Victoria Lorente

Impacto en tiempos de actuación y perfil de los pacientes tratados con angioplastia primaria en el área metropolitana sur de Barcelona al implantar el programa Código Infarto

INTRODUCTION AND OBJECTIVES A standardized protocol of emergent transfer for primary percutaneous coronary intervention for patients with ST elevation myocardial infarction, defined as the Infarction Code, was implemented in June 2009 in the Catalan regional health system. The objective of this study was to evaluate the impact of the new protocol on delay times, number of procedures and clinical characteristics compared with the previous period in the population of patients referred to our hospital. METHODS All consecutive patients undergoing primary percutaneous coronary intervention in our hospital were prospectively registered. The clinical characteristics, delay times and mortality in the follow-up of the protocol implementation period (June 2009-May 2010) were analyzed and compared with the previous year (June 2008-May 2009). RESULTS During the protocol period, 514 patients were included, compared with 241 in the previous year. Age, cardiovascular risk factors, anterior myocardial infarction and procedure characteristics were similar in the 2 groups. The first medical contact to balloon time was lower in the protocol period (median time 120 min vs 88 min; P<.001). Patients in the protocol period showed a trend toward less severe disease (Killip III, rescue angioplasty). The multivariate regression analysis showed a significant association between 1-year mortality and age, Killip class ≥ III at admission, anterior infarction and 3-vessel disease. CONCLUSIONS The introduction of the Infarction Code program increased the number of patients treated by primary percutaneous coronary intervention with a reduction in delay times and better clinical characteristics at presentation. Full English text available from:www.revespcardiol.org.

Clinical Characteristics and Vital and Functional Prognosis of Out-of-hospital Cardiac Arrest Survivors Admitted to Five Cardiac Intensive Care Units

INTRODUCTION AND OBJECTIVES Survivors of out-of-hospital cardiac arrest constitute an increasing patient population in cardiac intensive care units. Our aim was to characterize these patients and determine their vital and functional prognosis in accordance with the latest evidence. METHODS A multicenter, prospective register was constructed with information from patients admitted to 5 cardiac intensive care units from January 2010 through January 2012 with a diagnosis of resuscitated out-of-hospital cardiac arrest. The information included clinical status, cardiac arrest characteristics, in-hospital course, and vital and neurologic status at discharge and at 6 months. RESULTS A total of 204 patients were included. In 64% of cases, a first shockable rhythm was identified. The time to return of spontaneous circulation was 29 (18) min. An etiologic diagnosis was made in 86% of patients; 44% were discharged with no neurologic sequelae; 40% died in the hospital. At 6 months, 79% of survivors at discharge were still alive and neurologically intact with minimal sequelae. Short resuscitation time, first recorded rhythm, pH on admission >7.1, absence of shock, and use of hypothermia were the independent variables associated with a good neurologic prognosis. CONCLUSIONS Half the patients who recovered from out-of-hospital cardiac arrest had good neurologic prognosis at discharge, and 79% of survivors were alive and neurologically intact after 6 months of follow-up.

Efficacy of Bleeding Risk Scores in Elderly Patients with Acute Coronary Syndromes

INTRODUCTION AND OBJECTIVES The incidence of acute coronary syndromes is high in the elderly population. Bleeding is associated with a poorer prognosis in this clinical setting. The available bleeding risk scores have not been validated specifically in the elderly. Our aim was to assess predictive ability of the most important bleeding risk scores in patients with acute coronary syndrome aged ≥ 75 years. METHODS We prospectively included consecutive acute coronary syndromes patients. Baseline characteristics, laboratory findings, and hemodynamic data were collected. In-hospital bleeding was defined according to CRUSADE, Mehran, ACTION, and BARC definitions. CRUSADE, Mehran, and ACTION bleeding risk scores were calculated for each patient. The ability of these scores to predict major bleeding was assessed by binary logistic regression, receiver operating characteristic curves, and area under the curves. RESULTS We included 2036 patients, with mean age of 62.1 years; 369 patients (18.1%) were ≥ 75 years. Older patients had higher bleeding risk (CRUSADE, 42 vs 22; Mehran, 25 vs 15; ACTION, 36 vs 28; P<.001) and a slightly higher incidence of major bleeding events (CRUSADE bleeding, 5.1% vs 3.8%; P=.250). The predictive ability of these 3 scores was lower in the elderly (area under the curve, CRUSADE: 0.63 in older patients, 0.81 in young patients; P=.027; Mehran: 0.67 in older patients, 0.73 in younger patients; P=.340; ACTION 0.58 in older patients, 0.75 in younger patients; P=.041). CONCLUSIONS Current bleeding risk scores showed poorer predictive performance in elderly patients with acute coronary syndromes than in younger patients.

