Abordaje de la adherencia en diabetes mellitus tipo 2: situación actual y propuesta de posibles soluciones / Adherence of Type 2 Diabetes Mellitus approach: Current situation and possible solutions

OBJETIVOS: Definir el impacto y las causas de la falta de adherencia terapéutica en los pacientes con diabetes mellitus tipo 2 (DM2), las posibles intervenciones para mejorarla y el papel de las distintas partes implicadas. DISEÑO: Valoración de cuestionario estructurado mediante método Delphi aplicado en 2 rondas. Emplazamiento: Estudio realizado en el ámbito de atención primaria. PARTICIPANTES: Panel formado por profesionales médicos de reconocido prestigio y con amplia experiencia en diabetes. MEDICIONES PRINCIPALES: Valoración a través de una escala Likert de 9 puntos del grado de acuerdo o desacuerdo de 131 ítems agrupados en 4 bloques: impacto; causas de incumplimiento; diagnóstico de la falta de adherencia y de sus posibles causas, y mejores intervenciones y papel de los distintos roles implicados en la mejora de la adherencia. RESULTADOS: Con una tasa de participación del 76,31%, los profesionales sanitarios de atención primaria consensuaron 110 de las 131 aseveraciones propuestas (84%), mostrando acuerdo en 102 ítems (77,9%) y desacuerdo en 8 (6,1%). No se logró consenso en 21 ítems. CONCLUSIONES: La falta de adherencia en los pacientes con DM2 dificulta lograr el control terapéutico. La formación específica y disponer de los recursos necesarios en la consulta son esenciales para minimizar el impacto de la falta de adherencia terapéutica

OBJECTIVES: Define the impact and causes of non-adherent type-2 diabetes mellitus (DM2) patients, possible solutions and the role of the different health care professionals involved in the treatment. DESIGN: Structured questionnaire rating by a two-round Delphi method. LOCATION: The study was conducted in the Primary Care settings. PARTICIPANTS: The expert panel consisted of renowned medical professionals with extensive experience in diabetes. MAIN MEASUREMENTS: Assessment through a 9-point Likert scale, of the degree of agreement or disagreement on 131 items grouped into 4 blocks: impact; causes of nonadherence; diagnosis of non-adherence, and possible causes, solutions and role of the different professionals involved in adherence. RESULTS: The participation rate was 76.31%. The primary care health professionals agreed on 110 of the 131 proposals statements (84%), showing agreement on 102 items (77.9%) and disagreement in 8 (6.1%). Consensus was not reached on 21 items. CONCLUSIONS: The lack of adherence of DM2 patients makes the achievement of therapeutic control difficult. The medical practice needs to have specific training and enough resources to reduce the impact of the lack of therapeutic compliance

[Adherence of Type 2 Diabetes Mellitus approach: Current situation and possible solutions]. / Abordaje de la adherencia en diabetes mellitus tipo2: situación actual y propuesta de posibles soluciones.

OBJECTIVES: Define the impact and causes of non-adherent type-2 diabetes mellitus (DM2) patients, possible solutions and the role of the different health care professionals involved in the treatment. DESIGN: Structured questionnaire rating by a two-round Delphi method. LOCATION: The study was conducted in the Primary Care settings. PARTICIPANTS: The expert panel consisted of renowned medical professionals with extensive experience in diabetes. MAIN MEASUREMENTS: Assessment through a 9-point Likert scale, of the degree of agreement or disagreement on 131 items grouped into 4 blocks: impact; causes of nonadherence; diagnosis of non-adherence, and possible causes, solutions and role of the different professionals involved in adherence. RESULTS: The participation rate was 76.31%. The primary care health professionals agreed on 110 of the 131 proposals statements (84%), showing agreement on 102 items (77.9%) and disagreement in 8 (6.1%). Consensus was not reached on 21 items. CONCLUSIONS: The lack of adherence of DM2 patients makes the achievement of therapeutic control difficult. The medical practice needs to have specific training and enough resources to reduce the impact of the lack of therapeutic compliance.

[Possibilities of clinical echocardiography in patients with heart failure: some examples from clinical practice]. / Posibilidades de la ecocardiografía clínica en el paciente con insuficiencia cardíaca: algunos ejemplos extraídos de la práctica clínica.

Clinical echocardiography is a fast, non-invasive and safe diagnostic method carried out at the patient's bedside by clinicians, not necessarily cardiologists, and can provide useful information about cardiac anatomy, with estimates of volumes, diameters, the presence or absence pericardial effusion, and visualization of ventricular wall motion and valve function. The most practical measure of ventricular function to distinguish between patients with systolic dysfunction and those with preserved systolic function is ejection fraction, which can be estimated approximately. The new small pocket echocardiography devices that have become available in recent years offer major advantages in terms of availability and their cost can be considered accessible compared with that of other devices. An undisputed practical advantage is their portability and ease of use. Clinical echocardiography is perfectly compatible with the subsequent performance of echocardiography by a highly qualified expert.

