Situación actual de los anticoagulantes orales de acción directa en atención primaria de España. Posicionamiento de SEMERGEN en 2023 / Current situation of direct oral anticoagulants in primary care in Spain: Positioning of SEMERGEN in 2023

La anticoagulación oral es clave para disminuir el riesgo de ictus en la fibrilación auricular. Aunque clásicamente los antagonistas de la vitaminaK (AVK) se han empleado para este fin, han sido ampliamente superados por los anticoagulantes orales de acción directa (ACOD), como lo demuestran las evidencias provenientes de los ensayos clínicos, estudios de vida real y poblacionales. De hecho, todas las guías de práctica clínica recomiendan su uso de manera preferencial sobre los AVK. Sin embargo, en España la prescripción de los ACOD está subordinada a un visado de inspección que recoge las condiciones clínicas definidas en el Informe de Posicionamiento Terapéutico de la Agencia Española del Medicamento, y que todavía impone importantes restricciones a su uso, limitando los beneficios del empleo de los ACOD en los pacientes con fibrilación auricular (FA), y generando además inequidades entre las diferentes comunidades autónomas. De hecho, el empleo de los ACOD en España es muy inferior a los países de nuestro entorno. Esto ha provocado que en otros países ha disminuido la incidencia de ictus isquémico a nivel poblacional, junto con una reducción del coste por paciente con FA, pero en España este descenso ha sido discreto. Por todo ello, y en aras de la sostenibilidad del sistema sanitario, pedimos la eliminación del visado para que los ACOD se puedan prescribir de acuerdo a las recomendaciones realizadas por las guías. Además, también apostamos por el refuerzo de la formación y de las decisiones consensuadas con el paciente, siendo el médico de familia un actor clave en la protección del paciente con FA.(AU)

Oral anticoagulation is the key to reduce the risk of stroke in atrial fibrillation. Although vitaminK antagonists (VKA) have classically been used for this purpose, they have been largely overcome by direct oral anticoagulants (DOAC), as demonstrated by evidence from clinical trials, real-life and population studies. In fact, all clinical practice guidelines recommend their use preferentially over VKA. However, in Spain the prescription of DOAC is subordinated to an inspection visa that includes the clinical conditions defined in the Therapeutic Positioning Report of the Spanish Medicines Agency, and that still imposes important restrictions on their use, limiting the benefits of using DOACs in patients with atrial fibrillation (AF), and also generating inequalities between the different autonomous communities. In fact, the use of DOAC in Spain is much lower than that observed in neighboring countries. This has made that while in other countries the incidence of ischemic stroke has decreased at the population level, along with a reduction in the cost per patient with AF, in Spain this decrease has been modest. For all these reasons, and for assuring the sustainability of the health care system, we ask for the elimination of the visa so that DOAC can be prescribed according to the recommendations made by the guidelines. In addition, we are also committed to reinforce medical education and decisions made by consensus with the patient, with the primary care physician acquiring a key role in the protection of the patient with AF.(AU)

Prevalence, impact and management of hypertension-mediated organ damage in type 2 diabetes patients.

OBJECTIVE: To determine the prevalence, impact and management of hypertension-mediated organ damage (HMOD) according to the presence of type 2 diabetes (T2DM). METHODS: IBERICAN is an ongoing multicenter, observational and prospective study, including outpatients aged 18-85 years who attended the Primary Care setting in Spain. In this study, the prevalence, impact and management of HMOD according to the presence of T2DM at baseline were analyzed. RESULTS: At baseline, 8066 patients (20.2% T2DM, 28.6% HMOD) were analyzed. Among patients with T2DM, 31.7% had hypertension, 29.8% dyslipidemia and 29.4% obesity and 49.3% had ≥1 HMOD, mainly high pulse pressure (29.6%), albuminuria (16.2%) and moderate renal impairment (13.6%). The presence of T2DM significantly increased the risk of having CV risk factors and HMOD. Among T2DM population, patients with HMOD had more dyslipidemia (78.2% vs 70.5%; P=0.001), hypertension (75.4% vs 66.4%; P=0.001), any CV disease (39.6% vs 16.1%; P=0.001) and received more drugs. Despite the majority of types of glucose-lowering agents were more frequently taken by those patients with HMOD, compared to the total T2DM population, the use of SGLT2 inhibitors and GLP-1 receptor agonists was marginal. CONCLUSIONS: In patients daily attended in primary care setting in Spain, one in five patients had T2DM and nearly half of these patients had HMOD. In patients with T2DM, the presence of HMOD was associated with a higher risk of CV risk factors and CV disease. Despite the very high CV risk, the use of glucose-lowering agents with proven CV benefit was markedly low.

