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The environment is a strong determinant of cardiovascular health. Environmental cardiology studies the contribution of environmental exposures with the aim of minimizing the harmful influences of pollution and promoting cardiovascular health through specific preventive or therapeutic strategies. The present review focuses on particulate matter and metals, which are the pollutants with the strongest level of scientific evidence, and includes possible interventions. Legislation, mitigation and control of pollutants in air, water and food, as well as environmental policies for heart-healthy spaces, are key measures for cardiovascular health. Individual strategies include the chelation of divalent metals such as lead and cadmium, metals that can only be removed from the body via chelation. The TACT (Trial to Assess Chelation Therapy, NCT00044213) clinical trial demonstrated cardiovascular benefit in patients with a previous myocardial infarction, especially in those with diabetes. Currently, the TACT2 trial (NCT02733185) is replicating the TACT results in people with diabetes. Data from the United States and Argentina have also shown the potential usefulness of chelation in severe peripheral arterial disease. More research and action in environmental cardiology could substantially help to improve the prevention and treatment of cardiovascular disease.

The treatment of dyslipidemia exhibits wide variability in clinical practice and important limitations that make lipid-lowering goals more difficult to attain. Getting to know the management of these patients in clinical practice is key to understand the existing barriers and to define actions that contribute to achieving the therapeutic goals from the most recent Clinical Practice Guidelines.Observatory where the information gathered is based on routine clinical practice and the experience from the healthcare professionals involved in the treatment of dyslipidemia in Spain. The information is collected by health area through: (i) face-to-face meeting with three different medical specialties and (ii) quantitative information related to hypercholesterolemia patients' management (ad-hoc questionnaire). Information includes patients' profiles, assistance burden, guidelines and protocols used, goal attainment, limitations and opportunities in clinical practice.145 health areas are planned to be included, with the participation of up to 435 healthcare professionals from the 17 Autonomous Regions of Spain. Information collection will result in aggregated data from over four thousand patients.This observatory aims to understand how hypercholesterolemia is being treated in routine clinical practice in Spain. Even though the preliminary results show important improvement areas in the treatment of dyslipidemias, mechanisms to drive a change towards health outcomes optimization are also identified.

The reduction of low-density lipoprotein cholesterol with lipid lowering therapy has demonstrated to decrease the risk of developing cardiovascular complications during the follow-up in primary and secondary prevention. Unfortunately, a great number of patients do not achieve recommended targets. This is mainly due to an insufficient use of the lipid-lowering therapy currently available. Although healthy life style changes are the basis of the treatment, in many cases this is not enough and it is necessary to add lipid lowering drugs to attain these targets. For these reasons, the current consensus document of the Spanish Society of Cardiology proposes 4 simple and feasible decision-making algorithms according to cardiovascular risk, with the aim of attaining cholesterol goals in the majority of primary prevention patients in a rapid an efficient way.

Resumen La reduccion del colesterol unido a lipoproteinas de baja densidad con el tratamiento hipolipidemiante ha demostrado disminuir el riesgo de presentar complicaciones cardiovasculares durante el seguimiento, tanto en prevencion primaria como secundaria. Desafortunadamente, un gran numero de pacientes no logran los objetivos de control recomendados. Esto se debe principalmente a un uso insuficiente de las terapias hipolipidemiantes actualmente disponibles. Aunque la base del tratamiento lo constituyen los cambios hacia un estilo de vida mas saludable, en numerosas ocasiones esto no es suficiente y es necesario anadir un tratamiento hipolipidemiante para alcanzar estos objetivos. Por estos motivos, en el presente documento de consenso de la Sociedad Espanola de Cardiologia se proponen 4 algoritmos de abordaje en funcion del riesgo cardiovascular de los pacientes, sencillos y facilmente aplicables, con el objetivo de lograr que la mayoria de los pacientes en prevencion primaria cumplan los objetivos de control de colesterol de manera rapida y eficiente.

Resumen Introduccion y objetivos La eficacia de la rehabilitacion cardiaca (RC) se basa en controlar los factores de riesgo cardiovascular y lograr adherencia al ejercicio fisico y a un estilo de vida saludable. Se han descrito diferencias por genero en la practica de ejercicio fisico tras la RC, peor en las mujeres, probablemente por las diferencias en sus roles sociales. El objetivo del presente trabajo fue estudiar la adherencia al ejercicio fisico a largo plazo de las mujeres que completaron un programa de RC (PRC) y los factores que influyen en ella. Metodos Se selecciono a 99 mujeres que completaron el PRC desde 2013 hasta 2018. Se evaluaron, mediante un cuestionario basado en el de EUROASPIRE V, variables psicosociales, antropometricas y analiticas. Resultados De las 99 mujeres incluidas en el estudio, 84 (84%; IC95%, 76,5-90,6) afirmaron continuar practicando ejercicio fisico regular. El tiempo transcurrido desde la finalizacion de la RC, estar al cuidado de un familiar o ser laboralmente activas no supuso una barrera en la adherencia al ejercicio de las pacientes del estudio (p > 0,05). Aquellas asesoradas periodicamente por profesionales sanitarios (82%) fueron mas constantes en la practica de ejercicio fisico regular. Conclusiones La adherencia al ejercicio fisico en mujeres tras el PRC en nuestro centro continua siendo muy elevada: 84% y sin decaer en el tiempo. Dicha adherencia no esta influida por factores psicosociales o el paso del tiempo y es mejor en aquellas pacientes que reciben asesoramiento sobre actividad fisica del profesional sanitario.

