A García-Alcántara

Prognostic impact of atrial fibrillation in acute coronary syndromes: results from the ARIAM registry

Aims: The prognostic ability of atrial fibrillation (AF) in acute coronary syndromes (ACS) is unclear. Studies regarding patient outcomes with respect to the timing of AF are scarce and conflicting. The present study aimed to determine the frequency, predictors and impact on clinical outcome of AF in patients with ACS. Methods: We analysed 39,237 consecutive patients with ACS included in the ARIAM registry between January /2001 and December 2011. Patients with AF were compared with patients in sinus rhythm. We differentiate between new-onset AF and previous AF cases to analyse mortality and other major adverse cardiac events (MACE) during hospitalization. Results: Of the patients, 2851 (7.3%) developed AF; 1568 (55%) of these were new-onset AF and 1283 (45%) had previous AF. The AF group had a higher risk profile at baseline and poorer clinical presentation at admission than non-AF patients. Compared with previous AF patients, new-onset AF presented with fewer comorbidities, including hypertension, diabetes, prior myocardial infarction, and chronic renal impairment. The inhospital mortality for new-onset AF, previous AF, and non-AF patients were 14, 11.6, and 5.2%, respectively (new-onset AF unadjusted HR 2.19, 95% CI 1.9–2.53, p<0.001; adjusted HR 1.70, 95% CI 1.12–3.4, p<0.001). After propensity score analysis, only new-onset AF persisted as an independent predictor for mortality (HR 1.62, 95% CI 1.09–2.89, p<0.001). Other MACE such as reinfarction, malignant arrhythmias, and heart failure were also more frequent in new-onset AF patients than in previous AF or non-AF patients. Conclusions: These findings suggest that the presence of new-onset AF during ACS is associated with a significant increase in mortality, even after adjusting for confounding variables.

Estancia media y pronóstico en la angina inestable: resultados del registro ARIAM

Fundamento y objetivo: El proposito de este trabajo es investigar los factores predictores de mortalidad y la estancia media de los pacientes diagnosticados de angina inestable (AI) durante su ingreso en las unidades de cuidados intensivos o unidades de cuidados coronarios (UCI/UCC). Pacientes y metodo: Estudio de cohorte retrospectivo que incluyo a los pacientes del registro espanol ARIAM (Analisis del Retraso en el Infarto Agudo de Miocardio). El periodo de estudio comprendio de junio de 1996 a diciembre de 2003. Su seguimiento se limito a UCI/UCC. Se realizo un analisis univariante entre los pacientes fallecidos y los vivos y otro entre los pacientes con estancia prolongada y no prolongada. Se realizaron ademas 3 analisis multivariantes con el objetivo de evaluar los factores relacionados con la mortalidad, las variables asociadas a la realizacion de intervencion coronaria percutanea (ICP) y los factores asociados a la estancia media prolongada en UCI/UCC. Resultados: Se incluyo a 14.096 pacientes con AI. La mortalidad fue del 1,1% y se asocio a la clase Killip, edad, necesidad de reanimacion cardiopulmonar y presencia de shock cardiogenico, arritmias y diabetes; mientras que los pacientes fumadores se asociaron a una menor mortalidad. Se realizo ICP solo a 1.226 (8,9%) pacientes, aunque su realizacion se incremento con los anos. La ICP se asocio a edad, traslado interhospitalario, tabaquismo, infarto de miocardio previo, shock cardiogenico o ante el bloqueo auriculoventricular de alto grado (BAVAG) y tratamiento con bloqueadores beta. La estancia media (desviacion estandar) fue de 3,15 (18,65) dias. La estancia media prolongada dependio de la edad, haber sido sometido a una coronariografia o ICP, clase Killip, ecocardiografia o ventilacion mecanica y presentar complicaciones graves. Conclusiones: La mortalidad se explica por la comorbilidad y la gravedad de la isquemia. Los pacientes a los que se realiza ICP son una poblacion menos grave, y su realizacion con el tiempo se incrementa. La estancia media prolongada se asocia a la mayor gravedad de la isquemia miocardica y a la ICP.

Los residentes en las unidades de cuidados intensivos, ¿cuál es su percepción de la formación que reciben?

La formación de los médicos residentes en las Unidades de Cuidados Intensivos (UCI) persigue prepararlos para una buena práctica clínica basada en el trabajo en equipo multidisciplinar; así mismo promueve la investigación, enseña a trabajar dentro de las dimensiones del profesionalismo, entrena en una buena comunicación en cualquier circunstancia y enseña a gestionar con calidad los recursos que dependan de ellos [1,2]. Paralelamente, la necesidad del reciclaje permanente para adaptarse a escenarios cambiantes hace que el autoaprendizaje y el pensamiento crítico sean imprescindibles en su Los residentes en las unidades de cuidados intensivos, ¿cuál es su percepción de la formación que reciben?

