1
|
Lopez-de-Sa E. Acute coronary occlusion in non-STEMI: If you change the way you look at things, the things you look at change. Int J Cardiol 2020; 322:49-50. [PMID: 33091522 DOI: 10.1016/j.ijcard.2020.10.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Accepted: 10/15/2020] [Indexed: 10/23/2022]
Affiliation(s)
- Esteban Lopez-de-Sa
- Cardiology Department, Hospital Universitario La Paz, IdiPaz, CIBERCV, Paseo de la Castellana, 261, 28046 Madrid, Spain.
| |
Collapse
|
2
|
López-Sendón J, González-Juanatey JR, Pinto F, Cuenca Castillo J, Badimón L, Dalmau R, González Torrecilla E, López-Mínguez JR, Maceira AM, Pascual-Figal D, Pomar Moya-Prats JL, Sionis A, Zamorano JL. Indicadores de calidad en cardiología. Principales indicadores para medir la calidad de los resultados (indicadores de resultados) y parámetros de calidad relacionados con mejores resultados en la práctica clínica (indicadores de práctica asistencial). INCARDIO (Indicadores de Calidad en Unidades Asistenciales del Área del Corazón): Declaración de posicionamiento de consenso de SEC/SECTCV. CIRUGIA CARDIOVASCULAR 2015. [DOI: 10.1016/j.circv.2015.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
|
3
|
López-Sendón J, González-Juanatey JR, Pinto F, Cuenca Castillo J, Badimón L, Dalmau R, González Torrecilla E, López-Mínguez JR, Maceira AM, Pascual-Figal D, Pomar Moya-Prats JL, Sionis A, Zamorano JL. Indicadores de calidad en cardiología. Principales indicadores para medir la calidad de los resultados (indicadores de resultados) y parámetros de calidad relacionados con mejores resultados en la práctica clínica (indicadores de práctica asistencial). INCARDIO (Indicadores de Calidad en Unidades Asistenciales del Área del Corazón): Declaración de posicionamiento de consenso de SEC/SECTCV. Rev Esp Cardiol 2015. [DOI: 10.1016/j.recesp.2015.07.005] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
|
4
|
López-Sendón J, González-Juanatey JR, Pinto F, Cuenca Castillo J, Badimón L, Dalmau R, González Torrecilla E, López-Mínguez JR, Maceira AM, Pascual-Figal D, Pomar Moya-Prats JL, Sionis A, Zamorano JL. 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. ACTA ACUST UNITED AC 2015; 68:976-995.e10. [PMID: 26315766 DOI: 10.1016/j.rec.2015.07.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Accepted: 07/21/2015] [Indexed: 02/06/2023]
Abstract
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.
Collapse
Affiliation(s)
- José López-Sendón
- Servicio de Cardiología, Hospital Universitario La Paz, IdiPaz, Madrid, Spain.
| | - José Ramón González-Juanatey
- Sociedad Española de Cardiología, Madrid, Spain; Servicio de Cardiología, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, A Coruña, Spain
| | - Fausto Pinto
- European Society of Cardiology; Department of Cardiology, University Hospital Santa Maria, Lisbon, Portugal
| | - José Cuenca Castillo
- Sociedad Española de Cirugía Torácica-Cardiovascular; Servicio de Cirugía Cardiaca, Complexo Hospitalario Universitario de A Coruña, A Coruña, Spain
| | - Lina Badimón
- Centro de Investigación Cardiovascular (CSIC-ICCC), Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Regina Dalmau
- Unidad de Rehabilitación Cardiaca, Servicio de Cardiología, Hospital Universitario La Paz, IdiPaz, Madrid, Spain
| | - Esteban González Torrecilla
- Unidad de Electrofisiología y Arritmias, Servicio de Cardiología, Hospital Universitario Gregorio Marañón, Madrid, Spain
| | - José Ramón López-Mínguez
- Unidad de Cardiología intervencionista, Servicio de Cardiología, Hospital Infanta Crsitina, Badajoz, Spain
| | - Alicia M Maceira
- Unidad de Imagen Cardiaca, Servicio de Cardiología, ERESA Medical Center, Valencia, Spain
| | - Domingo Pascual-Figal
- Servicio de Cardiología, Hospital Universitario Virgen de la Arrixaca, El Palmar, Murcia, Spain
| | | | - Alessandro Sionis
- Unidad de Cuidados Intensivos Cardiológicos, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - José Luis Zamorano
- Servicio de Cardiología, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | | |
Collapse
|
5
|
Knezevic B, Vasiljevic Z, Music L, Krivokapic L, Ljubic V, Tomic SC, Omer S, Radojicic S, Radoman C, Rajovic G, Riger L, Saranovic M, Velickovic M, Rajic D, Zivkovic S, Lasica R, Bankovic-Milenkovic N, Ljubica D, Jovanovic D, Jelica M, Radakovic G, Zdravkovic M, Ricci B, Manfrini O, Martelli I, Koller A, Badimon L, Bugiardini R. Management of heart failure complicating acute coronary syndromes in Montenegro and Serbia. Eur Heart J Suppl 2014. [DOI: 10.1093/eurheartj/sut014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
|
6
|
