Abstract Background Elderly patients are underrepresented in acute myocardial infarction trials. Our aim was to determine whether, in elderly patients, changes in management in the past 15 years is ...associated with improved one-year mortality after hospital admission for myocardial infarction. Methods We used data from 4 one-month French registries, conducted 5 years apart from 1995 to 2010, including 3,389 elderly patients (≥75 years). Results From 1995 to 2010, mean age remained stable (82.1 years), similar in ST- and non-ST-elevation myocardial infraction patients. Obesity, diabetes, hypertension, and hypercholesterolemia increased. History of prior myocardial infarction, stroke and peripheral artery disease remained stable, while history of heart failure decreased. Major changes in management were noted: early percutaneous coronary intervention, early treatment with antiplatelet agents, low molecular weight heparin, beta-blockers, angiotensin-converting-enzyme inhibitor or angiotensin receptor blocker and statins all increased. Early mortality after hospital admission decreased from 25.0% to 8.4%. One-year mortality decreased from 36.2% to 20.0% (adjusted hazard ratio 2010 vs 1995: 0.47, 0.39-0.57), both for ST-elevation myocardial infraction (36.8% to 21.1%) and non-ST-elevation myocardial infraction (34.8% to 19.1%). Mortality reduction was observed in all age groups, including those ≥85 years of age (from 46.2% to 31.4%). Study period, however was no longer associated with decreased mortality when variables reflecting management changes were taken into account. Conclusions Early and one-year mortality after hospital admission of elderly patients with acute myocardial infarction has dramatically decreased over the past 15 years. This improvement is likely mediated by increasing use of recommended management strategies. These data support the application of guidelines derived from trials mostly including younger patients to elderly populations as well.
Background There is controversy regarding a potential increased risk of lymphoma in patients with atopic dermatitis (AD). Objective To assess the risk of lymphoma and the role of topical treatments ...in patients with AD. Methods A systematic literature search and a separate meta-analysis were performed on case control and cohort studies. Results Of the 3979 articles retrieved, 24 references met the inclusion criteria. In cohort studies, the risk of lymphoma was slightly increased, with a relative risk (RR) of 1.43 (95% confidence interval CI, 1.12-1.81). In case control studies, no significant increased risk of lymphoma was found, with an odds ratio (OR) of 1.18 (95% CI, 0.94-1.47). Severity of AD was a significant risk factor. Highly potent topical steroids were associated with an increased risk of lymphoma. For topical calcineurin inhibitors (TCIs), a significant association between tacrolimus and mostly skin lymphoma was found in 1 study. Limitations Confusion between severe AD and cutaneous T-cell lymphoma may account for part of the increased risk of lymphoma in patients with AD. Conclusion This systematic literature review shows a slightly increased risk of lymphoma in patients with AD. Severity of AD appears to be a significant risk factor. The role of topical steroids and TCIs is unlikely to be significant.
Early infarct-related artery (IRA) patency is associated with better clinical outcomes in patients with ST-elevation myocardial infarction (STEMI). Using the French Registry of ST-elevation and ...non–ST-elevation Myocardial Infarction (FAST-MI) 2010 registry, we investigated factors related to IRA patency (thrombolysis in myocardial infarction TIMI 2/3 flow) at the start of procedure in patients admitted for primary percutaneous coronary intervention. FAST-MI 2010 is a nationwide French registry including 4,169 patients with acute MI. Of 1,452 patients with STEMI with primary percutaneous coronary intervention, 466 (32%) had TIMI 2/3 flow of IRA before the procedure. Mean age (62 ± 14 years in both groups), Global Registry of Acute Coronary Event score (141 ± 31 vs 142 ± 34), and time from onset to angiography (472 ± 499 vs 451 ± 479 minutes) did not differ according to IRA patency (TIMI 2/3 vs TIMI 0/1). Using multivariate logistic regression analysis, IRA patency was more frequently found in patients having called earlier (time from onset to electrocardiogram ECG <120 minutes; odds ratio OR 1.49; 95% confidence interval CI 1.17 to 1.89), or receiving rapid-onset of action (prasugrel or glycoprotein IIb-IIIa) antiplatelet therapy in the prehospital setting (OR 1.59, 95% CI 1.14 to 2.21). Increasing time from diagnostic ECG to angiography was also associated with IRA patency (>90 minutes; OR 1.37, 95% CI 1.08 to 1.75). In conclusion, preprocedural IRA patency is observed in one third of patients with STEMI, it is more frequently found in patients having received fast-acting antiplatelet therapy before angiography, and in patients having called early. Higher IRA patency with increasing time delays from qualifying ECG to angiography suggests an additional role of spontaneous or medication-mediated fibrinolysis.
