Rationale and design of the artificial intelligence scalable solution for acute myocardial infarction (ASSIST) study.

BACKGROUND: Acute coronary syndrome (ACS), specifically ST-segment elevation myocardial infarction is a major cause of morbidity and mortality throughout Europe. Diagnosis in the acute setting is mainly based on clinical symptoms and physician's interpretation of an electrocardiogram (ECG), which may be subject to errors. ST-segment elevation is the leading criteria to activate urgent reperfusion therapy, but a clear ST-elevation pattern might not be present in patients with coronary occlusion and ST-segment elevation might be seen in patients with normal coronary arteries. METHODS: The ASSIST project is a retrospective observational study aiming to improve the ECG-assisted assessment of ACS patients in the acute setting by incorporating an artificial intelligence platform, Willem™ to analyze 12­lead ECGs. Our aim is to improve diagnostic accuracy and reduce treatment delays. ECG and clinical data collected during this study will enable the optimization and validation of Willem™. A retrospective multicenter study will collect ECG, clinical, and coronary angiography data from 10,309 patients. The primary outcome is the performance of this tool in the correct identification of acute myocardial infarction with coronary artery occlusion. Model performance will be evaluated internally with patients recruited in this retrospective study while external validation will be performed in a second stage. CONCLUSION: ASSIST will provide key data to optimize Willem™ platform to detect myocardial infarction based on ECG-assessment alone. Our hypothesis is that such a diagnostic approach may reduce time delays, enhance diagnostic accuracy, and improve clinical outcomes.

Heart failure hospitalization following surgical or transcatheter aortic valve implantation in low-risk aortic stenosis.

AIMS: In low-risk patients with severe aortic stenosis (AS), sutureless surgical aortic valve replacement (SU-SAVR) may be an alternative to transcatheter aortic valve implantation (TAVI). The risk of heart failure hospitalization (HFH) after aortic valve replacement (AVR) in this population is incompletely characterized. This study aims to investigate the incidence, predictors, and outcomes of HFH in patients undergoing SU-SAVR versus TAVI. METHODS AND RESULTS: Patients referred for AVR between 2013 and 2020 at two centres were consecutively included. The decision for SU-SAVR or TAVI was determined by a multidisciplinary Heart Team. Cox regression and competing risk analysis were conducted to assess adverse events. Of 594 patients (mean age 77.5 ± 6.4, 59.8% male), 424 underwent SU-SAVR, while 170 underwent TAVI. Following a mean follow-up of 34.1 ± 23.1 months, HFH occurred in 112 (27.8%) SU-SAVR patients and in 8 (4.8%) TAVI patients (P < 0.001). The SU-SAVR cohort exhibited higher all-cause mortality (138 [32.5%] patients compared with 30 [17.6%] in the TAVI cohort [P < 0.001]). These differences remained significant after sensitivity analyses with 1:1 propensity score matching for baseline variables. SU-SAVR with HFH was associated with increased all-cause mortality (61.6% vs. 23.1%, P < 0.001). Independent associates of HFH in SU-SAVR patients included diabetes, atrial fibrillation, chronic obstructive pulmonary disease, lower glomerular filtration rate and lower left ventricular ejection fraction. SU-SAVR patients with HFH had a 12-month LVEF of 59.4 ± 12.7. CONCLUSIONS: In low-risk AS, SU-SAVR is associated with a higher risk of HFH and all-cause mortality compared to TAVI. In patients with severe AS candidate to SU-SAVR or TAVI, TAVI may be the preferred intervention.

Experience with the ACURATE neo and neo2 transcatheter aortic valves in Spain. The PRECISA (PRospective Evaluation Complementing Investigation with ACURATE devices) registry.

BACKGROUND: Previous studies have documented a high rate of implantation success with the ACURATE neo2 valve, as well as a reduction in paravalvular leak (PVL) compared to its predecessor, the ACURATE neo. However, there are no studies that have reviewed and compared the long-term clinical and hemodynamic outcomes of these patients. AIMS: This study aimed to evaluate the results of the ACURATE neo transcatheter aortic valve in a real-world context, and to compare the results of the outcomes of both generations of this device (ACURATE neo and ACURATE neo2), with a specific focus on procedural success, safety, and long-term effectiveness. METHODS: A prospective study including all consecutive patients treated with the ACURATE neo device in seven hospitals was conducted (Clinical Trials Identification Number: NCT03846557). The primary endpoint consisted of a composite of adverse events, including mortality, aortic insufficiency, and other procedural complications. As the second-generation device (ACURATE neo2) replaced the ACURATE neo during the study period, hemodynamic and clinical results before admission, at 30 days, and at 1 year of follow-up were compared between the two generations. RESULTS: A total of 296 patients underwent transcatheter aortic valve implantation with the ACURATE device, with 178 patients receiving the ACURATE neo and 118 patients receiving the ACURATE neo2. In the overall population, the absence of device success occurred in 14.5%. The primary reason for the absence of device success was the presence of para-valvular regurgitation ≥ 2. There were no instances of coronary occlusions, valve embolization, annulus rupture, or procedural deaths. ACURATE neo2 was associated with a significantly higher device success rate (91.7% vs. 82%, p = 0.04), primarily due to a significantly lower rate of para-valvular regurgitation, which remained significant at 1 year. CONCLUSION: The use of ACURATE neo and neo2 transcatheter aortic valves is associated with satisfactory clinical results and an extremely low rate of complications. The ACURATE neo2 enables a significantly higher device success rate, primarily attributed to a significant reduction in the rate of PVL.

