[Assessment of cardiovascular risk in population groups. Comparison of Score system and Framingham in hypertensive patients]. / Valoración de riesgo cardiovascular en grupos de población. Comparación de los sistemas Score y Framingham en pacientes hipertensos.

INTRODUCTION AND OBJECTIVES: Calculation of cardiovascular risk in populations allows for developing and assessing of intervention programs and adapting health resources. While the Framingham System has been used in the past, a group of European researchers have proposed a different method called the Score project. The purpose of this paper is to compare the value of both methods for assessing cardiovascular risk. METHODS: In 6,775 evaluable hypertensive patients distributed over the 17 Spanish autonomous communities (ACs), the 10-year risk of experiencing a coronary event (CR) was calculated using the Framingham equation, while risk of coronary death (RCD) and vascular death (RVD) was calculated using the Score project system, both at baseline and after one year of blood pressure control with amlodipine at the required dose. A comparison was made of the capacity to detect risk differences by both methods between populations with known different risks, and in the same population as a result of blood pressure control. RESULTS: Both the Score and the Framingham systems detected the significant decrease in both CR and RCD or RVD at one year of application of the CORONARIA study protocol. Risk decrease measured by any of the two methods was significant (p < 0.05) overall, by genders, and by ACs. However, the Score System, unlike the Framingham system, could not detect the reported differences in the mortality risk for coronary and vascular disease between the ACs of the North and the South-East parts of Spain.

Valoración de riesgo cardiovascular en grupos de población. Comparación de los sistemas Score y Framingham en pacientes hipertensos / Assessment of cardiovascular risk in population groups. Comparison of Score system and Framingham in hypertensive patients

Introducción y objetivos. El cálculo del riesgo cardiovascular en poblaciones permite desarrollar programas de intervención y adecuar recursos sanitarios. En el pasado se ha utilizado el sistema de Framingham, actualmente un grupo europeo ha propuesto el método Score. Nos proponemos comparar la utilidad de ambos métodos en la valoración del riesgo cardiovascular. Métodos. En 6.775 pacientes hipertensos valorables, procedentes de las 17 Comunidades Autónomas (CC.AA.) de España, se calculó el riesgo de padecer un accidente coronario (RC) en los siguientes 10 años (Framingham) y el riesgo de muerte por enfermedad coronaria (RMC) y por enfermedad vascular (RMV) (Score), tanto en situación basal como tras un año de control de la presión arterial mediante amlodipino. Se comparó la capacidad para detectar diferencias de riesgo entre distintas poblaciones con morbimortalidad cardiovascular diferente y en la misma población como consecuencia del control de la presión arterial. Resultados. Tanto el sistema Score como el de Framingham detectaron el descenso del riesgo de accidente coronario y del de muerte por causa coronaria o vascular, secundario al control de la presión arterial. El descenso del riesgo en cualquiera de los dos métodos fue significativo (p < 0,05) en datos globales, por sexos y por CC.AA. Sin embargo el sistema Score, al contrario que el de Framingham, no fue capaz de detectar las diferencias RMC y RMV, que han sido descritas entre las CC.AA. del norte de España y las del Sureste

Introduction and objectives. Calculation of cardiovascular risk in populations allows for developing and assessing of intervention programs and adapting health resources. While the Framingham System has been used in the past, a group of European researchers have proposed a different method called the Score project. The purpose of this paper is to compare the value of both methods for assessing cardiovascular risk. Methods. In 6,775 evaluable hypertensive patients distributed over the 17 Spanish autonomous communities (ACs), the 10-year risk of experiencing a coronary event (CR) was calculated using the Framingham equation, while risk of coronary death (RCD) and vascular death (RVD) was calculated using the Score project system, both at baseline and after one year of blood pressure control with amlodipine at the required dose. A comparison was made of the capacity to detect risk differences by both methods between populations with known different risks, and in the same population as a result of blood pressure control. Results. Both the Score and the Framingham systems detected the significant decrease in both CR and RCD or RVD at one year of application of the CORONARIA study protocol. Risk decrease measured by any of the two methods was significant (p < 0.05) overall, by genders, and by ACs. However, the Score System, unlike the Framingham system, could not detect the reported differences in the mortality risk for coronary and vascular disease between the ACs of the North and the South-East parts of Spain

[Analysis of the effectiveness and costs of amlodipine on the hospitalizations for cardiovascular events in patients with ischemic cardiopathy]. / Análisis de la eficacia y costes de amlodipino sobre las hospitalizaciones por eventos cardiovasculares en pacientes con cardiopatía isquémica.

