[Variability in the management and prognosis at short- and medium-term of myocardial infarct in Spain: the PRIAMHO study. Registration Project of Hospital Acute Myocardial Infarct]

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.

The Effect of Monthly Medication on Mortality After a Coronary Event

AIM

The aim of this study was to analyze how the consumption of medication over time affects the survival rate in patients with a coronary event and whether there is a gender difference.

METHODS

The study included 804 patients admitted to 4 hospitals with a coronary event during 2007. Monitoring after coronary event was carried out during 2007 and every 6 months in the subsequent 2 years (2008 and 2009) throughout the review of the clinical history of the patient. The main outcome was the analysis of mortality after the coronary event. Kaplan-Meier survival curves were plotted to calculate the time to death, comparing women versus men for 4 medication groups: aspirin, statins, β-blockers, and angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (ACEIs/ARBs). A Cox regression model was used for the final mortality analysis.

RESULTS

During the follow-up time, 172 deaths were assessed. Each month of treatment with aspirin, statins, β-blockers, or ACEI/ARB was associated with a decrease in mortality between 13.0% and 0.5% (univariate analysis). The Kaplan-Meier method revealed a significant reduction in mortality after the coronary event for each month of treatment with aspirin (men), statins (men), and β-blockers (both men and women). No significant effect in survival was observed in either gender with ACEI/ARB treatment. The final multivariable model (Cox regression) showed that the taking of aspirin, statins, β-blockers, or ACEI/ARB is able to reduce mortality rates up to 7.0% (aspirin) throughout each month of treatment after a coronary event without any influence of gender.

CONCLUSION

Aspirin, statins, β-blockers, and ACEI/ARB revealed a protective character with each month of treatment throughout the follow-up period, in terms of risk reduction of death. Aspirin and statins showed the maximum benefit, followed by ACEI/ARB and β-blockers.

Quality Markers in Cardiology. Main Markers to Measure Quality of Results (Outcomes) and Quality Measures Related to Better Results in Clinical Practice (Performance Metrics). INCARDIO (Indicadores de Calidad en Unidades Asistenciales del Área del Corazón): A SEC/SECTCV Consensus Position Paper

Cardiology practice requires complex organization that impacts overall outcomes and may differ substantially among hospitals and communities. The aim of this consensus document is to define quality markers in cardiology, including markers to measure the quality of results (outcomes metrics) and quality measures related to better results in clinical practice (performance metrics). The document is mainly intended for the Spanish health care system and may serve as a basis for similar documents in other countries.

Update on ischemic heart disease and intensive cardiac care

This article summarizes the main developments reported in 2014 on ischemic heart disease, together with the most important innovations in intensive cardiac care.

Demographic and clinical characteristics of patients with stable coronary artery disease: results from the CLARIFY registry in Spain

INTRODUCTION AND OBJECTIVES

Coronary artery disease is associated with high morbidity and mortality. The objective of the CLARIFY registry is to study the treatment of outpatients with coronary artery disease in the setting of daily clinical practice.

METHODS

The CLARIFY registry is a prospective registry conducted in 41 countries that included outpatients with stable coronary artery disease attending primary care or specialist units between October 2009 and June 2010. The present study describes the baseline characteristics of the Spanish cohort compared with the western European cohorts included in the registry.

RESULTS

A total of 33,248 patients were included: 14,726 in western Europe and 2257 in Spain (selected by 192 cardiologists). The majority of the participants in Spain were men (81%) with a mean age of 65 years. There was a higher frequency of diabetes (34% vs 25%; P<.0001), coronary artery disease family history (19% vs 31%; P<.0001), myocardial infarction (64% vs 60%; P<.0001), and stroke (5% vs 3%; P=.0007) in the Spanish cohort than in the western European cohorts. The most common treatments in the Spanish sample were lipid-lowering drugs (96%), acetylsalicylic acid (89%), and beta-blockers (74%).

CONCLUSIONS

Patients in the Spanish cohort are similar to those in the western European cohorts and seem to be representative of the Spanish population with coronary artery disease. Therefore, they form a suitable basis for the study of prognostic factors at 5-year follow-up.

