Comparison of one-year prognosis of patients classified as chronic critical lower limb ischaemia according to TASC II or European consensus definition in the COPART cohort.

BACKGROUND: We compared one-year amputation and survival rates in patients fulfilling 1991 European consensus critical limb ischaemia (CLI) definition to those clas, sified as CLI by TASC II but not European consensus (EC) definition. PATIENTS AND METHODS: Patients were selected from the COPART cohort of hospitalized patients with peripheral occlusive arterial disease suffering from lower extremity rest pain or ulcer and who completed one-year follow-up. Ankle and toe systolic pressures and transcutaneous oxygen pressure were measured. The patients were classified into two groups: those who could benefit from revascularization and those who could not (medical group). Within these groups, patients were separated into those who had CLI according to the European consensus definition (EC + TASC II: group A if revascularization, group C if medical treatment) and those who had no CLI by the European definition but who had CLI according to the TASC II definition (TASC: group B if revascularization and D if medical treatment). RESULTS: 471 patients were included in the study (236 in the surgical group, 235 in the medical group). There was no difference according to the CLI definition for survival or cardiovascular event-free survival. However, major amputations were more frequent in group A than in group B (25 vs 12 %, p = 0.046) and in group C than in group D (38 vs 20 %, p = 0.004). CONCLUSIONS: Major amputation is twice as frequent in patients with CLI according to the historical European consensus definition than in those classified to the TASC II definition but not the EC. Caution is required when comparing results of recent series to historical controls. The TASC II definition of CLI is too wide to compare patients from clinical trials so we suggest separating these patients into two different stages: permanent (TASC II but not EC definition) and critical ischaemia (TASC II and EC definition).

Chronic kidney disease and the short-term risk of mortality and amputation in patients hospitalized for peripheral artery disease.

OBJECTIVE: The aim of the present study was to determine the prevalence of chronic kidney disease (CKD) and its prognostic value in patients hospitalized for lower extremity peripheral artery disease (PAD). METHODS: Data from the COhorte des Patients ARTériopathes registry, a prospective multicenter, observational study of consecutive patients hospitalized for PAD in academic hospitals of southwestern France, were analyzed. All the subjects were in Rutherford grade ≥ 3, and 55.6% were in grade ≥ 5-6. Associations between CKD and 1-year mortality, as well as amputation rates, were evaluated by Cox analysis. Kaplan-Meier survival curves were analyzed according to estimated glomerular filtration rate (eGFR). RESULTS: From May 2004 to January 2009, we enrolled 1010 patients. They were classified into four groups according to the eGFR: 21.7% were in group 1 (≥ 90 mL/min per 1.73 m(2)), 34% in group 2 (60-89 mL/min per 1.73 m(2)), 32.2% in group 3 (30-59 mL/min per 1.73 m(2)), and 12.1% in group 4 (<30 mL/min per 1.73 m(2) including dialysis). All-cause mortality was 25.1% at 1 year. The rate of major amputation was 26.3%. Mortality rates were, respectively, at 16%, 18%, 31.7%, and 44.3% (P < .0001) in groups 1 to 4. The major amputation rates were at 23.7%, 21.5%, 28%, and 40.2% (P = .0006), respectively. The presence of severe CKD (group 4) was associated with all-cause mortality (hazard ratio, 1.84; 95% confidence interval, 1.02-3.32; P = .044). In contrast, the risk of amputation was not associated with CKD after adjustments to risk factors. CONCLUSIONS: The prevalence of CKD in patients hospitalized for PAD is high. CKD is an independent predictor of 1-year mortality, but is not an independent predictor of limb amputation.

Improved outcome of cardiogenic shock at the acute stage of myocardial infarction: a report from the USIK 1995, USIC 2000, and FAST-MI French nationwide registries.

