The Current State of Cardiology in Spain

Late last year I visited Spain on the 10th anniversary of one of my international collaborative efforts with my colleagues in Córdoba and Las Palmas. ¹ I was invited to serve as a visiting professor in the University of Córdoba, University of Las Palmas, and Universidad Complutense in Madrid. It was my 1st visit to Spain. The following is my recollection of one of the richest and most stimulating experiences of my professional life.

Spanish Society of Cardiology

My visit started with attendance at the 36th National Congress of the Spanish Society of Cardiology, upon the invitation of its president, Dr. Federico Vallés Belsué. The Congress in 2000 was held in Granada in southern Spain, home of the monumental hilltop Alhambra palace. Walking to the Alhambra can be as in–spiring as walking around it. One should start in the Plaza Nueva and climb the Cuesta de Gomerez—through the slopes of green elms planted by the Duke of Wellington—to reach the Puerta de las Granadas (Pomegranate Gate), a Renaissance gateway built by Charles V. It is topped by 3 pomegranates, which take their name from Granada. The sight is most magical at dawn, dusk, and on nights when the Alhambra is floodlit. (During a visit to Spain in 1997, former President Bill Clinton went out of his way to show his wife and daughter the sunset from here, a view he remembered from an earlier trip to Granada as a student.) The 36th National Congress had returned to Granada after an absence of a mere 3 years, just as the American Heart Association and the American College of Cardiology return often to the popular convention city of New Orleans.

The meeting lasted 3 days. The program contained 542 scientific presentations, of which 209 were oral, 178 were moderated poster sessions, and 155 were unmoderated poster sessions. Altogether, 880 abstracts had been submitted, so the acceptance rate for 2000 was 62%. A “first” for the year 2000 was that 334 of the 880 submissions, or 38%, had been submitted via the Internet.

In addition to the individual presentations, there were 20 roundtable discussions and many sessions on the “latest” (“Lo último en …”) and “how to” (“Actuaciön práctica ante …”). New for 2000 were sessions on “late-breaking clinical trials” (“Últimos resultados”), which included results of multicenter clinical trials, both national and international.

The official publication of the Spanish Society of Cardiology is the Revista Española de Cardiología. I had the opportunity to meet its editor-in-chief, Dr. Xavier Bosch, a young and energetic cardiologist from Barcelona. He was very proud, and rightly so, of the impact factor of his journal, which in 1999 was 0.460, ahead of the Texas Heart Institute Journal (0.457), Archives des Maladies du Coeur et des Vaisseaux (0.392), Acta Cardiologica (0.311), Japanese Heart Journal (0.293), Journal of Invasive Cardiology (0.259), Journal of Interventional Cardiology (0.237), and Kardiologiia (0.220). These figures, obtained from the 1999 Science Citation Index, placed Revista Española de Cardiologí 49th in the overall ranking. It took many years of hard work to achieve this result, and a readership survey published in 1997 indicated that most readers were satisfied with the journal's usefulness and with its scientific and editorial quality. ² Under the present editorial board, the quality of the journal continues to improve.

The Spanish Society of Cardiology has kept a registry of hemodynamic and interventional procedures in 82 centers, which constitute all the cardiac catheteri–zation laboratories in Spain. ³ According to the latest published data (for 1998), ³ a total of 74,364 diagnostic catheterization procedures were performed, 80% of which were coronary angiographies. Coronary interventions were 20,146 in number (509 per million population). Stenting continues to be the principal technique for coronary intervention. In 1998, cor-onary stents were used in 14,497 cases, or 72% of all coronary revascularization procedures. A total of 19,378 stents were implanted, with a low rate of complications (1.5% subacute closure, 1.5% myocardial infarction, and 0.94% mortality). As in previous years, there was a slight decrease in adult valvuloplasties (505 vs 559 in 1997). Pediatric interventional procedures increased by 20% (557 vs 465 procedures), compared with the 1997 Registry. ³

CORPAL

Without knowledge of the similar work done in November 1985 ⁴ by interventional cardiologists from the Guangdong Cardiovascular Institute in Guang-zhou, China, a group from the universities of Córdoba and Las Palmas, in May 1986, ⁵ independently began percutaneous balloon mitral valvuloplasty as a valid nonsurgical alternative for treatment of rheu-matic mitral stenosis. When I learned about the CORPAL group's experience (COR from Córdoba and PAL from Palmas) with this technique in treatment of mitral restenosis, ⁵ I immediately asked Drs. Medina and Suárez and their colleagues to contribute a chapter on their experiences to my book Percutaneous Balloon Valvuloplasty, ⁶ which was published in 1992. Although the CORPAL group originally used the transarterial approach, it later switched to the transseptal approach, which the Chinese group had used all along. Due to scheduling conflicts, I was unable to visit the CORPAL group in Spain until 2000 (Fig. 1).

Fig. 1 Staff members in the cardiac catheterization laboratory of Hospital Universitario “Reina Sofía.” This group photograph was kindly autographed for the author (second from left) by each staff member.

