Cardiovascular risk in the elderly population of Spain. The EPICARDIAN risk score

BACKGROUND AND OBJECTIVES

Cardiovascular risk estimation in people over 70 years of age is problematic. Most scores have been created based on cohorts of middle-aged people, with an underrepresentation of older adults. The predictive power of classical cardiovascular risk factors declines with age. The aim of this work is to develop a specific score for estimating cardiovascular risk among the elderly population in Spain.

METHODS

This work is a population-based cohort established in 1995.

SETTING

Three geographical areas of Spain (Madrid, Ávila, and Lugo).

PARTICIPANTS

3,729 people older than 64 years with no cardiovascular diseases (CVD) at baseline.

MEASUREMENTS

Suspected fatal and nonfatal CVD (both coronary heart disease and stroke) were investigated annually and confirmed using the WHO-MONICA criteria. All participants were followed-up on until occurrence of a first CVD event, until death, or until December 31, 2015.

RESULTS

Age was the strongest predictor of CVD at 10 years in both men and women. In men, variables associated with CVD were high blood pressure treatment (HR: 1.35; 95% CI: 1.067-1.710), diabetes (HR: 1.359; 95% CI: 0.997-1.852), and smoking (HR: 1.207; 95% CI: 0.945-1.541) and in women, the variables were smoking (HR: 1.881; 95% CI: 1.356-2.609) and diabetes (HR: 1.285; 95% CI: 0.967-1.707). Total cholesterol did not increase the risk of CVD in men or women. However, total cholesterol levels >200 mg/dL were inversely associated with 10-year risk of CVD in men and women.

CONCLUSIONS

In elderly Spanish men, total CVD at 10 years is significantly increased by age, diabetes, and antihypertensive treatment and in elderly Spanish women by diabetes and smoking. Total cholesterol levels did not increase the risk of CVD, particularly in males.

Conventional versus Rosemont endoscopic ultrasound criteria for chronic pancreatitis: interobserver agreement in same day back-to-back procedures

BACKGROUND AND STUDY AIMS

Endoscopic ultrasound (EUS) is a commonly used and fairly sensitive method of assessing changes of chronic pancreatitis (CP) when routine noninvasive imaging has not shown overt features of CP. The aim of this study is to evaluate the interobserver agreement (IOA) for the classic (MSC) and the Rosemont (RC) criteria for the diagnosis of chronic pancreatitis on the basis of clinical practice.

PATIENTS AND METHODS

Two experienced endosonographers evaluated on the same day patients referred for EUS in a blinded fashion. Data from the sonographic criteria of both MSC and RC were collected. Agreement was calculated using k statistics.

RESULTS

A total of 69 patients were evaluated. The study population included mainly patients without pancreatic diseases, resulting in a low number of sonographic findings. Agreement for the final diagnosis was moderate for both classification systems of chronic pancreatitis (k = 0.53 for conventional and k = 0.46 for Rosemont).

CONCLUSIONS

The IOA of EUS in the diagnosis of CP is moderate. The concordance values obtained in clinical practice are similar to those obtained in multicenter studies. The RC does not seem to improve the IOA of MSC.

Attenuated severity of new acute ischemic events in patients with previous coronary heart disease receiving long-acting nitrates

BACKGROUND

Platelet aggregation and secondary vasoconstriction are key events in the genesis of acute coronary syndromes.

HYPOTHESIS

Since nitrates have vasodilatory and antiaggregant effects, treatment with long-acting nitrates at the time of onset of acute coronary syndromes could be associated with attenuation of their severity.

METHODS

A consecutive series of 533 patients with acute coronary syndrome and past history of coronary artery disease admitted to the Cardiology Service of a general hospital was studied. A specific questionnaire assessed the use of nitrates and other relevant drugs, as well as other clinical variables. The diagnosis of unstable angina or acute myocardial infarction (MI) was established according to clinical, electrocardiographic, and enzymatic criteria.

