Early and late onset cardiotoxicity following anthracycline-based chemotherapy in breast cancer patients: Incidence and predictors.

INTRODUCTION: Cardiotoxicity represents a major limitation for the use of anthracyclines or trastuzumab in breast cancer patients. Data on longitudinal studies about early and late onset cardiotoxicity in this group of patients is scarce. The objective of the present study was to assess predictors of early and late onset cardiotoxicity in patients with breast cancer treated with A. METHODS: 100 consecutive patients receiving anthracycline-based chemotherapy (CHT) to treat breast cancer were included in this prospective study. All patients underwent evaluation at baseline, at the end of CHT, 3 months after the end of CHT and 1 and 4 years after the beginning of CHT. Clinical data, systolic and diastolic echo parameters and cardiac biomarkers including high sensitivity Troponin T (TnT), N-terminal pro-brain natriuretic peptide (NT-proBNP) and Heart-type fatty acid binding protein (H-FABP) were assessed. RESULTS: Mean doxorubicin dose was 243 mg/m2. Mean follow-up was 51.8 ± 8.2 months. At one-year incidence of anthracycline related-cardiotoxicity (AR-CT) was 4% and at the end of follow-up was 18% (15 patients asymptomatic left ventricular systolic dysfunction, 1 patients heart failure and 2 patients a sudden cardiac death). Forty-nine patients developed diastolic dysfunction (DD) during first year. In the univariate analysis DD during first year was the only parameter associated with AR-CT (Table 1). In the logistic regression model DD was independently related with the development of AR-CT, with an odds ratio value of 7.5 (95% CI 1.59-35.3). CONCLUSIONS: Incidence of late-onset cardiotoxicity is high but mostly subclinical. Diastolic dysfunction early after chemotherapy is a strong predictor of anthracycline cardiotoxicity.

Cardiogenic shock code 2023. Expert document for a multidisciplinary organization that allows quality care.

Despite the efforts made to improve the care of cardiogenic shock (CS) patients, including the development of mechanical circulatory support (MCS), the prognosis of these patients continues to be poor. In this context, CS code initiatives arise, based on providing adequate, rapid, and quality care to these patients. In this multidisciplinary document we try to justify the need to implement the SC code, defining its structure/organization, activation criteria, patient flow according to care level, and quality indicators. Our specific purposes are: a) to present the peculiarities of this condition and the lessons of infarction code and previous experiences in CS; b) to detail the structure of the teams, their logistics and the bases for the management of these patients, the choice of the type of MCS, and the moment of its implantation, and c) to address challenges to SC code implementation, including the uniqueness of the pediatric SC code. There is an urgent need to develop protocolized, multidisciplinary, and centralized care in hospitals with a large volume and experience that will minimize inequity in access to the MCS and improve the survival of these patients. Only institutional and structural support from the different administrations will allow optimizing care for CS.

Selección de temas de actualidad en cardiopatía isquémica y cuidados agudos cardiológicos 2015 / Ischemic heart disease and acute cardiac care 2015: a selection of topical issues

No disponible

Prevalencia de angina estable en España. Resultados del estudio OFRECE / Prevalence of stable angina in Spain. Results of the OFRECE study

