Association between new-onset right bundle branch block and primary or secondary ventricular fibrillation in ST-segment elevation myocardial infarction.

AIMS: New-onset right bundle branch block (RBBB) in myocardial infarction (MI) is often associated with ventricular fibrillation (VF) but the nature of this relationship has not been determined. METHODS AND RESULTS: Between 1998 and 2014, among other data, incidence and duration of RBBB and VF occurrence were prospectively collected in 5301 patients with ST-segment elevation MI (STEMI) admitted to two University Hospitals in Murcia (Spain). Multinomial adjusted logistic regression analyses were used to examine the association between RBBB, attending to its duration, and VF according to its primary VF (PVF) or secondary VF (SVF) character. Among 284 (5.4%) patients with new-onset RBBB, 158 were transient and 126 permanent. VF occurred in 339 (6.4%) patients, 201 PVF and 138 SVF, documented within the first 2 h of symptoms-onset in 78% and 60%, respectively. New-onset RBBB was more frequent in PVF (11.4%) and SVF (20.3%), than in non-VF (4.7%). Transient RBBB incidence was higher in PVF (9.0%) and SVF (9.4) than in non-VF (2.6%), whereas permanent RBBB was higher in SVF (10.9%) than PVF (2.5%) and non-VF (2.1%). New-onset RBBB 1.83 [95% confidence interval (CI): 1.07-3.11] and new-onset transient RBBB 2.39 (95% CI: 1.32-4.32) were independently associated with PVF. New-onset 3.03 (95% CI: 1.83-5.02), transient 2.40 (95% CI: 1.27-4.55), and permanent 2.99 (95% CI: 1.52-5.86) RBBB were independently associated with SVF. CONCLUSION: New-onset RBBB and VF in STEMI are independently associated and show particularities based on the duration of the conduction disturbance and/or the primary or secondary character of the arrhythmia.

Effect of part-time cardiac catheterization facilities in patients with acute myocardial infarction.

BACKGROUND: Although the easy availability of invasive cardiac care facilities is associated with an increase in their use, their influence on outcomes is not clear. We sought to investigate whether a newly available cardiac catheterization laboratory (CCL) performing percutaneous coronary intervention (PCI) on a part-time (PT) basis might improve outcomes in patients with acute myocardial infarction (AMI). METHODS: This was an observational cohort study that included all consecutive patients with AMI admitted to a secondary-level hospital in Spain before and after the PT-CCL opened in January 2006: during 1998-2005 and 2006-2014, respectively. All-cause in-hospital and long-term mortality were the co-primary endpoints. In-hospital complications and length of stay were secondary endpoints. For the analyses, patients were stratified according to propensity-score (PS) quintiles. RESULTS: A total of 5339 patients were recruited, and 50.3% were managed after the opening of the PT-CCL. The PT-CCL was associated with greater use of PCI (81.2 vs. 32.5%, p<0.001) and guidelines-recommended medication (all p<0.001), lower risk of recurrent angina (PS-adjusted RR=0.160, 95% CI 0.115-0.222) and shorter length of hospital stay (PS-adjusted RR for length of stay <8days=0.357, 95% CI 0.301-0.422). In patients with NSTEMI, PT-CCL was associated with improved long-term survival (PS-adjusted HR=0.764, 95% CI 0.602-0.970). CONCLUSIONS: In patients with AMI, a new PT-CCL was associated with greater use of PCI and guideline-recommended medication, lower risk of recurrent angina and shorter length of hospital stay. In a subset of patients with NSTEMI, PT-CCL was associated with improved long-term survival.

Nivel de estudios y mortalidad a largo plazo en pacientes con infarto agudo de miocardio / Educational level and long-term mortality in patients with acute myocardial infarction

Introducción y objetivos. Existe controversia acerca del valor del nivel socieconómico como marcador pronóstico en el infarto agudo de miocardio. El objetivo de este estudio fue evaluar el impacto del nivel de estudios, como marcador del estatus socioeconómico, sobre el pronóstico vital a largo plazo tras un infarto agudo de miocardio. Métodos. Estudio prospectivo y observacional de 5.797 pacientes hospitalizados por un infarto agudo de miocardio. Se estudió la mortalidad por todas las causas a largo plazo (mediana 8,5 años) mediante modelos de regresión ajustados. Resultados. Un 73,1% de los pacientes había cursado estudios primarios (n = 4.240), los segundos más frecuentes fueron los estudios medios (secundaria, bachiller) (n = 843; 14,5%). Un 7,0% (n = 407) era analfabeto y el 5,3% tenía estudios superiores (n = 307). Los pacientes con un nivel de estudios medio o superior fueron significativamente más jóvenes, en mayor proporción varones y presentaban menos factores de riesgo y comorbilidad. Eran pacientes que acudían antes al hospital y se presentaban con menor grado de insuficiencia cardiaca. Durante el ingreso recibieron con más frecuencia terapia de reperfusión y su mortalidad cruda fue inferior. El tratamiento hospitalario y al alta incluyó más fármacos recomendados por las guías. En un contexto multivariado, el nivel de estudios medio o superior se mostró como un predictor independiente y protector respecto de la mortalidad a largo plazo (hazard ratio = 0,85; intervalo de confianza del 95%, 0,74-0,98). Conclusiones. Este estudio muestra una relación inversa e independiente entre el nivel de estudios previos y la mortalidad a largo plazo en pacientes que han experimentado un infarto agudo de miocardio (AU)

