Reducción de la mortalidad por infarto del miocardio en hospitales chilenos / Reduction of acute myocardial infarction mortality in Chilean hospitals

Background: The characteristics of patients with acute myocardial infarction (MI) admitted to 37 Chilean hospitals (GEMI Registry Group), have been analyzed in the periods 1993-1995 and 1997-1998. Aim: To report the changes in hospital mortality between these 2 periods, with a particular emphasis on the impact of treatment. Patients and methods: Between 1993-1995 we collected information from 2,957 patients and between 1997-1998 we registered 1,981 patients with MI. Analysis of the changes in mortality between periods was adjusted by demographic variables, coronary risk factors, MI location, Killip class on admission and the different therapeutic strategies utilized. The effects of different treatments on hospital mortality were adjusted by the previously determined mortality risk variables. Results: Hospital mortality decreased from 13.3 percent to 10.8 percent between both periods (Odds Ratio (OR) 0.78, confidence intervals (95 percent) (CI) 0.65-0.93). A significant reduction in mortality was observed among patients below 60 years of age, in men, in diabetics and in subjects with an infarction classified as Killip class over II. The use of beta blockers (OR 0.65, CI 0.42-0.99) and intravenous nitrates (OR 0.78, CI 0.61-0.99) and the lower use of calcium channel blockers (OR 0.72, CI 0.60-0.87) were significantly associated with a lower mortality. The administration of angiotensin converting enzyme inhibitors was associated with a 29.3 percent mortality reduction (OR 0.69, CI 0.47-1.02). Conclusions: There has been a significant reduction in the mortality rate for MI in Chilean hospitals during the 2 registry periods analyzed, which was significant among some high risk patients and was related to treatment changes, according to evidence based guidelines

El perfil de seguridad de las estatinas / Safety profile of statins

HMG-CoA reductase inhibitors (statins) are the treatment of choice for patients with hypercholesterolaemia. Several large-scale clinical trials have examined the efficacy and tolerability of statins, providing a wealth of information on their safety and adverse effect profile. Adverse hepatic effect is reflected as asymptomatic elevations in serum levels of aminotransaminases. Myopathy, occasionally leading to myoglobulinuria secondary to rhabdomyolysis, is a rare and potentially fatal complication. Cerivastatin, the last statin approved for use in humans, was voluntarily withdrawn from the market by Bayer, because fatal rhabdomyolysis was most frequently reported with cerivastatin than for other approved statins. The concomitant use of statins with drugs that inhibit CYP3A4 (cyclosporin, erythromycin, clarithromycin, itraconazole, and ketoconazole), may result in increased plasma concentrations of HMG-CoA reductase inhibitors leading occasionally to myotoxicity. Fibric acid derivatives can produce myotoxicity, and the association of both types of drugs increases the risk of this adverse event. The reason for the greater association of rhabdomyolysis with cerivastatin than with other statins is unknown. The efficiency of post marketing drug surveillance programs in different countries, was the clue for the awareness of this problem

Impacto de los factores de riesgo coronario en mujeres de edad media / Cardiovascular risk factors in mid age women with acute coronary syndromes

Background: In Chile, 40 percent of deaths due to acute myocardial infarction occur in women. Aim: To assess the presence of cardiovascular risk factors in women with acute coronary syndromes. Patients and methods: Thirty four women aged 46 to 55 years old, admitted to the hospital due to an acute coronary syndrome and 102 age matched healthy women were studied. A clinical history was obtained, blood pressure and fasting serum lipids were measured. Results: A history of high blood pressure was present in 65 and 16 percent of patients and healthy controls respectively. Seventy seven percent of patients and 36 percent of controls smoked, 76 percent of patients and 48 percent of controls were postmenopausal, 21 percent of patients an 5 percent of controls were diabetic. In patients and controls respectively serum total cholesterol was 230.1ñ36.2 and 211.2ñ34.8 mg/dl, serum triacylglycerol was 213.4ñ109.4 and 143.2ñ76.9 mg/dl and serum HDL cholesterol was 44.1ñ10.8 and 49.8ñ13.3 mg/dl (p<0.001 or less). In univariate analysis, the risk of acute coronary syndrome increased with high blood pressure (OR: 9.3, CI: 2.5-18.6), menopause (OR: 8.3, CI: 2,2-31:5), smoking (OR: 6.9, CI: 2.5-18.6), diabetes mellitus (OR: 5.0, CI: 1.4-17.5), a high total cholesterol/HDL cholesterol ratio (OR: 6.6, CI: 1.8-12.5) and hypertriglyceridemia (OR: 3.6, CI: 1.5-8.5). Logistic regression analysis showed that hypertension and menopause had the higher predictive values for acute coronary syndrome. Conclusions: In this group of women with acute coronary syndromes, the main coronary risk factors were high blood pressure and menopause

Cambios en los patrones de prescripción de medicamentos en el infarto agudo del miocardio: comparación de dos períodos / Changes in pharmacotherapy for acute myocardial infarction: comparison of 2 periods

