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Resumen Objetivos Conocer las tramitaciones y gestiones requeridas en la prescripcion del tratamiento con inhibidores PCSK9 en los servicios de cardiologia de los hospitales espanoles, haciendo propuestas de mejoras para optimizar el proceso de prescripcion. Metodos Una primera fase de recogida de informacion sobre variables y procedimientos administrativos requeridos en la prescripcion de inhibidores PCSK9 y elaboracion de un cuestionario especifico. Una segunda fase de recogida de datos a traves de un cuestionario electronico autoadministrado. Resultados Participaron 88 hospitales (numero medio de camas 625; numero medio de cardiologos 18 ± 10; 78% hospitales universitarios). Hubo una infrautilizacion de inhibidores PCSK9 (prescripcion real 30 tratamientos/ano; prescripcion potencial 80), principalmente por no cumplir con informe de posicionamiento terapeutico (52%), con la denegacion de solicitud en un 31%. Se requirieron una media de 1,2 ± 0,4 formularios, con un promedio de 8,5 ± 4,2 variables, ademas de los requisitos del informe de posicionamiento terapeutico. Solo en el 21% de los hospitales no es necesario un proceso de autorizacion previa, y en el resto es necesaria la aprobacion por una comision. El tiempo acumulado en el proceso de prescripcion es de seis semanas. La discontinuacion del tratamiento durante el seguimiento es de 9 ± 12%. Conclusiones Los inhibidores PCSK9 se encuentran claramente infrautilizados en Espana. Esto se debe a una incorrecta identificacion de los pacientes, y a la existencia de complejos procedimientos de tipo administrativo que podrian inhibir/desmotivar su prescripcion por parte de los cardiologos, y consecuentemente, limitar su prescripcion. Asimismo, existe un retraso notable desde la aprobacion del farmaco hasta su administracion.

Aims To ascertain the formalities and procedures required for the prescription of PCSK9 inhibitors in the cardiology departments of Spanish hospitals, making proposals for improvement to optimize the prescription process. Methods A first phase of collecting information about the variables and administrative procedures required for the prescription of PCK9 inhibitors and the elaboration of a specific questionnaire and a second phase of collecting data with an online self-administered questionnaire. Results A total of 88 hospitals participated in the study (mean number of beds 625; mean number of cardiologists 18 ± 10; 78% university hospitals). There was underuse of PCSK9 inhibitors (real prescription of 30 treatments/year; potential prescription of 80), mainly because of not fulfilling the therapeutic positioning report (52%) and application refusal (31%). Beyond the requirements of the therapeutic positioning report, 1.2 ± 0.4 applications are required with 8.5 ± 4.2 variables. Only 21% of hospitals did not require a previous authorization process and in the remaining hospitals, approval from a committee was necessary. The accumulated time of the prescription process was 6 weeks. Discontinuation rates during follow-up were 9% ± 12%. Conclusions Treatment with PCSK9 inhibitors is clearly underused in Spain. This is mainly due to both inappropriate identification of patients, and complex administrative procedures that could inhibit/discourage prescription by cardiologists and consequently, limit their use. In addition, there is a substantial delay from drug approval tadministration.

Recommendations on the diagnosis and management of myocardial injury in noncardiac surgery (MINS) show remarkable variability. Mortality reports also vary. We aimed to describe mortality and major adverse cardiovascular and cerebrovascular event (MACCE) rates in patients with silent MINS treated with postoperative aspirin-statin therapy and with cardiology follow-up.Prospective descriptive cohort study of patients aged 45 years or older scheduled for noncardiac surgery with high risk for cardiovascular complications from May 2017 to April 2019. Aspirin-statin therapy and cardiology follow-up were prescribed for patients with silent (asymptomatic) MINS. The primary outcome was one-year mortality in patients with silent MINS. Secondary outcomes were mortality in MINS patients with perioperative myocardial infarction (PMI) or chronic myocardial injury (CMI) and MACCE.We identified 766 eligible patients and enrolled 747. MINS occurred in 166 patients (22.2%); 151 (91%) had silent MINS and 15 (9%) had PMI. Thirty-one patients (4.1%) had CMI. One-year mortality was higher in patients with silent MINS (22.5%) than in patients with no MINS (7.8%) (P0.001). One-year mortality rates in MINS patients with PMI or CMI were 27 and 19 %, respectively. MACCE were more frequent in patients with silent MINS at 30 days and one year (18 and 25%) than in patients with no MINS (6 and 12%, respectively).Rates of mortality and MACCE in patients with silent MINS were high despite aspirin-statin therapy and cardiology follow-up. Further prospective research is needed to assess new postoperative care protocols that might effectively improve outcomes.

Resumen Introduccion y objetivos El adecuado control lipidico tras un sindrome coronario agudo (SCA) es una estrategia de prevencion secundaria crucial para disminuir el riesgo de reinfarto y muerte cardiovascular. Existen tablas que predicen la dosificacion necesaria del tratamiento hipolipidemiante segun el colesterol LDL (cLDL) inicial pero no han sido probadas en el SCA. Analizamos los factores asociados al control del cLDL tras un SCA y la utilidad de las tablas de Masana y Plana en este contexto. Metodos Entre enero de 2015 y mayo de 2016 se incluyeron 326 pacientes con SCA. Se registraron las concentraciones basales de cLDL y el tratamiento hipolipidemiante al alta. Se analizaron las variables asociadas a un adecuado control del cLDL ( Resultados La edad media fue 66 ± 13 anos, el 72% varones. El tratamiento hipolipidemiante al alta se ajusto a las recomendaciones de Masana en 196 (60%) pacientes. Tras 122 [66-184] dias, en 148 (45%) se alcanzo el objetivo de cLDL, siendo este porcentaje mayor (109/196 –56%– vs. 39/130 –30%– pacientes) cuando el tratamiento fue planificado segun las tablas de Masana y Plana (p Conclusiones El control lipidico adecuado tras un SCA se alcanza en menos de la mitad de casos. La dosificacion de la terapia hipolipidemiante segun las tablas de Masana y Plana mejora la consecucion de este crucial objetivo terapeutico.

Adequate LDL cholesterol (LDLc) control after an acute coronary syndrome (ACS) is a crucial secondary prevention strategy to minimize the incidence of recurrent myocardial infarction and cardiovascular death. There are tables that predict the necessary dosage of lipid-lowering treatment from the initial LDLc but have not been tested in ACS. Variables associated with optimal LDLc after an ACS were analyzed and the therapeutic yield of the use of Masana's recommendations in this setting.A total number of 326 ACS-patients were included between January-2015 and May-2016. Baseline LDLc concentration and prescribed hypolipemiant treatment at hospital discharge were registered. We analyzed the variables associated with optimal LDLc levels (70mg/dL) control during follow-up.Among our patient population (72% male, age 66±13 years), the hypolipemiant treatment at hospital discharge fulfilled the Masana's recommendations in 196 (60%) patients. After a follow-up period of 122 [66-184] days the targeted LDLc levels were achieved in 148 (45%) patients, being this percentage greater among those in whom the Masana's recommendations were fulfilled (109/196, 56%), as compared with the remaining (39/130, 30%; P.001). The male gender (P.001), the absence of prior history of dyslipemia (P.001) and the adherence to Masana's recommendations (P=.007) were independent predictors for the achievement of targeted LDLc levels during follow-up.In less than half of ACS-patients adequate mid-term LDLc control is obtained. The dosage of the lipid-lowering therapy according to Masana's recommendations helps to achieve this important therapeutic goal.

Introduction and objectives The epidemiology of heart failure (HF) that complicates ST-segment elevation myocardial infarction (STEMI) is not well defined. Our aim was to analyze the epidemiology and prognosis of HF that complicates STEMI treated with primary percutaneous coronary intervention (PCI). Methods Multicentre registry of 14 070 patients with STEMI treated with primary PCI from January 2010 to December 2015. Results Patients with HF were older, more frequently female, and diabetic and had chronic ischaemic heart disease. Only 10.3% of patients with STEMI treated with primary PCI had HF on admission and the majority of them had the mildest form (Killip–Kimball II 77.8%). HF was associated with high mortality (30-day mortality was 2.9% of patients in Killip–Kimball I, 9.5% of Killip–Kimball II and 17.4% in Killip–Kimball III, P Conclusions HF complicates 10.3% of patients with STEMI treated with primary PCI and it was associated with a higher risk of developing cardiogenic shock and with 30-day and 1-year mortality in 30-day survivors. In this high-risk population, primary PCI and posterior medical treatment should be prioritized to avoid worsening of HF.