AIM: The historical evolution of incidence and outcome of cardiogenic shock (CS) in acute myocardial infarction (AMI) patients is debated. This study compared outcomes in AMI patients from 1995 to 2005, according to the presence of CS. METHOD AND RESULTS: Three nationwide French registries were conducted 5 years apart, using a similar methodology in consecutive patients admitted over a 1-month period. All 7531 AMI patients presenting ≤48 h of symptom onset were included. The evolution of mortality was compared in the 486 patients with CS vs. those without CS. The incidence of CS tended to decrease over time (6.9% in 1995; 5.7% in 2005, P = 0.07). Thirty-day mortality was considerably higher in CS patients (60.9 vs. 5.2%). Over the 10-year period, mortality decreased for both patients with (70-51%, P = 0.003) and without CS (9-4%, P < 0.001). In CS patients, the use of percutaneous coronary intervention (PCI) increased from 20 to 50% (P < 0.001). Time period was an independent predictor of early mortality in CS patients (OR for death, 2005 vs. 1995 = 0.45; 95% CI: 0.27-0.75, P = 0.005), along with age, diabetes, and smoking status. When added to the multivariate model, PCI was associated with decreased mortality (OR = 0.38; 95% CI: 0.24-0.58, P < 0.001). In propensity-score-matched cohorts, CS patients with PCI had a significantly higher survival. CONCLUSIONS: Cardiogenic shock remains a clinical concern, although early mortality has decreased. Improved survival is concomitant with a broader use of PCI and recommended medications at the acute stage. Beyond the acute stage, however, 1-year survival has remained unchanged.

Association of changes in clinical characteristics and management with improvement in survival among patients with ST-elevation myocardial infarction.

CONTEXT: The contemporary decline in mortality reported in patients with ST-segment elevation myocardial infarction (STEMI) has been attributed mainly to improved use of reperfusion therapy. OBJECTIVE: To determine potential factors-beyond reperfusion therapy-associated with improved survival in patients with STEMI over a 15-year period. DESIGN, SETTING, AND PATIENTS: Four 1-month French nationwide registries, conducted 5 years apart (between 1995, 2000, 2005, 2010), including a total of 6707 STEMI patients admitted to intensive care or coronary care units. MAIN OUTCOME MEASURES: Changes over time in crude 30-day mortality, and mortality standardized to the 2010 population characteristics. RESULTS: Mean (SD) age decreased from 66.2 (14.0) to 63.3 (14.5) years, with a concomitant decline in history of cardiovascular events and comorbidities. The proportion of younger patients increased, particularly in women younger than 60 years (from 11.8% to 25.5%), in whom prevalence of current smoking (37.3% to 73.1%) and obesity (17.6% to 27.1%) increased. Time from symptom onset to hospital admission decreased, with a shorter time from onset to first call, and broader use of mobile intensive care units. Reperfusion therapy increased from 49.4% to 74.7%, driven by primary percutaneous coronary intervention (11.9% to 60.8%). Early use of recommended medications increased, particularly low-molecular-weight heparins and statins. Crude 30-day mortality decreased from 13.7% (95% CI, 12.0-15.4) to 4.4% (95% CI, 3.5-5.4), whereas standardized mortality decreased from 11.3% (95% CI, 9.5-13.2) to 4.4% (95% CI, 3.5-5.4). Multivariable analysis showed a consistent reduction in mortality from 1995 to 2010 after controlling for clinical characteristics in addition to the initial population risk score and use of reperfusion therapy, with odds mortality ratios of 0.39 (95%, 0.29-0.53, P <.001) in 2010 compared with 1995. CONCLUSION: In France, the overall rate of cardiovascular mortality among patients with STEMI decreased from 1995 to 2010, accompanied by an increase in the proportion of women younger than 60 years with STEMI, changes in other population characteristics, and greater use of reperfusion therapy and recommended medications.

Comparison of thrombolysis followed by broad use of percutaneous coronary intervention with primary percutaneous coronary intervention for ST-segment-elevation acute myocardial infarction: data from the french registry on acute ST-elevation myocardial infarction (FAST-MI).

