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Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): CIBERCV of cardiovascular diseases; CIBERESP. OnBehalf REGICOR investigators Background Although myocardial infarction (MI) severity trends are systematically measured with mortality rates, MI incidence trends and the precision of its estimation by linkage of anonymized electronic databases are relatively untested. We validated a linked-data method (LDM) to estimate a population MI incidence and case-fatality, and to analyse the 1990-2016 trends in North-Eastern Spain. Methods LDM consisted of linking MI hospital discharges (n = 4,533,981) and mortality registry data (n = 40,676) for 2008-2016, selecting key MI diagnostic codes. The prospective REGICOR study, including all MI cases in Girona, 1990-2009, was used as the gold standard for validation purposes. Standardized MI cumulated incidence and 28-day case fatality for population aged 35-74 years was calculated, 1990-2016 trends were analysed by linear and joinpoint regression and annual percentage change (APC). Results LDM and REGICOR MI incidence and case-fatality estimates were similar for 2008-09 (Table). LDM MI incidence and case-fatality significantly decreased: APC 1990-2016 [95% CI]) was -1.8 [-2.6;-0.9] in women, and APC 2002-2016 -2.8 [-3.8;-1.8] in men; case-fatality APC 1990-2016 was -4.7% [-5.7;-3.8] in women and APC 1995-2005 -6.5%[-8.5;-4.5] in men. Conclusions LDM in population aged 35-74 reliably estimated MI incidence and case-fatality. MI incidence and case-fatality significantly decreased after 1990. Comparative analysis of REGICOR vs LDM REGICOR 2008-2009 LDM 2008-2009 Estimate 95% CI Estimate 95% CI P-Value Cumulated incidence Men 245.4 228.3; 262.5 239.7 222.5; 256.3 0.626 Women 61.1 52.6; 69.6 58.2 49.9; 66.4 0.626 Overall 28-day case-fatality Men 23.5% 19.7; 27.2 21.3% 17.8; 24.9 0.422 Women 19.3% 6.7; 31.9 17.7% 6.3; 29.1 0.855 In-hospital case-fatality Men 6.9% 4.8; 9.0 5.7% 3.8; 7.6 0.394 Women 5.0% 1.9; 8.2 3.7% 1.0; 6.5 0.540 Pre-hospital case-fatality Men 16.5% 11.8; 21.3 15.6% 11.2; 20.1 0.791 Women 14.2 % 6.6; 21.9 14.0% 6.3; 21.7 0.961 CI Confidence Interval

Resumen Introduccion y objetivos Estudiar la validez de la funcion SCORE original de bajo riesgo sin y con colesterol unido a lipoproteinas de alta densidad y SCORE calibrada en poblacion espanola. Metodos Analisis agrupado con datos individuales de 12 estudios de cohorte de base poblacional. Se incluyo a 30.919 participantes de 40-64 anos sin enfermedades cardiovasculares en el momento del reclutamiento, que se siguieron durante 10 anos para la mortalidad cardiovascular contemplada en el proyecto SCORE. La validez de las funciones se analizo mediante el area bajo la curva ROC (discriminacion) y el test de Hosmer-Lemeshow (calibracion), respectivamente. Resultados Se dispuso de 286.105 personas/ano. La mortalidad a 10 anos por causas cardiovasculares fue del 0,6%. La razon de casos esperados/observados fue de 9,1, 6,5 y 9,1 en varones y de 3,3, 1,3 y 1,9 en mujeres con las funciones SCORE original de bajo riesgo sin y con colesterol unido a lipoproteinas de alta densidad y SCORE calibrada, respectivamente; diferencias estadisticamente significativas con el test de calibracion de Hosmer-Lemeshow entre la mortalidad predicha con SCORE y la observada (p Conclusiones Todas las versiones de las funciones SCORE disponibles en Espana sobreestiman significativamente la mortalidad cardiovascular observada en la poblacion espanola. A pesar de la aceptable capacidad de discriminacion, la prediccion del numero de acontecimientos cardiovasculares mortales (calibracion) fue significativamente imprecisa.

Resumen Introduccion y objetivos La fibrilacion auricular (FA) es la arritmia mas frecuente en la practica clinica. Nuestro objetivo es determinar la asociacion entre la duracion de la onda P y el bloqueo interauricular (BIA) avanzado y la FA. Metodos Estudio de casos y controles anidado en una cohorte (REGICOR: REgistre GIroni del COR) emparejada por edad y sexo. Entre 1999 y 2005 se realizaron 2 estudios transversales en los que participaron 9.380 individuos; entre 2009 y 2013 se invito a todos los participantes a un segundo examen. Se selecciono a los participantes de 25-79 anos que participaron en el segundo examen. Dos observadores determinaron la duracion y la morfologia de la onda P para determinar la presencia de BIA (ausencia, parcial o avanzado). Resultados La mediana de seguimiento fue 7,12 anos. Se incluyo a 80 participantes que sufrieron FA y 160 controles. La duracion de la onda P y la presencia de BIA se asociaron con la FA. Al considerar simultaneamente las 2 variables, solo la duracion de la onda P (≥ 110 ms) se asocio con la aparicion de FA. Las odds ratio de FA para la duracion de la onda P entre 110-119, 120-129 y ≥ 130 ms frente a Conclusiones La duracion de la onda P ≥ 110 ms aumenta el riesgo de FA. No parece que el BIA avanzado aporte un riesgo adicional al de la duracion de la onda P.

Background Current evidence shows that single-stage treatment of concomitant choledocholithiasis and cholelithiasis is as effective and safe as two-stage treatment. However, several studies suggest that single-stage approach requires shorter hospitalization time and is more cost-effective than the two-stage approach, even though it requires considerable training. This study aimed to evaluate the implementation of a protocol for managing concomitant choledocholithiasis and cholelithiasis using single-stage treatment. Methods A prospective cohort study of patients diagnosed with cholelithiasis and choledocholithiasis who were treated with the single-stage treatment – transcystic instrumentation, choledocotomy or intraoperative endoscopic retrograde cholangiopancreatography (ERCP) – between September 2010 and June 2017 was assessed. The primary outcomes were complications, hospital stay, operative time and recurrence rate. Results 164 patients were enrolled. 141 (86%) were operated laparoscopically. Preoperatively diagnosed stones were not found by intraoperative imaging or disappeared after “flushing” in 38 patients (23.2%). Surgical approach was transcystic in 45 patients (27.41%), choledochotomy in 74 (45.1%), intraoperative ERCP in 4 (2.4%), and bilioenteric derivation in 3 (1.8%). Mean hospitalization stay was 4.4 days. Mean operative time was 166 min 27 patients (16.5%) had complications and 1 patient was exitus (0.6%). Recurrence rate was 1.2%. Conclusions Single-stage approach is a safe and effective management option for concomitant cholelithiasis and choledocolithiasis. Furthermore, a significant number of common bile duct stones pass spontaneously to duodenum or can benefit from a transcystic approach, with presumable low morbidity and cost-efficiency.

Resumen Antecedentes y objetivos La fibrilacion auricular es la arritmia cronica mas comun. El proposito de este estudio fue determinar la prevalencia de la fibrilacion auricular y su relacion con los factores de riesgo cardiovascular en Espana. Metodologia Estudio transversal a partir de un analisis agrupado de 17.291 individuos aleatorizados reclutados en 6 estudios poblacionales. Resultados La prevalencia de fibrilacion auricular fue de 1,5%. (intervalo de confianza 95%: 1,3-1,7%). Los hombres tuvieron mayor prevalencia que las mujeres (1,9 vs. 1,1%, respectivamente). La prevalencia de fibrilacion auricular se incremento progresivamente con la edad: 0,05% en los menores de 45 anos, 0,5% entre los 45-59 anos, 2,3% entre los 60-74 anos, y 6,3% en los mayores de 75 anos. El porcentaje de individuos que recibia tratamiento anticoagulante fue de 74,3%. Los factores de riesgo asociados significativamente con la arritmia fueron: edad mayor de 60 anos (odds ratio [OR]: 7,6; IC 95%: 5,1-11,2), sexo masculino (OR : 1,8; IC 95%: 1,4-2,4), hipertension arterial (OR : 1,6; IC 95%: 1,2-2,1), obesidad (OR : 1,5; IC 95%: 1,2-2,1), y antecedentes de enfermedad coronaria (OR : 1,9; IC 95%: 1,3-3,0). Conclusion La fibrilacion auricular es una enfermedad frecuente en los individuos de mayor edad mientras que su prevalencia es baja en individuos menores de 60 anos. La mayoria de los individuos con fibrilacion auricular estaban bajo tratamiento anticoagulante. Los factores de riesgo para padecer esta arritmia fueron la edad, el sexo masculino, la hipertension, la obesidad y los antecedentes de enfermedad coronaria.