A Prospective, Multicenter, Real-World Registry of Coronary Lithotripsy in Calcified Coronary Arteries: The REPLICA-EPIC18 Study.

BACKGROUND: Intravascular lithotripsy (IVL) has demonstrated effectiveness in the treatment of calcified lesions in selected patients with stable coronary disease. OBJECTIVES: The authors sought to assess the performance of coronary IVL in calcified coronary lesions in a real-life, all comers, setting. METHODS: The REPLICA-EPIC18 study prospectively enrolled consecutive patients treated with IVL in 26 centers in Spain. An independent core laboratory performed the angiographic analysis and event adjudication. The primary effectiveness endpoint assessed procedural success (successful IVL delivery, final diameter stenosis <20%, and absence of in-hospital major adverse cardiovascular events [MACE]). The primary safety endpoint measured freedom from MACE at 30 days. A predefined substudy compared outcomes between acute coronary syndrome (ACS) and chronic coronary syndrome (CCS) patients. RESULTS: A total of 426 patients (456 lesions) were included, 63% of the patients presenting with ACS. IVL delivery was successful in 99% of cases. Before IVL, 49% of lesions were considered undilatable. The primary effectiveness endpoint was achieved in 66% of patients, with similar rates among CCS patients (68%) and ACS patients (65%). Likewise, there were no significant differences in angiographic success after IVL between CCS and ACS patients. The rate of MACE at 30 days (primary safety endpoint) was 3% (1% in CCS and 5% in ACS patients [P = 0.073]). CONCLUSIONS: Coronary IVL proved to be a feasible and safe procedure in a "real-life" setting, effectively facilitating stent implantation in severely calcified lesions. Patients with ACS on admission showed similar angiographic success rates but showed a trend toward higher 30-day MACE compared with patients with CCS. (REPLICA-EPIC18 study [Registry of Coronary Lithotripsy in Spain]; NCT04298307).

Perfil clínico y pronóstico de pacientes jóvenes con infarto agudo de miocardio con elevación del segmento ST tratados en la red Codi IAM / Clinical profile and prognosis of young patients with ST-elevation myocardial infarction managed by the emergency-intervention Codi IAM network

Introducción y objetivos: Los datos sobre el perfil clínico y los resultados de los pacientes jóvenes con infarto agudo de miocardio con elevación del segmento ST (SCACEST) son escasos. Este estudio compara las características y los resultados clínicos entre pacientes de edades<45 años y ≥ 45 con IAMCEST atendidos por el sistema catalán Codi IAM. También se analizaron las diferencias por sexo en el grupo de menores de 45 años.Métodos: Entre 2015 y 2020, se incluyó a todos los pacientes ingresados por IAMCEST. Los objetivos primarios fueron la mortalidad por cualquier causa en los primeros 30 días, a 1 año y 2 años.Resultados: Se incluyó a 18.933 pacientes (el 23% mujeres). De ellos, 1.403 (7,4%) eran menores de 45 años. Los pacientes más jóvenes eran más fumadores (p<0,001) y presentaron tasas más altas de muerte súbita y flujo TIMI 0 antes de la ICPp (p<0,05), pero el tiempo desde el primer contacto médico hasta el paso de la guía fue más corto en comparación con el grupo de más edad (p<0,05). Se observaron tasas de mortalidad por cualquier causa más bajas en los pacientes menores de 45 (p<0,001). Con respecto a las diferencias estratificadas por sexo en los pacientes más jóvenes, el shock cardiogénico fue más frecuente en las mujeres que en los varones (p=0,002) y el tiempo desde el inicio de los síntomas hasta la reperfusión fue más largo (p<0,05) en el grupo de las mujeres. En comparación con los varones de menos de 45, las mujeres más jóvenes tenían menos probabilidades de tratarse con ICPp (p=0,004).Conclusiones: Pese a presentar características de alto riesgo al ingreso, los pacientes jóvenes que sufren un IAMCEST tienen mejor pronóstico que sus contrapartes mayores. Se observaron diferencias en los tiempos de isquemia y tratamiento entre varones y mujeres.(AU)

Introduction and objectives: Data on the clinical profile and outcomes of younger patients with ST-elevation myocardial infarction (STEMI) is scarce. This study compared clinical characteristics and outcomes between patients aged<45 years and those aged ≥ 45 years with STEMI managed by the acute myocardial infarction code (AMI Code) network. Sex-based differences in the younger cohort were also analyzed.Methods: This multicenter study collected individual data from the Catalonian AMI Code network. Between 2015 and 2020, we enrolled patients with an admission diagnosis of STEMI. Primary endpoints were all-cause mortality within 30 days, 1 year, and 2 years.Results: Overall, 18 933 patients (23% female) were enrolled. Of them, 1403 participants (7.4%) were aged<45 years. Younger patients with STEMI were more frequently smokers (P<.001) and presented with cardiac arrest and TIMI flow 0 before pPCI (P<.05), but the time from first medical contact to wire crossing was shorter than in the older group (P<.05). All-cause mortality rates were lower in patients aged<45 years (P<.001). Among younger patients, cardiogenic shock was most prevalent in women than in their male counterparts (P=.002), with the time from symptom onset to reperfusion being longer (P<.05). Compared with men aged<45 years, younger women were less likely to undergo pPCI (P=.004).Conclusions: Despite showing high-risk features on admission, young patients exhibit better outcomes than older patients. Differences in ischemia times and treatment were observed between men and women.(AU)

