Estrategia invasiva precoz ajustada al riesgo en pacientes con síndrome coronario agudo sin elevación de segmento ST en Unidades de Cuidados Intensivos Cardiológicos / Risk-adjusted early invasive strategy in patients with non-ST-segment elevation acute coronary syndrome in Intensive Cardiac Care Units

OBJETIVO: Las guías de práctica clínica recomiendan la estrategia invasiva precoz ajustada al riesgo (EIPAR) en pacientes con síndrome coronario agudo sin elevación del segmento ST (SCASEST). El objetivo fue analizar la aplicación de la EIPAR, sus condicionantes e impacto sobre el pronóstico en pacientes con SCASEST ingresados en Unidades de Cuidados Intensivos Cardiológicos (UCIC). DISEÑO: Estudio de cohortes prospectivo. ÁMBITO: UCIC de 8 hospitales en Cataluña. PACIENTES: Pacientes consecutivos con SCASEST entre octubre del 2017 y marzo del 2018. El perfil de riesgo se definió mediante los criterios de la Sociedad Europea de Cardiología. INTERVENCIONES: Se definió como EIPAR la realización de coronariografía en las primeras 6 h en pacientes de muy alto riesgo o en 24 h en pacientes de alto riesgo. VARIABLES DE INTERÉS: Mortalidad/reingreso a los 6 meses. RESULTADOS: Se incluyó a 629 pacientes (edad media 66,6 años), 225 (35,9%) de muy alto riesgo y 392 (62,6%) de alto riesgo. La estrategia invasiva fue mayoritaria (96,2%). La EIPAR se aplicó en 284 pacientes (45,6%), especialmente pacientes más jóvenes, con menos comorbilidades. Estos pacientes presentaron menor estancia en UCIC y hospitalaria, así como menor incidencia de SCA, revascularizaciones y menor incidencia de muerte/reingreso a 6 meses. Tras ajustar por factores de confusión, la asociación entre adherencia y muerte/reingreso a 6 meses persistió de manera significativa (razón de riesgos: 0,66 [0,45-0,97] p = 0,035). CONCLUSIONES: La EIPAR se aplica en una minoría de SCASEST ingresados en UCIC, asociándose con una menor incidencia de eventos

OBJECTIVE: Current guidelines recommend a risk-adjusted early invasive strategy (EIS) in patients with non-ST-segment elevation acute coronary syndrome (NSTEACS). The present study assesses the application if this strategy, the conditioning factors and prognostic impact upon patients with NSTEACS admitted to Intensive Cardiac Care Units (ICCU). DESIGN: A prospective cohort study was carried out. SETTING: The ICCUs of 8 hospitals in Catalonia (Spain). PATIENTS: Consecutive patients with NSTEACS between October 2017 and March 2018. The risk profile was defined by the European Society of Cardiology criteria. INTERVENTIONS: EIS was defined as the performance of coronary angiography within the first 6hours in patients at very high-risk or within 24hours in high-risk patients. OUTCOME VARIABLES: Mortality or readmission at 6 months. RESULTS: A total of 629 patients were included (mean age 66.6 years), of whom 225 (35.9%) were at very high risk, and 392 (62.6%) at high risk. Most patients (96.2%) underwent an invasive strategy. EIS was performed in 284 patients (45.6%), especially younger patients with fewer comorbidities. These patients had a shorter ICCU and hospital stay, as well as a lesser incidence of ACS, revascularization and death or readmission at 6 months. After adjusting for confounders, the association between EIS and death or readmission at 6 months remained significant (hazard ratio: .66, 95% confidence interval .45-.97; P=.035). CONCLUSIONS: The EIS was performed in a minority of NSTEACS admitted to ICCU, being associated with better outcomes

Risk-adjusted early invasive strategy in patients with non-ST-segment elevation acute coronary syndrome in Intensive Cardiac Care Units. / Estrategia invasiva precoz ajustada al riesgo en pacientes con síndrome coronario agudo sin elevación de segmento ST en Unidades de Cuidados Intensivos Cardiológicos.

