Evaluación del haz espinotalámico mediante tractografía por resonancia magnética: nuevos aportes en la fisiopatología del dolor en pacientes con síndrome X / Spinothalamic Assessment by Magnetic Resonance Tractography: new Contributions in the Pathophysiology of Pain in Patients with Syndrome X

Introducción El síndrome X se asocia con signos y síntomas de isquemia, sin obstrucción significativa de las arterias coronarias. En los pacientes con este síndrome existe un aumento en la percepción de los estímulos cardíacos, aunque la causa de este trastorno se desconoce. Objetivo Explorar los tractos nerviosos sensitivos involucrados en la percepción anormal del dolor en mujeres que sufren de síndrome X. Material y métodos Estudio prospectivo que incluyó 24 mujeres: 12 con síndrome X, 6 con enfermedad coronaria documentada y 6 controles sanas. Se realizó el mapeo del tracto espinotalámico lateral mediante tractografía por difusión. Se analizaron las características anatómicas (líneas, vóxels, longitud) y físicas (anisotropía fraccional, coeficiente de difusión aparente, difusividad) de cada tracto. Resultados El haz espinotalámico lateral se pudo aislar en todas las pacientes evaluadas. No hubo diferencias en las características físicas de los tractos, pero existió una diferencia significativa en el número de vóxels de los tres grupos a expensas del grupo síndrome X (101,2 ± 46,9 vs. 83,2 ± 24 vs. 66 ± 16; p = 0,030), con una tendencia a presentar un número mayor de líneas en cada tracto. Conclusiones Se hallaron diferencias en las características anatómicas de los tractos de las pacientes con síndrome X respecto de los controles sanos y de las pacientes con enfermedad coronaria, con indemnidad en las características físicas de las fibras. Es probable que este estudio experimental sea el primero en demostrar que es posible evaluar in vivo los tractos neurológicos involucrados en la transmisión del dolor en este grupo de pacientes, lo cual abre un nuevo campo de investigación.(AU)

Background Syndrome X is associated with signs and symptoms of ischemia without significant coronary artery obstruction. There is an increased perception of cardiac stimuli in these patients, although the cause of this disorder is unknown. Objective The aim of this study was to analyze sensory nerve tracts involved in abnormal perception of pain in women with syndrome X. Methods This prospective study included 24 women: 12 with syndrome X; 6 with documented coronary heart disease, and 6 healthy controls. Lateral spinothalamic tract mapping by diffusion trac-tography was performed. The anatomic features (lines, voxels, and length) and physical features (fractional anisotropy, apparent diffusion coefficient, diffusivity) of each tract were analyzed. Results The lateral spinothalamic tract was isolated in all patients. No differences were found in the physical characteristics of the tracts, but there was a significant difference in the number of voxels of the syndrome X group when compared to the other two groups (101.2±46.9 vs. 83.2±24 vs. 66±16; p=0.030), with a tendency towards larger number of lines in each tract. Conclusions There were differences in the anatomic characteristics of tracts in syndrome X patients with respect to healthy controls and coronary artery disease patients, with indemnity in the physical characteristics of the fibers. This is probably the first experimental study to show that it is possible to evaluate "in vivo" neurological tracts involved in pain transmission in syndrome X patients, opening a new field of research.(AU)

Evaluación del haz espinotalámico mediante tractografía por resonancia magnética: nuevos aportes en la fisiopatología del dolor en pacientes con síndrome X / Spinothalamic Assessment by Magnetic Resonance Tractography: new Contributions in the Pathophysiology of Pain in Patients with Syndrome X

Introducción El síndrome X se asocia con signos y síntomas de isquemia, sin obstrucción significativa de las arterias coronarias. En los pacientes con este síndrome existe un aumento en la percepción de los estímulos cardíacos, aunque la causa de este trastorno se desconoce. Objetivo Explorar los tractos nerviosos sensitivos involucrados en la percepción anormal del dolor en mujeres que sufren de síndrome X. Material y métodos Estudio prospectivo que incluyó 24 mujeres: 12 con síndrome X, 6 con enfermedad coronaria documentada y 6 controles sanas. Se realizó el mapeo del tracto espinotalámico lateral mediante tractografía por difusión. Se analizaron las características anatómicas (líneas, vóxels, longitud) y físicas (anisotropía fraccional, coeficiente de difusión aparente, difusividad) de cada tracto. Resultados El haz espinotalámico lateral se pudo aislar en todas las pacientes evaluadas. No hubo diferencias en las características físicas de los tractos, pero existió una diferencia significativa en el número de vóxels de los tres grupos a expensas del grupo síndrome X (101,2 ± 46,9 vs. 83,2 ± 24 vs. 66 ± 16; p = 0,030), con una tendencia a presentar un número mayor de líneas en cada tracto. Conclusiones Se hallaron diferencias en las características anatómicas de los tractos de las pacientes con síndrome X respecto de los controles sanos y de las pacientes con enfermedad coronaria, con indemnidad en las características físicas de las fibras. Es probable que este estudio experimental sea el primero en demostrar que es posible evaluar in vivo los tractos neurológicos involucrados en la transmisión del dolor en este grupo de pacientes, lo cual abre un nuevo campo de investigación.

