Carmen Suárez Fernández

Control integral de los factores de riesgo en pacientes de alto y muy alto riesgo cardiovascular en España. Estudio CIFARC

Fundamento y objetivo: El objetivo del presente estudio es determinar el porcentaje de pacientes con alto riesgo cardiovascular que tienen controlados de forma global todos sus factores de riesgo mayores (hipertension arterial, hipercolesterolemia, diabetes mellitus, tabaco y obesidad). Pacientes y metodo: Estudio transversal sobre pacientes ambulatorios de medicina interna, mayores de 18 anos y con riesgo cardiovascular alto o muy alto (segun la escala de Framingham, superior al 20% a los 10 anos). Se evaluo el grado de control de los factores de riesgo cardiovascular (hipertension arterial, diabetes mellitus, colesterol unido a lipoproteinas de baja densidad, tabaquismo y obesidad) segun las definiciones de control de la Organizacion Mundial de la Salud/Sociedad Internacional de Hipertension, Joint National Committee VI, National Cholesterol Education Program-Adult Treatment Panel III y American Diabetes Association. Resultados: Se estudio a 2.264 pacientes (el 53,7% eran varones), con una edad media (desviacion estandar) de 66,1 (11,5) anos. El 74,6% eran hipertensos; el 61,1%, dislipemicos; el 59,8%, diabeticos tipo 2; el 31,1%, fumadores; el 38%, obesos, y el 36,7% se hallaba en prevencion secundaria. El control de la hipertension arterial fue del 34,5%; el de la dislipemia, del 50,3%; y el de la diabetes mellitus, del 35,5%. El control de todos los factores de riesgo de forma global fue del 6,9% (y del 10,2% si se excluye la obesidad). Los factores relacionados de forma independiente con un mal control integral fueron la diabetes mellitus (odds ratio [OR] = 0,33; intervalo de confianza [IC] del 95%, 0,23-0,47), la dislipemia (OR = 0,34; IC del 95%, 0,24-0,48) y la existencia de proteinuria (OR = 0,36; IC del 95%, 0,18-0,71); se relacionaron con un mejor control integral el sexo varon (OR = 1,67; IC del 95%, 1,18-2,38), la hipertrofia ventricular izquierda (OR = 1,62; IC del 95%, 1,15-2,30) y la realizacion de pruebas complementarias (OR = 1,01; IC del 95%, 1,01-1,08). Conclusiones: Solamente el 6,9% de los pacientes de alto o muy alto riesgo cardiovascular tienen controlados los 5 principales factores de riesgo mayores. La existencia de diabetes mellitus, dislipemia o proteinuria predisponen a un mal control integral de dichos factores, mientras que el numero de exploraciones complementarias realizadas se asocia con un mejor control.

Reducción de la morbimortalidad cardiovascular tras un episodio cardiovascular agudo mediante el tratamiento intensivo de los factores de riesgo (proyecto MIRVAS)

Background and objective In spite of publication of many guidelines, management of patients on secondary prevention of cardiovascular disease is still not appropriated. We design a randomized trial, in usual clinical practice conditions, to compare the results in cardiovascular morbimortality of intensive and integral management of cardiovascular risk factors (CVRF) management versus conventional care. Patients and method We selected patients discharged between October 2002 and January 2004 who suffered an acute coronary syndrome with or without ST-segment elevation or a stroke, 247 patients that met inclusions criteria were randomized to intensive care of CVRF in a specific Internal Medicine outpatient clinic (n = 121) or usual care according to National Health Service recommendations (n = 126). A year after randomization, the percentage of patients who met CVRF control, treatment received and the number of cardiovascular events (cardiovascular death, acute coronary syndrome with or without ST-segment elevation, stroke, transient ischemic attack, revascularization, lower limb amputation, heart failure admission and sudden death) were revised. Results CVRF control was greater in patients assigned to intensive care. 74.1% of hypertensive patients assigned to this treatment were controlled vs 41.7% in the usual care group (relative risk [RR] = 1.78; 95% confidence interval [CI], 1.27-2-49); 70.2% of patients had low-densi-tiy lipoprotein cholesterol lower than 100 mg/dl vs 55.8% (RR = 1.26; 95% CI, 1.00-1.58) of patients in usual care group; 93.1% of diabetic patients had glycosylated haemoglobin lower than 7% vs. 57.1% (RR = 1.63; 95% CI, 1.11-2.39) in the usual care group. There were 12 cardiovascular events in the intensive care group vs 35 in the usual care group. Conclusions Intensive management of CVRF leads to a better control of them and a reduction of the morbimortality one year after an acute cardiovascular event.

