Seguridad y eficacia clínica con prasugrel y ticagrelor en síndrome coronario agudo. Resultados de un registro multicéntrico en el mundo real / Safety and efficacy of prasugrel and ticagrelor in acute coronary syndrome. Results of a 'real world' multicenter registry

Introducción y objetivos: La incorporación de los nuevos antiagregantes (NAA) prasugrel y ticagrelor a la práctica clínica está siendo errática. Los datos del mundo real todavía son escasos. Se analizó la tendencia temporal de uso de NAA, su seguridad y eficacia clínica frente a clopidogrel en una cohorte actual de pacientes con síndrome coronario agudo (SCA). Métodos: Estudio multicéntrico observacional retrospectivo de pacientes con SCA ingresados en unidades coronarias incluidos de forma prospectiva en el registro ARIAM-Andalucía entre 2013 y 2015. Se analizaron las tasas de eventos cardiovasculares mayores y hemorragias intrahospitalarias mediante modelos de propensión y regresión multivariante. Resultados: Se incluyó a 2.906 pacientes: el 55% recibió clopidogrel y el 45% NAA. Un 60% presentó SCA con elevación del segmento ST. El uso de NAA se incrementó de forma significativa a lo largo del estudio. El grupo de clopidogrel presentó mayor edad y comorbilidad. La tasa de mortalidad total, el ictus isquémico y la trombosis del stent fue menor con NAA (2 frente a 9%, p < 0,0001; 0,1 frente a 0,5%, p = 0,025; 0,07 frente a 0,5%, p = 0,025, respectivamente). No hubo diferencias en la tasa de hemorragias totales (3 frente a 4%; p = NS). Tras el análisis de propensión, se mantuvo la reducción de mortalidad con NAA (OR = 0,37; IC95%, 0,13-0,60; p< 0,0001) sin incremento en las hemorragias totales (OR = 1,07; IC95%, 0,18-2,37; p = 0,094). Conclusiones: En el mundo real, los NAA se usan de forma selectiva en sujetos más jóvenes y con menor comorbilidad. Su uso se asocia con una reducción de eventos cardiacos mayores, incluida mortalidad, sin aumentar las hemorragias en comparación con clopidogrel (AU)

Introduction and objectives: The incorporation of the new antiplatelet agents (NAA) prasugrel and ticagrelor into routine clinical practice is irregular and data from the 'real world' remain scarce. We aimed to assess the time trend of NAA use and the clinical safety and efficacy of these drugs compared with those of clopidogrel in a contemporary cohort of patients with acute coronary syndromes (ACS). Methods: A multicenter retrospective observational study was conducted in patients with ACS admitted to coronary care units and prospectively included in the ARIAM-Andalusia registry between 2013 and 2015. In-hospital rates of major cardiovascular events and bleeding with NAA vs clopidogrel were analyzed using propensity score matching and multivariate regression models. Results: The study included 2906 patients: 55% received clopidogrel and 45% NAA. A total of 60% had ST-segment elevation ACS. Use of NAA significantly increased throughout the study. Patients receiving clopidogrel were older and were more likely to have comorbidities. Total mortality, ischemic stroke, and stent thrombosis were lower with NAA (2% vs 9%, P < .0001; 0.1% vs 0.5%, P = .025; 0.07% vs 0.5%, P = .025, respectively). There were no differences in the rate of total bleeding (3% vs 4%; P = NS). After propensity score matching, the mortality reduction with NAA persisted (OR, 0.37; 95%CI, 0.13 to 0.60; P < .0001) with no increase in total bleeding (OR, 1.07; 95%CI, 0.18 to 2.37; P = .094). Conclusions: In a 'real world' setting, NAA are selectively used in younger patients with less comorbidity and are associated with a reduction in major cardiac events, including mortality, without increasing bleeding compared with clopidogrel (AU)

Prognostic implication of early ventricular fibrillation among patients with ST elevation myocardial infarction.

OBJECTIVE: The aim of this study was to analyze the prognosis of patients presenting early ventricular fibrillation (VF) in the setting of ST elevation myocardial infarction (STEMI). PATIENTS AND METHODS: Among patients included in the ARIAM (Análisis del Retraso en el Infarto Agudo de Miocardio) registry with the diagnosis of STEMI, those who received primary revascularization and were admitted in the first 12 h were analyzed retrospectively. RESULTS: From January 2007 to January 2012, 8340 patients were included in the STEMI cohort and 680 (8.2%) of them presented with VF before admission to the ICU (VF). This group comprised younger patients with fewer comorbidities. They received more often primary angioplasty (33.7 vs. 24.9%; P<0.001), had more prevalence of Killip class greater than or equal to 2 at admission (37.5 vs. 17.8%; P<0.001), and suffered more often cardiogenic shock (18.5 vs. 5.9%, P<0.001). By logistic regression analysis, VF was associated with a greater in-hospital mortality [odds rate (OR): 2.08, 95% confidence interval (CI): 1.57-2.81, P<0.001]. After a propensity score matching process, VF was associated with in-hospital mortality (OR: 1.53, 95% CI: 1.05-2.25, P=0.028). However, when analyzing patients treated by primary angioplasty, the mortality was not significantly related to VF (OR: 0.86, 95% CI: 0.45-1.61, P=0.628). CONCLUSION: Our results show that VF before ICU admission was an independent predictor of in-hospital outcome in a cohort of patients in whom fibrinolysis was the most used revascularization therapy. However, this prognostic value was not found in patients treated with primary angioplasty.