RESULTS

In the whole cohort, 169 patients had MI and 364 had unstable angina. Previous use of long-acting nitrates was significantly more common in patients with unstable angina (56%) than in those with MI (37%) (p < 0.0001). Multivariate analysis identified being a nonsmoker [odds ratio: 95%, confidence limits (CL) 0.37, 0.23-0.59], previous unstable angina (CL 0.62, 0.41-0.92), use of aspirin (CL 0.58, 0.41-0.92), and use of long-acting nitrates (CL 0.61, 0.40-0.93) as the independent predictors of the development of unstable angina rather than MI; of these the combination of nitrates and aspirin was the strongest predictor.

CONCLUSIONS

Long-acting nitrates as well as aspirin are suggested to have a protective or modifying effect on the development of acute coronary syndromes, favoring unstable angina rather than acute MI.

Two-stage treatment with preoperative endoscopic retrograde cholangiopancreatography (ERCP) compared with single-stage treatment with intraoperative ERCP for patients with symptomatic cholelithiasis with possible choledocholithiasis

BACKGROUND AND STUDY AIMS

An ideal treatment for choledocholithiasis in the laparoscopic era has not been established. The objective of this study was to elucidate whether a treatment strategy of performing intraoperative endoscopic retrograde cholangiopancreatography (ERCP) during laparascopic cholecystectomy (when choledocholithiasis is confirmed by intraoperative cholangiography) is better for patients with suspected common bile duct stones than the current strategy (preoperative ERCP followed by laparoscopic cholecystectomy).

PATIENTS AND METHODS

This was a prospective randomized study to evaluate which of these two approaches was most benefit- and cost-effective for patients with intermediate risk of choledocholithiasis. Patients underwent either preoperative ERCP followed by a laparoscopic cholecystectomy a few weeks later (the "preoperative ERCP" group) or intraoperative ERCP (the "intraoperative ERCP" group). Intraoperative ERCP was performed using the rendezvous technique.

RESULTS

There were 64 patients in the preoperative ERCP group and 59 patients in the intraoperative ERCP group. The demographic and clinical characteristics of the two groups were similar, except that the bilirubin and gamma-glutamyl transferase (GGT) levels and the number of patients treated on an inpatient basis were higher in the preoperative ERCP group. Success rates were similar (96.6 % in the preoperative ERCP group vs. 90.2 % in the intraoperative ERCP group in the per-protocol study). Total morbidity, post-ERCP morbidity, and post-ERCP acute pancreatitis rates were higher in the preoperative ERCP group, but there were no differences between the two groups in the frequency of residual common bile duct stones, the conversion rate to open cholecystectomy, or surgical morbidity. The length of hospital stay and costs were lower in the intraoperative ERCP group despite the longer surgical times in this group. Univariate analysis did not find any relationship between morbidity and total bilirubin or GGT. Logistic regression analysis confirmed that morbidity was related only to the treatment group and the time spent in the operating room: the relative risk (RR) was 4.37 for morbidity and 1.015 for the time spent in the operating room); the RR for papillotomy was 5.49.

CONCLUSIONS

Both treatment approaches were equally effective but the intraoperative ERCP group had less morbidity, a shorter hospital stay, and reduced costs. The lower morbidity in the intraoperative ERCP group resulted from the lower rate of papillotomy and lower rates of post-ERCP pancreatitis and cholecystitis. Total morbidity was principally related to the type of treatment approach used.

Validation of the Agency for Health Care Policy and Research (AHCPR) classification for managing unstable angina

To validate the AHCPR classification for the prognosis of unstable angina, 225 consecutive patients were recruited with a suspected diagnosis of that condition attending a tertiary hospital from November 1994 through April 1995 and followed for one year. One-hundred fifty-six (69.3%) patients were considered at high risk, 37 (16.5%) at intermediate, and 32 (14.2%) at low risk of cardiac complications. All of the patients with major in-hospital cardiac complications (8 patients) had at least one of the features of the high risk group. The high to intermediate-low hazard ratio (HR) for one-year cardiac complications after the onset of unstable angina was 4.03. Predictors of major complications (myocardial infarction or death) after the follow-up were age > 65 (HR, 5.69); diabetes (HR, 4.94); heart failure (HR, 2.65); and prolonged angina (HR, 2.55). AHCPR classification correctly identified patients with risk of severe outcomes at the hospital. Also, the classification predicted outcomes one year after hospitalization, diabetes being an important determinant of adverse cardiac events.

