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Abstract Background Cardiovascular diseases are becoming more frequent throughout the world. Adherence to both pharmacological and non-pharmacological treatment, as well as lifestyles, is important for good management and control of the disease. This study aims to explore the opinions and perceptions of patients with ischemic heart disease on the difficulties associated with therapeutic adherence. Methods An interpretive phenomenological study was carried out using focus groups and one semi-structured interview. The MAXQDA qualitative data analysis program was used for inductive interpretation of the group discourses and interview. Data were coded, and these were grouped by categories and then consolidated under the main themes identified. Results Two in-person focus groups and one remote semi-structured interview were performed. Twelve participants (6 men and 6 women) from the Hospital de San Juan de Alicante participated, two of them being family companions . The main themes identified were aspects related to the individual, heart disease, drug treatment, and the perception of the health care system. Conclusions Adhering to recommendations on healthy behaviors and taking prescribed medications for cardiovascular disease was important for most participants. However, they sometimes found polypharmacy difficult to manage, especially when they did not perceive the symptoms of their disease. Participants related the concept of fear to therapeutic adherence, believing that the latter increased with the former. The relationship with health professionals was described as optimal, but, nevertheless, the coordination of the health care system was seen as limited.

Current cardiovascular prevention guidelines emphasise considering sex, gender, and gender identity in risk assessment. This study evaluated the impact of lifestyle habits and chronic diseases on cardiovascular mortality risk in women over 50 with high vascular risk and developed a predictive model for menopausal women with cardiovascular risk factors. A retrospective cohort study used data from the 2011 Spanish National Health Survey and the national death register, focusing on menopausal and postmenopausal women without prior cardiovascular events but with at least one major risk factor. Participants were followed for up to 10 years, assessing mortality from circulatory system diseases and other causes. Exposure variables included socio-demographics, lifestyle habits, health status, self-perceived health, health service use, and pharmacological treatments. Of the 21,007 respondents, 3057 women met the inclusion criteria. The 10-year cumulative incidence of mortality from circulatory causes was 5.9%, and from other causes, 12.7%. Independent predictors of cardiovascular mortality were never consuming legumes, poor self-perceived health, diabetes treatment, lack of physical activity, and older age. Lipid-lowering treatment was protective. The model demonstrated good fit and predictive capacity (C-index = 0.773). This study highlights the significant influence of physical activity, legume consumption, self-perceived health, and specific treatments on cardiovascular mortality risk in menopausal women.

Introduction and objectives Only about 50% of chronic patients in high-income countries adhere to their treatment. There are methods to measure medication adherence but none of them can be considered optimal. This study will aim to design and validate a questionnaire to measure medication adherence in patients with ischaemic heart disease using a direct method as a gold-standard adherence measure and taking into account the gender perspective. Moreover, the profile of low adherence in these patients will be determined.Methods and analysis First study phase consists on the questionnaire design following the next steps: identification of the dimensions, definition of the target population, questionnaire items and order, response coding, questionnaire instructions, content validity by experts and understandability. In the second phase, a cross-sectional study will be performed to end the questionnaire development and validate it. Four hundred and forty patients (50% female) with acute coronary syndrome receiving treatment within the previous 12 months will be included. Patient will answer the initial questionnaire and adherence to aspirin and statin will be measured using a direct method (drug concentration analysis in blood) and other questionnaires. From the set of preselected questionnaire items, those most closely associated with the gold standard measure will be selected using multivariate statistics.Ethics and dissemination All participants gave their written informed consent before participating in the study. The study protocol follows the recommendations of the Declaration of Helsinki and was approved by the ethics committees of the three participating centres. The results of this study will be displayed at national and international conferences and in peer-reviewed scientific journals.

Background: Lipoprotein(a) [Lp(a)] is a proatherogenic particle associated with increased cardiovascular risk. It is mainly genetically determined; so, the aim of our study is to evaluate the levels of Lp(a) in the relatives of a prospective cohort of patients who have suffered from an acute coronary syndrome (ACS) with Lp(a) ≥ 50 mg/dL. Methods: We conducted a multicenter prospective study, in which consecutive patients who had suffered from an ACS and presented Lp(a) ≥ 50 mg/dL and their first-degree relatives were included. Results: We included 413 subjects, of which 56.4% were relatives of the patients. Family history of early ischemic heart disease was present in 57.5%, and only 20.6% were receiving statin treatment. The family cohort was younger (37.5 vs. 59.1 years; p < 0.001), and 4% had ischemic heart disease and fewer cardiovascular risk factors. Mean Lp(a) levels were 64.9 mg/dL, 59.4% had levels ≥ 50 mg/dL, and 16.1% had levels ≥ 100 mg/dL. When comparing the patients with respect to their relatives, the mean level of Lp(a) was lower but without significant differences regarding the levels of LDLc, ApoB, and non-HDL. However, relatives with Lp(a) ≥ 50 mg/dL, had values similar to the group of patients with ACS (96.8 vs. 103.8 mg/dL; p = 0.18). No differences were found in Lp(a) levels in relatives based on the other lipid parameters. Conclusions: Overall, 59.4% of the first-degree relatives of patients who suffered from an ACS with Lp(a) ≥ 50 mg/dL also had elevated levels. Relatives with elevated Lp(a) had similar levels as patients.