Safety and Efficacy of Prasugrel and Ticagrelor in Acute Coronary Syndrome. Results of a "Real World" Multicenter Registry.

INTRODUCTION AND OBJECTIVES: The incorporation of the new antiplatelet agents (NAA) prasugrel and ticagrelor into routine clinical practice is irregular and data from the "real world" remain scarce. We aimed to assess the time trend of NAA use and the clinical safety and efficacy of these drugs compared with those of clopidogrel in a contemporary cohort of patients with acute coronary syndromes (ACS). METHODS: A multicenter retrospective observational study was conducted in patients with ACS admitted to coronary care units and prospectively included in the ARIAM-Andalusia registry between 2013 and 2015. In-hospital rates of major cardiovascular events and bleeding with NAA vs clopidogrel were analyzed using propensity score matching and multivariate regression models. RESULTS: The study included 2906 patients: 55% received clopidogrel and 45% NAA. A total of 60% had ST-segment elevation ACS. Use of NAA significantly increased throughout the study. Patients receiving clopidogrel were older and were more likely to have comorbidities. Total mortality, ischemic stroke, and stent thrombosis were lower with NAA (2% vs 9%, P < .0001; 0.1% vs 0.5%, P = .025; 0.07% vs 0.5%, P = .025, respectively). There were no differences in the rate of total bleeding (3% vs 4%; P = NS). After propensity score matching, the mortality reduction with NAA persisted (OR, 0.37; 95%CI, 0.13 to 0.60; P < .0001) with no increase in total bleeding (OR, 1.07; 95%CI, 0.18 to 2.37; P = .094). CONCLUSIONS: In a "real world" setting, NAA are selectively used in younger patients with less comorbidity and are associated with a reduction in major cardiac events, including mortality, without increasing bleeding compared with clopidogrel.

Supervivencia y estado neurológico tras muerte súbita cardiaca extrahospitalaria. Resultados del Registro Andaluz de Parada Cardiorrespiratoria Extrahospitalaria / Survival and neurologic outcome after out-of-hospital cardiac arrest. Results of the andalusian out-of-hospital cardiopulmonary arrest registry

Introducción y objetivos: No hay demasiados datos sobre la muerte súbita prehospitalaria en España. El objetivo es describir su incidencia, las características de los pacientes y los resultados de su atención por un servicio de emergencias extrahospitalario. Métodos: Análisis retrospectivo de un registro prospectivo de parada cardiorrespiratoria atendida por un servicio de emergencias extrahospitalario entre enero de 2008 y diciembre de 2012. Se incluyó a todos los pacientes con estimación de etiología cardiaca como causa de la parada. Se realizó análisis descriptivo de las características generales de los pacientes y de los factores asociados con alta hospitalaria con buen estado neurológico. Resultados: Se incluyó a 4.072 pacientes, con una incidencia estimada de 14,6 eventos por 100.000 habitantes y año, el 72,6% varones. La media de edad era 62,0 ± 15,8 años. El 58,6% de los casos ocurrieron en domicilio. El 25% de los pacientes tenían un ritmo inicial desfibrilable. El 28,8% de los pacientes llegaron con pulso al hospital, el 58,3% del grupo con ritmo desfibrilable. El 10,2% recibió el alta en buen estado neurológico. Las variables asociadas con esta recuperación fueron: parada presenciada (p = 0,04), parada presenciada por el equipo de emergencias (p = 0,005), realización previa de soporte vital (p = 0,04), ritmo inicial desfibrilable (p = 0,0001) y realización de intervencionismo coronario (p = 0,0001). Conclusiones: Más de la mitad de los casos de muerte súbita ocurren en el domicilio. Afectan a una población relativamente joven. Aunque 1 de cada 10 pacientes tuvo una recuperación satisfactoria, la fase previa a la llegada de los equipos de emergencias debe mejorar. El intervencionismo coronario tuvo gran impacto en el pronóstico de los pacientes (AU)

