Revista Espanola de Cardiologia Suplementos最新文献

Atrial fibrillation is associated with up to a five-fold increase in the risk of stroke. Cardioembolic stroke is usually more severe than other types of stroke and has higher rates of recurrence and permanent disability. Consequently, reducing the risk of stroke through adequate anticoagulation is one of the main goals of treatment in patients with atrial fibrillation. Vitamin K antagonists have been largely superseded by direct oral anticoagulants because the results of clinical trials, real-life studies and, recently, population studies have all demonstrated that direct oral anticoagulants are more effective (i.e. the risk of stroke and death is lower) and safer (i.e. the risk of intracranial hemorrhage is lower) than vitamin K antagonists. In addition, COVID-19 pandemic, the preferential use of direct oral anticoagulants instead of vitamin K antagonists has been a key strategy for ensuring that the quality of anticoagulation is optimal and that patients are better protected against SARS-CoV-2 infection, as no international normalized ratio control is required.

Atrial fibrillation markedly increases the risk of stroke. Numerous clinical trials and real-life studies have demonstrated that anticoagulant treatment decreases the risk of thromboembolic complications. For anticoagulation, direct oral anticoagulants (DOACs) have a better efficacy and safety profile than vitamin K antagonists. Studies performed in countries neighboring Spain in recent years have identified reductions in the incidence of ischemic stroke that could be related to increased prescripción of oral anticoagulants, particularly DOACs. In Spain itself, información about this issue is very scarce. Nevertheless, the data available indicate that, here too, increased prescripción of oral anticoagulants, particularly DOACs, has also been associated with a significant decrease in the incidence of both ischemic stroke and intracranial hemorrhage. Therefore, it is recommended that DOACs be used more frequently in patients with atrial fibrillation, as this would contribute to reducing not only the incidence of ischemic stroke and intracranial hemorrhage but also the associated economic burden.

Cardiovascular complications are common in patients with coronavirus disease 2019 (COVID-19), particularly in severe cases: up to 10-30% of hospitalized COVID-19 patients are affected and there is an associated increase in mortality. Important cardiovascular complications include: acute coronary syndrome; acute myocardial injury (elevated troponin levels with normal coronary arteries); arrhythmias (mainly atrial fibrillation and ventricular arrhythmias); heart failure; pericarditis or pericardial effusion; and thromboembolic events (e.g. arterial and venous thromboembolism, microvascular thrombosis, pulmonary embolism, and stroke). Therefore, one of the aims of treatment for patients with COVID-19, particularly in its most serious forms, is the prevention of cardiovascular and thrombotic complications, which will unquestionably have a positive impact on these patients’ prognoses.

In other contexts, data from both clinical trials and real-life studies demonstrate that rivaroxabán is effective and safe across the whole spectrum of cardiovascular disease, including atrial fibrillation, venous thromboembolic disease, and atherosclerotic cardiovascular disease. Consequently, rivaroxabán could provide additional benefits for patients by helping prevent thrombotic and cardiovascular complications during the COVID-19 pandemic.

Despite progress in the treatment of heart failure with reduced ejection fraction (HFrEF), mortality and hospitalization rates remain very high. The DAPA-HF trial demonstrated that, compared with standard treatment, the addition of dapagliflozin, 10 mg/day, was associated with marked clinical benefits in patients with HFrEF. Significant reductions were observed in several outcomes: (i) a 26% reducción in the risk of cardiovascular death, hospitalization or an emergency department visit for heart failure that resulted in intravenous treatment; (ii) a 30% reduccion in the risk of a first hospitalization for heart failure; (iii) an 18% reduccion in cardiovascular mortality; and (iv) a 17% reduccion in all-cause mortality. In addition, the adverse event rate was low. These beneficial effects were independent of the presence of diabetes. Moreover, it was found that the earlier treatment with dapagliflozin was started, the greater the benefit, irrespective of the patient’s existing treatment for heart failure. This article provides an update on dapagliflozin treatment for patients with HFrEF and presents recommendations on the drug’s use in practice.

