Sergio Raposeiras Roubín

High-sensitivity C-reactive protein predicts adverse outcomes after non-ST-segment elevation acute coronary syndrome regardless of GRACE risk score, but not after ST-segment elevation myocardial infarction

INTRODUCTION Atherosclerosis is an active process and the inflammatory component appears to be particularly correlated with the development of acute coronary syndromes (ACS). C-reactive protein (CRP) is an acute phase protein that appears in the circulation in response to inflammatory cytokines. The present study investigated the association between high-sensitivity C-reactive protein (hsCRP) on admission and follow-up prognosis after an ACS. METHODS We included 151 consecutive patients admitted to the coronary care unit with a diagnosis of ACS (47% ST-segment elevation myocardial infarction [STEMI]). The primary endpoint was the combination of cardiac death and myocardial reinfarction during the follow-up period (median 19.8 months, interquartile range 16.3-23.7 months). RESULTS The occurrence of follow-up events was significantly related to admission hsCRP level, which was an excellent predictor of cardiac death and reinfarction during follow-up (HR 1.091, 95% CI 1.014-1.174; p=0.019). Stratifying the population based on type of ACS, adjusted by variables associated with cardiac events in univariate analysis (hsCRP, diabetes, depressed ejection fraction and GRACE risk score), hsCRP proved to be an independent predictor of follow-up outcomes only in non-STEMI patients (HR 1.217, 95% CI: 1.093-1.356, p<0.001), not in STEMI patients. The best cutoff level of hsCRP to predict follow-up outcomes was 1.1mg/dl, with sensitivity of 77.8% and specificity of 63.2%. CONCLUSION Although the GRACE risk score is routinely used for stratification of patients with ACS, assessment of hsCRP may provide additional prognostic value in the follow-up of non-STEMI patients.

Relation of Contrast Induced Nephropathy to New Onset Atrial Fibrillation in Acute Coronary Syndrome

Chronic renal failure has been described as a risk factor for the development of atrial fibrillation (AF). The aim of this study was to examine the association between contrast-induced nephropathy (CIN) and new-onset AF in patients with acute coronary syndromes. A total of 1,520 consecutive patients (mean age 67.1 ± 12.7 years) with acute coronary syndromes (34.4% with ST-segment elevation myocardial infarctions) who underwent coronary angiography were studied. CIN was defined as an increase in serum creatinine of 0.5 mg/dl within 72 hours of contrast exposure. The independent effect of AF history (chronic or paroxysmal AF before catheterization) on the development of CIN, as well as the independent effect of CIN on the development of new-onset AF (after catheterization, during the in-hospital phase), were tested by using different logistic regression models. One hundred thirty-nine patients (9.1%) had histories of AF before catheterization (60 with paroxysmal and 79 with chronic AF), and 56 (4.1%) developed new-onset AF after catheterization. Eighty-seven patients (5.7%) had CIN. AF history was a predictor of CIN in univariate analysis (odds ratio 2.19, 95% confidence interval 1.22 to 3.95, p = 0.007) but not in multivariate analysis, after adjusting for confounding variables (odds ratio 1.69, 95% confidence interval 0.89 to 3.22, p = 0.111). In contrast, those with CIN had an increased prevalence of new-onset AF (15.3% vs 3.4%, p <0.001). After adjusting for those variables associated with new-onset AF in the univariate analysis, CIN continued to show a significant association with new-onset AF, with a twofold increased risk (odds ratio 2.45, 95% confidence interval 1.07 to 5.64, p = 0.035). In conclusion, the development of CIN is an independent predictor of new-onset AF in the context of acute coronary syndromes.