Introduction and objectives: The value of socioeconomic status as a prognostic marker in acute myocardial infarction is controversial. The aim of this study was to evaluate the impact of educational level, as a marker of socioeconomic status, on the prognosis of long-term survival after acute myocardial infarction. Methods: We conducted a prospective, observational study of 5797 patients admitted to hospital with acute myocardial infarction. We studied long-term all-cause mortality (median 8.5 years) using adjusted regression models. Results: We found that 73.1% of patients had primary school education (n = 4240), 14.5% had secondary school education (including high school) (n = 843), 7.0% was illiterate (n = 407), and 5.3% had higher education (n = 307). Patients with secondary school or higher education were significantly younger, more were male, and they had fewer risk factors and comorbidity. These patients arrived sooner at hospital and had less severe heart failure. During admission they received more reperfusion therapy and their crude mortality was lower. Their drug treatment in hospital and at discharge followed guideline recommendations more closely. On multivariate analysis, secondary school or higher education was an independent predictor and protective factor for long-term mortality (hazard ratio = 0.85; 95% confidence interval, 0.74-0.98). Conclusions: Our study shows an inverse and independent relationship between educational level and long-term mortality in patients with acute myocardial infarction (AU)

Importancia de la presencia de cardiomegalia en el pronóstico de los pacientes con infarto agudo de miocardio / Prognostic importance of cardiomegaly in patients with acute myocardial infarction

Objetivos: Conocer el significado pronóstico intrahospitalario y a largo plazo de la presencia de cardiomegalia en la radiología simple inicial de los pacientes ingresados por infarto agudo de miocardio. Métodos: Estudio prospectivo de 7.644 pacientes ingresados por un infarto agudo de miocardio en dos hospitales. Se obtuvo información clínica detallada y se prestó especial atención a la presencia/ausencia de cardiomegalia en la radiografía de tórax. Realizamos modelos ajustados para predecir mortalidad (por cualquier causa) hospitalaria y tras el alta con una mediana de 6 años. Resultados: 1.351 (17,7%) pacientes presentaron cardiomegalia. La mortalidad hospitalaria global fue 11,2% y la densidad de incidencia de mortalidad a largo plazo fue de 5,7 por cada 100 pacientes-año. Los pacientes con cardiomegalia presentaron mayor edad y más factores de riesgo cardiovascular excepto tabaquismo activo, mayor comorbilidad, fueron menos revascularizados y tratados al alta de forma subóptima. Durante la hospitalización, la cardiomegalia se asoció a mayores tasas de complicaciones, especialmente insuficiencia cardiaca (70,8 vs 21,4%, p < 0,001) y mortalidad (27,8 vs 7,7%, p < 0,001). La cardiomegalia resultó predictor independiente sobre la mortalidad hospitalaria (odds ratio = 1,34; p = 0,02) y tras el alta (hazard ratio = 1,16, p < 0,01). Conclusiones: En pacientes con infarto agudo de miocardio la cardiomegalia resultó predictor independiente de mortalidad hospitalaria y a largo plazo tras el alta (AU)

Objectives: To assess the in-hospital and long-term prognostic importance of cardiomegaly demonstrated by a simple admission radiograph in patients hospitalized for acute myocardial infarction. Methods: Prospective study of 7644 patients admitted for acute myocardial infarction; 2 hospitals participated. We recorded detailed clinical data, especially noting the presence or absence of cardiomegaly in the chest radiograph. Adjusted predictive models for all-cause mortality in hospital or after discharge were constructed. The median follow-up was 6 years. Results: Cardiomegaly was detected in 1351 (17.7%) of the patients. Hospital mortality was 11.2% overall; the incidence of long-term mortality was 5.7 per 100 patient-years. Patients with cardiomegaly were older and had more cardiovascular risk factors other than current smoking; they also had more concomitant conditions, had undergone fewer revascularization procedures, and received suboptimal care after discharge. Cardiomegaly was associated with higher in-hospital rates of adverse events, especially heart failure (70.8% in patients with cardiomegaly vs 21.4% in others, P<.001) and death (27.8% vs 7.7%, P<.001). Cardiomegaly was also an independent predictor of hospital mortality (odds ratio, 1.34; P=.02) as well as mortality after discharge (hazard ratio, 1.16; P<.01). Conclusions: Cardiomegaly was an independent predictor of both hospital mortality and long-term mortality after discharge in this series (AU)

Relation of New Permanent Right or Left Bundle Branch Block on Short- and Long-Term Mortality in Acute Myocardial Infarction Bundle Branch Block and Myocardial Infarction.