BACKGROUND: Intravenous thrombolysis remains a widely used treatment for ST-elevation myocardial infarction; however, it carries a higher risk of reinfarction than primary PCI (PPCI). There are few data comparing PPCI with thrombolysis followed by routine angiography and PCI. The purpose of the present study was to assess contemporary outcomes in ST-elevation myocardial infarction patients, with specific emphasis on comparing a pharmacoinvasive strategy (thrombolysis followed by routine angiography) with PPCI. METHODS AND RESULTS: This nationwide registry in France included 223 centers and 1714 patients over a 1-month period at the end of 2005, with 1-year follow-up. Sixty percent of the patients underwent reperfusion therapy, 33% with PPCI and 29% with intravenous thrombolysis (18% prehospital). At baseline, the Global Registry of Acute Coronary Events score was similar in thrombolysis and PPCI patients. Time to initiation of reperfusion therapy was significantly shorter in thrombolysis than in PPCI (median 130 versus 300 minutes). After thrombolysis, 96% of patients had coronary angiography, and 84% had subsequent PCI (58% within 24 hours). In-hospital mortality was 4.3% for thrombolysis and 5.0% for PPCI. In patients with thrombolysis, 30-day mortality was 9.2% when PCI was not used and 3.9% when PCI was subsequently performed (4.0% if PCI was performed in the same hospital and 3.3% if performed after transfer to another facility). One-year survival was 94% for thrombolysis and 92% for PPCI (P=0.31). After propensity score matching, 1-year survival was 94% and 93%, respectively. CONCLUSIONS: When used early after the onset of symptoms, a pharmacoinvasive strategy that combines thrombolysis with a liberal use of PCI yields early and 1-year survival rates that are comparable to those of PPCI.

Additional prognostic value of physical examination, exercise testing, and arterial ultrasonography for coronary risk assessment in primary prevention.

BACKGROUND: The choice of noninvasive tests used in primary prevention of cardiovascular diseases must be based on medical evidence. The aim of this study was to assess the additional prognostic value, over conventional risk factors, of physical examination, exercise testing, and arterial ultrasonography, in predicting a first coronary event. METHODS: A prospective cohort study was conducted between 1996 and 2004 (n = 2,709), with follow-up in 2006 (response rate 96.6%). Participants had no history or symptoms of cardiovascular disease and had a standardized physical examination, a cardiac exercise testing, and carotid and femoral ultrasonography at baseline. Incident cases of definite coronary events were recorded during follow-up. RESULTS: Over the Framingham risk score, femoral bruit, positive exercise test, intima-media thickness >0.63 mm, and a femoral plaque provided significant additional information to the prediction model. The addition of the exercise test to the traditional risk factors, then the intima-media thickness and lastly the presence of femoral plaques, produces incremental increases in the area under the receiver operating characteristic curve (0.73-0.78, P = .02) and about a 50% increase in the positive predictive value (15.8%-31.4%), with no effect on the negative predictive value (96.4%-96.9%). CONCLUSION: Physical examination, exercise testing, and arterial ultrasonography provide incremental information on the risk of coronary event in asymptomatic adults. Exercise testing and femoral ultrasonography also improve the accuracy of the risk stratification.

Outcomes of myocardial infarction in hospitals with percutaneous coronary intervention facilities.

BACKGROUND: Despite evidence on the efficacy and safety of percutaneous coronary intervention (PCI) for patients with acute myocardial infarction, it is unclear whether patients admitted to hospitals with on-site PCI facilities (herein after, PCI hospitals) have improved outcomes in routine practice. METHODS: We compared processes of care, hospital outcomes, and 1-year mortality rate for 1176 consecutive patients admitted to 126 PCI hospitals and 738 patients admitted to 190 non-PCI hospitals in France from November 1 to November 30, 2000. RESULTS: Patients admitted to PCI hospitals were more likely to receive evidence-based acute (within 48 hours of admission) and discharge medications and to undergo PCI within 48 hours of admission than those admitted to non-PCI hospitals (54% vs 6.2%; P<.001). Despite comparable rates of in-hospital stroke (0.9% vs 1.1%; P=.75) and reinfarction (1.7% vs 2.5%; P=.25), patients admitted to PCI vs non-PCI hospitals had lower in-hospital (7.5% vs 12%; P=.001) and 1-year (13% vs 20%; P<.001) mortality rates. Admission to PCI hospitals was associated with decreased hazard ratios of mortality after adjusting for baseline characteristics (0.75; 95% confidence interval, 0.57-0.98) or propensity score (0.76; 95% confidence interval, 0.59-0.97). Most of the survival benefit of admission to a PCI hospital was explained by the use of PCI and evidence-based discharge medications. CONCLUSIONS: In this prospective observational study, admission of patients with acute myocardial infarction to PCI hospitals was associated with greater use of PCI and evidence-based medications and with improved 1-year survival. Although we cannot exclude the possibility that some unmeasured confounding factors might explain the survival benefit of admission to PCI hospitals, our findings support routine use of PCI and evidence-based medications for these patients.

