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      Control de la colesterolemia en España, 2000 un instrumento para la prevención cardiovascular Translated title: Cholesterolemia control in Spain, 2000. A toolfor cardiovascular disease prevention

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      Revista Española de Salud Pública
      Ministerio de Sanidad

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          Abstract

          El documento "Control de la Colesterolemia en España, 2000. Un instrumento para la Prevención Cardiovascular" revisa la evidencia existente en el campo de la prevención cardiovascular y los avances terapéuticos producidos en los últimos años, con el objetivo de ayudar a tomar decisiones clínicas basadas en el riesgo cardiovascular. Las enfermedades del aparato circulatorio son la primera causa de muerte en España, originando casi el 40% de todas las defunciones. En los últimos años se ha producido un descenso de las tasas ajustadas de mortalidad por enfermedades del aparato circulatorio, pero el número de muertes por cardiopatía isquémica está aumentando debido fundamentalmente al envejecimiento de la población. La menor mortalidad por cardiopatía isquémica unido al aumento de la incidencia de dicha enfermedad ha condicionado que actualmente sea la primera causa de consulta hospitalaria. El impacto demográfico, sanitario y social de estas enfermedades está aumentando y va a continuar haciéndolo en las próximas décadas. El adecuado tratamiento de la hipercolesterolemia y del resto de los factores de riesgo es fundamental para prevenir las enfermedades cardiovasculares. Las acciones concretas a realizar dependen del riesgo de enfermar. La estratificación del riesgo de las personas es esencial, por cuanto condiciona la periodicidad del seguimiento y la intensidad del tratamiento. Basándose en dicha estratificación se han establecido unas prioridades de control de la colesterolemia y del riesgo cardiovascular derivado de la misma. Los grupos de intervención ordenados de mayor a menor prioridad son los siguientes: 1.- Prevención Secundaria: Pacientes con enfermedad coronaria establecida u otras enfermedades ateroscleróticas. 2.- Prevención Primaria: Personas sanas, pero con riesgo alto de desarrollar enfermedad coronaria u otra enfermedad aterosclerótica, porque presentan una combinación de factores de riesgo- entre ellos están la dislipemia (colesterol total y cLDL elevados, cHDL bajo y triglicéridos elevados), el tabaquismo, la elevación de la presión arterial, la elevación de la glucemia y la historia familiar de enfermedad coronaria prematura- o porque presentan una elevación muy importante o forma grave de un solo factor de riesgo, como la hipercolesterolemia u otras formas de dislipemia, hipertensión arterial o diabetes. 3.- Familiares de primer grado de pacientes con enfermedad coronaria de aparición precoz u otras formas de enfermedad aterosclerótica. 4.- Otras personas a las que se accede en el curso de la práctica clínica habitual. En prevención primaria en los pacientes de riesgo alto (riesgo igual o superior al 20% - según la tabla de riesgo las Sociedades Europeas de Cardiología, Aterosclerosis, Hipertensión - o personas que presentan dos o más factores de riesgo - National Cholesterol Education Program II -) el objetivo terapéutico se establece en un cLDL inferior a 130 mg/dl. En prevención secundaria el tratamiento farmacológico se instaurará con un cLDL ³ 130 mg/dl y el objetivo terapéutico será cLDL < 100 mg/dl. Las estatinas son los fármacos de primera elección en el tratamiento de la hipercolesterolemia. Cuando exista hipertrigliceridemia moderada-grave y cHDL bajo se emplearan los fibratos. En el síndrome coronario agudo el tratamiento hipolipemiante, cuando esté indicado, debe iniciarse precozmente. Los pacientes con cardiopatía isquémica se deben incluir en programas de prevención secundaria que aseguren, de forma continuada, un buen control clínico y de los factores de riesgo, con fármacos con una razón coste-efectividad adecuada.

