Manuel Anguita Sánchez

Quality of Vitamin K Antagonist Anticoagulation in Spain: Prevalence of Poor Control and Associated Factors

INTRODUCTION AND OBJECTIVES To study the prevalence of poorly controlled vitamin K antagonist anticoagulation in Spain in patients with nonvalvular atrial fibrillation, and to identify associated factors. METHODS We studied 1056 consecutive patients seen at 120 cardiology clinics in Spain between November 2013 and March 2014. We analyzed the international normalized ratio from the 6 months prior to the patients visit, calculating the prevalence of poorly controlled anticoagulation, defined as < 65% time in therapeutic range using the Rosendaal method. RESULTS Mean age was 73.6 years (standard deviation, 9.8 years); women accounted for 42% of patients. The prevalence of poorly controlled anticoagulation was 47.3%. Mean time in therapeutic range was 63.8% (25.9%). The following factors were independently associated with poorly controlled anticoagulation: kidney disease (odds ratio = 1.53; 95% confidence interval, 1.08-2.18; P = .018), routine nonsteroidal anti-inflammatory drugs (odds ratio = 1.79; 95% confidence interval, 1.20-2.79; P = .004), antiplatelet therapy (odds ratio = 2.16; 95% confidence interval, 1.49-3.12; P < .0001) and absence of angiotensin receptor blockers (odds ratio = 1.39; 95% confidence interval, 1.08-1.79; P = .011). CONCLUSIONS There is a high prevalence of poorly controlled vitamin K antagonist anticoagulation in Spain. Factors associated with poor control are kidney disease, routine nonsteroidal anti-inflammatory drugs, antiplatelet use, and absence of angiotensin receptor blockers.

The RECALCAR Project. Healthcare in the Cardiology Units of the Spanish National Health System, 2011 to 2014

The RECALCAR project (Spanish acronym for Resources and Quality in Cardiology Units) uses 2 data sources: a survey of cardiology units and an analysis of the Minimum Basic Data set of all hospital discharges of the Spanish National Health System. From 2011 to 2014, there was marked stability in all indicators of the availability, utilization, and productivity of cardiology units. There was significant variability between units and between the health services of the autonomous communities. There was poor implementation of process management (only 14% of the units) and scarce development of health care networks (17%). Structured cardiology units tended to have better results, in terms of both quality and efficiency. No significant differences were found between the different types of unit in the mean length of stay (5.5±1.1 days) or the ratio between successive and first consultations (2:1). The mean discharge rate was 5/1000 inhabitants/y and the mean rate of initial consultations was 16±4/1000 inhabitants/y. No duty or on-call cardiologist was available in 30% of cardiology units with 24 or more beds; of these, no critical care beds were available in 45%. Our findings support the recommendation to regionalize cardiology care and to promote the development of cardiology unit networks.

Efecto de la concentración de nitrógeno sobre atributos morfológicos, potencial de crecimiento radical y estatus nutricional en plantas de Eucalyptus globulus producidas a raíz cubierta

Se evaluo el efecto de la aplicacion de cuatro concentraciones de nitrogeno (50, 100, 150 y 200 mg L-1) sobre atributos morfologicos, potencial de crecimiento radical y estatus nutricional de plantas de Eucalyptus globulus producidas a raiz cubierta. La frecuencia de aplicacion fue semanal, manteniendo constantes los niveles de los otros macroelementos. Ademas, se considero un esquema de riego al 20% de disminucion de perdida de peso de bandeja. Las variables altura de planta y area foliar alcanzaron su maximo valor al fertilizar con 200 mg L-1, mientras que para el diametro de cuello y numero de raices nuevas los valores obtenidos no difieren estadisticamente al fertilizar con concentraciones de 150 y 200 mg L-1. Para el rango de concentraciones ensayadas se concluye que los mejores resultados se obtienen al fertilizar con 200 mg L-1, ya que produce plantas con un mayor potencial de crecimiento radical y mejores atributos morfologicos, siendo la unica desventaja los bajos niveles de nitrogeno foliar obtenidos al finalizar el ensayo.

