ADAM-C score: New risk score for predicting diagnostic yield of transesophageal echocardiography after cerebral ischemia.

BACKGROUND AND AIM: The clinical utility of transesophageal echocardiography (TEE) after brain ischemia (BI) remains a matter of debate. We aimed to evaluate the clinical impact of TEE and to build a score that could help physicians to identify which patients should better benefit from TEE. METHODS: This prospective, multicenter, observational study included patients over 18 years old, hospitalized for BI. TEE findings were judged discriminant if the results showed important information leading to major changes in the management of patients. Most patients with patent foramen ovale were excluded. Variables independently associated with a discriminant TEE were used to build the prediction model. RESULTS: Of the entire population (1479 patients), 255 patients (17%) were classified in the discriminant TEE group. Five parameters were selected as predictors of a discriminant TEE. Accordingly, the ADAM-C score could be calculated as follows: Score = 4 (if age ≥60) + 2 (if diabetes) + 2 (if aortic stenosis from any degrees) + 1 (if multi-territory stroke) + 2 (if history of coronary artery disease). At a threshold lower than 3, the sensitivity, specificity, positive predictive value, and negative predictive value (NPV) of detecting discriminant TEE were 88% (95% CI 85-90), 44% (95% CI 41-47), 21% (95% CI 19-27), and 95% (95% CI 94-97), respectively. CONCLUSION: A simple score based on clinical and transthoracic echocardiographic parameters can help physicians to identify patients who might not benefit from TEE. Indeed, a score lower than 3 has an interesting NPV of 95% (95% CI 94-97).

Pre-infarction angina and outcomes in non-ST-segment elevation myocardial infarction: data from the RICO survey.

BACKGROUND: The presence of pre-infarction angina (PIA) has been shown to confer cardioprotection after ST-segment elevation myocardial infarction (STEMI). However, the clinical impact of PIA in non-ST-segment elevation myocardial infarction (NSTEMI) remains to be determined. METHODS AND RESULTS: From the obseRvatoire des Infarctus de Côte d'Or (RICO) survey, 1541 consecutive patients admitted in intensive care unit with a first NSTEMI were included. Patients who experienced chest pain <7 days before the episode leading to admission were defined as having PIA and were compared with patients without PIA. Incidence of in-hospital ventricular arrhythmias (VAs), heart failure and 30-day mortality were collected. Among the 1541 patients included in the study, 693 (45%) patients presented PIA. PIA was associated with a lower creatine kinase peak, as a reflection of infarct size (231(109-520) vs. 322(148-844) IU/L, p<0.001) when compared with the group without PIA. Patients with PIA developed fewer VAs, by 3 fold (1.6% vs. 4.0%, p = 0.008) and heart failure (18.0% vs. 22.4%, p = 0.040) during the hospital stay. Overall, there was a decrease in early CV events by 26% in patients with PIA (19.2% vs. 25.9%, p = 0.002). By multivariate analysis, PIA remained independently associated with less VAs. CONCLUSION: From this large contemporary prospective study, our work showed that PIA is very frequent in patients admitted for a first NSTEMI, and is associated with a better prognosis, including reduced infarct size and in hospital VAs. Accordingly, protecting the myocardium by ischemic or pharmacological conditioning not only in STEMI, but in all type of MI merits further attention.

Relation between body mass index, waist circumference, and death after acute myocardial infarction.

BACKGROUND: An elevated body mass index (BMI) has been reported to be associated with a lower rate of death after acute myocardial infarction (AMI). However, waist circumference (WC) may be a better marker of cardiovascular risk than BMI. We used data from a contemporary French population-based cohort of patients with AMI to analyze the impact of WC and BMI on death rates. METHODS AND RESULTS: We evaluated 2229 consecutive patients with AMI. Patients were classified according to BMI as normal, overweight, obese, and very obese (BMI <25, 25 to 29.9, 30 to 34.5, and >35 kg/m(2), respectively) and as increased waistline (WC >88/102 cm for women/men) or normal. Half of the patients were overweight (n=1044), and one quarter were obese (n=397) or very obese (n=128). Increased WC was present in half of the patients (n=1110). Increased BMI was associated with a reduced death rate, with a 5% risk reduction for each unit increase in BMI (hazard ratio, 0.95; 95% CI, 0.93 to 0.98; P<0.001). In contrast, WC as a continuous variable had no impact on all-cause death (P=0.20). After adjustment for baseline predictors of death, BMI was not independently predictive of death. The group of patients with high WC but low BMI had increased 1-year death rate. CONCLUSIONS: Neither BMI nor WC independently predicts death after AMI. Much of the inverse relationship between BMI and the rate of death after AMI is due to confounding by characteristics associated with survival. This study emphasizes the need to measure both BMI and WC because patients with a high WC and low BMI are at high risk of death.