Resumen Introduccion y objetivos El deficit de hierro (DH) es una condicion frecuente en pacientes con cardiopatia isquemica o insuficiencia cardiaca. Pero se desconoce su impacto en la capacidad funcional y la calidad de vida (CdV) tras un sindrome coronario agudo (SCA). Metodos Se evaluo prospectivamente el impacto del DH en la capacidad funcional y la CdV de 244 pacientes 30 dias despues de haber sufrido un SCA. La CdV se evaluo mediante el test EuroQol-5 dimensiones, la escala visual analogica y el Heart-QoL. La capacidad funcional se midio mediante ergometria en cinta sin fin o con la prueba de los 6 min de marcha. Se evaluo el impacto del DH en la morbimortalidad cardiovascular. Resultados Se documento DH en el 46% de los pacientes. Estos pacientes realizaban ejercicio menos tiempo (366 ± 162 frente a 462 ± 155 s; p Conclusiones El DH implica peor capacidad funcional y peor calidad de vida a medio plazo tras un SCA.

Iron deficiency (ID) is a prevalent condition in patients with ischemic heart disease and heart failure. Little is known about the impact of ID on exercise capacity and quality of life (QoL) in the recovery phase after an acute coronary syndrome (ACS).Iron status and its impact on exercise capacity and QoL were prospectively evaluated in 244 patients 30 days after the ACS. QoL was assessed by the standard EuroQoL-5 dimensions, EuroQoL visual analogue scale, and Heart-QoL questionnaires. Exercise capacity was analyzed by treadmill/6-minute walk tests. The effect of ID on cardiovascular mortality and readmission rate was also investigated.A total of 46% of the patients had ID. These patients had lower exercise times (366±162 vs 462±155seconds; P.001), metabolic consumption rates (7.9±2.9 vs 9.3±2.6 METS; P=.003), and EuroQoL-5 dimensions (0.76±0.25 vs 0.84±0.16), visual analogue scale (66±16 vs 72±17), and Heart-QoL (1.9±0.6 vs 2.2±0.6) scores (P.05). ID independently predicted lower exercise times (OR, 2.9; 95%CI, 1.1-7.6; P=.023) and worse QoL (OR, 1.9; 95%CI, 1.1-3.3; P.001) but had no effect on cardiovascular morbidity or mortality.ID, a prevalent condition in ACS patients, results in a poorer mid-term functional recovery, as measured by exercise capacity and QoL.

Background: ST Segment Elevation Acute myocardial infarction (STEMI) preferred treatment is culprit artery reperfusion with primary percutaneous coronary intervention (PPCI). We ought to analyze the benefit of early reperfusion vs. optimal medical therapy in STEMI before and after the set-up of a regional STEMI network that prioritizes PPCI. Methods: Between January 2002 and December 2013, 1268 STEMI patients were consecutively admitted in a University Hospital. Patients were classified in two groups: pre-STEMI Network (January 2002-June 2009; n = 670) and post-STEMI network (July 2009-December 2013; n = 598). Vital status was available at 2-year follow-up. Results: The STEMI network increased reperfusion (89.2% vs 64.4%, p < 0.001) mainly using PCI (99.0% vs 43.9%, p < 0.001). In univariate analysis, in-hospital mortality was significantly lower in the post-STEMI network period (2.51% vs. 7.16%, p < 0.001). After multivariate adjustment, including age, sex, comorbidities, severity and reperfusion therapy, a trend to a lower in-hospital mortality was observed (post-Network OR: 0.50, 95% CI: 0.16-1.59, p = 0.24); this trend disappeared when optimal medical therapy was included in the model (post-Network OR: 1.14, 95% CI: 0.32-4.08, p = 0.840). No differences in 2-year mortality were observed (post-Network HR: 0.83; CI 95%: 0.55-1.25, p = 0.37). Conclusion: A STEMI network with PPCI 24/7 improved reperfusion therapy, resulting in an increase on PPCI. Despite in-hospital mortality decreased with a STEMI network, 2-year mortality remained similar in both periods, pre- and post-Network. Optimal medical therapy could be as important as reperfusion therapy in a STEMI reperfusion network.

