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Resumen Fundamento Todos los Centros de Medicina Hiperbarica reciben de vez en cuando buceadores asintomaticos que han omitido una parada de descompresion despues de inmersiones largas y profundas, razon por la cual temen desarrollar un accidente de descompresion en las horas siguientes. Algunos de ellos solicitan ser recomprimidos de forma preventiva, pero muchos otros rechazan rotundamente esta posibilidad. En estas situaciones, los Centros de Medicina Hiperbarica con alta experiencia en Medicina Subacuatica adoptan diferentes actitudes en funcion de su criterio clinico y experiencia. Algunos importantes manuales de buceo recomiendan re-comprimir el buceador segun la Tabla 5-USN. En la practica civil muchos medicos expertos son reacios a recomprimir buceadores asintomaticos con la sola intencion de evitar un riesgo potencial que nunca ha sido determinado. Esto implicaria un incremento importante en el nombre de recompresiones que se aplican, y las companias de seguros en algunas ocasiones rechazarian el pago de lo que considerarian tratamientos injustificados. La decision es clara en muchos casos, pero en otros es dificil. Metodo Hemos desarrollado un indice de puntuacion destinado a establecer un procedimiento a modo de recomendacion para los casos dudosos. Partiendo de nuestra experiencia cercana a los 600 casos recomprimidos en un periodo de 30 anos, hemos evaluado los cuatro grupos de factores posiblemente relacionados con el desarrollo de una enfermedad por descompresion. 1. Factores individuales y personales. Edad, sexo, tipo constitucional, grasa corporal, historia de buceo, antecedentes patologicos, consumo regular de medicamentos, embarazo, habito tabaquico, y otros. 2. Factores previos a la inmersion. Consumo de alcohol en las 12 horas anteriores, inmersiones continuadas, sucesivas, y repetitivas, ejercicio, estres, falta de sueno, otros factores. 3. Factores de la inmersion en si misma. Profundidad maxima, tiempo total en el fondo, minutos de descompresion omitidos, perfil de la inmersion, ejercicio y trabajo en el fondo, control flotacional, accidentes y traumatismos bajo el agua, fatiga, trastornos respiratorios, frio, estres. 4. Factores posteriores a la inmersion. Tiempo transcurrido desde la emersion, horas de intervalo hasta tomar un avion, buceo en apnea, ducha caliente, comida copiosa, ejercicio o trabajo en el fondo, percepcion personal del buceador. Se atribuye a cada grupo una puntuacion de I al 10, siguiendo un cuestionario, y por acumulacion de los 4 grupos, se obtiene una cifra entre 0 y 40. En funcion de este valor se formulan las siguientes recomendaciones. 0-10: riesgo nulo. No es necesario aplicar ninguna medida. 11 -20: sin riesgo evidente. Control durante las 24 horas siguientes. 21-30: riesgo descompresivo moderado. Aplicar un dispositivo de desnitrogenizacion normobarica (respirar oxigeno al 100 % mediante regulador a demanda, sistema en circuito cerrado, o aparato de bajo flujo de alta concentracion) durante 30 minutos. 31-40: riesgo descompresivo elevado. Recompresion en camara hiperbarica multiplaza a como minimo 2.2 ata durante al menos 60 minutos. En algunos casos hay que recomendar recompresion inmediata con independencia del indice DOLA, por ejemplo cuando se ha realizado un escape libre, si el medico experto en medicina Subacuatica tienen la impresion de que el buceador se encuentra situacion de riesgo descompresivo, o cuando existe un imperativo legal o reglamentario. Conclusion El criterio clinico de ser siempre dominante y la impresion del medico es la que establecera los pasos a seguir. Sin embargo el indice DOLA nos ha sido de gran utilidad para establecer una linea de actuacion frente al riesgo de desarrollar una enfermedad disbarica en los casos descompresion omitida de valoracion dificil.

Aims There is increasing evidence that paraoxonase, an HDL-linked enzyme, exerts its effect by removing lipid-peroxidation products. We have conducted a case-control study in Gerona, Spain, to find out whether paraoxonase1 polymorphism at codon 192 (Q and R alleles) is associated with increased risk of coronary heart disease, and how diabetes mellitus, associated with high oxidative risk, influences such an association. Methods and Results One hundred and fifty six consecutive myocardial infarction patients and 310 age- and sex-matched control subjects were studied. There were no differences in the distribution of genotype and allele frequencies between patients and controls. The odds ratios for diabetes and dyslipaemia in control and patients stratified by genotype group were compared. Whereas dyslipaemic status was significantly related to myocardial infarction in QQ homozygotes and R carriers, diabetes mellitus was significantly associated with myocardial infarction only in R-carrier subjects. In logistic regression analysis, diabetic R carriers demonstrated a more than two and a half-fold increase in myocardial infarction risk compared with non-diabetic R carriers (OR: 2·65, P

OBJECTIVES The study assessed whether varying accessibility of patients with unstable angina (UA) to coronary angiography and revascularization determined differing usages and outcomes. BACKGROUND The appropriate use rate of coronary angiography and revascularization procedures in UA remains to be established. METHODS A total of 791 consecutive patients with UA without previous acute myocardial infarction (AMI) admitted to four reference teaching hospitals (one with tertiary facilities) were followed for six months. End points were six-month mortality and readmission for AMI, UA, heart failure, or severe ventricular arrhythmias. RESULTS Patients admitted to the tertiary hospital were 3.27 (95% confidence interval [CI] 2.32 to 4.62) times more likely to undergo coronary angiography after adjustment for comorbidity and severity than were those admitted to nontertiary facilities (overall six-month use rates 70.1% and 48.3%, respectively). Revascularization procedures were performed in 36.2% of patients in the tertiary hospital and 24.6% in the others (p = 0.0007); adjusted relative risk (RR) 2.37 (95% CI 1.55 to 3.63). Median delay for urgent coronary angiography was shorter in the tertiary hospital (24 h vs. 4 days, p < 0.0002). Six-month mortality and readmission rates were similar in tertiary and nontertiary hospitals: 3.9% versus 5.3% and 16.9% versus 21.2%, respectively. Adjusted RR of death or readmission for the nontertiary hospitals was 1.23 (95% CI 0.57 to 2.67). CONCLUSIONS The use of coronary angiography and revascularization procedures in UA patients with no previous AMI is higher in tertiary than in nontertiary hospitals, but the more selective use of these procedures in nontertiary centers does not imply worse outcome.

The aim of this study was to assess the clinical course of unstable angina and the prognostic value of clinical and electrocardiographic variables measured during admission in a prospective, multicenter cohort study with 6-month follow-up. The population corresponds to 4 general teaching hospitals in Catalonia, Spain. The clinical course was analyzed in 839 consecutive patients aged up to 80 years with primary unstable angina, without myocardial infarction or previous coronary bypass. The main outcome measures were cardiac mortality and nonfatal myocardial infarction. Patients involved in the present analysis belonged to the Resources Used in Acute Coronary Syndromes and Delays in Treatment (RESCATE) study. Six-month overall mortality, cardiac mortality, and nonfatal myocardial infarction rates were 4.6%, 4.1%, and 3.9%, respectively. Six-month cardiac mortality or myocardial infarction rate did not differ among clinical forms of presentation. Peripheral artery disease (RR 3.5, 95% confidence interval [CI] 1.88 to 6.50, p = 0.0001), ST-T-wave electrocardiographic changes on admission (RR 2.22, 95% CI 1.13 to 4.36, p = 0.0203), and age >65 years (RR 1.74, 95% CI 1.04 to 2.91, p = 0.0356) independently predicted 6-month cardiac mortality or nonfatal myocardial infarction. Their positive predictive values were 21%, 10%, and 11%, respectively, whereas their negative predictive value was ≥93% in all cases. Prevalences were 9%, 70%, and 41%, respectively. In this prospective study, patients with unstable angina without prior myocardial infarction have a relatively low, although not negligible, 6-month severe complication rate. Stratification risk can easily be established with clinical and electrocardiographic characteristics measured during admission. Their absence almost rules out future adverse events, while their presence does not necessarily imply bad prognosis.

