Situación actual de los anticoagulantes orales de acción directa en atención primaria de España. Posicionamiento de SEMERGEN en 2023 / Current situation of direct oral anticoagulants in primary care in Spain: Positioning of SEMERGEN in 2023

La anticoagulación oral es clave para disminuir el riesgo de ictus en la fibrilación auricular. Aunque clásicamente los antagonistas de la vitaminaK (AVK) se han empleado para este fin, han sido ampliamente superados por los anticoagulantes orales de acción directa (ACOD), como lo demuestran las evidencias provenientes de los ensayos clínicos, estudios de vida real y poblacionales. De hecho, todas las guías de práctica clínica recomiendan su uso de manera preferencial sobre los AVK. Sin embargo, en España la prescripción de los ACOD está subordinada a un visado de inspección que recoge las condiciones clínicas definidas en el Informe de Posicionamiento Terapéutico de la Agencia Española del Medicamento, y que todavía impone importantes restricciones a su uso, limitando los beneficios del empleo de los ACOD en los pacientes con fibrilación auricular (FA), y generando además inequidades entre las diferentes comunidades autónomas. De hecho, el empleo de los ACOD en España es muy inferior a los países de nuestro entorno. Esto ha provocado que en otros países ha disminuido la incidencia de ictus isquémico a nivel poblacional, junto con una reducción del coste por paciente con FA, pero en España este descenso ha sido discreto. Por todo ello, y en aras de la sostenibilidad del sistema sanitario, pedimos la eliminación del visado para que los ACOD se puedan prescribir de acuerdo a las recomendaciones realizadas por las guías. Además, también apostamos por el refuerzo de la formación y de las decisiones consensuadas con el paciente, siendo el médico de familia un actor clave en la protección del paciente con FA.(AU)

Oral anticoagulation is the key to reduce the risk of stroke in atrial fibrillation. Although vitaminK antagonists (VKA) have classically been used for this purpose, they have been largely overcome by direct oral anticoagulants (DOAC), as demonstrated by evidence from clinical trials, real-life and population studies. In fact, all clinical practice guidelines recommend their use preferentially over VKA. However, in Spain the prescription of DOAC is subordinated to an inspection visa that includes the clinical conditions defined in the Therapeutic Positioning Report of the Spanish Medicines Agency, and that still imposes important restrictions on their use, limiting the benefits of using DOACs in patients with atrial fibrillation (AF), and also generating inequalities between the different autonomous communities. In fact, the use of DOAC in Spain is much lower than that observed in neighboring countries. This has made that while in other countries the incidence of ischemic stroke has decreased at the population level, along with a reduction in the cost per patient with AF, in Spain this decrease has been modest. For all these reasons, and for assuring the sustainability of the health care system, we ask for the elimination of the visa so that DOAC can be prescribed according to the recommendations made by the guidelines. In addition, we are also committed to reinforce medical education and decisions made by consensus with the patient, with the primary care physician acquiring a key role in the protection of the patient with AF.(AU)

Prevalence, impact and management of hypertension-mediated organ damage in type 2 diabetes patients.

OBJECTIVE: To determine the prevalence, impact and management of hypertension-mediated organ damage (HMOD) according to the presence of type 2 diabetes (T2DM). METHODS: IBERICAN is an ongoing multicenter, observational and prospective study, including outpatients aged 18-85 years who attended the Primary Care setting in Spain. In this study, the prevalence, impact and management of HMOD according to the presence of T2DM at baseline were analyzed. RESULTS: At baseline, 8066 patients (20.2% T2DM, 28.6% HMOD) were analyzed. Among patients with T2DM, 31.7% had hypertension, 29.8% dyslipidemia and 29.4% obesity and 49.3% had ≥1 HMOD, mainly high pulse pressure (29.6%), albuminuria (16.2%) and moderate renal impairment (13.6%). The presence of T2DM significantly increased the risk of having CV risk factors and HMOD. Among T2DM population, patients with HMOD had more dyslipidemia (78.2% vs 70.5%; P=0.001), hypertension (75.4% vs 66.4%; P=0.001), any CV disease (39.6% vs 16.1%; P=0.001) and received more drugs. Despite the majority of types of glucose-lowering agents were more frequently taken by those patients with HMOD, compared to the total T2DM population, the use of SGLT2 inhibitors and GLP-1 receptor agonists was marginal. CONCLUSIONS: In patients daily attended in primary care setting in Spain, one in five patients had T2DM and nearly half of these patients had HMOD. In patients with T2DM, the presence of HMOD was associated with a higher risk of CV risk factors and CV disease. Despite the very high CV risk, the use of glucose-lowering agents with proven CV benefit was markedly low.

[Current situation of direct oral anticoagulants in primary care in Spain: Positioning of SEMERGEN in 2023]. / Situación actual de los anticoagulantes orales de acción directa en atención primaria de España. Posicionamiento de SEMERGEN en 2023.

