Initial complications and factors related to prehospital mortality in acute myocardial infarction with ST segment elevation.

OBJECTIVE: Hospital mortality in myocardial infarction ST-elevation myocardial infarction has decreased in recent years, in contrast to prehospital mortality. Our objective was to determine initial complications and factors related to prehospital mortality in patients with acute myocardial infarction with ST segment elevation (STEMI). METHODS: Observational study based on a prospective continuous register of patients of any age attended by out-of-hospital emergency teams in Andalusia between January 2006 and June 2009. This includes patients with acute coronary syndrome-like symptoms whose initial ECG showed ST elevation or presumably new left bundle branch block (LBBB). Epidemiological, prehospital data and final diagnostic were recorded. The study included all patients with STEMI on the register, without age restrictions. Forward stepwise logistic regression analysis was performed to control for confounders. RESULTS: A total of 2528 patients were included, 24% were women. Mean age 63.4±13.4 years; 16.7% presented atypical clinical symptoms. Initial complications: ventricular fibrillation (VF) 8.4%, severe bradycardia 5.8%, third-degree atrial-ventricular (AV) block 2.4% and hypotension 13.5%. Fifty-two (2.1%) patients died before reaching hospital. Factors associated with prehospital mortality were female sex (OR 2.36, CI 1.28 to 4.33), atypical clinical picture (OR 2.31, CI 1.21 to 4.41), hypotension (OR 4.95, CI 2.60 to 9.20), LBBB (OR 4.29, CI 1.71 to 10.74), extensive infarction (ST elevation in ≥5 leads) (OR 2.53, CI 1.28 to 5.01) and VF (OR 2.82, CI 1.38 to 5.78). CONCLUSIONS: A significant proportion of patients with STEMI present early complications in the prehospital setting, and some die before reaching hospital. Prehospital mortality was associated with female sex and atypical presentation, as pre-existing conditions, and hypotension, extensive infarction, LBBB and VF on emergency team attendance.

[Mean length of stay and prognosis in unstable angina. Results from the ARIAM database]. / Estancia media y pronóstico en la angina inestable. Resultados del registro ARIAM.

BACKGROUND AND OBJECTIVE: The objective of this project is to investigate the factors predicting mortality and mean length of stay in patients diagnosed with unstable angina (UA) during admission to the Intensive Care Unit or Critical Care Unit (ICU/CCU). PATIENTS AND METHOD: A retrospective cohort study including all the UA patients listed in the Spanish ARIAM register. The study period comprised from June, 1996 to December, 2003. The follow-up period is limited to the stay in the ICU/CCU. One univariate analysis was performed between deceased and live patients; and another between prolonged and non-prolonged stay patients. Three multivariate analyses were also performed; one to evaluate the factors related to mortality, another to evaluate the variables associated to percutaneous coronary intervention (PCI) and another to evaluate the factors associated to the prolonged mean stay in ICU/CCU. RESULTS: 14,096 patients with UA were included in the study. The UA mortality rate during ICU/CCU admission was 1.1%. Mortality was associated to Killip classification, age, the need for CPR, development of cardiogenic shock, development of arrhythmia (such as VF, sinus tachycardia or high-degree atrioventricular block) and diabetes; whereas patients who smoke were associated to a lower mortality rate. PCI was only performed in 1,226 patients (8.9%), increasing over the years. The PCI-predicting variables were: age, being referred from another hospital, smoking, presenting prior acute myocardial infarction (AMI), complications consisting of cardiogenic shock or high-degree atrioventricular block and being treated with oral beta blockers. The mean length of stay in ICU/CCU was 3.15 (18.65) days (median, 2 days), depending on age, a coronariography having previously been performed, the Killip classification, having required coronariography and PCI or echocardiography or mechanical ventilation, and presenting complications such as angina that is difficult to control, arrhythmia, right ventricular failure or death. CONCLUSIONS: The factors are associated to mortality were; greater age, diabetes, Killip classification, arrhythmia, cardiogenic shock and the need for CPR, whereas smoking is associated to a lower mortality rate. The patients on whom PCI was performed represent a less severe population. Management has changed over the years, with an increase in PCI. A prolonged mean length of stay is associated to the appearance of arrhythmia, right or left heart failure, angina that is difficult to control, age and PCI.

