Emergency percutaneous coronary intervention in unprotected left main coronary arteries. Predictors of mortality and impact of cardiogenic shock.

INTRODUCTION AND OBJECTIVES: Percutaneous coronary intervention (PCI) for unprotected left main coronary artery (LMCA) disease may be essential following acute myocardial infarction (AMI). However, few data are available on the use of emergency PCI in unprotected LMCAs outside of clinical trials. The objective of this study was to determine the frequency of in-hospital mortality, its predictors and its association with cardiogenic shock, and long-term outcomes in patients with unprotected LMCA disease who undergo emergency PCI because of AMI. METHODS: The study included 71 consecutive patients who underwent emergency angioplasty of the LMCA and who were followed up clinically. RESULTS: Overall, 42 patients (59%) had ST-elevation AMI and 47 (66%) had cardiogenic shock or developed it during PCI. Eleven patients (16%) died in the catheterization laboratory and 33 (47%) died during hospitalization. Inhospital mortality was similar in those with and without evidence of ST-segment elevation on ECG (48% vs. 45%; P=1). Multivariate analysis showed that the predictors of in-hospital mortality were cardiogenic shock (odds ratio [OR]=4.5; 95% confidence interval [CI], 1.1-18) and incomplete revascularization (OR=5.1; 95% CI, 1.0-26). After discharge, 39 patients were followed up for a median of 32 months. Mortality in the first year was 10%. CONCLUSIONS: Emergency PCI is a viable therapeutic option for AMI due to unprotected LMCA disease. However, in-hospital mortality is high, regardless of ST-segment elevation, particularly if there is cardiogenic shock or complete revascularization has not been achieved.

Unusual presentation of acute coronary syndrome. Bilateral coronary dissection after car accident.

Dissection of large and small vessels can be caused by deceleration trauma. Management of dissections is often difficult technically, and invasive interventions are associated with complications. We report the case of a 45-year-old woman admitted with acute coronary syndrome after a car accident and deceleration trauma. The coronary angiogram showed a focal stenotic dissection of the left main and a long nonstenotic dissection of the right coronary artery. Aortography was normal. After a complicated but finally successful angioplasty, the patient developed an abdominal hemorrhagic complication due to her previous trauma, which required urgent laparotomy; spleen was then removed and laceration on liver surface was surgically repaired. The patient developed a severe coagulopathy after surgery, which led to an irreversible stage and death within 24 hours.

Intervencionismo percutáneo urgente sobre el tronco coronario izquierdo no protegido. Factores predictores de mortalidad y análisis del shock cardiogénico / Emergency percutaneous coronary intervention in unprotected left main coronary arteries. Predictors of mortality and impact of cardiogenic shock

Introducción y objetivos. El intervencionismo coronario percutáneo (ICP) de la enfermedad de tronco coronario izquierdo (TCI) no protegido puede ser necesaria en el infarto agudo de miocardio (IAM). Sin embargo, la evidencia del ICP urgente en el TCI fuera de ensayos clínicos no es muy amplia. El objetivo del estudio es evaluar la mortalidad intrahospitalaria, sus predictores y su asociación con shock, así como eventos a largo plazo en pacientes con enfermedad de TCI tratado con ICP urgente debido a un IAM. Métodos. Se incluyó a 71 pacientes consecutivos en los que se realizó una angioplastia urgente sobre el TCI y seguimiento clínico posterior. Resultados. Presentaron IAM con elevación del ST 42 (59%) y presentaban shock cardiogénico o lo desarrollaron durante el procedimiento 47 (66%). Murieron en la sala de hemodinámica 11 (16%) y 33 (47%) durante la hospitalización. La mortalidad intrahospitalaria fue independiente de la elevación del ST en el ECG (el 45 frente al 48%; p = 1). Los predictores multivariables de mortalidad intrahospitalaria fueron el shock cardiogénico (4,5; intervalo de confianza [IC], 1,1-18) y la revascularización incompleta (odds ratio [OR] = 5,1; IC, 1-26). Tras el alta hospitalaria se siguió a 39 pacientes durante una mediana de 32 meses. La mortalidad durante el primer año de seguimiento fue del 10%. Conclusiones. El ICP es una opción terapéutica en el seno del IAM debido a enfermedad de TCI. Sin embargo, la mortalidad intrahospitalaria es elevada independientemente de la elevación del ST en el ECG y especialmente cuando se asocia a shock cardiogénico y no se logra una revascularización completa (AU)

