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BACKGROUND: The effectiveness of statin treatment to reduce coronary events and mortality has been hardly examined considering goals of LDL-C. We aimed to analyse such association in secondary cardiovascular prevention. METHODS: Retrospective cohort analysis of electronic health records from the SIDIAP database, Catalonia-Spain. Recruitment period was from 2006 to 2017 and study period finished at the end of 2018. We included 54,175 people aged ≥35 years in cardiovascular secondary prevention starting statin treatment. We analysed the association of achieved LDL-C goals after statin initiation with coronary heart disease and all-cause mortality. RESULTS: Mean age was 69 years and 20,146 (37.2%) were women. Coronary heart disease occurred in 5687 (10.5%) participants, and 10,676 (19.7%) persons passed away. Median follow-up lasted 5.7 years (interquartile range, 3.4-8.1). The coronary heart disease HRs (95% CI) for the LDL-C goals of 70-100, <70-55 and <55 mg/dL were .86 (.81-.92), .83 (.76-.9) and .8 (.72-.88), respectively. They were .89 (.83-.96) in the group with 30%-40% reduction and .86 (.8-.93) in the groups with 40%-50% and ≥50% reduction. We observed no association with mortality. We observed no relevant differences by sex or age. CONCLUSIONS: This population-level retrospective analysis of real-world data observed that treatment with statins is effective to achieve certain LDL-C goals and CHD reduction. The lack of significant difference between LDL-C goals needs confirmation in additional studies with real-world data. The LDL-C target should consider the magnitude of the decrease in coronary events.
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LDL-Colesterol , Enfermedad Coronaria , Inhibidores de Hidroximetilglutaril-CoA Reductasas , Prevención Secundaria , Humanos , Femenino , Masculino , LDL-Colesterol/efectos de los fármacos , LDL-Colesterol/sangre , Anciano , Persona de Mediana Edad , Inhibidores de Hidroximetilglutaril-CoA Reductasas/uso terapéutico , Estudios Retrospectivos , Enfermedad Coronaria/prevención & control , Enfermedades Cardiovasculares/prevención & control , Enfermedades Cardiovasculares/mortalidad , España/epidemiología , Causas de Muerte , ObjetivosRESUMEN
AIM: To evaluate the risk of alcohol consumption after acute coronary syndromes (ACS). METHODS: A total of 6557 patients hospitalized for ACS at 4 Swiss centres were followed over 12 months. Weekly alcohol consumption was collected at baseline and 12 months. Binge drinking was defined as consumption of ≥6 units of alcohol on one occasion. Major adverse cardiovascular events (MACE) were defined as a composite of cardiac death, myocardial infarction, stroke or clinically indicated target vessel coronary revascularization. Cox regression analysis was performed to assess the risk of MACE in patients with heavy (>14 standard units/week), moderate (7-14 standard units per week), light consumption (<1 standard unit/week) or abstinence, and with binge drinking episodes, adjusted for baseline differences. RESULTS: At baseline, 817 (13.4%) patients reported heavy weekly alcohol consumption. At one-year follow-up, 695/1667 (41.6%) patients reported having at least one or more episodes of binge drinking per month. The risk for MACE was not significantly higher in those with heavy weekly consumption compared to abstinence (8.6% vs. 10.2%, HR 0.97, 95%CI 0.69-1.36) or light consumption (8.6% vs. 8.5 %, HR 1.41, 95%CI 0.97-2.06). Compared to patients with no-binge drinking, the risk of MACE was dose-dependently higher in those with binge drinking with less than one episode per month (9.2% vs 7.8%, HR 1.61, 95%CI 1.23-2.11), or one or more episodes per month (13.6% vs 7.8%, HR 2.17, 95%CI 1.66-2.83). CONCLUSION: Binge drinking during the year following an ACS, even less than once per month, is associated with worse clinical outcomes.
The cardiovascular risk of alcohol consumption and of binge drinking episodes after acute coronary syndrome (ACS) has not been established. Our data suggested the following: After ACS, regular weekly alcohol consumption is not associated with the risk of major adverse cardiovascular events (MACE), except for patients reporting binge drinking who have a two-fold increased risk of MACE within one year of the index event.After ACS, episodes of binge drinking, even less than once per month, are associated with worse clinical outcomes. It is not the frequency, but rather the quantity of alcohol intake in a binge drinking episode, that is associated with worse prognosis in patients after an ACS.