Safety and Efficacy of Prasugrel and Ticagrelor in Acute Coronary Syndrome. Results of a "Real World" Multicenter Registry.

INTRODUCTION AND OBJECTIVES: The incorporation of the new antiplatelet agents (NAA) prasugrel and ticagrelor into routine clinical practice is irregular and data from the "real world" remain scarce. We aimed to assess the time trend of NAA use and the clinical safety and efficacy of these drugs compared with those of clopidogrel in a contemporary cohort of patients with acute coronary syndromes (ACS). METHODS: A multicenter retrospective observational study was conducted in patients with ACS admitted to coronary care units and prospectively included in the ARIAM-Andalusia registry between 2013 and 2015. In-hospital rates of major cardiovascular events and bleeding with NAA vs clopidogrel were analyzed using propensity score matching and multivariate regression models. RESULTS: The study included 2906 patients: 55% received clopidogrel and 45% NAA. A total of 60% had ST-segment elevation ACS. Use of NAA significantly increased throughout the study. Patients receiving clopidogrel were older and were more likely to have comorbidities. Total mortality, ischemic stroke, and stent thrombosis were lower with NAA (2% vs 9%, P < .0001; 0.1% vs 0.5%, P = .025; 0.07% vs 0.5%, P = .025, respectively). There were no differences in the rate of total bleeding (3% vs 4%; P = NS). After propensity score matching, the mortality reduction with NAA persisted (OR, 0.37; 95%CI, 0.13 to 0.60; P < .0001) with no increase in total bleeding (OR, 1.07; 95%CI, 0.18 to 2.37; P = .094). CONCLUSIONS: In a "real world" setting, NAA are selectively used in younger patients with less comorbidity and are associated with a reduction in major cardiac events, including mortality, without increasing bleeding compared with clopidogrel.

Prognostic implication of early ventricular fibrillation among patients with ST elevation myocardial infarction.

OBJECTIVE: The aim of this study was to analyze the prognosis of patients presenting early ventricular fibrillation (VF) in the setting of ST elevation myocardial infarction (STEMI). PATIENTS AND METHODS: Among patients included in the ARIAM (Análisis del Retraso en el Infarto Agudo de Miocardio) registry with the diagnosis of STEMI, those who received primary revascularization and were admitted in the first 12 h were analyzed retrospectively. RESULTS: From January 2007 to January 2012, 8340 patients were included in the STEMI cohort and 680 (8.2%) of them presented with VF before admission to the ICU (VF). This group comprised younger patients with fewer comorbidities. They received more often primary angioplasty (33.7 vs. 24.9%; P<0.001), had more prevalence of Killip class greater than or equal to 2 at admission (37.5 vs. 17.8%; P<0.001), and suffered more often cardiogenic shock (18.5 vs. 5.9%, P<0.001). By logistic regression analysis, VF was associated with a greater in-hospital mortality [odds rate (OR): 2.08, 95% confidence interval (CI): 1.57-2.81, P<0.001]. After a propensity score matching process, VF was associated with in-hospital mortality (OR: 1.53, 95% CI: 1.05-2.25, P=0.028). However, when analyzing patients treated by primary angioplasty, the mortality was not significantly related to VF (OR: 0.86, 95% CI: 0.45-1.61, P=0.628). CONCLUSION: Our results show that VF before ICU admission was an independent predictor of in-hospital outcome in a cohort of patients in whom fibrinolysis was the most used revascularization therapy. However, this prognostic value was not found in patients treated with primary angioplasty.

Mid-regional pro-adrenomedullin as prognostic biomarker in septic shock.

