[Computerized interpretation of the electrocardiogram in the diagnosis of left ventricular hypertrophy. The ELECTROPRES project]. / Interpretación computarizada del electrocardiograma para el diagnóstico de hipertrofia del ventrículo izquierdo. Proyecto ELECTROPRES.

INTRODUCTION: Despite its low sensitivity, the electrocardiogram (ECG) is the tool used the most in the daily practice for detection of left ventricular hypertrophy (LVH). This study has aimed to assess the impact of the computerized interpretation of the ECG on the diagnosis of LVH in the practical clinical setting. METHODS: ELECTROPRES is a project based on a free access computer platform that permits an online interpretation of the electrocardiogram. It includes 19 different left LVH criteria previously validated by echocardiography in a substudy. We analyzed the data from the first 669 patients with essential arterial hypertension (ATH) included in the ELECTROPRES platform from 21 primary care centers in 9 of the 17 Spanish autonomous communities. RESULTS: Up to April 2010, a cohort of 669 hypertensive patients (51.7% women), with a mean age of 66.3±11.89 years, was analyzed. The mean evolution of the disease was 8 years, and the patients had been receiving an average of 2.4 antihypertensive agents. Systolic blood pressure was 139±17 mmHg and diastolic blood pressure 76±11. The ECG-known frequency of LVH was 3%. The prevalence of LVH increased up to 33.3% (P<0.001) with the ELECTROPRES platform. When all the criteria were independently examined, the Lewis index (R-I+S-III) and the Cornell product [(R-aVL+S-V3 (+6 for women)] were those in which the most cases of left ventricular hypertrophy were detected (24.8% and 13.3%, respectively). The Lewis index and the Cornell product were the criteria that detected more cases of left ventricular hypertrophy, regardless of the AHT stage and of the presence of cardiovascular complications. CONCLUSIONS: The ECG computerized reading (ELECTROPRES platform) significantly increases detection of left ventricular hypertrophy in a population of essential hypertense subjects compared to conventional detection with the ECG by the physician in the usual clinical practice setting.

Additive value of diabetes and peripheral arterial disease in the risk stratification of patients admitted after an acute coronary syndrome: a subanalysis of the PAMISCA Study.

BACKGROUND: There is an increasing interest in the use of non-invasive methods for the detection of subclinical atherosclerosis to better identify patients with high risk of cardiovascular events The presence of diabetes mellitus (DM) and peripheral arterial disease (PAD) is associated with increased risk of events but their value in the acute coronary syndrome (ACS) patient has not been ascertained. METHODS: We performed a subanalysis of the PAMISCA study, designed to investigate the prevalence of PAD in patients admitted to Spanish hospitals with a diagnosis of an ACS. RESULTS: A total of 1410 patients were analysed (71.4% men, age 66 +/- 11.9 years, 35% DM). The prevalence of PAD was higher in DM vs. no-DM (41.5% vs. 30.6% respectively, p < 0.001). Patients with PAD and DM had more in-hospital cardiac complications such as atrial fibrillation/flutter, recurrent myocardial ischaemia and heart failure and a trend towards higher in-hospital mortality (p = 0.08). Non-DM patients with PAD and DM without PAD shared similar cardiac complications and the group without neither PAD nor DM had the best prognosis. In patients without PAD, DM was an independent predictor of three-vessel coronary disease (OR 1.6; 95% CI: 1.1-2.5, p < 0.05) after adjustment by age, sex, low density lipoproteins (LDL), smoking and the previous myocardial infarction. However, in PAD patients, DM failed to be an independent risk factor in the multivariate analysis (OR 1.0; 95% CI 0.6-1.6, p < 0.05). CONCLUSIONS: The concurrence of DM and PAD helps identify patients with an adverse risk profile.

[Anthropometric measurements of general and central obesity and discriminative capacity on cardiovascular risk: RICARTO study]. / Medidas antropométricas de obesidad general y central y capacidad discriminativa sobre el riesgo cardiovascular: estudio RICARTO.