Introducción y objetivos. El objetivo del estudio OFRECE fue estimar la prevalencia de angina estable en España. Esta es actualmente desconocida por falta de estudios recientes y cambios en la epidemiología y el tratamiento de la cardiopatía isquémica. Métodos. Estudio transversal. Se obtuvo una muestra representativa de la población española de edad mayor o igual a 40 años mediante muestreo aleatorio en dos etapas: la primera fue una selección aleatoria de médicos de atención primaria de cada provincia y la segunda, una selección de 20 individuos de la población asignada a cada médico. La prevalencia se ponderó por edad, sexo y área geográfica. Se clasificó a los participantes como pacientes con angina si cumplían criterios de «angina segura» del cuestionario de Rose y como angina confirmada si además tenían antecedentes de cardiopatía isquémica aguda, revascularización o confirmación tras evaluación cardiológica. Resultados. Se analizó a 8.378 personas (media de edad, 59,2 años), el 71% de las 11.831 invitadas a participar. La prevalencia ponderada de angina segura (Rose) fue del 2,6% (intervalo de confianza del 95%, 2,1-3,1%), mayor en mujeres (2,9%) que en varones (2,2%), y la de angina confirmada, del 1,4% (intervalo de confianza del 95%, 1,0-1,8%) sin diferencias entre varones (1,5%) y mujeres (1,3%). La prevalencia se incrementó con la edad (angina segura, el 0,7% en el grupo de 40-49 años y el 7,1% en el de edad mayor o igual a 70 años), los antecedentes de enfermedad cardiovascular y los factores de riesgo cardiovascular, salvo el tabaquismo. Conclusiones. La prevalencia de angina segura (Rose) en la población española de edad mayor o igual a 40 años es del 2,6% y la de angina confirmada, del 1,4%, y ambas se incrementan con la edad, los factores de riesgo cardiovascular y los antecedentes cardiovasculares (AU)

Introduction and objectives. The objective of the OFRECE study was to estimate the prevalence of stable angina in Spain. This prevalence is currently unknown, due to a lack of recent studies and to changes in the epidemiology and treatment of ischemic heart disease. Methods. This cross-sectional study involved a representative sample of the Spanish population aged 40 years or older, obtained via 2-stage random sampling: in the first stage, primary care physicians were randomly selected from each Spanish province, whereas in the second stage 20 people were selected from the population assigned to each physician. The prevalence was weighted by age, sex, and geographical area. Participants were classified as having angina if they met the 'definite angina' criteria of the Rose questionnaire and as having confirmed angina if the angina was confirmed by a cardiologist or if they had a history of acute ischemic heart disease or revascularization. Results. Of the 11 831 people invited to participate, 8378 (71%) were analyzed (mean age, 59.2 years). The weighted prevalence of definite angina (Rose) was 2.6% (95% confidence interval, 2.1%-3.1%) and was higher in women (2.9%) than in men (2.2%), whereas that of confirmed angina was 1.4% (95% confidence interval, 1.0%-1.8%), without differences between men (1.5%) and women (1.3%). The prevalence of definite angina (Rose) increased with age (0.7% in patients aged 40 to 49 years and 7.1% in those aged 70 years or older), history of cardiovascular disease, and cardiovascular risk factors, except smoking. Conclusions. The prevalence of definite angina (Rose) in the Spanish population aged 40 years or older was 2.6%, whereas that of confirmed angina was 1.4%. Both prevalences increased with age, cardiovascular risk factors, and cardiovascular history (AU)

Diastolic Dysfunction Following Anthracycline-Based Chemotherapy in Breast Cancer Patients: Incidence and Predictors.

INTRODUCTION: Cardiotoxicity represents a major limitation for the use of anthracyclines or trastuzumab in breast cancer patients. Data from longitudinal studies of diastolic dysfunction (DD) in this group of patients are scarce. The objective of the present study was to assess the incidence, evolution, and predictors of DD in patients with breast cancer treated with anthracyclines. METHODS: This analytical, observational cohort study comprised 100 consecutive patients receiving anthracycline-based chemotherapy (CHT) for breast cancer. All patients underwent clinical evaluation, echocardiogram, and measurement of cardiac biomarkers at baseline, end of anthracycline-based CHT, and at 3 months and 9 months after anthracycline-based CHT was completed. Fifteen patients receiving trastuzumab were followed with two additional visits at 6 and 12 months after the last dose of anthracycline-based CHT. A multivariate analysis was performed to find variables related to the development of DD. Fifteen of the 100 patients had baseline DD and were excluded from this analysis. RESULTS: At the end of follow-up (median: 12 months, interquartile range: 11.1-12.8), 49 patients (57.6%) developed DD. DD was persistent in 36 (73%) but reversible in the remaining 13 patients (27%). Four patients developed cardiotoxicity (three patients had left ventricular systolic dysfunction and one suffered a sudden cardiac death). None of the patients with normal diastolic function developed systolic dysfunction during follow-up. In the logistic regression model, body mass index (BMI) and age were independently related to the development of DD, with the following odds ratio values: BMI: 1.19 (95% confidence interval [CI]: 1.04-1.36), and age: 1.12 (95% CI: 1.03-1.19). Neither cardiac biomarkers nor remaining clinical variables were predictors of DD. CONCLUSION: Development of diastolic dysfunction after treatment with anthracycline or anthracycline- plus trastuzumab chemotherapy is common. BMI and age were independently associated with DD following anthracycline chemotherapy.

