José María García Acuña

Impacto de la hipertensión en las cardiopatías en España. Estudio CARDIOTENS 1999

Introduccion y objetivos Se presentan los resultados globales del estudio CARDIOTENS 99, un estudio transversal de ambito estatal sobre prevalencia y grado de control de la hipertension arterial asociada con diversas enfermedades cardiovasculares, realizado sobre 32.051 pacientes atendidos en consultas de cardiologia y de atencion primaria. Metodos Se registraron de forma prospectiva en un cuestionario uniformizado los datos demograficos, clinicos, tensionales y terapeuticos de todos los pacientes atendidos en un mismo dia por 1.159 medicos (21% cardiologos y 79% de atencion primaria). Resultados El 33% de la muestra total de 32.051 pacientes tenia hipertension arterial y el 19% antecedentes de cardiopatia. Presentaban hipertension y cardiopatia 4.022 pacientes (13%). La hipertension acompanaba al 77% de la insuficiencia cardiaca, al 66% de la cardiopatia isquemica (angina e infarto) y al 66% de la fibrilacion auricular. El 47% de los hipertensos con insuficiencia cardiaca tomaba un inhibidor de la enzima convertidora de la angiotensina, el 32% de los hipertensos con insuficiencia coronaria un betabloqueador y el 25% de los hipertensos con fibrilacion auricular estaban anticoagulados. Menos del 20% de los hipertensos con cardiopatia estaban controlados (presion arterial menor de 130/85 mmHg); el porcentaje de controlados entre los atendidos por cardiologos era algo menor que en atencion primaria. Conclusiones La insuficiencia cardiaca, cardiopatia isquemica y fibrilacion auricular cronica se asocian con gran frecuencia con hipertension arterial. El control tensional de los hipertensos cardiopatas es muy limitado. El empleo de farmacos de indicacion obligada en hipertensos con cardiopatias es escaso.

Impacto de la diabetes en las enfermedades cardíacas en España. Estudio CARDIOTENS 1999

Fundamento Estudio transversal de ambito estatal que pretende conocer el impacto de los diferentes factores de riesgo en las cardiopatias, llevado a cabo sobre 32.051 pacientes atendidos en consultas de cardiologia y de atencion primaria. Pacientes y metodo Se registraron, de forma prospectiva, en un cuestionario uniformizado, las principales caracteristicas demograficas, clinicas y terapeuticas de todos los pacientes atendidos en un mismo dia por 1.159 medicos (un 21% cardiologos y un 79% de atencion primaria). Resultados El 19% de la muestra (6.194 pacientes) de 32.051 pacientes tenia antecedentes de cardiopatia, de los cuales 1.275 (el 20,6% del total de pacientes con cardiopatias) eran diabeticos, el 74% de ellos eran hipertensos. El 45% de los diabeticos con insuficiencia cardiaca presentaba tambien cardiopatia isquemica (angina o infarto previo). Menos del 30% de los diabeticos con cardiopatia tenia un adecuado control tensional (presion arterial menor de 130/85 mmHg), sin diferencias entre el porcentaje de controlados entre los atendidos por cardiologos o medicos de atencion primaria. Tan solo el 12% de los diabeticos con cardiopatia isquemica tenia unas cifras de colesterol unido a lipoproteinas de baja densidad menor de 100 mg/dl; la media del colesterol total y colesterol unido a lipoproteinas de baja densidad de los vistos por cardiologos eran significativamente menores (p Conclusiones La diabetes es una enfermedad asociada a mas del 20% de los pacientes con cardiopatia. Tan solo una escasa proporcion de diabeticos con cardiopatia cumple los objetivos recomendados de presion arterial y lipidos plasmaticos. El empleo de farmacos de beneficio pronostico probado en diabeticos con cardiopatia es muy limitado.

Cystatin C provides more information than other renal function parameters for stratifying risk in patients with acute coronary syndrome.

