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Se presenta la adaptación española de las Guías Europeas de Prevención Cardiovascular 2021. En esta actualización, además del abordaje individual, se pone mucho más énfasis en las políticas sanitarias como estrategia de prevención poblacional. Se recomienda el cálculo del riesgo vascular de manera sistemática a todas las personas adultas con algún factor de riesgo vascular. Los objetivos terapéuticos para el colesterol LDL, la presión arterial y la glucemia no han cambiado respecto a las anteriores guías, pero se recomienda alcanzar estos objetivos de forma escalonada (etapas 1 y 2). Se recomienda llegar siempre hasta la etapa 2, y la intensificación del tratamiento dependerá del riesgo a los 10 años y de por vida, del beneficio del tratamiento, de las comorbilidades, de la fragilidad y de las preferencias de los pacientes. Las guías presentan por primera vez un nuevo modelo para calcular el riesgo —SCORE2 y SCORE2-OP— de morbimortalidad vascular en los próximos 10 años (infarto de miocardio, ictus y mortalidad vascular) en hombres y mujeres entre 40 y 89 años. Otra de las novedades sustanciales es el establecimiento de diferentes umbrales de riesgo dependiendo de la edad (< 50, 50-69, ≥ 70 años). Se presentan diferentes algoritmos de cálculo del riesgo vascular y tratamiento de los factores de riesgo vascular para personas aparentemente sanas, pacientes con diabetes y aquellos con enfermedad vascular aterosclerótica. Los pacientes con enfermedad renal crónica se considerarán de riesgo alto o muy alto, según la tasa del filtrado glomerular y el cociente albúmina/creatinina. Se incluyen innovaciones en las recomendaciones sobre los estilos de vida, adaptadas a las recomendaciones del Ministerio de Sanidad, así como aspectos novedosos relacionados con el control de los lípidos, la presión arterial, la diabetes y la insuficiencia renal crónica. Palabras clave: prevención y control, enfermedades vasculares, guías de práctica clínica, dieta saludable, hipertensión arterial, diabetes, control de lípidos, tabaco, riesgo cardiovascular.

There is currently a degree of divergence among the main clinical practice guidelines on the management of risk factors for peripheral arterial disease (PAD). This project aims to gain understanding of the management of PAD risk factors in clinical practice and to reach a multidisciplinary consensus on the strategies to be followed in order to optimize its identification, treatment, and follow-up.A multidisciplinary consensus following the Delphi methodology.Professionals (n = 130) with extensive experience in PAD participated in this consultation. The results suggest that in order to optimize the control of risk factors, efforts should be aimed at: (1) promoting the involvement and awareness of all specialists in the identification of and screening for the disease; (2) guaranteeing the possibility of evaluating the ankle-brachial index (ABI) in all the medical specialties involved; (3) promoting strategies for patients to quit smoking through the use of drugs, programs, or referrals to specialized units; (4) promoting an appropriate Mediterranean-based diet and the prescription of daily exercise; (5) raising awareness of the importance of ensuring LDL cholesterol values below 70 mg/dL, especially in symptomatic but also in asymptomatic patients (55 mg/dL following the publication of the ESC/EAS guide); (6) recommending the use of antiplatelet therapy in asymptomatic patients with diabetes mellitus (DM) and/or a pathological ABI; and (7) protocolizing the annual evaluation of ABI in high-risk patients.This document presents the 22 agreed-upon strategies which are intended to help professionals optimize multidisciplinary management of PAD risk factors.

Objective: The aim of this study was to evaluate, through a survey, the opinion of primary care (PC) physicians on the magnitude of dyslipidemia and its degree of control in their clinical practice. Materials and methods: An ecological study was carried out, in which the physicians were invited to participate by means of an online letter. Data were collected at a single timepoint and were based only on the experience, knowledge, and routine clinical practice of the participating physician. Results: A total of 300 physicians answered the questionnaire and estimated the prevalence of dyslipidemia between 2% and 80%. They estimated that 23.5% of their patients were high-risk, 18.2% were very high-risk, and 14.4% had recurrent events in the last 2 years. The PC physicians considered that 61.5% of their patients achieved the targets set. The participants fixed the presence of side-effects to statins at 14%. The statin that was considered safest with regard to side-effects was rosuvastatin (69%). Conclusions: PC physicians in Spain perceive that the CVR of their patients is high. This, together with the overestimation of the degree of control of LDL-C, could justify the inertia in the treatment of lipids. Moreover, they perceive that one-sixth of the patients treated with statins have side-effects.

The reduction of low-density lipoprotein cholesterol with lipid lowering therapy has demonstrated to decrease the risk of developing cardiovascular complications during the follow-up in primary and secondary prevention. Unfortunately, a great number of patients do not achieve recommended targets. This is mainly due to an insufficient use of the lipid-lowering therapy currently available. Although healthy life style changes are the basis of the treatment, in many cases this is not enough and it is necessary to add lipid lowering drugs to attain these targets. For these reasons, the current consensus document of the Spanish Society of Cardiology proposes 4 simple and feasible decision-making algorithms according to cardiovascular risk, with the aim of attaining cholesterol goals in the majority of primary prevention patients in a rapid an efficient way.

Resumen La reduccion del colesterol unido a lipoproteinas de baja densidad con el tratamiento hipolipidemiante ha demostrado disminuir el riesgo de presentar complicaciones cardiovasculares durante el seguimiento, tanto en prevencion primaria como secundaria. Desafortunadamente, un gran numero de pacientes no logran los objetivos de control recomendados. Esto se debe principalmente a un uso insuficiente de las terapias hipolipidemiantes actualmente disponibles. Aunque la base del tratamiento lo constituyen los cambios hacia un estilo de vida mas saludable, en numerosas ocasiones esto no es suficiente y es necesario anadir un tratamiento hipolipidemiante para alcanzar estos objetivos. Por estos motivos, en el presente documento de consenso de la Sociedad Espanola de Cardiologia se proponen 4 algoritmos de abordaje en funcion del riesgo cardiovascular de los pacientes, sencillos y facilmente aplicables, con el objetivo de lograr que la mayoria de los pacientes en prevencion primaria cumplan los objetivos de control de colesterol de manera rapida y eficiente.

