Manejo de las rinosinusitis en Atención Primaria / Management of Rhinosinusitis in Primary Care

La rinosinusitis aguda representa un importante problema de salud, y, aunque su frecuencia no está bien establecida en nuestro país, es motivo de una no desdeñable carga económica, alterando notablemente la calidad de vida de los pacientes que la padecen. Su diagnóstico es eminentemente clínico, debiendo reservar las exploraciones complementarias para el diagnóstico diferencial de las complicaciones y de procesos tumorales. Las causas más frecuentes son las infecciones, siendo los virus los agentes más comunmnte implicados. De entre las bacterias Streptococcus pneumoniae y Haemophilus influenzae son las más habitualmenta aisladas. Hoy las complicaciones no son frecuentes, pero sí pueden llegar a ser graves, de las cuales las más comunes son las orbitarias, seguidas de las endocráneales y las óseas. El tratamiento se basa en médidas sintomáticas, como los lavados con soluciones salinas y antibióticos para los casos de etiología bacteriana. Management of Rhinosinusitis in Primary Care

Acute rhinosinusitis is an important health problem. Even though its frequency is not well documented in our country?, the economic burden it bears is not insignificant as it notably alters the quality of life of affected patients. Its diagnosis is generally clinical in nature, with further studies reserved only for the differential diagnoses of complications or tumour-like processes. The most frequent causes are viral infections, although Streptococcus pneumoniae and Haemophilus influenzae are the most commonly isolated bacterial agents. Although complications are uncommon nowadays, they can be serious when they occur, and commonly include orbital infections, closely followed in frequency by intracranial and bone infections. Treatment should consist of symptomatic measures, like saline rinses and antibiotics in cases of bacterial origin

Riesgo de eventos fatales/no fatales en pacientes con enfermedad coronaria/infarto agudo de miocardio previo y tratamiento con antiinflamatorios no esteroideos / Risk of fatal/non-fatal events in patients with previous coronary heart disease/acute myocardial infarction and treatment with non-steroidal anti-inflammatory drugs

Antecedentes: La Atención Primaria es el eje fundamental de nuestro sistema sanitario y nos obliga a ser consecuentes con nuestras prescripciones. Los antiinflamatorios no esteroideos (AINE) se han asociado con un incremento en el riesgo cardiovascular y de muerte por todas las causas y por infarto agudo de miocardio (IAM) en pacientes con infarto de miocardio previo. El manejo del dolor y de los pacientes cardiópatas son 2 pilares básicos en nuestra actividad diaria, y debemos conocer las limitaciones de los AINE en pacientes con riesgo cardiovascular establecido. Objetivos: Presentamos una revisión de la literatura científica con especial interés en la relación entre los AINE y el riesgo cardiovascular. El objetivo es analizar la relación entre el consumo de diferentes AINE y los eventos fatales y no fatales en pacientes con enfermedad coronaria conocida. Método: Revisión de la literatura científica con un interés inicial en el papel de los AINE y el riesgo cardiovascular. La revisión de la literatura se realizó en los motores de búsqueda PubMed y Tripdatabase, con determinadas palabras clave. Contamos con 15 documentos originales, de los cuales 9 no correspondían completamente al enfoque central, por lo que el desarrollo se decidió a partir de 6 artículos originales de los últimos 5 años que sí abordan, como enfoque principal, el aumento del riesgo cardiovascular encontrado (eventos fatales y no fatales) en pacientes con enfermedad cardiovascular o IAM previo a los que se les prescribió algún AINE por cualquier razón. El riesgo de eventos fatales/no fatales en cada uno de los estudios se expresa por la odds ratio (OR)/hazard ratio (HR), definido como la probabilidad de que ocurra un evento. Resultados: Se observó un riesgo moderado para el ibuprofeno. Aumenta el riesgo de síndrome coronario agudo tras 5 años del evento cardiovascular, sobre todo en el segundo año (OR 1,63; IC 95% 1,42-1,87), y eleva el riesgo de ACVA (HR 1,23; IC 95% 1,10-1,38). Los inhibidores de la ciclooxigenasa-2 fueron el tercer grupo de riesgo, por detrás de nabumetona y diclofenaco: celecoxib aumenta el riesgo a partir del día 14 de tratamiento (HR 2,3; IC 95% 1,79-3,02), presentando una OR de 1,47 (IC 95% 1,05-2,07) para un nuevo IAM; rofecoxib presenta riesgo de eventos fatales cardiovasculares incluso a dosis bajas y tras 7 días de tratamiento (HR 2,5; IC 95% 1,91-3,46), con una OR de 2,30 (IC 95% 1,76-2,99) para un nuevo IAM; naproxeno presentó un menor riesgo de muerte cardiovascular y de nuevos eventos cardiovasculares, pero sin resultados significativos excepto para el tratamiento durante más de 90 días (HR 1,55; IC 95% 1,10-2,17). Aumento del sangrado gastrointestinal y comorbilidad asociada durante el primer año de tratamiento (HR 1,44; IC 95% 1,07-1,94). Se observa que el ketorolaco es el fármaco de mayor riesgo de nuevo IAM: vía oral OR 3,91 (IC 95% 2,02-7,58). Destaca, como dato de interés, el factor cardioprotector que ejercen ciertos fármacos, tales como los antiagregantes plaquetarios y las estatinas, en pacientes con consumo de AINE. Por ejemplo, en pacientes con mayor comorbilidad se observaron diferencias en la OR. La toma de antiagregantes ofreció una OR de 1,37 (IC 95% 0,68-2,74) en comparación a la no toma de estos, OR 1,79 (IC 95% 1,16-2,78). Conclusiones: Se estratificó por años el consumo de varios AINE y su relación con un mayor riesgo de síndrome coronario agudo fatal y no fatal. Aumenta el riesgo independientemente del tiempo transcurrido en relación con los que no lo toman, manteniéndose prácticamente estables durante 5 años. Se observó que el diclofenaco y los inhibidores de la ciclooxigenasa-2 (especialmente rofecoxib) mostraron un mayor riesgo, a diferencia del naproxeno, que presenta un menor aumento del riesgo. Sin embargo, el naproxeno, debido a su mayor capacidad para generar sangrado gastrointestinal, aumentó por esta razón los eventos fatales y la comorbilidad en estos pacientes. A pesar de esto, sigue siendo el que presenta mejor perfil de seguridad cardiovascular

