Cardiovascular disease and survival in non-small cell lung cancer: a multicenter prospective assessment.

PURPOSE: Chronic inflammation contributes to cancer development via multiple mechanisms. We hypothesized that cardiovascular diseases (CVD) are also an independent risk factor for survival in non-small cell lung cancer (NSCLC). MATERIALS AND METHODS: Prospective multicenter data from 345 consecutive NSCLC patients treated from January 2013 to January 2017 were assessed. Median follow-up for all patients was 13 months (range 3-60 months). There were 109 patients with baseline heart disease (HD 32%), 149 with arterial hypertension (43%), 85 with diabetes mellitus (25%), 129 with hyperlipidemia (37%) and 45 with venous thromboembolism events (VTE 13%). A total of 289 patients (84%) were treated with platinum-based chemotherapy (CT), 300 patients (87%) received thoracic radiation therapy (RT; median radiation dose: 60 Gy [range 12-70]); and 50 (15%) patients underwent surgery. RESULTS: Our cohort consisted of 305 men (88%) and 40 (12%) women, with a median age of 67 years (range 31-88 years). Seventy percent had a Karnofsky performance status (KPS) ≥ 80. Multivariate analyses showed a lower OS and higher risk of distant metastasis in patients with advanced stages (p = 0.05 and p < 0.001, respectively) and HD (HR 1.43, p = 0.019; and HR 1.49, p = 0.025, respectively). Additionally, patients with VTE had lower local control (HR 1.84, p = 0.025), disease-free survival (HR 1.64, p = 0.020) and distant metastasis-free survival (HR 1.73, p = 0.025). CONCLUSIONS: HD and VTE are associated with a higher risk of mortality and distant metastasis in NSCLC patients. Chronic inflammation associated with CVDs could be an additional pathophysiologic factor in the development of distant metastasis.

Morbimortalidad y consumo de recursos asociados tras síndrome coronario agudo en una población española / Morbi-mortality and use of recourses after acute coronary syndrome in a Spanish population

Objetivo. Describir el manejo de los pacientes con síndrome coronario agudo (SCA) y determinar sus consecuencias clínicas y económicas en la población española. Pacientes y métodos. Estudio multicéntrico y retrospectivo basado en revisión de registros médicos, de dos años de seguimiento con pacientes de 6 centros de Atención Primaria y dos hospitales. Se incluyeron pacientes mayores de 30 años, que padecieron un primer SCA entre 2003 y 2007. Grupos: pacientes con SCA con y sin elevación del segmento ST. Variables: sociodemográficas, comorbilidades, síndrome metabólico (SM), parámetros bioquímicos, fármacos, incidencia acumulada (mortalidad total y eventos cardiovasculares [ECV]: incluyendo infarto de miocardio, accidente vasculocerebral y arteriopatía periférica que requieren hospitalización]) y costes totales. Análisis estadístico: regresión logística, curvas Kaplan-Meier y ANCOVA; p<0 05 esultados. Fueron incluidos 1.020 pacientes. Edad media: 69 años; 65% hombres. Grupos: SCA con elevación ST (N=632; 62%). Comorbilidades: hipertensión (56%), dislipemia (46%) y diabetes (38%). Prevalencia de SM: 59% (IC 95%: 56-62%). Todos los parámetros bioquímicos mejoraron tras dos años. El coste medio por paciente fue de 14.069 € (87% costes directos y el 13% costes por pérdida de productividad). Costes directos: Atención Primaria (20%), atención especializada (67%); los costes de hospitalización representaron el 63% de los costes totales. El coste medio por paciente con más de un ECV fue 22.750 € vs 12.380 € de los que presentaron un único evento (p<0 001 incidencia acumulada: mortalidad total 14 cve: 16 Conclusiones. En la práctica clínica habitual y a pesar de los esfuerzos clínicos realizados, los pacientes con SCA siguen manteniendo un elevado riesgo de sufrir futuros ECV, representando un alto coste para el sistema sanitario(AU)

Objectives. To describe the management of patients suffering acute coronary syndrome (ACS) and to determine its clinical and economic consequences in a Spanish population. Methods. A multicenter, retrospective claim database study including patient medical records from 6 primary care centers, two hospitals and two years of follow-up was carried out. Patients ≥30 years, suffering a first acute coronary syndrome (ACS), between 2003 and 2007, were included. Groups: acute coronary syndrome with and without ST segment elevation. Variables: socio-demographic, co-morbidities, metabolic syndrome (MS), biochemical parameters, drugs, cumulative incidence (total mortality and cardiovascular events (CVE: including myocardial infarction, stroke and peripheral artery disease) and total costs. Statistical analysis: logistic regression, Kaplan-Meier curves and ANCOVA; (P<.05). Results. A total of 1020 patients were included. Mean age: 69 years; males: 65%. Groups: ST segment elevation ACS (N=632; 62%). Co-morbidities: hypertension (56%), dyslipidemia (46%) and diabetes (38%). Prevalence of MS: 59% (CI 95%: 56-62%). All biochemical parameters had improved after two years of follow-up. The average total cost per patient was €14,069 (87% direct costs; 13% productivity loss costs). Direct costs: primary care (20%), specialty care (67%); hospitalization costs represented 63% of total costs. The average total cost for patients presenting more than one CVE was 22,750€ vs 12,380€ for those patients who suffered only one (P<.001). Cumulative incidence: total mortality 14%; CVE: 16%. Conclusions. In the current clinical practice, and despite the clinical efforts carried out, patients with an ACS are still at a high risk of suffering further CVE, representing a high cost burden to the health care system(AU)

