Fernando Worner

Guías de actuación clínica de la Sociedad Española de Cardiología en el infarto agudo de miocardio

En los ultimos anos han surgido nuevas posibilidades en el diagnostico y tratamiento del infarto agudo de miocardio con elevacion del segmento ST y sus complicaciones. Ademas, se ha producido una profunda transformacion en la organizacion del sistema sanitario particularmente en aspectos relacionados con la atencion del paciente con dolor toracico no traumatico, tanto en el area prehospitalaria como hospitalaria. Todos estos aspectos justificaban un documento de consenso en Espana sobre el papel que deben ocupar estas novedades en el manejo de los pacientes con infarto agudo de miocardio. Este documento revisa y actualiza todos los aspectos clinicos fundamentales del paciente con infarto agudo desde el momento en el que entra en contacto con el sistema sanitario fuera del hospital, hasta que vuelve a su domicilio, despues de pasar por la unidad coronaria y la planta de hospitalizacion. Y todo ello, tanto en el infarto complicado como en el no complicado. Ademas esta revision incluye un apartado sobre aspectos organizativos y estructurales referidos sobre todo al ambito prehospitalario y de los servicios de urgencia.

La Sociedad Española de Cardiología y las guías de práctica clínica de la ESC: hacia una nueva orientación

Clinical practice guidelines have become a tool of great importance and interest in medical practice, including cardiology. Indeed, these documents drafted by groups of experts on the topic in question and guaranteed by highly prestigious scientific societies provide vast detailed information on pathology, diagnosis and treatment, based on the most up-to-date literature and evidence obtained from original studies, clinical trials, and the latest meta-analyses. Furthermore, these guides are based on available evidence and provide recommendations on clinical practice in all areas, classified pursuant to level of evidence. In addition to their great scientific, educational, and practical interest, these guidelines have a certain legal value in most countries. Thus, it is hardly surprising they have become a great source of information and the basis of many decisions made in our daily clinical practice, as well as the origin and basis of changes and innovations introduced in that practice. In fact, they are the most widely read documents in scientific journals, as can be objectively checked in the journal queries posed online. Indeed, if we consult the webpage of Revista Española de Cardiologı́a (REC) under the section ‘‘most often read,’’ 9 of the 10 most-read articles in Journal history refer to clinical practice guidelines. Most scientific societies draw up their own guidelines for clinical practice. The most prestigious and widely followed in the cardiology sector are those of the American Heart Association/ American College of Cardiology (AHA/ACC) and the European Society of Cardiology (ESC). Thanks to the effort of the scientific sections, work groups, and guest experts, the Spanish Society of Cardiology (SEC) published a very successful series of guidelines on the most important cardiology topics. In fact, among the nine guidelines appearing as the most-read REC articles, six are Spanish in origin and only three from European societies. However, at the beginning of the last decade, SEC directors wisely decided that an enormous effort, possibly unsustainable over time, was being made; the guidelines required on-going revision and updating and, moreover, they overlapped with the ESC guidelines being published. As the SEC and all our members are members of the ESC, the logical decision was to stop publishing our own guidelines and assume those of the ESC, and this has been the case since 2003. Since then the European guidelines have been translated into Spanish as soon as they become available on the ESC webpage and REC publishes them approximately 3 months later together with specific comments from Spanish guest experts. The publication policy of the ESC guidelines in Spanish in REC was also considered to aid their greater diffusion throughout the Spanish-speaking medical and cardiology community. Likewise, facilitating awareness of them could contribute to the REC impact factor when it was starting to take off in this area. Nevertheless, the clinical practice guidelines also have their limitations, as we will discuss. Furthermore, the SEC and its executive committee have the obligation to continually and periodically assess the validity and usefulness of the previously approved policies. With regard to the European guidelines limitations and their automatic acceptance by the SEC, the most important problems are probably derived from their practical application within the local reality of each country. These include the actual handling of each illness at different assistance levels, availability of the means recommended, and the cost-benefit ratio. In this respect, the National Institute for Clinical Excellence (NICE) guidelines are more complex but provide more information. It has also been noted that some guidelines have controversial, arguable, or hurried recommendations with excessive level C recommendations (ie, taken by expert consensus without sufficient evidence to support them). This leads to discrepancies between guidelines of different scientific societies published within very short time frames. Other limitations might be the scarce participation of Spanish cardiologists in their drafting and lack of ‘‘official’’ recognition from the Spanish health authorities, leading to problems of legal applicability. This lack of recognition is because some of the conditions demanded by our Ministry are not met. Nor has the initial presumption that the translation and publication of European guidelines in REC might greatly increase the impact of our Journal been confirmed. Although this impact has grown considerably in recent years, it was not due to a large number of citations of the translated European guidelines. Rev Esp Cardiol. 2011;64(9):795–796

