Guidelines of the Spanish Society of Cardiology for cardiovascular disease prevention and cardiac rehabilitation

The priorities for the prevention of cardiovascular diseases should be focused on patients with established disease and high risk subjects, with individual global risk always being taken into account.The current evidence on the influence of the main risk factors are unanimous (dyslipemia, tobacco, hypertension and diabetes mellitus), being somewhat less so in cases of sedentarism, obesity and the metabolic syndrome. The evidence concerning other risk factors still remains controversial.Guidelines for the control of the different risk factors should be based on the evidence derived from both epidemiological or clinical trials. The recommendations published by several scientific societies should also be followed.There are, at present, important evidence on the efficacy of smoking cessation, the treatment of arterial hypertension and particularly on the successful control of lipid levels with lipid-lowering drugs, especially with statins. There is also evidence on the need for rigorous control of diabetic patients not only in relation to the glucose levels but also to dyslipemia. The most efficient measures for a reduction in morbidity and mortality are cessation of smoking, appropriate hypertensive therapy, a comprehensive program of cardiac rehabilitation and overall the successful control of lipid levels with statins.     

Guidelines of the Spanish Society of Cardiology on valve heart disease

Valvular heart diseases, which continue to be a major cause of morbidity and mortality world wide, have undergone radical changes since the first valve prostheses were implanted 40 years ago. These changes have been the result of both scientific progress and improved standard of living in developed countries. The availability of penicillin to treat streptococcal pharyngitis and less crowded living conditions have now made rheumatic fever uncommon in these countries. However, other forms of valve impairment have appeared over the past several years. The etiology of some of these valvular diseases remains obscure (e. g. myxomatous mitral valve); others, such as the senile type of calcific aortic valve stenosis, seem to be the price to be paid for the extension of life expectancy. With regard to diagnosis, echocardiography has constituted a formidable tool for visualizing anatomic valve changes, interpreting complex hemodynamic derangements, and evaluating repercussion on the left ventricle. In addition, the iteration of this non-invasive examination has allowed a much better understanding of the natural history of non-severe valvular disease and therefore of the precise timing for surgical intervention, without awaiting, in most cases, the appearance of advanced symptomatology. This has also been possible because of the great advances in cardiac surgery which can be summarised as: a) the improvement in extracorporeal circulation and myocardial preservation techniques; b) the greatly improved biologic and mechanic valve substitutes; c) the introduction of imaginative mitral valve repair procedures, and d) the use of intraoperative transesophageal echocardiography to assess the adequacy of valve repair. At the same time, percutaneous catheter balloon valvuloplasty has emerged as a valid alternative to mitral surgical commissurotomy for mitral stenosis. All these changes, and many more that can not be described in this brief summary, make a review of the management of patients with valve heart disease appropriate.     

Guidelines of the Spanish Society of Cardiology for cardiopulmonary resuscitation]

Cardiac arrest, consistent on cessation of cardiac mechanical activity, is diagnosed in the absence of consciousness, pulse and breath. The totality of measurements applied to revert it is called cardiopulmonary resuscitation. Two different levels can be distinguished: basic vital support and advanced cardiac vital support. In the basic vital support methods which do not require special technology are used: opening of air lines, mouth to mouth ventilation, cardiac massage; recently, there is a tendency to include the use of defibrillator. Advanced cardiac vital support should be the continuation of basic vital support. In this situation defibrillator, venous cannulation, orotracheal intubation, mechanical ventilation with high content in oxygen and drugs are used. Before beginning cardiopulmonary resuscitation, one should make sure that a real cardiac arrest is present, less than 10 min have elapsed, the victim does not have an immediately fatal prognosis and there is no deny by the victim or his/her family to receive cardiopulmonary resuscitation. In case of doubt it should be always practised. It is important to know the diagnosis and prognosis of the cause of cardiac arrest as soon as possible, in order to treat it and decide if the maneuvers should be continued. Hydro-electrolytic disturbances must be treated and neurological damage after cardiopulmonary resuscitation must be assessed. Only 20% of patients who recover an effective cardiac rhythm after cardiopulmonary resuscitation are discharged from hospital without neurological sequelae.     

Practice Guidelines of the Spanish Society of Cardiology in the postoperative course of congenital heart diseases

Improvements in myocardial protection, surgical techniques, and perioperative care have made it possible to achieve better prognosis in most congenital heart defects. This requires a coordinated, multidisciplinary approach to patient care, based on the preservation of adequate oxygen delivery to vital organs. It is important to have an understanding of normal postoperative status after cardiac surgery so that abnormal postoperative convalescence can be identified and treated.The causes of abnormal convalescence may be grouped into three categories: a) the pathophysiology of the defect before surgery and the acute changes in physiology that result from surgery; b) the effects of hypothermic cardiopulmonary bypass and deep hypothermic circulatory arrest on organ function, and c) the presence of residual anatomic defects. These conditions may result in prolonged convalescence as well as increased morbidity and mortality.Three primary hemodynamic pathophysiologic disturbances may occur during the postoperative period and lead to abnormal convalescence: left ventricular dysfunction, right ventricular dysfunction and pulmonary hypertension.Though sometimes not directly related to either the cardiac defect or surgery, specific problems involving different organs may alter the normal postoperative period. Neurologic, pneumologic, renal, gastrointestinal and infective complications are discussed separately.     

