Carlos Guijarro

Fiabilidad del conjunto mínimo básico de datos (CMBD) en el diagnóstico de la enfermedad tromboembólica

La base de datos administrativa que recoge el conjunto mi-nimo basico de datos (CMBD) incorpora la codificacion dela novena revision de la Clasificacion Internacional de lasEnfermedades (CIE-9-MC) para diagnosticos y procedimien-tos terapeuticos, quirurgicos y obstetricos que figuran en elinforme medico de alta. Es de uso obligado y comun en to-dos los hospitales publicos de Espana y fue creada y pro-mocionada desde el Ministerio de Sanidad y Consumo

Dislipemia en población diabética tratada con estatinas. Resultados del estudio DYSIS en España

BACKGROUND AND OBJECTIVE Type 2 diabetes mellitus (DM2) is characterized by carrying a high cardiovascular risk. This situation underscores the importance of intensively treating the risk factors present in diabetic patients, notably dyslipemia. The treatment with cholesterol-lowering drugs may be especially effective to reduce the cardiovascular risk in diabetic patients. Therefore, LDL-cholesterol is a priority target in the lipid management of these patients. This study analyzes the alterations in the lipid profile of diabetic patients receiving treatment with statins, which therefore may contribute to persistent cardiovascular risk in such individuals. PATIENTS AND METHODS The DYSIS (Dyslipidemia International Study) is an international, observational trial analyzing the lipid profile of patients treated with statins and followed-up on in outpatient clinics by primary care physicians and specialists. This study is referred to the data on the diabetic patients. RESULTS Of the total patients enrolled in the DYSIS, the present study included 3703 patients, 39% being diabetics. A total of 59.2% of diabetics showed LDL-C out of goal; triglyceride elevation was observed in 43.6% and 36.4% showed low HDL-C. In diabetics patients with coronary heart disease, 31% had uncontrolled levels of all three lipid parameters. The prevalence of out of goal LDL-C in diabetic patients with metabolic syndrome was close to 60%; 39.8% had low levels of HDL-C and 46,6% high levels of triglycerides. In addition, 57% of diabetic patients with obesity showed LDL-C out of control, despite statins treatment. CONCLUSIONS Cardiovascular diseases remain the main cause of morbidity-mortality in patients with DM2. The results of the present study show that in diabetic patients the degree of control is very limited with regard to LDL-cholesterol. More than half of diabetic patients treated with statins had LDL-cholesterol out of goal. The level of dyslipidemia control was low, despite statins treatment. Therefore, the detection of atherogenic dyslipidemia may point to the advisability of using combination therapy for dyslipidemia in diabetic patients.

Similitudes y diferencias entre los pacientes con aterosclerosis sintomática de distintos territorios. Cohorte AIRVAG (Atención Integral al Riesgo VAscular Global)

BACKGROUND AND OBJECTIVE: Even though atherosclerosis is a systemic disease, few prospective studies have evaluated in a thorough and systematic manner the whole vascular tree in patients with clinical damage of different territories. PATIENTS AND METHOD: Prospective protocolized study of 269 consecutive patients younger than 70, attended because of symptomatic arteriosclerosis of any territory -53% coronary (CHD), 32% cerebrovascular (CVD), 15% peripheral (PVD)-. Patients underwent evaluation of risk factors and their control, systematic non-invasive study of the vascular tree (Doppler-ultrasound) and comparison between groups according to the index territory. RESULTS: Even though all risk factors were represented in the 3 groups, male sex, smoking and diabetes were more frequent in PVD and dyslipemia was more common in CHD (p < 0.05) Abdominal aortic diameter and carotid intima-media thickness were similar for all groups, while the number of carotid plaques was higher in PVD. CHD patients more often presented left ventricular hypertrophy and reduced ejection fraction. PVD patients showed a marked reduction of the ankle-brachial index as well as increased C-reactive protein and homocysteine (p < 0.05). Severe unsuspected vascular lesions were found in 13% of cases (95% confidence interval, 9.5-17.6%). Risk factor control was better for CHD, followed by CVD and PVD, but was globally poor. CONCLUSIONS: The systematic evaluation of the vascular tree detects generalized atherosclerotic lesions, in some cases severe and clinically unsuspected. New markers to identify patients at very high risk are necessary. Peripheral vascular disease identifies a group of patients of particular risk. Risk factor control is deficient, particularly among PVD patients.

