Análisis crítico y propuestas de mejora de los sistemas de información sobre enfermedades cardiovasculares en España

Impact of creating a haemodynamics room, a coronary unit and a primary angioplasty programme on the prognosis of acute coronary syndrome in a district hospital

OBJECTIVE

This work aims to analyze the prognosis and mortality of patients hospitalized for acute coronary syndrome before and after the implementation of a coronary care unit, hemodynamics room, and the Código Corazón [Infarction Code] primary angioplasty program METHODS: We conducted an observational, retrospective study that analyzed the epidemiological characteristics, reperfusion strategies, adverse cardiovascular events, and mortality over a follow-up period of five years. The results from the post-code period (March 1 - December 31, 2012; n=471) were compared with those from the pre-code period (March 1 - December 31, 2009; n=432).

RESULTS

There were no differences in the baseline characteristics of the two groups. However, an increase in ST-elevation acute coronary syndrome (STE-ACS) from 17.6% to 34.8% (p<.001) was observed during the postcode phase. The use of percutaneous coronary intervention was made widespread at the hospital and was used in 64.8% of non-ST-elevation acute coronary syndrome (NSTE-ACS) cases and in 95.5% of STE-ACS cases. A reduction was observed in readmissions (from 38.2% to 25.1% for NSTE-ACS (p=.001) and from 23.7% to 11.0% for STE-ACS (p=.018)), the composite prognostic variable of adverse cardiovascular events and 5-year mortality (from 58.7% to 45% (p=.001) for NSTE-ACS and from 40.8% to 23.8% (p=.009) for STE-ACS), and a decrease in 30-day mortality in STE-ACS (from 11.8% to 3.7%; p=.021).

CONCLUSIONS

With the structural changes in the hospital, the use of percutaneous coronary intervention was made widespread and improved the prognosis of patients with acute coronary syndrome, decreasing admissions, adverse cardiovascular events and mortality.

Impact of creating a hemodynamics room, a coronary care unit, and a primary angioplasty program on the prognosis of acute coronary syndrome in a district hospital

OBJECTIVE

This work aims to analyze the prognosis and mortality of patients hospitalized for acute coronary syndrome before and after the implementation of a coronary care unit, hemodynamics room, and the Código Corazón [Infarction Code] primary angioplasty program.

METHODS

We conducted an observational, retrospective study that analyzed the epidemiological characteristics, reperfusion strategies, adverse cardiovascular events, and mortality over a follow-up period of five years. The results from the post-code period (March 1 - December 31, 2012; n=471) were compared with those from the pre-code period (March 1 - December 31, 2009; n=432).

RESULTS

There were no differences in the baseline characteristics of the two groups. However, an increase in ST-elevation acute coronary syndrome (STE-ACS) from 17.6% to 34.8% (p<.001) was observed during the postcode phase. The use of percutaneous coronary intervention was made widespread at the hospital and was used in 64.8% of non-ST-elevation acute coronary syndrome (NSTE-ACS) cases and in 95.5% of STE-ACS cases. A reduction was observed in readmissions (from 38.2% to 25.1% for NSTE-ACS (p=.001) and from 23.7% to 11.0% for STE-ACS (p=.018)), the composite prognostic variable of adverse cardiovascular events and 5-year mortality (from 58.7% to 45% (p=.001) for NSTE-ACS and from 40.8% to 23.8% (p=.009) for STE-ACS), and a decrease in 30-day mortality in STE-ACS (from 11.8% to 3.7%; p=.021).

CONCLUSIONS

With the structural changes in the hospital, the use of percutaneous coronary intervention was made widespread and improved the prognosis of patients with acute coronary syndrome, decreasing admissions, adverse cardiovascular events, and mortality.

Prevalence and determinants of metabolically healthy obesity in Spain

BACKGROUND AND AIMS

Obesity is a heterogeneous disorder, so some obese individuals do not have cardiometabolic abnormalities (CA) which mediate the association between obesity and coronary heart disease. This study assessed the prevalence of metabolically healthy obesity and its determinants in Spain.

