Relationship of therapeutic improvements and 28-day case fatality in patients hospitalized with acute myocardial infarction between 1978 and 1993 in the REGICOR study, Gerona, Spain. The REGICOR Investigators

Trends in Short- and Long-Term ST-Segment-Elevation Myocardial Infarction Prognosis Over 3 Decades: A Mediterranean Population-Based ST-Segment-Elevation Myocardial Infarction Registry

Background Coronary artery disease remains a major cause of death despite better outcomes of ST-segment-elevation myocardial infarction (STEMI). We aimed to analyze data from the Ruti-STEMI registry of in-hospital, 28-day, and 1-year events in patients with STEMI over the past 3 decades in Catalonia, Spain, to assess trends in STEMI prognosis. Methods and Results Between February 1989 and December 2017, a total of 7589 patients with STEMI were admitted consecutively. Patients were grouped into 5 periods: 1989 to 1994 (period 1), 1995 to 1999 (period 2), 2000 to 2004 (period 3), 2005 to 2009 (period 4), and 2010 to 2017 (period 5). We used Cox regression to compare 28-day and 1-year STEMI mortality and in-hospital complication trends across these periods. Mean patient age was 61.6±12.6 years, and 79.3% were men. The 28-day all-cause mortality declined from period 1 to period 5 (10.4% versus 6.0%; P<0.001), with a 40% reduction after multivariable adjustment (hazard ratio [HR], 0.6; 95% CI, 0.46-0.80; P<0.001). One-year all-cause mortality declined from period 1 to period 5 (11.7% versus 9.0%; P=0.001), with a 24% reduction after multivariable adjustment (HR, 0.76; 95% CI, 0.60-0.98; P=0.036). A significant temporal reduction was observed for in-hospital complications including postinfarct angina (-78%), ventricular tachycardia (-57%), right ventricular dysfunction (-48%), atrioventricular block (-45%), pericarditis (-63%), and free wall rupture (-53%). Primary ventricular fibrillation showed no significant downslope trend. Conclusions In-hospital STEMI complications and 28-day and 1-year mortality rates have dropped markedly in the past 30 years. Reducing ischemia-driven primary ventricular fibrillation remains a major challenge.

[Trend of lipid profile in general population from Caceres Health Area]

INTRODUCTION AND OBJECTIVES

Dyslipidaemias are a modifiable cardiovascular risk factor. The aim of our study was to analyse lipid profile in general population, prevalence, and trend in five years.

METHODS

From January 2010 to December 2014, all biochemical controls from Primary Care in 18 years-old adults were analysed. We used as reference for lipid levels those stablished for the European Society Cardiology and Hypertension. When several controls from same patient were found, the best and worst levels were used for prevalence.

RESULTS

304.523 controls were included from 97.470 patients (mean age 53.4±19.4 years, 57.2% were women). Mean levels of total cholesterol, LDL-c, HDL-c and triglycerides were 193.2±38.7mg/dL, 114.9±33.6mg/dL, 56.9±15.4mg/dL and 113.2±78.1mg/dL, respectively. Prevalence of hypercholesterolemia, high LDL-c, low HDL-c and hypertriglyceridemia, in the best and worst levels, were 33.9% vs. 63.4%, 31.7% vs. 59.1%, 11.2% vs 23.9% and 9.9% vs. 27.5%. Between 2010 and 2014, mean levels of total cholesterol and LDL-c decreased in 12.2% and 14%.

CONCLUSIONS

Prevalence of dyslipidaemia is high, although a decreased in mean levels of total cholesterol and LDL-c has been achieved.

Age, Period, and Cohort Effects on Mortality From Ischemic Heart Disease in Southern Spain

INTRODUCTION AND OBJECTIVES

Ischemic heart disease is the leading cause of death and one of the top 4 causes of burden of disease worldwide. The aim of this study was to evaluate age-period-cohort effects on mortality from ischemic heart disease in Andalusia (southern Spain) and in each of its 8 provinces during the period 1981-2008.

METHODS

A population-based ecological study was conducted. In all, 145 539 deaths from ischemic heart disease were analyzed for individuals aged between 30 and 84 years who died in Andalusia in the study period. A nonlinear regression model was estimated for each sex and geographical area using spline functions.

RESULTS

There was an upward trend in male and female mortality rate by age from the age of 30 years. The risk of death for men and women showed a downward trend for cohorts born after 1920, decreasing after 1960 with a steep slope among men. Analysis of the period effect showed that male and female death risk first remained steady from 1981 to 1990 and then increased between 1990 and 2000, only to decrease again until 2008.

CONCLUSIONS

There were similar age-period-cohort effects on mortality in all the provinces of Andalusia and for Andalusia as a whole. If the observed cohort and period effects persist, male and female mortality from ischemic heart disease will continue to decline.

Health systems organization for emergency care

The increasing number of acute and severe digestive diseases presenting to hospital emergency departments, mainly related with an ageing population, demands an appropriate answer from health systems organization, taking into account the escalating pressure on cost reduction. However, patients expect and deserve a response that is appropriate, effective, efficient and safe. The huge variety of variables which can influence the evolution of such cases warranting intensive monitoring, and the coordination and optimization of a range of human and technical resources involved in the care of these high-risk patients, requires their admission in hospital units with conveniently equipped facilities, as is done for heart attack and stroke patients. Little information of gastroenterology emergencies as a function of structure, processes and outcome is available at the organizational level. Surveys that have been conducted in different countries just assess local treatment outcome and question the organizational structure and existing resources but its impact on the outcome is not clear. Most studies address the problem of upper gastrointestinal bleeding and the out-of-hours endoscopy services in the hospital setting. The demands placed on emergency (part of the overall continuum of care) are obvious, as are the needs for the efficient use of resources and processes to improve the quality of care, meaning data must cover the full care cycle. Gastrointestinal emergencies, namely gastrointestinal bleeding, must be incorporated into the overall emergency response as is done for heart attack and stroke. This chapter aims to provide a review of current literature/evidence on organizational health system models towards a better management of gastroenterology emergencies and proposes a research agenda.

