Mortalidad intrahospitalaria por infarto agudo de miocardio. Relevancia del tipo de hospital y la atención dispensada. Estudio RECALCAR

Impact of Gender, Race, and Insurance Status on Inhospital Management and Outcomes in Patients With COVID-19 and ST-Elevation Myocardial Infarction (a Nationwide Analysis)

There is a paucity of data exploring the impact of gender, race, and insurance status on invasive management and inhospital mortality in patients with COVID-19 with ST-elevation myocardial infarction (STEMI) in the United States. The National Inpatient Sample database for the year 2020 was queried to identify all adult hospitalizations with STEMI and concurrent COVID-19. A total of 5,990 patients with COVID-19 with STEMI were identified. Women had 31% lower odds of invasive management and 32% lower odds of coronary revascularization than men. Black patients had lower odds of invasive management (odds ratio [OR] 0.61, 95% confidence interval [CI] 0.43 to 0.85, p = 0.004) than White patients. Black and Asian patients had lower odds of percutaneous coronary intervention (Black: OR 0.55, 95% CI 0.38 to 0.80, p = 0.002; Asian: OR 0.39, 95% CI 0.18 to 0.85, p = 0.018) than White patients. Uninsured patients had higher odds of getting percutaneous coronary intervention (OR 1.78, 95% CI 1.05 to 2.98, p = 0.031) and lower odds of inhospital mortality (OR 0.41, 95% CI 0.19 to 0.89, p = 0.023) than privately insured patients. Patients with out-of-hospital STEMI had 19 times higher odds of invasive management and 80% lower odds of inhospital mortality than inhospital STEMI. In conclusion, we note important gender and racial disparities in invasive management of patients with COVID-19 with STEMI. Surprisingly, uninsured patients had higher revascularization rates and lower mortality than privately insured patients.

Trends in cardiovascular care in the National Health System in Spain. Data from the RECALCAR project 2011-2020

INTRODUCTION AND OBJECTIVES

The RECALCAR project (Resources and Quality in Cardiology), an initiative of the Spanish Society of Cardiology, aims to standardize information to generate evidence on cardiovascular health outcomes. The objective of this study was to analyze trends in the resources and activity of cardiology units and/or services and to identify the results of cardiovascular care during the last decade in Spain.

METHODS

The study was based on the 2 annual data sources of the RECALCAR project: a survey on resources and activity of cardiology units and/or services (2011-2020) and the minimum data set of the National Health System (2011-2019), referring to heart failure (HF), STEMI, and non-STEMI.

RESULTS

The survey included 70% of cardiology units and/or services in Spain. The number of hospital beds and length of stay decreased, while there was a notable increase in the number of cardiac imaging studies and percutaneous therapeutic procedures performed. Age- and sex-adjusted admissions for HF tended to decrease, despite an increase in mortality and the percentage of readmissions. In contrast, the trend in mortality and readmissions was highly favorable in STEMI; in non-STEMI, although positive, the trend was less marked.

CONCLUSIONS

The information provided by the RECALCAR project shows a favorable trend in the last decade in resources, activity and results of certain cardiovascular processes and constitutes an essential source for future improvements and decision-making in health policy.

Variablity of Mechanical or Tissue Valve Implantation in Patients Undergoing Surgical Aortic Valve Replacement in Spain: National Retrospective Analysis from 2007 to 2018

Background: There is no robust evidence regarding the types of valves implanted among patients undergoing surgical aortic valve replacement (SAVR) in Spain. Methods: All cases of patients undergoing SAVR ± coronary artery bypass grafting from January 2007 to December 2018 in the public Spanish National Health System were included. We analyzed the trends of SAVR volume, risk profile and type of implanted valve across time and place. Using multivariable logistic regression, we identified factors associated with biological SAVR. Results: In total, 62,870 episodes of SAVR in 15 Spanish territories were included. In 35,693 (56.8%), a tissue valve was implanted. The annual volume of procedures increased from 107.3/million (2007) to 128.6 (2017). In 2018, it fell to 108.5. Age increased and Charlson’s comorbity index worsened throughout the study period. Tissue valve implantation increased in most regions. After adjusting for other covariates, we observed a high variability in aortic valve implantation across different regions, with differences of as much as 20-fold in the use of tissue valves. Conclusions: Between 2007 and 2018, we detected a significant increase in the use of bioprostheses in patients undergoing SAVR in Spain, and a great variability in the types of valve between the Spanish territories, which was not explained by the different risk profiles of patients.

