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Biomedical subjects

G Permanyer Miralda

Publications and source records attributed to G Permanyer Miralda.

At least 19 recordsLinked to original sources
PubMed1999

[Meta-analysis, megatrials, and clinical practice in cardiology].

One of the factors that raises more scepticism and concern in physicians is the combination of data from different clinical trials. In order to combine the results of different trials three requisites must be followed through: similar treatment, the patients have the same disease, and the main outcome variables must be the same. Publication bias is one important limitation of meta-analysis, and it occurs when studies with negative results are not published, which causes the effect of the treatment to be overestimated. It might seem reasonable that the demonstrated effect in the entire study population with a large sample size could be easily analyzed in different subgroups of patients, getting closer to the prediction of effect in the individual patient. This apparently obvious observation is a fallacy and subgroup analysis is often problematic. Possibly the most important condition in the analysis of subgroups is the definition of the subgroups in the design stage of the study, which can permit an adequate presight of the necessary requisites for the validity of the study. The problem of generalization of the results has been traditionally related with of extrapolation of the results to certain groups of patients not included in the clinical trial. In these cases it is important to consider other nonexperimental epidemiological studies, its internal validity and the consistency of their results. The most important characteristics that differentiate conventional clinical trials from megatrials are the following: megatrials recruit a very large and heterogenous population, with few inclusion and exclusion criteria; the only outcome variable that can be better assessed in these heterogenous conditions is eventually mortality; due to their very large sample size, results are obtained with a high level of precision (very narrow confidence intervals).

Clinical Trials as Topic↗
PubMed1998

[The unequal clinical profile, quality of life and hospital mortality in patients undergoing aortocoronary bypass in the public and private centers of Catalonia. The CIRCORCA Study].

INTRODUCTION AND AIMS: The influence of the type of health care funding and management of hospital centres on hospital mortality in coronary artery bypass surgery (CABG) has not been analyzed in detail. We therefore assessed clinical and quality of life preoperative profiles and in-hospital mortality in public and private patients undergoing coronary bypass surgery in Catalonia. METHODS: Clinical questionnaires, Duke Activity Status Index (DASI) and SF-36 were preoperatively administered to all patients undergoing first coronary bypass surgery without associated procedures in Catalonia between November 1996-June 1997. In-hospital morbidity and mortality were recorded. RESULTS: Predictors of in-hospital death, including DASI, SF-36 and comorbidity scores, were significantly worse in public than in private patients. In-hospital mortality rate was more than ten times greater in public than in private patients (8.2% vs 0.7%; p < 0.001). Multivariate analysis identified private funding of health care, among others, as an independent predictor of in-hospital survival. Non evidence-based indications for surgery were significantly more common in private than in public patients (6% vs 0.7%, p < 0.001). CONCLUSIONS: a) In catalonia, the risk profile of public patients undergoing coronary bypass surgery was significantly higher than that of private patients, accounting, at least in part, for a remarkable mortality difference; b) non evidence-based indications for surgery were more common in private than in public patients; c) these unequal patterns raise questions about the adequacy of care and referral patterns in both private and public sectors.

Aged↗
PubMed1998

[Patients with acute coronary syndrome: therapeutic approach (management patterns) and 1-year prognosis in a tertiary general hospital].

BACKGROUND: To assess the determinants of short-term and one-year prognosis of all patients with suspected acute coronary syndrome seen by the cardiologist on duty in the Emergency Service of a tertiary hospital during a six month period. PATIENTS AND METHODS: 153 consecutive patients with a diagnosis of acute myocardial infarction, 225 with a diagnosis of unstable angina and 89 with a diagnosis of atypical chest pain were identified and their in-hospital characteristics and one-year prognosis were prospectively assessed. RESULTS: Age was higher than 65 years in 53% of acute myocardial infarction and in 54% of unstable angina patients. Only 3 patients were lost to follow-up. 35% of acute myocardial infarction patients had died or had reinfarction after one year and 16% of unstable angina patients had died or had suffered acute myocardial infarction. Baseline features, management patterns and prognosis of patients admitted with acute myocardial infarction to the Cardiology Service, to other hospital areas or to other hospitals were markedly different, and admission in areas other than the Cardiology Service was an independent mortality predictor. In unstable angina, complications happened in patients older than 75 years, those with previous revascularization procedures, those undergoing revascularization or those with lesions not deemed revascularizeable. CONCLUSIONS: a) In the study population there was a predominance of elderly patients; the proportion of patients with poor prognosis was considerably high; b) a sizeable proportion of patients with severe complications was scarcely represented in the major clinical trials; c) the possibility arises of a distribution of care resources tending to concentrate the greater therapeutic efforts in the patients with good prognosis.

Acute Disease↗
PubMed1998

[Impact of biomedical publications on the incorporation of new therapeutic attitudes in cardiovascular pathology].