METHODS

The data were taken from a cross-sectional study conducted in 2008-2010 among 11,520 individuals representative of the population of Spain aged ≥18 years. Normal-weight was defined as body mass index (BMI) <25 kg/m(2), and obesity as BMI ≥30 kg/m(2). Six CA were considered: elevated blood pressure, low high-density lipoprotein cholesterol, and elevated levels of triglycerides, fasting glucose, homeostasis model assessment of insulin resistance value, and C-reactive protein. Then, two phenotypes were defined: healthy (0-1 CA) and abnormal (≥2 CA).

RESULTS

The prevalence of metabolically healthy obesity was 6.5% overall (95% confidence interval: 6.0-7.1), and corresponds to 28.9% of obese individuals. Lower age, being female, current smoking, moderate alcohol consumption, and high level of physical activity were independently associated with the healthy phenotype among the obese. The prevalence of normal weight with a metabolically abnormal phenotype was 6.4% overall (95% confidence interval: 5.8-6.9) and corresponds to 16.8% of normal-weight subjects. Factors associated with this phenotype in normal-weight persons were higher age, being male, never smoking, no alcohol consumption and larger waist circumference.

CONCLUSION

Metabolically healthy obesity represents almost one-third of the obese population in Spain. Since this was a cross-sectional study, the association of metabolic healthy obesity with smoking consumption, alcohol intake and physical activity warrants more research.

Systematic review of three decades of Spanish cardiovascular epidemiology: improving translation for a future of prevention

BACKGROUND

In order to improve national cardiovascular disease (CVD) epidemiology and prevention, we systematically reviewed and analyzed the relevant literature produced in the last three decades for Spain.

DESIGN

Systematic Review.

METHODS

We searched for all the articles aiming to monitor CVD clinical endpoints and risk factors in the Spanish general population that were indexed in MEDLINE and EMBASE. Based on international recommendations, we analyzed each article with a three-level scoring system (low to high) for the following criteria: data quality, representativeness and translation of results into preventive interventions.

RESULTS

We reviewed 2565 articles, selecting 314 for in-depth analysis. Articles about diet, blood pressure, obesity and smoking represented 53% of all published CVD studies, whereas those about physical activity or psychosocial factors represented only 5%. Low data quality was found in 67% and 60% of the articles about physical activity and smoking, respectively. High data quality was found in 77% and 61% of the articles dedicated to diet and blood pressure, respectively. Representativeness was low for 41%, 31% and 25% of the studies focusing on diet, smoking and diabetes, respectively. Translation of research results into prevention scored lowest of all three criteria, as 41% of all 314 articles scored low. None of the articles on obesity, diabetes, lipids, physical activity or psychosocial factors identified any specific preventive intervention.

CONCLUSION

Future Spanish CVD epidemiology research will benefit from improving not just the quality and representativeness of the data measured, but drastically improving the translation of research results into future preventive interventions. The lack of a translational focus remains the fundamental gap in CVD research.

Aragon workers' health study--design and cohort description

Background

Spain, a Mediterranean country with relatively low rates of coronary heart disease, has a high prevalence of traditional cardiovascular risk factors and is experiencing a severe epidemic of overweight/obesity. We designed the Aragon Workers’ Health Study (AWHS) to characterize the factors associated with metabolic abnormalities and subclinical atherosclerosis in a middle aged population in Spain free of clinical cardiovascular disease. The objective of this paper is to describe the study design, aims and baseline characteristics of participants in the AWHS.

Methods/Design

Longitudinal cohort study based on the annual health exams of 5,400 workers of a car assembly plant in Figueruelas (Zaragoza, Spain). Study participants were recruited during a standardized clinical exam in 2009–2010 (participation rate 95.6%). Study participants will undergo annual clinical exams and laboratory assays, and baseline and triennial collection of biological materials for biobanking and cardiovascular imaging exams (carotid, femoral and abdominal ultrasonography, coronary calcium score, and ankle-arm blood pressure index). Participants will be followed-up for 10 years.

