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Treatment of Acute Coronary Syndromes
in Esquel, Norwest Area of Chubut
(Patagonia) (1991-2001)

Piegaro, Ricardo; Cohen Arazi, Carlos;
Simeone, Carla; Dominguez, Alfredo;
Mingo, Marcelo; Fossatti, Alejandro;
Romanelli, Liliana; Guazzone, María

Hospital Zonal Esquel (Hospital Zonal Esquel), Clínica Los Alerces (IMLA), Esquel.Chubut-Argentina

SUMMARY
Introduction: Cardiovascular diseases are the first death cause in Chubut(29,8%)- Early fibrinolytic therapy decrease AMI mortality(FTT/Lancet/1994).
Objetives: 1)Analize our experience in the acute coronary Syndromes(ACS); 2) Hospital Mortality determination.
Material and Methods: Retrospective study:Admitted patients with ACS, betwen october/91 and march/01 in the ICUHZE. Sex, age, rural(GrR)/urban(GrU) residency,cardiovascular risk fctors(CRF), Killip-Kimbal score at admission(KK), time betwen first symptoms and initial treatment(Window), admission diagnosis and hospital mortality were analyzed.We established 3 diferents diagnosis cathegories:1) S-T elevation MI(AMITM; 2)Unstable angina(UA);3)Non Q wave MI(NoQwMI).The patients of group 1 (AMITM were separated in two groups:A)Those who receive STK, B)Those no elegible for STK.We administrate STK(1.500.000 U I.V infussion in 1 hour),betwen the first 6 hours from the beginig of symptoms.(CI=95%).We evaluated cholesterol level(>250mg/dl), Hypertension(>140/90mmHg), smoking habit(>10 cig/day).
Results: We admitted 979 patients, 105 with ACS.
88(83,8%) males, with X age=58.9
17(16,1%) females with X age=68.9
GrR(n=36),(34,3%)           GrU(n=69),(65,7%)
From the 105 patients:
1)AMITM group, (n=80),(76,2%), 46 of them (53,7% were elegibles for STK treaatment), 37(46,7%) were non elegibles.
2)UA group ,(n=20),(19%)
3) NoQwMI,(n=5),(4,7%)
Mortality (Tables 1 and 2):

The global motality was 15,2%(16/105)
AMITM,mort=17,5%(14/80)      UA,mort=0%        NoQwMI,mort=40%(2/5)
According to KK:
KK A-B(n=91),(86,6%), mort=8,79%, GrR mort=10%, GrU mort= 9,8%
KK C-D(n=14),(12,6%),mort= 50%(p=0,0002), GrR mort= 83,3%, GrU mort= 25% (p=0,00008)
According to CRF:
*Hypertension (n=69),(65,7), mort= 15.9%(p=NS), GrR mort=25%, GrU mort=11,1%
*Smoking (n=60),(57%), mort=10%(p=NS), GrR mort=20%, GrU mort=5,3%
*Diabetes (n=14),(13,3%), mort= 35,7%(p=0,002,RR=2,95), GrR mort=75%, GrU mort= 20%(p=0,004)
*Cholesterol (n=36),(43,3%) mort=11,1%(p=NS), GrR mort=37,5%, GrU mort=3,6%(p=0,0007)
Discussion: The C-D KK score shows the highest mortality in the study. Diabetes was the only risk factor who increase mortality.Hypercholesterolemia shows more risk in the rural group.The rural group had less posibilities to receive adecuate treatment, with worst prognosis.
Conclusion: We suggest to improve trinning of human resources in rural in order to:
1-Start the early fibrinolitic therapy in MI with S-T elevation.
2-Decrease MI morbidity.
3-Decrease Healt spending for chronic heart diseases.

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INTRODUCTION
   The Intensive Care Uinit (ICU) of the Esquel´s Hospital (H.Z.E.) admit all the patients from the NW
area of Chubut.

   Cardiovascular diseases are the first cause of death in Chubut (29,8%).
The early administration of an fibrinolitic agent decrease the myocardial infarction (MI) mortality (FTT/Lancet/1994)

OBJECTIVES
   1) Analyze our experience in the acute treatment of the acute coronary syndromes (ACS) 2) Hospital mortality determination.

