Tendência temporal da mortalidade por infarto no nordeste do Brasil / Temporal trend of myocardial infarction mortality in northeast Brazil / Tendencia temporal de la mortalidad por infarto de miocardio en el noreste de Brasil

OBJETIVO: analisar o perfil sociodemográfico e a tendência da mortalidade por infarto agudo miocárdio no Nordeste do Brasil entre os anos de 2011 a 2021. MÉTODOS: estudo ecológico que utilizou dados do Sistema de Informação sobre Mortalidade. Foram calculadas as taxas de mortalidade para o sexo dos indivíduos e estados da região nordestina. Para análise temporal foi utilizado o software Joinpoint. RESULTADOS: a maioria dos óbitos ocorreu entre homens (57,02%), pardos (60,81%) e idosos (76,22%). As médias da taxa de mortalidade foram elevadas nos homens acima dos 80 anos de idade (234,74 óbitos por 100 mil habitantes). Observou-se maiores tendências de aumento significativos de 3,8% e 3,2% ao ano da mortalidade por infarto em Alagoas e Bahia, respectivamente. CONCLUSÃO: entre os anos de 2011 a 2021 o infarto do miocárdio acometeu homens, idosos, da cor parda. Houve maior tendência de aumento nos estados de Alagoas e Bahia durante todo o período estudado. O estudo contribui para o direcionamento de políticas que identifique fatores de risco e elabore intervenções preventivas efetivas, investindo em diagnóstico precoce, programas de prevenção e promoção de saúde.

OBJECTIVE: to analyze the sociodemographic profile and temporal trend of acute myocardial infarction mortality in Northeast Brazil from 2011 to 2021. METHODS: this ecological study utilized data from the Mortality Information System. Mortality rates were calculated based on gender and states within the Northeast region. The Joinpoint software was used for temporal analysis. RESULTS: the majority of deaths occurred among males (57.02%), individuals of mixed race (60.81%), and elderly individuals (76.22%). The average mortality rate was highest among men above 80 years of age (234.74 deaths per 100,000 inhabitants). Significant increasing trends of 3.8% and 3.2% per year were observed for myocardial infarction mortality in Alagoas and Bahia, respectively. CONCLUSION: between 2011 and 2021, myocardial infarction predominantly affected elderly, male individuals of mixed race. Alagoas and Bahia showed the highest increasing trends in mortality throughout the study period. The study contributes to guiding policies that identify risk factors and develop effective preventive interventions, emphasizing early diagnosis, prevention programs, and health promotion. KEYWORDS: Myocardial Infarction; Mortality; Epidemiology; Time Series Studies.

OBJETIVO: Analizar el perfil sociodemográfico y la tendencia temporal de la mortalidad por infarto agudo de miocardio en el Noreste de Brasil entre los años 2011 y 2021. MÉTODOS: Este estudio ecológico utilizó datos del Sistema de Información sobre Mortalidad. Se calcularon tasas de mortalidad según el sexo de los individuos y los estados dentro de la región nordestina. Para el análisis temporal, se utilizó el software Joinpoint. RESULTADOS: La mayoría de los fallecimientos ocurrieron entre hombres (57,02%), individuos de raza mestiza (60,81%) y personas de edad avanzada (76,22%). La tasa media de mortalidad fue más alta en hombres mayores de 80 años (234,74 muertes por 100 mil habitantes). Se observaron tendencias significativamente crecientes del 3,8% y el 3,2% por año en la mortalidad por infarto en Alagoas y Bahía, respectivamente. CONCLUSIÓN: Entre 2011 y 2021, el infarto de miocardio afectó principalmente a hombres de edad avanzada, de raza mestiza. Alagoas y Bahía mostraron las tendencias crecientes más altas en mortalidad durante todo el período de estudio. El estudio contribuye a orientar políticas que identifiquen factores de riesgo y desarrollen intervenciones preventivas efectivas, haciendo hincapié en el diagnóstico temprano, programas de prevención y promoción de la salud.