BACKGROUND: The aim was to ascertain the prognostic value of mid-regional pro-adrenomedullin (MR-proADM), measured within 24 hours from the onset of septic shock (SS). METHODS: We performed a prospective, observational study on all patients admitted to our hospital's Intensive Care Unit with SS over a one year period from January to December 2011 to examine the outcomes in 100 consecutive SS cases. Demographic data and severity score (APACHEII and SOFA) were recorded. MR-proADM, C-reactive protein and procalcitonin were measured within the first 24 hours from SS onset. The outcome variable studied was 28-day mortality. Data were evaluated with non-parametric statistics bivariant and multivariate analyses for survival analysis. RESULTS: In patients who died within 28 days (36%), MR-proADM, Lactate, APACHE II as well as SOFA were significantly higher compared with survivors. MR-proADM showed the best association with 28-day mortality, as well as a prognostic value (logrank test: P=0.0012). Statistical significance was also seen in the Cox regression analysis (P=0.0004) for all patients with a Relative Risk of 1.26 times that of the baseline for each mmol/L of increase in MR-proADM. CONCLUSIONS: In our study MR-proADM levels measured on admission correlates with 28-day mortality in patients with septic shock.

Survival and Neurologic Outcome After Out-of-hospital Cardiac Arrest. Results of the Andalusian Out-of-hospital Cardiopulmonary Arrest Registry.

INTRODUCTION AND OBJECTIVES: There is a paucity of data on prehospital cardiac arrest in Spain. Our aim was to describe the incidence, patient characteristics, and outcomes of out-of-hospital emergency care for this event. METHODS: We conducted a retrospective analysis of a prospective registry of cardiopulmonary arrest handled by an out-of-hospital emergency service between January 2008 and December 2012. The registry included all patients considered to have a cardiac etiology as the cause of arrest, with a descriptive analysis performed of general patient characteristics and factors associated with good neurologic outcome at hospital discharge. RESULTS: A total of 4072 patients were included, with an estimated incidence of 14.6 events per 100000 inhabitants and year; 72.6% were men. The mean age was 62.0 ± 15.8 years, 58.6% of cases occurred in the home, 25% of patients had initial defibrillable rhythm, 28.8% of patients arrived with a pulse at the hospital (58.3% of the group with defibrillable rhythm), and 10.2% were discharged with good neurologic outcome. The variables associated with this recovery were: witnessed arrest (P=.04), arrest witnessed by emergency team (P=.005), previous life support (P=.04), initial defibrillable rhythm (P=.0001), and performance of a coronary interventional procedure (P=.0001). CONCLUSIONS: More than half the cases of sudden cardiac arrest occur at home, and the population was found to be relatively young. Although recovery was satisfactory in 1 out of every 10 patients, there is a need for improvement in the phase prior to emergency team arrival. Coronary interventional procedures had an impact on patient prognosis.

Influence of the previous use of ß-blockers on the early clinical course of acute coronary syndromes.

Recent studies have recently questioned the current role of ß-blockers in myocardial infarction. Our purpose is to analyze the influence of the previous use of ß-blockers on the early course of patients admitted because of acute coronary syndrome (ACS). We analyzed the data of 37.359 patients included in the ARIAM-Andalucia Registry. Of them, 7759 (20.8%) were previously receiving ß-blockers. BB patients were older, more often female, had more risk factors and vascular disease, and less often had an ST-elevation myocardial infarction. In the unadjusted analysis, BB patients less often had ventricular fibrillation or atrioventricular block, and more often a Killip classification >1, and no difference of in-hospital mortality (5.7 vs 5.6%). After logistic regression analysis and propensity score matching, no differences in complications or mortality (odds ratio 0.997, 95% confidence interval 0.882-1.128) were found in relationship to previous ß-blockers. In conclusion, we find that the previous administration of ß-blockers is not an independent predictor of the early prognosis of ACS.

Prognostic impact of clopidogrel pretreatment in patients with acute coronary syndrome managed invasively.

