Sin elevación, también puede haber oclusión / Without elevation, there may also be occlusion

Resumen Ante un dolor torácico agudo y evidencia de elevación del segmento ST, se debe instaurar un tratamiento de reperfusión urgente, con el objetivo de abrir la arteria ocluida y minimizar el daño miocárdico y, así, mejorar el pronóstico del paciente. Por ello, es necesario conocer aquellos patrones eléctricos de alto riesgo equivalentes a una elevación del segmento ST e indicativos de una oclusión coronaria aguda, para evitar que se produzca una demora inadmisible en los tiempos de actuación, tal y como ocurrió en el caso que se presenta.

Abstract In light of an acute chest pain and evidence of ST-segment elevation, an emergent reperfusion treatment should be started with the objective of opening the occluded artery and reducing myocardial damage, thus, improving the patients´s prognosis. Therefore, it is mandatory to keep in mind those high-risk electrical patterns equivalent to a ST-segment elevation and indicative of an acute coronary occlusion to avoid an unacceptable delay in the times of action, such was the case that is reported.

Mortalidad previa y posterior a la implementación código infarto en un hospital de segundo nivel de atención / Mortality before and after the implementation of the infarct code in a second level of care hospital / Mortalidade antes e depois da implantação do protocolo de ataque cardíaco em um hospital de segundo nível de atendimento

Resumen: Introducción: Desde 1987, la tasa de incidencia de hospitalización por infarto agudo de miocardio o enfermedad arterial coronaria fatal en los Estados Unidos ha disminuido en 4 a 5% por año. Sin embargo, cada año ocurren aproximadamente 550,000 nuevos episodios y 200,000 infartos agudos de miocardio recurrentes. Ante esta problemática se desarrolló el primer programa de atención integral a nivel institucional llamado «A todo corazón¼, que pretende fortalecer las acciones para promoción de hábitos saludables, la prevención y atención de las enfermedades cardiovasculares. Objetivo: Determinar mortalidad previa y posterior a la implementación de código infarto en pacientes que presentaron infarto agudo al miocardio con elevación del segmento ST, en el Servicio de Urgencias en el Hospital General Regional No. 20 del IMSS. Material y métodos: Se realizó un estudio transversal, descriptivo, comparativo y retrospectivo para valorar mortalidad en los pacientes que un año previo y uno posterior a implementar código infarto recibieron atención médica en el servicio de urgencias. Se estudiaron variables sociodemográficas, factores de riesgo para infarto agudo de miocardio (IAM), clasificación de riesgo y severidad IAM, enzimas cardiacas, tiempo puerta electrocardiograma, tiempo puerta-aguja, trombólisis, reperfusión, mortalidad. Se realizó estadística descriptiva e inferencial con prueba de diferencia de medias para variables cuantitativas y U de Mann-Whitney para cualitativa. Resultados: El tiempo puerta electrocardiograma fue de 125.93 minutos y de 29.81 minutos (p < 0.001). El tiempo puerta-aguja fue de 186.56 ± 83.17 minutos para el grupo precódigo y postcódigo, respectivamente (p < 0.001). La tasa de reperfusión fue de 41.7% en el grupo precódigo, mientras que el grupo postcódigo obtuvo una tasa de reperfusión de 78.9%. La tasa de mortalidad para ambos grupos fue de 37.5% para el grupo precódigo y de 21.1% para el grupo postcódigo. Conclusiones: De forma posterior a la implementación de código infarto en un hospital de segundo nivel de atención existieron modificaciones con evidencia de mejoría en el abordaje, tratamiento y desenlace de los pacientes con IAM.

