Rafael Sanjuán

Papel del índice de Charlson en el pronóstico a 30 días y 1 año tras un infarto agudo de miocardio

Introduccion y objetivos.El indice de Charlson (iCh) ha sido utilizado como variable de ajuste en modelos multivariables como indicador de comorbilidad. Debido a que su valor pronostico per se para complicaciones cardiovasculares tras un infarto agudo de miocardio no ha sido ampliamente evaluado, nos propusimos determinar su valor predictivo para muerte de cualquier causa y/o reinfarto, a 30 dias y 1 ano del evento indice. Pacientes y metodo. Se incluyo a 1.035 pacientes con el diagnostico de infarto (508 con elevacion del segmento ST y 527 sin elevacion del segmento ST). La presencia de eventos se determino a 30 dias (13,9%) y a un ano (26,3%). El iCh se calculo junto con otras variables de valor pronostico en el momento del ingreso, y se establecieron 4 grupos: 1, iCh = 0 (control); 2, iCh = 1; 3, iCh = 2, y 4, iCh ≥ 3. Para el analisis multivariable se utilizo la regresion de riesgos proporcionales de Cox; su poder discriminativo se evaluo mediante el indice C. Resultados. Los riesgos relativos (RR) y el intervalo de confianza [IC] del 95% para las categorias del iCh fueron: a los 30 dias, para la categoria 2, RR = 1,69; IC del 95%, 1,10-2,59; para la 3, RR = 1,78; IC del 95%,1,08-2,92, y para la 4, RR = 1,57; IC del 95%, 0,87-2,83; los valores a 1 ano fueron, para la categoria 2, RR = 1,62; IC del 95%, 1,18-2,23; para la 3, RR = 2,00; IC del 95%, 1,39-2,89, y para la 4, RR = 2,24; IC del 95%, 1,50-3,36. La diferencia en el indice C del modelo con y sin la variable iCh fue 0,765 y 0,750 a los 30 dias y 0,751 y 0,735 a 1 ano. Conclusiones. El iCh proporciono informacion pronostica independiente para muerte y/o reinfarto a los 30 dias y a 1 ano tras el infarto indice. Palabras clave: Infarto agudo de miocardio. Comorbilidad. Indice de Charlson.

Pronóstico a corto plazo de los pacientes ingresados por probable síndrome coronario agudo sin elevación del segmento ST. Papel de los nuevos marcadores de daño miocárdico y de los reactantes de fase aguda

Objectives. The relative value of classic markers, myocardial damage variables, and levels of acute-phase reactants in establishing the pre-discharge prognosis of acute coronary syndrome without ST-segment elevation was analyzed. Method. We prospectively studied 385 consecutive patients admitted from our chest pain unit with a highprobability diagnosis of acute coronary syndrome without ST-segment elevation. The clinical and electrocardiographic data, myocardial damage markers (troponin I, CK-Mb mass, myoglobin), and acute-phase reactants (high-sensitivity C-reactive protein, fibrinogen) were recorded. Results. During admission, 15 deaths (3.9%) and 16 complicative infarctions (4.2%) occurred, for a total of 31 major events (death and/or infarction: 8.1%). Age (p = 0.03), insulin-dependent diabetes (p = 0.009), and C-reactive protein (p = 0.05) were independently related to death. Fibrinogen was related to infarction (p = 0.01); by fibrinogen quartiles: 1.4%; 1.4%; 2.9%, and 11.7% (p = 0.02). Age (p = 0.01), insulin-dependent diabetes (p = 0.02), and C-reactive protein (p = 0.04) were independent predictors of major events; by C-reactive protein quartiles: 1.4%; 5.5%; 5.4%, and 16.7% (p = 0.004). Troponin I was related to major events (p = 0.03), but it was not an independent predictor. Conclusions. Acute-phase reactants add independent information to clinical variables in the short-term risk stratification of patients with an acute coronary syndrome. The predictive power of troponins is lower than that of

Prognostic Value of Charlson Comorbidity Index at 30 Days and 1 Year After Acute Myocardial Infarction

