Evolution in the management of acute myocardial infarction in the autonomous community of valencia (Spain): ten years of the primvac registry (1995-2004).

INTRODUCTION AND OBJECTIVES: Several registries of acute myocardial infarction (AMI) have been carried out in Spain, but few remain active. This work analyses the evolution of the characteristics and control of patients with AMI during the first 10 years of the PRIMVAC registry, initiated in 1995. METHODS: The demographical and clinical characteristics, therapeutic-diagnostic procedures and pharmacological treatment of patients admitted with AMI between January 1995 and December 2004, were analysed in 17 coronary centres in the Autonomous Community of Valencia (South eastern Spain). RESULTS: The mean age of the 19,719 patients recruited was of 65. The percentage of women, hypertension, hypercholestrolemia and diabetes increased during registry period. The median time of symptoms onset-hospital arrival was 151 minutes, without a decrease over the time, and the delay of thrombolysis fell from 200 to 154 minutes (p<0.01). Percentage of thrombolytic treatment oscillated between 39% and 48%. The mortality in the coronary units decreased (14.1% vs. 8.9%; p<0.001). The number of coronary angiography and percutaneous revascularisation performed increased up to 61% and 32%, respectively, of patients included. On discharge, the use of beta-blockers (29.3% vs. 66.7%), angiotensin-converting enzyme (ACE) inhibitors (41.7% vs. 57.9%) and statins (29.3% vs. 71%) went up. CONCLUSIONS: Overall mortality in the coronary unit decreased, without any variation in the incidence of serious complications. Time to thrombolysis was reduced over the time, with no significant increment in its use. The performance of coronary angiography and percutaneous revascularisation increased, with a low use of primary angioplasty. The use of beta-blockers, ACE inhibitors and statins increased at discharge.

Smoking and myocardial infarction case-fatality: hospital and population approach.

BACKGROUND: Smoking is a risk factor for coronary heart disease, but it has been associated with better short-term prognosis in hospitalized patients with acute myocardial infarction. The aims of this study were to determine the association between smoking and myocardial infarction 28-day case-fatality in hospitalized patients and at the population level; and, whether smokers presenting with fatal myocardial infarction are more likely to die before reaching a hospital. DESIGN AND METHODS: Population-based myocardial infarction registry, carried out in 1997-1998 in seven regions of Spain, used standardized methods to find and analyze suspected myocardial infarction patients (10 654 patients; 7796 hospitalized). Four categories of smoking status were defined: never-smokers, former smokers for more than 1 year, former smokers for less than 1 year, and current smokers. RESULTS: The main end-point was 28-day case-fatality, found to be 20.1, 17.1, 15.6, and 8.9%, in the four smoking status categories, respectively, for hospitalized patients; and 37.4, 33.0, 24.5, and 23.2%, respectively, at population level. Hospitalized current smokers had lower age, sex, and comorbidity-adjusted 28-day case-fatality than never-smokers (odds ratio=0.71; 95% confidence interval: 0.56-0.90). This association held at population level (odds ratio=0.68; 95% confidence interval: 0.60-0.76), in which former smoking was also associated with lower case-fatality. In fatal cases, recent former smokers presented a lower risk of out-of-hospital death than never-smokers (odds ratio=0.47; 95% confidence interval: 0.29-0.77), whereas current smoking was marginally associated with out-of-hospital death (odds ratio=1.22; 95% confidence interval: 0.99-1.50). CONCLUSIONS: Current smoking is associated with lower 28-day case-fatality in hospitalized myocardial infarction patients. This association held at population level. Among fatal cases, smoking is associated with higher and recent former smoking with lower risk of dying out-of-hospital.

Septal rupture with right ventricular wall dissection after myocardial infarction.

