Identificación de variables predictivas de riesgo en la evaluación incial de la angina inestable.

RESUMEN Objetivo: 1. Conocer el perfil clínico y electrocardiográfico de los pacientes ingresados con síndrome coronario agudo sin elevación persistente del segmento ST (SCASEST). 2. Incidencia de eventos adversos isquémicos intrahospitalarios. 3. Identificar las variables que obtenidas en el ingreso, sean predictivas de eventos adversos intrahospitalarios. 4. Analizar la incidencia de eventos adversos a largo plazo 5. Identificar las variables predictivas de eventos adversos isquémicos a largo plazo. Material y método: Estudio prospectivo observacional de los pacientes ingresados consecutivamente desde puertas de urgencias con diagnóstico de SCASEST. Se analizaron variables clínicas, electrocardiográficas y analíticas obtenidas en el momento del ingreso. Seguimiento clínico de 50 meses. Los eventos adversos intrahospitalarios fueron: angina recurrente, angina refractaria, arritmias ventriculares graves, infarto agudo de miocardio y muerte cardíaca. El evento adverso principal fue el combinado de muerte cardíaca o infarto. Se hizo un análisis descriptivo de las variables, expresando las cualitativas como porcentajes y las continuas como media ± desviación estándar. Se realizó un análisis de la varianza para las variables cuantitativas y 2 para las cualitativas. Las variables predictivas del evento principal en el análisis univariado y las consideradas clínicamente relevantes fueron introducidas en un modelo de regresión logística multivariada. Los eventos isquémicos analizados en el seguimiento fueron: infarto de miocardio y muerte cardíaca. El evento adverso principal fue el combinado de muerte cardíaca o infarto. El análisis univariado se realizó mediante el método de Kaplan-Meier y las diferencias entre las curvas se analizaron con el test de log-rank. Aquellas variables predictoras del evento principal en el análisis univariado y las consideradas clínicamente relevantes fueron introducidas en un modelo de regresión de Cox multivariado. Resultados: Ingresaron 494 pacientes con sospecha inicial de SCASEST, de los que 26 fueron diagnosticados de angina inestable secundaria y 53 de dolor torácico no isquémico. Los 415 pacientes restantes con diagnóstico de SCASEST definido (infarto agudo de miocardio 13.5% y angina inestable 86.5%) fueron los finalmente analizados. La incidencia de eventos intrahospitalarios fue: angina recurrente 26%, angina refractaria 14%, infarto de miocardio no fatal 1.9%, muerte cardíaca 2.7% y evento combinado 4.6%. Edad 70 años, descenso del segmento ST y niveles de fibrinógeno 385 mg/dl fueron predictores independientes del evento principal intrahospitalario. El seguimiento medio fue de 50 meses. Se registraron 54 muertes cardíacas (13.6%) y 33 infartos de miocárdio (8.2%). La incidencia de muerte o infarto (70 pacientes) fue del 17.3%. La edad 70 años, hipertensión arterial, diabetes, ictus previo, insuficiencia cardíaca Killip >I, insuficiencia renal, descenso del segmento ST y niveles de fibrinógeno 385 mg/dl fueron predictores independientes del evento pricipal en el seguimiento. Conclusiones: 1. Los pacientes con SCASEST presentan una elevada prevalencia de factores de riesgo y cardiopatía isquémica previa. La forma de presentación más frecuente es la tipo IIIB de Braunwald. En el momento del ingreso, el 30% no presentan alteraciones de la repolarización. 2. La mortalidad intrahospitalaria fue del 2.7% y la incidencia del evento combinado del 4.6%, presentándose más de la mitad de estos episodios en las primeras 48 horas. 3. Las variables predictoras independientes del evento combinado intrahospitalario fueron: edad 70 años, descenso del segmento ST y niveles de fibrinógeno 385 mg/dl. 4. Los pacientes con SCASEST presentan una elevada incidencia de complicaciones graves isquémicas durante los tres primeros meses tras el alta hospitalaria. Posteriormente, el pronóstico es bueno, comparable a la cardiopatía isquémica crónica estable. 5. Las variables predictivas independientes del evento principal a largo plazo fueron: edad 70 años, diabetes mellitus, hipertensión arterial, insuficiencia renal, ictus previo, insuficiencia cardíaca Killip > I al ingreso, descenso del segmento ST y niveles de fibrinógeno 385 mg/dl. __________________________________________________________________________________________________Background and purpose: Patients with suspected non-ST-segment elevation acute coronary syndromes (NSTEACS) constitute a heterogeneous population with variable outcomes. Risk stratification in this population is dificult due to the complexity in patient risk profile. We conducted this study to characterize the value of clinical and electrocardiographical variables for risk stratification in an unselected population of consecutive patients with NSTEACS on admission. Methods: We prospectively included 415 consecutive patients admitted with non-ST elevation acute coronary syndrome (65±11 y.; 27% female) between November 1997 and July 1998 and looked for the combined end-point of cardiac death or myocardial infarction during hospitalization and at long-term (mean follow-up 50 months). Baseline clinical and electrocardiographical data as well as serum concentrations of CPK-MB, creatinine and fibrinogen were prospectively recorded. The Student t-test was applied for comparisons between continuous variables with normal distribution, the chi-squared test for categorical data, Kaplan-Meier curves (log-rank test) for survival analysis and the Cox regression model to investigate the effect of several variables upon the follow-up. Results: In-hospital cardiovascular mortality was 2.7% and the rate for the outcome of either cardiovascular death or nonfatal myocardial infarction was 4.6%. Independent predictors of in-hospital death or nonfatal myocardial infarction were age (65 years), ST segment depression and elevation of fibrinogen levels. The incidence of cardiovascular mortality or nonfatal myocardial infarction at long term was of 17.3%. Significant multivariate predictors of long term mortality or nonfatal myocardial infarction were age (65 years), ST segment depression, arterial hypertension, stroke, diabetes mellitus, Killip class II at admission, renal dysfunction and elevation of fibrinogen levels. Conclusions: 1. The in-hospital prognosis of NSTEACS is good. However, patients discharged from hospital after clinical stabilization present an important number of ischemic complications during the following 3 months, similar to that presented by all patients during the acute phase. 2. Simple clinical, electrocardiographical and biochemical data obtained at hospital admission allow an accurate risk stratification of patients with NSTEACS

