The prognostic significance of atrial fibrillation in heart failure with preserved ejection function: insights from KaRen, a prospective and multicenter study.

The prognostic value of atrial fibrillation (AF) in heart failure with preserved ejection fraction (HFPEF) remains controversial. We sought to study the prognostic value of AF in a prospective cohort and to characterize the HFPEF patients with AF. KaRen was a prospective, multicenter, international, observational study intended to characterize HFPEF; 538 patients presenting with an acute decompensated cardiac failure and a left ventricular EF > 45% were included. EKG and echocardiogram performed 4-8 week following the index hospitalization were analyzed in core centers. Clinical and echocardiographic characteristics of patients in sinus rhythm vs. with documented AF at enrolment (decompensated HF), upon their 4-8-week visit (in presumed stable clinical condition) and according to patients' cardiac history, were compared. The primary study endpoint was death from any cause or first hospitalization for decompensated heart failure (HF). A total of 413 patients (32% in AF) were analyzed, with a mean follow-up period of 28 months. The patients were primarily elderly individuals (mean age: 76.2 years), with a slight female predominance and a high prevalence of non-cardiovascular comorbidities. The baseline echocardiographic characteristics and the natriuretic peptide levels were indicative of a more severe heart condition among the patients with AF. However, the patients with AF exhibited a similar survival-free interval compared with the patients in sinus rhythm. In this elderly HFPEF population with a high prevalence of non-cardiovascular comorbidities, the presence of AF was not associated with a worse prognosis despite impaired clinical and echocardiographic features.ClinicalTrials.gov: NCT00774709.

Prevalence and clinical phenotype of hereditary transthyretin amyloid cardiomyopathy in patients with increased left ventricular wall thickness.

AIMS: Increased left ventricular wall thickness (LVWT) is a common finding in cardiology. It is not known how often hereditary transthyretin-related familial amyloid cardiomyopathy (mTTR-FAC) is responsible for LVWT. Several therapeutic modalities for mTTR-FAC are currently in clinical trials; thus, it is important to establish the prevalence of TTR mutations (mTTR) and the clinical characteristics of the patients with mTTR-FAC. METHODS AND RESULTS: In a prospective multicentre, cross-sectional study, the TTR gene was sequenced in 298 consecutive patients diagnosed with increased LVWT in primary cardiology clinics in France. Among the included patients, median (25-75th percentiles) age was 62 [50;74]; 74% were men; 23% were of African origin; and 36% were in NYHA Class III-IV. Median LVWT was 18 (16-21) mm. Seventeen (5.7%; 95% confidence interval [CI]: [3.4;9.0]) patients had mTTR of whom 15 (5.0%; 95% CI [2.9;8.2]) had mTTR-FAC. The most frequent mutations were V142I (n = 8), V50M (n = 2), and I127V (n = 2). All mTTR-FAC patients were older than 63 years with a median age of 74 [69;79]. Of the 15 patients with mTTR-FAC, 8 were of African descent while 7 were of European descent. In the African descendants, mTTR-FAC median age was 74 [72;79] vs. 55 [46;65] years in non-mTTR-FAC (P < 0.001). In an adjusted multivariate model, African origin, neuropathy, carpal tunnel syndrome, electrocardiogram (ECG) low voltage, and late gadolinium enhancement (LGE) at cardiac-magnetic resonance imaging were all independently associated with mTTR-FAC. CONCLUSION: Five per cent of patients diagnosed with hypertrophic cardiomyopathy have mTTR-FAC. Mutated transthyretin genetic screening is warranted in elderly subjects with increased LVWT, particularly, those of African descent with neuropathy, carpal tunnel syndrome, ECG low voltage, or LGE.

Causes-of-death analysis of patients with cardiac resynchronization therapy: an analysis of the CeRtiTuDe cohort study.

