Albert Ariza Solé

Predictors of Late Reperfusion in STEMI Patients Undergoing Primary Angioplasty. Impact of the Place of First Medical Contact

INTRODUCTION AND OBJECTIVES The benefit of primary angioplasty may be reduced if there are delays to reperfusion. Identification of the variables associated with these delays could improve health care. METHODS Analysis of the Codi Infart registry of Catalonia and of the time to angioplasty depending on the place of first medical contact. RESULTS In 3832 patients analyzed, first medical contact took place in primary care centers in 18% and in hospitals without a catheterization laboratory in 37%. Delays were longer in these 2 groups than in patients attended by the outpatient emergency medical system or by hospitals with a catheterization laboratory (P < .0001, results in median): first medical contact to reperfusion indication time was 42minutes in both (overall 35minutes); first medical contact to artery opening time was 131 and 143minutes, respectively (overall 121minutes); total ischemia time was 230 and 260minutes (overall 215minutes). First medical contact to artery opening time > 120minutes was strongly associated with first medical contact in a center without a catheterization laboratory (OR, 4.96; 95% confidence interval, 4.14-5.93), and other factors such as age, previous coronary surgery, first medical contact during evening hours, nondiagnostic electrocardiogram, and Killip class ≥ III. Mortality at 30 days and 1 year was 5.6% and 8.7% and was independently associated with age, longer delay to angioplasty, Killip class ≥ II, and first medical contact in a center with a catheterization laboratory. CONCLUSIONS In more than 50% of patients requiring primary angioplasty, the first medical contact occurs in centers without a catheterization laboratory, which is an important predictor of delay from diagnosis to artery opening.

Comments on the 2016 ESC Guidelines for the Diagnosis and Treatment of Acute and Chronic Heart Failure

In accordance with the policy on clinical practice guidelines established by the Executive Committee of the Spanish Society of Cardiology, the current article discusses the most notable and novel aspects of the European Society of Cardiology (ESC) guidelines for the diagnosis and treatment of acute and chronic heart failure (HF). The aim of the guidelines is to update our knowledge of the diagnosis and treatment of HF based on the best clinical evidence available.

Clinical Cardiology, Geriatric Cardiology, Heart Failure, and Transplantation 2015: A Selection of Topical Issues.

Manuel Martinez-Selles,* Jose Luis Lambert Rodriguez, Vivencio Barrios, Pablo Diez-Villanueva, Jose Manuel Garcia Pinilla, Juan Cosin, Albert Ariza Sole, Sonia Mirabet Perez, Carlos Escobar, Oscar Diaz-Castro, Javier Segovia Cubero, and Jose Angel Rodriguez a Servicio de Cardiologia, Hospital Universitario Gregorio Maranon, Universidad Europea y Universidad Complutense, Madrid, Spain b Servicio de Cardiologia, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain c Servicio de Cardiologia, Hospital Universitario Ramon y Cajal, Madrid, Spain d Servicio de Cardiologia, Hospital Universitario de la Princesa, Madrid, Spain e Servicio de Cardiologia, Hospital Universitario Virgen de la Victoria, Malaga, Spain f Servicio de Cardiologia, Hospital Arnau de Vilanova, Valencia, Spain g Servicio de Cardiologia, Hospital Universitario de Bellvitge, L’Hospitalet de Llobregat, Barcelona, Spain h Servicio de Cardiologia, Hospital Universitario de la Santa Creu i Sant Pau, Barcelona, Spain i Servicio de Cardiologia, Hospital Universitario La Paz, Madrid, Spain j Servicio de Cardiologia, Hospital de Pontevedra, Pontevedra, Spain k Servicio de Cardiologia, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain l Servicio de Cardiologia, Hospital Universitario Juan Canalejo, A Coruna, Spain

Prognosis of Patients With Severe Aortic Stenosis After the Decision to Perform an Intervention

INTRODUCTION AND OBJECTIVES Current therapeutic options for severe aortic stenosis (AS) include transcatheter aortic valve implantation (TAVI) and surgical aortic valve replacement (SAVR). Our aim was to describe the prognosis of patients with severe AS after the decision to perform an intervention, to study the variables influencing their prognosis, and to describe the determinants of waiting time > 2 months. METHODS Subanalysis of the IDEAS (Influence of the Severe Aortic Stenosis Diagnosis) registry in patients indicated for TAVI or SAVR. RESULTS Of 726 patients with severe AS diagnosed in January 2014, the decision to perform an intervention was made in 300, who were included in the present study. The mean age was 74.0 ± 9.7 years. A total of 258 (86.0%) underwent an intervention: 59 TAVI and 199 SAVR. At the end of the year, 42 patients (14.0%) with an indication for an intervention did not receive it, either because they remained on the waiting list (34 patients) or died while waiting for the procedure (8 patients). Of the patients who died while on the waiting list, half did so in the first 100 days. The mean waiting time was 2.9 ± 1.6 for TAVI and 3.5 ± 0.2 months for SAVR (P = .03). The independent predictors of mortality were male sex (HR, 2.6; 95%CI, 1.1-6.0), moderate-severe mitral regurgitation (HR, 2.6; 95%CI, 1.5-4.5), reduced mobility (HR, 4.6; 95%CI, 1.7-12.6), and nonintervention (HR, 2.3; 95%CI, 1.02-5.03). CONCLUSIONS Patients with severe aortic stenosis awaiting therapeutic procedures have a high mortality risk. Some clinical indicators predict a worse prognosis and suggest the need for early intervention.

ECG de abril de 2016

Varón de 55 años de edad, fumador, que consultó por dolor torácico intenso, vegetatismo y mal estado general en las 72 horas previas. En el domicilio se apreciaron hipotensión y bradicardia graves, con signos de hipoperfusión periférica. Se colocó un marcapasos externo y se procedió con la intubación y la ventilación mecánica. El ECG realizado a su llegada se muestra en la figura. Un ecocardiograma reveló que el ventrı́culo izquierdo estaba ligeramente dilatado con disfunción sistólica muy grave, el ventrı́culo derecho no estaba dilatado y no habı́a valvulopatı́as ni derrame pericárdico. A su llegada al hospital, el paciente presentaba hipotensión grave a pesar de la administración de dosis altas de inotropos y vasopresores, acidosis metabólica e insuficiencia renal. ? Cuál es su diagnóstico y su actitud terapéutica inmediata?

Balón de contrapulsación: ¿ha llegado el momento de su jubilación?

The intra-aortic balloon pump has been the most commonly used ventricular assist device for the last 40 years. Its main indications are cardiogenic shock, acute myocardial infarction and the support of patients undergoing high-risk percutaneous coronary interventions. However, scientific evidence supporting this practice is scarce. Previous studies suggest that the benefits of the intra-aortic balloon pump in patients with cardiogenic shock is limited to patients who have not undergone reperfusion and to those who have received thrombolysis, whereas, in those undergoing primary percutaneous coronary interventions, both the hemodynamic and clinical benefits appear to be small. Recently, the findings of the IABP–SHOCK II trial have markedly changed recommendations on the use of the intra-aortic balloon pump in patients with shock, and its routine use in this context is now discouraged. This article contains a review of the main evidence available on the use of the intra-aortic balloon pump for its different indications. Broad experience of the clinical and hemodynamic benefits of the technique in a large number of patients in routine clinical practice is particularly important for determining where best it can be used: patients in the early stages of hemodynamic deterioration and those with unstable, residual coronary lesions scheduled for a second revascularization could be particularly promising candidates.