Background —The aim of this study was to analyze 28-day case fatality trends between 1978 and 1993 among hospitalized acute myocardial infarction (AMI) patients in the REGICOR registry, Gerona, Spain, and relate them to thrombolytic and antiplatelet drug use and changes in patient characteristics. Methods and Results —A total of 2053 consecutive patients 25 to 74 years of age with a first Q-wave AMI admitted to the reference hospital between 1978 and 1993 were registered. Clinical characteristics and patient management were recorded. Four 4-year periods were considered: 1978 to 1981, 1982 to 1985 (prethrombolytic therapy), 1986 to 1989 (thrombolytic and antiplatelet drugs introduced), and 1990 to 1993 (thrombolytic and antiplatelet drugs used routinely). The end point was death at 28 days. Case fatality at 28 days decreased 6% per year between 1978 and 1993. A logistic model adjusted for comorbidity and severity showed the last 3 periods to present a steep decrease in the OR of death at 28 days: 0.86 (95% CI, 0.52 to 1.41), 0.59 (95% CI, 0.35 to 0.99), and 0.40 (95% CI, 0.24 to 0.69), respectively, compared with the first period. After 1986, 85.7% of the 112 lives saved could be attributed to the use of antiplatelet and thrombolytic drugs. Adjusted relative risk reduction was 56.0% for antiplatelet drugs, 34.1% for thrombolytic drugs, and 77.9% for the 2 combined. Conclusions —Our results strongly suggest that new therapies introduced since 1986 have contributed to the decrease in 28-day case fatality of patients admitted with a first Q-wave AMI. This decrease could be attributable mainly to the use of antiplatelet and thrombolytic drugs. These findings should encourage the routine use of thrombolytic and antiplatelet drugs and particularly their combination in the acute phase of AMI.

Objetivos El objetivo del presente estudio ha sido la identificacion de factores antropometricos y dieteticos que influyen en la concentracion de colesterol HDL en la provincia de Girona. Poblacion y metodos Se diseno un estudio transversal, con un muestreo aleatorio y se incluyeron 798 varones y 852 mujeres. Se recogieron variables antropometricas, se calculo el gasto energetico diario en actividad fisica en el tiempo libre y se administro un cuestionario dietetico que permitio la obtencion de datos nutricionales. Asimismo, se determinaron los lipidos y lipoproteinas. Resultados Se observaron diferencias significativas de los trigliceridos sericos, indice de masa corporal, indice cintura/cadera, valores de glucemia basal y consumo de alcohol entre el tercil superior y el inferior de colesterol HDL en ambos sexos. En los varones, el gasto energenico diario en actividad fisica se asocio significativamente con los valores de colesterol HDL, al igual que el consumo de grasa total y grasa monoinsaturada. En las mujeres, ademas del indice cintura/cadera y la glucemia basal, la vitamina C fue la variable nutricional positivamente relacionada con el colesterol HDL. Conclusiones El consumo moderado de alcohol, el ejercicio fisico, el consumo de vitamina C y la optimizacion del peso corporal aportan una importante contribucion al incremento de la concentracion del colesterol HDL en nuestro medio.

Objectives. The aim of the present study was to ascertain whether the degree of accessibility to coronary angiography and revascularization results in differing usages or outcomes, or both, in the setting of a high coverage national health system. Background. The selective use of coronary angiography and revascularization procedures in the management of acute myocardial infarction (MI) remains controversial. Methods. A cohort of 1,460 consecutive patients with a first MI admitted to four referral teaching hospitals (one with tertiary facilities) were followed up for 6 months after admission. Only patients initially admitted to each of the study hospitals were retained for analysis in the original hospital’s cohort. End points were 6-month mortality and readmission for reinfarction, unstable angina, heart failure or severe ventricular arrhythmia. Results. Patients admitted to the tertiary hospital were more likely to undergo coronary angiography (adjusted relative risk 4.22, 95% confidence interval [CI] 3.37 to 5.45) than those admitted to the nontertiary sites (use rate: 22.1% for nontertiary care, 55.5% for tertiary care). Revascularization procedures were performed in 21.2% of patients in the tertiary hospital and in 8.3% in the nontertiary hospitals (p < 0.0001). Median delay for emergency coronary angiography was shorter in the tertiary hospital (within 1 vs. 2 days, p < 0.0001). Six-month mortality or readmission rates were similar (23.7% and 24.7% for tertiary and nontertiary care, respectively). After adjustment for comorbidity and disease severity, the relative risk of death or readmission for the tertiary hospital was 1.03 (95% CI 0.69 to 1.53) times that of the nontertiary hospitals. Conclusions. Selective use of coronary angiography and revascularization procedures may be as effective as less restricted use in the management of acute MI.

La efectividad de los procedimientos diagnosticos,preventivos y terapeuticos cuya eficacia se haevaluado en los ensayos clinicos deberia contrastarseen el escenario asistencial real. En particular,la de los empleados en el manejo del infartoagudo de miocardio (IAM), puede evaluarse medianteestudios de cohorte que incluyan a todos lospacientes consecutivos ingresados en uno o mashospitales. Denominamos a dichos estudios registroshospitalarios, y son mas simples de organizar yeconomicos que los primeros. Por otro lado, los registrospoblacionales de esta enfermedad permitenestablecer las tasas de incidencia y mortalidad, y laletalidad al incluir aquellos pacientes que fallecenpor un IAM sin llegar a entrar en contacto con elsistema hospitalario. En ambos casos se recoge unconjunto de datos sobre la comorbilidad, edad,sexo, gravedad, utilizacion de procedimientos yevolucion de cada paciente, sistematica y estandarizadamentepara garantizar la validez interna delestudio. En los registros hospitalarios, la validezexterna, o generalizacion de los resultados, dependerade si la muestra de hospitales seleccionadaes representativa de la poblacion a la que se deseaextrapolar los resultados. Un buen registrodebe incluir pacientes de una franja de edad amplia,permitir el analisis de subgrupos de pacientes(p ej., IAM transmural o primeros IAM) para facilitarla comparacion con otros registros, realizar seguimientosal menos a medio plazo, respetar los aspectoseticos, estar convenientemente financiado ymantener implicado a un equipo multidisciplinarioen su diseno y desarrollo.

MyOcean is setting up a European system of systems for ocean monitoring and forecasting. MyOcean provides ocean physics and bio-geo-chemical parameters. MyOcean is the candidate for being the Marine Core Service within Copernicus (former GMES).

Background and objectiveCoronary heart disease (CHD) is the leading cause of death, and smoking its strongest modifiable risk factor. Our aim was to determine the impact of the Spanish 2006 partial smoke-free legislation on acute myocardial infarction (AMI) incidence, hospitalization and mortality rates, and 28-day case-fatality in Girona, Spain.MethodsUsing a population-based registry (the REGICOR Study), we compared population incidence, hospitalization, and mortality rates, and 28-day case-fatality in the pre- and post-ban periods (2002-2005 and 2006-2008, respectively) by binomial regression analysis adjusted for confounding factors. We also analyzed the ban's impact on the outcomes of interest using the AMI definitions of the American Heart Association (AHA)/European Society of Cardiology (ESC) and the World Health Organization (WHO)-Monitoring trends and determinants in cardiovascular diseases (MONICA).ResultsIn the post-ban period, AMI incidence and mortality rates significantly decreased (relative risk [RR] = 0.89; 95% confidence interval [CI] = 0.81-0.97 and RR = 0.82; 95% CI = 0.71-0.94, respectively). Incidence and mortality rates decreased in both sexes, especially in women, and in people aged 65-74 years. Former and non-smokers (passive smokers) showed diminished incidence rates. Implementation of the ban was not associated with AMI case-fatality. Models tended to be more significant with the WHO-MONICA than with the AHA/ESC definition.ConclusionsThe 2006 Spanish partial smoke-free legislation was associated with a decrease in population AMI incidence and mortality, particularly in women, in people aged 65-74 years, and in passive smokers. These results clarify the association between AMI mortality and the enactment of a partial smoke-free legislation and reinforce the effectiveness of smoking regulations in preventing CHD.