Introduction and objectives. Percutaneous coronary intervention (PCI) for unprotected left main coronary artery (LMCA) disease may be essential following acute myocardial infarction (AMI). However, few data are available on the use of emergency PCI in unprotected LMCAs outside of clinical trials. The objective of this study was to determine the frequency of in-hospital mortality, its predictors and its association with cardiogenic shock, and long-term outcomes in patients with unprotected LMCA disease who undergo emergency PCI because of AMI. Methods. The study included 71 consecutive patients who underwent emergency angioplasty of the LMCA and who were followed up clinically. Results. Overall, 42 patients (59%) had ST-elevation AMI and 47 (66%) had cardiogenic shock or developed it during PCI. Eleven patients (16%) died in the catheterization laboratory and 33 (47%) died during hospitalization. Inhospital mortality was similar in those with and without evidence of ST-segment elevation on ECG (48% vs. 45%; P=1). Multivariate analysis showed that the predictors of in-hospital mortality were cardiogenic shock (odds ratio [OR]=4.5; 95% confidence interval [CI], 1.1-18) and incomplete revascularization (OR=5.1; 95% CI, 1.0-26). After discharge, 39 patients were followed up for a median of 32 months. Mortality in the first year was 10%. Conclusions. Emergency PCI is a viable therapeutic option for AMI due to unprotected LMCA disease. However, in-hospital mortality is high, regardless of ST-segment elevation, particularly if there is cardiogenic shock or complete revascularization has not been achieved (AU)

Red blood cell distribution width predicts long-term outcome regardless of anaemia status in acute heart failure patients.

AIMS: To study the long-term prognostic value of red blood cell distribution width (RDW) in patients hospitalized with acute heart failure (AHF) and to compare the value of this measurement with haemoglobin levels and anaemia status. METHODS AND RESULTS: During a 2-year period, we studied 628 consecutive patients (aged 71 years [interquartile range, IQR: 61-77], 68% male) hospitalized with AHF. Demographic, clinical, echocardiographic, and laboratory characteristics were registered at discharge and patients were closely followed-up for 38.1 months [16.5-49.1]. Median RDW was 14.4% [13.5-15.5] and was higher among decedents (15.0% [13.8-16.1] vs. 14.2 [13.3-15.3], P < 0.001). After adjustment for other prognostic factors in a multivariable Cox proportional-hazards model, RDW remained a significant predictor (P = 0.004, HR 1.072, 95% CI 1.023-1.124); whereas, haemoglobin or anaemia status did not add prognostic information. RDW levels above the median were associated with a significantly lower survival rate on long-term follow-up (log rank <0.001). These levels were predictive of death in anaemic patients (n = 263, P = 0.029) and especially in non-anaemic patients (n = 365) (P < 0.001, HR 1.287, 95% CI 1.147-1.445), even after adjustment in the multivariable model. CONCLUSION: Higher RDW levels at discharge were associated with a worse long-term outcome, regardless of haemoglobin levels and anaemia status.

Comparison of late mortality in hospitalized patients >70 years of age with systolic heart failure receiving beta blockers versus those not receiving beta blockers.

