Revista Espanola de Cardiologia Suplementos最新文献

The pandemic caused by the rapid spread of the SARS-CoV-2 virus has produced the greatest health crisis of modern times. The close relationship between the virus and angiotensin-II converting enzyme has provoked a torrent of speculation about the possible role of the renin-angiotensin-aldosterone system (RAAS) in mediating infection. The subsequent alarm has raised questions about the use of RAAS inhibitors, such as angiotensin-converting enzyme inhibitors and angiotensin-II receptor blockers. The result has been the publication of several studies that have failed to find an association between the use of RAAS inhibitors and greater susceptibility to infección or a worse clínical outlook. This review considers the most significant aspects of the interaction between SARS-CoV-2 and the RAAS and the clínical implications of using RAAS inhibitors during the pandemic.

In recent years, it has been shown that the circulating level of particles containing apolipoprotein B, especially low-density lipoproteins (LDLs) and lipoprotein(a), is not a risk factor for cardiovascular disease but is instead a major etiological factor. Indisputable evidence has come from prospective observational studies, Mendelian randomization studies, animal models of arteriosclerosis involving the manipulation of lipid-related genes, human genetic diseases (e.g. monogenic familial hypercholesterolemia and hypercholesterolemia associated with an elevated lipoprotein(a) concentration), and interventional studies with lipid-lowering agents. This article reviews these findings and summarizes current understanding of the principle pathogenic mechanisms that make LDL cholesterol one of the main causes of atherosclerotic cardiovascular disease.

There is extensive, strong evidence that low-density lipoprotein (LDL) cholesterol is a causal factor for atherosclerosis. The use of lipid-lowering drugs to reduce the atherogenic load of lipoproteins containing apolipoprotein B, mainly LDLs, slows the progression of atheromatous disease and could even reverse it if treatment is started early and aggressively. This review provides a historical perspective on the development of the various lipid-lowering drugs used for cardiovascular prevention, excluding proprotein convertase subtilisin/kexin type-9 (PCSK9) inhibitors, and summarizes the findings of the main prospective interventional clinical trials of individual agents in order to identify the potential cardiovascular benefits associated with their ability to reduce LDL-cholesterol concentrations.

Cardiovascular complications are highly prevalent in patients with COVID-19 and frequently lead to hospitalization, death and long-term morbidity. This article describes the principle pathophysiological mechanisms involved in the development of these complications. After the initial viremia, viralinvasión and replication occurs in the lungs, accompanied by immune system activation, cytokine release and the induction of a proinflammatory state, with sepsis and multiorgan failure. Myocardial injury could be due to the direct effect of viralinvasión and a local inflammatory response or to the indirect effect of inappropriate systemic inflammation involving a cytokine storm. Furthermore, the development of a prothrombotic state, together with vascular disease due to the virus, could trigger ischemic and thrombotic events secondary to microvascular damage or to the destabilization of pre-existing atheromatous plaque. New research is needed to reveal the pathophysiological mechanisms underlying these cardiovascular events and to support the development of effective new treatments.

Atrial fibrillation is common in elderly patients. Although vitamin K antagonists have been widely used for many years, they have a number of limitations in elderly patients, who are particularly susceptible to bleeding and in whom anticoagulation control is poorer than in the general population. Direct oral anticoagulants have been shown to be a better therapeutic option for these patients, not only because they are simpler to use, but also because they are more effective and safer than vitamin K antagonists. Moreover, their performance in practice is generally consistent with that in pivotal clinical trials. Nevertheless, there is a tendency to administer inappropriate doses to elderly patients, generally underdosing, particularly in certain subgroups. This can result in less protection against stroke without any clear reduction in bleeding risk. Rivaroxaban has been widely studied in the elderly population, not only in clinical trials, but also in a range of studies in routine clinical practice – findings have been highly consistent. According to these studies, and compared to vitamin K antagonists, rivaroxaban reduces the risk of stroke without increasing the rate of fatal bleeding, with a net clinical benefit in patients with nonvalvular atrial fibrillation and a high thromboembolic risk.

Traditionally the primary aim of anticoagulation in patients with atrial fibrillation was the prevention of stroke. However, these patients actually have numerous comorbidities that also have a substantial impact on prognosis and that must be treated. These considerations should also play a role in selecting the best anticoagulant treatment for patients with a high cardiovascular risk. In general, direct oral anticoagulants have consistently been shown to have superior efficacy and safety to warfarin, irrespective of whether patients have a history of stroke, transient ischemic attack, diabetes, renal insufficiency or myocardial infarction. In particular, studies have shown that rivaroxaban is associated with a lower risk of myocardial infarction and fewer renal complications than warfarin. In a subgroup study of the ROCKET-AF trial, it was found that rivaroxaban significantly reduced cardiovascular mortality in patients with diabetes mellitus (by 20%). Moreover, studies carried out in routine clinical practice showed that the drug significantly reduces the risk of both major cardiovascular events and peripheral artery disease. As a result, rivaroxaban could be considered the preferred option for anticoagulation in patients with nonvalvular atrial fibrillation and a high cardiovascular risk, given the additional benefits it provides in this population.

The publication of pivotal clínical trials, such as the FOURIER and ODYSSEY OUTCOMES trials, and of other types of clínical study since 2016 has resulted in changes in the clínical practice guidelines for patients with dyslipidemias, which were updated in 2019. Cardiovascular risk stratification has been improved by the use of: (i) noninvasive cardiovascular imaging, involving for example the coronary calcium score, carotid or femoral artery ultrasonography, and coronary CT angiography; and (ii) biomarkers, particularly lipoprotein(a). However, the principle novelties were much stricter low-density lipoprotein cholesterol treatment targets and new recommendations on ezetimibe and proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors, added to statins, which have now become class-I treatment recommendations. Furthermore, the Spanish Society of Cardiology’s consensus on improving lipid control in secondary prevención provides a simple and practical way of optimizing lipid-lowering therapy.