OBJECTIVE: Evaluation of the effect of amlodipine on the hospitalizations for cardiovascular events (CVE) and their associated costs in patients with ischemic cardiopathy. METHODS: Data from the multicenter, randomized, double-blind, placebo-controlled PREVENT (Prospective Randomized Evaluation of the Vascular Effects of Norvasc Trial) clinical trial were utilized. A tree-type model of decision was used in order to analyze the incremental costs expected from the treatment with amlodipine with regard to placebo. Hospitalization costs were estimated with regard to the DRG weights of the American Medicare adapted for the costs of average stay available in our environment. RESULTS: Amlodipine reduced significantly the incidence of CVE that required hospitalization in contrast to placebo; 0.60 +/- 1.16 versus 0.77 +/- 1.31 (average +/- SD), p < 0.05. The expected direct expenses due to hospitalizations were higher in the placebo group than in the amlodipine group (saving of 205.76 Euro/patient). Total cost for patient in the amlodipine group was 1,723.52 Euro while in the placebo group was 1,929.28 Euro. When the relation cost/price shifted in the sensitivity analysis from 1.20 to 0.66 (cost of every hospitalization ranged between + 20% and -34%), the saving fluctuated from 330.56 Euro to 0. Accordingly, the breakeven point of the cost/price relation it is 0.66, and above this the treatment with amlodipine still generates savings in regard to its cost. CONCLUSIONS: Amlodipine is cost-effective in the treatment of the patients with ischemic cardiopathy, being able to reduce the hospital costs related to ischemic episodes in this type of patients.

Tratamiento metabólico de la cardiopatía isquémica / Metabolic treatment of ischemic cardiopathy

No disponible

[Coronary risk differences in hypertensive patients of different autonomous communities. CORONARY study]. / Diferencias de riesgo coronario en pacientes hipertensos de las Comunidades Autónomas. Estudio CORONARIA.

OBJECTIVES: Various articles describe the existence of differences in cardiovascular morbidity and mortality between different Spanish Autonomous Communities (SACs). We have intended to know if there are coherent differences in hypertensive patients cardiovascular risk. MATERIAL AND METHODS: 1,720 family physicians distributed in the 17 SACs as the number of inhabitants of each one selected 5 consecutive patients maximum within a period of 2 months, with blood pressure > or = 140/90 mmHg and at least another coronary risk factor. In 6,775 of 7,469 patients (51% males), the risk of a coronary event (CE) in the next 10 years according to Framingham equation and the risk of fatal cardiovascular event (RCV) according to Score formula were calculated. RESULTS: CE calculated in the group of patients in primary prevention (and without diabetes) in northern SACs (Cantábrico) was 18.8%, and 20.5% in south-east SACs (Mediterranean) (p < 0.0001). In addition, CE in secondary prevention was 26.1% in northern SACs and 28.6% in south-east SACs (p < 0.0001). The differences remained upon considering diabetics in primary prevention. There were no significant differences, however, in the risk of cardiovascular death (Score) between both areas, being 8.9% in the north and 8.8% in the south-east. CONCLUSIONS: Our study demonstrates that coronary risk is increased in hypertensive populations of south east SACs with respect to SACs of the north and to national average, while the risk of suffering a fatal cardiovascular event is not different.

Seguridad cardiovascular de los inhibidores de la ciclooxigenasa 2 / Cardiovascular safety of ciclooxigenase 2 inhibitors

Los inhibidores de la ciclooxigenasa 2 (celecoxib y rofecoxib) son fármacos antiinflamatorios no esteroideos potentes y con un excelente perfil de seguridad cardiovascular. Sin embargo, en un artículo reciente se sugiere que estos fármacos podrían presentar un incremento del riesgo de complicaciones cardiovasculares tromboembólicas. En el presente artículo analizamos los datos disponibles hasta la fecha sobre la seguridad cardiovascular de los inhibidores de la ciclooxigenasa 2 (AU)

Función endotelial y vino tinto / Endothelial function and red wine

La disfunción endotelial se considera esencial en la génesis y desarrollo de las patologías cardiovasculares. Existen estudios que demuestran el efecto beneficioso del vino tinto sobre la funcionalidad del endotelio. Particularmente el extracto de piel de uva ha demostrado mejorar la vasodilatación dependiente del endotelio en diferentes modelos experimentales. Se ha sugerido que los polifenoles que contiene piel de la uva mediante su acción antioxidante protegen la funcionalidad endotelial. El vino blanco, en cuya elaboración se elimina la piel de la uva, tiene un efecto protector del endotelio menor que el vino tinto. El vino tinto además de proteger la capacidad vasodilatadora dependiente del endotelio reduce también la activación plaquetaria probablemente mediante la protección del óxido nítrico (NO). No obstante, el efecto protector del vino tinto sobre la funcionalidad del endotelio no pueda explicarse únicamente a través de la acción antioxidante. En este sentido, la protección de la expresión de la óxido nítrico sintasa endotelial (NOSe) enzima que genera NO en el endotelio se ha demostrado esencial en la prevención de la funcionalidad endotelial. Futuros estudios deberán determinar el efecto del vino tinto sobre la modulación de la expresión de esta NOSe en la protección de la funcionalidad del endotelio y si otras sustancias contenidas en el vino tinto, además de los polifenoles, intervienen en este proceso (AU)