Aims To estimate the attributable risk of renal function on all-cause mortality and cardiovascular hospitalization in patients with diabetes. Methods A prospective cohort study in 19,469 adults with diabetes, free of cardiovascular disease, attending primary care in Spain (2008–2011). The estimated glomerular filtration rate (eGFR) and other variables were collected and patients were followed to the first hospitalization for coronary or stroke event, or death, until the end of 2012. The cumulative incidence of the study endpoints by eGFR categories was graphically displayed and adjusted population attributable risks (PARs) for low eGFR was calculated. Results Mean follow-up was 3.2 years and 506 deaths and 1720 hospitalizations were recorded. The cumulative risk for the individual events increased as eGFR levels decreased. The PAR associated with having an eGFR of 60 mL/min/1.73 m2 or less was 11.4% (95% CI 4.8–18.3) for all-cause mortality, 9.2% (95% CI 5.3–13.4) for coronary heart disease, and 2.6% (95% CI −1.8 to 7.4) for stroke. Conclusions Reduced eGFR levels were associated with a larger proportion of avoidable deaths and cardiovascular hospitalizations in people with diabetes compared to previously reported results in people with other cardiovascular risk factors.

Background: Implementing preventive strategies for patients with obesity would improve the future burden of cardiovascular diseases. The objective was to present the opinions of experts on the approach to treat patients with obesity and other cardiovascular risk factors from a primary care perspective in Spain.Methods: Using the Delphi technique, a 42-question questionnaire was developed based on results from the scientific literature and sent to 42 experts in primary care. The blocks of knowledge addressed were (1) evaluation of the degree of incidence of obesity and associated cardiovascular risk factors, (2) evaluation of the barriers in diagnosis, prescription, and follow-up by the primary care physician or specialist of these patients, (3) improvement in obesity-related parameters in a patient being treated with lipid-lowering and antihypertensive drugs, and (4) analysis of improvements in cardiovascular parameters in responding patients under pharmacological treatment. Two rounds of participation were held.Results: Overall, 78.57% of the experts agreed with the questions posed in block 1, 10.00% in block 2, 61.9% in block 3, and 85.71% in block 4. Our results show the high awareness of the close relationship between obesity and cardiovascular risk factors among primary care physicians. It is necessary to use a checklist in primary care that includes metabolic parameters such as body mass index, waist circumference, and levels of C-reactive protein and ferritin. It is also useful to combine pharmacological treatment, such as liraglutide, with a change in lifestyle to achieve therapeutic goals in this population.Conclusions: There is a high awareness among experts in Spain about obesity and other cardiovascular risk factors and the need to address this pathology comprehensively. The need to incorporate specific tools in primary care consultations that allow better assessment and follow-up of these patients, such as cuffs adapted to arm size or imaging techniques to assess body fat, is evident.

Atención primaria; Hipertensión; Telemedicina Atenció primària; Hipertensió; Telemedicina Primary care; Hypertension; Telemedicine Aim: Members of the working groups on hypertension or cardiovascular disease of the Spanish Societies of Primary Care Physicians (PCPs) [SEMERGEN], Family and Community Medicine [semFYC] and General and Family Physicians [SEMG], conducted a Delphi study to validate with a panel of PCPs with expertise in hypertension several recommendations to optimize teleconsultation in hypertensive patients. Materials and methods: Delphi study based on an online questionnaire with 59 recommendations based on the available evidence and the clinical experience of the authors. Results: 118 PCPs participated in two rounds of the questionnaire (98.3% of the invited physicians), reaching consensus in 53/62 statements (85%). The Primary Care team must proactively select the hypertensive patients suitable for telematic consultation and contact them to set up an appointment. Telematic consultation must begin explaining the reason and aims pursued, continuing with anamnesis, which must explore signs and symptoms of disease worsening, current treatments and level of adherence. In patients with a home blood pressure measurement (HBPM) ≤135/85mmHg, it is recommended to schedule a new telematic appointment in 3-6months. On the contrary, asymptomatic patients with a HBPM ≥135/85mmHg should undergo ambulatory blood pressure monitoring, treatment modification or, in case of warning signs or symptoms, referral to a face-to-face visit or to emergency department. Conclusions: Teleconsultation can complement face-to-face consultation, constituting an additional tool for the appropriate follow-up of hypertensive patients. Objetivo Representantes de los grupos de trabajo de hipertensión o enfermedad cardiovascular de las Sociedades Españolas de Médicos de Atención Primaria (MAP) [SEMERGEN], de Medicina Familiar y Comunitaria [semFYC] y de Médicos Generales y de Familia [SEMG] realizaron un estudio Delphi para validar con un panel de MAP expertos en hipertensión una propuesta de recomendaciones para optimizar la teleconsulta en pacientes hipertensos. Materiales y métodos Estudio Delphi basado en un cuestionario online con 59 recomendaciones, elaborado en base a la bibliografía relacionada disponible y a la experiencia clínica aportada por los autores. Resultados Un total de 118 MAP participaron en dos rondas del cuestionario (98,3% de los invitados), alcanzándose el consenso en 53/62 sentencias (85%). El equipo de Atención Primaria debe seleccionar a los pacientes hipertensos candidatos a realizar la consulta telemática proactivamente, informando de la cita con antelación. Al iniciar la consulta telemática, se recomienda explicar el motivo y los objetivos de la misma, y realizar la anamnesis preguntando por signos y síntomas de empeoramiento de la enfermedad, tratamientos actuales y adherencia a los mismos. En pacientes con una automedida de la presión arterial (AMPA) ≤ 135/85 mmHg se recomienda pautar una nueva cita telemática en 3-6 meses. Por el contrario, en pacientes asintomáticos que reporten una AMPA ≥ 135/85 mmHg se recomienda la monitorización ambulatoria de la presión arterial, modificar el tratamiento, o derivar al paciente a visita presencial o al hospital en caso de signos o síntomas de alarma. Conclusiones La teleconsulta puede complementar la consulta presencial, constituyendo un elemento más a tener en cuenta para el adecuado control de los pacientes hipertensos.

