Nekane Murga

Inercia terapéutica en el manejo extrahospitalario de la dislipemia en pacientes con cardiopatía isquémica. Estudio Inercia

Introduccion y objetivos Se ha descrito infratratamiento de las dislipemias. En sucesivas revisiones clinicas, aunque no se alcancen los objetivos terapeuticos marcados por las guias de practica clinica, no se modifican los tratamientos a pesar de que se dispone de alternativas terapeuticas. Esta actitud, conocida como inercia terapeutica, produce un incremento de la morbimortalidad. Pretendemos medirla en pacientes con dislipemia y cardiopatia isquemica y analizar sus posibles causas. Metodos Diseno: estudio observacional multicentrico nacional, con recogida de datos mediante cuestionario al medico y revision de historias clinicas de pacientes con cardiopatia isquemica. Variable principal: inercia terapeutica en la visita, sin modificacion de medicacion a pesar de indicacion de cambio (colesterol de las lipoproteinas de baja densidad > 100 mg/dl o > 70 mg/dl en diabeticos). Covariables: del medico, del paciente y de la visita. Analisis estadistico: estudio multivariable de regresion logistica de los factores asociados a la inercia terapeutica en la visita. Resultados En un 43% de las visitas se actua con inercia terapeutica; la asociacion con factores de riesgo coronario, incluida la diabetes, no motiva cambio del tratamiento. La inercia terapeutica esta favorecida por un mayor tiempo desde el diagnostico y el tratamiento de la dislipemia y de la cardiopatia isquemica. Las mujeres estan especialmente infratratadas a pesar de un mayor riesgo total. Los medicos mas experimentados tratan mejor a los pacientes mas jovenes. La formacion en congresos mejora la practica clinica. Conclusiones Elevada inercia terapeutica en pacientes con cardiopatia isquemica cronica y dislipemia, independientemente del riesgo cardiovascular total. Intervienen factores dependientes del paciente, de la enfermedad y del medico.

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

Clinical profile and management of hypertensive patients with chronic ischemic heart disease and renal dysfunction attended by cardiologists in daily clinical practice

Objective The present study was designed to assess the influence of renal function on the clinical profile and management of the hypertensive outpatients with chronic ischemic heart disease. Methods A total of 112 investigators, all cardiologists, were asked to consecutively enrol outpatients of at least 18 years of age, both sexes, with an established diagnosis of hypertension and chronic ischemic heart disease. Renal function was assessed by serum creatinine levels and estimated glomerular filtration rate using the Modification of Diet in Renal Disease formula. Renal impairment was considered a serum creatinine of at least 1.2/1.3 mg/dl (women/men) or an estimated glomerular filtration rate less than 60 ml/min/1.73 m2. Blood pressure was considered controlled when it was less than 140/90 mmHg and less than 130/80 mmHg in diabetic patients or patients with chronic kidney disease. Results A total of 2024 patients (66.8 ± 10.1 years; 31.7% women) were included. A total of 666 (32.9%) and 498 (24.6%) patients exhibited renal function impairment assessed by estimated glomerular filtration rate and serum creatinine, respectively. The subgroup of patients with renal dysfunction was older, with a higher proportion of women with atrial fibrillation, diabetes, organ damage, associated clinical conditions and a worse blood pressure control. No differences were found in clinical profile when the two subgroups of patients with impaired renal function [serum creatinine ≥1.2/≥1.3 mg/dl (women/men) vs. estimated glomerular filtration rate <60 ml/min per 1.73 m2] were compared. Conclusion Renal function impairment is frequent in the hypertensive population with coronary artery disease. Patients with renal dysfunction represent a subgroup of very high-risk population with more risk factors and comorbidities and worse blood pressure control. The clinical profiles of hypertensive patients with renal function impairment are similar whether renal dysfunction is detected by high serum creatinine or by low estimated glomerular filtration rate.

Sex differences in the hypertensive population with chronic ischemic heart disease.

Cardiopatía Isquémica Crónica e Hipertensión Arterial en la Práctica Clínica en España (CINHTIA) was a survey designed to assess the clinical management of hypertensive outpatients with chronic ischemic heart disease. Sex differences were examined. Blood pressures (BP) was considered controlled at levels of <140/90 or <130/80 mm Hg in diabetics (European Society of Hypertension/European Society of Cardiology 2003); low‐density lipoprotein cholesterol (LDL‐C) was considered controlled at levels <100 mg/dL (National Cholesterol Education Program Adult Treatment Panel III). In total, 2024 patients were included in the study. Women were older, with a higher body mass index and an increased prevalence of atrial fibrillation. Dyslipidemia, smoking, sedentary lifestyle, and peripheral arterial disease were more frequent in men. In contrast, diabetes, left ventricular hypertrophy, and heart failure were more common in women. BP and LDL‐C control rates, although poor in both groups, were better in men (44.9% vs 30.5%, P<.001 and 33.0% vs 25.0%, P<.001, respectively). Stress testing and coronary angiography were more frequently performed in men.

