Cardiovascular news 2013/2014 | Revista Clínica Española

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Cuende, C. Lahoz, P. Armario, J. García-Alegría, J. Ena, G. García de Casasola, J.M. Mostaza" "autores" => array:7 [ 0 => array:3 [ "nombre" => "J.I." "apellidos" => "Cuende" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 1 => array:3 [ "nombre" => "C." "apellidos" => "Lahoz" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "P." "apellidos" => "Armario" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "c" "identificador" => "aff0015" ] ] ] 3 => array:3 [ "nombre" => "J." "apellidos" => "García-Alegría" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "d" "identificador" => "aff0020" ] ] ] 4 => array:3 [ "nombre" => "J." "apellidos" => "Ena" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "e" "identificador" => "aff0025" ] ] ] 5 => array:3 [ "nombre" => "G. 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"apellidos" => "Mostaza" "email" => array:1 [ 0 => "jmostaza.hciii@salud.madrid.org" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:6 [ 0 => array:3 [ "entidad" => "Servicio de Medicina Interna, Complejo Asistencial Universitario de Palencia, Palencia, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Medicina Interna, Hospital Carlos III, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Medicina Interna, Hospital Transversal (Moisès Broggi, Hospital General de l’Hospitalet), Consorci Sanitari Integral, Barcelona, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Servicio de Medicina Interna, Hospital Costa del Sol, Marbella, Málaga, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Servicio de Medicina Interna, Hospital Marina Baixa, Villajoyosa, Alicante, Spain" "etiqueta" => "e" "identificador" => "aff0025" ] 5 => array:3 [ "entidad" => "Servicio de Medicina Interna, Hospital Infanta Cristina, Parla, Madrid, Spain" "etiqueta" => "f" "identificador" => "aff0030" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Novedades cardiovasculares 2013/2014" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "Source: Perk et al.<a class="elsevierStyleCrossRef" href="#bib0075">15</a>" "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1596 "Ancho" => 1470 "Tamanyo" => 61955 ] ] "descripcion" => array:1 [ "en" => "Change in cardiovascular risk after 12 months according to intervention group." ] ] ] "textoCompleto" => "In recent decades, we have witnessed a progressive reduction in cardiovascular mortality in developed countries. Coronary mortality in Spain from 1988 to 2005 declined by 40%<a class="elsevierStyleCrossRef" href="#bib0005">1</a> as the result of a populational reduction in cardiovascular risk factors, better prevention and better treatment of already established disease. The reduction in cardiovascular mortality has contributed the most to increasing the life expectancy in industrialized countries in general and in Spain in particular.<a class="elsevierStyleCrossRef" href="#bib0010">2</a> The reduction is the result of continuous developments in this area, mainly those related to primary and secondary prevention of the disease. Keeping abreast of these developments requires health professionals to continuously update their knowledge and skills, which is one of the commitments of the Cardiovascular Risk Workgroup of the Spanish Society of Internal Medicine. Every year<a class="elsevierStyleCrossRefs" href="#bib0015">3,4</a> the Group meeting reserves a round table to conduct an update on issues of cardiovascular risk. In this article, we present the lectures from the meeting held on May 2014 in Alicante.Risk guidelines (Dr. José Ignacio Cuende)Last year, several publications emerged in the field of cardiovascular risk assessment that merit discussion. The new American treatment guidelines for blood cholesterol<a class="elsevierStyleCrossRef" href="#bib0025">5</a> have undoubtedly sparked an interesting debate. These guidelines, sponsored by the American Heart Association and the American College of Cardiology, base their recommendations on the strict reading of clinical trials, recommendations on which not all of the scientific community agree. These guidelines were published simultaneously with the guidelines for the quantification of cardiovascular risk,<a class="elsevierStyleCrossRef" href="#bib0030">6</a> lifestyle management<a class="elsevierStyleCrossRef" href="#bib0035">7</a> and excess weight and obesity control in adults.<a class="elsevierStyleCrossRef" href="#bib0040">8</a> They were published shortly after the guidelines of the International Atherosclerosis Society<a class="elsevierStyleCrossRef" href="#bib0045">9</a> and 2 years after the European Guidelines for the Management of Dyslipidemia.<a class="elsevierStyleCrossRef" href="#bib0050">10</a> The American guidelines for managing cholesterol use a new cardiovascular risk assessment scale presented in the risk quantification guidelines.<a class="elsevierStyleCrossRef" href="#bib0035">7</a> These guidelines establish a new equation for measuring atherosclerotic cardiovascular risk based on pooled data from several American cohort studies (Framingham, ARIC, CARDIA, etc.), creating a pooled cohort, measuring the risk of cardiovascular morbidity and mortality at 10 years and establishing a cutoff of 7.5% as an indicator of high risk. The guidelines consider the white non-Hispanic and black African-American races, as well as the variables of sex, age (40–79 years), diabetes, smoking, systolic blood pressure (BP), treatment for BP, total cholesterol and HDL-cholesterol.The guidelines also answer clinical questions about the usefulness of other risk factors and markers and the use of lifelong risk. If there are questions about patient management based on measured risk, we can consider the patient's family history of early cardiovascular events, ultrasensitive C-reactive protein levels and the quantification of coronary calcium and the ankle-brachial index. The routine quantification of the intima-media thickness is not recommended. The guidelines establish that there is no clear evidence compared with other markers such as apoB, renal function, microalbuminuria and cardiopulmonary condition. Moreover, if a patient of between 20 and 59 years of age is not determined to be high risk with the new scale, we can apply the risk quantification at 30 years or throughout life with the educational intention of changing lifestyles and promoting adherence to medical advice but not as a guideline for clinical decision making.After the publication of the American guidelines on risk quantification and cholesterol treatment, two articles were published that concluded that the new risk equation has a lower diagnostic performance (measured by the area under the ROC curve) in Europe than the SCORE system.<a class="elsevierStyleCrossRef" href="#bib0055">11</a> The American guidelines overestimated risk and indicated statins at a much higher rate than the European guidelines (approximately double, but especially in younger participants),<a class="elsevierStyleCrossRef" href="#bib0060">12</a> with a consequent increase in initial healthcare drug expenditure.Another topic of interest is vascular age. In 2008, the concept of calculated vascular age was published with the new risk equation derived from the Framingham study.<a class="elsevierStyleCrossRef" href="#bib0065">13</a> In 2010, the table of vascular age derived from SCORE was published,<a class="elsevierStyleCrossRef" href="#bib0070">14</a> and in 2012 the European Guidelines for Cardiovascular Prevention<a class="elsevierStyleCrossRef" href="#bib0065">13</a> were published, which included a key message in the strategy for managing and calculating risk: the concept of vascular age derived from SCORE<a class="elsevierStyleCrossRef" href="#bib0075">15</a> and the relative risk (RR) as methods for helping communicate the need for lifestyle changes to the youth. It had been previously demonstrated that informing patients of their vascular age enables them to be more aware of their risk condition than by telling them their absolute risk.<a class="elsevierStyleCrossRef" href="#bib0080">16</a> In this context, there was a lack of clinical trials that demonstrated that the use of vascular age enabled better control of cardiovascular risk factors. A randomized, unblinded clinical trial<a class="elsevierStyleCrossRef" href="#bib0085">17</a> with 3000 participants (health professionals) in primary prevention was published in 2014, which divided the participants into three groups: control group, group informed of their absolute risk using REGICOR and a group informed of their vascular age calculated using the Framingham scale. The analyzed variables were weight, abdominal circumference, body mass index, systolic and diastolic BP, glycemia, total cholesterol, HDL-cholesterol, triglyceride levels, physical activity and smoking, which were assessed at the start and after a 12-month follow-up. The control group worsened in all variables except physical exercise. The group informed of their absolute risk improved in all variables. The group informed of their vascular age improved in all variables and improved in all of them more than the group informed of their absolute risk. There were statistically significant differences in all variables, showing that informing participants of their vascular age had a greater impact on the management of patients than reporting the cardiovascular risk or not reporting the risk condition (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).<elsevierMultimedia ident="fig0005"></elsevierMultimedia>Lipids (Dr. Carlos Lahoz)New 2013 American College of Cardiology/American Heart Association guidelines on the treatment of hypercholesterolemiaThe new 2013 guidelines of the American College of Cardiology/American Heart Association<a class="elsevierStyleCrossRef" href="#bib0025">5</a> broke the dominant paradigm at the time (the therapeutic objectives of LDL-cholesterol), focusing on cardiovascular risk prevention with statin treatment.The guidelines describe 4 groups of patients who benefit from statin treatment: patients with cardiovascular disease, patients with LDL-cholesterol levels ≥190mg/dL, patients with diabetes and patients between the ages of 40 and 75 who have no cardiovascular disease or diabetes and have a calculated risk of atherosclerotic cardiovascular disease >7.5% at 10 year. Furthermore, the guidelines classify statins according to their potency in reducing LDL-cholesterol: high >50%, medium 30–50% and low <30%. The management of patients according to the new guidelines is diagramed in <a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>.<elsevierMultimedia ident="fig0010"></elsevierMultimedia>The new guidelines are based on solid evidence (clinical trials) and are focused on the patient, who is consulted before starting multiple-step lipid-lowering treatment. The guidelines are simple, easy to use and do not require a mixture of hypolipidemic agents. They are focused on reducing cardiovascular risk and not on the diagnosis and management of dyslipidemia. They are accompanied by a new risk equation that calculates the risk at 10 years and the lifetime risk of experiencing a cardiovascular event.The guidelines’ drawbacks include the disappearance of the LDL-cholesterol therapeutic objectives, after more than 10 years of educating patients on this topic. They relegate the use of other nonstatin hypolipidemic agents for patients who are intolerant or hyporesponsive, given that there are no studies that have shown that they decrease cardiovascular morbidity and mortality.The combination of statins and ezetimibe: waiting for IMPROVE-ITWhile waiting for the results of the IMPROVE-IT<a class="elsevierStyleCrossRef" href="#bib0090">18</a> trial that investigates whether the combination of simvastatin and ezetimibe is better than simvastatin alone in terms of cardiovascular morbidity and mortality, two studies have been published on this combination with conflicting results.The first is a study with the results of the HPS-2.