Elena Aldasoro

Variabilidad en el manejo hospitalario del infarto agudo de miocardio en España. Estudio IBERICA (Investigación, Búsqueda Específica y Registro de Isquemia Coronaria Aguda)*

Introduccion y objetivos Los datos sobre el manejo de los pacientes con infarto agudo de miocardio (IAM) que llegan a un hospital en Espana no garantizan la exhaustividad en el registro. El objetivo de este trabajo es conocer las caracteristicas y el manejo de los pacientes con IAM que llegan a todos los hospitales de distintas areas de 8 comunidades autonomas espanolas. Metodos El estudio IBERICA es un registro poblacional de IAM entre 25 y 74 anos de edad realizado en ocho comunidades autonomas espanolas. Para este trabajo se incluyeron los casos de IAM que llegaron vivos al hospital durante 1997. Se recogen las caracteristicas, tratamiento y evolucion a los 28 dias del episodio. Se realizo un analisis descriptivo y se calculo el coeficiente de variacion. Resultados Se registraron 4.041 casos de IAM: el 79,9% eran varones y la edad media fue de 61,1 anos. El 10,9% (IC del 95%: 9,9-11,9%) no ingresaron en una unidad de cuidados intensivos cardiologicos, existiendo una gran variabilidad entre las zonas (coeficiente de variacion del 53%). Existe tambien una gran variabilidad en la realizacion e indicacion de tecnicas diagnosticas y terapeuticas invasivas y no invasivas, asi como en el tratamiento farmacologico empleado: unicamente la utilizacion de antiagregantes (91,5%) y trombolisis (41,8%) presenta un coeficiente de variacion Conclusion Las caracteristicas de los pacientes varian entre las zonas estudiadas. Las diferencias geograficas en el manejo y pronostico sugieren que puede existir desigualdades en la atencion al enfermo con IAM en Espana.

Regional variability in population acute myocardial infarction cumulative incidence and mortality rates in Spain 1997 and 1998

Background: Myocardial infarction (MI) incidence and mortality display a high geographic variation. Aims: The objective of the present study was to analyze MI mortality, cumulative incidence rate variability in seven regions of Spain from 1997 to 1998. Methods and Results: Standardized methods were used to identify, find, register, and classify MI cases that were classified as definite, possible,insufficient-dataMI, and non-MI. The total population of the seven monitored regions was 7,364,682 inhabitants. Of the 11,256 cases fulfilling eligibility criteria to investigate, 10,660 were selected to calculate MI rates: 6554 (61.5%)non-fatal definite MI, 1179 (11.1%)fatal definite MI, 1859 (17.4%)fatal possible MI, 1068 (10.0%)fatal cases with insufficient data. The IBERICA 25–74 years age-standardized cumulative incidence rates for men and women, were 207 (range: 175–252) and 45 (range: 36–65) per 100,000, respectively. The age-standardized mortality rates for men and women, were 73 (range: 62–94) and 20 (range: 13–29) per 100,000, respectively. Age-standardized case-fatality was 31.4 and 24.2% in men aged 25–74 and 35–64 years, respectively, and 32.7 and 27.0%, respectively, in women. Conclusions: MI cumulative incidence and mortality rates are low compared with other industrialized countries but, vary considerably among regions in a Mediterranean country like Spain.

Recursos hospitalarios y letalidad por infarto de miocardio. Estudio IBERICA

Determinar el porcentaje depacientes con infarto agudo de miocardio (IAM) que noingresan en una unidad de cuidados intensivos corona-rios (UCIC), las variables asociadas al ingreso en unaUCIC y si el ingreso en una UCIC, su disponibilidad y lade hemodinamica en el hospital se asocian a la letalidada 28 dias.

Hospital resources and myocardial infarction case fatality. The IBERICA study

INTRODUCTION AND OBJECTIVESnTo determine the proportion of patients with myocardial infarction (MI) not admitted to a coronary care unit (CCU), the variables associated with admission into a CCU, and whether admission to a CCU, and the availability of coronary angiography in the same hospital, were associated with 28-day case fatality.nnnPATIENTS AND METHODnPopulation-based registry of MI in patients 25 to 74 years of age, admitted during 1996-1998. Demographic and clinical characteristics were recorded, as well as management, clinical course and survival after 28 days. Hospitals were classified according to the availability of a CCU and catheterization laboratory (advanced hospital), CCU only (intermediate hospital) or neither (basic hospital). Admission to the CCU was also recorded.nnnRESULTSnIn all, 9046 cases of MI were recorded; in 11.3% the patient was not admitted to a CCU. Age, smoking (OR=1.33; 95% CI, 1.08-1.64), non-Q MI (OR=0.62; 95% CI, 0.49-0.78) or undetermined location of MI (OR=0.34; 95% CI, 0.23-0.50), Killip 4 score on admission (OR=0.63; 95% CI, 0.40-1.00) and delay in arrival at the hospital >6 h were associated with CCU admission. Patients admitted to a CCU showed a lower case fatality in the first 24 h (4.2% vs 23.5%), which was independent of comorbidity, severity and treatment. The 24-hour survivors admitted to a basic hospital had higher case fatality (17.3% vs 7.8%) than other groups, which was related to differences in treatment.nnnCONCLUSIONSnCCU admission is associated with a lower case fatality in the first 24 h. Admission to a basic hospital is associated with a higher 28-day case fatality even in patients who survive 24 h.