Therapeutic Inertia in the Outpatient Management of Dyslipidemia in Patients With Ischemic Heart Disease. The Inertia Study

INTRODUCTION AND OBJECTIVES Studies indicate that dyslipidemia is undertreated. Numerous systematic reviews have shown that, even when therapeutic targets set by clinical practice guidelines have not been met, treatment remains unchanged despite the availability of alternatives approaches. The result is increased morbidity and mortality. Our aims were to investigate this phenomenon, known as therapeutic inertia, in patients with dyslipidemia and ischemic heart disease, and to determine its possible causes. METHODS DESIGN national, multicenter, observational study of data obtained from physicians by questionnaire and from the clinical records of patients with ischemic heart disease. Main variable: therapeutic inertia during a consultation, defined as treatment remaining the same despite a change being indicated (e.g. low-density lipoprotein cholesterol >100 mg/dl or >70 mg/dl in diabetics). Covariates: physician, patient and consultation characteristics. STATISTICAL ANALYSIS multivariate logistic regression analysis of factors associated with therapeutic inertia during a consultation. RESULTS Overall, 43% of consultations involved therapeutic inertia, and an association with coronary risk factors, including diabetes, did not result in a change in treatment. Therapeutic inertia occurred more frequently when there was a long time between the diagnosis and treatment of dyslipidemia and that of ischemic heart disease. Undertreatment was particularly common in women despite a greater overall risk. The more experienced physicians treated younger patients more appropriately. Clinical practice was improved by educational sessions at conferences. CONCLUSIONS Therapeutic inertia was common in patients with chronic ischemic heart disease and dyslipidemia, irrespective of overall cardiovascular risk. Factors associated with the patient, disease and physician had an influence.

Control de los factores de riesgo en los pacientes hipertensos con cardiopatía isquémica crónica atendidos en las consultas de cardiología. Estudio CINHTIA

Objetivo CINHTIA es un estudio transversal y multicentrico disenado para conocer el manejo clinico de los hipertensos con cardiopatia isquemica cronica atendidos en consultas de cardiologia. Pacientes y metodos Se incluyeron pacientes ≥ 18 anos, con diagnostico de hipertension arterial y cardiopatia isquemica cronica. Se excluyeron aquellos pacientes con un sindrome coronario agudo en los tres meses previos. Se considero como buen control de presion arterial (PA) Resultados Se incluyeron un total de 2.024 pacientes (66,8 ± 10,1 anos; 31,7% mujeres). La PA sistolica fue 142,7 ± 17,9 mmHg y la diastolica 81,8 ± 11,3 mmHg. El 78,4% de los pacientes tenian dislipemia y el 32,3%, diabetes. El 99,7% de los pacientes estaba tomando al menos un antihipertensivo, el mas frecuente de los cuales eran los bloqueadores beta (67,1%). El 74,9% tomaba hipolipemiantes y el 27,9%, antidiabeticos. El 40,5% de los pacientes tenian la PA controlada; el 30,6% de los dislipemicos, el c-LDL controlado y el 26,6% de los diabeticos, la glucemia controlada. Conclusiones En esta poblacion de tan alto riesgo, a pesar de que la mayoria de los pacientes toman varios farmacos, el control de factores de riesgo es aun insuficiente.OBJECTIVE The CINHTIA study is a cross-sectional and multicentre survey designed to assess the clinical management of the hypertensive outpatients with chronic ischemic heart disease attended by cardiologists. PATIENTS AND METHODS Patients > or = 18 years, with a diagnosis of hypertension and chronic ischemic heart disease, were included in the study. Patients with an acute coronary syndrome within the three months prior to the inclusion were excluded. Good blood pressure (BP) control was considered < 140/90 mmHg, < 130/80 mmHg for diabetics (ESH-ESC 2003). LDL cholesterol (LDL-c) < 100 mg/dl (NCEP-ATP III) and fasting glucose between 90 and 130 mg/dl (ADA 2005) were considered as good control rates. RESULTS A total of 2,024 patients (66.8+/-10.1 years; 31.7% women) were included in the study. Systolic BP was 142.7 +/- 17.9 mmHg and diastolic BP 81.8 +/- 11.3 mmHg. 78.4% of the patients had dyslipidemia and 32.3% diabetes. Almost all the patients (99.7%) were taking at least one antihypertensive drug, beta blockers being the most frequent (67.1%). A total of 74.9% of the patients were taking lipid lowering drugs and 27.9% antidiabetics. BP was controlled in 40.5% of the patients, LDL-c in 30.6% of the dyslipidemic subgroup and fasting glucose in 26.6% of the diabetics. CONCLUSIONS In this high-risk population, the control rates of risk factors continues to remain low even though the majority of patients were taking several drugs.