Prevalence of Stable Angina in Spain. Results of the OFRECE Study.

INTRODUCTION AND OBJECTIVES: The objective of the OFRECE study was to estimate the prevalence of stable angina in Spain. This prevalence is currently unknown, due to a lack of recent studies and to changes in the epidemiology and treatment of ischemic heart disease. METHODS: This cross-sectional study involved a representative sample of the Spanish population aged 40 years or older, obtained via 2-stage random sampling: in the first stage, primary care physicians were randomly selected from each Spanish province, whereas in the second stage 20 people were selected from the population assigned to each physician. The prevalence was weighted by age, sex, and geographical area. Participants were classified as having angina if they met the "definite angina" criteria of the Rose questionnaire and as having confirmed angina if the angina was confirmed by a cardiologist or if they had a history of acute ischemic heart disease or revascularization. RESULTS: Of the 11 831 people invited to participate, 8378 (71%) were analyzed (mean age, 59.2 years). The weighted prevalence of definite angina (Rose) was 2.6% (95% confidence interval, 2.1%-3.1%) and was higher in women (2.9%) than in men (2.2%), whereas that of confirmed angina was 1.4% (95% confidence interval, 1.0%-1.8%), without differences between men (1.5%) and women (1.3%). The prevalence of definite angina (Rose) increased with age (0.7% in patients aged 40 to 49 years and 7.1% in those aged 70 years or older), history of cardiovascular disease, and cardiovascular risk factors, except smoking. CONCLUSIONS: The prevalence of definite angina (Rose) in the Spanish population aged 40 years or older was 2.6%, whereas that of confirmed angina was 1.4%. Both prevalences increased with age, cardiovascular risk factors, and cardiovascular history.

Primary angioplasty vs. fibrinolysis in very old patients with acute myocardial infarction: TRIANA (TRatamiento del Infarto Agudo de miocardio eN Ancianos) randomized trial and pooled analysis with previous studies.

AIMS: To compare primary percutaneous coronary intervention (pPCI) and fibrinolysis in very old patients with ST-segment elevation myocardial infarction (STEMI), in whom head-to-head comparisons between both strategies are scarce. METHODS AND RESULTS: Patients ≥75 years old with STEMI <6 h were randomized to pPCI or fibrinolysis. The primary endpoint was a composite of all-cause mortality, re-infarction, or disabling stroke at 30 days. The trial was prematurely stopped due to slow recruitment after enrolling 266 patients (134 allocated to pPCI and 132 to fibrinolysis). Both groups were well balanced in baseline characteristics. Mean age was 81 years. The primary endpoint was reached in 25 patients in the pPCI group (18.9%) and 34 (25.4%) in the fibrinolysis arm [odds ratio (OR), 0.69; 95% confidence interval (CI) 0.38-1.23; P = 0.21]. Similarly, non-significant reductions were found in death (13.6 vs. 17.2%, P = 0.43), re-infarction (5.3 vs. 8.2%, P = 0.35), or disabling stroke (0.8 vs. 3.0%, P = 0.18). Recurrent ischaemia was less common in pPCI-treated patients (0.8 vs. 9.7%, P< 0.001). No differences were found in major bleeds. A pooled analysis with the two previous reperfusion trials performed in older patients showed an advantage of pPCI over fibrinolysis in reducing death, re-infarction, or stroke at 30 days (OR, 0.64; 95% CI 0.45-0.91). CONCLUSION: Primary PCI seems to be the best reperfusion therapy for STEMI even for the oldest patients. Early contemporary fibrinolytic therapy may be a safe alternative to pPCI in the elderly when this is not available.