Impact of left atrial appendage closure in patients on anticoagulation for atrial fibrillation and recurrent or chronic gastrointestinal bleeding / Impacto del cierre de la orejuela izquierda en pacientes anticoagulados por fibrilación auricular y con sangrado gastrointestinal recurrente o crónico

Background: Oral anticoagulation in non-valvular atrial fibrillation is associated with an increased risk of bleeding, particularly gastrointestinal bleeding, leading to treatment withdrawal in up to 50% of patients and putting them at risk of embolic events. Left atrial appendage closure (LAAC) can be an alternative to chronic anticoagulation. We aim to describe the impact of LAAC in patients with gastrointestinal bleeding (GIB) or chronic iron deficiency anaemia (CIDA) on healthcare resources consumption. Methods: Observational retrospective study of patients who underwent LAAC for GIB or CIDA at a single centre. Results: Nineteen patients with a median age of 74 years and a median Charlson score of six points were included in the study. Angiodysplasias were the most frequent cause of GIB or CIDA. The procedural success rate of LAAC was 100% with a median anticoagulant and antiplatelet treatment duration of 92 days. One year after the LAAC, we found a significant improvement in the lowest haemoglobin concentration and a reduction in the number of red blood cells transfusion, hospital admissions due to GIB and CIDA and the number of endoscopic examinations. One patient died due to a pulmonary thromboembolism. No deaths related to GIB were observed. Conclusions: LAAC seems to be a safe and effective alternative to anticoagulation in patients with GIB or CIDA. (AU)

Introducción: La anticoagulación oral en la fibrilación auricular no valvular se asocia a un incremento del riesgo de sangrado, especialmente gastrointestinal, lo que conlleva la retirada del tratamiento hasta en el 50% de los pacientes e implica un mayor riesgo de padecer un evento embólico. El cierre de la orejuela izquierda (COI) puede ser una alternativa a la anticoagulación crónica. Nuestro objetivo es describir el impacto del COI en pacientes con sangrado gastrointestinal (SGI) o anemia crónica ferropénica (ACF) en el consumo de recursos sanitarios. Métodos: Estudio observacional retrospectivo de pacientes sometidos a COI por SGI o ACF. Resultados: Diecinueve pacientes con una mediana de edad de 74años y una mediana del índice de Charlson de 6puntos fueron incluidos en el estudio. Las angiodisplasias fueron la causa más frecuente de SGI o ACF. La tasa de éxito técnico del COI fue del 100%, con una duración mediana del tratamiento anticoagulante y antiagregante de 92días. Tras un año del COI, se observó una mejoría significativa del valor mínimo de hemoglobina, así como una reducción en el número de transfusiones de concentrados de hematíes, en la necesidad de hospitalización por SGI o ACF y en el número de endoscopias. Un paciente falleció debido a un tromboembolismo pulmonar. Ningún paciente falleció por SGI. Conclusiones: El COI parece una alternativa segura y efectiva a la anticoagulación en pacientes con SGI o ACF. (AU)

Análisis de una red de atención al IAMCEST: impacto pronóstico del tipo de primer contacto médico / Performance analysis of a STEMI network: prognostic impact of the type of first medical contact facility

Introducción y objetivos: El tipo de primer contacto médico (PCM) en una red de angioplastia (ICPP) para el infarto con elevación del ST (IAMCEST) se asocia con diferentes grados de demora hasta ICPP y podría condicionar el pronóstico. Métodos: Registro de IAMCEST tratados con ICPP (2010-2020) en la red Codi Infart. Analizamos la mortalidad al año por cualquier causa según el tipo de PCM: servicio de emergencias médicas (SEM), hospital comarcal (HC), hospital de angioplastia (H-ICP) y centro de atención primaria (CAP). Resultados: Incluimos 18.332 pacientes (SEM 34,3%; HC 33,5%; H-ICP 12,3%; CAP 20,0%). La proporción de clases Killip III-IV fue: SEM 8,43%, HC 5,54%, H-ICP 7,51%, CAP 3,76% (p <0.001). Comorbilidades y complicaciones en el PCM fueron más frecuentes en los grupos SEM y H-ICP (p <0.05), y menores en el grupo CAP. El grupo H-ICP obtuvo el mejor tiempo PCM-ICPP (mediana 82 min); el grupo SEM consiguió el menor tiempo total de isquemia (mediana 151 min); el grupo HC obtuvo los mayores retrasos (p <0.001). En un modelo de regresión logística ajustado, los grupos H-ICP y HC se asociaron con mayor mortalidad, OR=1,22 (IC95% 1,00-1,48; p=0.048) y OR=1,17 (IC95% 1,02-1,36; p=0,030) respectivamente, y el grupo CAP con menor mortalidad que el grupo SEM, OR=0,71 (IC95% 0,58-0,86; p <0.001). Conclusiones: El PCM con H-ICP y HC se asoció con mayor mortalidad ajustada a 1 año en comparación con el SEM. El grupo CAP se asoció con mejor pronóstico a pesar de reperfusiones más tardías.(AU)