Background Syndrome X is associated with signs and symptoms of ischemia without significant coronary artery obstruction. There is an increased perception of cardiac stimuli in these patients, although the cause of this disorder is unknown. Objective The aim of this study was to analyze sensory nerve tracts involved in abnormal perception of pain in women with syndrome X. Methods This prospective study included 24 women: 12 with syndrome X; 6 with documented coronary heart disease, and 6 healthy controls. Lateral spinothalamic tract mapping by diffusion trac-tography was performed. The anatomic features (lines, voxels, and length) and physical features (fractional anisotropy, apparent diffusion coefficient, diffusivity) of each tract were analyzed. Results The lateral spinothalamic tract was isolated in all patients. No differences were found in the physical characteristics of the tracts, but there was a significant difference in the number of voxels of the syndrome X group when compared to the other two groups (101.2±46.9 vs. 83.2±24 vs. 66±16; p=0.030), with a tendency towards larger number of lines in each tract. Conclusions There were differences in the anatomic characteristics of tracts in syndrome X patients with respect to healthy controls and coronary artery disease patients, with indemnity in the physical characteristics of the fibers. This is probably the first experimental study to show that it is possible to evaluate "in vivo" neurological tracts involved in pain transmission in syndrome X patients, opening a new field of research.

Estimation of coronary length-volume allometric relations of human arteries in vivo using CT.

Assessing the individual geometry of the coronary arteries in a patient can help to explain diffuse artery disease. Some allometric functions, relating arterial length and volume, were verified in porcine arteries and human autopsies but not in vivo. In this work we use skeletonization methods on MSCT images to render the whole coronary tree in healthy and cardiovascular patients. Twenty patients with and without coronary artery disease were recruited. The coronary was segmented with minimum user intervention. Vessels were separated and measured. A 3D coronary map was individually calculated. The allometric length-volume function L=k(v)V(ß) was evaluated in each patient and plotted in a Log-Log scale. The coefficient k(v) ranged 1.00 ± 0.35. Slopes ranged ß = 0.69-0.88 and seemed to overlap in the scatter Log plot. The analysis of covariance verified this perception and concluded that lines were parallel. In other words, the allometric function stood for all patients. Values were not different from other studies in humans and pigs. The combination of multislice CT with morphological extraction algorithms was effective to extract allometric functions from coronary arteries in patients and can be easily applied in the clinic.

Clínica y seguimiento de la pericarditis constrictiva crónica / Clinical finding and follow up of chronic constrictive pericarditis

El objetivo de este estudio fue describir la etiología, presentación clínica, métodos diagnósticos, tratamiento, evolución y pronóstico alejado de 35 pacientes con pericarditis constrictiva crónica que fueron evaluados prospectivamente de acuerdo a un protocolo de enfermedad pericárdica que se aplica en nuestra Institución. En 24 (68%) la pericarditis constrictiva fue idiopática y 11 (32%) presentaron etiología definida, realizándose pericardiectomía en 34 (97%). Hubo 4 (12%) muertes intrahospitalarias, todas con etiología definida. La mediana de seguimiento fue de 5.6 años (percentilos 25-75: 2.4-7.4 años). La supervivencia de acuerdo al método de Kaplan-Meier fue de 97% al año (IC 95% 80 - 99%), 83% a los 5 años (IC 95% 65 - 93%), 78% a los 7 años (IC 95% 60 - 90%), y 69% a los 10 años (IC 95% - 50% - 84%). En conclusión, la pericarditis constrictiva crónica es una enfermedad generalmente idiopática, de diagnóstico tardío, cuyo tratamiento es la pericardiectomía. Los pacientes con etiología específica presentaron mayor mortalidad intrahospitalaria. En el seguimiento a 10 años 2/3 de los pacientes están vivos y con mejoría de los síntomas.

