[Factors associated with cardiovascular risk and cardiovascular and renal disease in the IBERICAN study: Final results]

Prevalence, impact and management of hypertension-mediated organ damage in type 2 diabetes patients

OBJECTIVE

To determine the prevalence, impact and management of hypertension-mediated organ damage (HMOD) according to the presence of type 2 diabetes (T2DM).

METHODS

IBERICAN is an ongoing multicenter, observational and prospective study, including outpatients aged 18-85 years who attended the Primary Care setting in Spain. In this study, the prevalence, impact and management of HMOD according to the presence of T2DM at baseline were analyzed.

RESULTS

At baseline, 8066 patients (20.2% T2DM, 28.6% HMOD) were analyzed. Among patients with T2DM, 31.7% had hypertension, 29.8% dyslipidemia and 29.4% obesity and 49.3% had ≥1 HMOD, mainly high pulse pressure (29.6%), albuminuria (16.2%) and moderate renal impairment (13.6%). The presence of T2DM significantly increased the risk of having CV risk factors and HMOD. Among T2DM population, patients with HMOD had more dyslipidemia (78.2% vs 70.5%; P=0.001), hypertension (75.4% vs 66.4%; P=0.001), any CV disease (39.6% vs 16.1%; P=0.001) and received more drugs. Despite the majority of types of glucose-lowering agents were more frequently taken by those patients with HMOD, compared to the total T2DM population, the use of SGLT2 inhibitors and GLP-1 receptor agonists was marginal.

CONCLUSIONS

In patients daily attended in primary care setting in Spain, one in five patients had T2DM and nearly half of these patients had HMOD. In patients with T2DM, the presence of HMOD was associated with a higher risk of CV risk factors and CV disease. Despite the very high CV risk, the use of glucose-lowering agents with proven CV benefit was markedly low.

Clinical profile of severe hypercholesterolemia in 156,000 adults in primary care

OBJECTIVE

To examine the frequency of severe hypercholesterolemia (HS) and its clinical profile, and the phenotype of familial hypercholesterolemia (FH), in the primary-care setting in a large health area of the Community of Madrid (CAM).

MATERIAL AND METHODS

Multicenter study of subjects with a health card assigned to 69 health centers (Northwest/CAM area). HS was defined as cholesterol ≥300mg/dL or LDL-cholesterol ≥220mg/dL in any analysis performed (1-1-2018 to 12-30-2021); and FH phenotype as c-LDL ≥240mg/dL (≥160mg/dL if lipid-lowering treatment) with triglycerides <200mg/dL and TSH <5μIU/mL.

RESULTS

156,082 adults ≥18years with an available lipid profile were analyzed. 6187 subjects had HS (3.96% of the laboratory tests studied, 95%CI: 3.87-4.06%). The mean evolution time of the diagnosis of hyperlipidemia in the computerized clinical record was 10.8years, 36.5% had hypertension, 9.5% diabetes and 62.9% overweight/obesity. 83.7% were taking lipid-lowering drugs (65.7% low/moderate and 28.6% high/very high intensity). 6.1% had cardiovascular disease (94.2% treated with lipid-lowering agents), with LDL-cholesterol <55, <70 and <100mg/dL of 1.8%, 5.8% and 20.2%, respectively (vs. 1%, 2.3% and 11.2% if no cardiovascular disease). 1600 subjects had FH phenotype (95%CI: 1.03%, 0.98-1.08%).

CONCLUSIONS

Four out of 100 patients analyzed in primary care have HS, with high treatment level, but insufficient intensity, and poor achievement of treatment goals. One in 100 have the FH phenotype. The identification of both dyslipidemias by computerized records would allow their more precise and early detection and establish cardiovascular preventive strategies.

Clinical characteristics, treatment, and blood pressure control in patients with hypertension seen by primary care physicians in Spain: the IBERICAN study

Objectives

To determine the clinical profile, according to the history of hypertension, the risk of developing hypertension, current antihypertensive treatment and BP control rates in patients with hypertension from the IBERICAN cohort.

