Teresa Mantilla

Estudio PREVENCAT: control del riesgo cardiovascular en atención primaria

Fundamento y objetivo: Muchos estudios de factores de riesgo cardiovascular (FRCV) realizados en nuestro medio se centran en solo uno. El estudio PREVENCAT se diseno para estimar el control de los principales FRCV en poblacion asistida en atencion primaria que presenta hipertension arterial (HTA), diabetes mellitus tipo 2 (DM-2) y/o hipercolesterolemia (HC) y para conocer la prevalencia de sindrome metabolico en estos pacientes. Pacientes y metodo: Estudio multicentrico, transversal, en pacientes con HTA, DM-2 y/o HC, reclutados de forma consecutiva por medicos de atencion primaria en Espana. Se evaluaron la presion arterial, el colesterol, la glucemia basal, la obesidad, el tabaquismo y el ejercicio fisico, y se estimaron el grado de control de estos FRCV y la prevalencia del sindrome metabolico. Resultados: Se incluyo en el estudio a 2.649 pacientes (un 51,6% mujeres) con una media (desviacion estandar) de edad de 64 (11,3) anos de edad. El diagnostico mas frecuente fue la HTA (78,9%), seguido de HC (58,4%) y de DM-2 (37,4%). En toda la muestra, el porcentaje de pacientes que tenia bien controlada o basalmente normal la presion arterial, el colesterol y la glucemia basal fue del 40,0% (intervalo de confianza [IC] del 95%, 38,2-41,9), del 42,6% (IC del 95%, 40,5-44,7) y del 62,7% (IC del 95%, 60,8-64,5), respectivamente. El 15,6% de los casos (IC del 95%, 14,3-17,0) tenia un indice de masa corporal menor o igual a 25 kg/m2, el 87,5% no fumaba en la actualidad (IC del 95%, 86,2-88,8) y el 46,2% practicaba ejercicio fisico regular (IC del 95%, 44,3-48,1). El 40% de los pacientes presentaba 2 o menos FRCV bien controlados. La prevalencia del sindrome metabolico fue del 50,6% (IC del 95%, 48,7-52,5). Conclusiones: El control de los FRCV considerados en poblacion atendida en atencion primaria es insuficiente. Apenas uno de cada 2 pacientes con HTA, DM-2 o HC esta controlado. El control del sobrepeso y el sedentarismo es aun peor.BACKGROUND AND OBJECTIVE Most studies of cardiovascular risk factors (CVRF) conducted in our environment concentrate in a single CVRF. The PREVENCAT study was designed to estimate the control of CVRF in the population attended in primary care presenting arterial hypertension (HT), type 2 diabetes mellitus (DM2) and/or hypercholesterolemia (HC) as well as to assess the prevalence of Metabolic Syndrome in these patients. PATIENTS AND METHOD Multicenter, cross-sectional study, in patients with HT, DM2 and/or HC, consecutively recruited by primary care physicians in Spain. The blood pressure, cholesterol, basal glycaemia, obesity, smoking and physical activity were assessed. The degree of control of these CVRF and the prevalence of MS were estimated. RESULTS 2,649 patients were recruited, aged 64 (11.3) years, with a 51.6% of women. The most frequent diagnosis was HT (78.9%), followed by HC (58.4%) and DM2 (37.4%). In the whole sample, the percentages of patients who had a control or had initially normal values of blood pressure, cholesterol and basal glycemia were 40.0% (confidence interval [CI], 95% 38.2-41.9), 42.6% (95% CI, 40.5-44.7) and 62.7% (95% CI, 60.8-64.5), respectively. 15.6% of cases (95% CI, 14.3-17.0) had body mass index < or = 25 kg/m2; 87.5% were non-current smokers (95% CI, 86.2-88.8); and 46.2% practiced regular physical activity (95% CI, 44.3-48.1). 40% of patients had < or = 2 CVRF in good control. The prevalence of metabolic syndrome was 50.6% (95% CI, 48.7-52.5). CONCLUSIONS The control of the CVRF considered in primary care attended population is insufficient. Hardly one of each 2 patients with HT, DM2 and HC is under control. The overweight and sedentarism control is still poorer.