Ekelund U, Akbarzadeh M, Khoshnood A, Björk J, Ohlsson M. Likelihood of acute coronary syndrome in emergency department chest pain patients varies with time of presentation. BMC Res Notes 2012; 5:420. [PMID: 22871081 PMCID: PMC3514348 DOI: 10.1186/1756-0500-5-420] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2012] [Accepted: 04/30/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There is a circadian and circaseptal (weekly) variation in the onset of acute coronary syndrome (ACS). The aim of this study was to elucidate whether the likelihood of ACS among emergency department (ED) chest pain patients varies with the time of presentation. METHODS All patients presenting to the Lund ED at Skåne University Hospital with chest pain or discomfort during 2006 and 2007 were retrospectively included. Age, sex, arrival time at the ED and discharge diagnose (ACS or not) were obtained from the electronic medical records. RESULTS There was a clear but moderate circadian variation in the likelihood of ACS among presenting chest pain patients, the likelihood between 8 and 10 am being almost twice as high as between 6 and 8 pm. This was mainly explained by a variation in the ACS likelihood in females and patients under 65 years, with no significant variation in males and patients over 65 years. There was no significant circaseptal variation in the ACS likelihood. CONCLUSIONS Our results indicate that there is a circadian variation in the likelihood of ACS among ED chest pain patients, and suggest that physicians should consider the time of presentation to the ED when determining the likelihood of ACS.
Collapse
Affiliation(s)
- Ulf Ekelund
- Department of Emergency Medicine, Skåne University Hospital, Lund, SE-221 85, Sweden.
| | | | | | | | | |
Collapse
|
7
|
Killip classification in patients with acute coronary syndrome: insight from a multicenter registry. Am J Emerg Med 2012; 30:97-103. [DOI: 10.1016/j.ajem.2010.10.011] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2010] [Revised: 10/09/2010] [Accepted: 10/10/2010] [Indexed: 11/17/2022] Open
|
8
|
Bossaert L, O'Connor RE, Arntz HR, Brooks SC, Diercks D, Feitosa-Filho G, Nolan JP, Hoek TLV, Walters DL, Wong A, Welsford M, Woolfrey K. Part 9: Acute coronary syndromes: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Resuscitation 2011; 81 Suppl 1:e175-212. [PMID: 20959169 DOI: 10.1016/j.resuscitation.2010.09.001] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
|
9
|
O'Connor RE, Bossaert L, Arntz HR, Brooks SC, Diercks D, Feitosa-Filho G, Nolan JP, Vanden Hoek TL, Walters DL, Wong A, Welsford M, Woolfrey K. Part 9: Acute coronary syndromes: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation 2010; 122:S422-65. [PMID: 20956257 DOI: 10.1161/circulationaha.110.985549] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
|
10
|
Ferreira-González I, Permanyer Miralda G, Heras M, Ribera A, Marsal JR, Cascant P, Arós F, Bueno H, Sánchez PL, Cuñat J, Civeira E, Marrugat J. Prognosis and management of patients with acute coronary syndrome and polyvascular disease. Rev Esp Cardiol 2010; 62:1012-21. [PMID: 19712622 DOI: 10.1016/s1885-5857(09)73267-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
INTRODUCTION AND OBJECTIVES To assess prognosis and patterns of care in patients with acute coronary syndrome and peripheral arterial disease (PAD), cerebrovascular disease or both (i.e., polyvascular disease) in everyday clinical practice. METHODS We used data from the MASCARA acute coronary syndrome registry for 2004 and 2005. Patients were stratified according to the presence of PAD, cerebrovascular disease, neither, or both. In-hospital management, treatment at discharge and outcomes at 6 months were recorded. RESULTS Of 6745 patients, 597 (8.85%) had PAD, 392 (5.8%) had cerebrovascular disease, 131 (1.94%) had both and 5625 (83.4%) had neither. Patients with polyvascular disease had more extensive coronary disease, but less often received regularly recommended treatment (e.g., 75% with PAD received aspirin at discharge versus 84% of those without). In-hospital and 6-month mortality were significantly higher (P< .001) in patients with PAD (9.1% and 24.5%, respectively) or cerebrovascular disease (9.2% and 22.4%, respectively) or, especially, both (16.0% and 29.8%, respectively) than in those free from these conditions (4.8% and 10.8%, respectively). Cerebrovascular disease, PAD and their combination were all independently associated with in-hospital and 6-month mortality: for cerebrovascular disease, the odds ratio (OR) for mortality at 6 months was 1.45 (95% confidence interval [CI], 1.10-2.02); for PAD, it was 1.88 (95% CI, 1.45-2.40); and for both combined, 1.88 (95% CI, 1.17-3.00). CONCLUSIONS Patients with acute coronary syndrome and concomitant arterial disease had more extensive coronary artery disease and poorer outcomes, both inhospital and at 6 months, but frequently did not receive regularly recommended treatment.
