We have read carefully and with special interest the article by Mate Redondo et al.1 published in Revista Española de Cardiología on the in-hospital mortality of acute myocardial infarction in the Canary Islands. In relation to this article, we would like to make some comments. As noted by the authors, cardiovascular mortality in the Canary Islands is one of the highest in Spain. However, from our point of view, even more worrying is the slight incremental trend (27.08%) vs previous years.2–4 This tendency is the opposite of what is seen on a national scale.
Probably at least partly due to the origin and characteristics of the data, the study by Mate Redondo et al.1 did not describe variables such as the characteristics of the hospital and the department in charge of the treatment, as well as whether revascularization therapy was applied or not, the type of revascularization, and the delay until treatment. These factors markedly affect patient prognosis. The RECALCAR trial5 showed that hospital characteristics, treatment in a cardiology unit, and percutaneous coronary intervention are associated with the in-hospital survival of patients with acute myocardial infarction.
Due to the geographical peculiarities of the Canarian archipelago, the management of acute coronary syndrome and access to revascularization therapies differ considerably among islands, particularly between capital and noncapital cities. During the study period of the article by Mate Redondo et al.,1 primary angioplasty was not systematically performed in the archipelago for ST-segment elevation acute myocardial infarction (STEMI), given that the Canarian Infarction Code (CODICAN) was only implemented in July 2018. This delay could be related to the excess mortality due to acute myocardial infarction observed in the Canary Islands. Several studies have shown a significant reduction in STEMI mortality and have improved prognosis after the establishment of care networks for its management.6,7
In fact, in the Canary Islands, the rates of poor dietary patterns, obesity, and diabetes mellitus are several percentage points higher than the Spanish average, with a consequent higher incidence of cardiovascular disease. These findings are also confirmed in the Acute Coronary Syndrome Registry, promoted by the Canarian Society of Cardiology prospectively in several hospitals of the autonomous community from 2015 to 2016, which included more than 500 patients. According to the data from this registry, the Canarian diabetic population had higher mortality in the whole patient sample (ST-segment elevation and non–ST-segment elevation infarctions): 8.3% of in-hospital mortality in the diabetic population vs 3.5% in the nondiabetic population (P=.021). Patients who received mechanical revascularization (primary, delayed, or rescue) had lower mortality vs nonrevascularized patients (7.1% vs 3.3%, P=.037). This difference was even more pronounced upon analysis of the STEMI population because those who did not receive primary revascularization had higher mortality (17.9% vs 4.5%, P=.002), whether diabetic or not. However, patients with STEMI who were diabetic showed slightly but nonsignificantly higher mortality vs nondiabetics (12.5% vs 6%, P=.055).8
Regardless of the implementation of health policies aimed at the primary prevention of cardiovascular disease through lifestyle modifications and control of risk factors, particularly diabetes, a new analysis would be appropriate to determine the changes wrought in the Canarian population by implementation of a “Canarian infarction code”.
