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Introduction and objectives Information regarding long-term outcomes in patients surviving out-of-hospital cardiac arrest (OHCA) is scarce. Our aim was to study the long-term clinical outcomes of a large cohort of OHCA patients surviving until hospital discharge and to identify predictors of mortality and cardiovascular events. Methods Consecutive OHCA patients admitted in the Acute Cardiac Care Unit who survived at least until hospital discharge between 2007 and 2019 were included. All received therapeutic hypothermia according to the local protocol. Pre- and intra-hospital clinical and analytical variables were analyzed, as well as the clinically relevant events during follow-up. Results A total of 201 patients were included, with a mean age of 57.6 ± 14.2 years, 168 (83.6%) were male. Thirty-six (17.9%) died during a median follow-up of 40.3 months (18.9–69.1), the most frequent causes of death being cardiovascular and neurological, followed by cancer. We calculated a predictive model for mortality during follow-up using Cox regression that included the following variables: poor neurological outcome [HR 3.503 (1.578–7.777)], non-shockable rhythm [HR 2.926 (1.390–6.163)], time to onset of CPR [HR 1.063 (0.997–1.134)], older age [1.036 (1.008–1.064)) and worse ejection fraction at discharge [1.033 (1.009–1.058)]. Conclusions Even though few patients experience recurrent cardiac arrest events, survivors after OHCA face high morbidity and mortality during long-term follow-up. Therefore, they may benefit from multidisciplinary teams providing an integral management and ensuring continuity of care.

Introduction and objectives To analyze neuron-specific enolase (NSE) kinetics as a prognostic biomarker of neurological outcome in cardiac arrest survivors treated with targeted temperature management. Methods We performed a retrospective analysis of patients resuscitated from in- or out-of-hospital cardiac arrest admitted from September 2006 to May 2018 in a single tertiary care center and cooled to 32 °C to 34 °C for 24 hours. Blood samples for measurement of NSE values were drawn at hospital admission and at 24, 48, and 72 hours after return of spontaneous circulation (ROSC). Neurological outcome was evaluated by means of the Cerebral Performance Category (CPC) score at 3 months and was characterized as good (CPC 1-2) or poor (CPC 3-5). Results Of 451 patients, 320 fulfilled the inclusion criteria and were analyzed (80.3% male, mean age 61 ± 14.1 years). Among these, 174 patients (54.4%) survived with good neurological status. Poor outcome patients had higher median NSE values at hospital admission and at 24, 48 and 72 hours after ROSC. At 48 and 72 hours after ROSC, NSE predicted poor neurological outcome with areas under the receiver-operating characteristic curves of 0.85 (95%CI, 0.81-0.90) and 0.88 (95%CI, 0.83-0.93), respectively. In addition, delta NSE values between 72 hours after ROSC and hospital admission predicted poor neurological outcome with an area under the receiver-operating characteristic curve of 0.90 (95%CI, 0.85-0.95) and was an independent predictor of unfavorable outcome on multivariate analysis (P Conclusions In cardiac arrest survivors treated with targeted temperature management, delta NSE values between 72 hours after ROSC and hospital admission strongly predicted poor neurological outcome.

Resumen Introduccion y objetivos Analizar la cinetica de la enolasa neuroespecifica (EN) como biomarcador de pronostico neurologico de los pacientes que sobreviven a una parada cardiaca tratados con control de temperatura. Metodos Analisis retrospectivo de pacientes ingresados tras sufrir una parada cardiaca dentro o fuera del hospital entre septiembre de 2006 y mayo de 2018 en un centro terciario y enfriados a 32-34 ° C durante 24 h. Las muestras de EN se tomaron al ingreso hospitalario y a las 24, 48 y 72 h del retorno a circulacion espontanea (RCE). El estado neurologico se evaluo a los 3 meses mediante la escala Cerebral Performance Category (CPC) y se categorizo como favorable (CPC 1-2) o desfavorable (CPC 3-5). Resultados De los 451 pacientes, 320 cumplian los criterios de inclusion (el 80,3% varones; media de edad, 61 ± 14,1 anos). De estos, 174 (54,4%) sobrevivieron con una evolucion neurologica favorable. Los pacientes con estado neurologico desfavorable tenian valores de EN mas altos al ingreso hospitalario y a las 24, 48 y 72 h del RCE. A las 48 y las 72 h, los valores de EN predijeron un estado neurologico desfavorable, con areas bajo la curva de 0,85 (IC95%, 0,81-0,90) y 0,88 (IC95%, 0,83-0,93). Ademas, el area bajo la curva de los valores delta de EN entre las 72 h y el ingreso hospitalario fue de 0,90 (IC95%, 0,85-0,95), y en el analisis multivariante resulto predictor independiente (p Conclusiones En pacientes que sobrevivieron a una parada cardiaca tratados con control de la temperatura, se ha demostrado que los valores delta de EN entre las 72 h del RCE y el ingreso hospitalario son un potente predictor de resultado neurologico desfavorable.