Impact of Anaemia on Mortality and its Causes in Elderly Patients with Acute Coronary Syndromes

BACKGROUND Prognostic impact of anaemia in the elderly with acute coronary syndromes has not been specifically analysed, and little information exists about causes of mortality in this setting. METHODS We prospectively included consecutive patients with acute coronary syndromes. Anaemia was defined as haemoglobin < 130 g/L in men, and < 120 g/L in women. Primary outcome was mid-term mortality and its causes. Analyses were performed by Cox regression method. RESULTS We included 2128 patients, of whom 394 (18.6%) were aged 75 years or older. Anaemia was more common in the elderly (40.4% vs 19.5%, p <0.001). Mean follow-up was 386 days. Anaemia independently predicted overall mortality (HR 1.47, 95% CI 1.05-2.06), cardiac mortality (HR 1.76, 95% CI 1.06-2.94) and non-cardiac mortality (HR 1.59, 95% CI 1.03-2.45) in the overall cohort. In young patients the association between anaemia and mortality was significant only for non-cardiac causes. The association between anaemia and mortality was not significant in the elderly (HR 1.08, 95% CI 0.71-1.63, p 0.736). CONCLUSIONS The impact of anaemia on cause specific of mortality seem to be different according to age subgroup. The association between anaemia and mortality was not observed in elderly patients from our series.

Predictive ability of bleeding risk scores in the routine clinical practice

Background: Previous predictive models of bleeding in acute coronary syndromes (ACSs) used different definitions of bleeding and some of them come from populations lacking important predictors of haemorrhagic complications. Our group previously developed a predictive model of bleeding (PMB), including clinically meaningful variables, providing an optimal predictive ability. We aimed to compare the ability of this PMB with the main available bleeding risk scores for predicting major bleeding according to different definitions in non-selected ACS patients from daily clinical practice. Methods: All ACS patients admitted to the Coronary Care Unit were prospectively included. CRUSADE, Mehran and ACTION bleeding risk scores were calculated for each patient. In-hospital bleeding was recorded using the CRUSADE, TIMI, Mehran, ACTION and BARC definitions. For reasons of clinical relevance, BARC 3 and 5 categories were considered severe BARC bleeding for this study. The predictive ability of the PMB and other bleeding risk scores was assessed by binary logistic regression, ROC curves and areas under the curves (AUCs). Results: We included 1976 patients. Mean age was 62.1 years. Almost all patients underwent angiography, 65% of them by the radial approach. The incidence of major bleeding was: CRUSADE bleeding 3.9% (77/1976); Mehran bleeding 4.8% (94/1976); ACTION bleeding 3.9% (78/1976); and BARC 3/5 bleeding 2.4% (48/1976). The PMB showed the best ability for predicting major bleeding regardless of the definition used. The differences were specially significant for predicting BARC 3/5 bleeding (AUC: PMB 0.87, Mehran score 0.68, CRUSADE score 0.70 and ACTION score 0.70). The predictive ability of CRUSADE, ACTION and Mehran scores was similar for all the definitions analysed. Conclusions: Current bleeding risk scores showed a similar predictive ability for major bleeding regardless of the definitions used. Including other clinically meaningful predictors of bleeding into the new PMB significantly improved its predictive ability in the clinical scenario of ACS.

Prognostic Impact of Chronic Total Occlusion in a Nonculprit Artery in Patients With Acute Myocardial Infarction Undergoing Primary Angioplasty

INTRODUCTION AND OBJECTIVES The prognostic value of chronic total occlusion in nonculprit coronary arteries in patients with myocardial infarction undergoing primary angioplasty remains controversial. Several publications have described different methodologies and conflicting findings. In addition, causes of death were not reported. Our aim is to analyze the prognostic impact of chronic total occlusion in nonculprit coronary arteries and the role of left ventricular ejection fraction in this analysis. METHODS Prospective inclusion of consecutive patients with ST-segment elevation myocardial infarction who underwent primary angioplasty. We recorded baseline characteristics, in-hospital clinical course, and mortality and its causes during follow-up. We assessed the impact of chronic total occlusion on mortality using Cox regression analysis. RESULTS Chronic total occlusion in nonculprit arteries was present in 125 of 1176 patients (10.6%); in 79 of these 125 patients, chronic total occlusion was present in the proximal segments. The mean follow-up was 339 days; 64 (5.8%) patients died during the first 6 months. Patients with chronic total occlusions had more comorbidities, poorer ventricular function, and higher mortality (hazard ratio=2.79; 95% confidence interval, 1.71-4.56). Chronic total occlusion was also associated with noncardiac death (hazard ratio=3.83; 95% confidence interval, 2.10-7.01). Chronic total occlusion in proximal segments was associated with both cardiac (hazard ratio=3.22; 95% confidence interval, 1.42-7.30) and noncardiac deaths (hazard ratio=3.43; 95% confidence interval, 1.67-7.06). The multivariate analysis performed without including left ventricular ejection fraction showed a significant association between chronic total occlusion and mortality. However, when left ventricular ejection fraction was included in the analysis, this association was nonsignificant (hazard ratio=1.76; 95% confidence interval, 0.85-3.65; P=.166). CONCLUSIONS Chronic total occlusion in this clinical setting identified patients at higher risk with more comorbidities and higher mortality, but did not behave as an independent predictor of mortality when left ventricular ejection fraction was included in the analysis.