OBJECTIVE: Current guidelines recommend a risk-adjusted early invasive strategy (EIS) in patients with non-ST-segment elevation acute coronary syndrome (NSTEACS). The present study assesses the application if this strategy, the conditioning factors and prognostic impact upon patients with NSTEACS admitted to Intensive Cardiac Care Units (ICCU). DESIGN: A prospective cohort study was carried out. SETTING: The ICCUs of 8 hospitals in Catalonia (Spain). PATIENTS: Consecutive patients with NSTEACS between October 2017 and March 2018. The risk profile was defined by the European Society of Cardiology criteria. INTERVENTIONS: EIS was defined as the performance of coronary angiography within the first 6hours in patients at very high-risk or within 24hours in high-risk patients. OUTCOME VARIABLES: Mortality or readmission at 6 months. RESULTS: A total of 629 patients were included (mean age 66.6 years), of whom 225 (35.9%) were at very high risk, and 392 (62.6%) at high risk. Most patients (96.2%) underwent an invasive strategy. EIS was performed in 284 patients (45.6%), especially younger patients with fewer comorbidities. These patients had a shorter ICCU and hospital stay, as well as a lesser incidence of ACS, revascularization and death or readmission at 6 months. After adjusting for confounders, the association between EIS and death or readmission at 6 months remained significant (hazard ratio: .66, 95% confidence interval .45-.97; P=.035). CONCLUSIONS: The EIS was performed in a minority of NSTEACS admitted to ICCU, being associated with better outcomes.

Prognosis of left-sided infective endocarditis in patients transferred to a tertiary-care hospital--prospective analysis of referral bias and influence of inadequate antimicrobial treatment.

The aims of this study were to compare the characteristics of adult patients with left-sided infective endocarditis (LSIE) diagnosed and treated in a tertiary-care hospital with those of patients referred from a second-level community hospital, and to establish the accuracy of diagnosis and adequacy of treatment in referred patients and the influence of this factor on outcome. A prospective observational cohort study was conducted at Hospital Universitari Vall d'Hebron, a 1000-bed teaching hospital in Barcelona (Spain) and a referral centre for cardiac surgery. One hundred and fourteen of 337 (34%) episodes of LSIE treated in our hospital occurred in transferred patients. As compared with patients diagnosed in our hospital, transferred patients acquired LSIE within the healthcare system less often (16.7% vs. 38.1%, p <0.001), were in better health (Charlson index 3 (interquartile range (IQR)) 1-4) vs. 4 (IQR 2-6), p <0.001), had more complications (94.7% vs. 78.9%, p <0.001), underwent more operations (69.3% vs. 22.1%, p <0.001), and experienced similar mortality (22.8% vs. 31.4%, p 0.100). Only 52 of 114 (45.6%) referred patients received an antimicrobial regimen included in the American, European or Spanish guidelines at the hospital of origin. After adjustment for congestive heart failure and staphylococcal infection in multivariate logistic regression, inadequate or no antimicrobial treatment at origin was a risk factor for in-hospital mortality (OR 3.3, 95% CI 1.1-10.0, p 0.030). Errors in the initial antimicrobial treatment prescribed for LSIE are associated with greater mortality.

Therapeutic strategies after coronary stenting in chronically anticoagulated patients: the MUSICA study.

OBJECTIVES: To identify the therapeutic regimens used at discharge in patients receiving oral anticoagulant therapy (OAT) who undergo stenting percutaneous coronary intervention and stent implantation (PCI-S), and to assess the safety and efficacy associated with different therapeutic regimens according to thromboembolic risk. DESIGN: A prospective multicentre registry. SETTING: In hospital, after discharge and follow-up by telephone call. PATIENTS AND METHODS: 405 patients (328 male/77 female; mean (SD) age 71 (9) years) receiving OAT who underwent PCI-S between November 2003 and June 2006 from nine catheterisation laboratories of tertiary care teaching hospitals in Spain and one in the United Kingdom were included. RESULTS: Three therapeutic regimens were identified at discharge: triple therapy (TT) -- that is, any anticoagulant (AC) plus double antiplatelet therapy (DAT; 278 patients (68.6%); AC and a single antiplatelet (AC+AT; 46 (11.4%)) and DAT only (81 (20%)). At 6 months, patients receiving TT showed the greatest rate of bleeding events. No patients receiving DAT at low thromboembolic risk presented a bleeding event (14.8% receiving TT, 11.8% receiving AC+AT and 0% receiving DAT, p = 0.033) or cardiovascular event (6.7% receiving TT, 0% receiving AC+AT and 0% receiving DAT, p = 0.126). The combination of AC+AT showed the worst rate of adverse events in the whole cohort, especially in patients at moderate-high thromboembolic risk. CONCLUSIONS: In patients receiving OAT, TT was the most commonly used regimen after PCI-S. DAT was associated with the lowest rate of bleeding events and a similar efficacy to TT in patients at low thromboembolic risk. TT should probably be restricted to patients at moderate-high thromboembolic risk.

The PFA-100 detects sub-optimal antiplatelet responses in patients on aspirin.

