Enfermedad pulmonar obstructiva crónica en pacientes con tromboembolia de pulmón aguda sintomática

Background

The diagnosis of pulmonary embolism (PE) is often complicated by the presence of chronic obstructive pulmonary disease (COPD). Some studies have suggested that patients with PE and concomitant COPD have a worse prognosis than patients without COPD.

Patients and methods

Outpatients diagnosed with acute symptomatic PE at a university tertiary care hospital were prospectively included in the study. Clinical characteristics, time between onset of symptoms and diagnosis, and outcome were analyzed according to presence or absence of COPD. The primary endpoint was all-cause deaths at 3 months.

Results

Of 882 patients with a confirmed diagnosis of acute symptomatic PE, 8% (95% confidence interval [CI], 6%–9%) had COPD. Patients with COPD were significantly more likely to have a delay in diagnosis of more than 3 days and to have a low pretest probability of pulmonary embolism according to a standardized clinical score. The total number of deaths during 3 months of follow-up was 128 (14%; 95% CI, 12%–17%). Factors significantly associated with mortality from all causes were a history of cancer or immobilization, systolic blood pressure less than 100 mm Hg, and arterial oxyhemoglobin saturation less than 90%. COPD was significantly associated with PE-related death in the logistic regression analysis (relative risk, 2.2; 95% CI, 1.0–5.1).

Conclusions

Patients with COPD and PE more often have a lower pretest probability and a longer delay in diagnosis of PE. COPD is significantly associated with PE-related death in the 3 months following diagnosis.     

Elaboración de un score predictivo preoperatorio de coledocolitiasis

Introduction

Choledocholithiasis is the most common cause of obstructive jaundice and occurs in 5-10% of patients with cholelithiasis.

Objectives

To design a preoperative predictive score for choledocholithiasis.

Material and methods

A prospective study was carried out in 556 patients admitted to our department for biliary disease. Preoperative clinical, laboratory, and ultrasound variables were compared between patients without choledocholithiasis and 65 patients with this diagnosis. A multivariate logistic analysis was performed to obtain a predictive model of choledocholithiasis, determining sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV).

Results

Predictors of choledocholithiasis were the presence of a prior history of biliary disease (history of biliary colic, acute cholecystitis, choledocholithiasis or acute biliary pancreatitis) (p = 0.021, OR = 2.225, 95% CI: 1.130-4.381), total bilirubin values > 4 mg/dl (p = 0.046, OR = 2.403, 95% CI: 1.106-5.685), alkaline phosphatase values > 150 mg/dl (p = 0.022 income, OR = 2.631, 95%: 1.386-6.231), gamma-glutamyltransferase (GGT) values > 100 mg/dl (p = 0.035, OR = 2.10, 95% CI: 1.345-5.850), and an ultrasound finding of biliary duct > 8 mm (p = 0.034, OR = 3.063 95% CI: 1086-8649). A score superior to 5 had a specificity and PPV of 100% for detecting choledocholithiasis and a score less than 3 had a sensitivity and NPV of 100% for excluding this diagnosis.

Conclusions

The preoperative score can exclude or confirm the presence of choledocholithiasis and allows patients to directly benefit from laparoscopic cholecystectomy (LC) or prior endoscopic retrograde cholangiopancreatography (ERCP).     

Biopsia pleural con aguja Tru-cut y citología como primer procedimiento en el estudio del derrame pleural

Introduction and objectives

The evaluation of pleural effusion (PE) includes various techniques, including pleural biopsy (PB). Our aim was to study the diagnostic yield of Tru-Cut needle PB (TCPB) and to define clinical/radiological situations in which TCPB might be indicated as an initial procedure.

Methodology

Retrospective study of TCPB in a hospital centre (2010-2012). Cases of pleural lesions without effusion were excluded. Clinical and radiological variables, diagnostic yield, TCPB complications and factors associated with the diagnostic yield of the combination of TCPB and thoracocentesis as initial procedure were analysed.

