Asunto(s)

Antagonistas Adrenérgicos beta/administración & dosificación , Instituciones Cardiológicas/estadística & datos numéricos , Servicios Médicos de Urgencia/estadística & datos numéricos , Infarto del Miocardio/tratamiento farmacológico , Infarto del Miocardio/mortalidad , Femenino , Humanos , Masculino

RESUMEN

OBJECTIVES: Despite the recommendations to initiate ß-blockade to all patients with an ST-segment elevation myocardial infarction, data concerning the timing of the administration of ß-blockers are controversially discussed. In view of these controversies, we analyzed the effect of immediate vs. delayed ß-blockade on all-cause mortality of patients with ST-segment elevation myocardial infarction in the Lower Austrian Myocardial Infarction Network. DESIGN: Nonrandomized, prospective observational cohort study. SETTING: Myocardial infarction network including the out-of-hospital emergency services, five primary-care hospitals and a percutaneous coronary intervention-capable hospital in the western part of Lower Austria. PATIENTS: The data of all patients with ST-segment elevation myocardial infarction defined according to the American Heart Association criteria and treated according to the treatment protocol of the network were consecutively collected. For the purpose of survival analyses, the baseline survival time was set to 48 hours after the first electrocardiogram, and in all patients with recurrent MI within the observational period, only the first MI was regarded. INTERVENTIONS: The treatment protocol recommended either the immediate oral administration of 2.5 mg bisoprolol (within 30 min after the first electrocardiogram) or 24 hours after acute myocardial infarction (delayed ß-blockade). MEASUREMENTS AND MAIN RESULTS: In total, out of the 664 patients with ST-segment elevation myocardial infarction, 343 (n = 52%) received immediate ß-blockade and 321 (48%) received delayed ß-blockade. The probability of any death (baseline survival time: 48 hours after first electrocardiogram; 640 patients) was 19.2% in the delayed treatment group and 10.7% in the immediate treatment group (p = 0.0022). Also the probability of cardiovascular mortality was significantly lower in the immediate ß-blocker treatment group (immediate treatment group: 9 (5.2%); delayed treatment group: 30 (13.4%); p = 0.0002). Multivariable Cox regression analysis identified immediate ß-blocker therapy to be independently protective against death of any cause (odds ratio: 0.55, p = 0.033). CONCLUSION: Immediate ß-blocker administration in the emergency setting is associated with a reduction of all-cause and cardiovascular mortality in patients with ST-segment elevation myocardial infarction and seems to be superior to a delayed ß-blockade in our patient cohort.

Asunto(s)

Antagonistas Adrenérgicos beta/administración & dosificación , Instituciones Cardiológicas/estadística & datos numéricos , Servicios Médicos de Urgencia/estadística & datos numéricos , Infarto del Miocardio/tratamiento farmacológico , Infarto del Miocardio/mortalidad , Antagonistas Adrenérgicos beta/uso terapéutico , Anciano , Austria , Protocolos Clínicos , Comorbilidad , Electrocardiografía , Servicios Médicos de Urgencia/métodos , Servicio de Urgencia en Hospital/organización & administración , Servicio de Urgencia en Hospital/estadística & datos numéricos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos

Asunto(s)

Síndrome Coronario Agudo/tratamiento farmacológico , Inhibidores de Agregación Plaquetaria/farmacología , Síndrome Coronario Agudo/epidemiología , Adenosina/análogos & derivados , Adenosina/farmacología , Aspirina/farmacología , Clopidogrel , Femenino , Humanos , Masculino , Piperazinas/farmacología , Inhibidores de Agregación Plaquetaria/farmacocinética , Inhibidores de Agregación Plaquetaria/uso terapéutico , Clorhidrato de Prasugrel , Antagonistas del Receptor Purinérgico P2Y/farmacología , Fumar/epidemiología , Tiofenos/farmacología , Ticagrelor , Ticlopidina/análogos & derivados , Ticlopidina/farmacología , Resultado del Tratamiento

RESUMEN

OBJECTIVE: Arterial hypertension is the most frequently observed vascular risk factor. Physical and rehabilitative interventions may affect arterial blood pressure. The frequency of hypertensive patients in an outpatient clinic of physical medicine is unknown. DESIGN: Prospective data collection. PATIENTS: Overall, 3,826 patients admitted to the outpatient clinic for physical and rehabilitative interventions were included to assess arterial blood pressure, additional vascular risk factors, history of cardiovascular events and antihypertensive drug treatment. METHODS: Arterial blood pressure was measured using an oscillometric method on the non-dominant arm. The patients were divided into sufficiently treated (< 140/90 mmHg, drug treatment), insufficiently treated (≥ 140/90 mmHg, drug treatment and history of hypertension) or de novo hypertensive patients (≥ 140/90 mmHg, no history of hypertension). RESULTS: Arterial hypertension was observed in 48% of all patients (n = 1,840). In 719 (19%) of patients blood pressure above normal values. Due to significant hypertension 189 (5.2%) patients were either not permitted to start treatment or had to interrupt their physical treatment. CONCLUSION: Insufficiently treated hypertension or previously undiagnosed hypertension is relatively common in a physical medicine clinic. We therefore recommend the implementation of arterial blood pressure measurement into the admission procedures in order to reduce such events.

