Evolution of REperfusion Strategies and impact on mortality in Old and Very OLD STEMI patients. The RESOVOLD-e-MUST study.

BACKGROUND: The use of myocardial reperfusion-mainly via angioplasty-has increased in our region to over 95%. We wondered whether old and very old patients have benefited from this development. METHODS: Setting: Greater Paris Area (Ile-de-France). DATA: Regional registry, prospective, including since 2003, data from 39 mobile intensive care units performing prehospital treatment of patients with ST segment elevation myocardial infarction (STEMI) (<24 h). PARAMETERS: Demographic, decision to perform reperfusion and outcome (in-hospital mortality). PRIMARY ENDPOINT: Reperfusion decision rate by decade over age 70. SECONDARY ENDPOINT: Outcome. RESULTS: We analysed the prehospital management of 27,294 patients. There were 21,311 (78%) men and 5,919 (22%) women with a median age of 61 (52-73 years). Among these patients, 8,138 (30%) were > 70 years, 3,784 (14%) > 80 years and 672 (2%) > 90 years.The reperfusion decision rate was 94%. It decreased significantly with age: 93, 90 and 76% in patients in their seventh, eighth and ninth decade, respectively. The reperfusion decision rate increased significantly over time. It increased in all age groups, especially the higher ones. Mortality was 6%. It increased significantly with age: 8, 16 and 25% in patients in their seventh, eighth and ninth decade, respectively. It significantly decreased over time in all age groups. The odds ratio of the impact of reperfusion decision on mortality reached 0.42 (0.26-0.68) in patients over 90 years. CONCLUSION: the increase in the reperfusion decision rate was the greatest in the oldest patients. It reduced mortality even in patients over 90 years of age.

[e-MUST Registry - Evaluation of prehospital medical management of STEMI in Île-de-France]. / Registre e-MUST - Évaluation de la prise en charge médicale préhospitalière du SCA ST+ en Île-de-France.

The e-MUST registry has continuously and comprehensively documented ST-segment elevation myocardial infarctions (STEMIs) managed in the prehospital setting by the 39 Mobile Emergency and Resuscitation Services (SMUR) of the 8 Emergency Medical Assistance System (SAMU) and subsequently managed in the 36 interventional cardiology services in Île-de-France since 2000. This encompasses a population of over 12 million residents. To date, nearly 44,000 patients have been enrolled. The analysis of these findings reflects the real-world management of these patients and the evolution of their care. The results are shared annually with the investigators' teams and have led to around twenty publications. The latest acquired results have demonstrated, in a series of over 630 patients aged over 90, that nonagenarians particularly benefit from prehospital coronary reperfusion decisions, resulting in a nearly 60% reduction in mortality.

[Registry CARDIO-ARSIF - Database on coronary angiography and percutaneous coronary invasive performed in Île-de-France]. / Registre CARDIO-ARSIF - Base de données sur les coronarographies et angioplasties coronaires réalisées en Île-de-France.

The CARDIO-ARSIF registry has been continuously collecting comprehensive data on coronary angiography and percutaneous coronary interventions (PCI) performed in the 36 catheterization laboratories across the Île-de-France region since 2000. Over the period from 2003 to 2022, this registry has recorded information from more than 330,000 patients, encompassing more than one million procedures. Among these procedures, 58% consisted of coronary angiography, 13% were percutaneous coronary interventions (PCI), and the remaining 28% were PCI performed on an ad-hoc basis. This extensive dataset serves as a valuable resource for both qualitative and quantitative assessments of practices and the relevance of procedures in the field of coronary invasive cardiology. The results of these analyses undergo annual validation by a dedicated scientific committee and are shared with the teams of investigators. The exploitation of this data has led to scientific publications, with one notable finding being a consistent reduction in the radiation doses received by patients, regardless of the type of procedure.

Efecto de la edad, el sexo y el momento del díaen el tiempo hasta el aviso a emergenciasen pacientes con infarto agudo de miocardiocon elevación del segmento ST. Estudio CLOC’AGE / Effect of age, gender, and time of day on pain-to-call times in patients with acute ST-segment elevation myocardial infarction: the CLOC’AGE study

