Maximiliano De Abreu

Multivessel versus Single Vessel Angioplasty in Non-ST Elevation Acute Coronary Syndromes: A Systematic Review and Metaanalysis

Background Multivessel disease is common in acute coronary syndrome patients. However, if multivessel percutaneous coronary intervention is superior to culprit-vessel angioplasty has not been systematically addressed. Methods A metaanalysis was conducted including studies that compared multivessel angioplasty with culprit-vessel angioplasty among non-ST elevation ACS patients. Since all studies were observational adjusted estimates of effects were used. Pooled estimates of effects were computed using the generic inverse of variance with a random effects model. Results Twelve studies were included (n = 117,685). Median age was 64.1 years, most patients were male, 29.3% were diabetic and 36,9% had previous myocardial infarction. Median follow-up was 12 months. There were no significant differences in mortality risk (HR 0.79; 95% CI 0.58 to 1.09; I2 67.9%), with moderate inconsistency. Also, there were no significant differences in the risk of death or MI (HR 0.90; 95% CI 0.69 to 1.17; I2 62.3%), revascularization (HR 0.76; 95% CI 0.55 to 1.05; I2 49.9%) or in the combined incidence of death, myocardial infarction or revascularization (HR 0.83; 95% CI 0.66 to 1.03; I2 70.8%). All analyses exhibited a moderate degree of inconsistency. Subgroup analyses by design reduced the inconsistency of the analyses on death or myocardial infarction, revascularization and death, myocardial infarction or revascularization. There was evidence of publication bias (Egger’s test p = 0.097). Conclusion Routine multivessel angioplasty in non-ST elevation acute coronary syndrome patients with multivessel disease was not superior to culprit-vessel angioplasty. Randomized controlled trials comparing safety and effectiveness of both strategies in this setting are needed.

Analysis of Interhospital Transfer of Critically Ill Patients to the Coronary Care Unit of a Highly Complex Hospital

Background: Interhospital transfer of critically ill patients is frequent in our country. However, despite the existence of emergency medical transfer services both in public and private settings, no scientific publications have been generated regarding the transfer of critically ill patients to understand their operation, planning and results. Objective: The aim of this study was to describe the conditions of interhospital transfer of cardiovascular disease patients. Methods: This was an observational, prospective, multicenter design study, analyzing interhospital land transfer of patients admitted to a third level coronary care unit between April 2014 and April 2015. The transfer physician was surveyed. Complications related to hospital transfer and mortality were also recorded. Results: A total of 214 transfers were analyzed. Median transfer time was 30 minutes (IQR 18.5-50). Among all transfers, 16.1% of cases were considered to be at high risk, 71.2% at moderate risk and 12.7% at low risk, according to a validated score. The main diagnoses were acute coronary syndrome (66.8%), heart failure (8.9%) and bradyarrhythmia or blockade (3.7%). In 73.5% of highrisk transfers, high complexity ambulances were used, and in low- and moderate-risk transfers (30.8% and 28.9%, respectively), they were carried out with low complexity ambulances. Fifty percent of transfers were performed by resident physicians; 10.8% of cases presented with some complication during the transfer and/or during the first hour. Complications were more frequent in high-risk transfers and were associated with in-hospital mortality. There was no association between estimated increased risk of transfer and greater ambulance complexity (p=0.6). Conclusion: Transfer scheduling was not adequate. The calculated risk of transfers was predominantly low, with a high proportion of severe complications, which impacted in in-hospital mortality.

Asociación entre marcadores bioquímicos y disfunción ventricular izquierda en infarto con elevación del segmento ST

OBJECTIVE The association between biochemical markers and left ventricular ejection fraction in patients with myocardial infarction was not completely studied. Our goal is to study the association between biochemical markers and left ventricular dysfunction in patients with ST-elevation acute myocardial infarction. METHODS With an observational and prospective design we included patients with less than 24h ST-elevation myocardial infarction. Leukocytes, glucose, B-type natriuretic peptide and T troponin were measured at admission, and creatine-phosphokinase and creatine-phosphokinase-MB were measured at admission and serially, and correlated with the ejection fraction estimated by echocardiography. RESULTS A total of 108 patients were included. The median left ventricular ejection fraction was 48% (interquartile range 41-57). Simple linear regression analysis showed that B-type natriuretic peptide (P=.005), peak creatine-phosphokinase-MB (P=.01), leukocyte count (P=.001) and glucose (P=.033) were inversely and significantly associated with the left ventricular ejection fraction. The other parameters showed no association. B-type natriuretic peptide (P=.01) and peak creatine-phosphokinase-MB (P=.02) were the only two variables significantly associated with the left ventricular ejection fraction in the multiple linear regression analysis. Both markers were significantly associated with a left ventricular ejection fraction < 50%, independently of other clinical variables. CONCLUSION B-type natriuretic peptide and peak creatine-phosphokinase-MB showed significant association with left ventricular ejection fraction in the acute phase of ST elevation acute myocardial infarction. This association was independent of the presence of other biochemical markers and clinical variables related to ventricular dysfunction.