The aim of this study was to describe the etiology, clinical findings, diagnostic methods, treatment, outcome and long-term prognosis of 35 patients with chronic constrictive pericarditis (CCP) that were prospectively analyzed according to a pericardial disease protocol performed in our Institution. Etiology of CCP was idiopathic in 24 patients (68%), and specific in 11 (32%). The majority (34 patients, 97%) underwent pericardiectomy. Perioperative mortality was 12% (4/33) no deaths were registered among patients with idiopathic CCP. Median follow-up was 5.6 years (percentile 25-75: 2.4-7.4 years). The cumulative actuarial survival probability was 97% at 1 year (confidence interval [CI] 80% to 99%); 83% at 5 years, (95% CI 65% to 93%); 78% at 7 years, (95% CI 60% to 90%), and 69% at 10 years (95% CI 50% to 84%). In conclusion, nowadays CCP is generally an idiopathic disease with late diagnosis. The clinical course of the disease produces severe symptoms of congestive heart failure. In a 10 years follow-up 2/3 of patients are alive and improved their quality of life. Idiopathic form of pericarditis did not show mortality during early postoperative period.

Age and sex differences, and changing trends, in the use of evidence-based therapies in acute coronary syndromes: perspectives from a multinational registry.

BACKGROUND: A limited number of studies have examined the age and sex differences, and potentially changing trends, in cardiac medication and procedure use in patients hospitalized with an acute coronary syndrome (ACS). METHODS: Using data from a large multinational study, we examined the age and sex differences, and changing trends (1999-2007) therein, in the hospital use of evidence-based therapies in patients hospitalized with an ACS using data from the Global Registry of Acute Coronary Events (n=50 096). RESULTS: After adjustment for several variables, in comparison with men below 65 years, patients in other age-sex strata had a significantly lower odds of receiving aspirin [odds ratios (ORs) for men 65-74, 75-84, and >or=85 years, women <65, 65-74, 75-84, and >or=85 years were 0.86, 0.84, 0.72, 0.80, 0.86, 0.68 and 0.46, respectively], angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers (ORs, 1.08, 1.01, 0,71, 0.83, 0.90, 0.89, and 0.63), beta blockers (ORs, 0.66, 0.52, 0.53, 0.67, 0.54, 0.53, and 0.52), statins (ORs, 0.72, 0.49, 0.29, 0.82, 0.68, 0.44, and 0.22), and undergoing coronary artery bypass graft surgery or a percutaneous coronary intervention (ORs, 0.79, 0.53, 0.21, 0.64, 0.57, 0.38, and 0.13) during their acute hospitalization. Age and sex differences in the receipt of these therapies remained relatively unchanged during the period under study. CONCLUSION: Although there were increasing trends in the use of evidence-based medications and cardiac procedures over time, important gaps in the utilization of effective cardiac treatment modalities persist in elderly patients and younger women.

Coronary arteries simplified with 3D cylinders to assess true bifurcation angles in atherosclerotic patients.

The geometry of coronary arteries affects regional atherogenic processes. Accurate images can be assessed using multislice computer tomography (MSCT) to estimate bifurcations angles. We propose a three-dimensional (3D) method to measure true bifurcation angles of coronary arteries and to determine possible correlations between plaque presence and angulations. The left main (LM) coronary artery, left anterior descendent (LAD) and left circumflex artery (LCX) were imaged in 40 atherosclerotic and 35 healthy patients, using 64-rows MSCT. This Y-junction was simplified fitting a 3D cylinder to each vessel to estimate true bifurcation angles and diameters. The method was tested in phantoms and interobserver variability was assessed. Geometrical results were compared between groups using an unpaired t-test. The cylinders fitted reasonably well with mean distances to measured points below 0.4 mm. LAD-LCX bifurcation angles were wider in the atherosclerotic group (p < 0.01). LAD (p < 0.01) and LCX (p < 0.05) diameters were also larger. In phantoms mean absolute difference between true and estimated angles (N = 27) was 0.44 +/- 0.54 degrees . Interobserver mean difference (N = 135) was 1.8 +/- 5.8 degrees . Simplifying coronary bifurcation with cylinders results in a reliable technique to assess coronary artery geometry in 3D, avoiding planar projections and decreasing interobserver variability. Geometrical risk factors should be incorporated to properly predict atherosclerosis processes.