Long-term Survival in a Spanish Population With Stable Ischemic Heart Disease. The CICCOR Registry

INTRODUCTION AND OBJECTIVES Data are lacking on the long-term prognosis of stable ischemic heart disease (SIHD). Our aim was to analyze long-term survival in patients with SIHD and to identify predictors of mortality. METHODS A total of 1268 outpatients with SIHD were recruited in this single-center prospective cohort study from January 2000 to February 2004. Cardiovascular and all-cause death during follow-up were registered. All-cause and cardiovascular mortality rates were compared with those in the Spanish population adjusted by age, sex, and year. Predictors of these events were investigated. RESULTS The mean age was 68±10 years and 73% of the patients were male. After a follow-up lasting up to 17 years (median 11 years), 629 (50%) patients died. Independent predictors of all-cause mortality were age (HR, 1.08; 95%CI, 1.07-1.11; P <.001), diabetes (HR, 1.36; 95%CI, 1.14-1.63; P <.001), resting heart rate (HR, 1.01; 95%CI, 1.00-1.02; P <.001), atrial fibrillation (HR, 1.61; 95%CI, 1.22-2.14; P=.001), electrocardiographic changes (HR, 1.23; 95%CI, 1.02-1.49; P=.02) and active smoking (HR, 1.85; 95%CI, 1.31-2.80; P=.001). All-cause mortality and cardiovascular mortality rates were significantly higher in the sample than in the general Spanish population (47.81/1000 patients/y vs 36.29/1000 patients/y (standardized mortality rate, 1.31; 95%CI, 1.21-1.41) and 15.25/1000 patients/y vs 6.94/1000 patients/y (standardized mortality rate, 2.19; 95%CI, 1.88-2.50, respectively). CONCLUSIONS The mortality rate was higher in this sample of patients with SIHD than in the general population. Several clinical variables can identify patients at higher risk of death during follow-up.

EditorialDo All Patients With Heart Failure Benefit From a Program for Early Follow-up After Hospital Discharge?Seguimiento mediante programas específicos de consulta precoz tras el alta de un episodio de insuficiencia cardiaca: ¿en todos los pacientes?

Without a doubt, heart failure (HF) is one of the most important medical problems—even beyond the cardiologic setting—that we are facing today. Because of the ever-increasing life expectancy of the population and advances in the treatment for acute cardiologic conditions, the prevalence of HF is rising, with a current estimated rate in Spain of 4% to 7%. This condition is the main cause of hospitalization in the very elderly population, and it requires considerable health expenditure and resource use. Despite the widespread belief that HF is simple and easy to resolve, it is actually a complex syndrome that is challenging to diagnose and treat. Although spectacular progress has been made in HF care over the last few years, as reflected in clinical practice guidelines, this disease remains an important cause of hospitalization, markedly impairs the quality of life of affected patients, and is associated with high mortality rates. If factors such as the current characteristics of real-world HF patients—increasingly older, more frail, and with a higher prevalence of comorbidities—are added to the complexity of HF management, it is easy to understand why this condition creates a huge demand on the health system and affects all health areas and professionals, not only cardiologists. These factors may help to explain why adequate care by specialists limited to the hospital setting does not offer a definite solution to the problem. A more integrated approach is needed, in which the care provided is configured within interdisciplinary HF programs and units. This strategy is supported by scientific evidence documenting the prognostic benefit of this type of organizational approach. In the HF guidelines of the European Society of Cardiology published in 2016, the organization of HF care within multidisciplinary teams was assigned a class I A recommendation. Numerous studies and meta-analyses have reported the effectiveness of programs based on HF units for reducing readmissions and even mortality rates. In Spain these programs have been developed by proactive rather than institutional efforts, and they coexist with advanced units that arose in relation to cardiac transplant. Due to the individual initiatives of many centers with professionals interested in HF, and the structured programs organized by the Heart Failure Section of the Spanish Society of Cardiology, increasingly larger numbers of hospitals are equipped with HF units, and they are now becoming commonplace in both cardiology and internal medicine departments. Within its SECExcellence program, the Spanish Society of Cardiology recently established a new nomenclature for the various types of cardiology units (community, specialized, and advanced), depending on the level, equipment, and services portfolio offered by the hospital, cardiology department, and HF unit. In addition, a series of minimum standards have been established (related to processes, infrastructure, human resources, equipment, and results), which must be met by these units and departments to receive SECExcellence accreditiation. This is important to ensure the quality of HF care at all levels and to guarantee the development and implementation of these units in the Spanish health system. As mentioned, HF units provide benefits for both patients and the health system, with reductions in the number of readmissions and in some studies, decreases in mortality. Nonetheless, most of the studies evaluating these aspects, particularly those in the cardiology setting, mainly include HF patients with a low ejection fraction, age that is not too advanced, and a low prevalence of comorbidities. One aspect that clearly influences this choice of participants is that it is impossible to follow up all HF patients within intensive programs in units with a limited infrastructure. However, another factor to consider is that one of the basic benefits of these programs is optimization of medication and other treatments with a favorable effect on the prognosis, which is only possible in HF with systolic dysfunction. To date, there are no treatments that improve the prognosis in HF with preserved ejection fraction. Furthermore, these latter patients tend to be older, more frail and have a higher prevalence of comorbidities, factors that often limit optimal use of drug therapy and make integrated treatment difficult. However, some studies including patients with both preserved and reduced ejection fraction have reported that both types can benefit from specific treatment in specialized units. In their article published in Revista Española de Cardiologı́a, Pacho et al., of the Heart Failure Unit of Hospital de Badalona, a team with extensive experience in HF programs, confirm these results in the STOP-HF-CLINIC study, which includes a population of HF patients with unfavorable characteristics: very advanced age Rev Esp Cardiol. 2017;70(8):624–625

