José Manuel Ribera

El anciano con cardiopatía terminal

El objetivo de este documento del Grupo de Estudio «El anciano con cardiopatia terminal», de la Seccion de Cardiologia Geriatrica de la Sociedad Espanola de Cardiologia, es aportar un punto de vista experto que permita un mejor conocimiento de la situacion y una mejora en el manejo y la toma de decisiones en los ultimos dias de vida del paciente de edad avanzada que sufre una cardiopatia. Los cardiopatas ancianos constituyen un grupo heterogeneo y es necesaria una valoracion exhaustiva, especialmente de los factores que condicionan el pronostico (cardiopatia, comorbilidad, situacion funcional y datos de fragilidad) antes de tomar decisiones, sobre todo aquellas que conlleven limitacion del esfuerzo terapeutico como las ordenes de no reanimar o la desactivacion de desfibriladores automaticos implantables. Los ancianos con cardiopatias terminales tienen derecho a disponer de una serie de cuidados y atenciones, entre ellos no sufrir inutilmente, respeto a su libertad de conciencia, conocer su situacion, opinar sobre posibles intervenciones y recibir asistencia psicoespiritual. Los cuidados paliativos deben dirigirse al control de los sintomas tras el diagnostico de la enfermedad incurable y no iniciarse unicamente en la fase de agonia. Estos cuidados estan poco desarrollados en las cardiopatias y deben de tenerse presentes en los ancianos con insuficiencia cardiaca avanzada. Su objetivo es conseguir el maximo bienestar para el paciente desde un punto de vista integral, mejorar su calidad de vida antes del fallecimiento y evitar el empleo de tratamientos agresivos que consumen recursos sin resultados.

Hospitalizations for ambulatory care sensitive conditions and quality of primary care: their relation with socioeconomic and health care variables in the Madrid regional health service (Spain).

Background:Hospitalizations for ambulatory care sensitive conditions (ACSH) have been proposed as an indirect indicator of the effectiveness and quality of care provided by primary health care. Objective:To investigate the association of ACSH rates with population socioeconomic factors and with characteristics of primary health care. Research Design:Cross-sectional, ecologic study. Using hospital discharge data, ACSH were selected from the list of conditions validated for Spain. Setting:All 34 health districts in the Region of Madrid, Spain. Subjects:Individuals aged 65 years or older residing in the region of Madrid between 2001 and 2003, inclusive. Measures:Age- and gender-adjusted ACSH rates in each health district. Results:The adjusted ACSH rate per 1000 population was 35.37 in men and 20.45 in women. In the Poisson regression analysis, an inverse relation was seen between ACSH rates and the socioeconomic variables. Physician workload was the only health care variable with a statistically significant relation (rate ratio of 1.066 [95% CI; 1.041–1.091]). These results were similar in the analyses disaggregated by gender. In the multivariate analyses that included health care variables, none of the health care variables were statistically significant. Conclusions:ACSH may be more closely related with socioeconomic variables than with characteristics of primary care activity. Therefore, other factors outside the health system must be considered to improve health outcomes in the population.

Negative Blood Culture Infective Endocarditis in the Elderly: Long-Term Follow-Up

Background and Aim: Since the appearance of transesophageal echocardiography, the long-term prognosis of patients with negative blood culture infective endocarditis (NBCIE) has been found to be similar to that of patients with positive blood culture infective endocarditis (PBCIE). Nevertheless, the prognostic implications of NBCIE in the elderly (>65 years) has not, to date, been well documented. Our aim was to study the long-term prognosis of elderly patients with NBCIE and compare it with that of elderly patients with PBCIE. Methods: Our study group was composed of 60 consecutive patients >65 years old with a diagnosis of IE (confirmed by vegetation analysis or following Duke’s criteria). Every patient underwent transthoracic and transesophageal echocardiography. Fifty patients (83.3%) had PBCIE and 10 (16.7%) had NBCIE. All patients were followed up long-term, and the study end point was a composite one of death or need for valvular heart surgery. Results: Mean age was 72.9 ± 5 years (56.7% male). Similar clinical and echocardiographic characteristics were found in both groups. Global mortality, need for surgery, predisposing factors and infection location were also similar in both groups. In addition, no differences were found in the long-term prognosis (log rank p = 0.29). Conclusions: In our series, the long-term prognosis in elderly patients with IE is independent of the presence of a negative or positive blood culture. Thus, age cannot be considered an independent risk factor of negative outcome in elderly patients with NBCIE.

Initial results and long-term clinical and angiographic implications of coronary stenting in elderly patients

Results of 378 consecutive elderly patients (> or = 65 years) undergoing coronary stenting were compared with those of 601 younger patients. Although the restenosis rate was similar in the 2 groups, age > or = 65 years was an independent predictor of in-hospital mortality (relative risk 5.4, 95% confidence interval 1.2 to 20.1) and follow-up mortality (relative risk 2.8, 95% confidence interval 1.3 to 6.1).

Disección intramiocárdica postinfarto de la pared posterior del ventrículo izquierdo con comunicación con el seno coronario

Paciente diabetica de 83 anos ingresada en nuestro centro por infarto agudo de miocardio posteroinferior en evolucion. Al cuarto dia de estancia presento un soplo pansistolico en mesocardio y apex de nueva aparicion. El ecocardiograma transtoracico puso de manifiesto acinesia de la pared posterior e inferior con imagen indicativa de diseccion de la pared posterior del ventriculo izquierdo, que se originaba en el segmento medio-distal de la misma, con orificio de entrada de 7 mm de diametro. Se apreciaba flujo turbulento en el interior de la auricula derecha, indicativo de proceder del seno coronario. Con el ecocardiograma transesofagico se confirmo la diseccion intramiocardica de la pared posterior del ventriculo izquierdo y su comunicacion con el seno coronario, identificando el flujo turbulento de la auricula derecha como procedente del mismo. Tras optar por el tratamiento medico, la paciente ha sido seguida por espacio de dos anos. El diametro del orificio de entrada del trayecto disecante permanecio sin cambios, si bien se observo crecimiento del diametro de la zona disecada y del seno coronario, aunque no dilatacion significativa de las cavidades derechas.