Significance of tilt table testing in patients with suspected arrhythmic syncope and negative electrophysiologic study.

BACKGROUND: The diagnostic significance of a tilt table test (TTT) in patients with a suspected arrhythmic etiology for syncope and negative electrophysiologic study (EPS) has not been previously assessed comparing the TTT results with the findings of prolonged monitoring using an implantable loop recorder (ILR). We sought to assess the diagnostic yielding of TTT in patients with suspected arrhythmic syncope and negative EPS. METHODS AND RESULTS: In 81 patients with suspected arrhythmic etiology for syncope and negative EPS, TTT was performed and an ILR implanted regardless the results of TTT. TTT was positive in 38 patients. During follow-up, syncope or presyncope recurred in 32 patients (39.5%). No differences were found in recurrence rates in patients with positive and negative TTT (31.5% vs 46.5%, P = ns). According to rhythm registered during ILR activation, mechanisms of syncopal events were classified as: arrhythmic (atrioventricular [AV] block and ventricular tachycardia; n = 18), neurally mediated (sinus bradycardia and sinus pause; n = 9), and indeterminate (normal sinus rhythm; n = 5). There was no statistical association between the results of TTT and the mechanism of syncope. CONCLUSIONS: In patients with a suspected arrhythmic etiology for syncope and a negative EPS, TTT is of little value to predict the mechanism of syncope and the ILR implantation seems to be a useful and safe diagnostic strategy.

[Influence of comorbidity on admission management and pharmacological treatment prescribed at discharge in acute myocardial infarction]. / Influencia de la comorbilidad en el tratamiento intrahospitalario y al alta de los pacientes con infarto de miocardio.

BACKGROUND AND OBJECTIVE: The management of cardiac ischemic patients differs depending on their comorbidity. The Charlson Index (ChI) and its adaptations are well established and widely used tools to quantify a patient comorbidity. The aim of this study is to evaluate the influence of comorbidity quantified by the ChI in the treatment administered at admission and in the pharmacological treatment prescribed at discharge in the setting of an acute myocardial infarction with and without ST segment elevation. PATIENTS AND METHOD: We studied a total of 955 patients consecutively admitted in our hospital with the diagnosis of acute myocardial infarction. Comorbidity was obtained at the first day of admission applying the ChI. According to this value patients were classified from minor to major in 2 subgroups (ChI or= 2) and differences in the admission and discharge treatments between both groups were analyzed. RESULTS: Patients admitted with acute myocardial infarction without ST segment elevation and ChI > 2 received less frequently betablockers at discharge, but there were no significant differences in the use of ACE inhibitors, calcium channel blockers or statins. In addition they were submitted less frequently to revascularization procedures or treadmills, and no differences were found in the use of echocardiograms. Patients with ST segment elevation and ChI > 2 were less frequently treated with betablockers or statins at discharge, and were submitted to less treadmills or echocardiograms; furthermore, in these patients, there were no significant differences in the use of ACE inhibitors, calcium channel blockers, thrombolytics or revascularization procedures. CONCLUSIONS: Comorbidity quantified on admission by the ChI is an independent factor that modifies in-hospital and ambulatory management of patients with acute myocardial infarction. There is a lower use of invasive techniques as well as a lower prescription of betablockers at discharge in patients with greater comorbidity.

Influencia de la comorbilidad en el tratamiento intrahospitalario y al alta de los pacientes con infarto de miocardio / Influence of comorbidity on admission management and pharmacological treatment prescribed at discharge in acute myocardial infarction

