Clinical characteristics, process of care and outcomes among Mexican, Hispanic and non-Hispanic white patients presenting with non-ST elevation acute coronary syndromes, Data from RENASICA and CRUSADE registries
Características clínicas. tratamiento hospitalario y evolución entre población mexicana. latina y anglosajones no hispánicos con infarto agudo del miocardio sin elevación del segmento ST. Datos tomados de los registros RENASICA y CRUSADE
Carlos Jerjes Sánchez-Diaza, Edgar García-Badillob, Carlos Jerjes Sánchez-Ramírezc, Úrsulo Juárezd, Carlos Martínez-Sánchezd
a Departamento de Investigación Clínica del Instituto de Cardiología y Medicina Vascular del Tecnológico de Monterrey. Departamento de la Unidad de Investigación Clínica en Medicina SC. Monterrey, N.L., México.
b Unidad de Investigación Clínica en Medicina AC. Monterrey, N.L., México.
c Escuela de Medicina del Tecnológico de Monterrey, en Monterrey N.L.
d Servicio de Urgencias y Unidad Coronaria del Instituto Nacional de Cardiología Ignacio Chávez, México, D.F., México.
Read
4998
Timeswas read the article
918
Total PDF
4080
Total HTML
Share statistics
array:20 [ "pii" => "X1405994012228819" "issn" => "14059940" "estado" => "S300" "fechaPublicacion" => "2012-01-01" "documento" => "article" "crossmark" => 0 "licencia" => "http://www.elsevier.com/open-access/userlicense/1.0/" "subdocumento" => "fla" "cita" => "Arch Cardiol Mex. 2012;82:14-21" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 3703 "formatos" => array:3 [ "EPUB" => 36 "HTML" => 3154 "PDF" => 513 ] ] "itemSiguiente" => array:16 [ "pii" => "X1405994012228827" "issn" => "14059940" "estado" => "S300" "fechaPublicacion" => "2012-01-01" "documento" => "article" "crossmark" => 0 "licencia" => "http://www.elsevier.com/open-access/userlicense/1.0/" "subdocumento" => "fla" "cita" => "Arch Cardiol Mex. 2012;82:22-30" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 4422 "formatos" => array:3 [ "EPUB" => 49 "HTML" => 3579 "PDF" => 794 ] ] "en" => array:12 [ "idiomaDefecto" => true "titulo" => "Electrocardiographic pattern combined with echocardiographic wall motion abnormalities in stress related cardiomyopathies, clinical and pathophysiological insights" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "es" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "22" "paginaFinal" => "30" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Cuadro electrocardiográfico combinado con movimientos anormales de la pared ventricular en miocardiopatías por estrés, aspectos clínicos y fisiopatológicos" ] ] "contieneResumen" => array:2 [ "es" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig1" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "293v82n01-90122882fig2.jpg" "Alto" => 1225 "Ancho" => 2029 "Tamanyo" => 258212 ] ] "descripcion" => array:1 [ "en" => "A) A 60-year-old woman. During anginal pain, mild ST segment depression in the precordial leads from V1 to V3 at the ECG is associated with akinesia of mid segments of the left ventricle at the echocardiogram. B) Two days later ECG: T wave inversion in the inferior leads and in the precordial leads from V4 to V6. The echocardiogram repeated on the same day revealed restoring of normal motion in all left ventricular segments." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Marco Berti, Giuseppe Ghizzoni, Anna Gualeni, Paola Cantamessa, Carlo Oneglia." "autores" => array:5 [ 0 => array:2 [ "nombre" => "Marco" "apellidos" => "Berti" ] 1 => array:2 [ "nombre" => "Giuseppe" "apellidos" => "Ghizzoni" ] 2 => array:2 [ "nombre" => "Anna" "apellidos" => "Gualeni" ] 3 => array:2 [ "nombre" => "Paola" "apellidos" => "Cantamessa" ] 4 => array:2 [ "nombre" => "Carlo" "apellidos" => "Oneglia." ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X1405994012228827?idApp=UINPBA00004N" "url" => "/14059940/0000008200000001/v0_201307091008/X1405994012228827/v0_201307091009/en/main.assets" ] "itemAnterior" => array:16 [ "pii" => "X1405994012228800" "issn" => "14059940" "estado" => "S300" "fechaPublicacion" => "2012-01-01" "documento" => "article" "crossmark" => 0 "licencia" => "http://www.elsevier.com/open-access/userlicense/1.0/" "subdocumento" => "fla" "cita" => "Arch Cardiol Mex. 2012;82:7-13" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 21680 "formatos" => array:3 [ "EPUB" => 88 "HTML" => 19989 "PDF" => 1603 ] ] "en" => array:12 [ "idiomaDefecto" => true "titulo" => "The TIMI risk score for STEMI predicts in-hospital mortality and adverse events in patients without cardiogenic shock undergoing primary angioplasty" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "es" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "7" "paginaFinal" => "13" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "La escala de riesgo TIMI para infarto del miocardio con elevación del segmento ST predice mortalidad y eventos adversos intrahospitalarios en pacientes sin choque cardiogénico sometidos a angioplastía coronaria" ] ] "contieneResumen" => array:2 [ "es" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig1" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "293v82n01-90122880fig3.jpg" "Alto" => 1012 "Ancho" => 1933 "Tamanyo" => 85149 ] ] "descripcion" => array:1 [ "en" => "TIMI risk score for STEMI to predict in hospital mortality." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Héctor González-Pacheco, Alexandra Arias-Mendoza, Amada Álvarez-Sangabriel, Úrsulo Juárez-Herrera, Félix Damas, Guering Eid-Lidt, Francisco Azar-Manzur, Carlos Martínez-Sánchez" "autores" => array:8 [ 0 => array:2 [ "nombre" => "Héctor" "apellidos" => "González-Pacheco" ] 1 => array:2 [ "nombre" => "Alexandra" "apellidos" => "Arias-Mendoza" ] 2 => array:2 [ "nombre" => "Amada" "apellidos" => "Álvarez-Sangabriel" ] 3 => array:2 [ "nombre" => "Úrsulo" "apellidos" => "Juárez-Herrera" ] 4 => array:2 [ "nombre" => "Félix" "apellidos" => "Damas" ] 5 => array:2 [ "nombre" => "Guering" "apellidos" => "Eid-Lidt" ] 6 => array:2 [ "nombre" => "Francisco" "apellidos" => "Azar-Manzur" ] 7 => array:2 [ "nombre" => "Carlos" "apellidos" => "Martínez-Sánchez" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X1405994012228800?idApp=UINPBA00004N" "url" => "/14059940/0000008200000001/v0_201307091008/X1405994012228800/v0_201307091008/en/main.assets" ] "en" => array:14 [ "idiomaDefecto" => true "titulo" => "Clinical characteristics, process of care and outcomes among Mexican, Hispanic and non-Hispanic white patients presenting with non-ST elevation acute coronary syndromes, Data from RENASICA and CRUSADE registries" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "14" "paginaFinal" => "21" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "Carlos Jerjes Sánchez-Diaz, Edgar García-Badillo, Carlos Jerjes Sánchez-Ramírez, Úrsulo Juárez, Carlos Martínez-Sánchez" "autores" => array:5 [ 0 => array:3 [ "nombre" => "Carlos" "apellidos" => "Jerjes Sánchez-Diaz" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] 1 => array:3 [ "nombre" => "Edgar" "apellidos" => "García-Badillo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "affb" ] ] ] 2 => array:3 [ "nombre" => "Carlos" "apellidos" => "Jerjes Sánchez-Ramírez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "affc" ] ] ] 3 => array:3 [ "nombre" => "Úrsulo" "apellidos" => "Juárez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "affd" ] ] ] 4 => array:3 [ "nombre" => "Carlos" "apellidos" => "Martínez-Sánchez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "affd" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Departamento de Investigación Clínica del Instituto de Cardiología y Medicina Vascular del Tecnológico de Monterrey. Departamento de la Unidad de Investigación Clínica en Medicina SC. Monterrey, N.L., México. " "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] 1 => array:3 [ "entidad" => "Unidad de Investigación Clínica en Medicina AC. Monterrey, N.L., México." "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "affb" ] 2 => array:3 [ "entidad" => "Escuela de Medicina del Tecnológico de Monterrey, en Monterrey N.L." "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "affc" ] 3 => array:3 [ "entidad" => "Servicio de Urgencias y Unidad Coronaria del Instituto Nacional de Cardiología Ignacio Chávez, México, D.F., México. " "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "affd" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Características clínicas. tratamiento hospitalario y evolución entre población mexicana. latina y anglosajones no hispánicos con infarto agudo del miocardio sin elevación del segmento ST. Datos tomados de los registros RENASICA y CRUSADE" ] ] "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">Introduction</span></p><p class="elsevierStylePara"> Worldwide, acute coronary syndromes (ACS) are estimated to be the leading cause of death and loss of disability- adjusted life years in developing and developed countries.<span class="elsevierStyleSup">1 </span>Current knowledge about therapeutic and mortality trends in non-ST elevation (NSTE) ACS is largely derived from randomized control clinical trials.<span class="elsevierStyleSup">2,3 </span>Prospective registries provide a unique opportunity to accurately assess current clinical practice and outcomes, and compare these with other institutions and clinical practice guidelines. These data contribute to an ongoing process of quality assurance, indicating areas where education is necessary.<span class="elsevierStyleSup">4</span> RENASICA II<span class="elsevierStyleSup">5</span> and CRUSADE6 are contemporaneous high quality clinical registries that could identify in the "real clinical practice" if knowledge from clinical trials is being properly applied in NSTE ACS patients under different health care systems. We analyzed clinical characteristics, process of care, clinical practice guidelines (CPGs) compliance, and in-hospital outcomes among Mexican, Hispanic and non-Hispanic white patients presenting with NSTE ACS.</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Methods</span></p><p class="elsevierStylePara"> In a <span class="elsevierStyleItalic">post - hoc</span> study data from patients enrolled in two contemporaneous registries were analyzed. Objective is to identify clinical characteristics, process of care, resource use, CPGs compliance and in-hospital mortality among Mexican, Hispanic and non-Hispanic white patients at Mexican and United States of America (USA) hospitals. <span class="elsevierStyleItalic">Inclusion</span>: patients enrolled with final diagnosis of NSTE ACS secondary to ischemic heart disease. <span class="elsevierStyleItalic">Design</span>: RENASICA II<span class="elsevierStyleSup">5 </span>and CRUSADE<span class="elsevierStyleSup">6 </span>designs have been published previously. <span class="elsevierStyleItalic">In brief</span>: RENASICA II was a prospective and observational registry that aimed to reflect an unbiased and representative population with final diagnosis of ACS secondary to ischemic heart disease to identify diagnosis, stratification and treatment trends. In-hospital outcome was analyzed through major adverse cardiovascular events (MACE) including death, recurrent ischemia, acute myocardial infarction, reinfarction, cardiogenic shock and stroke. Patients were included in the registry if during hospital admission they had high clinical suspicion of ACS: acute ischemia manifestations, with or without ECG changes or necrosis and proven ischemic heart disease by invasive or non-invasive tests. Patients with symptoms precipitated by anemia, hypertension, heart failure, etcetera, were not considered. With or without ST elevation nomenclature was standardized on admission and at discharge. All treatment decisions were taken by the patient's respective physicians. To ensure quality control of registry data the criteria developed by Alpert were applied. An electronic case report form was used.<span class="elsevierStyleSup">5 </span></p><p class="elsevierStylePara"> CRUSADE<span class="elsevierStyleSup">6 </span>was a multidisciplinary quality improvement initiative for patients with NSTE ACS across 443 hospitals in the United States. Criteria for enrollment included ischemic symptoms at rest within 24 hours before presentation with high-risk features including ST-segment depression >0.5 mm, transient ST-segment elevation 0.5 to 1.0 mm (lasting for<10 minutes), and/or positive cardiac markers (elevated troponin I or T and/or creatinekinase - MB higher than upper limit of normality). Patient information was collected retrospectively in an anonymous fashion using a three page case report form that captured demographic and clinical characteristics at enrollment, use of evidence-based therapies within 24 hours of presentation, laboratory results, use and timing of coronary angiography and revascularization procedures, discharge medications, and in-hospital clinical outcomes. Contra-indications to therapies given class IA or IB recommendations by the American College of Cardiology/American Heart Association Guidelines were recorded. The institutional review board of each institution approved participation in CRUSADE.<span class="elsevierStyleSup">6 </span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Definitions</span></p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Hispanic patient</span>: term used exclusively in the United States coined without a scientific basis by the Office of Management and Budget in 1978 to standardize data collection among federal agencies. Hispanics are an amalgamation of different cultures and nationalities (Mexican, Puerto Rican, and Cuban), whose origins and race are diverse.<span class="elsevierStyleSup">7 </span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Acute Coronary Syndrome NSTE </span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">RENASICA II </span></p><p class="elsevierStylePara"> High - risk: characteristic ischemic chest pain lasting > 20 minutes during the last 48 hours with dynamic or persistent ST depression > 1 mm in 2 consecutive leads or > 3 leads, left ventricular dysfunction, independent of troponin or creatininekinase - MB status.</p><p class="elsevierStylePara"> Low - risk: characteristic ischemic chest pain lasting < 20 minutes in the last 48 hours with negative t waves, non-specific changes or normal ECG, without left ventricular dysfunction and normal biomarkers.