Psychiatric morbidity as a risk factor for hospital readmission for acute myocardial infarction: an 8-year follow-up study in Spain

BACKGROUND AND OBJECTIVE

Most previous studies assess the effect of depression and other psychiatric variables as risk factors for acute myocardial infarction; however, studies that assess the effect of psychiatric disorders as a whole are scarce, compared with other non-psychiatric factors. The aim of this study is to assess the importance of psychiatric morbidity, compared with other risk factors, in hospital readmission for acute myocardial infarction.

METHODS

This is a 8-year follow-up study in which the Hospital Discharge Administrative Database was used.

RESULTS

From the total sample (11,062 patients), 590 patients (4.88%) were diagnosed with some mental disorder. Psychiatric disorders were more common in women than in men with myocardial infarction (4.76 % and 6.20%, respectively, p-value = 0.002). For those who have had recurrence of stroke, mental disease influences in the consecutive readmission for AMI with the same severity as did tobacco, diabetes, or obesity.

CONCLUSIONS

The main finding of this study is the enormous impact of psychiatric disorders on readmissions for AMI, comparable to diabetes, obesity, cerebral vascular disease, and hypertension. Interestingly, the efforts made to treat and prevent psychiatric disorders in AMI patients are clearly lower than those health authorities make with respect to classic risk factors.

[How beta-blockers are used in Spain? Analysis of limitations in their use in internal medicine and cardiology: CARACTER-BETA study]

INTRODUCTION AND OBJECTIVES

Beta-blocker treatment has a class I indication, level of evidence A, in guidelines for the treatment of heart failure, ischemic heart disease, and atrial fibrillation. However, beta-blocker use continues to be less than optimal. In this study, beta blocker use in Spain is analyzed in patients with heart failure, ischemic heart disease, and atrial fibrillation.

METHODS

Observational, epidemiologic, cross-sectional, multicenter study including 1608 patients with heart failure, ischemic heart disease, and/or atrial fibrillation, recruited in 150 healthcare centers by cardiologists and internal medicine specialists.

RESULTS

Cardiologists enrolled 78.6% patients and internal medicine specialists 21.4%; 25.8% were recruited at hospital discharge and 74.2% at outpatient centers. Men accounted for 77% of the sample, and age was 68 (12) years. Of the total, 73% had ischemic heart disease, 42% heart failure, and 36% atrial fibrillation (multiresponse variable). Beta blockers were given to 82.8% of those consulting in cardiology compared to 71.6% of those treated in internal medicine (P<.0001). By pathology, the prescription rate was 85.1% of patients with ischemic heart disease, 77.0% of those with heart failure, and 72.4% of those with atrial fibrillation. Cardiology prescribed significantly more beta blockers for ischemic heart disease and heart failure than did internal medicine. Multivariate analysis showed that beta blocker use increased when the patient had ischemic heart disease, was treated by a cardiologist, and had dyslipidemia, stroke, and/or left ventricular hypertrophy. beta blocker use decreased with age and with a history of bronchospasm, asthma, bradycardia, chronic obstructive pulmonary disease, and/or intermittent claudication.

CONCLUSIONS

There is still room for improvement in beta blocker prescription in Spain for patients with ischemic heart disease, heart failure, and/or atrial fibrillation.

[Reduction in 28 days and 6 months of acute myocardial infarction mortality from 1995 to 2005. Data from PRIAMHO I, II and MASCARA registries]

INTRODUCTION AND OBJECTIVES

To determine whether mortality from acute myocardial infarction has reduced in Spain and the possibly related therapeutic factors.

METHODS

Nine thousand, nine hundred and forty-nine patients with ST-segment elevation myocardial infarction admitted to the Coronary Care Unit were identified from PRIAMHO I, II and MASCARA registries performed in 1995, 2000 and 2005, with a 6 month follow-up.

RESULTS

From 1995 to 2005 patients were increasingly more likely to have hypertension, hyperlipidemia and anterior infarction, but age of onset and the proportion of females did not increase. Twenty-eight-day mortality rates were 12.6%, 12.3% and 6% in 1995, 2000 and 2005 respectively, and 15.3%, 14.6% and 9.4% at 6 months (both P-trend <.001). Multivariate analysis was performed and the adjusted odds ratio for 28-day mortality for an infarction occuring in 2005 (compared with 1995) was 0.62 (95% confidence interval: 0.44-0.88) whereas the adjusted hazard ratio for mortality at 6 months was 0.40 (95% confidence interval: 0.24-0.67). Other variables independently associated with lower mortality at 28 days were: reperfusion therapy, and the use of anti-thrombotic treatment, beta-blockers and angiotensin-converting enzyme inhibitors. The 28-day-6-month period had an independent protective effect on the following therapies: coronary reperfusion, and prescription of antiplatelet agents, beta-blockers and lipid lowering drugs upon discharge.

