[Inflammation and infection in stable coronary disease and acute coronary syndrome]. / Inflamación e infección en la enfermedad coronaria estable y en el síndrome coronario agudo.

OBJECTIVE: To study whether inflammation and infection are related to coronary artery disease. DESIGN: Sixty patients (44 males, mean age 62 +/- 13 years) with acute coronary syndrome and 40 with stable coronary artery disease (31 males, age 64 +/- 10 years) and a control group of 40 individuals (34 males, 53 +/- 5 years) were analyzed. IgG against Chlamydia pneumoniae, Cytomegalovirus and Helicobacter pylori plus C-reactive protein were assessed in all serum samples. In addition, IgM against C. pneumoniae and Cytomegalovirus on admission and C-reactive protein one month later were measured in acute patients. RESULTS: No IgM seropositivity was observed. A high prevalence of IgG seropositivity with no significant differences among the groups was found: C. pneumoniae: acute group 44 (73%), stable group 29 (73%) and control group 25 (63%); Cytomegalovirus: 55 (92%), 37 (92%) and 38 (95%), respectively; and H. pylori, 43 (72%), 32 (80%) and 34 (85%) respectively. There was a high rate of positive C-reactive protein in the acute group: 48 (80%) vs 10 (25%) the stable group and 0% the control group (p < 0.001). C-reactive protein levels were higher in Q-wave infarction than in unstable angina/ non-Q-wave infarction (median 22.65 vs 7.69, p < 0.001). One month later, C-reactive protein levels decreased (median 22.65 vs 3.38, p < 0.001), but were still positive in 40%. CONCLUSIONS: These data suggest that inflammation is detected by the commonly used methods in clinic practice in acute coronary syndromes and to a lesser extent in stable coronary artery disease. It seems that different mechanisms other than infection account for this inflammatory response, at least this being so when infection is assessed by serology. Serology does not appear to be an adequate method to determine the possible relationship among coronary syndromes, infection and inflammation.

[Thrombolysis in the elderly with acute myocardial infarction. The PRIAMHO study]. / Trombólisis en el anciano con infarto agudo de miocardio. El estudio PRIAMHO.

INTRODUCTION: In the elderly with acute myocardial infarction the risks and benefits of thrombolytic therapy are not well defined due mainly to the lack of randomized trials. In the present study we examined the clinical profile of the aged treated with thrombolytic agents and the effects of that therapy on 28 day and 1 year mortality. PATIENTS AND METHODS: We studied 733 patients aged > 75 years (mean: 79.9) admitted to the Coronary Care Unit (CCU) of 24 Spanish hospitals with a confirmed diagnosis of Q-Wave myocardial infarction (MI). On admission, 293 patients were treated with thrombolytics and 440 patients received standard therapy. The difference between the two groups in the clinical profile of MI, treatments administered in CCU, evolutive course and 28 day and 1 year mortality were assessed. RESULTS: The independent predictors related to the use of thrombolytic therapy were age (OR: 0.93; 95% CI: 0.89-0.97), history of arterial hypertension (OR: 0.85; 95% CI: 0.71-1.01), delay time to admission (OR: 0.998; 95% CI: 0.997-0.999), anterior location of infarct (OR: 1.21; 95% CI: 1.01-1.24) and Killip Class III-IV (OR: 0.79; 95% CI: 0.64-0.97). During the evolution thrombolysis therapy was associated with lower rates of Killip III-IV (p < 0.00001), complete AV block (p = 0.037), intraventricular conduction defects (p = 0.046) and a higher incidence of stroke (p < 0.01). The 28-day mortality was also significantly lower in the group receiving thrombolytics (27 vs 31. 3%; p = 0.035). However, this difference disappeared when the analysis was adjusted with other variables such as age, administration of aspirin and Killip Class III-IV (OR: 1.29; 95% IC: 0.87-1.92). CONCLUSIONS: The results of this trial suggest that in the elderly with acute myocardial infarction thrombolysis is associated with a less complicated evolutive course and a lower 28-day mortality. However, these findings could be mediated by other covariables such as age, more frequent use of aspirin and a higher number of patients with Killip Class III-IV excluded from the thrombolytic therapy.

[Unstable angina in the elderly: clinical, profile, management and mortality at three months. The PEPA Registry Data]. / Angina inestable en el anciano: perfil clínico, manejo y mortalidad a los tres meses. Datos del registro PEPA.

