[Cardiovascular preventive recommendations. PAPPS 2020 update]. / Recomendaciones preventivas cardiovasculares. Actualización PAPPS 2020.

The recommendations of the semFYC's Program for Preventive Activities and Health Promotion (PAPPS) for the prevention of cardiovascular diseases (CVD) are presented. The following sections are included: Epidemiological review, where the current morbidity and mortality of CVD in Spain and its evolution as well as the main risk factors are described; Cardiovascular (CV) risk tables and recommendations for the calculation of CV risk; Main risk factors such as arterial hypertension, dyslipidemia and diabetes mellitus, describing the method for their diagnosis, therapeutic objectives and recommendations for lifestyle measures and pharmacological treatment; Indications for antiplatelet therapy, and recommendations for screening of atrial fibrillation. The quality of testing and the strength of the recommendation are included in the main recommendations.

Austerity Policies and Mortality in Spain After the Financial Crisis of 2008.

OBJECTIVES: To analyze mortality in Spain and the United States before and after these countries implemented divergent policies in response to the financial crisis of 2008. METHODS: We examined mortality statistics in both countries in the years 2000 to 2015. Spain started austerity policies in 2010. We compared differences in mortality ratios, on the basis of trends and effect size analysis. RESULTS: During 2000 to 2010, overall mortality rates (r = 0.98; P < .001; Cohen's d = -0.228) decreased in both countries. In 2011, this trend changed abruptly in Spain, where observed mortality surpassed expected mortality by 29% in 2011 and by 41% in 2015. By contrast, observed mortality surpassed expected mortality in the United States by only 8% in 2015. As the mortality statistics diverged, the effect size greatly increased (d = 7.531). During this 5-year period, there were 505 559 more deaths in Spain than the expected number, while in the United States the difference was 431 501 more deaths despite the 7-fold larger population in the United States compared with Spain. CONCLUSIONS: The marked excess mortality in 2011 to 2015 in Spain is attributable to austerity policies.

Recomendaciones preventivas cardiovasculares. Actualización PAPPS 2018 / No disponible

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Inverse association of resistin with physical activity in the general population.

AIM: Resistin is a cytokine related with inflammation and ischemic heart disease. Physical activity (PA) prevents chronic inflammation and ischemic heart disease. We studied the relationship of serum concentration of resistin with HDL cholesterol, a known biomarker of PA, and with different measures of PA, in a large sample of the general adult population in the Canary Islands. METHODS: Cross-sectional study of 6636 adults recruited randomly. We analyzed the correlation of resistin and HDL cholesterol with PA (as metabolic equivalent level [MET]), and fitted the results with linear and logistic regression models using adjustment for age, alcohol consumption and smoking. RESULTS: Mean resistin level was higher in women (p<0.001), correlated inversely with age, HDL cholesterol (p<0.001) and alcohol consumption (p<0.001 in men), and correlated directly with smoking (p<0.001). Resistin correlated inversely with the duration of leisure time PA (p<0.001), leisure time MET (p<0.001) and moderate leisure time PA (p<0.001), with some differences between sexes. Men (OR = 0.78 [0.61-0.99; p<0.05]) and women (OR = 0.75 [0.61-0.92; p<0.01]) in the upper quintile of leisure time PA had a lower risk of elevated resistin. In contrast, a high degree of sedentarism was associated with an increased risk elevated resistin in women (OR = 1.24 [1.04-1.47; p<0.05] and in men (OR = 1.40 [1.01-1.82; p<0.05]). CONCLUSIONS: In our sample of the general population, resistin was inversely associated with measures and levels of PA and HDL cholesterol. The association of resistin with PA was stronger than the association of HDL cholesterol with PA, making resistin a potentially useful biomarker of PA.

Incidence, Mortality and Positive Predictive Value of Type 1 Cardiorenal Syndrome in Acute Coronary Syndrome.

OBJECTIVES: To determine whether the risk of cardiovascular mortality associated with cardiorenal syndrome subtype 1 (CRS1) in patients who were hospitalized for acute coronary syndrome (ACS) was greater than the expected risk based on the sum of its components, to estimate the predictive value of CRS1, and to determine whether the severity of CRS1 worsens the prognosis. METHODS: Follow-up study of 1912 incident cases of ACS for 1 year after discharge. Cox regression models were estimated with time to event (in-hospital death, and readmission or death during the first year after discharge) as the dependent variable. RESULTS: The incidence of CRS1 was 9.2/1000 person-days of hospitalization (95% CI = 8.1-10.5), but these patients accounted for 56.6% (95% CI = 47.4-65.) of all mortality. The positive predictive value of CRS1 was 29.6% (95% CI = 23.9-36.0) for in-hospital death, and 51.4% (95% CI = 44.8-58.0) for readmission or death after discharge. The risk of in-hospital death from CRS1 (RR = 18.3; 95% CI = 6.3-53.2) was greater than the sum of risks associated with either acute heart failure (RR = 7.6; 95% CI = 1.8-31.8) or acute kidney injury (RR = 2.8; 95% CI = 0.9-8.8). The risk of events associated with CRS1 also increased with syndrome severity, reaching a RR of 10.6 (95% CI = 6.2-18.1) for in-hospital death at the highest severity level. CONCLUSIONS: The effect of CRS1 on in-hospital mortality is greater than the sum of the effects associated with each of its components, and it increases with the severity of the syndrome. CRS1 accounted for more than half of all mortality, and its positive predictive value approached 30% in-hospital and 50% after discharge.

Lipid and inflammatory biomarker profiles in early insulin resistance.

AIMS: To analyze the serum lipid and inflammatory biomarker profile in the early insulin resistance (e-IR). METHODS: Cross-sectional study of 5943 adults without diabetes, stratified into no IR group (C-peptide

Recomendaciones preventivas cardiovasculares. PAPPS 2016 / No disponible

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C-peptide as a risk factor of coronary artery disease in the general population.

OBJECTIVE: To analyse the association between serum C-peptide and coronary artery disease in the general population. METHODS: Follow-up study of 6630 adults from the general population. They were stratified into group 1 (no insulin resistance: C-peptide < third tercile and glycaemia < 100 mg/dL), group 2 (initial insulin resistance: C-peptide ⩾ third tercile and glycaemia < 100 mg/dL) and group 3 (advanced insulin resistance: glycaemia ⩾ 100 mg/dL). RESULTS: After 3.5 years of follow-up, group 2 had a higher incidence of myocardial infarction (relative risk (RR) = 4.2, 95% confidence interval (CI) = 1.7-10.6) and coronary artery disease (RR = 3.5, 95% CI = 1.9-6.6) than group 1. Group 3 also had increased incidences of both diseases. In multivariable analysis of the entire population, groups 2 and 3 showed significant risks of myocardial infarction and coronary artery disease (RR > 3 and RR > 2, respectively). However, when people with diabetes were excluded, the increased risks were corroborated only in group 2 for myocardial infarction (RR = 2.8, 95% CI = 1.1-6.9; p = 0.025) and coronary artery disease (RR = 2.4, 95% CI = 1.3-4.6; p = 0.007). CONCLUSION: Elevated C-peptide is associated with the incidence of myocardial infarction and coronary artery disease in the general population. It can be an earlier predictor of coronary events than impaired fasting glucose.

