First national survey on management strategies in non ST-elevation acute ischaemic syndromes in Argentina. Results of the STRATEG-SIA study.

AIMS: To assess the management strategies applied in non-ST elevation acute ischaemic syndromes in Argentina, the factors influencing the choice of treatment, and their relationship to short- and long-term (1 year) patient outcomes. METHODS AND RESULTS: We conducted a 1 month, prospective, population-based survey in 77 hospitals (all over the country). We recruited 492 patients (age 63.9+/-11.7 years, male sex 68.3%, and 59.8% acute ischaemic ECG changes). Subjects were stratified according to the AHCPR classification as: high risk 62.2%, intermediate 25.0% and low 12.8%. At 1 year, the rate of death or myocardial infarction according to risk category and invasive procedures employed were: high risk (angioplasty 5.4% vs coronary artery bypass grafting 12.1% vs medical treatment 17.2%; P=0.001), intermediate risk (angioplasty 5.7% vs coronary artery bypass grafting 12.5% vs medical treatment 4.7%, P=ns), and low risk (angioplasty 10.0% vs coronary artery bypass grafting 15.2% vs medical treatment 1.9%; P<0.001). In the overall population, the 1 year event rate was not significantly different between the invasive and medical treatment groups (11.5% vs 7.2%, P=0.09). CONCLUSIONS: A routine, unselected invasive approach in non-ST elevation acute ischaemic syndromes in Argentina is associated with no apparent improvement of patients' outcome.

Estatinas en prevención secundaria / Statins in secondary prevention

El efecto positivo de las estatinas en prevención secundaria está sobradamente demostrado en los tres grandes estudios, 4S, CARE, y LIPID. El tratamiento con estatinas debe instaurarse lo más precozmente posible en el paciente que ha presentado un síndrome coronario agudo, puesto que 6 meses después de iniciado el tratamiento ya se observa un beneficio en cuanto a la reducción de mortalidad. Respecto al nivel de LDL aconsejable, en principio el nivel que sugieren los estudios existentes es 100 mg/dl, aunque hay estudios en curso destinados a valorar si una mayor reducción aportaría mayor beneficio. En cuanto a qué fármaco es el más aconsejable, es obligado tener en cuenta no sólo el nivel de LDL sino también el de HDL y TG, puesto que cuanto el HDL es menor de 35 mg/dl probablemente el mejor fármaco sea simvastatina, mientras que atorvastatina no modifica los niveles de HDL de forma significativa. Por último, los probables efectos estabilizador de la placa y antiinflamatorio conducen a la posible utilización de atorvastatina en el síndrome coronario agudo, aunque todavía no hay evidencias definitivas (AU)

Morbidity and mortality following early administration of amiodarone in acute myocardial infarction. GEMICA study investigators, GEMA Group, Buenos Aires, Argentina. Grupo de Estudios Multicéntricos en Argentina.

AIMS: The objective of this study was to ascertain the effect of intravenous and oral amiodarone on morbidity and mortality in patients during the first hours after the onset of an acute myocardial infarction. METHODS AND RESULTS: A cohort of 1073 patients admitted to the CCU within 24 h of the onset of symptoms of an acute myocardial infarction and heart failure (Killip and Kimball A-B) were randomized to receive amiodarone (n=542) or placebo (n=531) for 6 months. Because of the higher mortality, on an interim analysis, from a 'high dose' of amiodarone or placebo (516 patients) the protocol was changed to a 'low dose' or placebo (557 patients). Mortality with high doses of amiodarone was 16.30% vs 10.16% in the placebo group (P=0.04), whereas mortality with low doses was 6.61% vs 9.47% in the control group (P=0.20). Several non-fatal adverse effects were observed in 108 and 73 patients treated with amiodarone and placebo, respectively. CONCLUSION: This study demonstrated that early administration of amiodarone in low doses to patients with an acute myocardial infarction may be used only if life-threatening arrhythmia justify its prescription. Conversely, when given in high doses, it might increase mortality.

Independent prognostic value of elevated C-reactive protein in unstable angina.