Collapse
|
11
|
Impact of metabolic syndrome on future cardiovascular events in patients with first acute myocardial infarction. Coron Artery Dis 2009; 20:370-5. [PMID: 19609207 DOI: 10.1097/mca.0b013e32832ed31e] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
The prevalence of metabolic syndrome (MetS) is increasing worldwide and patients with MetS have increased risk of cardiovascular events. Recent studies in different populations showed higher prevalences of MetS in patients with acute myocardial infarction (MI) and identified MetS as an independent predictor of future cardiac events. This study sought to determine the prevalence of MetS in patients with acute MI and investigate the impact of MetS on adverse cardiovascular events after acute MI. One hundred and eighty-eight patients (155 men, 33 women) admitted with first acute MI were enrolled into the study. Of the total patients, 80 (42.6%) patients were diagnosed with MetS according to the National Cholesterol Education Program Adult Treatment Panel III criteria with modifications for high blood pressure and high fasting plasma glucose. Kaplan-Meier curves showed that the cumulative event-free survival rates did not differ between the patients with and without MetS during a median follow-up period of 27.7 (min:14, max:42) months (P>0.05). On multivariate Cox regression analysis controlling for hypertension, diabetes mellitus, glucose, MetS, and waist-to-hip ratio, there was no association between the major adverse coronary events and the presence of MetS (P>0.05), whereas Killip class (relative risk: 2.853, 95% confidence interval: 1.606-5.070; P<0.001) was identified as the only independent predictor of long-term cardiovascular outcomes. This study shows that MetS has no effect on long-term prognosis after MI. However, Killip class was identified as an independent predictor of major cardiac events.
Collapse
|
12
|
|
13
|
Moussa ID, Jaff MR, Mehran R, Gray W, Dangas G, Lazic Z, Moses JW. Prevalence and prediction of previously unrecognized peripheral arterial disease in patients with coronary artery disease: The peripheral arterial disease in Interventional Patients Study. Catheter Cardiovasc Interv 2009; 73:719-24. [DOI: 10.1002/ccd.21969] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
|
14
|
San Román Terán C, Guijarro Merino R, Guil García M, Villar Jiménez J, Martín Pérez M, Gómez Huelgas R. Analysis of 27,248 hospital discharges for heart failure: a study of an administrative database 1998-2002. Rev Clin Esp 2008; 208:281-7. [DOI: 10.1157/13123187] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
|
15
|
Prognostic value of the Thrombolysis in Myocardial Infarction risk score in a unselected population with chest pain. Construction of a new predictive model. Am J Emerg Med 2008; 26:439-45. [DOI: 10.1016/j.ajem.2007.07.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2007] [Revised: 07/20/2007] [Accepted: 07/21/2007] [Indexed: 11/18/2022] Open
|
16
|
Sanchis J, Bodí V, Núñez J, Bosch X, Loma-Osorio P, Mainar L, Santas E, Miñana G, Robles R, Llàcer A. Limitations of clinical history for evaluation of patients with acute chest pain, non-diagnostic electrocardiogram, and normal troponin. Am J Cardiol 2008; 101:613-7. [PMID: 18308008 DOI: 10.1016/j.amjcard.2007.10.024] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2007] [Revised: 10/02/2007] [Accepted: 10/02/2007] [Indexed: 12/22/2022]
Abstract
Decision making and risk stratification for patients with acute chest pain, nondiagnostic electrocardiogram results, and normal troponin levels are challenging. The aim of this study was to optimize the clinical history for the evaluation of these patients. A total of 1,011 patients presenting to an emergency department were included. The following data were collected: clinical presentation (pain characteristics and number of pain episodes), coronary risk factors, previous ischemic heart disease, and extracardiac vascular disease (peripheral artery disease, stroke, or creatinine >1.4 mg/dl). Two different predictive models were calculated according to the end points: model 1 for 1-year major events (death or myocardial infarction) and model 2 for 30-day cardiac events (major events or