Identificación y cuantificación del efecto fin de semana y festivos en la atención del síndrome coronario agudo en el Sistema Nacional de Salud / The effect of weekends and public holidays on the care of acute coronary syndrome in the Spanish National Health System

Introducción y objetivos Analizar si el ingreso en fin de semana o festivo (IFSF), frente al ingreso en días laborables, influye en el tratamiento (angioplastia, intervención coronaria percutánea [ICP]) y los resultados (mortalidad hospitalaria) de los pacientes hospitalizados por síndrome coronario agudo en el Sistema Nacional de Salud. Métodos Estudio observacional retrospectivo de pacientes ingresados por infarto agudo de miocardio con elevación del segmento ST (IAMCEST) o con síndrome coronario agudo sin elevación del segmento ST (SCASEST) en los hospitales del Sistema Nacional de Salud durante el periodo 2003-2018. Resultados Se seleccionaron 438.987 episodios de IAMCEST y 486.565 de SCASEST, de los cuales fueron IFSF el 28,8 y el 26,1% respectivamente. El IFSF se mostraba como un factor de riesgo de mortalidad hospitalaria en los modelos ajustados por riesgo del IAMCEST (OR=1,05; IC95%, 1,03-1,08; p<0,001) y del SCASEST (OR=1,08; IC95%, 1,05-1,12; p <0,001). La tasa de ICP en el IAMCEST fue más de 2 puntos porcentuales mayor en los pacientes ingresados en días laborables durante el periodo 2003-2011 y similar o incluso más baja en 2012-2018, sin cambios significativos para el SCASEST. El IFSF se mostró como factor de riesgo estadísticamente significativo tanto para el IAMCEST como para el SCASEST. Conclusiones El IFSF puede aumentar el riesgo de muerte hospitalaria en un 5% (IAMCEST) y un 8% (SCASEST). La persistencia del riesgo de mayor mortalidad hospitalaria tras ajustar por la realización de ICP y las demás variables explicativas probablemente indique dficiencias en el tratamiento durante el fin de semana respecto de los días laborables (AU)

Introduction and objectives To analyze whether admission on weekends or public holidays (WHA) influences the management (performance of angioplasty, percutaneous coronary intervention [PCI]) and outcomes (in-hospital mortality) of patients hospitalized for acute coronary syndrome in the Spanish National Health System compared with admission on weekdays. Methods Retrospective observational study of patients admitted for ST-segment elevation myocardial infarction (STEMI) or for non–ST-segment elevation acute coronary syndrome (NSTEACS) in hospitals of the Spanish National Health system from 2003 to 2018. Results A total of 438 987 episodes of STEMI and 486 565 of NSTEACS were selected, of which 28.8% and 26.1% were WHA, respectively. Risk-adjusted models showed that WHA was a risk factor for in-hospital mortality in STEMI (OR, 1.05; 95%CI,1.03-1.08; P < .001) and in NSTEACS (OR, 1.08; 95%CI, 1.05-1.12; P < .001). The rate of PCI performance in STEMI was more than 2 percentage points higher in patients admitted on weekdays from 2003 to 2011 and was similar or even lower from 2012 to 2018, with no significant changes in NSTEACS. WHA was a statistically significant risk factor for both STEMI and NSTEACS. Conclusions WHA can increase the risk of in-hospital death by 5% (STEMI) and 8% (NSTEACS). The persistence of the risk of higher in-hospital mortality, after adjustment for the performance of PCI and other explanatory variables, probably indicates deficiencies in management during the weekend compared with weekdays (AU)

Sex differences in treatment strategy for coronary artery aneurysms: Insights from the international Coronary Artery Aneurysm Registry.

INTRODUCTION: Sex disparities exist in coronary artery disease (CAD) in terms of risk profile, clinical management and outcome. It is unclear if differences are also present in coronary aneurysms, a rare variant of CAD. METHODS: Patients were selected from the international Coronary Artery Aneurysm Registry (CAAR; ClinicalTrials.gov: NCT02563626), and differences between groups were analysed according to sex. The CAAR database is a prospective multicentre registry of 1565 patients with coronary aneurysms (336 females). Kaplan-Meier method was used for event-free survival analysis for death, major adverse cardiac events (MACE: composite endpoint of death, heart failure and acute coronary syndrome) and bleeding. RESULTS: Female patients were older, were more often hypertensive and less frequently smoker. They were treated conservatively more often compared to male patients and received significantly less frequently aspirin (92% vs 88%, p = 0.002) or dual antiplatelet therapy (DAPT) (67% vs 58%, p = 0.001) at discharge. Median DAPT duration was also shorter (3 vs 9 months, p = 0.001). Kaplan-Meier analysis revealed no sex differences in death, MACE or bleeding during a median follow-up duration of 37 months, although male patients did experience acute coronary syndrome (ACS) more often during follow-up (15% vs 10%, p = 0.015). CONCLUSIONS: These CAAR findings showed a comparable high-risk cardiovascular risk profile for both sexes. Female patients were treated conservatively more often and received DAPT less often at discharge, with a shorter DAPT duration. ACS was more prevalent among male patients; however, overall clinical outcome was not different between male and female patients during follow-up.