Comentarios a la guía de práctica clínica de la ESC para el manejo del infarto agudo de miocardio en pacientes con elevación del segmento ST

The European Society of Cardiology (ESC) guidelines are endorsed by the Spanish Society of Cardiology (SEC) and translated into Spanish for their publication in the Revista Española de Cardiología. Under the policy introduced in 2011, each new guideline is accompanied by an article that formulates comments in accordance with the objectives and methodology recommended in the article that established the Guidelines Committee of the SEC.1 In the present article, we discuss the new European guidelines for ST-segment elevation acute myocardial infarction (STEMI).2 The Guidelines Committee established a work group composed of members proposed by the Ischemic Heart Disease, Hemodynamics, Clinical Cardiology, Heart Failure, and Geriatric Cardiology work groups. As a general comment, we consider that the present guidelines introduce highly interesting developments and that the topics are dealt with clearly and in detail. However, we should also point out that it contains 157 recommendations, 69 (44%) of which are accompanied by level C evidence (expert consensus), predominantly in the sections on in-hospital management, heart failure, and complications, fields in which there thus remains ample room for individualization and progress in clinical research. In applying them, we should not forget that the guidelines themselves remind us that the level A and B recommendations are based on clinical trials, and that even these results are open to interpretation. The different therapeutic options could be influenced by the available resources. Thus, it will be increasingly necessary to perform cost-efficiency studies that aid us in choosing among the different strategies. For the purpose of making the article more readable and to highlight the most relevant or novel aspects, as well as those that are not made clear or are not addressed, we have summarized them in Tables 1 and 2, respectively.

Manejo del infarto de miocardio en España (1995-99). Datos del registro de infartos de la Sección de Cardiopatía Isquémica y Unidades Coronarias (RISCI)* de la Sociedad Española de Cardiología

Introduccion y objetivos Poseemos insuficiente informacion sobre como se trata a los pacientes con infarto agudo de miocardio en Espana. Con el fin de subsanar esta deficiencia, la Seccion de Cardiopatia Isquemica y Unidades Coronarias de la Sociedad Espanola de Cardiologia inicio a finales de 1994 un registro de pacientes con infarto atendidos en las unidades coronarias de los hospitales espanoles, que se mantiene abierto en la actualidad. Metodos El reclutamiento de pacientes se realiza en hospitales con unidad coronaria. Se recogen caracteristicas demograficas, factores de riesgo y antecedentes de enfermedad coronaria asi como complicaciones clinicas y procedimientos diagnosticos y terapeuticos utilizados durante la estancia en la unidad coronaria. Resultados Durante el periodo 1995-1999 se registraron un total de 28.537 pacientes. La edad media aumento ligeramente (de 64,4 ± 12,2 a 65,2 ± 12,7 anos; p Conclusiones En nuestro medio, en el periodo 1995-1999, aumento el porcentaje de pacientes que reciben aspirina, bloqueadores beta e inhibidores de la enzima convertidora de la angiotensina en la fase aguda del infarto. Sin embargo, se estabilizo la utilizacion de tromboliticos y el retraso en su administracion. Disminuyo la estancia media en la unidad coronaria asi como la mortalidad precoz, a pesar de que las caracteristicas clinicas de los pacientes no mejoraron.

Comentarios a la guía de práctica clínica de la ESC sobre prevención de la enfermedad cardiovascular (versión 2012). Un informe del Grupo de Trabajo del Comité de Guías de Práctica Clínica de la Sociedad Española de Cardiología

As proposed by the SEC clinical practice guidelines committee, the Hypertension and Preventive Cardiology and Rehabilitation sections selected a group of CVD prevention experts to review the ESC guidelines published in 2012 and translated in REVISTA ESPAÑOLA DE CARDIOLOGÍA. Their objective was to discuss the contents and appropriacy of the guidelines, analyze the method and highlight issues considered innovative, positive or questionable, as well as any left with no comment. The guidelines were divided into 5 parts and each was independently commented on by 2 experts. Based on their opinions, a document was prepared and, in turn, reviewed and approved by a group of experts designated by the SEC sections involved. All the experts have declared their conflicts of interest, which are stated in detail at the end of this article.