Asunto(s)

Hipertensión/patología , Modalidades de Fisioterapia , Resultado del Tratamiento , Anciano , Austria , Determinación de la Presión Sanguínea , Índice de Masa Corporal , Distribución de Chi-Cuadrado , Femenino , Encuestas Epidemiológicas , Humanos , Masculino , Persona de Mediana Edad , Pacientes Ambulatorios , Estudios Prospectivos , Factores de Riesgo , Factores de Tiempo

RESUMEN

OBJECTIVES: Patients with acute myocardial infarction are at high risk of dying within the first hours after onset of coronary ischemia. Therefore, pharmacological intervention should be started in the prehospital setting. This study investigates the effect of the prehospital administration of bivalirudin on short-term morbidity and mortality compared to heparin plus abciximab in patients with ST-segment-elevation myocardial infarction (STEMI). METHODS: One hundred ninety-eight patients with STEMI treated with bivalirudin in the prehospital setting were prospectively collected. Coronary angiography was performed to identify the infarct-related artery. In case of a percutaneous coronary intervention, bivalirudin was given according to the guidelines. The historic control group consisted of 171 consecutive patients from the same myocardial infarction network treated with unfractioned heparin and abciximab administration before the admission to the emergency department of the percutaneous coronary intervention center. The primary outcome parameter was the incidence of major adverse cardiac events (recurrent myocardial infarction, stroke, death, target vessel revascularization for ischemia) within 30 days after the primary event. RESULTS: The overall rate of major adverse cardiac events was significantly lower in the bivalirudin group compared to the abciximab group (7.6% vs 14.6%; P = .04). The number of major bleedings was significantly higher in the abciximab group compared to the bivalirudin group (11.8% vs 3.8%; P = .03). CONCLUSIONS: The use of bivalirudin in the prehospital setting leads to a reduced rate of major cardiovascular events compared to a standard treatment with abciximab plus heparin. Bivalirudin is a reasonable choice of treatment in the prehospital setting for patients with STEMI.

Asunto(s)

Antitrombinas/uso terapéutico , Servicios Médicos de Urgencia/métodos , Infarto del Miocardio/tratamiento farmacológico , Fragmentos de Péptidos/uso terapéutico , Abciximab , Anciano , Angioplastia/métodos , Anticuerpos Monoclonales/administración & dosificación , Anticuerpos Monoclonales/efectos adversos , Anticuerpos Monoclonales/uso terapéutico , Anticoagulantes/administración & dosificación , Anticoagulantes/efectos adversos , Anticoagulantes/uso terapéutico , Antitrombinas/administración & dosificación , Antitrombinas/efectos adversos , Cateterismo Cardíaco , Quimioterapia Combinada , Femenino , Hemorragia/prevención & control , Heparina/efectos adversos , Heparina/uso terapéutico , Hirudinas/administración & dosificación , Hirudinas/efectos adversos , Humanos , Fragmentos Fab de Inmunoglobulinas/administración & dosificación , Fragmentos Fab de Inmunoglobulinas/efectos adversos , Fragmentos Fab de Inmunoglobulinas/uso terapéutico , Masculino , Persona de Mediana Edad , Infarto del Miocardio/complicaciones , Infarto del Miocardio/mortalidad , Fragmentos de Péptidos/administración & dosificación , Fragmentos de Péptidos/efectos adversos , Cuidados Preoperatorios/efectos adversos , Cuidados Preoperatorios/métodos , Estudios Prospectivos , Proteínas Recombinantes/administración & dosificación , Proteínas Recombinantes/efectos adversos , Proteínas Recombinantes/uso terapéutico , Factores de Tiempo , Resultado del Tratamiento

RESUMEN

OBJECTIVE: Pharmacologic cardioversion of atrial fibrillation (AF) is a reasonable mode of treatment if the arrhythmia is of recent onset. Results concerning the response rates of different drugs, respectively, in daily clinical practice and data with regard to the parameters associated with successful cardioversion are not very prevalent. METHODS: Three-hundred seventy-six patients who were admitted to the emergency department with acute AF and a duration of shorter than 48 hours were enrolled into the AF registry. RESULTS: The most effective drugs were flecainide and ibutilide (95% and 76%). Low response rates were observed with amiodarone (36%) and the individual use of digoxin or diltiazem (19% and 18%). Factors associated with a successful cardioversion were a lower blood pressure on admission (P = .002), a shorter time interval between the onset of AF and admission to the ED (P = .003), and adherence to treatment guidelines (P < .0001). CONCLUSION: The use of flecainide and ibutilide is associated with a much higher rate of cardioversion than other drugs we studied.