Experiencia inicial con catéter multielectrodo en denervación renal. ¿Una técnica que ha vuelto para quedarse? / Initial experience with a multi-electrode catheter in renal denervation. A technique that has come back to stay?

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Occupational eye lens doses in interventional cardiology. A multicentric study.

New European regulation regarding radiological protection of workers and more specifically the new occupational dose limit for the eye lens recently reduced to 20 mSv yr(-1) may affect interventional cardiologists. This paper presents a set of measurements of occupational doses performed in five interventional cardiology centres and then compared with the new dose limit. The measurement of occupational doses was performed over the apron at chest level using electronic dosemeters recording H p(10). In one of the centres, scatter dose at goggles was also measured with optically stimulated luminescence dosemeters calibrated in terms of H p(0.07). An average H p(10) over the apron of 46 µSv/procedure was measured for cardiologists. Lower doses were noted in other professionals like second cardiologists, nurses or anaesthetists. Procedures for valvular and other structural heart diseases involved the highest occupational doses, averaging over 100 µSv/procedure. Important differences in occupational doses among centres may be indicative of different radiation protection habits. The new occupational dose limit for the eye lens is likely to be exceeded by those among the interventionalists who do not use protection tools (ceiling suspended screen and/or goggles) even with standard workloads.

Lower-normal TSH is associated with better metabolic risk factors: A cross-sectional study on Spanish men.

BACKGROUND AND AIMS: Subclinical thyroid conditions, defined by normal thyroxin (T4) but abnormal thyroid-stimulating hormone (TSH) levels, may be associated with cardiovascular and metabolic risk. More recently, TSH levels within the normal range have been suggested to be associated with metabolic syndrome and cardiovascular risk. This work studies the linearity of the relationship between metabolic syndrome and TSH across the euthyroid range. METHODS AND RESULTS: We studied 3533 male participants of the Aragon Workers' Health Study (AWHS) with normal TSH and free T4 levels, across quintiles of these variables, after adjusting for age, alcohol intake, and smoking. Compared with the lowest TSH quintile, the odds ratios for metabolic syndrome at the higher quintiles, which indicate lower thyroid function, were 1.34 (1.04, 1.73), 1.56 (1.21, 2.01), 1.57 (1.22, 2.03), and 1.71 (1.32, 2.21). The lowest free T4 quintile also showed an odds ratio of 1.49 (1.16, 1.90) with respect to the highest quintile. In addition, spline models showed departures from linearity: the risk of metabolic syndrome mostly increases at TSH values below the median (sample half-closest to subclinical hyperthyroidism). Interestingly, glucose also increases with TSH primarily below the median TSH, diastolic blood pressure shows similar changes across the entire TSH range, whereas body mass index, triglycerides, and high-density lipoprotein (HDL)-cholesterol change only at the highest normal TSH values, which are associated with lower free T4 concentration. CONCLUSIONS: TSH and free T4 within the normal range are associated with the metabolic syndrome. The sample half-below the TSH median (with probably higher functional thyroid status) exhibited better metabolic and cardiovascular profiles.

Relevancia clínica del tratamiento farmacológico completo precoz en el pronóstico del síndrome coronario agudo sin elevación del ST / Clinical importance of early intensive medical treatment for improving prognosis in non-ST-elevation acute coronary syndrome

Objetivo: Las guías actuales insisten en la relevancia de un tratamiento farmacológico optimizado para mejorar el pronóstico de los pacientes diagnosticados de síndrome coronario agudo sin elevación del segmento ST (SCASEST), pero son pocos los estudios que analizan sus resultados. El presente estudio analiza este aspecto. Método: Se incluyeron en una cohorte retrospectiva 1.118 pacientes ingresados en la unidad coronaria con el diagnóstico de SCASEST, y se analizaron sus (..) (AU)

Background and objective: Current guidelines emphasize the importance of optimal medical treatment for improving the prognosis of patients diagnosed with acute coronary syndrome without persistent ST-segment elevation, although few studies have analyzed the importance of implementing prescribing guidelines on (..) (AU)

Heart failure and non-ST-segment elevation myocardial infarction: a review for a widespread situation.