Advances in coronary heart disease surgery in Latin America.

BACKGROUND: The beginnings of coronary artery bypass graft in Latin America could be set in the year 1971. Since then, improvements in technique and greater experience have resulted in a rapid increase in the rate of interventions performed in the region. METHODS AND RESULTS: Searches through PubMed and Literatura Latinoamericana y del Caribe en Ciencias de la Salud, as well as personal communications from specialists from Latin America, have been the source of information. Articles were selected by their content related to the theme, and the authors' nationality and information is mainly from Latin America. Demographic information of the population of Latin America denotes higher age averages, and this implies an increase in the severity of comorbidities in patients who undergo surgery. Longer life expectancy and improvements in medical therapy have implied that patients survive a first intervention beyond the expected time a bypass persists patent. Wall vessel properties of arterial conduits, plus a better anastomotic technique, seem to be the current solution to worsening in the coronary health of patients who undergo revascularization surgery in Latin America. CONCLUSIONS: Despite scarce economic investment in medical sciences, many academic groups contribute to the exploration of therapeutic pharmacological combinations and inclusively apply genetic strategies.

Invasive vs non-invasive treatment in acute coronary syndromes and prior bypass surgery.

BACKGROUND: We evaluated the association between invasive and non-invasive management and hospital and 6-month outcomes in patients with a prior coronary artery bypass graft (CABG) who experienced an acute coronary syndrome. METHODS: Data were analysed from patients with a prior CABG who developed an acute coronary syndrome and were enrolled in the Global Registry of Acute Coronary Events. From 44,991 patients included in the study, 3853 fulfilled the inclusion criteria. Of these, 3356 received non-invasive treatment approaches while 497 underwent invasive treatment (percutaneous coronary intervention [PCI] within 48 h of admission). RESULTS: The primary composite endpoint of death, non-fatal myocardial infarction, and recurrent ischaemia during hospitalization was similar in patients in the non-invasive and invasive groups (31% vs 30%, respectively; P=0.53). The rates of hospital mortality (non-invasive 3.4% vs invasive 3.2%) and non-fatal myocardial infarction (3.4% vs 5.1%, respectively) were similar. At 6-month follow-up, the mortality rate was 6.5% in the non-invasive group vs 3.4% in the invasive group (P<0.02); the combined endpoint of death or myocardial infarction was lower in the invasive group (P<0.01). Multivariable analysis showed that, at 6-month follow-up, the combined endpoint of death, non-fatal myocardial infarction, and rehospitalization for heart disease was similar (P=0.10). A greater proportion of patients in the invasive group required unscheduled diagnostic and therapeutic invasive procedures compared with those in the non-invasive group (angiography 15.4% vs 8.1%; PCI 10% vs 5.0%; both P<0.001). CONCLUSIONS: The results from this observational study show no statistically significant differences in hospital outcomes between acute coronary syndrome patients with a prior CABG who undergo invasive or non-invasive treatment. Invasively treated patients experienced higher rates of readmission and additional cardiac procedures than non-invasively treated patients but a lower incidence of cardiovascular complications at 6 months.

Prevention of myocardial infarction.

PURPOSE OF REVIEW: There is an enormous literature on the prevention of myocardial infarction. However, most articles are focused categorically on evidence-based medicine and give no room for conceptual analyses. In this article, we attempt to review the main aspects of this theme from a different point of view. RECENT FINDINGS: In the last decade, scientists have encouraged the understanding and gradual application of genetics in the study of common diseases. This is one of the main angles from which we try to review the prevention of myocardial infarction. Another important factor is the consideration of cost-effectiveness. Consequently, we remark on the value of interventions that can have an impact on cost. SUMMARY: In preventing myocardial infarction modern physicians should emphasize the importance of behavioral and cultural changes and learn from genetic advances in restoring the delicate balance that is altered in atherosclerotic disease.

