Transcatheter pulmonary valve replacement after pulmonary homograft dysfunction.

Pulmonary homograft dysfunction is challenging to treat in patients with a previous Ross procedure, and results in significant morbidity and mortality in case of reoperation. We report the case of a patient with early severe pulmonary homograft stenosis 18 months after a Ross procedure and successful management using transcatheter pulmonary valve replacement.

Cost-effectiveness analysis of patent foramen ovale closure with Amplatzer plus medical therapy compared to medical therapy in patients with a history of stroke in France.

BACKGROUND: A patent foramen ovale (PFO) is formed when the ovale foramen does not close spontaneously or re-opens leaving the right and left atrium connected. The present study was conducted to analyze the cost-effectiveness of PFO closure with Amplatzer device plus medical therapy (MT) compared to MT alone in the French reimbursement system for PFO patients with a prior history of stroke, using the RESPECT study data. METHODS: A multi-state Markov model was used. The analysis was conducted from a collective perspective over a 10-year time horizon with 4% discount applied for costs and health effects. The simulated population included adult patients with PFO. Sub-group analysis was limited to patients with atrial septal aneurysm and/or a large-shunt. Clinical inputs were derived from the RESPECT study and literature. Costs associated with the device, drugs, and management were sourced from literature and national databases. The outcomes of analyses included life-years (LYs), quality-adjusted LYs (QALYs), incremental cost-effectiveness ratio (ICER), and number of recurrent strokes avoided. Scenario and sensitivity analyses were conducted to assess the robustness of the results. RESULTS: The use of Amplatzer plus MT provided additional QALYs (0.16) at an incremental cost of 7301€, generating an ICER of 46,288€/QALY for Amplatzer vs. MT alone. In the sub-group analysis, Amplatzer plus MT provided additional QALYs (0.20) at an incremental cost of 5818€, generating an ICER of 28,624€/QALY for Amplatzer plus MT vs. MT alone. Amplatzer plus MT led to lower number of recurrent strokes in comparison to MT alone in both populations. Scenario and sensitivity analyses confirmed the robustness of the results. CONCLUSION: Amplatzer plus MT represents a cost-effective treatment option and is associated with lower stroke recurrence compared to MT alone for PFO patients with a prior history of stroke.

Safety and efficacy of left atrial appendage occlusion with the ACP or Watchman device guided by intracardiac echocardiography from the left atrium.

BACKGROUND: There is a paucity of randomized data regarding the safety and efficacy of the use of intracardiac echocardiography (ICE) from the left atrium (LA) to guide left atrial appendage occlusion (LAAO) procedures under local anesthesia using either of the available devices. HYPOTHESIS: The aim of this study was to compare the efficacy and safety of ICE from the LA with transesophageal echocardiography (TEE) for guidance during transcatheter LAAO procedures. METHODS: Single-center, cohort study of patients undergoing LAAO with the Amplatzer Cardiac Plug or Watchman device. Procedures were guided by ICE from the LA with local anesthesia (n = 175) or TEE under general anesthesia (n = 49). Efficacy outcomes were procedural success and peri-device leaks 6 weeks after LAAO. The safety outcome was a composite of procedure-related complications. RESULTS: Procedural success was similar between groups: 100% in the TEE-guided group, and 98% in the ICE-guided group. Procedure-related complications such as death, embolism, migration, or major vascular complications occurred similarly between groups (p = 0.590). The rate and degree of peri-device leaks or presence of a thrombus on the device did not differ between groups on follow-up CT. Turnover time in the catheter laboratory and use of contrast agent were reduced with ICE. CONCLUSIONS: ICE in the left atrium to guide LAAO procedures appears to be as effective and safe as TEE. There was no increase in procedure-related complications, whatever the device used. ICE resulted in similar procedural success while decreasing procedure time and requiring only local anesthesia.

Left Atrial Remodeling and Brain Natriuretic Peptide Levels Variation after Left Atrial Appendage Occlusion.