Abstract: Introduction: Since 1987, the incidence rate of hospitalization for acute myocardial infarction or fatal coronary artery disease in the United States has decreased by 4% to 5% per year. However, approximately 550,000 new episodes and 200,000 recurrent acute myocardial infarctions occur each year. Faced with this problem, the first comprehensive care program at the institutional level called «A todo corazón¼ was developed, which aims to strengthen actions to promote healthy habits, prevention and care of cardiovascular diseases. Objective: To determine mortality before and after the implementation of the infarction code in patients who presented acute myocardial infarction with ST segment elevation, in the Emergency Service of the Hospital General Regional No. 20 of the IMSS. Material and methods: A cross-sectional, descriptive, comparative and retrospective study was carried out to assess mortality in patients who a year before and a year after implementing the infarction code received medical attention in the emergency department. Sociodemographic variables, risk factors for AMI, AMI risk classification and severity, cardiac enzymes, gate-electrocardiogram time, gate-needle time, thrombolysis, reperfusion, and mortality were studied. Descriptive and inferential statistics were performed with the mean difference test for quantitative variables and Mann-Whitney U for qualitative variables. Results: The electrocardiogram gate time was 125.93 minutes and 29.81 minutes (p < 0.001). The needle gate time was 186.56 ± and 83.17 minutes for the pre-code and post-code group, respectively (p < 0.001). The reperfusion rate was 41.7% in the pre-code group, while the post-code group obtained a 78.9% reperfusion rate. The mortality rate for both groups, where we found that it was 37.5% for the pre-code group and 21.1% for the post-code group. Conclusions: Subsequent to the implementation of the infarction code in a second level of care hospital, there were modifications with evidence of improvement in the approach, treatment and outcome of patients with AMI.

Resumo: Introdução: Desde 1987, a taxa de incidência de hospitalização por infarto agudo do miocárdio ou doença arterial coronariana fatal nos Estados Unidos diminuiu de 4 a 5% ao ano. No entanto, cerca de 550,000 novos episódios e 200,000 infartos agudos do miocárdio recorrentes ocorrem a cada ano. Diante desse problema, foi desenvolvido o primeiro programa de atenção integral em nível institucional, denominado «Com todo meu coração¼, que visa fortalecer ações de promoção de hábitos saudáveis, prevenção e atenção às doenças cardiovasculares. Objetivo: Determinar a mortalidade antes e após a implementação do protocolo de infarto em pacientes que apresentaram infarto agudo do miocárdio com supradesnivelamento do segmento ST, no Serviço de Emergência do Hospital Geral Regional No. 20 do IMSS. Material e métodos: Realizou-se um estudo transversal, descritivo, comparativo e retrospectivo para avaliar a mortalidade em pacientes atendidos no pronto-socorro um ano antes e um ano após a implantação do protocolo do infarto. Foram estudadas variáveis sociodemográficas, fatores de risco para IAM, classificação de risco e gravidade do IAM, enzimas cardíacas, tempo porta-eletrocardiograma, tempo porta-agulha, trombólise, reperfusão e mortalidade. Estatísticas descritivas e inferências foram realizadas com teste de diferença de médias para variáveis quantitativas e teste U de Mann-Whitney para variáveis qualitativas. Resultados: O tempo porta do eletrocardiograma foi de 125.93 minutos e 29.81 minutos (p < 0.001). O tempo de porta da agulha foi de 186.56 ± e 83.17 minutos para os grupos pré-protocolo e pós-protocolo, respectivamente (p < 0.001). A taxa de reperfusão foi de 41.7% no grupo pré-protocolo, enquanto o grupo pós-protocolo teve uma taxa de reperfusão de 78.9%. A taxa de mortalidade para ambos os grupos, encontramos que foi de 37.5% para o grupo pré-protocolo e 21.1% para o grupo pós-protocolo. Conclusões: Após a implantação do protocolo de infarto em um hospital de atenção secundária, houve modificações com evidências de melhora na abordagem, tratamento e desfecho dos pacientes com IAM.

Impact of creating a hemodynamics room, a coronary care unit, and a primary angioplasty program on the prognosis of acute coronary syndrome in a district hospital.

