Alberto Zamora

Impact of a partial smoke-free legislation on myocardial infarction incidence, mortality and case-fatality in a population-based registry: the REGICOR Study.

Background and Objective Coronary heart disease (CHD) is the leading cause of death, and smoking its strongest modifiable risk factor. Our aim was to determine the impact of the Spanish 2006 partial smoke-free legislation on acute myocardial infarction (AMI) incidence, hospitalization and mortality rates, and 28-day case-fatality in Girona, Spain. Methods Using a population-based registry (the REGICOR Study), we compared population incidence, hospitalization, and mortality rates, and 28-day case-fatality in the pre- and post-ban periods (2002–2005 and 2006–2008, respectively) by binomial regression analysis adjusted for confounding factors. We also analyzed the bans impact on the outcomes of interest using the AMI definitions of the American Heart Association (AHA)/European Society of Cardiology (ESC) and the World Health Organization (WHO)-Monitoring trends and determinants in cardiovascular diseases (MONICA). Results In the post-ban period, AMI incidence and mortality rates significantly decreased (relative risk [RR] = 0.89; 95% confidence interval [CI] = 0.81–0.97 and RR = 0.82; 95% CI = 0.71–0.94, respectively). Incidence and mortality rates decreased in both sexes, especially in women, and in people aged 65–74 years. Former and non-smokers (passive smokers) showed diminished incidence rates. Implementation of the ban was not associated with AMI case-fatality. Models tended to be more significant with the WHO-MONICA than with the AHA/ESC definition. Conclusions The 2006 Spanish partial smoke-free legislation was associated with a decrease in population AMI incidence and mortality, particularly in women, in people aged 65–74 years, and in passive smokers. These results clarify the association between AMI mortality and the enactment of a partial smoke-free legislation and reinforce the effectiveness of smoking regulations in preventing CHD.

Recursos hospitalarios y letalidad por infarto de miocardio. Estudio IBERICA

Determinar el porcentaje depacientes con infarto agudo de miocardio (IAM) que noingresan en una unidad de cuidados intensivos corona-rios (UCIC), las variables asociadas al ingreso en unaUCIC y si el ingreso en una UCIC, su disponibilidad y lade hemodinamica en el hospital se asocian a la letalidada 28 dias.

Hospital resources and myocardial infarction case fatality. The IBERICA study

INTRODUCTION AND OBJECTIVES To determine the proportion of patients with myocardial infarction (MI) not admitted to a coronary care unit (CCU), the variables associated with admission into a CCU, and whether admission to a CCU, and the availability of coronary angiography in the same hospital, were associated with 28-day case fatality. PATIENTS AND METHOD Population-based registry of MI in patients 25 to 74 years of age, admitted during 1996-1998. Demographic and clinical characteristics were recorded, as well as management, clinical course and survival after 28 days. Hospitals were classified according to the availability of a CCU and catheterization laboratory (advanced hospital), CCU only (intermediate hospital) or neither (basic hospital). Admission to the CCU was also recorded. RESULTS In all, 9046 cases of MI were recorded; in 11.3% the patient was not admitted to a CCU. Age, smoking (OR=1.33; 95% CI, 1.08-1.64), non-Q MI (OR=0.62; 95% CI, 0.49-0.78) or undetermined location of MI (OR=0.34; 95% CI, 0.23-0.50), Killip 4 score on admission (OR=0.63; 95% CI, 0.40-1.00) and delay in arrival at the hospital >6 h were associated with CCU admission. Patients admitted to a CCU showed a lower case fatality in the first 24 h (4.2% vs 23.5%), which was independent of comorbidity, severity and treatment. The 24-hour survivors admitted to a basic hospital had higher case fatality (17.3% vs 7.8%) than other groups, which was related to differences in treatment. CONCLUSIONS CCU admission is associated with a lower case fatality in the first 24 h. Admission to a basic hospital is associated with a higher 28-day case fatality even in patients who survive 24 h.

Pronóstico de los pacientes diabéticos con cardiopatía isquémica

La prevalencia de la diabetes mellitus (DM) en la poblacion espanola es cercana al 6%, y aumenta con la edad y la obesidad. Alrededor del 25% de los pacientes afectados de enfermedad coronaria tienen DM. Tanto los estados prediabeticos como la DM se asocian a una enfermedad arteriosclerotica temprana, extensa y especialmente agresiva. La DM elimina el efecto protector del ciclo hormonal menstrual y presenta un efecto sinergico con el resto de los factores de riesgo cardiovascular. Los objetivos de la prevencion primaria en los pacientes diabeticos seran los mismos que en aquellos no diabeticos que ya han sufrido un infarto de miocardio. Es especialmente importante aconsejar sobre habitos de vida saludable, realizar un control estricto de la glucemia y de los factores de riesgo asociados, en particular de la hipertension.

