Francisco Martín

Prognostic relations between inflammatory markers and mortality in diabetic patients with non-ST elevation acute coronary syndrome

Objective: To determine the differences in the inflammatory status between diabetic and non-diabetic patients and to evaluate the usefulness of C reactive protein, fibrinogen, and leucocyte count as predictors of death in diabetic patients with unstable coronary disease. Design: Nested case-control comparisons of the inflammatory status between diabetic and non-diabetic patients. Prospective cohort analysis of C reactive protein concentration, fibrinogen concentration, and leucocyte count as predictors of cardiovascular death in diabetic patients. Setting: Coronary care unit in Spain. Participants: 83 diabetic patients with non-ST elevation acute coronary syndrome and 83 sex and aged matched patients selected from 361 non-diabetic patients with non-ST elevation acute coronary syndrome. Main outcome measures: Plasma concentrations of C reactive protein and fibrinogen, and leucocyte count. Investigators contacted patients to assess clinical events. Results: Concentrations of C reactive protein and fibrinogen, and leucocyte count on admission were higher in diabetic than in non-diabetic patients (7 mg/l v 5 mg/l, p  =  0.020; 3.34 g/l v 2.90 g/l, p  =  0.013; and 8.8 × 109/l v 7.8 × 109/l, p  =  0.040). Among diabetic patients, these values were also higher in those who died during the 22 month follow up (13 mg/l v 6 mg/l, p  =  0.001; 3.95 g/l v 3.05 g/l, p < 0.001; and 11.4 × 109/l v 8.4 × 109/l, p  =  0.005). After adjustment for confounding factors, diabetic patients in the highest tertile of C reactive protein had a hazard ratio for cardiovascular death of 4.51 (95% confidence interval (CI) 1.62 to 12.55). Similar hazard ratios were for fibrinogen 3.74 (95% CI 1.32 to 10.62) and for leucocyte count 3.64 (95% CI 1.37 to 9.68). Conclusions: Inflammation appears more evident in diabetic than in non-diabetic patients with acute coronary syndrome. C reactive protein concentration, fibrinogen concentration, and leucocyte count constitute independent predictors of cardiovascular death in diabetics with unstable coronary disease.

Seguridad y eficacia clínica de la estimulación con el modo AAI en la disfunción del nodo sinusal: seguimiento a largo plazo

Introduction and objectives. Although atrial pacing is a more physiological mode of stimulation in sinus node dysfunction, the pacing modes most often are used DDD and VVI. The aim of our study was to demonstrate that AAI/AAIR pacing is effective and safe by analyzing the complications and mortality of this pacing mode in a longterm follow-up study. Patients and method. Between 1982 and 2000 definitive AAI-mode pacemakers were implanted for sinus node dysfunction in mode AAI in 160 patients. We analyzed the clinical characteristics, evolution, and complications of the AAI pacing mode during a follow-up of 5.4 ± 4.5 years. Results. The sample was made up of 104 women and 56 men with an average age of 72 ± 12 years. During follow-up, it was necessary to change the pacing mode for symptomatic bradycardia in 11 patients (annual incidence 1.2%), which was caused by second or third-degree atrioventricular block in 7 patients (annual incidence 0.8%), and chronic atrial fibrillation with bradycardia in 4 patients (annual incidence 0.4%). During follow-up, atrial arrhythmias occurred in 32 patients (annual incidence 3.7%), stroke in 4 patients (annual incidence 0.4%), and 27 patients (annual incidence 3.1%) died. Conclusions. The AAI/AAIR pacing mode was safe and effective in sinus node dysfunction, with a low percentage of pacing changes required for progression to atrioventricular block, low incidence of atrial arrhythmias, stroke and low mortality during long term follow-up.

[Kinetics of C-reactive protein release in different forms of acute coronary syndrome].