revascularization). For 1-year major events, model 1 showed optimal discrimination capacity (C statistic = 0.80), which was significantly better than that of model 2 (C statistic = 0.77, p = 0.04). With respect to 30-day cardiac events, however, discrimination was lower in the 2 models, without differences between them (C statistic = 0.74 vs 0.75, p = NS). Using model 1, a large low-risk subgroup with <3 predictive variables could be defined, including 442 patients (44% of the total population) with a 1.4% rate of 1-year major events; however, the incidence of 30-day cardiac events (8%) was not negligible, mainly because of revascularizations. In conclusion, in patients with acute chest pain of uncertain coronary origin, clinical predictive models afford good risk stratification for long-term major events. Short-term outcomes, including revascularization, however, are not predicted as well. Therefore, ancillary tools, such as noninvasive stress tests, should be implemented for decision making at initial hospitalization or discharge.
Collapse
Affiliation(s)
- Juan Sanchis
- Servei de Cardiologia, Hospital Clínic Universitari, Universitat de València, València, Spain.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
17
|
Sanchis J, Bodí V, Núñez J, Bosch MJ, Bertomeu-González V, Consuegra L, Santas E, Gómez C, Bosch X, Chorro FJ, Llàcer A. A practical approach with outcome for the prognostic assessment of non-ST-segment elevation chest pain and normal troponin. Am J Cardiol 2007; 99:797-801. [PMID: 17350368 DOI: 10.1016/j.amjcard.2006.10.042] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2006] [Revised: 10/09/2006] [Accepted: 10/09/2006] [Indexed: 12/22/2022]
Abstract
Patients with non-ST-elevation chest pain constitute a heterogeneous population. Our aim is to compare the outcome of patients with chest pain, non-ST-segment deviation, and normal troponin, categorized using a risk score, with that of patients with ST depression or troponin increase. A total of 1,449 patients with non-ST-elevation chest pain were evaluated. A validated risk score (using pain characteristics and risk factors) was applied to patients without ST depression or troponin increase. Accordingly, 4 risk categories were defined: group 1, no troponin increase, no ST depression, and risk score <3 points (n = 633); group 2, no troponin increase, no ST depression, but risk score > or = 3 points (n = 158); group 3, no troponin increase, ST depression (n = 106); and group 4, troponin increase (n = 552). Median follow-up was 26 months, and the end point was death or myocardial infarction. Group 1 experienced fewer events at 30 days (1.7%, p = 0.0001) and long-term follow-up (9.4%, p = 0.0001) than groups 2 (10.8% and 26%), 3 (6.6% and 30%), and 4 (9.5% and 25%). Kaplan-Meier curves overlapped among groups 2, 3, and 4, whereas group 1 showed a flatter curve (p = 0.0001). Using multivariate analysis, risk group (group 1 vs remaining groups) predicted 30-day (p = 0.0003) and long-term (p = 0.0001) outcome. There were no differences among groups 2, 3, and 4. In conclusion, application of a risk score to patients without troponin increase or ST deviation identified a high-risk group with prognosis similar to that of patients with troponin increase or ST depression and affords a practical classification for the full spectrum of non-ST-elevation chest pain.
Collapse
Affiliation(s)
- Juan Sanchis
- Servei de Cardiologia, Hospital Clínic Universitari, Universitat de València, Barcelona, Spain.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
18
|
Martinez-Rumayor A, Januzzi JL. Non-ST Segment Elevation Acute Coronary Syndromes: A Comprehensive Review. South Med J 2006; 99:1103-10. [PMID: 17100031 DOI: 10.1097/01.smj.0000215764.22650.29] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
As the non-ST segment elevation acute coronary syndromes (NSTEACS) include unstable angina pectoris (UAP) and the non-ST segment elevation myocardial infarction (NSTEMI), acute diagnosis and risk stratification can often prove challenging. This review will cover guidelines and strategies for risk assessment, contemporary approaches to acute patient management as well as recommendations for timing of specialist referral.