Beneficial effects of statin therapy on survival in hypertensive patients with acute myocardial infarction: data from the RICO survey.

BACKGROUND: Randomized studies have shown a reduction in cardiovascular events associated with low doses of statin among hypertensive patients at only moderate cardiovascular risk. The hypothesis of the present study was that statin therapy initiated during hospitalization could improve the long-term outcome after acute myocardial infarction (MI) in hypertensive patients. METHODS: From the French regional obserRvatoire des Infarctus de Côte d'Or (RICO) survey, 1076 patients with a history of hypertension, surviving acute MI were included. Patients on statin therapy initiated before their hospitalization were excluded from the study. Patients were categorized into two groups based on whether or not statin treatment was initiated during the hospital stay. RESULTS: Patients in the statin group were younger (70 years [range, 58 to 77 years] v 75 years [range, 65 to 82 years], P < .001) and were more likely to have hypercholesterolemia (42% v 28 %, P < .001). No differences were observed between the two groups for LDL-cholesterol levels on admission. At 1-year follow-up, cardiovascular mortality and rehospitalization for heart failure were lower in the statin group (respectively, 5% v 15%, P < .001; 5% v 7%, P < .001). Multivariate analysis showed that statin therapy was associated with decreased mortality (hazard ratio [95% confidence interval; CI]: 0.58 [0.32-0.98], P = .035) independently of either hypercholesterolemia, the use of beta-blockers, angiotensin-converting enzyme inhibitors, or diuretics, but not with a decreased incidence of heart failure (hazard ratio [95% CI]: 0.88 [0.55-1.23], P = .152). CONCLUSIONS: In this observational study, the long-term benefits of statin therapy initiated in-hospital in hypertensive patients after acute MI was demonstrated. These findings may have implications for treatment optimization of hypertensive patients in secondary prevention.

Impact of fasting glycemia on short-term prognosis after acute myocardial infarction.

OBJECTIVE: The prognosis of patients with acute myocardial infarction (MI), according to the new criteria for impaired fasting glucose (IFG) (FG 100-126 mg/dl), has not been evaluated. RESEARCH DESIGN AND METHODS: A total of 2353 patients with acute MI and surviving at d 5 after admission were analyzed for short-term morbidity and mortality. FG was obtained at d 4 and 5. Patients were classified as diabetes mellitus (known diabetes or FG > or = 126 mg/dl), high IFG (110 < or = FG < 126 mg/dl), low IFG (100 < or = FG < 110 mg/dl), and normal fasting glucose (NFG) (FG < 100 mg/dl). RESULTS: Among the 2353 patients, 968 (41%) had diabetes mellitus, 262 (11%) had high IFG, 332 (14%) had low IFG, and 791 (34%) had NFG. Compared with NFG patients, 30-d cardiovascular mortality was increased in high but not low IFG subjects. In-hospital heart failure was increased in high IFG subjects (42 vs. 20% for NFG, P < 0.0001) but not low IFG subjects (21 vs. 20%). High IFG, but not low IFG, was an independent factor associated with 30-d cardiovascular mortality [odds ratio 2.33 (1.55-3.47)] and in-hospital heart failure [odds ratio 1.70 (1.36-2.07)]. The optimal threshold levels of FG on the receiver-operating characteristic curves were 114 and 112 mg/dl to predict mortality and in-hospital heart failure, respectively. CONCLUSION: The present study, based on a nonselected cohort of MI patients, underscores the high prevalence of IFG (25%) and highlights the clinical relevance of 110 mg/dl, but not 100 mg/dl, as a cutoff value to define the risk for worse outcome.

Factors affecting the management of outcome in elderly patients with acute myocardial infarction particularly with regard to reperfusion. Data from the French regional RICO survey.

