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La pandemia de enfermedad por coronavirus 2019 (COVID-19) ha incidido de forma negativa en los programas de rehabilitación cardiaca (PRC) españoles.Este trabajo tiene como objetivo fundamental el analizar la posibilidad de mantenerlos abiertos y como secundario valorar si se mantienen los beneficios demostrados a nivel físico y psicológico.Analizamos los resultados de nuestro PRC en el año 2020 (119 pacientes) y los comparamos con los del año 2019 (121 pacientes), libre de COVID-19. Se comparan distintas variables generales, y los resultados obtenidos en capacidad física, a nivel psicológico, así como las complicaciones y abandonos.No existen diferencias significativas entre ambos grupos en la edad (61.6 vs. 61.5), sexo (mujeres: 12.6 vs. 14.8%), diagnóstico de cardiopatía isquémica (106 vs. 99) y fracción de eyección de ventrículo izquierdo (55.9 vs. 55.8%). La ansiedad media-alta fue superior al inicio (p = 0.02) y final (p = 0.002) del programa en el año 2019, así como las puntuaciones del patrón de conducta tipo A (p = 0.041 vs. 0.034). El porcentaje de depresión fue similar. Más del 95% de los pacientes del año 2020 referían miedo al contagio. La capacidad funcional aumentó, pero menos en el año 2020 (p = 0.001). La duración del programa fue superior en el año 2020 (p = 0.001). Los abandonos (15 vs. 11 pacientes) no mostraron diferencias significativas.Los PRC en época COVID-19 son posibles y siguen mostrando beneficios. La duración del programa fue mayor por periodos de falta de asistencia. La menor capacidad física puede estar relacionada con el uso de la mascarilla.COVID-19 pandemic has had a negative impact on Spanish Cardiac Rehabilitation Programmes (CRP).The main objective of this study is to analyze the possibility of keeping these units open and, secondly, to assess whether demonstrated physical and psychological benefits are preserved.We analyzed results of our CRP in 2020 (119 patients) and compared them with those of 2019 (121 patients), year free of Covid. We compare different general variables, and results obtained in physical capacity, psychological level, as well as complications and dropouts.There were no significant differences between two groups in age (61.6 vs. 61.5), sex (women: 12.6% vs. 14.8%), diagnosis of ischemic heart disease (106 vs. 99) and left ventricular ejection fraction (55.9% vs. 55.8%). Mean-high anxiety was higher at baseline (p = 0.02) and endline (p = 0.002) of program in 2019, as well as type A behavior pattern scores (p=0.041 and 0.034). Percentage of depression was similar. More than 95% of patients in 2020 reported fear of infection. Functional capacity increased, but less in 2020 (p = 0.001). Programme duration was longer in 2020 (p=0.001). Dropouts (15 vs. 11 patients) showed no significant differences.CR programmes in COVID-19 era are possible and continue to show benefits. The duration of programme was longer due to periods of non-attendance. Lower physical capacity may be related to mask use.

