Maria Prat Grau

Trends in cardiovascular risk factor prevalence (1995-2000-2005) in northeastern Spain

Background High prevalence of cardiovascular risk factors has been observed in Spain along with low incidence of acute myocardial infarction. Our objective was to determine the trends of cardiovascular risk factor prevalence between 1995 and 2005 in the 35-74-year-old population of Gerona, Spain. Design Comparison of cross-sectional studies were conducted in random population samples in 1995, 2000, and 2005 at Gerona, Spain. Methods An electrocardiogram was obtained, along with standardized measurements of body mass index, lipid profile, systolic and diastolic blood pressure, glycaemia, energy expenditure in physical activity, smoking, use of lipid-lowering and antihypertensive medications, and cardiovascular risk. Prevalence of diabetes, hypertension, and obesity was calculated and standardized for age. Results A total of 7571 individuals (52.0% women) were included (response rate 72%). Low-density lipoprotein cholesterol > 3.4 mmol/l (130 mg/dl) (49.7%) and hypertension (39.1%) were the most prevalent cardiovascular risk factors. In 1995, 2000 and 2005, low-density lipoprotein cholesterol decreased in both men and women: 4.05-3.913.55 mmol/l (156-151-137 mg/dl) and 3.84-3.81-3.40 mmol/l (148-147-131 mg/dl), respectively. Increases were observed in lipid-lowering drug use (5.7-6.3-9.6% in men and 4.0-5.8-8.0% in women), controlled hypertension (14.8-35.4-37.7% in men and 21.3-36.9-45.0% in women); (all P-trends < 0.01), and obesity (greatest for men: 17.5-26.0-22.7%, P-trends = 0.020). Prevalence of myocardial infarction or possibly abnormal Q waves in electrocardiogram also increased significantly (3.9-4.7-6.4%, P-trends = 0.018). Conclusions The cardiovascular risk factor prevalence change in Gerona was marked in this decade by a shift of total cholesterol and low-density lipoprotein cholesterol distributions to the left, independent of the increase in lipid-lowering drug use, and better hypertension control with increased use of antihypertensive drugs. Eur J Cardiovasc Prev Rehabil 14:653-659

Estimated glomerular filtration rate and prognosis in heart failure: value of the Modification of Diet in Renal Disease Study-4, chronic kidney disease epidemiology collaboration, and cockroft-gault formulas.

OBJECTIVES The purpose of this study was to assess the value of estimated glomerular filtration rate (eGFR) calculated by different formulas for predicting the risk of death in heart failure (HF) outpatients. BACKGROUND Patients with both HF and renal insufficiency have a poor prognosis. Three formulas are mostly used to assess renal function: Cockroft-Gault formula, MDRD-4 (Modification of Diet in Renal Disease Study) formula, and the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation. The prognostic values of these formulas have not been adequately compared in HF patients. METHODS A total of 925 patients (72% men; age 69 years; interquartile range: 59 to 75.5 years) with a left ventricular ejection fraction of 31% (interquartile range: 23.5% to 39%) were studied. Follow-up was 1,202 days (interquartile range: 627.5 to 2,156.5 days). Measures of performance were evaluated using continuous data and by dividing patients into 4 subgroups according to the eGFR: ≥90, 89 to 60, <60 to 30, and <30 ml/min/1.73 m(2). RESULTS The 3 formulas correlated significantly, with the best correlation found between the MDRD-4 and CKD-EPI formulas. The 3 formulas afforded independent prognostic information over long-term follow-up. However, risk prediction was most accurate using the Cockroft-Gault formula as evaluated by Cox proportional hazards models (hazard ratio: 0.75 vs. 0.81 with the MDRD-4 formula and 0.80 with the CKD-EPI equation), area under the curve (0.67 vs. 0.62 and 0.64, respectively), and Bayesian information criterion (both analyzing eGFR as a continuous or categorical variable). Indeed, net reclassification improvement and integrated discrimination improvement using the Cockroft-Gault formula were 21% and 5.04, respectively, versus the MDRD-4 formula (the most used) and 13.1% and 3.77 respectively versus CKD-EPI equation (the more recent) (all p values <0.001). CONCLUSIONS In this ambulatory, real-life cohort of HF patients, the Cockroft-Gault formula was the most accurate of the 3 used eGFR formulas to improve the risk stratification for death.