Results

One hundred and twenty-seven (127) TCPB were reviewed: 29.1% were cases of malignant PE and in 18.9% the cause of the PE could not be determined. The diagnostic yield of TCPB for tuberculosis was 76.5% (13/17) and 54% (20/37) for malignant PE. Complications occurred in 4.7% of the cases. In 72 patients with a final definitive diagnosis, TCPB was performed at the same time as the initial thoracocentesis. Diagnostic yield for the combination of TCPB/cytology as an initial technique was 43% (31/72) compared to 12.5% (9/72) for cytology only (p = 0.01). The only predictive variable for the indication of TCBP as an initial technique was a PE volume > 2/3 (P = .04).

Conclusions

TCPB is safe and provides an acceptable diagnostic yield, particularly when combined with simultaneous cytology in the evaluation of PE of various aetiologies. Radiological criteria may help guide the selection of patients who could benefit from this technique as an initial procedure combined with thoracocentesis.     

Endocarditis infecciosa en 2 hospitales universitarios españoles que difieren en su localización y en la presencia de servicio quirúrgico

Objectives

To assess possible differences in clinical presentation, microbiology, morbidity and mortality of infective endocarditis between two Spanish hospitals, one on the mainland that has cardiac surgery and one in the Canary Islands without this service.

Method

A total of 229 patients consecutively diagnosed of endocarditis between 2005 and 2012, including pediatric population, were studied in the Reina Sofía Hospital (Córdoba, n = 119) and Nuestra Señora de Candelaria Hospital (Tenerife, n = 110). We compared the clinical, microbiological and echocardiographic data and analyzed mortality differences by binary logistic regression analysis.

Results

There were no differences in underlying heart disease, proportion of surgery, or the microbiological profile. The proportion of infections attributable to catheter was higher in the Canary Islands hospital (13.6% vs 3.4%). Mortality was also higher (31.8% vs 18.5%, P = .020), although this difference was no longer significant in the multivariate analysis (OR = 1.85; 95% CI, 0.70-4.87; P = .213). Age (OR = 1.04/year; 95% CI, 1.01-1.07; P = .006), cardiac complications (OR = 5.05; 95% CI, 1.78-14.34; P = .002), persistent sepsis (OR = 4.89; 95% CI, 2.09-11.46; P < .001), and emergent surgery (OR = 4.43, 95% CI, 1.75-11.19; P = .002) were independent predictors of death. Time to surgery, length of stay in the hospital without a surgical service (20 [13-30.5] vs 13 [6-25] days; P = .019) was not associated with outcome.

Conclusions

There are differences in the presentation of endocarditis between two distant hospitals in Spain. The different hospital mortality can not be directly related to the presence of a surgery service.     

Predicción en tiempo real de la malignidad de ganglios linfáticos mediastínicos mediante ecografía endobronquial

Objective

To evaluate the utility of different ultrasonographic (US) features in differentiating benign and malignant lymph node (LN) by endobronchial ultrasound (EBUS) and validate a score for real-time clinical application.

Methods

208 mediastinal LN acquired from 141 patients were analyzed. Six different US criteria were evaluated (short axis ≥ 10 mm, shape, margin, echogenicity, and central hilar structure [CHS], and presence of hyperechoic density) by two observers independently. A simplified score was generated where the presence of margin distinction, round shape and short axis ≥ 10 mm were scored as 1 and heterogeneous echogenicity and absence of CHS were scored as 1.5. The score was evaluated prospectively for real-time clinical application in 65 LN during EBUS procedure in 39 patients undertaken by two experienced operators. These criteria were correlated with the histopathological results and the sensitivity, specificity, positive and negative predictive values (PPV and NPV) were calculated.

Results

Both heterogenicity and absence of CHS had the highest sensitivity and NPV (≥ 90%) for predicting LN malignancy with acceptable inter-observer agreement (92% and 87% respectively). On real-time application, the sensitivity and specificity of the score > 5 were 78% and 86% respectively; only the absence of CHS, round shape and size of LN were significantly associated with malignant LN.

Conclusions

Combination of different US criteria can be useful for prediction of mediastinal LN malignancy and valid for real-time clinical application.     

Valor predictivo de la infiltración por linfocitos T intraepiteliales (CD3) en el pronóstico del cáncer colorrectal resecado

Introduction

Colorectal cancer (CRC) can induce an anti-tumoral immune response mediated by T-lymphocytes, which express CD3.

Objectives

To analyze the prognostic value of tissue expression of intraepithelial CD3 (CD3I) both overall and in the early tumoral stages.