Valor del BNP y de la proteína C reactiva en el diagnóstico diferencial entre angina primaria y secundaria por hipertensión arterial / Value of BNP and C reactive protein testing in the differential diagnosis between primary angina and hypertension-related angina

Introducción: A los episodios de inestabilidad anginosa precipitados por causas secundarias que, no infrecuentemente, no pueden discernirse de razones primarias se les concede poca atención. El presente trabajo intenta responder si algunos biomarcadores pueden contribuir a identificar a aquellos individuos con angina IIIb de los conocidos como anginosos IIIa de la clasificación de Braunwald. Material y métodos: En total, participaron del ensayo 64 pacientes seleccionados. De éstos, 33 tuvieron diagnóstico final de angina inestable secundaria a hipertensión arterial y 21 de angina primaria, en tanto que 10 enfermos anginosos estables, referidos para la práctica de un estudio angiográfico diagnóstico, sirvieron de control. En todos ellos, en el momento de la admisión se obtuvieron alícuotas de sangre venosa para la determinación del péptido natriurético auricular tipo B (BNP) y de proteína C reactiva ultrasensible (hs-CRP), y luego se realizó un estudio angiográfico invasivo a fin de analizar la carga aterosclerótica con puntajes (scores)angiográficos. Resultados: Los pacientes con angina primaria tuvieron una extensión aterosclerótica mayor en la angiografía (p < 0,025), más vasos comprometidos (p = 0,029) y un porcentaje mayor de estenosis (p < 0,001) que los anginosos secundarios. Los pacientes controles presentaron valores de BNP de 133 pg/mL (41; 224) [mediana (percentiles 25 y 75] y de 1,6 mg/L (0,4; 3,6) de hs-CRP. Los anginosos primarios no difirieron de los controles: 129 (95; 231) y 4,0(2,0; 5,6) para BNP y hs-CRP, respectivamente. Los anginosos secundarios tuvieron valores de 73 (19; 325) y de 4,5 (2,2; 9,0), respectivamente. No hubo diferencias significativas entre ambos cuadros anginosos: p = 0,458 para BNP y p = 0,552 para hs-CRP. Conclusiones: Independientemente de la carga aterosclerótica elevada en los anginosos primarios, el BNP y la hs-CRP no reconocieron con precisión la inestabilidad clínica inducida por un accidente de placa de la inducida...(AU)

Valor del BNP y de la proteína C reactiva en el diagnóstico diferencial entre angina primaria y secundaria por hipertensión arterial / Value of BNP and C reactive protein testing in the differential diagnosis between primary angina and hypertension-related angina

Introducción: A los episodios de inestabilidad anginosa precipitados por causas secundarias que, no infrecuentemente, no pueden discernirse de razones primarias se les concede poca atención. El presente trabajo intenta responder si algunos biomarcadores pueden contribuir a identificar a aquellos individuos con angina IIIb de los conocidos como anginosos IIIa de la clasificación de Braunwald. Material y métodos: En total, participaron del ensayo 64 pacientes seleccionados. De éstos, 33 tuvieron diagnóstico final de angina inestable secundaria a hipertensión arterial y 21 de angina primaria, en tanto que 10 enfermos anginosos estables, referidos para la práctica de un estudio angiográfico diagnóstico, sirvieron de control. En todos ellos, en el momento de la admisión se obtuvieron alícuotas de sangre venosa para la determinación del péptido natriurético auricular tipo B (BNP) y de proteína C reactiva ultrasensible (hs-CRP), y luego se realizó un estudio angiográfico invasivo a fin de analizar la carga aterosclerótica con puntajes (scores)angiográficos. Resultados: Los pacientes con angina primaria tuvieron una extensión aterosclerótica mayor en la angiografía (p < 0,025), más vasos comprometidos (p = 0,029) y un porcentaje mayor de estenosis (p < 0,001) que los anginosos secundarios. Los pacientes controles presentaron valores de BNP de 133 pg/mL (41; 224) [mediana (percentiles 25 y 75] y de 1,6 mg/L (0,4; 3,6) de hs-CRP. Los anginosos primarios no difirieron de los controles: 129 (95; 231) y 4,0(2,0; 5,6) para BNP y hs-CRP, respectivamente. Los anginosos secundarios tuvieron valores de 73 (19; 325) y de 4,5 (2,2; 9,0), respectivamente. No hubo diferencias significativas entre ambos cuadros anginosos: p = 0,458 para BNP y p = 0,552 para hs-CRP. Conclusiones: Independientemente de la carga aterosclerótica elevada en los anginosos primarios, el BNP y la hs-CRP no reconocieron con precisión la inestabilidad clínica inducida por un accidente de placa de la inducida...(AU)

Valor del BNP y de la proteína C reactiva en el diagnóstico diferencial entre angina primaria y secundaria por hipertensión arterial / Value of BNP and C reactive protein testing in the differential diagnosis between primary angina and hypertension-related angina

