Síndrome coronario agudo con elevación del segmento ST (SCACEST). Estrategia de consenso para una reperfusión precoz. Empresa pública de emergencias sanitarias (EPES) y grupo ARIAM-Andalucía / Acute coronary syndrome (ACS) with elevated ST segment: consensus strategy for early reperfusion. The Public Enterprise for Health Emergencies and the ARIAM Project Andalusia

El manejo adecuado de los pacientes con infarto agudo de miocardio con elevación del segmento ST (IAMEST) requiere, como elementos centrales, la accesibilidad inmediata a la desfibrilación y la instauración precoz de tratamiento de reperfusión. La empresa pública de emergencias sanitarias de Andalucía (EPES) y el proyecto análisis de los retrasos en el tratamiento del infarto agudo de miocardio (ARIAM), pretenden construir una estrategia básica común, sobre la cual adaptar aspectos locales, que facilite la toma de decisiones sobre el tratamiento de estos pacientes. Ámbito. Comunidad Autónoma de Andalucía. Período: marzo-mayo 2006. Participantes. Profesionales que atienden a pacientes con IAMEST: médicos del grupo de trabajo en procesos cardiológicos de la EPES, médicos de Servicios de Urgencias hospitalarios y médicos de las Unidades de Cuidados Intensivos de los hospitales del sistema sanitario público de Andalucía. Sistema de trabajo. Niveles de evidencia. Se emplearon los niveles de evidencia recogidos en la guía de práctica clínica ACC/AHA de 2004. Elaboración del consenso. Se mantuvo una reunión de discusión sobre los aspectos que debía abordar el documento. Se realizó un documento base que se distribuyó por correo electrónico entre los participantes. En una reunión final se elaboró el documento de consenso. Conclusiones. El consenso establece como prioritarios los siguientes aspectos: 1. Mantener una aplicación estricta y adecuada del conjunto de medidas generales aconsejadas en el proceso de asistencia al IAMEST. 2. Favorecer la realización de reperfusión precoz a la mayor cantidad de pacientes, promoviendo la extensión de la fibrinólisis extrahospitalaria y la derivación a centro útil para intervencionismo coronario percutáneo primario. 3. Monitorizar y evaluar el manejo realizado, con especial atención sobre los resultados y la seguridad de los pacientes

The two pillars of the appropriate management of patients with ST-elevation myocardial infarction (STEMI) are immediate access to defibrillation and early reperfusion. The Public Enterprise for Health Emergencies (EPES) and the Andalusian ARIAM (Analysis of the Delay in the Treatment of Acute Myocardial Infarction) Project aim to implement a common basic strategy that can be adapted to local situations in order to facilitate decision making about the treatment of these patients. Context. The Autonomous Community of Andalusia. Period: March-May 2006. Participants. Professionals that attend patients with STEMI: physicians in the EPES’ work group on cardiological processes, emergency department physicians, and physicians working in the intensive care units in the hospitals of the public healthcare system of Andalusia. Approach. Levels of evidence. The levels of evidence laid out in the 2004 ACC/AHA Clinical Practice Guidelines. Reaching a consensus. A meeting was held to discuss the aspects to be included in the document. A working document was drafted and distributed to the participants via email. The final consensus document was drafted at another meeting. Conclusions. The consensus document establishes the following priorities: 1. To apply the set of general measures recommended for the care of STEMI patients strictly and appropriately 2. To foster the use of early reperfusion in as many patients as possible, promoting the extension of fibrinolysis outside of hospitals and referral to a center with facilities for primary percutaneous coronary intervention. 3. To monitor and evaluate the management of these patients, with special attention placed on outcome and safety

[Acute coronary syndrome (ACS) with elevated ST segment: consensus strategy for early reperfusion. The Public Enterprise for Health Emergencies and the ARIAM Project Andalusia]. / Síndrome coronario agudo con elevación del segmento ST (SCACEST). Estrategia de consenso para una reperfusión precoz. Empresa pública de emergencias sanitarias (EPES) y grupo ARIAM-Andalucía.

UNLABELLED: The two pillars of the appropriate management of patients with ST-elevation myocardial infarction (STEMI) are immediate access to defibrillation and early reperfusion. The Public Enterprise for Health Emergencies (EPES) and the Andalusian ARIAM (Analysis of the Delay in the Treatment of Acute Myocardial Infarction) Project aim to implement a common basic strategy that can be adapted to local situations in order to facilitate decision making about the treatment of these patients. CONTEXT: The Autonomous Community of Andalusia. PERIOD: March-May 2006. PARTICIPANTS: Professionals that attend patients with STEMI: physicians in the EPES' work group on cardiological processes, emergency department physicians, and physicians working in the intensive care units in the hospitals of the public healthcare system of Andalusia. APPROACH: Levels of evidence. The levels of evidence laid out in the 2004 ACC/AHA Clinical Practice Guidelines. REACHING A CONSENSUS: A meeting was held to discuss the aspects to be included in the document. A working document was drafted and distributed to the participants via email. The final consensus document was drafted at another meeting. CONCLUSIONS: The consensus document establishes the following priorities: 1. To apply the set of general measures recommended for the care of STEMI patients strictly and appropriately 2. To foster the use of early reperfusion in as many patients as possible, promoting the extension of fibrinolysis outside of hospitals and referral to a center with facilities for primary percutaneous coronary intervention. 3. To monitor and evaluate the management of these patients, with special attention placed on outcome and safety.