INTRODUCTION AND OBJECTIVES: Overweight and obese patients have an increased risk of cardiovascular disease and general mortality. It is not clear which obesity index should be used in the clinic. The objective is to compare the relationship between body mass index (BMI), waist circumference (WC), waist-height ratio (WHR), and conicity index (Conicity-I) with 10-year Framingham cardiovascular risk (CVR). MATERIAL AND METHODS: Population cross-sectional study in subjects ≥18years, residents in the Toledo (Spain) Health Area. Selection by random sampling. Measurements were made of the BMI, WC, and weight to height ratio with standardised methods. Framingham CVR. Calculation of AUC, and optimal cut-off points. RESULTS: The study included 1,309 subjects, with mean age of 48.9±15.8years, and 55% women. The response rate was 36.6%. In women, the index that was best associated with CVR in women was the WC with an AUC=0.85 (95%CI: 0.81-0.88). In men it was the I-Conicity, with an AUC=0.81 (95%CI: 0.77-0.84). Cut points for BMI were similar in women (27.08kg/m2) and men (26.99kg/m2). The WC was lower in women (87.75cm) than in men (94.5cm). The WHR was higher in women (0.59) than in men (0.56). The I-Conicity was slightly lower in women (1.25) than in men (1.28). In women, all the ROC curves were closest to each other. CONCLUSIONS: The central obesity indexes (WC and WHR) discriminated better than the BMI the CVR. In women, all the indices had greater AUCs than in men, except for the I-Conicity.

[Prevalence of obesity and cardiovascular comorbidity associated in patients included in the IBERICAN study]. / Prevalencia de obesidad y comorbilidad cardiovascular asociada en los pacientes incluidos en el estudio IBERICAN (Identificación de la poBlación Española de RIesgo CArdiovascular y reNal).

OBJECTIVES: To analyse the prevalence of obesity and its association with other cardiovascular risk factors and cardiovascular disease in a sample of patients from the (Identification of the Spanish population at cardiovascular and renal risk) IBERICAN study. MATERIAL AND METHODS: Analysis of the inclusion visit of the first 5,013 patients of the IBERICAN longitudinal, observational, and multicentre study in which individuals aged 18 to 85 years were included in Primary Care Clinics in the different regions of Spain. In this work obesity was defined as a body mass index ≥ 30kg/m2. RESULTS: The prevalence of obesity was 35.7% (95% CI: 35.0-36.4%), of which 36.6% were men and 34.9% were women (P=0.214), and significantly increasing with age (0.001). The obesity had the associated higher prevalence of hypertension (62.8% vs. 39.4%, P<001), dyslipidaemia (56.9% vs. 47.1%, P<0.001), sedentary lifestyle (40.6% vs. 24.6%, P<.001), diabetes (27.5% vs. 14.8%, P<.001), hyperuricaemia (23.6% vs. 12.7%, P<.001), subclinical organ injury (33.7% vs. 26.5%, P<.001) and cardiovascular disease (21.2% vs. 15.3%, P<.001). The multivariate analysis showed that the variables associated with obesity were: arterial hypertension (P<.001), hyperuricemia (P<.001), sedentary lifestyle (P<.001), diabetes mellitus (P<0.001), age (P<0.001), low educational level (P<0.001) and lower consumption of tobacco (P<0.001). CONCLUSIONS: The analysis of the IBERICAN study shows that approximately one third of the analysed population meets criteria of obesity and cardiovascular risk factors. Target organ damage and cardiovascular disease were more frequent in obese patients.

CPAP decreases plasma levels of soluble tumour necrosis factor-alpha receptor 1 in obstructive sleep apnoea.