Prevalencia de diabetes mellitus tipo 2 en pacientes ambulatorios con sobrepeso u obesidad en España. Estudio OBEDIA / Prevalence of type 2 diabetes mellitus in overweight or obese patients outpatients in Spain. OBEDIA Study

Fundamento y objetivo: El incremento de la prevalencia de diabetes mellitus tipo 2 (DM2) está relacionado con el aumento de la obesidad. El estudio pretendió determinar la prevalencia de DM2 en pacientes con sobrepeso u obesidad que acudían a centros de atención primaria y especializada de España. Pacientes y método: Estudio transversal (con 2 fases simultáneas) y multicéntrico, de ámbito nacional, en condiciones de práctica clínica habitual. En la primera fase, diseñada para el cálculo de la prevalencia de DM2, se incluyeron 169.023 pacientes, y en la segunda, 7.754 pacientes sobre los que definir el perfil sociodemográfico, clínico y metabólico de la DM2 en función del índice de masa corporal (IMC). Resultados: La prevalencia de DM2 en sobrepeso u obesidad fue del 23,6%, en los pacientes con sobrepeso del 17,8% y en los obesos del 34,8%. En función del sexo, la DM2 se constató en el 20,2% de los varones y en el 16,4% de las mujeres. Globalmente, la media (DE) de factores de riesgo asociados a DM2 fue de 4,4 (0,8), destacando dislipidemia (92,6%), hipertensión (73,7%) y sedentarismo (62,5%). El 37,8% presentó complicaciones vasculares de su DM2. El 43,1% se consideró bien controlado metabólicamente (hemoglobina glucosilada < 7%). Conclusiones: La DM2 se asocia a sobrepeso y obesidad y aumenta con el grado de IMC. Dislipidemia, hipertensión y sedentarismo en DM2 se incrementan con el aumento del IMC. Los pacientes con peor control metabólico se asocian a mayor grado de obesidad (AU)

Background and objective: The increase in the prevalence of type 2 diabetes mellitus (T2DM) is related to the increase of obesity. We aimed to determine the Spanish prevalence of T2DM in patients with overweight or obesity attended by either family or specialist physicians. Patients and method: Cross-sectional, multicenter and simultaneous 2-phase design, performed under clinical conditions. Phase A was designed to determine T2DM prevalence: 169,023 patients were recruited. Phase B was designed to define socio-demographic, clinical and metabolic profile of T2DM according to the body mass index (BMI): 7,754 patients were included. Results: T2DM prevalence in overweight or obese patients was 23.6%; 17.8% of overweight patients were diabetic and T2DM was present in 34.8% of obese people. According to sex, 20.2% of men and 16.4% of women had T2DM. Overall, the mean of risk factors related to T2DM was 4.4 (SD 0,8); out of them, 92.6% patients had dyslipidemia, 73.7% hypertension and 62.5% performed a low physical activity. 37.8% of diabetic patients had vascular involvement. Only 43.1% of patients showed a proper metabolic control of T2DM (glycosilated hemoglobin < 7%). Conclusions: T2DM is related to overweight and obesity and higher the BMI is, higher the T2DM prevalence. Dyslipidemia, hypertension and a low physical activity in diabetic patients are more frequent when BMI increases. Patients with inadequate metabolic control have a higher BMI (AU)

Posibilidades de la ecocardiografía clínica en el paciente con insuficiencia cardíaca: algunos ejemplos extraídos de la práctica clínica / Possibilities of clinical echocardiography in patients with heart failure: some examples from clinical practice

La ecocardiografía clínica es un método diagnóstico rápido, no invasivo y seguro, realizado a la cabecera del paciente por médicos clínicos no necesariamente especialistas en cardiología y que puede proporcionar una información útil sobre la anatomía cardíaca con estimación de los volúmenes, diámetros, presencia o no de derrame pericárdico y visualización del movimiento de las paredes ventriculares y la función valvular. La medida más práctica de la función ventricular para distinguir entre los pacientes con disfunción sistólica y pacientes con función sistólica conservada es la fracción de eyección del ventrículo izquierdo, que puede estimarse por lo común de forma aproximativa. Los nuevos y pequeños ecocardiógrafos de bolsillo que se encuentran disponibles en los últimos años ofrecen grandes ventajas en cuanto a su disponibilidad, tienen un coste que puede ser considerado accesible en comparación con otros aparatos y aportan la indiscutible ventaja práctica de su portabilidad y su facilidad de uso. La ecocardiografía clínica es perfectamente compatible con la realización posterior de una ecocardiografía experta por personal altamente cualificado (AU)

