ABSTRACT
OBJECTIVE: To study the impact on outcomes of direct admission versus emergency room (ER) admission in patients with ST-segment elevation myocardial infarction (STEMI) DESIGN: Nationwide observational registry of STEMI patients SETTING: 369 intensive care units in France. INTERVENTIONS: Patients were categorised on the basis of the initial management pathway (direct transfer to the coronary care unit or catheterisation laboratory versus transfer via the ER). MAIN OUTCOME MEASURES: Delays between symptom onset, admission and reperfusion therapy. Mortality at five days and one year. RESULTS: Of 1204 patients enrolled, 66.9% were admitted direct and 33.1% via the ER. Bypassing the ER was associated with more frequent use of reperfusion (61.7% v 53.1%; p = 0.001) and shorter delays between symptom onset and admission (244 (interquartile range 158) v 292 (172) min; p < 0.001), thrombolysis (204 (150) v 258 (240) min; p < 0.01), hospital thrombolysis (228 (156) v 256 (227) min, p = 0.22), and primary percutaneous coronary intervention (294 (246) v 402 (312) min; p < 0.005). Five day mortality rates were lower in patients who bypassed the ER (4.9% v 8.6%; p = 0.01), regardless of the use and type of reperfusion therapy. After adjusting for the simplified Thrombolysis in Myocardial Infarction (TIMI) risk score, admission via the ER was an independent predictor of five day mortality (odds ratio 1.67, 95% confidence interval 1.01 to 2.75). CONCLUSIONS: In this observational analysis, bypassing the ER was associated with more frequent and earlier use of reperfusion therapy, and with an apparent survival benefit compared with admission via the ER.
Subject(s)
Myocardial Infarction/therapy , Aged , Coronary Care Units/statistics & numerical data , Female , France/epidemiology , Humans , Male , Middle Aged , Myocardial Infarction/mortality , Myocardial Reperfusion/statistics & numerical data , Odds Ratio , Patient Admission , Registries , Time FactorsABSTRACT
OBJECTIVE: To assess the use of mobile coronary care units (MCU) in hypertensive patients previously treated for cardiovascular diseases in comparison with those with no history of cardiovascular disease and to estimate the influence of the use of MCU on cardiovascular outcome in this population. PATIENTS: We used a nationwide prospective registry of all patients admitted for AMI in French intensive care units in 2000. Patients without history of hypertension or patients admitted with pulmonary oedema or cardiogenic shock were excluded. Men (N = 514) and women (N = 291) were analysed separately. RESULTS: The proportion of patients with history of myocardial infarction, peripheral artery disease and stroke was not significantly higher in subjects who used physician-staffed MCU as compared with patients with no history of myocardial infarction, peripheral artery disease or stroke. In each sex, revascularization (pre hospital fibrinolysis, in hospital fibrinolysis or coronary angioplasty) were more frequent in patients who used MCU. Also, one year cardiovascular mortality was lower in men who used MCU. CONCLUSION: Known high risk hypertensive patients did not use physician-staffed MCU more than subjects free of such condition. Education of hypertensive patients at risk during routine visits is required to increase of the use of physician-staffed MCU in case of symptoms suggestive of AMI.
Subject(s)
Coronary Care Units/statistics & numerical data , Emergency Medical Services , Hypertension/therapy , Mobile Health Units/statistics & numerical data , Myocardial Infarction/therapy , Aged , Cardiac Care Facilities , Emergency Medical Services/methods , Female , France , Humans , Hypertension/complications , Hypertension/mortality , Male , Middle Aged , Myocardial Infarction/complications , Myocardial Infarction/mortality , Outcome Assessment, Health Care , Patient Education as Topic , Prospective Studies , RegistriesABSTRACT
OBJECTIVE: To analyse the short and long term prognostic significance of admission glycaemia in a large registry of non-diabetic patients with acute myocardial infarction. METHODS: Assessment of short and long term prognostic significance of admission blood glucose in a consecutive population of 1604 non-diabetic patients admitted to intensive care units in France in November 2000 for a recent (Subject(s)
Blood Glucose/analysis
, Myocardial Infarction/mortality
, Female
, France/epidemiology
, Hospital Mortality
, Hospitalization
, Humans
, Male
, Middle Aged
, Multivariate Analysis
, Myocardial Infarction/blood
, Prognosis
, Survival Analysis
ABSTRACT
The in-hospital management and short- and long-term outcomes was assessed in 2 registries of consecutive patients admitted for acute myocardial infarction, 5 years apart, in France. The 2000 cohort was younger and with a less frequent history of cardiac diseases, but was more often diabetic and with anterior infarcts. Time to admission was actually longer in 2000 than in 1995 (median 5.25 hours vs 4.00 hours). Overall, reperfusion therapy was used in 43% of the patients in both registries. However, the use of reperfusion therapy increased from 1995 to 2000 in patients admitted within 6 hours of symptom onset (64 vs 58%), with an increasing use of primary angioplasty (from 12 to 30%). Five-day mortality significantly improved from 7.7 to 6.1% (p < 0.03) and one-year survival was also less in the most recent period (85 vs 81%, p < 0.01). Multivariate analyses showed that the period of inclusion (2000 vs 1995) was an independent predictor of both short- and long-term mortality in patients admitted within 6 hours of symptom onset. Thus, in the real world setting, a continued decline in one-year mortality was observed in patients admitted to intensive care units for recent acute myocardial infarction, especially for patients admitted early. This goes along with a shift in reperfusion therapy towards a broader use of primary angioplasty, and with an increased use of the early prescription of recognised secondary prevention medications.
