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Resumen Introduccion y objetivos La ventilacion no invasiva (VNI) es capaz de reducir la necesidad de intubacion endotraqueal y la mortalidad de los pacientes con insuficiencia cardiaca aguda (ICA). Sin embargo, de muchos de los ensayos clinicos se ha excluido a los pacientes con ICA secundaria a sindrome coronario agudo o infarto agudo de miocardio (SCA-IAM). El objetivo de este estudio es comparar la efectividad de la VNI entre pacientes con ICA desencadenada por SCA-IAM y por otras causas. Metodos Estudio prospectivo de cohortes, durante un periodo de 20 anos, de todos los pacientes con ICA tratados con VNI ingresados en una unidad de cuidados intensivos. Se agrupo a los pacientes por la presencia o ausencia de SCA-IAM como causante del evento de ICA. Se definio el fracaso de la VNI por la necesidad de intubacion endotraqueal o muerte. Resultados Se analizo a 1.009 pacientes, 403 (40%) con SCA-IAM y 606 (60%) con otras etiologias. La VNI fracaso en 61 casos (15,1%) del grupo de SCA-IAM y 64 (10,6%) del grupo sin SCA-IAM (p = 0,031), sin diferencias en la mortalidad hospitalaria (el 16,6 y el 14,9%; p = 0,478). Conclusiones El SCA-IAM como causa desencadenante de la ICA no influye en el pronostico de los pacientes con insuficiencia respiratoria aguda que precisan asistencia respiratoria no invasiva.

Introduction and objectives Noninvasive ventilation (NIV) has been shown to reduce the rate of endotracheal intubation and mortality in patients with acute heart failure (AHF). However, patients with AHF secondary to acute coronary syndrome/acute myocardial infarction (ACS-AMI) have been excluded from many clinical trials. The purpose of this study was to compare the effectiveness of NIV between patients with AHF triggered by ACS-AMI and by other etiologies. Methods Prospective cohort study of all patients with AHF treated with NIV admitted to the intensive care unit for a period of 20 years. Patients were divided according to whether they had ACS-AMI as the cause of the AHF episode. NIV failure was defined as the need for endotracheal intubation or death. Results A total of 1009 patients were analyzed, 403 (40%) showed ACS-AMI and 606 (60%) other etiologies. NIV failure occurred in 61 (15.1%) in the ACS-AMI group and in 64 (10.6%) in the other group (P = .031), without differences in in-hospital mortality (16.6% and 14.9%, respectively; P = .478). Conclusions The presence of ACS-AMI as the triggering cause of AHF did not influence patients with acute respiratory failure requiring noninvasive respiratory support .

The impact of hypocapnia in the prognosis of cardiogenic acute pulmonary edema (CAPE) has not been sufficiently studied. The aim of this study was to analyse whether hypocapnia is a risk factor for non-invasive ventilation (NIV) failure and hospital mortality, in CAPE patients CAPE.Retrospective observational study of all patients with CAPE treated with NIV. Patients were classified in three groups according to PaCO1138 patients were analysed, 390 (34.3%) of which had hypocapnia, 186 (16.3%) had normocapnia and 562 (49.4%) had hypercapnia. NIV failure was more frequent in hypocapnic (60 patients, 15.4%) than in eucapnic (16 pacientes, 8.6%) and hypercapnic group (562 pacientes, 10.7%), with statistical significance (p = 0.027), as well as hospital mortality, 73 (18.7%), 19(10.2%) and 83 (14.8%) respectively (p = 0.026). The predicted factors for NIV failure were the presence of do-not-intubate order, complications related to NIV, a lower left ventricular ejection fraction, higher SAPS II and SOFA score and a higher HACOR score at one hour of NIV initiation.Hypocapnia in patients with CAPE is associated with NIV failure and a greater in-hospital mortality.

