The cost-effectiveness of a uniform versus age-based threshold for one-off screening for prevention of cardiovascular disease.

The objective of this article was to assess the cost-effectiveness of screening strategies for cardiovascular diseases (CVD). A decision analytic model was constructed to estimate the costs and benefits of one-off screening strategies differentiated by screening age, sex and the threshold for initiating statin therapy ("uniform" or "age-adjusted") from the Spanish NHS perspective. The age-adjusted thresholds were configured so that the same number of people at high risk would be treated as under the uniform threshold. Health benefit was measured in quality-adjusted life years (QALY). Transition rates were estimated from the European Prospective Investigation into Cancer and Nutrition (EPIC-CVD), a large multicentre nested case-cohort study with 12 years of follow-up. Unit costs of primary care, hospitalizations and CVD care were taken from the Spanish health system. Univariate and probabilistic sensitivity analyses were employed. The comparator was no systematic screening program. The base case model showed that the most efficient one-off strategy is to screen both men and women at 40 years old using a uniform risk threshold for initiating statin treatment (Incremental Cost-Effectiveness Ratio of €3,274/QALY and €6,085/QALY for men and women, respectively). Re-allocating statin treatment towards younger individuals at high risk for their age and sex would not offset the benefit obtained using those same resources to treat older individuals. Results are sensitive to assumptions about CVD incidence rates. To conclude, one-off screening for CVD using a uniform risk threshold appears cost-effective compared with no systematic screening. These results should be evaluated in clinical studies.

Separate and combined associations of obesity and metabolic health with coronary heart disease: a pan-European case-cohort analysis.

Aims: The hypothesis of 'metabolically healthy obesity' implies that, in the absence of metabolic dysfunction, individuals with excess adiposity are not at greater cardiovascular risk. We tested this hypothesis in a large pan-European prospective study. Methods and results: We conducted a case-cohort analysis in the 520 000-person European Prospective Investigation into Cancer and Nutrition study ('EPIC-CVD'). During a median follow-up of 12.2 years, we recorded 7637 incident coronary heart disease (CHD) cases. Using cut-offs recommended by guidelines, we defined obesity and overweight using body mass index (BMI), and metabolic dysfunction ('unhealthy') as ≥ 3 of elevated blood pressure, hypertriglyceridaemia, low HDL-cholesterol, hyperglycaemia, and elevated waist circumference. We calculated hazard ratios (HRs) and 95% confidence intervals (95% CI) within each country using Prentice-weighted Cox proportional hazard regressions, accounting for age, sex, centre, education, smoking, diet, and physical activity. Compared with metabolically healthy normal weight people (reference), HRs were 2.15 (95% CI: 1.79; 2.57) for unhealthy normal weight, 2.33 (1.97; 2.76) for unhealthy overweight, and 2.54 (2.21; 2.92) for unhealthy obese people. Compared with the reference group, HRs were 1.26 (1.14; 1.40) and 1.28 (1.03; 1.58) for metabolically healthy overweight and obese people, respectively. These results were robust to various sensitivity analyses. Conclusion: Irrespective of BMI, metabolically unhealthy individuals had higher CHD risk than their healthy counterparts. Conversely, irrespective of metabolic health, overweight and obese people had higher CHD risk than lean people. These findings challenge the concept of 'metabolically healthy obesity', encouraging population-wide strategies to tackle obesity.

Relationship between drugs affecting the renin-angiotensin system and colorectal cancer: The MCC-Spain study.

