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Editorial
A glow in the secondary prevention of cardiovascular disease
Un resplandor en la prevención secundaria de la enfermedad cardiovascular
J. Pedro-Botet, E. Climent
Lipids and Vascular Risk Unit, Hospital del Mar, Universitat Autònoma de Barcelona, Barcelona, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The main objective of cardiovascular prevention is to reduce morbidity and mortality&#44; improve quality of life and increase longevity with good health&#46; The modification of risk factors is the best standard of quality in clinical practice that an individual doctor can and should do to effectively and plausibly achieve a reduction in the burden of cardiovascular disease&#46; Thus&#44; in countries where there has been a significant reduction in cardiovascular disease&#44; control of blood pressure&#44; control of lipid levels and smoking cessation were the main contributors&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">An abundance of clinical evidence supports the idea that lipid-lowering therapy in the secondary prevention of cardiovascular disease is one of the most effective strategies&#46; The latest 2016 European guidelines for cardiovascular prevention make it clear that low-density lipoprotein &#40;LDL&#41; cholesterol is a causal factor for atherosclerosis&#44;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> and that high cholesterol is a prerequisite for atheromatous plaque formation&#46; Multiple interventional studies in very high-risk patients have shown that achieving LDL cholesterol levels &#60;70<span class="elsevierStyleHsp" style=""></span>mg&#47;dL or even lower is associated with a decrease in cardiovascular events and a regression of atherosclerosis&#46; In addition&#44; no subgroup of subjects has been identified that does not benefit from the decrease in concentrations of LDL cholesterol&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">However&#44; despite the evidence of the cardiovascular benefits attributed to strict lipid control&#44; the degree of achievement of therapeutic goals in patients with very high cardiovascular risk&#44; such as patients with ischaemic heart disease&#44; is unacceptable and universally low&#46; Thus&#44; in EUROASPIRE IV&#44;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> a cross-sectional study conducted in 78 hospitals in 24 European countries in the period 2012&#8211;13&#44; which included patients under 80 years of age with coronary heart disease&#44; only 22&#37; of men and 17&#37; of women achieved the therapeutic goals of LDL cholesterol &#60;70<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#44; despite the fact that&#44; overall&#44; 85&#46;7&#37; were treated with statins&#46; Recently&#44; the data of the <span class="elsevierStyleItalic">Dyslipidaemia International Study</span> &#40;DYSIS&#41; were published for the period 2013&#8211;14&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> The results are stratified by country and are obtained from a global registry&#44; so that achievement rates of objectives can be compared within the different national health systems&#46; Overall&#44; of the 41&#44;953 patients at very high risk in this registry&#44; only 21&#46;7 achieved the aforementioned LDL cholesterol goal&#46; It is worth noting that Spain and Greece were the two countries with the worst rates&#58; 10&#46;1&#37; and 9&#46;2&#37;&#44; respectively&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The <span class="elsevierStyleItalic">Spanish Registry on Lipid Control in Very High-Risk Patients</span> &#40;REPAR&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> which included 1103 patients with stable ischaemic heart disease&#44; showed that 95&#46;3&#37; received lipid-lowering pharmacological treatment&#44; but only 26&#37; achieved strict lipid control&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">In conclusion&#44; and based on the above&#44; we can affirm that with the pharmacological treatment available at the time of the studies&#44; together with the changes in lifestyle&#44; only one in four patients at very high cardiovascular risk achieved the lipid-control objectives recommended by clinical practice guidelines&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">In this issue of &#8220;CL&#205;NICA E INVESTIGACI&#211;N EN ARTERIOSCLEROSIS&#8221;&#44; an observational study was conducted in C&#225;ceres to learn the degree of lipid control in patients with ischaemic heart disease in this area of health&#59; there are several aspects of this study that we wish to highlight&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> First&#44; it included all patients who were admitted to hospital consecutively with a diagnosis of acute and chronic stable heart disease from January 2009 to June 2015 and for whom a recent lipid profile was available&#46; As far as secondary prevention is concerned&#44; there are two different clinical scenarios to positively modify the lipid profile&#58; the immediate post-acute coronary syndrome &#40;ACS&#41; phase and the long-term phase&#46; Therefore&#44; we consider it a success in the design of the LIPICERES study to have included patients with heart disease in an acute phase&#44; since secondary prevention begins from the appearance of the first cardiovascular complication&#44; such as an ACS&#46; It is well established that initiating treatment with high-intensity statins&#44; unless contraindicated&#44; immediately after a cardiovascular event&#44; is the most effective therapy and its impact on morbidity and mortality is not only immediate but also long-term&#46; This validates the axiom applicable to patients at very high cardiovascular risk&#58; &#8220;LDL cholesterol&#44; the lower and the sooner the better&#8221;&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The main outcome of the LIPICERES study was that one in every two patients with heart disease achieved the objectives of lipid control in LDL cholesterol&#44; an extremely positive and encouraging finding compared with previous studies&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#8211;5</span></a> In addition&#44; there was a progressive increase in the percentage of patients with LDL cholesterol in objectives in the period from 2013&#8211;14 to 2015&#44; going from 42&#46;8&#37; to 55&#46;9&#37;&#44; respectively&#46; Without intending to make a simplistic reading of these promising results&#44; given that there are many possible determinants&#44; we consider that the message of a conceptual change from a high-intensity statin therapy to a high-intensity hypocholesterolaemic therapy<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> is being received by the professionals involved in cardiovascular prevention&#46; This aspect has recently been endorsed by a meta-analysis and systematic review by Silverman et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> which showed that statins and other drugs&#44; such as ezetimibe and anti-PCSK9 monoclonal antibodies&#44; which act through the upregulation of LDL-receptor expression&#44; are associated with similar reductions of risk of severe cardiovascular events by similar percentage reduction in LDL&#46; We must remember that with the co-administration treatment of a high-intensity statin and ezetimibe the maximum effect of LDL cholesterol reduction is 60&#37;&#44; and if we add as a third drug a PCSK9 inhibitor we can achieve a reduction of 84&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Another aspect to be highlighted in the LIPICERES study is that 59&#46;3&#37; of patients older than 75 years had LDL cholesterol &#60;70<span class="elsevierStyleHsp" style=""></span>mg&#44; compared with 49&#37; of those younger than 75 years&#46; The increase in the population of elderly patients&#44; together with better primary prevention strategies&#44; has increased the importance of secondary prevention of cardiovascular disease<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> and has in some way called into question certain unscientifically proven states of opinion that proposed the suppression of hypolipidaemic treatment in this specific population&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">We consider that the extraordinary improvement reflected by the results of the LIPICERES study&#44; compared with the previous experiences&#44; is excellent news for patients&#44; health professionals and health institutions&#44; because it establishes that strict lipid control in secondary prevention is clearly feasible&#46; Undoubtedly&#44; the correct planning of the hypocholesterolaemic pharmacological strategy in patients with very high cardiovascular risk&#44; with a greater use of co-administration treatments&#44; is the way forward&#46;</p></span>"
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es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos