Predictores de demora en el intervencionismo coronario percutáneo primario en el infarto de miocardio diagnosticado en hospitales sin hemodinámica / Time from electrocardiographic diagnosis of ST-elevation myocardial infarction to guidewire crossing in patients transferred to a hospital for primary angioplasty: factors associated with delay

Objetivos: Identificar variables predictoras del retraso hasta la angioplastia primaria, en los pacientes con infarto agudo de miocardio con elevación del ST (IAMEST) trasladados desde el medio extrahospitalario o desde hospitales sin hemodinámica. Método: Estudio de cohortes, retrospectivo, realizado entre 2008 y 2018 en un hospital universitario receptor de pacientes con diagnóstico de IAMEST y que requirieron angioplastia primaria. Se realizó un análisis multivariable de regresión logística y lineal para identificar variables predictoras de demora de tiempo de electrocardiograma (ECG) diagnóstico hasta el paso de guía. Resultados: Se incluyeron 1.039 pacientes en el estudio. Doscientos noventa y seis pacientes (28,4%) presentaban tiempos ECG diagnóstico-paso de guía > 120 minutos. Las variables asociadas a tiempos prolongados de angioplastia primaria fueron la edad avanzada [odds ratio (OR) = 1,02; IC 95%: 1,01-1,04] la insuficiencia cardiaca grave al ingreso (OR = 2,28; IC 95%: 1,23-4,22), la cirugía cardiaca previa de bypass (OR = 10,01; IC 95%: 2,60-41,81), la muerte súbita extrahospitalaria recuperada (OR = 4,34; IC 95%: 1,84-10,32), la localización lateral del infarto (OR = 1,64; IC 95%: 1,06-2,51), el primer contacto con hospital sin disponibilidad de hemodinámica (OR = 1,52; IC 95%: 1,05- 2,21), la atención fuera de horas (OR = 1,46; IC 95%: 1,06-2,02) y finalmente la distancia en kilómetros al centro con hemodinámica (OR = 1,04; IC 95%: 1,03-1,05). Conclusiones: En los pacientes con IAMEST que requirieron traslado a un centro con hemodinámica, la demora en la realización de la angioplastia primaria se relacionó con factores clínicos, con características del infarto y logísticas. (AU)

Objective: To identify predictors of primary angioplasty delay in patients with ST-elevation myocardial infarction (STEMI) transported from out-of-hospital sites or from hospitals without percutaneous coronary intervention (PCI) suites. Methods: Retrospective cohort study of cases between 2008 and 2018 in a university hospital receiving patients diagnosed with STEMI who required a PCI. We performed linear and multivariate regression analyses to identify factors that predicted delay in interpreting a diagnostic electrocardiogram (ECG) until the guidewire passed the lesion (diagnosis–guidewire-crossing time). Results: A total of 1039 cases were studied; 296 patients (28.4%) had delays of more than 120 minutes between STEMI diagnosis and guidewire crossing. Factors associated with PCI delay were advanced age (odds ratio [OR] = 1.02; 95% CI, 1.01–1.04]), severe heart failure on admission (OR = 2.28; 95% CI, 1.23–4.22), history of cardiac bypass surgery (OR = 10.01; 95% CI, 2.60–41.81), out-of-hospital cardiac arrest (OR = 4.34; 95% CI, 1.84–10.32), lateral ischemia (OR, 1.64; 95% CI, 1.06–2.51), first medical attention in a hospital without a PCI suite (OR = 1.52; 95% CI, 1.05–2.21), first medical attention outside regular working hours (OR = 1.46; 95% CI, 1.06–2.02), and distance in kilometers to a PCI suite (OR = 1.04; 95% CI, 1.03–1.05). Conclusions: Patients with STEMI who required transport to a hospital with a PCI suite experienced primary angioplasty delays. Delays were related to logistical and clinical factors as well as to infarction characteristics. (AU)

Predictors of primary percutaneous coronary intervention delay in cases of myocardial infarction diagnosed in hospitals without hemodynamic support systems / Predictores de demora en el intervencionismo coronario percutáneo primario en el infarto de miocardio diagnosticado en hospitales sin hemodinámica.

OBJECTIVES: The need for primary percutaneous coronary intervention in hospitals without hemodynamic support capability is associated with delays between first medical contact (FMC) and reperfusion. It is important to identify factors involved in delays, particularly if they are relevant to the organization of emergency services. MATERIAL AND METHODS: Analysis of a registry of patients treated in hospitals without advanced hemodynamic support systems in a catchment area with an established care network for acute ST-segment elevation myocardial infarction (STEMI). The registry included care times. RESULTS: The network served 2542 patients with a mean (SD) age of 63 (13) years. FMC-to-reperfusion time was within 120 minutes in 42% of the cases. Nine of the hospitals had a chest-pain unit in the emergency department, and this factor was an independent predictor of FMC-to-reperfusion times of 120 minutes or less (odds ratio, 0.64; 95% CI, 0.54­0.77; P < .0001); the time was shortened by 11 minutes in such hospitals. FMC-to-reperfusion was delayed beyond 120 minutes in relation to the following factors: shock and need for intubation at start of care, age, gender, FMC at night, left bundle branch block, and Killip class. One-month and 1-year mortality rates increased in hospitals without hemodynamic support systems in proportion to reperfusion delay, by 1.7% and 3.5% if the delay was 106 minutes or less and by 7.3% and 12.4% if the delay was 176 minutes or longer (P < .0001). CONCLUSION: FMC-to-reperfusion time in STEMI exceeds recommendations in 58% of the hospitals without hemodynamic support systems and delay is inversely proportional to the availability of an emergency department chest pain unit. One-month and 1-year mortality is proportional to the degree of delay.

OBJETIVO: La indicación de intervencionismo coronario percutáneo primario (ICPP) en hospitales sin hemodinámica (HSH) se asocia con tiempos primera asistencia-apertura de la arteria (TPA) prolongados. Es pertinente identificar los factores implicados, especialmente aquellos relacionados con la organización de los servicios de urgencias. METODO: Análisis de un registro de pacientes atendidos en HSH en una región sanitaria con una red asistencial para infarto agudo de miocardio con elevación del segmento ST (IAMEST) establecida y de sus tiempos de actuación. RESULTADOS: En 2.542 pacientes, de edad 63 ± 13 años, se alcanzó un TPA 120 minutos en un 42% de casos. En 9 de los 16 HSH analizados existía un box de dolor torácico en el área de urgencias, que se comportó como factor predictor independiente de un TPA 120 minutos [OR 0,64 (IC 95% 0,54-0,77), p 0,001], con una reducción de 11 minutos de este. Se asociaron de forma independiente con un TPA superior a 120 minutos la intubación y shock durante la primera asistencia, edad, sexo, atención en horario nocturno, bloqueo de rama izquierda y la clase Killip. La mortalidad al mes y al año aumentó en los HSH proporcionalmente al TPA (1,7% y 3,5% si TPA 106 minutos y del 7,3% y 12,4% si TPA 176 minutos, p 0,001). CONCLUSIONES: El TPA alcanzado en activaciones procedentes de HSH supera las recomendaciones en el 58% de casos y se relaciona inversamente con la disponibilidad de un box de dolor torácico en urgencias. La mortalidad al mes y al año es proporcional al grado de retraso en la reperfusión.

