Management and in-hospital outcome of patients with acute myocardial infarction admitted to intensive care units at the turn of the century: results from the French nationwide USIC 2000 registry.

OBJECTIVE: To assess actual practices and in-hospital outcome of patients with acute myocardial infarction on a nationwide scale. METHODS: Of 443 intensive care units in France, 369 (83%) prospectively collected data on all cases of infarction (within < 48 hours of symptom onset) in November 2000. RESULTS: 2320 patients (median age 68 years, 73% men) were included, of whom 83% had ST segment elevation infarction (STEMI). Patients without STEMI were older and had a more frequent history of cardiovascular disease. Median time to admission was 5.0 hours for patients with and 6.5 hours for those without STEMI. Reperfusion therapy was used for 53% of patients with STEMI (thrombolysis 28%, primary angioplasty 25%). In-hospital mortality was 8.7% (5.5% of patients without and 9.3% of those with STEMI). Multivariate analysis found that age, Killip class, lower blood pressure, higher heart rate on admission, anterior location of infarct, STEMI, diabetes mellitus, previous stroke, and no current smoking independently predicted in-hospital mortality. At hospital discharge, 95% received antiplatelet agents, 75% received beta blockers, and over 60% received statins. Angiotensin converting enzyme inhibitors were prescribed for 40% of the patients without and 52% of those with ST elevation. CONCLUSIONS: This nationwide registry, including all types of centres irrespective of their size and experience, shows continued improvement in patient care and outcomes. Time from symptom onset to admission, however, has not improved in recent years and reperfusion therapy is used for just over 50% of patients with STEMI, with an increasing use of primary angioplasty.

Control of diabetes and cardiovascular risk factors in patients with type 2 diabetes: a nationwide French survey.

OBJECTIVES: To evaluate in France in 2001 the therapeutic management and control of diabetes and of modifiable cardiovascular risk factors in patients with type 2 diabetes receiving specialist care. METHODS: The study was proposed to 575 diabetologists across France. The first 8 consecutive ambulatory patients with type 2 diabetes treated by oral antidiabetic drugs (OADs) and/or insulin attending for consultation with a diabetologist were eligible for inclusion in the survey. The following data were collected: demographics, diabetic and cardiovascular history, cardiovascular risk factors, blood pressure, last recorded measurements of HbA(1c) and LDL cholesterol, and details of diabetes medication and cardiovascular medication. RESULTS: 4, 930 patients (53% men) aged 62 +/- 11 years were recruited by 410 specialists in diabetes care. The mean duration of diabetes was 12 +/- 9 years. 71% of patients were treated with OADs, 18% with an OAD + insulin and 9% with insulin alone. Mean HbA(1c) was 7.6 +/- 1.6%; HbA(1c) was<=6.5% in 27% of patients, between 6.6% and 8% in 39% of patients, and > 8% in 34% of patients. Mean blood pressure was 140 +/- 16/80 +/- 9 mmHg. In the study population as a whole the target blood pressure (systolic BP<140 mmHg and diastolic BP<80 mmHg) was attained by 29% of patients. Among the 3, 085 patients (63%) treated for hypertension, this target was attained in only 23% of patients; 40% of patients treated for hypertension received one single antihypertensive treatment, 36% received 2 treatments and 24% received 3 treatments or more. Among the 1, 845 patients considered by the investigators as not having hypertension, the target blood pressure was attained by 39%. A measurement for LDL cholesterol was available in 4, 036 patients (82%). 58% of these patients had LDL cholesterol<1.3 g/l, 29% had values between 1.3 and 1.6 g/l, and 13% had values > 1.6 g/l. 52% of patients were not receiving any lipid-lowering agents, 28% were treated with statins, 19% with fibrates, and 1% with statins + fibrates. LDL cholesterol was<1.3 g/l in only 66% of the 646 patients with associated coronary heart disease. CONCLUSION: According to this large nationwide survey, the prevalence of cardiovascular risk factors remains high. Control of glycaemia, blood pressure and LDL cholesterol does not appear to be optimal. This is due in part to the severity of diabetes in these patients seen by specialists in diabetes care; however, both awareness and application of published recommendations need to be reinforced.

Use of electronic pill boxes to assess risk of poor treatment compliance: results of a large-scale trial.

