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Renasica ii mexican registry of acute coronary syndromes

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Mexican Registry of Acute CoronarySyndromes Instituto Nacional de Cardiología Ignacio Chávez Otras secciones de
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Mexican Registry of Acute Coronary Syndromes Armando García-Castillo,* Carlos Jerjes-Sánchez,* Pedro Martínez Bermúdez,* JoséRamón Azpiri-López,** Alonso Autrey Caballero,*** Carlos Martínez Sánchez,**** MarcoAntonio Ramos Corrales,***** Guillermo Llamas,****** Jesús Martínez Sánchez,*******Alfonso J Treviño* Objective: The registry intends to establish the
clinical characteristics, identify therapeutic ap- proaches and describe in-hospital outcome of patients with acute coronary syndromes in Mex-
ico. Methods and results: RENASICA II is a pro-
Objetivo: El registro pretende establecer en
spective registry that included 8,098 patients with México las características clínicas, identificar final diagnosis of acute coronary syndromes.
abordajes terapéuticos y conocer la evolución Three thousand five hundred and forty three pa- hospitalaria en pacientes con síndromes coro- tients had unstable angina or non-ST elevation narios agudos. Métodos y resultados: RENA-
myocardial infarction (UA/NSTEMI) and 4,555 ST SICA II es un registro prospectivo que incluye elevation myocardial infarction. (STEMI) On ad- 8,098 pacientes con diagnóstico final de síndro- mission typical chest pain was identified in 78% me coronario agudo. Tres mil quinientos cuaren- and 85% respectively. Non-ST elevation high risk ta y tres tuvieron angina inestable o infarto sin group was identified in 36%. In STEMI group elevación del segmento ST (AI/IMNEST) y 4,555 anterior myocardial infarction and Killip class I tuvieron infarto con elevación del ST (IMEST). A had a higher occurrence. The use of aspirin, su ingreso al hospital se identificó dolor torácico unfractionated heparin, low molecular weight típico de isquemia en 78% y 85% respectivamen- heparin, nitrates, beta blockers and ACE inhibi- te. Se consideró de alto riesgo al 36% de los tors for patients with UA/NSTEMI were 90%, pacientes con AI/IMNEST. En la mayoría de los 50%, 45%, 58%, 50% and 54% respectively, with pacientes con IMEST la localización fue ante- corresponding rates of 88%, 54%, 44%, 66%, rior y se encontraban en clase KK I. En AI/IM- 51% and 64% for STEMI patients. Coronary an- NEST se utilizó aspirina en el 90%, heparina no giography, angioplasty and coronary bypass fraccionada 50%, heparina de bajo peso mole- surgery were performed in 62%, 30% and 8% in cular 45%, nitratos 58%, bloqueadores beta 50% § A complete list of participating registry hospitals is available at the end of the text.
RENASICA is a national registry of the Mexican Cardiology Society and had unrestricted support by AVENTIS-PHARMA MEXICO.
The protocol, data base, statistics, results, conclusions and final report are completely responsibility of the Steering Committee.
* Hospital de Enfermedades Cardiovasculares y del Tórax IMSS 34, Monterrey.
** Hospital Universitario, Monterrey.
*** Hospital de Cardiología Siglo XXI CMN, IMSS México DF.
edigraphic.com
Instituto Nacional de Cardiología “Ignacio Chávez”, México DF.
***** Centro Médico “La Raza”, México DF.
Correspondence: Dr. Carlos Jerjes–Sánchez, Santander 316, Col. Bosques de San Ángel Sector Palmillas, CP 66290, San PedroGarza García, NL, México.
E-mail: HIPERVÍNCULO “mailto:jerjes@infosel.net.mx”, jerjes@infosel.net.mx, jerjes@prodigy.net.mx, armandogc1@.net.mx UA/NSTEMI patients respectively with corre- e inhibidores de enzima convertidora en el 54%.
sponding rates of 44%, 27% and 4% for the En IMEST estos medicamentos se utilizaron en STEMI group. Among patients with STEMI 37% el 88%, 54%, 44%, 66%, 51% y 64% respectiva- were under fibrinolytic therapy and 15% received mente. En pacientes con AI/IMNEST se realizó primary or facilitated angioplasty. Overall In-hos- angiografía en el 62%, angioplastía coronaria pital mortality was 7%, 4% UA/NSTEMI and 10% 30% y cirugía de revascularización 8%. En el STEMI 10%. Conclusion: The largest registry
grupo con IMEST estos procedimientos se reali- ACS in Latin-America provides important and zaron en el 44%, 27% y 4% respectivamente.
reliable information on the complete spectrum, En IMEST el 37% recibió terapia fibrinolítica y outcome, quality of care, and identifies areas for 15% fueron llevados a angioplastía primaria o further improvement of the quality of our cardio- facilitada. Se observó una mortalidad hospitala- vascular care. RENASICA II broadens our knowl- ria global del 7%, en AI/IMNEST fue del 4% y en edge about how reperfusion and antithrombotic IMEST del 10%. Conclusión: El más grande re-
approaches modify the outcome and what needs gistro de síndromes coronarios agudos en Lati- to be improved in the real practice in Mexico.
noamérica provee información importante sobreel espectro clínico, evolución hospitalaria, cali-dad de atención e identifica áreas de oportuni-dad para mejorar la atención médica. El RENA-SICA II extiende nuestro conocimiento sobrecómo los abordajes de reperfusión y el tratamien-to antitrombótico modifican la evolución en lapráctica real en México y cuáles procesos nece-sitamos mejorar.