Perceived health over 3 years after percutaneous coronary balloon angioplasty

The magnitude of the benefit of percutaneous transluminal coronary angioplasty (PTCA) in terms of quality of life depending on baseline and outcome clinical variables is not sufficiently understood because of the restrictive inclusion criteria of randomized clinical trials. The present study was designed to assess perceived health outcome at 3 years and its association with clinical variables after successful elective PTCA in a tertiary hospital throughout a prospective cohort study. Questionnaires were administered on the day before the procedure and 1 month and 3.4 years later (as mean follow-up) to 106 patients recruited during a 15-month period. Mean perceived health scores improved significantly for the population as a whole 1 month after PTCA, and improvement was maintained at the end of follow-up. The magnitude of the effect was different depending on clinical subgroups: (a) It was greatest in patients free from angina, myocardial infarction, or new revascularization procedures at the end of follow-up; (b) It was moderately reduced in patients with comorbidity; (c) Patients who reported to have dyspnea or angina at rest after the latest revascularization procedure did not improve, with poor final perceived health scores. Elective PTCA is associated with a significant improvement in perceived health, which varies depending on the clinical outcome. Comorbidity and initial perceived health influence outcome but do not preclude improvement.

[Patients with acute coronary syndrome: therapeutic approach (management patterns) and 1-year prognosis in a tertiary general hospital]

BACKGROUND

To assess the determinants of short-term and one-year prognosis of all patients with suspected acute coronary syndrome seen by the cardiologist on duty in the Emergency Service of a tertiary hospital during a six month period.

PATIENTS AND METHODS

153 consecutive patients with a diagnosis of acute myocardial infarction, 225 with a diagnosis of unstable angina and 89 with a diagnosis of atypical chest pain were identified and their in-hospital characteristics and one-year prognosis were prospectively assessed.

RESULTS

Age was higher than 65 years in 53% of acute myocardial infarction and in 54% of unstable angina patients. Only 3 patients were lost to follow-up. 35% of acute myocardial infarction patients had died or had reinfarction after one year and 16% of unstable angina patients had died or had suffered acute myocardial infarction. Baseline features, management patterns and prognosis of patients admitted with acute myocardial infarction to the Cardiology Service, to other hospital areas or to other hospitals were markedly different, and admission in areas other than the Cardiology Service was an independent mortality predictor. In unstable angina, complications happened in patients older than 75 years, those with previous revascularization procedures, those undergoing revascularization or those with lesions not deemed revascularizeable.

CONCLUSIONS

a) In the study population there was a predominance of elderly patients; the proportion of patients with poor prognosis was considerably high; b) a sizeable proportion of patients with severe complications was scarcely represented in the major clinical trials; c) the possibility arises of a distribution of care resources tending to concentrate the greater therapeutic efforts in the patients with good prognosis.

[Trends of morbidity and mortality in chronic heart failure in Catalonia]

INTRODUCTION

The epidemiology of chronic heart failure, specifically its morbidity and mortality, is insufficiently known, despite the fact that it has an important economic impact because of the pharmacological treatment and the high hospitalization rate.

OBJECTIVE

To analyze the trends of mortality and morbidity of chronic heart failure in Catalonia during the periods 1975-1994 and 1989-1994 respectively.

PATIENTS AND METHODS

Specific mortality and morbidity rates (ages 45-65, and older than 65) were calculated for both sexes. Standardised mortality rates were also calculated for mortality rates using the European population as the reference.