The potential protective effect of renin-angiotensin system (RAS) inhibitors is a subject of increasing interest due to their possible role as chemopreventive agents against colorectal cancer (CRC). To evaluate this association, we conducted a case-control study with 2165 cases of colorectal cancer, diagnosed between 2007 and 2012, and 3912 population controls frequency matched (by age, sex and region) from the Spanish multicenter case-control study MCC-Spain. We found a significant protective effect of the angiotensin-converting enzyme Inhibitors (ACEIs) against CRC, limited to the under-65years group (OR=0.65 95%CI (0.48-0.89)) and to a lesser degree to men (OR=0.81 95%CI (0.66-0.99). In contrast, the angiotensin receptor blockers (ARBs) did not show a significant effect. Regarding the duration of use, a greater protection was observed in men as the length of consumption increases. In contrast, in the under-65 stratum, the strongest association was found in short-term treatments. Finally, by analyzing ACEIs effect by colon subsite, we found no differences, except for under 65years old, where the maximum protection was seen in the proximal intestine, descending in the distal and rectum (without statistical significance). In conclusion, our study shows a protective effect on CRC of the ACEis limited to males and people under 65years old, which increases in proximal colon in the latter. If confirmed, these results may suggest a novel approach to proximal CRC prevention, given the shortcomings of colonoscopy screening in this location.

Association of diabetes and diabetes treatment with incidence of breast cancer.

AIMS: The aim of this study was to evaluate the association of diabetes and diabetes treatment with risk of postmenopausal breast cancer. METHODS: Histologically confirmed incident cases of postmenopausal breast (N = 916) cancer were recruited from 23 Spanish public hospitals. Population-based controls (N = 1094) were randomly selected from primary care center lists within the catchment areas of the participant hospitals. ORs (95 % CI) were estimated using mixed-effects logistic regression models, using the recruitment center as a random effect term. Breast tumors were classified into hormone receptor positive (ER+ or PR+), HER2+ and triple negative (TN). RESULTS: Diabetes was not associated with the overall risk of breast cancer (OR 1.09; 95 % CI 0.82-1.45), and it was only linked to the risk of developing TN tumors: Among 91 women with TN tumors, 18.7 % were diabetic, while the corresponding figure among controls was 9.9 % (OR 2.25; 95 % CI 1.22-4.15). Regarding treatment, results showed that insulin use was more prevalent among diabetic cases (2.5 %) as compared to diabetic controls (0.7 %); OR 2.98; 95 % CI 1.26-7.01. They also showed that, among diabetics, the risk of developing HR+/HER2- tumors decreased with longer metformin use (ORper year 0.89; 95 % CI 0.81-0.99; based on 24 cases and 43 controls). CONCLUSION: This study reinforces the need to correctly classify breast cancers when studying their association with diabetes. Given the low survival rates in women diagnosed with TN breast tumors and the potential impact of diabetes control on breast cancer prevention, more studies are needed to better characterize this association.

Validity of self-reported prevalent cases of stroke and acute myocardial infarction in the Spanish cohort of the EPIC study.

BACKGROUND: Information on the validity of self-reported cases of stroke and acute myocardial infarction (AMI) is varied. The aim of this study was to assess the validity and agreement of self-reported prevalent cases of stroke and AMI in the Spanish cohort of the European Prospective Investigation into Cancer and Nutrition (EPIC). METHODS: At recruitment, 1992-1996, and in the follow-up (3 years after recruitment), each participant in the Spanish EPIC cohort (15,630 men and 25,808 women) was asked if a doctor had ever said that they had had a stroke or AMI, and the results were compared with information available in medical records. Validity of self-reported prevalent cases of stroke and AMI was examined by calculating sensitivity, specificity, positive predictive values and κ statistics. RESULTS: The sensitivity of self-reported prevalent cases of stroke was 81.3% and that for AMI was 97.7%. The positive predictive value was 22.2% and 60.7% for stroke and AMI, respectively, whereas specificity was very high (>99%) for both diseases. The agreement between self-report questionnaire results and medical records was substantial (κ=0.75) for AMI but not for stroke (κ=0.35). CONCLUSION: Self-reported information on stroke and AMI included in the EPIC questionnaire is a valid instrument for the assessment of AMI disease but should be used with caution in stroke.

Unfavourable life-course social gradient of coronary heart disease within Spain: a low-incidence welfare-state country.