Prognostic Impact of Clopidogrel Pretreatment in Patients With Acute Coronary Syndrome Managed Invasively

Pretreatment with antiP2Y12 agents before angiography in acute coronary syndrome (ACS) is associated with a reduction in thrombotic events. However, recent evidences have questioned the benefits of upstream antiP2Y12, reporting a higher incidence of bleeding. We analyzed the prognostic impact of clopidogrel pretreatment in a large cohort of invasively managed patients with ACS. In hospital, safety and efficacy of clopidogrel pretreatment were retrospectively analyzed in patients included in the ARIAM-Andalucía Registry (Analysis of Delay in Acute Myocardial Infarction). Propensity score and inverse probability of treatment weighting analysis were performed to control treatment selection bias. Results were stratified by ACS type. Sensitivity analyses were used to explore stability of the overall treatment effect. Of 9,621 patients managed invasively, 69% received clopidogrel before coronary angiography. In the ST-elevation myocardial infarction group, pretreatment was associated with a significant reduction in reinfarction (odds ratio 0.53, 95% confidence interval [CI] 0.27 to 0.96; p = 0.027), stent thrombosis (odds ratio 0.15, 95% CI 0.06 to 0.38; p <0.0001), and mortality (odds ratio 0.67, 95% CI 0.48 to 0.94; p = 0.020), with an increase in minor bleeding but remained as a net clinical benefit strategy. Those benefits were not present in patients without ST elevation (non-ST elevation ACS). The weighting and propensity analysis confirmed the same results. An interaction between pretreatment duration and bleeding was observed. In conclusion, pretreatment with clopidogrel reduced the occurrence of death and thrombotic outcomes at the cost of minor bleeding. Those benefits exclusively affected ST-elevation myocardial infarction cases. The potential benefit of routine upstream pretreatment in patients with non-ST-elevation ACS should be reappraised at the present.

Prognostic implication of early ventricular fibrillation among patients with ST elevation myocardial infarction

Objective The aim of this study was to analyze the prognosis of patients presenting early ventricular fibrillation (VF) in the setting of ST elevation myocardial infarction (STEMI). Patients and methods Among patients included in the ARIAM (Análisis del Retraso en el Infarto Agudo de Miocardio) registry with the diagnosis of STEMI, those who received primary revascularization and were admitted in the first 12 h were analyzed retrospectively. Results From January 2007 to January 2012, 8340 patients were included in the STEMI cohort and 680 (8.2%) of them presented with VF before admission to the ICU (VF). This group comprised younger patients with fewer comorbidities. They received more often primary angioplasty (33.7 vs. 24.9%; P<0.001), had more prevalence of Killip class greater than or equal to 2 at admission (37.5 vs. 17.8%; P<0.001), and suffered more often cardiogenic shock (18.5 vs. 5.9%, P<0.001). By logistic regression analysis, VF was associated with a greater in-hospital mortality [odds rate (OR): 2.08, 95% confidence interval (CI): 1.57–2.81, P<0.001]. After a propensity score matching process, VF was associated with in-hospital mortality (OR: 1.53, 95% CI: 1.05–2.25, P=0.028). However, when analyzing patients treated by primary angioplasty, the mortality was not significantly related to VF (OR: 0.86, 95% CI: 0.45–1.61, P=0.628). Conclusion Our results show that VF before ICU admission was an independent predictor of in-hospital outcome in a cohort of patients in whom fibrinolysis was the most used revascularization therapy. However, this prognostic value was not found in patients treated with primary angioplasty.

Biomarkers mesuared within 24 hours from the onset of septic shock and 28-day mortality

Despite the remarkable advances in septic shock (SSh) management is still among the primary causes of death worldwide and there have been no significant changes in mortality over the last few decades.

Etiology of bacteremias associated with c-reactive protein, procalcitonin and lactate levels

Because of the high morbidity and mortality associated with bacteremia, prompt evaluation and adequate therapy are of paramount importance. The clinical manifestations of gram- positive and gram-negative bacterial infections are similar while biomarkers may be useful for the early diagnosis of the nature of a pathogen.

Efficiency diagnostic and advantages of procalcitonin and C-reactive protein in the early diagnosis of sepsis

The goal of our study is to assess the diagnostic profitability of procalcitonin (PCT) in septic shock and another biomarker as C-reactive protein (CRP).

Bloqueo auriculoventricular en la angina inestable: Resultados del registro ARIAM

Objective. Describe the frequency of high degree atrioventricular block (HDAVB) in patients with unstable angina (UA), analyze the variables associated with their appearance and evaluate whether HDAVB is independently associated with increased mortality or increased length of ICU stay. Design. Retrospective descriptive study of patients with UA included in the ARIAM registry. Setting. ICUs from 129 hospitals in Spain. Patients. From June 1996 to December 2003 a total of 14,096 patients were included in the ARIAM registry with a diagnosis of UA. Main variables of interest. Variables associated with the development of HDAVB, variables associated with the mortality of patients with UA, variables associated with the length of ICU stay of patients with UA. Results. HDAVB frequency was 1%. Development of HDAVB was independently associated with the Killip classification and the presence of sustained ventricular tachycardia or ventricular fibrillation. Crude mortality of patients was significantly increased when HDAVB was present (9% versus 1%, p < 0,001). When adjusted for other variables, HDAVB was not associated with increased mortality. Development of HDAVB in patients with UA was independently associated with an increase in the length of ICU stay (adjusted odds ratio 1.89: 95% confidence interval: 1.33-5.69). Conclusions. Patients with UA complicated with HDAVB represent a high-risk population with an increased ICU stay.

Multiple organ disfunction, surgical techniques and prognostic markers in acute pancreatitis

Multiple organ dysfunction (MOD) is the leading cause of morbidity and mortality in patients admitted to an intensive care unit (ICU).