Mauricio Pellicer

Estratificación del riesgo de pacientes con dolor torácico sin elevación del segmento ST en la puerta de urgencias

Objectives. To investigate the prognostic factors in patients who come to the emergency room with chest pain but without ST segment elevation. Patients and method. 743 consecutive patients were evaluated by recording clinical history, electrocardiogram and troponin I determination, and early (< 24 h) exercise testing was done for the low-risk subgroup of patients (n = 203). All patients were followed during 3 months for major events (acute myocardial infarction or death). Results. Major events occurred in 71 patients (9.6%). Multivariate analysis (C stadistic = 0.79; 95% CI 0.730.84; p = 0.0001) identified the following predictors: age ≥ 72 years (OR = 1.7; 95% CI, 1.0-2.9; p = 0.05), insulindependent diabetes mellitus (OR = 2.9; 95% CI, 1.5-5.4; p = 0.001), previous ischemic heart disease (OR = 1.9; 95% CI, 1.1-3.2; p = 0.02), ST depression (OR = 2.1; 95% CI, 1.2-3.8; p = 0.01) and troponin I elevation (OR = 2.9; 95% CI, 1.5-5.3; p = 0.001). These five predictors were used to construct a risk score based on their odds ratios, which allowed event rate stratification by quartiles of the score: 0-2 points (1.6% events), 3-4 points (8.1% events), 5-7 points (11.9% events) and ≥ 8 points (26.2% events); p = 0.0001. No patient with negative findings in the early exercise testing had major events. Conclusions. In patients with chest pain, the combination of clinical, electrocardiographic and biochemical data available on admission to the emergency service allows rapid prognostic stratification. Early exercise testing is advisable for the final stratification of low risk patients.

Usefulness of concomitant myoglobin and troponin elevation as a biochemical marker of mortality in non-ST-segment elevation acute coronary syndromes.

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Infarto de miocardio sin elevación del ST con coronarias normales: predictores y pronóstico

Introduccion y objetivos. El manejo invasivo del infarto agudo de miocardio sin elevacion del ST (IAMSEST) detecta en ocasiones arterias coronarias sin estenosis significativas. Nuestro objetivo fue evaluar los factores asociados y el pronostico de esta poblacion. Metodos. Estudiamos a 504 pacientes ingresados por IAMSEST y sometidos a cateterismo cardiaco. El objetivo primario fue el hallazgo de coronarias sin estenosis significativas y el secundario, la mortalidad o el infarto a una mediana de 3 anos. Para evaluar el objetivo secundario, se utilizo un grupo control de 160 pacientes ingresados por dolor toracico durante el mismo periodo con troponina normal y coronarias sin estenosis significativas. Resultados. Encontramos coronarias sin lesiones significativas en 64 (13%) pacientes. Los predictores fueron: ser mujer (odds ratio [OR] = 6,6; p = 0,0001), edad < 55 anos (OR = 3,0; p = 0,001) y ausencia de diabetes (OR = 2,4; p = 0,02), tratamiento antiagregante previo (OR = 3,9; p = 0,007) o descenso del ST (OR = 2,4; p = 0,008). La variable ser mujer con al menos dos variables adicionales identifico una coronariografia sin estenosis significativas con especificidad del 85% y sensibilidad del 53%. La ausencia de estenosis coronarias significativas disminuyo la probabilidad de muerte o infarto durante el seguimiento (hazard ratio = 0,3; intervalo de confianza del 95%, 0,2-0,9; p = 0,03). En el total de pacientes sin estenosis coronarias significativas (n = 224), no hubo diferencias en la tasa de sucesos entre los pacientes con troponina elevada y normal. Conclusiones. El sexo femenino, la edad < 55 anos y la ausencia de diabetes, tratamiento antiagregante previo o descenso del ST se asociaron a una coronariografia sin estenosis significativas en el IAMSEST. El pronostico a largo plazo de esta poblacion fue bueno

Estrategia invasiva en el síndrome coronario agudo sin elevación del segmento ST. De los grandes estudios al mundo real

Rev Esp Cardiol 2004;57(12):1143-5

Fiabilidad de los índices de viabilidad miocárdica por resonancia magnética para predecir la mejoría de la función sistólica en pacientes con un primer infarto reciente y arteria abierta