Beta blockers are underprescribed to elderly patients with systolic heart failure (HF). We studied whether the prescription of a beta blocker is associated with a survival benefit in a nonselected population of patients >70 years of age hospitalized with acute HF and systolic dysfunction. We studied 272 consecutive patients >70 years (median 77.0, interquartile range 73.4 to 81.1) hospitalized with acute HF (left ventricular ejection fraction 34 +/- 8%) during a 2-year period. At discharge, beta-blocker therapy was prescribed in 139 patients (51.1%). A propensity score for the likelihood of receiving beta-blocker therapy was developed and showed a good performance (c-statistic = 0.825 and Hosmer-Lemeshow p = 0.820). After discharge, 120 patients (44.1%) died during the follow-up (median 31 months, interquartile range 12 to 46). Cox regression analysis showed a lower risk of death associated with beta-blocker prescription (p <0.001, hazard ratio [HR] 0.450, 95% confidence interval [CI] 0.310 to 0.655), which persisted after risk adjusting for the propensity score (HR 0.521, 95% CI 0.325 to 0.836, p = 0.007). In a propensity-matched cohort of 130 patients, there was a significantly lower mortality in patients receiving beta blockers (log rank 0.009, HR 0.415, 95% CI 0.234 to 0.734, p = 0.003). Risk reduction associated with beta blockade was observed with both high doses (HR 0.472, 95% CI 0.300 to 0.742, p = 0.001) and low doses (HR 0.425, 95% CI 0.254 to 0.711, p = 0.001). In conclusion, beta-blocker prescription at discharge in a nonselected population >70 years of age hospitalized with systolic HF is associated with a significantly lower risk of death even at low doses. This benefit remains consistent after adjustment for potential confounders.

[Prognostic value of BNP and cardiopulmonary exercise testing in patients with systolic heart failure on beta-blocker therapy]. / Valor pronóstico del BNP y la prueba de esfuerzo cardiopulmonar en la insuficiencia cardiaca sistólica en tratamiento con bloqueadores beta.

INTRODUCTION AND OBJECTIVES: The long-term prognostic value of the B-type natriuretic peptide (BNP) level and cardiopulmonary exercise testing in patients with heart failure (HF) who are receiving beta-blocker therapy is not well established. METHODS: The study involved 80 outpatients (78% male, age 50 [11] years) with stable HF, severe systolic dysfunction (left ventricular ejection fraction 25 [9]%), and intermediate functional impairment (New York Heart Association functional class 2.4 [0.6]) who were receiving optimum therapy, including beta-blockers. Their BNP levels (pg/mL) were measured and cardiopulmonary exercise testing was carried out to determine maximal oxygen uptake (VO2max) and ventilatory efficiency (VE/VCO2 slope). Patients were followed up for 2.7 (0.8) years. The study endpoints were cardiovascular death, heart transplantation, and HF hospitalization. RESULTS: The BNP level and VE/VCO2 slope were greater in patients who died (n=7), at 211 pg/mL (51-266 pg/mL) vs. 46 pg/mL (16-105 pg/mL) (P=.017) and 39 (3) vs. 33.8 (5.5) (P=.018), respectively, or who had an adverse event (n=19), at 139 pg/mL (88-286 pg/mL) vs. 40 pg/mL (13-81 pg/mL) (P< .001) and 38.7 (4.3) vs. 32.9 (5.2) (P< .001), respectively. Only the combined endpoint was associated with a significant difference in VO2max (19.7 [5.4] vs. 16.8 [3.9] mL/kg per min, P=.016). On multivariate analysis, BNP >102 pg/mL (P=.002; hazard ratio [HR]=5.2; 95% confidence interval [CI], 1.8-14.8) and VE/VCO2 slope >35 (P=.012; HR =4.3; 95% CI, 1.4-13.2) were the best predictors of an adverse event. In patients who satisfied neither, one or both criteria, 36-month cumulative adverse event rates were 2%, 25% and 63%, respectively (log rank, P< .001). CONCLUSIONS: In ambulatory HF patients with intermediate functional impairment who are receiving optimum beta-blocker therapy, the persistence of a high BNP level (>102 pg/mL) combined with poor ventilatory efficiency (VE/VCO2 slope >35) identify those with a poor long-term prognosis.