AIMS: The choice of resynchronization therapy between with (CRT-D) and without (CRT-P) a defibrillator remains a contentious issue. Cause-of-death analysis among CRT-P, compared with CRT-D, patients could help evaluate the extent to which CRT-P patients would have additionally benefited from a defibrillator in a daily clinical practice. METHODS AND RESULTS: A total of 1705 consecutive patients implanted with a CRT (CRT-P: 535 and CRT-D: 1170) between 2008 and 2010 were enrolled in CeRtiTuDe, a multicentric prospective follow-up cohort study, with specific adjudication for causes of death at 2 years. Patients with CRT-P compared with CRT-D were older (P < 0.0001), less often male (P < 0.0001), more symptomatic (P = 0.0005), with less coronary artery disease (P = 0.003), wider QRS (P = 0.002), more atrial fibrillation (P < 0.0001), and more co-morbidities (P = 0.04). At 2-year follow-up, the annual overall mortality rate was 83.80 [95% confidence interval (CI) 73.41-94.19] per 1000 person-years. The crude mortality rate among CRT-P patients was double compared with CRT-D (relative risk 2.01, 95% CI 1.56-2.58). In a Cox proportional hazards regression analysis, CRT-P remained associated with increased mortality (hazard ratio 1.54, 95% CI 1.07-2.21, P = 0.0209), although other potential confounders may persist. By cause-of-death analysis, 95% of the excess mortality among CRT-P subjects was related to an increase in non-sudden death. CONCLUSION: When compared with CRT-D patients, excess mortality in CRT-P recipients was mainly due to non-sudden death. Our findings suggest that CRT-P patients, as currently selected in routine clinical practice, would not potentially benefit with the addition of a defibrillator.

Impact of gender on use of revascularization in acute coronary syndromes: the national observational study of diagnostic and interventional cardiac catheterization (ONACI).

OBJECTIVES: To assess the impact of gender on myocardial revascularization using data collected in a French nationwide registry: the national observational study of diagnostic and interventional cardiac catheterization (ONACI). BACKGROUND: Gender differences in management of patients with acute coronary syndromes (ACS) have been reported. METHODS: We analysed data from a nationwide French prospective multicentre registry including 64,932 suspected ACS patients recruited in 99 centres from 2004 to 2008. RESULTS: Overall, women were older (70.7 ± 12.7 vs. 63.8 ± 12.9 years), had a higher cardiovascular risk profile, and were more frequently admitted with non ST-elevation myocardial infarction or unstable angina (NSTEMI/UA) compared to men (73% vs. 68%). Women had significantly more angiographically normal coronary arteries or non-significant coronary artery disease (CAD) in both STEMI (6% vs. 3%) and NSTEMI/UA (21% vs. 11%) while men had more severe CAD. After adjusting for age, cardiovascular risk factors, and extent of disease, myocardial revascularization (defined as the use of percutaneous coronary intervention (PCI) or coronary artery bypass grafting) was less frequently used in women (adjusted OR = 0.78; 95% CI: 0.77-0.83). For those receiving PCI, in-hospital mortality within 24 hr of intervention was higher in women (3.6% vs. 1.2%; adjusted OR = 1.51; 95% CI: 1.22-1.87). CONCLUSIONS: In the present study, despite having a higher cardiovascular risk profile, women more frequently had normal vessel/non-significant angiographic coronary artery disease. In patients with significant coronary artery disease, myocardial revascularization was less frequently used in women whatever the type of ACS.

Socioeconomic factors and mortality in diastolic heart failure.

BACKGROUND: Mortality in patients with heart failure with preserved ejection fraction (HFPEF) has remained stable over recent decades. Few studies have explored prognostic characteristics specifically in HFPEF, and none of them has assessed the potential impact of socioeconomic factors. We aimed to evaluate the impact of socioeconomic factors on all-cause and cardiovascular mortality in HFPEF patients. MATERIALS AND METHODS: We used data from the French ODIN cohort. All patients with heart failure and a left ventricular ejection fraction (LVEF) > 45%, included in ODIN between July 2007 and July 2010, were eligible here. Socioeconomic, demographic, clinical, biological and therapeutic data were collected at inclusion. The endpoints were all-cause and cardiovascular mortality between inclusion and 30 September 2011. The impact of patient socioeconomic characteristics on mortality was assessed using Cox regression models. RESULTS: Of 575 HFPEF patients considered, 58·6% were male; their mean age was 71·1 ± 13·5 years, and their mean LVEF was 58·1 ± 8·5%. After adjustment for confounders, living alone and limitations on activities of daily living were associated with all-cause mortality [HR = 1·77, 95%CI(1·11-2·81) and 2·61(1·35-5·03), respectively] and cardiovascular mortality [2·26 (1·24-4·10) and 3·16 (1·33-7·54), respectively]. Having a professional occupation was associated with a lower cardiovascular mortality only [0·37(0·15-0·94)]. CONCLUSIONS: Poor social conditions impair survival in patients with HFPEF. These findings may shed new light on how best to detect HFPEF patients with high health-care needs.

