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To blind or not researcher’s identity has often been a topic of debate in the context of peer-review process for scientific publication and research grant application. This article reports on how knowing the name and experience of researchers/institutions influences the qualification of a proposal. We present our experience of managing the peer-review process of different biomedical research grants. The peer-review process included three evaluation stages: first, blinded assessment; second, unblinded assessment by the same reviewer; and final, assessment of the better qualified proposals by an ad hoc committee. The change between the first (applicants blinded) and the second assessments (unblinded) for each evaluation and reviewer was evaluated. Factors associated with change were analysed, taking into account the characteristics of proposals, reviewers, and researchers. A qualitative content analysis of the reviewers’ comments was also carried out to assess the reasons for change. The analysis of 5,002 evaluations indicated that in 18.5% of the evaluations (from 10.5 to 27.7% depending on the year of the edition), the reviewer changed the second assessment: either for better (11.9%) or worse (6.6%). Our findings also suggest that a change in the second assessment was highly correlated with a positive evaluation of the experience of the principal investigator or research team. With a change of 1 in 10 to 1 in 4 depending on the year of the edition, we believe that concealing the identity of researchers/institutions could help to focus exclusively on the proposal and reduce some of the common biases of the peer-review process in grant decisions.

Resumen Introduccion y objetivos El objetivo del estudio OFRECE fue estimar la prevalencia de angina estable en Espana. Esta es actualmente desconocida por falta de estudios recientes y cambios en la epidemiologia y el tratamiento de la cardiopatia isquemica. Metodos Estudio transversal. Se obtuvo una muestra representativa de la poblacion espanola de edad mayor o igual a 40 anos mediante muestreo aleatorio en dos etapas: la primera fue una seleccion aleatoria de medicos de atencion primaria de cada provincia y la segunda, una seleccion de 20 individuos de la poblacion asignada a cada medico. La prevalencia se pondero por edad, sexo y area geografica. Se clasifico a los participantes como pacientes con angina si cumplian criterios de «angina segura» del cuestionario de Rose y como angina confirmada si ademas tenian antecedentes de cardiopatia isquemica aguda, revascularizacion o confirmacion tras evaluacion cardiologica. Resultados Se analizo a 8.378 personas (media de edad, 59,2 anos), el 71% de las 11.831 invitadas a participar. La prevalencia ponderada de angina segura (Rose) fue del 2,6% (intervalo de confianza del 95%, 2,1-3,1%), mayor en mujeres (2,9%) que en varones (2,2%), y la de angina confirmada, del 1,4% (intervalo de confianza del 95%, 1,0-1,8%) sin diferencias entre varones (1,5%) y mujeres (1,3%). La prevalencia se incremento con la edad (angina segura, el 0,7% en el grupo de 40-49 anos y el 7,1% en el de edad mayor o igual a 70 anos), los antecedentes de enfermedad cardiovascular y los factores de riesgo cardiovascular, salvo el tabaquismo. Conclusiones La prevalencia de angina segura (Rose) en la poblacion espanola de edad mayor o igual a 40 anos es del 2,6% y la de angina confirmada, del 1,4%, y ambas se incrementan con la edad, los factores de riesgo cardiovascular y los antecedentes cardiovasculares.

Resumen Introduccion y objetivos La fibrilacion auricular se asocia con elevadas morbilidad y mortalidad, y tanto su incidencia como su prevalencia son altas. No obstante, hay escasos datos poblacionales sobre su epidemiologia en Espana. El objetivo de este estudio es estimar la prevalencia de fibrilacion auricular en Espana. Metodos Estudio transversal en poblacion espanola de 40 o mas anos. Se realizo un muestreo en dos etapas, una primera seleccion aleatoria de medicos de atencion primaria de cada provincia espanola y, en segundo lugar, se selecciono aleatoriamente a 20 individuos de la poblacion asignada a cada medico participante. La prevalencia se pondero por edad, sexo y area geografica. Se realizo una lectura centralizada de los registros electrocardiograficos. Resultados Se evaluo a 8.343 personas (media de edad, 59,2 [intervalo de confianza del 95%, 58,6-59,8] anos; el 52,4% mujeres). La prevalencia total de fibrilacion auricular fue del 4,4% (intervalo de confianza del 95%, 3,8-5,1). La prevalencia fue similar en varones (4,4% [3,6-5,2]) y mujeres (4,5% [3,6-5,3]) y se incrementa progresivamente a partir de los 60 anos de edad. En los mayores de 80 anos, la prevalencia fue del 17,7% (14,1-21,3). En un 10% de pacientes se diagnostico una fibrilacion auricular no conocida. Conclusiones La prevalencia de fibrilacion auricular en la poblacion general espanola mayor de 40 anos es elevada, del 4,4%. La prevalencia es similar en varones y mujeres y se incrementa escalonadamente a partir de los 60 anos. Se estima en mas de 1 millon de pacientes con fibrilacion auricular en la poblacion espanola, de los que mas de 90.000 estan sin diagnosticar.

Introduction The study aims to illustrate the impact of Spanish research in clinical decision making. To this end, we analysed the characteristics of the most significant Spanish publications cited in clinical practice guidelines (CPG) on mental health. Material and methods We conducted a descriptive qualitative study on the characteristics of ten articles cited in Spanish CPG on mental health, and selected for their “scientific quality”. We analysed the content of the articles on the basis of the following characteristics: topics, study design, research centres, scientific and practical relevance, type of funding, and area or influence of the reference to the content of the guidelines. Results Among the noteworthy studies, some basic science studies, which have examined the establishment of genetic associations in the pathogenesis of mental illness are included, and others on the effectiveness of educational interventions. The content of those latter had more influence on the GPC, because they were cited in the summary of the scientific evidence or in the recommendations. Some of the outstanding features in the selected articles are the sophisticated designs (experimental or analytical), and the number of study centres, especially in international collaborations. Debate or refutation of previous findings on controversial issues may have also contributed to the extensive citation of work. Conclusions The inclusion of studies in the CPG is not a sufficient condition of “quality”, but their description can be instructive for the design of future research or publications.