(Arch Cardiol Mex 2005; 75:S20-S32).
Key words: Acute coronary syndromes. Acute myocardial infarction. Unstable angina. Acute ischemic heart
disease.
Palabras clave: Síndromes coronarios agudos. Infarto agudo del miocardio. Angina inestable. Cardiopatía
isquémica aguda.
tify good clinical practice indicators that reflect High quality clinical registries may help to un- derstand if the knowledge coming from clinical more than 6 million people will have an acute trials is being properly applied and if their resul- myocardial infarction and its prevalence will in- ts are reproducible in day-to-day clinical practi- crease 33% in the next year.3,4 According epide- ce. The second Registro Nacional de ndromes
miologic data from Mexico, ischemic heart di- Coronarios Agudos (RENASICA-II) in Mexico
sease emerges as the first mortality cause in the intends establish the clinical characteristics, iden- elderly, second in general population, being res- tify therapeutic approaches, describe in-hospital ponsible for 50,000 deaths in the year 2003 and outcome and hopefully, extend the knowledge ob- roughly accounting for 10% of all deaths.5,6 Advances in the knowledge of ACS pathophy-siology establish a new classification according to ST findings in the ECG7 (with or without ST It is a prospective and observational registry of elevation). The management of ACS continues the Mexican Cardiology Society designed to re- to undergo major changes based on sound evi- flect an unbiased and representative population dence derived from well conducted clinical trials with final diagnosis of ACS secondary to ische- edigraphic.com
and guidelines developed by cardiology socie- mic heart disease to identify diagnosis, stratifi- ties.8-11 Although excellent studies have been un- cation and treatment trends. In-hospital outcome dertaken, their results are open to interpretation, was analyzed through major adverse cardiovas- may not be applicable in all clinical settings and cular events (MACE) including death, recurrent the treatment options could be limited by resour- ischemia, acute myocardial infarction, reinfarc- ces. All these evidences suggest the need to iden- fermedades Cardiovasculares y Tórax) in the city Investigators with expertise and experience in of Monterrey. Electronic database and case report diagnosis, stratification and treatment of ACS at form had 300 variables that included demogra- primary and tertiary hospitals were considered.
phic data, medical history, clinical, laboratory and The hospitals varied in terms of access to on-site ECG findings, antithrombotic and fibrinolytic the- cardiac catheterization, number of acute care beds rapy, other treatments, risk stratification, invasi- and the type of practice setting, aimed at esta- ve and non invasive procedures, adverse events blishing a representative rather than a selective and in-hospital outcome. Data information was sent to the Central Data Center through: a) websi-te www.renasica.com.mx, b) E-mail (renasica@ prodigy.net.mx), c) diskette or CD-ROM, d) fax, Patients entered into the registry if during the hospital admission they had high clinical suspi-cion of ACS: acute ischemia manifestations, with or without ECG changes, with necrosis or not Chi square tests for discrete and two – tailed t and proved ischemic heart disease by invasive tests for continuous variables. For analysis of or non invasive tests at the end. Patients with differences Yates corrected chi square was used.
symptoms precipitated by anemia, hypertension, To test median value Wilcoxon test was consi- heart failure, etcetera, were not considered. On dered. A logistic regression model to evaluate admission and at discharge with or without ST the effect between dependent and independent elevation nomenclature was standardized. All variables on mortality was done. As a measure treatment decisions were made at discretion of of association odds ratio with 95% confidence interval (CI) was considered. Statistical signifi-cance was assumed with P < 0.05 level. Data are expressed in percent, median, mean and SD. All To ensure quality control of registry data the fo- statistical analyses were performed using a com- llowing criteria developed by Alpert were applied mercial available statistical package. (GBSTAT in RENASICA II:12 a) standardized definitions version 6.5 of Dynamic Microsystems, Inc.) and all participants were familiarized with them,b) careful hospital selection, c) hospitals appro- ved registry data collection process as dictated The study sample consisted of 8,600 patients with by local policies, d) all collected data were re- proved ACS admitted to participate in RENA- ported, e) original data sheets and electronic sub- missions were centralized, f) a professional sta- ber 2003. Five hundred two were excluded and tistician monitored the data collection and 8,098 patients were considered in the final re- analysis, g) each data sheets and electronic sub- port. Of these, 3,543 developed unstable angina mission were carefully examined by the central or non–ST elevation myocardial infarction (UA/ data center, h) Principal Investigator and Stee- NSTEMI) and 4,555 coursed with ST elevation ring Committee maintained administrative order, myocardial infarction (STEMI). A total of 76 adjudicated disagreements and encouraged time- investigators in 66 primary and tertiary hospi- ly submission of documents and data analysis.
