[Unstable angina in the elderly: clinical, profile, management and mortality at three months. The PEPA Registry Data]

[Prognostic impact of interventional approach in non-ST segment elevation acute coronary syndrome in very elderly patients]

INTRODUCTION AND OBJECTIVES

In moderate or high risk non-ST segment elevation acute coronary syndrome, clinical practice guidelines recommend a coronary angiography with intent to revascularize. However, evidence to support this recommendation in very elderly patients is poor.

METHODS

All patients over 85 years old admitted to our hospital between 2004 and 2009 with a diagnosis of non-ST segment elevation acute coronary syndrome were retrospectively included. Using a propensity score, patients undergoing the interventional approach and those undergoing conservative management were matched and compared for survival and survival without ischemic events.

RESULTS

We included 228 consecutive patients with a mean age of 88 years (range: 85 to 101). Those in the interventional approach group (n=100) were younger, with a higher proportion of males and less comorbidity, less cognitive impairment and lower troponin I levels compared with patients in the conservative management group (n=128). We matched 63 patients from the interventional approach group and 63 from the conservative management group using propensity score. In the matched patients, the interventional approach group exhibited better survival (log rank 4.24; P=.039) and better survival free of ischemic events (log rank 8.63; P=.003) at the 3-year follow-up. In the whole population, adjusted for propensity score quintiles, the interventional approach group had lower mortality (hazard ratio 0.52; 95% confidence interval: 0.32-0.85) and a better survival free of ischemic events (hazard ratio 0.48; 95% confidence interval: 0.32-0.74).

CONCLUSIONS

Nearly all the very elderly patients admitted with non-ST segment elevation acute coronary syndrome were of moderate or high risk. In these patients, the interventional approach was associated with overall better survival and better survival free of ischemic events.

[Secondary prevention of coronary heart disease is less agressive in patients over 64 years]

INTRODUCTION AND OBJECTIVES

Although elderly people has a higher incidence of coronary heart disease, this group is seldom included in clinical trials. Studies performed in Spain on elderly coronary heart disease patients have been conducted in hospital settings. The aim of our study was to analyse wether the management of coronary heart disease patients over 64 years of age cared by family physicians differed from that of the rest.

PATIENTS AND METHOD

Cross-sectional multicentre study embedded in a clinical trial on 1,022 patients with stable coronary heart disease in which socio-demographic variables, comorbidity, treatment and cardiovascular risk- factor control were collected.

RESULTS

Mean age was 64 10, 74.0% were men and 53.8% of subjects were over 64 years. Patients over 64 years had a greater cardiovascular comorbidity (87.7 vs 82.6%; p = 0.002) and received lower number of drugs than the rest in the prevention of recurrences (60.4 vs 70.9%; p < 0.001). Probability to receive less than two drugs on secondary prevention by subjects over 64 years was 0.45 (95% CI, 0.30-0.68) despite comorbidity, sex and cardiovascular risk profile.Conclusions. Coronary heart disease patients over 64 years receive less drugs for coronary event recurrence prevention than their younger counterparts despite their worse cardiovascular risk profile.

[Clinical characteristics, prognosis, and variability in the management of non-ST-segment elevation acute coronary syndromes. Data from the PEPA registry]

OBJECTIVES

To assess the clinical characteristics and inter-hospital variability in the treatment and prognosis of patients with non-ST-segment elevation acute coronary syndromes.

PATIENTS AND METHOD

Data from the PEPA study, a prospective registry that enrolled 4,115 patients in 18 Spanish hospitals, were analyzed.

RESULTS

The mean age of the patients enrolled was 65 years, 33% were women, and 26% had diabetes. Large differences were observed in the clinical profile of patients admitted to different centers, especially relative the history of previous disease, prior coronary revascularization, and co-morbidity. Antiplatelet treatment was used in 93% of patients, heparin in 45%, beta-blockers in 42%, nitrates in 67%, and calcium antagonists in 46%. During hospitalization, exercise stress testing was performed in 37% of patients, coronary angiography in 32%, coronary angioplasty in 9%, and coronary surgery in 4%. Inter-hospital variability was minimal for the use of antiplatelet agents, wide for the use of heparin and beta-blockers, and huge for the use of revascularization procedures. Mortality and the incidence of death or myocardial infarction were 2.6% and 4.4% during hospitalization, and 4.6% and 8% at 3 months, with wide inter-hospital variability. These differences were not significant once adjusted for clinical characteristics and the treatment received at admission.

CONCLUSIONS

Patients with non-ST-segment elevation acute coronary syndromes represent an heterogeneous group with a high incidence of complications. Pharmacologic and, especially, invasive treatment varies widely in different hospitals. These results underline the importance of correct initial risk stratification and uniform treatment following the recommendations of clinical guidelines.

[Long-term prognosis of women with non-ST-segment elevation acute coronary syndromes. a case-control study]

BACKGROUND AND OBJECTIVES

Women with ST-segment-elevation myocardial infarction have a worse prognosis than men. However, information about the prognosis of women with non-ST-segment-elevation acute coronary syndromes (NSTEACS) is scarce. The aim of this study was to determine if the long-term prognosis of men and women with NSTEACS differs.

PATIENTS AND METHOD

Case-control study. In a consecutive series of 300 patients admitted for a NSTEACS and ischemic ECG changes, we compared the clinical characteristics, in-hospital and long-term follow-up of 95 women and 95 men matched for age, presence of diabetes, and past history of hypertension.