[Current situation of direct oral anticoagulants in primary care in Spain: Positioning of SEMERGEN in 2023]. / Situación actual de los anticoagulantes orales de acción directa en atención primaria de España. Posicionamiento de SEMERGEN en 2023.

Oral anticoagulation is the key to reduce the risk of stroke in atrial fibrillation. Although vitaminK antagonists (VKA) have classically been used for this purpose, they have been largely overcome by direct oral anticoagulants (DOAC), as demonstrated by evidence from clinical trials, real-life and population studies. In fact, all clinical practice guidelines recommend their use preferentially over VKA. However, in Spain the prescription of DOAC is subordinated to an inspection visa that includes the clinical conditions defined in the Therapeutic Positioning Report of the Spanish Medicines Agency, and that still imposes important restrictions on their use, limiting the benefits of using DOACs in patients with atrial fibrillation (AF), and also generating inequalities between the different autonomous communities. In fact, the use of DOAC in Spain is much lower than that observed in neighboring countries. This has made that while in other countries the incidence of ischemic stroke has decreased at the population level, along with a reduction in the cost per patient with AF, in Spain this decrease has been modest. For all these reasons, and for assuring the sustainability of the health care system, we ask for the elimination of the visa so that DOAC can be prescribed according to the recommendations made by the guidelines. In addition, we are also committed to reinforce medical education and decisions made by consensus with the patient, with the primary care physician acquiring a key role in the protection of the patient with AF.

[Clinical and practical management of sodium-glucose cotransporter type 2 inhibitors in patients with chronic kidney disease]. / Manejo clínico-práctico de los inhibidores del cotransportador sodio-glucosa tipo 2 en pacientes con enfermedad renal crónica.

The discovery of the nephroprotective role of sodium-glucose cotransporter type 2 (iSGLT2) inhibitor drugs in people with type 2 diabetes mellitus (DM 2) following the results obtained in the respective cardiovascular safety trials led to a change in the approach to diabetic kidney disease in recent years, positioning this group in the first step in the treatment of this comorbidity. The publication of the results of the DAPA-CKD study with dapagliflozin, demonstrating its benefit in slowing the progression of chronic kidney disease (CKD) in patients with and without DM, has opened a new age in the management of this pathology. These drugs are also safe and easy to use for the clinician. This article reviews the management of iSGLT2 in patients with diabetic and non-diabetic CKD.

[Renal pathophysiology and pharmacological mechanisms of nephroprotection]. / Fisiopatología renal y mecanismos farmacológicos de nefroprotección.

Several risk factors may affect the progression of chronic kidney disease (CKD). Arterial hypertension, proteinuria, obesity, intraglomerular hypertension, smoking and metabolic control in diabetes mellitus are the main modifiable risk factors for progression. The progression of CKD involves many cellular processes that originate in specific compartments of the kidney, the vascular compartment with nephroangiosclerosis and the tubulointerstitial compartment with fibrosis and tubulointerstitial atrophy, and there may be overlap between both mechanisms. Given the involvement of so many risk factors and so many pathogenic pathways in the progression of CKD, the best hope for delaying or preventing the progression of CKD lies in a combined and multidisciplinary therapeutic approach, based on the existing evidence and acting on all these processes and pathways from the mechanistic point of view, and on a global process that is cardiovascular and renal risk to improve the prognosis of patients.

Home blood pressure self-measurement: "Current situation and new perspectives".