Oral anticoagulation is the key to reduce the risk of stroke in atrial fibrillation. Although vitaminK antagonists (VKA) have classically been used for this purpose, they have been largely overcome by direct oral anticoagulants (DOAC), as demonstrated by evidence from clinical trials, real-life and population studies. In fact, all clinical practice guidelines recommend their use preferentially over VKA. However, in Spain the prescription of DOAC is subordinated to an inspection visa that includes the clinical conditions defined in the Therapeutic Positioning Report of the Spanish Medicines Agency, and that still imposes important restrictions on their use, limiting the benefits of using DOACs in patients with atrial fibrillation (AF), and also generating inequalities between the different autonomous communities. In fact, the use of DOAC in Spain is much lower than that observed in neighboring countries. This has made that while in other countries the incidence of ischemic stroke has decreased at the population level, along with a reduction in the cost per patient with AF, in Spain this decrease has been modest. For all these reasons, and for assuring the sustainability of the health care system, we ask for the elimination of the visa so that DOAC can be prescribed according to the recommendations made by the guidelines. In addition, we are also committed to reinforce medical education and decisions made by consensus with the patient, with the primary care physician acquiring a key role in the protection of the patient with AF.

Utilidad de una aplicación web interactiva en la mejora del control de los factores de riesgo cardiovascular. Proyecto Control-RC / Impact of an interactive web application on the improvement of cardiovascular risk factors control. Control-RCV project

Objetivo Valorar la utilidad de una aplicación web interactiva en la mejora del control del riesgo cardiovascular (CV). Métodos Estudio observacional en el que médicos de Atención Primaria, incluyeron consecutivamente a pacientes con un riesgo CV elevado/muy elevado y al menos uno de los siguientes factores de riesgo mal controlado: hipertensión, dislipidemia o diabetes. Al introducir los datos, la aplicación generaba un informe indicando los objetivos recomendados y los reales, y el médico podía modificar la actitud terapéutica. El estudio consistió en 2visitas: basal y a los 4-6 meses. Resultados Se incluyó a 379 pacientes (66,4 ± 9,0 años; 67,3% varones; 67,5/32,5% con un riesgo CV elevado/muy elevado). Basalmente, la mayoría recibió recomendaciones sobre la restricción de sal (90,2%), dieta (94,2%) y actividad física (94,5%). En cuanto al tratamiento farmacológico, el 53,6% no tomaba combinaciones fijas. Solo el 35,1% cumplía siempre con el tratamiento. En el 95,8% se realizó educación sanitaria, en el 29,8% se empleó la polipíldora y en el 24,3% se incidió sobre los cambios en hábitos de vida. En la segunda visita se objetivó una mejoría significativa de los cambios en el estilo de vida (menor tabaquismo y consumo de alcohol, y mayor actividad física, restricción de sal, dieta), factores de riesgo CV (menor obesidad, presión arterial, lípidos, HbA1c), así como una reducción del riesgo CV. El cumplimiento terapéutico mejoró. Conclusiones El empleo de la aplicación permite mejorar los estilos de vida y el control de los factores de riesgo, reduciendo el riesgo CV y mejorando el cumplimiento terapéutico (AU)

Objective To ascertain the utility of an interactive web application in the improvement of cardiovascular (CV) risk control. Methods Observational study in which primary care physicians consecutively included high/very high CV risk patients with at least one of the following risk factors poorly controlled: hypertension, dyslipidemia or diabetes. After the introduction of data, the application generated a report comparing the recommended and the real targets. Then, the physicians could modify the therapeutic approach. The study consisted of 2 visits, at baseline and after 4-6 months. Results A total of 379 patients (66.4±9.0 years; 67.3% male; 67.5/32.5% with high/very high CV risk) were included. At baseline, most patients received recommendations about salt restriction (90.2%), diet (94.2%), and physical activity (94.5%). With regard to pharmacological treatments, 53.6% of patients were not taking fixed-dose combinations. Only 35.1% met always with treatment. In 95.8% of patients sanitary education was given, in 29.8% the polypill was prescribed and in 24.3% lifestyle changes were recommended. During the second visit, a significant improvement in lifestyle changes (less smoking and alcohol consumption, and more physical activity, salt restriction and diet), CV risk factors (less obesity, blood pressure, lipids, HbA1c), as well as CV risk reduction were observed. The therapeutic compliance also improved. Conclusions The use of the application allows improving lifestyle and CV risk factors control, leading to a reduction of CV risk and an improvement of therapeutic compliance (AU)

[Impact of an interactive web application on the improvement of cardiovascular risk factors control. Control-RCV project]. / Utilidad de una aplicación web interactiva en la mejora del control de los factores de riesgo cardiovascular. Proyecto Control-RCV.

OBJECTIVE: To ascertain the utility of an interactive web application in the improvement of cardiovascular (CV) risk control. METHODS: Observational study in which primary care physicians consecutively included high/very high CV risk patients with at least one of the following risk factors poorly controlled: hypertension, dyslipidemia or diabetes. After the introduction of data, the application generated a report comparing the recommended and the real targets. Then, the physicians could modify the therapeutic approach. The study consisted of 2 visits, at baseline and after 4-6 months. RESULTS: A total of 379 patients (66.4±9.0 years; 67.3% male; 67.5/32.5% with high/very high CV risk) were included. At baseline, most patients received recommendations about salt restriction (90.2%), diet (94.2%), and physical activity (94.5%). With regard to pharmacological treatments, 53.6% of patients were not taking fixed-dose combinations. Only 35.1% met always with treatment. In 95.8% of patients sanitary education was given, in 29.8% the polypill was prescribed and in 24.3% lifestyle changes were recommended. During the second visit, a significant improvement in lifestyle changes (less smoking and alcohol consumption, and more physical activity, salt restriction and diet), CV risk factors (less obesity, blood pressure, lipids, HbA1c), as well as CV risk reduction were observed. The therapeutic compliance also improved. CONCLUSIONS: The use of the application allows improving lifestyle and CV risk factors control, leading to a reduction of CV risk and an improvement of therapeutic compliance.

