Impact of socioeconomic status on diabetes and cardiovascular risk factors: results of a large French survey.

AIM: This study examined the association between deprivation and diabetes in a large French population, and evaluated the impact of deprivation on diabetes after taking in account a number of confounding factors. METHODS: A total of 32,435 men and 16,378 women, aged 35 to 80 years, who had a health checkup at the "Centre d'Investigations Préventives et Cliniques" (IPC Centre: a preventive medical center in Paris, France), between January 2003 and December 2006, were evaluated. Socioeconomic deprivation was assessed using the EPICES score. The most deprived subjects were those in the fifth quintile of score distribution. RESULTS: Several cardiovascular risk markers increased significantly in deprived subjects. In both genders, deprivation was associated with deleterous health status and lifestyle habits. In women, BMI, central obesity and the metabolic syndrome were associated with deprivation. The prevalence of diabetes increased with deprivation level. Compared with the first quintile of EPICES score distribution, the prevalence of diabetes was three to eight times higher in the fifth quintile. After taking into account age, and biological, clinical and lifestyle parameters, the risk of diabetes onset (odds ratio) among deprived vs. non-deprived subjects was 2.54 (95% CI: 1.99-3.24) in men and 2.2 (95% CI: 1.44-3.35) in women. CONCLUSION: In the general French population, deprivation was associated with deleterious health status and lifestyle. Risk of diabetes increased linearly with deprivation level and, after taking into account various confounding factors, the risk of diabetes remained significantly higher among deprived subjects. Other factors such as nutrition should now be examined to explain the excess risk of diabetes among the most deprived people.

Cost analysis of bivalirudin versus reference anticoagulants without GP IIb/IIIa inhibitors in patients undergoing percutaneous coronary intervention for acute coronary syndrome in routine clinical practice. Pompidou registry.

Randomized controlled trials have shown improved short-term bleeding outcomes for bivalirudin compared to other anticoagulant in patients undergoing percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS). This study analyzed the cost/efficacy profile of bivalirudin-based anticoagulation strategy versus non bivalirudin-based anticoagulant strategy without use of GP IIb/IIIa inhibitors in routine clinical practice. From January 2009 to December 2010, 216 patients who underwent PCI for ACS at hospital Georges-Pompidou without GP IIb/IIIa inhibitors were studied. Of these patients, 24 (11%) received bivalirudin and 192 (88%) received others anticoagulants (mainly unfractionated heparin or low molecular weight heparin). Ischemic events and bleeding or transfusion were slightly lower in bivalirudin group (0 vs. 4.2%, P=0.60 and 4.2 vs. 8.9%, P=0.70, respectively). In spite of a higher cost of the medication, the overall cost of the bivalirudin strategy was slightly lower (9167±3688 € vs. 14,016±14,749 €, P=0.23), in relation with a shorter average duration of the hospital stay. In conclusion, in this limited, single-center, population of patients with ACS, the clinical efficacy and safety of bivalirudin appeared at least as good as that of reference anticoagulants in real world clinical practice, with no increase in overall costs.

[Clinical and economical evaluation of bivalirudin during percutaneous coronary interventions]. / Evaluations clinique et économique de la bivalirudine au cours des procédures d'angioplasties coronaires.

Bivalirudin, with provisional GP IIb/IIIa inhibitor use allows the same protection against ischemic complications while reducing the hemorrhagic complications compared with the systematic association of a GP IIb/IIIa inhibitor plus heparin (The Randomized Evaluation in PCI Linking Angiomax to Reduced Clinical Events-2 [Replace-2]). In clinical practice, the use of heparin is not systematically associated with a GP IIb/IIIa inhibitor. That's why we studied the clinical and economic interest of bivalirudin only versus heparin (UFH) only. Opened pragmatic monocentric study carried out in 2007. We made a chronological matching: for each patient treated with bivalirudin, we included the next patient with the same clinical presentation treated with unfractionated heparin. Ninety-two patients were included (46 in each group). The need for a GP IIb/IIIa inhibitor during the PCI was not significantly different between the two groups (p=0.11). No major hemorrhagic complications were observed in the two groups. Prevalence of ecchymosis was not significantly different: 22 % in the UFH group versus 13 % in the bivalirudin group (p=0.27). The average troponin level the next day was significantly higher in the bivalirudin group (p=0,049), although the change in troponin levels before and after the procedure was similar in the two groups. The average cost by patient of anticoagulation by bivalirudin and HNF is very different, respectively 473+/-150 and 51+/-146 euro (p=0.0001). Bivalirudin can be an interesting alternative for patients with a high risk of having complications. But considering its cost this therapy must be used only for selected patients.