Although the easy availability of invasive cardiac care facilities is associated with an increase in their use, their influence on outcomes is not clear. We sought to investigate whether a newly available cardiac catheterization laboratory (CCL) performing percutaneous coronary intervention (PCI) on a part-time (PT) basis might improve outcomes in patients with acute myocardial infarction (AMI).This was an observational cohort study that included all consecutive patients with AMI admitted to a secondary-level hospital in Spain before and after the PT-CCL opened in January 2006: during 1998-2005 and 2006-2014, respectively. All-cause in-hospital and long-term mortality were the co-primary endpoints. In-hospital complications and length of stay were secondary endpoints. For the analyses, patients were stratified according to propensity-score (PS) quintiles.A total of 5339 patients were recruited, and 50.3% were managed after the opening of the PT-CCL. The PT-CCL was associated with greater use of PCI (81.2 vs. 32.5%, p0.001) and guidelines-recommended medication (all p0.001), lower risk of recurrent angina (PS-adjusted RR=0.160, 95% CI 0.115-0.222) and shorter length of hospital stay (PS-adjusted RR for length of stay8days=0.357, 95% CI 0.301-0.422). In patients with NSTEMI, PT-CCL was associated with improved long-term survival (PS-adjusted HR=0.764, 95% CI 0.602-0.970).In patients with AMI, a new PT-CCL was associated with greater use of PCI and guideline-recommended medication, lower risk of recurrent angina and shorter length of hospital stay. In a subset of patients with NSTEMI, PT-CCL was associated with improved long-term survival.

Resumen Introduccion y objetivos Existe controversia acerca del valor del nivel socieconomico como marcador pronostico en el infarto agudo de miocardio. El objetivo de este estudio fue evaluar el impacto del nivel de estudios, como marcador del estatus socioeconomico, sobre el pronostico vital a largo plazo tras un infarto agudo de miocardio. Metodos Estudio prospectivo y observacional de 5.797 pacientes hospitalizados por un infarto agudo de miocardio. Se estudio la mortalidad por todas las causas a largo plazo (mediana 8,5 anos) mediante modelos de regresion ajustados. Resultados Un 73,1% de los pacientes habia cursado estudios primarios (n = 4.240), los segundos mas frecuentes fueron los estudios medios (secundaria, bachiller) (n = 843; 14,5%). Un 7,0% (n = 407) era analfabeto y el 5,3% tenia estudios superiores (n = 307). Los pacientes con un nivel de estudios medio o superior fueron significativamente mas jovenes, en mayor proporcion varones y presentaban menos factores de riesgo y comorbilidad. Eran pacientes que acudian antes al hospital y se presentaban con menor grado de insuficiencia cardiaca. Durante el ingreso recibieron con mas frecuencia terapia de reperfusion y su mortalidad cruda fue inferior. El tratamiento hospitalario y al alta incluyo mas farmacos recomendados por las guias. En un contexto multivariado, el nivel de estudios medio o superior se mostro como un predictor independiente y protector respecto de la mortalidad a largo plazo ( hazard ratio = 0,85; intervalo de confianza del 95%, 0,74-0,98). Conclusiones Este estudio muestra una relacion inversa e independiente entre el nivel de estudios previos y la mortalidad a largo plazo en pacientes que han experimentado un infarto agudo de miocardio.

Introduction and objectives The value of socioeconomic status as a prognostic marker in acute myocardial infarction is controversial. The aim of this study was to evaluate the impact of educational level, as a marker of socioeconomic status, on the prognosis of long-term survival after acute myocardial infarction. Methods We conducted a prospective, observational study of 5797 patients admitted to hospital with acute myocardial infarction. We studied long-term all-cause mortality (median 8.5 years) using adjusted regression models. Results We found that 73.1% of patients had primary school education (n = 4240), 14.5% had secondary school education (including high school) (n = 843), 7.0% was illiterate (n = 407), and 5.3% had higher education (n = 307). Patients with secondary school or higher education were significantly younger, more were male, and they had fewer risk factors and comorbidity. These patients arrived sooner at hospital and had less severe heart failure. During admission they received more reperfusion therapy and their crude mortality was lower. Their drug treatment in hospital and at discharge followed guideline recommendations more closely. On multivariate analysis, secondary school or higher education was an independent predictor and protective factor for long-term mortality (hazard ratio = 0.85; 95% confidence interval, 0.74-0.98). Conclusions Our study shows an inverse and independent relationship between educational level and long-term mortality in patients with acute myocardial infarction.