Posicionamiento SEMERGEN en el abordaje de la insuficiencia cardíaca crónica en atención primaria / SEMERGEN positioning on approaching chronic heart failure in primary care

La insuficiencia cardíaca (IC) es un problema de salud pública que genera una gran carga asistencial tanto hospitalaria como en atención primaria (AP). La publicación de numerosos estudios sobre IC durante los últimos años ha supuesto un cambio de paradigma en el abordaje de este síndrome, en el que la labor de los equipos de AP va adquiriendo un protagonismo mayor. Las recientes guías publicadas por la Sociedad Europea de Cardiología han introducido cambios fundamentalmente en el manejo del paciente con IC. La nueva estrategia propuesta, con fármacos que reducen las hospitalizaciones y frenen la progresión de la enfermedad, debe ser ya una prioridad para todos los profesionales implicados. En este documento de posicionamiento se analiza una propuesta de abordaje basada en equipos multidisciplinares con el liderazgo de los médicos de familia, clave para proporcionar una atención de calidad a lo largo de todo el proceso de la enfermedad, desde su prevención hasta el final de la vida (AU)

Heart failure (HF) is a public health problem that generates a large healthcare burden both in hospitals and in Primary Care (PC). The publication of numerous studies about HF in recent years has led to a paradigm shift in the approach to this syndrome, in which the work of PC teams is gaining greater prominence. The recent guidelines published by the European Society of Cardiology have fundamentally introduced changes in the management of patients with HF. The new proposed strategy, with drugs that reduce hospitalizations and slow the progression of the disease, should now be a priority for all professionals involved. This position document analyzes a proposal for an approach based on multidisciplinary teams with the leadership of family doctors, key to providing quality care throughout the entire process of the disease, from its prevention to the end of the life (AU)

Evaluation of prophylaxis in primary prevention with acetylsalicylic acid in people with diabetes: A scoping review.

BACKGROUND: The efficacy and safety of acetylsalicylic acid (ASA) prophylaxis for the primary prevention of atherosclerotic cardiovascular disease (ACVD) remain controversial in people with diabetes (DM) without ACVD, because the possible increased risk of major bleeding could outweigh the potential reduction in the risk of mortality and of major adverse cardiovascular events (MACE) considered individually or together. OBJECTIVE: To evaluate the overall risk-benefit of ASA prophylaxis in primary prevention in people with DM and to compare the recommendations of the guidelines with the results of the meta-analyses (MA) and systematic reviews (SR). MATERIAL AND METHODS: We searched Medline, Google Scholar, Embase, and the Cochrane Library for SR and MA published from 2009 to 2020 which compared the effects of ASA prophylaxis versus placebo or control followed up for at least one year in people with DM without ACVD. Heterogeneity among the randomized clinical trials (RCT) included in the SR and MA was assessed. Cardiovascular outcomes of efficacy (all-cause mortality [ACM], cardiovascular mortality [CVM], myocardial infarction [MI], stroke and MACE) and of safety (major bleeding events [MBE], major gastrointestinal bleeding events [MGIBE], and intracranial and extracranial bleeding) were shown. RESULTS: The recommendations of 12 guidelines were evaluated. The results of 25 SR and MA that included a total of 20 RCT were assessed. None of the MA or SR showed that ASA prophylaxis decreased the risk of ACM, CVM or MI. Only two of the 19 SR and MA that evaluated ischemic stroke showed a decrease in the stroke risk (mean 20.0% [SD±5.7]), bordering on statistical significance. Almost half of the MA and SR showed, bordering on statistical significance, a risk reduction for the MACE composite endpoint (mean 10.5% [SD±3.3]). The significant increases in MGIBE risk ranged from 35% to 55%. The significant increases in the risk of MBE and extracraneal bleeding were 33.4% (SD±14.9) and 54.5% (SD±0.7) respectively. CONCLUSION: The overall risk-benefit assessment of ASA prophylaxis in primary prevention suggests that it should not be applied in people with DM.

[SEMERGEN positioning on approaching chronic heart failure in primary care]. / Posicionamiento SEMERGEN en el abordaje de la insuficiencia cardíaca crónica en atención primaria.

Heart failure (HF) is a public health problem that generates a large healthcare burden both in hospitals and in Primary Care (PC). The publication of numerous studies about HF in recent years has led to a paradigm shift in the approach to this syndrome, in which the work of PC teams is gaining greater prominence. The recent guidelines published by the European Society of Cardiology have fundamentally introduced changes in the management of patients with HF. The new proposed strategy, with drugs that reduce hospitalizations and slow the progression of the disease, should now be a priority for all professionals involved. This position document analyzes a proposal for an approach based on multidisciplinary teams with the leadership of family doctors, key to providing quality care throughout the entire process of the disease, from its prevention to the end of the life.