Objetivo La hipertrofia ventricular izquierda es el marcador de daño de órgano diana más frecuente en la hipertensión arterial. Habitualmente se realiza un ECG para su identificación. El objetivo de este trabajo es analizar la utilidad pronóstica de otras alteraciones electrocardiográficas en pacientes hipertensos, más allá de la hipertrofia ventricular. Materiales y métodos Se incluyeron 1.003 pacientes hipertensos mayores de 65 años. Se recogieron factores de riesgo, historia cardiovascular previa y tratamiento médico. Se analizaron diferentes alteraciones electrocardiográficas, incluyendo índice de Sokolow-Lyon, índice de Cornell, presencia de sobrecarga ventricular y bloqueos de rama, entre otros. Se llevó a cabo un seguimiento de 2 años con recogida de eventos cardiovasculares mayores (mortalidad, infarto de miocardio, accidentes cerebrovascular o ingreso por insuficiencia cardiaca). Resultados La edad media de la población era de 72,9 ± 5,8 años, con un 47,5% de varones. Durante el seguimiento el 13,9% sufrieron un evento cardiovascular mayor. Estos pacientes eran de mayor edad, más fumadores y practicaban menos ejercicio físico, sin presentar diferencias en el tratamiento antihipertensivo empleado ni en el control tensional. El patrón de sobrecarga ventricular (HR: 1,93; IC 95%: 1,160-3,196; p = 0,011) y el bloqueo completo de rama izquierda (HR: 2,27; IC 95%: 1,040-4,956; p = 0,040) se comportaron como factores electrocardiográficos predictores independientes de eventos cardiovasculares mayores, no así la hipertrofia ventricular izquierda por Sokolow y/o Cornell. Conclusiones En pacientes hipertensos, la existencia en el ECG basal de un bloqueo completo de rama izquierda o un patrón de sobrecarga ventricular identifica a una población de mayor riesgo cardiovascular. Objective Left ventricular hypertrophy is the most common marker of target organ damage in arterial hypertension. Electrocardiograms are typically performed to identify left ventricular hypertrophy. The aim of this study was to analyse the prognostic utility of other electrocardiographic abnormalities in patients with arterial hypertension, beyond ventricular hypertrophy. Materials and methods The study included 1003 patients older than 65 years with arterial hypertension. We recorded risk factors, previous cardiovascular history and medical treatment and analysed various electrocardiographic abnormalities including the Sokolow-Lyon index, the Cornell index, ventricular overload and branch blocks. The study conducted a 2-year follow-up, recording the major cardiovascular events (mortality, myocardial infarction, stroke and hospitalisation for heart failure). Results The study population's mean age was 72.9 ± 5.8 years, 47.5% of whom were men. During the follow-up, 13.9% of the patients experienced a major cardiovascular event. These patients were older, more often smokers and engaged in less physical exercise, without presenting differences in the antihypertensive therapy or blood pressure control. The ventricular overload pattern (HR: 1.93; 95% CI: 1.160-3.196; P = .011) and the complete left bundle branch block (HR: 2.27; 95% CI: 1.040-4.956; P = .040) behaved as independent electrocardiographic predictors of major cardiovascular events; however, left ventricular hypertrophy using the Sokolow and/or Cornell index did not behave as such. Conclusions For patients with hypertension, the presence in the baseline electrocardiogram of complete left bundle branch block or a pattern of ventricular overload identifies a population at increased cardiovascular risk.

Resumen Objetivo La hipertrofia ventricular izquierda es el marcador de dano de organo diana mas frecuente en la hipertension arterial. Habitualmente se realiza un ECG para su identificacion. El objetivo de este trabajo es analizar la utilidad pronostica de otras alteraciones electrocardiograficas en pacientes hipertensos, mas alla de la hipertrofia ventricular. Materiales y metodos Se incluyeron 1.003 pacientes hipertensos mayores de 65 anos. Se recogieron factores de riesgo, historia cardiovascular previa y tratamiento medico. Se analizaron diferentes alteraciones electrocardiograficas, incluyendo indice de Sokolow-Lyon, indice de Cornell, presencia de sobrecarga ventricular y bloqueos de rama, entre otros. Se llevo a cabo un seguimiento de 2 anos con recogida de eventos cardiovasculares mayores (mortalidad, infarto de miocardio, accidentes cerebrovascular o ingreso por insuficiencia cardiaca). Resultados La edad media de la poblacion era de 72,9 ± 5,8 anos, con un 47,5% de varones. Durante el seguimiento el 13,9% sufrieron un evento cardiovascular mayor. Estos pacientes eran de mayor edad, mas fumadores y practicaban menos ejercicio fisico, sin presentar diferencias en el tratamiento antihipertensivo empleado ni en el control tensional. El patron de sobrecarga ventricular (HR: 1,93; IC 95%: 1,160-3,196; p = 0,011) y el bloqueo completo de rama izquierda (HR: 2,27; IC 95%: 1,040-4,956; p = 0,040) se comportaron como factores electrocardiograficos predictores independientes de eventos cardiovasculares mayores, no asi la hipertrofia ventricular izquierda por Sokolow y/o Cornell. Conclusiones En pacientes hipertensos, la existencia en el ECG basal de un bloqueo completo de rama izquierda o un patron de sobrecarga ventricular identifica a una poblacion de mayor riesgo cardiovascular.

