Víctor López García-Aranda

Marcadores de inflamación y estratificación de riesgo en pacientes con síndrome coronario agudo: diseño del estudio SIESTA (Systemic Inflammation Evaluation in patients with non-ST segment elevation Acute coronary syndromes)

Introduccion y objetivos A pesar de que se conoce el valor pronostico de varios marcadores de inflamacion en el sindrome coronario agudo sin elevacion del segmento ST (SCASEST), aun se ignora que subconjunto de estos proporciona mejor informacion y que grado de asociacion existe entre ellos. El objetivo del estudio SIESTA es establecer el valor pronostico de la proteina C reactiva, fibrinogeno, neopterina, interleucinas 6, 8, 10 y 18, factor de necrosis tumoral, e-selectina, endotelina 1, factor tisular, molecula de adhesion celular vascular-1 (VCAM-1) e intercelular-1 (ICAM-1), proteina plasmatica-A asociada al embarazo (PAPP-A), peptido natriuretico ventricular (tipo B), troponina I o T, leucocitos e isoforma MB de la creatinfosfocinasa (CK-MB), en pacientes con SCASEST. Pacientes y metodo SIESTA es un estudio prospectivo, multicentrico, que incluira a pacientes que hayan presentado dolor toracico sugestivo de sindrome coronario agudo en las ultimas 48 h y alguna de las siguientes condiciones: signos electrocardiograficos de isquemia miocardica, enfermedad vascular documentada o elevacion de la concentracion de troponinas. Se realizara un seguimiento clinico durante un ano, con determinaciones hematologicas y bioquimicas en el momento del ingreso, del alta, y a los 30, 180 y 365 dias. Se validaran las escalas TIMI (Thrombolysis In Myocardial Infarction) y PEPA (Proyecto de Estudio del Pronostico de la Angina). La variable principal estara compuesta de muerte por cualquier causa, muerte de origen cardiaco, infarto de miocardio no letal y angina inestable que requiera hospitalizacion o revascularizacion urgente. La evaluacion individual de cada una de las variables se considerara como objetivo secundario. Este estudio ofrecera valiosa informacion prospectiva acerca del valor pronostico de un importante numero de marcadores inflamatorios en pacientes de origen mediterraneo asistidos en la practica medica habitual.

Disfunción eréctil como marcador de vasculopatía en la diabetes mellitus tipo 2 en España. Estudio DIVA

BACKGROUND AND OBJECTIVES Erectile dysfunction (ED) is a sign of vascular disease in type 2 diabetic patients. The present subanalysis of the DIVA Registry, whose main objective was to estimate the prevalence of clinical vascular disorder and silent vascular disorder, as well as risk factors in type 2 diabetic patients treated in Spain, aims to analyze the relationship between those data and the prevalence of ED in these patients. PATIENTS AND METHODS A total of 2444 type 2 diabetic patients (56% male; mean age 65.2 years) attended by 387 cardiologists and endocrinologists at ambulatory care were included. RESULTS Coronary heart disease was present in 37% of the patients, cerebrovascular disease in 12%, and peripheral arterial disease in 13%. Forty percent of male patients had ED (according to the IIEF criteria), although in this group, as compared to those patients without ED, the prevalence of cardiovascular disease and signs of subclinical vascular disorder (microalbuminuria and abnormal ankle/brachial index (ABI)) was higher. The only independent predictor of ED was left ventricular hypertrophy (OR 5.2; 95% CI: 1.1-24.1; P=.03), with the ABI <0,9 being of borderline significance (OR 5.9; 95% CI: 0.9-39.9; P=.06). Poor glycemic and lipemic control (P<.05 in both cases) as well as cerebrovascular and peripheral arterial disease (P<.01 in both cases) and renal dysfunction (P<.001) were all more frequent among patients with severe ED. CONCLUSIONS Forty percent of diabetic patients suffer from ED. The results of this study suggest that ED may be considered as an atherosclerosis marker and could be included in algorithms for risk stratification and subclinical vascular disorder detection.