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Cardiovascular diseases (CVD), including myocardial infarction and stroke, are currently the leading cause of morbidity, disability and mortality worldwide. Recently, researchers have focused their attention on the alterations of the gut and oral microbiota, investigating the possible role of their dysbiosis in the pathogenesis and/or progression of CVD. In this regard, it has been shown that endothelial dysfunction, a major feature of CVD, can also be induced by chronic periodontal infection, due to a systemic pro-inflammatory condition, as suggested by increased plasma levels of acute phase proteins, IL-6 and fibrinogen. Moreover, proatherogenic dysfunctions can also be promoted by direct bacterial invasion of the endothelium. This review reports the current evidence about the possible role of oral microbiota dysbiosis and the related immunoinflammatory components in the pathophysiology of atherosclerosis and associated CVD. It is concluded that integration of oral microbiota sampling into clinical practice may result in a more accurate assessment of CV risk in patients and even modify their prognosis.
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There is a pandemic of physical inactivity that appears to parallel the widespread prevalence of cardiovascular disease (CVD). Yet, regular physical activity (PA) and exercise can play an important role not only in primary cardiovascular prevention but also in secondary prevention. This review discusses some of the main cardiovascular effects of PA/exercise and the mechanisms involved, including a healthier metabolic milieu with attenuation of systemic chronic inflammation, as well as adaptations at the vascular (antiatherogenic effects) and heart tissue (myocardial regeneration and cardioprotection) levels. The current evidence for safe implementation of PA and exercise in patients with CVD is also summarized.
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Enfermedades Cardiovasculares , Sistema Cardiovascular , Humanos , Enfermedades Cardiovasculares/prevención & control , Enfermedades Cardiovasculares/epidemiología , Ejercicio Físico , Corazón , Inflamación , Factores de RiesgoRESUMEN
AIM: To investigate the association between dental health and incident cardiovascular disease (CVD) in secondary prevention setting. MATERIALS AND METHODS: A total of 888 patients with known CVD hospitalized in the cardiology unit were prospectively enrolled. We assessed the association between missing teeth and three variables of periodontitis and major adverse cardiovascular events (MACE), defined as a composite of cardiac death, acute myocardial infarction, stroke and hospital re-admission for congestive heart failure. RESULTS: During a median (Q1, Q3) follow-up of 4.6 (1.4, 6.7) years, an additional missing tooth was associated with a 3% (95% confidence interval [CI]: 1%-5%) higher hazard of MACE (p = .004). Compared with patients with 0 to ≤4 missing teeth, periods free from MACE (95% CI) by 5 years of follow-up were, on average, shorter by 0.17 (-0.04 to 0.37) years, 0.26 (0.04-0.49) years and 0.59 (0.34-0.85) years in patients with 5 to ≤7, 8 to ≤13 and >13 missing teeth, respectively. No significant associations were observed between periodontal measures and MACE incidence. CONCLUSIONS: In hospitalized patients with existing CVD, the total number of missing teeth was associated with incident MACE.
