Factores pronósticos de mortalidad en pacientes con enfermedad pulmonar obstructiva crónica tras su ingreso en una Unidad de Medicina Intensiva. El papel de la calidad de vida / Mortality prognostic factors in patients with chronic obstructive pulmonary disease after their admission in an Intensive Care Unit The role of quality of life

Objetivo. Analizar la asociación entre calidad de vida y mortalidad de los pacientes con enfermedad pulmonar obstructiva crónica (EPOC) ingresados en una Unidad de Medicina Intensiva (UMI) y las modificaciones de la calidad de vida a los 6 meses del alta. Diseño. Estudio de cohortes prospectivo de dos años con seguimiento durante un año tras el alta hospitalaria. Ámbito. Una Unidad de Medicina Intensiva. Pacientes. Pacientes con EPOC que ingresan por insuficiencia respiratoria aguda.Intervenciones. Se realizó una encuesta de calidad de vida al ingreso y a los 6 meses del alta. Variables de interés principales. Calidad de vida medida mediante una encuesta validada para enfermos críticos (PAEEC). Mortalidad en UMI, en hospital, a los 6 meses y al año. Resultados. Se incluyeron 91 pacientes. La mortalidad hospitalaria fue del 25,3%, a los 6 meses del 37,4% y al año del 45,5%. El análisis multivariante mostró que la mortalidad hospitalaria se asociaba con APACHE II > 18 (odds ratio 3,7; IC 95%: 1,1-12,2), calidad de vida previa al ingreso > 6 puntos (odds ratio 7,1; IC 95%: 2,1-24,1), y edad > 70 años (odds ratio 4,3; IC 95%: 1,3-14,2). A los 6 meses y al año sólo se asocia de forma independiente con la mortalidad la calidad de vida previa al ingreso. A los 6 meses, la calidad de vida de los supervivientes empeoraba de manera global (8,02 ± 4,85 frente a 5,57 ± 3,39, p = 0,001), así como en las actividades fisiológicas básicas, las actividades de la vida diaria y el estado emocional. Conclusiones. La calidad de vida previa se asocia a la mortalidad hospitalaria, a los 6 meses y al año del alta. La mitad de los pacientes sobrevive al año y son autónomos para sus necesidades básicas

Objective. To analyze the association between quality of life and mortality in patients with chronic obstructive pulmonary disease (COPD) cared in an Intensive Care Unit (ICU), and to determine the modifications of the quality of life at 6 months of discharge. Design. Prospective cohort study with 2 years duration and 1 year follow-up after hospital discharge. Context. An Intensive Care Unit. Patients. Patients with COPD admitted because of respiratory insufficiency. Interventions. A survey of quality of life was conducted at admission and at 6 months of discharge. Primary endpoints. Quality of life measured through a survey validated for critically ill patients (PAEEC). Mortality in ICU, in hospital, at 6 months, and per year. Results. Ninety one patients were included. Hospital mortality was 25.3%, at 6 months was 37.4%, and annual mortality 45.5%. Multivariate analysis showed that hospital mortality was associated with APACHE II scoring > 18 (odds ratio 3.7; CI 95%: 1.1-12.2), quality of life prior to admission > 6 points (odds ratio 7.1; CI 95%: 2.1-24.1), and age > 70 years (odds ratio 4.3; CI 95%: 1.3-14.2). At 6 months and annually only quality of life is independently associated with mortality prior to admission. At 6 months, the quality of life of survivors worsened globally (8.02 ± 4.85 versus 5.57 ± 3.39, p = 0.001), as well as in with regard to basic physiological activities, daily life activities, and emotional stress. Conclusions. Previous quality of life is associated with hospital mortality, with mortality at 6 months after discharge, and with mortality at 1 year after discharge. Half of patients survive at 1 year and can carry out autonomously their daily life activities

Factores asociados al uso de la reperfusión en pacientes con infarto agudo de miocardio y elevación del segmento ST en España: Proyecto de Registro del Infarto Agudo de Miocardio en Hospitales (PRIAMHO II) / Factors associated with the use of reperfusion therapy in patients with acute myocardial infarction and st segment elevation in spain: the register of acute myocardial infarction in hospitals project (priamho ii)