Objetivos: La indicación de intervencionismo coronario percutáneo primario (ICPP) en hospitales sin hemodinámica (HSH) se asocia con tiempos primera asistencia-apertura de la arteria (TPA) prolongados. Es pertinente identificar los factores implicados, especialmente aquellos relacionados con la organización de los servicios de urgencias. Método: Análisis de un registro de pacientes atendidos en HSH en una región sanitaria con una red asistencial para infarto agudo de miocardio con elevación del segmento ST (IAMEST) establecida y de sus tiempos de actuación. Resultados: En 2.542 pacientes, de edad 63 ± 13 años, se alcanzó un TPA# 120 minutos en un 42% de casos. En 9 de los 16 HSH analizados existía un box de dolor torácico en el área de urgencias, que se comportó como factor predictor independiente de un TPA# 120 minutos [OR 0,64 (IC 95% 0,54-0,77), p < 0,001], con una reducción de 11 minutos de este. Se asociaron de forma independiente con un TPA superior a 120 minutos la intubación y shock durante la primera asistencia, edad, sexo, atención en horario nocturno, bloqueo de rama izquierda y la clase Killip. La mortalidad al mes y al año aumentó en los HSH proporcionalmente al TPA (1,7% y 3,5% si TPA# 106 minutos y del 7,3% y 12,4% si TPA# 176 minutos, p <0,001). Conclusiones: El TPA alcanzado en activaciones procedentes de HSH supera las recomendaciones en el 58% de casos y se relaciona inversamente con la disponibilidad de un box de dolor torácico en urgencias. La mortalidad al mes y al año es proporcional al grado de retraso en la reperfusión. (AU)

Objetive: The need for primary percutaneous coronary intervention in hospitals without hemodynamic support capability is associated with delays between first medical contact (FMC) and reperfusion. It is important to identify factors involved in delays, particularly if they are relevant to the organization of emergency services. Methods: Analysis of a registry of patients treated in hospitals without advanced hemodynamic support systems in a catchment area with an established care network for acute ST-segment elevation myocardial infarction (STEMI). The registry included care times. Results: The network served 2542 patients with a mean (SD) age of 63 (13) years. FMC-to-reperfusion time was within 120 minutes in 42% of the cases. Nine of the hospitals had a chest-pain unit in the emergency department, and this factor was an independent predictor of FMC-to-reperfusion times of 120 minutes or less (odds ratio, 0.64; 95% CI, 0.54–0.77; P < .0001); the time was shortened by 11 minutes in such hospitals. FMC-to-reperfusion was delayed beyond 120 minutes in relation to the following factors: shock and need for intubation at start of care, age, gender, FMC at night, left bundle branch block, and Killip class. One-month and 1-year mortality rates increased in hospitals without hemodynamic support systems in proportion to reperfusion delay, by 1.7% and 3.5% if the delay was 106 minutes or less and by 7.3% and 12.4% if the delay was 176 minutes or longer (P < .0001). Conclusions: FMC-to-reperfusion time in STEMI exceeds recommendations in 58% of the hospitals without hemodynamic support systems and delay is inversely proportional to the availability of an emergency department chest pain unit. One-month and 1-year mortality is proportional to the degree of delay. (AU)

Effect of age, gender, and time of day on pain-to-call times in patients with acute ST-segment elevation myocardial infarction: the CLOC'AGE study. / Efecto de la edad, el sexo y el momento del día en el tiempo hasta el aviso a emergencias en pacientes con infarto agudo de miocardio con elevación del segmento ST. Estudio CLOC'AGE.

BACKGROUND: The time lapse between onset of symptoms and a call to an emergency dispatch center (pain-to-call time) is a critical prognostic factor in patients with chest pain. It is therefore important to identify factors related to delays in calling for help. OBJECTIVES: To analyze whether age, gender, or time of day influence the pain-to-call delay in patients with acute STsegment elevation myocardial infarction (STEMI). MATERIAL AND METHODS: Data were extracted from a prospective registry of STEMI cases managed by 39 mobile intensive care ambulance teams before hospital arrival within 24 hours of onset in our region, the greater metropolitan area of Paris, France. We analyzed the relation between pain-to-call time and the following factors: age, gender, and the time of day when symptoms appeared. We also assessed the influence of pain-to-call time on the rate of prehospital decisions to implement reperfusion therapy. RESULTS: A total of 24 662 consecutive patients were included; 19 291 (78%) were men and 4371 (22%) were women. The median age was 61 (interquartile range, 52-73) years (men, 59 [51-69] years; women, 73 [59-83] years; P .0001). The median pain-to-call time was 60 (24-164) minutes (men, 55 [23-150] minutes; women, 79 [31-220] minutes; P .0001). The delay varied by time of day from a median of 40 (17-101) minutes in men between 5 pm and 6 pm to 149 (43-377) minutes in women between 2 am and 3 am. The delay was longer in women regardless of time of day and increased significantly with age in both men and women (P .001). A longer pain-to-call time was significantly associated with a lower rate of implementation of myocardial reperfusion (P .001). CONCLUSION: Pain-to-call delays were longer in women and older patients, especially at night. These age and gender differences identify groups that would benefit most from health education interventions.