Impact of betablockers on general and local outcome in patients hospitalized for lower extremity peripheral artery disease: The COPART Registry.

Lower extremity peripheral artery disease (PAD) is one manifestation of atherosclerosis. Patients with PAD have an increased rate of mortality due to concurrent coronary artery disease and hypertension. Betablockers (BB) may, therefore, be prescribed, especially in case of heart failure. However, BB safety in PAD is controversial, because of presumed peripheral hemodynamic consequences of BB that could lead to worsening of symptoms in patients with PAD. In this context, we aimed to determine the impact of BB on all-cause and cardiovascular mortality and amputation rate at 1 year after hospitalization for PAD from the COPART Registry population. This is a prospective multicenter observational study collecting data from consecutive patients hospitalized for PAD in vascular medicine departments of 4 academic hospitals in France. Patients with, either claudication, critical limb ischemia or acute lower limb ischemia related to a documented PAD were included. We compared the outcomes of patients with BB versus those without BB in their prescription list at hospital discharge. The mean age of the study population was 70.9 years, predominantly composed of males (71%). Among the 1267 patients at admission, 28% were treated by BB for hypertension, prior myocardial infarction or heart failure. During their hospital stay, 40% underwent revascularization (including bypass surgery 29% and angioplasty 74%), 17% required an amputation, and 5% died. In a multivariate analysis, only prior myocardial infarction was found associated with BB prescription with an odds ratio (OR) of 3.11, P < 0.001. Conversely, chronic obstructive pulmonary disease or PAD with ulcer impeded BB prescription (OR: 0.57 and 0.64, P = 0.007; P = 0.001, respectively). One-year overall mortality of patients with BB did not differ from those without (23% vs. 23%, P = 0.95). The 1-year amputation rate did not differ either (4% vs. 6%, P = 0.14). Patients hospitalized for PAD with a BB in their prescription did not worsen their outcome at 1 year compared to patients without BB. Based on these safety data, prospective study could be conducted to assess the effect of BB on long-term mortality and amputation rate in patients with mild, moderate, and severe PAD.

Key factors associated with the under-prescription of statins in elderly coronary heart disease patients: Results from the ELIAGE and ELICOEUR surveys.

INTRODUCTION: The reasons why statins are under-utilized in elderly patients remain poorly understood. The aim of this study was to identify the reasons given by cardiologist for the non-prescription of statins in elderly CHD patients. METHODS: Two cross-sectional pharmaco-epidemiological surveys were carried out among French cardiologists. The sample consisted of 1148 coronary patients aged 35 to 69 years and 1489 patients aged > or =70 years. Patients' risk factors, medical history, treatments, lipid values and the physicians' various motives for the non-prescription of statins were recorded. RESULTS: Patients not treated with statins reached 37% in the age-group > or =70 years and 14% in the age-group 35-69 years. The main reason given for statin non-prescription was the lack of a medical indication (2.5% of the age-group 35-69 years and 14% of the age-group > or =70 years). Among patients > or =70 years, the lack of indication was more often cited in the following conditions: 1) in very old patients (36% of lack of indication in the age-group >85 years vs. 10% in 70-75 years), 2) when lipid values were not available (20% when data were not available vs. 9%) and 3) when the patient had no prior history of myocardial infarction (MI) (20% when no history of MI vs. 7%). These factors were not associated with lack of indication among patients <70 years. History of intolerance or side effect was given for 1.3% and 14% of patients for each of the groups (35-69 and > or =70) and poor overall patient adherence was cited in 1% and 2%, respectively. CONCLUSION: The primary reason for the under-prescription of statins in elderly coronary patients is the perceived lack of indication, which stresses the need of extensive guidelines for prescription in elderly patients. Several factors associated with this perception seem to be specific to the elderly.