Background and objectives Atrial fibrillation (AF) is the most common type of arrhythmia. The purpose of this study was to determine the prevalence of atrial fibrillation and its relationship with cardiovascular risk factors in Spain. Methodology Cross-sectional study based on a grouped analysis of 17,291 randomized individuals recruited in 6 population studies. Results The prevalence of atrial fibrillation was 1.5% (95% CI: 1.3–1.7%). Men had a greater prevalence of the disease than women (1.9 vs. 1.1%, respectively). The prevalence of atrial fibrillation progressively increased with age: 0.05% for patients younger than 45 years, 0.5% for those between 45 and 59 years of age, 2.3% for those between 60 and 74 years of age and 6.3% for those older than 75 years. The percentage of individuals who underwent anticoagulant treatment was 74.3%. The risk factors significantly associated with arrhythmia were ages older than 60 years (odds ratio [OR]: 7.6; 95% CI: 5.1–11.2), the male sex (OR: 1.8; 95% CI: 1.4–2.4), arterial hypertension (OR: 1.6; 95% CI: 1.2–2.1), obesity (OR: 1.5; 95% CI: 1.2–2.1) and a history of coronary artery disease (OR: 1.9; 95% CI: 1.3–3.0). Conclusion Atrial fibrillation is a common disease in elderly individuals, while its prevalence is low in individuals younger than 60 years. Most individuals with atrial fibrillation were on anticoagulant treatment. The risk factors for this type of arrhythmia are age, the male sex, hypertension, obesity and a history of coronary artery disease.

Introduction Blood pressure increases in cold periods, but its implications on prevalence of hypertension and on individual progression to hypertension remain unclear. Our aim was to develop a pre-screening test for identifying candidates to suffer hypertension only in cold months among non-hypertensive subjects. Methods We included 95,277 subjects registered on a primary care database from Girona (Catalonia, Spain), with ≥3 blood pressure measures recorded between 2003 and 2009 and distributed in both cold (October–March) and warm (April–September) periods. We defined four blood pressure patterns depending on the presence of hypertension through these periods. A Cox model determined the risk to develop vascular events associated with blood pressure patterns. A logistic regression distinguished those nonhypertensive individuals who are more prone to suffer cold-induced hypertension. Validity was assessed on the basis of calibration (using Brier score) and discrimination (using the area under the receiver operating characteristics). Results In cold months, the mean systolic blood pressure increased by 3.3±0.1 mmHg and prevalence of hypertension increased by 8.2%. Cold-induced hypertension patients were at higher vascular events risk (Hazard ratio=1.44 [95% Confidence interval 1.15–1.81]), than nonhypertensive individuals. We identified age, diabetes, body mass index and prehypertension as the major contributing factors to cold-induced hypertension onset. Discussion Hypertension follows a seasonal pattern in some individuals. We recommend screening for hypertension during the cold months, at least in those nonhypertensive individuals identified as cold-induced hypertensive by this assessment tool.

AIM To determine whether circulating antibodies against oxidized low-density lipoprotein (LDL; OLAB) levels are associated with acute myocardial infarction (AMI) in individuals without classical cardiovascular risk factors. METHODS A case-control study including 34 first AMI patients without classical risk factors (smoking, dyslipidemia, hypertension or diabetes) and 45 population-based healthy controls. RESULTS There were no differences in anthropometric variables between cases and controls. Oxidized LDL levels were similar in both groups. Total cholesterol, LDL cholesterol, apolipoprotein B and physical activity were lower in cases than in controls. OLAB levels were also lower in cases than controls (128 versus 447 U/l, P < 0.001). After adjusting for age, oxidized LDL and physical activity, participants with OLAB levels of 165 U/l or less had a higher risk of AMI (odds ratio, OR = 7.48, 95% confidence interval: 1.57-35.66). When the model was fitted with OLAB as a continuous variable, the natural logarithm (LnOLAB) levels were independently associated with AMI with an OR of 0.40 (95% confidence interval: 0.19-0.86). After adjusting the model by Framingham-risk-adapted score and oxidized LDL, the LnOLAB levels maintained their independent association (OR of 0.43, 95% confidence interval: 0.23-0.79). CONCLUSION First AMI patients without classical risk factors had lower levels of OLAB compared with healthy controls. It is likely that the immunological reaction due to oxidized LDL participates as a preventive factor in the physiopathology of atherosclerosis.

Objective To derive and validate a set of functions to predict coronary heart disease (CHD) and stroke, and validate the Framingham-REGICOR function. Method Pooled analysis of 11 population-based Spanish cohorts (1992–2005) with 50,408 eligible participants. Baseline smoking, diabetes, systolic blood pressure (SBP), lipid profile, and body mass index were recorded. A ten-year follow-up included re-examinations/telephone contact and cross-linkage with mortality registries. For each sex, two models were fitted for CHD, stroke, and both end-points combined: model A was adjusted for age, smoking, and body mass index and model B for age, smoking, diabetes, SBP, total and HDL cholesterol, and for hypertension treatment by SBP, and age by smoking and by SBP interactions. Results The 9.3-year median follow-up accumulated 2973 cardiovascular events. The C-statistic improved from model A to model B for CHD (0.66 to 0.71 for men; 0.70 to 0.74 for women) and the combined CHD-stroke end-points (0.68 to 0.71; 0.72 to 0.75, respectively), but not for stroke alone. Framingham-REGICOR had similar C-statistics but overestimated CHD risk. Conclusions The new functions accurately estimate 10-year stroke and CHD risk in the adult population of a typical southern European country. The Framingham-REGICOR function provided similar CHD prediction but overestimated risk.

Background The use of validated multivariate cardiovascular predictive models in a population setting is of interest for public health policy makers. We aimed to validate the estimations of the CASSANDRA model (coronary heart disease (CHD) incidence and CHD risk distribution), considering the population changes in age, sex and CHD risk factors prevalence in a 10-year period. Methods We compared the projected CHD incidence estimated with CASSANDRA with that observed in the Girona Heart Registry (REGICOR) for 1995–2004 and 2000–2009 in the population of Girona (Spain) aged 35–74 years. We used official age and sex distributions for this population. Baseline cardiovascular risk factors prevalence and the distribution of cardiovascular risk were obtained from three cross-sectional studies performed in 1995, 2000 and 2005. To validate the future distribution of cardiovascular risk, we tested the yearly CHD risk variance over the study period. Results No significant differences between the estimated and observed annual CHD incidence per 100 000 men were found in 1995–2004 (CASSANDRA=457.8 and REGICOR=420.3, incidence rate ratio (IRR) (95% CI)=0.92 (0.89 to 0.96)) and in 2000–2009 (441.4 and 409.6, respectively, IRR=0.93 (0.90 to 0.96)). However, overpredictions of 18% and 22%, respectively, were observed in women (198.8 and 160.4, IRR=0.82 (0.77 to 0.86), and 197.1 and 152.8, IRR=0.78 (0.74 to 0.83), respectively). No significant differences were found in the CHD risk variance in the three different cross-sectional studies. Conclusions The CASSANDRA model produces valid estimates, particularly in men, of the future burden of disease and in the distribution of cardiovascular risk in individuals aged 35–74 years.

Objectives To assess 1) the association of lipid oxidation biomarkers with 10-year coronary artery disease (CAD) events and subclinical atherosclerosis, and 2) the reclassification capacity of these biomarkers over Framingham-derived CAD risk functions, in a general population. Methods Within the framework of the REGICOR study, 4782 individuals aged between 25 and 74 years were recruited in a population-based cohort study. Follow-up of the 4042 who met the eligibility criteria was carried out. Plasma, circulating oxidized low-density lipoprotein (oxLDL) and oxLDL antibodies (OLAB) were measured in a random sample of 2793 participants. End-points included fatal and non-fatal acute myocardial infarction (AMI) and angina. Carotid intima-media thickness (IMT) in the highest quintile and ankle-brachial index Results Mean age was 50.0 (13.4) years, and 52.4% were women. There were 103 CAD events (34 myocardial infarction, 43 angina, 26 coronary deaths), and 306 subclinical atherosclerosis cases. Oxidized LDL was independently associated with higher incidence of CAD events (HR = 1.70; 95% Confidence Interval: 1.02–2.84), but not with subclinical atherosclerosis. The net classification index of the Framingham-derived CAD risk function was significantly improved when ox-LDL was included (NRI = 14.67% [4.90; 24.45], P = 0.003). No associations were found between OLAB and clinical or subclinical events. The reference values for oxLDL and OLAB are also provided (percentiles). Conclusions OxLDL was independently associated with 10-year CAD events but not subclinical atherosclerosis in a general population, and improved the reclassification capacity of Framingham-derived CAD risk functions.

