Search

Introduction and Objectives: The optimal chronic antithrombotic regimen for patients with atrial fibrillation undergoing transcatheter aortic valve implantation (TAVI) remains uncertain. Our aim was to compare the incidence of late bleeding events between patients on direct oral anticoagulants (DOACs) and those on vitamin-K antagonists (VKA)., Methods: This single-center observational study included TAVI patients requiring oral anticoagulation at discharge between 2015 and 2021. The primary endpoint was any clinically significant bleeding event. Secondary endpoints were stroke, heart failure, and all-cause mortality., Results: A total of 702 TAVI procedures were performed, with 297 patients requiring oral anticoagulation at discharge. Among them, 206 (69.4%) received VKA and 91 (30.6%) received DOAC. Baseline clinical, procedural and in-hospital characteristics did not significantly differ between groups, except for better renal function among DOAC patients. The median length of follow-up was 2.8 years. The risk of bleeding events was higher in patients receiving DOACs than in those receiving VKA (HR, 2.27; 95%CI, 1.21-4.26; incidence of 9.7 and 4.2 events per 100 patient-years of follow-up for DOAC and VKA patients, respectively). There were no statistically significant differences in the rates of stroke (HR, 1.28; 95%CI, 0.4-4.3), heart failure hospitalization (HR, 0.92; 95%CI, 0.46-1.86), or all-cause mortality (HR, 1.02; 95%CI, 0.68-1.55)., Conclusions: In older patients undergoing TAVI and receiving anticoagulant therapy for atrial fibrillation, the use of DOAC was associated with a higher risk of late bleeding events than VKA., (Copyright © 2024 Sociedad Española de Cardiología. Published by Elsevier España, S.L.U. All rights reserved.)

Competing Interests: CONFLICTS OF INTEREST P. Avanzas is Associate Editor at Revista Española de Cardiología. The journal's editorial procedure has been followed to guarantee the impartial handling of this manuscript. The other authors declare that they have no conflicts of interest.

Navigation in total knee arthroplasties has been recommended in recent years to facilitate the technique and improve its results. An extensive literature has compared it with conventional surgery, but its superiority has not been able to be demonstrated. Given the abundant bibliography and disparity in their conclusions, a good number of meta-analyses have been published that have attempted to summarize and schematize the results. We have reviewed 41 published meta-analyses comparing both techniques. Most of them have focused on the placement of implants and the restoration of the axes of the extremity, demonstrating the superiority of navigation. On the contrary, no clinically valuable differences have been observed when analyzing the clinical and functional results. However, navigation allows a dynamic view of the knee, an objective evaluation of the soft tissues and ligaments, and is essential for functional alignment as an individualized technique.

Introduction and Objectives: There is controversy about the optimal revascularization strategy in severe coronary artery disease (CAD), including left main disease and/or multivessel disease. Several meta-analyses have analyzed the results at 5-year follow-up but there are no results after the fifth year. We conducted a systematic review and meta-analysis of randomized clinical trials, comparing results after the fifth year, between coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) using drug-eluting stents in patients with severe CAD., Methods: We analyzed all clinical trials between January 2010 and January 2023. The primary endpoint was all-cause mortality. The databases of the original articles were reconstructed from Kaplan-Meier curves, simulating an individual-level meta-analysis. Comparisons were made at certain cutoff points (5 and 10 years). The 10-year restricted median survival time difference between CABG and PCI was calculated. The random effects model and the DerSimonian-Laird method were applied., Results: The meta-analysis included 5180 patients. During the 10-year follow-up, PCI showed a higher overall incidence of all-cause mortality (HR, 1.19; 95%CI, 1.04-1.32; P=.008)]. PCI showed an increased risk of all-cause mortality within 5 years (HR, 1.2; 95%CI, 1.06-1.53; P=.008), while no differences in the 5-10-year period were revealed (HR, 1.03; 95%CI, 0.84-1.26; P=.76). Life expectancy of CABG patients was slightly higher than that of PCI patients (2.4 months more)., Conclusions: In patients with severe CAD, including left main disease and/or multivessel disease, there was higher a incidence of all-cause mortality after PCI compared with CABG at 10 years of follow-up. Specifically, PCI has higher mortality during the first 5 years and comparable risk beyond 5 years., (Copyright © 2023 Sociedad Española de Cardiología. Published by Elsevier España, S.L.U. All rights reserved.)