Sex-related differences in prognosis after myocardial infarction: changes from 1978 to 2007

Women with myocardial infarction (MI) have shown a 28-day survival disadvantage compared with men. However, results were less consistent when considering long-term mortality in 28-day survivors. The aim was to estimate the trends for sex-related differences in the three endpoints considered for this study: (1) 28-day mortality or severe ventricular dysfunction (acute pulmonary oedema or cardiogenic shock) during the hospital stay, (2) 28-day mortality and (3) two-year cardiovascular mortality or non-fatal MI in 28-day survivors after a first MI. A cohort of 3,982 consecutive patients with first Q-wave MI admitted to a university tertiary reference hospital between 1978 and 2007 was followed for 2 years. Short-term prognosis improved in women over the studied period; similar rates were observed in both sexes in the 2000s. After adjusting for age, co-morbidities and anterior location of MI, female sex had an odds ratio=1.71 (95% confidence interval [CI] 1.34-2.17) of short-term severe MI or death over the studied period. Overall, sex differences in long-term prognosis remained similar over the studied period (hazard ratio=1.40; 95% CI 1.02-1.91). In conclusion, short-term prognosis improved over the past 30 years for first Q-wave MI patients, becoming similar for both men and women in the most recent decade. Long-term prognosis did not improve in either men or women, indicating that secondary prevention should be reinforced to achieve consistent reductions in the number of cardiovascular events.

Trends in Q-wave acute myocardial infarction case fatality from 1978 to 2007 and analysis of the effectiveness of different treatments

BACKGROUND

We sought to analyze the trends in first Q-wave acute myocardial infarction (AMI) case fatality from 1978 to 2007 in a population-based hospital register, to determine the variables related to these changes, and to assess the effectiveness of current AMI management.

METHODS

Population-based hospital registry included patients with first Q-wave AMI aged 25 to 74 years admitted between 1978 and 2007. Sociodemographic and clinical characteristics, treatments, and procedures used during hospital stay, and 28-day case fatality were recorded. Logistic regression was used for multivariate analysis of six 5-year periods.

RESULTS

The 30-year study included 3,982 patients. Mean 28-day case fatality was 8.96%, with a decreasing trend from 16.6% in the first 5-year period to 4.7% in the sixth (P for trend < .001). Study period was independently associated with case fatality. Case-fatality reduction attributable to pharmacologic treatments was 51% overall; in 24-hour survivors, pharmacologic treatments and broad use of invasive procedures explained 39% and 38%, respectively, of the difference between the observed case fatality in 2003-2007 and 1978-1982.

CONCLUSION

A dramatic decrease in 28-day case fatality occurred during this 30-year period and was mainly related to the use of antiplatelet drugs, β-blockers, thrombolysis, and invasive procedures. These data support the current guidelines for the management of acute coronary syndrome.

Long-term prognosis after hospital admission for acute myocardial infarction from 1987 to 2006

BACKGROUND

Recent population-based estimates for long-term cardiovascular disease (CVD) mortality after hospitalization for a first acute myocardial infarction (AMI) are not well established.

METHODS

Data from the Swedish hospital discharge and death registries were used to record all first-ever hospital admissions in patients (n=348,772) 35-84 years with AMI from 1987 to 2006 and subsequent all-cause and CVD case fatality during up to 5 years.

RESULTS

During the 20-year period, 28-day case fatality was reduced by almost two thirds in patients aged <75 years. For cases with a first AMI 1999-2002 long-term case fatality for men surviving the first 28 days and <55 years was 10.3/1000 person years, with rates of 23.6, 58.0 and 137.0 for men aged 55-64, 65-74 and 75-84 years. Corresponding figures for women were 10.5, 24.3, 51.8, 124.1 deaths/1000 years. In 1999-2002 estimated long-term risk of fatal CVD (based on survival until 2007) for men below 55 years was 6.1/1000 years, and 13.8, 34.6, 92.9 for men aged 55-64, 65-74, and 75-84 years, respectively. Corresponding figures for women were 4.8, 11.9, 30.1, 86.2/1000 years. The total reduction in CVD case fatality was two thirds among patients aged <55 and approximately one third among those aged 75-84.

CONCLUSIONS

Long-term case fatality after hospitalization for AMI decreased markedly from 1987 to 2006, particularly with respect to CVD mortality and in younger patients. However, because of a steep increase in case fatality with age and a large proportion of older patients, long-term prognosis overall still remains poor.

The impact of medical technology on health: a longitudinal analysis of ischemic heart disease

OBJECTIVES

This article estimates the costs and benefits of changes in ischemic heart disease (IHD) care in Spain from 1980 to 2003.

METHODS

We use joinpoint regression to identify trends in the standardized rates of mortality and hospitalization for IHD in general and acute myocardial infarction (AMI) in particular. We estimate also logistic regression models for the probability of in-hospital death of patients admitted for AMI. To measure costs and benefits between 1980 and 2003 we use the microdata from Spanish Hospital Morbidity Survey, and the reports of the Cardiac Catheterization and Coronary Intervention Registry of the Spanish Society of Cardiology.

RESULTS

Mortality from IHD in Spain has been substantially reduced in the past 25 years. Medical advances have saved lives of many patients admitted to hospitals. If the patients with AMI admitted in 2003 had been treated with 1980 procedures the rate of hospital mortality for AMI would have doubled. The estimated benefits in 2003 are the lives of the 5326 patients saved. The unit real costs have increased from euro2143 to euro4550 per AMI admission. If this cost increase is applied to the 57,842 Spanish AMI inpatients admitted in 2003, one could say that advances in medical technology from 1980 to 2003 carry a cost of euro26,140 per life saved.