Hypertension is one of the most prevalent cardiovascular risk factors and blood pressure control remains a clinical challenge, especially for patients with established cardiovascular disease. Late-breaking clinical trials and other evidence in hypertension have evolved to assess the most accurate ways to measure blood pressure, the use of combination therapies, considerations in special populations and evaluation of new techniques. Recent evidence supports the superiority of ambulatory or 24-hour blood pressure measurements, rather than office blood pressure measurements, for the assessment of cardiovascular risk. The use of fixed-dose combinations and polypills has been demonstrated to be valid and to provide clinical benefits beyond blood pressure control. There have also been advances in new approaches such as telemedicine, devices and the use of algorithms. Clinical trials have provided valuable data on blood pressure control in primary prevention, during pregnancy and in the elderly. The role of renal denervation remains unsolved but innovative techniques using ultrasound or alcohol injections are being explored. Current evidence and results of latest trials are summarised in this review.

The benefit of complete revascularization in elderly patients with non-ST elevation myocardial infarction (NSTEMI), and multivessel disease remains debated (MVD). The aim of our study was to determine the current long-term prognostic benefit of complete revascularization in this population. A retrospective cohort study of 1722 consecutive elderly NSTEMI patients was performed. Among the study participants 30.4% (n = 524) were completed revascularizated and in 69.6% (n = 1198) culprit vessel only revascularization was performed. A propensity score analysis was performed and we divided the study population into two groups: complete revascularization (n = 500) and culprit vessel only revascularization (n = 500). The median follow-up was 45.7 months, the all cause mortality (44.5% vs 30.5%, p < 0.001) (HR 0.74 (0.57–0.97); p = 0.035) and cardiovascular mortality (32.6% vs 17.4%, p < 0.001) (HR = 0.67 (0.47–0.94); p = 0.021) were significantly lower in patients with complete revascularization. In our study, we observed a long-term benefit of complete revascularization in elderly NSTEMI and MVD patients. Elderly patients should also be managed according to current guidelines to improve their long-term prognosis.

Resumen: Antecedentes y objetivo: El objetivo del estudio fue caracterizar el perfil clínico y terapéutico de los pacientes con cardiopatía isquémica en España en los pacientes (grupo 1) al alta tras un síndrome coronario agudo, (grupo 2) en primera visita post-alta y (grupo 3) entre uno o 2 años tras el síndrome coronario agudo. Materiales y métodos: Estudio observacional, multicéntrico, transversal, de ámbito nacional, realizado en condiciones de práctica clínica habitual. Resultados: Se incluyeron 1.018 pacientes: 354 (34,8%) del grupo 1, 326 (32,0%) del 2 y 338 (33,2%) del 3. En comparación con el grupo 3, en el grupo 1 había un porcentaje significativamente mayor de pacientes fumadores (32,2 contra 10,9%), que consumían alcohol (28,2 contra 19,5%), que no realizaba ejercicio físico (61,0 contra 38,2%) o que no seguían una dieta (57,1 contra 32,5%). El 65,4% de los pacientes del grupo 1 no fue derivado a un programa de rehabilitación cardiaca (PRC). Del grupo 2, el 53,1% no tenía cita prevista para comenzar un PRC. Respecto al grupo 3, al 58,3% no se le recomendó nunca hacer rehabilitación cardiaca. Las variables asociadas al control de los factores de riesgo cardiovascular fueron la ausencia de obesidad y la asistencia a un PRC. Conclusiones: En el momento actual, menos de la mitad de los pacientes con cardiopatía isquémica en España son remitidos a un PRC, aunque estos programas se asocian a un mejor control de los factores de riesgo cardiovascular. Abstract: Introduction and objectives: The objective of the study was to characterize the clinical and therapeutic profile of patients with ischemic cardiopathy (IC) in Spain in patients (group 1) at the time of hospital discharge after an acute coronary syndrome (ACS), (group 2) at the first post-discharge follow-up visit, and (group 3) after one year of the ACS. Patients and methods: Observational, multicenter, cross-sectional, nationwide, performed in conditions of routine clinical practice. Results: A total of 1018 patients were included: 354 (34.8%) in the group 1, 326 (32.0%) in the 2, and 338 (33.2%) in the 3. Compared with group 3, a higher percentage of patients from group 1 were smokers (32.2% versus 10.9%), consumed alcohol (28.2% versus 19.5%), did not do any physical exercise (61.0% versus 38.2%) or followed a diet (57.1% versus 32.5%). Of patients in group 1, 65.4% were referred to a cardiac rehabilitation program (CRP). Of those in group 2, 53.1% had not a scheduled appointment to initiate a CRP. Regarding group 3, 58.3% did not receive the recommendation of doing a CRP. Absence of obesity and attendance to a CRP were variables associated with the control of cardiovascular risk factors. Conclusions: Currently, less than 50% of patients with IC in Spain are remitted to a CRP despite being associated with an improved control of cardiovascular risk factors.