The method typically used to diagnose and monitor hypertensive patients has been to measure blood pressure in the physician's surgery; however, it is a well-known fact that this approach poses certain drawbacks, such as observer bias, failure to detect an alert reaction in the clinic, etc., difficulties that affect its accuracy as a diagnostic method. In recent years, the varying international scientific societies have persistently recommended the use of blood pressure measurements outside the clinic (at home or in the outpatient setting), using validated automatic devices. Data from some studies suggest that if we rely solely on in-office measurements, approximately 15-20% of the time we may be wrong when making decisions, both in terms of diagnosis and patient follow-up. Home blood pressure measurements are a simple and very affordable method that has a similar reproducibility and prognostic value as ambulatory blood pressure monitoring, the availability of which is currently very limited. Moreover, ambulatory self-measurements have the significant benefit of being able to improve control of hypertensive individuals. Healthcare professionals and patients should be aware of the methodology of home blood pressure measurement, its usefulness and limitations.

Los péptidos natriuréticos en el diagnóstico de la insuficiencia cardíaca en atención primaria / The natriuretic peptides in the diagnosis of heart failure in primary care setting

La insuficiencia cardíaca (IC) es un síndrome clínico que se caracteriza por síntomas y signos causados por anomalías estructurales y/o funcionales del corazón que provocan una reducción en el gasto cardíaco y/o elevación de las presiones intracardíacas en reposo o durante el ejercicio. Su prevalencia y su incidencia están aumentando y constituye la primera causa de hospitalización en mayores de 65años. Las nuevas guías europeas y americanas para el manejo de la IC destacan que la medición de las concentraciones de péptidos natriuréticos (PN) constituye una piedra angular del manejo diagnóstico de la IC, y que la anamnesis, la exploración física, el electrocardiograma y la radiografía de tórax completan el inicio del proceso diagnóstico de la IC. Todas estas acciones y pruebas diagnósticas son susceptibles de realizarlas y solicitarlas desde la consulta del médico de familia. Los autores del presente documento, en nombre del Grupo de Trabajo de Hipertensión Arterial y Enfermedad Cardiovascular de SEMERGEN, han revisado la evidencia científica más reciente relacionada con el manejo diagnóstico de los PN en los pacientes con IC en el ámbito de la atención primaria (AU)

Heart failure (HF) is a clinical syndrome characterized by symptoms and signs caused by structural and/or functional abnormalities of the heart that cause reduced cardiac output and/or elevated intracardiac pressures at rest or during exercise. Its prevalence and incidence are increasing and it is the leading cause of hospitalization in people over 65years of age. The new American and European guidelines for the management of HF emphasize that the measurement of natriuretic peptide (NP) concentrations constitutes a cornerstone of the diagnostic management of HF, and that the history, physical examination, electrocardiogram, and chest X-ray, complete the beginning of the HF diagnostic process. All these actions and diagnostic tests can be performed and requested from the primary care office. The authors of this document, on behalf of the SEMERGEN Hypertension and Cardiovascular Disease Working Group, have reviewed the most recent scientific evidence related to the preventive diagnostic management of NP in patients with HF in primary care setting (AU)

[The natriuretic peptides in the diagnosis of heart failure in primary care setting]. / Los péptidos natriuréticos en el diagnóstico de la insuficiencia cardíaca en atención primaria.

Heart failure (HF) is a clinical syndrome characterized by symptoms and signs caused by structural and/or functional abnormalities of the heart that cause reduced cardiac output and/or elevated intracardiac pressures at rest or during exercise. Its prevalence and incidence are increasing and it is the leading cause of hospitalization in people over 65years of age. The new American and European guidelines for the management of HF emphasize that the measurement of natriuretic peptide (NP) concentrations constitutes a cornerstone of the diagnostic management of HF, and that the history, physical examination, electrocardiogram, and chest X-ray, complete the beginning of the HF diagnostic process. All these actions and diagnostic tests can be performed and requested from the primary care office. The authors of this document, on behalf of the SEMERGEN Hypertension and Cardiovascular Disease Working Group, have reviewed the most recent scientific evidence related to the preventive diagnostic management of NP in patients with HF in primary care setting.