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Cardiología , Enfermedades Cardiovasculares , Insuficiencia Cardíaca , Infarto del Miocardio , Pérdida de Diente , Humanos , Enfermedades Cardiovasculares/complicaciones , Enfermedades Cardiovasculares/prevención & control , Infarto del Miocardio/complicaciones , Infarto del Miocardio/prevención & control , Insuficiencia Cardíaca/complicaciones , Insuficiencia Cardíaca/epidemiología , Pérdida de Diente/complicaciones , Factores de Riesgo , Prevención SecundariaRESUMEN
BACKGROUND: Low-grade chronic inflammation, promoted by dysbiosis of the gut and oral microbiota, has been shown to contribute to individual susceptibility to atherosclerotic cardiovascular disease (ASCVD). High oral Porphyromonas gingivalis (Pg) and lower Fusobacterium nucleatum (Fn) concentrations have been associated with clinical and experimental atherosclerosis. We assessed oral Pg and Fn abundance in very high-risk patients with previously diagnosed ASCVD, with or without heterozygous familial hypercholesterolemia (HeFH), in subjects with HeFH in primary prevention and in healthy subjects. METHODS: In this cross-sectional study, 40 patients with previously diagnosed ASCVD (10 with genetically proven HeFH, and 30 without FH), 26 subjects with HeFH in primary prevention, and 31 healthy subjects were selected to quantify oral Pg and Fn abundance by qPCR and assess oral health status. RESULTS: Compared to healthy subjects, patients with previously diagnosed ASCVD showed greater Pg abundance (1101.3 vs. 192.4, p = 0.03), but similar Fn abundance. HeFH patients with ASCVD had an even greater Pg abundance than did non-HeFH patients and healthy subjects (1770.6 vs. 758.4 vs. 192.4, respectively; p = 0.048). No differences were found in the levels of Pg and Fn abundance in HeFH subjects in primary prevention, as compared to healthy subjects. CONCLUSIONS: Greater oral Pg abundance is present in very high-risk patients with previously diagnosed ASCVD, with or without FH, suggesting a potential relationship with CV events. Future studies will assess the predictive value of Pg abundance measurement in ASCVD risk stratification.
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AIMS: To evaluate the association of ultra-processed food (UPF) intake and mortality among individuals with history of cardiovascular disease (CVD) and analyse some biological pathways possibly relating UPF intake to death. METHODS AND RESULTS: Longitudinal analysis on 1171 men and women (mean age: 67 ± 10 years) with history of CVD, recruited in the Moli-sani Study (2005-10, Italy) and followed for 10.6 years (median). Food intake was assessed using a food frequency questionnaire. UPF was defined using the NOVA classification according to degree of processing and categorized as quartiles of the ratio (%) between UPF (g/day) and total food consumed (g/day). The mediating effects of 18 inflammatory, metabolic, cardiovascular, and renal biomarkers were evaluated using a logistic regression model within a counterfactual framework. In multivariable-adjusted Cox analyses, higher intake of UPF (Q4, ≥11.3% of total food), as opposed to the lowest (Q1, UPF <4.7%), was associated with higher hazards of all-cause (hazard ratio [HR]: 1.38; 95% confidence interval (CI): 1.00-1.91) and CVD mortality (HR: 1.65; 95% CI: 1.07-2.55). A linear dose-response relationship of 1% increment in UPF intake with all-cause and CVD mortality was also observed. Altered levels of cystatin C explained 18.3% and 16.6% of the relation between UPF (1% increment in the diet) with all-cause and CVD mortality, respectively. CONCLUSION: A diet rich in UPF is associated with increased hazards of all-cause and CVD mortality among individuals with prior cardiovascular events, possibly through an altered renal function. Elevated UPF intake represents a major public health concern in secondary CVD prevention.
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Enfermedades Cardiovasculares , Anciano , Causas de Muerte , Dieta , Ingestión de Alimentos , Comida Rápida/efectos adversos , Femenino , Humanos , Masculino , Persona de Mediana EdadRESUMEN
AIMS: Patients with coronary heart disease (CHD) are at very high risk of recurrent events. A strategy to reduce excess risk might be to deliver structured secondary prevention programmes, but their efficacy has been mostly evaluated in the short term and in experimental settings. This is a retrospective case-control study aimed at assessing, in the real world, the efficacy of a secondary prevention programme in reducing long-term coronary event recurrences after coronary artery bypass surgery (CABG). METHODS AND RESULTS: Programme participants (henceforth 'cases') were men and women aged <75 years subjected to CABG between 2002 and 2014, living within 100 km of the hospital. Key programme actions included optimization of treatments according to the most updated European preventive guidelines, surveillance of therapy adherence, and customized lifestyle counselling. Controls were analogous patients not involved in the programme because living farther than 100 km away, matched 1:1 with cases for gender, age at CABG, and year of CABG. Both groups (n = 1248) underwent usual periodic cardiology follow-up at our centre. Data on symptomatic or silent CHD recurrences were obtained from the hospital electronic health records. Cox analysis (adjusted for baseline differences between groups) shows that programme participation was associated with a significantly lower incidence throughout 5 years post-CABG of symptomatic [hazard ratio (95% confidence interval): 0.59 (0.38-0.94)] and silent [0.53 (0.31-0.89)] coronary recurrences. CONCLUSION: In a real-world setting, taking part in a structured longstanding secondary prevention programme, in addition to usual cardiology care, meaningfully lowers the risk of coronary recurrences.