Alterações Hematológicas durante um Período de Sete Dias de Internação em Pacientes com Infarto Agudo do Miocárdio / Hematological Changes during Seven Days of Hospitalization in Patients with Acute Myocardial Infarction

Resumo Fundamento O infarto agudo do miocárdio é uma das principais causas de mortalidade em todo o mundo e a formação de placa aterosclerótica é o principal mecanismo fisiopatológico, que resulta em inflamação crônica e induz a maturação eritrocitária, podendo causar aumento no índice de amplitude de distribuição dos glóbulos vermelhos (RDW). Objetivo Avaliar o papel do índice de anisocitose em pacientes com infarto agudo do miocárdio em ambos os tipos de infarto como preditor de gravidade. Métodos Os pacientes foram incluídos no estudo de acordo com os critérios de inclusão e exclusão, seguindo a rotina hospitalar baseada na história clínica e laboratorial. As análises estatísticas foram realizadas de acordo com cada variável. Chegou-se a todas as conclusões considerando o nível de significância de 5%. Resultados Durante o período de acompanhamento, nos 349 pacientes analisados, a taxa de mortalidade esteve associada às variáveis RDW (CV) e RDW (SD). Nos pacientes que foram a óbito, notou-se aumento, conforme demonstrado no modelo multivariado, nos efeitos de um infarto agudo do miocárdio com supradesnivelamento do segmento ST e RDW, ajustado para fatores de confusão (valor-p = 0,03 e 0,04). Em contrapartida, o número total de eritrócitos (valor-p = 0,00) e hemoglobina (valor-p = 0,03) apresentou diminuição durante a internação de pacientes graves. Conclusão O índice de anisocitose foi fator preditivo de mortalidade e pode ser utilizado como indicador de pior prognóstico em pacientes com infarto agudo do miocárdio.

Abstract Background Acute myocardial infarction is a major cause of mortality worldwide, and atherosclerotic plaque formation is the main pathophysiological mechanism, which results in chronic inflammation that induces erythrocyte maturation and may cause an increase in the red cell distribution width (RDW) index. Objective Evaluate the role of the anisocytosis index in patients with acute myocardial infarction in both types of infarctions as a predictor of severity. Methods Patients were included in the study according to the inclusion/exclusion criteria, following the hospital routine based on their clinical and laboratory history. Statistical analyzes were performed according to each variable. All conclusions were drawn considering the significance level of 5%. Results During the follow-up period, in the 349 patients analyzed, the mortality rate was associated with the variables RDW (CV) and RDW (SD), in those patients who died, an increase was noted, as demonstrated in the multivariate model, for the effects of an acute ST elevation myocardial infarction and the RDW, adjusted for confounding factors (p-value = 0.03 and 0.04). In contrast, the total number of erythrocytes (p-value = 0.00) and hemoglobin (p-value = 0.03) showed a decrease during severe patients' hospitalization. Conclusion The anisocytosis index was a predictive factor of mortality and can be used as an indicator of worse prognosis in patients with acute myocardial infarction.

Mortalidade Hospitalar Por Infarto do Miocárdio na América Latina e no Caribe: Revisão Sistemática e Metanálise / Hospital Mortality from Myocardial Infarction in Latin America and the Caribbean: Systematic Review and Meta-Analysis

Resumo Fundamento: A maioria das mortes por doenças cardiovasculares ocorrem em países de renda baixa e média, e o infarto do miocárdio é uma das condições com maior risco de morte. Objetivos: Avaliar a mortalidade hospitalar por todas as causas em pacientes admitidos por infarto do miocárdio (IAMCSST e IAMSSST) na América Latina e no Caribe no ano de 2000 em diante. Métodos: Realizamos uma busca sistemática em bancos de dados eletrônicos por estudos do tipo coorte que relataram morte hospitalar por IAMCSST e IAMSSST. Foi realizada uma metanálise e um valor de p<0,05 foi considerado estatisticamente significativo. Resultados: Identificamos 38 estudos (29 com pacientes com IAMCSST, 3 com IAMSSST e 6 com IAMCSST e IAMSSST). A mortalidade por IAMCSST agrupada foi de 9,9% (IC95%: 9,1 - 10,7). Observou-se importante heterogeneidade (I2 = 74% e o intervalo de predição foi de 6,6 - 14.5). A porcentagem de terapia de reperfusão e a década em que os estudos foram conduzidos explicam parte dessa heterogeneidade (I2 = 54%). Quanto maior a taxa de terapia de reperfusão, menor a mortalidade hospitalar (coeficiente = −0,009, IC95%: −0,013 a −0,006, p<0,001). A mortalidade foi maior na primeira década em comparação com a mortalidade na segunda década (coeficiente = −0,14, IC95%: −0,27 a −0,02, p=0,047). A mortalidade hospitalar por IAMSSST foi de 6,3% (IC95%: 5,4 - 7,4) e a heterogeneidade foi nula. Conclusão: A mortalidade por IAMCSST em países de renda baixa e média foi maior em comparação com as taxas relatadas em outros países. Para melhorar essas estimativas, deve-se buscar um maior uso de terapia de reperfusão. A mortalidade hospitalar por IAMSSST agrupada foi similar às taxas descritas em países de alta renda. Contudo, esse dado foi baseado em poucos estudos, cuja maioria foi conduzida em dois países.

