Type 2 diabetes mellitus in acute myocardial infarction: a persistent significant burden on long-term mortality.

Objective: The long-term impact of type 2 diabetes mellitus (T2DM) after an acute myocardial infarction (AMI) has not been thoroughly investigated yet. This study aimed to assess the long-term impact of T2DM after AMI. Research design and methods: We analyzed the data of three nationwide observational studies from the French Registry of Acute ST-elevation and non-ST-elevation Myocardial Infarction (FAST-MI) program, conducted over a 1-month period in 2005, 2010, and 2015. Patients presenting T2DM were classified as diabetic, and patients presenting type 1 diabetes mellitus were excluded. We identified factors related to all-cause death at 1-year follow-up and divided 1,897 subjects into two groups, paired based on their estimated 1-year probability of death as determined by a logistic regression model. Results: A total of 9,181 AMI patients were included in the analysis, among them 2,038 (22.2%) had T2DM. Patients with diabetes were significantly older (68.2 ± 12.0 vs. 63.8 ± 14.4, p < 0.001) and had a higher prevalence of a prior history of percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG), or heart failure (22.5% vs. 13.0%, 7.1% vs. 3.1% and 6.7 vs. 3.8% respectively, p < 0.001 for all). Even after matching two groups of 1,897 patients based on propensity score for their 1-year probability of death, diabetes remained associated with long-term mortality, with an HR of 1.30, 95%CI (1.17-1.45), p < 0.001. Conclusions: T2DM per se has an adverse impact on long-term survival after myocardial infarction. Independently of the risk of short-term mortality, patients with diabetes who survived an AMI have a 30% higher risk of long-term mortality.

Guideline adherence in the management of acute pulmonary oedema: Study protocol for a French survey involving cardiologists, emergency physicians and intensivists.

BACKGROUND: Because of their high morbidity and mortality, patients with acute pulmonary oedema (APE) require early recognition of symptoms, identification of precipitating factors and admission to specialized care units (cardiac critical care or intensive care). APE is at the crossroads of different specialties (cardiology, emergency medicine and intensive care medicine). Although multidisciplinary expertise and management may be a strength, it can also be a source of confusion, with unexpected heterogeneity in patient care. We hypothesized that the management of severe APE may be heterogeneous between specialties and, in some situations, may differ from international recommendations. AIM: We designed a survey to compare management of different APE phenotypes according to the physicians' medical specialty, and to compare the results with what experts would do and European guidelines. METHODS: Four clinical cases of typical APE with questions pertaining to the latest guidelines were designed by a Scientific Committee designated by the French Scientific Societies for Cardiology, Emergency Medicine and Intensive Care Medicine. We focused on oxygenation and ventilation strategies, management of precipitating factors, including timing of coronary revascularization, use of diuretics and management of diuretic resistance, and discharge coverage. From 20 June 2022 until 09 September 2022, the four cases of APE (two during hypertensive crises, two during acute coronary syndromes) were proposed to French physicians involved in APE care, and to experts, using an open online survey. To avoid any diagnostic ambiguity, the diagnosis of APE was given at the beginning of each clinical case. RESULTS: The intention is to present the results at national and international conferences and publish them in a peer-reviewed journal. CONCLUSIONS: The results of this survey are intended to pave the way for the generation of novel hypotheses for future clinical trials in case of equipoise between subsets of therapeutic procedures in APE.

Acute coronary syndrome in patients treated by vitamin K antagonists or non-vitamin K antagonist oral anticoagulants: Proposed management algorithm for the first 48hours.

Around 10% of patients with acute coronary syndrome are treated by vitamin K antagonists or non-vitamin K antagonist oral anticoagulants for various indications. The initial management of these patients is highly complex, and new guidelines specify that, only during percutaneous coronary intervention, a bolus of unfractionated heparin is recommended in one of the following circumstances: (1) if the patient is receiving a non-vitamin K antagonist oral anticoagulant; or (2) if the international normalized ratio is<2.5 in a patient being treated with a vitamin K antagonist. In this review, we report on five key messages essential for the management of these patients. There are no randomized studies to date, and we propose two diagnostic and/or therapeutic decision algorithms. However, randomized studies are needed to validate these strategies.

