[Practical approach of dapagliflozin for the treatment of heart failure. Role of primary care physician]. / Abordaje práctico de dapagliflozina en el tratamiento de la insuficiencia cardíaca. Papel del médico de atención primaria.

Despite traditional treatments, morbidity and mortality of patients with heart failure (HF) and reduced left ventricular ejection fraction remains unacceptably high. Traditionally, guidelines recommended a step by step approach in the management of this population. However, this approach could delay the prescription of some drugs with proven efficacy on morbidity and prognosis. As current HF guidelines recommend, an initial comprehensive approach with the aim of targeting all neurohormonal systems that are implied in the etiopathogenesis of HF seems necessary. The DAPA-HF trial demonstrated that dapagliflozin markedly reduces the risk of HF hospitalization, and also improves prognosis. Consequently, dapagliflozin should be considered as a first-line therapy in the management of these patients. On the other hand, primary care physicians are essential for the prevention and treatment of patients with HF and reduced left ventricular ejection fraction. As a result, it is mandatory that they know when and how dapagliflozin should be used. In this review, a practical approach for an appropriate use of this drug is provided.

[Impact of dapagliflozin on cardiovascular risk factors. Beyond glycemic control]. / Impacto de dapagliflozina en los factores de riesgo cardiovascular. Más allá del control de la glucemia.

Sodium-glucose transport protein 2 (SGLT2) inhibitors are a new class of oral hypoglycemic agents that increase urinary glucose excretion independently of insulin secretion, although an apparently simple mechanism, but with multiple metabolic effects. Dapagliflozin was the first SGLT2 inhibitor marketed in Europe in 2012 for the treatment of patients with type 2 diabetes, and consequently, with the greatest clinical experience. The results of different clinical trials and real-life studies have demonstrated its effectiveness in glycemic control, as they reduce glycosylated hemoglobin, while achieving a decrease in body weight and blood pressure, among others, providing a comprehensive metabolic protection.

[Dapagliflozin in the prevention and treatment of heart failure]. / Dapagliflozina en la prevención y tratamiento de la insuficiencia cardiaca.

To substantially reduce the risk of hospitalization and death among subjects with heart failure (HF) and reduced left ventricular ejection fraction, it is necessary to make a comprehensive approach of the different neurohormonal systems that are implied in its etiopathogenesis, including not only sympathetic nervous system, and renin-angiotensin system, but also vasoactive peptides and sodium-glucose transport protein 2. The DAPA-HF trial demonstrated that the addition of dapagliflozin to the standard treatment in HF with reduced left ventricular ejection fraction, markedly decreases the risk of cardiovascular death, HF hospitalization and overall death. In addition, dapagliflozin improves functional class and quality of life. Importantly, the prognostic benefit starts early after initiating treatment with dapagliflozin, regardless baseline therapy or the presence of diabetes. All these evidences make dapagliflozin as one of the mainstays of treatment for the management of HF with reduced left ventricular ejection fraction.

Clinical characteristics and management of patients with atrial fibrillation treated with direct oral anticoagulants according to blood pressure control / Características clínicas y manejo de pacientes con fibrilación auricular tratados con anticoagulantes orales directos de acuerdo al control de presión arterial

Objective: To determine the clinical characteristics and management of hypertensive patients with nonvalvular atrial fibrillation (AF) treated with direct oral anticoagulants (DOACs) according to blood pressure (BP) control. Methods: For this purpose, data from two observational, cross-sectional and multicenter studies were combined. In both studies, patients on chronic treatment with anticoagulants and that were on current treatment with DOACs at least for 3 months were included. Adequate BP was defined as a systolic BP < 140 mmHg and a diastolic BP < 90 mmHg (< 140/85 mmHg if diabetes). Results: Overall, 1036 patients were included. Of these, 881 (85%) had hypertension that were finally analyzed. The presence of other risk factors and cardiovascular disease was common. Mean BP was 132.6 ± 14.3/75.2 ± 9.2 mmHg and 70.5% of patients achieved BP goals. Those patients with a poor BP control had more frequently diabetes, and a history of prior labile INR. Patients had a high thromboembolic risk, but without significant differences according to BP control. By contrast, more patients with a poor BP control had a higher bleeding risk (HAS-BLED ≥3: 24.0% vs 35.4%; P < 0.001). HAS-BLED score was an independent predictor of poor BP control (odds ratio 1.435; 95% confidence interval 1.216-1.693; P < 0.001). Satisfaction with anticoagulant treatment was independent of BP control. Conclusions: More than two thirds of our patients with hypertension and AF anticoagulated with DOACs achieve BP targets, what is clearly superior to that reported in the general hypertensive population