CONCLUSIONS

In Spain advances in hospital technology for the treatment of IHD since 1980 are well worth the cost.

Short-term (28 days) prognosis between genders according to the type of coronary event (Q-wave versus non-Q-wave acute myocardial infarction versus unstable angina pectoris)

The type of acute coronary syndrome may account for different prognoses between men and women after myocardial infarction. This study assessed gender differences in 28-day mortality rates for first or recurrent Q-wave and non-Q-wave myocardial infarctions and unstable angina by using data from 5 registries that included 20,836 patients (24.8% women). Mortality rates were higher in women with first Q-wave myocardial infarction but not in the other patients after adjusting for confounding variables.

[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.

Six-month outcomes in a multinational registry of patients hospitalized with an acute coronary syndrome (the Global Registry of Acute Coronary Events [GRACE])

Relatively limited data are available, particularly from the perspective of a multinational registry, about the post-discharge outcomes and management practices of patients with an acute coronary syndrome (ACS). The objectives of this longitudinal study were to examine 6-month outcomes in a large multinational sample of patients hospitalized with an ACS. A total of 5,476 patients with ST-segment elevation acute myocardial infarction (STEAMI), 5,209 patients with non-ST-segment elevation acute myocardial infarction (NSTEAMI), and 6,149 patients with unstable angina pectoris discharged from 90 hospitals in 14 countries comprised the study population. The study sample was recruited from 18 cluster sites in 14 countries that are currently collaborating in the Global Registry of Acute Coronary Events (GRACE) study. The 6-month post-discharge death rates were 4.8% in patients with STEAMI, 6.2% in patients with NSTEAMI, and 3.6% in patients with unstable angina pectoris. Approximately 1 in 5 of each of our comparison groups were rehospitalized for heart disease during the 6-month follow-up, and approximately 15% of each of the respective study cohorts underwent coronary revascularization during follow-up. Demographic and clinical characteristics of post-discharge decedents were identified according to type of ACS. Our results suggest that a considerable proportion of patients who were discharged from the hospital after an ACS, with some differences noted according to type of ACS, remain at increased risk for adverse outcomes during the relatively brief post-discharge period. These data suggest the need for better long-term medical management and more intense follow-up of patients with an ACS to improve their long-term outlook.

[Clinical characteristics, management, and prognosis of patients with acute myocardial infarction not admitted to the coronary care unit. Usefulness of an intermediate care unit as the initial admission site]

INTRODUCTION AND OBJECTIVES

There is little information about the management and prognosis of patients with acute myocardial infarction (AMI) who are not admitted to coronary care units (CCU) because of the lack of available beds. The aim of this study was to evaluate the characteristics and prognosis of the patients who were admitted to the intermediate care unit (INTCU) of a cardiology department.

METHODS

We compared the clinical profile, management, and 12-month prognosis of the patients admitted to the INTCU or general ward (Ward) instead of the CCU.

RESULTS

Out of 242 patients with AMI, 62 (23%) were not admitted to the CCU due to the lack of available beds. Of these, 29 (12%) were admitted to the INTCU and 26 (11%) to the Ward after being monitored for at least 24 h in the emergency room. Patients admitted to the CCU arrived at the hospital early, were younger, less frequently female, and had a lower prevalence of diabetes. ST-segment elevation AMI was more frequent in patients admitted to the CCU than in patients admitted to the INTCU or Ward (67 vs 17 and 23%, respectively; p < 0.0001), and non-Q wave AMI was less frequent (30 vs 76 and 81%; p < 0.0001). No differences were found between groups in the number of stress tests or revascularization procedures performed after the first 24 h, the duration of the hospital stay (median 8 days), or in-hospital mortality. The 12-month survival was 82, 80, and 64% in the patients admitted to the CCU, INTCU, or Ward (p < 0.05), respectively. These differences ceased to be significant after adjusting for the patients' baseline clinical profile and treatment received at admission.

CONCLUSION

Compared to patients with AMI admitted to the CCU, patients admitted to the INTCU or Ward after being monitored at least 24 h had non-ST elevation and non-Q wave AMI more frequently, but a less favorable risk profile for long-term mortality. The different types of AMI were managed similarly and had a similar 12-month prognosis. Intermediate care units may be useful for palliating the lack of CCU beds and care for some patients with AMI.

[Questionnaire for patients with ischaemic cardiopathy on their reaction to various alarm symptoms]

OBJECTIVES

To find the degree of information that patients with ischaemic cardiopathy (IC) possess and their behaviour on alarm symptoms (thoracic pain of ischaemic profile under stress, at rest, worsening under stress and for over 20'), how they manage sub-lingual nitro-glycerine (SLNTG), and the source of their information.

DESIGN

Transversal descriptive study based on personal interview and our own questionnaire, from September to December 2001.

SETTING

Primary Care. Six clinics in three urban Health Areas.Participants. Randomised sample of 98 patients with IC (stable angina, unstable angina, angina with infarct).

MEASUREMENTS AND RESULTS

93 people (57 male, 36 women) were surveyed. Their average age was 71 19.34 had diagnosis of infarct. 17.2% (95% CI, 9.5%24.9%) had no SLNTG available. 78.5% (95% CI; 70.2%-86.8%) and 81.7% (95% CI; 73.8%-89.6%) of those with angina under stress or at rest, respectively, did not know when to attend the hospital Emergency department. 37.8% (95% CI, 26.8%-48.8%) with steady stress angina would attend a hospital or their doctor urgently. 100% of patients had received no information on angina at rest, under steady stress and for over 20'. There was no difference in behaviour before stress angina between patients who had been informed by Primary Care and those informed by Specialists. There was a difference, though, for good use of SLNTG between infarct and non-infarct patients (p = 0.003).

CONCLUSIONS

Our cardiopaths do not recognise alarm signals quickly; and so do not benefit as well as they might from hospital treatment. No doctor (Primary Care or specialist) informed them of the different ways to confront stable and unstable angina. Only a very small number used SLNTG in stress angina properly and knew when to attend Casualty. There is an urgent need to improve the health education of our cardiopaths.