Do All Patients With Heart Failure Benefit From a Program for Early Follow-up After Hospital Discharge?

Without a doubt, heart failure (HF) is one of the most important medical problems—even beyond the cardiologic setting—that we are facing today. Because of the ever-increasing life expectancy of the population and advances in the treatment for acute cardiologic conditions, the prevalence of HF is rising, with a current estimated rate in Spain of 4% to 7%. This condition is the main cause of hospitalization in the very elderly population, and it requires considerable health expenditure and resource use. Despite the widespread belief that HF is simple and easy to resolve, it is actually a complex syndrome that is challenging to diagnose and treat. Although spectacular progress has been made in HF care over the last few years, as reflected in clinical practice guidelines, this disease remains an important cause of hospitalization, markedly impairs the quality of life of affected patients, and is associated with high mortality rates. If factors such as the current characteristics of real-world HF patients—increasingly older, more frail, and with a higher prevalence of comorbidities—are added to the complexity of HF management, it is easy to understand why this condition creates a huge demand on the health system and affects all health areas and professionals, not only cardiologists. These factors may help to explain why adequate care by specialists limited to the hospital setting does not offer a definite solution to the problem. A more integrated approach is needed, in which the care provided is configured within interdisciplinary HF programs and units. This strategy is supported by scientific evidence documenting the prognostic benefit of this type of organizational approach. In the HF guidelines of the European Society of Cardiology published in 2016, the organization of HF care within multidisciplinary teams was assigned a class I A recommendation. Numerous studies and meta-analyses have reported the effectiveness of programs based on HF units for reducing readmissions and even mortality rates. In Spain these programs have been developed by proactive rather than institutional efforts, and they coexist with advanced units that arose in relation to cardiac transplant. Due to the individual initiatives of many centers with professionals interested in HF, and the structured programs organized by the Heart Failure Section of the Spanish Society of Cardiology, increasingly larger numbers of hospitals are equipped with HF units, and they are now becoming commonplace in both cardiology and internal medicine departments. Within its SECExcellence program, the Spanish Society of Cardiology recently established a new nomenclature for the various types of cardiology units (community, specialized, and advanced), depending on the level, equipment, and services portfolio offered by the hospital, cardiology department, and HF unit. In addition, a series of minimum standards have been established (related to processes, infrastructure, human resources, equipment, and results), which must be met by these units and departments to receive SECExcellence accreditiation. This is important to ensure the quality of HF care at all levels and to guarantee the development and implementation of these units in the Spanish health system. As mentioned, HF units provide benefits for both patients and the health system, with reductions in the number of readmissions and in some studies, decreases in mortality. Nonetheless, most of the studies evaluating these aspects, particularly those in the cardiology setting, mainly include HF patients with a low ejection fraction, age that is not too advanced, and a low prevalence of comorbidities. One aspect that clearly influences this choice of participants is that it is impossible to follow up all HF patients within intensive programs in units with a limited infrastructure. However, another factor to consider is that one of the basic benefits of these programs is optimization of medication and other treatments with a favorable effect on the prognosis, which is only possible in HF with systolic dysfunction. To date, there are no treatments that improve the prognosis in HF with preserved ejection fraction. Furthermore, these latter patients tend to be older, more frail and have a higher prevalence of comorbidities, factors that often limit optimal use of drug therapy and make integrated treatment difficult. However, some studies including patients with both preserved and reduced ejection fraction have reported that both types can benefit from specific treatment in specialized units. In their article published in Revista Española de Cardiologı́a, Pacho et al., of the Heart Failure Unit of Hospital de Badalona, a team with extensive experience in HF programs, confirm these results in the STOP-HF-CLINIC study, which includes a population of HF patients with unfavorable characteristics: very advanced age Rev Esp Cardiol. 2017;70(8):624–625