There is increasing evidence that inflammation plays an important role in the development of cardiovascular complications in patients with obstructive sleep apnoea (OSA). No previous works have studied levels of soluble tumour necrosis factor-alpha receptor (sTNFR)-1 in patients with OSA. The aims of the present study were to examine serum levels of sTNFR-1 and the effect of nasal continuous positive airway pressure (CPAP) in patients with OSA. A prospective, randomised, placebo-controlled crossover study was performed. In total, 30 consecutive newly diagnosed OSA patients (apnoea/hypopnoea index 43.8+/-27.0 events x h(-1)) and 15 healthy obese patients were selected. Urinary levels of norepinephrine and epinephrine, as well as plasma sTNFR-1, tumour necrosis factor (TNF)-alpha, interleukin (IL)-6 and leukotriene (LT)B(4) levels were obtained at baseline and after 3 months of CPAP or sham CPAP. Nocturnal urinary levels of norepinephrine, epinephrine and sTNFR-1 (1,053+/-269 versus 820+/-166 pg x mL(-1)) were significantly higher in OSA patients. There were no significant differences in plasma levels of IL-6, LTB(4), or TNF-alpha between the two study groups. There were no significant differences in blood pressure, urinary catecholamine levels, or plasma IL-6, LTB(4) and TNF-alpha levels after both treatment modalities. However, after 3 months of effective CPAP usage, sTNFR-1 levels were significantly reduced (1,053+/-269 versus 899+/-254 pg x mL(-1)). Obstructive sleep apnoea patients have higher levels of soluble tumour necrosis factor-alpha receptor 1 than individuals without OSA; soluble tumour necrosis factor-alpha receptor 1 levels are lowered by continuous positive airway pressure therapy. These findings further corroborate a potential role of inflammation in the natural history of obstructive sleep apnoea.

Prevalence and prognostic influence of peripheral arterial disease in patients >or=40 years old admitted into hospital following an acute coronary event.

OBJECTIVE: A significant proportion of patients with ischemic heart disease have associated peripheral arterial disease (PAD), but many are asymptomatic and this condition remains underdiagnosed. We aimed to study the prevalence of PAD in patients with an acute coronary syndrome (ACS) and to evaluate its influence in hospital clinical outcomes. METHODS: The PAMISCA register is a prospective, multicenter study involving patients >or=40 years old with ACS admitted to selected Spanish hospitals. All patients had their ankle-brachial index (ABI) measured between days 3 and 7 after the ischemic event. RESULTS: 1410 ACS patients (71.4% male) were included. PAD determined by ABI was documented in 561 patients (39.8%). Factors independently related to PAD were age (OR: 1.04; 95% CI: 1.03-1.06; p<0.001), smoking (OR: 1.88; 95% CI: 1.41-2.49; p<0.0001), diabetes (OR: 1.30; 95% CI: 1.02-1.65; p<0.05), previous cardiac disease (OR: 1.54; 95% CI: 1.22-1.95; p<0.001) and previous cerebrovascular disease (OR: 1.90; 95% CI: 1.28-2.80; p<0.001). Following the ACS, an ABIor=40 years presenting with ACS is high and it is associated with increased cardiovascular risk.

Amlodipine reduces predicted risk of coronary heart disease in high-risk patients with hypertension in Spain (The CORONARIA Study).

We evaluated the efficacy and safety of amlodipine besylate alone or in combination with other antihypertensive agents in high-risk hypertensive patients in Spanish primary care. In this 1-year, open-label, prospective cohort study, 7468 patients were treated with amlodipine 5 - 10 mg as a monotherapy or as an add-on therapy to attain blood pressure control (target of < 140/90 mmHg or, in patients with conditions such as diabetes or chronic kidney disease, < 130/85 mmHg). At 12 months, the primary outcome (change from baseline in predicted 10-year coronary heart disease risk) was -8.6%, down from 24.7% at baseline (relative risk reduction, 31.6%). Change in blood pressure from baseline (162.5/95.3 mmHg) was -26.7/-14.6 mmHg, and 38.6% of patients achieved their blood pressure target. In summary, significant reductions in predicted coronary heart disease risk and blood pressure were observed with amlodipine both as a monotherapy and as an add-on therapy. Amlodipine was well tolerated and compliance with treatment was good.

[Control of blood pressure by using an intelligent telephone application with feedback and competitiveness strategy. HTApp Control project]. / Control de la presión arterial mediante el uso de una aplicación para teléfono inteligente con estrategia de retroalimentación y competitividad. Proyecto Control HTApp.

INTRODUCTION AND OBJECTIVE: Arterial hypertension is a highly important cardiovascular risk factor, with low control percentages. New technologies can help to obtain a better control of this disease. The intention is to know if a mobile application can help achieve this goal. METHOD: A mobile phone application is used to give feedback to physicians with the aim of generate competitiveness in achieving objectives. The application could, at any time, determine the rate of controlled patients (<140/90mmHg) by each physician, and compare them with the mean number of the patients controlled by the group. The possible changes in the therapeutic attitude of physicians are also analysed and the differences in achieving objectives are compared based on specific characteristics of patients. RESULTS: The study included 220 patients aged 18-80 years, with mean blood pressure>140/90mmHg, despite medical treatment, tracked for 4 visits. At the end of the follow-up, 69.03% achieved good control, compared to 12.8% in the baseline study (P<.001), with no differences between gender (control of 68.6 and 69.29% of women and men, respectively), nor among the different levels of cardiovascular risk. CONCLUSIONS: The use of interactive tools that allow the dynamic process of feedback on the results fosters the motivation and improves the therapeutic inertia in the control of blood pressure.