Impacto del tratamiento antitrombótico y los síndromes geriátricos en octogenarios con fibrilación auricular y cardiopatía isquémica. Fibrilación Auricular y Cardiopatía Isquémica en Longevos (FACIL) / Impact of antithrombotic treatment and geriatric syndromes in octogenarians with atrial fibrillation and ischaemic heart disease. Atrial Fibrillation and Ischemic Heart Disease in the Elderly

ANTECEDENTES Y OBJETIVOS: La prevalencia de fibrilación auricular (FA) y cardiopatía isquémica (CI) aumenta con la edad. Coexisten en hasta un 20% de los pacientes octogenarios, situación que supone un desafío terapéutico. Los ensayos que han abordado este escenario, que incluyeron un porcentaje bajo de octogenarios, demostraron que la doble terapia (antiagregación simple + anticoagulación) en comparación con la triple terapia (doble antiagregación + anticoagulación) se asocia menos eventos hemorrágicos, especialmente con anticoagulantes orales de acción directa. Estos estudios no tenían potencia suficiente para detectar diferencias en eventos isquémicos. Por otro lado, aspectos prevalentes en la población mayor, como los síndromes geriátricos, no se valoraron en estos estudios, y tampoco en la práctica clínica habitual, desconociéndose su impacto pronóstico en este contexto clínico. MATERIAL Y MÉTODOS: Estudio observacional, prospectivo y multicéntrico, que incluirá pacientes ≥ 80 años con FA y CI en España. Se valorarán las características basales y los síndromes geriátricos, así como la elección del tratamiento antitrombótico. El objetivo primario es conocer la mortalidad cardiovascular y por todas las causas a uno y tres años. RESULTADOS: Este estudio permitirá conocer las características y el pronóstico de pacientes octogenarios con FA y CI en nuestro medio, los factores implicados en la elección del tratamiento antitrombótico y la incidencia de eventos isquémicos y hemorrágicos durante el seguimiento a corto y largo plazo. CONCLUSIONES: Nuestro trabajo contribuirá a mejorar el conocimiento en términos de seguridad y eficacia de las distintas opciones terapéuticas en pacientes mayores con FA y CI y su impacto pronóstico

BACKGROUND AND OBJECTIVES: The prevalence of atrial fibrillation (AF) and ischaemic heart disease (IHC) increases with age. They coexist in up to 20% of octogenarian patients, a situation that poses a therapeutic challenge. Trials that have addressed this scenario, which included a low percentage of octogenarians, showed that double therapy (single antiplatelet + anticoagulation) compared to triple therapy (double antiplatelet + anticoagulation) was associated with less bleeding events, especially with direct oral anticoagulants. These studies did not have sufficient power to detect differences in ischaemic events. On the other hand, prevalent characteristics in the elderly, such as geriatric syndromes, were not assessed in these studies, and are not usually evaluated in clinical practice. Accordingly, their prognostic impact remains unknown in this clinical context. METHODS: Observational, prospective, and multicentre study that will include patients ≥ 80 years with AF and IHC in Spain. Baseline characteristics and geriatric syndromes will be assessed, as well as the choice of antithrombotic treatment. The primary endpoint is cardiovascular and overall mortality at one and three years follow-up. RESULTS: This study will assess both characteristics and prognosis of octogenarian patients with AF and IHC in Spain, the factors involved in the choice of antithrombotic treatment, and the incidence of ischaemic and haemorrhagic events during the short- and long-term follow-up. CONCLUSION: This study will contribute to improve the knowledge in terms of safety and efficacy of the different therapeutic options in older patients with AF and IHC, as well as their prognostic impact

[Impact of antithrombotic treatment and geriatric syndromes in octogenarians with atrial fibrillation and ischaemic heart disease. Atrial Fibrillation and Ischemic Heart Disease in the Elderly]. / Impacto del tratamiento antitrombótico y los síndromes geriátricos en octogenarios con fibrilación auricular y cardiopatía isquémica. Fibrilación Auricular y Cardiopatía Isquémica en Longevos (FACIL).