Asunto(s)

Antiarrítmicos/uso terapéutico , Fibrilación Atrial/tratamiento farmacológico , Servicio de Urgencia en Hospital/estadística & datos numéricos , Enfermedad Aguda , Adulto , Anciano , Anciano de 80 o más Años , Amiodarona/efectos adversos , Amiodarona/uso terapéutico , Antiarrítmicos/efectos adversos , Digoxina/efectos adversos , Digoxina/uso terapéutico , Diltiazem/efectos adversos , Diltiazem/uso terapéutico , Femenino , Flecainida/efectos adversos , Flecainida/uso terapéutico , Humanos , Masculino , Persona de Mediana Edad , Sulfonamidas/efectos adversos , Sulfonamidas/uso terapéutico , Factores de Tiempo , Resultado del Tratamiento

Asunto(s)

Antagonistas Adrenérgicos beta/administración & dosificación , Angioedema/inducido químicamente , Angioedema/tratamiento farmacológico , Inhibidores de la Enzima Convertidora de Angiotensina/efectos adversos , Bradiquinina/análogos & derivados , Adulto , Bradiquinina/administración & dosificación , Antagonistas del Receptor de Bradiquinina B2 , Humanos , Masculino

RESUMEN

OBJECTIVE: To determine whether patients with hypertensive urgency have a higher risk for subsequent cardiovascular events compared with hypertensive patients without this event. METHODS: Overall, 384 patients with hypertensive urgency and 295 control patients were followed up for at least 2 years. Hypertensive urgency was defined as a systolic blood pressure above 220 mmHg and/or a diastolic blood pressure above 120 mmHg without any evidence of acute end-organ damage. The control group consisted of patients admitted to the emergency department with a systolic blood pressure between 135 to 180 mmHg and a diastolic blood pressure between 85-110 mmHg. The number of cardiovascular events defined as acute coronary syndrome, acute stroke, atrial fibrillation, acute left ventricular failure and aortic aneurysm were consecutively analyzed during follow-up. The median follow-up time was 4.2 years (interquartile range 2.9-5.7 years). Twenty-six patients of the urgency group and 23 patients of the control group were lost for follow-up. RESULTS: Overall, 117 (17%) patients had nonfatal clinical cardiovascular events and 13 had (2%) fatal cardiovascular events. The frequency of cardiovascular events was significantly higher in patients with hypertensive urgencies (88 vs. 42; P = 0.005). The Cox regression analysis identified age (P < 0.001) and hypertensive urgencies (P = 0.035) as independent predictors for subsequent cardiovascular events. CONCLUSIONS: Hypertensive urgencies are associated with an increased risk for subsequent cardiovascular events in patients with arterial hypertension.

Asunto(s)

Presión Sanguínea , Enfermedades Cardiovasculares/epidemiología , Servicios Médicos de Urgencia/estadística & datos numéricos , Hipertensión/epidemiología , Índice de Severidad de la Enfermedad , Síndrome Coronario Agudo/epidemiología , Enfermedad Aguda , Adulto , Anciano , Aneurisma de la Aorta/epidemiología , Fibrilación Atrial/epidemiología , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Factores de Riesgo , Accidente Cerebrovascular/epidemiología , Disfunción Ventricular Izquierda/epidemiología

RESUMEN

The effects of the angiotensin II receptor blocker candesartan and the angiotensin-converting enzyme inhibitor lisinopril on the fibrinolytic system were investigated in a double-blinded, prospective, randomized study. Seventy-seven hypertensive patients taking candesartan (n=41) and lisinopril (n=36) with a systolic blood pressure >130 mm Hg and/or a diastolic blood pressure >80 mm Hg obtained by 24-hour ambulatory blood pressure measurement were included in the study. Blood pressure, plasminogen activator inhibitor 1 (PAI-1), tissue plasminogen activator (tPA), and the molar ratio of PAI-1/tPA were determined before treatment and 6 weeks later. Blood pressure decreased in both groups (candesartan, 155/85 mm Hg to 140/84 mm Hg; P<.05; lisinopril, 152/85 mm Hg to 138/83 mm Hg; P<.05). The fibrinolytic balance was significantly different between treatment groups (molar ratio of PAI-1/tPA: candesartan, 3.66 [2.2;] lisinopril, 5.44 [2.6;] P<.05). In contrast to lisinopril, the balance between coagulation and fibrinolytic activity shifted toward fibrinolysis during candesartan treatment.

Asunto(s)

Antihipertensivos/farmacología , Bencimidazoles/farmacología , Fibrinólisis/efectos de los fármacos , Hipertensión/enzimología , Lisinopril/farmacología , Tetrazoles/farmacología , Adulto , Bloqueadores del Receptor Tipo 1 de Angiotensina II/farmacología , Bloqueadores del Receptor Tipo 1 de Angiotensina II/uso terapéutico , Inhibidores de la Enzima Convertidora de Angiotensina/farmacología , Inhibidores de la Enzima Convertidora de Angiotensina/uso terapéutico , Antihipertensivos/uso terapéutico , Bencimidazoles/uso terapéutico , Compuestos de Bifenilo , Presión Sanguínea/efectos de los fármacos , Presión Sanguínea/fisiología , Método Doble Ciego , Femenino , Humanos , Hipertensión/tratamiento farmacológico , Hipertensión/fisiopatología , Lisinopril/uso terapéutico , Masculino , Persona de Mediana Edad , Inhibidor 1 de Activador Plasminogénico/sangre , Estudios Prospectivos , Tetrazoles/uso terapéutico , Activador de Tejido Plasminógeno/sangre