¿Bivalirudina o heparina asociada a inhibidores de la glucoproteína IIb/IIIa en el síndrome coronario agudo sin elevación del ST? / Bivalirudin or heparin plus glycoprotein-IIb/IIIa inhibitors for non-ST-elevation acute coronary syndrome?

La bivalirudina, análogo sintético de la hirudina que se une reversiblemente a la trombina, pertenece al grupo de anticoagulantes que son inhibidores directos de la trombina con un efecto muy predecible. El objetivo de esta revisión es responder a la pregunta: ¿cuáles son la eficacia y la seguridad del tratamiento con bivalirudina en pacientes con síndrome coronario agudo sin elevación del ST, en comparación con la combinación de heparina (no fraccionada o de bajo peso molecular) e inhibidores de la glucoproteína IIb/ IIIa? Ambas estrategias han sido comparadas en dos estudios (ACUITY y REPLACE-2), de diseño e interpretación difícil, y que han mostrado una eficacia en términos de prevención de eventos cardiacos similar y disminución de las complicaciones hemorrágicas en los grupos asignados a recibir tratamiento con bivalirudina. Se realiza un análisis crítico de las evidencias y de las limitaciones existentes, que pueden servir de base para implantar una u otra estrategia en los protocolos de manejo del síndrome coronario agudo sin elevación del ST (AU)

Bivalirudin is a synthetic analog of hirudin that binds reversibly to thrombin. It belongs to a group of anticoagulants that act as direct thrombin inhibitors and whose effect is highly predictable. The aim of this review was to answer the question: How does the efficacy and safety of bivalirudin in patients with nonST-elevation acute coronary syndrome compare with that of the combination of (unfractionated or lowmolecular-weight) heparin and a glycoprotein-IIb/IIIa inhibitor? The two treatment strategies have been compared in two studies (i.e. ACUITY and REPLACE-2), both of which had a complex design and were difficult to interpret. These studies demonstrated that the two treatment strategies had similar efficacy in terms of preventing cardiac events and that fewer hemorrhagic complications occurred in the groups assigned to bivalirudin. We carried out a thorough analysis of the data available and their limitations, the results of which can serve as a basis for implementing one or other strategy in treatment protocols for nonST-elevation acute coronary síndrome (AU)

Role of the paclitaxel-eluting stent and tirofiban in patients with ST-elevation myocardial infarction undergoing postfibrinolysis angioplasty: the GRACIA-3 randomized clinical trial.