Abstract Background: Most cardiovascular deaths occur in low- and middle-income countries and myocardial infarction is one of the main life-threatening conditions. Objective: We assessed all-cause in-hospital mortality in patients admitted for myocardial infarction (STEMI and NSTEMI) in Latin America and the Caribbean from 2000 onward. Methods: We systematically searched in electronic bibliographic databases for cohort studies which reported in-hospital mortality due to STEMI and NSTEMI. A meta-analysis was performed and a p-value < 0.05 was considered significant. Results: We identified 38 studies (29 STEMI, 3 NSTEMI and 6 both). Pooled STEMI in-hospital mortality was 9.9% (95% CI: 9.1 - 10.7). Heterogeneity was not trivial (I2 = 74% and prediction interval = 6.6 - 14.5). The percentage of reperfusion therapy and decade explain part of the heterogeneity (I2 = 54%). The higher the rate of reperfusion therapy, the lower the in-hospital mortality (coefficient = −0.009, 95% CI: −0.013 to −0.006, p<0.001). This mortality was higher in the first decade as compared with the second (coefficient = −0.14, 95% CI: −0.27 to −0.02, p=0.047). Pooled NSTEMI in-hospital mortality was 6.3% (95% CI: 5.4 - 7.4) and heterogeneity was null. Conclusion: Pooled STEMI in-hospital mortality in low- and middle-income countries was high in comparison with rates reported in high income countries. To improve these estimates, higher use of reperfusion therapy must be pursued. Pooled NSTEMI in-hospital mortality was similar to the ones found in high-income countries; however, it was based on few studies and most of them were carried out in two countries.

County-Level Socioeconomic Status Adjustment of Acute Myocardial Infarction Mortality Hospital Performance Measure in the U.S.

The U.S. Centers for Medicare and Medicaid Services' (CMS's) Hospital Compare (HC) data provides a collection of risk-adjusted hospital performance metrics intended to allow comparison of hospital-provided care. However, CMS does not adjust for socioeconomic status (SES) factors, which have been found to be associated with disparate health outcomes. Associations between county-level SES factors and CMS's risk-adjusted 30-day acute myocardial infarction (AMI) mortality rates are explored for n = 2462 hospitals using a variety of sources for county-level SES information. Upon performing multiple imputation, a stepwise backward elimination model selection approach using Akaike's information criteria was used to identify the optimal model. The resulting model, comprised of 14 predictors mostly at the county level, provides an additional 8% explanatory power to capture the variability in 30-day risk-standardized AMI mortality rates, which already account for patient-level clinical differences. SES factors may be an important feature for inclusion in future risk-adjustment models, which will have system and policy implications for distributing resources to hospitals, such as reimbursements. It also serves as a stepping stone to identify and address long-standing SES-related inequities.

Does Tight Glucose Control During the First 24 hours of Hospitalization Reduce Scintigraphic Infarct Size in STEMI Patients?

Abstract Background Hyperglycemia at the time of admission is related to increased mortality and poor prognosis in patients diagnosed with ST-segment elevation myocardial infarction (STEMI). Objective We aimed to investigate whether tight glucose control during the first 24 hours of STEMI decreases the scintigraphic infarct size. Methods The study population consisted of 56 out of 134 consecutive patients hospitalized with STEMI in a coronary care unit. Twenty-eight patients were treated with continuous insulin infusion during the first 24 hours of hospitalization, while the other 28 patients were treated with subcutaneous insulin on an as-needed basis. The final infarct size was evaluated with single-photon emission computed tomography (SPECT) in all patients on days 4 to 10 of hospitalization. The groups were compared and then predictors of final infarct size were analyzed with univariate and multivariate linear regression analysis. A p-value < 0.05 was considered statistically significant. Results The mean glucose level in the first 24 hours was 130 ± 20 mg/dL in the infusion group and 152 ± 31 mg/dL in the standard care group (p = 0.002), while the mean final infarct size was 20 ± 12% and 27 ± 15% (p = 0.06), respectively. The multivariate linear regression analysis demonstrated that the mean 24-hour glucose level was an independent predictor of the final infarct size (beta 0.29, p = 0.026). Conclusion Tight glucose control with continuous insulin infusion was not associated with smaller infarct size when compared to standard care in STEMI patients. (Int J Cardiovasc Sci. 2020; [online].ahead print, PP.0-0)