Impact of interstitial lung disease on the survival of systemic sclerosis with pulmonary arterial hypertension

To assess severity markers and outcomes of patients with systemic sclerosis (SSc) with or without pulmonary arterial hypertension (PAH-SSc/non-PAH-SSc), and the impact of interstitial lung disease (ILD) on PAH-SSc. Non-PAH-SSc patients from the Spanish SSc registry and PAH-SSc patients from the Spanish PAH registry were included. A total of 364 PAH-SSc and 1589 non-PAH-SSc patients were included. PAH-SSc patients had worse NYHA-functional class (NYHA-FC), worse forced vital capacity (FVC) (81.2 +/- 20.6% vs 93.6 +/- 20.6%, P < 0.001), worse tricuspid annular plane systolic excursion (TAPSE) (17.4 +/- 5.2 mm vs 19.9 +/- 6.7 mm, P < 0.001), higher incidence of pericardial effusion (30% vs 5.2%, P < 0.001) and similar prevalence of ILD (41.8% vs. 44.9%). In individuals with PAH-SSc, ILD was associated with worse hemodynamics and pulmonary function tests (PFT). Up-front combination therapy was used in 59.8% and 61.7% of patients with and without ILD, respectively. Five-year transplant-free survival rate was 41.1% in PAH-SSc patients and 93.9% in non-PAH-SSc patients (P < 0.001). Global survival of PAH-SSc patients was not affected by ILD regardless its severity. The multivariate survival analysis in PAH-SSc patients confirmed age at diagnosis, worse NYHA-FC, increased PVR, reduced DLCO, and lower management with up-front combination therapy as major risk factors. In conclusion, in PAH-SSc cohort risk of death was greatly increased by clinical, PFT, and hemodynamic factors, whereas it was decreased by up-front combination therapy. Concomitant ILD worsened hemodynamics and PFT in PAH-SSc but not survival regardless of FVC impairment

Impact of interstitial lung disease on the survival of systemic sclerosis with pulmonary arterial hypertension

To assess severity markers and outcomes of patients with systemic sclerosis (SSc) with or without pulmonary arterial hypertension (PAH-SSc/non-PAH-SSc), and the impact of interstitial lung disease (ILD) on PAH-SSc. Non-PAH-SSc patients from the Spanish SSc registry and PAH-SSc patients from the Spanish PAH registry were included. A total of 364 PAH-SSc and 1589 non-PAH-SSc patients were included. PAH-SSc patients had worse NYHA-functional class (NYHA-FC), worse forced vital capacity (FVC) (81.2 ± 20.6% vs 93.6 ± 20.6%, P &lt; 0.001), worse tricuspid annular plane systolic excursion (TAPSE) (17.4 ± 5.2 mm vs 19.9 ± 6.7 mm, P &lt; 0.001), higher incidence of pericardial effusion (30% vs 5.2%, P &lt; 0.001) and similar prevalence of ILD (41.8% vs. 44.9%). In individuals with PAH-SSc, ILD was associated with worse hemodynamics and pulmonary function tests (PFT). Up-front combination therapy was used in 59.8% and 61.7% of patients with and without ILD, respectively. Five-year transplant-free survival rate was 41.1% in PAH-SSc patients and 93.9% in non-PAH-SSc patients (P &lt; 0.001). Global survival of PAH-SSc patients was not affected by ILD regardless its severity. The multivariate survival analysis in PAH-SSc patients confirmed age at diagnosis, worse NYHA-FC, increased PVR, reduced DLCO, and lower management with up-front combination therapy as major risk factors. In conclusion, in PAH-SSc cohort risk of death was greatly increased by clinical, PFT, and hemodynamic factors, whereas it was decreased by up-front combination therapy. Concomitant ILD worsened hemodynamics and PFT in PAH-SSc but not survival regardless of FVC impairment