Background The use of drug-eluting stents (DES) is an example of the disparity between recommendations given by regulatory agencies and the real clinical world. Such disparity might lead cardiologists to adopt different routines in the use of DES. We aimed to assess variability of off-label DES use between hospitals and to what extent it can be explained by differences in patient or hospital characteristics. Methods Characteristics of consecutive patients receiving DES in 29 hospitals were recorded. Individual and hospital determinants of receiving DES for off-label indications were assessed by multilevel logistic regression. Results 1903 patients were recruited and 1188 (62.4%) received DES for off-label indications. Individual variables associated with off-label use were age (OR 1.01 (1–1.02)), previous percutaneous (OR 2.24 (1.68–2.97)) or surgical (2.41 (1.52–3.84)) revascularization, repeated procedure at the same admission (OR 4.66 (2.7–8.05)), receiving two (OR 4.17 (3.24–5.37)) or three or more DES (OR 14.12 (9.08–21.96)) vs one. Adjusting for individual variables, the Odds of receiving DES for off-label indication was higher in public funding hospitals with surgery availability vs private hospitals: 1.49 (0.86–2.6), and in public hospitals without surgery vs public with surgery availability: OR 1.76 (1.02–3.03). Interhospital variability reminded significant after adjustment for individual and contextual variables. Conclusion Off-label DES use is highly variable between centers. Although this variability is partially determined by hospital type of funding and cardiac surgery availability, the substantial interhospital variability after multilevel adjustment suggests heterogeneity in the process of care.

Objectives The goal of this study was to assess the risk associated with double antiplatelet therapy (DAT) discontinuation, and specifically, temporary discontinuation, during the first year after drug-eluting stent (DES) implantation. Background Doubts remain about the risk of temporary DAT discontinuation within 1 year after DES implantation. Methods A total of 1,622 consecutive patients undergoing DES implantation at 29 hospitals were followed up at 3, 6, 9, and 12 months to record the 1-year antiplatelet therapy discontinuation (ATD) rate, the number of days without DAT, and the rate of 1-year major cardiac events. Cox regression was used to analyze the association between ATD considered as a time-dependent covariate and 1-year cardiac events. Results One hundred seventy-two (10.6%) patients interrupted at least 1 antiplatelet drug during the first year after DES implantation, although only 1 during the first month. Most (n = 111, 64.5%) interrupted DAT temporarily (median: 7 days; range: 5 to 8.5): 79 clopidogrel (31 temporarily), 38 aspirin (27 temporarily), and 55 both drugs (53 temporarily). Discontinuation was followed by acute coronary syndrome in 7 (4.1%; 95% confidence interval [CI]: 1.7 to 8.2), a similar rate of major cardiac events to that in patients without ATD (n = 80; 5.5%; 95% CI: 4.4 to 6.8; p = 0.23). ATD was not independently associated with 1-year major cardiac events (hazard ratio: 1.32 [95% CI: 0.56 to 3.12]). Conclusions ATD within the first year and beyond the first month after DES is not exceptional, is usually temporary, and does not appear to have a large impact on risk.

Background— Patent false lumen in aortic dissection has been associated with poor prognosis. We aimed to assess the natural evolution of this condition and predictive factors. Methods and Results— One hundred eighty-four consecutive patients, 108 surgically treated type A and 76 medically treated type B, were discharged after an acute aortic dissection with patent false lumen. Transesophageal echocardiography was performed before discharge, and computed tomography was performed at 3 months and yearly thereafter. Median follow-up was 6.42 years (quartile 1 to quartile 3: 3.31–10.49). Forty-nine patients died during follow-up (22 type A, 27 type B), 31 suddenly. Surgical or endovascular treatment was indicated in 10 type A and 25 type B cases. Survival free from sudden death and surgical-endovascular treatment was 0.90, 0.81, and 0.46 (95% CI, 0.36–0.55) at 3, 5, and 10 years, respectively. Multivariate analysis identified baseline maximum descending aorta diameter (hazard ratio [HR]: 1.32 [1.10–1.59]; P =0.003), proximal location (HR: 1.84 [1.06–3.19]; P =0.03), and entry tear size (HR: 1.13 [1.08–1.2]; P P =0.008), entry tear size (HR: 1.1 [1.04–1.16]; P =0.001), and Marfan syndrome (HR: 3.66 [1.65–8.13]; P =0.001). Conclusions— Aortic dissection with persistent patent false lumen carries a high risk of complications. In addition to Marfan syndrome and aorta diameter, a large entry tear located in the proximal part of the dissection identifies a high-risk subgroup of patients who may benefit from earlier and more aggressive therapy.

Background and Purpose— To investigate the 30-day and 12-month mortality risks among hospitalized stroke patients according to compliance with guideline-based process indicators. Methods— We used data from the Second Stroke Audit and the Mortality Register of Catalonia (Spain). The audit retrospectively explored quality of stroke care based on compliance with indicators among patients discharged from all public hospitals in Catalonia in 2007; they were identified and selected through a pre-established sampling method. The magnitude of the independent association of each indicator with 30-day and 12-month mortality was assessed using logistic regression with generalized estimating equations to account for clustering of patients within hospitals. Generalized estimating equations modeling was initially restricted to patients alive >72 hours poststroke to control for confounding by severity. Analyses were also run in 3 other samples (all patients, patients alive >7 days, and patients alive >14 days). Results— Of 1767 stroke admissions in the Second Stroke Audit, 1697 patients survived >72 hours poststroke. Within this sample, the adjusted 30-day mortality risk was negatively associated with nonadherence to different indicators, of which only antithrombotics at discharge (OR, 4.3; 95% CI, 1.72–10.78) remained significant in all data sets. At 12 months, the adjusted mortality risk was negatively associated with management of hypertension (OR, 1.87; 95% CI, 1.22–2.86) and antithrombotics at discharge (OR, 2.79; 95% CI, 1.41–5.54). Both remained unchanged across different samples. Conclusions— Assessing the impact of quality of stroke care on mortality is complex and is hampered by residual confounding, particularly in the short-term. Nevertheless, this study suggests that at least a few indicators should be used to monitor quality of stroke services.