RESUMEN

A prospective multicenter study including 1410 chest pain patients with suspected acute coronary syndromes was carried out to examine the predictive value of biological cardiac markers for adverse events measured by a point-of-care system. Admission cardiac troponin T (cTnT) and myoglobin were measured in parallel on a point-of-care system in the emergency department and -- together with CK-MB mass -- on lab analyzers. In a one-year follow-up, cardiac and non-cardiac death, acute myocardial infarction, unstable angina pectoris and need for revascularization were registered. Median time between onset of symptoms and admission was 285 min; 172 patients (12.2%) had no event during follow-up. If the cTnT, measured either by the point-of-care system or a conventional lab analyzer, was >0.05 microg/L, then the chance of a cardiac event during the follow-up period was doubled (18% vs. 9%). Serial cTnT measurement did not add any further value to the predictive power of the admission cTnT. Myoglobin and CK-MB mass identified increasing risk with increasing concentration quartiles; cardiac event rates were 2.8- to 4.4-fold higher between the quartiles with the lowest and those with the highest analyte concentration, respectively. There was no difference in non-cardiac death rates between any concentration quartiles. In conclusion, the prediction of clinical events by cardiac troponin T and myoglobin measured with a point-of-care analyzer in the emergency department was as good as that of the same cardiac markers and CK-MB mass measured on lab analyzers.

Asunto(s)

Dolor en el Pecho , Servicio de Urgencia en Hospital , Infarto del Miocardio/diagnóstico , Mioglobina/sangre , Sistemas de Atención de Punto , Troponina T/sangre , Anciano , Forma MB de la Creatina-Quinasa/sangre , Femenino , Humanos , Masculino , Persona de Mediana Edad , Infarto del Miocardio/sangre , Medición de Riesgo , Sensibilidad y Especificidad

RESUMEN

STUDY OBJECTIVE: The relation between course of blood pressure within the first 24 hours after acute stroke and early neurologic outcome remains a matter of dispute. We investigate this relation with adjustment for other influencing variables. METHODS: Three hundred seventy-two patients with the diagnosis of ischemic stroke were included to evaluate the relation between blood pressure course and early neurologic outcome. The following data were collected: age; sex; history of hypertension, diabetes mellitus, hyperlipidemia, coronary heart disease, peripheral vascular disease, and stroke; smoking habits; preadmission blood pressure, blood pressure on admission, and blood pressure 24 hours later; antihypertensive treatment; and stroke localization. We assessed outcome at day 5 after admission as dependent or independent (Rankin Scale score

Asunto(s)

Isquemia Encefálica/complicaciones , Hipertensión/etiología , Hipertensión/fisiopatología , Recuperación de la Función , Accidente Cerebrovascular/complicaciones , Actividades Cotidianas , Anciano , Anciano de 80 o más Años , Antihipertensivos/uso terapéutico , Presión Sanguínea , Isquemia Encefálica/rehabilitación , Diástole , Evaluación de la Discapacidad , Femenino , Humanos , Hipertensión/diagnóstico , Hipertensión/tratamiento farmacológico , Modelos Logísticos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Valor Predictivo de las Pruebas , Estudios Retrospectivos , Factores de Riesgo , Índice de Severidad de la Enfermedad , Método Simple Ciego , Rehabilitación de Accidente Cerebrovascular , Sístole , Factores de Tiempo , Resultado del Tratamiento

RESUMEN

BACKGROUND: The aim of this study was to evaluate the sensitivity and specificity of a combination of fasting plasma glucose (FPG) and glycosylated hemoglobin (HbA(1c)) for screening for diabetes in hypertensive patients. The oral glucose tolerance test (OGTT) served as a gold standard for the detection of diabetes. METHODS: The cross-sectional study was performed in the Hypertension Unit of the Department of Emergency Medicine in the General Hospital of Vienna between January 1999 and July 2001. The FPG, HbA(1c), and OGTT were performed in 152 hypertensive patients (77 male and 75 female) to identify those individuals with diabetes. RESULTS: A total of 33 patients were identified as diabetic based on the results of the OGTT. Diabetes was detected in 25 (16%) of 152 patients using an FPG > or =7.0 mmol/L. In addition, HbA(1c) was measured in the remaining 127 (84%) patients with an FPG <7.0 mmol/L. In these patients HbA(1c) > or =6.1% showed a sensitivity of 100% and a specificity of 75%. Cost analysis of both approaches (FPG + HbA(1c) versus OGTT in all patients) demonstrated a cost sparing effect of 31.03 $/patient (31.66$/patient) in favor of the combined use of FPG and HbA(1c). CONCLUSION: The combination of FPG and HbA(1c) is a reasonable alternative to the generally recommended OGTT for the screening of diabetes, as diabetes was correctly diagnosed in all patients by this stepwise procedure.