Retrospective cohort analysis of Spanish national trends of coronary artery bypass grafting and percutaneous coronary intervention from 1998 to 2017

INTRODUCTION

Spain is one of the countries with the lowest rates of revascularisation and highest ratio of percutaneous coronary intervention (PCI) to coronary artery bypass grafting (CABG).

OBJECTIVES

To investigate the changes and trends in the two revascularisation procedures between 1998 and 2017 in Spain.

DESIGN

Retrospective cohort study. Analysis of in-hospital outcomes.

SETTING

Minimum basic data set from the Spanish National Department of Health: mandatory database collecting information of patients who are attended in the Spanish public National Health System.

PARTICIPANTS

603 976 patients who underwent isolated CABG or PCI in the Spanish National Health System. The study period was divided in four 5-year intervals. Patients with acute myocardial infarction on admission were excluded.

PRIMARY AND SECONDARY OUTCOMES

We investigated the volume of procedures nationwide, the changes of the risk profile of patients and in-hospital mortality of both techniques.

RESULTS

We observed a 2.2-fold increase in the rate of any type of myocardial revascularisation per million inhabitants-year: 357 (1998) to 776 (2017). 93 682 (15.5%) had a coronary surgery. PCI to CABG ratio rose from 2.2 (1998-2002) to 8.1 (2013-2017). Charlson's index increased by 0.8 for CABG and 1 for PCI. The median annual volume of PCI/hospital augmented from 136 to 232, while the volume of CABG was reduced from 137 to 74. In the two decades, we detected a significant reduction of CABG in-hospital mortality (6.5% vs 2.6%, p<0.001) and a small increase in PCI (1.2% vs 1.5%, p<0.001). Risk adjusted mortality rate was reduced for both CABG (1.51 vs 0.48, p<0.001), and PCI (1.42 vs 1.05, p<0.001).

CONCLUSION

We detected a significant increase in the volume of revascularisations (particularly PCI) in Spain. Risk-adjusted in-hospital mortality was significantly reduced.

Incidence and outcomes of hospital treated acute myocarditis from 2003 to 2015 in Spain

BACKGROUND

There are no data on population-based epidemiological changes in acute myocarditis in Europe. Our aim was to evaluate temporal trends in incidence, clinical features and outcomes of hospital treated acute myocarditis (AM) in Spain from 2003 to 2015.

METHODS

We conducted a retrospective longitudinal study using information of all hospital discharges of the Spanish National Health System. All episodes with a discharge diagnosis of AM from 1 January 2003 to 31 December 2015 were included. The risk-standardized in-hospital mortality ratio (RSMR) was calculated using a multilevel risk-adjustment model developed by the Medicare and Medicaid Services. Temporal trends for in-hospital mortality were modelled using Poisson regression analysis.

RESULTS

A total of 11 147 episodes of AM were analysed, most of them idiopathic (94.7%). The rate of AM discharges increased along the period, from 13 to 30/million inhabitants/year (2003-2015), and this increase was statistically significant when weighted by age and sex (incidence rate ratio, IRR 1.06, 95% CI 1.04-1.08, P = .001). In-hospital crude mortality rate was 3.1%, diminishing significantly along 2003-2015 (IRR 0.95, 95% CI 0.92-0.99, P = .02). RSMR also significantly diminished along the period (IRR 0.95, 95% CI 0.92-0.99, P = .01). Renal failure (OR 7.03, 5.38-9.18, P = .001), liver disease (OR 4.61, 2.59-8.21, P = .001), pneumonia (OR 4.13, 2.75-6.20, P = .001) and heart failure (OR 1.91, 95% CI 1.47-2.47, P = .001) were the strongest independent factors associated with in-hospital mortality.

CONCLUSIONS

Acute myocarditis is an uncommon entity, although hospital discharges have increased in Spain along the study period. Most of AM were idiopathic. Adjusted mortality was low and seemed to decrease from 2003 to 2015, suggesting an improvement in AM management.

The importance of organizational variables in treatment time for patients with ST-elevation acute myocardial infarction improve delays in STEMI

BACKGROUND

The time between arrival at the emergency department (ED) and balloon (D2B) in STEMI is one of the best indicators of the quality of care. Our aim is to describe treatment times and evaluate the causes of delay.

METHODS

This is an observational retrospective study, including all consecutive STEMI code patients ≥18 years old treated in the ED from 2013 to 2016.All the patients were stratified into two groups: delayed group with D2B>70min and non-delayed ≤70. The primary variable was D2B time.

