José C. Sánchez-Salado

Impacto en tiempos de actuación y perfil de los pacientes tratados con angioplastia primaria en el área metropolitana sur de Barcelona al implantar el programa Código Infarto

INTRODUCTION AND OBJECTIVES A standardized protocol of emergent transfer for primary percutaneous coronary intervention for patients with ST elevation myocardial infarction, defined as the Infarction Code, was implemented in June 2009 in the Catalan regional health system. The objective of this study was to evaluate the impact of the new protocol on delay times, number of procedures and clinical characteristics compared with the previous period in the population of patients referred to our hospital. METHODS All consecutive patients undergoing primary percutaneous coronary intervention in our hospital were prospectively registered. The clinical characteristics, delay times and mortality in the follow-up of the protocol implementation period (June 2009-May 2010) were analyzed and compared with the previous year (June 2008-May 2009). RESULTS During the protocol period, 514 patients were included, compared with 241 in the previous year. Age, cardiovascular risk factors, anterior myocardial infarction and procedure characteristics were similar in the 2 groups. The first medical contact to balloon time was lower in the protocol period (median time 120 min vs 88 min; P<.001). Patients in the protocol period showed a trend toward less severe disease (Killip III, rescue angioplasty). The multivariate regression analysis showed a significant association between 1-year mortality and age, Killip class ≥ III at admission, anterior infarction and 3-vessel disease. CONCLUSIONS The introduction of the Infarction Code program increased the number of patients treated by primary percutaneous coronary intervention with a reduction in delay times and better clinical characteristics at presentation. Full English text available from:www.revespcardiol.org.

Clinical Characteristics and Vital and Functional Prognosis of Out-of-hospital Cardiac Arrest Survivors Admitted to Five Cardiac Intensive Care Units

INTRODUCTION AND OBJECTIVES Survivors of out-of-hospital cardiac arrest constitute an increasing patient population in cardiac intensive care units. Our aim was to characterize these patients and determine their vital and functional prognosis in accordance with the latest evidence. METHODS A multicenter, prospective register was constructed with information from patients admitted to 5 cardiac intensive care units from January 2010 through January 2012 with a diagnosis of resuscitated out-of-hospital cardiac arrest. The information included clinical status, cardiac arrest characteristics, in-hospital course, and vital and neurologic status at discharge and at 6 months. RESULTS A total of 204 patients were included. In 64% of cases, a first shockable rhythm was identified. The time to return of spontaneous circulation was 29 (18) min. An etiologic diagnosis was made in 86% of patients; 44% were discharged with no neurologic sequelae; 40% died in the hospital. At 6 months, 79% of survivors at discharge were still alive and neurologically intact with minimal sequelae. Short resuscitation time, first recorded rhythm, pH on admission >7.1, absence of shock, and use of hypothermia were the independent variables associated with a good neurologic prognosis. CONCLUSIONS Half the patients who recovered from out-of-hospital cardiac arrest had good neurologic prognosis at discharge, and 79% of survivors were alive and neurologically intact after 6 months of follow-up.

CRUSADE bleeding risk score validation for ST-segment-elevation myocardial infarction undergoing primary percutaneous coronary intervention

