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Introduccion y objetivo Evaluar las caracteristicas diferenciales del infarto agudo de miocardio en el paciente joven (menor de 45 anos) en relacion con el paciente de mayor edad. Pacientes y metodos Se han recogido las caracteristicas clinicas, retrasos en la asistencia, estrategias diagnosticas y terapeuticas y complicaciones de los pacientes ingresados con diagnostico de infarto agudo de miocardio entre los anos 1995 y 1999 en las unidades de cuidados intensivos de los 17 hospitales que participan en el registro PRIMVAC. Resultados Se han registrado 10.213 pacientes, de los cuales el 6,8% tenia una edad menor de 45 anos (691 pacientes). Los pacientes jovenes presentan una mayor prevalencia de tabaquismo (80,9 frente a 34,1%; p Conclusiones El infarto agudo de miocardio en el paciente joven presenta unas caracteristicas clinicas y un tratamiento diagnostico y terapeutico diferentes respecto al grupo de mayor edad, asi como un pronostico a corto plazo mas favorable.

Introduction and objectives There is little evidence on the prognostic influence of intravenous nitrates in patients with acute heart failure. Our purpose was to determine the influence of this treatment on early mortality and new visits. Methods Prospective, multicenter cohort study of patients with acute heart failure in an emergency room during 2 periods (May 2009 and November-December 2011). Patients with systolic blood pressure > 110 mmHg were included, grouped according to whether they received intravenous nitroglycerin or not. Endpoints were mortality at 3, 7, 14, and 30 days and new visits at 30 days. The propensity score was estimated by logistic regression to determine the prognostic influence of the treatment. Results We included 3178 of 4897 individuals. A total of 308 (9.7%) had died within 30 days and 465 (17%) attended new visits. The mean (standard deviation) age was 79.5 (10.0) years, and 796 (25%) patients received intravenous nitrates. After matching, there were 685 individuals in each group. The hazard ratio for 30-day mortality with nitrates was 1.21 (95% confidence interval, 0.87-1.70) and was 0.93 for new visits (95% confidence interval, 0.71-1.22). The results were similar for mortality at 3, 7, and 14 days (hazard ratio = 1.05 [95% confidence interval, 0.56-1.96], hazard ratio = 1.20 [95% confidence interval, 0.74-1.94], and hazard ratio = 1.23 [95% confidence interval, 0.82-1.84], respectively). In the presence of hypertensive pulmonary edema, the nitrates group showed a hazard ratio of 0.88 (95% confidence interval, 0.47-1.63) for 30-day mortality. Conclusions Intravenous nitrates do not influence early mortality or new visits in patients with acute heart failure.

Assessment of the characteristics of patients with Staphylococcus aureus (SA) infections, and factors associated with resistance to methicillin in a hospital emergency department (ED) in Spain.All adult patients admitted between January 2007 and December 2010 with a SA infection confirmed by a positive culture in a sample obtained in the hospital emergency department were selected for enrolment. Epidemiological, clinical, therapeutic and microbiological variables were retrospectively collected from the patients' medical charts. The variable assessed within the primary outcome of the study was the isolation of methicillin resistant Staphylococcus aureus (MRSA). For the purpose of the analysis, the sample was divided in terms of the presence or not of the resistance to methicillin and a logistic regression analysis was performed to identify the factors associated with isolation and empirical antibiotic coverage of MRSA.A total of 207 patients with a confirmed SA infection were included in the study analysis, with a mean age of 64.7 (SD 20) years. MRSA was isolated in a total of 63 (30.4%) patients, and a linear incremental trend was observed over the course of the study (p=0,047). MRSA was empirically covered in the emergency department on an average rate of one in three patients. Independent factors associated with the isolation of MRSA were: age above 65 years [OR 2.97 (95% CI 1.24 to 7.1), P = 0.014], severe baseline functional dependence [OR 2.41 (95 % 1.02 to 5.69), P = 0.045], chronic obstructive pulmonary disease [OR 4.83 (95% CI 1.88 to 12.42), P = 0.001], history of antibiotic treatment within the previous 2 months [OR 4.94 (95% CI 2.27 to 10.76), P0.001] and a confirmed urinary infection [OR 5.98 (95% CI 1.65 to 21.69) p = 0.007]. Independent factors associated with empiric coverage of MRSA in the ED were history of antibiotic treatment within the previous 2 months [OR 3.88 (95% CI 1.76 to 8.57), P0.001] and the presence of a catheter device [OR 6.28 (95% CI 1.64 to 24.07), P = 0.007].Resistance to methicillin appears to be increasingly frequent in patients infected with SA admitted in our emergency department and there appears to be a need for a more optimal empiric antibiotic treatment in these patients.