Resultados de la campaña “ahora sí” / No disponible

Introducción: La Sociedad Española de Cardiología (SEC), Sociedad Española de Médicos de Atención Primaria, (SEMERGEN) y Sociedad Española de Neumología y Cirugía Torácica, (SEPAR) quisieron aprovechar la oportunidad que les brindaba la implantación de la nueva ley reguladora del consumo del tabaco en los lugares públicos, para promover una campaña en favor de la prevención y el control del tabaquismo. Objetivo: Los principales objetivos han sido: informar a toda la población general sobre los diferentes aspectos sanitarios relacionados con el tabaquismo, formar a los profesionales sanitarios en las disciplinas de prevención, diagnóstico y tratamiento del tabaquismo y crear o potenciar recursos sanitarios para ayudar a dejar de fumar. Metodología: La campaña ha sido dirigida por un comité constituido por expertos de las tres sociedades cientí cas y se ha llevado a cabo con la colaboración de los colegios o ciales de médicos y de los ayuntamientos. La campaña, que ha tenido una duración de 8 meses, se ha realizado en 13 ciudades de tamaño medio y repartidas por todo el territorio español: Alcobendas, Ávila, Cáceres, Calatayud, Córdoba, Cuenca, Girona, Irún, Las Palmas de Gran Canaria, Menorca, Ontinyent, Oviedo y Xátiva. La campaña consistió en la distribución de carteles informativos, ruedas de prensa, notas de prensa, realización de charlas para adultos, charlas para jóvenes, realización de cursos de formación en diagnóstico y tratamiento del tabaquismo para profesionales sanitarios y creación de consultas de tabaquismo o potenciaciónde las existentes. Resultados: Se han realizado 13 ruedas de prensa a las que acudieron 74 medios informativos. Se han repartidomas 7800 carteles. Se impartieron un total de 13 charlas dirigidas a la población general y 10 dirigidas a los jóvenes. Ello ha supuesto que se ha llegado de forma directa a un total de 500 personas adultas y a un total de 400 jóvenes. Se calcula que los mensajes de la campaña han llegado a más de 24.500.000 de ciudadanos en todo el territorio español. Se han realizado un total de 11 cursos que han servido para formar a 317 profesionales sanitarios. Se ha actuado en 14 consultas tratándose a un total de 466 fumadores. De estas 14 consultas, 5 eran consultas establecidas con anterioridad y 9 han sido consultas de nueva creación. Todas ellas continúan sus trabajos después de la nalización de la campaña. Conclusiones: La campaña “Ahora Si” ha servido para enviar mensajes sanitarios en favor del control del tabaquismo a mas de 24.500.000 de ciudadanos, ha facilitado la formación de 317 profesionales sanitarios y ha potenciado y creado nuevos recursos sanitarios asistenciales en tabaquismo (AU)

Introduction: Sociedad Española de Cardiología (SEC), Sociedad Española de Médicos de Atención Primaria, (SEMERGEN) and Sociedad Española de Neumología y Cirugía Torácica, (SEPAR) have wanted to take advantage from the implementation of the new Spanish anti-smoking Law in order to promote a campaign in favor of smoking control. Objective: The main objectives are as follows: to give information about smoking to the Spanish general population, to teach health professionals on smoking control and to create and develop smoking cessation resources. Methods: The campaign has been conducted by experts from the three scienti c societies and in collaboration with physicians colleages and representatives of the local administration. The campaign has lasted 8 months and has taken places in 13 medium size towns: Alcobendas, Ávila, Cáceres, Calatayud, Córdoba, Cuenca, Girona, Irún, Las Palmas de Gran Canaria, Menorca, Ontinyent, Oviedo y Xátiva. The campaign consisted of distribution of posters, media meetings, talks for adults and children, training courses for health professionals and development of smoking cessation resources. Results: 13 media meetings were undertaken. 7800 posters were distributed. 13 talks were spoken focusing general population and 10 focusing young people. The campaign impacted directely to 500 adults and 400 youngs. The campaign impacted indirectely in more tan 24.500.000 people. 11 training courses gave knowledge on smoking cessation to 317 health professionals. 14 of ces for smoking cessation has been created and all of them continue working after the campaign has nished Conclusions: “Ahora Si” campaign has served to send messages in favour of smoking control to more than 24.500.000 people all over the Spain, has increased knowledge on smoking cessation in 317 health professionals and has increased the number of Spanish smoking cessation resources

[Morbi-mortality and use of recourses after acute coronary syndrome in a Spanish population]. / Morbimortalidad y consumo de recursos asociados tras síndrome coronario agudo en una población española.

OBJECTIVES: To describe the management of patients suffering acute coronary syndrome (ACS) and to determine its clinical and economic consequences in a Spanish population. METHODS: A multicenter, retrospective claim database study including patient medical records from 6 primary care centers, two hospitals and two years of follow-up was carried out. Patients ≥30 years, suffering a first acute coronary syndrome (ACS), between 2003 and 2007, were included. Groups: acute coronary syndrome with and without ST segment elevation. VARIABLES: socio-demographic, co-morbidities, metabolic syndrome (MS), biochemical parameters, drugs, cumulative incidence (total mortality and cardiovascular events (CVE: including myocardial infarction, stroke and peripheral artery disease) and total costs. STATISTICAL ANALYSIS: logistic regression, Kaplan-Meier curves and ANCOVA; (P<.05). RESULTS: A total of 1020 patients were included. Mean age: 69 years; males: 65%. Groups: ST segment elevation ACS (N=632; 62%). Co-morbidities: hypertension (56%), dyslipidemia (46%) and diabetes (38%). Prevalence of MS: 59% (CI 95%: 56-62%). All biochemical parameters had improved after two years of follow-up. The average total cost per patient was €14,069 (87% direct costs; 13% productivity loss costs). Direct costs: primary care (20%), specialty care (67%); hospitalization costs represented 63% of total costs. The average total cost for patients presenting more than one CVE was 22,750€ vs 12,380€ for those patients who suffered only one (P<.001). Cumulative incidence: total mortality 14%; CVE: 16%. CONCLUSIONS: In the current clinical practice, and despite the clinical efforts carried out, patients with an ACS are still at a high risk of suffering further CVE, representing a high cost burden to the health care system.

