Correction: Lipid profile, cardiovascular disease and mortality in a Mediterranean high-risk population: The ESCARVAL-RISK study.

[This corrects the article DOI: 10.1371/journal.pone.0186196.].

Lipid profile, cardiovascular disease and mortality in a Mediterranean high-risk population: The ESCARVAL-RISK study.

INTRODUCTION: The potential impact of targeting different components of an adverse lipid profile in populations with multiple cardiovascular risk factors is not completely clear. This study aims to assess the association between different components of the standard lipid profile with all-cause mortality and hospitalization due to cardiovascular events in a high-risk population. METHODS: This prospective registry included high risk adults over 30 years old free of cardiovascular disease (2008-2012). Diagnosis of hypertension, dyslipidemia or diabetes mellitus was inclusion criterion. Lipid biomarkers were evaluated. Primary endpoints were all-cause mortality and hospital admission due to coronary heart disease or stroke. We estimated adjusted rate ratios (aRR), absolute risk differences and population attributable risk associated with adverse lipid profiles. RESULTS: 51,462 subjects were included with a mean age of 62.6 years (47.6% men). During an average follow-up of 3.2 years, 919 deaths, 1666 hospitalizations for coronary heart disease and 1510 hospitalizations for stroke were recorded. The parameters that showed an increased rate for total mortality, coronary heart disease and stroke hospitalization were, respectively, low HDL-Cholesterol: aRR 1.25, 1.29 and 1.23; high Total/HDL-Cholesterol: aRR 1.22, 1.38 and 1.25; and high Triglycerides/HDL-Cholesterol: aRR 1.21, 1.30, 1.09. The parameters that showed highest population attributable risk (%) were, respectively, low HDL-Cholesterol: 7.70, 11.42, 8.40; high Total/HDL-Cholesterol: 6.55, 12.47, 8.73; and high Triglycerides/HDL-Cholesterol: 8.94, 15.09, 6.92. CONCLUSIONS: In a population with cardiovascular risk factors, HDL-cholesterol, Total/HDL-cholesterol and triglycerides/HDL-cholesterol ratios were associated with a higher population attributable risk for cardiovascular disease compared to other common biomarkers.

Construction and Validation of a 14-Year Cardiovascular Risk Score for Use in the General Population: The Puras-GEVA Chart.

UNLABELLED: The current cardiovascular risk tables are based on a 10-year period and therefore, do not allow for predictions in the short or medium term. Thus, we are unable to take more aggressive therapeutic decisions when this risk is very high.To develop and validate a predictive model of cardiovascular disease (CVD), to enable calculation of risk in the short, medium and long term in the general population.Cohort study with 14 years of follow-up (1992-2006) was obtained through random sampling of 342,667 inhabitants in a Spanish region. MAIN OUTCOME: time-to-CVD. The sample was randomly divided into 2 parts [823 (80%), construction; 227 (20%), validation]. A stepwise Cox model was constructed to determine which variables at baseline (age, sex, blood pressure, etc) were associated with CVD. The model was adapted to a points system and risk groups based on epidemiological criteria (sensitivity and specificity) were established. The risk associated with each score was calculated every 2 years up to a maximum of 14. The estimated model was validated by calculating the C-statistic and comparison between observed and expected events.In the construction sample, 76 patients experienced a CVD during the follow-up (82 cases per 10,000 person-years). Factors in the model included sex, diabetes, left ventricular hypertrophy, occupational physical activity, age, systolic blood pressure × heart rate, number of cigarettes, and total cholesterol. Validation yielded a C-statistic of 0.886 and the comparison between expected and observed events was not significant (P: 0.49-0.75).We constructed and validated a scoring system able to determine, with a very high discriminating power, which patients will develop a CVD in the short, medium, and long term (maximum 14 years). Validation studies are needed for the model constructed.

Is the physician's behavior in dyslipidemia diagnosis in accordance with guidelines? Cross-sectional ESCARVAL study.