Asunto(s)

Glucemia/análisis , Complicaciones de la Diabetes , Diabetes Mellitus/diagnóstico , Hemoglobina Glucada/análisis , Hipertensión/complicaciones , Anciano , Estudios Transversales , Diabetes Mellitus/sangre , Ayuno/sangre , Femenino , Prueba de Tolerancia a la Glucosa/economía , Costos de la Atención en Salud , Humanos , Masculino , Persona de Mediana Edad

RESUMEN

The aim of the study was to investigate the clinical significance of additional ST-segment elevation that occurs during thrombolytic therapy. Therefore, we classified 153 patients with a first acute myocardial infarction (MI) into two groups: Group A, 55 patients with additional ST-segment elevation > or = 1 mm above the initial ST elevation during thrombolytic therapy and Group B, 98 patients without this electrocardiographic pattern. Among the patients with anterior MI, Group A (n = 33) had no reduction from ST-predicted to final QRS-estimated infarct size (+12% versus -27%; p = 0.0005) and a larger final infarct size (QRS-score: 18% versus 12%; p = 0.0002) than Group B (n = 41). Among the patients with inferior MI, Group A (n = 22) had a smaller reduction from ST-predicted to final QRS-estimated infarct size (-30% versus -53%; p = 0.03) and a larger final infarct size (QRS-score: 15% versus 9%; p = 0.03) than Group B (n = 57). The area under the curve (AUC) of CK and CK-MB was higher in patients from Group A compared with those from Group B (anterior MI: AUC-CK: 22,048 versus 19,490 U.h.l-1; p = 0.07; AUC-MB: 2227 versus 2016 U.h.l-1; p = 0.11; inferior MI: AUC-CK: 17,206 versus 11,004 U.h.l-1; p = 0.01; AUC-MB: 2193 versus 1046 U.h.l-1; p = 0.007). Both global left ventricular function and ST-segment elevation resolution were significantly better in Group B. Two and three vessel disease was observed more frequently in Group A. Additional ST-segment elevation during thrombolytic therapy suggests reduced myocardial salvage by thrombolytic therapy and thus may result in larger final infarct size.

Asunto(s)

Electrocardiografía , Infarto del Miocardio/diagnóstico , Terapia Trombolítica , Anciano , Pruebas Enzimáticas Clínicas , Angiografía Coronaria , Creatina Quinasa/sangre , Interpretación Estadística de Datos , Ecocardiografía , Femenino , Humanos , Isoenzimas/sangre , Masculino , Persona de Mediana Edad , Infarto del Miocardio/clasificación , Infarto del Miocardio/diagnóstico por imagen , Infarto del Miocardio/tratamiento farmacológico , Terapia Recuperativa , Factores de Tiempo , Función Ventricular Izquierda

RESUMEN

OBJECTIVE: Comparison of oscillometric blood pressure measurement with two different devices (M3000A using a new algorithm and M1008A using an established algorithm, both Hewlett Packard) and evaluation of current recommendations concerning the relation between cuff size and upper arm circumference in critically ill patients. DESIGN: Prospective data collection. SETTING: Emergency department in a 2000-bed inner-city hospital. PATIENTS: A total of 30 patients categorized into three groups according to their upper arm circumference (I, 18-25 cm; II, 25.1-33 cm; III, 33.1-47.5 cm) were enrolled in the study protocol. INTERVENTIONS In each patient, two noninvasive blood pressure devices with three different cuff sizes were used to perform oscillometric blood pressure measurement. Invasive mean arterial blood pressure measurement was done by cannulation of the radial artery. MEASUREMENT AND MAIN RESULTS: Overall, 1,011 pairs of simultaneous oscillometric and invasive blood pressure measurements were collected in 30 patients (group I, n = 10; group II, n = 10; group III, n = 10). The overall discrepancy between both methods with the M3000A was -2.4 +/- 11.8 mm Hg (p <.0001) and, with the M1008A, -5.3 +/- 11.6 mm Hg (p <.0001) if the recommended cuff size according to the upper arm circumference was used (352 measurements). If smaller cuff sizes than recommended were used (308 measurements performed in group II and III), the overall discrepancy between both methods with the M3000A was 1.3 +/- 13.4 mm Hg (p <.024) and, with the M1008A, -2.3 +/- 11.5 mm Hg (p <.0001). CONCLUSION: The new algorithm reduced the overall bias of the oscillometric method but still showed a significant discrepancy between both methods of blood pressure measurement, primarily due to the mismatch between upper arm circumference and cuff size. The improvement of the algorithm alone could not result in a sufficient improvement of oscillometric blood pressure measurement. A reevaluation of the recommendations concerning the relation between upper arm circumference and cuff size are urgently required if oscillometric blood pressure measurement should become a reasonable alternative to intra-arterial blood pressure measurement in critically ill patients.

