Showing papers in "Revista Espanola De Cardiologia in 2011"

Factores de riesgo cardiovascular en España en la primera década del siglo xxi: análisis agrupado con datos individuales de 11 estudios de base poblacional, estudio DARIOS ☆

Abstract: Resumen Introduccion y objetivos Analizar la prevalencia de factores de riesgo cardiovascular en personas de 35-74 anos en 10 comunidades autonomas espanolas y determinar el grado de variabilidad geografica en la distribucion de los factores de riesgo cardiovascular. Metodos Analisis agrupado con datos individuales de 11 estudios desarrollados en la primera decada del siglo xxi con un promedio de tasa de participacion del 73%. Se midio el perfil lipidico (con validacion cruzada de laboratorios), glucemia, presion arterial, perimetro de la cintura, peso y talla y se administraron cuestionarios estandarizados. Se estimo la prevalencia estandarizada a la poblacion europea de tabaquismo, diabetes, hipertension arterial, dislipemia y obesidad. Ademas, se estimo el coeficiente de variacion entre estudios componentes en la prevalencia de cada factor de riesgo. Resultados Se incluyo a 28.887 participantes. Los factores de riesgo cardiovascular mas prevalentes fueron: hipertension arterial (el 47% en varones y el 39% en mujeres), dislipemia con colesterol total ≥ 250 mg/dl (el 43 y el 40%), obesidad (el 29% en ambos sexos), tabaquismo (el 33 y el 21%) y diabetes mellitus (el 16 y el 11%). El colesterol total ≥ 190 y ≥ 250 mg/dl presento el coeficiente de variacion minimo y maximo, respectivamente (el 7-24% en varones y el 7-26% en mujeres). La concordancia media en las determinaciones lipidicas entre laboratorios fue excelente. Conclusiones La prevalencia de hipertension arterial, dislipemia, obesidad, tabaquismo y diabetes mellitus, es elevada, con variabilidad relativamente baja en la poblacion de 35 a 74 anos entre comunidades autonomas. Canarias, Extremadura y Andalucia presentan mayor numero de factores de riesgo cardiovascular significativamente mas prevalentes que el promedio de los 11 estudios componentes.

Cardiovascular Risk Factors in Spain in the First Decade of the 21st Century, a Pooled Analysis With Individual Data From 11 Population-Based Studies: the DARIOS Study

Abstract: Introduction and objectives: To estimate the prevalence of cardiovascular risk factors in individuals aged 35-74 years in 10 of Spain’s autonomous communities and determine the geographic variation of cardiovascular risk factors distribution. Methods: Pooled analysis with individual data from 11 studies conducted in the first decade of the 21st century. The average response rate was 73%. Lipid profile (with laboratory crossvalidation), glucose level, blood pressure, waist circumference, height, and weight were measured and standard questionnaires administered. Age-standardized prevalence of smoking, diabetes, hypertension, dyslipidemia, and obesity in the European population were calculated. Furthermore, the coefficient of variation between component studies was determined for the prevalence of each risk factor. Results: In total, 28,887 participants were included. The most prevalent cardiovascular risk factors were high blood pressure (47% in men, 39% in women), total cholesterol � 250 mg/dL (43% and 40%, respectively), obesity (29% and 29%, respectively), tobacco use (33% and 21%, respectively), and diabetes (16% and 11%, respectively). Total cholesterol � 190 and � 250 mg/dL were the respective minimum and maximum coefficients of variation (7%-24% in men, 7%-26% in women). Average concordance in lipid measurements between laboratories was excellent. Conclusions: Prevalence of high blood pressure, dyslipidemia, obesity, tobacco use and diabetes is high. Little variation was observed between autonomous communities in the population aged 35-74 years. However, presence of the most prevalent cardiovascular risk factors in the Canary Islands, Extremadura and Andalusia was greater than the mean of the 11 studies.

[ESC/EAS Guidelines for the management of dyslipidaemias].

Abstract: Authors/Task Force Members: Alberico L. Catapano* (Chairperson) (Italy), Ian Graham* (Chairperson) (Ireland), Guy De Backer (Belgium), Olov Wiklund (Sweden), M. John Chapman (France), Heinz Drexel (Austria), Arno W. Hoes (The Netherlands), Catriona S. Jennings (UK), Ulf Landmesser (Germany), Terje R. Pedersen (Norway), Željko Reiner (Croatia), Gabriele Riccardi (Italy), Marja-Riita Taskinen (Finland), Lale Tokgozoglu (Turkey), W. M. Monique Verschuren (The Netherlands), Charalambos Vlachopoulos (Greece), David A. Wood (UK), Jose Luis Zamorano (Spain)

Justificación y métodos del estudio sobre nutrición y riesgo cardiovascular en España (ENRICA)