Clinical events as a function of proton pump inhibitor use, clopidogrel use, and cytochrome P450 2C19 genotype in a large nationwide cohort of acute myocardial infarction: results from the French Registry of Acute ST-Elevation and Non-ST-Elevation Myocardial Infarction (FAST-MI) registry.

BACKGROUND: Clopidogrel requires metabolic activation by cytochrome P450 2C19 (CYP2C19). Proton pump inhibitors (PPIs) that inhibit CYP2C19 are commonly coadministered with clopidogrel to reduce the risk of gastrointestinal bleeding. This analysis compares treatment outcomes for patients in the French Registry of Acute ST-Elevation and Non-ST-Elevation Myocardial Infarction (FAST-MI) who did or did not receive clopidogrel and/or PPIs. METHODS AND RESULTS: The FAST-MI registry included 3670 patients (2744 clopidogrel- and PPI-naïve patients) presenting with definite MI. Patients were categorized according to use of clopidogrel and/or PPI within 48 hours after hospital admission. PPI use was not associated with an increased risk for any of the main in-hospital events (in-hospital survival, reinfarction, stroke, bleeding, and transfusion). Likewise, PPI treatment was not an independent predictor of 1-year survival (hazard ratio, 0.97; 95% confidence interval [CI], 0.87 to 1.08; P=0.57) or 1-year MI, stroke, or death (hazard ratio, 0.98; 95% CI, 0.90 to 1.08; P=0.72). No differences were seen when the type of PPI or CYP2C19 genotype was taken into account. In the propensity-matched cohorts, the odds ratios for major in-hospital events in PPI versus no PPI were 0.29 (95% CI, 0.06 to 1.44) and 1.70 (95% CI, 0.10 to 30.3) for patients with 1 and 2 variant alleles, respectively. Similarly, the hazard ratio for 1-year events in hospital survivors was 0.68 (95% CI, 0.26 to 1.79) and 0.55 (95% CI, 0.06 to 5.30), respectively. CONCLUSION: PPI use was not associated with an increased risk of cardiovascular events or mortality in patients administered clopidogrel for recent MI, whatever the CYP2C19 genotype, although harm could not be formally excluded in patients with 2 loss-of-function alleles.

Management of patients with acute ST-elevation myocardial infarction: Results of the FAST-MI Tunisia Registry.

BACKGROUND: The FAST-MI Tunisia registry was set up by the Tunisian Society of Cardiology and Cardiovascular Surgery to assess the demographic and clinical characteristics, management and hospital outcome of patients with ST-elevation myocardial infarction (STEMI). METHODS: Data for 459 consecutive patients (mean age 60.8 years; 88.5% male) with STEMI, treated in 16 public hospitals (representing 72.2% of public hospitals in Tunisia treating STEMI patients), were collected prospectively.The most common risk factors were smoking (63.6%), hypertension (39.7%), diabetes (32%) and dyslipidaemia (18.2%). RESULTS: Among the 459 patients, 61.8% received reperfusion therapy: 30% with primary percutaneous coronary intervention (PPCI) and 31.8% with intravenous fibrinolysis (IF) (28.6% with pre-hospital thrombolysis). The median time from symptom onset to thrombolysis was 185 min and to PPCI was 358 min. In-hospital mortality was 5.3%. Compared with those managed at regional hospitals, patients managed at interventional university hospitals (n = 357) were more likely to receive reperfusion therapy (52.9% vs. 34.1%; p<0.001), with less IF (28.6% vs. 43.1%; p = 0.002) but more PPCI (37.8% vs. 3.9%; p<0.0001). However, in-hospital mortality in the two types of hospitals was similar (5.3% vs. 5.1%; p = 0.866). CONCLUSIONS: Data from the FAST-MI Tunisia registry show that a pharmaco-invasive strategy of management for STEMI should be promoted in non-interventional regional hospitals.