INTRODUCTION AND OBJECTIVES The protein cystatin C has a stable plasma concentration and is eliminated exclusively by the kidneys. The aim of this study was to determine the prognostic value of cystatin C in patients with acute coronary syndrome (ACS). METHODS The prospective study included 203 hospitalized ACS patients. Clinical evaluation during the first 24 hours of hospitalization included a hemogram and measurement of creatinine, cystatin C, total and fractionated cholesterol and markers of myocardial necrosis. The glomerular filtration rate (GFR) was estimated using the MDRD (Modification of Diet in Renal Disease) equation. A comparison was made between two groups of patients divided according to a serum cystatin-C level above or below 0.95 mg/L. The mean follow-up period was 151 days. RESULTS In total, 90 patients (44.3%) had a cystatin-C level < or =0.95 mg/L and 113 (55.7%) had a level >0.95 mg/L. Those with a cystatin-C level >0.95 mg/L had poorer in-hospital outcomes, including more frequent heart failure (51.3% vs. 13.3%; P=.001) and higher in-hospital mortality (17.6% vs. 3.3%; P=.001), as well as higher mortality throughout follow-up (22.0% vs. 5.6%; P=.001). Multivariate analysis adjusted for age, ejection fraction and troponin-I and high-sensitivity C-reactive protein concentrations showed that cystatin C was the most powerful independent predictor of a cardiovascular event (relative risk=1.91; 95% confidence interval, 1.03-3.53). Patients with a GFR >60 mL/1.73 m(2) and a cystatin-C level >0.95 mg/L had higher in-hospital mortality (10.2% vs. 3.9%; P=.001). CONCLUSIONS Measurement of cystatin C in high-risk ACS patients may be clinically useful for risk stratification during hospitalization, particularly in those with a normal GFR.

Empleo de fármacos antitrombóticos en pacientes hipertensos con fibrilación auricular crónica. Estudio CARDIOTENS 99

BACKGROUND: Our main goals were to know the actual degree of oral anticoagulation and antiaggregation in hypertensive patients with atrial fibrillation in the daily clinical practice in Spain and to analyze any differences between primary care physicians and cardiologists. PATIENTS AND METHOD: 32,051 outpatients attended the same day by 1,159 physicians (21% cardiologists) were prospectively included in a database taking into account a history of hypertension and atrial fibrillation, demographic data and ongoing treatments. RESULTS: Hypertension was detected in 10,555 patients and 999 of them had both hypertension and atrial fibrillation (9.46%: 435 males [44%] and 564 females [56%]). 53% patients were attended by primary care physicians and the rest by cardiologists. 33% of hypertensive patients with atrial fibrillation were on oral anticoagulation: 41% of them attended by cardiologists and 26% by primary care physicians (p 80 years-old) were found to receive less anticoagulants and more antiaggregants both in primary health-care and cardiology health-care.

Evolution of left ventricular hypertrophy and function during long-term treatment of systemic hypertension with enalapril.

Continued treatment of hypertensive patients with enalapril reduced left ventricular (LV) hypertrophy steadily over a period of 5 years (by which time gross structural parameters were normal) and produced no further reduction during the following 2 years. Temporary suspension of treatment after 5-year follow-up gave rise to an increase in blood pressure, and to deterioration of LV isovolumic relaxation time and deceleration of the ventricular filling E wave, both of which chiefly reflect the active relaxation of the ventricle.

Relation of Contrast Induced Nephropathy to New Onset Atrial Fibrillation in Acute Coronary Syndrome

Chronic renal failure has been described as a risk factor for the development of atrial fibrillation (AF). The aim of this study was to examine the association between contrast-induced nephropathy (CIN) and new-onset AF in patients with acute coronary syndromes. A total of 1,520 consecutive patients (mean age 67.1 ± 12.7 years) with acute coronary syndromes (34.4% with ST-segment elevation myocardial infarctions) who underwent coronary angiography were studied. CIN was defined as an increase in serum creatinine of 0.5 mg/dl within 72 hours of contrast exposure. The independent effect of AF history (chronic or paroxysmal AF before catheterization) on the development of CIN, as well as the independent effect of CIN on the development of new-onset AF (after catheterization, during the in-hospital phase), were tested by using different logistic regression models. One hundred thirty-nine patients (9.1%) had histories of AF before catheterization (60 with paroxysmal and 79 with chronic AF), and 56 (4.1%) developed new-onset AF after catheterization. Eighty-seven patients (5.7%) had CIN. AF history was a predictor of CIN in univariate analysis (odds ratio 2.19, 95% confidence interval 1.22 to 3.95, p = 0.007) but not in multivariate analysis, after adjusting for confounding variables (odds ratio 1.69, 95% confidence interval 0.89 to 3.22, p = 0.111). In contrast, those with CIN had an increased prevalence of new-onset AF (15.3% vs 3.4%, p <0.001). After adjusting for those variables associated with new-onset AF in the univariate analysis, CIN continued to show a significant association with new-onset AF, with a twofold increased risk (odds ratio 2.45, 95% confidence interval 1.07 to 5.64, p = 0.035). In conclusion, the development of CIN is an independent predictor of new-onset AF in the context of acute coronary syndromes.