<a class="elsevierStyleCrossRef" href="#bib0095">19</a> This trial included high-risk patients who, before starting, had LDL-cholesterol levels <70mg/dL. To this end, approximately half of the participants took simvastatin 40mg/day and the other half took simvastatin combined with ezetimibe. Once the LDL-cholesterol levels fell below 70mg/dL, the patients were randomized to take niacin with laropiprant or placebo. At the end of the trial, there were no differences in the rate of cardiovascular complications between the 2 groups. However, if the rate of cardiovascular events is compared according to those who took statins alone or combined with ezetimibe, we find that the rate was significantly lower in those who took the combination, regardless of whether they took placebo or niacin. These results should be viewed with caution, given that the study was a posteriori and not adjusted.<a class="elsevierStyleCrossRef" href="#bib0095">19</a>The other study was a retrospective registry of 9500 patients who had experienced an acute myocardial infarction (AMI).<a class="elsevierStyleCrossRef" href="#bib0100">20</a> The mean follow-up was 3.2 years. The participants who took only simvastatin were considered the control group. Those who took the combination had a nonsignificant reduction in mortality. Lastly, those treated with high potency statins presented a significant reduction in mortality of 33% compared with the control group (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). These results should also be taken with prudence, given that the study was observational and retrospective.<elsevierMultimedia ident="fig0015"></elsevierMultimedia>Anti-PCSK-9: adequate progressThere are currently 2 anti-PCSK-9 antibodies in advanced phases of development, alirocumab of Sanofi and evolocumab of Amgen, which are in phase 3 studies. The results of several clinical trials with these drugs have been published this year. In one of these trials (which had more than 300 participants with statin intolerance for myalgia), the monoclonal antibody injected every 2 or 4 weeks achieved LDL-cholesterol reductions of 55% compared with 17–19% for patients treated with ezetimibe. The patients treated with the antibody also had a lower percentage of myalgia than those treated with ezemtimibe (8% versus 18%, respectively).<a class="elsevierStyleCrossRef" href="#bib0105">21</a> In another study, patients treated with different hypolipidemic agent regimens underwent monthly injections of evolocumab. After a year, the mean reduction in LDL-cholesterol was 57%, with no relevant adverse effects.<a class="elsevierStyleCrossRef" href="#bib0110">22</a>Statins, caloric intake and weightIn a recent study with more than 27,000 participants representing the general population of the United States, the change in caloric intake, fat consumption and weight from 1999 to 2010 were assessed.<a class="elsevierStyleCrossRef" href="#bib0115">23</a> By dividing the population according to the consumption or not of statins, it was observed that over time those treated with statins progressively increased their caloric intake, while those that did not take the drug maintained a slight trend toward decreased intake. At 10 years of follow-up, the participants treated with statins had increased their caloric intake by almost 10%, their fat consumption by 14% and their BMI by an average of 1.3kg/m2 (approximately 3–5kg). Therefore, patients treated with statins should be strongly advised not to neglect their diet.Arterial hypertension (P. Armario)This review covers the main articles published in 2013 and the first quarter of 2014, which include the publication of the guidelines of the European Society of Hypertension and the European Society of Cardiology.<a class="elsevierStyleCrossRef" href="#bib0120">24</a> The recently published Eighth Report of the Joint National Committee<a class="elsevierStyleCrossRef" href="#bib0125">25</a> will not be commented on as it falls outside the purview of this brief review.Renovascular hypertensionRenovascular hypertension (RVHT) is one of the prototypes of secondary hypertension, affecting 1–5% of the population with hypertension. Previous traditional uncontrolled studies have shown that treatment using angioplasty with stent placement results in a significant reduction in systolic BP. The CORAL study,<a class="elsevierStyleCrossRef" href="#bib0130">26</a> a multicenter, controlled, open clinical trial with randomization to medical treatment only or medical treatment and stent placement, found no significant differences in the prevention of clinical events in the group with stent placement, compared with multifactorial medical treatment. It should be noted, however, that the incidence of events was lower than expected in both groups, highlighting the importance of implementing multifactorial treatment with optimal management of risk factors.Salt and arterial hypertensionThe relationship between the dietary intake of sodium and various health indicators has been investigated in numerous observational studies and randomized clinical trials. To achieve an effective reduction in sodium intake, it is not enough to reduce the amount of salt in the preparation of food or withdraw the saltshaker; the quantity of sodium in processed foods needs to be reduced. Healthcare and industry must therefore collaborate for the benefit to be reflected in the general population. Although this is not easy, it is possible, as has been observed in recent years in the United Kingdom, as shown by the study referenced here. He et al.<a class="elsevierStyleCrossRef" href="#bib0135">27</a> have shown how, by reducing the salt content in processed food, a 15% reduction in 24-h urinary sodium excretion was achieved over 7 years.Treatment of arterial hypertensionIn the section on treatment, we can include three articles published last year. In the first article, Lapi et al.<a class="elsevierStyleCrossRef" href="#bib0140">28</a> conducted a case–control study with an extensive cohort of 487,372 patients with antihypertensive medication, followed-up for a mean period of 5.9 years (SD, 3.4). The authors observed that triple therapy with diuretics, renin-angiotensin system inhibitors and nonsteroidal anti-inflammatory drugs was associated with a 31% greater risk of acute kidney damage over the course of the follow-up, with the period of maximum risk occurring during the first 30 days from the start of this therapeutic combination (hazard ratio [HR], 1.82; 95% confidence interval [95% CI] 1.35–2.46).The second article is the meta-analysis published by the Blood Pressure Lowering Treatment Trialists’ Collaboration,<a class="elsevierStyleCrossRef" href="#bib0145">29</a> whose objective was to analyze the cardiovascular effects of reducing BP in participants with and without chronic kidney disease. Compared with placebo, lowering BP produced fewer major cardiovascular complications, with no significant differences between the 2 groups. Although the effect was similar, the absolute benefit was greater for the participants with chronic kidney disease, given that this had a higher risk.The third article was a meta-analysis of the clinical consequences of lack of adherence to cardiovascular therapy.<a class="elsevierStyleCrossRef" href="#bib0150">30</a> The study confirmed a high prevalence of noncompliance with various cardiovascular drug regimens, finding a significant reduction in the incidence of cardiovascular disease and total mortality in the group with good adherence, especially with the use of statins and antihypertensive drugs.Antihypertensive treatment and secondary prevention of strokeAHT is the most prevalent and significant modifiable risk factor for stroke, in atherothrombotic stroke and especially in stroke associated with small vessel disease (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). Based on currently available evidence, the therapeutic goal currently recommended by the new guidelines for patients who have experienced an ischemic stroke is to reduce the BP below 1490/90mm Hg, although a number of authors advocate a greater reduction in BP.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>The SPS3 clinical trial<a class="elsevierStyleCrossRef" href="#bib0155">31</a> included patients who had experienced a recent, symptomatic lacunar stroke, confirmed by magnetic resonance imaging. One group was assigned a therapeutic systolic BP goal of between 130 and 149mm Hg and another to a systolic BP goal of <130mm Hg. After 1 year, the mean systolic BP was 138mm Hg (95% CI 137–139) in the first group and 127mm Hg (95% CI 126–128mm Hg) in the second. In the second group, a reduction in the primary objective was observed (the total number of ischemic and hemorrhagic strokes). Nevertheless, it should be noted that the difference was not significant (p=.08) and that the results cannot be extrapolated to other patients who have experienced atherothrombotic strokes with greater functional involvement. New data are therefore required before we can modify the recommendations of the current guidelines concerning the optimal therapeutic goal for the secondary prevention of stroke.Resistant or refractory arterial hypertensionIn this section, we highlight two articles, one concerning a new proposed definition of refractory AHT, differentiated from resistant AHT<a class="elsevierStyleCrossRef" href="#bib0160">32</a> and the second concerning the results of the SYMPLICITY HTN-3 study.<a class="elsevierStyleCrossRef" href="#bib0165">33</a>In the first article, Calhoun et al.