OBJECTIVE: Social position has yet to be established as a risk factor of coronary heart disease (CHD). Our aim was to investigate an individual life-course social position gradient link with CHD incidence in the EPIC-Spain cohort. METHODS: 41,066 participants, mostly 30-65 years old, and free of cardiovascular disease at baseline (1992-1996) were followed up for a mean of 10.4 years. A combined score of paternal occupation in childhood and own adult education was used to assess individual life-course risk accumulation. Hazard ratios of CHD were estimated using Cox models, stratifying by centre, and age, and adjusting for cardiovascular risk factors. RESULTS: 583 participants (80 % men) developed a definite CHD event. Paternal occupational class IV was associated with CHD in all models in men. The educational gradient remained significant after adjusting for diet and physical activity (p = 0.01). All adjusted risk of incident CHD rose by 23 % (95 % CI 6-42 %) per category increase of life-course social position score in men. No significant associations were found in women. CONCLUSIONS: Individual life-course social position gradient was adversely related to incident CHD in Spanish men.

Saturated fat intake and alcohol consumption modulate the association between the APOE polymorphism and risk of future coronary heart disease: a nested case-control study in the Spanish EPIC cohort.

The association is still not clear between the common APOE polymorphism and coronary heart disease (CHD) risk, nor its modulation by diet. Thus, our aim was to study the association between the APOE genotypes and incident CHD and how dietary fat and alcohol consumption modify these effects. We performed a nested case-control study in the Spanish European Prospective Investigation into Cancer and Nutrition cohort. Healthy men and women (41,440, 30-69 years) were followed up over a 10-year period, with the incident CHD cases being identified. We analyzed 534 incident CHD cases and 1123 controls. APOE, dietary intake and plasma lipids were determined at baseline. The APOE polymorphism was significantly associated with low-density lipoprotein cholesterol (LDL-C), and gene-alcohol interactions in determining LDL-C were detected. In the whole population, the E2 allele was significantly associated with a lower CHD risk than E3/E3 subjects [odds ratio (OR), 0.58; 95% confidence interval (CI), 0.38-0.89]. The E4 allele did not reach statistical significance vs. E3/E3 (OR, 1.17; 95% CI, 0.88-1.58). However, saturated fat intake modified the effect of the APOE polymorphism in determining CHD risk. When saturated fat intake was low (<10% of energy), no statistically significant association between the APOE polymorphism and CHD risk was observed (P=.682). However, with higher intake (≥10%), the polymorphism was significant (P=.005), and the differences between E2 and E4 carriers were magnified (OR for E4 vs. E2, 3.33; 95% CI, 1.61-6.90). Alcohol consumption also modified the effect of the APOE on CHD risk. In conclusion, in this Mediterranean population, the E2 allele is associated with lower CHD risk, and this association is modulated by saturated fat and alcohol consumption.

Phytosterol plasma concentrations and coronary heart disease in the prospective Spanish EPIC cohort.

Phytosterol intake with natural foods, a measure of healthy dietary choices, increases plasma levels, but increased plasma phytosterols are believed to be a coronary heart disease (CHD) risk factor. To address this paradox, we evaluated baseline risk factors, phytosterol intake, and plasma noncholesterol sterol levels in participants of a case control study nested within the European Prospective Investigation into Cancer and Nutrition (EPIC) Spanish cohort who developed CHD (n = 299) and matched controls (n = 584) who remained free of CHD after a 10 year follow-up. Sitosterol-to-cholesterol ratios increased across tertiles of phytosterol intake (P = 0.026). HDL-cholesterol level increased, and adiposity measures, cholesterol/HDL ratios, and levels of glucose, triglycerides, and lathosterol, a cholesterol synthesis marker, decreased across plasma sitosterol tertiles (P < 0.02; all). Compared with controls, cases had nonsignificantly lower median levels of phytosterol intake and plasma sitosterol. The multivariable-adjusted odds ratio for CHD across the lowest to highest plasma sitosterol tertile was 0.59 (95% confidence interval, 0.36-0.97). Associations were weaker for plasma campesterol. The apolipoprotein E genotype was unrelated to CHD risk or plasma phytosterols. The data suggest that plasma sitosterol levels are associated with a lower CHD risk while being markers of a lower cardiometabolic risk in the EPIC-Spain cohort, a population with a high phytosterol intake.