Análisis del impacto presupuestario para el Sistema Nacional de Salud de la combinación fija de amlodipino 5 o 10mg y atorvastatina 10mg / Analysis of the budget impact for the Spanish National Health System of the fixed combination of amlodipine 5 or 10mg and atorvastatin 10mg

Objetivo Realizar un análisis de impacto presupuestario (AIP) de la introducción en la prestación sanitaria del sistema nacional de salud (SNS) de la combinación fija (CF) de amlodipino 5 o 10mg y atorvastatina 10mg en la indicación aprobada. Material y métodos El AIP se ha realizado desde la perspectiva del SNS para un periodo de 3 años (2009–2011). Se ha diseñado un modelo de decisión tipo árbol (árbol de pacientes) construido a partir de datos epidemiológicos y la literatura científica para estimar la población hipertensa susceptible de tratamiento con la CF. El AIP, por año y en total, se ha calculado imputando el coste a PVP-IVA de la CF al número de pacientes a tratar, del que se sustrae el coste del tratamiento antihipertensivo que se sustituye y el coste por paciente promedio actualizado de los eventos cardiovasculares prevenidos para el SNS por el uso de la CF en el periodo de referencia. Resultados La población susceptible de tratamiento con la CF es de 51.104 pacientes (1.er año), con una tasa de crecimiento entre 1–2% en los sucesivos años, lo que supone un coste (€) anual de 15,9M (2009), 19,9M (2010) y 24,1M (2011), totalizando 60,0M. El AIP se ve compensado mostrando valores de impacto negativo para el SNS cuando se descuentan los costes del tratamiento antihipertensivo sustituido y eventos cardiovasculares prevenidos, mostrando un ahorro de 69,9M € en 3 años. Conclusión El AIP de la CF de atorvastatina y amlodipino muestra que su uso en la indicación aprobada podría generar ahorros netos para el SNS en el periodo 2009–2011 de 9,9M (AU)

Objective To carry out a Budget Impact Analysis (BIA) of the inclusion of the administration, within the Spanish National Health System (SNS), of the fixed combination (FC) of amlodipine 5 or 10mg and atorvastatin 10mg for approved indications. Materials and Methods A BIA was carried out from the SNS perspective for a 3 year period (2009–2011). A tree type decision model was designed (tree of patients), based on epidemiological data and scientific literature, to estimate the hypertensive population that could be treated with a FC. The total per annum BIA was calculated by attributing the retail price- VAT of the FC to the number of patients to be treated, and deducting the cost of the treatment for hypertension that was replaced and the updated average cost per patient of cardiovascular events (CVEs) prevented by the use of the FC by the SNS during the period of study. Results The patient population susceptible to treatment with the FC was 51,104 patients (1st year), with a growth rate of between 1–2% over the following years, which means an annual cost (€) of 15.9M (2009), 19.9M (2010) and 24.1M (2011), with a total of 60.0M. The BIA was compensated showing negative impact values for the SNS when the cost of replaced antihypertensive treatment and prevented CVEs was deducted, with savings of €69.9M over 3 years. Conclusion The BIA of a FC of atorvastatin and amlodipine shows that the use of this medication for approved indications could generate net savings for the SNS of €9.9M for the period 2009–2011 (AU)

[Analysis of the budget impact for the Spanish National Health System of the fixed combination of amlodipine 5 or 10mg and atorvastatin 10mg]. / Análisis del impacto presupuestario para el Sistema Nacional de Salud de la combinación fija de amlodipino 5 o 10mg y atorvastatina 10mg.

OBJECTIVE: To carry out a Budget Impact Analysis (BIA) of the inclusion of the administration, within the Spanish National Health System (SNS), of the fixed combination (FC) of amlodipine 5 or 10mg and atorvastatin 10mg for approved indications. MATERIALS AND METHODS: A BIA was carried out from the SNS perspective for a 3 year period (2009-2011). A tree type decision model was designed (tree of patients), based on epidemiological data and scientific literature, to estimate the hypertensive population that could be treated with a FC. The total per annum BIA was calculated by attributing the retail price- VAT of the FC to the number of patients to be treated, and deducting the cost of the treatment for hypertension that was replaced and the updated average cost per patient of cardiovascular events (CVEs) prevented by the use of the FC by the SNS during the period of study. RESULTS: The patient population susceptible to treatment with the FC was 51,104 patients (1(st) year), with a growth rate of between 1-2% over the following years, which means an annual cost (euro) of 15.9M (2009), 19.9M (2010) and 24.1M (2011), with a total of 60.0M. The BIA was compensated showing negative impact values for the SNS when the cost of replaced antihypertensive treatment and prevented CVEs was deducted, with savings of euro69.9M over 3 years. CONCLUSION: The BIA of a FC of atorvastatin and amlodipine shows that the use of this medication for approved indications could generate net savings for the SNS of euro9.9M for the period 2009-2011.

Comorbilidades y consumo de recursos sanitarios en población fumadora. Un análisis desde Atención Primaria / Comorbidity and health resources use in smokers. An analysis from a primary care setting

FundamentoMedir el perfil de morbilidad, la consecución de objetivos terapéuticos, el uso de recursos y la incidencia de eventos cardiovasculares (ECV) de sujetos fumadores en Atención Primaria (AP).Pacientes y métodosDiseño retrospectivo y multicéntrico. Se incluyó a todos los pacientes fumadores de más de treinta años de edad de cinco equipos de AP (año 2006). Se formó una cohorte comparativa formada por no fumadores. Las principales medidas fueron presencia de ECV, edad, sexo, índice de Charlson, comorbilidad, parámetros clínicos y costes directos (fijos y variables; visitas, medicamentos, pruebas y derivaciones). Se empleó un análisis de regresión logística y un análisis de la covarianza para la corrección del modelo (p<0,05).ResultadosSe incluyó a 55.653 pacientes. Un 20,8% (intervalo de confianza del 95%: 20,5–21,1%) fueron fumadores. El promedio de edad de los fumadores fue menor (48,2 frente a 55,9 años), con predominio de varones (60,8%) (p<0,01) y similar índice de Charlson (0,3 frente a 0,3; p=no significativa [NS]). La proporción de fumadores en hipertensos fue del 18,8% y en diabéticos del 9,6%. La prevalencia de ECV en fumadores fue del 4,9 frente al 4,2% y la incidencia acumulada/anual del 14,2 frente al 12,5‰ (p<0,028). Los fumadores mostraron mayores niveles de triglicéridos séricos (136,3 mg/dl) y colesterol ligado a lipoproteínas de baja densidad (128,0 mg/dl) (p<0,001). El tabaquismo tuvo una relación independiente con el alcoholismo (odds ratio [OR]=5,3) y la enfermedad pulmonar obstructiva crónica (OR=2,5) en presencia de ECV (OR=1,2) (p<0,001). Los costes directos corregidos no mostraron diferencias: 660,10 frente a 654,11 € (p=NS) (en todos sus componentes)...(AU)