Collapse
Affiliation(s)
- Abelardo Martinez-Rumayor
- Department of Medicine and Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston MA 02114, USA
| | | |
Collapse
|
19
|
Björk J, Forberg JL, Ohlsson M, Edenbrandt L, Ohlin H, Ekelund U. A simple statistical model for prediction of acute coronary syndrome in chest pain patients in the emergency department. BMC Med Inform Decis Mak 2006; 6:28. [PMID: 16824205 PMCID: PMC1559601 DOI: 10.1186/1472-6947-6-28] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2005] [Accepted: 07/06/2006] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Several models for prediction of acute coronary syndrome (ACS) among chest pain patients in the emergency department (ED) have been presented, but many models predict only the likelihood of acute myocardial infarction, or include a large number of variables, which make them less than optimal for implementation at a busy ED. We report here a simple statistical model for ACS prediction that could be used in routine care at a busy ED. METHODS Multivariable analysis and logistic regression were used on data from 634 ED visits for chest pain. Only data immediately available at patient presentation were used. To make ACS prediction stable and the model useful for personnel inexperienced in electrocardiogram (ECG) reading, simple ECG data suitable for computerized reading were included. RESULTS Besides ECG, eight variables were found to be important for ACS prediction, and included in the model: age, chest discomfort at presentation, symptom duration and previous hypertension, angina pectoris, AMI, congestive heart failure or PCI/CABG. At an ACS prevalence of 21% and a set sensitivity of 95%, the negative predictive value of the model was 96%. CONCLUSION The present prediction model, combined with the clinical judgment of ED personnel, could be useful for the early discharge of chest pain patients in populations with a low prevalence of ACS.
Collapse
Affiliation(s)
- Jonas Björk
- Competence Center for Clinical Research, Lund University Hospital, Lund, Sweden.
| | | | | | | | | | | |
Collapse
|
20
|
Froehlich JB, Mukherjee D, Avezum A, Budaj A, Kline-Rogers EM, López-Sendón J, Allegrone J, Eagle KA, Mehta RH, Goldberg RJ. Association of peripheral artery disease with treatment and outcomes in acute coronary syndromes. The Global Registry of Acute Coronary Events (GRACE). Am Heart J 2006; 151:1123-8. [PMID: 16644349 DOI: 10.1016/j.ahj.2005.11.005] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2005] [Accepted: 11/16/2005] [Indexed: 11/20/2022]
Abstract
BACKGROUND National guidelines recommend the use of secondary prevention modalities for patients with peripheral artery disease (PAD) and coronary artery disease. The effect of prior PAD on the treatment and outcomes of patients with acute coronary syndromes (ACS), however, is not well characterized. The objectives of this study were to assess treatment practices and hospital outcomes in patients with ACS and prior PAD. METHODS Data were analyzed from 41,108 patients aged > or =18 years with ACS and enrolled in the large multinational GRACE between 1999 and 2004. RESULTS Of the 41,108 patients, 4003 (9.7%) had prior PAD. Patients with PAD were older, more likely to be men, to have a variety of prior comorbidities, and to present with non-ST-segment elevation myocardial infarction and a higher Killip class than patients without PAD. Patients with PAD were less likely to be treated with effective cardiac medications than patients without PAD. At the time of hospital presentation, patients with prior PAD had low rates of use of beneficial cardiac medications, including angiotensin-converting enzyme inhibitors, aspirin, beta-blockers, and lipid-lowering agents. Patients with PAD were significantly more likely to experience the composite hospital end point (death, shock, recurrent angina, stroke) than patients without prior PAD (adjusted OR 1.17; 95% CI 1.08-1.26). CONCLUSIONS Patients with prior PAD received less aggressive treatment with proven cardiac medications during hospitalization for an ACS than patients without PAD. Utilization of beneficial medical therapies in patients with PAD before hospitalization with ACS was also less than optimal. Given the poorer hospital outcomes in patients with PAD, our findings suggest considerable opportunity to improve care for these high-risk patients.