OBJECTIVE: This work aims to analyze the prognosis and mortality of patients hospitalized for acute coronary syndrome before and after the implementation of a coronary care unit, hemodynamics room, and the Código Corazón [Infarction Code] primary angioplasty program. METHODS: We conducted an observational, retrospective study that analyzed the epidemiological characteristics, reperfusion strategies, adverse cardiovascular events, and mortality over a follow-up period of five years. The results from the post-code period (March 1 - December 31, 2012; n=471) were compared with those from the pre-code period (March 1 - December 31, 2009; n=432). RESULTS: There were no differences in the baseline characteristics of the two groups. However, an increase in ST-elevation acute coronary syndrome (STE-ACS) from 17.6% to 34.8% (p<.001) was observed during the postcode phase. The use of percutaneous coronary intervention was made widespread at the hospital and was used in 64.8% of non-ST-elevation acute coronary syndrome (NSTE-ACS) cases and in 95.5% of STE-ACS cases. A reduction was observed in readmissions (from 38.2% to 25.1% for NSTE-ACS (p=.001) and from 23.7% to 11.0% for STE-ACS (p=.018)), the composite prognostic variable of adverse cardiovascular events and 5-year mortality (from 58.7% to 45% (p=.001) for NSTE-ACS and from 40.8% to 23.8% (p=.009) for STE-ACS), and a decrease in 30-day mortality in STE-ACS (from 11.8% to 3.7%; p=.021). CONCLUSIONS: With the structural changes in the hospital, the use of percutaneous coronary intervention was made widespread and improved the prognosis of patients with acute coronary syndrome, decreasing admissions, adverse cardiovascular events, and mortality.

Impacto de la creación de una sala de hemodinámica, una unidad coronaria y un programa de angioplastia primaria en el pronóstico del síndrome coronario agudo en un hospital comarcal / Impact of creating a haemodynamics room, a coronary unit and a primary angioplasty programme on the prognosis of acute coronary syndrome in a district hospital

Objetivo Analizar el pronóstico y mortalidad de los pacientes ingresados en un hospital por síndrome coronario agudo antes y después de la implantación de la unidad coronaria, la sala de hemodinámica y el programa de angioplastia primaria (Código corazón). Métodos Estudio observacional y retrospectivo. Se analizaron las características epidemiológicas, las estrategias de reperfusión, los eventos adversos cardiovasculares y la mortalidad durante 5 años de seguimiento. Los resultados del periodo post-código (1 marzo 2012-31 diciembre 2012; n=471) se compararon con la etapa precódigo (1 marzo 2009-31 diciembre 2009; n=432). Resultados No hubo diferencias en las características basales de ambos grupos, pero en la fase poscódigo se observó un incremento del síndrome coronario agudo con elevación del ST (SCACEST) del 17,6 al 34,8% (p<0,001). Se generalizó el intervencionismo coronario percutáneo, que alcanzó cifras del 64,8% en el síndrome coronario agudo sin elevación del ST (SCASEST) y del 95,5% en el SCACEST. Se redujeron los reingresos (38,2 vs. 25,1% en el SCASEST, p=0,001 y 23,7 vs. 11% en el SCACEST, p=0,018), la variable pronóstica combinada de eventos adversos cardiovasculares y mortalidad en 5 años de seguimiento (58,7 vs. 45%, p=0,001 en el SCASEST y 40,8 vs. 23,8%, p=0,009 en el SCACEST) y, además, en el SCACEST disminuyó la mortalidad a los 30 días (11,8 vs. 3,7%, p=0,021). Conclusiones Con los cambios estructurales realizados en el hospital se ha generalizado el intervencionismo coronario percutáneo y ha mejorado el pronóstico de los pacientes con síndrome coronario agudo, disminuyendo los ingresos, los eventos adversos cardiovasculares y la mortalidad (AU)

Objective This work aims to analyze the prognosis and mortality of patients hospitalized for acute coronary syndrome before and after the implementation of a coronary care unit, hemodynamics room, and the Código Corazón [Infarction Code] primary angioplasty program Methods We conducted an observational, retrospective study that analyzed the epidemiological characteristics, reperfusion strategies, adverse cardiovascular events, and mortality over a follow-up period of five years. The results from the post-code period (March 1 – December 31, 2012; n=471) were compared with those from the pre-code period (March 1 – December 31, 2009; n=432). Results There were no differences in the baseline characteristics of the two groups. However, an increase in ST-elevation acute coronary syndrome (STE-ACS) from 17.6% to 34.8% (p<.001) was observed during the postcode phase. The use of percutaneous coronary intervention was made widespread at the hospital and was used in 64.8% of non-ST-elevation acute coronary syndrome (NSTE-ACS) cases and in 95.5% of STE-ACS cases. A reduction was observed in readmissions (from 38.2% to 25.1% for NSTE-ACS (p=.001) and from 23.7% to 11.0% for STE-ACS (p=.018)), the composite prognostic variable of adverse cardiovascular events and 5-year mortality (from 58.7% to 45% (p=.001) for NSTE-ACS and from 40.8% to 23.8% (p=.009) for STE-ACS), and a decrease in 30-day mortality in STE-ACS (from 11.8% to 3.7%; p=.021). Conclusions With the structural changes in the hospital, the use of percutaneous coronary intervention was made widespread and improved the prognosis of patients with acute coronary syndrome, decreasing admissions, adverse cardiovascular events and mortality (AU)

