Manuel Jiménez Navarro

Prevalencia de la insuficiencia cardiaca en la población general española mayor de 45 años. Estudio PRICE

Introduccion y objetivos La insuficiencia cardiaca congestiva (ICC) tiene elevadas incidencia, morbilidad y mortalidad y una gran prevalencia. Sin embargo, no hay datos directos sobre este aspecto en nuestro pais. El objetivo de nuestro estudio es evaluar la prevalencia de ICC en Espana. Metodos Se diseno un estudio poblacional en el que participaron 15 centros repartidos por toda Espana. Se selecciono de forma aleatoria una muestra de la poblacion de 45 o mas anos de edad atendida en cada area de salud, que fue estudiada por sus medicos de atencion primaria. Se utilizaron los criterios de Framingham para el diagnostico. Las personas con criterios de ICC fueron remitidas a una consulta de cardiologia para confirmacion diagnostica y realizacion de ecocardiograma. Resultados Se evaluo a 1.776 personas, con una media ± desviacion estandar (intervalo) de edad de 64 ± 12 (45-100) anos; eran varones el 44%. Se remitio a cardiologia a 242 pacientes. La prevalencia ponderada de ICC fue del 6,8% (intervalo de confianza [IC] del 95%, 4%- 8,7%). La prevalencia fue similar en varones (6,5%; IC del 95%, 4,7%-8,4%) y en mujeres (7%; IC del 95%, 4,4%-9,6%). Por edades, la prevalencia fue del 1,3% (0,4%-2,1%) entre los 45 y 54 anos; el 5,5% (2,4%-8,5%) entre 55 y 64 anos; el 8% (4,2%-11,8%) entre 65 y 74 anos, y el 16,1% (11%-21,1%) en personas de 75 o mas anos. Conclusiones La prevalencia de ICC en Espana es alta, en torno a un 7-8%. La prevalencia es similar varones y mujeres, y parece aumentar con la edad.

Comparison of Paclitaxel-Eluting Stents (Taxus) and Everolimus-Eluting Stents (Xience) in Left Main Coronary Artery Disease With 3 Years Follow-Up (from the ESTROFA-LM Registry)

Evidence regarding therapy with drug-eluting stents in the left main coronary artery (LM) is based mostly on trials performed with first-generation drug-eluting stents. The aim of this study was to evaluate long-term clinical outcomes after treatment for unprotected LM disease with paclitaxel-eluting stents (PES) and everolimus-eluting stents (EES). The ESTROFA-LM is a multicenter retrospective registry including consecutive patients with unprotected LM disease treated with PES or EES. A total of 770 patients have been included at 21 centers, 415 with treated PES and 355 with EES. Treatment with 2 stents was more frequent with PES (17% vs 10.4%, p = 0.007), whereas intravascular ultrasound was more frequently used with EES (35.2% vs 26%, p = 0.006). The 3-year death and infarction survival rates were 86.1% for PES and 87.3% for EES (p = 0.50) and for death, infarction, and target lesion revascularization were 83.6% versus 82% (p = 0.60), respectively. Definite or probable thrombosis was 1.6% for PES and 1.4% for EES (p = 0.80). The use of 2 stents, age, diabetes, and acute coronary syndromes were independent predictors of mortality. In the subgroup of distal lesions, the use of intravascular ultrasound was an independent predictor of better outcome. Comparison of propensity score-matched groups did not yield differences between the 2 stents. In conclusion, the results of this multicenter registry show comparable safety and efficacy at 3 years for PES and EES in the treatment of LM disease. The use of bifurcation stenting techniques in distal lesions was a relevant independent predictor for events. The use of intravascular ultrasound appears to have a positive impact on patients treated for LM distal disease.

Does angina the week before protect against first myocardial infarction in elderly patients

Mortality rates for coronary artery disease are greater in elderly patients. Although prodromal angina occurring shortly before an acute myocardial infarction (MI) has protective effects against ischemia, this effect has not been well documented in older patients. This study investigated whether angina 1 week before a first MI provides protection in this group of patients. A total of 290 consecutive elderly (>64 years old, n = 143) and adult patients (<65 years old, n = 147) with a first MI were examined to assess the effect of preceding angina on the short- and long-term prognosis. Elderly patients with a history of prodromal angina were less likely than those without angina to experience in-hospital death, heart failure, or the combined end point of in-hospital death and heart failure (6% vs 20.4%, p = 0.02; 10% vs 23.7%, p = 0.07; 14% vs 32.3%, p = 0.01, respectively). Left ventricular function was more frequently depressed (ejection fraction <40%) in elderly patients without (44.8%) than with (26%, p = 0.04) preinfarction angina, and the incidence of arrhythmias (complete heart block and ventricular fibrillation) was greater in the former group (16.1% vs 4%, p = 0.03). Multivariate analysis confirmed that the presence of preinfarction angina was an independent predictor of in-hospital death and heart failure in older patients (odds ratio 0.28, p = 0.009). The occurrence of angina 1 week before a first MI may confer protection against in-hospital adverse outcomes, and may preserve left ventricular function in older patients.