We aimed to determine the frequency of use and accessibility over time of electronic citations in Revista Española de Cardiología and 3 other Spanish biomedical journals, and to identify the factors that influence the accessibility and retrievability of these links.A cross-sectional, descriptive study was performed of all the references in articles published in the first issue of each even year from 2002 to 2012 in selected journals. Data were collected on the journal, publication, references, and links. The variables analyzed were the percentage of articles with at least 1 electronic citation, the percentage of electronic citations with respect to the total number of citations in the full sample, and the percentages of link accessibility and retrievability.We included 377 articles, of which 73 (19.4%; 95% confidence interval, 15.2%-23.5%) had at least 1 electronic citation, and a total of 7077 references, of which 164 (2.3%; 95% confidence interval, 2.0%-2.7%) were electronic citations. Revista Española de Cardiología had 17 (15.2%) and 38 (1.3%), respectively. Use of electronic citations significantly increased over time (linear tendency, P.001); 58 (35.4%; 95% confidence interval, 27.7%-43.0%), links were accessible, and information was retrieved in 55 cases (51.9%; 95% confidence interval, 41.9%-61.9%). Accessibility significantly decreased over time (linear tendency, P.001); 45 electronic citations (27.5%; 95% confidence interval, 20.3%-34.6%) had complete additional information. Retrievability was significantly associated with the amount of additional information (linear tendency, P.001).Electronic citations are increasingly used in some Spanish biomedical journals. Access to electronic citations is lost over time, and the probability of its retrieval is associated with the existence of additional information.

To determine prognostic role of NT-proBNP as predictor of 30 day-mortality and readmission in the elderly with acute heart failure (AHF) treated in Spanish Emergency Departments (EDs), and to analyse the confounding factors when the NT-proBNP value is interpreted.A multicentre and multi-purpose cohort study with prospective follow-up was conducted on all patients aged 65 years or older with AHF treated in Spanish EDs. The variables recorded include demographic characteristics, comorbidity, details of episode, and NT-proBNP value. The outcome variables were 30 day-mortality and readmission. An NT-proBNP ≥ 5,180 pg/ml was adopted as the cut-off limit. The statistical package SPSS 18.0 was used to analyse the data.A total of 585 patients were included, with a mean age of 80.4 (SD: 6.9) years old. The cut-off NT-proBNP ≥ 5,180 pg/ml was independently associated with a severely impaired glomerular filtration (30 ml/h) (P.001) and severe episode (NYHA II-IV) (P = .012). The NT-proBNP area under curve (AUC) for 30 day-mortality was 0.71 (CI 95%: 0.63-0.77; P.001) and for 30 day-readmission, was 0.50 (CI 95%: 0.45-0.56; P = .846). A multivariable analysis showed that the cut-off NT-proBNP ≥ 5,180 pg/ml was an independent factor associated with 30 day-mortality in the elderly with AHF attended in Spanish EDs.The NT-proBNP value is associated with short-term mortality in the elderly with AHF attended in the EDs independently of the presence of confounding factors, such as the severity of the episode and glomerular filtration reduction, but not with 30 day-readmission.

Patients older than 65 years are increasingly attended in the Emergency Department (ED). This means that internists working in ED are responsible for improving their geriatric training. The frail elders are the one who have the higher probability to suffer an adverse event. The detection of this profile is very important for making a decision in ED. A possible geriatric emergency model would be the one that screens frailty among all patients older than 65 years old in ED by nurses, and, in those triaged as of high risk, a geriatric assessment must be done by a geriatric trained doctor or nurse. All this information will be helpful for the final location and discharge follow-up plan.