Extracellular vesicles (EVs) are involved in intercellular signalling through the transfer of molecules during physiological and pathological conditions, such as ischaemic disease. EVs might therefore play a role in ischaemic stroke (IS) and myocardial infarction (MI). In the present study, we analysed the similarities and differences in the content of circulating EVs in patients with IS and MI. This prospective observational study enrolled 140 participants (81 patients with IS, 37 with MI and 22 healthy controls [HCs]). We analysed the protein and microRNA content from EVs using proteomics and reverse transcription quantitative real-time polymerase chain reaction and compared it between the groups. In the patients with IS and MI, we identified 14 common proteins. When comparing IS and MI, we found differences in the protein profiles (apolipoprotein B, alpha-2-macroglobulin, fibronectin). We also found lower levels of miR-340 and miR-424 and higher levels of miR-29b in the patients with IS and MI compared with the HCs. Lastly, we found higher miR-340 levels in IS than in MI. In conclusion, proteomic and miRNA analyses suggest a relationship between circulating EV content and the patient’s disease state. Although IS and MI affect different organs (brain and heart) with distinct histological characteristics, certain EV proteins and miRNAs appear to participate in both diseases, while others are present only in patients with IS., This work was sponsored by a grant from Miguel Servet (CP15/00069 to María Gutiérrez- Fernández), a predoctoral fellowship (FI17/00188 to Mari Carmen Gómez-de Frutos;FI18/00026 to Fernando Laso-García), a Sara Borrell postdoctoral fellowship (CD19/00033 to María Pérez-Mato), the INVICTUS PLUS network grant (RD16/0019/0005) from the Carlos III Health Institute Health Care Research Fund and was co-funded by the European Regional Development Fund (ERDF) and Juan de la Cierva postdoctoral fellowship (IJCI-2017-33505 to Laura Otero-Ortega, Spanish State Research Agency) and the Spanish Ministry of Science and Innovation.

Background Once return of spontaneous circulation (ROSC) is achieved in cardiac arrest (CA) patients (pts), guidelines recommend immediate acquisition of a 12-lead electrocardiogram (ECG) in order to try to identify those with underlying ischemic heart disease that would benefit from an emergent coronary angiography. Nevertheless, post-ROSC ECG findings may be influenced by factors such as drugs used during CPR (e.g., adrenaline) or metabolic state of pts (e.g., lactic acidosis) and therefore its diagnostic value for identification acute coronary lesions has not yet been established. Objectives To describe the correlation between post-ROSC ECG findings and acute coronary angiography lesions in out-of-hospital CA (OHCA) pts. Methods Retrospective analysis from a prospective database of pts admitted consecutively to the acute cardiac care unit of a tertiary care hospital from September 2006 to April 2019. Post-ROSC ECG of OHCA pts who underwent emergent coronary angiography were blindly and separately classified by 2 cardiologists as follows 1) ST-s elevation, 2) ST-s depression, 3) LBBB, 4) T wave changes/unespecific and 5) normal ECG. If discordant diagnosis, a senior cardiologist made a third and separate analysis. Additionally, coronary lesions were considered to be acute in presence of thrombi or unstable plaque (with or without complete occlusion). Results From 412 pts, 211 had an available and interpretable post-ROSC ECG and underwent emergent coronary angiography. Mean age 60±13 years, male sex 183 (86.7%). Correlation between ECG findings and acute coronary lesions are shown in table 1. Pts with ST-s elevation had an underlying acute coronary lesion in 55.2%. Moreover ST-s elevation had a positive predictive value of 84% and sensitivity of 58.8% for identifying acute coronary lesions. Other post-ROSC ECG findings did not significantly associate acute coronary lesions, in fact LBBB had a high negative predictive value for acute lesions. Conclusion Among post-ROSC ECG findings, ST-s elevation is significantly associated with acute coronary lesions and when identified, an invasive strategy should be considered as established by current practice guidelines. On the contrary, LBBB rarely associates acute coronary lesions at least in OHCA scenario and when its “new onset” is not specified. Funding Acknowledgement Type of funding sources: Public hospital(s). Main funding source(s): University Hospital La Paz (Madrid) ECG findings and acute coronary lesions

This data article contains the data related to the research article entitled “Long-term neurological outcomes in out-of-hospital cardiac arrest patients treated with targeted-temperature management” (Caro-Codon et al., 2018). In this dataset, we report details regarding the flow chart of the included patients and the specific exclusion criteria. We also include information on the difference between the patients who attended the structured personal interview (and therefore were finally included in the study) and those who did not attend. Neuropsychiatric and functional data before and after cardiac arrest are also reported. Finally, we list all the “de novo” focal neurological deficits identified after cardiac arrest in the related population.

Background Platelet/lymphocyte ratio (PLR), an inflammatory marker associated with poor outcomes in different clinical situations, may play a role in the proinflammatory state triggered during hypoxic-ischemic brain injury secondary to cardiac arrest. Purpose To study PLR dynamics and its relationship with neurologic outcomes in survivors after CA treated with target-temperature-management (TTM). Methods Observational retrospective study from a prospective database of survivors of in-hospital and out-of-hospital CA admitted to our Acute Cardiac Care Unit between August 2006 to December 2018. All patients received TTM according to our local protocol. Results A total of 466 patients were included. Mean age was 62.7±14.4 years and 102 (21.9%) were women. Baseline characteristics are shown in Table 1. 430 (92.2%) of CA were witnessed, 312 (67.0%) had ventricular fibrillation as initial cardiac rhythm. Among them, 236 (51.1%) survived until hospital discharge and 208 (45.1%) presented favorable neurological outcomes (a score 1 or 2 on cerebral performance category (CPC)). The mean value of PLR at admission and during targeted temperature was 100.4±5.2 and 224.5±7.3 respectively (mean difference 123.1±7.1, p Table 1 Hypertension, n (%) 235 (54.9) Diabetes, n (%) 113 (26.4) Dyslipidaemia, n (%) 171 (40.0) Smocking habit, n (%) 208 (48.5) Time to ROSC mean ± SD, min 26.6±18.6 Mean arterial pressure at HA mean±DS, mmHg 81.3±22.1 pH at HA mean ± SD 7.18±0.16 Lactic at HA mean ± SD 6.37±4.42 ROSC: return of spontaneus circulation; HA: hospital admission. Conclusion Our findings reflect the impact of inflammation in neurological outcomes after OHCA treated with TTM. Major increases of PLR constitute a novel marker of poor prognosis during early assessment of OHCA patients.