BACKGROUND: Few data are available about brain natriuretic peptide (BNP) variation and left atrial remodeling after the left atrial appendage occlusion (LAAO) technique. METHODS: Prospective study included all consecutive patients successfully implanted with an LAAO device. Contrast-enhanced cardiac computed tomography (CT) was performed before and 6 weeks after the procedure with reverse left atrial remodeling defined by an increase in LA volume >10%, together with blood sampling obtained before, 48 h after device implantation and at the first visit after discharge (30-45 days) for BNP measurement. RESULTS: Among the 43 patients implanted with a complete dataset, mean end-diastolic LA volume was 139 ± 64 mL and 141 ± 62 mL at baseline and during follow-up (45 ± 15 days), respectively, showing no statistical difference (p = 0.45). No thrombus was seen on the atrial side of the device. Peridevice leaks (defined as presence of dye in the LAA beyond the device) were observed in 17 patients (40%) but were trivial or mild. Reverse atrial remodeling (RAR) at 6 weeks was observed in six patients (14%). Despite no difference in BNP levels on admission, median BNP levels at 48 h were slightly increased in RAR patients when compared with controls. During FU, BNP levels were strictly identical in both groups. These results were not modified even when each RAR case was matched with two controls on age, LVEF, creatinine levels and ACE inhibitors treatment to avoid potential confounders. CONCLUSION: Our study showed that despite the fact that the LAAO technique can induce left atrial remodeling measured by a CT scan, it does not seem to impact BNP levels on the follow-up. The results need to be transposed to clinical outcomes of this expanding population in future studies.

A case report of an acute coronary syndrome in a 10-year-old boy with homozygous familial hypercholesterolaemia.

BACKGROUND: Familial hypercholesterolaemia is a well-known disorder, but clinical diagnoses tend to be delayed. Acute coronary syndrome may occur in childhood. CASE SUMMARY: Our patient, a young boy with homozygous familial hypercholesterolaemia, complained of persistent chest pain at rest and suffered a non-ST-elevation myocardial infarction (NSTEMI). The diagnosis of NSTEMI was made on the basis of his clinical features, dynamic electrocardiogram changes, troponin elevation, and cardiac computed tomography findings. The patient was managed surgically by intrathoracic artery (ITA) bypass graft. During post-operative follow-up, the young patient suffered from angina pectoris from unexpected and exceptional atheroma stenosis on the ITA. DISCUSSION: Familial hypercholesterolaemia needs to be identified quickly in young patients and lipid lowering therapies should be started without delay.

Reduced Rivaroxaban Dose Versus Dual Antiplatelet Therapy After Left Atrial Appendage Closure: ADRIFT a Randomized Pilot Study.

BACKGROUND: Percutaneous left atrial appendage closure (LAAC) exposes to the risk of device thrombosis in patients with atrial fibrillation who frequently have a contraindication to full anticoagulation. Thereby, dual antiplatelet therapy (DAPT) is usually preferred. No randomized study has evaluated nonvitamin K antagonist oral anticoagulant after LAAC, and we decided to evaluate the efficacy and safety of reduced doses of rivaroxaban after LAAC. METHODS: ADRIFT (Assessment of Dual Antiplatelet Therapy Versus Rivaroxaban in Atrial Fibrillation Patients Treated With Left Atrial Appendage Closure) is a multicenter, phase IIb study, which randomized 105 patients after successful LAAC to either rivaroxaban 10 mg (R10, n=37), rivaroxaban 15 mg (R15, n=35), or DAPT with aspirin 75 mg and clopidogrel 75 mg (n=33). The primary end point was thrombin generation (prothrombin fragments 1+2) measured 2 to 4 hours after drug intake, 10 days after treatment initiation. Thrombin-antithrombin complex, D-dimers, rivaroxaban concentrations were also measured at 10 days and 3 months. Clinical end points were evaluated at 3-month follow-up. RESULTS: The primary end point was reduced with R10 (179 pmol/L [interquartile range (IQR), 129-273], P<0.0001) and R15 (163 pmol/L [IQR, 112-231], P<0.0001) as compared with DAPT (322 pmol/L [IQR, 218-528]). We observed no significant reduction of the primary end point between R10 and R15 while rivaroxaban concentrations increased significantly from 184 ng/mL (IQR, 127-290) with R10 to 274 ng/mL (IQR, 192-377) with R15, P<0.0001. Thrombin-antithrombin complex and D-dimers were numerically lower with both rivaroxaban doses than with DAPT. These findings were all confirmed at 3 months. The clinical end points were not different between groups. A device thrombosis was noted in 2 patients assigned to DAPT. CONCLUSIONS: Thrombin generation measured after LAAC was lower in patients treated by reduced rivaroxaban doses than DAPT, supporting an alternative to the antithrombotic regimens currently used after LAAC and deserves further evaluation in larger studies. Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT03273322.