Table S1. Complications and in-hospital treatment. (DOCX 16 kb)

Introduccion y objetivos La anemia al ingreso por un sindrome coronario agudo es un factor de mal pronostico. Sin embargo, hay poca informacion sobre la anemia que se adquiere durante el ingreso por un sindrome coronario. Nuestro objetivo es determinar posibles predictores de anemia nosocomial y evaluar su influencia pronostica en el sindrome coronario agudo. Metodos Se incluyo prospectivamente a 221 pacientes que ingresaron en nuestro centro por un sindrome coronario (2009-2010) con valores de hemoglobina normales. Se definio anemia nosocomial sin sangrado evidente como reduccion de hemoglobina a valores < 13 g/dl en varones y < 12 g/dl en mujeres. Se analizo el pronostico a 1 ano de seguimiento comparando a los pacientes con anemia nosocomial con los que se mantuvieron sin anemia. Se excluyo del analisis a los pacientes con complicaciones hemorragicas. Resultados Se observo anemia nosocomial en el 25% de los pacientes. El analisis multivariable revelo una asociacion entre proteina C reactiva > 3,1 mg/dl y aparicion de anemia nosocomial (odds ratio = 5,9; intervalo de confianza del 95%, 2,6-13,4; p 3,1 mg/dl, puede predecir la aparicion de anemia durante la hospitalizacion

fraction: comorbidities drive myocardial dysfunction and remodeling through coronarymicrovascular endothelial inflammation. J AmColl Cardiol 2013;62:263–71. [15] Sekhri V, Sanal S, DeLorenzo LJ, Aronow WS, Maguire GP. Cardiac sarcoidosis: a comprehensive review. Arch Med Sci 2011;7(4):546–54. [16] Hunt SA, Abraham WT, Chin MH, et al. 2009 focused update incorporated into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/ American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation. Circulation 2009;119(14):e391–479. [17] Baughman RP, Teirstein AS, Judson MA, et al. Clinical characteristics of patients in a case control study of sarcoidosis. Am J Respir Crit Care Med 2001;164:1885–9. [18] Quarta G, Holdright DR, Plant GT, et al. Cardiovascular magnetic resonance in cardiac sarcoidosis with MR conditional pacemaker in situ. J Cardiovasc Magn Reson 2011;13:26. [19] Fang L, Beale A, Ellims AH, et al. Associations between fibrocytes and postcontrast myocardial T1 times in hypertrophic cardiomyopathy. J Am Heart Assoc 2013;2(5): e000270.

El objetivo del estudio es disminuir el tiempo puertaaguja en el infarto con elevacion del ST mediante la creacion de un box de dolor toracico. Se compara el tiempo puerta-aguja entre los pacientes que recibieron fibrinolisis en los 2 anos previos a la creacion del box (grupo 1) y los que se sometieron a trombolisis en los 2 anos siguientes (grupo 2), y el pronostico a 1 ano de ambos grupos. En el grupo 1, la mediana de tiempo puerta-aguja fue de 40 (P25-75, 23-52) min y en el grupo 2, 27 (15-43) min (p = 0,003). Se incremento el tratamiento de reperfusion del 55,2% en el grupo 1 al 64,7% en el grupo 2 (p

The cost-effectiveness of neonatal electrocardiographic (ECG) screening has been questioned. The objective of this study was to establish normal values for the QT interval in newborns of different ethnic origin. Between 2005 and 2006, ECGs were obtained during the first 48 h of life from 1305 full-term newborns at the Hospital del Mar in Barcelona, Spain. The mean corrected QT interval (QTc) was 417.79 (28.47) ms. A QTc longer than 440 ms was observed in 240 newborns (18.33%). The frequency of a pathologic QTc in Spanish newborns was 17.9%, compared with 27.7% in those of Maghreb or Near Eastern origin (P=.016), and 28.2% in those of Indian or Pakistani origin (P=.033). The QTc may vary for genetic reasons. A routine neonatal ECG is advisable only in ethnic groups in which the QTc is lengthened, to help counter the greater risk of sudden death in these infants.