FUNDAMENTO Y OBJETIVO: El tratamiento del paciente cardiológico varía según su comorbilidad. Elíndice de Charlson (ICh) y sus adaptaciones son herramientas utilizadas y contrastadas globalmenteque intentan objetivar la comorbilidad de un paciente. El objetivo del presente trabajoes evaluar la influencia de la comorbilidad, cuantificada mediante el ICh, en el tratamiento intrahospitalarioy farmacológico prescrito al alta hospitalaria en el infarto de miocardio con o sinelevación del segmento ST.PACIENTES Y MÉTODO: Se estudió a 955 pacientes consecutivos ingresados en un hospital por infartode miocardio. Se analizó la comorbilidad obtenida el primer día del ingreso mediante laaplicación del ICh, se clasificó a los pacientes en 2 subgrupos de menor o mayor comorbilidad(ICh ≤ 2; ICh > 2) y se determinó si había diferencias entre ambos subgrupos según el tratamientointrahospitalario y al alta.RESULTADOS: Los pacientes ingresados por infarto agudo de miocardio sin elevación del ST e IChsuperior a 2 recibieron con menor frecuencia bloqueadores beta al alta, mientras que no existendiferencias significativas en el tratamiento con inhibidores de la enzima de conversión de laangiotensina, antagonistas del calcio o estatinas. Además, se les practicaron menos procedimientosde revascularización y menos ergometrías, mientras que no hubo diferencias en la realizaciónde ecocardiogramas. Los pacientes con elevación del segmento ST e ICh superior a 2era menos probable que fueran tratados al alta con bloqueadores beta y estatinas, y se les realizaronmenos ergometrías y ecocardiogramas, mientras que no hubo diferencias significativasen el tratamiento con inhibidores de la enzima de conversión del la angiotensina, antagonistasdel calcio, trombólisis o tratamiento intervencionista (revascularización).CONCLUSIONES: La comorbilidad presente en el momento del ingreso y cuantificada mediante elICh condiciona de manera independiente el tratamiento intrahospitalario y el alta de los pacientescon infarto de miocardio. Hay un menor uso de técnicas invasivas, junto con una menorprescripción de bloqueadores beta al alta en los pacientes con mayor comorbilidad

BACKGROUND AND OBJECTIVE: The management of cardiac ischemic patients differs depending ontheir comorbidity. The Charlson Index (ChI) and its adaptations are well established and widelyused tools to quantify a patient comorbidity. The aim of this study is to evaluate the influenceof comorbidity quantified by the ChI in the treatment administered at admission and in thepharmacological treatment prescribed at discharge in the setting of an acute myocardial infarctionwith and without ST segment elevation.PATIENTS AND METHOD: We studied a total of 955 patients consecutively admitted in our hospitalwith the diagnosis of acute myocardial infarction. Comorbidity was obtained at the first day ofadmission applying the ChI. According to this value patients were classified from minor to majorin 2 subgroups (ChI 2) and differences in the admission and discharge treatmentsbetween both groups were analyzed.RESULTS: Patients admitted with acute myocardial infarction without ST segment elevation and ChI> 2 received less frequently betablockers at discharge, but there were no significant differences inthe use of ACE inhibitors, calcium channel blockers or statins. In addition they were submittedless frequently to revascularization procedures or treadmills, and no differences were found in theuse of echocardiograms. Patients with ST segment elevation and ChI > 2 were less frequently treatedwith betablockers or statins at discharge, and were submitted to less treadmills or echocardiograms;furthermore, in these patients, there were no significant differences in the use of ACEinhibitors, calcium channel blockers, thrombolytics or revascularization procedures.CONCLUSIONS: Comorbidity quantified on admission by the ChI is an independent factor that modifiesin-hospital and ambulatory management of patients with acute myocardial infarction.There is a lower use of invasive techniques as well as a lower prescription of betablockers atdischarge in patients with greater comorbidity

[Seasonal variations in admissions for acute myocardial infarction. The PRIMVAC study]. / Variaciones estacionales en los ingresos por infarto agudo de micardio. El estudio PRIMVAC.