INTRODUCTION AND OBJECTIVES The Charlson comorbidity index (CCI), an indicator of comorbidity, has been used as an adjusting variable in multivariate models. Because of its prognostic value per se for cardiovascular complications after acute myocardial infarction (AMI), we sought to determine the predictive value of the CCI for all-cause mortality and recurrent AMI 30 days and 1 year after the index event. PATIENTS AND METHOD We analyzed 1035 consecutive patients admitted with the diagnosis of AMI (ST elevation=508 and non-ST elevation=527). The composite endpoint was determined after 30 days (13.9%) and 1 year (26.3%) of follow-up. The CCI was calculated on admission, and other variables with prognostic value were also recorded. CCI was stratified in 4 categories: 1: CCI=0 (control), 2: CCI=1, 3: CCI=2,4: CCI> or =3. Cox proportional risks analysis was used for the multivariate analysis, and the C-statistic was calculated to assess the discriminative power of the models. RESULTS Hazard ratios (95% CI) estimated for each category of CCI were: 2=1.69 (1.10-2.59), 3=1.78 (1.08-2.92) and 4=1.57 (0.87-2.83) at 30 days; 2=1.62 (1.18-2.23), 3=2.00 (1.39-2.89) and 4=2.24 (1.50-3.36) at 1 year. Comparisons with the C-statistic between the nested multivariate models (with and without CCI) yielded values of 0.765 vs 0.750 after 30 days, and 0.751 vs 0.735 after 1 year. CONCLUSIONS Our data indicate that CCI is an independent predictor of mortality or recurrent AMI 30 days and 1 year after the index AMI.

Resultados de la estrategia farmacoinvasiva y de la angioplastia primaria en la reperfusión del infarto con elevación del segmento ST. Estudio con resonancia magnética cardiaca en la primera semana y en el sexto mes

INTRODUCTION AND OBJECTIVES Pharmacoinvasive strategy represents an attractive alternative to primary angioplasty. Using cardiovascular magnetic resonance imaging we compared the left ventricular outcome of the pharmacoinvasive strategy and primary angioplasty for the reperfusion of ST-segment elevation myocardial infarction. METHODS Cardiovascular magnetic resonance was performed 1 week and 6 months after infarction in two consecutive cohorts of patients included in a prospective university hospital ST-segment elevation myocardial infarction registry. During the period 2004-2006, 151 patients were treated with pharmacoinvasive strategy (thrombolysis followed by routine non-immediate angioplasty). During the period 2007-2008, 93 patients were treated with primary angioplasty. A propensity score matched population was also evaluated. RESULTS At 1-week cardiovascular magnetic resonance, pharmacoinvasive strategy and primary angioplasty patients showed a similar extent of area at risk (29±15 vs. 29±17%, P=.9). Non-significant differences were detected by cardiovascular magnetic resonance at 1 week and at 6 months in infarct size, salvaged myocardium, microvascular obstruction, ejection fraction, end-diastolic volume index and end-systolic volume index (P>.2 in all cases). The same trend was observed in 1-to-1 propensity score matched patients. The rate of major adverse cardiac events (death and/or re-infarction) at 1 year was 6% in pharmacoinvasive strategy and 7% in primary angioplasty patients (P=.7). CONCLUSIONS A pharmacoinvasive strategy including thrombolysis and routine non-immediate angioplasty represents a widely available and logistically attractive approach that yields identical short-term and long-term cardiovascular magnetic resonance-derived left ventricular outcome compared to primary angioplasty.

Implicaciones pronosticas de la hiperglucemia de estres en el infarto agudo de miocardio con elevacion del ST. Estudio observacional prospectivo

INTRODUCTION AND OBJECTIVES In patients with acute myocardial infarction, elevation of plasma glucose levels is associated with worse outcomes. The aim of this study was to evaluate the association between stress hyperglycemia and in-hospital mortality in patients with acute myocardial infarction with ST-segment elevation (STEMI). METHODS We analyzed 834 consecutive patients admitted for STEMI to the Coronary Care Unit of our center. Association between admission glucose and mortality was assessed with Cox regression analysis. Discriminative accuracy of the multivariate model was assessed by Harrells C statistic. RESULTS Eighty-nine (10.7%) patients died during hospitalization. Optimal threshold glycemia level of 140mg/dl on admission to predict mortality was obtained by ROC curves. Those who presented glucose ≥140mg/dl showed higher rates of malignant ventricular tachyarrhythmias (28% vs. 18%, P=.001), complicative bundle branch block (5% vs. 2%, P=.005), new atrioventricular block (9% vs. 5%, P=.05) and in-hospital mortality (15% vs. 5%, P<.001). Multivariate analysis showed that those with glycemia ≥140mg/dl exhibited a 2-fold increase of in-hospital mortality risk (95% CI: 1.2-3.5, P=.008) irrespective of diabetes mellitus status (P-value for interaction=0.487 and 0.653, respectively). CONCLUSIONS Stress hyperglycemia on admission is a predictor of mortality and arrhythmias in patients with STEMI and could be used in the stratification of risk in these patients.