Methods

We revised 251 patients with resected CRC and favorable clinical course. CD3I expression was analyzed by immunohistochemistry. Multivariate analysis was used to analyze the variables independently associated with survival. We analyzed CD3I(+) expression in relation to survival and tumoral progression, both overall and in patients with pTNM(I-II) stage tumors. The sensitivity, specificity, positive and negative predictive values and diagnostic accuracy of CD3I expression were analyzed.

Results

A total of 25.9% of patients with CRC were CD3I(+). After a mean follow-up of 74 months, CD3I(+) expression showed a favorable prognostic value for survival in the multivariate analysis (p = 0.045). Survival curves and absence of tumoral progression were more favorable in CD3I(+) cases, both overall (p = 0.009 and p = 0.004, respectively), and in stages I-II (p = 0.029 and p = 0.015). The specificity and positive predictive value of CD3I(+) were as follows: Survival: overall: specificity =0.89; positive predictive value =0.91. Stage (I-II): specificity =0.94; positive predictive value =0.98. Absence of tumoral progression: overall: specificity = 0.89; positive predictive value =0.88. Stage (I-II): specificity =0.92; positive predictive value =0.96.

Conclusions

CD3I expression has an favorable independent prognostic value, with statistically significantly higher percentages of survival and absence of tumoral progression. This more favorable outcome is maintained in the less advanced stages (I-II). CD3I expression shows high specificity and positive predictive value.     

Calidad de vida relacionada con la salud en una cohorte nacional de pacientes con hipertensión arterial pulmonar o hipertensión pulmonar tromboembólica crónica

Background

Patients with pulmonary arterial hypertension (PAH) and chronic thromboembolic pulmonary hypertension (CTEPH) experience impaired health-related quality of life (HRQL). The objective of this study was to evaluate HRQL in a nation-wide sample.

Patients and methods

This is a prospective, multicenter, non-interventional study of HRQL including 139 (89%) PAH and 17 (11%) CTEPH patients (women 70.5%; mean age, 52.2) recruited from 21 Spanish hospitals. 55% had idiopathic PAH, 34% other PAH and 11% CTEPH. HRQL was measured using the Short Form 36 Health Survey (SF-36) and EuroQoL-5D (baseline and after 6 months).

Results

HRQL in the patients with PAH or CTEPH was impaired. The physical component of SF-36 and the EuroQol-5D correlated with the functional class (FC). Mean EuroQol-5D visual analogical scale (EQ-5D VAS) scores were 73.5 ± 18.4, 62.9 ± 20.7 and 51.3 ± 16.0 (P < .0001) in patients with FC I, II and III, respectively. Every increase of one FC represented a loss of 4.0 on the PCS SF-36 and a loss of 9.5 on the EQ-5D VAS. Eight patients who died or received a transplant during the study period presented poorer initial HRQL compared with the rest of the population. No significant changes in HRQL were observed in survivors after 6 months of follow-up.

Conclusions

HRQL is impaired in this population, especially in PAH/CTEPH patients near death. HRQL measurements could help predict the prognosis in PAH and CTPH and provide additional information in these patients.     

Intervención domiciliaria y variables predictoras para reingreso hospitalario en la enfermedad pulmonar obstructiva crónica agudizada

Background

Chronic obstructive pulmonary disease (COPD) exacerbation increases mortality and resources used associated with hospitalization. We studied whether early home monitoring reduces the rate of readmission and if there are any predictor variables.

Patients and methods

We performed a prospective, controlled, parallel-group study in patients who were hospitalized for COPD. Patients whose residence was within less than 15 km from the hospital were assigned to an interventional group (home visits by nurses about 48-72 hours after discharge), the remainder were assigned to a conventional care group. The rate of rehospitalization within the first month was compared between the two groups, as well as those variables that showed a predictive capability.

Results

Seventy one patients were included: 35 in the conventional care group and 36 in the interventional group. In the latter, the treatment was modified in 13 patients (36%). The hospital readmission rate was 17%, which was similar in both groups (P = .50). For every 5-year increase in age, the risk for readmission was 2.54 (95% CI, 1.06-5.07) and for each increase of 10 mmHg in PaCO₂, the risk of readmission was 8.34 (95% CI, 2.43-18.55).

Conclusions

Early home monitoring did not decrease the readmission rate during the first month. Older age and high PaCO₂ are factors that identify the group with a high risk for rehospitalization.     