Asunto(s)

Determinación de la Presión Sanguínea/instrumentación , Determinación de la Presión Sanguínea/métodos , Enfermedad Crítica , Manometría/instrumentación , Manometría/métodos , Oscilometría/instrumentación , Oscilometría/métodos , Adulto , Anciano , Anciano de 80 o más Años , Algoritmos , Antropometría , Brazo/anatomía & histología , Sesgo , Determinación de la Presión Sanguínea/normas , Diseño de Equipo , Femenino , Humanos , Modelos Lineales , Masculino , Manometría/normas , Persona de Mediana Edad , Oscilometría/normas , Guías de Práctica Clínica como Asunto , Estudios Prospectivos

RESUMEN

OBJECTIVE: To assess whether the sum of ST segment elevation and depression (ST segment deviation score [SUMSTdev]) is a better predictor for 24 h, nonfatal complications in patients with acute myocardial infarction (MI) than the sum of ST segment elevation (SUMSTelev) alone in the admission electrocardiogram. METHODS: Patients with acute MI receiving thrombolytic therapy were observed and ST scores were evaluated. Nonfatal, 24 h complications were defined as acute congestive heart failure or severe rhythm disturbances within 24 h after the start of thrombolysis. The outcome measures were the relationship between both the SUMSTdev and the SUMSTelev and the occurence of 24 h complications, and the identification of a cut-off value with the highest sensitivity and specificity for the prediction of complications. RESULTS: Three hundred eighty-two patients (288 male patients, mean age 58 years) with acute MI (179 patients with anterior MI) were included in the study. The SUMSTdev was significantly higher in patients with 24 h complications than in patients without complications (anterior MI 23.9 mm versus 11.5 mm, respectively, P<0.001; inferior MI 21.6 mm versus 12.0 mm, respectively, P<0.001). Using the receiver operating characteristic analysis, the SUMSTdev significantly improved the ability to estimate the occurence of 24 h complications for anterior and inferior MI compared with the SUMSTelev (anterior MI 0.87+/-0.03 versus 0.84+/-0.03, P=0.04; inferior MI 0.79+/-0.03 versus 0.74+/-0.04, P=0.03). The optimal cut-off for the SUMSTdev was found at 16 mm for anterior MI and 13 mm for inferior MI. Multivariate regression analysis showed that the SUMSTdev was an independent predictor of the occurrence of early complications in patients with anterior MI (odds ratio 28.4, 95% CI 11.0 to 73.6, P<0.0001) and inferior MI (odds ratio 9.7, 95% CI 4.7 to 20.2, P<0.001). CONCLUSIONS: The SUMSTdev is superior to the SUMSTelev in predicting 24 h, nonfatal complications after acute MI. The use of the SUMSTdev is therefore recommended for the stratification of patients with acute MI into low and high risk patients.

Asunto(s)

Electrocardiografía/métodos , Fibrinolíticos/uso terapéutico , Infarto del Miocardio/complicaciones , Infarto del Miocardio/tratamiento farmacológico , Terapia Trombolítica , Adulto , Anciano , Arritmias Cardíacas/etiología , Aspirina/uso terapéutico , Insuficiencia Cardíaca/etiología , Heparina/uso terapéutico , Mortalidad Hospitalaria , Humanos , Masculino , Persona de Mediana Edad , Infarto del Miocardio/diagnóstico , Infarto del Miocardio/mortalidad , Valor Predictivo de las Pruebas , Estudios Prospectivos , Factores de Riesgo , Activador de Tejido Plasminógeno/uso terapéutico

RESUMEN

Whereas clinic blood pressure (CBP) above normality is divided into stages, no corresponding classifications are available for 24-hour ambulatory blood pressure (ABP). We conducted a study (1) to define stages of hypertension by ABP corresponding to CBP stages and (2) to evaluate if these stages have prognostic impact similar to CBP stages. Seven hundred thirty-six hypertensive patients were included. Mean systolic blood pressure was 149+/-15.2/87+/-8.6 mm Hg for CBP and 135+/-13/79+/-9.7 mm Hg for ABP. The mean bias between both methods was -13.3 mm Hg (95% CI, -14.3 to -12.2; 1.96xSD limits of agreement, 15.7 to -42.3) and -7.3 mm Hg (95% CI, -7.9 to -6.6; 1.96xSD limits of agreement, 9.8 to -24.3) for systolic and diastolic blood pressure (P>0.0001 for both), respectively. Classification of hypertension by ABP revealed lower cutoff values for the different stages of hypertension compared with the corresponding cutoff values for CBP (CBP versus ABP: 140/90 versus 132/81 mm Hg; 160/100 versus 140/88 mm Hg; 180/110 versus 148/94 mm Hg, P<0.001). Overall, 82 (11.1%) patients had nonfatal clinical cardiovascular events and 9 (1.2%) patients died of a cardiovascular cause during follow-up. The distribution of cardiovascular events was significantly associated with increasing ABP value (P<0.006). Staging of hypertension by ABP may facilitate the use of this method in daily clinical practice, as ABP can now be used not only to confirm the diagnosis of hypertension but also to assess the severity and prognosis of hypertensive disease.