This article presents the ex-post assessment of a program of clinical and health services research and the evaluation of the social impact. The Catalan Agency for Health Information, Assessment, and Quality (CAHIAQ) promotes a biannual open, public, competitive extramural research call to conduct non-commercial clinical and health services research. Its aim is to address local needs of research (knowledge gaps) and to assess the implementation of innovation. Approximately 5.8 million Euros have been allocated to the call. To meet the Agency’s mission, a periodical ‘call for expressions of interest’ and topic prioritization is organized prior to the research call. The awarded projects are submitted to an ex-ante, ongoing, and ex-post assessment. Impact assessment of the research call on advancing knowledge and healthcare decision making is based on the Canadian Academy of Health Sciences framework (Panel on Return on Investment in Health Research, 2009). The methods used include bibliometric analysis, surveys to researchers and decision-makers, and a more in-depth case study of translation pathways. This includes a crossover of cases from 1996 to 2004. Some results are compared against other international health services research calls. The conclusion is that local agencies can significantly contribute to fill knowledge gaps in a specific context. Assessment of the complete research cycle provides opportunities for improving the entire research process (identification of knowledge needs, call for proposals, funding allocation, research completion, subsequent impact). Specifically, assessment of the different types of impact of research development on knowledge generation and decision making closes the evaluation cycle fulfilling the Agency's mission. Fil: Adam, Paula. Catalan Agency for Health Information; España. Epidemiologia y Salud Pública; España Fil: Solans Doménech, Maite. Catalan Agency for Health Information; España. Epidemiologia y Salud Pública; España Fil: Pons, Joan M. V.. Catalan Agency for Health Information; España. Epidemiologia y Salud Pública; España. Gobierno de Catalunya. Ministerio de Salud; España Fil: Aymerich, Marta. Gobierno de Catalunia. Ministerio de Salud; España. Universidad de Girona; España Fil: Berra, Silvina del Valle. Universidad Nacional de Córdoba. Facultad de Medicina. Escuela de Salud Pública; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina Fil: Guillamon, Imma. Catalan Agency for Health Information; España. Epidemiologia y Salud Pública; España Fil: Sánchez, Emilia. Universitat Ramon Llull; España Fil: Permanyer Miralda, Gaieta. Catalan Agency for Health Information; España. Epidemiologia y Salud Pública; España. Universidad Autonoma de Barcelona. Hospital Vall D; España

Resumen Introduccion y objetivos Determinar el cambio en la mortalidad a corto y medio plazo por infarto agudo de miocardio en Espana y los factores terapeuticos relacionados. Metodos Se identifico y se siguio durante 6 meses a 9.949 pacientes con infarto agudo de miocardio con elevacion del ST ingresados en la unidad coronaria en los registros PRIAMHO I, II y MASCARA realizados en 1995, 2000 y 2005. Resultados En el periodo 1995-2005 aumento (p Conclusiones La mortalidad precoz y a los 6 meses del infarto con elevacion del ST disminuyo en 1995-2005. Los factores terapeuticos relacionados son: incremento de la reperfusion y mayor utilizacion de antitromboticos, bloqueadores beta, inhibidores del sistema renina-angiotensina e hipolipemiantes.

Advanced atherosclerotic disease increases the risk of stent thrombosis after drug-eluting stent (DES) implantation. We aimed to determine if an abnormal ankle-brachial index (ABI) value as a surrogate of atherosclerotic disease and vascular inflammation provides information on 1-year risk of cardiovascular events after DES implantation. A prospective cohort of 1,437 consecutive patients undergoing DES implantation from January through April 2008 in 26 Spanish hospitals was examined. ABI was calculated by Doppler in a standardized manner. Patients were followed to 12 months after the percutaneous coronary intervention to determine total and cardiovascular mortality, stroke, nonfatal acute coronary syndrome (ACS), and new revascularizations. Association of an abnormal ABI value (i.e., ≤ 0.9 or ≥ 1.4) with outcomes was assessed by conventional logistic regression and by propensity-score analysis. Patients with abnormal ABI values (n = 582, 40.5%) in general had higher global cardiovascular risk, the reason for DES implantation was more often ACS, and had a higher rate of complications during admission (heart failure or stroke or major hemorrhage 11.3% vs 5.3%, p

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

This article analyzes the role of ICT within the complicated gear between information, knowledge and healthcare practices, which particular focus on two specific cases: the digitalization process of the healthcare system and the application of knowledge into the healthcare practices. In both cases, international and local experiences suggest, and sometimes demonstrate the importance of the participation, capacity-building and empowerment of healthcare practitioners for the generation, transfer and use of information and knowledge empowered by the digital tools which should bring into the system better performance, more efficacy, efficiency, equity, equality, security, quality.

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.

Introduccion y objetivos Valorar el pronostico y los patrones de manejo de pacientes con sindrome coronario agudo y arteriopatia periferica, enfermedad cerebrovascular o ambos (enfermedad polivascular) en condiciones de practica clinica real. Metodos Se utilizaron los datos del registro MASCARA de sindrome coronario agudo entre 2004 y 2005. Se estratifico a los pacientes segun presentaran arteriopatia periferica, enfermedad cerebrovascular, ambas o ninguna. Se analizaron el manejo intrahospitalario, el tratamiento al alta y los resultados clinicos a 6 meses. Resultados De 6.745 pacientes, 597 (8,85%) tenian arteriopatia periferica; 392 (5,8%), enfermedad cerebrovascular; 131 (1,94%), ambas y 5.625 (83,4%), ninguna. Los pacientes con enfermedad polivascular tenian enfermedad coronaria mas extensa, pero recibieron menos tratamientos habitualmente recomendados (por ejemplo, recibieron aspirina al alta el 75% de los pacientes con arteriopatia periferica y el 84% de los libres de ella). La mortalidad hospitalaria y a 6 meses fue mas alta en pacientes con arteriopatia periferica (el 9,1 y el 24,5%, respectivamente), enfermedad cerebrovascular (el 9,2 y el 22,4%) y especialmente con ambas (el 16 y el 29,8%) que en los libres de estas afecciones (el 4,8 y el 10,8%) (p Conclusiones Los pacientes con sindrome coronario agudo y arteriopatia concomitante tienen enfermedad coronaria mas extensa y peores resultados clinicos intrahospitalarios y a los 6 meses, pero habitualmente reciben menos tratamientos regularmente recomendados.

