Patterns of use and effectiveness of early invasive strategy in non-ST-segment elevation acute coronary syndromes: an assessment by propensity score

BACKGROUND

The patterns of use and the benefit of an early invasive strategy (EIS) in patients with non-ST-segment elevation acute coronary syndrome in a real-life population are not well established.

METHODS

All consecutive patients hospitalized because of non-ST-segment elevation acute coronary syndrome between November 2004 and June 2005 in 32 randomly selected hospitals were prospectively included. Patients were stratified by their baseline risk profile using the Global Registry of Acute Coronary Events (GRACE) risk score in 2 groups. Inhospital mortality and 1- and 6-month mortality or rehospitalization for acute coronary syndromes were analyzed. To ensure optimal adjustment propensity score, conventional logistic regression and Cox regression were used.

RESULTS

Of 2,856 patients analyzed, 1,616 (56%) had low/intermediate risk (GRACE<or=140) and 1,240 had high risk (GRACE>140). Patients who underwent EIS had lower risk than those who did not (GRACE score 128.2+/-41 vs 138.5+/-43, P<.001). Coronary angiography facility emerged as the strongest predictor of EIS (odds ratio [OR] 13.7 [95% CI 7.1-25]). Patients who underwent EIS had lower rate of the 6-month outcome in both the whole population (9% [95% CI 6.6-11.9] vs 14% [95% CI 12.5-15.6], P=.003) and in high-risk patients (16.5% [95% CI 11-23] vs 23.6% [95% CI 20.8-26.5], P=.04). However, this benefit of EIS was not apparent after statistical adjustment in the whole population (OR 0.8, CI 0.55-1.1, P=.17) or in high-risk patients (OR 0.7, CI 0.46-1.1, P=.16).

CONCLUSIONS

In a real-life population, EIS was mainly performed in patients of low/intermediate risk. An obvious benefit of this strategy could not be found.

Chest pain in the emergency department: incidence, clinical characteristics and risk stratification

INTRODUCTION AND OBJECTIVES

Although chest pain is a common presenting symptom in emergency departments, its clinical management is highly variable. Our aims were to describe the characteristics of patients with chest pain and to evaluate the usefulness of the CPU-65 index for risk stratification. The CPU-65 index awards one point for each of the following variables: Comorbid diabetes, typical Pain, Use of aspirin, and age 65 years or more.

METHODS

Details of emergency department patients admitted for nontraumatic chest pain were recorded in a prospective registry.

RESULTS

Over a 3-month period, 1518 patients were admitted with nontraumatic chest pain (6.1% of medical emergencies). Chest pain was classified as nonischemic in 909 patients (59.9%), undefined in 370 (24.4%) and ischemic in 239 (15.7%). An ECG was performed in 1342 patients (88.4%), the troponin-T level was measured in 656 (43.2%), chest radiography was performed in 831 (54.7%), and 385 (25.4%) were evaluated by the cardiologist on duty. Overall, 230 (15.2%) were admitted to hospital; of these, 99 (6.5%) had an acute myocardial infarction (AMI) and seven (0.5%) died during admission. Among patients discharged from the emergency department, the most frequent diagnoses were atypical chest pain (59%) and respiratory infection (12%). The CPU-65 index was associated with the presence of AMI. In total, 50% of patients had a CPU-65 index score of 0, none of whom either had an AMI or died during admission.

CONCLUSIONS

Half of all patients who presented at an emergency department with chest pain were at a very low risk.

MASCARA (Manejo del Síndrome Coronario Agudo. Registro Actualizado) study. General findings

INTRODUCTION AND OBJECTIVES

To investigate the clinical characteristics and treatment of acute coronary syndromes (ACS), and to determine the effects of an early invasive strategy (EIS) in non-ST-elevation ACS (NSTEACS) and of primary percutaneous coronary intervention (PCI) in ST-elevation ACS (STEACS).

METHODS

Data were collected prospectively for 9 months during 2004-2005 from 50 hospitals, which were randomly selected according to the level of care provided. In addition, follow-up data on mortality and readmission for ACS were collected for 6 months. The adjusted effects of different reperfusion strategies were analyzed.

RESULTS

After checking data quality, the analysis included data from 32 hospitals, which covered 7923 coronary events (4431 [56%] STEACS, 3034 [38%] NSTEACS and 458 [6%] unclassified ACS) in 7251 patients. Compared with previous studies, the use of primary PCI in STEACS had increased markedly (from 10.7% to 36.8% of patients undergoing reperfusion), as had the use of EIS in NSTEACS (from 11.1% to 19.6%). Overall in-hospital mortality was 5.7% (95% confidence interval [CI], 5.1%-6.2%); for STEACS it was 7.6% (95% CI, 6.7%-8.7%), for NSTEACS 3.9% (95% CI, 3.3%-4.6%), and for unclassified ACS 8.8% (95% CI, 6.2%-12.2%). In the population as a whole, there was no association between prognosis (i.e., 6-month mortality) and EIS in NSTEACS (hazard ratio [HR]=0.94; 95% CI, 0.66-1.3) or between prognosis and primary PCI in STEACS (HR=1; 95% CI, 0.7-1.5). Findings for mortality and rehospitalization for ACS at 6 months were similar.

CONCLUSIONS

Data for 2004-2005 demonstrated a marked increase in the use of invasive procedures. However, the procedures employed were poorly matched to the patients' baseline risk.