Abstract: Resumen Introduccion y objetivos El estudio ENRICA pretende medir la frecuencia y la distribucion de los principales componentes de la historia natural de la enfermedad cardiovascular en Espana, incluyendo el consumo alimentario y otros factores de riesgo conductuales, factores de riesgo biologicos, dano precoz en organos diana y morbilidad diagnosticada. Metodos Estudio transversal realizado de junio de 2008 a octubre de 2010 sobre 11.991 personas representativas de la poblacion no institucionalizada de 18 y mas anos de edad en Espana. La recogida de datos se hizo en tres etapas secuenciales: a) entrevista telefonica asistida por ordenador sobre estilos de vida, conocimiento y actitudes sobre factores de riesgo de enfermedad cardiovascular y sobre signos y sintomas de alerta de ataque al corazon e ictus, salud subjetiva y morbilidad; b) primera visita al domicilio, para obtener muestras de sangre y orina que se envian a un laboratorio central para las determinaciones analiticas, y c) segunda visita al domicilio, para realizar antropometria, medir presion arterial y completar historia dietetica electronica. De las personas de 65 y mas anos, se obtuvo informacion sobre limitaciones funcionales. Discusion El estudio ENRICA ha mostrado en Espana la factibilidad de un gran estudio con entrevista y examen fisico en los domicilios. Este estudio proporcionara informacion valiosa para orientar y evaluar las estrategias nacionales contra la enfermedad cardiovascular y otras enfermedades cronicas. Ademas, esta previsto que en el segundo semestre de 2011 comience el seguimiento durante 3 anos de los participantes en el estudio. Con ello se actualizara la informacion de estilos de vida y sobre variables biologicas obtenidas en un nuevo examen fisico (ClinicalTrials.gov number, NCT01133093 ).

Rationale and methods of the study on nutrition and cardiovascular risk in Spain (ENRICA)

Abstract: Introduction and objectives The ENRICA study aims to assess the frequency and distribution of the main components of the natural history of cardiovascular disease in Spain, including food consumption and other behavioral risk factors, biological risk factors, early damage of target organs, and diagnosed morbidity. Methods A cross-sectional survey of 11 991 individuals representative of the non-institutionalized population aged 18 years and older in Spain was conducted from June 2008 to October 2010. Data collection comprised 3 sequential stages: a) computer-assisted telephone interview to obtain information on lifestyle, knowledge and attitudes about cardiovascular disease risk factors, and the signs and symptoms of heart attack and stroke, subjective health, and morbidity; b) first homevisit, to collect blood and urine samples for analysis by a central laboratory, and c) second home visit, to measure anthropometric variables and blood pressure and to administer a computer-assisted dietary history; data on functional limitations are also collected from participants aged 65 years and older. Discussion The ENRICA study has shown the feasibility of a large home-based health interview and examination survey in Spain. It will provide valuable information to support and evaluate national strategies against cardiovascular disease and other chronic diseases in Spain. Moreover, a 3-year prospective follow-up of the study participants, including a new physical exam, is planned to start in the second semester of 2011 and will update lifestyle information and biological variables. (ClinicalTrials.gov number, NCT01133093 ).

Regression Modeling Strategies

Abstract: Multivariable regression models are widely used in health science research, mainly for two purposes: prediction and effect estimation. Various strategies have been recommended when building a regression model: a) use the right statistical method that matches the structure of the data; b) ensure an appropriate sample size by limiting the number of variables according to the number of events; c) prevent or correct for model overfitting; d) be aware of the problems associated with automatic variable selection procedures (such as stepwise), and e) always assess the performance of the final model in regard to calibration and discrimination measures. If resources allow, validate the prediction model on external data.

Validez relativa de la estimación del riesgo cardiovascular a 10 años en una cohorte poblacional del estudio REGICOR

Abstract: Introduction and objectives: Cardiovascular risk screening requires accurate risk functions. The relative validity of the Framingham-based REGICOR adapted function is analyzed and the population distribution of cardiovascular 10-year cardiovascular events is described by risk group. Methods: A population cohort of 3856 participants recruited between 1995 and 2000, aged 35 to 74 years from Girona without symptoms of cardiovascular diseases, was followed between 2006 and 2009. Standardized laboratory and blood pressure measurements, questionnaires, and case definitions were used. The follow-up combined cross-linkage of our databases with our regional mortality registry, reexamination, and telephone contact with participants. Coronary disease endpoints alone were considered. Results: A total of 27 487 person-years were obtained (mean follow-up 7.1 years), and the follow-up was achieved in 97% of participants (120 coronary disease events). Validity was good: the regression coefficients estimated with the cohort data did not differ from those obtained in the original Framingham function. Function calibration was good: the observed incidence of cardiovascular events in the decile groups of risk did not differ from the function prediction (P = .127 in women, and P = .054 in men). The C statistic (discrimination) was 0.82 (95% confidence interval , 0.76-0.88) in women, and 0.78 (95% confidence interval, 0.73-0.83) in men. More than 50% of cardiovascular events occurred in participants whose 10-year risk was 5% to 14.9%.