To assess prognosis and patterns of care in patients with acute coronary syndrome and peripheral arterial disease (PAD), cerebrovascular disease or both (i.e., polyvascular disease) in everyday clinical practice.We used data from the MASCARA acute coronary syndrome registry for 2004 and 2005. Patients were stratified according to the presence of PAD, cerebrovascular disease, neither, or both. In-hospital management, treatment at discharge and outcomes at 6 months were recorded.Of 6745 patients, 597 (8.85%) had PAD, 392 (5.8%) had cerebrovascular disease, 131 (1.94%) had both and 5625 (83.4%) had neither. Patients with polyvascular disease had more extensive coronary disease, but less often received regularly recommended treatment (e.g., 75% with PAD received aspirin at discharge versus 84% of those without). In-hospital and 6-month mortality were significantly higher (P.001) in patients with PAD (9.1% and 24.5%, respectively) or cerebrovascular disease (9.2% and 22.4%, respectively) or, especially, both (16.0% and 29.8%, respectively) than in those free from these conditions (4.8% and 10.8%, respectively). Cerebrovascular disease, PAD and their combination were all independently associated with in-hospital and 6-month mortality: for cerebrovascular disease, the odds ratio (OR) for mortality at 6 months was 1.45 (95% confidence interval [CI], 1.10-2.02); for PAD, it was 1.88 (95% CI, 1.45-2.40); and for both combined, 1.88 (95% CI, 1.17-3.00).Patients with acute coronary syndrome and concomitant arterial disease had more extensive coronary artery disease and poorer outcomes, both inhospital and at 6 months, but frequently did not receive regularly recommended treatment.

Introduction and objectives Little is known about the long-term outcomes of coronary surgery and their determinants in Spain. The objectives of this study were to evaluate clinical outcomes, quality of life and survival in a cohort of patients 5 years after undergoing a first aortocoronary bypass operation without any other associated procedure. Methods Patients who survived the operation and whose pre- and postoperative data had been collected prospectively were followed up by telephone interview after 5 years. Results Information was available after 5 years on 1300 (85.2%) of the 1525 patients who survived until hospital discharge. Of these, 13.6% had died, while 24% had either died, undergone revascularization or were readmitted because of a cardiac complaint. The cumulative survival rate (excluding the period of hospitalization) was 0.87 (95% confidence interval, 0.85-0.89). Mortality varied significantly with the level of preoperative risk (ie, the EuroSCORE), to the extent that mortality in the low-risk group was equivalent to that in the general reference population. Conclusions Three-quarters of patients who survived until hospital discharge after coronary surgery did not experience a major cardiac event within 5 years and their level of functioning and quality of life were good. The survival rate after the immediate postoperative period varied according to the patient's preoperative risk profile and, in low-risk patients, was equivalent to that in the general reference population.

Introduccion y objetivos El resultado tardio de la cirugia coronaria y sus determinantes son poco conocidos en Espana. Este estudio evalua la evolucion clinica, la calidad de vida y la supervivencia de una cohorte de pacientes, transcurridos 5 anos de un primer injerto aortocoronario sin otros procedimientos asociados. Metodos Seguimiento telefonico a los 5 anos a los supervivientes de la operacion, de los que se habia recogido prospectivamente los datos preoperatorios y postoperatorios. Resultados De los 1.525 pacientes dados de alta vivos, a los 5 anos se obtuvo informacion de 1.300 (85,2%), de los que el 13,6% habia fallecido y el 24% habia fallecido o habia sido revascularizado o ingresado por causa cardiaca. La supervivencia acumulada (excluyendo la fase hospitalaria) fue de 0,87 (intervalo de confianza [IC] del 95%, 0,85-0,89). La tasa de mortalidad fue distinta segun el riesgo preoperatorio (EuroSCORE); la del grupo con bajo riesgo fue equivalente a la de la poblacion general de referencia. Conclusiones De cada 4 supervivientes al alta 3 estan libres de eventos mayores a los 5 anos, con buenas capacidad funcional y calidad de vida. La supervivencia despues del postoperatorio inmediato varia en funcion de las caracteristicas prequirurgicas de riesgo y en el grupo con bajo riesgo es equivalente a la de la poblacion general de referencia.

To assess health-related quality of life (HRQL) in Spanish outpatients with chronic heart failure (CHF). Cross-sectional study carried out in a sample of CHF patients (echocardiography was performed in all of them) followed either in Primary Care (PC) centres or Cardiology outpatient clinics throughout Spain. HRQL was evaluated using the EuroQol 5D (EQ-5D) and Minnesota Living with Heart Failure (MLWHF) Questionnaire. The study subjects were 2161 CHF patients (1412 PC; 749 Cardiology). Patients were older and had more severe disease in PC than in Cardiology settings. Their HRQL scores were likewise worse. After adjusting for clinical variables, the differences in global and physical MLWHF disappeared, but persisted to a smaller degree in EQ-5D and mental MLWHF. HRQL was worse than in a representative sample of the Spanish population and in other chronic conditions such as rheumatoid arthritis or type 2 diabetes, being only comparable to severe chronic obstructive pulmonary disease (COPD). All domains of HRQL were significantly impaired in CHF patients. Differences found in HRQL between PC and Cardiology should possibly be attributed to a large extent to the different clinical characteristics of the patients attended. In spite of the differences between EQ-5D and MLWHF, our results suggest that both questionnaires adequately reflect the severity of the disease.

Introduccion y objetivos Determinar el perfil clinico, el manejo del sindrome coronario agudo (SCA) y el efecto de la estrategia intervencionista precoz (EIP) en el SCA sin elevacion del ST (SCASEST) y del intervencionismo coronario percutaneo (ICP) primario en el SCA con elevacion del ST (SCACEST). Metodos Inclusion prospectiva en 50 hospitales seleccionados aleatoriamente segun nivel asistencial, durante 9 meses entre 2004 y 2005, y seguimiento a 6 meses de la mortalidad o el reingreso por SCA. Se analizo el efecto ajustado de las estrategias de reperfusion. Resultados Tras control de calidad, se analizaron los datos de 32 hospitales, correspondientes a 7.923 acontecimientos coronarios (4.431 SCASEST [56%], 3.034 SCACEST [38%] y 458 SCA inclasificable [6%]) de 7.251 pacientes. Respecto a registros anteriores, destaca un incremento del ICP primario en el SCACEST (del 10,7 al 36,8% de los reperfundidos) y la EIP en el SCASEST (del 11,1 al 19,6%). La mortalidad hospitalaria total fue del 5,7% (intervalo de confianza [IC] del 95%, 5,1%-6,2%); del SCACEST, el 7,6% (IC del 95%, 6,7%-8,7%); del SCASEST, el 3,9% (IC del 95%, 3,3%-4,6%), y del indeterminado, el 8,8% (IC del 95%, 6,2%-12,2%). No se observo, en el total de la poblacion, relacion con el pronostico (mortalidad a 6 meses) de la EIP en el SCASEST (hazard ratio [HR] = 0,94; IC del 95%, 0,66-1,3) ni del ICP primario en el SCACEST (HR = 1; IC del 95%, 0,7-1,5). Se observaron resultados similares con la variable muerte o reingreso por SCA a 6 meses. Conclusiones En 2004-2005 se registro en Espana un aumento de estrategias invasivas. Se observo una insuficiente adecuacion de estas al riesgo basal de los pacientes.

