Consenso de manejo del paciente con diabetes mellitus y patología cardiovascular / Consensus on the management of patients with diabetes mellitus and cardiovascular disease

Este Consenso sale a la luz en medio de una de las peores crisis sanitarias globales de los últimos 100 años. El SARS-CoV-2 y su manifestación clínica, la COVID-19, han provocado una disrupción en cómo médicos y pacientes nos relacionamos. Si bien se trata de una enfermedad infecciosa, una de las características más notables es que su mortalidad se acrecienta en pacientes con enfermedades crónicas no transmisibles y, en particular, con antecedentes de diabetes y enfermedad cardiovascular. En tal contexto, entonces, creemos que cobran más relevancia las recomendaciones vertidas en este documento, que apuntan a identificar y proteger a estos pacientes, al tiempo que se vuelve prioritaria la implementación, más allá de los enunciados, de políticas concretas de prevención cardiometabólica. Metodología: este consenso es el fruto de la voluntad de dos Sociedades Científicas que han reconocido la necesidad de complementar el enfoque sobre una misma problemática: la de los pacientes con diabetes mellitus (DM) y con enfermedad cardiovascular (ECV), o bien que están en riesgo de sufrirla. Tanto la Sociedad Argentina de Cardiología (SAC) como la Sociedad Argentina de Diabetes (SAD) tienen una reconocida trayectoria en la producción de guías de práctica y documentos de consenso, aunque cada una tiene prácticas y culturas de trabajo diferentes. En consecuencia, la primera tarea que se afrontó fue la de acordar, no solamente el temario y el abordaje de los diferentes asuntos, sino también modalidades de trabajo comunes: objetivo general del documento, forma de analizar y evaluar el peso de la información, definir los niveles de evidencia y determinar los grados de recomendación. Se acordó adoptar la modalidad utilizada por la SAC en todos los documentos producidos por el Área de Consensos y Normas, expuestos en el siguiente cuadro: Grado de recomendación • Clase I: condiciones para las cuales hay evidencia y/o acuerdo general en que el tratamiento/procedimiento es beneficioso, útil y eficaz. • Clase II: evidencia conflictiva y/o divergencia de opinión acerca de la utilidad, eficacia del método, procedimiento y/o tratamiento. - IIa: el peso de la evidencia/opinión está a favor de la utilidad/eficacia. - IIb: la utilidad/eficacia está menos establecida. • Clase III: evidencia o acuerdo general que el tratamiento método/procedimiento no es útil/eficaz y en algunos casos puede ser perjudicial. Nivel de evidencia • A: evidencia sólida, proveniente de estudios clínicos aleatorizados o de cohortes con diseño adecuado para alcanzar conclusiones estadísticamente conectadas y biológicamente significativas. • B: datos procedentes de un único ensayo clínico aleatorizado o de grandes estudios no aleatorizados. • C: consenso de opinión de expertos. Los expertos que colaboraron en la redacción del Consenso fueron seleccionados e invitados a participar con el acuerdo unánime del grupo de Directores y Secretarios pertenecientes a ambas Sociedades Científicas. Se convocó a colegas con reconocida trayectoria en las disciplinas abordadas para el análisis de la evidencia y la redacción de las recomendaciones. Todos los aspectos metodológicos y las recomendaciones finales de este documento fueron definidos por acuerdo entre el grupo de Directores y Secretarios del Consenso. El proceso de consolidación de la información fue lento: desde la decisión de ambas sociedades hasta la redacción de este documento, el campo del manejo de la DM y la ECV sufrió profundas transformaciones que trascienden la aparición de nuevos agentes terapéuticos. Lo que se ha desarrollado es un nuevo modelo de abordaje que es, según las palabras de la Dra. Alicia Elbert, transdisciplinario. Esto ha implicado esperar y poder entender y "procesar" toda la información surgida en estos años. Este documento, que pretende asistir a los médicos en la práctica diaria, ha intentado adoptar esa nueva mirada integradora