BackgroundTo ascertain the morbidity profile, achievement of the clinical control objectives, resources use and the incidence of cardiovascular events (CVE) in smoking subjects in Primary Care settings (PC).MethodsRetrospective multicentric study. All smoker subjects older than thirty years attended in any of five PC settings were included. A comparative cohort was established with non-smokers. Primary measures were: presence of CVE, age, gender, Charlson index, history/co-morbidity and clinics parameters and direct costs (fixed and variable; visits, drugs, diagnostic test and referrals). Multiple logistic regression analysis and ANCOVA models were applied for models correction, P<0.05.Results55,653 patients were included. 20.8% (95% confidence intervals [CI]:20.5–21.1%) were smokers. Non-smokers were younger (48.2 versus 55.9 years), with more men (60.8%), P<0.01; and a similar Charlson index (0.3 versus 0.3; P=NS). The proportion of smokers in hypertensive population was 18.8% and in diabetics 9.6%. CVE presence in smokers were 4.9% versus 4.2% and the accumulated incidence/annual of 14.2‰ versus 12.5‰, P<0.028. Smokers showed higher levels of serum triglycerides (136.3 mg/dl) and LDL-cholesterol (128.0 mg/dl, P<0.001). Smoking habit was independent related to the alcoholism (Odds ratio, OR=5.3) and the EPOC (OR=2.5), in presence of CVE (OR=1.2, P<0.001). Adjusted direct costs non differences showed: €660.10 versus €654.11, P=NS (in all components).ConclusionsCVE annual incidence in smoking subjects was greater, with a minor average of age. Smokers presented a similar number of co-morbidities and total/patient costs. Clinical control objectives should be better in Primary prevention of the cardiovascular risk factors. To give up smoking should be the best strategy to diminish CVE incidence(AU)

[Comorbidity and health resources use in smokers. An analysis from a primary care setting]. / Comorbilidades y consumo de recursos sanitarios en población fumadora. Un análisis desde Atención Primaria.

BACKGROUND: To ascertain the morbidity profile, achievement of the clinical control objectives, resources use and the incidence of cardiovascular events (CVE) in smoking subjects in Primary Care settings (PC). METHODS: Retrospective multicentric study. All smoker subjects older than thirty years attended in any of five PC settings were included. A comparative cohort was established with non-smokers. Primary measures were: presence of CVE, age, gender, Charlson index, history/co-morbidity and clinics parameters and direct costs (fixed and variable; visits, drugs, diagnostic test and referrals). Multiple logistic regression analysis and ANCOVA models were applied for models correction, P<0.05. RESULTS: 55,653 patients were included. 20.8% (95% confidence intervals [CI]:20.5-21.1%) were smokers. Non-smokers were younger (48.2 versus 55.9 years), with more men (60.8%), P<0.01; and a similar Charlson index (0.3 versus 0.3; P=NS). The proportion of smokers in hypertensive population was 18.8% and in diabetics 9.6%. CVE presence in smokers were 4.9% versus 4.2% and the accumulated incidence/annual of 14.2 per thousand versus 12.5 per thousand, P<0.028. Smokers showed higher levels of serum triglycerides (136.3 mg/dl) and LDL-cholesterol (128.0 mg/dl, P<0.001). Smoking habit was independent related to the alcoholism (Odds ratio, OR=5.3) and the EPOC (OR=2.5), in presence of CVE (OR=1.2, P<0.001). Adjusted direct costs non differences showed: euro660.10 versus euro654.11, P=NS (in all components). CONCLUSIONS: CVE annual incidence in smoking subjects was greater, with a minor average of age. Smokers presented a similar number of co-morbidities and total/patient costs. Clinical control objectives should be better in Primary prevention of the cardiovascular risk factors. To give up smoking should be the best strategy to diminish CVE incidence.

[Kidney disease: therapeutic implications in heart failure and coronary heart disease]. / Enfermedad renal: implicaciones terapéuticas en insuficiencia cardíaca y cardiopatía isquémica.

Heart failure (HF) is more prevalent and evolves more rapidly in patients with renal failure (RF). Renal failure not only produces myocardial damage, but also induces the development of clinical heart failure thus making the treatment of these patients more difficult. The incidence of HF in patients with RF is around 15%. Renal function in patients with RF is lower than in the general population. This is true for patients with preserved and depressed left ventricular ejection fraction (LVEF). HF mortality increases 30% for every 1-mg/dL increase in creatinine and renal function should always be considered when assessing the cardiovascular risk and therapeutic alternatives of cardiovascular patients. Angiotensin converting enzyme inhibitors, Angiotensin receptor blockers and aldosterone blockers may cause acute renal failure and serum creatinine and potassium should be closely monitored. Chronic RF is a human model of accelerated atherosclerosis. It induces a rapid progression of coronary atherosclerosis and make atherosclerotic plaques more vulnerable to acute coronary syndromes (ACS) because of coagulation changes inherent to RF. Ischemia is also more frequent due to the imbalance between oxygen requirements and supplies. Chronic RF is associated with a worse outcome in patients with ACS and increases the risk of bleeding, and is associated with a higher mortality in patients under surgical or percutaneous coronary revascularization. Of the patients treated with an interventional coronary procedure (ICP), 3,3% suffer acute RF. Saline administration at a dose of 1 ml/kg/h for 12 hours before and 12 hours after ICP prevents the development of acute RF. Although the role of N-acetylcysteine is under discussion, taking into account the favourable risk profile of this drug, it seems reasonable to administer N-acetylcysteine in addition to saline administration. In ACS patients with severe RF, the risk of severe bleeding depends upon the anticoagulation regimen, increasing particularly when unfractionated heparin is used in combination with GP IIb/IIIa inhibitors.

Enfermedad renal: implicaciones terapéuticas en insuficiencia cardíaca y cardiopatía isquémica / Kidney disease: therapeutic implications in heart failure and coronary heart diseas