BACKGROUND: Acute myocardial infarction (AMI) in elderly patients is often unrecognized and associated with poor prognosis. OBJECTIVES: To investigate management and efficacy of reperfusion therapy to the elderly patients with AMI. METHODS: From the January 1, 2001 to October 31, 2002, 964 patients with AMI were included in the French regional RICO survey. The patients were divided into three groups: younger (<70 years old), elderly (70-79 years old) and very elderly (>or=80 years old). RESULTS: Distribution of groups was 56, 27, and 16%, respectively. The longest time delay to first request for medical attention was found in the very elderly group (30 and 55 vs. 90 min, respectively, p < 0.05). Rate of lysis fell significantly with increasing age (35, 22 and 9%, respectively, p < 0.001) but the time delay to lysis was similar for the 3 groups. The proportion of patients who benefited from primary percutaneaous transluminal coronary angioplasty decreased with age (21, 15, 11%, respectively, p < 0.001), but time delay to balloon angioplasty was similar and no difference in mortality rate was observed between the three groups after reperfusion. The incidence of in-hospital cardiovascular events (cardiogenic shock and recurrent myocardial infarction/ischemia) and in-hospital mortality increased with age (5, 13, 17%, respectively, p < 0.001). Moreover, multivariate analysis showed that only ejection fraction and Killip >1 were independent predictive factors for in-hospital cardiovascular mortality, respectively (OR 5.15, 95% CI 2.08-12.74, p < 0.0001 and OR 3.81, 95% CI 1.90-7.65, p < 0.0001), whereas age, sex, diabetes and anterior location were not significant. CONCLUSION: Our data in an unselected population indicate that very elderly patients were characterized by increased pre-hospital delays and less frequent utilization of reperfusion therapy, although no difference in the mortality in reperfused patients could be observed between the three age groups.

Prevalence and impact of metabolic syndrome on hospital outcomes in acute myocardial infarction.

BACKGROUND: The impact of metabolic syndrome after acute myocardial infarction (AMI) has not yet been studied. In a population-based sample of patients with AMI, we sought to determine the prevalence of metabolic syndrome in patients with AMI, its impact on hospital outcomes, and to assess the relative influence of each of the components of the National Cholesterol Education Program (NCEP) Adult Treatment Panel (ATP) III definition of metabolic syndrome on the risk of death and heart failure. METHODS: A total of 633 unselected, consecutive patients hospitalized with AMI were categorized according to the NCEP ATP III metabolic syndrome criteria (presence of >/=3 of the following: hyperglycemia; triglyceride level >/=150 mg/dL [>/=1.7 mmol/L]; high-density lipoprotein cholesterol level <40 mg/dL [<1.04 mmol/L] in men and <50 mg/dL [<1.30 mmol/L] in women; blood pressure >/=130/85 mm Hg; and waist circumference >102 cm in men or 88 cm in women). RESULTS: Among the 633 patients, 290 (46%) fulfilled the criteria for metabolic syndrome. Patients with metabolic syndrome were older and more likely to be women. Acute myocardial infarction characteristics and left ventricular ejection fraction rates were similar for both groups. In-hospital case fatality was higher in patients with metabolic syndrome compared with those without, as was the incidence of severe heart failure (Killip class >II). In multivariate analysis, metabolic syndrome was a strong and independent predictor of severe heart failure, but not in-hospital death. Analysis of the predictive value of each of the 5 metabolic syndrome components for severe heart failure showed that hyperglycemia was the major determinant (odds ratio, 3.31; 95% confidence interval, 1.86-5.87). CONCLUSIONS: In an unselected population of patients with AMI, the prevalence of metabolic syndrome was high. Metabolic syndrome appeared associated with worse in-hospital outcome, with a higher risk of development of severe heart failure. Among metabolic syndrome components, hyperglycemia was the main correlate of the risk of development of severe heart failure during AMI.

High plasma N-terminal pro-brain natriuretic peptide level found in diabetic patients after myocardial infarction is associated with an increased risk of in-hospital mortality and cardiogenic shock.

