Predicting the development of in-hospital cardiogenic shock in patients with ST-segment elevation myocardial infarction treated by primary percutaneous coronary intervention: the ORBI risk score.

Aims: To derive and validate a readily useable risk score to identify patients at high-risk of in-hospital ST-segment elevation myocardial infarction (STEMI)-related cardiogenic shock (CS). Methods and results: In all, 6838 patients without CS on admission and treated by primary percutaneous coronary intervention (pPCI), included in the Observatoire Régional Breton sur l'Infarctus (ORBI), served as a derivation cohort, and 2208 patients included in the obseRvatoire des Infarctus de Côte-d'Or (RICO) constituted the external validation cohort. Stepwise multivariable logistic regression was used to build the score. Eleven variables were independently associated with the development of in-hospital CS: age >70 years, prior stroke/transient ischaemic attack, cardiac arrest upon admission, anterior STEMI, first medical contact-to-pPCI delay >90 min, Killip class, heart rate >90/min, a combination of systolic blood pressure <125 mmHg and pulse pressure <45 mmHg, glycaemia >10 mmol/L, culprit lesion of the left main coronary artery, and post-pPCI thrombolysis in myocardial infarction flow grade <3. The score derived from these variables allowed the classification of patients into four risk categories: low (0-7), low-to-intermediate (8-10), intermediate-to-high (11-12), and high (≥13). Observed in-hospital CS rates were 1.3%, 6.6%, 11.7%, and 31.8%, across the four risk categories, respectively. Validation in the RICO cohort demonstrated in-hospital CS rates of 3.1% (score 0-7), 10.6% (score 8-10), 18.1% (score 11-12), and 34.1% (score ≥13). The score demonstrated high discrimination (c-statistic of 0.84 in the derivation cohort, 0.80 in the validation cohort) and adequate calibration in both cohorts. Conclusion: The ORBI risk score provides a readily useable and efficient tool to identify patients at high-risk of developing CS during hospitalization following STEMI, which may aid in further risk-stratification and thus potentially facilitate pre-emptive clinical decision making.

Low Systolic Blood Pressure and Mortality in Elderly Patients After Acute Myocardial Infarction.

Background Optimal blood pressure in elderly patients after acute myocardial infarction is still a matter of debate. In a prospective observational study, we aimed to identify optimal systolic blood pressure during the 48 first hours after admission for acute myocardial infarction and its prognostic value for cardiovascular mortality. Methods and Results From the Observatoire des Infarctus de Côte d'Or survey, all consecutive patients aged >75 years admitted for an acute myocardial infarction in a coronary care unit from 2012 to 2015 and discharged alive were included (n=814). Exclusion criteria were in-hospital death, cardiogenic shock, and end-stage renal disease. Average systolic blood pressure (aSBP) values over the first 48 hours after admission were recorded, and the population was dichotomized into 2 groups: low aSBP group (<125 mm Hg) and control group (aSBP ≥125 mm Hg). When compared with patients without cardiovascular death at 1-year follow-up, patients who died from a cardiovascular cause had higher rate of cardiovascular risks factors, including age, diabetes mellitus, comorbidities, and cardiovascular history. They had higher rates of low body mass index (<21 kg/m2) and more elevated Global Registry of Acute Coronary Events risk score. Patients with aSBP <125 mm Hg had a 2-fold risk of 1-year cardiovascular death (47 [12.0%] versus 28 [6.6%]; P=0.008). By multivariable logistic regression analysis, low aSBP (odds ratio [95% CI], 1.91 [1.07-3.41]) remained a strong and independent predictor of 1-year cardiovascular mortality. Conclusions In our large population-based study in elderly patients with acute myocardial infarction, low aSBP was an independent and powerful predictor of 1-year cardiovascular mortality. Early aSBP measurement could help to improve risk stratification. Moreover, our results may suggest an optimal blood pressure target in elderly patients.

Post-Infectious Myocardial Infarction: Does Percutaneous Coronary Intervention Improve Outcomes? A Propensity Score-Matched Analysis.