The reduction in cholesterol levels obtained with lipid-lowering therapy is associated with a marked decrease in the risk of cardiovascular complications. However, a substantial proportion of patients with hypercholesterolemia do not achieve the recommended target level, irrespective of their cardiovascular risk. Although this is partly due to the intensity of lipid-lowering treatment being inadequate and although combination therapy could be prescribed more frequently, there is still a need for new drugs to help achieve therapeutic goals. Bempedoic acid is a new, first-in-class, oral, lipid-lowering drug that reduces cholesterol levels by inhibiting the enzyme adenosine triphosphate-citrate lyase, which plays a role in the cholesterol synthesis pathway upstream from where statins act. Importantly, bempedoic acid is not activated in skeletal muscle, which reduces the risk of muscle-related side effects. An extensive series of clinical trials has demonstrated the drug’s efficacy in reducing cholesterol levels when given as monotherapy or in combination with other lipid-lowering drugs. Moreover, its safety profile is good. In this document, a simple and easily applied algorithm is proposed for identifying those patients who potentially stand to benefit most from treatment with bempedoic acid. The algorithm takes into account cardiovascular risk, previous lipid-lowering therapy and the low-density lipoprotein cholesterol level. Its purpose is help the majority of patients achieve the treatment goals as soon as possible.

Heart failure is a condition that requires a multidisciplinary approach to treatment because of the wide range of causes and clinical contexts that may be involved and because the diverse treatment strategies used necessitate the participation of multiple disciplines. In cardiology departments, the presence of both heart failure units that focus on the treatment of affected patients and cardiac rehabilitation units that, as well as targeting reductions in morbidity and mortality, are also involved in caring for the same patients can create difficulties for coordination and can result in the loss of comprehensive patient-centered care. For these reasons, this paper presents a strategy for coordinating the different units involved in patient management in cardiology departments and for ensuring continuity of care in primary care, both immediately after achieving stabilization and subsequently, when these interactions are important for effective coordination.

Atrial fibrillation markedly increases the risk of ischemic stroke. Although vitamin K antagonists (VKAs) reduce this risk, they have limited efficacy and several disadvantages, which has meant that over the years a substantial proportion of patients with atrial fibrillation have remained without anticoagulation. In contrast, clinical trials, studies in routine clinical practice and, more recently, population-based studies have all demonstrated that direct oral anticoagulants (DOACs) are more effective and safer than VKAs and also have a greater net clinical benefit. In fact, in regions where the DOAC prescription rate is high, the incidence of ischemic stroke has decreased, as have the overall costs associated with atrial fibrillation. Although the prescription of DOACs in Spain has increased in recent years, the country has one of the lowest prescription rates in Europe, which may be associated with a higher incidence of ischemic stroke. Despite clinical guidelines all recommending that DOACs should be used in preference to VKAs in patients with nonvalvular atrial fibrillation, more prescriptions are issued for VKAs in Spain, largely due to restrictions imposed by national statements on appropriate medicine use (including the need for approval), but also because of therapeutic inertia. Immediate action should be taken to correct this situation and to improve patients‘ prognoses.

In December 2019, clinicians in China first observed cases of pneumonia whose cause was identified as a new coronavirus, SARS-CoV-2. This virus causes COVID-19 disease, which has a virulence and transmission rate that, coupled with the absence of a vaccine or specific treatment, has had an unprecedented impact on health systems.

COVID-19 can cause serious cardiovascular disease. Patients with cardiovascular risk factors or with an underlying cardiovascular condition form a particularly vulnerable population with a very high risk of complications and death. However, these patients had to be treated on the basis of very limited or nonexistent scientific evidence.

This supplement discusses the pathophysiology of COVID-19, the direct and indirect mechanisms of associated cardiovascular disease, and the different types of cardiovascular complications that can occur. It also summarizes Spanish Society of Cardiology publications that have been produced to provide a practical response to the resulting complex health-care situation.

In addition, the supplement describes how outpatient care can be reorganized in the future to ensure continuity of care, principally through telemedicine. Finally, the different types of pharmacological treatment available are discussed, along with their potential interactions. This supplement, which contains a series of articles prepared by influential authors, summarizes current knowledge about this disease and provides data and Información of great practical value.

Monoclonal antibodies that target proprotein convertase subtilisin/kexin type 9 (PCSK9) increase recycling of low-density lipoprotein receptors, and reduce plasma levels of these lipoproteins by 50-60%. Moreover, these agents also decrease lipoprotein(a) levels and increase high-density lipoprotein levels, as well as having other beneficial effects on lipid metabolism. clínically, these drugs decrease the incidence of cardiovascular events in patients with chronic atherosclerosis and in those who have recently experienced acute coronary syndrome. Furthermore, in these patients, the use of alirocumab has been associated with lower overall mortality. Patients with extensive atherosclerosis, diabetic patients and those with a low-density lipoprotein level >100 mg/dL achieve the greatest clínical benefits. In general, these drugs are safe and appear to offer an excellent additional tool for treating dyslipidemia. Today, the challenge is to promote the use of these agents in patients with cardiovascular disorders in order to improve their prognosis.