BACKGROUND: Clinical inertia has been defined as mistakes by the physician in starting or intensifying treatment when indicated. Inertia, therefore, can affect other stages in the healthcare process, like diagnosis. The diagnosis of dyslipidemia requires ≥2 high lipid values, but inappropriate behavior in the diagnosis of dyslipidemia has only previously been analyzed using just total cholesterol (TC). OBJECTIVES: To determine clinical inertia in the dyslipidemia diagnosis using both TC and high-density lipoprotein cholesterol (HDL-c) and its associated factors. DESIGN: Cross-sectional. SETTING: All health center visits in the second half of 2010 in the Valencian Community (Spain). PATIENTS: 11,386 nondyslipidemic individuals aged ≥20 years with ≥2 lipid determinations. MEASUREMENT VARIABLES: Gender, atrial fibrillation, hypertension, diabetes, cardiovascular disease, age, and ESCARVAL training course. Lipid groups: normal (TC<5.17 mmol/L and normal HDL-c [≥1.03 mmol/L in men and ≥1.29 mmol/L in women], TC inertia (TC≥5.17 mmol/L and normal HDL-c), HDL-c inertia (TC<5.17 mmol/L and low HDL-c), and combined inertia (TC≥5.17 mmol/L and low HDL-c). RESULTS: TC inertia: 38.0% (95% CI: 37.2-38.9%); HDL-c inertia: 17.7% (95% CI: 17.0-18.4%); and combined inertia: 9.6% (95% CI: 9.1-10.2%). The profile associated with TC inertia was: female, no cardiovascular risk factors, no cardiovascular disease, middle or advanced age; for HDL-c inertia: female, cardiovascular risk factors and cardiovascular disease; and for combined inertia: female, hypertension and middle age. LIMITATIONS: Cross-sectional study, under-reporting, no analysis of some cardiovascular risk factors or other lipid parameters. CONCLUSIONS: A more proactive attitude should be adopted, focusing on the full diagnosis of dyslipidemia in clinical practice. Special emphasis should be placed on patients with low HDL-c levels and an increased cardiovascular risk.

[Relationship between inflammation marker and all-cause and cardiovascular mortality in a prospective cohort study]. / Relación entre el proceso inflamatorio y la mortalidad de origen cardiovascular y por todas las causas en un estudio de cohortes prospectivo de base poblacional.

INTRODUCTION: Inflammation is present in every stage of the atherosclerosis process, therefore, inflammation hallmarks such as the fibrinogen can be related to the complications in which it intervenes, mortality is one of them. The objective of this study is to assess the association of the fibrinogen with all-cause mortality in men from general population sample obtained by random sampling in the Spanish region of Albacete. METHODS: A total of 506men without cardiovascular events with 10.6years (SD=2.3) of follow-up, volunteered to participate in a prospective cohort study. The assessment of the fibrinogen as a predictor variable has been calculated after adjusting it by age, hypertension, diabetes mellitus, obesity, total cholesterol, HDL-cholesterol/triglycerides ratio, and smoking habit applying a Cox regression model. The adjustment has been made by adding the fibrinogen to the model, as a qualitative variable (<400 and ≥400mg/dl). RESULTS: The average age of the participants was 46.6years old (DE=16.8). After the adjustment, the hyperfibrinogenemia (≥400mg/dl) showed a hazard ratio (HR) for all-cause mortality of 1.85 (95%CI: 1.05-3.26) and for cardiovascular mortality HR=2.69 (95%CI: 1.09-6.63). CONCLUSIONS: In men without cardiovascular events of our study, fibrinogen was showed as an independent predictor of all-cause mortality and cardiovascular mortality.

