Is the ORBIT Bleeding Risk Score Superior to the HAS-BLED Score in Anticoagulated Atrial Fibrillation Patients?

BACKGROUND: Several bleeding risk scores have been validated in patients with atrial fibrillation (AF). The ORBIT score has been recently proposed as a simple score with the best ability to predict major bleeding. The present study aimed to test the hypothesis that the ORBIT score was superior to the HAS-BLED score for predicting major bleeding and death in "real world" anticoagulated AF patients. METHODS AND RESULTS: We analyzed the predictive performance for bleeding and death of 406 AF patients who underwent 571 electrical cardioversion procedures and 1,276 patients with permanent/persistent AF from the FANTASIIA registry. In the cardioversion population, 21 patients had major bleeding events and 26 patients died. The predictive performance for major bleeding of HAS-BLED and ORBIT were not significantly different (c-statistics 0.77 (95% CI 0.66-0.88) and 0.82 (95% CI 0.77-0.93), respectively; P=0.080). For the FANTASIIA population, 46 patients had major bleeding events and 50 patients died. The predictive performances for major bleeding of HAS-BLED and ORBIT were not significantly different (c-statistics 0.63 (95% CI 0.56-0.71) and 0.70 (95% CI 0.62-0.77), respectively; P=0.116). For death, the predictive performances of HAS-BLED and ORBIT were not significantly different in both populations. The ORBIT score categorized most patients as "low risk". CONCLUSIONS: Despite the original claims in its derivation paper, the ORBIT score was not superior to HAS-BLED for predicting major bleeding and death in a "real world" oral anticoagulated AF population. (Circ J 2016; 80: 2102-2108).

Oral anticoagulation improves the prognosis of octogenarian patients with atrial fibrillation undergoing percutaneous coronary intervention and stenting.

BACKGROUND: a significant proportion of octogenarian patients with atrial fibrillation (AF) undergo percutaneous coronary intervention (PCI) with stenting. Dual antiplatelet therapy is recommended in these patients, requiring a period of triple therapy with dual antiplatelet agent plus oral anticoagulation (OAC). Concerns remain regarding the appropriateness of OAC in octogenarians. METHODS: we reviewed 604 patients (15.7% ≥80 years) with AF undergoing PCI. Clinical follow-up was performed, recording any bleeding episode, thrombo-embolism and major adverse cardiac events (MACE = death, acute myocardial infarction and/or revascularisation of target lesion). We compared octogenarian patients in relation to treatment with OAC at discharge. A secondary aim was to compare octogenarian patients with non-octogenarian patients in terms of their clinical and demographic characteristics, management and clinical outcome. RESULTS: among the 604 patients, 95(15.7%) were aged ≥80 years. Octogenarians had a higher median CHADS2 score (2.78 versus 2.01; P < 0.001) and HAS-BLED score (3.05 versus 2.84; P = 0.028). After a follow-up of 17 ± 14 months, all-cause death occurred in 33%, MACE in 44%, and major bleeding in 21%. OAC was associated with less MACE (28.9 versus 58.3%; P = 0.012) and a similar rate of major bleeding. On multivariable analysis, non-use of OAC at discharge was associated with increased MACE (OR = 4.3; 95% CI = 1.3-14.6; P = 0.02). CONCLUSION: octogenarian AF patients undergoing PCI/stenting have a high mortality rate and MACE, which can be reduced by means of OAC therapy.

Oxidative damage is present in plasma and circulating neutrophils 4 weeks after a high mountain expedition.

It is well known that exposure to extreme environments, such as in high-mountain expeditions, is associated with increased production of reactive oxygen species and related oxidative damage. However, there is little information concerning antioxidant recovery after this type of expedition. Thus, the aim of this study is to analyze the antioxidant recovery status at sea level of five expert alpinists 4 weeks after climbing Cho-Oyu (8,201 m). Body composition, cardiorespiratory capacity, and circulating parameters were almost similar to the values obtained at the beginning of the study. However, the alpinists presented high erythrocyte number, related hemogram values, and ferritin. Sodium, alkaline phosphatase, and γ-glutamyltransferase plasma levels were lower. Concerning oxidative stress, plasma uric acid levels were significantly increased, as well as malondialdehyde and protein carbonyls. Neutrophils displayed significantly higher levels of malondialdehyde and lower catalase activity. Therefore, these data indicate that the oxidative stress during a high mountain expedition is the most probable cause to explain an incomplete recovery in plasma and neutrophil antioxidant status.

