Adaptación española de las guías europeas de 2016 sobre prevención de la enfermedad cardiovascular en la práctica clínica / Spanish adaptation of the 2016 European guidelines on cardiovascular disease prevention in clinical practice

Las VI Guías Europeas de Prevención Cardiovascular recomiendan combinar las estrategias poblacional y de alto riesgo, con los cambios de estilo de vida como piedra angular de la prevención, y proponen la función SCORE para cuantificar el riesgo cardiovascular. Esta guía hace más hincapié en las intervenciones específicas de las enfermedades y las condiciones propias de las mujeres, las personas jóvenes y las minorías étnicas. No se recomienda el cribado de aterosclerosis subclínica con técnicas de imagen no invasivas. La guía establece cuatro niveles de riesgo (muy alto, alto, moderado y bajo), con objetivos terapéuticos de control lipídico según el riesgo. La diabetes mellitus confiere un riesgo alto, excepto en sujetos con diabetes tipo 2 con menos de diez años de evolución, sin otros factores de riesgo ni complicaciones, o con diabetes tipo 1 de corta evolución sin complicaciones. La decisión de iniciar el tratamiento farmacológico de la hipertensión arterial dependerá del nivel de presión arterial y del riesgo cardiovascular, teniendo en cuenta la lesión de órganos diana. Siguen sin recomendarse los fármacos antiplaquetarios en prevención primaria por el riesgo de sangrado. La baja adherencia al tratamiento exige simplificar el régimen terapéutico e identificar y combatir sus causas. La guía destaca que los profesionales de la salud pueden ejercer un papel importante en la promoción de intervenciones poblacionales y propone medidas eficaces, tanto a nivel individual como poblacional, para promover una dieta saludable, la práctica de actividad física, el abandono del tabaquismo y la protección contra el abuso de alcohol (AU)

The VI European Guidelines for Cardiovascular Prevention recommend combining population and high-risk strategies with lifestyle changes as a cornerstone of prevention, and propose the SCORE function to quantify cardiovascular risk. The guidelines highlight disease specific interventions, and conditions specific to women, young people and ethnic minorities. Screening for subclinical atherosclerosis with noninvasive imaging techniques is not recommended. The guidelines distinguish four risk levels (very high, high, moderate and low) with therapeutic objectives for lipid control according to risk. Diabetes mellitus confers a high risk, except for subjects with type 2 diabetes with less than ten years of evolution, with no other risk factors or complications, or type 1 diabetes of short evolution without complications. The decision to start pharmacological treatment of arterial hypertension will depend on the blood pressure level and cardiovascular risk, taking into account the lesion of target organs. The guidelines do not recommend antiplatelet drugs in primary prevention because of the increased risk of bleeding. The low adherence to the medication requires simplified therapeutic regimes and identifying and combating its causes. The guidelines highlight the responsibility of health professionals to play an active role in promoting evidence-based interventions at the population level, and propose effective interventions, both at individual and population level, to promote a healthy diet, the practice of physical activity, the cessation of smoking and the protection against alcohol abuse (AU)

Posicionamiento del Comité Español Interdisciplinario de Prevención Cardiovascular y la Sociedad Española de Cardiología en el tratamiento de las dislipemias: divergencia entre las guías europea y estadounidense / Spanish Interdisciplinary Committee for Cardiovascular Disease Prevention and the Spanish Society of Cardiology Position Statement on Dyslipidemia Management. Differences Between the European and American Guidelines

La publicación en EE. UU. de la guía de 2013 de American College of Cardiology/American Heart Association para el tratamiento del colesterol elevado ha tenido gran impacto por el cambio de paradigma que supone. El Comité Español Interdisciplinario de Prevención Cardiovascular y la Sociedad Española de Cardiología han revisado esa guía, en comparación con la vigente guía europea de prevención cardiovascular y de dislipemias. El aspecto más destacable de la guía estadounidense es el abandono de los objetivos de colesterol unido a lipoproteínas de baja densidad, de modo que proponen el tratamiento con estatinas en cuatro grupos de riesgo aumentado. En pacientes con enfermedad cardiovascular establecida, ambas guías conducen a una estrategia terapéutica similar (estatinas potentes, dosis altas). Sin embargo, en prevención primaria, la aplicación de la guía estadounidense supondría tratar con estatinas a un número de personas excesivo, particularmente de edades avanzadas. Abandonar la estrategia según objetivos de colesterol, fuertemente arraigada en la comunidad científica, podría tener un impacto negativo en la práctica clínica y crear cierta confusión e inseguridad entre los profesionales y quizá menos seguimiento y adherencia de los pacientes. Por todo ello, el presente documento reafirma las recomendaciones de la guía europea. Ambas guías tienen aspectos positivos pero, en general y mientras no se resuelvan las dudas planteadas, la guía europea, además de utilizar tablas basadas en la población autóctona, ofrece mensajes más apropiados para el entorno español y previene del posible riesgo de sobretratamiento con estatinas en prevención primaria (AU)