Impact of prehospital thrombolysis for acute myocardial infarction on 1-year outcome: results from the French Nationwide USIC 2000 Registry.

BACKGROUND: Limited data are available on the impact of prehospital thrombolysis (PHT) in the "real-world" setting. METHODS AND RESULTS: Of 443 intensive care units in France, 369 (83%) prospectively collected all cases of infarction (< or =48 hours of symptom onset) in November 2000; 1922 patients (median age, 67 years; 73% men) with ST-segment-elevation infarction were included, of whom 180 (9%) received intravenous thrombolysis before hospital admission (PHT). Patients with PHT were younger than those with in-hospital thrombolysis, primary percutaneous interventions, or no reperfusion therapy. Median time from symptom onset to hospital admission was 3.6 hours for PHT, 3.5 hours for in-hospital lysis, 3.2 hours for primary percutaneous interventions, and 12 hours for no reperfusion therapy. In-hospital death was 3.3% for PHT, 8.0% for in-hospital lysis, 6.7% for primary percutaneous interventions, and 12.2% for no reperfusion therapy. One-year survival was 94%, 89%, 89%, and 79%, respectively. In a multivariate analysis of predictors of 1-year survival, PHT was associated with a 0.49 relative risk of death (95% CI, 0.24 to 1.00; P=0.05). When the analysis was limited to patients receiving reperfusion therapy, the relative risk of death for PHT was 0.52 (95% CI, 0.25 to 1.08; P=0.08). In patients with PHT admitted in < or =3.5 hours, in-hospital mortality was 0% and 1-year survival was 99%. CONCLUSIONS: The 1-year outcome of patients treated with PHT compares favorably with that of patients treated with other modes of reperfusion therapy; this favorable trend persists after multivariate adjustment. Patients with PHT admitted very early have a very high 1-year survival rate.

Impact of combined secondary prevention therapy after myocardial infarction: data from a nationwide French registry.

BACKGROUND: Several classes of medications improve survival in patients with coronary artery disease. Whether these medications, as used in the real world, have additive efficacy remains speculative. OBJECTIVES: To assess whether patients discharged on combined secondary prevention medications after acute myocardial infarction (AMI) have improved 1-year survival, compared with the action of any single class of medications. DESIGN AND SETTING: Nationwide registry of consecutive patients admitted to intensive care units for AMI in November 2000 in France. Multivariate Cox regression analysis, including a propensity score for the prescription of combined therapy, was used. RESULTS: Of the 2119 patients discharged alive, 1095 (52%) were prescribed a combination of antiplatelet agents, beta-blockers, and statins (triple therapy), of whom 567 (27%) also received angiotensin-converting enzyme inhibitors (quadruple therapy) and 528 (25%) did not. One-year survival was 97% in patients receiving triple combination therapy versus 88% in those who received either none, 1, or 2 of these medications (P < .0001). After multivariate adjustment including the propensity score, the hazard ratio for 1-year mortality in patients with triple combination therapy was 0.52 (95% CI 0.33-0.81). In patients with ejection fraction < or = 35%, beta-blockers and angiotensin-converting enzyme 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 AMI.

Effect of early initiation of statins on survival in patients with acute myocardial infarction (the USIC 2000 Registry).

We evaluated the association of statin initiation within 48 hours of admission for an acute myocardial infarction with a 1-year prognosis on a nationwide scale. Patients who received a statin within 48 hours of admission but not before hospitalization had an improved prognosis (hazard ratio 0.57, 95% confidence interval 0.38 to 0.86, p <0.007) after adjustment for covariates and propensity score.