Cumplimiento terapéutico y seguimiento del paciente hipertenso en atención primaria / Therapeutic compliance and follow-up of hypertensive patients in primary care

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Inercia terapéutica en pacientes hipertensos asistidos en atención primaria en España. Estudio Objetivo Kontrol / Objective KONTROL study: therapeutic inertia in hypertensive patients attended in primary care of Spain

ObjetivosConocer el grado de inercia terapéutica (IT) y determinar los factores asociados al paciente, médico y organización sanitaria en pacientes hipertensos asistidos en atención primaria (AP).DiseñoEstudio transversal y multicéntrico.EmplazamentoMuestra de Equipos de AP de toda España.ParticipantesEl estudio fue realizado entre médicos de AP mediante un cuestionario y registro clínico de 4 pacientes.Mediciones principalesSe calculó la IT para cada paciente (ITp) como la proporción de visitas en las que no se produce un cambio en la medicación cuando está indicado.ResultadosUn total de 543 médicos aportaron datos de 2.032 pacientes, que cumplían el requisito de indicación de cambio, en el 77,8% de los casos se actuó con IT. La ITp observada fue inexistente o baja para el 17,1% de los pacientes, intermedia para el 42% y alta para el 40,8%. Los factores, relativos a los pacientes, que más se asociaron con la ITp alta fueron la edad (p<0,001), diabetes (p<0,001), ictus (p<0,01), obesidad (p<0,01) y el nivel bajo de estudios (p<0,001). Ser mujer, tener menos de 45 años o más de 55, ser médico de familia con un programa de formación diferente al MIR y trabajar en el sector público aumentaron la probabilidad de ITp (p<0,001 para todos los supuestos).ConclusionesLos resultados del estudio indican que en 7 de cada 10 visitas realizadas por pacientes hipertensos en AP se produce IT. Existen diferencias importantes en función de las características clínicas de los pacientes, de los médicos y de las consultas(AU)

ObjectivesTo determine the level of therapeutic inertia (TI), and the factors associated to the patient, doctor and the health organisation, in hypertensive patients treated in Primary Care (PC).DesignCross-sectional, multicentre study.SettingA sample of PC Teams from all over Spain.ParticipantsThe study was conducted among PC doctors using a questionnaire and clinical records of 4 patients.Main measurementsThe TI was calculated for each patient (TIp) as the proportion of visits in which there was no change in medication when this was indicated.ResultsA total of 543 PC doctors provided data on 2,032 patients, who fulfilled the indication of a change in requirement. There was TI In 77.8% of cases. The TIp observed was non-existent or low for 17.1% of the patients, intermediate for 42% and high for 40.8%. For the patients, the factors most associated with TIp were, age (P<.001), diabetes (P<.001), stroke (P<.01), obesity (P<.01) and a low education level (P<.001). To be female, be less than 40years or more than 55years, to be a family doctor with a training program other than MIR and to work in the public sector increased the probability of TIp (P<.001 for all the assumptions).ConclusionsThe results of the study indicate that there is TI in 7 out every 10 visits made by hypertensive patients in Primary care. There are significant differences as regards the clinical characteristics of the patients and of the doctors(AU)

Índice tobillo-brazo e incidencia de la mortalidad por todas las causas y morbilidad cardiovascular en una cohorte prospectiva de origen poblacional / Ankle-brachial index and the incidence of all-cause mortality and cardiovascular morbidity in a prospective cohort study of a general population