Effectiveness of a patient education programme in heart failure with preserved ejection fraction: Results from the ODIN cohort study using propensity score matching.

BACKGROUND: Patient education programmes (PEP) are recommended for patients with heart failure but have not been specifically assessed in heart failure with preserved ejection fraction (HFpEF). AIM: To assess the effectiveness of a structured PEP in reducing all-cause mortality in patients with HFpEF. METHODS: Patients with HFpEF were selected from the ODIN cohort, designed to assess PEP effectiveness in patients with HF whatever their ejection fraction, included from 2007 to 2010, and followed up until 2013. Baseline sociodemographic, clinical, biological and therapeutic characteristics were collected. At inclusion, patients were invited to participate in the PEP, which consisted of educational diagnosis, education sessions and final evaluation. Education focused on HF pathophysiology and medication, symptoms of worsening HF, dietary recommendations and management of exercise. Propensity score matching and Cox models were performed. RESULTS: Of 849 patients with HFpEF, 572 (67.4%) participated in the PEP and 277 (32.6%) did not. Patients who participated in the PEP were younger (67.0±13.1 vs 76.1±13.2 years; standardized difference [StDiff] =-54.6%), less often women (39.7% vs 48.4%; StDiff =-17.6%) and presented more often with hypercholesterolaemia (55.2% vs 35.2%; StDiff 41.2%), smoking (35.1% vs 28.7%; StDiff 13.8%), alcohol abuse (14.1% vs 8.9%; StDiff 16.5%) and ischaemic HF (38.7% vs 29.2%; StDiff 20.0%) than those who did not; they also presented with better clinical cardiovascular variables. After propensity score matching, baseline characteristics were balanced, except hypertension (postmatch StDiff 19.1%). The PEP was associated with lower all-cause mortality (pooled hazard ratio 0.70, 95% confidence interval 0.49-0.99; P=0.042). This association remained significant after adjustment for hypertension (adjusted pooled hazard ratio 0.68, 95% confidence interval 0.48-0.97; P=0.036). CONCLUSIONS: In this investigation, a structured PEP was associated with lower all-cause mortality. Patient education might be considered an effective treatment in patients with HFpEF.

Changes in One-Year Mortality in Elderly Patients Admitted with Acute Myocardial Infarction in Relation with Early Management.

BACKGROUND: Elderly patients are underrepresented in acute myocardial infarction trials. Our aim was to determine whether, in elderly patients, changes in management in the past 15 years are associated with improved 1-year mortality after hospital admission for myocardial infarction. METHODS: We used data from 4 1-month French registries, conducted 5 years apart from 1995 to 2010, including 3389 elderly patients (≥75 years of age). RESULTS: From 1995 to 2010, mean age remained stable (82.1 years), similar in ST- and non-ST-elevation myocardial infarction patients. Obesity, diabetes, hypertension, and hypercholesterolemia increased. History of prior myocardial infarction, stroke, and peripheral artery disease remained stable, while history of heart failure decreased. Major changes in management were noted: early percutaneous coronary intervention, early treatment with antiplatelet agents, low-molecular-weight heparin, beta-blockers, angiotensin-converting enzyme inhibitor or angiotensin receptor blocker, and statins all increased. Early mortality after hospital admission decreased from 25.0% to 8.4%. One-year mortality decreased from 36.2% to 20.0% (adjusted hazard ratio 2010 vs 1995: 0.47, 0.39-0.57), both for ST-elevation myocardial infarction (36.8% to 21.1%) and non-ST-elevation myocardial infarction (34.8% to 19.1%). Mortality reduction was observed in all age groups, including those ≥85 years of age (from 46.2% to 31.4%). The study period, however, was no longer associated with decreased mortality when variables reflecting management changes were taken into account. CONCLUSIONS: Early and 1-year mortality after hospital admission of elderly patients with acute myocardial infarction has substantially decreased over the past 15 years. This improvement is likely mediated by increasing use of recommended management strategies. These data support the application of guidelines derived from trials mostly including younger patients to elderly populations as well.