Análisis de la disminución de la mortalidad por enfermedad coronaria en una población mediterránea: España 1988-2005

Abstract: Resumen Introduccion y objetivos Examinar el grado en que la disminucion de las tasas de mortalidad por cardiopatia isquemica en Espana entre 1988 y 2005 podria explicarse por cambios en los factores de riesgo cardiovascular y por el uso de tratamientos medicos y quirurgicos. Metodos Se utilizo el modelo IMPACT previamente validado para combinar y analizar datos de las tendencias en la prevalencia de factores de riesgo y el uso y la efectividad de tratamientos cardiacos basados en la evidencia, entre varones y mujeres adultos de 35-74 anos de edad. Las principales fuentes de datos incluyeron estadisticas oficiales de mortalidad, resultados de estudios longitudinales, encuestas nacionales, ensayos clinicos aleatorizados y metaanalisis. La diferencia entre las muertes coronarias observadas y esperadas en 2005 se distribuyo entre los tratamientos y los factores de riesgo. Resultados Desde 1988 a 2005, la tasa de mortalidad ajustada por edad cayo un 40%, y hubo 8.530 muertes menos en 2005. Aproximadamente el 47% de la caida en la mortalidad se ha atribuido a los tratamientos. Los abordajes que contribuyeron en mayor medida fueron el tratamiento en fase aguda de los sindromes coronarios (11%), la prevencion secundaria (10%) y el tratamiento de la insuficiencia cardiaca (9%). El 50% de la reduccion de la mortalidad se ha atribuido a cambios en los factores de riesgo. El mayor beneficio en la mortalidad viene de los cambios en el colesterol total (cerca de un 31% de la caida de la mortalidad) y de la presion arterial sistolica (cerca de un 15%). Pero se observaron importantes diferencias entre sexos en las tendencias de los factores de riesgo: se incremento la diabetes mellitus y la obesidad entre los varones y la prevalencia del consumo de tabaco entre las mujeres jovenes, lo cual produjo muertes adicionales. Conclusiones Aproximadamente la mitad del descenso en la mortalidad coronaria en Espana se ha atribuido a la reduccion de los principales factores de riesgo y la otra mitad, a los tratamientos basados en la evidencia. Estos resultados incrementan la comprension de tendencias pasadas y ayudaran a planificar futuras estrategias preventivas y de tratamientos en poblaciones con bajo riesgo.

Revisiones sistemáticas y metaanálisis: bases conceptuales e interpretación

Abstract: Systematic reviews represent a specific type of medical research in which the units of analysis are the original primary studies. They are essential tools in synthesizing available scientific information, increasing the validity of the conclusions of primary studies, and identifying areas for future research. They are also indispensable for the practice of evidence-based medicine and the medical decision- making process. However, conducting high quality systematic reviews is not easy and they can sometimes be difficult to interpret. This special article presents the rationale for carrying out and interpreting systematic reviews and uses a hypothetical example to draw attention to key-points.

Analyzing the Coronary Heart Disease Mortality Decline in a Mediterranean Population: Spain 1988-2005

Abstract: Introduction and objectives To examine the extent to which the decrease in mortality rates in Spain between 1988 and 2005 could be explained by changes in cardiovascular risk factors and by the use of medical and surgical treatments. Methods We used the previously validated IMPACT model to examine the contributions of exposure factors (risk factors and treatments) to the main outcome, changes in the mortality rates of death from coronary heart disease, among adults 35 to 74 years of age. Main data sources included official mortality statistics, results of longitudinal studies, national surveys, randomized controlled trials, and meta-analyses. The difference between observed and expected coronary heart disease deaths in 2005 was then partitioned between treatments and risk factors. Results From 1988 to 2005, the age-adjusted coronary heart disease mortality rates fell by almost 40%, resulting in 8530 fewer coronary heart disease deaths in 2005. Approximately 47% of the fall in deaths was attributed to treatments. The major treatment contributions came from initial therapy for acute coronary syndromes (11%), secondary prevention (10%), and heart failure (9%). About 50% of the fall in mortality was attributed to changes in risk factors. The largest mortality benefit came from changes in total cholesterol (about 31% of the mortality fall) and in systolic blood pressure (about 15%). However, some substantial gender differences were observed in risk factor trends with an increase in diabetes and obesity in men and an increase in smoking in young women. These generated additional deaths. Conclusions Approximately half of the coronary heart disease mortality fall in Spain was attributable to reductions in major risk factors, and half to evidence-based therapies. These results increase understanding of past trends and will help to inform planning for future prevention and treatment strategies in low-risk populations.

