Josep Comín

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.

Heart failure in acute ischemic stroke

AbstractBackgroundTo determine the impact of heart failure (HF), with preserved or decreased left ventricular function (LVF), on outcome in patients with acute ischemic stroke (AIS).MethodsWe studied 503 unselected ischemic stroke patients. Poor outcome was defined as moderate-severe disability or death at 90 days. We analyzed the association between poor outcome and HF with preserved LVF or decreased LVF (systolic HF: ejection fraction lower than 50%). We tested this association adjusted by possible confounders in a logistic regression model.Results89 patients (17.7 %) had HF; 49 patients (9.7%) with systolic HF, and 40 (8%) patients with HF and preserved LVF. HF with preserved LVF patients were older [79.4 (7.9) vs. 74.3 (10.4), p = 0.013],more likely to be women [p < 0.001,OR = 8.61, 95% CI (3.3–22.6)], and with lower current smoking habits [p = 0.018, OR = 8.77 (1.1–72.6)] than patients with systolic HF. 151 patients (30 %) had poor outcome. We found an independent association with initial stroke severity, systolic HF (adjusted OR = 3.01), HF with preserved LVF (adjusted OR = 2.52), thrombolytic treatment, statin pre-treatment (as protectors) and poor outcome.ConclusionBoth forms of HF (with or without decreased systolic function) are associated with poor outcome in AIS.

Nuevas evidencias, nuevas controversias: análisis crítico de la guía de práctica clínica sobre fibrilación auricular 2010 de la Sociedad Europea de Cardiología

Manuel Anguita,* Fernando Worner, Pere Domenech, Francisco Marı́n, Javier Ortigosa, Julián Pérez-Villacastı́n, Antonio Fernández-Ortiz, Angel Alonso, Angel Cequier, Josep Comı́n, Magda Heras, Manuel Pan, Javier Alzueta, Angel Arenal, Gonzalo Barón, Xavier Borrás, Ramón Bover, Mariano de la Figuera, Carlos Escobar, Miguel Fiol, Benito Herreros, José L. Merino, Lluis Mont, Nekane Murga, Alonso Pedrote, Aurelio Quesada, Tomás Ripoll, José Rodrı́guez, Martı́n Ruiz, and Ricardo Ruiz Coordinadores del Grupo de Trabajo sobre Guı́as de Fibrilación Auricular de la Sociedad Española de Cardiologı́a, Madrid, Spain Grupo de Trabajo sobre Guı́as de Fibrilación Auricular de la Sociedad Española de Cardiologı́a, Madrid, Spain Comité de Guı́as de Práctica Clı́nica de la Sociedad Española de Cardiologı́a, Madrid, Spain Grupo de expertos revisores del documento sobre Guı́as de Fibrilación Auricular de la Sociedad Española de Cardiologı́a, Madrid, Spain

Seven-year mortality in heart failure patients with undiagnosed diabetes: an observational study

BackgroundPatients with type 2 diabetes mellitus and heart failure have adverse clinical outcomes, but the characteristics and prognosis of those with undiagnosed diabetes in this setting has not been established.MethodsIn total, 400 patients admitted consecutively with acute heart failure were grouped in three glycaemic categories: no diabetes, clinical diabetes (previously reported or with hypoglycaemic treatment) and undiagnosed diabetes. The latter was defined by the presence of at least two measurements of fasting plasma glycaemia ≥ 7 mmol/L before or after the acute episode.Group differences were tested by proportional hazards models in all-cause and cardiovascular mortality during a 7-year follow-up.ResultsThere were 188 (47%) patients without diabetes, 149 (37%) with clinical diabetes and 63 (16%) with undiagnosed diabetes. Patients with undiagnosed diabetes had a lower prevalence of hypertension, dyslipidaemia, peripheral vascular disease and previous myocardial infarction than those with clinical diabetes and similar to that of those without diabetes. The adjusted hazards ratios for 7-year total and cardiovascular mortality compared with the group of subjects without diabetes were 1.69 (95% CI: 1.17-2.46) and 2.45 (95% CI: 1.58-3.81) for those with undiagnosed diabetes, and 1.48 (95% CI: 1.10-1.99) and 2.01 (95% CI: 1.40-2.89) for those with clinical diabetes.ConclusionsUndiagnosed diabetes is common in patients requiring hospitalization for acute heart failure. Patients with undiagnosed diabetes, despite having a lower cardiovascular risk profile than those with clinical diabetes, show a similar increased mortality.

Comentarios a la guía de práctica clínica de la ESC para el manejo del síndrome coronario agudo en pacientes sin elevación persistente del segmento ST. Un informe del Grupo de Trabajo del Comité de Guías de Práctica Clínica de la Sociedad Española de Cardiología

doi: 10.1016/j.rec.2011.12.004 The new guidelines for the management of acute coronary syndrome in patients without persistent ST-elevation (NSTE-ACS),1 prepared in 2011 by the European Society of Cardiology (ESC), have been accepted by the Spanish Society of Cardiology (SEC) and translated to Spanish for publication in their entirety in the Revista Española de Cardiología2. As a support tool for the implementation of these guidelines, and in accordance with the new SEC policy for clinical practice guidelines,3 this editorial discusses the innovations and new recommendations in these guidelines and evaluates some aspects considered to be controversial, so as to facilitate the implementation of the new guidelines in our field.

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

Insuficiencia mitral funcional. Fisiopatología e impacto del tratamiento médico y de las técnicas quirúrgicas de reducción ventricular izquierda

La insuficiencia mitral funcional es un hallazgo frecuente en la disfuncion ventricular izquierda. Su presencia es un marcador de mal pronostico en pacientes con miocardiopatia isquemica o idiopatica. El mecanismo responsable de este fenomeno es un balance alterado entre las fuerzas de tension y las de coaptacion que actuan sobre las valvas mitrales en el corazon con insuficiencia. Las fuerzas de tension representan un estiramiento anomalo sobre los velos mitrales originado por el desplazamiento de los puntos de anclaje de la valvula mitral. Dicho desplazamiento se debe al incremento en la esfericidad de la cavidad ventricular izquierda asociado a la disfuncion ventricular sistolica. Por otro lado, las fuerzas de coaptacion son debiles e incapaces de contrarrestar la tension anormal que restringe su cierre y conduce a la regurgitacion. Los farmacos vasodilatadores e inotropicos son efectivos en el manejo de la insuficiencia mitral funcional. Aunque la ventriculectomia izquierda parcial o intervencion de Batista aun se considera una tecnica en investigacion, este nuevo procedimiento parece ofrecer un optimo control de la insuficiencia mitral funcional, asi como una mejoria de la capacidad funcional y de la supervivencia de ciertos pacientes con insuficiencia cardiaca.

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.

Medical resource use and expenditure in patients with chronic heart failure: a population-based analysis of 88 195 patients: a population-based analysis of 88 195 patients

Heart failure (HF) is one of the diseases with greater healthcare expenditure. However, little is known about the cost of HF at a population level. Hence, our aim was to study the population‐level distribution and predictors of healthcare expenditure in patients with HF.