Relationship of classical and non-classical risk factors with genetic variants relevant to coronary heart disease.

Background In addition to the well established cardiovascular risk factors, evidence suggests a possible role of genetic and non-classical risk factors in the development and progression of atherothrombosis. We aimed to determine the relationship of classical and non-classical cardiovascular risk factors with candidate gene polymorphisms potentially involved in cardiovascular risk in the general Mediterranean population. Design Cross-sectional study. Methods We have determined the prevalence of classical (lipid profile, blood pressure, glycaemia, diabetes, smoking, body mass index, menopause and family history of coronary heart disease) and non-classical cardiovascular risk factors (infectious processes, homocysteinaemia, oxidative status, C-reactive protein, lipoprotein (a) and fibrinogen) in a population-based study. We analysed the relationship of these risk factors with the following five gene polymorphisms potentially involved in cardiovascular risk: ATP-binding cassette transporter A1-R219K, Peroxisome proliferator-activated receptor (PPAR)-α-L162V, Lipoprotein lipase (LPL)–HindIII, Paraoxonase (PON)1-Q192R, and Tumour necrosis factor (TNF)-α- G-308A. Results We found PPAR-α-V and LPL-H+ alleles to be associated with decreased high-density lipoprotein-cholesterol (HDL-c) concentration and with increased total cholesterol: HDL-c and triglyceride: HDL-c ratios. Regarding the non-classical risk factors, C-reactive protein concentration was higher for the PPAR-α-V allele. A higher oxidative status was shown in homozygotes for LPL-H+ and TNF-α-G alleles, although the latter also had lower homocysteinaemia. Conclusions Three of the genetic variants analysed, PPAR-α-L162V, LPL-HindIII, and TNF-α-G-308A, were associated with non-classical risk factors, specifically lipid profile, inflammation, and oxidative status.

Theoretical Impact on Coronary Disease of Using a Computerized Clinical Decision Support System in the Prescription of Lipid-lowering Treatment

in vascular risk. The objective of the present study was to assess the theoretical impact on the frequency of coronary artery disease of using the HTE-DLP throughout Spain with the CASSANDRAREGICOR methodology. The CASSANDRA-REGICOR system permits an estimate of the number of fatal and nonfatal coronary events that would occur in the Spanish population in the next 10 years in different scenarios according to trends in prevalence of cardiovascular risk factors. The system uses incidence data on coronary disease and risk factor prevalence from the REGICOR study. Extrapolation to Spain is based on data from the IBERICA study (incidence) and the DARIOS study (risk factor prevalence). The number of coronary events was predicted for 2010 to 2020 in patients aged between 35 and 75 years old. Population projections were provided by the Catalan Statistics Institute (IDESCAT) and Spanish National Statistics Institute (INE). The application enables an assessment of the 4 MedD, as key elements for the superior efficacy of this diet compared with a low-fat diet. It is likely that the MedD will be clearly reinforced as an intervention to be included in nonpharmacological treatment for preventing cardiovascular disease, thanks to the possibility of new studies backing the results published by de Lorgeril et al. The data from this study show that a majority of patients with CAD (63%) had acceptable adherence to the MedD. The application of the MEDAS–14 screener makes it possible to identify which aspects require improvement and provides the opportunity to focus and adapt a dietary intervention.

The association between education and cardiovascular disease incidence is mediated by hypertension, diabetes, and body mass index

Education and cardiovascular disease (CVD) are inversely associated but the mediating factors have not been totally elucidated. Our aim was to analyze the mediating role of modifiable risk factors. Cohort study using the REGICOR population cohorts. Participants without previous CVD were included (n = 9226). Marginal structural models were used to analyze the association between education and CVD incidence at 6 years of follow-up. Mediation by modifiable risk factors (diabetes, dyslipidemia, hypertension, smoking, body mass index, and physical activity) was assessed using the counterfactual framework. Participants with a university degree had a CVD incidence hazard ratio (HR) of 0.51 (95% confidence interval (CI) = 0.30, 0.85), compared to those with primary or lower education. Only hypertension, BMI, and diabetes mediated the association between education and CVD incidence, accounting for 26% of the association (13.9, 6.9, and 5.2%, respectively). Sensitivity analyses showed that hypertension was the strongest mediator (average causal mediation effect [95% CI] = increase of 2170 days free of CVD events [711, 4520]). The association between education and CVD incidence is partially mediated by hypertension, BMI, and diabetes. Interventions to decrease the prevalence of these risk factors could contribute to diminish the CVD inequalities associated with educational level.