Resumen Introduccion y objetivos Analizar las diferencias en funcion del sexo en las caracteristicas clinicas, tratamiento y mortalidad a los 28 dias y a los 7 anos de un primer infarto de miocardio. Metodos Entre 2001 y 2003, 2.042 pacientes con un primer infarto de miocardio ingresaron consecutivamente en seis hospitales espanoles. Se recogen prospectivamente las caracteristicas clinicas, el tratamiento y la mortalidad a los 28 dias. Se dispone del estado vital a los 7 anos mediante consulta del Indice Nacional de Defunciones. Resultados Se incluyo a 449 mujeres y 1.593 varones con un primer infarto de miocardio. En comparacion con los varones, las mujeres eran mayores y tenian mayor prevalencia de hipertension y diabetes mellitus; tambien recibieron mas tratamiento con inhibidores de la enzima de conversion de la angiotensina, pero menos bloqueadores beta y trombolisis. No hubo diferencias en el uso de procedimientos invasivos. Las mujeres tuvieron mas infartos de miocardio sin elevacion del segmento ST o no clasificables (el 37,9 frente al 31,3% y el 9,8 frente al 6,1% respectivamente; p Conclusiones Hay diferencias clinicas y demograficas entre varones y mujeres que ingresan por un primer infarto de miocardio. El pronostico a corto plazo es similar en ambos sexos. La mortalidad a 7 anos de un primer infarto de miocardio es peor en varones que en mujeres. Estos resultados se observan en infartos agudos de miocardio con y sin elevacion del segmento ST.

There is limited prospective evidence at population scale of the impacts of lifestyle and surrogate measures of general and abdominal adiposity on the transition of a metabolically healthy (absence of a metabolic disorder) overweight/obese (MHOO) phenotype to a metabolically abnormal overweight/obese (MAOO) phenotype. Therefore, we determined the relationship between 10-year body mass index (BMI), waist circumferences (WC), waist to height ratio (WHtR), and lifestyle changes and the transition of the MHOO phenotype.We conducted a prospective population-based study of 3,052 male and female Spaniards aged 25-74 years who were followed from 2000 through 2009. Diet and leisure-time physical activity were recorded on validated questionnaires. Weight, height, WC, blood lipids, glycemia, and blood pressure were measured. All variables were obtained at baseline (BL) and follow-up (FL). Participants with a BMI ≥ 25 kg/m(2) and free from hypercholesterolemia, hypertriglyceridemia, diabetes, hypertension, and low HDL and high LDL cholesterol levels were characterized as the MHOO phenotype. A composite healthy lifestyle index (HLI) was constructed by including temporary changes in 3 lifestyle variables (diet, leisure-time physical activity, and smoking).Initially, 20.8% of subjects had the MHOO phenotype; 49.2% of these shifted to MAOO phenotype. In multivariate analysis, changes in BMI, WC, WHtR were positively associated (p = 0.004, p = 0.018, and p = 0.016, respectively) with this transition. One unit increase in the HLI was associated with a 33% lower risk (p = 0.025) to the MAOO phenotype transition after adjusting for age, sex, educational level, and baseline energy intake, BMI, WC, and WHtR.The presence of metabolic disorders in the MHOO phenotype is predicted by an increase in anthropometric surrogate measures of general and abdominal adiposity. In contrast, a healthy lifestyle protects against a transition to the MAOO phenotype.

Anal (EcoA) and rectal endosonography (EcoEAR) is a useful test in the evaluation of patients with anorectal pathology. However, there is no clear consensus on its indications. The aim of this study was to determine the opinion of clinicians regarding the current indications and usefulness of this diagnostic test in daily clinical practice. A cross-sectional observational study was conducted using a survey sent to the services of General surgery in a specific area of Spain. The clinical usefulness of the test was evaluated using an analog scale from 0 (lowest value) to 10 (maximum utility) for each pathology. Of the 47 hospitals, 23 responded to the questionnaire (48.9%). The average number of ultrasounds performed in these centers was 217 per year (standard deviation: 140.1, range 73–450) during the last 3 years. The most common indications for this test were: rectal tumor (85%), anal fistula (80%), and fecal incontinence (70%). This test was suggested more, depending on availability in the hospital itself. In conclusion, anal and rectal endosonography remains a very useful diagnostic clinical test in the opinion of clinicians in general and digestive surgery, especially in the evaluation of patients with anal fistula, fecal incontinence, or rectal tumors.

Resumen Introduccion La fistula quilosa es poco frecuente en el postoperatorio de diferentes tipos de intervenciones abdominales, especialmente del espacio retroperitoneal, como las pancreaticas. Puede desarrollarse tambien en el curso de una pancreatitis aguda grave. El tratamiento inicialmente es conservador y puede dilatarse en el tiempo, aunque puede abreviarse con el uso de somatostatina u octreotido. Pacientes y metodos Los pacientes afectos de enfermedad pancreatica que presentaron una fistula quilosa durante su ingreso (debito mayor de 100 cc/24 h, niveles de amilasa pancreatica normales y trigliceridos superiores a 110 mg/dl) fueron tratados inicialmente con dieta absoluta y nutricion parenteral total, seguido de la administracion de octreotido 0,1 mg/8 h por via subcutanea. Resultados Cuatro pacientes mujeres de entre 55 y 80 anos, presentando cirugia pancreatica o pancreatitis aguda, desarrollaron una fistula quilosa con debitos entre 100 y 2.000 ml cada 24 h. Tras la administracion de octreotido, las fistulas se solucionaron entre el quinto y el septimo dia de tratamiento, sin presentar recidiva durante un seguimiento de 2 a 4 anos. Conclusiones Dado que el tratamiento medico de la fistula quilosa en general se asocia a un curso lento, y que la administracion de somatostatina u octreotido produce una drastica resolucion del cuadro, tal como hemos constatado en nuestra observacion y como aparece descrito por otros autores, el inicio precoz de este tratamiento puede acelerar su curacion, lo que redunda en un acortamiento de la recuperacion del paciente y en una disminucion del gasto hospitalario.

Atrial fibrillation (AF) is the most common clinically significant cardiac arrhythmia. P-wave duration and interatrial blocks (IAB) have been reported to be associated with AF. Our aim was to determine the individual and combined association of P-wave duration and advanced IAB morphology with AF.We designed an age-, sex-, and survey-matched case-control study nested in a population-based cohort (REGICOR: REgistre GIroní del COR). Two different surveys recruited a total of 9380 participants from 1999 to 2005; all participants were invited to a second examination between 2009 and 2013. For the present study, we selected participants aged 25 to 79 years with follow-up through the end of the study. All electrocardiograms were analyzed by 2 observers to determine P-wave duration and morphology (normal, partial, or advanced IAB).The median follow-up was 7.12 years. Eighty participants presented with AF, had a legible baseline electrocardiogram, and were included in the study, along with 160 controls. P-wave duration and the presence of partial or advanced IAB were associated with AF. When P-wave duration and morphology were considered together, only P-wave duration (≥ 110 milliseconds) showed an independent and strong association with AF. The odds ratio for AF of P-wave duration between 110-119, 120-129 and ≥ 130 milliseconds vs110 milliseconds were 5.33; 95%CI, 1.74-16.33, 5.08; 95%CI, 1.73-14.90 and 5.44; 95%CI, 1.95-15.15, respectively.A P-wave longer than 110 milliseconds increases the risk of AF. Advanced IAB morphology did not seem to provide an additional AF risk beyond that of P-wave duration.

Introduction and objectives To assess the validity of the original low-risk SCORE function without and with high-density lipoprotein cholesterol and SCORE calibrated to the Spanish population. Methods Pooled analysis with individual data from 12 Spanish population-based cohort studies. We included 30 919 individuals aged 40 to 64 years with no history of cardiovascular disease at baseline, who were followed up for 10 years for the causes of death included in the SCORE project. The validity of the risk functions was analyzed with the area under the ROC curve (discrimination) and the Hosmer-Lemeshow test (calibration), respectively. Results Follow-up comprised 286 105 persons/y. Ten-year cardiovascular mortality was 0.6%. The ratio between estimated/observed cases ranged from 9.1, 6.5, and 9.1 in men and 3.3, 1.3, and 1.9 in women with original low-risk SCORE risk function without and with high-density lipoprotein cholesterol and calibrated SCORE, respectively; differences were statistically significant with the Hosmer-Lemeshow test between predicted and observed mortality with SCORE (P < .001 in both sexes and with all functions). The area under the ROC curve with the original SCORE was 0.68 in men and 0.69 in women. Conclusions All versions of the SCORE functions available in Spain significantly overestimate the cardiovascular mortality observed in the Spanish population. Despite the acceptable discrimination capacity, prediction of the number of fatal cardiovascular events (calibration) was significantly inaccurate.