La insuficiencia cardíaca (IC) en pacientes con insuficiencia renal (IR) es más frecuente y evoluciona de forma más rápida. La IR no sólo condiciona daño miocárdico, sino que facilita el desarrollo de IC clínica y dificulta el tratamiento. La incidencia de IC en pacientes con IR se sitúa en torno al 15%. La función renal de los pacientes con IC está disminuida, tanto en los casos de función sistólica preservada como en los de función sistólica disminuida. La mortalidad de la IC aumenta en un 30% por cada aumento de 1 mg/dl de creatinina; por tanto, la función renal siempre debe tenerse en cuenta a la hora de estratificar el riesgo y evaluar las alternativas terapéuticas. Los inhibidores de la enzima de conversión de la angiotensina, los antagonistas de los receptores de la angiotensina II y los antagonistas de la aldosterona pueden precipitar IR aguda, por lo que en todos los pacientes se debe vigilar de forma atenta el potasio sérico y los valores de creatinina. La IR crónica es un modelo humano de aterosclerosis acelerada, no sólo produce una rápida progresión de la aterosclerosis coronaria, sino que hace más probables los episodios agudos y más frecuente la isquemia, debido a las alteraciones de la coagulación propias de la IR y al deterioro del equilibrio entre oferta y demanda de oxígeno. La presencia de IR crónica predice la mala evolución de los pacientes con síndrome coronario agudo (SCA), aumenta el riesgo de hemorragia y se asocia a una mortalidad mayor en los pacientes sometidos a revascularización percutánea o quirúrgica. El 3,3% de los individuos sometidos a intervención coronaria percutá- nea (ICP) presentan un episodio de IR aguda. La administración de suero salino a dosis de 1 ml/kg/h las 12 h precateterismo y poscateterismo previene el desarrollo de IR aguda tras una ICP. Aunque el papel de la N-acetilcisteína es controvertido, dado su buen perfil de seguridad, parece razonable administrarla junto con el suero salino. En pacientes con SCA con IR grave, el riesgo de hemorragia grave depende del régimen de anticoagulación, el cual aumenta especialmente cuando se combinan heparina no fraccionada e inhibidores de la glucoproteína IIb/IIIa (AU)

Heart failure (HF) is more prevalent and evolves more rapidly in patients with renal failure (RF). Renal failure not only produces myocardial damage, but also induces the development of clinical heart failure thus making the treatment of these patients more difficult. The incidence of HF in patients with RF is around 15%. Renal function in patients with RF is lower than in the general population. This is true for patients with preserved and depressed left ventricular ejection fraction (LVEF). HF mortality increases 30% for every 1-mg/dL increase in creatinine and renal function should always be considered when assessing the cardiovascular risk and therapeutic alternatives of cardiovascular patients. Angiotensin converting enzyme inhibitors, Angiotensin receptor blockers and aldosterone blockers may cause acute renal failure and serum creatinine and potassium should be closely monitored. Chronic RF is a human model of accelerated atherosclerosis. It induces a rapid progression of coronary atherosclerosis and make atherosclerotic plaques more vulnerable to acute coronary syndromes (ACS) because of coagulation changes inherent to RF. Ischemia is also more frequent due to the imbalance between oxygen requirements and supplies. Chronic RF is associated with a worse outcome in patients with ACS and increases the risk of bleeding, and is associated with a higher mortality in patients under surgical or percutaneous coronary revascularization. Of the patients treated with an interventional coronary procedure (ICP), 3,3% suffer acute RF. Saline administration at a dose of 1ml/kg/h for 12 hours before and 12 hours after ICP prevents the development of acute RF. Although the role of N-acetylcisteine is under discussion, taking into account the favourable risk profile of this drug, it seems reasonable to administer N-acetylcisteine in addition to saline administration. In ACS patients with severe RF, the risk of severe bleeding depends upon the anticoagulation regimen, increasing particulary when unfractionated heparin is used in combination with GP IIb/IIIa inhibitors (AU)

Efecto del tratamiento intensivo con atorvastatina frente a dosis estándar de estatinas en el riesgo de ictus de pacientes con enfermedad coronaria previa. Metaanálisis de cinco ensayos aleatorizados con 25.709 pacientes / Effect of intensive tretament with atorvastatin versus standard doses of statins on the risk of stroke. A meta analysis form five randomized trials incluiding 25, 709 patients

Objetivo. Evaluar, mediante técnicas de metaanálisis, la eficacia hipolipemiante del tratamiento intensivo con atorvastatina frente a dosis estándar de estatinas (sinvastatina, atorvastatina, lovastatina o pravastatina) en el riesgo de ictus en pacientes con enfermedad coronaria previa. Pacientes y métodos. Se incluyeron los cinco ensayos clínicos realizados hasta enero de 2006 que cumplieron los siguientes criterios: comparación de atorvastatina intensiva –80 mg u objetivo de lipoproteínas de baja densidad (LDL) < 70 mg/dL– con dosis estándar de estatinas; duración de más de 12 meses e ictus como objetivo del estudio (secundario o principal combinado). TNT (n = 9.917): atorvastatina 80 mg frente a 10 mg; IDEAL (n = 8.888): atorvastatina 80 mg frente a sinvastatina 20-40 mg; PROVE-IT (n = 4.162): atorvastatina 80 mg frente a pravastatina 40 mg; ALLIANCE (n = 2.442): atorvastatina 80 mg u objetivo LDL < 70 mg/dL frente a dosis estándar de estatinas; y VBSS (n = 300): atorvastatina 80 mg frente a dosis bajas de lovastatina. Los estudios considerados incluyeron población en prevención secundaria (síndrome coronario agudo, enfermedad coronaria estable, pacientes elegibles para angioplastia). Se incluyeron 25.709 pacientes (12.910 en la rama con atorvastatina intensiva y 12.799 en la rama con dosis estándar de estatinas). Se comparó la incidencia de ictus entre ambas ramas. Resultados. 713 pacientes (2,77%) de los 25.709 sufrió un ictus durante el seguimiento. La incidencia de ictus fue significativamente menor en la rama atorvastatina intensiva que en la rama tratada con dosis estándar de estatinas: 2,52% (n = 325) frente a 3,03% (n = 388); riesgo relativo = 0,83; intervalo de confianza al 95% = 0,72-0,96; p = 0,0121. Conclusiones. En pacientes con enfermedad coronaria previa, el tratamiento hipolipemiante intensivo con atorvastatina se asocia a una reducción del 17% en el riesgo de ictus en comparación con dosis estándar de estatinas (AU)