RESULTS

The median age of patients was 69 years, 36% had diabetes, and 65% had a history of hypertension. There were no gender differences in the history of angina or hypercholesterolemia, clinical presentation, number of patients with ST-segment depression, and CK-MB elevation. However, smoking, coronary artery disease, and peripheral vascular disease were less frequent in women. Treatment at admission and at discharge was similar in men and women, as was the use of in-hospital diagnostic and therapeutic procedures (echocardiography: 80 vs 88%; coronary angiography: 57 vs 59%; percutaneous coronary intervention: 17 vs 14%; coronary surgery 13 vs. 11%). Women had a better mean ejection fraction (55 13 vs 49 14%; p < 0.01) and fewer stenosed coronary vessels (1.4 1.1 vs 2.2 0.9; p < 0.01). There were no differences in the frequency of recurrent angina (28 vs 25%), death, or infarction (both 3.2%) during hospitalization. However, during a 30-month follow-up the incidence of death, myocardial infarction, or a new episode of NSTEACS was significantly lower in women with a relative risk (RR) of 0.53 (95% CI: 0.33-0.86; p < 0.01). This apparently better prognosis persisted after adjusting for clinical data and ejection fraction (RR: 0.57 (0.33-0.98); p < 0.05), but disappeared after adjusting for the number of diseased coronary vessels (RR: 0.71 (0.35-1.47); p = 0.36).

CONCLUSIONS

Women with NSTEACS had a better long-term prognosis than men. This better prognosis was independent of the patients' clinical characteristics and treatment, and could be explained by a less severe and less extensive coronary artery disease.

[Prognosis of diabetic patients with ischemic cardiopathy]

The prevalence of diabetes in Spain is about 6% and increases with age and obesity. Diabetes is present in approximately 25% of patients with coronary heart disease (CHD). Pre-diabetic and diabetic patients have a higher incidence of CHD and poorer prognosis, with high short- and long-term mortality. The protective effect of pre-menopause status is suppressed by diabetes. Diabetes has a synergic effect with other cardiovascular risk factors. Primary prevention in diabetic patients should be approached as in non-diabetic post-infarction patients. In diabetes, a healthy life-style and strict control of blood sugar and the other cardiovascular risk factors, particularly hypertension, is mandatory.

[Prognostic value of fibrinogen in patients admitted with suspected unstable angina and non-q-wave myocardial infarction]

INTRODUCTION AND OBJECTIVE

In recent years, the relation between biological markers of inflammation and prognosis in patients suffering from acute coronary syndromes has been investigated. The aim of this study was to evaluate the association between baseline fibrinogen concentrations and the development of clinical events in patients admitted with suspicion of unstable angina and non-Q-wave myocardial infarction.

MATERIAL AND METHOD

Levels of fibrinogen at enrollment were analyzed in 325 consecutive patients with acute coronary syndromes. Fibrinogen values were divided into tertiles and the incidence of clinical events was evaluated at each level. The combination of death and/or myocardial infarction was the main endpoint.

RESULTS

Fibrinogen levels were significantly higher in patients who subsequently had myocardial infarction, cardiac death, or both during follow up. The probabilities of death and/or myocardial infarction were 6%, 13%, and 29% (p < 0.0001), respectively, in patients grouped by fibrinogen tertiles (304, 305-374 and 375 mg/dl). Multivariate predictors of combined events were age, previous angina, ST-segment depression in the admission ECG, and fibrinogen into tertiles. The adjusted hazard ratio (95% CI) for patients in the upper tertile was 4.8 (1.6-14; p = 0.004).

CONCLUSIONS

High fibrinogen levels were related to a less favorable long-term or short-term outcome in patients admitted for suspicion of unstable angina and non-Q-wave myocardial infarction. This association persists after adjustment for other classical risk factors such as age, prior angina, and ST-segment depression in the ECG.

[Epidemiology of ischaemic heart disease in Spain: estimation of the number of cases and trends from 1997 to 2005]

INTRODUCTION AND OBJECTIVES

. The large amount of information on rates of acute coronary syndrome accumulated in Spain over the last two decades is summarized in this paper, which also estimates the number of cases expected in 2002 and the trend for 1997 to 2005.

METHODS

Published information on the situation in the 90's was reviewed and summarized. We present the incidence of acute myocardial infarction (AMI), and an estimate of the absolute number of patients expected for various acute coronary syndromes in each autonomous community in Spain in 2002, along with the trend for 1997 to 2005.

RESULTS

Approximately 68,500 patients will suffer AMI in 2002 and 40,989 of them will be hospitalized, while the rest will die before admission. A further 24.9% of admitted patients will not survive 28 days. Slightly less than half will be younger than 75 years old, an age with a better prognosis (28-day mortality 38.8%). Approximately 33,500 patients with unstable angina will be admitted, and 4.5% of them will die within 3 months of admission. Assuming the incidence of AMI remains stable, the absolute number of cases will increase by 2.28% yearly (9,847 cases in total) and hospitalizations for acute coronary syndromes will increase by 1.41% (8,817 cases in total) between 1997 and 2005.

CONCLUSION

Ischaemic heart disease generates increasing demand for health care in Spain. Case fatality is high among the approximately 68,500 AMI patients, given that scarcely two thirds will have been hospitalized in 2002.