BACKGROUND: A catheter-based approach after fibrinolysis is recommended if fibrinolysis is likely to be successful in patients with acute ST-elevation myocardial infarction. We designed a 2x2 randomized, open-label, multicenter trial to evaluate the efficacy and safety of the paclitaxel-eluting stent and tirofiban administered after fibrinolysis but before catheterization to optimize the results of this reperfusion strategy. METHODS AND RESULTS: We randomly assigned 436 patients with acute ST-elevation myocardial infarction to (1) bare-metal stent without tirofiban, (2) bare-metal stent with tirofiban, (3) paclitaxel-eluting stent without tirofiban, and (4) paclitaxel-eluting stent with tirofiban. All patients were initially treated with tenecteplase and enoxaparin. Tirofiban was started 120 minutes after tenecteplase in those patients randomly assigned to tirofiban. Cardiac catheterization was performed within the first 3 to 12 hours after inclusion, and stenting (randomized paclitaxel or bare stent) was applied to the culprit artery. The primary objectives were the rate of in-segment binary restenosis of paclitaxel-eluting stent compared with that of bare-metal stent and the effect of tirofiban on epicardial and myocardial flow before and after mechanical revascularization. At 12 months, in-segment binary restenosis was similar between paclitaxel-eluting stent and bare-metal stent (10.1% versus 11.3%; relative risk, 1.06; 95% confidence interval, 0.74 to 1.52; P=0.89). However, late lumen loss (0.04+/-0.055 mm versus 0.27+/-0.057 mm, P=0.003) was reduced in the paclitaxel-eluting stent group. No evidence was found of any association between the use of tirofiban and any improvement in the epicardial and myocardial perfusion. Major bleeding was observed in 6.1% of patients receiving tirofiban and in 2.7% of patients not receiving it (relative risk, 2.22; 95% confidence interval, 0.86 to 5.73; P=0.14). CONCLUSIONS: This trial does not provide evidence to support the use of tirofiban after fibrinolysis to improve epicardial and myocardial perfusion. Compared with bare-metal stent, paclitaxel-eluting stent significantly reduced late loss but appeared not to reduce in-segment binary restenosis. CLINICAL TRIAL REGISTRATION: URL: http://clinicaltrials.gov. Unique identifier: NCT00306228.

Síndrome del seno carotídeo y meningioma intracraneal / No disponible

No disponible

[Intermediate coronary care units: rationale, infrastructure, equipment, and referral criteria]. / Unidades coronarias de cuidados intermedios: base racional, infraestructura, equipamiento e indicaciones de ingreso.

The Spanish Working Group on Coronary Artery Disease of Spanish Society of Cardiology has considered to be necessary the development of this document on the need, structure and organization of Intermediate Cardiac Care Units (ICCU). Acute coronary syndrome registries show that an important percentage of patients receive a suboptimal care, due to an inadequate management of health resources or absence of them. Intermediate cardiac care units arise to solve these challenges and to manage in an efficient way these expensive and limited resources. Their aims are: a) to provide each patient the level of care required; b) to optimize the structural, technical and human resources, and c) to make easier continuous care and care gradient. As a result, ICCU should be established as an essential part of the cardiology department aim to cardiac patients requiring monitoring and medical care superior to those available in a regular cardiac ward but whose risk does not justify the technical and human costs of a Coronary Unit. This document describes the structure (equipment, human resources, management) required to reach the goals previously reported and includes recommendations about indications of admission in a ICCU. These indications include: a) patients with NSTE-ACS with intermediate or high risk but hemodynamically stable, and b) low risk STEAMI or high risk STEAMI stabilized after an initial admission at the Coronary Unit. The admission of some patients undergoing invasive procedures or suffering non-coronary acute cardiac diseases, is also considered.

Unidades coronarias de cuidados intermedios: base racional, infraestructura, equipamiento e indicaciones de ingreso / Intermediate coronary care units: rationale, infrastructure, equipment, and referral criteria