Aim. To evaluate the efficacy of intensive lipid lowering treatment with atorvastatin versus standard doses of statins (simvastatin, atorvastatin, lovastatin or pravastatin) on the risk of stroke, using meta-analytic techniques. Patients and methods. The meta-analysis included 5 randomized trials that met the inclusion criteria: comparison between intensive atorvastatin treatment (atorvastatin 80 mg or target LDL < 70 mg/dL) and standard doses of statins, with a clinical follow-up of more than 12 months and stroke as clinical endpoint. TNT (n = 9,917) atorvastatin 80 mg vs. 10 mg; IDEAL (n = 8,888) atorvastatin 80 mg vs. simvastatin 20-40 mg; PROVE-IT (n = 4,162) atorvastatin 80 mg vs. pravastatin 40 mg; ALLIANCE (n = 2,442) atorvastatin 80 mg or target LDL < 70 mg/dL vs. standard treatment; and VBBS (n = 300) atorvastatin 80 mg vs. low dose lavastatin. The selected studies included secondary prevention patients (acute coronary syndrome, stable coronary disease and patients eligible for angioplasty). 25,709 patients were included (12,910 allocated to intensive atorvastatin treatment, and 12,799 to standard doses of statins). Stroke incidence, as reported from each trial, was compared between both treatments. Results. Out of the 25,709 patients, 713 (2.77%) suffered a stroke during follow-up. The incidence of stroke was significantly reduced with intensive atorvastatin treatment in comparison with conventional doses of statins: 2.52% (n = 325) vs. 3.03% (n = 388); relative risk = 0.83; 95% confidence interval = 0.72-0.96; p = 0.0121. Conclusions. Intensive lipid lowering treatment with atorvastatin is associated with a 17% relative risk reduction of stroke in comparison with conventional doses of statins in secondary prevention population (AU)

Morbilidad y costes asociados al síndrome depresivo en sujetos con ictus en un ámbito poblacional / Morbidity and costs associated with depressive syndrome in stroke sufferers in a population

Objetivo: Medir la morbilidad y los costes asociados al síndrome depresivo (SD) en sujetos con ictus en población atendida por equipos de atención primaria y en condiciones de práctica clínica habitual. Método: Estudio transversal de carácter retrospectivo. Se incluyeron pacientes adultos con presencia de ictus y de SD atendidos por 5 equipos de atención primaria durante el año 2006. Se formó una cohorte comparativa con el resto de pacientes sin SD. Las principales medidas fueron: edad, sexo, historial/comorbilidad, índice de Charlson, parámetros clínicos y costes totales (visitas, pruebas complementarias, derivaciones y medicamentos). Se efectuó un análisis de regresión logística y de ANCOVA para la corrección de los modelos. Resultados: El total de pacientes atendidos con ictus fue de 2.566. Un 17,7% (intervalo de confianza del 95%, 16,2-19,2%) se identificaron con SD; promedio de edad: 69,5 años (desviación estándar: 12,6); el 57,2% eran mujeres. En la corrección del modelo, el sexo femenino (odds ratio [OR]: 2,1), la obesidad (OR: 1,1) y las neuropatías (OR: 2,2) se asociaron significativamente al SD en sujetos con ictus. Los costes totales ajustados del SD fueron superiores en la mayoría de sus componentes, 2.037,55 frente a 1.498,24 ¿, p < 0,001. El 73,4% de los costes se derivó de los medicamentos. Conclusiones: La prevalencia del SD en sujetos con ictus es elevada, se asocia al sexo femenino y a la presencia de obesidad y neuropatías. Los costes de estos pacientes son altos y ocasionan un elevado consumo de recursos sanitarios (AU)

Objective: To measure morbidity and the associated costs of depressive disorders (DD) in subjects who have had a stroke in a population treated by primary care settings under usual clinical practice conditions. Method: Cross-sectional, retrospective studies. Adult stroke patients with DD were included in the study, and treated by five primary care settings (PCS) during 2006. A comparative group was formed with the rest of non-DD patients. The main measurements taken were: age, sex, history/co-morbidity, Charlson index, clinical parameters and corresponding outpatient costs; drugs, diagnostic tests, referrals and visits. Multiple logistic regression analysis and ANCOVA were used to correct the models. Results: A total of 2,566 stroke patients were assessed. 17.7% (95% CI, 16.2-19.2%) were identified as having DD; average age: 69.5 years (12.6); 57.2% of those were female. In the correction of the model, females (OR: 2.1), obesity (OR: 1.1) and neuropathy (OR: 2.2), were significantly associated with DD in stroke patients. The adjusted total costs of DD were higher in most components, ¿ 2,037.55 versus ¿ 1,498.24, p < 0.001. 73.4% of the total cost was drugs-derived. Conclusions: Prevalence of DD was higher in stroke patients, and was more associated with females, obesity and neuropathy. The patient cost is high and patients use more health resources (AU)

[Estimation of the prevalence, incidence, comorbidities and direct costs associated to stroke patients requiring care in an area of the Spanish population]. / Estimación de la prevalencia, incidencia, comorbilidades y costes directos asociados en pacientes que demandan atención por ictus en un ámbito poblacional español.

AIM: To determinate the prevalence, incidence, co-morbidities and therapeutic objectives and costs of stroke among Spanish population. PATIENTS AND METHODS: A retrospective study was performed based on data from patients attended for stroke, aged > 30 years, from five Spanish primary care centres and two hospitals in 2006. Comparative group: patients without stroke. Main analysed variables were: age, sex, co-morbidity (cardiovascular/others), clinical parameters and direct costs (pharmacy, derivations, visits, emergencies, procurement, and hospitalisation). An ANCOVA analysis and logistic regression were used to fit the model. RESULTS: A 4.5% of 57.026 patients (n = 2.585; CI 95% = 4.3-4.7%) suffered stroke. The incidence of stroke was 220 new-cases/100.000 populations. Main differences between patients suffering stroke/control group were: age (72.5 vs. 53.5), men (58.2% vs. 44.6%), episodes/year (7,9 vs. 4,8), visits/year (15,8 vs. 8,1), p < 0,001. Stroke had an independent relation with age (OR = 1,4), male (OR = 2,3), diabetes (OR = 1,6), hypertension (OR = 1,5), smoking (OR = 1,5), alcohol (OR = 1,4), depression (OR = 1,4), dyslipidemia (OR = 1,3) and dementia (OR = 1,2). Some of the results were: systolic pressure (134.1 vs. 127.6 mmHg) and LDL-cholesterol (116.4 vs. 126.2 mg/dL), in presence/absence of stroke, p < 0,001. The average of annual costs of stroke was 2,590.36 vs. 985.26 euros, p < 0.001. After the correction of the logistic model results did not change: 1,774.33 (CI 95% = 1,720.10-1.828.55) vs. 1,021.98 euros (CI 95% = 1,010.92-1,033.03), p < 0,001. All components of costs were higher in the stroke group. CONCLUSIONS: Patients that demanded assistance for stroke had a higher number of co-morbidities and a higher total cost/patient/year. Therapeutic objectives could be improved, mainly in primary prevention of cardiovascular risk factors.