Failure of hybrid therapy for the prevention of long-term recurrence of atrial fibrillation

OBJECTIVES To determine the long-term effectiveness of hybrid therapy in the control of atrial fibrillation (AF) as well as the differences in clinical outcomes between patients with antiarrhythmic drug atrial flutter (AAD-AFl), those with coexistent AFl and AF, and isolated AFl. METHODS Four hundred eight patients who consecutively underwent cavotricuspid isthmus (CTI) ablation between 1998 and 2010 were followed for 5.9 years. Twenty-seven patients had AAD-AF1 (Group 1): they had AF but not AFl at baseline but on AAD therapy they showed typical AFl. They underwent CTI ablation and continued with AAD therapy, 96 patients had coexistent AF1 and AF at baseline (Group 2) and continued with AAD therapy at the discretion of their cardiologists and 284 patients had isolated AFl (Group 3). RESULTS AF recurred in the majority of the AAD-AF1 patients (74%, incident density rate (IDR): 19.1/100 person-years). This incidence rate was similar to the recurrence rate of AF in patients with coexistent AFl and AF (59%, IDR: 19.2/100 person-years). The patients in Group 1 had a similar IDR of stroke as Group 2 and a slightly higher rate than Group 3. There were no significant differences in the IDR for death among Groups 1, 2 and 3. CONCLUSIONS Hybrid therapy was not effective for long-term control of AF. The clinical outcomes (AF, stroke and death) were similar for AAD-AF1 patients and patients with coexistent AF and AFl.

Estudio SHIFT: papel de la ivabradina en la insuficiencia cardiaca y su importancia en la práctica clínica

El Systolic Heart failure treatment with If inhibitor ivabradine Trial (SHIFT) es un estudio de referencia sobre un enfoque novedoso en el tratamiento de los pacientes con insuficiencia cardiaca, acorde con el hecho de que la frecuencia cardiaca elevada no solo es un marcador de riesgo, sino tambien un factor de riesgo modificable con potencial para ser objetivo terapeutico en pacientes con insuficiencia cardiaca y funcion sistolica deprimida. Incluyo a 6.558 pacientes con insuficiencia cardiaca cronica, disfuncion sistolica ventricular izquierda (fraccion de eyeccion ? 35%) y ritmo sinusal ? 70lpm; se objetivo con ivabradina un beneficio adicional en la reduccion del combinado de muerte cardiovascular o reingreso por insuficiencia cardiaca, a expensas fundamentalmente de la reduccion de las hospitalizaciones por reagudizacion de la clinica congestiva. Asimismo, tenia un efecto adicional en el proceso de remodelado ventricular y en la calidad de vida, con una tasa muy baja de efectos secundarios. La combinacion de la eficacia y la seguridad de este farmaco es un hecho que sin duda determina la inclusion de la ivabradina en las guias de practica clinica de insuficiencia cardiaca.

Noninvasive Treatment of Acute Myocardial Infarction. Clinical Profile and Predictors of Poor Prognosis