Prevalence, Treatment, and Control of Hypercholesterolemia in High Cardiovascular Risk Patients: Evidences from a Systematic Literature Review in Spain

IntroductionCardiovascular diseases (CVDs) represent a major Public Health burden. High serum cholesterol levels have been linked to major CV risk. The objectives of this study were to review the epidemiology of hypercholesterolemia in high risk CV patients from Spain, by assessing its prevalence, the proportion of diagnosed patients undergoing pharmacological treatment and the degree of attained lipid control.MethodsA systematic literature review was carried out using Medline and two Spanish databases. Manuscripts containing information on hypercholesterolemia in several high CV risk groups [diabetes mellitus (DM), Systematic COronary Risk Evaluation (SCORE) risk >5, or documented CVD], published between January 2010 and October 2014, were included.ResultsOf the 1947 published references initially retrieved, a full-text review was done on 264 manuscripts and 120 were finally included. Prevalence of hypercholesterolemia ranged from 50 to 84% in diabetics, 30–60% in patients with DM or elevated SCORE risk, 64–74% with coronary heart disease, 40–70% in stroke patients, and 60–80% in those with peripheral artery disease. Despite the finding that most of them were on pharmacological treatment, acceptable control of serum lipids was very variable, ranging from 15% to 65%. Among those with heterozygous familial hypercholesterolemia, 95–100% received treatment but less than 50% achieved their therapeutic goals.ConclusionsAn elevated prevalence of hypercholesterolemia can be found in targeted groups at high CV risk. Although most patients are receiving pharmacological treatment, rates of lipid control continue to be low, both in primary and secondary prevention.

Differences in the use of health resources by Spanish and immigrant HIV-infected patients

BACKGROUND HIV-immigrant use of health services and related cost has hardly been analysed. We compared resource utilisation patterns and direct health care costs between Spanish and immigrant HIV-infected patients. METHODS All HIV-infected adult patients treated during the years 2003-2005 (372 patients) in this hospital were included. We evaluated the number of out-patient, Emergency Room (ER) and Day-care Unit visits, and number and length of admissions. Direct costs were analysed. We compared all variables between immigrant and Spanish patients. RESULTS Immigrants represented 12% (n=43) of the cohort. There were no differences in the number of out-patient, ER, and day-care hospital visits per patient between both groups. The number of hospital admissions per patient for any cause was higher in immigrant than in Spanish patients, 1.3 (4.4) versus 0.9 (2.7), P=.034. A high proportion of visits, both for the immigrant (45.1%) and Spanish patients (43.0%), took place in services other than Infectious Diseases. Mean unitary cost per patient per admission, out-patient visits and ER visits were similar between groups. Pharmacy costs per year was higher in Spanish patients than in immigrants (7351.8 versus 7153.9 euros [year 2005], P=.012). There were no differences in the total cost per patient per year between both groups. The global distribution of cost was very similar between both groups; almost 75% of the total cost was attributed to pharmacy in both groups. CONCLUSIONS There are no significant differences in health resource utilisation and associated costs between immigrant and Spanish HIV patients.

Recomendaciones para la utilización clínica de los alimentos enriquecidos con fitoesteroles/fitoestanoles en el manejo de la hipercolesterolemia

Raised low-density lipoprotein cholesterol (LDLc) plasma concentration is a major risk factor for atherosclerotic cardiovascular disease. Despite international recommendations on hypercholesterolemia management the percentage of individuals with LDLc plasma concentration above goals according to their global cardiovascular risk remains high, and additional therapeutic strategies should be evaluated. Consumption of functional foods enriched with phytosterols (PSRs) and phytostanols (PSNs) reduces LDLc concentrations by 10% as average. Although recommended as part of any lipid-lowering diet in the first intervention step, PSRs/PSNs maintain their LDL reduction capacity when administered with lipid-lowering drugs; therefore, they can be also considered in some cases as an adjuvant to drug therapy. In this document we summarise the latest evidence regarding the LDL reducing effects of PSR/PSN supplementation, alone or as an add-on to hipolipemic drugs and the international recommendations of its clinical use.