Involvement of Autonomic Nervous System in New-Onset Atrial Fibrillation during Acute Myocardial Infarction.

Background: Atrial fibrillation (AF) is common after acute myocardial infarction (AMI) and associated with in-hospital and long-term mortality. However, the pathophysiology of AF in AMI is poorly understood. Heart rate variability (HRV), measured by Holter-ECG, reflects cardiovascular response to the autonomic nervous system and altered (reduced or enhanced) HRV may have a major role in the onset of AF in AMI patients. Objective: We investigated the relationship between autonomic dysregulation and new-onset AF during AMI. Methods: As part of the RICO survey, all consecutive patients hospitalized for AMI at Dijon (France) university hospital between June 2001 and November 2014 were analyzed by Holter-ECG <24 h following admission. HRV was measured using temporal and spectral analysis. Results: Among the 2040 included patients, 168 (8.2%) developed AF during AMI. Compared to the sinus-rhythm (SR) group, AF patients were older, had more frequent hypertension and lower left ventricular ejection fraction LVEF. On the Holter parameters, AF patients had higher pNN50 values (11% vs. 4%, p < 0.001) and median LH/HF ratio, a reflection of sympathovagal balance, was significantly lower in the AF group (0.88 vs 2.75 p < 0.001). The optimal LF/HF cut-off for AF prediction was 1.735. In multivariate analyses, low LF/HF <1.735 (OR(95%CI) = 3.377 (2.047-5.572))was strongly associated with AF, ahead of age (OR(95%CI) = 1.04(1.01-1.06)), mean sinus-rhythm rate (OR(95%CI) = 1.03(1.02-1.05)) and log NT-proBNP (OR(95%CI) = 1.38(1.01-1.90). Conclusion: Our study strongly suggests that new-onset AF in AMI mainly occurs in a dysregulated autonomic nervous system, as suggested by low LF/HF, and higher PNN50 and RMSSD values.

Silent atrial fibrillation: clinical management and perspectives.

Silent atrial fibrillation (AF) is an asymptomatic atrial arrhythmia that can be diagnosed by chance during a systematic electrocardiogram, an external Holter, or from implanted cardiac devices. There is a significant body of the literature around silent AF, yet it remains largely underdiagnosed in everyday clinical practice. Meanwhile, new diagnostic tools have significantly improved the detection of silent AF, creating a potential for mass screening via new technologies and the promise of a major step forward in e-health progress. However, it is not yet known whether silent AF is associated with the same thromboembolic risk as symptomatic AF, and whether these asymptomatic and often short-lasting episodes therefore require anticoagulation therapy and rhythm management.

Incidence, Predictive Factors, and Prognostic Impact of Silent Atrial Fibrillation After Transcatheter Aortic Valve Implantation.