We present the Spanish adaptation of the 2021 European Guidelines on Cardiovascular Disease (CVD) prevention in clinical practice. The current guidelines besides the individual approach greatly emphasize on the importance of population level approaches to the prevention of cardiovascular diseases. Systematic global CVD risk assessment is recommended in individuals with any major vascular risk factor. Regarding LDL-Cholesterol, blood pressure, and glycemic control in patients with diabetes mellitus, goals and targets remain as recommended in previous guidelines. However, it is proposed a new, stepwise approach (Step 1 and 2) to treatment intensification as a tool to help physicians and patients pursue these targets in a way that fits patient profile. After Step 1, considering proceeding to the intensified goals of Step 2 is mandatory, and this intensification will be based on 10-year CVD risk, lifetime CVD risk and treatment benefit, comorbidities and patient preferences. The updated SCORE algorithm (SCORE2, SCORE-OP) is recommended in these guidelines, which estimates an individual's 10-year risk of fatal and non-fatal CVD events (myocardial infarction, stroke) in healthy men and women aged 40-89 years. Another new and important recommendation is the use of different categories of risk according different age groups (50, 50-69,70 years). Different flow charts of CVD risk and risk factor treatment in apparently healthy persons, in patients with established atherosclerotic CVD, and in diabetic patients are recommended. Patients with chronic kidney disease are considered high risk or very high-risk patients according to the levels of glomerular filtration rate and albumin-to-creatinine ratio. New lifestyle recommendations adapted to the ones published by the Spanish Ministry of Health as well as recommendations focused on the management of lipids, blood pressure, diabetes and chronic renal failure are included.Presentamos la adaptación española de las Guías Europeas de Prevención Cardiovascular 2021. En esta actualización además del abordaje individual, se pone mucho más énfasis en las políticas sanitarias como estrategia de prevención poblacional. Se recomienda el cálculo del riesgo vascular de manera sistemática a todas las personas adultas con algún factor de riesgo vascular. Los objetivos terapéuticos para el colesterol LDL, la presión arterial y la glucemia no han cambiado respecto a las anteriores guías, pero se recomienda alcanzar estos objetivos de forma escalonada (etapas 1 y 2). Se recomienda llegar siempre hasta la etapa 2, y la intensificación del tratamiento dependerá del riesgo a los 10 años y de por vida, del beneficio del tratamiento, de las comorbilidades, de la fragilidad y de las preferencias de los pacientes. Las guías presentan por primera vez un nuevo modelo para calcular el riesgo (SCORE2 y SCORE2 OP) de morbimortalidad vascular en los próximos 10 años (infarto de miocardio, ictus y mortalidad vascular) en hombres y mujeres entre 40 y 89 años. Otra de las novedades sustanciales es el establecimiento de diferentes umbrales de riesgo dependiendo de la edad (50, 50-69,70 años). Se presentan diferentes algoritmos de cálculo del riesgo vascular y tratamiento de los factores de riesgo vascular para personas aparentemente sanas, pacientes con diabetes y pacientes con enfermedad vascular aterosclerótica. Los pacientes con enfermedad renal crónica se considerarán de riesgo alto o muy alto según la tasa del filtrado glomerular y el cociente albúmina/creatinina. Se incluyen innovaciones en las recomendaciones sobre los estilos de vida, adaptadas a las recomendaciones del Ministerio de Sanidad, así como aspectos novedosos relacionados con el control de los lípidos, la presión arterial, la diabetes y la insuficiencia renal crónica.

Background: The impact of vitamin D supplementation on cardiovascular outcomes and mortality risk reduction remains unclear due to conflicting study findings. Methods: We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs), published between 1983 and 2022, that reported the effect of vitamin D supplementation in adults versus placebo or no treatment on all-cause mortality (ACM), cardiovascular mortality (CVM), non-cardiovascular mortality (non-CVM), and cardiovascular morbidities. Only studies with a follow-up period longer than one year were included. The primary outcomes were ACM and CVM. Secondary outcomes were non-CVM, myocardial infarction, stroke, heart failure, and major or extended adverse cardiovascular events. Subgroup analyses were performed according to low-, fair- and good-quality RCTs. Results: Eighty RCTs were assessed, including 82,210 participants receiving vitamin D supplementation and 80,921 receiving placebo or no treatment. The participants’ mean (SD) age was 66.1 (11.2) years, and 68.6% were female. Vitamin D supplementation was associated with a lower risk of ACM (OR: 0.95 [95%CI 0.91–0.99] p = 0.013), was close to statistical significance for a lower risk of non-CVM (OR: 0.94 [95%CI 0.87–1.00] p = 0.055), and was not statistically associated with a lower risk of any cardiovascular morbi-mortality outcome. Meta-analysis of low-quality RCTs showed no association with cardiovascular or non-cardiovascular morbi-mortality outcomes. Conclusions: The emerging results of our meta-analysis present evidence that vitamin D supplementation appears to decrease the risk of ACM (especially convincing in the fair- and good-quality RCTs), while not showing a decrease in the specific cardiovascular morbidity and mortality risk. Thus, we conclude that further research is warranted in this area, with well-planned and executed studies as the basis for more robust recommendations.

Este artículo se encuentra disponible en la siguiente URL: https://www.mdpi.com/1660-4601/19/9/5546 Este artículo pertenece la número especial "Exclusive Papers Collection of Editorial Board Members (and Invited Scholars) in Section Public Health Statistics and Risk Assessment". Background: Forecasting the behavior of epidemic outbreaks is vital in public health. This makes it possible to anticipate the planning and organization of the health system, as well as possible restrictive or preventive measures. During the COVID-19 pandemic, this need for prediction has been crucial. This paper attempts to characterize the alternative models that were applied in the first wave of this pandemic context, trying to shed light that could help to understand them for future practical applications. Methods: A systematic literature search was performed in standardized bibliographic repertoires, using keywords and Boolean operators to refine the findings, and selecting articles according to the main PRISMA 2020 statement recommendations. Results: After identifying models used throughout the first wave of this pandemic (between March and June 2020), we begin by examining standard data-driven epidemiological models, including studies applying models such as SIR (Susceptible-Infected-Recovered), SQUIDER, SEIR, time-dependent SIR, and other alternatives. For data-driven methods, we identify experiences using autoregressive integrated moving average (ARIMA), evolutionary genetic programming machine learning, short-term memory (LSTM), and global epidemic and mobility models. Conclusions: The COVID-19 pandemic has led to intensive and evolving use of alternative infectious disease prediction models. At this point it is not easy to decide which prediction method is the best in a generic way. Moreover, although models such as the LSTM emerge as remarkably versatile and useful, the practical applicability of the alternatives depends on the specific context of the underlying variable and on the information of the target to be prioritized. In addition, the robustness of the assessment is conditioned by heterogeneity in the quality of information sources and differences in the characteristics of disease control interventions. Further comprehensive comparison of the performance of models in comparable situations, assessing their predictive validity, is needed. This will help determine the most reliable and practical methods for application in future outbreaks and eventual pandemics.