Clinical utility of N-terminal pro-B-type natriuretic peptide for risk stratification of patients with acute decompensated heart failure. Derivation and validation of the ADHF/NT-proBNP risk score

Background

NT-proBNP has been associated with prognosis in acute decompensated heart failure (ADHF). Whether NT-proBNP provides additional prognostic information beyond that obtained from standard clinical variables is uncertain. We sought to assess whether N-terminal pro-B-type natriuretic peptide (NT-proBNP) determination improves risk reclassification of patients with ADHF and to develop and validate a point-based NT-proBNP risk score.

Methods

This study included 824 patients with ADHF (453 in the derivation cohort, 371 in the validation cohort). We compared two multivariable models predicting 1-year all-cause mortality, including clinical variables and clinical variables plus NT-proBNP. We calculated the net reclassification improvement (NRI) and the integrated discrimination improvement (IDI). Then, we developed and externally validated the NT-proBNP risk score.

Results

One-year mortalities for the derivation and validation cohorts were 28.3% and 23.4%, respectively. Multivariable predictors of mortality included chronic obstructive pulmonary disease, estimated glomerular filtration rate, sodium, hemoglobin, left ventricular ejection fraction, and moderate to severe tricuspid regurgitation. Adding NT-proBNP to the clinical variables only model significantly improved the NRI (0.129; p = 0.0027) and the IDI (0.037; p = 0.0005). In the derivation cohort, the NT-proBNP risk score had a C index of 0.839 (95% CI: 0.798–0.880) and the Hosmer–Lemeshow statistic was 1.23 (p = 0.542), indicating good calibration. In the validation cohort, the risk score had a C index of 0.768 (95% CI: 0.711–0.817); the Hosmer–Lemeshow statistic was 2.76 (p = 0.251), after recalibration.

Conclusions

The NT-proBNP risk score provides clinicians with a contemporary, accurate, easy-to-use, and validated predictive tool. Further validation in other datasets is advisable.     

Influencia del fenómeno migratorio sobre la tuberculosis en una zona semiurbana

Aims

To describe the epidemiology of tuberculosis and analyzing the differences among native and immigrant patients in Area III of the Region of Murcia.

Methods

Cohort study of tuberculosis cases reported to the Epidemiological Surveillance Service from 2004 to 2009. Data collection was performed through the System of Notification Diseases, reviewing clinical files and epidemiological surveys.

Results

One hundred sixty two cases were detected; 110 (67.9%) were immigrants, whose incidence rates ranged from 43.4 to 101.2 cases per 100,000 inhabitants. Ecuador (42.7%), Bolivia (30%) and Morocco (18.2%) were the main nationalities.Immigrants were younger than Spanish population (P < .001). The overall diagnostic delay was 50.5 days: 59.5 in Spanish and 47 in foreigners. Moroccans had higher proportions of extrapulmonary TB (P = .02). Mainly, immigrant population took treatment with four drugs (P < .001). Natives had better treatment adherence (P = .04). Spanish cases tuberculosis were associated with smoking (P < .001), the same as alcohol consumption (P = .01) and injection drug use (P < .001), nevertheless in the foreign-born population the most relevant risk factor was overcrowding (P < .001).

Conclusions

The incidence tuberculosis rates are higher among immigrant population, whose the main risk factor is overcrowding. In contrast, Spanish cases are associated with toxic substances consumption and increasing age.     

Evolución del uso de la ventilación mecánica no invasiva en enfermedad pulmonar obstructiva crónica en una región española, 1997-2010

Introduction

Noninvasive mechanical ventilation (NIV) appeared in the 1980s as an alternative to invasive mechanical ventilation (IMV) in patients with acute respiratory failure. We evaluated the introduction of NIV and the results in patients with acute exacerbation of chronic obstructive pulmonary disease in the Region of Murcia (Spain).

Subjects and methods

A retrospective observational study based on the minimum basic hospital discharge data of all patients hospitalised for this pathology in all public hospitals in the region between 1997 and 2010. We performed a time trend analysis on hospital attendance, the use of each ventilatory intervention and hospital mortality through joinpoint regression.