<span class="elsevierStyleSup">5 </span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">CRUSADE</span></p><p class="elsevierStylePara"> High - risk: ischemic symptoms at rest within 24 hours before presentation with risk features including ST depression > 0.5 mm, transient ST elevation of 0.5 to 1.0 mm (lasting for < 10 minutes), and/or positive cardiac markers (elevated troponin I or T and/or creatinekinase - MB higher than upper limit of normal values).<span class="elsevierStyleSup">6 </span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Statistics</span></p><p class="elsevierStylePara"> Chi square tests for discrete and two - tailed <span class="elsevierStyleItalic">t </span>tests for continuous variables, Yates corrected chi square and Wilcoxon test were used. As a measure of association odds ratio with 95% confidence interval (CI) was considered. Statistical significance was assumed with <span class="elsevierStyleItalic">p</span><0.05 level. Data are expressed in percentage, median, mean and SD.</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Results</span></p><p class="elsevierStylePara"> Between December 2002 and November 2003, 8098 Mexican patients were considered in the final report of RENA-SICA II. Of these, 3 543 had NSTE ACS. A total of 76 investigators in 66 primary and tertiary hospitals participated. Regarding the hospitals participating in the registry, 90% (60 hospitals) had active participation, 48% belong to government health system, 39% from private medicine, and 12% were teaching hospitals from other health systems. Hospitals located throughout the country enrolled 52% of the total of patients and those in Mexico City accounted for 48%. Tertiary hospitals with capabilities for coronary arteriography, percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass graft (CABG) surgery enrolled 90% of the patients.</p><p class="elsevierStylePara"> Between November 2001 and December 2004, 3 936 Hispanics and 90 280 non-Hispanic whites were enrolled in CRUSADE. The regional distribution of Hispanic enrollment closely paralleled the distribution of the Hispanic population across the USA. Hispanics were treated in hospitals of similar size compared with non-Hispanic whites but were less commonly treated on-site with surgical revascularization capabilities and cared for by a cardiologist. However, Hispanics were more frequently treated at academic facilities compared with non-Hispanic whites.</p><p class="elsevierStylePara"> Non-ST elevation ACS Mexican patients were younger with different cardiovascular risk profile, fewer incidences of hypertension (<span class="elsevierStyleItalic">p</span><0.001), hyperlipidemia (<span class="elsevierStyleItalic">p</span><0.001), renal failure (<span class="elsevierStyleItalic">p</span><0.001) and prior revascularization (<span class="elsevierStyleItalic">p</span><0.001), but were more likely to have diabetes (<span class="elsevierStyleItalic">p</span><0.001) and to be currently smoking (<span class="elsevierStyleItalic">p</span><0.001) compared with Hispanics and non-Hispanic white populations (<span class="elsevierStyleBold">Table 1</span>). At clinical presentation Mexican patients were more likely to had ST depression (<span class="elsevierStyleItalic">p</span><0.001) but less likely to have left ventricular dysfunction (<span class="elsevierStyleItalic">p</span><0.001), high-risk (<span class="elsevierStyleItalic">p</span><0.001), and angiographic (<span class="elsevierStyleItalic">p</span>=0.01) or troponin stratification (<span class="elsevierStyleItalic">p</span><0.001). All groups had clinical stability (<span class="elsevierStyleBold">Table 2</span>). Regarding antithrombotic treatment only aspirin was used in according CPGs compliance. Clopidogrel and heparins were used in 50% of patients or less. Mexican patients were less likely to receive glycoprotein IIb / IIIa inhibitors and revascularization (<span class="elsevierStyleBold">Table 3</span>). In spite of clinical differences and therapeutic trends, in - hospital cardiovascular mortality (Mexicans 4%, Hispanics4% and non-Hispanic whites 5%) and other major cardiovascular adverse events were similar among all groups (<span class="elsevierStyleBold">Table 4</span>).</p><p class="elsevierStylePara"><img alt="Table 1. Demographics characteristics. " src="293v82n01-90122881fig1.jpg"></img></p><p class="elsevierStylePara"><img alt="Table 2. Clinical presentation, risk and angiographic findings." src="293v82n01-90122881fig2.jpg"></img></p><p class="elsevierStylePara"><img alt="Table 3. Evidence based guidelines to clinical practice. " src="293v82n01-90122881fig3.jpg"></img></p><p class="elsevierStylePara"><img alt="Table 4. In-hospital outcome." src="293v82n01-90122881fig4.jpg"></img></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Discussion</span></p><p class="elsevierStylePara"> In our results three relevant findings were identified. First, in the contemporary era of evidence-based medicine, although invasive processes of care probably depend on income capacity, no difference in the in-hospital mortality was observed. Second, Mexican patients had different risk factors and clinical presentation profile than patients living in USA. Third, strategies to improve CPGs compliance have to be implemented in developed and developing countries.</p><p class="elsevierStylePara"> Ischemic heart disease is the leading cause of deathglobally.<span class="elsevierStyleSup">8</span> At the beginning of this century it was responsible for 7.1 million deaths worldwide;<span class="elsevierStyleSup">7</span>of these, 5.7 million (80%) happened in low-income countries.<span class="elsevierStyleSup">9,10 </span>In relation to baseline levels in 1990, by 2020 this disease is expected to increase by 120% in women and 137% in men in developing countries, compared with a 30% - 60% increase in developed countries.<span class="elsevierStyleSup">11</span>According to epidemiological data from Mexico, it is the first mortality cause in the elderly and second in general population, being responsible for 50 000 deaths in 2003 and roughly accounting for 10% of all deaths.<span class="elsevierStyleSup">5</span> Recently, evidence coming from CREATE registry in India suggested that by 2010, 60% of the world's heart disease will occur in this country.<span class="elsevierStyleSup">12</span></p><p class="elsevierStylePara"> A panoramic view on 227 431 NST ACS patients from developing<span class="elsevierStyleSup">5,12</span> and developed6,13-16 countries is shown in <span class="elsevierStyleBold">Table 5</span>. In Mexico and India STEMI was the most frequent clinical expression of coronary instability. This ratio between STEMI and unstable angina/NSTEMI was higher than reported for other registries. A less STEMI incidence in developed countries can be attributed to cultural differences in the perceptions of disease, insurance status (USA 27% <span class="elsevierStyleItalic">vs</span> Mexico 4% and Indian 4%), access to care, social support and educational level. In RENASICA II, mechanical reperfusion facilities in participating hospitals and the overall prevalence of STEMI associated to other co-morbidities (diabetes) that increased rather rapidly<span class="elsevierStyleSup">5 </span>as a possible explanation were considered. In CREATE registry this issue was not analyzed.