RESUMEN Introducción y objetivos: La comorbilidad en ancianos con síndrome coronario agudo sin elevación del segmento ST empeora el pronóstico. El objetivo fue analizar la influencia de la carga de comorbilidad en la decisión del tratamiento invasivo en ancianos con SCASEST. Métodos: Se incluyeron 7.211 pacientes mayores de 70 años procedentes de 11 registros españoles. Los datos se analizaron en una base de datos conjunta. Se evaluó la presencia de 6 enfermedades simultáneas y su asociación con la realización de coronariografía durante el ingreso. Resultados: La edad media fue de 79 ± 6 años y la puntuación GRACE media fue de 150 ± 21 puntos. Fueron tratados de manera conservadora 1.179 pacientes (16%). La presencia de cada enfermedad se asoció con un menor abordaje invasivo (ajustado por variables clínicas predictivas): enfermedad cerebrovascular (odds ratio [OR] = 0,78; intervalo de confianza del 95% [IC95%], 0,64-0,95; p = 0,01), anemia (OR = 0,64; IC95%, 0,54-0,76; p < 0,0001), insuficiencia renal (OR = 0,65; IC95%, 0,56-0,75; p < 0,0001), arteriopatía periférica (OR = 0,79; IC95%, 0,65-0,96; p = 0,02), enfermedad pulmonar crónica (OR = 0,85; IC95%, 0,71-0,99; p = 0,05) y diabetes mellitus (OR = 0,85; IC95%, 0,74-0,98; p = 0,03). Asimismo, el aumento del número de enfermedades (carga de comorbilidad) se asoció con menor realización de coronariografías, ajustado por la escala GRACE: 1 enfermedad (OR = 0,66; IC95%, 0,54-0,81); 2 (OR = 0,55; IC95%, 0,45-0,69); 3 (OR = 0,37; IC95%, 0,29-0,47); 4 (OR = 0,33; IC95%, 0,24-0,45); ≥ 5 (OR = 0,21; IC95%, 0,12-0,36); todos p < 0,0001, en comparación con ninguna enfermedad. Conclusiones: Conforme aumenta la comorbilidad disminuye la realización de coronariografías en ancianos con síndrome coronario agudo sin elevación del segmento ST. Se necesitan estudios que investiguen la mejor estrategia diagnóstico-terapéutica en estos pacientes.

ABSTRACT Introduction and objectives: The presence of comorbidities in elderly patients with non-ST-segment elevation acute coronary syndrome worsens its prognosis. The objective of the study was to analyze the impact of the burden of comorbidities in the decision of using invasive management in these patients. Methods: A total of 7211 patients > 70 years old from 11 Spanish registries were included. Individual data were analyzed in a common database. We assessed the presence of 6 comorbidities and their association with coronary angiography during admission. Results: The mean age was 79 ± 6 years and the mean CRACE score was 150 ± 21 points. A total of 1179 patients (16%) were treated conservatively. The presence of each comorbidity was associated with less invasive management (adjusted for predictive clinical variables): cerebrovascular disease (OR, 0.78; 95%CI, 0.64-0.95; P = .01), anemia (OR, 0.64; 95%CI, 0.54-0.76; P < .0001), chronic kidney disease (OR, 0.65; 95%CI, 0.56-0.75; P < .0001), peripheral arterial disease (OR, 0.79; 95%CI, 0.65-0.96; P = .02), chronic lung disease (OR, 0.85; IC95%, 0.71-0.99; P = .05), and diabetes mellitus (OR, 0.85; 95%CI, 0.74-0.98; P < .03). The increase in the number of comorbidities (comorbidity burden) was associated with a reduction in coronary angiographies after...

Patients admitted for acute coronary syndrome (ACS) usually have high cardiovascular risk scores with low levels of high-density lipoprotein cholesterol (HDL-C) and high low-density lipoprotein cholesterol (LDL-C) levels. Here, we investigated the role of lipoprotein functionality as well as particle number and size in patients with a first-onset ACS with on-target LDL-C levels. Ninety-seven patients with chest pain and first-onset ACS with LDL-C levels of 100 ± 4 mg/dL and non-HDL-C levels of 128 ± 4.0 mg/dL were included in the study. Patients were categorized as ACS and non-ACS after all diagnostic tests were performed (electrocardiogram, echocardiogram, troponin levels and angiography) on admission. HDL-C and LDL-C functionality and particle number/size by nuclear magnetic resonance (NMR) were blindly investigated. A group of matched healthy volunteers (n = 31) was included as a reference for these novel laboratory variables. LDL susceptibility to oxidation was higher and HDL-antioxidant capacity lower in the ACS patients than in the non-ACS individuals. ACS patients had lower HDL-C and Apolipoprotein A-I levels than non-ACS patients despite the same prevalence of classical cardiovascular risk factors. Cholesterol efflux potential was impaired only in the ACS patients. ACS-STEMI (Acute Coronary Syndrome—ST-segment-elevation myocardial infarction) patients, had a larger HDL particle diameter than non-ACS individuals (8.4 ± 0.02 vs. 8.3 ± 0.02 and, ANOVA test, p = 0.004). In conclusion, patients admitted for chest pain with a first-onset ACS and on-target lipid levels had impaired lipoprotein functionality and NMR measured larger HDL particles. This study shows the relevance of HDL functionality rather than HDL-C concentration in ACS patients.