Towards medicine of excellence in Mexico: the "Código Infarto" protocol, a view from the perspective of translational bioethics.

INTRODUCTION: Mexico is the country with the highest mortality due to ST-elevation acute myocardial infarction (STEMI), and the IMSS has therefore developed the protocol of care for emergency departments called Código Infarto (Infarction Code). In this article, aspects of translational medicine are discussed with a bioethical and comprehensive perspective. OBJECTIVE: To analyze the Código Infarto protocol from the perspective of translational bioethics. METHOD: A problem-centered approach was carried out through reflective equilibrium (or Rawls' method), as well as by applying the integral method for ethical discernment. RESULTS: The protocol of care for emergency services Código Infarto is governed by evidence-based medicine and value-based medicine; it is guided by a principle of integrity that considers six dimensions of quality for the care of patients with STEMI. CONCLUSION: The protocol overcomes some adverse social determinants that affect STEMI medical care, reduces mortality and global economic disease burden, and develops medicine of excellence with high social reach.

INTRODUCCIÓN: México es el país con mayor mortalidad por infarto agudo de miocardio con elevación del segmento ST (IAM CEST), por lo que el Instituto Mexicano del Seguro Social desarrolló el protocolo de atención para los servicios de urgencias denominado Código Infarto. En este artículo se discuten aspectos de la medicina traslacional con una perspectiva bioética e integral. OBJETIVO: Analizar el protocolo Código Infarto desde la perspectiva de la bioética traslacional. MÉTODO: Se realizó una aproximación centrada en el problema a través del equilibrio reflexivo, así como la aplicación del método integral para el discernimiento ético. RESULTADOS: El protocolo de atención para los servicios de urgencias Código Infarto se rige por la medicina basada en la evidencia y la medicina basada en valores; se orienta por el principio de integridad que considera las seis dimensiones de la calidad para la atención de pacientes con IAM CEST. CONCLUSIÓN: El protocolo supera algunos determinantes sociales adversos que afectan la atención médica del IAM CEST, disminuye la mortalidad, la carga económica global de la enfermedad y desarrolla una medicina de excelencia de alto alcance social.

Guía práctica interinstitucional para el tratamiento del infarto agudo de miocardio / Interinstitutional clinical practice guidelines for the treatment of acute myocardial infarction

Resumen Introducción: México tiene la mortalidad más alta a 30 días por infarto agudo de miocardio (IAM), el cual constituye una de las principales causas de mortalidad en el país: 28 % versus 7.5 % del promedio de los países de la Organización para la Cooperación y el Desarrollo Económicos. Objetivo: Establecer las rutas críticas y las estrategias farmacológicas esenciales interinstitucionales para la atención de los pacientes con IAM en México, independientemente de su condición socioeconómica. Método: Se reunió a un grupo de expertos en diagnóstico y tratamiento de IAM, representantes de las principales instituciones públicas de salud de México, así como las sociedades cardiológicas mexicanas, Cruz Roja Mexicana y representantes de la Sociedad Española de Cardiología, con la finalidad de optimizar las estrategias con base en la mejor evidencia existente. Resultados: Se diseñó una guía de práctica clínica interinstitucional para el diagnóstico temprano y tratamiento oportuno del IAM con elevación del segmento ST, siguiendo el horizonte clínico de la enfermedad, con la propuesta de algoritmos que mejoren el pronóstico de los pacientes que acuden por IAM a los servicios de urgencias. Conclusión: Con la presente guía práctica, el grupo de expertos propone universalizar el diagnóstico y tratamiento en el IAM, independientemente de la condición socioeconómica del paciente.

