[Takotsubo cardiomyopathy]. / Cardiomyopathie de Takotsubo.

Takotsubo cardiomyopathy. Takotsubo cardiomyopathy, or transient apical ballooning syndrome of the left ventricle, affects women after menopause often after mental or physical stress. Mimicking clinical, electrocardiographic and biological features of an acute coronary syndrome, it requires admission to the intensive care unit and an immediate coronary angiography, which will show the absence of coronary occlusion or rupture of atheromatous plaque. Echocardiogram, left ventriculography if performed, and magnetic resonance imaging will confirm the left ventricular deformation and impairment of systolic function, and the absence of myocardial infarction. Evolution is usually towards recovery of ventricular deformation, and improvement of systolic function, but complications in the acute phase, and recurrences are possible. Treatment is not yet standardised and should include psychological care.

Cardiomyopathie de takotsubo. La cardiomyopathie de Takotsubo ou syndrome de ballonisation apicale transitoire du ventricule gauche touche préférentiellement les femmes après la ménopause, souvent après un stress mental ou physique. Simulant un tableau de syndrome coronaire aigu clinique, électrocardiographique et biologique, elle nécessite l'admission en unité de soins intensifs et la réalisation immédiate d'une coronarographie qui montre l'absence d'occlusion coronaire ou de rupture de plaque athéromateuse. L'échocardiogramme, la ventriculographie éventuelle et l'imagerie par résonance magnétique confirment la déformation et l'altération de la fonction systolique ventriculaire gauche et l'absence d'infarctus myocardique. L'évolution habituelle se fait vers une résolution de la dysmorphie ventriculaire, l'amélioration de la fonction systolique, mais des complications sont possibles à la phase aiguë ainsi que d'éventuelles récidives. Le traitement n'est pas codifié et doit comporter une prise en charge psychologique. K. Yayehd déclare des liens d'intérêts avec Clipa, Menarini, Sanofi et Servier. J.-L. Georges déclare des liens d'intérêts avec Amgen, AstraZeneca, Sanofi et Terumo.

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.

Quality of care for myocardial infarction at academic and nonacademic hospitals.

BACKGROUND: Whether academic hospitals provide better quality of care for patients with acute myocardial infarction is widely debated. The aim of this study was to compare processes of care and mortality between academic and nonacademic hospitals in the contemporary era of acute myocardial infarction management. METHODS: We analyzed the original data from a prospective cohort study of 3059 patients, including 1714 with ST-segment elevation and 1345 with non-ST-segment elevation myocardial infarction, enrolled at 39 and 183 academic and nonacademic hospitals, respectively, in France. RESULTS: Unadjusted 1-year mortality for academic and nonacademic hospitals was 10% versus 15% for patients with ST-segment elevation myocardial infarction (P=.01) and 13% versus 14% for patients with non-ST-segment elevation myocardial infarction (P=.75). Patients treated in academic or nonacademic hospitals with percutaneous coronary intervention capability were more likely to receive reperfusion and recommended drug therapies than those treated in nonacademic hospitals without percutaneous coronary intervention capability. After adjusting for baseline characteristics, the hazards of death associated with admission to nonacademic hospitals with and without percutaneous coronary intervention capability relative to academic hospitals were 1.13 (95% confidence interval [CI], 0.79-1.62) and 1.65 (95% CI, 1.09-2.49) for those with ST-segment elevation myocardial infarction and 0.95 (95% CI, 0.66-1.36) and 1.06 (95% CI, 0.72-1.58) for those with non-ST-segment elevation myocardial infarction, respectively. Further adjustment for receipt of acute reperfusion and recommended drug therapies eliminated all differences in mortality between the study groups. CONCLUSION: Admission to academic hospitals was associated with a more frequent use of recommended therapies, conveying a survival advantage for patients with ST-segment elevation myocardial infarction.

Stent for Life in France.