Association of Use and Dose of Lipid-Lowering Therapy Post Acute Myocardial Infarction With 5-Year Survival in Older Adults.

BACKGROUND: Older people are underrepresented in randomized trials. The association between lipid-lowering therapy (LLT) and its intensity after acute myocardial infarction and long-term mortality in this population deserves to be assessed. METHODS: The FAST-MI (French Registry of Acute ST-Elevation or Non-ST-Elevation Myocardial Infarction) program consists of nationwide French surveys including all patients admitted for acute myocardial infarction ≤48 hours from onset over a 1- to 2-month period in 2005, 2010, and 2015, with long-term follow-up. Numerous data were collected and a centralized 10-year follow-up was organized. The present analysis focused on the association between prescription of LLT (atorvastatin ≥40 mg or equivalent, or any combination of statin and ezetimibe) and 5-year mortality in patients aged ≥80 years discharged alive. Cox multivariable analysis and propensity score matching were used to adjust for baseline differences. RESULTS: Among the 2258 patients aged ≥80 years (mean age, 85±4 years; 51% women; 39% ST-segment elevation myocardial infarction; 58% with percutaneous coronary intervention), 415 were discharged without LLT (18%), 866 with conventional doses (38%), and 977 with high-dose LLT (43%). Five-year survival was 36%, 47.5%, and 58%, respectively. Compared with patients without LLT, high-dose LLT was significantly associated with lower 5-year mortality (adjusted hazard ratio, 0.78 [95% CI, 0.66-0.92]), whereas conventional-intensity LLT was not (adjusted hazard ratio, 0.93 [95% CI, 0.80-1.09]). In propensity score-matched cohorts (n=278 receiving high-intensity LLT and n=278 receiving no statins), 5-year survival was 52% with high-intensity LLT at discharge and 42% without statins (hazard ratio, 0.78 [95% CI, 0.62-0.98]). CONCLUSIONS: In these observational cohorts, high-intensity LLT at discharge after acute myocardial infarction was associated with reduced all-cause mortality at 5 years in an older adult population. These results suggest that high-intensity LLT should not be denied to patients on the basis of old age. REGISTRATION: URL: https://www.clinicaltrials.gov; Unique identifiers: NCT00673036, NCT01237418, and NCT02566200.

Recalled body silhouette trajectories over the lifespan and oral conditions in adulthood: A cross-sectional analysis of the Paris Prospective Study 3.

OBJECTIVES: To examine the association between life-course body silhouette changes and oral conditions in adulthood. METHODS: At study recruitment (2008-2012), 5430 adults underwent a full-mouth clinical examination and recalled their body silhouettes at ages 8, 15, 25, 35 and 45. Life-course trajectories of body silhouettes were computed using group-based trajectory modelling. Gingival inflammation, dental plaque, masticatory units, numbers of healthy, missing, decayed and filled teeth at study recruitment were clustered. The associations between body silhouette trajectories and clusters of oral conditions were assessed by multinomial logistic regression. RESULTS: The final analysis included 4472 participants. Five body silhouette trajectories were established: lean-stable (30.0%), lean-increased (19.3%), moderate stable (18.1%), lean-marked increased (25.8%) and heavy stable (6.7%). Three clusters of oral conditions were identified: optimal oral health and preserved masticatory capacity (70.0%, cluster 1), moderate oral health and moderately impaired masticatory capacity (25.4%, cluster 2) and poor oral health and severely impaired masticatory capacity (4.7%, cluster 3). Participants with a lean-increased trajectory were 58% more likely than those with a lean-stable trajectory to be in cluster 3 (aOR 1.58 [95% CI 1.07; 2.35]) relative to cluster 1, independently of covariates measured at study recruitment and including age, sex, smoking, socioeconomic status, BMI, hypertension, type 2 diabetes, cholesterol and triglycerides. CONCLUSIONS: A life-course lean-increased body silhouette trajectory is associated with higher likelihood of poor oral health and severely impaired masticatory capacity in adulthood.