<a class="elsevierStyleCrossRef" href="#bib0160">32</a> authors of the 2008 consensus document who proposed the classical definition of resistant AHT based on data from the REGARDS study, propose identifying a subgroup to be known as refractory AHT. This group is composed of patients with uncontrolled hypertension despite following a therapeutic regimen with 5 or more antihypertensive drugs. The authors show that the prevalence of this new subgroup of patients with hypertension that is uncontrolled with 5 or more drugs is very low: 0.5% of the total number of patients treated for hypertension and 3.6% of participants with resistant AHT.The SYMPLICITY HTN-1 and 2 study and other previous studies on renal sympathetic denervation in the management of patients with resistant AHT had provided encouraging results, although they were uncontrolled studies. The SYMPLICITY HTN-3 study<a class="elsevierStyleCrossRef" href="#bib0165">33</a> was designed as a prospective, multicenter trial with a sham control group. Its main objective was to reduce 24-h systolic BP at 6 months, and its secondary objective was the safety of the intervention. There were no significant differences in the reduction in 24-h systolic BP between the 2 groups, in contrast to the expectations raised by the results of previous studies, although the technique was confirmed to be safe.Antivitamin K and antiplatelet drugs (Dr. Javier García Alegría)There have been several noteworthy articles regarding the use of antivitamin K (VKA). Various genetic variants determine the metabolization of these drugs. It has been proposed that the pharmacogenomics could reduce variability in the management of anticoagulation. An issue of the New England Journal of Medicine included three original articles that addressed this problem. The first of these,<a class="elsevierStyleCrossRef" href="#bib0170">34</a> a multicenter study on patients with venous thrombosis or atrial fibrillation (AF), used a test to determine various genotypes, in which a warfarin regimen was employed using a predetermined algorithm versus a control group. The primary objective was the therapeutic time in range over 12 weeks, which, in the genotype-guided group, was 67.4% compared with 60.3% in the control group (adjusted difference, 7.0%; p<.001). The pharmacogenetic adjusted dosage was therefore significantly better. However, in the other 2 studies,<a class="elsevierStyleCrossRefs" href="#bib0175">35,36</a> which had a similar design and more patients, there were no differences between the 2 strategies. To complete this information, a recent meta-analysis<a class="elsevierStyleCrossRef" href="#bib0185">37</a> of 9 trials of warfarin treatment guided by genotype showed a difference in the therapeutic time in range of 0.14% (p=.25). This strategy therefore offered no clinical benefit.Warfarin-associated nephropathy (WAN) is a recently recognized condition in which excess anticoagulation (INR>3.0) induces an acute renal lesion with no evidence of clinically relevant hemorrhaging, which is attributed to intratubular bleeding. A retrospective Korean study<a class="elsevierStyleCrossRef" href="#bib0190">38</a> attempted to establish the incidence of WAN and its prognostic implication. The study analyzed data from 1297 patients who had a baseline creatinine reading one week after an INR>3. The WAN criteria were a 50% reduction in creatinine clearance or a creatinine increase >0.3mg/dL. Some 19.3% of the patients developed WAN, and the risk was greater with hypoalbuminemia and heart failure, without any relationship to the degree of renal function. The mortality at 108 weeks was higher in the WAN group. Clinicians should recognize this condition and be alert to the possibility of worsening renal function in conditions of excess anticoagulation.In the field of antiplatelet treatment, there are several relevant articles. A recent topic of debate has been optimal treatment in permanent anticoagulation and the need for a coronary stent. The WOEST study has attempted to answer this issue.<a class="elsevierStyleCrossRef" href="#bib0195">39</a> The randomized, multicenter open study attempted to establish the safety and efficacy of clopidogrel alone or combined with acetylsalicylic acid for patients who have been anticoagulated. The primary objective was to quantify any episode of hemorrhaging in the first year of implantation, with the patients assigned by intention to treat to double or triple therapy. There was bleeding in 19.4% of patients with double therapy and 44.4% with triple therapy (HR, 0.36; 95% CI 0.26–0.50; p<.0001). The requirements for transfusion were also different (3.9% versus 9.5%; odds ratio, 0.39; 95% CI 0.17–0.84; p=.011). There was no difference in the incidence of thrombotic events between the 2 groups. The authors therefore concluded that double therapy with clopidogrel is safer than triple therapy.Another method of addressing the same problem was the 2 analyses of the national Danish registry.<a class="elsevierStyleCrossRefs" href="#bib0200">40,41</a> The first of these<a class="elsevierStyleCrossRef" href="#bib0200">40</a> explored the risk of thrombosis and hemorrhaging according to the antithrombotic treatment in patients with AF, anticoagulated after an AMI and/or coronary intervention. Between 2001 and 2009, 12,165 hospitalizations were recorded for AMI and/or coronary procedures (60.7% men; mean age, 75.6 years). The risk of AMI/coronary death, ischemic stroke and hemorrhaging according to the antithrombotic regimen was calculated with a Cox regression. The main results are listed in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>. For patients with AF with an indication for multiple antithrombotic drugs after an AMI and/or coronary intervention, oral anticoagulation combined with clopidogrel was equal or superior in terms of benefits and safety than triple therapy. The other analysis<a class="elsevierStyleCrossRef" href="#bib0205">41</a> sought to determine the best antithrombosis strategy for patients with AF and stable coronary artery disease, defined after 12 months of a coronary event. It analyzed the cardiovascular events and severe bleeding, with hospitalization, of 8700 patients, with a mean follow-up of 3.3 years. The raw rates of AMI/coronary death, thromboembolism and hemorrhaging were 7.2%, 3.8% and 4%, respectively. In terms of monotherapy with VKA, the risk of AMI/coronary death with VKA plus acetylsalicylic acid was similar (HR, 1.12; 95% CI 0.94–1.34), as was the combination of VKA plus clopidogrel (HR, 1.53; 95% CI 0.93–2.52). The risk of thromboembolism was comparable in all regimens that included VKA, while the risk of bleeding increased when VKA was combined with acetylsalicylic acid (HR, 1.50; 95% CI 1.23–1.82) or clopidogrel (HR, 1.84; 95% CI 1.11–3.06). The authors concluded that the addition of antiplatelet drugs to VKA in patients with AF and stable coronary artery disease was not associated with a reduction in coronary or embolic events and increased the risk of severe bleeding. This standard practice therefore needs to be revised.<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>Diabetes mellitus (Dr. Javier Ena)In the field of diabetes, there are a number of noteworthy contributions. The Look AHEAD study<a class="elsevierStyleCrossRef" href="#bib0210">42</a> was a controlled clinical trial with 5145 patients with type 2 diabetes and excess weight and obesity that compared a strategy of lifestyle changes (150min/week of physical exercise and low-calorie diets of 1800kcal/day). The study outcomes measured at 10 years proved to be neutral in the reduction of cardiovascular events and cardiovascular mortality. The intervention was very effective during the first year in reducing weight, improving aerobic capacity and increasing insulin resistance but lacked a long-term effect. The primary outcome occurred in 403 patients in the intervention group and 418 patients in the control group (1.83 and 1.92 events per 100 person-years, respectively; RR, 0.95; 95% CI 0.83–1.09; p=.51). During the extended study time, the control group showed contamination due to co-interventions with drugs that controlled cholesterol and BP levels. The number of observed outcomes was lower than expected, and the study's power was insufficient to demonstrate significant differences in the evaluated outcomes.In contrast, a Mediterranean diet supplemented with extra virgin olive oil showed effectiveness in the general population for reducing cardiovascular events (AMI, stroke and cardiovascular death) and the onset of diabetes.<a class="elsevierStyleCrossRefs" href="#bib0215">43,44</a> The PREDIMED study was a clinical trial conducted for a mean of 4 years with 7447 individuals aged between 55 and 80 years. The study compared the efficacy of a Mediterranean diet supplemented with extra virgin olive oil or a Mediterranean diet supplemented with nuts versus a low-calorie, low-fat diet (no more than 30% of calories supplied from fat). The multivariate analysis showed a RR of 0.70 (95% CI 0.54–0.92) and 0.72 (95% CI 0.54–0.96) for the groups assigned the Mediterranean diet with extra virgin olive oil (96 events) and the Mediterranean diet supplemented with nuts (83 events), respectively, compared with the control group (109 events). A subanalysis of the study that included a total of 3541 individuals assessed the impact of different types of diet on the onset of diabetes mellitus. During the follow-up, a total of 80, 92 and 101 new cases of diabetes were recorded in participants who were treated with a Mediterranean diet supplemented with extra virgin olive oil, a Mediterranean diet supplemented with nuts and a low-calorie diet, respectively, which corresponds to a rate of 16.0, 18.7 and 23.6 cases per 1000 person-years. In other words, the relative reduction in the risk of diabetes with the Mediterranean diet supplemented with extra virgin olive oil was 67% compared to a low-fat diet.The aging of the population will cause an increase in chronic degenerative diseases, the greatest of which is the onset of dementia, which constitutes a public health problem of considerable magnitude. The association between diabetes and dementia is well known, due to glucose level disorders and the increased prevalence of vascular disease. Recently, the risk of dementia has been analyzed in relation to baseline glycemia levels in fasting conditions in a total of 2067 participants (232 with diabetes and 1835 without diabetes).<a class="elsevierStyleCrossRef" href="#bib0225">45</a> During the 6.8-year follow-up, the presence of dementia was confirmed using a cognitive skills’ screening test in a total of 524 participants (74 with diabetes and 450 without diabetes). In the participants without diabetes, a statistically significant association was observed between the onset of dementia and baseline glycemia levels in fasting conditions of 115mg/dL compared with 100mg/dL, with an RR of 1.18 (95% CI 1.04–1.33). Among the patients with diabetes, the RR of dementia when comparing baseline glycemia values of 190–160mg/dL was 1.40 (95% CI 1.12–1.76). These calculations were adjusted for age, sex, educational level, BP, presence of coronary artery disease or cerebrovascular level, AF, treatment for AHT and smoking.Two recent studies, SAVOR-TIMI 53 and EXAMINE, have helped assess the cardiovascular safety of 2 oral hypoglycemic agents that belong to the dipeptidyl-peptidase-4 inhibitor group. The SAVOR-TIMI 53<a class="elsevierStyleCrossRef" href="#bib0230">46</a> study assessed the safety of saxagliptin in a placebo-controlled, double-blind, noninferiority trial with a total of 16,492 patients with type 2 diabetes mellitus and high cardiovascular risk. The primary study outcome, which was a composite of cardiovascular death, stroke and coronary events, occurred in 613 patients of the saxagliptin group and 609 patients in the placebo group (7.3% and 7.2%, respectively; RR, 1.00; 95% CI 0.89–1.12). Although the number of hospitalizations for heart failure was statistically higher in the saxagliptin group than in the placebo group (3.5% versus 2.8%; RR, 1.27; 95% CI 1.07–1.51; p=.007), the absolute increase in risk (0.7%) was very low. Overall, the patients treated with saxagliptin had statistically significant reductions in glycemia values under fasting conditions and in glycated hemoglobin levels, although with low absolute values.Alogliptin, another dipeptidyl-peptidase-4 inhibitor, was subjected to cardiovascular safety assessment as required by the regulatory agencies.<a class="elsevierStyleCrossRef" href="#bib0235">47</a> The EXAMINE study was a noninferiority clinical trial of alogliptin compared with placebo in 5380 patients with acute coronary syndrome. The study assessed an outcome composed of cardiovascular death, stroke and AMI during a 40-month follow-up. Alogliptin caused a 0.36% reduction in glycated hemoglobin levels in the intervention group compared with the placebo group. In terms of the primary outcome, 305 (11.3%) events occurred in the group assigned to alogliptin, and 316 (11.8%) events occurred in the placebo group (RR, 0.96; upper limit of the confidence interval 1.16), meeting the criterion of noninferiority.More recently, the ESTAMPEDE study assessed the long-term effectiveness of metabolic surgery in comparison with the intensive treatment of diabetes to achieve clinical control of the disease, defined as glycated hemoglobin levels below 6% (with or without hypoglycemic treatment) at the end of 3 years of follow-up.