tals contributed patients to RENASICA II. About Participants were trained in data entry utilizing the hospitals participating in the registry 90% (60 standardized manual of instructions and defini- hospitals) had active participation, 48% were tions in meetings devote to it. A randomized cli- from the government health system, 39% from nical monitoring visit was scheduled in some private medicine, 12% were teaching hospitals from other health systems. Hospitals locatedthroughout the country enrolled 52% of the total edigraphic.com
of patients and those in Mexico City accounted An electronic case report form was developed by for 48%. Tertiary hospitals with capabilities for Cyberworks Inc in SQL Microsoft environment coronary arteriography, percutaneous translumi- (Structured Query Language). For the electronic nal coronary angioplasty (PTCA) and coronary data reception a Dell computer server was insta- artery bypass graft (CABG) surgery enrolled lled in the Central Data Center (Hospital de En- 90% of the patients. The mechanisms to send in- formation to the Central Data Center were writ- major risk factor at least. The range of age was ten case reports in 55% and electronic case re- 21 to 100 years and UA/NSTEMI patients had a ports, diskette, CD-ROM or e-mail in 45%.
greater prevalence for most of the co-morbidi-ties examined and were more likely to have had prior coronary interventional procedures and Over the study period, in all groups, (Table I) cardiovascular surgery compared with STEMI patients were significantly older and more likely to be male and with one historic atherosclerosis Clinical presentationOn admission most patients had typical ische- Table I. Demographic characteristics in patients with ACS.
mic chest pain and clinical stability (Table I).
Atypical chest pain was observed in 13% UA/ NSTEMI and 9% STEMI patients, non-chest pain history in 8% and 6% respectively. Both groups had 1% of asymptomatic patients. Non-ST ele- vation high risk group was considered in 36%, with clinical stability 49% and instability 14%.
Medical history
In the STEMI group anterior myocardial infarc- tion Killip class I had the highest occurrence, class II was in 17%, class III 5% and class IV in The information was collected on the first ECG with acute ischemia findings previously recor- ded or when the patient arrived at the hospital.
Among the entire patient population (8,098) 65% had ST-depression, 45% T wave inversion, 43% Clinical characteristics
Q-wave and 34% ST-elevation. In UA/NSTEMI high risk patients unspecific ST changes and T wave inversion were identified in 56%, extensi- ve ST depression (> 1 mm in > 3 adjacent leads) High risk UA/NSTEMI
in 26% and non-extensive in 18%. Other ECG findings included conduction system abnorma- lities, ventricular and supraventricular arrhyth- In-hospital treatment
Creatinine kinase-total (CK-T) measurements were available in 3,525 UA/NSTEMI patients (99%). Among these determinations, 70% were < 1.5 X, 13% between 1.5 to 3 X and 17% > 3 X.
Creatinine kinase-MB (CK-MB) determination was obtained in 3,221 (91%) with similar fin- dings, 70% < 1.5 X, 14% 1.5 – 3 X and 16% > 3 X. Troponin measurements were available in only edigraphic.com
712 patients (20%) and troponin I (76%) was the most common micronecrosis marker (24%). In were obtained in 4,512 (99%) and 3,681 (81%) respectively. These markers were > 3 X, (57% PAD: peripheral artery disease; SBP: systolic blood pressure; DBP: diastolic blood pressure; UHF: and 55%) between 1.5 – 3.0 X, (19% and 20%) unfractionated heparin; LMWH: low molecular weight heparin; CChB: calcium channel blockers;ACE: angiotensin-converting enzyme; PCI: percutaneous coronary intervention.
Table II. Electrocardiographic findings.
Reperfusion therapyAmong 4,555 STEMI patients, 1,685 (37%) were under fibrinolytic therapy, the time to onset symptoms and drug administration was < 2 hours in 31%, from 2 to 4 hours in 36%, 4 to 6 hours in Conduction system abnormalities
19% and finally > 6 hours in 15%. Streptokinase was the most frequently fibrinolytic regimen used (82%) followed by alteplase (17%). Tecnetepla- se and reteplase were used only in few patients.