AIMS: No studies have yet been conducted concerning plasma N-terminal pro-brain natriuretic peptide (Nt-pro-BNP) levels after Myocardial Infarction (MI) and their relationship with short-term outcomes in diabetic patients. METHODS AND RESULTS: Five hundred and sixty patients hospitalized for MI from the RICO survey, including 199 diabetic and 361 non-diabetic subjects, were included in the study. Plasma Nt-pro-BNP levels were measured on admission. Median Nt-pro-BNP levels were significantly higher in diabetic patients compared with non-diabetic patients [245 (81-77) vs. 130 (49-199) pmol/L, P<0.0001]. This difference remained highly significant after adjustment for age, female gender, creatinine clearance, left ventricular ejection fraction (LVEF), plasma peak troponin, anterior wall necrosis, and hypertension. In multivariable analysis, Nt-pro-BNP levels were negatively associated with creatinine clearance (P<0.0001) and LVEF (P<0.0001) and positively associated with plasma peak troponin (P<0.0001), age (P=0.0029), diabetes (P=0.0031), and female gender (P=0.0102). Diabetic patients showed a 4.7-fold increase in hospital mortality (15.6 vs. 3.3%, P<0.0001) and a 2.2-fold increase in cardiogenic shock (17.6 vs. 7.7%, P=0.0004). In multivariable analysis, diabetes was an independent factor for mortality [OR: 1.79 (1.45-2.20); P=0.0064] and cardiogenic shock [OR: 1.45 (1.22-1.72); P=0.0364] when the variable Nt-pro-BNP level was not introduced into the model, but was less significantly associated with mortality [OR: 1.73 (1.39-2.16); P=0.0107] and no longer associated with cardiogenic shock when Nt-pro-BNP was in the model. CONCLUSION: After MI, diabetes is independently associated with high plasma Nt-pro-BNP levels. This elevated Nt-pro-BNP is strongly associated with the increased incidence of in-hospital mortality and cardiogenic shock observed in diabetes. Our findings clearly indicate that plasma Nt-pro-BNP provides highly valuable prognostic information on in-hospital outcome after MI, in particular in diabetic patients.

Beneficial effects of direct call to emergency medical services in acute myocardial infarction.

OBJECTIVES: We investigated the impact of an emergency medical services call on the management of acute myocardial infarction, considering time intervals for intervention and revascularization procedures. METHODS: Data were prospectively collected from January 2001 to October 2002 from 531 patients hospitalized for myocardial infarction with ST segment elevation and a pre-hospital delay of less than 24 h. RESULTS: Only 26% of patients called the emergency medical services at the onset of symptoms (n=140). Other patients (n=391, 74%) called another medical contact. Baseline characteristics and cardiovascular history were similar in the two groups, except for the percutaneous coronary intervention history (10% in the emergency medical services group versus 4% in the other medical contact group, P<0.05). Time intervals from the onset of symptoms of myocardial infarction to call or to medical intervention, as well as the time interval from medical intervention to hospital admission were significantly shorter in the emergency medical services group. The early reperfusion rate was also significantly greater in the emergency medical services group (77%) compared with the other medical contact group (64%), mainly because of a greater incidence of primary percutaneous coronary intervention (36 versus 26%, P<0.03, respectively). Multivariate analysis adjusted for sex and age showed that less than three medical care providers [odds ratio (OR) 5.042, P<0.001], percutaneous coronary intervention history (OR 2.462, P<0.05), as well as rhythmic disorders (OR 2.105, P<0.05) and complete atrioventricular block (OR 2.757, P<0.05) were independent predictors of emergency medical services care. CONCLUSION: This study demonstrated that a call to the emergency medical services is underutilized by patients with symptoms of myocardial infarction, and documented the beneficial effects of an emergency medical services call by reducing pre-hospital delays and increasing early revascularization therapies.

Impaired fasting glucose and cardiogenic shock in patients with acute myocardial infarction.

OBJECTIVES: In-hospital outcome after acute myocardial infarction (MI) has not yet been evaluated with regard to the new category of Impaired Fasting Glucose level (IFG) patients defined by the American Diabetes Association (ADA). METHODS: Nine hundred and ninety-nine patients with acute MI from the RICO survey were included in the study. Fasting blood glucose was measured after admission. Patients were grouped according to ADA definitions: Diabetes Mellitus (DM) (FG >/=7mmol/l or personal history of DM); IFG (FG 6.1 to 7mmol/l); NFG (normal FG <6.1mmol/l). RESULTS: Three hundred and eighty-one patients (38%) had DM, 145 (15%) IFG and 473 (47%) NFG. Mortality in the IFG group was twice that of the NFG group (8% vs 4%, P=0.049). A significant increase in cardiogenic shock (12% vs 6%, P=0.011) and ventricular arrhythmia (15% vs 9%, P=0.035) was observed in the IFG vs NFG group. IFG, after adjustment for confounding factors (age, sex, anterior location, and LVEF), was a strong independent predictive factor for cardiogenic shock (P=0.005). CONCLUSION: MI patients with IFG had an overall worse outcome, characterized by a higher risk of developing cardiogenic shock during their hospital stay.