Utilidad de una aplicación web interactiva en la mejora del control de los factores de riesgo cardiovascular. Proyecto Control-RC / Impact of an interactive web application on the improvement of cardiovascular risk factors control. Control-RCV project

Objetivo Valorar la utilidad de una aplicación web interactiva en la mejora del control del riesgo cardiovascular (CV). Métodos Estudio observacional en el que médicos de Atención Primaria, incluyeron consecutivamente a pacientes con un riesgo CV elevado/muy elevado y al menos uno de los siguientes factores de riesgo mal controlado: hipertensión, dislipidemia o diabetes. Al introducir los datos, la aplicación generaba un informe indicando los objetivos recomendados y los reales, y el médico podía modificar la actitud terapéutica. El estudio consistió en 2visitas: basal y a los 4-6 meses. Resultados Se incluyó a 379 pacientes (66,4 ± 9,0 años; 67,3% varones; 67,5/32,5% con un riesgo CV elevado/muy elevado). Basalmente, la mayoría recibió recomendaciones sobre la restricción de sal (90,2%), dieta (94,2%) y actividad física (94,5%). En cuanto al tratamiento farmacológico, el 53,6% no tomaba combinaciones fijas. Solo el 35,1% cumplía siempre con el tratamiento. En el 95,8% se realizó educación sanitaria, en el 29,8% se empleó la polipíldora y en el 24,3% se incidió sobre los cambios en hábitos de vida. En la segunda visita se objetivó una mejoría significativa de los cambios en el estilo de vida (menor tabaquismo y consumo de alcohol, y mayor actividad física, restricción de sal, dieta), factores de riesgo CV (menor obesidad, presión arterial, lípidos, HbA1c), así como una reducción del riesgo CV. El cumplimiento terapéutico mejoró. Conclusiones El empleo de la aplicación permite mejorar los estilos de vida y el control de los factores de riesgo, reduciendo el riesgo CV y mejorando el cumplimiento terapéutico (AU)

Objective To ascertain the utility of an interactive web application in the improvement of cardiovascular (CV) risk control. Methods Observational study in which primary care physicians consecutively included high/very high CV risk patients with at least one of the following risk factors poorly controlled: hypertension, dyslipidemia or diabetes. After the introduction of data, the application generated a report comparing the recommended and the real targets. Then, the physicians could modify the therapeutic approach. The study consisted of 2 visits, at baseline and after 4-6 months. Results A total of 379 patients (66.4±9.0 years; 67.3% male; 67.5/32.5% with high/very high CV risk) were included. At baseline, most patients received recommendations about salt restriction (90.2%), diet (94.2%), and physical activity (94.5%). With regard to pharmacological treatments, 53.6% of patients were not taking fixed-dose combinations. Only 35.1% met always with treatment. In 95.8% of patients sanitary education was given, in 29.8% the polypill was prescribed and in 24.3% lifestyle changes were recommended. During the second visit, a significant improvement in lifestyle changes (less smoking and alcohol consumption, and more physical activity, salt restriction and diet), CV risk factors (less obesity, blood pressure, lipids, HbA1c), as well as CV risk reduction were observed. The therapeutic compliance also improved. Conclusions The use of the application allows improving lifestyle and CV risk factors control, leading to a reduction of CV risk and an improvement of therapeutic compliance (AU)

[Impact of an interactive web application on the improvement of cardiovascular risk factors control. Control-RCV project]. / Utilidad de una aplicación web interactiva en la mejora del control de los factores de riesgo cardiovascular. Proyecto Control-RCV.

OBJECTIVE: To ascertain the utility of an interactive web application in the improvement of cardiovascular (CV) risk control. METHODS: Observational study in which primary care physicians consecutively included high/very high CV risk patients with at least one of the following risk factors poorly controlled: hypertension, dyslipidemia or diabetes. After the introduction of data, the application generated a report comparing the recommended and the real targets. Then, the physicians could modify the therapeutic approach. The study consisted of 2 visits, at baseline and after 4-6 months. RESULTS: A total of 379 patients (66.4±9.0 years; 67.3% male; 67.5/32.5% with high/very high CV risk) were included. At baseline, most patients received recommendations about salt restriction (90.2%), diet (94.2%), and physical activity (94.5%). With regard to pharmacological treatments, 53.6% of patients were not taking fixed-dose combinations. Only 35.1% met always with treatment. In 95.8% of patients sanitary education was given, in 29.8% the polypill was prescribed and in 24.3% lifestyle changes were recommended. During the second visit, a significant improvement in lifestyle changes (less smoking and alcohol consumption, and more physical activity, salt restriction and diet), CV risk factors (less obesity, blood pressure, lipids, HbA1c), as well as CV risk reduction were observed. The therapeutic compliance also improved. CONCLUSIONS: The use of the application allows improving lifestyle and CV risk factors control, leading to a reduction of CV risk and an improvement of therapeutic compliance.