The publication of the 2013 American College of Cardiology/American Heart Association guidelines on the treatment of high blood cholesterol has had a strong impact due to the paradigm shift in its recommendations. The Spanish Interdisciplinary Committee for Cardiovascular Disease Prevention and the Spanish Society of Cardiology reviewed this guideline and compared it with current European guidelines on cardiovascular prevention and dyslipidemia management. The most striking aspect of the American guideline is the elimination of the low-density lipoprotein cholesterol treat-to-target strategy and the adoption of a risk reduction strategy in 4 major statin benefit groups. In patients with established cardiovascular disease, both guidelines recommend a similar therapeutic strategy (high-dose potent statins). However, in primary prevention, the application of the American guidelines would substantially increase the number of persons, particularly older people, receiving statin therapy. The elimination of the cholesterol treat-to-target strategy, so strongly rooted in the scientific community, could have a negative impact on clinical practice, create a certain amount of confusion and uncertainty among professionals, and decrease follow-up and patient adherence. Thus, this article reaffirms the recommendations of the European guidelines. Although both guidelines have positive aspects, doubt remains regarding the concerns outlined above. In addition to using risk charts based on the native population, the messages of the European guideline are more appropriate to the Spanish setting and avoid the possible risk of overtreatment with statins in primary prevention (AU)

[Normal anatomy, anatomical variants, and anomalies of the origin and course of the coronary arteries on multislice CT]. / Anatomía normal, variantes anatómicas y anomalías del origen y trayecto de las arterias coronarias por tomografía computarizada multicorte.

Cardiovascular disease is the leading cause of death in adults in developed countries. Conventional coronary angiography is the technique of choice for the detection of coronary disease; however, this technique is not without complications. Nowadays, a significant proportion of conventional coronary angiography examinations are performed solely for diagnostic purposes. Multislice CT enables noninvasive study of the coronary arteries. This technique involves many professionals from different specialties and is constantly evolving. This article aims to provide an initiation to the fundamentals of multislice CT coronary angiography. We describe the classification of coronary arteries, as well as the normal anatomy, anatomical variants, and anomalies of the origin and course of the coronary arteries in axial images, in maximum intensity reconstructions, and in volumetric reconstructions. We also describe the myocardial segments and their vascularization.

Anatomía normal, variantes anatómicas y anomalías del origen y trayecto de las arterias coronarias por tomografía computarizada multicorte / Normal anatomy, anatomical variants, and anomalies of the origin and course of the coronary arteries on multislice CT

Las enfermedades cardiovasculares constituyen la primera causa de muerte en adultos en los países desarrollados. La técnica de elección para diagnosticar enfermedad coronaria es la coronariografía convencional, un procedimiento no exento de complicaciones. Actualmente, un porcentaje significativo de las exploraciones anuales se realizan únicamente con fines diagnósticos. La tomografía computarizada multicorte (TCMC) permite estudiar las arterias coronarias de forma no invasiva. Se trata de una técnica en continuo desarrollo, que involucra un gran número de profesionales de distintas especialidades. Como aproximación básica inicial a la coronariografía por TCMC en este trabajo se describen la clasificación de las arterias coronarias, la anatomía normal de las arterias coronarias en imágenes axiales, reconstrucciones de proyección de máxima intensidad y reconstrucciones volumétricas, y las variantes anatómicas y las anomalías del origen y trayecto de las arterias coronarias. Se describen, además, los segmentos miocárdicos y su correspondiente vascularización (AU)

Cardiovascular disease is the leading cause of death in adults in developed countries. Conventional coronary angiography is the technique of choice for the detection of coronary disease; however, this technique is not without complications. Nowadays, a significant proportion of conventional coronary angiography examinations are performed solely for diagnostic purposes. Multislice CT enables noninvasive study of the coronary arteries. This technique involves many professionals from different specialties and is constantly evolving. This article aims to provide an initiation to the fundamentals of multislice CT coronary angiography. We describe the classification of coronary arteries, as well as the normal anatomy, anatomical variants, and anomalies of the origin and course of the coronary arteries in axial images, in maximum intensity reconstructions, and in volumetric reconstructions. We also describe the myocardial segments and their vascularization (AU)

