[Variability in the in-hospital management of acute myocardial infarction in Spain. IBERICA Study (Investigación, Búsqueda Específica y Registro de Isquemia Coronaria Aguda)]. / Variabilidad en el manejo hospitalario del infarto agudo de miocardio en España. Estudio IBERICA (Investigación, Búsqueda Específica y Registro de Isquemia Coronaria Aguda)

Introduction and objective. Although some in-hospital studies have described the management of acute myocardial infarction (MI) patients in Spain, none has been able to guarantee the exhaustiveness of patient registry. This study sought to determine the clinical characteristics and in-hospital management of patients with MI in eight Spanish population registries.Methods. The IBERICA study is a population-based MI registry carried out in the 25 to 74 year-old population, in eight Spanish regions in 1997. A standardized methodology was used to register and investigate all MI arriving alive to a hospital. Clinical characteristics, cardiovascular risk factors prevalence, pharmacological treatment, invasive and non-invasive procedures performed and complications at 28 days of evolution were recorded. A descriptive analysis was performed and the variation coefficient (VC) was calculated.Results. In 1997, 4,041 MI patients were registered, 79.9% were men with a mean age of 61.1 years. Although 10.9% (95% CI: 9.9-11.9%) were not admitted to the coronary care unit, a large variability existed among different areas (VC = 53%). There was a high variability in the utilization and performance of non-invasive and invasive procedures among regions, as well as in the use of pharmacological treatment. Only the use of antiaggregants (91.5%) and thrombolytic therapy (41.8%) showed a low variability (VC < 10%). Twenty-eight day mortality was 16.2% (95% CI: 15.1-17.4%) with a high variability being observed among the different regions (VC = 20.6%).Conclusion. Patient characteristics vary among the different Spanish regions. The differences in management and prognosis suggest a lack of equality in the health care provided to MI patients in the different regions in Spain.

[The practical clinical guidelines of the Sociedad Española de Cardiología on coronary surgery]. / Guías de práctica clínica de la Sociedad Española de Cardiología en cirugía coronaria.

Surgery in coronary disease, including myocardial revascularization and the surgery of mechanical complications of acute myocardial infarction, has shown to improve the symptoms, quality of life and/or prognosis in certain groups of patients. The expected benefit in each patient depend on many well-known factors among which the appropriateness of the indication for surgery is fundamental. The objective of these guidelines is to review current indications for cardiac surgery in patients with coronary heart disease through an evaluation of the degree of evidence of effectiveness in the light of current knowledge (systematic review of bibliography) and expert opinion gathered from various reports. Indications and the degree of recommendation for conventional coronary artery bypass grafting have been established for each of the most frequent anatomo-clinical situations defined by clinical symptoms (stable angina, unstable angina and acute myocardial infarction) as well as by left ventricular function and extend of coronary disease. Furthermore, the subgroups with the greatest surgical risk and stratification models are described to aid the decision making process. Also we analyse the rational basis and indication for the new surgical techniques such as minimally invasive coronary surgery and total arterial revascularization. Finally, the indication and timing of surgery in patients with mechanical complications of acute myocardial infarction are considered.

Randomized comparative trial of triflusal and aspirin following acute myocardial infarction.

AIMS: To compare the efficacy and tolerability of the antiplatelet agent triflusal with aspirin in the prevention of cardiovascular events following acute myocardial infarction. METHODS AND RESULTS: In this double-blind, multicentre, sequential design study, patients were randomized within 24 h of acute myocardial infarction symptom onset to receive triflusal 600 mg or aspirin 300 mg once daily for 35 days. The primary end-point was death, non-fatal myocardial reinfarction or a non-fatal cerebrovascular event. The incidences of these individual outcomes and urgent revascularization were secondary end-points. The null hypothesis of no difference between treatments in the primary combined end-point was accepted with 80% power after recruiting 2124 validated patients (odds ratio (OR) for failure [95% confidence interval (CI)]: 0.882 [0.634-1.227]). Non-fatal cerebrovascular events were significantly less frequent with triflusal (OR [95% CI]: 0.364 [0.146-0.908]; P = 0.030). There was no significant difference between treatments for death (OR [95% CI]: 0.816 [0.564-1.179]; P = 0.278), non-fatal reinfarction (OR [95% CI]: 1.577 [0.873-2.848]; P = 0.131) or revascularization (OR [95% CI]: 0.864 [0.644-1.161]; P = 0.334). Overall, both drugs were well tolerated, although there was a trend towards fewer bleeding episodes with triflusal; significantly fewer central nervous system bleeding episodes were observed in triflusal-treated patients (0.27% vs. 0.97%; P = 0.033). CONCLUSION: Triflusal and aspirin have similar efficacy in preventing further cardiovascular events after acute myocardial infarction, but triflusal showed a more favourable safety profile. Triflusal significantly reduced the incidence of non-fatal cerebrovascular events compared with aspirin.