Enfermedad arterial oclusiva en los estudios REACH, FRENA y AIRVAG

Pocos estudios han comparado las caracteristicas de los pacientes con afectacion aterosclerotica de distintos territorios en nuestro medio. En los ultimos anos se han desarrollado 3 estudios que han abordado de modo comprensivo el problema clinico de la aterotrombosis, con inclusion de pacientes afectados de distintos territorios vasculares y con un seguimiento clinico relativamente homogeneo de al menos 1 ano de duracion. Los registros REACH (REduction of Atherothrombosis for Continued Health) (grupo espanol), FRENA (Factores de Riesgo y ENfermedad Arterial) y el estudio AIRVAG (Atencion Integral al Riesgo VAscular Global) muestran un patron similar de los pacientes con enfermedad arterial oclusiva de las extremidades (EAO): predominio de varones fumadores con alta prevalencia de diabetes. Los pacientes con EAO reciben una intensidad terapeutica promedio (antiagregacion, hipolipemiantes, hipotensores) claramente inferior a la de los pacientes coronarios y cerebrovasculares. Como consecuencia, el grado de control de los factores de riesgo es peor en pacientes con EAO que en el resto de territorios vasculares. Los pacientes con EAO tienen con mas frecuencia afectacion de otros territorios vasculares que el resto de los pacientes con aterosclerosis. Por ultimo, los pacientes con EAO tienen un mayor riesgo de presentar nuevos episodios isquemicos de cualquier territorio. Los registros espanoles demuestran que la EAO identifica a un grupo de pacientes de muy alto riesgo vascular que reciben, paradojicamente, una intensidad terapeutica inferior a otros pacientes con aterosclerosis. La EAO constituye el grupo de pacientes con aterosclerosis mas necesitado de un esfuerzo vigoroso para el control de los factores de riesgo vascular.

Consensus document of the Spanish Society of Arteriosclerosis on indications of inhibitors of PCSK9

http://dx.doi.org/10.1016/j.arteri.2016.02.001 0214-9168/© 2016 Publicado por Elsevier España, S.L.U. en nombre de S izadas de forma aislada o asociadas a ezetimiba o resinas, en aquellos sujetos de alto o muy alto riesgo intolerantes estatinas. Las efectos beneficiosos y secundarios tras la admiistración de anticuerpos monoclonales inhibidores de la CSK9 han sido resumidos en un metaanálisis publicado ecientemente1, que incluye más de 10.000 sujetos trataos, en los que se obtuvo una reducción media del colesterol DL de un 50% (entre el 42-66%), tanto en sujetos no trataos previamente, como en los que ya llevaban tratamiento on estatinas. Esta reducción estadísticamente significativa

Letter by Guijarro Regarding Article, “Cerebrovascular Outcomes With Proton Pump Inhibitors and Thienopyridines: A Systematic Review and Meta-Analysis”

A recent meta-analysis suggests that the use of proton pump inhibitors (PPI) may increase the risk for stroke in patients receiving antithrombotic treatment with thienopyridines.1 However, among the 22 trials included in the meta-analysis, only 2 were specifically designed as randomized controlled trials (RCT) evaluating the interaction of PPI and thienopyridines.2,3 In both trials, patients receiving clopidogrel were randomly allocated to receive either a PPI (esomeprazole or omeprazole) or placebo. In both trials, PPI therapy was associated with a …

Colesterol ligado a lipoproteínas de baja densidad (LDL) y reducción del riesgo vascular. Proproteína convertasa subtilisina / kexina tipo 9 (PCSK9): una nueva diana terapéutica

Las enfermedades cardiovasculares continúan siendo la principal causa de mortalidad y una causa importante de morbilidad en nuestro medio. Las concentraciones elevadas de colesterol total, y especı́ficamente del colesterol ligado a las low density lipoproteins (LDL, «lipoproteı́nas de baja densidad»), presentan una asociación positiva y creciente para todos los niveles habituales en la población occidental con el desarrollo de cardiopatı́a isquémica y mortalidad cardiovascular. La teorı́a lipı́dica de la arteriosclerosis ha tenido un refrendo muy potente con un gran número de ensayos clı́nicos que ha mostrado de modo consistente que la reducción del colesterol total (y del colesterol LDL) se asocia con una reducción del riesgo de enfermedad coronaria, ictus y mortalidad cardiovascular. Los datos más rotundos son, sin duda, los obtenidos en ensayos clı́nicos con estatinas, tanto en prevención primaria como en prevención secundaria. Adicionalmente, el tratamiento intensivo con estatinas ha mostrado efectos protectores superiores al tratamiento con dosis medias o bajas. A pesar del éxito incuestionable de las estatinas, la mayorı́a de los ensayos muestran una reducción del riesgo relativo en torno al 30%. El otro 70% es lo que se suele denominar «riesgo residual», pero quizá serı́a más adecuado llamarlo «riesgo persistente». Aunque es ilusorio pretender controlar por completo una enfermedad multifactorial como la arteriosclerosis atendiendo a un único factor de riesgo, es razonable plantear que el tratamiento hipolipidemiante todavı́a ofrece opciones potencialmente protectoras. En tal sentido, es oportuno recordar que la elevación del colesterol HDL muestra en estudios epidemiológicos una clara asociación con la reducción de complicaciones cardiovasculares. Desgraciadamente la mayorı́a de los ensayos terapéuticos orientados a la elevación del colesterol ligado a las high density lipoproteins (HDL, «lipoproteıı́nas de alta densidad») se han saldado con resultados decepcionantes, en particular los ensayos