Prevalencia de obesidad en los diversos grupos de riesgo vascular en la población laboral de Navarra / Prevalence of obesity in the various vascular risk groups among the working population in Navarre

Objetivos: Conocer la prevalencia de obesidad y su contribución al riesgo cardiovascular global en la población laboral de Navarra.Métodos: Se desarrolló un estudio epidemiológico observacional transversal en una muestra de trabajadores en activo de 22.386 trabajadores afiliados a Mutua Navarra, que acudieron a reconocimiento médico de vigilancia de la salud en el marco de la prevención de riesgos laborales, sobre una población total afiliada de unos 60.000 empleados.Resultados: La mediana (rango intercuartílico) de edad de la muestra fue de 35 (28-45) años. El 52,8% tenían peso normal o bajo, el 35,8% sobrepeso y el 11,4% obesidad. El sobrepeso era más prevalente en los varones y aumentaba en relación con la edad. En los individuos con riesgo calculado según el baremo SCORE ≥ 5, la prevalencia de sobrepeso u obesidad era del 84%.Conclusiones: La mayoría de los individuos laboralmente activos con riesgo cardiovascular alto según el baremo SCORE presentan sobrepeso u obesidad. Se trata, por tanto, del factor de riesgo más prevalente y sobre el que mayor énfasis preventivo debería realizarse en dicho colectivo (AU)

Aims: To assess the prevalence of obesity and its contribution to overall cardiovascular risk among the working population in Navarre.Methods: Cross-sectional observational epidemiologic study in a sample of 22,386 active workers affiliated to Mutua Navarra who attended a Health Survey medical examination within the Labour Risk Prevention programme from among a total affiliated population of some 60,000 employees. Results: The median (interquartile range) age of the sample was 35 (28 – 45) years. Normal or low body weight was recorded in 52.8% of the sample, with 35.8% evidencing overweight and 11.4% frank obesity. Overweight was more evident in males and increased with age. Among individuals with SCORE-calculated risk ≥ 5 the prevalence of overweight and/or obesity was 84%. Conclusions: Most of the occupationally active subjects with a high cardiovascular risk level according to the SCORE scale evidence overweight or frank obesity. This is therefore the most prevalent cardiovascular risk factor, and thus the one upon which the greatest preventive amphasis should be made in this particular population (AU)

Control de los factores de riesgo cardiovascular en el paciente hipertenso con disfunción cardíaca: Atención Primaria frente a Especializada / Cardiovascular risk factors control in hypertensive patients with cardiac dysfunction: Primary or Specialized Care

Introducción. El objetivo del estudio es conocer el grado de control tensional y de los diferentes factores de riesgo cardiovascular en el paciente hipertenso con disfunción cardíaca en función del ámbito asistencial, sea Atención Primaria o Especializada, en España. Material y métodos. Se han reclutado de manera consecutiva 3.984 pacientes hipertensos con disfunción cardíaca (23,2 % desde Atención Primaria). Se han recogido parámetros demográficos y antropométricos, antecedentes cardiovasculares, factores de riesgo, presión arterial, electrocardiograma y ecocardiograma, datos analíticos y tratamiento. Resultados. Los pacientes reclutados desde Atención Primaria tenían una significativa mayor edad (71,46 frente a 68,51 años; p < 0,0001), así como un mayor índice de masa corporal (29,78 frente a 29,46 kg/m2; p < 0,05). En el análisis multivariante se observó un manejo terapéutico diferente entre ambas poblaciones, con un mayor empleo de betabloqueantes, antagonistas del calcio e inhibidores del eje renina-angiotensina en Atención Especializada. En ésta se observó una significativa mayor proporción de pacientes con colesterol HDL < 40 mg/dl, triglicéridos > 150 mg/dl, glucemias elevadas y microalbuminuria. No hubo diferencias en el control de las cifras de presión arterial, con un alto porcentaje de pacientes con valores > 130/80 mmHg (83,7 % en Atención Primaria frente a 85,9 % en Atención Especializada). Conclusiones. El manejo terapéutico del paciente hipertenso con disfunción cardíaca es diferente según el ámbito asistencial analizado. El control de las cifras de presión arterial y sobrepeso en esta población es subóptimo en ambos entornos

