[Reduction in 28 days and 6 months of acute myocardial infarction mortality from 1995 to 2005. Data from PRIAMHO I, II and MASCARA registries]. / Reducción de la mortalidad precoz y a 6 meses en pacientes con IAM en el periodo 1995-2005. Datos de los registros PRIAMHO I, II y MASCARA.

INTRODUCTION AND OBJECTIVES: To determine whether mortality from acute myocardial infarction has reduced in Spain and the possibly related therapeutic factors. METHODS: Nine thousand, nine hundred and forty-nine patients with ST-segment elevation myocardial infarction admitted to the Coronary Care Unit were identified from PRIAMHO I, II and MASCARA registries performed in 1995, 2000 and 2005, with a 6 month follow-up. RESULTS: From 1995 to 2005 patients were increasingly more likely to have hypertension, hyperlipidemia and anterior infarction, but age of onset and the proportion of females did not increase. Twenty-eight-day mortality rates were 12.6%, 12.3% and 6% in 1995, 2000 and 2005 respectively, and 15.3%, 14.6% and 9.4% at 6 months (both P-trend <.001). Multivariate analysis was performed and the adjusted odds ratio for 28-day mortality for an infarction occuring in 2005 (compared with 1995) was 0.62 (95% confidence interval: 0.44-0.88) whereas the adjusted hazard ratio for mortality at 6 months was 0.40 (95% confidence interval: 0.24-0.67). Other variables independently associated with lower mortality at 28 days were: reperfusion therapy, and the use of anti-thrombotic treatment, beta-blockers and angiotensin-converting enzyme inhibitors. The 28-day-6-month period had an independent protective effect on the following therapies: coronary reperfusion, and prescription of antiplatelet agents, beta-blockers and lipid lowering drugs upon discharge. CONCLUSIONS: Twenty-eight-day and six-month mortality rates fell among patients with ST-elevation myocardial infarction in Spain from 1995 to 2005. The possibly related therapeutic factors were the following: more frequent reperfusion therapy and increased use of anti-thrombotic drugs, beta-blockers, angiotensin-converting enzyme inhibitors and lipid lowering drugs.

Evolution in the management of acute myocardial infarction in the autonomous community of valencia (Spain): ten years of the primvac registry (1995-2004).

INTRODUCTION AND OBJECTIVES: Several registries of acute myocardial infarction (AMI) have been carried out in Spain, but few remain active. This work analyses the evolution of the characteristics and control of patients with AMI during the first 10 years of the PRIMVAC registry, initiated in 1995. METHODS: The demographical and clinical characteristics, therapeutic-diagnostic procedures and pharmacological treatment of patients admitted with AMI between January 1995 and December 2004, were analysed in 17 coronary centres in the Autonomous Community of Valencia (South eastern Spain). RESULTS: The mean age of the 19,719 patients recruited was of 65. The percentage of women, hypertension, hypercholestrolemia and diabetes increased during registry period. The median time of symptoms onset-hospital arrival was 151 minutes, without a decrease over the time, and the delay of thrombolysis fell from 200 to 154 minutes (p<0.01). Percentage of thrombolytic treatment oscillated between 39% and 48%. The mortality in the coronary units decreased (14.1% vs. 8.9%; p<0.001). The number of coronary angiography and percutaneous revascularisation performed increased up to 61% and 32%, respectively, of patients included. On discharge, the use of beta-blockers (29.3% vs. 66.7%), angiotensin-converting enzyme (ACE) inhibitors (41.7% vs. 57.9%) and statins (29.3% vs. 71%) went up. CONCLUSIONS: Overall mortality in the coronary unit decreased, without any variation in the incidence of serious complications. Time to thrombolysis was reduced over the time, with no significant increment in its use. The performance of coronary angiography and percutaneous revascularisation increased, with a low use of primary angioplasty. The use of beta-blockers, ACE inhibitors and statins increased at discharge.

Smoking and myocardial infarction case-fatality: hospital and population approach.