Introduction and objectives: There is a paucity of data on prehospital cardiac arrest in Spain. Our aim was to describe the incidence, patient characteristics, and outcomes of out-of-hospital emergency care for this event. Methods: We conducted a retrospective analysis of a prospective registry of cardiopulmonary arrest handled by an out-of-hospital emergency service between January 2008 and December 2012. The registry included all patients considered to have a cardiac etiology as the cause of arrest, with a descriptive analysis performed of general patient characteristics and factors associated with good neurologic outcome at hospital discharge. Results: A total of 4072 patients were included, with an estimated incidence of 14.6 events per 100 000 inhabitants and year; 72.6% were men. The mean age was 62.0 ± 15.8 years, 58.6% of cases occurred in the home, 25% of patients had initial defibrillable rhythm, 28.8% of patients arrived with a pulse at the hospital (58.3% of the group with defibrillable rhythm), and 10.2% were discharged with good neurologic outcome. The variables associated with this recovery were: witnessed arrest (P = .04), arrest witnessed by emergency team (P = .005), previous life support (P = .04), initial defibrillable rhythm (P = .0001), and performance of a coronary interventional procedure (P = .0001). Conclusions: More than half the cases of sudden cardiac arrest occur at home, and the population was found to be relatively young. Although recovery was satisfactory in 1 out of every 10 patients, there is a need for improvement in the phase prior to emergency team arrival. Coronary interventional procedures had an impact on patient prognosis (AU)

Mid-regional pro-adrenomedullin as prognostic biomarker in septic shock.

BACKGROUND: The aim was to ascertain the prognostic value of mid-regional pro-adrenomedullin (MR-proADM), measured within 24 hours from the onset of septic shock (SS). METHODS: We performed a prospective, observational study on all patients admitted to our hospital's Intensive Care Unit with SS over a one year period from January to December 2011 to examine the outcomes in 100 consecutive SS cases. Demographic data and severity score (APACHEII and SOFA) were recorded. MR-proADM, C-reactive protein and procalcitonin were measured within the first 24 hours from SS onset. The outcome variable studied was 28-day mortality. Data were evaluated with non-parametric statistics bivariant and multivariate analyses for survival analysis. RESULTS: In patients who died within 28 days (36%), MR-proADM, Lactate, APACHE II as well as SOFA were significantly higher compared with survivors. MR-proADM showed the best association with 28-day mortality, as well as a prognostic value (logrank test: P=0.0012). Statistical significance was also seen in the Cox regression analysis (P=0.0004) for all patients with a Relative Risk of 1.26 times that of the baseline for each mmol/L of increase in MR-proADM. CONCLUSIONS: In our study MR-proADM levels measured on admission correlates with 28-day mortality in patients with septic shock.

Survival and Neurologic Outcome After Out-of-hospital Cardiac Arrest. Results of the Andalusian Out-of-hospital Cardiopulmonary Arrest Registry.

INTRODUCTION AND OBJECTIVES: There is a paucity of data on prehospital cardiac arrest in Spain. Our aim was to describe the incidence, patient characteristics, and outcomes of out-of-hospital emergency care for this event. METHODS: We conducted a retrospective analysis of a prospective registry of cardiopulmonary arrest handled by an out-of-hospital emergency service between January 2008 and December 2012. The registry included all patients considered to have a cardiac etiology as the cause of arrest, with a descriptive analysis performed of general patient characteristics and factors associated with good neurologic outcome at hospital discharge. RESULTS: A total of 4072 patients were included, with an estimated incidence of 14.6 events per 100000 inhabitants and year; 72.6% were men. The mean age was 62.0 ± 15.8 years, 58.6% of cases occurred in the home, 25% of patients had initial defibrillable rhythm, 28.8% of patients arrived with a pulse at the hospital (58.3% of the group with defibrillable rhythm), and 10.2% were discharged with good neurologic outcome. The variables associated with this recovery were: witnessed arrest (P=.04), arrest witnessed by emergency team (P=.005), previous life support (P=.04), initial defibrillable rhythm (P=.0001), and performance of a coronary interventional procedure (P=.0001). CONCLUSIONS: More than half the cases of sudden cardiac arrest occur at home, and the population was found to be relatively young. Although recovery was satisfactory in 1 out of every 10 patients, there is a need for improvement in the phase prior to emergency team arrival. Coronary interventional procedures had an impact on patient prognosis.

Influence of the previous use of ß-blockers on the early clinical course of acute coronary syndromes.