Objetivo. Un porcentaje cercano al 30 por ciento de los pacientes con síndrome coronario agudo, elevación del segmento ST en el electrocardiograma (ECG) y menos de 12 h de evolución, no recibe tratamiento de reperfusión. En este estudio, se investigan los factores asociados a ese comportamiento y su influencia en la evolución hasta un año. Material y método. El registro PRIAMHO II fue diseñado como un estudio de cohorte, con seguimiento a un año, de pacientes ingresados por infarto agudo de miocardio (IAM) en un período de 6 meses, en el año 2000, en las unidades de cuidados intensivos cardiológicos (UCIC) de 58 hospitales españoles seleccionados de manera aleatoria. Se analizaron las características demográficas y clínicas, la evolución y la mortalidad, a los 28 días y al año, de los pacientes tratados con y sin reperfusión. Resultados. Se incluyeron 6.221 pacientes entre el 15 de mayo y el 15 de diciembre de 2000, ingresados en 58 hospitales. De ellos, 3.735 cumplían las indicaciones para reperfusión primaria, pero sólo se realizó en 2.675 (71,6 por ciento). En el 89,3 por ciento de los casos se hizo fibrinólisis y en el resto intervención percutánea. El análisis univariante mostró que las variables asociadas a no recibir tratamiento de reperfusión son: la edad avanzada, el sexo femenino, los antecedentes de diabetes mellitus, de hipertensión arterial o de infarto de miocardio, el retraso en la llegada al hospital, el no poder precisar la localización del IAM por el ECG y la clase IV en la clasificación de Killip. La mortalidad fue superior en los pacientes no reperfundidos, tanto la mortalidad hospitalaria (17,4 frente a 10,3 por ciento), como al año (23,8 frente a 12,9 por ciento). En el 1,2 por ciento de los pacientes que recibieron fibrinolíticos apareció un accidente cerebrovascular. Conclusiones. Los resultados muestran que sólo un 72 por ciento de los pacientes con IAM y ST elevado o bloqueo completo de la rama izquierda del haz de His (BCRIHH) que acuden al hospital con menos de 12 h de evolución, reciben tratamiento de reperfusión. De ellos, un 11 por ciento lo reciben mediante intervencionismo percutáneo. Los pacientes que no son tratados con métodos de reperfusión tienen un perfil de riesgo peor, y la mortalidad es superior a corto y, especialmente, a largo plazo (AU)

[Management of myocardial infarction in Spain (1995-99). Data from the registry of the Ischaemic Heart Disease Working Group (RISCI) of the Spanish Society of Cardiology]. / Manejo del infarto de miiocardio en España (1995-99). Datos del registro de infartos de la sección de cardiopatía Isquémica y unidades coronarias (RISCI) de la Sociedad Española de Cardiología.

INTRODUCTION AND OBJECTIVES: Limited information is available on how patients with myocardial infarction are treated in Spain. In order to make up for this deficiency, in October 1994, the Ischaemic Heart Disease Working Group of the Spanish Society of Cardiology initiated a myocardial infarction registry, which is currently active. METHODS: Patients are recruited from hospitals with intensive coronary care facilities. Demographic characteristics coronary risk factors and previous conditions are collected, as well as clinical events, and diagnostic and therapeutic procedures performed during the stay in the coronary care unit. RESULTS: From 1995 to 1999, 28,357 patients were registered. During this period the mean age increased slightly (from 64.4 +/- 12.2 to 65.2 +/- 12.7; p < 0.001), although the male proportion remained stable (from 76.7% to 77.1%). The median "onset of symptoms-hospital arrival for 1st emergency" time fell from 135 min to 120 min, and the median "onset of symptoms-needle" time from 180 to 175 (NS). The use of thrombolytic therapy did not change (from 42.4 to 43.9%), but the use of aspirin (from 87.4 to 91.7%), beta-blockers (from 32.7 to 39.6%) and angiotensin-converting inhibitors (from 27.9 to 34.8%) increased significantly (p < 0.001). The Swan-Ganz catheter and the intra-aortic balloon counterpulsation were rarely placed during the five years (4.2% and 1.2% respectively in 1999). Both early mortality (11.4 to 9.3%) and the median duration of intensive coronary care stay declined, in these 5 years. CONCLUSIONS: In Spain, during the 1995-1999 period, the use of aspirin, beta-blockers, and angiotensin-converting inhibitors increased significantly during the acute phase of infarction in the coronary care unit. However, both the usage of thrombolytic therapy and the delay between the onset of symptoms and therapy initiation remained unchanged. At the same time, the length of stay in the coronary care unit and early mortality declined, although the clinical profile of the patients did not improve.