INTRODUCTION AND OBJECTIVES Better knowledge of C-reactive protein (CRP) kinetics could lead to improved clinical application of this biomarker. METHODS We studied 110 patients: 42 had ST-elevation acute myocardial infarction (STEMI), 35 had non-ST-elevation acute myocardial infarction (NSTEMI), and 33 had unstable angina. Patients were admitted to our institution within 6 hours of symptom onset. The levels of CRP, troponin-I, and creatine kinase MB fraction (CK-MB) were measured on admission and every 6 hours during the first 48 h. The CRP level was also measured daily until hospital discharge. RESULTS The median (interquartile range) CRP level increased relative to baseline from 6 hours after admission, from 5 (2-9) mg/L to 6 (3-10) mg/L (P=.004). Although, CRP levels on admission were similar in all groups, there was a significant difference in peak CRP level: it was 67 (36-112) mg/L in the STEMI group, 29 (20-87) mg/L in the NSTEMI group, and 18 (12-36) mg/L in the unstable angina group. The maximum CRP level was observed 49 (38-53) hours after the onset of symptoms, but occurred later in patients with STEMI. Although there was only a weak non-significant correlation between CRP and troponin levels (r=0.135) at admission, the maximum CRP level was found to be influenced by the degree of myocardial damage (r=0.496; P< .001). CONCLUSIONS The pattern of CRP release observed was clearly different in different forms of acute coronary syndrome. Although the CRP level measured at admission was similar in all patient groups, it was influenced by the degree of early myocardial tissue necrosis. This variation in CRP kinetics should be taken into consideration when designing future studies.

Pronóstico hospitalario del síndrome coronario agudo sin elevación del segmento ST determinado por una nueva escala de riesgo integrada por variables electrocardiográficas obtenidas al ingreso

Diferentes variables electrocardiograficas tienen capacidad predictiva en el sindrome coronario agudo sin elevacion del ST (SCASEST). Tras analizar a 427 pacientes, construimos una escala de riesgo (ER) basada en el ECG al ingreso (ER-ECG) para definir la probabilidad de muerte o isquemia recurrente (M-IsqR) durante la hospitalizacion, que fue del 36%. En un analisis de regresion logistica que incluyo siete variables electrocardiograficas y las de la ER TIMI, alcanzaron la significacion estadistica: QTc ≥ 450 ms (odds ratio [OR] = 4,2; p 0,5 (OR = 2,7; p 0,5 mm y 1 a crecimiento auricular izquierdo. Agrupando a los pacientes segun la ER-ECG en: ≤ 1, 2-3, ≤ 4, esta discrimino adecuadamente la probabilidad de M-IsqR: el 11 frente al 27 frente al 58% (p

Early Reduction of QT Dispersion after Primary Percutaneous Intervention in ST-Segment Elevation Acute Myocardial Infarction

Objectives: To determine, in patients with ST-segment elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PPCI), the mechanisms and clinical implications of the acute changes in QT dispersion (QTd). Methods: In this prospective study we included 216 patients admitted with a STEMI of <12 h of evolution. All were treated with PPCI. QTd was measured prior to PPCI and within 1 h after. Results: The ratio of QTd reduction after PPCI (QTd-R) – defined as [(QTd before PPCI – QTd after PPCI)/QTd before PPCI] ×100 – was significantly correlated with the percentage of ST-segment elevation resolution (ST-R; p < 0.001). To determine the significance of the different values of QTd-R, we further subdivided our population into 3 groups according to the tertiles of QTd-R (<10, 11–49, ≥50%). Patients with longer QTd-R had higher percentages of ST-R: 32 ± 43 for QTd-R <10% vs. 60 ± 21 for 11–49% vs. 71 ± 12 for ≥50% (p < 0.05). By logistic regression, patients with QTd-R ≥50% had a reduction of 75% in the adjusted frequency of death or severe heart failure during hospitalization (95% CI 13–73%, p = 0.03). Conclusion: QTd-R after PPCI occurs early, is closely related to the restoration of reperfusion at the microvascular level and provides additional prognostic information.