Acute infection is a frequent trigger of myocardial infarction (MI). However, whether percutaneous coronary intervention (PCI) improves post-infectious MI prognosis is a major but unsolved issue. In this prospective multicenter study from coronary care units, we performed propensity score-matched analysis to compare outcomes in patients with and without PCI for post-infectious MI with angiography-proven significant coronary stenosis (>50%). Among 4573 consecutive MI patients, 476 patients (10%) had a concurrent diagnosis of acute infection at admission, of whom 375 underwent coronary angiography and 321 patients had significant stenosis. Among the 321 patients, 195 underwent PCI. Before the matching procedure, patients without PCI had a similar age and sex ratio but a higher rate of risk factors (hypertension, diabetes, chronic renal failure, and prior coronary artery disease), pneumonia, and SYNTAX score than patients without PCI. After propensity score matching, neither in-hospital mortality (13% with PCI vs. 8% without PCI; p = 0.4) nor one-year mortality (24% with PCI vs. 19% without PCI, p = 0.5) significantly differed between the two groups. In this first prospective cohort of post-infectious MI in coronary care units, PCI might not improve short- and long-term prognosis in patients with angiography-proven significant coronary stenosis. If confirmed, these results do not argue for systematic invasive procedures after post-infectious MI.

Relation between body mass index, waist circumference, and death after acute myocardial infarction.

BACKGROUND: An elevated body mass index (BMI) has been reported to be associated with a lower rate of death after acute myocardial infarction (AMI). However, waist circumference (WC) may be a better marker of cardiovascular risk than BMI. We used data from a contemporary French population-based cohort of patients with AMI to analyze the impact of WC and BMI on death rates. METHODS AND RESULTS: We evaluated 2229 consecutive patients with AMI. Patients were classified according to BMI as normal, overweight, obese, and very obese (BMI <25, 25 to 29.9, 30 to 34.5, and >35 kg/m(2), respectively) and as increased waistline (WC >88/102 cm for women/men) or normal. Half of the patients were overweight (n=1044), and one quarter were obese (n=397) or very obese (n=128). Increased WC was present in half of the patients (n=1110). Increased BMI was associated with a reduced death rate, with a 5% risk reduction for each unit increase in BMI (hazard ratio, 0.95; 95% CI, 0.93 to 0.98; P<0.001). In contrast, WC as a continuous variable had no impact on all-cause death (P=0.20). After adjustment for baseline predictors of death, BMI was not independently predictive of death. The group of patients with high WC but low BMI had increased 1-year death rate. CONCLUSIONS: Neither BMI nor WC independently predicts death after AMI. Much of the inverse relationship between BMI and the rate of death after AMI is due to confounding by characteristics associated with survival. This study emphasizes the need to measure both BMI and WC because patients with a high WC and low BMI are at high risk of death.

Major prognostic impact of persistent microvascular obstruction as assessed by contrast-enhanced cardiac magnetic resonance in reperfused acute myocardial infarction.

The aim of this study was to compare the prognostic significance of microvascular obstruction (MO) and persistent microvascular obstruction (PMO) as assessed by cardiac magnetic resonance (CMR) in patients with acute myocardial infarction (AMI). CMR was performed in 184 patients within the week following successfully reperfused first AMI. First-pass images were performed to evaluate extent of MO and late gadolinium-enhanced images to assess PMO and infarct size (IS). Major adverse cardiac events (MACE) were collected at 1-year follow-up. MO and PMO were found in 127 (69%) and 87 (47%) patients, respectively. By using univariate logistic regression analysis, high Global Registry of Acute Coronary Events (GRACE) risk score (odds ratio [OR] 95% confidence interval [CI]: 3.6 [1.8-7.4], p < 0.001), IS greater than 10% (OR [95% CI]: 2.7 [1.1-6.9], p = 0.036), left ventricular ejection fraction less than 40% (OR [95% CI]: 2.4 [1.1-5.2], p = 0.027), presence of MO (OR [95% CI]: 3.1 [1.3-7.3], p = 0.004) and presence of PMO (OR [95% CI]:10 [4.1-23.9], p < 0.001) were shown to be significantly associated with the outcome. By using multivariate analysis, presence of MO (OR [95% CI]: 2.5 [1.0-6.2], p = 0.045) or of PMO (OR [95% CI]: 8.7 [3.6-21.1], p < 0.001), associated with GRACE score, were predictors of MACE. Presence of microvascular obstruction and persistent microvascular obstruction is very common in AMI patients even after successful reperfusion and is associated with a dramatically higher risk of subsequent cardiovascular events, beyond established prognostic markers. Moreover, our data suggest that the prognostic impact of PMO might be superior to MO.

