Angioplastia primaria en el Área Norte de Galicia: cambios asistenciales y resultados tras la implantación del programa PROGALIAM / Primary angioplasty in northern Galicia: care changes and results following implementation of the PROGALIAM protocol

Introducción y objetivos. Analizar los resultados y cambios asistenciales del programa de angioplastia primaria del Complejo Hospitalario Universitario A Coruña tras iniciar el Programa Gallego de Atención al Infarto de Miocardio (PROGALIAM). Métodos. Registro observacional de 1.434 pacientes remitidos para angioplastia primaria entre 2003 y 2007. Los resultados de la era PROGALIAM (de mayo de 2005 a diciembre de 2007; n = 963) se compararon con los de la etapa previa (de enero de 2003 a abril de 2005; n = 388). Resultados. Tras iniciar el PROGALIAM, aumentó el número de casos de angioplastia primaria (etapa previa, 14,4 casos/mes; PROGALIAM, 32,3 casos/mes), la media de edad (etapa previa, 61,3 ± 11,9 años; PROGALIAM, 64,2 ± 11,7 años; p < 0,001) y la proporción de pacientes procedentes de hospitales periféricos y pacientes tratados fuera del horario laboral. La mediana de retraso primer contacto-balón se incrementó en el conjunto del programa (etapa previa, 106 min; etapa PROGALIAM, 113 min; p = 0,02), pero se redujo entre los pacientes procedentes de centros secundarios (etapa previa, 171 min; etapa PROGALIAM, 146 min; p < 0,001). La proporción de casos con retraso primer contacto-balón < 120 min permaneció invariable entre los pacientes del centro intervencionista (etapa previa, 69%; etapa PROGALIAM, 71%; p = 0,56) y se incrementó entre los pacientes de centros periféricos, si bien en este subgrupo continuó siendo baja (etapa previa, 17%; etapa PROGALIAM, 30%; p = 0,04). La mortalidad a 30 días (etapa previa, 5,2%; etapa PROGALIAM, 6,2%; p = 0,85) y a 1 año (etapa previa, 9,5%; etapa PROGALIAM, 10,2%; p = 0,96) fue similar en ambas etapas. Conclusiones. El PROGALIAM ha permitido incrementar la proporción de pacientes tratados con angioplastia primaria manteniendo los resultados de esta terapia (AU)

Introduction and objectives. To analyze changes in healthcare delivery and results for primary angioplasty at Centro Hospitalario Universitario A Coruña following implementation of the PROGALIAM protocol. Methods. Observational registry of 1434 patients referred for primary angioplasty between 2003 and 2007. Results under PROGALIAM (May 2005 - December 2007; n=963) were compared with those from the preceding period (January 2003 - April 2005; n=388). Results. After implementing PROGALIAM, there were increases in the number of primary angioplasty procedures (preceding period, 14.4 cases/month; PROGALIAM, 32.2 cases/month), mean patient age (preceding period, 61.3 (11.9) years; PROGALIAM, 64.2 (11.7) years; P<.001), and the percentage of patients referred from peripheral hospitals and treated after normal working hours. Overall median first medical contact-to-balloon time increased (previous period, 106min; PROGALIAM, 113min; P=.02), but decreased significantly among patients referred from noninterventional centers (previous period, 171min; PROGALIAM, 146min; P<.001). Percentage of cases with an first medical contact-to-balloon time <120min remained unchanged among interventional-center patients (preceding period, 69%; PROGALIAM, 71%; P=.56) and increased among patients at noninterventional centers, although it remained low in this subgroup (preceding period, 17%; PROGALIAM, 30%; P=.04). Thirty-day mortality (preceding period, 5.2%; PROGALIAM, 6.2%; P=.85) and 1-year mortality (preceding period, 9.5%; PROGALIAM, 10.2%; P=.96) remained unchanged. Conclusions. Implementation of PROGALIAM allowed us to increase the percentage of patients receiving primary angioplasty without jeopardizing the clinical results of this treatment (AU)

Primary angioplasty in Northern Galicia: care changes and results following implementation of the PROGALIAM protocol.