Asunto(s)

Monitoreo Ambulatorio de la Presión Arterial , Presión Sanguínea , Hipertensión/clasificación , Hipertensión/diagnóstico , Distribución por Edad , Anciano , Austria/epidemiología , Presión Sanguínea/efectos de los fármacos , Enfermedades Cardiovasculares/epidemiología , Comorbilidad , Quimioterapia Combinada , Femenino , Estudios de Seguimiento , Humanos , Hipertensión/tratamiento farmacológico , Hipertensión/epidemiología , Incidencia , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Pronóstico , Índice de Severidad de la Enfermedad , Resultado del Tratamiento

RESUMEN

BACKGROUND: Several predictors of survival have been described in selected subgroups of patients suffering from acute myocardial infarction. However, data on unselected patients with acute myocardial infarction and cardiogenic shock, including patients with out-of hospital cardiac arrest, are missing. We aimed to assess predictors of survival for an unselected cohort of patients representative of clinical practice who experienced acute myocardial infarction and required continuous catecholamine support for circulatory failure. METHODS: The study was performed at a 2000 bed university hospital. All consecutive patients admitted to our emergency department with acute myocardial infarction were prospectively enrolled in a clinical trial from 1993 to 2000. DESIGN: A retrospective cohort study was performed on patients with myocardial infarction requiring catecholamine support within the first 24 h. Primary endpoint was in-hospital mortality. RESULTS: The analysis was carried out on 262 patients, 189 men (72%), median age 65 years (IQR 53-73). Out-of-hospital cardiac arrest was reported in 47% (122/262). In-hospital mortality was 53% (138/262). Survivors as compared to non-survivors exhibited significant differences with respect to age (60 vs. 68 years, P<0.0001), systolic and diastolic blood pressure on admission (110 vs. 102 mmHg, P=0.01 and 64 vs. 58 mmHg, P=0.006, respectively), initial blood serum lactate (6.8 vs. 8.3, P=0.01), peak CKMB level (93 vs. 138 U/l, P=0.005), use of adrenaline (epinephrine) (38 vs. 68%, P<0.0001) and any attempt of revascularisation (76 vs. 63%, P=0.03). In a multivariate model younger age [OR 1.06 (CI 1.03-1.10), P<0.001], no use of adrenaline [OR 2.63 (CI 1.35-5.26) P=0.005] and lower peak CKMB [OR 1.01 (CI 1.01-1.01), P<0.0001] were independently associated with in-hospital survival. CONCLUSION: In unselected patients including CPR survivors with acute myocardial infarction requiring continuous catecholamine support, younger age, the absence of continuous adrenaline administration and a lower peak CKMB were independently associated with increased in-hospital survival.

Asunto(s)

Cardiotónicos/uso terapéutico , Catecolaminas/uso terapéutico , Infarto del Miocardio/mortalidad , Choque Cardiogénico/tratamiento farmacológico , Anciano , Presión Sanguínea , Reanimación Cardiopulmonar , Ensayos Clínicos como Asunto , Dobutamina/uso terapéutico , Dopamina/uso terapéutico , Electrocardiografía , Epinefrina/uso terapéutico , Femenino , Humanos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Infarto del Miocardio/complicaciones , Infarto del Miocardio/diagnóstico , Norepinefrina/uso terapéutico , Estudios Retrospectivos , Factores de Riesgo , Choque Cardiogénico/etiología , Choque Cardiogénico/mortalidad , Tasa de Supervivencia

RESUMEN

OBJECTIVE: The genetic background of hypertensive crisis is unknown. We examined the association of polymorphisms in genes involved in the renin-angiotensin-aldosterone-system with hypertensive crisis. DESIGN: Population-based case-control study. SETTING: Emergency department at a tertiary care university hospital. PATIENTS: A total of 182 patients with essential hypertension who were admitted to an emergency department for treatment of hypertensive crisis and 182 age- and sex-matched healthy individuals. INTERVENTIONS: None. MEASUREMENTS: Analysis of polymorphisms in genes coding for angiotensinogen (AJT 704T-->C), angiotensin II receptor 1 (AGTR1 1166A-->C), renin (REN 2646G-->A), renin-binding protein (RENBP 61T-->C), alpha-adducin (ADD1 1378G-->T), beta-2-adrenergic receptor (ADRB2 46A-->G, 79C-->G), and angiotensin I converting enzyme (ACE I/D) was performed by polymerase chain reaction and restriction fragment length polymorphism analysis. MAIN RESULTS Among patients, the ACE I/D polymorphism showed a deviation from Hardy-Weinberg equilibrium (p =.01). In controls, all polymorphisms were in the Hardy-Weinberg equilibrium. The frequency of the DD genotype was increased in patients (n = 70, 38.5%) vs. controls (n = 51; 28.0%;p =.03; odds ratio, 1.61; 95% confidence interval, 1.03-2.50), which was due to the DD genotype in 40 male patients (44%) vs. 23 in male controls (25.3%;p =.004; odds ratio, 3.48; 95% confidence interval, 1.47-8.30). There were no differences in genotype distributions among other polymorphisms. CONCLUSION: We demonstrate a possible association of the DD genotype with hypertensive crisis in men.