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Enfermedades Cardiovasculares , Enfermedad de la Arteria Coronaria , Enfermedades Cardiovasculares/etiología , Estudios de Casos y Controles , Puente de Arteria Coronaria/efectos adversos , Enfermedad de la Arteria Coronaria/etiología , Enfermedad de la Arteria Coronaria/cirugía , Femenino , Humanos , Masculino , Recurrencia , Estudios Retrospectivos , Prevención Secundaria , Resultado del TratamientoRESUMEN
Patients suffering acute coronary syndrome have a very high risk for a repeated syndrome. After stabilization of acute coronary syndrome and discharge of a patient it is important to educate the patient how to prevent it in the future (dietary and life style changes), but treatment of all cardiovascular risk factors/diseases, as hypertension, dyslipidemia, diabetes but stabilization of all cardiovascular diseases is also important. Important is also antithrombotic treatment (mostly double antiplatelet treatment when percutaneous coronary intervention was used with a coronary stents), RAAS blockers, betablockers and statins (strong as atorvastatin and rosuvastatin in the highest possible dose). There are also new risk factors, and vascular inflammation belongs here. We have nowadays also some successful clinical studies how to block inflammation and how to use this treatment. A good secondary cardiovascular prevention is able to improve enourmously prognosis of these patients.
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Síndrome Coronario Agudo , Dislipidemias , Inhibidores de Hidroximetilglutaril-CoA Reductasas , Intervención Coronaria Percutánea , Síndrome Coronario Agudo/prevención & control , Atorvastatina , Humanos , Inhibidores de Hidroximetilglutaril-CoA Reductasas/uso terapéutico , Prevención SecundariaRESUMEN
PURPOSE: Adherence to a healthy dietary pattern positively influences clinical outcomes in cardiovascular prevention, but long-term adherence is difficult to maintain. We evaluated 5-year changes in dietary habits, adherence achieved, and its maintenance in a cohort of coronary patients from the CORDIOPREV study. METHODS: 1002 coronary patients were randomized to a Mediterranean diet (n = 502) or a low-fat diet (n = 500) and received individual-group-telephone visits and personalized dietary advice. A validated food-frequency questionnaire, a 14-point Mediterranean diet adherence screener, and a 9-point low-fat diet adherence score were used. Dietary adherence was categorized into Low, Medium, and High Adherence. Changes in nutrient intake, food consumption, and adherence were analyzed on a yearly basis. The maintenance of long-term dietary adherence was evaluated using data after the first year and fifth year. RESULTS: From baseline to 5 years, significant increases were observed in overall dietary adherence (Mediterranean diet from 8.9 to 11.4; low-fat diet from 3.9 to 7.1) and in the percentage of patients considered High Adherence (Mediterranean diet from 41 to 89%; low-fat diet from 4 to 67%). When we evaluated the maintenance of adherence, patients considered Low and Medium Adherence at 1 year increased their adherence at the 5 years with both diets and patients considered High Adherence maintained their adherence with a Mediterranean diet, but decreased their adherence with a low-fat diet. CONCLUSIONS: A comprehensive dietary intervention results in an overall long-term improvement and maintenance of adherence to the Mediterranean and low-fat diets. In our population, the Mediterranean diet group achieved a high level of adherence in the short term which was maintained in the long term.
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Dieta con Restricción de Grasas , Dieta Mediterránea , Ingestión de Alimentos , Ingestión de Energía , Conducta Alimentaria , HumanosRESUMEN
Introduction: Potent platelet inhibition reduces the risk of thrombotic complications including myocardial infarction and death in patients with acute coronary syndrome (ACS). Targeting different pathways involved in thrombotic processes have synergistic effects and more effectively counteract thrombosis both in the acute and long-term following an ACS. Unavoidably, more potent platelet inhibition increases the risk of bleeding. In light of the adverse prognostic implications associated with bleeding, including increased mortality, safety aspects with antiplatelet therapy have gained increased importance.Areas covered: This review aims at describing the safety of different antiplatelet agents, particularly with regards to the risk of bleeding complications, used in the management of ACS patients. New bleeding reduction strategies to enhance the safety of antiplatelet therapy are also reviewed.Expert opinion: The final goal of a well-structured antiplatelet treatment strategy is that of tackling the spectrum of ischemic risk without compromising patient safety. A simple mnemonic rule for guiding therapeutic decisions in this complex clinical scenario can be summarized with the acronym 'ABC', meaning the sequential process of assessing, balancing and customizing treatment strategies in individual patients on the tradeoff between bleeding and ischemic risk. This approach is recommended for maximizing the ischemic benefits, while preserving safety, with the use of antiplatelet therapy.
