Causes of ineligibility in randomized controlled trials and long-term mortality in patients with non-ST-segment elevation acute coronary syndromes.

PURPOSE: To determine the long-term mortality of patients with non-ST-segment elevation acute coronary syndromes (NSTEACS) that are eligible versus those not eligible in randomized controlled trials (RCT), and how each exclusion criteria is associated with outcome. METHODS: Common causes of exclusion in six published RCT on intravenous antithrombotic therapy were prospectively assessed in a cohort of 452 consecutive patients with NSTEACS that were followed for up to 3 years. RESULTS: Forty-one percent of patients had one or more exclusion criteria establishing the ineligible group. These patients were older, more likely to have coronary risk factors, ischemic ECG changes, heart failure at admission, higher creatinine levels and a lower ejection fraction than eligible patients. There were no differences between both groups in the antithrombotic treatment received or in the performance of revascularization procedures during hospitalization or in the prescription of antiplatelet treatment and beta-blockers at discharge. Cumulative 3-year mortality rate was 25% in ineligible patients compared to 9% in eligible patients (p<0.001). The hazard ratio (HR) of mortality was of 9.1 (95% CI: 4.5-18.7) for severe renal dysfunction; 6.0 (3.3-11.4) for concomitant non-vascular diseases; 3.0 (1.6-5.5) for contraindications to anticoagulation; 2.5 (1.1-5.7) for heart failure; and 2.3 (1.1-4.6) for prior cerebrovascular disease. After adjusting for baseline differences, ineligible patients had a HR of total mortality of 1.88 (1.04-3.38), and of cardiac mortality of 2 (1.01-3.98). CONCLUSION: Patients with NSTEACS who are ineligible in RCT have a higher risk profile and a two-fold adjusted long-term mortality than eligible patients, especially those with comorbid conditions and those with contraindications to anticoagulation.

Tratamiento de la insuficiencia cardiaca en la fase aguda del infarto de miocardio / Management of heart failure in acute myocardial infarction

La insuficiencia cardiaca por disfunción ventricular es una de las peores complicaciones del infarto agudo de miocardio, pues aumenta de 2 a 10 veces su mortalidad. En su fisiopatología intervienen, además de la pérdida muscular, la isquemia y el aturdimiento miocárdico, potencialmente reversibles, la activación neurohormonal, el proceso de remodelado ventricular y fenómenos de inflamación. Para su tratamiento es importante conocer bien los fármacos de que disponemos y sus indicaciones en el contexto del infarto agudo de miocardio, así como el correcto control hemodinámico del tratamiento. En todos los casos es primordial tratar los factores agravantes y desencadenantes de la insuficiencia cardiaca, la hipoxemia y la acidosis, y realizar una estrategia terapéutica guiada por el tiempo de evolución del infarto y la presencia de congestión pulmonar, hipotensión arterial o hipoperfusión periférica. Por último, se hace especial hincapié en la eficacia de la reperfusión coronaria en estos pacientes y en el tratamiento del shock cardiogénico y del infarto de ventrículo derecho (AU)

Heart failure due to ventricular dysfunction is one of the worst complications of acute myocardial infarction; it increases mortality 2 to 10 times. In addition to muscle loss, the pathophysiology of this condition involves (potentially reversible) ischemia and myocardial stunning, neurohormonal activation, ventricular remodeling, and inflammatory processes. Appropriate treatment requires comprehensive knowledge of the different drugs available, their application in the specific context of acute myocardial infarction, and the best way to monitor treatment hemodynamically. In each individual, it is crucial that any factors that trigger or aggravate heart failure, hypoxemia or acidosis are treated, and that the treatment strategy is guided by the time that has elapsed since the infarction and by the presence of pulmonary congestion, low blood pressure, and peripheral hypoperfusion. Finally, this review places particular emphasis on the efficacy of coronary reperfusion in these patients and on the treatment of cardiogenic shock and right ventricular infarction (AU)

[Previous infection with Chlamydia pneumoniae and long-term prognosis in patients with acute coronary syndrome with non-ST segment elevation]. / Infección previa por Chlamydia pneumoniae y pronóstico a largo plazo en pacientes con síndrome coronario agudo sin elevación del segmento ST.

BACKGROUND AND OBJECTIVE: Contradictory data exists from case-control studies and in patients with stable coronary artery disease on the association of prior exposure to Chlamydia pneumoniae and cardiovascular events. We underwent a prospective study to investigate the prognostic value of C. pneumoniae seropositivity in patients with acute coronary syndromes. PATIENTS AND METHOD: In a prospective cohort of 259 consecutive patients (194 men and 65 women), mean age 65 (10 years) with non-ST elevation acute coronary syndromes, we measured serum levels of IgG antibodies directed against C. pneumoniae. RESULTS: After a mean follow-up of 28 (25, 29) months, the incidence of cardiovascular death or myocardial infarction was of 15% in seropositive patients versus 13% in seronegatives at IgG titers (1:64 (p=0.58); of 14% versus 14% at IgG titers > or = 1:128 (p=0.96); and of 14% versus 15% at IgG titers (1:256 (p=0.82). The relative risks (RR, 95% CI) of these major cardiac events adjusted for possible confounding factors were 1.11 (0.52-2.40); 1.01 (0.52-1.96); and 0.94 (0.48-1.87) respectively. CONCLUSIONS: Chlamydia pneumoniae IgG seropositivity is not associated with a higher incidence of death or myocardial infarction in patients with non-ST segment elevation acute coronary syndromes.