FINDINGS

In total 327 patients were included, stratified according to their D2B as follows: 166 (67·48%) in the delayed group and 80 (32·52%) in the non-delayed group. The delayed group was older (p=0·005), with more females (p=0·060) and more atypical electrocardiogram (ECG) STEMI signs or symptoms (p=0·058) (p=0·087). Predictors of shorter D2B time were: typical STEMI ECG signs and short training sessions for nurses on identifying STEMI patients.

INTERPRETATION

There are delays particularly in specific groups with atypical clinical presentations. Short training sessions aimed at emergency nurses correlate with shorter delay. This suggests that continuing training for emergency nurses, along with organizational strategies, can contribute to increasing the quality of care.

CLINICAL TRIAL NUMBER

NCT04333381.

Isolated aortic valve replacement in Spain: national trends in risks, valve types, and mortality from 1998 to 2017

INTRODUCTION AND OBJECTIVES

To help to illustrate the trends in isolated surgical aortic valve replacement (SAVR) in Spain, we performed a national-level analysis to investigate the changes from 1998 to 2017 in a) SAVR volume, b) patients' risk profiles, c) in-hospital mortality, and d) types of aortic valve prostheses.

METHODS

We included all episodes of patients undergoing isolated SAVR from January 1998 to December 2017 recorded in the Minimum Basic Data Set (Ministry of Health, Consumer Affairs, and Social Welfare, Spain). The study duration was divided into four 5-year periods. We analyzed the trends in SAVR volume, comorbidity prevalence, and in-hospital mortality. Through multivariate logistic regression, we identified factors associated with mortality and type of prosthesis. The risk-adjusted mortality rate was compared over the study period.

RESULTS

In total, 73 668 patients underwent an isolated SAVR from 1998 to 2017. The annual volume of procedures increased from 16 363 between 1998 and 2002 to 22 685 between 2013 and 2017. The prevalence of all investigated comorbidities increased, except for history of previous myocardial infarction and unplanned admission. The Charlson comorbidity index worsened from 1998-2002 (2.3; SD, 1.4) to 2013-2017 (3.6; SD, 1.7) (P <.001). In-hospital mortality decreased from 7.2% to 3.3% (P <.001) while the risk-adjusted mortality index improved from 1.3 to 0.7. The proportion of bioprostheses increased from 20.7% (1998-2002) to 59.6% (2013-2017) (P <.001).

CONCLUSIONS

We detected an increase in the annual SAVR volume in Spain, with more patients receiving bioprostheses. Despite an increased risk profile of the patients, in-hospital mortality substantially reduced.

Acute Myocardial Infarction among Hospitalizations for Heat Stroke in the United States

Background: This study aimed to assess the risk factors and impact of acute myocardial infarction on in-hospital treatments, complications, outcomes, and resource utilization in hospitalized patients for heat stroke in the United States. Methods: Hospitalized patients with a principal diagnosis of heat stroke were identified in the National Inpatient Sample dataset from the years 2003 to 2014. Acute myocardial infarction was identified using the hospital International Classification of Diseases, Ninth Revision (ICD-9), diagnosis of 410.xx. Clinical characteristics, in-hospital treatment, complications, outcomes, and resource utilization between patients with and without acute myocardial infarction were compared. Results: A total of 3372 heat stroke patients were included in the analysis. Of these, acute myocardial infarction occurred in 225 (7%) admissions. Acute myocardial infarction occurred more commonly in obese female patients with a history of chronic kidney disease, but less often in male patients aged <20 years with a history of hypothyroidism. The need for mechanical ventilation, blood transfusion, and renal replacement therapy were higher in patients with acute myocardial infarction. Acute myocardial infarction was associated with rhabdomyolysis, metabolic acidosis, sepsis, gastrointestinal bleeding, ventricular arrhythmia or cardiac arrest, renal failure, respiratory failure, circulatory failure, liver failure, neurological failure, and hematologic failure. Patients with acute myocardial infarction had 5.2-times greater odds of in-hospital mortality than those without myocardial infarction. The length of hospital stay and hospitalization cost were also higher when an acute myocardial infarction occurred while hospitalized. Conclusion: Acute myocardial infarction was associated with worse outcomes and higher economic burden among patients hospitalized for heat stroke. Obesity and chronic kidney disease were associated with increased risk of acute myocardial infarction, while young male patients and hypothyroidism were associated with decreased risk.