          Translated abstract

          The report "Cholesterolemia Control In Spain, 2000. A tool for Cardiovascular Disease Prevention" reviews current evidence on cardiovascular prevention and therapeutical advances occurred in the last years, in order to help overall risk-based clinical decision-making. Cardiovascular disease ranks as the first cause of death in Spain, accounting for almost 40% of total mortality. During the last years age-adjusted cardiovascular death rates have been declining, but the absolute number of deaths by coronary heart disease is ascending due mainly to the population aging. Coronary heart disease is the first cause of hospital consultation due both to the lesser coronary heart disease mortality and to the increase in coronary heart disease incidence. The demographic, health and social impact of cardiovascular disease is increasing and it is likely to go on in the next decades. Appropriate treatment of high blood cholesterol and of other major modifiable risk factors is crucial for preventing cardiovascular disease. Specific actions to carry out depend on the risk to get ill. Individual risk stratification is essential as it determines the follow up periodicity and treatment intensity. Priorities of control of cholesterolemia and its consequent risk are based on risk stratification. The groups for intervention are ordered in a descendent priority hierarchy as follows: 1. - Secondary prevention: Patients with established coronary heart disease or other atherosclerotic disease. 2. - Primary prevention: Healthy individuals who are at high risk of developing coronary heart disease or other atherosclerotic disease, because of a combination of risk factors - including lipids (raised total cholesterol, and LDL-cholesterol, low HDL-cholesterol and raised triglycerides), smoking, raised blood pressure, raised blood glucose, family history of premature coronary disease - or who have severe hypercholesterolaemia, or other forms of dyslipidaemia, hypertension or diabetes. 3. - Close relatives of patients with early onset coronary heart disease or other atherosclerotic disease. 4. - Others individuals met in connection with ordinary clinical practice. In primary prevention, the therapeutic objective in high risk patients (risk ³ 20% -upon the risk chart of the European Societies of Cardiology, Atherosclerosis, Hypertension- or individuals with 2 or more risk factors -National Cholesterol Education Program II-) is set up at LDL-cholesterol <130 mg/dl. In secondary prevention, the drug treatment will be indicated when LDL-cholesterol ³ 130 mg/dl and the therapeutic objective will be LDL-cholesterol <100 mg/dl. Statins are first line drugs for treatment of high blood cholesterol. Where moderate-severe hypertrigliceridemia or low HDL-cholesterol fibrates are prefered. In acute coronary syndrome hypolipemiant treatment, where indicated, should be used as soon as possible. Coronary heart disease patients should be offered secondary prevention programmes which provide, in a continuous manner, a good clinical and risk factor control, with appropriate cost-effectiveness drugs.

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          Prediction of Coronary Heart Disease Using Risk Factor Categories

          The objective of this study was to examine the association of Joint National Committee (JNC-V) blood pressure and National Cholesterol Education Program (NCEP) cholesterol categories with coronary heart disease (CHD) risk, to incorporate them into coronary prediction algorithms, and to compare the discrimination properties of this approach with other noncategorical prediction functions. This work was designed as a prospective, single-center study in the setting of a community-based cohort. The patients were 2489 men and 2856 women 30 to 74 years old at baseline with 12 years of follow-up. During the 12 years of follow-up, a total of 383 men and 227 women developed CHD, which was significantly associated with categories of blood pressure, total cholesterol, LDL cholesterol, and HDL cholesterol (all P or =130/85). The corresponding multivariable-adjusted attributable risk percent associated with elevated total cholesterol (> or =200 mg/dL) was 27% in men and 34% in women. Recommended guidelines of blood pressure, total cholesterol, and LDL cholesterol effectively predict CHD risk in a middle-aged white population sample. A simple coronary disease prediction algorithm was developed using categorical variables, which allows physicians to predict multivariate CHD risk in patients without overt CHD.
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            Randomised trial of cholesterol lowering in 4444 patients with coronary heart disease: the Scandinavian Simvastatin Survival Study (4S)