Management of Takotsubo cardiomyopathy in non-academic hospitals in France: The Observational French SyndromEs of TakoTsubo (OFSETT) study.

BACKGROUND: Takotsubo cardiomyopathy (TTC) is a rare condition characterized by a sudden temporary weakening of the heart. TTC can mimic acute myocardial infarction and is associated with a minimal release of myocardial biomarkers in the absence of obstructive coronary artery disease. AIMS: To provide an extensive description of patients admitted to hospital for TTC throughout France and to study the management and outcomes of these patients. METHODS: In 14 non-academic hospitals, we collected clinical, electrocardiographic, biological, psychological and therapeutic data in patients with a diagnosis of TTC according to the Mayo Clinic criteria. RESULTS: Of 117 patients, 91.5% were women, mean ± SD age was 71.4 ± 12.1 years and the prevalence of risk factors was high (hypertension: 57.9%, dyslipidaemia: 33.0%, diabetes: 11.5%, obesity: 11.5%). The most common initial symptoms were chest pain (80.5%) and dyspnoea (24.1%). A triggering psychological event was detected in 64.3% of patients. ST-segment elevation was found in 41.7% of patients and T-wave inversion in 71.6%. Anterior leads were most frequently associated with ST-segment elevation, whereas T-wave inversion was more commonly associated with lateral leads, and Q-waves with septal leads. The ratio of peak B-type natriuretic peptide (BNP) or N-terminal prohormone BNP (NT-proBNP) level to peak troponin level was 1.01. No deaths occurred during the hospital phase. After 1 year of follow-up, 3 of 109 (2.8%) patients with available data died, including one cardiovascular death. Rehospitalizations occurred in 17.4% of patients: 2.8% due to acute heart failure and 14.7% due to non-cardiovascular causes. There was no recurrence of TTC. CONCLUSIONS: This observational study of TTC included primarily women with atherosclerotic risk factors and mental stress. T-wave inversion was more common than ST-segment elevation. There were few adverse cardiovascular outcomes in these patients after 1-year follow-up.

Impact of age-adjusted insulin-like growth factor 1 on major cardiovascular events after acute myocardial infarction: results from the fast-MI registry.

BACKGROUND: The GH/IGF-1 axis is being targeted for therapeutic development in diseases such as short stature, cancer, and metabolic disorders. The impact of IGF-1 in cardiovascular disease remains controversial. We therefore studied whether IGF-1 at admission for acute myocardial infarction (AMI) predicted death, recurrent AMI, and stroke over a 2-year follow-up. METHODS: Using data from the French registry of Acute ST-elevation and non-ST-elevation Myocardial Infarction registry, we measured IGF-1 among all the 1005 patients with AMI who participated in the serum data bank. Because IGF-1 decreases with age, a standardized IGF-1 score was calculated as previously described [IGF-1 score = (log [IGF-1 (micrograms per liter)] + 0.00625 × age - 2.555)/0.104]. Impact of IGF-1 score (continuous and quartiles) on outcomes were compared using Cox proportional hazards regression models. RESULTS: During follow-up, 190 patients died or had a recurrent AMI or stroke. Patients in the lowest quartile of IGF-1 were older and more frequently female and diabetic compared with patients in the other quartiles. After adjustment for known cardiovascular factors, an increase of five units of IGF-1 score was associated with a 30% decrease of the risk of events during follow-up (adjusted hazard ratio 0.70; 95% confidence interval 0.54-0.92; P = .0093). Similarly, the lowest quartile of IGF-1 was associated with an increased risk of events (adjusted hazard ratio 1.52, 95% confidence interval 1.11-2.08; compared with others quartiles, P = .010). CONCLUSIONS: Low IGF-1 score is associated with an increased risk of all-cause death, recurrent myocardial infarction, and stroke in AMI patients. Whether patients treated by IGF-1 axis inhibitors have a specific clinical course after AMI would be worth studying.

Management of non-traumatic chest pain by the French Emergency Medical System: Insights from the DOLORES registry.

