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Resumen Introduccion y objetivos Las redes de tratamiento del infarto agudo de miocardio con elevacion del segmento ST (IAMCEST) han incrementado la tasa de reperfusion y reducido los tiempos de isquemia. Nuestro objetivo fue analizar la diferencia en el pronostico entre generos en pacientes con un primer IAMCEST. Metodos Se realizo un estudio de cohorte multicentrico de pacientes con primer IAMCEST durante 2010-2016 para determinar el efecto del genero/sexo ajustado sobre la mortalidad, la combinacion de mortalidad, fibrilacion ventricular, shock cardiogenico o edema agudo de pulmon a 30 dias, y sobre la mortalidad al ano. Resultados Entre 2010 y 2016 se incluyeron 14.690 pacientes, un 24% fueron mujeres. En el periodo de estudio, la mediana [rango intercuartilico] de tiempo entre electrocardiograma y apertura de arteria descendio en ambos sexos (119 min [85-160] frente a 109 min [80-153] en 2010 en mujeres, y 102 min [81-133] frente a 96 min [74-124] en 2016 en mujeres, ambos valores p = 0,001). En el mismo periodo, el porcentaje de angioplastia primaria en Conclusiones Las mujeres con un primer IAMCEST presentan un porcentaje de muerte o complicaciones al mes similar a la de los varones y, en cambio, menos mortalidad al ano tras ajustar por edad y gravedad.

Introduction and objectives: ST-segment elevation myocardial infarction (STEMI) emergency care networks aim to increase reperfusion rates and reduce ischemic times. The influence of sex on prognosis is still being debated. Our objective was to analyze prognosis according to sex after a first STEMI. Methods: This multicenter cohort study enrolled first STEMI patients from 2010 to 2016 to determine the influence of sex after adjustment for revascularization delays, age, and comorbidities. End points were 30-day mortality, the 30-day composite of mortality, ventricular fibrillation, pulmonary edema, or cardiogenic shock, and 1-year all-cause mortality. Results: From 2010 to 2016, 14 690 patients were included; 24% were women. The median [interquartile range] time from electrocardiogram to artery opening decreased throughout the study period in both sexes (119 minutes [85-160] vs 109 minutes [80-153] in 2010, 102 minutes [81-133] vs 96 minutes [74124] in 2016, both P = .001). The rates of primary PCI within 120 minutes increased in the same period (50.4% vs 57.9% and 67.1% vs 72.1%, respectively; both P = .001). After adjustment for confounders, female sex was not associated with 30-day complications (OR, 1.06; 95%CI, 0.91-1.22). However, female 30-day survivors had a lower adjusted 1-year mortality than their male counterparts (HR,0.76; 95%CI, 0.61-0.95). Conclusions: Compared with men, women with a first STEMI had similar 30-day mortality and complication rates but significantly lower 1-year mortality after adjustment for age and severity. (C) 2020 Sociedad Espanola de Cardiologia. Published by Elsevier Espana, S.L.U. All rights reserved.U

The IFFANIAM study (Impact of frailty and functional status in elderly patients with ST segment elevation myocardial infarction undergoing primary angioplasty) is an observational multicenter registry to assess the impact of frailty and functional status on outcomes of elderly patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary angioplasty. STEMI patients age 75 years or older undergoing primary angioplasty will be extensively studied during admission in 4 tertiary care Hospitals in Spain, assessing their baseline functional status (Barthel index, Lawton-Brody index), frailty (Fried criteria, FRAIL scale [fatigue, resistance, ambulation, illnesses, and loss of weight]), comorbidities (Charlson index), nutritional status (Mini Nutritional Assessment–Short Form), and quality of life (Seattle Angina Questionnaire). Participants will be managed according current recommendations. The primary outcome will be the description of 1-year mortality, its causes, and associated factors. Secondary outcomes will be functional capacity and quality of life. Results will help to better understand the impact of frailty and functional ability on outcomes in elderly STEMI patients undergoing primary angioplasty, thus potentially contributing to improving their clinical management. Higher life expectancy has resulted in a large segment of elderly population and an increase in myocardial infarction in these patients. This calls attention to healthcare systems to focus on promoting methods to improve the clinical management of this population.

Resumen Introduccion y objetivos Los supervivientes a una muerte subita extrahospitalaria constituyen un grupo de pacientes cada vez mas numeroso en las unidades de cuidados intensivos cardiologicos. Nuestro objetivo es caracterizar a estos pacientes y determinar su pronostico vital y funcional desde una perspectiva actualizada. Metodos Registro prospectivo multicentrico de los pacientes ingresados en cinco unidades de cuidados intensivos cardiologicos con el diagnostico de muerte subita extrahospitalaria recuperada entre enero de 2010 y enero de 2012. Se registraron datos clinicos, caracteristicas de la parada cardiaca, curso hospitalario, asi como el estado vital y la situacion neurologica al alta y a los 6 meses. Resultados Se incluyo a 204 pacientes. En un 64% de los casos se identifico un primer ritmo desfibrilable. El tiempo hasta la recuperacion de la circulacion espontanea fue de 29 ± 18 min. En un 86% se llego a un diagnostico etiologico. Un 44% de los pacientes fue dado de alta sin secuelas neurologicas, mientras que el 40% murio en la fase hospitalaria. A los 6 meses, el 79% de los supervivientes al alta permanecian vivos y neurologicamente indemnes o con minimas secuelas. Un tiempo corto de reanimacion, un primer ritmo desfibrilable, un pH al ingreso > 7,1, la ausencia de shock y la aplicacion de hipotermia son las variables independientes asociadas a un buen pronostico neurologico. Conclusiones La mitad de los pacientes recuperados de una muerte subita extrahospitalaria tenian buen pronostico neurologico al alta. Un 79% de los supervivientes permanecian vivos y neurologicamente indemnes a los 6 meses de seguimiento.