<a class="elsevierStyleCrossRef" href="#bib0240">48</a> A total of 150 patients with diabetes were randomized 1:1.1 to intensive medical treatment, tubular gastrectomy or jejunum-ileal Roux-en-Y bypass. The patients’ mean age was 48±8 years, their mean body mass index was 36±3.5 and 49 patients (36%) had a BMI below 35. The mean glycated hemoglobin level was 9.3±1.5%, and the mean duration of the diabetes was 8.3±5.1 years, with 43% of the patients undergoing insulin treatment. At the end of the study, 5% of the patients undergoing intensive medical treatment achieved the main objective, while 24% of the patients who underwent tubular gastrectomy (p=.01) and 38% of the patients who underwent intestinal bypass (p<.001) achieved this objective. Surgical treatment also improved other evaluated domains such as body pain, overall health, and limitations due to emotional problems, energy, emotional wellbeing, social function, physical function and limitations due to health conditions.Conflicts of interestThe authors declare that they have no conflicts of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres632907" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec645550" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres632908" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec645551" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Risk guidelines (Dr. José Ignacio Cuende)" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Lipids (Dr. Carlos Lahoz)" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "New 2013 American College of Cardiology/American Heart Association guidelines on the treatment of hypercholesterolemia" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "The combination of statins and ezetimibe: waiting for IMPROVE-IT" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Anti-PCSK-9: adequate progress" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "Statins, caloric intake and weight" ] ] ] 6 => array:3 [ "identificador" => "sec0035" "titulo" => "Arterial hypertension (P. Armario)" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0040" "titulo" => "Renovascular hypertension" ] 1 => array:2 [ "identificador" => "sec0045" "titulo" => "Salt and arterial hypertension" ] 2 => array:2 [ "identificador" => "sec0050" "titulo" => "Treatment of arterial hypertension" ] 3 => array:2 [ "identificador" => "sec0055" "titulo" => "Antihypertensive treatment and secondary prevention of stroke" ] 4 => array:2 [ "identificador" => "sec0060" "titulo" => "Resistant or refractory arterial hypertension" ] ] ] 7 => array:2 [ "identificador" => "sec0065" "titulo" => "Antivitamin K and antiplatelet drugs (Dr. Javier García Alegría)" ] 8 => array:2 [ "identificador" => "sec0070" "titulo" => "Diabetes mellitus (Dr. Javier Ena)" ] 9 => array:2 [ "identificador" => "sec0075" "titulo" => "Conflicts of interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2014-07-27" "fechaAceptado" => "2014-07-29" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec645550" "palabras" => array:10 [ 0 => "Vascular risk" 1 => "Lipids" 2 => "Diabetes" 3 => "Cholesterol" 4 => "Arterial hypertension" 5 => "Anticoagulants" 6 => "Antiplatelets" 7 => "PCSK-9" 8 => "Nicotinic acid" 9 => "Sympathetic denervation" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec645551" "palabras" => array:10 [ 0 => "Riesgo vascular" 1 => "Lípidos" 2 => "Diabetes" 3 => "Colesterol" 4 => "Hipertensión arterial" 5 => "Anticoagulantes" 6 => "Antiagregantes" 7 => "PCSK-9" 8 => "Ácido nicotínico" 9 => "Denervación simpática" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "During 2013 and the first months of 2014, numerous studies have been published in the cardiovascular field. New guidelines have appeared for managing arterial hypertension and reducing cardiovascular risk by lowering cholesterol levels. New data have emerged on the considerable lipid-lowering efficacy of monoclonal antibodies against PCSK-9, in contrast, however, to the clinical trials directed toward raising HDL-cholesterol with nicotinic acid, which have not shown a reduction in the rate of cardiovascular complications. In the field of hypertension, neither stent placement in patients with renovascular hypertension nor sympathetic denervation in patients with resistant hypertension has been shown to be effective in reducing blood pressure. In terms of antithrombotic treatment, the pharmacogenetic tests do not seem useful for maintaining patients anticoagulated with warfarin within the therapeutic range for longer periods. Moreover, there is increasing evidence that, for patients with coronary artery disease and atrial fibrillation, antiplatelet therapy adds no benefit to anticoagulation therapy and is associated with a greater risk of bleeding. Lastly, a Mediterranean diet could prevent the onset of diabetes, while bariatric surgery could be a reasonable option for improving the disease in patients with obesity. Many of these studies have immediate practice applications in daily clinical practice." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "Durante el año 2013 y los primeros meses de 2014 se han publicado numerosos estudios relevantes en el campo cardiovascular. Han aparecido nuevas guías para el manejo de la hipertensión arterial y para reducir el riesgo cardiovascular descendiendo el colesterol. También han aparecido nuevos datos sobre la gran eficacia hipolipidemiante de los anticuerpos monoclonales frente a PCSK-9, decepcionando, sin embargo, los ensayos clínicos dirigidos a elevar el colesterol-HDL con ácido nicotínico, los cuales no han demostrado una reducción de la tasa de complicaciones cardiovasculares. Tampoco en el campo de la hipertensión, la colocación de un stent en pacientes con hipertensión renovascular, o la denervación simpática en pacientes con hipertensión resistente, han demostrado ser eficaces para reducir la presión arterial. Con relación al tratamiento antitrombótico, los test farmacogenéticos no parecen útiles para mantener más tiempo en rango terapéutico a los pacientes anticoagulados con warfarina. A su vez, cada vez existen más evidencias de que en pacientes con enfermedad coronaria y fibrilación auricular, la antiagregación no añade beneficio a la anticoagulación y se asocia con un mayor riesgo de sangrado. Por último, una dieta de tipo mediterráneo podría prevenir la aparición de diabetes, mientras que la cirugía bariátrica podría ser una opción razonable para mejorar la enfermedad en pacientes obesos. Muchos de estos estudios tienen una aplicación práctica inmediata en el trabajo clínico diario." ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Cuende JI, Lahoz C, Armario P, García-Alegría J, Ena J, Casasola GGd, et al. Novedades cardiovasculares 2013/2014. Rev Clin Esp. 2015;215:33–42." ] ] "multimedia" => array:5 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "Source: Perk et al.<a class="elsevierStyleCrossRef" href="#bib0075">15</a>" "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1596 "Ancho" => 1470 "Tamanyo" => 61955 ] ] "descripcion" => array:1 [ "en" => "Change in cardiovascular risk after 12 months according to intervention group." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1881 "Ancho" => 1662 "Tamanyo" => 129051 ] ] "descripcion" => array:1 [ "en" => "Regimen for managing hypercholesterolemia according to the new 2013 guidelines by the American College of Cardiology/American Heart Association. DM, diabetes mellitus; HIS, high-intensity statins; LDL, low-density lipoproteins; MIS, moderate-intensity statins; Tx, treatment; y, years." ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "Source: Cannon et al.<a class="elsevierStyleCrossRef" href="#bib0090">18</a>" "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1275 "Ancho" => 1404 "Tamanyo" => 69213 ] ] "descripcion" => array:1 [ "en" => "Overall mortality risk (hazard ratio) according to LDL-cholesterol level reached and reduction of the same in participants treated with simvastatin (simva, control group), the combination simvastatin-ezetimibe (exetim) and high-potency statins (atorvastatin, rosuvastatin)." ] ] 3 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Hypertensive encephalopathy \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Large-artery atherothrombosis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Carotid occlusive disease \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Vertebrobasilar occlusive disease \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Small-vessel disease \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Ischemic brain lesions: lacunar infarctions \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">White matter lesion: leukoaraiosis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Cerebral microbleeds \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Prominent perivascular spaces \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Intracerebral hemorrhaging \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1038051.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Forms of cerebrovascular involvement in arterial hypertension." ] ] 4 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "Source: An et al.<a class="elsevierStyleCrossRef" href="#bib0190">38</a>" "tabla" => array:2 [ "leyenda" => "Triple therapy: antivitamin K with clopidogrel and acetylsalicylic acid." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Anticoagulation plus acetylsalicylic acid \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Anticoagulation plus clopidogrel \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Acetylsalicylic acid plus clopidogrel \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">All-cause mortality \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.52 (1.17–1.99) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.87 (0.56–1.34) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.60 (1.25–2.05) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Myocardial infarction and coronary death \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.96 (0.77–1.19) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.69 (0.48–1.00) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.17 (0.96–1.42) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Hemorrhagic complications \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.69 (0.53–0.90) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.78 (0.55–1.12) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.48 (0.38–0.61) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1038052.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Hazard ratios and confidence intervals (95%) of the results compared with triple therapy by antithrombotic treatment group of 12,165 patients of the Danish Registry." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:48 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Analyzing the coronary heart disease mortality decline in a Mediterranean population: Spain 1988–2005" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "G. 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Clinical up-date

