Unanswered clinical questions in the management of cardiometabolic risk in the elderly: a statement of the Spanish Society of Internal Medicine.

BACKGROUND: Despite the progressive increase in life expectancy and the relationship between aging with multi-morbidities and the increased use of healthcare resources, current clinical practice guidelines (CPG) on cardiometabolic risk cannot be adequately applied to elderly subjects with multiple chronic conditions. Its management frequently becomes complicated by both, an excessive use of medications that may lead to overtreatment, drug interactions and increased toxicity, and errors in dosage and non-compliance. Concerned by this gap, the Spanish Society of Internal Medicine created a group of independent experts on cardiometabolic risk who discussed what they considered to be unanswered questions in the management of elderly patients. DISCUSSION: Current guidelines do not specifically address the problem of elderly with multiple chronic conditions. For this reason, the combined use of the limited available evidence, clinical experience and common sense, could all help us to address this unmet need. In very old people, life expectancy and functionality are the most important factors for guiding potential treatments. Their higher propensity to develop serious adverse events and their shorter lifespan could prevent them from obtaining the potential benefits of the interventions administered. SUMMARY: In this document, experts on cardiometabolic risk factors have established a number of consensual recommendations that have taken into account international guidelines and clinical experience, and have also considered the more effective use of healthcare resources. This document is intended to provide general recommendations for clinicians and to promote the effective use of procedures and medications.

How to calculate vascular age with the SCORE project scales: a new method of cardiovascular risk evaluation.

AIMS: In 2008, a new cardiovascular risk table from the Framingham Heart Study was published, which incorporated the new concept 'vascular age'. The aim of the present study was to determine the vascular age calculated from the two SCORE project scales and to determine the degree of agreement in vascular age between the two scales. METHODS AND RESULTS: Vascular age was calculated according to its definition, but using the SCORE scale equations (for low- and high-risk countries) instead of the Framingham equations. Vascular age calculations were obtained covering all the absolute risk values in the SCORE charts, obtaining results of vascular age beyond 65 years of age. To determine the degree of agreement between vascular age calculated with the two SCORE scales (for high- and low-risk countries), the intraclass correlation coefficient was calculated. Of the 400 boxes in the SCORE charts, the vascular age differed between high- and low-risk countries by 1 year or less in 347 boxes (86.75%). In just six boxes (1.5%), the difference was 3 years. Agreement between the scales was very high, as demonstrated by their intraclass correlation coefficient of 0.997. CONCLUSION: Vascular age is a new concept derived from Framingham risk tables that can be calculated with other risk scales, like SCORE. Agreement of vascular age calculated from the SCORE equations for high- and low-risk countries was extremely high, in contrast to the poor agreement in absolute risk.

[Cardiovascular risk percentiles avoid overestimation or underestimation of risk calculated by the SCORE risk function]. / La adopción de los percentiles de riesgo cardiovascular evita la sobreestimación o infraestimación del riesgo cardiovascular calculado con el SCORE.

BACKGROUND: Cardiovascular risk evaluation is of the utmost importance for treatment of patients with cardiovascular risk factors. There are various scales or equations and they can be adapted to a particular population to try to avoid over or under estimation of risk. We propose risk percentiles as a new method of adapting risk scoring systems to our population. METHODS: A cross sectional study of the prevalence of cardiovascular risk factors in the province of Palencia (ERVPA: Cardiovascular Risk Study in Palencia) was conducted. Age, gender, blood pressure, total cholesterol, tobacco consumption and diabetes were evaluated. 514 subjects aged 20 - 79 taken from the general population were studied in 9 health centers from Palencia (Spain). Fatal cardiovascular risk was measured with SCORE project equations. Percentiles were calculated and compared to both equations and a Spearman's correlation coefficient and a kappa agreement coefficient were calculated. RESULTS: The percentages of high risk range from 0% in young subjects to 92% in males over the age of 70 and 67% in females over the age of 70. The concordance with high risk country equations has a kappa coefficient of 0.741. Concordance varies greatly with age and gender. On comparing the percentiles, the concordance between both equations is almost absolute. CONCLUSIONS: Adopting risk percentiles as a method of cardiovascular risk evaluation permits us to adapt any risk equation to a particular area and avoids underestimation or overestimation of risk. Risk percentiles allow us to extrapolate absolute risk for any age.

Vascular age calculation and equivalent risk factors in HIV-infected patients obtained from the D:A:D risk equation.

BACKGROUND: Vascular age is a concept that represents the hypothetical age of the cardiovascular system and might be an alternative way of expressing the cardiovascular risk of a patient. The Data Collection on Adverse Effects of Anti-HIV Drugs Study (D:A:D) developed a cardiovascular risk equation from a population of HIV-infected patients, incorporating exposure to individual antiretroviral therapy drugs and traditional classic cardiovascular risk factors. OBJECTIVES: The aim of this study was to determine the vascular age calculated from the D:A:D equation, for HIV infected patients. METHODS: Vascular age was calculated according to its definition by using the D:A:D equation. The Poisson regression model used in the D:A:D equation is an exponential model to calculate the vascular age to match the exponent of the equation with the factors of a patient with the exponent of a subject with controlled risk factors. RESULTS: We obtained an equation that allows calculating the vascular age of a patient considering cardiovascular risk factors listed in the same D:A:D equation. From the equation, we have built a table for easy calculation of the vascular age and a table of cardiovascular risk equivalents. CONCLUSIONS: Vascular age is a new concept derived from Framingham risk tables that can be calculated with other risk scales, such as D:A:D for HIV patients. The calculation of vascular age in HIV patients could be a useful tool for communicating cardiovascular risk and to improve the control of modifiable risk factors.