The aim of this study was to investigate the prognosis associated with bundle branch block (BBB) depending on location, time of appearance, and duration in patients with myocardial infarction (MI). From January 1998 to January 2008, we recruited 5,570 patients with acute MI. Thirty-day and 7-year all-cause mortality, according to BBB location, time of appearance, and duration were analyzed by multivariable analyses. BBB was present in 964 patients (17.3%); right BBB (RBBB) 10.6% and left BBB (LBBB) 6.7%. Overall mortality rate at 30 days was 13.2% (n = 738) and 7 years was 6.34 deaths per 100 patient-year. Both RBBB and LBBB were more frequently previous, 42.9% and 58.8%. Compared with non-BBB, all BBB groups showed higher prevalence of co-morbidities, especially rates of diabetes (49.0% vs 34.3%, p

Resumen Introduccion y objetivos El impacto de la fibrilacion auricular en el pronostico del infarto de miocardio sigue siendo controvertido. Se analizo la importancia pronostica de la fibrilacion auricular previa y de nueva aparicion (de novo) en el hospital y a largo plazo en el infarto agudo de miocardio. Metodos Estudio prospectivo de 4.284 pacientes con infarto agudo de miocardio con elevacion del segmento ST. Se estudio la mortalidad por todas las causas hospitalaria y a largo plazo (mediana, 7,2 anos) mediante modelos ajustados. Resultados El 3,2% de los pacientes tenian fibrilacion auricular previa y el 9,8%, de novo. En general ambos grupos de pacientes tenian un perfil de mayor riesgo basal y mayor probabilidad de complicaciones intrahospitalarias. La mortalidad bruta hospitalaria fue mayor entre los pacientes con fibrilacion auricular previa que en la de novo (el 22 frente al 12%; p Conclusiones La fibrilacion auricular de novo durante el ingreso es un factor independiente de mortalidad hospitalaria en el infarto agudo de miocardio.

To assess the in-hospital and long-term prognostic importance of cardiomegaly demonstrated by a simple admission radiograph in patients hospitalized for acute myocardial infarction.Prospective study of 7644 patients admitted for acute myocardial infarction; 2 hospitals participated. We recorded detailed clinical data, especially noting the presence or absence of cardiomegaly in the chest radiograph. Adjusted predictive models for all-cause mortality in hospital or after discharge were constructed. The median followup was 6 years.Cardiomegaly was detected in 1351 (17.7%) of the patients. Hospital mortality was 11.2% overall; the incidence of long-term mortality was 5.7 per 100 patient-years. Patients with cardiomegaly were older and had more cardiovascular risk factors other than current smoking; they also had more concomitant conditions, had undergone fewer revascularization procedures, and received suboptimal care after discharge. Cardiomegaly was associated with higher in-hospital rates of adverse events, especially heart failure (70.8% in patients with cardiomegaly vs 21.4% in others, P.001) and death (27.8% vs 7.7%, P.001). Cardiomegaly was also an independent predictor of hospital mortality (odds ratio, 1.34; P=.02) as well as mortality after discharge (hazard ratio, 1.16; P.01).Cardiomegaly was an independent predictor of both hospital mortality and long-term mortality after discharge in this series.Conocer el significado pronóstico intrahospitalario y a largo plazo de la presencia de cardiomegalia en la radiología simple inicial de los pacientes ingresados por infarto agudo de miocardio.Estudio prospectivo de 7.644 pacientes ingresados por un infarto agudo de miocardio en dos hospitales. Se obtuvo información clínica detallada y se prestó especial atención a la presencia/ausencia de cardiomegalia en la radiografía de tórax. Realizamos modelos ajustados para predecir mortalidad (por cualquier causa) hospitalaria y tras el alta con una mediana de 6 años.1.351 (17,7%) pacientes presentaron cardiomegalia. La mortalidad hospitalaria global fue 11,2% y la densidad de incidencia de mortalidad a largo plazo fue de 5,7 por cada 100 pacientes-año. Los pacientes con cardiomegalia presentaron mayor edad y más factores de riesgo cardiovascular excepto tabaquismo activo, mayor comorbilidad, fueron menos revascularizados y tratados al alta de forma subóptima. Durante la hospitalización, la cardiomegalia se asoció a mayores tasas de complicaciones, especialmente insuficiencia cardiaca (70,8 vs 21,4%, p0,001) y mortalidad (27,8 vs 7,7%, p0,001). La cardiomegalia resultó predictor independiente sobre la mortalidad hospitalaria (odds ratio = 1,34; p = 0,02) y tras el alta (hazard ratio = 1,16, p0,01).En pacientes con infarto agudo de miocardio la cardiomegalia resultó predictor independiente de mortalidad hospitalaria y a largo plazo tras el alta.