Pretreatment with antiP2Y12 agents before angiography in acute coronary syndrome (ACS) is associated with a reduction in thrombotic events. However, recent evidences have questioned the benefits of upstream antiP2Y12, reporting a higher incidence of bleeding. We analyzed the prognostic impact of clopidogrel pretreatment in a large cohort of invasively managed patients with ACS. In hospital, safety and efficacy of clopidogrel pretreatment were retrospectively analyzed in patients included in the ARIAM-Andalucía Registry (Analysis of Delay in Acute Myocardial Infarction). Propensity score and inverse probability of treatment weighting analysis were performed to control treatment selection bias. Results were stratified by ACS type. Sensitivity analyses were used to explore stability of the overall treatment effect. Of 9,621 patients managed invasively, 69% received clopidogrel before coronary angiography. In the ST-elevation myocardial infarction group, pretreatment was associated with a significant reduction in reinfarction (odds ratio 0.53, 95% confidence interval [CI] 0.27 to 0.96; p = 0.027), stent thrombosis (odds ratio 0.15, 95% CI 0.06 to 0.38; p <0.0001), and mortality (odds ratio 0.67, 95% CI 0.48 to 0.94; p = 0.020), with an increase in minor bleeding but remained as a net clinical benefit strategy. Those benefits were not present in patients without ST elevation (non-ST elevation ACS). The weighting and propensity analysis confirmed the same results. An interaction between pretreatment duration and bleeding was observed. In conclusion, pretreatment with clopidogrel reduced the occurrence of death and thrombotic outcomes at the cost of minor bleeding. Those benefits exclusively affected ST-elevation myocardial infarction cases. The potential benefit of routine upstream pretreatment in patients with non-ST-elevation ACS should be reappraised at the present.

Prognostic impact of atrial fibrillation in acute coronary syndromes: results from the ARIAM registry.

AIMS: The prognostic ability of atrial fibrillation (AF) in acute coronary syndromes (ACS) is unclear. Studies regarding patient outcomes with respect to the timing of AF are scarce and conflicting. The present study aimed to determine the frequency, predictors and impact on clinical outcome of AF in patients with ACS. METHODS: We analysed 39,237 consecutive patients with ACS included in the ARIAM registry between January /2001 and December 2011. Patients with AF were compared with patients in sinus rhythm. We differentiate between new-onset AF and previous AF cases to analyse mortality and other major adverse cardiac events (MACE) during hospitalization. RESULTS: Of the patients, 2851 (7.3%) developed AF; 1568 (55%) of these were new-onset AF and 1283 (45%) had previous AF. The AF group had a higher risk profile at baseline and poorer clinical presentation at admission than non-AF patients. Compared with previous AF patients, new-onset AF presented with fewer comorbidities, including hypertension, diabetes, prior myocardial infarction, and chronic renal impairment. The inhospital mortality for new-onset AF, previous AF, and non-AF patients were 14, 11.6, and 5.2%, respectively (new-onset AF unadjusted HR 2.19, 95% CI 1.9-2.53, p<0.001; adjusted HR 1.70, 95% CI 1.12-3.4, p<0.001). After propensity score analysis, only new-onset AF persisted as an independent predictor for mortality (HR 1.62, 95% CI 1.09-2.89, p<0.001). Other MACE such as reinfarction, malignant arrhythmias, and heart failure were also more frequent in new-onset AF patients than in previous AF or non-AF patients. CONCLUSIONS: These findings suggest that the presence of new-onset AF during ACS is associated with a significant increase in mortality, even after adjusting for confounding variables.

APACHE-II score and Killip class for patients with acute myocardial infarction.