Impact of asymmetric dimethylarginine on mortality after acute myocardial infarction.

OBJECTIVE: Asymmetrical dimethylarginine (ADMA) is an endogenous competitive inhibitor of nitric oxide (NO) synthases. From a prospective cohort of patients with acute myocardial infarction (MI), we aimed to analyze the predictive value of circulating ADMA concentrations on prognosis. METHODS AND RESULTS: Blood samples from 249 consecutive patients hospitalized for acute MI <24 hours were taken on admission. Serum levels of ADMA and its stereoisomer, symmetrical dimethylarginine (SDMA), were determined using high-performance liquid chromatography. The independent predictors of ADMA were glomerular filtration rate, female sex, and SDMA (R(2)=0. 25). Baseline ADMA levels were higher in patients who had died than in patients who were alive at 1 year follow-up (1.23 [0.98 to 1.56] versus 0.95 [0.77 to 1.20] micromol/L, P<0.001). By Cox multivariate analysis, the higher tertile of ADMA (median [interquartile range]: 1.45 [1.24 to 1.70] micromol/L) was a predictor for mortality (Hazard Ratio [95% CI], 4.83 [1.59 to 14.71]), when compared to lower tertiles, even when adjusted for potential confounders, such as acute therapy, biological, and clinical factors. CONCLUSIONS: Our study suggests that the baseline ADMA level has a strong prognostic value for mortality after MI, beyond traditional risk factors and biomarkers.

Prevalence, risk factor burden, and severity of coronary artery disease in patients with heterozygous familial hypercholesterolemia hospitalized for an acute myocardial infarction: Data from the French RICO survey.

BACKGROUND: Individuals with heterozygous familial hypercholesterolemia (FH) are at high risk of early myocardial infarction (MI). However, coronary artery disease (CAD) burden of FH remains not well described, especially for French patients. OBJECTIVE: The objective of this study was to assess the prevalence of FH and severity of CAD from a large database of a French regional registry of acute MI. METHODS: All consecutive patients hospitalized for an acute MI in a multicenter database from 2001 to 2017 were considered. FH was diagnosed using an algorithm adapted from the Dutch Lipid Clinic Network criteria. The prevalence and clinical features of FH and the severity of CAD were assessed. RESULTS: Among the 11,624 patients included in the study, the proportion of "probable/definite", "possible", and "unlikely" FH in patients with MI was 2.1% (n = 249), 20.7% (n = 2405), and 77.2% (n = 8970), respectively. When compared with patients with "unlikely" FH, patients with "probable/definite" FH were 20 years younger (51 vs 71, P < .001), with a lower rate of diabetes (17% vs 25%, P = .007) and a higher prevalence of personal and familial history of CAD. Chronic statin treatment was only used in 48% of FH patients and ezetimibe in 8%. After adjustment for age, sex, and diabetes, patients with FH were characterized by increased extent of CAD (SYNTAX score 11 vs 7, P < .001) and multivessel disease (55% vs 40%, P < .001). CONCLUSIONS: In this large cohort of French individuals, FH was common in patients with MI, associated with markedly early age of MI and severity of CAD burden and limited use of preventive lipid-lowering therapy.

Blood Transfusion in Elderly Patients with Acute Myocardial Infarction: Data from the RICO Survey.

BACKGROUND: Red blood cell transfusion benefit during acute myocardial infarction remains unclear in the elderly. We aimed to assess the transfusion impact on 1-year mortality in acute myocardial infarction patients aged ≥65 years, according to their age and hemoglobin nadir. METHODS: We included 3316 consecutive patients with acute myocardial infarction aged ≥65 years from the "obseRvatoire des Infarctus de Côte d'Or" (RICO) survey. They were categorized according to their hemoglobin nadir (≤8, >8 to ≤10, and >10 g/dL) and age (<80 or ≥80 years). RESULTS: A total of 1906 patients (57%) were 65-79 years old, and 1410 (43%) were aged ≥80 years, of whom 103 (5%) and 145 (10%) patients received red blood cell transfusion, respectively (P < .001). In Cox regression analysis, transfusion was associated with increased 1-year mortality for hemoglobin nadir >10 g/dL but no significant effect for hemoglobin nadir between 8 and 10 g/dL. When hemoglobin nadir was ≤8 g/dL, transfusion did not influence 1-year mortality for younger patients (65-79 years). However, for older patients (≥80 years), transfusion was associated with lower mortality (hazard ratio 0.43 [95% confidence interval, 0.22-0.86], P = .016). CONCLUSION: Among older patients with acute myocardial infarction, the effect of transfusion was largely dependent on hemoglobin threshold and age. Transfusion was associated with increased 1-year mortality when hemoglobin nadir was >10 g/dL. However, in patients aged ≥80 years with hemoglobin nadir <8 g/dL, transfusion was associated with a 50% reduction in 1-year mortality.