The objective of the present study was to determine the predictive factors of treatment compliance in hypertensive patients. This was an open large-scale multicenter study where mild to moderate essential hypertensive patients received trandolapril (2 mg) once daily for 30 to 60 days in addition to their usual treatment. Trandolapril was packed in electronic pill boxes that registered date and time of each opening. The main compliance parameters were the percentage of missed doses, the percentage of delayed doses, and the percentage of correct dosing periods. Predictive factors of poor compliance (correct dosing periods < 80%) were determined using a multivariate stepwise logistic regression analysis. Two thousand one hundred seventy-three patients aged 60 +/- 12 years were analyzed. Of the total patients 37% were poor compliers; 29% of patients forgot more than 10% of doses and 36% of patients delayed more than 10% of doses. Ranked predictive factors of poor compliance were: age < 60 years (odds ratio [OR], 1.80 [1.49 to 2.17], P = .0001), the Paris area (OR, 1.70 [1.32 to 2.19], P = .0001), smokers (OR, 1.65 [1.29 to 2.11], P = .0001), monotherapy (OR, 1.40 [1.14 to 1.72], P = .0012), and baseline diastolic blood pressure > or = 100 mm Hg (OR, 1.21 [1.01 to 1.46], P = .044). Therefore, we conclude that young hypertensives, large city dwellers, and smokers are more likely to be poor compliers. The presence of some of these characteristics might incite the physician either to encourage patient compliance or to prescribe antihypertensive drugs that have an effect that persists even beyond 24 h.

[Evaluation of the effect of tobacco on trandolapril tolerance]. / Evaluation de l'influence du tabac sur la tolérance du trandolapril.

The objective of this study was to evaluate the impact of smoking habits on safety of trandolapril assessed by interrogation and by visual analogue scales (VAS). A total of 3402 hypertensive smokers (> or = 1 cigarette/d for at least 6 months) and non-smokers (no smoking or ceased at least 6 months previously) received trandolapril 2 mg/d for 4 weeks. The safety profile of trandolapril was assessed by both interrogation and by VAS. The VAS completed by the patients at D0 and D28 explored the following symptoms: asthenia, nausea, cough, headaches and dizziness. A significant change in cough VAS was previously defined by an at least 19 mm change. VAS analysis was performed on 2840 patients (1296 smokers and 1544 non-smokers), mean age 59 +/- 12 years. Smokers and non-smokers were significantly different for age 56 +/- 12 years vs. 62 +/- 12 years, sex ratio 74 per cent males vs. 45 per cent, history of hypertension 4.5 +/- 6.1 years vs. 5.3 +/- 6.5 years and cough VAS score at D0 35 +/- 26 mm vs. 20 +/- 21 mm. In the total population, 214 adverse events were reported by 177 patients (5.2 per cent). The most frequent adverse events were a cough (2.1 per cent), bronchitis (0.6 per cent), headaches (0.5 per cent), rhinitis (0.4 per cent), nausea (0.4 per cent) and asthenia (0.3 per cent). Cough was reported by 23 smokers (1.5 per cent) and by 49 (2.6 per cent) non-smokers (p = 0.02). In the VAS population, 151 adverse events were reported by 130 patients, 47 smokers (3.6 per cent) and 83 non-smokers (5.4 per cent, p = 0.03). The difference between the two groups was mainly due to a cough: 15 smokers (1.2 per cent) reported a cough vs. 38 non-smokers (2.5 per cent, p = 0.01) and 77 smokers (5.9 per cent) presented a significant change of cough VAS score vs. 124 non-smokers (8.0 per cent, p = 0.03). In this large scale study, 1.9 per cent of patients treated with trandolapril exhibited a cough. Smokers were less likely to present a cough. Use of VAS confirmed this trend.

[Circadian rhythm in myocardial infarct in France. Results of the USIK study]. / Rythme circadien des infarctus du myocarde en France: résultats de l'étude USIK.

OBJECTIVES: To analyze the circadian pattern of the first signs of myocardial infarction in France. METHODS: The USIK study was conducted in November 1995 among patients hospitalized in cardiac intensive care units within 48 hours after the first signs of confirmed myocardial infarction. This prospective study recorded the day and hour of onset for each eligible patient. RESULTS: Three hundred seventy-three centers throughout France participated, including 2563 patients (71% men), mean age 68 years, with confirmed myocardial infarction. The day of the week in which the first signs occurred was recorded between November 3 and 30, 1995. The pattern did not show any peaks, notably on Monday as reported in the literature. The hour of onset was known in 2468 patients (96.3%). Demographic features and past history did not vary for the overall population. Hour of onset was: between midnight and 6 a.m. 20.1%; between 6 and 12 a.m. 30.6%; between noon and 6 p.m. 25.7%; between 6 p.m. and midnight 23.6% (p < 0.001). This pattern was also studied in several subgroups of patients defined by age, sex, presence or absence of different cardiovascular risk factors or pertinent cardiovascular history. Univariate analysis showed that the distribution in the 6 a.m.-noon period was significantly different by age group. Older patients had a higher morning peak than younger patients (32.6% versus 28.7%; p = 0.03). Inversely, this peak was lower in smokers compared with non-smokers (26.7% versus 32.4%; p = 0.005); likewise, in patients with recurrent infarction compared with first infarction patients (24.7% versus 31.9%; p = 0.003). Other variables did not affect the circadian pattern. After multivariate analysis, only 2 of these 3 factors had an influence on distribution in the 6-12 a.m. period: smoking habits (odds ratio = 0.75; p < 0.01) and prior myocardial infarction (odds ratio = 0.70; p < 0.01). CONCLUSION: This large epidemiology study confirms that there is a morning peak in the circadian pattern of myocardial infarction in France. Smoking and past history of infarction significantly affect the circadian pattern.