Recent studies have recently questioned the current role of ß-blockers in myocardial infarction. Our purpose is to analyze the influence of the previous use of ß-blockers on the early course of patients admitted because of acute coronary syndrome (ACS). We analyzed the data of 37.359 patients included in the ARIAM-Andalucia Registry. Of them, 7759 (20.8%) were previously receiving ß-blockers. BB patients were older, more often female, had more risk factors and vascular disease, and less often had an ST-elevation myocardial infarction. In the unadjusted analysis, BB patients less often had ventricular fibrillation or atrioventricular block, and more often a Killip classification >1, and no difference of in-hospital mortality (5.7 vs 5.6%). After logistic regression analysis and propensity score matching, no differences in complications or mortality (odds ratio 0.997, 95% confidence interval 0.882-1.128) were found in relationship to previous ß-blockers. In conclusion, we find that the previous administration of ß-blockers is not an independent predictor of the early prognosis of ACS.

Prognostic impact of clopidogrel pretreatment in patients with acute coronary syndrome managed invasively.

Pretreatment with antiP2Y12 agents before angiography in acute coronary syndrome (ACS) is associated with a reduction in thrombotic events. However, recent evidences have questioned the benefits of upstream antiP2Y12, reporting a higher incidence of bleeding. We analyzed the prognostic impact of clopidogrel pretreatment in a large cohort of invasively managed patients with ACS. In hospital, safety and efficacy of clopidogrel pretreatment were retrospectively analyzed in patients included in the ARIAM-Andalucía Registry (Analysis of Delay in Acute Myocardial Infarction). Propensity score and inverse probability of treatment weighting analysis were performed to control treatment selection bias. Results were stratified by ACS type. Sensitivity analyses were used to explore stability of the overall treatment effect. Of 9,621 patients managed invasively, 69% received clopidogrel before coronary angiography. In the ST-elevation myocardial infarction group, pretreatment was associated with a significant reduction in reinfarction (odds ratio 0.53, 95% confidence interval [CI] 0.27 to 0.96; p = 0.027), stent thrombosis (odds ratio 0.15, 95% CI 0.06 to 0.38; p <0.0001), and mortality (odds ratio 0.67, 95% CI 0.48 to 0.94; p = 0.020), with an increase in minor bleeding but remained as a net clinical benefit strategy. Those benefits were not present in patients without ST elevation (non-ST elevation ACS). The weighting and propensity analysis confirmed the same results. An interaction between pretreatment duration and bleeding was observed. In conclusion, pretreatment with clopidogrel reduced the occurrence of death and thrombotic outcomes at the cost of minor bleeding. Those benefits exclusively affected ST-elevation myocardial infarction cases. The potential benefit of routine upstream pretreatment in patients with non-ST-elevation ACS should be reappraised at the present.

Initial complications and factors related to prehospital mortality in acute myocardial infarction with ST segment elevation.

OBJECTIVE: Hospital mortality in myocardial infarction ST-elevation myocardial infarction has decreased in recent years, in contrast to prehospital mortality. Our objective was to determine initial complications and factors related to prehospital mortality in patients with acute myocardial infarction with ST segment elevation (STEMI). METHODS: Observational study based on a prospective continuous register of patients of any age attended by out-of-hospital emergency teams in Andalusia between January 2006 and June 2009. This includes patients with acute coronary syndrome-like symptoms whose initial ECG showed ST elevation or presumably new left bundle branch block (LBBB). Epidemiological, prehospital data and final diagnostic were recorded. The study included all patients with STEMI on the register, without age restrictions. Forward stepwise logistic regression analysis was performed to control for confounders. RESULTS: A total of 2528 patients were included, 24% were women. Mean age 63.4±13.4 years; 16.7% presented atypical clinical symptoms. Initial complications: ventricular fibrillation (VF) 8.4%, severe bradycardia 5.8%, third-degree atrial-ventricular (AV) block 2.4% and hypotension 13.5%. Fifty-two (2.1%) patients died before reaching hospital. Factors associated with prehospital mortality were female sex (OR 2.36, CI 1.28 to 4.33), atypical clinical picture (OR 2.31, CI 1.21 to 4.41), hypotension (OR 4.95, CI 2.60 to 9.20), LBBB (OR 4.29, CI 1.71 to 10.74), extensive infarction (ST elevation in ≥5 leads) (OR 2.53, CI 1.28 to 5.01) and VF (OR 2.82, CI 1.38 to 5.78). CONCLUSIONS: A significant proportion of patients with STEMI present early complications in the prehospital setting, and some die before reaching hospital. Prehospital mortality was associated with female sex and atypical presentation, as pre-existing conditions, and hypotension, extensive infarction, LBBB and VF on emergency team attendance.

Prognostic impact of atrial fibrillation in acute coronary syndromes: results from the ARIAM registry.