Cardiovascular news 2013/2014

Novedades cardiovasculares 2013/2014

J.I. Cuendea, C. Lahozb, P. Armarioc, J. García-Alegríad, J. Enae, G. García de Casasolaf, J.M. Mostazab,

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jmostaza.hciii@salud.madrid.org

Corresponding author.

a Servicio de Medicina Interna, Complejo Asistencial Universitario de Palencia, Palencia, Spain

b Servicio de Medicina Interna, Hospital Carlos III, Madrid, Spain

c Servicio de Medicina Interna, Hospital Transversal (Moisès Broggi, Hospital General de l’Hospitalet), Consorci Sanitari Integral, Barcelona, Spain

d Servicio de Medicina Interna, Hospital Costa del Sol, Marbella, Málaga, Spain

e Servicio de Medicina Interna, Hospital Marina Baixa, Villajoyosa, Alicante, Spain

f Servicio de Medicina Interna, Hospital Infanta Cristina, Parla, Madrid, Spain

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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">In recent decades&#44; we have witnessed a progressive reduction in cardiovascular mortality in developed countries&#46; Coronary mortality in Spain from 1988 to 2005 declined by 40&#37;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> as the result of a populational reduction in cardiovascular risk factors&#44; better prevention and better treatment of already established disease&#46; The reduction in cardiovascular mortality has contributed the most to increasing the life expectancy in industrialized countries in general and in Spain in particular&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> The reduction is the result of continuous developments in this area&#44; mainly those related to primary and secondary prevention of the disease&#46; Keeping abreast of these developments requires health professionals to continuously update their knowledge and skills&#44; which is one of the commitments of the Cardiovascular Risk Workgroup of the Spanish Society of Internal Medicine&#46; Every year<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;4</span></a> the Group meeting reserves a round table to conduct an update on issues of cardiovascular risk&#46; In this article&#44; we present the lectures from the meeting held on May 2014 in Alicante&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Risk guidelines &#40;Dr&#46; Jos&#233; Ignacio Cuende&#41;</span><p id="par0010" class="elsevierStylePara elsevierViewall">Last year&#44; several publications emerged in the field of cardiovascular risk assessment that merit discussion&#46; The new American treatment guidelines for blood cholesterol<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> have undoubtedly sparked an interesting debate&#46; These guidelines&#44; sponsored by the American Heart Association and the American College of Cardiology&#44; base their recommendations on the strict reading of clinical trials&#44; recommendations on which not all of the scientific community agree&#46; These guidelines were published simultaneously with the guidelines for the quantification of cardiovascular risk&#44;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> lifestyle management<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> and excess weight and obesity control in adults&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> They were published shortly after the guidelines of the International Atherosclerosis Society<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> and 2 years after the European Guidelines for the Management of Dyslipidemia&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> The American guidelines for managing cholesterol use a new cardiovascular risk assessment scale presented in the risk quantification guidelines&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> These guidelines establish a new equation for measuring atherosclerotic cardiovascular risk based on pooled data from several American cohort studies &#40;Framingham&#44; ARIC&#44; CARDIA&#44; etc&#46;&#41;&#44; creating a pooled cohort&#44; measuring the risk of cardiovascular morbidity and mortality at 10 years and establishing a cutoff of 7&#46;5&#37; as an indicator of high risk&#46; The guidelines consider the white non-Hispanic and black African-American races&#44; as well as the variables of sex&#44; age &#40;40&#8211;79 years&#41;&#44; diabetes&#44; smoking&#44; systolic blood pressure &#40;BP&#41;&#44; treatment for BP&#44; total cholesterol and HDL-cholesterol&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The guidelines also answer clinical questions about the usefulness of other risk factors and markers and the use of lifelong risk&#46; If there are questions about patient management based on measured risk&#44; we can consider the patient&#39;s family history of early cardiovascular events&#44; ultrasensitive C-reactive protein levels and the quantification of coronary calcium and the ankle-brachial index&#46; The routine quantification of the intima-media thickness is not recommended&#46; The guidelines establish that there is no clear evidence compared with other markers such as apoB&#44; renal function&#44; microalbuminuria and cardiopulmonary condition&#46; Moreover&#44; if a patient of between 20 and 59 years of age is not determined to be high risk with the new scale&#44; we can apply the risk quantification at 30 years or throughout life with the educational intention of changing lifestyles and promoting adherence to medical advice but not as a guideline for clinical decision making&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">After the publication of the American guidelines on risk quantification and cholesterol treatment&#44; two articles were published that concluded that the new risk equation has a lower diagnostic performance &#40;measured by the area under the ROC curve&#41; in Europe than the SCORE system&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> The American guidelines overestimated risk and indicated statins at a much higher rate than the European guidelines &#40;approximately double&#44; but especially in younger participants&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> with a consequent increase in initial healthcare drug expenditure&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Another topic of interest is vascular age&#46; In 2008&#44; the concept of calculated vascular age was published with the new risk equation derived from the Framingham study&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> In 2010&#44; the table of vascular age derived from SCORE was published&#44;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> and in 2012 the European Guidelines for Cardiovascular Prevention<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> were published&#44; which included a key message in the strategy for managing and calculating risk&#58; the concept of vascular age derived from SCORE<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> and the relative risk &#40;RR&#41; as methods for helping communicate the need for lifestyle changes to the youth&#46; It had been previously demonstrated that informing patients of their vascular age enables them to be more aware of their risk condition than by telling them their absolute risk&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> In this context&#44; there was a lack of clinical trials that demonstrated that the use of vascular age enabled better control of cardiovascular risk factors&#46; A randomized&#44; unblinded clinical trial<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> with 3000 participants &#40;health professionals&#41; in primary prevention was published in 2014&#44; which divided the participants into three groups&#58; control group&#44; group informed of their absolute risk using REGICOR and a group informed of their vascular age calculated using the Framingham scale&#46; The analyzed variables were weight&#44; abdominal circumference&#44; body mass index&#44; systolic and diastolic BP&#44; glycemia&#44; total cholesterol&#44; HDL-cholesterol&#44; triglyceride levels&#44; physical activity and smoking&#44; which were assessed at the start and after a 12-month follow-up&#46; The control group worsened in all variables except physical exercise&#46; The group informed of their absolute risk improved in all variables&#46; The group informed of their vascular age improved in all variables and improved in all of them more than the group informed of their absolute risk&#46; There were statistically significant differences in all variables&#44; showing that informing participants of their vascular age had a greater impact on the management of patients than reporting the cardiovascular risk or not reporting the risk condition &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Lipids &#40;Dr&#46; Carlos Lahoz&#41;</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">New 2013 American College of Cardiology&#47;American Heart Association guidelines on the treatment of hypercholesterolemia</span><p id="par0030" class="elsevierStylePara elsevierViewall">The new 2013 guidelines of the American College of Cardiology&#47;American Heart Association<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> broke the dominant paradigm at the time &#40;the therapeutic objectives of LDL-cholesterol&#41;&#44; focusing on cardiovascular risk prevention with statin treatment&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The guidelines describe 4 groups of patients who benefit from statin treatment&#58; patients with cardiovascular disease&#44; patients with LDL-cholesterol levels &#8805;190<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#44; patients with diabetes and patients between the ages of 40 and 75 who have no cardiovascular disease or diabetes and have a calculated risk of atherosclerotic cardiovascular disease &#62;7&#46;5&#37; at 10 year&#46; Furthermore&#44; the guidelines classify statins according to their potency in reducing LDL-cholesterol&#58; high &#62;50&#37;&#44; medium 30&#8211;50&#37; and low &#60;30&#37;&#46; The management of patients according to the new guidelines is diagramed in <a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">The new guidelines are based on solid evidence &#40;clinical trials&#41; and are focused on the patient&#44; who is consulted before starting multiple-step lipid-lowering treatment&#46; The guidelines are simple&#44; easy to use and do not require a mixture of hypolipidemic agents&#46; They are focused on reducing cardiovascular risk and not on the diagnosis and management of dyslipidemia&#46; They are accompanied by a new risk equation that calculates the risk at 10 years and the lifetime risk of experiencing a cardiovascular event&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The guidelines&#8217; drawbacks include the disappearance of the LDL-cholesterol therapeutic objectives&#44; after more than 10 years of educating patients on this topic&#46; They relegate the use of other nonstatin hypolipidemic agents for patients who are intolerant or hyporesponsive&#44; given that there are no studies that have shown that they decrease cardiovascular morbidity and mortality&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">The combination of statins and ezetimibe&#58; waiting for IMPROVE-IT</span><p id="par0050" class="elsevierStylePara elsevierViewall">While waiting for the results of the IMPROVE-IT<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> trial that investigates whether the combination of simvastatin and ezetimibe is better than simvastatin alone in terms of cardiovascular morbidity and mortality&#44; two studies have been published on this combination with conflicting results&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">The first is a study with the results of the HPS-2&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> This trial included high-risk patients who&#44; before starting&#44; had LDL-cholesterol levels &#60;70<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#46; To this end&#44; approximately half of the participants took simvastatin 40<span class="elsevierStyleHsp" style=""></span>mg&#47;day and the other half took simvastatin combined with ezetimibe&#46; Once the LDL-cholesterol levels fell below 70<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#44; the patients were randomized to take niacin with laropiprant or placebo&#46; At the end of the trial&#44; there were no differences in the rate of cardiovascular complications between the 2 groups&#46; However&#44; if the rate of cardiovascular events is compared according to those who took statins alone or combined with ezetimibe&#44; we find that the rate was significantly lower in those who took the combination&#44; regardless of whether they took placebo or niacin&#46; These results should be viewed with caution&#44; given that the study was a posteriori and not adjusted&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">The other study was a retrospective registry of 9500 patients who had experienced an acute myocardial infarction &#40;AMI&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> The mean follow-up was 3&#46;2 years&#46; The participants who took only simvastatin were considered the control group&#46; Those who took the combination had a nonsignificant reduction in mortality&#46; Lastly&#44; those treated with high potency statins presented a significant reduction in mortality of 33&#37; compared with the control group &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; These