Utilización del ácido acetilsalicílico en pacientes con cardiopatía isquémica atendidos en los servicios de urgencias españoles (resultados del estudio EVICURE) / Use of acetil salicilic acid in patients affected of ischemic cardiomiopathy attender in the emergency services of Spain (results of Evicure study)

Fundamento: El ácido acetilsalicílico es un fármaco de eficacia demostrada en pacientes con cardiopatía isquémica. El objetivo de nuestro estudio fue conocer la utilización de este fármaco en los servicios de urgencias de España. Pacientes y métodos: Se utilizaron los datos correspondientes al estudio EVICURE analizando el uso de la aspirina en 35 servicios de urgencias de hospitales españoles. Resultados: Se estudiaron 2.168 pacientes que consultaron por cardiopatía isquémica. De los 473 pacientes con angina estable, un 9,2 por ciento recibieron ácido acetilsalicílico antes de acudir al hospital y un 90,7 por ciento en el hospital. De los 1.067 pacientes con angina inestable, sólo un 13 por ciento recibieron ácido acetilsalicílico antes de acudir al hospital y un 56 por ciento a su llegada al hospital. De los 600 pacientes con infarto agudo de miocardio, sólo un 17,6 por ciento recibieron ácido acetilsalicílico antes de acudir al hospital y un 59,8 por ciento en el servicio de urgencias. Conclusiones: La utilización de ácido acetilsalicílico en pacientes con cardiopatía isquémica atendidos en los servicios de urgencias extrahospitalarios y hospitalarios es inadecuadamente baja. (AU)

[Clinical practice guidelines of the Spanish Society of Cardiology on unstable angina/infarction without ST elevation]. / Guías de práctica clínica de la Sociedad Española de Cardiología en la angina inestable/infarto sin elevación ST.

This paper up-dates the Clinical Guidelines for Unstable Angina/Non Q wave Myocardial Infarction of the Spanish Society of Cardiology. Due to the increased efficacy of adequate management in the early phases, it has been considered necessary to include recommendations for the pre Hospital and Emergency department phase. Prehospital management. Patients with thoracic pain compatible with myocardial ischemia should be transferred to Hospital as quickly as possible and an ECG tracing performed. Initial management includes rest, sublingual nitroglycerin and aspirin. In the Emergency department. Immediate clinical attention and accessibility to a defibrillator should be available. If ECG tracing discloses ST elevation reperfusion strategy is to be implemented immediately. If no ST elevation is present, the probability of myocardial ischemia and risk factor evaluation is essential for adequate management. A simplified risk stratification classification is presented, that also determines the most adequate site for admission: Coronary Care Unit if high risk factors are present, Cardiology ward for the intermediate risk patient and ambulatory treatment if low risk. Management in Coronary Care Unit. Includes routine ECG monitoring and analgesia. Antithrombotic and anti ischemic treatment include new indication for GP IIb-IIIa and Low molecular weight heparins. Coronary arteriography and revascularisation are recommended, if refractory or recurrent angina, left ventricles dysfunction or other complications are present. Management in the ward is based on adequate chronic medical treatment, risk stratification, and secondary prevention strategy. Coronary arteriography before discharge must be considered in the light of the result of non-invasive tests.

La cardiopatía isquémica en los servicios de urgencia hospitalarios. Proyecto EVICURE / Coronary heart disease in the hospital emergency service. EVICURE Project