OBJECTIVE: To evaluate the application degree of results from three clinical trials on cardiovascular pathology in clinical practice: SOLVD trial (in patients with congestive heart failure), SAVE trial (in patients with acute myocardial infarction) and SPINAF trial (in patients with chronic atrial fibrillation). DESIGN: Retrospective cross-sectional study performed in the first six months in 1990 and 1992 (SOLVD trial) and in the first six months in 1991 and 1993 (SAVE trial) admitted to the Consorci Hospitalari del Parc Taulí, and a cross-sectional study in a single randomized sample of all patients with the discharge diagnosis of atrial fibrillation at Hospital Vall d'Hebron during 1994. An absolute increase of 23% and 19% in the prescription of ACEI agents was observed for patients with heart failure and myocardial infarction, respectively. Forty-eight percent of patients with atrial fibrillation received antithrombotic therapy, which included aspirin and acenocoumarine for 51% and 49% of cases, respectively.

Aged↗
PubMed1997

[Assessment of quality of life related to health 2 years after coronary surgery].

BACKGROUND: The determinants of quality of life after coronary artery surgery in well defined health care populations are still incompletely understood. The aim of the present study was to assess the health related quality of life associated with coronary artery bypass surgery as performed in a tertiary public hospital, and also to investigate its association with clinical variables. PATIENTS AND METHODS: All survivors of a first coronary artery bypass grafting operation performed during a calendar year in a single center (100 patients) were included for assessment two years after surgery. Assessment included a review of the clinical records, a structured clinical interview and the administration of three questionnaires of perceived health (Nottingham Health Profile, Duke Activity Status Index and SF-36 Health Survey). RESULTS: The mean scores of the administered questionnaires corresponded to a moderate overall impairment of perceived health, with wide individual variations. Chronic stable postoperative angina pectoris (28% of patients), worse clinical functional grade (either due to angina or to others causes), comorbidity (51% of patients) and female sex were significantly associated with worse scores. CONCLUSIONS: In the study population, postoperative angina, impairment of the clinical functional grade (due to angina or to other conditions), and female gender were the major determinants of impaired health related quality of life after coronary artery bypass surgery. As such determinants are associated with anatomoclinical variables in the population undergoing coronary bypass surgery and also with perioperative variables, appropriate effectively studies appear to be indicated for the assessment of this surgical procedure.

Aged↗
PubMed1995

[The postinfarct prognostic value of right ventricular systolic function].

BACKGROUND: Right ventricular extension of inferior myocardial infarction has been shown to be a predictor of poor prognosis during the acute phase. However, it is not known whether right ventricular dysfunction predicts long term complications. The aim of the present study was to assess whether right ventricular ejection fraction is also a predictor of poor prognosis during the first five follow-up years. METHODS: Ninety-eight consecutive patients (age < or = 65 years) with acute noncomplicated myocardial infarction (49 anterior and 49 inferior) were evaluated before hospital discharge. In all of them the ejection fraction of both ventricles was evaluated with radionuclide ventriculography at rest and during submaximal exercise. All patients were clinically followed up for at least 5 years. The prognostic relevance of right and left ventricular function for the prediction of all complications and severe complications was assessed using univariate and multivariate analysis. RESULTS: After 5 years, 66 patients had 94 complications (angina in 44, heart failure in 21, reinfarction in 10, revascularization procedures in 11, death in 6). In the univariate analysis, resting right ventricular ejection fraction was significantly lower in patients with inferior infarction and severe complications at one year (32 +/- 12% vs 38 +/- 6%, p = 0.03). However, in multivariate analysis only resting left ventricular ejection fraction was predictive of complications at 5 years (odds ratio 5.93, 95% confidence interval = 1.32-26.6). Statistical results did not change when the ejection fraction of both ventricles during submaximal exercise was considered. CONCLUSIONS: Although right ventricular ejection fraction, measured before hospital discharge, is predictive of complications at five years in inferior infarctions, multivariate analysis shows that it does not add prognostic information to the measurement of left ventricular ejection fraction in patients with uncomplicated acute myocardial infarction, either anterior or inferior.

Chi-Square Distribution↗
PubMed1995

[Acute myocardial infarct and Friedreich's disease].

The association between Friedreich's ataxia and heart disease is well known. Microvascular disease and spasm of coronary arteries have been reported. We report now a patient with the association between this disease and acute myocardial infarction, which raises the hypothesis that it may be related with the already known cardiac abnormalities in this disease.

Cardiac Catheterization↗
PubMed1993

[A cost-effectiveness analysis of prognostic studies in acute uncomplicated myocardial infarct].