BACKGROUND: There is growing evidence of the prognostic importance of C-reactive protein (CRP) in unstable angina. However, the independent value of CRP relative to other conventional markers at different stages of treatment has not been established. Therefore, we assessed the in-hospital and 90-day prognostic values of serum CRP in unstable angina. We also compared the relation of CRP at admission and discharge with 90-day outcome. METHODS AND RESULTS: One hundred ninety-four consecutive patients were included in a derivation (n = 105) and a validation set (n = 89). Serum CRP was measured at admission, at 48 hours, and at hospital discharge. A cutoff point of 1.5 mg/dL for CRP provided optimum sensitivity and specificity for adverse outcome, based on the receiver operator curves. No association was found between CRP on admission and in-hospital outcome. CRP at admission, adjusted for age, ECG findings on admission, silent ischemia, left ventricular wall motion score, and high-risk clinical presentation, was related to the combined end point of refractory angina, myocardial infarction, or death at 90 days (hazard ratio [HR] 1.9, 95% CI 1.2 to 8.3, P = 0.002). CRP at hospital discharge was the strongest independent marker of an adverse outcome (HR 3.16, 95% CI 2.0 to 5.2, P = 0.0001). These results were confirmed in the validation set (CRP at discharge: HR 3. 3, 95% CI 2.0 to 7.69, P = 0.0001). CONCLUSIONS: In unstable angina, CRP is a strong independent marker of increased 90-day risk. Compared with CRP at admission, CRP at discharge is better related to later outcome and could be of great utility for risk stratification.

Outcome of Hispanic patients treated with thrombolytic therapy for acute myocardial infarction: results from the GUSTO-I and III trials. Global Utilization of Streptokinase and TPA for Occluded Coronary Arteries.

OBJECTIVES: We sought to describe the differences in the process of care and clinical outcomes between Hispanics and non-Hispanics receiving thrombolytic therapy for myocardial infarction (MI). BACKGROUND: Hispanics are the fastest growing and second largest minority in the U.S. but most cardiovascular disease data on Hispanics has been derived from retrospective studies and vital statistics. Despite their higher cardiovascular risk-factor profile, better outcomes after MI have been reported in Hispanics. METHODS: We studied the baseline characteristics, resource use and outcomes of 734 Hispanics and 27,054 non-Hispanics treated for MI in the GUSTO-I and -III trials. The primary end point of both trials was 30-day mortality. RESULTS: Hispanics were younger, shorter, lighter and more often diabetic and began thrombolysis 9 min later, compared with non-Hispanics. Measures of socioeconomic status (educational level, employment and health insurance) were lower among Hispanics. Fewer Hispanics than non-Hispanics underwent in-hospital angiography (70% vs. 74%, p = 0.013) or bypass surgery (11% vs. 13.5%, p = 0.04). Hispanics received more angiotensin-converting enzyme (ACE) inhibitors and less calcium-channel blockers, prophylactic lidocaine and inotropic agents. Mortality at 30 days and at one year did not differ significantly between Hispanics and non-Hispanics (6.4% vs. 6.7% and 9.0% vs. 9.7%, respectively). We noted no interactions between thrombolytic strategy and Hispanic status on major outcomes (30-day death, stroke and major bleeding). CONCLUSIONS: The care of Hispanics with MI differed slightly from that of non-Hispanics. Nevertheless, these differences in care did not affect long-term outcomes.

Cambios clínicos, bioquímicos e inmunológicos obtenidos en pacientes tratados con insulina porcina biobras / Clinical, biochemical and immunological changes in patientstreated with porcine insulin Biobras

Se estudiaron los cambios ocurridos a nivel clínico, bioquímico e inmunológico en pacientes diabéticos insulinodependientes (adultos y niños) tratados con insulina NPH de origen porcino (Biobras) durante 90 días y se loscomparó con los obtenidos previamente en esos mismos pacientes tratados con otras insulinas disponibles en el mercado nacional. Los resultados obtenidos no mostraron cambios importantes en el corto plazo en ninguno de los parámetros estudiados, lo que sugiere que la insulina Biobras presenta características apropiadas para el tratamiento del diabético insulinodependiente. Ello brinda al paciente, junto con una correcta alimentación, una actividad física apropiada y el permanente soporte educativo, otra alternativa de elección para el tratamiento insulínico de esta enfermedad metabólica

Cambios clínicos, bioquímicos e inmunológicos obtenidos en pacientes tratados con insulina porcina biobras / Clinical, biochemical and immunological changes in patientstreated with porcine insulin Biobras