Descripción de los aspectos generales del manejo del síndrome coronario agudo en España durante el año 2002 / Description of general aspects of the management of acute coronary syndrome in Spain during the year 2002

Objetivo. Describir los aspectos más relevantes en el manejo inicial del paciente con síndrome coronario agudo (SCA) durante el año 2002. Diseño y ámbito. Estudio observacional prospectivo. Participaron 84 hospitales. Pacientes, variables y resultados. Se han seleccionado los 12.743 casos incluidos en el registro ARIAM desde el 1 de enero al 31 de diciembre de 2002. Las variables analizadas se agrupan en 4 apartados: características generales, diagnóstico de infarto agudo de miocardio (IAM), atención prehospitalaria y tratamiento fibrinolítico. Ingresaron 6.879 pacientes con diagnóstico de IAM, incrementándose este diagnóstico en un 16,8% al alta. La mortalidad en Unidad de Cuidados Intensivos (UCI) para los pacientes con IAM ha sido del 8,4%. Cinco mil trescientos sesenta y ocho (47%) casos llegaron al hospital a través del sistema sanitario prehospitalario con una mediana de retraso desde el inicio de los síntomas de 155 minutos. El 59% de los IAM ST elevado recibieron tratamiento fibrinolítico. El 6,7% de las fibrinolisis se realizaron en la primera hora y el 31,1% en las dos primeras horas. De los pacientes con menos de tres criterios de reperfusión sólo se realizó angioplastia de rescate en 144 casos (7%). Conclusiones. El descenso de mortalidad del IAM respecto a años previos puede estar en relación con la aplicación de los nuevos criterios diagnósticos. La atención prehospitalaria comporta mayor retraso a su llegada al hospital pero aporta un acceso más precoz acceso a las medidas básicas de atención. Los porcentajes de fibrinolisis en las dos primeras horas y de angioplastias de rescate son bajos respecto a otras series

Objective. A description of the most relevant aspects in the initial management of the patient with acute coronary syndrome (ACS) during the year 2002. Design and scope. Prospective observational study. Eighty-four participating hospitals. Patients, variables and results. The 12,743 cases included in the ARIAM registry from January 1 to December 31, 2002 were selected. The variables analyzed have been grouped into 4 sections: general characteristics, acute myocardial infarction (AMI) diagnosis, prehospital care and fibrinolytic treatment. A total of 6,879 patients were admitted with the diagnosis of AMI, this diagnosis increasing by 16.8% on discharge. Mortality in the Intensive Care Unit (ICU) for patients with AMI was 8.4%. The number of cases that reached the hospital through the prehospital health care system was 5,368 (47%) with a median delay from onset of the symptoms of 155 minutes. A 59% of the elevated ST AMI received fibrinolytic treatment. A 6.7% of the fibrinolysis were performed in the first hour and 31.1% in the first 2 hours. Rescue angioplasty was only done in 144 cases (7%) of the patients with less than three reperfusion criteria. Conclusions. Decrease in AMI mortality regarding previous years may be related with the application of new diagnostic criteria. Prehospital care entails greater delay of arrival to the hospital but supplies earlier access to the basic care measures. The percentage of fibrinolysis in the first 2 hours and rescue angioplasties are low regarding other series

Variabilidad en el manejo del infarto agudo de miocardio en el registro ARIAM en el año 2002 / Variability in the management of acute myocardial infarction in the ARIAM registry in the year 2002

Objetivo. Analizar las diferencias en el manejo del infarto agudo de miocardio (IAM) entre las distintas comunidades autónomas de los hospitales participantes en el registro ARIAM durante el año 2002. Diseño. Registro multicéntrico nacional de base hospitalaria de pacientes ingresados en Unidades de Cuidados Intensivos Cardiológicos (UCIC) por sospecha de síndrome coronario agudo. Ámbito. UCIC de 80 hospitales españoles de 14 comunidades autónomas. Pacientes o participantes. Se incluyen todos los pacientes del registro ARIAM del año 2002 cuyo motivo de ingreso hospitalario es IAM de menos de 24 horas de evolución. Intervenciones. Ninguna Variables de interés principales. Se registraron variables demográficas, antecedentes, clínicas, retrasos y lugar de actuación inicial, uso de técnicas diagnósticas y terapéuticas, tiempos de estancia y morbimortalidad. Se agruparon los casos por áreas geográficas que corresponden a las diferentes comunidades autónomas de España. Se analizaron las diferencias mediante el uso del coeficiente de variación (CV). Resultados. Se incluyeron 6.820 pacientes. Las características basales fueron similares, salvo para la presencia de diabetes como factor de riesgo (CV: 21%). Los CV excesivos correspondieron al modo de acceso al sistema sanitario (061: 29%), lugar de realización de la fibrinolisis (extrahospitalaria: 155%, urgencias: 120%), tipo de fibrinolítico (rTPA: 78%), retrasos intrahospitalarios (puerta-aguja: 24% y puerta-balón: 39%), uso de angioplastia coronaria transluminal percutánea (ACTP) primaria (122%), realización de coronariografía (75%) y tratamiento con anti-IIb/IIIa (34%). La mortalidad en UCIC global fue del 8,0%, con un CV de 16%. Conclusiones. Existen diferencias en el manejo del IAM entre las distintas comunidades autónomas estudiadas, especialmente en lo concerniente a la atención prehospitalaria y el uso de las técnicas de revascularización. Sin embargo, en la población estudiada, no se traducen en diferencias significativas respecto al resultado a corto plazo

