Nuevas estrategias en prevención cardiovascular / New strategies in cardiovascular prevention

Las enfermedades cardiovasculares son la principal causa de mortalidaden España y en los países occidentales, especialmente la cardiopatíaisquémica. La prevención de las complicaciones se basa enla estratificación del riesgo cardiovascular, que se basa en la presenciade los factores de riesgo clásicos. Existen diferentes escalas quepermiten estratificar el riesgo cardiovascular de un sujeto como bajo,intermedio o alto. Pese a que el impacto y tratamiento de los factoresde riesgo es bien conocido, el control de los mismos es bastantepobre. Además, la obesidad, la diabetes y la hipertensión parecenestar aumentando debido a los cambios en los estilos de vida yalimentación que están experimentando nuestras comunidades.En las últimas décadas se han identificado nuevos factores de riesgocardiovascular, o emergentes, que pueden mejorar la estratificacióndel riesgo cardiovascular y son principalmente la proteína C-reactiva,la homocisteína y la lipoproteína a. El síndrome metabólico es unaasociación de factores de riesgo cardiovascular que tienden a aparecerde forma conjunta por tener un nexo fisiopatológico común: laresistencia insulínica. Su presencia se asocia con la mayoría de losfactores de riesgo cardiovascular, tanto clásicos o emergentes, especialmentela obesidad, hipertensión arterial y la proteína C-reactiva.Por otra parte, la detección de formas subclínicas o incipientes deaterosclerosis, especialmente mediante la medición del grosor de laíntima-media carotídea, aporta información indirecta pero estrechamenterelacionada con la aterosclerosis coronaria que mejora laestratificación en sujetos de riesgo intermedio

Cardiovascular diseases, especially coronary heart disease, are theleading cause of mortality in Spain and western countries. The preventionof complications is based on a cardiovascular risk stratificationthat is based on the presence of classical cardiovascular riskfactors. There are many scales for cardiovascular risk stratificationthat classify subjects into low, intermediate or high risk. Despite thefact that the impact and treatment of risk factors are well known, theircontrol remains poor. Obesity, diabetes, and hypertension seems alsoseem to be increasing trends due to the changes in lifestyles andnutritional habits of our communities.In recent decades some new, or emerging, cardiovascular risk factorshave been identified that can improve the stratification of cardiovascularrisk: C-reactive protein, homocysteine, and lipoprotein a. Themetabolic syndrome is an association of cardiovascular risk factorsthat cluster in the same subject because they share a physiopathologiclink: insulin resistance. Its presence is related to most cardiovascularrisk factors, classical or emerging, especially obesity, hypertension,and C-reactive protein. On the other hand, detection of subclinicalor incipient atherosclerosis, especially with the measurementof intima-media thickness, offers indirect information closely relatedto coronary atherosclerosis that improves the stratification of subjectsat intermediate risk

[New strategies in cardiovascular prevention]. / Nuevas estrategias en prevención cardiovascular.

Cardiovascular diseases, especially coronary heart disease, are the leading cause of mortality in Spain and western countries. The prevention of complications is based on a cardiovascular risk stratification that is based on the presence of classical cardiovascular risk factors. There are many scales for cardiovascular risk stratification that classify subjects into low, intermediate or high risk. Despite the fact that the impact and treatment of risk factors are well known, their control remains poor. Obesity, diabetes, and hypertension seems also seem to be increasing trends due to the changes in lifestyles and nutritional habits of our communities. In recent decades some new, or emerging, cardiovascular risk factors have been identified that can improve the stratification of cardiovascular risk: C-reactive protein, homocysteine, and lipoprotein a. The metabolic syndrome is an association of cardiovascular risk factors that cluster in the same subject because they share a physiopathologic link: insulin resistance. Its presence is related to most cardiovascular risk factors, classical or emerging, especially obesity, hypertension, and C-reactive protein. On the other hand, detection of subclinical or incipient atherosclerosis, especially with the measurement of intima-media thickness, offers indirect information closely related to coronary atherosclerosis that improves the stratification of subjects at intermediate risk.

Development of a short dietary intake questionnaire for the quantitative estimation of adherence to a cardioprotective Mediterranean diet.

Our objective was to develop a short questionnaire that can be easily used to estimate quantitatively the level of adherence to cardioprotective Mediterranean diets. The short questionnaire assessed the consumption of cardioprotective elements included in the Mediterranean diet (olive oil, wine, fruits, vegetables, fish, legumes and whole-grain intake). A low consumption of meat or meat-products was also included in the composite score. The relative risk of myocardial infarction for each category of the composite score obtained (range 0-9) was computed using data from a case-control study that included 171 cases of first myocardial infarction and 171 matched controls. We found an adjusted odds ratio=0.18 (95% confidence interval (CI): 0.03-0.97; P=0.04) for those scoring 7-9 points when comparing them with those scoring 1-2 points. An increment of one point in the score was associated with an 18% reduction in the relative risk of myocardial infarction (P=0.05).

