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            "entidad" => "Hospital Cl&#237;nico Universitario Virgen de la Victoria&#44; Internal Medicine Department&#44; Malaga&#44; Spain"
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        "titulo" => "Decisiones cl&#237;nicas en pacientes con diabetes y otros factores de riesgo cardiovascular&#46; Una declaraci&#243;n de la sociedad espa&#241;ola de medicina interna"
      ]
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Diabetes and obesity&#46; Percentage of participants agreeing with the answers proposed for each question&#46; The answer to one question required a second vote to reach an agreement&#46; The vertical line represents the minimum percentage &#40;75&#37;&#41; of votes required to reach a consensus among participants&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Cardiovascular diseases &#40;CVD&#41; are still the leading cause of death worldwide&#44;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> being the first cause of death in the Spanish population&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> In addition&#44; CVD are responsible for high social and economical burden&#44; including direct costs related to the use of health resources for the diagnosis and treatment of the various forms of CVD&#44; and indirect cost derived from early mortality&#44; absenteeism from work&#44; family care or disability&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Among the direct costs&#44; and according to the Spanish Ministry of Health&#44; CVD ranks first in drug consumption &#40;considering the percentage of defined daily dose &#40;DDD&#41; over the total of therapeutic groups&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Atorvastatin&#44; enalapril and simvastatin are included among the ten top active ingredients in number of vials&#47;packages prescribed&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Cardiovascular mortality rates in Spain have decreased over the last decades&#46; This reduction could be explained by a better control of risk factors and the use of evidence-based treatments&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> It is generally accepted that the prevention of CVD &#8211; and CVD related mortality &#8211; is based on the detection and control of modifiable risk factors&#44; such as hypercholesterolemia&#44; hypertension&#44; diabetes mellitus &#40;DM&#41; or overweight&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> In Spain&#44; the most important achievements contributing to mortality reduction have been the better control of cholesterol levels and blood pressure&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;9</span></a> However&#44; other risk factors have not followed this beneficial trend&#46; The increases in body mass index &#40;BMI&#41; in men&#44; smoking in women&#44; and diabetes mellitus &#40;DM&#41; in both sexes<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> could be slowing down the mortality reduction in Spain&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">In the CVD-related burden settings&#44; multiple documents have been written to help clinicians in their daily clinical decision making&#46; These documents include clinical practice guidelines &#40;CPG&#41;&#44; recommendations and algorithms based on the available clinical evidence&#46; In light of this wide amount of documentation&#44; the difficulty for clinicians of being properly informed in their clinical practice is understandable&#46; For this reason&#44; the Spanish Society of Internal Medicine &#40;SEMI&#41; has coordinated an experience and knowledge exchange of experts&#44; to help the clinicians to make decisions and solve questions of the daily practice&#44; providing a practical approach to patients with potential cardiovascular risk &#40;CVR&#41;&#46; This document is not intended to increase the already available information&#46; Considering the current situation of the health system&#44; and in line with other similar initiatives from American scientific societies&#44;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#44;12</span></a> this statement pretends to promote the effective use of procedures or medications in the management of CV risk factors&#44; identifying practices that are not often necessary and which may cause detrimental effects&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Methodology</span><p id="par0020" class="elsevierStylePara elsevierViewall">A panel of experts conducted a comprehensive analysis of the scientific literature related to diabetes and other CVR factors&#46; This expert panel comprised 51 internal medicine physicians specialized in diabetes and CVD&#46; Five of the 51 internists acted as coordinators and 8 as moderators&#46; After reviewing the existing evidence each moderator proposed the key issues to be discussed by the experts&#46; The 5 coordinators defined 21 relevant questions concerning diabetes and CVR factors&#44; and proceeded to