Vacuna COVID-19 y pacientes anticoagulados por alto riesgo cardiovascular. Recomendaciones SEMERGEN / COVID-19 vaccine and anticoagulation patients at high cardiovascular risk. SEMERGEN recommendations

No disponible

[Factors associated with cardiovascular risk and cardiovascular and renal disease in the IBERICAN study: Final results]. / Factores asociados al riesgo cardiovascular y enfermedad cardiovascular y renal en el estudio IBERICAN (Identificación de la poBlación Española de RIesgo CArdiovascular y reNal): resultados definitivos.

OBJECTIVE: To analyse the prevalence in clinical practice of cardiovascular risk factors (CVRF) and cardiovascular disease (CVD), as well as their causal relationship, in the study inclusion visit. MATERIAL AND METHODS: Cross-sectional analysis of the study inclusion visit of 8,066 patients of 18 to 85years of age included in the IBERICAN study. By reviewing the medical history, analytics and medical visits, the patient's physician has collected socio-demographic information, personal and family history and prevalence of CVRF and CVD and renal disease. A multivariate analysis was carried out using a logistic regression that included the autonomous region variable as a random effect variable, in order to analyse the impact of certain variables on the development of each CVRF, metabolic syndrome, subclinical organ damage, renal disease, and CVD. RESULTS: Dyslipidaemia was 2.4 times more frequent in diabetics, and the risk was increased by 59% in hypertensive patients. Arterial hypertension was twice as frequent in diabetics, and increased 94% in hyperuricaemic patients and 62.1% in dyslipidaemia patients. Diabetes mellitus was 2.5 times higher in dyslipidaemia patients, and 2.2 times higher in hypertensive patients. CVD was four times more frequent in patients with a family history, and the risk in women was increased by 90.8% and by 53.8% in patients with renal disease. CONCLUSIONS: The Spanish population seen in Primary Care that were analysed in the IBERICAN study had a high prevalence of CVRF and CVD, which gives it a high CVR. The multivariate analysis performed shows a close causal relationship between the CVRF with each other, and with renal disease and CVD.

Factores asociados al riesgo cardiovascular y enfermedad cardiovascular y renal en el estudio IBERICAN (Identificación de la poBlación Española de RIesgo CArdiovascular y reNal): resultados definitivos / Factors associated with cardiovascular risk and cardiovascular and renal disease in the IBERICAN study: final results

OBJETIVO: Analizar la prevalencia en práctica clínica de los factores de riesgo cardiovascular (FRCV) y la enfermedad cardiovascular (ECV), así como su relación causal, en la visita de inclusión. MATERIAL Y MÉTODOS: Análisis transversal de la visita de inclusión de los 8.066 pacientes de 18 a 85años de edad incluidos en el estudio IBERICAN. Se analizó la información socio-demográfica, los antecedentes personales y familiares, y la prevalencia de FRCV, de ECV y de enfermedad renal. Se ha realizado un análisis multivariante, mediante regresión logística que incluía la variable comunidad autónoma como variable de efectos aleatorios, para analizar el impacto de determinadas variables en el desarrollo de cada FRCV, síndrome metabólico, lesión de orden subclínica (LOS), enfermedad renal y ECV. RESULTADOS: La dislipemia fue 2,4 veces más frecuente en diabéticos y se incrementó el riesgo un 59% en hipertensos. La hipertensión arterial fue dos veces más frecuente en diabéticos y se incrementó un 94% en hiperuricémicos y un 62,1% en dislipémicos. La diabetes mellitus fue 2,5 veces mayor en dislipémicos y 2,2 veces mayor en hipertensos. La ECV fue cuatro veces más frecuente en pacientes con antecedentes familiares, y se incrementó un 90,8% el riesgo en mujeres y un 53,8% en pacientes con enfermedad renal. CONCLUSIONES: La población española asistida en atención primaria (AP) que ha sido analizada en el estudio IBERICAN presenta una elevada prevalencia de FRCV y ECV establecida, lo que le confiere un elevado RCV. El análisis multivariante realizado muestra una estrecha relación causal entre los FRCV entre sí y con la enfermedad renal y la ECV

OBJECTIVE: To analyse the prevalence in clinical practice of cardiovascular risk factors (CVRF) and cardiovascular disease (CVD), as well as their causal relationship, in the study inclusion visit. MATERIAL AND METHODS: Cross-sectional analysis of the study inclusion visit of 8,066 patients of 18 to 85years of age included in the IBERICAN study. By reviewing the medical history, analytics and medical visits, the patient's physician has collected socio-demographic information, personal and family history and prevalence of CVRF and CVD and renal disease. A multivariate analysis was carried out using a logistic regression that included the autonomous region variable as a random effect variable, in order to analyse the impact of certain variables on the development of each CVRF, metabolic syndrome, subclinical organ damage, renal disease, and CVD. RESULTS: Dyslipidaemia was 2.4 times more frequent in diabetics, and the risk was increased by 59% in hypertensive patients. Arterial hypertension was twice as frequent in diabetics, and increased 94% in hyperuricaemic patients and 62.1% in dyslipidaemia patients. Diabetes mellitus was 2.5 times higher in dyslipidaemia patients, and 2.2 times higher in hypertensive patients. CVD was four times more frequent in patients with a family history, and the risk in women was increased by 90.8% and by 53.8% in patients with renal disease. CONCLUSIONS: The Spanish population seen in Primary Care that were analysed in the IBERICAN study had a high prevalence of CVRF and CVD, which gives it a high CVR. The multivariate analysis performed shows a close causal relationship between the CVRF with each other, and with renal disease and CVD