[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.

Prevalence of angina pectoris in Spain. PANES Study group.

The frequency of coronary heart disease in a community is usually measured by myocardial infarction incidence and mortality rates. The measurement of the prevalence of angina pectoris may, however, become a convenient way of assessing coronary heart disease morbidity in the future. The aim of this study was to determine the prevalence of angina and validity of the Rose questionnaire in the Spanish population aged from 45 to 74 years. A cross-sectional study was conducted in 10,248 subjects (45-74 years), representative of the Spanish population. The WHO Rose questionnaire was used and a construct validation against regional mortality rates and cardiovascular risk factor prevalence was devised. The overall angina prevalence increased with age both in men and women, but was higher in the latter (7.3% and 7.7%, respectively). Angina prevalence also increased with the number of cardiovascular risk factors present and correlated with regional CHD mortality rates (r = 0.66). Sensitivity and specificity results of the Rose questionnaire were low when tested against exercise test (52.9% and 52.1%, respectively). As conclusions, Rose questionnaire is a reliable tool for assessing angina prevalence in the Spanish population which is similar to that of other industrialized countries with higher myocardial infarction morbidity and mortality.

[The characteristics, management and prognosis of the acute myocardial infarct patient in the Valencian Community in 1995: the results of the PRIMVAC Registry (The Registry Project of Acute Myocardial Infarct in Valencia, Alicante and Castellón). As representatives of the PRIMVAC investigators]. / Características, manejo y pronóstico del paciente con infarto agudo de miocardio en la Comunidad Valenciana en 1995: resultados del registro PRIMVAC (Proyecto de Registro de Infarto Agudo de Miocardio de Valencia, Alicante y Castellón). En represntación de los investigadores del PRIMVAC.

BACKGROUND AND OBJECTIVES: Regional registers of patients with acute myocardial infarction are scarce in Spain. The PRIMVAC register (Proyecto de Registro de Infarto agudo de Miocardio de Valencia, Alicante y Castellón) was initiated to obtain updated information on the management of these patients in the Valencia Autonomous Community. Data of the first twelve months of the register are presented. METHODS: The 17 participating hospitals cover 2,833,938 inhabitants. Demographic, clinical, procedural and outcome data as well as predictive variables of mortality were analysed in the patients with acute myocardial infarction during their stay in the coronary care units from 1 December 1994 to 30 November 1995. RESULTS: During 12 months, 2,377 patients were included. Mean age was 65.3 years (SD 11.9) and 23.2% were female. Left ventricular failure was present in 39.8%. Thrombolytic therapy was applied in 42.1% with a median time delay of 195 min from chest pain onset. This time was longer in the women (250 min) and in the elderly (210 min). The in-coronary-care-unit-mortality rate was 13.9%. Age, female gender, diabetes, previous myocardial infarction, Q wave and right ventricular infarction independently predicted increased early mortality. CONCLUSION: Present data show the feasibility of an acute myocardial infarction register in the Valencia Autonomous Community. Although an acceptable level of thrombolysis has been reached, the mortality rate is still high. The long delay in initiating thrombolysis, particularly in female and elderly patients is remarkable.

[The prevalence of angina and cardiovascular risk factors in the different autonomous communities of Spain: the PANES Study. Prevalencia de Angina en España]. / Prevalencia de angina y factores de riesgo cardiovascular en las diferentes comunidades autónomas de España: estudio PANES.