CONCLUSIONS

Twenty-eight-day and six-month mortality rates fell among patients with ST-elevation myocardial infarction in Spain from 1995 to 2005. The possibly related therapeutic factors were the following: more frequent reperfusion therapy and increased use of anti-thrombotic drugs, beta-blockers, angiotensin-converting enzyme inhibitors and lipid lowering drugs.

Effect of diabetes on the clinical characteristics and prognosis of patients with chronic ischemic heart disease. The CIBAR study

The aim of this study was to evaluate the effect of diabetes mellitus on the prognosis of patients with chronic ischemic heart disease. The multicenter prospective cohort study involved 1108 outpatients with ischemic heart disease whose clinical characteristics were recorded by 69 primary care physicians. Morbidity and mortality were recorded during a mean follow-up period of 6.9 months. Overall, 29% of patients were diabetic; they were older than non-diabetics, presented with more risk factors, had poorer blood pressure control, and had more comorbid conditions. In addition, diabetics were more likely to be prescribed renin-angiotensin system blockers, calcium channel blockers, diuretics and lipid-lowering drugs. Cardiovascular mortality and hospitalization rates were higher in diabetics. On multivariate analysis, diabetes was found to be an independent predictor of a cardiovascular event (hazard ratio=1.81; 95% confidence interval, 1.17-2.82). Prognosis in chronic ischemic heart disease is relatively good, although it is worse in diabetics, which means that treatment and disease controls targets must be more rigorously applied in these patients.

Human mortality seasonality in Castile-León, Spain, between 1980 and 1998: the influence of temperature, pressure and humidity

This study was carried out in the region of Castile and Leon, Spain, from 1980 to 1998 and analyzes the relationship between the number of monthly deaths caused by cardiovascular, respiratory and digestive diseases and three meteorological variables: temperature, pressure and humidity. One of the innovations in this study is the application of principal component analysis in a way that differs from its usual application: one single series representing the whole region was constructed for each meteorological variable from the series of eight weather stations. Annual and seasonal mortality trends were also studied. Cardiovascular diseases are the leading cause of death in Castile and Leon. The mortality related to cardiovascular, respiratory and digestive systems shows a statistically significant rising trend across the study period (an annual increase of 6, 16 and 4 per thousand, respectively). The pressure at which mortality is lowest is approximately the same for all causes of death (about 915 hPa), but temperature values vary greatly (16.8-19.7 degrees C for the mean, 10.9-18.1 degrees C for the minimum, and 24.1-27.2 degrees C for the maximum temperature). The most comfortable temperatures for patients with cardiovascular diseases (16.8 degrees C) are apparently lower than those for patients with respiratory diseases (18.1 degrees C), which are, in turn, lower than in the case of diseases of the digestive system (19.7 degrees C). Finally, the optimal humidity for patients with respiratory diseases is the lowest (24%) among the diseases, and the highest (51%) corresponds to diseases of the digestive system, while the optimal relative humidity for the cardiovascular system is 45%.

APACHE-II score and Killip class for patients with acute myocardial infarction

OBJECTIVE

To analyse the influence on the prognosis of intensive care unit (ICU) patients with acute myocardial infarction (AMI): prognostic index score, Killip class, AMI site, thrombolysis and other variables that might improve prognostic capacity and functioning of the APACHE-II index.

DESIGN

Cohort study using prospectively gathered ARIAM project data.

SETTING

ICUs from 129 Spanish hospitals.

PATIENTS

ICU-admitted AMI patients in ARIAM database during 4-year period were retrospectively studied.

MEASUREMENTS AND MAIN RESULTS

The sample comprised 6,458 patients, 76.8% males, age 64.97 +/- 12.56 years, APACHE-II score 9.49 +/- 7.03 points and ICU mortality 8.9%. Mortality was higher for females (p < 0.001), anterior AMI site (p < 0.001), previous AMI (p < 0.001), delay-to-hospital arrival >180 min (p = 0.003) and non-receipt of thrombolysis (p = 0.015). ICU mortality was related to age (p < 0.001) and APACHE-II score (p < 0.001). In multivariate analysis, it was related to APACHE-II (OR 1.16), age (OR 1.05), gender (OR 1.64), previous AMI (OR 1.57), anterior AMI (OR 2.05) and delay >180 min (OR 1.37). Killip class, gathered in 1,893 patients, was significantly associated with ICU mortality, and two predictive models were constructed for this group using multivariate analysis. Area under ROC curve was 0.94 in one (Killip class, age, gender, APACHE-II) versus 0.92 in the other (same variables without APACHE-II).