The aim of this study was to investigate the prognosis associated with bundle branch block (BBB) depending on location, time of appearance, and duration in patients with myocardial infarction (MI). From January 1998 to January 2008, we recruited 5,570 patients with acute MI. Thirty-day and 7-year all-cause mortality, according to BBB location, time of appearance, and duration were analyzed by multivariable analyses. BBB was present in 964 patients (17.3%); right BBB (RBBB) 10.6% and left BBB (LBBB) 6.7%. Overall mortality rate at 30 days was 13.2% (n = 738) and 7 years was 6.34 deaths per 100 patient-year. Both RBBB and LBBB were more frequently previous, 42.9% and 58.8%. Compared with non-BBB, all BBB groups showed higher prevalence of co-morbidities, especially rates of diabetes (49.0% vs 34.3%, p <0.001) and more often heart failure during hospitalization (54.5% vs 26.6%, p <0.001). Compared with RBBB, patients with LBBB had a higher prevalence of co-morbidities and a higher mortality, especially the new BBB, 30 days: 52.5% versus 31.6% and 7 years (incident rate): 27.2 versus 13.3 per 100 patient-year. New transient BBB had lower heart failure on admission (42.6% vs 58.3%, p = 0.008) and 30-day mortality (20.3% vs 69.6%, p <0.001) compared with permanent in both locations. New permanent RBBB was independently associated with 30-day (hazard ratio [HR] 2.01, 95% confidence interval [CI] 1.45 to 2.79) and 7-year mortality (HR 3.12, 95% CI 2.38 to 4.09). New-permanent LBBB was independently associated with 30-day (HR 2.15, 95% CI 1.47 to 3.15) and 7-year mortality (HR 2.91, 95% CI 2.08 to 4.08). In conclusion, in patients with acute MI, the appearance of a new BBB was independently associated with a higher 30-day and 7-year all-cause mortality.

Educational Level and Long-term Mortality in Patients With Acute Myocardial Infarction.

INTRODUCTION AND OBJECTIVES: The value of socioeconomic status as a prognostic marker in acute myocardial infarction is controversial. The aim of this study was to evaluate the impact of educational level, as a marker of socioeconomic status, on the prognosis of long-term survival after acute myocardial infarction. METHODS: We conducted a prospective, observational study of 5797 patients admitted to hospital with acute myocardial infarction. We studied long-term all-cause mortality (median 8.5 years) using adjusted regression models. RESULTS: We found that 73.1% of patients had primary school education (n=4240), 14.5% had secondary school education (including high school) (n=843), 7.0% was illiterate (n=407), and 5.3% had higher education (n=307). Patients with secondary school or higher education were significantly younger, more were male, and they had fewer risk factors and comorbidity. These patients arrived sooner at hospital and had less severe heart failure. During admission they received more reperfusion therapy and their crude mortality was lower. Their drug treatment in hospital and at discharge followed guideline recommendations more closely. On multivariate analysis, secondary school or higher education was an independent predictor and protective factor for long-term mortality (hazard ratio=0.85; 95% confidence interval, 0.74-0.98). CONCLUSIONS: Our study shows an inverse and independent relationship between educational level and long-term mortality in patients with acute myocardial infarction.

Pronóstico a corto y largo plazo de la fibrilación auricular previa y de novo en pacientes con infarto agudo de miocardio con elevación del segmento ST / Short- and long-term prognosis of previous and new-onset atrial fibrillation in ST-segment elevation acute myocardial infarction

Introducción y objetivos El impacto de la fibrilación auricular en el pronóstico del infarto de miocardio sigue siendo controvertido. Se analizó la importancia pronóstica de la fibrilación auricular previa y de nueva aparición (de novo) en el hospital y a largo plazo en el infarto agudo de miocardio. Métodos Estudio prospectivo de 4.284 pacientes con infarto agudo de miocardio con elevación del segmento ST. Se estudió la mortalidad por todas las causas hospitalaria y a largo plazo (mediana, 7,2 años) mediante modelos ajustados. Resultados El 3,2% de los pacientes tenían fibrilación auricular previa y el 9,8%, de novo. En general ambos grupos de pacientes tenían un perfil de mayor riesgo basal y mayor probabilidad de complicaciones intrahospitalarias. La mortalidad bruta hospitalaria fue mayor entre los pacientes con fibrilación auricular previa que en la de novo (el 22 frente al 12%; p < 0,001; 30 frente al 10%; p < 0,001). La densidad de incidencia de mortalidad a largo plazo fue de 11,11/100 pacientes-año en la fibrilación auricular previa y 5,35/100 pacientes-año en la de novo (ambos grupos, p < 0,001). Únicamente la fibrilación auricular de novo (odds ratio = 1,55; intervalo de confianza del 95%, 1,08-2,22) fue predictor independiente de mortalidad hospitalaria. La fibrilación auricular previa (hazard ratio = 1,24; intervalo de confianza del 95%, 0,94-1,64) y la de novo (hazard ratio = 0,98; intervalo de confianza del 95%, 0,80-1,21) no resultaron predictores independientes de mortalidad a largo plazo. Conclusiones La fibrilación auricular de novo durante el ingreso es un factor independiente de mortalidad hospitalaria en el infarto agudo de miocardio (AU)