<span class="elsevierStyleSup">12 </span>In NSTE ACS, in - hospital mortality ranged from 2% to 6% (<span class="elsevierStyleBold">Table 5</span>), except in EUR-HEART (11%)<span class="elsevierStyleSup">14</span> and RENASICA II (7%).5 In both, troponin use was low (36% and 21%, respectively), so under diagnosis of NSTEMI has to be considered and should be fundamental to increase use of micronecrosis biomarkers to identify high-risk patients according current CPGs.<span class="elsevierStyleSup">2,3 </span></p><p class="elsevierStylePara"><img alt="Table 5. Incidence and mortality in Non ST Elevation ACS." src="293v82n01-90122881fig5.jpg"></img></p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Risk factors.</span> Mexican patients had a different cardiovascular risk factors profile. They were more likely to be younger, diabetic and smokers, with less degree of renal failure. In accordance with previous evidence a higher incidence of diabetes was observed in Mexican and Hispanic patients.<span class="elsevierStyleSup">5,17,18 </span>RENASICA II had the highest diabetes incidence (50%) ever reported in the setting of an ACS survey.<span class="elsevierStyleSup">5 </span>Low smoking rate in American patients has to be attributed to effective anti-tobacco programs. Cigarette smoking is a powerful independent risk factor for sudden cardiac death in patients with coronary heart disease and smokers have about twice the risk of non-smokers. Primary and secondary prevention through effective anti-tobacco programs have to be implemented in order to improve the natural history of ischemic heart disease in Mexico. In RENASICA II body mass index was not considered, so it is not possible to known obesity degree; however, in American patients being overweight was the rule. The lower incidence of hyperlipidemia in Mexican patients could be attributed to genetic, nutritional habits or under-registry.</p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Clinical presentation and process of care.</span> Although Mexican patients had a higher incidence of ST depression on initial ECG, CRUSADE patients had highest risk considering left ventricular dysfunction incidence and biomarkers use. In this registry patients were assisted promptly, with similar times to first electrocardiogram (< 15 minutes) and first cardiac marker assessment (~1 hour), however, several factors may explain the more conservative process of care in Hispanics: non-cardiologist management with fewer catheterization, revascularization capabilities, and insurance status.<span class="elsevierStyleSup">19 </span>In RENASICA II, in spite of 90% being enrolled in tertiary hospitals with cardiologists and capabilities for angiographic stratification and percutaneous or surgical reperfusion, a conservative approach was observed too. Physician and hospitals profile, insurance use, resource and real accessibility have to be considered.</p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Clinical practice guidelines compliance</span>. In-hospital antithrombotic use does not differ among groups. In spite of clinical risk and previous evidence and recommendations<span class="elsevierStyleSup">2,3 </span>dual antiplatelet treatments were low in both medical care systems (middle and high income). There was a trend toward lower use of beta blockers and statins in Mexican patients (<span class="elsevierStyleBold">Table 3</span>). Mexican and Hispanics were more often treated with ACE inhibitors, if this therapeutic trend was used considering a higher prevalence of diabetes and its beneficial effects to delaying macro and microvascular complications it is unknown.<span class="elsevierStyleSup">19,20</span> A similar trend was observed with glycoprotein IIb / IIIa inhibitors in Mexican and Hispanic patients in whose less invasive management was used. Considering current therapeutic directions in NSTE ACS,<span class="elsevierStyleSup">2,3</span> strategies to improve compliance have to be implemented. However, whether or not low compliance is due to drug contraindication or collateral effects is unknown.</p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Mortality</span>. Despite differences in baseline risk factors and process of care, and risk stratification, in-hospital mortality was similar in all groups of patients (<span class="elsevierStyleBold">Table 4</span>). Although Mexicans and Hispanics could have higher rates of diabetes, obesity, lower socioeconomic status and difficulties to proper health care, they had lower all-cause and cardiovascular mortality rates than non-Hispanic whites. This phenomenon has been dubbed the "Hispanic paradox".<span class="elsevierStyleSup">21-23 </span>Although, similar outcomes have also been reported in STEMI,<span class="elsevierStyleSup">24-26</span> better short-term outcomes and long-term follow-up studies are needed to assess these observations. Continued cardiac care for secondary prevention may be unfavorably affected by socioeconomic factors such as poverty, limited insurance coverage, and restricted access.<span class="elsevierStyleSup">27 </span></p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Registries role in evidence-based medicine</span>. Non-randomized prospective registries document the treatment and outcomes for consecutive patients in clinical practice.</p><p class="elsevierStylePara"> Therefore, data are gained from a 'real-world' selection of patients, many of whom would be excluded from randomized control trials (RCTs), in a variety of clinical settings. These studies are costly, which limits the size of the populations under study. In contrast, registries can survey large populations, providing a powerful scientific tool.<span class="elsevierStyleSup">4 </span>Currently, the main goal of evidence-based medicine is to guide therapeutic decisions; in ST elevation MI only 13% of the recommendations in the USA guidelines are based on level A evidence.<span class="elsevierStyleSup">28 </span>CRUSADE and RENASICA II are contemporaneous high quality registries<span class="elsevierStyleSup">4,28,29</span> including entire spectrum of NSTE ACS in a representative population with co-morbidities under-represented in RCTs. The findings have the potential to provide a link between RCTs and the real clinical situation. In addition, both prospective registries provide a unique opportunity to accurately assess current clinical practice and in-hospital outcome and contribute to an ongoing process of quality assurance, indicating areas where education is necessary, in which treatment practices are suboptimal or conflicting with guideline recommendations.<span class="elsevierStyleSup">4 </span></p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Limitations</span>. <span class="elsevierStyleItalic">Post-hoc</span> analysis, lack oflong-term follow-up and several variables were not considered in either registry. Higher clinical risk profile in CRUSADE patients compared to RENASICA II patients has induced mortality bias. CRUSADE was not specifically designed to assess patterns of care according to ethnicity and, therefore, did not collect information on subcategories of Hispanic origin. Another important bias was that all patients in RENASICA II and CRUSADE registries were already hospitalized and, therefore, may represent a population with better access to health care and with higher socioeconomic status than the general population in both countries. In both registries contraindications or collateral effects for specific drugs were not analyzed.