Primary or facilitated PTCA were performed in Ventricular arrhythmias
15%. The overall rate of revascularization du- ring index hospitalization either PTCA or CABG was 30% (1,366 patients). In UA/NSTEMI phar- macological reperfusion was achieved in 149 Supraventricular arrhythmias
Atrial fibrillation
patients (4%) and the overall rate of revasculari- LBBB: left bundle branch block; RBBB: right bundle branch block Non-invasive and invasiveproceduresInvasive and non-invasive procedures performed during hospitalization are shown in Table III. A ST elevation patients showed significantly hig- greater proportion of patients with UA/NSTE- her leukocytes median 10,200/uL (7,900 – MI required invasive diagnosis, and also mecha- 12,900/uL) and lymphocytes (3,043 + 3,265) nical and surgical reperfusion. A high rate of values than the non-ST elevation group, median 8,360 (6,609 – 10,500) and lymphocytes 2,859 1,087 (92%) and STEMI 1,234 (85%) patients.
+ 3,604. Qualitative C-reactive protein measu- Failure was observed in 5% and 8% and was rements were obtained in 3% (103) of UA/NS- considered a sub-optimal procedure in 3% and TEMI patients and in 4% (167) of STEMI group, 6% respectively. Stenting was employed in 88% this prototypical acute-phase reactant was po- of UA/NSTEMI and in 85% STEMI patients. In sitive in 21% and 42% of both groups respecti- 3,543 UA/NSTEMI group the main angiographic findings were: left anterior descending diseasein 60%, right coronary 49%, circumflex in 44%, left main 9% and by-pass occlusions in 3%. In There was an upward trend to use aspirin, un- 4,555 STEMI patients coronary angiography fractionated heparin, low molecular weight he- showed: left anterior descending in 65%, right parin, (LMWH) nitrates, beta blockers and an- coronary 53%, circumflex in 37%, left main 5% giotensin-converting enzyme inhibitors. Among and by-pass occlusion in 1%. Patients with STE- patients under LMWH treatment, enoxaparin was MI were more likely to receive cardiovascular the most frequently used. Patients presenting with and invasive respiratory support whereas UA/ UA/NSTEMI were less likely to receive unfrac- NSTEMI group was subjected to non-invasive tionated heparin, nitrates, statins, angiotensin- diagnoses and stratification tests. Transthoracic converting enzyme inhibitors or fibrinolytic the- echocardiograms were performed in more than rapy, but were more likely to receive clopidogrel, calcium channel blockers, percutaneous corona-ry intervention and CABG during index hospi- edigraphic.com
gulation use were infrequent in both groups. In Among 8,098 ACS, global mortality was 7% and UA/NSTEMI and STEMI patients drugs used in in STEMI group a marked difference was seen the setting of complications were digoxin, (7% in terms of death. Other in-hospital MACE had vs 8%) diuretics, (14% vs 17%) vasoactive ami- similar rates to those observed in UA/NSTEMI nes, (7% vs 15%) amiodarone and (6% vs 2%) and STEMI patients (Table IV). Patients with STEMI had more severe left ventricular dysfunc- tion, ventricular arrhythmias, mechanical com- brinolytic infusion and renal failure was most plications and cardiac arrest. Regarding bleeding frequently seen in STEMI patients (Table IV).
complications no difference was observed bet-ween both groups. Hypotension induced by fi- Multivariate analysis
Unstable and non-ST elevation myocardial
Table III. Invasive and non – invasive diagnostic, stra-
infarction
tification and therapeutic procedures.
A logistic regression analysis performed to assessthe effect of independent variables on mortality while adjusting for potentially confounding fac- tors in UA/NSTEMI and ST patients is shown inTables V and VI. Chronic endothelial dysfunction Invasive
states, inadequate renal function, long-lasting chest pain and non-chest pain history, ventricular fibri- llation, severe conduction system abnormalities and cardiac arrest, were the strongest predictors.
Other in-hospital complications such as acute re- nal dysfunction and pulmonary embolism had sta- tistical relevance. Fibrinolytic therapy and drugs used in severe left ventricular dysfunction and Non – invasive
arrhythmic complications settings had negative association. The most important angiographic fin- ding was left main (Table V).
Elderly and female patients with any degree of IABP: intra-aortic balloon counterpulsation; TTE: transthoracic echocar- left ventricular dysfunction, extensive jeopardi- diogram; TEE: transesophageal echocardiogram zed myocardium, severe conduction abnormali-ties, or any in-hospital complication related to Table IV. Major adverse cardiovascular events and
new ischemic event, severe ventricular dysfunc- tion, (KK III – IV) ventricular arrhythmias, me-chanical complications and stroke were stronger predictors. Non-successfully PTC was closely related with an inadequate outcome (Table VI).
During the study period 8,600 patients were en- rolled with high clinical ACS suspicion. The pro- portion of initial diagnoses among non-specific In-hospital outcome
chest pain, UA/NSTE and STEMI is shown in Cardiovascular
Figure 1. Diagnostic accuracy for UA/NSTEMI and STEMI was 82% and 89% respectively. Pa- tients with initial unspecified chest pain had STE- MI or UA/NSTEMI in 16% (Fig. 1).