Introducción El objetivo del estudio ha sido valorar la capacidad predictiva del índice tobillo-brazo (ITB) en la mortalidad por todas las causas y en el criterio compuesto de valoración morbilidad de causa cardiovascular (CV) y mortalidad total en una muestra de origen poblacional. Métodos Estudio de cohortes prospectivo en el que han participado 1.143 individuos seguidos durante 10,8 años (DE=2,2) libres de eventos CV. El ITB se estratificó en 2 niveles: menos de 0,9 y entre 0,9 y 1,4. Las variables predictoras incluidas en el ajuste fueron: sexo, edad (corte en 50 años), hipertensión arterial, diabetes mellitus, obesidad, hipercolesterolemia (corte en 200mg/dl), cociente cHDL/triglicéridos, fumador e hiperfibrinogenemia. Se calcularon curvas de supervivencia (Kaplan-Meier) y se aplicó un modelo de regresión de Cox.ResultadosLa edad media de los participantes (56,8% mujeres) fue de 47,1 años (DE=17,4), rango 18-91 años. Un 6,9% de la muestra presentó un ITB menor de 0,9. Tras el ajuste, un ITB menor de 0,9 presentó para la mortalidad por todas las causas una hazard ratio (HR) de 1,90, intervalo de confianza (IC) del 95%: 1,10-3,26, y para el combinado morbilidad CV y mortalidad por todas las causas una HR de 1,69 (IC del 95%: 1,07-2,67). Conclusiones Un ITB<0,9 ha demostrado ser un factor de riesgo independiente de mortalidad por todas las causas y del combinado morbilidad CV y mortalidad global tras un seguimiento de 10,8 años en la muestra procedente de nuestra población (AU)

Introduction: The aim of this study was to investigate the predictive value of the ankle-brachialindex (ABI) in all-cause mortality and composite end-point all-cause mortality and cardiovascularmorbidity in a sample of a general population. Methods: We performed a prospective cohort study of 1143 individuals free of cardiovascularevents followed up for 10.8 years (SD = 2.2). The ABI was stratified in two levels: less than 0.9and between 0.9 and 1.4. The predictive variables included in the adjustment were sex, age(cut-off: 50 years), hypertension, diabetes, obesity, hypercholesterolemia (cut-off: 200 mg/dl),high-density lipoprotein-cholesterol (HDLc)/triglyceride ratio, smoking and hyperfibrinogenemia. Kaplan-Meier survival curves and multivariate Cox proportional hazards analysis wereused. Results: The mean age of the participants (56.8% female) was 47.1 years (SD = 17.4), range 18-91years. An ABI value < 0.9 was found in 6.9% of the sample. After adjustment, an ABI of < 0.9 hada hazard ratio (HR) of 1.90 [95% confidence interval (CI) 1.10-3.26] for all-cause mortality, andan HR of 1.69 (95% CI 1.07-2.67) for composite all-cause mortality and cardiovascular morbidity.Conclusions: In our population, an ABI < 0.9 was a risk factor independent of all-cause mortalityand of composite all-cause mortality and cardiovascular morbidity after a follow-up of 10.8years (AU)

Estudio “Objetivo Kontrol”: inercia terapéutica en hipertensión arterial. Diseño y metodología / “Kontrol Objective” Study: therapeutic inertia in arterial hypertension. Design and methodology

Introducción: En la actualidad, únicamente el 40% de los hipertensos tratados mantienen cifras tensionales dentro de los límites recomendados por las guías de práctica clínica. La inercia terapéutica (IT) es uno de los problemas para alcanzar un buen control de la presión arterial, y se desconoce en gran medida los factores que influyen en ella. Objetivos: elaborar y validar un cuestionario para medir la IT en el control de la HTA e identificar factores relacionados con la organización sanitaria que faciliten o prevengan la IT.Métodos: En la elaboración del cuestionario se utilizarán técnicas cualitativas (revisión de la literatura, informantes clave, grupos de discusión, análisis semiológico de la discusión y extracción de ítems). Posteriormente, mediante técnicas cuantitativas, se validará el cuestionario en un trabajo de campo, comparando la puntuación obtenida en el cuestionario con la medida directa de la IT obtenida a partir de las historias clínicas de pacientes (validez de criterio). Simultáneamente se identificarán factores asociados a la IT, en particular en aspectos del paciente, del médico, de enfermería y del tiempo dedicado a la consulta.Conclusiones: El producto principal de este estudio será un instrumento que ayude a medir el grado de IT del médico y a conocer qué factores del paciente, del médico y de su entorno contribuyen a producir en el médico la intención de actuar o no frente a un fracaso terapéutico. La principal limitación del estudio dependerá de en qué medida un test autoaplicable sobre conocimientos teóricos y juicios de valor sobre situaciones clínicas concretas pueda ser un reflejo fiable de la actuación clínica en circunstancias reales(AU)