Background There is scarce evidence about the prevalence and clinical relevance of moderate to severe valvular heart disease (VHD) in survivors of out of hospital cardiac arrest (OHCA). Purpose To determine whether VHD influence prognosis of OHCA survivors. Methods All consecutive patients admitted to the Acute Cardiac Care Unit after OHCA and surviving until hospital discharge were included. All patients received targeted-temperature management according to our local protocol. Univariate and multivariate Cox-proportional hazard models were employed. Results A total of 201 patients were included in the analysis. Mean age was 57.6±14.2 years and 168 (83.6%) were male. Eighteen patients (9.0%) had moderate or severe VHD during index admission (Table 1). Patients with VHD were less frequently of male sex, [11 (61.1%) vs 157 (85.8%), p=0.014], experienced less acute coronary syndrome-related arrhytmias [2 (11.1%) vs 85 (46.5%), p=0.005], and had a lower pH at hospital admission (6.9±1.6 vs 7.2±0.15, p=0.008). During a median follow-up of 40.3 (18.9–69.1) months, patients with VHD showed higher mortality [7 (38.9%) vs 28 (15.3%), p=0.004] and more heart failure-related admissions [7 (38.9%) vs 15 (8.2%), p Table1 Variable With valvular disease Without valvular disease p value Age, mean±DS, years 63.5±13.2 57.0±14.1 0.066 Hypertension, n (%) 12 (66.7) 95 (51.9) 0.231 Diabetes, n (%) 5 (27.8) 24 (13.1) 0.149 Dyslipidaemia, n (%) 7 (38.9) 79 (43.2) 0.726 Smokin habit, n (%) 4 (22.2) 90 (49.2) 0.045 Witnessed cardiac arrest, n (%) 18 (100) 175 (95.6) 1.000 Time from CA to ROSC, mean±DS, minute 19.1±7.5 21.2±13.1 0.506 Shockable rhythm, n (%) 13 (72.2) 163 (89.1) 0.055 LVEF at hospital discharge (%) 42.8±12.1 46.9±14.6 0.254 Figure 1 Conclusion The presence of significant VHD in survivors after OHCA is a predictor of poor outcomes. Specific management of VHD may be specially relevant in this high-risk patients and guideline-oriented therapy, including surgery and percutaneous intervention should be encouraged when indicated.

Target temperature management (TTM) has shown to reduce brain damage after an out-of-hospital cardiac arrest (CA), but the time to neurological recovery is not defined yet. We sought to determine the time these patients need to regain consciousness, as well as factors associated with a late post-arrest awakening.We performed a retrospective analysis of patients cooled to 32-34°C during 24h after CA, who regained neurological responsiveness after rewarming. We measured the time until awakening, defined as obedience to verbal commands.We included 163 CA survivors (84.7% male, 60.2 years) who regained consciousness after TTM: target temperature was either 32°C (36.2%), 33°C (56.4%) or 34°C (6.7%). Mean time of awakening was 3.8 days. Thirty-four patients (20.9%) regained neurological responsiveness after 5 days after CA. All of them had been cooled to either 32°C (18 patients) or 33°C (16), and no patient cooled to 34°C awakened after day 5. A lower target temperature was associated with a later awakening (p0.001). The time to advanced cardiopulmonary resuscitation (CPR) was shorter among the early awakers (p=0.04), but we found no other predictors of an earlier awakening.A high proportion of CA survivors induced to TTM regained consciousness after 5 days, and cooling to a lower target temperature may influence on a late neurological recovery. Therefore, withdrawal of life supporting treatment should be delayed to more than 5 days in patients cooled to 33°C or less. Time to advanced CPR was found to be a predictor of early awakening.

Background This study aimed to assess long-term cognitive and functional outcomes in out-of-hospital cardiac arrest (OHCA) patients treated with targeted-temperature management, investigate the existence of prognostic factors that could be assessed during initial admission and evaluate the usefulness of classic neurological scales in this clinical scenario. Methods Patients admitted due to OHCA from August 2007 to November 2015 and surviving at least one year were included. Each patient completed a structured interview focused on the collection of clinical, social and demographic data. All available information in clinical records was reviewed and a battery of neurocognitive and psychometric tests was performed. Results Seventy-nine patients were finally included in the analysis. Forty-three patients (54.4%) scored below the usual cut-off points for the diagnosis of mild cognitive impairment, even though most of these deficits went unnoticed when patients were assessed using CPC and modified Rankin scale. Nineteen (24%) developed certain degree of impairment in their attention capacity and executive functions. A significant proportion developed new memory-related disorders (43%), depressive symptoms (17.7%), aggressive/uninhibited behavior (12.7%) and emotional lability (8.9%). A greater number of weekly hours of intellectual activity and a qualified job were independent protective factors for the development of cognitive impairment. However, being older at the time of the cardiac arrest was identified as a poor prognostic factor. Conclusions There is a high prevalence of long-term cognitive deficits and functional limitations in OHCA survivors. Most commonly used clinical scales in clinical practice are crude and lack sensitivity to detect most of these deficits.