INTRODUCTION AND OBJECTIVES: To analyze changes in healthcare delivery and results for primary angioplasty at Centro Hospitalario Universitario A Coruña following implementation of the PROGALIAM protocol. METHODS: Observational registry of 1434 patients referred for primary angioplasty between 2003 and 2007. Results under PROGALIAM (May 2005 - December 2007; n=963) were compared with those from the preceding period (January 2003 - April 2005; n=388). RESULTS: After implementing PROGALIAM, there were increases in the number of primary angioplasty procedures (preceding period, 14.4 cases/month; PROGALIAM, 32.2 cases/month), mean patient age (preceding period, 61.3 (11.9) years; PROGALIAM, 64.2 (11.7) years; P<.001), and the percentage of patients referred from peripheral hospitals and treated after normal working hours. Overall median first medical contact-to-balloon time increased (previous period, 106 min; PROGALIAM, 113 min; P=.02), but decreased significantly among patients referred from noninterventional centers (previous period, 171 min; PROGALIAM, 146 min; P<.001). Percentage of cases with an first medical contact-to-balloon time <120 min remained unchanged among interventional-center patients (preceding period, 69%; PROGALIAM, 71%; P=.56) and increased among patients at noninterventional centers, although it remained low in this subgroup (preceding period, 17%; PROGALIAM, 30%; P=.04). Thirty-day mortality (preceding period, 5.2%; PROGALIAM, 6.2%; P=.85) and 1-year mortality (preceding period, 9.5%; PROGALIAM, 10.2%; P=.96) remained unchanged. CONCLUSIONS: Implementation of PROGALIAM allowed us to increase the percentage of patients receiving primary angioplasty without jeopardizing the clinical results of this treatment.

Utilidad de la escala INTERMACS para estratificar el pronóstico tras el trasplante cardiaco urgente / Usefulness of the INTERMACS scale for predicting outcomes after urgent heart transplantation

Introducción y objetivos. Analizar el valor pronóstico de la escala INTERMACS (Interagency Registry for Mechanically Assisted Circulatory Support) en pacientes tratados con trasplante cardiaco urgente. Métodos. Análisis retrospectivo de 111 pacientes tratados con trasplante cardiaco urgente en nuestro centro entre abril de 1991 y octubre de 2009. Se asignó retrospectivamente a los pacientes a tres niveles de la escala INTERMACS en función de su situación clínica previa al trasplante cardiaco. Resultados. Los pacientes del grupo INTERMACS 1 (n=31) presentaban mayor frecuencia de cardiopatía isquémica (p=0,03) y shock tras cardiotomía (p=0,02) que los pacientes del grupo INTERMACS 2 (n=55) y los pacientes del grupo INTERMACS 3–4 (n=25), así como mayores dosis de catecolaminas (p=0,001), mayor empleo de ventilación mecánica (p<0,001), balón de contrapulsación (p=0,002) y dispositivos de asistencia ventricular (p=0,002) y mayores tasas de infección preoperatoria (p=0,015). El grupo INTERMACS 1 también mostraba mayores cifras de presión venosa central (p=0,02), GOT (p=0,002), GPT (p=0,006) y creatinina (p<0,001) y menores cifras de hemoglobina (p=0,008) y aclaramiento de creatinina (p=0,001). Tras el trasplante cardiaco, los pacientes del grupo INTERMACS 1 presentaron mayores incidencias de fracaso primario del injerto (p=0,03) y necesidad de terapia de sustitución renal (p=0,004), y su supervivencia a largo plazo fue menor que la de los pacientes de los grupos INTERMACS 2 (log rank=5,1; p=0,023; razón de riesgos [HR]=3,1; intervalo de confianza [IC] del 95%, 1,4-6,8) e INTERMACS 3-4 (log rank=6,1; p=0,013; HR=4; IC del 95%, 1,3-12,3). Conclusiones. Nuestros resultados indican que la escala INTERMACS resulta útil para estratificar el pronóstico postoperatorio tras el trasplante cardiaco urgente(AU)

Introduction and objectives: Our aim was to assess the prognostic value of the INTERMACS (Interagency Registry for Mechanically Assisted Circulatory Support) scale in patients undergoing urgent heart transplantation (HT). Methods: Retrospective analysis of 111 patients treated with urgent HT at our institution from April, 1991 to October, 2009. Patients were retrospectively assigned to three levels of the INTERMACS scale according to their clinical status before HT. Results: Patients at the INTERMACS 1 level (n = 31) more frequently had ischemic heart disease (P = .03) and post-cardiothomy shock (P = .02) than patients at the INTERMACS 2 (n = 55) and INTERMACS 3-4 (n = 25) levels. Patients at the INTERMACS 1 level showed higher preoperative catecolamin doses (P = .001), a higher frequency of use of mechanical ventilation (P < .001), intraaortic balloon (P = .002) and ventricular assist devices (P = .002), and a higher frequency of preoperative infection (P = .015). The INTERMACS 1 group also presented higher central venous pressure (P = .02), AST (P = .002), ALT (P = .006) and serum creatinine (P < .001), and lower hemoglobin (P = .008) and creatinine clearance (P = .001). After HT, patients at the INTERMACS 1 level had a higher incidence of primary graft failure (P = .03) and postoperative need for renal replacement therapy (P = .004), and their long-term survival was lower than patients at the INTERMACS 2 (log rank 5.1, P = .023; HR 3.1, IC 95% 1.1-8.8) and INTERMACS 3-4 level (log rank 6.1, p = 0.013; HR 6.8, IC 95% 1.2-39.1). Conclusions: Our results suggest that the INTERMACS scalemay be a useful tool to stratify postoperative prognosis after urgent HT(AU)

Usefulness of the INTERMACS Scale for predicting outcomes after urgent heart transplantation.