INTRODUCCION: En el dolor torácico, el tiempo desde el inicio de los síntomas hasta el aviso al sistema de emergencias (TAE) es un factor pronóstico decisivo. Es necesario conocer los factores que pueden influir en su duración. OBJETIVO: Analizar el efecto de la edad, el sexo y el momento del día en el TAE en pacientes con infarto agudo de miocardio con elevación del segmento ST (IAMEST). METODO: Se analizaron los datos de un registro regional prospectivo que incluye a todos los pacientes con IAMEST y 24 horas de evolución atendidos por 39 equipos de ambulancias de soporte vital avanzado en un entorno prehospitalario en el área metropolitana de París, Francia. Se analizó el TAE en relación con la edad, el sexo y el momento de aparición de los síntomas. Se valoró la influencia del TAE en la decisión prehospitalaria de tratamiento de reperfusión. RESULTADOS: Se incluyeron 24.662 pacientes consecutivos, de los cuales 19.291 (78%) eran hombres; la edad mediana fue de 61 años (RIC 52-73); 59 (51-69) en hombres y 73 (59-83) en mujeres (p 0,0001). El TAE fue de 60 minutos (24-164); 55 (23-150) minutos en hombres y 79 (31-220) minutos en mujeres (p 0,0001), y oscilaba entre 40 (17-101) minutos en hombres entre las 17:00 y las 18:00 y 149 (43-377) en mujeres entre las 02:00 y las 03:00. Independientemente de la hora de aparición del dolor, el TAE fue mayor en mujeres, y aumentó con la edad, tanto en hombres como en mujeres (p 0,001). El TAE prolongado se asoció con un descenso significativo en la decisión prehospitalaria de tratamiento de reperfusión (p 0,001). CONCLUSIONES: El intervalo de TAE fue más largo en mujeres y pacientes mayores, especialmente por la noche. Estos resultados permiten identificar los grupos de pacientes que más se beneficiarían de medidas de educación sanitaria.

Angiography and Percutaneous Coronary Intervention for Chronic Total Coronary Occlusion in Daily Practice (from a Large French Registry [CARDIO-ARSIF]).

The aim of this study was to provide contemporary data on chronic total occlusion (CTO) prevalence and management in a large unselected population representing the daily activity of cathlabs, in the greater Paris area, and to compare percutaneous coronary intervention (PCI) features in patients with and without CTO. Procedures were collected from the CARDIO-ARSIF (Agence Régionale de Santé Ile de France) registry from 2012 to 2015. Patients with acute coronary syndrome or previous coronary artery bypass grafting were excluded. CTO features were assessed and PCIs with and without CTO were compared. Among 128,739 included patients, 10,468 (8.1%) had at least 1 CTO. Cardiovascular risk-factor burden was higher in the CTO group, which had more patients with multivessel disease (74% vs 24%) and with referral for interventional management (59% vs 33%). Of all PCIs during the study period, 5.7% involved a CTO; this proportion increased significantly over the study period. PCI success rate was 75.9% in the CTO group. CTO-PCI volume per center did not correlate with CTO-PCI success rate. In conclusion, CTO is common in patients who underwent scheduled coronary angiography. Invasive management is done more often in patients with than without CTO. The success rate of PCI in CTO is not associated with case volume per center.

Incidence, Mortality, and Outcome-Predictors of Sudden Cardiac Arrest Complicating Myocardial Infarction Prior to Hospital Admission.

BACKGROUND: Mortality of ST-segment-elevation myocardial infarction (STEMI) decreased drastically, mainly through reduction in inhospital mortality. Prehospital sudden cardiac arrest (SCA) became one of the most feared complications. We assessed the incidence, outcome, and prognosis' predictors of prehospital SCA occurring after emergency medical services (EMS) arrival. METHODS AND RESULTS: Data were taken between 2006 and 2014 from the e-MUST study (Evaluation en Médecine d'Urgence des Strategies Thérapeutiques des infarctus du myocarde) that enrolls all STEMI managed by EMS in the Greater Paris Area, including those dead before hospital admission. Among 13 253 STEMI patients analyzed, 749 (5.6%) presented EMS-witnessed prehospital SCA. Younger age, absence of cardiovascular risk factors, symptoms of heart failure, extensive STEMI, and short pain onset-to-call and call-to-EMS arrival delays were independently associated with increased SCA risk. Mortality rate at hospital discharge was 4.0% in the nonSCA group versus 37.7% in the SCA group ( P<0.001); 26.8% of deaths occurred before hospital admission. Factors associated with increased mortality after SCA were age, heart failure, and extensive STEMI, while male sex and cardiovascular risk factors were associated with decreased mortality. Among patients admitted alive, PCI was the most important mortality-reduction predictor (odds ratio, 0.40; 95% CI, 0.25-0.63; P<0.0001). CONCLUSIONS: More than 1 of 20 STEMI presents prehospital SCA after EMS arrival. SCA occurrence is associated with a 10-fold higher mortality at hospital discharge compared with STEMI without SCA. PCI is the strongest survival predictor, leading to a twice-lower mortality. This highlights the persistently dramatic impact of SCA on STEMI and the major importance of PCI in this setting.