This Consensus comes to light in the midst of one of the worst global health crises in the last 100 years. SARS-CoV-2 and its clinical manifestation, COVID-19, have caused a disruption in how doctors and patients interact. Although it is an infectious disease, one of the most notable characteristics is that its mortality increases in patients with chronic non-communicable diseases and, in particular, with a history of diabetes and cardiovascular disease. In this context, then, we believe that the recommendations made in this document, which aim to identify and protect these patients, become more relevant, while the implementation, beyond the statements, of specific cardiometabolic prevention policies becomes a priority. Methodology: this consensus is the result of the will of two Scientific Societies that have recognized the need to complement the focus on the same problem: that of patients with diabetes mellitus (DM) and cardiovascular disease (CVD), or who are at risk to suffer it. Both the Argentine Society of Cardiology (SAC) and the Argentine Society of Diabetes (SAD) have a recognized track record in the production of practice guidelines and consensus documents, although each has different work practices and cultures. Consequently, the first task that was faced was to agree, not only on the agenda and the approach to the different issues, but also on common working methods: general objective of the document, how to analyze and evaluate the weight of the information, define the levels of evidence and determine the degrees of recommendation. It was agreed to adopt the modality used by the SAC in all the documents produced by the Consensus and Standards Area, set out in the following table: Grade of recommendation • Class I: conditions for which there is evidence and/or general agreement that the treatment/procedure is beneficial, useful and effective. • Class II: conflicting evidence and/or divergence of opinion about the usefulness, efficacy of the method, procedure and / or treatment. - IIa: the weight of evidence/opinion is in favor of utility/ efficacy. - IIb: utility/efficacy is less established. • Class III: evidence or general agreement that the treatment method/procedure is not useful/effective and in some cases may be harmful. Level of evidence • A: solid evidence, from randomized clinical studies or from cohorts with adequate design to reach statistically connected and biologically significant conclusions. • B: data from a single randomized clinical trial or large nonrandomized studies. • C: consensus of expert opinión. The experts who collaborated in the drafting of the Consensus were selected and invited to participate with the unanimous agreement of the group of Directors and Secretaries belonging to both Scientific Societies. Colleagues with recognized experience in the disciplines addressed were summoned to analyze the evidence and write the recommendations. All the methodological aspects and the final recommendations of this document were defined by agreement between the group of Directors and Consensus Secretaries. The information consolidation process was slow: from the decision of both companies until the writing of this document, the field of DM and CVD management underwent profound transformations that transcend the appearance of new therapeutic agents. What has been developed is a new approach model that is, in the words of Dr. Alicia Elbert, transdisciplinary. This has implied waiting and being able to understand and "process" all the information that has emerged in these years. This document, which aims to assist physicians in daily practice, has tried to adopt this new integrative perspective

Concordance between two versions of world health organization/international society of hypertension risk prediction chart and framingham risk score among postmenopausal women in a rural area of Bangladesh

Background: Prevention of cardiovascular disease (CVD) among postmenopausal women with limited resource is a great challenge for a country like Bangladesh. Objectives: This study aimed to evaluate the level of agreement among different risk prediction tools to find out the cost-effective and suitable one that can be applied in a low-resource setting. Methods: This was a cross-sectional study conducted from February through December 2016 among 265 postmenopausal women of 40–70 years age. Data were collected from the outpatient department of a rural health-care center situated in the village Karamtola of Gazipur district, Bangladesh. The CVD risk was estimated using the World Health Organization/International Society of Hypertension (WHO/ISH) “with” and “without” cholesterol risk charts and the Framingham Risk Score (FRS). Concordance among the tools was evaluated using Cohen's kappa (?), prevalence-adjusted bias-adjusted kappa (PABAK), and first-order agreement coefficient (AC1). Results: The “without” cholesterol version showed 79% concordance against the “with” cholesterol and 75.4% concordance against the FRS. In between the WHO/ISH risk charts, slight-to-substantial levels of agreement (? = 0.14, PABAK = 0.58, and AC1 = 0.72; P = 0.023) were observed. With FRS, the “without” cholesterol version showed higher agreement (? = 0.38, fair; PABAK = 0.50, moderate; and AC1 = 0.60, moderate; P = 0.000) compared to “with” cholesterol version (? = 0.13, slight; PABAK = 0.30, fair; and AC1 = 0.44, moderate; P = 0.013). Predictability of CVD risk positive (?10%) cases was similar for both the versions of WHO/ISH risk charts. Conclusion: In a low-resource setting, the “without” cholesterol version of WHO/ISH risk chart is a good option to detect and target the population with high CVD risk.

Cardiovascular Risk Assessment among Patients with Hypertension Presenting at a Family Medicine Clinic in Southwest Nigeria

Aims:To determine the 10-year cardiovascular risk (CV) and its association with socio-demographic characteristics of hypertensive patients. Study Design:This was across-sectional study.Place and Durationof Study:Family Medicine Clinic of the University College Hospital, Ibadan, Nigeria, between June 2013 and September 2013.Methodology:We included 345 hypertensive patients (84 men, 261 women) aged 30 years and above with no clinical history suggestive of cardiovascular disease. Data collection was with an interviewer-administered semi-structured questionnaire, physical examination and blood investigation. CV risk was determined by using General Framingham cardiovascular risk profile for use in primary care Results:The mean+SD age of the 345 respondents was 57.4+9.7 years and 75.7% were female. High proportion of the respondents (42.3%) were in the high CV risk category of 10-year risk for cardiovascular disease while 27.0% and 30.7% had intermediate and low CV risk respectively. CV risk was significantly associated with age (p < .001), sex (p < .001), family type (p= .047), level of education (p=.02), employment status (p<.001) and occupational class (p=.007). Logistic regression showed advanced age (OR=0.014, 95% CI =0.002-0.094) and male gender (OR=26.765, 95% CI = 8.802-81.383) as the predictors of high CV risk. Conclusion:The findings show that CV risk assessment should be part of patients’ evaluation by physicians and necessary intervention should be instituted on time in order to reduce the burden of cardiovascular disease in Nigeria.