review and select the most pertinent bibliography which was sent to the experts for their review&#46; After this preliminary work&#44; a consensus conference took place in C&#243;rdoba &#40;Spain&#41; on 23 November 2012&#46; The whole-day conference was divided into three sessions&#58; three moderators presented the key topics &#40;diabetes and obesity&#44; dyslipidemia&#44; hypertension and platelet antiaggregation&#41; and formulated the questions to be discussed&#46; Then&#44; the members of the panel were distributed into 4 working groups to discuss and formulate precise answers to the questions being posed&#46; Each working group had 2 moderators who conducted the discussions and summarized the conclusions&#46; Finally&#44; a plenary session took place&#44; in which one moderator from each working group communicated the answers agreed upon by the groups and put to an anonymous vote by electronic system to reach a global agreement&#46; Attendees had 3 vote options&#58; &#8220;I agree&#8221;&#44; &#8220;I do not agree&#8221; and &#8220;I cannot define based on the evidence&#8221;&#46; A consensus agreement was considered when at least 75&#37; of the votes were &#8220;I agree&#8221;&#46; When the cut-off point was not reached&#44; the question was discussed by the whole panel&#44; reworded accordingly&#44; and then put to a vote again&#46; After the vote and once a consensus were reached&#44; the 5 coordinators supervised all the questions and answers to confirm its accuracy&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Results</span><p id="par0025" class="elsevierStylePara elsevierViewall">A total of 21 questions were answered by a mean of 41 participants &#40;range 32&#8211;44&#41;&#46; Eleven &#40;52&#37;&#41; questions were approved on the first ballot&#44; and the rest underwent a second vote to achieve the minimum 75&#37; of agreement&#46; Some of the latest were reworded to better express the opinion of the experts&#46; The result of this consensus is presented in the form of answers to the questions clustered under the four key topics &#40;<a class="elsevierStyleCrossRefs" href="#fig0005">Figs&#46; 1&#8211;4</a>&#41;&#46;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">A&#46;</span><p id="par0030" class="elsevierStylePara elsevierViewall">DM and obesity &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;</p></li></ul><ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">1&#46;</span><p id="par0035" class="elsevierStylePara elsevierViewall">Is it appropriate to test for myocardial ischemia in all DM2 asymptomatic patients&#63;</p></li></ul><ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">&#8226;</span><p id="par0040" class="elsevierStylePara elsevierViewall">The detection of myocardial ischemia is not indicated as a routine practice&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13&#44;14</span></a> In DM2 asymptomatic patients&#44; a comprehensive clinical history searching for CVR&#44; including symptoms and signs of CVD&#44; and an electrocardiogram obtained at rest should be enough&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a></p></li></ul><ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">2&#46;</span><p id="par0045" class="elsevierStylePara elsevierViewall">Is it necessary to carry out a self-monitoring of blood glucose &#40;SMBG&#41; in DM2 patients not treated with insulin&#63;</p></li></ul><ul class="elsevierStyleList" id="lis0025"><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">&#8226;</span><p id="par0050" class="elsevierStylePara elsevierViewall">Routine SMBG is not needed in DM2 patients with a stable disease and a good glycemic control&#44;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> particularly in those patients treated with anti-diabetics non-related to higher risk of hypoglycemia&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">&#8226;</span><p id="par0055" class="elsevierStylePara elsevierViewall">Patients treated with insulin secretagogues must have access to SMBG&#44; to confirm hypoglycemia if it is suspected&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a></p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">&#8226;</span><p id="par0060" class="elsevierStylePara elsevierViewall">In newly diagnosed patients&#44; a SMBG during the first 2 months could be suggested as part of the patient diabetic education&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a></p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">&#8226;</span><p id="par0065" class="elsevierStylePara elsevierViewall">An efficient use of self-checks would decrease the cost of the management of DM patients&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a></p></li></ul><ul class="elsevierStyleList" id="lis0030"><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">3&#46;</span><p id="par0070" class="elsevierStylePara elsevierViewall">When and how frequently should HbA1c be tested&#63;</p></li></ul><ul class="elsevierStyleList" id="lis0035"><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">&#8226;</span><p