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Vol. 68. Issue 2.
Pages 163 (February 2015)
Vol. 68. Issue 2.
Pages 163 (February 2015)
Letter to the Editor
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DIOCLES: Some Caveats and New Questions
DIOCLES: algunos matices y nuevas preguntas
Fernando Rosell-Ortiza,
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Corresponding author:
, Francisco Mellado-Vergelb, Javier García del Águilaa
a Empresa Pública de Emergencias Sanitarias de Andalucía, Málaga, Spain
b Servicio de Urgencias, Hospital El Toyo, Almería, Spain
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To the Editor,

We have carefully read the much-anticipated publication of the findings of the DIOCLES project.1 The results show an encouraging general improvement in the mortality rates for acute coronary syndrome in Spain, although some points require clarification.

The increase in the number of patients who reach hospital via out-of-hospital emergency medical services is a positive finding and is reassuring for patients. We know that up to 8% of patients manage to reach hospital despite ventricular fibrillation when they are attended by an out-of-hospital emergency medical team2 as the first medical contact. However, the mortality rate for ST-elevation myocardial infarction in DIOCLES (6.4%) should be combined with a mortality rate of at least 2% in the prehospital care phase, understood to be the period from when the patient calls the out-of-hospital emergency medical team until transfer to the destination hospital.2

It would also be interesting to know whether mortality, at least in the case of ST-elevation myocardial infarction, differs according to the level of care offered by the recipient hospital, as this has been shown to be a prognostic factor in these patients.3,4 It seems reasonable to suppose that this is the case and that the availability of primary angioplasty would be a determining factor, although pharmacoinvasive strategies,5,6 with early referral to a hospital with interventional capabilities, may place smaller hospitals at a similar level to referral hospitals in terms of mortality. Such a finding would be relevant and encouraging, and may enable the implementation of feasible strategies in areas where it is particularly difficult to maintain 24-hour primary angioplasty programs.7 Such a finding would also require us to reflect on the worrying fact that a high percentage of thrombolysis in Spain is still applied in intensive care units. Early thrombolysis could be a good treatment.8 When performed too late after the first medical contact, it is a serious problem for the health system. If, in addition, the first medical contact in these cases is an out-of-hospital emergency medical team, it is important that the DIOCLES findings clarify this point.

A third aspect, not well reflected in other registries, is the prognosis of patients with suspected acute coronary syndrome. Some studies suggest that these patients receive different care, probably of a lower quality, which along with the associated comorbidities may lead to the worse prognosis shown in DIOCLES.9 The composition of this group is particularly noteworthy, with many more women and a higher mean age. This group requires special care and only data from clinical practice can bring this to light.

One last reflection is related to the possible adjustment and comparison of data between a prospective study with a meticulous methodology, such as DIOLCES, and results based on administrative databases, as is the case of the RECALCAR reports.10 It would be helpful to know whether the differences, which are essentially inequalities, that the RECALCAR reports found among autonomous regions can also be detected in the DIOCLES results.

J.A. Barrabés, A. Bardají, J. Jiménez-Candil, F. del Nogal Sáez, V. Bodí, N. Basterra, et al.
Pronóstico y manejo del síndrome coronario agudo en España en 2012: estudio DIOCLES.
Rev Esp Cardiol., 68 (2015), pp. 98-106
F. Rosell-Ortiz, F.J. Mellado-Vergel, P. Fernández-Valle, I. González-Lobato, M. Martínez-Lara, M. Ruiz-Montero, et al.
Initial complications and factors related to prehospital mortality in acute myocardial infarction with ST segment elevation.
Emerg Med J., (2014),
A. Reina Toral, M. Colmenero Ruiz, C. García Pérez, M. Expósito Ruiz, E. de Antonio Martín, C. Bermúdez Tamayo, et al.
Diferencias en los resultados de la atención a los pacientes con síndrome coronario agudo con elevación del segmento ST (SCACEST) en función del acceso inicial a hospitales con o sin sala de hemodinámica en Andalucía.
Emergencias., 26 (2014), pp. 101-108
V. Bertomeu, A. Cequier, J.L. Bernal, F. Alfonso, M.P. Anguita, J. Muñiz, et al.
Mortalidad intrahospitalaria por infarto agudo de miocardio. Relevancia del tipo de hospital y la atención dispensada. Estudio RECALCAR.
Rev Esp Cardiol., 66 (2013), pp. 935-942
P.W. Armstrong, A.H. Gershlick, P. Goldstein, R. Wilcox, T. Danays, Y. Lambert, for the STREAM Investigative Team, et al.
Fibrinolysis or primary PCI in ST-segment elevation myocardial infarction.
N Engl J Med., 368 (2013), pp. 1379-1387
N. Danchin, E. Puymirat, P.G. Steg, P. Goldstein, F. Schiele, L. Belle, on behalf of the FAST-MI 2005 Investigators, et al.
Five-Year Survival in Patients With ST-Segment-Elevation Myocardial Infarction According to Modalities of Reperfusion Therapy The French Registry on Acute ST-Elevation and Non-ST-Elevation Myocardial Infarction (FAST-MI) 2005 Cohort.
Circulation., 129 (2014), pp. 1629-1636
N. Danchin, N. Dos Santos Teixeira, E. Puymirat.
Limitaciones de los programas regionales de angioplastia coronaria primaria: ¿la estrategia farmacoinvasiva todavía es una alternativa?.
Rev Esp Cardiol., 67 (2014), pp. 659-665
N.D. Maleki, F. van de Werf, P. Goldstein, J.A. Adgey, Y. Lambert, V. Sulimov, et al.
Aborted myocardial infarction in ST-elevation myocardial infarction: insights from the STrategic Reperfusion Early After Myocardial infarction trial.
Heart., (2014 Jun 10),
M. Sánchez, J. Vázquez, R. Temboury, C. Capdepon, J. Povar, M. Santaló.
El síndrome coronario agudo inclasificable en los servicios de urgencias españoles. Aportaciones del registro MUSICA.
Emergencias., 25 (2013), pp. 263-267
Sociedad Española de Cardiología. Registro RECALCAR. La atención al paciente con cardiopatía en el Sistema Nacional de Salud. Recursos, actividad y calidad assistencial. Informe 2013 [accessed 28 July 2014]. Available at:
Copyright © 2014. Sociedad Española de Cardiología
Revista Española de Cardiología (English Edition)

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