Introduction and objectives: Prognosis in ST-elevation myocardial infarction (STEMI) is determined by delay in primary percutaneous coronary intervention (PPCI). The impact of first medical contact (FMC) facility type on reperfusion delays and mortality remains controversial. Methods: We performed a prospective registry of primary coronary intervention (PCI)-treated STEMI patients (2010-2020) in the Codi Infart STEMI network. We analyzed 1-year all-cause mortality depending on the FMC facility type: emergency medical service (EMS), community hospital (CH), PCI hospital (PCI-H), or primary care center (PCC). Results: We included 18 332 patients (EMS 34.3%; CH 33.5%; PCI-H 12.3%; PCC 20.0%). Patients with Killip-Kimball classes III-IV were: EMS 8.43%, CH 5.54%, PCI-H 7.51%, PCC 3.76% (P <.001). All comorbidities and first medical assistance complications were more frequent in the EMS and PCI-H groups (P <.05) and were less frequent in the PCC group (P <.05 for most variables). The PCI-H group had the shortest FMC-to-PCI delay (median 82 minutes); the EMS group achieved the shortest total ischemic time (median 151 minutes); CH had the longest reperfusion delays (P <.001). In an adjusted logistic regression model, the PCI-H and CH groups were associated with higher 1-year mortality, OR, 1.22 (95%CI, 1.00-1.48; P=.048), and OR, 1.17 (95%CI 1.02-1.36; P=.030), respectively, while the PCC group was associated with lower 1-year mortality than the EMS group, OR, 0.71 (95%CI 0.58-0.86; P <.001). Conclusions: FMC with PCI-H and CH was associated with higher adjusted 1-year mortality than FMC with EMS. The PCC group had a much lower intrinsic risk and was associated with better outcomes despite longer revascularization delays.(AU)

Predictores de demora en el intervencionismo coronario percutáneo primario en el infarto de miocardio diagnosticado en hospitales sin hemodinámica / Time from electrocardiographic diagnosis of ST-elevation myocardial infarction to guidewire crossing in patients transferred to a hospital for primary angioplasty: factors associated with delay

Objetivos: Identificar variables predictoras del retraso hasta la angioplastia primaria, en los pacientes con infarto agudo de miocardio con elevación del ST (IAMEST) trasladados desde el medio extrahospitalario o desde hospitales sin hemodinámica. Método: Estudio de cohortes, retrospectivo, realizado entre 2008 y 2018 en un hospital universitario receptor de pacientes con diagnóstico de IAMEST y que requirieron angioplastia primaria. Se realizó un análisis multivariable de regresión logística y lineal para identificar variables predictoras de demora de tiempo de electrocardiograma (ECG) diagnóstico hasta el paso de guía. Resultados: Se incluyeron 1.039 pacientes en el estudio. Doscientos noventa y seis pacientes (28,4%) presentaban tiempos ECG diagnóstico-paso de guía > 120 minutos. Las variables asociadas a tiempos prolongados de angioplastia primaria fueron la edad avanzada [odds ratio (OR) = 1,02; IC 95%: 1,01-1,04] la insuficiencia cardiaca grave al ingreso (OR = 2,28; IC 95%: 1,23-4,22), la cirugía cardiaca previa de bypass (OR = 10,01; IC 95%: 2,60-41,81), la muerte súbita extrahospitalaria recuperada (OR = 4,34; IC 95%: 1,84-10,32), la localización lateral del infarto (OR = 1,64; IC 95%: 1,06-2,51), el primer contacto con hospital sin disponibilidad de hemodinámica (OR = 1,52; IC 95%: 1,05- 2,21), la atención fuera de horas (OR = 1,46; IC 95%: 1,06-2,02) y finalmente la distancia en kilómetros al centro con hemodinámica (OR = 1,04; IC 95%: 1,03-1,05). Conclusiones: En los pacientes con IAMEST que requirieron traslado a un centro con hemodinámica, la demora en la realización de la angioplastia primaria se relacionó con factores clínicos, con características del infarto y logísticas. (AU)

Objective: To identify predictors of primary angioplasty delay in patients with ST-elevation myocardial infarction (STEMI) transported from out-of-hospital sites or from hospitals without percutaneous coronary intervention (PCI) suites. Methods: Retrospective cohort study of cases between 2008 and 2018 in a university hospital receiving patients diagnosed with STEMI who required a PCI. We performed linear and multivariate regression analyses to identify factors that predicted delay in interpreting a diagnostic electrocardiogram (ECG) until the guidewire passed the lesion (diagnosis–guidewire-crossing time). Results: A total of 1039 cases were studied; 296 patients (28.4%) had delays of more than 120 minutes between STEMI diagnosis and guidewire crossing. Factors associated with PCI delay were advanced age (odds ratio [OR] = 1.02; 95% CI, 1.01–1.04]), severe heart failure on admission (OR = 2.28; 95% CI, 1.23–4.22), history of cardiac bypass surgery (OR = 10.01; 95% CI, 2.60–41.81), out-of-hospital cardiac arrest (OR = 4.34; 95% CI, 1.84–10.32), lateral ischemia (OR, 1.64; 95% CI, 1.06–2.51), first medical attention in a hospital without a PCI suite (OR = 1.52; 95% CI, 1.05–2.21), first medical attention outside regular working hours (OR = 1.46; 95% CI, 1.06–2.02), and distance in kilometers to a PCI suite (OR = 1.04; 95% CI, 1.03–1.05). Conclusions: Patients with STEMI who required transport to a hospital with a PCI suite experienced primary angioplasty delays. Delays were related to logistical and clinical factors as well as to infarction characteristics. (AU)