Methods

IBERICAN is an ongoing prospective cohort study, whose primary objective is to determine the frequency, incidence, and distribution of CVRF in the adult Spanish population seen in primary care settings. This analysis shows the baseline clinical characteristics of patients with hypertension. Adequate BP control was defined as BP <140/90 mmHg according to 2013 ESH/ESC guidelines.

Results

A total of 8,066 patients were consecutively included, of whom 3,860 (48.0%) had hypertension. These patients were older (65.8 ± 10.9 vs. 51.6 ± 14.7 years; p < 0.001), had more cardiovascular risk factors, target organ damage and cardiovascular disease (CVD) in comparison with those without hypertension. The risk of hypertension increased with the presence of associated CV risk factors and comorbidities, particularly diabetes, obesity and the metabolic syndrome, and decreased with the intensity of physical activity. Regarding antihypertensive treatments, 6.1% of patients did not take any medication, 38.8% were taking one antihypertensive drug, 35.5% two drugs, and 19.6% three or more antihypertensive drugs. Overall, 58.3% achieved BP goals <140/90 mmHg. A greater probability of BP control was observed with increasing age of patients and the greater number of antihypertensive drugs. Blood pressure control was lower in hypertensive patients with diabetes, obesity, the metabolic syndrome, increased urinary albumin excretion, higher pulse pressure, and lack of antihypertensive treatment.

Conclusions

About half of patients attended in primary care settings have hypertension in Spain. Patients with hypertension have a worse CV clinical profile than non-hypertensive patients, with greater association of CVRF and CVD. Around four out of ten patients do not achieve the recommended BP goals, and higher use of combination therapies is associated with a better BP control.

Case-fatality rate of SARS-CoV-2 infection during the third and fifth epidemic waves in Spain: Impact of vaccination

INTRODUCTION

During the first and second epidemic waves in Spain, the SARS-CoV-2 case-fatality rates (CFRs) showed significant differences between Autonomous Communities (ACs). Comparing CFRs in the third and fifth epidemic waves can provide information on the impact of the different vaccination coverages in the ACs.

OBJECTIVE

To evaluate the impact of vaccination on COVID-19 CFRs in the third and fifth epidemic waves in Spain, according to sex, age, and AC.

METHODS

This work is an observational, descriptive study which uses data on COVID-19 infections, deaths, and vaccinees published by the Spanish Ministry of Health and the regional Health Departments of the ACs. The third epidemic wave was defined as the period from 26th December 2020 to 19th April 2021, and the fifth wave, from 19th July to 19th September 2021. The CFRs (deaths per 1000 infected [‰]) were calculated according to sex, age group, and AC. The standardized case-fatality ratio (SCFR) was adjusted for age and sex for each wave. We estimated the correlation between CFRs and their change between the two epidemic waves with the vaccination coverages reached at the beginning of the fifth wave.

RESULTS

The CFR in the fifth wave (5.7‰) was lower than in the third wave (16.5‰). In addition, the CFR in both waves was significantly higher in men than in women, and in older people than in younger ones. A decrease in the CFR between both waves was only observed in those older than 49. A strong direct and positive correlation (R2a=0.8399) was found between vaccination coverage by age group and decrease in CFR between both epidemic waves. Significant differences were seen between ACs in the two waves, as regards both CFRs and SCFRs. When comparing ACs, a direct correlation was observed between vaccination coverage and CFRs in the fifth wave, and also - although weak - between vaccination coverage and decrease in CFR between both waves.

CONCLUSION

The CFR significantly decreased in Spain between the third and the fifth epidemic waves in population aged 50 or older, probably due to the high vaccination coverage in that age group. Differences were observed between CFRs and SCFRs between ACs that are not explained by the differences in vaccination coverage, suggesting the need for further research and evaluation.

[Twenty-year experience in strict versus non-strict control of arterial hypertension in a health center in Spain]

INTRODUCTION AND AIMS

During clinical trials effective reduction of blood pressure (BP) leads to a reduction in the incidence of cardiovascular (CV) morbimortality. Our main aim is to ascertain whether, under actual conditions of clinical practice, BP monitoring leads to a long-term reduction in CV events.