Introduction and Objectives: Transcatheter aortic valve implantation (TAVI) using the cusp overlap technique (COT) has shown a lower pacemaker implantation rate at 30 days. The objective of this study was to compare electrocardiogram changes and clinical outcomes between COT and the traditional technique (TT) at 1 year of follow-up., Methods: Observational, retrospective, nonrandomized study of consecutive patients undergoing TAVI between January 2015 and January 2021. Patients were matched using a propensity score and the TT was compared with COT. The primary endpoints were electrocardiogram changes and a combined endpoint including pacemaker implantation, hospitalization, or cardiovascular death at 1 year., Results: We included 254 patients. After propensity score matching, 184 patients (92 per group) remained. There were no statistically significant differences in baseline characteristics. At 1 year, COT patients showed a significant reduction in new onset left bundle branch block (49% vs 27%, P=.002) and less P wave (13.1±21.0 msec vs 5.47±12.5 msec; P=.003) and QRS prolongation (29.77±27.0 msec vs 16.38±25.4 msec, P <.001). COT was associated with a significant reduction in the occurrence of the primary endpoint (SHR, 0.39 [IC95%, 0.21-0.76]; P=.005)., Conclusions: At 1 year of follow-up, COT reduced the incidence of new onset left bundle branch block and diminished QRS and P wave widening compared with the TT. COT was also associated with a statistically significant reduction in the occurrence of the combined primary cardiovascular endpoint., (Copyright © 2023 Sociedad Española de Cardiología. Published by Elsevier España, S.L.U. All rights reserved.)

Introduction and Objectives: Despite medical advances, mortality after ST-elevation myocardial infarction (STEMI) remains high. Women are often underrepresented in trials and registries, limiting knowledge of their management and prognosis. It is unknown whether life expectancy in women of all ages treated with primary percutaneous coronary intervention (PPCI) is similar to that in a reference population free of the disease. The main objective of this study was to determine whether life expectancy in women undergoing PPCI and surviving the main event returns to a similar level to that in the general population of the same age and region., Methods: We included all patients diagnosed with STEMI from January 2014 to October 2021. We matched women to a reference population of the same age and region from the National Institute of Statistics to determine observed survival, expected survival, and excess mortality (EM) using the Ederer II method. We repeated the analysis in women aged ≤ 65 and> 65 years., Results: A total of 2194 patients were recruited, of whom 528 were women (23.9%). In women surviving the first 30 days, EM at 1, 5 and 7 years was 1.6% (95%CI, 0.3-4), 4.7% (95%CI, 0.3-10.1), and 7.2% (95%CI, 0.5-15.1), respectively., Conclusions: EM was reduced in women with STEMI who were treated with PPCI and who survived the main event. However, life expectancy remained lower than that in a reference population of the same age and region., (Copyright © 2023 Sociedad Española de Cardiología. Published by Elsevier España, S.L.U. All rights reserved.)

Objectives: To analyze whether urinary catheterization in a hospital emergency department (ED) affects short-term prognosis in patients with acute heart failure (AHF)., Material and Methods: We prospectively recorded baseline and other clinical data in a consecutive cohort of ED patients treated for AHF. Crude and adjusted associations were calculated between catheterization and a primary composite outcome (30-day readmission for AHF and/or death) and secondary outcomes (in-hospital mortality, urinary tract infection [UTI], and duration of hospital stay.)., Results: Nine hundred ninety-one patients were admitted for AHF. The mean (SD) age was 66 (10.5) years; 71% were women. Catheterization was required for 29.2% in the ED. The primary composite outcome was observed in 7.7% of the patients who were not catheterized and 12.8% of the catheterized patients (P = .02). In-hospital mortality occurred in 5.9% and 9.7% of non-catheterized and catheterized patients, respectively (P = .04), and UTIs occurred in 19.1% and 26.6% (P = .01). Twelve of the non-catheterized patients (1.7%) were readmitted for AHF (vs 11 (3.8%) of the catheterized patients (P = .06), and there were no differences between the groups in hospital stay (11 vs 10.9 days, P = .78). In the adjusted analysis of associations between catheterization and the primary outcome the odds and hazard ratios (OR and HR, respectively) were OR, 1.7 (95% CI, 1.1-2.7) (P = .02) and HR, 1.6 (95% CI, 1.1-2.5) (P = .03). For secondary outcomes, significant associations emerged between catheterization and UTIs (OR, 1.8 [95% CI, 1.1-2.2]; P = .008) and readmission for AHF (OR, 2.9 [95% CI, 1.2-7.3]; P = .02)., Conclusion: Routine insertion of a urinary catheter in patients with AHF in the ED is associated with worse 30-day clinical outcomes.