Rescue angioplasty: characteristics and results in a single-center experience.

PURPOSE AND METHODS: Rescue angioplasty (RA) has demonstrated its efficacy for the treatment of failed thrombolysis after acute myocardial infarction (AMI). We analyzed clinical, angiographic, and procedural characteristics, and prognosis at 30 days of prospective cohort of unselected patients admitted for RA. RESULTS: From August 2004 to August 2009, 361 patients were included in a single center. The median time pain to the thrombolysis was 140 minutes (interquartile range [IQR] 90-210), delay transfer 100 minutes (IQR 65-120); pain to PCI was 330 minutes (IQR 270-400). Initial flow TIMI 3 (Thrombolysis in Myocardial Infarction) was presented in 102 (28.3%) of cases and blush grade 3 in 88 (24.4%). After the procedure, TIMI 3 flow was achieved in 286 (79.2%) and blush grade 3 in 256 (71%) (P < 0.001 and P < 0,001, respectively). A glycoprotein IIb/IIIa receptor inhibitor (Abciximab) was used in 115 patients (32%). Stents were implanted in 339 (94%) of patients, 137 (38%) of which were drug-eluting stent. Complete ST segment resolution was observed in 202 (64.5%) patients in 12-lead electrocardiogram (ECG) and procedural success was 77.6%. Adverse cardiac events and death after 30 days follow-up were 13.6% and 10.7%, respectively. Target vessel revascularization at 30 days was 1.9%. CONCLUSIONS: Routine application of RA in patients with persistent ST elevation 90 minutes after thrombolysis is a useful technique for achieving revascularization of the affected artery. In-hospital mortality remains high especially in patients with cardiac shock, despite new interventional techniques available, and adjunctive antithrombotic therapy.

Efficacy and safety of drug-eluting stent use in patients with atrial fibrillation.

AIMS: Drug-eluting stents (DES) have never been sufficiently studied in patients with atrial fibrillation (AF). The latter are considered as a high-risk population with uncertainty over the optimal antithrombotic therapy strategy to prevent stroke, stent thrombosis, and recurrent cardiac ischaemia, balanced against the high risk of haemorrhage. The aim of this study was to evaluate the safety and efficacy of the use of DES vs. bare-metal stents (BMS) in a cohort of patients with AF. METHODS AND RESULTS: We reviewed 604 patients with AF who had undergone percutaneous coronary intervention with stent over a period of 7 years (January 2001-January 2008). After a propensity score selection, we identified two matched cohorts who received DES (n = 207) or BMS (n = 207). Clinical follow-up was performed, and all bleeding episodes, thrombo-embolism, and major adverse cardiac events (MACE; i.e. death, acute myocardial infarction, target vessel failure) were recorded. Complete follow-up was achieved in 95.9% of the cohort (mean: 693 +/- 427 days, median: 564). The incidence density of MACE as well as the incidence of all-cause mortality in both groups was similar. There was a higher incidence of major bleeding in DES group (2.26 vs. 1.19 per 10 000 days of exposure; P = 0.03). In a multivariate analysis, age, chronic AF, chronic renal failure, and non-use of dicoumarin were predictors of MACE and of all-cause mortality. The use of DES was not a predictor of reduced events. CONCLUSION: On the basis of this study, the routine use of DES in patients with AF does not seem to be justified. A higher risk of major bleeding with DES in comparison with BMS raises the possibility that DES should be limited to lesions or patients with a high risk of restenosis.

Lessons learned in attempting catheter-based interatrial electrical disconnection for nonpharmacologic rate control of atrial fibrillation or flutter.

PURPOSE: Ablation of atrioventricular (AV) conduction and pacemaker implantation is the therapy of last resort for symptomatic atrial tachyarrythmias when rhythm and rate control fail, but is far from ideal. To evaluate whether interatrial electrical disconnection as a result of catheter ablation is feasible and of potential clinical utility as a means of non-pharmacological heart rate control. METHODS: Eleven patients with medically refractory atrial fibrillation or left atrial flutter and symptomatic rapid ventricular response were included. The ablation strategy consisted primarily of right atrial ablation of the interatrial electrical connections, which were located by electroanatomical activation maps performed during coronary sinus stimulation. Successive activation maps were performed as each connection was blocked. If the procedure was considered unsuccessful AV nodal ablation was performed. RESULTS: The coronary sinus ostium was earliest in 10/11 and could be ablated in 5/10 patients. Interatrial conduction block was only achieved in one patient (9.1%). An unexpected AV nodal modulation with an increase in the Wenckebach cycle length (> 50 ms) occurred in 8/11 patients. These patients remained without pacemaker implantation and only 1/8 required AV nodal ablation during the 1-year follow-up. Quality of life questionnaires indicated significant improvement in patients with AV nodal modulation. CONCLUSION: Interatrial electrical disconnection by right atrial catheter ablation is a not feasible with present day technology. The extensive right atrial septal ablation performed resulted in significant AV nodal modulation in most patients, which persisted and resulted in improvement in quality of life.

