Post-thrombolysis intracerebral hemorrhage: data from the Spanish Register ARIAM.

OBJECTIVE: Our objective was to investigate the predisposing factors in patients with acute myocardial infarction (AMI) treated with thrombolysis and complicated by intracranial hemorrhage (ICH), as well as the factors associated with death for patients whose conditions were complicated by ICH. DESIGN: A retrospective study. SETTING: An intensive care/critical care unit. PATIENTS: All patients with AMI listed in the Spanish ARIAM register. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The study period was from June 1996 to December 2003. The follow-up period was limited to the time spent in the intensive care unit/coronary care unit. Associations with the development of ICH were studied by univariate analysis. Another univariate analysis was used to evaluate the differences between patients affected by AMI complicated by ICH who died and those who survived. Two multivariate analyses were also used: one to evaluate the factors related to the development of ICH and the other to evaluate the factors associated with the death of patients with ICH. A total of 17,111 patients with AMI were included in the study. ICH occurred in 151 (0.9%) of these patients during their stay in the intensive care unit/coronary care unit. The multivariate analysis showed that the variables associated with ICH development were smoking (odds ratio [OR], 0.684; 95% confidence interval [CI], 0.478-0.979); oral b-blockers (OR, 0.488; CI, 0.337-0.706); angiotensin-converting enzyme (ACE) inhibitors (OR, 0.480; CI, 0.340-0.678); arterial hypertension (OR, 4.900; CI, 2.758-8.705); age of 55-64 yrs (OR, 2.253; CI, 1.117-4.546); age of 65-74 yrs (OR, 4.240; CI, 2.276-7.901); age of 75-84 yrs (OR, 4.450; CI, 2.319-8.539); and age of >84 yrs (OR, 2.997; CI, 1.039-8.647). The mortality rate among patients with ICH was 48.3%, vs. 8.3% among patients without ICH. The multivariate study showed that the mortality rate among patients with ICH was associated with age (OR, 1.086; CI, 1.033-1.143), arterial hypertension cardiovascular risk factor (OR, 2.773; CI, 1.216-6.324), and the need for mechanical ventilation (OR, 4.324; CI, 1.665-11.230) or cardiopulmonary resuscitation (OR, 12.258; CI, 1.268-118.523). However, the administration of b-blockers (OR, 0.369; CI, 0.136-0.997) or ACE inhibitors (OR, 0.367; CI, 0.149-0.902) was associated with a reduction in the mortality rate. CONCLUSIONS: Factors associated with the development of ICH in our population were age and arterial hypertension, whereas smoking and the administration of b-blockers or ACE inhibitors were associated with a reduction in incidence. Among patients with AMI complicated by ICH, mortality was associated with age, arterial hypertension, cardiopulmonary resuscitation, and the use of mechanical ventilation, whereas the administration of oral b-blockers and ACE inhibitors could be associated with a reduction in mortality.

Paradoxical effect of smoking in the Spanish population with acute myocardial infarction or unstable angina: results of the ARIAM Register.

OBJECTIVES: The paradoxical effect of smoking after acute myocardial infarction (AMI) is a phenomenon consisting of a reduction in the mortality of smokers compared to nonsmokers. However, it is not known whether the benefit of this reduction in mortality is due to smoking itself or to other covariables. Despite acceptance of the paradoxical effect of smoking in AMI, it is not known whether a similar phenomenon occurs in unstable angina. The objective of this study was to investigate the paradoxical effect of smoking in AMI and unstable angina, and to study specifically whether smoking is an independent prognostic variable. METHODS AND RESULTS: The study population was selected from the multicentric ARIAM (Análisis del Retraso en el Infarto Agudo de Miocardio [analysis of delay in AMI]) Register, a register of 29,532 patients with a diagnosis of unstable angina or AMI. Tobacco smokers were younger, presented fewer cardiovascular risk factors such as diabetes or hypertension, fewer previous infarcts, a lower Killip and Kimball class, and a lower crude and adjusted mortality in AMI (odds ratio, 0.774; 95% confidence interval, 0.660 to 0.909; p = 0.002). Smokers with unstable angina were younger, with less hypertension or diabetes. In the multivariate analysis, no statistically significant difference in mortality was found. CONCLUSIONS: The reduced mortality observed in smokers with AMI during their stay in the ICU cannot be explained solely by clinical covariables such as age, sex, other cardiovascular factors, Killip and Kimball class, or treatment received. Therefore, smoking may have a direct beneficial effect on reduced mortality in the AMI population. The lower mortality rates found in smokers with unstable angina are not supported by the multivariate analysis. In this case, the difference in mortality can be explained by the other covariables.

Clinical implications of acute myocardial infarction complicated by high grade atrioventricular block.

BACKGROUND: The purpose of this study was to assess the incidence, clinical course, prognosis and mean length of stay in acute myocardial infarction (AMI) complicated by high-grade atrioventricular block (HAVB). MATERIAL/METHODS: A retrospective cohort study including all AMI patients listed from January 1995 to September 2000 in the ARIAM multi-center register. Univariate analysis was carried out to study the factors associated with the development of HAVB, the mortality rate, and the mean length of stay, and multivariate logistic regression analysis to study whether HAVB is an independent predictive variable for mortality or prolongation of stay. RESULTS: Of the 14,181 AMI patients included in the register, 837 (5.9%) presented with HAVB, which was associated with age, female sex, increased severity, diabetes, inferior and Q-wave AMIs, and a higher peak creatine phosphokinase (CPK) level. The HAVB patients developed more complications, required more diagnostic-therapeutic resources, and showed significantly higher mortality (p<0.0001) and increased mean length of stay (p<0.0001). The independent risk factors for HAVB were age, maximum peak CPK, inferior or combined localization of the AMI, Q-wave AMI, diabetes, a Killip and Kimball score > 1, and thrombolysis. HAVB was found to be an independent predictive variable for mortality and increased mean length of stay. CONCLUSIONS: AMI patients with HAVB, despite thrombolytic treatment, are at risk for complications, mortality and longer mean admissions. Further study is needed on the outcome of a more active reperfusion policy, such as direct, rescue angioplasty etc.