Results

We identified 30.027 hospital discharges. Joinpoint analysis: downward trend in attendance (annual percentage change [APC] = −3.4, 95% CI: − 4.8; −2.0, P <.05) and in the group without ventilatory intervention (APC = −4.2%, −5.6; −2.8, P <.05); upward trend in the use of NIV (APC = 16.4, 12.0; 20. 9, P <.05), and downward trend that was not statistically significant in IMV (APC = −4.5%, −10.3; 1.7). We observed an upward trend without statistical significance in overall mortality (APC = 0.5, −1.3; 2.4) and in the group without intervention (APC = 0.1, −1.6; 1.9); downward trend with statistical significance in the NIV group (APC = −7.1, −11.7; −2.2, P <.05) and not statistically significant in the IMV group (APC = −0,8, −6, 1; 4.8). The mean stay did not change substantially.

Conclusions

The introduction of NIV has reduced the group of patients not receiving assisted ventilation. No improvement in results was found in terms of mortality or length of stay.     

Infradiagnóstico de la enfermedad pulmonar obstructiva crónica en mujeres: cuantificación del problema,determinantes y propuestas de acción

Introduction

The distribution of chronic obstructive pulmonary disease (COPD) in women, and its underdiagnosis and determinants in the general population, have not been well described. The EPI-SCAN study is an epidemiologic, observational study conducted at 11 Spanish centers on the general population aged 40 to 80.

Patients and method

This paper describes the rates and extrapolates the population burden from the 3,802 participants of the EPI-SCAN study.

Results

With 2,005 female and 1,797 male participants, there was a lower prevalence of COPD in women (5.7%; 95% CI, 4.7-6.7) than in men (15.1%; 95% CI, 13.5-16.8; P < .05). Among the 386 participants with COPD, 114 (29.5%) were women, who were younger, currently smoked less and had lower tobacco smoke exposure, while reporting a lower level of education (P < .05). As for the respiratory symptoms, there were no differences between sexes for cough, dyspnea or wheezing, but the women with COPD reported sputum less frequently (P < .05). There were no differences in the spirometric severity of COPD between women and men. Overall, 73% of the patients with a spirometric COPD criteria were underdiagnosed, and this percentage is unevenly distributed by sex, being 1.27 times more frequent in women (86.0%) than in men (67.6%) (P < .05). By extrapolating the rates of prevalence and underdiagnosis of COPD to the general population, we estimate that there are 628,102 Spanish women between the ages of 40 and 80 with COPD, 540,168 of whom still have not been diagnosed.

Conclusions

There is a greater underdiagnosis of COPD in women than in men in Spain.     

Ancho de distribución eritrocitaria y predicción adicional del riesgo de hemorragia mayor en el síndrome coronario agudo sin elevación del ST

Introduction and objectives

Red cell distribution width has been linked to an increased risk for in-hospital bleeding in patients with non–ST-segment elevation acute coronary syndrome. However, its usefulness for predicting bleeding complications beyond the hospitalization period remains unknown. Our aim was to evaluate the complementary value of red cell distribution width and the CRUSADE scale to predict long-term bleeding risk in these patients.

Methods

Red cell distribution width was measured at admission in 293 patients with non–ST-segment elevation acute coronary syndrome. All patients were clinically followed up and major bleeding events were recorded (defined according to Bleeding Academic Research Consortium Definition criteria).

Results

During a follow-up of 782 days [interquartile range, 510-1112 days], events occurred in 30 (10.2%) patients. Quartile analyses showed an abrupt increase in major bleedings at the fourth red cell distribution width quartile (> 14.9%; P = .001). After multivariate adjustment, red cell distribution width > 14.9% was associated with higher risk of events (hazard ratio = 2.67; 95% confidence interval, 1.17-6.10; P = .02). Patients with values ≤ 14.9% and a CRUSADE score ≤ 40 had the lowest events rate, while patients with values > 14.9% and a CRUSADE score > 40 points (high and very high risk) had the highest rate of bleeding (log rank test, P < .001). Further, the addition of red cell distribution width to the CRUSADE score for the prediction of major bleeding had a significant integrated discrimination improvement of 5.2% (P < .001) and a net reclassification improvement of 10% (P = .001).

