrategias de manejo de las crisis hipertensivas.Se han encontrado guías sobre el manejo de la HTA que sustentan sus recomendaciones en niveles de evidencia, pero no se han encontrado guías similares para las crisis hipertensivas, con excepción del manejo de la pre-eclampsia/eclampsia

Hypertensive crises are a frequent motive for consultation in the emergency services. Approximately1-2% of hypertensive patients develop a hypertensive crisis at some time of their lives. The presentwork aims to review the most recent clinical manuals for management of this condition, in order topropose some clinical recommendations. The subject of this study is usually treated in the consensusdocuments published on the management of arterial hypertension.The clinical manuals evaluated have very similar contents and recommendations, almost all of themincluding an introduction section, classifi cation, defi nitions and general management. Differencesappear, however, in hypertensive urgencies and emergencies depending on the absence or presenceof acute lesion of target organs of the arterial hypertension.There are few published randomised clinical trials that have compared different drugs or managementstrategies for hypertensive crises.Manuals have been found on the management of AHT that base their recommendations on evidence,but similar manuals for hypertensive crises do not exist, except for the management of preeclampsia/eclampsia

Experiencia Educativa con un Paciente Experto / Educational experience with the expert patient

El perfil de la relación médico-paciente ha cambiado en los últimos años pasando de un modelo paternalistaa un modelo en el que la autonomía del paciente ha adquirido una importancia fundamental.El paciente se está convirtiendo en un personaje activo, con unos derechos claros, como los de ser debidamente informado sobre su enfermedad o participar en las decisiones que afectan a su patología, pero también con los deberes de ser responsable de su enfermedad y de su estado de salud (1). Presentamos una experiencia realizada en nuestra consulta acerca de un paciente que se había responsabilizado de su problema de obesidad desde que se le diagnosticó, identifi cando muy bien losmotivos que le encaminaron a seguir nuestros indicaciones terapéuticas, las difi cultades que se lefueron planteando durante el tratamiento y cómo fue resolviendo algunas difi cultades

The doctor-patient relationship has changed considerably in recent years, from a paternalistic modelto one in which the patient’s autonomy has acquired a signifi cant relevance. The patient has becomean active individual, with clear rights, such as that of being well informed about his/her illness andparticipation in decisions that can affect their condition, but also certain obligations such as beingresponsible for their illness and health. We present an experiment carried out in our clinic of a patient who had taken on responsibility for his obesity since he was diagnosed, who clearly identifi ed the reasons for following our therapeutic indications, the difficulties he came across during the treatment and how he resolved some of them

[Different uses of home blood pressure measurement in the diagnosis and monitoring of hypertension]. / Diferentes utilidades de la automedición de la presión arterial domiciliaria en el diagnóstico y seguimiento de la hipertensión arterial.

OBJECTIVE: To find differences between measurements of clinical blood pressure and self-monitored home blood pressure measurement (HBPM). DESIGN: Descriptive study developed in a general population census. SETTING: Primary care. SUBJECTS: A total of 1411 subjects > or =18 years old were selected by stratified randomized sampling. METHODS: A skilled nurse made 3 clinical blood pressure (CBP) measurements, and trained patients or their relatives in HBPM, doing 12 in one day. CBP and HBPM employed an electronic device (OMRON 705CP). RESULTS: A total of 12 HBPM from 1184 subjects (52% women) were completed, with a mean age of 47.6 (SD, 17.2); 195 subjects were known to have hypertension. White-coat effect was diagnosed in 14.9% of subjects with normal pressure, 22.3% of hypertense patients treated and 57.6% of subjects with suspicion of isolated clinical hypertension. Possible isolated clinical hypertension was diagnosed in 10% of subjects without hypertension. White Coat normal pressure was found in 2.3% of untreated subjects and 4.7% of subjects with treated hypertension. 20.7% of subjects with hypertension poorly controlled in the clinic were considered pseudo-refractory (11.4% at the end of dosage interval). 77% of subjects conducted HBPM on their own and 89% thought it easy to do so. CONCLUSION: Incorporation of HBPM into daily medical practice could avoid 20%-30% of possible mistakes in diagnosis and monitoring of hypertense patients.

Insulinoterapia en Diabetes Tipo 2. Revisión / The Insulin-therapy and type II diabetes. A revision

Los profesionales de Atención Primaria atendemos a la gran mayoría de los pacientes diabéticos tipo 2, por lo que debemos conocer bien todas las pautas de tratamiento con insulina y no retrasar el inicio de este tratamiento cuando esté realmente indicado. La insulina es una de las varias posibilidades terapéuticas de las que disponemos para el tratamiento de la diabetestipo 2, imprescindible cuando el deterioro de la célula beta provoca estados de insulinopenia, que ha demostrado su efi cacia en el control metabólico de esta enfermedad y consecuentemente en la reducción de las complicaciones micro y macrovasculares. La introducción en el mercado de los análogos de insulina (insulinas modifi cadas por bioingeniería genética en las que se ha procedido a sustituir, cambiar de posición o añadir uno o más aminoácidos de su molécula, con el fi n de modifi car su confi guración espacial y así modifi car su perfi l farmacodinámico), coincidiendo con la retirada de otros tipos, así como las modifi caciones en los diferentes sistemas de administración, algunos de los cuales también retirados y sustituidos por otros sistemas, están creando alguna confusión en los profesionales, confusión que puede contribuir también al retraso en el inicio de los tratamientos con insulina.El objetivo de esta revisión es aclarar los tipos de insulina comercializados en la actualidad,las diferencias entre ellos en cuanto a su perfi l de acción, sus indicaciones particulares y laspautas más comunes de insulinización

Professionals at primary care level has the responsibility of attend most of type II diabeticpatients, then they have to know different patterns of insulin-therapy in order to avoid delay inbeginning treatment when it is required. Insulin is one of the different therapeutic possibilitiesfor type II diabetic patient management, involved when beta cell failure carry an state of insulindefi cit, what has demonstrated to be effectiveness in metabolic control of the pathology, reducingmacro and micro-vascular complications. The introduction in the market of insulin analogous (insulin modifi ed by genetic engineering with changes in position, removing or addition of amino-acids in the molecule in order to change spatial design and linked or pharmacodynamicprofi le), removing another and changes in the delivering systems, are involved in a confusionphenomena in professionals that contributes to delay the insulin treatment implementation.Objective of this work is to revise different types of insulin at the market today, the differencesin the profi le between them, the particular indications and the more commons patterns oftreatment (AU)