[Risk factors of adverse effects of angiotensin-converting enzyme inhibitors. Apropos of 30,072 patients treated by trandolapril]. / Facteurs de risque de survenue d'effets indésirables sous inhibiteur de l'enzyme de conversion: à propos de 30,072 patients traités per trandolapril.

SUMMARY: The aim of the present study was to investigate the incidence of adverse effects and the prognostic value of various risk factors in a large population of unselected hypertensive patients treated with the ACE inhibitor trandolapril. Among the 30 072 patients investigated in this post marketing retrospective study, 1813 patients (6.0 per cent) reported an adverse effect. The five most frequent side effects were coughing (3.1 per cent), dizziness (0.7 per cent), headache (0.6 per cent) asthenia (0.5 per cent) and nausea (0.3 per cent). Intolerance risk factors for trandolapril were researched using both univariate and multivariate analysis. In the univariate analysis, a prior intolerance of an ACE inhibitor and female gender were strongly correlated with either overall intolerance or coughing. The most relevant variables for the occurrence of adverse effects, listed according to their entry order in the multivariate analysis, were: prior intolerance of ACE inhibitors (OR: 4.19, 95 per cent CI: 3.66-4.78), female gender (OR: 1.46, 95 per cent CI: 1.31-1.63), prior intolerance of other antihpertensive agents (OR: 1.27, 95 per cent CI: 1.14-1.41), smoking (OR: 0.76, 95 per cent CI: 0.66-0.87) and combination with a beta blocker (OR: 1.31, 95 per cent CI: 1.08-1.58). A prior intolerance of an ACE inhibitor appears to be a very strong predictor of coughing (OR: 6.14, 95 per cent CI: 5.24-7.19). The following variables, namely female gender (OR: 1.61, 95 per cent CI: 1.40-1.85), age 60-80 (OR: 1.25, 95 per cent CI: 1.09-1.44) and prior intolerance of other antihypertensive agents (OR: 1.20, 95 per cent CI: 1.03-2.39) appear less significant.

[Epidemiology of myocardial infarction in France. Regional specificities]. / Epidémiologie de l'infarctus du myocarde en France. Spécificités régionales.

A national epidemiological study undertaken in November 1995 recensed the data of 2563 patients admitted to 373 Intensive Care Units for acute myocardial infarction. There were 1827 men and 736 women with an average age of 67 years. Seventeen per cent of patients had left ventricular ejection fration (LVEF) < or = 35%. The mortality rate at 5 days was 7.7%. Clinical heart failure (Killip > 1) was observed in 34.4% of patients. 63% of patients were admitted before the 6th hour. Forty-six per cent of patients underwent early revascularisation by thrombolysis and/or angioplasty. The most widely used drugs in the first 5 days were heparin (96%), aspirin (89%), betablockers (65%), and angiotension converting enzyme inhibitors (46%). The influence of region on the demographical features, morbidity, mortality and therapeutic practice was studied. France was divided into 6 regions. In the Centre, the patients were older, with increased morbidity and mortality compared with the national average. Patients in the North East were similar and had a higher incidence of obesity. In the Ile de France, patients were generally younger with a higher incidence of tobacco consumption and their infarcts were generally less severe. Finally, in the South East, the mortality was particularly low. In multivariate analysis living in this region was good prognostic factor whereas low LVEF (< or = 35%) and age > or = 65 years were poor prognostic factors. This study, for the first time in France, describes the clinical features of myocardial infarction admitted to the Intensive Care Unit with respect to criteria of severity (LVEF, Killip) and region of origin of the patients. Its confirms large regional variations in the severity of acute myocardial infarction.