Conclusions

In non–ST-segment elevation acute coronary syndrome patients, elevated red cell distribution width is predictive of increased major bleeding risk and provides additional information to the CRUSADE scale.Full English text available from: www.revespcardiol.org/en     

Particularités cliniques de l’embolie pulmonaire chez la personne âgée : étude comparative de 64 patients

Purpose

To date only a few studies regarding pulmonary embolism (PE) in elderly have been published. The aim of this study was to determine the clinical features of PE in elderly patients (≥ 75 years).

Methods

All patients hospitalized for PE in our internal medicine department from January 2005 to December 2010 were included in the study. The aim was to compare the features of PE in elderly patients (≥ 75 years) to those of patients younger than 75 years. The following data were recorded: past medical history, risk factors for venous thrombo-embolism (VTE), clinical features, and PE etiologies.

Results

The population was composed of 64 patients (women 56%) with a median age of 82 years (IQR: 13.5). There was no statistical difference for risk factors of VTE. Syncope was more frequent in elderly patients (33% versus 7%, P = 0.04) whereas thoracic pain predominated in younger patients (36,5% versus 7%, P = 0.005). Chronic obstructive pulmonary disease was more frequent in the past medical history of elderly patients. The diagnostic of PE was less suspected in elderly patients (47% versus 72%, P = 0.035). The etiologies were similar between the two groups.

Conclusion

Our study highlights the frequency of syncope as the presenting feature of PE in elderly, whereas thoracic pain is uncommon. We confirmed the difficulty to diagnose PE in elderly population.     

Beneficio clínico de la terapia de resincronización cardiaca con desfibrilador para pacientes con fracción de eyección > 35% por resonancia magnética

Introduction and objectives

Cardiac resynchronization therapy with a defibrillator prolongs survival and improves quality of life in advanced heart failure. Traditionally, patients with ejection fraction > 35% estimated by echocardiography have been excluded. We assessed the prognostic impact of this therapy in a group of patients with severely depressed systolic function as assessed by echocardiography but with an ejection fraction > 35% as assessed by cardiac magnetic resonance.

Methods

We analyzed consecutive patients admitted for decompensated heart failure between 2004 and 2011. The patients were in functional class II-IV, with a QRS ≥ 120 ms, ejection fraction ≤ 35% estimated by echocardiography, and a cardiac magnetic resonance study. We included all patients (n = 103) who underwent device implantation for primary prevention. Ventricular arrhythmia, all-cause mortality and readmission for heart failure were considered major cardiac events. The patients were divided into 2 groups according to systolic function assessed by magnetic resonance.

Results

The 2 groups showed similar improvements in functional class and ejection fraction at 6 months. We found a nonsignificant trend toward a higher risk of all-cause mortality in patients with systolic function ≤ 35% at long-term follow-up. The presence of a pattern of necrosis identified patients with a worse prognosis for ventricular arrhythmias and mortality in both groups.

Conclusions

We conclude that cardiac resynchronization therapy with a defibrillator leads to a similar clinical benefit in patients with an ejection fraction ≤ 35% or > 35% estimated by cardiac magnetic resonance. Analysis of the pattern of late gadolinium enhancement provides additional information on arrhythmic risk and long-term prognosis.Full English text available from:www.revespcardiol.org/en     

Tratamiento antirretroviral de inicio en pacientes infectados por el virus de la inmunodeficiencia humana en España: decisiones con relación a características inmunovirológicas específicas (estudio PERFIL-es)

Introduction

The purpose of Perfil-es study was to identify the proportion of patients starting ARV treatment based on NNRTIs or PI/r, and to identify the variables involved in the therapeutic decision-making in standard clinical practice.

Methods

An observational restrospective study performed in 65 Spanish hospitals.

Results

Was a total of 1,687 starts: 53% with NNRTI-based regimen and 42% with PI/r, and of the 642 patients analyzed, 72% had a CD4 count < 350 cells/μl.

Conclusion

The initiation of ARV treatment is still late in Spain. NNRTIs are the more frequent choice, although PI/r plays an important role.     

Asociación entre presión arterial y mortalidad en una cohorte de individuos de edad igual o superior a 65 años de España: un modelo dinámico

Introduction and objectives

Few studies have used time-dependent correction to analyze the relationship between blood pressure and all-cause mortality, and to our knowledge none has been performed in older people from the Mediterranean area. This study aimed to estimate the relationship between baseline blood pressure and blood pressure as a time-dependent covariate with the risk of all-cause mortality in a population cohort of persons aged 65 or older in Spain.