Objectives To evaluate the cost-effectiveness of the ST-segment elevation myocardial infarction (STEMI) network of Catalonia ( Codi Infart ). Design Cost-utility analysis. Setting The analysis was from the Catalonian Autonomous Community in Spain, with a population of about 7.5 million people. Participants Patients with STEMI treated within the autonomous community of Catalonia (Spain) included in the IAM CAT II-IV and Codi Infart registries. Outcome measures Costs included hospitalisation, procedures and additional personnel and were obtained according to the reperfusion strategy. Clinical outcomes were defined as 30-day avoided mortality and quality-adjusted life-years (QALYs), before (N=356) and after network implementation (N=2140). Results A substitution effect and a technology effect were observed; aggregate costs increased by 2.6%. The substitution effect resulted from increased use of primary coronary angioplasty, a relatively expensive procedure and a decrease in fibrinolysis. Primary coronary angioplasty increased from 31% to 89% with the network, and fibrinolysis decreased from 37% to 3%. Rescue coronary angioplasty declined from 11% to 4%, and no reperfusion from 21% to 4%. The technological effect was related to improvements in the percutaneous coronary intervention procedure that increased efficiency, reducing the average length of the hospital stay. Mean costs per patient decreased from €8306 to €7874 for patients with primary coronary angioplasty. Clinical outcomes in patients treated with primary coronary angioplasty did not change significantly, although 30-day mortality decreased from 7.5% to 5.6%. The incremental cost-effectiveness ratio resulted in an extra cost of €4355 per life saved (30-day mortality) and €495 per QALY. Below a cost threshold of €30 000, results were sensitive to variations in costs and outcomes. Conclusions The Catalan STEMI network ( Codi Infart ) is cost-efficient. Further studies are needed in geopolitical different scenarios.

In primary angioplasty, the interval between first medical contact (FMC) and reperfusion should be less than 120 minutes. The time to reperfusion varies depending on where FMC is established. Recent studies suggest longer times in patients presenting in off-hours. The objective is to evaluate the time intervals between the onset of symptoms and reperfusion according to where the FMC occurs and time of day of patient presentation.Prospective observational study of acute myocardial infarction patients treated with primary angioplasty (February 2007 to May 2009). Depending on the FMC, patients were classified as belonging to the hospital group (hospital with primary angioplasty), the transfer group (hospital without primary angioplasty), or the emergency medical system (EMS) group (out-of-hospital care). For each group, the prehospital delay, diagnostic delay, delay in activation and/or transfer, and procedure delay were recorded.Primary angioplasty was performed in 457 patients: 155 in the hospital group, 228 in the transfer group and 72 in the EMS group. The median [interquartile range] door-to-reperfusion times were 80 [63-107], 148 [118-189] and 81 [66-98] minutes, respectively (P.0001). The transfer group showed a greater delay in diagnosis (P.0001) and delayed activation and/or transfer (P.0001). The EMS group had the shortest total time due to a reduced prehospital delay (P=.001). No difference was found with regard to the time of presentation (P=.42).Transfer group patients were treated later and EMS group patients much earlier. There were no differences in association with the time of presentation. The identification of inappropriate delays should enable the introduction of measures to improve the efficiency of treatment.

Introduction and objectives: In primary angioplasty, the interval between first medical contact (FMC) and reperfusion should be less than 120 minutes. The time to reperfusion varies depending on where FMC is established. Recent studies suggest longer times in patients presenting in off-hours. The objective is to evaluate the time intervals between the onset of symptoms and reperfusion according to where the FMC occurs and time of day of patient presentation. Methods: Prospective observational study of acute myocardial infarction patients treated with primary angioplasty (February 2007 to May 2009). Depending on the FMC, patients were classified as belonging to the hospital group (hospital with primary angioplasty), the transfer group (hospital without primary angioplasty), or the emergency medical system (EMS) group (out-of-hospital care). For each group, the prehospital delay, diagnostic delay, delay in activation and/or transfer, and procedure delay were recorded. Results: Primary angioplasty was performed in 457 patients: 155 in the hospital group, 228 in the transfer group and 72 in the EMS group. The median [interquartile range] door-to-reperfusion times were 80 [63-107], 148 [118-189] and 81 [66-98] minutes, respectively (P < .0001). The transfer group showed a greater delay in diagnosis (P < .0001) and delayed activation and/or transfer (P < .0001). The EMS group had the shortest total time due to a reduced prehospital delay (P = .001). No difference was found with regard to the time of presentation (P = .42).