Obesidad y corazón

Abstract: Excess weight is the most prevalent cardiovascular risk factor and certainly the factor that improves the least over time among those with established cardiovascular disease. The association between obesity and cardiovascular disease is complex and not limited to the standard risk factors like hypertension, dyslipidemia, and type 2 diabetes mellitus. In recent years, multiple studies have shown that obesity may cause cardiovascular diseases via multiple disease mechanisms like subclinical inflammation, endothelial dysfunction, increased sympathetic tone, atherogenic lipid profiles, enhanced thrombogenic factors and also through obstructive sleep apnea. Despite the overwhelming data linking obesity to cardiovascular disease, several studies have shown a paradoxical association between obesity and prognosis among those with coronary disease and heart failure, which may be due to limitations of the way we currently define obesity. There is abundant data suggesting that measuring central obesity or total body fat content might be more appropriate than using the body mass index alone. The management of obesity is challenging and studies using lifestyle modification alone or with pharmacologic agents generally have limited success and high levels of weight regain. Bariatric surgery has proven to be an effective and safe way to induce and maintain significant weight loss but is limited to those with medically complicated obesity or people who are severely obese.

Prevalencia y caracteristicas de la dislipemia en pacientes en prevencion primaria y secundaria tratados con estatinas en Espana. Estudio DYSIS-Espana

Abstract: Introduction and objectives: Patients at high risk of suffering cardiovascular events require medical treatment to optimize their lipid profile. The present analysis evaluates the lipid profiles among Spanish patients receiving statin therapy in the international DYSIS study. Methods: DYSIS is a multinational cross-sectional study carried out in Canada and Europe (n = 22,063). In Spain, 3710 patients treated with statin therapy for at least 3 months were included. We compared data relating to demographic parameters and cardiovascular risk profile. Results: Complete lipid profiles of 3617 patients were recorded. Regarding the high cardiovascular risk patients with complete lipid profiles (n = 2273), 78.9% had a disorder in at least one of the three main lipid parameters: low-density lipoprotein cholesterol (LDLc), high-density lipoprotein cholesterol (HDLc) and/or triglycerides. LDLc was not within target levels in 61.4% of these high risk patients; HDLc was abnormal in 25.3%, and triglycerides were elevated in 37.8%. Overall, LDLc was outside the target range in 63.1%, and 20.7% (n = 668) of those treated with statins were normal for all parameters. Conclusions: Most patients in this study who received statin therapy, particularly those at high cardiovascular risk, were not at the normal lipid parameter levels according to cardiovascular guidelines. Although it is necessary to wait for the final results of current studies on the use of combined lipidmodifying treatments, the management of lipid levels in Spain still has potential for improvement.

Influencia de la desnutrición en la mortalidad a largo plazo de pacientes hospitalizados por insuficiencia cardiaca

Abstract: Actualmente se desconoce la prevalencia de desnutricion entre los pacientes con insuficiencia cardiaca y el papel que este estado pudiera tener en su pronostico. El objetivo de este estudio es analizar la prevalencia y riesgo de desnutricion y su posible influencia en la mortalidad a largo plazo de los pacientes con insuficiencia cardiaca. Metodos Se analizo prospectivamente a 208 pacientes dados de alta consecutivamente desde nuestro centro entre enero de 2007 y marzo de 2008 tras un ingreso por insuficiencia cardiaca. Antes del alta, se realizo una completa valoracion nutricional y se realizo el diagnostico de desnutricion y riesgo de desnutricion mediante la encuesta Mini Nutritional Assessment. Su posible asociacion independiente con la mortalidad se valoro mediante un analisis multivariable de Cox. Resultados La media de edad fue 73±10 anos, el 46% eran mujeres y la etiologia mas frecuente de la insuficiencia cardiaca fue la isquemica (41%). El 13% de los pacientes fueron clasificados como desnutridos; el 59,5%, en riesgo de desnutricion y el 27,5%, bien nutridos. A los 25 meses (mediana de seguimiento), la mortalidad en los tres grupos fue del 76, el 35,9 y el 18,9% respectivamente (log-rank test, p<0,001). En el analisis multivariable de Cox, el estado de desnutricion resulto ser un predictor independiente de mortalidad (hazard ratio=3,75; intervalo de confianza del 95%, 1,75-8,02; p=0,001). Conclusiones La desnutricion y el de riesgo de desnutricion alcanzan una prevalencia elevada en pacientes hospitalizados por insuficiencia cardiaca. Ademas, hemos encontrado que el estado de desnutricion definido mediante el Mini Nutritional Assessment es un predictor independiente de mortalidad en estos pacientes