Is it possible to separate ischemic and bleeding risk in patients with non-ST segment elevation acute coronary syndromes?

nade. Color Doppler-flow examination revealed flow within the anterior portion of the pericardial effusion directed toward the right ventricle in systole and toward the right atrium in diastole. No communication with the right atrium or right ventricle was seen [1]. The intrapericardial flow pattern could also be demonstrated by pulsed-wave Doppler examination. The authors hypothesize that in their case, probably secondary to anticoagulation, the viscosity of the pericardial fluid was low enough to demonstrate, by way of fluid shifts within the confines of the pericardium, the changes of volume and pressure of the heart chambers throughout the cardiac cycle. Nevertheless, the small amount of effusion can be commonly seen in post-radiofrequency ablation, which should be general fluid without red blood cells and could not generate Doppler signal. In our case, the patient has only a small amount pericardial effusion. The flow was clearly demonstrated by color and pulse Doppler which might be due to mild injury around the pulmonary vein during radiofrequency ablation operation. The absence of red blood cells prevents the reflection of the ultrasound beam and, therefore, generates a Doppler signal. This case indicated that in patients with pericardial effusion postprocedure, we should pay more attention to find if there is any flow signal by color and pulse Doppler, which can early detect the communication between chambers and pericardium.

Mid Term Bleeding Risk Prediction After an Acute Coronary Syndrome: An Unsolved Question

hindered by the valve effect generated by the suction of the device (Figure 2B). External examination revealed a rounded shadow in the blood chamber during systole, whereas a rounded bulge was seen in the air chamber during systole. This mechanism of air entrapment led to progressive pump dysfunction (pump obstruction) that had a substantial hemodynamic impact on the patient. In this situation, cardiogenic shock can develop in a question of minutes. The 2 cases presented and the schematics help us to understand the development of this complication, each one with a different appearance on examination, different clinical course, and different associated complications. In our opinion, awareness of this complication and its pathophysiology is important for early detection, as emergency replacement of the ventricle is essential to avoid adverse outcomes.

Early Anticoagulation May Improve Preprocedural Patency of the Infarct-related Artery in Primary Percutaneous Coronary Intervention

que el tercer tercil de FPI se mantenı́a como predictor independiente de mortalidad intrahospitalaria: odds ratio = 2,42 (intervalo de confianza del 95%, 1,08-5,43; p = 0,032). Nuestro estudio tiene principalmente dos limitaciones. La primera es un posible sesgo de selección, ya que la FPI se determinó en el primer hemograma matutino tras el ingreso, y este hemograma se extrae a los pacientes de mayor riesgo, por lo que nuestros resultados serı́an válidos para dicha población. La segunda limitación se debe al escaso tamaño muestral y el pequeño número de eventos adversos que impiden un ajuste preciso por todas las variables potencialmente relacionadas con la mortalidad, lo que limita la solidez de nuestros resultados. Por lo tanto, se concluye que, en pacientes ingresados por un SCA, los valores elevados de FPI determinados en las primeras 24 h del ingreso se asocian con peor pronóstico intrahospitalario por incremento de la mortalidad, incluso entre pacientes de riesgo no alto según la escala GRACE. Se puede identificar mediante un hemograma habitual a estos pacientes, que podrı́an beneficiarse de un tratamiento más intensivo, tanto farmacológico como utilizando una estrategia de revascularización precoz. Futuros estudios deberán corroborar la asociación entre FPI y mortalidad e investigar la fisiopatologı́a de estos hallazgos.

Body mass index and acute coronary syndromes: Paradox or confusion?

Background: A better prognosis in obese patients has been described in acute coronary syndromes (ACS). However, this evidence is mostly based on retrospective studies and has provided conflicting results. No study reported cause-specific mortality according to body mass index (BMI) in ACS. We aimed to prospectively assess the impact of BMI on mortality and its specific causes in ACS patients. Methods: We included non-selected ACS patients admitted in a tertiary care coronary unit, collecting baseline characteristics, management and clinical course. Patients were stratified into five clinically meaningful BMI subgroups of <20, 20–24.9, 25–29.9, 30–35, >35 kg/m2. The primary outcome was 1 year mortality, its causes and its association with BMI. This association was assessed by the Cox regression method. Results: We included 2040 patients in our study with a mean age of 62.1 years. Low weight patients (BMI <20) were older, with less cardiovascular risk factors, higher prevalence of chronic obstructive pulmonary disease and worse renal function. Mean follow up was 334 days. The unadjusted analysis showed lower all-cause mortality in all subgroups as compared to low weight patients. After adjusting for potential confounders, this association remained significant for patients with a BMI 20–24.9. Cardiac mortality was similar across BMI subgroups. In contrast, the adjusted analysis showed a significantly lower non-cardiac mortality in patients with a BMI 20–24.9, 25–29.9 and 30–35 as compared to low weight patients. Conclusions: Baseline characteristics in ACS patients significantly differ according to their BMI status. The prognostic impact of BMI seems mostly related to extra-cardiac causes in low weight patients.