Predictores del uso de la estrategia invasiva precoz en mujeres con síndrome coronario agudo sin elevación de ST / Predictors of the use of the early invasive strategy in women with non-ST-elevation acute coronary syndrome

OBJETIVO: Identificar los determinantes asociados a la estrategia invasiva precoz (EIP) en mujeres con síndrome coronario agudo sin elevación de ST (SCASEST). DISEÑO: Estudio de cohortes retrospectivo. Análisis crudo y ajustado de la realización de EIP mediante regresión logística no condicional. Ámbito: Unidades coronarias participantes en 2010-2011 en el registro ARIAM-SEMICYUC. PACIENTES: Cuatrocientas cuarenta mujeres con SCASEST. Se excluyeron 16 por datos insuficientes y 58 con coronariografía electiva (> 72 h). Variables analizadas: Demográficas, factores de riesgo coronario, medicación previa, comorbilidad. Características clínicas, analíticas, hemodinámicas y electrocardiográficas del episodio. RESULTADOS: Las mujeres tratadas conservadoramente presentaban mayor edad, mayor prevalencia de anticoagulación oral, diabetes, lesiones coronarias previas e insuficiencia cardiaca (p < 0,005), mayor riesgo hemorrágico e isquémico basal (p = 0,05) y mayor frecuencia cardiaca al ingreso (p < 0,05). Tras el ajuste solo la edad mayor de 80 años (OR: 0,48; IC 95%: 0,27-0,82; p = 0,009), las lesiones coronarias conocidas (OR: 0,47; IC 95%: 0,26-0,84, p = 0,011) y la frecuencia cardiaca (OR: 0,98; IC 95%: 0,97-0,99, p = 0,003) se asociaron de forma independiente al tratamiento conservador. El tabaquismo (OR: 2,50; IC 95%: 1,20-5,19; p = 0,013) y el electrocardiograma de alto riesgo (OR: 2,96; IC 95%: 1, 72-4,97; p < 0,001) se asociaron a la EIP. La exclusión de muertes precoces (< 24 h) no alteró estos resultados. CONCLUSIONES: En mujeres con SCASEST el tabaquismo y el electrocardiograma de alto riesgo al ingreso son factores independientes asociados a la EIP. Las lesiones coronarias previas conocidas, la edad > 80 años y el aumento de la frecuencia cardiaca son factores independientes asociados al tratamiento conservador

OBJECTIVE: To identify determinants associated to an early invasive strategy in women with acute coronary syndromes without ST elevation (NSTE-ACS). DESIGN: A retrospective cohort study was made. Crude and adjusted analysis of the performance of the early invasive strategy using logistic regression. SETTING: Coronary Units enrolled in 2010 - 2011 in the ARIAM-SEMICYUC registry. PATIENTS: A total of 440 women with NSTE-ACS were studied. Sixteen patients were excluded due to insufficient data, together with 58 patients subjected to elective coronary angiography (> 72h). Variables analyzed: Demographic parameters, coronary risk factors, previous medication, comorbidity. Clinical, laboratory, hemodynamic and electrocardiographic data of the episode. RESULTS: Women treated conservatively were of older age, had oral anticoagulation, diabetes, previous coronary lesions, and heart failure (p < 0,005), increased baseline bleeding and ischemic risk (p = 0,05) and a higher heart rate upon admission (p < 0,05). After adjustment, only age > 80 years (OR 0,48, 95% CI 0,27 to 0,82, p = 0,009), known coronary lesions (OR 0,47, 95% CI 0,26-0,84, p = 0,011), and heart rate (OR 0,98, 95% CI 0,97-0,99, p = 0,003) were independently associated to conservative treatment. Smoking (OR 2.50, 95% CI 1.20 to 5.19, p = 0,013) and high-risk electrocardiogram (OR 2.96, 95% CI 1.72 to 4.97, p < 0,001) were associated to the early invasive strategy. The exclusion of early deaths (<24h) did not alter these results. CONCLUSIONS: In women with NSTE ACS, smoking and a high-risk electrocardiogram upon admission were independent factors associated to the early invasive strategy. Previous coronary lesions, age > 80 years and increased heart rate were independent factors associated to conservative treatment

[Predictors of the use of the early invasive strategy in women with non-ST-elevation acute coronary syndrome]. / Predictores del uso de la estrategia invasiva precoz en mujeres con síndrome coronario agudo sin elevación de ST.