Collapse
|
21
|
Heras M, Bueno H, Bardají A, Fernández-Ortiz A, Martí H, Marrugat J. Magnitude and consequences of undertreatment of high-risk patients with non-ST segment elevation acute coronary syndromes: insights from the DESCARTES Registry. Heart 2006; 92:1571-6. [PMID: 16644860 PMCID: PMC1861221 DOI: 10.1136/hrt.2005.079673] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- M Heras
- Department of Cardiology of Hospital Clinic, IDIBAPS, University of Barcelona, Barcelona, Spain.
| | | | | | | | | | | |
Collapse
|
22
|
|
23
|
Sanchis J, Bodí V, Núñez J, Bertomeu-González V, Gómez C, Bosch MJ, Consuegra L, Bosch X, Chorro FJ, Llàcer A. New Risk Score for Patients With Acute Chest Pain, Non-ST-Segment Deviation, and Normal Troponin Concentrations. J Am Coll Cardiol 2005; 46:443-9. [PMID: 16053956 DOI: 10.1016/j.jacc.2005.04.037] [Citation(s) in RCA: 106] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2005] [Revised: 03/29/2005] [Accepted: 04/13/2005] [Indexed: 11/28/2022]
Abstract
OBJECTIVES The purpose of this research was to develop a risk score for patients with chest pain, non-ST-segment deviation electrocardiogram (ECG), and normal troponin levels. BACKGROUND Prognosis assessment in this population remains a challenge. METHODS A total of 646 consecutive patients were evaluated by clinical history (risk factors and chest pain score according to pain characteristics), ECG, and early exercise testing. ST-segment deviation and troponin elevation were exclusion criteria. The primary end point was mortality or myocardial infarction at one year. The secondary end point was mortality, myocardial infarction, or urgent revascularization at 14 days (similar to the Thrombolysis In Myocardial Infarction [TIMI] risk score). RESULTS Primary and secondary end point rates were 6.7% and 5.4%. A risk score was constructed using the variables related to the primary end point: chest pain score > or =10 points (hazard ratio [HR] = 2.5; 1 point), > or =2 pain episodes in last 24 h (HR = 2.2; 1 point), age > or =67 years (HR = 2.3; 1 point), insulin-dependent diabetes mellitus (HR = 4.2; 2 points), and prior percutaneous transluminal coronary angioplasty (HR = 2.2; 1 point). Patients were classified into five categories of risk (p = 0.0001): 0 points, 0% event rate; 1 point, 3.1%; 2 points, 5.4%; 3 points, 17.6%; > or =4 points, 29.6%. The accuracy of the score was greater than that of the TIMI risk score for the primary (C index of 0.78 vs. 0.66, p = 0.0002) and secondary (C index of 0.70 vs. 0.66, p = 0.1) end points. CONCLUSIONS Patients presenting with chest pain despite no ST-segment deviation or troponin elevation show a non-negligible rate of events at one year. A risk score derived from this specific population allows more accurate stratification than when using the TIMI risk score.
Collapse
Affiliation(s)
- Juan Sanchis
- Servei de Cardiologia, Hospital Clínic Universitari, Universitat de València, València, Spain.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
24
|
Sanchis J, Bodí V, Llácer A, Núñez J, Consuegra L, Bosch MJ, Bertomeu V, Ruiz V, Chorro FJ. Risk stratification of patients with acute chest pain and normal troponin concentrations. Heart 2005; 91:1013-8. [PMID: 16020586 PMCID: PMC1769052 DOI: 10.1136/hrt.2004.041673] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/25/2004] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVE To investigate the outcome of patients with acute chest pain and normal troponin concentrations. DESIGN Prospective cohort design. SETTING Single centre study in a teaching hospital in Spain. PATIENTS 609 consecutive patients with chest pain evaluated in the emergency department by clinical history (risk factors and a chest pain score according to pain characteristics), ECG, and early (< 24 hours) exercise testing for low risk patients with physical capacity (n = 283, 46%). All had normal troponin concentrations after serial determination. MAIN OUTCOME MEASURES Myocardial infarction or cardiac death during six months of follow up. RESULTS 29 events were detected (4.8%). No patient with a negative early exercise test (n = 161) had events versus the 6.9% event rate in the remaining patients (p = 0.0001). Four independent predictors were found: chest pain score > or = 11 points (odds ratio (OR) 2.4, 95% confidence interval (CI) 1.1 to 5.5, p = 0.04), diabetes mellitus (OR 2.3, 95% CI 1.1 to 4.7, p = 0.03), previous coronary surgery (OR 3.1, 95% CI 1.3 to 7.6, p = 0.01), and ST segment depression (OR 2.8, 95% CI 1.3 to 6.3, p = 0.003). A risk score proved useful for patient stratification according to the presence of 0-1 (2.7% event rate), 2 (10.2%, p = 0.008), and 3-4 predictors (29.2%, p = 0.0001). CONCLUSIONS A negative troponin result does not assure a good prognosis for patients coming to the emergency room with chest pain. Early exercise testing and clinical data should be carefully evaluated for risk stratification.