Background Diagnosis of unrecognized myocardial infarction (UMI) remains an open question in epidemiological and clinical studies, inhibiting effective secondary prevention of myocardial infarction. We aimed to determine the prevalence and incidence of Q-wave UMI in asymptomatic individuals aged 35 to 74years, and to ascertain the positive predictive value (PPV) of asymptomatic Q-wave to diagnose UMI. Methods Two population-based cross-sectional studies were conducted, in 2000 (with 10-year follow-up) and in 2005. A baseline electrocardiogram was obtained for each participant. Imaging techniques (echocardiography, cardiac magnetic resonance imaging, and myocardial perfusion single-photon emission computerized tomography) were used to confirm UMI in patients with asymptomatic Q-wave. Results The prevalence of confirmed Q-wave UMI in the 5580 participants was 0.18% (95% confidence interval [CI]: 0.10–0.33) and the incidence rate was 27.1 Q-wave UMI per 100,000person-years. The proportion of confirmed Q-wave UMI with respect to all prevalent MI was 8.1% (95% CI: 4.4–14.2). The PPV of asymptomatic Q-wave to diagnose Q-wave UMI was 29.2% (95% CI: 18.2–43.2%) overall, but much higher (75%, 95% CI: 40.9–92.9%) in participants with 10-year CHD risk ≥10%, compared to lower-risk participants. Conclusion Opportunistic identification of asymptomatic Q-waves by routine electrocardiogram overestimates actual Q-wave UMI, which represents 8% to 13% of all myocardial infarction in the population aged 35 to 74years. This overestimation is particularly high in the population at low cardiovascular risk. In epidemiological studies and in clinical practice, diagnosis of a pathologic Q-wave in asymptomatic patients requires detailed analysis of imaging tests to confirm or rule out myocardial necrosis.

The American Heart Association has established criteria for the evaluation of novel markers of cardiovascular risk. In accordance with these criteria, we assessed the association between a multi-locus genetic risk score (GRS) and incident coronary heart disease (CHD), and evaluated whether this GRS improves the predictive capacity of the Framingham risk function.Using eight genetic variants associated with CHD but not with classical cardiovascular risk factors (CVRFs), we generated a multi-locus GRS, and found it to be linearly associated with CHD in two population based cohorts: The REGICOR Study (n=2351) and The Framingham Heart Study (n=3537) (meta-analyzed HR [95%CI]: ~1.13 [1.01-1.27], per unit). Inclusion of the GRS in the Framingham risk function improved its discriminative capacity in the Framingham sample (c-statistic: 72.81 vs.72.37, p=0.042) but not in the REGICOR sample. According to both the net reclassification improvement (NRI) index and the integrated discrimination index (IDI), the GRS improved re-classification among individuals with intermediate coronary risk (meta-analysis NRI [95%CI]: 17.44 [8.04; 26.83]), but not overall.A multi-locus GRS based on genetic variants unrelated to CVRFs was associated with a linear increase in risk of CHD events in two distinct populations. This GRS improves risk reclassification particularly in the population at intermediate coronary risk. These results indicate the potential value of the inclusion of genetic information in classical functions for risk assessment in the intermediate risk population group.

Claims due to presumed medical malpractice are increasing in all developed countries and many of them have no basis. To prevent legal complaints, the physicians should know the reasons why complaints are made by their patients and adopt the adequate preventive measures. In the case of a complaint, it is essential to follow the guidelines that allow for adequate legal defense and the action of the physician before the judge that inspires confidence and credibility. The risk of the claims can be reduced with adequate information to the patient, the following of the clinical guidelines, control of the risk factors and adoption of verification lists in each invasive procedure. In case of complication or serious adverse effect, explanations should be given to the patient and family and it should be reported to the facility where one works and to the insurance company. If the physician received a claim, he/she should report it to the insurance compare so that it can name a lawyer responsible for the legal defense who will advise the physician regarding the appearance in court before the judge.

Resumen Introduccion y objetivos Las bases de datos clinicas de atencion primaria ofrecen un gran potencial para la investigacion. Nuestro objetivo es analizar la validez de los datos del estudio EMMA, basado en el Sistema de Informacion para el Desarrollo de Investigacion en Atencion Primaria. Metodos Se compararon las prevalencias de los factores de riesgo cardiovascular —hipertension, diabetes mellitus, hipercolesterolemia (y sus tratamientos), obesidad y tabaquismo— observadas en el EMMA con datos equivalentes del estudio Registre Gironi del Cor (REGICOR) en el ano 2000. Tambien se compararon la incidencia de enfermedad vascular y su asociacion con dichos factores de riesgo en un seguimiento a 5 anos. Resultados Se analizaron datos de 34.823 participantes de 35 a 74 anos incluidos en el EMMA y 2.540 participantes del estudio REGICOR2000. Las prevalencias de los factores de riesgo no difirieron significativamente entre los dos estudios, excepto para la prevalencia de exfumadores varones, que fue superior en el REGICOR2000 (el 24,7% [intervalo de confianza del 95%, 23,9-25,5%] frente al 30,1% [intervalo de confianza del 95%, 27,1-33,1%]) y la proporcion de hipertensos tratados y pacientes con tratamiento hipolipemiante, que fueron superiores en el EMMA (el 46,9 frente al 32,7% y el 8,7 frente al 6,3%, respectivamente). No se observaron diferencias entre uno y otro estudio en la comparacion de la incidencia de enfermedad vascular (varones, el 2,1% en ambos estudios; mujeres, el 1,18% [intervalo de confianza del 95%, 0,7-1,7%] en el REGICOR2000 frente al 0,75% [intervalo de confianza del 95%, 0,64-0,87%] en el EMMA) ni en su asociacion con los factores de riesgo. Conclusiones Las prevalencias de los factores de riesgo cardiovascular y su relacion con la incidencia de enfermedades vasculares observada en el EMMA concuerdan con las observadas en un estudio epidemiologico estandarizado de base poblacional.

Resumen Introduccion y objetivos Determinar la distribucion de la practica de actividad fisica y la prevalencia de sedentarismo, su tendencia y las variables asociadas en la poblacion de 35-74 anos de Girona en el periodo 1995-2005. Metodos Analisis de tres estudios transversales independientes de la poblacion de 35-74 anos de Girona realizados en 1995 (n = 1.419), 2000 (n = 2.499) y 2005 (n = 5.628). La actividad fisica se recogio mediante el cuestionario de actividad fisica en el tiempo libre de Minnesota. Se definio el sedentarismo como: gasto energetico en actividad fisica moderada (4-5,5 MET) Resultados Las prevalencias de sedentarismo estandarizadas por edad fueron del 53,8, el 39,5 y el 32,6% en 1995, 2000 y 2005 respectivamente. La prevalencia de sedentarismo ha disminuido durante el periodo, especialmente en mujeres de mas de 50 anos residentes en areas urbanas. Se observo un incremento de la actividad fisica ligera y moderada en los varones mayores de 50 anos y de la actividad fisica ligera en las mujeres mayores de 50 anos. Las variables asociadas a mayor prevalencia de sedentarismo fueron: el sexo femenino, la edad, el consumo de tabaco y el menor nivel de estudios. Conclusiones La prevalencia de sedentarismo ha disminuido, especialmente entre las mujeres del area urbana, pero continua siendo elevada. La promocion de actividad fisica debe ser un elemento importante de las campanas de prevencion y debe tener en cuenta las desigualdades sociales y de sexo existentes.

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

The aim of this study was to describe differences in the characteristics and short- and long-term prognoses of patients with first acute myocardial infarction (MI) according to the presence of ST-segment elevation or non-ST-segment elevation. From 2001 and 2003, 2,048 patients with first MI were consecutively admitted to 6 participating Spanish hospitals and categorized as having ST-segment elevation MI (STEMI), non-ST-segment elevation MI (NSTEMI), or unclassified MI (pacemaker or left bundle branch block) according to electrocardiographic results at admission. The proportions of female gender, hypercholesterolemia, hypertension, and diabetes were higher among NSTEMI patients than in the STEMI group. NSTEMI 28-day case fatality was lower (2.99% vs 5.26%, p = 0.02). On multivariate analysis, the odds ratio of 28-day case fatality was 2.23 for STEMI patients compared to NSTEMI patients (95% confidence interval 1.29 to 3.83, p = 0.004). The multivariate adjusted 7-year mortality for 28-day survivors was higher in NSTEMI than in STEMI patients (hazard ratio 1.31, 95% confidence interval 1.02 to 1.68, p = 0.035). However, patients with unclassified MI presented the highest short- and long-term mortality (11.8% and 35.4%, respectively). The excess of short-term mortality in unclassified and STEMI patients was mainly observed in those patients not treated with revascularization procedures. In conclusion, patients with first NSTEMI were older and showed a higher proportion of previous coronary risk factors than STEMI patients. NSTEMI patients had lower 28-day case fatality but a worse 7-year mortality rate than STEMI patients. Unclassified MI presented the worst short- and long-term prognosis. These results support the invasive management of patients with acute coronary syndromes to reduce short-term case fatality.