In current clinical practice, only a small percentage of patients with acute coronary syndrome are treated conservatively (receiving neither coronary angiography nor fibrinolysis). Evidence-based clinical practice guidelines recommend that patients suffering an acute myocardial infarction (AMI) undergo invasive intervention, in addition to medical treatment of proven prognostic efficacy; this invasive treatment should take the form of emergent reperfusion therapy for ST segment elevation myocardial infarction (STEMI) and early coronary angiography for non-ST segment elevation myocardial infarction (NSTEMI). Certain clinical situations accompanying acute coronary syndrome exclude patients from this intensive management strategy. The typical clinical profile in such cases is that of a fragile elderly patient with anemia and renal failure or other important comorbidities that justify conservative management. Here we present an analysis of in-hospital and long-term mortality among AMI patients in our population who were assigned to conservative treatment by the on-duty physician. The aim was to identify variables that predict poor prognosis in these patients. We analyzed the records of 4408 patients consecutively admitted to our hospital between 2003 and 2012 with a diagnosis of AMI (1745 with STEMI and 2663 with NSTEMI). Of these patients, 460 received conservative medical treatment (127 [7.3%] with STEMI and 333 [12.5%] with NSTEMI); 84 STEMI patients presented > 24 hours after symptom onset. Among the total group of STEMI patients, 54 (3.1%) received fibrinolytic treatment and all were later examined by angiography. Patients assigned to conservative management tended to be older, and this group included a higher percentage of women and patients with diabetes mellitus, had a worse Killip class, and had lower hemoglobin and higher creatinine readings (Table). All of this, as is well known, implies a poor prognosis for patients receiving conservative medical treatment. Among patients receiving conservative treatment, we analyzed variables associated with a worse prognosis during in-hospital care and long-term follow-up; in-hospital and long-term mortality were analyzed independently in the two types of AMI by multivariate analysis (binary logistic regression for in-hospital mortality and Cox regression for long-term mortality), with adjustments for first-order interactions between covariates. Among NSTEMI patients, univariate analysis indicated an association of high in-hospital mortality with diabetes mellitus (odds ratio [OR] = 1.79; 95% confidence interval [95%CI], 1.02-3.14; P = .042), Killip class II (OR = 6.81; 95%CI, 3.46-13.43; P < .001), hemoglobin (OR = 0.85; 95%CI, 0.73-0.98; P = .027), creatinine (OR = 1.49; 95%CI, 1.17-1.90; P = .001) and troponin (OR = 1.02; 95%CI, 1.01-1.04; P = .001). In-hospital mortality in these patients was also associated with nontreatment with beta-blockers (OR = 0.19; 95%CI, 0.09-0.39; P < .001), angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers (OR = 0.35; 95%CI, 0.19-0.63; P < .001), or statins (OR = 0.23; 95%CI, 0.16-0.32; P < .001). In the multivariate analysis, only Killip class II persisted as an independent predictor of in-hospital mortality (OR = 4.5; 95%CI, 2.13-9.53; P < .001). Long-term mortality in NSTEMI patients (4.2 2.8 years) was positively associated with the following variables: age (hazard ratio [HR] = 1.06; 95%CI, 1.04-1.08; P < .001), peripheral artery disease (HR = 1.70; 95%CI, 1.18-2.46; P = .005), previous AMI (HR = 1.46; 95%CI, 1.06-2.02; P = .022), Killip class II (HR = 2.43, 95%CI, 1.79-3.28; P < .001), hemoglobin (HR = 0.88; 95%CI, 0.81-0.95; P = .001), creatinine (HR = 1.27; 95%CI, 1.13-1.44; P < .001), and troponin (HR = 1.01; 95%CI, 1.01-1.02; P < .001). Indicators of good prognosis were treatments with beta-blockers (HR = 0.50; 95%CI, 0.37-0.68; P < .001) and statins (HR = 0.55; 95%CI, 0.47-0.66; P < .001). After the multivariate analysis, the following persisted as independent predictors of mortality: age (HR = 1.06; 95%CI, 1.031.09; P < .001), peripheral artery disease (HR = 1.71; 95%CI, 1.06-2.76; P = .028), previous AMI (HR = 1.76; 95%CI, 1.15-2.71; P = .009), Killip class II (HR = 1.59; 95%CI, 1.05-2.41; P = .028), hemoglobin (HR = 0.87; 95%CI, 0.77-0.98; P = .020), creatinine (HR = 1.38; 95%CI, 1.07-1.77; P = .013), and nontreatment with statins (HR = 0.79; 95%CI, 0.62-0.99; P = .042). Among patients with STEMI, univariate analysis showed association of high in-hospital mortality with Killip class II (OR = 8.00; 95%CI, 3.02-21.17; P < .001), creatinine (OR = 1.72; 95%CI, 0.97-3.05; p = .062), and troponin (OR = 1.01; 95%CI, 0.99-1.02; P = .079). Indicators of good prognosis were treatments with betablockers (OR = .21; 95%CI, 0.08-0.56; P = .002), angiotensinconverting enzyme inhibitors or angiotensin II receptor blockers OR = 0.19; 95%CI, 0.08-0.48; P < .001), and statins (OR = 0.15; 95%CI, 0.06-0.36; P < .001). In the multivariable analysis, the only independent predictors of in-hospital mortality were Killip class II (OR = 5.22; 95%CI, 1.44-18.86; P = .012) and treatment with statins (OR = 0.79; 95%CI, 0.06-0.63; P = .006). Long-term mortality of STEMI patients was associated with age (HR = 1.09; 95%CI, 1.04-1.15; P = .001), hemoglobin (HR = 0.86; 95%CI, 0.76-0.97; P = .015), and creatinine (HR = 1.72; 95%CI, 1.182.49; P = .004). After multivariate analysis, only age persisted as an independent mortality predictor (HR = 1.09; 95%CI, 1.04-1.15; p = .001). For in-hospital mortality, we conducted a sensitivity analysis, eliminating patients who died during the first 48 hours (68 with STEMI and 18 with NSTEMI, out of 307 in-hosptial deaths). Killip class II remained as an independent mortality predictor in both the NSTEMI group (OR = 7.41; 95%CI, 4.82-11.39; P < .001) and the STEMI group (OR = 10.58; 95%CI, 6,26-17,89; P < .001), and statins treatment persisted as a predictor of good prognosis in the STEMI group (OR = 0.19; 95%CI, 0.12-0.32; p < .001). Our results clearly show that patients under conservative management have a higher basal risk than those treated invasively, which could justify invasive therapy. Of the variables analyzed, the only independent predictor of in-hospital mortality in the 2 infarction groups is Killip class II, an indicator of major clinical and hemodynamic instability. Notably, age is not a predictor of inhospital mortality in either of the AMI groups, but is a predictor of mortality risk during follow-up. The influence of age on the treatment of acute coronary syndrome was analyzed in the MINAP registry, which showed that the use of invasive treatment was Rev Esp Cardiol. 2015;68(4):343–354