Tablas de evaluación del riesgo coronario adaptadas a la población española. Estudio DORICA

Fundamento y objetivo Los factores de riesgo independientes (consumo de tabaco, hipertensionarterial, hipercolesterolemia ydiabetes mellitus) son causa directa de cardiopatia isquemica y son frecuentes en la poblacion.Resulta mas apropiado estimar el riesgo global considerando la presencia de los diferentes factores de riesgo. El objetivo de este trabajo es presentar unas ta-blas de riesgo coronario confeccionadas a partir de la ecuacion de Framingham adaptada a la prevalencia de factores de riesgo en Espana Sujetos y metodo Se ha estimado la prevalencia de factores de riesgo en la poblacion espanola a partir del analisis de un conjunto de estudios poblacionales transversales. Se ha sustituido enla ecuacion de Framingham los datos estimados de prevalencia y la tasa de incidencia de acon-tecimientos coronarios. Se ha calculado la probabilidad de riesgo a 10 anos y se ha confeccio-nado una tablas que clasifican el riesgo con un codigo de colores Resultados La fraccion atribuible (FA) estimada para la hipertension arterial en la poblacionespanola es del 26,7% en varones y el 22,9% en mujeres, y para la hipercolesterolemia es del 15,7% en varones y el 12,7% en mujeres. El tabaquismo se situa en tercer lugar en orden de importancia en los varones (FA, 13,13%) y en cuarto en las mujeres (FA, 3,71%). Se estimouna prevalencia de obesidad del 13,2% en varones y el 17,5% en mujeres.En varones la FA a la obesidad es del 4% y en mujeres del 5% Conclusiones La adaptacion de la ecuacion de Framingham calibrada segun la prevalencia de los factores de riesgo independientes en la poblacion espanola y a la incidencia de aconteci-mientos coronarios en esta poblacion permiteconfeccionar herramientas utiles para estimar el riesgo coronario a 10 anos mientras no se disponga de estimaciones basadas en una ecuacionpropia a partir de un estudio de cohortes

Parámetros antropométricos asociados al riesgo cardiovascular en España. Estudio DORICA

Introduccion El riesgo cardiovascular de cualquier poblacion esta directamente relacionado con la prevalencia de los distintos factores de riesgo y con el impacto que cada uno de ellos pueda tener en la morbimortalidad por enfermedades cardiovasculares. Estas singularidades poblacionales son las que obligan a tener en consideracion los datos extraidos de la propia poblacion a la hora de sacar consecuencias para la valoracion del riesgo cardiovascular individual. Objetivos El objetivo del presente trabajo ha sido conocer, a partir de amplios estudios poblacionales, cuales son las caracteristicas antropometricas que en la poblacion espanola se asocian con los distintos factores de riesgo, a fin de establecer–si fuera possible–puntos de corte de parametros antropometricos relacionados con un mayor riesgo cardiovascular. Metodos Los datos han sido extraidos del estudio DORICA, llevado a cabo con datos de casi 15.000 individuos procedentes de 9 comunidades autonomas. Se analiza la prevalencia de los diferentes factores de riesgo, y se establecen los resultados de los puntos de corte para la poblacion espanola que permiten establecer ciertos marcadores antropometricos asociados al riesgo cardiovascular. En este sentido, el indice de masa corporal (IMC) se situa en 27 kg/m 2 para las mujeres y en 30 kg/m 2 para los varones. El perimetro de la cintura, que en la poblacion espanola se acompana de agrupacion de factores de riesgo metabolicos, resulto ser, en la mujer, de 80 y 90 cm, y en el varon, de 88 cm y 98 cm para un IMC de 25 y 30, respectivamente. Conclusiones Estos datos sugieren que, tal y como se propone, los parametros antropometricos sugerentes de riesgo cardiovascular elevados deben adaptarse a las caracteristicas poblaciones, lo que tiene una enorme trascendencia a la hora de establecer criterios diagnosticos para procesos con riesgo elevado.