Purpose: To obtain initial data on the effect of different levels of targeted temperature management (TTM) in out-of-hospital cardiac arrest (OHCA). Methods: We designed a multicentre pilot trial with 1:1:1 randomization to either 32 °C (n = 52), 33 °C (n = 49) or 34 °C (n = 49), via endovascular cooling devices during a 24-h period in comatose survivors of witnessed OHCA and initial shockable rhythm. The primary endpoint was the percentage of subjects surviving with good neurologic outcome defined by a modified Rankin Scale (mRS) score of ≤ 3, blindly assessed at 90 days. Results: At baseline, different proportions of patients who had received defibrillation administered by a bystander were assigned to groups of 32 °C (13.5%), 33 °C (34.7%) and 34 °C (28.6%; p = 0.03). The percentage of patients with an mRS ≤ 3 at 90 days (primary endpoint) was 65.3, 65.9 and 65.9% in patients assigned to 32, 33 and 34 °C, respectively, non-significant (NS). The multivariate Cox proportional hazards model identified two variables significantly related to the primary outcome: male gender and defibrillation by a bystander. Among the 43 patients who died before 90 days, 28 died following withdrawal of life-sustaining therapy, as follows: 7/16 (43.8%), 10/13 (76.9%) and 11/14 (78.6%) of patients assigned to 32, 33 and 34 °C, respectively (trend test p = 0.04). All levels of cooling were well tolerated. Conclusions: There were no statistically significant differences in neurological outcomes among the different levels of TTM. However, future research should explore the efficacy of TTM at 32 °C. Clinical trial registration: ClinicalTrials.gov unique identifier: NCT02035839 (http://clinicaltrials.gov). © 2018, Springer-Verlag GmbH Germany, part of Springer Nature and ESICM. Sanofi España 18.967 JCR (2018) Q1, 2/33 Critical Care Medicine 3.654 SJR (2018) Q1, 2/91 Critical Care and Intensive Care Medicine No data IDR 2018 UEM

Sudden cardiac death is an important cause of mortality in developed countries, most of them being consequence of acute ventricular arrhythmias. These arrhythmias, in some cases, owe to QT interval prolongation. A major risk factor for this condition is the use of drugs that prolong the QT interval. In fact, in recent years, one of the most common reasons for drug withdrawal or usage restrictions has been drug induced QT interval prolongation that involves both cardiovascular and non-cardiovascular drugs. Taking into account the severity that the occurrence of such an event may have, it is important for clinicians to know the risks of these drugs in certain patients. In this review we analyze the drugs that prolong the QT interval, the risk factors that can enhance QT prolongation and the drug interactions that can increase these risks.

To evaluate the effects of a computerized physician order entry (CPOE) system in the cardiac intensive care unit by detecting prescription errors (PEs) and also to assess the impact on working conditions.A longitudinal, prospective, before-after study was conducted during the periods before and after the implementation of the CPOE system. Clinical pharmacists were responsible for the registration, description and classification of PEs, and their causes and severity, according to an international taxonomy. Professionals were also surveyed for their opinion, concerns, and level of satisfaction.A total of 470 treatment orders containing 5729 prescriptions were evaluated. The CPOE resulted in a marked reduction in the number of PEs: error rate was 44.8% (819 errors among 1829 prescriptions) with handwritten orders and 0.8% (16 among 2094 prescriptions) at the final electronic phase (P.001). Lapses were the main cause of error in both prescription methods. Most errors did not reach the patients. Errors related with the computerized system were scarce. Most users were satisfied with many aspects of this technology, although a higher workload was reported.Computerized physician order entry in the cardiac intensive care unit proved to be a safe and effective strategy in reducing PEs and was globally well received by professionals.

Background Obstructive sleep apnea (OSA) is linked to increased cardiovascular risk, but the association between OSA and myocardial infarction (MI) remains controversial. Our objectives were to compare the frequency of OSA in patients with acute MI and in a population-based sample of control subjects, and to evaluate the impact of CPAP on recurrent MI and coronary revascularization. Methods Case–control study with a 6-year follow-up of the case cohort. 192 acute MI patients and 96 matched control subjects without coronary artery disease (CAD) (ratio 2:1). After overnight polysomnography, CPAP was recommended if apnea–hypopnea index (AHI) ≥5, and a mean daily use >3.5h/day was considered necessary to maintain the treatment. Lipids, fasting glucose, blood pressure, spirometry, comorbidity and current treatment were also registered. End-points were recurrent MI or need of revascularization. Results OSA was an independent predictor of MI, with odds ratio 4.9 (95% confidence interval [CI] 2.9–8.3, p=0.017). 63 MI patients without OSA, 52 untreated patients with OSA and 71 OSA patients treated with CPAP were included in the follow-up study. After adjustment for confounding factors, treated OSA patients had a lower risk of recurrent MI (adjusted hazard ratio 0.16 [95%CI 0.03–0.76, p=0.021]) and revascularization (adjusted hazard ratio 0.15 [95%CI 0.03–0.79, p=0.025]) than untreated OSA patients, and similar to non-OSA patients. Conclusion Mild-severe OSA is an independent risk factor for MI. Risk of recurrent MI and revascularization was lower in OSA patients who tolerated CPAP.