Introduction and Objectives: Severe tricuspid regurgitation (TR) is associated with poor prognosis when left untreated, and a growing number of studies on transcatheter tricuspid valve repair (TTVr) have been published over the last few months., Methods: We performed a comprehensive systematic review of published literature providing clinical data on TTVr for patients with significant TR. Early and mid-term clinical and echocardiographic outcomes were evaluated. Risk ratios (RR) or mean differences (MD) were obtained when comparing pre- and postprocedural data. A sensitivity analysis was also performed according to the main approach for repair (edge-to-edge vs annuloplasty)., Results: A total of 19 studies (all observational or single-arm trials) and 991 patients who underwent isolated TTVr were included. Thirty-day mortality and stroke rates were 2.8% and 0.2%, respectively. Pooled random-effects resulted in a significant reduction of ≥ severe TR (RR, 0.33; 95%CI, 0.26-0.42; P < .001), vena contracta width (MD, 5.9mm; 95%CI, 4-7.9; P <.001), right ventricular end-diastolic diameter (MD, 3.5mm; 95%CI, 2.5-4.5; P <.001), and New York Heart Association (NYHA) class III or IV at last follow-up (RR, 0.32; 95%CI, 0.27-0.37; P <.001). Bleeding complications and residual ≥ severe TR were numerically higher in the annuloplasty-like group compared with edge-to-edge repair (13.3% vs 3.8% for bleeding and 40.4% vs 27.9% for residual severe TR)., Conclusions: Among 991 patients comprising the early experience for several TTVr devices, there was a statistically significant reduction in ≥ severe TR, NYHA class III-IV, vena contracta width and right ventricular end-diastolic diameter after TTVr. Thus far, the edge-to-edge approach seems to be associated with a better safety profile., (Copyright © 2022 Sociedad Española de Cardiología. Published by Elsevier España, S.L.U. All rights reserved.)

Objectives: The midazolam vs morphine (MIMO) trial showed that patients treated with midazolam had fewer serious adverse events than those treated with morphine. In many patients with acute pulmonary edema, the left ventricular ejection fraction (LVEF) is preserved, at 50% or higher. We aimed to determine whether left ventricular (LV) systolic dysfunction (D), defined by an LVEF of less than 50%, modifies the protective effect of midazolam vs morphine., Material and Methods: The MIMO trial randomized 111 patients with acute pulmonary edema to receive intravenous midazolam in 1-mg doses to a maximum of 3 mg (n = 55) or morphine in 2- to 4-mg doses to a maximum of 8 mg (n= 56). We calculated the relative risk (RR) for a serious adverse event in patients with and without systolic LVD., Results: LVEF was preserved in 84 (75.7%) of the patients with acute pulmonary edema. In patients with systolic LVD, 4 patients (26.9%) in the midazolam arm vs 6 (50%) in the morphine arm developed serious adverse events (RR, 0.53; 95% CI, 0.2-1.4). In patients without systolic LVD, 6 patients (15%) in the midazolam arm vs 18 (40.9%) in the morphine arm experienced such events (RR, 0.37; 95% CI, 0.16-0.83). The presence of systolic LVD did not modify the protective effect of midazolam on serious adverse effects (P=.57)., Conclusion: The effect of midazolam vs morphine in protecting against the development of serious adverse events or death is similar in patients with and without systolic LVD.