[The value of an intervention for improving secondary prevention in patients undergoing cardiac surgery]

Given that treatment for secondary prevention in patients undergoing cardiac surgery is underused, we devised a hospital intervention to increase its implementation. The intervention involved all physicians in the department of cardiac surgery agreeing to complete a report on each patient before hospital discharge. The document recorded the indications for the recommended treatments, and prompted for details of the drugs prescribed, the doses used, the reasons for not prescribing the recommended drugs, if that was the case, and the use of alternative medicines. The efficacy of the intervention was evaluated by comparing the rate of drug use in the year in which it was introduced (2003, n=341) with retrospective data on the rate in the previous year (n=369). The rates of use of aspirin, statins, angiotensin-converting enzyme inhibitors, and beta-blockers by patients who required them all showed an absolute increase, of 13.4%, 38.3%, 21.8%, and 21.5%, respectively. In conclusion, the introduction of a simple and inexpensive intervention was able to significantly increase the use of drugs for secondary prevention in patients undergoing cardiac surgery.

[Ischemic heart disease: 2006 update]

This article contains a review of the main developments reported in publications and conference presentations in 2006 on the pathophysiology, secondary prevention, prognosis, and treatment of ST-segment elevation and non-ST-segment elevation acute coronary syndrome. The latest clinical practice guidelines are also discussed.

[Intermediate coronary care units: rationale, infrastructure, equipment, and referral criteria]

The Spanish Working Group on Coronary Artery Disease of Spanish Society of Cardiology has considered to be necessary the development of this document on the need, structure and organization of Intermediate Cardiac Care Units (ICCU). Acute coronary syndrome registries show that an important percentage of patients receive a suboptimal care, due to an inadequate management of health resources or absence of them. Intermediate cardiac care units arise to solve these challenges and to manage in an efficient way these expensive and limited resources. Their aims are: a) to provide each patient the level of care required; b) to optimize the structural, technical and human resources, and c) to make easier continuous care and care gradient. As a result, ICCU should be established as an essential part of the cardiology department aim to cardiac patients requiring monitoring and medical care superior to those available in a regular cardiac ward but whose risk does not justify the technical and human costs of a Coronary Unit. This document describes the structure (equipment, human resources, management) required to reach the goals previously reported and includes recommendations about indications of admission in a ICCU. These indications include: a) patients with NSTE-ACS with intermediate or high risk but hemodynamically stable, and b) low risk STEAMI or high risk STEAMI stabilized after an initial admission at the Coronary Unit. The admission of some patients undergoing invasive procedures or suffering non-coronary acute cardiac diseases, is also considered.

Prevalence of peripheral arterial disease and prior stroke in octogenarians with symptomatic severe aortic stenosis or severe coronary artery disease: influence in management and outcome

AIM

Severe aortic stenosis (SAS) and severe coronary artery disease (SCAD) are the most frequent reasons to perform cardiac surgery in octogenarians. Non-coronary vascular disease is frequently present in these patients.

METHODS

We assessed the prevalence and impact of previous stroke (PS) and peripheral arterial disease (PAD) on the management and outcome of 130 consecutive symptomatic patients (80 years old with SAS or SCAD.

RESULTS

Mean age was 82.8+/-3.1 years. PS was present in 24 patients (18.5%) and PAD in 15 (11.5%). We found a non-significant trend to a higher prevalence of PAD in patients with SCAD than in patients with SAS (14.5% vs 6.4%, P=0.13), while no relevant differences were seen for PS prevalence (19.3% vs 17%, P=0.75). Patients with PS tended to be operated less frequently than patients without PS (20.8% vs 37.7%, P=0.08), while no relevant differences were seen for patients with and without PAD (26.7% vs 35.7%, P=0.5). Thirty-nine patients (30%) died during follow-up, mean of 1.1(0.7 years (median 1 years; 100% complete). There was a trend to a worse prognosis in patients with PAD (adjusted hazard ratio [HR] 2.2; 95% confidence interval [CI] 0.96-4.8; P=0.06), while PS showed no independent influence on survival (adjusted HR 1.3, 95% CI 0.6-2.8, P=0.53).

CONCLUSIONS

PS and PAD are frequently present in octogenarians with SAS or SCAD. Patients with PS show a similar long-term mortality, but tend to be operated less frequently. On the other hand, PAD did not influence the decision of surgical treatment, but is associated with a lower survival rate.

Predictors of stroke within 30 days in patients with non-ST-segment elevation acute coronary syndromes

AIMS

Stroke is an uncommon but serious complication after non-ST-segment elevation acute coronary syndrome (NSTE-ACS). We aimed to identify predictors of stroke within 30 days in patients who suffered NSTE-ACS.

METHODS AND RESULTS

We pooled data from six trials (n=31 402) that randomized NSTE-ACS patients either to platelet glycoprotein (GP) IIb/IIIa receptor blockers or to placebo/control therapy. Potential predictors of stroke included treatment, demographic, and clinical characteristics. We identified predictors using univariable and multivariable logistic models, and their performance was evaluated with calibration (Hosmer-Lemeshow test) and discrimination (c-statistic). We found 228 (0.7%) all-cause strokes: 155 (0.5%) non-haemorrhagic, 20 (0.06%) haemorrhagic, and 53 without computed tomography (CT) confirmation. Patients with any type of stroke had a 30-day mortality of 25%. Randomization to GP IIb/IIIa receptor blockers was not significantly associated with all-cause stroke [OR (95% CI) 1.08 (0.83-1.41)]. Older age [OR per 10-year increase 1.5 (1.3-1.7)], prior stroke [2.1 (1.4-3.1)], and elevated heart rate [per 10-beat increase 1.1 (1.0-1.2)] were the strongest predictors of 30-day all-cause stroke. Similar predictors were found for non-haemorrhagic and haemorrhagic strokes. Smoking, previous myocardial infarction, diabetes, and hypertension were not independent predictors of all-cause stroke. The multivariable model to predict all-cause stroke was well calibrated, but its discrimination was only moderate [c-statistic 0.69 (0.65-0.72)].