Introduction To assess the frequency of medication errors (ME) induced or enhanced by computerized physician order entry (CPOE). Error type, drug classes involved, specialty, patient outcome and system failures were also evaluated. Methods Observational quantitative study in a large tertiary care medical center over March 2012 3 years after CPOE implementation. Pharmacists detected ME associated with CPOE (those that wouldn’t have occurred if the clinician had prescribed manually) and unassociated in pharmacological treatments in inpatients of 13 specialties (421 beds). Main outcome measured were ME associated and unassociated with CPOE. Results We found 714 ME with 85.857 drug prescriptions (a 0.8 % error rate, 95 % CI 0.6–0.7). Percentage of error associated with CPOE was 77.7 %. The main types of error related to CPOE were wrong medication selection (20.9 %) and improper data placement (20.3 %). Failures with medications prescribed in primary care, unavailable in the hospital pharmacy, were involved in 21.6 % of all ME. Errors involving surgical specialties were double those involving medical specialties (1.2 vs. 0.6 %). Most ME associated with CPOE were potential errors (90 %). During the study system failures occurred four times. Conclusions The use of CPOE minimises the occurrence of medication errors, however, they still occur. Most errors are associated with the CPOE technology. We therefore face a new challenge in the prevention of ME that require a change in strategy for patient safety. Continued training of prescribers, standardization of the electronic prescription programs and integration between computer applications in hospitals and with primary care should be a priority.

Background— It is recommended that comatose survivors of out-of-hospital cardiac arrest should be cooled to 32° to 34°C for 12 to 24 hours. However, the optimal level of cooling is unknown. The aim of this pilot study was to obtain initial data on the effect of different levels of hypothermia. We hypothesized that deeper temperatures will be associated with better survival and neurological outcome. Methods and Results— Patients were eligible if they had a witnessed out-of-hospital cardiac arrest from March 2008 to August 2011. Target temperature was randomly assigned to 32°C or 34°C. Enrollment was stratified on the basis of the initial rhythm as shockable or asystole. The target temperature was maintained during 24 hours followed by 12 to 24 hours of controlled rewarming. The primary outcome was survival free from severe dependence (Barthel Index score ≥60 points) at 6 months. Thirty-six patients were enrolled in the trial (26 shockable rhythm, 10 asystole), with 18 assigned to 34°C and 18 to 32°C. Eight of 18 patients in the 32°C group (44.4%) met the primary end point compared with 2 of 18 in the 34°C group (11.1%) (log-rank P =0.12). All patients whose initial rhythm was asystole died before 6 months in both groups. Eight of 13 patients with initial shockable rhythm assigned to 32°C (61.5%) were alive free from severe dependence at 6 months compared with 2 of 13 (15.4%) assigned to 34°C (log-rank P =0.029). The incidence of complications was similar in both groups except for the incidence of clinical seizures, which was lower (1 versus 11; P =0.0002) in patients assigned to 32°C compared with 34°C. On the contrary, there was a trend toward a higher incidence of bradycardia (7 versus 2; P =0.054) in patients assigned to 32°C. Although potassium levels decreased to a greater extent in patients assigned to 32°C, the incidence of hypokalemia was similar in both groups. Conclusions— The findings of this pilot trial suggest that a lower cooling level may be associated with a better outcome in patients surviving out-of-hospital cardiac arrest secondary to a shockable rhythm. The benefits observed here merit further investigation in a larger trial in out-of-hospital cardiac arrest patients with different presenting rhythms. Clinical Trial Registration— URL: http://www.clinicaltrials.gov . Unique identifier: NCT01155622.

Background: Proton-pump-inhibitors are often prescribed unnecessarily in hospitals, which in turn induces their prescriptions after discharge. Objective: To evaluate patients starting treatment with proton-pump-inhibitors during hospitalisation and proportion of inappropriate prescriptions. Patient risk factors and whether initiation in hospital induced their continuation in ambulatory care were also analyzed. Methods: An observational, cross-sectional study in a tertiary hospital (1350 beds) was carried out on the first Tuesday in February 2015. Pharmacists screened admitted patients treated with proton-pump-inhibitors using an electronic prescription program (FarmaTools®-5.0). They also checked patients’ home medications before admission by accessing a primary care program (Horus®). Authorized indications according to Spanish-MedicinesAgency and those recommended in Spanish-Clinical-PracticeGuidelines were considered appropriate. Hospital-medical-records were checked to know whether proton-pump-inhibitors were prescribed at discharge. Results: Three hundred seventy nine patients were analysed. Two hundred ninety four of them were prescribed proton-pumpinhibitors (77.6%). Treatment was initiated during admission for 143 patients (48.6%, 95% CI: 42.8-54.5). Of them, 91 (63.6%, 95% CI: 55.2-71.5) were inappropriate, mainly due to its inclusion unnecessarily in protocols associated with surgeries or diseases (56 cases of 91, 61.5%). Additional inappropriate indications were surgical stress ulcer prophylaxis for surgeries without bleeding risks (19.8%) and polypharmacy without drugs that increase the risk of bleeding (18.7%). Of 232 discharge reports assessed, in 153 (65.9%, 95% CI: 59.5-72), proton-pump-inhibitor continuation was recommended, of them, 51 (33.3%) were initiated at admission. Conclusion: In hospitalized patients there is a high prevalence of prescription of proton-pump-inhibitors unnecessarily. The superfluous use is often associated with the prescription of treatment protocols. Those treatments started in the hospital generally did not contribute to over-use existing primary care, most of them were removed at discharge.