RESULTS

The trend of mortality of chronic heart failure in the population of 45-65 is stable, the rates being higher for men than for women. The trend in the age group older than 65 shows an important increase from 1983 on, higher in women than in men. Morbidity (hospitalization discharge rates) increases slightly in the population of 45-65 years, especially in men; in the population older than 65 an important increase is observed for both sexes.

CONCLUSIONS

Trend of mortality is increasing specifically in women older than 65, while trends of morbidity are clearly increasing for both age groups.

Is prophylactic treatment after myocardial infarction evidence-based?

OBJECTIVE

We aimed to evaluate the use of evidence-based prophylactic treatment after myocardial infarction on hospital discharge and in primary care after 1 year of hospitalization.

METHODS AND RESULTS

We conducted a 1-year prospective study of all the patients discharged from a tertiary hospital who had been treated for myocardial infarction from January 1 to December 31 1995. Three hundred and eighty surviving patients were consecutively discharged from the hospital. Seventy per cent of patients were treated with aspirin, 45% with beta-blockers, 27% with calcium channel blockers, 26% with ACE inhibitors, 40% with nitrates and 8% with cholesterol-lowering drugs after discharge from the hospital. In primary care, prescription of lipid-lowering drugs increased to 17%, while prescription of beta-blockers decreased to 34%. ACE inhibitor prescriptions at discharge were clearly more common in patients with impaired ventricular function or heart failure (57%).

CONCLUSION

According to the evidence, there is still potential for reducing the risk of a further ischaemic event or death in patients with MI, especially by increasing the use of beta-blockers and lipid-lowering drugs.

[Preventive treatment of nonrheumatic atrial fibrillation: from the efficacy of clinical trials to the effectiveness of clinical practice]

OBJECTIVES

To know the percentage of patients with nonrheumatic atrial fibrillation treated with anticoagulants as an approach to the effectiveness of the prophylactic treatment of stroke.

DESIGN

Multicenter observational study.

SETTING

Six primary health centers from Barcelona.

PARTICIPANTS

465 patients with the diagnosed of AF were selected during the second semester of 1996. Patients that had suffered a hemorrhagic stroke, or with mitral stenosis, or with a prosthetic valve, or had hyperthyroidism, or receiving anticoagulant therapy were excluded.

MEASUREMENTS AND MAIN RESULTS

299 patients (64%) were finally included for the analysis. 15.8% of the patients were treated with acenocoumarin, and 35.4% were treated with aspirin. The percentage of patients treated improved for high risk patients (higher than 50%).

CONCLUSIONS

The percentage of patients with nonrheumatic AF treated with acenocoumarin or aspirin is low, and physicians might be reluctant to use them because of bleeding complications, compliance with the treatment, or problems of accessibility.

[Assessment of quality of life related to health 2 years after coronary surgery]

BACKGROUND

The determinants of quality of life after coronary artery surgery in well defined health care populations are still incompletely understood. The aim of the present study was to assess the health related quality of life associated with coronary artery bypass surgery as performed in a tertiary public hospital, and also to investigate its association with clinical variables.

PATIENTS AND METHODS

All survivors of a first coronary artery bypass grafting operation performed during a calendar year in a single center (100 patients) were included for assessment two years after surgery. Assessment included a review of the clinical records, a structured clinical interview and the administration of three questionnaires of perceived health (Nottingham Health Profile, Duke Activity Status Index and SF-36 Health Survey).

RESULTS

The mean scores of the administered questionnaires corresponded to a moderate overall impairment of perceived health, with wide individual variations. Chronic stable postoperative angina pectoris (28% of patients), worse clinical functional grade (either due to angina or to others causes), comorbidity (51% of patients) and female sex were significantly associated with worse scores.

CONCLUSIONS

In the study population, postoperative angina, impairment of the clinical functional grade (due to angina or to other conditions), and female gender were the major determinants of impaired health related quality of life after coronary artery bypass surgery. As such determinants are associated with anatomoclinical variables in the population undergoing coronary bypass surgery and also with perioperative variables, appropriate effectively studies appear to be indicated for the assessment of this surgical procedure.