The role of uric acid levels in the cardiovascular continuum is not clear. Our objective is to analyze the prevalence of hyperuricemia (HU) and its association with cardiovascular risk factors (CVRF), subclinical target organ damage (sTOD), and cardiovascular diseases (CVD). We evaluated the prevalence of HU in 6.927 patients included in the baseline visit of the IBERICAN study. HU was defined as uric acid levels above 6 mg/dL in women, and 7 mg/dL in men. Using adjusted logistic regression models, the odds ratios were estimated according to CVRF, sTOD, and CVD. The prevalence of HU was 16.3%. The risk of HU was higher in patients with pathological glomerular filtration rate (aOR: 2.92), heart failure (HF) (aOR: 1.91), abdominal obesity (aOR: 1.80), hypertension (HTN) (aOR: 1.65), use of thiazides (aOR: 1.54), left ventricular hypertrophy (LVH) (aOR: 1.36), atrial fibrillation (AFIB) (aOR: 1.29), and albuminuria (aOR: 1.27). On the other hand, being female (aOR: 0.82) showed a reduced risk. The prevalence of HU was higher in men, in patients presenting CVRF such as HTN and abdominal obesity, and with co-existence of LVH, atrial fibrillation (AFIB), HF, and any form of kidney injury. These associations raise the possibility that HU forms part of the early stages of the cardiovascular continuum. This may influence its management in Primary Healthcare because the presence of HU could mean an increased CV risk in the patients.

Evidence shows that objectives for detecting and controlling dyslipidemia are not being effectively met, and outcomes differ between men and women. This study aimed to assess gender-related differences in diagnostic inertia around dyslipidemia. This ambispective, epidemiological, cohort registry study included adults who presented to public primary health care centers in a Spanish region from 2008 to 2012, with dyslipidemia and without cardiovascular disease. Diagnostic inertia was defined as the registry of abnormal diagnostic parameters—but no diagnosis—on the person’s health record in a window of six months from inclusion. A total of 58,970 patients were included (53.7% women) with a mean age of 58.4 years in women and 57.9 years in men. The 6358 (20.1%) women and 4312 (15.8%) men presenting diagnostic inertia had a similar profile, although in women the magnitude of the association with younger age was larger. Hypertension showed a larger association with diagnostic inertia in women than in men (prevalence ratio 1.81 vs. 1.56). The overall prevalence of diagnostic inertia in dyslipidemia is high, especially in women. Both men and women have a higher risk of cardiovascular morbidity and mortality.

Resumen El embarazo es predictor de riesgo cardiovascular futuro que puede desenmascarar trastornos metabolicos o vasculares latentes. El retraso en la edad reproductiva y su asociacion a otros factores de riesgo han incrementado los embarazos con complicaciones medicas. Actualmente existe un excelente protocolo nacional de atencion continuada a las mujeres que desarrollan estas complicaciones durante el embarazo. Pero tras el parto se inicia este periodo llamado «cuarto trimestre», que hace referencia al resto de la vida de la mujer tras el embarazo y donde disminuye el seguimiento. El objetivo de este documento es establecer recomendaciones en el «cuarto trimestre», avaladas por la Sociedad Espanola de Obstetricia y Ginecologia (SEGO), la Sociedad Espanola de Medicos de Atencion Primaria (SEMERGEN), la Sociedad Espanola de Medicina de Familia y Comunitaria (semFYC) y la Sociedad Espanola de Cardiologia (SEC), para asegurar el seguimiento de los factores de riesgo y potenciales complicaciones cardiovasculares que puedan desarrollarse a partir del «cuarto trimestre».

Evidence shows that objectives for detecting and controlling cardiovascular risk factors are not being effectively met, and moreover, outcomes differ between men and women. This study will assess the gender-related differences in diagnostic inertia around the three most prevalent cardiovascular risk factors: dyslipidemia, arterial hypertension, and diabetes mellitus, and to evaluate the consequences on cardiovascular disease incidence. This is an epidemiological and cohort study. Eligible patients will be adults who presented to public primary health care centers in a Spanish region from 2008 to 2011, with hypertension, dyslipidemia, or/and diabetes and without cardiovascular disease. Participants’ electronic health records will be used to collect the study variables in a window of six months from inclusion. Diagnostic inertia of hypertension, dyslipidemia, and/or diabetes is defined as the registry of abnormal diagnostic parameters—but no diagnosis—on the person’s health record. The cohort will be followed from the date of inclusion until the end of 2019. Outcomes will be cardiovascular events, defined as hospital admission due to ischemic cardiopathy, stroke, and death from any cause. The results of this study could inform actions to rectify the structure, organization and training of health care teams in order to correct the inequality.

Background and aim Atherosclerosis is the underlying process in cardiovascular disease (CVD), the first cause of death in developed countries. We aimed to identify people with no known CVD and normal values of LDL-C and HDL-C, but with alterations in the number and size of lipoprotein particles (as measured by nuclear magnetic resonance [NMR]) and to analyse their sociodemographic, clinical and biochemical characteristics. Methods Cross-sectional study in occupational risks prevention centre in Castellon (Spain) in 2017 and 2018, in consecutively recruited adults (18-65 years) with no known CVD. Sociodemographic, clinical and biochemical variables were collected. Lipid profiles were analysed (Liposcale test), along with the concentration, size and number of the main types of lipoprotein particles, determined by 2D diffusion-ordered NMR spectroscopy. Using contingency tables, we analysed the characteristics of people with normal LDL and HDL cholesterol but abnormal levels of LDL and HDL particles. The magnitude of association between explanatory variables and abnormal levels of each kind of lipoprotein was assessed with multivariable logistic regression models. Results Of the 400 total participants (31.3% women; age 46.4 ± 4.3 years), 169 had normal LDL and HDL cholesterol. Abnormal lipoprotein particle values depended on the subtype: prevalence of abnormal LDL levels ranged from 8.3% to 36.7%; and of HDL, from 28.4% to 42.6%. High systolic blood pressure and total cholesterol were significantly associated with abnormal LDL levels. Male sex and high systolic blood pressure were associated with abnormalities in HDL. Conclusions An extended lipids profile, obtained by NMR, enables the identification of people with normal HDL-C and LDL-C levels who present abnormal levels of LDL-P and/or HDL-P. Higher total cholesterol, systolic blood pressure, BMI and male sex were significantly associated with these abnormal values.