Background: Epidemiological evidence of the effects of long-term exposure to air pollu tion on the chronic processes of athero genesis is limited. Objective: We investigated the association of long-term exposure to traffic-related air pollu tion with subclinical atherosclerosis, measured by carotid intima media thickness (IMT) and ankle–brachial index (ABI). Methods: We performed a cross-sectional analysis using data collected during the reexamination (2007–2010) of 2,780 participants in the REGICOR (Registre Gironí del Cor: the Gerona Heart Register) study, a population-based prospective cohort in Girona, Spain. Long-term exposure across residences was calculated as the last 10 years’ time-weighted average of residential nitrogen dioxide (NO2) estimates (based on a local-scale land-use regression model), traffic intensity in the nearest street, and traffic intensity in a 100 m buffer. Associations with IMT and ABI were estimated using linear regression and multinomial logistic regression, respectively, controlling for sex, age, smoking status, education, marital status, and several other potential confounders or intermediates. Results: Exposure contrasts between the 5th and 95th percentiles for NO2 (25 μg/m), traffic intensity in the nearest street (15,000 vehicles/day), and traffic load within 100 m (7,200,000 vehicle-m/day) were associated with differences of 0.56% (95% CI: –1.5, 2.6%), 2.32% (95% CI: 0.48, 4.17%), and 1.91% (95% CI: –0.24, 4.06) percent difference in IMT, respectively. Exposures were positively associated with an ABI of > 1.3, but not an ABI of < 0.9. Stronger associations were observed among those with a high level of education and in men ≥ 60 years of age. Conclusions: Long-term traffic-related exposures were associated with subclinical markers of atherosclerosis. Prospective studies are needed to confirm associations and further examine differences among population subgroups.key words: ankle–brachial index, average daily traffic, cardiovascular disease, exposure assessment, exposure to tailpipe emissions, intima media thickness, land use regression model, Mediterranean diet, nitrogen dioxide

Introduction A chyle fistula is an uncommon complication following abdominal and pancreatic surgery, particularly in the retroperitoneal compartment. It can also appear as a complication of a severe acute pancreatitis. Medical treatment is the initial approach, but resolution is often slow. Somatostatin or octreotide can help in accelerating the resolution of fistulae. Patients and methods Patients developing a chyle fistula (output >100 ml/24 h, normal amylase levels and triglyceride concentrations above 110 mg/dl) associated with pancreatic disorders were treated with oral intake restriction and parenteral nutrition, followed by subcutaneous octreotide 0.1 mg/8 h. Results Four female patients aged 55–80 years, who underwent pancreatic surgery or presented with an acute pancreatitis, were treated. Chyle fistulae ranging from 100 to 2000 ml/24 h were treated with octreotide, being resolved within five to seven days. No recurrence has been found in a 2–4 years follow up. Conclusions We have found that chyle fistula medical treatment is often related to a slow resolution, somatostatin or octreotide administration dramatically reduces its duration. Other previously reported studies have also shown that the quick onset of such treatment can accelerate the whole process, leading to a shorter recovery and lower hospital costs.

Women with myocardial infarction (MI) have shown a 28-day survival disadvantage compared with men. However, results were less consistent when considering long-term mortality in 28-day survivors. The aim was to estimate the trends for sex-related differences in the three endpoints considered for this study: (1) 28-day mortality or severe ventricular dysfunction (acute pulmonary oedema or cardiogenic shock) during the hospital stay, (2) 28-day mortality and (3) two-year cardiovascular mortality or non-fatal MI in 28-day survivors after a first MI. A cohort of 3,982 consecutive patients with first Q-wave MI admitted to a university tertiary reference hospital between 1978 and 2007 was followed for 2 years. Short-term prognosis improved in women over the studied period; similar rates were observed in both sexes in the 2000s. After adjusting for age, co-morbidities and anterior location of MI, female sex had an odds ratio = 1.71 (95 % confidence interval [CI] 1.34–2.17) of short-term severe MI or death over the studied period. Overall, sex differences in long-term prognosis remained similar over the studied period (hazard ratio = 1.40; 95 % CI 1.02–1.91). In conclusion, short-term prognosis improved over the past 30 years for first Q-wave MI patients, becoming similar for both men and women in the most recent decade. Long-term prognosis did not improve in either men or women, indicating that secondary prevention should be reinforced to achieve consistent reductions in the number of cardiovascular events.

The effect of gender and other clinical variables on short-term and long-term cardiac mortality after a first transmural myocardial infarction (MI) was assessed in a population-based hospital register. A cohort of 1216 consecutive patients (1023 men and 193 women), 25–74 years old admitted to the only reference hospital with a coronary care unit at Girona, Northeastern Spain, were recruited for 1978 to 1988 and followed-up for a mean period of almost 5 years (3–12 years). Compared with men, women had a relative risk (RR) of 1.56 (95% confidence interval (CI) of 0.99–2.48) of dying in the acute phase of MI after adjusting for age, MI location, presence of severe arrhythmias, diabetes and hypertension. However, when additionally adjusting for severity (Killip class), women presented a RR of 1.11. Age and hypertension were independent risk factors for acute mortality. Women surviving the acute period of MI showed a RR of 1.37 (CI 0.97–1.92) for long-term mortality, that was only slightly modified by Killip class during hospital stay (RR = 1.27). Age and diabetes were independent risk factors for long term mortality. It is concluded that women have a 56% excess risk for early mortality after a first transmural MI than men mainly explained by a higher severity.

Background and aims: Traffic-related air pollution causes cardiovascular disease and death. Most evidence relates to short-term exposure causing acute effects like myocardial infarction and stroke....

To investigate comorbid conditions with prognostic influence in non-ST-segment elevation acute coronary syndrome (NSTEACS).The study group consisted of a derivation cohort of 1017 patients (admitted from October 1, 2002, through October 1, 2008) and an external validation cohort of 652 patients (admitted from February 1, 2006, through September 30, 2009). Comorbid conditions, including risk factors and components of the Charlson comorbidity index (ChCI) and coronary artery disease-specific index, were recorded. The main outcome was one-year mortality.During follow-up, 103 patients died. After adjusting for variables associated with NSTEACS characteristics (base model), 5 comorbid conditions predicted mortality: severe or mild renal failure (hazard ratio [HR], 2.9 and HR, 1.6, respectively), dementia (HR, 3.1), peripheral artery disease (HR, 2.0), previous heart failure (HR, 2.6), and previous myocardial infarction (HR, 1.4). A simple comorbidity index (SCI) was developed using these variables, (per point: HR, 1.6; 95% confidence interval, 1.4-1.8; P = .0001). Adding the SCI, Charlson comorbidity index, or coronary artery disease-specific index to the base model resulted in a gain of 6.58%, 5.00%, and 4.04%, respectively, in discriminative ability (P = .001), without significant differences among the 3 indices. In patients with comorbid conditions, the highest risk period was in the first weeks after NSTEACS. The strength of the association between SCI and mortality rate was similar in the external validation cohort (HR, 1.3; 95% confidence interval, 1.1-1.6; P = .001).Renal dysfunction, dementia, peripheral artery disease, previous heart failure, and previous myocardial infarction are the comorbid conditions that predict mortality in NSTEACS. A simple index using these variables proved to be as accurate as the more complex comorbidity indices for risk stratification. In-hospital management of patients with comorbid conditions merits further investigation.