Cómo clasificar la fibrilación auricular de un modo clínicamente útil / as classifying the atrial fibrilation in a way clinically useful

Actualmente existe un renovado interés en lo que concierne a la fibrilación auricular (FA), avalado por el gran número de publicaciones dedicadas a su estudio y tratamiento, pero en ellas se emplean distintas nomenclaturas para referirse a un mismo tipo de FA o se la define de forma diferente, lo que crea un estado de confusión en la comunidad científica. Además, la FA adopta múltiples formas de presentación clínica, por lo que hay muchas clasificaciones posibles de la misma, lo que hace que no se disponga de una clasificación y nomenclatura acordadas para referirse a sus formas de presentación, y por tanto existe la necesidad de una clasificación sistemática, que sea clínicamente útil, que emplee una nomenclatura uniforme y que, a su vez, clasifique los distintos subtipos de pacientes en orden a un manejo terapéutico específico. El propósito del presente artículo es revisar el estado actual de las clasificaciones de la FA para ayudar al cardiólogo clínico a encuadrar, de la forma más científica y didáctica posible, las distintas maneras de presentarse la FA que observa en su quehacer diario (AU)

¿Es eficaz la trimetazidina en el aturdimiento miocárdico? Estudio experimental en un modelo canino / Is trimetazidine effective in myocardial stunning? An experimental study in dogs

Objetivos. El objetivo del presente estudio fue evaluar la acción de la trimetazidina (TMZ), un fármaco antiisquémico, en el deterioro de la función sistólica que se produce en el miocardio sometido a isquemias breves y repetidas. Métodos. Se han analizado 12 perros mestizos de ambos sexos, randomizados a tratamiento con TMZ durante 7 días (grupo TMZ) o a tratamiento con placebo (grupo control). Se ha realizado un protocolo isquémico consistente en 20 obstrucciones completas de la arteria coronaria descendente anterior de 2 minutos de duración y separadas de 3 minutos de reperfusión entre ellas. Las variables analizadas al final de cada período de oclusión y reperfusión han sido: frecuencia cardíaca (FC), presión ventricular izquierda (PVI), dP/dt y las curvas de función regional de la zona isquémica y de una zona testigo (longitud telediastólica, telesistólica y fracción de acortamiento). Resultados. El grupo placebo está formado por 6 perros, con un peso medio de 30,08 kg; el grupo TMZ está constituido por 6 perros, con un peso medio de 24,25 kg. Los parámetros hemodinámicos (FC, PVI y dP/dt) no presentan diferencias significativas entre ambos grupos, con poca variabilidad de sus valores respecto a los basales en los diferentes procesos de isquemia/reperfusión. La fracción de acortamiento de la zona isquémica experimenta una caída, estadísticamente significativa, durante las sucesivas fases de isquemia en ambas series, alcanzando valores de acinesia/discinesia, con recuperación parcial durante las reperfusiones en el grupo placebo (aturdimiento), mientras que en la serie TMZ la recuperación es completa (64 por ciento frente 94 por ciento).Conclusiones. Nuestro estudio indica que la TMZ mejora la recuperación de la contractilidad miocárdica afectada por isquemias/reperfusiones breves y repetidas, limitando la aparición de miocardio aturdido (AU)

[Clinical trials on heart failure]. / Ensayos clínicos en insuficiencia cardíaca.

n 1987 the results of the Consensus study were published, and showed that enalapril, an angiotensin convertor enzyme inhibitor (ACEI), was able to modify the clinical course of the heart failure syndrome thereby reducing mortality. Other ACEI later demonstrated the same effect on the different degrees of symptomatic heart failure, left ventricular dysfunction, myocardial infarction and more recently in diabetic patients. In 1996 studies on the betablockers carvedilol, bisoprolol and metoprolol showed their efficacy in reducing deaths due to progressive heart impairment and sudden death in chronic heart failure. The RALES study showed that small doses of spironolactone also improved the prognosis on this disease. Digital improves the quality of life but not the survival rate. Only amiodarone (among the antiarrhythmics) reduces sudden death. Other drugs and groups of drugs can not be considered for chronic outpatient treatment of heart failure. Multicenter trials make it possible to obtain scientific evidence for establishing rational treatments. Many groups of patients such as women, elderly people and the more severe cases of the disease are often not included in these trials. Occasionally, multicenter trials are badly designed (CIBIS and MCD), which in the case of betablockers, led to a substantial delay in their administration. Other times, as in the ELITE study, the results were badly interpreted. The knowledge obtained from these studies is slow in reaching patients, with few patients taking betablockers. It is known that most patients do not take the doses found to be effective in multicenter trials.