Resumen La pandemia producida por la infeccion por el coronavirus SARS-CoV-2 (COVID-19) ha cambiado la forma de entender nuestras consultas. Para reducir el riesgo de contagio de los pacientes mas vulnerables (aquellos con cardiopatias) y del personal sanitario, se han suspendido la mayoria de las consultas presenciales y se han puesto en marcha las consultas telematicas. Este cambio se ha implementado en muy poco tiempo, pero parece que ha venido para quedarse. No obstante, hay grandes dudas sobre aspectos organizativos, legales, posibilidades de mejora, etc. En este documento de consenso de la Sociedad Espanola de Cardiologia, tratamos de dar las claves para mejorar la calidad asistencial en nuestras nuevas consultas telematicas, revisando las afecciones que el cardiologo clinico atiende con mas frecuencia en su consulta ambulatoria y proponiendo unos minimos en ese proceso asistencial. Estas enfermedades son la cardiopatia isquemica, la insuficiencia cardiaca y las arritmias. En los 3 escenarios tratamos de clarificar los aspectos fundamentales que hay que revisar en la entrevista telefonica, a que pacientes habra que atender en una consulta presencial y cuales seran los criterios para su seguimiento en atencion primaria. El documento tambien recoge distintas mejoras que pueden introducirse en la consulta telematica para mejorar la asistencia de nuestros pacientes.

Resumen Objetivos Determinar la prevalencia y la incidencia de los factores de riesgo cardiovascular en Espana, asi como de los eventos cardiovasculares, en poblacion adulta espanola asistida en atencion primaria. Metodologia IBERICAN es un estudio longitudinal, observacional y multicentrico en el que se estan incluyendo pacientes de 18 a 85 anos atendidos en las consultas de atencion primaria en Espana. La cohorte obtenida se seguira anualmente durante al menos 5 anos. La muestra final estimada es de 7.000 pacientes. Se presentan las caracteristicas basales del segundo corte (n = 3.042). Resultados La edad media de los sujetos incluidos es de 57,9 ± 14,6 anos, y el 55,5% son mujeres. El 54,9% viven en un habitat urbano, y el 57,3% tienen estudios primarios. El 50,3% tienen dislipidemia, el 47,4% hipertension arterial, el 29,7% sedentarismo, el 28,2% obesidad abdominal y el 19% diabetes mellitus. El grado de control de hipertension arterial, dislipidemia y diabetes mellitus tipo 2 fue del 58,5, del 25,8 y del 75,9%, respectivamente. El 28,2% cumplen criterios de sindrome metabolico. El 15,6% de los pacientes presentaban una enfermedad cardiovascular previa. El 7,8% tienen antecedentes de cardiopatia isquemica, el 8,4% de filtrado glomerular (CKD-EPI) Conclusiones A pesar de que la poblacion atendida en atencion primaria es relativamente joven, la elevada prevalencia de factores de riesgo, su mal control y la existencia de patologia cardiovascular previa condicionaran el impacto en el pronostico de la cohorte.

Cardiovascular diseases are the leading cause of death in the world. Coronary artery diseases, atrial fibrillation or hypertensive heart disease, are among the most important cardiovascular disorders. Hypertension represents a significant risk factor for cardiovascular mortality; thus, control of high blood pressure has become a priority to prevent major complications. Although the choice of drugs for treating hypertension remains controversial, extensive clinical evidences point to calcium channel blockers as first-line agents. Diltiazem, a non-dihydropyridine calcium channel blocker, is an effective and safe antihypertensive drug, alone or in combination with other agents. Diltiazem lowers myocardial oxygen demand through a reduction in heart rate, blood pressure, and cardiac contractility, representing also a good alternative for the treatment of stable chronic angina. Furthermore, diltiazem reduces conduction in atrioventricular node, which is also useful for heart rate control in patients with atrial fibrillation. In this review, clinical experts highlight studies on diltiazem effectiveness and safety for the treatment of several cardiovascular diseases and make evidence-based recommendations regarding the management of diltiazem in the clinical prac Sponsorship for this review and the article processing charges was funded by Lacer Spain. All named authors meet the International Committee of Medical Journal Editors (ICMJE) criteria for authorship for this manuscript, take responsibility for the integrity of the work as a whole, and have given final approval to the version to be published. Writing assistance in the preparation of this manuscript was provided by Patricia Rodriguez, PhD, and editorial assistance was provided by Springer Healthcare. Support for this assistance was funded by Lacer Spain.

Original [ES] Dos aspectos relevantes de la medicina laboral son estudiar la salud del individuo en su ámbito de trabajo y promover entornos laborales saludables. Actualmente, los factores de riesgo cardiovascular siguen liderando la morbi-mortalidad en nuestra sociedad. El entorno laboral es la oportunidad de conocer la situación real e iniciar estrategias de prevención precoz. Uno de los factores más prevalentes son las alteraciones de los lípidos, siendo el colesterol LDL el que define el riesgo del paciente, pero sabemos que no identifica a todos los pacientes en riesgo de padecer un evento, persistiendo un riesgo residual. Determinar el número y tamaño de partículas de lipoproteínas mediante resonancia magnética nuclear, aporta valor añadido en la identificación de pacientes con riesgo lipídico. Esta revisión presenta una actualización de la situación del riesgo lipídico y muestra las características de un nuevo método para la caracterización de las lipoproteínas basada en espectroscopia de RMN de difusión 2D. [EN] Two relevant aspects of occupational medicine are studying the health of the individual in their occupational environment and promoting healthy occupational environments. Currently, cardiovascular risk factors continue to lead morbidity and mortality in our society. The occupational environment is the opportunity to know the real situation and initiate early prevention strategies. One of the most prevalent factors are the alterations of the lipids, being the LDL cholesterol (low-density lipoprotein) the one that defines the risk of the patient, but we know that it does not identify all patients at risk of suffering an event, persisting a residual risk. Determining the number and size of lipoprotein particles by nuclear magnetic resonance provides added value in the identification of patients with lipid risk. This review presents an update of the status of lipid risk and shows the characteristics of a new method for the characterization of lipoproteins based on 2D diffusion NMR spectroscopy. No