The aims of the study were: to describe the distribution of physical activity practice; to determine the prevalence and trends of sedentary lifestyle in the population aged 35 to 74 years of Girona in the 1995-2005 period; and to identify the variables associated to sedentary lifestyle at the population level.Data from three independent population-based cross-sectional studies undertaken in 1995 (n=1419), 2000 (n=2499), and 2005 (n=5628) were analyzed. Physical activity was measured using the Minnesota Leisure Time Physical Activity questionnaire. Sedentary lifestyle was defined as an energy expenditure in moderate physical activity (4-5.5 METs)675 kcal/week or420 kcal/week in intense PA (≥ 6 METs). Logistic regression was used to determine the variables associated with sedentary lifestyle.The age-standardized prevalence of sedentary lifestyle was 53.8%, 39.5%, and 32.6% in 1995, 2000, and 2005 respectively. The prevalence of sedentary lifestyle has decreased especially in women older than 50 years living in the urban areas. An increase in light and moderate physical activity practice in men older than 50 years and in light physical activity practice in women older than 50 years was observed. Female gender, age, smoking and lower educational level were associated with a higher prevalence of sedentary lifestyle.Prevalence of sedentary lifestyle has decreased in the 1995-2005 period in Girona, especially in women, but is still high. Health promotion programs should include physical activity practice as a key element and should take into account gender and social inequalities.

This study was conducted to establish the attack rate, mortality rate and 28-day case-fatality rates of acute myocardial infarction (AMI) occurring in Girona, Spain, between October 1987 and September 1988. The study was carried out using a population register of AMI, and took place in one central hospital, and eight county hospitals in Girona (in the autonomous community of Catalonia, northeast Spain). Subjects comprised 222 fatal cases selected from 4069 death certificates, and 210 non-fatal cases from hospital records, among subjects aged between 25 and 74 years (reference population 263,778). The age standardized attack rate was 105.6 per 100,000 inhabitants in the age group 35-64 (193.6 in men and 17.6 in women). The age standardized mortality rate was 36.3 per 100,000 inhabitants in the age group 35-64 (63.1 among men and 9.9 among women). The age standardized 28-day case-fatality was 34.6% in men and 50.1% in women in this same age group. Attack and mortality rates of AMI in a region of Spain are presented for the first time. These rates are lower than in other developed countries, nevertheless the 28-day case-fatality is similar to that of these countries.

Purpose To determine the differences and trends in the prevalence, awareness, treatment and control of cardiovascular risk factors and lifestyle variables across educational level in the 1995−2005 period in a country with a universal free health care system. Methods Data from three consecutive independent population-based surveys were used. Cardiovascular risk factors, lifestyle variables, and self-reported educational level were collected in 9646 individuals ages 35–74 years throughout the decade. Results The prevalence of hypertension and diabetes was inversely associated with education. An increase in the proportion of hypertension and dyslipidemia awareness, treatment, and control in all educational level groups was observed. This increase was greater among the lowest education group, reducing the disparities between groups. The prevalence of lifestyle-related risk factors decreased in the greatest but increased in the lowest education group, widening the disparities between groups. Conclusions A universal free health care system is effective in avoiding inequalities in the diagnosis, treatment, and control of cardiovascular risk factors. However, other social determinants seem to explain the social inequalities in the prevalence of these risk factors and in the adoption of healthy lifestyles.

Introduction and objectives: Cardiovascular risk screening requires accurate risk functions. The relative validity of the Framingham-based REGICOR adapted function is analyzed and the population distribution of cardiovascular 10-year cardiovascular events is described by risk group. Methods: A population cohort of 3856 participants recruited between 1995 and 2000, aged 35 to 74 years from Girona without symptoms of cardiovascular diseases, was followed between 2006 and 2009. Standardized laboratory and blood pressure measurements, questionnaires, and case definitions were used. The follow-up combined cross-linkage of our databases with our regional mortality registry, reexamination, and telephone contact with participants. Coronary disease endpoints alone were considered. Results: A total of 27 487 person-years were obtained (mean follow-up 7.1 years), and the follow-up was achieved in 97% of participants (120 coronary disease events). Validity was good: the regression coefficients estimated with the cohort data did not differ from those obtained in the original Framingham function. Function calibration was good: the observed incidence of cardiovascular events in the decile groups of risk did not differ from the function prediction (P = .127 in women, and P = .054 in men). The C statistic (discrimination) was 0.82 (95% confidence interval, 0.76-0.88) in women, and 0.78 (95% confidence interval, 0.73-0.83) in men. More than 50% of cardiovascular events occurred in participants whose 10-year risk was 5% to 14.9%. Conclusions: The studied function accurately predicts coronary disease events at 10 years. Risk stratification could be simplified in 4 groups: low (

This article describes the limitations of the currently available screening modalities used for determining cardiovascular risk in the general population. In addition, it contains an analysis of the potential ways in which the predictive and classificatory abilities of the cardiovascular risk charts used in primary care can be improved to enable them to function more effectively. Also included are discussions of existing opportunities for improving current strategies for screening and cardiovascular prevention, of the value of measuring new biomarkers in individual patients, including genetic predisposition to coronary heart disease, and of some of the clinical measures used in practice, such as the ankle-brachial index and the carotid intima-media thickness. In addition, the most important subgroups of individuals at a high cardiovascular risk, as judged by their size and the number of cardiovascular events experienced at 10 years, are described. Finally, there is a brief review of the potential role that image modalities currently being developed could play in particular subgroups of asymptomatic individuals with an elevated disease risk.

The value of body mass index in the prognosis of patients with ischemic heart disease is not well defined. The objective of our study was to determine the association of body mass index with classic and emergent cardiovascular risk factors and with intra-hospital and 6-months mortality.We conducted a prospective, multicenter study with a 6-months follow-up. We included 1063 patients between the ages of 25-75 years old who were consecutively admitted to the hospital within the first 24 hours of the onset of symptoms between years 2001 and 2003. We determined demographic and anthropometric variables, as well as classic and emergent factors of risk, clinical variables and the treatment administered. We carried out a univariate and multivariate analysis.The percentage of patients with overweight or obesity in this population was 73.56%. Overweight and obesity were associated with classical risk factors, except for smoking, and emergent risk factors. Body mass index was not associated with short-or mid-term prognosis.Body mass index is not a useful anthropometric measure to determine the prognosis of patients after a first myocardial infarction.

To determine the effect of age and study period on coronary heart disease (CHD) risk attributable to cardiovascular risk factors.A cohort of cardiovascular disease (CVD)-free randomly participants from Girona (Spain) aged 35-74 years recruited in 1995 and 2000 and followed for an average of 6.9 years. A survey conducted in the same area in 2005 was also used for the analysis. Smoking, hypertension, diabetes, sedentary lifestyle, obesity, total cholesterolor = 240 mg/dl, low-density lipoprotein (LDL) cholesterolor = 160 mg/dl, and high-density lipoprotein cholesterol40 mg/dl were the risk factors considered. The composite end-point included myocardial infarction, angina pectoris, and CHD death.LDL cholesterol had the highest potential for CHD prevention between 35 and 74 years [42% (95% Confidence Interval: 23,58)]. The age-stratified analysis showed that the population attributable risk (PAF) for smoking was 64% (30,80) in subjects55 years; for thoseor = 55 years, the PAF for hypertension was 34% (1,61). The decrease observed between 1995 and 2005 in the population's mean LDL cholesterol level reduced that PAF in all age groups.Overall, LDL cholesterol levels had the highest potential for CHD prevention. Periodic PAF recalculation in different age groups may be required to adequately monitor population trends.

We evaluate the merits of routine waist circumference measurements for screening of impaired fasting glucose (IFG). Waist circumference and body mass index showed a strong association with the risk of IFG. The present data indicate the need for routine anthropometric measurements in clinical practice screening for IFG.