Prevalence and outcome of patients with cancer and acute coronary syndrome undergoing percutaneous coronary intervention: a BleeMACS substudy

Background: The prevalence and outcome of patients with cancer that experience acute coronary syndrome (ACS) have to be determined. Methods and results: The BleeMACS project is a multicentre observational registry enrolling patients with acute coronary syndrome undergoing percutaneous coronary intervention worldwide in 15 hospitals. The primary endpoint was a composite event of death and re-infarction after one year of follow-up. Bleedings were the secondary endpoint. 15,401 patients were enrolled, 926 (6.4%) in the cancer group and 14,475 (93.6%) in the group of patients without cancer. Patients with cancer were older (70.8±10.3 vs. 62.8±12.1 years, P<0.001) with more severe comorbidities and presented more frequently with non-ST-segment elevation myocardial infarction compared with patients without cancer. After one year, patients with cancer more often experienced the composite endpoint (15.2% vs. 5.3%, P<0.001) and bleedings (6.5% vs. 3%, P<0.001). At multiple regression analysis the presence of cancer was the strongest independent predictor for the primary endpoint (hazard ratio (HR) 2.1, 1.8–2.5, P<0.001) and bleedings (HR 1.5, 1.1–2.1, P=0.015). Despite patients with cancer generally being undertreated, beta-blockers (relative risk (RR) 0.6, 0.4–0.9, P=0.05), angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (RR 0.5, 0.3–0.8, P=0.02), statins (RR 0.3, 0.2–0.5, P<0.001) and dual antiplatelet therapy (RR 0.5, 0.3–0.9, P=0.05) were shown to be protective factors, while proton pump inhibitors (RR 1, 0.6–1.5, P=0.9) were neutral. Conclusion: Cancer has a non-negligible prevalence in patients with acute coronary syndrome undergoing percutaneous coronary intervention, with a major risk of cardiovascular events and bleedings. Moreover, these patients are often undertreated from clinical despite medical therapy seems to be protective. Registration:The BleeMACS project (NCT02466854).