N-acetilcisteína: beneficio clínico a corto plazo tras coronariografía en pacientes renales de alto riesgo

Introduccion y objetivos. El papel de la N-acetilcisteina en la prevencion de la nefropatia por contraste tras coronariografia y sus efectos a largo plazo se presentan con resultados contradictorios en la literatura previa. Este estudio pretende clarificar su beneficio clinico. Metodos. Estudio prospectivo, aleatorizado y a doble ciego de pacientes sometidos a angiografia coronaria con insuficiencia renal cronica (creatinina plasmatica = 1,4 mg/dl). Representa asi el segundo brazo del diseno del estudio principal, previamente publicado, respecto al brazo de pacientes con funcion renal normal. Igualmente, se los aleatorizo a recibir N-acetilcisteina intravenosa (600 mg/12 h) o placebo. El objetivo principal es el desarrollo de nefropatia inducida por contraste. Resultados. Se incluyo a 81 pacientes (N-acetilcisteina, 39 pacientes; placebo, 42 pacientes), equiparables respecto a las caracteristicas clinicas basales. La incidencia total de nefropatia por contraste fue del 14,8% (12 pacientes), el 5,1% (2 pacientes) en el grupo con N-acetilcisteina y el 23,8% (10 pacientes) en el grupo a placebo (odds ratio [OR] = 0,17; intervalo de confianza [IC] del 95%, 0,03-0,84); p = 0,027). Un paciente de este ultimo grupo requirio dialisis mientras se encontraba ingresado en la unidad coronaria (1,2%). En el analisis multivariable, la N-acetilcisteina resulto factor protector independiente de la variable compuesta por nefropatia inducida por contraste, necesidad de dialisis y mortalidad durante la estancia en la unidad coronaria (OR = 0,20; IC del 95%, 0,04-0,97; p = 0,04). Sin embargo, no se observaron diferencias significativas en cuanto a mortalidad hospitalaria y al ano de seguimiento (el 10,3 frente al 16,7% y el 15,4 frente al 21,4% en los grupos con N-acetilcisteina y placebo respectivamente). Conclusiones. La administracion profilactica de N-acetilcisteina conlleva importantes beneficios clinicos a corto plazo en los pacientes renales con alto riesgo sometidos a angiografia coronaria.

Estudio RICVAL. El infarto agudo de miocardio en la ciudad de Valencia. Datos de 1.124 pacientes en los primeros 12 meses del Registro ( diciembre de 1993-noviembre de 1994)

Introduccion y objetivos La informacion sobre laasistencia al paciente con infarto agudo de miocardioes todavia escasa en Espana. El Registro de InfartoAgudo de Miocardio en la Ciudad de Valencia(RICVAL) se puso en marcha para recoger, de formaprospectiva y uniforme, datos de los pacientescon infarto agudo de miocardio, dados de alta delas unidades de cuidados intensivos cardiologicosde la ciudad de Valencia, con la finalidad de obtenerinformacion actualizada sobre el tratamientode esos pacientes. Se presentan los datos de losprimeros doce meses del Registro. Metodos Mediante la utilizacion de variablespreviamente definidas, se registraron los datos demograficos,clinicos, pronosticos, y de procedimientosdiagnosticos y terapeuticos, de pacientes coninfarto agudo de miocardio de los ocho hospitalesparticipantes en el RICVAL, entre el 1 de diciembrede 1993 y el 30 de noviembre de 1994. Resultados Los ocho hospitales participantes cubrenun area poblacional de 1.665.720 habitantes.Durante el tiempo de estudio, 1.124 pacientes conel diagnostico de infarto agudo de miocardio fuerondados de alta de las unidades coronarias integradasen el estudio. La media de edad fue de 65,1anos. El 23,9% eran mujeres. La mortalidad fue del16,9%. La insuficiencia ventricular izquierda (Killip2, 3 y 4) estuvo presente en el 42%. La terapeuticatrombolitica se realizo en el 43,5% de los casoscon una mediana del tiempo de retraso desde el iniciodel dolor de 210 minutos. Este retraso fue mayoren las mujeres y en los ancianos. Conclusion Del analisis de los datos se deduce lafactibilidad de un registro de infarto agudo de miocardioen la ciudad de Valencia. El estudio RICVALpermitira un mejor conocimiento de los datos demograficos,clinicos y pronosticos en los pacientescon infarto agudo de miocardio, asi como de losprocedimientos diagnosticos y terapeuticos utilizados.Hay que resaltar la cifra todavia alta de mortalidad,a pesar de un aceptable nivel de terapiatrombolitica, y el retraso en iniciar la trombolisis,sobre todo en las mujeres y en los ancianos.