CONCLUSION

Stroke is a rare complication occurring early after NSTE-ACS, but is associated with high mortality. We found no evidence that GP IIb/IIIa receptor blockers increase stroke risks. A few clinical characteristics predicted higher stroke risks. Thus, incident strokes in NSTE-ACS patients remain largely unexplained.

Effects of platelet glycoprotein IIb/IIIa receptor blockers in non-ST segment elevation acute coronary syndromes: benefit and harm in different age subgroups

OBJECTIVE

To investigate whether the beneficial and harmful effects of platelet glycoprotein IIb/IIIa receptor blockers in non-ST elevation acute coronary syndromes (NSTE-ACS) depend on age.

METHODS

A meta-analysis of six trials of platelet glycoprotein IIb/IIIa receptor blockers in patients with NSTE-ACS (PRISM, PRISM-PLUS, PARAGON-A, PURSUIT, PARAGON-B, GUSTO IV-ACS; n = 31 402) was performed. We applied multivariable logistic regression analyses to evaluate the drug effects on death or non-fatal myocardial infarction at 30 days, and on major bleeding, by age subgroups (<60, 60-69, 70-79, > or =80 years). We quantified the reduction of death or myocardial infarction as the number needed to treat (NNT), and the increase of major bleeding as the number needed to harm (NNH).

RESULTS

Subgroups had 11 155 (35%), 9727 (31%), 8468 (27%) and 2049 (7%) patients, respectively. The relative benefit of platelet glycoprotein IIb/IIIa receptor blockers did not differ significantly (p = 0.5) between age subgroups (OR (95% CI) for death or myocardial infarction: 0.86 (0.74 to 0.99), 0.90 (0.80 to 1.02), 0.97 (0.86 to 1.10), 0.90 (0.73 to 1.16); overall 0.91 (0.86 to 0.99). ORs for major bleeding were 1.9 (1.3 to 2.8), 1.9 (1.4 to 2.7), 1.6 (1.2 to 2.1) and 2.5 (1.5-4.1). Overall NNT was 105, and overall NNH was 90. The oldest patients had larger absolute increases in major bleeding, but also had the largest absolute reductions of death or myocardial infarction. Patients > or =80 years had half of the NNT and a third of the NNH of patients <60 years.

CONCLUSIONS

In patients with NSTE-ACS, the relative reduction of death or non-fatal myocardial infarction with platelet glycoprotein IIb/IIIa receptor blockers was independent of patient age. Larger absolute outcome reductions were seen in older patients, but with a higher risk of major bleeding. Close monitoring of these patients is warranted.

Treatment and outcomes of severe cardiac disease with surgical indication in very old patients

OBJECTIVE

To describe and compare the crude and risk-adjusted survival of a series of octogenarians with symptomatic severe aortic stenosis (SAS) or severe coronary artery disease (SCAD).

METHODS

We reviewed the treatment and outcomes of 130 consecutive patients > or = 80 years old hospitalized for SAS or SCAD.

RESULTS

Mean age was 82.8+/-3.1 years, 52% were women. Of 83 patients with SCAD, 52 were treated by coronary stenting (63%), 12 by coronary artery bypass grafting (15%) and 19 medically (23%). There were no significant differences in baseline characteristics among different treatment groups. When comparing the medically treated group with the intervention group (coronary artery bypass grafting or stenting), the former showed a trend to a worse prognosis (adjusted HR 2.5, 95% CI 0.98-6.6, p=0.056). Of 47 patients treated with SAS, 33 were treated surgically (70%), 26 by aortic valve replacement (AVR) alone and 7 combined with coronary revascularization. Fourteen patients were treated medically (30%). Patients treated with AVR were younger, presented less frequently a previous MI and had better left ventricular systolic function. Multivariate analysis did not find AVR associated to a better survival (HR 1.1, 95% CI 0.2-5.4).

CONCLUSION

Cardiac surgery in octogenarians is more frequently performed in patients with SAS than in patients with SCAD, but survival benefit is probably greater in the latter. A more conservative approach with medical therapy in patients with SAS and coronary stenting in patients with SCAD are alternatives that should be considered.

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

OBJECTIVE

To analyse intensity of treatment of high-risk patients with non-ST elevation acute coronary syndromes (NSTEACS) included in the DESCARTES (Descripción del Estado de los Sindromes Coronarios Agudos en un Registro Temporal Español) registry.

PATIENTS AND SETTING

Patients with NSTEACS (n = 1877) admitted to 45 randomly selected Spanish hospitals in April and May 2002 were studied.

DESIGN

Patients with ST segment depression and troponin rise were considered high risk (n = 478) and were compared with non-high risk patients (n = 1399).

RESULTS

46.9% of high-risk patients versus 39.5% of non-high-risk patients underwent angiography (p = 0.005), 23.2% versus 18.8% (p = 0.038) underwent percutaneous revascularisation, and 24.9% versus 7.4% (p < 0.001) were given glycoprotein IIb/IIIa inhibitor. In-hospital and six-month mortality were 7.5% versus 1.1% and 17% versus 4.6% (p < 0.001), respectively. A treatment score (> or = 4, 2-3 and < 2) was defined according to the number of class I interventions recommended in clinical guidelines: aspirin, clopidogrel, beta blockers, angiotensin-converting enzyme inhibitors, statins and revascularisation. Independent predictors of six-month mortality were age (odds ratio (OR) 1.07, 95% confidence interval (CI) 1.04 to 1.10, p < 0.001), diabetes (OR 1.92, 95% CI 1.14 to 3.22, p = 0.014), previous cardiovascular disease (OR 4.17, 95% CI 1.63 to 10.68, p = 0.003), high risk (OR 2.20, 95% CI 1.30 to 3.71, p = 0.003) and treatment score < 2 versus > or = 4 (OR 2.87, 95% CI 1.27 to 6.52, p = 0.012).