Eventos adversos relacionados con la medicacionen los ancianos atendidos en urgenciasDrug-induced adverse events in elderly personspresenting to the emergency departmentSra. directora:Hemos leido con interes el articulo recientemente publicado ensu revista sobre los problemas relacionados con los farmacos enel servicio de urgencias de un hospital de Brasil, que documentoque casi un tercio de los pacientes atendidos eran a consecuen-cia del consumo de farmacos y que la principal razon fue lapolifarmacia

Kandis et al showed that mean platelet volume (MPV) is increased during acute heart failure (AHF) and predicts 30-day mortality in patients attended at the emergency department (ED).1 We have ascertained their hypothesis including all patients attended at …

OBJECTIVE: Ideally, discharges from the emergency department (ED) should be as safe as discharges after hospitalization. We have ascertained this hypothesis in patients with acute heart failure (AHF) directly discharged from EDs, analyzing their short-term outcome. PATIENTS AND METHODS: A prospective, cohort, multicentric, noninterventional study of consecutive patients with AHF who visited in 20 Spanish EDs was conducted. Patients were grouped according to whether discharge had been from the ED (maximum 24-h ED stay) or after hospitalization. We collected baseline and current AHF episode data. Short-term outcome (30-day mortality and revisit rates) of both groups was compared by univariate crude analysis and stratified by predicted risk of 30-day mortality as well as by logistic regression adjustment for the differences found between ED and hospital groups. RESULTS: A total of 1669 patients were analysed: 546 (32.7%) discharged from ED and 1123 (67.3%) after hospitalisation; 75 (4.5%) died and 420 (25.2%) revisited the ED. Crude 30-day mortality rates of ED and hospital discharges were 2.9 and 5.3%, respectively (odds ratio for ED discharge: 0.56; 95% confidence interval: 0.33-0.96), whereas 30-day revisit rates were 23.8 and 26.4% (odds ratio: 0.96; 95% confidence interval: 0.77-1.19). Stratified analysis according to predicted risk of mortality and multivariate analysis adjusted for the discrepancy in baseline and current AHF episode characteristics in ED and hospital discharges confirmed the lack of short-term outcome differences between the two groups. CONCLUSION: Direct ED discharge of patients with AHF after treatment and a short observation period is as safe as discharge after a longer time of inpatient hospitalization in general wards.

Objective: To estimate the health and economic impact of the reduction in mortality and cardiovascular hospitalizations, associated with correct diagnosis of cardiac transthyretin amyloidosis (ATTR-CM), from the Spanish National Health System (NHS) perspective. Methods: A costs and effects analysis were performed (probabilistic Markov model) with time horizons between 1 and 15 years, comparing the correct diagnosis of ATTR-CM versus the non-diagnosis. Transition probabilities were obtained from the ATTR-ACT study (placebo arm) and from the literature. Costs and healthcare resources were obtained from Spanish sources (euro 2019) and from a panel of Spanish clinical experts. Results: After 1, 5, 10 and 15 years, the diagnosis of ATTR-CM would generate a gain of 0.031 (95%CI 0.025; 0.038); 0.387 (95%CI 0.329; 0.435); 0.754 (95%CI 0.678; 0.781) and 0.944 (95%CI 0.905; 0.983) life years per patient, respectively, with savings of euro 212 (95%CI euro -632; 633), euro 2,289 (95%CI euro 2,250; 2,517), euro 2,859 (95%CI euro 2,584; 3,149) and euro 2,906 (95%CI euro 2,669; 3,450) per patient, respectively, versus the non-diagnosis. Conclusions: Just by correctly diagnosing ATTR-CM, years of life would be gained, cardiovascular hospitalizations would be avoided, and savings would be generated for the NHS, compared to the non-diagnosis of the disease.

Complexes of 6-amino-2-thiouracil (H2ATU) with the metal ions Ni(II), Co(II), Zn(II), Cd(II), Cu(I), Ag(I), and Hg(II) have been isolated and characterized by means of elemental analysis, infrared, NMR, and visible spectroscopies, and magnetic measurements. The crystal structure of [Zn(HATU)2(H2O)] • 2H2O has been solved by X-ray diffraction showing that the metal atom is five-coordinated by a water molecule and two ligands that bind through the sulphur and N1 atoms, closing a four-member chelate ring. Diffuse reflectance spectra and magnetic measurements suggest that [Co(HATU)2(H2O)] • 2H2O has a similar structure to that of the zinc complex, and that the nickel complexes [Ni(HATU)2] and [Ni(HATU)2(H2O)2] have, respectively, a tetrahedral and a D4h-distorted octahedral environment.