Revascularização Completa Versus Tratamento da Artéria Culpada no Infarto com Supradesnivelamento do Segmento ST: Registro Multicêntrico / Complete Revascularization Versus Treatment of the Culprit Artery Only in ST Elevation Myocardial Infarction: A Multicenter Registry

Resumo Fundamento São restritos os dados sobre o manejo e o prognóstico dos pacientes com infarto agudo do miocárdio com supradesnivelamento do segmento ST (IAMCSST) com acometimento multiarterial no Brasil, o que mostra a necessidade de investigar as estratégias de revascularização disponíveis. Objetivo Avaliar os desfechos relacionados à revascularização completa em comparação com o tratamento da artéria culpada em pacientes multiarteriais com IAMCSST. Métodos Foi realizada um estudo de coorte prospectiva em dois centros de hemodinâmica do Sul do Brasil, com seguimento de 1 ano após a intervenção índice. O desfecho primário foi composto de óbito cardiovascular, reinfarto ou angina recorrente e secundários acidente vascular encefálico, parada cardiorrespiratória não fatal, sangramento maior ou necessidade de reintervenção. A probabilidade de ocorrência de desfechos foi comparada entre os grupos através de regressão logística binária. Considerou-se como estatisticamente significativo o valor de probabilidade < 0,05. Resultados Participaram 85 pacientes, com média de idade de 62±12 anos, sendo 61 (71,8%) do sexo masculino. Cinquenta e oito (68,2%) pacientes receberam a estratégia de revascularização completa e 27 (31,8%), a de revascularização incompleta. A chance de ocorrência tanto do desfecho primário quanto do secundário foi significativamente maior entre os indivíduos tratados com revascularização incompleta quando comparados com os tratados com estratégia completa [razão de chances (OR) 5,1, intervalo de confiança de 95% (IC95%) 1,6-16,1 vs. OR 5,2, IC95% 1,2-22,9, respectivamente], assim como os óbitos cardiovasculares (OR 6,4, IC95% 1,2-35,3). Conclusão Dados deste registro regional, de dois centros do Sul do Brasil, demonstram que a estratégia de revascularização completa esteve associada à redução significativa dos desfechos primário e secundário no seguimento de 1 ano quando comparada à estratégia de revascularização incompleta. (Arq Bras Cardiol. 2020; 115(2):229-237)

Abstract Background Data on the management and prognosis of patients with ST-segment elevation myocardial infarction (STEMI) and multivessel disease are limited in Brazil, showing that the available revascularization strategies should be investigated Objective To assess the outcomes of complete revascularization versus treatment of the culprit artery only in patients with STEMI and multivessel disease. Methods A prospective cohort study was conducted at two medical centers in southern Brazil with a 1-year follow-up after the index procedure. The primary outcome was a composite of cardiac death, reinfarction, or recurrent angina, while the secondary outcome was stroke, nonfatal cardiac arrest, major bleeding, or need for reintervention. The probability of outcomes occurring was compared between the groups using binary logistic regression. A p-value < 0.05 was considered statistically significant. Results Eighty-five patients were included. Their mean age was 62±12 years, and 61 (71.8%) were male. Fifty-eight (68.2%) were treated with complete revascularization and 27 (31.8%) with incomplete revascularization. The chance of both the primary and secondary outcomes occurring was significantly greater among patients treated with incomplete revascularization when compared to those treated with complete revascularization (odds ratio [OR] 5.1, 95% confidence interval [CI] 1.6-16.1 vs. OR 5.2, 95% CI 1.2-22.9, respectively), as well as cardiac death (OR 6.4, 95% CI 1.2-35.3). Conclusion Registry data from two centers in southern Brazil demonstrate that the complete revascularization strategy is associated with a significant reduction in primary and secondary outcomes in a 1-year follow-up when compared to the incomplete revascularization strategy (Arq Bras Cardiol. 2020; 115(2):229-237)