New onset atrial fibrillation post-transcatheter aortic valve implantation (TAVI) is common and is associated with adverse outcomes. However, silent atrial fibrillation (AF) is poorly documented in the context. This study sought to evaluate the incidence, predictive factors, and prognostic value of Silent AF post-TAVI. All the consecutive patients with TAVI were prospectively analyzed by continuous electrocardiogram monitoring≥48 hours after implantation. Silent AF was defined as asymptomatic episodes lasting at least 30 seconds. The population was divided into 3 groups: history of AF, no-AF, and silent AF. Among the 206 patients implanted with TAVI, 19 (16.1%) developed silent AF. Compared with the no-AF group, patients with silent AF shared the same clinical characteristics and cardiovascular risk factors. Procedural success and echography parameters after the device implantation were similar between groups. Left atrial volume was significantly increased (p <0.001) in the silent AF group, together with preimplantation C-reactive protein (CRP) >3 mg/L and glucose (p = 0.048 and p = 0.002). By multivariate analysis, CRP >3 mg/dl and logistic European System for Cardiac Operative Risk Evaluation were identified as independent predictors of silent AF. In-hospital and 1-year mortalities were higher in pre-existing AF patients, whereas no-AF and the silent AF patients share the same prognosis. Our prospective study showed for the first time that silent AF is frequent after TAVI procedures. In conclusion, our work suggests that CRP could help to predict the risk of developing silent AF. However, the onset of silent AF is not associated with worse prognosis in the year following the procedure in our study.

High rate of recurrence at long-term follow-up after new-onset atrial fibrillation during acute myocardial infarction.

Aims: Silent and symptomatic atrial fibrillation (AF) are common during acute myocardial infarction (AMI), and associated with higher in-hospital and 1-year mortality. Are silent and symptomatic AF associated with higher rates of AF recurrence after hospitalization for AMI? Methods and results: All consecutive patients admitted for AMI between January 2012 and August 2015 were prospectively analysed by continuous electrocardiogram monitoring <48 h after admission. Silent AF was defined as asymptomatic episodes lasting at least 30 s. The population was divided into three groups: no-AF, silent AF, and symptomatic AF. Altogether, 1621 patients were included in the prospective study and discharged alive from hospital. After excluding those with previous AF, permanent AF since the AMI and coronary artery bypass grafting surgeries and those lost to follow-up, 1282 remained. During the AMI, 1058 patients (83%) had a persistent sinus rhythm (SR), 168 (13%) had silent AF, and 55 (4%) had symptomatic AF. After a median follow-up of 1037 days (interquartile range 583-1342), new AF episodes were recorded in 59 patients (6%) of the SR group, 21 (13%) in the silent AF group, and 13 (24%) in the symptomatic AF group (P < 0.001). After Cox multivariate analysis, AF during AMI, indexed left atrial volume, age, and creatinine at discharge were identified as independent risk factors of AF after AMI. Conclusion: The results of our large-scale study suggest that patients experiencing paroxysmal new-onset AF (silent or symptomatic) during AMI are at higher risk of AF at follow-up. Our data raise the question of implementing anticoagulation therapy following these brief and often neglected episodes.

Predicting the development of in-hospital cardiogenic shock in patients with ST-segment elevation myocardial infarction treated by primary percutaneous coronary intervention: the ORBI risk score.

Aims: To derive and validate a readily useable risk score to identify patients at high-risk of in-hospital ST-segment elevation myocardial infarction (STEMI)-related cardiogenic shock (CS). Methods and results: In all, 6838 patients without CS on admission and treated by primary percutaneous coronary intervention (pPCI), included in the Observatoire Régional Breton sur l'Infarctus (ORBI), served as a derivation cohort, and 2208 patients included in the obseRvatoire des Infarctus de Côte-d'Or (RICO) constituted the external validation cohort. Stepwise multivariable logistic regression was used to build the score. Eleven variables were independently associated with the development of in-hospital CS: age >70 years, prior stroke/transient ischaemic attack, cardiac arrest upon admission, anterior STEMI, first medical contact-to-pPCI delay >90 min, Killip class, heart rate >90/min, a combination of systolic blood pressure <125 mmHg and pulse pressure <45 mmHg, glycaemia >10 mmol/L, culprit lesion of the left main coronary artery, and post-pPCI thrombolysis in myocardial infarction flow grade <3. The score derived from these variables allowed the classification of patients into four risk categories: low (0-7), low-to-intermediate (8-10), intermediate-to-high (11-12), and high (≥13). Observed in-hospital CS rates were 1.3%, 6.6%, 11.7%, and 31.8%, across the four risk categories, respectively. Validation in the RICO cohort demonstrated in-hospital CS rates of 3.1% (score 0-7), 10.6% (score 8-10), 18.1% (score 11-12), and 34.1% (score ≥13). The score demonstrated high discrimination (c-statistic of 0.84 in the derivation cohort, 0.80 in the validation cohort) and adequate calibration in both cohorts. Conclusion: The ORBI risk score provides a readily useable and efficient tool to identify patients at high-risk of developing CS during hospitalization following STEMI, which may aid in further risk-stratification and thus potentially facilitate pre-emptive clinical decision making.