INTRODUCTION AND OBJECTIVES: Some authors have described seasonal variations in the incidence of acute myocardial infarction. The aim of this study was to determine the existence of seasonal rhythms in admissions for acute myocardial infarction to coronary care units, and in mortality, and to analyze the influence of age on environmental factors. PATIENTS AND METHOD: The study included a total of 8400 consecutive patients with acute myocardial infarction admitted to 12 coronary care units in the PRIMVAC registry from January 1995 to December 1999. Seasonal rhythms were analyzed with the time series method and the Cosinor regression equation. The influence of age was analyzed with the chi 2 test. RESULTS: The total number of admissions increased in winter and decreased in summer. The highest peak (acrophase) occurred in winter, with 2183 cases (r2=0.91), specifically in February, with 742 cases (r2=0.66). The age of the patients conditioned seasonal variations (P=.006), and the influence was statistically significant for patients over 65 years of age. Changes in mortality with time did not reach statistical significance. CONCLUSIONS: A seasonal rhythm in admissions for acute myocardial infarction was found, with an increase in winter and a decrease in summer. Age conditioned the effect of environmental factors on acute myocardial infarction, and patients aged 65 years or older were more sensitive to mechanisms that led to increases in admissions in winter.

Variaciones estacionales en los ingresos por infarto agudo de miocardio. El estudio PRIMVAC / Seasonal variations in admissions for acute myocardial infarction. The PRIMVAC study

Introducción y objetivos. Se ha descrito un aumento en la incidencia del infarto agudo de miocardio durante los meses fríos. Se pretende averiguar si existe un ritmo estacional en los ingresos por infarto en las unidades coronarias y en su mortalidad, y determinar si la edad condiciona el efecto de los factores ambientales. Pacientes y método. A partir del registro PRIMVAC, se estudió a 8.400 pacientes ingresados consecutivamente por infarto agudo de miocardio desde enero de 1995 a diciembre de 1999 en 12 hospitales de la Comunidad Valenciana. Se analizó el ritmo estacional mediante el estudio de series temporales y la ecuación de regresión Cosinor. El análisis de la influencia de la edad en los ingresos y la mortalidad se realizó mediante el test de la 2.Resultados. El número de ingresos por infarto agudo de miocardio aumentó en invierno y disminuyó en verano. El pico máximo (acrofase) se produjo en invierno, con 2.183 casos (r2 = 0,91), concretamente en el mes de febrero, con 742 casos (r2 = 0,66). La edad condiciona las variaciones estacionales en el número de ingresos (p = 0,006), con diferencias estadísticas a partir de los 65 años. Las variaciones en la mortalidad no alcanzan significación. Conclusiones. Existe un patrón estacional en los ingresos por infarto agudo de miocardio, con un aumento en el número de casos durante el invierno y un descenso durante el verano. La edad de los pacientes condiciona el efecto de los factores ambientales en el infarto. A partir de los 65 años, los sujetos son más sensibles a los mecanismos causantes del aumento de ingresos en invierno (AU)

Selective use of diagnostic tests inpatients with syncope of unknown cause.

OBJECTIVE: We sought to prospectively assess the diagnostic yielding of a protocol in which electrophysiologic studies (EPS), tilt-table tests (TTTs), and loop recorder implantation are selectively used. BACKGROUND: The optimal strategy in the diagnosis of patients with syncope of unknown cause has not been defined. METHODS: A total of 184 consecutive patients with syncope of unknown cause were classified into two groups. Group A consisted of 72 patients fulfilling any of the following criteria: 1) presence of structural heart disease or family history of sudden death; 2) abnormal electrocardiogram; 3) significant non-symptomatic arrhythmia on Holter monitoring; and 4) paroxysmal palpitations immediately before or after syncope. These patients initially underwent an EPS and, if this study was negative, TTT. In the remaining 112 patients (group B), TTT was performed. RESULTS: The EPS was positive in 32 patients (44%) in group A. The TTT was positive in 80 patients (71%) in group B. An additional patient had carotid sinus hypersensitivity. In patients of group A with a negative EPS, the TTT was positive in 23 (57%). A loop recorder was implanted in 15 patients from group A with negative conventional testing, and diagnostic activation was obtained in seven patients. Overall, a positive diagnosis was achieved in 143 patients (78%). CONCLUSIONS: In patients with syncope of unknown cause, selective use of EPS or TTT leads to a positive diagnosis in >70% of the cases. An implantable loop recorder can be useful in non-diagnosed cases.