Análisis de la tendencia en la letalidad, incidencia y mortalidad por infarto de miocardio en Girona entre 1990 y 1999

Introduccion y objetivos La incidencia por infarto de miocardio en Espana es baja y la mortalidad esta disminuyendo en las ultimas decadas. Hemos analizado las tendencies en las tasas de mortalidad, incidencia y ataque, y en la letalidad a 28 dias por infarto de miocardio entre 1990 y 1999 en la poblacion de 35 a 74 anos de Girona. Metodos Se incluyeron todos los casos de infarto de miocardio de Girona clasificados segun el algoritmo MONICA. Se calcularon las tasas de ataque, incidencia y mortalidad, y la letalidad, asi como el porcentaje de cambio annual en cada uno de los indicadores durante el periodo analizado. Resultados La tasa anual media de ataque fue de 258 (intervalo de confianza [IC] del 95%, 249-267) y 55 (IC del 95%, 51-59) por 100.000 habitantes para varones y mujeres, respectivamente, y la de mortalidad de 99 (IC del 95%, 93-104) por 100.000 en varones y de 25 (IC del 95%, 22-28) por 100.000 en mujeres. Las tasas de ataque, incidencia y recurrencia disminuyeron significativamente en varones de 35 a 64 anos durante el periodo 1990-1999, pero no en los de 65 a 74 anos ni en las mujeres. Conclusiones La incidencia y la mortalidad por IAM fueron bajas en la poblacion de 35 a 64 anos, y mejoraron en los varones de 35 a 64 anos durante el periodo 1990-1999, pero no en los de 65 a 74 anos, lo que indica que la combinacion de prevencion primaria y secundaria ha retrasado la edad de aparicion del infarto de miocardio o de las recurrencias. Las tasas en mujeres fueron inferiors y no cambiaron durante el periodo estudiado.

Funciones de riesgo en la prevención primaria de las enfermedades cardiovasculares

Las funciones de riesgo cardiovascular constituyen la mejor herramienta para establecer prioridades en prevencion primaria. Despues de descartarse la original de Framingham por sobrestimar excesivamente el riesgo real, las funciones adaptadas de REGICOR y SCORE son las dos disponibles en Espana, aunque la funcion de REGICOR es la unica validada en nuestra poblacion. La estimacion del riesgo ha mostrado su utilidad en la toma de decisiones, especialmente para el tratamiento de la hipercolesterolemia; sin embargo, el hecho de que la mayoria de los acontecimientos cardiovasculares se den en individuos clasificados en el grupo de riesgo moderado refleja la escasa capacidad de discriminacion de los factores de riesgo clasicos. Con todo, los nuevos elementos propuestos para el calculo del riesgo (proteina C-reactiva, deteccion de calcio intracoronario, indice intima-media carotidea, indice tobillo/brazo) no mejoran la capacidad predictiva de los factores de riesgo clasicos. La alternativa mas solida parece entonces la identificacion del «paciente vulnerable» basada en los marcadores de placa vulnerable (inestable o de alto riesgo), sangre vulnerable (tendencia a la trombosis) y miocardio vulnerable (electricamente inestable o arritmogenico). Discutimos la posible efectividad de la utilizacion combinada de las funciones de riesgo, junto con nuevos marcadores de riesgo y pruebas no invasivas, para aumentar la precision de la seleccion de pacientes candidatos a prevencion primaria de las enfermedades cardiovasculares.

Impact of a partial smoke-free legislation on myocardial infarction incidence, mortality and case-fatality in a population-based registry: the REGICOR Study.

Background and Objective Coronary heart disease (CHD) is the leading cause of death, and smoking its strongest modifiable risk factor. Our aim was to determine the impact of the Spanish 2006 partial smoke-free legislation on acute myocardial infarction (AMI) incidence, hospitalization and mortality rates, and 28-day case-fatality in Girona, Spain. Methods Using a population-based registry (the REGICOR Study), we compared population incidence, hospitalization, and mortality rates, and 28-day case-fatality in the pre- and post-ban periods (2002–2005 and 2006–2008, respectively) by binomial regression analysis adjusted for confounding factors. We also analyzed the bans impact on the outcomes of interest using the AMI definitions of the American Heart Association (AHA)/European Society of Cardiology (ESC) and the World Health Organization (WHO)-Monitoring trends and determinants in cardiovascular diseases (MONICA). Results In the post-ban period, AMI incidence and mortality rates significantly decreased (relative risk [RR] = 0.89; 95% confidence interval [CI] = 0.81–0.97 and RR = 0.82; 95% CI = 0.71–0.94, respectively). Incidence and mortality rates decreased in both sexes, especially in women, and in people aged 65–74 years. Former and non-smokers (passive smokers) showed diminished incidence rates. Implementation of the ban was not associated with AMI case-fatality. Models tended to be more significant with the WHO-MONICA than with the AHA/ESC definition. Conclusions The 2006 Spanish partial smoke-free legislation was associated with a decrease in population AMI incidence and mortality, particularly in women, in people aged 65–74 years, and in passive smokers. These results clarify the association between AMI mortality and the enactment of a partial smoke-free legislation and reinforce the effectiveness of smoking regulations in preventing CHD.