Noninvasive Treatment of Acute Myocardial Infarction. Clinical Profile and Predictors of Poor Prognosis

In current clinical practice, only a small percentage of patients with acute coronary syndrome are treated conservatively (receiving neither coronary angiography nor fibrinolysis). Evidence-based clinical practice guidelines recommend that patients suffering an acute myocardial infarction (AMI) undergo invasive intervention, in addition to medical treatment of proven prognostic efficacy; this invasive treatment should take the form of emergent reperfusion therapy for ST segment elevation myocardial infarction (STEMI) and early coronary angiography for non-ST segment elevation myocardial infarction (NSTEMI). Certain clinical situations accompanying acute coronary syndrome exclude patients from this intensive management strategy. The typical clinical profile in such cases is that of a fragile elderly patient with anemia and renal failure or other important comorbidities that justify conservative management. Here we present an analysis of in-hospital and long-term mortality among AMI patients in our population who were assigned to conservative treatment by the on-duty physician. The aim was to identify variables that predict poor prognosis in these patients. We analyzed the records of 4408 patients consecutively admitted to our hospital between 2003 and 2012 with a diagnosis of AMI (1745 with STEMI and 2663 with NSTEMI). Of these patients, 460 received conservative medical treatment (127 [7.3%] with STEMI and 333 [12.5%] with NSTEMI); 84 STEMI patients presented > 24 hours after symptom onset. Among the total group of STEMI patients, 54 (3.1%) received fibrinolytic treatment and all were later examined by angiography. Patients assigned to conservative management tended to be older, and this group included a higher percentage of women and patients with diabetes mellitus, had a worse Killip class, and had lower hemoglobin and higher creatinine readings (Table). All of this, as is well known, implies a poor prognosis for patients receiving conservative medical treatment. Among patients receiving conservative treatment, we analyzed variables associated with a worse prognosis during in-hospital care and long-term follow-up; in-hospital and long-term mortality were analyzed independently in the two types of AMI by multivariate analysis (binary logistic regression for in-hospital mortality and Cox regression for long-term mortality), with adjustments for first-order interactions between covariates. Among NSTEMI patients, univariate analysis indicated an association of high in-hospital mortality with diabetes mellitus (odds ratio [OR] = 1.79; 95% confidence interval [95%CI], 1.02-3.14; P = .042), Killip class II (OR = 6.81; 95%CI, 3.46-13.43; P < .001), hemoglobin (OR = 0.85; 95%CI, 0.73-0.98; P = .027), creatinine (OR = 1.49; 95%CI, 1.17-1.90; P = .001) and troponin (OR = 1.02; 95%CI, 1.01-1.04; P = .001). In-hospital mortality in these patients was also associated with nontreatment with beta-blockers (OR = 0.19; 95%CI, 0.09-0.39; P < .001), angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers (OR = 0.35; 95%CI, 0.19-0.63; P < .001), or statins (OR = 0.23; 95%CI, 0.16-0.32; P < .001). In the multivariate analysis, only Killip class II persisted as an independent predictor of in-hospital mortality (OR = 4.5; 95%CI, 2.13-9.53; P < .001). Long-term mortality in NSTEMI patients (4.2 2.8 years) was positively associated with the following variables: age (hazard ratio [HR] = 1.06; 95%CI, 1.04-1.08; P < .001), peripheral artery disease (HR = 1.70; 95%CI, 1.18-2.46; P = .005), previous AMI (HR = 1.46; 95%CI, 1.06-2.02; P = .022), Killip class II (HR = 2.43, 95%CI, 1.79-3.28; P < .001), hemoglobin (HR = 0.88; 95%CI, 0.81-0.95; P = .001), creatinine (HR = 1.27; 95%CI, 1.13-1.44; P < .001), and troponin (HR = 1.01; 95%CI, 1.01-1.02; P < .001). Indicators of good prognosis were treatments with beta-blockers (HR = 0.50; 95%CI, 0.37-0.68; P < .001) and statins (HR = 0.55; 95%CI, 0.47-0.66; P < .001). After the multivariate analysis, the following persisted as independent predictors of mortality: age (HR = 1.06; 95%CI, 1.031.09; P < .001), peripheral artery disease (HR = 1.71; 95%CI, 1.06-2.76; P = .028), previous AMI (HR = 1.76; 95%CI, 1.15-2.71; P = .009), Killip class II (HR = 1.59; 95%CI, 1.05-2.41; P = .028), hemoglobin (HR = 0.87; 95%CI, 0.77-0.98; P = .020), creatinine (HR = 1.38; 95%CI, 1.07-1.77; P = .013), and nontreatment with statins (HR = 0.79; 95%CI, 0.62-0.99; P = .042). Among patients with STEMI, univariate analysis showed association of high in-hospital mortality with Killip class II (OR = 8.00; 95%CI, 3.02-21.17; P < .001), creatinine (OR = 1.72; 95%CI, 0.97-3.05; p = .062), and troponin (OR = 1.01; 95%CI, 0.99-1.02; P = .079). Indicators of good prognosis were treatments with betablockers (OR = .21; 95%CI, 0.08-0.56; P = .002), angiotensinconverting enzyme inhibitors or angiotensin II receptor blockers OR = 0.19; 95%CI, 0.08-0.48; P < .001), and statins (OR = 0.15; 95%CI, 0.06-0.36; P < .001). In the multivariable analysis, the only independent predictors of in-hospital mortality were Killip class II (OR = 5.22; 95%CI, 1.44-18.86; P = .012) and treatment with statins (OR = 0.79; 95%CI, 0.06-0.63; P = .006). Long-term mortality of STEMI patients was associated with age (HR = 1.09; 95%CI, 1.04-1.15; P = .001), hemoglobin (HR = 0.86; 95%CI, 0.76-0.97; P = .015), and creatinine (HR = 1.72; 95%CI, 1.182.49; P = .004). After multivariate analysis, only age persisted as an independent mortality predictor (HR = 1.09; 95%CI, 1.04-1.15; p = .001). For in-hospital mortality, we conducted a sensitivity analysis, eliminating patients who died during the first 48 hours (68 with STEMI and 18 with NSTEMI, out of 307 in-hosptial deaths). Killip class II remained as an independent mortality predictor in both the NSTEMI group (OR = 7.41; 95%CI, 4.82-11.39; P < .001) and the STEMI group (OR = 10.58; 95%CI, 6,26-17,89; P < .001), and statins treatment persisted as a predictor of good prognosis in the STEMI group (OR = 0.19; 95%CI, 0.12-0.32; p < .001). Our results clearly show that patients under conservative management have a higher basal risk than those treated invasively, which could justify invasive therapy. Of the variables analyzed, the only independent predictor of in-hospital mortality in the 2 infarction groups is Killip class II, an indicator of major clinical and hemodynamic instability. Notably, age is not a predictor of inhospital mortality in either of the AMI groups, but is a predictor of mortality risk during follow-up. The influence of age on the treatment of acute coronary syndrome was analyzed in the MINAP registry, which showed that the use of invasive treatment was Rev Esp Cardiol. 2015;68(4):343–354

Isquemia coronaria producida por seudoxantoma elástico y revascularización miocárdica con doble injerto arterial

We present a case of an 18 year-old woman with pseudoxanthoma elasticum, who had a biopsy taken from a lesion. Although she was asymptomatic, we tried to rule out myocardial ischemia with a treadmill and cardiac gammagraphy with Talio. The isotopic studies and the ergometry were positive and the patient underwent coronariography. This study showed a severe triple-vessel disease. We did an angiography of the supraaortic arteries, mamarian artery, and mesenteric artery. These studies showed no obstructive lesions. The treatment of patient was a double by-pass with internal mammary artery and one by-pass with safena vein grafts with satisfactory results.