I was most impressed by the work carried out by the CORPAL group over the years, including the 1st use of transluminal balloon dilation of discrete sub-aortic stenosis, reported in the English medical literature in 1986. ⁷ Following the 1st Spanish report on angioplasty procedures in congenital heart disease by Pérez Martínez and colleagues ⁸ in 1983, the CORPAL group was among the pioneers in interventional cardiology in Spain. ⁹

While I was a visiting professor in Córdoba, Las Palmas, and Madrid, I witnessed several procedures: percutaneous balloon mitral valvuloplasty; balloon-expandable stent repair of aortic coarctation; cor-onary stenting of left main coronary obstructions under in-laboratory percutaneous cardiopulmonary bypass (the 126th such case by the CORPAL group was done on 23 October 2000); percutaneous balloon dilation of critical pulmonic stenosis in infants; transcatheter closure of complex atrial septal defects (which the CORPAL group recently reported ¹⁰); and intracoronary ultrasonic investigation of Prinzmetal's angina. I wish to describe briefly 1 example in each of the last 2 categories, because of their impressive results.

A 6-year-old child with a congenital secundum atrial septal defect who had received a Sideris device 4 years earlier was found to have a recurrence of the left-to-right atrial shunt. On transesophageal echo-cardiography, the Sideris device was found to be lying transversely astride the atrial septal defect (Figs. 2A and 2B). Therefore, an Amplatzer septal occluder was deployed to trap the tilted Sideris device and to re-close the defect completely, in a sort of sandwich (Figs. 2C through 2F).

Fig. 2 Transesophageal echocardiograms from a boy with a recurrent secundum atrial septal defect (arrowhead in A) due to a partially detached Sideris device (arrow in B) implanted 4 years earlier. An Amplatzer septal occluder (C) was consequently deployed to re-close the defect by trapping the tilted Sideris device (arrows in D and E). The levophase of a post-procedure pulmonary angiogram (F) showed an intact atrial septum between the opacified left atrium (LA) and the non-opacified right atrium.

(Images courtesy of Dr. J. Suárez de Lezo, Córdoba.)

The next example is that of an adult patient with Prinzmetal's angina, who was found upon coronary arteriography to have severe subtotal stenosis at the origin of the anterior descending branch of the left coronary artery (Fig. 3A). After the intracoronary administration of nitroglycerin, the stenosis completely disappeared, as would be expected of spasm (Fig. 3B). However, on intravascular ultrasonography, a thrombus was seen at the site of the coronary spasm (Fig. 3C), with a wide-open lumen beyond (Fig. 3D). Before the advent of intravascular ultrasonography, this patient would have been diagnosed as having a “variant of the variant,” ¹¹ or variant angina of Prinzmetal with normal coronary arteriograms.

Fig. 3 A patient with Prinzmetal's angina showing a severe subtotal stenosis (arrow in A) at the origin of the anterior de-scending branch of the left coronary artery. The stenosis dis-appeared completely (B) after intracoronary administration of nitroglycerin (IC NTG). However, intravascular ultrasonography revealed a thrombus (arrows in C) at the site of the stenosis (1 in B and C) and a normal vessel beyond (2 in B and D).

(Images courtesy of Dr. J. Suárez de Lezo, Córdoba.)

The most striking phenomenon that I observed during my visit was the close, harmonious, and productive working relationship between these 2 car–diology groups in Spanish cities, Córdoba and Las Palmas, at such a geographic remove from one another. Las Palmas, the Canary Islands' capital and largest city, is nearly 1,200 miles from Córdoba (more than 2½ hours by airplane) and is actually much closer to North Africa than to Spain (Fig. 4). (Incidentally, the Canary Islands were named not for the yellow songbirds but for a breed of dog, canum in Latin, a mastiff found here by ancient explorers; the birds were later named after the islands. ¹²) The interesting logo of the CORPAL group incorporates the heart beneath a striped arch of Mezquita (Fig. 5). The arch is a symbol of the sublime mosque in Córdoba that contains some 850 majestic columns of jasper, marble, granite, and onyx; crowning these are endless red-and-white-striped Moorish arches that curve away into the dim light.

Fig. 4 Las Palmas of the Canary Islands is much closer to North Africa than to Córdoba on the Spanish mainland. Córdoba (not labeled on the map) is 90 miles northeast of Sevilla.

Fig. 5 The sublime Mezquita in Córdoba, Spain, is a mosque with a cathedral in the center. The CORPAL group's logo (inset) was designed to recall the red-and-white-striped arches of the Mezquita.

(Photo of Mezquita courtesy of the Spanish Embassy in Washington, DC.)