Tratamiento de los factores de riesgo vascular en el paciente mayor de 80 años / Management of vascular risk factors in patients older than 80

Los sujetos muy ancianos, de 80 o más años de edad, constituyen el grupo etario de más rápido crecimiento demográfico en los países desarrollados. Las enfermedades cardiovasculares son la principal causa de muerte, representan una importante causa de discapacidad y generan una enorme carga económica en este grupo de edad. Sin embargo, son muy escasas las evidencias científicas disponibles que respaldan la toma de decisiones sobre prevención cardiovascular en dichos sujetos. Las escalas de riesgo actualmente disponibles no son aplicables en los ancianos, y, además, están centradas en el riesgo de muerte cardiovascular y no aportan información sobre factores que han mostrado ser de capacidad pronóstica relevante en esta población (incapacidad funcional, demencia). Los ancianos forman un grupo muy heterogéneo de pacientes, con diferentes grados de comorbilidad y de capacidad funcional y cognitiva. Además, los cambios fisiológicos propios del envejecimiento y la frecuente presencia de polimedicación incrementan el riesgo de efectos adversos medicamentosos en los ancianos, por lo que la indicación de fármacos en esta población debe considerar siempre la relación riesgo/beneficio. Por tanto, la toma de decisiones terapéuticas en pacientes muy ancianos debe ser un proceso individualizado basado en un adecuado juicio clínico y en una valoración geriátrica integral. El presente documento de consenso tiene como objetivo proponer unas pautas de actuación prácticas de prevención cardiovascular primaria y secundaria en la población de 80 y más años de edad, realizando una serie de recomendaciones sobre la modificación del estilo de vida y el tratamiento farmacológico de los principales factores de riesgo cardiovascular (AU)

The number of patients older than 80 years is steadily increasing and it represents the main basis for increasing population figures in developed countries. Cardiovascular diseases are the leading causes of mortality and disability causes result in a huge burden of disease in elderly people. However, available scientific evidence to support decision-making on cardiovascular prevention in elderly patients is scarce. Currently available risk assessment scales cannot be applied to elderly people. They are focused on cardiovascular mortality risk and do not provide information on factors with a proven prognostic value in the very old (functioning disability, dementia). Elderly people are a highly heterogeneous population, with a variety of co-morbidities, as well as several functional and cognitive impairment degrees. Furthermore, aging-associated physiological changes and common use of multiple drugs result in an increased risk of adverse drug reactions. Thus, drug use should always be based on a risk/benefitassessment in the elderly. Therefore, therapeutic decision-making in the very old must be an individually tailored and based on an appropriate clinical judgement and a comprehensive geriatric assessment. The current consensus report aims to present a proposal for clinical practices in the primary and secondary cardiovascular prevention in the very old and to provide a number of recommendations on lifestyle changes and drug therapy for the management of major cardiovascular risk factors (AU)

Frecuencia cardiaca en reposo y enfermedad cardiovascular / Resting heart rate and cardiovascular disease

La frecuencia cardiaca refleja la actividad del sistema nervioso autónomo. Numerosos estudios han demostrado que la frecuencia cardiaca elevada en reposo se asocia con la morbimortalidad cardiovascular como factor de riesgo independiente. Se ha evidenciado una relación entre balance autonómico cardiaco e inflamación, de tal forma que la frecuencia cardiaca elevada produce una respuesta microinflamatoria e interviene en la patogénesis de la disfunción endotelial. A su vez, la disminución de la frecuencia se asocia a beneficios en insuficiencia cardiaca congestiva, infarto de miocardio, fibrilación auricular, obesidad, hiperinsulinemia, resistencia a la insulina y aterosclerosis. La alteración de otros parámetros relacionados con la frecuencia cardiaca, tales como su variabilidad y su recuperación tras realizar ejercicio, se asocia con riesgo de episodios cardiovasculares. Los fármacos que reducen la frecuencia (betabloqueantes, antagonistas del calcio e inhibidores de canales If) tienen el potencial de reducir sucesos cardiovasculares. Aunque en sujetos sanos no se recomienden intervenciones para la reducción de la frecuencia cardiaca, en determinadas enfermedades constituye un objetivo terapéutico razonable (AU)