Resumen El Codigo Infarto de Cataluna se inicio en junio de 2009 con el fin de implantar el tratamiento de reperfusion en red, basado en la intervencion coronaria percutanea primaria, a los pacientes con infarto de miocardio y elevacion del segmento ST, siguiendo las recomendaciones de las Guias de la Sociedad Europea de Cardiologia. El protocolo, unico para toda Cataluna, fue impulsado por la Sociedad Catalana de Cardiologia y fue desarrollado conjuntamente con el Departamento de Salud, el CatSalut y el Servicio de Emergencias Medicas (SEM). El protocolo de actuacion se basa en la sectorizacion de Cataluna alrededor de cinco centros con atencion permanente, la participacion de otros cinco centros con intervencionismo durante su horario laboral y la activa participacion del SEM, que realiza el diagnostico de infarto, decide el tipo de tratamiento en funcion de las isocronas, realiza el traslado del paciente directamente a las salas de hemodinamica y asegura su retorno a la unidad coronaria mas proxima al domicilio del paciente. Otros aspectos importantes son la obligatoriedad de aceptar a los pacientes por parte de los hospitales, tanto en el traslado primario como en el retorno, y de realizar un registro por internet de los datos de todos los pacientes atendidos. Desde el inicio del programa, el numero de intervenciones coronarias percutaneas primarias se ha duplicado, con una media de 250 al mes, y los tiempos de actuacion se han reducido entre un 20 y un 40%, especialmente entre los pacientes atendidos inicialmente por el SEM.

La terapia de reperfusion ha supuesto un notable descenso de la morbimortalidad hospitalaria y a largo plazo de los pacientes con infarto agudo de miocardio. En los ultimos anos, se ha demostrado que la angioplastia es mas eficaz que la fibrinolisis siempre que se realice en un intervalo de tiempo adecuado. Sin embargo, la angioplastia primaria no es el tratamiento mayoritariamente utilizado debido a que requiere una infraestructura adecuada y una organizacion muy eficiente. Para incrementar el uso de la angioplastia primaria y homogeneizar el tratamiento de los pacientes con infarto agudo de miocardio hemos revisado las principales barreras del circuito de la angioplastia primaria. Se describen diferentes estrategias que permiten acortar el tiempo puerta-balon y distintos programas de caracter nacional, regional y local que han facilitado el acceso a la angioplastia primaria y han mejorado los tiempos de reperfusion.

Se calcula que en 2025 existiran en el mundo 300 millones de diabeticos, de los que el 90% tendra diabetes mellitus tipo 2 (DM2). La prevalencia de la DM2 en la poblacion adulta oscila entre el 0,7 y el 34% en funcion del area geografica estudiada: un 6-15% en los paises desarrollados y un 5,6-18,7% en Espana1. Su incidencia en los paises europeos es de 1,2-4,1 casos/1.000 habitantes/ano, y en un estudio realizado en nuestro pais fue de 0,8 casos/1.000 habitantes/ano1. Un dato destacable es que en todos los estudios epidemiologicos realizados sobre la DM2 (independientemente del criterio diagnostico empleado) entre el 30 y el 50% de los pacientes desconocen que tienen la enfermedad. Los diabeticos tipo 2 tienen 2-3 veces mas riesgo de enfermedades cardiovasculares que los no diabeticos. Alrededor del 70% de los pacientes con DM2 fallecen como consecuencia de complicaciones macrovasculares, especialmente la cardiopatia isquemica y la enfermedad cerebrovascular. Aproximadamente el 20% de los diabeticos tipo 2 ya presentan complicaciones vasculares en el momento del diagnostico. La estrecha relacion entre DM2 y riesgo coronario quedo bien reflejada en un estudio de Haffner et al2, publicado en 1998, en el que compararon la mortalidad de causa coronaria entre 1.059 sujetos con DM2 y 1.373 no diabeticos. Tras 7 anos de seguimiento, los pacientes con DM2 sin infarto de miocardio previo tenian una mortalidad similar a la de los no diabeticos con infarto previo. Aunque posteriormente algunos trabajos mostraran resultados discordantes, el impacto de ese estudio fue tan importante que sirvio de base para que la DM2 se considerase como equivalente de enferRelevancia de la hiperglucemia en el sindrome coronario agudo