BACKGROUND: Smoking is a risk factor for coronary heart disease, but it has been associated with better short-term prognosis in hospitalized patients with acute myocardial infarction. The aims of this study were to determine the association between smoking and myocardial infarction 28-day case-fatality in hospitalized patients and at the population level; and, whether smokers presenting with fatal myocardial infarction are more likely to die before reaching a hospital. DESIGN AND METHODS: Population-based myocardial infarction registry, carried out in 1997-1998 in seven regions of Spain, used standardized methods to find and analyze suspected myocardial infarction patients (10 654 patients; 7796 hospitalized). Four categories of smoking status were defined: never-smokers, former smokers for more than 1 year, former smokers for less than 1 year, and current smokers. RESULTS: The main end-point was 28-day case-fatality, found to be 20.1, 17.1, 15.6, and 8.9%, in the four smoking status categories, respectively, for hospitalized patients; and 37.4, 33.0, 24.5, and 23.2%, respectively, at population level. Hospitalized current smokers had lower age, sex, and comorbidity-adjusted 28-day case-fatality than never-smokers (odds ratio=0.71; 95% confidence interval: 0.56-0.90). This association held at population level (odds ratio=0.68; 95% confidence interval: 0.60-0.76), in which former smoking was also associated with lower case-fatality. In fatal cases, recent former smokers presented a lower risk of out-of-hospital death than never-smokers (odds ratio=0.47; 95% confidence interval: 0.29-0.77), whereas current smoking was marginally associated with out-of-hospital death (odds ratio=1.22; 95% confidence interval: 0.99-1.50). CONCLUSIONS: Current smoking is associated with lower 28-day case-fatality in hospitalized myocardial infarction patients. This association held at population level. Among fatal cases, smoking is associated with higher and recent former smoking with lower risk of dying out-of-hospital.

Clinical course of acute myocardial infarction in the hypertensive patient in Eastern Spain: the PRIMVAC registry.

OBJECTIVE: The study's objective was to analyze the acute complications and prognosis of acute myocardial infarction (AMI) in hypertensive patients in Spain. METHOD: Complications and early mortality were recorded among the patients with AMI admitted to the coronary care units of the 17 hospitals in the Valencia Community (Spain) between 1995 and 2000. RESULTS: A total of 12.071 patients were registered, of whom 46% were hypertensive (5.550 cases). Atrial fibrillation was more frequent in the hypertensive group, whereas ventricular fibrillation was more common among normotensive patients. We found higher mortality rates in the hypertensive group (14.4% vs 12.4%; P<.001). However, after multivariate adjustment, hypertension was not independently associated with mortality (odds ratio: .95; P=.46), and remained independently associated with a lower risk of primary ventricular fibrillation (odds ratio: .83; P<.05). CONCLUSION: Hypertensive patients do not present comparatively greater mortality during AMI, although primary ventricular fibrillation is less common in such subjects.

[Analysis with the propensity score of the association between likelihood of treatment and event of interest in observational studies. An example with myocardial reperfusion]. / Análisis de la asociación entre un tratamiento y un acontecimiento de interés en estudios observacionales utilizando la probabilidad de recibir el tratamiento (Propensity Score). Un ejemplo con la reperfusión miocárdica.

INTRODUCTION AND OBJECTIVES: Analysis of the effect of treatment in observational studies is complex due to differences between treated and nontreated patients. Calculating the probability of receiving treatment conditioned on relevant covariates (propensity score [PS]) has been proposed as a method to control for these differences. We report an application of PS to assess the association between reperfusion treatment and 28-day case fatality in patients with acute myocardial infarction (AMI). METHOD: We describe the procedure used to calculate PS for receiving reperfusion treatment, and different strategies to analyze the association between PS and case fatality with regression modeling and matching. Data were from a population-based registry of 6307 patients with AMI in Spain during 1997-98. RESULTS: The PS for reperfusion was calculated in 5622 patients. In the multivariate analysis, reperfusion was associated with lower case fatality (OR = 0.59; 95% confidence interval [95% CI]: 0.46-0.77). When PS was included as a covariate, this association became non- significant (OR = 0.76; 95% CI: 0.57-1.01). In the subgroup of matched patients with a similar PS (n = 3138), treatment was not associated with case fatality (OR = 0.95; 95% CI: 0.72-1.26). When the influence of cases with missing data on PS was controlled for, reperfusion treatment was associated with lower fatality (OR = 0.66; 95% CI: 0.55-0.80). CONCLUSIONS: Calculating propensity score is a method that controls for differences between treated and nontreated patients. This score has limitations when matching is incomplete and when data are missing. Results of the present example suggest that reperfusion treatment reduces AMI case fatality.