INTRODUCTION The CRUSADE bleeding risk score (CBRS) accurately predicts major bleeding in non-ST segment elevation myocardial infarction NSTEMI patients. However, little information exists about its application in ST segment elevation myocardial infarction STEMI. We aimed to assess the ability of CBRS to predict in-hospital major bleeding in STEMI patients undergoing primary percutaneous coronary intervention (PPCI). MATERIALS AND METHODS We prospectively analyzed consecutive STEMI patients undergoing PPCI. Baseline characteristics, in-hospital complications and mid term mortality were recorded. Major bleeding was defined by the CRUSADE definition. Predictive ability of the CBRS was assessed by logistic regression method and the area under the ROC curve (AUC). RESULTS We included 1064 patients (mean age 63years). Mean CBRS value was 24. Most of patients (740/1064 (69.6%)) were in the two lowest risk quintiles of CBRS. Incidence of in-hospital major bleeding was 33/1064 (3.1%). The rates of in-hospital bleeding across the quintiles of risk groups were 0.4% (very low risk), 2.6% (low), 4.6% (moderate), 7.2% (high), and 13.4% (very high) (p 0.001). AUC was 0.80 (95% CI 0.73-0.87 p 0.001). In patients with radial access angiography (n=621) AUC was 0.81 (95% CI: 0.65-0.97). Mean follow up was 344days. Patients with bleeding events had higher mortality during follow up (HR 6.91; 95% CI 3.72-12.82; p 0.001). CONCLUSIONS Our patients had a significantly lower bleeding risk as compared to CRUSADE NSTEMI population. CBRS accurately predicted major in-hospital bleeding in this different clinical scenario, including patients with radial artery approach.

Efficacy of Bleeding Risk Scores in Elderly Patients with Acute Coronary Syndromes

INTRODUCTION AND OBJECTIVES The incidence of acute coronary syndromes is high in the elderly population. Bleeding is associated with a poorer prognosis in this clinical setting. The available bleeding risk scores have not been validated specifically in the elderly. Our aim was to assess predictive ability of the most important bleeding risk scores in patients with acute coronary syndrome aged ≥ 75 years. METHODS We prospectively included consecutive acute coronary syndromes patients. Baseline characteristics, laboratory findings, and hemodynamic data were collected. In-hospital bleeding was defined according to CRUSADE, Mehran, ACTION, and BARC definitions. CRUSADE, Mehran, and ACTION bleeding risk scores were calculated for each patient. The ability of these scores to predict major bleeding was assessed by binary logistic regression, receiver operating characteristic curves, and area under the curves. RESULTS We included 2036 patients, with mean age of 62.1 years; 369 patients (18.1%) were ≥ 75 years. Older patients had higher bleeding risk (CRUSADE, 42 vs 22; Mehran, 25 vs 15; ACTION, 36 vs 28; P<.001) and a slightly higher incidence of major bleeding events (CRUSADE bleeding, 5.1% vs 3.8%; P=.250). The predictive ability of these 3 scores was lower in the elderly (area under the curve, CRUSADE: 0.63 in older patients, 0.81 in young patients; P=.027; Mehran: 0.67 in older patients, 0.73 in younger patients; P=.340; ACTION 0.58 in older patients, 0.75 in younger patients; P=.041). CONCLUSIONS Current bleeding risk scores showed poorer predictive performance in elderly patients with acute coronary syndromes than in younger patients.

Impact of Anaemia on Mortality and its Causes in Elderly Patients with Acute Coronary Syndromes

BACKGROUND Prognostic impact of anaemia in the elderly with acute coronary syndromes has not been specifically analysed, and little information exists about causes of mortality in this setting. METHODS We prospectively included consecutive patients with acute coronary syndromes. Anaemia was defined as haemoglobin < 130 g/L in men, and < 120 g/L in women. Primary outcome was mid-term mortality and its causes. Analyses were performed by Cox regression method. RESULTS We included 2128 patients, of whom 394 (18.6%) were aged 75 years or older. Anaemia was more common in the elderly (40.4% vs 19.5%, p <0.001). Mean follow-up was 386 days. Anaemia independently predicted overall mortality (HR 1.47, 95% CI 1.05-2.06), cardiac mortality (HR 1.76, 95% CI 1.06-2.94) and non-cardiac mortality (HR 1.59, 95% CI 1.03-2.45) in the overall cohort. In young patients the association between anaemia and mortality was significant only for non-cardiac causes. The association between anaemia and mortality was not significant in the elderly (HR 1.08, 95% CI 0.71-1.63, p 0.736). CONCLUSIONS The impact of anaemia on cause specific of mortality seem to be different according to age subgroup. The association between anaemia and mortality was not observed in elderly patients from our series.