Introduction and objectives To determine the prevalence of acute myocardial infarction (AMI) without classical risk factors, and to ascertain whether affected patients exhibit a higher prevalence of emergent risk factors and whether the presence of specific emergent risk factors influence prognosis at 6 months. Methods The FORTIAM (Factores Ocultos de Riesgo Tras un Infarto Agudo de Miocardio) study is a multicenter cohort study that includes 1371 AMI patients who were admitted within 24 hours of symptom onset. Strict definitions were used for classical risk factors and the concentrations of the following markers were determined: lipoprotein (a) [Lp(a)], oxidized low-density lipoprotein (oxLDL), high-sensitivity C-reactive protein, fibrinogen, homocysteine, and antibody to Chlamydia. The endpoints observed during the 6-month follow-up were death, angina, and re-infarction. Results The prevalence of AMI without classical risk factors was 8.0%. The absence of classical risk factors did not affect the 6-month prognosis. The only emergent risk factors independently associated with a poorer prognosis were the Lp(a) and oxLDL concentrations. Cutpoints were determined using smoothing splines: 60 mg/dL for Lp(a) and 74 U/L for oxLDL. The associated hazard ratios, adjusted for age, sex, and classical risk factors, were 1.40 (95% confidence interval, 1.06-1.84) and 1.48 (95% confidence interval, 1.06-2.06), respectively. Conclusions The proportion of AMI patients without classical risk factors was low and their prognosis was similar to that in other AMI patients. Both oxLDL and Lp(a) concentrations were independently associated with a poorer 6-month prognosis, irrespective of the presence of classical risk factors.

Background: Coronary heart disease (CHD) is the leading cause of mortality worldwide. CHD clusters in families but this familial aggregation remains largely unexplained. ESR1 is a candidate gene for CHD although recent meta-analyses of the rs2234693 variant reported inconsistent evidence for association with myocardial infarction (MI) in men. The objectives of this study were to perform a qualitative and a quantitative assessment of all evidence to date regarding this association. Methods: We performed structured literature searches for studies addressing the association between the ESR1 rs2234693 and CHD. We assessed the quality of these studies collectively and individually according to recently published guidelines on the reporting and interpretation of genetic association studies. We also performed a meta-analysis of all studies to date, including a sample of MI cases and controls from our region. Results: The qualitative assessment indicated that many studies met a low proportion of the criteria proposed by the current guidelines. No significant association between ESR1 rs2234693 and MI was observed in our sample or in the meta-analysis (16 studies; N ∼ 32,000; OR ∼ 1). Strong between-study heterogeneity was largely explained by a quality score based on the quality criteria. Studies that reported significant associations were generally of poorer quality. Conclusion: We confirm the lack of association between the ESR1 rs223469 and CHD, and show that inconsistencies between previous studies is explained by differences in their quality. © 2009 Elsevier Ireland Ltd. All rights reserved.

We conducted a genome-wide association study testing single nucleotide polymorphisms (SNPs) and copy number variants (CNVs) for association with early-onset myocardial infarction in 2,967 cases and 3,075 controls. We carried out replication in an independent sample with an effective sample size of up to 19,492. SNPs at nine loci reached genome-wide significance: three are newly identified (21q22 near MRPS6-SLC5A3-KCNE2, 6p24 in PHACTR1 and 2q33 in WDR12) and six replicated prior observations1, 2, 3, 4 (9p21, 1p13 near CELSR2-PSRC1-SORT1, 10q11 near CXCL12, 1q41 in MIA3, 19p13 near LDLR and 1p32 near PCSK9). We tested 554 common copy number polymorphisms (>1% allele frequency) and none met the pre-specified threshold for replication (P < 10-3). We identified 8,065 rare CNVs but did not detect a greater CNV burden in cases compared to controls, in genes compared to the genome as a whole, or at any individual locus. SNPs at nine loci were reproducibly associated with myocardial infarction, but tests of common and rare CNVs failed to identify additional associations with myocardial infarction risk.

The REACH Registry is the largest worldwide designed to obtain information on cardiovascular risk factor control and preventive treatment in a population who have, or are at risk of having, symptoms of atherothrombosis. The objective of this study is to show the results of cardiovascular events obtained in a sample of the Spanish population at one year follow-up and intervention.The REACH Spain registry is a prospective cohort study of subjects with vascular risk factors (ORF) for atherothrombosis or with symptomatic vascular disease (VD): coronary artery disease (CAD) and/or cerebrovascular disease (CVD) and/or peripheral artery disease (PAD). The main outcome measures were rates of all-cause mortality, cardiovascular (CV) death, and the overall combined CV death, myocardial infarction (MI), or stroke and CV hospitalization at one year follow-up.In Spain 2,516 patients were recruited and 2,252 completed one year follow-up, the mean age was 68,1 (73,8% men), 11,6% of subjects with ORF and 88,5% with VD, 55% with CAD, 33% with CVD and 17% with PAD. The annual rate of all-cause mortality in VD and ORF groups were 3,57% and 1,98% (NS) respectively, while for CV death they were 2,69% and 0,62% (P.05) and for overall combined CV death myocardial infarction (MI), or stroke and CV hospitalization they were 15,34% and 5,47% (P=.0001). The annual rate of CV death for CAD, CVD and PAD groups were 3,47%, 2,78% and 1,46% respectively, and for the overall combined CV death, myocardial infarction (MI) , or stroke and CV hospitalization they were 18,52%, 13,75% and 14,52%. These event rates increased with the number of symptomatic arterial disease locations from 0,1,2 or 3 for CV death (0,62%, 2,46%, 3,55% and 4,32%, respectively P.05) and for overall combined CV death myocardial infarction (MI), or stroke and CV hospitalization (5,50%, 4,18%, 20,59% y 19,40%, respectively P.0001). At one year follow-up, 82,8% of the patients were with at least one antiplatelet drug and 86,2% were receiving lipid-lowering agents.The REACH Spain Registry at one year follow-up in patients with atherothrombotic disease or at risk of having symptoms of atherothrombosis shows a high rate of all-cause mortality and of overall combined major CV events, which is becoming higher as the number of symptomatic arterial disease locations increases.

Complete ventricular septal defects (VSD) can be congenital (estimated prevalence 0.5% in live births) (Roguin N, et al. High prevalence of muscular ventricular septal defect in neonates. J Am Coll Cardiol 1995;26:1545-1548) or may be a complication of acute myocardial infarction (estimated incidence in the era of thrombolysis 0.2%) [Crenshaw BS, et al. Risk factors, angiographic patterns, and outcomes in patients with ventricular septal defect complicating acute myocardial infarction. GUSTO-I (Global Utilization of Streptokinase and TPA for Occluded Coronary Arteries) Trial Investigators. Circulation 2000;101:27-32]. In this paper, we report two unique cases of partial VSD.

Two particular polymorphisms, namely PON1-192 and PON2-311, in the genes encoding the antioxidant enzymes paraoxonase-1 (PON1) and paraoxonase-2 (PON2) have been associated with an increased risk of acute myocardial infarction (AMI). However, previous findings have been contradictory. The aim of this study was to investigate the association between the PON1-192 and PON2-311 polymorphisms and their interaction on AMI risk.This case-control study involved 746 consecutive AMI patients and 1796 control subjects without cardiovascular disease, who were randomly selected from the same population from which the patients came. All participants were recruited between 1999 and 2000 from four Spanish autonomous regions. All were assessed for the presence of PON1-192 and PON2-311 and for classical cardiovascular risk factors. Multivariate analysis was carried out using logistic regression modeling.The odds ratios (OR) of AMI for patients with the PON1-192 QQ and PON2-311 SS genotypes (who comprised 50% and 66% of the population, respectively) were 1.26 (95% confidence interval [CI], 1.02-1.55) and 1.25 (95% CI, 1.04-1.50), respectively, compared with R and C allele carriers. Moreover, in patients with both QQ and SS genotypes, the adjusted OR of AMI increased to 1.41 (95% CI, 1.13-1.76).Our results indicate that the PON1-192 and PON2-311 polymorphisms were independent risk factors of AMI in our population.