Rationale and design of the FRENch CoHort of myocardial Infarction Evaluation (FRENCHIE) study.

BACKGROUND: Despite major advances in prevention and treatment, cardiovascular diseases - particularly acute myocardial infarction - remain a leading cause of death worldwide and in France. Collecting contemporary data about the characteristics, management and outcomes of patients with acute myocardial infarction in France is important. AIMS: The main objectives are to describe baseline characteristics, contemporary management, in-hospital and long-term outcomes of patients with acute myocardial infarction hospitalized in tertiary care centres in France; secondary objectives are to investigate determinants of prognosis (including periodontal disease and sleep-disordered breathing), to identify gaps between evidence-based recommendations and management and to assess medical care costs for the index hospitalization and during the follow-up period. METHODS: FRENCHIE (FRENch CoHort of myocardial Infarction Evaluation) is an ongoing prospective multicentre observational study (ClinicalTrials.gov Identifier: NCT04050956) enrolling more than 19,000 patients hospitalized for acute myocardial infarction with onset of symptoms within 48hours in 35 participating centres in France since March 2019. Main exclusion criteria are age<18 years, lack of health coverage and procedure-related myocardial infarction (types 4a and 5). Detailed information was collected prospectively, starting at admission, including demographic data, risk factors, medical history and treatments, initial management, with prehospital care pathways and medication doses, and outcomes until hospital discharge. The follow-up period (up to 20 years for each patient) is ensured by linking with the French national health database (Système national des données de santé), and includes information on death, hospital admissions, major clinical events, healthcare consumption (including drug reimbursement) and total healthcare costs. FRENCHIE is also used as a platform for cohort-nested studies - currently three randomized trials and two observational studies. CONCLUSIONS: This nationwide large contemporary cohort with very long-term follow-up will improve knowledge about acute myocardial infarction management and outcomes in France, and provide a useful platform for nested studies and trials.

Three-Year Outcomes With Fractional Flow Reserve-Guided or Angiography-Guided Multivessel Percutaneous Coronary Intervention for Myocardial Infarction.

BACKGROUND: In patients with multivessel disease with successful primary percutaneous coronary intervention for ST-segment-elevation myocardial infarction, the FLOWER-MI trial (Flow Evaluation to Guide Revascularization in Multivessel ST-Elevation Myocardial Infarction) showed that a fractional flow reserve (FFR)-guided strategy was not superior to an angiography-guided strategy for treatment of noninfarct-related artery lesions regarding the 1-year risk of death from any cause, myocardial infarction, or unplanned hospitalization leading to urgent revascularization. The extension phase of the trial was planned using the same primary outcome to determine whether a difference in outcomes would be observed with a longer follow-up. METHODS: In this multicenter trial, we randomly assigned patients with ST-segment-elevation myocardial infarction and multivessel disease with successful percutaneous coronary intervention of the infarct-related artery to receive complete revascularization guided by either FFR (n=586) or angiography (n=577). RESULTS: After 3 years, a primary outcome event occurred in 52 of 498 patients (9.40%) in the FFR-guided group and in 44 of 502 patients (8.17%) in the angiography-guided group (hazard ratio, 1.19 [95% CI, 0.79-1.77]; P=0.4). Death occurred in 22 patients (4.00%) in the FFR-guided group and in 23 (4.32%) in the angiography-guided group (hazard ratio, 0.96 [95% CI, 0.53-1.71]); nonfatal myocardial infarction in 23 (4.13%) and 14 (2.56%), respectively (hazard ratio, 1.63 [95% CI, 0.84-3.16]); and unplanned hospitalization leading to urgent revascularization in 21 (3.83%) and 18 (3.36%; hazard ratio, 1.15 [95% CI, 0.61-2.16]), respectively. CONCLUSIONS: Although event rates in the trial were lower than expected, in patients with ST-segment-elevation myocardial infarction undergoing complete revascularization, an FFR-guided strategy did not have a significant benefit over an angiography-guided strategy with respect to the risk of death, myocardial infarction, or urgent revascularization up to 3 years. REGISTRATION: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02943954.