Introduction. This study aims to evaluate the degree of blood pressure (BP) and the control of different cardiovascular risk factors in hypertensive patients with cardiac dysfunction, according to the type of health care setting in Spain: Primary or Specialized Care. Material and methods. A total of 3,984 hypertensive patients with cardiac dysfunction were recruited consecutively (23.2 % from Primary Care). Demographic and anthropometric parameters, cardiovascular events, risk factors, BP, electrocardiogram, echocardiogram, laboratory analysis data and treatment were collected. Results. Patients from Primary Care were significantly older (71.46 vs 68.51 years; p < 0.0001), and had higher body mass index (29.78 vs 29.46 kg/m2; p < 0.05). The multivariate analysis showed differences between both groups regarding therapeutic management: beta blockers, calcium channel blockers and renin-angiotensin inhibitors were used more in specialized care vs. Primary Care setting. Patients recruited from specialized care settings showed significantly higher proportion of plasma HDL-cholesterol level < 40 mg/dl, plasma triglyceride level > 150 mg/dl, hyperglycemia and microalbuminuria. There were no differences in BP control between groups, with a very high percentage of patients with values of BP > 130/80 mmHg (83.7 % in Primary Care versus 85.9 % in Specialized Care). Conclusion. Therapeutic management of hypertensive patients with cardiac dysfunction differs according to the health-care setting analyzed. In this population analyzed, both BP and overweight control is suboptimal in both groups

[Prevalence of metabolic syndrome and association with ischemic heart disease in cardiological outpatients]. / Prevalencia de síndrome metabólico y asociación con la cardiopatía isquémica en pacientes cardiológicos ambulatorios.

INTRODUCTION: The metabolic syndrome (MS) is a cluster of cardiovascular risk factors with a common pathological link: insulin resistance. We analyzed its prevalence and its impact for the presence of ischemic heart disease (IHD). METHODS: We recorded data from 1,000 consecutive patients that attended the outpatient clinic of the Department of Cardiology from a tertiary hospital for the first time. The assessment of the metabolic syndrome was made according to the ATP-III. RESULTS: The global prevalence of the MS was 27.3% (95% CI: 25.6-28.9), and increased parallel to age. The highest prevalence of MS was found in patients with diabetes or impaired fasting glucose (70.1%) followed by patients with obesity (58.6%) or hypertension (4.3%). MS conferred higher risk for IHD (OR: 5.5) as compared to diabetes (OR: 3.8). Half of the patients with IHD had MS as well as 90% of the diabetics with ischemic heart disease. MS conferred the highest risk for IHD in patients with obesity (OR: 8.6), hypertriglyceridemia (OR: 6.5), family history of IHD (OR: 5.6), overweight (OR: 5.5) or hypertension (OR: 4.6). CONCLUSIONS: MS is highly prevalent in the patients from a Cardiological outpatient clinic and is an important risk factor for IHD, especially in subjects with obesity.

Prevalencia de síndrome metabólico y asociación con la cardiopatía isquémica en pacientes cardiológicos ambulatorios / Prevalence of metabolic syndrome and association with ischemic heart disease in cardiological outpatients

Introducción. El síndrome metabólico (SM) es una asociación de factores de riesgo cardiovascular con un nexo fisiopatológico común: la resistencia insulínica. Analizamos su prevalencia y su impacto para la presencia de cardiopatía isquémica (CI). Métodos. Se registraron los datos de 1.000 pacientes consecutivos que acudieron por primera vez a la consulta externa de un Servicio de Cardiología de un hospital terciario. El diagnóstico del SM se realizó según los criterios del Adult Treatment Pannel (ATP-III). Resultados. La prevalencia global de SM fue del 27,3% (IC al 95%: 25,6-29,0) y aumentó de forma paralela a la edad. La mayor prevalencia se encontró entre los pacientes con diabetes mellitus o intolerancia hidrocarbonada (70,1%) seguidos de los que tienen obesidad (58,6%) o hipertensión (48,3%). El SM confirió mayor riesgo de CI (odds ratio [OR]: 5,5) que la diabetes (OR: 3,8). La mitad de los pacientes con CI presentaron síndrome metabólico y el 90% de los diabéticos con CI. El SM confiere el mayor riesgo de tener CI en los pacientes con obesidad (OR: 8,6), hipertrigliceridemia (OR: 6,5), antecedentes familiares de CI (OR: 5,6), sobrepeso (OR: 5,5) o hipertensión arterial (OR: 4,6). Conclusiones. El SM es altamente prevalente en los pacientes atendidos en una consulta de Cardiología y es un importante factor de riesgo para la CI, especialmente en los pacientes que tienen obesidad