Se estudiaron los cambios ocurridos a nivel clínico, bioquímico e inmunológico en pacientes diabéticos insulinodependientes (adultos y niños) tratados con insulina NPH de origen porcino (Biobras) durante 90 días y se loscomparó con los obtenidos previamente en esos mismos pacientes tratados con otras insulinas disponibles en el mercado nacional. Los resultados obtenidos no mostraron cambios importantes en el corto plazo en ninguno de los parámetros estudiados, lo que sugiere que la insulina Biobras presenta características apropiadas para el tratamiento del diabético insulinodependiente. Ello brinda al paciente, junto con una correcta alimentación, una actividad física apropiada y el permanente soporte educativo, otra alternativa de elección para el tratamiento insulínico de esta enfermedad metabólica (AU)

[Subcutaneous and intranasal use of a LH-RH analog in the treatment of girls with central precocious puberty]. / Utilización de un análogo de LH-RH subcutáneo e intranasal en el tratamiento de niñas con pubertad precoz central.

Luteinizing hormone-releasing hormone analogues (LH-RHa) offer a novel approach for non-steroidal manipulation of the reproductive endocrine axis. LH-RH agonists are now employed in the management of central precocious puberty (CPP). The aim of the present work is to show the results of one of the first experiences in our country in the therapeutics of this pathology with LH-RHa (Buserelin) both subcutaneously (SC) and intranasally (IN). Five girls with CPP, aged 1.3 to 6.8 years, were selected (Table 1). The doses employed were: 25 micrograms/kg/day in 2 SC applications followed by 1200 micrograms/day IN. In case 4 IN route only was used because she presented an allergic cutaneous reaction to the SC injection and in case 3 only the SC route was employed because of her chronological age. The period of treatment oscillated between 3 and 21 months. In 2 girls 150 mg of medroxyprogesterone was administered before the analogue therapy and it was maintained during a week. In 4 patients a regression of breast development was observed to Tanner's I or II incipient grades and in case 1 only partial involution was noted. In 4 of the 5 patients, annual growth velocity could be evaluated, showing in 3 of them a reduction between 40 and 55% VS pretreatment associated with a desacceleration of the skeletal maturation (Figs. 1, 2). The prediction of adult height increased 2 cm in one case and 4.5 cm in 2 cases; 4/5 girls showed a reduction of FSH, LH and estradiol levels to prepubertal values after 3 months of treatment and in one patient after 6 months of therapy (Fig. 3).(ABSTRACT TRUNCATED AT 250 WORDS)

Utilización de un análogo de LH-RH subcutáneo e intranasal en el tratamiento de niñas con pubertad precoz central. / [Subcutaneous and intranasal use of a LH-RH analog in the treatment of girls with central precocious puberty]

Luteinizing hormone-releasing hormone analogues (LH-RHa) offer a novel approach for non-steroidal manipulation of the reproductive endocrine axis. LH-RH agonists are now employed in the management of central precocious puberty (CPP). The aim of the present work is to show the results of one of the first experiences in our country in the therapeutics of this pathology with LH-RHa (Buserelin) both subcutaneously (SC) and intranasally (IN). Five girls with CPP, aged 1.3 to 6.8 years, were selected (Table 1). The doses employed were: 25 micrograms/kg/day in 2 SC applications followed by 1200 micrograms/day IN. In case 4 IN route only was used because she presented an allergic cutaneous reaction to the SC injection and in case 3 only the SC route was employed because of her chronological age. The period of treatment oscillated between 3 and 21 months. In 2 girls 150 mg of medroxyprogesterone was administered before the analogue therapy and it was maintained during a week. In 4 patients a regression of breast development was observed to Tanners I or II incipient grades and in case 1 only partial involution was noted. In 4 of the 5 patients, annual growth velocity could be evaluated, showing in 3 of them a reduction between 40 and 55

VS pretreatment associated with a desacceleration of the skeletal maturation (Figs. 1, 2). The prediction of adult height increased 2 cm in one case and 4.5 cm in 2 cases; 4/5 girls showed a reduction of FSH, LH and estradiol levels to prepubertal values after 3 months of treatment and in one patient after 6 months of therapy (Fig. 3).(ABSTRACT TRUNCATED AT 250 WORDS)