</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Conclusions</span></p><p class="elsevierStylePara"> In <span class="elsevierStyleItalic">post-hoc</span> analysis Mexican patients with NSTE ACS had a different cardiovascular risk factors profile, clinical presentation, risk and less intensive in-hospital treatment than Hispanic and non-Hispanic white patients. However, these differences do not appear to affect in-hospital mortality.</p><hr></hr><p class="elsevierStylePara"><span class="elsevierStyleBold">Corresponding author:</span> Carlos Martínez Sánchez. <br></br> Instituto Nacional de Cardiología Ignacio Chávez. Juan Badiano No. 1. Colonia Sección XVI, Tlalpan. CP.14050. México. <br></br> (52) 55 73 29 11. <br></br> E-mail: <a href="mailto:marcar@cardiologia.org.mx" class="elsevierStyleCrossRefs">marcar@cardiologia.org.mx</a></p><p class="elsevierStylePara"> Received on May 27, 2011; <br></br> accepted on January 16, 2012.</p>" "pdfFichero" => "293v82n01a90122881pdf001.pdf" "tienePdf" => true "PalabrasClave" => array:2 [ "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec191984" "palabras" => array:1 [ 0 => "Síndromes coronarios agudos; Síndrome coronario agudo sin elevación del ST; Infarto del miocardio; Tratamiento antitrombótico; Registros; México" ] ] ] "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec191985" "palabras" => array:1 [ 0 => "Acute coronary syndromes; Non-ST elevation acute coronary syndromes; Myocardial infarction; Antithrombotic treatment; Registries; Mexico" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "es" => array:1 [ "resumen" => "<p class="elsevierStylePara"> <span class="elsevierStyleItalic">Introducción: Existe poca información que compara características clínicas y tendencias terapéuticas en población mexicana, hispánica y anglosajona, con síndrome coronario agudo sin elevación del ST (SCA SEST).</span></p> <p class="elsevierStylePara"> <span class="elsevierStyleItalic">Métodos: Describimos características clínicas, proceso de atención y evolución hospitalaria en población mexicana, hispánica y anglosajona con SCA SEST, en hospitales mexicanos y americanos. En tres mil cuatrocientos veinticuatro mexicanos, 3 936 hispánicos y 90 280 anglosajones de los registros RENASICA y CRUSADE, se analizaron características basales, uso de recursos, apego a las guías clínicas y mortalidad hospitalaria.</span></p> <p class="elsevierStylePara"> <span class="elsevierStyleItalic">Resultados: Los pacientes mexicanos fueron más jóvenes y con diferente perfil de riesgo cardiovascular, por menor incidencia de hipertensión (p< 0.001), hiperlipidemia (p<0.001), insuficiencia renal (p<0.001) e historia de revascularización (p< 0.001), pero tuvieron mayor historia de tabaquismo (p<0.001) en comparación con hispánicos y anglosajones. La mayor incidencia de diabetes se observó en pacientes hispánicos y mexicanos (p<0.001). En </span>éstos<span class="elsevierStyleItalic">, al ingreso se observó mayor incidencia de desnivel negativo del ST (p<0.001), y menor grado de disfunción ventricular (p<0.001) y uso de troponinas (p<0.001). En relación al apego de las guías clínicas, en prácticamente todos se utilizó aspirina (90%), pero el uso de clopidogrel y heparina no fraccionada o de bajo peso molecular, sólo se utilizó en aproximadamente el 50%. Los pacientes mexicanos recibieron menos inhibidores de la glicoproteínas IIb / IIIa y menos revascularización. A pesar de algunas diferencias clínicas y terapéuticas, la mortalidad cardiovascular fue similar en los tres grupos (mexicanos 4%, hispánicos 4% y anglosajones 5%). En todos los grupos, el apego a las guías clínicas no fue el ideal.</span></p> <p class="elsevierStylePara"> <span class="elsevierStyleItalic">Conclusiones: En un análisis retrospectivo, pacientes mexicanos con un SCA SEST tuvieron diferente perfil de riesgo cardiovascular, presentación clínica y tratamiento hospitalario, que los pacientes hispánicos y anglosajones. Sin embargo, estas diferencias no parecen afectar la mortalidad hospitalaria.</span></p>" ] "en" => array:1 [ "resumen" => "<p class="elsevierStylePara"> <span class="elsevierStyleItalic">Introduction</span>: Data regarding management characteristics of non-ST elevation acute coronary syndromes (NSTE ACS) in Mexican, Hispanic and Non- Hispanic white patients are scarce.</p> <p class="elsevierStylePara"> <span class="elsevierStyleItalic">Methods</span>: We sought to describe the clinical characteristics, process of care, and outcomes of Mexicans, Hispanics and non-Hispanic whites presenting with NSTE ACS at Mexican and US hospitals. We compared baseline characteristics, resource use, clinical practice guidelines (CPGs) compliance and in-hospital mortality among 3 453 Mexicans, 3 936 Hispanics and 90, 280 non-Hispanic whites with NSTE ACS from the RENASICA and CRUSADE registries.</p> <p class="elsevierStylePara"> <span class="elsevierStyleItalic">Results</span>: Mexicans were younger with a different cardiovascular risk profile, fewer incidences of hypertension (<span class="elsevierStyleItalic">p</span><0.001), hiperlipidemia (<span class="elsevierStyleItalic">p</span><0.001), renal failure (<span class="elsevierStyleItalic">p</span><0.001) and prior revascularization (<span class="elsevierStyleItalic">p</span><0.001) but were more likely to be smoking compared with Hispanics and non-Hispanic white populations. Mexicans and Hispanics had a higher incidence of diabetes (<span class="elsevierStyleItalic">p</span><0.001). At clinical presentation Mexican patients were more likely to have ST depression (<span class="elsevierStyleItalic">p</span><0.001) but less likely to have left ventricular dysfunction (<span class="elsevierStyleItalic">p</span><0.001) and troponin stratification (<span class="elsevierStyleItalic">p</span><0.001). Regarding CPGs compliance, aspirin was used in 90% of patients in all groups, but clopidogrel or unfractionated or low-molecular weight heparin in 50% of patients or less. Mexican patients were less likely to receive glycoprotein IIb/IIIa inhibitors and revascularization. In spite of clinical differences and therapeutic trends, cardiovascular mortality was similar among all groups (Mexicans 4%, Hispanics 4% and non-Hispanic white 5%). In all groups of patients, a poor CPGs compliance was observed.</p> <p class="elsevierStylePara"> <span class="elsevierStyleItalic">Conclusions</span>: In a <span class="elsevierStyleItalic">post-hoc </span>analysis, Mexican patients with NSTE ACS had a different cardiovascular risk factor profile and clinical presentation, and less intensive in - hospital treatment than Hispanic and non-Hispanic white patients. However, these differences do not appear to affect in - hospital mortality.