Objetivo: Determinar las características clínicas y el manejo de hipertensos con fibrilación auricular no valvular (FANV) tratados con anticoagulantes orales directos (ACOD) de acuerdo al control de la presión arterial (PA). Métodos: Se combinaron los datos de 2 estudios observacionales, transversales y multicéntricos. En ambos estudios se incluyeron a pacientes tratados crónicamente con anticoagulantes y que estuviesen actualmente siendo tratados con ACOD al menos durante 3 meses. Se definió como control adecuado de la PA, tener una PA sistólica < 140 mmHg y una PA diastólica < 90 mmHg (< 140/85 mmHg, si diabetes). Resultados: Se incluyeron 1.036 pacientes. De estos, 881 (85%) tenían hipertensión, que fueron finalmente analizados. La presencia de otros factores de riesgo y enfermedades cardiovasculares fue frecuente. La PA media fue de 132,6 ± 14,3/75,2 ± 9,2 mmHg; el 70,5% de los pacientes lograron los objetivos de PA. Aquellos pacientes con un pobre control de PA tuvieron más frecuentemente diabetes, y antecedentes de INR lábil. Los pacientes tenían un elevado riesgo tromboembólico, pero sin diferencias de acuerdo al control de PA. Hubo más pacientes con un pobre control de PA con un mayor riesgo de sangrado (HAS-BLED ≥3: 24,0 vs. 35,4%; p < 0,001). La puntuación HAS-BLED fue un predictor independiente de pobre control de PA (OR: 1,435; IC 95%: 1,216-1,693; p < 0,001). La satisfacción con el tratamiento anticoagulante fue independiente del control de PA. Conclusiones: Más de dos tercios de nuestros hipertensos con FANV anticoagulados con ACOD logran los objetivos de PA, lo que es claramente superior a lo reportado en la población hipertensa general

Diferencias en el manejo de los pacientes con fibrilación auricular según inicie el tratamiento con anticoagulantes orales de acción directa el médico de atención primaria o el especialista. Estudios SILVER-AP y BRONCE-AP / Differences in the management of patients with atrial fibrillation according to whether primary care or the specialist initiates treatment with direct oral anticoagulants. The SILVER-AP and BRONCE-AP studies

Objetivos: Describir las características clínicas y el manejo de pacientes con fibrilación auricular no valvular (FANV) tratados con anticoagulantes orales de acción directa (ACOD) de acuerdo a quién inicia su prescripción: el médico de atención primaria (AP) o el especialista. Material y métodos: Se compararon 2 estudios observacionales, transversales y multicéntricos. El estudio SILVER-AP se realizó en aquellas comunidades autónomas en las que el médico de AP podía prescribir ACOD y el estudio BRONCE-AP en aquellas comunidades autónomas en las que el médico de AP debía derivar al especialista para tal fin. Se incluyeron pacientes diagnosticados de FANV con riesgo de ictus o embolia sistémica que estuviesen en tratamiento crónico con anticoagulantes, que hubiesen modificado su pauta terapéutica y que actualmente estuviesen en tratamiento con un ACOD durante al menos 3meses. Resultados: Se incluyeron un total de 1.036 pacientes (790 provenientes del estudio SILVER-AP y 246 del BRONCE-AP). En comparación con el estudio BRONCE-AP, los pacientes incluidos en el SILVER-AP eran mayores, tenían más comorbilidades y el riesgo tromboembólico y hemorrágico era más elevado (CHA2DS2-VASc 4,3±1,6 vs. 3,8±1,8; p<0,001; HAS-BLED 2,1±0,8 vs. 1,8±1,0; p<0,001). El cumplimiento terapéutico fue elevado, al igual que la satisfacción con el tratamiento. Las dosis bajas de ACOD se emplearon frecuentemente, en especial con dabigatrán. Conclusiones: Los pacientes en los que el médico de AP puede prescribir ACOD tienen un peor perfil clínico, con un mayor riesgo tromboembólico y de hemorragias que aquellos casos en los que debe derivar al especialista

Objectives: To determine the clinical characteristics and management of patients with non-valvular atrial fibrillation (NVAF) treated with direct oral anticoagulants (DOAC) according to who initiates their prescription, the Primary Care (PC) physician or referring the patient to a specialist. Material and methods: Two observational, cross-sectional and multicentre studies were compared for this purpose. The SILVER-AP study was performed in those autonomous communities in which the PC physician can prescribe DOAC directly, and the BRONCE-AP study in those autonomous communities in which the PC physician has to refer the patient to the specialist to start treatment with DOAC. Patients on chronic treatment with anticoagulants, in whom therapy was changed, and those that were on current treatment with DOAC for at least 3months, were included. Results: A total of 1,036 patients (790 from SILVER-AP study and 246 from BRONCE-AP study) were included. Compared with the BRONCE-AP study, those patients included in SILVER-AP were older and had more comorbidities, as well as a higher thromboembolic and haemorrhagic risk (CHA2DS2-VASc 4.3±1.6 vs. 3.8±1.8; P<.001; HAS-BLED 2.1±0.8 vs. 1.8±1.0; P<.001). Therapeutic adherence and satisfaction with treatment were high. Low doses of DOAC were frequently prescribed, particularly with dabigatran. Conclusions: Those patients in whom the PC physician can prescribe DOAC directly have a worse clinical profile, as well as a higher thromboembolic and haemorrhagic risk than those patients in whom the PC physician has to refer to the specialist