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Síndrome Coronario Agudo/tratamiento farmacológico , Hemorragia/inducido químicamente , Inhibidores de Agregación Plaquetaria/efectos adversos , Síndrome Coronario Agudo/complicaciones , Hemorragia/epidemiología , Hemorragia/prevención & control , Humanos , Inhibidores de Agregación Plaquetaria/administración & dosificación , Trombosis/etiología , Trombosis/prevención & controlRESUMEN
BACKGROUND: Drug treatment for secondary prevention of cardiovascular disease is recommended by guidelines, but it is not always followed in real life. This study wanted to assess the size of this gap and its impact on mortality in subjects after a cardiovascular event (MACE). METHODS: Patients with any of MACE in the period from January 1st 2011 to December 31st 2013, and more than one year of follow-up were selected from population of the Valencian Community. Drugs for secondary prevention were antiplatelets, renin-angiotensin system blockers and statins. Assessment of treatment was performed one year after the initial event. Mortality risk was assessed using Cox by the number of drug classes (G0 no medication, G1 one, G2 two and G3 three drugs) adjusted by confounders. RESULTS: A total of 92,436 patients (62% men, mean age 72â¯years) of whom 60.5% presented with stroke, 30.6% with myocardial infarction and 8.9% with revascularization were included. Among them, 4.1% were G0, 20.2% G1, 32.9% G2 and 42.7% G3. A progressive decrease in mortality was observed in G1 (HR 0.83, CI 95% 0.73-0.95), G2 (HR 0.70, CI 95% 0.60-0.82) and G3 (HR 0.61, CI95% 0.51-0.74) vs. G0. In diabetic subgroup, significant reduction of risk was observed in the G2 (0.79, CI 95% 0.63-0.98) and G3 (0.72, CI9 5% 0.56-0.95), but not in G1 (0.97, CI 95% 0.80-1.17). CONCLUSION: A gap between guidelines and reality in the use of cardiovascular protecting drugs one year after the initial event still exists and it is largely related with all-cause late mortality.
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Antagonistas de Receptores de Angiotensina/uso terapéutico , Inhibidores de la Enzima Convertidora de Angiotensina/uso terapéutico , Inhibidores de Hidroximetilglutaril-CoA Reductasas/uso terapéutico , Infarto del Miocardio , Inhibidores de Agregación Plaquetaria/uso terapéutico , Accidente Cerebrovascular , Anciano , Femenino , Humanos , Masculino , Administración del Tratamiento Farmacológico/normas , Administración del Tratamiento Farmacológico/estadística & datos numéricos , Infarto del Miocardio/mortalidad , Infarto del Miocardio/prevención & control , Brechas de la Práctica Profesional , Medición de Riesgo/métodos , Prevención Secundaria/métodos , España/epidemiología , Accidente Cerebrovascular/mortalidad , Accidente Cerebrovascular/prevención & control , Análisis de SupervivenciaRESUMEN
PURPOSE OF REVIEW: Stable and unstable ischemic heart disease are a growing component in all facets of healthcare, including ER visits, hospitalizations, and financial costs. With the changing emphasis of healthcare shifting towards the outpatient setting, the onus is on clinicians to appropriately manage such patients to avoid adverse effects and complications. Antithrombotic medications, including aspirin, P2Y12 inhibitors, and rivaroxaban, are currently prescribed or have potential roles in the management of secondary cardiovascular prevention in ischemic heart disease patients. While the majority of studies and findings involve aspirin and clopidogrel, newer oral anticoagulation drugs are arriving, prompting new research to assess their impact on preventing mortality, myocardial infarction, and stroke in such patients. RECENT FINDINGS: Aspirin has a well-established history of safety and efficacy in management of secondary cardiovascular protection in ischemic heart disease patients. A dual-antiplatelet regimen, most commonly including aspirin plus clopidogrel, has been documented to be effective as well in achieving the same goals. Newer agents, such as rivaroxaban, are being analyzed to see if there is scope to include these agents for secondary prevention. One recent study, the COMPASS trial, revealed the major concern of these newer medications: while better cardiovascular outcomes were achieved in subjects on aspirin plus rivaroxaban, this was accomplished in the setting of a higher rate of major bleeding events. In conclusion, the evidence thus far has not been significant enough for the American College of Cardiology to recommend the incorporation of oral anticoagulants in the management of stable ischemic heart disease patients, in contrast to aspirin and clopidogrel. As the antithrombotic and antiischemic properties of these newer agents seem evident, so does their potential for increase in risk of bleeding events. Doctors have to individually tailor antithrombotic medication decisions based on the patient's risk-benefit profile.
