Purificació Cascant

Características basales y determinantes de la evolución en pacientes ingresados por insuficiencia cardíaca en un hospital general

Introduccion y objetivos Analizar las caracteristicas basales, los patrones de manejo y los resultados clinicos a los 18 meses del ingreso en pacientes diagnosticados de insuficiencia cardiaca en un hospital terciario de Cataluna. Metodos Se identificaron y analizaron las historias clinicas de los 256 pacientes ingresados en el Hospital General Vall d’Hebron desde julio a diciembre de 1998, diagnosticados de insuficiencia cardiaca y que cumplieran los criterios del estudio. Se entrevisto a los pacientes telefonicamente 18 meses despues. Resultados La edad media de los pacientes era de 75 ± 12 anos, el 42% correspondia a varones, el 19% habia ingresado por enfermedades distintas de la insuficiencia cardiaca y el 62% tenia comorbilidad significativa. Se estudio la funcion ventricular en el 68% (basicamente en pacientes con mejor pronostico), y se considero normal en un 41%. Se administraron inhibidores de la enzima conversiva o antagonistas de la angiotensina II en un 54% y bloqueadores beta en un 4%. La mortalidad a los 18 meses fue del 46%, siendo de causa cardiaca en el 77% de estos. Los predictores independientes de mortalidad fueron la edad avanzada, la insuficiencia cardiaca grave o antigua y la comorbilidad. A los 18 meses, un 69% de los supervivientes se hallaba en clase funcional I o II. Conclusiones 1) Al igual que sucede en otras areas geograficas, los pacientes de este estudio constituyen, como media, una poblacion anciana y con pobre supervivencia; 2) los patrones de manejo registrados son claramente mejorables; 3) la comorbilidad afecta significativamente al pronostico, y 4) la calidad de vida despues del alta es aceptable en una llamativa proporcion de supervivientes.

Predicting In-Hospital Mortality With Coronary Bypass Surgery Using Hospital Discharge Data: Comparison With a Prospective Observational Study

INTRODUCTION AND OBJECTIVES The aim was to determine the usefulness of the hospital discharge Minimum Basic Data Set (MBDS) for predicting in-hospital mortality with coronary bypass surgery by using data from a prospective observational study as a reference. METHODS The observational study involved collecting data on all patients undergoing first coronary bypass surgery at five hospitals in Catalonia, Spain between November 2001 and November 2003. In addition, data covering the same period and hospitals were obtained from the MBDS for procedure code 36.1. We investigated the concordance between the information from the two data sources and logistic regression was used to derive predictive models for in-hospital mortality. The model derived using MBDS data was validated using data from the prospective observational study and MBDS data for the years 2004-2006. Model validity was evaluated using discrimination and calibration indices. RESULTS Some 4.1% of cases in the observational study could not be found in the MBDS. The concordance between the two data sources was highly variable and generally low (kappa values ranged from 0.16 to 0.79). The discriminative ability of the MBDS model was equivalent to that of the observational study model (c=0.80 vs. c=0.79), but when the validity of the former was tested using prospective data and MBDS data for 2004-2006, the discrimination c-index decreased to 0.76 and 0.65, respectively, and the calibration worsened significantly (P< .001). CONCLUSIONS The risk of in-hospital mortality following coronary surgery cannot be accurately evaluated using MBDS data. However, our results indicate that their use as a predictive tool could be improved.

Pacientes con síndrome coronario agudo: abordaje terapéutico ( patrones de manejo) y pronóstico al año en un hospital general terciario

Introduccion y objetivos Conocer los determinantes del pronostico a corto plazo y a un ano de toda la poblacion atendida por el cardiologo de guardia del servicio de urgencias de un hospital de tercer nivel con sospecha de sindrome coronario agudo durante un periodo de seis meses. Pacientes y metodos Fueron identificados 153 pacientes consecutivos con diagnostico de infarto agudo de miocardio, 225 con diagnostico de angina inestable y 89 con diagnostico de dolor toracico atipico, estudiandose prospectivamente sus datos hospitalarios y su pronostico a largo plazo. Resultados La edad era superior a 65 anos en el 53% de pacientes con infarto agudo de miocardio y en el 54% con angina inestable. El 35% de los pacientes con infarto agudo de miocardio y el 16% de los pacientes con angina inestable sufrieron muerte o reinfarto al ano. Las caracteristicas basales, patrones de manejo y pronostico de los pacientes ingresados con infarto agudo de miocardio en el servicio de cardiologia, otras areas del hospital u otros centros diferian de forma importante, siendo el ingreso fuera del servicio de cardiologia un predictor independiente de mortalidad. En la angina inestable, las complicaciones se observaron en pacientes mayores de 75 anos, o previamente revascularizados, o tratados con revascularizacion, o con lesiones consideradas no revascularizables. Conclusiones a ) en la poblacion estudiada predominan los pacientes de edad avanzada y con una proporcion de mal pronostico considerablemente alta; b ) una significativa proporcion de los pacientes con complicaciones graves esta escasamente representada en los grandes ensayos clinicos, y c ) se tiende a concentrar el mayor esfuerzo terapeutico en los pacientes con un buen pronostico.