The RENASICA II is the largest registry of ACS Bleeding complications
Major
Minor
edigraphic.com
in Latin-America providing important and relia- ble information about the quality of care. This evidence provides important insights on thera- peutic approaches and in-hospital outcome and it was obtained through pre-determined specific definitions and quality criteria set out for regis- MACE: major adverse cardiovascular events; FT: fibrinolytic therapy.
tries.13 RENASICA II takes an important step Table V. Multivariate analysis. Predictors of hospital death in UA/NSTEMI.
towards identifying evidence that permits to re-cognize in a more realistic view mortality and morbidity similitudes and differences with pre-vious registries,12,14-18 and from it we can learn Demographic characteristics
Acute coronary syndrome is a term that refers to any constellation of clinical symptoms consis- tent with acute myocardial ischemia. The clini- cal spectrum includes silent myocardial ische- mia on one side and STEMI at the other side, Clinical presentation
Ischemic chest pain > 20 min
NSTE with or without micronecrosis occupies the middle of this spectrum. Although, in all groups rupture of a vulnerable plaque with throm- bus formation is the typical inciting event short- and long-term outcome differs.19,20 In-hospital mortality is greater in STEMI and reinfarction, recurrent ischemia and long-term mortality ap- pear to be higher for UA/NSTEMI.21 Given the Complications
impact of ACS in Mexico5,6,12 RENASICA II emerges as another link between randomized cli- nical trials, guidelines and daily clinical practi- Drugs therapy
Angiography
This registry of 4,353 ACS patients with or without ST elevation highlights current practi-ces and therapeutic approaches at the twenty andtwenty-one centuries transition. Non-ST eleva-tion ACS was a common cause of hospital ad- Table VI. Multivariate analysis. Predictors of hospital death in STEMI.
mission and initial troponin determinations werenot available. In non-ST elevation ACS, > 65 years-old, ST depression, macronecrosis and Demographic characteristics
angiographic extensive coronary disease were risk markers. Ischemic chest pain, dyspnea, and diaphoresis had close relationship with macro- necrosis and STEMI diagnosis. Less than half of Clinical presentation
the patients were under reperfusion approach, despite that 90% of the hospitals had pharmaco- logical and mechanical reperfusion facilities.
Antiplatelet and antithrombin standard treatments were used in 70% and low molecular weight he- parin and IIb/IIIa receptor platelet antagonists in a lower proportion of patients. RENASICA I es- tablished information that could help Mexican health authorities to better apply health resour- ces in the forthcoming future of ACS treatment.12 Outcome
Reinfarction
edigraphic.com
This project has generated a large volume of data on the incidence and relative frequency of ACS with or without ST elevation as a cause of hospi- tal admission. ST elevation myocardial infarc- LBBB: left bundle branch block; RBBB: right bundle branch block tion was the most frequent cause of hospitaliza- Initial diagnosis
Final diagnosis
Fig. 1. Correlation between initial and final diagnosis of 8,600 patients enrolled in RENASICA II. UA/NSTEMI:
unstable angina/non ST elevation myocardial infarction; STEMI: ST elevation myocardial infarction.
tion (56%) followed by UA/NSTEMI (44%). The a currently rapidly expanding disease at present is ratio 1.3:1 (STEMI to UA/NSTEMI) is higher a major risk factor for cardiovascular morbidity than reported in RENASICA I (35% vs 65%)12 and mortality and is associated with poor progno- and other previous registries.15,16,18 A partial ex- sis after myocardial infarction.24 Diabetes alone planation may be the mechanical reperfusion fa- or associated with other chronic endothelial dys- cilities in hospitals participating. Another poten- function and inflammation states (elderly, smo- tial reason is that the overall prevalence of STEMI king, hypertension, abnormal lipids) could explain associated to other co-morbidities (diabetes) in- the higher STEMI incidence in RENASICA II and creased rather rapidly. These results underline the impact of STEMI on the national health care strong predictor for hospital mortality.
resources as a main cause of hospital admission.
Since the main target in RENASICA II was not Both groups were hospitalized for a median of metabolic state assessment, non-fasting blood 8.1 days, these results relate closely with GRA- glucose, glycated hemoglobin A1c, or oral glu- CE (8 days) and ENACT (unstable angina 8.5 cose tolerance tests were not done. In this way days) and according to European experiences diabetes, impaired glucose tolerance and insulin were shorter regarding myocardial infarction.14,16 resistance states could be under evaluated. In However we are far from of the impressive and addition, obesity rate was not established. The dramatic decline in hospital stay (4.3 days) in high incidence of diabetes strongly underlines patients under pharmacological or mechanical the importance of including diagnostic tests for reperfusion observed in NRMI 1, 2, 3.23 This may glucose abnormalities to improve risk stratifica- be related with the increasing use of appropriate tion and outcome. It is necessary to establish or reperfusion approaches to limit infarct size and increase the strength of some secondary preven- recurrent ischemia and also with the health care tive efforts and apply even more strict targets to reform with implementation of critical pathways blood pressure, lipid and obesity control in any and other quality control measures to improve efficiency and reduce the cost of hospital care.