Estratificación basal de riesgo en pacientes mayores de 75 años con infarto y shock cardiogénico referidos para angioplastia primaria / Baseline risk stratification of patients older than 75 years with infarction and cardiogenic shock undergoing primary angioplasty

Introducción y objetivos: Los pacientes mayores de 75 años con infarto agudo de miocardio con elevación del segmento ST sometidos a angioplastia primaria en situación de shock cardiogénico sufren una gran mortalidad. La identificación previa al procedimento de variables predictoras de la posterior mortalidad sería muy útil para guiar la toma de decisiones. Métodos: Análisis del registro multicéntrico de angioplastia primaria en pacientes mayores de 75 años (ESTROFA MI+75), que incluye a 3.576 pacientes. Se analizaron las características y la evolución clínica del subgrupo con shock cardiogénico para identificar predictores de supervivencia a 1 año tras la angioplastia y elaborar un índice pronóstico. Se validó el índice en una cohorte independiente. Resultados: Se incluyó a 332 pacientes. Los predictores basales independientes fueron: la localización anterior (HR=2,8; IC95%, 1,4-6,0; p=0,005), una fracción de eyección<40% (HR=2,3; IC95%, 1,14-4,50; p=0,018) y un tiempo entre el inicio de los síntomas y la angioplastia >6 h (HR=3,2; IC95%, 1,6-7,5; p=0,001). Se diseñó un índice basado en estas variables (índice «6-ANT-40»). La supervivencia a 1 año fue del 54,5% de aquellos con índice 0, el 32,3% con índice 1, el 27,4% con índice 2 y el 17% con índice 3 (p=0,004, estadístico C=0,70). En una cohorte independiente de 124 pacientes, las supervivencias a 1 año fueron del 64,5, el 40,0, el 28,9 y el 22,2% respectivamente (p=0,008; estadístico C=0,68). Conclusiones: Un índice basado en simples variables clínicas previas al procedimiento (localización anterior, fracción de eyección<40%, demora >6 h) permite estimar la supervivencia tras una angioplastia primaria de los pacientes mayores con shock cardiogénico, y así ayudar en la toma de decisiones

Background and objectives: Patients older than 75 years with ST-segment elevation myocardial infarction undergoing primary angioplasty in cardiogenic shock have high mortality. Identification of preprocedural predictors of short- and long-term mortality could be useful to guide decision-making and further interventions. Methods: We analyzed a nationwide registry of primary angioplasty in the elderly (ESTROFA MI+75) comprising 3576 patients. The characteristics and outcomes of the subgroup of patients in cardiogenic shock were analyzed to identify associated factors and prognostic predictors in order to derive a baseline risk prediction score for 1-year mortality. The score was validated in an independent cohort. Results: A total of 332 patients were included. Baseline independent predictors of mortality were anterior myocardial infarction (HR 2.8, 95%CI, 1.4-6.0; P=.005), ejection fraction<40% (HR 2.3, 95%CI, 1.14-4.50; P=.018), and time from symptom onset to angioplasty >6hours (HR 3.2, 95%CI, 1.6-7.5; P=.001). A score was designed that included these predictive factors (score "6-ANT-40"). Survival at 1 year was 54.5% for patients with score 0, 32.3% for score 1, 27.4% for score 2 and 17% for score 3 (P=.004, c-statistic 0.70). The score was validated in an independent cohort of 124 patients, showing 1-year survival rates of 64.5%, 40.0%, 28.9%, and 22.2%, respectively (P=.008, c-statistic 0.68). Conclusions: A preprocedural score based on 3 simple clinical variables (anterior location, ejection fraction<40%, and delay time >6 hours) may be used to estimate survival after primary angioplasty in elderly patients with cardiogenic shock and to guide preinterventional decision-making

Angioplastia primaria en mayores de 75 años. Perfil de pacientes y procedimientos, resultados y predictores pronósticos en el registro ESTROFA IM + 75 / Primary angioplasty in patients older than 75 years. profile of patients and procedures, outcomes, and predictors of prognosis in the ESTROFA IM + 75 registry

Introducción y objetivos: La proporción de pacientes de edad avanzada que se someten a angioplastia primaria está creciendo. Este estudio describe el perfil clínico, las características de los procedimientos, la evolución y los predictores pronósticos. Métodos: Registro en 31 centros de pacientes consecutivos mayores de 75 años tratados con angioplastia primaria. Se recogieron variables clínicas y del procedimiento y se efectuó seguimiento clínico. Resultados: Se incluyó a 3.576 pacientes (el 39,3% mujeres, el 48,5% con insuficiencia renal, el 11,5% en Killip III o IV y el 29,8% con más de 6 h de dolor). El 55,4% presentaba enfermedad multivaso y al 24,8% se les trató además lesiones no culpables. Se utilizó vía radial en el 56,4%, bivalirudina en el 11,8%, aspiración de trombo en el 55,9% y stents farmacoactivos en el 26,6%. La incidencia de muerte cardiaca al mes era del 10,1% y a los 2 años, del 14,7%. A los 2 años la trombosis definitiva o probable era del 3,1%; la revascularización de lesión tratada, del 2,3% y las hemorragias BARC > 2, del 4,2%. Los predictores pronósticos fueron: diabetes mellitus, insuficiencia renal, fibrilación auricular, retraso > 6 h, fracción de eyección < 45%, clase Killip III-IV, vía radial, bivalirudina, stents farmacoactivos, flujo final TIMI III y revascularización incompleta al alta. Conclusiones: En este registro destaca el frecuente retraso en la presentación y la alta prevalencia de factores adversos como la insuficiencia renal o la enfermedad multivaso. Se identificaron como factores protectores relacionados con el procedimiento el menor retraso, el uso de vía radial, la bivalirudina, los stents farmacoactivos y la revascularización completa antes del alta (AU)