Prevalence of hypotension in hypertensive treated patients within the Primary Care setting. The PRESCAP 2010 study / Prevalencia de hipotensión en pacientes tratados con hipertensión atendidos en el ámbito de la atención primaria. El estudio PRESCAP 2010

OBJECTIVE: To determine the prevalence of hypotension and associated factors in hypertensive patients treated in the Primary Care setting. MATERIALS AND METHODS: A cross-sectional, descriptive, and multicentre study was conducted with a total of 2635 general practitioners consecutively including 12,961 hypertensive patients treated in a Primary Care setting in Spain. An analysis was performed on the variables of age, gender, weight, height, body mass index, waist circumference, cardiovascular risk factors (diabetes, dyslipidaemia, smoking, obesity, sedentary lifestyle), fasting plasma glucose, complete lipid profile, as well as the presence of target organ damage (left ventricular hypertrophy, microalbuminuria, carotid atherosclerosis) and associated clinical conditions. Hypotension was defined as a systolic blood pressure less than 110mmHg or a diastolic blood pressure less than 70mmHg. A multivariate analysis was performed to determine the variables associated with the presence of hypotension. RESULTS: The mean age was 66.2 years, and 51.7% of patients were women. The mean time of onset of hypertension was 9.1 years. A total of 13.1% of patients (95% confidence interval 12.4-13.6%) had hypotension, 95% of whom had low diastolic blood pressure. The prevalence of hypotension was higher in elderly patients (25.7%) and in those individuals with coronary heart disease (22.6%). The variables associated with the presence of hypotension included a history of cardiovascular disease, being treated with at least 3 antihypertensive drugs, diabetes, and age. CONCLUSIONS: One out of 4-5 elderly patients, or those with cardiovascular disease, had hypotension. General practitioners should identify these patients in order to determine the causes and adjust treatment to avoid complications

OBJETIVO: Determinar la prevalencia de hipotensión y los factores asociados en pacientes hipertensos tratados en atención primaria. MATERIAL Y MÉTODOS: Estudio transversal, descriptivo y multicéntrico; 2.635 médicos generales incluyeron consecutivamente a 12.961 pacientes hipertensos tratados y atendidos en atención primaria en España. Fueron analizados: edad, sexo, peso, altura, índice de masa corporal, perímetro de cintura, factores de riesgo cardiovascular (diabetes, dislipidemia, tabaquismo, obesidad, sedentarismo), glucemia en ayunas, perfil de lípidos, así como la presencia de daño en órgano diana (hipertrofia ventricular, microalbuminuria, aterosclerosis carotídea) y enfermedades clínicas asociadas. La hipotensión se definió como presión arterial sistólica inferior a 110mmHg o presión arterial diastólica inferior a 70mmHg. Se realizó un análisis multivariante para determinar las variables asociadas a la presencia de hipotensión. RESULTADOS: La edad media fue de 66,2 años, un 51,7% de los pacientes eran mujeres. La antigüedad de la hipertensión fue de 9,1 años. Un 13,1% de los pacientes (intervalo de confianza del 95%: 12,4-13,6%) tenían hipotensión, de los cuales el 95% era presión arterial diastólica baja. La prevalencia de hipotensión fue mayor en pacientes de edad avanzada (25,7%) y en individuos con enfermedad coronaria (22,6%). Las variables asociadas con la presencia de hipotensión incluyeron los antecedentes de enfermedad cardiovascular, pacientes tratados con al menos 3 fármacos antihipertensivos, diabetes y edad. CONCLUSIONES: Uno de cada 4-5 pacientes de edad avanzada o con enfermedad cardiovascular tenía hipotensión. Los médicos generales deben identificar a estos pacientes para determinar las causas y ajustar el tratamiento para evitar complicaciones

Descripción de la muestra, diseño y métodos del estudio para la identificación de la población española de riesgo cardiovascular y renal (IBERICAN) / Description of the sample, design and methods of the study for the identification of the Spanish population at cardiovascular and renal risk (IBERICAN)

ANTECEDENTES Y OBJETIVO: Las enfermedades cardiovasculares (ECV) son la primera causa de muerte en nuestro país, y aunque las tasas de incidencia disminuyen desde hace años por las mejoras en la prevención y el tratamiento, aún hay margen para una mayor reducción. La atención primaria tiene un papel primordial en la prevención y el control de estas enfermedades. Conocer la prevalencia e incidencia de los factores de riesgo cardiovascular y de las enfermedades cardiovasculares en población adulta española asistida en atención primaria es el objetivo del estudio para la identificación de la población española de riesgo cardiovascular y renal (IBERICAN). MATERIAL Y MÉTODOS: Estudio de cohortes prospectivas. Población asistida en centros de atención primaria entre 18 y 85 años seleccionada mediante muestreo consecutivo no probabilístico entre el 1 de abril de 2014 y el 31 de octubre de 2018. Mediante revisión de la historia clínica, analíticas y visitas médicas el médico del paciente ha recogido información sociodemográfica, antecedentes personales y familiares y prevalencia e incidencia de factores de riesgo cardiovascular y enfermedad cardiovascular y renal. Se estimarán las incidencias y factores asociados mediante modelos de riesgos proporcionales de Cox y curvas de Kaplan-Meier. RESULTADOS: Forman parte de la cohorte IBERICAN 8.066 pacientes reclutados por 531 médicos de atención primaria de todas las CC. AA. de España, con la excepción de Ceuta. La edad media de la cohorte es de 57,9 años, con un 54,5% de mujeres. La obesidad, la dislipidemia y la HTA son los factores de riesgo cardiovascular más prevalentes. El 16,3% presentaba antecedentes de ECV y el 25,5% alguna lesión de órgano subclínica. CONCLUSIÓN: El estudio IBERICAN es una cohorte de personas atendidas en atención primaria que espera aportar información relevante sobre los factores que determinan la incidencia de ECV y renal en España