Remodelado cardiaco inverso estructural y funcional en pacientes con aleteo auricular típico sometidos a ablación del istmo cavotricuspídeo

INTRODUCTION AND OBJECTIVES The purpose of the present study is to determine the structural and functional cardiac changes that occur in patients at 1-year follow-up after ablation of typical atrial flutter. METHODS We enrolled 95 consecutive patients referred for cavotricuspid isthmus ablation. Echocardiography was performed at ≤6h post-procedure and 1-year follow-up. RESULTS Of 95 patients initially included, 89 completed 1-year follow-up. Hypertensive cardiopathy was the most frequently associated condition (39%); 24% of patients presented low baseline left ventricular systolic dysfunction. We observed a significant reduction in right and left atrial areas, end-diastolic and end-systolic left ventricular diameters, and interventricular septum. We observed substantial improvement in right atrium contraction fraction and left ventricular ejection fraction, and a reduction in pulmonary hypertension. Changes in diastolic dysfunction pattern were observed: 60% of patients progressed from baseline grade III to grade I; at 1-year follow-up, this improvement was found in 81%. We found no structural differences between paroxysmal and persistent atrial flutter at baseline and 1-year follow-up, exception for basal diastolic function. CONCLUSIONS In patients with typical atrial flutter undergoing cavotricuspid isthmus catheter ablation, we found inverse structural and functional cardiac remodeling at 1-year follow-up with much improved left ventricular ejection fraction, right atrium contraction fraction, and diastolic dysfunction pattern. Full English text available from:www.revespcardiol.org.

Dry pericarditis, diagnosis with cardiac magnetic resonance imaging.

A 47-year-old-woman with an unremarkable medical history was admitted to hospital for nonspecific central chest pain of 1 month’s duration, fever, and asthenia. The physical examination and electrocardiography study showed no abnormal findings. The hemogram and myocardial injury markers were normal, as were serologies for cytomegalovirus, Epstein-Barr virus, hepatitis B and C virus, human immunodeficiency virus, Coxsackie virus, and bacteria (syphilis by rapid plasma reagin, Brucella, Lyme disease). Inflammatory markers were elevated (erythrocyte sedimentation rate, 103 mm/h and C-reactive protein, 56 mg/L). There were no abnormal findings on echocardiography. Magnetic resonance imaging showed preserved left ventricular size and contractility, and generalized pericardial thickening that was more marked in the basal segments (5.5 mm) than in the apical segments (4.5 mm), with no effusion and no evidence of constriction on tagging sequences. Sequences acquired in the acute phase (Fig. 1) depict increased pericardial thickness with no effusion (cine, Fig. 1A), increased signal intensity in both pericardial layers indicating inflammation with extensive edema (short time inversion recovery sequences [STIR], Fig. 1B), and late gadolinium enhancement, consistent with pericardial inflammation. Concomitant myocardial involvement was ruled out (inversion-recovery sequences, Fig. 1C). Figure 2 illustrates the possibilities of magnetic resonance to measure pericardial thickening with different sequences. A diagnosis of acute, dry pericarditis was established, and the patient was treated with anti-inflammatory therapy for 4 weeks. A follow-up cardiac magnetic resonance study was performed 3 months later (Fig. 3). STIR sequences showed complete resolution of the pericardial edema (Fig. 3B), with sight persistence of late gadolinium enhancement (Fig. 3C), typical features of this condition after the acute phase. Cine TrueFISP, acute phase T2-STIR, acute phase IR-FLASH, acute phase A B C

Another brick in the wall: The impact of ticagrelor use on the incidence of stroke in a large registry