Abstract Introduction: Mexico has the highest 30-day acute myocardial infarction (AMI) mortality rate: 28% versus 7.5% on average for the OECD countries, and it constitutes one of the main causes of mortality in the country. Objective: To establish critical pathways and essential interinstitutional pharmacological strategies for the care of patients with AMI in Mexico, regardless of their socioeconomic status. Method: A group of experts in AMI diagnosis and treatment, representatives of the main public health institutions in Mexico, as well as the Mexican cardiology societies, the Mexican Red Cross and representatives of the Spanish Society of Cardiology, were brought together in order to optimize strategies based on the best existing evidence. Results: An interinstitutional clinical practice guideline was designed for early diagnosis and timely treatment of AMI with ST elevation, following the clinical horizon of the disease, with the proposal of algorithms that improve the prognosis of patients who attend the emergency services due to an AMI. Conclusion: With these clinical practice guidelines, the group of experts proposes to universalize AMI diagnosis and treatment, regardless of patient socioeconomic status.

Hacia una medicina de excelencia en México: el protocolo Código Infarto, una visión desde la bioética traslacional / Towards medicine of excellence in Mexico: the "Código Infarto" protocol, a view from the perspective of translational bioethics

Resumen Introducción: México es el país con mayor mortalidad por infarto agudo de miocardio con elevación del segmento ST (IAM CEST), por lo que el Instituto Mexicano del Seguro Social desarrolló el protocolo de atención para los servicios de urgencias denominado Código Infarto. En este artículo se discuten aspectos de la medicina traslacional con una perspectiva bioética e integral. Objetivo: Analizar el protocolo Código Infarto desde la perspectiva de la bioética traslacional. Método: Se realizó una aproximación centrada en el problema a través del equilibrio reflexivo, así como la aplicación del método integral para el discernimiento ético. Resultados: El protocolo de atención para los servicios de urgencias Código Infarto se rige por la medicina basada en la evidencia y la medicina basada en valores; se orienta por el principio de integridad que considera las seis dimensiones de la calidad para la atención de pacientes con IAM CEST. Conclusión: El protocolo supera algunos determinantes sociales adversos que afectan la atención médica del IAM CEST, disminuye la mortalidad, la carga económica global de la enfermedad y desarrolla una medicina de excelencia de alto alcance social.

Abstract Introduction: Mexico is the country with the highest mortality due to ST-elevation acute myocardial infarction (STEMI), and the IMSS has therefore developed the protocol of care for emergency departments called Código Infarto (Infarction Code). In this article, aspects of translational medicine are discussed with a bioethical and comprehensive perspective. Objective: To analyze the Código Infarto protocol from the perspective of translational bioethics. Method: A problem-centered approach was carried out through reflective equilibrium (or Rawls' method), as well as by applying the integral method for ethical discernment. Results: The protocol of care for emergency services Código Infarto is governed by evidence-based medicine and value-based medicine; it is guided by a principle of integrity that considers six dimensions of quality for the care of patients with STEMI. Conclusion: The protocol overcomes some adverse social determinants that affect STEMI medical care, reduces mortality and global economic disease burden, and develops medicine of excellence with high social reach.

Impact of creating a haemodynamics room, a coronary unit and a primary angioplasty programme on the prognosis of acute coronary syndrome in a district hospital. / Impacto de la creación de una sala de hemodinámica, una unidad coronaria y un programa de angioplastia primaria en el pronóstico del síndrome coronario agudo en un hospital comarcal.