Abstract Background Elderly patients represent a large proportion of patients admitted for Acute Coronary Syndrome (ACS). Whether frailty, defined as a biological syndrome that reflects a state of ...decreased physiological reserve and vulnerability to stressors, may impact the clinical outcomes in this population remains unclear. We aimed to determine the prevalence of frailty and its impact on mortality in patients aged ≥ 80 years admitted for ACS. Methods This prospective observational study was conducted among patients aged 80 or older admitted in a tertiary hospital for ACS. Frailty was assessed using the Edmonton Frail Scale (EFS) which provides a score ranging from 0 (not frail) to 17 (very frail). Population was divided into 3 classes: 0-3 EFS-score, 4-6 EFS-score, and >7 EFS-score. Results 236 patients were included with a mean follow-up duration of 470 days. The mean age was 85.9 years. 75 patients died during follow-up period.119 subjects (50.4%) had a 0-3 EFS-score, 68 patients (28.8%) had a 4-6 EFS-score and 49 patients (20.8%) had a ≥ 7 EFS-score. All-cause mortality rate was 17.7% in the 0-3 EFS-score group, 35.3% in the 4-6 EFS-score group and 61.2% in the ≥ 7 EFS-score group, (p<0.001). After multivariate analysis, frailty status remained associated with all-cause mortality: HR was 1.53 (95% CI 0.74 - 3.16) within the 4-6 EFS-score group, and HR was 3.60 (95% CI 1.70 - 7.63) within the ≥ 7 EFS-score group. Conclusion Frailty is a strong and independent prognosis factor of midterm all-cause mortality in elderly patients presenting with ACS.
In this study, we aimed to report clinical characteristics and outcomes of patients with and without SARS-CoV-2 infection who were referred for acute coronary syndrome (ACS) during the peak of the ...pandemic in France.
We included all consecutive patients referred for ST-elevation myocardial infarction (STEMI) or non-STEMI (NSTEMI) during the first 3 weeks of April 2020 in 5 university hospitals (Paris, south, and north of France), all performing primary percutaneous coronary intervention.
The study included 237 patients (67 ± 14 years old; 69% male), 116 (49%) with STEMI and 121 (51%) with NSTEMI. The prevalence of SARS-CoV-2-associated ACS was 11% (n = 26) and 11 patients had severe hypoxemia on presentation (mechanical ventilation or nasal oxygen > 6 L/min). Patients were comparable regarding medical history and risk factors, except a higher prevalence of diabetes mellitus in SARS-CoV-2 patients (53.8% vs 25.6%; P = 0.003). In SARS-CoV-2 patients, cardiac arrest on admission was more frequent (26.9% vs 6.6%; P < 0.001). The presence of significant coronary artery disease and culprit artery occlusion in SARS-CoV-2 patients respectively, was 92% and 69.4% for those with STEMI, and 50% and 15.5% for those with NSTEMI. Percutaneous coronary intervention was performed in the same percentage of STEMI (84.6%) and NSTEMI (84.8%) patients, regardless of SARS-CoV-2 infection, but no-reflow (19.2% vs 3.3%; P < 0.001) was greater in SARS-CoV-2 patients. In-hospital death occurred in 7 SARS-CoV-2 patients (5 from cardiac cause) and was higher compared with noninfected patients (26.9% vs 6.2%; P < 0.001).
