Jejunal varix with a high transfusion requirement: therapy with cyanoacrylate with radiological control by double-balloon enteroscopy.

A jejunal varix with high transfusion requirement is treated by double-balloon enteroscopy with cyanoacrylate/ lipiodol with radiological control. The patient had not gastrointestinal hemorrhage or transfusion requeriment after 8 months follow up. Our recent previous article in Rev Esp Enferm Dig on advanced therapeutics by enteroscopy is referenced, providing this new therapeutic possibility.

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 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.

[Consequences of obesity in outcomes after cardiac surgery. Analysis of ARIAM registry]. / Consecuencias de la obesidad en los resultados de la cirugía cardiaca. Análisis del registro ARIAM.

BACKGROUND AND OBJETIVE: Obesity is a disease that affects a large part of the population and has been associated with worse outcomes after cardiac surgery. The aim of our study is to evaluate the consequences of obesity related to postoperative complications, hospital length of stay and mortality. METHODS: Observational, prospective, multicenter study of patients included in ARIAM registry of adult cardiac surgery between March 2008 to March 2011. We analyzed clinical variables, the surgical procedure, postoperative complications and mortality, comparing the group of patients with body mass index (BMI) greater or less than 30 kg/m(2). RESULTS: The study included 4,172 patients with a mean age of 64.03 (SD 12.08) years, BMI 28.53 (4.7) and EuroSCORE 5.58 (2.91). In 1,490 patients (35.7%) BMI was greater than 30. There were no differences in the development of overall postoperative complications (33% in obese and non-obese 35.8%, P=.07), although there were less appreciated reoperation rate or stroke (P<.05), as well as further development postoperative renal failure (P=.009). After adjusting for severity and length of cardio by pass time, obese patients had lower mortality without being statistically significant. OR 0.94 (0.79-1.04). There were no differences in ICU length of stay, but obese patients had greater Ward length of stay 9.04 (10.43) vs. 8.18 (9.2) days, P=.01. CONCLUSIONS: Obese patients undergoing cardiac surgery have a mortality, rate of complications and length of stay similar to non-obese. Obese patients required less reoperations but developed more frequently postoperative renal failure.

Paradoxical effect of smoking in the Spanish population with acute myocardial infarction or unstable angina: results of the ARIAM Register.

OBJECTIVES: The paradoxical effect of smoking after acute myocardial infarction (AMI) is a phenomenon consisting of a reduction in the mortality of smokers compared to nonsmokers. However, it is not known whether the benefit of this reduction in mortality is due to smoking itself or to other covariables. Despite acceptance of the paradoxical effect of smoking in AMI, it is not known whether a similar phenomenon occurs in unstable angina. The objective of this study was to investigate the paradoxical effect of smoking in AMI and unstable angina, and to study specifically whether smoking is an independent prognostic variable. METHODS AND RESULTS: The study population was selected from the multicentric ARIAM (Análisis del Retraso en el Infarto Agudo de Miocardio [analysis of delay in AMI]) Register, a register of 29,532 patients with a diagnosis of unstable angina or AMI. Tobacco smokers were younger, presented fewer cardiovascular risk factors such as diabetes or hypertension, fewer previous infarcts, a lower Killip and Kimball class, and a lower crude and adjusted mortality in AMI (odds ratio, 0.774; 95% confidence interval, 0.660 to 0.909; p = 0.002). Smokers with unstable angina were younger, with less hypertension or diabetes. In the multivariate analysis, no statistically significant difference in mortality was found. CONCLUSIONS: The reduced mortality observed in smokers with AMI during their stay in the ICU cannot be explained solely by clinical covariables such as age, sex, other cardiovascular factors, Killip and Kimball class, or treatment received. Therefore, smoking may have a direct beneficial effect on reduced mortality in the AMI population. The lower mortality rates found in smokers with unstable angina are not supported by the multivariate analysis. In this case, the difference in mortality can be explained by the other covariables.

Influence of age on clinical course, management and mortality of acute myocardial infarction in the Spanish population.

BACKGROUND: To assess age-related differences in cardiovascular risk factors, clinical course and management of patients with acute myocardial infarction (AMI) in intensive care (ICU) or coronary care units (CCU). METHODS: A retrospective cohort study was conducted of all AMI patients listed in the ARIAM register (Analysis of Delay in AMI), a multi-centre register in which 119 Spanish hospitals participated. The study period was from January 1995 to January 2001. A univariate analysis was carried out to evaluate differences between different age groups. Multivariate analysis was used to assess whether age difference was an independent predisposing factor for mortality and for differences in patient management. RESULTS: 17,761 patients were admitted to the ICUs/CCUs with a diagnosis of AMI. The distribution by ages was: <55 years, 3,954 patients (22.3%); 55-64 years, 3,593 (22.2%); 65-74 years, 5,924 (33.4%); 75-84 years, 3,686 (20.8%); and >84 years, 604 (3.4%) (P<0.0001); 24.6% of the patients were female, and the relative proportion of females increased with age. There were clear differences in risk factors between the different age groups, with a predominance of tobacco, cholesterol and family history of heart disease in the younger patients. The incidence of complications, including haemorrhagic complications, increased significantly with age. The older age groups had a lower rate of thrombolysis and less use of revascularisation techniques. The mortality of the above groups was 2.6, 5.4, 10.7, 17.7 and 25.8%, respectively. Age difference was an independent predictive variable for mortality and the administration of thrombolysis. CONCLUSIONS: The distinct age groups differed in cardiovascular risk factors, management and mortality. Age is a significant independent predictive variable for mortality and for the administration of thrombolysis.