Evaluation of prophylaxis in primary prevention with acetylsalicylic acid in people with diabetes: A scoping review

Background: The efficacy and safety of acetylsalicylic acid (ASA) prophylaxis for the primary prevention of atherosclerotic cardiovascular disease (ACVD) remain controversial in people with diabetes (DM) without ACVD, because the possible increased risk of major bleeding could outweigh the potential reduction in the risk of mortality and of major adverse cardiovascular events (MACE) considered individually or together. Objective: To evaluate the overall risk-benefit of ASA prophylaxis in primary prevention in people with DM and to compare the recommendations of the guidelines with the results of the meta-analyses (MA) and systematic reviews (SR). Material and methods: We searched Medline, Google Scholar, Embase, and the Cochrane Library for SR and MA published from 2009 to 2020 which compared the effects of ASA prophylaxis versus placebo or control followed up for at least one year in people with DM without ACVD. Heterogeneity among the randomized clinical trials (RCT) included in the SR and MA was assessed. Cardiovascular outcomes of efficacy (all-cause mortality [ACM], cardiovascular mortality [CVM], myocardial infarction [MI], stroke and MACE) and of safety (major bleeding events [MBE], major gastrointestinal bleeding events [MGIBE], and intracranial and extracranial bleeding) were shown. Results: The recommendations of 12 guidelines were evaluated. The results of 25 SR and MA that included a total of 20 RCT were assessed. None of the MA or SR showed that ASA prophylaxis decreased the risk of ACM, CVM or MI. Only two of the 19 SR and MA that evaluated ischemic stroke showed a decrease in the stroke risk (mean 20.0% [SD±5.7]), bordering on statistical significance. Almost half of the MA and SR showed, bordering on statistical significance, a risk reduction for the MACE composite endpoint (mean 10.5% [SD±3.3]). The significant increases in MGIBE risk ranged from 35% to 55% (AU)

Antecedentes: La eficacia y la seguridad de la profilaxis con ácido acetilsalicílico (AAS) para la prevención primaria de la enfermedad cardiovascular arteriosclerótica (ECVA) siguen siendo controvertidas en personas con diabetes (DM) sin ECVA, ya que el posible aumento del riesgo de hemorragias graves podría superar la posible disminución del riesgo de mortalidad y de los principales episodios adversos cardiovasculares (MACE) considerados individualmente o en conjunto. Objetivo: Evaluar el riesgo-beneficio de la profilaxis con AAS en prevención primaria en personas con DM y comparar las recomendaciones de las guías de práctica clínica con los resultados de los metaanálisis (MA) y revisiones sistemáticas (RS). Material y métodos: Se realizaron búsquedas en Medline, Google Scholar, Embase y Biblioteca Cochrane de RS y MA publicados desde 2009 hasta 2020 que compararan los efectos de AAS versus placebo o control en seguimiento durante al menos un año en personas con DM sin ECVA. Se valoraron la heterogeneidad entre los ensayos clínicos aleatorizados (ECA) incluidos en las RS y MA. Se mostraron los resultados cardiovasculares de eficacia (muerte por cualquier causa [MCC], muerte cardiovascular [MCV], infarto de miocardio [IM], ictus y MACE) y de seguridad (episodios hemorrágicos importantes [EHI], episodios hemorrágicos gastrointestinales importantes [EHGI], hemorragias intracraneales y extracraneales). Resultados: Se valoraron las recomendaciones de 12 guías de práctica clínica. Se evaluaron los resultados de 25 RS y MA que incluyeron un total de 20ECA. Ningún MA ni RS mostró que la profilaxis con AAS disminuyera el riesgo de MCC, MCV o IM. Solo dos de los 19 SR y MA que evaluaron el ictus isquémico mostraron una disminución en el riesgo de ictus (media 20,0% [DE±5,7]), rozando la significación estadística (AU)

[Statement of the Spanish Interdisciplinary Vascular Prevention Committee on the updated European Guidelines on Cardiovascular Disease Prevention]. / Comentario del CEIPV a las nuevas Guías Europeas de Prevención Cardiovascular 2021.