Objective— The contribution of human cytomegalovirus (HCMV) to vascular disease may depend on features of the immune response not reflected by the detection of specific antibodies. Persistent HCMV infection in healthy blood donors has been associated with changes in the distribution of NK cell receptors (NKR). The putative relationship among HCMV infection, NKR distribution, subclinical atherosclerosis, and coronary heart disease was assessed. Methods and Results— NKR expression was compared in acute myocardial infarction (AMI) patients ( n =70) and a population-based control sample ( n =209). The relationship between NKR expression and carotid intima-media thickness (CIMT) in controls ( n =149) was also studied. HCMV infection was associated with higher proportions of NKG2C+ and LILRB1+ NK and T-cells. In contrast, only LILRB1+ NK and CD56+ T-cells were found to be increased in AMI patients, independent of age, sex, conventional vascular risk factors, and HCMV seropositivity. Remarkably, LILRB1 expression in NK and T-cells significantly correlated with CIMT in controls. Conclusion— The association of overt and subclinical atherosclerotic disease with LILRB1+ NK and T-cells likely reflects a relationship between the immune challenge by infections and cardiovascular disease risk, without attributing a dominant role for HCMV. Our findings may lead to the identification of novel biomarkers of vascular disease.

Introduction and objectives: Modulation of vascular tone is one of the most relevant estrogen effects. A beneficial effect on endothelial function in postmenopausal women has also been proposed for the selective estrogen receptor modulator raloxifene. However, its effects in women with established cardiovascular disease have not been fully elucidated. In addition, recent trials have generated controversy regarding thromboembolic risk with raloxifene use. The aim of the study was to assess the effect of raloxifene on: a) endothelial function and b) coagulation and fibrinolysis pathways. Methods: The MERCED trial was a prospective, randomized clinical trial. Thirty-three postmenopausal women with ischemic heart disease were enrolled in the study. Raloxifene treatment was administered for a 3-month period, according to a double-blind crossover design. Assessment of vascular function and biologic parameters related to coagulation pathways were conducted at various pre-established timepoints. Results: Flow-mediated dilatation was severely impaired in the study population, and raloxifene had no effect on endothelial function. Treatment with raloxifene was associated to decreased levels of fibrinogen (3.41 [3.11-3.74] vs. 3.69 [3.40-4.00], P < .05); prothrombin fragments F 1+2 (0.93 [0.77-1.12] vs. 0.94 [0.78-1.15], P < .05); and plasmin/antiplasmin complexes (211 [166-267] vs. 242 [199-295], P < .01).

Introduction and objectives: Modulation of vascular tone is one of the most relevant estrogen effects. A beneficial effect on endothelial function in postmenopausal women has also been proposed for the selective estrogen receptor modulator raloxifene. However, its effects in women with established cardiovascular disease have not been fully elucidated. In addition, recent trials have generated controversy regarding thromboembolic risk with raloxifene use. The aim of the study was to assess the effect of raloxifene on: a) endothelial function and b) coagulation and fibrinolysis pathways. Methods: The MERCED trial was a prospective, randomized clinical trial. Thirty-three postmenopausal women with ischemic heart disease were enrolled in the study. Raloxifene treatment was administered for a 3-month period, according to a double-blind crossover design. Assessment of vascular function and biologic parameters related to coagulation pathways were conducted at various pre-established timepoints. Results: Flow-mediated dilatation was severely impaired in the study population, and raloxifene had no effect on endothelial function. Treatment with raloxifene was associated to decreased levels of fibrinogen (3.41 [3.11-3.74] vs. 3.69 [3.40-4.00], P < .05); prothrombin fragments F 1+2 (0.93 [0.77-1.12] vs. 0.94 [0.78-1.15], P < .05); and plasmin/antiplasmin complexes (211 [166-267] vs. 242 [199-295], P < .01). Conclusions: The present study provides evidence that in postmenopausal women with demonstrated endothelial dysfunction and ischemic heart disease, mid-term treatment with raloxifene does not affect endothelial function. In the MERCED trial, no increased thrombotic risk was observed, but a decreased thrombotic and fibrinolytic activity was observed with raloxifene. Further studies are required to determine whether thrombotic risk is associated with specific clinical characteristics or subgroups of postmenopausal women with cardiovascular disease.

Aims To perform a meta-analysis of the association between CYP2C19 loss- and gain-of-function variants and cardiovascular outcomes and bleeding in patients with coronary artery disease treated with clopidogrel, and to explore the causes of heterogeneity between studies. Methods A comprehensive literature search was conducted. A random-effects model was used to summarise the results. In the presence of between-study heterogeneity, a meta-regression analysis was performed to identify study characteristics explaining this heterogeneity. Results Patients who carried a loss-of-function allele, mainly CYP2C19*2, did not present an increased risk of a cardiovascular event, HR ¼1.23 (95% CI 0.97 to 1.55). Substantial heterogeneity was observed between studies (I 2 ¼35.6), which was partially explained by the study sample size: the pooled HR was higher among studies with a sample size

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

Introduction and objectives: To determine the effect of opening an on-site diagnostic catheterization facility on 30-day and 2-year mortality rates in patients with myocardial infarction (MI). Methods: The study included 1539 consecutive MI patients aged 25–74 years who were recruited before and after the catheterization laboratory opened in 1998: during 1995–1997 and 1999–2003, respectively. Results: The 641 consecutive MI patients recruited in 1995–1997 had worse 30-day mortality than the 898 recruited between 1999–2003 (11.2% versus 6.35%, respectively; P = .001). The number of coronary angiographies and percutaneous coronary interventions (PCIs) carried out was greater in the second period (19.4% versus 3.3%, and 54.8% versus 23.0%, respectively; P < .001). Two-year survival curves were significantly better in the second period for all-cause and cardiovascular death. The adjusted odds ratio for death at 30 days was 0.58 (95% confidence interval [CI] 0.36–0.95) for the second period compared with the first and the adjusted hazard ratio for cardiovascular death at 2 years for patients still alive at 30 days was 0.62 (95%CI 0.39–0.99). After adjustment for the prescription of statins, angiotensinconverting enzyme inhibitors, beta-blockers and antiplatelet drugs at discharge, the effect observed at 2 years was no longer significant. Conclusions: Opening a new on-site diagnostic catheterization unit significantly increased the 30-day survival of MI patients. However, the increase in 2-year survival of 30-day survivors observed was largely explained by the implementation of better secondary prevention.

The recommendation of screening with ankle brachial index (ABI) in asymptomatic individuals is controversial. The aims of the present study were to develop and validate a pre-screening test to select candidates for ABI measurement in the Spanish population 50-79 years old, and to compare its predictive capacity to current Inter-Society Consensus (ISC) screening criteria.Two population-based cross-sectional studies were used to develop (n = 4046) and validate (n = 3285) a regression model to predict ABI0.9. The validation dataset was also used to compare the model's predictive capacity to that of ISC screening criteria. The best model to predict ABI0.9 included age, sex, smoking, pulse pressure and diabetes. Assessment of discrimination and calibration in the validation dataset demonstrated a good fit (AUC: 0.76 [95% CI 0.73-0.79] and Hosmer-Lemeshow test: χ(2): 10.73 (df = 6), p-value = 0.097). Predictions (probability cut-off value of 4.1) presented better specificity and positive likelihood ratio than the ABI screening criteria of the ISC guidelines, and similar sensitivity. This resulted in fewer patients screened per diagnosis of ABI0.9 (10.6 vs. 8.75) and a lower proportion of the population aged 50-79 years candidate to ABI screening (63.3% vs. 55.0%).This model provides accurate ABI0.9 risk estimates for ages 50-79, with a better predictive capacity than that of ISC criteria. Its use could reduce possible harms and unnecessary work-ups of ABI screening as a risk stratification strategy in primary prevention of peripheral vascular disease.