Impact of Board-Certified Cardiologist Characteristics on Risk of In-Hospital Mortality

Background: This study examined the influence of board-certified cardiologist characteristics on the in-hospital mortality of patients with cardiovascular disease.

Methods and Results: Data were collected between 2012 and 2014 from a nationwide database of acute care hospitals in Japan. Overall, there were 1,422,703 patients, of whom 883,746 were analyzed. The primary outcome was all-cause in-hospital mortality. The association between board-certified cardiologist characteristics and in-hospital mortality was estimated using multilevel mixed-effect logistic regression modeling. Median age of cardiologists in a hospital was not related to in-hospital mortality (OR, 1.003; 95% CI: 0.998–1.008, P=0.316), but a greater cardiologist age range was associated with a lower risk of in-hospital mortality (OR, 0.992; 95% CI: 0.988–0.995 per 1-unit increment in age range, P<0.001). Meanwhile, the average years of experience of the board-certified cardiologists in a hospital was not associated with a lower risk of in-hospital mortality (OR, 1.002; 95% CI: 0.996–1.007, P=0.525), but a greater range of years of experience was (OR, 0.986; 95% CI: 0.983–0.990 per 1-unit increment in range of years of experience, P<0.001).

Conclusions: Median board-certified cardiologist age/experience at an institution is not related to in-hospital mortality, but a greater range in age/experience is associated with a lower risk of mortality.

The Two-way Relationship Between Cancer and Atherosclerosis

In the last few years, there has been growing interest in the relationship between cancer and cardiovascular disease. The increase in life expectancy in both diseases has led to their frequent coexistence in the same patient, which can lead to adverse drug reactions that increase patient risk. This is especially relevant in the case of atherosclerosis, which seems to share a common pathophysiological substrate with cancer. In this review, we analyze these common risk factors, and specifically analyze the relationship between different cancer treatments with the risk of coronary or cerebrovascular disease, as well as the current scientific evidence on the possible relationship between antiplatelet therapy and cancer risk. We also review the incidence and prognosis of cancer in patients with atherosclerosis and vice versa, based on the information reported in the most recently published studies in the field of cardio-oncology.

Sex differences in treatment and prognosis of acute coronary syndrome with interventional management

OBJECTIVE

Female sex has been associated with differences in diagnostic and management of acute coronary syndrome (ACS). Our aim was to analyze sex differences in ACS with interventional management in a tertiary care hospital.

METHODS

Patients with ACS admitted to a Spanish tertiary care referral center were included prospectively and consecutively. All patients included in the study underwent a coronary angiography.

RESULTS

From the total cohort of 1214 patients, 290 (24%) were women. Women were older (71 ± 12.8 vs 64 ± 13.4 years, p < 0.001) and showed lower ischemic risk and higher hemorrhagic risk scores (GRACE 159 ± 45 vs 171 ± 42, p = 0.005; CRUSADE 41 ± 19 vs 28 ± 17, p < 0.001). There were no significant differences in time to coronary angiography and revascularization rates between sex groups. A lower proportion of women received high-potency antiplatelet agents (29% vs 41.3%, p = 0.004). In-hospital evolution and one-year mortality were similar between groups.

CONCLUSIONS

In our population, there were no gender differences in management and prognosis of ACS. Differences in risk profile among groups could have an influence on antiplatelet therapy.

Does size matter? The impact of caseload and expertise concentration on AMI 30-day mortality-A comparison across 10 OECD countries

OBJECTIVE

To examine the variability of hospital performance within and across countries, using 30-day acute myocardial infarction (AMI) mortality, and to study the impact of hospital characteristics on performance.

STUDY SETTING

Hospital-level adjusted risk standardized mortality rates (RSMR) and hospital characteristics were collected from 10 OECD and two collaborating countries including 1,163 hospitals.

STUDY DESIGN

Associations between RSMR and hospital characteristics were studied using univariate and multivariate linear regressions. Clusters of hospitals were created using hierarchical clustering and mortality compared using linear regression.

FINDINGS

Wide variation between countries was found for RSMR and hospital characteristics. Regression models showed large country effects. A high volume of AMI admission was associated with lower RSMR in a model using a restricted number of hospital characteristics (-0.83, p < 0.001) but not in a model using all characteristics (-1.03, p = 0.06). Analysis within countries supported this association. Hospital clusters showed clear differences in characteristic distributions but no difference in RSMR.