Impact of fasting glycemia on short-term prognosis after acute myocardial infarction.

OBJECTIVE: The prognosis of patients with acute myocardial infarction (MI), according to the new criteria for impaired fasting glucose (IFG) (FG 100-126 mg/dl), has not been evaluated. RESEARCH DESIGN AND METHODS: A total of 2353 patients with acute MI and surviving at d 5 after admission were analyzed for short-term morbidity and mortality. FG was obtained at d 4 and 5. Patients were classified as diabetes mellitus (known diabetes or FG > or = 126 mg/dl), high IFG (110 < or = FG < 126 mg/dl), low IFG (100 < or = FG < 110 mg/dl), and normal fasting glucose (NFG) (FG < 100 mg/dl). RESULTS: Among the 2353 patients, 968 (41%) had diabetes mellitus, 262 (11%) had high IFG, 332 (14%) had low IFG, and 791 (34%) had NFG. Compared with NFG patients, 30-d cardiovascular mortality was increased in high but not low IFG subjects. In-hospital heart failure was increased in high IFG subjects (42 vs. 20% for NFG, P < 0.0001) but not low IFG subjects (21 vs. 20%). High IFG, but not low IFG, was an independent factor associated with 30-d cardiovascular mortality [odds ratio 2.33 (1.55-3.47)] and in-hospital heart failure [odds ratio 1.70 (1.36-2.07)]. The optimal threshold levels of FG on the receiver-operating characteristic curves were 114 and 112 mg/dl to predict mortality and in-hospital heart failure, respectively. CONCLUSION: The present study, based on a nonselected cohort of MI patients, underscores the high prevalence of IFG (25%) and highlights the clinical relevance of 110 mg/dl, but not 100 mg/dl, as a cutoff value to define the risk for worse outcome.

Predictors and prognosis for complex coronary lesions in patients with acute myocardial infarction: data from RICO survey.

BACKGROUND: We aimed to investigate the determinants and outcomes of multiple complex lesions (MCLs) on coronary angiography in patients with an acute myocardial infarction. METHODS: One thousand one hundred fifty-two consecutive nonselected myocardial infarction patients who underwent coronary angiography within 24 hours after admission were analyzed. A complex lesion was defined by the presence of thrombus, ulceration, irregular plaque, and flow impairment. Patients with < or = 1 complex lesion were considered with single complex lesion (SCL), and patients with > 1 complex lesions with MCLs. RESULTS: Multiple complex lesions were identified in 360 patients (31%). Patients from the MCL group were older and had a higher rate of cardiovascular risk factors but were less likely to be smokers when compared with the SCL group. Patients with MCLs were more likely to have altered left ventricular ejection fraction and multivessel disease and showed a trend toward an increased median time delay to revascularization (360 vs 285 minutes; P = .070). Moreover, the C-reactive protein (CRP) plasma levels increased with the number of CLs. By multivariate analysis, multivessel disease and CRP level were associated with the presence of MCLs. When compared with the SCL group, patients with MCLs had a higher risk of inhospital cardiogenic shock (18% vs 11%; P = .005) and 30-day mortality (11% vs 6%; P = .002). At 1-year follow-up, the presence of MCLs was an independent predictive factor of death. CONCLUSIONS: This study shows that the presence of MCLs is associated with worse outcomes and that risk factors such as CRP are able to identify patients at a high risk for MCLs.

Beneficial effects of statin therapy on survival in hypertensive patients with acute myocardial infarction: data from the RICO survey.