[Flecainide acetate utilisation review among general practitioners and hospital or office-based cardiologists in France. Obepine: observational study of flecainide]. / Etude de l'usage de l'acétate de flécainide auprès des médecins généralistes et des cardiologues hospitaliers ou libéraux en France. OBEPINE: etude observationnelle des prescriptions de flécaïnide.

A pharmacoepidemiological cross-sectional observational study was performed among a representative sample of French general practitioners and cardiologists. The aim of this study was to describe the prescription modalities of flecainide acetate, an Ic class antiarrhythmic, and how these modalities match the marketing authorization and the current summary of product characteristics. A total of 941 physicians participated in the study, 496 GPs and 445 cardiologists, and 1116 patients treated with flecainide for more than one month were included. On average, the patients were 68.7-years-old and 54% of them were women. Most of the initial flecainide prescriptions came from cardiologists (96%) and the check-up included an electrocardiogram (98%), a Holter monitoring (56%) and/or an echocardiography (71%). The preferred indication was supraventricular rhythm disorders (95%) and mostly atrial fibrillation (63%). A small proportion of coronary patients (7%) and of patient suffering from cardiac insufficiency (4%) was found. Flecainide was prescribed with a median posology of 150 mg per day, mostly as LP form (64%). Overall, the indications specified in the summary of product characteristics were respected in 90% of the cases, the contraindications in 91% of the cases and the patient follow-up was appropriate in 99% of the cases. In conclusion, the study showed that the prescription's conditions of flecainide in France complied with the summary of product characteristics data for most of the prescribing physicians with a respect of the indications, contraindications and management recommendations in 84% of the cases.

Audit and quality control in angioplasty in Europe: procedural results of the AQUA Study 1997: assessment of 250 randomly selected coronary interventions performed in 25 centres of five European countries. AQUA Study Group, Nucleus Clinical Issues, Working Group Coronary Circulation, of the European Society of Cardiology.

AIMS: Percutaneous transluminal coronary angioplasty (PTCA) has become the most widely used major intervention in western medicine. However, there is disparate use of this technique among different European countries and the U.S.A. In an attempt at quality assurance, the working group Coronary Circulation of the European Society of Cardiology has carried out a study on appropriateness, necessity, and performance of PTCA in Europe. The present paper reports on the procedural results of this survey. METHODS: In a multicentre case-control study in Europe, 750 patients (544 men, 206 women) with documented vascular disease of the From the countries participating in the European Registry of Coronary Intervention, the three countries with the highest absolute PTCA volume (Germany, France, and the United Kingdom) and two randomly selected countries (Belgium and Italy) were chosen for investigation. In these countries, five centres were selected at random according to the following criteria: one centre with >1000, three centres with 300-1000, and one centre with <300 procedures per year. In each of these, 10 cases from the first half of 1997 were randomly identified and all pertinent documentation was collected. RESULTS: In 250 cases, 325 stenoses were addressed as target lesions. Single vessel disease was present in 41%. History included stable angina in 49%, unstable angina in 32%, atypical chest pain in 6%, no anginal pain in 12%, and acute/subacute myocardial infarction in 13%. The percentage of patients with either positive stress test and/or unstable angina, acute/subacute infarction, previous infarction (within 6 months) or coronary revascularization amounted to 98%. Single vessel intervention accounted for 90%. In 41% balloon-only angioplasty was performed and in 54% at least one stent was implanted with considerable variation among countries. The use of other new devices amounted to only 3%. In 92%, the operators documented a successful procedure. Major complications (myocardial infarction, emergency bypass surgery, or death) were found in 4.8%. CONCLUSIONS: Based on scrutinized hospital and operator data, the present study revealed a satisfactorily high percentage of justifiable indications, an adequate procedural success rate, and an acceptably low complication rate. Further analysis by an expert panel will address appropriateness, necessity, and procedural performance of the individual cases.