Clinical echocardiography is a fast, non-invasive and safe diagnostic method carried out at the patient’s bedside by clinicians, not necessarily cardiologists, and can provide useful information about cardiac anatomy, with estimates of volumes, diameters, the presence or absence pericardial effusion, and visualization of ventricular wall motion and valve function. The most practical measure of ventricular function to distinguish between patients with systolic dysfunction and those with preserved systolic function is ejection fraction, which can be estimated approximately. The new small pocket echocardiography devices that have become available in recent years offer major advantages in terms of availability and their cost can be considered accessible compared with that of other devices. An undisputed practical advantage is their portability and ease of use. Clinical echocardiography is perfectly compatible with the subsequent performance of echocardiography by a highly qualified expert (AU)

[Prevalence of type 2 diabetes mellitus in overweight or obese outpatients in Spain. OBEDIA Study]. / Prevalencia de diabetes mellitus tipo 2 en pacientes ambulatorios con sobrepeso u obesidad en España. Estudio OBEDIA.

BACKGROUND AND OBJECTIVE: The increase in the prevalence of type 2 diabetes mellitus (T2DM) is related to the increase of obesity. We aimed to determine the Spanish prevalence of T2DM in patients with overweight or obesity attended by either family or specialist physicians. PATIENTS AND METHOD: Cross-sectional, multicenter and simultaneous 2-phase design, performed under clinical conditions. Phase A was designed to determine T2DM prevalence: 169,023 patients were recruited. Phase B was designed to define socio-demographic, clinical and metabolic profile of T2DM according to the body mass index (BMI): 7,754 patients were included. RESULTS: T2DM prevalence in overweight or obese patients was 23.6%; 17.8% of overweight patients were diabetic and T2DM was present in 34.8% of obese people. According to sex, 20.2% of men and 16.4% of women had T2DM. Overall, the mean of risk factors related to T2DM was 4.4 (SD 0,8); out of them, 92.6% patients had dyslipidemia, 73.7% hypertension and 62.5% performed a low physical activity. 37.8% of diabetic patients had vascular involvement. Only 43.1% of patients showed a proper metabolic control of T2DM (glycosilated hemoglobin<7%). CONCLUSIONS: T2DM is related to overweight and obesity and higher the BMI is, higher the T2DM prevalence. Dyslipidemia, hypertension and a low physical activity in diabetic patients are more frequent when BMI increases. Patients with inadequate metabolic control have a higher BMI.

Core competencies in internal medicine.

The working group on Competencies of Internal Medicine from the Spanish Society of Internal Medicine (SEMI) proposes a series of core competencies that we consider should be common to all European internal medicine specialists. The competencies include aspects related to patient care, clinical knowledge, technical skills, communication skills, professionalism, cost-awareness in medical care and academic activities. The proposal could be used as a working document for the Internal Medicine core curriculum in the context of the educational framework of medical specialties in Europe.

Relación del grado de control glucémico con las características de la diabetes y el tratamiento de la hiperglucemia en la diabetes tipo 2. Estudio DIABES / Relationship between the degree of glycemic control and diabetes characteristics and hyperglycemia treatment in type 2 diabetes. DIABES Study

Fundamento y objetivo: Evaluar la relación del grado de control glucémico con las características de la enfermedad y el tratamiento antihiperglucemiante en pacientes con diabetes mellitus tipo 2 en España. Pacientes y método: Estudio epidemiológico transversal y multicéntrico en el territorio español con muestreo consecutivo. Se registraron variables demográficas y clínicas de pacientes con seguimiento en el centro >12 meses. Resultados: Se analizaron datos de 6.801 pacientes reclutados por 734 médicos especialistas y 965 de atención primaria: el 97,8% recibían tratamiento farmacológico (30,3% monoterapia, 51,4% con 2 fármacos, 16,1%≥3 fármacos y 26,6% con insulina). La hemoglobina glucosilada (HbA1c) media (DE) era de 7,3 (1,2) % y el 40,4% de los pacientes tenían HbA1c<7,0%. Esta proporción varió (p<0,0001) según el tiempo de evolución de la diabetes (51,8% con <5 años, 39,6% con 5-10 años, 35,1% con 10-15 años y 31,4% con >15 años) y el tipo de tratamiento (monoterapia 52,9%, biterapia 35,6%, triple terapia 28,0% e insulina 25,2%). En el análisis multivariante, el tratamiento con insulina (odds ratio [OR] 0,329; intervalo de confianza del 95% [IC 95%] 0,267-0,405) y la existencia de componentes del síndrome metabólico (hipertrigliceridemia y/o colesterol unido a lipoproteínas de alta densidad bajo y/u obesidad abdominal) (OR 0,728; IC 95% 0,595-0,890) se asociaron con peor control glucémico. Conclusiones: Se constata el deterioro del control glucémico con la evolución de la enfermedad y la complejidad del proceso y del tratamiento, lo que en parte puede estar relacionado con la inadecuada selección e intensificación del tratamiento (AU)