La auténtica dimensión del colesterol-no-HDL: colesterol aterogénico

Lowe density lipoproteins (LDL) are the causal agent of cardiovascular diseases. In practice, we identify LDL with cholesterol transported in LDL (cLDL). So, cLDL has become the major target for cardiovascular prevention. Howewer, we have progressive evidences about the role of triglycerides rich lipoproteins, particularly those very low density lipoprotein (VLDL) in promotion and progression of atherosclerosis, that leads cholesterol in VLDL and its remanents as a potential therapeutic target. This feature is particularly important and of a great magnitude, in patients with hypertiglyceridemia. We can to considere, that the non-HDL cholesterol -cLDL+cVLDL+c-remmants+Lp(a)- is the real measurement of atherogenic cholesterol. In addition, non-HDL-cholesterol do not show any variations between postprandial states. In fact, non-HDL-cholesterol should be an excellent marker of atherogenic cholesterol, and an major therapeutic target in patients with atherogenic dyslipidaemia. According with different clinical trials and with the epidemiological and mendelian studies, in patients with high cardiovascular risk, optimal level of cLDL will be under 70mg/dl, and under 100 ng/dl for non-HDL-cholesterol; and in high risk patients, 100mg/dl and 130mg/dl, respectively.

Variables associated with change in blood pressure control status after 1-year follow up in primary care: a retrospective analysis: the TAPAS study.

Purpose This 1-year, retrospective, observational study assessed factors associated with changes in hypertension control status and differences in blood pressure (BP) management among general practitioners in Spain. Methods In 2009, 307 investigators from 260 primary care centres in Spain recruited the first four consecutive patients with hypertension that fit into one of four predefined cohorts: (1) uncontrolled BP at baseline and at a 1-year follow-up visit; (2) uncontrolled BP at baseline and good BP control at the 1-year follow-up visit; (3) good BP control at baseline and loss of BP control at the 1-year follow-up visit; and (4) good BP control at baseline and at the 1-year follow-up visit. Results A total of 1385 patients were included. Patients with poor BP and patients that lost BP control exhibited more cardiovascular risk factors. Although antihypertensive treatment was increased more markedly in these patients, this was not sufficient to attain/remain BP goals. Predictors for attaining BP control were no smoking, absence of diabetes, reduction in cholesterol, low baseline cholesterol, and no weight gain. Predictors for failing to maintain BP goals were weight gain, high baseline LDL cholesterol, and no reduction in fasting glucose. NSAID prescriptions increased markedly in patients that lost BP control compared to those that maintained BP control. Conclusion Antihypertensive therapy should be intensified and healthy lifestyle changes should be emphasized, particularly weight control to improve BP control. Drugs that may increase BP levels, such as NSAIDs, should also be avoided.

Enfermedad del hígado graso no alcohólico, asociación con la enfermedad cardiovascular y tratamiento (II). Tratamiento de la enfermedad del hígado graso no alcohólico

Disease nonalcoholic fatty liver disease (NAFLD) comprises a series of histologically similar to those induced by alcohol consumption in people with very little or no liver damage same. The importance of NAFLD is its high prevalence in our Western societies, from the point of view liver in its progressive evolution from steatosis to steatohepatitis, cirrhosis and liver cancer. During the last decade it has been observed that NAFLD leads to an increased cardiovascular risk with accelerated atherosclerosis and cardiovascular events, the leading cause of morbidity and mortality. This updated January 2016 revision consists of two parts. In this second part, the treatment of NAFLD and its influence on cardiovascular disease and drugs used in the control of cardiovascular risk factors showing a beneficial effect on the liver disease will be reviewed.