BACKGROUND: The early recognition of acute coronary syndromes is a priority in health care systems, to reduce revascularization delays. In France, patients are encouraged to call emergency numbers (15, 112), which are routed to a Medical Dispatch Centre where physicians conduct an interview and decide on the appropriate response. However, the effectiveness of this system has not yet been assessed. AIM: To describe and analyse the response of emergency physicians receiving calls for chest pain in the French Emergency Medical System. METHODS: From 16 November to 13 December 2009, calls to the Medical Dispatch Centre for non-traumatic chest pain were included prospectively in a multicentre observational study. Clinical characteristics and triage decisions were collected. RESULTS: A total of 1647 patients were included in the study. An interview was conducted with the patient in only 30.5% of cases, and with relatives, bystanders or physicians in the other cases. A Mobile Intensive Care Unit was dispatched to 854 patients (51.9%) presenting with typical angina chest pains and a high risk of cardiovascular disease. Paramedics were sent to 516 patients (31.3%) and a general practitioner was sent to 169 patients (10.3%). Patients were given medical advice only by telephone in 108 cases (6.6%). CONCLUSIONS: Emergency physicians in the Medical Dispatch Centre sent an effecter to the majority of patients who called the Emergency Medical System for chest pain. The response level was based on the characteristics of the chest pain and the patient's risk profile.

Prescription of cardiovascular drugs in the French ODIN cohort of heart failure patients according to age and type of chronic heart failure.

BACKGROUND: Chronic heart failure (CHF) is a frequent severe disease. Disease-management programmes, which contain a therapeutic patient education component, will play a central role in improving delivery of care and reducing mortality and hospitalizations for CHF. AIMS: In order to have an up-to-date overview of medical treatment of CHF in France implemented by hospital and clinic cardiologists especially interested in CHF and therapeutic patient education, we described the prescription of cardiovascular drugs in the large ODIN cohort of CHF patients, according to age and type of CHF. METHODS: From 2007 to 2010 (median follow-up 27.2 months), CHF patients were prospectively enrolled in a multicentre 'real-world' French cohort by centres previously trained in therapeutic patient education. Patients were grouped according to age (< 60 years, 60 to<70 years, 70 to<80 years and ≥ 80 years) and type of CHF (characterized by level of LVEF: reduced, borderline or preserved). Medical prescription was described and mortality was assessed at long-term follow-up. RESULTS: The cohort consisted of 3237 patients (67.6 years; 69.4% men). The oldest age group had the highest LVEF. Blockers of the angiotensin-aldosterone system were prescribed progressively and significantly less frequently as the population advanced in age or as LVEF was more preserved. The mean dosages of the main prescribed CHF drugs remained ≥ 50% lower than those recommended for most drugs in all age and LVEF groups. Drug prescriptions were related to aetiology of reduced or preserved CHF. A global decrease in CHF drug prescription was observed for all medication classes except calcium blockers, according to maintenance of relatively or totally preserved LVEF. Survival was related to age but not to type of CHF. CONCLUSION: In CHF, and despite management by cardiologists particularly interested in CHF and specifically trained to deliver therapeutic patient education, medical prescription differed substantially from guidelines. Age and type of CHF (reduced versus preserved) appeared to be important factors in lack of adherence to guidelines. However, only age influenced mortality; the type of CHF did not affect survival.

Presentation and revascularization patterns of patients admitted for acute coronary syndromes in France between 2004 and 2008 (from the National Observational Study of Diagnostic and Interventional Cardiac Catheterization [ONACI]).

Patients with acute coronary syndrome (ACS) comprise a heterogeneous group. Despite clear guidelines, the management of ACS in clinical practice is variable. We aimed to evaluate clinical characteristics and myocardial revascularization patterns of patients presenting with ACS from a large French nationwide registry. The National Observational Study of Diagnostic and Interventional Cardiac Catheterization is a multicenter registry including all interventional cardiology procedures performed since 2004. Patient demographics and co-morbidities, invasive parameters, treatment options, and procedural techniques were prospectively collected. The present study is focused on data collected between 2004 and 2008. Patients were recruited in 99 hospitals (55% in private clinics, 45% in public institutions). Over a 5-year period, 64,932 patients with ACS were included (mean age 65.7 ± 13.3; 73% men, 31% ST-elevation myocardial infarction [STEMI]). Patients presenting with unstable angina pectoris and non-ST-elevation myocardial infarction weresimilar with regards to clinical presentation and coronary artery disease (CAD) extension. Overall, these patients were older, had a higher cardiovascular risk profile, and had more severe CAD compared with STEMI patients. In-hospital mortality during the first 24 hours was higher in STEMI patients. Patient's characteristics and CAD were highly dependent on the type of ACS. Patients with unstable angina/non-STEMI were older and had a more severe CAD. In-hospital complications were higher in STEMI patients.