INTRODUCTION AND OBJECTIVE: The study of angina prevalence has received little attention in the analysis of the dimension of coronary heart disease. The aim of this study was to determine the prevalence of angina and cardiovascular risk factors in the 45- to 74-year-old population of the different autonomous regions of Spain. METHODS: A sample of 10,248 subjects was recruited. Sampling was stratified by gender and age groups (45-54, 55-64 and 65 to 74 years), and proportional to the population distribution of the different autonomous regions. A multistage sampling was performed, firstly 200 villages were randomly selected, secondly three different socio-economic household were chosen. Sample unit was neighbouring households. Rose questionnaire of angina and a structured questionnaire to collect socio-demographic and risk factor variables were administered. RESULTS: Angina prevalence in the 45- to 74-year-old Spanish population was 7.5%. The autonomous regions with the higher and lower prevalence were Baleares (11.4%) and Basque Country (3.1%), respectively. The Pearson correlation coefficient between angina prevalence and ischemic heart disease or cardiovascular disease mortality in men and women was 0.52 and 0.55, and 0.31 and 0.44, respectively. The self reported prevalence of hypertension, dyslipemia, diabetes and smoking was 31.1%, 24.2%, 14.3% and 34.6% respectively. CONCLUSIONS: Angina prevalence in Spain is similar to that of developed countries although significant differences were observed among the autonomous regions of Spain. These differences correlate with those observed in ischemic heart disease or cardiovascular mortality among them and are associated with the cardiovascular risk factors prevalence which also varies among communities.

[The RICVAL study. Acute myocardial infarct in the city of Valencia. Data on 1,124 patients during the first twelve months of the registry (December, 1993--November, 1994)]. / Estudio RICVAL. El infarto agudo de miocardio en la ciudad de Valencia. Datos de 1,124 pacientes en los primeros 12 meses del Registro (diciembre de 1993-noviembre de 1994). Investigadores del RICVAL.

BACKGROUND AND OBJECTIVES: Information on the management of acute myocardial infarction in Spain is still scarce. The Register of Acute Myocardial Infarction of Valencia City (RICVAL) was established to collect, in a prospectively and uniformly way, data of patients with acute myocardial infarctions discharged from Valencia coronary care units, in order to obtain updated information on the management of these patients. Data of the first twelve months of the register are presented. METHODS: Using standardised variables, demographic, clinical, procedural and outcome data from patients with acute myocardial infarction were collected at the eight hospitals collaborating in the RICVAL, from 1 December 1993 to 30 November 1994. RESULTS: The eight participating hospitals cover 1,665,720 people. During 12 months, 1,124 patients were discharged from the participating coronary care units. Mean age was 65.1 years and 23.9% were female. The case fatality rate was 16.9%. Left ventricular failure (Killip 2, 3 and 4) was present in 42%. Thrombolytic therapy was applied in 43.5% with a median time delay of 210 minutes from chest pain onset. The delay time in initiating thrombolysis was longer in the women and in the elderly. CONCLUSION: Analysis of present data shows the feasibility of an acute myocardial infarction register in Valencia City. The RICVAL study will allow a better knowledge of demographic, clinical, procedural and outcome data in patients with myocardial infarction. The case fatality rate is still high when we consider that an acceptable level of thrombolytic therapy has been reached. The long delay time in initiating thrombolysis, particularly in the elderly and in the women, must be emphasized.

[Differential characteristics and survival of women with acute myocardial infarction. Registry of Acute Myocardial Infarctions of the City of Valencia (RICVAL). Researchers of the RICVAL]. / Características diferenciales y supervivencia del infarto agudo de miocardio en la mujer. Registro de infartos agudos de miocardio de la ciudad de Valencia (RICVAL). Investigadores del RICVAL.

