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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 and 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.

Resumen: Las VI Guías Europeas de Prevención Cardiovascular recomiendan combinar las estrategias poblacional y de alto riesgo, con los cambios de estilo de vida como piedra angular de la prevención, y proponen la función SCORE para cuantificar el riesgo cardiovascular. Esta guía hace más hincapié en las intervenciones específicas de las enfermedades y las condiciones propias de las mujeres, las personas jóvenes y las minorías étnicas. No se recomienda el cribado de aterosclerosis subclínica con técnicas de imagen no invasivas. La guía establece cuatro niveles de riesgo (muy alto, alto, moderado y bajo), con objetivos terapéuticos de control lipídico según el riesgo. La diabetes mellitus confiere un riesgo alto, excepto en sujetos con diabetes tipo 2 con menos de diez años de evolución, sin otros factores de riesgo ni complicaciones, o con diabetes tipo 1 de corta evolución sin complicaciones. La decisión de iniciar el tratamiento farmacológico de la hipertensión arterial dependerá del nivel de presión arterial y del riesgo cardiovascular, teniendo en cuenta la lesión de órganos diana. Siguen sin recomendarse los fármacos antiplaquetarios en prevención primaria por el riesgo de sangrado. La baja adherencia al tratamiento exige simplificar el régimen terapéutico e identificar y combatir sus causas. La guía destaca que los profesionales de la salud pueden ejercer un papel importante en la promoción de intervenciones poblacionales y propone medidas eficaces, tanto a nivel individual como poblacional, para promover una dieta saludable, la práctica de actividad física, el abandono del tabaquismo y la protección contra el abuso de alcohol.

RESUMEN Las VI Guías Europeas de Prevención Cardiovascular recomiendan combinar las estrategias poblacionales y de alto riesgo, con los cambios de estilo de vida como piedra angular de la prevención, y proponen la función SCORE para cuantificar el riesgo cardiovascular. Esta guía hace más hincapié en las intervenciones específicas de las enfermedades y las condiciones propias de las mujeres, las personas jóvenes y las minorías étnicas. No se recomienda el cribado de aterosclerosis subclínica con técnicas de imagen no invasivas. La guía establece cuatro niveles de riesgo (muy alto, alto, moderado y bajo), con objetivos terapéuticos de control lipídico según el riesgo. La diabetes mellitus confiere un riesgo alto, excepto en sujetos con diabetes tipo 2 con menos de 10 años de evolución, sin otros factores de riesgo ni complicaciones, o con diabetes tipo 1 de corta evolución sin complicaciones. La decisión de iniciar el tratamiento farmacológico de la hipertensión arterial dependerá del nivel de presión arterial y del riesgo cardiovascular, teniendo en cuenta la lesión de órganos diana. Siguen sin recomendarse los fármacos antiplaquetarios en prevención primaria por el riesgo de sangrado. La baja adherencia al tratamiento exige simplificar el régimen terapéutico e identificar y combatir sus causas. La guía destaca que los profesionales de la salud pueden ejercer un papel importante en la promoción de intervenciones poblacionales y propone medidas eficaces, tanto a nivel individual como poblacional, para promover una dieta saludable, la práctica de actividad física, el abandono del tabaquismo y la protección contra el abuso de alcohol. ABSTRACT The VI European Guidelines for Cardiovascular Prevention recommend combining population and high-risk strategies with lifestyle changes as a cornerstone of prevention, and propose the SCORE function to quantify cardiovascular risk. The guidelines highlight disease specific interventions, and conditions as women, young people and ethnic minorities. Screening for subclinical atherosclerosis with noninvasive imaging techniques is not recommended. The guidelines distinguish four risk levels (very high, high, moderate and low) with therapeutic objectives for lipid control according to risk. Diabetes mellitus confers a high risk, except for subjects with type 2 diabetes with less than 10 years of evolution, without other risk factors or complications, or type 1 diabetes of short evolution without complications. The decision to start pharmacological treatment of arterial hypertension will depend on the blood pressure level and the cardiovascular risk, taking into account the lesion of target organs. The guidelines don't recommend antiplatelet drugs in primary prevention because of the increased bleeding risk. The low adherence to the medication requires simplified therapeutic regimes and to identify and combat its causes. The guidelines highlight the responsibility of health professionals to take an active role in advocating evidence-based interventions at the population level, and propose effective interventions, at individual and population level, to promote a healthy diet, the practice of physical activity, the cessation of smoking and the protection against alcohol abuse.