Abstract Aims Type 2 diabetes mellitus (T2DM) is common in patients with heart failure (HF) and is related with worse outcomes. Insulin treatment is associated with sodium and water retention, weight gain, and hypoglycaemia—all pathophysiological mechanisms related to HF decompensation. This study aimed to evaluate the association between insulin treatment and the risk of 1 year readmission for HF in patients discharged for acute HF. Methods and results We prospectively included 2895 consecutive patients discharged after an episode of acute HF in a single tertiary hospital. Multivariable Cox regression, adapted for competing events, was used to assess the association between insulin treatment and 1 year readmission for HF in patients discharged after acute HF. Participants' mean age was 73.4 ± 11.2 years, 50.8% were women, 44.7% had T2DM [including 527 (18.2%) on insulin therapy], and 52.7% had preserved ejection fraction. At 1 year follow‐up, 518 (17.9%) patients had died and 693 (23.9%) were readmitted for HF. The crude risk of readmission for HF was higher in patients on insulin, with no differences in 1 year mortality. After multivariable adjustment, patients on insulin were at significantly higher risk of 1 year readmission for HF than patients with diabetes who were not on insulin (hazard ratio 1.28; 95% confidence interval 1.04–1.59, P = 0.022) and patients without diabetes (hazard ratio 1.26; 95% confidence interval 1.02–1.55, P = 0.035). Conclusion Following acute HF, patients with T2DM on insulin therapy are at increased risk of readmission for HF. Further studies unravelling the mechanisms behind this association are warranted.

Introduction: Today's healthcare policies rely heavily on data that has been gathered from multiple small studies in intrinsically varied populations. We sought to describe the prevalence, comorbidities and outcomes of atrial fibrillation (AF) in the population of a specific region where all healthcare centers have implemented a common information technology (IT) structure. Methods: The total number of inhabitants was obtained from the healthcare area's IT system. Information pertaining to AF was derived from various datasets in the data warehouse of the Galician regional health service. Results: In the healthcare area of Santiago de Compostela (n=383 000), the diagnosis of AF was coded in 7990 (2.08%) individuals in 2013. Mean age was 76.83±10.5 years, mean CHA2DS2-VASc score was 3.5, 4056 (50.8%) were female and 72.6% were receiving oral anticoagulants. Up until December 31, 2015, 1361 patients died from all causes (17%), 478 (6%) of them in-hospital, with 30 deaths secondary to intracranial bleeding (0.4%) and 125 to stroke (1.6%). On multivariate analysis, age, gender, heart failure, diabetes, previous thromboembolic events and dementia were independently associated with all-cause mortality. Similarly, age, gender and previous thromboembolic events were associated with future thromboembolic events. Oral anticoagulation was found to be protective against mortality and thromboembolic events. Conclusions: In this study, we report for the first time the true prevalence of diagnosed AF and its clinical characteristics, treatment and prognosis in a Spanish healthcare area, based on the systematic integration of data available from a universally adopted health IT system within the region. Resumo: Introdução: As políticas dos cuidados de saúde confiam essencialmente em dados provenientes de múltiplos pequenos estudos no âmbito de populações diversificadas. Desejamos descrever a prevalência, as comorbilidades e os resultados da fibrilhação auricular (FA) numa população pertencente a uma área específica onde os centros dos cuidados de saúde implementaram uma estrutura informática comum. Métodos: O número total de habitantes foi obtido através do sistema informático das áreas dos cuidados de saúde. A informação relativa à FA provém de diversos conjuntos de dados proveniente do banco de dados do Serviço Saúde da Galiza. Resultados: Na área dos cuidados de saúde de Santiago de Compostela (n = 348 985), ao longo de 2013, o diagnóstico de FA foi codificado em 7990 (2,08%) indivíduos. A idade média foi 76,83 ± 10,5 anos, valor médio CHA2DS2-VASc = 3,5, sendo 4056 (50,8%) mulheres, 72,6% das quais administradas com anticoagulantes orais. Até 31 de dezembro de 2015, 1361 doentes morreram de mortalidade geral (17%). Destes, 478 (6%) estavam internados, tendo sido registadas 30 mortes secundárias a hemorragia intracraneana (0,4%) e 125 acidentes vasculares cerebrais (1,6%). Numa análise multivariável, a idade, o sexo, a insuficiência cardíaca, a diabetes, os eventos tromboembólicos e a demência foram associados independentemente da mortalidade em geral. Do mesmo modo, a idade, o sexo e o(s) tromboembólico(s) prévio(s) foram associados à ocorrência de futuros eventos tromboembólicos. Considerou-se que a anticoagulação oral teve um efeito protetor na mortalidade e nos eventos tromboembólicos. Conclusões: Neste estudo, apresentamos pela primeira vez a prevalência real da FA diagnosticada, com as características clínicas, tratamento e prognóstico de uma área específica de cuidados de saúde em Espanha, em conformidade com a integração sistemática dos dados disponíveis num processamento informático sanitário adotado na região. Keywords: Big data, CHA2DS2-VASc, Atrial fibrillation, Palavras-chave: Bancos de dados, CHA2DS2-VASC2, Fibrilhação auricular