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.

Las variables de resultado combinadas en los ensayos clinicos son un recurso metodologico usado con frecuencia, especialmente en los estudios cardiovasculares. Las motivaciones mas importantes para su utilizacion son aumentar la potencia estadistica del estudio, valorar el beneficio neto de una intervencion y evitar una interpretacion erronea del resultado en presencia de riesgos competitivos. Sin embargo, su interpretacion puede ser problematica si hay heterogeneidad entre los componentes en cuanto a su importancia, la frecuencia de eventos o el efecto de la intervencion. En la discusion que sigue se presenta un revision conceptual de los problemas del uso y la interpretacion de las variables de resultado combinadas en ensayos clinicos, especialmente los cardiovasculares. Se presenta ademas una sencilla guia de interpretacion de los resultados de los estudios que utilizan variables de resultado combinadas a partir de la cual se puede valorar nuestra confianza en dichos resultados. Finalmente, se presenta un estudio empirico sobre cual ha sido el uso real de variables de resultado combinadas potencialmente problematicas en ensayos clinicos cardiovasculares.

Introduction and objectives. To investigate the clinical characteristics and treatment of acute coronary syndromes (ACS), and to determine the effects of an early invasive strategy (EIS) in non-ST-elevation ACS (NSTEACS) and of primary percutaneous coronary intervention (PCI) in ST-elevation ACS (STEACS). Methods. Data were collected prospectively for 9 months during 2004-2005 from 50 hospitals, which were randomly selected according to the level of care provided. In addition, follow-up data on mortality and readmission for ACS were collected for 6 months. The adjusted effects of different reperfusion strategies were analyzed. Results. After checking data quality, the analysis included data from 32 hospitals, which covered 7923 coronary events (4431 [56%] STEACS, 3034 [38%] NSTEACS, and 458 [6%] unclassified ACS) in 7251 patients. Compared with previous studies, the use of primary PCI in STEACS had increased markedly (from 10.7% to 36.8% of patients undergoing reperfusion), as had the use of EIS in NSTEACS (from 11.1% to 19.6%). Overall in-hospital mortality was 5.7% (95% confidence interval [CI], 5.1-6.2); for STEACS it was 7.6% (95% CI, 6.7-8.7), for NSTEACS 3.9% (95% CI, 3.3-4.6), and for unclassified ACS 8.8% (95% CI, 6.2-12.2). In the population

Composite endpoints are often used in clinical trials, especially in the cardiovascular area. Decreases in sample size requirements, ability to assess the net effect of an intervention and to avoid bias in presence of competing risks are the most cited advantages for their use. However, there is a risk of misinterpretation when heterogeneity among components with respect to either importance, number of events, or magnitude of treatment effect exist. In the following review we present a conceptual discussion about the rationale and interpretation of such variables. Also, a user’s friendly guide to interpret the results of clinical trials based on composite endpoints is presented. We also present an empirical study that provides evidence of the use of misleading composite endpoints in cardiovascular clinical trials.

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.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.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).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.

Background— Low-pressure cardiac tamponade is a form of cardiac tamponade in which a comparatively low pericardial pressure results in cardiac compression because of low filling pressure. This syndrome is poorly characterized because only isolated cases have been reported. We conducted a study of its clinical and hemodynamic profiles. Methods and Results— From 1986 through 2004, we evaluated all patients at our institution with combined pericardiocentesis and cardiac catheterization. We identified those patients who fulfilled catheterization-based criteria of low-pressure cardiac tamponade and compared their clinical and catheterization data with those of patients with classic tamponade. A total of 1429 patients with pericarditis were evaluated, 279 of whom underwent combined pericardiocentesis and catheterization. Criteria of low-pressure cardiac tamponade were met in 29, whereas 114 had criteria of classic cardiac tamponade. Patients with low-pressure tamponade less frequently had clinical signs of tamponade, but the rate of constitutional symptoms, use of diuretics, and echocardiographic findings of tamponade were similar in both groups. Patients with low-pressure tamponade showed a significant increase in cardiac output after pericardiocentesis, but they usually had less severe cardiac tamponade compared with patients with classic tamponade. Prognosis was related mainly to the underlying disease. Conclusions— Low-pressure cardiac tamponade was identified in 20% of patients with catheterization-based criteria of tamponade. Clinical recognition may be difficult because of the absence of typical physical findings of tamponade in most patients. Although some patients are critically ill, most show a stable clinical condition. However, these patients obtain a clear benefit from pericardiocentesis.

Introduccion y objetivos En estudios previos se senala que hay diferencias en la efectividad de la cirugia coronaria segun si la intervencion se realiza en centros de gestion publica o privada. Este estudio evalua la mortalidad hospitalaria de la cirugia coronaria en ambos tipos de centro, ajustada al riesgo preoperatorio, en pacientes de la sanidad publica catalana. Metodos Se incluyo prospectivamente a todos los pacientes intervenidos de un primer bypass coronario durante 2 anos, con financiacion publica, en 5 hospitales de gestion publica y privada. Se evaluo el riesgo mediante el EuroSCORE y el modelo de la AATRM. Resultados Se intervino a 1.605 pacientes (el 21% en hospitales privados). En centros privados se opero a mas pacientes no electivos (el 64 frente al 50%), con angina inestable (el 17 frente al 11%) y grado funcional IV (el 20 frente al 11%). La odds ratio (OR) para la mortalidad hospitalaria en centros privados frente a publicos fue de 0,56 (intervalo de confianza [IC] del 95%, 0,29-1,06) tras ajustar por el EuroSCORE, y de 0,56 (IC del 95%, 0,29-1,07) tras ajustar por la escala de la AATRM. La mortalidad observada (el 4,8%; IC del 95%, 3,8-5,6) no era significativamente distinta de la esperada. Al ajustar por las caracteristicas basales de los pacientes, la gestion privada del centro se asocio con una menor mortalidad (OR = 0,43; IC del 95%, 0,21-0,87). Conclusiones a) La mortalidad hospitalaria es equivalente o inferior a la esperada segun 2 instrumentos de ajuste de riesgo; b) el ajuste segun las caracteristicas de los pacientes indica que hay una diferencia favorable a los centros de gestion privada, y c) la comparacion con resultados previos evidencia una mejora de la efectividad de la cirugia coronaria en los ultimos anos.