Decision to deploy coronary reperfusion is not affected by the volume of ST-segment elevation myocardial infarction patients managed by prehospital emergency medical teams.

OBJECTIVE: Mortality in patients with ST-segment elevation myocardial infarction (STEMI) has been associated with the volume of activity of percutaneous coronary intervention (PCI) facilities. This observational study investigated whether the coronary reperfusion-decision rate is associated with the volume of activity in a prehospital emergency setting. METHODS: Prospectively collected data for the period 2003-2013 were extracted from a regional registry of all STEMI patients handled by eight dispatch centers (SAMUs) in and around Paris [41 mobile ICU (MICUs)]. A possible association between volume of activity (number of STEMIs) and coronary reperfusion-decision rate, and subsidiarily between volume of activity and choice of technique (fibrinolysis vs. primary PCI), were investigated. Explanatory factors (patient age, sex, delay between pain onset and first medical contact, and access to a PCI facility) were analyzed in a multivariate analysis. RESULTS: Overall, 18 162 patients; male/female 3.5/1; median age 62 (52-72) years were included in the analysis. The median number of STEMIs per MICU was 339 (IQ 220-508) and that of reperfusion-decisions was 94% (91-95). There was no association between the decision rate and the number of STEMIs (P = 0.1). However, the decision rate was associated with age, sex, delay, and access to a PCI facility (P < 0.0001) in a highly significant way. Fibrinolysis was a more frequent option for low-volume (remoter PCI facilities) than high-volume MICUs (30 vs. 16%). CONCLUSION: The decision of coronary reperfusion in a prehospital emergency setting depended on patient characteristics, delay between pain onset and first medical contact, and access to a PCI facility, but not on volume of activity. Promoting fibrinolysis use in underserved areas might help increase the reperfusion-decision rate.

Evolution of ST-Elevation Acute Myocardial Infarction Prevalence by Gender Assessed Age Pyramid Analysis-The Piramyd Study.

INTRODUCTION: Recent studies reported a decrease in the incidence of acute myocardial infarction. This favorable evolution does not extend to young women. The interaction between gender, risk factors and myocardial infarction incidence remains controversial. OBJECTIVE: To compare the evolution of the age pyramid of patients with ST-elevation myocardial infarction (STEMI) according to gender. METHODS: Data from patients with STEMI managed in pre-hospital settings prospectively collected in the greater Paris area. Evolution of patient demographics and risk factors was investigated. RESULTS: 28,249 patients with STEMI were included in the registry between 2002 and 2014, 21,883 (77%) males and 6,366 (23%) females. The sex ratio did not significantly vary over the study period (p = 0.4). Median patient age was 60.1 years (51.1⁻73.0) and was significantly different between males and females, respectively 57.9 (50.0⁻68.3) vs. 72.9 years (58.3⁻82.2) (p = 0.0004). The median age of males significantly (p = 0.0044) increased from 57.6 (50.1⁻70.0) in 2002 to 58.1 years (50.5⁻67.8) in 2014. The median age of females significantly (p = 0.0006) decreased from 73.7 (57.9⁻81.8) to 69.6 years (57.0⁻82.4). The median gap between the age of men and women significantly (p = 0.0002) decreased, from 16.1 to 11.5 years. Prevalence of risk factors was unchanged or decreased except for hypertension which significantly increased in males. The rate of STEMI without reported risk factors increased in both males and females. CONCLUSION: The age of STEMI onset significantly decreased in females, whereas it significantly increased in males. The prevalence of risk factors decreased in males, whereas no significant variation was found in females.

Time-Course Reduction in Patient Exposure to Radiation From Coronary Interventional Procedures: The Greater Paris Area Percutaneous Coronary Intervention Registry.