OBJECTIVE: To analyse the prognosis and mortality of patients hospitalised for acute coronary syndrome before and after the implementation of a coronary unit, haemodynamics room and the Código corazón primary angioplasty programme. METHODS: We conducted an observational and retrospective study that analysed the epidemiological characteristics, reperfusion strategies, adverse cardiovascular events and mortality for 5 years of follow-up. The results of the post-code period (March 1 - December 31, 2012; n=471) were compared with those of the pre-code stage (March 1 - December 31, 2009; n=432). RESULTS: There were no differences in the baseline characteristics of the 2 groups; however, an increase in ST-segment elevation acute coronary syndrome (STE-ACS) from 17.6% to 34.8% (P<.001) was observed during the post-code phase. The use of percutaneous coronary intervention was made widespread at the hospital, achieving rates of 64.8% in non-ST-segment elevation acute coronary syndrome (NSTE-ACS) and of 95.5% in STE-ACS. Readmissions were reduced (from 38.2% to 25.1% for NSTE-ACS [P=.001] and from 23.7% to 11.0% for STE-ACS [P=.018]), the combined prognostic variable of adverse cardiovascular events and mortality at 5 years of follow-up was reduced (from 58.7% to 45% [P=.001] for NSTE-ACS and from 40.8% to 23.8% [p=.009] for STE-ACS), and 30-day mortality was decreased for STE-ACS (from 11.8% to 3.7%; P=.021). CONCLUSIONS: With the structural changes in the hospital, the use of percutaneous coronary intervention was made widespread and improved the prognosis of patients with acute coronary syndrome, decreasing admissions, adverse cardiovascular events and mortality.

Interinstitutional clinical practice guidelines for the treatment of acute myocardial infarction.

INTRODUCTION: Mexico has the highest 30-day mortality due to acute myocardial infarction (AMI), which constitutes one of the main causes of mortality in the country: 28 % versus 7.5 % on average for the Organization for Economic Co-operation and Development member countries. OBJECTIVE: To establish critical pathways and essential interinstitutional pharmacological strategies for the care of patients with AMI in Mexico, regardless of their socioeconomic status. METHOD: A group of experts in AMI diagnosis and treatment, representatives of the main public health institutions in Mexico, as well as the Mexican cardiology societies, the Mexican Red Cross and representatives of the Spanish Society of Cardiology, were brought together in order to optimize strategies based on the best existing evidence. RESULTS: An interinstitutional clinical practice guideline was designed for early diagnosis and timely treatment of AMI with ST-segment elevation, following the clinical horizon of the disease, with the proposal of algorithms that improve the prognosis of patients who attend the emergency services due to an AMI. CONCLUSION: With these clinical practice guidelines, the group of experts proposes to universalize AMI diagnosis and treatment, regardless of patient socioeconomic status. INTRODUCCIÓN: México tiene la mortalidad más alta a 30 días por infarto agudo de miocardio (IAM), el cual constituye una de las principales causas de mortalidad en el país: 28 % versus 7.5 % del promedio de los países de la Organización para la Cooperación y el Desarrollo Económicos. OBJETIVO: Establecer las rutas críticas y las estrategias farmacológicas esenciales interinstitucionales para la atención de los pacientes con IAM en México, independientemente de su condición socioeconómica. MÉTODO: Se reunió a un grupo de expertos en diagnóstico y tratamiento de IAM, representantes de las principales instituciones públicas de salud de México, así como las sociedades cardiológicas mexicanas, Cruz Roja Mexicana y representantes de la Sociedad Española de Cardiología con la finalidad de optimizar las estrategias con base en la mejor evidencia existente. RESULTADOS: Se diseñó una guía de práctica clínica interinstitucional para el diagnóstico temprano y tratamiento oportuno del IAM con elevación del segmento ST, siguiendo el horizonte clínico de la enfermedad, con la propuesta de algoritmos que mejoren el pronóstico de los pacientes que acuden por IAM a los servicios de urgencias. CONCLUSIÓN: Con la presente guía práctica, el grupo de expertos propone universalizar el diagnóstico y tratamiento en el IAM, independientemente de la condición socioeconómica del paciente.

