Phenotypic clustering of patients hospitalized in intensive cardiac care units: Insights from the ADDICT-ICCU study.

BACKGROUND: Intensive cardiac care units (ICCUs) were created to manage ventricular arrhythmias after acute coronary syndromes, but have diversified to include a more heterogeneous population, the characteristics of which are not well depicted by conventional methods. AIMS: To identify ICCU patient subgroups by phenotypic unsupervised clustering integrating clinical, biological, and echocardiographic data to reveal pathophysiological differences. METHODS: During 7-22 April 2021, we recruited all consecutive patients admitted to ICCUs in 39 centers. The primary outcome was in-hospital major adverse events (MAEs; death, resuscitated cardiac arrest or cardiogenic shock). A cluster analysis was performed using a Kamila algorithm. RESULTS: Of 1499 patients admitted to the ICCU (69.6% male, mean age 63.3±14.9 years), 67 (4.5%) experienced MAEs. Four phenogroups were identified: PG1 (n=535), typically patients with non-ST-segment elevation myocardial infarction; PG2 (n=444), younger smokers with ST-segment elevation myocardial infarction; PG3 (n=273), elderly patients with heart failure with preserved ejection fraction and conduction disturbances; PG4 (n=247), patients with acute heart failure with reduced ejection fraction. Compared to PG1, multivariable analysis revealed a higher risk of MAEs in PG2 (odds ratio [OR] 3.13, 95% confidence interval [CI] 1.16-10.0) and PG3 (OR 3.16, 95% CI 1.02-10.8), with the highest risk in PG4 (OR 20.5, 95% CI 8.7-60.8) (all P<0.05). CONCLUSIONS: Cluster analysis of clinical, biological, and echocardiographic variables identified four phenogroups of patients admitted to the ICCU that were associated with distinct prognostic profiles. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT05063097.

The SYNERGY II Everolimus elutiNg stent In patients Older than 75 years undergoing coronary Revascularisation associated with a short dual antiplatelet therapy (SENIOR) trial: rationale and design of a large-scale randomised multicentre study.

AIMS: In the elderly population, bare metal stents (BMS) are often preferred over drug-eluting stents (DES) because of the longer duration of dual antiplatelet therapy (DAPT) associated with the latter. The SENIOR trial is designed to determine whether one of the latest generation of DES can reduce major cardiovascular events compared to BMS, despite a similar short DAPT duration. METHODS AND RESULTS: The SENIOR trial is a multicentre, single-blind, prospective, randomised trial comparing the latest generation DES (SYNERGY™ II; Boston Scientific, Marlborough, MA, USA) to BMS (Rebel™; Boston Scientific) in 1,200 patients ≥75 years old. DAPT will be given for one or six months according to clinical presentation, irrespective of stent type. The primary outcome is the composite of all-cause mortality, non-fatal myocardial infarction, stroke or ischaemia-driven target lesion revascularisation at one year. Secondary endpoints include the rate of major bleedings and the rate of stent thrombosis at one year. CONCLUSIONS: This trial is designed to evaluate a new revascularisation strategy combining DES and short duration DAPT in elderly patients. It has the potential to decrease the need for target lesion revascularisation without a significant DAPT-related increase in bleeding compared to BMS.

Discharge heart rate and mortality after acute myocardial infarction.

BACKGROUND: We aimed to describe the determinants of discharge heart rate in acute coronary syndrome patients and assess the impact of discharge heart rate on 5-year mortality in hospital survivors. METHODS: French Registry of Acute ST-Elevation or non-ST-elevation Myocardial Infarction (FAST-MI) 2005 is a nationwide French registry that included all consecutive patients with acute myocardial infarction over 1 month in 223 institutions in 2005. Discharge heart rate was recorded in 3079 patients discharged alive; all had 5-year follow-up. Logistic regression was used to detect predictors of high heart rate at discharge. Cox's proportional hazards model was used to assess the hazard ratio for mortality at 5 years. Heart rate was categorized into 4 groups by quartiles (<60, 61-67, 68-75, >75 beats per minute). High heart rate was defined as ≥75 beats per minute. Landmark analysis was performed at 1 year. RESULTS: Independent predictors of heart rate ≥75 beats per minute at discharge were female sex, ST-segment elevation myocardial infarction, diabetes, chronic obstructive pulmonary disease, bleeding/transfusion during hospitalization, left ventricular dysfunction, renal dysfunction, and prescription (type, but not dose category) of beta-blockers at discharge. Discharge heart rate was significantly related to mortality at 1 year (hazard ratio 1.13; 95% confidence interval, 1.03-1.24 per 10 beats per minute, P = .02); this was confirmed by landmark analysis, with a 39% increase (hazard ratio 1.39; 95% confidence interval 1.05-1.84) in the risk of 1-year death for discharge heart rate ≥75 beats per minute vs <75 beats per minute. This relationship was no longer significant between 2 and 5 years. CONCLUSIONS: After acute myocardial infarction, patients discharged with high heart rate (≥75 beats per minute) are at higher risk of death during the first year, but not later, irrespective of beta-blocker use.