[Prognostic value of fibrinogen in patients admitted with suspected unstable angina and non-q-wave myocardial infarction]. / Valor pronóstico del fibrinógeno en pacientes ingresados con sospecha de angina inestable o infarto de miocardio sin onda Q.

INTRODUCTION AND OBJECTIVE: In recent years, the relation between biological markers of inflammation and prognosis in patients suffering from acute coronary syndromes has been investigated. The aim of this study was to evaluate the association between baseline fibrinogen concentrations and the development of clinical events in patients admitted with suspicion of unstable angina and non-Q-wave myocardial infarction. MATERIAL AND METHOD: Levels of fibrinogen at enrollment were analyzed in 325 consecutive patients with acute coronary syndromes. Fibrinogen values were divided into tertiles and the incidence of clinical events was evaluated at each level. The combination of death and/or myocardial infarction was the main endpoint. RESULTS: Fibrinogen levels were significantly higher in patients who subsequently had myocardial infarction, cardiac death, or both during follow up. The probabilities of death and/or myocardial infarction were 6%, 13%, and 29% (p < 0.0001), respectively, in patients grouped by fibrinogen tertiles (304, 305-374 and 375 mg/dl). Multivariate predictors of combined events were age, previous angina, ST-segment depression in the admission ECG, and fibrinogen into tertiles. The adjusted hazard ratio (95% CI) for patients in the upper tertile was 4.8 (1.6-14; p = 0.004). CONCLUSIONS: High fibrinogen levels were related to a less favorable long-term or short-term outcome in patients admitted for suspicion of unstable angina and non-Q-wave myocardial infarction. This association persists after adjustment for other classical risk factors such as age, prior angina, and ST-segment depression in the ECG.

Rendimiento diagnóstico de un protocolo de estudio del síncope de causa no aparente / Diagnostic Accuracy of a Protocol in the Evaluation of Unexplained Syncope

Introducción y objetivos. Valorar la capacidad diagnóstica de un protocolo de estudio del síncope de causa indeterminada que utiliza, selectivamente, los estudios electrofisiológicos y las pruebas de tabla basculante. Pacientes y método. El estudio se realizó en 137 pacientes consecutivos (94 varones y 43 mujeres, con una edad media de 57,6 ñ 18,3 años), con síncope de causa indeterminada tras la evaluación clínica inicial, que fueron divididos en dos grupos. El grupo A estaba compuesto por 77 pacientes que cumplían alguno de los siguientes criterios: a) presencia de cardiopatía estructural; b) ECG anormal; c) presencia de arritmias significativas no sintomáticas en el Holter, y d) presencia de palpitaciones paroxísticas. Estos pacientes fueron sometidos inicialmente a estudio electrofisiológico. El grupo B estaba compuesto por 60 pacientes que no cumplían ninguno de los criterios anteriores y fueron sometidos en un principio a pruebas de tabla basculante. Resultados. En el grupo A el estudio electrofisiológico fue positivo en 43 pacientes (55 por ciento). En el grupo B el test de basculación fue positivo en 41 pacientes (68 por ciento). De los pacientes del grupo A con estudio negativo, 20 (59 por ciento) fueron sometidos a test de tabla basculante, con 7 positividades (35 por ciento). Cinco pacientes del grupo B con test de basculación negativo fueron sometidos a estudio electrofisiológico, que fue negativo en todos ellos. Globalmente se consiguió un diagnóstico positivo en 91 de 137 pacientes (66 por ciento). Conclusiones. En pacientes con síncope de causa inaparente en la evaluación inicial, la utilización dirigida de manera selectiva por criterios clínicos, bien de estudios electrofisiológicos bien de pruebas de tabla basculante, permite establecer un diagnóstico positivo en más del 60 por ciento de los casos. Nuestros resultados sugieren que el test de tabla basculante debería ser realizado en aquellos casos del grupo A con estudio electrofisiológico negativo (AU)