The aim of this study was to reduce the door-to-needle time in patients with ST-elevation acute myocardial infarction by setting up a chest pain service. We compared the door-to-needle time and outcomes at the end of first year of follow-up in patients who received fibrinolysis in the 2 years before implementation of the service (Group 1) and those who received fibrinolysis in the 2 years after its creation (Group 2). In Group 1, the median door-to-needle time was 40 min (P(25-75), 23-52 min); in Group 2, it was 27 min (P(25-75), 15-43 min; P=.003). In addition, the use of reperfusion therapy increased from 55.2% in Group 1 to 64.7% in Group 2 (P.01). After a follow-up period of 1 year, there was no difference in the rate of revascularization, hospital readmission, reinfarction or cardiovascular mortality.

La rentabilidad del cribado electrocardiografico neonatal esta en discusion. El objetivo es conocer los valores normales del intervalo QT en recien nacidos de diferentes origenes etnicos. Durante 12 meses entre 2005 y 2006 se realizo un ECG a 1.305 neonatos a termino en el Hospital del Mar (Barcelona), en las primeras 48 h de vida. El intervalo QTc medio fue 417,79 ± 28,47 ms. Se hallo un QTc > 440 ms en 240 (18,33%) neonatos. Se encontro un 17,9% de QTc patologicos en neonatos autoctonos, frente a un 27,7% en el grupo de Magreb y Proximo Oriente (p = 0,016) y un 28,2% en el grupo de India-Pakistan (p = 0,033). El intervalo QTc puede ser diferente por causas geneticas. Seria recomendable hacer un ECG neonatal solo en los grupos etnicos con QTc mas largos, para evitar un posible mayor riesgo de muerte subita del lactante.

Anemia at hospital admission predicts a poor outcome in patients presenting with acute coronary syndrome. It remains unclear whether in-hospital hemoglobin levels decrease (nosocomial anemia) not related to bleeding also implies a poor prognosis. We aimed to identify predictors of nosocomial anemia and its prognostic significance.We prospectively included 221 acute coronary syndrome patients admitted in our institution during the years 2009-2010, with normal hemoglobin levels at admission. Nosocomial anemia was defined as a decrease in hemoglobin levels to13 g/dL in men and12 g/dL in women in the absence of apparent bleeding. Clinical variables and hematological inflammatory parameters were assessed in order to identify predictors for the development of nosocomial anemia. We compared the clinical outcome after a 1-year follow-up period of patients without anemia as opposed to those who developed nosocomial anemia.Nosocomial anemia was registered in 25% of study patients. A3.1 mg/dL value of C-reactive protein was highly predictive of developing nosocomial anemia (odds ratio=5.9; 95% confidence interval, 2.6-13.4; P.001). The incidence of mortality and cardio-vascular morbidity was higher in the patients who developed nosocomial anemia (34.5% vs 9%; P.001). Nosocomial anemia was a strong predictor of cardio-vascular morbidity and mortality in the long-term follow-up (hazard ratio=2.47; 95% confidence interval, 1.23-4.96; P=.01).Nosocomial anemia predicts a poorer outcome in patients with acute coronary syndrome. Increased C-reactive protein levels, indicating inflammatory state, are predictive of developing in-hospital anemia unrelated to apparent bleeding.

A 70-year-old patient with a history of hypertension and dyslipidemia was receiving treatment with enalapril, simvastatin, and hydrochlorothiazide. He was referred to our hospital for presyncope and suspected acute myocardial infarction in an anterior location. The first electrocardiogram (Fig. 1A) showed a saddlebag-type ST segment elevation in V1 to V3. Echocardiography excluded a segmental wall motion abnormality. Despite the patient’s advanced age and the absence of previous episodes of syncope or a family history of sudden death, the presumptive diagnosis was Brugada syndrome. The initial analyses showed creatinine 4.88 mg/dL, Na 127 mEq/L, K 7.53 mEq/L, pH 7.22, and troponin T