Fitoesteroles plasmáticos: marcadores de una dieta saludable y un riesgo cardiometabólico menor en la población española del estudio EPIC / Plasma phytosterols: markers of a healthy diet and a lower cardiometabolic risk in the Spanish EPIC population study

Introducción. Las concentraciones elevadas de fitoesteroles plasmáticos, que reflejan una mayor absorción intestinal de colesterol se han relacionado con un aumento del riesgo cardiovascular. Sin embargo, una situación de riesgo alto, el síndrome metabólico (SM), se asocia a un aumento de la síntesis y una disminución de la absorción de colesterol y, por tanto, a una menor fitoesterolemia. En este estudio hemos investigado la relación entre los fitoesteroles del plasma y la dieta y la presencia de factores de riesgo cardiovascular, incluidos los componentes del SM. Métodos y resultados. En un estudio transversal, se evaluaron la ingesta de fitoesteroles y concentraciones plasmáticas de esteroles nocolesterol ajustadas por colesterol en 592 individuos sanos de la cohorte española del estudio EPIC (European Prospective Investigation into Cancer and Nutrition) fenotipados para factores de riesgo cardiovascular, incluidas las variables del SM. La ingesta de fitoesteroles, que se asoció a alimentos saludables, y el colesterol unido a lipoproteínas de alta densidad (HDL) aumentaron, y las medidas de adiposidad, cociente colesterol/ HDL y concentraciones de glucosa, triglicéridos y latosterol, un precursor del colesterol, disminuyeron con los terciles de sitosterol plasmático ajustado por colesterol (p < 0,05; todos). Los resultados para latosterol fueron opuestos a los de sitosterol. El genotipo de la apolipoproteína E no se relacionó con los terciles de esteroles no-colesterol del plasma. Las odds ratio (OR) ajustadas de ser portador de un SM o sus componentes para el tercil superior de sitosterol plasmático comparado con el inferior oscilaron entre 0,23 y 0,42 (p < 0,05; todas). Las OR de las mismas variables para los terciles respectivos de latosterol variaron entre 1,99 y 3,00 (p < 0,05; todas) (..) (AU)

Introduction. Increased plasma phytosterols, which reflect increased cholesterol absorption, have been related to an increased cardiovascular risk. However, the metabolic syndrome (MetS), a cluster of risk factors that carries a high risk for cardiovascular diseases, has been associated with increased cholesterol synthesis and reduced cholesterol absorption, which translate into lower plasma phytosterol levels. In this study we investigated the relationships between plasma and dietary phytosterols and cardiovascular risk factors, including the components of MetS. Methods and results. In a cross-sectional study, we measured phytosterol intake and cholesterol-adjusted plasma non-cholesterol sterol levels in 592 healthy subjects of the Spanish EPIC (European Prospective Investigation into Cancer and Nutrition) cohort who were phenotyped for cardiovascular risk factors, including MetS constituents. Phytosterol intake, which reflects healthy food choices, and the HDL-cholesterol level increased and adiposity measures, cholesterol/HDL ratios, and glucose levels, triglycerides and lathosterol, a cholesterol synthesis marker, decreased across tertiles of plasma sitosterol-to-cholesterol ratios (P<0.05; all). Results were inverse for plasma lathosterol. The ApoE genotype was unrelated to plasma non-cholesterol sterol tertiles. The multivariable-adjusted odds ratios (OR) for the MetS and its components across the lowest to the highest plasma sitosterol tertile ranged between 0.23 and 0.42 (P<0.05; all). The OR for the same variables across respective lathosterol tertiles ranged between 1.99 and 3.00 (P<0.05; all). Conclusions. The MetS is associated with increased plasma lathosterol, a cholesterol synthesis marker, and decreased plasma sitosterol, a joint marker of cholesterol absorption and a healthy diet. Thus, elevated plasma phytosterol concentrations are related to a lower cardiometabolic risk (AU)

[Evaluation of the surveillance system for human immunodeficiency virus infections of Navarra, Spain, 1985-2003]. / Evaluación del sistema de información de Navarra sobre diagnósticos de infección por el VIH, 1985-2003.