id="par0075" class="elsevierStylePara elsevierViewall">For diagnostic purposes&#44; HbA1c should be tested in patients with altered basal glycemia&#44; in those with high CVR&#44; and in patients with overt CVD&#46;</p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">&#8226;</span><p id="par0080" class="elsevierStylePara elsevierViewall">For metabolic control&#44; in diabetic patients&#58; at least every 6 months when the disease is stable&#59; every 3 months in non-stable patients or after treatment modifications&#46;</p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">&#8226;</span><p id="par0085" class="elsevierStylePara elsevierViewall">HbA1c interpretation has to take into account some limitations&#44; including hemoglobinopathy&#44; pregnancy&#44; chronic kidney disease&#44; etc&#46;</p></li></ul><ul class="elsevierStyleList" id="lis0040"><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">4&#46;</span><p id="par0090" class="elsevierStylePara elsevierViewall">How low should LDL-cholesterol &#40;LDL-C&#41; be kept in DM2&#63;</p></li></ul><ul class="elsevierStyleList" id="lis0045"><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">&#8226;</span><p id="par0095" class="elsevierStylePara elsevierViewall">The primary goal is an LDL-C<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>100<span class="elsevierStyleHsp" style=""></span>mg&#47;dl in all diabetic patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13&#44;19</span></a></p></li><li class="elsevierStyleListItem" id="lsti0075"><span class="elsevierStyleLabel">&#8226;</span><p id="par0100" class="elsevierStylePara elsevierViewall">A further target of LDL-C below 70<span class="elsevierStyleHsp" style=""></span>mg&#47;dL has been proposed in patients&#58;</p></li></ul><ul class="elsevierStyleList" id="lis0050"><li class="elsevierStyleListItem" id="lsti0080"><span class="elsevierStyleLabel">&#8211;</span><p id="par0105" class="elsevierStylePara elsevierViewall">With a very high CVR&#58; atherogenic dyslipidemia &#40;defined as decreased HDL cholesterol &#91;HDL-C&#93; and increased triglycerides &#91;TG&#93;&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> chronic renal impairment &#40;glomerular filtration rate<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>45<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#41; with proteinuria&#44;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> or peripheral artery disease&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a></p></li><li class="elsevierStyleListItem" id="lsti0085"><span class="elsevierStyleLabel">&#8211;</span><p id="par0110" class="elsevierStylePara elsevierViewall">With overt CVD&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13&#44;19</span></a></p></li></ul><ul class="elsevierStyleList" id="lis0055"><li class="elsevierStyleListItem" id="lsti0090"><span class="elsevierStyleLabel">5&#46;</span><p id="par0115" class="elsevierStylePara elsevierViewall">Which diabetic patients would benefit from a lipid lowering medication aimed to reduce TG and increase HDL-C levels&#63;</p></li></ul><ul class="elsevierStyleList" id="lis0060"><li class="elsevierStyleListItem" id="lsti0095"><span class="elsevierStyleLabel">&#8226;</span><p id="par0120" class="elsevierStylePara elsevierViewall">Once the LDL-C target is achieved &#40;as stated in question 4&#41;&#44; patients with HDL-C<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>35<span class="elsevierStyleHsp" style=""></span>mg&#47;dl and TG<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>200<span class="elsevierStyleHsp" style=""></span>mg&#47;dl would benefit from additional lipid lowering medication&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a></p></li></ul><ul class="elsevierStyleList" id="lis0065"><li class="elsevierStyleListItem" id="lsti0100"><span class="elsevierStyleLabel">6&#46;</span><p id="par0125" class="elsevierStylePara elsevierViewall">Is there any evidence on the superiority of certain weight-loss diets in improving the CVR&#63;</p></li></ul><ul class="elsevierStyleList" id="lis0070"><li class="elsevierStyleListItem" id="lsti0105"><span class="elsevierStyleLabel">&#8226;</span><p id="par0130" class="elsevierStylePara elsevierViewall">There is no consistent evidence supporting the superiority of any particular diet in terms of weight loss&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> However&#44; the Mediterranean diet improves the cardio-metabolic profile over the long term in obese patients<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> and it has shown to reduce the incidence of CV events among people at high CVR&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a></p></li><li class="elsevierStyleListItem" id="lsti0110"><span class="elsevierStyleLabel">&#8226;</span><p id="par0135" class="elsevierStylePara elsevierViewall">Clinical studies are needed to establish the cardiovascular safety of dissociated diets&#46;</p></li></ul><ul class="elsevierStyleList" id="lis0075"><li