The REACH Registry is the largest worldwide registry designed to obtain information on cardiovascular risk factor control and preventive treatment in a population who have, or are at high risk of having, symptoms of atherothrombosis. The objective of this study is to show the results obtained in a sample of the Spanish population included in that registry.Registry of consecutive patients who have risk factors only (RFO) for atherothrombosis or who have symptomatic vascular disease (VD): coronary heart disease (CHD) and/or cerebrovascular disease (CVD) and/or peripheral artery disease (PAD). Cardiovascular risk factor control and the use of antithrombotic and lipid lowering therapy were evaluated.In Spain 2,515 patients were recruited; 297 had RFO and 2,218 had VD: 61.4% with CHD, 36.6% with CVD and 18.7% with PAD. The rates of noncontrolled blood pressure, glycemia, total cholesterol and triglyceride levels in the RFO group compared to those of the VD group were: 76.5% vs 57.1% (p0.005), 61.6% vs 30.9% (p0.005), 55.7% vs 41.3% (p0.005) and 45.5% vs 35.1% (p0.005), respectively. The antiplatelet therapy rate in these two groups was 44.1% vs 86.5% (p0.005), the anticoagulant therapy rate was 11.4% vs 12.6% (no significant difference) and statin therapy rate was 65.2% vs 65.6% (no significant difference). Significant differences were found among the CHD, CVD and PAD groups as regards noncontrolled blood pressure rate (49.8%. 57.1% and 67.1%, respectively p0.005), total cholesterol control rate (41.3%, 48.2% and 50.2% respectively, p0.005) as well as antiplatelet therapy rate (86.5%. 83.2% and 81.6% respectively p0.005) and statin therapy rate (78.2%. 51.9% and 57.8% respectively p0.005).Cardiovascular risk factor control in subjects at high risk of atherothrombosis or who have established VD is poor. It is poorer in primary prevention and in PAD patients. Whilst the use of statins is insufficient, the use of antithrombotic medication is acceptable in secondary prevention but considerably lacking in primary prevention.

To analyze patients', physicians' and nurses' attitudes to and perceptions of patient rights in the public hospitals of the Reus health district in Catalonia (Spain).We performed a qualitative analysis, through focus groups composed of health professionals (physicians and nurses) and discharged patients, followed by three surveys aimed at physicians, nurses, and patients. A descriptive analysis was performed of the results and of the differences among the three collectives. A principal components analysis for categorical data was used to reduce the number of dimensions and to reveal the associations among the different variables.Among discharged patients and nurses, the most important patient rights were "the right to information" and "patient autonomy", whereas among physicians, the most important dimensions were the "right to autonomy" and "the patient's right to form an opinion". A minority of patients was reluctant to participate in decision-making. The groups with the most favorable attitudes to exercising patient autonomy were women, younger patients, and those with the highest educational level. Patients were less in favor of patient autonomy than physicians while nurses had the most radical attitudes in favor of patient autonomy.Patient's rights are not sufficiently well known, and the right to information is valued more highly than the right to exercise autonomy. Discharged patients, physicians and nurses have different attitudes to and perceptions of the same issue.

Both mortality due to cerebrovascular disease in individuals aged under 85 years and mortality due to acute myocardial infarction (AMI) are lower in women than men. In contrast, the age-adjusted 28-day case fatality rate after a first AMI is 20% higher in women, particularly in countries where the incidence of AMI is low. In Spain, the case fatality rate is elevated in women hospitalized for a first AMI, but not in those with other forms of coronary heart disease. The pattern of mortality observed after symptom onset, which shows that death is delayed in women, suggests that the mechanism of death is different in the two sexes. The substantial variation that exists in the way results are adjusted and presented make it very difficult to compare the findings of different studies. Relative to men, women with AMI are 10 years older, reach hospital one hour later on average, more frequently have a comorbid condition (mainly diabetes and hypertension), progress to a more serious clinical state, and have a higher adjusted 28-day mortality risk. Moreover, the treatment given to women during the acute phase is less aggressive. A change in healthcare workers' attitudes is needed so that women with acute coronary syndromes can be identified earlier, thereby increasing the use of diagnostic and therapeutic procedures to a level that corresponds to the greater severity of AMI observed in women at presentation.

Background Most studies that have analysed the effect of secondary prevention of coronary heart disease come from hospitals. Those that are community-based have been conducted mainly by nurses and follow-up was generally too short to show impact on cardiovascular events. Methods This is a multi-centre randomised controlled clinical trial in which patients in the intervention group received periodic postal reminders to see their general practitioner every three months during a 3-year follow-up. General practitioners reinforced healthy lifestyle recommendations to patients and reviewed drug therapies at these quarterly intervals. Patients in the control group received usual care. Results A total of 983 patients aged 30–79 were included. During the 3-year follow-up, 67 patients died and 156 experienced a non-fatal cardiovascular event. The event rates and all-cause mortality were similar in the intervention and control groups (24.0% and 23.5%, and 8.1% and 9.9%, respectively). Improvement in quality of life was similar in both groups. Blood pressure and high-density lipoprotein cholesterol were more frequently within recommended levels in the intervention group than in controls: odds ratio 1.63, 95% confidence interval 1.05–2.51, and odds ratio 2.61, 95% confidence interval 1.32–5.18, respectively. Conclusions Intensive secondary prevention conducted by general practitioners may improve long-term blood pressure control and increase high-density lipoprotein cholesterol in patients with stable coronary disease.

A patient's social circumstances at the time when acute myocardial infarction (AMI) symptoms first appear might influence survival. Our objectives were to study the living conditions, the location where symptoms started, the type of symptoms, and the delay before action was taken in patients with AMI who survived more than one hour, and to analyze the relationship between these variables and mortality in different time periods.Population-based observational cohort study carried out in 1997-1998. Main data source: Registre Gironí del Cor (REGICOR). Death certificates provided information on patients who died before they could be included in the register. The patients' demographic characteristics, lifestyle, clinical history, electrocardiographic abnormalities, cardiac enzyme levels, treatment, and diagnosis were recorded. Mortality before and during hospitalization, and overall mortality at 28 days were studied.Of the 1,097 patients included, 274 (24.97%) died before reaching hospital, 171 (15.58%) died in hospital, and 652 (59.4%) were alive at 28 days. Mortality was lower in patients who went directly to hospital (OR = 0.32, 95% CI, 0.17-0.59). Mortality at 28 days was higher in those with atypical symptoms (OR = 5.52, 95% CI, 2.90-10.50), and in those who lived in an institution (OR = 9.47, 95% CI, 1.05-84.9).In the absence of specially equipped ambulances, AMI patients who went directly to the hospital or who had typical symptoms had a better chance of survival both before hospitalization and at 28 days. In contrast, 28-day mortality was higher in institutionalized patients.

Objective: The characteristics of the 36 item Medical Outcome Short Form Health Study Survey (SF-36) questionnaire, designed as a generic indicator of health status for the general population, allow it to be self-administered or used in personal or telephone interviews. The main objective of the study was to compare the telephone and self-administered modes of SF-36 for a population from Girona (Spain). Methods: A randomized crossover administration of the questionnaire design was used in a cardiovascular risk factor survey. Of 385 people invited to participate in the survey, 351 agreed to do so and were randomly assigned to two orders of administration (i.e., telephone-self and self-telephone); 261 completed both questionnaires. Scores were compared between administration modes using a paired t test. Internal consistency and agreement between modalities were analyzed by respectively applying Chronbach's alpha and intraclass correlation coefficients. The effect of the order of administration on the test-retest difference was analyzed by one-way ANOVA for repeated measurements. Results: Physical function, physical role and social functioning received significantly lower scores when the self-administered questionnaire was used prior to the telephone survey. When the initial survey was conducted by telephone, all Chronbach's alpha coefficients (except social functioning) scored over 0.70 in the self-administered modality. The intraclass correlation coefficient ranged from 0.41 to 0.83 for the telephone-self order and from 0.32 to 0.73 for the self-telephone order. No clinically significant effect was observed for the order of application. Conclusions: The results of the present study suggest that the telephone-administration mode of SF-36 is equivalent to and as valid as the self-administered mode.