The treatment of acute coronary syndrome (ACS) in elderly patients continues to be a challenge because of the characteS.G.B.ristics of this population and the lack of data and specific recommendations. This review summarizes the current evidence about critical points of oral antithrombotic therapy in elderly patients. To this end, we discuss the peculiarities and differences reported referring to dual antiplatelet therapy (DAPT) in ACS management in elderly patients and what might be the best option considering these population characteristics. Furthermore, we analyze antithrombotic strategies in patients with atrial fibrillation (AF), with a particular focus on those cases that also present coronary artery disease (CAD). It is imperative to deepen our knowledge regarding the management of these challenging patients through real-world data and specifically designed geriatric studies to help resolve the questions remaining in their disease management.

Selective realist projects seek to strengthen scientific realism, but influential reactions (from anti-realist as well as realist camps) regard selectivist achievements as problematic and misguided developments, because -the story goes- those developments disfigure and devalue realism, transforming it into a position that is not worth taking into account. An examination of the charges formulated against selective realism and their respective historical background suggests, however, that the charges in question rest in myths and falsehoods about the character of realist positions; if so, the charges fail.

These data are linked to the research article, entitled Hyperuricemia as a prognostic factor after acute coronary syndrome published in Atherosclerosis. Data from patients admitted for acute coronary syndrome between 2008 and 2013 were collected during the hospitalization, and a follow-up until endpoint or end of study was carried out. Multivariate analysis of variables associated with long term mortality after acute coronary syndrome in patients stratified by the presence of diabetes, hypertension or kidney failure is provided in this article.

Direct oral anticoagulants (DOACs) have been demonstrated to be more effective and safer than vitamin-K antagonist (VKA) for stroke prevention in patients with nonvalvular atrial fibrillation (AF). This meta-analysis aims to assess the effect of DOACS vs. VKA in patients ≥ 80 and AF. Primary endpoints were stroke or systemic embolism and all-cause death. Secondary endpoints included major bleeding, intracranial bleeding, and gastrointestinal bleeding. A random-effects model was selected due to significant heterogeneity. A total of 147,067 patients from 16 studies were included, 71,913 (48.90%) treated with DOACs and 75,154 with VKA (51.10%). The stroke rate was significantly lower in DOACs group compared with warfarin group (Relative risk (RR): 0.72; 95% confidence interval (CI): 0.63–0.82; p < 0.001). All-cause mortality was significantly lower in DOACs group compared with warfarin group (RR: 0.82; 95% CI: 0.70–0.96; p = 0.012). Compared to warfarin, DOACs were not associated with reductions in major bleeding (RR: 0.85, 95% CI 0.69–1.04; p = 0.108) or gastrointestinal bleeding risk (RR: 1.08, 95% CI 0.76–1.53; p = 0.678) but a 43% reduction of intracranial bleeding (RR: 0.47, IC 95% 0.36–0.60; p < 0.001) was observed. Our meta-analysis demonstrates that DOACs are effective and safe with statistical superiority when compared with warfarin in octogenarians with AF.

Coronary artery disease is one of the leading causes of morbidity and mortality, and its prevalence increases with age. The growing number of older patients and their differential characteristics make its management a challenge in clinical practice. The aim of this review is to summarize the state-of-the-art in diagnosis and treatment of acute coronary syndromes in this subgroup of patients. This comprises peculiarities of ST-segment elevation myocardial infarction (STEMI) management, updated evidence of non-STEMI therapeutic strategies, individualization of antiplatelet treatment (weighting ischemic and hemorrhagic risks), as well as assessment of geriatric conditions and ethical issues in decision making.

Few studies have addressed to date the interaction between sex and diabetes mellitus (DM) in the prognosis of elderly patients with non-ST-segment elevation acute coronary syndrome (NSTEACS). Our aim was to address the role of DM in the prognosis of non-selected elderly patients with NSTEACS according to sex. A retrospective analysis from 11 Spanish NSTEACS registries was conducted, including patients aged ≥70 years. The primary end point was one-year all-cause mortality. A total of 7211 patients were included, 2,770 (38.4%) were women, and 39.9% had DM. Compared with the men, the women were older (79.95 ± 5.75 vs. 78.45 ± 5.43 years, p < 0.001) and more often had a history of hypertension (77% vs. 83.1%, p < 0.01). Anemia and chronic kidney disease were both more common in women. On the other hand, they less frequently had a prior history of arteriosclerotic cardiovascular disease or comorbidities such as peripheral artery disease and chronic pulmonary disease. Women showed a worse clinical profile on admission, though an invasive approach and in-hospital revascularization were both more often performed in men (p < 0.001). At a one-year follow-up, 1090 patients (15%) had died, without a difference between sexes. Male sex was an independent predictor of mortality (HR = 1.15, 95% CI 1.01 to 1.32, p = 0.035), and there was a significant interaction between sex and DM (p = 0.002). DM was strongly associated with mortality in women (HR: 1.45, 95% CI = 1.18–1.78; p < 0.001), but not in men (HR: 0.98, 95% CI = 0.84–1.14; p = 0.787). In conclusion, DM is associated with mortality in older women with NSTEACS, but not in men.