class="elsevierStyleListItem" id="lsti0115"><span class="elsevierStyleLabel">B&#46;</span><p id="par0140" class="elsevierStylePara elsevierViewall">High blood pressure &#40;HBP&#41; <a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a></p></li></ul><ul class="elsevierStyleList" id="lis0080"><li class="elsevierStyleListItem" id="lsti0120"><span class="elsevierStyleLabel">1&#46;</span><p id="par0145" class="elsevierStylePara elsevierViewall">Do antihypertensive drugs make a significant difference that justify their choice as first-line treatment for HBP&#63;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a></p></li></ul><ul class="elsevierStyleList" id="lis0085"><li class="elsevierStyleListItem" id="lsti0125"><span class="elsevierStyleLabel">&#8226;</span><p id="par0150" class="elsevierStylePara elsevierViewall">First of all&#44; changes in lifestyle&#44; such as diet or exercise&#44; should not be overlooked as an essential first step in the treatment of HBP&#46;</p></li><li class="elsevierStyleListItem" id="lsti0130"><span class="elsevierStyleLabel">&#8226;</span><p id="par0155" class="elsevierStylePara elsevierViewall">First-line drugs should include angiotensin converting enzyme inhibitors&#44; angiotensin II receptor blockers&#44; calcium channel blockers and diuretics&#46;</p></li><li class="elsevierStyleListItem" id="lsti0135"><span class="elsevierStyleLabel">&#8226;</span><p id="par0160" class="elsevierStylePara elsevierViewall">Treatment must be tailored according to the degree of CVR&#44; co-morbidities&#44; age&#44; ethnicity&#44; tolerance&#44; blood pressure level&#44; therapeutic purposes and cost&#47;effectiveness profile&#46;</p></li><li class="elsevierStyleListItem" id="lsti0140"><span class="elsevierStyleLabel">&#8226;</span><p id="par0165" class="elsevierStylePara elsevierViewall">Renin&#8211;angiotensin system inhibitors are the right choice for patients with DM and metabolic syndrome&#46;</p></li></ul><ul class="elsevierStyleList" id="lis0090"><li class="elsevierStyleListItem" id="lsti0145"><span class="elsevierStyleLabel">2&#46;</span><p id="par0170" class="elsevierStylePara elsevierViewall">When should ambulatory blood pressure monitoring &#40;ABPM&#41;&#47;Self Monitoring of Blood Pressure &#40;SMBP&#41; be carried out in hypertensive patients&#63;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a></p></li></ul><ul class="elsevierStyleList" id="lis0095"><li class="elsevierStyleListItem" id="lsti0150"><span class="elsevierStyleLabel">&#8226;</span><p id="par0175" class="elsevierStylePara elsevierViewall">We should optimize the arterial blood pressure measure at the doctor&#39;s office&#46;</p></li><li class="elsevierStyleListItem" id="lsti0155"><span class="elsevierStyleLabel">&#8226;</span><p id="par0180" class="elsevierStylePara elsevierViewall">It would be advisable to generalize the SMBP records for a better control of blood pressure values&#46;</p></li><li class="elsevierStyleListItem" id="lsti0160"><span class="elsevierStyleLabel">&#8226;</span><p id="par0185" class="elsevierStylePara elsevierViewall">In case of doubt on HBP diagnosis or degree of therapeutic control&#44; SMBP or preferably ABMP &#40;when available&#41; must be preformed&#46;</p></li><li class="elsevierStyleListItem" id="lsti0165"><span class="elsevierStyleLabel">&#8226;</span><p id="par0190" class="elsevierStylePara elsevierViewall">It would be desirable that all hypertensive patients had at least one ABPM record &#40;when available&#41;&#46;</p></li></ul><ul class="elsevierStyleList" id="lis0100"><li class="elsevierStyleListItem" id="lsti0170"><span class="elsevierStyleLabel">3&#46;</span><p id="par0195" class="elsevierStylePara elsevierViewall">Which diagnostic tests should be carried out in every newly diagnosed hypertensive patient&#63;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a></p></li></ul><ul class="elsevierStyleList" id="lis0105"><li class="elsevierStyleListItem" id="lsti0175"><span class="elsevierStyleLabel">&#8226;</span><p id="par0200" class="elsevierStylePara elsevierViewall">A proper clinical history together with a comprehensive physical examination is essential&#46;</p></li><li class="elsevierStyleListItem" id="lsti0180"><span class="elsevierStyleLabel">&#8226;</span><p id="par0205" class="elsevierStylePara elsevierViewall">Every patient should undergo the following&#58;</p></li></ul><ul class="elsevierStyleList" id="lis0110"><li class="elsevierStyleListItem" id="lsti0185"><span class="elsevierStyleLabel">&#8211;</span><p id="par0210" class="elsevierStylePara elsevierViewall">Laboratory tests &#40;including plasma glucose&#44; lipid profile&#44; glomerular filtration rate &#40;GFR&#41;&#44; and albumin&#8211;creatinine ratio in a fresh urine sample&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0190"><span class="elsevierStyleLabel">&#8211;</span><p id="par0215" class="elsevierStylePara elsevierViewall">Electrocardiogram&#46;</p></li></ul><ul class="elsevierStyleList" id="lis0115"><li