La Sección de Cardiopatía Isquémica y Unidades de la Sociedad Española ha considerado necesario el desarrollo de este documento sobre la necesidad, la estructura y la organización de las unidades coronarias de cuidados intermedios (UCCI). Los registros de síndrome coronario agudo (SCA) realizados en España indican que una proporción importante de pacientes recibe una atención subóptima, en parte debido a una organización inadecuada de los recursos asistenciales o a la falta de éstos. Las UCCI surgen de la necesidad de corregir estos aspectos y gestionar con eficiencia unos recursos escasos y costosos. Sus objetivos son: a) proporcionar a cada paciente el grado de cuidados que requiere; b) optimizar los recursos estructurales, técnicos y humanos, y c) facilitar el continuo asistencial y el gradiente de cuidados. Las UCCI se deben constituir en una parte esencial del servicio de cardiología destinada a la atención de enfermos cardiológicos que requieren monitorización, cuidados y capacidad de respuesta médica superiores a los disponibles en una planta de hospitalización convencional de cardiología, pero cuyo riesgo no justifica la utilización de los recursos técnicos y humanos de una unidad coronaria. Este documento describe la infraestructura (equipamiento, dotación de personal y organización) que se precisa para cumplir los objetivos descritos anteriormente y contiene recomendaciones sobre las indicaciones de ingreso en estas unidades intermedias. Éstas incluyen a determinados pacientes con: a) SCA sin elevación del segmento ST de riesgo intermedio o alto pero estables hemodinámicamente, y b) infarto agudo de miocardio con elevación del segmento ST no de alto riesgo, o bien, de alto riesgo, pero estabilizado después de una fase inicial complicada en la unidad coronaria. También se contempla el ingreso de algunos pacientes después de determinados procedimientos invasivos y de algunas formas de cardiopatías agudas no coronarias (AU)

The Spanish Working Group on Coronary Artery Disease of Spanish Society of Cardiology has considered to be necessary the development of this document on the need, structure and organization of Intermediate Cardiac Care Units (ICCU). Acute coronary syndrome registries show that an important percentage of patients receive a suboptimal care, due to an inadequate management of health resources or absence of them. Intermediate cardiac care units arise to solve these challenges and to manage in an efficient way these expensive and limited resources. Their aims are: a) to provide each patient the level of care required; b) to optimize the structural, technical and human resources, and c) to make easier continuous care and care gradient. As a result, ICCU should be established as an essential part of the cardiology department aim to cardiac patients requiring monitoring and medical care superior to those available in a regular cardiac ward but whose risk does not justify the technical and human costs of a Coronary Unit. This document describes the structure (equipment, human resources, management) required to reach the goals previously reported and includes recommendations about indications of admission in a ICCU. These indications include: a) patients with NSTE-ACS with intermediate or high risk but hemodynamically stable, and b) low risk STEAMI or high risk STEAMI stabilized after an initial admission at the Coronary Unit. The admission of some patients undergoing invasive procedures or suffering non-coronary acute cardiac diseases, is also considered (AU)

Primary angioplasty vs. early routine post-fibrinolysis angioplasty for acute myocardial infarction with ST-segment elevation: the GRACIA-2 non-inferiority, randomized, controlled trial.

AIMS: In patients with acute myocardial infarction and ST-segment elevation (STEMI), primary angioplasty is frequently not available or performed beyond the recommended time limit. We designed a non-inferiority, randomized, controlled study to evaluate whether lytic-based early routine angioplasty represents a reasonable reperfusion option for victims of STEMI irrespective of geographic or logistical barriers. METHODS AND RESULTS: A total of 212 STEMI patients were randomized to full tenecteplase followed by stenting within 3-12 h of randomization (early routine post-fibrinolysis angioplasty; 104 patients), or to undergo primary stenting with abciximab within 3 h of randomization (primary angioplasty; 108 patients). The primary endpoints were epicardial and myocardial reperfusion, and the extent of left ventricular myocardial damage, determined by means of the infarct size and 6-week left ventricular function. The secondary endpoints were the acute incidence of bleeding and the 6-month composite incidence of death, reinfarction, stroke, or revascularization. Early routine post-fibrinolysis angioplasty resulted in higher frequency (21 vs. 6%, P = 0.003) of complete epicardial and myocardial reperfusion (TIMI 3 epicardial flow and TIMI 3 myocardial perfusion and resolution of the initial sum of ST-segment elevation > or = 70%) following angioplasty. Both groups were similar regarding infarct size (area under the curve of CK-MB: 4613 +/- 3373 vs. 4649 +/- 3632 microg/L/h, P = 0.94); 6-week left ventricular function (ejection fraction: 59.0 +/- 11.6 vs. 56.2 +/- 13.2%, P = 0.11; endsystolic volume index: 27.2 +/- 12.8 vs. 29.7 +/- 13.6, P = 0.21); major bleeding (1.9 vs. 2.8%, P = 0.99) and 6-month cumulative incidence of the clinical endpoint (10 vs. 12%, P = 0.57; relative risk: 0.80; 95% confidence interval: 0.37-1.74). CONCLUSION: Early routine post-fibrinolysis angioplasty safely results in better myocardial perfusion than primary angioplasty. Despite its later application, this approach seems to be equivalent to primary angioplasty in limiting infarct size and preserving left ventricular function.