[Cardiovascular risk and cardiovascular events in the general population of the sanitary area of Toledo. RICARTO Study]. / Justificación, objetivos y diseño metodológico del estudio RICARTO (RIesgo CARdiovascular y eventos cardiovasculares en la población general del área sanitaria de TOledo).

INTRODUCTION: The main aim of this study is to ascertain the prevalence of cardiovascular risk factors (CVRF), target organ damage (TOD), cardiovascular disease (CVD), as well as life habits (physical exercise, alcohol consumption, and Mediterranean diet) in the population of a Health Area in Toledo, Spain, to assess cardiovascular risk (CVR). MATERIAL AND METHODS: Epidemiological and observational study that will analyse a sample from the general population aged 18 years or older, randomly selected from a database of health cards, and stratified by age and gender. Clinical history, physical examination, and complementary tests will be performed. Aliquots of whole blood and serum samples will be stored at a temperature of-85°C to evaluate future genetic studies. CVR will be estimated by using SCORE project scales calibrated for Spanish population and the Framingham Heart Study scale. When the estimated sample size has been achieved and after a minimum follow-up of 5 years, a final visit will performed in which CVRF, TOD, CVD, CVRF control, and fatal and non-fatal outcomes will be evaluated. DISCUSSION: The RICARTO study is aimed to assess the prevalence of the main CVRF, TOD and CVD in order to determine the CVR in the general population of a health area of Toledo. An analysis will be repeated on the final sample after at least 5 years of follow-up to ascertain the incidence of CV outcomes and the temporal trends of life style, as well as the prevalence of CVRF, TOD, and CVD.

[Characteristics and cardiovascular events in a general population included in the RICARTO (RIesgo CARdiovascular TOledo) study: Data from the first 1,500 individuals included in the study]. / Características de la población general incluida en el estudio RICARTO (RIesgo CARdiovascular y eventos cardiovasculares en la población general del área sanitaria de TOledo): resultados con los primeros 1.500 individuos incluidos en el estudio.

INTRODUCTION: The aim of this study was to assess cardiovascular risk (CVR) by investigating the prevalence of CVR factors (CVRF), target organ damage (TOD), and cardiovascular disease (CVD) in general population of the health area of Toledo, Spain. MATERIAL AND METHODS: Epidemiological and observational study that analysed a sample from the general population aged 18years or older, randomly selected from a database of health cards stratified by age and gender. Clinical history, physical examination, and complementary tests were performed. Total blood and serum samples were frozen at -85°C to evaluate genetic studies in the future. Standard statistical analysis was performed. CVR was assessed by the SCORE scale calibrated for the Spanish population, and the Framingham Heart Study scale. RESULTS: A total of 1,500 individuals (mean age 49.1±15.8years, 55.6% women) were included. Prevalences: dyslipidaemia 56.9% (95% confidence interval [95% CI]: 54.3-59.4), hypertension 33.0% (95%CI: 30.6-35.4), diabetes mellitus 8.6% (95%CI: 7.17-10.1), smoking 24.2% (95%CI; 122.0-26.4), obesity 25.3% (95%CI; 23.1-27.5), and sedentary life-style 39.4% (95%CI; 36.9-41.8). No CVRF was reported in 21.1% of cases, and 18.6% had 3-5 CVRF. TOD: electrocardiographic left ventricular hypertrophy, 4.3%, peripheral artery disease, 10.1% (Doppler ultrasound), and 15.3% (oscillometric device), microalbuminuria, 4.3%, sub-clinical renal disease, 3.2%, and nephropathy in 3.8% (CKD-EPI). At least one CVD was reported in 9.2% of cases. A low CVR (SCORE) was present in 44.6% of individuals. CONCLUSIONS: Dyslipidaemia was found in 60% of individuals, 40% had a sedentary life-style, 30% with hypertension, 20% smoked, 20% obesity, and almost 10% with diabetes. More than a half of individuals have a moderate-high-very high risk. The prevalence of TOD and CVD are significant.