Relación entre las situaciones clínicas que llevan al tratamiento exclusivamente farmacológico del SCASEST y su pronóstico / Association between clinical pathways leading to medical management and prognosis in patients with NSTEACS

Introducción y objetivos: Una proporción importante de pacientes con síndrome coronario agudo sin elevación del segmento ST (SCASEST) se tratan exclusivamente con fármacos (TEF) sin revascularización coronaria inicial. El objetivo del estudio es evaluar las situaciones clínicas que conducen al TEF y su influencia en el pronóstico del SCASEST. Métodos: Se registraron las características basales, las situaciones clínicas que llevaron a TEF y los resultados a 2 años de una cohorte prospectiva de 5.591 pacientes con SCASEST reclutados en 555 hospitales de 20 países de Europa y América Latina. El impacto del TEF en la mortalidad tras el alta se evaluó mediante modelos de surpervivencia de Cox. Resultados: Se utilizó un TEF en 2.306 pacientes (41,2%), de los que 669 (29%) tenían enfermedad coronaria (EC) significativa y 451 (19,6%), EC no significativa y a 1.186 (51,4%) ni siquiera se les practicó una coronariografía. Los pacientes con TEF eran mayores y de más riesgo. La mortalidad a 2 años fue mayor con TEF que con revascularización coronaria (el 11,0 frente al 4,4%; p < 0,001), superior para quienes no se sometieron a coronariografía (14,6%) y aquellos con EC significativa (9,3%). La mortalidad ajustada por riesgo fue superior entre los pacientes a los que no se hizo coronariografía (HR = 1,81; IC95%, 1,23-2,65) o no se revascularizó pese a tener EC significativa (HR = 1,90; IC95%, 1,23-2,95) que con revascularización coronaria. Conclusiones: Los pacientes con SCASEST en TEF constituyen una población heterogénea con perfiles de riesgo y pronóstico diferentes. Se debe considerar estas diferencias al diseñar futuros estudios en esta población (AU)

Introduction and objectives: A large proportion of patients with non—ST-segment elevation acute coronary syndrome (NSTEACS) are initially selected for medical management (MM) and do not undergo coronary revascularization during or immediately after the index event. The aim of this study was to explore the clinical pathways leading to MM in NSTEACS patients and their influence on prognosis. Methods: Patient characteristics, pathways leading to MM, and 2-year outcomes were recorded in a prospective cohort of 5591 NSTEACS patients enrolled in 555 hospitals in 20 countries across Europe and Latin America. Cox models were used to assess the impact of hospital management on postdischarge mortality. Results: Medical management was the selected strategy in 2306 (41.2%) patients, of whom 669 (29%) had significant coronary artery disease (CAD), 451 (19.6%) had nonsignificant disease, and 1186 (51.4%) did not undergo coronary angiography. Medically managed patients were older and had higher risk features than revascularized patients. Two-year mortality was higher in medically managed patients than in revascularized patients (11.0% vs 4.4%; P < .001), with higher mortality rates in patients who did not undergo angiography (14.6%) and in those with significant CAD (9.3%). Risk-adjusted mortality was highest for patients who did not undergo angiography (HR = 1.81; 95%CI, 1.23-2.65), or were not revascularized in the presence of significant CAD (HR = 1.90; 95%CI, 1.23-2.95) compared with revascularized patients. Conclusions: Medically managed NSTEACS patients represent a heterogeneous population with distinct risk profiles and outcomes. These differences should be considered when designing future studies in this population (AU)

Limitaciones de los programas regionales de angioplastia coronaria primaria: ¿la estrategia farmacoinvasiva todavía es una alternativa? / Weaknesses in regional primary coronary angioplasty programs: is there still a role for a pharmaco-invasive approach?