Background: N-terminal pro-brain natural peptide (NT-pro-BNP) is a well-established biomarker of tissue congestion and has prognostic value in patients with heart failure (HF). Nonetheless, there is scarce evidence on its predictive capacity for HF re-admission after an acute coronary syndrome (ACS). We performed a prospective, single-center study in all patients discharged after an ACS. HF re-admission was analyzed by competing risk regression, taking all-cause mortality as a competing event. Results are presented as sub-hazard ratios (sHR). Recurrent hospitalizations were tested by negative binomial regression, and results are presented as incidence risk ratio (IRR). Results: Of the 2133 included patients, 528 (24.8%) had HF during the ACS hospitalization, and their pro-BNP levels were higher (3220 pg/mL vs. 684.2 pg/mL; p < 0.001). In-hospital mortality was 2.9%, and pro-BNP was similarly higher in these patients. Increased pro-BNP levels were correlated to increased risk of HF or death during the hospitalization. Over follow-up (median 38 months) 243 (11.7%) patients had at least one hospital readmission for HF and 151 (7.1%) had more than one. Complete revascularization had a preventive effect on HF readmission, whereas several other variables were associated with higher risk. Pro-BNP was independently associated with HF admission (sHR: 1.47) and readmission (IRR: 1.45) at any age. Significant interactions were found for the predictive value of pro-BNP in women, diabetes, renal dysfunction, STEMI and patients without troponin elevation. Conclusions: In-hospital determination of pro-BNP is an independent predictor of HF readmission after an ACS.

[This corrects the article DOI: 10.1371/journal.pone.0186196.].

La publicación en Estados Unidos de la guía de 2013 de American College of Cardiology/American Heart Association para el tratamiento del colesterol elevado ha tenido gran impacto por el cambio de paradigma que supone. El Comité Español Interdisciplinario de Prevención Cardiovascular y la Sociedad Española de Cardiología han revisado esa guía, en comparación con la vigente guía europea de prevención cardiovascular y de dislipemias. El aspecto más destacable de la guía estadounidense es el abandono de los objetivos de colesterol unido a lipoproteínas de baja densidad, de modo que proponen el tratamiento con estatinas en cuatro grupos de riesgo aumentado. En pacientes con enfermedad cardiovascular establecida, ambas guías conducen a una estrategia terapéutica similar (estatinas potentes, dosis altas). Sin embargo, en prevención primaria, la aplicación de la guía estadounidense supondría tratar con estatinas a un número de personas excesivo, particularmente de edades avanzadas. Abandonar la estrategia según objetivos de colesterol, fuertemente arraigada en la comunidad científica, podría tener un impacto negativo en la práctica clínica y crear cierta confusión e inseguridad entre los profesionales y quizá menos seguimiento y adherencia de los pacientes. Por todo ello, el presente documento reafirma las recomendaciones de la guía europea. Ambas guías tienen aspectos positivos pero, en general y mientras no se resuelvan las dudas planteadas, la guía europea, además de utilizar tablas basadas en la población autóctona, ofrece mensajes más apropiados para el entorno español y previene del posible riesgo de sobretratamiento con estatinas en prevención primaria.

INTRODUCTIONThe potential impact of targeting different components of an adverse lipid profile in populations with multiple cardiovascular risk factors is not completely clear. This study aims to assess the association between different components of the standard lipid profile with all-cause mortality and hospitalization due to cardiovascular events in a high-risk population.METHODSThis prospective registry included high risk adults over 30 years old free of cardiovascular disease (2008-2012). Diagnosis of hypertension, dyslipidemia or diabetes mellitus was inclusion criterion. Lipid biomarkers were evaluated. Primary endpoints were all-cause mortality and hospital admission due to coronary heart disease or stroke. We estimated adjusted rate ratios (aRR), absolute risk differences and population attributable risk associated with adverse lipid profiles.RESULTS51,462 subjects were included with a mean age of 62.6 years (47.6% men). During an average follow-up of 3.2 years, 919 deaths, 1666 hospitalizations for coronary heart disease and 1510 hospitalizations for stroke were recorded. The parameters that showed an increased rate for total mortality, coronary heart disease and stroke hospitalization were, respectively, low HDL-Cholesterol: aRR 1.25, 1.29 and 1.23; high Total/HDL-Cholesterol: aRR 1.22, 1.38 and 1.25; and high Triglycerides/HDL-Cholesterol: aRR 1.21, 1.30, 1.09. The parameters that showed highest population attributable risk (%) were, respectively, low HDL-Cholesterol: 7.70, 11.42, 8.40; high Total/HDL-Cholesterol: 6.55, 12.47, 8.73; and high Triglycerides/HDL-Cholesterol: 8.94, 15.09, 6.92.CONCLUSIONSIn a population with cardiovascular risk factors, HDL-cholesterol, Total/HDL-cholesterol and triglycerides/HDL-cholesterol ratios were associated with a higher population attributable risk for cardiovascular disease compared to other common biomarkers.