Background: Primary Care is the fundamental axis of our health system and obliges us to be consistent with our prescriptions. The non-steroidal anti-inflammatory drugs (NSAIDs) have been associated with increased cardiovascular risk and increased risk of all causes of death, as well as acute myocardial infarction (AMI) in patients with a previous myocardial infarction. Pain and cardiac patient management are 2 basic pillars in our daily activity, and we must know the limitations of NSAIDs in patients with established cardiovascular risk. Objectives: We present a review of the scientific literature with primary interest in the role of NSAIDs and cardiovascular risk. The objective is to determine the relationship between the consumption of different NSAIDs and the fatal and non-fatal events among patients with known coronary disease. Method: This is a review of the scientific literature with primary interest in the role of NSAIDs and cardiovascular risk. The literature review was conducted in PubMed search engines like Tripdatabase and with certain keywords. Of the 15 original papers found, 9 did not correspond completely to the central focus, so the approach was decided from 6 original articles from the past 5 years, which address the central focus of increased cardiovascular risk found (fatal and non-fatal events) in patients with prior cardiovascular disease or AMI being prescribed NSAIDs for any reason. The risk of fatal/non-fatal events in each of the studies is expressed by the odds ratio (OR)/hazard ratio (HR), defined as the probability of an event occurring. Results: A moderate risk was observed for ibuprofen. It increases the risk of acute coronary syndrome after 5 years of cardiovascular event, especially in the 2nd year (OR 1.63; 95% CI 1.42-1.87). It also increases the risk of stroke (HR 1.23; 95% IC 1.10-1.38). Cyclo-oxygenase-2 inhibitors were the third risk group, after nabumetone and diclofenac. Celecoxib increases risk from the 14th day of treatment (HR 2.3; 95% CI 1.79-3.02), having an OR of 1.47 (95% CI 1.05-2.07) for new AMI. Rofecoxib shows a risk of fatal cardiovascular events, even at low doses, and after 7 days of treatment (HR 2.5; 95% CI 1.91-3.46), with an OR of 2.30 (95% CI 1.76-2.99) for new AMI. Naproxen had a lower risk of cardiovascular death and new cardiovascular events, but no significant results except for treatment longer than 90 days (HR 1.55; 95% CI 1.10-2.17), with increased gastrointestinal bleeding and associated comorbidity during the first year of treatment (HR 1.44; 95% CI 1.07-1.94). Ketorolac is seen as the drug of greatest risk for new AMI: Oral treatment (OR 3.91; 95% CI 2.02-7.58). The review highlights the cardio-protective factor of certain drugs, such as antiplatelet agents and statins in patients, with NSAIDs use. For example, in patients with greater comorbidity, differences were observed in the OR, with antiplatelet agents consumption giving an OR of 1.37 (95% CI 0.68-2.74), compared to the non-consumption, OR 1.79 (95% CI 1.16-2.78). Conclusions: The consumption of various NSAIDs and their relationship to increased risk of fatal and non-fatal acute coronary syndrome is classified by years. Consumption increases the risk regardless of the time elapsed in relation to those that did not take them, with the figures remaining virtually stable for five years. Diclofenac and cyclooxygenase-2 inhibitors (especially Rofecoxib) showed an increased risk, unlike naproxen, which had a lower risk. However, naproxen, and because of its greater capacity to generate gastrointestinal bleeding, increased for this reason, fatal events and comorbidity in these patients. Despite this, it still has the best cardiovascular safety profile