A pharmacogenetic effect of factor XIII valine 34 leucine polymorphism on fibrinolytic therapy for acute myocardial infarction.

OBJECTIVES: The aim of this study was to evaluate the pharmacogenetic role of the factor XIII (FXIII) valine 34 leucine (Val34Leu) polymorphism in the fibrinolytic therapy of acute myocardial infarction (MI). BACKGROUND: Fibrinolytic therapy is an established treatment for acute MI, but up to 40% of treated patients do not achieve optimal tissue reperfusion. The FXIII Val34Leu polymorphism is one of the most relevant functional polymorphisms described in the haemostatic system. The common Leu34 allele associates with an increased FXIII-transglutaminase activity, which results in an increased and faster rate of fibrin stabilization. METHODS: We genotyped this polymorphism in 293 consecutive MI patients (62 +/- 12 years; 231 males) from two different European populations. All patients were treated with standard doses of fibrinolytic drugs. Noninvasive assessment of the efficacy of coronary fibrinolysis was evaluated by serial electrocardiograms and creatine kinase time-activity curves. The clinical outcome was also re-evaluated at 24 h (death, reinfarction, or urgent revascularization). RESULTS: Multivariate analysis showed that Leu34 carriers displayed a significantly less efficient fibrinolysis than carriers of Val/Val genotype (p = 0.021; odds ratio [OR] 1.90, 95% confidence interval [CI] 1.10 to 3.28). At 24 h, Leu34 allele carriers had the worst outcome (p = 0.006; OR 2.14, 95% CI 1.25 to 3.68). Interestingly, the combination of the Leu34 allele and nonsmoking status increased the risk of non-reperfusion criteria (p = 0.003, OR 3.77), and worse outcomes at 24 h (p = 0.001, OR 4.55). CONCLUSIONS: In a large cohort of nonselected and consecutive acute MI patients from two different European populations, we show clinical evidence that the presence of the Leu34 allele reduces the efficacy of fibrinolytic therapy.

Growth hormone therapy and the heart.

The growth hormone (GH)-insulin-like growth factor-1 axis has great relevance for the regulation of cardiac growth, structure, and function. GH deficiency may result in impaired cardiac performance, manifest by a reduction in left ventricular mass and ejection fraction, but data are inconsistent. GH therapy is recommended treatment in adult patients with GH deficiency, but in acromegaly, in which there is excess GH, the main cause of mortality is cardiovascular disease. The purposes of this study were to perform (1) a case-controlled study comparing cardiac morphology and function in 53 GH-deficient patients (34 men, mean age 38.1 +/- 15.2 years, 22 with childhood-onset GH deficiency) and 46 healthy controls (29 men, mean age 37.8 +/- 12.4 years) and (2) a longitudinal study to assess the effect of introducing GH therapy in 37 subjects for a mean period of 26 +/- 22 months. At study entry, all subjects underwent electrocardiography and 24-hour ambulatory electrocardiographic monitoring, systolic and diastolic blood pressure assessment, detailed echocardiography, and exercise tolerance tests. There were no significant differences in left ventricular mass, left ventricular dimensions, systolic or diastolic function indexes, or blood pressure at rest in patients compared with controls. Exercise duration was significantly shorter and peak heart rate during exercise (chronotropic response) lower in the GH-deficiency group than in controls (p <0.05). After GH treatment, there were no significant changes in echocardiographic parameters or blood pressure, but an improvement in exercise duration (p = 0.019) was found, particularly in the subgroup with childhood-onset GH deficiency (n = 16). In conclusion, patients with GH deficiency did not show cardiac structural or functional differences compared with healthy controls, with no significant changes after GH treatment. However, these patients exhibited improved exercise capacity, especially those with childhood-onset GH deficiency.