Up to 15% of patients with NSTEMI present at admission with heart failure. Scientific evidence for its management is limited but much progress has been made during the last years. Our purpose was to review the last data concerning heart failure in NSTEMI and perform an update on the subject, with the following findings as main highlights. As Killip classes III and IV, Killip class II onset in the context of NSTEMI has also proven bad prognosis significance. Beta-blocker therapy has proven benefit to patients with Killip class II in observational studies and small trials. Angiotensin-converting enzyme inhibitor therapy shows stronger evidence of benefit in patients with heart failure than in patients without it. Eplerenone is indicated for patients with left ventricular dysfunction and heart failure or diabetes mellitus. Implantable cardioverter defibrillators improve survival in patients with severe ventricular dysfunction after a myocardial infarction. Cardiac resynchronization therapy indications must be carefully assessed due to the high rate of implants that do not fulfill guidelines indications. In conclusion, heart failure during a NSTEMI is a common and meaningful situation which warrants careful management and further investigation to reach stronger evidence for clinical recommendations.

Aspectos proteómicos y genéticos de la resistencia a la aspirina / Proteomics and genetics aspects of aspirin resistance

Objetivo: Analizar si existe alguna asociación entre la resistencia a aspirina (RA) y la presencia de polimorfismos genéticos de un único nucleótido (SNPs) en el gen de la COX-1, así como su relación con modificaciones en la expresión de proteínas plasmáticas en pacientes con enfermedad isquémica estable y tratamiento continuado de aspirina. Materiales y métodos: Analizamos el proteoma plasmático de 19 pacientes sensibles, 19 resistentes. RA se definió mediante el sistema PFA-100. Se realizó electroforesis bidimensional (IPG 17cm, pH(4-7), geles SDS-PAGE 10%) y tinción con plata. Se analizaron cambios en tres SNPs (A-842G, C22T y C50T) en 50 pacientes sensibles, 33 resistentes y 83 controles mediante PCR a tiempo real. Resultados: La expresión de cuatro isoformas de alfa1-antitripsina estaba aumentada en los pacientes resistentes. No encontramos diferencias en la expresión de ceruloplasmina, precursor de haptoglobina, apolipoproteína AI y precursor de albúmina entre ambos tipos de pacientes. Ningún paciente presentó cambios en el SNP A-842G. La frecuencia de cambio en C22T y C50T fue relativamente baja con respecto a la población total. Conclusiones: No encontramos asociación entre la presencia de polimorfismos en el gen de la COX-1 y la peor respuesta a la aspirina. Los cambios en observados alfa1-antitripsina podrían estar relacionados con un diferente estado inflamatorio entre ambos tipos de pacientes (AU)

Aim: To evaluate the existence of a possible association between Aspirin resistance (AR), COX-1 single-nucleotide polymorphisms (SNPs) and the modifications in the plasma proteome of clinically stable coronary patients. Materials and methods: AR was defined according to the PFA-100 assay. AR-sensitive and AR-resistant patients had been taken aspirin for the last 9 months. The proteomic study (19 AR-sensitive, 19 AR-resistant) was performed using IPG strips (17cm, pH 4-7), SDS-PAGE gels (10%) and silver staining. We study three SNPs (A- 842G, C22T y C50T) in 50 AR-sensitive patients, 33 AR-resistant and 83 controls using a real-time PCR. Results: The expression of four alpha1-antitripsin isoforms was increased in the aspirin-resistant patients. No differences were found in the expression of ceruloplasmin, haptoglobin-precursor, apolipoprotein-AI and albumin- precursor between both groups of patients. The A-842G SNP was undetectable in all subjects. The remaining two SNPs (C22T y C50T) showed a low frequency with respect the global population. Conclusions: The low SNPs frequencies were unlikely to explain the difference in aspirin responsiveness between both groups of patients. The changes in alpha1-antitripsin could be linked with a different inflammatory state in these patients (AU)

Magnitude and consequences of undertreatment of high-risk patients with non-ST segment elevation acute coronary syndromes: insights from the DESCARTES Registry.