Introduction and Objectives: Surgical aortic valve replacement (SAVR) can modify the natural history of severe aortic stenosis (SAS). However, compared with the general population, these patients have a loss of life expectancy. The life expectancy of patients who undergo SAVR due to low-gradient SAS with preserved left ventricular ejection fraction (LVEF) is unknown., Methods: We included all patients between 50 and 65 years who underwent isolated SAVR in 27 Spanish centers during an 18-year period. We analyzed observed and expected survival at 18 years in patients with low-gradient SAS with preserved LVEF and all other types of SAS. We used propensity score matching to compare the life expectancy of patients with low-gradient SAS with preserved LVEF vs those with high-gradient SAS with preserved LVEF., Results: We analyzed 5084 patients, of whom 413 had low-gradient SAS with preserved LVEF. For these patients, observed survival at 10, 15 and 18 years was 86.6% (95%CI, 85.3-87.8), 75% (95%CI, 72.7-77.2), and 63.5% (95%CI, 58.8-67.8). Expected survival at 10, 15 and 18 years was 90.2%, 82.1%, and 75.7%. In the matched sample, survival of patients with low-gradient SAS with preserved LVEF was similar to that of patients with high-gradient with preserved LVEF, log-rank test, P=.95; HR=1 (95%CI, 0.7-1.4; P=.95)., Conclusions: There is a loss of life expectancy in patients with all types of SAS undergoing SAVR. This loss is higher in patients with left ventricular dysfunction and lower in patients with low-gradient or high-gradient aortic stenosis with preserved LVEF. The benefit of surgery is similar between these last 2 groups., (Copyright © 2022 Sociedad Española de Cardiología. Published by Elsevier España, S.L.U. All rights reserved.)

Objectives: To analyze gender disparity in scientific productivity reflected by the authorship of articles in the journal Emergencias over the past decade., Material and Methods: Retrospective longitudinal study. We included articles in all issues published between January 2011 and December 2020, analyzing the number of authors, their gender, article type, year of publication, and preferential authorship credit (first author, corresponding author, and last author positioning). The percentages of women named in each position were calculated, and the trend over time was analyzed., Results: A total of 1240 articles signed by 5213 authors were collected; a woman was named in 1889 of the cases (36.2%). A woman was the first author of 384 articles (31%), the corresponding author of 352 (28.4%), and the last author of 358 (28.9%). The number of female authors of original research articles or meta-analyses tended to increase over time (P = .047), but no statistically significant gender trends were observed in the authorship of editorials, narrative reviews, scientific letters or short communications, letters to the editor, or any other publication category., Conclusion: The publication of articles by women in Emergencias has increased over the past decade. However, women continue to author fewer articles than men.

Introduction and Objectives: This study aimed to determine the safety and efficacy of modifying the classic implantation technique for aortic transcatheter heart valve (THV) implantation to a cusp-overlap-projection (COP) technique to achieve a higher implantation depth and to reduce the burden of new permanent pacemaker implantation (PPMI) at 30 days. Aortic self-expanding THV carries an elevated risk for PPMI. A higher implantation depth minimizes the damage in the conduction system and may reduce PPMI rates., Methods: From March 2017, 226 patients were consecutively included: 113 patients were treated using the COP implantation technique compared with the previous 113 consecutive patients treated using the classic technique. In all patients, implantation depth was assessed by 3 methods (noncoronary cusp to the THV, mean of the noncoronary cusp and the left coronary cusp to the THV, and the deepest edge from the left coronary cusp and the noncoronary cusp to the THV)., Results: The COP group had a lower implantation depth than the group treated with the classic technique (4.8 mm± 2.2 vs 5.7 mm± 3.1; P=.011; 5.8 mm± 3.1 vs 6.5 mm± 2.4; P=.095; 7.1 mm± 2.8 vs 7.4 mm±3.2; P=.392). Forty patients (17.7%) required a new PPMI after the 30-day follow-up but this requirement was significantly lower in the COP group (12.4% vs 23%, P=.036). The COP implantation technique consistently protected against the main event (OR, 0.45; 95%CI, 0.21-0.97; P=.043), with similar procedural success rates and complications., Conclusions: The COP implantation technique is a simple modification of the implantation protocol and provides a higher implantation depth of self-expanding-THV with lower conduction disturbances and PPMI rates., (Copyright © 2021 Sociedad Española de Cardiología. Published by Elsevier España, S.L.U. All rights reserved.)

