Estatinas: eficacia, seguridad e indicaciones / Statins: useful, security and indications

Las estatinas han demostrado que son útiles en la prevención de la enfermedad cardiovascular: infarto de miocardio, ictus, mortalidad cardiovascular y total. Los beneficios del tratamiento se manifiestan sobre todo en pacientes que han padecido una enfermedad cardiovascular o con un riesgo cardiovascular alto. Las dosis mínimas eficaces de las estatinas en la prevención de la enfermedad cardiovascular son: atorvastatina 10 mg/dia, simvastatina 20-40 mg/dia, lovastatina 20-40 mg/dia y pravastatina 40 mg/dia. Estas dosis consiguen un 20% de reducción del cLDL (colesterol de las lipoproteínas de baja densidad) en los ensayos clínicos. La hepatotoxicidad y miotoxicidad son los efectos secundarios más importantes de las estatinas. La elevación de las transaminasas y la aparición de síntomas musculares son la forma de detectarlos. Las estatinas están indicadas para el tratamiento de la enfermedad cardiovascular o en un paciente con riesgo cardiovascular alto cuando el cLDL sea superior a 115 mg/dl

The statins have demonstrated that they are useful in the prevention of the cardiovascular illness: myocardial infarction, stroke, cardiovascular and total mortality. The benefits of the treatment are manifested mainly in patients that have suffered a cardiovascular illness or with a high cardiovascular risk. The effective minimum dose daily of the statins in the prevention of the cardiovascular illness is: atorvastatin 10 mg, simvastatin 20-40 mg, lovastatin 20- 40 mg and pravastatin 40 mg. These doses get 20% of reduction of the cLDL (cholesterol of the lipoproteins of low density) in the randomised clinical trials. The hepatic and muscular effects are the most important adverse events. The elevation of the AST or ALT and the appearance of muscular symptoms are the form of detecting them. The treatment with statins is suitable for patients with cardiovascular illness or with high cardiovascular risk when the cLDL is superior to 115 mg/dl

Efectividad de la prevención cardiovascular en atención primaria / Effectiveness of cardiovascular prevention in primary care

Objetivos. Evaluar la modificación de los factores de riesgo y del riesgo coronario en adultos (14-75 años) tras un período de entre 1 y 5 años de ser incluidos en el PAPPS. Diseño. Estudio multicéntrico de intervención sin asignación aleatoria antesdespués. Emplazamiento. Atención primaria. Participantes. Se evalúa a los pacientes incluidos en el PAPPS de 3 centros salud, 634 seguidos durante 5 años, 890 durante 4 años, 1.605 durante 3 años y 2.829 durante 2 años. Intervenciones. Consejo mínimo para abandonar tabaco y consumo excesivo de alcohol, medidas educacionales y farmacológicas para reducir colesterol y presión arterial. Mediciones principales. Toma de la presión arterial, colesterol, peso, consumo tabaco y alcohol. En el subgrupo 30-75 años determinación del riesgo coronario. Estas variables se determinaron al inicio y al final de los distintos períodos de seguimiento. Resultados. La reducción del riesgo coronario fue entre el 0,2 y el 0,3 por ciento, de la presión arterial sistólica entre 0,4 y 0,9 mmHg, y de la diastólica entre 0,3 y 0,7 mmHg, del colesterol entre 0,5 y 2,5 mg/dl, del porcentaje de fumadores entre el 0,3 y el 2,8 por ciento y del consumo excesivo de alcohol entre el 0,2 y el 1 por ciento. Conclusiones. Escasa repercusión de las intervenciones realizadas para reducir el riesgo coronario o los factores de riesgo en la población total. La utilidad principal de los programas de prevención cardiovascular y multifactoriales estribaría en la detección de los pacientes de alto riesgo para, posteriormente, intervenir sobre ellos (AU)

[Effectiveness of cardiovascular prevention in primary care]. / Efectividad de la prevención cardiovascular en atención primaria.