Rendimiento de la estimación del riesgo cardiovascular en España mediante la utilización de distintas funciones

Introduccion y objetivos A pesar de que presentan una baja incidencia, las enfermedades cardiovasculares son la causa mas frecuente de morbimortalidad en Espana. Se dispone de diversas funciones para calcular el riesgo cardiovascular en la prevencion primaria, cuya capacidad para identificar a los pacientes que desarrollaran acontecimientos cardiovasculares es poco conocida. Comparamos el rendimiento de las funciones de Framingham original, adaptada de REGICOR (Registre Gironi del Cor) y SCORE (Systematic COronary Risk Evaluation) para paises de bajo riesgo. Metodos Se registraron todos los acontecimientos cardiovasculares en un seguimiento de 5 anos de una cohorte sin enfermedad coronaria en 9 comunidades autonomas. Se midieron los factores de riesgo cardiovascular entre 1995 y 1998. Se considero que el riesgo era elevado a los 10 anos en ≥ 20% para Framingham, ≥ 10, ≥ 15 y ≥ 20% para REGICOR y ≥ 5% para SCORE. Resultados Se produjeron 180 (3,1%) acontecimientos coronarios (112 en varones y 68 en mujeres) en las 5.732 personas (57,3% de mujeres) en las que se realizo el seguimiento. Se produjo muerte cerebrovascular en 43 personas, asi como 24 acontecimientos vasculares no coronarios. Con la funcion REGICOR se obtuvo el mayor valor predictivo positivo para enfermedad coronaria y cardiovascular a cualquier edad, y, tomando un limite de 10% de riesgo a los 10 anos, se clasifico a menos poblacion de alto riesgo de 35-74 anos (12,4%) que con la funcion de Framingham (22,4%). SCORE y Framingham clasificaron al 8,4 y al 16,6% de la poblacion de 35-64 anos como de alto riesgo cardiovascular y REGICOR, al 7,5%. Conclusiones La funcion adaptada de REGICOR es la opcion aplicable hasta los 74 anos que muestra el mejor equilibrio en la capacidad de clasificacion de riesgo de acontecimientos cardiovasculares. Su aplicacion permite la clasificacion de alto riesgo a individuos con un perfil mas adecuado para ser candidatos a tratamiento hipolipemiante.

Grosor íntima-media carotídeo en población española: valores de referencia y asociación con los factores de riesgo cardiovascular

INTRODUCTION AND OBJECTIVES Carotid intima-media thickness as measured with ultrasonography is an inexpensive and noninvasive predictor of cardiovascular events. The objectives of this study were to determine the population reference ranges of carotid intima-media thickness for individuals aged 35-84 years in Spain and to analyze the association of carotid intima-media thickness with cardiovascular risk factors (age, smoking, diabetes, pulse pressure, lipid profile, and body mass index). METHODS Population-based cross-sectional study conducted in Gerona (Spain). We described the mean and maximal values of carotid intima-media thickness of the carotid artery and of its 3 segments (common carotid, carotid bulb and internal carotid). We assessed cardiovascular risk factors and analyzed their association with carotid intima-media thickness using adjusted linear regression models. RESULTS A total of 3161 individuals (54% women) were included, with mean age 58 years. Men showed significantly higher mean common carotid intima-media thickness than did women (0.71 vs 0.67 mm). The strongest predictors of this measure were age (coefficients for 10-year increase: 0.65 and 0.58 for women and men, respectively), smoking in men (coefficient: 0.26), high-density lipoprotein cholesterol in women (coefficient for 10 mg/dL, increase: -0.08) and pulse pressure in both sexes (coefficients for 10 mmHg increase: 0.08 and 0.23 for women and men, respectively). The results were similar for the mean carotid intima-media thickness of all the segments. CONCLUSIONS This population-based study presents the reference ranges for carotid intima-media thickness in the Spanish population. The main determinants of carotid intima-media thickness were age and pulse pressure in both sexes.

