¿Podemos mejorar el tratamiento de los síndromes coronarios agudos en la atención primaria? / Can we improve the management of acute coronary syndromes in primary care?

ObjetivoEvaluar un plan de formación sobre el tratamiento del síndrome coronario agudo (SCA) en la atención primaria.DiseñoEstudio transversal comparativo antes-durante-después.EmplazamientoÁreas de salud de Lleida, Alto Pirineo y Arán del 2003 to 2006.ParticipantesPacientes con SCA atendidos en la Unidad de Medicina Intensiva y la Unidad Coronaria del Hospital Universitario Arnau de Vilanova de Lleida, ingresados tras un contacto previo con la atención primaria en su domicilio, consultorio local o centro de salud.IntervencionesPlan de formación dirigido a establecer unos protocolos de actuación en los SCA asistidos en la atención primaria (administrar ácido acetilsalicílico, nitroglicerina y cloruro mórfico, realizar un electrocardiograma y establecer una vía venosa permeable, y agilizar los tiempos asistenciales).Medidas principalesSe analizó la tendencia lineal en los 3 períodos de estudio a través de la razón de prevalencias y el test de tendencia lineal.ResultadosLa intervención consiguió un incremento estadísticamente significativo y lineal en la aplicación de todas las medidas terapéuticas propuestas, a excepción de la nitroglicerina, que partía del nivel basal más elevado. La realización de un electrocardiograma consiguió niveles casi óptimos. Los tiempos asistenciales contemplados mejoraron sensiblemente.ConclusionesLos planes de formación constituyen un instrumento útil para mejorar la asistencia de los SCA en la atención primaria. Adelantar el diagnóstico y el inicio del tratamiento debería redundar en una disminución de su morbimortalidad(AU)

ObjectiveTo evaluate a training programme in the primary care of acute coronary syndrome.DesignA before-during-after comparative cross-sectional study.SettingHealth areas of Lleida, High Pyrenees and Aran (Spain), from 2003–2006.ParticipantsPatients with acute coronary syndrome admitted to the intensive medicine unit and the coronary unit of the Arnau de Vilanova University Hospital of Lleida after being referred from home, general practitioner or health centre.InterventionA training program was introduced to establish protocols of pre-hospital performance in acute coronary syndrome (the administration of acetylsalicylic acid, nitroglycerin and morphine chloride, the performing of an electrocardiogram, the insertion of an intravenous tube and to speed up care times).Main measuresLinear trend of the three periods of the study was analyzed through prevalences ratio and linear trend test.ResultsThe intervention showed a statistically significant linear increase in the application of the aforementioned therapeutic procedures, with the exception of nitroglycerin, which started out with a higher baseline level, and an improvement of care times. The application of an electrocardiogram obtained almost optimal levels. Care times considerably improved.ConclusionsTraining programs are a useful tool in improving treatment of acute coronary syndromes in primary care. Advance diagnosis and an early start to treatment almost certainly results in a decrease of its morbidity-mortality(AU)

[Can we improve the management of acute coronary syndromes in primary care?]. / ¿Podemos mejorar el tratamiento de los síndromes coronarios agudos en la atención primaria?

OBJECTIVE: To evaluate a training programme in the primary care of acute coronary syndrome. DESIGN: A before-during-after comparative cross-sectional study. SETTING: Health areas of Lleida, High Pyrenees and Aran (Spain), from 2003-2006. PARTICIPANTS: Patients with acute coronary syndrome admitted to the intensive medicine unit and the coronary unit of the Arnau de Vilanova University Hospital of Lleida after being referred from home, general practitioner or health centre. INTERVENTION: A training program was introduced to establish protocols of pre-hospital performance in acute coronary syndrome (the administration of acetylsalicylic acid, nitroglycerin and morphine chloride, the performing of an electrocardiogram, the insertion of an intravenous tube and to speed up care times). MAIN MEASURES: Linear trend of the three periods of the study was analyzed through prevalences ratio and linear trend test. RESULTS: The intervention showed a statistically significant linear increase in the application of the aforementioned therapeutic procedures, with the exception of nitroglycerin, which started out with a higher baseline level, and an improvement of care times. The application of an electrocardiogram obtained almost optimal levels. Care times considerably improved. CONCLUSIONS: Training programs are a useful tool in improving treatment of acute coronary syndromes in primary care. Advance diagnosis and an early start to treatment almost certainly results in a decrease of its morbidity-mortality.

Administración upstream de inhibidores de la glucoproteína IIb/IIIa en el síndrome coronario agudo sin elevación del segmento ST: la estrategia TACTICS / Upstream administration of tirofiban in Non-ST-elevation acute coronary syndrome: the TACTICS strategy

El empleo de los inhibidores de la glucoproteína IIb/IIIa en el contexto del síndrome coronario agudo sin elevación del segmento ST es un tema muy controvertido. A pesar de la oposición a su uso en las últimas guías de revascularización de la Sociedad Europea de Cardiología, los autores seguimos defendiendo el beneficio de la estrategia utilizada en el ensayo clínico TACTICS: actitud intervencionista facilitada con tirofibán en los pacientes con riesgo moderado y alto. Argumentamos esta defensa basándonos en que consideramos que el tirofibán es superior a los otros inhibidores de la glucoproteína IIb/IIIa en estos pacientes, unido a las dudas que todavía nos plantea la bivalirudina y al convencimiento de que los nuevos antiagregantes no deben considerarse sustitutivos, sino complementarios (AU)

The use of glycoprotein-IIb/IIIa inhibitors in non-ST-elevation acute coronary syndrome is highly controversial. Despite opposition to their use in the European Society of Cardiology’s most recent guidelines on myocardial revascularization, the authors of this article maintain that clear clinical benefits were obtained with the treatment strategy used in the TACTICS clinical trial, namely the invasive approach facilitated by tirofiban that was used in moderate- and high-risk patients. The argument in favor of this approach is based on the contention that tirofiban is superior to other glycoprotein-IIb/IIIa inhibitors in these patients, as well as on the knowledge that there are still uncertainties about bivalirudin and on the conviction that new antiplatelet agents should not be regarded as substitutes but rather as complementary treatments (AU)