Introduction. The metabolic syndrome (MS) is a cluster of cardiovascular risk factors with a common pathological link: insulin resistance. We analyzed its prevalence and its impact for the presence of ischemic heart disease (IHD). Methods. We recorded data from 1,000 consecutive patients that attended the outpatient clinic of the Department of Cardiology from a tertiary hospital for the first time. The assessment of the metabolic syndrome was made according to the ATP-III. Results. The global prevalence of the MS was 27.3% (95% CI: 25.6-28.9), and increased parallel to age. The highest prevalence of MS was found in patients with diabetes or impaired fasting glucose (70.1%) followed by patients with obesity (58.6%) or hypertension (4.3%). MS conferred higher risk for IHD (OR: 5.5) as compared to diabetes (OR: 3.8). Half of the patients with IHD had MS as well as 90% of the diabetics with ischemic heart disease. MS conferred the highest risk for IHD in patients with obesity (OR: 8.6), hypertriglyceridemia (OR: 6.5), family history of IHD (OR: 5.6), overweight (OR: 5.5) or hypertension (OR: 4.6). Conclusions. MS is highly prevalent in the patients from a Cardiological outpatient clinic and is an important risk factor for IHD, especially in subjects with obesity

Hipertensión arterial y síndrome metabólico / Hypertension and metabolic syndrome

Las interrelaciones existentes entre hipertensión arterial y el síndrome metabólico obedecen a nexos fisiopatológicos comunes y tienen importantes implicaciones terapéuticas y pronósticas. La obesidad, la resistencia insulínica y las alteraciones de la función renal se encuentran en el centro del sustrato fisiopatológico y deben ser el objetivo al que dirigir todas las estrategias preventivas y terapéuticas

The interrelations between hypertension and the metabolic syndrome are due to common physiopathologic links and have important therapeutic and prognostic implications. Obesity, insulin resistance, and renal dysfunction are in the core of the physiopathologic substrate and must be the main objective for preventive and therapeutical measures

Hipertensión arterial e insuficiencia cardíaca en las consultas de Atención Primaria y de Cardiología en España / Hypertension and heart failure in Primary Care and Cardiology consultations of in Spain

Objetivo del estudio. Analizar los resultados referentes a los pacientes con insuficiencia cardíaca del estudio CARDIOTENS 99, un estudio transversal de la hipertensión arterial asociada a patología cardiovascular realizado sobre 32.051 pacientes atendidos en consultas de Cardiología y de Atención Primaria. Métodos. Se incluyeron prospectivamente los datos demográficos, clínicos, de presión arterial y terapéuticos de todos los pacientes atendidos en un mismo día por 1.159 médicos (21 por ciento cardiólogos; 79 por ciento de Atención Primaria).Resultados. El 4 por ciento del total de 32.051 pacientes tenía insuficiencia cardíaca, representando el 23 por ciento de los pacientes con cardiopatía. La edad media fue de 70,8ñ6,7 años; 53 por ciento mujeres. La hipertensión fue el factor de riesgo más frecuente, apareciendo en el 71 por ciento de los pacientes con insuficiencia cardíaca. La hipertensión fue más frecuente en Atención Primaria (76 por ciento frente a 63 por ciento; p0,05). Los fármacos más usados fueron los diuréticos (63 por ciento). El 44 por ciento de los pacientes con insuficiencia cardíaca tomaba un inhibidor de la enzima conversora de angiotensina y el 14 por ciento tomaban bloqueadores beta. Sólo el 19 por ciento de los hipertensos con insuficiencia cardíaca tenían la presión arterial sistólica bien controlada según las directrices internacionales (<130 mmHg). La proporción de pacientes con presión arterial mayor de 140 mmHg fue superior en los pacientes atendidos por cardiólogos que en los atendidos por Atención Primaria (57 por ciento frente a 47 por ciento; p<0,01).Conclusiones. La insuficiencia cardíaca se asocia con gran frecuencia con la hipertensión arterial. La mayoría de los pacientes con insuficiencia cardíaca tienen un control inadecuado de la presión arterial. En los pacientes atendidos por cardiólogos es más frecuente la cardiopatía isquémica como causa de insuficiencia cardíaca que en los pacientes de Atención Primaria, donde la causa principal es la hipertensión. El empleo de los fármacos recomendados en insuficiencia cardíaca es, en general, muy escaso (AU)

[Hypertension and heart failure in Primary Care and Cardiology consultations of in Spain]. / Hipertensión arterial e insuficiencia cardíaca en las consultas de Atención Primaria y de Cardiología en España.