Invasive mechanical ventilation in acute coronary syndromes in the era of percutaneous coronary intervention

Background: Percutaneous coronary intervention (PCI) improves prognosis in patients with acute coronary syndromes (ACS) reducing ischaemic complications and the development of heart failure, thus potentially changing invasive mechanical ventilation (IMV) requirements. Little information exists about patients with ACS requiring IMV in the current era. We aimed to analyze IMV requirements and characteristics of ACS patients treated under current recommendations (including a high rate of PCI). Methods: Baseline characteristics, indications for IMV, management and in-hospital and mid-term clinical course were analyzed prospectively in a consecutive series of patients with ACS admitted to a tertiary care hospital. Results: We included 1821 patients, of which 106 (5.8%) required IMV. Mean follow-up was 347 days. PCI was performed in 84% of cases. Patients with IMV had more comorbidities, worse left ventricular function and more unstable hemodynamic parameters on admission. In-hospital mortality in patients requiring IMV was 29%. These patients also had higher mid-term mortality (hazard ratio (HR) 6.58; 95% confidence interval (CI) 4.49−9.64; p 0.001). The most common indication for IMV was cardiopulmonary arrest (CA) (65; 61%), followed by pulmonary oedema (27; 26%) and shock (14; 13.2%). Patients with CA were younger, with better hemodynamic parameters at admission, more favourable coronary anatomy and higher rates of PCI. There were no significant differences in overall mortality between the three groups. The main cause of death in CA patients was persistent vegetative state. Conclusions: Mortality in patients with ACS requiring IMV remained high despite a high rate of PCI. Baseline characteristics, management and clinical course were different according to the reason for IMV. The most common cause for IMV requirement was CA.

Predictive ability of bleeding risk scores in the routine clinical practice

Background: Previous predictive models of bleeding in acute coronary syndromes (ACSs) used different definitions of bleeding and some of them come from populations lacking important predictors of haemorrhagic complications. Our group previously developed a predictive model of bleeding (PMB), including clinically meaningful variables, providing an optimal predictive ability. We aimed to compare the ability of this PMB with the main available bleeding risk scores for predicting major bleeding according to different definitions in non-selected ACS patients from daily clinical practice. Methods: All ACS patients admitted to the Coronary Care Unit were prospectively included. CRUSADE, Mehran and ACTION bleeding risk scores were calculated for each patient. In-hospital bleeding was recorded using the CRUSADE, TIMI, Mehran, ACTION and BARC definitions. For reasons of clinical relevance, BARC 3 and 5 categories were considered severe BARC bleeding for this study. The predictive ability of the PMB and other bleeding risk scores was assessed by binary logistic regression, ROC curves and areas under the curves (AUCs). Results: We included 1976 patients. Mean age was 62.1 years. Almost all patients underwent angiography, 65% of them by the radial approach. The incidence of major bleeding was: CRUSADE bleeding 3.9% (77/1976); Mehran bleeding 4.8% (94/1976); ACTION bleeding 3.9% (78/1976); and BARC 3/5 bleeding 2.4% (48/1976). The PMB showed the best ability for predicting major bleeding regardless of the definition used. The differences were specially significant for predicting BARC 3/5 bleeding (AUC: PMB 0.87, Mehran score 0.68, CRUSADE score 0.70 and ACTION score 0.70). The predictive ability of CRUSADE, ACTION and Mehran scores was similar for all the definitions analysed. Conclusions: Current bleeding risk scores showed a similar predictive ability for major bleeding regardless of the definitions used. Including other clinically meaningful predictors of bleeding into the new PMB significantly improved its predictive ability in the clinical scenario of ACS.