BACKGROUND: Randomized studies have shown a reduction in cardiovascular events associated with low doses of statin among hypertensive patients at only moderate cardiovascular risk. The hypothesis of the present study was that statin therapy initiated during hospitalization could improve the long-term outcome after acute myocardial infarction (MI) in hypertensive patients. METHODS: From the French regional obserRvatoire des Infarctus de Côte d'Or (RICO) survey, 1076 patients with a history of hypertension, surviving acute MI were included. Patients on statin therapy initiated before their hospitalization were excluded from the study. Patients were categorized into two groups based on whether or not statin treatment was initiated during the hospital stay. RESULTS: Patients in the statin group were younger (70 years [range, 58 to 77 years] v 75 years [range, 65 to 82 years], P < .001) and were more likely to have hypercholesterolemia (42% v 28 %, P < .001). No differences were observed between the two groups for LDL-cholesterol levels on admission. At 1-year follow-up, cardiovascular mortality and rehospitalization for heart failure were lower in the statin group (respectively, 5% v 15%, P < .001; 5% v 7%, P < .001). Multivariate analysis showed that statin therapy was associated with decreased mortality (hazard ratio [95% confidence interval; CI]: 0.58 [0.32-0.98], P = .035) independently of either hypercholesterolemia, the use of beta-blockers, angiotensin-converting enzyme inhibitors, or diuretics, but not with a decreased incidence of heart failure (hazard ratio [95% CI]: 0.88 [0.55-1.23], P = .152). CONCLUSIONS: In this observational study, the long-term benefits of statin therapy initiated in-hospital in hypertensive patients after acute MI was demonstrated. These findings may have implications for treatment optimization of hypertensive patients in secondary prevention.

Relation of hyperglycemia to ST-segment resolution after reperfusion for acute myocardial infarction (from Observatoire des Infarctus de Côte-d'Or Survey [RICO]).

Hyperglycemia has been shown to be a powerful predictor of worse outcome after ST-segment-elevation myocardial infarction (STEMI), which could be related to impaired myocardial reperfusion. This study investigated the association between hyperglycemia and ST-segment resolution (STR) after thrombolysis. From the French regional Observatoire des Infarctus de Côte-d'Or survey, admission glucose in 371 patients with STEMIs who were treated by lysis<12 hours was analyzed. The single worst lead electrocardiogram before and 90 minutes after lysis was analyzed, and patients were divided into 3 groups according to the degree of STR: none (<30%), partial (30% to 70%), or complete (>or=70%). Of the 371 patients, 101 (27.2%) had no STR, 124 (33.4%) had partial STR, and 146 (39.4%) had complete STR. STR decreased with increasing glycemia (p=0.029), and patients with hyperglycemia (glycemia>or=11 mmol/L) were more likely to have no STR. Moreover, hyperglycemia was an independent predictor of incomplete STR even after adjustment for potential confounders (odds ratio 2.348, 95% confidence interval 1.212 to 4.547). In conclusion, the present study suggests a strong association between hyperglycemia and electrocardiographic signs of reperfusion in patients with STEMIs after lysis and suggests the usefulness of evaluating early glycemic control in the setting of reperfusion for acute myocardial infarction.

Prevalence and impact of metabolic syndrome on hospital outcomes in acute myocardial infarction.