</p>" ] ] "multimedia" => array:5 [ 0 => array:8 [ "identificador" => "tbl1" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tablaImagen" => array:1 [ 0 => array:4 [ "imagenFichero" => "293v82n01-90122881fig1.jpg" "imagenAlto" => 1054 "imagenAncho" => 2095 "imagenTamanyo" => 214866 ] ] ] ] ] "descripcion" => array:1 [ "en" => "Demographics characteristics." ] ] 1 => array:8 [ "identificador" => "tbl2" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tablaImagen" => array:1 [ 0 => array:4 [ "imagenFichero" => "293v82n01-90122881fig2.jpg" "imagenAlto" => 920 "imagenAncho" => 2083 "imagenTamanyo" => 184204 ] ] ] ] ] "descripcion" => array:1 [ "en" => "Clinical presentation, risk and angiographic findings." ] ] 2 => array:8 [ "identificador" => "tbl3" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tablaImagen" => array:1 [ 0 => array:4 [ "imagenFichero" => "293v82n01-90122881fig3.jpg" "imagenAlto" => 1275 "imagenAncho" => 2095 "imagenTamanyo" => 245099 ] ] ] ] ] "descripcion" => array:1 [ "en" => "Evidence based guidelines to clinical practice." ] ] 3 => array:8 [ "identificador" => "tbl4" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tablaImagen" => array:1 [ 0 => array:4 [ "imagenFichero" => "293v82n01-90122881fig4.jpg" "imagenAlto" => 929 "imagenAncho" => 2045 "imagenTamanyo" => 163981 ] ] ] ] ] "descripcion" => array:1 [ "en" => "In-hospital outcome." ] ] 4 => array:8 [ "identificador" => "tbl5" "etiqueta" => "Table 5" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tablaImagen" => array:1 [ 0 => array:4 [ "imagenFichero" => "293v82n01-90122881fig5.jpg" "imagenAlto" => 812 "imagenAncho" => 2091 "imagenTamanyo" => 200068 ] ] ] ] ] "descripcion" => array:1 [ "en" => "Incidence and mortality in Non ST Elevation ACS." ] ] ] "bibliografia" => array:2 [ "titulo" => "Bibliography" "seccion" => array:1 [ 0 => array:1 [ "bibliografiaReferencia" => array:29 [ 0 => array:3 [ "identificador" => "bib1" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "The global burden of disease: a comprehensive assessment of mortality and disability from diseases, injuries, and risk factors in 1990 and projected to 2020. Boston." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "Murray CJL" 1 => "Lopez AD." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:3 [ "tituloSerie" => "Harvard School of Public Health. " "fecha" => "1996" "volumen" => "4-8" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib2" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Guidelines for the management of patients with unstable angina/Non-ST-elevation myocardial infarction." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "ACC/AHA 2007." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "fecha" => "J Am Coll Cardiol 2007" "volumen" => "50" "paginaInicial" => "e3" "paginaFinal" => "e133" ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib3" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Guidelines for the diagnosis and treatment of non-ST-segment elevation acute coronary syndromes." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "The Task Force for the diagnosis and treatment of non-ST-segment elevation acute coronary syndromes of the European Society of Cardiology." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "fecha" => "Eur Heart J 2007" "volumen" => "28" "paginaInicial" => "1598" "paginaFinal" => "1660" ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib4" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "The role of cardiac registries in evidence based - medicine." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "Gitt AK" 1 => "Bueno H" 2 => "Danchin N" 3 => "et al." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "fecha" => "Eur Heart J 2010" "volumen" => "31" "paginaInicial" => "525" "paginaFinal" => "529" ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib5" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Renasica II." "idioma" => "es" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "Garcia A" 1 => "Jerjes-Sanchez C" 2 => "Martinez BP" 3 => "et al." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "A Mexican registry of acute coronary syndromes. " "fecha" => "Arch Cardiol Mex 2005" "volumen" => "75" "paginaInicial" => "S6" "paginaFinal" => "S19" ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib6" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Clinical characteristics, process of care, and outcomes of hispanic patients presenting with non-ST-segment elevation acute coronary syndromes: Results from can rapid risk stratification of unstable angina patients suppress adverse outcomes with early implementation of the ACC/AHA guidelines (CRUSADE)." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "Cohen MG" 1 => "Roe MT" 2 => "Mulgund J" 3 => "et al." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "fecha" => "Am Heart J 2006" "volumen" => "152" "paginaInicial" => "110" "paginaFinal" => "117" ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib7" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Use of race and ethnicity in public health surveillance." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "Center for Disease Control and Prevention." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Summary of the CDC/ATSDR Workshop. " "fecha" => "MMWR Morb Mortal Wkly Rep 1993" "volumen" => "42" "paginaInicial" => "1" "paginaFinal" => "17" ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib8" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Global and regional burden of disease and risk factors, 2001: systematic analysis of population health data." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "Lopez AD" 1 => "Mathers CD" 2 => "Ezzati M" 3 => "et al." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "fecha" => "Lancet 2006" "volumen" => "367" "paginaInicial" => "1747" "paginaFinal" => "1757" ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib9" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Global burden of cardiovascular diseases: part I: general considerations, the epidemiologic transition, risk factors, and impact of urbanization." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "Yusuf S" 1 => "Reddy S" 2 => "Ounpuu S" 3 => "et al." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "fecha" => "Circulation 2001" "volumen" => "104" "paginaInicial" => "2746" "paginaFinal" => "2753" ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib10" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Cardiovascular disease in non-Western countries." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "Reddy KS." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "fecha" => "N Engl J Med 2004" "volumen" => "350" "paginaInicial" => "2438" "paginaFinal" => "2440" ] ] ] ] ] ] 10 => array:3 [ "identificador" => "bib11" "etiqueta" => "11" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Global burden of cardiovascular diseases: Part II: variations in cardiovascular disease by specific ethnic groups and geographic regions and prevention strategies." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "Yusuf S" 1 => "Reddy S" 2 => "Ounpuu S" 3 => "et al." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "fecha" => "Circulation 2001" "volumen" => "104" "paginaInicial" => "2855" "paginaFinal" => "2864" ] ] ] ] ] ] 11 => array:3 [ "identificador" => "bib12" "etiqueta" => "12" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "On behalf of the CREATE registry investigators." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "Xavier D" 1 => "Pais P" 2 => "Devereaux PJ" 3 => "et al." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Treatment and outcomes of acute coronary syndromes in India (CREATE): a prospective analysis of registry data. " "fecha" => "Lancet 2008" "volumen" => "371" "paginaInicial" => "1435" "paginaFinal" => "1442" ] ] ] ] ] ] 12 => array:3 [ "identificador" => "bib13" "etiqueta" => "13" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "For the GRACE Investigators. Management of acute coronary syndromes. Variations in practice and outcome." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "Fox KKA" 1 => "Goodman SG" 2 => "Klein W" 3 => "et al." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Findings from the Global Registry of Acute Coronary Events (GRACE). " "fecha" => "Eur Heart J 2002" "volumen" => "23" "paginaInicial" => "1177" "paginaFinal" => "1189" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12127920" "web" => "Medline" ] ] ] ] ] ] ] ] 13 => array:3 [ "identificador" => "bib14" "etiqueta" => "14" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "A prospective survey of the characteristics, treatments and outcomes of patients with acute coronary syndromes in Europe and the Mediterranean basin." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "Hasdai D" 1 => "Behar S" 2 => "Wallentin L" 3 => "et al." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "The Euro Heart Survey of Acute Coronary Syndromes (Euro Heart Survey ACS). " "fecha" => "Eur Heart J 2002" "volumen" => "23" "paginaInicial" => "1190" "paginaFinal" => "1201" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12127921" "web" => "Medline" ] ] ] ] ] ] ] ] 14 => array:3 [ "identificador" => "bib15" "etiqueta" => "15" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "On behalf of the ENACT (European Network for Acute Coronary Treatment) investigators." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "Fox KAA" 1 => "Cokkinos DV" 2 => "Deckers J" 3 => "et al." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "The ENACT study: a pan-European survey of acute coronary syndromes. " "fecha" => "Eur Heart J 2000" "volumen" => "21" "paginaInicial" => "1440" "paginaFinal" => "1449" ] ] ] ] ] ] 15 => array:3 [ "identificador" => "bib16" "etiqueta" => "16" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "For the PRAIS-UK Investigators Clinical outcomes, risk stratification and practice patterns of unstable angina and myocardial infarction without ST elevation: Prospective registry of acute ischaemic syndromes in the UK (PRAIS-UK)." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "Collinson J" 1 => "Flather D" 2 => "Fox KKA" 3 => "et al." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "fecha" => "Eur Heart J 2000" "volumen" => "21" "paginaInicial" => "1450" "paginaFinal" => "1457" ] ] ] ] ] ] 16 => array:3 [ "identificador" => "bib17" "etiqueta" => "17" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "The relation of diabetes to the severity of acute myocardial infarction and post-myocardial infarction survival in Mexican-Americans and non-Hispanic whites." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "Orlander PR" 1 => "Goff DC" 2 => "Morrissey M." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "The Corpus Christi Heart Project. " "fecha" => "Diabetes 1994" "volumen" => "43" "paginaInicial" => "897" "paginaFinal" => "902" ] ] ] ] ] ] 17 => array:3 [ "identificador" => "bib18" "etiqueta" => "18" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "All-cause and cardiovascular mortality among Mexican-American and non-Hispanic white older participants in the San Antonio Heart Study—evidence against the "Hispanic paradox"." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "Hunt KJ" 1 => "Resendez RG" 2 => "Williams K." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "fecha" => "Am J Epidemiol 2003" "volumen" => "158" "paginaInicial" => "1048" "paginaFinal" => "1057" ] ] ] ] ] ] 18 => array:3 [ "identificador" => "bib19" "etiqueta" => "19" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Determinants of the use of coronary angiography and revascularization after thrombolysis for acute myocardial infarction." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "Pilote L" 1 => "Miller DP" 2 => "Califf RM." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "fecha" => "N Engl J Med 1996" "volumen" => "335" "paginaInicial" => "1198" "paginaFinal" => "1205" ] ] ] ] ] ] 19 => array:3 [ "identificador" => "bib20" "etiqueta" => "20" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Effects of ramipril on cardiovascular and microvascular outcomes in people with diabetes mellitus: results of the HOPE study and MICRO-HOPE substudy." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "Heart Outcomes Prevention Evaluation (HOPE) Study Investigators." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "fecha" => "Lancet 2000" "volumen" => "355" "paginaInicial" => "253" "paginaFinal" => "259" ] ] ] ] ] ] 20 => array:3 [ "identificador" => "bib21" "etiqueta" => "21" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Secular trends in ischemic heart disease and stroke mortality from 1970 to 1976 in Spanish-surnamed and other white individuals in Bexar County, Texas." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "Stern MP" 1 => "Gaskill SP." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "fecha" => "Circulation 1978" "volumen" => "58" "paginaInicial" => "537" "paginaFinal" => "543" ] ] ] ] ] ] 21 => array:3 [ "identificador" => "bib22" "etiqueta" => "22" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Is the risk of coronary heart disease lower in Hispanics than in non-Hispanic whites? The San Luis Valley Diabetes Study." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "Rewers M" 1 => "Shetterly SM" 2 => "Hoag S." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "fecha" => "Ethn Dis 1993" "volumen" => "3" "paginaInicial" => "44" "paginaFinal" => "54" ] ] ] ] ] ] 22 => array:3 [ "identificador" => "bib23" "etiqueta" => "23" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Cardiovascular disease mortality in Hispanics and non-Hispanic whites." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "Swenson CJ" 1 => "Trepka MJ" 2 => "Rewers MJ." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "fecha" => "Am J Epidemiol 2002" "volumen" => "156" "paginaInicial" => "919" "paginaFinal" => "928" ] ] ] ] ] ] 23 => array:3 [ "identificador" => "bib24" "etiqueta" => "24" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Race and prognosis after myocardial infarction." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "Taylor HA" 1 => "Chaitman BR" 2 => "Rogers WJ." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Results of the thrombolysis in myocar-dial infarction (TIMI) phase II trial. " "fecha" => "Circulation 1993" "volumen" => "88" "paginaInicial" => "1484" "paginaFinal" => "1494" ] ] ] ] ] ] 24 => array:3 [ "identificador" => "bib25" "etiqueta" => "25" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Presenting characteristics, treatment patterns, and clinical outcomes of non-black minorities in the National Registry of Myocardial Infarction 2." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "Canto JG" 1 => "Taylor Jr HA" 2 => "Rogers WJ." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "fecha" => "Am J Cardiol 1998" "volumen" => "82" "paginaInicial" => "1013" "paginaFinal" => "1018" ] ] ] ] ] ] 25 => array:3 [ "identificador" => "bib26" "etiqueta" => "26" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Health insurance coverage and utilization of health services by Mexican Americans, mainland Puerto Ricans, and Cuban Americans." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "Trevino FM" 1 => "Moyer ME" 2 => "Valdez RB." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "fecha" => "JAMA 1991" "volumen" => "265" "paginaInicial" => "233" "paginaFinal" => "237" "itemHostRev" => array:3 [ "pii" => "S1542356509010829" "estado" => "S300" "issn" => "15423565" ] ] ] ] ] ] ] 26 => array:3 [ "identificador" => "bib27" "etiqueta" => "27" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Community-wide coronary heart disease mortality in Mexican Americans equals or exceeds that in non-Hispanic whites: the Corpus Christi Heart Project." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "Pandey DK" 1 => "Labarthe DR" 2 => "Goff DC." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "fecha" => "Am J Med 2001" "volumen" => "110" "paginaInicial" => "81" "paginaFinal" => "87" ] ] ] ] ] ] 27 => array:3 [ "identificador" => "bib28" "etiqueta" => "28" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Clinical trials and registries in cardiovascular disease: competitive or complementary?." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "Granger CB" 1 => "Gersh BJ." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "fecha" => "Eur Heart J 2010" "volumen" => "31" "paginaInicial" => "520" "paginaFinal" => "521" ] ] ] ] ] ] 28 => array:3 [ "identificador" => "bib29" "etiqueta" => "29" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Are data from clinical registries of any value?." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "Alpert JS." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "fecha" => "Eur Heart J 2000" "volumen" => "21" "paginaInicial" => "1399" "paginaFinal" => "1401" ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/14059940/0000008200000001/v0_201307091008/X1405994012228819/v0_201307091008/en/main.assets" "Apartado" => array:4 [ "identificador" => "14592" "tipo" => "SECCION" "es" => array:2 [ "titulo" => "Investigación clínica" "idiomaDefecto" => true ] "idiomaDefecto" => "es" ] "PDF" => "https://static.elsevier.es/multimedia/14059940/0000008200000001/v0_201307091008/X1405994012228819/v0_201307091008/en/293v82n01a90122881pdf001.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X1405994012228819?idApp=UINPBA00004N" ]
Article information
ISSN: 14059940Original language: English
The statistics are updated each day
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 3 | 1 | 4 |
| 2024 October | 12 | 6 | 18 |
| 2024 September | 13 | 3 | 16 |
| 2024 August | 25 | 4 | 29 |
| 2024 July | 9 | 5 | 14 |
| 2024 June | 12 | 4 | 16 |
| 2024 May | 11 | 7 | 18 |
| 2024 April | 9 | 3 | 12 |
| 2024 March | 22 | 6 | 28 |
| 2024 February | 31 | 6 | 37 |
| 2024 January | 23 | 2 | 25 |
| 2023 December | 25 | 5 | 30 |
| 2023 November | 15 | 4 | 19 |
| 2023 October | 18 | 7 | 25 |
| 2023 September | 13 | 3 | 16 |
| 2023 August | 10 | 4 | 14 |
| 2023 July | 9 | 2 | 11 |
| 2023 June | 12 | 3 | 15 |
| 2023 May | 20 | 9 | 29 |
| 2023 April | 16 | 5 | 21 |
| 2023 March | 9 | 0 | 9 |
| 2023 February | 13 | 4 | 17 |
| 2023 January | 7 | 8 | 15 |
| 2022 December | 22 | 6 | 28 |
| 2022 November | 15 | 8 | 23 |
| 2022 October | 11 | 6 | 17 |
| 2022 September | 9 | 7 | 16 |
| 2022 August | 13 | 5 | 18 |
| 2022 July | 15 | 7 | 22 |
| 2022 June | 5 | 6 | 11 |
| 2022 May | 18 | 8 | 26 |
| 2022 April | 29 | 10 | 39 |
| 2022 March | 11 | 9 | 20 |
| 2022 February | 10 | 2 | 12 |
| 2022 January | 18 | 7 | 25 |
| 2021 December | 15 | 9 | 24 |
| 2021 November | 11 | 13 | 24 |
| 2021 October | 18 | 16 | 34 |
| 2021 September | 8 | 11 | 19 |
| 2021 August | 15 | 8 | 23 |
| 2021 July | 17 | 7 | 24 |
| 2021 June | 25 | 6 | 31 |
| 2021 May | 17 | 6 | 23 |
| 2021 April | 62 | 25 | 87 |
| 2021 March | 25 | 7 | 32 |
| 2021 February | 14 | 4 | 18 |
| 2021 January | 17 | 10 | 27 |
| 2020 December | 17 | 14 | 31 |
| 2020 November | 18 | 9 | 27 |
| 2020 October | 13 | 3 | 16 |
| 2020 September | 12 | 9 | 21 |
| 2020 August | 27 | 8 | 35 |
| 2020 July | 15 | 9 | 24 |
| 2020 June | 8 | 3 | 11 |
| 2020 May | 23 | 16 | 39 |
| 2020 April | 12 | 17 | 29 |
| 2020 March | 18 | 10 | 28 |
| 2020 February | 16 | 7 | 23 |
| 2020 January | 7 | 6 | 13 |
| 2019 December | 28 | 7 | 35 |
| 2019 November | 16 | 6 | 22 |
| 2019 October | 16 | 1 | 17 |
| 2019 September | 20 | 4 | 24 |
| 2019 August | 16 | 1 | 17 |
| 2019 July | 22 | 14 | 36 |
| 2019 June | 33 | 13 | 46 |
| 2019 May | 70 | 9 | 79 |
| 2019 April | 35 | 14 | 49 |
| 2019 March | 7 | 4 | 11 |
| 2019 February | 9 | 9 | 18 |
| 2019 January | 3 | 7 | 10 |
| 2018 December | 5 | 3 | 8 |
| 2018 November | 6 | 3 | 9 |
| 2018 October | 12 | 14 | 26 |
| 2018 September | 35 | 20 | 55 |
| 2018 August | 6 | 4 | 10 |
| 2018 July | 6 | 0 | 6 |
| 2018 June | 5 | 5 | 10 |
| 2018 May | 7 | 4 | 11 |
| 2018 April | 2 | 8 | 10 |
| 2018 March | 11 | 1 | 12 |
| 2018 February | 6 | 1 | 7 |
| 2018 January | 16 | 0 | 16 |
| 2017 December | 5 | 0 | 5 |
| 2017 November | 7 | 1 | 8 |
| 2017 October | 19 | 4 | 23 |
| 2017 September | 6 | 2 | 8 |
| 2017 August | 10 | 0 | 10 |
| 2017 July | 6 | 4 | 10 |
| 2017 June | 8 | 2 | 10 |
| 2017 May | 9 | 3 | 12 |
| 2017 April | 17 | 3 | 20 |
| 2017 March | 14 | 36 | 50 |
| 2017 February | 7 | 3 | 10 |
| 2017 January | 7 | 3 | 10 |
| 2016 December | 11 | 4 | 15 |
| 2016 November | 16 | 4 | 20 |
| 2016 October | 23 | 4 | 27 |
| 2016 September | 17 | 3 | 20 |
| 2016 August | 12 | 3 | 15 |
| 2016 July | 14 | 3 | 17 |
| 2016 June | 46 | 16 | 62 |
| 2016 May | 33 | 8 | 41 |
| 2016 April | 26 | 7 | 33 |
| 2016 March | 28 | 8 | 36 |
| 2016 February | 26 | 10 | 36 |
| 2016 January | 24 | 8 | 32 |
| 2015 December | 24 | 8 | 32 |
| 2015 November | 21 | 4 | 25 |
| 2015 October | 29 | 6 | 35 |
| 2015 September | 29 | 9 | 38 |
| 2015 August | 25 | 4 | 29 |
| 2015 July | 16 | 4 | 20 |
| 2015 June | 23 | 4 | 27 |
| 2015 May | 24 | 2 | 26 |
| 2015 April | 32 | 7 | 39 |
| 2015 March | 26 | 6 | 32 |
| 2015 February | 14 | 1 | 15 |
| 2015 January | 46 | 4 | 50 |
| 2014 December | 62 | 6 | 68 |
| 2014 November | 43 | 4 | 47 |
| 2014 October | 60 | 7 | 67 |
| 2014 September | 49 | 5 | 54 |
| 2014 August | 47 | 2 | 49 |
| 2014 July | 48 | 3 | 51 |
| 2014 June | 37 | 5 | 42 |
| 2014 May | 30 | 2 | 32 |
| 2014 April | 35 | 2 | 37 |
| 2014 March | 78 | 17 | 95 |
| 2014 February | 54 | 8 | 62 |
| 2014 January | 62 | 4 | 66 |
| 2013 December | 57 | 7 | 64 |
| 2013 November | 55 | 7 | 62 |
| 2013 October | 59 | 6 | 65 |
| 2013 September | 42 | 6 | 48 |
| 2013 August | 81 | 7 | 88 |
| 2013 July | 66 | 7 | 73 |
| 2013 June | 16 | 2 | 18 |
| 2013 May | 18 | 2 | 20 |
| 2013 April | 28 | 12 | 40 |
| 2013 March | 16 | 11 | 27 |
| 2013 February | 16 | 9 | 25 |
| 2013 January | 23 | 3 | 26 |
| 2012 December | 16 | 4 | 20 |
| 2012 November | 2 | 2 | 4 |
| 2012 October | 5 | 2 | 7 |
| 2012 September | 3 | 1 | 4 |
| 2012 January | 937 | 0 | 937 |
Show all