Introduccion y objetivo Analizar la fiabilidad del analisis precoz de los indices mas ampliamente utilizados en resonancia magnetica cardiaca (RMC) para predecir la recuperacion de la funcion sistolica y el remodelado ventricular en pacientes con un primer infarto agudo de miocardio y arteria causante del infarto permeable. Pacientes y metodo Se estudio a 17 pacientes mediante RMC en la que se valoro el grosor de la pared, la respuesta a bajas dosis de dobutamina, la perfusion miocardica de primer paso con gadolinio y el porcentaje de captacion tardia de contraste. Los hallazgos de la RMC inicial se correlacionaron con la funcion segmentaria y global obtenida en la RMC al sexto mes. Resultados De los 272 segmentos de la RMC inicial, 73 mostraron disfuncion sistolica severa, a partir de los cuales se calcularon la sensibilidad y especificidad de cada unos de los indices para predecir viabilidad miocardica. Un grosor diastolico. 5,5 mm obtuvo una sensibilidad del 100% y una especificidad del 12%; en la respuesta a la dobutamina, estas fueron del 41 y el 93%; en una perfusion normal, del 78 y el 68%, y en una captacion tardia Conclusiones La captacion tardia mediante RMC es un indice cuantificable y fiable para predecir la mejoria de la funcion sistolica y el remodelado ventricular en pacientes tras un primer infarto con arteria abierta.

Non-ST-Elevation Acute Myocardial Infarction With Normal Coronary Arteries: Predictors and Prognosis

INTRODUCTION AND OBJECTIVES Occasionally, coronary arteries without significant stenosis are observed during invasive treatment of acute non-ST-elevation myocardial infarction (NSTEMI). The aim was to investigate predictive factors and prognosis in these patients. METHODS The study involved 504 patients admitted for NSTEMI who underwent cardiac catheterization. The primary end-point was the observation of coronary arteries without significant stenosis, and the secondary end-point was death or myocardial infarction within a median of 3 years. In evaluating the secondary end-point, a control group of 160 patients with a normal troponin level and no significant coronary artery stenosis who were admitted for chest pain during the same period was included. RESULTS Overall, 64 patients (13%) had coronary arteries without significant lesions. The predictors were: female sex (odds ratio [OR]=6.6; P=.0001), age <55 years (OR=3.0; P=.001), and the absence of diabetes (OR=2.4, P=.02), previous antiplatelet treatment (OR=3.9, P=.007) or ST-segment depression (OR=2.4, P=.008). The composite variable of female sex plus at least two additional predictive factors had a specificity of 85% and a sensitivity of 53% for coronary angiography showing no significant stenosis. The absence of coronary artery stenosis decreased the probability of death or myocardial infarction during follow-up (hazard ratio=0.3, 95% confidence interval, 0.2-0.9; P=.03). Among all patients without significant stenosis (n=224), there was no difference in the event rate between those with elevated and normal troponin levels. CONCLUSIONS In NSTEMI, female sex, age <55 years and the absence of diabetes, previous antiplatelet treatment or ST-segment depression were all associated with coronary angiography showing no significant stenosis. The long-term prognosis in these patients was good.

Prognostic Value of Serum Creatinine in Non-ST-Elevation Acute Coronary Syndrome

INTRODUCTION AND OBJECTIVES Cardiovascular disease is the main cause of death in patients with kidney failure. Moreover, the presence of impaired renal function is an important prognostic factor in patients with heart disease, and is a determinant of outcome during follow-up. The main aim was to investigate the relationship between kidney failure at admission and one-year mortality in patients with non-ST-elevation acute coronary syndrome. PATIENTS AND METHOD We studied 1029 consecutive patients admitted to our institution. The serum creatinine level and glomerular filtration rate were determined at admission, and classical risk factors and biochemical markers were assessed. The primary endpoint was all-cause mortality at one year. RESULTS Patients who died were older, more frequently had a history of diabetes or coronary artery disease, were more likely to have heart failure at admission, had higher troponin-I, myoglobin and creatinine levels, and were less likely to have dyslipidemia or to be a smoker. Multivariate analysis showed that the independent predictors of all-cause mortality at one year were age, diabetes, troponin-I level, Killip class > 1, male gender, creatinine level, and glomerular filtration rate. There was a linear correlation between increased risk and creatinine level. CONCLUSIONS Creatinine level at admission is one of the most important covariates in early prognostic stratification in these patients. A high serum creatinine level (or a low glomerular filtration rate) increases the probability of death due to all causes. The serum creatinine level is, moreover, an inexpensive, easy-to-use, and widely available prognostic marker.