Introduccion y objetivos El paciente con sindrome coronario agudo con antecedentes de cardiopatia isquemica, arteriopatia periferica y/o accidente cerebrovascular previos muestra un peor pronostico. Sin embargo, la relacion existente entre dichos antecedentes y el pronostico a largo plazo no ha sido aclarada del todo. Metodos Estudio prospectivo de 4.247 pacientes con infarto agudo de miocardio y segmento ST elevado. Se obtuvo informacion clinica detallada que incluye los antecedentes de cardiopatia isquemica, arteriopatia periferica y accidente cerebrovascular. Estudiamos la mortalidad intrahospitalaria y a largo plazo (mediana, 7,2 anos) mediante modelos ajustados. Resultados Se observo que 1.131 (26,6%) pacientes tenian un territorio enfermo y 221 (5,2%), ? 2 territorios. La mortalidad hospitalaria total fue del 12,3% y la densidad de incidencia de mortalidad a largo plazo fue de 3,5/100 pacientes-ano. Los antecedentes de cardiopatia isquemica (odds ratio = 0,83; p = 0,35), arteriopatia periferica (odds ratio = 1,30; p = 0,34) y accidente cerebrovascular (odds ratio = 1,15; p = 0,59) no fueron predictores independientes de mortalidad hospitalaria. En un modelo ajustado, los dos ultimos fueron predictores de mortalidad a largo plazo (hazard ratio = 1,57; p < 0,001; y hazard ratio = 1,34; p = 0,001, respectivamente). La afeccion de ? 2 territorios vasculares fue predictora de mortalidad a largo plazo (hazard ratio = 2,35; p < 0,001), aunque no de mortalidad intrahospitalaria (odds ratio = 1,07; p = 0,844). Conclusiones En el infarto de miocardio con segmento ST elevado, la carga vascular previa condiciona mayor mortalidad a largo plazo. Individualmente, la arteriopatia periferica y el accidente cerebrovascular previos son predictores de muerte tras el alta.

Resumen Objetivo Las alteraciones del metabolismo hidrocarbonado no conocidas son frecuentes en los pacientes con infarto agudo de miocardio, sin que exista un consenso en que pacientes estudiar para su identificacion precoz. Nuestro objetivo es evaluar que variables al ingreso se asocian al diagnostico posterior de una alteracion de dicho metabolismo. Diseno Estudio de cohortes prospectivo. Ambito Servicio de Medicina Intensiva del Hospital Universitario Virgen de la Arrixaca (Murcia), Espana. Pacientes Un total de 138 pacientes ingresados en la UCI con infarto agudo de miocardio sin diabetes conocida ni de novo fueron, transcurrido un ano, estudiados mediante un test de sobrecarga oral de glucosa. Variables principales Se recogieron variables clinicas y parametros analiticos al ingreso y trascurrido un ano. Ademas, al ano, se realizo una sobrecarga oral de glucosa y se estudio la capacidad diagnostica para la diabetes de las variables al ingreso mediante las curvas ROC y analisis multivariable. Resultados Entre 138 pacientes estudiados, 112 (72,5%) presentaron una alteracion del metabolismo hidrocarbonado, incluido un 16,7% de diabetes. La HbA1c se asocio independientemente con el diagnostico de diabetes (RR: 7,28, IC 95%: 1,65-32,05, p = 0,009) y presento la mejor area bajo la curva ROC para diabetes (0,81, IC 95%: 0,69-0,92, p Conclusiones En los pacientes con infarto agudo de miocardio, la HbA1c ayuda a identificar aquellos con alteracion del metabolismo hidrocarbonado transcurrido un ano. De esta forma, su determinacion en este grupo de pacientes puede ser utilizada para identificar a aquellos que precisan un estudio mas detallado para establecer un diagnostico precoz.

Resumen Objetivo Determinar si existe una asociacion lineal de la edad y la administracion de aspirina, betabloqueantes, inhibidores de la enzima convertidora de la angiotensina y estatinas, en que medida los pacientes de edad avanzada reciben estos tratamientos y si la edad se asocia de forma independiente a estos tratamientos. Diseno Estudio de cohortes prospectivo. Ambito Unidades Coronarias de 2 hospitales de la Region de Murcia Pacientes Pacientes consecutivos ingresados con el diagnostico de infarto agudo de miocardio entre enero de 1998 y enero de 2008. Intervenciones Ninguna. Variables principales Las relacionadas con la administracion de aspirina, betabloqueantes, inhibidores de la enzima convertidora de la angiotensina y estatinas durante la estancia en la Unidad Coronaria. Resultados Respecto al resto de pacientes, los octogenarios recibieron en similar proporcion inhibidores de la enzima convertidora de la angiotensina (70,8 vs 69,3%, p=0,41) y con menor frecuencia aspirina (90,4 vs 94,6%, p Conclusiones Los pacientes octogenarios reciben con menor frecuencia tratamiento con aspirina, betabloqueantes y estatinas, sin embargo, la edad avanzada no constituyo un factor independiente asociado a la menor administracion de aspirina.