Valor pronóstico del BNP y la prueba de esfuerzo cardiopulmonar en la insuficiencia cardiaca sistólica en tratamiento con bloqueadores beta / Prognostic value of BNP and cardiopulmonary exercise testing in patients with systolic heart failure on beta-blocker therapy

Introducción y objetivos. En pacientes con insuficiencia cardiaca y tratamiento con bloqueadores beta, el valor pronóstico a largo plazo del péptido natriurético tipo B (BNP) y la prueba de esfuerzo cardiopulmonar no está bien establecido. Métodos. Se estudió a 80 pacientes ambulatorios con insuficiencia cardiaca estable (el 78% varones; media de edad, 50 ± 11 años), disfunción ventricular severa (FEVI, 25% ± 9%), deterioro funcional intermedio (NYHA, 2,4 ± 0,6) y tratamiento optimizado que incluyera bloqueadores beta. Se midió el BNP (pg/ml) y se realizó una prueba de esfuerzo cardiopulmonar, en la que se midió el consumo máximo de oxígeno (VO2máx) y la ineficiencia ventilatoria (pendiente VE/VCO2). El seguimiento fue de 2,7 ± 0,8 años y se estudió la muerte cardiovascular, el trasplante y el ingreso hospitalario por insuficiencia cardiaca. Resultados. La concentración de BNP y la pendiente VE/VCO2 fueron mayores en los pacientes que fallecieron (n = 7) (211 [51-266] contra 46 [16-105], p = 0,017; 39 ± 3 contra 33,8 ± 5,5, p = 0,018) o presentaron cualquier evento adverso (n = 19) (139 [88-286] contra 40 [13-81], p < 0,001; 38,7 ± 4,3 contra 32,9 ± 5,2, p < 0,001). El VO2máx sólo alcanzó significación para el evento combinado (19,7 ± 5,4 contra 16,8 ± 3,9 ml/kg/min, p = 0,016). Tras el análisis multivariable, el BNP > 102 pg/ml (p = 0,002; hazard ratio [HR] = 5,2; intervalo de confianza [IC] del 95%, 1,8-14,8) y la pendiente VE/VCO2>35 (p = 0,012; HR = 4,3; IC del 95%, 1,4-13,2) fueron los mejores predictores de complicaciones. En presencia de ninguno, alguno o ambos predictores, la incidencia acumulada de eventos a 36 meses fue del 2, el 25 y el 63% respectivamente (log rank < 0,001). Conclusiones. En pacientes con insuficiencia cardiaca, deterioro funcional intermedio y tratamiento optimizado con bloqueadores beta, la persistencia de un BNP elevado (> 102 pg/ml) y la ineficiencia ventilatoria (pendiente VE/VCO2 > 35) identifican a los pacientes con peor pronóstico a largo plazo

Introduction and objectives. The long-term prognostic value of the B-type natriuretic peptide (BNP) level and cardiopulmonary exercise testing in patients with heart failure (HF) who are receiving beta-blocker therapy is not well established. Methods. The study involved 80 outpatients (78% male, age 50 [11] years) with stable HF, severe systolic dysfunction (left ventricular ejection fraction 25 [9]%), and intermediate functional impairment (New York Heart Association functional class 2.4 [0.6]) who were receiving optimum therapy, including beta-blockers. Their BNP levels (pg/mL) were measured and cardiopulmonary exercise testing was carried out to determine maximal oxygen uptake (VO2max) and ventilatory efficiency (VE/VCO2 slope). Patients were followed up for 2.7 (0.8) years. The study endpoints were cardiovascular death, heart transplantation, and HF hospitalization. Results. The BNP level and VE/VCO2 slope were greater in patients who died (n=7), at 211 pg/mL (51­266 pg/mL) vs. 46 pg/mL (16­105 pg/mL) (P=.017) and 39 (3) vs. 33.8 (5.5) (P=.018), respectively, or who had an adverse event (n=19), at 139 pg/mL (88­286 pg/mL) vs. 40 pg/mL (13­81 pg/mL) (P<.001) and 38.7 (4.3) vs. 32.9 (5.2) (P<.001), respectively. Only the combined endpoint was associated with a significant difference in VO2max (19.7 [5.4] vs. 16.8 [3.9] mL/kg per min, P=.016). On multivariate analysis, BNP >102 pg/mL (P=.002; hazard ratio [HR]=5.2; 95% confidence interval [CI], 1.8­14.8) and VE/VCO2 slope >35 (P=.012; HR =4.3; 95% CI, 1.4­13.2) were the best predictors of an adverse event. In patients who satisfied neither, one or both criteria, 36-month cumulative adverse event rates were 2%, 25% and 63%, respectively (log rank, P<.001). Conclusions. In ambulatory HF patients with intermediate functional impairment who are receiving optimum beta-blocker therapy, the persistence of a high BNP level (>102 pg/mL) combined with poor ventilatory efficiency (VE/VCO2 slope >35) identify those with a poor long-term prognosis

Relation of B-type natriuretic peptide levels before and after exercise and functional capacity in patients with idiopathic dilated cardiomyopathy.