Determinants of improved one-year survival in non-ST-segment elevation myocardial infarction patients: insights from the French FAST-MI program over 15 years.

BACKGROUND: Improved early outcome in non-ST elevation myocardial infarction (NSTEMI) patients has been mainly attributed to a broader use of invasive strategies. Little is known about the impact of other changes in early management. METHODS: We aimed to assess 15-year trends in one-year mortality and their determinants in NSTEMI patients. We used data from 4 one-month French registries, conducted 5 years apart from 1995 to 2010 including 3903 NSTEMI patients admitted to intensive care units. RESULTS: From 1995 to 2010, no major change was observed in patient characteristics, while therapeutic management evolved considerably. Early use of antiplatelet agents, ß-blockers, ACE-inhibitors and statins increased over time (P < 0.001); use of newer anticoagulants (low-molecular-weight heparin, bivalirudin or fondaparinux) increased from 40.8% in 2000 to 78.9% in 2010 (P < 0.001); percutaneous coronary intervention (PCI)≤ 3 days of admission rose from 7.6% to 48.1% (P < 0.001). One-year death decreased from 20% to 9.8% (HR adjusted for baseline parameters, 2010 vs. 1995 = 0.47, 95% CI: 0.35-0.62). Early PCI (HR = 0.67; 95% CI: 0.49-0.90), use of newer anticoagulants (HR = 0.62; 95% CI: 0.48-0.78) and early use of evidence based medical therapy (HR = 0.54; 95% CI: 0.40-0.72) were predictors of improved one year-survival. CONCLUSIONS: One-year mortality of NSTEMI patients decreased by 50% in the past 15years. Our data support current guidelines recommending early invasive strategies and use of newer anticoagulants for NSTEMI, and also show a strong positive association between early use of appropriate medical therapies and one-year survival, suggesting that these medications should be used from the start.

[Acute myocardial infarction in the elderly. The FAST-MI registry]. / L'infarctus du sujet âgé : données du registre FAST-MI 2010.

The FAST-MI 2010 registry collected information on characteristics and management of patients hospitalized for acute myocardial infraction during a one-month period in 213 centers across France, at the end of 2010. Among the 3079 patients included, 31% were aged 75 years or over (25% of those with ST-elevation myocardial infarction, and 38% of those with non-ST-elevation myocardial infarction). The clinical profile and risk factors differ in elderly patients, but chest pain remains the most common presenting symptom, although a substantial percentage of patients also present with signs of heart failure. Elderly individuals receive less recommended medications, including reperfusion therapy for STEMI, with the largest difference observed beyond 85 years of age. In-hospital mortality increases with age, particularly after 85 years, but has decreased compared with previous French surveys.

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.

Therapeutic patient education and all-cause mortality in patients with chronic heart failure: a propensity analysis.