            Drug therapy for hypercholesterolaemia has remained controversial mainly because of insufficient clinical trial evidence for improved survival. The present trial was designed to evaluate the effect of cholesterol lowering with simvastatin on mortality and morbidity in patients with coronary heart disease (CHD). 4444 patients with angina pectoris or previous myocardial infarction and serum cholesterol 5.5-8.0 mmol/L on a lipid-lowering diet were randomised to double-blind treatment with simvastatin or placebo. Over the 5.4 years median follow-up period, simvastatin produced mean changes in total cholesterol, low-density-lipoprotein cholesterol, and high-density-lipoprotein cholesterol of -25%, -35%, and +8%, respectively, with few adverse effects. 256 patients (12%) in the placebo group died, compared with 182 (8%) in the simvastatin group. The relative risk of death in the simvastatin group was 0.70 (95% CI 0.58-0.85, p = 0.0003). The 6-year probabilities of survival in the placebo and simvastatin groups were 87.6% and 91.3%, respectively. There were 189 coronary deaths in the placebo group and 111 in the simvastatin group (relative risk 0.58, 95% CI 0.46-0.73), while noncardiovascular causes accounted for 49 and 46 deaths, respectively. 622 patients (28%) in the placebo group and 431 (19%) in the simvastatin group had one or more major coronary events. The relative risk was 0.66 (95% CI 0.59-0.75, p < 0.00001), and the respective probabilities of escaping such events were 70.5% and 79.6%. This risk was also significantly reduced in subgroups consisting of women and patients of both sexes aged 60 or more. Other benefits of treatment included a 37% reduction (p < 0.00001) in the risk of undergoing myocardial revascularisation procedures. This study shows that long-term treatment with simvastatin is safe and improves survival in CHD patients.
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              Mortality from coronary heart disease in subjects with type 2 diabetes and in nondiabetic subjects with and without prior myocardial infarction.

              Type 2 (non-insulin-dependent) diabetes is associated with a marked increase in the risk of coronary heart disease. It has been debated whether patients with diabetes who have not had myocardial infarctions should be treated as aggressively for cardiovascular risk factors as patients who have had myocardial infarctions. To address this issue, we compared the seven-year incidence of myocardial infarction (fatal and nonfatal) among 1373 nondiabetic subjects with the incidence among 1059 diabetic subjects, all from a Finnish population-based study. The seven-year incidence rates of myocardial infarction in nondiabetic subjects with and without prior myocardial infarction at base line were 18.8 percent and 3.5 percent, respectively (P<0.001). The seven-year incidence rates of myocardial infarction in diabetic subjects with and without prior myocardial infarction at base line were 45.0 percent and 20.2 percent, respectively (P<0.001). The hazard ratio for death from coronary heart disease for diabetic subjects without prior myocardial infarction as compared with nondiabetic subjects with prior myocardial infarction was not significantly different from 1.0 (hazard ratio, 1.4; 95 percent confidence interval, 0.7 to 2.6) after adjustment for age and sex, suggesting similar risks of infarction in the two groups. After further adjustment for total cholesterol, hypertension, and smoking, this hazard ratio remained close to 1.0 (hazard ratio, 1.2; 95 percent confidence interval, 0.6 to 2.4). Our data suggest that diabetic patients without previous myocardial infarction have as high a risk of myocardial infarction as nondiabetic patients with previous myocardial infarction. These data provide a rationale for treating cardiovascular risk factors in diabetic patients as aggressively as in nondiabetic patients with prior myocardial infarction.
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                Author and article information

                Journal
                resp
                Revista Española de Salud Pública
                Rev. Esp. Salud Publica
                Ministerio de Sanidad (Madrid, Madrid, Spain )
                1135-5727
                2173-9110
                June 2000
                : 74
                : 3
                Article
                S1135-57272000000300002 S1135-5727(00)07400302
                2fe4e4f4-c859-4f81-a537-831b29a753ef

                This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 3.0 International License.

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