The diagnosis of ACS with or without ST eleva- There was no difference in-hospital stay between tion is a clinical process depending of historical risk both reperfusion modalities.23 RENASICA II factors, chest pain characteristics and ECG findings.
database could be used to establish treatment Available macro or micronecrosis data establish priorities and care standards in order to reduce final diagnosis but are not necessary to start opti- edigraphic.com
mal reperfusion and/or antithrombotic approach. In Most demographic data were very similar to those the ACS clinical spectrum, typical ischemic chest obtained from other ACS populations, however, in pain, ST segment, and T wave abnormalities were RENASICA I12 and II diabetes (50% and 42%) had clinical features at presentation. A similar clinical the highest incidence ever reported in the setting of profile has been observed in several risk models26,27 an ACS survey, to our knowledge.14-18,23 Diabetes, sustraídode-m.e.d.i.g.r.a.p.h.i.c
Unstable angina and NSTEMI are closely rela- :rop odarobale FDP
tients require pharmacologic and non-pharmaco- cihpargidemedodabor
ted clinical syndromes often undistinguishable at presentation, and frequently entail similar early VC ed AS, cidemihparG
At present reperfusion strategy is the standard diagnostic and therapeutic approaches. Risk stra- therapy for STEMI patients and mechanical and tification is of crucial importance for the practi- pharmacological options are valid alternatives.
ce of contemporary medicine due to the high risk The proportion of FT decreases from RENASI- toward outcome, in this setting troponin measu- acidémoiB arutaretiL :cihpargideM
CA I (50%) to RENASICA II, (37%) a possible rements are an important diagnostic tool. Obser- explanation could be the high number of hospi- vations from RENASICA I, (12%)12 II (20%) and sustraídode-m.e.d.i.g.r.a.p.h.i.c
tals with coronary intervention facilities. Howe- ENACT (36%)16 indicate that its availability is ver, the reasons for this reduction should be stu- still very limited, however, among biochemical died in more detail, since a significant proportion markers, troponin was the only mortality predic- of patients, arrive in time to obtain reperfusion tor. A similar trend with C-reactive protein mea- benefit. In NSTEMI FT use (4%) was similar to surements was observed. These remarks establish that observed in other registries.15,16 Although in the need to identify an appropriate risk model this group FT was a stronger in-hospital morta- tailored to middle-income countries.
lity predictor, high rate of clinical instability, Although an upward trend in the use of anti- conduction system abnormalities, macronecro- thrombotic and antiischemic standard treatment sis, and left ventricular dysfunction were identi- was identified,12 RENASICA II highlights spe- fied. Probably FT was used as rescue therapy in cific areas to improve the knowledge and current the setting of non-mechanical reperfusion facili- practice among all physicians related with ACS ties. No major bleeding complications were ob- care. In UA/NSTEMI the results showed that the served. Although percutaneous coronary inter- use of nitrates, beta blockers, unfractionated and vention had a low rate, (15%) these findings are LMWH use was markedly lower than expected.
in line with previous evidence reported elsewhe- The high use of ACE inhibitors (54%) is so- re.14,16 Considering the significant proportion of mewhat surprising given the lack of evidence and STEMI patients without any reperfusion strate- is likely to be related with co-morbidities.15,16 In gy, new directions from the health system are STEMI aspirin, nitrates, ACE inhibitors and un- required to improve quality of care.
fractionated heparin use was lower. Considering Variations in invasive and non-invasive proce- pharmacological advantages of enoxaparin and dures were found among all groups. Coronary clopidogrel in STEMI setting with or without angiography, percutaneous and surgical revas- reperfusion strategy its use could be considered cularizations were surprisingly high in UA/NSE- appropriate, however more evidence is necessary.
MI. However these results are not different from In patients under pharmacological reperfusion the previous evidences14 and reflect availability of final evidence comes from TIMI 25 and 28 trials.
specialists and appropriate equipment. A similar Glycoprotein IIb/IIIa inhibitors use was low in trend was observed with non-invasive diagno- both groups (16%). It is likely that this trend pos- sibly reflects its use mainly in conjunction with The observed mortality rates in STEMI were hig- percutaneous coronary intervention in view of her than expected and higher than reported pre- disappointing GUSTO IV28 and V29 results or tho- viously.14-16,23 However, this is not unexpected se they were an unavailable resource. The pro- since a substantial proportion of patients had not portion of statins in all patients (13%) was lower access to reperfusion facilities. Left ventricular than in European registries,15,16 it could reflect than dysfunction was the most important MACE and physicians embrace therapeutic directions based the strongest mortality predictor, which is in line on their personal experiences and reject results of with the low incidence of reperfusion approaches contemporaneous trials. Although, in ACS there and possible long ischemia time. New pharma- edigraphic.com
cological reperfusion directions including FT acute use of statins to improve outcome, it remains bolus, as is currently used in several countries, as an open question. Meanwhile, statins are pro- might improve even further STEMI outcome.