Introduction and Objectives: In young patients with severe aortic stenosis, it is unknown whether their life expectancy restored after aortic valve replacement (AVR) is unknown., Methods: We analyzed all patients aged between 50 and 65 years who underwent isolated AVR in 27 Spanish centers during an 18-year period. We compared observed and expected survival at 15 years of follow-up. We repeated all analyses for patients without complications in the postoperative period., Results: A total of 5084 patients were analyzed. For the overall sample, observed survival at 10 and 15 years was 85.3% (95%CI, 84.1%-86.4%) and 73.7% (95%CI, 71.6%-75.6%), respectively. Expected survival was 90.1% and 82.1%. Cumulative relative survival for 1, 5, 10 and 15 years of follow-up was 97.4% (95%CI, 96.9%-97.9%), 96.5% (95%CI, 95.7%-97.3%), 94.7% (95%CI, 93.3%-95.9%), and 89.8% (95%CI, 87.3%-92.1%). For patients without complications, cumulative relative survival for 1, 5, 10 and 15 years was 100.3% (95%CI, 99.8%-100.5%), 98.9% (95%CI 97.6% -99.9%), 97.3% (95%CI, 94.9%-99.4%), and 91.9% (95%CI, 86.5%-96.8%)., Conclusions: Life expectancy in young patients who have severe aortic stenosis and undergo AVR is lower than that of the general population. Life expectancy of individuals without complications during the postoperative period is also reduced. Therefore, baseline characteristics are likely the main factors that explain the reduction in life expectancy., (Copyright © 2021 Sociedad Española de Cardiología. Published by Elsevier España, S.L.U. All rights reserved.)

Introduction and Objectives: In the last few decades, there has been a continuous process of improvement in medical treatment and secondary prevention measures after ST-segment elevation myocardial infarction (STEMI). Patients older than 65 years are at increased risk of death due to this event. Our aim was to determine whether patients aged less than 65 years and 65 years and older experiencing a STEMI can recover a life expectancy similar to that of the general population of the same age, sex, and geographical region., Methods: We included all patients experiencing a STEMI at our institution during a 6-year period in an observational-study (SurviSTEMI: survival in STEMI). We calculated their observed survival, expected survival, and excess mortality. We repeated all analyses for survivors of the acute event stratifying by 65 years., Results: For patients aged <65 years who survived the STEMI, observed survival at 3 and 5 years of follow-up was 97.68% (95%CI, 96.05%-98.64%) and 94.14% (95%CI, 90.89%-96.25%), respectively. Expected survival at 3 and 5 years was 98.12% and 96.61%. For patients ≥ 65 years who survived the STEMI, observed survival at 3 and 5 years was 85.52% (95%CI, 82.23%-88.24%) and 75.43% (95%CI, 70.26%-79.83%), respectively. Expected survival at 3 and 5 years was 86.48% and 76.56%, respectively., Conclusions: For survivors of the acute event, life expectancy is fairly similar to that of the general population of the same age, sex, and geographical region., (Copyright © 2020 Sociedad Española de Cardiología. Published by Elsevier España, S.L.U. All rights reserved.)

Introduction and Objectives: To help to illustrate the trends in isolated surgical aortic valve replacement (SAVR) in Spain, we performed a national-level analysis to investigate the changes from 1998 to 2017 in a) SAVR volume, b) patients' risk profiles, c) in-hospital mortality, and d) types of aortic valve prostheses., Methods: We included all episodes of patients undergoing isolated SAVR from January 1998 to December 2017 recorded in the Minimum Basic Data Set (Ministry of Health, Consumer Affairs, and Social Welfare, Spain). The study duration was divided into four 5-year periods. We analyzed the trends in SAVR volume, comorbidity prevalence, and in-hospital mortality. Through multivariate logistic regression, we identified factors associated with mortality and type of prosthesis. The risk-adjusted mortality rate was compared over the study period., Results: In total, 73 668 patients underwent an isolated SAVR from 1998 to 2017. The annual volume of procedures increased from 16 363 between 1998 and 2002 to 22 685 between 2013 and 2017. The prevalence of all investigated comorbidities increased, except for history of previous myocardial infarction and unplanned admission. The Charlson comorbidity index worsened from 1998-2002 (2.3; SD, 1.4) to 2013-2017 (3.6; SD, 1.7) (P <.001). In-hospital mortality decreased from 7.2% to 3.3% (P <.001) while the risk-adjusted mortality index improved from 1.3 to 0.7. The proportion of bioprostheses increased from 20.7% (1998-2002) to 59.6% (2013-2017) (P <.001)., Conclusions: We detected an increase in the annual SAVR volume in Spain, with more patients receiving bioprostheses. Despite an increased risk profile of the patients, in-hospital mortality substantially reduced., (Copyright © 2020 Sociedad Española de Cardiología. Published by Elsevier España, S.L.U. All rights reserved.)