Introduction and objectives Previous studies suggest that the effectiveness of coronary surgery is influenced by the type of management at the healthcare centre where the intervention is performed. The present study assessed the risk-adjusted hospital mortality of coronary surgery in the Catalan healthcare system in hospitals under either private or public management. Methods We carried out a prospective study of all consecutive patients receiving a first coronary artery bypass graft, with public financial support, in a period of 2 years at 5 hospitals under either public or private management. Preoperative risk was assessed using the EuroSCORE and Catalan Agency for Health Technology Assessment (CAHTA) predictive models. Results Overall, 1605 patients underwent interventions, 21% of which were at private hospitals. The percentage of patients undergoing non-elective surgery was higher at private hospitals (64% vs 50%), as was the percentage needing intravenous nitrates (17% vs 11%) and the percentage in functional class IV (20% vs 11%). The odds ratio for in-hospital mortality in private compared with public hospitals was 0.56 (95% Cl, 0.29-1.06) when adjusted for EuroSCORE, 0.56 (95% Cl, 0.29-1.07) when adjusted for CAHTA score, and 0.43 (95% Cl, 0.21-0.87) when adjusted for patient characteristics. The mortality observed, 4.8% (95% Cl 3.8-5.6), was not significantly higher than that predicted. Conclusions a) Hospital mortality was equivalent to or lower than that expected after adjustment for the 2 risk scores; b) after adjustment for baseline patient characteristics, the results favored privately managed centers; and c) comparison with previous results suggests that coronary surgery effectiveness has improved in recent years.

Objectives The purpose of this study was to compare postoperative outcome in two groups of patients with chronic severe aortic regurgitation (AR): those operated on early and those operated on late according to the guidelines. Background The impact of earlier surgery for chronic severe AR as defined in guidelines has not been evaluated. Methods A total of 170 patients with chronic severe AR submitted to aortic valve replacement were prospectively followed up. Patients were divided in two groups depending on the clinical situation at the time of surgery. Group A were 60 patients who were operated on following guidelines advice of earlier surgery, and group B were 110 patients who were operated on late with regard to guideline recommendations. Results Follow-up was 10 ± 6 years (1 to 22 years). During follow-up 44 patients died, 7 patients (12%) from group A and 37 (37%) from group B (p = 0.001). The cause of death was non-cardiac in 11 patients, 2 (3%) in group A and 9 (8%) in group B. Cardiac deaths occurred in 33 patients, 5 (9%) from group A and 28 (28%) from group B (p = 0.002). Causes of death differed between groups A and B: heart failure or sudden death were significantly more frequent in group B (20 patients vs. 1 patient, p = 0.001). Overall survival in groups A and B was 90 ± 4% vs. 75 ± 8% at 5 years, 86 ± 5% vs. 64 ± 5% at 10 years, and 78 ± 7% vs. 53 ± 6% at 15 years, respectively (p = 0.009). Conclusions Early operation as defined in the guidelines improves long-term survival in patients with chronic AR.

BACKGROUND Vasodilator therapy can reduce the left ventricular volume and mass and improve left ventricular performance in patients with aortic regurgitation. Accordingly, it has been suggested that such therapy may reduce or delay the need for aortic-valve replacement. METHODS We randomly assigned 95 patients with asymptomatic severe aortic regurgitation and normal left ventricular function to receive open-label nifedipine (20 mg every 12 hours), open-label enalapril (20 mg per day), or no treatment (control group) to identify the possible beneficial effects of vasodilator therapy on left ventricular function and the need for aortic-valve replacement. RESULTS After a mean of seven years of follow-up, the rate of aortic-valve replacement was similar among the groups: 39 percent in the control group, 50 percent in the enalapril group, and 41 percent in the nifedipine group (P=0.62). In addition, there were no significant differences among the groups in aortic regurgitant volume, left ventricular size, left ventricular mass, mean wall stress, or ejection fraction. One year after valve replacement, the left ventricular end-diastolic diameter and end-systolic diameter had decreased to a similar degree among the patients who underwent surgery in each of the three groups, and all the patients had a normal ejection fraction. CONCLUSIONS Long-term vasodilator therapy with nifedipine or enalapril did not reduce or delay the need for aortic-valve replacement in patients with asymptomatic severe aortic regurgitation and normal left ventricular systolic function. Furthermore, such therapy did not reduce the aortic regurgitant volume, decrease the size of the left ventricle, or improve left ventricular function.

Los sindromes pericardicos agudos incluyen basicamente la pericarditis aguda y el taponamiento cardiaco. El presente trabajo esta dedicado fundamentalmente al manejo diagnostico y terapeutico de la pericarditis aguda. En nuestro medio, la gran mayoria de pericarditis cuya causa no es evidente en la presentacion clinica inicial corresponde a pericarditis idiopaticas o virales, que tienen un curso benigno y autolimitado (aunque algunos pacientes pueden desarrollar taponamiento cardiaco). Esta nocion de prevalencia es fundamental para establecer un protocolo de manejo logico que evite, por un lado, el excesivo uso de procedimientos invasivos del pericardio, pero que permita, por otro lado, diagnosticar los casos de pericarditis especificas (tuberculosa, purulenta y neoplasica). Segun estas consideraciones y nuestra propia experiencia proponemos un protocolo de estudio y manejo de las enfermedades agudas del pericardio que difieren sustancialmente de las recientes «Guias de practica clinica para el diagnostico y tratamiento de las enfermedades del pericardio» de la Sociedad Europea de Cardiologia. Tambien se comentan aspectos del taponamiento cardiaco y de las formas de constriccion aguda y subaguda que se pueden presentar en la fase de resolucion de las pericarditis agudas.

«[. . .] scientists would think of the original work on apoptosis (programmed cell death) as high quality, but 30 years after it was discovered there has been no measurable impact on health. In contrast, research that is unlikely to be judged as high quality by scientists —say, on the cost effectiveness of different incontinence pads— may have immediate and important social benefits» Smith R. Measuring the social impact of research. BMJ. 2001;323:528.

