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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">In this issue of the journal&#44; a consensus document on clinical decisions in relation to risk factors for cardiovascular disease &#40;CVD&#41; is presented&#46; The worldwide epidemic of obesity and metabolic syndrome has led to an increased risk profile of many subjects&#46; They usually cannot be assessed and treated on evidence based medicine principles since evidence often is lacking or scarce&#44; whereas the long term impact on health care is potentially enormous&#46; As the authors correctly state&#58; &#8220;<span class="elsevierStyleItalic">we have to promote an efficient use of diagnostic and therapeutic proceedings to ensure the viability of public health care systems</span>&#8221;<span class="elsevierStyleItalic">&#46;</span><a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> The consensus document is a good example of translating common knowledge to modern day practice&#46; Part of this very laudable effort to reach practical consensus through expert opinion could be enhanced or may be contradicted by known literature&#46; For example&#44; the expert opinions regarding assessment of cardiovascular risk and treatment of lipid profile disturbances are somewhat at odds and not as detailed as the presented evidence in the latest ACC&#47;AHA guidelines&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2&#44;3</span></a> Still&#44; many down to earth and valuable advices are formulated&#46; Again as an example&#44; life style interventions have proven to be successful in a primary care setting but certainly are not &#8220;one size fits all&#8221; recommendations and if we are to convince our patients we simply have to do more&#46; This consensus document&#44; where intuitive sense comes into play&#44; may be the first step although additional measures have to be taken&#46; Apart from smoking&#44; diabetes has a predominant role in the identification of patients at risk for CVD&#44; so many of the recommendations relate to diabetes&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Diabetes has profound effects on the cardiovascular system and usually leads to a reduced life expectancy&#46; Accelerated progression of atherosclerosis observed in diabetes necessitates a broad implementation of early and rather aggressive treatment of derangements of glucose metabolism&#44; hypertension&#44; and lipid profile disturbances&#46; Still&#44; in many patients&#44; the presence of diabetes results in the need for cardiac intervention therapies&#46; Revascularization of narrowed or occluded coronary vessels can be performed by surgeons or by interventional cardiologists&#46; However the modalities are entirely different with regard to their mode of action&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Percutaneous coronary intervention &#40;PCI&#41; is targeted at the &#8220;culprit&#8221; lesion or lesions&#44; whereas coronary artery bypass grafting &#40;CABG&#41; is directed at the epicardial vessel&#44; including the &#8220;culprit&#8221; lesion or lesions and future culprits&#44; a difference that may account for the superiority of CABG over PCI&#44; at least in the intermediate term&#44; in patients with diabetes&#44; and in particular in those with multivessel disease&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#8211;6</span></a> This need for early &#40;partly preventive&#41; medical measures combined with the increased need for invasive procedures necessitates a &#8220;shared decision making&#8221; and more specifically&#44; a close collaboration between vascular internal medicine&#44; interventional cardiology and cardiovascular surgery and is commonly referred to as the &#8220;Heart Team&#8221; concept&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Such a collaborative effort is an attempt to come to a &#8220;final common pathway&#8221; in presenting patients with diabetes and coronary artery disease the best treatment options available&#44; whether it is optimal medical treatment &#40;OMT&#41;&#44; PCI or CABG&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;8</span></a> This applies to stable patients as well as patients presenting with acute coronary syndrome&#46; In many patients a strategy of OMT &#40;with delayed revascularization as needed&#41; is the preferred and cost-effective treatment compared to prompt revascularization&#44; but sometimes it is very difficult to convince patients that revascularization is not the first treatment option and the Heart Team can be of great help in these situations&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;9</span></a> On the other hand&#44; patients with a high-risk profile may benefit from an invasive approach and should be identified as early as possible&#44; though with an eye for cost-effectiveness and omitting costly&#44; often unnecessary diagnostic procedures&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The current consensus document<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> addresses every-day dilemmas in patients with&#44; or at risk for CVD&#44; but does not go beyond diagnostic procedures&#44; medical treatment and&#47;or modifiable risk factors&#46; The next step will be to accomplish agreement on active treatment decisions made by cooperative efforts as presented with the Heart Team&#46; In this document a practical and comprehensive format is used and it elegantly brings to light a common opinion on complex clinical questions but providing&#44; as the authors state&#44; simple answers&#46; The methodology used in this paper seems to be an efficient and practical approach and may be extended to the &#8220;Heart Team&#8221; as a tool to optimize complex patient care issues&#46;</p></span>"
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Vol. 214. Núm. 4.
Páginas 200-201 (mayo 2014)
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Vol. 214. Núm. 4.
Páginas 200-201 (mayo 2014)
Editorial
Clinical decision making and cardiovascular risk factors: What about the Heart Team?
Toma de decisions clínicas y factores de riesgo cardiovascuolar: ¿qué sucede con el Heart Team?
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626
M.-J. de Boera,
Autor para correspondencia
menkojan@gmail.com

Corresponding author.
, H.J.G. Bilob,c
a Department of Cardiology, Radboud University Medical Center Nijmegen, The Netherlands
b Department of Internal Medicine, Isala Clinics, Zwolle, The Netherlands
c Department of Internal Medicine, University Medical Center Groningen, Groningen, The Netherlands
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