Introducción: A los episodios de inestabilidad anginosa precipitados por causas secundarias que, no infrecuentemente, no pueden discernirse de razones primarias se les concede poca atención. El presente trabajo intenta responder si algunos biomarcadores pueden contribuir a identificar a aquellos individuos con angina IIIb de los conocidos como anginosos IIIa de la clasificación de Braunwald. Material y métodos: En total, participaron del ensayo 64 pacientes seleccionados. De éstos, 33 tuvieron diagnóstico final de angina inestable secundaria a hipertensión arterial y 21 de angina primaria, en tanto que 10 enfermos anginosos estables, referidos para la práctica de un estudio angiográfico diagnóstico, sirvieron de control. En todos ellos, en el momento de la admisión se obtuvieron alícuotas de sangre venosa para la determinación del péptido natriurético auricular tipo B (BNP) y de proteína C reactiva ultrasensible (hs-CRP), y luego se realizó un estudio angiográfico invasivo a fin de analizar la carga aterosclerótica con puntajes (scores)angiográficos. Resultados: Los pacientes con angina primaria tuvieron una extensión aterosclerótica mayor en la angiografía (p < 0,025), más vasos comprometidos (p = 0,029) y un porcentaje mayor de estenosis (p < 0,001) que los anginosos secundarios. Los pacientes controles presentaron valores de BNP de 133 pg/mL (41; 224) [mediana (percentiles 25 y 75] y de 1,6 mg/L (0,4; 3,6) de hs-CRP. Los anginosos primarios no difirieron de los controles: 129 (95; 231) y 4,0(2,0; 5,6) para BNP y hs-CRP, respectivamente. Los anginosos secundarios tuvieron valores de 73 (19; 325) y de 4,5 (2,2; 9,0), respectivamente. No hubo diferencias significativas entre ambos cuadros anginosos: p = 0,458 para BNP y p = 0,552 para hs-CRP. Conclusiones: Independientemente de la carga aterosclerótica elevada en los anginosos primarios, el BNP y la hs-CRP no reconocieron con precisión la inestabilidad clínica inducida por un accidente de placa de la inducida...

Socio economic crisis and mortality. Epidemiological testimony of the financial collapse of Argentina.

BACKGROUND: Natural disasters, war, and terrorist attacks, have been linked to cardiac mortality. We sought to investigate whether a major financial crisis may impact on the medical management and outcomes of acute coronary syndromes. METHODS: We analyzed the Argentine cohort of the international multicenter Global Registry of Acute Coronary Events (GRACE). The primary objective was to estimate if there was an association between the financial crisis period (April 1999 to December 2002) and in- hospital cardiovascular mortality, with the post-crisis period (January 2003 to September 2004) as the referent. Each period was defined according to the evolution of the Gross Domestic Product. We investigated the demographic characteristics, diagnostic and therapeutic procedures, morbidity and mortality. RESULTS: We analyzed data from 3220 patients, 2246 (69.8%) patients in the crisis period and 974 (30.2%) in the post-crisis frame. The distribution of demographic and clinical baseline characteristics were not significantly different between both periods. During the crisis period the incidence of in-hospital myocardial infarction was higher (6.9% Vs 2.9%; p value < 0.0001), as well as congestive heart failure (16% Vs 11%; p value < 0.0001). Time to intervention with angioplasty was longer during the crisis, especially among public sites (median 190 min Vs 27 min). The incidence proportion of mortality during hospitalization was 6.2% Vs 5.1% after crisis. The crude OR for mortality was 1.2 (95% C.I. 0.87, 1.7). The odds for mortality were higher among private institutions {1.9 (95% C.I. 0.9, 3.8)} than for public centers {1.2 (95% C.I. 0.83, 1.79)}. We did not observe a significant interaction between type of hospital and crisis. CONCLUSION: Our findings suggest that the financial crisis may have had a negative impact on cardiovascular mortality during hospitalization, and higher incidence of medical complications.

Nadroparine calcium or enoxaparine in acute coronary syndrome patients suffering renal insufficiency: The nadroparin versus enoxaparin (NaVe) study design.