Introduction and objectives: The proportion of elderly patients undergoing primary angioplasty is growing. The present study describes the clinical profile, procedural characteristics, outcomes, and predictors of outcome. Methods: A 31-center registry of consecutive patients older than 75 years treated with primary angioplasty. Clinical and procedural data were collected, and the patients underwent clinical follow-up. Results: The study included 3576 patients (39.3% women, 48.5% with renal failure, 11.5% in Killip III or IV, and 29.8% with > 6 hours of chest pain). Multivessel disease was present in 55.4% and nonculprit lesions were additionally treated in 24.8%. Radial access was used in 56.4%, bivalirudin in 11.8%, thromboaspiration in 55.9%, and drug-eluting stents in 26.6%. The 1-month and 2-year incidences of cardiovascular death were 10.1% and 14.7%, respectively. The 2-year rates of definite or probable thrombosis, repeat revascularization, and BARC bleeding > 2 were 3.1%, 2.3%, and 4.2%, respectively. Predictive factors were diabetes mellitus, renal failure, atrial fibrillation, delay to reperfusion > 6 hours, ejection fraction < 45%, Killip class III-IV, radial access, bivalirudin, drug-eluting stents, final TIMI flow of III, and incomplete revascularization at discharge. Conclusions: Notable registry findings include frequently delayed presentation and a high prevalence of adverse factors such as renal failure and multivessel disease. Positive procedure-related predictors include shorter delay, use of radial access, bivalirudin, drug-eluting stents, and complete revascularization before discharge (AU)

Variabilidad interhospitalaria en la prescripción tras un síndrome coronario agudo: hallazgos del estudio ACDC / Interhospital variability in drug prescription after acute coronary syndrome: insights from the acdc study

Introducción y objetivos: Analizar la tasa de pacientes ingresados por síndrome coronario agudo que recibieron al alta conjuntamente ácido acetilsalicílico, estatinas e inhibidores de la enzima de conversión de la angiotensina, la variabilidad entre hospitales en dicha prescripción y el pronóstico asociado a esta. Métodos: Se estimó la variabilidad entre hospitales en la prescripción con el coeficiente de correlación intraclase y la odds ratio mediana ajustada (análisis jerárquico). El riesgo de muerte o infarto a 2 años se estimó mediante modelos de Cox. Resultados: De un total de 917 pacientes, 489 (53,3%) tenían prescritos los 3 fármacos, sin apenas variación entre hipertensos y diabéticos (56,8%). Se observó una alta variabilidad entre centros en la prescripción (23-77% de los pacientes). La hipertensión (odds ratio = 1,93; intervalo de confianza del 95%, 1,42-2,61), la fracción de eyección < 45% (odds ratio = 2,2; intervalo de confianza del 95%, 1,44-3,37), la inclusión en el ensayo clínico (odds ratio = 1,89; intervalo de confianza del 95%, 1,24-2,88) y la insuficiencia renal (odds ratio = 0,53; intervalo de confianza del 95%, 0,29-0,94) se asociaron con la prescripción. En el análisis ajustado persistió una variabilidad residual (coeficiente de correlación intraclase 0,046 [intervalo de credibilidad del 95%, 0,007 a 0,192]; odds ratio mediana =1,46 [intervalo credibilidad del 95%, 1,16-2,32]). No se verificó un mayor riesgo de eventos durante el seguimiento (hazard ratio = 0,81; intervalo de confianza del 95%, 0,55-1,18; p = 0,27). Conclusiones: Tras un síndrome coronario agudo, en casi la mitad de los pacientes no se prescribieron los tres fármacos al alta. La prescripción fue variable entre centros y posiblemente relacionada con hábitos asistenciales diferentes (AU)

Introduction and objectives: To analyze the rate of patients admitted for acute coronary syndrome who concomitantly received acetylsalicylic acid, statins, and angiotensin-converting enzyme inhibitors at discharge, and to analyze interhospital variability in the prescription of these drugs and its potential prognostic impact. Methods: Interhospital variability in drug prescription was estimated using the intraclass correlation coefficient and median odds ratio (hierarchical analysis). Cox regression analysis was used to estimate the risk of death or myocardial infarction associated with prescription of all 3 agents at 2-years of follow-up. Results: In total, 489 (53.3%) of 917 patients were prescribed all 3 agents. The rate was similar in patients with hypertension and diabetes (56.8%). There was significant variability among centers in the prescription of the 3 drugs at discharge (from 23% to 77% of patients). Hypertension (odds ratio = 1.93; 95% confidence interval, 1.42-2.61), ejection fraction < 45% (odds ratio = 2.2; 95% confidence interval, 1.44-3.37), being in a clinical trial (odds ratio = 1.89; 95% confidence interval, 1.24-2.88), and renal failure (odds ratio = 0.53; 95% confidence interval, 0.29-0.94) were associated with prescription of the 3 drugs. After adjustment for these factors, residual variability persisted (intraclass correlation coefficient 0.046 [95% credibility interval, 0.007 to 0.192]; median odds ratio = 1.46 [95% credibility interval, 1.16-2.32]). There was no clear association between the prescription of all 3 drugs and the risk of events during follow-up (hazard ratio = 0.81, 95% confidence interval, 0.55-1.18;P = .27). Conclusions: The prescription rate for acetylsalicylic acid, angiotensin-converting enzyme inhibitors, and statins after acute coronary syndrome is suboptimal, varies among centers, and is possibly related to different health care approaches (AU)

