Programade atención al Infarto Agudo de Miocardio con elevación del segmento ST en el área Centro de Galicia. Determinantes pronósticos, detección de grupos de riesgo y oportunidades de mejora

Esta tesis doctoral recoge el análisis de 2170 pacientes con Infarto Agudo de Miocardio con elevación del segmento ST (IAMCEST) sometidos a terapia de reperfusión urgente en el Complexo Hospitalario Universitario de Santiago de Compostela (CHUS) entre los años 2008 y 2018. Se ha llevado a cabo una valoración exhaustiva de las características clínicas, tratamiento y resultados a corto y largo plazo, tanto a nivel global como en subgrupos de alto riesgo. El objetivo principal es conocer el pronóstico de la población a estudio, así como los factores que lo determinan en el Área Centro de Galicia, que se caracteriza por una red de atención al IAMCEST consolidada con muchos años de experiencia y donde la terapia de reperfusión es casi exclusivamente el intervencionismo coronario percutáneo primario (ICPp). Se ha evaluado el pronóstico de los pacientes en términos de mortalidad y eventos intrahospitalarios, tanto a corto como a largo plazo, con un seguimiento medio de 5,5 años. Este análisis ha permitido identificar los determinantes independientes clínicos y de intervención en la población a estudio, así como detectar los subgrupos de riesgo. Por otro lado, en un análisis de tendencias temporales, se ha estudiado la adhesión a los cambios que se han ido produciendo en las Guías de Práctica Clínica a lo largo de diez años, y como estos cambios han influido en el pronóstico de los pacientes. Finalmente, un estudio de estas características nos ha permitida detectar puntos débiles en la atención al IAMCEST y plantear oportunidades de mejora

Manejo intervencionista de una insuficiencia mitral por pseudocleft en paciente pluripatológico

We report a case of heart failure with poor response to conventional medical treatment in a multi-pathological patient with severe mitral valve insufficiency secondary to pseudocleft in which an interventional approach was decided with a MitraClip implant. This clinical case describes the importance of a multidisciplinary approach in the treatment of heart failure patients by integrating multiples areas of cardiology such as clinical, advanced imaging and percutaneous interventions.Se presenta un caso de insuficiencia cardíaca refractaria a tratamiento médico en paciente pluripatológico con insuficiencia mitral grave por pseudocleft en el que se decide un manejo intervencionista con implante de MitraClip. Este caso destaca la importancia del manejo multidisciplinar de la insuficiencia cardíaca integrando distintas áreas de la cardiología como la clínica, la imagen avanzada y el intervencionismo percutáneo

Regional differences in STEMI care in Spain. Data from the ACI-SEC Infarction Code Registry

Introduction and objectives: Geographical and organizational differences between different autonomous communities (AC) can generate differences in care for ST-segment elevation myocardial infarction (STEMI). A total of 17 heart attack code programs have been compared in terms of incidence rate, clinical characteristics, reperfusion therapy, delay to reperfusion, and 30-day mortality. Methods: National prospective observational study (83 centers included in 17 infarction networks). The recruitment period was 3 months (April 1 to June 30, 2019) with clinical follow-up at 30 days. Results: 4366 patients with STEMI were included. The incidence rate was variable between different AC (P <.0001), as was gender (P =.003) and the prevalence of cardiovascular risk factors (P <.0001). Reperfusion treatment was primary angioplasty (range 77.5%-97.8%), fibrinolysis ( range 0%-12.9%) or no treatment (range 2.2%- 13.5%). The analysis of the delay to reperfusion showed significant differences (P <.001) for all the intervals analyzed. There were significant differences in 30-days mortality that disappeared after adjusting for clinical and healthcare network characteristics. Conclusions: Large differences in STEMI care have been detected between the different AC, in terms of incidence rate, clinical characteristics, reperfusion treatment, delay until reperfusion, and 30-day mortality. The differences in mortality disappeared after adjusting for the characteristics of the patient and the care network

Instantaneous Wave-Free Ratio for the Assessment of Intermediate Left Main Coronary Artery Stenosis: Correlations With Fractional Flow Reserve/Intravascular Ultrasound and Prognostic Implications: The iLITRO-EPIC07 Study