OBJECTIVE: Analyze the results concerning the heart failure population of CARDIOTENS 99, a cross-sectional study of hypertension associated with cardiovascular disease carried out on 32,051 patients seen in Cardiology and Primary Care consultations. METHODS: In the analysis we included prospectively demographic, clinical, blood pressure, and therapeutic data of all patients seen on a single day by 1,159 physicians (21% cardiologists; 79% Primary Care physicians). RESULTS: 4% of the total sample of 32,051 patient had heart failure, representing 23% of the patients with heart disease. Median age was 70,8 6,7 years; 53% were women. Hypertension was the most frequent risk factor, appearing in 71% of the patients with heart failure. Hypertension was most frequent in Primary Care patients (76% versus 63%; p < 0,01), while ischemic heart disease was most frequent in cardiology patients (38% versus 27%; p < 0,01). Cardiology patients showed a trend for greater use of drugs in comparison with patients seen in primary care consultations but without significant differences (3,39 versus 3,35; p > 0,05). Diuretics were the drugs with greater prescription (63%). 44% patients with heart failure were on an angiotensin-conversing enzyme inhibitor and 14% on beta-adrenergic blockers. Systolic blood pressure was well controlled in only 19% of hypertensive patients with heart failure, according to the international recommendations (< 130 mmHg). The proportion of patients with blood pressure higher than 140 mmHg was superior among the patients seen by cardiologists than between those seen by Primary Care physicians (57% versus 47%; p < 0.01). CONCLUSIONS: Heart failure is often associated with hypertension. Control of blood pressure is inadequate in the majority of patients with heart failure. Ischemic heart disease is a more frequent cause of in the patients seen by cardiologists than in those seen by Primary Care physicians, and hypertension is the leading cause of heart failure in these patients. Prescription of drugs recommended for the treatment of heart failure it is generally very scant.

[The role of diabetes mellitus in cardiac disease in Spain. The CARDIOTENS Study 1999]. / Impacto de la diabetes en las enfermedades cardíacas en España, Estudio CARDIOTENS 1999.

BACKGROUND: We analyse the characteristics of the patients with diabetes and cardiac disease included in the CARDIOTENS 1999 study. PATIENTS AND METHOD: 32,051 outpatients who were seen the same day by 1,159 primary healthcare physicians (79%) and cardiologists (21%) were prospectively registered in a database including demographic and clinical data and therapeutic profile. RESULTS: History of cardiac disease was present in 19% (6,194 patients) of the whole population, and 1,275 of them (20.6%) were diabetics. Hypertension was present in 74% of diabetic patients with cardiac disease. Coronary heart disease (angina pectoris or previous myocardial infarction) was present in 45% of diabetic patients with heart failure. Less than 30% of these patients had blood pressure levels under 130/85 mmHg, as recommended by international guidelines. An LDL-cholesterol level lower than 100 mgrs/dl was observed in only 12% of diabetic patients with coronary heart disease; the mean values of total cholesterol and LDL-cholesterol of these patients were significantly (p < 0.01) higher in those seen by primary healthcare physicians. Less than 40% of diabetic patients with cardiac disease were treated with an angiotensin converting enzyme inhibitor, a therapy which was otherwise used in 50% of diabetic patients with heart failure. A beta-blocker therapy was used in 26% of diabetic patients with coronary heart disease and 39% of them were being treated with statins. CONCLUSIONS: More than 20% of patients with cardiac disease in this study were diabetics. Blood pressure and cholesterol levels recommended by current guidelines were attained in a limited proportion of these patients. The use of drugs with demonstrated prognostic benefit in diabetic patients with heart disease is scarce.

Indicaciones de la cirugía coronaria / Indications of coronary surgery

Tras pasar revista a los condicionantes técnicos y complicaciones de la cirugía coronaria, así como a sus resultados comparativos con la angioplastia, se presentan las indicaciones actuales de la derivación aortocoronaria, resumida de las directrices internacionales al uso. (AU)

[The prevalence of classic cardiovascular risk factors in a working Mediterranean population of 4996 men]. / Prevalencia de los factores de riesgo cardiovascular clásicos en una población laboral mediterránea de 4.996 varones.