[Prognosis at six months for primary care patients: prognostics factors analysis]. / Pronostic a six mois des patients coronariens suivis en médecine de ville: etude des facteurs influençant le devenir.

UNLABELLED: AIM OF THE SURVEY: The aim of the PREVENIR III study was to assess, in secondary prevention, the risk of subsequent coronary and cerebrovascular events at six months in a population of patients in private practice. METHODS: This was a prospective observational survey (6-month follow-up), including patients diagnosed with previous myocardial infarction, unstable angina or ischemic stroke, carried out by French general practitioners and cardiologists in private practice. RESULTS: 8288 patients were selected by 3746 physicians (2961 general practitioners and 785 cardiologists) representative of French metropolitan physicians in private practice. In this analysis the medical records of 6859 coronary patients were analyzed. After a 6-month follow-up, 84 patients had been hospitalized for a subsequent coronary or cerebrovascular event (1.2%) i.e. cumulative incidence 3.1 event per 100 person-years (95% CI 2.4-3.8). In the coronary population 77.4% of the subsequent vascular events were coronary events and 22.6% were cerebrovascular events. The event rate of coronary events was 0.9% and the cumulative incidence 2.3 event per 100 person-years (95% CI 1.8-2.8), the risk of secondary ischemic stroke was 0.3% and the cumulative incidence 0.7 event per 100 person-years (95% CI 0.4-1.0), and the all-cause mortality rate was 1.0% and the cumulative incidence 2.5 event per 100 person-years (95% CI 1.9-3.1). 61.0% of total death was cardiovascular deaths. Multivariate analysis showed that older age, recent index event, three vessel disease were more likely to undergo recurrent events. CONCLUSION: Our survey enabled a better understanding of the prognosis at six months for a large sample of coronary patients recruited in private practice medicine. For coronary patients treated in private practice the risk of subsequent events and total mortality is far from insignificant.

[Prognosis at six months for coronary patients: impact of antiplatelet agents and statins]. / Pronostic a six mois des patients coronariens: impact de l'association antiagrégants plaquettaires-statines.

PURPOSE: The aim of the PREVENIR III study was to assess, in secondary prevention, the risk after six months of subsequent coronary and cerebrovascular events. METHODS: A prospective observational survey, including patients diagnosed with previous myocardial infarction, unstable angina or ischemic stroke, was carried out by French general practitioners and cardiologists. RESULTS: 9556 patients were selected by 3746 physicians representative of French physicians. The medical records of 6859 patients with previous unstable angina or myocardial infarction were analyzed. After a 6-month follow-up, 84 patients (1.2%) had been hospitalized for coronary or cerebrovascular event i.e. cumulative incidence 3.1 per 100 person-years (95% CI 2.4-3.8) and 67 patients died (1.0%) i.e. 2.5 per 100 person-years (95% CI 1.9-3.1). Patients treated with statins and antiplatelet agents were less likely to undergo subsequent vascular events (relative risk: 0.35; 95% CI 0.20-0.61) than patients not receiving statins or antiplatelet agents. All-cause mortality rate decreased dramatically (relative risk: 0.32; 95% CI 0.16-0.65) in patients treated with a combination of statins and antiplatelet agents when compared to patients treated with neither statins nor antiplatelet agents. CONCLUSION: This work enabled a better understanding of the prognosis at six months in a large sample of coronary patients. We observed the beneficial impact of the combination of statins and antiplatelet agents in secondary prevention.

[Reasons for the under-use of secondary prevention therapies in coronary patients over the age of 70 years]. / Motifs de sous-utilisation des thérapeutiques de prévention secondaire chez les coronariens de plus de 70 ans.