Background and objective: To evaluate the relationship between the degree of glycemic control and the features of the disease and glucose-lowering treatment in patients with type 2 diabetes mellitus in Spain. Patients and methods: Cross-sectional epidemiological study in Spain with consecutive sampling. We recorded demographic and clinical variables of patients who were followed up in the center for >12 months. Results: We analyzed data from 6,801 patients enrolled by 734 specialist and 965 primary care physicians: 97.8% received pharmacological treatment (30.3% monotherapy, 51,4% dual therapy, 16.1% triple therapy and 26.6% insulin). HbA1c was 7.3 (1.2) % and 40.4% of patients had HbA1c<7.0%. This proportion varied (P<.0001) according to the duration of diabetes (51.8% with <5 years, 39.6% with 5-10 years, 35.1% with 10-15 years and 31 4%>15 years) and the type of treatment (52.9% monotherapy, 35.6% dual therapy, 28.0% triple therapy and 25.2% insulin). In the multivariate analysis, insulin therapy (odds ratio [OR] 0.329; IC95% 0,267-0,405) and the presence of components of metabolic syndrome (hypertriglyceridemia and/or low HDL and/or abdominal obesity (OR 0.728; IC95% 0,595-0,890) were associated with poor glycemic control. Conclusions: We observed an impairment of glycemic control with the progression of the disease and the complexity of the process and treatment, which in part may be related to the inadequate treatment selection and intensification (AU)

[Relationship between the degree of glycemic control and diabetes characteristics and hyperglycemia treatment in type 2 diabetes. DIABES Study]. / Relación del grado de control glucémico con las características de la diabetes y el tratamiento de la hiperglucemia en la diabetes tipo 2. Estudio DIABES.

BACKGROUND AND OBJECTIVE: To evaluate the relationship between the degree of glycemic control and the features of the disease and glucose-lowering treatment in patients with type 2 diabetes mellitus in Spain. PATIENTS AND METHODS: Cross-sectional epidemiological study in Spain with consecutive sampling. We recorded demographic and clinical variables of patients who were followed up in the center for >12 months. RESULTS: We analyzed data from 6,801 patients enrolled by 734 specialist and 965 primary care physicians: 97.8% received pharmacological treatment (30.3% monotherapy, 51,4% dual therapy, 16.1% triple therapy and 26.6% insulin). HbA(1c) was 7.3 (1.2) % and 40.4% of patients had HbA(1c)<7.0%. This proportion varied (P<.0001) according to the duration of diabetes (51.8% with <5 years, 39.6% with 5-10 years, 35.1% with 10-15 years and 31 4%>15 years) and the type of treatment (52.9% monotherapy, 35.6% dual therapy, 28.0% triple therapy and 25.2% insulin). In the multivariate analysis, insulin therapy (odds ratio [OR] 0.329; IC(95%) 0,267-0,405) and the presence of components of metabolic syndrome (hypertriglyceridemia and/or low HDL and/or abdominal obesity (OR 0.728; IC(95%) 0,595-0,890) were associated with poor glycemic control. CONCLUSIONS: We observed an impairment of glycemic control with the progression of the disease and the complexity of the process and treatment, which in part may be related to the inadequate treatment selection and intensification.

¿Cómo se usan los bloqueadores beta en España? Análisis de las limitaciones para su uso en medicina interna y cardiología: estudio CARACTER-BETA / How Beta-Blockers Are Used in Spain? Analysis of Limitations in Their Use in Internal Medicine and Cardiology: CARACTER-BETA Study

Introducción y objetivos. El tratamiento con bloqueadores beta tiene una indicación de clase I y nivel de evidencia A en las guías de tratamiento de insuficiencia cardiaca, cardiopatía isquémica y fibrilación auricular. A pesar de ello, el uso de bloqueadores beta sigue siendo inferior a lo deseable. El objetivo principal del estudio es analizar el uso de los bloqueadores beta en España en pacientes con cardiopatía isquémica, insuficiencia cardiaca, fibrilación auricular. Métodos. Estudio epidemiológico observacional, transversal y multicéntrico, que incluye a 1.608 pacientes con cardiopatía isquémica, insuficiencia cardiaca y/o fibrilación auricular reclutados en 150 centros sanitarios por cardiólogos y médicos internistas. Resultados. El 78,6% de los pacientes fueron incluidos en cardiología, y el 21,4%, en medicina interna; se recogió al 25,8% en altas hospitalarias y al 74,2%, en consultas externas. El 67% eran varones. La media de edad era 68±12 años. El 73% tenía cardiopatía isquémica; el 42%, insuficiencia cardiaca, y el 36%, fibrilación auricular (variable multirrespuesta). El 82,8% de los tratados en cardiología recibió bloqueadores beta, frente al 71,6% de los tratados en medicina interna (p<0,0001). Por enfermedades, el 85,1% de los pacientes con cardiopatía isquémica, el 77% con insuficiencia cardiaca y el 72,4% con fibrilación auricular. Cardiología prescribió significativamente más bloqueadores beta que medicina interna en cardiopatía isquémica e insuficiencia cardiaca. El análisis multivariable mostró que los bloqueadores beta aumentan si se padece cardiopatía isquémica, se es tratado por un cardiólogo, se tiene dislipemia, accidente cerebrovascular y/o hipertrofia ventricular izquierda. Disminuyen los bloqueadores beta con la edad, el broncospasmo y el asma bronquial, la bradicardia, la enfermedad pulmonar obstructiva crónica y/o la claudicación intermitente. Conclusiones. Todavía existen márgenes de mejora en la prescripción de bloqueadores beta a pacientes con cardiopatía isquémica, insuficiencia cardiaca y/o fibrilación auricular en España (AU)

