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Vol. 58. Issue 4.
Pages 457-458 (April 2005)
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Vol. 58. Issue 4.
Pages 457-458 (April 2005)
DOI: 10.1016/S1885-5857(06)60679-8
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Invasive Treatment of Non-ST-Segment Elevation Acute Coronary Syndrome: Is There More Than One Real World?
Estrategia invasiva en el síndrome coronario agudo sin elevación del segmento ST: ¿hay más de un mundo real?
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Jesús M de la Heraa, César Morisb, Vicente Barrialesb
a Unidad de Cardiología, Hospital Carmen y Severo Ochoa, Cangas del Narcea, Asturias, Spain.
b Servicio de Cardiología, Hospital Universitario Central
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We have read with great interest Bodí et al's recent original article1 drawing us closer to the real world of non-ST elevation acute coronary syndrome (NSTE ACS). However, it should not be forgotten that the authors belong to a research team with great interest and a long tradition in the stratification of NSTE ACS,2 that they work in a university hospital with a cardiac catheterization laboratory and that, in fact, there may well be more than one real world.

In this respect, we present data from a provincial hospital (with no on-duty cardiologist or specific intensive cardiac care unit) that is interested in improving the quality of performance in dealing with NSTE ACS.3 In line with Spanish Cardiology Society clinical practice guidelines,4 this hospital introduced a protocol of invasive management for the subgroup of high risk NSTE ACS patients. During 2003, we received 30 such patients (pain, electrocardiographic changes and troponin elevation) with an average age of 72±12 years (vs 69±12 years in Bodí et al). We prescribed antiplatelet agents in 96.6% of patients (vs 96%), a combination of aspirin and clopidogrel in 86.6%, anticoagulants in 86.6% (vs 89%) and glycoprotein IIb/IIIa inhibitors in 43.3% (vs 41%). Coronary angiography was performed on 46.6% (vs 73%) and 30% (vs 48%) underwent revascularization, with in-hospital mortality of 13.3% (vs 4%).

Clearly, by comparison with Bodí et al,1 these data are different. However, the 2 teams were "willing to invade" in dealing with these patients. We believe the principal motive for the difference lies in the availability of an on-site cardiac catheterization laboratory5 although other factors might be the type of hospital and clinical service attending these patients,6 the older age range of our group7 and, even, different interpretations of the guidelines attributable to the idiosyncrasies of each hospital (Bodí et al only start to use glycoprotein IIb/IIIa inhibitors in the cardiac catheterization laboratory whereas in our hospital they are used from the time of admission).

Finally, we wish to congratulate Bodí et al for presenting their results to the scientific community. It is interesting to confirm in the real world what randomized studies have previously validated even though, as we have demonstrated, different results are possible in different contexts. This, together with differences in access to coronary intervention services8 (where one Spanish autonomous region may have twice the resources of another), leads us to conclude that patients with NSTE ACS receive a far-from-homogeneous attention across the country. Strategies such as the Ministry of Health and Consumer Affairs' Integrated Plan for Ischemic Heart Disease9 can help improve the current situation.

Bibliography
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Bodí V, Sanchis J, Llácer A, Fácila L, Núñez J, Pellicer M, et al..
Estrategia invasiva en el síndrome coronario agudo sin elevación del segmento ST. De los grandes estudios al mundo real..
Rev Esp Cardiol, 57 (2004), pp. 1143-50
[2]
Sanchis J, Bodí V, Llácer A, Fácila L, Núñez J, Bertomeu V, et al..
Uselfulness of concomitant myoglobin and troponin elevation as biochemical marker of mortality in non-ST-segment elevation acute coronary syndromes..
Am J Cardiol, 91 (2003), pp. 13-6
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Hospital comarcal e infarto agudo de miocardio: la mejora de la calidad es posible [abstract]. Rev Esp Cardiol. 2004; 57 Supl 2:44.
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López Bescós L, Arós F, Lidón RM, Cequier A, Bueno H, Alonso JJ, et al..
Actualización (2002) de las guías de práctica clínica de la Sociedad Española de Cardiología en angina inestable/infarto sin elevación del segmento ST..
Rev Esp Cardiol, 55 (2002), pp. 631-42
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de la Hera JM, Barriales V, Moris C, Álvarez JA, Rubín J, Barriales-Villa R, et al..
Registro del infarto de miocardio en Asturias: Proyecto RIMAS..
Med Clin (Barc), 123 (2004), pp. 169-73
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Bosch X, Verbal F, López de Sá E, Miranda-Guardiola F, Bórquez E, Bethencourt A, et al..
Diferencias en el tratamiento y la evolución clínica de los pacientes con síndrome coronario agudo sin elevación del segmento ST en función del servicio clínico de ingreso..
Rev Esp Cardiol, 57 (2004), pp. 283-90
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Bermejo J, López de Sá E, López-Sendón JL, Pabón P, García E, Bethencourt A, et al..
Angina inestable en el anciano: perfil clínico, manejo y mortalidad a los tres meses. Datos del registro PEPA..
Rev Esp Cardiol, 53 (2000), pp. 1564-72
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López-Palop R, Moreu J, Fernández-Vazquez F, Hernández-Antolín R..
Registro Español de Hemodinámica y Cardiología Intervencionista. XIII Informe Oficial de la Sección de Hemodinámica y Cardiología Intervencionista de la Sociedad Española de Cardiología (1990-2003)..
Rev Esp Cardiol, 57 (2004), pp. 1076-89
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Disponible en: www.msc. es/planesIntegrales/PICI/pdf/cardiopatia.pdf
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Revista Española de Cardiología (English Edition)

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