Objective: The main objective of this study is to know the prevalence and the clinical and epidemiological characteristics of patients with metabolic syndrome (MetS) and premorbid metabolic syndrome (pre-MetS) included in the Identification of the Spanish Population at Cardiovascular and Renal Risk (IBERICAN) study. Materials and Methods: The IBERICAN study is an epidemiological, multicentric observational study carried out in Primary Healthcare Centers from all over Spain, in which an open cohort of subjects with/without cardiovascular risk factors (CVRF) is constituted. The MetS was defined according to the international criterion based on the presence of at least three of the five criteria of the harmonized definition. Results: A total of 4304 patients were selected; 38.5% patients (95% confidence interval 37.0–40.0) met the MetS criteria. In both groups (MetS and pre-MetS), patients were older (62.3 ± 12.1 vs. 54.4 ± 15.2, P

This study aimed to determine the clinical profile, blood pressure (BP) control rates, therapeutic management and physicians' therapeutic behavior regarding very elderly hypertensive patients. A total of 1540 hypertensive patients 80 years old on antihypertensive therapy and receiving care in primary care settings in Spain were included in this cross-sectional study. The mean patient age was 83.4±3.1 years, 61.9% of patients were women and 49.3% of patients had cardiovascular disease. Of the patients, 27.7% were on monotherapy and 72.3% were on combined therapy (47.4% on two antihypertensive agents and 24.9% on three or more antihypertensive agents). A total of 40.8% (95% confidence interval (CI): 38.4-43.3%) of patients achieved BP goals (140/90 mm Hg;130/80 in patients with diabetes, chronic renal disease or cardiovascular disease). Patients with uncontrolled BP were more likely to have metabolic syndrome, diabetes, obesity, a history of cardiovascular disease, ischemic heart disease, renal disease and stroke and were more frequently smokers. Physicians modified the antihypertensive regimens for 27.4% (95% CI: 23.9-30.8%) of the patients with uncontrolled BP, and the addition of another antihypertensive agent was the most frequent modification. With regard to the physicians' perception of patients' BP control, the BPs of 44.1% of the patients with uncontrolled BP were considered well controlled by the physicians.

Previous studies have examined control rates of office blood pressure (BP) in chronic kidney disease (CKD). However, recent evidence suggests major discrepancies between office and 24-hour BP values in hypertensive populations. This study examined concordance/discordance between office- and ambulatory-based BP control in a large cohort of patients with CKD.Cross-sectional.5,693 hypertensive individuals with CKD stages 1-5 from the Spanish ABPM (ambulatory BP monitoring) Registry.Thresholds of 140/90 and 130/80 mm Hg for office BP and 24-hour ambulatory BP, respectively. Age, sex, body mass index, waist circumference, hypertension duration, kidney measures, diabetes, dyslipidemia, target-organ damage, and cardiovascular comorbid conditions.Misclassification of BP control as "white-coat" hypertension (office BP ≥140/90 mm Hg, 24-hour BP130/80 mm Hg) or masked hypertension (office BP140/90 mm Hg, 24-hour BP ≥130/80 mm Hg).Standardized office-based BP and 24-hour ABPM.Mean age was 61.0 ± 13.9 (SD) years and 52.6% were men. The proportion with white-coat hypertension was 28.8% (36.8% of patients with office BP ≥140/90 mm Hg) and that of masked hypertension was 7.0% (but 32.1% of patients with office BP140/90 mm Hg). Female sex, aging, obesity, and target-organ damage were associated with white-coat hypertension; aging and obesity were associated with masked hypertension. Only 21.7% and 8.1% of the CKD population had office BP140/90 and130/80 mm Hg, respectively. In contrast, 43.5% of individuals had average 24-hour BP130/80 mm Hg.Cross-sectional design, longitudinal associations cannot be established.Misclassification of BP control at the office was observed in 1 of 3 hypertensive patients with CKD. Ambulatory-based control rates were far better than office-based rates. Nevertheless, the burden of uncontrolled ambulatory BP and misclassification of BP control at the office constitutes a call for wider use of ABPM to evaluate the success of hypertension treatment in patients with CKD.

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 allcause 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.

To determine the prevalence and incidence of cardiovascular risk factors in Spain, as well as cardiovascular events, in Spanish adult population attended in primary care.IBERICAN is a longitudinal, observational, multicenter study in which patients aged 18 to 85years attended in primary care health center in Spain are being included. The obtained cohort will be followed annually for at least 5years. The estimated final sample is 7,000 patients. The baseline characteristics of the second cut (n=3,042) are presented.The mean age of the subjects included is 57.9±14.6 years, and 55.5% are women. 54.9% live in urban habitat, and 57.3% have primary education. 50.3% had dyslipidemia, 47.4% hypertension, 29.7% physical inactivity, 28.2% abdominal obesity and 19% diabetes mellitus. The degree of control of hypertension, dyslipidemia and type2 diabetes was 58.5%, 25.8% and 75.9%. 28.2% have criteria for metabolic syndrome. 15.6% of patients had previous cardiovascular disease. 7.8% have a history of coronary heart disease, a glomerular filtration rate60ml/min (CKD-EPI) 8.4%, microalbuminuria 9.6%, atrial fibrillation 5.5%, stroke 4.6%, and heart failure 2.9%.Although the population treated in primary care is relatively young, the high prevalence of risk factors, their poor control and the existence of previous cardiovascular disease will determine the impact on the prognosis of the cohort.