To what extent are the effects of diet on coronary heart disease lipid-mediated?

BACKGROUND: Cohort and case-control studies support the effect of diet on coronary heart disease. The objective of this study was to analyze the strength of the influence of dietary fat subtypes and other nutrients on serum lipids levels in patients with a first acute myocardial infarction. METHODS: We studied 139 patients with a first myocardial infarction and no previous history of vascular disease. Serum lipids were determined, and nutrient intake was analyzed using a validated 118-food item questionnaire. RESULTS: Multiple regression models found weak but significant associations between the intake of different fatty acids and total to HDL cholesterol ratio (atherogenic index) when we adjusted for age, gender and body mass index (BMI). Positive associations with serum HDL cholesterol concentration were observed for energy-adjusted intake of red wine, alcohol intake, and omega-3 fatty acids intake. However, these nutrients explained less than 12% of the variability in the atherogenic index, and less than 17% in the variability of HDL. CONCLUSIONS: Our results suggest only a modest contribution of the investigated nutrients on serum lipids (atherogenic index and HDL cholesterol) in coronary patients. Alternative mechanisms of dietary factors not directly related with serum lipids or, more likely, a global effect of diet on inflammatory and antioxidant parameters should be studied in order to better understand the nature of dietary habits' influence on cardiovascular disease.

Type of alcoholic beverage and first acute myocardial infarction: a case-control study in a Mediterranean country.

BACKGROUND: Although international comparisons have consistently found an inverse association between wine and coronary heart disease, few epidemiologic studies are available in Southern Europe. We assessed the association of wine, red wine, and the pattern of drinking wine during meals with the risk of myocardial infarction. HYPOTHESIS: We specifically evaluated three hypotheses: (1) Is the protection against incidence of nonfatal myocardial infarction stronger for wine than for other alcoholic beverages? (2) Does the wine consumed during meals represent a more beneficial pattern of alcohol consumption? (3) Is red wine more advantageous than other types of wine? METHODS: A case-control study (171 cases, 171 matched controls) was conducted in Spain. Multiple dietary and nondietary potential confounders were assessed. RESULTS: Exposure to wine, red wine, and wine during meals was associated with risk reductions similar to those of other alcoholic beverages (point estimates of the odds ratio for low and high intake were 0.48 and 0.38 for wine; 0.42 and 0.55 for other beverages). However, after controlling for total alcohol intake, wine consumption (g/day) improved the prediction of a myocardial infarction. CONCLUSIONS: Our data showed that red wine or drinking wine during meals was similar to alcohol from other sources for reducing coronary risk. However, an additional benefit of wine, keeping constant overall alcohol intake, deserves further research.

Role of fibre and fruit in the Mediterranean diet to protect against myocardial infarction: a case-control study in Spain.

OBJECTIVE: To assess the association between a first acute myocardial infarction and the consumption of fibre and fruit. DESIGN: Hospital-based case-control study with incident cases. A validated semi-quantitative food frequency questionnaire (136 items) was used to assess food intake. SETTING: Three third-level university hospitals in Pamplona (Spain). SUBJECTS: Cases were subjects aged under 80, newly diagnosed with acute myocardial infarction. Each case patient (n=171) was matched to a control subject of the same gender and age (5 y bands) admitted to the same hospital. RESULTS: An inverse association was apparent for the three upper quintiles of fibre intake. After adjustment for non-dietary and dietary confounders, an inverse linear trend was clearly significant, showing the highest relative reduction of risk (86%) for the fifth quintile (OR=0.14, 95% confidence interval: 0.03-0.67). An inverse association was also apparent for fruit intake, but not for vegetables or legumes. CONCLUSIONS: Our data suggest that a substantial part of the postulated benefits of the Mediterranean diet on coronary risk might be attributed to a high intake of fibre and fruit.

Risk of first non-fatal myocardial infarction negatively associated with olive oil consumption: a case-control study in Spain.

BACKGROUND: Olive oil is the main source of dietary lipids in most Mediterranean countries where mortality and incidence rates for coronary heart disease (CHD) are the lowest in Europe. Although international comparisons and mechanistic reasons support the hypothesis that a high olive oil intake may prevent CHD, limited data from studies of individuals are available. METHODS: A hospital-based case-control study was conducted in Pamplona (Spain) recruiting 171 patients (81% males, age <80 years) who suffered their first acute myocardial infarction and 171 age-, gender- and hospital-matched controls (admitted to minor surgery, trauma or urology wards). A validated semi-quantitative food frequency questionnaire (136 items) was used to appraise previous long-term dietary exposures. The same physician conducted the face-to-face interview for each case patient and his/her matched control. Conditional logistic regression modelling was used to take into account potential dietary and non-dietary confounders. RESULTS: The exposure to the upper quintile of energy-adjusted olive oil (median intake: 54 g/day) was associated with a statistically significant 82% relative reduction in the risk of a first myocardial infarction (OR = 0.18; 95% CI : 0.06-0.63) after adjustment for dietary and non-dietary confounders. CONCLUSIONS: Our data suggest that olive oil may reduce the risk of coronary disease. These findings require confirmation in further observational studies and trials.

