RESUMO
background: Early management of myocardial infarction in the area of public health requires the integration of specific programs for the coordination of healthcare services. Objective: The aim of this study was to evaluate the impact on delay times and reperfusion rate of a comprehensive program for the reperfusion of myocardial infarction in a hospital network of the Southern Greater Buenos Aires. Methods: The network consists of six low-mid-complexity hospitals and a third-level referral center with 24-hour cath-lab. Stage 1 of the program (2009-2010) evaluated the existing barriers to reperfusion; Stage 2 (2011-2013) implemented the progressive incorpora-tion of improvements and Stage 3 assessed the program (2013-2014) complemented with fellows in each hospital. Program impact was evaluated by the proportion of patients reperfused and time to its implementation. results: A total of 432 patients referred from the network were hospitalized with diagnosis of ST-segment elevation myocardial infarction. Mean age was 56±9 years and 83.3% were men. The proportion of reperfused patients progressively increased: S1 60.7%, S2 69% and S3 78%, p for trend=0.01. Time to reperfusion decreased significantly between S1 and S3, from 120 minutes (IQR 55-240) to 90 minutes (IQR 35-150), p=0.04, with a median reduction of 30 minutes in the door-to-balloon and door-to-needle times. Conclusions: The application of a program for myocardial reperfusion based on the diagnosis of barriers was associated with 28.5% increase in reperfusion, and a significant reduction in the implementation times. This public network model built on algorithms adapted to local barriers may contribute to improve the care of myocardial infarction in our country.
RESUMO
Observational studies have reported a marked discrepancy between the risk estimated by scores and the use of an invasive strategy in patients with acute coronary syndromes. The objective is to describe the criteria used to decide an early invasive strategy and to determine the differences between those criteria and the thrombolysis in myocardial infarction risk score (TRS). Patients entered to the Epi-Cardio registry with a diagnosis of non-ST-elevation acute coronary syndrome were analyzed. A logistic regression model including variables associated with an early invasive strategy was developed and validated in 2 consecutive cohorts. The association between the TRS and the clinical decision model with an early invasive strategy was evaluated by receiver operating characteristic (ROC) curves. We included a total of 3,187 patients. In the derivation cohort, variables associated with an early invasive strategy were previous angioplasty (odds ratio [OR] 1.63), hypercholesterolemia (OR 1.36), ST changes (OR 1.49), elevated biomarkers (OR 1.42), catheterization laboratory availability (OR 1.7), recurrent angina (OR 3.45), age (OR 0.98), previous coronary bypass (OR 0.65), previous heart failure (OR 0.40), and heart rate at admission (OR 0.98). The areas under the ROC curves to predict invasive strategy were 0.55 for the TRS and 0.69 for the clinical decision model, p <0.0001. In the validation cohort, ROC areas were 0.58 and 0.70, respectively, p <0.0001. In conclusion, invasive strategy was guided by variables not completely included in risk scores. The clinical, evolutionary, and structural variables included in the model can explain, partially, the discordance existing between risk stratification and medical strategies.
Assuntos
Síndrome Coronariana Aguda/mortalidade , Síndrome Coronariana Aguda/terapia , Mortalidade Hospitalar/tendências , Terapia Trombolítica/métodos , Síndrome Coronariana Aguda/diagnóstico , Idoso , Argentina , Causas de Morte , Estudos de Coortes , Angiografia Coronária/métodos , Ponte de Artéria Coronária/métodos , Ponte de Artéria Coronária/mortalidade , Tomada de Decisões , Eletrocardiografia , Feminino , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Razão de Chances , Prognóstico , Estudos Prospectivos , Curva ROC , Sistema de Registros , Reprodutibilidade dos Testes , Medição de Risco , Índice de Gravidade de Doença , Análise de Sobrevida , Terapia Trombolítica/mortalidade , Resultado do TratamentoRESUMO
Introducción Los pacientes con síndrome coronario agudo presentan diferencias clínicas según el grupo etario al que pertenezcan. No obstante, son pocos los estudios que han comparado pacientes jóvenes versus mayores en el contexto de este síndrome. Objetivos Describir las características clínicas y angiográficas, los usos terapéuticos y el pronóstico de los pacientes jóvenes con síndrome coronario agudo y compararlos con los pacientes mayores. Material y métodos Se analizaron 5.055 pacientes incluidos en el registro Epi-Cardio con diagnóstico de síndrome coronario agudo. Se consideraron jóvenes los hombres ≤ 45 años y las mujeres ≤ 50 años. Resultados De los pacientes incluidos, 519 eran jóvenes (10,3%) y 4.536 eran mayores (89,7%). El 49,9% de los jóvenes presentaron síndrome coronario agudo con elevación del segmento ST y el 50,1% sin elevación del segmento ST. Entre los mayores, el 38,4% presentaron el síndrome con elevación del segmento ST y el 61,6% sin elevación del segmento ST (p < 0,00001). Se realizó cateterismo coronario a 2.845 pacientes (56,3%). Entre los jóvenes, el 54,2% tenían enfermedad significativa de un vaso, el 20% de dos vasos, el 9,7% de tres vasos y el 16,1% no tenían lesiones significativas. Entre los mayores, el 39,6% tenían enfermedad de un vaso, el 28,4% de dos vasos, el 22,5% de tres vasos y el 9,5% sin lesiones significativas (p < 0,001). No existieron diferencias significativas en los tratamientos entre ambos grupos etarios durante la internación. La mortalidad fue del 1% en jóvenes y del 3,5% en mayores (OR 0,26; p = 0,02). La mortalidad corregida fue significativamente menor entre los jóvenes (OR 0,25; p = 0,038). Conclusiones Los pacientes jóvenes con síndrome coronario agudo presentaron más frecuentemente eleva¡ción del segmento ST que los mayores. La mortalidad de los mayores fue tres a cuatro veces mayor que en los jóvenes. El perfil de riesgo cardiovascular y la extensión de la enfermedad coronaria de ambos grupos justifican la diferencia en la presentación clínica.(AU)