Treatment recommendations in acute coronary syndromes are experiencing rapid changes. Decades of stable therapeutic passiveness (except for treatment of arrhythmic complications) are now being followed by ever more frequent changes in recommendations and increased complexity, all leading on from the diffusion of thrombolysis and percutaneous revascularization. Furthermore, changes in nomenclature have contributed to growing uncertainty as well as to an increased perception of treatment of acute coronary syndromes as a powerful challenge. Not all aspects of cardiology can be associated so truly with Moliere’s woodcutter turned physician when he remarked: “nous avons change tout cela.” It is no surprise, therefore, that we have for years been trying to unravel the accumulation of norms and indications derived from clinical practice guidelines for the treatment of acute coronary syndromes, based mainly on studies of efficacy (clinical trials). Hospital databases have been created to determine the repercussion of these recommendations in daily clinical practice and evaluate their effectiveness. What, then, is the effectiveness of the management of acute coronary syndromes and what is the role of these registries in this evaluation?

Background Effusive–constrictive pericarditis is an uncommon pericardial syndrome characterized by concomitant tamponade, caused by tense pericardial effusion, and constriction, caused by the visceral pericardium. We conducted a prospective study of its clinical evolution and management. Methods From 1986 through 2001, all patients with effusive–constrictive pericarditis were prospectively evaluated. Combined pericardiocentesis and cardiac catheterization were performed in all patients, and pericardiectomy was performed in those with persistent constriction. Follow-up ranged from 1 month to 15 years (median, 7 years). Results A total of 1184 patients with pericarditis were evaluated, 218 of whom had tamponade. Of these 218, 190 underwent combined pericardiocentesis and catheterization. Fifteen of these patients had effusive–constrictive pericarditis and were included in the study. All patients presented with clinical tamponade; however, concomitant constriction was recognized in only seven patients. At ca...

Intramural haematoma (IMH) forms part of the acute aortic syndrome presenting physiopathologic and evolutive patterns different from those of aortic dissection. The aim of this study was to determine the mortality and predictive factors of IMH in the first 3 months of evolution.Sixty-eight consecutive patients diagnosed of IMH (12 type A, 56 type B) were prospectively studied. Ten patients (eight type A, two type B) were surgically treated for clinical or haemodynamic evolution. Mortality rate was 19% (six type A and seven type B): five surgically treated (three type A, two type B) and eight medically treated (three type A, five type B). No relationship was observed between clinical variables and evolution. Maximum aortic diameter was greater in the group of patients who died (65.5+/-14.4 mm vs 46.0+/-7.6 mm; P0.0001). Mortality rate in patients with aortic diameter50 mm was 50% (P0.0001). Significant periaortic bleeding was mortality-related (47%; P0.005). Multivariate analysis showed only a significant relationship between mortality and maximum aortic diameter50 mm (OR=11.33; P0.005) and ascending aorta involvement (OR=11.18; P0.05).Intramural haematoma mortality in the first 3 months of evolution is high (19%). Maximum aortic diameter50 mm and ascending aorta involvement are predictive of early mortality.

Objetivos Evaluar la influencia de los metodos de presentacion de los resultados sobre la percepcion cuantitativa de la eficacia de farmacos utilizados en prevencion primaria y secundaria de la enfermedad coronaria y la probabilidad de comenzar el tratamiento con dichos farmacos. Metodo Estudio realizado en 1.408 cardiologos espanoles a los que se asigno, de forma aleatoria, tres cues-tionarios en los que se utilizaban diferentes medidas de efecto de ensayos clinicos publicados. Resultados Se pudo aplicar 559 cuestionarios (40%). A partir de las respuestas a los cuestionarios se estimo, en una escala del 0 al 10 (valor este maximo de eficacia), la percepcion de la eficacia media de diferentes farmacos utilizados en ensayos clinicos cuyos resultados fueron expresados en terminos de reduccion relativa del riesgo, reduccion absoluta del riesgo y numero necesario de pacientes a tratar para evitar un caso, respectivamente, obteniendose: prevencion primaria con estatinas: 6,79, 6,38 y 5,43; prevencion primaria con aspirina: 6,84, 5,06 y 4,25; prevencion secundaria con estatinas: 8,16, 7,76 y 7,54; prevencion secundaria con inhibidores de la enzima conversiva de la angiotensina (IECA): 7,11, 7,81 y 7,19, y prevencion secundaria con bloqueadores beta: 7,22, 7,43 y 6,98. Sin embargo, la probabilidad de iniciar el tratamiento con los farmacos considerados se vio poco influida debido a la forma de presentacion de los resultados en los ensayos clinicos. Conclusiones La presentacion de resultados en los ensayos clinicos en forma de reduccion relativa del riesgo, en comparacion con su presentacion en forma de reduccion absoluta del riesgo o numero necesario de pacientes a tratar, dio lugar globalmente a una percepcion de mayor eficacia de la intervencion, sin influir, sin embargo, en la probabilidad de iniciar el tratamiento con los farmacos.

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.

Aida Ribera,1–3 Sònia Abilleira,1,3 Gaietà Permanyer-Miralda,2,3 Ricard Tresserras,4 Joan MV Pons,1,3 Miquel Gallofré3,4 1Stroke Program, Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain; 2Cardiovascular Epidemiology Unit, Hospital Vall d'Hebron, Barcelona, Spain; 3CIBER Epidemiología y Salud Pública, Madrid, Spain; 4Stroke Program, Department of Health, Autonomous Government of Catalonia, Barcelona, Spain Background: Development of process-based quality measures has been of increasing interest. We aimed to construct a composite quality measure for acute stroke care and to evaluate its performance at the hospital level. Methods: We used data from the Stroke Audit 2007, based on retrospective review of medical charts linked to the Mortality Register 2007–2008 (Catalonia, Spain). Eight quality measures were selected on the basis of clinical relevance, scientific evidence, and relationship to mortality: screening of dysphagia, initiation of antiplatelets at less than 48 hours (if ischemic stroke), early mobilization, assessment of rehabilitation, management of hypertension, management of dyslipidemia, anticoagulation in case of atrial fibrillation (if ischemic stroke), and antithrombotics on discharge (ischemic strokes only). We constructed an opportunity-based composite quality measure of eight individual measures and correlated noncompliance with the individual and composite quality measures with risk-standardized 30-day mortality at the hospital level. Noncompliance with the opportunity-based composite measure was calculated as the sum of the total instances that a required individual measure was not performed or not documented. Multilevel linear regression analyses were conducted to assess the variability of noncompliance at the hospital level and to what extent variability could be explained by differences in hospital characteristics. Results: We analyzed data from 1,686 patients (representing 9,334 opportunities for compliance with the composite quality measure) admitted to 47 acute hospitals. Noncompliance with the composite was 32.7% (95% confidence interval [CI], 31.5%–33.9%), and the correlation with hospital risk-adjusted 30-day mortality was 0.24 (P=0.1). Using multilevel logistic modeling, hospitals with an intermediate number of annual stroke admissions (150–350 versus