Todas las guías recomiendan la intervención coronaria percutánea primaria como estrategia por defecto para el tratamiento de reperfusión de pacientes con infarto agudo de miocardio con elevación del segmento ST. Estas recomendaciones se basan en ensayos aleatorizados en los que se ha comparado la intervención coronaria percutánea primaria con la fibrinolisis intravenosa sola. Sin embargo, desde la época en que se llevaron a cabo esos ensayos, se han realizado otros estudios que han puesto de manifiesto que usar la intervención coronaria percutánea de rescate en pacientes que no presentan signos de reperfusión después del tratamiento lítico y la angiografía coronaria sistemática en las primeras 24 h tras la administración de dicho tratamiento para todos los demás pacientes mejora los resultados del tratamiento fibrinolítico intravenoso. Esto ha llevado a proponer la estrategia farmacoinvasiva como alternativa a la intervención coronaria percutánea primaria. De hecho, no es infrecuente que las circunstancias concretas impidan la intervención coronaria percutánea primaria dentro de los límites temporales recomendados en las guías. En tales casos, el uso de una estrategia farmacoinvasiva puede ser una alternativa válida. Tanto el ensayo aleatorizado STREAM como la experiencia de la práctica clínica real, y en especial los resultados a largo plazo del registro FAST-MI, indican que la estrategia farmacoinvasiva, cuando se utiliza en una población adecuada, puede compararse favorablemente con la intervención coronaria percutánea primaria. Así pues, la puesta en práctica de un protocolo de estrategia farmacoinvasiva puede ser un complemento importante para compensar las posibles limitaciones de las redes de tratamiento del infarto agudo de miocardio con elevación del segmento ST (AU)

All guidelines recommend primary percutaneous coronary intervention as the default strategy for achieving reperfusion in ST-segment elevation myocardial infarction patients. These recommendations are based upon randomized trials which compared primary percutaneous coronary intervention with stand-alone intravenous fibrinolysis. Since the time these trials were performed, however, it has been shown in further trials that use of rescue percutaneous coronary intervention in patients without signs of reperfusion after lysis, and routine coronary angiography within 24 h of the administration of lysis for all other patients, substantially improved the results of intravenous fibrinolytic treatment. This has led to proposing the pharmaco-invasive strategy as an alternative to primary percutaneous coronary intervention. Actually, it is not uncommon that circumstances prevent performing primary percutaneous coronary intervention within the recommended time limits set by the guidelines. In such cases, using a pharmaco-invasive strategy may constitute a valid alternative. Both the STREAM randomized trial and real-world experience, in particular the long-term results from the FAST-MI registry, suggest that the pharmaco-invasive strategy, when used in an appropriate population, compares favorably with primary percutaneous coronary intervention. Therefore, implementing a pharmaco-invasive strategy protocol may be an important complement to compensate for potential weaknesses in ST-segment elevation myocardial infarction networks (AU)

Insuficiencia cardiaca en el infarto agudo de miocardio: comparación de pacientes con o sin criterios de insuficiencia cardiaca del registro FAST-MI / Heart failure in acute myocardial infarction: a comparison between patients with or without heart failure criteria from the FAST-MI registry