Statement of the Spanish Interdisciplinary Vascular Prevention Committee on the updated European Guidelines on Cardiovascular Disease Prevention. We present the Spanish adaptation of the 2021 European Guidelines on Cardiovascular Disease (CVD) prevention in clinical practice. The current guidelines besides the individual approach greatly emphasize on the importance of population level approaches to the prevention of cardiovascular diseases. Systematic global CVD risk assessment is recommended in individuals with any major vascular risk factor. Regarding LDL-Cholesterol, blood pressure, and glycemic control in patients with diabetes mellitus, goals and targets remain as recommended in previous guidelines. However, it is proposed a new, stepwise approach (Step 1 and 2) to treatment intensification as a tool to help physicians and patients pursue these targets in a way that fits patient profile. After Step 1, considering proceeding to the intensified goals of Step 2 is mandatory, and this intensification will be based on 10-year CVD risk, lifetime CVD risk and treatment benefit, comorbidities and patient preferences. The updated SCORE algorithm-SCORE2, SCORE-OP- is recommended in these guidelines, which estimates an individual's 10-year risk of fatal and non-fatal CVD events (myocardial infarction, stroke) in healthy men and women aged 40-89 years. Another new and important recommendation is the use of different categories of risk according different age groups (< 50, 50-69 ≥ 70 years). Different flow charts of CVD risk and risk factor treatment in apparently healthy persons, in patients with established atherosclerotic CVD, and in diabetic patients are recommended. Patients with chronic kidney disease are considered high risk or very high-risk patients according to the levels of glomerular filtration rate and albumin-to-creatinine ratio. New lifestyle recommendations adapted to the ones published by the Spanish Ministry of Health as well as recommendations focused on the management of lipids, blood pressure, diabetes and chronic renal failure are included.

Posicionamiento SEMERGEN en el abordaje de la insuficiencia cardíaca crónica en atención primaria / SEMERGEN positioning on approaching chronic heart failure in primary care

La insuficiencia cardíaca (IC) es un problema de salud pública que genera una gran carga asistencial tanto hospitalaria como en atención primaria (AP). La publicación de numerosos estudios sobre IC durante los últimos años ha supuesto un cambio de paradigma en el abordaje de este síndrome, en el que la labor de los equipos de AP va adquiriendo un protagonismo mayor. Las recientes guías publicadas por la Sociedad Europea de Cardiología han introducido cambios fundamentalmente en el manejo del paciente con IC. La nueva estrategia propuesta, con fármacos que reducen las hospitalizaciones y frenen la progresión de la enfermedad, debe ser ya una prioridad para todos los profesionales implicados. En este documento de posicionamiento se analiza una propuesta de abordaje basada en equipos multidisciplinares con el liderazgo de los médicos de familia, clave para proporcionar una atención de calidad a lo largo de todo el proceso de la enfermedad, desde su prevención hasta el final de la vida (AU)

Heart failure (HF) is a public health problem that generates a large healthcare burden both in hospitals and in Primary Care (PC). The publication of numerous studies about HF in recent years has led to a paradigm shift in the approach to this syndrome, in which the work of PC teams is gaining greater prominence. The recent guidelines published by the European Society of Cardiology have fundamentally introduced changes in the management of patients with HF. The new proposed strategy, with drugs that reduce hospitalizations and slow the progression of the disease, should now be a priority for all professionals involved. This position document analyzes a proposal for an approach based on multidisciplinary teams with the leadership of family doctors, key to providing quality care throughout the entire process of the disease, from its prevention to the end of the life (AU)

Evaluation of prophylaxis in primary prevention with acetylsalicylic acid in people with diabetes: A scoping review.