Effects of medical therapy on outcome assessment using exercise thallium-201 single photon emission computed tomography imaging: evidence of a protective effect of beta-blocking antianginal medications.

OBJECTIVES: The purpose of this study was to determine whether antianginal medications modify the prognostic significance of exercise single photon emission computed tomography (SPECT) ischemia. BACKGROUND: Antianginal medications (especially beta-adrenergic blocking agents) limit exercise SPECT ischemia, but it is not known whether such medications also modify the prognostic effect of exercise SPECT ischemia. METHODS: We included 352 patients with coronary heart disease, who had exercise Tl-201 SPECT and coronary angiography, and who were initially treated medically. Survival Cox models were applied in patients for whom classes of antianginal medications taken at exercise SPECT were the same as those prescribed for follow-up (GI; n = 136), and in patients for whom new classes of antianginal medications, including beta-blockers (GII; n = 79) or not including beta-blockers (GIII; n = 113), were added for follow-up. RESULTS: During a mean 5.3+/-1.6 years of follow-up, 45 patients had cardiac death or myocardial infarction. Variables reflecting necrosis (irreversible defect extent, left ventricular ejection fraction) and those from coronary angiography provided equivalent prognostic information in the three groups. In contrast, the SPECT variable reflecting ischemia (reversible defect extent), which provided comparable prognostic information in GI (p = 0.005) and GIII (p = 0.004), lost its prognostic significance (p = 0.54) in GII, and was associated with a lower relative risk in GII than in GI or GIII (both p < 0.05). CONCLUSIONS: In patients with coronary heart disease, the introduction of antianginal medications, when including beta-blockers, appears to have a favorable effect on the deleterious prognostic effect of exercise ischemia.

Assessment of myocardial viability in patients with previous myocardial infarction by using single-photon emission computed tomography with a new metabolic tracer: [123I]-16-iodo-3-methylhexadecanoic acid (MIHA). Comparison with the rest-reinjection thallium-201 technique.

OBJECTIVES: We compared the ability of rest single-photon emission computed tomography (SPECT) with [123I]-16-iodo-3-methylhexadecanoic acid (MIHA) and the thallium-201 (Tl-201) rest-reinjection technique to detect myocardial viability after infarction. BACKGROUND: After myocardial infarction, MIHA frequently shows increased uptake in the areas with exercise Tl-201 defects (mismatch), even in patients with an irreversible Tl-201 reinjection defect. Whether such increased uptake is indicative of ischemic but viable myocardium is not known. METHODS: We studied 38 patients who 1) underwent exercise SPECT Tl-201 with rest-reinjection and rest SPECT with MIHA before undergoing percutaneous transluminal coronary angioplasty (PTCA) of an infarct-related coronary artery, and 2) were found to have successful revascularization at follow-up angiography. The relation between SPECT results before PTCA and subsequent improvement in left ventricular wall motion was assessed. RESULTS: A mismatch was evident before PTCA in 51 of 76 infarct-related segments and correlated with subsequent improvement in wall motion (overall accuracy 71%), even for the 27 segments whose exercise defects remained irreversible after Tl-201 reinjection (overall accuracy 81%). The finding of a mismatch clearly enhanced the results provided by the finding of > or = 50% Tl-201 uptake as determined at redistribution (p < 0.05), but not as determined at reinjection, although there was a trend toward a better specificity for the findings of a mismatch. CONCLUSIONS: MIHA is an efficient marker of viability inside exercise-underperfused areas after infarction, even in patients with irreversible Tl-201 reinjection defects. Assessment by conventional SPECT of a mismatch between results obtained with a metabolic tracer (MIHA) and a flow tracer analyzed at exercise (Tl-201) as a marker of myocardial viability is a promising area of research.