Results

The average (SD) age, body mass index, and waist circumference were 49.3 (8.7) years, 27.7 (3.6) kg/m² and 97.2 (9.9) cm, respectively, among males (N = 5,048), and 40.8 (11.6) years, 24.4 (3.8) kg/m², and 81.9 (9.9) cm, among females (N = 351). The prevalence of overweight, obesity, current smoking, hypertension, hypercholesterolemia, and diabetes were 55.0, 23.1, 37.1, 40.3, 75.0, and 7.4%, respectively, among males, and 23.7, 8.3, 45.0, 12.1, 59.5, and 0.6%, respectively, among females. In the initial 587 study participants who completed all imaging exams (94.5% male), the prevalence of carotid plaque, femoral plaque, coronary calcium score >1 to 100, and coronary calcium score >100 was 30.3, 56.9, 27.0, and 8.8%, respectively. 67.7% of study participants had at least one plaque in the carotid or femoral arteries.

Discussion

Baseline data from the AWHS show a high prevalence of cardiovascular risk factors and of sublinical atherosclerosis. Follow-up of this cohort will allow the assessment of subclinical atherosclerosis progression and the link of disease progression to traditional and emergent risk factors.

Magnitude and management of hypercholesterolemia in the adult population of Spain, 2008-2010: The ENRICA Study

INTRODUCTION AND OBJECTIVES

Only a few studies have reported nationwide population-based data on the magnitude and control of hypercholesterolemia. This work examines the prevalence and management of hypercholesterolemia in Spain.

METHODS

Cross-sectional study conducted from June 2008 to October 2010 on 11,554 individuals representative of the population aged ≥ 18 years in Spain. Study participants provided 12-h fasting blood samples, which were analyzed in a central laboratory with standardized methods.

RESULTS

In the whole population, 50.5% had hypercholesterolemia (total cholesterol ≥ 200 mg/dL or drug treatment) and 44.9% high levels of low-density lipoprotein cholesterol (≥ 130 mg/dL or drug treatment), with no substantial sex-related differences. Moreover, 25.5% of men showed high-density lipoprotein cholesterol < 40 mg/dL and 26.4% of women high-density lipoprotein cholesterol <50mg/dL. Also, 23.2% of men and 11.7% of women had triglycerides ≥ 150 mg/dL. Frequency of dyslipidemia increased up to 65 years, except for low high-density lipoprotein cholesterol which did not vary with age. Among those with high low-density lipoprotein cholesterol, 53.6% knew of it and 44.1% of them received lipid-lowering treatment; among the latter, 55.7% had a controlled level (13.2% of all hypercholesterolemics). Control of high low-density lipoprotein cholesterol increased with age and with the number of visits to the specialist physician, but was lower among diabetics (odds ratio=0.38; 95% confidence interval, 0.28-0.53) and patients with cardiovascular disease (odds ratio=0.55; 95% confidence interval, 0.33-0.92).

CONCLUSIONS

About half of the Spanish population has elevated serum cholesterol; moreover, cholesterol control is poor, particularly among those with highest cardiovascular risk, such as diabetics or patients with cardiovascular disease.

Prevalence of cardiovascular risk factors and cardiovascular prevention quality in primary healthcare in Russia and European countries: EURIKA Study results