[Reinfarction as a complication of acute myocardial infarction. PRIMVAC Registry data]. / El reinfarto como complicación del infarto agudo de miocardio. Datos del registro PRIMVAC.

INTRODUCTION AND OBJECTIVES: The clinical profile of patients with acute myocardial infarction (AMI) who have reinfarction (REAMI) during their stay in the intensive cardiologic care unit (ICCU) is not well known. The aim of this study was to identify factors predictive of REAMI, as well as its global incidence and mortality. PATIENTS AND METHOD: All patients with AMI admitted to the ICCU of 17 hospitals in the Comunidad de Valencia (Spain) in the period 1995-2000 (PRIMVAC Registry) were included. Differential characteristics between patients with or without REAMI were determined, and odds ratios (OR) for possible predictive factors were estimated with their 95% confidence intervals by logistic regression. RESULTS: A total of 12,071 patients were included. Mean age of the patients was of 65.5 years, the percentage of women was 23.8%, and the incidence of REAMI was 2.8%. The REAMI group was significantly older than the non-REAMI group. Female sex was significantly more common in the REAMI group. More diagnostic and therapeutic procedures were carried out, more drugs were used and there were more complications in the REAMI group. Mortality was significantly higher in the REAMI group (37.8% vs 12.6%). Only age, diabetes mellitus, previous myocardial infarction and the appearance of Q waves in the electrocardiogram were independently associated with the presence of REAMI. CONCLUSIONS: REAMI in the ICCU was associated with high mortality. Some clinical factors present during the first few hours after AMI were associated independently with the appearance of REAMI.

Short-term (28 days) prognosis between genders according to the type of coronary event (Q-wave versus non-Q-wave acute myocardial infarction versus unstable angina pectoris).

The type of acute coronary syndrome may account for different prognoses between men and women after myocardial infarction. This study assessed gender differences in 28-day mortality rates for first or recurrent Q-wave and non-Q-wave myocardial infarctions and unstable angina by using data from 5 registries that included 20,836 patients (24.8% women). Mortality rates were higher in women with first Q-wave myocardial infarction but not in the other patients after adjusting for confounding variables.

Regional variability in population acute myocardial infarction cumulative incidence and mortality rates in Spain 1997 and 1998.

BACKGROUND: Myocardial infarction (MI) incidence and mortality display a high geographic variation. AIMS: The objective of the present study was to analyze MI mortality, cumulative incidence rate variability in seven regions of Spain from 1997 to 1998. METHODS AND RESULTS: Standardized methods were used to identify, find, register, and classify MI cases that were classified as definite, possible, insufficient-data MI, and non-MI. The total population of the seven monitored regions was 7,364,682 inhabitants. Of the 11,256 cases fulfilling eligibility criteria to investigate, 10,660 were selected to calculate MI rates: 6554 (61.5%) non-fatal definite MI, 1179 (11.1%) fatal definite MI, 1859 (17.4%) fatal possible MI, 1068 (10.0%) fatal cases with insufficient data. The IBERICA 25-74 years age-standardized cumulative incidence rates for men and women, were 207 (range: 175-252) and 45 (range: 36-65) per 100,000, respectively. The age-standardized mortality rates for men and women, were 73 (range: 62-94) and 20 (range: 13-29) per 100,000, respectively. Age-standardized case-fatality was 31.4 and 24.2% in men aged 25-74 and 35-64 years, respectively, and 32.7 and 27.0%, respectively, in women. CONCLUSIONS: MI cumulative incidence and mortality rates are low compared with other industrialized countries but, vary considerably among regions in a Mediterranean country like Spain.

[Hospital resources and myocardial infarction case fatality. The IBERICA study]. / Recursos hospitalarios y letalidad por infarto de miocardio. Estudio IBERICA.