BACKGROUND: The efficacy and safety of acetylsalicylic acid (ASA) prophylaxis for the primary prevention of atherosclerotic cardiovascular disease (ACVD) remain controversial in people with diabetes (DM) without ACVD, because the possible increased risk of major bleeding could outweigh the potential reduction in the risk of mortality and of major adverse cardiovascular events (MACE) considered individually or together. OBJECTIVE: To evaluate the overall risk-benefit of ASA prophylaxis in primary prevention in people with DM and to compare the recommendations of the guidelines with the results of the meta-analyses (MA) and systematic reviews (SR). MATERIAL AND METHODS: We searched Medline, Google Scholar, Embase, and the Cochrane Library for SR and MA published from 2009 to 2020 which compared the effects of ASA prophylaxis versus placebo or control followed up for at least one year in people with DM without ACVD. Heterogeneity among the randomized clinical trials (RCT) included in the SR and MA was assessed. Cardiovascular outcomes of efficacy (all-cause mortality [ACM], cardiovascular mortality [CVM], myocardial infarction [MI], stroke and MACE) and of safety (major bleeding events [MBE], major gastrointestinal bleeding events [MGIBE], and intracranial and extracranial bleeding) were shown. RESULTS: The recommendations of 12 guidelines were evaluated. The results of 25 SR and MA that included a total of 20 RCT were assessed. None of the MA or SR showed that ASA prophylaxis decreased the risk of ACM, CVM or MI. Only two of the 19 SR and MA that evaluated ischemic stroke showed a decrease in the stroke risk (mean 20.0% [SD±5.7]), bordering on statistical significance. Almost half of the MA and SR showed, bordering on statistical significance, a risk reduction for the MACE composite endpoint (mean 10.5% [SD±3.3]). The significant increases in MGIBE risk ranged from 35% to 55%. The significant increases in the risk of MBE and extracraneal bleeding were 33.4% (SD±14.9) and 54.5% (SD±0.7) respectively. CONCLUSION: The overall risk-benefit assessment of ASA prophylaxis in primary prevention suggests that it should not be applied in people with DM.

[SEMERGEN positioning on approaching chronic heart failure in primary care]. / Posicionamiento SEMERGEN en el abordaje de la insuficiencia cardíaca crónica en atención primaria.

Heart failure (HF) is a public health problem that generates a large healthcare burden both in hospitals and in Primary Care (PC). The publication of numerous studies about HF in recent years has led to a paradigm shift in the approach to this syndrome, in which the work of PC teams is gaining greater prominence. The recent guidelines published by the European Society of Cardiology have fundamentally introduced changes in the management of patients with HF. The new proposed strategy, with drugs that reduce hospitalizations and slow the progression of the disease, should now be a priority for all professionals involved. This position document analyzes a proposal for an approach based on multidisciplinary teams with the leadership of family doctors, key to providing quality care throughout the entire process of the disease, from its prevention to the end of the life.

Vacuna COVID-19 y pacientes anticoagulados por alto riesgo cardiovascular. Recomendaciones SEMERGEN / COVID-19 vaccine and anticoagulation patients at high cardiovascular risk. SEMERGEN recommendations

No disponible

¿Han influido el algoritmo de prescripción de la Administración y las guías de manejo de la dislipemia de la ACC/AHA 2013 en el manejo de la dislipemia? Proyecto MEJORA-LO CV / Have the Government's prescription algorithm and the 2013 American College of Cardiology/American Heart Association guidelines for managing dyslipidaemia influenced the management of dyslipidaemia? The MEJORALO-CV Project