INTRODUCTION AND OBJECTIVES: Few reports in the literature have studied the characteristics and management of unstable angina in the elderly in Spain. The aim of this study was to analyze the clinical characteristics and the use of diagnostic and therapeutic resources in patients > or = 70 years of age. PATIENTS AND METHODS: A total of 1,551 patients > or = 70 years of age were included out of 4,115 included in the PEPA registry with a follow up of 90 days. These patients were compared with 2,564 < 70 years. RESULTS: In comparison, the elderly (76 +/- 5 years) versus the younger group (58 +/- 8.5 years) included a higher proportion of women (43 vs 27%), diabetics (30 vs 23%)and hypertensive patients (60 vs 49%) with a lower proportion (p < 0.001) of hypercholesterolemia (33 vs 43%), smoking (40 vs 60%) or family history (9 vs 17%). A previous history of angina (49 vs 35%) or infarction (38 vs31%) and comorbidity was found to be significantly more frequent in the elderly, with a worse previous functional class (NYHA > 2 out of 34 vs 15%). The elderly were treated with fewer invasive procedures (25 vs 44%) or catheterization (26 vs 36%) and they were more frequently controlled with medical treatment (86 vs 83%) although with a lower use of beta blockers (45 vs 53%). The mortality at 3 months was greater in the elderly (7.4 vs 3.0%;p < 0.005) with age being an independent predictor of bad prognosis. Cox multivariate analysis showed the age, ST segment depression, diabetes and heart failure on admission to be predictors of bad prognosis in the elderly. CONCLUSIONS: A different pattern is observed in cardiovascular risk factors with a more unfavorable clinical profile in elderly patients with unstable angina. The management of these patients is less aggressive and the mortality is greater. Diabetes, heart failure and ST segment depression on admission are independent predictors of bad prognosis in elderly patients.

[Prognostic implications of early discharge from the coronary unit in patients with acute myocardial infarction]. / Implicaciones pronósticas del alta precoz de la unidad coronaria en pacientes con infarto agudo de miocardio.

INTRODUCTION AND OBJECTIVES: The high demand for health care has obliged Coronary Units to hasten the discharge of patients in less serious condition and this might be an influence on their prognosis. Our objective have been: a) to analyse the characteristics and the evolution (death or readmission) during the first month of patients with myocardial infarction and very early discharge from the Coronary Unit (stay of 2 days or less), and b) to assess the profile of very low risk group patients for complications who could be discharged early from the Coronary Unit. PATIENTS AND METHODS: A study of 978 consecutive patients who had been admitted for acute myocardial, in faration were divided into two groups according to their length of stay in the Coronary Unit (A < or = 2 and B > 2 days). Their baseline characteristics, course of stay and vital status at month, were compared. A subgroup of patients at low risk was studied and complications that might have arisen from their early discharge from the Coronary Unit were assessed. RESULTS: Seventy-three patients (7.5%) died within the first two days. Of the remaining 905, the stay was 2 days or less for 336 patients (group A); and longer than 2 days for 569 (group B). Group A had a higher frequency of dyslipemia, Killip class I on admission, uncomplicated myocardial infarction in the Coronary Unit and the use of beta-blockers and had less frequency of diabetes, Q wave myocardial infarction, anterior infarction or the use of fibrinolytics. In the first month after discharge from the Coronary Unit, 10 patients from group A and 18 patients from group B died, the rate of death or readmission into the Coronary Unit within 30 days was similar between both groups (group A = 13% and group B = 13%). A multiple regression showed that Killip class on admission (p < 0.001) and an uncomplicated course (p < 0.001) were independently related with the length of stay in the coronary unit. A subset of 378 low risk patients (Killip I on admission, uncomplicated course in the ICU and age < 71 years) had no mortality at 30 days and their readmission rate in the first month was 4%. In this subgroup, those patients whose stay was equal to or less than two days were more frequently readmitted in the first week. (group A = 9/197 [5%] and group B = 1/181 ([0.5%]; p = 0.034). CONCLUSION: Selected patients with myocardial infarction can be discharged very early from the Coronary Unit with a low risk of death. A readmission rate following discharge of some 5% must be allowed for these patients.

[Preoperative coronary angiography in valve patients. Criteria for indication in a determined population]. / Coronariografía preoperatoria en pacientes valvulares. Criterios de indicación en una determinada población.