class="elsevierStyleListItem" id="lsti0195"><span class="elsevierStyleLabel">4&#46;</span><p id="par0220" class="elsevierStylePara elsevierViewall">When should secondary HBP be screened&#63;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a></p></li></ul><ul class="elsevierStyleList" id="lis0120"><li class="elsevierStyleListItem" id="lsti0200"><span class="elsevierStyleLabel">&#8226;</span><p id="par0225" class="elsevierStylePara elsevierViewall">It is advisable in newly diagnosed patients aged &#60;20 and &#62;65 years&#46;</p></li><li class="elsevierStyleListItem" id="lsti0205"><span class="elsevierStyleLabel">&#8226;</span><p id="par0230" class="elsevierStylePara elsevierViewall">In patients with resistant hypertension&#46;</p></li><li class="elsevierStyleListItem" id="lsti0210"><span class="elsevierStyleLabel">&#8226;</span><p id="par0235" class="elsevierStylePara elsevierViewall">When physical or complementary examinations show alterations suggesting secondary HBP&#46;</p></li></ul><ul class="elsevierStyleList" id="lis0125"><li class="elsevierStyleListItem" id="lsti0215"><span class="elsevierStyleLabel">C&#46;</span><p id="par0240" class="elsevierStylePara elsevierViewall">Dyslipidemia</p></li></ul><ul class="elsevierStyleList" id="lis0130"><li class="elsevierStyleListItem" id="lsti0220"><span class="elsevierStyleLabel">1&#46;</span><p id="par0245" class="elsevierStylePara elsevierViewall">When should creatine kinase &#40;CK&#41; be measured in patients on statins&#63;</p></li></ul><ul class="elsevierStyleList" id="lis0135"><li class="elsevierStyleListItem" id="lsti0225"><span class="elsevierStyleLabel">&#8226;</span><p id="par0250" class="elsevierStylePara elsevierViewall">We do not believe that CK levels should be determined systematically&#44; due to its low specificity and sensibility&#59; thus it should be reserved for symptomatic patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">29&#8211;32</span></a></p></li></ul><ul class="elsevierStyleList" id="lis0140"><li class="elsevierStyleListItem" id="lsti0230"><span class="elsevierStyleLabel">2&#46;</span><p id="par0255" class="elsevierStylePara elsevierViewall">Does statin treatment provide cardiovascular benefits in patients with low-CVR&#63;</p></li></ul><ul class="elsevierStyleList" id="lis0145"><li class="elsevierStyleListItem" id="lsti0235"><span class="elsevierStyleLabel">&#8226;</span><p id="par0260" class="elsevierStylePara elsevierViewall">Statins are beneficial in patients at low-CVR&#44;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a> although the decision of starting treatment with those drugs must take into account efficiency criteria&#46;</p></li></ul><ul class="elsevierStyleList" id="lis0150"><li class="elsevierStyleListItem" id="lsti0240"><span class="elsevierStyleLabel">3&#46;</span><p id="par0265" class="elsevierStylePara elsevierViewall">Should the potential risk of DM associated with statin treatment modify our clinical practice&#63;</p></li></ul><ul class="elsevierStyleList" id="lis0155"><li class="elsevierStyleListItem" id="lsti0245"><span class="elsevierStyleLabel">&#8226;</span><p id="par0270" class="elsevierStylePara elsevierViewall">The low risk of incident diabetes showed with statins in clinical trials should not modify the indication of those drugs in non-diabetic patients meeting the criteria for statin treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a></p></li></ul><ul class="elsevierStyleList" id="lis0160"><li class="elsevierStyleListItem" id="lsti0250"><span class="elsevierStyleLabel">4&#46;</span><p id="par0275" class="elsevierStylePara elsevierViewall">When should serum transaminases be monitored during statin therapy&#63;</p></li></ul><ul class="elsevierStyleList" id="lis0165"><li class="elsevierStyleListItem" id="lsti0255"><span class="elsevierStyleLabel">&#8226;</span><p id="par0280" class="elsevierStylePara elsevierViewall">We recommend to measure transaminases levels at the beginning of treatment&#44; when new symptoms or signs appear &#40;e&#46;g&#46; jaundice&#41;&#44; in patients with liver disease and when the treatment pattern is changed &#40;e&#46;g&#46; changes in dosage&#44; new drug combination&#44; etc&#46;&#41;</p></li></ul><ul class="elsevierStyleList" id="lis0170"><li class="elsevierStyleListItem" id="lsti0260"><span class="elsevierStyleLabel">5&#46;</span><p id="par0285" class="elsevierStylePara elsevierViewall">Does the non-fasting TG evaluation have any clinical relevance&#63;</p></li></ul><ul class="elsevierStyleList" id="lis0175"><li class="elsevierStyleListItem" id="lsti0265"><span class="elsevierStyleLabel">&#8226;</span><p id="par0290" class="elsevierStylePara elsevierViewall">Although recent epidemiological studies remark the higher value of non-fasting &#40;as compared to fasting&#41; TG as predictors of CVD&#44;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> due to the lack of clear recommendations in current CPG&#44; together with the difficulty in interpreting laboratory results under non-fasting conditions&#44; including