Introduction and objectives The impact of atrial fibrillation on the prognosis of myocardial infarction is still the subject of debate. We analyzed the influence of previous and new-onset atrial fibrillation on in-hospital and long-term prognosis in patients with acute myocardial infarction. Methods Prospective study of 4284 patients with ST-segment elevation acute myocardial infarction. We studied all-cause in-hospital and long-term mortality (median, 7.2 years) using adjusted models. Results In total, 3.2% of patients had previous atrial fibrillation and 9.8% had new-onset atrial fibrillation. In general, both groups of patients had a high baseline risk profile and an increased likelihood of in-hospital complications. The crude in-hospital mortality rate was higher in patients with previous atrial fibrillation than in those with new-onset atrial fibrillation (22% vs 12%; P < .001; 30% vs 10%; P < .001). The long-term mortality rate was 11.11/100 patient-years in patients with previous atrial fibrillation and 5.35/100 patient years in those with new-onset atrial fibrillation (both groups, P < .001). New-onset fibrillation alone (odds ratio = 1.55; 95% confidence interval, 1.08-2.22) was an independent predictor of in-hospital mortality. Previous atrial fibrillation (hazard ratio = 1.24; 95% confidence interval, 0.94-1.64) and new-onset atrial fibrillation (hazard ratio = 0.98; 95% confidence interval, 0.80-1.21) were not independent predictors of long-term mortality. Conclusions New-onset atrial fibrillation during hospitalization is an independent risk factor for in-hospital mortality in acute myocardial infarction (AU)

Short- and long-term prognosis of previous and new-onset atrial fibrillation in ST-segment elevation acute myocardial infarction.

INTRODUCTION AND OBJECTIVES: The impact of atrial fibrillation on the prognosis of myocardial infarction is still the subject of debate. We analyzed the influence of previous and new-onset atrial fibrillation on in-hospital and long-term prognosis in patients with acute myocardial infarction. METHODS: Prospective study of 4284 patients with ST-segment elevation acute myocardial infarction. We studied all-cause in-hospital and long-term mortality (median, 7.2 years) using adjusted models. RESULTS: In total, 3.2% of patients had previous atrial fibrillation and 9.8% had new-onset atrial fibrillation. In general, both groups of patients had a high baseline risk profile and an increased likelihood of in-hospital complications. The crude in-hospital mortality rate was higher in patients with previous atrial fibrillation than in those with new-onset atrial fibrillation (22% vs 12%; P<.001; 30% vs 10%; P<.001). The long-term mortality rate was 11.11/100 patient-years in patients with previous atrial fibrillation and 5.35/100 patient years in those with new-onset atrial fibrillation (both groups, P<.001). New-onset fibrillation alone (odds ratio=1.55; 95% confidence interval, 1.08-2.22) was an independent predictor of in-hospital mortality. Previous atrial fibrillation (hazard ratio=1.24; 95% confidence interval, 0.94-1.64) and new-onset atrial fibrillation (hazard ratio=0.98; 95% confidence interval, 0.80-1.21) were not independent predictors of long-term mortality. CONCLUSIONS: New-onset atrial fibrillation during hospitalization is an independent risk factor for in-hospital mortality in acute myocardial infarction.

[Prognostic importance of cardiomegaly in patients with acute myocardial infarction]. / Importancia de la presencia de cardiomegalia en el pronóstico de los pacientes con infarto agudo de miocardio.

OBJECTIVES: To assess the in-hospital and long-term prognostic importance of cardiomegaly demonstrated by a simple admission radiograph in patients hospitalized for acute myocardial infarction. MATERIAL AND METHODS: Prospective study of 7644 patients admitted for acute myocardial infarction; 2 hospitals participated. We recorded detailed clinical data, especially noting the presence or absence of cardiomegaly in the chest radiograph. Adjusted predictive models for all-cause mortality in hospital or after discharge were constructed. The median followup was 6 years. RESULTS: Cardiomegaly was detected in 1351 (17.7%) of the patients. Hospital mortality was 11.2% overall; the incidence of long-term mortality was 5.7 per 100 patient-years. Patients with cardiomegaly were older and had more cardiovascular risk factors other than current smoking; they also had more concomitant conditions, had undergone fewer revascularization procedures, and received suboptimal care after discharge. Cardiomegaly was associated with higher in-hospital rates of adverse events, especially heart failure (70.8% in patients with cardiomegaly vs 21.4% in others, P<.001) and death (27.8% vs 7.7%, P<.001). Cardiomegaly was also an independent predictor of hospital mortality (odds ratio, 1.34; P=.02) as well as mortality after discharge (hazard ratio, 1.16; P<.01). CONCLUSION: Cardiomegaly was an independent predictor of both hospital mortality and long-term mortality after discharge in this series.