Diferencias de género en el tratamiento de revascularización precoz del infarto agudo de miocardio

Fundamento y objetivo Diferencias en la presentacion clinica del infarto agudo de miocardio (IAM), como la edad, la comorbilidad y la frecuencia de sintomas atipicos, podrian condicionar un proceso de cuidados hospitalarios distinto segun el sexo. Este estudio analiza la magnitud y los determinantes de las diferencias entre sexos en la revascularizacion precoz en personas ingresadas por IAM. Pacientes y metodo Se estudio a 2.836 pacientes con IAM que accedieron a cuidados hospitalarios (IBERICA-Pais Vasco). Se estimo el riesgo relativo (RR) de revascularizacion precoz en los varones respecto a las mujeres teniendo en cuenta la edad, la presentacion clinica, los antecedentes y la demora extrahospitalaria. Se aplico la metodologia de descomposicion de efectos y el analisis de regresion log-binomial. Resultados El 29% de los pacientes eran mujeres y su edad mediana, de 77 anos. El RR de revascularizacion de los varones respecto a las mujeres fue distinto segun la edad. Tras ajustar por hipertension arterial, diabetes, Killip III-IV al ingreso y sintomas atipicos, no se apreciaban diferencias significativas a los 45 anos (RRxa0=xa00,91; intervalo de confianza [IC] del 95%, 0,77-1,07), mientras que para los mayores de 64 anos, el RR de revascularizacion fue de 1,24 (IC del 95%, 1,05-1,47). Al ajustar por la demora extrahospitalaria, las diferencias por sexo y la interaccion del sexo con la edad no eran significativas. Conclusiones El retraso en el acceso a la atencion sanitaria de las mujeres mayores es causa de las diferencias por sexo en la revascularizacion precoz. Es necesario analizar las razones de esta demora.

Smoking and myocardial infarction case-fatality: hospital and population approach

Background Smoking is a risk factor for coronary heart disease, but it has been associated with better short-term prognosis in hospitalized patients with acute myocardial infarction. The aims of this study were to determine the association between smoking and myocardial infarction 28-day case-fatality in hospitalized patients and at the population level; and, whether smokers presenting with fatal myocardial infarction are more likely to die before reaching a hospital. Design and methods Population-based myocardial infarction registry, carried out in 1997-1998 in seven regions of Spain, used standardized methods to find and analyze suspected myocardial infarction patients (10 654 patients; 7796 hospitalized). Four categories of smoking status were defined: never-smokers, former smokers for more than 1 year, former smokers for less than 1 year, and current smokers. Results The main end-point was 28-day case-fatality, found to be 20.1, 17.1, 15.6, and 8.9%, in the four smoking status categories, respectively, for hospitalized patients; and 37.4, 33.0, 24.5, and 23.2%, respectively, at population level. Hospitalized current smokers had lower age, sex, and comorbidity-adjusted 28-day case-fatality than never-smokers (odds ratio = 0.71; 95% confidence interval: 0.56-0.90). This association held at population level (odds ratio = 0.68; 95% confidence interval: 0.60-0.76), in which former smoking was also associated with lower case-fatality. In fatal cases, recent former smokers presented a lower risk of out-of-hospital death than never-smokers (odds ratio = 0.47; 95% confidence interval: 0.29-0.77), whereas current smoking was marginally associated with out-of-hospital death (odds ratio = 1.22; 95% confidence interval: 0.99-1.50). Conclusions Current smoking is associated with lower 28-day case-fatality in hospitalized myocardial infarction patients. This association held at population level. Among fatal cases, smoking is associated with higher and recent former smoking with lower risk of dying out-of-hospital.

Socioeconomic differences in incidence and relative survival after a first acute myocardial infarction in the Basque Country, Spain

OBJECTIVEnTo estimate the incidence and 28-day and 5-year survival rates after a first acute myocardial infarction (AMI) in relation to socioeconomic status in the Basque Country (Spain) between 1999 and 2000.nnnMETHODSnData from a population-based registry of AMI were used. The study included 3,619 patients to calculate age-standardized incidence by the direct method and 2,003 patients (out-of-hospital deaths were excluded) to calculate observed and relative survival using the Kaplan-Meier and Hakulinen methods, respectively. Socioeconomic status was quantified using a deprivation index ecologically assigned to each patient according to the census tract of residence at diagnosis of AMI and was categorized into quintiles.nnnRESULTSnAmong men, the risk of AMI was higher in the lowest socioeconomic group than in the highest socioeconomic group (RR=1.17; 95%CI: 1.02-1.34). In men, a higher risk of death was observed in the middle (Q3; HR=1.60; 95%CI: 1.02-2.51) and low (Q5; HR=1.65; 95%CI: 1.02-2.69) quintiles compared with the least deprived group for age-adjusted survival during the acute phase. In the fully adjusted model, this effect was attenuated and no significant differences were observed in long-term survival. Among women, no significant differences were observed either in incidence or in short- and long-term survival.nnnCONCLUSIONSnSocioeconomic inequalities were only observed in men in incidence and in survival during the acute phase after an AMI.