INTRODUCTION AND OBJECTIVES: Our aim was to assess the prognostic value of the INTERMACS (Interagency Registry for Mechanically Assisted Circulatory Support) scale in patients undergoing urgent heart transplantation (HT). METHODS: Retrospective analysis of 111 patients treated with urgent HT at our institution from April, 1991 to October, 2009. Patients were retrospectively assigned to three levels of the INTERMACS scale according to their clinical status before HT. RESULTS: Patients at the INTERMACS 1 level (n=31) more frequently had ischemic heart disease (P=.03) and post-cardiothomy shock (P=.02) than patients at the INTERMACS 2 (n=55) and INTERMACS 3-4 (n=25) levels. Patients at the INTERMACS 1 level showed higher preoperative catecolamin doses (P=.001), a higher frequency of use of mechanical ventilation (P<.001), intraaortic balloon (P=.002) and ventricular assist devices (P=.002), and a higher frequency of preoperative infection (P=.015). The INTERMACS 1 group also presented higher central venous pressure (P=.02), AST (P=.002), ALT (P=.006) and serum creatinine (P<.001), and lower hemoglobin (P=.008) and creatinine clearance (P=.001). After HT, patients at the INTERMACS 1 level had a higher incidence of primary graft failure (P=.03) and postoperative need for renal replacement therapy (P=.004), and their long-term survival was lower than patients at the INTERMACS 2 (log rank 5.1, P=.023; HR 3.1, IC 95% 1.1-8.8) and INTERMACS 3-4 level (log rank 6.1, p=0.013; HR 6.8, IC 95% 1.2-39.1). CONCLUSIONS: Our results suggest that the INTERMACS scale may be a useful tool to stratify postoperative prognosis after urgent HT.

Effect of stent thrombosis on the risk-benefit balance of drug-eluting stents and bare metal stents.

INTRODUCTION AND OBJECTIVES: To determine the difference in the risk of stent thrombosis between drug-eluting stents (DES) and bare-metal stents (BMS) and to assess the clinical implications. METHODS: A retrospective analysis of two cohorts of patients treated at our center with either > or =1 paclitaxeleluting stents (PES) (n=430) or > or =1 BMSs (n=1230) during 2003-2004 was carried out using propensity score methods to compare the adjusted risks of stent thrombosis, instent restenosis, cardiovascular death, acute myocardial infarction (AMI), and target-lesion revascularization with the two stent types. RESULTS: After a median follow-up of 46 months, there was a higher risk of stent thrombosis in PESs (hazard ratio [HR]=3; 95% confidence interval [CI], 1.2-7.1] though the risk of in-stent restenosis was lower (HR=0.3; 95% CI, 0.2-0.7]. There was no difference in the risk of cardiovascular death, AMI or target-lesion revascularization. With PESs, the risks of target-lesion revascularization (HR=0.33; 95% CI, 0.2-0.7) and in-stent restenosis (HR=0.32; 95% CI, 0.2-0.7) were reduced during the first year of follow-up. After this time, the risks of target-lesion revascularization (HR=1.8; 95% CI, 1-3.2) and very late stent thrombosis (HR=12.8; 95% CI, 3-55.1) both increased. CONCLUSIONS: Our findings indicate that the balance of risks and benefits of PESs compared with BMSs is different in the early and late periods after stent implantation. The greatly increased risk of very late stent thrombosis in PESs could cancel out the clinical benefits associated with the reduction in in-stent restenosis observed in PESs relative to BMSs.

Prevalence, etiology and outcome of catheterization laboratory false alarms in patients with suspected ST-elevation myocardial infarction.