Cardiovascular Diseases: A 2016 Perspective

A review was made of the current literature on cardiovascular diseases. The following key findings were found: (1) CVDs need to be reduced in Singapore and worldwide. (2) CVD risk assessment tools are population specific – use the FRS modified score for Singapore. (3) New ideas about therapeutic lifestyle change as primary prevention are to take note of the individuals who fail in lifestyle change early and to direct them to alternative strategies; educating patients to reduce sitting time, increasing physical activity, and cardio-respiratory fitness is beneficial; higher protein diets help in creating weight loss and reducing weight regain; trans fats are associated with all-cause mortality, total CHD, and CHD mortality. (4) Paradigm shifts in secondary prevention are: statin treatment intensity recommended in the 2013 ACC/AHA cholesterol treatment guidelines; setting the blood pressure targets for patients with diabetes mellitus to be less than 140/90 mmHg; and noting that the older patient (beyond 70 to 74 years) with diabetes mellitus need to be managed as one would do so with a middle-aged patient. (5) The iCVH model as the 2020 impactful strategy for cardiovascular disease reduction for Americans provides food for thought as a potential Singapore strategy -- Promote in each patient especially the young patient, the simultaneous presence of optimal levels of 4 health behaviours (body mass index, physical activity, nonsmoking status, and diet quality) and reduction of 3 disease factors (total cholesterol, blood pressure, and fasting blood glucose).

A Web-based Fuzzy Inference System Based Tool for Cardiovascular Disease Risk Assessment / Herramienta Fuzzy de Inferencia basada en Web para la evaluación del riesgo vascular

Objective: a Web-based Fuzzy Inference Tool for cardiovascular risk assessment has been developed. The tool makes use of inference rules from evidence-based medicine for membership classification. Methods: the system framework allows adding variables such as gender, age, weight, height, medication intake, and blood pressure, with various types of membership functions based on classification rules. Results: the tool allows health professional to enter patient clinical data and obtain a prediction of cardiovascular risk. The tool can also be later used to predict other types of risks including cognitive and physical disease conditions.

Objetivo: desarrollar una herramienta Fuzzy de Inferencia basada en Web para la evaluación del riesgo cardiovascular. La herramienta hace uso de reglas de inferencia de medicina basada en evidencia para la clasificación de membresía. Métodos: el marco del sistema permite la adición de variables como el género, la edad, el peso, la altura, la ingesta de medicamentos, y la tensión arterial, con varios tipos de funciones de pertenencia basada en reglas de clasificación. Resultados: la herramienta permite a los profesionales de la salud ingresar los datos clínicos del paciente y obtener una predicción del riesgo cardiovascular. La herramienta también puede ser utilizada más adelante para predecir otros tipos de riesgos, incluyendo condiciones de la enfermedad cognitivas y físicas.

Estimación del riesgo cardiovascular y detección de ateromatosis carotídea subclínica en mujeres posmenopáusicas de mediana edad / Estimation of Cardiovascular Risk and Detection of Subclinical Carotid Atheromatosis in Middle-aged Postmenopausal Women

Introducción La incidencia de enfermedad cardiovascular en la mujer aumenta luego de la menopausia.Los puntajes de riesgo tradicionales subestiman el riesgo en la mujer posmenopáusica. El diagnóstico de placa aterosclerótica carotídea (PAC) podría mejorar la estratificación del riesgo. Objetivos 1) Estimar el riesgo cardiovascular en mujeres posmenopáusicas de mediana edad en prevención primaria. 2) Conocer la prevalencia de PAC. 3) Calcular la precisión de los puntajes de riesgo para detectar PAC. Material y métodos Se calcularon el puntaje de Framingham a 10 años (PF10) y el puntaje recomendado por la Organización Mundial de la Salud (POMS), evaluando la concordancia entre ellos. Se determinó la prevalencia de PAC mediante ultrasonido. Se realizó un análisis ROC. Resultados Se incluyeron 334 mujeres (edad 57 ± 5 años). El 96% y el 91% de la población se clasificó como de "riesgo bajo" según el PF10 y el POMS, respectivamente. La concordancia entre los dos puntajes fue regular (kappa 0,31). La prevalencia de PAC fue del 29%. Se observó una correspondencia entre el riesgo estimado por los puntajes y la prevalencia de PAC. Las mujeres con PAC presentaron una prevalencia mayor de hipertensión arterial y tabaquismo, mostrando más frecuentemente un patrón "metabólico" que las mujeres sin PAC. El área bajo la curva del PF10 para detectar PAC fue de 0,79 (IC 95% 0,73-0,84), siendo el punto de corte óptimo = 3%. Conclusiones En esta población clasificada en su mayoría como de riesgo bajo, la prevalencia de PAC fue considerable. Ante un PF10 = 3%, la solicitud de una ecografía carotídea podría optimizar la estratificación del riesgo cardiovascular.