ving long-term safety and effectiveness for secon- The low frequency of major bleeding complica- dary prevention in stable coronary disease, in ACS tions and ventricular arrhythmias could be ex- they are safe and could improve endothelium dys- plained by the center expertise and early (24 function.30 In addition, the majority of these pa- hours) intensive antithrombotic treatment. In non-ST elevation ACS mortality rate was simi- II broadens our knowledge about how reperfu- sion and antithrombotic approaches modify the The RENASICA II results highlight the diagnos- outcome and what needs to be improved in the tic challenges in patients admitted with high cli- nical suspicion of ACS (Fig. 1). Among patientswith initial UA/NSTEMI and STEMI suspicion over 80% had this final diagnosis. The high ACS rate in patients with unspecified chest pain em- Alonso Autrey Caballero, Gabriela Borrayo, phasizes limited diagnosis sensitivity even with Hospital de Cardiología Siglo XXI CMN IMSS, the participation of well-skilled physicians. In this México DF; (1,354). Armando García-Castillo, group of patients clinicians should carefully avoid Carlos Jerjes Sánchez-Díaz, Beatriz Maldonado, Armando Astorga, Jorge García; Hospital de En- A relevant question is whether the patients are fermedades Cardiovasculares y del Tórax IMSS, representative of a general ACS population. Re- Mty. NL; (1,269). Carlos Martínez Sánchez, Úr- gistries have a more limited possibility than clini- sulo Juárez, Héctor González, Instituto Nacio- cal trials to monitor the inclusion process ensu- nal de Cardiología, México DF; (890). Guiller- ring enrollment of consecutive patients. On the mo Llamas Esperón, Hospital Cardiológica other hand a survey recruits patients as seen in the Aguascalientes; (519). Marco A. Ramos Corra- every day clinical practice free from exclusion les, Centro Médico “La Raza”, México DF; criteria commonly applied in clinical trials. At any (455). Jesús Martínez Sánchez, Hospital ABC, rate the size of the current survey, comprising México DF; (353). Octavio González Chon, Hos- 8,098 individuals with a wide spectrum of ACS, pital Médica Sur, México DF; (305). Jorge Cor- makes it reasonable to assume that patterns dis- tez Lawrenz, Hospital CIMA, Hermosillo Sono- closed indeed represent a true picture of the cu- ra; (228). Miguel Ángel Luna Calvo, Hospital rrent clinical situation in selected hospitals at least.
General de Durango; (218). Eduardo Salazar The above summarized data show important simi- Weill, Hospital N° 1 IMSS, Tepic; (207). Carlos larities between RENASICA I12 and II. This suppor- Martínez Hernández, Hospital Regional Adolfo ts the validity of the findings, and strengthens the López Mateos, ISSSTE, México DF; (192). Ju- need for further improvement of medical care.
lio López Cuéllar, Hospital Español, México DF; However, there are some important differences, (156). Berenice López Cuéllar, Hospital del Car- which make it difficult to compare outcome in spe- men, Guadalajara; (135). Bernardo R. Encarna- cific patient groups. Data presented in this issue, ción, Centro Médico Nacional “Ruiz Cortines”, provide insight into the practice of cardiology in Veracruz; (125). Marco A. Zúñiga, Centro Mé- different hospital settings in Mexico.
dico Nacional Occidente, Guadalajara; (117).
Ramiro Flores Ramírez, Hospital Universitario, Monterrey NL; (113). Jorge Carrillo, José Luis Since it was not a population-based epidemiolo- Arenas, Hospital Central “Morones Prieto”, SLP; gical study, some bias may have been introdu- (112). Alejandro García Reyes, Hospital Espe- ced with respect to: a) selection of participating cialidades N° 71, IMSS, Torreón Coahuila; (102).
centers, b) limited monitoring visits was focu- Marco A. Alcocer, Hospital Ángeles, Queréta- sed on the accuracy of data entry, c) it is possi- ro; (99). Ismael Hernández Santa María, Hospi- ble that some patients that died in the emergen- tal Juárez México DF; (94). Carlos Urbano Cas- cy room were not included, d) no long-term tillo, Hospital ISSSTE, Guadalajara; (87).
follow-up, e) high proportion of centers with re- Federico Rodríguez Wever, Hospital Ángeles del vascularization facilities impair generalization of Pedregal, México DF; (80). Germán A. Gómez the results in all hospitals of the country.