BACKGROUND: Meta-analyses of disease management programs have shown favorable effects in chronic heart failure. Therapeutic patient education forms an integral part of these programs and may influence mortality per se. We aimed to determine the relationship between therapeutic patient education applied in routine clinical practice and long-term mortality in chronic heart failure. METHODS: From 2007 to 2010 (median follow-up: 27.2 months), heart failure patients were prospectively enrolled in a multicenter, 'real-world', French cohort by centers previously trained in therapeutic patient education. As educated and non-educated patient profiles were expected to differ, mortality was assessed using conventional multivariate analyses and analyses made on propensity-matched cohorts for the application of therapeutic patient education. RESULTS: Of the 3237 patients who participated in the study (67.5 years; 69.5% men), 2347 were educated (72.5%) and 890 were not educated (27.5%). Non-educated patients were older, more often female, and more severely diseased than educated patients. All-cause mortality was 17.3% in the educated group vs. 31.0% in the non-educated group (adjusted HR 0.70, 95% CI 0.58-0.84, P<.001). This association remained in paired groups after adjustment for all baseline covariates excluding (model 1) or including (model 2) cardiovascular medications and propensity score (HR 0.72, 95% CI 0.58-0.90, P=.003; HR 0.73, 95% CI 0.59-0.90, P=.004, respectively). CONCLUSION: In chronic heart failure, therapeutic patient education by trained healthcare professionals appears associated with lower all-cause mortality. These data may have important implications in terms of healthcare organization, because they suggest that therapeutic patient education should be developed in all types of cardiology centers.

Study design and baseline characteristics of the national observational study of diagnostic and interventional cardiac catheterization by the French Society of Cardiology.

The national observational study of diagnostic and interventional cardiac catheterization (ONACI) is a prospective multicenter registry of the French Society of Cardiology including all interventional cardiology procedures performed from 2004. We aimed to evaluate "real-world" management of patients with coronary artery disease in France from this registry. The present study was focused on data collected from 2004 to 2008. Patient demographics and co-morbidities, invasive parameters, treatment options, and procedural techniques were prospectively collected. Patients were recruited from 99 hospitals (55% of patients were hospitalized in private clinics and 45% in public institutions). During a 5-year period, a total of 298,105 patients underwent coronary angiography and 176,166 patients underwent percutaneous coronary intervention. Diagnosis was acute coronary syndrome in 22%, stable angina or silent ischemia in 23%, and atypical chest pain in 9% of cases. Normal coronary arteries or nonsignificant coronary narrowing were found in 26% of patients. Radial access was increasingly used over the years regardless of the indication. The average number of percutaneous coronary interventions per procedure was 1.5 ± 0.7 (range, 1.3 ± 0.7 to 1.5 ± 0.7) and that of stents per procedure was 1.5 ± 0.8 (range, 1.5 ± 0.8 to 1.6 ± 0.8). Drug-eluting stents were used in 45% (range, 34% to 62%), increasing from 2004 to 2006, and then decreasing after the 2006 controversy. In conclusion, ONACI is one of the largest catheterization registries during this period, providing a detailed and comprehensive global description of the spectrum and management of patients with suspected coronary artery disease undergoing cardiac catheterization.

Current aspects of the spectrum of acute heart failure syndromes in a real-life setting: the OFICA study.

AIMS: To improve knowledge of epidemiological data, management, and clinical outcome of acute heart failure (AHF) in a real-life setting in France. METHODS AND RESULTS: We conducted an observational survey constituting a single-day snapshot of all unplanned hospitalizations because of AHF in 170 hospitals throughout France (the OFICA survey). A total of 1658 patients (median age 79 years, 55% male) were included. Family doctors were the first medical contact in 43% of cases, and patients were admitted through emergency departments in 64% of cases. Clinical scenarios were mainly acutely decompensated HF (48%) and acute pulmonary oedema (38%) with similar clinical and biological characteristics as well as outcome. Characteristics were different and severity higher in both shock and right HF. Infection and arrhythmia were the most frequent precipitating factors (27% and 24% of cases); diabetes and chronic pulmonary disease were the most frequent co-morbidities (31% and 21%). Over 80% of patients underwent both natriuretic peptide testing and echocardiography. LVEF was preserved (>50%) in 36% of patients and associated with specific characteristics and lower severity. Median hospital stay was 13 days; in-hospital mortality was 8.2%, and independent predictors were age, blood pressure, and creatinine. Treatment at discharge in patients with reduced LVEF included ACE inhibitors/ARBs, beta-blockers, and aldosterone inhibitors in 78, 67, and 27% cases. Non-surgical devices were reported in <20% of potential candidates. CONCLUSION: This comprehensive survey analysing AHF in real life emphasizes the heterogeneous nature and overall high severity of AHF. It could be a useful tool to identify unsolved medical issues and improve outcome. TRIAL REGISTRATION: NCT01080937.