In the general population, mild renal impairment is associated with increases risk for coronary artery disease and stroke, suggesting that cardiovascular disease begins to develop early in the natural history of renal dysfunction. Patients with renal failure are known to be at increased risk of death following acute myocardial infarction or congestive heart failure.In such sense, anticoagulation in addition to antiplatelet inhibitor drugs became the standard of care, particularly, among high risk unstable angina patients associated with a scarce side effects.The Nadroparin calcium Versus Enoxaparin (NaVe) Study will evaluate in a head to head basis the anti Xa activity reached by nadroparine or enoxaparine, both low molecular weight heparins, in patients at high risk for ischemic episodes, and renal insufficiency to eventually be undergone to angiographic diagnosis studies, and in consequence proposing the best anticoagulant strategies for these patients before being invasively treated.Patients will be randomly assigned to one of the two groups: Group 1: thirty patients will be given with subcutaneous enoxaparine injections into the abdominal wall in a dose of 0,85 mg/kg every 12 hours for a maximum of 48 hours. A saline infusion dose will be given in between. Total number of injections: 6. Group 2:Thirty patients will be receiving subcutaneous injections into the abdominal wall in a doses of 30% less in relationship with his / her body weight every 8 hours for a maximum of 48 hours.In order to achieve the goal of the study, the antiXa activity will be measure using venous blood samples taken as follows: Group 1:*Within 3rd and 4 hour of the second doses of HBPM for enoxaparine.*Within 11 th and 12 th hour next to fourth doses of enoxaparine. Group 2: *Within 3rd and 4 th hour next to 3rd doses of HBPM for the nadroparine.*Within 7th and 8th hour next to 4th doses HBPM for the nadroparine.The primary end point is to analyze during the in-hospital stay phase the stability of the anti Xa activity within the therapeutic ranges which will be estimated between 0.5 to 1.0 IU during the first 48 hours.

Two-year follow-up of the FLU Vaccination Acute Coronary Syndromes (FLUVACS) Registry.

We have previously determined that there is a significant benefit of vaccination against influenza in patients hospitalized due to an acute coronary event. The purpose of this study is to determine whether the observed benefits of vaccination were maintained over a 2-year follow-up among those who were re-vaccinated during the subsequent winter season. During the winter season of 2001, a total of 301 acute coronary patients were prospectively enrolled within 72 hours of the onset of symptoms. Follow-up was conducted at 6 and 12 months. Patients who survived participated in a registry 1 year after the 2nd influenza vaccination period (winter 2002), as a cohort of chronic and stable coronary patients. The incidence of the primary endpoint cardiovascular death at 1 year was significantly lower in patients receiving vaccination than in controls (6% vs 17%, respectively) by intention-to-treat analysis. The relative risk with vaccination in comparison with controls was 0.34; 95% confidence interval, 0.17-0.71; P = 0.002. In the winter of 2002, 116 patients were vaccinated according to their physicians' instructions, and 114 subjects remained unvaccinated. The combined endpoints of total death plus myocardial infarction 1 year later were 4 (3.4%) in the vaccinated group vs 11 (9.7%) among those who were not vaccinated (P = 0.05). Influenza vaccination may reduce the risk of death and ischemic events in patients admitted with acute coronary syndromes. There is also a beneficial trend in the quiescent phase of ischemia.

Flu vaccination in acute coronary syndromes and planned percutaneous coronary interventions (FLUVACS) Study.

AIMS: We have previously reported a significant benefit of vaccination against flu on the incidence of a single and composite end-point of death, myocardial infarction or recurrent ischaemia in patients with myocardial necrosis and planned percutaneous coronary interventions. To determine whether the observed benefits of vaccination against flu were maintained beyond the winter season a 1-year follow-up was conducted. METHODS AND RESULTS: During the winter season, we enrolled prospectively 200 myocardial infarction patients admitted in the first 72 h, and 101 planned angioplasty/stent patients (PCI) without unstable coronary artery disease, prior by-pass surgery, angioplasty or tissue necrosis. Only four patients failed to meet the inclusion criteria. Participants were randomly allocated to receive flu vaccination or remain unvaccinated on top of standard medication (control group). The study was conducted in hospitalized patients with the aim to test the potential beneficial effect of flu vaccination in a secondary prevention scenario. Under intention to treat analysis the incidence of the primary end-point cardiovascular death at 1 year was significantly lower among patients receiving vaccination, 6% as compared with controls, 17% (relative risk with vaccine as compared with controls, 0.34; 95% confidence interval (CI), 0.17 to 0.71; P=0.002). The triple composite end-point occurred in 22% of the patients in the vaccine group vs 37% in controls, hazard ratio 0.59, 95% CI 0.4 to 0.86) P=0.004. The beneficial effect was mainly detected in acute myocardial infarction patients (four events in the active arm vs 21 in the control group, P=0.0002 [95% CI 0.19, 0.07-0.53]), and Cox regression analyses revealed that there was a greater benefit with flu vaccination in patients at high risk according with the TIMI score, and those with non-ST-segment deviation myocardial infarction (95% CI: 0.13 [0.03-0.52]) CONCLUSIONS: Influenza vaccination may reduce the risk of death and ischaemic events in patients suffering from infarction and post-angioplasty during flu season. This effect was significantly evident at 1-year follow-up. Larger confirmatory studies are needed to evaluate the real impact on flu vaccination on outcome after acute coronary syndromes.