Subject(s)
Hospitalization , Myocardial Infarction/therapy , Age Factors , Aged , Angioplasty, Balloon, Coronary/statistics & numerical data , Diabetes Complications , Female , France/epidemiology , Humans , Male , Middle Aged , Myocardial Infarction/mortality , Myocardial Reperfusion/statistics & numerical data , Outcome Assessment, Health Care , Registries , Stroke/complications , Survival Analysis , Time Factors , Ventricular Dysfunction, Left/diagnosisABSTRACT
OBJECTIVE: Several studies underlined the worse prognosis of myocardial infarction (MI) among patients with peripheral arterial disease (PAD). We sought to describe the presentation and management modalities of a cohort of PAD patients presenting an acute MI, compared to those without PAD. MATERIALS AND METHODS: The USIC 2000 registry, a nationwide database on all patients admitted to a CCU for an acute MI < 48 hours in France in November 2000 was used for this study. RESULTS: Among the 2311 patients included, PAD was reported in 215 subjects (9.3%). In multivariate analysis, the following factors were positively related to the presence of PAD (P < or = 0.05): age >75 y (OR = 2.3), diabetes (OR = 2.0), hypertension (OR = 1.4), active smoking (OR = 4.6), renal failure (OR =3.1), and treatments with antiplatelets (OR = 3.9), anti-vitamin K (OR = 1.9), statins (OR = 1.7) and low molecular weight heparins (OR = 6.8). By introducing the data concerning the arrival in CCUs in the model, the following factors were also significantly more frequent among PAD patients: male sex (OR = 1.6), past history of coronary artery disease (OR = 2.2), left bundle branch block (OR = 1.8) and late management >6 hours (OR = 1.4). Conversely, ST-segment elevation was less frequent (OR = 0.7). When the CCU stay data were introduced in the model, a lower rate of coronary stenting (OR = 0.7) and betablockers use within 48 hours of admission (OR = 0.6) were noted. CONCLUSION: Beyond the presence of PAD per se, several particularities do exist, especially the coexistence of a high number of pejorative factors and an under-utilization of treatments presenting prognostic benefits.
Subject(s)
Myocardial Infarction/epidemiology , Myocardial Infarction/therapy , Peripheral Vascular Diseases/epidemiology , Aged , Female , France/epidemiology , Humans , Intensive Care Units , Male , Middle Aged , Peripheral Vascular Diseases/therapy , Prospective Studies , RegistriesABSTRACT
The objective of the SPOT study (Study of Practice versus Objectives of Treatment) was the biochemical evaluation of the results of long term lipid regulating treatment in France, compared to the objectives defined by AFSSAPS (French regulatory agency for the safety of medical products) in 2000. A random sample of doctors was recruited in 21 French regions by the Regional Health Observation service. To be included in the SPOT study, the patients had to be on lipid regulating medication for at least six months and consent to biochemical evaluation following a consultation. A sample of 641 doctors examined 2,479 patients treated for 7 years on average. These middle aged patients (aged 63 +/- 11 years) were mostly taking statins (72%). They had an average total cholesterol level of 5.41 +/- 1.01 mmol/L (2.10 +/- 0.39 g/L). and LDL of 3.25 +/- 0.93 mmol/L (1.26 +/- 0.36 g/L), reflecting previous results and confirming the stability of their treatment. In primary prevention and in low risk subjects (with less than 2 associated risk factors), the AFSSAPS objectives were achieved in 95% of cases. In secondary prevention or in very high risk subjects (at least 3 associated risk factors 0), 35% of patients had LDL cholesterol greater than 3.4 mmol/L (1.30 g/L). The SPOT study, performed on subjects who had in theory been stabilised with lipid regulating medication, gave two conclusions: cardiovascular prevention with lipid regulating medication is improving in France, and the subjects at greatest risk attain the recommended objectives less often despite the expected benefit of treatment being higher.