France was chosen to be one of the six first pilot countries of the "Stent for Life" European initiative. First, a prospective registry was set up in five representative French regions, including all admissions within the first 48 hours of ST-elevated acute cardiac syndrome between 1st and 30th November 2010. The second step was to improve results. The main objective was to encourage members of the public experiencing chest pain to call immediately the SAMU's direct line (phone number "15"). Another action was to organise medical meetings in order to improve the management of these patients. Letters were also sent to general physicians to alert them to the issue and to the Stent for Life project. The third step consisted of creating a new registry, in November 2011, to assess the impact of the above actions on an area basis. It has resulted in streamlining the networks and bringing the rate of non-reperfusion down below the 10% threshold. Much remains to be done to improve public awareness of life-saving actions.

Observational study of adherence to European clinical practice guidelines for the management of acute coronary syndrome in revascularized versus non-revascularized patients - the CONNECT Study.

BACKGROUND: The CONNECT study compared clinician adherence to guideline-recommended secondary prevention therapies prescribed at discharge for patients hospitalized for acute coronary syndrome (ACS) in those managed initially with percutaneous coronary intervention (PCI; revascularized) and those who did not undergo revascularization. METHODS: Patients aged greater than or equal to 18 years, hospitalized for a documented ST-segment elevation or non-ST-segment elevation ACS, were enrolled consecutively over 1 month at 238 sites in France. RESULTS: Compared with revascularized patients (n=870), non-revascularized patients (n=706) were significantly older, and a greater proportion were women, had high-blood pressure, type-2 diabetes or a history of atherothrombotic or cardiac disease, but a smaller proportion had a history of coronary angioplasty. On discharge, non-revascularized patients were prescribed beta-blockers, aspirin, statins, angiotensin-converting enzyme inhibitors or adenosine diphosphate receptor antagonists less frequently than revascularized patients. An adherence score greater than or equal to 80% (at least four of the five recommended agents prescribed at discharge) was found in 96.7% of revascularized patients and 74.4% of non-revascularized patients (P<0.001). CONCLUSIONS: Despite a similar or even higher level of cardiovascular risk, non-revascularized ACS patients were prescribed guideline-recommended secondary prevention therapy less frequently than revascularized patients.

Impact of polyvascular disease on baseline characteristics, management and mortality in acute myocardial infarction. The Alliance project.

BACKGROUND: A substantial number of patients with acute myocardial infarction (AMI) have polyvascular disease (PolyVD), defined as cerebrovascular disease (CVD), peripheral arterial disease (PAD) or both. AIM: To investigate the impact of PolyVD on baseline characteristics, management and outcomes. METHODS: The Alliance project is a multicentre, cross-sectional database of patients with myocardial infarction throughout France from 2000 to 2005. A pooled analysis of individual patient data was performed by aggregating data from five registries, representing 9783 patients hospitalized for acute coronary syndromes. Data were collected on history of PAD and CVD and correlated to baseline characteristics, management and hospital outcomes. RESULTS: Eight thousand nine hundred and four patients had full datasets for this analysis (13% with a history of CVD or PAD, 87% without). Patients with PolyVD were older (72 vs 65 years, p<0.0001), had a more frequent history of AMI (26% vs 15%, p<0.0001), percutaneous coronary intervention (PCI), coronary artery bypass graft (CABG), renal insufficiency (12% vs 3%, p<0.0001) and consistently more risk factors for atherosclerosis (hypertension, dyslipidaemia, smoking, diabetes), but less frequently a body mass index>30 kg/m(2) (14.0% vs 20.1%, p<0.0001) compared to patients with coronary artery disease (CAD) alone. Killip class, left-ventricular ejection fraction and GUSTO risk score were all worse among patients with PolyVD. Management of patients with PolyVD was less aggressive (with later admission and less frequent use of in-hospital angiography or evidence-based therapies at discharge). Mortality of patients with PolyVD was consistently higher than in those with CAD alone, regardless of age. Multivariable analysis, adjusting for age, showed that both PAD (odds ratio 1.36 95% confidence interval 1.03-1.79) and history of CVD (odds ratio 1.74, 95% confidence interval 1.27-2.40) were independent predictors of hospital mortality relative to patients with CAD only. CONCLUSION: Patients with PolyVD represented a substantial group among AMI patients, at particularly high risk of death, yet were managed less aggressively than patients with CAD alone. This was associated with markedly higher in-hospital mortality. Further research is warranted to design and test strategies to decrease mortality in this high-risk subset.