Silvia Gómez

Efficacy of Sirolimus-Eluting Stents in Diabetics With Complex Coronary Lesions

INTRODUCTION AND OBJECTIVES Diabetics are at an increased risk of restenosis and adverse events after coronary stenting. Drug-eluting stents may, therefore, be useful in these patients. Our objective was to evaluate the use of sirolimus-eluting stents in diabetics with complex coronary lesions. PATIENTS AND METHOD Between May 2002 and August 2003, we treated 231 patients with 260 complex coronary lesions using sirolimus-eluting stents. Of these patients, 56% did not have diabetes (ND), 22% had non-insulin-dependent diabetes (NIRD), and 20% had insulin-dependent diabetes (IRD). The primary clinical endpoint was target vessel failure at 1 year. The primary angiographic endpoints in the stent were late loss and binary restenosis at 6 months. RESULTS At 6 months, late loss was greater in the IRD group (0.35 [0.71] mm) than in the ND group (0,096 [0.54] mm; P =.016) or the NIRD group (0.058 [0.52] mm; P=.017), and restenosis was more frequent (IRD, 16.3%; ND, 6.3%; and NIRD 7.8%; P=.05 for linear trend). At one year, target vessel failure occurred more frequently in the IRD group (IRD, 17.4%; NIRD, 7.7%; ND, 7.7%; P=.07 for linear trend) and the rate of survival free of target vessel failure was lower in the IRD group (82.1%) compared with the ND group (92.3%, P=.06) or the NIRD group (92.3%, P=NS). The only independent predictor of restenosis and target vessel failure was female sex. CONCLUSIONS Despite IRD patients having greater late lumen loss and more frequent restenosis at six months and a trend towards a poorer clinical outcome at 1 year, no independent relationship was found between type of diabetes and clinical outcome.

Observance of Antiplatelet Therapy after Stent Implantation in Patients under Chronic Oral Anticoagulant Treatment

PURPOSE Patients undergoing coronary stenting must take dual antiplatelet therapy during a variable period. The combination of chronic oral anticoagulants (COA) with antiplatelet therapy has been related to an increased risk of hemorrhage. The aim of this study was to evaluate the level of the antiplatelet therapy observance in those patients and the incidence of adverse events after 1 year. METHODS Patients with prior COA treatment with coronary lesions suitable for stenting were included. Clinical assessment was performed on admission, with follow-up at 1, 6, and 12 months. Antiplatelet and COA treatment, adverse cardiac events, and hemorrhagic episodes were registered. RESULTS A total of 70 patients were included. Mean age was 70.5 +/- 8.7 years. The most common cause of COA was atrial fibrillation. Conventional stents were used in 40% and drug-eluting stents (DES) in 60%. Treatment at discharge was: ASA + clopidogrel + COA 64.2%, ASA + clopidogrel 25.4%, COA + clopidogrel 7.5%, and COA + ASA 3%. Observance of antiplatelet and COA therapy at 1-6-12 month follow-up after conventional stent was: COA 73.1-70.8-69.6%; ASA 92.3-75.4-65.2%; clopidogrel 92.3-62.5-43.5%. In patients receiving DES, it was: COA 76.9-78.9-80.6%, ASA 79.5-65.8-55.7%, and clopidogrel 94.9-84.2-61.1%. Dual antiplatelet therapy in patients with DES over these periods was taken in 79.5-51.4-27.8%, respectively. The incidence of adverse events was minor bleeding 11.4%, major bleeding 8.6%, myocardial infarction 4.3%, stent thrombosis 1.4%, and death 12.8%. CONCLUSIONS There is a great variability in the treatment prescribed at discharge. Low observance with dual antiplatelet therapy has been detected in these patients, particularly after DES implantation, and they present a very high rate of complications in the follow-up.

Calidad de vida en los pacientes con síncope vasovagal. Influencia de parámetros clínicos

BACKGROUND AND OBJECTIVE: The prevalence and morbidity of the vaso-vagal syncope are well-known. With the intention of measuring the Quality of Life (QoL) of patients with vaso-vagal syncope, as well as age and gender influence, we have used the Spanish version of Short form 36 (SF-36) questionnaire in those patients and have compared it with the general population and with patients with heart failure. PATIENTS AND METHOD: All consecutive patients with vaso-vagal syncope submitted for head-up tilt test performance from January 2001 to December 2002 were included. SF-36 was self-administered prior to the head-up tilt test. RESULTS: Two hundred and seventy one patients were included (50.5% females). In these patients, QoL scores were lower than those of the Spanish general population and similar to those in patients with heart failure. Womens scores were lower in eight dimensions, and only four were lower in mens. Women QoL was worst than mens (p < 0.05). Age had a negative influence on the eight dimensions of SF-36, especially in women. The number of syncopes was the most influential clinic parameter on the QoL of such patients. CONCLUSIONS: In our series, patients suffering from vaso-vagal syncope had a poor QoL when compared with heart failure or control populations. Women had lower QoL than men, and there was an age-related worsening in both men and women. Our data show that the number of syncopes is the clinic parameter having the best correlation with QoL.