CONCLUSIONS

The effect of volume may support policies toward a concentration of services within the hospital sector. The effect of other hospital characteristics was inconclusive and suggests the importance of system-wide characteristics or pathways of care (i.e. timeliness and nature of initial response and during transportation to a hospital, transfers between hospitals, post-discharge organization) in explaining variation.

Implications of the transcription factor WT1 linked to the pathologic cardiac remodeling post-myocardial infarction

New advances in the treatment of acute myocardial infarction involve novel signaling pathways and cellular progeny. In this sense, regeneration is a novel tool that would contribute to post-infarction physiological ventricular remodeling. More specifically, re-expression of the WT1 transcription factor in the myocardial wall by ischemia and infarction would be related to the invasion of cells with the capacity for regeneration. This mechanism seems not to be sufficient to restore muscle cells and lost vessels entirely. Of particular interest, the presence of the heat-shock response protein 70 (Hsp70) and its interaction with the vitamin D receptor would modulate the expression of WT1 positively. In this context, it is proposed that the activation of vitamin D receptors associated with Hsp70 could favor physiological cardiac remodeling and reduce the progression to heart failure.

Hospital Mortality in 415 798 AMI Patients: 4 Years Earlier in the Canary Islands Than in the Rest of Spain

INTRODUCTION AND OBJECTIVES

The Canary Islands has the highest mortality from diabetes in Spain. The aim of this study was to determine possible differences in mortality due to acute myocardial infarction (AMI) during hospital admission between this autonomous community and the rest of Spain, as well as the factors associated with this mortality and the population fraction attributable to diabetes.

METHODS

Cross-sectional study of hospital admissions for AMI in Spain from 2007 to 2014, registered in the Minimum Basic Data Set.

RESULTS

A total of 415 798 AMI were identified. Canary Island patients (16 317) were younger than those living in the rest of Spain (63.93 ± 13.56 vs 68.25 ± 13.94; P < .001) and death occurred 4 years earlier in the archipelago (74.03 ± 11.85 vs 78.38 ± 11.10; P < .001). This autonomous community had the highest prevalence of smoking (44% in men and 23% in women); throughout Spain, AMI occurred 13 years earlier in smokers than in nonsmokers. Patients in the Canary Islands had the highest mortality rates whether they had diabetes (8.7%) or not (7.6%), and they also showed the highest fraction of AMI mortality attributable to diabetes (9.4; 95%CI, 4.8-13.6). After adjustment for type of AMI, diabetes, dyslipidemia, hypertension, smoking, cocaine use, renal failure, sex and age, the Canary Islands showed the highest risk of mortality vs the rest of Spain (OR = 1.25; 95%CI, 1.17-1.33; P < .001) and it was one of the autonomous communities showing no significant improvement in the risk of mortality due to AMI during the study period.

CONCLUSIONS

Mortality due to AMI during hospital admission is higher in the Canary Islands than in the rest of Spain.

Clinical and Administrative Data on the Research of Acute Coronary Syndrome in Spain. Minimum Basic Data Set Validity

INTRODUCTION AND OBJECTIVES

Health outcomes research is done from clinical registries or administrative databases. The aim of this work was to evaluate the concordance of the Minimum Basic Data Set (MBDS) with the DIOCLES (Descripción de la Cardiopatía Isquémica en el Territorio Español) registry and to analyze the implications of use of the MBDS in the study of acute coronary syndrome in Spain.

METHODS

Through indirect identifiers, DIOCLES was linked with MBDS and unique matches were selected. Some of most relevant variables for risk adjustment of in-hospital mortality due to acute myocardial infarction were considered. Kappa coefficient was used to evaluate the concordance; sensitivity, specificity and positive and negative predictive values to measure the validity of the MBDS, and the area under ROC (receiver operating characteristic) curve to calculate its discrimination. The results were compared among hospitals quintiles according to their contribution to DIOCLES. The influence of unmatched episodes on results was assessed by a sensitivity analysis, using looser linking criteria.

RESULTS

Overall, 1539 (60.85%) unique matches were achieved. The prevalence was higher in DIOCLES (acute myocardial infarction: 71.09%; Killip 3-4: 9.17%; cerebrovascular accident: 0.97%; thrombolysis: 8.64%; angioplasty: 61.92% and coronary bypass: 1.75%) than in the MBDS (P < .001). The agreement level observed was almost perfect (κ = 0.863). The MBDS showed a sensitivity of 85.10% and a specificity of 98.31%. Most results were confirmed by using sensitivity analysis (79.95% episodes matched).