Radionuclide assessment of regional differences in left ventricular wall motion and myocardial perfusion in idiopathic dilated cardiomyopathy.

Regional variations in left ventricular contractility and myocardial perfusion are frequent in idiopathic dilated cardiomyopathy and might result from an increase in left ventricular wall stress responsible for regional wall motion abnormalities. The aim of the study was to perform radionuclide studies in patients with idiopathic dilated cardiomyopathy to assess regional left ventricular wall motion and myocardial perfusion abnormalities in this myocardial disease. We studied 29 men referred with idiopathic dilated cardiomyopathy and normal coronary angiograms. Rest radionuclide left ventriculography and exercise thallium-201 tomography were performed in all patients. The thallium-201 tomograms were divided into 20 segments for each patient. Mean left ventricular ejection fraction was 27 +/- 11%; 17 patients had diffuse hypokinesia (mean left ventricular ejection fraction: 24 +/- 9%) and 12 patients had predominant regional hypokinesia (mean left ventricular ejection fraction: 32 +/- 12%). Of all 580 tomographic segments, 186 had a reduction of thallium-201 uptake at exercise. Among them, reversibility was found in 53%. On the whole, 68% (158/232) of anterior, inferior and apical segments had a perfusion abnormality, compared with 8% (28/348) of septal and lateral segments (P < 0.0001). Left ventricular wall motion and myocardial perfusion abnormalities are heterogeneous and not evenly distributed in dilated cardiomyopathy. The alterations are predominant on the myocardial regions delineating the antero-posterior axis of the left ventricle. These findings suggest the possible role of increased left ventricular wall stress on this axis.

Visual versus quantitative assessment of the severity of coronary artery stenoses: can the angiographer's eye be reeducated?

The percent reduction of intraluminal diameter of 102 coronary stenoses before (n = 26), immediately after (n = 24), and 6 months after (n = 52) coronary balloon angioplasty as assessed by two observers experienced in quantitative coronary angiography and by automated measurement by means of the Cardiovascular Angiographic Analysis System (CAAS) was compared. Two hundred twenty-seven still frames were selected for analysis by CAAS and displayed for assessment by each of the observers, who were unaware of CAAS results. Comparisons with CAAS measurements were made for all still frames ("per view" analyses) and for each coronary stenosis after averaging the values obtained for a given coronary segment ("per stenosis" analyses). Intraobserver variability was tested on 21 still frames from 10 stenoses, assessed 6 weeks apart by one observer. Intraobserver variability was 5% (r = 0.98); interobserver variability was 6% (r = 0.94). Per view analyses showed that observer measurements correlated well with CAAS measurements (r = 0.89 and r = 0.90); the accuracy was -0.9% and -0.7% for observers 1 and 2, and the precision was 9% and 8%, respectively; for per stenosis analyses, the accuracy was -0.5% and -0.8% (r = 0.92 and 0.94) and the precision 7% and 6%, respectively. There was no difference in the accuracy and precision of visual assessment for lesions with < 50%- or > 50%-diameter stenoses. The occurrence of restenosis was likewise detected visually with a high sensitivity and specificity compared with CAAS.(ABSTRACT TRUNCATED AT 250 WORDS)

Two-dimensional echocardiographic assessment of the right ventricle in patients with chronic obstructive lung disease.