Angina de pecho estable. Trascendencia clínica en la era de la intervención, limitaciones y avances actuales de su terapia farmacológica / Stable angina pectoris. Clinical relevance in the era of coronary interventions and limitations of pharmacological therapy

La angina de pecho estable continúa siendo en la era de la revascularización un problema relevante. Su trascendencia se sustenta en su alta prevalencia (un 2-4% de la población) y en el consumo de recursos sanitarios que origina. Su pronóstico es más favorable que el de los síndromes coronarios agudos, pero origina deterioro de la calidad de vida y frecuentes problemas terapéuticos. La mortalidad anual se encuentra en torno a un 0,5-2,6% y la incidencia de infarto no fatal es del 1-2% al año. Los objetivos del tratamiento de los pacientes con angina estable son: a) mejorar el pronóstico previniendo el infarto de miocardio y la muerte mediante la reducción de la incidencia de eventos trombóticos agudos y el desarrollo de disfunción ventricular izquierda, y b) mejorar los síntomas reduciendo los episodios isquémicos y aumentar la calidad de vida. El tratamiento antianginoso frecuentemente es subóptimo por un bajo grado de adhesión a las guías y por los frecuentes efectos secundarios. Intervenciones destinadas a mejorar la cumplimentación de las guías y nuevos fármacos, como la ivabradina, pueden ayudar a optimizar el tratamiento de los pacientes con angina estable (AU)

Stable angina continues to be an important problem, even in the era of coronary revascularization. Its significance lies in its high prevalence (i.e., 2-4 % of the population) and its impact on health resources. Although the prognosis of stable angina is more favorable than that of acute coronary syndrome, angina leads to a deterioration in quality of life and to frequent problems with therapy. Annual mortality is some 0.5-2.6% and the incidence of nonfatal myocardial infarction is 1-2% a year. The aims of treatment in patients with stable angina are: 1) to improve prognosis by preventing myocardial infarction and death by reducing the incidence of acute thrombotic events and by countering the development of left ventricular dysfunction, and 2) to improve symptoms by reducing the number of ischemic episodes and improving quality of life. Antianginal treatment is frequently suboptimal because of a low level of adherence to treatment guidelines, which also results in frequent side effects. Interventions aimed at increasing guideline adherence and new drugs, such as ivabradine, can help improve treatment in patients with stable angina (AU)

Routine invasive strategy within 24 hours of thrombolysis versus ischaemia-guided conservative approach for acute myocardial infarction with ST-segment elevation (GRACIA-1): a randomised controlled trial.