Anestesia obstétrica en Cataluña

Fundamento y objetivo: Describir la actividad anestesica y analgesica en obstetricia en Cataluna (Espana). Pacientes y metodo: De los datos obtenidos de la encuesta de actividad anestesica ANESCAT, realizada en Cataluna durante el ano 2003, se identificaron las anestesias relacionadas con procedimientos obstetricos: partos, cesareas y otros no relacionados con el parto. Se analizaron las caracteristicas de las pacientes, las tecnicas anestesicas y su impacto en la poblacion. Resultados: Realizaron procedimientos obstetricos 71 centros (54%). La anestesia obstetrica represento el 11,3% de toda la actividad anestesica y una estimacion de 67.864 anestesias anuales. El 87,7% de dichos procedimientos estuvo relacionado con el parto. Se estimo que el 82% de los 71.851 partos habidos en Cataluna recibio la asistencia de un anestesiologo. La tasa de cesareas fue del 25,1% y hubo un aumento con la edad. La anestesia regional para el parto y la cesarea se utilizo en el 98,7 y el 96,2% de los casos, respectivamente. En el parto vaginal se empleo anestesia epidural en el 96,9% de los casos. En cesareas programadas y urgentes el bloqueo subaracnoideo se utilizo en un 75,5 y un 44,8% de los casos, respectivamente, y el epidural en un 23,3 y un 53,3%, respectivamente. Conclusiones: La cobertura con anestesia de los partos en Cataluna es la mas alta publicada. La tasa de utilizacion de tecnicas anestesicas regionales tambien es la mas alta registrada. La analgesia epidural continua es la tecnica mas utilizada, aunque se aprecia el uso emergente del bloqueo subaracnoideo.

Bayesian analysis under ε-contaminated priors: a trade-off between robustness and precision

Abstract Wasserman (1989) proved that the γ-level highest likelihood region is robust in the sense that its posterior probability content is least sensitive, when the prior goes through an e-contamination class. First, Wassermans result is slightly improved upon (less restrictive assumptions, a simpler proof,…). Then, a credible region is considered as an estimate of the parameter; if the most robust region is searched in the class of sets with posterior probability content greater than or equal to γ0, we find that all the precision for estimating the parameter θ is lost; so, it seems sensible to consider the class of credible regions with a posterior probability level at least equal to γ0 and a certain precision (Lebesgue measure at most l0); if Θ is an open interval in R , a method for obtaining the most robust interval (in this class) is developed.

Avances en el tratamiento anticoagulante de la fibrilación auricular

Atrial fibrillation is currently a very prevalent disease and it represents one of the most common causes of disabling stroke. Antithrombotic therapies have reduced the incidence of this complication although they pose many limitations and difficulties. As a result, a large number of high risk patients do not receive an appropriate treatment. In recent years, four new oral anticoagulants (NOAC) with relevant advantages in comparison to vitaminK antagonists have been released. Four large phaseiii clinical trials have demonstrated that NOAC are at least as safe and efficacious as warfarin in stroke prevention in non-valve atrial fibrillation patients with moderate-high thrombotic risk, being their main advantage the reduction in intracranial hemorrhage. The arrival of these drugs has caused great expectations in the management of these patients but also new doubts. Lacking data in some subgroups of frail patients, the absence of specific antidotes available and specially their high cost represent nowadays the main limitations for their generalization.

Asociación de antiagregantes, ¿cuándo y cómo?

La enfermedad aterotrombotica (coronaria, cerebrovascular y de la circulacion arterial periferica) es la causa mas frecuente de muerte y discapacidad en todo el mundo, y la medicacion antiagregante constituye uno de los pilares de su tratamiento y prevencion. En la actualidad contamos con farmacos que actuan en diferentes niveles de la agregacion plaquetaria (inhibidores de la ciclooxigenasa, de la fosfodiesterasa, del receptor P2Y12 del adenosindifosfato, del receptor IIb/IIIa). En este trabajo se revisan la eficacia y seguridad de la asociacion de antiagregantes en los escenarios clinicos de mayor relevancia, ademas de recogerse las recomendaciones clinicas actuales y un analisis de la evidencia en que se fundamentan.

Relación entre hormona paratiroidea y riesgo cardiovascular en pacientes con insuficiencia de vitamina D

Background and objectives Vitamin D deficiency and parathyroid hormone (PTH) are associated with an increased cardiovascular risk and arterial stiffness. The aim of our study is to compare the cardiovascular risk in subjects with low vitamin D, attending to the PTH concentration, as well as evaluating the response after administration of vitamin D.BACKGROUND AND OBJECTIVES Vitamin D deficiency and parathyroid hormone (PTH) are associated with an increased cardiovascular risk and arterial stiffness. The aim of our study is to compare the cardiovascular risk in subjects with low vitamin D, attending to the PTH concentration, as well as evaluating the response after administration of vitamin D. PATIENTS AND METHODS Prospective study of patients with a concentration of 25(OH)-vitamin D below 30nmol/l. We evaluated vascular risk parameters as blood pressure, arterial stiffness, lipid profile and glucose metabolism. Patients received vitamin D supplements for 3 months, after which the previous parameters were reassessed. RESULTS A total of 32 patients were included. Those with PTH over 65pg/ml were older, had worse renal function, higher systolic blood pressure, pulse pressure and arterial stiffness. Treatment with vitamin D showed a statistically significant trend to lower blood pressure and pulse wave velocity. CONCLUSIONS The increase in PTH in patients with low vitamin D involves poor control of blood pressure and increased vascular stiffness. Vitamin D replacement shows a tendency to reduce these parameters.