Consenso sobre tratamiento farmacológico de la dislipidemia aterogénica con terapia combinada estatina-fenofibrato

LDLc levels are associated with increase of cardiovascular risk, and statins are currently used for their control. Nevertheless, a despite of LDLc levels at goal, a residual risk is persistent, commonly associated with persistent lipids modifications (high triglycerides and low HDLc). So, it is necessary to evaluate triglycerides and HDL to assessment cardiovascular risk. Clinical data are consistent with efficacy and safety of combination therapy with statin and other lipid lowering drugs, for instance fenofibrate. Patients with hipertriglyceridemia and low HDLc are the group with most potential improve. In that patients with atherogenic dyslipidemia, the target for therapeutic objectives related with non-HDL-cholesterol is a priority, because non-HDL-cholesterol is considered as a more accuracy measure to assessment cardiovascular risk.

Consecución de objetivos terapéuticos

Resumen La consecucion de los objetivos terapeuticos en los pacientes con dislipemia aterogenica se consigue mejorando el cumplimiento y la adherencia del paciente. Las guias de practica clinica abordan la importancia del cumplimiento para conseguir los objetivos. La combinacion a dosis fija de pravastatina y fenofibrato aumenta la adherencia, ya que simplifica el regimen medicamentoso reduciendo el numero de dosis diaria. La buena tolerancia, el coste de la combinacion y la posibilidad de adecuar la administracion al estilo de vida del paciente facilitan la consecucion de los objetivos en esos pacientes de alto riesgo cardiovascular.Therapeutic objectives for patients with atherogenic dyslipidemia are achieved by improving patient compliance and adherence. Clinical practice guidelines address the importance of treatment compliance for achieving objectives. The combination of a fixed dose of pravastatin and fenofibrate increases the adherence by simplifying the drug regimen and reducing the number of daily doses. The good tolerance, the cost of the combination and the possibility of adjusting the administration to the patients lifestyle helps achieve the objectives for these patients with high cardiovascular risk.

Fibrates in the secondary prevention of cardiovascular disease (infarction and stroke). Results of a systematic review and meta-analysis of the Cochrane collaboration

Abstract Fibrates are a group of drugs that are known mainly for reducing triglycerides, increasing high density lipoproteins (HDL), and reducing the fraction of small, dense LDL particles. The results of a Cochrane Collaboration study have recently been published on their efficacy and safety in the secondary prevention of severe cardiovascular accidents, including coronary and cerebrovascular disease. The study included randomised clinical trials in which the fibrate was compared with placebo or with no treatment. Clinical trials comparing two different fibrates were excluded. The clinical trials evaluated included a total of 16,112 patients (13 trials). The meta-analysis (including all the trials with fibrates) showed evidence of a protective effect of the fibrates compared with placebo as regards a compound objective of non-fatal stroke, non-fatal myocardial infarction, and death of cardiovascular origin (hazard ration of 0.88, with a 95% confidence interval of 0.83–0.94; in 16,064 individuals included in 12 studies). Thus, the results showed, with a moderate level of evidence, that fibrates could be effective in secondary prevention considering a compound objective of non-fatal stroke, non-fatal myocardial infarction, and death of cardiovascular origin.

Los fibratos en la prevención secundaria de la enfermedad cardiovascular (infarto e ictus). Resultados de una revisión sistemática y metaanálisis de la colaboración Cochrane

Fibrates are a group of drugs that are known mainly for reducing triglycerides, increasing high density lipoproteins (HDL), and reducing the fraction of small, dense LDL particles. The results of a Cochrane Collaboration study have recently been published on their efficacy and safety in the secondary prevention of severe cardiovascular accidents, including coronary and cerebrovascular disease. The study included randomised clinical trials in which the fibrate was compared with placebo or with no treatment. Clinical trials comparing two different fibrates were excluded. The clinical trials evaluated included a total of 16,112 patients (13 trials). The meta-analysis (including all the trials with fibrates) showed evidence of a protective effect of the fibrates compared with placebo as regards a compound objective of non-fatal stroke, non-fatal myocardial infarction, and death of cardiovascular origin (hazard ration of 0.88, with a 95% confidence interval of 0.83 to 0.94; in 16,064 individuals included in 12 studies). Thus, the results showed, with a moderate level of evidence, that fibrates could be effective in secondary prevention considering a compound objective of non-fatal stroke, non-fatal myocardial infarction, and death of cardiovascular origin.