Based on the two main frameworks for evaluating scientific evidence (SEC and GRADE) European cardiovascular prevention guidelines recommend interventions across all life stages using a combination of population-based and high-risk strategies with diet as the cornerstone of prevention. The evaluation of cardiovascular risk (CVR) incorporates HDL levels and psychosocial factors, a very high risk category, and the concept of age-risk. They also recommend cognitive-behavioural methods (e.g., motivational interviewing, psychological interventions) led by health professionals and with the participation of the patient's family, to counterbalance psychosocial stress and reduce CVR through the institution of positive habits such as a healthy diet, physical activity, smoking cessation, and adherence to treatment. Additionally, public health interventions such as smoking ban in public areas or the elimination of trans fatty acids from the food chain are also essential. Other innovations include abandoning antiplatelet therapy in primary prevention and the recommendation of maintaining blood pressure within the 130-139/80-85 mmHg range in diabetic patients and individuals with high CVR. Finally, due to the significant impact on patient progress and medical costs, special emphasis is given to the low therapeutic adherence levels observed. In sum, improving cardiovascular prevention requires a true partnership among the political class, public administrations, scientific and professional associations, health foundations, consumer associations, patients and their families. Such partnership would promote population-based and individual strategies by taking advantage of the broad spectrum of scientific evidence available, from clinical trials to observational studies and mathematical models to evaluate population-based interventions, including cost-effectiveness analyses. (C) 2013 Sociedad Espanola de Neurologia. Published by Elsevier Espana, S.L.U. All rights reserved.

The publication of the 2013 American College of Cardiology/American Heart Association guidelines on the treatment of high blood cholesterol has had a strong impact due to the paradigm shift in its recommendations. The Spanish Interdisciplinary Committee for Cardiovascular Disease Prevention and the Spanish Society of Cardiology reviewed this guideline and compared it with current European guidelines on cardiovascular prevention and dyslipidemia management. The most striking aspect of the American guideline is the elimination of the low-density lipoprotein cholesterol treat-to-target strategy and the adoption of a risk reduction strategy in 4 major statin benefit groups. In patients with established cardiovascular disease, both guidelines recommend a similar therapeutic strategy (high-dose potent statins). However, in primary prevention, the application of the American guidelines would substantially increase the number of persons, particularly older people, receiving statin therapy. The elimination of the cholesterol treat-to-target strategy, so strongly rooted in the scientific community, could have a negative impact on clinical practice, create a certain amount of confusion and uncertainty among professionals, and decrease follow-up and patient adherence. Thus, this article reaffirms the recommendations of the European guidelines. Although both guidelines have positive aspects, doubt remains regarding the concerns outlined above. In addition to using risk charts based on the native population, the messages of the European guideline are more appropriate to the Spanish setting and avoid the possible risk of overtreatment with statins in primary prevention.

The publication of the 2013 American College of Cardiology/American Heart Association guidelines on the treatment of high blood cholesterol has had a strong impact due to the paradigm shift in its recommendations. The Spanish Interdisciplinary Committee for Cardiovascular Disease Prevention and the Spanish Society of Cardiology reviewed this guideline and compared it with current European guidelines on cardiovascular prevention and dyslipidemia management. The most striking aspect of the American guideline is the elimination of the low-density lipoprotein cholesterol treat-to-target strategy and the adoption of a risk reduction strategy in 4 major statin benefit groups. In patients with established cardiovascular disease, both guidelines recommend a similar therapeutic strategy (high-dose potent statins). However, in primary prevention, the application of the American guidelines would substantially increase the number of persons, particularly older people, receiving statin therapy. The elimination of the cholesterol treat-to-target strategy, so strongly rooted in the scientific community, could have a negative impact on clinical practice, create a certain amount of confusion and uncertainty among professionals, and decrease follow-up and patient adherence. Thus, this article reaffirms the recommendations of the European guidelines. Although both guidelines have positive aspects, doubt remains regarding the concerns outlined above. In addition to using risk charts based on the native population, the messages of the European guideline are more appropriate to the Spanish setting and avoid the possible risk of overtreatment with statins in primary prevention. (C) 2014 Published by Elsevier Espana, S.L.U. on behalf of Sociedad Espanola de Arteriosclerosis.