Dose-response association of physical activity with acute myocardial infarction: Do amount and intensity matter?

OBJECTIVEnThe aims of this study were to analyze the dose-response association between leisure time physical activity (PA) practice and myocardial infarction (MI), considering not only the total amount but also the amount of PA at different levels of intensity, and to determine whether these associations were modified by age.nnnMETHODnIn a population-based age- and sex-matched case-control study, all first acute MI patients aged 25 to 74 years were prospectively registered in four Spanish hospitals between 2002 and 2004. Controls were randomly selected from population-based samples recruited during the same period of time. The Minnesota PA questionnaire was administered to assess total energy expenditure in PA and in light-, moderate-, and high-intensity PA.nnnRESULTSnFinally, 1339 cases and 1339 controls were included. The association between PA and MI likelihood was non-linear, with significantly lower MI odds at low practice levels (≥ 500 MET·min/week), lowest odds around 1500 MET·min/week, and a plateau thereafter. Light- (in subjects older than 64 years), moderate-, and high-intensity PA produced similar benefits.nnnCONCLUSIONnMost of the population could reduce their likelihood of MI by engaging in PA at a moderate level of intensity or, in individuals older than 64 years, at a light level of intensity.

Association Between Paraoxonase-1 and Paraoxonase-2 Polymorphisms and the Risk of Acute Myocardial Infarction

INTRODUCTION AND OBJECTIVESnTwo particular polymorphisms, namely PON1-192 and PON2-311, in the genes encoding the antioxidant enzymes paraoxonase-1 (PON1) and paraoxonase-2 (PON2) have been associated with an increased risk of acute myocardial infarction (AMI). However, previous findings have been contradictory. The aim of this study was to investigate the association between the PON1-192 and PON2-311 polymorphisms and their interaction on AMI risk.nnnMETHODSnThis case-control study involved 746 consecutive AMI patients and 1796 control subjects without cardiovascular disease, who were randomly selected from the same population from which the patients came. All participants were recruited between 1999 and 2000 from four Spanish autonomous regions. All were assessed for the presence of PON1-192 and PON2-311 and for classical cardiovascular risk factors. Multivariate analysis was carried out using logistic regression modeling.nnnRESULTSnThe odds ratios (OR) of AMI for patients with the PON1-192 QQ and PON2-311 SS genotypes (who comprised 50% and 66% of the population, respectively) were 1.26 (95% confidence interval [CI], 1.02-1.55) and 1.25 (95% CI, 1.04-1.50), respectively, compared with R and C allele carriers. Moreover, in patients with both QQ and SS genotypes, the adjusted OR of AMI increased to 1.41 (95% CI, 1.13-1.76).nnnCONCLUSIONSnOur results indicate that the PON1-192 and PON2-311 polymorphisms were independent risk factors of AMI in our population.

Diferencias por sexo en la supervivencia relativa y los factores pronósticos de pacientes con un primer infarto agudo de miocardio en Guipúzcoa

Introduccion y objetivos Estimar la supervivencia a los 28 dias y a los 5 anos y los factores pronosticos asociados en personas que han sufrido un primer infarto agudo de miocardio. Metodos Se estudio a 1.677 pacientes con un primer infarto agudo de miocardio que accedieron a un hospital de Guipuzcoa entre 1997 y 2000. Resultados Las mujeres eran unos 10 anos mayores, presentaron mas diabetes mellitus e hipertension y un cuadro clinico mas desfavorable y recibieron menos recursos terapeuticos, aunque eran menos fumadoras que los varones. La supervivencia fue superior entre los varones mayores de 60 anos a los 28 dias y a los 5 anos. En el periodo de 29 dias a 5 anos, los varones de todos los grupos de edad presentaron una supervivencia relativa mas larga. Los factores relacionados con la supervivencia a corto y largo plazo difirieron entre uno y otro sexo. La gravedad de la enfermedad en la fase aguda y la edad en la fase tardia fueron factores relacionados con la supervivencia de varones y mujeres y en el resto de las variables el comportamiento fue distinto entre uno y otro sexo. Conclusiones El infarto es una enfermedad con una elevada mortalidad en la fase aguda. Existe una interaccion entre el sexo y la edad que afecta a la supervivencia tras un infarto agudo de miocardio. Varios factores se asocian a un peor pronostico precoz y tardio en ambos sexos.