Epidemiología de la insuficiencia cardiaca en España: por una foto más global

El estudio PRICE1 muestra una prevalencia de insuficiencia cardiaca del 6,8% en la población española de 45 o más años, cifra cercana al 5% encontrado en un estudio previo realizado en Asturias2, y que se eleva hasta el 16% cuando se considera sólo a la población por encima de los 75 años. Estos resultados confirman el notable aumento del número de casos de insuficiencia cardiaca en los últimos 20 años en los países occidentales, que condiciona una necesidad cada vez mayor de atención sanitaria y un elevado consumo de recursos para su tratamiento. Sin embargo, para valorar con mayor precisión la carga asistencial total de un problema de salud es necesario conocer, como medida complementaria a la prevalencia, el número de hospitalizaciones que genera. Así, el grupo de diagnóstico relacionado 127, en el que se encuadran insuficiencia cardiaca y shock, supone, con un 2,68%, la segunda causa de ingreso hospitalario en España y la primera de pacientes mayores de 65 años3. Desde nuestro punto de vista, una medida que puede complementar a la del número de hospitalizaciones en la valoración de la carga asistencial sería el número de atenciones urgentes, ya que en muchas ocasiones el ingreso de un paciente depende de los recursos asistenciales del sistema sanitario en cada centro o región. A modo de ejemplo, las áreas de observación que durante los últimos años se han generalizado en los servicios de urgencias (SU) constituyen lugares excelentes donde solventar, en 24 horas y sin ingreso, trastornos que hasta hace poco lo requerían4. Así, el estudio EAHFE5 (un estudio descriptivo transversal realizado en 10 SU de hospitales españoles en el que se recogió la información de 1.017 pacientes consecutivos atendidos por insuficiencia cardiaca durante 1 mes) mostró que el 70% de los pacientes fueron hospitalizados (más de la mitad en unidades de corta estancia vinculadas a los servicios de urgencias) y, del 30% que fue dado de alta desde urgencias, el 17% pasó por estas unidades de observación. Dichos datos indican de lo que puede suponerse que representó una importante modificación de los hábitos asistenciales en breve tiempo. Cabría plantear la hipótesis de que el complejo proceso que permite unos buenos resultados (tiempos de espera prehospitalarios y hospitalarios, selección adecuada de pacientes4, etc.) y que ciertamente va más allá de la correcta ejecución técnica de la intervención no hubiera alcanzado en 2004-2005 la madurez necesaria. El mensaje de esta interpretación sería que poner en práctica las intervenciones invasivas recomendadas en las guías comporta no sólo realizarlas, sino modificar adecuadamente el proceso asistencial. Nuestro estudio podría ser útil como punto de referencia para que cada centro comprobara en qué medida esto es así en la actualidad. Por otra parte, los requisitos de calidad que debe poseer un registro válido están mucho menos establecidos que para los ensayos clínicos, lo que puede dificultar aún más su lectura correcta. Las dificultades para realizar registros que reflejen adecuadamente la realidad de los centros participantes están habitualmente infravaloradas y poco reconocidas en los estudios. En el MASCARA fue necesario un complejo control de calidad que llevó a la exclusión de 18 centros para asegurar la validez de los resultados obtenidos. No es nada fácil asegurar la inclusión consecutiva y exhaustiva en las condiciones actuales de práctica hospitalaria. Y en su ausencia, los sesgos resultantes pueden ser insospechadamente altos. Sirvan estos comentarios para ilustrar lo complejo de realizar e interpretar estudios observacionales, cuya necesidad ponen adecuadamente de manifiesto JiménezNavarro et al.

Valor pronóstico tardío de la troponina I en los pacientes ingresados en una unidad coronaria por angina inestable

Introduccion y objetivos La troponina I (TnI) es un marcador de dano miocardico utilizado en la estratificacion pronostica del sindrome coronario agudo. El objetivo del estudio fue analizar el valor pronostico tardio del nivel maximo de TnI obtenido en las 48 h tras el ingreso en una unidad coronaria por angina inestable. Metodos Se incluyo a 149 pacientes consecutivos. Se realizaron determinaciones seriadas de la fraccion MB de la creatincinasa (CK-MB) y TnI. Los pacientes sin elevacion de la CK-MB fueron clasificados en dos grupos, en funcion de la presencia de TnI elevada (n = 58) o normal (n = 91). Se analizaron prospectivamente los factores clinicos y evolutivos relacionados con la probabilidad de muerte, nuevo episodio agudo coronario o revascularizacion coronaria tras un ano de seguimiento. Resultados No se observaron diferencias entre los dos grupos en relacion con las caracteristicas clinicas, salvo la edad, que fue mayor en el grupo con TnI elevada (69 frente a 64 anos; p = 0,01). Tras un ano de seguimiento no se apreciaron diferencias en la incidencia de nuevos acontecimientos coronarios agudos ni en la revascularizacion; sin embargo, la mortalidad fue mayor en el grupo con TnI elevada (el 13 frente al 4%; p = 0,01). Los predictores independientes de mortalidad fueron el infarto previo (riesgo relativo [RR] = 3), TnI elevada (RR = 3,2), fraccion de eyeccion 70 anos (RR = 15). Conclusiones En la angina inestable, un valor elevado de TnI dentro de las primeras 48 h del ingreso se asocia con un aumento de la mortalidad al ano de seguimiento.