BACKGROUND AND OBJECTIVE: Cardiovascular diseases (CVD) are the leading cause of death in Spain, and although the incidence rates have been declining for years due to improvements in prevention and treatment, there is still room for further reduction. Primary Care has a leading role in the prevention and control of these diseases. Determining the prevalence and incidence of cardiovascular risk factors and cardiovascular diseases in the Spanish adult population attended in Primary Care is the objective of the study to identify the Spanish population at cardiovascular and renal risk (IBERICAN). MATERIAL AND METHODS: A prospective cohort study was conducted using a consecutive non-probabilistic sampling population between 18 and 85 years that attended Primary Care centres between April 1, 2014 and October 31, 2018. By reviewing the medical history, laboratory results, and medical visits, the Primary Care physicians collected socio-demographic information, personal and family history of the patients, as well as prevalence and incidence of cardiovascular risk factors and cardiovascular and renal disease. The incidents and associated factors will be estimated using proportional risk models of Cox and Kaplan-Meier Curves. RESULTS: A total of 8,066 patients have been recruited by 531 Primary Care physicians from all Autonomous Communities of Spain as part of the IBERICAN cohort, with the exception of Ceuta. The mean age of the cohort is 57.9 years with 54.5% women. Obesity, dyslipidaemia, and hypertension are the most prevalent cardiovascular risk factors. There was a history of CVD in16.3%, and 25.5% had a subclinical organ lesion. CONCLUSION: The IBERICAN study is a cohort of people treated in Primary Care that expects to provide relevant information on the factors that determine the incidence of cardiovascular and renal disease in Spain

Prevalence of hypotension in hypertensive treated patients within the Primary Care setting. The PRESCAP 2010 study.

OBJECTIVE: To determine the prevalence of hypotension and associated factors in hypertensive patients treated in the Primary Care setting. MATERIALS AND METHODS: A cross-sectional, descriptive, and multicentre study was conducted with a total of 2635 general practitioners consecutively including 12,961 hypertensive patients treated in a Primary Care setting in Spain. An analysis was performed on the variables of age, gender, weight, height, body mass index, waist circumference, cardiovascular risk factors (diabetes, dyslipidaemia, smoking, obesity, sedentary lifestyle), fasting plasma glucose, complete lipid profile, as well as the presence of target organ damage (left ventricular hypertrophy, microalbuminuria, carotid atherosclerosis) and associated clinical conditions. Hypotension was defined as a systolic blood pressure less than 110mmHg or a diastolic blood pressure less than 70mmHg. A multivariate analysis was performed to determine the variables associated with the presence of hypotension. RESULTS: The mean age was 66.2 years, and 51.7% of patients were women. The mean time of onset of hypertension was 9.1 years. A total of 13.1% of patients (95% confidence interval 12.4-13.6%) had hypotension, 95% of whom had low diastolic blood pressure. The prevalence of hypotension was higher in elderly patients (25.7%) and in those individuals with coronary heart disease (22.6%). The variables associated with the presence of hypotension included a history of cardiovascular disease, being treated with at least 3 antihypertensive drugs, diabetes, and age. CONCLUSIONS: One out of 4-5 elderly patients, or those with cardiovascular disease, had hypotension. General practitioners should identify these patients in order to determine the causes and adjust treatment to avoid complications.

[Description of the sample, design and methods of the study for the identification of the Spanish population at cardiovascular and renal risk (IBERICAN)]. / Descripción de la muestra, diseño y métodos del estudio para la identificación de la población española de riesgo cardiovascular y renal (IBERICAN).

BACKGROUND AND OBJECTIVE: Cardiovascular diseases (CVD) are the leading cause of death in Spain, and although the incidence rates have been declining for years due to improvements in prevention and treatment, there is still room for further reduction. Primary Care has a leading role in the prevention and control of these diseases. Determining the prevalence and incidence of cardiovascular risk factors and cardiovascular diseases in the Spanish adult population attended in Primary Care is the objective of the study to identify the Spanish population at cardiovascular and renal risk (IBERICAN). MATERIAL AND METHODS: A prospective cohort study was conducted using a consecutive non-probabilistic sampling population between 18 and 85 years that attended Primary Care centres between April 1, 2014 and October 31, 2018. By reviewing the medical history, laboratory results, and medical visits, the Primary Care physicians collected socio-demographic information, personal and family history of the patients, as well as prevalence and incidence of cardiovascular risk factors and cardiovascular and renal disease. The incidents and associated factors will be estimated using proportional risk models of Cox and Kaplan-Meier Curves. RESULTS: A total of 8,066 patients have been recruited by 531 Primary Care physicians from all Autonomous Communities of Spain as part of the IBERICAN cohort, with the exception of Ceuta. The mean age of the cohort is 57.9 years with 54.5% women. Obesity, dyslipidaemia, and hypertension are the most prevalent cardiovascular risk factors. There was a history of CVD in16.3%, and 25.5% had a subclinical organ lesion. CONCLUSION: The IBERICAN study is a cohort of people treated in Primary Care that expects to provide relevant information on the factors that determine the incidence of cardiovascular and renal disease in Spain.