Terapia antiplaquetaria doble de 6 o de 12 meses tras implante de stents farmacoactivos de nueva generación: análisis emparejado de los registros ESTROFA-DAPT y ESTROFA-2 / Dual antiplatelet therapy for 6 months vs 12 months after new-generation drug-eluting stent implantation: matched analysis of ESTROFA-DAPT and ESTROFA-2

Introducción y objetivos: El periodo de uso recomendado del tratamiento antiagregante plaquetario combinado doble tras implante de stents farmacoactivos va de los 6 a los 12 meses o más. Ensayos recientes indican que es seguro utilizar un tratamiento antiagregante plaquetario combinado doble durante 6 meses, si bien ciertas limitaciones de estos estudios hacen que sea escasa la aplicabilidad de esta estrategia de tratamiento antiagregante plaquetario combinado doble de menor duración en la práctica clínica real. Métodos: Se puso en marcha un registro con la inscripción de pacientes consecutivos a los que se había implantado stent farmacoactivo de nueva generación seguido de una prescripción de 6 meses de tratamiento antiagregante plaquetario combinado doble. Se realizó una igualación por puntuación de propensión con una cohorte histórica de pacientes tratados con stentsfarmacoactivos de segunda generación que recibieron luego 12 meses de tratamiento antiagregante plaquetario combinado doble del registro ESTROFA-2. El tamaño muestral se calculó para el criterio de no inferioridad y el objetivo principal fue la combinación de muerte cardiaca, infarto de miocardio, revascularización o hemorragia mayor a los 12 meses. Resultados: Se incluyó en el análisis a 1.286 pacientes de cada grupo, que no presentaban diferencias significativas en sus características basales. Se produjeron episodios del objetivo principal en el 5,0 y el 6,6% de los pacientes en los grupos de 6 y de 12 meses respectivamente (p = 0,001 para no inferioridad). La incidencia de trombosis del stent definitiva o probable fue del 0,5 y el 0,7% en los grupos de tratamiento de 6 y 12 meses respectivamente (p = 0,4). Los episodios de hemorragia mayor fueron menos en el grupo de 6 meses que en el de 12 (el 0,8 y el 1,4%; p = 0,2). Conclusiones: En pacientes seleccionados de este amplio estudio multicéntrico, la seguridad y la eficacia de 6 meses de tratamiento antiagregante plaquetario combinado doble después del implante de stents farmacoactivos de nueva generación fueron no inferiores a las observadas con 12 meses de tratamiento antiagregante plaquetario combinado doble (AU)

Introduction and objectives: The recommendation for dual antiplatelet therapy following drug-eluting stent implantation ranges from 6 months to 12 months or beyond. Recent trials have suggested the safety of a 6-month dual antiplatelet therapy regimen, yet certain caveats to these studies limit the applicability of this shorter duration dual antiplatelet therapy strategy in real world settings. Methods: A registry was constructed with consecutive recruitment of patients undergoing new-generation drug-eluting stent implantation and prescribed 6 months of dual antiplatelet therapy. Propensity score matching was undertaken with a historical cohort of patients treated with second-generation drug-eluting stents who received 12 months of dual antiplatelet therapy from the ESTROFA-2 registry. The sample size was calculated using a noninferiority basis and the primary endpoint was the combination of cardiac death, myocardial infarction, revascularization, or major bleeding at 12 months. Results: The analysis included 1286 patients in each group, with no significant differences in baseline characteristics. The primary endpoint occurred in 5.0% and 6.6% in the 6-month and 12-month groups, respectively (P = .001 for noninferiority). The incidence of definite or probable stent thrombosis was 0.5% and 0.7% in the 6-month and 12-month groups, respectively (P = .4). Major bleeding events were lower in the 6-month group than in the 12-month group (0.8% vs 1.4%; P = .2) Conclusions: In selected patients in this large multicenter study, the safety and efficacy of a 6-month dual antiplatelet therapy regimen after implantation of new-generation drug-eluting stents appeared to be noninferior to those of a 12-month dual antiplatelet therapy regimen (AU)

¿Los trastornos por cocaína asociados al infarto agudo de miocardio son lo mismo que el infarto de miocardio asociado al consumo reciente de cocaína? / Is cocaine-associated acute myocardial infarction the same as myocardial infarction associated with recent cocaine consumption?