It is thought that in 2025 there will be some 300 million diabetics worldwide, of whom some 90% will have diabetes mellitus type 2 (DM2). The prevalence of DM2 in the adult population varies from 0.7% to 34% depending on the area in question (eg, it is some 6%-15% in most developed countries and in Spain ranges from 5.6% to 18.7%).1 Its incidence in European countries is 1.24-4.1 cases per 1000 inhabitants/year; in a Spanish study it was reported as 0.8 cases/1000 inhabitants/year.1 A remarkable fact is that in all the epidemiological studies performed on DM2 (independent of the diagnostic criteria used), some 30%-50% of people did not realize they had the disease. People with DM2 have a 2-3 times greater risk of developing cardiovascular disease than non-diabetics, and about 70% die from macrovascular complications, especially ischemic heart disease and cerebrovascular disease. Approximately 20% of DM2 sufferers already have vascular complications at the time of diagnosis. The strong relationship between DM2 and coronary disease risk is well reflected in a study by Haffner et al (1998)2 in which these authors compare mortality of coronary cause in 1059 patients with DM2 and 1373 nondiabetics. After 7 years of follow-up the patients with DM2 who had not suffered a prior myocardial infarction had a mortality rate similar to the non-diabetics who had suffered a prior myocardial infarction. Although later works provided discrepant data, the impact of this study The Significance of Hyperglycemia in Acute Coronary Syndrome

a Cardiology Department, Hospital Clinic, IDIBAPS, University of Barcelona, Spain b Subdireccio de Planificacio Sanitaria, Direccion General de Planificacio i Recerca en Salut, Health Department, Autonomous Government of Catalonia, Barcelona, Spain c HELIS Partners Consulting, Prague, Czech Republic d Stent for Life Initiative, Czech Republic e STEMI Code Registry Office, Departament de Salut, Generalitat de Catalunya, Barcelona, Spain f Master Plan of Cardiovascular Diseases, Health Department, Autonomous Government of Catalonia, Barcelona, Spain

Initial thrombolysis in myocardial infarction (TIMI) flow and mortality are related in ST-elevation myocardial infarction (STEMI) patients treated with primary angioplasty (PPCI). It is unclear whether early adjunctive treatment with unfractionated heparin (UFH) is beneficial for coronary patency. We investigated the effect of UFH administered before transfer versus in the catheterization laboratory (CathLab) on initial patency of the infarct related artery (IRA) in transferred STEMI patients treated with PPCI.Consecutive STEMI patients (n=1326, February 2007-December 2013) were allocated in two groups relative to UFH administration: pre-transfer group - administration by ambulance crew or physician-in-charge at the non-PPCI centre, 758 patients (57%); post-transfer group - administration in the CathLab, 568 patients (43%). The time range between symptom onset (SO) and UFH administration (SO-UFH) was assessed and the 1-year mortality prediction was analysed by logistic regression. Initial IRA TIMI 2-3 flow was 30.3% in pre-transfer group vs. 21.2% in post-transfer group (p0.001). A time-dependent association was found between SO-UFH and initial TIMI 2-3 in pre- vs. post-transfer groups [120 min: 33.2% vs. 18%, p0.001; 120-240 min: 29.2% vs. 22.8%, p=0.18;240 min: 25% vs. 28%, p=0.57]. No differences in major bleeding were found between groups. UFH administration before transfer remained an independent predictor for initial TIMI 2-3 flow (OR 1.60 CI 95% 1.22-2.11, p=0.01) and for 1-year mortality (OR 0.51 CI 95% 0.29-0.91, p=0.02).Early UFH administration in STEMI patients transferred for PPCI results in higher IRA initial patency in a time-dependent manner and improves clinical outcomes.

Introduccion y objetivos En la estratificacion del syndrome coronario agudo disponemos de variables clinicas para identificar a los pacientes con alto riesgo de presentar complicaciones. Analizamos si los pacientes de alto riesgo, sin antecedentes de cardiopatia isquemica, que presentan un primer episodio de sindrome coronario agudo sin elevacion del segmento ST presentan variables clinicas predictoras de estenosis significativa (> 50%) del tronco comun. Metodos Se analizo a 102 pacientes de alto riesgo sin antecedentes de cardiopatia isquemica con sindrome coronario agudo sin elevacion del segmento ST, a los que se les practico coronariografia. Establecemos 2 grupos: con estenosis significativa del tronco comun (n = 14) y el resto (n = 88). Resultados Variables relacionadas con la estenosis del tronco comun en el analisis univariado: edad > 65 anos (el 57,1 frente al 15,9%; p = 0,002), diabetes mellitus (el 71,4 frente al 33,0%; p = 0,006), insuficiencia renal cronica (el 28,6 frente al 5,7%; p = 0,019), insuficiencia cardiaca izquierda (el 71,4 frente al 6,8%; p Conclusiones La presencia de insuficiencia cardiaca izquierda en la evaluacion inicial del sindrome coronario agudo sin elevacion del ST, en pacientes de alto riesgo sin antecedentes de cardiopatia isquemica, puede ser un predictor util de enfermedad del tronco comun.