Introduction and objectives. Beta-blocker treatment has a class I indication, level of evidence A, in guidelines for the treatment of heart failure, ischemic heart disease, and atrial fibrillation. However, beta-blocker use continues to be less than optimal. In this study, beta-blocker use in Spain is analyzed in patients with heart failure, ischemic heart disease, and atrial fibrillation. Methods. Observational, epidemiologic, cross-sectional, multicenter study including 1608 patients with heart failure, ischemic heart disease, and/or atrial fibrillation, recruited in 150 healthcare centers by cardiologists and internal medicine specialists. Results. Cardiologists enrolled 78.6% patients and internal medicine specialists 21.4%; 25.8% were recruited at hospital discharge and 74.2% at outpatient centers. Men accounted for 77% of the sample, and age was 68 (12) years. Of the total, 73% had ischemic heart disease, 42% heart failure, and 36% atrial fibrillation (multiresponse variable). beta-blockers were given to 82.8% of those consulting in cardiology compared to 71.6% of those treated in internal medicine (P<.0001). By pathology, the prescription rate was 85.1% of patients with ischemic heart disease, 77.0% of those with heart failure, and 72.4% of those with atrial fibrillation. Cardiology prescribed significantly more beta-blockers for ischemic heart disease and heart failure than did internal medicine. Multivariate analysis showed that beta-blocker use increased when the patient had ischemic heart disease, was treated by a cardiologist, and had dyslipidemia, stroke, and/or left ventricular hypertrophy. Beta-blocker use decreased with age and with a history of bronchospasm, asthma, bradycardia, chronic obstructive pulmonary disease, and/or intermittent claudication. Conclusions. There is still room for improvement in beta-blocker prescription in Spain for patients with ischemic heart disease, heart failure, and/or atrial fibrillation (AU)

[How beta-blockers are used in Spain? Analysis of limitations in their use in internal medicine and cardiology: CARACTER-BETA study]. / ¿Cómo se usan los bloqueadores beta en España? Análisis de las limitaciones para su uso en medicina interna y cardiología: estudio CARACTER-BETA.

INTRODUCTION AND OBJECTIVES: Beta-blocker treatment has a class I indication, level of evidence A, in guidelines for the treatment of heart failure, ischemic heart disease, and atrial fibrillation. However, beta-blocker use continues to be less than optimal. In this study, beta blocker use in Spain is analyzed in patients with heart failure, ischemic heart disease, and atrial fibrillation. METHODS: Observational, epidemiologic, cross-sectional, multicenter study including 1608 patients with heart failure, ischemic heart disease, and/or atrial fibrillation, recruited in 150 healthcare centers by cardiologists and internal medicine specialists. RESULTS: Cardiologists enrolled 78.6% patients and internal medicine specialists 21.4%; 25.8% were recruited at hospital discharge and 74.2% at outpatient centers. Men accounted for 77% of the sample, and age was 68 (12) years. Of the total, 73% had ischemic heart disease, 42% heart failure, and 36% atrial fibrillation (multiresponse variable). Beta blockers were given to 82.8% of those consulting in cardiology compared to 71.6% of those treated in internal medicine (P<.0001). By pathology, the prescription rate was 85.1% of patients with ischemic heart disease, 77.0% of those with heart failure, and 72.4% of those with atrial fibrillation. Cardiology prescribed significantly more beta blockers for ischemic heart disease and heart failure than did internal medicine. Multivariate analysis showed that beta blocker use increased when the patient had ischemic heart disease, was treated by a cardiologist, and had dyslipidemia, stroke, and/or left ventricular hypertrophy. beta blocker use decreased with age and with a history of bronchospasm, asthma, bradycardia, chronic obstructive pulmonary disease, and/or intermittent claudication. CONCLUSIONS: There is still room for improvement in beta blocker prescription in Spain for patients with ischemic heart disease, heart failure, and/or atrial fibrillation.

Housing conditions and mortality in older patients hospitalized for heart failure.