Objetivo: Comparando los resultados obtenidos en los estudios EUROASPIRE I y EUROASPIRE III en pacientes con cardiopatía isquémica se muestra que el grado de control de los factores de riesgo mayores es mejorable. El objetivo de este estudio es evaluar la eficacia de una intervención multifactorial orientada a la mejora del grado de control en estos pacientes en el ámbito de la atención primaria. Métodos: En este estudio de intervención aleatorizado, con 1 año de seguimiento, se reclutó a pacientes con diagnóstico de cardiopatía isquémica (145 en el grupo de intervención y 1.461 en el grupo control). Se aplicó una intervención organizativa mixta basada en la mejora de la relación profesional sanitario-paciente (de acuerdo a los modelos del Chronic Care, el Stanford Expert Patient Programme y el Kaiser Permanente) y en la formación profesional continuada. Los principales resultados fueron el efecto sobre el tabaquismo, el colesterol unido a lipoproteínas de baja densidad (cLDL), la presión arterial sistólica (PAS) y la presión arterial diastólica (PAD) a través de un análisis multivariable. Resultados: Las características de los pacientes fueron: edad (68,4 ± 11,8 años), varones (71,6%), diabetes mellitus (51,3%), dislipemia (68,5%), hipertensión arterial (76,7%), no fumadores (76,1%); cLDL < 100 mg/dl (46,9%); PAS < 140 mmHg (64,5%); PAD < 90 (91,2%). El análisis multivariable mostró que el riesgo para el buen control en el grupo de intervención fue tabaquismo, riesgo relativo ajustado (RRa): 15,7 (intervalo de confianza del 95% [IC95%], 4,2–58,7); p < 0,001; cLDL, RRa: 2,98 (IC95%, 1,48–6,02); p < 0,002; PAS, RRa: 1.97 (IC95%, 1,21–3,23); p < 0,007, y PAD; RRa: 1,51 (IC95%, 0,65–3,50); p < 0,342. Conclusiones: Una intervención multifactorial basada en el modelo de paciente crónico centrada en atención primaria y que facilite la toma de decisiones compartidas con los pacientes y la formación de los profesionales mejora el grado de control de los factores de riesgo cardiovascular (tabaquismo, cLDL y PAS). Las estrategias de mejora en la atención de la cronicidad pueden ser una herramienta eficaz para conseguir mejores resultados.

Aim: We sought to define trends in AF prevalence and its medical management using recent data based on data from two cross-sectional studies performed in a European country in 1999 and 2009. Methods: CARDIOTENS 1999 and CARDIOTENS 2009 were two observational, cross-sectional, multicenter studies. Patients were recruited in from primary care and cardiology outpatient clinics. A total of 32 051 and 25 137 subjects were analyzed in the two studies, 1540 and 1524 of them, respectively, diagnosed with AF. Results: Over the course of the study period there was an increase in the prevalence of AF (from 4.8% to 6.1%), mainly due to the higher prevalence of AF in patients aged over 70 years (24.7% vs. 37.1%). Furthermore, patients with AF had a higher prevalence of hypertension (64.9% vs. 87.0%), diabetes (19.0% vs. 37.4%), heart failure (30.8% vs. 34.8%), coronary artery disease (23.0% vs. 25.8%) and previous stroke (1.5% vs. 8.9%). An overall increase in prescription of antithrombotic/antiplatelet therapy was observed (33.0% vs. 62.7% and 31.0% vs. 38.2% respectively); the difference observed in 1999 between prescription of oral anticoagulation by general practitioners and cardiologists was not seen in the later study. Differences in prescription of angiotensin-converting enzyme inhibitors (28.0% vs. 40.7%), angiotensin receptor blockers (10.0% vs. 40.0%), beta-blockers (14.0% vs. 41.5%) and calcium channel blockers (21.0% vs. 34.9%) were also identified. Conclusions: The number of patients with AF and a higher risk for thromboembolic events increased over the last 10 years. More aggressive antithrombotic treatment has been observed, especially in older patients. Resumo: Objetivos: Procuramos definir as tendências prevalentes de fibrilhação auricular (FA) e o tratamento médico utilizando dados recentes, colhidos de dois estudos transversais realizados num país europeu entre 1999 e 2009. Métodos: CARDIOTENS 1999 e CARDIOTENS 2009 são dois estudos observacionais, transversais multicêntricos. Os pacientes foram recrutados de clínicas de ambulatório dirigidas por generalistas e cardiologistas. Um total de 32 051 e de 25 137 indivíduos foram analizados; 1 540 e 1 524 dos quais foram diagnosticados com FA. Resultados: Durante a realização do nosso estudo houve um aumento na incidência de FA (de 4,8% a 61,%) sobretudo devido à elevada prevalência de FA em pacientes com mais de 70 anos de idade (24,7% versus 37,1%). Para além disso doentes com FA revelam mais tendência para hipertensão (64,9% versus 87,0%), diabetes mellitus (19,0% versus 37,4%), insuficiência cardíaca (30,8% versus 34,8%), doença coronária (23% versus 25,8%) e acidente vascular cerebral prévio (1,5% versus 8,9%). No que se refere a terapia antitrombótica/antiplaquetária, foi observado um aumento generalizado na sua prescrição (33,0% versus 62,7% e 31,0% versus 38,2% respetivamente). Sobre este assunto, a diferença de prescrição de anticoagulantes orais observada em 1999 entre os generalistas e cardiologistas não se verifica atualmente. Diferenças nos agentes inibidores da enzima de conversão da angiotensina (28,0% versus 40,7%), bloqueadores recetores da angiotensina (10,0% versus 40,0%), beta-bloqueantes (14,0% versus 41,5%) e bloqueadores dos canais de cálcio (21,0% versus 34,9%) foram igualmente identificadas. Conclusões: O número de pacientes com FA e eventos trombo-embólicos com risco mais elevado aumentou ao longo da última década. Um tratamento antitrombótico mais agressivo foi observado sobretudo na população mais idosa. Keywords: Atrial fibrillation, Risk factors, Oral anticoagulation, Upstream therapies, Palavras-chave: Fibrilhação auricular, Fatores de risco, Anticoagulação oral, Terapias de upstream