Profiling of patients with non-valvular atrial fibrillation and moderate-to-high risk of stroke not receiving oral anticoagulation in Spain / Perfil de los pacientes con fibrilación auricular no valvular y riesgo moderado-alto de accidente cerebrovascular que no reciben anticoagulación oral en España

OBJECTIVE: In non-valvular atrial fibrillation (NVAF) with embolic risk, the guidelines recommend oral anticoagulation (OAC), although not all patients receive it. In this study, an attempt is made to identify these patients, and to study factors related to non-anticoagulation. MATERIAL AND METHODS: Non-interventional, cross-sectional, multicentre study was performed on a population of patients ≥18 years with a NVAF diagnosis, moderate-high embolic risk (CHADS2 score≥2), not treated with OAC. Atrial fibrillation (AF) prevalence was also collected. RESULTS: AF prevalence was 4.5%, and 80.7% of the patients had NVAF (20.0% did not receive OAC). A total of 1310 non-OAC-treated patients were included (51.8% male, mean age: 76.0 years). The mean time since AF diagnosis was 58.4 months. The main therapeutic decision for stroke prevention was prescription of antiplatelet agents (82.4%, n=1078), and the main reasons were: patient refusal to monitoring (37.3%), high bleeding risk (31.1%), uncontrolled hypertension (27.9%), and frequent falls (27.6%). The mean CHA2DS2-VASc score was 4.6, and the HAS-BLED was 2.7 (55.9% of patients scoring HAS-BLED≥3). The most common thromboembolic risk factors were: hypertension (89.1%), age≥75 years (61.5%); the haemorrhagic factors: use of drugs increasing the bleeding risk (41.2%), uncontrolled blood pressure (33.7%). CONCLUSIONS: About 20% of Spanish NVAF patients do not receive OAC in the clinical practice and are treated with antiplatelet agents, which do not reduce haemorrhagic risk. Most patients do not clearly show a contraindication to OACs, particularly considering that there are other available options (direct oral anticoagulant drugs [DOACs])

OBJETIVO: En la fibrilación auricular no-valvular (FANV) con riesgo embólico las guías recomiendan la anticoagulación oral (ACO), aunque no todos los pacientes la reciben. En este estudio, tratamos de identificar estos pacientes y estudiar los factores relacionados con la no-anticoagulación. MATERIAL Y MÉTODOS: Estudio observacional, transversal y multicéntrico. Población de estudio: pacientes ≥18 años con FANV, riesgo embólico moderado-alto (puntuación CHADS2≥2), no tratados con ACO. También se recogió la prevalencia de fibrilación auricular (FA). RESULTADOS: La prevalencia de FA fue del 4,5% y del 80,7% de los pacientes presentaban FANV (20,0% no recibía ACO). Se incluyeron 1.310 pacientes no tratados con ACO (51,8% varones, edad media: 76,0 años). El tiempo medio desde el diagnóstico de FA fue de 58,4 meses. La estrategia terapéutica principal para la prevención tromboembólica fue la antiagregación (82,4%; n=1.078) y las principales razones: negativa del paciente a la monitorización (37,3%), alto riesgo de sangrado (31,1%), hipertensión no controlada (27,9%) y caídas frecuentes (27,6%). La puntuación CHA2DS2-VASc media fue 4,6 y HAS-BLED 2,7 (55,9% HAS-BLED≥3). Los factores de riesgo tromboembólico más frecuentes fueron: hipertensión (89,1%) y edad ≥75 años (61,5%); los factores de riesgo hemorrágico fueron: uso de fármacos que aumentan el riesgo de sangrado (41,2%) y presión arterial no controlada (33,7%). CONCLUSIONES: En la práctica clínica en España, un 20% de los pacientes con FANV no recibe ACO, y son tratados con antiagregantes, lo que no reduce el riesgo hemorrágico. La mayoría de los pacientes no presenta una clara contraindicación para ACO, más aún considerando otras opciones disponibles (anticoagulantes orales directos [ACOD])

Utilización de los anticoagulantes orales de acción directa en Atención Primaria de España. Posicionamiento de SEMERGEN ante la situación actual / Use of direct-acting oral anticoagulants in Primary Care in Spain. Positioning statement by SEMERGEN on the current situation

Los anticoagulantes orales de acción directa (ACOD) son fármacos que han demostrado tener un perfil de seguridad superior a los antivitaminaK (AVK). En España la prescripción de los ACOD está subordinada a un visado de inspección que recoge las condiciones clínicas definidas en el Informe de Posicionamiento Terapéutico (IPT) de la Agencia Española del Medicamento del año 2013, actualizado en 2016. Estas recomendaciones no coinciden con las de la Sociedad Europea de Cardiología (2016), limitando el uso de ACOD a un tratamiento de segunda línea en la mayoría de los casos. Además, el IPT se aplica de manera distinta en las comunidades autónomas e incluso en las áreas sanitarias, lo que origina una gran variabilidad en las condiciones de prescripción, generando desigualdades territoriales en la accesibilidad a estos fármacos por parte de los pacientes. La eliminación del visado y la adecuación de la prescripción a las recomendaciones de las guías de práctica clínica son dos aspectos clave para neutralizar las actuales barreras administrativas y clínicas para el uso eficiente de los ACOD en atención primaria (AP). SEMERGEN apuesta por el refuerzo de la formación clínica del médico de AP y la alianza con los pacientes para promover la concienciación y el conocimiento de la fibrilación auricular