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Aspirina/administración & dosificación , Enfermedades Cardiovasculares/tratamiento farmacológico , Clopidogrel/administración & dosificación , Fibrinolíticos/administración & dosificación , Inhibidores de Agregación Plaquetaria/administración & dosificación , Rivaroxabán/administración & dosificación , Prevención Secundaria , Aspirina/uso terapéutico , Enfermedades Cardiovasculares/prevención & control , Quimioterapia Combinada , Fibrinolíticos/uso terapéutico , Humanos , Inhibidores de Agregación Plaquetaria/uso terapéutico , Rivaroxabán/uso terapéuticoRESUMEN
BACKGROUND: Despite the well-established benefits of secondary cardiovascular prevention, the importance of concurrent medical therapy in clinical trials of coronary revascularization is often overlooked. OBJECTIVES: The goal of this study was to assess compliance with guideline-directed medical therapy (GDMT) in clinical trials and its potential impact on the comparison between percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG). METHODS: The Cochrane Central Register of Controlled Trials and MEDLINE were searched from 2005 to August 2017. Clinical trial registries and reference lists of relevant studies were also searched. Randomized controlled trials comparing PCI with drug-eluting stents versus CABG and reporting medical therapy after revascularization were included. The study outcome was compliance with GDMT, defined as the following: 1) any antiplatelet agent plus beta-blocker plus statin (GDMT1); and 2) any antiplatelet agent plus beta-blocker plus statin plus angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (GDMT2). Data collection and analysis were performed according to the methodological recommendations of The Cochrane Collaboration. RESULTS: From a total of 439 references, 5 trials were included based on our inclusion and exclusion criteria. Overall, compliance with GDMT1 was low and decreased over time from 67% at 1 year to 53% at 5 years. Compliance with GDMT2 was even lower and decreased from 40% at 1 year to 38% at 5 years. Compliance with both GDMT1 and GDMT2 was higher in PCI than in CABG at all time points. Meta-regression suggested an association between lower use of GDMT1 and adverse clinical outcomes in PCI versus CABG at 5 years. CONCLUSIONS: Compliance with GDMT in contemporary clinical trials remains suboptimal and is significantly lower after CABG than after PCI, which may influence the comparison of clinical trial endpoints between those study groups.