INTRODUCTION AND OBJECTIVES: The prognostic assessment of the acute myocardial infarction may be obtained through clinical criteria, particularly in patients who are symptomatic during admission, or with several studies in patients without complications. The "effectiveness" of such investigations has been long studied, but not so their "efficiency", which analyses the relationships between costs and outcomes. The goal of the present study is to report the results of a cost-effectiveness analysis of various combinations of diagnostic tests. METHODS: One hundred and fifteen patients (age < 65) with uncomplicated first acute myocardial infarction were evaluated. In all patients exercise test, two-dimensional echocardiogram thallium-201 scintigraphy, radionuclide ventriculography, Holter monitoring and cardiac catheterization were performed. The effectiveness was calculated as the "global value" (rate of correctly diagnosed patients: complications prediction during the first year follow-up) of every of such tests combinations. We have used the direct differential costs estimated following the "Colegio Oficial de Médicos de Barcelona" standards. The index used in the cost-effectiveness analysis was the medium cost person/global value. The lowest index corresponded to the most efficient test combination. RESULTS: The highest effectiveness was found for the exercise test plus bidimensional echocardiography combination (global value = 0.64). At the same time it was the less expensive combination (medium cost = 14.444 ptas); therefore, its index was the lowest (21.724 ptas/patient). CONCLUSIONS: In patients with a first uncomplicated myocardial infarction, the performance of exercise test and echocardiogram is the less costly and most effective combination of studies for one year prognosis. In these patients, routine cardiac catheterization does not improve the results.

Chi-Square Distribution↗
PubMed1993

[An analysis of the responses to the tilt-table test depending on the clinical characteristics of the syncopal episodes in patients without apparent cardiopathy].

Seventy-six consecutive patients were evaluated to assess whether the response to head-up tilt test was related to the type of clinical presentation in patients with syncope of unknown origin and free from heart disease. The syncopal attacks were clinically characterized in a prospective fashion before the tilt test. In 44 patients (group I) syncope had been preceded by autonomic symptoms or was associated with recent or static sustained orthostatism. In 32 patients (group II), syncope had been sudden, without prodromal or autonomic symptoms. Mean age was 49 +/- 17 years in group I patients and 47 +/- 17 years in group II patients (NS). The degree of tilt was 75 degrees. During 30 min no drugs were administered, and then isoproterenol was infused for an additional 20 min (1-5 micrograms/min until a maximal heart rate of 140 bpm was achieved). Tilt test was considered as positive when the patient developed syncope or presyncope with hypotension. Tilt test was positive in 33 patients from group I (75%) and 12 from group II (37.5%)(p = 0.001). The positive response developed within the 30 initial min of the test (without isoproterenol infusion) in 19 of 33 patients from group I (57%) and in 3 of 12 patients from group II (25%) (p = 0.053). It is concluded that the response to tilt test is related to the clinical features of syncopal attacks.

Adult↗
PubMed1992

Ventricular arrhythmias in aortic valve disease: a further marker of impaired left ventricular function.

One hundred and twenty stable patients with pure and severe aortic valve disease and without coronary lesions (aortic stenosis, 43 patients; aortic regurgitation, 45 patients; combined aortic stenosis and regurgitation, 32 patients) who had been submitted to haemodynamic studies were prospectively studied with standard electrocardiograms, M-mode echocardiograms, and 24-hour ambulatory electrocardiography (Holter recording). The frequency and complexity of ventricular arrhythmias were related to clinical parameters such as functional class, type of lesion and presence of syncope, and to parameters of left ventricular hypertrophy and function. Ventricular arrhythmias were present in 92% of patients. A high number of ventricular premature beats was directly correlated with parameters of complexity of the arrhythmia. A significant relation was found between electrocardiographic left ventricular hypertrophy and Ryan class (P less than 0.05), and an inverse relation between maximal number of ventricular premature beats in any hour and left ventricular ejection fraction (P less than 0.05). The group of patients with aortic regurgitation showed a higher total number of ventricular premature beats per 24 hours (P less than 0.001), a higher maximal number of these in any hour (P less than 0.01), a higher number of patients with pairs (P less than 0.001), and a higher number of patients in Ryan classes 3, 4A, 4B (P less than 0.01). This study shows a high incidence of ventricular arrhythmias in aortic valve disease, and especially in aortic regurgitation, with a significant relation between left ventricular hypertrophy and function, and number and complexity of arrhythmias.

Adult↗
PubMed1990

[Electrical cardioversion after quinidine administration].

The aim of the present study was to investigate the influence of quinidine on the effectiveness of electrical cardioversion (CV) for the reversion of supraventricular arrhythmias, the amount of electrical energy necessary for the CV and the possible complications of electrical CV. Initially, 100 CV procedures were allocated to the control group (patients free from the action of any antiarrhythmic drug), and 50 CV to the quinidine group. Quinidine was given as dihydroquinidine C1H at a dose of 500 mg/12 hours since the day before CV. In the last group, 6 (12%) patients reverted to normal sinus rhythm before electrical CV. At the time of electrical CV (100 procedures in the control group and 44 in the quinidine group), the patients who received quinidine required a lower amount of electrical energy, and showed a lower incidence of atrial premature beats as compared with the control group (11.3% versus 28%, p less than 0.05). A similar proportion of patients reverted to sinus rhythm in both groups. We conclude that the administration of quinidine before electrical CV has the following advantages: 1) 12% of patients reverted to normal sinus rhythm before electrical CV; 2) quinidine reduced the amount of electrical energy necessary for the CV, and 3) quinidine reduced the incidence of atrial premature beats after electrical CV. On the other hand, quinidine had no influence on the incidence of ventricular arrhythmias after electrical CV.

Adult↗