Infección previa por Chlamydia pneumoniae y pronóstico a largo plazo en pacientes con síndrome coronario agudo sin elevación del segmento ST / Previous infection with Chlamydia pneumoniae and long-term prognosis in patients acute coronary syndrome and with non-ST segment elevation

Fundamento y objetivo: Existen datos contradictorios procedentes de estudios de casos y controles y en pacientes con enfermedad coronaria estable sobre la asociación entre exposición previa a Chlamydia pneumoniae y accidentes cardiovasculares. Realizamos un estudio prospectivo con el fin de investigar el valor pronóstico de la seropositividad anti-C. pneumoniae en pacientes con síndrome coronario agudo. Pacientes y método: Se determinó la concentración en suero de anticuerpos inmunoglobulina (Ig) G anti-C. pneumoniae en una cohorte de 259 pacientes consecutivos con síndrome coronario agudo sin elevación del segmento ST (194 varones y 65 mujeres), con una edad media ( desviación estándar) de 65 (10) años. Resultados: Tras un seguimiento medio de 28 (percentiles 25, 75: 25, 29) meses, la incidencia de mortalidad cardiovascular o infarto de miocardio fue del 15% en los pacientes seropositivos frente al 13% en los seronegativos para concentraciones de IgG mayores o iguales a 1:64 (p = 0,58); del 14% frente al 14% para IgG mayor o igual a 1:128 (p = 0,96); y del 14% frente al 15% para IgG mayor o igual a 1:256 (p = 0,82). El riesgo relativo (intervalo de confianza del 95%) ajustado por posibles factores de confusión fue de 1,11 (0,52-2,40), 1,01 (0,52-1,96) y 0,94 (0,48-1,87), respectivamente. Conclusiones: La existencia de seropositividad IgG para C. pneumoniae no se asocia con una mayor incidencia de muerte o infarto en pacientes con síndrome coronario agudo sin elevación del ST

Background and objective: Contradictory data exists from case-control studies and in patients with stable coronary artery disease on the association of prior exposure to Chlamydia pneumoniae and cardiovascular events. We underwent a prospective study to investigate the prognostic value of C. pneumoniae seropositivity in patients with acute coronary syndromes. Patients and method: In a prospective cohort of 259 consecutive patients (194 men and 65 women), mean age 65 (10 years) with non-ST elevation acute coronary syndromes, we measured serum levels of IgG antibodies directed against C. pneumoniae. Results: After a mean follow-up of 28 (25, 29) months, the incidence of cardiovascular death or myocardial infarction was of 15% in seropositive patients versus 13% in seronegatives at IgG titers (1:64 (p=0.58); of 14% versus 14% at IgG titers >= 1:128 (p=0.96); and of 14% versus 15% at IgG titers (1:256 (p=0.82). The relative risks (RR, 95% CI) of these major cardiac events adjusted for posible confounding factors were 1.11 (0.52-2.40); 1.01 (0.52-1.96); and 0.94 (0.48-1.87) respectively. Conclusions: Chlamydia pneumoniae IgG seropositivity is not associated with a higher incidence of death or myocardial infarction in patients with non-ST segment elevation acute coronary syndromes

[Differences in the management and prognosis of patients with non-ST segment elevation acute coronary syndrome according to the department of initial admission]. / Diferencias en el tratamiento y la evolución clínica de los pacientes con síndrome coronario agudo sin elevación del segmento ST en función del servico clínico de ingreso.

OBJECTIVES: To assess the influence of the department of initial admission on the hospital management and 3-month prognosis of patients with non-ST elevation acute coronary syndromes. PATIENTS AND METHOD: The data for the 4115 patients admitted to 18 hospitals in the PEPA study were compared according to the department of initial admission. RESULTS: Twenty-six percent of the patients were admitted to the coronary care unit, 53% to the cardiology department, 9% to the internal medicine department, and 12% were discharged from the emergency ward. The baseline risk profile was high in patients admitted to the coronary care unit and decreased progressively in patients admitted to the cardiology, internal medicine and emergency departments (P<.00001). The intensity of medical management was progressively lower in these departments, but not in parallel to their different baseline lower risk profile. Beta blockers were administered to 50%, 45%, 27% and 21% of the patients, respectively; an exercise test was performed in 34%, 44%, 35% and 12%; coronary angiography in 46%, 34%, 19% and 0%; and coronary revascularization in 22%, 12%, 9% and 0% (P<.00001). The 3-month incidence of mortality or myocardial infarction was 12.2%, 6.4%, 8.7% and 3.8%, respectively (P<.00001), differences that became nonsignificant after adjustment for risk profile on admission. CONCLUSIONS: Patients with non-ST elevation acute coronary syndrome admitted to the coronary care unit or cardiology department have a profile of higher risk on admission than patients admitted to the internal medicine department. Also, these patients more frequently receive pharmacological treatments and diagnostic and therapeutic procedures of proven efficacy but not in a manner that parallels their different risk profile on admission. However, these differences in the intensity of in-hospital management do not seem to lead to differences in the 3-month prognosis.