OBJETIVO: Conocer el manejo de la dislipemia en atención primaria tras la publicación de la Guía de la American College of Cardiology/American Heart Association (ACC/AHA) del año 2013 y el algoritmo de la Administración. MÉTODO: Estudio transversal descriptivo con encuesta a médicos de atención primaria de la Comunidad Valenciana entre enero y octubre de 2016. RESULTADOS: Participaron 199 facultativos con una media (desviación típica) de 48,9 (11) años de edad y 21,3 (11,1) años de experiencia. Las guías más seguidas eran las de la European Society of Cardiology (37,5%) y las de la Administración (23,4%). El 6,3% seguía la de la ACC/AHA 2013. El 88% establecía objetivos según colesterol LDL y riesgo cardiovascular. La elección del hipolipemiante estaba basada en su capacidad reductora de colesterol LDL (28,6%), algoritmo de la Administración (23,4%) y seguridad (20,4%). Estatinas, ezetimiba y fibratos eran los hipolipemiantes preferidos, y la combinación (51%) e incremento de dosis (35%) las estrategias en ausencia de control. Se determinaba perfil lipídico, transaminasas y creatincinasa cada 6 (59,5; 52,3 y 54,3%, respectivamente) o 12 meses (25,1; 29,2 y 30,3%, respectivamente). Un 41% era conocedor de la polémica con la Guía ACC/AHA 2013, y aunque un 60% reconocía su relevancia, solo un 21% modificó su quehacer diario por ella. CONCLUSIONES: El algoritmo de la Administración tuvo mayor impacto que la Guía ACC/AHA 2013 en atención primaria. Campos de mejora fueron el bajo uso de guías y tablas de riesgo validadas, y racionalización de la periodicidad de las analíticas

OBJECTIVE: To determine the management of dyslipidaemia in primary care after the publication of the American College of Cardiology/American Heart Association (ACC/AHA) 2013 guidelines and Valencian government's algorithm. METHOD: We conducted a cross-sectional descriptive study that employed a survey of primary care physicians of the Community of Valencia between January and October 2016. RESULTS: A total of 199 physicians (mean age, 48.9±11.0 years; experience, 21.3±11.1 years) participated in the survey. The most followed guidelines were those of the European Society of Cardiology (37.5% of respondents) and Valencian government (23.4% of respondents). Some 6.3% of the respondents followed the 2013 ACC/AHA guidelines, and 88.0% established objectives based on LDL cholesterol and cardiovascular risk. The choice of lipid-lowering drug was based on its LDL cholesterol lowering capacity (28.6% of respondents), on the Valencian government's algorithm (23.4%) and on the drug's safety (20.4%). Statins, ezetimibe and fibrates were the preferred hypolipemiant agents, and their combination (51% of respondents) and dosage increases (35%) were the strategies employed for poor control. Lipid profile and transaminase and creatine kinase levels were measured every 6 (59.5%, 52.3% and 54.3% of respondents, respectively) or 12 months (25.1%, 29.2% and 30.3%, respectively). Forty-one percent of the respondents were aware of the controversy surrounding the 2013 ACC/AHA guidelines. Although 60% of the respondents acknowledged its relevance, only 21% changed their daily practices accordingly. CONCLUSIONS: The Valencian government's algorithm had a greater impact than the 2013 ACC/AHA guidelines in primary care in Valencia. Areas for improvement included the low use of validated guidelines and risk tables and the streamlining of laboratory test periodicity

[COVID-19 and cardiovascular and kidney disease: Where are we? Where are we going?] / COVID-19 y enfermedad cardiovascular y renal: ¿Dónde estamos? ¿Hacia dónde vamos?

The SARS-CoV-2 pandemic is a global health emergency and we need to know more about it. Patients with cardiovascular risk and previous kidney risk have been identified as especially vulnerable for greater morbidity and mortality when they suffer from COVID-19. A considerable proportion of patients can develop a vascular lesion in the context of the disease that entails a greater lethality. Cardiovascular and renal complications represent a problem and, probably in the near future, may pose a threat to patients who have survived COVID-19. As physicians, we cannot forget that during an epidemic like this, other chronic diseases are present, and patients continue to require care. We are obliged to monitor even more intensely their treatments and control degree. Furthermore, we must not forget that urgent situations continue to arise in this pandemic situation and require prompt attention. In this current situation, it is very likely that many patients, out of fear, have not sought medical attention. The situation during the epidemic and the uncertainty of the post-COVID-19 period, requires intensification in the control and monitoring of cardiovascular and kidney disease in our patients. Primary care constitutes a key level of care for the care of the population with cardiovascular disease. Likewise, and in the face of this new health scenario, we need to promote the prevention and control measures that emanate from the studies currently underway. Now, more than ever, we need research, crucial to improve the cardiovascular and renal prognosis of our patients.