CONCLUSIONS

APACHE-II score and Killip class are useful for assessing the severity of patients with AMI and are complementary. Each can be used with a few commonly gathered clinical variables to construct prognostic models to assess severity. Their joint application yields a model with excellent discrimination capacity.

[The secondary prevention of ischaemic heart disease in Spain. A systematic review of observational studies]

OBJECTIVE

To describe the use of ischaemic heart disease (IHD) secondary prevention measures in the Spanish National Health System.

DESIGN

Systematic review of observational studies with information on the use of preventive treatment and measures in the prevention of secondary IHD.

SETTING

Primary care and specialised out-patient clinics.

DATA SOURCES

Medline search and complementary searches of studies published between 1995 and 2004 with a description of the use secondary prevention measures on hospital discharge or in the follow up after discharge.

SELECTION OF STUDIES

A total of 125 references were found after the MEDLINE search, 13 of which were selected after an independent review by 2 researchers. The complementary sources provided 9 more studies giving a total of 22.

DATA EXTRACTION

One researcher extracted information on the characteristics of the study and the results variables, which were independently verified by a second evaluator. RESULTS. In the 22 studies found, a high level of variation was shown in the different treatment rates: anti-aggregants (at discharge, 72%-97.1%; follow-up, 46.4%-93.8%); beta-blockers (at discharge, 29%-68.3%; follow-up, 22.4%-59.0%); drugs with action on the renin-angiotensin system (at discharge, 16.2%-52.2%; follow-up, 6.1%-53.1%); lipid lowering drugs (at discharge, 6.7%-88.7%; follow-up, 24.5%-89.5%). The treatment rates showed a progressive improvement over time during the period studied.

CONCLUSIONS

In the period 1994-2003 treatment rates in the secondary prevention of IHD have increased, although there is still much room for improvement.

[Descriptive study of vascular complications secondary to antithrombotic agents and percutaneous cardiovascular interventionism in a coronary unit]

Administration of drugs in the patients diagnosed of acute coronary syndrome and treated with percutaneous transluminal coronary angioplasty (PTCA) has noticeably reduced morbidity-mortality and appearance of new ischemic events. However, these drug agents may cause bleeding problems secondary to therapeutic intervention. The objectives of this research are: to know the incidence of vascular complications developed in patients treated with antithrombotic drugs and percutaneous cardiovascular interventionism and describe variables that may be related with their appearance. A retrospective descriptive study was done on the registries of the clinical histories of 153 patients subjected to primary angioplasty and rescue treatment during the period ranging from October 1, 2001 to October 31, 2002 in the Hospital Universitario Marques de Valdecilla. Mean age of the patients was 63 years, 75% diagnosed of acute myocardial infarction and 71% subjected to primary angioplasty. Drugs used were anticoagulants, antiaggregants and fibrinolytics. Furthermore compression methods and arterial sheath duration time were analyzed. Complications appeared in 39% of the patients, the most frequent complication being the hematoma in 28%. It is concluded that when antithrombotic drugs are combined with PTCA, vascular complications appear in one third of the patients studied, the appearance of hematomas standing out in the first place and in the second place, femoral bleeding. The main study variables also contributing to their appearance are the permanence of the sheath and its removal.

[Study of unmatched cases and controls: hyperhomocysteinaemia and chronic ischaemic cardiopathy]

OBJECTIVE

To evaluate the extent of the association between hyperhomocysteinaemia and chronic ischaemic heart disease.

DESIGN

Unmatched, case-control (1:3) study.

SETTING

Pintores Health Centre, Area 10, Primary Care, Madrid, Spain.

PARTICIPANTS

Patients of the health centre over 35 with chronic ischaemic heart disease or without it.

METHOD

Consecutive, non-randomized sample. Analysis of cases and controls with chi2 test and odds ratio (OR). The quantitative variables were analysed with the Student's t test.