AIM OF THE STUDY: To report a cross-sectional study on the incidence of cardiovascular risk factors among 4,996 male workers (mean age = 47 years) at an automobile factory in the Spanish mediterranean region. METHODS: The following parameters were obtained by means of standardized forms, medical visits and laboratory exams: obesity indexes, smoking habits, family history of atherosclerosis, physical activity, blood pressure at rest, abnormal electrocardiogram, total cholesterol, plasma triglycerides, lipidemia, and fasting glucose. The results are presented by age groups and labor categories (manual work or managing activities). RESULTS: Family history was positive in 27.2% of individuals; 43.7% were smokers. A body mass index > or = 30 was presented in 19% of the population, while in 29% blood pressure readings were > or = 140/90 mmHg. Plasma values of triglycerides > or = 200 mg/dl, total cholesterol > or = 220 mg/dl and fasting glucose > or = 110 mg/dl appeared in 16.5%; 35.8% and 8.1% respectively. An abnormal electrocardiogram was presented in 3.1% of the patients. A hundred and twenty individuals (2.4%) presented the triad high blood pressure-smoking-hypercholesterolemia. CONCLUSIONS: a) There is a high level of overweight and obesity; b) high blood pressure has similar prevalence to the general population of same age, and almost doubly prevalent among managers than manual workers; c) smoking and sedentarism were less prevalent than in general population, smoking being more frequent in manual workers; d) lipid levels are very similar to those of Mediterranean populations of same age.

[Therapy with glucose-insulin-potassium reduces the complications in the acute phase of myocardial infarct. Arguments in favor]. / La terapia con glucosa-insulina-potasio reduce las complicaciones en la fase aguda del infarto de miocardio. Argumentos a favor.

Several therapeutic approaches have been proposed for the management of acute myocardial infarction (AMI). In 1961, Sodi-Pallarés presented the Glucose-Insulin-Potassium (GIK) infusion as a valid adjunctive therapy for the treatment of the acute phase. He observed a decrease in mortality which could be explained by some mechanisms such as: arrhythmia prevention, hypoxic cell nutrition, diminution of infarct size and others. Due to the lack of Coronary Care Units at that time, acute myocardial ischemia was considered a high mortality disease. Therefore, the first studies concerning the efficacy of this treatment showed a significant decrease in mortality. After the development of better care and medical attention of AMI patients, and above all after the introduction of fibrinolysis, mortality dramatically diminished. Thus, GIK was considered to give no additional benefit, and its use became restricted to a small number of centers. In this review the physiopathological bases of GIK solution use are given, as well as the results of the main experimental studies and a critical analysis of the scarce clinical studies available. It is concluded that there are enough data to support the use of GIK solution in non-thrombolized AMIs. It could probably also benefit thrombolised ones, although there is no available evidence in this context.

[Study of myocardial viability using single-photon emission computed tomography with 201-thallium and re-injection in 4 series (early and late images]. / Estudio de la viabilidad miocárdica mediante tomografía de emisión de fotón único con talio-201 y reinyección en 4 series (imágenes precoces y tardías).

OBJECTIVE: The present study was designed to determine whether 24-hour imaging after thallium reinjection or imaging obtained shortly after reinjection provides better results regarding reversibility of fixed perfusion defects observed in conventional stress-redistribution imaging. PATIENTS AND METHODS: We studied 24 patients undergoing stress-redistribution thallium tomography with fixed defects (15 exercise, 6 adenosine, 3 dobutamine). All patients had coronary angiography and 17 a history of myocardial infarction. After obtaining the redistribution images, 1 mCi thallium was injected at rest, and images were acquired at 30 minutes and 24 hours after reinjection. The tomograms obtained were divided into 12 segments and analyzed quantitatively. RESULTS: Of the 190 abnormal segments on the stress images, 53 (28%) demonstrated improved thallium uptake on redistribution images and 137 had persistent defects. Shortly after reinjection, 33 (24%) segments had improved thallium uptake and 104 had persistent defects, 29 (28%) of which showed further improvement in the 24-hour study. In patients with myocardial infarction, of the 36 fixed severe defects, 9 (25%) had improved thallium uptake shortly after reinjection, increasing activity from 36 +/- 10% to 53 +/- 8%, and 22 (61%) defects improved at 24 hours, increasing activity from 37 +/- 8% to 56 +/- 6%. Therefore, 13 irreversible segments in the short-term study after reinjection were reversible on 24-hour images. CONCLUSION: These data indicate that 24-hour imaging after thallium reinjection provides better results regarding reversibility of fixed perfusion defects observed in conventional stress-redistribution imaging than imaging obtained shortly after reinjection.

[How to choose and adequate antihypertensive drug depending on the type of the existing heart damage?]. / Cómo se elige el fármaco antihipertensivo adecuado dependiendo de la complicación cardíaca dominante?