CONCLUSIONS

The MBDS can be a useful tool for outcomes research of acute coronary syndrome in Spain. The contrast of DIOCLES and MBDS with medical records could verify their validity.

Prevalence and Postdischarge Incidence of Malignancies in Patients With Acute Coronary Syndrome

INTRODUCTION AND OBJECTIVES

Malignancies are the second cause of death in developed countries after cardiovascular disease and both share common risk factors.

METHODS

This prospective study assessed the prevalence and postdischarge incidence of malignancies in all consecutive patients admitted for an acute coronary syndrome.

RESULTS

A total of 1819 patients were included. On admission, the prevalence of malignancies was 3.4%, and 41.9% of the patients were considered disease-free; of the 1731 discharged patients, the incidence was 3.1% (53 cases) and the most common locations were the colon, lung, bladder, and pancreas. Patients with prevalent malignancies were older and had more comorbidities and complications. There were no differences in the revascularization rate, but implantation of drug-eluting stents was less frequent in patients with prevalent malignancies. During follow-up, the median time to diagnosis of incident malignancies was 25 months. On multivariate analysis, independent risk factors were age and current or former smoking. All-cause mortality was much higher in patients with incident (64.2%) or prevalent (40.0%) malignancies. Multivariate analysis showed that prevalent and incident malignancies increased the risk of all-cause mortality by 4-fold.

CONCLUSIONS

Among patients admitted for an acute coronary syndrome, 3.8% had a history of malignancy, with less than 50% considered cured. The incidence of new malignancies was 3.4% and both types of malignancies substantially impaired the long-term prognosis.

Management of myocardial infarction in the elderly. Insights from Spanish Minimum Basic Data Set

Background:

We aimed to assess the impact of implementation of reperfusion networks, the type of hospital and specialty of the treating physician on the management and outcomes of ST segment elevation myocardial infarction in patients aged ⩾75 years.

Methods:

We analysed data from the Minimum Basic Data Set of the Spanish public health system, assessing hospital discharges between 2004 and 2013. Discharges were distributed in three groups depending on the clinical management: percutaneous coronary intervention, thrombolysis or no reperfusion. Primary outcome measure was all cause in-hospital mortality. For risk adjustment, patient comorbidities were identified for each index hospitalization.

Results:

We identified 299,929 discharges, of whom 107,890 (36%) were in-patients aged ⩾75 years. Older patients had higher prevalence of comorbidities, were less often treated in high complexity hospitals and were less frequently managed by cardiologists ( p<0.001). Both percutaneous coronary intervention and fibrinolysis were less often performed in elderly patients ( p<0.001). A progressive increase in the rate of percutaneous coronary intervention was observed in the elderly across the study period (from 17% in 2004 to 45% in 2013, p<0.001), with a progressive reduction of crude mortality (from 23% in 2004 to 19% in 2013, p<0.001). Adjusted analysis showed an association between being treated in high complexity hospitals, being treated by cardiologists and lower in-hospital mortality ( p <0.001).

Conclusions:

Elderly patients with ST segment elevation myocardial infarction are less often managed in high complexity hospitals and less often treated by cardiologists. Both factors are associated with higher in-hospital mortality.

The RECALCAR Project. Healthcare in the Cardiology Units of the Spanish National Health System, 2011 to 2014

The RECALCAR project (Spanish acronym for Resources and Quality in Cardiology Units) uses 2 data sources: a survey of cardiology units and an analysis of the Minimum Basic Data set of all hospital discharges of the Spanish National Health System. From 2011 to 2014, there was marked stability in all indicators of the availability, utilization, and productivity of cardiology units. There was significant variability between units and between the health services of the autonomous communities. There was poor implementation of process management (only 14% of the units) and scarce development of health care networks (17%). Structured cardiology units tended to have better results, in terms of both quality and efficiency. No significant differences were found between the different types of unit in the mean length of stay (5.5±1.1 days) or the ratio between successive and first consultations (2:1). The mean discharge rate was 5/1000 inhabitants/y and the mean rate of initial consultations was 16±4/1000 inhabitants/y. No duty or on-call cardiologist was available in 30% of cardiology units with 24 or more beds; of these, no critical care beds were available in 45%. Our findings support the recommendation to regionalize cardiology care and to promote the development of cardiology unit networks.