results should also be taken with prudence&#44; given that the study was observational and retrospective&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Anti-PCSK-9&#58; adequate progress</span><p id="par0065" class="elsevierStylePara elsevierViewall">There are currently 2 anti-PCSK-9 antibodies in advanced phases of development&#44; alirocumab of Sanofi and evolocumab of Amgen&#44; which are in phase 3 studies&#46; The results of several clinical trials with these drugs have been published this year&#46; In one of these trials &#40;which had more than 300 participants with statin intolerance for myalgia&#41;&#44; the monoclonal antibody injected every 2 or 4 weeks achieved LDL-cholesterol reductions of 55&#37; compared with 17&#8211;19&#37; for patients treated with ezetimibe&#46; The patients treated with the antibody also had a lower percentage of myalgia than those treated with ezemtimibe &#40;8&#37; versus 18&#37;&#44; respectively&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> In another study&#44; patients treated with different hypolipidemic agent regimens underwent monthly injections of evolocumab&#46; After a year&#44; the mean reduction in LDL-cholesterol was 57&#37;&#44; with no relevant adverse effects&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Statins&#44; caloric intake and weight</span><p id="par0070" class="elsevierStylePara elsevierViewall">In a recent study with more than 27&#44;000 participants representing the general population of the United States&#44; the change in caloric intake&#44; fat consumption and weight from 1999 to 2010 were assessed&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> By dividing the population according to the consumption or not of statins&#44; it was observed that over time those treated with statins progressively increased their caloric intake&#44; while those that did not take the drug maintained a slight trend toward decreased intake&#46; At 10 years of follow-up&#44; the participants treated with statins had increased their caloric intake by almost 10&#37;&#44; their fat consumption by 14&#37; and their BMI by an average of 1&#46;3<span class="elsevierStyleHsp" style=""></span>kg&#47;m<span class="elsevierStyleSup">2</span> &#40;approximately 3&#8211;5<span class="elsevierStyleHsp" style=""></span>kg&#41;&#46; Therefore&#44; patients treated with statins should be strongly advised not to neglect their diet&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Arterial hypertension &#40;P&#46; Armario&#41;</span><p id="par0075" class="elsevierStylePara elsevierViewall">This review covers the main articles published in 2013 and the first quarter of 2014&#44; which include the publication of the guidelines of the European Society of Hypertension and the European Society of Cardiology&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> The recently published Eighth Report of the Joint National Committee<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> will not be commented on as it falls outside the purview of this brief review&#46;</p><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Renovascular hypertension</span><p id="par0080" class="elsevierStylePara elsevierViewall">Renovascular hypertension &#40;RVHT&#41; is one of the prototypes of secondary hypertension&#44; affecting 1&#8211;5&#37; of the population with hypertension&#46; Previous traditional uncontrolled studies have shown that treatment using angioplasty with stent placement results in a significant reduction in systolic BP&#46; The CORAL study&#44;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> a multicenter&#44; controlled&#44; open clinical trial with randomization to medical treatment only or medical treatment and stent placement&#44; found no significant differences in the prevention of clinical events in the group with stent placement&#44; compared with multifactorial medical treatment&#46; It should be noted&#44; however&#44; that the incidence of events was lower than expected in both groups&#44; highlighting the importance of implementing multifactorial treatment with optimal management of risk factors&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Salt and arterial hypertension</span><p id="par0085" class="elsevierStylePara elsevierViewall">The relationship between the dietary intake of sodium and various health indicators has been investigated in numerous observational studies and randomized clinical trials&#46; To achieve an effective reduction in sodium intake&#44; it is not enough to reduce the amount of salt in the preparation of food or withdraw the saltshaker&#59; the quantity of sodium in processed foods needs to be reduced&#46; Healthcare and industry must therefore collaborate for the benefit to be reflected in the general population&#46; Although this is not easy&#44; it is possible&#44; as has been observed in recent years in the United Kingdom&#44; as shown by the study referenced here&#46; He et al&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> have shown how&#44; by reducing the salt content in processed food&#44; a 15&#37; reduction in 24-h urinary sodium excretion was achieved over 7 years&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Treatment of arterial hypertension</span><p id="par0090" class="elsevierStylePara elsevierViewall">In the section on treatment&#44; we can include three articles published last year&#46; In the first article&#44; Lapi et al&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> conducted a case&#8211;control study with an extensive cohort of 487&#44;372 patients with antihypertensive medication&#44; followed-up for a mean period of 5&#46;9 years &#40;SD&#44; 3&#46;4&#41;&#46; The authors observed that triple therapy with diuretics&#44; renin-angiotensin system inhibitors and nonsteroidal anti-inflammatory drugs was associated with a 31&#37; greater risk of acute kidney damage over the course of the follow-up&#44; with the period of maximum risk occurring during the first 30 days from the start of this therapeutic combination &#40;hazard ratio &#91;HR&#93;&#44; 1&#46;82&#59; 95&#37; confidence interval &#91;95&#37; CI&#93; 1&#46;35&#8211;2&#46;46&#41;&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">The second article is the meta-analysis published by the Blood Pressure Lowering Treatment Trialists&#8217; Collaboration&#44;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> whose objective was to analyze the cardiovascular effects of reducing BP in participants with and without chronic kidney disease&#46; Compared with placebo&#44; lowering BP produced fewer major cardiovascular complications&#44; with no significant differences between the 2 groups&#46; Although the effect was similar&#44; the absolute benefit was greater for the participants with chronic kidney disease&#44; given that this had a higher risk&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">The third article was a meta-analysis of the clinical consequences of lack of adherence to cardiovascular therapy&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> The study confirmed a high prevalence of noncompliance with various cardiovascular drug regimens&#44; finding a significant reduction in the incidence of cardiovascular disease and total mortality in the group with good adherence&#44; especially with the use of statins and antihypertensive drugs&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Antihypertensive treatment and secondary prevention of stroke</span><p id="par0105" class="elsevierStylePara elsevierViewall">AHT is the most prevalent and significant modifiable risk factor for stroke&#44; in atherothrombotic stroke and especially in stroke associated with small vessel disease &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; Based on currently available evidence&#44; the therapeutic goal currently recommended by the new guidelines for patients who have experienced an ischemic stroke is to reduce the BP below 1490&#47;90<span class="elsevierStyleHsp" style=""></span>mm Hg&#44; although a number of authors advocate a greater reduction in BP&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0110" class="elsevierStylePara elsevierViewall">The SPS3 clinical trial<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a> included patients who had experienced a recent&#44; symptomatic lacunar stroke&#44; confirmed by magnetic resonance imaging&#46; One group was assigned a therapeutic systolic BP goal of between 130 and 149<span class="elsevierStyleHsp" style=""></span>mm Hg and another to a systolic BP goal of &#60;130<span class="elsevierStyleHsp" style=""></span>mm Hg&#46; After 1 year&#44; the mean systolic BP was 138<span class="elsevierStyleHsp" style=""></span>mm Hg &#40;95&#37; CI 137&#8211;139&#41; in the first group and 127<span class="elsevierStyleHsp" style=""></span>mm Hg &#40;95&#37; CI 126&#8211;128<span class="elsevierStyleHsp" style=""></span>mm Hg&#41; in the second&#46; In the second group&#44; a reduction in the primary objective was observed &#40;the total number of ischemic and hemorrhagic strokes&#41;&#46; Nevertheless&#44; it should be noted that the difference was not significant &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;08&#41; and that the results cannot be extrapolated to other patients who have experienced atherothrombotic strokes with greater functional involvement&#46; New data are therefore required before we can modify the recommendations of the current guidelines concerning the optimal therapeutic goal for the secondary prevention of stroke&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Resistant or refractory arterial hypertension</span><p id="par0115" class="elsevierStylePara elsevierViewall">In this section&#44; we highlight two articles&#44; one concerning a new proposed definition of refractory AHT&#44; differentiated from resistant AHT<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a> and the second concerning the results of the SYMPLICITY HTN-3 study&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">In the first article&#44; Calhoun et al&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a> authors of the 2008 consensus document who proposed the classical definition of resistant AHT based on data from the REGARDS study&#44; propose identifying a subgroup to be known as refractory AHT&#46; This group is composed of patients with uncontrolled hypertension despite following a therapeutic regimen with 5 or more antihypertensive drugs&#46; The authors show that the prevalence of this new subgroup of patients with hypertension that is uncontrolled with 5 or more drugs is very low&#58; 0&#46;5&#37; of the total number of patients treated for hypertension and 3&#46;6&#37; of participants with resistant AHT&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">The SYMPLICITY HTN-1 and 2 study and other previous studies on renal sympathetic denervation in the management of patients with resistant AHT had provided encouraging results&#44; although they were uncontrolled studies&#46; The SYMPLICITY HTN-3 study<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a> was designed as a prospective&#44; multicenter trial with a sham control group&#46; Its main objective was to reduce 24-h systolic BP at 6 months&#44; and its secondary objective was the safety of the intervention&#46; There were no significant differences in the reduction in 24-h systolic BP between the 2 groups&#44; in contrast to the expectations raised by the results of previous studies&#44; although the technique was confirmed to be safe&#46;</p></span></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Antivitamin K and antiplatelet drugs &#40;Dr&#46; Javier Garc&#237;a Alegr&#237;a&#41;</span><p id="par0130" class="elsevierStylePara elsevierViewall">There have been several noteworthy articles regarding the use of antivitamin K &#40;VKA&#41;&#46; Various genetic variants determine the metabolization of these drugs&#46; It has been proposed that the pharmacogenomics could reduce variability in the management of anticoagulation&#46; An issue of the New England Journal of Medicine included three original articles that addressed this problem&#46; The first of these&#44;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a> a multicenter study on patients with venous thrombosis or atrial fibrillation &#40;AF&#41;&#44; used a test to determine various genotypes&#44; in which a warfarin regimen was employed using a predetermined algorithm versus a control group&#46; The primary objective was the therapeutic time in range over 12 weeks&#44; which&#44; in the genotype-guided group&#44; was 67&#46;4&#37; compared with 60&#46;3&#37; in the control group &#40;adjusted difference&#44; 7&#46;0&#37;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41;&#46; The pharmacogenetic adjusted dosage was therefore significantly better&#46; However&#44; in the other 2 studies&#44;<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">35&#44;36</span></a> which had a similar design and more patients&#44; there were no differences between the 2 strategies&#46; To complete this information&#44; a recent meta-analysis<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a> of 9 trials of warfarin treatment guided by genotype showed a difference in the therapeutic time in range of 0&#46;14&#37; &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;25&#41;&#46; This strategy therefore offered no clinical benefit&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Warfarin-associated nephropathy &#40;WAN&#41; is a recently recognized condition in which excess anticoagulation &#40;INR<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>3&#46;0&#41; induces an acute renal lesion with no evidence of clinically relevant hemorrhaging&#44; which is attributed to intratubular bleeding&#46; A retrospective Korean study<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">38</span></a> attempted to establish the incidence of WAN and its prognostic implication&#46; The study analyzed data from 1297 patients who had a baseline creatinine reading one week after an INR<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>3&#46; The WAN criteria were a 50&#37; reduction in creatinine clearance or a creatinine increase &#62;0&#46;3<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#46; Some 19&#46;3&#37; of the patients developed WAN&#44; and the risk was greater with hypoalbuminemia and heart failure&#44; without any relationship to the degree of renal function&#46; The mortality at 108 weeks was higher in the WAN group&#46; Clinicians should recognize this condition and be alert to the possibility of worsening renal function in conditions of excess anticoagulation&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">In the field of antiplatelet treatment&#44; there are several relevant articles&#46; A recent topic of debate has been optimal treatment in permanent anticoagulation and the need for a coronary stent&#46; The WOEST study has attempted to answer this issue&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">39</span></a> The randomized&#44; multicenter open study attempted to establish the safety and efficacy of clopidogrel alone or combined with acetylsalicylic acid for patients who have been anticoagulated&#46; The primary objective was to quantify any episode of hemorrhaging in the first year of implantation&#44; with the patients assigned by intention to treat to double or triple therapy&#46; There was bleeding in 19&#46;4&#37; of patients with double therapy and 44&#46;4&#37; with triple therapy &#40;HR&#44; 0&#46;36&#59; 95&#37; CI 0&#46;26&#8211;0&#46;50&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;0001&#41;&#46; The requirements for transfusion were also different &#40;3&#46;9&#37; versus 9&#46;5&#37;&#59; odds ratio&#44; 0&#46;39&#59; 95&#37; CI 0&#46;17&#8211;0&#46;84&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;011&#41;&#46; There was no difference in the incidence of thrombotic events between the 2 groups&#46; The authors therefore concluded that double therapy with clopidogrel is safer than triple therapy&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Another method of addressing the same problem was the 2 analyses of the national Danish registry&#46;<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">40&#44;41</span></a> The first of these<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">40</span></a> explored the risk of thrombosis and hemorrhaging according to the antithrombotic treatment in patients with AF&#44; anticoagulated after an AMI and&#47;or coronary intervention&#46; Between 2001 and 2009&#44; 12&#44;165 hospitalizations were recorded for AMI and&#47;or coronary procedures &#40;60&#46;7&#37; men&#59; mean age&#44; 75&#46;6 years&#41;&#46; The risk of AMI&#47;coronary death&#44; ischemic stroke and hemorrhaging according to the antithrombotic regimen was calculated with a Cox regression&#46; The main results are listed in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#46; For patients with AF with an indication for multiple antithrombotic drugs after an AMI and&#47;or coronary intervention&#44; oral anticoagulation combined with clopidogrel was equal or superior in terms of benefits and safety than triple therapy&#46; The other analysis<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">41</span></a> sought to determine the best antithrombosis strategy for patients with AF and stable coronary artery disease&#44; defined after 12 months of a coronary event&#46; It analyzed the cardiovascular events and severe bleeding&#44; with hospitalization&#44; of 8700 patients&#44; with a mean follow-up of 3&#46;3 years&#46; The raw rates of AMI&#47;coronary death&#44; thromboembolism and hemorrhaging were 7&#46;2&#37;&#44; 3&#46;8&#37; and 4&#37;&#44; respectively&#46; In terms of monotherapy with VKA&#44; the risk of AMI&#47;coronary death with VKA plus acetylsalicylic acid was similar &#40;HR&#44; 1&#46;12&#59; 95&#37; CI 0&#46;94&#8211;1&#46;34&#41;&#44; as was the combination of VKA plus clopidogrel &#40;HR&#44; 1&#46;53&#59; 95&#37; CI 0&#46;93&#8211;2&#46;52&#41;&#46; The risk of thromboembolism was comparable in all regimens that included VKA&#44; while the risk of bleeding increased when VKA was combined with acetylsalicylic acid &#40;HR&#44; 1&#46;50&#59; 95&#37; CI 1&#46;23&#8211;1&#46;82&#41; or clopidogrel &#40;HR&#44; 1&#46;84&#59; 95&#37; CI 1&#46;11&#8211;3&#46;06&#41;&#46; The authors concluded that the addition of antiplatelet drugs to VKA in patients with AF and stable coronary artery disease was not associated with a reduction in coronary or embolic events and increased the risk of severe bleeding&#46; This standard practice therefore needs to be revised&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Diabetes mellitus &#40;Dr&#46; Javier Ena&#41;</span><p id="par0150" class="elsevierStylePara elsevierViewall">In the field of diabetes&#44; there are a number of noteworthy contributions&#46; The Look AHEAD study<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">42</span></a> was a controlled clinical trial with 5145 patients with type 2 diabetes and excess weight and obesity that compared a strategy of lifestyle changes &#40;150<span class="elsevierStyleHsp" style=""></span>min&#47;week of physical exercise and low-calorie diets of 1800<span class="elsevierStyleHsp" style=""></span>kcal&#47;day&#41;&#46; The study outcomes measured at 10 years proved to be neutral in the reduction of cardiovascular events and cardiovascular mortality&#46; The intervention was very effective during the first year in reducing weight&#44; improving aerobic capacity and increasing insulin resistance but lacked a long-term effect&#46; The primary outcome occurred in 403 patients in the intervention group and 418 patients in the control group &#40;1&#46;83 and 1&#46;92 events per 100 person-years&#44; respectively&#59; RR&#44; 0&#46;95&#59; 95&#37; CI 0&#46;83&#8211;1&#46;09&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;51&#41;&#46; During the extended study time&#44; the control group showed contamination due to co-interventions with drugs that controlled cholesterol and BP levels&#46; The number of observed outcomes was lower than expected&#44; and the study&#39;s power was insufficient to demonstrate significant differences in the evaluated outcomes&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">In contrast&#44; a Mediterranean diet supplemented with extra virgin olive oil showed effectiveness in the general population for reducing cardiovascular events &#40;AMI&#44; stroke and cardiovascular death&#41; and the onset of diabetes&#46;<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">43&#44;44</span></a> The PREDIMED study was a clinical trial conducted for a mean of 4 years with 7447 individuals aged between 55 and 80 years&#46; The study compared the efficacy of a Mediterranean diet supplemented with extra virgin olive oil or a Mediterranean diet supplemented with nuts versus a low-calorie&#44; low-fat diet &#40;no more than 30&#37; of calories supplied from fat&#41;&#46; The multivariate analysis showed a RR of 0&#46;70 &#40;95&#37; CI 0&#46;54&#8211;0&#46;92&#41; and 0&#46;72 &#40;95&#37; CI 0&#46;54&#8211;0&#46;96&#41; for the groups assigned the Mediterranean diet with extra virgin olive oil &#40;96 events&#41; and the Mediterranean diet supplemented with nuts &#40;83 events&#41;&#44; respectively&#44; compared with the control group &#40;109 events&#41;&#46; A subanalysis of the study that included a total of 3541 individuals assessed the impact of different types of diet on the onset of diabetes mellitus&#46; During the follow-up&#44; a total of 80&#44; 92 and 101 new cases of diabetes were recorded in participants who were treated with a Mediterranean diet supplemented with extra virgin olive oil&#44; a Mediterranean diet supplemented with nuts and a low-calorie diet&#44; respectively&#44; which corresponds to a rate of 16&#46;0&#44; 18&#46;7 and 23&#46;6 cases per 1000 person-years&#46; In other words&#44; the relative reduction in the risk of diabetes with the Mediterranean diet supplemented with extra virgin olive oil was 67&#37; compared to a low-fat diet&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">The aging of the population will cause an increase in chronic degenerative diseases&#44; the greatest of which is the onset of dementia&#44; which constitutes a public health problem of considerable magnitude&#46; The association between diabetes and dementia is well known&#44; due to glucose level disorders and the increased prevalence of vascular disease&#46; Recently&#44; the risk of dementia has been analyzed in relation to baseline glycemia levels in fasting conditions in a total of 2067 participants &#40;232 with diabetes and 1835 without diabetes&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">45</span></a> During the 6&#46;8-year follow-up&#44; the presence of dementia was confirmed using a cognitive skills&#8217; screening test in a total of 524 participants &#40;74 with diabetes and 450 without diabetes&#41;&#46; In the participants without diabetes&#44; a statistically significant association was observed between the onset of dementia and baseline glycemia levels in fasting conditions of 115<span class="elsevierStyleHsp" style=""></span>mg&#47;dL compared with 100<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#44; with an RR of 1&#46;18 &#40;95&#37; CI 1&#46;04&#8211;1&#46;33&#41;&#46; Among the patients with diabetes&#44; the RR of dementia when comparing baseline glycemia values of 190&#8211;160<span class="elsevierStyleHsp" style=""></span>mg&#47;dL was 1&#46;40 &#40;95&#37; CI 1&#46;12&#8211;1&#46;76&#41;&#46; These calculations were adjusted for age&#44; sex&#44; educational level&#44; BP&#44; presence of coronary artery disease or cerebrovascular level&#44; AF&#44; treatment for AHT and smoking&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">Two recent studies&#44; SAVOR-TIMI 53 and EXAMINE&#44; have helped assess the cardiovascular safety of 2 oral hypoglycemic agents that belong to the dipeptidyl-peptidase-4 inhibitor group&#46; The SAVOR-TIMI 53<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">46</span></a> study assessed the safety of saxagliptin in a placebo-controlled&#44; double-blind&#44; noninferiority trial with a total of 16&#44;492 patients with type 2 diabetes mellitus and high cardiovascular risk&#46; The primary study outcome&#44; which was a composite of cardiovascular death&#44; stroke and coronary events&#44; occurred in 613 patients of the saxagliptin group and 609 patients in the placebo group &#40;7&#46;3&#37; and 7&#46;2&#37;&#44; respectively&#59; RR&#44; 1&#46;00&#59; 95&#37; CI 0&#46;89&#8211;1&#46;12&#41;&#46; Although the number of hospitalizations for heart failure was statistically higher in the saxagliptin group than in the placebo group &#40;3&#46;5&#37; versus 2&#46;8&#37;&#59; RR&#44; 1&#46;27&#59; 95&#37; CI 1&#46;07&#8211;1&#46;51&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;007&#41;&#44; the absolute increase in risk &#40;0&#46;7&#37;&#41; was very low&#46; Overall&#44; the patients treated with saxagliptin had statistically significant reductions in glycemia values under fasting conditions and in glycated hemoglobin levels&#44; although with low absolute values&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">Alogliptin&#44; another dipeptidyl-peptidase-4 inhibitor&#44; was subjected to cardiovascular safety assessment as required by the regulatory agencies&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">47</span></a> The EXAMINE study was a noninferiority clinical trial of alogliptin compared with placebo in 5380 patients with acute coronary syndrome&#46; The study assessed an outcome composed of cardiovascular death&#44; stroke and AMI during a 40-month follow-up&#46; Alogliptin caused a 0&#46;36&#37; reduction in glycated hemoglobin levels in the intervention group compared with the placebo group&#46; In terms of the primary outcome&#44; 305 &#40;11&#46;3&#37;&#41; events occurred in the group assigned to alogliptin&#44; and 316 &#40;11&#46;8&#37;&#41; events occurred in the placebo group &#40;RR&#44; 0&#46;96&#59; upper limit of the confidence interval 1&#46;16&#41;&#44; meeting the criterion of noninferiority&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">More recently&#44; the ESTAMPEDE study assessed the long-term effectiveness of metabolic surgery in comparison with the intensive treatment of diabetes to achieve clinical control of the disease&#44; defined as glycated hemoglobin levels below 6&#37; &#40;with or without hypoglycemic treatment&#41; at the end of 3 years of follow-up&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">48</span></a> A total of 150 patients with diabetes were randomized 1&#58;1&#46;1 to intensive medical treatment&#44; tubular gastrectomy or jejunum-ileal Roux-en-Y bypass&#46; The patients&#8217; mean age was 48<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>8 years&#44; their mean body mass index was 36<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#46;5 and 49 patients &#40;36&#37;&#41; had a BMI below 35&#46; The mean glycated hemoglobin level was 9&#46;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;5&#37;&#44; and the mean duration of the diabetes was 8&#46;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>5&#46;1 years&#44; with 43&#37; of the patients undergoing insulin treatment&#46; At the end of the study&#44; 5&#37; of the patients undergoing intensive medical treatment achieved the main objective&#44; while 24&#37; of the patients who underwent tubular gastrectomy &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;01&#41; and 38&#37; of the patients who underwent intestinal bypass &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41; achieved this objective&#46; Surgical treatment also improved other evaluated domains such as body pain&#44; overall health&#44; and limitations due to emotional problems&#44; energy&#44; emotional wellbeing&#44; social function&#44; physical function and limitations due to health conditions&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conflicts of interest</span><p id="par0180" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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          "titulo" => "Risk guidelines &#40;Dr&#46; Jos&#233; Ignacio Cuende&#41;"