[Trends in the proportion of patients younger than 75 years with acute myocardial infarction and Killip class III and IV. variables associated with occurence and case-fatality: 1978-1997]

INTRODUCTION

Acute pulmonary edema (Killip III) or cardiogenic shock (Killip IV) is associated with a higher mortality in the acute phase of myocardial infarction (AMI).

OBJECTIVES

To analyze trends in the proportion of patients who developed Killip III and IV in AMI over a 20-year period in order to identify the variables associated with occurrence and case-fatality.

METHODS

Hospital registry of first AMI in patients under than 75 years, from 1978 to 1997. Sociodemographic variables, cardiovascular risk factors, clinical variables, treatments, procedures, and worst Killip class were recorded.

RESULTS

The registry included 2,590 patients. Mean age was 60 years and 17% were women. Thirteen percent (13.5%) of the patients developed Killip III and IV, and no changes in this proportion were observed over the time period studied. Age, diabetes, previous angina, and anterior location of AMI were associated with a higher risk of Killip III and IV. Case-fatality at 28 days in this subgroup was 51.7%, with a decreasing linear trend over the years. Variables associated with a higher case-fatality were age and malignant ventricular arrhythmias, whereas the periods 1990-93 and 1994-97 were associated with a lower case-fatality. This protective effect disappeared after adjusting for treatment variables (antiplatelet agents and thrombolysis).

CONCLUSIONS

The proportion of patients with AMI in which Killip class III and IV develops has remained stable in the last two decades. Although the 28-day case-fatality in these patients is high, a decrease has been observed in recent years in relation to the availability of new treatments (antiplatelet agents and thrombolysis).

Short-term mortality of myocardial infarction patients with diabetes or hyperglycaemia during admission

AIM

The hypothesis that patients with hyperglycaemia during admission, regardless of previous diagnosis of diabetes, have worse prognosis than those with normal glucose values is controversial. The objective was to assess the role of hyperglycaemia on short-term mortality after myocardial infarction (MI).

METHODS AND RESULTS

A cohort study nested in a prospective registry of MI patients in the reference hospital of Gerona, Spain was performed. All consecutive MI patients under 75 were registered between 1993 and 1996. Patient and clinical characteristics, including previous diagnosis of diabetes, glycaemia on admission and in the next four days, were recorded. Patients with glycaemia on admission or four day mean glycaemia >6.67 mmol/l were considered hyperglycaemic. The main outcome measure was mortality at 28 days. Of 662 patients with MI included, 195 (29.7%) had previously known diabetes mellitus, but 457 (69.0%) had glycaemia >6.67 mmol/l on admission. Patients with hyperglycaemia on admission were older, more often female, more frequently had a previous diagnosis of diabetes, developed more complications, and had higher 28 day mortality. The effect of admission glycaemia >6.67 mmol/l on 28 day mortality was independent of major confounding factors, particularly previous diagnosis of diabetes (OR=4.20, 95% confidence intervals 1.18 to 14.96).

CONCLUSIONS

Higher 28 day mortality was observed among MI patients with glycaemia on admission >6.67 mmol/l compared with patients with lower levels, independently of major confounding variables and, particularly, previous diagnosis of diabetes. This early, simple, and inexpensive marker of bad prognosis after MI should prompt the application of more aggressive treatment of MI and risk factors and, probably, of glycaemia during admission.

[Epidemiology of ischaemic heart disease in Spain: estimation of the number of cases and trends from 1997 to 2005]

INTRODUCTION AND OBJECTIVES

. The large amount of information on rates of acute coronary syndrome accumulated in Spain over the last two decades is summarized in this paper, which also estimates the number of cases expected in 2002 and the trend for 1997 to 2005.

METHODS

Published information on the situation in the 90's was reviewed and summarized. We present the incidence of acute myocardial infarction (AMI), and an estimate of the absolute number of patients expected for various acute coronary syndromes in each autonomous community in Spain in 2002, along with the trend for 1997 to 2005.

RESULTS

Approximately 68,500 patients will suffer AMI in 2002 and 40,989 of them will be hospitalized, while the rest will die before admission. A further 24.9% of admitted patients will not survive 28 days. Slightly less than half will be younger than 75 years old, an age with a better prognosis (28-day mortality 38.8%). Approximately 33,500 patients with unstable angina will be admitted, and 4.5% of them will die within 3 months of admission. Assuming the incidence of AMI remains stable, the absolute number of cases will increase by 2.28% yearly (9,847 cases in total) and hospitalizations for acute coronary syndromes will increase by 1.41% (8,817 cases in total) between 1997 and 2005.

CONCLUSION

Ischaemic heart disease generates increasing demand for health care in Spain. Case fatality is high among the approximately 68,500 AMI patients, given that scarcely two thirds will have been hospitalized in 2002.

Changes in the prevalence of overweight and obesity and their risk factors in Spain, 1987-1997

BACKGROUND

The aim of this study was to examine the relationship of the changes in the prevalence of overweight and obesity with the changes in some of their risk factors in Spain from 1987 to 1997.

METHODS

Data were obtained from three interview-based health surveys, covering representative samples of the noninstitutionalized Spanish population aged 16 years and over and undertaken in 1987 (n = 17,434), 1995 (n = 4,736), and 1997 (n = 4,678). To compensate for the different sample sizes, the 1995 and 1997 surveys were combined. Risk factors for obesity and overweight considered in this study were age, educational level, physical activity at work, physical activity during leisure time, tobacco use, alcohol consumption, and civil status. Data analysis was performed with logistic regression.