Derivation and validation of a set of 10-year cardiovascular risk predictive functions in Spain: The FRESCO Study

OBJECTIVE To derive and validate a set of functions to predict coronary heart disease (CHD) and stroke, and validate the Framingham-REGICOR function. METHOD Pooled analysis of 11 population-based Spanish cohorts (1992-2005) with 50,408 eligible participants. Baseline smoking, diabetes, systolic blood pressure (SBP), lipid profile, and body mass index were recorded. A ten-year follow-up included re-examinations/telephone contact and cross-linkage with mortality registries. For each sex, two models were fitted for CHD, stroke, and both end-points combined: model A was adjusted for age, smoking, and body mass index and model B for age, smoking, diabetes, SBP, total and HDL cholesterol, and for hypertension treatment by SBP, and age by smoking and by SBP interactions. RESULTS The 9.3-year median follow-up accumulated 2973 cardiovascular events. The C-statistic improved from model A to model B for CHD (0.66 to 0.71 for men; 0.70 to 0.74 for women) and the combined CHD-stroke end-points (0.68 to 0.71; 0.72 to 0.75, respectively), but not for stroke alone. Framingham-REGICOR had similar C-statistics but overestimated CHD risk. CONCLUSIONS The new functions accurately estimate 10-year stroke and CHD risk in the adult population of a typical southern European country. The Framingham-REGICOR function provided similar CHD prediction but overestimated risk.

Validez del cuestionario cardiovascular MONICA comparado con la historia clínica

OBJECTIVE To assess the validity of the questionnaire Multinational Monitoring of Trends and Determinants in Cardiovascular Disease (MONICA) compared with clinical records. METHODS A descriptive, prospective, multicenter study was performed within the framework of the Peripheral Arterial Disease Study (PERART) in 3,329 persons aged >50 years old. The sample was selected by simple random sampling in 32 primary health care centers. The diagnoses included were acute myocardial infarction, angina pectoris, cerebrovascular disease, hypertension, diabetes mellitus, and hypercholesterolemia. Treatment variables were also considered (antihypertensive, lipid-lowering and hypoglycemic agents or insulin, as well as antiplatelet or anticoagulant agents). The sensitivity, specificity, predictive values, and kappa index were computed to test the validity of the MONICA questionnaire. RESULTS The mean age was 65 years (SD 8.9) and 54.8% were women. The sensitivity of the questionnaire was >90% for all the variables apart from angina pectoris (89.9%) and cerebrovascular disease (86.5%). Specificity was also >90%, except for angina pectoris (88.3%) and hypercholesterolemia (77.5%). The positive predictive value was >90% for all the treatments; >80% for angina pectoris, acute myocardial infarction and hypertension; 79.4% for cerebrovascular disease; 79.1% for hypercholesterolemia and 73.4% for diabetes mellitus. The negative predictive value was >90% for all the variables. The kappa indexes were >0.80 for all the variables apart from hypercholesterolemia (0.69) and diabetes mellitus (0.79). CONCLUSIONS The MONICA cardiovascular questionnaire is valid in the assessment of cardiovascular disease, risk factors and treatments in patients aged >50 years old.

Why should population attributable fractions be periodically recalculated? An example from cardiovascular risk estimation in southern Europe.

OBJECTIVE To determine the effect of age and study period on coronary heart disease (CHD) risk attributable to cardiovascular risk factors. METHODS A cohort of cardiovascular disease (CVD)-free randomly participants from Girona (Spain) aged 35-74 years recruited in 1995 and 2000 and followed for an average of 6.9 years. A survey conducted in the same area in 2005 was also used for the analysis. Smoking, hypertension, diabetes, sedentary lifestyle, obesity, total cholesterol > or = 240 mg/dl, low-density lipoprotein (LDL) cholesterol > or = 160 mg/dl, and high-density lipoprotein cholesterol <40 mg/dl were the risk factors considered. The composite end-point included myocardial infarction, angina pectoris, and CHD death. RESULTS LDL cholesterol had the highest potential for CHD prevention between 35 and 74 years [42% (95% Confidence Interval: 23,58)]. The age-stratified analysis showed that the population attributable risk (PAF) for smoking was 64% (30,80) in subjects < 55 years; for those > or = 55 years, the PAF for hypertension was 34% (1,61). The decrease observed between 1995 and 2005 in the populations mean LDL cholesterol level reduced that PAF in all age groups. CONCLUSION Overall, LDL cholesterol levels had the highest potential for CHD prevention. Periodic PAF recalculation in different age groups may be required to adequately monitor population trends.