INTRODUCTION AND OBJECTIVES: To determine the proportion of patients with myocardial infarction (MI) not admitted to a coronary care unit (CCU), the variables associated with admission into a CCU, and whether admission to a CCU, and the availability of coronary angiography in the same hospital, were associated with 28-day case fatality. PATIENTS AND METHOD: Population-based registry of MI in patients 25 to 74 years of age, admitted during 1996-1998. Demographic and clinical characteristics were recorded, as well as management, clinical course and survival after 28 days. Hospitals were classified according to the availability of a CCU and catheterization laboratory (advanced hospital), CCU only (intermediate hospital) or neither (basic hospital). Admission to the CCU was also recorded. RESULTS: In all, 9046 cases of MI were recorded; in 11.3% the patient was not admitted to a CCU. Age, smoking (OR=1.33; 95% CI, 1.08-1.64), non-Q MI (OR=0.62; 95% CI, 0.49-0.78) or undetermined location of MI (OR=0.34; 95% CI, 0.23-0.50), Killip 4 score on admission (OR=0.63; 95% CI, 0.40-1.00) and delay in arrival at the hospital >6 h were associated with CCU admission. Patients admitted to a CCU showed a lower case fatality in the first 24 h (4.2% vs 23.5%), which was independent of comorbidity, severity and treatment. The 24-hour survivors admitted to a basic hospital had higher case fatality (17.3% vs 7.8%) than other groups, which was related to differences in treatment. CONCLUSIONS: CCU admission is associated with a lower case fatality in the first 24 h. Admission to a basic hospital is associated with a higher 28-day case fatality even in patients who survive 24 h.

[Mortality of myocardial infarction in the PRIMVAC registry. Prognostic factors]. / Mortalidad del infarto de miocardio en el registro PRIMVAC. Factores pronósticos.

BACKGROUND AND OBJECTIVE: The aim of this study was to determine the mortality due to acute myocardial infarction in the coronary units from Comunidad Valenciana (Spain) and the prognostic factors associated with a higher mortality. PATIENTS AND METHOD: Demographic characteristics, coronary risk factors, electrocardiographic ischemic signs, complications and mortality of patients with acute myocardial infarction admitted in the coronary units were collected. The study period comprised January 1995-December 1999. Death incidence was measured during coronary unit's stay. Factors associated with poor prognosis were analyzed. RESULTS: 10.213 patients entered into the study. Mean age at admission was 65 12 years. 23.8% were females (76.2% males). Global mortality in coronary units was 13.3%. Independent variables associated with higher mortality were (p < 0.05): advanced age (OR=1.06 [1.05-1.06]), female sex (OR=1.45 [1.26-1.66]), diabetes mellitus (OR=1.53 [1.35-1.74]), previous myocardial infarction (OR=1.46 [1.23-1.70]), previous angor pectoris (OR=1.29 [1.13-1.49]) and Q-wave infarction (OR=1.23 [1.03-1.43]). Factors associated with lower mortality were: hypercholesterolemia (OR=0.76 [0.66-0.78]), smoking (OR=0.65 [0.57-0.74]) and thrombolysis (OR=0.85 [0.78-0.92]). CONCLUSIONS: At present, in the reperfusion therapy era, acute myocardial infarction has a high mortality after coronary unit admission. Several clinical factors are associated with a worse prognosis.

[Acute myocardial infarction in patients under 45 years]. / Infarto agudo de miocardio en pacientes menores de 45 años.

INTRODUCTION AND OBJECTIVE: To evaluate the differential features of acute myocardial infarction in patients younger than 45 years old compared to older patients. PATIENTS AND METHODS: From 1995 to 1999, delays in the assistance, evaluation, and therapeutic strategies as well as complications in patients hospitalized with a diagnosis of acute myocardial infarction, have been registered in the intensive care units of the 17 hospitals participating in the PRIMVAC Register. RESULTS: During the study, 10,213 patients were registered, 6.8% younger than 45 years old (691 patients). Young patients show a greater prevalence of cigarette smoking (80.9 vs 34.1%; p < 0.0001) and hypercholesterolemia (39.9 vs 28.6%; p < 0.0001), whereas arterial hypertension, diabetes, and history of coronary disease were significantly more frequent in the older group. This subgroup reached the healthcare system at an earlier stage (120 vs 160 min; p < 0.0001). Thrombolysis was performed in 59.9% of patients younger than 45 years and in 45.9% of patients older than 45 years. Young patients were more frequently given aspirin (94.5%), heparin (70.6%), and beta-blocker drugs (38.4%), whereas patients older than 45 years were given a higher percentage of ACEI, digoxin, and inotropic drugs. Younger patients had a better prognosis and a lower mortality rate (3.5 vs 14%; p < 0.00001). CONCLUSIONS: Acute myocardial infarction in patients younger than 45 years had different clinical features and responded to different therapeutic and diagnostic approaches than acute myocardial infarction in patients over 45 years, as well as a better short-term prognosis.