BACKGROUND AND OBJECTIVES: The prevalence of atrial fibrillation (AF) and ischaemic heart disease (IHC) increases with age. They coexist in up to 20% of octogenarian patients, a situation that poses a therapeutic challenge. Trials that have addressed this scenario, which included a low percentage of octogenarians, showed that double therapy (single antiplatelet + anticoagulation) compared to triple therapy (double antiplatelet + anticoagulation) was associated with less bleeding events, especially with direct oral anticoagulants. These studies did not have sufficient power to detect differences in ischaemic events. On the other hand, prevalent characteristics in the elderly, such as geriatric syndromes, were not assessed in these studies, and are not usually evaluated in clinical practice. Accordingly, their prognostic impact remains unknown in this clinical context. METHODS: Observational, prospective, and multicentre study that will include patients ≥ 80 years with AF and IHC in Spain. Baseline characteristics and geriatric syndromes will be assessed, as well as the choice of antithrombotic treatment. The primary endpoint is cardiovascular and overall mortality at one and three years follow-up. RESULTS: This study will assess both characteristics and prognosis of octogenarian patients with AF and IHC in Spain, the factors involved in the choice of antithrombotic treatment, and the incidence of ischaemic and haemorrhagic events during the short- and long-term follow-up. CONCLUSION: This study will contribute to improve the knowledge in terms of safety and efficacy of the different therapeutic options in older patients with AF and IHC, as well as their prognostic impact.

Estrategias de reperfusión en hospitales sin intervención coronaria percutánea primaria. Respuesta / No disponible

No disponible

Predictores de la demora en la reperfusión de pacientes con IAMCEST que reciben angioplastia primaria. Impacto del lugar de primera asistencia / Predictors of late reperfusion in STEMI patients undergoing primary angioplasty. Impact of the place of first medical contact

Introducción y objetivos: El beneficio de la angioplastia primaria puede reducirse si se producen demoras hasta la reperfusión, y es preciso identificar los factores implicados. Métodos: Análisis del registro Codi Infart de Cataluña y el tiempo transcurrido hasta la angioplastia según el lugar de primera asistencia médica. Resultados: En 3.832 pacientes, la primera asistencia se produjo en un 18% en centros de atención primaria y un 37% en hospitales sin hemodinámica. Hubo mayores demoras en estos 2 grupos que en los casos atendidos por el sistema de emergencias extrahospitalario o en hospitales con hemodinámica (p < 0,0001, resultados en medianas): tiempo primera asistencia-indicación angioplastia, 42 min en ambos (total, 35 min); primera asistencia-apertura de la arteria, 131 y 143 min respectivamente (total, 121 min); tiempo total de isquemia, 230 y 260 min (total, 215 min). El tiempo primera asistencia-apertura de la arteria > 120 min mostró fuerte asociación con la primera asistencia en centros sin hemodinámica (odds ratio = 4,96; intervalo de confianza del 95%, 4,14-5,93) y edad, cirugía coronaria previa, primera asistencia en horario nocturno, electrocardiograma no diagnóstico y clase Killip ≥ III. La mortalidad al mes y al año fue del 5,6 y el 8,7% y se relacionó independientemente con la edad, el retraso hasta la angioplastia, la clase Killip ≥ II y la primera asistencia en un hospital con hemodinámica. Conclusiones: La primera asistencia de los pacientes tributarios de angioplastia primaria se produce en un centro sin hemodinámica en más de la mitad de casos y es un importante factor predictor de retraso hasta la apertura de la arteria (AU)

Introduction and objectives: The benefit of primary angioplasty may be reduced if there are delays to reperfusion. Identification of the variables associated with these delays could improve health care. Methods: Analysis of the Codi Infart registry of Catalonia and of the time to angioplasty depending on the place of first medical contact. Results: In 3832 patients analyzed, first medical contact took place in primary care centers in 18% and in hospitals without a catheterization laboratory in 37%. Delays were longer in these 2 groups than in patients attended by the outpatient emergency medical system or by hospitals with a catheterization laboratory (P < .0001, results in median): first medical contact to reperfusion indication time was 42 minutes in both (overall 35 minutes); first medical contact to artery opening time was 131 and 143 minutes, respectively (overall 121 minutes); total ischemia time was 230 and 260 minutes (overall 215 minutes). First medical contact to artery opening time > 120 minutes was strongly associated with first medical contact in a center without a catheterization laboratory (OR, 4.96; 95% confidence interval, 4.14-5.93), and other factors such as age, previous coronary surgery, first medical contact during evening hours, nondiagnostic electrocardiogram, and Killip class ≥ III. Mortality at 30 days and 1 year was 5.6% and 8.7% and was independently associated with age, longer delay to angioplasty, Killip class ≥ II, and first medical contact in a center with a catheterization laboratory. Conclusions: In more than 50% of patients requiring primary angioplasty, the first medical contact occurs in centers without a catheterization laboratory, which is an important predictor of delay from diagnosis to artery opening (AU)