Clinical profile and management of patients with chronic ischemic heart disease according to age in the population daily attended by cardiologists in Spain: The ELDERCIC study

OBJECTIVES This study was aimed to evaluate the differences according to age in the clinical profile and management of outpatients with chronic ischemic heart disease attended by cardiologists in Spain. METHODS Patients with an established diagnosis of chronic ischemic heart disease were included in this cross-sectional multicenter study. The age of 65 years was considered as the cut-off point for the present analysis. RESULTS A total of 1038 subjects were included, 524 of them (50.5%) >65 years. Patients >65 years had a lesser prevalence of smoking, a longer history of hypertension, a worse left ventricular ejection fraction and a higher prevalence of heart failure and renal insufficiency than younger subjects. The number of prescribed drugs was higher in patients >65 years (6.1+/-1.9 vs 5.7+/-2.1, p=0.004). Blood pressure control rate was lower in older patients (38.1% vs 46.5%, p=0.008). No significant differences were found either in LDL-cholesterol (42.4% vs 46.5%), or glycemic control rates (42.4% vs 41.4%), both p=NS. Diagnostic and therapeutic procedures were also compared in >65 vs < or =65 years, exercise test was performed in 51.5% vs 62.8% (p<0.0001); stress echocardiography in 18.3% vs 13.2% (p=0.027); coronary angiography in 38.6% vs 53.5% (p<0.0001); and coronary revascularization in 37.2% vs 46.9% (p=0.002), without significant differences in electrocardiogram, echocardiogram, or isotopic exams. CONCLUSIONS Older patients exhibited a worse clinical profile and a worse blood pressure control rate than the younger. However, diagnostic and therapeutic procedures appear to be frequently underused in the old patients.

High heart rate: More than a risk factor. Lessons from a clinical practice survey

Several epidemiological studies have reported that an elevated heart rate (HR) is associated with coronary atherosclerosis independently of other risk factors. Nevertheless, it is still unclear whether HR is itself the cause or there is merely an association between HR and mortality in this population. A total of 1686 patients with hypertension and chronic ischemic heart disease were included in this study. According to the resting HR, the patients were distributed in 3 groups (group 1: HR<63 bpm; group 2: 63-82 bpm; group 3: >82 bpm). 580 patients (34.4%) belonged to group 1; 936 (55.5%) to group 2 and 170 (10.1%) to group 3. Patients with high HR exhibited a poorer prognosis not only due to a worse clinical profile (more concomitant cardiovascular risk factors and organ damage), but suggestively because despite the use of a similar number of drugs, patients with higher HR were associated with lesser risk control rates in daily clinical practice. Despite current guidelines that do not still recognize HR as a cardiovascular risk factor, it appears that physicians should pay more attention to it in clinical practice since high HR is warning about an increased risk.

Novedades en cardiología clínica: electrocardiografía de superficie, enfermedad vascular y mujer y novedades terapéuticas

Desde la Seccion de Cardiologia Clinica y Extrahospitalaria se revisan las novedades actuales en el campo de la cardiologia clinica, en esta ocasion con especial enfasis en las novedades en electrocadiografia de superficie y en el campo de mujer y cardiopatia. Se realiza asimismo una somera revision de las principales novedades terapeuticas con fuerte impacto en la clinica diaria y se resume la actividad de la seccion.

Vascular Risk and Cardiac Rehabilitation 2015: A Selection of Topical Issues.

Almudena Castro Conde*, Domingo Marzal Martin, Regina Dalmau Gonzalez-Gallarza, Vicente Arrarte Esteban, Miren Morillas Bueno, Xavier Garcia-Moll Marimon, Alejandro Berenguel Senen, Nekane Murga y Manuel Abeytua a Servicio de Cardiologia, Unidad de Rehabilitacion Cardiaca, Hospital Universitario La Paz, Madrid, Espana b Servicio de Cardiologia, Complejo Hospitalario de Merida, Merida, Badajoz, Espana c Servicio de Cardiologia, Hospital Universitario La Paz, Madrid, Espana Unidad de Rehabilitacion Cardiaca, Hospital General Universitario de Alicante, Alicante, Espana e Servicio de Cardiologia, Hospital Osakidetza, Barakaldo, Vizcaya, Espana f Servicio de Cardiologia, Hospital de la Santa Creu i Sant Pau, Barcelona, Espana g Servicio de Cardiologia, Complejo Hospitalario de Toledo, Toledo, Espana h Servicio de Cardiologia, Seccion de Cardiologia Clinica, Hospital de Basurto, Bilbao, Vizcaya, Espana i Servicio de Cardiologia, Unidad de Rehabilitacion Cardiaca, Hospital General Universitario Gregorio Maranon, Madrid, Espana