La Cardiopatía Isquémica (CI) supone una importante carga asistencial en los Servicios de Urgencias hospitalarios (SUH). La carga asistencial viene definida por el número de casos, las características de los mismos, las medidas asistenciales aplicadas y el tiempo de permanencia en el servicio de urgencias. Objetivo: La cuantificación de las variables que identifican la carga asistencial. Diseño: Estudio prospectivo multicéntrico de corte transversal. Métodos: Registro de todos los casos con diagnóstico final de CI atendidos en los servicios de urgencias de 35 hospitales españoles durante tres semanas. Se consideran variables de interés, clasificación y destino de los distintos tipos de CI atendidos; tiempo de permanencia en el servicio de urgencia. Maniobras terapéuticas y asistenciales realizadas. Se utiliza el Therapeutic Intervention Score (TISS) para cuantificar la carga asistencial. Resultados: Se registraron un total de 2216 casos de CI durante el estudio. La proporción de casos de CI sobre visitas a urgencia fue de 1,3 por ciento (1,1-1,5 IC al 95 por ciento). El 48,1 por ciento corresponde a Angina Inestable (AI) y el 27,1 por ciento a Infarto Agudo de Miocardio (IAM), de los cuales sólo el 49,7 por ciento ingresan directamente en las Unidades Coronarias (UCs); el resto lo hace tras un período de observación. La mortalidad del IAM en el SUH fue del 2,5 por ciento. Solamente ingresan el 19,8 por ciento de las AI en las UCs. El tiempo de permanencia en el servicio de urgencia de los IAM fue de 100 min. de media y 32 min. de mediana, para los que ingresan directamente en las UCs. De 540 min. de media y 305 min. de mediana para los que ingresan en UCs tras un período de observación en urgencias. El 35,2 por ciento de los pacientes tiene un TISS > de 9. Conclusiones: La CI constituye el 1,3 por ciento de las visitas a los SUH de nuestro país. Solamente el 49,7 por ciento de los IAM ingresan directamente en las UCs; el resto lo hace tras un período de observación produciendo una importante carga asistencial. La mortalidad del 2,5 por ciento para el IAM durante su estancia en el SU es muy elevada y es preciso tenerla en cuenta para no infraestimar la mortalidad hospitalaria del IAM. Los hospitales con más de 300 visitas día tendrán permanentemente un paciente con Síndrome Coronario Agudo (SCA) que requiera cuidados a nivel de UCs (AU)

[The use of acetylsalicylic acid in patients with ischemic cardiomyopathy cared for in Spanish emergency services (results of the EVICURE Study). Evaluacion del Manejo de la cardiopatia isquemica en los Servicios de Urgencias Hospitalarios of the Sociedad Espanola de Medicina de Urgencias y Emergencias (SEMES)]. / Utilizacin del cido acetilsaliclico en pacientes con cardiopata isquemica atendidos en los servicios de urgencias espaoles (resultados del estudio EVICURE).

BACKGROUND: Acetyl salicylic acid is a drug with demonstrated effectiveness in ischemic cardiomyopathy. The objective of our study was to know the use of this drug in the emergency services of Spain. PATIENTS AND METHOD: The EVICURE study analyzes the use of acetyl salicylic acid in 35 emergency services of Spanish hospitals. RESULTS: 2,168 patients were studied. Of the 473 patients with stable angina, 9.2% received acetyl salicylic acid before going to the hospital and 90,7% at the arrival to the hospital, of 1,067 with unstable angina 13% received acetyl salicylic acid before the arrival to the hospital and 56% at the arrival to the hospital. Of 600 patients affected of myocardial infarction only 17% received acetyl salicylic acid before the arrival to the hospital and 59.8% received this drug in the emergency room. CONCLUSIONS: The use of acetyl salicylic acid in patients affected of ischemic cardiopathy assisted in the emergency services of Spain is improperly low.

[The clinical management guidelines of the Sociedad Española de Cardiología in acute myocardial infarct]. / Guías de actuación clínica de la Sociedad Española de Cardiología en el infarto agudo de miocardio.

In the recent years, new possibilities have emerged in the diagnosis and management of acute myocardial infarction with ST segment elevation and its complications. Moreover, a deep transformation has taken place in the health care system organization, particularly in aspects related to care of patients presenting non-traumatic chest pain, both in pre-hospital and hospital areas. All these issues warrant a consensus document in Spain dealing with the role that these important changes should play in the whole management of myocardial infarction patients. This document revises and updates all the main clinical issues of acute myocardial infarction patients from the moment they contact with the health care system outside the hospital until they return home, after staying at the coronary care unit and the general hospitalization ward. All those aspects are considered not only in the uncomplicated myocardial infarction but also in the complicated one. This review also includes a set of recommendations on structural and organisational aspects, mainly referred to the prehospital and emergency levels.

[Variability in the management and prognosis at short- and medium-term of myocardial infarct in Spain: the PRIAMHO study. Registration Project of Hospital Acute Myocardial Infarct]. / Variabilidad en el manejo y pronóstico a corto y medio plazo del infarto de miocardio en España: el estudio PRIAMHO. Proyecto de Registro de Infarto Agudo de Miocardio Hospitalario.