In this registry, ACS in SARS-CoV-2 patients presented with high a percentage of cardiac arrest on admission, high incidence of no-reflow, and high in-hospital mortality.
Notre étude avait pour but d’établir les caractéristiques cliniques et les résultats de patients infectés ou non par le SRAS-CoV-2 qui ont été orientés en raison d’un syndrome coronarien aigu (SCA) pendant la phase aiguë de la pandémie en France.
Nous avons inclus dans l’étude tous les patients consécutifs qui ont présenté un infarctus du myocarde avec sus-décalage du segment ST (STEMI) ou sans sus-décalage du segment ST (NSTEMI) au cours des 3 premières semaines d’avril 2020 et qui ont été orientés vers 5 hôpitaux universitaires (situés à Paris, ainsi que dans le sud et le nord de la France), tous en mesure de réaliser des interventions co-ronariennes percutanées primaires.
L’étude comprenait 237 patients (âge : 67 ± 14 ans; proportion d’hommes : 69 %); 116 (49 %) présentaient un STEMI et 121 (51 %), un NSTEMI. La prévalence d’un SCA associé à une infection par le SRAS-CoV-2 s’établissait à 11 % (n = 26), et 11 patients étaient en hypoxémie grave (nécessitant une ventilation artificielle ou l’administration d’oxygène par voie nasale à un débit de plus de 6 l/min) à leur arrivée. Les patients présentaient des antécédents médicaux et des facteurs de risque comparables, à l’exception du fait que la prévalence du diabète était plus élevée chez les patients infectés par le SRAS-CoV-2 (53,8 % vs 25,6 %; p = 0,003). Ces derniers avaient plus souvent subi un arrêt cardiaque à leur admission (26,9 % vs 6,6 %; p < 0,001). Chez les patients infectés par le SRAS-CoV-2, une coronaropathie importante et une occlusion de l’artère coupable ont été observées chez respectivement 92 % et 69,4 % des patients présentant un STEMI, et chez 50 % et 15,5 % des patients présentant un NSTEMI. Une intervention coronarienne percutanée a été effectuée dans les mêmes proportions chez les patients subissant un STEMI (84,6 %) que chez ceux présentant un NSTEMI (84,8 %), sans égard à la présence ou à l’absence d’une infection par le SRAS-CoV-2, mais les cas de non-reperfusion (no-reflow) ont été plus fréquents chez les patients infectés que chez les autres patients (19,2 % et 3,3 %, respectivement; p < 0,001). Sept patients infectés par le SRAS-CoV-2 sont morts à l’hôpital (5 de cause cardiaque), ce qui représente un taux de mortalité plus élevé que chez les patients non infectés (26,9 % vs 6,2 %; p < 0,001).
Dans le cadre de cette étude, le SCA survenu chez les patients infectés par le SRAS-CoV-2 était associé à un fort pourcentage d’arrêt cardiaque à l’admission, à une fréquence élevée de cas de non-reperfusion et à un taux élevé de mortalité hospitalière.
Unfractionated heparin has been the standard anticoagulant used immediately after mechanical heart valve replacement (MHVR). The purpose of this study was to assess a postoperative anticoagulation ...protocol with low-molecular-weight heparin (LMWH) immediately after MHVR without the use of unfractionated heparin or anti-factor Xa monitoring.
We performed a prospective, single-center, observational study of 1,063 consecutive patients undergoing elective MHVR with postoperative LMWH anticoagulation treatment. The exclusion criteria were as follows: renal failure, intraaortic balloon counterpulsation, critical perioperative state, or a recent neurologic event. The postoperative anticoagulation protocol used subcutaneous enoxaparin as a bridging anticoagulant treatment beginning on the first postoperative day and continuing until vitamin K antagonist treatment was fully effective. Patients were followed for 6 weeks. The primary endpoints were the incidence of thromboembolic or major bleeding events.