The type of acute coronary syndrome may account for different prognoses between men and women after myocardial infarction. This study assessed gender differences in 28-day mortality rates for first or recurrent Q-wave and non–Q-wave myocardial infarctions and unstable angina by using data from 5 registries that included 20,836 patients (24.8% women). Mortality rates were higher in women with first Q-wave myocardial infarction but not in the other patients after adjusting for confounding variables.

[Abstract] Background: Myocardial infarction (MI) incidence and mortality display a high geographic variation. Aims: The objective of the present study was to analyze MI mortality, cumulative incidence rate variability in seven regions of Spain from 1997 to 1998. Methods and Results: Standardized methods were used to identify, find, register, and classify MI cases that were classified as definite, possible, insufficient-dataMI, and non-MI. The total population of the seven monitored regions was 7,364,682 inhabitants. Of the 11,256 cases fulfilling eligibility criteria to investigate, 10,660 were selected to calculate MI rates: 6554 (61.5%)non-fatal definite MI, 1179 (11.1%)fatal definite MI, 1859 (17.4%)fatal possible MI, 1068 (10.0%)fatal cases with insufficient data. The IBERICA 25–74 years age-standardized cumulative incidence rates for men and women, were 207 (range: 175–252) and 45 (range: 36–65) per 100,000, respectively. The age-standardized mortality rates for men and women, were 73 (range: 62–94) and 20 (range: 13–29) per 100,000, respectively. Age-standardized case-fatality was 31.4 and 24.2% in men aged 25–74 and 35–64 years, respectively, and 32.7 and 27.0%, respectively, in women. Conclusions: MI cumulative incidence and mortality rates are low compared with other industrialized countries but, vary considerably among regions in a Mediterranean country like Spain. Cataluña. Comissió Interdepartamental de Recerca i Innovació Tecnològica; CIRIT/2001 SGR 00408 Instituto de Salud Carlos III; FIS 96/0026-01 to 05 Instituto de Salud Carlos III; FIS 97/1270 Instituto de Salud Carlos III; FIS 98/1535

[Abstract] Introduction and objectives. To determine the proportion of patients with myocardial infarction (MI) not admitted to a coronary care unit (CCU), the variables associated with admission into a CCU, and whether admission to a CCU, and the availability of coronary angiography in the same hospital, were associated with 28-day case fatality. Patients and method. Population-based registry of MI in patients 25 to 74 years of age, admitted during 1996-1998. Demographic and clinical characteristics were recorded, as well as management, clinical course and survival after 28 days. Hospitals were classified according to the availability of a CCU and catheterization laboratory (advanced hospital), CCU only (intermediate hospital) or neither (basic hospital). Admission to the CCU was also recorded. Results. In all, 9046 cases of MI were recorded; in 11.3% the patient was not admitted to a CCU. Age, smoking (OR=1.33; 95% CI, 1.08-1.64), non-Q MI (OR=0.62; 95% CI, 0.49-0.78) or undetermined location of MI (OR=0.34; 95% CI, 0.23-0.50), Killip 4 score on admission (OR=0.63; 95% CI, 0.40-1.00) and delay in arrival at the hospital >6 h were associated with CCU admission. Patients admitted to a CCU showed a lower case fatality in the first 24 h (4.2% vs 23.5%), which was independent of comorbidity, severity and treatment. The 24-hour survivors admitted to a basic hospital had higher case fatality (17.3% vs 7.8%) than other groups, which was related to differences in treatment. Conclusions. CCU admission is associated with a lower case fatality in the first 24 h. Admission to a basic hospital is associated with a higher 28-day case fatality even in patients who survive 24 h. [Resumen] Introducción y objetivos. Determinar el porcentaje de pacientes con infarto agudo de miocardio (IAM) que no ingresan en una unidad de cuidados intensivos coronaries (UCIC), las variables asociadas al ingreso en una UCIC y si el ingreso en una UCIC, su disponibilidad y la de hemodinámica en el hospital se asocian a la letalidad a 28 días. Pacientes y método. Registro poblacional (1996-1998) de casos de IAM en pacientes con edades comprendidas entre los 25 y los 74 años. Se recogieron variables demográficas, clínicas, el ingreso en UCIC y la letalidad a los 28 días. Se clasificaron los hospitales según la disponibilidad de UCIC y hemodinámica (hospital avanzado), solamente UCIC (hospital intermedio) o ninguno (hospital básico). Resultados. Se registraron 9.046 casos; el 11,3% no ingresó en una UCIC. La edad, el consumo de tabaco (odds ratio [OR] = 1,33; intervalo de confianza [IC] del 95%, 1,08-1,64), el infarto sin onda Q (OR = 0,62; IC del 95%, 0,49-0,78) o ilocalizable (OR = 0,34; IC del 95%, 0,23-0,50), el grado Killip 4 al ingreso (OR = 0,63; IC del 95%, 0,40-1,00) y el retraso > 6 h en llegar al hospital se asociaron al ingreso en UCIC. Los pacientes ingresados en UCIC presentaban menor letalidad que los ingresados en hospitales básicos en las primeras 24 h (el 4,2 frente al 23,5%), independientemente de la gravedad del IAM y de las variables relacionadas con el tratamiento. Los su-pervivientes a 24 h que ingresaban en un hospital bÁsico presentaban mayor letalidad a los 28 días (el 17,3 frente al 7,8%), relacionada con las variables de tratamiento. Conclusiones. El ingreso en una UCIC se asocia a una menor letalidad de los pacientes con IAM en las primeras 24 h. El ingreso en un hospital bÁsico se asocia a una mayor letalidad a los 28 días. Insituto de Salud Carlos III; FIS96/0026-01 to 05 Insituto de Salud Carlos III; FIS97/1270 Insituto de Salud Carlos III; FIS98/1535

The magnitude of the problem of myocardial infarction (MI) is better understood by assessing the population case-fatality than by analyzing only the number of patients attending hospitals.Our data come from the IBERICA Study (Investigation, Specific Search and Registry of Acute Myocardial Ischemic Syndrome). Twenty eight-day MI population case-fatality is described in the population aged 25 to 74 years during 1997 and 1998 in the following Spanish autonomous communities: Castilla-La Mancha (Toledo and Albacete), Catalonia (Girona), Valencia Community (Valencia), Balearic Islands (Majorca), Murcia, Navarra and Basque Country. The relationship between case-fatality and other variables such as sex, age and geographic area is also analyzed.A total of 10,660 MI cases were registered, 4,106 of whom died within the period of 28 days following the onset of symptoms (38.5%; CI 95%, 37.6-39.4%). The overall case-fatality was 37.0% (CI 95%, 35.9-38.0%) in men and 44.3% (CI 95%, 42.3-46.4%) in women. Death occurred out of hospitals in 2,869 (69.9%) cases. An increased case-fatality in women was associated with a higher in-hospital case-fatality (45% higher than men). The proportion of patients who died before reaching a hospital was similar in both genders. Classical symptoms of MI were more common among men than women (82.7% vs. 77.6%, p0,001). The interval between symptoms' onset and hospitalization was 30 minute longer among hospitalized women as compared with men (p0,001).Population MI case-fatality is high in the seven Spanish autonomous communities studied. Approximately 2 out of 3 deaths occur without patients being able to reach a hospital. These results emphasize the importance of primary and secondary prevention measures and the necessity to design ready-access systems to defibrillation and resuscitation manoeuvres for patients with cardiopulmonary arrest.