Asunto(s)

Hipertensión/genética , Peptidil-Dipeptidasa A/genética , Polimorfismo Genético , Sistema Renina-Angiotensina/genética , Angiotensinógeno/genética , Proteínas de Unión a Calmodulina/genética , Carbohidrato Epimerasas/genética , Proteínas Portadoras/genética , Estudios de Casos y Controles , Urgencias Médicas , Femenino , Frecuencia de los Genes , Genotipo , Humanos , Hipertensión/metabolismo , Masculino , Persona de Mediana Edad , Reacción en Cadena de la Polimerasa , Polimorfismo de Longitud del Fragmento de Restricción , Receptor de Angiotensina Tipo 1 , Receptores Adrenérgicos beta 2/genética , Receptores de Angiotensina/genética , Renina/genética

RESUMEN

BACKGROUND: Diagnosis of acute coronary syndromes (ACS) is a major challenge for emergency physicians. Because soluble fibrin (sF) has been suggested as a potential early marker of impending myocardial ischemia, we were interested whether a sF bedside test could help in early identification of patients with ACS in the emergency department. METHODS: We evaluated plasma coagulation markers, including a newly developed sF bedside test, prothrombin fragment (F(1+2)), sF, and D-dimer, in a cross-sectional trial with 184 patients suggestive of ACS. RESULTS: Whereas 76% (13 of 17) of patients with unstable angina pectoris (UAP) had a positive sF bedside test, only 10 of 33 patients (30%) with non-ST-segment-elevation myocardial infarction and 10 of 44 patients (23%) with ST-elevation myocardial infarction tested positive. Three percent of controls (1 of 33) and 11% of patients (6 of 57) with preexisting stable angina had a positive sF bedside test (P <0.001 for noncardiac chest pain vs ACS), yielding an overall specificity of 92% and a sensitivity of 35%. The sensitivity of the established coagulation markers was significantly less to detect ACS (11% for F(1+2), 20% for thrombus precursor protein, and 18% for D-dimer; P <0.02 vs sF bedside test). The sF bedside test presented the earliest objective indicator of impending myocardial damage in the majority (10 of 13) of ACS patients with a normal or nondiagnostic electrocardiogram (ECG). CONCLUSIONS: A sF bedside test offers a specific tool for early identification of patients with ACS in an emergency department setting, although its sensitivity seems sufficient only for the early identification of patients with UAP. A sF bedside test could be useful, particularly in UAP patients with a nondiagnostic ECG.

Asunto(s)

Productos de Degradación de Fibrina-Fibrinógeno/análisis , Fibrina/análisis , Isquemia Miocárdica/diagnóstico , Sistemas de Atención de Punto , Enfermedad Aguda , Angina Inestable/diagnóstico , Biomarcadores/sangre , Pruebas de Coagulación Sanguínea , Servicios Médicos de Urgencia , Femenino , Humanos , Masculino , Persona de Mediana Edad , Infarto del Miocardio/diagnóstico , Sensibilidad y Especificidad

RESUMEN

In a placebo-controlled, double-blinded, randomized study we evaluated the effect of ramipril prior to thrombolysis on the course of PAI-1 plasma levels and on the frequency of postinfarct ischemic events in patients with acute myocardial infarction. Fifty-one out of 99 patients received 2.5 mg ramipril orally prior to thrombolysis and 12 h later. The blood samples for determination of PAI-1 plasma levels were collected on admission and 2, 4, 8, 12 and 24 h after thrombolysis. Postinfarct ischemic events were registered until coronary angiography was performed and defined as recurrent chest pain and/or evidence of ischemic signs on the ECG (ST-depression or ST-segment elevation of 1 mm in one or more inferior or anterior leads). Coronary angiography was performed within 7 days after the onset of myocardial infarction. Patients were classified into two groups: those without reperfusion of the infarct-related artery (TIMI grade 0 or 1) and those with reperfusion of the infarct-related artery (TIMI grade 2.3). On admission, PAI-1 plasma levels were similar in both groups (ramipril: 47.1 [4.8] ng/ml; placebo: 49.1 [4.8] ng/ml). The PAI-1AUC was 77.2 [6.7] ng/ml/h in the ramipril group and 95.4 [6.2] ng/ml/h in the placebo group (p = 0.013). Significant differences between groups were observed at 4, 8 and 12 h after thrombolysis (4 h: 85.5 (11.3) vs. 116 (12.3) ng/ml, p < 0.01; 8 h: 79.1 (11.2) vs. 100.9 (9.3) ng/ml, p < 0.01; 12 hrs: 71.3 (9.5) vs. 87.4 (7.7) ng/ml, p < 0.05). The relative frequency of postinfarct ischemic events was significantly lower in the ramipril group (2.5% versus 7.1%, p = 0.001). Additionally, we observed a significant higher rate of TIMI grade 2 and 3 of the infarct-related artery in patients receiving oral ramipril compared to the placebo group (73% versus 54%; p = 0.035). Our study demonstrates a favorable effect of ramipril on the fibrinolytic system after thrombolysis associated with a lower rate of postinfarct ischemic events within the first days after myocardial infarction. Therefore, the application of ramipril prior to thrombolysis appears to be a reasonable concomitant treatment which may reduce early infarct-related complications.

Asunto(s)

Infarto del Miocardio/tratamiento farmacológico , Inhibidor 1 de Activador Plasminogénico/sangre , Ramipril/administración & dosificación , Terapia Trombolítica , Adulto , Anciano , Causas de Muerte , Método Doble Ciego , Quimioterapia Combinada , Servicios Médicos de Urgencia/métodos , Femenino , Hemodinámica/efectos de los fármacos , Humanos , Hipotensión/inducido químicamente , Isquemia/etiología , Persona de Mediana Edad , Infarto del Miocardio/sangre , Infarto del Miocardio/complicaciones , Ramipril/farmacología