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)

Recomendaciones preventivas cardiovasculares / Preventive cardiovascular recommendations

No disponible

No disponible

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

Nadie es profeta en su tierra. Réplica de los autores / No-one is a prophet in their own land. Author´s reply

No disponible

Valoración del riesgo cardiovascular. ¿Qué tabla utilizar? / Evaluation of cardiovascular risk. What table to use?

No disponible

Actividades preventivas cardiovasculares en atención primaria / Cardiovascular preventive activities in primary care

No disponible

El riesgo coronario en España y el tratamiento con fármacos hipolipemiantes / Coronary risk in Spain and its treatment with lipid-lowering drugs

No disponible

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.

[Preventive activities in primary health care: identifying the agreement among evidence-based guidelines]. / Actividades preventivas en atención primaria: identificación de áreas de concordancia entre guías de práctica clínica basadas en la evidencia.

BACKGROUND: The purpose of this article is to identify the agreement among evidence-based guidelines about recommendations on preventive activities in low risk adults. METHODS: For which we identified, from the 1996 US Task Force on Preventive Services Guide those preventives activities classified like A or B (recommendation in favour of provision) and like D or E (recommendation against provision), excepting those D and E recommendations based on descriptives studies or expert opinions. Both preventive activities aimed at pregnant women and children and those which are not applicable to our context were excluded. Selected preventive services were compared with the range of age, sex and periodicity in which agreement with the recommendations of American College of Physicians and Canadian Task Force on Preventive Services existed. RESULTS: We found the following agreements. Screening activities. In favour: screening for hypercholesterolemia, hypertension, breast cancer, colorectal cancer, uterine cervix cancer, rubella, visual and hearing impairment and problem drinking. Against: cancer of prostate, lung, bladder and thyroid, and asymptomatic bacteriuria. Counseling activities. In favour: smoking, motor-vehicles injuries, alcohol consumption, unintended pregnancy. Immunizations and quimioprophylaxis. In favour: Vaccines for influenza, tetanus-diphtheria, hepatitis B and measles-mumps-rubella. Postexposure prophylaxis to hepatitis A, hepatitis B, meningococcal, rabies and tetanus. CONCLUSIONS: We see then, that a high degree in agreement among the main guidelines exists; about the preventive activities to perform in Primary Health Services, nevertheless we observed low fulfillment of certain preventive activities in Primary Health Services, different barriers for the accomplishment from these activities were described.

[Recommendations for the control of cholesterolemia in Spain]. / Recomendaciones para el control de la colesterolemia en España.

A number of recommendations are provided regarding the detection, assessment and management in primary and secondary prevention, approaching hypercholesterolaemia from a multifactorial standpoint based on cardiovascular risk. Cardiovascular diseases are the leading cause of death in Spain. The major risks involved are coronary heart disease and cerebrovascular disease. The demographic, health-related and social impact thereof will be increasing over the coming decades. Controlling hypercholesterolaemia, in conjunction with eradicating the smoking habit and controlling hypertension, diabetes, obesity and physical inactivity comprise one of the main strategies for preventing cardiovascular diseases. Breaking down the risk of individuals based on the major cardiovascular risk factors is essential, given that these factors condition the frequency with which these individuals must be monitored and the type and degree of treatment entailed. Based on this breakdown, the priorities have been set for taking steps to prevent cardiovascular disease. In primary prevention, the therapeutic objective in high-risk persons (20% risk or higher or those persons involving two or more risk factors) has been established as LDL-cholesterol < 130 mg/dl. In secondary prevention, drug treatment is indicated when LDL-cholesterol (130 mg/dl and the therapeutic objective is LDL-cholesterol < 100 mg/dl. Those patients having coronary heart disease must be included in secondary prevention programs that will ensure good, constant clinical and risk factor-related control.

[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.