Prognostic Impact of Chronic Total Occlusion in a Nonculprit Artery in Patients With Acute Myocardial Infarction Undergoing Primary Angioplasty

INTRODUCTION AND OBJECTIVES The prognostic value of chronic total occlusion in nonculprit coronary arteries in patients with myocardial infarction undergoing primary angioplasty remains controversial. Several publications have described different methodologies and conflicting findings. In addition, causes of death were not reported. Our aim is to analyze the prognostic impact of chronic total occlusion in nonculprit coronary arteries and the role of left ventricular ejection fraction in this analysis. METHODS Prospective inclusion of consecutive patients with ST-segment elevation myocardial infarction who underwent primary angioplasty. We recorded baseline characteristics, in-hospital clinical course, and mortality and its causes during follow-up. We assessed the impact of chronic total occlusion on mortality using Cox regression analysis. RESULTS Chronic total occlusion in nonculprit arteries was present in 125 of 1176 patients (10.6%); in 79 of these 125 patients, chronic total occlusion was present in the proximal segments. The mean follow-up was 339 days; 64 (5.8%) patients died during the first 6 months. Patients with chronic total occlusions had more comorbidities, poorer ventricular function, and higher mortality (hazard ratio=2.79; 95% confidence interval, 1.71-4.56). Chronic total occlusion was also associated with noncardiac death (hazard ratio=3.83; 95% confidence interval, 2.10-7.01). Chronic total occlusion in proximal segments was associated with both cardiac (hazard ratio=3.22; 95% confidence interval, 1.42-7.30) and noncardiac deaths (hazard ratio=3.43; 95% confidence interval, 1.67-7.06). The multivariate analysis performed without including left ventricular ejection fraction showed a significant association between chronic total occlusion and mortality. However, when left ventricular ejection fraction was included in the analysis, this association was nonsignificant (hazard ratio=1.76; 95% confidence interval, 0.85-3.65; P=.166). CONCLUSIONS Chronic total occlusion in this clinical setting identified patients at higher risk with more comorbidities and higher mortality, but did not behave as an independent predictor of mortality when left ventricular ejection fraction was included in the analysis.

Is it possible to separate ischemic and bleeding risk in patients with non-ST segment elevation acute coronary syndromes?

nade. Color Doppler-flow examination revealed flow within the anterior portion of the pericardial effusion directed toward the right ventricle in systole and toward the right atrium in diastole. No communication with the right atrium or right ventricle was seen [1]. The intrapericardial flow pattern could also be demonstrated by pulsed-wave Doppler examination. The authors hypothesize that in their case, probably secondary to anticoagulation, the viscosity of the pericardial fluid was low enough to demonstrate, by way of fluid shifts within the confines of the pericardium, the changes of volume and pressure of the heart chambers throughout the cardiac cycle. Nevertheless, the small amount of effusion can be commonly seen in post-radiofrequency ablation, which should be general fluid without red blood cells and could not generate Doppler signal. In our case, the patient has only a small amount pericardial effusion. The flow was clearly demonstrated by color and pulse Doppler which might be due to mild injury around the pulmonary vein during radiofrequency ablation operation. The absence of red blood cells prevents the reflection of the ultrasound beam and, therefore, generates a Doppler signal. This case indicated that in patients with pericardial effusion postprocedure, we should pay more attention to find if there is any flow signal by color and pulse Doppler, which can early detect the communication between chambers and pericardium.

Ventricular Support With Extracorporeal Membrane Oxygenation: A New Rescue Alternative for Refractory Cardiogenic Shock

en una evolucion favorable. Como conclusion, creemos que en la miocarditis aguda lo mas importante es el tratamiento de soporte en la fase inicial. Algunos pacientes precisan asistencia ventricular, sin que ello implique un mal pronostico a largo plazo. En cuanto al diagnostico, la resonancia magnetica es una exploracion de gran utilidad. El reto principal es obtener una exploracion de buena calidad en los pacientes de menor edad (neonatos y lactantes). La biopsia endomiocardica podria reservarse para los pacientes con peor evolucion. En cuanto al pronostico, la afeccion del ventriculo derecho podria ser mas frecuente en los neonatos, pues estos tienen una reactividad vascular pulmonar muy marcada. En estos pacientes, la disfuncion derecha podria ser secundaria a la hipertension pulmonar y no implicar necesariamente mal pronostico.