Temporal Trends in Transcatheter Aortic Valve Replacement in France: FRANCE 2 to FRANCE TAVI.

BACKGROUND: Transcatheter aortic valve replacement (TAVR) is standard therapy for patients with severe aortic stenosis who are at high surgical risk. However, national data regarding procedural characteristics and clinical outcomes over time are limited. OBJECTIVES: The aim of this study was to assess nationwide performance trends and clinical outcomes of TAVR during a 6-year period. METHODS: TAVRs performed in 48 centers across France between January 2013 and December 2015 were prospectively included in the FRANCE TAVI (French Transcatheter Aortic Valve Implantation) registry. Findings were further compared with those reported from the FRANCE 2 (French Aortic National CoreValve and Edwards 2) registry, which captured all TAVRs performed from January 2010 to January 2012 across 34 centers. RESULTS: A total of 12,804 patients from FRANCE TAVI and 4,165 patients from FRANCE 2 were included in this analysis. The median age of patients was 84.6 years, and 49.7% were men. FRANCE TAVI participants were older but at lower surgical risk (median logistic European System for Cardiac Operative Risk Evaluation [EuroSCORE]: 15.0% vs. 18.4%; p < 0.001). More than 80% of patients in FRANCE TAVI underwent transfemoral TAVR. Transesophageal echocardiography guidance decreased from 60.7% to 32.3% of cases, whereas more recent procedures were increasingly performed in hybrid operating rooms (15.8% vs. 35.7%). Rates of Valve Academic Research Consortium-defined device success increased from 95.3% in FRANCE 2 to 96.8% in FRANCE TAVI (p < 0.001). In-hospital and 30-day mortality rates were 4.4% and 5.4%, respectively, in FRANCE TAVI compared with 8.2% and 10.1%, respectively, in FRANCE 2 (p < 0.001 for both). Stroke and potentially life-threatening complications, such as annulus rupture or aortic dissection, remained stable over time, whereas rates of cardiac tamponade and pacemaker implantation significantly increased. CONCLUSIONS: The FRANCE TAVI registry provided reassuring data regarding trends in TAVR performance in an all-comers population on a national scale. Nonetheless, given that TAVR indications are likely to expand to patients at lower surgical risk, concerns remain regarding potentially life-threatening complications and pacemaker implantation. (Registry of Aortic Valve Bioprostheses Established by Catheter [FRANCE TAVI]; NCT01777828).

Relation between high levels of myeloperoxidase in the culprit artery and microvascular obstruction, infarct size and reverse remodeling in ST-elevation myocardial infarction.