Guidelines of the Spanish Society of Cardiology on magnetic resonance

A wide perspective of the cardiac applications of magnetic resonance is presented in this report, including technical aspects of the practice, recommendations on the appropriate training of medical personnel for the practice of examination and also, an extensively commented review of the accepted clinical indications for the practice of a cardiac magnetic resonance imaging study at present.     

Guidelines of the Spanish Society of Cardiology on aortic diseases

Acute aortic pathology is an urgent clinical situation, of which prognosis mainly related to prompt and accurate diagnosis as well as a quick treatment. In this paper we review the aortic pathology, specially focused on aortic dissection. We review its etiology, clinical presentation and diagnostic methods. In addition the medical therapy and the surgical indications of aortic aneurysm, dissection and aortic intramural haematoma are described.     

Guidelines of the Spanish Society of Cardiology for clinical practice in exercise testing

Most exercise testing is performed in adults with known or suspected ischemic heart disease. In the last few years cardiac imaging techniques have been applied in this field, improving the information obtained with the procedure. However, the exceptions to this rule are emerging rapidly not only in healthy people (asymptomatic individuals, athletes, handicapped people) but also in cardiac patients (advanced congestive heart failure, hypertension, rhythm disorders, congenital heart disease, etc.). All the-se issues justify the need for a multidisciplinary consensus document in Spain.This paper reviews and updates the methodological aspects of the stress test, including those related to oxygen consumption measurements. The main aim of this review was to determine the role of exercise testing in the evaluation of ischemic heart disease as well as the applications of imaging stress testing. The usefulness of this test in other non-ischemic cardiac disorders and in selected subsets of healthy people is also reviewed.     

Practice guidelines of the Spanish Society of Cardiology on endocarditis

Infectious endocarditis is a disease which mainly involves the cardiac valves. It has a bad prognosis and is caused by a great variety of microorganisms. Prophylaxis is important although the effectiveness and the best way to achieve it remain unclear. Recommendations are herein presented. The diagnosis is based on clinical, bacteriological, and echocardiographic findings mainly based on Duke's criteria. Transthoracic and transesophageal echography are not only of diagnostic value but are also a tool to determine the therapy to follow. Antibiotic therapy should be selected according to the organisms isolated and their in vitro susceptibility. Guidelines for empirical antibiotic therapy in cases of negative cultures are also included. Lastly, indications and time for surgery are discussed.     

Guidelines of the Spanish Society of Cardiology on requirements and equipment in electrophysiology]

Due to the enormous qualitative and quantitative evolution that clinical electrophysiology has experienced over the past years, specific Units dedicated to the management of patients with cardiac arrhythmias have been created. In these guidelines, the minimum technical and human needs of an Arrhythmia Unit are discussed.     

2003 update of the Guidelines of the Spanish Society of Cardiology on High Blood Pressure

Since publication of the Spanish Society of Cardiology Clinical Practice Guidelines on High Blood Pressure in January 2000, a new body of scientific evidence has been obtained that needs to be taken into account in clinical practice. A complete clinical evaluation by assessment of the global cardiovascular risk score should be done in patients with hypertension. In this connection, ECG findings and urine albumin excretion are of particular value. Up to now, the results of most important clinical trials indicate that the aim should be to normalize blood pressure, with stricter control in patients at higher risk (diabetes, target organ damage or left ventricular hypertrophy). Antihypertensive therapy should be selected on an individual basis, taking in account that patients with certain associated pathologies will benefit more from particular groups of drugs. Those with diabetes or left ventricular hypertrophy seem to benefit from pharmacological block of the renin-angiotensin system, and patients with heart failure from combined therapy with ACE inhibitors plus beta-blockers.     

Guidelines of the Spanish Society of Cardiology for car driving, airplane flying,and underwater activities in subjects with heart disease

Car driving, airplane piloting and underwater activities by subjects with heart disease may cause sudden incapacitation leading to the loss of the safety margins necessary to avoid accidents. In the case of car driving and airplane piloting the risk affects, not only the driver or pilot, but also passengers and/or bystanders within an accident zone. In the case of diving the risk resides basically in the loss of control of the vital support mechanisms necessary in a very hostile medium. This document reviews the possible causes of unexpected incapacitation, with or without loss of consciousness, in the light of the pathophysiologic consequences of fatigue, hypoxia, stress or barotrauma posed by each activity. Detailed recommendations are made for limiting driving, piloting and diving, based on official Spanish and European regulations and the addresses of specialized centers are provided for consultation. Moreover, recommendations for airplane travel for patients with heart disease are indicated.     