Background Patients with acute coronary syndrome have clinical differences which are determined by the age-group to which they belong. Yet, few studies have compared young patients versus elder patients presenting with this syndrome. Objectives To describe the clinical and angiographic characteristics, the therapeutic uses and the outcome of young patients with acute coronary syndrome, and to compare them with those of elder patients. Methods A total of 5,055 patients with diagnosis of acute coronary syn-drome, included in the Epi-Cardio registry, were analyzed. Men ≤ 45 years and women ≤ 50 years were considered young. Results Young patients represented 10.3% of the population (519) and 89.7% (4,536) were elder patients. Among young pa-tients, 49.9% presented ST-segment elevation acute coronary syndrome and 50.1% had non ST-segment elevation. In elder patients, ST-segment elevation acute coronary syndrome occurred in 38.4% and 61.6% had non ST-segment eleva-tion (p Conclusions ST-segment elevation acute coronary syndrome was more frequent among young patients compared to elder patients. Mortality was three to four times greater in elder patients. The difference in the clinical presentation is justified by the profile of cardiovascular risk and extension of coronary artery disease of both groups.(AU)
RESUMO
Introducción Los pacientes con síndrome coronario agudo presentan diferencias clínicas según el grupo etario al que pertenezcan. No obstante, son pocos los estudios que han comparado pacientes jóvenes versus mayores en el contexto de este síndrome. Objetivos Describir las características clínicas y angiográficas, los usos terapéuticos y el pronóstico de los pacientes jóvenes con síndrome coronario agudo y compararlos con los pacientes mayores. Material y métodos Se analizaron 5.055 pacientes incluidos en el registro Epi-Cardio con diagnóstico de síndrome coronario agudo. Se consideraron jóvenes los hombres ≤ 45 años y las mujeres ≤ 50 años. Resultados De los pacientes incluidos, 519 eran jóvenes (10,3%) y 4.536 eran mayores (89,7%). El 49,9% de los jóvenes presentaron síndrome coronario agudo con elevación del segmento ST y el 50,1% sin elevación del segmento ST. Entre los mayores, el 38,4% presentaron el síndrome con elevación del segmento ST y el 61,6% sin elevación del segmento ST (p < 0,00001). Se realizó cateterismo coronario a 2.845 pacientes (56,3%). Entre los jóvenes, el 54,2% tenían enfermedad significativa de un vaso, el 20% de dos vasos, el 9,7% de tres vasos y el 16,1% no tenían lesiones significativas. Entre los mayores, el 39,6% tenían enfermedad de un vaso, el 28,4% de dos vasos, el 22,5% de tres vasos y el 9,5% sin lesiones significativas (p < 0,001). No existieron diferencias significativas en los tratamientos entre ambos grupos etarios durante la internación. La mortalidad fue del 1% en jóvenes y del 3,5% en mayores (OR 0,26; p = 0,02). La mortalidad corregida fue significativamente menor entre los jóvenes (OR 0,25; p = 0,038). Conclusiones Los pacientes jóvenes con síndrome coronario agudo presentaron más frecuentemente elevación del segmento ST que los mayores. La mortalidad de los mayores fue tres a cuatro veces mayor que en los jóvenes. El perfil de riesgo cardiovascular y la extensión de la enfermedad coronaria de ambos grupos justifican la diferencia en la presentación clínica.
Background Patients with acute coronary syndrome have clinical differences which are determined by the age-group to which they belong. Yet, few studies have compared young patients versus elder patients presenting with this syndrome. Objectives To describe the clinical and angiographic characteristics, the therapeutic uses and the outcome of young patients with acute coronary syndrome, and to compare them with those of elder patients. Methods A total of 5,055 patients with diagnosis of acute coronary syn-drome, included in the Epi-Cardio registry, were analyzed. Men ≤ 45 years and women ≤ 50 years were considered young. Results Young patients represented 10.3% of the population (519) and 89.7% (4,536) were elder patients. Among young pa-tients, 49.9% presented ST-segment elevation acute coronary syndrome and 50.1% had non ST-segment elevation. In elder patients, ST-segment elevation acute coronary syndrome occurred in 38.4% and 61.6% had non ST-segment eleva-tion (p Conclusions ST-segment elevation acute coronary syndrome was more frequent among young patients compared to elder patients. Mortality was three to four times greater in elder patients. The difference in the clinical presentation is justified by the profile of cardiovascular risk and extension of coronary artery disease of both groups.