MAIN OBJECTIVE: To better understand the role of myeloperoxidases (MPO) in microvascular obstruction (MO) phenomenon and infarct size (IS) using cardiac magnetic resonance (CMR) data in patients with acute myocardial infarction (AMI). METHOD: 40 consecutive patients classified according to the median level of MPO in the culprit artery. A CMR study was performed during the week following AMI and at 6 months, with late gadolinium enhancement sequences. RESULTS: Persistent MO was observed in the same proportion (50 vs. 65%, p = 0.728) between the low vs. high MPO group levels. However, the extent of the microvascular obstruction was significantly greater in the high-MPO group (6 (0-9) vs.16.5 (0-31), p = 0.027), together with a greater infarct size, and a trend towards a lower left ventricular ejection fraction (LVEF) (p = 0.054) at one week. CMR data at 6 months showed that reverse systolic remodeling was two fold more present in the low-MPO group (p = 0.058). Interestingly, the extent of MO (8.5 (6.5-31) vs. 4.1 (3-11.55), p = 0.042) and IS remained significantly greater (24.5 (9.75-35) vs. 7.5 (2.5-18.75), p = 0.022) in the high-MPO group. Moreover, MPO in the culprit artery appeared to correlate positively with MPO in non-culprit arteries and serum, and with troponin levels and peak CK. CONCLUSION: This patient-based study revealed in patients after AMI that high MPO levels in the culprit artery were associated with more severe microvascular obstruction and greater IS. These findings may provide new insights pathophysiology explanation for the adverse prognostic impact of MO.

Incremental predictive value of mean platelet volume/platelet count ratio in in-hospital stroke after acute myocardial infarction.

Stroke is a serious complication after acute myocardial infarction (AMI) and is associated with an increased risk of death. Though the pathophysiological mechanisms are not exactly known, increased inflammation and platelet reactivity could play an important role in the occurrence of stroke during AMI. We aimed to investigate the relationship between both mean platelet volume (MPV), a parameter of platelet function, and C-reactive protein (CRP) and the occurrence of in-hospital ischemic stroke (IHS) after AMI. Data were obtained from a French regional survey for AMI that included 5976 patients admitted to an intensive care unit (ICU) between 2001 and 2010. Patients were divided into two groups according to the occurrence of IHS. MPV, platelet count (PC), and CRP were routinely measured at admission to the ICU; 99 (1.6%) IHSs were recorded during hospitalization after admission for AMI. In multivariate analysis, IHS was independently associated with a history of stroke (OR: 1.99%, CI: 1.1-3.49, p = 0.01), impaired left ventricular ejection fraction <40% (OR: 1.88, 95% CI: 1.20-2.94, p = 0.006), impaired renal function (OR: 1.94, 95% CI: 1.27-2.95, p = 0.002), CRP > 10 mg/l (OR: 2.19, 95% CI: 1.44-3.33, p < 0.001), and MPV/PC ratio (OR: 1.04, 95% CI: 1.01-1.08, p = 0.023). Compared with the first to fourth quintiles, the last quintile of the MPV/PC ratio was associated with higher rates of IHS on survival curve analysis (p = 0.014). At hospital admission, a high MPV/PC ratio and a high level of CRP might help to identify patients at increased risk of IHS. Moreover, these results provide new insights into the potential role played by increased inflammation and platelet reactivity in the occurrence of stroke after AMI.

Clinical effectiveness of the systematic use of the GRACE scoring system (in addition to clinical assessment) for ischaemic outcomes and bleeding complications in the management of NSTEMI compared with clinical assessment alone: a prospective study.

UNLABELLED: We assessed the interest of systematically using the GRACE scoring system (in addition to clinical assessment) for in- hospital outcomes and bleeding complications in the management of NSTEMI compared with clinical assessments alone. Multicentre, randomized study that included 572 consecutive NSTEMI patients, randomized 1:1, into group A: clinical stratification alone and group B: clinical+ GRACE score stratification. MAIN OUTCOME MEASURES: in-hospital outcomes and bleeding complications. There was no significant difference between the two groups for baseline data or for in-hospital MACE. In multivariate analysis, only a GRACE >140 (OR: 3.5, 95 % CI: 1.8-6.6, p < 0.001) and PCI (OR: 0.55, 95 % CI: 0.3-1.0; p = 0.05) were independent predictors of in-hospital MACE. The sub-analysis of group B showed that 56 patients (20 %) were given a compliance score of 0, showing that diagnostic angiography was performed later than as recommended by the guidelines. Interestingly, 91 % had a GRACE score >140, and these patients were significantly older, and were more likely to have a history of diabetes, stroke and renal failure, together with symptoms of heart failure. After multivariate analysis, the independent predictors of a lack of compliance with guideline delays were a GRACE score >140 (OR: 9.2; CI: 4.2-20.3, p < 0.001) and secondary referral from a non-PCI cardiology department (OR: 2.7; CI: 1.4-5.2, p = 0.003). In a real-world setting of patients admitted with NSTEMI, the systematic use of the GRACE scoring system at admission in the PCI centre does not improve in-hospital outcomes and bleeding complications.