Pericardial effusion is a common finding in everyday practice. Sometimes, its cause is obviously related to an underlying general or cardiac disease, or to a syndrome of inflammatory or infectious acute pericarditis. On other occasions, pericardial effusion is an unexpected finding that requires specific evaluation. In these cases, the main issues are aetiology, the clinical course, and the possibility of evolution to haemodynamic embarrassment. This is especially relevant in cases of large pericardial effusions, in which echocardiographic recordings not infrequently show findings suggestive of subclinical haemodynamic derangement, mainly right atrial or right ventricular wall collapse. These uncertainties have led to a heterogeneous approach to the management of the syndrome of pericardial effusion by different groups of investigators. The main goal of this article is to give a comprehensive review of aetiology, haemodynamic findings, and management of pericardial effusion. In addition, some comments on the management of neoplastic pericardial effusion are also provided. In an asymptomatic patient, a pericardial effusion of less than 10 mm on the echocardiogram may be an incidental finding, especially in elderly women, as shown in the Framingham study.1 In these patients, neither invasive studies nor treatment are required. A follow up echocardiogram is probably warranted to see if the echocardiographic findings are unchanged. Further investigation or treatment of these patients is not necessary if the echo findings are stable. A wide variety of conditions may result in pericardial effusion. All types of acute pericarditis (inflammatory, infectious, immunologic or of physical origin) can be associated with pericardial effusion.2 In addition, pericardial effusion of varying degrees can be seen in other conditions such as neoplasia (with or without direct pericardial involvement), myxoedema, renal insufficiency, pregnancy, aortic or cardiac rupture, trauma, chylopericardium, or in the setting of chronic salt and water retention of many causes, including chronic heart …

Fundamento Describir las medidas de prevencion secundaria en los pacientes intervenidos de derivacion aortocoronaria en nuestro medio y la calidad de vida relacionada con la salud al ano de la intervencion. Pacientes y metodo Estudio prospectivo de un ano de seguimiento, realizado en hospitales publicos y privados de Cataluna. Resultados Se incluyeron 710 pacientes cuya edad media era de 63 anos. El 74,8% de las mujeres y el 48,7% de los varones eran hipertensos, el 70,2% de las mujeres y el 55% de los varones tenian hipercolesterolemia, el 42,3% de las mujeres y el 28,7% de los varones eran diabeticos y el 31,2% de los varones y el 2,9% de las mujeres eran fumadores (p Conclusiones Los pacientes intervenidos de cirugia aortocoronaria mejoran clinicamente al cabo de un ano de la intervencion, mejorando tambien la calidad de vida relacionada con la salud. Tanto el porcentaje de fumadores como el grado de tratamiento antihipertensivo e hipolipemiante al final del seguimiento indican un grado de control suboptimo de la prevencion secundaria en pacientes de alto riesgo.

Although different Doppler methods have been validated for aortic regurgitation quantification, the benefit of combining information from different methods has not been defined.Our study included 2 phases. In the initial phase (60 patients), Doppler parameters (jet width, short-axis jet area, apical jet area, regurgitant fraction from pulmonary and mitral flow, and deceleration slope) were correlated with angiography; range values for each severity grade were defined and intraobserver and interobserver and intermachine variability were studied. In the validation phase (158 patients), defined value ranges were prospectively tested and a strategy based on considering as the definitive severity grade that in which the two best methods agreed was tested.Jet width had the best correlation with angiography (r = 0.91), and its ratio with the left ventricular outflow diameter did not improve the correlation (r = 0.85) and decreased reproducibility. Apical jet area and regurgitant fraction from pulmonary flow permitted acceptable quantification (r = 0.87 and 0.86, respectively) but with worse reproducibility. The other methods were not assessable in 20% to 30% of studies. Concordance with angiography decreased in jet width when the jet was eccentric (90% vs 77%, P.01), in apical jet area when mitral valve disease was present (84% vs 65%, P.02), and in short-axis jet area and regurgitant fraction from pulmonary flow with concomitant aortic stenosis (77% vs 44%, P.002 and 77% vs 53%, P.02, respectively). Agreement with angiography was very high (94 [95%] of 99) when severity grade coincided in both jet width and apical jet area. In 59 cases without concordance, regurgitant fraction from pulmonary flow was used as a third method. Overall, this strategy permitted concordance with angiography in 146 patients (92%).Jet width is the best predictor in aortic regurgitation quantification by Doppler echocardiography. However, better results were obtained when a strategy based on concordance between jet width and another Doppler method was established, particularly when the jet was eccentric.

Introduccion y objetivos . El objetivo de este estudio es valorar si existen diferencias en el espectro etiologico y el curso clinico del derrame pericardico en pacientes ancianos, como se ha sugerido, lo que implicaria un manejo clinico distinto en funcion de la edad del paciente. Metodos . Todos los ecocardiogramas practicados en nuestro hospital entre 1990 y 1996 fueron revisados para seleccionar aquellos con derrame pericardico moderado o severo. Los pacientes con edad inferior a 66 anos fueron incluidos en el grupo I, y aquellos con edad superior a 65 anos fueron asignados al grupo II. Resultados . Se seleccionaron 322 pacientes con derrame moderado (122) o severo (200). En el grupo I fueron incluidos 221 pacientes (edad 15-65 anos; media, 47) y 101 pacientes fueron asignados al grupo II (edad 66-88 anos; media, 72,5). El derrame era severo en el 60% del grupo I y en el 66% del grupo II (p = NS), y se produjo taponamiento en 36% del grupo I y 38,6% del grupo II (p = NS). Las infecciones pericardicas especificas (pericarditis tuberculosa y purulenta) fueron mas frecuentes en el grupo I (el 5,9 frente al 0,9%; p Conclusiones . Este estudio sugiere que el derrame pericardico tiene, en general, una etiologia, curso clinico y pronostico similares en pacientes ancianos respecto a los de la poblacion general. Por tanto, su manejo deberia ser similar y cualquier posibilidad etiologica debe ser considerada en el diagnostico diferencial, con independencia de la edad del paciente.