Adult congenital heart disease in Spain: health care structure and activity, and clinical characteristics

Red Española de Cardiopatías Congénitas del Adulto (RECCA).[ES] Introducción y objetivos: Analizar la estructura asistencial y las características clínicas de las cardiopatías congénitas del adulto en España. Métodos: En 2014 se realizó una encuesta entre 32 centros que se clasificaron como nivel 1 o 2 en función de su estructura asistencial. En 2017 se realizó un registro clínico de todos los pacientes asistidos consecutivamente en cada centro durante un periodo de 2 meses. Resultados: Un total de 31 centros (97%) respondieron la encuesta. Se excluyó a 7 por no disponer de consulta especializada. Hasta el año 2005 solo había 5 centros con dedicación específica, pero en 2014 había 10 centros de nivel 1 y 14 de nivel 2 con un total de 19.373 pacientes en seguimiento. La estructura institucional era completa en la mayoría de los centros, pero solo el 33% disponía de enfermería propia y el 29%, de unidad de transición estructurada. La actividad terapéutica específica supuso el 99 y el 91% de la publicada en los registros nacionales de cirugía y cateterismo terapéutico. Del total, el 44% de los pacientes tenían cardiopatía de complejidad moderada y el 24%, de gran complejidad. Aunque el 46% de los pacientes atendidos en centros de nivel 2 tenían cardiopatías simples, el 17% eran cardiopatías de gran complejidad. Conclusiones: La estructura y la actividad de los centros españoles cumplen las recomendaciones internacionales y son comparables a las de otros países desarrollados. El espectro de cardiopatías en seguimiento muestra una concentración de lesiones de complejidad moderada y gran complejidad incluso en centros de nivel 2. Sería aconsejable reordenar el seguimiento de los pacientes en función de las recomendaciones internacionales.[EN] Introduction and objectives: To assess the structure of health care delivery and the clinical characteristics of adults with congenital heart disease (ACHD) attending specialized centers in Spain. Methods: A survey was conducted among 32 Spanish centers in 2014. The centers were classified into 2 levels based on their resources. In 2017, a clinical dataset was collected of all consecutive patients attended for a 2-month period at these centers. Results: A total of 31 centers (97%) completed the survey. Seven centers without specialized ACHD clinics were excluded from the analysis. In 2005, only 5 centers met the requirements for specific care. In 2014, there were 10 level 1 and 14 level 2 centers, with a total of 19 373 patients under follow-up. Health care structure was complete in most centers but only 33% had ACHD nurse specialists on staff and 29% had structured transition programs. Therapeutic procedures accounted for 99% and 91% of those reported by National Registries of Cardiac Surgery and Cardiac Catheterization, respectively. Among attended patients, 48% had moderately complex lesions and 24% had highly complex lesions. Although 46% of patients attending level 2 centers had simple lesions, 17% had complex lesions. Conclusions: The structure for ACHD health care delivery in Spain complies with international recommendations and is similar to that of other developed countries. Congenital heart diseases under specialized care consist mostly of moderately and highly complex lesions, even in level 2 centers. It would be desirable to reorganize patient follow-up according to international recommendations in clinical practice

The economic burden of pulmonary arterial hypertension in Spain.

Pulmonary Arterial Hypertension (PAH) is a rare, debilitating, and potentially fatal disease. This study aims to quantify the economic burden of PAH in Spain. The study was conducted from a societal perspective, including direct and indirect costs associated with incident and prevalent patients. Average annual costs per patient were estimated by multiplying the number of resources consumed by their unit cost, differentiating the functional class (FC) of the patient. Total annual costs per FC were also calculated, taking the 2020 prevalence and incidence ranges into account. An expert committee validated the information on resource consumption and provided primary information on pharmacological consumption. Unit costs were estimated using official tariffs and salaries in Spain. A deterministic sensitivity analysis was conducted to test the uncertainty of the model. The average annual total cost was estimated at €98,839 per prevalent patient (FC I-II: €65,233; FC III: €103,736; FC IV: €208,821), being €42,110 for incident patients (FC I-II: €25,666; FC III: €44,667; FC IV: €95,188). The total annual cost of PAH in Spain, taking into account a prevalence between 16.0 and 25.9 cases per million adult inhabitants (FC I-II 31.8%; FC III 61.3%; FC IV 6.9%) and an incidence of 3.7, was estimated at €67,891,405 to €106,131,626, depending on the prevalence considered. Direct healthcare costs accounted for 64% of the total cost, followed by indirect costs (24%), and direct non-healthcare costs (12%). The total costs associated with patients in FC I-II ranged between €14,161,651 and €22,193,954, while for patients in FC III costs ranged between €43,763,019 and €68,391,651, and for patients in FC IV between €9,966,735 and €15,546,021. In global terms, patients with the worst functional status (FC IV) account for only 6.9% of the adults suffering from PAH in Spain, but are responsible for 14.7% of the total costs. PAH places a considerable economic burden on patients and their families, the healthcare system, and society as a whole. Efforts must be made to improve the health and management of these patients since the early stages of the disease