Cardiac rehabilitation and 5-year mortality after acute coronary syndromes: The 2005 French FAST-MI study.

BACKGROUND: Clinical studies have shown a beneficial effect of cardiac rehabilitation (CR) on mortality. OBJECTIVE: To study the effect of CR prescription at discharge on 5-year mortality in patients with acute myocardial infarction (AMI). METHODS: Participants, from the 2005 French FAST-MI hospital registry, were 2894 survivors at discharge, divided according to AMI type: ST-segment elevation myocardial infarction (STEMI; n=1523) and non-STEMI (NSTEMI; n=1371). The effect of CR prescription on mortality was analysed using a Cox proportional hazards model. RESULTS: At discharge, 22.1% of patients had a CR prescription. Patients referred to CR were younger (62.4 vs. 67.5years), were more frequently men and more had presented with STEMI (67.8% vs. 48.3%) than non-referred patients. Ninety-four (14.7%) deaths occurred among patients referred to CR and 585 (25.9%) among non-referred patients (P<0.001). After multivariable adjustment, the association between CR and mortality remained significant (hazard ratio [HR] 0.76, 95% confidence interval [CI] 0.60-0.96). Analyses stratified by sex, age (<60 vs.≥60years) and AMI type showed that the inverse association was stronger in men (HR 0.64, 95% CI 0.48-0.87) than in women (HR 0.95, 95% CI 0.64-1.39), in younger (HR 0.34, 95% CI 0.15-0.77) than in older patients (HR 0.84, 95% CI 0.65-1.07) and in NSTEMI (HR 0.63, 95% CI 0.46-0.88) than in STEMI (HR 0.99, 95% CI 0.69-1.40). CONCLUSION: After hospitalization for AMI, referral to CR remains a significant predictor of improved patient survival; some subgroups seem to gain greater benefit.

New insights into symptomatic or silent atrial fibrillation complicating acute myocardial infarction.

Atrial fibrillation (AF) is the most frequent heart rhythm disorder in the general population and contributes not only to a major deterioration in quality of life but also to an increase in cardiovascular morbimortality. The onset of AF in the acute phase of myocardial infarction (MI) is a major event that can jeopardize the prognosis of patients in the short-, medium- and long-term, and is a powerful predictor of a poor prognosis after MI. The suspected mechanism underlying the excess mortality is the drop in coronary flow linked to the acceleration and arrhythmic nature of the left ventricular contractions, which reduce the left ventricular ejection fraction. The principal causes of AF-associated death after MI are linked to heart failure. Moreover, the excess risk of death in these heart failure patients has also been associated with the onset of sudden death. Whatever its form, AF has a major negative effect on patient prognosis. In recent studies, symptomatic AF was associated with inhospital mortality of 17.8%, to which can be added mortality at 1year of 18.8%. Surprisingly, silent AF also has a negative effect on the prognosis, as it is associated with an inhospital mortality rate of 10.4%, which remains high at 5.7% at 1year. Moreover, both forms of AF are independent predictors of mortality beyond traditional risk factors. The frequency and seriousness of silent AF in the short- and long-term, which were until recently rarely studied, raises the question of systematically screening for it in the acute phase of MI. Consequently, the use of continuous ECG monitoring could be a simple, effective and inexpensive solution to improve screening for AF, even though studies are still necessary to validate this strategy. Finally, complementary studies also effect of oxidative stress and endothelial dysfunction, which seem to play a major role in triggering this rhythm disorder.