Methods

Data were taken from the population-based study «Aging in Leganés» with 17 years of follow-up, launched in 1993 in a random sample (n=1560) of persons aged ≥65 years. Mortality was assessed in 2010. Cox proportional hazards models were fitted to examine the effects on mortality of blood pressure at baseline and of blood pressure as a time-dependent covariate.

Results

The lowest mortality was observed at baseline systolic blood pressure of 136 mmHg and time-dependent covariate value of 147 mmHg. The highest risk of mortality for time-dependent covariates occurred with systolic blood pressure<115 mmHg and >93 mmHg and diastolic blood pressure<80 mmHg. Diastolic blood pressure over 85 mmHg did not increase the risk of death.

Conclusions

Based on the dynamic association between blood pressure and mortality, a U-shaped relationship was found for systolic blood pressure and a negative relationship for diastolic blood pressure and all-cause mortality. The lowest mortality corresponded to a systolic blood pressure level slightly over the diagnostic hypertension value and suggests that a value of 140 mmHg is not adequate as a diagnostic and therapeutic threshold in an elderly population.Full English text available from:www.revespcardiol.org/en.     

Clasificación de la gravedad de la enfermedad pulmonar obstructiva crónica según la nueva guía Iniciativa Global para la Enfermedad Obstructiva Crónica 2011: COPD Assessment Test versus modified Medical Research Council

Introduction

The GOLD 2011 revision proposes to stratify patients with chronic obstructive pulmonary disease (COPD) by measuring the impact of the disease using the modified Medical Research Council (mMRC) scale or COPD assessment test (CAT). Our aim was to determine whether both methods are equivalent.

Patients and methods

Observational study on a cohort of 283 patients diagnosed with COPD. We analyzed the demographic and lung function results. Patients were assessed by CAT and mMRC on the same day by the same interviewer, and divided into GOLD 2011 categories according to the result of the evaluation. The degree of concordance and Spearman correlation were determined. We used ANOVA on the clinical and functional variables of the four GOLD 2011 categories.

Results

Assessing the classification of patients according to the method used, an overall correlation ρ = 0.613 and a degree of concordance κ = 0.63 (moderate) were obtained. κ = 0.44 was obtained for the 152 patients in categories A and B (moderate-low), and 0.38 for the 131 patients in categories C and D (low). Differences were observed between categories in terms of functional parameters.

Conclusions

The classification of patients with COPD using the assessment proposed by GOLD 2011 varies according to the method used (CAT or mMRC); more than 25% of patients were reclassified into different categories, implying differences in the recommended therapeutic strategy. Longitudinal studies are needed to appraise which method better classifies patients, according to its prognostic ability.     

Escalas de probabilidad clínica y algoritmo diagnóstico en la embolia pulmonar: ¿se siguen en la práctica clínica?

Introduction

Clinical probability scores (CPS) determine the pre-test probability of pulmonary embolism (PE) and assess the need for the tests required in these patients. Our objective is to investigate if PE is diagnosed according to clinical practice guidelines.

Materials and methods

Retrospective study of clinically suspected PE in the emergency department between January 2010 and December 2012. A D-dimer value ≥ 500 ng/ml was considered positive. PE was diagnosed on the basis of the multislice computed tomography angiography and, to a lesser extent, with other imaging techniques. The CPS used was the revised Geneva scoring system.

Results

There was 3,924 cases of suspected PE (56% female). Diagnosis was determined in 360 patients (9.2%) and the incidence was 30.6 cases per 100,000 inhabitants/year. Sensitivity and the negative predictive value of the D-dimer test were 98.7% and 99.2% respectively. CPS was calculated in only 24 cases (0.6%) and diagnostic algorithms were not followed in 2,125 patients (54.2%): in 682 (17.4%) because clinical probability could not be estimated and in 482 (37.6%), 852 (46.4%) and 109 (87.9%) with low, intermediate and high clinical probability, respectively, because the diagnostic algorithms for these probabilities were not applied.

Conclusions

CPS are rarely calculated in the diagnosis of PE and the diagnostic algorithm is rarely used in clinical practice. This may result in procedures with potential significant side effects being unnecessarily performed or to a high risk of underdiagnosis.