BACKGROUND AND PURPOSE: The paucity of data on myocardial infarction management and results in Spain lead to the design of the PRIAMHO study (Proyecto de Registro de Infarto Agudo de Miocardio Hospitalario [Acute Myocardial Infarction Hospital Registration Project]) which developed standard methods to collect information on the management of patients with such a condition and their characteristics. The variability results among hospitals in myocardial infarction management and in one-year mortality are presented. METHODS: A cohort study with a one-year follow-up was designed to register all patients diagnosed with acute myocardial infarction discharged from 24 Spanish hospitals that completed all the requisites to participate. The demographic and clinical characteristics of the patients, their management during the coronary care unit stage, and the outcome and complications were prospectively registered. Standard definitions for diagnosis were used. Confidentiality regarding patient identity and participating centers was guaranteed. RESULTS: 5,242 (77.6%) of the 6,756 patients with myocardial infarction admitted in the 24 participating hospitals were registered in the coronary care units. Half of the centers had an on-site hemodynamic laboratory and in seven coronary surgery. The delay between symptom-onset and emergency room admission was 2 hours. Acute pulmonary edema or cardiogenic shock was developed by 16.6% of patients and 41.8% received thrombolysis. Mean time delay between symptom-onset and thrombolysis was 3 hours. A large variability in the use of beta-blockers, thrombolysis, echocardiography, coronary catheterization angiography and invasive revascularization was observed among hospitals. Mortality in the coronary care unit was 10.9% and increased to 14.0% at 28 days and to 18.5% at one year with considerable variation among hospitals. Four hospitals showed higher mortality among their patients, independently from the proportion of diabetes, hypertension, women, anterior location of myocardial infarction, non-Q-wave infarction, age and severity. CONCLUSIONS: The results of this study show that early and mid-term mortality from myocardial infarction is still high in Spain in the reperfusion era, and that a considerable variability in management and outcome exists among Spanish hospitals, which is not explained by the different case-mix among them.

[Diagnosis of unstable angina in the emergency room. The clinical value and limitations of electrocardiography and other tests]. / Diagnóstico de la angina inestable en el servicio de urgencias. Valor y limitaciones de la clínica, el electrocardiograma y las pruebas complementarias.

The quick and accurate diagnosis of acute coronary heart disease in the emergency department constitutes a first line medical challenge. About 5% of patients attending to the emergency department present chest pain or symptoms suggesting myocardial ischemia. A prompt diagnosis contributes to patient survival while an incorrect one can be associated to an increased risk of unfavorable outcome. On the other hand, unnecessary admissions into high technology hospital areas determine important expenses unacceptable from a cost-benefit point of view. In the present paper, the usefulness of different diagnostic tools used in emergency department (case history, electrocardiogram, nuclear perfusion imaging, echocardiography, exercise test) is reviewed, their advantages and limitations reviewed, with special emphasis on the importance of having an electrocardiogram as soon as possible, and based on the electrocardiographic findings the most appropiate management is discussed.

[Therapy with glucose-insulin-potassium reduces the complications in the acute phase of myocardial infarct. Arguments against]. / La terapia con glucosa-insulina-potasio reduce las complicaciones en la fase aguda del infarto de miocardio. Argumentos en contra.

Glucose-insulin-potassium therapy has shown its efficacy in diminishing the myocardial damage under ischemia-reperfusion conditions in experimental models. This effect appears to be mainly due to the increase of anaerobic glycolysis in ischemic cells with a consequent reduction in the use of fatty acids. On the other hand, clinical studies in the acute phase of myocardial infarction are out-dated and almost non-existent in the thrombolytic era. The absence of current consistent data makes it difficult to draw conclusions concerning the real utility of this therapy in the clinical practice.

[Stratification of arrhythmia risk and therapeutic options in survivors of acute myocardial infarction]. / Estratificación del riesgo arrítmico y opciones terapéuticas en los supervivientes a infarto agudo de miocardio.