Introduction: The objective of this work was to perform a comparative analysis of the different medical errors achieved when using manual orders entry and computerized physician order entry. Method: Longitudinal study of drug prescriptions recorded in the pharmaceutical service over the deployment period of a computerized physician order entry (CPOE) in the pulmonology unit. The prescription errors in inpatient care treatments were analyzed over three different periods of time of one week: the week prior to the deployment of the CPOE (manual physician order entry: control group) and before the end of the 1 st and 2 nd months from the deployment of the aforementioned system (EP1 and EP2 respectively: experimental group). Results: 3,257 drugs prescribed in 309 treatment orders (mean 10.5 drugs per patient) were analyzed detecting 422 prescription errors. 352 (34.9 %) were identified in the first stage of the study, corresponding to the manual physician order entry (MPOE), 45 (4.1%), one month after the deployment of the CPOE (EP1) and 25 (2.2%) after two months from the deployment (EP2). The decrease was significant when the results of the MPOE were compared against the results obtained in both CPOEs. Also, a decrease of prescription errors was found when comparing both CPOE stages. These results imply a decrease of the RR of 88.2% (comparing EP1 vs MPOE), 93.7 (EP2 vs MPOE) and 46% (EP2 vs EP1). Conclusion: Errors in drug prescription to patient in the pulmonology unit are significantly reduced when a computerized physician order entry is applied. This drop is mainly related to the doses and measurement units of the prescriptions.

Background: Early prognosis in comatose survivors after cardiac arrest due to ventricular fibrillation (VF) is unreliable, especially in patients undergoing mild hypothermia. We aimed at developing a reliable risk-score to enable early prediction of cerebral performance and survival. Methods: Sixty-one out of 239 consecutive patients undergoing mild hypothermia after cardiac arrest, with eventual return of spontaneous circulation (ROSC), and comatose status on admission fulfilled the inclusion criteria. Background clinical variables, VF time and frequency domain fundamental variables were considered. The primary and secondary outcomes were a favorable neurological performance (FNP) during hospitalization and survival to hospital discharge, respectively. The predictive model was developed in a retrospective cohort (n = 32; September 2006 September 2011, 48.5 ± 10.5 months of follow-up) and further validated in a prospective cohort (n = 29; October 2011 July 2013, 5 ± 1.8 months of follow-up). Results: FNP was present in 16 (50.0%) and 21 patients (72.4%) in the retrospective and prospective cohorts, respectively. Seventeen (53.1%) and 21 patients (72.4%), respectively, survived to hospital discharge. Both outcomes were significantly associated (p < 0.001). Retrospective multivariate analysis provided a prediction model (sensitivity = 0.94, specificity = 1) that included spectral dominant frequency, derived power density and peak ratios between high and low frequency bands, and the number of shocks delivered before ROSC. Validation on the prospective cohort showed sensitivity = 0.88 and specificity = 0.91. A model-derived risk-score properly predicted 93% of FNP. Testing the model on follow-up showed a c-statistic ≥ 0.89. Conclusions: A spectral analysis-based model reliably correlates time-dependent VF spectral changes with acute cerebral injury in comatose survivors undergoing mild hypothermia after cardiac arrest., the CNIC is supported by the Spanish Ministry of Economy and Competitiveness and the Pro-CNIC Foundation.

AIM: To assess the safety of therapeutic hypothermia (TH) concerning arrhythmias we analyzed serial electrocardiograms (ECG) during TH. METHODS: All patients recovered from a cardiac arrest with Glasgow < 9 at admission were treated with induced mild TH to 32-34 °C. TH was obtained with cool fluid infusion or a specific intravascular device. Twelve-lead ECG before, during, and after TH, as well as ECG telemetry data was recorded in all patients. From a total of 54 patients admitted with cardiac arrest during the study period, 47 patients had the 3 ECG and telemetry data available. ECG analysis was blinded and performed with manual caliper by two independent cardiologists from blinded copies of original ECG, recorded at 25 mm/s and 10 mm/mV. Coronary care unit staff analyzed ECG telemetry for rhythm disturbances. Variables measured in ECG were rhythm, RR, PR, QT and corrected QT (QTc by Bazett formula, measured in lead v2) intervals, QRS duration, presence of Osborn’s J wave and U wave, as well as ST segment displacement and T wave amplitude in leads II, v2 and v5. RESULTS: Heart rate went down an average of 19 bpm during hypothermia and increased again 16 bpm with rewarming (P < 0.0005, both). There was a non-significant prolongation of the PR interval during TH and a significant decrease with rewarming (P = 0.041). QRS duration significantly prolonged (P = 0.041) with TH and shortened back (P < 0.005) with rewarming. QTc interval presented a mean prolongation of 58 ms (P < 0.005) during TH and a significant shortening with rewarming of 22.2 ms (P = 0.017). Osborn or J wave was found in 21.3% of the patients. New arrhythmias occurred in 38.3% of the patients. Most frequent arrhythmia was non-sustained ventricular tachycardia (19.1%), followed by severe bradycardia or paced rhythm (10.6%), accelerated nodal rhythm (8.5%) and atrial fibrillation (6.4%). No life threatening arrhythmias (sustained ventricular tachycardia, polymorphic ventricular tachycardia or ventricular fibrillation) occurred during TH. CONCLUSION: A 38.3% of patients had cardiac arrhythmias during TH but without life-threatening arrhythmias. A concern may rise when inducing TH to patients with long QT syndrome.