To determine the level of knowledge about possible disease outcomes and living wills among patients with heart failure (HF) treated in an emergency department and to evaluate their willingness to draw up a living will.This cross-sectional, multicenter, noninterventional, prospective study included a consecutive series of patients. Patients' demographic and clinical characteristics were recorded. Once their symptoms were under control, patients were interviewed about their knowledge of and opinions about HF. The dependent variables were a good objective understanding of the disease and a willingness to draw up a living will, and factors associated with these variables were investigated.The study included 309 patients: 79% considered themselves well-informed, 51.5% really were well-informed, 39.8% wanted more information, and 54.7% wanted to participate more in decision-making. In addition, 13.3% knew what living wills involved, 4.9% had received information about them from their doctor, and 28.8% agreed to draw one up. There was an independent association between being objectively well-informed and willingness to draw up a living will. Moreover, the former was associated with admission to intensive care, feeling well-informed, and having participated sufficiently in decision-making; the latter with age75 years, wanting more information, understanding what a living will involved, and the referral center.The knowledge possessed by HF patients about the natural history of their disease was suboptimal, as was their knowledge about living wills and their willingness to draw one up. Providing better information about these issues is an essential part of the doctor-patient relationship.

Demand in emergency care has been growing progressively in recent years and this increase is more pronounced in the elderly population. Taking into account that the elderly patient requires more complex evaluations with a greater requirement for complementary tests and consultations with other specialists, longer stays in the emergency ward and a greater percentage of admissions, the progressive ageing of the population might come to have a serious repercussion on hospital emergency departments. It is vital to detect high risk elderly patients before assigning them a definitive placement. For this purpose it is important to install a sieving process amongst elderly patients who attend the emergency department in order to select those that will benefit from a comprehensive geriatric assessment and thus be able to design a specific care plan. Emergency intervention in elderly patients should not be faced exclusively as a medical problem, but functional, mental or social aspects should be taken into account. This represents a challenge for emergency care. This article considers different aspects such as the detection and assessment of the geriatric patient, as well as establishing certain recommendations for emergency setting.

To investigate factors associated with short-term mortality in elderly patients seen in emergency departments for an episode of acute heart failure.A prospective, non-interventional, multicenter, cohort study was carried out in patients aged 65 years and older who were treated in the emergency department of one of eight tertiary hospitals in Spain. Twenty-eight independent variables that could influence mortality at 30 days were assessed. They covered epidemiological and clinical factors and daily functioning. Data were obtained by reviewing medical records or by interviewing the patient or a relative. Multivariate logistic regression analysis was performed.The study included 623 patients, 42 of whom (6.7%) died within 30 days of visiting the emergency department. Four variables were significantly associated with higher mortality: functional dependence at baseline (i.e., Barthel index=60; odds ratio [OR]=2.9; 95% confidence interval [CI], 1.2-6.5), New York Heart Association class III-IV (OR=3; 95% CI, 1.3-7), systolic blood pressure100 mmHg (OR=4.8; 95% CI, 1.6-14.5) and blood sodium135 mEq/l (OR=4.2; 95% CI, 1.8-9.6).Several factors evaluated on initial assessment in the emergency department, including the level of functional dependence, were found to determine a poor short-term prognosis in elderly patients who present with an episode of acute heart failure.

To evaluate the differences by sex in clinic presentation, diagnostic approach and initial treatment in patients with acute heart failure who are attended in emergency rooms.Prospective, evaluated, descriptive, transverse and multicentric study, which includes all patients attended by acute heart failure in emergency rooms of 10 Spanish centers between April 15th and May 15th, 2007 (n=944). Data were recorded regarding socio-demographic, comorbidity, previous heart disease, complementary explorations, previous home treatment, and therapeutic measurements in emergency.Regarding men, women (n=501; 53%) were older (79+/-9 and 75+/-10, P.001), and had more hypertension (83,4% vs 74,9%, P.01), valvular heart disease (23,1% vs 17,8%, P.05) and obesity (21,9% vs 15,6%, P.05); however, they also had less prevalence of coronary heart disease (26,5% vs 43,3%, P=.001) and smoking (4,4 % vs 18,7%, P.001). According to outpatient treatment, women were less likely to be treated with beta blockers (19,6% vs 30,2%, P.001) and antithrombotics (34,1% vs 41,3%, P.05). Treatment administered in the emergency was similar in both groups, yet women received more frequently digoxin (25,7% vs 17,4%, P.01). Moreover, women were admitted to the cardiology department less often (8,0% vs 13,8%, P.01).In emergency, the diagnostic and therapeutic approach is very similar in both sexes and the most cases, differences can be justified due to the different patients' profile and the ambulatory handling before their consultation to emergency.