How to limit radial artery spasm during percutaneous coronary interventions: The spasmolytic agents to avoid spasm during transradial percutaneous coronary interventions (SPASM3) study.

AIMS: To compare the efficacy of three vasodilators in preventing radial artery spasm (RAS) in patients undergoing transradial percutaneous coronary interventions (PCI). METHODS AND RESULTS: 731 patients were randomized to receive diltiazem 5 mg, verapamil 2.5 mg, or isosorbide dinitrate (ISDN) 1 mg before coronary intervention. RAS occurred in 20.1% in the whole population and was significantly reduced by verapamil and ISDN compared to diltiazem (16.2, 17.2, and 26.6%, respectively; P < 0.006). There was also a trend towards less severe pain (more than 8 on a numerical scale from 0 [no pain] to 10 [maximal pain]), and less severe RAS (complete catheter blockage or severe pain), among patients treated by verapamil compared to ISDN and diltiazem (1.3% vs. 2.8% vs. 2.9%, P = 0.43 and 5.1% vs. 6.2% vs. 9.5%, respectively, P = 0.13). No difference was found between the three vasodilators in terms of crossover or safety events. Female gender, failure at first attempt to access the radial artery, emergency procedures, and the use of diltiazem were independent predictors of RAS. CONCLUSION: Verapamil and ISDN considerably reduce the incidence of RAS compared to diltiazem during transradial PCI.

Comparison of bleeding complications and one-year survival of low molecular weight heparin versus unfractioned heparin for acute myocardial infarction in elderly patients. The FAST-MI registry.

BACKGROUND: There are limited data on the safety and efficacy of low molecular weight heparin (LMWH) in elderly patients with acute myocardial infarction (AMI). METHODS: We aimed to compare LMWH with unfractioned heparin (UFH) in the management of AMI in elderly patients. FAST-MI is a nationwide registry carried out over a 1-month period in 2005, including consecutive patients with AMI admitted to intensive care unit <48 h from symptom onset in 223 participating centers. We assessed the impact of LMWH on bleeding, the need for blood transfusion and one-year survival in elderly patients (≥ 75 years). RESULTS: 963 patients treated with heparin were included (mean age 82 ± 5 years; 51% women; 42.5% ST-elevation myocardial infarction). Major bleeding (2.4% vs. 6.1%, P=0.004) and blood transfusions (4.6% vs. 9.7%, P=0.002) were significantly less frequent with LMWH compared with the UFH, a difference that persisted after multivariate adjustment (OR=0.41, 95% CI: 0.20-0.83 and OR=0.49, 95% CI: 0.28-0.85, respectively). One-year survival and stroke and reinfarction-free survival were also significantly higher with LMWH compared with UFH (OR=0.66, 95% CI: 0.50-0.85 and OR=0.71, 95% CI: 0.56-0.91, respectively). In two cohorts of patients matched on a propensity score for getting LMWH and with similar baseline characteristics (328 patients per group), major bleeding and transfusion were significantly lower while one-year survival was significantly higher in patients receiving LMWH. CONCLUSIONS: The present data show that in elderly patients admitted for AMI, use of LMWH is associated with less bleeding, less need for transfusion, and higher survival, compared with the use of UFH.

Percutaneous left ventricular assistance in post cardiac arrest shock: comparison of intra aortic blood pump and IMPELLA Recover LP2.5.

AIM: To compare the feasibility, safety and outcome of IMPELLA Recover LP2.5 cardiac assistance and intra aortic balloon pump (IABP) in patients with post-cardiac arrest shock. BACKGROUND: The high early mortality rate of post-cardiac arrest patients is attributed to a "post cardiac arrest syndrome" characterized by an acute and transient left ventricular (LV) systolic dysfunction. LV assistance with IMPELLA Recover LP2.5 is proposed in most severe patients. METHODS: Retrospective single center registry from January 2007 to October 2010. All survivors of out-of-hospital cardiac arrest with patent or predictive factors for the occurrence of post-resuscitation shock assisted by either IMPELLA or intra aortic balloon pump (IABP) device immediately after the coronary angiogram were included. RESULTS: 78 post-cardiac arrest patients were assisted by one of the devices (35 by IMPELLA and 43 by IABP). Median "no flow" and median "low flow" were similar at admission as were hemodynamic parameters. The feasibility of IMPELLA implantation was good (97%). At 28 days, the survival rate without sequellae was 23.0% in the IMPELLA and 29.5% in the IABP group (p=0.61). Vascular complications were observed equally in both groups (3 vs. 2, p=0.9). Serious bleeding complications occurred in 26% of IMPELLA patients vs. 9% of IABP patients (p=0.06). CONCLUSION: Early LV assistance by the IMPELLA LP2.5 is feasible in patients with post-resuscitation shock. The rate of complications did not differ substantially in the two groups, except for a trend toward a higher rate of bleeding events with IMPELLA. These encouraging findings must be confirmed in a larger clinical study.