Heart rate reflects autonomic nervous system activity. Numerous studies have demonstrated that an increased heart rate at rest is associated with cardiovascular morbidity and mortality as an independent risk factor. It has been shown a link between cardiac autonomic balance and inflammation. Thus, an elevated heart rate produces a micro-inflammatory response and is involved in the pathogenesis of endothelial dysfunction. In turn, decrease in heart rate produces benefits in congestive heart failure, myocardial infarction, atrial fibrillation, obesity, hyperinsulinemia, insulin resistance, and atherosclerosis. Alteration of other heart rate-related parameters, such as their variability and recovery after exercise, is associated with risk of cardiovascular events. Drugs reducing the heart rate (beta-blockers, calcium antagonists and inhibitors of If channels) have the potential to reduce cardiovascular events. Although not recommended in healthy subjects, interventions for reducing heart rate constitute a reasonable therapeutic goal in certain pathologies (AU)

[Management of vascular risk factors in patients older than 80]. / Tratamiento de los factores de riesgo vascular en el paciente mayor de 80 años.

The number of patients older than 80 years is steadily increasing and it represents the main basis for increasing population figures in developed countries. Cardiovascular diseases are the leading causes of mortality and disability causes result in a huge burden of disease in elderly people. However, available scientific evidence to support decision-making on cardiovascular prevention in elderly patients is scarce. Currently available risk assessment scales cannot be applied to elderly people. They are focused on cardiovascular mortality risk and do not provide information on factors with a proven prognostic value in the very old (functioning disability, dementia). Elderly people are a highly heterogeneous population, with a variety of co-morbidities, as well as several functional and cognitive impairment degrees. Furthermore, aging-associated physiological changes and common use of multiple drugs result in an increased risk of adverse drug reactions. Thus, drug use should always be based on a risk/benefit assessment in the elderly. Therefore, therapeutic decision-making in the very old must be an individually tailored and based on an appropriate clinical judgement and a comprehensive geriatric assessment. The current consensus report aims to present a proposal for clinical practices in the primary and secondary cardiovascular prevention in the very old and to provide a number of recommendations on lifestyle changes and drug therapy for the management of major cardiovascular risk factors.

Recomendaciones preventivas cardiovasculares / Recommendations on prevention of cardiovascular disease

No disponible

[Resting heart rate and cardiovascular disease]. / Frecuencia cardiaca en reposo y enfermedad cardiovascular.

Heart rate reflects autonomic nervous system activity. Numerous studies have demonstrated that an increased heart rate at rest is associated with cardiovascular morbidity and mortality as an independent risk factor. It has been shown a link between cardiac autonomic balance and inflammation. Thus, an elevated heart rate produces a micro-inflammatory response and is involved in the pathogenesis of endothelial dysfunction. In turn, decrease in heart rate produces benefits in congestive heart failure, myocardial infarction, atrial fibrillation, obesity, hyperinsulinemia, insulin resistance, and atherosclerosis. Alteration of other heart rate-related parameters, such as their variability and recovery after exercise, is associated with risk of cardiovascular events. Drugs reducing the heart rate (beta-blockers, calcium antagonists and inhibitors of If channels) have the potential to reduce cardiovascular events. Although not recommended in healthy subjects, interventions for reducing heart rate constitute a reasonable therapeutic goal in certain pathologies.

El cociente perímetro abdominal/estatura como índice antropométrico de riesgo cardiovascular y de diabetes / The waist to height ratio as an index of cardiovascular risk and diabetes