Practice guidelines of the Spanish Society of Cardiology. Cardiac and heart-lung transplants

Cardiac transplantation is the only therapy that is able to substantially modify the natural evolution of patients with severe heart failure, along with angiotensin converting enzyme inhibitors. Nevertheless, because of the limited number of donors, its impact is scarce compared to the magnitude of the problem. Up to the end of 1998, 48,541 orthotopic cardiac transplantations and about 2,510 heart and both lung transplantations have been registered throughout the world. In Spain 2,780 procedures have been performed in the last 15 years. The survival expectations for a transplanted patient is 75% after the first year and 60% the following 5 years. The average duration of the graft is 8 years and 6 months. Cardiac transplantation is indicated for young and middle-age patients with irreversible cardiac process in bad clinical condition, with no other possibility of medical or surgical management and with a limited life expectancy. The major debate when choosing this therapy appears with the critical patients, patients older than 65 years, and some patients with systemic diseases. The great demand of transplantation obliges the teams to enlarge the criteria for donors' acceptance. At the same time, the increase of the knowledge about the transmission of some infections, mainly viral, forces to review those criteria day-to-day. The use of different immunosuppressive strategies pursues the control of rejection. The most commonly used is the so-called triple therapy (cyclosporine-azathioprine and steroids). The use of antilymphocytic antibodies such as cytolytic induction treatment is not unanimously accepted. Some of the new immunosuppressive agents such as myphenolate-mofetil and tacrolimus seem to offer advantages mainly due to their greater potency. Since transplantation is a limited procedure, of which its practise has an effect on the whole health system of a country, a perfect planning and adequacy of the Centers is compulsory, as well as the setting-up of clear rules for the use of donors and priority of transplantation. Finally, the patient must be informed clearly and comprehensively at length of the risks, limitations and expectations of these complex procedures.     

Guidelines of the Spanish Society of Cardiology on requirements and equipment in hemodynamic and interventional cardiology]

In the last 20 years the work performed in catheterization laboratories has changed greatly, and while also taking the diagnostic aspects also into account, interventional cardiology has acquired an important role. Work in the catheterisation laboratory has evolved from only diagnostic studies of cardiac anatomy and function, and evaluation of potential surgical candidates, to interventional procedures mainly based on catheters techniques. As new diagnostic and interventional procedures are now available, human and technical requirements of the catheterization laboratory have changed. The aim of this report is to make an update of the requirements needed to perform diagnostic and interventional procedures in the cardiac catheterization laboratory.     

Practice guidelines of the Spanish Society of Cardiology. Recommendations for the use of antithrombotic treatment in cardiology

The indications for the use of antithrombotic therapy are evolving as new drugs become available or new indications or dosages are recommended for drugs already in use. This document reviews and updates the former one published in 1994. To that end, an exhaustive revision of the literature published in the last 15 years has been undertaken. Following the evidence based medicine dictates, and aiming to select all the relevant publications for each pathology, all studies were selected through MEDLINE, using the specified key words for each subject, and were filtered using the following steps: a) only randomized, controlled studies, meta-analysis, guidelines and review articles were chosen; b) then, the Best-Evidence and Cochrane Collaboration databases were consulted; c) finally, the evidence based medicine validation, relevance and applicability criteria were assessed for each publication. The use of antiaggregants and anticoagulants are given for the following conditions: a) prevention of deep vein thrombosis and pulmonary embolism; b) prevention of systemic emboli in patients with lone atrial fibrillation, atrial fibrillation associated or not with rheumatic heart disease, in patients with biological or mechanical cardiac valvular prostheses and in dilated cardiomyopathy; c) antithrombotic therapy in coronary heart disease and in coronary intervention; d) the interactions with oral anticoagulants and how to control these therapies are also discussed.     

2002 Update of the Guidelines of the Spanish Society of Cardiology for Unstable Angina/Without ST-Segment Elevation Myocardial Infarction

Since the Spanish Society of Cardiology Clinical Practice Guidelines on Unstable Angina/Non-Q-Wave Myocardial Infarction were released in 1999, the conclusions of several studies that have been published make it advisable to update current clinical recommendations. The main findings are related to the developing role of Chest Pain Units in the management and early risk stratification of acute coronary syndromes in the emergency department; new information concerning the efficacy of glycoprotein IIb/IIIa inhibitors, clopidogrel and low-molecular-weight heparins in the pharmacological treatment of acute coronary syndromes without ST-segment elevation; and the role of early invasive strategy in improving the prognosis of these patients. The published evidence is reviewed and the corresponding clinical recommendations for the management of acute coronary syndromes without persistent ST-segment elevation are updated.