OBJECTIVE: To identify determinants associated to an early invasive strategy in women with acute coronary syndromes without ST elevation (NSTE-ACS). DESIGN: A retrospective cohort study was made. Crude and adjusted analysis of the performance of the early invasive strategy using logistic regression. SETTING: Coronary Units enrolled in 2010 - 2011 in the ARIAM-SEMICYUC registry. PATIENTS: A total of 440 women with NSTE-ACS were studied. Sixteen patients were excluded due to insufficient data, together with 58 patients subjected to elective coronary angiography (> 72 h). VARIABLES ANALYZED: Demographic parameters, coronary risk factors, previous medication, comorbidity. Clinical, laboratory, hemodynamic and electrocardiographic data of the episode. RESULTS: Women treated conservatively were of older age, had oral anticoagulation, diabetes, previous coronary lesions, and heart failure (p<0.005), increased baseline bleeding and ischemic risk (p=0.05) and a higher heart rate upon admission (p<0.05). After adjustment, only age > 80 years (OR 0.48, 95% CI 0.27 to 0.82, p=0.009), known coronary lesions (OR 0.47, 95% CI 0.26-0.84, p=0.011), and heart rate (OR 0.98, 95% CI 0.97-0.99, p=0.003) were independently associated to conservative treatment. Smoking (OR 2.50, 95% CI 1.20 to 5.19, p=0.013) and high-risk electrocardiogram (OR 2.96, 95% CI 1.72 to 4.97, p<0.001) were associated to the early invasive strategy. The exclusion of early deaths (<24 h) did not alter these results. CONCLUSIONS: In women with NSTE ACS, smoking and a high-risk electrocardiogram upon admission were independent factors associated to the early invasive strategy. Previous coronary lesions, age > 80 years and increased heart rate were independent factors associated to conservative treatment.

[Early invasive strategy in non-ST-segment elevation acute coronary syndrome. The paradox continues]. / Uso de la estrategia invasiva precoz en el síndrome coronario agudo sin elevación de ST. La paradoja continúa.

OBJECTIVE: Observational studies have reported a paradoxical inverse relationship between the use of an early invasive strategy (EIS) and the risk of events in patients with non-ST-segment elevation acute coronary syndrome (NSTE ACS). The study objectives are: 1) to examine the association between baseline risk in patients with NSTE ACS and the use of EIS; and 2) to identify some of the factors independently associated to the use of EIS. DESIGN: Retrospective cohort study. SETTING: Intensive care units participating in the SEMICYUC ARIAM Registry. PATIENTS: Consecutive patients admitted with a diagnosis of NSTE-ACS within 48 hours of evolution between the months of April-July 2010. INTERVENTIONS: None. MAIN OUTCOMES: Coronary angiography with or without angioplasty within 72 hours, risk stratification using the GRACE scale. RESULTS: We analyzed 543 patients with NSTE-ACS, of which 194 were of low risk, 170 intermediate risk and 179 high risk. The EIS was used in 62.4% of the patients at low risk, in 60.2% of those with intermediate risk, and in 49.7% of those at high risk (p for tendency 0.0144). The EIS was used preferentially in patients with low severity and comorbidity. In the logistic regression model, EIS was independently associated to the availability of a catheterization laboratory (OR 2.22 [CI 95% 1.55 to 3.19]), the presence of ST changes on ECG (OR 1.80 [1.23 to 2.64]), or the existence of a low risk of bleeding (OR 0.76 [0.66 to 0.88)]. Conversely, EIS was less prevalent in patients with diabetes (OR 0.60 [0.41 to 0.88]) or tachycardia upon admission (OR 0.54 [0 36 to 0.82]). CONCLUSIONS: In 2010 there remained a lesser relative use of EIS in patients at high risk, due in part to an increased risk of bleeding in these patients.