glycemia or calculated LDL-C&#44; we strongly discourage its use for clinical decision making&#46;</p></li></ul><ul class="elsevierStyleList" id="lis0180"><li class="elsevierStyleListItem" id="lsti0270"><span class="elsevierStyleLabel">D&#46;</span><p id="par0295" class="elsevierStylePara elsevierViewall">Antiaggregation</p></li></ul><ul class="elsevierStyleList" id="lis0185"><li class="elsevierStyleListItem" id="lsti0275"><span class="elsevierStyleLabel">1&#46;</span><p id="par0300" class="elsevierStylePara elsevierViewall">Is antiaggregation useful in primary prevention&#63; Who would benefit&#63;</p></li></ul><ul class="elsevierStyleList" id="lis0190"><li class="elsevierStyleListItem" id="lsti0280"><span class="elsevierStyleLabel">&#8226;</span><p id="par0305" class="elsevierStylePara elsevierViewall">Antiaggregation is not useful in primary prevention on a general basis&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13&#44;35&#44;36</span></a></p></li><li class="elsevierStyleListItem" id="lsti0285"><span class="elsevierStyleLabel">&#8226;</span><p id="par0310" class="elsevierStylePara elsevierViewall">It can be considered in high CVR patients&#44; balancing the risk of bleeding in each patient&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13&#44;37</span></a></p></li><li class="elsevierStyleListItem" id="lsti0290"><span class="elsevierStyleLabel">&#8226;</span><p id="par0315" class="elsevierStylePara elsevierViewall">Although antiaggregation could be considered in cancer prevention&#44; currently there is not enough evidence to support this recommendation&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">38</span></a></p></li></ul><ul class="elsevierStyleList" id="lis0195"><li class="elsevierStyleListItem" id="lsti0295"><span class="elsevierStyleLabel">2&#46;</span><p id="par0320" class="elsevierStylePara elsevierViewall">Should antiaggregation be used in DM as primary prevention&#63;</p></li></ul><ul class="elsevierStyleList" id="lis0200"><li class="elsevierStyleListItem" id="lsti0300"><span class="elsevierStyleLabel">&#8226;</span><p id="par0325" class="elsevierStylePara elsevierViewall">Antiaggregation in DM is associated to higher pharmacologic resistance and higher risk of bleeding&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">39</span></a></p></li><li class="elsevierStyleListItem" id="lsti0305"><span class="elsevierStyleLabel">&#8226;</span><p id="par0330" class="elsevierStylePara elsevierViewall">The scientific evidence has not proven net clinical benefit in DM&#44; and there are discrepancies among CPG&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a></p></li><li class="elsevierStyleListItem" id="lsti0310"><span class="elsevierStyleLabel">&#8226;</span><p id="par0335" class="elsevierStylePara elsevierViewall">Thus&#44; antiaggregation in primary prevention is only justified in patients with DM and high CVR&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">40</span></a></p></li></ul><ul class="elsevierStyleList" id="lis0205"><li class="elsevierStyleListItem" id="lsti0315"><span class="elsevierStyleLabel">3&#46;</span><p id="par0340" class="elsevierStylePara elsevierViewall">Is double antiaggregation useful in secondary prevention&#63;</p></li></ul><ul class="elsevierStyleList" id="lis0210"><li class="elsevierStyleListItem" id="lsti0320"><span class="elsevierStyleLabel">&#8226;</span><p id="par0345" class="elsevierStylePara elsevierViewall">Except in the case of acute coronary syndrome &#40;ACS&#41;&#44; double antiaggregation has not demonstrated clear net clinical benefit&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">41</span></a></p></li><li class="elsevierStyleListItem" id="lsti0325"><span class="elsevierStyleLabel">&#8226;</span><p id="par0350" class="elsevierStylePara elsevierViewall">In ACS not under percutaneous coronary intervention &#40;PCI&#41;&#44; we recommend double antiaggregation after balancing the risk of bleeding&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">42</span></a></p></li><li class="elsevierStyleListItem" id="lsti0330"><span class="elsevierStyleLabel">&#8226;</span><p id="par0355" class="elsevierStylePara elsevierViewall">In ACS undergoing PCI&#44; we recommend double antiaggregation&#44; with a minimum of 1 month for metallic-stents and 3&#8211;6 months for pharmacological-stents&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">41</span></a></p></li></ul><ul class="elsevierStyleList" id="lis0215"><li class="elsevierStyleListItem" id="lsti0335"><span class="elsevierStyleLabel">4&#46;</span><p id="par0360" class="elsevierStylePara elsevierViewall">Can we use proton pump inhibitors &#40;PPI&#41; in patients on antiaggregation treatment&#63;</p></li></ul><ul class="elsevierStyleList" id="lis0220"><li class="elsevierStyleListItem" id="lsti0340"><span class="elsevierStyleLabel">&#8226;</span><p id="par0365" class="elsevierStylePara elsevierViewall">There is not enough evidence supporting a potential increased risk of cardiovascular events with the