BACKGROUND This study was undertaken to determine whether use of the direct renin inhibitor aliskiren would reduce cardiovascular and renal events in patients with type 2 diabetes and chronic kidney disease, cardiovascular disease, or both. METHODS In a double-blind fashion, we randomly assigned 8561 patients to aliskiren (300 mg daily) or placebo as an adjunct to an angiotensin-converting-enzyme inhibitor or an angiotensin-receptor blocker. The primary end point was a composite of the time to cardiovascular death or a first occurrence of cardiac arrest with resuscitation; nonfatal myocardial infarction; nonfatal stroke; unplanned hospitalization for heart failure; end-stage renal disease, death attributable to kidney failure, or the need for renal-replacement therapy with no dialysis or transplantation available or initiated; or doubling of the baseline serum creatinine level. RESULTS The trial was stopped prematurely after the second interim efficacy analysis. After a median follow-up of 32.9 months, the primary end point had occurred in 783 patients (18.3%) assigned to aliskiren as compared with 732 (17.1%) assigned to placebo (hazard ratio, 1.08; 95% confidence interval [CI], 0.98 to 1.20; P = 0.12). Effects on secondary renal end points were similar. Systolic and diastolic blood pressures were lower with aliskiren (between-group differences, 1.3 and 0.6 mm Hg, respectively) and the mean reduction in the urinary albumin-to-creatinine ratio was greater (between-group difference, 14 percentage points; 95% CI, 11 to 17). The proportion of patients with hyperkalemia (serum potassium level, = 6 mmol per liter) was significantly higher in the aliskiren group than in the placebo group (11.2% vs. 7.2%), as was the proportion with reported hypotension (12.1% vs. 8.3%) (P CONCLUSIONS The addition of aliskiren to standard therapy with renin-angiotensin system blockade in patients with type 2 diabetes who are at high risk for cardiovascular and renal events is not supported by these data and may even be harmful. (Funded by Novartis; ALTITUDE ClinicalTrials.gov number, NCT00549757.)

Presentamos la Guía europea para la prevención de las enfermedades cardiovasculares (ECV), traducida y adaptada por el Comité Español Interdisciplinario para la Prevención Cardiovascular. Esta guía se centra en la prevención de la ECV en su conjunto, recomienda el modelo SCORE para valorar el riesgo y prioriza la atención a los pacientes y sujetos de alto riesgo. El objetivo es prevenir la muerte prematura por ECV, mediante el manejo de sus factores de riesgo en la práctica clínica. Así, se requiere una intervención profesional sostenida para que los pacientes e individuos de alto riesgo incrementen su actividad física y elijan dietas cardiosaludables, y para que los fumadores abandonen el tabaco. La decisión de iniciar el tratamiento de la presión arterial dependerá de sus valores, del riesgo cardiovascular y de posibles lesiones de órganos diana. La meta terapéutica es lograr una presión arterial

It is difficult to draw definite conclusions about the prevalence and clinical characteristics of patients with resistant hypertension because of the heterogeneity of study designs described in published studies.To estimate the prevalence of resistant hypertension, the associated cardiovascular risk factors and the degree of target-organ damage, and to analyze the differences between true resistant hypertension (TRH) and white-coat resistant hypertension (WCRH).Cross-sectional study.Patients who visited the Hypertension Clinic with resistant hypertension were sequentially included. Resistant hypertension was defined as an average of three measurements of systolic blood pressure,/= 160 mmHg or a diastolic blood pressure/= 95 mmHg, or both, in patients treated with a triple-drug regimen, over at least 2 months. Twenty-four-hour ambulatory blood pressure monitoring and M-mode bi-dimensional echocardiography were performed. WCRH was defined as a mean daytime ambulatory blood pressure/= 135/85 mmHg; patients with higher values were classified as having TRH.Of 1200 hypertensive subjects who visited the clinic, 60 patients with resistant hypertension were included [mean age 59+/-8 years; 38 women (63%)]. Office blood pressure was 173+/-14/100+/- 8 mmHg. Of 36 patients with a good quality echocardiograph, 18 had left ventricular hypertrophy. Twenty cardiovascular events were recorded in 16 patients. Obesity was present in 43% of patients, diabetes in 28%, and hypercholesterolemia in 47%. Hypoalphalipoproteinemia was detected in 18%of the patients, all of whom had TRH (P = 0.01). Nineteen subjects (32%) had WCRH. The subjects with TRH had a higher office systolic blood pressure, greater frequency of hypoalphalipoproteinemia than those who had WCRH and a greater proportion of clinical target-organ damage.Resistant hypertension is uncommon in clinical practice. Resistant hypertension is associated with multiple cardiovascular risk factors, including left ventricular hypertrophy. A third of patients with resistant hypertension achieve adequate control of their blood pressure outside the physician's office. The proportion of patients with clinical target-organ damage is greater in subjects with TRH than in those with WCRH.