Introduction: Only 40% of persons treated for arterial hypertension (AHT) currently maintain blood pressure levels within the limits recommended by clinical practice guidelines. Treatment inertia (TI) is one of the problems in achieving good blood pressure control, however the factors influencing TI are largely unknown.Objectives: To develop and validate a questionnaire to measure TI in controlling AHT and to identify factors related with the organization of healthcare that facilitate or prevent TI. Methods: Qualitative techniques (literature review, key informants, discussion groups, subsequent semiologic analysis of the discussion and extraction of items) were used in developing the questionnaire. Quantitative techniques were then used to validate the questionnaire in fieldwork, comparing the score obtained on the questionnaire with the direct measurement of TI obtained from clinical histories of patients (criterion validity). At the same time, factors associated with TI were identified, in particular, aspects related with the patient, physician, nursing staff and time devoted to the medical consultation.Conclusions: The main product of this study will be an instrument that helps to measure the physician’s degree of TI and to determine what factors related with the patient, physician and setting help produce the physician’s intention to act or not when faced with treatment failure. The main study limitation will depend on the extent to which a self-completed test on theoretical knowledge and value judgments about specific clinical situations can reliably reflect clinical actions in real circumstances(AU)

[Evaluation of a protocol to monitor cardiovascular risk factors in diabetic patients attended in primary care]. / Evaluación de un protocolo de control de factores de riesgo cardiovascular en pacientes diabéticos atendidos en atención primaria.

OBJECTIVE: To evaluate a primary care protocol for intensive monitoring of cardiovascular risk (CVR) factors in type-2 diabetes patients versus usual care. DESIGN: Randomised trial with clusters. SETTING: Primary care clinics. PARTICIPANTS: Sixty family physicians. INTERVENTIONS: Participants were randomised between following a protocol of intensive monitoring of CVR factors and maintaining their habitual practice with DM2 patients. Follow-up lasted 12 months. Data on HbA1C, CVR factors and CVR were collected at the start of the study and at 12 months. RESULTS: In all, 188 patients (94 intervention group and 94 control group) were included. At baseline measurement, CVR in control group (CG) was 36.3% (95% CI, 33.9%-38.6%); and in intervention group (IG), 35.9% (95% CI, 33.5%-38.4%), with no significant differences between groups. At one year, CVR in CG was 33.1% (95% CI, 30%-36.1%) and in IG 30.5% (95% CI, 27.8%-33.2%). The CVR difference between baseline and 1-year measurements was 2.9% (95% CI, 0.2%-5.7%) in CG and 5.4% (95% CI, 2.8%-7.1%) in IG. CONCLUSIONS: Although improvement of CVR is greater in the IG, the difference between the two groups is not significant. The characteristics of the doctors chosen may have meant that the patients of the two groups received similar treatment.

Evaluación de un protocolo de control de factores de riesgo cardiovascular en pacientes diabéticos atendidos en atención primaria / Evaluation of a protocol to monitor cardiovascular risk factors in diabetic patients attended in primary care