Rotura miocárdica de ventrículo izquierdo secundaria a infarto agudo de miocardio / Myocardial rupture of left ventricle secondary to myocardial infarction

RESUMEN Fundamento: la rotura miocárdica es una complicación rara del infarto agudo de miocardio con una incidencia global de alrededor del 6,2 %. Objetivo: caracterizar los fallecidos por infarto agudo de miocardio con la rotura de pared de ventrículo izquierdo. Métodos: se realizó un estudio retrospectivo, descriptivo y observacional, en el cual se analizaron los fallecidos con diagnóstico de causa directa de muerte: taponamiento cardíaco por hemopericardio, rotura de miocardio e infarto agudo de miocardio. Resultados: de 877 infartos agudos de miocardio diagnosticados entre 2010 a 2018, 16 de ellos presentaron rotura de pared miocárdica de los cuales 68,8 % eran del masculino. El hábito de fumar fue el factor de riesgo predominante. Solo en un 35,7 % se realizó el diagnóstico clínico correcto de IAM y en ninguno de los casos fue planteado el diagnóstico de rotura de miocardio o taponamiento cardíaco por hemopericardio. La región anatómica del corazón donde con mayor frecuencia se localizaron las roturas de miocardio fue en la pared posterior. Conclusiones: la rotura de la pared de miocardio es una complicación del infarto poco frecuente pero catastrófica con una mortalidad elevada, sin embargo, esta puede reducirse si el cuadro clínico es sospechado, y se realiza un diagnóstico precoz con instauración de medidas de apoyo para mantener la estabilidad hemodinámica.

ABSTRACT Background: myocardial rupture is a rare complication of acute myocardial infarction with an overall incidence of around 6.2 %. Objective: to characterize the deaths due to acute myocardial infarction with the rupture of the left ventricle wall. Methods: a retrospective, descriptive and observational study was carried out in which the deceased were analyzed with a diagnosis of direct cause of death: cardiac tamponade due to hemopericardium, myocardial rupture and acute myocardial infarction. Results: of 877 acute myocardial infarcts diagnosed between 2010 and 2018, 16 of them had myocardial wall rupture of which 68.8% were male. The habit of smoking was the predominant risk factor. Only in 35.7 % the correct clinical diagnosis of AMI was made and in none of the cases was the diagnosis of myocardial rupture or cardiac tamponade due to hemopericardium. The anatomical region of the heart where myocardial ruptures were most frequently located was in the posterior wall. Conclusions: rupture of the myocardial wall is a rare but catastrophic complication of infarction with a high mortality, however, this can be reduced if the clinical picture is suspected, and an early diagnosis is made with the introduction of support measures to maintain hemodynamic stability.

Geographic disparities and temporal changes in risk of death from myocardial infarction in Florida, 2000-2014.

BACKGROUND: Identifying disparities in myocardial infarction (MI) burden and assessing its temporal changes are critical for guiding resource allocation and policies geared towards reducing/eliminating health disparities. Our objectives were to: (a) investigate the spatial distribution and clusters of MI mortality risk in Florida; and (b) assess temporal changes in geographic disparities in MI mortality risks in Florida from 2000 to 2014. METHODS: This is a retrospective ecologic study with county as the spatial unit of analysis. We obtained data for MI deaths occurring among Florida residents between 2000 and 2014 from the Florida Department of Health, and calculated county-level age-adjusted MI mortality risks and Spatial Empirical Bayesian smoothed MI mortality risks. We used Kulldorff's circular spatial scan statistics and Tango's flexible spatial scan statistics to identify spatial clusters. RESULTS: There was an overall decline of 48% in MI mortality risks between 2000 and 2014. However, we found substantial, persistent disparities in MI mortality risks, with high-risk clusters occurring primarily in rural northern counties and low-risk clusters occurring exclusively in urban southern counties. MI mortality risks declined in both low- and high-risk clusters, but the latter showed more dramatic decreases during the first nine years of the study period. Consequently, the risk difference between the high- and low-risk clusters was smaller at the end than at the beginning of the study period. However, the rates of decline levelled off during the last six years of the study, and there are signs that the risks may be on an upward trend in parts of North Florida. Moreover, MI mortality risks for high-risk clusters at the end of the study period were on par with or above those for low-risk clusters at the beginning of the study period. Thus, high-risk clusters lagged behind low-risk clusters by at least 1.5 decades. CONCLUSION: Myocardial infarction mortality risks have decreased substantially during the last 15 years, but persistent disparities in MI mortality burden still exist across Florida. Efforts to reduce these disparities will need to target prevention programs to counties in the high-risk clusters.