RESULTS

The prevalence of overweight and obesity (body mass index >or= 25 kg/m(2)) rose from 35.6% in 1987 to 40.9% in 1995/1997 among women and from 47.1 to 56.2% among men. In the period 1987-1995/1997, the proportion of persons with secondary or university education increased by 11.3% in women and 10.8% in men. Similarly, the prevalence of intense or regular leisure-time physical activity increased by 5.7 and 6.2% in women and men, respectively. The remaining risk factors for overweight and obesity registered no substantial change in prevalence over the study period. The prevalence of overweight and obesity expected in 1995/1997, had educational level and leisure-time physical activity been the same as in 1987, is higher than the observed figures; for educational level, expected figures are 7.3 and 1.4% higher than those observed among women and men, respectively, while for leisure-time physical activity corresponding values are 2.8 and 1.6%.

CONCLUSIONS

The rise in the prevalence of overweight and obesity in Spain from 1987 to 1997 may have been attenuated by an increase in leisure-time physical activity and by an improvement in educational level, particularly among women. The contribution to overweight and obesity trends attributable to physical activity at work or to tobacco and alcohol consumption appears to be small or null.

[Management of myocardial infarction in Spain (1995-99). Data from the registry of the Ischaemic Heart Disease Working Group (RISCI) of the Spanish Society of Cardiology]

INTRODUCTION AND OBJECTIVES

Limited information is available on how patients with myocardial infarction are treated in Spain. In order to make up for this deficiency, in October 1994, the Ischaemic Heart Disease Working Group of the Spanish Society of Cardiology initiated a myocardial infarction registry, which is currently active.

METHODS

Patients are recruited from hospitals with intensive coronary care facilities. Demographic characteristics coronary risk factors and previous conditions are collected, as well as clinical events, and diagnostic and therapeutic procedures performed during the stay in the coronary care unit.

RESULTS

From 1995 to 1999, 28,357 patients were registered. During this period the mean age increased slightly (from 64.4 +/- 12.2 to 65.2 +/- 12.7; p < 0.001), although the male proportion remained stable (from 76.7% to 77.1%). The median "onset of symptoms-hospital arrival for 1st emergency" time fell from 135 min to 120 min, and the median "onset of symptoms-needle" time from 180 to 175 (NS). The use of thrombolytic therapy did not change (from 42.4 to 43.9%), but the use of aspirin (from 87.4 to 91.7%), beta-blockers (from 32.7 to 39.6%) and angiotensin-converting inhibitors (from 27.9 to 34.8%) increased significantly (p < 0.001). The Swan-Ganz catheter and the intra-aortic balloon counterpulsation were rarely placed during the five years (4.2% and 1.2% respectively in 1999). Both early mortality (11.4 to 9.3%) and the median duration of intensive coronary care stay declined, in these 5 years.

CONCLUSIONS

In Spain, during the 1995-1999 period, the use of aspirin, beta-blockers, and angiotensin-converting inhibitors increased significantly during the acute phase of infarction in the coronary care unit. However, both the usage of thrombolytic therapy and the delay between the onset of symptoms and therapy initiation remained unchanged. At the same time, the length of stay in the coronary care unit and early mortality declined, although the clinical profile of the patients did not improve.

Role of age and sex in short-term and long term mortality after a first Q wave myocardial infarction

STUDY OBJECTIVE

The objective of this study was to analyse whether the risk of death within 28 days and three years after a first Q wave myocardial infarction was higher in hospitalised women than in men.

DESIGN

Follow up study.

PATIENTS AND SETTING

All consecutive first Q wave myocardial infarction patients aged 25 to 74 years (447 women and 2322 men) admitted to a tertiary hospital in Gerona, Spain, from 1978 to 1997 were registered and followed up for three years.

MAIN RESULTS

Women were older, presented more comorbidity and developed more severe myocardial infarctions than men. A significant interaction was found between sex and age. Women aged 65-74 had higher early mortality risk than men of the same age (OR 1.62; 95% CI 1.01, 2.66) after adjusting for age, comorbidity and acute complications including heart failure. Women under 65 tended to be at lower risk of early mortality than men (0.45 (95% CI 0.19, 1.04). Three year mortality of 28 day survivors did not differ between sexes.

CONCLUSIONS

These data support the idea that the higher 28 day mortality in hospitalised women with a first Q wave myocardial infarction is mainly attributable to the large number of patients aged 65 to 74 years in whom the risk is higher than that in men. Women under 65 with myocardial infarction do not seem to be a special group of risk.

Twenty-two year (1975 to 1997) trends in the incidence, in-hospital and long-term case fatality rates from initial Q-wave and non-Q-wave myocardial infarction: a multi-hospital, community-wide perspective

OBJECTIVES

The goal of this study was to examine long-term trends in the incidence, in-hospital and long-term mortality patterns in patients with an initial non-Q-wave myocardial infarction (NQWMI) as compared with those with an initial Q-wave myocardial infarction (QWMI).

BACKGROUND

Limited data are available describing trends in the incidence and mortality from an initial QWMI and NQWMI from a multi-hospital community-wide perspective.

METHODS

Our study was an observational study of 5,832 metropolitan Worcester, Massachusetts residents (1990 census = 437,000) hospitalized with validated initial acute MI in all greater Worcester hospitals during 11 annual periods between 1975 and 1997.

RESULTS

The incidence of QWMI progressively decreased between 1975/78 (incidence rate = 171/100,000 population) and 1997 (101/100,000 population). In contrast, the incidence of NQWMI progressively increased between 1975/78 (62/100,000 population) and 1997 (131/100,000 population). Hospital death rates were 19.5% for patients with QWMI and 12.5% for those with NQWMI. After controlling for various covariates, patients with QWMI remained at significantly increased risk for hospital mortality (adjusted odds ratio = 1.63; 95% confidence interval: 1.35, 1.97). While the hospital mortality of QWMI has progressively declined over time (1975/78 = 24%; 1997 = 14%), the in-hospital mortality for NQWMI has remained the same (1975/78 = 12%; 1997 = 12%). These trends remained after adjusting for potentially confounding prognostic factors. The multivariable adjusted two-year mortality after hospital discharge declined over time for patients with QWMI and NQWMI.