[Cardiovascular disease and systemic inflammatory diseases]. / Enfermedades cardiovasculares y enfermedades inflamatorias sistémicas.

More than a century of research has shown that atherosclerosis is an inflammatory process more than an infiltrative or thrombogenic process. It has been demonstrated epidemiologically and by imaging techniques, that systemic inflammatory diseases (in particular, but not exclusively, rheumatoid arthritis and systemic lupus erythematosus) increase the atherosclerotic process, and has a demonstrated pathophysiological basis. Furthermore, treatments to control inflammatory diseases can modify the course of the atherosclerotic process. Although there are no specific scales for assessing cardiovascular risk in patients with these diseases, cardiovascular risk is high. A number of specific risk scales are being developed, that take into account specific factors such as the degree of inflammatory activity.

[Vascular risk in endocrine diseases other than diabetes]. / Riesgo vascular en enfermedades endocrinológicas distintas a la diabetes.

Endocrinological diseases directly affect the cardiovascular system. The deleterious effects on cardiovascular function can be direct, and linked to the increase or reduction of circulating hormones. Equally, the adverse effects may be indirect; for example following the rise in blood pressure, increase or redistribution of lean mass, or increased plasma lipoproteins. The best health care and the increasing availability of biochemical tests lead to the diagnosis of many endocrine diseases before the onset of clinical signs. This review will focus on presenting evidence of cardiovascular functional or structural impairment in cases of primary hyperparathyroidism, Cushing's syndrome, and hypothyroidism in their sub-clinical forms, as well as the reversibility of complications after appropriate treatment.

[Risk percentiles: a new adapted method for evaluating vascular risk. ERVPA study]. / Percentiles de riesgo: un nuevo método adaptado para la valoración del riesgo vascular. Estudio ERVPA.

BACKGROUND AND OBJECTIVE: Various cardiovascular scoring systems estimating the risk in the Spanish population are currently used. The aim of our study was to create graphs and charts of populational percentiles to assess the total burden of risk of a population and to place each subject individually in the context of their own population setting by using cardiovascular risk charts. SUBJECTS AND METHOD: A cross-sectional study of 514 individuals of both sexes from a general population setting was carried out. Cardiovascular risk was calculated according to the SCORE project equations and charts and graphs of cardiovascular risk were formulated. RESULTS: In primary prevention, 17.11% of men and 22.36% of women aged 20-79 showed a high cardiovascular risk. The percentages vary from 0% in persons of both sexes aged 20-39 to 91.2% of men and 97.9% of women in their 70s. Risk medians range in men from 0.11% (age 20-39) to 8.86% (age 70-79) and in women from 0.02% (age 20-39) to 15.20% (age 70-79). Graphs of cardiovascular risk percentiles were formulated for both sexes; graphs can be used to situate each subject individually in the context of their own population setting and to project the risk to any age. CONCLUSIONS: Nearly a fifth of the population has a high cardiovascular risk. More than 90% of men and women in their 70s have a high cardiovascular risk.

Edad vascular, RR, ALLY, RALLY y velocidad de envejecimiento, basados en el SCORE: relaciones entre nuevos conceptos de prevención cardiovascular / Vascular age, RR, ALLY, RALLY and vascular speed, based on SCORE: relations between new concepts of cardiovascular prevention

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[Ischaemic heart disease]. / Cardiopatía isquémica.

In the year 2011, cardiovascular diseases were responsible of 31.2% of total deaths in Spain. The absolute number of cases of acute coronary syndrome in this year will be approximately 115,752 cases (95%CI: 114,822-116,687). The prevalence of stable angina in the population aged 25-74 years is 2.6% in men and 3.5% in women. Cardiovascular diseases were in the year 2011 the first cause of hospitalizations representing 14.1% of the total hospitalizations. Diagnose of ischaemic heart disease and acute myocardial infarction were responsible of 110,950 and 50,064 hospitalizations, respectively. In the year 2003, the hospitalization rate was 314 while in the year 2011 was 237 per 100,000, a reduction of 24.4%. The average cost of hospitalization due to ischaemic heart disease in 1997 was 3,093.7euros while in the year 2011 was 7,028.71euros. Cardiovascular mortality rates have decreased from 2007 to 2011, showing a relative reduction of 7% in women and 8% in men. With regard to myocardial infarction, it was observed a relative reduction of 17% in men and 20% in women. According to EUROASPIREIII survey done in 8,966 patients with ischaemic heart disease in Europe, 17% of patients were still smokers, 35% were obese, 56% has uncontrolled blood pressure, 51% has raised blood cholesterol and 25% were diabetics. With regard to drugs utilisation, 91% were treated with antiplatelets agents, 80% with beta blockers, 71% with ACE inhibitors/ARBs.