Attitudes and practices with regard to hypertension were the subject of a survey conducted in 1987 among 2,500 Spanish general practitioners. Their responses showed almost complete use of diagnostic criteria adhering to WHO recommendations and guidelines, the wide prescription of diuretics as first-step medication and beta-blockers as the drug of choice in second-step treatment, and a non-compliance rate of 25% attributed to inadequate information and bureaucracy, similar to other countries.

The objectives of this paper were to study the association between the prevalence of uncontrolled hypertension (PUHT) and stroke mortality at the ecological level, in nine geographical areas of Catalonia (Spain); to develop an ecological regression model and to assess its ability to predict crude stroke mortality rate (CMR) from the PUHT. The regression equation obtained for the population older than 25 yrs was CSMR x 10(3) = 0.67035 + 4.94752 PUTH x 10(-2). The ecological risk ratio was 8.38 and the ecological attributable proportion 71.1%. The CSMR estimation obtained by applying the model in a concrete case was close to that observed. The results support an ecological association between the studied variables. The ecological model can be useful in the assessment of observed changes in health problems and risk factor levels in the community. It could also be used in the evaluation of intervention programmes.

We present the Spanish adaptation made by the CEIPC of the European Guidelines on Cardiovascular Disease Prevention (CVD) in Clinical Practice 2008. This guide recommends the SCORE model for risk evaluation. The aim is to prevent premature mortality and morbidity due to CVD through the management of its related risk factors in clinical practice. The guide focuses on primary prevention and emphasizes the role of the nurses and primary care medical doctors in promoting a healthy life style, based on increasing physical activity, change dietary habits, and non smoking. The therapeutic goal is to achieve a Blood Pressure140/90 mmHg, but among patients with diabetes, chronic kidney disease, or definite CVD, the objective is130/80 mmHg. Serum cholesterol should be200 mg/dl and cLDL130 mg/dl, although among patients with CVD or diabetes, the objective is100 mg/dl (80 mg/dl if feasible in very high-risk patients). Patients with type 2 diabetes and those with metabolic syndrome must lose weight and increase their physical activity, and drugs must be administered whenever applicable, to reach body mass index (BMI) guided and waist circumference objectives. In diabetic type 2 patients, the objective is glycated haemoglobin7%. Allowing people to know the guides and developing implementation programs, identifying barriers and seeking solutions for them, are priorities for the CEIPC in order to transfer the recommendations established into the daily clinical practice.

It has been previously reported that an exaggerated response of blood pressure to mental stress tasks is associated to an increased cardiovascular risk. The objective of this cross-sectional study, with sequential inclusion of subjects who met the inclusion criteria, was to asses the relationships between the response of blood pressure and heart rate to two different mental stress tasks and early target organ-damage, defined as abnormalities in the echocardiogram and/or an increase of urinary albumin excretion (UAE) or microalbuminuria, in untreated mild hypertensive subjects.Two hundred and eleven subjects aged 18 to 65 years (56% males) with mild hypertension (SBP between 140-180 mmHg and/or DBP between 90-105 mmHg) were included in Hospitalet Study. One hundred and thirty seven of them accepted to participate in the study of cardiovascular reactivity. Two different tasks were applied in the same day: a stressful interview (SI) and a mental arithmetic stress tasks (MAST). An echocardiogram of good quality was obtained in 123 cases (89.8%) and 24 h UAE was measured in 108 cases (78.8%).The prevalence of left ventricular hypertrophy was 21.1% (95% CI = 14.3-29.4) and the prevalence of microalbuminuria was 15.7% (95% CI = 9.4-24.4%). After adjusting for the baseline blood pressure, a significant correlation was observed between increase of systolic BP during SI and UAE (r = 0.21; p = 0.03) and between increase of diastolic BP during SI and relative wall thickness (r = 0.32; p0.005). When we analyzed the changes of BP during MAST, a significant correlation was observed between increase of diastolic BP (adjusted for baseline diastolic BP) and left atrial size (r = 0.21; p = 0.02). We did not find any significant correlation between the increases of BP (systolic or diastolic) during MAST or increases of heart rate during both tasks and left ventricular mass index or UAE.A weak correlation was observed between cardiovascular reactivity of blood pressure during mental stress tasks and early target organ damage in mild hypertension. We did not find any relationship between the response to heart rate during the tasks and early target organ damage.