A consecutive series of 40 patients (39 men, one woman; mean age 54.1 +/- 8.2 years) with chronic obstructive lung disease (COLD) underwent right heart catheterization and 2-D echocardiographic examination within 72 hr. An adequate 2-D echocardiographic study was obtained in 32 patients (80 percent) using the apical and/or subcostal views. Mean pulmonary artery pressure at rest and during exercise were correlated with right ventricular diameters and areas in end-systole and end-diastole (r = 0.63 to 0.73). Correlations between right ventricular free wall thickness and pulmonary artery pressure were weak (r = 0.51 and 0.57). Right ventricular end-diastolic pressure was also weakly correlated with right ventricular dimensions (r = 0.45 to 0.51), whereas right ventricular area fractional shortening was not correlated with hemodynamic parameters. Patients with previous episode of right heart failure had larger right ventricles than those without such episodes. Thus, 2-D echocardiography appears useful to study the right heart chambers in patients with COLD.

Assessment of right ventricular outflow tract in children by two-dimensional echocardiography using a new subcostal view. Angiocardiographic and morphologic correlative study.

Evaluation of the right ventricular (RV) outflow tract in congenital heart disease is extremely important for surgical management. Therefore, the value of 2-dimensional echocardiography (2-D echo) to assess the RV outflow tract was studied using a new approach: the subcostal elongated right oblique view. Twenty normal children and 49 children with congenital heart disease, aged 1 day to 11 years, were studied. Significant pulmonary infundibular obstruction was present in 22 patients with conotruncal malformations. To obtain the subcostal elongated right oblique view from the short-axis view at the aortic valve level, the transducer was slightly rotated clockwise with an anterior angulation of about 30 degrees so that the ascending aorta was seen in its long axis, providing an image similar to that obtained by a right ventriculogram in the elongated right anterior oblique view. The deviation of infundibular septum was appreciated by measurement of the angle alpha, defined by the long axis of the infundibular septum and the plane of aortic cusps. This view could be obtained in 64 patients (92%). In correlation with angiographic or anatomic data, the subcostal elongated right oblique view permitted recognition of several types of RV outflow tract: type I--normally formed RV outflow tract; type II--disorganized RV outflow tract with obstruction (alpha less than 90 degrees); type III and IV--disorganized RV outflow tract with obstruction (alpha greater than 90 degrees). This view could visualize the crista supraventricularis in type I, but also the anatomic components of RV outflow tract that may contribute to obstruction in the other types: infundibular septum, septoparietal trabeculations and trabecula septomarginalis.(ABSTRACT TRUNCATED AT 250 WORDS)

[Cost of a coronary transluminal angioplasty compared with a single coronary bypass. Economic effects]. / Coût d'une angioplastie transluminale coronaire comparé à celui du pontage aorto-coronaire unique. Incidences économiques.

The authors discuss the financial incidence of transluminal coronary angioplasty (TCA) compared to isolated coronary bypass surgery (CBS). The study was limited to 1982 (76 cases of TCA) and compares two groups: successful TCA (17 consecutive cases: group I); isolated CBS (18 cases: group II). The following parameters were studied in each group: average length of hospital study, credits received from the Department of Social Security, hospital expenditure. Hospital expenditure was classified under 6 headings: personnel, material, investigations, drugs, hospital costs and administration costs. The results expressed as the mean per patient were: in group I: hospital stay, 10 days; Social Security reimbursement, 10 813 FF; hospital expenditure, 10 586 FF. In group II: hospital stay, 18 days (including 4 days in the ICU); Social Security reimbursement 46 656 FF; hospital expenditure, 28 955 FF. The hospital costs of personnel were relatively small (especially for TCA). The economies realised by reutilising catheters designed for single usage were significant: the use of guide wires, catheters and balloon catheters falls from 1.64, 1.9 and 0.1 per patient to 0.47, 0.53 and 0.05 respectively, a saving of 5 068 FF per TCA and 385 168 FF per year. Compared to costs in the United States (4 773 and 14 952 dollars) TCA and CBS is much cheaper in France.(ABSTRACT TRUNCATED AT 250 WORDS)

[Rehabilitation and return to work of patients after aortocoronary bypass]. / Réhabilitation et retour au travail des malades après pontage aorto-coronarien.