AIMS: The prognostic ability of atrial fibrillation (AF) in acute coronary syndromes (ACS) is unclear. Studies regarding patient outcomes with respect to the timing of AF are scarce and conflicting. The present study aimed to determine the frequency, predictors and impact on clinical outcome of AF in patients with ACS. METHODS: We analysed 39,237 consecutive patients with ACS included in the ARIAM registry between January /2001 and December 2011. Patients with AF were compared with patients in sinus rhythm. We differentiate between new-onset AF and previous AF cases to analyse mortality and other major adverse cardiac events (MACE) during hospitalization. RESULTS: Of the patients, 2851 (7.3%) developed AF; 1568 (55%) of these were new-onset AF and 1283 (45%) had previous AF. The AF group had a higher risk profile at baseline and poorer clinical presentation at admission than non-AF patients. Compared with previous AF patients, new-onset AF presented with fewer comorbidities, including hypertension, diabetes, prior myocardial infarction, and chronic renal impairment. The inhospital mortality for new-onset AF, previous AF, and non-AF patients were 14, 11.6, and 5.2%, respectively (new-onset AF unadjusted HR 2.19, 95% CI 1.9-2.53, p<0.001; adjusted HR 1.70, 95% CI 1.12-3.4, p<0.001). After propensity score analysis, only new-onset AF persisted as an independent predictor for mortality (HR 1.62, 95% CI 1.09-2.89, p<0.001). Other MACE such as reinfarction, malignant arrhythmias, and heart failure were also more frequent in new-onset AF patients than in previous AF or non-AF patients. CONCLUSIONS: These findings suggest that the presence of new-onset AF during ACS is associated with a significant increase in mortality, even after adjusting for confounding variables.

Los residentes en las unidades de cuidados intensivos, ¿cuál es su percepción de la formación que reciben? / Residents in an Intensive Care Unit, what perception they have on their training?

Objetivo. Este trabajo intenta responder a la pregunta de cuál es la visión que tienen los residentes de su formación en las unidades de cuidados intensivos (UCI).Sujetos y métodos. Hemos realizado un estudio cualitativo tipo grounded theory. Los participantes son residentes de cualquier especialidad que estuviesen trabajando en las UCI durante el estudio. El diseño tiene tres partes: percepción subjetiva de los residentes de aquellos aspectos que ellos consideran más útiles para su formación, priorización de las actividades regulares más características de las UCI y entrevistas semiestructuradas con informadores claves. Resultados. Nuestro trabajo identifica que los residentes consideran como eje de su formación la práctica clínica a ‘pie de cama’ desarrollada con autonomía y apoyada en una buena tutorización. Paralelamente, otras competencias nucleares como la investigación, la comunicación en situaciones complejas, el trabajo en equipo o la gestión de recursos están infravaloradas, mientras que otras como la seguridad del paciente o la bioética no se han detectado en las respuestas de los residentes. Conclusión. La percepción de los residentes sobre formación durante su estancia en las UCI adolece de algunas carencias, dado que ciertos aspectos claves de la medicina actual no se perciben como prioridades en dicha formación (AU)

Aim. Our work tries to answer the following question: what is the perception of residents on their training in the Intensive Care Units (ICU)?Subjects and methods. We have conducted a qualitative study based on grounded theory. Participants are residents from different specialties working in the ICU of four hospitals of our National Health Service. The study consist of three parts: resident’s subjective perception of those aspects most appreciate in their clinical practice; resident’s prioritizations of routine ICU’s activities, and semi-structured interviews with key informants. Results. According to the resident’s opinions, the clinical practice at the beside of patients, and carried out with autonomy and with a good tutoring support are central to their training; nevertheless some central competencies such as research, difficult communication, team work or resource management are undervalued, while others such as patient safety or bioethics are absent from their comments. Conclusions. Our work highlight that resident’s perception about their training during they compulsory period in ICU has some shortcoming, because some key aspects of current medicine are not perceived as priorities in their training (AU)

APACHE-II score and Killip class for patients with acute myocardial infarction.

OBJECTIVE: To analyse the influence on the prognosis of intensive care unit (ICU) patients with acute myocardial infarction (AMI): prognostic index score, Killip class, AMI site, thrombolysis and other variables that might improve prognostic capacity and functioning of the APACHE-II index. DESIGN: Cohort study using prospectively gathered ARIAM project data. SETTING: ICUs from 129 Spanish hospitals. PATIENTS: ICU-admitted AMI patients in ARIAM database during 4-year period were retrospectively studied. MEASUREMENTS AND MAIN RESULTS: The sample comprised 6,458 patients, 76.8% males, age 64.97 +/- 12.56 years, APACHE-II score 9.49 +/- 7.03 points and ICU mortality 8.9%. Mortality was higher for females (p < 0.001), anterior AMI site (p < 0.001), previous AMI (p < 0.001), delay-to-hospital arrival >180 min (p = 0.003) and non-receipt of thrombolysis (p = 0.015). ICU mortality was related to age (p < 0.001) and APACHE-II score (p < 0.001). In multivariate analysis, it was related to APACHE-II (OR 1.16), age (OR 1.05), gender (OR 1.64), previous AMI (OR 1.57), anterior AMI (OR 2.05) and delay >180 min (OR 1.37). Killip class, gathered in 1,893 patients, was significantly associated with ICU mortality, and two predictive models were constructed for this group using multivariate analysis. Area under ROC curve was 0.94 in one (Killip class, age, gender, APACHE-II) versus 0.92 in the other (same variables without APACHE-II). CONCLUSIONS: APACHE-II score and Killip class are useful for assessing the severity of patients with AMI and are complementary. Each can be used with a few commonly gathered clinical variables to construct prognostic models to assess severity. Their joint application yields a model with excellent discrimination capacity.

