Clinical outcomes with high-intensity statins according to atherothrombotic risk stratification after acute myocardial infarction: The FAST-MI registries.

BACKGROUND: Current guidelines strongly recommend high-intensity statin therapy after acute myocardial infarction. AIMS: To analyse the relationship between prescription of high-intensity statin therapy at discharge and long-term clinical outcomes according to risk level defined by the Thrombolysis In Myocardial Infarction Risk Score for Secondary Prevention (TRS-2P) after acute myocardial infarction. METHODS: We used data from the FAST-MI 2005 and 2010 registries - two nationwide French surveys including 7839 consecutive patients with acute myocardial infarction. Level of risk was stratified in three groups using the TRS-2P score: Group 1 (low risk; TRS-2P=0-1); Group 2 (intermediate risk; TRS-2P=2); and Group 3 (high risk; TRS-2P≥3). RESULTS: Among the 7348 patients discharged alive with a TRS-2P available, high-intensity statin therapy was used in 41.3% in Group 1, 31.3% in Group 2 and 18.5% in Group 3. After multivariable adjustment, high-intensity statin therapy was associated with a non-significant decrease in major adverse cardiovascular events (death, stroke or recurrent myocardial infarction) at 5 years in the overall population compared with that in patients receiving intermediate- or low-intensity statins or without a statin prescription (14.3% vs 29.6%; hazard ratio 0.94, 95% confidence interval 0.81-1.09; P=0.42). In absolute terms, the decrease in major adverse cardiovascular events was positively correlated with risk level (Group 1: 8.1% vs 10.7%; Group 2: 14.8% vs 21.6%; Group 3: 30.8% vs 51.6%). However, after adjustment, the benefits of high-intensity statin therapy were associated with lower mortality only in high-risk patients (hazard ratio 0.79, 95% confidence interval 0.64-0.97; P=0.02). CONCLUSIONS: High-intensity statin therapy at discharge after acute myocardial infarction was associated in absolute terms with fewer major adverse cardiovascular events at 5 years, regardless of atherothrombotic risk stratification, although the highest absolute reduction was found in the high-risk TRS-2P class.

Prognostic impact of prepercutaneous coronary intervention TIMI flow in patients with ST-segment and non-ST-segment elevation myocardial infarction: Results from the FAST-MI 2010 registry.

BACKGROUND: Thrombolysis in myocardial infarction (TIMI) flow grade 2 or 3 before percutaneous coronary intervention (PCI) in acute myocardial infarction (AMI) is associated with improved outcomes. However, no recent data are available on its impact beyond 1 year and/or by type of AMI. AIMS: To assess the prognostic impact of prePCI TIMI flow at 30 days and 3 years in patients with ST-segment elevation (STEMI) or non-ST-segment elevation (NSTEMI) AMI. METHODS: We compared long-term outcomes associated with TIMI flow grade 2/3 versus 0/1 in patients referred for PCI in the nationwide French registry of acute ST-segment elevation or non-ST-segment elevation myocardial infarction (FAST-MI) 2010. RESULTS: TIMI flow grade 2/3 was found in 41% of patients with STEMI and 69% of patients with NSTEMI; it was associated with a lower risk of 30-day death in patients with STEMI (odds ratio 0.30, 95% confidence interval [CI] 0.12-0.77; P=0.01), but not in patients with NSTEMI (odds ratio 0.57, 95% CI 0.22-1.42; P=0.23). TIMI grade flow 2/3 was also associated with a lower risk of 3-year death in patients with STEMI (hazard ratio 0.69, 95% CI 0.49-0.98; P=0.04), but not in patients with NSTEMI (hazard ratio 0.79, 95% CI 0.56-1.11; P=0.17). CONCLUSION: TIMI flow grade 2/3 is observed more often in patients with NSTEMI; it is an independent predictor of early and late survival in patients with STEMI, but is not significantly related to early or long-term survival in patients with NSTEMI.

Temporal trends in clinical characteristics and management according to sex in patients with cardiogenic shock after acute myocardial infarction: The FAST-MI programme.

BACKGROUND: Cardiogenic shock (CS) complicating acute myocardial infarction (AMI) occurs more frequently in women, but little is known about its potential specificities according to sex. AIMS: To analyse the incidence, management and 1-year mortality of CS according to sex using the FAST-MI programme. METHODS: The FAST-MI programme consists of four nationwide French surveys carried out 5 years apart from 1995 to 2010, including consecutive patients with AMI over a 1-month period, and with a 1-year follow-up. RESULTS: Among the 10,610 patients included in the surveys, the incidence of CS was 4.8% in men and 8.2% in women (P<0.001). Absolute incidence of CS decreased from 1995 to 2010 in both sexes. Mean age in patients with CS tended to decrease in men (from 72±12 to 69±13 years) and to increase in women (from 78±10 to 80±9 years). One-year mortality decreased significantly in men (from 70% in 1995 to 48% in 2010) and in women (from 81% to 54%). Using Cox multivariable analysis, female sex was not an independent correlate of 1-year mortality [hazard ratio (HR): 0.98, 95% confidence interval (CI): 0.78-1.22]. Early use of percutaneous coronary intervention was, however, an independent predictor of 1-year survival in women (HR: 0.55, 95% CI: 0.37-0.81), but showed only a non-significant trend in men (HR: 0.85, 95% CI: 0.61-1.19). CONCLUSIONS: The incidence of CS-AMI has decreased in both men and women, but remains higher in women. One-year mortality has significantly decreased for both men and women, and the role of early percutaneous coronary intervention as a potential mediator of decreased mortality seems greater in women than in men.