CONCLUSIONS

Class I recommended treatments were underused in high-risk patients in the DESCARTES registry. This undertreatment was an independent predictor of death of patients with an acute coronary syndrome.

Actualización en cardiopatía isquémica 2005

This article is a review of the main developments in acute coronary syndromes reported in publications and conference presentations in 2005. It covers the pathophysiology, secondary prevention, prognosis, and treatment of ST-segment elevation and non-ST-segment elevation acute coronary syndromes, and the latest clinical practice guidelines.

[Short-and long-term cost-effectiveness analysis of adding clopidogrel to standard therapy in acute coronary syndrome patients in Spain]

INTRODUCTION AND OBJECTIVES

The CURE study showed that adding clopidogrel to standard therapy with acetylsalicylic acid reduces the risk of cardiovascular events (i.e., stroke, myocardial infarction, and cardiovascular death) in patients with acute coronary syndrome but without ST-segment elevation. The objective of this study was to carry out short- and long-term cost-effectiveness analyses of administering clopidogrel in addition to standard therapy during the first year of treatment.

PATIENTS AND METHOD

For the short-term analysis, clinical data and information on health resource utilization were taken from the CURE study. For the long-term analysis, an adaptation of an internationally used Markov model involving six health states was employed. Clinical data were obtained from clinical trials and epidemiological studies. Information on resource use was obtained from two Spanish registries of patients with acute coronary syndrome, a literature review, and consultations with an expert panel. Results are expressed in terms of incremental cost per event avoided or per life-year gained.

RESULTS

In the short-term analysis, the incremental cost per event avoided of adding clopidogrel to standard therapy was ;17 190. In the long-term analysis, the incremental cost per life-year gained was ;8132, which is below the Spanish cost-effectiveness threshold of ;30 000 per life-year gained.

CONCLUSIONS

Adding clopidogrel to standard therapy during the first year of treatment is cost-effective in both the short and long term.

Influence of age on gender differences in the management of acute inferior or posterior myocardial infarction

STUDY OBJECTIVES

To assess the effect of gender on the in-hospital management of patients with acute inferior or posterior myocardial infarction (MI).

DESIGN

Retrospective analysis of clinical records. Gender differences in management and prognosis were assessed by stepwise multiple logistic regression analysis.

SETTING

University, large-volume, tertiary hospital.

PATIENTS

We studied 1,178 consecutive patients admitted to our coronary care unit with an acute inferior or posterior MI, and evaluated the influence of gender on clinical management and outcome.

INTERVENTIONS

None.

MEASUREMENTS AND RESULTS

Women were older (73 years vs 66 years), had a higher prevalence of diabetes and hypertension, presented later (8 h vs 6 h after symptom onset), and had a higher in-hospital mortality rate (26% vs 9%) [all p values < 0.01]. Women underwent reperfusion therapy (45% vs 61%, p < 0.01), noninvasive studies (30% vs 62%, p < 0.001), and coronary angiography (34% vs 48%, p < 0.01) less often than men. Multivariable analysis revealed that female gender was an independent predictor of a lower use of noninvasive studies (odds ratio [OR], 0.41; 95% confidence interval [CI], 0.24 to 0.63; p < 0.005) and coronary angiography (OR, 0.59; 95% CI, 0.37 to 0.93; p = 0.02). A significant interaction between age and gender was found (p = 0.002); therefore, women > or = 75 years old had a much lower probability of undergoing noninvasive tests and coronary angiography than men of the same age.

CONCLUSION

Despite their worse prognosis, women undergo noninvasive studies and coronary angiography less frequently than men after an acute inferior or posterior MI. The gender gap increases in patients > or = 75 years old.

[A new risk score for patients with a normal or non-diagnostic ECG admitted to a chest pain unit]

INTRODUCTION AND OBJECTIVES

Patients admitted to chest pain units are usually classified on the basis of the results of non-invasive tests. However, the large number of potential patients places a strain on limited resources. Our aim was to identify clinical variables that may help determining the risk of coronary artery disease.

PATIENTS AND METHOD

We studied 365 consecutive patients admitted to the chest pain unit at our institution, all of whom had an ECG that did not show significant changes in repolarization.

RESULTS

The patients' mean age was 62.3 years. Independent predictors of coronary artery disease were: typical chest pain, aspirin use, diabetes, and age >64 years. A risk score obtained by combining these 4 factors was related to the occurrence of a clinical event during the patient's stay in the chest pain unit, to coronary artery disease prevalence (which varied from 3.9% in those with a score of 0 to 66.7% in those with a score of 4), to all-cause mortality, and to the development of acute coronary syndrome during the 6-month follow-up period.

CONCLUSIONS

The presence of typical chest pain, aspirin use, diabetes, and an age >64 years is associated with an increased probability of coronary artery disease in patients admitted to chest pain units. A risk score obtained by combining these four factors may be clinically useful and help optimizing resource management.

Effect of thrombolytic therapy on the risk of cardiac rupture and mortality in older patients with first acute myocardial infarction†

AIMS

To evaluate the effect of thrombolysis on mortality and its causes in older patients with acute myocardial infarction (AMI).