CONCLUSIONS

Despite impressive declines in the incidence, in-hospital and long-term mortality associated with QWMI, NQWMI is increasing in frequency and has the same in-hospital mortality now as it did 22 years ago.

[Variability in the in-hospital management of acute myocardial infarction in Spain. IBERICA Study (Investigación, Búsqueda Específica y Registro de Isquemia Coronaria Aguda)]

Introduction and objective. Although some in-hospital studies have described the management of acute myocardial infarction (MI) patients in Spain, none has been able to guarantee the exhaustiveness of patient registry. This study sought to determine the clinical characteristics and in-hospital management of patients with MI in eight Spanish population registries.Methods. The IBERICA study is a population-based MI registry carried out in the 25 to 74 year-old population, in eight Spanish regions in 1997. A standardized methodology was used to register and investigate all MI arriving alive to a hospital. Clinical characteristics, cardiovascular risk factors prevalence, pharmacological treatment, invasive and non-invasive procedures performed and complications at 28 days of evolution were recorded. A descriptive analysis was performed and the variation coefficient (VC) was calculated.Results. In 1997, 4,041 MI patients were registered, 79.9% were men with a mean age of 61.1 years. Although 10.9% (95% CI: 9.9-11.9%) were not admitted to the coronary care unit, a large variability existed among different areas (VC = 53%). There was a high variability in the utilization and performance of non-invasive and invasive procedures among regions, as well as in the use of pharmacological treatment. Only the use of antiaggregants (91.5%) and thrombolytic therapy (41.8%) showed a low variability (VC < 10%). Twenty-eight day mortality was 16.2% (95% CI: 15.1-17.4%) with a high variability being observed among the different regions (VC = 20.6%).Conclusion. Patient characteristics vary among the different Spanish regions. The differences in management and prognosis suggest a lack of equality in the health care provided to MI patients in the different regions in Spain.

Role of coronary interventional procedures in improved postinfarction survival in the 1990s

The contribution of increased use of same-admission percutaneous coronary interventional procedures to recent improvements in hospital survival of patients with acute myocardial infarction (AMI) remains unclear. Patients with International Classification of Diseases codes for AMI (code 410), who were admitted to the emergency coronary care unit and underwent an initial episode of treatment, were studied over the 9-year period 1990 to 1998 (n = 2,628). Three triennia between 1990 and 1998 were compared. Trends in risk, the use of procedures, and hospital outcomes were analyzed. Hospital mortality was 33% lower (p <0.02) in the third triennium (5.8%) than in the earlier 2 triennia (8.7%), equivalent to an absolute reduction of 29 hospital deaths/1,000 patients treated. The lower hospital mortality was not due to: (1) shorter hospital stays (reduction in mortality was primarily in the first 3 hospital days), (2) treatment of lower risk subjects (a risk score based on age, gender, and presence of diabetes increased between the first and third triennia), or (3) use of in-hospital interventional procedures (although the use of percutaneous coronary intervention more than doubled in the third triennium, most procedures were performed in patients with a 1% risk of hospital death). We conclude from this study that there has been a substantial improvement over a 9-year period in early case fatality after AMI, but that this cannot be attributed to the increased use of in-hospital coronary interventions, which were largely performed on low-risk patients.

Outcomes and early revascularization for patients > or = 65 years of age with cardiogenic shock

Hospital survival of patients with acute myocardial infarction (AMI) complicated by cardiogenic shock has improved during recent years. It is unclear whether this mortality benefit also applies to elderly patients with cardiogenic shock. Elderly residents (age > or = 65 years) of the Worcester, Massachusetts metropolitan area (1990 census population = 437,000) hospitalized with confirmed AMI and cardiogenic shock in all metropolitan Worcester, Massachusetts hospitals between 1986 and 1997 constituted the sample of interest. We examined the use of coronary reperfusion strategies, adjunctive therapy, and hospital mortality in a cohort of 166 cardiogenic patients treated early in the reperfusion era (1986 to 1991) compared with 144 patients with AMI treated approximately 1 decade later (1993 to 1997). There was a significant increase in the use of an early revascularization strategy over time (2% vs 16%, p <0.001). Marked increases in use of antiplatelet therapy, beta blockers, and angiotensin-converting enzyme inhibitors were also observed over the decade-long experience. In-hospital case fatality declined significantly over time, from 80% (1986 to 1991) to 69% (1993 to 1997) in elderly patients who developed cardiogenic shock (p = 0.03). After adjusting for differences in potentially confounding prognostic characteristics between patients hospitalized in the 2 study periods, an even more pronounced reduction in hospital mortality (42%) was observed for the most recently hospitalized cohort. The most powerful predictor of in-hospital survival was use of an early revascularization approach to treatment. Thus, hospital mortality has declined for patients > or = 65 years of age with AMI complicated by cardiogenic shock, and this decline has occurred in the setting of broader use of early revascularization and adjunctive medical therapy for this high-risk population.

[Impact of thrombolytic therapy on short and long-term survival of a cohort of patients with acute myocardial infarction consecutively admitted to all the hospitals of a health care area. GESIR-5 study]

AIM

This study aims to assess the application of thrombolysis in patients with acute myocardial infarction admitted to all the hospitals of a health care area in Catalonia (Spain), and to estimate the effect of thrombolysis on short and long-term survival.

METHODS

From May 1992 to May 1993, all the patients with myocardial infarction admitted to the hospitals of the Costa de Ponent area in the first 72 hours after the initial symptoms were consecutively included in this prospective study. Information on pre-hospital phase, emergency room management and hospitalization was collected. All the patients discharged alive from hospital were followed up by telephone one and four years after hospital admission.