Metabolic syndrome and vascular risk estimation in a Mediterranean non-diabetic population without cardiovascular disease.

AIMS: Vascular risk equations are tools used to help prevent cardiovascular events. Our aim was to compare the REGICOR and SCORE equations in a general population and in persons with the metabolic syndrome (MS) according to the criteria of the International Diabetes Federation. METHODS AND RESULTS: We calculated the cardiovascular risk with both equations in a random sample of 838 non-diabetic persons aged 40-65years without a history of cardiovascular disease, of whom 251 had the MS. Of the 838 persons, 3.6% had a high risk according to SCORE and 1.5% according to REGICOR, and of these, 53.3% and 61.5%, respectively, had the MS. The mean risk was greater in the persons with the MS than those without (REGICOR 4.6% vs. 2.6% and SCORE 1.7% vs. 1%; p<0.01 for each). In comparison with the group without the MS, the percentage of persons with the MS who had a high risk was greater with both scales: REGICOR (3.2% vs. 0.8%, p=0.027) and SCORE (6.4% vs. 2.4%, p=0.004). The agreement (kappa index) classifying the subjects with a high risk, was 0.453 in the overall sample and 0.391 in the subgroup with the MS. CONCLUSIONS: The percentage of persons classified as having a high cardiovascular risk differed between REGICOR and SCORE. Using these scales only a small percentage of non-diabetic persons with the MS have a high risk. The presence of the MS multiplies the percentage of non-diabetic persons with a high vascular risk two-fold with SCORE and four-fold with REGICOR.

La edad vascular frente al riesgo cardiovascular: aclarando conceptos / Vascular age versus cardiovascular risk: clarifying concepts

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Enfermedades cardiovasculares y enfermedades inflamatorias sistémicas / Cardiovascular disease and systemic inflammatory diseases

A lo largo de más de un siglo, las investigaciones han demostrado que la arteriosclerosis más que un proceso infiltrativo o trombogénico es un proceso inflamatorio. Se ha demostrado epidemiológicamente y mediante técnicas de imagen que las enfermedades inflamatorias sistémicas (especialmente, pero no exclusivamente, la artritis reumatoide y el lupus eritematoso sistémico) aumentan el proceso arteriosclerótico, lo cual tiene base fisiopatológica demostrada. Además, los tratamientos para controlar las enfermedades inflamatorias pueden modificar el curso del proceso aterosclerótico. Aunque todavía no hay escalas específicas validadas para valoración del riesgo cardiovascular en los pacientes con estas enfermedades, su riesgo cardiovascular es elevado. Se están desarrollando varias escalas de riesgo específicas, considerando factores propios como el grado de actividad inflamatoria

More than a century of research has shown that atherosclerosis is an inflammatory process more than an infiltrative or thrombogenic process. It has been demonstrated epidemiologically and by imaging techniques, that systemic inflammatory diseases (in particular, but not exclusively, rheumatoid arthritis and systemic lupus erythematosus) increase the atherosclerotic process, and has a demonstrated pathophysiological basis. Furthermore, treatments to control inflammatory diseases can modify the course of the atherosclerotic process. Although there are no specific scales for assessing cardiovascular risk in patients with these diseases, cardiovascular risk is high. A number of specific risk scales are being developed, that take into account specific factors such as the degree of inflammatory activity

Riesgo vascular en enfermedades endocrinológicas distintas a la diabetes / Vascular risk in endocrine diseases other than diabetes

Las enfermedades endocrinológicas afectan directamente al sistema cardiocirculatorio. Los efectos deletéreos sobre la función cardiovascular pueden ser directos y ligados al incremento o reducción de las hormonas circulantes. Igualmente, los efectos nocivos pueden ser indirectos, por ejemplo los que siguen a la elevación de la presión arterial, el incremento o redistribución de la masa grasa o la elevación de las lipoproteínas plasmáticas. La mejor asistencia sanitaria y la disponibilidad cada vez mayor de pruebas bioquímicas hacen que muchas enfermedades endocrinológicas se diagnostiquen antes de la aparición de la clínica. Esta revisión se va a centrar en mostrar evidencias de alteración funcional o estructural cardiovasculares para casos de hiperparatiroidismo primario, síndrome de Cushing e hipotiroidismo, en sus formas subclínicas, y la reversibilidad de sus complicaciones tras tratamiento adecuado

Endocrinological diseases directly affect the cardiovascular system. The deleterious effects on cardiovascular function can be direct, and linked to the increase or reduction of circulating hormones. Equally, the adverse effects may be indirect; for example following the rise in blood pressure, increase or redistribution of lean mass, or increased plasma lipoproteins. The best health care and the increasing availability of biochemical tests lead to the diagnosis of many endocrine diseases before the onset of clinical signs. This review will focus on presenting evidence of cardiovascular functional or structural impairment in cases of primary hyperparathyroidism, Cushing's syndrome, and hypothyroidism in their sub-clinical forms, as well as the reversibility of complications after appropriate treatment