Although it is suspected that some patients with acute coronary syndromes (ACS) could have a sub-optimal response to aspirin (SASAR), currently a fixed dose of ASA is long-term used in all individuals. This study was designed to determine SASAR and whether a SASAR is a predictor for recurrence of ischemic events in patients on low-dose ASA with a previous ACS. One hundred patients taking ASA 100 mg/day were assessed at 1 and 6 months after a first ACS. SASAR was initially defined as a failure of the ASA treatment to significantly prolong the closure time in the Platelet Function Analyzer (PFA-100). SASAR in these samples was reconfirmed by conventional aggregometry. TXB2 levels were determined in plasma. At one month 49 patients showed SASAR in the PFA-100; only 25 of them showed SASAR by conventional aggregometry. At six months, 39 of 81 patients showed SASAR by PFA-100, but conventional aggregometry detected SASAR in only 12 of the 39 patients. TXB2 levels were significantly higher in patients with SASAR. Five patients with SASAR, by both tests, died during follow-up (p = 0.013). The PFA-100 detected a high rate of SASAR in patients with ACS. This instrument could be used to screen for suboptimal response to the antiplatelet action of ASA. Whether persistence of SASAR could relate to a higher risk of recurrence and how adjusting the dose of ASA could reduce the rate of SASAR are issues that deserve further investigations.

Streptococcus agalactiae infective endocarditis: analysis of 30 cases and review of the literature, 1962-1998.

We describe 30 cases (1.7%) of community-acquired penicillin-susceptible Streptococcus agalactiae endocarditis among 1771 episodes of endocarditis diagnosed in 4 Spanish hospitals from 1975 through 1998. Endocarditis affected a native valve (most often the mitral valve) in 25 cases (83%). Surgical valve replacement was performed for 12 patients (40%). Fourteen patients (47%) died. Mortality rates for patients with native and prosthetic valve endocarditis were 36% and 100%, respectively (P=.01). The mortality rate for native valve endocarditis decreased during the last 6 years of the study (from 61% in 1975-1992 to 8% in 1993-1998; P<.05). Additionally, 115 cases in the literature from 1962-1998 were reviewed. During 1980-1998, the percentage of patients who underwent cardiac surgery increased from 24% (in the previous period, 1962-1979) to 43% (P=.05) and the mortality rate decreased from 45% to 34% (P=NS). S. agalactiae is an uncommon cause of endocarditis with a high mortality rate, although the prognosis of native valve endocarditis has improved in recent years, probably because of an increased use of cardiac surgery.

Long-lasting sport practice and lone atrial fibrillation.

AIMS: To analyse whether the proportion of patients with lone atrial fibrillation engaged in chronic sport practice was higher than that observed in the general population. METHODS AND RESULTS: The records of 1160 patients, seen at the arrhythmia outpatient clinic, were reviewed. A total of 70 patients (6%) suffered lone atrial fibrillation and were younger than 65 years. Thirty two of them had been engaged in long-term sport practice. All patients in the sport group were men as compared to only 50% in the sedentary group (P<0 x 0001). To avoid the confounding effect of sex distribution, women were excluded. Sportsmen started their episodes of atrial fibrillation at a younger age, they had a lower incidence of mild hypertension and their episodes of atrial fibrillation were predominantly vagal in contrast to the sedentary patients. The echocardiographic parameters were similar to those observed in the sedentary patients, but when compared with 20 healthy controls, they showed greater atrial and ventricular dimensions and a higher ventricular mass. The proportion of sportsmen among patients with lone atrial fibrillation is much higher than that reported in the general population of Catalonia: 63% vs 15% (P<0 x 05). CONCLUSION: Long-term vigorous exercise may predispose to atrial fibrillation.

[Use of thrombolytic treatment in patients with acute myocardial infarction in Spain. Observations from the PRIAMHO study]. / Utilización de la trombólisis en los pacientes con infarto agudo de miocardio en España: observaciones del estudio PRIAMHO.