BACKGROUND: The frequency of complex percutaneous coronary interventions (PCIs) has increased in the last few years, with a growing concern on the radiation dose received by the patients. Multicenter data from large unselected populations on patients' radiation doses during coronary angiography (CA) and PCI and temporal trends are lacking. This study sought to evaluate the temporal trends in patients' exposure to radiation from CA and PCI. METHODS AND RESULTS: Data were taken from the CARDIO-ARSIF registry that prospectively collects data on all CAs and PCIs performed in the 36 catheterization laboratories in the Greater Paris Area, the most populated regions in France with about 12 million inhabitants. Kerma area product and Fluoroscopy time from 152 684 consecutive CAs and 103 177 PCIs performed between 2009 and 2013 were analyzed. A continuous trend for a decrease in median [interquartile range] Kerma area product was observed, from 33 [19-55] Gy cm2 in 2009 to 27 [16-44] Gy cm2 in 2013 for CA (P<0.0001), and from 73 [41-125] to 55 [31-91] Gy cm2 for PCI (P<0.0001). Time-course differences in Kerma area product remained highly significant after adjustment on Fluoroscopy time, PCI procedure complexity, change of x-ray equipment, and other patient- and procedure-related covariates. CONCLUSIONS: In a large patient population, a steady temporal decrease in patient radiation exposure during CA and PCI was noted between 2009 and 2013. Kerma area product reduction was consistent in all types of procedure and was independent of patient-related factors and PCI procedure complexity.

Longer pre-hospital delays and higher mortality in women with STEMI: the e-MUST Registry.

AIMS: The mortality rate in patients with STEMI is higher in women than in men. This higher mortality rate is partly accounted for by certain known characteristics inherent in the female population (age, diabetes). Using data from the e-MUST registry on STEMI patients in the Greater Paris area, we assessed the differences between men and women treated with reperfusion strategies. METHODS AND RESULTS: Patients presenting within 24 hours of pain onset between 2006 and 2010 were included in the study. The male and female subpopulations were compared according to their baseline characteristics, their management delays and their early outcomes. Five thousand eight hundred and forty males (78.9%) and 1,557 females (21.1%) were included in the study. In-hospital mortality was significantly higher in women than in men, 143 (9.4%) vs. 254 (4.4%), p<0.0001, with a longer time to treatment initiation, symptoms to call (2.7±3.6 vs. 2.2±3.4 hours, p<0.0001), symptoms to first medical contact (FMC) (3.1±3.7 vs. 2.6±3.4 hours, p<0.0001), and call to FMC (25.6±23.5 vs. 23.6±18.3 min, p=0.02). After adjustment for clinical factors, severity criteria, myocardial infarction (MI) location and delays, mortality remained higher in women than in men with an odds ratio of 1.40 [1.06-1.84], p=0.017. CONCLUSIONS: We demonstrated longer pre-hospital delays and higher in-hospital mortality in women. The increase in the time to treatment alone does not completely explain the persistent increase in mortality. Further studies, public awareness programmes and physician education are necessary to reduce delays and improve the prognosis of STEMI in women.

Outcomes of primary percutaneous coronary interventions in nonagenarians with acute myocardial infarction.

BACKGROUND: Few data are available on primary percutaneous coronary intervention (pPCI) in nonagenarians. In a large prospective registry on pPCI for STEMI we compared the demographics, procedural and in-hospital outcomes between nonagenarians (age ≥ 90 years) and patients aged < 90 years. METHODS AND RESULTS: We included 26,157 consecutive patients with pPCI in the Greater Paris Area region between 2003 and 2011. Of these, 418 (1.6%) were ≥ 90 years old. Nonagenarians (versus patients < 90 years) were more likely to be female (62.3% versus 22.5%, p < 0.0001), nonsmokers (81.6% versus 36.7%, p < 0.0001), in cardiogenic shock (Killip IV) upon admission (10.5% versus 4.8%, p < 0.001), and had significant co-morbidities. Over two-thirds of patients underwent procedures via the radial artery (61% versus 72.1%, p = 0.007). Both groups had high and similar angiographic success rates (98.1% versus 98.7%, p = 0.33). Drug-eluting stents were used less often in nonagenarians (4.4% versus 16.7%, p < 0.0001). Hospital mortality was significantly much higher in patients over 90 years old (24.9% versus 5.1%, p < 0.001) in univariate analysis. After adjustment for sex, cardiogenic shock, diabetes, triple vessel disease, drug-eluting stent use and glycoprotein IIb/IIIa inhibitors use, mortality remains higher in nonagenarian patients (OR: 4.31; 95% CI: 3.26-5.71, p < 0.0001). CONCLUSIONS: In a real-world setting, we found important demographic differences in nonagenarian compared to younger patients. Despite achieving a high rate of reperfusion with pPCI using mainly radial access, similar to that achieved in younger patients, hospital mortality was higher in nonagenarians.