Cómo mejorar el tratamiento de la insuficiencia cardíaca con una propuesta de formación continuada: improvement of heart failure / How to improve therapy of heart failure with a proposal of continued training. Improvement of Heart Failure

El conocimiento de la insuficiencia cardíaca, así como su diagnóstico y tratamiento, han sufrido cambios profundos en la última década. En este informe se revisan las recomendaciones actuales para el diagnóstico y tratamiento tanto de medidas no farmacológicas como farmacológicas.Hoy se sabe que los médicos pueden intervenir para retrasar en gran medida e incluso invertir el curso de lo que antes se consideraba una enfermedad evolutiva mortal inevitable. La gran prevalencia de insuficiencia cardíaca en las poblaciones envejecidas de Occidente compromete cada vez más la atención hospitalaria aguda de los pacientes menos graves, de ahí la necesidad de potenciar los medios y los conocimientos para el tratamiento de estos pacientes en Atención Primaria.La complejidad relativa del diagnóstico y el tratamiento de la insuficiencia cardíaca constituye un reto considerable para el médico de Atención Primaria. Para determinar el grado en que la comunidad médica ha asumido los cambios recientes en la práctica especializada, un grupo de cardiólogos está llevando a cabo una iniciativa denominada "Improvement of Heart Failure" (Mejoría de la Insuficiencia Cardíaca), patrocinada por Servier Internacional. Basándose en los datos aportados por 1.000 médicos de Atención Primaria sobre 10.000 pacientes de diez países europeos: a) se comparará la percepción teórica de los médicos de Atención Primaria sobre el tratamiento de la insuficiencia cardíaca con el ejercicio real de la profesión; b) se desarrollarán programas educativos según las necesidades identificadas y c) se auditarán los efectos de estos programas y de toda la iniciativa en la práctica clínica. (AU)

[Clinical practice guidelines of the Spanish Society of Cardiology on stable angina]. / Guías de práctica clínica de la Sociedad Española de Cardiología en la angina estable.

Stable angina pectoris is the most common clinical manifestation of chronic ischemic heart disease, the prognosis of which depends on many factors. The authors have analyzed the incidence, evolution and prognosis of this problem in Spain and have reviewed the methods to determine the diagnosis and degree of clinical severity. A careful clinical history, an electrocardiogram, and the evaluation of the severity of the ischemia and left ventricle systolic function are, in most cases, useful to determine the degree of disease severity and establish the prognosis. In other cases, more sophisticated or complex diagnostic techniques such as perfusion tests, stress echocardiography and lastly coronary arteriography, which is the only method currently available to study coronary anatomy are required to carry out an adequate study of the patient. At present, the therapeutic arsenal for the treatment of ischemic coronary disease is extensive, from both a pharmacological and revascularization point of view. Nonetheless it is essential to carry out aggressive therapy to control the risk factors. The decision as to the type of treatment required mainly depends on the severity of the ischemia and in the case of revascularization, on the clinical and anatomical factors as well as on the preferences of the patient and the experience and results of the medical-surgical group involved in the therapy of these patients.

The Euro Heart Failure Survey of the EUROHEART survey programme. A survey on the quality of care among patients with heart failure in Europe. The Study Group on Diagnosis of the Working Group on Heart Failure of the European Society of Cardiology. The Medicines Evaluation Group Centre for Health Economics University of York.