Reduction of radiation exposure associated with renewal of the radiologic systems in coronary interventions.

PURPOSE: Interventional coronary procedures are an important source of radiation. This study sought to evaluate the effect of the renewal of the radiologic system on patient exposure during diagnostic coronary angiography (DCA) and percutaneous coronary interventions (PCIs). METHODS: DCA and PCIs were obtained from three centres, which renewed their radiologic systems during their participation in the multicentre prospective observational RAY'ACT-2 study. Data were analysed from the months before and after the radiologic system was changed. The primary outcomes were the dose reduction estimated by the kerma.area product (KAP in Gy·cm2) and the ratio of the KAP to fluoroscopy time (Gy·cm2·min-1). RESULTS: A total of 2148 patients underwent DCA (1575 before and 573 after the system change), and 1563 underwent PCI (1196 before and 367 after). A change in the radiologic system was associated with a KAP reduction of 43% for DCA (median [interquartile range]: 18.1Gy·cm2 [10.2-34.0] versus 31.5 [19.0-49.0], P<0.0001), and 38% for PCI (42.2Gy·cm2 [23.8-81.7] versus 70.1 [42.0-109.0], P<0.0001). Fluoroscopy time did not vary significantly, and the ratio KAP to fluoroscopy time significantly decreased by 54%. The dose reduction was homogeneous between the three centres and between different manufacturer's systems. CONCLUSIONS: In this multicentre study, the renewal of the radiologic system was associated with a highly significant 40%-50% reduction in radiation dose, irrespective of the manufacturer. A close interaction between manufacturers and operators is needed to optimise the use of new equipment and the effectiveness of radiation reduction tools and techniques.

[Acute anterior myocardial infarction as presenting feature of antiphospholipid syndrome related lupus arthritis]. / Infarctus du myocarde antérieur inaugural révélateur d'un syndrome des antiphospholipides dans le cadre d'une polyarthrite lupique.

INTRODUCTION: Antiphospholipid syndrome is an autoimmune disorder causing venous and arterial thrombosis. Acute coronary complications are rare but potentially dramatic. CASE REPORT: We report a 39-year-old woman who presented with an acute anterior myocardial infarction after intravenous corticosteroids as part of the treatment of lupus arthritis and revealing antiphospholipid syndrome. Emergency coronary angiography was performed with drug-eluting stent angioplasty despite the need for anticoagulation and dual antiplatelet therapy. CONCLUSION: Antiplatelet and anticoagulant therapy management is pivotal in patients with antiphospholipid syndrome and acute coronary syndrome to prevent thrombosis recurrence.

Fully bioresorbable drug-eluting coronary scaffolds: A review.

Following the development of stents, then drug-eluting stents (DES), bioresorbable scaffolds are proposed as a third evolution in coronary angioplasty, aiming to reduce the incidence of restenosis and stent thrombosis and to restore vascular physiology. At least 16 such devices are currently under development, but published clinical data were available for only three of them in September 2014. The first device is Abbott's BVS(®), a poly-L-lactic acid (PLLA)-based everolimus-eluting device, which has been tested in a registry and two non-randomized trials. Clinical results seem close to what is expected from a modern DES, but possibly with more post-procedural side-effects. Two randomized trials versus DES are underway. This device is already marketed in many European countries. The second device is Elixir's DESolve(®), a PLLA-based novolimus-eluting device, which has been evaluated in two single-arm trials. Results are not widely different from those expected from a DES. The third device is Biotronik's DREAMS(®), a metallic magnesium-based paclitaxel-eluting device, which has been assessed in an encouraging single-arm trial; its second version is currently undergoing evaluation in a single-arm trial. The available results suggest that the technological and clinical development of bioresorbable scaffolds is not yet complete: their possible clinical benefits are still unclear compared with third-generation DES; the impact of arterial physiology restoration has to be assessed over the long term; and their cost-effectiveness has to be established. From the perspective of a health technology assessment, there is no compelling reason to hasten the clinical use of these devices before the results of ongoing randomized controlled trials become available.

Dual antiplatelet therapy in patients with a long coronary artery lesion over 30 mm: Determinants and impact on prognosis.