BACKGROUND: Although decent housing is recognized as a prerequisite for good health, very few studies in developed countries have examined the influence of housing characteristics on disease prognosis. This work examined whether housing conditions predict mortality in older adults with heart failure (HF). METHODS: This is a cohort study comprising 433 patients hospitalized for HF-related emergencies in 4 Spanish hospitals between January 1, 2000, and June 30, 2001. At baseline, patients reported whether their homes lacked an elevator (in an apartment building), hot water, heating, an indoor bathroom, a bathtub or shower, individual bedroom, automatic washing machine, and telephone and whether they frequently felt cold. Analyses included all-cause deaths identified prospectively until January 1, 2005. RESULTS: Among study participants, 165 (38.1%) lived in a home without one of the services considered; and 111 (25.6%) lacked ≥2 services. During follow-up, 260 deaths (60%) occurred. After adjustment for the main confounders, mortality was higher in those who lived in homes without an elevator (hazard ratio [HR] 1.39, 95% CI 1.07-1.80) and in those who frequently felt cold (HR 1.39, 95% CI 1.01-1.92). In comparison with living in a home with all the services considered, mortality was higher for persons living in a home lacking 1 service (HR 1.42, 95% CI 1.10-1.93) or ≥2 services (HR 1.94, 95% CI 1.37-2.74). Patients living in homes lacking any of the services more often had poor functional status, higher comorbidity, lower educational level, and less income. CONCLUSION: Poor housing conditions are associated with higher mortality in HF. Patients living in these homes are especially vulnerable because they have poorer clinical situation and lower socioeconomic position.

Degree of control and delayed intensification of antihyperglycaemic treatment in type 2 diabetes mellitus patients in primary care in Spain.

OBJECTIVES: Primary aim: to determine the degree of control of HbA(1c) at the time of treatment intensification (TI) in T2DM patients. Secondary aims: fasting plasma glucose levels; estimation of the elapsed time between HbA(1c) exceeding 7% and TI; antidiabetic combinations used, % patients with good cardiometabolic control (LDL-c<100mg/dL; SBP<130 and DPB<80mmHg and HbA(1c)<7%). RESEARCH DESIGN AND METHODS: one-cohort, multicenter, retrospective, observational study conducted in Spain. Patients diagnosed with T2DM that had switched from monotherapy to combination antidiabetic therapy were evaluated at baseline and after one year of follow-up. RESULTS: a total of 1202 T2DM patients were analyzed. At the time of TI: mean HbA(1c) 8.1%; median time of uncontrolled disease: 2.0 years. After one-year of TI: significant reduction in mean HbA(1c) (8.1% vs.7.0%, p<0.001) and a mean fasting plasma glucose levels reduction (181.1mg/dL vs.144.1mg/dL, p<0.001) was also observed. The percentage of patients under glycemic control (HbA(1c)<7%) increased from 12.2% to 51.6% (p<0.001). Most common antidiabetic combinations: metformin+sulfonylurea (44.1%) and metformin+thiazolidindione (15.9%). CONCLUSIONS: in the population of T2DM patients analyzed, TI was carried out when HbA(1c) values were above those recommended in clinical guidelines (≤ 7%), with a delay of two years to address the second step of therapy, despite the consensus recommendation of the ADA/EASD of 3 months. TI was shown to be effective since addition of a second antidiabetic drug led to an average reduction of HbA(1c) of approximately 1%. Metformin was the drug most commonly used as monotherapy being the most frequent combination metformin+sulfonylurea.

Mechanisms of the association between depressive symptoms and long-term mortality in heart failure.

BACKGROUND: The long-term prognostic influence of depression on patients hospitalized for heart failure (HF) is unknown. No previous study has examined systematically the mechanisms of the relationship between depression and mortality in HF. METHODS: Prospective study of 433 patients hospitalized for HF-related emergencies in 4 Spanish hospitals. Baseline depressive symptoms were assessed with the 10-item Geriatric Depression Scale (GDS). The association between depressive symptoms and mortality was summarized with hazard ratios (HRs) obtained from Cox regression, with sequential adjustment for possible mechanisms of the association. RESULTS: Of the 433 study participants, 103 (23.8%) had major depression (GDS-10 > or =5) at baseline. During a mean follow-up of 5.7 years, 305 deaths (70%) occurred. Compared with those who were not depressed, subjects with major depression showed higher mortality (age and sex-adjusted HR 1.52, 95% CI 1.15-2.01). Subsequent adjustment for comorbidity reduced the HR to 1.45 (95% CI 1.10-1.93). Additional adjustment for severity of cardiac lesion and for lifestyles, foremost physical inactivity, led to a HR of 1.27 (95% CI 0.95-1.70). After further adjustment for pharmacologic treatment of HF and particularly for disability in instrumental activities of daily living, the HR dropped almost to the null value (HR 1.10, 95% CI 0.82-1.49). CONCLUSIONS: Depressive symptoms in patients hospitalized for HF are associated with higher long-term mortality; this association is largely explained by the frequent comorbidity, physical inactivity, and disability of these patients.

Erectile dysfunction in high-risk hypertensive patients treated with beta-blockade agents.