Performance assessment of a chest pain unit: Preliminary 2-year experience in the European Georges Pompidou Hospital.

BACKGROUND: Chest pain units (CPUs) are very popular in the USA for the triage of low-to-intermediate-risk chest pains. However, CPUs do not yet exist in France. AIMS: To determine the prevalence and clinical characteristics of patients admitted to a new CPU in France, and to assess the quality of care with regard to identification and exclusion of an acute coronary syndromes (ACS). METHODS: This prospective study included 906 consecutive patients with non-traumatic chest pain admitted to our CPU between September 2006 and August 2008. Patients were managed according to their probability of presenting with an ACS. Clinical characteristics, diagnostic tests, final diagnosis, destination and length of stay were recorded. We also assessed the 30-day outcome of patients in whom an ACS was excluded. RESULTS: Of the 906 patients, 27.9% had an ACS (1.3% with and 26.6% without ST-segment elevation, respectively). Non-ischaemic cardiac aetiologies and non-cardiac aetiologies were found in 123 (12.6%) and 63 (7.0%) patients, respectively. A final diagnosis of chest pain of undetermined origin was made in 51.5% of patients; among these, 17 (6.5%) patients were re-admitted to the CPU between September 2006 and September 2007. Thirty-day follow-up revealed that only one patient had subsequent confirmation of coronary artery disease requiring further hospitalization. CONCLUSIONS: This prospective study reports the first experience of a CPU in a cardiology department in France. Our preliminary results suggest that our CPU can exclude an ACS safely. Further studies are warranted to assess the value of CPUs in France.

Impact of purely internal thoracic artery T-graft technique on the mode and quality of surgical myocardial revascularization evaluated by early postoperative coronary angiography.

BACKGROUND: The use of the internal thoracic artery for coronary artery bypass has improved the results of such surgery. However, bypass using only the internal thoracic arteries sometimes requires a T-graft. This purely internal thoracic artery T-graft technique has progressively become part of our surgical protocol for coronary artery bypass surgery. AIMS: The aim of the study was to analyse the impact of this surgical technique on the degree and quality of coronary revascularization using early postoperative angiography. METHODS: Between January 2004 and December 2006, 148 patients underwent coronary artery bypass surgery exclusively using both internal thoracic arteries in a T-graft configuration. Systematic postoperative angiography was offered to all 148 patients; it was accepted by 108 patients and refused by 40 patients. RESULTS: There were no statistically significant differences between the two groups. In-patient mortality was 2.02% (n=3) for the whole population studied, and 1.49% (n=2) for the 134 patients who received only coronary artery bypass grafts. The revascularization rate was 89% and 3.46 coronary anastomoses were constructed per patient (range 2-6). Angiography was performed on 108 right internal thoracic artery to left internal thoracic artery anastomoses, 374 anastomoses of internal thoracic arteries to coronary arteries and 382 inter-anastomosis segments: 98% of the anastomoses and segments were patent. CONCLUSION: The exclusive recourse to the purely internal thoracic artery T-graft technique meant that it has been possible to dispense with other types of graft while achieving complete and effective revascularization of the coronary artery.

[Combination therapy at hospital discharge in the USIC 2000 survey]. / Les associations thérapeutiques a la sortie de l'hôpital dans l'enquête USIC 2000 : corrélations avec la survie a un an.

UNLABELLED: We tried to determine the prognostic impact of triple (antiplatelet agents, statins and beta-blockers) and quadruple (the same+ACE inhibitors) combination therapy at hospital discharge after acute myocardial infarction. The USIC 2000 survey is nationwide registry of consecutive patients admitted to intensive care units for acute myocardial infarction in November 2000 in France. Of the 2119 patients discharged alive, 1095 (52%) were prescribed a combination of antiplatelet agents, beta-blockers and statins (triple therapy), including 567 (27%) with a similar combination plus ACE inhibitors (quadruple therapy). One-year survival was 97% in patients receiving triple combination therapy versus 88% in those who received either no, one or two of these medications (p < 0.0001). After multivariate adjustment, the odds ratio for one-year mortality in patients with triple combination therapy was 0.49 (95% confidence interval: 0.32-0.75). Quadruple combination therapy had no additional predictive value in the entire population. In patients with ejection fraction < or = 35%, however, beta-blockers and ACE inhibitors were independent predictors of survival, and combination therapy had no additional prognostic value. CONCLUSIONS: compared with the prescription of any single class of secondary prevention medications, combination therapy offers additional protection in patients with acute myocardial infarction.