Prevalence of Heart Failure in the Spanish General Population Aged Over 45 Years. The PRICE Study

INTRODUCTION AND OBJECTIVES Congestive heart failure is associated with substantial morbidity and mortality and both its incidence and prevalence are high. Nevertheless, comprehensive data on this condition in Spain are lacking. The aim of this study was to determine the prevalence of congestive heart failure in Spain. METHODS A demographic study which involved the participation of 15 healthcare centers throughout Spain was carried out. In each health area, a random sample was taken of the population aged 45 years or more. These individuals were examined by their primary care physicians, who made their diagnoses using Framingham criteria. Individuals who satisfied criteria for congestive heart failure were referred to a cardiologist for confirmation of the diagnosis and for echocardiography. RESULTS Overall, 1776 individuals were evaluated. Their mean age was 64+/-12 years (range, 45-100 years) and 44% were male. Of these, 242 were referred to a cardiologist. The weighted prevalence of congestive heart failure was 6.8% (95% confidence interval [CI] 4%-8.7%). The prevalence was similar in men (6.5%, 95% CI 4.7%-8.4%) and women (7%, 95% CI 4.4%-9.6%). When analyzed by age, the prevalence was 1.3% (0.4%-2.1%) in those aged 45-54 years, 5.5% (2.4%-8.5%) in those aged 55-64 years, 8% (4.2%-11.8%) in those aged 65-74 years, and 16.1% (11%-21.1%) in those aged over 74 years. CONCLUSIONS Prevalence of congestive heart failure in Spain is high, at about 7%-8%. The prevalence was similar in males and females, and appeared to increase with age.

Garantía y mejora de calidad de la atención al paciente con infarto agudo de miocardio. Implantación de un programa de calidad

Introduccion y objetivos En la atencion hospitalaria del paciente con infarto agudo de miocardio, existe una serie de medidas terapeuticas y de estratificacion de riesgo cuya no realizacion es inexcusable, ya que han demostrado claramente su eficacia. El proposito de este estudio es desarrollar un programa interno de garantia y mejora de calidad de la atencion hospitalaria al paciente con infarto agudo de miocardio. Metodos Se utilizo como proceso evaluativo el audit medico. En primer lugar, se analizaron en el informe de alta de 163 pacientes consecutivos siete criterios de evaluacion considerados de clase I por las guias para el tratamiento de estos pacientes. Tras evaluar los resultados, se aplicaron medidas correctoras. En una segunda fase se realizo una revaluacion de 40 nuevos pacientes para conocer la eficacia de las medidas adoptadas. Resultados Tras la primera evaluacion se encontro que el uso de acido acetilsalicilico, inhibidores de la enzima conversora de la angiotensina y betabloqueadores se indico correctamente en el 95, el 80 y el 72% de los pacientes, respectivamente. Se realizo una estrategia de estratificacion de riesgo adecuada y se valoro la funcion ventricular en el 93 y el 96% de los casos. Se indico tratamiento hipolipemiante correcto en el 54%. La dieta adecuada se prescribio en un 100%. Tras 3 meses de la intervencion, se evaluaron 40 nuevos pacientes y se observo que se cumplian todos los criterios analizados en el 100% de los casos. Conclusiones El uso de tecnicas de evaluacion y mejora de la calidad asistencial en la atencion del infarto agudo de miocardio permite conocer que tipo de practica realizamos y corregirla, si es necesario, para aproximarnos a las recomendaciones consensuadas sobre el cuidado de estos pacientes.

Significado pronóstico a largo plazo de la anemia en una población no seleccionada de pacientes con insuficiencia cardíaca

BACKGROUND AND OBJECTIVE: Prevalence of anemia in heart failure is variable. Many studies have established a relation between anemia and prognosis in selected patients with heart failure. We have poor information anout the long-term prognosis in non- selected populations. PATIENT AND METHOD: We analyze the presence of anemia during 2 month in 100 consecutive patients in our hospital with a main diagnosis of heart failure (Cardiology or Internal Medicine departments). We defined anemia according to WHO criteria: hemoglobin level lower than 130 g/l (men) and 120 g/l (women). We studied the influence of anemia in long-term prognosis (follow-up of 25+/-18 m). RESULTS: Mean age was 71.8 (9) years. 41% of patients had anemia. Values of hemoglobin were related to age and creatinine, but not with cardiovascular risk factors. Patients who died (38%) had lower hemoglobin than patients who survived (121 [22] gr/dl vs 130 [17] gr/dl; p<0.02). Mortality in the anemia group was 52.5% vs 32.1% (p<0.04). In the Cox multivariable analisis, anemia was a predictor factor of mortality in the follow-up (RR = 1,55; CI 95%, 1.05-2.47; p<0.04) and functional class (III/IV) (RR=2.52; CI 95%, 1.56-4.07; p<0.001). CONCLUSIONS: In a non-selected population of patients with heart failure, the prevalence of anemia is high and has independiente prognostic value in long-term mortality with functional advanced class.