METHODS AND RESULTS

An analysis of 706 consecutive patients > or =75 years old with a first AMI enrolled in the PPRIMM75 registry showed that although there were important differences in baseline characteristics among patients treated with thrombolysis, primary angioplasty (PA) and those who did not receive reperfusion therapy, 30 day mortality did not differ (29, 25, and 32%, respectively). The main cause of death in patients treated with thrombolysis was cardiac rupture (54%), whereas most of the other patients died in cardiogenic shock. Patients who received thrombolysis had a higher (P<0.0001) incidence of free wall rupture (FWR) (17.1%) compared with those who did not receive reperfusion therapy (7.9%) or who underwent PA (4.9%). By multivariable analysis, patients treated with thrombolytic therapy (TT) showed an excess risk of FWR (OR, 3.62; 95% CI, 1.79-7.33), a hazard not observed in patients who underwent PA. When compared with patients who did not receive reperfusion therapy, the odds ratio of 30 day mortality was 1.07 (95% CI, 0.65-1.76) for patients treated with thrombolysis and 0.78 (95% CI, 0.45-1.34) for those who underwent PA. The figures for 24 month mortality were 0.78 (95% CI, 0.65-1.76) and 0.67 (95% CI, 0.28-0.81), respectively.

CONCLUSION

Treatment of first AMI with TT increases the risk of FWR in very old patients, a risk not observed in patients treated with PA.

[Characteristics and mortality following primary percutaneous coronary intervention for acute myocardial infarction in Spain. Results from the TRIANA 1 (TRatamiento del Infarto Agudo de miocardio eN Ancianos) Registry]

INTRODUCTION AND OBJECTIVES

Although more elderly patients will experience acute myocardial infarction (AMI) in coming years, the best reperfusion strategy in these patients remains unknown.

PATIENTS AND METHOD

The Spanish TRIANA (TRatamiento del Infarto Agudo de miocardio eN Ancianos) registry was set up to determine the feasibility of performing a randomized study of percutaneous coronary intervention (PCI) versus thrombolysis in AMI patients aged > or =75 years. The TRIANA 1 subregistry included consecutive patients of all ages with ST-segment-elevation AMI (< or =12 h from onset) who underwent PCI in selected hospitals.

RESULTS

In total, 459 TRIANA-1 patients were included at 25 hospitals over 3 months. Some 11% had cardiogenic shock. PCI was performed as rescue therapy in 24% and, in 15% because thrombolysis was contraindicated. After PCI, 83% had TIMI grade-3 flow without significant residual stenosis. Mortality at 1 month was 10.8%. Independent predictors of mortality identified by multivariate analysis were: cardiogenic shock at admission (OR, 7.2, 95% CI, 2.2-23.3), age (OR, 1.05 per year, 95% CI, 1.005-1.100), maximum creatine kinase MB fraction (OR, 1.01, 95% CI, 1.004-1.270) and post-PCI TIMI grade <3 (OR, 2.8, 95% CI, 1.0-8.3). Of 104 participants aged > or =75 years (mortality, 24%), 58 (55.7%) fulfilled criteria for inclusion in a randomized study.

CONCLUSIONS

1) The TRIANA 1 subregistry probably reflects the reality of PCI for AMI in Spain. 2) Mortality at 1 month was associated with classic predictive factors. 3) Some 50% of patients > or =75 years old who underwent PCI could be included in a randomized study. These findings indicate that randomized study to determine the best reperfusion strategy in elderly AMI patients is feasible.

[Type of treatment and short-term outcome in elderly patients with acute myocardial infarction admitted to hospitals with a primary coronary angioplasty facility. The TRIANA (TRatamiento del Infarto Agudo de miocardio eN Ancianos) Registry]

INTRODUCTION AND OBJECTIVES

The nature and outcome of treatment for acute myocardial infarction in elderly patients admitted to Spanish hospitals with primary angioplasty facilities are not well documented.

PATIENTS AND METHOD

Prospective analysis of registry data on patients > or =75 years old with ST-segment-elevation acute myocardial infarction admitted between April and July 2002 to Spanish hospitals with an active primary angioplasty program.

RESULTS

We followed up 410 consecutive patients for 1 month. Their mean age was 80 (4.3) years and 46% were female. The median delay between symptom onset and arrival at hospital was 190 minutes. Around 42% of patients received no reperfusion therapy, 35% were treated by thrombolysis, and 22% by primary angioplasty. Patients who underwent reperfusion therapy were younger, were more frequently male, had a shorter delay from symptom onset to hospital arrival, and had a better initial hemodynamic status (Killip Class). However, they were more likely to have extensive anterior infarctions. Overall, 30-day mortality was 24.9%. Independent predictors of death were age, systolic blood pressure, and Killip class >1, but not use of thrombolysis or primary angioplasty.

CONCLUSIONS

Over 42% of elderly patients with myocardial infarction admitted to Spanish hospitals with angioplasty facilities did not receive reperfusion therapy. Thrombolysis was the most frequently used reperfusion therapy. However, neither thrombolysis nor primary angioplasty improved 30-day mortality.

[Management of non-ST-segment-elevation acute coronary syndromes in Spain. The DESCARTES (Descripción del Estado de los Síndromes Coronarios Agudos en un Registro Temporal ESpañol) study]

INTRODUCTION AND OBJECTIVES

There is little information regarding the management of non-ST segment elevation acute coronary syndromes (NSTE ACS) in Spain from a population-based perspective. Our objective was to study the status of clinical care in patients with NSTE ACS in Spain from a representative perspective of the situation on a national level.

PATIENTS AND METHOD

A prospective registry was used for consecutive patients with NSTE ACS admitted to 52 Spanish hospitals with different cardiological facilities. Centers that fulfilled the quality control criteria for the study were randomly selected for inclusion.

RESULTS

Between April and May, 2002, 1877 patients were recruited. Median age was 69 years, 93% had at least one risk factor and 73% had antecedents of cardiovascular disease. The electrocardiogram on admission was abnormal in 76% of the cases, and troponin levels were elevated in 53%. Twenty-seven percent of the patients were admitted to a cardiac care unit or intensive care unit. The rates of use of diagnostic techniques were: echocardiography 56%; non-invasive test for detection of ischemia 39%; coronary angiography 41%. During hospitalization, 24% underwent coronary revascularization, 88% received aspirin, 81% heparin, 37% clopidogrel, 12% glycoprotein IIb/IIIa inhibitors, 63% ss-blockers, 46% angiotensin-converting enzyme inhibitors, and 52% statins. The final diagnosis was angina in 54%, myocardial infarction in 28%, and other in 18%. Mortality was 3.7% at 28 days and 7.8% at 6 months.