The risk of ischaemic stroke is a common concern among physicians who care for patients with acute coronary syndrome (ACS). These patients typically have multiple cardiovascular risk factors and require treatment with a dedicated medical regimen. The interesting work of Ulvenstam and colleagues seeks to further explore the impact of recent changes in medical treatment following percutaneous coronary interventions (PCIs) on stroke, which is often considered a secondary endpoint in the field of interventional cardiology. In their manuscript, the authors retrospectively evaluated the one-year incidence of ischaemic stroke among 34,933 patients following PCI for acute myocardial infarction (AMI) from 2009 to 2013 in Sweden. They assessed the impact of ticagrelor on ischaemic stroke by dividing the population into two time-blocks based on the introduction of ticagrelor. The first period was from December 2009 to December 2011, during which only clopidogrel was used. During the second period, from December 2011 to December 2013, 40% of patients were treated with clopidogrel and 60% with ticagrelor. Interestingly, there was a 21% relative risk reduction of ischaemic stroke in the second time block with a significant absolute lower incidence of ischaemic stroke (2.2% vs. 1.8%, see Figure 1). Moreover, the authors identified several variables associated with increased stroke risk, including older age, hypertension, diabetes mellitus, atrial fibrillation, heart failure during hospitalization, previous ischaemic stroke, and STEMI. The authors concluded that ticagrelor was associated with a significant reduction of ischaemic stroke rate over the time. Dual anti-platelet therapy (DAPT) is considered a standard of care for patients with AMI treated with PCI. The favourable results of the randomized clinical trial PLATO (see Figure 1) led to a progressive replacement of clopidogrel with the newer P2Y12 receptor blocker ticagrelor in the setting of PCI for ACS. However, no difference was observed in ischaemic stroke at 12 months’ follow-up (1.1% in both groups). The difference between the paper of Ulvenstam and the PLATO trial lies in the different populations considered in the two studies, as the authors comprehensively discussed in their paper. In the modern era of evidence-based medicine, results from randomized controlled trials (RCTs) are promptly translated into guidelines that greatly impact our daily practice. Nevertheless, cohorts enrolled in RCTs are usually composed of highly selected patients, substantially different from that seen in real-world practice. Despite the presence of typical cardiovascular risk factors and a higher incidence of STEMI in the PLATO population, patients in the observational study by Ulvenstam et al. were older and more likely to have a history of prior ischaemic stroke, a recognized predictor of further ischaemic cerebral accidents. Moreover, patients with atrial fibrillation with an indication for oral anticoagulation were excluded from PLATO. On the other hand, physicians ordinarily deal with difficulties like the choice of a correct combination of anti-coagulant and anti-platelet drugs along with sub-optimal therapy regimens in patients suffering of both AF and other risk factors for cerebrovascular diseases. These baseline differences may make the real-world population at great risk for ischaemic stroke and help account for the beneficial effect of ticagrelor in regard to the reduction of ischaemic stroke in the real-world population.

Therapeutic strategy in patients with severe anemia admitted for non-ST-segment elevation acute coronary syndrome and prognostic impact.