PATIENTS AND METHODS

The study was performed on 164 patients with hypertension (HT) selected among patients who came to family medicine consultations because of HT. An analysis was performed between patients who presented clinical BP lower than 140/90mmHg and those that had higher levels. When patients entered the study, they were followed up until a CV event occurred or up to a maximum of 20 years, at which time follow up ended.

RESULTS

Of the total of 164 patients, good control of BP was attained by 93 (56.7%), and 71 did not attain good control (42.2%). In the multivariate analysis, the only predictive variable for CV events was the lack of strict control of BP (HR: 2.93; 95% CI: 1.45-5.89; p=0.003), and the female sex was protective for CV events (HR: 0.37; 95% CI: 0.18-0.74; p=0.005).

CONCLUSIONS

The fundamental predictor variable of CV morbimortality in patients with HT is the lack of HT strict control; the women also had fewer CV complications.

Regional differences in the degree of glycaemic diabetes control in Spain and associated factors. IBERICAN study

BACKGROUND AND OBJECTIVE

The prevalence of type 2 diabetes (T2D) is high, it is increasing and its degree of control seems to be improvable with important social and health consequences. The objective of this study is to determine the regional differences in the degree of glycaemic control of T2D in Spain and its associated factors.

MATERIAL AND METHODS

Cross-sectional, multicentre, observational study in patients with T2D between 18 and 85 years of age selected by consecutive sampling between 2014 and 2018. The population was divided into four regions: north, centre, Mediterranean and south-east. The main variable was the value of glycated haemoglobin (HbA1c). Sociodemographic and clinical variables, presence or absence of other risk factors and treatment were recorded.

RESULTS

A total of 1587 patients with T2D were analysed, with a mean age of 65.93 years (standard deviation [SD] 10.14); 54.5% were men; the mean duration of T2D was 8.63 years (SD 6.64) and the mean HbA1c value was 7.05%. Of the total, 59.8% had an HbA1c value ≤ 7% (north 59.5%, centre 59.5%, Mediterranean 60.6% and south-east 59.8%; P=.99). The factors for poor control were: in the north, duration of T2D and being sedentary; in the centre, duration of T2D and having a low income; in the Mediterranean, duration of T2D; and in the south-east, duration of T2D and having a low level of education or income. Overall, 76.2% of the subjects had hypertension, 75.1% dyslipidaemia, and 51.7% obesity, with significant differences between regions only being observed in the case of dyslipidaemia (P<.001).

CONCLUSIONS

No differences were observed in the degree of diabetes control in the different regions, with the percentage of patients needing intensification in their control being high in all of them. The factors associated with poor control were the duration of the disease, a low level of education or income, and a sedentary lifestyle.

[Overcoming the barriers in the approach of the chronic patient]

At least one in three adults has multiple chronic conditions. The assistance of patients with chronic conditions is mandatory. This is one of the main tasks of the primary care physicians. The approach in these patients is challenging, as there are many barriers at different levels (sanitary system, healthcare professionals and patients). In addition, COVID-19 pandemic has worsened this situation even more. Therefore, it is necessary to take actions that try to improve this state. For this purpose, with the aim to find solutions/recommendations that may be helpful to attain a better diagnosis, treatment and follow-up of patients with chronic diseases, a group of experts of SEMERGEN have tried to identify the problems in the attention to these patients, searching for potential solutions and areas of improvement. The present document has specifically focused on four prevalent chronic conditions in primary care: dyslipidemia, arterial hypertension, chronic venous disease and depression.

Cardiovascular Risk in Patients with Dyslipidemia and Their Degree of Control as Perceived by Primary Care Physicians in a Survey-TERESA-Opinion Study

OBJECTIVE

The aim of this study was to evaluate, through a survey, the opinion of primary care (PC) physicians on the magnitude of dyslipidemia and its degree of control in their clinical practice.

MATERIALS AND METHODS

An ecological study was carried out, in which the physicians were invited to participate by means of an online letter. Data were collected at a single timepoint and were based only on the experience, knowledge, and routine clinical practice of the participating physician.