Fundamento y objetivos: Identificar el índice antropométrico que mejor detecta riesgo cardiovascular (RCV) y diabetes mellitus de tipo 2 (DM2) en población adulta española y cuál es su punto de corte ideal. Sujetos y métodos: Estudio transversal en población general (n=6.729). Se estimó sensibilidad y especificidad de varios índices antropométricos: cintura abdominal, índice de masa corporal, ratio abdomen/pelvis y ratio abdomen/estatura (RA/E). Se obtuvieron sus áreas bajo la curva operador-receptor con respecto a los siguientes factores de RCV: riesgo coronario alto estimado según la ecuación de Framingham, hipertensión arterial, hiperlipidemia, DM2, síndrome metabólico (SM) y glucemia en ayunas alterada (GAA). Para estimar los riesgos relativos, calculamos la razón de ventajas con intervalo de confianza (IC) del 95%. Resultados: La RA/E produjo la mayor área de los 4 índices en DM2 y demás factores de RCV, que osciló entre 0,65 para GAA en varones (IC del 95%: 0,63–0,68) y 0,87 para SM en mujeres (IC del 95%: 0,86–0,89). La RA/E alcanzó la máxima sensibilidad (0,91) y especificidad (0,70) en el SM, y su punto de corte óptimo fue 0,55; con él, los riesgos estimados por la RA/E fueron también mayores que con los demás índices, y variaron desde 2,30 para GAA (IC del 95%: 1,96–2,70) hasta 16,20 para SM (IC del 95%: 13,68–19,20).Conclusiones: La RA/E es el índice con mejor capacidad de detección de DM2 y demás factores de RCV en esta población, y es el que mayor fuerza alcanza en su asociación con ellos. De su punto de corte (0,55) se deduce que conviene evitar que la cintura abdominal supere la mitad de la estatura (AU)

Background and objectives: To identify the anthropometric index that best detects cardiovascular risk (CVR) and type 2 diabetes (DM2) in the adult Spanish population and to determine its cut-off point. Subjects and methods: cross-sectional study in the general population (n=6279). Sensitivity and specificity were estimated for the anthropometric indexes: abdominal waist, body mass index, waist to hip ratio and waist to height ratio (WtHR). The areas of these indexes under ROC curve (AUC) were obtained for the following CVR factors: high coronary risk computed with Framingham model, Hypertension, Hyperlipemia, DM2, Metabolic Syndrome (MS) and Impaired Fasting Glucose (IFG). The odds ratio, with 95% confidence interval (CI95%), was calculated. Results: WtHR was the index showing the highest AUC for DM2 and the remaining CVR factors, varying between 0.65 (CI95%=0.63–0.68) for IFG in men and 0.87 (CI95%=0.86–0.89) for MS in women. RA/E reached the maximum sensitivity (0.91) and specificity (0.70) in SM and its optimal cut-off point was 0.55, which displayed the highest risks amongst indexes, varying from 2.30 (1.96–2.70) in IFG to 16’20 (13.68–19.20) in MS. Conclusions: RA/E is the index presenting the best ability to detect DM2 and CVR in this population, and it shows the stronger association with them. Its cut-off point, 0.55, confirms the convenience of keeping the abdominal waist to less than half the height (AU)

[The waist to height ratio as an index of cardiovascular risk and diabetes]. / El cociente perímetro abdominal/estatura como índice antropométrico de riesgo cardiovascular y de diabetes.

BACKGROUND AND OBJECTIVES: To identify the anthropometric index that best detects cardiovascular risk (CVR) and type 2 diabetes (DM2) in the adult Spanish population and to determine its cut-off point. SUBJECTS AND METHODS: Cross-sectional study in the general population (n=6279). Sensitivity and specificity were estimated for the anthropometric indexes: abdominal waist, body mass index, waist to hip ratio and waist to height ratio (WtHR). The areas of these indexes under ROC curve (AUC) were obtained for the following CVR factors: high coronary risk computed with Framingham model, Hypertension, Hyperlipemia, DM2, Metabolic Syndrome (MS) and Impaired Fasting Glucose (IFG). The odds ratio, with 95% confidence interval (CI(95%)), was calculated. RESULTS: WtHR was the index showing the highest AUC for DM2 and the remaining CVR factors, varying between 0.65 (CI(95%)=0.63-0.68) for IFG in men and 0.87 (CI(95%)=0.86-0.89) for MS in women. RA/E reached the maximum sensitivity (0.91) and specificity (0.70) in SM and its optimal cut-off point was 0.55, which displayed the highest risks amongst indexes, varying from 2.30 (1.96-2.70) in IFG to 16'20 (13.68-19.20) in MS. CONCLUSIONS: RA/E is the index presenting the best ability to detect DM2 and CVR in this population, and it shows the stronger association with them. Its cut-off point, 0.55, confirms the convenience of keeping the abdominal waist to less than half the height.