En los ultimos anos se ha producido un notable avance en el tratamiento de las enfermedades cardiovasculares y, mas especificamente, en el caso de las diferentes entidades clinicas que constituyen lo que ahora conocemos como sindrome coronario agudo. Un punto clave e imprescindible en el tratamiento de nuestros pacientes ha sido la implantacion del concepto de medicina basada en la evidencia (MBE), utilizado y reconocido de forma universal como el mejor metodo clinico para demostrar la eficacia de cualquier tratamiento. La MBE se ha definido como la utilizacion consistente y juiciosa de la mejor evidencia derivada de la investigacion clinica para la toma de decisiones en la atencion individualizada de los pacientes, entendiendo por evidencia lo que esta comprobado o verificado. De un modo mas simple, se trata de aplicar las intervenciones medicas mas eficaces para maximizar la calidad y la cantidad de vida de los pacientes. No hay duda de que el ensayo clinico aleatorizado es realmente la evidencia cientifica mas solida de que disponemos en lo que se refiere a la eficacia de una intervencion terapeutica. Cuando no se dispone de ensayos clinicos concluyentes, el nivel de la evidencia se reduce de manera progresiva. En estos casos, utilizamos la informacion disponible, generalmente metaanalisis (analisis estadistico que combina los resultados de diferentes ensayos clinicos independientes pero generalmente de tamano muestral reducido que son considerados «combinables») o estudios observacionales, entre los que destacan los registros. Los registros, en cuanto se refieren al tratamiento administrado, son estudios de efectividad, no de eficacia como los ensayos clinicos, y valoran el efecto de dicho tratamiento en la vida real. De los ensayos clinicos a los registros: el registro PRIAMHO II

Introduction and objectives. Risk stratification in nonST-elevation acute coronary syndrome makes use of clinical variables that can identify patients at an increased risk of complications. Our objective was to identify clinical variables that predict significant stenosis (i.e., >50%) of the left main coronary artery in high-risk patients who have had a first episode of non-ST-elevation acute coronary syndrome but who do not have a history of coronary artery disease. Methods. The study included 102 high-risk patients with no history of coronary artery disease who were admitted because of non-ST-elevation acute coronary syndrome. All underwent coronary angiography. Patients were divided into 2 groups: those with significant left main coronary artery stenosis (n=14) and those without (n=88). Results. Univariate analysis showed that the variables significantly associated with left main coronary artery stenosis were age >65 years (57.1% vs 15.9%; P=.002), diabetes mellitus (71.4% vs 33.0%; P=.006), chronic renal failure (28.6% vs 5.7%; P=.019), left heart failure (71.4% vs 6.8%; P

Introduccion y objetivos El objetivo de nuestro estudio es determinar la duracion del bloqueo auriculoventricular completo (BAVC) en el transcurso de un infarto agudo de miocardio (IAM) de localizacion inferior tras la administracion de tratamiento fibrinolitico. Pacientes y metodo Entre el 1 de enero de 1992 y el 31 de enero de 2002 consultaron en primera instancia en nuestro centro 449 pacientes con IAM de localizacion inferior en las primeras 6 h de evolucion. El 64% (282 pacientes) recibio fibrinolisis. En este grupo, 39 (13,8%) pacientes presentaron BAVC (grupo A). En los 167 pacientes no tratados con trombolisis, 13 (8%) casos presentaron BAVC (grupo control). Se comparan ambos grupos y se analizan la duracion y presentacion del bloqueo, la repercusion hemodinamica y la conducta terapeutica seguida. Resultados En el 38% de los pacientes del grupo A habia BAVC en el momento del ingreso frente al 61% de los del grupo control (p = NS). La duracion mediana del bloqueo fue de 75 min (10 min-48 h) en el grupo A y de 24 h (15 min-9 dias) (p = 0,004) en el grupo control. Una vez realizada la fibrinolisis, el BAVC tuvo una duracion mediana de 45 min (5 min-48 h). Se implanto un marcapasos provisional en 17 pacientes del grupo A (43%) y en 11 del grupo control (84,6%) (p = 0,01). Conclusion El BAVC en el IAM de localizacion inferior aparece precozmente. La duracion del bloqueo parece ser menor al realizar la fibrinolisis.

Introduccion y objetivo Los marcapasos temporales (MT) permiten el tratamiento urgente de pacientes con bradiarritmias severas. Se los utiliza en las situaciones urgentes y con frecuencia en ancianos con estado general deteriorado, inestabilidad hemodinamica y escasa colaboracion. El objetivo es revisar los MT implantados en nuestro centro en los ultimos 6 anos y analizar sus indicaciones, incidencia y tipo de complicaciones. Pacientes y metodo Se han analizado las variables clinicas significativas, la indicacion, la via de acceso, el seguimiento, las complicaciones y los dias de mantenimiento del MT. Resultados Se implanto un total de 568 MT y se pudo revisar 530 casos (edad, 74,8 ± 11 anos). Las indicaciones para su implantacion fueron: bloqueo auriculoventricular sintomatico (51%) y profilactico por recambio de generador (14,7%), bloqueo en la fase aguda del infarto (12,6%), bradiarritmia por intoxicacion medicamentosa (12,2%), enfermedad del nodo sinusal (7,5%) e intervalo QT largo o taquicardia ventricular (2,5%). Se colocaron por la vena femoral en el 99% de los casos. La duracion del MT fue de 4,2 dias (rango, 1-31 dias). Requirieron un marcapasos definitivo 369 pacientes (69,6%). En cuanto a las complicaciones, se produjo el fallecimiento de 34 pacientes (6,4%), aunque solo en 3 fue atribuible al MT. En 98 pacientes (18,5%) se observaron otras complicaciones severas, entre ellas, disfuncion del MT en 48 pacientes (9%) por movilizacion del electrocateter. Conclusiones Los MT se emplean con frecuencia en ancianos con bradiarritmia extrema y, en ocasiones, infarto agudo de miocardio. Las complicaciones graves son frecuentes (22%) y se puede producir desde un hematoma femoral hasta un taponamiento cardiaco o incluso la muerte (6%). En un 9% de los casos, el electrodo debe ser recolocado por fallo del sensado o de la captura ventricular.