In recent years, the use of invasive strategies has become the generalized approach in the management of patients with acute coronary syndrome, not only those with ST-segment elevation, but also in those with non–ST-segment elevation (NSTEACS). An invasive strategy is justified by the associated prognostic benefit due to reduced mortality. However, the benefits of an invasive approach in NSTEACS are not all that clear in certain subgroups in which the risks and consequences of percutaneous coronary intervention (PCI) can outweigh the benefit associated with revascularization. One of the groups in which the benefit of an invasive approach is not clear is the population with significant anemia. In these patients, aggressive antithrombotic therapy associated with an invasive approach can produce deleterious effects, exacerbate the severity of anemia and, consequently, decrease oxygen delivery to tissue with an already reduced oxygen supply. A number of studies have demonstrated the independent negative prognostic value of anemia in acute coronary syndrome, which has been proposed as a variable to be taken into account in mortality risk stratification in these patients. In this context, we describe our experience in the management of patients hospitalized for NSTEACS with hemoglobin levels < 10 g/dL on admission. For this purpose, we used data from the CardioCHUS Registry, which includes 5443 acute coronary syndrome patients consecutively admitted to Hospital Clı́nico de Santiago in northwestern Spain (2003-2012); 3689 were admitted with NSTEACS, 765 of whom (20.7%) had anemia at admission (hemoglobin < 12 g/dL in women and < 13 g/dL in men); 109 (2.9%) had severe anemia, defined as hemoglobin levels < 10 g/dL. The main baseline characteristics of these patients are summarized in the Table. In comparison with those without severe anemia, patients with hemoglobin < 10 g/dL were older (mean age [standard deviation], 73.6 [SD,10.2] years vs 67.5 [SD,12.2] years; P = .001) and had a higher prevalence of diabetes mellitus (59.6% vs 29.2%; P < .001), hypertension (72.5% vs 60.3%; P = .010), and peripheral arterial disease (23.9% vs 10.3%; P < .001), poorer renal function (mean creatinine level, 1.8 [SD,1.1] mg/dL vs 1.1 [0.6] mg/dL; P < .001), and worse functional class (Killip 2, 43.1% vs 15.3%; P < .001). On admission, there was evidence of active bleeding in 33 patients (30.3%) (the origin was gastrointestinal in 23, urinary in 6, and respiratory in 4), and 58 patients required at least 1 transfusion. Of the 109 patients with NSTEACS and hemoglobin < 10 g/dL, 75 patients (68.8%) underwent cardiac catheterization. No significant differences were found between the patients who underwent an invasive strategy and those receiving conservative treatment (without catheterization) in terms of age, sex, the incidence of diabetes mellitus, hypertension, dyslipidemia, chronic renal failure, peripheral arterial disease, or mean hemoglobin level. Thirty-five patients underwent PCI, 32 with implantation of a conventional stent and 2 with a drug-eluting stent; only 1 patient underwent simple angioplasty. The management of the patients with severe anemia was most often conservative (without catheterization, 31.2% vs 21.0% of the patients with mild anemia vs 10.4% of those without anemia; P < .001), and PCI was less widely performed (32.1% vs 45.3% of the patients with mild anemia and vs 53.7% of the patients without anemia; P < .001). Regarding drug therapy, on admission, 99 patients (90.8%) were prescribed acetylsalicylic acid, 70 (64.2%) clopidogrel, 57 (52.3%) beta-blockers, 50 (45.9%) angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers, and 79 (72.5%) statins. Low-molecular-weight heparin was used in 76 patients (69.7%), unfractionated heparin in 16 (14.7%), and fondaparinux in 12 (11.0%). Dual antiplatelet therapy was initiated on admission in 67 patients (61.5%), although only 34 (31.2%) continued taking 2 antiplatelet agents at discharge and 42 (38.5%) were taking 1. Twelve patients (11.0%) left the hospital with a prescription for oral anticoagulation therapy. There were 13 in-hospital deaths (11.9%). Mortality was higher in patients with severe anemia than in those with mild anemia (8.4%) or without anemia (2.8%); 14 patients (12.8%) experienced heart failure during their hospital stay and another 14 (12.8%) had refractory angina. The performance of PCI had no significant impact on in-hospital mortality (odds ratio [OR] = 0.40; 95% confidence interval [95%CI], 0.09-1.83; P = .239) or on the combination of death, heart failure, and refractory angina (OR = 0.45; 95%CI, 0.29-1.75; P = .450). Of the 96 patients who were discharged from the hospital, half (n = 48) died during follow-up (2.8 [2.5] years), 20 (20.8%) had a reinfarction, and 32 (33.3%) experienced heart failure. In the univariate analysis, the performance of PCI was associated with a lower mortality rate during follow-up (hazard ratio [HR] = 0.49; 95%CI, 0.25-0.94; P = .032); however, this significance was lost after Rev Esp Cardiol. 2014;67(12):1058–1067