Rafael Ramos

Estimación del riesgo coronario en España mediante la ecuación de Framingham calibrada

Rev Esp Cardiol 2003;56(3):253-61 253 Introducción y objetivos. Las ecuaciones de Framingham sobrestiman el riesgo de enfermedad coronaria en los países cuya incidencia es baja. En éstos, la ecuación debería adaptarse para la correcta prevención de la enfermedad coronaria. Se presentan las tablas de riesgo coronario global de Framingham calibradas para la población española. Pacientes y método. Se utilizó el procedimiento de calibración de la ecuación de Framingham, consistente en sustituir la prevalencia de factores de riesgo cardiovascular y la tasa de incidencia de acontecimientos coronarios de Framingham por las de nuestro medio. Se ha usado la ecuación de Framingham, que incluye el colesterol unido a lipoproteínas de alta densidad (cHDL). Se han calculado las probabilidades de acontecimiento a los 10 años y se han elaborado unas tablas con códigos de color y la probabilidad exacta en cada casilla correspondiente a las distintas combinaciones de los factores de riesgo clásicos, para una concentración de cHDL de 35-59 mg/dl. Resultados. Las tasas de acontecimientos coronarios y la prevalencia de factores de riesgo difieren considerablemente entre la población estudiada y Framingham. Valores de cHDL < 35 mg/dl incrementan el riesgo en un 50% y los > 60 mg/dl lo reducen en un 50%, aproximadamente. La proporción de casillas con una probabilidad de acontecimiento coronario a los 10 años superior al 9% es 2,3 veces menor, y la de casillas con una probabilidad > 19% es 13 veces menor en las tablas calibradas que en las originales de Framingham. Conclusiones. La función de Framingham calibrada puede constituir un instrumento para estimar con más precisión el riesgo coronario global en la prevención primaria de esta enfermedad en España. Su uso debe acompañarse de una validación apropiada y se debe trabajar en la elaboración de ecuaciones propias españolas.

Comparación de la función de Framingham original y la calibrada del REGICOR en la predicción del riesgo coronario poblacional

Fundamento y objetivo: Se desconocen las implicaciones terapeuticas derivadas del uso de la funcion de riesgo coronario de Framingham calibrada por los investigadores de los estudios REGICOR y Framingham (Framingham-REGICOR) para la poblacion espanola. El objetivo de este estudio fue determinar las diferencias en la clasificacion del riesgo de la poblacion de 35 a 74 anos usando la funcion de Framingham clasica (Framingham-Wilson) y la calibrada y sus consecuencias en la indicacion de tratamiento hipolipemiante con las guias de practica clinica. Pacientes y metodo: Se comparo la clasificacion en las categorias de riesgo a 10 anos de = 40% observada mediante ambas funciones en 3.270 individuos de entre 35 y 74 anos sin antecedentes de cardiopatia isquemica ni tratamiento hipolipemiante, provenientes de 2 muestras poblacionales representativas de la provincia de Girona, reclutadas entre 1994 y 2001. Se calculo el numero de candidatos a tratamiento hipolipemiante segun las guias vigentes de practica clinica y las 2 funciones. Resultados: Un 5,9% del total de la muestra recibia tratamiento hipolipemiante en el momento del examen. La funcion Framingham-REGICOR asigno al 54,2% de las mujeres y al 67,9% de los varones no diabeticos a una categoria de riesgo inferior que la funcion Framingham-Wilson. El 0,2% de las mujeres y el 21,2% de los varones descendieron dos categorias. Un 75,7% de los participantes diabeticos descendio una categoria y el 18,5% descendio dos. Con las guias europeas de 2003 recibirian hipolipemiantes el 14,5 y el 4,4% de participantes no diabeticos usando las funciones de Framingham-Wilson y Framingham-REGICOR, respectivamente. Conclusiones: La funcion calibrada de Framingham-REGICOR adjudica una categoria de riesgo coronario menor que la de Framingham original en mas del 50% de mujeres y casi el 90% de varones. Es una herramienta mas recomendable que esta en la prevencion primaria de la enfermedad coronaria en Espana.