RESULTS

The 76.32% (87/114) of cases had 2 or more cardiovascular risk factors versus 33.56% (99/265) in the control group (P<.0001). Average homocysteinaemia was 10.07 micromol/L (SD, 3.64) in the control group; and 12.74 (SD, 4.59) in the cases group. The difference between the averages (2.67 micromol/L; 95% CI, 1.82-3.52) was significant (P<.001). The difference (16.07%; 95% CI, 6.91-25.23) in hyperhomocysteinaemia (> or =15 micromol/L) between cases (28.95%, 33/114) and controls (12.88%, 38/295) was significant (P=.0001), with an association between hyperhomocysteinaemia and chronic ischaemic heart disease (OR=2.76; 95% CI, 1.62-4.68). This association increased (OR=3.26; 95% CI, 2.07-5.13) when hyperhomocysteinaemia was taken as > or =12 micromol/L, with a significant difference of 27% (95% CI, 16.59-37.41) (P<.0001) between cases (51.75%, 59/114) and controls (24.75%, 73/295).

CONCLUSIONS

The risk factor of hyperhomocysteinaemia > or =15 micromol/L was significantly associated (OR=2.76) with chronic ischaemic heart disease. This association was greater (OR=3.26) when hyperhomocysteinaemia was taken as > or =12 micromol/L.

Factores asociados a la mortalidad intrahospitalaria del infarto de miocardio. Resultados de un estudio observacional

BACKGROUND AND OBJECTIVE

Myocardial infarction is one of the leading causes of death in Spain. This study assesses in-hospital mortality and associated factors.

PATIENTS AND METHOD

Mortality of episodes of initial attention of myocardial infarction attended in hospitals was analyzed using the 2001 Minimum Basic Group of Data corresponding to the Community of Madrid in relation with sociodemographic, hospitals, procedures, risk factors and comorbidities. Statistical descriptive techniques and logistic regression analyses were employed to analyze the data.

RESULTS

5,306 cases of myocardial infarction were studied. 71% were men and the mean age was 68 year. 73% were admitted in high technology hospitals, 49% received coronary angiography and 29% received a stent. Mortality rate was 10.8%. Multivariable analysis showed that increase in age, presence of arrhythmias, congestive heart failure, renal failure, cardiogenic shock and cerebrovascular disease were associated with in-hospital mortality, while admission in centers attending between 100 and 300 myocardial infarction cases, use of coronary angiography and stent, and previous history of arterial hypertension, smoking and high lipid levels, appeared to be protective factors.

CONCLUSIONS

Mortality estimated with an administrative data-base is similar than the mortality estimated in studies based on clinical data sets. Mortality is associated with several variables; although some of them have been previously reported, others need further investigations to confirm their relevance.

Postmyocardial infarction mortality in relation to depression: a systematic critical review

The aim of this review was to survey the literature on depression in patients with myocardial infarction to assess the methodological quality and to test whether depression leads to an increased postmyocardial infarction mortality. Medline, Psycinfo, and www.UMI.com were searched, and researchers were contacted in the autumn of 2003. Thirty-one articles were reviewed. Only seven articles scored above a predefined level of 75% for acceptable quality. The articles lack description of non-responders, recall period for depressive symptoms, validation of applied instrument on target population, and sample size large enough to show differences between groups. The prevalence rates of depression ranged from 1.6 to 50%. In eight articles, a diagnostic test was applied, in the rest of the studies, questionnaires were used. The prevalence of depression was highest in those using patient-completed questionnaires. A significant positive association was shown between depression and postmyocardial infarction mortality in 15 studies, a non-significant association in 14, and in two articles, this was not reported. In articles with data collection starting after 1994, a non-significant relation tended to be reported. The studies were generally not of acceptable quality. They lacked sufficient power to show differences in stated end points between groups. Application of non-validated instruments caused large differences in prevalence rates of depression. Future studies should include a minimum of 1,000 patients, use a validated instrument, re-examine the patients, and describe participants and non-participants in detail.

[Myocardial Infarction Registry in Asturias: the RIMAS project]

BACKGROUND AND OBJECTIVE

Spanish hospital registers of myocardial infarction (MI) are not uniform. The RIMAS project is trying to know the real situation of myocardial infarction in Asturias and to observe possible differences among hospitals and with other registers.

PATIENTS AND METHOD

It was a cohorts study using a hospital registry of patients with MI. All cases arriving alive to all public and private-public Asturian hospitals during 1998 were included. Demographic data, cardiovascular risk factors, delays, evolution, treatments and techniques used, were all registered.