OBJETIVO: Conocer el significado pronóstico intrahospitalario y a largo plazo de la presencia de cardiomegalia en la radiología simple inicial de los pacientes ingresados por infarto agudo de miocardio. METODO: Estudio prospectivo de 7.644 pacientes ingresados por un infarto agudo de miocardio en dos hospitales. Se obtuvo información clínica detallada y se prestó especial atención a la presencia/ausencia de cardiomegalia en la radiografía de tórax. Realizamos modelos ajustados para predecir mortalidad (por cualquier causa) hospitalaria y tras el alta con una mediana de 6 años. RESULTADOS: 1.351 (17,7%) pacientes presentaron cardiomegalia. La mortalidad hospitalaria global fue 11,2% y la densidad de incidencia de mortalidad a largo plazo fue de 5,7 por cada 100 pacientes-año. Los pacientes con cardiomegalia presentaron mayor edad y más factores de riesgo cardiovascular excepto tabaquismo activo, mayor comorbilidad, fueron menos revascularizados y tratados al alta de forma subóptima. Durante la hospitalización, la cardiomegalia se asoció a mayores tasas de complicaciones, especialmente insuficiencia cardiaca (70,8 vs 21,4%, p < 0,001) y mortalidad (27,8 vs 7,7%, p < 0,001). La cardiomegalia resultó predictor independiente sobre la mortalidad hospitalaria (odds ratio = 1,34; p = 0,02) y tras el alta (hazard ratio = 1,16, p < 0,01). CONCLUSIONES: En pacientes con infarto agudo de miocardio la cardiomegalia resultó predictor independiente de mortalidad hospitalaria y a largo plazo tras el alta.

Importancia de la carga vascular previa en la mortalidad intrahospitalaria y a largo plazo de pacientes con infarto de miocardio y segmento ST elevado / Impact of Previous Vascular Burden on In-hospital and Long-term Mortality in Patients With ST-segment Elevation Myocardial Infarction

Introducción y objetivos El paciente con síndrome coronario agudo con antecedentes de cardiopatía isquémica, arteriopatía periférica y/o accidente cerebrovascular previos muestra un peor pronóstico. Sin embargo, la relación existente entre dichos antecedentes y el pronóstico a largo plazo no ha sido aclarada del todo. Métodos Estudio prospectivo de 4.247 pacientes con infarto agudo de miocardio y segmento ST elevado. Se obtuvo información clínica detallada que incluye los antecedentes de cardiopatía isquémica, arteriopatía periférica y accidente cerebrovascular. Estudiamos la mortalidad intrahospitalaria y a largo plazo (mediana, 7,2 años) mediante modelos ajustados. Resultados Se observó que 1.131 (26,6%) pacientes tenían un territorio enfermo y 221 (5,2%), ≥ 2 territorios. La mortalidad hospitalaria total fue del 12,3% y la densidad de incidencia de mortalidad a largo plazo fue de 3,5/100 pacientes-año. Los antecedentes de cardiopatía isquémica (odds ratio = 0,83; p = 0,35), arteriopatía periférica (odds ratio = 1,30; p = 0,34) y accidente cerebrovascular (odds ratio = 1,15; p = 0,59) no fueron predictores independientes de mortalidad hospitalaria. En un modelo ajustado, los dos últimos fueron predictores de mortalidad a largo plazo (hazard ratio = 1,57; p < 0,001; y hazard ratio = 1,34; p = 0,001, respectivamente). La afección de ≥ 2 territorios vasculares fue predictora de mortalidad a largo plazo (hazard ratio = 2,35; p < 0,001), aunque no de mortalidad intrahospitalaria (odds ratio= 1,07; p = 0,844).Conclusiones En el infarto de miocardio con segmento ST elevado, la carga vascular previa condiciona mayor mortalidad a largo plazo. Individualmente, la arteriopatía periférica y el accidente cerebrovascular previos son predictores de muerte tras el alta (AU)

Introduction and objectives Patients with a current acute coronary syndrome and previous ischemic heart disease, peripheral arterial disease, and/or cerebrovascular disease are reported to have a poorer outcome than those without these previous conditions. It is uncertain whether this association with outcome is observed at long-term follow-up. Methods Prospective observational study, including 4247 patients with ST-segment elevation myocardial infarction. Detailed clinical data and information on previous ischemic heart disease, peripheral arterial disease, and cerebrovascular disease («vascular burden») were recorded. Multivariate models were performed for in-hospital and long-term (median, 7.2 years) all-cause mortality. Results One vascular territory was affected in 1131 (26.6%) patients and ≥ 2 territories in 221 (5.2%). The total in-hospital mortality rate was 12.3% and the long-term incidence density was 3.5 deaths per 100 patient-years. A background of previous ischemic heart disease (odds ratio = 0.83; P = .35), peripheral arterial disease (odds ratio = 1.30; P = .34), or cerebrovascular disease (stroke) (odds ratio = 1.15; P = .59) was not independently predictive of in-hospital death. In an adjusted model, previous cerebrovascular disease and previous peripheral arterial disease were both predictors of mortality at long-term follow-up (hazard ratio = 1.57; P < .001; and hazard ratio = 1.34; P = .001; respectively). Patients with ≥ 2 diseased vascular territories showed higher long-term mortality (hazard ratio = 2.35; P < .001), but not higher in-hospital mortality (odds ratio = 1.07; P = .844).Conclusions In patients with a diagnosis of ST-segment elevation acute myocardial infarction, the previous vascular burden determines greater long-term mortality. Considered individually, previous cerebrovascular disease and peripheral arterial disease were predictors of mortality at long-term after hospital discharge (AU)

Impact of previous vascular burden on in-hospital and long-term mortality in patients with ST-segment elevation myocardial infarction.