The direct-acting oral anticoagulants (DOACs) are drugs that have been shown to have a safety profile superior to the vitaminK antagonists (VKA). The prescribing of DOACs in Spain is subject to approval in the form of an inspection visa. This sets out the clinical conditions defined in the Spanish Medicines Agency Therapeutic Positioning Report (TPR) of 2013, updated in 2016. These recommendations do not coincide with those of the European Cardiology Society (2016), restricting the use of DOACs to a second-line treatment in the majority of cases. Furthermore, this TPR is applied differently in the Regional Autonomous Communities and even in different health areas. This leads to a wide variation in the prescribing conditions, causing territorial inequalities in accessibility to these drugs by patients. The removal of the visa, and the appropriateness of the prescription to the recommendations of the Clinical Practice guidelines are key aspects to neutralise the current administrative and clinical barriers for the efficient use of DOACs in Primary Care. SEMERGEN supports the boosting of the clinical training and alliance with the patients in order to promote awareness and knowledge of atrial fibrillation

[Use of direct-acting oral anticoagulants in Primary Care in Spain. Positioning statement by SEMERGEN on the current situation]. / Utilización de los anticoagulantes orales de acción directa en Atención Primaria de España. Posicionamiento de SEMERGEN ante la situación actual.

The direct-acting oral anticoagulants (DOACs) are drugs that have been shown to have a safety profile superior to the vitaminK antagonists (VKA). The prescribing of DOACs in Spain is subject to approval in the form of an inspection visa. This sets out the clinical conditions defined in the Spanish Medicines Agency Therapeutic Positioning Report (TPR) of 2013, updated in 2016. These recommendations do not coincide with those of the European Cardiology Society (2016), restricting the use of DOACs to a second-line treatment in the majority of cases. Furthermore, this TPR is applied differently in the Regional Autonomous Communities and even in different health areas. This leads to a wide variation in the prescribing conditions, causing territorial inequalities in accessibility to these drugs by patients. The removal of the visa, and the appropriateness of the prescription to the recommendations of the Clinical Practice guidelines are key aspects to neutralise the current administrative and clinical barriers for the efficient use of DOACs in Primary Care. SEMERGEN supports the boosting of the clinical training and alliance with the patients in order to promote awareness and knowledge of atrial fibrillation.

Posicionamiento para el manejo de la hipertensión arterial en atención primaria a partir del análisis crítico de las guías americana (2017) y europea (2018). Sociedad Española de Médicos de Atención Primaria (EMERGEN) / Positioning for the management of arterial hypertension in Primary Care from the critical analysis of the American (2017) and European (2018) guidelines. Spanish Society of Primary Care Physicians (SEMERGEN)

Parece necesario que las sociedades científicas de AP, ámbito en el cual la prevalencia de HTA es considerable, evalúen periódicamente las directrices internacionales para el manejo de la HTA, sobre todo ante recomendaciones dispares que dificultan la toma de decisiones, en la práctica clínica diaria. El presente documento tiene como objetivo analizar los cambios y novedades propuestos en la guía del American College of Cardiology y de la American Heart Association (ACC/AHA 2017) y en la guía de la European Society of Cardiology y de la European Society of Hypertension (ESC/ESH 2018). Además, analizar las posibles diferencias, limitaciones y su aplicabilidad a la AP de España. En definitiva, se trata de extraer la información más relevante disponible y pertinente, e integrarla para homogeneizar la asistencia al paciente hipertenso desde una perspectiva crítica, pero también razonada. Las discrepancias entre ambas GPC en aspectos tan trascendentales como el manejo de la enfermedad obligan a la recopilación y análisis crítico de la información que nos permita tomar posición como sociedad científica, interesada en trasladar a todos los médicos de AP las recomendaciones más relevantes, pero a la vez sensatas, de ambas GPC

The Scientific Societies of Primary Care, being the area in which there is a considerable prevalence of Arterial Hypertension (AHT), need to periodically evaluate the international guidelines for its management. This is particularly relevant when disparate guidelines make it difficult to make decisions in daily clinical practice. The present document has as its aim to analyse the changes and new developments proposed in the guidelines of the American College of Cardiology and the American Heart Association (ACC/AHA 2017), as well as in the guidelines of the European Society of Cardiology and European Society of Hypertension (ESC/ESH 2018). An analysis will be made of any differences, limitations, and their applicability to Primary Care in Spain. Finally, the most relevant available and appropriate information is extracted and integrated in order to homogenise the care of the hypertensive patient, from a critical, but also a reasoned, perspective. The discrepancies between the recommendations in such essential aspects as the management of the disease, require the compiling and critical analysis of the information that enables us as scientific society, interested in providing all PC physicians with the most relevant, and at the same time, sensible, recommendations of all the guidelines