Analysis of the invasive strategy decision in patients with acute coronary syndrome without ST-segment elevation in a real-world setting.

Observational studies have reported a marked discrepancy between the risk estimated by scores and the use of an invasive strategy in patients with acute coronary syndromes. The objective is to describe the criteria used to decide an early invasive strategy and to determine the differences between those criteria and the thrombolysis in myocardial infarction risk score (TRS). Patients entered to the Epi-Cardio registry with a diagnosis of non-ST-elevation acute coronary syndrome were analyzed. A logistic regression model including variables associated with an early invasive strategy was developed and validated in 2 consecutive cohorts. The association between the TRS and the clinical decision model with an early invasive strategy was evaluated by receiver operating characteristic (ROC) curves. We included a total of 3,187 patients. In the derivation cohort, variables associated with an early invasive strategy were previous angioplasty (odds ratio [OR] 1.63), hypercholesterolemia (OR 1.36), ST changes (OR 1.49), elevated biomarkers (OR 1.42), catheterization laboratory availability (OR 1.7), recurrent angina (OR 3.45), age (OR 0.98), previous coronary bypass (OR 0.65), previous heart failure (OR 0.40), and heart rate at admission (OR 0.98). The areas under the ROC curves to predict invasive strategy were 0.55 for the TRS and 0.69 for the clinical decision model, p <0.0001. In the validation cohort, ROC areas were 0.58 and 0.70, respectively, p <0.0001. In conclusion, invasive strategy was guided by variables not completely included in risk scores. The clinical, evolutionary, and structural variables included in the model can explain, partially, the discordance existing between risk stratification and medical strategies.

Doble antiagregación bajo la lupa: beneficio real y subgrupos de riesgo

CURE, TRITON-TIMI 38 and PLATO studies have de- monstrated clinical benefit with the use of dual antiplatelet therapy with clopidogrel, prasugrel or ticagrel...

Referral and counter-referral system between secondary and tertiary care facilities in a children's hospital network of Greater Buenos Aires.

Fil: Garcia Munitis, P. Hospital de Alta Complejidad en Red El Cruce Dr. Nestor C. Kirchner. Servicio de Pediatria. Florencio Varela, Argentina

Chief Complaints, Procedures, Outcomes and Discharge Treatment Plan of 54000 Patients

Background Epi-Cardio is a multicenter registry of the discharge summaries of cardiovascular care units in Argentina, focused on evaluating clinical epidemiology. Objective To identify chief complaints, treatment strategies, procedures and outcomes using the discharge summaries of Coronary Care Units created with the Epi-Cardio software. Methods The registry included 54,055 patients admitted to 54 cardiovascular care units which use the Epi-Cardio software as a medical care tool to create discharge summaries and generate a rigorous registry of the activity. Results Mean age was 64.9 years, and 63.9% were men. The most common chief complaints included acute coronary syndromes in 24.9%, heart failure in 11.7% and elective cardiac catheterization procedures in 10.5%. General mortality was of 2.62% (1,417 patients). Patients with non-ST segment elevation acute coronary syndrome underwent coronary angiography in 51.8% of cases and 26.3% underwent percutaneous coronary intervention. Discharge treatment plan included aspirin in 93.8% of cases, beta-blockers in 82.5%, statins in 85.2% and clopidogrel in 59.8%. Mortality was of 1.61%. In patients with ST-segment elevation acute coronary syndrome, a reperfusion strategy was indicated in 64.7%. Treatment at discharge included aspirin in 98.4%, beta-blockers in 86.9%, statins in 93.2% and enalapril in 69.6%. Mortality was of 5.4%. Conclusions Epi-Cardio has generated the largest prospective and permanent registry in Latin America, including more than 50,000 consecutive patients. This software has allowed describing the current outcomes of multiple conditions during hospitalization and the clinical practices applied in a wide network. With a simple tool as a discharge summary integrated to medical and administrative practice, the registry should be considered as a valuable strategy to improve clinical practice in cardiovascular care units.