Original breveRelación entre hormona paratiroidea y riesgo cardiovascular en pacientes con insuficiencia de vitamina DRelation between parathyroid hormone and cardiovascular risk in patients with vitamin D deficiency

Background and objectives Vitamin D deficiency and parathyroid hormone (PTH) are associated with an increased cardiovascular risk and arterial stiffness. The aim of our study is to compare the cardiovascular risk in subjects with low vitamin D, attending to the PTH concentration, as well as evaluating the response after administration of vitamin D.BACKGROUND AND OBJECTIVES Vitamin D deficiency and parathyroid hormone (PTH) are associated with an increased cardiovascular risk and arterial stiffness. The aim of our study is to compare the cardiovascular risk in subjects with low vitamin D, attending to the PTH concentration, as well as evaluating the response after administration of vitamin D. PATIENTS AND METHODS Prospective study of patients with a concentration of 25(OH)-vitamin D below 30nmol/l. We evaluated vascular risk parameters as blood pressure, arterial stiffness, lipid profile and glucose metabolism. Patients received vitamin D supplements for 3 months, after which the previous parameters were reassessed. RESULTS A total of 32 patients were included. Those with PTH over 65pg/ml were older, had worse renal function, higher systolic blood pressure, pulse pressure and arterial stiffness. Treatment with vitamin D showed a statistically significant trend to lower blood pressure and pulse wave velocity. CONCLUSIONS The increase in PTH in patients with low vitamin D involves poor control of blood pressure and increased vascular stiffness. Vitamin D replacement shows a tendency to reduce these parameters.

Bayesian robustness of credible regions in the presence of nuisance parameters

The problem of finding the most robust γ-level credible region for the parameter of interest in the presence of a nuisance parameter, with respect to a class of e-contaminated priors, is studied. The case of arbitrary con-taminations is first analyzed; it is proved that the most robust region for the parameter of interest is theγ-level highest marginal likelihood region (forγ ≥ 0.5). Then, the result is extended to any measurable (not necessarily one-to-one) function of the parameter. Finally, the case of contaminations assigning fixed probabilities to the sets of a partition of the parameter space is analyzed and a partial result is given.

Satisfaction with oral anticoagulants in patients with atrial fibrillation

Background Although, by itself, atrial fibrillation is associated with an impairment of quality of life antithrombotic therapy may play a role. Objective To evaluate the satisfaction with anticoagulant treatment in patients with nonvalvular atrial fibrillation who attended internal medicine departments in Spain. Methods Patients from two different cross-sectional studies were combined. To measure the satisfaction with anticoagulant treatment, the Anti-Clot-Treatment Scale (ACTS) questionnaire was completed by every patient. A multivariate analysis was performed to determine the variables associated with satisfaction of patients receiving oral anticoagulants. Results A total of 1,309 patients (mean age 78.5±8.4 years; 49.3% men; CHA2DS2VASC 4.9±1.5; HAS-BLED 2.0±0.9) were included in the study, of whom 902 (68.9%) were taking vitamin K antagonists (VKA) and 407 (31.1%) direct oral anticoagulants (DOACs). Overall, satisfaction with oral anticoagulation was high (ACTS Burdens scale 49.69±9.45; ACTS Benefits scale 11.35±2.61). The perceived burdens with anticoagulant treatment were lower in men, as well as in patients with no dependency, normal renal function, who were not polymedicated, or who had moderate bleeding risk. Among patients taking VKA, those subjects with a lower number of International Normalized Ratio (INR) determinations in the last 6 months or with an optimal time in the therapeutic range exhibited a lower perceived burden. Patients taking DOACs (vs VKA) showed a lower perceived burden with anticoagulation. Benefits with anti-coagulation were higher in men, younger patients, those with no dependency, or low bleeding risk. Perceived benefits were higher in patients taking DOACs (vs VKA). Conclusion Satisfaction with oral anticoagulation was high in patients with nonvalvular atrial fibrillation, who were attending internal medicine departments daily in Spain. Among patients taking VKA, those subjects with a lower number of INR determinations in the last 6 months or with an optimal time in the therapeutic range exhibited a lower perceived burden with anticoagulant therapy. Patients taking DOACs (vs VKA) showed lower perceived burdens and higher perceived benefits with anticoagulation.