OBJECTIVES: To evaluate the modification of risk factors and of coronary risk (CR) in adults (14-75 years old) after a period of 1 to 5 years in the PAPPS (special prevention programme). DESIGN: Multi-centre intervention study with no before-and-after random allocation. SETTING: Primary care. PARTICIPANTS: Patients included in the PAPPS at 3 health centres, 634 monitored for five years, 890 for four years, 1605 for 3 years and 2829 for 2 years, were evaluated.Interventions. Minimum counselling to give up tobacco and over-consumption of alcohol, and educational and pharmacological measures to reduce cholesterol and blood pressure. MAIN MEASUREMENTS: Recording of blood pressure, cholesterol, weight, and tobacco and alcohol consumption. CR was determined in the sub-group of 30-75 years old. These variables were determined at the start and end of the various monitoring periods. RESULTS: CR was reduced by between 0.2 and 0.3%; systolic blood pressure, by between 0.4 and 0.9 mmHg; diastolic pressure, by between 0.3 and 0.7 mmHg; cholesterol, by between 0.5 and 2.5 mg/dl; percentage of smokers, by between 0.3 and 2.8%; and over-consumption of alcohol, by between 0.2 and 1%. CONCLUSIONS: Scant success of the interventions to reduce CR and risk factors in the population as a whole. The main use of cardiovascular prevention programmes with many factors resides in detecting high-risk patients for subsequent intervention.

[The risk of suffering a cardiovascular disease in the making of decisions. From evidence to the clinic]. / El riesgo de sufrir una enfermedad cardiovascular en la toma de decisiones. De la evidencia a la clínica.

The importance of the atherosclerotic cardiovascular disease (which is multifactorial in its origin) in Spain and the need for and efficient management of the treatments make especially useful to consider the overall cardiovascular risk of the individual in order to take clinical decisions towards the follow-up and treatment of the disease. Current evidence from cardiovascular risk situations supports this strategy of considering all the risk factors as a whole instead of evaluating each of them separately. This paper tries to revalidate this approach with the most reliable of the available evidence from case studies. The global cardiovascular risk is suggested to be evaluated by a risk chart based on Framingham's study. A revision of the clinical priorities in cardiovascular disease prevention is made. Finally, some views on ordinary clinical cases are given, suggesting the treatment based on a global risk evaluation, considering and opposing evidence and recommended guidelines from the most common Spanish guides on prevention of cardiovascular diseases, evaluating the potential benefit of treatment for the patient, and making a clinical decision.

[Calculating coronary risk for patients included in the Preventive Activities and Health Promotion Program]. / Cálculo del riesgo coronario de los pacientes incluidos en el Programa de Actividades Preventivas y de Promoción de la Salud.

OBJECTIVE: To calculate coronary risk (CR), or the probability of suffering a "coronary event" within five years, for patients between 35 and 65 included in the Preventive Activities and Health Promotion Programme (PAHPP). DESIGN: A descriptive crossover study. SETTING: Manises Health Centre, Valencia. PATIENTS: All the patients between 35 and 65 included in the PAHPP, 431 in all, were selected. For the coronary risk calculation the coefficients and constants of the Dundee Coronary Risk-Disk were used, the variables being gender, systolic arterial pressure, the number of cigarettes and overall cholesterol. MEASUREMENTS AND MAIN RESULTS: Average CR was 5.1% (CI = 4.7-5.4) "coronary events" in five years. CR was less (p = 0.01) in patients aged between 55 and 65. The risk factors (tobacco dependency, arterial Hypertension and Hypercholesterolaemia) were presented in association in 37.7% of cases. The highest CR was found when the three risk factors were presented in association (CR = 14%), when tobacco dependency was associated with hypercholesterolaemia (CR = 10.4%) or with arterial hypertension (CR = 6.4%). CONCLUSIONS: CR can be calculated on the basis of data obtained by PAHPP: The risk factors are frequently presented in association and therefore require multifactorial vision for a correct assessment. Tobacco dependency is the factor which, whether by itself or in association, has most impact on the determination of modifiable CR.