BACKGROUND: Navarra has an information system of HIV diagnoses working since the beginning of the epidemic up to the present day. This study aims at describing and evaluating this system, focusing on its sensitivity. METHODS: The updated guidelines for evaluating public health surveillance systems from the CDC were used to describe the purpose and operation of the system and to analyse its attributes for the period 1985-2003. For the evaluation of the sensitivity the regional database of antiretrovirals distribution was used. RESULTS: The HIV surveillance system of Navarra is confidential and name-based, and includes all HIV-infection cases diagnosed each year. The information sources of the system are: (a) all the laboratories in the public health system that perform the western blot test, and (b) hospital discharge registries. The system covers the entire population of Navarre (584,734 inhabitants). It uses the HIV case definition proposed by the European Centre for the Epidemiological Monitoring of AIDS. The system is well-accepted by the community and by all the stakeholders, including those providing data. By the end of 2003 it included 2302 HIV cases, and 98.8% of all patients who had ever received antiretrovirals in Navarra. CONCLUSIONS: The HIV information system of Navarra is simple, useful, well-accepted and highly sensitive. The information about antiretroviral distribution was useful for this evaluation.

Smoking and myocardial infarction case-fatality: hospital and population approach.

BACKGROUND: Smoking is a risk factor for coronary heart disease, but it has been associated with better short-term prognosis in hospitalized patients with acute myocardial infarction. The aims of this study were to determine the association between smoking and myocardial infarction 28-day case-fatality in hospitalized patients and at the population level; and, whether smokers presenting with fatal myocardial infarction are more likely to die before reaching a hospital. DESIGN AND METHODS: Population-based myocardial infarction registry, carried out in 1997-1998 in seven regions of Spain, used standardized methods to find and analyze suspected myocardial infarction patients (10 654 patients; 7796 hospitalized). Four categories of smoking status were defined: never-smokers, former smokers for more than 1 year, former smokers for less than 1 year, and current smokers. RESULTS: The main end-point was 28-day case-fatality, found to be 20.1, 17.1, 15.6, and 8.9%, in the four smoking status categories, respectively, for hospitalized patients; and 37.4, 33.0, 24.5, and 23.2%, respectively, at population level. Hospitalized current smokers had lower age, sex, and comorbidity-adjusted 28-day case-fatality than never-smokers (odds ratio=0.71; 95% confidence interval: 0.56-0.90). This association held at population level (odds ratio=0.68; 95% confidence interval: 0.60-0.76), in which former smoking was also associated with lower case-fatality. In fatal cases, recent former smokers presented a lower risk of out-of-hospital death than never-smokers (odds ratio=0.47; 95% confidence interval: 0.29-0.77), whereas current smoking was marginally associated with out-of-hospital death (odds ratio=1.22; 95% confidence interval: 0.99-1.50). CONCLUSIONS: Current smoking is associated with lower 28-day case-fatality in hospitalized myocardial infarction patients. This association held at population level. Among fatal cases, smoking is associated with higher and recent former smoking with lower risk of dying out-of-hospital.

Evaluación del sistema de información de Navarra sobre diagnósticos de infección por el VIH, 1985-2003 / Evaluation of the surveillance system for Human Immunodeficiency Virus infections of Navarra, Spain, 1985-2003

Fundamento: Navarra cuenta con un sistema de información sobre los diagnósticos de infección por VIH que abarca desde el comienzo de la epidemia hasta la actualidad. El objetivo de este trabajo es describir y evaluar su funcionamiento y sus atributos, haciendo énfasis en el estudio de su sensibilidad. Métodos: Siguiendo las directrices para la Evaluación de Sistemas de Vigilancia en Salud Pública de los Centros para el Control y Prevención de Enfermedades de Atlanta, describimos el sistema de información sobre diagnósticos de infección por VIH de Navarra (el sistema) y analizamos sus atributos cualitativos y cuantitativos entre 1985 y 2003. Para valorar la sensibilidad se utilizó como referencia el registro de dispensación de antirretrovirales de los hospitales de Navarra. Resultados: El sistema de información sobre diagnósticos de infección por VIH de Navarra es nominal y confidencial, e incluye los casos nuevos diagnosticados cada año. Sus fuentes de información son todos los laboratorios que realizan la prueba de confirmación de Western blot en el sistema público, y el registro de altas hospitalarias de la Comunidad Autónoma. Cubre a toda la población de Navarra (584.734 habitantes), y utiliza la definición de caso de infección por VIH del Centro Europeo para la Vigilancia Epidemiológica del VIH y el sida. Es un sistema bien aceptado por la comunidad y por los responsables de suministrar los datos. Hasta diciembre de 2003 se habían incluido 2.302 casos, incluyendo al 98,8% de los pacientes que reciben o han recibido antirretrovirales en Navarra. Conclusiones: Este sistema de información es sencillo, útil, bien aceptado y altamente sensible. La información sobre uso de antirretrovirales ha sido de utilidad para su evaluación