Introduction. Dynamic intraventricular gradients (DIG) after valve replacement in severe aortic stenosis have been reported, although the incidence of DIG and clinical signs are still poorly understood. Aim. To evaluate the incidence of DIG and determine risk factors and associated morbimortality. Patients and method. One hundred nine consecutive patients with severe aortic valve stenosis undergoing valve replacement were studied prospectively by echocardiography to detect the postoperative appearance of DIG, defined as a maximum flow velocity ≥ 2.5 m/s. Results. Sixteen patients (14.9%) developed postoperative DIG. Significant differences between the patients with or without DIG were found for ventricular diameter (left end-diastolic ventricular diameter (LEDVD) 43.2 vs. 47.7 mm, respectively, P

Background: Many adverse drug events are related to medication errors during the ordering process and may be preventable. Computerized physician order entry (CPOE) appears as an effective tool in reducing them. Methods: We conducted a before-after prospective study in a chest diseases ward of an academic medical center. We compared rates of medication errors in medical orders during three phases: one before (manual prescription) and two after implementation of CPOE, at one and two months after. Secondarily we assessed error characteristics, process of medication use management and economic impact. Results: We detected 422 medication errors in 3257 medications prescribed: 352 in manual prescription phase (34.9% error rate) versus 45 one month after CPOE implementation (4.1% error rate)-88.2% relative risk reduction (p

Durante la gestacion normal se producen cambios hormonales, se establece la circulacion uteroplacentaria, se incrementa el volumen plasmatico, disminuyen las resistencias vasculares perifericas y se producen modificaciones que favorecen la hipercoagulabilidad. Todo ello favorece la aparicion de semiologia cardiovascular, haciendo que el diagnostico diferencial con la existencia de cardiopatia subyacente sea a la vez fundamental y complejo. Ademas, estos cambios fisiologicos aumentan el riesgo de complicaciones maternofetales en las mujeres con cardiopatia. Se considera que la cardiopatia en el embarazo es la primera causa de morbimortalidad materna de causa no obstetrica. Las cardiopatias reumatica y congenitas son, hoy dia, las mas frecuentes en la mujer embarazada, se

Most of the previous studies on white coat hypertension were performed in hypertension clinics or academic settings and included relatively small series of patients. Consequently, the prevalence of white coat hypertension in primary care settings and the clinical and epidemiologic characteristics of this subgroup of patients are not well known. We performed this study to estimate the frequency of white coat hypertension in a population of mildly to moderately hypertensive subjects attended in a primary care setting and to examine possible epidemiologic and clinical factors that may identify these patients. Patients included in the study underwent clinical interview, measurement of clinic blood pressure (BP) on three visits, determination of serum lipids, glucose, uric acid, and urinary albumin excretion, 24-h ambulatory BP monitoring, and M-mode and Doppler echocardiography. Patients were classified as white coat hypertensives if their daytime ambulatory BP were < 135/85 mm Hg. We studied 345 patients, 136 (39%) of whom were diagnosed with white coat hypertension. The frequency of white coat hypertension was inversely proportional to the severity of clinic BP values. The diagnosis of white coat hypertension was independently associated with female gender and low educational level. Left ventricular mass index and urinary albumin excretion were lower in the white-coat hypertensive group compared with the group with sustained hypertension. Our results show that a high proportion of patients with mild to moderate hypertension attended in a primary care setting have white coat hypertension. Some clinical characteristics may be helpful in the identification of this group of subjects. White coat hypertensives show less target-organ damage than sustained hypertensive patients.

Objetivo El proposito del presente estudio fuedeterminar la utilidad pronostica en la deteccion deenfermedad multivaso de la ecocardiografia de esfuerzopracticada antes del alta hospitalaria de uninfarto agudo de miocardio no complicado. Pacientes y metodos Se han estudiado 65 pacientesconsecutivos afectados de un primer episodiode infarto agudo de miocardio no complicado, confuncion ventricular normal o ligeramente deprimida(FE > 40%). Se practico una prueba de esfuerzosubmaxima (60% VO2max) a los 7-10 dias del infartorealizando un ecocardiograma antes e inmediatamentepostesfuerzo. El seguimiento fue de 15 ± 8meses presentando 15 pacientes angina y 9 revascularizacion.Un paciente fallecio. Resultados La aparicion de isquemia en el electrocardiogramatuvo una baja sensibilidad y valorpredictivo negativo respecto a la presencia decomplicaciones durante la evolucion (44 y 73%, respectivamente),pero su especificidad y su valor predictivopositivo fueron altos (97 y 92%, respectivamente).Por el contrario, la deteccion de isquemiaen el ecocardiograma presento mucha mejor sensibilidady valor predictivo negativo (72 y 83%, respectivamente),con una ligera disminucion de la especificidady del valor predictivo positivo (87 y78%, respectivamente). Tanto la evidencia de isquemiaa distancia como el incremento del indicede contractilidad segmentaria global superior a0,25 durante el esfuerzo tuvieron una alta significacionpronostica (p Conclusiones La ecocardiografia de esfuerzo esde gran utilidad en la estratificacion pronostica delos pacientes antes del alta hospitalaria despuesde un infarto de miocardio no complicado. La respuestaisquemica, a nivel submaximo de esfuerzo,valorada por ecocardiografia, fue mucho mas sensibleque la electrocardiografica en la prediccionde nuevos episodios coronarios y enfermedad multivaso.

Sudden cardiac death is an important cause of mortality in developed countries, most of them being consequence of acute ventricular arrhythmias. These arrhythmias, in some cases, owe to QT interval prolongation. A major risk factor for this condition is the use of drugs that prolong the QT interval. In fact, in recent years, one of the most common reasons for drug withdrawal or usage restrictions has been drug induced QT interval prolongation that involves both cardiovascular and non-cardiovascular drugs. Taking into account the severity that the occurrence of such an event may have, it is important for clinicians to know the risks of these drugs in certain patients. In this review we analyse the drugs that prolong the QT interval, the risk factors that can enhance QT prolongation and the drug interactions that can increase these risks.