[Reliability study on the interpretation of electrocardiograms by general practitioners and trainees]. / Estudio de fiabilidad en la interpretación del electrocardiograma por médicos de familia y médicos residentes.

OBJECTIVE: To determine the reliability of the interpretation of electrocardiograms (ECG) by general practitioners and those in training by making a comparison with the interpretation made by the cardiologist. MATERIAL AND METHODS: An observational study was conducted that included general practitioners working in the Toledo Health Area, physicians during their training in Family and Community Medicine, and cardiologists in their first 3 years of specialist training (R1-R3). A questionnaire was used that included 13 ECGs with no clinical details of the patient. The 13 ECGs were selected and their diagnoses made by consensus by 2 cardiologists from the Toledo Hospital Complex. RESULTS: The highest percentage of correct answers (82.3%) was obtained for ECG 5 (atrial fibrillation), and the lowest (26.5%) for ECG 11 (junctional rhythm). The highest diagnostic skill was achieved by the resident cardiologists, general practitioners, medical tutors, and doctors who had worked in hospital emergency departments. The highest odds ratio for a higher diagnostic skill was to work in an emergency department and be a practising general practitioner, both with almost significant results (P<.10). CONCLUSIONS: Family physicians and those in training have a medium level of reliability in the interpretation of an ECG compared to the cardiologist.

Thallium-201 exercise scintigraphy in patients having complete left bundle branch block with normal coronary arteries.

Eleven patients with left bundle branch block and chest pain suggestive of coronary arterial disease were analyzed using thallium-201 exercise scintigraphy, M-mode echocardiography and coronary arteriography. The coronary arteries were shown to be normal in all patients. A reversible anteroseptal defect on thallium-201 scintigraphy and an asynchronous septal motion on echocardiography were evident in eight patients. Thus, symptomatic patients with left bundle branch block may have reversible anteroseptal defects on thallium-201 scintigraphy which do not indicate coronary artery disease. Rather, they may be due to functional ischemia secondary to abnormal septal motion.

[The usefulness of the electrocardiogram in the diagnosis of left ventricular hypertrophy in essential arterial hypertension]. / Utilidad del electrocardiograma en el diagnóstico de hipertrofia ventricular izquierda en la hipertensión arterial esencial.

The aim of the study is to analyse the usefulness of electrocardiographic criteria of left ventricular hypertrophy in essential hypertension. Seventy four patients (27 males, 47 females), 49 +/- 11 years--old with mild--moderate systemic hypertension (blood pressure greater than or equal to 140/90 mmHg) have been prospectively studied. A 12-lead electrocardiogram and an echocardiogram (M and 2D mode) have been performed after the basic clinical study. A left ventricular mass index (Devereux's method) greater than 131 g/square meters (males) or greater than 110 g/square meters (females) has been considered as left ventricular hypertrophy. Sensitivity, specificity and accuracy of 11 current electrocardiographic criteria of left ventricular hypertrophy have been determined. Sensitivity of these criteria was very low (0-0.35), while specificity was high (0.71-1). Total QRS voltage showed the best accuracy (0.51), while V5 or V6 R wave amplitude greater than 26 mm showed the best sensitivity (0.35). Current electrocardiographic criteria of left ventricular hypertrophy are not very useful in the diagnosis of left ventricular hypertrophy in essential hypertension.

[Arterial hypertension unit in the health area]. / La consulta de hipertensión arterial en el área sanitaria.

For several decades the study of hypertension has been the subject of special attention in the arterial hypertension units and there has been a continuous search for different organizational models in order to improve diagnostic and therapeutic efficiency. The duty assigned to the cardiologist in each health area, according to the new model regulated by the Spanish health authority, and as a result of new scientific developments, convert him into a principal health agent in the fields of hypertension and risk factors. According to our organizational scheme the treatment of the hypertensive patient is undertaken in the preventive cardiology outpatient unit in conjunction with other hospital medical branches and the Family physician. This is backed up by a nursing team that selects the patients on entrance and carries out routine post-therapy.