Background: Navarra has an information system of HIV diagnoses working since the beginning of the epidemic up to the present day. This study aims at describing and evaluating this system, focusing on its sensitivity. Methods: The updated guidelines for evaluating public health surveillance systems from the CDC were used to describe the purpose and operation of the system and to analyse its attributes for the period 1985-2003. For the evaluation of the sensitivity the regional database of antiretrovirals distribution was used. Results: The HIV surveillance system of Navarra is confidential and name-based, and includes all HIV-infection cases diagnosed each year. The information sources of the system are: a) all the laboratories in the public health system that perform the western blot test, and b) hospital discharge registries. The system covers the entire population of Navarre (584,734 inhabitants). It uses the HIV case definition proposed by the European Centre for the Epidemiological Monitoring of AIDS. The system is well-accepted by the community and by all the stakeholders, including those providing data. By the end of 2003 it included 2,302 HIV cases, and 98.8% of all patients who had ever received antiretrovirals in Navarra. Conclusions: The HIV information system of Navarra is simple, useful, well-accepted and highly sensitive. The information about antiretroviral distribution was useful for this evaluation

Regional variability in population acute myocardial infarction cumulative incidence and mortality rates in Spain 1997 and 1998.

BACKGROUND: Myocardial infarction (MI) incidence and mortality display a high geographic variation. AIMS: The objective of the present study was to analyze MI mortality, cumulative incidence rate variability in seven regions of Spain from 1997 to 1998. METHODS AND RESULTS: Standardized methods were used to identify, find, register, and classify MI cases that were classified as definite, possible, insufficient-data MI, and non-MI. The total population of the seven monitored regions was 7,364,682 inhabitants. Of the 11,256 cases fulfilling eligibility criteria to investigate, 10,660 were selected to calculate MI rates: 6554 (61.5%) non-fatal definite MI, 1179 (11.1%) fatal definite MI, 1859 (17.4%) fatal possible MI, 1068 (10.0%) fatal cases with insufficient data. The IBERICA 25-74 years age-standardized cumulative incidence rates for men and women, were 207 (range: 175-252) and 45 (range: 36-65) per 100,000, respectively. The age-standardized mortality rates for men and women, were 73 (range: 62-94) and 20 (range: 13-29) per 100,000, respectively. Age-standardized case-fatality was 31.4 and 24.2% in men aged 25-74 and 35-64 years, respectively, and 32.7 and 27.0%, respectively, in women. CONCLUSIONS: MI cumulative incidence and mortality rates are low compared with other industrialized countries but, vary considerably among regions in a Mediterranean country like Spain.

[Myocardial infarction. Population case-fatality in seven Spanish autonomous communities: the IBERICA Study]. / Mortalidad poblacional por infarto agudo de miocardio. Estudio IBERICA.