INTRODUCTION AND OBJECTIVES: Scarce information is actually available in our country regarding the use of thrombolytic treatment in patients with acute myocardial infarction and how consistently the recommendations of the clinical guidelines are being implemented. METHODS: Cohort study with one year follow-up of patients with acute myocardial infarction admitted in 24 Spanish hospitals in 1995. Differences in clinical characteristics and prognosis from patients treated with or without thrombolysis were compared. RESULTS: 2,191 of the 5,242 patients (42%) admitted with an acute myocardial infarction received thrombolytic therapy (range: 23%-63%). Reasons for exclusion in the rest were the absence of ST segment elevation (35%), contraindications (16%), prehospital delay >12 h (35%), and other causes (15%). Thrombolysis treated patients were at lower risk in general because they had shorter prehospital delays and were younger, more likely to be male, less frequently diabetic, with less prior history of angina or infarction. The average delay in administering therapy was of 3 hours while the average in-hospital delay was 50 minutes and depended only on the hospital where patients where admitted, as it was shorter in small centers. t-PA was administered in 49% of patients, streptoquinase in 46% and other drugs in 5%. Although t-PA was given more often to younger patients, smokers, anterior and Q-wave infarctions, and to patients with shorter prehospital delays, the determinant factor was the admission hospital with a frequency ranging from 9% to 96%. Patients not treated with thrombolytics had more complications during the acute phase, and required more invasive procedures. They also had a higher mortality at 28 days (17% vs. 10%, p < 0.0001) and at one-year follow-up (27% vs. 15%, p < 0.0001). Furthermore, a correlation was observed between mortality and delay of treatment application. In multivariate analysis, thrombolytic treatment was an independent predictor of survival at one year, with an odds ratio for mortality of 0.8 (95% CI: 0.66-0.96). CONCLUSIONS: Thrombolytic therapy in Spain does not yet conform to the recommendations of the actual guidelines for the treatment of patients with acute myocardial infarction because it is underused, especially in high-risk patients, the prehospital and in-hospital delays are too long, and a huge variability exists between hospitals in the frequency and delays of administration and selection of the drug that are not sufficiently explained by the characteristics of the patients. In spite of this, mortality of treated patients was 20% lower in comparison to the non-treated patients, after adjusting for the other clinical factors with demonstrated prognostic value.

Arrhythmia recurrence in patients with a healed myocardial infarction who received an implantable defibrillator: analysis according to the clinical presentation.

OBJECTIVES: The purpose of this study was to analyze the type of arrhythmia recurrence, based on stored electrograms, in patients with a healed myocardial infarction (MI) who received an implantable defibrillator. BACKGROUND: Previous studies suggest that patients presenting with cardiac arrest (CA) tend to recur as ventricular fibrillation (VF), whereas those suffering sustained monomorphic ventricular tachycardia (SMVT) tend to recur as SMVT. However, these data have not been confirmed in a homogeneous population of patients with MI. METHODS: A total of 88 patients was divided into three groups according to their clinical presentation: SMVT (n = 57), CA (n = 16) or syncope (n = 15). RESULTS: There were no significant differences in clinical characteristics among groups. In the electrophysiologic study SMVT was induced in 93%, 94% and 80% of patients, respectively (p = NS). During the follow-up period, 52% of patients presented a total of 671 episodes of ventricular arrhythmia treated by the defibrillator. All recurrences were as SMVT except for one VF. There were 610 episodes of SMVT treated with antitachycardia pacing, with an effectiveness of 96%. A total of 61 episodes was treated initially with cardioversion. No differences in the probability of recurrence were observed among groups, although the statistical power was low (50%). CONCLUSIONS: In patients with an old infarction and malignant ventricular arrhythmias, the majority of recurrences are due to SMVT independently of the clinical presentation (SMVT, CA or syncope) or the induced arrhythmia at the electrophysiologic study. The programming of an antitachycardia zone seems to be appropriate also for patients who present with CA or syncope.

[Differences in the clinical presentation and prognosis of unstable angina and non-Q wave infarction]. / Diferencias en la presentación clínica y el pronóstico de la angina inestable y el infarto sin onda Q.

At present it is generally accepted that unstable angina and non-Q-wave myocardial infarction have a common underlying pathophysiology, however, clinical presentation and outcome of these syndromes depend on the location, grade and duration of myocardial ischemia. The most important difference between both syndromes is the myocardial necrosis from non-Q myocardial infarction, which may carry a higher risk death and reinfarction rate and for that reason a worse prognosis than unstable angina. Some studies suggest that the effect of antithrombotic treatment can be different in both syndromes. Nevertheless the differences do not achieve significance in most of these studies.

[Arrhythmia recurrence in patients with an old myocardial infarct treated by implantable defibrillator: an analysis according to the initial clinical presentation]. / Recurrencia de la arritmia en pacientes con infarto de miocardio antiguo tratados con desfibrilador implantable: análisis según la presentación clínica inicial.