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          "titulo" => "Lipids &#40;Dr&#46; Carlos Lahoz&#41;"
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              "titulo" => "New 2013 American College of Cardiology&#47;American Heart Association guidelines on the treatment of hypercholesterolemia"
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              "titulo" => "The combination of statins and ezetimibe&#58; waiting for IMPROVE-IT"
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              "identificador" => "sec0025"
              "titulo" => "Anti-PCSK-9&#58; adequate progress"
            ]
            3 => array:2 [
              "identificador" => "sec0030"
              "titulo" => "Statins&#44; caloric intake and weight"
            ]
          ]
        ]
        6 => array:3 [
          "identificador" => "sec0035"
          "titulo" => "Arterial hypertension &#40;P&#46; Armario&#41;"
          "secciones" => array:5 [
            0 => array:2 [
              "identificador" => "sec0040"
              "titulo" => "Renovascular hypertension"
            ]
            1 => array:2 [
              "identificador" => "sec0045"
              "titulo" => "Salt and arterial hypertension"
            ]
            2 => array:2 [
              "identificador" => "sec0050"
              "titulo" => "Treatment of arterial hypertension"
            ]
            3 => array:2 [
              "identificador" => "sec0055"
              "titulo" => "Antihypertensive treatment and secondary prevention of stroke"
            ]
            4 => array:2 [
              "identificador" => "sec0060"
              "titulo" => "Resistant or refractory arterial hypertension"
            ]
          ]
        ]
        7 => array:2 [
          "identificador" => "sec0065"
          "titulo" => "Antivitamin K and antiplatelet drugs &#40;Dr&#46; Javier Garc&#237;a Alegr&#237;a&#41;"
        ]
        8 => array:2 [
          "identificador" => "sec0070"
          "titulo" => "Diabetes mellitus &#40;Dr&#46; Javier Ena&#41;"
        ]
        9 => array:2 [
          "identificador" => "sec0075"
          "titulo" => "Conflicts of interest"
        ]
        10 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2014-07-27"
    "fechaAceptado" => "2014-07-29"
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      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec645550"
          "palabras" => array:10 [
            0 => "Vascular risk"
            1 => "Lipids"
            2 => "Diabetes"
            3 => "Cholesterol"
            4 => "Arterial hypertension"
            5 => "Anticoagulants"
            6 => "Antiplatelets"
            7 => "PCSK-9"
            8 => "Nicotinic acid"
            9 => "Sympathetic denervation"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec645551"
          "palabras" => array:10 [
            0 => "Riesgo vascular"
            1 => "L&#237;pidos"
            2 => "Diabetes"
            3 => "Colesterol"
            4 => "Hipertensi&#243;n arterial"
            5 => "Anticoagulantes"
            6 => "Antiagregantes"
            7 => "PCSK-9"
            8 => "&#193;cido nicot&#237;nico"
            9 => "Denervaci&#243;n simp&#225;tica"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">During 2013 and the first months of 2014&#44; numerous studies have been published in the cardiovascular field&#46; New guidelines have appeared for managing arterial hypertension and reducing cardiovascular risk by lowering cholesterol levels&#46; New data have emerged on the considerable lipid-lowering efficacy of monoclonal antibodies against PCSK-9&#44; in contrast&#44; however&#44; to the clinical trials directed toward raising HDL-cholesterol with nicotinic acid&#44; which have not shown a reduction in the rate of cardiovascular complications&#46; In the field of hypertension&#44; neither stent placement in patients with renovascular hypertension nor sympathetic denervation in patients with resistant hypertension has been shown to be effective in reducing blood pressure&#46; In terms of antithrombotic treatment&#44; the pharmacogenetic tests do not seem useful for maintaining patients anticoagulated with warfarin within the therapeutic range for longer periods&#46; Moreover&#44; there is increasing evidence that&#44; for patients with coronary artery disease and atrial fibrillation&#44; antiplatelet therapy adds no benefit to anticoagulation therapy and is associated with a greater risk of bleeding&#46; Lastly&#44; a Mediterranean diet could prevent the onset of diabetes&#44; while bariatric surgery could be a reasonable option for improving the disease in patients with obesity&#46; Many of these studies have immediate practice applications in daily clinical practice&#46;</p></span>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Durante el a&#241;o 2013 y los primeros meses de 2014 se han publicado numerosos estudios relevantes en el campo cardiovascular&#46; Han aparecido nuevas gu&#237;as para el manejo de la hipertensi&#243;n arterial y para reducir el riesgo cardiovascular descendiendo el colesterol&#46; Tambi&#233;n han aparecido nuevos datos sobre la gran eficacia hipolipidemiante de los anticuerpos monoclonales frente a PCSK-9&#44; decepcionando&#44; sin embargo&#44; los ensayos cl&#237;nicos dirigidos a elevar el colesterol-HDL con &#225;cido nicot&#237;nico&#44; los cuales no han demostrado una reducci&#243;n de la tasa de complicaciones cardiovasculares&#46; Tampoco en el campo de la hipertensi&#243;n&#44; la colocaci&#243;n de un <span class="elsevierStyleItalic">stent</span> en pacientes con hipertensi&#243;n renovascular&#44; o la denervaci&#243;n simp&#225;tica en pacientes con hipertensi&#243;n resistente&#44; han demostrado ser eficaces para reducir la presi&#243;n arterial&#46; Con relaci&#243;n al tratamiento antitromb&#243;tico&#44; los test farmacogen&#233;ticos no parecen &#250;tiles para mantener m&#225;s tiempo en rango terap&#233;utico a los pacientes anticoagulados con warfarina&#46; A su vez&#44; cada vez existen m&#225;s evidencias de que en pacientes con enfermedad coronaria y fibrilaci&#243;n auricular&#44; la antiagregaci&#243;n no a&#241;ade beneficio a la anticoagulaci&#243;n y se asocia con un mayor riesgo de sangrado&#46; Por &#250;ltimo&#44; una dieta de tipo mediterr&#225;neo podr&#237;a prevenir la aparici&#243;n de diabetes&#44; mientras que la cirug&#237;a bari&#225;trica podr&#237;a ser una opci&#243;n razonable para mejorar la enfermedad en pacientes obesos&#46; Muchos de estos estudios tienen una aplicaci&#243;n pr&#225;ctica inmediata en el trabajo cl&#237;nico diario&#46;</p></span>"
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Cuende JI&#44; Lahoz C&#44; Armario P&#44; Garc&#237;a-Alegr&#237;a J&#44; Ena J&#44; Casasola GGd&#44; et al&#46; Novedades cardiovasculares 2013&#47;2014&#46; Rev Clin Esp&#46; 2015&#59;215&#58;33&#8211;42&#46;</p>"
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Cerebral microbleeds&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Intracerebral hemorrhaging&nbsp;\t\t\t\t\t\t\n
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          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Forms of cerebrovascular involvement in arterial hypertension&#46;</p>"
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Hemorrhagic complications&nbsp;\t\t\t\t\t\t\n
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          "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Hazard ratios and confidence intervals &#40;95&#37;&#41; of the results compared with triple therapy by antithrombotic treatment group of 12&#44;165 patients of the Danish Registry&#46;</p>"
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    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:48 [
            0 => array:3 [
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              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Analyzing the coronary heart disease mortality decline in a Mediterranean population&#58; Spain 1988&#8211;2005"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "G&#46; Flores-Mateo"
                            1 => "M&#46; Grau"
                            2 => "M&#46; O&#8217;Flaherty"
                            3 => "R&#46; Ramos"
                            4 => "R&#46; Elosua"
                            5 => "C&#46; Violan-Fors"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.recesp.2011.05.033"
                      "Revista" => array:6 [
                        "tituloSerie" => "Rev Esp Cardiol"
                        "fecha" => "2011"
                        "volumen" => "64"
                        "paginaInicial" => "988"
                        "paginaFinal" => "996"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21962958"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0010"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Contributions of cardiovascular mortality to Spanish life expectancy from 1980 to 2009"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "J&#46;M&#46; Garc&#237;a-Gonz&#225;lez"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.rec.2013.05.013"
                      "Revista" => array:6 [
                        "tituloSerie" => "Rev Esp Cardiol"
                        "fecha" => "2013"
                        "volumen" => "66"
                        "paginaInicial" => "848"
                        "paginaFinal" => "853"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24773991"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0015"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "2010&#58; &#191;Qu&#233; ha habido de nuevo en riesgo vascular&#63;"
                      "autores" => array:1 [
                        0 => array:3 [
                          "colaboracion" => "en nombre del Grupo de Trabajo de Riesgo Vascular de la SEMI"
                          "etal" => false
                          "autores" => array:3 [
                            0 => "L&#46;A&#46; &#193;lvarez-Sala Walther"
                            1 => "C&#46; Su&#225;rez Fern&#225;ndez"
                            2 => "M&#46; Camafort Babkowski"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.rce.2011.05.019"
                      "Revista" => array:6 [
                        "tituloSerie" => "Rev Clin Esp"
                        "fecha" => "2011"
                        "volumen" => "211"
                        "paginaInicial" => "410"
                        "paginaFinal" => "422"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21816397"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib0020"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "&#191;Qu&#233; ha habido de nuevo en riesgo vascular en el a&#241;o 2012&#63;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "D&#46; S&#225;nchez Fuentes"
                            1 => "C&#46; Su&#225;rez Fern&#225;ndez"
                            2 => "F&#46; Garc&#237;a-Bragado Dalmau"
                            3 => "J&#46;M&#46; Mostaza Prieto"
                            4 => "P&#46; Conthe Guti&#233;rrez"
                            5 => "J&#46;I&#46; Cuende"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.rce.2013.06.009"
                      "Revista" => array:6 [
                        "tituloSerie" => "Rev Clin Esp"
                        "fecha" => "2013"
                        "volumen" => "213"
                        "paginaInicial" => "442"
                        "paginaFinal" => "452"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23932871"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
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                ]
              ]
            ]
            4 => array:3 [
              "identificador" => "bib0025"
              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
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Article information

ISSN: 22548874
Original language: English

DOI:10.1016/j.rceng.2014.07.005

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