Background and objectives: The value of body mass index in the prognosis of patients with ischemic heart disease is not well defined. The objective of our study was to determine the association of body mass index with classic and emergent cardiovascular risk factors and with intra-hospital and 6-months mortality. Patients and methods: We conducted a prospective, multicenter study with a 6-months follow-up. We included 1063 patients between the ages of 25–75 years old who were consecutively admitted to the hospital within the first 24 hours of the onset of symptoms between years 2001 and 2003. We determined demographic and anthropometric variables, as well as classic and emergent factors of risk, clinical variables and the treatment administered. We carried out a univariate and multivariate analysis. Results: The percentage of patients with overweight or obesity in this population was 73.56%. Overweight and obesity were associated with classical risk factors, except for smoking, and emergent risk factors. Body mass index was not associated with short-or mid-term prognosis.

Introduccion y objetivos. El tratamiento del infarto agudo de miocardio (IAM) ha cambiado considerablemente en los ultimos anos. El objetivo es determinar la evolucion de la mortalidad intrahospitalaria y del pronostico a 6 meses de los pacientes que ingresan con un primer IAM en dos registros realizados en 1992-1994 y 2001-2003. Metodos. Entre 1992 y 1994, ingresaron consecutivamente 1.440 pacientes con un primer IAM en cuatro hospitales universitarios (RESCATE I). Entre 2001 y 2003, ingresaron en los mismos centros 1.288 pacientes con un primer IAM con los mismos criterios diagnosticos (RESCATE II). Se compara el manejo clinico, la mortalidad hospitalaria y el pronostico y la evolucion a 6 meses entre estos dos registros. Resultados. Se realizo reperfusion en el 60,7% de los pacientes del primer registro y en el 72,6% del segundo (p < 0,001). En el RESCATE II, se redujo la mediana de tiempo puerta-aguja (41 frente a 93 min; p < 0,001), se realizaron mas coronariografias (el 65,2 frente al 28,1%; p < 0,001) y revascularizaciones (el 34,9 frente al 8,1%; p < 0,001). La mortalidad hospitalaria disminuyo en el RESCATE II (el 7,5 frente al 10,9%; p < 0,001). Al ajustar por edad, sexo, comorbilidad, gravedad del IAM y terapia de reperfusion, la odds ratio de mortalidad hospitalaria del RESCATE II, comparada con el primer registro, fue 0,52 (intervalo de confianza del 95%, 0,31-0,86). En el RESCATE II tambien disminuyo la mortalidad (el 1,4 frente al 3,6%; p = 0,001) y el reingreso a 6 meses. Conclusiones. La mortalidad intrahospitalaria y a 6 meses de los pacientes con un primer IAM ha disminuido en la ultima decada, probablemente debido a que se reperfunde y se revasculariza mas y al mejor tratamiento medico.

Introduccion y objetivos. La posicion socioeconomica se relaciona con la mortalidad cardiovascular. El objetivo de este estudio fue analizar la relacion entre la posicion socioeconomica y sus diferentes indicadores y el riesgo de infarto agudo de miocardio (IAM), y determinar si esta era independiente de los factores de riesgo cardiovascular (FRCV). Metodos. Estudio caso-control apareado por edad, sexo y ano de reclutamiento. Los casos se obtuvieron de un registro hospitalario y los controles, de estudios transversales de base poblacional. La posicion socioeconomica se determino por el nivel de estudios y la clase social basada en ocupacion. Se recogio informacion autodeclarada sobre los FRCV. Resultados. Se incluyo a 1.369 casos y controles. Hubo interaccion entre nivel de estudios y clase social: en los trabajadores no manuales el nivel de estudios se asocio de forma lineal, inversa e independiente de los FRCV con el riesgo de IAM (estudios secundarios, odds ratio [OR] = 1,63; intervalo de confianza [IC] del 95%, 1,16-2,3; estudios primarios, OR = 3,88; IC del 95%, 2,79-5,39) respecto a universitarios; en los trabajadores manuales no se observo una asociacion entre nivel de estudios y riesgo de IAM. Los trabajadores manuales presentaban un exceso de riesgo de IAM respecto a los no manuales universitarios, este exceso de riesgo era independiente de los FRCV en el grupo con estudios primarios (OR = 2,09; IC del 95%, 1,59-2,75). Conclusiones. Hay relacion entre la posicion socioeconomica y el riesgo de IAM. El grupo de la poblacion con nivel de estudios primarios presenta mayor riesgo de IAM que es independiente de los FRCV y de la clase social basada en la ocupacion

Objective To determine the effect of age and study period on coronary heart disease (CHD) risk attributable to cardiovascular risk factors. Methods A cohort of cardiovascular disease (CVD)-free randomly participants from Girona (Spain) aged 35–74 years recruited in 1995 and 2000 and followed for an average of 6.9 years. A survey conducted in the same area in 2005 was also used for the analysis. Smoking, hypertension, diabetes, sedentary lifestyle, obesity, total cholesterol ≥ 240 mg/dl, low-density lipoprotein (LDL) cholesterol ≥ 160 mg/dl, and high-density lipoprotein cholesterol Results LDL cholesterol had the highest potential for CHD prevention between 35 and 74 years [42% (95% Confidence Interval: 23,58)]. The age-stratified analysis showed that the population attributable risk (PAF) for smoking was 64% (30,80) in subjects Conclusion Overall, LDL cholesterol levels had the highest potential for CHD prevention. Periodic PAF recalculation in different age groups may be required to adequately monitor population trends.

Treatment of acute myocardial infarction (AMI) has changed considerably in recent years. The objective of this study was to investigate differences in in-hospital mortality and 6-month outcomes after a first AMI between patients who participated in two trials, in 1992-1994 and 2001-2003, respectively.The study involved 1440 consecutive patients with a first AMI who were admitted to four university hospitals during 1992-1994 (the RESCATE-I trial) and 1288 with a first AMI who met the same diagnostic criteria and who were admitted to the same hospitals during 2001-2003 (the RESCATE-II trial). Patient management, in-hospital mortality and 6-month prognosis and outcomes were compared between the two trials.Reperfusion therapy was carried out in 60.7% of patients in the first trial and in 72.6% in the second (P.001). In the RESCATE-II trial, the median door-to-needle time was shorter (41 min vs. 93 min; P.001) and patients more frequently underwent coronary angiography (65.2% vs. 28.1%; P.001) and revascularization (34.9% vs. 8.1%; P.001). In addition, in-hospital mortality was lower in RESCATE-II (7.5% vs. 10.9%; P.001). After adjustment for age, sex, comorbidity, AMI severity and reperfusion therapy, the odds ratio for in-hospital mortality in RESCATE-II compared with the first trial was 0.52 (95% confidence interval, 0.31-0.86). In addition, mortality (1.4% vs. 3.6%; P=.001) and readmissions at 6 months were also lower in RESCATE-II.Both in-hospital and 6-month mortality in patients with a first AMI decreased during the last decade, probably due to more frequent reperfusion and revascularization therapy and better medical treatment.

En este articulo se presentan las limitaciones actuales de las herramientas disponibles para cribar a la poblacion para determinar su riesgo cardiovascular. Se analizan las posibilidades de mejorar la capacidad predictiva y de reclasificacion de las tablas de riesgo cardiovascular en atencion primaria para actuar de manera mas efectiva. Se discuten las oportunidades existentes de mejorar las estrategias actuales de cribado y prevencion cardiovascular y cual es el papel de la determinacion individual de los nuevos biomarcadores, incluida la predisposicion genetica a la enfermedad coronaria y de algunas pruebas, como el indice tobillo/brazo o el grosor de intima-media carotidea. Se analizan los subgrupos de poblacion con riesgo cardiovascular mas importantes por su tamano y numero de acontecimientos cardiovasculares a 10 anos. Tambien se revisa brevemente cual puede ser el papel de las pruebas de imagen actualmente en desarrollo en ciertos subgrupos de riesgo de poblacion asintomatica.

Introduccion y objetivos. Determinar la prevalencia de pacientes que sufren un infarto agudo de miocardio (IAM) sin factores de riesgo (FR) clasicos, si presentan una mayor prevalencia de FR emergentes y si algun FR emergente modifica el pronostico a 6 meses. Metodos. FORTIAM (Factores Ocultos de Riesgo Tras un Infarto Agudo de Miocardio) es un estudio multicentrico de cohortes de 1.371 pacientes que sufrieron un IAM e ingresaron en las primeras 24 h. Se utilizaron definiciones estrictas para los FR clasicos y se determinaron: lipoproteina (a) [Lp(a)], lipoproteina de baja densidad oxidada (LDLox), proteina C reactiva ultrasensible, fibrinogeno, homocisteina y anticuerpos anticlamidia. Los acontecimientos de interes a 6 meses fueron: muerte, angina o reIAM. Resultados. La prevalencia de pacientes con IAM sin FR clasicos fue del 8%. La ausencia de FR clasicos no afecto al pronostico a 6 meses. Lp(a) y LDLox fueron los unicos FR emergentes que de forma independiente se asociaron a un peor pronostico. Puntos de corte (suavizacion con splines): 60 mg/dl para Lp(a) y 74 U/l para LDLox. La hazard ratio ajustada por edad, sexo y FR clasicos, 1,40 (intervalo de confianza [IC] del 95%, 1,06-1,84) y 1,48 (IC del 95%, 1,06-2,06) respectivamente. Conclusiones. La proporcion de pacientes con un IAM sin FR clasicos es baja y su pronostico es similar al resto de pacientes con IAM. LDLox y de Lp(a) se asociaron a un peor pronostico a 6 meses de forma independientemente de los FR clasicos.