[Risk of fatal/non-fatal events in patients with previous coronary heart disease/acute myocardial infarction and treatment with non-steroidal anti-inflammatory drugs]. / Riesgo de eventos fatales/no fatales en pacientes con enfermedad coronaria/infarto agudo de miocardio previo y tratamiento con antiinflamatorios no esteroideos.

BACKGROUND: Primary Care is the fundamental axis of our health system and obliges us to be consistent with our prescriptions. The non-steroidal anti-inflammatory drugs (NSAIDs) have been associated with increased cardiovascular risk and increased risk of all causes of death, as well as acute myocardial infarction (AMI) in patients with a previous myocardial infarction. Pain and cardiac patient management are 2 basic pillars in our daily activity, and we must know the limitations of NSAIDs in patients with established cardiovascular risk. OBJECTIVES: We present a review of the scientific literature with primary interest in the role of NSAIDs and cardiovascular risk. The objective is to determine the relationship between the consumption of different NSAIDs and the fatal and non-fatal events among patients with known coronary disease. METHOD: This is a review of the scientific literature with primary interest in the role of NSAIDs and cardiovascular risk. The literature review was conducted in PubMed search engines like Tripdatabase and with certain keywords. Of the 15 original papers found, 9 did not correspond completely to the central focus, so the approach was decided from 6 original articles from the past 5 years, which address the central focus of increased cardiovascular risk found (fatal and non-fatal events) in patients with prior cardiovascular disease or AMI being prescribed NSAIDs for any reason. The risk of fatal/non-fatal events in each of the studies is expressed by the odds ratio (OR)/hazard ratio (HR), defined as the probability of an event occurring. RESULTS: A moderate risk was observed for ibuprofen. It increases the risk of acute coronary syndrome after 5 years of cardiovascular event, especially in the 2nd year (OR 1.63; 95% CI 1.42-1.87). It also increases the risk of stroke (HR 1.23; 95% IC 1.10-1.38). Cyclo-oxygenase-2 inhibitors were the third risk group, after nabumetone and diclofenac. Celecoxib increases risk from the 14th day of treatment (HR 2.3; 95% CI 1.79-3.02), having an OR of 1.47 (95% CI 1.05-2.07) for new AMI. Rofecoxib shows a risk of fatal cardiovascular events, even at low doses, and after 7 days of treatment (HR 2.5; 95% CI 1.91-3.46), with an OR of 2.30 (95% CI 1.76-2.99) for new AMI. Naproxen had a lower risk of cardiovascular death and new cardiovascular events, but no significant results except for treatment longer than 90 days (HR 1.55; 95% CI 1.10-2.17), with increased gastrointestinal bleeding and associated comorbidity during the first year of treatment (HR 1.44; 95% CI 1.07-1.94). Ketorolac is seen as the drug of greatest risk for new AMI: Oral treatment (OR 3.91; 95% CI 2.02-7.58). The review highlights the cardio-protective factor of certain drugs, such as antiplatelet agents and statins in patients, with NSAIDs use. For example, in patients with greater comorbidity, differences were observed in the OR, with antiplatelet agents consumption giving an OR of 1.37 (95% CI 0.68-2.74), compared to the non-consumption, OR 1.79 (95% CI 1.16-2.78). CONCLUSIONS: The consumption of various NSAIDs and their relationship to increased risk of fatal and non-fatal acute coronary syndrome is classified by years. Consumption increases the risk regardless of the time elapsed in relation to those that did not take them, with the figures remaining virtually stable for five years. Diclofenac and cyclooxygenase-2 inhibitors (especially Rofecoxib) showed an increased risk, unlike naproxen, which had a lower risk. However, naproxen, and because of its greater capacity to generate gastrointestinal bleeding, increased for this reason, fatal events and comorbidity in these patients. Despite this, it still has the best cardiovascular safety profile.