Resumen Objetivos Describir los resultados de un sistema voluntario de notificacion de eventos adversos, dentro de un programa de Seguridad de Pacientes en el proceso asistencial de una Mutua de Accidentes de Trabajo. Metodo En 2008 se implanto un sistema de notificacion y registro de eventos adversos (reales o potenciales) en Union de Mutuas, mutua de accidentes de trabajo, con 36 centros asistenciales, que da cobertura a 259.922 trabajadores. El cuestionario de notificacion, contempla todos los ambitos de la asistencia sanitaria prestada por la Mutua. El acceso al cuestionario se realizo a traves de la intranet, fue voluntario, anonimo. Se describen las notificaciones registradas entre el 1 de enero de 2009 y el 31 de diciembre de 2010. Resultados Se cumplimentaron 116 cuestionarios, con un total de 205 incidentes. El perfil del notificador fue medico del primer nivel asistencial (57,7%), y una antiguedad en su puesto de trabajo entre 5-10 anos. Del total de notificaciones, la asistencia sanitaria se considero causante del incidente en el 43,5% de los casos, de los que el 85,9% de los incidentes hubieran podido evitarse. Del total de eventos notificados, un 71,7% estaban relacionados con cuidados en centro asistencial ambulatorio, y solo un 2,4% fue relacionado con procedimiento quirurgico. Conclusiones La mayoria de las notificaciones fueron incidentes evitables, y registrados por medicos del primer nivel asistencial. El cuestionario de notificacion se mostro como una herramienta valida en nuestro entorno de trabajo para la deteccion de eventos adversos en el proceso asistencial.

Introduccion El objetivo de este estudio fue analizar el control de la presion arterial (PA) y los factores asociados al mal control en una amplia muestra de hipertensos espanoles ≥ 65 anos. Material y metodos Estudio transversal realizado en Atencion Primaria en hipertensos tratados farmacologicamente. La PA se midio siguiendo normas estandarizadas y se considero bien controlada cuando era Resultados Se incluyeron a 5.385 pacientes (edad media 73,4 ± 5,9 anos; 58,5% mujeres). El 38,3% recibia monoterapia antihipertensiva y el 61,7% terapia combinada. El 38,2% (intervalo de confianza [IC] 95%, 36,9-39,5) mostro buen control de PA sistolica y diastolica. El control de PA fue mejor por las tardes que por las mananas (p Conclusiones Solo tres de cada 10 hipertensos ≥ 65 anos tienen adecuadamente controlada la PA. La diabetes hace 4 veces mas probable el mal control tensional y la percepcion del medico de buen control multiplica por 60 la probabilidad de que no se modifique el tratamiento en los pacientes mal controlados.

The authors would like to thank Professor Halil Dogan (Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Istanbul, Turkey) for informing them of the following error. The following sentence within the last paragraph of the ‘Diltiazem and Atrial Arrhythmias’ section, ‘‘A retrospective study evaluated 77 patients with supraventricular tachycardia treated with oral adenosine or intravenous diltiazem in the emergency department [21]’’, is incorrect. This sentence should read: ‘‘A retrospective study evaluated 77 patients with supraventricular tachycardia treated with intravenous adenosine or diltiazem in the emergency department [21]’’.

Modern medicine is characterized by a continuous genesis of evidence making it very difficult to translate the latest findings into a better clinical practice. Clinical practice guidelines (CPG) emerge to provide clinicians evidence-based recommendations for their daily clinical practice. However, the high number of existing CPG as well as the usual differences in the given recommendations usually increases the clinician’s confusion and doubts. It has apparently been the case for the 2013 American College of Cardiology/American Heart Association (ACC/AHA) Guideline on the Treatment of Blood Cholesterol. These CPG proposed new and controversial concepts that have usually been considered an antagonist shift respective to European CPG. The most controversial published proposals are: 1) to consider evidence just from randomized clinical trials, 2) creation of a new cardiovascular (CV) risk calculator, 3) to consider reducing CV risk instead of reducing low-density lipoprotein cholesterol (LDLc) as the target of the treatment, and 4) consideration of statins as the only drugs for treatment. A deep analysis of the 2013 American College of Cardiology/American Heart Association CPG and comparison with the European ones show that from a practical and clinical point of view, there are more similarities than differences. To further help clinicians in their daily work, in the present globalized world, it is time to discuss and adopt a mutually agreed upon document created by both sides of the Atlantic. Probably it is not a short-term solution. Meanwhile, taking advantage of the similarities, the recommended practical attitude for the daily clinical practice should be based on 1) early detection of people with increased CV risk promoting the use of validated local scales, 2) reinforce the mainstream importance of nonpharmacological treatment, and 3) need for periodically monitoring response with analytical parameters (LDL or non-highdensity lipoprotein cholesterol) and global CV risk estimation. Technological solutions such as the big data technology could help to obtain high-quality evidence in an intermediate term.

BACKGROUND: The ankle-brachial index (ABI) is widely used to diagnose subclinical peripheral artery disease (PAD) in the general population, but data assessing its prevalence and related factors in different chronic kidney disease (CKD) stages are scarce. The aim of this study is to evaluate the prevalence and associated factors of pathological ABI values in CKD patients. METHODS: NEFRONA is a multicentre prospective project that included 2445 CKD patients from 81 centres and 559 non-CKD subjects from 9 primary care centres across Spain. A trained team collected clinical and laboratory data, performed vascular ultrasounds and measured the ABI. RESULTS: PAD prevalence was higher in CKD than in controls (28.0 versus 12.3%, P < 0.001). Prevalence increased in more advanced CKD stages, due to more patients with an ABI ≥1.4, rather than ≤0.9. Diabetes was the only factor predicting both pathological values in all CKD stages. Age, female sex, carotid plaques, higher carotid intima-media thickness, higher high-sensitivity C-reactive protein (hsCRP) and triglycerides, and lower 25-hydroxi-vitamin D were independently associated with an ABI ≤0.9. Higher phosphate and hsCRP, lower low-density lipoprotein (LDL)-cholesterol and dialysis were associated with an ABI ≥1.4. A stratified analysis showed different associated factors in each CKD stage, with phosphate being especially important in earlier CKD, and LDL-cholesterol being an independent predictor only in Sage 5D CKD. CONCLUSIONS: Asymptomatic PAD is very prevalent in all CKD stages, but factors related to a low or high pathological ABI differ, revealing different pathogenic pathways. Diabetes, dyslipidaemia, inflammation and mineral-bone disorders play a role in the appearance of PAD in CKD.