INTRODUCTION AND OBJECTIVES: The prevalence of women who are admitted to the hospital after acute myocardial infarction is lower to that of men and their prognosis is worse. The reason for these differences is unclear. We studied the demographic and historical variables, the evolution, treatment and early survival in 269 women included in the Register of Acute Myocardial Infarctions of the City of Valencia (RICVAL) and compared them with the 855 men included in the same Register. PATIENTS AND METHODS: Register of patients admitted into a Coronary Care Unit in the City of Valencia since December, 1st, 1993 until November 30th, 1994. RESULTS: 23.9% of the patients were women with a mean age of 71.9 +/- 9 years; 46.8% of them were diabetics, 55.4% hypertensives, and 6.7% smokers. The women arrived for treatment later than men and 34.9% of them were thrombolised. The incidence in women of severe heart failure (Killip III and IV) was 40.1% and the mortality 29.7%. In women with thrombolytic treatment the mortality was 29.8%. In the logistic regression model performed, female sex predicted a higher mortality rate (odds ratio [OR] = 1.30; confidence interval [CI], 1.05-1.61). CONCLUSIONS: Early mortality in women after acute myocardial infarction is higher than in men in the RICVAL Register. The longer delay in initiating medical care and thrombolysis might be the cause for the higher proportion of heart failure among women and explain their worse prognosis after an acute myocardial infarction compared to men.

[Basis for a hospital registry of acute myocardial infarction in Spain. The PRIAMO study. Project of a Hospital Registry of Acute Myocardial Infarction]. / Bases para un registro hospitalario de infartos agudos de miocardio en España. El estudio PRIAMHO. Proyecto de Registro de Infarto Agudo de Miocardio Hospitalario.

BACKGROUND AND OBJECTIVES: Information on the management of myocardial infarction in Spain in scarce. PRIAMHO (Proyecto de Registro de Infarto Agudo de Miocardio Hospitalario) study is aimed at developing standardized methods to allow the registration of characteristics and management of patients discharged with a diagnosis of myocardial infarction. Methods and results of the pilot study are presented. METHODS: In the present collaborative study with one-year follow-up, all patients diagnosed with myocardial infarction discharged from 33 Spanish hospitals are registered for one year including their demographic, clinical and outcome characteristics, as well as details on their management when admitted to a coronary care unit. Standardized definitions of diagnosis and measurements are used. Confidentiality of patients' identity and anonymous participation of each center are also warranted. RESULTS: The 33 participant coronary care units, covering some 10,000,000 people, admitted on average 83.9% of myocardial infarction patients of their hospital. In 16 participating centers there is a laboratory of hemodynamics and in 11 coronary surgery. During the pilot study, 606 patients were discharged from the participating coronary care units where the case-fatality, rate was 10.3%. While 19.8% of patients developed left heart failure, 44.1% received thrombolytic therapy. The delay between onset of symptoms and first monitoring was approximately 6 hours, and thereafter admission to the coronary unit about 3 hours. CONCLUSION: PRIAMHO study will allow to establish of the fundamentals for developing a nation-wide myocardial infarction register and will provide an accurate perspective of the characteristics and management of this disease in Spain.

Protective effect of triflusal against acute myocardial infarction in patients with unstable angina: results of a Spanish multicenter trial. Grupo de Estudio del Triflusal en la Angina Inestable.

A multicenter, double-blind, placebo-controlled study was carried out to evaluate the effect of a new antiplatelet agent, triflusal (2-acetoxy-4-trifluoromethyl benzoic acid), in the prevention of nonfatal myocardial infarction and cardiac or vascular death (principal end-points) in patients with unstable angina. 281 patients were randomly assigned to triflusal (300 mg t.i.d.; n = 143) or placebo (n = 138). After 6 months of treatment, the incidence of nonfatal acute myocardial infarction was significantly lower in the triflusal than in the placebo group: 6 patients (4.2%) versus 17 (12.3%), p = 0.013. The low number of deaths (2/143 triflusal versus 0/138 placebo recipients) hampered statistical analysis of mortality rates. The need for revascularization was similar in the two groups: 24 patients (16.8%) in the triflusal group and 28 (20.3%) in the placebo group, p = 0.449. In conclusion, the results show that treatment with triflusal can reduce the incidence of myocardial infarction in patients with unstable angina.