OBJECTIVE: To analyse the influence on the prognosis of intensive care unit (ICU) patients with acute myocardial infarction (AMI): prognostic index score, Killip class, AMI site, thrombolysis and other variables that might improve prognostic capacity and functioning of the APACHE-II index. DESIGN: Cohort study using prospectively gathered ARIAM project data. SETTING: ICUs from 129 Spanish hospitals. PATIENTS: ICU-admitted AMI patients in ARIAM database during 4-year period were retrospectively studied. MEASUREMENTS AND MAIN RESULTS: The sample comprised 6,458 patients, 76.8% males, age 64.97 +/- 12.56 years, APACHE-II score 9.49 +/- 7.03 points and ICU mortality 8.9%. Mortality was higher for females (p < 0.001), anterior AMI site (p < 0.001), previous AMI (p < 0.001), delay-to-hospital arrival >180 min (p = 0.003) and non-receipt of thrombolysis (p = 0.015). ICU mortality was related to age (p < 0.001) and APACHE-II score (p < 0.001). In multivariate analysis, it was related to APACHE-II (OR 1.16), age (OR 1.05), gender (OR 1.64), previous AMI (OR 1.57), anterior AMI (OR 2.05) and delay >180 min (OR 1.37). Killip class, gathered in 1,893 patients, was significantly associated with ICU mortality, and two predictive models were constructed for this group using multivariate analysis. Area under ROC curve was 0.94 in one (Killip class, age, gender, APACHE-II) versus 0.92 in the other (same variables without APACHE-II). CONCLUSIONS: APACHE-II score and Killip class are useful for assessing the severity of patients with AMI and are complementary. Each can be used with a few commonly gathered clinical variables to construct prognostic models to assess severity. Their joint application yields a model with excellent discrimination capacity.

Preinfarction angina prior to first myocardial infarction does not influence long-term prognosis: a retrospective study with subgroup analysis in elderly and diabetic patients.

BACKGROUND AND HYPOTHESIS: Although prodromal angina occurring shortly before an acute myocardial infarction (MI) has protective effects against in-hospital complications, this effect has not been well documented after initial hospitalization, especially in older or diabetic patients. We examined whether angina 1 week before a first MI provides protection in these patients. METHODS: A total of 290 consecutive patients, 143 elderly (>64 years of age) and 147 adults (<65 years of age), 68 of whom were diabetic (23.4%) and 222 nondiabetic (76.6%), were examined to assess the effect of preceding angina on long-term prognosis (56 months) after initial hospitalization for a first MI. RESULTS: No significant differences were found in long-term complications after initial hospitalization in these adult and elderly patients according to whether or not they had prodromal angina (44.4% with angina vs 45.4% without in adults; 45.5% vs 58% in elderly, P < 0.2). Nor were differences found according to their diabetic status (61.5% with angina vs 72.7% without in diabetics; 37.3% vs 38.3% in nondiabetics; P = 0.4). CONCLUSION: The occurrence of angina 1 week before a first MI does not confer long-term protection against cardiovascular complications after initial hospitalization in adult or elderly patients, whether or not they have diabetes.

[Effect of angina in the week before myocardial infarction on long-term cardiovascular morbidity and mortality after hospital discharge]. / Influencia de la angina preinfarto en la semana previa en la morbimortalidad cardiovascular tardía tras el alta hospitalaria.

The occurrence of angina in the week preceding myocardial infarction is associated with a reduction in cardiovascular complications in the acute phase. However, little is known about it relationship with prognosis after hospitalization (e.g., cardiovascular death and the development of heart failure or ischemic cardiomyopathy). The study included 290 consecutive patients admitted for a first myocardial infarction: 107 (36.9%) had preceding angina while 183 did not. Those with a history of ischemic cardiomyopathy of more than 1 week or structural cardiopathy were excluded. There was no difference in baseline characteristics between the two groups. Moreover, there was no difference in the rates of cardiovascular complications after hospital discharge: cardiovascular death (7% vs. 12.6%; P=.3), heart failure (7.4% vs. 11.6%; P=.2), and myocardial ischemia, including myocardial infarction and unstable angina, requiring hospitalization (41.2% vs. 31.3%; P=.3). The occurrence of angina in the week before a first myocardial infarction did not influence cardiovascular complications after hospital discharge (odds ratio = 0.75 [0.51-1.11]; P=.15).