Introduccion y objetivos La paraoxonasa 1 (PON1) y la paraoxonasa 2 (PON2) son enzimas antioxidantes cuyos polimorfismos PON1-192 y PON2-311 se han relacionado con el riesgo de infarto agudo de miocardio, con resultados discordantes. El objetivo de este estudio es determinar la asociacion con el riesgo de infarto agudo de miocardio (IAM) de los polimorfismos PON1-192 y PON2-311 y su interaccion. Metodos Se realizo un estudio de casos y controles en el que se recluto a 746 pacientes consecutivos con IAM y 1.796 controles libres de enfermedad cardiovascular seleccionados al azar de la misma poblacion de la que provenian los casos, en 4 comunidades autonomas espanolas entre 1999 y 2000. Se determinaron los polimorfismos PON1-192 y PON2-311, ademas de los factores clasicos de riesgo cardiovascular. Se estimaron modelos de regresion logistica para los analisis multivaribles. Resultados Las odds ratio (OR) del genotipo QQ del polimorfismo PON1-192 y el SS del PON2-311 (presen-tes en el 50 y el 66% de la poblacion, respectivamente) de presentar un IAM fueron 1,26 (intervalo de confianza [IC] del 95%, 1,02-1,55) y 1,25 (IC del 95%, 1,04-1,50), respectivamente, en comparacion con los portadores de los alelos R y C. Ademas, para los sujetos que presentan ambos genotipos QQ y SS, la OR ajustada de tener un IAM se incremento hasta 1,41 (IC del 95%, 1,13-1,76). Conclusiones Nuestros resultados indican que los polimorfismos PON1-192 y PON2-311 son factores de riesgo de IAM independientes en nuestra poblacion.

Introduction and objectives Two particular polymorphisms, namely PON1-192 and PON2-311, in the genes encoding the antioxidant enzymes paraoxonase-1 (PON1) and paraoxonase-2 (PON2) have been associated with an increased risk of acute myocardial infarction (AMI). However, previous findings have been contradictory. The aim of this study was to investigate the association between the PON1-192 and PON2-311 polymorphisms and their interaction on AMI risk. Methods This case-control study involved 746 consecutive AMI patients and 1796 control subjects without cardiovascular disease, who were randomly selected from the same population from which the patients came. All participants were recruited between 1999 and 2000 from four Spanish autonomous regions. All were assessed for the presence of PON1-192 and PON2-311 and for classical cardiovascular risk factors. Multivariate analysis was carried out using logistic regression modeling. Results The odds ratios (OR) of AMI for patients with the PON1-192 QQ and PON2-311 SS genotypes (who comprised 50% and 66% of the population, respectively) were 1.26 (95% confidence interval [Cl], 1.02-1.55) and 1.25 (95% Cl, 1.04-1.50), respectively, compared with R and C allele carriers. Moreover, in patients with both QQ and SS genotypes, the adjusted OR of AMI increased to 1.41 (95% Cl, 1.13-1.76). Conclusiones Our results indicate that the PON1-192 and PON2-311 polymorphisms were independent risk factors of AMI in our population.

BACKGROUND: Evidence is lacking about the effectiveness of risk reduction interventions in patients with asymptomatic peripheral arterial disease. OBJECTIVES: This study aimed to assess whether statin therapy was associated with a reduction in major adverse cardiovascular events (MACE) and mortality in this population. METHODS: Data were obtained from 2006 through 2013 from the Catalan primary care system's clinical records database (SIDIAP). Patients age 35 to 85 years with an ankle-brachial index ≤0.95 and without clinically recognized cardiovascular disease (CVD) were included. Participants were categorized as statins nonusers or new-users (first prescription or represcribed after at least 6 months) and matched 1:1 by inclusion date and propensity score for statin treatment. Conditional Cox proportional hazards modeling was used to compare the groups for the incidence of MACE (myocardial infarction, cardiac revascularization, and ischemic stroke) and all-cause mortality. RESULTS: The matched-pair cohort included 5,480 patients (mean age 67 years; 44% women) treated/nontreated with statins. The 10-year coronary heart disease risk was low (median: 6.9%). Median follow-up was 3.6 years. Incidence of MACE was 19.7 and 24.7 events per 1,000 person-years in statin new-users and nonusers, respectively. Total mortality rates also differed: 24.8 versus 30.3 per 1,000 person-years, respectively. Hazards ratios were 0.80 for MACE and 0.81 for overall mortality. The 1-year number needed to treat was 200 for MACE and 239 for all-cause mortality. CONCLUSIONS: Statin therapy was associated with a reduction in MACE and all-cause mortality among participants without clinical CVD but with asymptomatic peripheral arterial disease, regardless of its low CVD risk. The absolute reduction was comparable to that achieved in secondary prevention. This project was supported by clinical research grants from the Ministerio de Salud (EC10-84, EC10-83); Spain’s Ministry of Science and Innovation through the Carlos III Health Institute, cofinanced with European Union ERDF funds (Network for Prevention and Health Promotion in primary Care RedIAPP RD12/0005, Programa HERACLES RD12/0042, and Miguel Servet Contract CP12/03287); and by the Departament de Salut, Generalitat de Catalunya, Agency for Health Technology Assessment (AATRM 034/33/02), and Agency for Management of University and Research Grants (2005SGR00577). Drs. Ramos and Garcia-Gil collaborate (without receiving any personal fee) in 2 projects of primary care for the institute IDIAP Jordi Gol funded by AstraZeneca and AMGEN that are unrelated to the present work. Dr. Marrugat has received lecture fees from Ferrer-in-Code; holds a patent with Gendiag SL; and has received payment for development of educational presentations from AstraZeneca.

Background High prevalence of cardiovascular risk factors has been observed in Spain along with low incidence of acute myocardial infarction. Our objective was to determine the trends of cardiovascular risk factor prevalence between 1995 and 2005 in the 35-74-year-old population of Gerona, Spain. Design Comparison of cross-sectional studies were conducted in random population samples in 1995, 2000, and 2005 at Gerona, Spain. Methods An electrocardiogram was obtained, along with standardized measurements of body mass index, lipid profile, systolic and diastolic blood pressure, glycaemia, energy expenditure in physical activity, smoking, use of lipid-lowering and antihypertensive medications, and cardiovascular risk. Prevalence of diabetes, hypertension, and obesity was calculated and standardized for age. Results A total of 7571 individuals (52.0% women) were included (response rate 72%). Low-density lipoprotein cholesterol > 3.4 mmol/l (130 mg/dl) (49.7%) and hypertension (39.1%) were the most prevalent cardiovascular risk factors. In 1995, 2000 and 2005, low-density lipoprotein cholesterol decreased in both men and women: 4.05-3.913.55 mmol/l (156-151-137 mg/dl) and 3.84-3.81-3.40 mmol/l (148-147-131 mg/dl), respectively. Increases were observed in lipid-lowering drug use (5.7-6.3-9.6% in men and 4.0-5.8-8.0% in women), controlled hypertension (14.8-35.4-37.7% in men and 21.3-36.9-45.0% in women); (all P-trends < 0.01), and obesity (greatest for men: 17.5-26.0-22.7%, P-trends = 0.020). Prevalence of myocardial infarction or possibly abnormal Q waves in electrocardiogram also increased significantly (3.9-4.7-6.4%, P-trends = 0.018). Conclusions The cardiovascular risk factor prevalence change in Gerona was marked in this decade by a shift of total cholesterol and low-density lipoprotein cholesterol distributions to the left, independent of the increase in lipid-lowering drug use, and better hypertension control with increased use of antihypertensive drugs. Eur J Cardiovasc Prev Rehabil 14:653-659 © 2007 The European Society of Cardiology

Fundamento y objetivo REACH es el mayor registro mundial disenado para obtener informacion sobre el control de factores de riesgo cardiovascular y tratamiento preventivo en una poblacion con aterotrombosis sintomatica o alto riesgo de desarrollarla. El objetivo del presente estudio es mostrar los resultados obtenidos en la muestra de la poblacion espanola incluida en el registro. Pacientes y metodo Registro de pacientes consecutivos con solo factores de riesgo cardiovascular (SFR) para aterotrombosis o con enfermedad vascular (EV) sintomatica: enfermedad coronaria (EC) y/o cerebrovascular (ECV) y/o arterial periferica (EAP). Se evaluo el control de factores de riesgo cardiovascular y tratamientos antitrombotico e hipolipemiante. Resultados Espana incluyo a 2.515 pacientes: 297 con SFR y 2.218 con EV (un 61,4% con EC,un 36,6% con ECV y un 18,7% con EAP). En los grupos SFR y EV los porcentajes de falta de control de la presion arterial, los valores plasmaticos de glucosa, de colesterol total y de trigliceridos fueron del 76,5 frente al 57,1% (p Conclusiones El control de los factores de riesgo cardiovascular en personas espanolas de alto riesgo o con EV establecida, especialmente EAP, es inadecuado. Mientras que el uso de estatinas es insuficiente, el de medicacion antitrombotica es aceptable en prevencion secundaria,pero bastante deficiente en prevencion primaria.