BACKGROUND: The impact of metabolic syndrome after acute myocardial infarction (AMI) has not yet been studied. In a population-based sample of patients with AMI, we sought to determine the prevalence of metabolic syndrome in patients with AMI, its impact on hospital outcomes, and to assess the relative influence of each of the components of the National Cholesterol Education Program (NCEP) Adult Treatment Panel (ATP) III definition of metabolic syndrome on the risk of death and heart failure. METHODS: A total of 633 unselected, consecutive patients hospitalized with AMI were categorized according to the NCEP ATP III metabolic syndrome criteria (presence of >/=3 of the following: hyperglycemia; triglyceride level >/=150 mg/dL [>/=1.7 mmol/L]; high-density lipoprotein cholesterol level <40 mg/dL [<1.04 mmol/L] in men and <50 mg/dL [<1.30 mmol/L] in women; blood pressure >/=130/85 mm Hg; and waist circumference >102 cm in men or 88 cm in women). RESULTS: Among the 633 patients, 290 (46%) fulfilled the criteria for metabolic syndrome. Patients with metabolic syndrome were older and more likely to be women. Acute myocardial infarction characteristics and left ventricular ejection fraction rates were similar for both groups. In-hospital case fatality was higher in patients with metabolic syndrome compared with those without, as was the incidence of severe heart failure (Killip class >II). In multivariate analysis, metabolic syndrome was a strong and independent predictor of severe heart failure, but not in-hospital death. Analysis of the predictive value of each of the 5 metabolic syndrome components for severe heart failure showed that hyperglycemia was the major determinant (odds ratio, 3.31; 95% confidence interval, 1.86-5.87). CONCLUSIONS: In an unselected population of patients with AMI, the prevalence of metabolic syndrome was high. Metabolic syndrome appeared associated with worse in-hospital outcome, with a higher risk of development of severe heart failure. Among metabolic syndrome components, hyperglycemia was the main correlate of the risk of development of severe heart failure during AMI.

New insights into symptomatic or silent atrial fibrillation complicating acute myocardial infarction.

Atrial fibrillation (AF) is the most frequent heart rhythm disorder in the general population and contributes not only to a major deterioration in quality of life but also to an increase in cardiovascular morbimortality. The onset of AF in the acute phase of myocardial infarction (MI) is a major event that can jeopardize the prognosis of patients in the short-, medium- and long-term, and is a powerful predictor of a poor prognosis after MI. The suspected mechanism underlying the excess mortality is the drop in coronary flow linked to the acceleration and arrhythmic nature of the left ventricular contractions, which reduce the left ventricular ejection fraction. The principal causes of AF-associated death after MI are linked to heart failure. Moreover, the excess risk of death in these heart failure patients has also been associated with the onset of sudden death. Whatever its form, AF has a major negative effect on patient prognosis. In recent studies, symptomatic AF was associated with inhospital mortality of 17.8%, to which can be added mortality at 1year of 18.8%. Surprisingly, silent AF also has a negative effect on the prognosis, as it is associated with an inhospital mortality rate of 10.4%, which remains high at 5.7% at 1year. Moreover, both forms of AF are independent predictors of mortality beyond traditional risk factors. The frequency and seriousness of silent AF in the short- and long-term, which were until recently rarely studied, raises the question of systematically screening for it in the acute phase of MI. Consequently, the use of continuous ECG monitoring could be a simple, effective and inexpensive solution to improve screening for AF, even though studies are still necessary to validate this strategy. Finally, complementary studies also effect of oxidative stress and endothelial dysfunction, which seem to play a major role in triggering this rhythm disorder.

Prognosis of silent atrial fibrillation after acute myocardial infarction at 1-year follow-up.

BACKGROUND: Silent atrial fibrillation (AF), assessed by continuous ECG monitoring (CEM), has recently been shown to be common in acute myocardial infarction (AMI), and associated with higher hospital mortality. However, the long-term prognosis is still unknown. We aimed to assess 1-year prognosis in patients experiencing silent AF in AMI. METHODS: All consecutive patients with AMI who were prospectively analysed by CEM during the first 48 h after admission and who survived at hospital discharge were included. Silent AF was defined as asymptomatic episodes lasting at least 30 s. Patients were followed up at 1 year for cardiovascular (CV) outcomes. RESULTS: Among the 737 patients analysed, 106 (14%) developed silent AF and 32 (4%) symptomatic AF. Compared with the no-AF group, patients with silent AF were markedly older (79 vs 62 years, p<0.001), more frequently hypertensive (71% vs 49%, p<0.001) and less likely to be smokers (23% vs 37%, p<0.001). Also, they were more likely to have impaired LVEF (50% vs 55%, p<0.001). Risk factors in patients with silent AF were similar to those in patients with symptomatic AF. However, a history of stroke or AF was less frequent in silent AF than in symptomatic-AF patients (10% vs 25% and 10% vs 38%, respectively). At 1 year, CV events including hospitalisation for heart failure (HF) and CV mortality were markedly higher in silent-AF patients than in no-AF patients (6.6% vs 1.3% and 5.7% vs 2.0%, p<0.001, respectively). CONCLUSIONS: Our large prospective study showed for the first time that silent AF is associated with worse 1-year prognosis after AMI. Systematic screening and specific management should be investigated in order to improve outcomes of patients after AMI.