El corazón durante el embarazo

Abstract: During pregnancy, there are a number of important changes to cardiovascular function which are necessary for progression of a successful pregnancy. Additionally, preexisting cardiovascular conditions can be exacerbated by the adaptations that occur during gestation. These can present serious therapeutic challenges in the management of the cardiology patient during pregnancy. Significantly, the number of pregnant women at risk of cardiovascular complications is on the rise, so identification of risk factors that predict cardiac outcomes is essential to proper screening of the obstetrical patient. In diagnosed preexisting conditions, such as pulmonary hypertension, counseling is important prior to pregnancy. In the case of underlying disorders unmasked by pregnancy, or new-onset complications like preeclampsia, appropriate monitoring and treatment of the cardiovascular complications is warranted. Ultimately, collaborative care by both obstetricians and cardiologists is essential for the successful resolution of cardiovascular dysfunction in the obstetrical patient.

Análisis de riesgos competitivos

Abstract: The need to develop treatments and/or programs specific to a disease requires the analysis of outcomes to be specific to that disease. Such endpoints as heart failure, death due to a specific disease, or control of local disease in cancer may become impossible to observe due to a prior occurrence of a different type of event (such as death from another cause). The event which hinders or changes the possibility of observing the event of interest is called a competing risk. The usual techniques for time-to-event analysis applied in the presence of competing risks give biased or uninterpretable results. The estimation of the probability of the event therefore needs to be calculated using specific techniques such as the cumulative incidence function introduced by Kalbfleisch and Prentice. The model introduced by Fine and Gray can be applied to test a covariate when competing risks are present. Using specific techniques for the analysis of competing risks will ensure that the results are unbiased and can be correctly interpreted.

Relative Validity of the 10-Year Cardiovascular Risk Estimate in a Population Cohort of the REGICOR Study

Abstract: Introduction and objectives: Cardiovascular risk screening requires accurate risk functions. The relative validity of the Framingham-based REGICOR adapted function is analyzed and the population distribution of cardiovascular 10-year cardiovascular events is described by risk group. Methods: A population cohort of 3856 participants recruited between 1995 and 2000, aged 35 to 74 years from Girona without symptoms of cardiovascular diseases, was followed between 2006 and 2009. Standardized laboratory and blood pressure measurements, questionnaires, and case definitions were used. The follow-up combined cross-linkage of our databases with our regional mortality registry, reexamination, and telephone contact with participants. Coronary disease endpoints alone were considered. Results: A total of 27 487 person-years were obtained (mean follow-up 7.1 years), and the follow-up was achieved in 97% of participants (120 coronary disease events). Validity was good: the regression coefficients estimated with the cohort data did not differ from those obtained in the original Framingham function. Function calibration was good: the observed incidence of cardiovascular events in the decile groups of risk did not differ from the function prediction (P = .127 in women, and P = .054 in men). The C statistic (discrimination) was 0.82 (95% confidence interval, 0.76-0.88) in women, and 0.78 (95% confidence interval, 0.73-0.83) in men. More than 50% of cardiovascular events occurred in participants whose 10-year risk was 5% to 14.9%. Conclusions: The studied function accurately predicts coronary disease events at 10 years. Risk stratification could be simplified in 4 groups: low (<5%), moderate (5%-9.9%), high (10%-14.9%) and very

Impact of Malnutrition on Long-Term Mortality in Hospitalized Patients With Heart Failure

Abstract: Introduction and objectives The prevalence of malnutrition among patients with heart failure and the role it might play in prognosis is not currently known. The aim of this study was to analyse the prevalence and risk of malnutrition as well as its possible influence on long-term mortality in patients with heart failure. Methods A prospective analysis was conducted on 208 patients discharged consecutively from our centre between January 2007 and March 2008 after being hospitalised with heart failure. Before discharge, a complete nutritional assessment was performed and diagnosis of malnutrition and risk of malnutrition was done with the Mini Nutritional Assessment. Its possible independent association with mortality was assessed by a Cox multivariate analysis. Results The mean age of the patients was 73 ± 10 years, with 46% women; the most common aetiology of heart failure was ischaemia (41%). In addition, 13% were classified as malnourished, 59.5% at risk of malnutrition and 27.5% were well-nourished. At a median follow-up of 25 months, mortality in the three groups was 76%, 35.9% and 18.9%, respectively (log-rank, P Conclusions Malnutrition and the risk of malnutrition are highly prevalent in patients hospitalised for heart failure. Furthermore, we found that the state of malnutrition as defined by the Mini Nutritional Assessment survey is an independent predictor of mortality in these patients.