BACKGROUND AND OBJECTIVE: The magnitude of the problem of myocardial infarction (MI) is better understood by assessing the population case-fatality than by analyzing only the number of patients attending hospitals. PATIENTS AND METHOD: Our data come from the IBERICA Study (Investigation, Specific Search and Registry of Acute Myocardial Ischemic Syndrome). Twenty eight-day MI population case-fatality is described in the population aged 25 to 74 years during 1997 and 1998 in the following Spanish autonomous communities: Castilla-La Mancha (Toledo and Albacete), Catalonia (Girona), Valencia Community (Valencia), Balearic Islands (Majorca), Murcia, Navarra and Basque Country. The relationship between case-fatality and other variables such as sex, age and geographic area is also analyzed. RESULTS: A total of 10,660 MI cases were registered, 4,106 of whom died within the period of 28 days following the onset of symptoms (38.5%; CI 95%, 37.6-39.4%). The overall case-fatality was 37.0% (CI 95%, 35.9-38.0%) in men and 44.3% (CI 95%, 42.3-46.4%) in women. Death occurred out of hospitals in 2,869 (69.9%) cases. An increased case-fatality in women was associated with a higher in-hospital case-fatality (45% higher than men). The proportion of patients who died before reaching a hospital was similar in both genders. Classical symptoms of MI were more common among men than women (82.7% vs. 77.6%, p < 0,001). The interval between symptoms' onset and hospitalization was 30 minute longer among hospitalized women as compared with men (p < 0,001). CONCLUSIONS: Population MI case-fatality is high in the seven Spanish autonomous communities studied. Approximately 2 out of 3 deaths occur without patients being able to reach a hospital. These results emphasize the importance of primary and secondary prevention measures and the necessity to design ready-access systems to defibrillation and resuscitation manoeuvres for patients with cardiopulmonary arrest.

Mortalidad poblacional por infarto agudo de miocardio. Estudio IBERICA / Myocardial infarction. Population case-fatality in seven Spanish autonomous communities: the IBERICA Study

FUNDAMENTO Y OBJETIVO: El estudio de la mortalidad poblacional del infarto agudo de miocardio (IAM), que incluye las muertes ocurridas antes de llegar al hospital, ofrece una visión más completa sobre la magnitud del problema que la obtenida estudiando únicamente la mortalidad de los casos que reciben atención hospitalaria. PACIENTES Y MÉTODO: Los datos provienen del estudio IBERICA (Investigación, Búsqueda Específica y Registro de Isquemia Coronaria Aguda). Se describe la mortalidad en los primeros 28 días desde el inicio de los síntomas de los episodios de IAM registrados, durante 1997 y 1998, en la población de 25 a 74 años residente en 7 comunidades autónomas españolas: Castilla-La Mancha (Toledo y Albacete), Cataluña (Girona), Comunidad Valenciana (Valencia), Islas Baleares (Mallorca), Murcia, Navarra y País Vasco. Además, se estudia la relación entre mortalidad y otras variables como el sexo, la edad y el área geográfica. RESULTADOS: Se registraron 10.654 casos de IAM de los que 4.105 fallecieron durante los 28 primeros días (38,5 por ciento; intervalo de confianza [IC] del 95 por ciento, 37,6-39,4 por ciento). La mortalidad fue del 37,0 por ciento (IC del 95 por ciento, 35,9-38,0 por ciento) en los varones y del 44,3 por ciento (IC del 95 por ciento, 42,3-46,4 por ciento) en las mujeres. La muerte se produjo fuera del hospital en 2.869 (69,9 por ciento) casos. La mayor mortalidad en mujeres estuvo relacionada fundamentalmente con una mayor mortalidad hospitalaria (45 por ciento superior a la registrada en los varones), siendo menor la diferencia en la proporción de casos que fallecieron fuera del hospital. La sintomatología típica de presentación del episodio fue más frecuente en varones (el 82,7 frente al 77,6 por ciento) (p < 0,001). Entre los pacientes que llegaron vivos al hospital, el tiempo transcurrido entre el comienzo de los síntomas y el inicio del tratamiento fue, en promedio, 30 min menor en los varones (p < 0,001). CONCLUSIONES: La mortalidad poblacional por IAM en estas 7 áreas españolas es muy elevada aunque inferior a la de otros países industrializados. Aproximadamente dos de cada tres muertes ocurren antes de llegar al hospital. Estos datos refuerzan el papel prioritario de la prevención primaria y secundaria, ya que los cuidados hospitalarios tienen un impacto limitado en el control de la mortalidad poblacional por IAM. También indican que una forma de reducir la mortalidad debería incluir el acceso rápido a la desfibrilación y a las maniobras de resucitación de los pacientes que presenten una muerte súbita (AU)