The main goal of the treatment for hypertensive vascular disease is to reduce the morbidity and mortality that follow the disease. In the patient with heart disease, the choice of antihypertensive treatment will depend on several factors, all of which must be considered prior to it: type of cardiopathy and complications, pharmacokinetics of the drug-selected and its side effects, interactions with specific treatment for the main heart disease, positive or negative interactions with risk factors and, finally, its prognostic benefits. In the present study we briefly analyze this considerations in relation to different diseases such as ischemic heart disease, ventricular dysfunction (hypertrophy, systolic and diastolic dysfunction), heart rhythm disorders (sinus node dysfunction, supraventricular and ventricular ectopies), vascular pathology (cerebral and peripheral vasculopathy) and risk factors (diabetes, dyslipemia, obesity). Based on this considerations, several recommendations are done in order to choose the best antihypertensive drug in such cardiovascular diseases.

[I. Usefulness of the exertion test and other methods based on the electrocardiogram in chronic ischemic disease]. / I. Utilidad de la prueba de esfuerzo y de otros metodos basados en el electrocardiograma en la cardiopatía isquémica crónica.

Exercise testing still plays an important role in the management of patients with chronic ischemic heart disease, not only in the diagnosis but also in their prognostic and functional evaluation, and in the assessment of effects of the therapy. Moreover, ambulatory electrocardiography, signal averaged electrocardiography and heart rate variability provide useful information for certain groups of patients. This paper reviews the rationale, methodology and indications of the above mentioned procedures applied to chronic ischemic heart disease, with special reference to exercise testing. Recommendations for their use in clinical practice are also made.

[Myocardial perfusion reserve studied by single-photon emission-computed tomography with thallium-201 and a drug stress test with adenosine triphosphate in patients with cardiovascular risk factors]. / Estudio de la reserva de perfusión miocárdica mediante tomografía de emisión de fotón único con talio-201 y estrés farmacológico con adenosina trifosfato en pacientes con factores de riesgo cardiovascular.

INTRODUCTION AND OBJECTIVE: Recent studies have suggested that the evaluation of coronary reserve is a sensitive method in the early detection of vascular alterations before plaques exist, and certainly before clinical detection of atherosclerotic lesions. Single-photon emission-computed tomography (SPECT) with thallium-201 (201Tl) provides a noninvasive tool for evaluating myocardial perfusion reserve. The objective of this study was to measure the myocardial perfusion reserve in two groups of subjects, some with and some without cardiovascular risk factors and in a group of patients with coronary artery disease. METHODS: Seventy-four subjects, divided into three groups, were recruited to assess regional and global myocardial perfusion reserve. The control group consisted of 11 asymptomatic individuals without cardiovascular risk factors. The second group was composed of 49 patients with one or more risk factors. Finally, the third group included 14 patients with coronary artery disease. 201Tl-SPECT at rest and after pharmacological stress with a 7 minute adenosine triphosphate (ATP) infusion (140 micrograms/kg/min) was performed in all patients. ATP minus rest value subtraction was applied in order to obtain the stress data. Relative myocardial perfusion reserve indices were calculated as the ratio between stress and rest values. RESULTS: Global and regional myocardial perfusion reserves of the vascular territories were significantly lower in patients with cardiovascular risk factors than in control subjects (Global: 1.48 +/- 0.19 vs 1.81 +/- 0.08, LAD: 1.52 +/- 0.21 vs 1.85 +/- 0.09, CX: 1.45 +/- 0.2 vs 1.79 +/- 0.86, RCA: 1.47 +/- 0.2 vs 1.79 +/- 0.86) and higher than in patients with coronary artery disease (Global: 1.48 +/- 0.19 vs 1.31 +/- 0.14, LAD: 1.52 +/- 0.21 vs 1.35 +/- 0.15, CX: 1.45 +/- 0.2 vs 1.2 +/- 0.24). Univariate linear regression analysis in a group of 40 patients with high risk lipid profiles revealed a significant negative correlation between myocardial perfusion reserve and total cholesterol (r = -0.35; p = 0.01), LDL-cholesterol (r = -0.38; p = 0.036) and LDL/HDL ratio (r = -0.39; p = 0.029). CONCLUSION: Determination of myocardial perfusion reserve with 201Tl-SPECT allows the detection of abnormal vasodilatory response to intravenous ATP in patients with cardiovascular risk factors. These patients have higher reserves than patients with coronary disease, which might suggest an early phase of atherosclerosis.