MATERIAL AND METHODS
   This is a Retrospective study of the medical records of patients admitted in the ICU of H.Z.E between October 1991 and March 2001. Sex, age, rural (GrR)/urban (GrU) residency, cardiovascular risk factors (CRF), Killip-Kimbal score at admission (KK), time between first symptoms and initial treatment (Window), admission diagnosis, and hospital mortality were analyzed.

   We established three diferents diagnosis categories (Graphic 1)
1) S-T elevation (AMITM); 2) Unstable angina (UA); NonQ wave infarction (NoQMI).
The patient of group 1(AMITM), were separated in two groups: A) those who receive STK, B) Those who were No Elegible for STK.

   We administrate STK (1500000 U./ I.V.infussion in one hour), during the first 6 hours from the beginning of symptoms.
We evaluate Hypercholeserolaemia (>250mg/dl.), Hypertension (HTA)(>140/90mmHg.), smoking habit (>10 cig/day), and Diabetes Mellitus (Diabetes)(Statistic study by EPI-INFO 5 software, C.I=95%).

RESULTS
We admitted 979 patients in the UCI, 105 with ACS.
88 males (83,8%) with Xage=58,9
17 females (16,1%) with Xage=68,9
GrR, n=36(34,3%), and GrU, n=69(65,7%)
From the 105 patient with ACS:
1) AMITM group, (n=80)(76,2%), 46 of them were elegibles for STK treatment, and 37(46,7%) were no elegibles.
2) UA group, n=20(19%)
3) NoQMI), n=5(4,7%)
Mortality:
The global mortality was 15,2%(16/105)
AMITM mortality = 17,5%(14/80)
UA mortality = 0%
NoQMI mortality = 40%(2/5)
According to KK: (Table 1)
KK A-B (n=91), (86,6%), mort=8,8%;
GrR mort=10%, GrU mort= 9,8%(p=NS)
KK C-D (n14),(12,6%), mort=50%(p=0,0002)
GrR mort=83,3%, GrU mort=25%(p=NS)
According to CRF:(Table 2)




*Hypertension      (n=69, 65,7%), mort =15,9% (p=NS); GrR mort. =25%; GrU mort. = 11,1%
*Smoking              (n=60, 57%), mort=10%8 (p=NS); GrR mort=20%, GrU mort=5,3%
*Diabetes             (n=14, 13,3%), mort=35,7% (p=0,002, RR2,95), GrR mort.=75%, GrU mot.= 20%(p=0,004)
*Cholesterol         (n=36, 43,3%) mort=11,1% (p=NS), GrR mort= 37,5%, GrU mort=3,6%(p=0,0007)

DISCUSSION
   The first report for the use of I.V infusion of fibrinolityc was from Koren et al.(Hadassh University, Jerusalem/1985), they administrate STK in 58 patients, nine of them in the pre-hospital period. That results were corroborate for the GISSI study (lancet/1986). In this study they demonstrate that the earlier administration of fibrinolytic , in the first hour, had a lower mortality (47% less). The ISIS-2 (Lancet 1988) demonstrated a 32% decrease of mortality when the fibrinolityc was administrated between the fourth hours from the first symptoms, and a 42% decrease of mortality if was indicated in the first hour.

   In our study the rural population do not have the possibility of early administration of STK . We couldn't demonstrate a higher mortality in rural patients because of the low number of cases.

   C-D KK score shows the highest mortality in the study.

   Diabetes was the only Risk factor who increase mortality.

   Hypercholesterolaemia shows more risk in the rural group.

   The rural group had fewer possibilities to receive adequate treatment, with worst prognosis.

CONCLUSION
   We suggest to improve trinning of human resources in rural, in order to:
1 Start the early fibrinolityc therapy in MI with ST elevation.
2 Decrease MI morbidity
3 Decrease health services spending for chronic heart diseases.

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2nd Virtual Congress of Cardiology

Dr. Florencio Garófalo
Steering Committee
President
Dr. Raúl Bretal
Scientific Committee
President
Dr. Armando Pacher
Technical Committee - CETIFAC
President
fgaro@fac.org.ar
fgaro@satlink.com
rbretal@fac.org.ar
rbretal@netverk.com.ar
apacher@fac.org.ar
apacher@satlink.com

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