[Analysis of head-up tilt test responses in patients suffering from syncope and high blood pressure].

We studied the difference in head-up tilt test responses between patients suffering from syncope who had hypertension and those who did not. A total of 338 consecutive patients with syncope underwent head-up tilt testing in our department from January 2003 to October 2004. Of these, 243 did not have hypertension (group A), whereas 95 did (group B). There were significant differences between the groups in age (P=.0001), sex (P=.048), timing of syncope development (P=.0001), and prevalence of diabetes mellitus (P=.0001). The head-up tilt test gave positive results in 168 patients (69.1%) in group A and in 63 (66.3%) in group B (P=.6; NS). There was no significant difference between the groups in the proportion of positive responses that occurred in either the baseline or nitroglycerin-enhanced phase of the test (P=.673; NS), nor in the time to onset of syncope in either phase (P=.69; NS, and P=.28; NS, respectively). However, there was a significant difference in the type of response (vasodepressor response, 33% in group A versus 49% in group B, P=.01). In the multivariate analysis, no independent variable was found to be associated with the result of the head-up tilt test.

Care Indicators in Patients With Atrial Fibrillation: Assessment of Sex Differences and Management of Clinical Problems

INTRODUCTION AND OBJECTIVES To assess sex differences and the management of clinical problems in patients with atrial fibrillation through the use of care indicators. METHODS Over a 5-month period, the study included all consecutive patients attended in the cardiology outpatient clinics of 2 tertiary hospitals with an atrial fibrillation episode or a clinical process due to atrial fibrillation. RESULTS A total of 533 patients were included (56.5% women; mean age, 70.5 ± 12.2 years), of whom 24.3% were younger than 65 years. Women had significantly more clinical problems and a higher stroke risk: CHADS2 (congestive heart failure, hypertension, age, diabetes, stroke [doubled]) (1.8 ± 1.2 vs 1.5 ± 1.1; P = .001) and CHA2DS2-VASc (congestive heart failure, hypertension, age ≥ 75 [doubled], diabetes, stroke [doubled]-vascular disease and sex category [female]) (3.7 ± 1.4 vs 2.2 ± 1.4; P = .0001). Referrals to the cardiology department were appropriate in 94% of the patients, the referral source was primary care or other hospital services in 53.8%, and echocardiography was performed or recommended in 93.4%. Treatment (antiarrhythmics and anticoagulants) was administered according to guideline recommendations. In the previous 3 months, the Rosendaal index was 48.4 ± 37.4. CONCLUSIONS One in every 4 patients seeking care for problems associated with atrial fibrillation are young; women have more clinical problems and seek care more frequently than men. Patients are correctly referred to the cardiology department and most are not referred from the emergency department. Echocardiography and antiarrhythmic and anticoagulant therapy were provided according to the recommendations of clinical practice guidelines. Vitamin K antagonists for anticoagulation therapy are underused.

Predictors of death after coronary stenting with sirolimus-eluting stent in high-risk patients

BACKGROUND Long-term safety of drug eluting stents (DES) is under evaluation. Whether late mortality with DES may be higher than with bare metal stents is controversial and factors influencing death after DES implantation are not well known. The present observational registry analyses predictors of death during follow up after coronary stenting with sirolimus-eluting stents (SES). METHODS We performed an analysis of the causes of death on 233 patients included in a prospective registry that evaluated angiographic and clinical outcomes after SES implantation in complex scenarios. We analysed the relation of death with: 1) clinical, angiographic and procedural variables, and 2) clinical events, after a median follow up of 3.7 [3.4-3.9] years. We performed Cox regression analysis to assess predictors of mortality. RESULTS Nineteen patients (8.1%) died. Survival free of death was 91.85%. Two deaths (0.8%) were due to ictus, 2 (0.8%) were due to cancer, 2 (0.8%) were of unknown causes--not cardiac--and 13 (5.6%) were cardiac. After multivariate analysis independent predictors of death were depressed left ventricular function (HR 10.8 [3.31-35.14], p=0.0001), age (HR 1.1 [1.04-1.19], p=0.001), AMI during follow up (HR 7.03 [2.04-24.29], p=0.002), proximal LAD lesions (HR 0.15 [0.04-0.59], p=0.006), female gender (HR 3.54 [1.18-10.57], p=0.023), renal insufficiency (HR 5.82 [1.25-27.11], p=0.025) and IIb-IIIa inhibitors (HR 0.31 [0.09-1.03], p=0.054). CONCLUSIONS Mortality after SES implantation seems to be related to basal conditions of the patient, use of IIb-IIIa inhibitors, left ventricular dysfunction and progression of disease.