BACKGROUND: Erectile dysfunction (ED) is a multifactorial disease related to age, vascular disease, psychological disorders, or medical treatments. Beta-blockade agents are the recommended treatment for hypertensive patients with some specific organ damage but have been outlined as one of leading causes of drug-related ED, although differences between beta-blockade agents have not been assessed. METHODS: Cross-sectional and observational study of hypertensive male subjects treated with any beta-blockade agent for at least 6 months. ED dysfunction was assessed by the International Index of Erectile Dysfunction (IIEF). RESULTS: 1.007 patients, mean age 57.9 (10.59) years, were included. The prevalence of any category of ED was 71.0% (38.1% mild ED; 16.8% moderate ED; 16.1% severe ED). Patients with ED had longer time since the diagnosis of hypertension and higher prevalence of risk factors and comorbidities. The prevalence of ED increased linearly with age. ED patients received more medications and were more frequently treated with carvedilol and less frequently with nebivolol. Patients treated with nebivolol obtained higher scores in every parameter of the IIEF questionnaire. The multivariate analysis identified independent associations between ED and coronary heart disease (OR: 1.57), depression (OR: 2.25), diabetes (OR: 2.27), atrial fibrillation (OR: 2.59), and dyhidopiridines calcium channel blockers (OR: 1.76); treatment with nebivolol was associated to lower prevalence of ED (OR: 0.27). CONCLUSION: ED is highly prevalent in hypertensive patients treated with beta-blockade agents. The presence of ED is associated with more extended organ damage and not to cardiovascular treatments, except for the lower prevalence in nebivolol-treated patients.

Relationship of abdominal obesity with cardiovascular disease, diabetes and hyperlipidaemia in Spain.

OBJECTIVES: To evaluate the relevance of obesity and abdominal obesity in the prevalence of cardiovascular disease (CVD), diabetes mellitus, hyperlipidaemia and hypertension in primary care patients and to ascertain whether waist circumference (WC) measurement should be included in routine clinical practice in addition to body mass index (BMI). METHODS: As part of the IDEA study, primary care physicians from Spain recruited patients aged 18-80 years. WC and BMI and the presence of CVD, diabetes mellitus, hyperlipidaemia and hypertension were recorded. Finally, 17 980 were analysed. An age-related increase in adiposity was observed. Overall 33% were obese by BMI, and 51% of subjects presented abdominal obesity by the National Cholesterol Education Program Adult Treatment Panel III (NCEP-ATPIII) (WC > 102 cm for men and > 88 cm for women). Although there was a correlation between BMI and WC, they presented different distribution patterns. Women, but not men, with a high level of education, professional activity and smoking were associated with a lower WC. Abdominal obesity was significantly associated with CVD. Some subjects with abdominal obesity but lean by BMI, showed an increased prevalence of CVD and diabetes. Furthermore, abdominal obesity was strongly associated with dyslipidaemia and hypertension. CONCLUSIONS: Half of the primary care patients studied showed abdominal obesity as measured by WC, whereas one-third was obese by BMI. Abdominal obesity was strongly associated with CVD and diabetes, even in patients lean by BMI. WC should be included in the routine clinical practice in addition to BMI.

TORAFIC study protocol: torasemide prolonged release versus furosemide in patients with chronic heart failure.

UNLABELLED: Loop diuretics, such as torasemide and furosemide, are important agents in the treatment of chronic heart failure. Beneficial effects of torasemide immediate-release formulation beyond diuresis have been documented as the ability of this compound to inhibit myocardial synthesis and deposition of collagen type I in patients with chronic heart failure. In addition, torasemide-treated patients, but not furosemide-treated patients, showed decreased serum concentrations of the C-terminal propeptide of procollagen type I, a biochemical marker of myocardial fibrosis. The aim of the TORAFIC study is to test the efficacy of torasemide prolonged-release formulation (PR) in reducing myocardial fibrosis in chronic heart failure in a large, randomized clinical trial. METHODS: This prospective, Phase IV, randomized, blinded end point, active-controlled clinical trial will randomize 142 patients with chronic heart failure in New York Heart Association functional class II-IV to 8 months treatment with either torasemide-PR (10-40 mg daily) or furosemide (40-160 mg daily). The primary objective is to test the hypothesis that torasemide-PR is superior to furosemide in reducing myocardial fibrosis. The primary outcome measure is the difference in the change of serum propeptide of procollagen type I concentration from the initial to the final visit between both study groups. Secondary outcome measures include all efficacy variables related to heart failure (signs and symptoms, ECG, echocardiogram and serum levels of N-terminal brain natriuretic propeptide). Secondary safety variables are heart rate, blood pressure, laboratory data, adverse events, cardiovascular events (hospital admission, emergency department visits) and quality of life (Minnesota questionnaire). DISCUSSION: This trial will test whether torasemide-PR possesses antifibrotic properties, which may provide an additional benefit beyond diuresis in patients with chronic heart failure.