Atrial Fibrillation Is Associated with a Marker of Endothelial Function and Oxidative Stress in Patients with Acute Myocardial Infarction.

BACKGROUND: Atrial fibrillation (AF), whether silent or symptomatic, is a frequent and severe complication of acute myocardial infarction (AMI). Asymmetric dimethylarginine (ADMA), an endogenous eNOS inhibitor, is a risk factor for endothelial dysfunction. We addressed the relationship between ADMA plasma levels and AF occurrence in AMI. METHODS: 273 patients hospitalized for AMI were included. Continuous electrocardiographic monitoring (CEM) ≥48 hours was recorded and ADMA was measured by High Performance Liquid Chromatography on admission blood sample. RESULTS: The incidence of silent and symptomatic AF was 39(14%) and 29 (11%), respectively. AF patients were markedly older than patients without AF (≈ 20 y). There was a trend towards higher ADMA levels in patients with symptomatic AF than in patients with silent AF or no AF (0.53 vs 0.49 and 0.49 µmol/L, respectively, p = 0.18,). After matching on age, we found that patients with symptomatic AF had a higher heart rate on admission and a higher rate of patients with LV dysfunction (28% vs. 3%, p = 0.025). Patients who developed symptomatic AF had a higher ADMA level than patients without AF (0.53 vs. 0.43 µmol/L; p = 0.001). Multivariate logistic regression analysis to estimate symptomatic AF occurrence showed that ADMA was independently associated with symptomatic AF (OR: 2.46 [1.21-5.00], p = 0.013) beyond history of AF, LVEF<40% and elevated HR. CONCLUSION: We show that high ADMA level is associated with the occurrence of AF. Although no causative role can be concluded from our observational study, our work further supports the hypothesis that endothelial dysfunction is involved in the pathogenesis of AF in AMI.

The Log book for the secondary prevention of coronary artery disease: A pilot study.

INTRODUCTION: In secondary prevention (SP) of coronary artery disease (CAD), in particular after an acute myocardial infarction (MI), a better knowledge and self-management by the patient may have various supports. The Log book (LB) for CAD patients in Côte d'Or, was created in 2010 by a multidisciplinary team of healthcare professionals of Côte d'Or, from a regional care network. This pilot study evaluated LB as novel support for SP after acute MI. METHODS: A prospective study on 183 patients hospitalised for an acute MI in the region of Côte d'Or from 1st May to 30th October 2010. Patients were randomized in 91 patients who received an LB at the time of their hospitalisation (LB+ group), and 92 patients who were not given an LB (LB- group). The follow up (FU) was performed at 4 months and 1 year. RESULTS: Baseline characteristics were similar in the 2 groups, except for smoking, which was more frequent in the LB-group than in the LB+ group. At FU, LB was usually well accepted by both patients and their general practitioners (GP). At 4 months FU, the patients LB+ were more prone to see their general practitioners than patients LB- (100% vs 85% in the LB- group, P=0.007). Moreover, in LB+ group, there was a trend towards a more frequent physical activity, including exercise bike (P=0.009) and an increase in HDL-cholesterol (HDL-c) (P=0.165). At 1 year FU, body mass index from LB+ was more reduced than in patients LB- (P=0.029). Finally, there was a trend towards lower morbi-mortality (hospitalisation for cardiovascular cause or death) in the LB+ group than in the LB- group (11 vs 22%, P=0.083). CONCLUSION: This pilot study showed the feasibility of LB as a support for SP and its interest in post MI management in a local care network setting. In addition, our study provides encouraging data on the potential benefits of this pioneer tool for SP.

Beneficial effects of direct call to emergency medical services in acute myocardial infarction.