OBJECTIVE: To analyse intensity of treatment of high-risk patients with non-ST elevation acute coronary syndromes (NSTEACS) included in the DESCARTES (Descripción del Estado de los Sindromes Coronarios Agudos en un Registro Temporal Español) registry. PATIENTS AND SETTING: Patients with NSTEACS (n = 1877) admitted to 45 randomly selected Spanish hospitals in April and May 2002 were studied. DESIGN: Patients with ST segment depression and troponin rise were considered high risk (n = 478) and were compared with non-high risk patients (n = 1399). RESULTS: 46.9% of high-risk patients versus 39.5% of non-high-risk patients underwent angiography (p = 0.005), 23.2% versus 18.8% (p = 0.038) underwent percutaneous revascularisation, and 24.9% versus 7.4% (p < 0.001) were given glycoprotein IIb/IIIa inhibitor. In-hospital and six-month mortality were 7.5% versus 1.1% and 17% versus 4.6% (p < 0.001), respectively. A treatment score (> or = 4, 2-3 and < 2) was defined according to the number of class I interventions recommended in clinical guidelines: aspirin, clopidogrel, beta blockers, angiotensin-converting enzyme inhibitors, statins and revascularisation. Independent predictors of six-month mortality were age (odds ratio (OR) 1.07, 95% confidence interval (CI) 1.04 to 1.10, p < 0.001), diabetes (OR 1.92, 95% CI 1.14 to 3.22, p = 0.014), previous cardiovascular disease (OR 4.17, 95% CI 1.63 to 10.68, p = 0.003), high risk (OR 2.20, 95% CI 1.30 to 3.71, p = 0.003) and treatment score < 2 versus > or = 4 (OR 2.87, 95% CI 1.27 to 6.52, p = 0.012). CONCLUSIONS: Class I recommended treatments were underused in high-risk patients in the DESCARTES registry. This undertreatment was an independent predictor of death of patients with an acute coronary syndrome.

Long term outcome of patients with postinfarction left ventricular pseudoaneurysm.

BACKGROUND: It is debatable whether surgical repair is routinely indicated in asymptomatic patients with left ventricular pseudoaneurysms. OBJECTIVE: To evaluate the long term outcome of patients with pseudoaneurysm after myocardial infarction, focusing on those treated conservatively. METHODS: 10 patients with postinfarction left ventricular pseudoaneurysm were followed up over a mean (SD) period of 3.8 (5.2) years. RESULTS: In those treated conservatively (n = 9), cumulative survival was 88.9 (10.5)% and 74.1 (16.1)% at one and four years, respectively. The probability of being free of cardiac death was 88.9 (10.5)% at both one and four years. No patient had complete fatal heart rupture during follow up. Three patients suffered ischaemic stroke (at 1, 11, and 62 months). The cumulative incidence of ischaemic stroke was 10% at one year and 32.5% at four years. CONCLUSIONS: Long term outcome of patients with postinfarction left ventricular pseudoaneurysm is relatively benign, with a very low risk (none in this series) of fatal rupture. Taking into consideration the relatively high risk of stroke, chronic anticoagulant treatment could be considered.

Effects of bosentan on neointimal response following coronary angioplasty.

BACKGROUND: Endothelins are important vasoconstrictors and cellular-growth promoters. ETA-specific antagonists have been shown to reduce neointimal response to injury in some experimental angioplasty models. However, there is little information on the effects of dual ETA/ETB receptor blockers, such as bosentan, on neointimal proliferation following experimental coronary angioplasty. MATERIALS AND METHODS: Coronary injury was achieved by directional atherectomy in the left anterior descending artery of 20 pigs. Animals were randomly assigned to receive a daily dose of oral bosentan (30 mg kg-1) (group I, n = 10) or no treatment (group II, n = 10). At 4 weeks, arteries were processed for histomorphometry and endothelin characterization. RESULTS: Vessel injury score was similar among the two groups. Overall, a linear correlation was found between injury and neointimal development (r = 0.57, P = 0.01). This correlation had a lower slope in group I compared with group II (P < 0.001), indicating a smaller amount of neointimal development for a similar degree of injury in bosentan-treated animals. Multivariate regression showed that neointimal response was reduced by oral treatment with bosentan (beta: -0.59 mm2, 95% CI: -1.11/-0.06 mm2). In addition, immunostaining revealed fewer positive endothelin areas in group I arteries. CONCLUSIONS: Oral treatment with bosentan reduces neointimal development following coronary angioplasty in this experimental model.

Multi-locus interactions predict risk for post-PTCA restenosis: an approach to the genetic analysis of common complex disease.

