Clinical presentation of acute coronary syndrome in patients previously treated with nitrates

Aims: Several reports have suggested that nitrates limit acute ischaemic damage by a mechanism similar to preconditioning. This study aims to evaluate the effect of chronic oral nitrates on the clinical presentation and short-term outcomes of patients admitted with acute coronary syndrome (ACS).Methods: A retrospective cohort study was conducted in patients with ACS admitted to 62 acute care units from 2010 to 2011. A propensity score-matched samples analysis was performed.Results: We analysed 3171 consecutive patients, of whom 298 (9.4%) were chronically treated with nitrates. Patients previously treated with nitrates had higher comorbidity and disease severity at admission, lower prevalence of ACS with ST elevation, lower troponin elevation, higher prevalence of initial Killip class 2-4 and higher hospital mortality. The propensity score-matched analysis confirmed that previous use of nitrates is independently associated with a lower prevalence of ST-elevation ACS [odds ratio (OR) 0.53, 95% confidence interval (CI) 0.36-0.78; P = 0.0014] and a lower troponin elevation (OR 0.61, 95% CI 0.41-0.92) but not with Killip class on admission (OR 1.18, 95% CI 0.83-1.67, P = 0.3697) or mortality (OR 0.71, 95% CI 0.37-1.38, P = 0.3196).Conclusion: The results support the hypothesis that nitrates have a protective effect on acute ischaemic injury

Uso de estrategia invasiva precoz en pacientes diabéticos con síndrome coronario agudo sin elevación del ST

Fundamento y objetivos: La estrategia invasiva reduce la mortalidad de los pacientes con síndrome coronario agudo sin elevación del ST (SCASEST) de alto riesgo, entre los que se incluyen los pacientes diabéticos. Sin embargo, diversas publicaciones han puesto de manifiesto una infrautilización de esta estrategia invasiva en estos pacientes. El objetivo de este estudio es conocer las características de los pacientes diabéticos que se tratan de forma conservadora, e identificar determinantes del uso de una u otra estrategia. Paciente y métodos: Estudio de cohortes retrospectivo, realizado en diabéticos con SCASEST incluidos en los cortes anuales de 2010 y 2011 en el registro ARIAM- EMICYUC. Se realizó un análisis bruto y ajustado mediante regresión logística no condicional. Resultados: Se han analizado 531 pacientes diabéticos, de los cuales 264 (49,7%) recibieron estrategia invasiva. Los pacientes diabéticos que se tratan de forma conservadora son un subgrupo caracterizado por su mayor edad y comorbilidad cardiovascular, mayor riesgo hemorrágico y ausencia de electrocardiograma (ECG) de alto riesgo. Se identifican como variables predictoras independientes asociadas al tratamiento conservador, el ECG de bajo riesgo, el Killip al ingreso superior a 1, alto riesgo hemorrágico y el tratamiento previo con clopidogrel. Conclusiones: El temor a las complicaciones hemorrágicas o la presencia de lesiones coronarias avanzadas podrían ser la causa de la infrautilización de la estrategia invasiva en los pacientes diabéticos con SCASEST.Background and objectives: In the management of non-ST-segment elevation acute coronary syndromes (NSTE-ACS), several studies have shown a reduction in mortality with the use of an invasive strategy in high-risk patients, including diabetic patients. Paradoxically, other studies have shown an under-utilization of this invasive strategy in these patients. The aim of this study is to determine the characteristics of patients managed conservatively and identify determinants of the use of invasive or conservative strategy.Patients and methods: Retrospective cohort study conducted in diabetic patients with NSTE-ACS included in the ARIAM-SEMICYUC registry (n=531) in 2010 and 2011. We performed crude and adjusted unconditional logistic regression. Results: We analyzed 531 diabetic patients, 264 (49.7%) of which received invasive strategy. Patients managed conservatively were a subgroup characterized by older age and cardiovascular comorbidity, increased risk of bleeding and the absence of high-risk electrocardiogram (ECG). In diabetic patients with NSTE-ACS, independent predictors associated with conservative strategy were low-risk ECG, initial Killip class>1, high risk of bleeding and pretreatment with clopidogrel.Conclusions: The fear of bleeding complications or advanced coronary lesions could be the cause of the underutilization of an invasive strategy in diabetic patients with NSTE-ACS