Identification of very low risk chest pain using clinical data in the emergency department

BACKGROUND Evaluation of chest pain of uncertain origin in the emergency department is a challenge. Chest pain units, involving non-invasive stress testing, have logistic constraints. Our aim was to identify very low risk patients for early discharge using clinical data. METHODS A total of 772 patients were studied. Ischemia in the electrocardiogram, troponin elevation or history of ischemic heart disease, were exclusion criteria. The primary end point was 30 day cardiac events (death, myocardial infarction or revascularization). The secondary end point was 1 year major events (death or myocardial infarction). RESULTS The primary and secondary end point rates were 123 (18%) and 31 (4%). Predictive variables for the primary end point were typical chest pain (OR=1.8, p=0.007), ≥ 2 pain episodes in last 24h (OR=3.4, p=0.0001), age ≥ 55 years (OR=1.8, p=0.03), male (OR=2.2, p=0.001), diabetes (OR=1.8, p=0.01) and family history of ischemic heart disease (OR=2.0, p=0.02). A very low risk category could be distinguished (<2 predictors, n=114) that showed only 3 (2.6%) events at 30 days (all 3 revascularizations), compared with 120 (18%) in the remaining patients (p=0.0001). The very low risk criteria had 97% negative predictive for 30 day cardiac events. No very low risk patient presented major events at 1 year compared with 31 (4.7%) in the remaining patients (p=0.009). CONCLUSION In patients presenting to the emergency department with chest pain of uncertain origin and without prior ischemic heart disease, very low risk patients can be identified using clinical data. These patients could be quickly discharged without further non-invasive stress testing.

Valor independiente de la proteína C reactiva para predecir acontecimientos mayores al primer mes y al año en los síndromes coronarios agudos sin elevación del ST

Fundamento y objetivo: Analizamos si la proteina C reactiva (PCR) aporta informacion pronostica independiente tras un sindrome coronario agudo sin elevacion del ST. Pacientes y metodo: Se estudio prospectivamente a 630 pacientes consecutivos ingresados por sindrome coronario agudo sin elevacion del ST. Los puntos de corte fueron: troponina I > 1 ng/ml (n = 354; 56%) y PCR > 11 mg/l (n = 273; 43%). Resultados: Durante un ano de seguimiento se detectaron 56 (9%) muertes de causa cardiaca, 85 (13%) infartos de miocardio y 127 (20%) primeros acontecimientos mayores. Los pacientes con PCR elevada mostraron mayor mortalidad al mes (el 8 frente al 1%) y al ano (el 15 frente al 4%); mayor porcentaje de infarto de miocardio al mes (el 8 frente al 4%) y al ano (el 19 frente al 9%), y mas eventos mayores al mes (el 15 frente al 5%) y al ano (el 30 frente al 13%). En el analisis multivariado, tras ajustarse por los datos tanto clinicos como electrocardiograficos y por la existencia o no de elevacion de los marcadores de lesion, la PCR elevada fue un predictor independiente de muerte al mes (odds ratio [OR] = 4,6) y al ano (OR = 2,7) y predijo acontecimientos mayores al mes (OR = 1,8) y al ano (OR = 1,8). La elevacion de la troponina I predijo la aparicion de infarto al mes (OR = 2,5) y al ano (OR = 2,2). Conclusiones: La PCR aporto informacion independiente para la prediccion de eventos mayores en los sindromes coronarios agudos sin elevacion del ST. La troponina I fue un predictor mas potente de infarto que la PCR. Parece aconsejable el analisis de esta ultima y de los marcadores de lesion para la estratificacion de riesgo a corto y largo plazo.

Usefulness of pain presentation characteristics for predicting outcome in patients presenting to the hospital with chest pain of uncertain origin

Background Decision making in chest pain of uncertain origin is challenging. Objectives To evaluate the predictive value of simple characteristics of pain presentation in patients coming to the emergency department with chest pain and without electrocardiogram ischaemia or raised troponin. Methods 789 patients were studied. The following categorical pain characteristics were collected: effort related pain, pressing character, radiation, associated symptoms, and ≥2 episodes in 24 h. Additionally, a predefined semi-quantitative pain score including seven items (Geleijnse score) was completed. Risk factors and co-morbidities were also recorded. The primary and secondary endpoints were cardiac events at 30 days and at 1 year. Results After adjusting for risk factors and co-morbidites, the pain characteristics associated with the primary and secondary endpoints were effort related pain (HR=2.1, 95% CI 1.5 to 3.0, p=0.0001; HR=1.8, 95% CI 1.3 to 2.5, p=0.0003) and ≥2 episodes in 24 h (HR=2.4, 95% CI 1.7 to 3.5, p=0.0001; HR=2.3, 95% CI 1.7 to 3.2, p=0.0001). Both variables retained their predictive value in women, diabetics and elderly (>70 years) patients. The discriminatory capacity of the predictive models including these two pain characteristics for the primary and secondary endpoints (C-statistic 0.76 and 0.76) was better than using the complex semi-quantitative pain score (C-statistic 0.69 and 0.71). Conclusion In patients presenting to the emergency department with chest pain and without electrocardiogram ischaemia or raised troponin, effort related pain and ≥2 episodes in 24 h are the main characteristics to be considered for decision making.