Collapse
Affiliation(s)
- J Sanchis
- Servei de Cardiologia, Hospital Clínic Universitari, Valencia, Spain.
| | | | | | | | | | | | | | | | | |
Collapse
|
25
|
García Almagro FJ, Gimeno JR, Villegas M, Muñoz L, Sánchez E, Teruel F, Hurtado J, González J, Antolinos MJ, Pascual D, Valdés M. Use of a Coronary Risk Score (the TIM I Risk Score) in a Non–Selected Patient Population Assessed for Chest Pain at an Emergency Department. ACTA ACUST UNITED AC 2005. [DOI: 10.1016/s1885-5857(06)60505-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
|
26
|
García Almagro FJ, Gimeno JR, Villegas M, Muñoz L, Sánchez E, Teruel F, Hurtado J, González J, Antolinos MJ, Pascual D, Valdés M. Aplicación de una puntuación de riesgo coronario (TIMI Risk Score) en una población no seleccionada de pacientes que consultan por dolor torácico en un servicio de urgencias. Rev Esp Cardiol 2005. [DOI: 10.1157/13077228] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
|
27
|
Sanchis J, Bodí V, Llácer A, Facila L, Pellicer M, Bertomeu V, Núñez J, Ruiz V, Chorro FJ. [Emergency room risk stratification of patients with chest pain without ST segment elevation]. Rev Esp Cardiol 2004; 56:955-62. [PMID: 14563289 DOI: 10.1016/s0300-8932(03)76992-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To investigate the prognostic factors in patients who come to the emergency room with chest pain but without ST segment elevation. PATIENTS AND METHOD 743 consecutive patients were evaluated by recording clinical history, electrocardiogram and troponin I determination, and early (<24 h) exercise testing was done for the low-risk subgroup of patients (n=203). All patients were followed during 3 months for major events (acute myocardial infarction or death). RESULTS Major events occurred in 71 patients (9.6%). Multivariate analysis (C statistic=0.79; 95% CI 0.73-0.84; p=0.0001) identified the following predictors: age > or =72 years (OR=1.7; 95% CI, 1.0-2.9; p=0.05), insulin-dependent diabetes mellitus (OR=2.9; 95% CI, 1.5-5.4; p=0.001), previous ischemic heart disease (OR=1.9; 95% CI, 1.1-3.2; p=0.02), ST depression (OR=2.1; 95% CI, 1.2-3.8; p=0.01) and troponin I elevation (OR=2.9; 95% CI, 1.5-5.3; p=0.001). These five predictors were used to construct a risk score based on their odds ratios, which allowed event rate stratification by quartiles of the score: 0-2 points (1.6% events), 3-4 points (8.1% events), 5-7 points (11.9% events) and > or =8 points (26.2% events); p=0.0001. No patient with negative findings in the early exercise testing had major events. CONCLUSIONS In patients with chest pain, the combination of clinical, electrocardiographic and biochemical data available on admission to the emergency service allows rapid prognostic stratification. Early exercise testing is advisable for the final stratification of low risk patients.
Collapse
Affiliation(s)
- Juan Sanchis
- Servei de Cardiologia, Hospital Clínic Universitari, Universitat de València, Valencia, España.