CONCLUSIONS

DESCARTES is the first representative registry of NSTE ACS management in Spain. It shows that despite their high-risk profile, these patients receive suboptimal medical care according to current clinical recommendations.

Acute myocardial infarction caused by paradoxical tumorous embolism as a manifestation of hepatocarcinoma

A 71 year old patient presented with a non-ST segment elevation acute myocardial infarction. The echocardiogram showed several masses attached to the interatrial septum. Several days after admission the patient died. A postmortem examination found a large hepatocarcinoma with intravascular and intracardiac metastases and several myocardial infarctions of different ages. The infarctions had been caused by coronary paradoxical embolisms through a patent foramen ovale and contained neoplastic cells from the liver carcinoma, which had not been diagnosed. The cause of death was a massive pulmonary embolism.

[Applicability of a new definition of myocardial infarction and the opinion of Spanish cardiologists]

INTRODUCTION AND OBJECTIVES

The Working Group on Ischemic Heart Disease and Coronary Care Units of the Spanish Society of Cardiology evaluated the applicability of a new definition of infarction in Spanish hospitals, its current use, and the opinion of Spanish cardiologists.

METHODS

A telephone survey was made (from late 2001 to early 2002) in Spanish hospitals to evaluate the availability of troponin or creatine kinase MB mass determinations. A questionnaire was sent to all members of the Spanish Society of Cardiology to query about the availability of determinations of cardiac necrosis markers at their respective hospitals, use of the new definition, and whether they agreed with the new definition.

RESULTS

An important proportion of Spanish hospitals cannot determine myocardial necrosis markers (troponin or creatine kinase MB mass), mainly due to low-volume activity (fewer than 200 beds). The new definition of myocardial infarction was used by Spanish cardiologists always (24%), frequently (31%), sometimes (17%), seldom (14%), and never (11%). Agreement with the definition was complete in 21%, almost complete in 33%, half and half in 26%, rare in 10%, and absent in 7% of Spanish cardiologists.

CONCLUSIONS

A large percentage of Spanish hospitals cannot use the new definition of myocardial infarction because they cannot determine specific cardiac necrosis markers. Spanish cardiologists are not generally using the new definition and many do not agree with it.

[Prevention and treatment of ischemic heart disease in patients with diabetes mellitus]

The incidence of cardiovascular diseases among diabetic patients is so high that diabetes mellitus is currently defined as a cardiovascular disease equivalent. Furthermore, diabetic patients who develop acute coronary syndromes have a poorer short-term and long-term prognosis, so primary and secondary preventive measures are critically important in this population subgroup. There is substantial evidence that pharmacological therapy for primary and secondary cardiovascular prevention is more effective in diabetic patients than in non-diabetics. This article reviews the evidence of the efficacy of pharmacological prevention therapies in diabetic patients in favor of an aggressive pharmacological preventive strategy. Every diabetic patient without known cardiovascular disease should be treated with angiotensin-converting enzyme inhibitors and statins. High-risk patients should also receive low-dose aspirin.Compared with non-diabetics, diabetic patients who develop acute coronary events benefit more from the addition of intensive antithrombotic therapy to aspirin treatment. Diabetic patients presenting with non-ST segment elevation syndromes have better outcomes when treated with clopidogrel or glycoprotein IIb/IIIa inhibitors, and diabetics presenting with ST-segment elevation or left bundle-branch block have a greater survival benefit when given thrombolytic therapy compared with non-diabetic patients.Unless formal contraindications are present, diabetic patients with ischemic heart disease, particularly those with previous myocardial infarction, should always be treated with aspirin, betablockers, angiotensin converting enzyme inhibitors, and statins, regardless of lipid levels, left ventricular systolic function or the presence of congestive heart failure.

[2002 Update of the Guidelines of the Spanish Society of Cardiology for Unstable Angina/Without ST-Segment Elevation Myocardial Infarction]

Since the Spanish Society of Cardiology Clinical Practice Guidelines on Unstable Angina/Non-Q-Wave Myocardial Infarction were released in 1999, the conclusions of several studies that have been published make it advisable to update current clinical recommendations. The main findings are related to the developing role of Chest Pain Units in the management and early risk stratification of acute coronary syndromes in the emergency department; new information concerning the efficacy of glycoprotein IIb/IIIa inhibitors, clopidogrel and low-molecular-weight heparins in the pharmacological treatment of acute coronary syndromes without ST-segment elevation; and the role of early invasive strategy in improving the prognosis of these patients. The published evidence is reviewed and the corresponding clinical recommendations for the management of acute coronary syndromes without persistent ST-segment elevation are updated.

Pulmonary embolism after pacemaker implantation

One day after implantation of a permanent pacemaker in an 82-year-old man, transthoracic echocardiography showed a mass in the right ventricle and a small pericardial effusion. Transesophageal echocardiography revealed a mass attached to the pacemaker lead. Subcutaneous administration of enoxaparin was begun, and the patient remained free of symptoms for the duration of his hospital stay Follow-up echocardiography performed before discharge failed to show the right ventricular mass, but a lung perfusion scan revealed multiple bilateral perfusion defects consistent with pulmonary emboli. The patient was discharged on a regimen of enoxaparin for another 30 days. Two years later, he remained asymptomatic.