Indicadores de calidad en el síndrome coronario agudo para el análisis del proceso asistencial pre e intrahospitalario / Quality indicators in the acute coronary syndrome for the analysis of the pre- and in-hospital care process

Se presenta un mapa de 27 indicadores para medir la calidad de la asistencia prestada a los pacientes con síndrome coronario agudo (SCA) que son atendidos en el ámbito pre e intrahospitalario. Se incluyen indicadores de proceso técnicos (registro de los intervalos asistenciales, realización del ECG, monitorización y acceso venoso, evaluación de los riesgos pronóstico, hemorrágico y de mortalidad intrahospitalaria, empleo de técnicas de reperfusión y realización de ecocardiografía), indicadores de proceso farmacológicos (antiagregación plaquetaria, anticoagulación, trombolisis, administración de beta-bloqueantes, inhibidores de conversión de la angiotensina e hipolipemiantes) e indicadores de resultado (escalas de calidad de la atención prestada y mortalidad) (AU)

We present a map of 27 indicators to measure the care quality given to patients with acute coronary syndrome attended in the pre- and hospital area. This includes technical process indicators (registration of care intervals, performance of electrocardiogram, monitoring and vein access, assessment of prognostic risk, hemorrhage and in-hospital mortality, use of reperfusion techniques and performance of echocardiograph), pharmacological process indicators (platelet receptors inhibition, anticoagulation, thrombolysis, beta-blockers, angiotensin converting inhibitors and lipid lowering drugs) and outcomes indicators (quality scales of the care given and mortality) (AU)

[Quality indicators in the acute coronary syndrome for the analysis of the pre- and in-hospital care process]. / Indicadores de calidad en el síndrome coronario agudo para el análisis del proceso asistencial pre e intrahospitalario.

We present a map of 27 indicators to measure the care quality given to patients with acute coronary syndrome attended in the pre- and hospital area. This includes technical process indicators (registration of care intervals, performance of electrocardiogram, monitoring and vein access, assessment of prognostic risk, hemorrhage and in-hospital mortality, use of reperfusion techniques and performance of echocardiograph), pharmacological process indicators (platelet receptors inhibition, anticoagulation, thrombolysis, beta-blockers, angiotensin converting inhibitors and lipid lowering drugs) and outcomes indicators (quality scales of the care given and mortality).

Vigilancia de la infección nosocomial en UCI mediante un ciclo de garantía de calidad / Nosocomial infection surveillance in the intensive care unit through measures designed for quality assurance

Fundamento. Analizar la incidencia de infección nosocomial (IN) en una UCI polivalente de nivel II, y evaluar el efecto de la utilización de sucralfato y la aplicación de medidas estrictas de asepsia sobre las distintas tasas de IN. Material y métodos. Se ha llevado a cabo un estudio prospectivo de cohortes, de 2 años de duración, sobre 400 pacientes distribuidos en dos grupos, grupo A (n = 200), observacional, y grupo B (n = 200), en el que se aplicaron medidas de mejora basadas en la administración de sucralfato, cumplimiento de la profilaxis antibiótica posquirúrgica y medidas estrictas de asepsia en las distintas instrumentalizaciones. Se han comparado las tasas de IN asociada a ventilación mecánica (NAVM), infección urinaria relacionada con sonda uretral, bacteriemia vinculada a infección de catéter venoso central e infección de herida quirúrgica entre ambos grupos, así como la mortalidad intra-UCI. Resultados. En el grupo A, 29 pacientes desarrollaron una o más IN frente a 18 en el grupo B (p = 0,06). No apreciamos diferencias en la mortalidad global intra-UCI entre ambos grupos (10,5 frente a 10 per cent; p = 0,89), aunque sí en la mortalidad de los pacientes con diagnóstico de IN (57,1 frente a 25 per cent; p = 0,03). En aquellos que desarrollaron una NAVM, observamos una reducción no significativa de la tasa de mortalidad (60 frente a 50 per cent; grupo A y B). A pesar de la reducción lograda en los indicadores de IN, el nivel de incumplimientos del protocolo de intervenciones de mejora propuesto para el control de la IN fue elevado. Conclusiones. Nuestros resultados se sitúan en un nivel aceptable dentro del contexto de los estándares admitidos sobre IN en UCI. La instauración de un sistema de vigilancia y la aplicación de medidas de mejora han logrado reducir tanto la incidencia como la mortalidad de la IN, no así la mortalidad global intra-UCI. (AU)