INTRODUCTION AND OBJECTIVES: To investigate the prevalence, causes and outcome of catheterization laboratory false alarms (CLFAs) in a regional primary angioplasty network. METHODS: A prospective registry of 1,662 patients referred for primary angioplasty between January 2003 and August 2008 was reviewed to identify CLFAs (i.e. when no culprit coronary lesion could be found). RESULTS: No culprit coronary lesion could be identified in 120 patients (7.2%; 95% confidence interval [CI], 5.9-8.5%). Of these, 104 (6.3%, 95% CI, 5.1-7.4%) had a discharge diagnosis other than ST-elevation myocardial infarction, 91 (5.5%; 95% CI, 4.3-6.6%) had no significant coronary disease, and 64 (3.8%; 95% CI, 2.9-4.8%) tested negative for cardiac biomarkers. The most frequent alternative diagnoses were: previous Q-wave myocardial infarction (18 cases), nonspecific ST-segment abnormalities (11), pericarditis (10) and transient apical dyskinesia (10). The 30-day mortality rate was similar in patients with and without culprit lesions (5.8% vs. 5.8%; P=.99). The prevalence of CLFAs was slightly higher in patients not previously evaluated by a cardiologist and referred from emergency departments in hospitals without catheterization laboratories than in those referred by cardiologists from emergency departments at hospitals with such facilities (9.5% vs. 6.1%; P=.02; odds ratio=1.64; 95% CI, 1.08-2.5). The prevalence of CLFAs was not significantly higher in patients referred by physicians with out-of-hospital emergency medical services (7.2%; P=.51; odds ratio=1.37; 95% CI, 0.79-2.37). CONCLUSIONS: The prevalence of CLFAs was 7.2%, with the criterion of no culprit coronary lesion. Our findings suggest that different patterns of referral to catheterization laboratories could account for small variations in the prevalence of CLFAs.

Prevalencia, causas y pronóstico de las «falsas alarmas» al laboratorio de hemodinámica en pacientes con sospecha de infarto de miocardio con elevación del segmento ST / Prevalence, etiology and outcome of catheterization laboratory false alarms in patients with suspected ST-elevation myocardial infarction

Introducción y objetivos. Determinar prevalencia, causas y pronóstico de las «falsas alarmas» al laboratorio de hemodinámica (FALH) en una red regional de angioplastia primaria. Métodos. Registro prospectivo de 1.662 pacientes remitidos para angioplastia primaria entre enero de 2003 y agosto de 2008. Se definió FALH como ausencia de lesión coronaria causal. Resultados. En 120 pacientes (7,2%; intervalo de confianza [IC] del 95%, 5,9-8,5) no se identificó ninguna lesión coronaria causal. De ellos, 104 (6,3%; IC del 95%, 5,1-7,4) recibieron un diagnóstico alternativo a IAMCEST, 91 (5,5%; IC del 95%, 4,3-6,6) no presentaron enfermedad coronaria significativa y 64 (3,8%; IC del 95%, 2,9-4,8) presentaron marcadores de daño miocárdico negativos. Los diagnósticos alternativos más frecuentes fueron: infarto con onda Q previo (18 casos), alteraciones inespecíficas del segmento ST (11), pericarditis (10) y discinesia apical transitoria (10). La mortalidad a 30 días fue similar en los pacientes con y sin lesión causal (el 5,8 frente al 5,8%; p = 0,99). La prevalencia de FALH fue discretamente superior entre los pacientes remitidos desde los servicios de urgencias de hospitales no intervencionistas sin evaluación previa por un cardiólogo que entre los remitidos por cardiólogos desde el servicio de urgencias del hospital intervencionista (el 9,5 frente al 6,1%; p = 0,02; odds ratio [OR] = 1,64; IC del 95%, 1,08-2,5). No observamos un exceso de FALH entre los pacientes remitidos por médicos de UVI Móviles-061 (7,2%; p = 0,51; OR = 1,37; IC del 95%, 0,79-2,37). Conclusiones. Hemos observado una prevalencia de FALH del 7,2% de acuerdo con el criterio de ausencia de lesión coronaria causal. Nuestros resultados indican que diferentes modelos de activación del laboratorio de hemodinámica podrían justificar discretas variaciones en la prevalencia de FALH (AU)