Influencia del grado de la severidad de la estenosis, del diámetro del vaso y del modelo de stent en el fenómeno del retroceso elástico en angioplastia coronaria. Evaluación angiográfica / No disponible

Objetivos: El fenómeno de retroceso elástico, tras la implantación del stent, sigue siendo de gran importancia en el éxito del procedimiento angiográfico. El objetivo de este estudio es valorar la influencia que el tamaño del vaso, el modelo de stent y el modelo angiográfico de lesión, puedan tener en el retroceso elástico. Material y métodos: Se incluyeron en el estudio 61 pacientes, en los que se implantaron con éxito 81 stents de diferentes modelos. Se valoró mediante angiografía coronaria cuantitativa los diámetros durante la implantación y tras la retirada del balón. Los resultados fueron analizados en función del modelo de stent, de las características del vaso y de las características angiográficas de la lesión. Resultados: No se hallaron diferencias significativas en el fenómeno del retroceso elástico en relación a la longitud, simetría y severidad de la lesión. Tampoco en relación al modelo de stent empleado. Sí hubo diferencias si se tenía en cuenta el tamaño del vaso, siendo significativamente menor en los vasos pequeños (<2,75 mm). Discusión: El hallazgo de que el retroceso elástico sea menor en los vasos pequeños supone una paradoja. Tradicionalmente se ha considerado el pequeño tamaño del vaso como un factor de riesgo independiente para el desarrollo de reestenosis tras la implantación del stent. Este hallazgo mantiene la polémica sobre el empleo del stent en vasos pequeños (AU)

Purpose: Stent recoil following stent deployment is still a very important outcome predictor after angiographic intervention. The aim of this study is to assess the influence of device model, angiographic characteristics of the lesion and vessel size on stent recoil. Methods: 61 consecutive patients were included in the study. 81 stents were successfully deployed. Maximal balloon diameter at peak pressure and maximal lumen diameter after stenting were measured by QCA (quantitative coronary angiography) Results: There were no significant differences regarding either the model of device or length, symmetry or severity of the lesion. There were significant differences regarding the vessel size. Stent recoil was greater in small vessels (<2,75 mm). Discussion: This finding is a paradox. The small size of the vessel has been always identified as an independent risk factor for the development of stenosis. The use of stents in small vessels remains controversial (AU)

Clandestine ischemia in patients with vasospastic angina.

BACKGROUND: Coronary vasospasms generally occur at rest, but can also be triggered by physical exercise. Anginal pain and ST-segment elevation may be seen during exercise-stress tests. ST-segment depression, due to nonocclusive vasospasms, has also been found to occur. When the result of a test is positive, scintigraphy usually reveals perfusion defects. True silent or clandestine ischemia (normal result of exercise test with perfusion defects) in these patients is very uncommon. OBJECTIVE: To stress the need for suspecting occurrence of coronary vasospasms in order to perform a proper diagnosis. METHODS: Eight patients with angina were selected for this study. They had negative results of exercise tests with perfusion defects detected by thallium-201 tomography, normal coronary arteries and vasospasms. Maximal exercise-stress tests with thallium-201 tomography were performed. Sizes of perfusion defects were quantified by examining polar maps. Coronary angiography and then an intracoronary ergonovine test were performed for each patient. RESULTS: Significant defects were seen in territory of the right coronary artery, the left anterior descending artery, or both. Lung:heart ratio was normal in every case. The coronary arteries were normal and vasospasms were elicited with ergonovine in all the patients. Correspondence between the location of perfusion defects and angiographic spasms was generally observed. After treatment with calcium antagonists and nitrates all of them improved and defects detected by thallium tomography were no longer found when tests were repeated. CONCLUSIONS: Some patients with vasospastic angina may have normal results of exercise-stress tests and reversible perfusion defects detectable by scintigraphy. This finding must lead one to perform coronary angiography without administration of nitroglycerine beforehand and an ergonovine test if the coronary arteries are normal.

Indicaciones de la cirugía coronaria / Indications of coronary surgery

Tras pasar revista a los condicionantes técnicos y complicaciones de la cirugía coronaria, así como a sus resultados comparativos con la angioplastia, se presentan las indicaciones actuales de la derivación aortocoronaria, resumida de las directrices internacionales al uso. (AU)