BACKGROUND: In patients with inferior myocardial infarction, septal rupture generally involves basal inferoposterior septum, and the communicating tract between left and right ventricle is often serpiginous with a variable degree of right ventricular wall extension. Right ventricular wall dissection following septal rupture related with previous myocardial infarction has been reported in a very few cases, in many of them this condition has been diagnosed in post-mortem studies. In a recent report long-term survival has been achieved after promptly echocardiographic diagnosis and surgical repair. CASE PRESENTATION: We present a case of a 59-year-old man who had a septal rupture with right ventricular wall dissection after inferior and right ventricular myocardial infarction. Transthoracic echocardiography, as first line examination, established the diagnosis, and prompt surgical repair allowed long-term survival in our patient. CONCLUSION: Outcomes after right ventricular intramyocardial dissection following septal rupture related to myocardial infarction has been reported to be dismal. Early recognition of this complication using transthoracic echocardiography at patient bedside, and prompt surgical repair are the main factors to achieve long-term survival in these patients.

[Mortality of myocardial infarction in the PRIMVAC registry. Prognostic factors]. / Mortalidad del infarto de miocardio en el registro PRIMVAC. Factores pronósticos.

BACKGROUND AND OBJECTIVE: The aim of this study was to determine the mortality due to acute myocardial infarction in the coronary units from Comunidad Valenciana (Spain) and the prognostic factors associated with a higher mortality. PATIENTS AND METHOD: Demographic characteristics, coronary risk factors, electrocardiographic ischemic signs, complications and mortality of patients with acute myocardial infarction admitted in the coronary units were collected. The study period comprised January 1995-December 1999. Death incidence was measured during coronary unit's stay. Factors associated with poor prognosis were analyzed. RESULTS: 10.213 patients entered into the study. Mean age at admission was 65 12 years. 23.8% were females (76.2% males). Global mortality in coronary units was 13.3%. Independent variables associated with higher mortality were (p < 0.05): advanced age (OR=1.06 [1.05-1.06]), female sex (OR=1.45 [1.26-1.66]), diabetes mellitus (OR=1.53 [1.35-1.74]), previous myocardial infarction (OR=1.46 [1.23-1.70]), previous angor pectoris (OR=1.29 [1.13-1.49]) and Q-wave infarction (OR=1.23 [1.03-1.43]). Factors associated with lower mortality were: hypercholesterolemia (OR=0.76 [0.66-0.78]), smoking (OR=0.65 [0.57-0.74]) and thrombolysis (OR=0.85 [0.78-0.92]). CONCLUSIONS: At present, in the reperfusion therapy era, acute myocardial infarction has a high mortality after coronary unit admission. Several clinical factors are associated with a worse prognosis.

Midterm clinical and echocardiographic results with patch glue repair of left ventricular free wall rupture.

BACKGROUND: Left ventricular free wall rupture (LVFWR) is a dramatic complication after myocardial infarction. We present our mid-term clinical and echocardiographic results of LVFWR with an epicardial patch without cardiopulmonary bypass. METHODS: From February 1993 to May 2001, 17 patients underwent surgery for LVFWR. The mean age+/-SD of 12 males and 5 females was 68+/-10 years. All patients presented for emergency surgery with cardiac tamponade confirmed on echocardiography. After opening the chest and identification of the site of rupture, a Goretex patch was fashioned and applied with enbucrilate surgical glue. RESULTS: Effective control of bleeding was achieved in all cases. There were no on-table deaths. The operative (30 day) mortality was 23.5% (4/17). One death occurred because of patch failure, two because of cardiogenic shock, and one from pneumonia. On follow-up at a median of 2.2 years (interquartile range, 1.1 to 4.3 years), two further deaths occurred, one from myocardial infarction and another of undetermined etiology. Echocardiography did not reveal any evidence of restriction to left ventricular free wall motion. CONCLUSIONS: Patch glue repair is expedient, simple and effective; with no adverse effects on mid-term ventricular dynamics. In view of superior published results to infarctectomy and repair with extra corporeal circulation, it should be considered to be the initial procedure of choice for the surgical repair of LVFWR.

[Acute myocardial infarction in patients under 45 years]. / Infarto agudo de miocardio en pacientes menores de 45 años.