Transfemoral transcatheter aortic valve replacement compared with surgical replacement in patients with severe aortic stenosis and comparable risk: cost-utility and its determinants.

OBJECTIVE To evaluate cost-effectiveness of transfemoral TAVR vs surgical replacement (SAVR) and its determinants in patients with severe symptomatic aortic stenosis and comparable risk. METHODS Patients were prospectively recruited in 6 Spanish hospitals and followed up over one year. We estimated adjusted incremental cost-effectiveness ratio (ICER) (Euros per quality-adjusted life-year [QALY] gained) using a net-benefit approach and assessed the determinants of incremental net-benefit of TAVR vs SAVR. RESULTS We analyzed data on 207 patients: 58, 87 and 62 in the Edwards SAPIEN (ES) TAVR, Medtronic-CoreValve (MC) TAVR and SAVR groups respectively. Average cost per patient of ES-TAVR was €8800 higher than SAVR and the gain in QALY was 0.036. The ICER was €148,525/QALY. The cost of MC-TAVR was €9729 higher than SAVR and the QALY difference was -0.011 (dominated). Results substantially changed in the following conditions: 1) in patients with high preoperative serum creatinine the ICERs were €18,302/QALY and €179,618/QALY for ES and MC-TAVR respectively; 2) a 30% reduction in the cost of TAVR devices decreased the ICER for ES-TAVR to €32,955/QALY; and 3) imputing hospitalization costs from other European countries leads to TAVR being dominant. CONCLUSIONS In countries with relatively low health care costs TAVR is not likely to be cost-effective compared to SAVR in patients with intermediate risk for surgery, mainly because of the high cost of the valve compared to the cost of hospitalization. TAVR could be cost-effective in specific subgroups and in countries with higher hospitalization costs.

Validation of the Agency for Health Care Policy and Research (AHCPR) Classification for Managing Unstable Angina

To validate the AHCPR classification for the prognosis of unstable angina, 225 consecutive patients were recruited with a suspected diagnosis of that condition attending a tertiary hospital from November 1994 through April 1995 and followed for one year. One-hundred fifty-six (69.3%) patients were considered at high risk, 37 (16.5%) at intermediate, and 32 (14.2%) at low risk of cardiac complications. All of the patients with major in-hospital cardiac complications (8 patients) had at least one of the features of the high risk group. The high to intermediate-low hazard ratio (HR) for one-year cardiac complications after the onset of unstable angina was 4.03. Predictors of major complications (myocardial infarction or death) after the follow-up were age > 65 (HR, 5.69); diabetes (HR, 4.94); heart failure (HR, 2.65); and prolonged angina (HR, 2.55). AHCPR classification correctly identified patients with risk of severe outcomes at the hospital. Also, the classification predicted outcomes one year after hospitalization, diabetes being an important determinant of adverse cardiac events.

Perceived Health over 3 Years after Percutaneous Coronary Balloon Angioplasty

The magnitude of the benefit of percutaneous transluminal coronary angioplasty (PTCA) in terms of quality of life depending on baseline and outcome clinical variables is not sufficiently understood because of the restrictive inclusion criteria of randomized clinical trials. The present study was designed to assess perceived health outcome at 3 years and its association with clinical variables after successful elective PTCA in a tertiary hospital throughout a prospective cohort study. Questionnaires were administered on the day before the procedure and 1 month and 3.4 years later (as mean follow-up) to 106 patients recruited during a 15-month period. Mean perceived health scores improved significantly for the population as a whole 1 month after PTCA, and improvement was maintained at the end of follow-up. The magnitude of the effect was different depending on clinical subgroups: (a) It was greatest in patients free from angina, myocardial infarction, or new revascularization procedures at the end of follow-up; (b) It was moderately reduced in patients with comorbidity; (c) Patients who reported to have dyspnea or angina at rest after the latest revascularization procedure did not improve, with poor final perceived health scores. Elective PTCA is associated with a significant improvement in perceived health, which varies depending on the clinical outcome. Comorbidity and initial perceived health influence outcome but do not preclude improvement.