Background Cardiovascular disease in women increases after menopause. Traditional risk scores underestimate the risk in postmeno-pausal women. The diagnosis of carotid atherosclerotic plaque (CAP) could improve risk stratification. Objectives The aim of the study was: 1) To estimate cardiovascular risk in middle-aged postmenopausal women in primary preven-tion. 2) To find CAP prevalence. 3) To assess the precision of risk scores used to detect CAP. Methods The level of agreement between the 10-year Framingham risk score (10-FRS) and the score recommended by the World Health Organization (WHOS) was assessed. Ultrasound was used to determine CAP occurrence. A ROC analysis was performed. Results The study included a total of 334 women with mean age 57 ± 5 years. According to 10-FRS and WHOS, 96% and 91% of the population were respectively classified as "low risk". An adequate level of agreement between both scores was found (kappa 0.31). CAP occurred in 29% of cases. Score estimated risk correlated with CAP prevalence. Women with CAP presented higher incidence of hypertension and smoking, evidencing a more frequent "metabolic" pattern than women without CAP. The area under the curve of 10-FRS to detect CAP was 0.79 (95% CI 0.73-0.84), with an optimal cut-off point = 3%. Conclusions In this population, mostly classified as low risk, there was considerable CAP prevalence. A carotid ultrasound might help to stratify cardiovascular risk when 10-FRS is = 3%.

Risk Assessment for Cardiovascular Diseases in Male Workers: Comparing KOSHA Guidelines and the Framingham Risk Score System / 대한산업의학회지

OBJECTIVES: This study aimed to investigate the 10-year risk of cardiovascular disease (CVD) by Framingham risk score (FRS) who classified as "healthy group" by Korean Occupational Safety and Health Agent (KOSHA)' s cardiovascular risk assessment. METHODS: The subjects of this study were 1,781 male workers in a large steel company. Health status was obtained periodically through medical examinations and questionnaires. We assessed cardiovascular risk using KOSHA guidelines and calculated the 10-year risk of cardiovascular disease using the Framingham risk score for those categorized to the "healthy group" by KOSHA guideline. A closer examination of cardiovascular risk factors was performed in 62 subjects paradoxically placed in the "healthy group" by KOSHA guidelines and the "high-risk group" by FRS. RESULTS: Among the "healthy group" by KOSHA's cardiovascular risk assessment, 230(15.8%) subjects had more than 3 CVD risk factors and 62(4.2%) subjects were high risk group (more than 20%) in 10-years risk of CVD by Framingham risk score. Modifiable risk factors included cigarette smoking (96.8%), high serum total cholesterol (82.3%), high serum triglyceride (66.1%), insufficient physical activity (66.1%), and obesity (58.1%). CONCLUSIONS: Among subjects with normal blood pressure, it seems that KOSHA guidelines underestimate CVD risk, identified by the Framingham risk score. For the effective prevention and management of CVD, modifiable risk factors, such as cigarette smoking, dyslipidemia, and obesity, need to be constructively controlled.

Cardiovascular Risk Assessment of Atherosclerotic Arterial Occlusive Diseases

PURPOSE: Cardiovascular risk assessment of atherosclerotic arterial occlusive diseases is a critical component of preoperative care. Many indexes have been developed to help identify patients at high risk for perioperative cardiac events. We sought to study guideline implementation and clinical outcomes in cardiovascular risk assessment. METHOD: We studied 75 patients who underwent preoperative cardiac risk assessment between 2003 and 2006 at the Kyung Hee University Medical Center. The American College of Cardiology/American Heart Association (ACC/AHA) guidelines were used to stratify the patients. RESULT: The mean age of patients was 67.9 years. When stratified into risk categories according to the ACC/AHA guidelines, 2 patients was high risk group, 51 intermediate risk group, and 22 low risk group. There were 3 perioperative cardiac complications (4.0%) including 2 mortalities (2.7%). There was a trend toward a higher frequency of cardiac complications when there was discordance with the ACC/AHA guidelines, but there was no significant difference (discordance 7.1%, concordance 0%, P=0.251). The guidelines recommended cardiac testing for 44 patients, but 12 patients (27.3%) were tested. The guidelines did not recommend for 31 patients, but additional cardiac tests were done for 10 patients (32.3%) and mainly associated with low risk group. CONCLUSION: Differences between clinician practice and guideline recommendations existed and did not result in a higher frequency of cardiac complications.