Resumen: Las guías europeas de prevención cardiovascular contemplan 2 sistemas de evaluación de la evidencia (SEC y GRADE) y recomiendan combinar 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 riesgo cardiovascular (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 presión arterial 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 la estrategia tanto poblacional como 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. Abstract: Based on the two main frameworks for evaluating scientific evidence (SEC and GRADE) European cardiovascular prevention guidelines recommend interventions across all life stages using a combination of population-based and high-risk strategies with diet as the cornerstone of prevention. The evaluation of cardiovascular risk (CVR) incorporates HDL levels and psychosocial factors, a very high risk category, and the concept of age-risk. They also recommend cognitive-behavioural methods (e.g., motivational interviewing, psychological interventions) led by health professionals and with the participation of the patient's family, to counterbalance psychosocial stress and reduce CVR through the institution of positive habits such as a healthy diet, physical activity, smoking cessation, and adherence to treatment. Additionally, public health interventions — such as smoking ban in public areas or the elimination of trans fatty acids from the food chain — are also essential. Other innovations include abandoning antiplatelet therapy in primary prevention and the recommendation of maintaining blood pressure within the 130-139/80-85 mmHg range in diabetic patients and individuals with high CVR. Finally, due to the significant impact on patient progress and medical costs, special emphasis is given to the low therapeutic adherence levels observed. In sum, improving cardiovascular prevention requires a true partnership among the political class, public administrations, scientific and professional associations, health foundations, consumer associations, patients and their families. Such partnership would promote population-based and individual strategies by taking advantage of the broad spectrum of scientific evidence available, from clinical trials to observational studies and mathematical models to evaluate population-based interventions, including cost-effectiveness analyses. Palabras clave: Prevención cardiovascular, Riesgo cardiovascular, Enfermedades cardiovasculares, Guías de práctica clínica, Keywords: Cardiovascular prevention, Cardiovascular risk, Cardiovascular diseases, Clinical practice guidelines

La prevencion es la herramienta mas eficaz y eficiente en la enfermedad cardiovascular y, de igual forma, los programas de rehabilitacion cardiaca son los mas eficaces y eficientes en la prevencion secundaria. Conocer la situacion de riesgo cardiovascular en nuestro pais a traves del estudio de la presentacion de los distintos factores de riesgo y de su relacion y asociacion en trabajadores espanoles es el objetivo principal del grupo de trabajo de nuestra seccion sobre sindrome metabolico. A traves de su primero registro y luego estudio denominado MESYAS (MEtabolic SYndrome Active Subjets), nos ha ofrecido importantes e interesantes resultados y sigue produciendo datos que nos ayudan en nuestra practica preventiva diaria. Por otra parte, los programas de rehabilitacion cardiaca y de prevencion secundaria de las enfermedades cardiovasculares son el metodo mas eficaz para disminuir su morbimortalidad. Sin embargo, es preocupante observar que en la asistencia cardiologica hay importantes lagunas en cuanto al seguimiento de las recomendaciones de las sociedades cientificas sobre esa prevencion secundaria. Le hemos pedido al coordinador del grupo de trabajo de rehabilitacion cardiaca que nos informe con los ultimos datos y evidencias del panorama de esta importante actividad preventiva.

Introduccion y objetivos La disfuncion erectil es frecuente en pacientes con cardiopatia. Analizamos la incidencia, los factores etiologicos y los resultados obtenidos en el tratamiento de esta afeccion en pacientes incluidos en un programa de rehabilitacion cardiaca. Metodos Se estudio a 420 varones cardiopatas sometidos a una terapia multifactorial de entrenamiento fisico, actuacion psicologica y control de factores de riesgo. Resultados Tuvieron disfuncion erectil 216 (52,6%) pacientes, en clara relacion con edad (p Conclusiones La incidencia de disfuncion erectil es muy significativa. Se relaciona con los factores de riesgo de aterosclerosis, con el tratamiento y con anomalias psicologicas (ansiedad y depresion). El miedo a las complicaciones y las malas relaciones de pareja puede favorecer que muchos pacientes declinen tomar inhibidores de la fosfodiesterasa.

This article reviews the main developments in cardiovascular disease prevention reported in recent publications. The prevention of coronary heart disease often begins with the identification of risk factors. Better understanding of emerging risk factors could help to improve risk assessment and increase the efficacy of preventative measures. Lifestyle modification and the introduction of better-tolerated and effective new drugs have been shown to prevent atherosclerosis and prolong survival.