| | | | | | | | | | | | | | | | | |
Collapse
|
28
|
Bosch X, Verbal F, López de Sá E, Miranda-Guardiola F, Bórquez E, Bethencourt A, López-Sendón JL. Diferencias en el tratamiento y la evolución clínica de los pacientes con síndrome coronario agudo sin elevación del segmento ST en función del servicio clínico de ingreso. Rev Esp Cardiol 2004. [DOI: 10.1016/s0300-8932(04)77105-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
29
|
Piombo AC, Gagliardi JA, Guetta J, Fuselli J, Salzberg S, Fairman E, Bertolasi C. A new scoring system to stratify risk in unstable angina. BMC Cardiovasc Disord 2003; 3:8. [PMID: 12930562 PMCID: PMC194644 DOI: 10.1186/1471-2261-3-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2002] [Accepted: 08/20/2003] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND We performed this study to develop a new scoring system to stratify different levels of risk in patients admitted to hospital with a diagnosis of unstable angina (UA), which is a complex syndrome that encompasses different outcomes. Many prognostic variables have been described but few efforts have been made to group them in order to enhance their individual predictive power. METHODS In a first phase, 473 patients were prospectively analyzed to determine which factors were significantly associated with the in-hospital occurrence of refractory ischemia, acute myocardial infarction (AMI) or death. A risk score ranging from 0 to 10 points was developed using a multivariate analysis. In a second phase, such score was validated in a new sample of 242 patients and it was finally applied to the entire population (n = 715). RESULTS ST-segment deviation on the electrocardiogram, age > or = 70 years, previous bypass surgery and troponin T > or = 0.1 ng/mL were found as independent prognostic variables. A clear distinction was shown among categories of low, intermediate and high risk, defined according to the risk score. The incidence of the triple end-point was 6 %, 19.2 % and 44.7 % respectively, and the figures for AMI or death were 2 %, 11.4 % and 27.6 % respectively (p < 0.001). CONCLUSIONS This new scoring system is simple and easy to achieve. It allows a very good stratification of risk in patients having a clinical diagnosis of UA. They may be divided in three categories, which could be of help in the decision-making process.
Collapse
Affiliation(s)
- Alfredo C Piombo
- D.I.C. (Development and Investigation in Cardiology) Group, Buenos Aires, Argentina.
| | | | | | | | | | | | | |
Collapse
|
30
|
Bosch X, López De Sá E, López Sendón J, Aboal J, Miranda-Guardiola F, Bethencourt A, Rubio R, Moreno R, Martín Jadraque L, Roldán I, Calviño R, Valle V, Malpartida F. [Clinical characteristics, prognosis, and variability in the management of non-ST-segment elevation acute coronary syndromes. Data from the PEPA registry]. Rev Esp Cardiol 2003; 56:346-53. [PMID: 12689568 DOI: 10.1016/s0300-8932(03)76877-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
OBJECTIVES To assess the clinical characteristics and inter-hospital variability in the treatment and prognosis of patients with non-ST-segment elevation acute coronary syndromes. PATIENTS AND METHOD Data from the PEPA study, a prospective registry that enrolled 4,115 patients in 18 Spanish hospitals, were analyzed. RESULTS The mean age of the patients enrolled was 65 years, 33% were women, and 26% had diabetes. Large differences were observed in the clinical profile of patients admitted to different centers, especially relative the history of previous disease, prior coronary revascularization, and co-morbidity. Antiplatelet treatment was used in 93% of patients, heparin in 45%, beta-blockers in 42%, nitrates in 67%, and calcium antagonists in 46%. During hospitalization, exercise stress testing was performed in 37% of patients, coronary angiography in 32%, coronary angioplasty in 9%, and coronary surgery in 4%. Inter-hospital variability was minimal for the use of antiplatelet agents, wide for the use of heparin and beta-blockers, and huge for the use of revascularization procedures. Mortality and the incidence of death or myocardial infarction were 2.6% and 4.4% during hospitalization, and 4.6% and 8% at 3 months, with wide inter-hospital variability. These differences were not significant once adjusted for clinical characteristics and the treatment received at admission. CONCLUSIONS Patients with non-ST-segment elevation acute coronary syndromes represent an heterogeneous group with a high incidence of complications. Pharmacologic and, especially, invasive treatment varies widely in different hospitals. These results underline the importance of correct initial risk stratification and uniform treatment following the recommendations of clinical guidelines.
Collapse
Affiliation(s)
- Xavier Bosch
- Servicio de Cardiología. Institut de Malalties Cardiovasculars. Hospital Clínic. Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS). Barcelona. España.
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
31
|
Carlos Kaski J, Cruz-Fernández JM, Fernández-Bergés D, García-Moll X, Martín Jadraque L, Mostaza J, López García-Aranda V, Ramón González Juanatey J, Castro Beiras A, Martín Luengo C, Alonso García Á, López-Bescós L, Marcos Gómez G. Marcadores de inflamación y estratificación de riesgo en pacientes con síndrome coronario agudo: diseño del estudio SIESTA (Systemic Inflammation Evaluation in patients with non-ST segment elevation Acute coronary syndromes). Rev Esp Cardiol (Engl Ed) 2003. [DOI: 10.1016/s0300-8932(03)76883-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
|