Introducción y objetivos. El papel las lipoproteínas de alta densidad en la estratificación de riesgo en pacientes con dolor torácico no está bien definido. El objetivo de este estudio es conocer la contribución relativa del perfil lipídico al riesgo de padecer síndrome coronario agudo de los pacientes ingresados por dolor torácico en una planta de cardiología. Métodos. Incluimos todos los ingresos consecutivos no programados en planta de cardiología durante 15 meses y realizamos seguimiento al año. Resultados. Se incluyó a 959 pacientes, 457 (47,7%) diagnosticados de dolor torácico no isquémico, 355 (37%) de síndrome coronario agudo sin elevación del ST y 147 (15,3%) de síndrome coronario agudo con elevación del ST. El 54,6% de los pacientes presentaron cifras de lipoproteínas de alta densidad < 40mg/dl y la prevalencia fue más elevada entre los pacientes con síndrome coronario agudo (el 69,4 frente al 30,6%; p<0,01). Se observó mayor presencia de síndrome coronario agudo a menores cifras medias de lipoproteínas de alta densidad. Edad, tabaquismo activo, diabetes mellitus, glucemia basal > 100mg/dl y concentraciones de lipoproteínas de alta densidad < 40mg/dl se asociaron independientemente a la presencia de síndrome coronario agudo, el factor con mayor asociación (odds ratio=4,11; intervalo de confianza del 95%, 2,87-5,96). El análisis de supervivencia determinó que los pacientes con síndrome coronario agudo, frente a dolor torácico no isquémico, asociaron un riesgo significativamente superior de mortalidad por cualquier causa, así como por causa cardiovascular. Conclusiones. Las concentraciones bajas de colesterol unido a las lipoproteínas de alta densidad (≤ 40mg/dl) se asociaron de manera independiente a diagnóstico de síndrome coronario agudo en pacientes ingresados por dolor torácico, con una relación inversa significativa entre los valores más bajos de lipoproteínas de alta densidad y el diagnóstico de síndrome coronario agudo (AU)

Introduction and objectives. To compare acute myocardial infarction patients with or without congestive heart failure in the French FAST-MI registry. Methods. The French FAST-MI registry included 374 centers and 3059 patients over a 1-month period at the end of 2005, with 1-year follow-up. Among this population, patients with at least one congestive heart failure criterion constituted group 1 (n=1149; 37.5%) and were compared to patients without congestive heart failure (group 2, n=1910; 62.5%). The congestive heart failure patients were further divided according to presence of both beta-blockers and antagonists of the renin-angiotensin-aldosterone system at hospital discharge (n=511) or not (n=498), in order to assess the real-world clinical importance of recommended medications. Results. Overall in-hospital and 1-year mortality rates were 3.4% and 13.2%, respectively. In hospital survivors, presence of congestive heart failure was associated with increased mortality (adjusted hazard ratio=1.55; 95% confidence interval, 1.10-2.17; P=.01). Survival was higher in patients without congestive heart failure, compared with congestive heart failure patients receiving or not recommended medications (P<.001). Congestive heart failure patients receiving neither renin-angiotensin-aldosterone system blockers nor beta-blockers (adjusted hazard ratio=1.66; 95% confidence interval, 1.08-2.55; P=.02) had a significantly higher risk of death than patients receiving both classes of medications (adjusted hazard ratio=1.16; 95% confidence interval, 0.82-1.64; not statistically significant). Patients receiving only one of the recommended classes had an intermediate risk (adjusted hazard ratio=1.47; 95% confidence interval, 1.04-2.07; P=.03). Conclusions. Patients admitted for acute myocardial infarction with congestive heart failure criteria are still at very high risk of mortality. When receiving major recommended medications, they presented with significantly reduced mortality rates. Additional efforts should therefore be made to encourage the prescription of recommended medications in acute myocardial infarction patients with congestive heart failure (AU)

1980-2010: las tres décadas gloriosas de la cardiología. Un esfuerzo colectivo y exhaustivo recompensado por unos resultados clínicos extraordinarios / 1980-2010: the three glorious decades of cardiology. A comprehensive and collective effort rewarded by outstanding clinical results

No disponible