Background Smoking is a risk factor for coronary heart disease, but it has been associated with better short-term prognosis in hospitalized patients with acute myocardial infarction. The aims of this study were to determine the association between smoking and myocardial infarction 28-day case-fatality in hospitalized patients and at the population level; and, whether smokers presenting with fatal myocardial infarction are more likely to die before reaching a hospital. Design and methods Population-based myocardial infarction registry, carried out in 1997-1998 in seven regions of Spain, used standardized methods to find and analyze suspected myocardial infarction patients (10 654 patients; 7796 hospitalized). Four categories of smoking status were defined: never-smokers, former smokers for more than 1 year, former smokers for less than 1 year, and current smokers. Results The main end-point was 28-day case-fatality, found to be 20.1, 17.1, 15.6, and 8.9%, in the four smoking status categories, respectively, for hospitalized patients; and 37.4, 33.0, 24.5, and 23.2%, respectively, at population level. Hospitalized current smokers had lower age, sex, and comorbidity-adjusted 28-day case-fatality than never-smokers (odds ratio = 0.71; 95% confidence interval: 0.56-0.90). This association held at population level (odds ratio = 0.68; 95% confidence interval: 0.60-0.76), in which former smoking was also associated with lower case-fatality. In fatal cases, recent former smokers presented a lower risk of out-of-hospital death than never-smokers (odds ratio = 0.47; 95% confidence interval: 0.29-0.77), whereas current smoking was marginally associated with out-of-hospital death (odds ratio = 1.22; 95% confidence interval: 0.99-1.50). Conclusions Current smoking is associated with lower 28-day case-fatality in hospitalized myocardial infarction patients. This association held at population level. Among fatal cases, smoking is associated with higher and recent former smoking with lower risk of dying out-of-hospital.

Introduccion y objetivos La incidencia por infarto de miocardio en Espana es baja y la mortalidad esta disminuyendo en las ultimas decadas. Hemos analizado las tendencies en las tasas de mortalidad, incidencia y ataque, y en la letalidad a 28 dias por infarto de miocardio entre 1990 y 1999 en la poblacion de 35 a 74 anos de Girona. Metodos Se incluyeron todos los casos de infarto de miocardio de Girona clasificados segun el algoritmo MONICA. Se calcularon las tasas de ataque, incidencia y mortalidad, y la letalidad, asi como el porcentaje de cambio annual en cada uno de los indicadores durante el periodo analizado. Resultados La tasa anual media de ataque fue de 258 (intervalo de confianza [IC] del 95%, 249-267) y 55 (IC del 95%, 51-59) por 100.000 habitantes para varones y mujeres, respectivamente, y la de mortalidad de 99 (IC del 95%, 93-104) por 100.000 en varones y de 25 (IC del 95%, 22-28) por 100.000 en mujeres. Las tasas de ataque, incidencia y recurrencia disminuyeron significativamente en varones de 35 a 64 anos durante el periodo 1990-1999, pero no en los de 65 a 74 anos ni en las mujeres. Conclusiones La incidencia y la mortalidad por IAM fueron bajas en la poblacion de 35 a 64 anos, y mejoraron en los varones de 35 a 64 anos durante el periodo 1990-1999, pero no en los de 65 a 74 anos, lo que indica que la combinacion de prevencion primaria y secundaria ha retrasado la edad de aparicion del infarto de miocardio o de las recurrencias. Las tasas en mujeres fueron inferiors y no cambiaron durante el periodo estudiado.

This issue of the journal includes a publication on the adaptation of the Systematic COronary Risk Evaluation (SCORE) to estimate the risk of death from preventable diseases such as cerebrovascular disease (CVD) and coronary heart disease (CHD), among other cardiovascular diseases. 1 The original system was designed to help guide clinicians responsible for the primary prevention of cardiovascular disease and provides risk estimates for non-diabetic patients aged 40-65 years based on sex, age, systolic blood pressure, total cholesterol, and smoking history. The function exists for countries with high and low cardiovascular risk. 2 Three functions are currently available to calculate cardiovascular risk in Spain: the classic Framingham function, which overestimates risk in the Spanish population, 3 a version of this function which was adapted for the Spanish population by the REGICOR (Registre Gironi del Cor) study investigators in collaboration with investigators from the Framingham Heart Study, and which provides estimates whose validity for Spain was shown in the VERIFICA (Validez de la Ecuacion de

Introduction and objectives The incidence of myocardial infarction in Spain is low, and mortality has been decreasing over the last few decades. The objective of this study was to analyze trends in myocardial infarction mortality, incidence, attack rates, and 28-day case-fatality attack rates between 1990 and 1999 in the general population aged 35-74 years in Girona, Spain. Methods The study included all myocardial infarction cases in Girona classified according to the MONICA algorithm. Attack, incidence, mortality rates and case- fatality were calculated. In addition, the annual percentage change in each of these indicators during the study period was also calculated. Results The mean attack rate per 100,000 inhabitants was 258 (95% CI, 249-267) in men and 55 (95% CI, 51- 59) in women. The mean mortality rate per 100,000 was 99 (95% CI, 93-104) in men and 25 (95% CI, 22-28) in women. Significant reductions in attack, incidence and recurrence rates were observed in men aged 35-64 years during the period 1990-1999, but not in men aged 65-74 years, nor in women. Conclusions Myocardial infarction incidence and mortality rates were low in the general population aged 35- 64 years. Rates improved in men aged 35-64 years during the period 1990-1999, but not in those aged 65-74 years, which indicates that a combination of primary and secondary prevention has increased the age at which a myocardial infarction or its recurrence is observed. Rates in women were lower and did not change during the study period.

Introduccion y objetivos El entorno y las circunstancias del paciente en el inicio de los sintomas del infarto agudo de miocardio (IAM) pueden condicionar su supervivencia. El objetivo es estudiar los aspectos relativos a la convivencia, las caracteristicas y el retraso en las primeras acciones tomadas por los pacientes con IAM que sobrevivieron mas de 1 h y analizar su relacion con la mortalidad en distintos periodos. Pacientes y metodo Se ha realizado un estudio de cohortes de base poblacional entre 1997 y 1998. La principal fuente de informacion ha sido el Registre Gironi del Cor (REGICOR) y, para los fallecidos antes de acceder a monitorizacion, los boletines estadisticos de defuncion. Se estudiaron las caracteristicas demograficas, los habitos y los antecedentes, los sintomas, las alteraciones electrocardiograficas, el valor de las enzimas miocardicas y los procedimientos terapeuticos y diagnosticos. Se analizo la mortalidad prehospitalaria, intrahospitalaria y global a los 28 dias. Resultados Se analizaron 1.097 casos: 652 (59,4%) supervivientes a 28 dias, 171 muertes en hospitales (15,58%) y 274 muertes prehospitalarias (24,97%). Los pacientes que fueron directamente al hospital presentaron menor mortalidad (odds ratio [OR] = 0,32; intervalo de confianza [IC] del 95%, 0,17-0,59). Hubo mayor mortalidad a los 28 dias entre los que tenian sintomas atipicos (OR = 5,52; IC del 95%, 2,90-10,50) y/o vivian institucionalizados (OR = 9,47; IC del 95%,1,05-84,9). Conclusiones En ausencia de un servicio de ambulancias medicalizadas, los pacientes con un IAM que se dirigen directamente a un hospital y/o presentan sintomas tipicos sobreviven en mayor proporcion a los 28 dias y en la fase prehospitalaria de la enfermedad, y los institucionalizados presentan una mayor mortalidad a los 28 dias.