RESULTS

A total of 300 physicians answered the questionnaire and estimated the prevalence of dyslipidemia between 2% and 80%. They estimated that 23.5% of their patients were high-risk, 18.2% were very high-risk, and 14.4% had recurrent events in the last 2 years. The PC physicians considered that 61.5% of their patients achieved the targets set. The participants fixed the presence of side-effects to statins at 14%. The statin that was considered safest with regard to side-effects was rosuvastatin (69%).

CONCLUSIONS

PC physicians in Spain perceive that the CVR of their patients is high. This, together with the overestimation of the degree of control of LDL-C, could justify the inertia in the treatment of lipids. Moreover, they perceive that one-sixth of the patients treated with statins have side-effects.

[Cardiovascular preventive recommendations. PAPPS 2022 thematic updates. Working groups of the PAPPS]

The recommendations of the semFYC's Program for Preventive Activities and Health Promotion (PAPPS) for the prevention of cardiovascular diseases (CVD) are presented. The following sections are included: epidemiological review, where the current morbidity and mortality of CVD in Spain and its evolution as well as the main risk factors are described; cardiovascular (CV) risk and recommendations for the calculation of CV risk; main risk factors such as arterial hypertension, dyslipidemia and diabetes mellitus, describing the method for their diagnosis, therapeutic objectives and recommendations for lifestyle measures and pharmacological treatment; indications for antiplatelet therapy, and recommendations for screening of atrial fibrillation, and recommendations for management of chronic conditions. The quality of testing and the strength of the recommendation are included in the main recommendations.

Characterizing Diagnostic Inertia in Arterial Hypertension With a Gender Perspective in Primary Care

Background and Objectives

Substantial evidence shows that diagnostic inertia leads to failure to achieve screening and diagnosis objectives for arterial hypertension (AHT). In addition, different studies suggest that the results may differ between men and women. This study aimed to evaluate the differences in diagnostic inertia in women and men attending public primary care centers, to identify potential gender biases in the clinical management of AHT.

Study Design/Materials and Methods

Cross-sectional descriptive and analytical estimates were obtained nested on an epidemiological ambispective cohort study of patients aged ≥30 years who attended public primary care centers in a Spanish region in the period 2008–2012, belonging to the ESCARVAL-RISK cohort. We applied a consistent operational definition of diagnostic inertia to a registry- reflected population group of 44,221 patients with diagnosed hypertension or meeting the criteria for diagnosis (51.2% women), with a mean age of 63.4 years (62.4 years in men and 64.4 years in women).

Results

Of the total population, 95.5% had a diagnosis of hypertension registered in their electronic health record. Another 1,968 patients met the inclusion criteria for diagnostic inertia of hypertension, representing 4.5% of the total population (5% of men and 3.9% of women). The factors significantly associated with inertia were younger age, normal body mass index, elevated total cholesterol, coexistence of diabetes and dyslipidemia, and treatment with oral antidiabetic drugs. Lower inertia was associated with age over 50 years, higher body mass index, normal total cholesterol, no diabetes or dyslipidemia, and treatment with lipid-lowering, antiplatelet, and anticoagulant drugs. The only gender difference in the association of factors with diagnostic inertia was found in waist circumference.

Conclusion

In the ESCARVAL-RISK study population presenting registered AHT or meeting the functional diagnostic criteria for AHT, diagnostic inertia appears to be greater in men than in women.

[SEMERGEN positioning on approaching chronic heart failure in primary care]

Heart failure (HF) is a public health problem that generates a large healthcare burden both in hospitals and in Primary Care (PC). The publication of numerous studies about HF in recent years has led to a paradigm shift in the approach to this syndrome, in which the work of PC teams is gaining greater prominence. The recent guidelines published by the European Society of Cardiology have fundamentally introduced changes in the management of patients with HF. The new proposed strategy, with drugs that reduce hospitalizations and slow the progression of the disease, should now be a priority for all professionals involved. This position document analyzes a proposal for an approach based on multidisciplinary teams with the leadership of family doctors, key to providing quality care throughout the entire process of the disease, from its prevention to the end of the life.