concomitant use of clopidogrel and PPI&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">43</span></a></p></li><li class="elsevierStyleListItem" id="lsti0345"><span class="elsevierStyleLabel">&#8226;</span><p id="par0370" class="elsevierStylePara elsevierViewall">We recommend the use of PPI in antiaggregated patients after considering the risk of gastrointestinal bleeding&#46;</p></li></ul><ul class="elsevierStyleList" id="lis0225"><li class="elsevierStyleListItem" id="lsti0350"><span class="elsevierStyleLabel">5&#46;</span><p id="par0375" class="elsevierStylePara elsevierViewall">Should antiaggregation be used in secondary prevention in DM&#63;</p></li></ul><ul class="elsevierStyleList" id="lis0230"><li class="elsevierStyleListItem" id="lsti0355"><span class="elsevierStyleLabel">&#8226;</span><p id="par0380" class="elsevierStylePara elsevierViewall">Unless contraindicated&#44; antiaggregation is mandatory in secondary prevention in DM patients&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">44</span></a></p></li></ul><ul class="elsevierStyleList" id="lis0235"><li class="elsevierStyleListItem" id="lsti0360"><span class="elsevierStyleLabel">6&#46;</span><p id="par0385" class="elsevierStylePara elsevierViewall">Do new antiaggregation agents &#40;P2Y12 inhibitors&#41; have any advantages&#63;</p></li></ul><ul class="elsevierStyleList" id="lis0240"><li class="elsevierStyleListItem" id="lsti0365"><span class="elsevierStyleLabel">&#8226;</span><p id="par0390" class="elsevierStylePara elsevierViewall">At present&#44; the indication for the new P2Y12 inhibitors is for secondary prevention after ACS&#46;</p></li></ul></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Discussion</span><p id="par0395" class="elsevierStylePara elsevierViewall">This study shows that there is an extensive agreement among Spanish internal medicine physicians concerning crucial issues on diabetes and CVR factors&#46; In addition&#44; it shows the SEMI position related to 21 measures to implement an efficient use of available recommendations&#46;</p><p id="par0400" class="elsevierStylePara elsevierViewall">Among the 6 questions on DM and obesity&#44; only one &#40;A-5&#41; was controversial&#46; Initially&#44; the working group proposed to recommend the specific use of fibrates and omega-3 agents to reduce triglycerides and increase HDL-C levels&#46; However&#44; it was not accepted by the majority of the whole panel&#59; thus the agreement was to avoid the specific mention of these drugs&#44; keeping the recommendation in a more generic level&#46;</p><p id="par0405" class="elsevierStylePara elsevierViewall">Regarding HBP&#44; three out of the four questions required further revision by the whole panel&#58; question B-2&#58; although the usefulness of both ABPM and SMBP are fully recognized&#44; the first is not always available in the medical practice&#46; For this reason&#44; the panel agreed to recommend spreading the use of SMBP&#44; although stressing that it would be desirable to have at least one ABMP per patient &#40;conditioned to its availability&#41;&#46; Question B-3&#58; considering the diagnostic tests to be carried out in newly diagnosed hypertensive patients&#44; the panel questioned the need of a routine chest X-ray and finally decided not to include this complementary test unless clinically indicated&#46; Question B-4&#58; After discussion&#44; the panel decided to focus the screening for secondary HBP on three key points&#58; age at diagnosis&#44; resistance to treatment and a suspected secondary HBP&#46;</p><p id="par0410" class="elsevierStylePara elsevierViewall">In the dyslipidemia section&#44; when monitoring patients on statins for dyslipidemia &#40;question C-1&#41;&#44; the working group initially recommended the systematic evaluation of CK levels in all patients on statin treatment&#46; However&#44; after discussing and evaluating the clinical evidence&#44; the whole panel acknowledged that it was not cost-efficient to systematically test CK levels during statin treatment&#46; Thus&#44; we recommend conducting the test only in symptomatic patients&#46; The other 2 questions requiring a second vote were approved after a slight modification of the answer or the question&#46;</p><p id="par0415" class="elsevierStylePara elsevierViewall">Finally&#44; there was controversy regarding the minimum time of double antiaggregation &#40;question D-3&#41; in patients with ACS and PCI&#59; this point was discussed and agreed upon according to the available evidence&#46; The other 2 questions requiring a second vote reached the consensus by modifying the answers&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conclusion</span><p id="par0420" class="elsevierStylePara elsevierViewall">In spite of the multiple available guidelines on CVR and diabetes&#44; there are practical questions needing simple answers&#46; Routine clinical practices should be reconsidered according to clinical evidence and experience&#46; Customary practices should be adapted to individual patients&#8217; characteristics&#46; A rational use of diagnostic and management procedures leads to improved cost-effectiveness&#46; Upon this consensus&#44; SEMI recommends 21 measures to promote the efficient use of medical CV procedures&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conflict of interest</span><p id="par0425" class="elsevierStylePara elsevierViewall">This initiative has been supported by the Spanish Society of Internal Medicine &#40;SEMI&#41; and funded by Boehringer Ingelheim and Lilly&#46; The authors declare no conflicts of interest&#46;</p></span></span>"