Propensity score methods for creating covariate balance in observational studies

Abstract: Randomization of treatment assignment in experiments generates treatment groups with approximately balanced baseline covariates. However, in observational studies, where treatment assignment is not random, patients in the active treatment and control groups often differ on crucial covariates that are related to outcomes. These covariate imbalances can lead to biased treatment effect estimates. The propensity score is the probability that a patient with particular baseline characteristics is assigned to active treatment rather than control. Though propensity scores are unknown in observational studies, by matching or subclassifying patients on estimated propensity scores, we can design observational studies that parallel randomized experiments, with approximate balance on observed covariates. Observational study designs based on estimated propensity scores can generate approximately unbiased treatment effect estimates. Critically, propensity score designs should be created without access to outcomes, mirroring the separation of study design and outcome analysis in randomized experiments. This paper describes the potential outcomes framework for causal inference and best practices for designing observational studies with propensity scores. We discuss the use of propensity scores in two studies assessing the effectiveness and risks of antifibrinolytic drugs during cardiac surgery.

Métodos de puntuación de propensión para crear una distribución equilibrada de las covariables en los estudios observacionales

Abstract: Resumen La asignacion aleatoria del tratamiento en los experimentos divide a los pacientes en grupos de tratamiento que estan aproximadamente equilibrados en cuanto a las covariables basales. Sin embargo, en los estudios observacionales, en los que la asignacion del tratamiento no es aleatoria, los pacientes de los grupos de tratamiento activo y de control difieren a menudo en covariables cruciales que estan relacionadas con las variables de respuesta. Estos desequilibrios en las covariables pueden conducir a estimaciones sesgadas del efecto del tratamiento. La puntuacion de propension (propensity score) es la probabilidad de que a un paciente con unas caracteristicas basales especificas se le asigne el tratamiento activo, y no el control. Aunque las puntuaciones de propension son desconocidas en los estudios observacionales, al parear o subclasificar a los pacientes segun las puntuaciones de propension estimadas, podemos disenar estudios observacionales que sean analogos a los experimentos aleatorios, con un equilibrio aproximado entre pacientes en cuanto a las covariables observadas. Los disenos de estudios observacionales basados en puntuaciones de propension estimadas pueden producir estimaciones aproximadamente insesgadas del efecto del tratamiento. Una cuestion crucial es que los disenos de puntuacion de propension deben crearse sin tener acceso a las respuestas, imitando la separacion entre el diseno del estudio y el analisis de las respuestas que es propia de los experimentos aleatorios. En este articulo se describen el marco conceptual de las respuestas potenciales para la inferencia causal y las mejores practicas para el diseno de estudios observacionales con puntuaciones de propension. Comentamos el uso de puntuaciones de propension en dos estudios en los que se evaluaron la efectividad y los riesgos de los farmacos antifibrinoliticos durante las cirugias cardiacas.

[Mitochondrial dynamics: a potential new therapeutic target for heart failure].

Abstract: A B S T R A C T Mitochondria are dynamic organelles able to vary their morphology between elongated interconnected mitochondrial networks and fragmented disconnected arrays, through events of mitochondrial fusion and fission, respectively. These events allow the transmission of signaling messengers and exchange of metabolites within the cell. They have also been implicated in a variety of biological processes including embryonic development, metabolism, apoptosis, and autophagy. Although the majority of these studies have been confined to noncardiac cells, emerging evidence suggests that changes in mitochondrial morphology could participate in cardiac development, the response to ischemia-reperfusion injury, heart failure, and diabetes mellitus. In this article, we review how the mitochondrial dynamics are altered in different cardiac pathologies, with special emphasis on heart failure, and how this knowledge may provide new therapeutic targets for treating cardiovascular diseases.

Estudio poblacional de la muerte subita cardiovascular extrahospitalaria: incidencia y causas de muerte en adultos de edad mediana

Abstract: Resumen Introduccion y objetivos Existen pocos trabajos sobre muerte subita cardiovascular extrahospitalaria en adultos de mediana edad. El objetivo de este estudio es analizar sus caracteristicas epidemiologicas y clinico-patologicas. Metodos Estudio poblacional de mortalidad cardiovascular en personas de 35-49 anos en Vizcaya entre 2003 y 2008. Se analizaron los datos del Registro de Mortalidad y del Servicio de Patologia Forense. Se identifico a los fallecidos por muerte subita extrahospitalaria sometidos a autopsia forense. Resultados De 465 muertes cardiovasculares, 216 fueron subitas. La principal causa fue la cardiopatia isquemica (n = 140/216). Otras fueron enfermedades del miocardio (n = 32), enfermedades cerebrovasculares (n = 19) y muerte subita arritmica en corazon estructuralmente normal (n = 10). Las causas variaron significativamente en razon del sexo y la edad. El 10% tenia antecedentes de enfermedad cardiovascular en vida; el 66%, factores de riesgo cardiovascular, y el 27% habia consumido recientemente etanol y/o drogas de abuso. La incidencia fue de 13,2 residentes/100.000 habitantes/ano. La incidencia fue 3,77 veces superior en varones que en mujeres y se incrementaba con la edad. Conclusiones La incidencia de muerte subita en Vizcaya fue menor que en otros paises industrializados. La mitad de las muertes cardiovasculares en adultos de mediana edad son muertes subitas extrahospitalarias, que afectan principalmente a sujetos sin enfermedad conocida en vida. El desarrollo de estrategias para identificar a las personas con mayor riesgo dentro de la poblacion general con bajo riesgo es esencial en la prevencion. Los estudios basados en autopsias forenses mejoran los conocimientos sobre mortalidad cardiovascular.