INTRODUCTION AND OBJECTIVES: Patients with a current acute coronary syndrome and previous ischemic heart disease, peripheral arterial disease, and/or cerebrovascular disease are reported to have a poorer outcome than those without these previous conditions. It is uncertain whether this association with outcome is observed at long-term follow-up. METHODS: Prospective observational study, including 4247 patients with ST-segment elevation myocardial infarction. Detailed clinical data and information on previous ischemic heart disease, peripheral arterial disease, and cerebrovascular disease ("vascular burden") were recorded. Multivariate models were performed for in-hospital and long-term (median, 7.2 years) all-cause mortality. RESULTS: One vascular territory was affected in 1131 (26.6%) patients and ≥ 2 territories in 221 (5.2%). The total in-hospital mortality rate was 12.3% and the long-term incidence density was 3.5 deaths per 100 patient-years. A background of previous ischemic heart disease (odds ratio = 0.83; P = .35), peripheral arterial disease (odds ratio = 1.30; P = .34), or cerebrovascular disease (stroke) (odds ratio = 1.15; P = .59) was not independently predictive of in-hospital death. In an adjusted model, previous cerebrovascular disease and previous peripheral arterial disease were both predictors of mortality at long-term follow-up (hazard ratio = 1.57; P < .001; and hazard ratio = 1.34; P = .001; respectively). Patients with ≥ 2 diseased vascular territories showed higher long-term mortality (hazard ratio = 2.35; P < .001), but not higher in-hospital mortality (odds ratio = 1.07; P = .844). CONCLUSIONS: In patients with a diagnosis of ST-segment elevation acute myocardial infarction, the previous vascular burden determines greater long-term mortality. Considered individually, previous cerebrovascular disease and peripheral arterial disease were predictors of mortality at long-term after hospital discharge.

El Jefe de Estudios y la Comisión de Docencia ante los cambios en la Formación Especializada introducidos por el Real Decreto 183/2008 / The Head of Studies and the Education Committee face the changes in Specialised Training introduced in the Royal Decree 183/2008

El Real Decreto 183/2008 sobre Formación Médica Especializada en Ciencias de la Salud ha supuesto un cambio sustancial de esta formación en nuestro país. Desde su publicación las Unidades Docentes (UU DD) han comenzado un proceso de adaptación a este decreto, proceso que es complejo y que por los múltiples e importantes cambios que introduce requiere mucho esfuerzo por parte de los docentes. Este viaje presenta dificultades añadidas por el incumplimiento de casi todas las instituciones competentes de elaborar la normativa que desarrolle la mayoría de sus contenidos, y por lo tanto las UU DD carecen de las guías y orientaciones al respecto. Como iniciativa de la Comisión de Docencia de Formación Especializada del Hospital Universitario Virgen de la Arrixaca, se presenta el resultado del trabajo en grupo de los asistentes (informadores clave) al taller de Actualización en la Normativa sobre las Figuras Docentes en la Formación Sanitaria Especializada celebrado en Murcia, febrero de 2010. En este caso se centra en las propuestas elaboradas sobre las figura del Jefe de Estudios de las Unidades Docentes y la Comisión de Docencia, con la intención de aportar ayuda para los jefes de estudios y los docentes en esta adaptación(AU)

The Spanish Royal Decree 183/2008 on Specialised Medical Training in Health Sciences has meant a substantial change to this kind of training in Spain. Since its publication, the Teaching Units (TUs) have started a process of adaptation to this decree, a process that is complex and that requires much effort in view of the many significant changes. The process is complicated even more because the competent institutions have failed to develop regulation on most of the Decree’s contents, leaving the TUs with no guidelines. As an initiative of the Education Committee on Specialised Training of the Teaching Hospital ‘Virgen de la Arrixaca’ we present the results of the teamwork (key informers) in a workshop on the Update of the Regulation on Educators in Specialised Health Training that took place in Murcia in February 2010. We focus on the proposals developed for the Head of Studies of the Teaching Units and the Education Committee, with the aim of providing support to the directors of studies and teachers in this adaptation(AU)

New regulations regarding Postgraduate Medical Training in Spain: perception of the tutor's role in the Murcia Region.