Objetivo. Valorar un protocolo de control intensivo de factores de riesgo cardiovascular (FRCV) frente al control habitual en pacientes con diabetes mellitus tipo 2 (DM2) en atención primaria. Diseño. Estudio aleatorizado de grupos. Emplazamiento. Consultas de atención primaria. Participantes. En total participaron 60 médicos de familia. Intervenciones. Los participantes fueron aleatorizados a seguir un protocolo de tratamiento intensivo de FRCV o a mantener su práctica habitual en pacientes con DM2. El seguimiento fue de 12 meses. Se recogieron datos acerca de la hemoglobina glucosilada, los FRCV y el riesgo cardiovascular al inicio del estudio y a los 12 meses. Resultados. Se incluyó a 188 pacientes (94 en el grupo de intervención y 94 en el grupo control). El riesgo cardiovascular basal en el grupo control (GC) fue del 36,3% (intervalo de confianza [IC] del 95%, 33,9-38,6%) y en el grupo de intervención (GI), del 35,9% (IC del 95%, 33,5-38,4%), sin diferencias significativas entre grupos. El riesgo cardiovascular a los 12 meses en el GC fue del 33,1% (IC del 95%, 30,0-36,1%) y en el GI del 30,5% (IC del 95%, 27,8-33,2%). La diferencia de riesgo cardiovascular a los 12 meses fue del ­2,9% (IC del 95%, 0,2-5,7%) en el GC y del ­5,4% (IC del 95%, 2,8-7,1%) en el GI. Conclusiones. Aunque se observa una disminución mayor del riesgo cardiovascular en el GI, la diferencia entre los grupos no es significativa. Las características de los médicos seleccionados pueden haber condicionado que los pacientes de ambos grupos hayan recibido un tratamiento similar

Objective. To evaluate a primary care protocol for intensive monitoring of cardiovascular risk (CVR) factors in type-2 diabetes patients versus usual care. Design. Randomised trial with clusters. Setting. Primary care clinics. Participants. Sixty family physicians. Interventions. Participants were randomised between following a protocol of intensive monitoring of CVR factors and maintaining their habitual practice with DM2 patients. Follow-up lasted 12 months. Data on HbA1C, CVR factors and CVR were collected at the start of the study and at 12 months. Results. In all, 188 patients (94 intervention group and 94 control group) were included. At baseline measurement, CVR in control group (CG) was 36.3% (95% CI, 33.9%-38.6%); and in intervention group (IG), 35.9% (95% CI, 33.5%-38.4%), with no significant differences between groups. At one year, CVR in CG was 33.1% (95% CI, 30%-36.1%) and in IG 30.5% (95% CI, 27.8%-33.2%). The CVR difference between baseline and 1-year measurements was 2.9% (95% CI, 0.2%-5.7%) in CG and 5.4% (95% CI, 2.8%-7.1%) in IG. Conclusions. Although improvement of CVR is greater in the IG, the difference between the two groups is not significant. The characteristics of the doctors chosen may have meant that the patients of the two groups received similar treatment

[Different uses of home blood pressure measurement in the diagnosis and monitoring of hypertension]. / Diferentes utilidades de la automedición de la presión arterial domiciliaria en el diagnóstico y seguimiento de la hipertensión arterial.

OBJECTIVE: To find differences between measurements of clinical blood pressure and self-monitored home blood pressure measurement (HBPM). DESIGN: Descriptive study developed in a general population census. SETTING: Primary care. SUBJECTS: A total of 1411 subjects > or =18 years old were selected by stratified randomized sampling. METHODS: A skilled nurse made 3 clinical blood pressure (CBP) measurements, and trained patients or their relatives in HBPM, doing 12 in one day. CBP and HBPM employed an electronic device (OMRON 705CP). RESULTS: A total of 12 HBPM from 1184 subjects (52% women) were completed, with a mean age of 47.6 (SD, 17.2); 195 subjects were known to have hypertension. White-coat effect was diagnosed in 14.9% of subjects with normal pressure, 22.3% of hypertense patients treated and 57.6% of subjects with suspicion of isolated clinical hypertension. Possible isolated clinical hypertension was diagnosed in 10% of subjects without hypertension. White Coat normal pressure was found in 2.3% of untreated subjects and 4.7% of subjects with treated hypertension. 20.7% of subjects with hypertension poorly controlled in the clinic were considered pseudo-refractory (11.4% at the end of dosage interval). 77% of subjects conducted HBPM on their own and 89% thought it easy to do so. CONCLUSION: Incorporation of HBPM into daily medical practice could avoid 20%-30% of possible mistakes in diagnosis and monitoring of hypertense patients.