OBJECTIVES: We investigated the impact of an emergency medical services call on the management of acute myocardial infarction, considering time intervals for intervention and revascularization procedures. METHODS: Data were prospectively collected from January 2001 to October 2002 from 531 patients hospitalized for myocardial infarction with ST segment elevation and a pre-hospital delay of less than 24 h. RESULTS: Only 26% of patients called the emergency medical services at the onset of symptoms (n=140). Other patients (n=391, 74%) called another medical contact. Baseline characteristics and cardiovascular history were similar in the two groups, except for the percutaneous coronary intervention history (10% in the emergency medical services group versus 4% in the other medical contact group, P<0.05). Time intervals from the onset of symptoms of myocardial infarction to call or to medical intervention, as well as the time interval from medical intervention to hospital admission were significantly shorter in the emergency medical services group. The early reperfusion rate was also significantly greater in the emergency medical services group (77%) compared with the other medical contact group (64%), mainly because of a greater incidence of primary percutaneous coronary intervention (36 versus 26%, P<0.03, respectively). Multivariate analysis adjusted for sex and age showed that less than three medical care providers [odds ratio (OR) 5.042, P<0.001], percutaneous coronary intervention history (OR 2.462, P<0.05), as well as rhythmic disorders (OR 2.105, P<0.05) and complete atrioventricular block (OR 2.757, P<0.05) were independent predictors of emergency medical services care. CONCLUSION: This study demonstrated that a call to the emergency medical services is underutilized by patients with symptoms of myocardial infarction, and documented the beneficial effects of an emergency medical services call by reducing pre-hospital delays and increasing early revascularization therapies.

Incidence and prognostic significance of silent atrial fibrillation in acute myocardial infarction.

BACKGROUND: Silent atrial fibrillation (AF) has been suggested to be frequent after acute myocardial infarction (MI). Continuous ECG monitoring (CEM) has been shown to improve AF screening in patients at risk of stroke. OBJECTIVES: We aimed to assess the incidence and prognosis of silent AF in patients with acute MI. METHODS: All the consecutive patients with acute MI were prospectively analyzed by CEM ≥ 48 h after admission. Silent AF was defined as asymptomatic episodes lasting at least 30s. The population was divided into three groups: no-AF, silent AF and symptomatic AF. RESULTS: Among the 849 patients, 135 (16%) developed silent AF and 45 (5%) symptomatic AF. Compared with the no-AF group, patients with silent AF were markedly older (80 vs. 62 y, p<0.001), more frequently women (43% vs. 30%, p=0.006) and less likely to be smokers (20% vs. 36%, p<0.001). They had impaired left ventricular ejection fraction (LVEF) and left atrial (LA) enlargement. By multivariate analysis, age, history of AF, indexed LA area and LVEF were identified as independent predictors of silent AF. In-hospital heart failure and death rates were markedly higher in silent AF group when compared with no-AF patients (41.8% vs 21.0% and 10.4% vs. 1.3%, respectively). CONCLUSION: Our large prospective study showed for the first time that silent AF is more frequent than symptomatic AF after MI. Our work suggests that indexed LA area could help to predict the risk of developing silent AF. Moreover, the onset of silent AF is associated with worse hospital prognosis.

Impact of diverting general practitioner's after-hour calls to emergency medical dispatch centers in patients with acute myocardial infarction.

OBJECTIVE: The aim of this study was to analyze the impact of diverting off-hour calls to Emergency Medical Dispatch Centers (EMDC) on time delays and revascularization procedures for patients with ST-segment elevation myocardial infarction (STEMI) in a French region. METHODS: A total of 3376 consecutive patients admitted for acute STEMI were included from the RICO survey (a French regional survey for acute myocardial infarction). Patients were retrospectively classified into two groups: before (2001-2004) and after EMDC (2005-2008) implementation and followed up for mortality as primary outcomes. In addition, we examined the impact of the diversion on the delay to definitive care. RESULTS: During the study, 1781 (53%) patients were evaluated before and 1595 (47%) after the EMDC implementation. Access to healthcare facilities was similar for the two groups. The rate of off-hour calls remained stable over time. The median delay from first medical intervention to hospital admission decreased from 75 to 60 min. The off-hour median interval from door to primary percutaneous coronary intervention dropped from 152 to 98 min. The multivariate analyses showed that EMDC implementing reduced preadmission delays even when adjusting for potential confounders. Moreover, EMDC implementing was associated with a fall in 30-day mortality by 60% in patients admitted during off hours and undergoing primary percutaneous coronary intervention (10 vs. 4%). CONCLUSION: In a real world setting, improving the quality of prehospital organization was effective not only on reducing delays but also on improving access to revascularization. Our results showed the beneficial impact of EMDC implementing on management of STEMI.