Eleven (1%) thromboembolic events occurred. Ten of these events were transient or permanent strokes. Major bleeding events occurred in 44 patients (4.1%), 7 of which were observed before the enoxaparin treatment period. At the time of discharge, 570 patients (53.6%) were no longer receiving LMWH treatment due to achieving the target international normalized ratio. The mean length of hospital stay was 8.5 ± 2.9 days. There were no deaths during the 6-week follow-up period.
In our highly selected population, after MHVR, postoperative anticoagulation using LMWH is associated with a low rate of thromboembolic and major bleeding events. This large observational study demonstrates that the use of LMWH as an anticoagulant is effective and safe after MHVR.
This study was conducted to identify preoperative predictors of postoperative atrial fibrillation (POAF) after isolated coronary artery bypass grafting (CABG) by using a Bayesian analysis that ...included information from prior studies.
We performed a prospective observational study from October 2008 to December 2013 of 1,481 patients who underwent isolated CABG with cardiopulmonary bypass and had no history of AF. Bayesian analysis was used to study the preoperative risks factors for POAF.
The POAF incidence was 21%. Multivariate analysis identified the following independent predictors of POAF after CABG: high CHA
DS
-VASc (Congestive heart failure, Hypertension blood pressure >140/90 mm Hg or treated hypertension on medication, Age ≥75 years, Diabetes mellitus, prior Stroke or transient ischemic attack or thromboembolism, vascular disease, Age 65 to 74 years, Sex category female sex) score (odds ratio OR, 1.23; 95% credible interval CI, 1.14 to 1.33 per 1-point increment, probability (Pr) OR > 1 = 1), severe obesity with a body mass index of 35 kg/m
or higher (OR, 1.28; 95% CI, 1.12 to 1.45; Pr OR > 1 = 1), preoperative β-blocker use (OR, 1.12; 95% CI, 1.06 to 1.20; Pr OR > 1 = 1), preoperative antiplatelet therapy (OR, 1.75; 95% CI, 1.14 to 2.79, Pr OR > 1 = 1), and renal insufficiency with a creatinine clearance of less than 60 mL/min (OR, 1.34; 95% CI, 1.03 to 1.74; Pr OR > 1 = 1).
This prospective Bayesian analysis identified five independent preoperative predictors of POAF after isolated CABG with cardiopulmonary bypass: CHA
DS
-VASc score, severe obesity, preoperative β-blocker use, preoperative antiplatelet therapy, and renal failure. The main interest in the CHA
DS
-VASc score as a predictor of POAF is that it is a simple and widely used bedside tool. Patients with these independent predictors of POAF may constitute a target population to test preventive strategies, such as non-antiarrhythmic and antiarrhythmic drugs.
Abstract Objective The influence of initial-thrombolysis in myocardial infarction (i-TIMI) coronary flow in the culprit coronary artery on myocardial infarct and microvascular obstruction (MVO) size ...is unclear. We assessed the impact on infarct size of i-TIMI flow in the culprit coronary artery, as well as on MVO incidence and size, by contrast-enhanced cardiac magnetic resonance (ce-CMR). Methods In a prospective, multicenter study, pre-percutaneous coronary intervention (PCI) coronary occlusion was defined by an i-TIMI flow ≤1, and patency was defined by an i-TIMI flow ≥2. Infarct size, as well as MVO presence and size, were measured on ce-CMR 72 h after admission. Results A total of 140 patients presenting with ST-elevated myocardial infarction referred for primary PCI were included. There was no significant difference in final post-PCI TIMI flow between the groups (2.95 ± 0.02 vs. 2.97 ± 0.02, respectively; p = 0.44). In the i-TIMI flow ≤1 group, infarct size was significantly larger (32 ± 17 g vs. 21 ± 17 g, respectively; p = 0.002), MVO was significantly more frequent (74% vs. 53%, respectively; p = 0.012), and MVO size was significantly larger 1.3 IQR (0; 7.1) vs. 0 IQR (0; 1.6), compared to in the i-TIMI ≥2 patient group. Conclusion Initial angiographic TIMI flow in the culprit coronary artery prior to any PCI predicted final infarct size and MVO size: the better was the i-TIMI flow, the smaller were the infarct and MVO size.