Amiloidosis. Tambien una enfermedad del corazon

Abstract: The term cardiac amyloidosis refers to the involvement of the heart as a result of amyloid deposition in heart tissue either in the context of a systemic disease or as a localized form. Several proamyloid proteins can produce amyloid deposits in the heart. Each of these amyloidoses has characteristic clinical (cardiac and extracardiac) features, its own course, and a specific diagnosis and treatment. Since cardiac involvement may be the first-manifestation of amyloidosis, the cardiologist may be the first healthcare professional to see the patient and must always consider this diagnosis. In this review, we consider the amyloidosis characteristics that may present with cardiac involvement, from the cardiologist's viewpoint and in light of our experience. We review in detail when and how to establish the diagnosis and how to treat these patients' cardiac involvement and the underlying amyloid disease.

Diagnosis and quantification of patent foramen ovale. Which is the reference technique? Simultaneous study with transcranial Doppler, transthoracic and transesophageal echocardiography

Abstract: Introduction and objectives: Patent foramen ovale (PFO) is the most common cause of cryptogenic stroke in patients younger than 55. Transesophageal echocardiography (TEE) has been accepted as the reference diagnostic technique. The purpose of this study was to compare the accuracy of transthoracic echocardiography (TTE), TEE and transcranial Doppler (TCD) in the diagnosis and quantification of patent foramen ovale. Methods: We studied 134 patients prospectively. Simultaneous TTE with TCD and TEE with TCD were performed, using agitated saline solution to detect right to left shunt. Results: In 93 patients diagnosed with PFO, the shunt was visualized at baseline by TCD in 69% of cases, by TTE in 74% and by TEE in 58%. The Valsalva maneuver produced a similar improvement in shunt diagnosis with all 3 techniques (26%-28%). TTE and TCD showed higher sensitivity (100% vs 97%; non significant difference) than TEE in the diagnosis of PFO (86%; P < .001). TCD performed during TEE did not diagnose 12 (13%) shunts previously diagnosed during TTE. Similarly, TEE underestimated shunt severity. Conclusions: TTE enables adequate diagnosis and quantification of PFO. TEE is less sensitive and tends to

Registro Español de Marcapasos. VIII Informe Oficial de la Sección de Estimulación Cardiaca de la Sociedad Española de Cardiología (2010)

Abstract: Resumen Introduccion y objetivos En este articulo se describe el analisis de los implantes y recambios de marcapasos remitidos al Registro Espanol de Marcapasos en 2010, con especial referencia a la seleccion de los modos de estimulacion. Metodos La recogida de datos se basa en la informacion de la Tarjeta Europea del Paciente Portador de Marcapasos, que se procesa mediante una aplicacion informatica especifica. Resultados Se recibio informacion de 101 centros hospitalarios, con un total de 11.648 tarjetas. Se estima un consumo de 738 generadores por millon de habitantes. Entre los varones hay mayor incidencia de implantes de marcapasos y a una media de edad mas baja. El 95,5% de los cables de estimulacion utilizados fueron bipolares, el 56% con sistema de fijacion activa y el 60% en cavidad auricular. La indicacion electrocardiografica mas frecuente es el bloqueo auriculoventricular, seguida de la enfermedad del nodulo sinusal. El 24% de los pacientes con bloqueo auriculoventricular y el 25,6% con enfermedad del nodulo sinusal se estimulan en modo VVI/R (el 12% de unos y otros entre los pacientes de 80 o menos anos). Los dispositivos de resincronizacion cardiaca alcanzan 47 unidades por millon de habitantes; un 25,7% no tiene desfibrilador automatico implantable asociado. Conclusiones Persiste el aumento del consumo de generadores de marcapasos. Los cables de estimulacion que se utilizan son bipolares, y en su mayoria son de fijacion activa. La edad sigue siendo un factor influyente en la adecuacion del modo de estimulacion en las diversas afecciones. La eleccion del modo de estimulacion se puede mejorar en mas del 20%.