BACKGROUND: The ideal duration of dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) is under debate. Lesion length is a well-recognized predictor of PCI complexity and long-term outcome. AIM: To evaluate the determinants and impact on outcome of long-term DAPT in a retrospective cohort of patients treated for a long coronary lesion. METHODS: Patients (n=460) who underwent PCI for a long lesion (>30 mm) were divided into two groups according to antiplatelet regimen at 1 year: patients who stopped DAPT before 1 year (single antiplatelet therapy group; n=168) and patients who continued DAPT for longer than 1 year (n=292). RESULTS: Mean lesion length was 35.7±7.1 mm. The proportion of patients who continued DAPT after 1 year was 63.5%. The main determinants of long-term DAPT were initial presentation as myocardial infarction and implantation of a drug-eluting stent. Median follow-up was 37.4 (23-51) months after the 1-year period following the index PCI. Long-term DAPT was highly associated with a lower risk of all-cause and cardiovascular mortality by multivariable analysis and after adjustment for other predictors: hazard ratios 0.11 (95% confidence interval 0.03-0.32) and 0.15 (95% confidence interval 0.04-0.62), respectively. No increase in major bleeding was noted. CONCLUSION: In a contemporary practice, nearly two-thirds of patients who undergo PCI for a long lesion are treated with DAPT for several years. Our results suggest that long-term DAPT is beneficial in this subset of patients identified as being at high risk.

Impact of initial clinical presentation on clopidogrel low response.

BACKGROUND: Large interindividual variability exists in clopidogrel response. Clopidogrel low response correlates with poor prognosis after percutaneous coronary intervention. Some authors also suggest intraindividual variability over time. AIM: To assess the impact of initial clinical presentation on clopidogrel low response. METHODS: In this prospective study, clopidogrel response was assessed in 100 patients. Fifty patients presenting with acute coronary syndromes (ACS group) were compared with 50 patients with stable coronary artery disease matched 1:1 for age, sex, body mass index and diabetes (stable group). All patients were tested 18-24h after a 600 mg loading dose of clopidogrel using the VerifyNow-P2Y12 test (results expressed as platelet reaction units [PRUs]). Patients under chronic clopidogrel therapy or treated with glycoprotein IIb/IIIa inhibitors, bivalirudin or thrombolytics were excluded. RESULTS: Mean age was 61 ± 12 years in each group; 28% of patients in each group were diabetic; mean body mass index was 27.6 ± 5.6 kg/m(2) in the ACS group and 27.9 ± 5.9 kg/m(2) in the stable group (p=0.80). Mean PRU values were 197 ± 81 in the ACS group and 159 ± 94 in the stable group (p=0.03). By multivariable analysis, the ACS group was significantly associated with a higher PRU value (p=0.02). There were significantly more clopidogrel low responders (PRU value>230) in the ACS group (38% vs. 18%; p=0.04). CONCLUSION: Our study confirms that initial clinical presentation, especially ACS, is a strong predictor of clopidogrel low response; this suggests that the evolution of coronary artery disease for one patient influences the clopidogrel response over time. These results are in accordance with recent trials showing a benefit for more aggressive antiplatelet therapy in ACS patients.

Safety and effectiveness of drug-eluting stents versus bare-metal stents in elderly patients with small coronary vessel disease.

BACKGROUND: Drug-eluting stents (DES) are more effective than bare-metal stents (BMS) in small coronary vessel disease. Whether this is true in elderly patients, it is unclear, as frailty and a high rate of comorbidities could increase the rate of DES-related complications. AIMS: To assess procedural and long-term clinical outcomes of elderly patients with small vessel disease treated with DES or BMS. METHODS: Consecutive elderly patients (≥ 75 years old) treated with stenting of native small coronary arteries (reference vessel diameter and implanted stent<3mm) were recruited during 2004-2008. Procedural and long-term clinical outcomes were compared between patients treated with BMS and DES. Propensity score-adjusted logistic regression analysis was performed to account for potential selection bias. RESULTS: Among 293 patients (175 BMS, 118 DES), peri-procedural myocardial infarction (12 [7%] vs. 5 [4%]; P=0.35) and blood transfusions (3 [2%] vs. 0; P=0.08) were not significantly different between the BMS and DES groups. Clinical follow-up (96% of patients, median [interquartile range] follow-up 3.5 [2.4] years) showed significantly lower adjusted major adverse cardiac events (hazard ratio [HR] 0.42, 95% confidence interval [CI] 0.24-0.72; P=0.002) and target vessel revascularization (TVR) (HR 0.33, 95% CI 0.14-0.76; P=0.009) in the DES group. No significant differences were observed between the groups in terms of death, myocardial infarction, stent thrombosis or bleeding. CONCLUSIONS: In this retrospective, non-randomized analysis of the treatment of small vessel disease in elderly patients, DES were as safe and more effective than BMS with a significant reduction in TVR.