INTRODUCTION AND OBJECTIVES: The importance of the clinical presentation in the frequency and type of recurrences of ventricular arrhythmias in patients that received an automatic implantable defibrillator is not well known. The purpose of this study was to analyze the frequency and type of recurrences in patients with an old myocardial infarction that received an automatic implantable defibrillator with electrogram recording. METHODS AND RESULTS: We analyzed 100 patients classified in 3 groups according to their clinical presentation: Sustained Monomorphic Ventricular Tachycardia (VT Group n = 65), Cardiac Arrest (CA Group = 19), and Syncope (Syncope Group n = 16). There were no significant differences in the clinical variables among the different groups, nor in the inducibility of arrhythmia at the electrophysiologic study. In a follow-up 27 +/- 14 months, 54% of patients presented at last one episode of sustained ventricular arrhythmia. All recurrences except one were as sustained monomorphic ventricular tachycardia (776 episodes). 81% of episodes of sustained monomorphic ventricular tachycardia (630) were treated with antitachycardia pacing with an effectiveness of 89%. There were no differences in the probability of arrhythmic recurrence among groups but death probability was higher in the ventricular fibrillation group at 36 follow-up months (38% vs 7% and 12% in the sustained monomorphic ventricular tachycardia and syncope groups respectively, p = 0.0113). CONCLUSIONS: In the patients with an old myocardial infarction and malignant ventricular arrhythmias, most of recurrences are due to sustained monomorphic ventricular tachycardia independently of the clinical presentation. The antitachycardia pacing is not only effective in patients with documented sustained monomorphic ventricular tachycardia but also in those that are presented as cardiac arrest or syncope.

[Improvement in the treatment of acute myocardial infarct by the establishment of a thrombolysis unit in a cardiology servic]. / Mejoría del tratamiento del infarto agudo de miocardio mediante la creación de una unidad de trombólisis en el servicio de cardiología.

INTRODUCTION AND OBJECTIVES: Lack of available beds in the coronary care unit, makes time to thrombolysis still too long. Although fibrinolytic therapy is administered in the emergency department in most hospitals, mean in-hospital delay continues to be long. Our purpose was to improve the treatment of these patients and to evaluate if this delay could be shortened by creating a thrombolysis unit for the treatment of patients with acute myocardial infarction. METHODS: A thrombolysis unit in the cardiology department was set up to treat patients with acute myocardial infarction who couldn't be admitted directly in the coronary care unit because of lack of available beds. Time to treatment in both groups of patients were compared. RESULTS: Two hundred twenty-five patients with acute myocardial infarction and ST-segment elevation were included: 86 (38%) of them were admitted to the thrombolysis unit and the other 139 (62%) to the coronary care unit. There were no differences in baseline characteristics or in the pre-hospital delay between both groups. Time from hospital admission to thrombolysis was 59 minutes in patients treated in the thrombolysis unit versus 70 minutes in those treated in the coronary care unit (p < 0.001), and time from the admission to both units to fibrinolytic therapy was of 20 minutes versus 30 minutes respectively (p < 0.0001). There were no differences between both groups in the incidence of complications. CONCLUSIONS: In-hospital delay in thrombolysis remains too long. Implementation of a thrombolysis unit in the cardiology department shortens this delay and offers the possibility to treat patients with acute myocardial infarction at least as well as in the coronary care unit, without dependence on the availability of free beds in this unit.

Previous aspirin use may attenuate the severity of the manifestation of acute ischemic syndromes.

BACKGROUND: The present study was designed to investigate whether the prior use of aspirin could influence the severity of the manifestation of acute coronary artery syndromes, given the well-documented observations that aspirin can prevent myocardial infarction, stroke, and death in cardiovascular disease. METHODS AND RESULTS: A series of 539 consecutive patients admitted to the Coronary Care Unit of a General Hospital was carefully characterized in a study with an ambidirectional design, with regard to previous medical history, aspirin use, and subsequent hospital diagnosis. Among the 214 patients previously taking aspirin, the hospital diagnosis was myocardial infarction in 24% and unstable angina in 76% compared with 54% and 46%, respectively, among the 325 not taking aspirin (P < .0001), for a reduction in the odds ratio of myocardial infarction with aspirin of 72% (95% CI, 59% to 90%). The decrease in odds was homogeneous in all subsets studied and independent of age, sex, previous angina, or previous myocardial infarction. The myocardial infarction was of a Q-wave type in 62% of aspirin users compared with 76% of nonusers (P < .05). By multivariate analysis, previous aspirin use was a strong predictor of unstable angina versus myocardial infarction and the only independent predictor of non-Q-wave versus Q-wave myocardial infarction. CONCLUSIONS: This study, thus, suggests a shift to less severe manifestation of acute coronary syndromes with aspirin use, implying that the failure of the drug in many patients with an acute coronary syndrome is only partial and that aspirin has the potential of attenuating the severity of the underlying acute thrombotic disease process.