La diabetes mellitus y el riesgo cardiovascular. ¿Es necesario el tratamiento integral de la diabetes mellitus tipo 2 y los factores de riesgo cardiovascular?

Cardiovascular disease (CVD) is the first cause of death in the Spanish population among both diabetics and non-diabetics. In diabetes, CVD is between 2 and 4 times more frequent, earlier and more aggressive. With current measures, approximately 50% of CVD can be prevented. The risk factors for CVD in diabetes are hypertension, dyslipidemia, smoking, obesity and sedentariness. More than 80% of patient with type 2 diabetes have hypertension and dyslipidemia and approximately 15% continue to smoke. However, all these factors are controlled in at least 10%. Although dyslipidemia is the most influential and least treated factor, the greatest benefit for CVD prevention is obtained with integrated intervention on all risk factors, reducing blood pressure to below 140/80 mmHg, low-density lipoprotein cholesterol (LDL-c) to below 100 mg/dl, encouraging smoking cessation, regular physical activity and maintaining a healthy weight (BMI < 25 kg/m²). In secondary prevention or persons with microvascular disease, the targets may be stricter (blood pressure 130/80 mmHg and LDL-c 80 mg/dl). Drug treatment should always include an angiotensin converting-enzyme inhibitor or an angiotensin II receptor antagonist and a statin. Aspirin should be reserved for patients in secondary prevention or with very high CV risk. Consequently, interventions should be prioritized according to the foreseeable risk for each patient, which can be estimated through the SCORE scale or other scales such as Regicor or UKPDS, with a SCORE > 5% indicating high risk. These high-risk patients should receive personalized care.     

Influencia del género sobre factores de protección y vulnerabilidad,la adherencia y calidad de vida en pacientes con enfermedad cardiovascular

ObjectivesTo examine gender differences on specific protective factors (PF: acceptance and resilience), vulnerability factors (VF: anger, depression, and anxiety; adherence to treatment and quality of life (QoL) in cardiovascular patients, as well as to study separately the relationships of these factors with adherence and QoL in females and males.DesignObservational and cross-sectional.SettingTwo Primary Care Centres in Gran Canaria.ParticipantsOne hundred and ninety-eight cardiovascular patients (91 males and 107 females) participated.Main measurementsAcceptance was assessed by the ICQ scale; resilience by the CD-RISC; depression by the PHQ-9; anxiety by the HADS; Anger-In and Anger-Out by the STAXI-2; QoL by the SF-36; and adherence by a self-reported scale.ResultsFemales exhibited higher anxiety (95% CI: 6.3-7.9) and adherence to reducing smoking (95% CI: 9.4-10.0) and drinking (95% CI: 9.6-10.1), and lower Anger-Out (95% CI: 8.9-10.0), mental QoL (95% CI: 47.0-51.3) and adherence to medication (95% CI: 22.2-23.3) compared to males. Acceptance was associated with better adherence only in women. There were more VF related to worse adherence in males. Anxiety had a negative impact on adherence, and QoL was positively associated with PF, and negatively with VF in both groups.ConclusionsGender differences in QoL, some VF, and adherence are observed, in addition to the beneficial role of Acceptance in women.     

Estudio descriptivo y comparativo de factores de riesgo cardiovascular y actividad física en pacientes con síndrome coronario agudo

Aim

To analyse several cardiovascular risk factors by means of the physical activity performed by patients with acute coronary syndrome (ACS).

Diagnóstico y control de la diabetes mellitus tipo 2

In 2010, the American Diabetes Association included glycosylated hemoglobin (HbA1c) as a criterion for the diagnosis of diabetes with a cut-off point of ≥ 6.5%. However, there may be a substantial percentage of false negative results. Other scientific societies have accepted this approach but with slight differences. HbA1c complements, but does not substitute, basal glycemia as a screening and diagnostic test or the 2-hour oral glucose tolerance test. HbA1c should not be used for the diagnosis of gestational diabetes.Interpretation of HbA1c is limited in persons with anemia and hemoglobinopathies. Therefore, in addition to its sensitivity and specificity, its costs and the epidemiological situation should also be evaluated. An important question is whether almost normal HbA1c levels are safe in patients with type 2 diabetes. The results of the ACCORD, ADVANCE and VADT trials are contradictory and have aroused considerable controversy. However, the extensions of the UKPDS and STENO-2 studies have shown the benefits of good glycemic control in the long term. As a general rule, a target of HbA1c < 7% seems appropriate.In patients at low risk of hypoglycemic episodes, short disease duration and young persons, HbA1c < 6.5% can be considered. In patients with frequent hypoglycemic episodes, the elderly and persons with short life expectancy, values of more than 7% are acceptable. This target should be achieved through individualized, early, intensive and safe treatment, without risk of hypoglycemia, and should be integrated in an overall program of cardiovascular risk prevention.     