Clinical characteristics and management of patients with atrial fibrillation treated with direct oral anticoagulants according to blood pressure control.

OBJECTIVE: To determine the clinical characteristics and management of hypertensive patients with nonvalvular atrial fibrillation (AF) treated with direct oral anticoagulants (DOACs) according to blood pressure (BP) control. METHODS: For this purpose, data from two observational, cross-sectional and multicenter studies were combined. In both studies, patients on chronic treatment with anticoagulants and that were on current treatment with DOACs at least for 3 months were included. Adequate BP was defined as a systolic BP<140mmHg and a diastolic BP<90mmHg (<140/85mmHg if diabetes). RESULTS: Overall, 1036 patients were included. Of these, 881 (85%) had hypertension that were finally analyzed. The presence of other risk factors and cardiovascular disease was common. Mean BP was 132.6±14.3/75.2±9.2mmHg and 70.5% of patients achieved BP goals. Those patients with a poor BP control had more frequently diabetes, and a history of prior labile INR. Patients had a high thromboembolic risk, but without significant differences according to BP control. By contrast, more patients with a poor BP control had a higher bleeding risk (HAS-BLED ≥3: 24.0% vs 35.4%; P<0.001). HAS-BLED score was an independent predictor of poor BP control (odds ratio 1.435; 95% confidence interval 1.216-1.693; P<0.001). Satisfaction with anticoagulant treatment was independent of BP control. CONCLUSIONS: More than two thirds of our patients with hypertension and AF anticoagulated with DOACs achieve BP targets, what is clearly superior to that reported in the general hypertensive population.

[Differences in the management of patients with atrial fibrillation according to whether primary care or the specialist initiates treatment with direct oral anticoagulants. The SILVER-AP and BRONCE-AP studies]. / Diferencias en el manejo de los pacientes con fibrilación auricular según inicie el tratamiento con anticoagulantes orales de acción directa el médico de atención primaria o el especialista. Estudios SILVER-AP y BRONCE-AP.

OBJECTIVES: To determine the clinical characteristics and management of patients with non-valvular atrial fibrillation (NVAF) treated with direct oral anticoagulants (DOAC) according to who initiates their prescription, the Primary Care (PC) physician or referring the patient to a specialist. MATERIAL AND METHODS: Two observational, cross-sectional and multicentre studies were compared for this purpose. The SILVER-AP study was performed in those autonomous communities in which the PC physician can prescribe DOAC directly, and the BRONCE-AP study in those autonomous communities in which the PC physician has to refer the patient to the specialist to start treatment with DOAC. Patients on chronic treatment with anticoagulants, in whom therapy was changed, and those that were on current treatment with DOAC for at least 3months, were included. RESULTS: A total of 1,036 patients (790 from SILVER-AP study and 246 from BRONCE-AP study) were included. Compared with the BRONCE-AP study, those patients included in SILVER-AP were older and had more comorbidities, as well as a higher thromboembolic and haemorrhagic risk (CHA2DS2-VASc 4.3±1.6 vs. 3.8±1.8; P<.001; HAS-BLED 2.1±0.8 vs. 1.8±1.0; P<.001). Therapeutic adherence and satisfaction with treatment were high. Low doses of DOAC were frequently prescribed, particularly with dabigatran. CONCLUSIONS: Those patients in whom the PC physician can prescribe DOAC directly have a worse clinical profile, as well as a higher thromboembolic and haemorrhagic risk than those patients in whom the PC physician has to refer to the specialist.