Blood strontium concentration related to the length of the agonal period in seawater drowning cases

The levels of ventricular blood strontium (Sr) from 70 seawater drowning victims were compared with their diagnosis of drowning based mainly on certain criteria selected from their autopsy report. From this comparison, intervals of either the difference of Sr concentration between the left and the right ventricle blood (LVSr-RVSr) or the Sr concentration in the left ventricle blood (LVSr), appear to be related to different time-lapses of the agonal period of drowning. In the aim to diagnose drownings, intervals of both LVSr-RVSr and LVSr were proposed to characterize three different agonal periods in seawater drowning cases: instantaneous death (ID), fast vital-submersion drowning (FVSD) and common vital-submersion drowning (CVSD).

Pulmonary venous flow in hypertrophic cardiomyopathy as assessed by the transoesophageal approach. The additive value of pulmonary venous flow and left atrial size variables in estimating the mitral inflow pattern in hypertrophic cardiomyopathy

AIMS

This study was conducted to assess the characteristics of the pattern of pulmonary venous flow and to document the interaction of this flow and left atrial function with the pattern of mitral inflow in hypertrophic cardiomyopathy.

METHODS AND RESULTS

Pulmonary venous and mitral flows were evaluated by the transoesophageal approach in 80 patients with hypertrophic cardiomyopathy. Left atrial size and function were measured by the transthoracic approach. Their values were compared with those obtained from 35 normal controls. Twelve patients showed significant (> 2+) mitral regurgitation. As a group, hypertrophic cardiomyopathy patients showed increased atrial reversal flow and longer deceleration time of the diastolic wave, but a wide variability of pulmonary venous flow patterns were observed. Thirty patients (37.5%) had pseudonormal mitral flow patterns. Stepwise multilinear regression analysis identified the ratio of systolic to diastolic pulmonary venous flow velocity, the ratio of velocity-time integrals of both flow waves at atrial contraction, the left atrial minimal volume and the systolic fraction as independent predictive variables of the mitral E/A wave velocity ratio (r = 0.82). By logistic regression, the former three variables were selected as independent predictive covariates of a pseudonormal mitral flow pattern (sensitivity: 83%, specificity: 90%). The ratio of velocity-time integrals of both atrial waves was the most important predictive variable in both analyses.

CONCLUSIONS

The observed variability in the configuration of pulmonary venous flow velocity waveform is related to what occurs in transmitral flow in patients with hypertrophic cardiomyopathy. Significant mitral regurgitation is not an independent correlate of pseudonormal mitral inflow patterns in these patients. Our results further emphasize the complementary, additive value of the pulmonary venous flow velocity pattern and left atrial size in the interpretation of the mitral flow velocity pattern, and indirectly suggest the underlying increased left ventricular filling pressures of patients with hypertrophic cardiomyopathy and pseudonormal mitral flow patterns.

Combined effect of age and right ventricular involvement on acute inferior myocardial infarction prognosis

BACKGROUND

In patients with acute inferior myocardial infarction (AIMI), right ventricular involvement (RVI) is one of the strongest predictors of in-hospital death. We hypothesized that the impact of RVI on AIMI prognosis depends on the patient's age.

METHODS AND RESULTS

The in-hospital clinical outcome of 798 consecutive patients admitted to the coronary care unit within 48 hours of symptom onset with AIMI was analyzed according to patient age and to the presence of RVI diagnosed by ECG and/or echocardiographic criteria. The total incidence of RVI was 37%, and it increased as age advanced. Patients with RVI had a significantly higher incidence of major complications (45% versus 19%, P<0.0001) and a higher in-hospital mortality rate (22% versus 6%, P<0.0001). The prognostic effect of RVI was independent of sex, smoking, diabetes, shock on admission, left ventricular ejection fraction, and reperfusion therapy, all age-dependent predictors. A multivariate analysis showed a significant (P=0.03) interaction between age and RVI on AIMI mortality. RVI increased mortality risk only in the oldest patients.

CONCLUSIONS

In patients with AIMI, RVI substantially increases mortality risk in elderly patients, whereas it has a nonsignificant effect in young subjects.

Validation of national algorithms for the diagnosis of sexually transmitted diseases in Brazil: results from a multicentre study

OBJECTIVE

To validate STD flow charts for the management of genital discharge and genital ulcer currently recommended by the National STD Control Programme in Brazil.

METHODS

A study was conducted in five Brazilian STD clinics from January to June 1995. After an interview, a clinical examination was performed by a physician, who recorded a presumptive diagnosis, based on his/her clinical experience. This diagnosis was compared with a gold standard laboratory diagnosis in order to calculate sensitivity, specificity, and positive predictive value of the clinical diagnosis. The validity of the simulated national flow charts was assessed using the same method.

RESULTS

A total of 607 men and 348 women participated in the study. Gonorrhoea was the aetiology most frequently detected in men with urethral discharge. The sensitivity of the clinical diagnosis was far lower than the sensitivity fo the national flow chart, using the syndromic approach, for both gonococcal and chlamydial urethritis. Adding a simple laboratory test (Gram stain) to the national flow chart increased the specificity and positive predictive value for gonorrhoea. Among the women with vaginal discharge, a cervical infection was detected in 17%, a vaginal infection in 74%, and mixed infection in 9%. The sensitivity of the diagnosis for cervical infection increased from 16% (clinical aetiological approach) to 54% (when adding a syndromic approach) and to 68% when adding a risk assessment, as in the national flow charts. The cure or improved rate of genital ulcers was 96% after 1 week.

CONCLUSIONS

The results of the study will help to convince policy makers and those involved in training healthcare workers in Brazil of the public health advantages of the syndromic approach, as an essential part of STD/HIV control activities.