Diagnostic and prognostic value of urine NT-proBNP levels in heart failure patients.

BACKGROUND: Plasma NT-proBNP levels are sensitive markers of ventricular dysfunction. However, studies of natriuretic peptides in urine are limited. AIMS: To compare urine and plasma NT-proBNP levels and to investigate the diagnostic and prognostic value of urine levels in heart failure (HF). METHODS: Urinary and plasma NT-proBNP levels were measured in 96 HF patients and 20 control subjects. The patients were functionally classified according to the NYHA criteria. RESULTS: Urine NT-proBNP was higher in HF patients than in control subjects (94+/-31 pg/ml vs. 67+/-6 pg/ml, p<0.0001), correlating with plasma NT-proBNP levels (r=0.78, p<0.0001). Urinary levels were elevated in the more severe functional classes and diminished in obese patients. Urine NT-proBNP was a good tool for diagnosis of HF, the area under the curve (AUC) being 0.96+/-0.02 (p<0.0001), and for predicting 12-month cardiac events (p=0.011). To determine the prognostic power of urinary NT-proBNP in detecting 12-month cardiac mortality, we obtained an AUC of 0.75+/-0.10 (p=0.015). CONCLUSION: Urinary NT-proBNP, a relatively simple non-invasive test, is a new candidate marker for the diagnosis and evaluation of prognosis in HF and for the characterization of functional status in these patients.

Antiplatelet versus anticoagulant therapies in advanced age: an unfinished task.

We have read with great interest a retrospective cohort study recently published by Blich and Gross. In our opinion, this article renews the controversy of the best antithrombotic therapy in patients with AF. The use of anticoagulant treatment to prevent the occurrence of stroke in patients with AF is supported by several randomized controlled clinical trials. Aspirin is also effective in preventing stroke in AF, but both direct and indirect comparisons with oral anticoagulation suggest less effectiveness. However, very probably these patients are quite different than those seen in the clinical practice. The role of antiplatelet therapy is not completely established, and the selection between aspirin or warfarin in advanced age remains an unfinished task.

Atrial stunning as predictor of early relapse into atrial fibrillation after cardioversion.

Although the high rate of success after cardioversion, less than 50% of patients maintain sinus rhythm for the first year. In view for the high percentage of relapse into atrial fibrillation, it is interesting to analyze the relationship between atrial stunning after cardioversion and relapse into atrial fibrillation. Thus, we evaluated 101 patients with atrial fibrillation and successful cardioversion. Atrial mechanical function was assessed by measures of transmitral peak A wave velocity, determined before and weekly after cardioversion during 1 month. Fifty-five percent of patient relapse into atrial fibrillation during follow-up. No significant differences were found in clinical and echocardiographic variables between the group with and without relapse. However, the group of patients who relapsed into atrial fibrillation showed a lower peak A wave velocity immediately after cardioversion than patients who maintain in sinus rhythm at month (0.44+/-0.27 vs. 0.60+/-0.38 m/s p<0.01). Impaired atrial function improves during the first 14 days after cardioversion.

[8-hydroxy-2'-deoxyguanosine and lipid peroxidation in patients with heart failure]. / Valores de 8-hidroxi-2'-desoxiguanosina y de peroxidación lipídica en pacientes con insuficiencia cardiaca.

INTRODUCTION AND OBJECTIVES: Heart failure is associated with increased free radical production, which leads to a state of oxidative stress. Known markers of oxidative stress include 8-hydroxy-2'-deoxyguanosine, which reflects oxidative damage to DNA, and lipid peroxidation, which can be used to quantify damage to lipid-rich structures. The aims of this study were to compare 8-hydroxy-2'-deoxyguanosine and lipid peroxidation levels in heart failure patients and healthy subjects and to assess how these levels are influenced by heart failure etiology. METHODS: The study included 78 patients (57 male, age 64 [14] years) with heart failure and 12 control subjects. Patients completed a questionnaire and were graded according to the New York Heart Association classification. Doppler echocardiography was performed and blood samples were obtained. 8-hydroxy-2'-deoxyguanosine and lipid peroxidation levels were determined. RESULTS: Significant differences were observed between patients and control subjects in 8-hydroxy-2'-deoxyguanosine and lipid peroxidation levels, at 0.34 (0.54) ng/mL vs 0.04 (0.07) ng/mL (P<.05), and 18 (10) microM vs 8 (3) microM (P<.01), respectively. Subsequent analysis showed that heart failure etiology had a significant effect on the levels of the two markers (P<.05), which were highest in patients with hypertensive cardiomyopathy. CONCLUSIONS: Levels of 8-hydroxy-2'-deoxyguanosine and lipid peroxidation were higher in heart failure patients than in control subjects. The most significant increases were found in patients with hypertensive cardiomyopathy.

