RESUMEN
UNLABELLED: We tried to determine the prognostic impact of triple (antiplatelet agents, statins and beta-blockers) and quadruple (the same+ACE inhibitors) combination therapy at hospital discharge after acute myocardial infarction. The USIC 2000 survey is nationwide registry of consecutive patients admitted to intensive care units for acute myocardial infarction in November 2000 in France. Of the 2119 patients discharged alive, 1095 (52%) were prescribed a combination of antiplatelet agents, beta-blockers and statins (triple therapy), including 567 (27%) with a similar combination plus ACE inhibitors (quadruple therapy). One-year survival was 97% in patients receiving triple combination therapy versus 88% in those who received either no, one or two of these medications (p < 0.0001). After multivariate adjustment, the odds ratio for one-year mortality in patients with triple combination therapy was 0.49 (95% confidence interval: 0.32-0.75). Quadruple combination therapy had no additional predictive value in the entire population. In patients with ejection fraction < or = 35%, however, beta-blockers and ACE inhibitors were independent predictors of survival, and combination therapy had no additional prognostic value. CONCLUSIONS: compared with the prescription of any single class of secondary prevention medications, combination therapy offers additional protection in patients with acute myocardial infarction.
Asunto(s)
Infarto del Miocardio/tratamiento farmacológico , Alta del Paciente , Adulto , Anciano , Recolección de Datos , Combinación de Medicamentos , Femenino , Humanos , MasculinoRESUMEN
OBJECTIVE: Few recommendations have been issued about the management of rheumatoid arthritis (RA), which varies widely across physicians. The primary care physician (PCP) plays a unique role as the first physician to evaluate the patient. The objective of this study was to evaluate the place of PCPs in the management of RA. METHODS: Medline was searched for articles reporting management of rheumatoid arthritis in primary care practice. RESULTS: Currently, the goal of initiating a disease modifying anti-rheumatic drug (DMARD) early is unrealistic for numerous patients. Agreement between PCPs and rheumatologists about the diagnosis of RA is only passable, but PCPs tend to overdiagnose RA. Median time from symptom onset to second-line treatment was 19 months and the best predictive factor for a longer lag time before DMARD prescription was the time from symptom onset to the first rheumatologist visit. Moreover, DMARDs are only rarely prescribed by PCPs. Some data suggest that the impact of rheumatologists care is positive on outcomes but it has to be confirmed by longitudinal, randomized studies, with valid outcomes and diagnosis criteria. Recognition of the need for timely referral is an important goal in the teaching of students and generalists. Moreover, the nature of management differences between rheumatologists and PCPs has to be explored. We should also think how to create a better coordination. This starts by knowing what are the needs of the PCP (e.g. education, access to phone advice or rapid consultation) and by defining common plan if the care should be shared. CONCLUSION: Several healthcare professionals, among whom the PCP plays a pivotal role, should share the management of RA. PCPs and rheumatologists should be encouraged to work together on optimizing the management of patients with RA.