Base de datos SIDIAP, la historia clínica informatizada de Atención Primaria como fuente de información para la investigación epidemiológica

a Institut Universitari d’Investigació en Atenció Primària (IDIAP) Jordi Gol, Barcelona, España b Universitat Autònoma de Barcelona, Bellaterra, Barcelona, España c Institut Català de la Salut, Barcelona, España d Facultad de Medicina, Universitat de Girona, Girona, España e Institut d’Investigació Biomèdica de Girona (IdIBGi), Girona, España f Unitat de Recerca en Fisiopatologia Òssia i Articular (URFOA), Institut Municipal d’Investigació Mèdica (IMIM)-Hospital del Mar), Barcelona, España

Association between Long-Term Exposure to Traffic-Related Air Pollution and Subclinical Atherosclerosis: The REGICOR Study

Background: Epidemiological evidence of the effects of long-term exposure to air pollution on the chronic processes of atherogenesis is limited. Objective: We investigated the association of long-term exposure to traffic-related air pollution with subclinical atherosclerosis, measured by carotid intima media thickness (IMT) and ankle–brachial index (ABI). Methods: We performed a cross-sectional analysis using data collected during the reexamination (2007–2010) of 2,780 participants in the REGICOR (Registre Gironí del Cor: the Gerona Heart Register) study, a population-based prospective cohort in Girona, Spain. Long-term exposure across residences was calculated as the last 10 years’ time-weighted average of residential nitrogen dioxide (NO2) estimates (based on a local-scale land-use regression model), traffic intensity in the nearest street, and traffic intensity in a 100 m buffer. Associations with IMT and ABI were estimated using linear regression and multinomial logistic regression, respectively, controlling for sex, age, smoking status, education, marital status, and several other potential confounders or intermediates. Results: Exposure contrasts between the 5th and 95th percentiles for NO2 (25 µg/m3), traffic intensity in the nearest street (15,000 vehicles/day), and traffic load within 100 m (7,200,000 vehicle-m/day) were associated with differences of 0.56% (95% CI: –1.5, 2.6%), 2.32% (95% CI: 0.48, 4.17%), and 1.91% (95% CI: –0.24, 4.06) percent difference in IMT, respectively. Exposures were positively associated with an ABI of > 1.3, but not an ABI of < 0.9. Stronger associations were observed among those with a high level of education and in men ≥ 60 years of age. Conclusions: Long-term traffic-related exposures were associated with subclinical markers of atherosclerosis. Prospective studies are needed to confirm associations and further examine differences among population subgroups.

Trends in the Prevalence, Awareness, Treatment, and Control of Cardiovascular Risk Factors across Educational Level in the 1995–2005 Period

PURPOSE To determine the differences and trends in the prevalence, awareness, treatment and control of cardiovascular risk factors and lifestyle variables across educational level in the 1995-2005 period in a country with a universal free health care system. METHODS Data from three consecutive independent population-based surveys were used. Cardiovascular risk factors, lifestyle variables, and self-reported educational level were collected in 9646 individuals ages 35-74 years throughout the decade. RESULTS The prevalence of hypertension and diabetes was inversely associated with education. An increase in the proportion of hypertension and dyslipidemia awareness, treatment, and control in all educational level groups was observed. This increase was greater among the lowest education group, reducing the disparities between groups. The prevalence of lifestyle-related risk factors decreased in the greatest but increased in the lowest education group, widening the disparities between groups. CONCLUSIONS A universal free health care system is effective in avoiding inequalities in the diagnosis, treatment, and control of cardiovascular risk factors. However, other social determinants seem to explain the social inequalities in the prevalence of these risk factors and in the adoption of healthy lifestyles.

Prevención cardiovascular: avances y el largo camino por recorrer

En este articulo se presentan las limitaciones actuales de las herramientas disponibles para cribar a la poblacion para determinar su riesgo cardiovascular. Se analizan las posibilidades de mejorar la capacidad predictiva y de reclasificacion de las tablas de riesgo cardiovascular en atencion primaria para actuar de manera mas efectiva. Se discuten las oportunidades existentes de mejorar las estrategias actuales de cribado y prevencion cardiovascular y cual es el papel de la determinacion individual de los nuevos biomarcadores, incluida la predisposicion genetica a la enfermedad coronaria y de algunas pruebas, como el indice tobillo/brazo o el grosor de intima-media carotidea. Se analizan los subgrupos de poblacion con riesgo cardiovascular mas importantes por su tamano y numero de acontecimientos cardiovasculares a 10 anos. Tambien se revisa brevemente cual puede ser el papel de las pruebas de imagen actualmente en desarrollo en ciertos subgrupos de riesgo de poblacion asintomatica.

Capacidad predictiva de las funciones de riesgo cardiovascular: limitaciones y oportunidades

Las funciones de riesgo cardiovascular son instrumentos utiles para el cribado inicial destinado a priorizar la prevencion primaria de las enfermedades cardiovasculares. Su uso debe de basarse en la demostracion de su validez mediante estudios prospectivos, debido a sus limitaciones en la sensibilidad y el valor predictivo positivo. Su precision y su fiabilidad podrian mejorarse mediante nuevos marcadores con buena capacidad predictiva, que sean, prioritariamente, faciles de medir, economicos y asequibles, como el perimetro de la cintura, la funcion renal o los tratamientos farmacologicos. En un futuro mas o menos proximo, los factores geneticos tambien podrian tener un papel relevante. Los nuevos modelos de funciones de riesgo tendran una vision mas integral del riesgo cardiovascular y, con la informatizacion, seran mas versatiles y faciles de aplicar. En un futuro muy cercano, el calculo del riesgo cardiovascular cambiara con la posibilidad de sustituir variables, el desarrollo de modelos basados en la edad y las expectativas de vida y la responsabilizacion conjunta de los pacientes respecto a su salud.