RESULTS

521 patients aged 74 years or less were included. Thrombolytic therapy was applied in 35.3%. There were no statistically significant differences in the proportion of thrombolysis between hospitals with or without intensive care or coronary units. Ten patients died in the emergency room; in the remaining cases, the 28-day case fatality was 10.0%. The effect of thrombolytic treatment on 28-day case fatality was estimated in a logistic regression model, after controlling for age, gender, Killip, ventricular arrhythmia and location of infarction (OR: 0.36; CI 95%: 0.15-0.88). In 28-day survivors, the 4-year cumulated probability of survival was 88.4%, being significantly higher in the group who had received thrombolytic therapy.

CONCLUSIONS

In the population studied, 28-day case mortality of acute myocardial infarction is similar to that reported in other Mediterranean regions. The benefits of thrombolysis in the acute phase are found to persist after 4 years.

Decreasing hospital mortality between 1994 and 1998 in patients with acute myocardial infarction treated with primary angioplasty but not in patients treated with intravenous thrombolysis. Results from the pooled data of the Maximal Individual Therapy in Acute Myocardial Infarction (MITRA) Registry and the Myocardial Infarction Registry (MIR)

OBJECTIVES

We investigated changes in the clinical outcome of primary angioplasty and thrombolysis for the treatment of acute myocardial infarction (AMI) from 1994 to 1998.

BACKGROUND

Primary angioplasty for the treatment of AMI is a sophisticated technical procedure that requires experienced personnel and optimized hospital logistics. Growing experience with primary angioplasty in clinical routine and new adjunctive therapies may have improved the outcome over the years.

METHODS

The pooled data of two German AMI registries: the Maximal Individual Therapy in AMI (MITRA) study and the Myocardial Infarction Registry (MIR) were analyzed.

RESULTS

Of 10,118 lytic eligible patients with AMI, 1,385 (13.7%) were treated with primary angioplasty, and 8,733 (86.3%) received intravenous thrombolysis. Patients characteristics were quite balanced between the two treatment groups, but there was a higher proportion of patients with a prehospital delay of >6 h in those treated with primary angioplasty. The proportion of an in-hospital delay of more than 90 min significantly decreased in patients treated with primary angioplasty over the years (p for trend = 0.015, multivariate odds ratio [OR] for each year of the observation period = 0.84, 95% confidence interval [CI]: 0.73-0.96) but did not change significantly in patients treated with thrombolysis. Hospital mortality decreased significantly in the primary angioplasty group (p = 0.003 for trend; multivariate OR for each year = 0.73, 95% CI: 0.58-0.93). However, for patients treated with thrombolysis, hospital mortality did not change significantly (p for trend 0.175, multivariate OR for each year: 1.02, 95% CI: 0.94- 1.11).

CONCLUSIONS

Compared with thrombolysis the clinical results of primary angioplasty for the treatment of AMI improved from 1994 to 1998. This indicates a beneficial effect of the growing experience and optimized hospital logistics of this technique over the years.

Ten-year trends in the incidence, treatment, and outcome of Q-wave myocardial infarction

The benefits of coronary reperfusion and antiplatelet therapy for patients with Q-wave acute myocardial infarction (Q-AMI) are well established in the context of randomized, controlled trials. The use and recent impact of these and other therapies on the broader, community-wide population of patients with Q-AMI is less well established. Residents of the Worcester, Massachusetts, metropolitan area (1990 census population 437,000) hospitalized with confirmed Q-AMI in all metropolitan Worcester, Massachusetts, hospitals in 4 1-year periods between 1986 and 1997 comprised the sample of interest. We examined the rates of occurrence, use of reperfusion strategies, and hospital mortality in a cohort of 711 patients with Q-AMI treated early in the reperfusion era (1986 and 1988) in comparison to 669 patients with Q-AMI treated a decade later (1995 and 1997). The percentage of Q-AMI among all hospitalized patients with AMI decreased over the decade of reperfusion therapy: 52% in 1986 and 1988 versus 35% in 1995 and 1997 (p < 0.001). Use of reperfusion therapy for patients with Q-AMI increased from 22% to 57%, with a marked increase in the use of primary angioplasty over time (1% vs 16%). The profile of patients receiving reperfusion therapy also changed significantly over the study period. Marked increases in use of antiplatelet therapy, beta blockers, angiotensin-converting enzyme inhibitors, and decreased use of calcium channel blockers, were observed over time. The crude in-hospital case fatality rate declined from 19% (1986 and 1988) to 14% (1995 and 1997) in patients with Q-AMI. Results of a multivariable regression analysis showed lack of reperfusion therapy, older age, anterior wall AMI, and cardiogenic shock to be independent predictors of in-hospital mortality in patients with Q-AMI. Thus, the percentage of all AMI's presenting as Q-AMI, and hospital mortality after Q-AMI, has decreased significantly in the past 10 years. The decrease in mortality occurs in the setting of broader use of reperfusion and adjunctive therapy (including primary angioplasty).

Early and pre-discharge aspirin administration among patients with acute myocardial infarction: current clinical practice and trends in the United States

OBJECTIVES

The purpose of our study was to determine the frequency of aspirin administration among patients with acute myocardial infarction (MI) as dictated by physicians practicing in the United States.

BACKGROUND

Aspirin (ASA), a widely available, inexpensive and generally well-tolerated platelet inhibitor, is recommended for patients with acute coronary syndromes, including acute MI. However, there is concern that aspirin is underutilized in daily clinical practice.

METHODS

Early (<24 hours) and predischarge ASA administration were determined among 220,171 patients with suspected acute MI enrolled in the Second National Registry of Myocardial Infarction (NRMI 2) between June, 1994 and April 30, 1996.