Differential trends in myocardial infarction mortality over 1975-2010 in France according to gender: An age-period-cohort analysis.

BACKGROUND: A dramatic reduction in mortality from myocardial infarction (MI) has been observed in France as in other western countries. The dynamics of this decline are likely to have differed according to age and sex. Our study sought to clarify the contributions of age, period and birth-cohort effects on post-MI mortality in France between 1975 and 2010 and to identify gender-specific trends. METHODS: Trends were analysed using an age-period-cohort (APC) model. MI mortality data were selected using the International Classification of Diseases (ICD) (8, 9 and 10th revision) codes from the French national mortality databases. RESULTS: Age-standardised MI mortality rates decreased by 70% from 1975 to 2010 in both sexes. Linear trend (drift) accounted for the majority of this decline and appeared very similar between genders. However, we found that increased MI mortality with advancing age was more pronounced in women than men beyond the age of 50. We also observed a slowdown in the decline among cohorts born after 1945, particularly in women. CONCLUSIONS: MI mortality showed a dramatic downward trend for the last 35years in France. The linear decline was modulated by cohort effects, whereas no major period effect was identified. This study also showed noticeable differential age and cohorts' effects between genders, especially the no longer decline in MI mortality for women born after World War II. This highlights the need for specific preventive measures to target this population in the future.

Influencia de la cobertura médica sobre el tratamiento y el pronóstico del infarto con supradesnivel del ST.: Subanálisis del registro SCAR / Influence of Medical Coverage on the Treatment and Prognosis of ST-segment Elevation Myocardial Infarction: SCAR Registry Subanalysis

Introducción: El registro sobre Síndromes Coronarios Agudos en Argentina (SCAR) analizó la evolución intrahospitalaria del infarto de miocardio en nuestro país en pacientes que contaban con diferentes coberturas del sistema de salud, lo cual ha llevado al presente subanálisis derivado del registro SCAR. Objetivo: Determinar la influencia de la cobertura médica en el pronóstico intrahospitalario del infarto de miocardio. Material y métodos: El registro SCAR fue un estudio transversal, prospectivo y multicéntrico, que incluyó 476 pacientes con diagnóstico de infarto agudo de miocardio con supradesnivel del segmento ST (IAMST). La cobertura médica se diferenció en prepaga, obra social, PAMI y sin cobertura (solo estatal). Resultados: El 80% de los IAMST recibieron reperfusión, el 75% por angioplastia transluminal coronaria primaria (ATCP). La ATCP fue más frecuente en quienes tenían prepaga [OR 5,5 (2,5-12,4); p < 0,001] y los pacientes con PAMI [OR 0,47 (0,24-087); p = 0,02] o sin cobertura recibieron menos ATCP [OR 0,34 (0,2-0,6); p < 0,001]. El 13% fueron derivados a otro centro, más frecuentemente si tenían PAMI (p = 0,002). El tiempo hasta la ATCP fue mayor en pacientes con PAMI [240 (88-370) min; p = 0,0005] y menor si tenían prepaga [80 (42-120) min; p < 0,001]. La mortalidad intrahospitalaria del IAMST fue del 8%, 2,8% con prepaga, 4,3% con cobertura estatal, 6,88% con obra social y 25% con PAMI (ANOVA < 0,001). Tener prepaga se asoció con una mortalidad menor [OR 0,27 (0,08-0,91); p = 0,035] y tener PAMI se asoció con una mortalidad mayor, aun ajustado por sexo, edad y comorbilidades [OR 2,40 (1,1-5,8); p = 0,05]. Conclusión: El tratamiento y la mortalidad del IAMST fueron diferentes según la cobertura médica.