Although much is known about the value of B-type natriuretic peptide (BNP) at rest, the significance of the responsiveness of BNP during exercise in patients with chronic heart failure (HF) without coronary artery disease remains to be established. A role of BNP release during exercise in the functional disability of patients with chronic HF and idiopathic dilated cardiomyopathy (IDC) was hypothesized. One hundred five consecutive patients with an established diagnosis of HF and IDC who underwent symptom-limited cardiopulmonary exercise testing were studied. BNP was measured immediately before exercise and within 1 minute of the end of exercise. BNP at rest increased significantly at peak exercise (median from 66.5 (first, third quartiles 18, 168) to 72.0 pg/ml (26, 208), p <0.001), but BNP response was not uniform. BNP response increased in 63% of patients, did not change in 22%, and decreased in 15%. BNP at rest and BNP response showed an inverse correlation (p <0.001, r = -0.523). Aging and low left ventricular ejection fraction were independent predictors of higher BNP levels at rest, but lower BNP response. Beta-blocker therapy did not influence BNP response. BNP at rest correlated negatively with functional capacity (p <0.001, r = -0.516), whereas BNP response correlated positively (p = 0.002, r = 0.326). Patients with BNP release (vs patients without) had higher maximum oxygen consumption (19.2 +/- 5.1 vs 15.9 +/- 3.6, p <0.001), better functional capacity (59 +/- 13% vs 50 +/- 15%, p = 0.002), and lower minute ventilation/carbon dioxide production slope (33.6 +/- 4.8 vs 36.5 +/- 7.7, p = 0.026) independent of other clinical parameters. In conclusion, BNP release during exercise could be a determinant of functional capacity in patients with chronic HF and IDC.

Hyperuricaemia and long-term outcome after hospital discharge in acute heart failure patients.

BACKGROUND: Uric acid (UA) may be involved in chronic heart failure (HF) pathogenesis, entailing a worse outcome. The purpose of this study was to examine the role of hyperuricaemia as a prognostic marker after hospital discharge in acute HF patients. METHODS: We studied 212 patients consecutively discharged after an episode of acute HF with LVEF<40%. Blood samples for UA measurement were extracted in the morning prior to discharge. The evaluated endpoints were death and new HF hospitalization. RESULTS: Mean UA levels were 7.4+/-2.4 mg/dl (range 1.6 to 16 mg/dl), with 127 (60%) of patients being within the range of hyperuricaemia. Hyperuricaemia was associated with a higher risk of death (n=48) (HR 2.0, 95% CI 1.1-3.9, p=0.028), new HF readmission (n=67) (HR 1.8, 95% CI 1.1-3.1, p=0.023) and the combined event (n=100) (HR 1.9, 95% CI 1.2-2.9, p=0.004). At 24 months, cumulative event-free survival was lower in the two higher UA quartiles (36.9% and 40.7% vs. 63.5% and 59.5%, log rank=0.006). After adjustment for potential confounders, hyperuricaemia remains an independent risk factor for adverse outcomes (HR 1.6, 95% CI 1.1-2.6, p=0.02). CONCLUSIONS: In hospitalized patients with acute HF and LV systolic dysfunction, hyperuricaemia is a long-term prognostic marker for death and/or new HF readmission.