Valor pronóstico del recuento leucocitario en el infarto agudo de miocardio: mortalidad a largo plazo

Introduccion y objetivos. Publicaciones recientes respaldan el papel pronostico del recuento leucocitario (RL) en pacientes con infarto agudo de miocardio (IAM). El objetivo de este trabajo fue determinar el valor predictivo atribuible al RL, con independencia de otras variables de contrastado valor pronostico, para predecir mortalidad a largo plazo en pacientes con IAM sin elevacion del segmento ST (IAMSEST) y con elevacion del segmento ST (IAMEST). Pacientes y metodo. Analizamos a 1.118 pacientes admitidos de forma consecutiva con el diagnostico de IAM (IAMSEST = 569; IAMEST = 549). El RL se obtuvo en la primera determinacion analitica. Se utilizaron modelos de regresion de Cox para determinar el grado de asociacion entre el RL y la mortalidad total para ambos tipos de IAM. La mediana de seguimiento fue de 10 ± 2 meses. El RL se incluyo en ambos modelos categorizado en los siguientes puntos de corte (x 10³ celulas/ml): < 10 (RL1); 10-14,9 (RL2) y = 15 (RL3). Resultados. Durante el seguimiento se registraron 105 muertes (18,5%) en pacientes con IAMSEST y 109 (19,9%) con IAMEST. Las hazard ratio ajustadas para las categorias RL2 y RL3 frente a RL1 en el grupo con IAMSEST fueron: 1,61 (1,03-2,51; p = 0,036) y 2,07 (1,08-3,94; p = 0,027), y en el IAMEST: 2,22 (1,35-3,63; p = 0,002) y 2,07 (1,13-3,76; p = 0,017), respectivamente. Conclusiones. El RL determinado en las primeras horas de un IAM demostro ser un predictor independiente de otras variables de contrastado valor pronostico para predecir la mortalidad total a largo plazo en el IAMSEST y el IAMEST.

N-acetylcysteine: Short-Term Clinical Benefits After Coronary Angiography in High-Risk Renal Patients

INTRODUCTION AND OBJECTIVES Previous studies on the role of N-acetylcysteine in the prevention of contrast-induced nephropathy after coronary angiography and on the drugs long-term effects have produced contradictory findings. The aim of this study was to clarify the benefits of N-acetylcysteine. METHODS A prospective, randomized, double-blind study was carried out in patients with chronic renal failure (plasma creatinine= >or=1.4 mg/dL) who underwent coronary angiography. This study concerns the second arm of the main study. Findings on the arm involving patients with normal renal function have been published previously. As before, patients were randomly assigned to receive either N-acetylcysteine, 600 mg every 12 h intravenously, or placebo. The primary end-point was the development of contrast-induced nephropathy. RESULTS The study included 81 patients (39 on N-acetylcysteine, 42 on placebo) with comparable baseline clinical characteristics. The overall incidence of contrast-induced nephropathy was 14.8% (12 patients): 5.1% (2 patients) in the N-acetylcysteine group and 23.8% (10 patients) in the placebo group (odds ratio [OR]=0.17; 95% confidence interval [CI], 0.03-0.84; P=.027). One patient (1.2%) in the latter group required dialysis while in the coronary unit. Multivariate analysis showed that N-acetylcysteine was an independent protective factor against the composite end-point of contrast-induced nephropathy, need for dialysis and mortality during the coronary unit stay (OR=0.20; 95% CI, 0.04-0.97; P=.04). Nevertheless, no significant difference was observed between the N-acetylcysteine and placebo groups in the rates of in-hospital (10.3% vs. 16.7%, respectively) or 1-year mortality (15.4% vs. 21.4%, respectively). CONCLUSIONS Prophylactic administration of N-acetylcysteine provided significant short-term clinical benefits in high-risk renal patients who underwent coronary angiography.

Induction of partial alterations in atriventricular conduction in dogs by percutaneous emission of high-frequency currents

Ten anesthetized dogs were studied in an attempt to provoke partial alterations in atrioventricular (AV) conduction by high-frequency current (HFC) transcatheter ablation. A discharge power (10 to 15 W) was used for less than 5 seconds after reaching complete AV block (CAVB). The catheter was placed within an area having an A/V ratio = 1 with His bundle deflection. If following discharge, no appreciable lengthening an AH, AV nodal block cycle length (Wenckebach point, WP), and/or functional nodal refractory period (FRPAVN) was observed, the procedure was repeated. Four dogs (group I) were killed immediately, and the other six (group II) after 2 to 4 weeks. The AH interval, WP, and FRPAVN were found to prolong significantly following HFC, without variations in HV interval. In group II, two dogs progressed to CAVB, whereas the other four maintained 1:1 AV conduction with AH, WP, and FRPAVN greater than before the power discharge. In conclusion, HFC is an efficient technique to induce partial alterations in AV conduction, since the discharge can be adjusted and the ablation can be localized to specific regions.