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        "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Although the mortality associated to cardiovascular diseases &#40;CVD&#41; has been reduced in the last decades&#44; CVD remains the main cause of mortality in Spain and they are associated with an important morbidity and a huge economic burden&#46; The increasing prevalence of obesity and diabetes could be slowing down the mortality reduction in Spain&#46; Clinicians have often difficulty making clinical decisions due to the multiple clinical guidelines available&#46; Moreover&#44; in the current context of economic crisis it is critical to promote an efficient use of diagnostic and therapeutic proceedings to ensure the viability of public health care systems&#46; The Spanish Society of Internal Medicine &#40;SEMI&#41; has coordinated a consensus document to answer questions of daily practice with the aim of facilitating physicians&#8217; decision-making in the management of diabetes and cardiovascular risk factors from a cost-efficiency point of view&#46;</p>"
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        "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Aunque la mortalidad asociada a enfermedades cardiovasculares &#40;ECV&#41; se ha reducido en las &#250;ltimas d&#233;cadas&#44; las ECV siguen siendo la causa principal de mortalidad en Espa&#241;a y est&#225;n asociadas a una morbilidad importante y una enorme carga econ&#243;mica&#46;</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">La creciente prevalencia de obesidad y de diabetes podr&#237;a estar frenando la reducci&#243;n en la mortalidad en Espa&#241;a&#46; Los m&#233;dicos suelen tener mucha dificultad en la toma de decisiones cl&#237;nicas debido a las m&#250;ltiples gu&#237;as cl&#237;nicas disponibles&#46; Por otro lado&#44; en el contexto actual de la crisis econ&#243;mica es imprescindible promover un uso eficaz de los procedimientos diagn&#243;sticos y terap&#233;uticos para garantizar la viabilidad de los sistemas de salud p&#250;blica&#46; La Sociedad Espa&#241;ola de Medicina Interna &#40;SEMI&#41; ha desarrollado un documento de consenso para responder a las dudas que surgen en la pr&#225;ctica rutinaria con el objetivo de facilitar a los m&#233;dicos la toma de decisiones en el control de la diabetes y en los factores de riesgo cardiovascular desde el punto de vista de la rentabilidad&#46;</p>"
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Clinical up-date
DOI: 10.1016/j.rce.2013.12.014
Clinical decisions in patients with diabetes and other cardiovascular risk factors. A statement of the Spanish Society of Internal Medicine
Decisiones clínicas en pacientes con diabetes y otros factores de riesgo cardiovascular. Una declaración de la sociedad española de medicina interna
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R. Gómez-Huelgasa,
Autor para correspondencia
ricardogomezhuelgas@hotmail.com

Corresponding author.
, F. Pérez-Jiménezb, M. Serrano-Ríosc, P. González-Santosd, P. Románe, M. Camafortf, P. Contheg, J. García-Alegríah, R. Guijarroi, J. López-Mirandab, R. Tirado-Mirandaj, P. Valdivielsok, the SEMI Working Group ◊
a Hospital Regional Universitario de Málaga, Internal Medicine Department, Málaga, Spain
b Hospital Universitario Reina Sofia, Lipid and Atherosclerosis Unit, IMIBIC/Hospital Universitario Reina Sofia/Universidad de Cordoba, and CIBER Fisiopatologia Obesidad y Nutricion (CIBEROBN), Instituto de Salud Carlos III, Córdoba, Spain
c Hospital Clínico San Carlos, Spanish Biomedical Research Centre in Diabetes and Associated Metabolic Disorders (CIBERDEM), Instituto de Investigacion (IdISSC), Madrid, Spain
d Hospital Clínico Universitario Virgen de la Victoria, Internal Medicine Service, Malaga, Spain
e Hospital General de Requena, Internal Medicine Department, Requena, Valencia, Spain
f Hospital Clinic IDIBAPS Universidad de Barcelona, Internal Medicine Department, Barcelona, Spain
g Hospital Gregorio Marañon, Internal Medicine Unit, Spain
h Hospital Costa del Sol, Internal Medicine Department, Autovia, Marbella, Málaga, Spain
i Hospital Regional Universitario Carlos Haya, Internal Medicine Unit, Malaga, Spain
j Hospital Infanta Margarita, Internal Medicine Department, Cabra, Cordoba, Spain
k Hospital Clínico Universitario Virgen de la Victoria, Internal Medicine Department, Malaga, Spain
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