Estimación de la prevalencia, incidencia, comorbilidades y costes directos asociados en pacientes que demandan atención por ictus en un ámbito poblacional español / Estimation of the prevalence, incidence, comorbidities and direct costs associated to stroke patients requiring care in an area of the Spanish population

Estimar la prevalencia e incidencia, así como la comorbilidad, objetivos terapéuticos y costes del ictusen un ámbito poblacional español. Pacientes y métodos. Es un diseño retrospectivo-multicéntrico. Se incluyeron pacientes mayores de 30 años que demandaron asistencia por ictus, pertenecientes a cinco equipos de atención primaria y dos hospitales durante el año 2006. Grupo comparativo: pacientes sin ictus. Principales variables: edad, sexo, casuística/comorbilid (cardiovascular/otras), parámetros bioquímicos y modelo de costes directos (medicamentos, procedimientos, derivaciones, visitas, hospitalizaciones y urgencias). Análisis estadístico: regresión logística y de análisis de covarianza (ANCOVA) para la corrección de los modelos, p < 0,05. Resultados. De los 57.026 pacientes, el 4,5% (n = 2.585; IC 95% = 4,3-4,7%) presentóictus. Incidencia: 220 casos nuevos por cada 100.000 habitantes. Los pacientes con/sin ictus mostraron: edad, 72,5/53,5 años; varones, 58,2/44,6%; episodios al año, 7,9/4,8; visitas al año, 15,8/8,1; p < 0,001. El ictus tuvo relación independiente con: edad (OR = 1,4), varones (OR = 2,3), diabetes (OR = 1,6), hipertensión (OR = 1,5), fumadores (OR = 1,5), alcoholismo(OR = 1,4), depresión (OR = 1,4), dislipemia (OR = 1,3) y demencias (OR = 1,2). Algunos resultados metabólicos fueron: tensión sistólica (134,1 frente a 127,6 mmHg) y colesterol-LDL (116,4 frente a 126,2 mg/dL), en presencia/ausencia de ictus,p < 0,001. El promedio de coste anual fue de 2.590,36 frente a 985,26 euros, p < 0,001, y se mantuvo después de corregir por edad-sexo y comorbilidades: 1.774,33 (IC 95% = 1.720,10-1.828,55) frente a 1.021,98 euros (IC 95% = 1.010,92-1.033,03), p < 0,001. Todos los componentes del coste fueron mayores en el ictus. Conclusiones. Los pacientes que demandaron atenciónpor ictus presentaron un elevado número de comorbilidades y un mayor coste total/paciente/año. Los objetivos terapéuticos de control siguen siendo mejorables, sobre todo en la prevención primaria de los factores de riesgo cardiovascular

To determinate the prevalence, incidence, co-morbidities and therapeutic objectives and costs of strokeamong Spanish population. Patients and methods. A retrospective study was performed based on data from patients attended for stroke, aged > 30 years, from five Spanish primary care centres and two hospitals in 2006. Comparative group: patientswithout stroke. Main analysed variables were: age, sex, co-morbidity (cardiovascular/others), clinical parameters and direct costs (pharmacy, derivations, visits, emergencies, procurement, and hospitalisation). An ANCOVA analysis and logisticregression were used to fit the model. Results. A 4.5% of 57.026 patients (n = 2.585; CI 95% = 4.3-4.7%) suffered stroke. The incidence of stroke was 220 new-cases/100.000 populations. Main differences between patients suffering stroke/control groupwere: age (72.5 vs. 53.5), men (58.2% vs. 44.6%), episodes/year (7,9 vs. 4,8), visits/year (15,8 vs. 8,1), p < 0,001. Stroke had an independent relation with age (OR = 1,4), male (OR = 2,3), diabetes (OR = 1,6), hypertension (OR = 1,5), smoking (OR =1,5), alcohol (OR = 1,4), depression (OR = 1,4), dyslipidemia (OR = 1,3) and dementia (OR = 1,2). Some of the results were: systolic pressure (134.1 vs. 127.6 mmHg) and LDL-cholesterol (116.4 vs. 126.2 mg/dL), in presence/absence of stroke, p <0,001. The average of annual costs of stroke was 2,590.36 vs. 985.26 euros, p < 0.001. After the correction of the logisticmodel results did not change: 1,774.33 (CI 95% = 1,720.10-1.828.55) vs. 1,021.98 euros (CI 95% = 1,010.92-1,033.03), p <0,001. All components of costs were higher in the stroke group. Conclusions. Patients that demanded assistance for stroke had a higher number of co-morbidities and a higher total cost/patient/year. Therapeutic objectives could be improved, mainly inprimary prevention of cardiovascular risk factors

[Morbidity and costs associated with depressive syndrome in stroke sufferers in a population]. / Morbilidad y costes asociados al síndrome depresivo en sujetos con ictus en un ámbito poblacional.

OBJECTIVE: To measure morbidity and the associated costs of depressive disorders (DD) in subjects who have had a stroke in a population treated by primary care settings under usual clinical practice conditions. METHOD: Cross-sectional, retrospective studies. Adult stroke patients with DD were included in the study, and treated by five primary care settings (PCS) during 2006. A comparative group was formed with the rest of non-DD patients. The main measurements taken were: age, sex, history/co-morbidity, Charlson index, clinical parameters and corresponding outpatient costs; drugs, diagnostic tests, referrals and visits. Multiple logistic regression analysis and ANCOVA were used to correct the models. RESULTS: A total of 2,566 stroke patients were assessed. 17.7% (95% CI, 16.2-19.2%) were identified as having DD; average age: 69.5 years (12.6); 57.2% of those were female. In the correction of the model, females (OR: 2.1), obesity (OR: 1.1) and neuropathy (OR: 2.2), were significantly associated with DD in stroke patients. The adjusted total costs of DD were higher in most components, euro 2,037.55 versus euro 1,498.24, p < 0.001. 73.4% of the total cost was drugs-derived. CONCLUSIONS: Prevalence of DD was higher in stroke patients, and was more associated with females, obesity and neuropathy. The patient cost is high and patients use more health resources.

[Antihypertensive and/or lipid-lowering treatments pattern of compliance in hypertense and/or dyslipemic patients in Primary Care]. / Patrón de cumplimiento terapéutico de antihipertensivos y/o hipolipemiantes en pacientes hipertensos y/o dislipémicos en Atención Primaria.