We thank Kagawa et al for their comments and appreciate their interest in our work.1 We agree with them that there are many possible factors that could influence the results of our pilot study. All of these factors could not be controlled in our study. Kagawa et al, based on the results of their retrospective study,2 consider that the relative risk of favorable neurological outcomes is 0.90 with a time interval of 1 minute from collapse to return of …

To the Editor: Pre-clinical and clinical hypothermia trials cooling subjects between 18°C and 33°C have suggested potential deleterious prothrombotic effects [(1)][1]. These data have raised major clinical concerns when considering that a large proportion of cardiac arrest survivors will undergo

Obstructive sleep apnea (OSA) is a common disorder characterized by repetitive interruption of ventilation during sleep caused by recurrent upper airway collapse, which leads to intermittent hypoxia. The disorder is commonly undiagnosed despite its relationship with substantial cardiovascular morbidity andmortality.Moreover, the effects of the disorder appear to be particularly dangerous in young subjects. In the last decade, substantial clinical evidence has identified OSA as independent risk factor for both bradyarrhythmias and tachyarrhythmias. To date the mechanisms leading to such arrhythmias have not been completely understood. However, recent data from animal models and new molecular analyses have increased our knowledge of the field, which might lead to future improvement in current therapeutic strategies mainly based on continuous positive airway pressure. This paper aims at providing readers a brief and specific revision of current knowledge about the mechanisms underlying atrial arrhythmias in OSA and their clinical and therapeutic implications

Coronary artery disease (CAD) and obstructive sleep apnea (OSA) are both complex and significant clinical problems. The pathophysiological mechanisms that link OSA with CAD are complex and can influence the broad spectrum of conditions caused by CAD, from subclinical atherosclerosis to myocardial infarction. OSA remains a significant clinical problem among patients with CAD, and evidence suggesting its role as a risk factor for CAD is growing. Furthermore, increasing data support that CAD prognosis may be influenced by OSA and its treatment by continuous positive airway pressure (CPAP) therapy. However, stronger evidence is needed to definitely answer these questions. This paper focuses on the relationship between OSA and CAD from the pathophysiological effects of OSA in CAD, to the clinical implications of OSA and its treatment in CAD patients.

The incidence of contrast-induced nephropathy (CIN) after percutaneous coronary intervention (PCI) is increasing. The aim of the study is to assess the benefits of prophylactic haemofiltration (PHF) in patients with high risk of developing CIN after PCI.20 patients who underwent PHF after PCI in the context of acute coronary syndrome were selected retrospectively and compared with 20 matched controls with similar risk characteristics. The main variable analysed was the appearance of CIN and the secondary variables were the development of acute clinical kidney failure, heart failure, therapeutic HF and mortality.The baseline characteristics were similar in both groups, with reference creatinine of 2.4 ± 1.3 mg/dl, contrast used 392 ± 213 cc and Mehran score of 21.9 ± 5.2 in the PHF group, as opposed to values of 2.0 ± 0.6 mg/dl, 368 ± 126 cc and 20.2 ± 6.9 respectively in controls. The incidence of CIN was of 6 patients (30%) in the PHF group and 13 patients (65%) in the control group (P=0.03). There were no significant differences in the rest of the variables studied.Haemofiltration after PCI may be an effective strategy for the prevention of CIN in patients at high risk of developing it.

There are limited data regarding the need for intensive care or the appropriate length of hospital stay for patients with ST elevation acute myocardial infarction (STEMI). In order to optimize resources, we tried to determine the need of coronary care unit (CCU) admission for patients with STEMI who remained in Killip class I after a successful primary percutaneous coronary intervention (PPCI).From August of 2006 till June of 2008, we analyzed data from all patients admitted in our CCU who met these criteria, a total of 278. We prospectively recorded all in-hospital adverse events and event-free survival at 30 and 90 days (all cause death, stroke, new acute coronary syndrome or re-hospitalization due to heart failure). Medical treatment was optimized according to the current guidelines.A coronary stent was implanted in 96% of the patients. None of the patients had any adverse event that could not be resolved in a step-down unit. Survival at 30 and at 90 days was 99.6% and 98.3% respectively. Event-free survival was 97.3% at 30 days and 94.3% at 90 days. The median length of stay was three days in the CCU and five days in the hospital.Patients with STEMI treated with PPCI who remained in Killip class I after the procedure and receive optimal pharmacological treatment have an excellent prognosis. All of them can probably be admitted safely to a step-down unit. Wide application of this management strategy may result in substantial cost savings.

Background Left ventricular hypertrophy (LVH) is an important predictor of cardiovascular risk, and its detection contributes to risk stratification. The aims of the present study were to estimate the prevalence of echocardiographic LVH and to evaluate the influence of echocardiography (ECHO) on cardiovascular risk stratification in hypertensive patients presenting in primary care. Methods In this cross-sectional study, 250 patients recently diagnosed with mild hypertension underwent clinical evaluation including electrocardiography (ECG), microalbuminuria measurement, 24-h blood pressure monitoring and ECHO. Level of cardiovascular risk was stratified, initially using routine procedures including ECG to assess target organ damage and then again after detection of LVH by ECHO. Results The frequency of echocardiographic LVH was 32%, substantially higher than that detected by ECG (9%). Initial cardiovascular risk stratification yielded the following results: 30% low risk, 49% medium risk, 16% high risk, and 5% very high risk subjects. The detection of LVH by ECHO provoked a significant change in the risk strata distribution, particularly in those patients initially classified as being at medium risk. In this group, 40% of subjects were reclassified as high risk subjects according to ECHO information. The new classification was as follows: 23% low risk, 30% medium risk, 42% high risk, and 5% very high risk subjects. Conclusions A substantial proportion of mildly hypertensive patients presenting in primary care have LVH determined by ECHO. Our results suggest that this procedure could significantly improve cardiovascular risk stratification in those patients with multiple risk factors, but no evidence of target organ damage by routine investigations.