[Clinical prediction of the early prognosis in acute myocardial infarct]

Several clinical factors can influence the pathophysiology, clinical course and prognosis of acute myocardial by different means. Some of them may be easily detected through the history, physical examination or ECG in an early phase. The knowledge of these factors may help the therapeutic decision making of patients with myocardial infarction. The influence for the main clinical factors (age, sex, risk factors, cardiologic antecedents and evolutive findings) on the short-term prognosis of acute myocardial infarction is reviewed. An analysis of the likely mechanisms of the influence of these factors on infarct prognosis is also performed.

Clinical and echocardiographic findings in HIV patients with pericardial effusion

BACKGROUND AND OBJECTIVES

Pericardial effusion (PE) is frequently found in patients infected with the human immunodeficiency virus (HIV), but its clinical significance remains unclear. Our purpose was to study the manifestations of HIV-infected patients with PE and the coexistence of these manifestations with other echocardiographic abnormalities, compared with patients without PE.

METHODS

We reviewed 141 HIV-infected patients in whom echocardiographic study was performed. We studied their epidemiological, clinical, hematological, immunological, electrocardiographic (ECG) and echocardiographic characteristics and their in-hospital outcome.

RESULTS

Patients with PE (n = 55), compared with those without PE (n = 86), were more often clinical stage C and immunological stage 3, had left-ventricular dysfunction and right-ventricular dilatation more frequently, and had been diagnosed as HIV-positive for a longer time. Seven patients with moderate to severe PE developed cardiac tamponade. Compared with patients with small PE (n = 34), those with moderate to large PE (n = 21), had pericardial rub, ECG repolarization abnormalities consistent with pericarditis, immunological stage 3, left-ventricular dysfunction and right-ventricular dilatation more frequently. In 3 patients, cardiac tamponade disappeared after anti-tuberculous therapy; in 3 cases, pericardial drainage was performed (anti-tuberculous therapy was not attempted); 1 patient with cardiac tamponade was not drainaged because he was a terminal patient with an extensive lymphoma.

CONCLUSIONS

PE in HIV-infected patients is associated with (1) advanced stages of infection, and (2) left-ventricular dysfunction and right-ventricular dilatation; (3) presence of pericardial rub and ECG alterations consistent with pericarditis suggests the existence of moderate to large PE.

In-hospital outcome of elderly patients with acute inferior myocardial infarction and right ventricular involvement

BACKGROUND

There are some specific high-risk subgroups of patients with acute inferior myocardial infarction, such as older patients and those with right ventricular involvement. However, the clinical implications of right ventricular infarction in elderly subjects have not been studied previously.

METHODS AND RESULTS

To determine the clinical impact of right ventricular involvement in elderly patients with inferior myocardial infarction, we studied the in-hospital outcome of 198 consecutive patients > or = 75 years of age with a first acute inferior myocardial infarction according to the presence of ECG or echocardiographic criteria of right ventricular infarction. In patients with right ventricular involvement (41%), in-hospital case fatality rate was 47% (mainly because of nonreversible low cardiac output cardiogenic shock) compared with 10% in patients without right ventricular involvement (P<.001). Patients with right ventricular involvement also had a significantly higher incidence of cardiogenic shock (32% versus 5%), which was independent of left ventricular ejection fraction, complete AV block (33% versus 9%), and interventricular septal rupture (9% versus 0%). After adjustment for age, sex, diabetes, shock on admission, left ventricular systolic dysfunction, and complete AV block, right ventricular infarction remained a powerful independent predictor of in-hospital death (adjusted odds ratio, 4.0; 95% confidence interval, 1.3 to 14.2).

CONCLUSIONS

Elderly patients with acute inferior myocardial infarction have a substantially increased risk of death during hospitalization when right ventricular involvement is present. The poorer outcome is due mainly to the high incidence of cardiogenic shock and its infrequent reversibility.

Effects of dobutamine on Doppler echocardiographic indexes of aortic stenosis

OBJECTIVES

This study sought to assess the diagnostic implications of the flow dependence of Doppler echocardiographic indexes of aortic valve stenosis.

BACKGROUND

Although valve area has been shown to change with alterations in flow rate, the diagnostic consequences of this phenomenon remain unknown. Valve resistance has been suggested as a more stable index for evaluating aortic stenosis.

METHODS

A low dose dobutamine protocol was performed in 35 patients with aortic stenosis. Hemodynamic indexes were obtained by Doppler echocardiography at baseline and at each dobutamine dose.

RESULTS

As a result of the shortening of the systolic ejection period, flow increased from (mean +/- SD) 164 +/- 48 to 229 +/- 102 ml/s (p < 0.0001). At peak flow, valve area increased by 28% (from 0.5 +/- 0.2 to 0.6 +/- 0.3 cm2, p < 0.0001), whereas valve resistance decreased by 4% (from 498 +/- 252 to 459 +/- 222 dynes.s.cm-5, p = 0.04). This observed change in resistance was smaller than that for valve area (p < 0.01). The flow dependence of valve area varied among individual patients (p < 0.0001). Multivariate analysis identified calcific degenerative etiology (beta 0.29, p = 0.002), left ventricular velocity of fiber shortening (beta 0.22, p = 0.01), baseline flow (beta -0.28, p = 0.04) and amount of flow increased induced by dobutamine (beta 0.90, p < 0.0001) as factors related to valve area flow dependence.

CONCLUSIONS

Although all Doppler echocardiographic indexes of aortic stenosis are affected by flow, valve resistance is more stable than valve area under dobutamine-induced hemodynamic changes. Baseline valve area may be unreliable in patients with calcific degenerative aortic stenosis and low output states.

[Bradycardia and asystolia secondary to epileptic crisis. Report of a case]

We report the case of a 21 year old man with bradycardia and asystolia after a seizure. No cardiac disease could be demonstrated, but electroencephalography after sleep deprivation showed the presence of a temporal irritative focus. The importance of differential diagnosis between cardiogenic syncope and loss of consciousness due to epilepsy is discussed.