Objective. Analyze the differences in the management of acute myocardial infarction (AMI) between the different regional communities of the hospitals participating in the ARIAM registry during the year 2002. Design. Hospital based multicenter, national registry of patients admitted to cardiology intensive care units (CICU) due to suspicion of acute coronary syndrome. Scope. CICU of 80 Spanish hospitals in 14 regional communities. Patients or participants. All the patients from the ARIAM registry in the 2002 whose cause of hospitalization is AMI of less than 24 hours evolution are included. Interventions. None. Variables of principal interest. Demographic variable, background, symptoms, delays and site of initial action, use of diagnostic and therapeutic techniques, stay time and morbidity-mortality were recorded. The cases were grouped by geographic areas that correspond to the different regional communities of Spain. Differences were analyzed with the variation coefficient (VC).Results. A total of 6,820 patients were included. Basal characteristics were similar, except for the presence of diabetes as risk factor (VC: 21%). Excessive variation coefficients corresponded to way of access to health care system (061: 29%), site fibrinolysis was done (community: 155%, emergency service: 120%), fibrinolytic type (rTPA: 78%), interhospital delays (door-to-needle: 24% and door-to-balloon: 39%), use of primary percutaneous transluminal coronary angioplasty (PTCA) (122%), conduction of coronariography (75%) and treatment with anti-IIb/IIIa (34%). Global mortality in the CICU was 8.0%, with a 16% VC. Conclusions. There are differences in the management of AMI between the different regional communities studied, especially in that regarding prehospital care and the use of revascularization techniques. However, no significant differences are found in the study population regarding short term result

[The thrombolytic treatment of acute myocardial infarct in an emergency department]. / Tratamiento trombolítico del infarto agudo de miocardio en el área de urgencias.

INTRODUCTION AND OBJECTIVES: Although the importance of the early use of thrombolytic therapy in acute myocardial infarction has been demonstrated, it is usual to detect an unacceptable delay in its administration. We measured the in-hospital delay and, when it was determined we designed a protocol to reduce it. METHOD: From January-92 to December-94 we performed a prospective analysis of the measured delay for patients with a diagnosis on admission of acute myocardial infarction or unstable angina within 24 hours of the onset of symptoms. To ensure a homogeneous population, we established a triage system: priority I, delay of the therapy not admissible and so immediate administration of thrombolytic agent (performed in the emergency department); priority II, need for a careful evaluation of the risk/benefit ratio for thrombolytic therapy and administration, when indicated, after admission to the coronary care unit, and priority III, thrombolytic therapy whether indicated or contraindicated. All data were evaluated periodically in order to detect possible failures and to correct them. RESULTS: A total of 1,462 patients with a diagnosis of acute myocardial infarction (n = 1,006) or unstable angina (n = 456) were included. The administration of lytic therapy in the emergency department reduced the In-Hospital delay for thrombolysis by 54% from a median of 65 minutes (45 and 110) to 30 minutes (15 and 60) (p < 0.001) in priority I patients (40% of the patients diagnosed with AMI). For all cases with thrombolytic therapy this time was reduced from 87.5 minutes (50 and 155) to 50 minutes (25 and 110) minutes (p < 0.001). CONCLUSIONS: Awareness of our in-hospital delay, establishing a triage system in the emergency department and administering thrombolytic drugs in the this area has made it possible to provide this therapy to selected patients as early as possible.

[A diffuse pulmonary hemorrhage following thrombolytic therapy in an acute myocardial infarct]. / Hemorragia pulmonar difusa tras terapia trombolítica en infarto agudo de miocardio.

A sixty-years-old man was admitted to the hospital because of acute myocardial infarction of anterior location. He had four episodes of ventricular fibrillation each requiring defibrillation and short-term cardiopulmonary resuscitation (less than 10 minutes). He was then managed with thrombolytic therapy, therapeutic doses of heparin and aspirin. He had persistent haemoptysis, chest X-ray revealing a diffuse bilateral alveolar infiltration. There was a continuous decrease in hemoglobin and hematocrit levels, with an evident clinical-radiographic dissociation. Right cardiac catheterisation showed a normal left ventricular function. The single breath carbon monoxide diffusing capacity (DLCOsb) was high, indicative of a diffuse intrapulmonary haemorrhage causing the alveolar infiltration.