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Puente de Arteria Coronaria/normas , Enfermedad de la Arteria Coronaria/cirugía , Intervención Coronaria Percutánea/normas , Guías de Práctica Clínica como Asunto/normas , Ensayos Clínicos como Asunto/métodos , Enfermedad de la Arteria Coronaria/diagnóstico , Humanos , Resultado del TratamientoRESUMEN
Background High levels of serum uric acid have been associated with adverse outcomes in cardiovascular diseases such as myocardial infarction and heart failure. The aim of the current study was to evaluate the prognostic role of serum uric acid levels in patients undergoing cardiac rehabilitation after myocardial revascularization and/or cardiac valve surgery. Design We performed an observational prospective cohort study. Methods The study included 1440 patients with available serum uric acid levels, prospectively followed for 50 ± 17 months. Mean age was 67 ± 11 years; 781 patients (54%) underwent myocardial revascularization, 474 (33%) cardiac valve surgery and 185 (13%) valve-plus-coronary artery by-pass graft surgery. The primary endpoints were overall and cardiovascular mortality while secondary end-points were combined major adverse cardiac and cerebrovascular events. Results Serum uric acid level mean values were 286 ± 95 µmol/l and elevated serum uric acid levels (≥360 µmol/l or 6 mg/dl) were found in 275 patients (19%). Overall mortality (hazard ratio = 2.1; 95% confidence interval: 1.5-3.0; p < 0.001), cardiovascular mortality (hazard ratio = 2.0; 95% confidence interval: 1.2-3.2; p = 0.004) and major adverse cardiac and cerebrovascular events rate (hazard ratio = 1.5; 95% confidence interval: 1.0-2.0; p = 0.019) were significantly higher in patients with elevated serum uric acid levels, even after adjustment for age, gender, arterial hypertension, diabetes, glomerular filtration rate, atrial fibrillation and medical therapy. Moreover, strong positive correlations between serum uric acid level and probability of overall mortality ( p < 0.001), cardiovascular mortality ( p < 0.001) and major adverse cardiac and cerebrovascular events ( p = 0.003) were found. Conclusions Serum uric acid levels predict mortality and adverse cardiovascular outcome in patients undergoing myocardial revascularization and/or cardiac valve surgery even after the adjustment for age, gender, arterial hypertension, diabetes, glomerular filtration rate and medical therapy.
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Puente de Arteria Coronaria/efectos adversos , Enfermedad de la Arteria Coronaria/cirugía , Enfermedades de las Válvulas Cardíacas/cirugía , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Hiperuricemia/sangre , Complicaciones Posoperatorias/epidemiología , Ácido Úrico/sangre , Factores de Edad , Anciano , Biomarcadores/sangre , Rehabilitación Cardiaca , Comorbilidad , Puente de Arteria Coronaria/mortalidad , Puente de Arteria Coronaria/rehabilitación , Enfermedad de la Arteria Coronaria/diagnóstico , Enfermedad de la Arteria Coronaria/mortalidad , Femenino , Enfermedades de las Válvulas Cardíacas/diagnóstico , Enfermedades de las Válvulas Cardíacas/mortalidad , Implantación de Prótesis de Válvulas Cardíacas/mortalidad , Implantación de Prótesis de Válvulas Cardíacas/rehabilitación , Humanos , Hiperuricemia/diagnóstico , Hiperuricemia/mortalidad , Italia/epidemiología , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/diagnóstico , Complicaciones Posoperatorias/mortalidad , Estudios Prospectivos , Sistema de Registros , Medición de Riesgo , Factores de Riesgo , Factores Sexuales , Factores de Tiempo , Resultado del TratamientoRESUMEN
Secondary cardiovascular prevention strategies. Patients with a documented peripheral or coronary artery disease, subclinical atheroma, diabetes associated with target organ damage or a major risk factor or severe kidney failure have a risk of cardiovascular death above 10% in the next 10 years. They all should be helped to adopt a healthier life style and be prescribed a targeted polytherapy. Unless intolerant or contraindicated, an antiplatelet agent, a statin (whatever may be the initial LDL-cholesterol level) and a renin-angiotensin blocker should be prescribed for all patients. Especially important, a LDL-cholesterol target below 1.8 mM/l (70 mg/dl) or reduced by at least 50% of the initial level should be obtained. Significant other changes have recently occurred in the European guidelines, which are summarized in this article.
Stratégies de prévention cardiovasculaire secondaire. Les sujets ayant une maladie artérielle prouvée (quel que soit le territoire impliqué), une athérosclérose infraclinique, un diabète avec l'atteinte d'un organe cible ou au moins un facteur de risque associé ou une insuffisance rénale sévère ont un risque évolutif d'événements cardiovasculaires graves supérieur 10 % à 10 ans et relèvent d'une prévention dite secondaire. Celle-ci repose toujours à la fois sur une incitation à modifier le style de vie et sur une polythérapie médicamenteuse ciblée. Sauf contre-indication ou intolérance, un antiagrégant, une statine (quel que soit le niveau de départ du cholestérol lié aux lipoprotéines de basse densité [LDLcholestérol]) et un bloqueur du système rénine-angiotensine (inhibiteur de l'enzyme de conversion de l'angiotensine [IEC] en première intention, bloqueur des récepteurs de l'angiotensine II [ARA II] en cas d'intolérance) sont la prescription de base. L'objectif de baisse du LDLcholestérol est d'obtenir un taux inférieur à 0,7 g/L (1,8 mmol/L) ou une baisse de plus de 50 % du LDL-cholestérol initial. Des changements significatifs d'autres recommandations sont intervenus depuis 2016, qui sont décrits dans cet article.