Introduccion y objetivos Hay muy pocos estudios en los que se analicen los resultados de los programas de rehabilitacion cardiaca sobre la supervivencia a largo plazo. El objetivo fundamental del presente trabajo es analizar la mortalidad y el secundario, la morbilidad, en pacientes que realizan estos programas despues de haber presentado un episodio de infarto de miocardio. Pacientes y metodo Se incluyo a 180 pacientes varones, con edad Resultados Hubo un descenso significativo en la mortalidad por todas las causas (supervivencia a los 10 anos del 81,7% en el grupo control y del 91,8% en el grupo de intervencion; p = 0,04); la mortalidad por causa cardiovascular tambien descendio, aunque de forma estadisticamente no significativa (supervivencia a 10 anos del 83,8% en el grupo control y del 91,8% en el grupo de intervencion; p = 0,10). El porcentaje de pacientes con complicaciones no mortales fue inferior en el grupo de actuacion (el 35,2 frente al 63,2%; p = 0,03) y tuvieron significacion estadistica el descenso en la presentacion de angina inestable (el 15,7 frente al 33,9%; p = 0,02), insuficiencia cardiaca (el 3,0 frente al 14,4%; p = 0,02) y la necesidad de cirugia de revascularizacion (el 8,4 frente al 22,9%; p = 0,02). Conclusiones La rehabilitacion cardiaca en pacientes de bajo riesgo tras un infarto agudo de miocardio da lugar a descensos significativos en la mortalidad y en la incidencia de nuevos eventos a largo plazo.

Introduction and objectives Very little information is available on the effect of cardiac rehabilitation programs on long-term survival. The primary aim of this study was to assess the effect of a structured cardiac rehabilitation program on mortality in patients who had suffered acute myocardial infarction. The secondary endpoint was the effect on morbidity. Patients and method The study included 180 low-risk male patients aged under 65 years. Patients were randomly assigned to one of 2 groups: 90 entered into a comprehensive cardiac rehabilitation program, and 90 served as a control group. The mean follow-up period was 10 years. Results All-cause mortality was significantly lower in the intervention group: the 10-year survival rate was 91.8% in the intervention group compared with 81.7% in the control group ( P = .04). There was also a decrease in cardiovascular mortality, though it was not statistically significant: the 10-year survival rate was 91.8% in the intervention group compared with 83.8% in the control group ( P = .10). The incidence of non-fatal complications was lower in the intervention group (35.2% vs 63.2%, P = .03), as was the incidence of unstable angina (15.7% vs 33.9%, P = .02) and cardiac heart failure (3.0% vs 14.4%, P = .02), and the need for coronary intervention (8.4% vs 22.9%, P = .02). Conclusions The application of a comprehensive cardiac rehabilitation program significantly decreased long-term mortality and morbidity in low-risk patients after acute myocardial infarction.

A B S T R A C T Cardiovascular disease develops in a slow and subclinical manner over decades, only to manifest suddenly and unexpectedly. The role of prevention is crucial, both before and after clinical appearance, and there is ample evidence of the effectiveness and usefulness of the early detection of at-risk individuals and lifestyle modifications or pharmacological approaches. However, these approaches require time, perseverance, and continuous development. The present article reviews the developments in 2013 in epidemiological aspects related to prevention, includes relevant contributions in areas such as diet, weight control methods (obesity is now considered a disease), and physical activity recommendations (with warnings about the risk of strenuous exercise), deals with habit-related psychosocial factors such as smoking, provides an update on emerging issues such as genetics, addresses the links between cardiovascular disease and other pathologies such as kidney disease, summarizes the contributions of new, updated guidelines (3 of which have recently been released on topics of considerable clinical importance: hypertension, diabetes mellitus, and chronic kidney disease), analyzes the pharmacological advances (largely mediocre except for promising lipid-related results), and finishes by outlining developments in the oft-neglected field of cardiac rehabilitation. This article provides a briefing on controversial issues, presents interesting and somewhat surprising developments, updates established knowledge with undoubted application in clinical practice, and sheds light on potential future contributions.