INTRODUCTION: Although platelet antiaggregants, beta-blockers and statins have proved their efficacy as secondary prevention in all types of patients with arterial and thrombotic disease, these therapeutic categories remain under-used in the elderly. The reasons for this under-prescription are poorly understood. The aim of this study was to determine the reasons for not prescribing the principal secondary prevention therapies in elderly coronary patients. METHODS: Two transversal pharmaco-epidemiological surveys were carried out in a representative sample of French cardiologists. They included 1489 coronary patients aged 35 to 69 years and 1148 patients aged over 70 years, respectively. Risk factors, medical history, current treatments and reasons for non-prescription of the principal therapies were collected. RESULTS: In subjects aged 70 years or over, antiaggregants were not prescribed in 24% of patients, versus 7.5% of younger patients. Statins were not prescribed in 37% of those over 70 years, versus 14% of younger patients. Beta-blockers were not prescribed in 42% of elderly patients versus 23% of younger patients. ACE inhibitors were not prescribed in 57.6% of elderly subjects and 48.2% of younger subjects. Combinations of three or four secondary prevention treatments were half as frequently prescribed in patients over the age of 70. According to the physicians, the main reason for non-prescription in elderly patients was a lack of indication, which concerned 8% of the entire sample with respect to antiaggregants, 9% for beta-blockers and 14% for statins. These very high percentages were not found in younger subjects (1%, 3% and 2.5%, respectively). CONCLUSION: Our results confirm under-use of the principal secondary prevention therapies in elderly subjects, mainly because of a lack of indication, according to the physicians. In these patients, indications for secondary prevention appear to be tributary to numerous factors, such as age, the type of medical history, the availability of lipid parameters or compliance. In response to questions by practitioners, specific recommendations would be useful concerning secondary prevention in elderly coronary patients.

[Changes in the prescription of cardiovascular prevention drugs in France between 1995 and 2003: factors influencing the gap between evidence base medicine and clinical practice]. / Evolution des prescriptions des classes thérapeutiques cardiovasculaires majeures en prévention secondaire en France de 1995 a 2003: les raisons décelables d'un ecart entre la médecine fondée sur les preuves et la pratique.

Dramatic progresses have occurred during the past 10 years in the field of cardiovascular secondary prevention. Many randomized trials have established the efficacy of statins, antiplatelet agents, beta-blockers and ACE inhibitors for reducing cardiovascular mortality, myocardial infarction and stroke in patients with coronary heart disease. Since 2002, American and European guidelines have emphasized the importance of optimal utilization of those four main therapeutic classes. Nevertheless, drugs prescription registries conducted in France since 1995 revealed a persistent gap between evidence based medicine and clinical practice, only a minority of patient received an optimal treatment. Some factors associated with lower rate prescription have been identified: elderly patients, female gender, missing of LDL-cholesterol measurement, history of peripheral artery disease or stroke, and finally the difficulty of observance. At this time, optimization of management of these patients require a systematic measurement of LDL-cholestererol level for all patients with CAD, PAD or history of stroke, a larger prescription of statins in female patients and in elderly particularly for secondary prevention. Increasing observance which is the main challenge could involved the utilization of fixed drugs associations.

[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.

Comparison of hypertension management after stroke and myocardial infarction: results from ECLAT1--a French nationwide study.

BACKGROUND AND PURPOSE: Hypertension control is a cornerstone of preventive treatment in patients at risk for cerebral attack. The aim of this study was to analyze hypertension management in secondary prevention of stroke as compared with patients in secondary prevention of myocardial infarction (MI). METHODS: The ECLAT1 study was a cross-sectional study conducted in all French regions in a random sample of 3009 practitioners. Patients with a documented history of atherothrombotic disease were included. Risk factors and the last measurement of blood pressure (BP) available in the medical record were noted. In the current study, patients with treated hypertension and a unique manifestation of atherothrombotic disease, ischemic stroke or MI, were analyzed. RESULTS: Among the 4346 patients included in the ECLAT1 study, 1416 patients with treated hypertension and stroke or MI were analyzed. Hypertension control was poorer in patients with stroke as compared with patients with MI (24.56% versus 34.16% P<0.01). Compared with patients with MI, systolic BP (140.61+/-14.14 versus 144.21+/-14.99; P<0.0001), pulse pressure (59.91+/-11.94 versus 62.48+/-12.49; P<0.001), and, to a lesser extent, diastolic BP (80.69+/-8.39 versus 81.72+/-8.85; P<0.05) were higher in stroke patients. Moreover, antihypertensive monotherapy was more frequently used in stroke than in MI patients (43.16% versus 31.44% P<0.0001). CONCLUSIONS: With respect to the beneficial influence of tight BP control in secondary prevention of stroke, our results highlight the need for information provided to practitioners to recall the importance of hypertension control in this situation and to increase the use of combination therapy.