Comentarios a la guía de práctica clínica de la ESC sobre diagnóstico y tratamiento de la insuficiencia cardiaca aguda y crónica 2012. Un informe del Grupo de Trabajo del Comité de Guías de Práctica Clínica de la Sociedad Española de Cardiología

El Comite de Guias de Practica Clinica de la SEC formo un grupo de trabajo integrado por cardiologos clinicos, electrofisiologos, cirujanos cardiacos y personal de enfermeria, expertos en los diversos aparta-dos de la IC que cubre la guia de la ESC, propuestos por la Seccion de Insuficiencia Cardiaca y Trasplante y el Grupo de Trabajo sobre Resin-cronizacion Cardiaca de la SEC y por la Asociacion Espanola de Enfer-meria Cardiovascular, con el objetivo general de revisar las evidencias y recomendaciones aportadas por la guia europea sobre IC antes citada

Comentarios a las guías de práctica clínica sobre manejo de las dislipemias de la Sociedad Europea de Cardiología y la Sociedad Europea de Aterosclerosis 2011. Un informe del Grupo de Trabajo del Comité de Guías de Práctica Clínica de la Sociedad Española de Cardiología

In line with the new philosophy on clinical practice guidelines adopted by the executive committee of the Sociedad Española de Cardiología (SEC: Spanish Society of Cardiology), which was explained and justifi ed in a recent document published in the Revista Española de Cardiología (REC),1 this article has the objective of discussing the most important and novel aspects of the guidelines on the management of dyslipidemias but without attempting to replace them. A joint effort by the European Society of Cardiology (ESC) and the European Atherosclerosis Society (EAS),2 these guidelines updated the old protocols for treating dyslipidemias developed by the National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (NCEP-ATP III) and published in 2001 (summary) and 2002 (complete text),3 with a minor update in 2004.4 In Spain, recommendations from the Comité Español Interdisciplinario para la Prevención Cardiovascular (CEIPC) have been used more recently,5 with the approval of the Spain’s Health Ministry and the participation of the SEC, although in this Spanish guideline dyslipidemia is just one section of the general recommendations on cardiovascular prevention.

A simple validated method for predicting the risk of hospitalization for worsening of heart failure in ambulatory patients: the Redin‐SCORE

Prevention of hospital readmissions is one of the main objectives in the management of patients with heart failure (HF). Most of the models predicting readmissions are based on data extracted from hospitalized patients rather than from outpatients. Our objective was to develop a validated score predicting 1‐month and 1‐year risk of readmission for worsening of HF in ambulatory patients.

A simple validated method for predicting the risk of hospitalization for worsening of heart failure in ambulatory patients

Prevention of hospital readmissions is one of the main objectives in the management of patients with heart failure (HF). Most of the models predicting readmissions are based on data extracted from hospitalized patients rather than from outpatients. Our objective was to develop a validated score predicting 1‐month and 1‐year risk of readmission for worsening of HF in ambulatory patients.

Effect of obstructive sleep apnoea on severity and short-term prognosis of acute coronary syndrome

The goal of this study was to evaluate the influence of obstructive sleep apnoea on the severity and short-term prognosis of patients admitted for acute coronary syndrome. Obstructive sleep apnoea was defined as an apnoea–hypopnoea index (AHI) >15 h−1. We evaluated the acute coronary syndrome severity (ejection fraction, Killip class, number of diseased vessels, and plasma peak troponin) and short-term prognosis (length of hospitalisation, complications and mortality). We included 213 patients with obstructive sleep apnoea (mean±sd AHI 30±14 h−1, 61±10 years, 80% males) and 218 controls (AHI 6±4 h−1, 57±12 years, 82% males). Patients with obstructive sleep apnoea exhibited a higher prevalence of systemic hypertension (55% versus 37%, p<0.001), higher body mass index (29±4 kg·m−2 versus 26±4 kg·m−2, p<0.001), and lower percentage of smokers (61% versus 71%, p=0.04). After adjusting for smoking, age, body mass index and hypertension, the plasma peak troponin levels were significantly elevated in the obstructive sleep apnoea group (831±908 ng·L−1 versus 987±884 ng·L−1, p=0.03) and higher AHI severity was associated with an increased number of diseased vessels (p=0.04). The mean length of stay in the coronary care unit was higher in the obstructive sleep apnoea group (p=0.03). This study indicates that obstructive sleep apnoea is related to an increase in the peak plasma troponin levels, number of diseased vessels, and length of stay in the coronary care unit. OSA is associated with an increase in the severity of acute coronary syndrome and extended coronary unit stay http://ow.ly/FEsBA