Background: Pharmacotherapy of Chilean patients with acute myocardial infarction has been recorded in 37 hospitals since 1993. Aim: to compare pharmacotherapy for acute myocardial infarction in the period 1993 to 1995 with the period 1997-1998. Patients and methods: Drug prescription during hospital stay was recorded in 2957 patients admitted to Chilean hospitals with an acute myocardial infarction in the period 1993-1995 and compared with that of 1981 subjects admitted in the period 1997-1998. Results: When compared with the former period, in the lapse 1997-1998 there was an increase in the frequency of prescription of aspirin (93 and 96.1 percent respectively) ß blockers (37 and 55.2 percent respectively) and angiotensin converting enzyme inhibitors (32 and 53 percent). The prescription of thrombolytic therapy did not change (33 and 33.7 percent respectively). There was a reduction in the prescription of calcium antagonists and antiarrhythmic drugs. Conclusions: During the period 1997-1998, the prescription of drugs with a potential to reduce the mortality of acute myocardial infarction, increased. The diffusion of guidelines for the management of this disease may have influenced this change

Infarto agudo del miocardio en hospitales chilenos: resultados finales del estudio GEMI / Acute myocardial infarction in chilean hospitals: results of the GEMI study

Background: Acute myocardial infarction is the leading cause of death in Chile. Aim: To report the main features, hospital evolution, complications and pharmacological treatment of patients admitted to Chilean hospitals with the diagnosis of acute myocardial infarction. Patients and methods: Between 1993 and 1995, the GEMI group registered 2,957 patients admitted to 37 hospitals with the diagnosis of acute myocardial infarction. Results: Mean age of patients was 62 ñ 2 years old and 74 percent were male. Forty six percent had a history of hypertension and 40 percent were smokers. During the first five days of admission, 93 percent of patients received aspirin, 59 percent received intravenous nitrates, 59 percent intravenous heparin, 56 percent oral nitrates, 37 percent beta blockers, 32 percent angiotensin-converting enzyme inhibitors, 33 percent thrombolytic agents, 29 percent antiarrhythmics and 23 percent calcium antagonists. Coronary angiograms were performed in 28 percent of patients, angioplasty in 9 percent and 8 percent were subjected to a coronary bypass. Global hospital mortality was 13.4 percent (19.5 percent in women and 11.1 percent in men, p <0.001). Conclusions: This work gives a picture of myocardial infarction in Chilean hospitals. Pharmacological treatment is similar to that used abroad, but certainly it can be optimized

Sildenafil (Viagra) en la hora de las advertencias / Sildenafil: the time for warnings

Sildenafil is the first orally administered available treatment for erectile dysfunction. It produces a selective vasodilatation of corpus carvernosum, mediated by the inhibition of phosphodiesterase 5, an enzyme that degrades GMPc. Its therapeutic efficacy has been demonstrated in organic as well as psychogenic or mixed erectile dysfunction. Most of its adverse effects, such as headache, flushing, gastroesophageal reflux and color vision disturbances, are related to the mechanism of action. Its interactions with other medications, can have severe adverse consequences. The concomitant use of sildenafil with drugs that release nitric oxide in their molecule, can produce severe hypotension. In patients with coronary heart disease or cardiac failure, this interaction can cause death. Sildenafil is metabolized in the liver through cytochrome P-450. This enzymatic system can be inhibited by cimetidine, ketoconazole or erythromycin. These drugs can increase plasma concentrations of sildenafil. We must identify the groups of patients that will have a better response to the drug and those in whom the drug will be useless. We must also know more about the security profile of the drug. With time, we will know the real role of sildenafil in the treatment of erectile dysfunction

Infarto agudo del miocardio en Chile: diferencias entre hombres y mujeres en su evolución y pronóstico / Myocardial acute infarction in Chile: diferences between male and female in its evolution and prognostic

Gender may be prognostic factor for the evolution of acute myocardial infarction and women may have higher mortality and complication rates. To study if there are differences in the evolution of acute myocardial infarction between men and women, we have recorded information on risk factors, clinical evolution, treatment and complications of 2052 patients hospitalized for acute myocardial infarction in 36 chilean hospitals. The odds ratio for female sex and mortality was calculated using a logistic regression analysis adjusted for risk factors, treatment, invasive procedures and complications. Twenty six percent of analyzed patients were female. Mortality rates among females and males were 11,8 and 20,2 percent respectively (p<0.01). Women had higher frequency of smoking, diabetes, obesity and hypertension. Blood lipid levels were similar in both sexes. Compared to men, a lesser proportion of women were treated with thrombolytic agents (25 and 35 percent respectively) intravenous heparin (54 and 61 percent respectively), beta blockers (31 and 42 percent respectively) and intravenous nitrates (53 and 61 percent respectively). Also, women were subjected to less invasive procedures. The odds ratio for mortality and sex was 1.72 (confidence interval from 1.13 to 2.62). Female sex is an independent risk factor for acute myocardial infarction mortality