Estilo de vida y adherencia al tratamiento de la población canaria con diabetes mellitus tipo 2 / Lifestyle and treatment adherence of type 2 diabetes mellitus people in the Canary Islands

Fundamento: la población canaria sufre la mayor mortalidadpor diabetes tipo 2 (DM2) en España. El objetivo de esteestudio es conocer el estilo de vida de las personas diabéticasdel archipiélago y su adherencia al tratamiento, así como laDM2 desconocida.Métodos: estudio transversal de 6.729 personas de la poblacióngeneral participantes en la cohorte “CDC de Canarias”(edad 18-75 años). Se obtuvieron sus antecedentes médicos,dieta, actividad física, medicamentos consumidos, tabaco, etc.Resultados: la prevalencia de DM2 fue 12% en varones y10% en mujeres (p=0,005). El 22% de varones y 9% de mujeresdesconocían su enfermedad (p<0,001). Sumando DM2desconocida, DM2 no tratada e incumplimiento terapéutico, el48% de los hombres y 28% en mujeres no seguían tratamientocorrecto. Los varones diabéticos eran más obesos que los nodiabéticos (45 versus 25%; p<0,001) pero no presentaban diferenciasen tabaquismo (28%; IC95%=23-33) o sedentarismo(62%; IC95%=56-68). Las mujeres diabéticas también eran másobesas (54 versus 27%; p<0,001) y, aunque fumaban menos(11 versus 22%; p<0,001), eran igual de sedentarias (75%;IC95%=70-79). La ingesta calórica era menor en quienes sufríanDM2 (p<0,001), pero el 93% (IC95%=91-95) superaba elconsumo recomendado de grasas saturadas y el 69%(IC95%=65-72) padecía síndrome metabólico.Conclusiones: la población diabética en Canarias essedentaria y obesa, muestra un consumo alto de grasas saturadasy gran prevalencia de síndrome metabólico. El porcentajeque sigue tratamiento regular es muy bajo, sobretodo en varones,que además mantienen el tabaquismo(AU)

Background: The Canary Islands population experiencesthe highest type 2 diabetes (DM2) mortality in Spain. We studiedlifestyle, unknown DM2 and treatment adherence in diabeticsof these islands.Methods: cross-sectional study of 6729 subjects from thegeneral population (age 18-75) that participate in the cohortstudy “CDC of the Canary Islands”. We found out their medicalproblems, diet, physical activity, medications, smoking, etc.Results: Prevalence of DM2 was 12% in men and 10% inwomen (p=0.005). The disease was unknown in 22% of menand 9% of women (p<0.001). Considering unknown DM2, lackof treatment and lack of adherence, 48% of men and 28% ofwomen did not follow a regular treatment. Diabetics’ men prevalencesof smoking (28%; CI95%=23-33) and sedentariness(62%; CI95%=56-68) were similar to non diabetic men, but obesitywas more frequent in diabetics (45 versus 25%; p<0.001).Diabetics women showed a higher obesity (54 versus 27%;p<0.001) and a lower smoking prevalence (11 versus 22%;p<0,001) than non diabetics, but they presented a similar sedentariness(75%; CI95%=70-79). In both sexes, energy intake waslower in diabetics (p<0.001), but 93% of them (CI95%=91-95)showed a high consumption of calories from saturated fat and69% (CI95%=65-72) presented metabolic syndrome.Conclusions: The Canarian diabetics are a sedentary andobese population that show a high consumption of saturatedfats and high prevalence of metabolic syndrome. The proportionof them following regular treatment is low, specially indiabetic men that, in addition, still smoke(AU)