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Análisis de los tiempos de atención en pacientes con infarto agudo de miocardio tratados con angioplastia primaria según su procedencia y según el horario de realización del procedimiento / Analysis of reperfusion delay in patients with acute myocardial infarction treated with primary angioplasty based on first medical contact and time of presentation

Introducción y objetivos. En la angioplastia primaria se recomienda un tiempo inferior a 120 min entre el primer contacto médico (PCM) y la reperfusión. El retraso hasta la reperfusión varía según dónde se realice el PCM. Estudios recientes señalan peores tiempos en horario de guardia. El objetivo es el análisis de distintos intervalos de tiempo hasta la reperfusión según dónde se produce el PCM y el horario de presentación. Métodos. Estudio prospectivo observacional de pacientes con infarto tratados con angioplastia primaria (febrero de 2007-mayo de 2009). Según el PCM, se diferenció: grupo Hospital (hospital con angioplastia primaria), grupo Traslado (hospital sin angioplastia primaria) y grupo SEM (sistema de emergencias médicas, atención extrahospitalaria). Para cada grupo se registró: retraso prehospitalario, retraso diagnóstico, retraso en activación y/o traslado y retraso en el procedimiento. Resultados. Se realizó angioplastia primaria a 457 pacientes, 155 en el grupo Hospital, 228 en el grupo Traslado y 72 en el grupo SEM. Las medianas [intervalo intercuartílico] del tiempo PCM-reperfusión fueron 80 [63-107], 148 [118-189] y 81 [66-98] min respectivamente (p<0,0001). El grupo Traslado presentó mayor retraso diagnóstico (p<0,0001) y retraso en activación y/o traslado (p<0,0001). El grupo SEM presentó el tiempo total más corto por tener un retraso prehospitalario menor (p=0,001). No se encontró diferencia según el horario de realización (p=0,42). Conclusiones. A los pacientes del grupo Traslado se los reperfundió más tardíamente y a los del grupo SEM, más precozmente. No hubo diferencias según el horario. La identificación de demoras injustificadas debe permitir adoptar medidas que mejoren la eficiencia del tratamiento (AU)

Introduction and objectives. In primary angioplasty, the interval between first medical contact (FMC) and reperfusion should be less than 120minutes. The time to reperfusion varies depending on where FMC is established. Recent studies suggest longer times in patients presenting in off-hours. The objective is to evaluate the time intervals between the onset of symptoms and reperfusion according to where the FMC occurs and time of day of patient presentation. Methods. Prospective observational study of acute myocardial infarction patients treated with primary angioplasty (February 2007 to May 2009). Depending on the FMC, patients were classified as belonging to the hospital group (hospital with primary angioplasty), the transfer group (hospital without primary angioplasty), or the emergency medical system (EMS) group (out-of-hospital care). For each group, the prehospital delay, diagnostic delay, delay in activation and/or transfer, and procedure delay were recorded. Results. Primary angioplasty was performed in 457 patients: 155 in the hospital group, 228 in the transfer group and 72 in the EMS group. The median [interquartile range] door-to-reperfusion times were 80 [63-107], 148 [118-189] and 81 [66-98] minutes, respectively (P <.0001). The transfer group showed a greater delay in diagnosis (P <.0001) and delayed activation and/or transfer (P <.0001). The EMS group had the shortest total time due to a reduced prehospital delay (P =.001). No difference was found with regard to the time of presentation (P =.42). Conclusions. Transfer group patients were treated later and EMS group patients much earlier. There were no differences in association with the time of presentation. The identification of inappropriate delays should enable the introduction of measures to improve the efficiency of treatment (AU)

Consumo de cocaína en el síndrome coronario agudo / Cocaine use in acute coronary syndrome

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Psychometric properties of the school fears survey scale for preadolescents (SFSS-II) / Propiedades psicométricas del Inventario de Miedos Escolares para Preadolescentes (SFSS-II)

This paper describes the psychometric properties of a new children’s self-report measure. The School Fears Survey Scale, Form II (SFSS-II) assesses school fears in children from ages 8 to 11. The factor solution with a Spanish sample of 3,665 children isolated four factors: Fear of academic failure and punishment, fear of physical discomfort, fear of social and school assessment and anticipatory and separation anxiety. The questionnaire was tested by confirmatory factor analysis, which accounted for 55.80% of the total variance. Results indicated that the SFSS-II has a high internal consistency (a= .89). The results revealed high test-retest reliability and appropriate relationship with other scales. The age by gender interaction was significant. Two-way analysis of variance found that older children and girls had higher anxiety. The instrument shows adequate psychometric guarantees and can be used for the multidimensional assessment of anxiety in clinical and educational settings(AU)

En este trabajo se describen las propiedades psicométricas de un nuevo autoinforme de evaluación infantil. El Inventario de Miedos Escolares, Forma II (SFSS-II), evalúa los temores relacionados con la escuela en niños de 8 a 11 años. La solución factorial con una muestra española de 3.665 niños aisló cuatro factores: miedo al fracaso escolar y al castigo, miedo al malestar físico, miedo a la evaluación social y escolar y ansiedad anticipatoria y de separación. El cuestionario fue probado mediante análisis factorial confirmatorio, explicando el 55.80% de la varianza. Los resultados indican que el SFSS-II tiene una alta consistencia interna (a= .89), una elevada fiabilidad test-retest y relación adecuada con otras escalas. La interacción entre la edad y el sexo fue significativa. Los análisis de varianza mostraron que los niños de más edad y las niñas tienen mayores niveles de ansiedad. El instrumento presenta adecuadas garantías psicométricas y puede ser utilizado para la evaluación multidimensional de la ansiedad escolar en el ámbito clínico y educativo(AU)

Cirugía de reparación valvular mitral en la rotura traumática del músculo papilar anterolateral / No disponible

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