Las guías europeas de prevención cardiovascular contemplan dos sistemas de evaluación de la evidencia (SEC y GRADE) y recomiendancombinar las estrategias poblacional y de alto riesgo, interviniendo en todas las etapas de la vida, con la dieta como piedra angular de la prevención.La valoración del RCV incorpora los niveles de HDL y los factores psicosociales, una categoría de muy alto riesgo y el concepto edad-riesgo. Se recomienda el uso de métodos cognitivo-conductuales (entrevista motivadora, intervenciones psicológicas), aplicados por profesionales sanitarios, con la participación de familiares de los pacientes, para contrarrestar el estrés psicosocial y reducir el RCV mediante dietas saludables, entrenamiento físico, abandono del tabaco y cumplimiento terapéutico. También se requieren medidas de salud pública, como la prohibición de fumar en lugares públicos o eliminar los ácidos grasos trans de la cadena alimentaria. Otras novedades consisten en desestimar el tratamiento antiagregante en prevención primaria y la recomendación de mantener la PA dentro del rango 130-139/80-85 mmHg en pacientes diabéticos o con RCV alto. Se destaca el bajo cumplimiento terapéutico observado, porque influye en el pronóstico de los pacientes y en los costes sanitarios. Para mejorar la prevención cardiovascular se precisa una verdadera alianza entre políticos, administraciones, asociaciones científicas y profesionales de la salud, fundaciones de salud, asociaciones de consumidores, pacientes y sus familias, que impulse las estrategias poblacional e individual, mediante el uso de toda la evidencia científica disponible, desde ensayos clínicos hasta estudios observacionales y modelos matemáticos para evaluar intervenciones a nivel poblacional, incluyendo análisis de coste-efectividad.

Se cree en algunos círculos que el proyecto del realismo científico lleva tiempo muerto, a manos –reza la historia– de las críticas propuestas en el último siglo por Thomas Kuhn, Bas van Fraassen, Larry Laudan y otros importantes pensadores. Entre las jugadas libradas en su contra se destacan algunos argumentos globales sobre la infradeterminación empírica de las teorías, así como argumentos inductivos en contra del modelo de refinamiento acumulativo del avance del conocimiento científico. La fuerza de tales argumentos, tal como se los ha presentado, parece, sin embargo, grandemente exagerada. Y aunque el proyecto del realismo científico dista de estar completo, tampoco hay un caso contundente que permita declararlo en agonía (y mucho menos muerto), o tal es mi argumento en este trabajo.

Según un viejo modo de pensar, la objetividad de una propuesta queda seriamente comprometida si, a cualquier nivel, ésta resulta problemática con respecto a la verdad o depende de teorías de cualquier tipo. Ningún discurso creíble satisface semejantes restricciones. Esto no afecta sin embargo, la existencia de logros como el conocimiento, las ideas correctas e incorrectas, racionales y no racionales. Simplemente, el mencionado modo de pensar es incapaz de representar los éxitos cognitivos que de hecho logramos. Mi objetivo en este trabajo es discutir un modo contemporáneo de abordar la diferencia entre ideas de alta y baja calidad descriptiva. Para ello apelo a la pertinencia general de ciertos criterios epistemológicos vigentes en las prácticas cientíticas más rigurosas y contiables.