Why is hypertension so frequently uncontrolled in secondary prevention?

OBJECTIVE: To analyze blood pressure (BP) control in secondary prevention. DESIGN: Individual data of two cross-sectional studies on preventive cardiology (PRATIK and ESPOIR studies conducted, respectively, in general practice and with private cardiologists) were analyzed. SETTING: Primary care. PARTICIPANTS: Patients both with treated hypertension and coronary disease. MAIN OUTCOME MEASURES: Risk factors, treatments, cardiovascular history and BP were recorded. Each population was divided in three groups: group I, no other risk factor; group II, one or two risk factors; group III, three or more risk factors or diabetes. RESULTS: A total of 1423 and 2596 patients, respectively, recruited in general practice and by cardiologists were analyzed. Of these, 473 (33.24%) and 1060 (40.83%) patients, respectively, had controlled hypertension. Among uncontrolled hypertensives, more than 50% had borderline isolated systolic hypertension. Associated risk factors negatively affect hypertension control, which had been achieved in a lower percentage of patients in group III than in group I (general practice, 26.28 versus 42.20%; cardiological practice, 32.42 versus 56.13%). In general practice, the percentage of patients receiving beta-blockers was significantly lower in group III. Among individuals with uncontrolled hypertension, only 17.58 and 26.69% received at least three-drug treatment including diuretics in general and in cardiological practice, respectively. CONCLUSION: The negative influence of associated risk factors and the under-use of combination therapy contribute to poor BP control. In addition the high frequency of borderline isolated systolic hypertension suggests that the prerequisite to improve hypertension control should be to convince practitioners of the beneficial effect of tight systolic BP control (below 140 mmHg) in secondary prevention.

Significant impact of the highly informative (CA)n repeat polymorphism of the APOA-II gene on the plasma APOA-II concentrations and HDL subfractions: The ECTIM study.

High density lipoproteins (HDL) are heterogeneous in their apolipoprotein composition and the role of apolipoprotein A-II (APOA-II) in HDL structure and metabolism is poorly understood. Yet, studies of naturally occurring variations of APOA-II in mice and experiments in transgenic mice overexpressing the APOA-II gene (APOA-II) have shown that APOA-II expression influences APOA-II plasma levels and HDL size and composition. In humans, two RFLPs (BstNI and MspI) have been described in the APOA-II gene. These RFLPs, however, have been inconstantly associated with variations in APOA-II plasma levels. In particular, the large multicentric ECTIM Study did not show any significant effect of the two RFLPs. Other polymorphisms consisting of repetitive sequences have been proposed as more informative markers than RFLPs. Thus, data from the ECTIM Study were reconsidered by integrating the additional information obtained from a highly informative multiallelic (CA)(n)-repeat polymorphism located in the second intron of the gene. The population study was composed of 763 non-treated male controls and 594 cases of myocardial infarction. In controls, the (CA)(19) allele was associated with significantly decreased APOA-II (P < 0.0009) and LpA-II:A-I (P < 0.02) plasma levels. Although the APOA-I plasma levels were not affected by the polymorphism, the (CA)(19) allele was associated with an increased LpA-I/LpA-II:A-I ratio (P < 0.004). No effect, however, could be detected on myocardial infarction. Study of the linkage disequilibrium and the estimation of haplotype frequencies indicated that the impact of the APOA-II locus could hardly be detected by using the BstNI and MspI RFLPs. These data revive interest in evaluating the role of the APOA-II locus in the control of APOA-II plasma levels and HDL composition.