BACKGROUND: In patients with ST-segment elevated myocardial infarction (STEMI), early post-thrombolysis routine angioplasty has been discouraged because of its association with high incidence of events. The GRACIA-1 trial was designed to reassess the benefits of an early post-thrombolysis interventional approach in the era of stents and new antiplatelet agents. METHODS: 500 patients with thrombolysed STEMI (with recombinant tissue plasminogen activator) were randomly assigned to angiography and intervention if indicated within 24 h of thrombolysis, or to an ischaemia-guided conservative approach. The primary endpoint was the combined rate of death, reinfarction, or revascularisation at 12 months. Analysis was by intention to treat. FINDINGS: Invasive treatment included stenting of the culprit artery in 80% (199 of 248) patients, bypass surgery in six (2%), non-culprit artery stenting in three, and no intervention in 40 (16%). Predischarge revascularisation was needed in 51 of 252 patients in the conservative group. By comparison with patients receiving conservative treatment, by 1 year, patients in the invasive group had lower frequency of primary endpoint (23 [9%] vs 51 [21%], risk ratio 0.44 [95% CI 0.28-0.70], p=0.0008), and they tended to have reduced rate of death or reinfarction (7% vs 12%, 0.59 [0.33-1.05], p=0.07). Index time in hospital was shorter in the invasive group, with no differences in major bleeding or vascular complications. At 30 days both groups had a similar incidence of cardiac events. In-hospital incidence of revascularisation induced by spontaneous recurrence of ischaemia was higher in patients in the conservative group than in those in the invasive group. INTERPRETATION: In patients with STEMI, early post-thrombolysis catheterisation and appropriate intervention is safe and might be preferable to a conservative strategy since it reduces the need for unplanned in-hospital revascularisation, and improves 1-year clinical outcome.

[Coronary angioplasty in diabetic patients. Current and future perspectives]. / Angioplastia coronaria en el paciente diabético. Situación actual y perspectivas futuras.

It has been estimated that 15-25% of patients who undergo percutaneous or surgical coronary angioplasty are diabetics. The indications for coronary revascularization and initial results of the procedure do not differ substantially between patients with diabetes mellitus and non-diabetics. However, the long-term results of both percutaneous and surgical coronary angioplasty are less favorable in diabetics in terms of mortality and the need for new revascularization procedures. The development and widespread use of stents and glycoprotein IIb/IIIa receptor inhibiting drugs have improved the clinical evolution of diabetics treated with angioplasty. Currently available data show that the administration of glycoprotein IIb/IIIa inhibitors to patients undergoing coronary angioplasty is especially useful in diabetics and improves short-term and long-term results, decreasing one-year mortality by 45%. There seem to be indications for the routine use of glycoprotein IIb/IIIa inhibitors in diabetics treated with angioplasty. While the use of stents has improved long-term and short-term results in diabetics, the success rates of angioplasty in diabetics are still lower than in non-diabetics. Diabetes is still an independent predictor of restenosis and long-term events after stenting interventions. Analysis of the studies comparing percutaneous and surgical revascularization in diabetic patients with multivessel disease shows that surgery is superior in terms of long-term mortality and need for new revascularization procedures. Stenting has improved, but not substantially, the results of multivessel angioplasty in diabetics. Therefore, the indications for angioplasty in multivessel diabetics should be evaluated individually. Factors that contribute to the less favorable post-angioplasty evolution of diabetic patients are more rapid progression of atherosclerosis and, especially, a higher rate of restenosis. New angioplasty techniques, such as brachytherapy and drug-eluting stents, are likely to significantly improve the results of percutaneous interventions in diabetics, thus allowing the indications for angioplasty in diabetics to be extended even further in the near future.

[2002 Update of the Guidelines of the Spanish Society of Cardiology for Unstable Angina/Without ST-Segment Elevation Myocardial Infarction]. / Actualización (2002) de las Guías de Práctica Clínica de la Sociedad Española de Cardiología en angina inestable/infarto sin elevación del segmento ST.

Since the Spanish Society of Cardiology Clinical Practice Guidelines on Unstable Angina/Non-Q-Wave Myocardial Infarction were released in 1999, the conclusions of several studies that have been published make it advisable to update current clinical recommendations. The main findings are related to the developing role of Chest Pain Units in the management and early risk stratification of acute coronary syndromes in the emergency department; new information concerning the efficacy of glycoprotein IIb/IIIa inhibitors, clopidogrel and low-molecular-weight heparins in the pharmacological treatment of acute coronary syndromes without ST-segment elevation; and the role of early invasive strategy in improving the prognosis of these patients. The published evidence is reviewed and the corresponding clinical recommendations for the management of acute coronary syndromes without persistent ST-segment elevation are updated.