Competencia clínica del personal de enfermería en Código Infarto de un hospital de tercer nivel / Clinical competence of the Infarction Code nursing staff in a third-level hospital

Introducción: el personal de enfermería es esencial para la atención oportuna en el programa Código Infarto. La evaluación por competencias es la clave para garantizar la calidad de los servicios de salud. Objetivo: evaluar las dimensiones de la competencia clínica del personal de enfermería para el protocolo de Código Infarto en una unidad de tercer nivel de atención. Métodos: estudio descriptivo transversal, en el que se incluyeron 80 miembros del personal de enfermería de los servicios de Admisión y Hemodinamia. Se diseñó y validó un instrumento de 48 ítems mediante ronda de expertos 3/3; para determinar el nivel de competencia clínica, se utilizó la teoría de Patricia Benner. Resultados: el nivel de competencia clínica fue competente en 38.8%. En las dimensiones, el área de conocimiento obtuvo 83.4%, habilidad 86.7% y actitud 87.2%. Se asoció el nivel de competencia con capacitación, grado académico y categoría (p < 0.001). Conclusiones: se identificaron áreas de oportunidad respecto a la dimensión de conocimiento, lo cual permite redireccionar los procesos educativos dirigidos al personal de enfermería.

Introduction: Nursing staff is essential in providing timely care in Código Infarto (Infarction Code) program. Competency assessment is the key to guarantee the quality of health services. Objective: To assess the clinical competence of Código Infarto nursing staff in a third-level unit. Methods: Cross-sectional analytical study, which included 80 members of the nursing staff of Admission and Cardiac Care; a 48-item instrument was designed and validated by experts in three rounds; Patricia Benner's theory was used to determine the level of clinical competence. Results: The level of clinical competence was competent (38.8%). In the dimensions, the area of knowledge obtained 83.4%, ability 86.7%, and attitude 87.2%. The level of competence was associated with training, academic degree and category (p < 0.001). Conclusions: Opportunity areas regarding knowledge were identified, which allows redirecting the educational processes addressed to the nursing staff.

Efecto de la rehabilitación cardiaca temprana en pacientes incluidos en Código Infarto / Effect of early cardiac rehabilitation in patients included in Codigo Infarto

Resumen Introducción: La rehabilitación cardiaca temprana (RCT) implementada en el protocolo Código Infarto (CI) es una estrategia en la atención del infarto agudo de miocardio. El objetivo fue identificar el efecto de la RCT en pacientes incluidos en CI. Método: Estudio de casos y controles. Se incluyeron pacientes consecutivos con diagnóstico de infarto agudo de miocardio ingresados a un hospital de cardiología entre febrero de 2015 y junio de 2017. Se crearon dos grupos: I y II, antes y después de CI y RCT. Resultados: Se incluyeron 1141 pacientes: 220 del grupo I y 921 del grupo II, edad 62.64 ± 10.53 años; 80.9 % hombres y 19.1 % mujeres. Los principales factores de riesgo para los grupos I y II fueron sedentarismo, 92.7 y 77.8 %; dislipidemia, 80.9 y 55.8 %; hipertensión, 63.2 y 62 %; tabaquismo, 66.8 y 59.2 %; y diabetes, 54.5 y 59.1 %. En el grupo II se inició antes la rehabilitación (1.8 ± 1.6 y 4.2 ± 3.2) y los días en terapia intensiva y hospitalización fueron menores (2.4 ± 2.2 y 4.8 ± 4.1; 8.6 ± 5.2 y 12.3 ± 7.7), así como los días de incapacidad (58.6 y 67.7). Conclusiones: CI y RCT son estrategias complementarias que permiten alta temprana de terapia intensiva y hospitalización, mejor calidad de vida y menos días de incapacidad laboral.

Abstract Introduction: Early cardiac rehabilitation (ECR) implemented in the Infarction Code (IC) protocol is a strategy in the care of acute myocardial infarction. The purpose of this study was to identify the effect of ECR in IC-included patients. Method: Case-control study. Consecutive patients diagnosed with acute myocardial infarction and admitted to a cardiology hospital between February 2015 and June 2017 were included. Two groups were created: I and II, before and after IC and ECR. Results: We included 1141 patients, 220 in group I and 921 in group II, with an age of 62.64 ± 10.53 years; 80.9 % were males and 19.1 % females. The main risk factors for groups I and II were sedentariness, 92.7 % versus 77.8 %; dyslipidemia, 80.9 % versus 55.8 %; hypertension, 63.2 % versus 62 %; smoking, 66.8 % versus 59.2 %; and diabetes, 54.5 % versus 59.1 %. Rehabilitation was started earlier (1.8 ± 1.6 versus 4.2 ± 3.2) and the days spent in intensive therapy and hospitalization were fewer in group II (2.4 ± 2.2 versus 4.8 ± 4.1 and 8.6 ± 5.2 versus 12.3 ± 7.7, p < 0.0001, respectively), as well as the days of disability (58.6 versus 67.7). Conclusions: IC and ECR are complementary strategies that allow an early discharge from intensive therapy and hospitalization, as well as better quality of life and fewer days of disability leave.