INTRODUCTION AND OBJECTIVE: To evaluate the differential features of acute myocardial infarction in patients younger than 45 years old compared to older patients. PATIENTS AND METHODS: From 1995 to 1999, delays in the assistance, evaluation, and therapeutic strategies as well as complications in patients hospitalized with a diagnosis of acute myocardial infarction, have been registered in the intensive care units of the 17 hospitals participating in the PRIMVAC Register. RESULTS: During the study, 10,213 patients were registered, 6.8% younger than 45 years old (691 patients). Young patients show a greater prevalence of cigarette smoking (80.9 vs 34.1%; p < 0.0001) and hypercholesterolemia (39.9 vs 28.6%; p < 0.0001), whereas arterial hypertension, diabetes, and history of coronary disease were significantly more frequent in the older group. This subgroup reached the healthcare system at an earlier stage (120 vs 160 min; p < 0.0001). Thrombolysis was performed in 59.9% of patients younger than 45 years and in 45.9% of patients older than 45 years. Young patients were more frequently given aspirin (94.5%), heparin (70.6%), and beta-blocker drugs (38.4%), whereas patients older than 45 years were given a higher percentage of ACEI, digoxin, and inotropic drugs. Younger patients had a better prognosis and a lower mortality rate (3.5 vs 14%; p < 0.00001). CONCLUSIONS: Acute myocardial infarction in patients younger than 45 years had different clinical features and responded to different therapeutic and diagnostic approaches than acute myocardial infarction in patients over 45 years, as well as a better short-term prognosis.

Infarto agudo de miocardio en pacientes menores de 45 años / Acute Myocardial Infarction in Patients Under 45

Introducción y objetivo. Evaluar las características diferenciales del infarto agudo de miocardio en el paciente joven (menor de 45 años) en relación con el paciente de mayor edad.Pacientes y métodos. Se han recogido las características clínicas, retrasos en la asistencia, estrategias diagnósticas y terapéuticas y complicaciones de los pacientes ingresados con diagnóstico de infarto agudo de miocardio entre los años 1995 y 1999 en las unidades de cuidados intensivos de los 17 hospitales que participan en el registro PRIMVAC.Resultados. Se han registrado 10.213 pacientes, de los cuales el 6,8 por ciento tenía una edad menor de 45 años (691pacientes). Los pacientes jóvenes presentan una mayor prevalencia de tabaquismo (80,9 frente a 34,1 por ciento; p < 0,0001) e hipercolesterolemia (39,9 frente a 28,6 por ciento; p < 0,0001), mientras que la hipertensión arterial, la diabetes y los antecedentes de enfermedad coronaria son significativamente superiores en el grupo de mayor edad.Este subgrupo contacta antes con el sistema sanitario (120 frente a 160 min; p < 0,0001). La trombólisis se realizó en el 59,9 por ciento de los pacientes jóvenes en comparación con el 45,9 por ciento de los pacientes mayores de 45 años.Los pacientes jóvenes recibieron más frecuentemente aspirina (94,5 por ciento), heparina (70,6 por ciento) y bloqueadores beta (38,4 por ciento), mientras que la administración de IECA, digoxina e inotrópicos fue superior en los mayores de 45 años.Los pacientes jóvenes tuvieron un pronóstico mejor, con una menor mortalidad (3,5 frente a 14 por ciento; p < 0,00001).Conclusiones. El infarto agudo de miocardio en el paciente joven presenta unas características clínicas y un tratamiento diagnóstico y terapéutico diferentes respecto al grupo de mayor edad, así como un pronóstico a corto plazo más favorable (AU)

Fibrosis endomiocárdica. Presentación como una tumoración ventricular derecha / Endomyocardial Fibrosis. Presentation as a Right Ventricular Tumor

La fibrosis endomiocárdica es una rara enfermedad en nuestro medio, que suele manifestarse como un cuadro de insuficiencia cardíaca congestiva lentamente progresiva y en la que la ecocardiografía bidimensional es una herramienta diagnóstica fundamental. La asociación con bloqueo auriculoventricular avanzado es excepcional. El tratamiento de elección en pacientes sintomáticos es quirúrgico. Presentamos el caso de un paciente con cuadro clínico de insuficiencia cardíaca congestiva secundaria a fibrosis endomiocárdica, con bloqueo auriculoventricular avanzado e imagen ecocardiográfica atípica de masa de aspecto poliquístico implantada en la pared libre del ventrículo derecho (AU)