Guía Europea de Prevención Cardiovascular en la Práctica Clínica. Adaptación española del CEIPC 2008 / European Guidelines on Cardiovascular Disease Prevention in Clinical Practice. CEIPC 2008 Spanish Adaptation

Presentamos la adaptación española realizada por el Comité Español Interdisciplinario para la Prevención Cardiovascular (CEIPC) de la Guía Europea de Prevención de las Enfermedades Cardiovasculares 2008. Esta guía recomienda el modelo SCORE de riesgo bajo para valorar el riesgo cardiovascular. El objetivo es prevenir la mortalidad y la morbilidad debidas a las enfermedades cardiovasculares (ECV) mediante el tratamiento de sus factores de riesgo en la práctica clínica. La guía hace énfasis en la prevención primaria y en el papel del médico y el personal de enfermería de atención primaria en la promoción de un estilo de vida cardiosaludable, basado en el incremento de los grados de actividad física, la adopción de una alimentación saludable y, en los fumadores, el abandono del tabaco. La meta terapéutica para la presión arterial es en general<140/90mmHg; pero en pacientes con diabetes mellitus, enfermedad renal crónica o ECV el objetivo es 130/80mmHg. El colesterol debe mantenerse por debajo de 200mg/dl (colesterol unido a lipoproteínas de baja densidad [cLDL]<130mg/dl); en los pacientes con ECV o diabetes mellitus el objetivo es cLDL<100mg/dl (80mg/dl si factible en individuos de riesgo muy alto). En pacientes con diabetes mellitus tipo 2 y en pacientes con síndrome metabólico se debe reducir el peso y aumentar la actividad física y, en su caso, utilizar los fármacos indicados, para alcanzar los objetivos del índice de masa corporal y de perímetro de cintura. El objetivo en pacientes con diabetes mellitus tipo 2 debe ser alcanzar una hemoglobina glucosilada<7%. La amplia difusión de las guías y el desarrollo de los programas destinados a favorecer su implantación, en los que se identifiquen barreras y se busquen soluciones, son objetivos prioritarios del CEIPC, como uno de los medios fundamentales para trasladar las recomendaciones establecidas a la práctica clínica diaria(AU)

The present CEIPC Spanish adaptation of the European Guidelines on Cardiovascular Disease Prevention in Clinical Practice 2008. This guide recommends the SCORE model for risk evaluation. The aim is to prevent premature mortality and morbidity due to CVD by means of dealing with its related risk factors in clinical practice. The guide focuses on primary prevention and emphasizes the role of the nurses and primary care doctors in promoting a healthy life style, based on increasing physical activity, changing dietary habits, and not smoking. The therapeutic goal is to achieve a Blood Pressure<140/90mmHg, but in patients with diabetes, chronic kidney disease, or definite CVD, the objective is<130/80mmHg. Serum cholesterol should be<200mg/dl and cLDL<130mg/dl, although in patients with CVD or diabetes, the objective is<100mg/dl (80mg/dl if feasible in very high-risk patients). Patients with type 2 diabetes and those with metabolic syndrome must lose weight and increase their physical activity, and drugs must be administered whenever applicable, with the objective guided by body mass index and waist circumference. In diabetic type 2 patients, the objective is glycated haemoglobin<7%. Allowing people to know the guides and developing implementation programs, identifying barriers and seeking solutions for them, are priorities for the CEIPC in order to put the recommendations into practice(AU)

[European Guidelines on Cardiovascular Disease Prevention in Clinical Practice. CEIPC 2008 Spanish Adaptation]. / Guía Europea de Prevención Cardiovascular en la Práctica Clínica. Adaptación española del CEIPC 2008.

The present CEIPC Spanish adaptation of the European Guidelines on Cardiovascular Disease Prevention in Clinical Practice 2008. This guide recommends the SCORE model for risk evaluation. The aim is to prevent premature mortality and morbidity due to CVD by means of dealing with its related risk factors in clinical practice. The guide focuses on primary prevention and emphasizes the role of the nurses and primary care doctors in promoting a healthy life style, based on increasing physical activity, changing dietary habits, and not smoking. The therapeutic goal is to achieve a Blood Pressure<140/90mmHg, but in patients with diabetes, chronic kidney disease, or definite CVD, the objective is<130/80mmHg. Serum cholesterol should be<200mg/dl and cLDL<130mg/dl, although in patients with CVD or diabetes, the objective is<100mg/dl (80mg/dl if feasible in very high-risk patients). Patients with type 2 diabetes and those with metabolic syndrome must lose weight and increase their physical activity, and drugs must be administered whenever applicable, with the objective guided by body mass index and waist circumference. In diabetic type 2 patients, the objective is glycated haemoglobin<7%. Allowing people to know the guides and developing implementation programs, identifying barriers and seeking solutions for them, are priorities for the CEIPC in order to put the recommendations into practice.