Preinfarction angina prior to first myocardial infarction does not influence long-term prognosis: a retrospective study with subgroup analysis in elderly and diabetic patients.

BACKGROUND AND HYPOTHESIS: Although prodromal angina occurring shortly before an acute myocardial infarction (MI) has protective effects against in-hospital complications, this effect has not been well documented after initial hospitalization, especially in older or diabetic patients. We examined whether angina 1 week before a first MI provides protection in these patients. METHODS: A total of 290 consecutive patients, 143 elderly (>64 years of age) and 147 adults (<65 years of age), 68 of whom were diabetic (23.4%) and 222 nondiabetic (76.6%), were examined to assess the effect of preceding angina on long-term prognosis (56 months) after initial hospitalization for a first MI. RESULTS: No significant differences were found in long-term complications after initial hospitalization in these adult and elderly patients according to whether or not they had prodromal angina (44.4% with angina vs 45.4% without in adults; 45.5% vs 58% in elderly, P < 0.2). Nor were differences found according to their diabetic status (61.5% with angina vs 72.7% without in diabetics; 37.3% vs 38.3% in nondiabetics; P = 0.4). CONCLUSION: The occurrence of angina 1 week before a first MI does not confer long-term protection against cardiovascular complications after initial hospitalization in adult or elderly patients, whether or not they have diabetes.

[Effect of angina in the week before myocardial infarction on long-term cardiovascular morbidity and mortality after hospital discharge]. / Influencia de la angina preinfarto en la semana previa en la morbimortalidad cardiovascular tardía tras el alta hospitalaria.

The occurrence of angina in the week preceding myocardial infarction is associated with a reduction in cardiovascular complications in the acute phase. However, little is known about it relationship with prognosis after hospitalization (e.g., cardiovascular death and the development of heart failure or ischemic cardiomyopathy). The study included 290 consecutive patients admitted for a first myocardial infarction: 107 (36.9%) had preceding angina while 183 did not. Those with a history of ischemic cardiomyopathy of more than 1 week or structural cardiopathy were excluded. There was no difference in baseline characteristics between the two groups. Moreover, there was no difference in the rates of cardiovascular complications after hospital discharge: cardiovascular death (7% vs. 12.6%; P=.3), heart failure (7.4% vs. 11.6%; P=.2), and myocardial ischemia, including myocardial infarction and unstable angina, requiring hospitalization (41.2% vs. 31.3%; P=.3). The occurrence of angina in the week before a first myocardial infarction did not influence cardiovascular complications after hospital discharge (odds ratio = 0.75 [0.51-1.11]; P=.15).

Influencia de la angina preinfarto en la semana previa en la morbimortalidad cardiovascular tardía tras el alta hospitalaria / Effect of Angina in the Week Before Myocardial Infarction on Long-Term Cardiovascular Morbidity and Mortality After Hospital Discharge

La angina preinfarto precoz (semana previa) se asociaa una reducción de las complicaciones cardiovascularesen la fase aguda del infarto, pero es escasa la información sobre su relación con el pronóstico tras la fase hospitalaria (muerte cardiovascular y desarrollo de insuficiencia cardiaca e isquemia miocárdica). Estudiamos a 290 pacientes consecutivos ingresados con un primer infarto, 107 con angina precoz (36,9%) y 183 sin ella. Se excluyó a los pacientes con antecedentes de cardiopatía isquémica de más de 1 semana o cardiopatía estructural de base. No se aprecian diferencias en las características basales de ambos grupos. No hay diferencias en las complicaciones cardiovasculares tras el alta hospitalaria (mortalidad cardiovascular, 7 frente a 12,6%; p = 0,3), insuficienciacardiaca (7,4 frente a 11,6%; p = 0,2) o isquemiamiocárdica (infarto o angina inestable, 41,2 frente a31,3%; p = 0,3) que motiven ingreso hospitalario. La angina precoz no es un factor asociado a complicaciones cardiovasculares tras el alta hospitalaria (odds ratio = 0,75; intervalo de confianza del 95%, 0,51-1,11; p = 0,15)