Introduction and objectives. The presence of postanoxic encephalopathy after an episode of aborted sudden cardiac death is a serious medical and social problem. Pacientes and method. Of 193 patients admitted to the coronary unit during a 12-year period with aborted sudden cardiac death, 104 died (54%) and 89 survived the episode (46%). We compared the characteristics and 6-month prognosis between survivors according to the presence or absence of post-anoxic encephalopathy. Results. Of 89 survivors, 38 patients were discharged alive with post-anoxic encephalopathy (42%) and 51 were discharged without neurological disturbances (58%). Patients with post-anoxic encephalopathy were older (65 ± 13.6 vs. 59 ± 12.9 years; p = 0.04). Mean time to care for cardiac arrest was 11.1±4.9 min in the post-anoxic encephalopathy group, versus 3.4±3 min (p < 0.01). The first documented rhythm was VF/VT in 57% and asystolia in 29% in the post-anoxic encephalopathy group, vs. 88% and 3% (p = 0.02). More than half (58%) of the patients in the postanoxic encephalopathy group had coronary artery disease, vs. 49% (p = NS). Slightly more than half (52%) of the patients in the post-anoxic encephalopathy group had infectious complications, vs. 21% (p = 0.01). After 6 months of follow-up, mortality in patients discharged with postanoxic encephalopathy was 62%, vs. 10% (p < 0.01); 21% of then showed significant functional improvement and 18% remained neurologically stable. Conclusions. Most patients admitted to a coronary unit with aborted sudden cardiac death died during hospitalization. Almost half of the survivors had post-anoxic encephalopathy at discharge; of these patients, 62% died within the following 6 months, and functional status improved only in a minority of them.

Autopsy studies show that dynamic coronary thrombosis leads to infarction. We studied intracoronary thrombus age in ST-segment elevation myocardial infarction (STEMI) and its relationship with clinical presentation and epicardial reperfusion grade.Intracoronary thrombectomy was performed in 131 STEMI patients within 24 h after symptom onset, and material sufficient for pathological analysis was retrieved from 81 patients. Thrombus age was classified as fresh (1day), lytic (1 to 5 days), or organized (5days). A fresh thrombus was found in 48 patients (60%), whereas the thrombus showed lytic or organized changes in 33 patients (40%). Both thrombus and plaque material were aspirated in 40% of cases. Lytic or organized thrombi were aspirated in one third of the cases early (12h) after symptom onset, and fresh thrombi were also aspirated in one third of STEMI of12h evolution. In multivariable analysis, fresh thrombus was associated with both persistent ST-segment elevation (even after 12 h of onset) during percutaneous coronary intervention [odds ratio (OR) 4.23, 95% confidence interval (CI) 1.05-17.42, P=.042) and a previous history of ischemic heart disease (OR 4.54, 95% CI 1.41-14.64, P=.011). There were no associations between thrombus composition and epicardial reperfusion grade or the presence of the no-reflow phenomenon. Plaque components were found in all cases of distal embolization (5%).Intracoronary thrombi aspirated in STEMI frequently show more than one stage of maturation. Fresh thrombi predominate in patients with known ischemic heart disease or persistent ST-segment elevation.In STEMI, thromboaspiration revealed thrombi at different stages of maturation, supporting a dynamic process of rupture and repair of the atherosclerotic plaque. Fresh thrombi were present more frequently within 12 h of infarction onset but also in patients with symptoms beyond 12 h. When containing plaque material, thrombi were often associated with macroscopic distal embolization during angioplasty.

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.

In recent years there has been marked progress in thetreatment of cardiovascular disease and, morespecifically, in the case of the different clinical entitiesthat are currently known as acute coronary syndrome. Akey, and indispensable, factor in treating our patients hasbeen the implementation of the concept of evidence-based medicine (EBM), used and recognized universallyas the best clinical method for demonstrating theefficacy of any treatment. Evidence-based medicine hasbeen defined as the consistent and sensible use of thebest evidence derived from clinical research on makingdecisions regarding individualized patient care, taking“evidence” to mean that which is verified or confirmed.More simply, this involves applying the most effectivemedical treatments to maximize the quality and quantityof life of the patients.It is clear that randomized clinical trials provide themost robust scientific evidence we have regarding the efficacy of a therapeutic intervention. Whenconclusive clinical trials are unavailable, the level ofevidence progressively decreases. In these cases, weuse the information available, usually a metaanalysis(a statistical analysis that combines the results ofdifferent independent clinical trials, usually consistingof small samples, that are considered “combinable”) orobservational studies, especially registries. Inasmuchas they refer to the treatment administered, registriesare studies of effectiveness rather than efficacy, likeclinical trials, and they assess the effect of suchtreatment in real life.There are several acute myocardial infarction (AMI)registries in Spain. The scope and duration of registriesare different, making it possible to quite precisely

