ST-segment elevation myocardial infarction: Management and association with prognosis during the COVID-19 pandemic in France.

BACKGROUND: Systems of care have been challenged to control progression of the COVID-19 pandemic. Whether this has been associated with delayed reperfusion and worse outcomes in French patients with ST-segment elevation myocardial infarction (STEMI) is unknown. AIM: To compare the rate of STEMI admissions, treatment delays, and outcomes between the first peak of the COVID-19 pandemic in France and the equivalent period in 2019. METHODS: In this nationwide French survey, data from consecutive STEMI patients from 65 centres referred for urgent revascularization between 1 March and 31 May 2020, and between 1 March and 31 May 2019, were analysed. The primary outcome was a composite of in-hospital death or non-fatal mechanical complications of acute myocardial infarction. RESULTS: A total of 6306 patients were included. During the pandemic peak, a 13.9±6.6% (P=0.003) decrease in STEMI admissions per week was observed. Delays between symptom onset and percutaneous coronary intervention were longer in 2020 versus 2019 (270 [interquartile range 150-705] vs 245 [140-646]min; P=0.013), driven by the increase in time from symptom onset to first medical contact (121 [60-360] vs 150 [62-420]min; P=0.002). During 2020, a greater number of mechanical complications was observed (0.9% vs 1.7%; P=0.029) leading to a significant difference in the primary outcome (112 patients [5.6%] in 2019 vs 129 [7.6%] in 2020; P=0.018). No significant difference was observed in rates of orotracheal intubation, in-hospital cardiac arrest, ventricular arrhythmias and cardiogenic shock. CONCLUSIONS: During the first peak of the COVID-19 pandemic in France, there was a decrease in STEMI admissions, associated with longer ischaemic time, exclusively driven by an increase in patient-related delays and an increase in mechanical complications. These findings suggest the need to encourage the population to seek medical help in case of symptoms.

Slow pathway elimination for atrioventricular nodal reentrant tachycardia with the 8-mm tip cryoablation catheter: an 18-month follow-up study.

PURPOSE: The 9-French 8-mm tip cryoablation catheter confers a high rate of acute slow pathway (SP) elimination and an acceptable short-term outcome in patients with atrioventricular nodal reentrant tachycardia (AVNRT). The aim of this study was to investigate the long-term outcome of patients treated with this electrode in this indication. METHODS: Eighty-two patients (female = 52) with a mean age of 54.9 ± 17.7 years underwent SP elimination for typical AVNRT with the 8-mm tip cryocatheter in our institution between November 2009 to June 2012. Clinical and procedural characteristics were prospectively collected. RESULTS: Acute procedural success defined as AVNRT non-inducibility at the end of the procedure was obtained in 81/82 patients (98.7 %). Mean procedure duration and fluoroscopy time were 74.4 ± 28.7 min (range, 35-160 min) and 8.7 ± 5.3 min (range, 2-26 min), respectively. Mean number of energy applications was 4.0 ± 2.4 (range, 2-15). No permanent atrioventricular block was observed. Transient atrioventricular block occurred in 12 patients (14.6 %). Traumatic fast pathway conduction block occurred in one patient before cryoenergy delivery. Using an intention-to-treat analysis, 78 patients (95.1 %) remained free of AVNRT recurrence during a mean follow-up of 17.8 ± 9.3 months. CONCLUSIONS: This study confirmed that the 8-mm tip cryocatheter is both safe and highly effective for SP conduction elimination in patients with AVNRT and demonstrated a low recurrence rate during a long-term follow-up.

Latest evidence in personalized antiplatelet therapy in patients with acute coronary syndromes undergoing percutaneous coronary intervention.

In patients with acute coronary syndromes undergoing percutaneous coronary intervention, the combination of aspirin and clopidogrel, a P2Y12 adenosine diphosphate (ADP) receptor antagonist, is the gold standard of antiplatelet therapy. Two more potent P2Y12 ADP receptor antagonists are now available. Pharmacodynamic studies have revealed a large interindividual variability in the biological response to clopidogrel that is primarily related to variable active metabolite generation, depending on clinical factors, drug-drug interactions, and genetic polymorphisms. Several assays to measure platelet function are available and have revealed a high prevalence of high on-treatment platelet reactivity (HTPR). Patients exhibiting HTPR after a clopidogrel loading dose have a higher risk of thrombotic recurrence after percutaneous coronary intervention. A recent consensus has defined HTPR for the main platelet assays available (using receiver operating characteristic curve analysis) to define the optimal cutoff value for each assay in order to predict thrombotic recurrences. In this article, we present several lines of evidence that suggest a therapeutic window of platelet reactivity inhibition with P2Y12 ADP receptor antagonists. Such a paradigm shift is supported by the results of the Platelet Inhibition and Patient Outcomes (PLATO) trial and the Trial to Assess Improvement in Therapeutic Outcomes by Optimizing Platelet Inhibition with Prasugrel-Thrombolysis in Myocardial Infarction (TRITON-TIMI) 38, which showed the superiority of ticagrelor and prasugrel on thrombotic events compared with clopidogrel; however, these 2 medications had an increased bleeding rate. With the results of these trials, in addition to the evidence of a therapeutic window with P2Y12 ADP receptor antagonists, we summarize the potential of platelet reactivity monitoring and pharmacogenomics to tailor therapy.

Effect of increased aspirin dose after stenting in association with ClOpidogrel: the FIASCO randomized study.

BACKGROUND: Increased doses of antiplatelet therapy have been proposed to overcome the variability of response. However, the chronic dose of aspirin after DES remains controversial. METHODS AND RESULTS: We assessed in a prospective and randomized study the benefit of higher dose of aspirin, in association with clopidogrel, on aspirin response and non COX-specific platelet testing in patients receiving Drug Eluting Stent (DES) for stable angina pectoris. 50 consecutive patients receiving DES for stable angina pectoris were prospectively included. They received loading dose of 250 mg aspirin and 600 mg clopidogrel and antiplatelet response was assessed with Arachidonic Acid-induced aggregation (AA-Ag) and ADP-induced aggregation (ADP-Ag) for aspirin and clopidogrel response respectively. Patients were randomized to either 75 or 160 mg of aspirin with 150 mg clopidogrel and platelet testing were repeated one month after hospital discharge. The two groups (aspirin "75 mg" or "160 mg") had no difference for aspirin response: AA-Ag (5.2 +/- 1.7% vs 6 +/- 2%, p = 0.75) and non COX-specific pathway testing: ADP-Ag (47 +/- 3% vs 49 +/- 4%, p = 0.61). CONCLUSION: The present study did not show any benefit of higher dose of aspirin neither on aspirin responsiveness, nor on inhibition of non COX-specific pathway. These data does not support use of higher dose than 75 mg of aspirin in association with clopidogrel in patients receiving DES, especially while higher doses have been associated with increased bleeding risk.