Objective d -lactate is the enantiomer of l -lactate, which is measured routinely in clinical practice to assess cell hypoxia. d -lactate has been proposed as a specific marker of gut ...ischemia-reperfusion (IR), particularly during surgery for ruptured abdominal aortic aneurysms. The aim of this study was to compare the use of d -lactate measurement and colonic tonometry (taken as a reference method) for gut IR detection during elective infrarenal aortic aneurysm (IrAA) surgery. Design Prospective, monocenter, observational study. Setting Vascular surgery unit, university hospital. Participants Candidates for elective IrAA surgery. Interventions Patients without (controls) and with gut IR (defined as ΔCO2 >2.6 kPa) were compared retrospectively. Measurement and Main Results d -lactate levels were compared with colonic perfusion levels (ΔCO2 ), as assessed by colonic tonometry, at 7 time points during surgery and until 24 hours after surgery. d -lactate also was measured in mesenteric vein blood before and after gut reperfusion. Plasma TNF-α level was measured at the same time points to assess systemic inflammatory response. Eighteen patients requiring elective IrAA surgery were included. The ΔCO2 and TNF-α level varied significantly over time. There was a significant ΔCO2 peak at the end of clamping (2.6±1.8 kPa, p = 0.006) and a significant peak in TNF-α level after 1 hour of reperfusion (183±53 ng/L, p = 0.05). d -lactate levels were undetectable in systemic and mesenteric blood in all the patients throughout the study period. Gut IR patients (n = 6) experienced a longer overall duration of intraoperative hypotensive episodes and received more catecholamines than the controls (n = 12). Conclusions Compared with colonic tonometry, d -lactate was not a reliable biomarker of gut IR during elective IrAA surgery.
Objectives We sought to determine whether low platelet response to the P2Y12 receptor antagonist clopidogrel as assessed by vasodilator-stimulated phosphoprotein flow cytometry test (VASP-FCT) ...differentially affects outcomes in patients with or without chronic kidney disease (CKD) undergoing percutaneous coronary intervention (PCI). Background Although both CKD and impaired platelet responsiveness to clopidogrel are strong predictors of unfavorable outcome after PCI, the impact of their association is unknown. The platelet VASP-FCT assay is specific for the P2Y12 ADP receptor pathway. In this test, platelet activation is expressed as the platelet reactivity index (PRI). Methods Four-hundred forty unselected patients (CKD: 126, estimated glomerular filtration rate eGFR <60 ml/min/1.73 m2 ), no-CKD: 314 eGFR >60 ml/min/1.73 m2 ) undergoing urgent (n = 336) or planned (n = 104) PCI were prospectively enrolled. In each subgroup, patients were classified as low-responders (LR: PRI ≥61%) or responders (R: PRI <61%) to clopidogrel. Results At a mean follow-up of 9 ± 2 months, all-cause mortality, cardiac death, and possible stent thrombosis were higher in CKD than in no-CKD patients. Within the CKD group, the LR status was associated with higher rates of all-cause mortality (25.5% vs. 2.8%, p < 0.001), cardiac death (23.5% vs. 2.8%, p < 0.001), all stent thrombosis (19.6% vs. 2.7%, p = 0.003), and MACE (33.3% vs. 12.3%, p = 0.007). Conversely, in no-CKD patients, the LR status did not affect outcomes. Multivariate analysis identified Killip class ≥3, drug-eluting stent implantation, and the interaction between LR and CKD (hazard ratio: 11.96, 95% confidence interval: 1.22 to 116.82; p = 0.033) as independent predictors of cardiac death. Conclusions In CKD patients, the presence of low platelet response to clopidogrel is associated with worse outcomes after PCI.
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