In-Hospital Prognosis in Non-ST-Segment Elevation Acute Coronary Syndrome Derived Using a New Risk Score Based on Electrocardiographic Parameters Obtained at Admission

Several electrocardiographic variables are of prognostic value in non-ST-segment elevation acute coronary syndrome (NSTEACS). From observations in 427 patients, we developed a new risk score (the ECG-RS) based on admission ECG findings that can be used to determine the likelihood of death or recurrent ischemia during hospitalization, which occurred in 36% of patients. Logistic regression analysis, which considered seven electrocardiographic variables and variables from the Thrombolysis in Myocardial Infarction (TIMI) risk score, identified the following significant predictors: corrected QT interval (QTc) > or =450 ms (odds ratio 4.2, P< .001), ST-segment depression >0.5 mm (odds ratio 2.7, P< .001), and left atrial enlargement (odds ratio 1.8, P =.005). After taking the odds ratios into consideration, we awarded 3 points for a QTc > or =450 ms, 2 points for ST-segment depression >0.5 mm, and 1 point for left atrial enlargement. When patients were divided into three groups on the basis of their ECG-RSs (i.e. < or =1, 2-3 and > or =4), the risk of death or recurrent ischemia was significantly different between the groups, at 11%, 27% and 58%, respectively (P< .001). In conclusion, the new ECG-RS provides a simple, rapid and accurate means of determining prognosis in patients with NSTEACS.

Epidemiology of Heart Failure in Spain: Toward a More Global Perspective

The PRICE1 study reported a prevalence of heart failure of 6.8% in the Spanish population aged 45 years or more, a figure close to the 5% found in a previous study conducted in Asturias (Spain),2 and that rose to 16% when only taking into account the population aged more than 75 years. These results confirm the striking increase in the number of cases of heart failure in the last 20 years in western countries, that has led to an ever-growing need for healthcare and an increased consumption of resources for its treatment. However, to more accurately assess the total burden involved in a specific health problem, we need to know, in addition to prevalence, the number of hospitalizations that it generates. Thus, the Diagnosis-Related Group 127 includes heart failure and shock, which, at 2.68%, are the second most frequent causes of hospital admission in Spain and are the first cause among patients older than 65 years.3 From our standpoint, a measure that could complement the number of hospitalizations in the assessment of health costs would be the number of urgent cases, since on many occasions patient admission depends on the healthcare system resources in each center or region. For example, the observation areas that have recently become widespread within hospital emergency services (HES) are excellent places where, within 24 hours and without admission, disorders can be resolved that until a short time ago would have required admission.4 Thus, the EAHFE study5 (a cross-sectional descriptive study conducted in 10 Spanish HES and that collected information on 1017 consecutive heart failure patients treated over a 1-month period) showed that 70% of the patients were hospitalized (more than half in emergency service short-stay units) and, of the 30% discharged from the emergency service, 17% passed through these observation units. These data indicate the high healthcare burden that heart failure currently places on the HES. Another relevant aspect highlighted by the EAHFE study is that 1 of 4 patients with heart failure treated in the HES did not have a previous of drugs and percutaneous coronary intervention, and it can be assumed that this represents an important change in healthcare practice over a short period. We could form the hypothesis that the process that would have enabled good outcomes (prehospital and hospital waiting periods, correct patient selection,4 etc) would have been highly complex; even with a certainly appropriate technical execution of the intervention, the whole process would not have been sufficiently well-developed by 2004-2005. The message of this interpretation would be that to implement the invasive procedures recommended in the guidelines would not only mean carrying these out, but also appropriately modifying the healthcare management process. Our study could be a useful reference point for each center to assess to what extent this is the case at present. On the other hand, the quality requirements that a valid registry should have are far less established than those for clinical trials, which can further hinder correct interpretation. The difficulties involved in registries that accurately reflect the situation of the participating centers are usually underestimated and barely recognized in the studies. The MASCARA study necessarily involved complex quality control that excluded 18 centers to ensure the validity of the results obtained. It is far from easy to ensure consecutive and complete inclusion in the current conditions of hospital practice. And in its absence, the resulting biases can be surprisingly high. These observations serve to illustrate the complexity involved in conducting and interpreting observational studies, the need for which JiménezNavarro et al make very clear.

Dependencia funcional del paciente atendido en urgencias por insuficiencia cardíaca aguda, factor pronóstico de mortalidad

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