Heart Transplantation

During my relatively short visit in the Hospital Universitario “Reina Sofía,” the teaching hospital of the University of Córdoba, I saw a young boy with dilated cardiomyopathy in severe congestive heart failure, who was on circulatory support by a left ventricular assist device while waiting to receive a heart transplant. “Reina Sofía” has longstanding experience with heart transplantation. ¹³ As a matter of fact, Spain leads the world in organ donations. In 2000, its annual rate approached 34.2 donors per million people; ¹⁴ and in 1999, the number of cadaveric organ donors in Spain was 33.5 per million people, which compares with 21 per million in the United States and 14 per million in the European Union. ¹⁵

The Spanish Transplantation Act of 1979 adopts the principle of “presumed consent” to donate, ¹⁵ according to which every person who dies becomes an organ donor if he or she qualifies and expressed no opposition during life. ¹⁶ (In practice, however, all Spanish hospitals require the express written and signed authorization of the family before organs are removed. ¹⁵) In Spain, the hospitals themselves procure organs for transplantation, and this process is controlled and carried out by the physicians and nurses. ¹⁵ Lopez-Navidad and Caballero ¹⁵ firmly believe that such a system is the only one that can guarantee adequate control and implementation of all phases of procurement. This system in Spain is so well established that the organ-donation rate approaches the maximum achievable. ¹⁷

According to the latest results of the Spanish Registry of Heart Transplantation, published in December 2000, ¹⁸ a total of 336 transplants were performed in 1999. From the beginning of 1984 through 1999, there were 3,092 heart transplants in Spain. For the past several years, the mean annual figure has been close to 250. ¹⁸

The mean clinical profile of the heart transplant recipient in Spain is as follows: a male (82%), 48 years of age (48 ± 15 years), blood type A (54%) or O (32%), with severe ischemic heart disease (39%) or idiopathic dilated cardiomyopathy (35%). ¹⁸ For the last decade, the mean early mortality rate (first 30 days after transplantation) has been 14%. Acute graft failure (35%), multiple organ failure (15%), and infection (10%) have been the most frequent causes of death. Survival rates in the 1st, 5th, and 10th years have been 74%, 62%, and 47%, respectively. ¹⁸

Medical Specialization

In Spain, young medical doctors can become specialists in either of 2 ways: through the MIR system (Médico Interno Residente, or internal medicine residency) or through the MESTO system (Médico Especialista Sin Titulo Oficial, or medical specialist without an official diploma). ¹⁹

The official route is through MIR. Medical graduates in MIR have to pass a competitive examination in order to be accepted into a residency program, which in cardiology lasts for a period of 5 years. The MIR doctors follow a program similar to that for training residents in the United States, with the exception that they follow only 1 year of the internal medicine program and do not sit for the Board of Internal Medicine examination. During the past 20 years, only 20% to 60% of these doctors have passed the examination, not because they failed but because there were many fewer positions than doctors who wanted to become specialists.^* (It should be mentioned in this context that MIR doctors are paid by the government; the actual limitation is on the number of specialists who can be supported by taxpayers.)

However, demand for more specialists has in fact existed, so hospitals have engaged the MESTO doctors as “pseudospecialists.” As a result, in Spain there are thousands of doctors working as specialists (most of them in small hospitals) who do not have the official diplomas of specialists and who may be fired at any time.

On 24 September 1999, as a consequence of pressure from various medical associations, the government passed a bill to enable MESTO doctors to be recognized as specialists. The MIR doctors appealed, but on 24 October 2000, the Spanish Supreme Court rejected their appeal, saying “MESTO and MIR doctors, via different ways, reach the same goal.… this happens as a result of a longer process for the former and an easier one for the latter.” ¹⁹

For more information on the cardiology training program that prevails in Spain, readers should consult 2 recent articles published in Revista Española de Cardiologí. ^20,21

Cigarette Smoking

Before I visited Spain in 2000, I thought that China was the worst country in the world in regard to cigarette smoking. China ranks 1st in the world both in population and in output of cigarette products. ²² In fact, 1 of every 3 cigarettes manufactured in the world is smoked by the people of China. ²³ Thirty percent of medical doctors ²² and 38% of male medical students in China ²⁴ smoke cigarettes. Three of every 5 Chinese smokers adopt the habit between the ages of 15 to 20 years; very few begin smoking in adulthood. ²⁵

Yet I was appalled by what I saw in Spain. The moment I arrived in Madrid, I noticed many people smoking cigarettes at the airports, train stations, and restaurants, and on the streets. I was struck in particular by the high prevalence of smoking among health-care professionals. The big difference that I noticed between China and Spain was that many young women smoke in Spain, whereas very few women smoke in China. The percentage of young Spanish women who smoke (49%) is among the highest in the European Economic Community. ²⁶ According to the World Health Organization's 1997 report “Tobacco or Health: A Global Status Report,” the prevalence of smoking among physicians in Spain is 52%, and the prevalence among Spanish women appears to rise as socioeconomic status rises. ²⁷ Because physicians seldom advise patients to stop smoking, there is an urgent need for Spanish health authorities to develop smoking-cessation programs. ²⁸ In Europe as a whole, smoking has actually become more widespread in the recent past. ²⁹ European physicians, from all appearances, are not modifying their patients' behavior in this regard. ²⁹

Conclusion

Spain is a highly unusual country, full of surprises. Tourism exceeds that of any other nation. Every year, 50 million tourists visit a country of 40 million residents. ³⁰ Spain has a young population: only 20% of its people are older than 60. ³⁰

Cardiology in Spain is as advanced as anywhere in the world, and Spanish cardiovascular research is becoming ever more visible, as is indicated by the growing number of journal articles from Spain in the Science Citation Index database and by a trend towards publication in high-impact-factor journals. ³¹