Paraoxonase (PON1) is an antioxidant enzyme closely associated with high-density lipoproteins. Low PON1 has been shown in oxidative stress-associated processes such as dyslipidemia, diabetes mellitus, advancing age, and smoking. Indeed, oxidative stress is related to the degree of insulin resistance, a key component of the metabolic syndrome. Therefore, the possible relationship between PON1 activity and the metabolic syndrome was investigated. From 1364 randomly recruited subjects, 285 were found to have the metabolic syndrome, according to the guidelines published by the National Cholesterol Education Program, Adult Treatment Panel III. PON1 activity, lipid peroxides, and PON1 codon 192 genotypes, which strongly modulate PON1 activity, were determined. Serum PON1 activity levels were found to be significantly lower, and lipid peroxide concentrations significantly higher, in subjects with the metabolic syndrome compared with unaffected subjects (P = 0.033 and0.001, respectively). Study subjects showed a significant decreasing trend in PON1 activity levels and a significant increasing trend in lipid peroxide concentrations, with the increase in the number of metabolic disturbances. No differences in the prevalence of PON1 codon 192 genotypes were found among the categories of metabolic abnormalities. In conclusion, a greater degree of severity of the metabolic syndrome is associated with a progressively worse antioxidant/oxidant balance, which is consistent with increased oxidative stress and lower antioxidant PON1 enzymatic capacity.

The therapeutic consequences of using the Framingham function calibrated by the REGICOR and Framingham investigators (Framingham-REGICOR) in the Spanish population are unknown. The objective of this study was to determine the differences in the classification of the population coronary risk when using the classical Framingham function (Framingham-Wilson) and that calibrated, and its consequences on the theoretical indication of lipid-lowering treatment.The classification into the2%, 2-4,9%, 5-9,9%, 10-19,9%, 20-39,9%, and= 40% risk categories observed by the two functions was compared in 3.270 individuals aged 35 to 74 years with no history of ischaemic heart disease or lipid-lowering drug treatment, recruited in two population samples representative of Girona between 1994 and 2001. The number of lipid-lowering treatment candidates was estimated applying the most recent guidelines for clinical practice, according to the risk level obtained with both functions.The proportion of patients excluded owing to the fact that they already were on lipid-lowering treatment was 6.2%. The Framingham-REGICOR assigned 54.2% of women and 67.9% of men to a lower level of risk as compared to the Framingham-Wilson function. In 0.2% of women and 21.2% of men the decrease was two categories of risk. The figures in diabetic participants were 75.7 and 18.5%, respectively. When the European recommendations published in 2003 were applied, lipid-lowering treatment would have been indicated in 14.5% and in 4.4% of non-diabetic participants by the Framingham-Wilson and the Framingham-REGICOR, respectively.The calibrated Framingham-REGICOR function assigns a lower coronary risk category in more than 50% of women and almost 90% of men than the uncalibrated Framingham function. The calibrated function is more suitable for risk estimation in primary prevention than the original function in Spain.

Aim: To determine whether the Framingham function accurately predicts the 10 year risk of coronary disease and to adapt this predictive method to the characteristics of a Spanish population. Method and Results: A Framingham function for predicting 10 year coronary deaths and non-fatal myocardial infarction was applied to the population of the province of Gerona, Spain, where the cumulated incidence rate of myocardial infarction has been determined since 1988 by a specific registry. The prevalence of cardiovascular risk factors in this region of Spain was established in 1995 by a cross sectional study on a representative sample of 1748 people. The number of cases estimated by the Framingham function for 10 year coronary deaths and non-fatal myocardial infarction was compared with that observed. The Framingham function estimated 2425 coronary heart disease cases in women and 1181 were observed. In men, 9919 were estimated and 3706 were observed. Recalibrating the Framingham equations to the event rate and the prevalence of the risk factors in Gerona led to estimates very close to the number of cases observed in Gerona men and women. Conclusions: The Framingham function estimates more than doubled the actual risk of coronary disease observed in north east Spain. After calibration, the Framingham function became an effective method of estimating the risk in this region with low coronary heart disease incidence.

The Framingham coronary heart disease (CHD) functions overestimate the risk of CHD in countries with a low incidence. Consequently, these functions should be calibrated for the purpose of primary prevention. Calibrated Framingham function charts of overall CHD risk for the Spanish population are presented. Patients and methods. The Framingham functions were calibrated by substituting the prevalence of CHD risk factors and incidence found in Framingham with the same values for Spain. The Framingham function that included high-density lipoprotein (HDL) cholesterol was used. The 10-year probability of developing a CHD event was estimated for several combinations of risk factors and HDL levels ranging from 35 to 59 mg/dl. Color-coded charts were prepared that show the exact probability of CHD corresponding to each combination of risk factors, shown in separate cells on the chart.The event rate and prevalence of CHD risk factors differed considerably between Girona and Framingham. HDL35 mg/dL increased risk by approximately 50% and HDL60 mg/dL reduced it by 50%. The proportion of cells in which the 10-year probability of developing a CHD event was9% was 2.3 times higher and that of cells with a probability19% was 13 times lower in the chart calibrated for Spain than in the original Framingham charts.The calibrated Framingham function may help to more accurately estimate the overall risk of CHD in the Spanish population for primary prevention purposes. The calibrated function should be validated, and the development of functions for the Spanish population should be promoted.

Acute pulmonary edema (Killip III) or cardiogenic shock (Killip IV) is associated with a higher mortality in the acute phase of myocardial infarction (AMI).To analyze trends in the proportion of patients who developed Killip III and IV in AMI over a 20-year period in order to identify the variables associated with occurrence and case-fatality.Hospital registry of first AMI in patients under than 75 years, from 1978 to 1997. Sociodemographic variables, cardiovascular risk factors, clinical variables, treatments, procedures, and worst Killip class were recorded.The registry included 2,590 patients. Mean age was 60 years and 17% were women. Thirteen percent (13.5%) of the patients developed Killip III and IV, and no changes in this proportion were observed over the time period studied. Age, diabetes, previous angina, and anterior location of AMI were associated with a higher risk of Killip III and IV. Case-fatality at 28 days in this subgroup was 51.7%, with a decreasing linear trend over the years. Variables associated with a higher case-fatality were age and malignant ventricular arrhythmias, whereas the periods 1990-93 and 1994-97 were associated with a lower case-fatality. This protective effect disappeared after adjusting for treatment variables (antiplatelet agents and thrombolysis).The proportion of patients with AMI in which Killip class III and IV develops has remained stable in the last two decades. Although the 28-day case-fatality in these patients is high, a decrease has been observed in recent years in relation to the availability of new treatments (antiplatelet agents and thrombolysis).

Paraoxonase-1 (PON1) is a high-density lipoprotein (HDL)-linked enzyme which appears to protect low-density lipoproteins (LDL) from oxidation. PON1 activity is associated with variation at the PON1 gene locus, specifically the common amino acid polymorphism at codon 192, for which the Q192 allele specifies low activity and the R192 allele specifies high activity. We investigated the association between the PON1 codon 192 polymorphism and fasting concentrations of glucose, lipids, lipoproteins and PON1 activity in 1380 subjects (724 men and 656 women). Several anthropometric and environmental factors were assessed in the present study. The PON1 Q192 allele frequency was 0.70 and 0.68 in men and women, respectively. In women, but not in men, significant associations were found between the PON1 codon 192 genotype and both total and LDL-cholesterol (p=0.004 and p=0.008, respectively), and subgroup analysis indicated that this relationship was predominant in postmenopausal women. Specifically, the Q192 allele was associated with increased total and LDL-cholesterol concentrations. Furthermore, these lipoprotein variables were higher among postmenopausal women with Q192/Q192 and Q192/R192 genotypes than in premenopausal women with the same genotypes (p