Predictors of Late Reperfusion in STEMI Patients Undergoing Primary Angioplasty. Impact of the Place of First Medical Contact.

INTRODUCTION AND OBJECTIVES: The benefit of primary angioplasty may be reduced if there are delays to reperfusion. Identification of the variables associated with these delays could improve health care. METHODS: Analysis of the Codi Infart registry of Catalonia and of the time to angioplasty depending on the place of first medical contact. RESULTS: In 3832 patients analyzed, first medical contact took place in primary care centers in 18% and in hospitals without a catheterization laboratory in 37%. Delays were longer in these 2 groups than in patients attended by the outpatient emergency medical system or by hospitals with a catheterization laboratory (P < .0001, results in median): first medical contact to reperfusion indication time was 42minutes in both (overall 35minutes); first medical contact to artery opening time was 131 and 143minutes, respectively (overall 121minutes); total ischemia time was 230 and 260minutes (overall 215minutes). First medical contact to artery opening time > 120minutes was strongly associated with first medical contact in a center without a catheterization laboratory (OR, 4.96; 95% confidence interval, 4.14-5.93), and other factors such as age, previous coronary surgery, first medical contact during evening hours, nondiagnostic electrocardiogram, and Killip class ≥ III. Mortality at 30 days and 1 year was 5.6% and 8.7% and was independently associated with age, longer delay to angioplasty, Killip class ≥ II, and first medical contact in a center with a catheterization laboratory. CONCLUSIONS: In more than 50% of patients requiring primary angioplasty, the first medical contact occurs in centers without a catheterization laboratory, which is an important predictor of delay from diagnosis to artery opening.

[Duration of complete atrioventricular block complicating inferior wall infarction treated with fibrinolysis]. / Duración del bloqueo auriculoventricular completo en el infarto inferior tratado con fibrinólisis.

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.

Duración del bloqueo auriculoventricular completo en el infarto inferior tratado con fibrinólisis / Duration of complete atrioventricular block complicating inferior wall infarction treated with fibrinolysis

Introducción y objetivos. El objetivo de nuestro estudio es determinar la duración del bloqueo auriculoventricular completo (BAVC) en el transcurso de un infarto agudo de miocardio (IAM) de localización inferior tras la administración de tratamiento fibrinolítico. Pacientes y método. 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 localización inferior en las primeras 6 h de evolución. El 64% (282 pacientes) recibió fibrinólisis. En este grupo, 39 (13,8%) pacientes presentaron BAVC (grupo A). En los 167 pacientes no tratados con trombólisis, 13 (8%) casos presentaron BAVC (grupo control). Se comparan ambos grupos y se analizan la duración y presentación del bloqueo, la repercusión hemodinámica y la conducta terapéutica seguida. Resultados. En el 38% de los pacientes del grupo A había BAVC en el momento del ingreso frente al 61% de los del grupo control (p = NS). La duración mediana del bloqueo fue de 75 min (10 min-48 h) en el grupo A y de 24 h (15 min-9 días) (p = 0,004) en el grupo control. Una vez realizada la fibrinólisis, el BAVC tuvo una duración mediana de 45 min (5 min-48 h). Se implantó un marcapasos provisional en 17 pacientes del grupo A (43%) y en 11 del grupo control (84,6%) (p = 0,01). Conclusión. El BAVC en el IAM de localización inferior aparece precozmente. La duración del bloqueo parece ser menor al realizar la fibrinólisis

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