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Enfermedades Cardiovasculares , Enfermedad de la Arteria Coronaria , Inhibidores de Hidroximetilglutaril-CoA Reductasas , Enfermedades Cardiovasculares/prevención & control , LDL-Colesterol , Humanos , Inhibidores de Hidroximetilglutaril-CoA Reductasas/uso terapéutico , Factores de Riesgo , Prevención SecundariaRESUMEN
Helping patients to engage in health care. Engaging in health care, be it preventive care, is a tough challenge for both patients and health care providers. Being threatened by the irruption of a chronic disease, or even by a hazard for his own health, every individual is seeking for a bearable daily living and tries to recover some autonomy and power upon his life. This long-standing process is actually a permanent endeavour to reconfigure beliefs and values, rebuild a new identity and learn how to cope with uncertainties. The role for all health care providers is to facilitate this complex process, using appropriate communication skills and pedagogic knowledge that we discuss in this article.
Repères conceptuels et pratiques pour faciliter l'engagement d'un patient dans ses soins. L'engagement d'un patient dans ses soins, fussent-ils des actions de prévention, est un enjeu et un défi pour tout patient comme pour tout soignant. Menacé par l'annonce d'une maladie chronique (ou même seulement d'un risque pour sa santé), un individu cherche à préserver une existence supportable, à retrouver une capacité à décider pour soi pour reprendre du pouvoir sur sa vie. Ce processus est un travail sur soi, qui passe à la fois par une reconfiguration des croyances et valeurs, une reconstruction de l'identité et des apprentissages nouveaux. Le rôle du soignant est de faciliter ce travail, par une communication et une pédagogie appropriées que nous détaillons dans cet article.
Asunto(s)
Participación del Paciente , Atención a la Salud , HumanosRESUMEN
BACKGROUND: The value of cardiac rehabilitation (CR) after a transient ischaemic attack (TIA) or minor stroke is untested despite these conditions sharing similar pathology and risk factors to coronary heart disease. We aimed to evaluate the feasibility of conducting a trial of an adapted home-based CR programme, 'The Healthy Brain Rehabilitation Manual', for patients following a TIA/minor stroke, participants' views on the intervention and, to identify the behaviour change techniques (BCTs) used. METHODS: Clinicians were asked to identify patients attending the Ulster Hospital, Belfast within 4 weeks of a first TIA or minor stroke. Those who agreed to participate underwent assessments of physical fitness, cardiovascular risk, quality of life and mental health, before random allocation to: Group (1) standard/usual care; (2) rehabilitation manual or (3) manual plus pedometer. All participants received telephone support at 1 and 4 weeks, reassessment at 6 weeks and an invitation to a focus group exploring views regarding the study. Two trained review authors independently assessed the manual to identify the BCTs used. RESULTS: Twenty-eight patients were invited to participate, with 15 (10 men, 5 women; 9 TIA, 6 minor stroke; mean age 69 years) consenting and completing the study. Mean time to enrolment from the TIA/stroke was 20.5 days. Participants completed all assessment measures except VO2max testing, which all declined. The manual and telephone contact were viewed positively, as credible sources of advice. Pedometers were valued highly, particularly for goal-setting. Overall, 36 individual BCTs were used, the commonest being centred around setting goals and planning as well as social support. CONCLUSION: Recruitment and retention rates suggest that a trial to evaluate the effectiveness of a novel home-based CR programme, implemented within 4 weeks of a first TIA/minor stroke is feasible. The commonest BCTs used within the manual revolve around goals, planning and social support, in keeping with UK national guidelines. The findings from this feasibility work have been used to further refine the next stage of the intervention's development, a pilot study. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02712385 . This study was registered prospectively on 18/03/2016.