Long-term Outcomes of Adults With Single Ventricle Physiology Not Undergoing Fontan Repair: A Multicentre Experience

[Background] To describe long-term survival and cardiovascular events in adult patients with single ventricle physiology (SVP) without Fontan palliation, focusing on predictors of mortality and comparing groups according to their cardiovascular physiology.[Methods] Multicentre observational and retrospective study including adult patients with SVP without Fontan palliation since their first adult clinic visit. The cohort was subdivided into 3 groups: Eisenmenger, restricted pulmonary flow, and aortopulmonary shunt. Death was considered as the main end point. Other clinical outcomes occurring during follow-up were considered as secondary end points.[Results] A total of 146 patients, mean age 32.5 ± 11.1 years, were analysed. Over a mean follow-up of 7.3 ± 4.1 years, 33 patients (22.6%) died. Survival was 86% and 74% at 5 and 10 years, respectively. Right ventricular morphology was not associated with higher mortality. Four variables at baseline were related to a higher mortality: at least moderate atrioventricular valve regurgitation, platelet count 120 ms). A total of 34.2% of patients were admitted to the hospital due to heart failure, and 7.5% received a heart transplant. Other cardiovascular outcomes were also frequent: atrial arrhythmias in 19.2%, stroke in 15.1%, and pacemaker/implantable cardioverter-defibrillator in 6.2%/2.7%.[Conclusions] Adult patients with SVP who had not undergone Fontan exhibit a high mortality rate and frequent major cardiovascular events. At least moderate atrioventricular valve regurgitation, thrombocytopenia, renal dysfunction, and QRS duration > 120 ms at baseline visit allow identification of a cohort of patients at higher risk of mortality.[Objectif] Décrire la survie à long terme et les événements cardiovasculaires chez les patients adultes présentant une physiologie à ventricule unique (PVU) sans intervention de Fontan, en se concentrant sur les prédicteurs de mortalité et en comparant les groupes en fonction de leur physiologie cardiovasculaire.[Méthodes] Étude observationnelle et rétrospective, multicentrique, incluant des patients adultes atteints de PVU sans intervention de Fontan depuis leur première visite en clinique adulte. La cohorte a été subdivisée en trois groupes : syndrome d'Eisenmenger, flux pulmonaire restreint ou fenêtre aorto-pulmonaire. Le décès a été considéré comme le critère principal d'évaluation. Les autres observations cliniques survenues au cours du suivi ont été considérées comme des critères secondaires.[Résultats] Un total de 146 patients, d'un âge moyen de 32,5 ± 11,1 ans, a été considéré pour l’analyse. Sur un suivi moyen de 7,3 ± 4,1 ans, 33 patients (22,6 %) sont décédés. La survie était de 86 % et 74 % à 5 et 10 ans, respectivement. La morphologie du ventricule droit n'était pas associée à une mortalité plus élevée. Quatre variables initiales étaient liées à une mortalité plus élevée : régurgitation au moins modérée de la valve auriculo-ventriculaire, numération plaquettaire 120 ms). Au total, 34,2 % des patients ont été admis à l'hôpital en raison d'une insuffisance cardiaque, et 7,5 % ont reçu une transplantation cardiaque. D'autres conséquences cardiovasculaires étaient également fréquentes : arythmies auriculaires dans 19,2 % des cas, accident vasculaire cérébral dans 15,1 % des cas et stimulateur cardiaque/ défibrillateur cardioverteur implantable dans 6,2 % / 2,7 % des cas.[Conclusions] Les patients adultes atteints de PVU qui n'ont pas subi d'intervention de Fontan présentent un taux de mortalité élevé et des événements cardiovasculaires majeurs fréquents. Une régurgitation au moins modérée de la valve auriculo-ventriculaire, une thrombocytopénie, une dysfonction rénale et une durée du QRS > 120 ms lors de la visite initiale permettent de distinguer une cohorte de patients présentant un risque de mortalité plus élevé.Peer reviewe