¿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

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. / ¿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.

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.

Analysing the concept of diagnostic inertia in hypertension: a cross-sectional study.

AIMS: The aim of this study was to quantify diagnostic inertia (DI) when the physician fails to diagnose hypertension and determine its associated factors. METHODS: This cross-sectional, observational study involved all patients without a diagnosis of hypertension who had their blood pressure (BP) measured at least three times during the second half of 2010 (N = 48,605). Patients with altered mean BP figures (≥ 140/90 mmHg) were considered to experience DI. Secondary variables: gender, atrial fibrillation, diabetes mellitus, dyslipidemia, cardiovascular disease, age and the physician having attended a cardiovascular training course (ESCARVAL). Associated factors were assessed by multivariate logistic regression analysis. RESULTS: Diagnostic inertia was present in 6450 patients (13.3%, 95% CI: 13.0-13.6%). Factors significantly associated with DI were: male gender (OR = 1.46, 95% CI: 1.37-1.55, p < 0.001), atrial fibrillation (OR = 0.73, 95% CI: 0.58-0.92, p = 0.007), the ESCARVAL cardiovascular course (OR = 0.88, 95% CI: 0.81-0.96, p = 0.005), diabetes mellitus (OR = 0.93, 95% CI: 0.87-0.99, p = 0.016), cardiovascular disease (OR = 0.77, 95% CI: 0.67-0.88, p < 0.001) and older age (years) (18-44→OR = 1; 45-59→OR = 12.45, 95% CI: 11.11-13.94; 60-74→OR = 18.11, 95% CI: 16.30-20.12; ≥ 75→OR = 20.43, 95% CI: 18.34-22.75; p < 0.001). The multivariate model had an area under the ROC curve of 0.81 (95% CI: 0.80-0.81, p < 0.001). CONCLUSIONS: This study will help clinical researchers differentiate between the two forms of DI (interpretation of a positive screening test and interpretation of positive diagnostic criteria). The results found here in patients with hypertension suggest that this problem is prevalent, and that a set of associated factors can explain the outcome well (AUC>0.80).

Arterioesclerosis sistemica precoz y enfermedad autoinflamatoria / Early systemic atherosclerosis and autoinflammatory disease

Las enfermedades autoinflamatorias sistémicas (EAS) se caracterizan por la presencia de episodios inflamatorios agudos, recurrentes o persistentes, en los cuales no se evidencian causas autoinmunitarias, infecciosas o neoplásicas. La inflamación a nivel sistémico se ha relacionado con el desarrollo y progresión de la arterioesclerosis. En el caso del síndrome de Muckle Wells (SMW), la inflamación vendría determinada por una hiperactivación de la interleucina-1β (IL-1β). Exponemos un caso clínico en donde se describen las complicaciones vasculares asociadas a arterioesclerosis precoz en el SMW

Systemic autoinflammatory diseases (SAD) are characterized by the presence of acute, recurrent or persistent inflammatory episodes, in which autoimmune, infectious or neoplastic causes are not evidenced. Systemic inflammation has been linked to development and progression of atherosclerosis. In the case of the Muckle Wells Syndrome (MWS), inflammation would be determined by hyperactivation of interleukin 1β (IL-1β). We present a case report in which vascular complications associated with early atherosclerosis in the MWS are described

Arteritis de Takayasu como causa de hipertensión secundaria / Takayasu’s arteritis as a cause of secondary hypertension

La baja prevalencia de hipertensión arterial secundaria(HTAS) en la población hipertensa general unido a susbajas tasas de reversibilidad y al ingente número de potencialesetiologías obliga a restringir su búsqueda a colectivosdeterminados y centrar esta búsqueda en lasformas más prevalentes y potencialmente corregibles.Las vasculitis son, dentro de las formas de HTAS, muypoco prevalentes. No obstante, su reversibilidad espotencialmente elevada cuando se detecta en fasestempranas; sin embargo, una vez en fase residual fibrótica,la lesión es irreversible. Presentamos un casode HTA debida a arteritis de Takayasu (AT), entidaden la que una de las formas principales de presentaciónes la HTA. El interés de su detección aún en fasefibrótica reside en que la población con esta arteritises joven (por definición, menor de 40 años) y con unriesgo cardiovascular incrementado derivado probablementede la disfunción endotelial asociada a lasvasculitis en general, así como a la rigidez arterial derivada.Se discute el diagnóstico diferencial de las aortitis,se incide en las formas más prevalentes en nuestromedio y se hace hincapié en el manejo terapéuticocomo pacientes de riesgo cardiovascular (RCV) incrementado.Siendo la AT una forma altamente infrecuentede HTAS, el que afecte a pacientes jóvenes yel que el diagnóstico de sospecha sea tan sencillo comola palpación de pulsos periféricos y el registro, almenos inicial, de los valores de PA en ambas extremidadessuperiores no hace sino recordarnos la importanciade seguir las guías terapéuticas a la hora deevaluar al paciente hipertenso general (AU)

The low prevalence of secondary hypertension (SH)in the overall hypertensive population, together withthe low rates of reversibility and the vast number ofpotential etiologies for this condition, makes it necessaryto limit the search to determinate groups and tofocus on the most prevalent and potentially correctabletypes. Although the vasculitides are not prevalent,they have potentially high reversibility when detectedin the early stages; however, lesions in the fibrotic residualstage are irreversible. We present a case of SHdue to Takayasu’s arteritis (TA), a disease in whichSH is one of the main presenting signs. It is importantto detect TA, even in the fibrotic stage, because TAaffects young people (by definition, under 40 years ofage) and involves increased cardiovascular risk, probablydue to the endothelial dysfunction that is associatedwith the vasculitides in general as well as to thearterial stiffness they cause. We discuss the differentialdiagnosis of aortitis and emphasize the most prevalenttypes in our environment and the therapeutic managementfor these patients with increased cardiovascularrisk. The fact that TA is a very rare type of SH thataffects young patients and that the diagnosis can besuspected simply palpating the peripheral pulses andrecording, at least at first, blood pressure in both arms,underlines the importance of following the recommendationsof the therapeutic guidelines when evaluatinggeneral hypertensive patients (AU)

Absceso epidural espinal con espondilitis. Descripción de un caso / Spinal epidural absceso with spondylitis. Case report]

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