BACKGROUND: Recently introduced regulatory changes have expanded the Tutor role to include their primary responsibility for Postgraduate Medical Training (PMT). However, accreditation and recognition of that role has been devolved to the autonomic regions. The opinions of the RT may be relevant to future decisions; METHODS: A comprehensive questionnaire, including demographic characteristics, academic and research achievement and personal views about their role, was sent to 201 RTs in the Murcia Region of Spain. The responses are described using median and interquartile ranges (IQR); RESULTS: There were 147 replies (response rate 73%), 69% male, mean age 45 +/- 7 yrs. RTs perception of the residents' initial knowledge and commitment throughout the program was 5 (IQR 4-6) and 7 (IQR 5-8), respectively. As regards their impact on the PMT program, RTs considered that their own contribution was similar to that of senior residents. RTs perception of how their role was recognised was 5 (IQR 3-6). Only 16% did not encounter difficulties in accessing specific RT training programs. Regarding the RTs view of their various duties, supervision of patient care was accorded the greatest importance (64%) while the satisfactory completion of the PMT program and supervision of day-to-day activities were also considered important (61% and 59% respectively). The main RT requirements were: a greater professional recognition (97%), protected time (95%), specific RT training programs (95%) and financial recognition (86%); CONCLUSIONS: This comprehensive study, reflecting the feelings of our RTs, provides a useful insight into the reality of their work and the findings ought to be taken into consideration in the imminent definitive regulatory document on PMT.

[Use of non-invasive ventilation in acute respiratory failure. Multicenter study in intensive care units]. / Utilización de la ventilación no invasiva en la insuficiencia respiratoria aguda. Estudio multicéntrico en unidades de cuidados intensivos.

OBJECTIVES: Study the use of non-invasive ventilation (NIV) in patients with acute respiratory failure in intensive care units (ICUs) in Spain. METHODS: A questionnaire was sent to 254 ICUs, after which, they were invited to participate in a multicenter, retrospective study, providing detailed information on ventilated patients. RESULTS: Answers were received from 123 hospitals. Of these, 119 used NIV, although its use varied greatly. NIV is the treatment of choice in 89% of the units for chronic obstructive pulmonary disease (COPD), in 79% for acute pulmonary edema (APE), in 53% for postextubation failure, in 53% for pneumonia 53%, and in 17% for acute respiratory distress syndrome (ARDS). It was used occasionally in COPD in 11% of the units, and in 21% of the units for APE. Eighteen hospitals provided additional information on 432 ventilated patients, 232 (54%) of whom received NIV as first line therapy. Presence of pneumonia or acute respiratory distress syndrome (ARDS) was an independent predictive factor of NIV failure (ORa=5.71; CI 95%, 1.83-17.8; p=0.003). Admission in a unit with experience in NIV in >50 patients/year (ORa=0.22; CI 95%, 0.07-0.63; p=0.005) and a higher PaO2/FiO2 ratio after one hour of ventilation (ORa=0.98 per point; CI 95%, 0.97-0.99; p<0.001) were protector factors. CONCLUSIONS: In Spain, NIV is widely used but it may continue to be underused in COPD and APE. The diagnosis of pneumonia or ARDS was an independent predictive risk factor. Admission in an ICU with NIV in more than 50 patients/year also have higher PaO2/FiO2 ratio after one hour of ventilation were predictive factors of success.

[Female sex is inversely and independently associated with marked ST-segment elevation. A study in patients with ST-segment elevation acute myocardial infarction and early admission]. / El sexo femenino se asocia de forma inversa e independiente a la marcada elevación del segmento ST. Estudio en pacientes con infarto agudo de miocardio con ST elevado e ingreso precoz.

INTRODUCTION AND OBJECTIVES: In patients with acute myocardial infarction, a number of variables in the initial ECG are useful prognostic indicators. The presence of ST-segment elevation, however, usually indicates the need for reperfusion therapy. The aims of this study were to investigate sex differences in the ECGs of patients with ST-elevation myocardial infarction (STEMI) and to look for a possible association between sex and marked ST-segment elevation. METHODS: A prospective observational longitudinal study of consecutive patients (n=1422) who were admitted early for a first STEMI to one of two coronary units was carried out. Initial ECG parameters were analyzed for sex differences. Multivariate analysis was performed to identify variables associated with marked ST-segment elevation (i.e., total ST-segment elevation >11 mm, according to the upper tertile of the frequency distribution). RESULTS: In women (n=336), Q-wave myocardial infarction was observed more often in the initial ECG (19% versus 15.6%; P< .03), the total ST-segment elevation was lower (10+/-6.6 mm versus 11.1+/-7.9 mm; P< .004), and marked ST-segment elevation was less common (26.4% versus 35.5%; P< .005). There was an independent inverse association between female sex and marked ST-segment elevation (odds ratio=0.70; 95% confidence interval, 0.52-0.96; P< .02). CONCLUSIONS: In patients with STEMI, female sex was associated with a lower total ST-segment elevation and there was an independent inverse association with marked ST-segment elevation.