[Up-dated treatment of arterial hypertension: progressive and individualized. Reduction of the heart mass]. / Tratamiento actualizado de la hipertensión arterial: escalonado e individualizado. Reducción de la masa cardíaca.

The usefulness and limitations of the current medical treatment of high blood pressure are analysed. The latest strategies in the management of hypertension are presented, with emphasis on the treatment of all associated cardiovascular risk factors. This is and important therapeutic goal of Preventive Cardiology. The individualized treatment, that is to say, the selection of the antihypertensive therapy according to the characteristics of each patient, is discussed as an objective of the present therapy. Finally, the new drugs and the recent advances in the classic ones are examined with a special focus on their hemodynamic actions and on their role in left ventricular hypertrophy.

[The comparative treatment with lovastatin and bezafibrate of primary hypercholesterolemia. A randomized and double-blind trial]. / Tratamiento comparativo de la hipercolesterolemia primaria con lovostatina y bezafibrato. Ensayo randomizado y a doble ciego.

The efficacy and tolerability of lovostatin (L) and bezafibrate (B) were compared in a total of 39 patients, 24 males and 15 females, 59 +/- 9 years old. Showing a total serum cholesterol superior to 250 mg/dl and total serum triglycerides inferior to 350 mg/dl, after 1 month on a low cholesterol diet and another on placebo, were eligible for participation. After randomization 19 treated with L started with 20 or 40 mg at night according to baseline cholesterol under or above 300 respectively and 20 with B received 200 mg tid. If after 6 weeks of therapy cholesterol remained above 200, the doses of L or matching placebo in those with B was double while dose of B or matching placebo remained constant. Cholesterol, triglycerides, LDL-cholesterol and HDL-cholesterol were determined using an enzymatic analytical method. Apolipoproteins were obtained by radial immunodiffusion. Routine hematological analysis and blood chemistry safety tests were performed at baseline and every 6 weeks during active treatment. The average most important results, after 12 weeks of treatment, comparing L vs B were: 1) cholesterol was reduced 26 vs 10% (p less than 0.001); 2) LDL-cholesterol decreased 35 vs 15% (p less than 0.001); 3) HDL-cholesterol increased 5 vs 19% (p = NS); 4) triglycerides diminished 15 vs 18% (p = NS). Three patients in L and 1 in B showed adverse events and two of them, one each group, were drop-out. In summary: a) L was more effective lowering total cholesterol and LDL-cholesterol; b) B was more potent decreasing triglycerides and increasing HDL-cholesterol; c) both drugs showed good tolerability.

[Clinical practice guidelines of the Spanish Society of Cardiology on echocardiography]. / Guías de práctica clínica de la Sociedad Española de Cardiología en ecocardiografía.

Doppler echocardiography has become the technique of choice for the diagnosis and follow-up of most heart diseases its main advantages are that it is non-invasive, easy to use, readily available, rapid and has a high cost-benefict ratio. Multiple studies have demonstrated the accuracy of the technique in the diagnosis and severity quantification of the severity of different diseases. Nevertheless, its main limitation lies in the fact that results are operator dependent, and therefore correct training of the echocardiographer is mandatory. In addition, adequate infrastructure and appropriate equipment are a required guarantee quality of the study. Finally, the technique should be used for the indications, in which beneficial information can be yielded. The aim of the present article was to define and update these considerations to enhance the usefulness of echocardiography in clinical practice.

[An adrenaline-induced vasospasm as the form of presentation of variant angina]. / Vasoespasmo inducido por adrenalina como forma de presentación de una angina variante.

A 41-year-old-man without previous ischemic heart disease, developed a severe anaphylactic reaction. After administration of epinephrine (0.5 mg) the patient complained of chest pain. The electrocardiogram showed an elevation of ST segment in inferior leads. Myocardial necrosis was ruled out. Coronary arteriography disclosed normal coronary arteries. Eight months later, the patient developed severe chest pain during physical activity. ST elevation was again seen in inferior leads. ECG changes disappeared, when sublingual nitroglycerin was administered. A diagnosis of vasospastic angina was made. Exercise test was negative, during treatment with calcium-blocking agents. The patient subsequently remain free of symptoms taking medication. The physiological mechanisms of vasospastic angina and precipitating factors are discussed.