Introduction and objectives. To investigate the prevalence, causes and outcome of catheterization laboratory false alarms (CLFAs) in a regional primary angioplasty network. Methods. A prospective registry of 1,662 patients referred for primary angioplasty between January 2003 and August 2008 was reviewed to identify CLFAs (i.e. when no culprit coronary lesion could be found). Results. No culprit coronary lesion could be identified in 120 patients (7.2%; 95% confidence interval [CI], 5.9- 8.5%). Of these, 104 (6.3%, 95% CI, 5.1-7.4%) had a discharge diagnosis other than ST-elevation myocardial infarction, 91 (5.5%; 95% CI, 4.3-6.6%) had no significant coronary disease, and 64 (3.8%; 95% CI, 2.9-4.8%) tested negative for cardiac biomarkers. The most frequent alternative diagnoses were: previous Q-wave myocardial infarction (18 cases), nonspecific ST-segment abnormalities (11), pericarditis (10) and transient apical dyskinesia (10). The 30-day mortality rate was similar in patients with and without culprit lesions (5.8% vs. 5.8%; P=.99). The prevalence of CLFAs was slightly higher in patients not previously evaluated by a cardiologist and referred from emergency departments in hospitals without catheterization laboratories than in those referred by cardiologists from emergency departments at hospitals with such facilities (9.5% vs. 6.1%; P=.02; odds ratio=1.64; 95% CI, 1.08-2.5). The prevalence of CLFAs was not significantly higher in patients referred by physicians with out-of-hospital emergency medical services (7.2%; P=.51; odds ratio=1.37; 95% CI, 0.79-2.37). Conclusions. The prevalence of CLFAs was 7.2%, with the criterion of no culprit coronary lesion. Our findings suggest that different patterns of referral to catheterization laboratories could account for small variations in the prevalence of CLFAs (AU)

Influencia de la trombosis del stent en la relación riesgo-beneficio de los stents farmacoactivos y los stents convencionales / Effect of stent thrombosis on the risk-benefit balance of drug-eluting stents and bare metal stents

Introducción y objetivos. Evaluar el riesgo de trombosis del stent (TS) de los stents liberadores de fármaco (SLF) frente a los stents convencionales (SC) y sus consecuencias clínicas. Métodos. Análisis retrospectivo de dos cohortes de pacientes tratados con al menos un stent liberador de paclitaxel (SLP) (n = 430) o uno o más SC (n = 1.268) en 2003-2004 en nuestro centro mediante métodos de score de propensión para comparar el riesgo ajustado de TS, reestenosis del stent (RIS), muerte cardiovascular, infarto de miocardio (IAM) y revascularización de la lesión tratada (RLT) entre ambos dispositivos. Resultados. Tras una mediana de seguimiento de 46 meses, los SLP presentaron mayor riesgo de TS (hazard ratio [HR] = 3; intervalo de confianza [IC] del 95%, 1,2-7,1), si bien redujeron el riesgo de RIS (HR = 0,3; IC del 95%, 0,2-0,7). No hubo diferencias en cuanto a muerte cardiovascular, IAM o RLT. Los SLP disminuyeron el riesgo de RLT (HR = 0,33; IC del 95%, 0,2-0,7) y RIS (HR = 0,32; IC del 95%, 0,2-0,7) durante el primer año de seguimiento. Tras este límite, presentaron mayor riesgo de RLT (HR = 1,8; IC del 95%, 1-3,2) y de TS muy tardía (HR = 12,8; IC del 95%, 3-55,1). Conclusiones. Nuestros hallazgos confirman que hay una relación riesgo-beneficio precoz y tardía diferente entre el implante de un SLP y el de un SC. El exceso de riesgo de TS muy tardía puede limitar los beneficios clínicos de los SLP frente a los SC, relacionados con la disminución de la RIS (AU)

Introduction and objectives. To determine the difference in the risk of stent thrombosis between drug-eluting stents (DES) and bare-metal stents (BMS) and to assess the clinical implications. Methods. A retrospective analysis of two cohorts of patients treated at our center with either ≥1 paclitaxeleluting stents (PES) (n=430) or ≥1 BMSs (n=1230) during 2003-2004 was carried out using propensity score methods to compare the adjusted risks of stent thrombosis, instent restenosis, cardiovascular death, acute myocardial infarction (AMI), and target-lesion revascularization with the two stent types. Results. After a median follow-up of 46 months, there was a higher risk of stent thrombosis in PESs (hazard ratio [HR]=3; 95% confidence interval [CI], 1.2-7.1] though the risk of in-stent restenosis was lower (HR=0.3; 95% CI, 0.2-0.7]. There was no difference in the risk of cardiovascular death, AMI or target-lesion revascularization. With PESs, the risks of target-lesion revascularization (HR=0.33; 95% CI, 0.2-0.7) and in-stent restenosis (HR=0.32; 95% CI, 0.2-0.7) were reduced during the first year of follow-up. After this time, the risks of target-lesion revascularization (HR=1.8; 95% CI, 1-3.2) and very late stent thrombosis (HR=12.8; 95% CI, 3-55.1) both increased. Conclusions. Our findings indicate that the balance of risks and benefits of PESs compared with BMSs is different in the early and late periods after stent implantation. The greatly increased risk of very late stent thrombosis in PESs could cancel out the clinical benefits associated with the reduction in in-stent restenosis observed in PESs relative to BMSs (AU)