The complexity of recognizing the potential contribution of a number of possible predictors of complex disorders is increasingly challenging with the application of large-scale single nucleotide polymorphism (SNP) typing. In the search for putative genetic factors predisposing to coronary artery restenosis following balloon angioplasty, we determined genotypes for 94 SNPs representing 62 candidate genes, in a prospectively assembled cohort of 342 cases and 437 controls. Using a customized coupled-logistic regression procedure accounting for both additive and interactive effects, we identified seven SNPs in seven genes that, together, showed a statistically significant association with restenosis incidence (P <0.0001), accounting for 11.6% of overall variance observed. Among them are candidate genes for cardiovascular pathophysiology (apolipoprotein-species and NOS), inflammatory response (TNF receptor and CD14), and cell-cycle control (p53 and p53-associated protein). Our results emphasize the need to account for complex multi-gene influences and interactions when assessing the molecular pathology of multifactorial medical entities.

Morning cortisol production in coronary heart disease patients.

BACKGROUND: The circadian cycle of the endogenous anti-inflammatory system (EAIS) is characterized by a morning increase in cortisol production. Circulating interleukin-6 (IL-6) activates the EAIS. A circadian variation in the onset of myocardial infarction, sudden death, stable angina (SA) and unstable angina (UA) has been reported. The aim of this study was to determine morning cortisol production in coronary heart disease (CHD) patients. MATERIALS AND METHODS: Serum cortisol and IL-6 were measured in 129 patients with either SA (n = 65) or UA (n = 64) and 40 healthy volunteers. Blood samples were taken between 9 : 00 h and 12 : 00 h. The upper normal range of cortisol (25 microg dL-1) was used as a reference to classify patients. RESULTS: Forty-eight patients had elevated cortisol levels (ECL) (32.5 +/- 5.4 microg dL-1), while 81 patients had normal cortisol levels (NCL) (15.7 +/- 5.9 microg dL-1). In NCL patients, IL-6 levels (26.6 pg mL-1, ranged from 0.2 to 183.7) were significantly higher (P < 0.004) than in ECL patients (9.70 pg mL-1, range 0.07-56.5). Forty-eight patients with UA belonged to the NCL group of patients, while only 16 UA patients belonged to the ECL group (chi(2) = 0.000). Thirty-two patients with SA belonged to the ECL group, and 33 to the NCL group (chi(2) = 0.08). CONCLUSIONS: Patients with 'inappropriately' normal morning cortisol production had high IL-6 levels. 'Inappropriately' normal cortisol, detected in 75% of UA and 50% of SA patients, may be insufficient for limiting inflammation. These findings have novel clinical implications and suggest new therapeutic approaches in the treatment of these patients.

[Effect of cAMP on the function of endothelial cells and fibromuscular proliferation after the injury of the carotid and coronary arteries in a porcine model]. / Efecto del AMPc sobre la función de las células endoteliales y la proliferación fibromuscular tras la lesión de las arterias carótida y coronaria en un modelo porcino.

INTRODUCTION AND OBJECTIVE: Reendothelization of damaged blood vessels protects against the vascular injury response. We evaluated in vivo whether a systemic increase in cAMP accelerates reendothelization and attenuates intimal hyperplasia in injured swine carotid and coronary arteries. METHODS: Both carotid arteries of 10 swines were subjected to balloon injury. Five animals had been treated with 2 ml (10 mg) of Forskolin, an activator of the adenylate cyclase, and another 5 with 2 ml of saline solution. These animals were sacrificed at day 8, and carotid artery reendothelization was evaluated. The descendent coronary (DC) artery of another 19 pigs was injured by atherotome. Nine animals had been treated with 2 ml of Forskolin, and another 10 with 2 ml of saline solution. These animals were sacrificed at day 28, with myointimal proliferation and arterial geometric remodelation being evaluated. Likewise, in these animals intracellular cAMP levels were measured at baseline and 28 and 60 minutes after saline solution or Forskolin administration and 90 min after arterial injury. RESULTS: Eight days after balloon injury, carotid artery reendothelization was greater in the Forskolin-treated group compared with the control group (p = 0.02), and the number of CD31 positive cells was statistically increased in the treated group (38 +/- 11 cells) versus controls (11 +/- 9 cells). Although the degree of vascular injury caused by atherotome was similar in all of the arteries in the control group, restenosis was only observed in 40% of these animals. Correlation analysis demonstrated that intracellular cAMP may condition arterial geometric remodeling and the diameter of the lumen after vascular injury. CONCLUSION: Our results suggest that cAMP may promote reendothelization and attenuate fibromuscular proliferation.

Acute stent thrombosis visualized by intravascular ultrasound.

Subacute stent thrombosis is currently a rare but feared complication in patients undergoing coronary intervention. Intravascular ultrasound is a useful technique to guide stent implantation. However, its value in patients suffering from acute stent thrombosis has not been described. Herein, we present the intravascular ultrasound findings of a patient experiencing ongoing stent thrombosis and impending vessel closure.