A great variety of cardiac disorders have been reported in HIV-infected patients: pericarditis, myocarditis, cardiomyopathies, endocarditis, cardiac involvement through malignancies, pulmonary hypertension, arrhythmias and thromboembolic disease. In general, these disorders are asymptomatic and often diagnosed in echocardiographic studies or autopsies. Pericardial involvement is the most common disorder. Pericardial effusions are asymptomatic and non-specific in a great proportion, but in some instances opportunistic infections or malignancies may lead to cardiac tamponade and are associated with an increased risk of mortality. The etiopathogenesis of myocarditis and cardiomyopathies is uncertain. There is controversy about the role of HIV as the primary etiologic agent. Opportunistic infections, cardiotoxic substances, nutritional deficiencies and autoimmune reactions have also been implicated as etiologic agents of myocardial damage. Short-term prognosis worsens as clinical manifestations of heart failure appear. Valvular involvement usually presents as marantic or infectious endocarditis, the latter most frequently in IVDU. This article reviews the main cardiovascular manifestations in AIDS.

Introduction and objectives: Survivors of out-of-hospital cardiac arrest constitute an increasing patient population in cardiac intensive care units. Our aim was to characterize these patients and determine their vital and functional prognosis in accordance with the latest evidence. Methods: A multicenter, prospective register was constructed with information from patients admitted to 5 cardiac intensive care units from January 2010 through January 2012 with a diagnosis of resuscitated out-of-hospital cardiac arrest. The information included clinical status, cardiac arrest characteristics, in-hospital course, and vital and neurologic status at discharge and at 6 months. Results: A total of 204 patients were included. In 64% of cases, a first shockable rhythm was identified. The time to return of spontaneous circulation was 29 (18) min. An etiologic diagnosis was made in 86% of patients; 44% were discharged with no neurologic sequelae; 40% died in the hospital. At 6 months, 79% of survivors at discharge were still alive and neurologically intact with minimal sequelae. Short resuscitation time, first recorded rhythm, pH on admission >7.1, absence of shock, and use of hypothermia were the independent variables associated with a good neurologic prognosis. Conclusions: Half the patients who recovered from out-of-hospital cardiac arrest had good neurologic prognosis at discharge, and 79% of survivors were alive and neurologically intact after 6 months of follow-up. (C) 2013 Sociedad Espanola de Cardiologia. Published by Elsevier Espana, S. L. All rights reserved.

Introduction and objectives The aim of this study was to determine the duration of complete atrioventricular block complicating inferior wall acute myocardial infarction after the administration of fibrinolytic therapy. Patients and Method From 1 January 1992 to 31 January 2002 a total of 449 patients were admitted directly to our hospital with inferior wall acute myocardial infarction in the first 6 hours; 282 of them (64%) received fibrinolytic therapy. Complete atrioventricular block appeared in 39 of these 282 patients (13.8%, group A). Of the 167 patients who did not receive thrombolytic therapy, complete atrioventricular block appeared in 13 (8%, control group). We compared the two groups by analyzing the duration of heart block, time to appearance, hemodynamic repercussion, and treatment required. Results On admission, 38% of the patients in group A and 61% (P=NS) of those in the control group had complete atrioventricular block. Median duration of the block was 75 minutes (10 minutes to 48 hours) in group A and 24 hours (15 minutes to 9 days) in the control group (P=.004). After fibrinolytic therapy was administered, median duration of the block was 45 minutes (5 minutes to 48 hours). A temporary pacemaker was implanted in 43% of the group A patients and 84.6% of the control group patients (P=.01). Conclusion Complete atrioventricular block appears as a complication of inferior myocardial infarction within the first hours after the event. Duration of the block seems to be shorter in patients treated with fibrinolytic therapy.

Introduction and objective. Temporary pacemakers (TP) are used in the emergency treatment of patients with severe bradyarrhythmia. They are often used in emergency situations and for older patients in poor general condition who are hemodynamically unstable and uncooperative. The aim of this study was to review and analyze the indications, incidence, and type of complications associated with TP implanted in our center during a 6-year period. Patients and method. We analyzed significant clinical variables, indication, route of insertion, follow-up, complications, and duration of temporary pacing. Results. A total of 568 TP were implanted, and 530 cases were available for review (mean age 74.8 [11] years). The main indications were symptomatic complete AV block (51%), prophylaxis for replacement with a definitive pacemaker (14.7%), blockage in the acute phase of myocardial infarction (12.6%), bradyarrhythmia due to drug intoxication (12.2%), symptomatic sick sinus syndrome (7.5%), and long QT interval or ventricular tachycardia (2.5%). The route of insertion was via the femoral vein in 99% of the cases. The duration of TP use was 4.2 days (range, 1 to 31 days). A total of 369 patients (69.6%) required a permanent pacemaker. Complications: 34 patients died (6.4%), but only 3 deaths were attributable to TP implantation. Other severe complications were seen in 98 patients (18.5%). Malfunction of the TP occurred in 48 patients (9%) because of electrode displacement. Conclusions. Temporary pacemakers are used in older patients with extreme bradyarrhythmia and occasionally with acute myocardial infarction. Serious complications are not uncommon (22% of all patients), and can range from femoral hematoma to cardiac tamponade and even death (6%). In 9% of the patients the electrode needed to be repositioned because of failure of sensing or loss of ventricular capture.