Lentos avances en el control del tabaquismo involuntario

El tabaquismo pasivo consiste en la exposicion involuntaria de las personas que no fuman al humo ambiental de tabaco (HAT), ya sea en el hogar, en el trabajo o en lugares publicos en general. Los datos provenientes de encuestas poblacionales indican un retroceso en el consumo de tabaco en nuestro pais tanto en varones como en mujeres (el 39,2% de los varones y el 24,7% de las mujeres en 2001, frente al 31,6 y el 21,5%, respectivamente, en la Encuesta Nacional de Salud [ENS] de 2006)1. El tabaquismo ha pasado de ser una conducta considerada socialmente aceptable a constituir un problema de salud publica que no solo alcanza a quienes fuman, sino que perjudica al espectador inocente que se convierte en fumador pasivo. El tabaquismo activo es, en muchos casos, el unico factor de riesgo cardiovascular encontrado en los infartos de pacientes menores de 45 anos, y afecta a un 76-91% de esta poblacion2. Tambien esta claro, y asi lo demuestra un estudio de casos y controles, que dejar de fumar reduce la mortalidad coronaria y seguir fumando tras un primer infarto condiciona un riesgo de padecer otro nuevo evento coronario 3 veces mayor que el de quienes dejan de fumar. Cuando el paciente consigue dejar de fumar gracias a los programas de prevencion secundaria, su riesgo se ve igualado con el de los no fumadores antes del primer infarto3. Estos datos han potenciado los programas de prevencion secundaria que se situan en la actualidad como uno de los principales pilares de la cardiologia clinica4. Conseguir una menor exposicion al HAT en pacientes coronarios ex fumadores aseguraria dos objetivos: mantener la abstinencia al encontrar ambientes libres del tentador humo y en segundo lugar disminuir los efectos cardiovasculares derivados de dicha exposicion involuntaria. Lentos avances en el control del tabaquismo involuntario Victor Lopez Garcia-Arandaa y Manuel Almendro Deliab

Slow Progress in Controlling Second-Hand Smoking

Passive smoking is defined as involuntary exposure to environmental tobacco smoke (ETS) by non-smokers at home, at work or in public places in general. Data from population surveys indicate a drop in tobacco use in Spain in men and women (39.2% among men and 24.7% among women in 2001 vs 31.6% and 21.5%, respectively, in the Spanish National Health Survey [NHS] of 2006). 1 Smoking has changed from being behavior considered socially acceptable to one that causes a public health problem not only for smokers, but also for the innocent bystander who becomes a passive smoker. In many cases, active smoking is the only cardiovascular risk factor found in patients with myocardial infarction under 45 years, and affects 76%-91% of this population. 2 It is also clear, and demonstrated by a case-control study, that quitting smoking reduces coronary mortality and continuing to smoke after a first infarction increases the risk of suffering a new coronary event that is 3 times greater than that among those who quit smoking. When the patient succeeds in quitting smoking after following a secondary prevention program, risk becomes equal to that of non-smokers before the first infarction. 3 These data have strengthened secondary prevention programs which are currently one of the main pillars of clinical cardiology. 4 Achieving less exposure to ETS in coronary patients who formerly smoked would fulfill 2 aims: first, abstinence would be maintained by there being more environments that were free from smoke and its temptation; and second, the impact on the cardiovascular system due to such involuntary exposure would be reduced. According to the International Agency for Research on Cancer (IARC) from the World Health Organization (WHO) and the United States Environmental Protection Agency, tobacco smoke is a class A carcinogen, which

Diabetes Mellitus in Clinical Cardiology in Spain. Survey by the Working Group on the Heart and Diabetes Regarding the Importance of Diabetes Mellitus in Relation With Other Cardiovascular Diseases

Introduction and objectives Diabetes mellitus has been defined as a cardiovascular disease of metabolic origin. This article reports the results of a survey of cardiologists regarding their knowledge about this disease and their management of patients with diabetes in daily practice. Methods A survey was mailed to all 1840 cardiologists who were members of the Spanish Society of Cardiology, and responses were returned by 348 (18.9%). The survey consisted of 16 questions dealing with organizational and practical aspects of cardiological management for patients with diabetes. Results The creation of a Working Group on the Heart and Diabetes was judged necessary by 90.2% of the responders. Almost two thirds of the members felt their knowledge of diabetes and its treatment was inadequate, and 82.5% declared that cardiologists should be better able to treat patients with diabetes, since between 15% and 30% of the patients they see have this disease. With respect to secondary prevention, 65.8% of the cardiologists felt that medical care is much better for coronary patients than for patients with diabetes. Among the latter, angiotensin-inhibiting drugs, statins and aspirin are used for secondary prevention. Conclusions Because of gaps in the cardiologists knowledge of how to manage diabetes, the high prevalence of diabetes and its unquestionable impact on the cardiovascular system additional clinical training and educational efforts are needed. One potentially useful measure is the creation of a specific Working Group on the Heart and Diabetes.