Background: There is little information available on agreement between fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR) in left main coronary artery (LMCA) intermediate stenosis. Besides, several meta-analyses support the use of FFR to guide LMCA revascularization, but limited information is available on iFR in this setting. Our aims were to establish the concordance between FFR and iFR in intermediate LMCA lesions, to evaluate with intravascular ultrasound (IVUS) in cases of FFR/iFR discordance, and to prospectively validate the safety of deferring revascularization based on a hybrid decision-making strategy combining iFR and IVUS. Methods: Prospective, observational, multicenter registry with 300 consecutive patients with intermediate LMCA stenosis who underwent FFR and iFR and, in case of discordance, IVUS and minimal lumen area measurements. Primary clinical end point was a composite of cardiovascular death, LMCA lesion-related nonfatal myocardial infarction, or unplanned LMCA revascularization. Results: FFR and iFR had an agreement of 80% (both positive in 67 and both negative in 167 patients); in case of disagreement (31 FFR+/iFR- and 29 FFR-/iFR+) minimal lumen area was & GE;6 mm(2) in 8.7% of patients with FFR+ and 14.6% with iFR+. Among the 300 patients, 105 (35%) underwent revascularization and 181 (60%) were deferred according to iFR and IVUS. At a median follow-up of 20 months, major adverse cardiac events incidence was 8.3% in the defer group and 13.3% in the revascularization group (hazard ratio, 0.71 [95% CI 0.30-1.72]; P=0.45). Conclusions: In patients with intermediate LMCA stenosis, a physiology-guided treatment decision is feasible either with FFR or iFR with moderate concordance between both indices. In case of disagreement, the use of IVUS may be useful to indicate revascularization. Deferral of revascularization based on iFR appears to be safe in terms of major adverse cardiac events

Narrativas audiovisuales emergentes: creaciones didácticas multimedia realizadas por alumnos para enseñanza y aprendizaje en campus virtuales

Diseño, escritura y realización de contenidos videográficos y multimedia para la enseñanza virtual. El alumnado de Ciencias de la Información analiza, crea y difunde materiales narrativos creados para campus virtuales y cursos online innovadores

Effectiveness of an intervention for improving drug prescription in primary care patients with multimorbidity and polypharmacy:Study protocol of a cluster randomized clinical trial (Multi-PAP project)

This study was funded by the Fondo de Investigaciones Sanitarias ISCIII (Grant Numbers PI15/00276, PI15/00572, PI15/00996), REDISSEC (Project Numbers RD12/0001/0012, RD16/0001/0005), and the European Regional Development Fund ("A way to build Europe").Background: Multimorbidity is associated with negative effects both on people's health and on healthcare systems. A key problem linked to multimorbidity is polypharmacy, which in turn is associated with increased risk of partly preventable adverse effects, including mortality. The Ariadne principles describe a model of care based on a thorough assessment of diseases, treatments (and potential interactions), clinical status, context and preferences of patients with multimorbidity, with the aim of prioritizing and sharing realistic treatment goals that guide an individualized management. The aim of this study is to evaluate the effectiveness of a complex intervention that implements the Ariadne principles in a population of young-old patients with multimorbidity and polypharmacy. The intervention seeks to improve the appropriateness of prescribing in primary care (PC), as measured by the medication appropriateness index (MAI) score at 6 and 12months, as compared with usual care. Methods/Design: Design:pragmatic cluster randomized clinical trial. Unit of randomization: family physician (FP). Unit of analysis: patient. Scope: PC health centres in three autonomous communities: Aragon, Madrid, and Andalusia (Spain). Population: patients aged 65-74years with multimorbidity (≥3 chronic diseases) and polypharmacy (≥5 drugs prescribed in ≥3months). Sample size: n=400 (200 per study arm). Intervention: complex intervention based on the implementation of the Ariadne principles with two components: (1) FP training and (2) FP-patient interview. Outcomes: MAI score, health services use, quality of life (Euroqol 5D-5L), pharmacotherapy and adherence to treatment (Morisky-Green, Haynes-Sackett), and clinical and socio-demographic variables. Statistical analysis: primary outcome is the difference in MAI score between T0 and T1 and corresponding 95% confidence interval. Adjustment for confounding factors will be performed by multilevel analysis. All analyses will be carried out in accordance with the intention-to-treat principle. Discussion: It is essential to provide evidence concerning interventions on PC patients with polypharmacy and multimorbidity, conducted in the context of routine clinical practice, and involving young-old patients with significant potential for preventing negative health outcomes. Trial registration: Clinicaltrials.gov, NCT02866799Publisher PDFPeer reviewe