El sexo femenino se asocia de forma inversa e independiente a la marcada elevación del segmento ST. Estudio en pacientes con infarto agudo de miocardio con ST elevado e ingreso precoz / Female sex is inversely and independently associated with marked ST-segment elevation. A study in patients with ST-segment elevation acute myocardial infarction and early admission

Introducción y objetivos. En el electrocardiograma inicial de los pacientes con infarto agudo de miocardio, diferentes variables tienen valor pronóstico. La elevación del segmento ST, además, es un indicador del tratamiento de reperfusión. Nuestro objetivo es conocer las diferencias electrocardiográficas en relación con el sexo de los pacientes con infarto agudo de miocardio con elevación del segmento ST (IAMEST) y la posible asociación del sexo con una marcada elevación del segmento ST. Métodos. Estudio observacional, longitudinal y prospectivo de los pacientes ingresados consecutivamente en dos unidades coronarias con un primer IAMEST e ingreso precoz (n = 1.422). Las variables del ECG inicial se compararon por sexos. Se realizó un análisis multivariable para conocer las variables con influencia en una marcada elevación del segmento ST (elevación ST > 11 mm, según tercil superior en distribución de frecuencias). Resultados. Las mujeres (n = 336) presentaron más frecuentemente en el ECG inicial onda Q patológica (el 19 frente al 15,6%; p < 0,03), menor elevación total del segmento ST (10 ± 6,6 frente a 11,1 ± 7,9 mm; p < 0,004) y, en menor proporción, marcada elevación del ST (el 26,4 frente al 35,5%; p < 0,005). Entre otras variables, el sexo femenino se asoció de forma inversa e independiente con una marcada elevación del ST (odds ratio = 0,70; intervalo de confianza del 95%, 0,52-0,96; p < 0,02). Conclusiones. En pacientes con IAMEST, el sexo femenino se acompaña de una menor magnitud de elevación del segmento ST y se asocia inversa e independientemente a la marcada elevación del ST (AU)

Introduction and objectives. In patients with acute myocardial infarction, a number of variables in the initial ECG are useful prognostic indicators. The presence of ST-segment elevation, however, usually indicates the need for reperfusion therapy. The aims of this study were to investigate sex differences in the ECGs of patients with ST-elevation myocardial infarction (STEMI) and to look for a possible association between sex and marked ST-segment elevation. Methods. A prospective observational longitudinal study of consecutive patients (n=1422) who were admitted early for a first STEMI to one of two coronary units was carried out. Initial ECG parameters were analyzed for sex differences. Multivariate analysis was performed to identify variables associated with marked ST-segment elevation (i.e., total ST-segment elevation >11 mm, according to the upper tertile of the frequency distribution). Results. In women (n=336), Q-wave myocardial infarction was observed more often in the initial ECG (19% versus 15.6%; P<.03), the total ST-segment elevation was lower (10±6.6 mm versus 11.1±7.9 mm; P<.004), and marked ST-segment elevation was less common (26.4% versus 35.5%; P<.005). There was an independent inverse association between female sex and marked ST-segment elevation (odds ratio=0.70; 95% confidence interval, 0.52-0.96; P<.02). Conclusions. In patients with STEMI, female sex was associated with a lower total ST-segment elevation and there was an independent inverse association with marked ST-segment elevation (AU)

Significado pronóstico de la implantación de marcapasos transitorio en pacientes con infarto agudo de miocardio / Prognostic Significance of Temporary Pacemakers Insertion in Patients with Acute Myocardial Infarction

Introducción y objetivos. La indicación de marcapasos transitorio en pacientes con infarto agudo de miocardio fue motivo de estudio en la era pretrombolítica, sin que se haya determinado si la generalización de la fibrinólisis ha podido conducir a un cambio en la indicación y significado pronóstico de la estimulación transitoria. Nuestro objetivo fue determinar la incidencia y el significado pronóstico de la implantación de marcapasos transitorio en pacientes con infarto agudo de miocardio. Pacientes y métodos. En 1.239 pacientes ingresados consecutivamente por infarto agudo de miocardio estudiamos las características clínicas y el pronóstico dependiendo de la implantación o no de marcapasos transitorio. Atendiendo a la mortalidad hospitalaria, las variables con significación estadística en el análisis univariado fueron introducidas en un análisis de regresión logística. Resultados. Se indicó estimulación transitoria en 55 casos (4,4 por ciento), profiláctica en el 22 por ciento y terapéutica en el resto. Se implantaron marcapasos en el 55 por ciento de los pacientes con bloqueo auriculoventricular avanzado y en el 10 por ciento de los bloqueos de rama. La implantación de marcapasos se asoció a una mayor afección electrocardiográfica y a un pico más elevado de creatinfosfocinasa, con independencia de su asociación a tratamiento trombolítico. Las siguientes complicaciones acompañaron con más frecuencia a la estimulación transitoria: fibrilación auricular, insuficiencia cardíaca, bloqueo de rama derecha, bloqueo auriculoventricular avanzado y mortalidad hospitalaria (45,4 frente al 10,2 por ciento; p < 0,001). La necesidad de implantación de marcapasos fue menor en los pacientes que recibieron trombólisis que en aquellos que no la recibieron (3,0 frente a 6,1 por ciento; p < 0,02). La implantación de marcapasos tuvo un valor pronóstico independiente sobre la mortalidad hospitalaria (OR = 5,51; IC del 95 por ciento, 2,71-11,19).Conclusión. La implantación de marcapasos transito- rio en el infarto agudo de miocardio es menos frecuente que la referida en la era pretrombolítica, se asocia a unos mayores índices de extensión del infarto y de la mortalidad y tiene un valor predictivo independiente sobre la mortalidad hospitalaria (OR = 5,51; IC del 95 por ciento, 2,71-11,19) (AU)