Hipertrofia ventricular izquierda por electrocardiograma o ecocardiograma y complicaciones cardiovasculares en hipertensos tratados de la Comunidad Autónoma de Madrid. Estudio MAVI-HTA / Left ventricular hypertrophy seen by electrocardiogram or echocardiogram and cardiovascular complications in hypertense subjects treated in the regional Community of Madrid. Anatomical modifications of left ventricle-HBP (AMLV-HBP) study

Objetivos. Evaluar la prevalencia de hipertrofia ventricular izquierda electrocardiográfica (HVI-ECG) y ecocardiográfica (HVI-ECO) en pacientes hipertensos en la Comunidad de Madrid, y su relación con la enfermedad cardiovascular (ECV) establecida. Pacientes y métodos. Estudio epidemiológico, transversal y multicéntrico en centros de Atención Primaria de la Comunidad Autónoma de Madrid. Se incluyeron pacientes hipertensos de edad >= 50 años. Se recogieron datos demográficos, antropométricos, de presión arterial, factores de riesgo y enfermedades cardiovasculares. La HVI-ECG se evaluó con los criterios de voltaje de Cornell y Sokolow-Lyon, y la HVI-ECO mediante la masa ventricular izquierda (MVI) utilizando la fórmula de Devereux. Resultados. En 620 pacientes evaluables, 71 presentaron HVI-ECG (prevalencia del 11,5 %, similar en varones [10,6 %] y en mujeres [12,1 %; p = 0,565], sin asociación con la edad). En 580 pacientes con ecocardiograma, la prevalencia de HVI-ECO (MVI indexada por la superficie corporal >= 125 g/m2 [varones] y >= 110 g/m2 [mujeres]) fue de 56,4 %, mayor en mujeres (66,6 % frente a 42,4 % en hombres; p < 0,001), y mayor en edades más avanzadas (p tendencia lineal < 0,001). En el análisis multivariante no se observó asociación entre HVI-ECG y prevalencia de ECV. Sin embargo, los pacientes con HVI-ECO presentaron, respecto a los pacientes sin HVI-ECO, una prevalencia más de tres veces superior de ECV (odds ratio: 3,48 [intervalo de confianza 95 %: 1,75-6,74]). Conclusiones. La prevalencia de HVI-ECG fue del 11,5 %, mientras que por ECO ascendió a 56,4 %, y ésta se asoció a una prevalencia de ECV tres veces superior. Determinados pacientes hipertensos podrían beneficiarse del ecocardiograma en la valoración del riesgo cardiovascular

Objective. To assess the prevalence of left ventricular hypertrophy using electrocardiogram (ECG-LVH) and echocardiogram (ECHO-LVH) in hypertensive patients of the Autonomic Community of Madrid and its relationship to established cardiovascular disease (CVD). Patients and methods. Cross-sectional multicenter, epidemiological study conducted in Primary Health Care Centers of the Madrid Community. Hypertensive patients aged 50 years or more were included. Demographic, anthropometric, blood pressure, cardiovascular risk factors and disease data were obtained. ECG-LVH was assessed using the voltage criteria of Cornell and Sokolow-Lyon and ECHO-LVH by calculating the left ventricular mass (LVM) with the Devereux equation. Results. A total of 71 out of 620 evaluable patients had ECG-LVH (prevalence 11.5 %, similar in men and in women [10.6 % vs. 12.1 %; p = 0.565]), with no association to age. Prevalence of ECHO-LVH (LVM indexed by body surface >= 125 g/m2 [men] and >= 110 g/m2 [women]) in 580 patients with echocardiographic evaluation was 56.4 %, this being greater in women (66.6 % vs. 42.4 % in men; p < 0.001) and in older subjects (p linear trend < 0,001). In the multivariate analysis, no association was observed between ECG-LVH and established CVD. However, patients with ECHO-LVH, compared to those without ECHO-LVH, had more than a three-fold prevalence of CVD (OR 3.48 [95 % CI: 1.75-6.74]). Conclusions. Prevalence of ECG-LVH was 11.5 %, while it increased to 56.4% when the ECHO-LVH was used. The latter was associated to a three-fold prevalence of CVD. Some hypertensive patients could benefit from an echocardiogram in the assessment of their cardiovascular risk

[The usefulness of intravascular echography during the percutaneous dilatation of aortic coarctation]. / Utilidad de la ecografía intravascular durante la dilatación percutánea de la coartación aórtica.

An intravascular ultrasound study was performed in a patient, to assess the anatomy of aortic coarctation and the results obtained after percutaneous dilation with a balloon catheter. Intravascular ultrasound imaging provides important additional information, not obtainable with other diagnostic procedures, regarding aortic wall structure and thickness. After balloon dilation, aortic disruption was clearly observed, accounting, together with the stretching of the outer layers of the aortic wall, for the increase in aortic luminal area. Intravascular ultrasound permitted also the accurate assessment of the improvement obtained. Intravascular imaging was clearly superior not only to conventional angiography, but also to transesophageal echocardiography in detecting the mechanism of dilation. We conclude that ultravascular ultrasound, with the additional information that it provides, may help in the selection of patients for percutaneous dilation of the coarctation as well as contributing to the identification of the mechanism of dilation.