Estudio de un protocolo de desintoxicación rápida en pacientes dependientes de opiáceos en una unidad de cuidados intensivos: resultados preliminares / Study of an ultrashort opiate detoxification protocol in an intensive care unit: preliminary results

Objetivo. Valorar la aplicación de un protocolo de desintoxicación en pacientes dependientes de opiáceos realizado en una unidad de cuidados intensivos (UCI). Métodos. Estudio abierto, prospectivo, realizado en pacientes seleccionados adictos a opiáceos (heroína, metadona, morfina o codeína) según criterios DSM-III o CIE-10.Tras el ingreso en la unidad de desintoxicación hospitalaria (UDH) y en el servicio de cuidados intensivos (UCI) recibían tratamiento farmacológico con agonistas -2-adrenérgicos, antagonistas opiáceos, atropina y sedación controlada con midazolam durante 6 h. Se valoró el síndrome de abstinencia a opiáceos (SAO) y el estado de sedación. El procesamiento estadístico se realizó mediante el paquete SPSS. Resultados. Se han estudiado 20 pacientes dependientes de opiáceos sometidos a una pauta de desintoxicación ultracorta. Todos los pacientes terminaron la desintoxicación sin complicaciones graves en el período establecido. Un caso fue considerado fracaso al obtener una sedación insuficiente. Conclusiones. La desintoxicación rápida a opiáceos puede ser una técnica eficaz y segura. Las posibles complicaciones de este método, por el elevado riesgo intrínseco que conlleva, parecen aconsejar que estos tratamientos sean instaurados en un servicio de cuidados intensivos. La selección de pacientes puede mejorar los resultados (AU)

[Severe acute intoxication treated in the intensive care unit in 1986-1997]. / Intoxicaciones agudas graves en un servicio de medicina intensiva (1986-1997).

BACKGROUND: To ascertain the epidemiology of the severe acute intoxications in an intensive care unit and to assess the PCR prognosis and death rate related to the different toxic substances. METHODS: Retrospective study conducted in the 10-bed polyvalent intensive care unit at a General Hospital for adult care. Study conducted over a 12-year period. Review of the clinical histories of the patients admitted as a result of severe acute intoxications. Data was gathered regarding demographic aspects. PCR at admission, need to VM, complications of the severe acute intoxications and death rate for the series. An overall as well as a year-by-year analysis was conducted. The data was processed statistically employing the SPSS package using the Student "t" or the Chi-square, taking values as being significant if p < 0.05. RESULTS: 233 subjects, 130 of whom were males, were included in this study. The average stay totaled 4 days. Sixty-three percent (63%) of the patients were under 40 years of age (p < 0.05). The most frequent type of intoxication was that caused by one single medication (72%). The survival rate following the PCR was 40% (4/10). The overall death rate totaled 5.6% (n = 13), 92% of the subjects who later died having been required VM at some point in time during their stay in the intensive care unit. CONCLUSIONS: In our environment, the most frequent type of intoxication is that which is caused by medication. The death rate has been revealed to depend upon the intentional aspect, however as being independent of the type of toxic substance (medication or non-medication). The PCR related to severe acute intoxication has a better prognosis for our series than that related to other diseases and disorders. The VM for severe acute intoxications has a low death rate (15.7%).