Eficacia de un programa intensivo de prevención secundaria de cardiopatía isquémica tras 5 años de intervención

BACKGROUND AND OBJECTIVE: Most evidence on the efficacy of intensive preventive programs of secondary prevention of coronary diseases comes from Anglo-Saxon countries and effectiveness remains controversial. We have scarce information about the efficacy of these types of programs in Spain. In the present analysis we show the results of the ICAR (Intervencion en la Comunidad de Alto Riesgo coronario) study, aimed to analyze the efficacy of an intensive preventive program primary care based in reducing the cardiovascular recurrences and mortality in patients with coronary heart disease. PATIENTS AND METHOD: We designed a randomized clinical trial, multicenter and community based, which included 23 health care areas in Catalonia, Spain. We followed for 5 years 2 cohorts of patients with coronary heart disease, aged 30-80 years. The intervention group was quarterly examined by their general practitioner, who adjusted treatments to control their cardiovascular risk factors thoroughly and reinforced life style behaviours. In order to do that, patients weight and blood pressure were determined in each visit and laboratory test carried out twice a year. Patients in the control group received the usual care. In order to analyze the effect of the intervention cardiovascular recurrences and mortality were registered. RESULTS: We included 983 patients. Mean (standard deviation) age was 64 (10) and 74.5% were men. During the follow-up 235 patients suffered some non-fatal cardiovascular recurrence (109 vs 126 in the control and intervention group, respectively; p = 0.84), and 45 died from cardiovascular recurrences (23 vs 22, respectively; p = 0.57). Adjusted hazard ratio of cardiovascular event and total mortality, for the intervention group were 1.01 (95% confidence interval, 0.74-1.39), and 0.92 (95% confidence interval, 0.54-1.56), respectively. CONCLUSIONS: The implementation of an intensive secondary prevention program based on periodical reminds to patients with stable coronary heart disease to attend their general practitioners did not reduce either the cardiovascular recurrences or mortality at 5 years as compared with usual care.

The Girona Territori Cardioprotegit Project: Performance Evaluation of Public Defibrillators

INTRODUCTION AND OBJECTIVES In recent years, public access defibrillation programs have exponentially increased the availability of automatic external defibrillators (AED) in public spaces but there are no data on their performance in our setting. We conducted a descriptive analysis of the performance of AED since the launch of a public defibrillation program in our region. METHODS A retrospective analysis was conducted of electrocardiographic tracings and the performance of AED in a public defibrillation program from June 2011 to June 2015 in the province of Girona, Spain. RESULTS There were 231 AED activations. Full information was available on 188 activations, of which 82% corresponded to mobile devices and 18% to permanent devices. Asystole was the most prevalent rhythm (42%), while ventricular fibrillation accounted for 23%. The specificity of the device in identifying a shockable rhythm was 100%, but there were 8 false negatives (sensitivity 83%). There were 47 shockable rhythms, with a spontaneous circulation recovery rate of 49% (23 cases). There were no accidents related to the use of the device. CONCLUSIONS Nearly half of the recorded rhythms were asystole. The AED analyzed showed excellent safety and specificity, with moderate sensitivity. Half the patients with a shockable rhythm were successfully treated by the AED.

Utility of a short quality of life questionnaire to predict cardiovascular events

Pending their work to have “high” impact factor and visibility. No one should pay for the honour and prestige... no one at all. Yet it is what is currently happening. SOME THOUGHTS ABOUT THIS WRITING It is true that there is too much stringency by the reviewers of many journals of high impact factor. It is also true that must have a double-blind between authors and reviewers in all the editorials. Thus, the bias of a possible tendentiousness would be disappeared. I personally know how wonderful clinical works have been rejected for the sake of a more or less gratuitous rigorously. Conversely, I have seen non-rigorous,even inconsistent clinical worksthat have been approved because these were signed by acclaimed authors. This should not be happening. A double-blind assessment is needed for any publication from any editorial. Maybe for this reason the aforementioned editorials (‘open access’) are taking advantage of these current circumstances. They buy vanity and sell publications. This must not be good for anyone. The authors of this manuscript have certified that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology (Shewan and Coats 2010;144:1–2).