RESULTS

Overall, 165,122 (74.9%) of patients received ASA within 24 hours of hospital admission, whereas 55,049 patients did not. Early ASA recipients were younger, more often male, arrived at the hospital earlier, and were more likely to be classified as Killip Class II or less compared to those who did not receive ASA. Patients who received aspirin were also more likely to have chest pain, electrocardiographic ST segment elevation, and tended to arrive at the hospital earlier than those who did not receive ASA. However, over 20% of patients with ST segment elevation did not receive early ASA therapy. From the total cohort of early ASA recipients, only 69% received ASA at the time of hospital discharge. Trends in early and pre-discharge aspirin administration over a 2 year time period in all patients (72.6 to 75.1% and 71.5 to 74.6%, respectively; p < 0. 001) and in specific patient subsets were encouraging with a gradual but steady increase; however, utilization remained comparatively low in women and the elderly. By multivariable analysis, in-hospital recurrent MI (OR 0.90, 95% CI;.78-1.0, p = 0.04), stroke (OR 0.65, 95% CI,.52-.80, p < 0.001) and death (OR 0.24, 95% CI,.22-.26, p < 0. 001) occurred less frequently when ASA was administered within 24 hours of hospitalization.

CONCLUSION

Aspirin is currently underutilized in routine clinical practice as both primary and adjunctive forms of therapy in MI, especially among patients known to be at risk for recurrent cardiothrombotic events. The targeted and timely use of aspirin reduces early cardiovascular events and should remain a priority in national health care efforts.

[Use of thrombolytic treatment in patients with acute myocardial infarction in Spain. Observations from the PRIAMHO study]

INTRODUCTION AND OBJECTIVES

Scarce information is actually available in our country regarding the use of thrombolytic treatment in patients with acute myocardial infarction and how consistently the recommendations of the clinical guidelines are being implemented.

METHODS

Cohort study with one year follow-up of patients with acute myocardial infarction admitted in 24 Spanish hospitals in 1995. Differences in clinical characteristics and prognosis from patients treated with or without thrombolysis were compared.

RESULTS

2,191 of the 5,242 patients (42%) admitted with an acute myocardial infarction received thrombolytic therapy (range: 23%-63%). Reasons for exclusion in the rest were the absence of ST segment elevation (35%), contraindications (16%), prehospital delay >12 h (35%), and other causes (15%). Thrombolysis treated patients were at lower risk in general because they had shorter prehospital delays and were younger, more likely to be male, less frequently diabetic, with less prior history of angina or infarction. The average delay in administering therapy was of 3 hours while the average in-hospital delay was 50 minutes and depended only on the hospital where patients where admitted, as it was shorter in small centers. t-PA was administered in 49% of patients, streptoquinase in 46% and other drugs in 5%. Although t-PA was given more often to younger patients, smokers, anterior and Q-wave infarctions, and to patients with shorter prehospital delays, the determinant factor was the admission hospital with a frequency ranging from 9% to 96%. Patients not treated with thrombolytics had more complications during the acute phase, and required more invasive procedures. They also had a higher mortality at 28 days (17% vs. 10%, p < 0.0001) and at one-year follow-up (27% vs. 15%, p < 0.0001). Furthermore, a correlation was observed between mortality and delay of treatment application. In multivariate analysis, thrombolytic treatment was an independent predictor of survival at one year, with an odds ratio for mortality of 0.8 (95% CI: 0.66-0.96).

CONCLUSIONS

Thrombolytic therapy in Spain does not yet conform to the recommendations of the actual guidelines for the treatment of patients with acute myocardial infarction because it is underused, especially in high-risk patients, the prehospital and in-hospital delays are too long, and a huge variability exists between hospitals in the frequency and delays of administration and selection of the drug that are not sufficiently explained by the characteristics of the patients. In spite of this, mortality of treated patients was 20% lower in comparison to the non-treated patients, after adjusting for the other clinical factors with demonstrated prognostic value.

The role of coronary angioplasty and stenting in acute myocardial infarction

Despite the improvements in the pharmacological treatment of acute myocardial infarction, it is recognised that thrombolysis fails to reproduce reperfusion in a significant proportion of patients. Coronary interventional techniques have been shown to offer an alternative reperfusion strategy. There is increasing evidence that mechanical reperfusion may offer significant advantages over established thrombolytic therapy.

[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]

BACKGROUND AND PURPOSE

The paucity of data on myocardial infarction management and results in Spain lead to the design of the PRIAMHO study (Proyecto de Registro de Infarto Agudo de Miocardio Hospitalario [Acute Myocardial Infarction Hospital Registration Project]) which developed standard methods to collect information on the management of patients with such a condition and their characteristics. The variability results among hospitals in myocardial infarction management and in one-year mortality are presented.

METHODS

A cohort study with a one-year follow-up was designed to register all patients diagnosed with acute myocardial infarction discharged from 24 Spanish hospitals that completed all the requisites to participate. The demographic and clinical characteristics of the patients, their management during the coronary care unit stage, and the outcome and complications were prospectively registered. Standard definitions for diagnosis were used. Confidentiality regarding patient identity and participating centers was guaranteed.

RESULTS

5,242 (77.6%) of the 6,756 patients with myocardial infarction admitted in the 24 participating hospitals were registered in the coronary care units. Half of the centers had an on-site hemodynamic laboratory and in seven coronary surgery. The delay between symptom-onset and emergency room admission was 2 hours. Acute pulmonary edema or cardiogenic shock was developed by 16.6% of patients and 41.8% received thrombolysis. Mean time delay between symptom-onset and thrombolysis was 3 hours. A large variability in the use of beta-blockers, thrombolysis, echocardiography, coronary catheterization angiography and invasive revascularization was observed among hospitals. Mortality in the coronary care unit was 10.9% and increased to 14.0% at 28 days and to 18.5% at one year with considerable variation among hospitals. Four hospitals showed higher mortality among their patients, independently from the proportion of diabetes, hypertension, women, anterior location of myocardial infarction, non-Q-wave infarction, age and severity.

CONCLUSIONS

The results of this study show that early and mid-term mortality from myocardial infarction is still high in Spain in the reperfusion era, and that a considerable variability in management and outcome exists among Spanish hospitals, which is not explained by the different case-mix among them.