Comparative analysis between 2 periods of acute myocardial infarction after a decade in Mallorca. IBERIA Study (996-1998) and Infarction-Code (2008-2010). / Análisis comparativo de 2 registros de infarto agudo de miocardio tras una década de cambios. Estudio IBERICA (1996-1998) y Código Infarto-Illes Balears (2008-2010).

OBJECTIVE: To investigate the differences in mortality at 28 days and other prognostic variables in 2 periods: IBERICA-Mallorca (1996-1998) and Infarction Code of the Balearic Islands (IC-IB) (2008-2010). DESIGN: Two observational prospective cohorts. SETTING: Hospital Universitario Son Dureta, 1996-1998 and 2008-2010. PATIENTS: Acute coronary syndrome with ST elevation of≤24h of anterior and inferior site. MAIN VARIABLES OF INTEREST: Age, sex, cardiovascular risk factors, site of AMI, time delays, reperfusion therapy with fibrinolysis and primary angioplasty, administration of acetylsalicylic acid, beta blockers and angiotensin converting enzyme inhibitors. Killip class, malignant arrhythmias, mechanical complications and death at 28 days were included. RESULTS: Four hundred and forty-two of the 889 patients included in the IBERICA-Mallorca and 498 of 847 in the IC-IB were analyzed. The site and Killip class on admission were similar in both cohorts. The main significant difference between IBERICA and IC-IB group were age (64 vs. 58 years), prior myocardial infarction (17.9 vs. 8.1%), the median symtoms to first ECG time (120 vs. 90min), median first ECG to fibrinolysis time (60 vs. 35min), fibrinolytic therapy (54.8 vs. 18.7%), patients without revascularization treatment (45.9 vs. 9.2%), primary angioplasty (1.0% vs. 92.0%). The mortality at 28 days was lower in the IC-IB (12.2 vs. 7.2%; hazard ratio 0.560; 95% CI 0.360-0.872; P=.010). CONCLUSION: The 28-day mortality in acute coronary syndrome with ST elevation in Mallorca has declined in the last decade, basically due to increased reperfusion therapy with primary angioplasty and reducing delays time to reperfusion.

Changes in Acute Coronary Syndrome Treatment and Prognosis After Implementation of the Infarction Code in a Hospital With a Cardiac Catheterization Unit.

INTRODUCTION AND OBJECTIVES: Emergency care systems have been created to improve treatment and revascularization in myocardial infarction but they may also improve the management of all patients with acute coronary syndrome. METHODS: A comparative study of all patients admitted with acute coronary syndrome before and after implementation of an infarction protocol. RESULTS: The study included 1210 patients. While the mean age was the same in both periods, the patient group admitted after implementation of the protocol had a lower prevalence of diabetes mellitus and hypertension but more active smokers and higher GRACE scores. The percentage of ST-segment elevation acute coronary syndrome (29.8%-39.5%) and coronary revascularizations (82.1%-90.1%) significantly increased among patients admitted with acute coronary syndrome, and primary angioplasty became routine (51.9%-94.9%); there was also a reduction in time to catheterization and an increase in early revascularization. The mean hospital stay was significantly shorter after implementation of the infarction protocol. In-hospital mortality was unchanged, except in high-risk patients (38.8%-22.4%). After discharge, no differences were observed between the 2 periods in cardiovascular mortality, all-cause mortality, reinfarction, or major cardiovascular complications. CONCLUSIONS: After implementation of the infarction protocol, the percentage of patients admitted with ST-segment elevation acute coronary syndrome and the mean GRACE score increased among patients admitted with acute coronary syndrome. Hospital stay was reduced, and primary angioplasty use increased. In-hospital mortality was reduced in high-risk patients, and prognosis after discharge was the same in both periods.