[The implantable cardioverter-defibrillator and hypertrophic cardiomyopathy. Experience at three centers]. / Desfibrilador automático en la miocardiopatía hipertrófica. Experiencia de 3 centros.

INTRODUCTION AND OBJECTIVES: Although implantable cardioverter-defibrillators (ICDs) are recommended for high-risk patients with hypertrophic cardiomyopathy (HCM), there is no agreement on their general use. Moreover, little information is available on ICD use in this setting in Spain. Our aims were to describe the characteristics of HCM patients who received ICDs at three hospitals in Spain, and to study indications for device implantation and the results of follow-up in device users. METHODS: We evaluated risk factors for sudden death in HCM patients with ICDs, including family history of sudden death, recurrent syncope, maximum wall thickness > or =30 mm, left ventricular outflow pressure gradient >30 mmHg, abnormal blood pressure response to exercise, and nonsustained ventricular tachycardia. During regular follow-up, appropriate and inappropriate administration of ICD therapy was recorded. RESULTS: Of 726 HCM patients, 45 (6.2%) had an ICD (mean age 43 [20] years). The proportion of patients with ICDs at the three centers studied was highly variable despite patients' clinical characteristics being similar. The indication for implantation was primary prevention in 27 patients and secondary prevention in 18. During follow-up (median 32 months), ICD therapy was administered appropriately in 10 (22.0%) patients (in nine, as secondary prevention and, in one, as primary prevention). The annual appropriate ICD therapy rate was 11.1% for secondary prevention and 1.6% for primary prevention. Two patients received an ICD to treat ventricular fibrillation and eight, to treat sustained ventricular tachycardia. The only significant predictor of appropriate ICD therapy was a history of sustained ventricular tachycardia or ventricular fibrillation (hazard ratio =13.3, P=.014). CONCLUSIONS: The percentage of HCM patients undergoing ICD implantation at Spanish hospitals was highly variable, possibly due to different selection criteria. When used as secondary prevention, ICD therapy was administered appropriately in a high proportion of cases (50% in 3 years).

Evaluation of a 'color coding' system for the assessment of patients undergoing primary percutaneous coronary intervention.

AIMS: The reduction of delay times as well as the rate of false alarms (FA) have become some of the main points of the different infarction networks. We propose a simple way of classifying patients derived for primary PCI (pPCI) into well-defined simple groups by colors, where we can assess real delays of each clinical presentation, define the FA and, furthermore, establish their immediate and short term prognosis. METHODS AND RESULTS: Prospective study of STEMI consecutive patients derived for pPCI during 2014. Patients were categorized into one of the 3 predesigned groups [(i) Green: diagnostic-ECG with compatible clinical presentation for pPCI; (ii) Yellow: LBBB, pacemaker rate or non-diagnostic ECG; and (iii) Red: very complex patients], always before performing the angiography in 518 patients. Delay times were highest in the Yellow group, with much longer first medical contact (FMC) to balloon time (median Green 118'; Yellow 163'; Red 130'; p<0.001) mainly due to higher times from the first medical contact to the diagnosis and team activation (median Green 30'; Yellow 70'; Red 39'; p<0.001). In the whole cohort, pPCI was performed in 80.2% of patients, with 11.9% of FA. The Green group had only a 2.5% FA rate, in contrast to the Yellow group where FA were 43.2%. CONCLUSIONS: This simple classification differentiates the 3 very clear groups in which delay times and prognosis are very different. This classification allows us to measure, evaluate and compare the performance of each of our pPCI networks with others and within different periods of times.

The HAS-BLED score predicts long-term major bleeding and death in anticoagulated non-valvular atrial fibrillation patients undergoing electrical cardioversion.