BACKGROUND: The EUROHEART programme is a rolling programme of cardiovascular surveys among the member nations of the European Society of Cardiology (ESC). These surveys will provide information on the nature of cardiovascular disease and its management. This manuscript describes a survey into the nature and management of heart failure. AIMS: The EuroHeart Failure survey aims to describe the quality of hospital care, diagnostic and therapeutic, for patients with suspected or confirmed heart failure in ESC member countries. Patients will be interviewed subsequent to hospital discharge to assess their understanding of their condition, side effects from and their compliance with therapy and their satisfaction with the management for heart failure. The quality of management will be judged against the recommendations contained in the ESC guidelines on diagnosis and treatment of heart failure. Outcome will be further assessed by repeat interviews in 6-12 months time. A further survey of heart failure in 2001/2002 is also planned. METHODS: A prospective survey of all deaths and discharges from medical (cardiology, internal medicine and geriatric medicine) and cardiac surgical wards to identify patients with heart failure, suspected or confirmed. Approximately 70 hospital clusters, comprising two to six hospitals in each cluster, in 24 member countries of the ESC are conducting the study. At the time of writing, approximately 30000 deaths and discharges have been screened and approximately 4000 patients have been enrolled. CONCLUSIONS: The EuroHeart Survey will allow actual practice to be compared to ESC guidelines on the diagnosis and treatment of heart failure. The surveys and guidelines should prove mutually informative. The main EuroHeart Failure project will be completed by late 2000. However, new centres volunteering to participate in the study (contact corresponding author) may be accepted providing they have the necessary research personnel and provided funding can be agreed for statistical support and administration.

[Guideline for the education of the specialist in cardiology in Spain. Comisión Nacional de la Especialidad de Cardiología]. / Guía de formación del especialista en cardiología en España. Comisión Nacional de la Especialidad de Cardiología.

This article presents the program for training in cardiology. The document was elaborated by the National Committee of the Specialty of Cardiology, from the Ministry of Health and Ministry of Education, and describes the theoretical and practical aspects of training in cardiology prevailing at present in Spain.

[Ischemic preconditioning. Is it always a beneficial phenomenon?]. / Precondicionamiento isquémico. Es siempre un fenómeno beneficioso?

INTRODUCTION AND OBJECTIVES: Hearts exposed to reversible ischemia stand a subsequent prolonged episode of coronary artery occlusion (ischemic preconditioning) better. The reduction of infarct size by means of preconditioning has been amply demonstrated, but the relationship between preconditioning and contractile function remains less well defined. In this study we assess the effect of a later ischemia on the regional contractility in a stunned-preconditioned myocardium. METHODS: We analyze the shortening fraction in the ischemic (dependent on the left anterior descending coronary artery), periischemic and control zone (dependent on the left circumflex coronary artery), using chronic implants of ultrasonic crystals in 17 adult mongrel dogs. In the control series, we quantified the effects of partial (30-60% reduction of coronary flow from the basal) and transitory (15 minutes) ischemic episode in the regional myocardial function in a "virgin" myocardium. In two other series, the myocardium was previously stunned-preconditioned through brief and repeated ischemias. Afterwards, at 5th day (series B) and at 15th day (series C), the dogs were subjected to ischemic episode similar to control ones. RESULTS: After comparing the results with the control series, we observed that the shortening fraction of the ischemic zone was decreased by 107% (p < 0.01) during partial ischemic episode when it was induced on the 5th day of the stunning-preconditioning (series B). CONCLUSIONS: In dogs, the brief and repeated episodes of ischemia could condition the contractile function so that a later partial and transitory reduction of coronary flow could induce a severe affectation of contractility expressed as a diskinetic area.

Long-term results of the Spanish trial on treatment and survival of patients with predominantly mild heart failure.

A randomized open-label clinical trial was conducted to determine whether mortality, readmission, or quality of life differed between heart failure patients managed with captopril plus diuretics and those with digoxin plus diuretics. A total of 345 heart failure patients in New York Heart Association functional classes 2 and 3 without atrial fibrillation, dyspnea of bronchopulmonary origin, or hypertension not controlled with diuretics was randomized for digoxin (n = 175) or captopril (n = 170) treatment and followed up for a median of 4.5 years. Socioeconomic, demographic, electrocardiographic, echocardiographic, spirometric, and chest radiograph data were obtained at the initial examination. In a random sample of half the patients, ergometric, echocardiographic, and Holter records were obtained at entry and at 3 and 18 months. Patients were followed up for > or = 3 years. The end points were mortality, hospitalization for cardiac events, deterioration in quality of life, worsening of functional class, and need for digoxin or captopril in the captopril and digoxin groups, respectively. The trial had to be terminated prematurely owing to the difficulty in finding candidates free of angiotensin-converting enzyme (ACE)-inhibitor treatment. Baseline patient characteristics were similar in both groups. From the clinical point of view, only the 48-month mortality was relevantly lower (20.9 vs. 31.9%, respectively) among patients treated with captopril than that in those receiving digoxin (log rank test, p = 0.07). No statistically or clinically relevant differences were found in other end points or adverse effects. The results suggest but do not confirm the hypothesis that captopril treatment in mild to moderate heart failure might provide better long-term survival than digoxin.