Prevalence and outcome of patients with cancer and acute coronary syndrome undergoing percutaneous coronary intervention: a BleeMACS substudy

Background: The prevalence and outcome of patients with cancer that experience acute coronary syndrome (ACS) have to be determined. Methods and results: The BleeMACS project is a multicentre observational registry enrolling patients with acute coronary syndrome undergoing percutaneous coronary intervention worldwide in 15 hospitals. The primary endpoint was a composite event of death and re-infarction after one year of follow-up. Bleedings were the secondary endpoint. 15,401 patients were enrolled, 926 (6.4%) in the cancer group and 14,475 (93.6%) in the group of patients without cancer. Patients with cancer were older (70.8±10.3 vs. 62.8±12.1 years, P<0.001) with more severe comorbidities and presented more frequently with non-ST-segment elevation myocardial infarction compared with patients without cancer. After one year, patients with cancer more often experienced the composite endpoint (15.2% vs. 5.3%, P<0.001) and bleedings (6.5% vs. 3%, P<0.001). At multiple regression analysis the presence of cancer was the strongest independent predictor for the primary endpoint (hazard ratio (HR) 2.1, 1.8–2.5, P<0.001) and bleedings (HR 1.5, 1.1–2.1, P=0.015). Despite patients with cancer generally being undertreated, beta-blockers (relative risk (RR) 0.6, 0.4–0.9, P=0.05), angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (RR 0.5, 0.3–0.8, P=0.02), statins (RR 0.3, 0.2–0.5, P<0.001) and dual antiplatelet therapy (RR 0.5, 0.3–0.9, P=0.05) were shown to be protective factors, while proton pump inhibitors (RR 1, 0.6–1.5, P=0.9) were neutral. Conclusion: Cancer has a non-negligible prevalence in patients with acute coronary syndrome undergoing percutaneous coronary intervention, with a major risk of cardiovascular events and bleedings. Moreover, these patients are often undertreated from clinical despite medical therapy seems to be protective. Registration:The BleeMACS project (NCT02466854).

Clinical impact of mineralocorticoid receptor antagonists treatment after acute coronary syndrome in the real world: A propensity score matching analysis

Background: Recent studies suggest that the benefit of mineralocorticoid receptor antagonists in the acute coronary syndrome setting is controversial. The aim of this study was to examine the current long-term prognostic benefit of mineralocorticoid receptor antagonists in patients with acute coronary syndrome. Material and methods: We conducted a retrospective cohort study of 8318 consecutive acute coronary syndrome patients. Baseline patient characteristics were examined and a follow-up period was established for registry of death, major cardiovascular adverse events and heart failure re-hospitalization. We performed a propensity-matching analysis to draw up two groups of patients paired according to whether or not they had been treated with mineralocorticoid receptor antagonists. The prognostic value of mineralocorticoid receptor antagonists to predict events during follow-up was analysed using Cox regression. Results: Among the study participants, only 524 patients (6.3%) were discharged on mineralocorticoid receptor antagonists. Patients on mineralocorticoid receptor antagonists had a different clinical and pharmacological profile. These differences disappeared after the propensity score analysis. The median follow-up was 40.7 months. After the propensity score analysis, the cardiovascular mortality and heart failure readmission rates were similar between patients who were discharged on mineralocorticoid receptor antagonists and those whose not. The use of mineralocorticoid receptor antagonists was only associated with a reduction in major cardiovascular adverse events (hazard ratio=0.83, 95% confidence interval 0.69–0.97, p=0.001). Conclusions: Our results do not corroborate the long-term benefit of mineralocorticoid receptor antagonists to improve survival after acute coronary syndrome in a large cohort of patients with heart failure or reduced left ventricular ejection fraction and diabetes. Their prescription was associated with a significantly lower incidence of major cardiovascular adverse events during the long-term follow-up without effect on heart failure development.