A significant improvement in late survival of post-myocardial infarction patients has been observed during the last few years, even before the beginning of the thrombolytic era. However, about half of the fatality rate in these patients is related to arrhythmic sudden death. So, a discussion of the value of different diagnostic and therapeutic tools available for reducing arrhythmic risk seems pertinent. Several features are considered risk markers for sudden arrhythmic death: symptomatic ventricular arrhythmias, left ventricular disfunction, myocardial ischemia, frequent or complex premature ventricular contractions, late ventricular potentials in high-resolution ECG and autonomous nervous system disturbances. It seems reasonable to state that the risk markers whose value was established before the thrombolytic era maintain most of their clinical applicability to the present, but none of them has specificity enough as a sudden death predictor to warrant a general systematic strategy to trace such risk arrhythmic factors. Prophylactic administration of Type I antiarrhythmic drugs to patients with frequent or complex premature ventricular contractions can no longer be justified. There is probably a place for betablockers, mainly in patients with mild to moderate depression in left ventricular function. The final results of several trials currently in progress should contribute to establish the potential role of low dose amiodarone. There is not enough evidence to determine which post-myocardial infarction patients will be candidates for an Implantable Cardioverter Defibrillator Device. Patients with risk factors for sudden death, in particular those who have a severe impairment of left ventricular function and/or severe ischemia in the stress test, would be able to take advantage of a revascularization procedure when the culprit vessel remains occluded. In the intermediate risk patients (20-40% of the total population), tests attempting to more precisely evaluate the arrhythmic risk would be warranted, always in an individualized, sequential schedule. In some cases, like the high-resolution ECG or the heart rate variability indices, more clinical investigation is necessary to adequately establish their value in routine clinical practice.

[Evaluation of home physical training soon after acute myocardial infarction]. / Evaluación del entrenamiento físico domiciliario precoz después de un infarto agudo de miocardio.

Little attention has been directed to the utility of unsupervised physical training at home in postmyocardial infarction patients. The present investigation was designed to assess the effects of exercise training at home on functional parameters soon after myocardial infarction. One hundred and eighteen male postmyocardial infarction patients under 70 years old, that performed a predischarge exercise test, were randomly allocated soon after the acute event, into a 12-14 weeks unsupervised physical training at home and into a control group. The control group patients were informally encouraged to practice exercise. Before training, the cardiorespiratory parameters were similar in both groups. After training, improvement of all these variables was seen in both groups, although the magnitude was greater in the training group. Maximal oxygen consumption increased 7.6 +/- 3.6 ml/kg/min in the training group by 3.8 +/- 2.6 ml/kg/min in the control group (p = 0.00001), maximal heart rate increased 14.6 +/- 13.4 by 8.4 +/- 5.7 beats/min (p = 0.001), and similar results were obtained with maximal double product and exercise test duration (33 +/- 46 versus 17 +/- 12, p = 0.009; 2.2 +/- 1.1 versus 0.9 +/- 1.1 min, p = 0.00001) always in trained patients favour. Nine trained patients and 16 control patients showed myocardial ischemia in both exercise tests. At ischemic threshold, the achieved improvement was again greater in trained patients, concerning to heart rate (p = 0.02), double product (p = 0.0005) and exercise time (p = 0.02).(ABSTRACT TRUNCATED AT 250 WORDS)

[The cardiology consultation in a health-service area hospital. The clinical aspects and the demand for diagnostic procedures]. / La consulta de cardiología en un hospital de área sanitaria. Aspectos clínicos y demanda de exploraciones diagnósticas.

Four consecutive years (1987-1990) outpatients attendance at a cardiology clinic was recorded in a district hospital with a catchment area of 200,000 inhabitants. The aim being to identify and evaluate the demand for cardiology consultations. A system for recording diagnoses was developed, based on the WONCA. The total number of consultations was 26,273, 27% being new patients, 78% of whom were referred by family doctors and health centers. Of the total, 57% were male. The most common age groups being from 60 to 69 (25%) and from 50 to 59 (23%); 22% were over 69. In 13.7% of the consultations, the find diagnosis was of "healthy hearts", in 16.7% valvular heart disease, in 31.5% ischaemic heart disease, in 15.1% arrhythmias, in 8.4% hypertension, and the remainder were other diseases. We carried out 4,406 echocardiograms, 1,408 exercise tests and 511 Holter monitoring traces. There were 322 direct hospital admissions, and 6,094 discharges in the four years period. We consider this type of records to be useful organizing cardiology outpatients clinics, analyzing the demand, and planning the use of health care resources, as well as estimating future needs and assessing quality of care.