Reducción de la mortalidad precoz y a 6 meses en pacientes con IAM en el periodo 1995-2005. Datos de los registros PRIAMHO I, II y MASCARA

Abstract: Resumen Introduccion y objetivos Determinar el cambio en la mortalidad a corto y medio plazo por infarto agudo de miocardio en Espana y los factores terapeuticos relacionados. Metodos Se identifico y se siguio durante 6 meses a 9.949 pacientes con infarto agudo de miocardio con elevacion del ST ingresados en la unidad coronaria en los registros PRIAMHO I, II y MASCARA realizados en 1995, 2000 y 2005. Resultados En el periodo 1995-2005 aumento (p Conclusiones La mortalidad precoz y a los 6 meses del infarto con elevacion del ST disminuyo en 1995-2005. Los factores terapeuticos relacionados son: incremento de la reperfusion y mayor utilizacion de antitromboticos, bloqueadores beta, inhibidores del sistema renina-angiotensina e hipolipemiantes.

High-Flow therapy via nasal cannula in acute heart failure.

Abstract: Various oxygenization methods are used in the treatment of respiratory failure in acute heart failure. Occasionally, after patients are stabilized by these ventilation methods, some maintain a degree of dyspnea or hypoxemia which does not improve and is unrelated to deterioration in the functional class or the need to optimize pharmacological treatment. High-flow oxygen systems administered via nasal cannula that are connected to heated humidifiers (HFT) are a good alternative for oxygenation, given that they are easy to use and have few complications. We studied a series of 5 patients with acute heart failure due to acute pulmonary edema with stable dyspnea or hypoxemia following noninvasive ventilation. All the patients were successfully treated with HFT, showing clinical and gasometric improvement and no complications or technical failures. We report our experience and discuss different aspects related to this oxygenation system.

Tratamiento y control de los factores de riesgo según el riesgo coronario en la población española del estudio DARIOS

Abstract: Resumen Introduccion y objetivos Tratar y controlar los factores de riesgo cardiovascular es una estrategia fundamental de prevencion primaria. El objetivo es analizar la proporcion de poblacion de prevencion primaria de 35-74 anos tratada y controlada, segun niveles de riesgo coronario. Metodos Analisis agrupado con datos individualizados de 11 estudios poblacionales de la primera decada del siglo xxi . Se utilizaron cuestionarios estandarizados y medidas de presion arterial, glucohemoglobina y perfil lipidico. Se considero buen control con presion arterial Resultados Se incluyo a 27.903 participantes (el 54% mujeres). Recibian tratamiento farmacologico el 68 y el 73% de los varones y las mujeres con antecedentes de hipertension, respectivamente (p Conclusiones La proporcion de personas con buen control es del 65% en el mejor de los casos. Los criterios de control de la hipercolesterolemia de las Sociedades Europeas apenas se alcanzan. El tratamiento hipolipemiante no se prioriza en personas de riesgo coronario alto.

An introduction to competing risks analysis

Abstract: The need to develop treatments and/or programs specific to a disease requires the analysis of outcomes to be specific to that disease. Such endpoints as heart failure, death due to a specific disease, or control of local disease in cancer may become impossible to observe due to a prior occurrence of a different type of event (such as death from another cause). The event which hinders or changes the possibility of observing the event of interest is called a competing risk. The usual techniques for time-to-event analysis applied in the presence of competing risks give biased or uninterpretable results. The estimation of the probability of the event therefore needs to be calculated using specific techniques such as the cumulative incidence function introduced by Kalbfleisch and Prentice. The model introduced by Fine and Gray can be applied to test a covariate when competing risks are present. Using specific techniques for the analysis of competing risks will ensure that the results are unbiased and can be correctly interpreted. Full English text available from: www.revespcardiol.org.

Terapia de alto flujo de oxígeno con cánulas nasales en la insuficiencia cardiaca aguda

Abstract: Resumen En el tratamiento de la insuficiencia respiratoria en la insuficiencia cardiaca aguda se utilizan diferentes metodos de oxigenacion. En ocasiones los pacientes, tras ser estabilizados con dichos modos ventilatorios, mantienen un grado de disnea o hipoxemia que no mejora y no es atribuible a un empeoramiento del grado funcional o la necesidad de optimizar el tratamiento farmacologico. Los sistemas de alto flujo con interfase nasal con un calentador humidificador acoplado (AFHC) son una buena alternativa como metodo de oxigenacion, de facil aplicacion y escasas complicaciones. Presentamos una serie de 5 pacientes con insuficiencia cardiaca aguda por edema agudo de pulmon con disnea o hipoxemia mantenidas tras la aplicacion de ventilacion no invasiva. Todos ellos fueron tratados con sistemas de AFHC de forma satisfactoria, con mejoria clinica y gasometrica, sin complicaciones ni fracasos de la tecnica. Describimos nuestra experiencia y discutimos diversos aspectos relacionados con dicho sistema de oxigenacion.