Introduction and Objectives: Asian desert dust has recently been recognized as a trigger for acute myocardial infarction. The inflow of dust from the Sahara into Spain impairs air quality due to an increase in particulate matter concentrations in the ambient air. The aim of the present study was to elucidate whether Saharan dust events are associated with the incidence of acute coronary syndrome (ACS) in patients living near North Africa, the major global dust source., Methods: We prospectively collected data on hospitalizations due to ACS in 2416 consecutive patients from a tertiary care hospital (Canary Islands, Spain) from December 2012 to December 2017. Concentrations of particulate matter with an aerodynamic diameter 10 microns or smaller (PM 10 ) and reactive gases were measured in the European Air Quality Network implemented in the Canary Islands. We applied the time-stratified case crossover design using conditional Poisson regression models to estimate the impact of PM 10 Saharan dust events on the incidence of ACS., Results: The occurrence of Saharan dust events observed 0 to 5 days before the onset of ACS was not significantly associated with the incidence of ACS. Incidence rate ratios (IRR) of PM 10 levels 1, 2, 3, 4 and 5 days before ACS onset (for changes in 10μg/m 3 ) were 1.27 (95%CI, 0.87-1.85), 0.92 (95%CI, 0.84-1.01), 0.74 (95%CI, 0.45-1.22), 0.98 (95%CI, 0.87-1.11), and 0.95 (95%CI, 0.84-1.06), respectively., Conclusions: Exposure to Saharan desert dust is unlikely to be associated with the incidence of ACS., (Copyright © 2020 Sociedad Española de Cardiología. Published by Elsevier España, S.L.U. All rights reserved.)

Introduction and Objectives: Severe symptomatic aortic stenosis carries a very poor prognosis. Transcatheter aortic valve replacement has been demonstrated to change the natural history of the disease. However, it is not known whether the probability of survival in older patients receiving this treatment returns to a similar value to that in the general population. Our objective was to determine survival in these patients vs that in the general population., Methods: We retrospectively analyzed the survival curves of patients older than 75 years who underwent transcatheter aortic valve implantation (TAVI) at our hospital and compared them with those in the general population of the same age, sex, and geographic region by using data from the Spanish National Institute of Statistics., Results: We analyzed 526 patients. Among postoperative survivors, survival curves were similar between the 2 groups during most of the follow-up. In TAVI patients, the probability of survival at 1, 3, 5, and 8 years of follow-up was 90.58% (confidence interval [CI] 95%, 87.54-92.91), 72.51% (95%CI, 67.38-76.97), 53.23% (95%CI, 46.52-59.48), and 35.73% (95%CI, 27.72-43.80). In the reference population, these percentages were 91.93%, 75.63%, 59.6%, and 37.47%., Conclusions: Long-term survival in elderly patients undergoing TAVI is influenced by postoperative mortality. In patients surviving the postoperative period, the probability of survival returns to a similar value to that in the general population of the same age, sex, and geographical area., (Copyright © 2019 Sociedad Española de Cardiología. Published by Elsevier España, S.L.U. All rights reserved.)

Introduction: Blood cobalt (Co) and chromium (Cr) ion levels have been used as surveillance tools for adverse reaction to metal debris in metal-on-metal (MoM) hip arthroplasty. The aim of our study was to present serial 7-13 year blood Co and Cr levels in a cohort of MoM total hip arthroplasties in asymptomatic patients., Material and Methods: A total of 52 MoM surface total hip arthroplasties were included in this study with data collected prospectively. Annual follow-up with blood Co and Cr measurements was performed. Revision surgery was necessary for 16 patients and therefore they dropped out of the study. The metal ion levels were analyzed separately in 31 asymptomatic patients., Results: High Cr or Co levels were not found continuously in any of the asymptomatic patients. The median Cr in blood was maintained between 1.3 and 5.4μg/L and that of Co between 0.5 and 1.2μg/L. After 7 years, there was no significant change in Co and Cr values., Conclusion: In the medium term and in asymptomatic patients, the metallic blood levels remained unchanged; therefore, it does not seem appropriate to repeat these tests on a permanent basis in annual controls., (Copyright © 2018 SECOT. Publicado por Elsevier España, S.L.U. All rights reserved.)