[Flu vaccination in patients with acute coronary syndromes: treatment benefit in prespecified subgroups]. / Vacunación antigripal en pacientes con síndromes coronarios agudos: beneficio del tratamiento en diferentes subgrupos.

BACKGROUND: The first prospective clinical Flu Vaccination in Acute Coronary Syndromes (FLUVACS) Trial has provided some evidence that flu vaccination together with standard therapy may be useful during the winter season to reduce the risk of death and major cardiac events in patients with acute myocardial infarction. PATIENTS AND METHOD: Information available in the FLUVACS database was analyzed to evaluate the efficacy of flu vaccination in different subgroups. Logistic regression was used to identify features related with better therapeutic results. RESULTS: Flu vaccination was effective in reducing the incidence of the composite endpoint (death, nonfatal myocardial reinfarction or recurrent angina prompting urgent revascularization) in most subgroups at 6 months after inclusion. The regression model showed a greater benefit of flu vaccination in patients with no ST-segment elevation or older than 65 years, nonsmokers and patients with a TIMI risk score higher than 6. CONCLUSIONS: Our data suggest that vaccination for secondary prevention of flu during the acute phase of myocardial infarction may be effective in a broad range of patients with acute coronary artery disease, regardless of their initial clinical risk.

Prospective evaluation of clinical outcomes after acute ST-elevation myocardial infarction in patients who are ineligible for reperfusion therapy: Preliminary results from the TETAMI registry nd randomized trial

BACKGROUND: Treatment with lytics or primary percutaneous coronary interventions (PCI) reduces the mortality rate of patients with ST-elevation myocardial infarction (STEMI) presenting within 12 hours. Patients presenting >12 hours are generally considered to be ineligible for reperfusion therapy, and there are currently no specific treatment recommendations for this subgroup.Methods- All patients with STEMI 12 hours. Apart from 34 of these patients who had a stuttering infarction and were referred for reperfusion, the remaining patients did not receive reperfusion therapy.Registry patients who received reperfusion therapy, compared with TETAMI randomized patients (all of whom received antithrombotic therapy) and registry patients who did not receive reperfusion, were younger (61 years versus 63 years and 67 years), were more likely to be male (78% versus 73% and 63%), and had persistent ST-segment elevation as opposed to LBBB or Q waves...

Impact of aspirin on presentation and hospital outcomes in patients with acute coronary syndromes (The Global Registry of Acute Coronary Events [GRACE]).

The long-term use of aspirin (ASA) reduces the risk of subsequent acute coronary syndromes in patients with coronary artery disease (CAD). It is less clear whether ASA therapy benefits patients who develop an acute coronary syndrome despite its use. Baseline characteristics, type of acute coronary syndrome, and in-hospital events were compared on the basis of previous use of ASA in 11,388 patients with and without a history of CAD presenting to 94 multinational hospitals. A total of 73.0% of patients with a history of CAD (n = 4,974) were previously on long-term ASA therapy compared with 19.4% of patients without a history of CAD (n = 6,414). After multivariate regression analysis controlling for various potentially confounding factors, patients with a history of CAD who were previously taking ASA were significantly less likely to present with ST-segment elevation myocardial infarction (MI) (adjusted odds ratio [OR] 0.52, 95% confidence intervals [CI] 0.44 to 0.61) or die during hospitalization (OR 0.69, 95% CI 0.50 to 0.95) in comparison to patients who were not taking ASA. Patients without a history of CAD and who were previously taking ASA also had a lower risk of developing ST-segment elevation MI (OR 0.35, 95% CI 0.30 to 0.40) and a trend toward a decreased hospital death rate (OR 0.77, 95% CI 0.55 to 1.07). These results demonstrate that patients with a history of CAD who present with an acute coronary syndrome despite prior ASA use have less severe clinical presentation, fewer hospital complications, and lower in-hospital death rates than patients not previously taking ASA.