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

In Spain, where cardiovascular disease (CVD) is the leading cause of death, hypercholesterolemia, one of the most prevalent risk factors in adults, is poorly controlled. Dyslipidemia should not be approached in isolation, but in the context of overall cardiovascular risk (CVR). Measurement of CVR facilitates decision making, but should not be the only tool nor should it take the place of clinical judgment, given the limitations of the available calculation methods. This document, prepared by the Interdisciplinary Spanish Committee on Cardiovascular Prevention, at the proposal of the Spanish Society of Arteriosclerosis, reviews the cardiovascular prevention activities of the regional health authorities, scientific societies and medical professionals. An initiation of a national strategy on cardiovascular prevention is proposed based on lifestyle modification (healthy diet, physical activity and smoking cessation) through actions in different settings. At the population level, regulation of food advertising, elimination of trans fats and reduction of added sugar are feasible and cost-effective interventions to help control dyslipidemias and reduce CVR. In the health setting, it is proposed to facilitate the application of guidelines, improve training for medical professionals, and include CVR assessment among the quality indicators. Scientific societies should collaborate with the health authorities and contribute to the generation and transmission of knowledge. Finally, it is in the hands of professionals to apply the concept of CVR, promote healthy lifestyles, and make efficient use of available pharmacological treatments.

Prevention is the most effective and efficient way of tackling cardiovascular disease and, similarly, cardiac rehabilitation programs are the most effective and efficient means of secondary prevention. The main objective of the metabolic syndrome working group is to increase understanding of cardiovascular risk in Spain by studying the occurrence of various risk factors, and the connections and associations between them, in economically active individuals. The group's first study and, subsequently, the MESYAS (Metabolic Syndrome in Active Subjects) study have led to significant and informative new findings, and continue to be produce data that can be used to improve disease prevention in everyday clinical practice. Furthermore, cardiac rehabilitation and secondary prevention programs for cardiovascular disease provide the most effective means of decreasing morbidity and mortality. However, it is worrying to observe that, in cardiological practice, there are significant gaps in compliance with scientific society recommendations on secondary prevention. On request, the coordinator of the cardiac rehabilitation working group has provided a report on the latest data and findings from across the full spectrum of activity in this vital area of disease prevention.

Erectile dysfunction is common in patients with coronary heart disease. The aim of this study was to investigate the incidence of, etiological factors associated with, and treatment results obtained in this condition in patients participating in a cardiac rehabilitation program.The study included 420 male patients with heart disease who were taking part in a multicomponent therapeutic program that involved physical exercise, psychological techniques and risk factor reduction.Overall, erectile dysfunction was present in 216 patients (52.6%) and there were clear associations with age (P.001), diabetes mellitus (P.001), arterial hypertension (P=.029), cigarette smoking (P=.044) and treatment with angiotensin-converting enzyme inhibitors (P=.003) and diuretics (P.001). However, there were no links to treatment with beta-blockers, calcium antagonists, statins or antiplatelet agents. There were direct associations with trait anxiety (P=.009) and state anxiety (P=.006) and with depression (P=.003). The final multivariate analysis model included diabetes mellitus, smoking, diuretic use, state anxiety and age as significant variables. Only 59 patients agreed to treatment with a phosphodiesterase-5 inhibitor, with positive results in 45 (76.27%). Treatment was contraindicated in 41 patients because they were taking nitrates for myocardial ischemia. The remaining patients expressed no interest, had relationship problems or were worried about complications.The incidence of erectile dysfunction was substantial. The condition was directly associated with risk factors for atherosclerosis, treatment, and psychological disorders (i.e., anxiety and depression). Relationship problems and the fear of complications may explain why many patients refused to take phosphodiesterase-5 inhibitors.

This article contains a review of the main developments in cardiovascular disease prevention reported during the last year. In addition, the most recent clinical practice guidelines are also discussed. The aims of cardiovascular prevention are to reduce mortality and morbidity in individuals at a high risk and to help those at a low risk to maintain their status. Lifestyle modification and the reduction of modifiable cardiovascular risk factors are key to cardiovascular disease prevention. The implementation of clinical practice guidelines provides the primary means of achieving these goals.