Briceño, Hospital General “Manuel Gea Gonzá-lez”, México DF; (76). José Luis Leyva, Centro edigraphic.com
Médico del Potosí, SLP; (74). Juan Parcero, Ma- The largest registry ACS in Latin-America pro- rio Zúñiga, Hospital Excel, Tijuana BCN; (72).
vides important and reliable information on the José Ramón Azpiri, Hospital Christus-Muguer- complete spectrum, outcome, quality of care, and za, Monterrey NL; (71). Amanda Castelán, Cen- identifies areas for further improvement of the tro Médico Nacional Obregón, Sonora; (70).
quality of our cardiovascular care. RENASICA Manuel Odín de los Ríos, Hospital General Culia- cán, Sinaloa; (69). Enrique López Rosas, Centro tal “San José” TEC de Monterrey; (21). José Luis de Especialidades Médicas, Jalapa Ver; (68). Gui- Rodríguez, HGZ N° 6, Madero Tamps; (16). Nor- llermo Ficker, Sanatorio Español, Torreón; (64).
berto Matadamas, Hospital General, Acapulco; José R. Ocampo, Hospital Santelena, México DF; (15). Héctor Barragán Mar, Hospital Metropoli- (59). Samuel Guízar, Raúl Rivas, Hospital PE- tano, México DF; (13). Carlos Hernández Herre- MEX Picacho, México DF; (59). Sergio Luna, ra, Hospital Especialidades, Monclova Coah; (9).
Centro Médico Nacional IMSS, León Guanajua- Hugo Aguilar Castillo, Hospital “Darío Fernán- to; (55). Darío Lemarroy, Hospital PEMEX Vill- dez” ISSSTE, México DF; (9). Marco Antonio ahermosa; (51). Alfredo Felipe Hoyos, Hospital Susarrey, Hospital Cardiomed, Ensenada BCN; Regional IMSS, Cuernavaca; (50). Juan Carlos (9). Abel Pavia, Hospital General SSA, México Núñez Fragoso, Hospital General N° 1 IMSS, Du- DF; (8). Miguel A. Romo, Hospital “San José”, rango; (49). Marco A. Alcocer, Hospital General, Zacatecas; (8). Demetrio Kosturakis, Arturo Mon- Querétaro; (46). Sergio Najar, Efraín Gaxiola, roy, Hospital CIMA, Chihuahua; (7). José Luis Hospital “Fray Bernardete”, Guadalajara; (43).
Álvarez Cabrera, Centro Médico Naval, México Enrique Gómez Álvarez, Hospital ISSSTE 20 de DF; (7). Adrián Medina Amarilla, Hospital AL- Noviembre, México DF; (43). Carmen Aurora Li- món, Centro Médico Nacional IMSS, Puebla; (41).
Julio González Jaramillo, Centro Médico Nacio- nal “El Fénix” IMSS, Mérida Yucatán; (41). Am- Our gratitude to J. Antonio González-Hermosi- brosio Cruz, PEMEX Central Norte, México DF; llo, President of the Mexican Cardiology Socie- (39). Alfredo Pérez Gea, Centro Español, Tampi- ty 2002-2003. RENASICA II Coordinating Sta- co; (34). Hernán Navarrete Alarcón, ISSSTE Za- ff: Mely Colomer, Cristina Gaytán and Cristina ragoza, México DF; (34). Jorge Durón, HGZ N° 2 IMSS, Saltillo; (30). Miguel Beltrán, Hospital Gutiérrez, Xenia Cruz, Lorena Vasto, Miguel ISSSTECALLI, Tijuana BCN; (32). Jesús Manuel Canale, Hospital General del Estado, Hermosillo;(28). Luis Mario Fuentes, Hospital Star Médica, Special mention to Steering Committee members Morelia Mich; (26). Marcos Ibarra Flores, Hospi- and all investigators involved in the project.
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Okguias endodoncia julio 02 2012

COLOMBIANA DE SALUD S.A. MANUAL DE CALIDAD GUIAS DE MANEJO Y Página 1 de 21 CDS-GDM 2.2.1-03 DIAGNOSTICO ODONTOLOGICO EN Revisión 02 Junio 2012 ENDODONCIA No de Revisión Elaboró COLOMBIANA DE SALUD S.A. MANUAL DE CALIDAD GUIAS DE MANEJO Y Página 2 de 21 CDS-GDM 2.2.1-03 DIAGNOSTICO ODONTOLOGICO EN Revisión 02

Eta1440_m027-web.dvi

THE η(1405), η(1475), f1(1420), AND f1(1510)Revised February 2012 by C. Amsler (Z¨The first observation of the η(1440) was made in pp anni-hilation at rest into η(1440)π+π−, η(1440) → KKπ [1]. Thisstate was reported to decay through a0(980)π and K∗(892)Kwith roughly equal contributions. The η(1440) was also ob-served in radiative J/ψ(1S) decay into KKπ [2

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