RESULTS

875 cases were registered with a coverage rate of 77%. The average age was 66.5 years (45.6% older than 70 years) and women represented 29.1%. Sixty three per cent of the patients had tobacco consumption, 43% had arterial hypertension, and 22.3% were diabetics. The extrahospital delay was 135 min and thrombolysis delay was 180 min. Thrombolytic therapy was administered to 34.1% of patients and 4% were treated with primary angioplasty. Intrahospital mortality was 14.4%. At discharge, antiagregant therapy was administrated to 94%, betablockers to 43.2%, ACE inhibitors to 33.3% and hypolipemiants to 25% of treated patients.

CONCLUSIONS

People attended in Asturias with a MI are older and there is a higher percentage of women. There are delays which include the start of thrombolytic therapy. However, there are significant differences with regard to the adhesion to clinical practice guidelines between different hospitals.

[Trends in mortality from ischemic heart disease in 50 Spanish provinces]

INTRODUCTION AND OBJECTIVES

Ischemic heart disease is the leading cause of cardiovascular mortality and the second most frequent cause in women in Spain. It is responsible for 12% and 10%, respectively, of all-cause mortality. Our aim was to identify those provinces where recent trends differ significantly from the overall national pattern of decreasing rates in recent years, and where intervention is probably needed.

PATIENTS AND METHOD

We report mortality trends due to ischemic heart disease for the periods 1988-1991 and 1994-1997 for each province in persons aged 35 to 64 years, and mortality trends in Spain in the last 19 years for all age groups. Data for ischemic heart disease mortality were obtained from files supplied by the Spanish National Institute for Statistics. Mortality rates in the two 4-year periods were compared with log-linear Poisson regression models to estimate trends. Age-adjusted and mortality hazard-rates are presented with 95% CI, and time trends and geographical variations are also reported.

RESULTS

The highest rates were seen at Andalucia (south), Levante (east) and the oversea provinces (Balearic [Mediterranean] and Canary Islands [Atlantic]). There were considerable geographical differences in mortality rates. Time trends showed a decrease in men in 27 provinces and a decrease in women in 12 provinces. Overall mortality trends decreased in the last 19 years in Spain.

CONCLUSIONS

Although the general trend is toward a decrease, there are differences between provinces in Spain. The previously reported North-South gradient and regional discrepancies were confirmed.

[Myocardial infarction. Population case-fatality in seven Spanish autonomous communities: the IBERICA Study]

BACKGROUND AND OBJECTIVE

The magnitude of the problem of myocardial infarction (MI) is better understood by assessing the population case-fatality than by analyzing only the number of patients attending hospitals.

PATIENTS AND METHOD

Our data come from the IBERICA Study (Investigation, Specific Search and Registry of Acute Myocardial Ischemic Syndrome). Twenty eight-day MI population case-fatality is described in the population aged 25 to 74 years during 1997 and 1998 in the following Spanish autonomous communities: Castilla-La Mancha (Toledo and Albacete), Catalonia (Girona), Valencia Community (Valencia), Balearic Islands (Majorca), Murcia, Navarra and Basque Country. The relationship between case-fatality and other variables such as sex, age and geographic area is also analyzed.

RESULTS

A total of 10,660 MI cases were registered, 4,106 of whom died within the period of 28 days following the onset of symptoms (38.5%; CI 95%, 37.6-39.4%). The overall case-fatality was 37.0% (CI 95%, 35.9-38.0%) in men and 44.3% (CI 95%, 42.3-46.4%) in women. Death occurred out of hospitals in 2,869 (69.9%) cases. An increased case-fatality in women was associated with a higher in-hospital case-fatality (45% higher than men). The proportion of patients who died before reaching a hospital was similar in both genders. Classical symptoms of MI were more common among men than women (82.7% vs. 77.6%, p < 0,001). The interval between symptoms' onset and hospitalization was 30 minute longer among hospitalized women as compared with men (p < 0,001).

CONCLUSIONS

Population MI case-fatality is high in the seven Spanish autonomous communities studied. Approximately 2 out of 3 deaths occur without patients being able to reach a hospital. These results emphasize the importance of primary and secondary prevention measures and the necessity to design ready-access systems to defibrillation and resuscitation manoeuvres for patients with cardiopulmonary arrest.