Resultados de un programa de telemedicina para pacientes con diabetes tipo 2 en atención primaria

ObjectiveTo evaluate the impact of a telemedicine program on self-perceived health in patients with type 2 diabetes in primary care, as well as patient acceptance of and satisfaction with this program.MethodWe conducted an 18-month follow-up through telemedicine in 52 diabetic patients. The study design was non-experimental (before and after). In addition to weekly electronic transmission of fasting glucose levels, we regularly provided advice to patients about healthy habits.ResultsNo statistically significant differences were observed when mean blood glucose values were compared during follow-up. However, at the end of participation, the mean score in self-perceived health was significantly higher than at the initial assessment (70.5 ± 12.8 vs. 62.8 ± 15.0, p = 0.02). After 18 months of participation in the telemedicine program, 57.7% of patients were satisfied and 38.5% were very satisfied.ConclusionsAlthough glycemic control did not improve during the follow-up, electronic transmission of information was found to be feasible and satisfactory for patients. The patients reported a higher level of self-perceived health.     

Efectividad de un proyecto de colaboración entre atención primaria y salud mental para mejorar el registro de factores de riesgo cardiovascular en pacientes con psicosis

ObjectiveTo evaluate the effectiveness of a joint team intervention between primary care (PC) and mental health (MH) to improve information on cardiovascular risk factors (CVRF) in psychotic patients.DesignMulticenter before-after intervention study.LocationSeven primary care and 2 mental health centers in Barcelona participated.ParticipantsAll patients between 18-65 years old with a confirmed diagnosis of psychosis assigned to PC teams (n = 690) are included.InterventionShared clinical sessions, developing a joint GP-MH protocol and implement it.Primary measurementsVariables: Gender, age, number of Appointments per center/year, smoking, blood pressure, body mass index (BMI), total cholesterol, HDL cholesterol, triglycerides, glucose, waist circumference (WC), Cardiovascular Risk.AnalysisComparison of CVRF records from 2008 to 2010 using statistical tests for paired data. Calculation of CVRF prevalence in accordance with metabolic syndrome criteria and the criteria for referral to GP.ResultsThe mean age was 42.3 (SD 11.4) years, with 67% males. All CVRF significantly Increased in clinical notes, particularly all blood test parameters and WC. More than 35% of patients had a CVRF according to metabolic syndrome criteria. Criteria to refer to PC physician (2010) identified: obesity 51.9%, 23.9% hypertension, high cholesterol 20.4% and 11.6% diabetes.ConclusionsCVRF recording improvement. High percentage of patients needed GP intervention due to a CVRF.     

Desigualdades socioeconómicas y diferencias según sexo y edad en los factores de riesgo cardiovascular

ObjectiveTo describe the cardiovascular risk factors in a working population in the Balearic Islands and to examine whether differences by social class vary according to age and gender.MethodsA cross-sectional study was carried out in a sample of active workers aged 20-65 years in the Balearic Islands. The participants were included in the study during their annual work health assessment in 2011. The following variables were collected: occupation, social class, age, gender, height, weight, smoking, blood pressure, lipid profile, and glucose levels. Cardiovascular risk was calculated using two different equations (Framingham and REGICOR).ResultsDifferences by social class were observed for most cardiovascular risk factors. The pattern of these differences differed depending on age group and gender. Differences in obesity by social class increased with age in women but decreased in men. More differences in hypertension by social class were found among women than among men, with differences increasing with age in both genders. Significant differences by social class were found among women in lipid profile, and these differences increased with age, mainly for low levels of high-density lipoprotein-cholesterol.ConclusionsInequalities in cardiovascular risk factors by social class were higher among women than among men. Some cardiovascular risk factors such as smoking and obesity showed significant inequalities from a very early age.     

Comorbilidad como predictor de utilización de servicios sanitarios y mortalidad en pacientes con diabetes

ObjectiveChronic diseases are the main cause of mortality worldwide. Study of the most prevalent diseases is essential, as well as the development of indicators of health services’ utilization and mortality in these patients. The objective of this study was to identify which comorbidity measure best predicts health services’ utilization and mortality in patients with diabetes mellitus in our environment.MethodsA longitudinal study was carried out in a cohort of diabetes mellitus patients diagnosed in 2006 in Zaragoza and followed up to 2010. Logistic regression predictive models were developed. The number of diagnosis, the number of ambulatory diagnostic groups (ADG), and the number of major ambulatory diagnostic groups (MADG) from the Ambulatory Care Groups system were used as comorbidity measures. The validity measure consisted of the improvement in the model's explanatory capacity (c-statistic).ResultsThe prevalence of diabetes mellitus was 8.8%. Both the number of diagnoses and comorbidity were associated with health services’ utilization and mortality. For mortality, the best indicator of comorbidity was the number of MADGs (c = 0.763). The model adjusted by sex, age, number of MADGs, and number of hospitalizations had the highest explanatory capacity (c = 0.818).ConclusionsThe ACG system allows resource consumption and mortality to be predicted in people with diabetes mellitus in our environment. This study confirms the substantial healthcare burden generated by patients with diabetes mellitus and the need to tackle this situation.     

Asociación entre diabetes mellitus tipo 2 y actividad física en personas con antecedentes familiares de diabetes

Objective

To investigate whether the association between type 2 diabetes (T2D) and family history of diabetes is modified by the levels of physical activity in the Chilean population.

Efectos a largo plazo de una intervención intensiva sobre cambios en los estilos de vida en pacientes con hiperfibrinogenemia y riesgo cardiovascular moderado-alto

Objectives

To determine whether the benefit on cardiovascular risk factors (CVRF) persists 5 years after an intensive intervention in lifestyle (LS) that lasted 2 years, in patients with hyperfibrinogenaemia and moderate or high cardiovascular risk.