Background: The Acute Coronary Syndromes in Argentina (SCAR) registry analyzed in-hospital myocardial infarction out-come in patients with different medical coverage provided by the healthcare system; this has led to the present subanalysis derived from the SCAR registry. Objective: The aim of this study was to determine the influence of medical coverage on myocardial infarction in-hospital prognosis. Methods: The SCAR registry was a cross-sectional, prospective, multicenter study including 476 patients with ST-segment elevation acute myocardial infarction (STEMI). Medical coverage was classified in prepaid health insurance, social security insurance, PAMI and without medical coverage (except public coverage). Results: Eighty percent of STEMI patients received reperfusion therapy, 75% by primary transluminal coronary angioplasty (PTCA). PTCA was more frequent in those with prepaid health insurance [OR 5.5 (2.5-12.4); p<0.001] and less frequent in PAMI patients [OR 0.47 (0.24-0.87), p=0.02] or in those without any medical coverage [OR=0.34 (0.2-0.6), p<0.001]. Thirteen percent of patients were transferred to another hospital, more frequently if they were PAMI patients (p=0.002). Time to PTCA was longer in patients with PAMI [240 (88-370) min, p=0.0005] and shorter in patients with prepaid health insurance [80 (42-120) min, p<0.001]. Overall in-hospital STEMI mortality was 8%, 2.8% in patients with prepaid health insurance, 4.3% in patients with public medical coverage, 6.88% in patients with social security insurance and 25% in patients covered by PAMI (ANOVA <0.001). Mortality was significantly lower in patients with prepaid health insurance [OR=0.27 (0.08-0.91), p=0.035] and higher in patients with PAMI, even after adjusting by sex, age and comorbidities [OR 2.40 (1.1-5.8), p=0.05]. Conclusion: STEMI treatment and mortality were different according to the type of medical coverage.

Door-to-balloon time in primary percutaneous coronary intervention predicts degree of myocardial necrosis as measured using cardiac biomarkers.

Reduced door-to-balloon time in primary percutaneous coronary intervention for the treatment of ST-elevation myocardial infarction has been associated with lower cardiac mortality rates. However, it remains unclear whether door-to-balloon time is predominantly a surrogate for overall peri-myocardial infarction care and is not independently predictive of outcomes, particularly when differences in door-to-balloon time have narrowed and previous studies have contained myocardial infarction-selection bias.We analyzed 179 consecutive patients who presented emergently at our cardiac catheterization laboratory with ST-elevation myocardial infarction within 12 hours of symptom onset and who underwent primary percutaneous coronary intervention within 3 hours of presentation. Our curve estimation regression model used the natural logarithm (ln) of area under the curve (AUC) of creatine kinase to evaluate the effect of door-to-balloon time on cardiac biomarker levels. We correlated ln (AUC-creatine kinase) with improvement of left ventricular ejection fraction at follow-up and with the intermediate-term mortality rate.Median door-to-balloon time was 87 minutes (interquartile range, 65-113 min). The ln (AUC-creatine kinase) correlated significantly with door-to-balloon time (r=0.2, P=0.02). Upon propensity-score analysis, door-to-balloon time remained a significant independent predictor of ln (AUC-creatine kinase) (beta=0.15, P=0.03). Upon use of a Cox regression model, ln (AUC-creatine kinase) independently predicted death (P=0.04) and recovery of left ventricular function (P=0.001) at follow-up (mean, 14 mo).Longer door-to-balloon time independently predicts increased myocardial cell damage, and ln (AUC-creatine kinase) predicts improvement in left ventricular systolic function and intermediate-term death after ST-elevation myocardial infarction.

Clinical predictors of late death in survivors of acute myocardial infarction.

Survivors of acute myocardial infarction have higher mortality rates than do the general population. This study examined the value of multiple clinical characteristics in predicting late death among patients who present with acute myocardial infarction.We reviewed the electronic medical records of patients who had been treated for acute myocardial infarction at our institution from 1992 through 2000. We abstracted the clinical, laboratory, electrocardiographic, echocardiographic, and treatment characteristics.Of 144 patients (79.2% men; 97.2% white; mean age, 63 +/- 14.2 yr) included in this analysis, 63 (43.8%) patients died during a follow-up period of 5.6 +/- 2.8 years (5 d-12.7 yr). Higher age (hazard ratio, 1.83 +/- 0.31 for every 10-year increase), elevated serum creatinine (hazard ratio, 2.87 +/- 0.76), and lower baseline left ventricular ejection fraction (hazard ratio, 0.74 +/- 0.21 for every 5% increase) were found to be predictors of late death after adjusting for the white blood cell count, the QRS duration, the presence of coronary revascularization or defibrillator implantation, and the history of coronary artery disease. Elevated white blood cell count predicted early but not late death. Patients with none of the above risk factors had 100% survival at 5 years, in comparison with 22.7% survival for those with 3 or more of the 4 risk factors identified above.In this study, we have identified clinical predictors of long-term survival after acute myocardial infarction that might help in prognostication, patient education, and risk modification.