BACKGROUND AND OBJECTIVE: Lack of compliance is a major factor responsible for the differences between clinical trial results and real effectiveness in daily medical practice, contributing to an insufficient control of the cardiovascular risk factors (CVRF). Knowledge of the factors contributing to lack of compliance is limited, and in Spain data are scarce. The objectives of this study are: a) to indirectly determine the level of compliance among patients with hypertension and/or dyslipidemia; and b) to determine factors associated with compliance. MATERIAL AND METHOD: 9,001 hypertensive and/or dyslipidemic patients from four primary care centres in Catalonia were enrolled in Disease Management programmes during the previous four years. Compliance was estimated by the relationship between the amount of dispensed and prescribed pills: a) the levels of compliance of dyslipidemic patients without hypertension (DL-non HT), hypertensive patients with dyslipidemia (HT+DL) and hypertensives without dyslipidemia (HT-non DL) were compared; and b) an stepwise, multivariate, descriptive; multiple regression model was designed in order to explain compliance. RESULTS: 1. Compliance was 79% in DL-non HT, significantly lower than in HT+DL (81.2%, p=0.000) and in HT-non DL (82.4%, p=0.000). There were also statistically significant differences between these last two groups (p=0.001). 2. Explanatory variables of a better compliance in the multivariate analysis were: a) patient related factors: labour inactivity (p = 0.000); b) management related factors: specific doctor (p = 0.000) and intensity of follow-up (p = 0.04); and c) drug related factors: the drug group (p < 0.0001); the drug price (the higher price determines higher compliance, p = 0.006) and the number of active principles used (the higher number determines lower compliance, p = 0.019). CONCLUSIONS: 1. Dyslipidemic patients show a worse compliance than hypertensive patients, and dyslipidemia worsened global compliance in hypertensive patients. 2. Patient characteristics, doctor attitude, follow-up intensity, drug group and simplicity of treatment are related to compliance in daily medical practice.

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Patrón de cumplimiento terapéutico de antihipertensivos y/o hipolipemiantes en pacientes hipertensos y/o dislipémicos en Atención Primaria / Antihypertensive and/or lipid-lowering treatments pattern of compliance in hypertensive and/or dyslipemic patients in primary care

Fundamento y objetivo: La falta de cumplimiento es uno de los principales factores responsables en las diferencias entre los resultados de los ensayos clínicos y la efectividad real encontrada en la práctica clínica diaria, y contribuye a un control insuficiente de los factores de riesgo cardiovascular (FRCV). Existe poco conocimiento de los factores que contribuyen a la falta de cumplimiento y en España los datos son escasos: Los objetivos de este estudio son: a) determinar de forma indirecta el grado de cumplimiento, en sujetos con hipetensión y/o dislipidemia; y b) estudiar qué factores se asocian con el cumplimiento. Material y método: Se seleccionaron 9.001 pacientes hipertensos y/o dislipémicos adscritos a cuatro centros de atención primaria de Cataluña: a) se comparó el grado de cumplimiento entre los pacientes dislipémicos sin hipertensión (DL sin HTA), hipertensos con dislipemia (HTA con DL) e hipertensos sin dislipemia (HTA sin DL); y b) se construyó un modelo multivariante de regresión múltiple escalonado descriptivo, para explicar la variable cumplimiento terapéutico. Resultados: 1. El cumplimiento fue 79,0% en los DL sin HTA, significativamente menor que en los HTA DL: 81,2% (p < 0,0001) y que en los HTA sin DL: 82,4% (p < 0,0001). También hubo diferencias significativas entre estos dos últimos grupos (p = 0,001). 2. Las variables explicativas de un mejor cumplimiento en el análisis multivariante fueron: a) inactividad laboral (p=0,000); b) relacionados con el médico que trata al sujeto (p = 0,000) y la intensidad del seguimiento (p = 0,04); y c) el tipo de fármaco (p = 0,000); el precio (a mayor precio mayor cumplimiento) (p = 0,006) y el número de principios activos utilizados (a menor número, mayor cumplimiento) (p = 0,019). Conclusiones: 1. Los pacientes dislipémicos muestran un peor cumplimiento que los hipertensos y la dislipemia es un FRCV que empeora el cumplimiento global en los pacientes hipertensos. 2. Las características del sujeto, la actitud del médico, el grado de seguimiento, el tipo de fármaco empleado y la simplicidad del tratamiento se asocian al cumplimiento terapéutico

Background and objective: Lack of compliance is a major factor responsible for the differences between clinical trial results and real effectiveness in daily medical practice, contributing to an insufficient control of the cardiovascular risk factors (CVRF). Knowledge of the factors contributing to lack of compliance is limited, and in Spain data are scarce. The objectives of this study are: a) to indirectly determine the level of compliance among patients with hypertension and/or dyslipidemia; and b) to determine factors associated with compliance. Material and method: 9,001 hypertensive and/or dyslipidemic patients from four primary care centres in Catalonia were enrolled in Disease Management programmes during the previous four years. Compliance was estimated by the relationship between the amount of dispensed and prescribed pills: a) the levels of compliance of dyslipidemic patients without hypertension (DL-non HT), hypertensive patients with dyslipidemia (HT+DL) and hypertensives without dyslipidemia (HT-non DL) were compared; and b) an stepwise, multivariate, descriptive; multiple regression model was designed in order to explain compliance. Results: 1. Compliance was 79% in DL-non HT, significantly lower than in HT+DL (81.2%, p=0.000) and in HT-non DL (82.4%, p=0.000). There were also statistically significant differences between these last two groups (p=0.001). 2. Explanatory variables of a better compliance in the multivariate analysis were: a) patient related factors: labour inactivity (p = 0.000); b) management related factors: specific doctor (p = 0.000) and intensity of follow-up (p = 0.04); and c) drug related factors: the drug group (p < 0.0001); the drug price (the higher price determines higher compliance, p = 0.006) and the number of active principles used (the higher number determines lower compliance, p = 0.019). Conclusions: 1. Dyslipidemic patients show a worse compliance than hypertensive patients, and dyslipidemia worsened global compliance in hypertensive patients. 2. Patient characteristics, doctor attitude, follow-up intensity, drug group and simplicity of treatment are related to compliance in daily medical practice