Evolución de la calidad de vida relacionada con la salud en pacientes ingresados por insuficiencia cardiaca. Estudio IC-QoL

Introduccion y objetivos. La insuficiencia cardiaca conlleva un mal pronostico tanto en la supervivencia como en el estado sintomatico. El objetivo de este estudio es evaluar en una poblacion heterogenea de pacientes con insuficiencia cardiaca los patrones de evolucion de la calidad de vida relacionada con la salud (CVRS), especialmente en subgrupos de interes clinico, asi como los determinantes de la mortalidad. Metodos. Estudio prospectivo de 1 ano de seguimiento con seis evaluaciones de la CVRS mediante un cuestionario generico (SF-36) y un cuestionario especifico (MLHFQ) a 883 pacientes dados de alta del hospital por insuficiencia cardiaca de 50 hospitales del territorio espanol. Resultados. Se observo una importante alteracion inicial de todas las dimensiones y de los componentes sumario fisico (CSF) (media, 34,1) y mental (CSM) (media, 40,1), del SF-36 y del MLHFQ (media, 37,5), y una clara mejora en el primer mes, que se mantuvo estable posteriormente, excepto en los menores de 40 anos, que mostraron una mejora progresiva de la CVRS. Se identificaron como predictores de mortalidad la edad, el grado funcional, la comorbilidad y los valores iniciales de CVRS. Conclusiones. La evolucion de la CVRS de los pacientes con insuficiencia cardiaca mejora durante el primer mes tras el alta hospitalaria, pero despues se mantiene estable, excepto en los pacientes mas jovenes, en los que se observa una mejora persistente

The EuroSCORE and a local model consistently predicted coronary surgery mortality and showed complementary properties

OBJECTIVE To revalidate a local model for prediction of in-hospital mortality after coronary surgery several years after its introduction and the EuroSCORE in a specific area within its original scope. To assess the specific advantages of one type of instrument over the other in a definite context. STUDY DESIGN AND SETTING Data from consecutive patients undergoing a first isolated coronary artery bypass between November 2001 and November 2003 in five hospitals in Catalonia were prospectively collected. RESULTS The study included 1,605 patients. Areas under the receiver-operating characteristics curves were around 0.75 for both models. Calibration was low for both models and the local model significantly overestimated risk. The ordering of operating centers by performance was identical with each strategy but the centers labeled as outliers differed. CONCLUSION (1) Evaluation of performance of individual hospitals was consistent using both systems and almost identical when they were internally recalibrated, (2) The impact of the benchmark population characteristics on model performance may be greater than that of risk factors considered for score calculation, (3) Promoting the use of a widely used instrument as the EuroSCORE might be sufficient for most evaluations. Local scales can be useful to highlight locally relevant features and temporal trends.

Improvements in Health-Related Quality of Life of Patients Admitted for Heart Failure. The HF-QoL Study

INTRODUCTION AND OBJECTIVES Heart failure (HF) is associated with a poor prognosis, both in terms of survival and ongoing symptoms. The objectives of this study were to investigate trends in the health-related quality of life (HRQoL) of a heterogeneous group of HF patients, with a focus on subgroups of particular clinical interest, and to identify determinants of mortality. METHODS Prospective study of 883 HF patients discharged from 50 Spanish hospitals and followed for 1 year, during which six HRQoL assessments were carried out using the generic Short Form-36 (SF-36) questionnaire and the specific Minnesota Living with Heart Failure Questionnaire (MLHFQ). RESULTS A marked change was noted at the beginning of the study on all dimensions of the SF-36, in its physical (mean 34.1) and mental (mean 40.1) component summary scores, and in the MLHFQ score (mean 37.5). There was a clear improvement in the first month, which subsequently remained unchanged, except in younger patients aged under 40 years whose HRQoL continued to improve progressively. The following predictors of mortality were identified: age, functional class, co-morbidity and baseline HRQoL. CONCLUSIONS In patients with HF, HRQoL showed a clear improvement during the first month after hospital discharge but subsequently remained unchanged, except in younger patients, whose HRQoL continued to improve progressively.