To carry out a systematic review about the information about the application of of virtual reality and videogames in cardiac rehabilitation.A systematic review was conducted. Jadad scale was applied to evaluate the methodological quality of the articles included and the degree of evidence and the level of recommendation were determined through the Oxford Center for Evidence-Based Medicine. PRISMA guidelines statement for systematic reviews were followed.The total number of articles included in the present review was 10, with heterogeneity in the study populations, cardiac rehabilitation phases, technology used and protocols. Most of the studies showed an increase in heart rate, less pain, a greater ability to walk, higher energy levels, an increase in physical activity and improvements of motivation and adherence. The methodological quality of the studies was between acceptable and poor.The use of virtual reality and videogames could be considered as complementary tools of physical training in patients with cardiovascular diseases in the different phases of cardiac rehabilitation. However, it is also necessary to carry out studies with adequate methodological quality to determine the ideal technological systems, target populations and clearly protocols to study their effects in the short, medium and long-term assessments.Implications for rehabilitationThe use of virtual reality and videogames could be considered as complementary tools for physical training in patients with cardiovascular diseases.Interactive virtual reality using exergames may promote heart rate, fatigue perception, physical activity and reduce pain in patients with cardiovascular diseases.Virtual reality and videogames enhance motivation and adherence in cardiac rehabilitation programs.

(1) Background: The aim of the present study was to determine the effects of a virtual reality (VR) program, as a complementary tool to a conventional cardiac rehabilitation (CR) program in phase II of patients with ischemic heart disease compared to a conventional treatment group. (2) Methods: A single blinded randomized clinical trial was conducted. The patients were randomized to a control group (CG) or an experimental group (EG). The EG carried out a training based on VR of aerobic exercise using the XBOX ONE console and Kinect sensor. Ergometry, metabolic equivalents (METS), Functional Independence Measure, 6-min walk test (6MWT), the Short Form Health Survey-36 Questionnaire (SF-36), the Beck Depression Inventory-II, and the degree of satisfaction and adherence to treatment were used as outcome measures. (3) Results: Our results showed no statistically significant differences between the two groups. Statistical analysis within group for the EG showed statistically significant changes in the variables HR final ergometry, ergometry minutes, % ergometry, METS, final HR 6MWT, 6MWT distance, 6MWT number of laps, and for the SF-36 and Beck Depression Inventory-II. (4) Conclusion: A VR-based video game program, as an adjunct tool to a CR program, showed improvements in ergometry, METS, resistance to fatigue and health-related quality of life with excellent adherence and satisfaction perceived by patients with ischemic heart disease in phase II.

Background Pulmonary hypertension (PH) is a common finding among patients with heart failure and preserved ejection fraction (HFpEF) and contributes to develop right ventricular systolic dysfunction (RVSD). Aims We evaluated the diagnostic accuracy of Flowers and Horan electrocardiographic criteria to detect significant right ventricular pressure overload. Methods 123 patients were prospectively included. We used the Flowers and Horan (FH) ECG criteria to define RV enlargement (score > 10). Echocardiographic measurements were performed blinded to the electrocardiographic results. Results Severe PH was found in 51.5%. Seventeen patients (16.5%) had a FH score > 10 points. This was associated to RVSD (RR 2.66; 1.51-4.67 CI 95%, p = 0.002), with 90.5% specificity and 34.4% sensitivity and to severe PH (RR 1.70; 1.16-2.50 CI 95%, p = 0.028) with 91.9% specificity and 27.5% sensitivity. Conclusions The ECG is a useful tool to classify HFpEF patients with echocardiographic signs of right ventricular pressure overload, in the absence of RBBB.

Introduction and objectives. Calculation of the effective regurgitant orifice (ERO) is regarded as the most accurate way of assessing the severity of mitral regurgitation (MR), but the technique’s complexity limits its use. Our objective was to modify and validate a previously published semiquantitative method of assessment based on measurement of the proximal isovelocity surface area (PISA) in order to adapt it to recent recommendations from American and European cardiology societies. Methods. In the PISA method, maximum regurgitant flow (MRF) is a function of the radius and aliasing velocity (AV). Using this relationship, it is possible to construct a nomogram formed by lines of different MRF value, which can be easily derived by looking for radius values on the graph and observing where they cross with AV values. The MR severity limits on the nomogram were set to reflect the different severity grades and limits recommended for use with ERO measurements by American and European cardiology societies. Results. We studied 76 patients with MR using Doppler echocardiography. There was an excellent correlation between MRF and ERO (r=0.98, P

The image shows a left atrium completely occupied by a giant non-homogeneous, irregularly-surfaced mass, obstructing the disc motion, mimicking severe mitral prosthetic stenosis.

Calculation of the effective regurgitant orifice (ERO) is regarded as the most accurate way of assessing the severity of mitral regurgitation (MR), but the technique's complexity limits its use. Our objective was to modify and validate a previously published semiquantitative method of assessment based on measurement of the proximal isovelocity surface area (PISA) in order to adapt it to recent recommendations from American and European cardiology societies.In the PISA method, maximum regurgitant flow (MRF) is a function of the radius and aliasing velocity (AV). Using this relationship, it is possible to construct a nomogram formed by lines of different MRF value, which can be easily derived by looking for radius values on the graph and observing where they cross with AV values. The MR severity limits on the nomogram were set to reflect the different severity grades and limits recommended for use with ERO measurements by American and European cardiology societies.We studied 76 patients with MR using Doppler echocardiography. There was an excellent correlation between MRF and ERO (r=0.98, P.001). Estimates of MR severity made using the new nomogram were in good agreement with those derived from the ERO: for a scale with three severity grades, kappa was 0.951 and the standard error was 0.11; for four grades, kappa was 0.969 and the standard error, 0.11.Estimates of MR severity derived semiquantitatively from MRF using the nomogram proposed here were in excellent agreement with quantitative estimates obtained using the ERO, and the method was faster and easier to use.