Introduction and objectives. In patients with acute myocardial infarction, a number of variables in the initial ECG are useful prognostic indicators. The presence of ST-segment elevation, however, usually indicates the need for reperfusion therapy. The aims of this study were to investigate sex differences in the ECGs of patients with ST-elevation myocardial infarction (STEMI) and to look for a possible association between sex and marked STsegment elevation. Methods. A prospective observational longitudinal study of consecutive patients (n=1422) who were admitted early for a first STEMI to one of two coronary units was carried out. Initial ECG parameters were analyzed for sex differences. Multivariate analysis was performed to identify variables associated with marked ST-segment elevation (ie, total ST-segment elevation >11 mm, according to the upper tertile of the frequency distribution). Results. In women (n=336), Q-wave myocardial infarction was observed more often in the initial ECG (19% vs 15.6%; P

Introduction and objectives The impact of atrial fibrillation on the prognosis of myocardial infarction is still the subject of debate. We analyzed the influence of previous and new-onset atrial fibrillation on in-hospital and long-term prognosis in patients with acute myocardial infarction. Methods Prospective study of 4284 patients with ST-segment elevation acute myocardial infarction. We studied all-cause in-hospital and long-term mortality (median, 7.2 years) using adjusted models. Results In total, 3.2% of patients had previous atrial fibrillation and 9.8% had new-onset atrial fibrillation. In general, both groups of patients had a high baseline risk profile and an increased likelihood of in-hospital complications. The crude in-hospital mortality rate was higher in patients with previous atrial fibrillation than in those with new-onset atrial fibrillation (22% vs 12%; P

Patients with a current acute coronary syndrome and previous ischemic heart disease, peripheral arterial disease, and/or cerebrovascular disease are reported to have a poorer outcome than those without these previous conditions. It is uncertain whether this association with outcome is observed at long-term follow-up.Prospective observational study, including 4247 patients with ST-segment elevation myocardial infarction. Detailed clinical data and information on previous ischemic heart disease, peripheral arterial disease, and cerebrovascular disease ("vascular burden") were recorded. Multivariate models were performed for in-hospital and long-term (median, 7.2 years) all-cause mortality.One vascular territory was affected in 1131 (26.6%) patients and ≥ 2 territories in 221 (5.2%). The total in-hospital mortality rate was 12.3% and the long-term incidence density was 3.5 deaths per 100 patient-years. A background of previous ischemic heart disease (odds ratio = 0.83; P = .35), peripheral arterial disease (odds ratio = 1.30; P = .34), or cerebrovascular disease (stroke) (odds ratio = 1.15; P = .59) was not independently predictive of in-hospital death. In an adjusted model, previous cerebrovascular disease and previous peripheral arterial disease were both predictors of mortality at long-term follow-up (hazard ratio = 1.57; P.001; and hazard ratio = 1.34; P = .001; respectively). Patients with ≥ 2 diseased vascular territories showed higher long-term mortality (hazard ratio = 2.35; P.001), but not higher in-hospital mortality (odds ratio = 1.07; P = .844).In patients with a diagnosis of ST-segment elevation acute myocardial infarction, the previous vascular burden determines greater long-term mortality. Considered individually, previous cerebrovascular disease and peripheral arterial disease were predictors of mortality at long-term after hospital discharge.

compared those registries data with ADHERE, Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure (OPTIMIZE-HF) and Euro Heart Failure Survey (EHFS) II database. Method: We analyzed characteristics and managements in 217 consecutive patients from hospital based ADHF registry database in a single National Cardiovascular Center in Japan. Results: In characteristics, age, serum BNP level and creatinine level were similar between four databases, but we had more patients with systolic dysfunction, hypotension and cardiomyopathy, and less frequently had COPD or asthma in Japan. There is considerable difference was seen in the use of inotrope and vasodilator. In the US, fewer patients were treated with inotropic agent or nitroglycerin as vasodilator than those in Japan or Europe. Especially in Japan, more than one third of patients were treated with human natriuretic peptide which has similar pharmacological effect as Nesiritide.