The occurrence of angina in the week precedingmyocardial infarction is associated with a reduction incardiovascular complications in the acute phase.However, little is known about it relationship withprognosis after hospitalization (e.g., cardiovascular death and the development of heart failure or ischemiccardiomyopathy). The study included 290 consecutivepatients admitted for a first myocardial infarction: 107(36.9%) had preceding angina while 183 did not. Thosewith a history of ischemic cardiomyopathy of more than 1week or structural cardiopathy were excluded. There wasno difference in baseline characteristics between the twogroups. Moreover, there was no difference in the rates ofcardiovascular complications after hospital discharge:cardiovascular death (7% vs. 12.6%; P=.3), heart failure(7.4% vs. 11.6%; P=.2), and myocardial ischemia,including myocardial infarction and unstable angina,requiring hospitalization (41.2% vs. 31.3%; P=.3). Theoccurrence of angina in the week before a first myocardial infarction did not influence cardiovascular complications after hospital discharge (odds ratio = 0.75 [0.51–1.11]; P=.15) (AU)

[Mean length of stay and prognosis in unstable angina. Results from the ARIAM database]. / Estancia media y pronóstico en la angina inestable. Resultados del registro ARIAM.

BACKGROUND AND OBJECTIVE: The objective of this project is to investigate the factors predicting mortality and mean length of stay in patients diagnosed with unstable angina (UA) during admission to the Intensive Care Unit or Critical Care Unit (ICU/CCU). PATIENTS AND METHOD: A retrospective cohort study including all the UA patients listed in the Spanish ARIAM register. The study period comprised from June, 1996 to December, 2003. The follow-up period is limited to the stay in the ICU/CCU. One univariate analysis was performed between deceased and live patients; and another between prolonged and non-prolonged stay patients. Three multivariate analyses were also performed; one to evaluate the factors related to mortality, another to evaluate the variables associated to percutaneous coronary intervention (PCI) and another to evaluate the factors associated to the prolonged mean stay in ICU/CCU. RESULTS: 14,096 patients with UA were included in the study. The UA mortality rate during ICU/CCU admission was 1.1%. Mortality was associated to Killip classification, age, the need for CPR, development of cardiogenic shock, development of arrhythmia (such as VF, sinus tachycardia or high-degree atrioventricular block) and diabetes; whereas patients who smoke were associated to a lower mortality rate. PCI was only performed in 1,226 patients (8.9%), increasing over the years. The PCI-predicting variables were: age, being referred from another hospital, smoking, presenting prior acute myocardial infarction (AMI), complications consisting of cardiogenic shock or high-degree atrioventricular block and being treated with oral beta blockers. The mean length of stay in ICU/CCU was 3.15 (18.65) days (median, 2 days), depending on age, a coronariography having previously been performed, the Killip classification, having required coronariography and PCI or echocardiography or mechanical ventilation, and presenting complications such as angina that is difficult to control, arrhythmia, right ventricular failure or death. CONCLUSIONS: The factors are associated to mortality were; greater age, diabetes, Killip classification, arrhythmia, cardiogenic shock and the need for CPR, whereas smoking is associated to a lower mortality rate. The patients on whom PCI was performed represent a less severe population. Management has changed over the years, with an increase in PCI. A prolonged mean length of stay is associated to the appearance of arrhythmia, right or left heart failure, angina that is difficult to control, age and PCI.

Estancia media y pronóstico en la angina inestable. Resultados del registro ARIAM / Mean length of stay and prognosis in unstable angina. Results from the ARIAM database

Fundamento y objetivo: El propósito de este trabajo es investigar los factores predictores de mortalidad y la estancia media de los pacientes diagnosticados de angina inestable (AI) durante su ingreso en las unidades de cuidados intensivos o unidades de cuidados coronarios (UCI/UCC). Pacientes y método: Estudio de cohorte retrospectivo que incluyó a los pacientes del registro español ARIAM (Análisis del Retraso en el Infarto Agudo de Miocardio). El período de estudio comprendió de junio de 1996 a diciembre de 2003. Su seguimiento se limitó a UCI/UCC. Se realizó un análisis univariante entre los pacientes fallecidos y los vivos y otro entre los pacientes con estancia prolongada y no prolongada. Se realizaron además 3 análisis multivariantes con el objetivo de evaluar los factores relacionados con la mortalidad, las variables asociadas a la realización de intervención coronaria percutánea (ICP) y los factores asociados a la estancia media prolongada en UCI/UCC. Resultados: Se incluyó a 14.096 pacientes con AI. La mortalidad fue del 1,1% y se asoció a la clase Killip, edad, necesidad de reanimación cardiopulmonar y presencia de shock cardiogénico, arritmias y diabetes; mientras que los pacientes fumadores se asociaron a una menor mortalidad. Se realizó ICP sólo a 1.226 (8,9%) pacientes, aunque su realización se incrementó con los años. La ICP se asoció a edad, traslado interhospitalario, tabaquismo, infarto de miocardio previo, shock cardiogénico o ante el bloqueo auriculoventricular de alto grado (BAVAG) y tratamiento con bloqueadores beta. La estancia media (desviación estándar) fue de 3,15 (18,65) días. La estancia media prolongada dependió de la edad, haber sido sometido a una coronariografía o ICP, clase Killip, ecocardiografía o ventilación mecánica y presentar complicaciones graves. Conclusiones: La mortalidad se explica por la comorbilidad y la gravedad de la isquemia. Los pacientes a los que se realiza ICP son una población menos grave, y su realización con el tiempo se incrementa. La estancia media prolongada se asocia a la mayor gravedad de la isquemia miocárdica y a la ICP