BACKGROUND AND PURPOSE: The indication for preoperative coronary angiography in patients with valvular heart disease depends on the prevalence of coronary disease in these patients, which differs among different geographical areas. Our aim was to determine the indication criteria for preoperative coronary angiography in our population. METHODS: We studied retrospectively the prevalence of significant coronary disease in 511 consecutive patients with valvular disease diagnosed by non-invasive methods, who underwent preoperative coronary angiography from August/1991 to July/1996. We analyzed in each patient: demographic data, symptoms and presence of risk factors for coronary artery disease. We considered that preoperative coronary angiography had to be performed on patients who had a coronary artery disease prevalence > or = 5%. RESULTS: Mean age was 64 +/- 10 years (51% male). There was mitral valvulopathy in 135 patients, aortic in 234 and combined mitro-aortic in 142. Angina was present in 30% of patients, and risk factors for coronary artery disease in 52%. The prevalence of significant coronary disease was 20.3%. It was significantly higher in patients with angina (35.3% versus 13.8% in patients without angina) and in those with risk factors (28% versus 12.2% in patients without risk factors); no differences between valvulopathies were found. Age was significantly higher in patients with coronary disease (69 +/- 8 versus 63 +/- 10 years). Multivariate analysis showed three independent predictors for significant coronary disease: 1) age; 2) previous angina, and 3) risk factors. Regarding the prevalence of significant coronary disease in patients neither angina nor risk factors was < 5% in males who were under 60 years old (1 man; 3.3%) and in females under 65 years old (2 women; 3.5%). CONCLUSIONS: In our reference population and in others with a similar cardiovascular profile, preoperative coronary angiography is indicated in males who are > or = 60 years old and in females who are > or = 65 years old, and in younger patients who present angina or risk factors, regardless of the valvulopathy present.

[The safety of the treatment of an acute myocardial infarct by immediate intravenous fibrinolysis in the regional hospital environment]. / Seguridad del tratamiento del infarto agudo de miocardio mediante fibrinólisis intravenosa inmediata en el ámbito hospitalario comarcal.

INTRODUCTION AND OBJECTIVES: Our aim was to evaluate the utility of thrombolytic therapy administered outside tertiary hospital. METHODS: We analyzed 80 consecutive patients with acute myocardial infarction admitted to the emergency area of primary hospital within 24 hours after the onset of symptoms and lastly transported to a coronary care unit (CCU) of a reference hospital. The thrombolytic protocol was performed by medicine department of primary hospital and the CCU of reference hospital. RESULTS: 23 patients without (group A) and 57 with (group B) fibrinolytic therapy (APSAC 50 patients and streptokinase 7 patients) were analyzed. Group A patient were older (mean: 67 +/- 11 vs mean: 62 +/- 10 years; p = 0.01), and arrived later to emergency area (mean 254 +/- 284 vs mean 163 SD 161 min; p = 0.04) and to the coronary care unit (mean 561 +/- 371 vs mean 334 +/- 177 min; p = 0.0002). The guard physician decision to start or not the fibrinolytic therapy, was adequate in 86% of the patients (sensitivity 87%, predictive positive value 95%, specificity 83%). Complications on emergency area or during transport in group B were ventricular fibrillation in 9%, AV block (2-3 degree) in 9%, severe nonsustained ventricular arrhythmia in 11% and transitory hypotension in 23%. No death occurred before CCU admission. In group B, 35% patients was treated within the first 2 hours. The average time gain was 124 min (thrombolysis administration--CCU admission). CONCLUSION: On emergency area of primary hospital, thrombolytic therapy is feasible and safe when administered by well-equipped and well-trained medical emergence area and ambulance staff.

[Acute pleuropericarditis and cardiac tamponade as extraintestinal complications of ulcerative colitis]. / Pleuropericarditis aguda y taponamiento cardíaco como complicaciones extraintestinales de la colitis ulcerosa.

Pericarditis and cardiac tamponade are very rare complications of inflammatory disease of the bowel. A case of a patient with ulcerative colitis, who subsequently developed pericarditis, cardiac tamponade and pleural effusion during a latent phase of the baseline disease, is presented. At the same time, the papers published on this subject are reviewed. The presence of dyspnea, tachypnea, of pleuritic pain in patients with ulcerative colitis must be taken into consideration, and all the tests necessary to study a pleuropericardial pathology should be performed.