Background. In the Russian Federation (RF), the prevalence of cardiovascular disease (CVD) and CVD mortality levels are very high. Selected aspects of cardiovascular risk factor (RF) control and preventive activity of healthcare professionals have been investigated in numerous studies; however, relatively little research has been done in the area of primary CVD prevention. The EURIKA Study (NCT00882336) is a multicentre international cross-sectional study which involved 12 countries. In the RF, 604 patients were enrolled in the study at 26 clinical centres. Material and methods. The participating patients were recruited during routine clinical visits. The study population included primary care and ambulatory patients aged over 50 years, with at least one additional RF, but without previously registered CVD events or CVD hospitalisations. Results. In the Russian sample, the proportion of patients under 65 years was 81,5% (mean age 58,3±7,3 years). The proportion of women was 68,2%. Mean levels of body mass index and waist circumference were, respectively, 29,6±5,1 kg/m2 and 96±14,0 cm. More than a half of the patients (54,5%) reported low levels of physical activity. Weekly alcohol consumption was 1,8±3,9 drinks; 25,5% of the patients were current smokers, and 15,4% were ex-smokers. Mean levels of systolic and diastolic blood pressure (BP) were 136,5±17,5 and 84,3±11 mm Hg, respectively. The prevalence of arterial hypertension (AH) was 80,5%, left ventricular hypertrophy – 14,3%, and microalbuminuria – only 0,7%. Family history of premature CVD, dyslipidemia (DLP), or diabetes mellitus was reported by 37,9%, 50,5%, and 15,7%, respectively. Among AH patients, 85,4% received antihypertensive therapy, but only 35,9% achieved target BP levels. Only 49,8% of DLP patients received lipidlowering therapy, with target levels of total cholesterol and low-density lipoprotein cholesterol achieved in 24,3%. Conclusion. Currently, the main target group for cardiovascular prevention in the Russian Federation is represented by women of early retirement age, with AH and low or moderate SCORE risk levels, who actively seek medical help. However, the highest risk of CVD events is observed in working-age men over 40 years, who rarely seek medical help and, therefore, are not covered by cardiovascular prevention measures.

Rationale and methods of the cardiometabolic Valencian study (Escarval-Risk) for validation of risk scales in Mediterranean patients with hypertension, diabetes or dyslipidemia

BACKGROUND

The Escarval-Risk study aims to validate cardiovascular risk scales in patients with hypertension, diabetes or dyslipidemia living in the Valencia Community, a European Mediterranean region, based on data from an electronic health recording system comparing predicted events with observed during 5 years follow-up study.

METHODS/DESIGN

A cohort prospective 5 years follow-up study has been designed including 25000 patients with hypertension, diabetes and/or dyslipidemia attended in usual clinical practice. All information is registered in a unique electronic health recording system (ABUCASIS) that is the usual way to register clinical practice in the Valencian Health System (primary and secondary care). The system covers about 95% of population (near 5 million people). The system is linked with database of mortality register, hospital withdrawals, prescriptions and assurance databases in which each individual have a unique identification number. Diagnoses in clinical practice are always registered based on IDC-9. Occurrence of CV disease was the main outcomes of interest. Risk survival analysis methods will be applied to estimate the cumulative incidence of developing CV events over time.

DISCUSSION

The Escarval-Risk study will provide information to validate different cardiovascular risk scales in patients with hypertension, diabetes or dyslipidemia from a low risk Mediterranean Region, the Valencia Community.

Rationale and methods of the European Study on Cardiovascular Risk Prevention and Management in Daily Practice (EURIKA)

Background

The EURIKA study aims to assess the status of primary prevention of cardiovascular disease (CVD) across Europe. Specifically, it will determine the degree of control of cardiovascular risk factors in current clinical practice in relation to the European guidelines on cardiovascular prevention. It will also assess physicians' knowledge and attitudes about CVD prevention as well as the barriers impeding effective risk factor management in clinical practice.

Methods/Design

Cross-sectional study conducted simultaneously in 12 countries across Europe. The study has two components: firstly at the physician level, assessing eight hundred and nine primary care and specialist physicians with a daily practice in CVD prevention. A physician specific questionnaire captures information regarding physician demographics, practice settings, cardiovascular prevention beliefs and management. Secondly at the patient level, including 7641 patients aged 50 years or older, free of clinical CVD and with at least one classical risk factor, enrolled by the participating physicians. A patient-specific questionnaire captures information from clinical records and patient interview regarding sociodemographic data, CVD risk factors, and current medications. Finally, each patient provides a fasting blood sample, which is sent to a central laboratory for measuring serum lipids, apolipoproteins, hemoglobin-A1c, and inflammatory biomarkers.

Discussion

Primary prevention of CVD is an extremely important clinical issue, with preventable circulatory diseases remaining the leading cause of major disease burden. The EURIKA study will provide key information to assess effectiveness of and attitudes toward primary prevention of CVD in Europe. A transnational study creates opportunities for benchmarking good clinical practice across countries and improving outcomes. (ClinicalTrials.gov number, NCT00882336.)