El aprendizaje de métodos anticonceptivos en la diplomatura de Enfermería / The learning of contraceptive method in the Nursing studies

Del profesional enfermero del futuro se espera que dé respuesta a lasnecesidades de la comunidad en la que desempeña su labor, asegurandola prestación de cuidados preventivos y curativos tanto en situaciónde salud como de enfermedad. Dicha asistencia sólo tiene cabidadentro de un sistema educativo cuyos contenidos respondan a las demandasque, de manera implícita o explícita, son formuladas en el senode la sociedad. La educación sexual se ha ido incorporando desdehace tiempo en los programas formativos de los estudiantes de pregradode Enfermería en nuestro país. En este contexto y partiendo denuestro firme compromiso por propiciar un aprendizaje significativoen los discentes, se ha puesto en marcha, desde hace dos años, el seminariode métodos anticonceptivos que a continuación presentamosy que ha ido dirigido a alumnos de Tercer curso de Enfermería. Su elaboraciónobedece a una convicción que compartimos ya muchos docentes:la necesidad de incorporar a la enseñanza en Ciencias de laSalud elementos básicos del ámbito de la metodología educativa, loscuales resultan imprescindibles para la elaboración de proyectos quepersigan un objetivo tan ambicioso como el propuesto. Desde la necesidaddel saber conocer, saber hacer, saber estar con los otros y saberser, la teoría se entremezcla con la práctica y el desarrollo de actitudesimprescindibles para el enfermero del siglo XXI

The future nursing professional is expected to give answers to the needsof the community in which he or she is carrying out the profession,ensuring the provision of preventive and curative care, both insickness and in health. Such care can only be envisioned within aneducation system the contents of which respond to the demandsthat, either implicit or explicitly, are required from the core of society.For quite some time now sexual education has gradually come toform part of the education curriculum of pregraduate nursing studentsin our country. Within this context and taking as our startingpoint our commitment to promote a significant learning two yearsago a seminar on contraceptive methods was started (which we willdescribe below) that was aimed at third year nursing students. Its elaborationobeys to a conviction shared by many of us, teachers, whichis the need to incorporate basic elements in the setting of educationalmethodology to the teaching of health sciences, which are essentialto elaborate projects that pursue an objective as ambitious as the oneproposed. From the need of learning, of knowing how to do things,how to be with others, and the need for the learning of the knowhow, theory is combined with practice aiding in the development ofessential attitudes that the nurse of the XXI century will need to have

Repercusión de la incontinencia urinaria en la calidad de vida de las mujeres de 40 a 65 años en un área sanitaria de Madrid / Effect of urinary incontinence on quality of life in women aged 40 to 65 years old in a health area of Madrid (Spain)

Introducción. El impacto de la incontinencia urinaria (IU) en la vida de las personas que la padecen es objeto de diversos estudios, principalmente en mujeres. Distintos trabajos muestran que la gravedad y el tipo de incontinencia influyen en el grado de afectación de la misma.La vida social y las relaciones personales son, en general, los aspectos de la vida más afectados.Objetivo. Estudiar la repercusión de la IU en la calidad de vida de las mujeres de entre 40 y 65 años en la población general.Diseño. Estudio observacional, descriptivo y transversal.Emplazamiento. Área 6 de Atención Primaria (AP) de Madrid.Participantes. Muestra de 485 mujeres de entre 40 y 65 años, escogidas por muestreo aleatorio del censo de tarjeta sanitaria, estratificada por edad y distritos sanitarios (rural, urbano y periurbano).Mediciones y resultados principales. La edad media de las mujeres del estudio fue de 52 años, con una prevalencia de IU del 15,4 por ciento, de la cual el 2,6 por ciento es de esfuerzo; el 10,6 por ciento, de urgencia, y el 2,1 por ciento, mixta. Del total de mujeres (n = 75) identificadas con algún tipo de IU, el 72 por ciento respondió al cuestionario sobre calidad de vida. La media global de las puntuaciones obtenidas en el cuestionario fue de 57,6 (62,3 para la IU de urgencia, 63,2 para la IU de esfuerzo y 30,1 para la IU mixta), con un intervalo de distribución entre 0 y 95. Estas diferencias fueron estadísticamente significativas (p = 0,001).Conclusiones. La IU en mujeres de entre 40 y 65 años del Área 6 es un problema de salud notable que afecta a una cuarta parte de las mujeres de mayor edad y que muestra un impacto negativo en su calidad de vida. La prevalencia y repercusión del trastorno justifican la puesta en marcha de programas coordinados de educación, promoción y prevención de la IU en el marco de la AP (AU)