A pilot project with medical, physical and psychosocial evaluation and a physical and psychosocial rehabilitation program included 59 men, under age 60, inactive for less than one year and who underwent aortocoronary bypass surgery between november 1978 and march 1980. A control group of 60 comparable patients was studied by questionnaire one year after the operation. The percentage of return-to-work was not significatively different: respectively 92 p. 100 and 89 p. 100. A previous study on a similar population determined 9 predictive sociodemographic and medical factors: age, angina class, duration of symptoms, associated vascular disease, non cardiovascular illness, education, physical workload, length of preoperative unemployment, annual income. The evaluations of this study showed the importance of the psychosocial factors and alcoholism. In comparison with our previous studies, the increased percentage of return-to-work (from 69 p. 100 to 89 p. 100) is mostly due to a shorter preoperative period of inactivity; the percentage of patients operated on within three months of inactivity increased from 44 p. 100 to 74 p. 100 in the last ten years. In the group of patients with a good or excellent preoperative prognosis, 94 p. 100 were working after one year. We conclude that a strategy for improving return-to-work after surgery is to decrease the period of preoperative inactivity. By using nine objective predictive factors and a psychosocial evaluation, it is possible to screen patients with a poor return-to-work prognosis and to submit them to an individualized rehabilitation program.

Coronary artery surgery as a measure of vocational rehabilitation: an analysis of the working status of patients with mild angina randomly assigned to medical or surgical treatment.

Work status was studied in 76 male patients under the age of 60, who had been randomly assigned to surgical or medical treatment for coronary artery disease with relatively stable angina (Class I or II NYHA) One year after catheterization or surgery, there were as many patients employed in the medical (84%) as in the surgical (81%) groups, despite a marked improvement of functional symptoms in the latter group; 8% in surgical patients and 11% in medical patients were on social welfare. Surgery did not improve work resumption in patients who had been unemployed for seven months or more before inclusion into the study (71%, versus 67% in medical patients). It is concluded that aorto-coronary bypass surgery cannot be considered as a measure of vocational rehabilitation sufficient to improve employment in patients with mild stable angina, when compared to medical treatment.

Factors predicting working status after aortocoronary bypass surgery.

The working status of 1165 patients aged 59 years or less (mean 49.8 years) was evaluated 7 to 77 months (mean 36 months) after aortocoronary bypass surgery. Although 76% of the patients eventually returned to work, only 56% were working 6 months after their operation. The proportion of patients working peaked at 2 years after the operation (at 66%) and decreased progressively to 56% at 4 years and 53% at 5 years without ever reaching the proportions that applied 12 and 6 months before the operation (84% and 69% respectively). Multivariate analysis identified three socioeconomic and three clinical variables as predicting the working status at 6 months and at yearly points during the first 4 years after the operation. Of the socioeconomic variables analysed, preoperative unemployment of long duration, a preoperative occupation that required strenuous physical effort and a low level of education were, in that order, the strongest predictors of postoperative unemployment. Among the clinical variables, associated noncardiovascular illness and the severity and duration of angina pectoris independently influenced the patients' post-operative working status. The authors conclude that modification of some of these variables should by attempted both before and after aortocoronary bypass surgery to see whether the rate of return to employment after the operation can be improved in selected patients.

Employment following aortocoronary bypass surgery in young patients.

The work status following aortocoronary bypass surgery was evaluated by questionnaire in 268 male patients aged 44 years or less, after a mean follow-up of 38 months. During follow-up, 87% resumed work; when analyzed on a yearly basis, the rate of patients at work peaked at 2 years (80%) and then declined to 70% at 4 years. Multivariate analyses showed that the two most important preoperative variables predictive of work status after surgery were (1) the length of the period of not working, and (2) the educational level. Other influential factors were the presence of an associated vascular disease and the type of work, annual income and functional class. The postoperative health status, as described by the patient, was also closely correlated with return to work. Recurrence of angina after surgery impaired work resumption. A majority of patients who were never gainfully employed after surgery attributed the reason to their physician, while 93% of them stated that they received financial aid from the government.