Number of Patients Eligible for PCSK9 Inhibitors Based on Real-world Data From 2.5 Million Patients

INTRODUCTION AND OBJECTIVES PCSK9 inhibitors (PCSK9i) are safe and effective lipid-lowering drugs. Their main limitation is their high cost. The aim of this study was to estimate the number of patients eligible for treatment with PCSK9i according to distinct published criteria. METHODS Data were obtained from the Information System for the Development of Research in Primary Care. Included patients were equal to or older than 18 years and had at least 1 low-density lipoprotein cholesterol measurement recorded between 2006 and 2014 (n = 2 500 907). An indication for treatment with PCSK9i was assigned according to the following guidelines: National Health System, Spanish Society of Arteriosclerosis, Spanish Society of Cardiology, National Institute for Health and Care Excellence, and the European Society of Cardiology/European Atherosclerosis Society Task Force. Lipid-lowering treatment was defined as optimized if it reduced low-density lipoprotein levels by ≥ 50% and adherence was > 80%. RESULTS Among the Spanish population aged 18 years or older, the number of possible candidates to receive PCSK9i in an optimal lipid-lowering treatment scenario ranged from 0.1% to 1.7%, depending on the guideline considered. The subgroup of patients with the highest proportion of potential candidates consisted of patients with familial hypercholesterolemia, and the subgroup with the highest absolute number consisted of patients in secondary cardiovascular prevention. CONCLUSIONS The number of candidates to receive PCSK9i in conditions of real-world clinical practice is high and varies widely depending on the recommendations of distinct scientific societies.

Analysis of Plasma Albumin, Vitamin D, and Apolipoproteins A and B as Predictive Coronary Risk Biomarkers in the REGICOR Study

INTRODUCTION AND OBJECTIVES New biomarkers could improve the predictive capacity of classic risk functions. The aims of this study were to determine the association between circulating levels of apolipoprotein A1 (apoA1), apolipoprotein B (apoB), albumin, and 25-OH-vitamin D and coronary events and to analyze whether these biomarkers improve the predictive capacity of the Framingham-REGICOR risk function. METHODS A case-cohort study was designed. From an initial cohort of 5404 individuals aged 35 to 74 years with a 5-year follow-up, all the participants who had a coronary event (n = 117) and a random group of the cohort (subcohort; n = 667) were selected. Finally, 105 cases and 651 individuals representative of the cohort with an available biological sample were included. The events of interest were angina, fatal and nonfatal myocardial infarction and coronary deaths. RESULTS Case participants were older, had a higher proportion of men and cardiovascular risk factors, and showed higher levels of apoB and lower levels of apoA1, apoA1/apoB ratio, 25-OH-vitamin D and albumin than the subcohort. In multivariate analyses, plasma albumin concentration was the only biomarker independently associated with coronary events (HR, 0.73; P = .002). The inclusion of albumin in the risk function properly reclassified a significant proportion of individuals, especially in the intermediate risk group (net reclassification improvement, 32.3; P = .048). CONCLUSIONS Plasma albumin levels are inversely associated with coronary risk and improve the predictive capacity of classic risk functions.

Acute Myocardial Infarction Population Incidence and Mortality Rates, and 28-day Case-fatality in Older Adults. The REGICOR Study

INTRODUCTION AND OBJECTIVES Our aims were to determine acute myocardial infarction (AMI) incidence and mortality rates, and population and in-hospital case-fatality in the population older than 74 years; variability in clinical characteristics and AMI management of hospitalized patients, and changes in the incidence and mortality rates, case-fatality, and management by age groups from 1996 to 1997 and 2007 to 2008. METHODS A population-based AMI registry in Girona (Catalonia, Spain) including individuals with suspected AMI older than 34 years. RESULTS The incidence rate increased with age from 169 and 28 cases/100 000 per year in the group aged 35 to 64 years to 2306 and 1384 cases/100 000 per year in the group aged 85 to 94 years, in men and women, respectively. Population case-fatality also increased with age, from 19% in the group aged 35 to 64 years to 84% in the group aged 85 to 94 years. A lower population case-fatality was observed in the second period, mainly explained by a lower in-hospital case-fatality. The use of invasive procedures and effective drugs decreased with age but increased in the second period in all ages up to 84 years. CONCLUSIONS Acute myocardial infarction incidence, mortality, and case-fatality increased exponentially with age. There is still a gap in the use of invasive procedures and effective drugs between younger and older patients.