Background and objective: The objective of this project is to investigate the factors predicting mortality and mean length of stay in patients diagnosed with unstable angina (UA) during admission to the Intensive Care Unit or Critical Care Unit (ICU/CCU). Patients and method: A retrospective cohort study including all the UA patients listed in the Spanish ARIAM register. The study period comprised from June, 1996 to December, 2003. The follow-up period is limited to the stay in the ICU/CCU. One univariate analysis was performed between deceased and live patients; and another between prolonged and non-prolonged stay patients. Three multivariate analyses were also performed; one to evaluate the factors related to mortality, another to evaluate the variables associated to percutaneous coronary intervention (PCI) and another to evaluate the factors associated to the prolonged mean stay in ICU/CCU. Results: 14,096 patients with UA were included in the study. The UA mortality rate during ICU/CCU admission was 1.1%. Mortality was associated to Killip classification, age, the need for CPR, development of cardiogenic shock, development of arrhythmia (such as VF, sinus tachycardia or high-degree atrioventricular block) and diabetes; whereas patients who smoke were associated to a lower mortality rate. PCI was only performed in 1,226 patients (8.9%), increasing over the years. The PCI-predicting variables were: age, being referred from another hospital, smoking, presenting prior acute myocardial infarction (AMI), complications consisting of cardiogenic shock or high-degree atrioventricular block and being treated with oral beta blockers. The mean length of stay in ICU/CCU was 3.15 (18.65) days (median, 2 days), depending on age, a coronariography having previously been performed, the Killip classification, having required coronariography and PCI or echocardiography or mechanical ventilation, and presenting complications such as angina that is difficult to control, arrhythmia, right ventricular failure or death. Conclusions: The factors are associated to mortality were; greater age, diabetes, Killip classification, arrhythmia, cardiogenic shock and the need for CPR, whereas smoking is associated to a lower mortality rate. The patients on whom PCI was performed represent a less severe population. Management has changed over the years, with an increase in PCI. A prolonged mean length of stay is associated to the appearance of arrhythmia, right or left heart failure, angina that is difficult to control, age and PCI

Influencia de la angina en la semana previa al primer infarto agudo de miocardio sobre su pronóstico intrahospitalario y a medio plazo / The Influence of Angina the Week Before a First Myocardial Infarction on Short and Medium-Term Prognosis

Introducción y objetivos. Existe controversia sobre el efecto de la angina de reciente comienzo en el pronóstico de los pacientes que presentan un infarto agudo de miocardio. El objetivo de este estudio fue determinar si esta angina confiere protección respecto a las complicaciones intrahospitalarias y en el seguimiento a medio plazo en pacientes con un primer infarto agudo de miocardio. Pacientes y método. Estudiamos a un total de 290 pacientes consecutivos ingresados con un primer infarto, 107 con angina de reciente comienzo en la semana previa y 183 sin ella, excluyendo a aquellos con antecedentes de cardiopatía isquémica de más de una semana de evolución o cardiopatía estructural de base. Estudiamos su pronóstico intrahospitalario y en el seguimiento a medio plazo (muerte e insuficiencia cardíaca). Resultados. Los pacientes con angina de reciente comienzo previo al infarto presentaron un menor número de muertes (3,7 frente a 11,5 por ciento), insuficiencia cardíaca (4,6 frente a 15,8 por ciento) y su combinación (7,5 frente a 21,3 por ciento) (p = 0,002). Esta asociación se confirma en el seguimiento (4,1 frente a 13,2 por ciento; p = 0,03). En el análisis multivariado, la angina de reciente comienzo preinfarto constituía un factor predictor de presentar un menor número de muertes y de desarrollar insuficiencia cardíaca en la fase hospitalaria y en el seguimiento. Conclusiones. La presencia de angina de reciente comienzo previa al primer infarto agudo de miocardio se asocia a una disminución del número de pacientes que mueren o presentan insuficiencia cardíaca, tanto en la fase hospitalaria como en el seguimiento a medio plazo (AU)