BACKGROUND: Atrial fibrillation (AF) patients eligible for cardioversion tend to be younger and are at lower risk than 'general' AF clinic populations. We evaluated the incidence of major bleeding and death, as well as the predictive value of the HAS-BLED score in non-valvular AF patients who underwent electrical cardioversion (ECV). METHODS: Consecutive non-valvular AF patients who underwent ECV were recruited. Major bleeding episodes and mortality were recorded. Factors associated with both endpoints and the predictive value of the HAS-BLED score were analysed. RESULTS: 406 patients (281 males; age 66.9±10.9years) undergoing 571 ECV were included. After a follow-up of nearly 3years, 20 patients presented with major bleeding (1.9%/year;) and 26 patients died (2.4%/year). The HAS-BLED score predicted both major bleeding [c-statistics: 0.77; 95%CI: 0.71-0.83; p<0.001] and mortality [c-statistics: 0.83; 95%CI: 0.79-0.87; p<0.001]. Variables associated with bleeding were: renal impairment (HR: 4.35; 95%CI: 1.22-15.52; p=0.02), poor quality anticoagulation (HR: 3.21; 95%CI: 1.11-9.32; p=0.03), previous bleeding-predisposition (HR: 5.43; 95%CI: 1.76-16.75; p=0.003) and the HAS-BLED score (HR: 1.88; 95%CI: 1.34-2.64; p<0.001). Factors associated with mortality were: age (HR: 1.08; 95%CI: 1.03-1.14; p=0.004), poor quality anticoagulation (HR: 3.11; 95%CI: 1.15-8.36; p=0.02), previous bleeding-predisposition (HR: 5.90; 95%CI: 1.41-24.65; p=0.01), liver impairment (HR: 9.27; 95%CI:1.64-52.34; p=0.01), the CHA2DS2-VASc score (HR: 1.63; 95%CI: 1.18-2.26; p=0.003) and the HAS-BLED score (HR: 2.74; 95%CI: 1.86-4.04); p<0.001). CONCLUSIONS: In AF patients undergoing ECV, major bleeding episodes and mortality were independently associated with poor quality anticoagulation control and previous bleeding-predisposition. The HAS-BLED score successfully predicted major bleeding and mortality.

Relation of interleukin-6 levels and prothrombin fragment 1+2 to a point-based score for stroke risk in atrial fibrillation.

Interleukin-6 levels, but not prothrombin fragment 1 + 2, correlates with a point-based score for stroke risk in atrial fibrillation, even after oral anticogulation.

Late anthracyclines cardiotoxicity associated with infection by Mycoplasma pneumoniae. A case report.

We report the case of a 15-year-old male developing progressive myocardiopathy secondary to late anthracycline cardiotoxicity. At 2 years of age, the patient received chemotherapy with anthracyclines (adriamycin) at an accumulated dose of 510 mg/m2 due to the presence of non-Hodgkin lymphoma which subsided completely and he has been asymptomatic since then. A number of recurrent respiratory infections occurred as triggering factors of the condition, and the laboratory tests evidenced positive serology for Mycoplasma pneumoniae suggesting a recent contact.

Cardiac tamponade following pacemaker implantation.

Cardiac tamponade is a rare complications after pacemaker implantation. However iatrogeny is becoming one of the main causes of severe pericardial effusions. We present the experience of our centre compiled in 17 years.

Are there ethnic differences in the circadian variation in onset of acute myocardial infarction? A comparison of 3 ethnic groups in Birmingham, UK and Alicante, Spain.

We hypothesised that ethnicity may influence the circadian pattern in acute myocardial infarction (MI), in view of the potential differences in genetic background, cardiovascular risk factors and cultural habits. To test our hypothesis, we studied 340 consecutive acute MI patients (268 males; mean age 61.6+/-12.3 years) from two different city-centre teaching hospitals in Birmingham (United Kingdom) and Alicante (Spain). A different circadian rhythm in MI onset was observed between the ethnic groups (p=0.001), with a significantly higher number of acute MI onset occurring between midnight and noon in British Caucasians and Indo-Asians. In contrast, Mediterranean Caucasians showed the converse circadian pattern, with most of the acute MI events happened between noon and midnight. Indo-Asian patients were the youngest patient group and showed the highest prevalence of diabetes and increased body mass index. Mediterranean patients had the highest prevalence of smokers but their mean serum cholesterol was the lowest. No differences in sex, blood pressure, height and weight were observed. In conclusion, this study has shown a different circadian rhythm in acute MI onset between 3 ethnic groups from two different city-centre teaching hospitals in Birmingham (United Kingdom) and Alicante (Spain) and, for the first time, provide data in the Indo-Asian population. Further studies are required to determine the pathophysiological mechanism(s) underlying these differences.

[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.