Neumopericardio en un paciente asmático. Descripción de un caso y revisión de la bibliografía

El neumopericardio es una afeccion infrecuente pero potencialmente grave cuya causa principal es el distres respiratorio en ninos prematuros sometidos a ventilacion mecanica. En adultos, las causas mas frecuentes son la iatrogenia en procedimientos tanto diagnosticos como terapeuticos y los trauma-tismos. Describimos un caso de neumopericardio en un adolescente, diagnosticado en el contexto de una crisis asmatica. Presentamos una revision bibliografica de los casos previamente publicados y discutimos cuales son los hallazgos mas relevantes del examen fisico y de las pruebas complementarias habituales.

Clinical Impact of Drug‐eluting Stents in an Unselected Population of Diabetic Patients

Drug‐eluting stents (DES) have been shown in randomized trials to reduce clinical events in diabetic patients. Our aim was to determine whether these clinical results are applicable in an unselected population of patients with non‐insulin‐dependent diabetes mellitus (NIDDM) and insulin‐dependent diabetes mellitus (IDDM).

Coronariografía preoperatoria en pacientes valvulares. Análisis de probabilidad de lesión coronaria

Introduccion y objetivos La indicacion de coronariografia en pacientes valvulares es recomendada de forma rutinaria previa a la realizacion de cirugia. La seleccion se hace en funcion de la edad, sexo y presencia de angina pero no suele estar basada en los factores de riesgo. El objetivo de este estudio es valorar marcadores que permitan predecir la probabilidad de lesion coronaria en este grupo de pacientes. Pacientes y metodos Se estudio retrospectivamente una poblacion de 541 pacientes con enfermedad valvular a los que se realizo coronariografia durante el periodo 1989-1994. De ellos, 301 eran varones y 240 mujeres con una edad media de 61,8 anos (rango, 34-82). Se relaciono la presencia de lesion coronaria con las variables edad, sexo, angina, hipertension, diabetes, hipercolesterolemia, tabaco, antecedentes familiares y la presencia de angina mediante analisis de regresion logistica. Resultados En 73 pacientes existia lesion coronaria superior al 50% (13,4%). La presencia de angina se aprecio en el 34,6% de los casos. El riesgo de lesion coronaria fue definido como odds ratio: angina 3,3, tabaco 2,6, diabetes 2,2, hipertension 1,8 y edad 1,4. El resto de variables no fueron predictoras de enfermedad coronaria. La probabilidad de lesion coronaria en pacientes sin angina y ausencia de los factores de riesgo descritos como predictores es del 4%. Si ademas analizamos la edad la probabilidad de enfermedad coronaria en pacientes menores de 65 anos era del 3% para los pacientes sin angina ni factores de riesgo, en cambio la probabilidad en el mismo grupo de pacientes > 65 anos fue del 6%. Conclusiones La ausencia de angina y de al menos los tres factores de riesgo descritos como predictores (tabaquismo, hipertension y diabetes) en pacientes menores de 65 anos permite descartar la enfermedad coronaria asociada en pacientes valvulares que van a ser intervenidos quirurgicamente lo que permite obviar la coronariografia en este grupo de pacientes.

Dual Antiplatelet Therapy for 6 Months vs 12 Months After New-generation Drug-eluting Stent Implantation: Matched Analysis of ESTROFA-DAPT and ESTROFA-2.

INTRODUCTION AND OBJECTIVES The recommendation for dual antiplatelet therapy following drug-eluting stent implantation ranges from 6 months to 12 months or beyond. Recent trials have suggested the safety of a 6-month dual antiplatelet therapy regimen, yet certain caveats to these studies limit the applicability of this shorter duration dual antiplatelet therapy strategy in real world settings. METHODS A registry was constructed with consecutive recruitment of patients undergoing new-generation drug-eluting stent implantation and prescribed 6 months of dual antiplatelet therapy. Propensity score matching was undertaken with a historical cohort of patients treated with second-generation drug-eluting stents who received 12 months of dual antiplatelet therapy from the ESTROFA-2 registry. The sample size was calculated using a noninferiority basis and the primary endpoint was the combination of cardiac death, myocardial infarction, revascularization, or major bleeding at 12 months. RESULTS The analysis included 1286 patients in each group, with no significant differences in baseline characteristics. The primary endpoint occurred in 5.0% and 6.6% in the 6-month and 12-month groups, respectively (P = .001 for noninferiority). The incidence of definite or probable stent thrombosis was 0.5% and 0.7% in the 6-month and 12-month groups, respectively (P = .4). Major bleeding events were lower in the 6-month group than in the 12-month group (0.8% vs 1.4%; P = .2) CONCLUSIONS: In selected patients in this large multicenter study, the safety and efficacy of a 6-month dual antiplatelet therapy regimen after implantation of new-generation drug-eluting stents appeared to be noninferior to those of a 12-month dual antiplatelet therapy regimen.