Giant cell myocarditis (GCM) is a rare condition whose histologic hallmark, the multinucleate giant cell, is of debated origin (monocytic v myogenic). We report the case of a 46-year-old woman with a previous diagnosis of ulcerative colitis who rapidly deteriorated and died as the result of refractory ventricular tachyarrhythmias. Postmortem examination showed a diffuse infiltration of the myocardium by round cells and multinucleate giant cells. Immunohistochemically, round cells were demonstrated to be T lymphocytes admixed with monocytes. Multinucleate giant cells expressed monocytic markers (MAC 387, lysozyme) and were negative for muscle markers (actin, desmin, myoglobin). This case illustrates the monocytic and macrophagic nature of multinucleate giant cells and lends support to the autoimmune hypothesis of GCM by the concurrence of the latter with ulcerative colitis.

The presence of post-anoxic encephalopathy after an episode of aborted sudden cardiac death is a serious medical and social problem.Of 193 patients admitted to the coronary unit during a 12-year period with aborted sudden cardiac death, 104 died (54%) and 89 survived the episode (46%). We compared the characteristics and 6-month prognosis between survivors according to the presence or absence of post-anoxic encephalopathy.Of 89 survivors, 38 patients were discharged alive with post-anoxic encephalopathy (42%) and 51 were discharged without neurological disturbances (58%). Patients with post-anoxic encephalopathy were older (65 13.6 vs. 59 12.9 years; p = 0.04). Mean time to care for cardiac arrest was 11.14.9 min in the post-anoxic encephalopathy group, versus 3.43 min (p0.01). The first documented rhythm was VF/VT in 57% and asystolia in 29% in the post-anoxic encephalopathy group, vs. 88% and 3% (p = 0.02). More than half (58%) of the patients in the post-anoxic encephalopathy group had coronary artery disease, vs. 49% (p = NS). Slightly more than half (52%) of the patients in the post-anoxic encephalopathy group had infectious complications, vs. 21% (p = 0.01). After 6 months of follow-up, mortality in patients discharged with post-anoxic encephalopathy was 62%, vs. 10% (p0.01); 21% of then showed significant functional improvement and 18% remained neurologically stable.Most patients admitted to a coronary unit with aborted sudden cardiac death died during hospitalization. Almost half of the survivors had post-anoxic encephalopathy at discharge; of these patients, 62% died within the following 6 months, and functional status improved only in a minority of them.

The reliability of electromechanical dissociation (EMD) in diagnosing acute left ventricular free wall rupture (LVFWR) was assessed in 479 consecutive patients with acute myocardial infarction (AMI). EMD was the mechanism of death in 193 patients, 140 without heart failure (group A, 74%), and 53 with heart failure (group B, 26%). Autopsies performed on 121 patients with EMD showed LVFWR in 81 (95%) of 85 from group A and in 7 (17%) of 36 from group B. Of the 106 patients without EMD (group C) autopsied, 5 (4.7%) had LVFWR. Excluding the eight patients with associated septal rupture, LVFWR occurred in 79 (95.2%) of 83 patients from group A, 4 (12.1%) of 33 from group B, and 2 (1.9%) of 103 from group C. Predictive accuracy of EMD for LVFWR in group A was 95% but only 17% in group B. Moreover, in 13 consecutive cases with a first AMI without heart failure and EMD, emergency surgery demonstrated LVFWR in all. Thus EMD has a highly predictive accuracy in diagnosing LVFWR in patients with a first AMI without overt heart failure.

Clinical and electrocardiographic features of 227 patients who died of an acute myocardial infarction (AMI) were compared with those of 150 survivors of a first AMI. Left ventricular (LV) free wall rupture was found in 93 patients aged50 years, but not in 134. The incidence of healed infarct (4 [4%] vs 50 [37%], p0.001), heart failure (11 [12%] vs 112 [84%], p0.001), and bundle branch block (11 [12%] vs 54 [40%], p0.001) was lower in patients with than without LV rupture. In patients with anterior AMI and early rupture (1 day), admission ST elevation was higher than in those with late LV rupture (1 day, 6.8 +/- 4.0 vs 4.0 +/- 2.7 mm, p0.01). However, lateral wall AMI had minimal ST elevation and accounted for 10% of ruptures. On day 2, the decrease in ST segment in patients with late LV rupture was less than in survivors (0.5 +/- 1.6 vs 3.2 +/- 2.9 mm, p0.001). Admission systolic blood pressure in patients who had early rupture was higher than in survivors (155 +/- 22 vs 137 +/- 22 mm Hg, p0.001) and in those with late rupture (135 +/- 23 mm Hg, p0.001). Late rupture was associated with infarct thinning and triggered by a physical strain in 18 of 45 patients (40%); infarct thinning, however, was present only in 4 of 48 patients (8%) with early rupture (p0.02).(ABSTRACT TRUNCATED AT 250 WORDS)