Subject(s)
Hyperlipidemias/drug therapy , Hypolipidemic Agents/therapeutic use , Practice Patterns, Physicians'/statistics & numerical data , Aged , Cardiovascular Diseases/etiology , Cardiovascular Diseases/prevention & control , Female , France , Health Care Surveys , Humans , Male , Middle Aged , Risk Factors , Treatment OutcomeABSTRACT
OBJECTIVE: To assess actual practices and in-hospital outcome of patients with acute myocardial infarction on a nationwide scale. METHODS: Of 443 intensive care units in France, 369 (83%) prospectively collected data on all cases of infarction (within < 48 hours of symptom onset) in November 2000. RESULTS: 2320 patients (median age 68 years, 73% men) were included, of whom 83% had ST segment elevation infarction (STEMI). Patients without STEMI were older and had a more frequent history of cardiovascular disease. Median time to admission was 5.0 hours for patients with and 6.5 hours for those without STEMI. Reperfusion therapy was used for 53% of patients with STEMI (thrombolysis 28%, primary angioplasty 25%). In-hospital mortality was 8.7% (5.5% of patients without and 9.3% of those with STEMI). Multivariate analysis found that age, Killip class, lower blood pressure, higher heart rate on admission, anterior location of infarct, STEMI, diabetes mellitus, previous stroke, and no current smoking independently predicted in-hospital mortality. At hospital discharge, 95% received antiplatelet agents, 75% received beta blockers, and over 60% received statins. Angiotensin converting enzyme inhibitors were prescribed for 40% of the patients without and 52% of those with ST elevation. CONCLUSIONS: This nationwide registry, including all types of centres irrespective of their size and experience, shows continued improvement in patient care and outcomes. Time from symptom onset to admission, however, has not improved in recent years and reperfusion therapy is used for just over 50% of patients with STEMI, with an increasing use of primary angioplasty.
Subject(s)
Critical Care/methods , Hospitalization , Myocardial Infarction/mortality , Adult , Aged , Aged, 80 and over , Analysis of Variance , Angioplasty, Balloon, Coronary/methods , Female , France/epidemiology , Humans , Male , Middle Aged , Myocardial Infarction/drug therapy , Myocardial Infarction/therapy , Myocardial Reperfusion/methods , Prospective Studies , Registries , Thrombolytic Therapy/methods , Treatment OutcomeABSTRACT
Interventional procedures associated with acute coronary syndromes or performed on saphenous bypass grafts frequently lead to embolic complications, resulting in no-reflow phenomenon, side-branch occlusion, or peri-procedural infarction. The RESCUE thrombo-aspiration system was used in 19 percutaneous coronary interventions. After initial use of the aspiration device, 81% of procedures were followed by stent deployment. TIMI flow 2 or higher was present in 42% at the beginning of the procedure and in 95% at the end. In-hospital MACE rate was 4.76%. This relatively user-friendly technique appears rapid and efficacious in the case of visible intracoronary thrombus.
Subject(s)
Angina Pectoris/complications , Catheterization , Coronary Thrombosis/complications , Coronary Thrombosis/therapy , Myocardial Infarction/complications , Acute Disease , Female , Humans , Male , Middle Aged , Suction , SyndromeSubject(s)
Coronary Stenosis/economics , Coronary Stenosis/therapy , Diabetes Complications/economics , Diabetes Complications/therapy , Drug Delivery Systems/economics , Immunosuppressive Agents/administration & dosage , Immunosuppressive Agents/economics , Registries , Sirolimus/administration & dosage , Sirolimus/economics , Stents/economics , Combined Modality Therapy , Cost-Benefit Analysis , Female , Follow-Up Studies , Humans , Male , Middle Aged , Surveys and QuestionnairesSubject(s)
Coronary Restenosis/prevention & control , Diabetes Complications/prevention & control , Diabetes Mellitus, Type 2/complications , Drug Delivery Systems , Immunosuppressive Agents/administration & dosage , Registries , Sirolimus/administration & dosage , Stents , Clinical Protocols , Combined Modality Therapy , Coronary Restenosis/complications , Coronary Stenosis/complications , Coronary Stenosis/therapy , Diabetes Complications/therapy , Female , Humans , Male , Middle Aged , Randomized Controlled Trials as Topic , Risk FactorsABSTRACT
Our purpose is to review the different mechanisms involved in the vascular response following percutaneous coronary revascularization, and their role in thrombotic complications and in restenosis. Specificities related to the various techniques of percutaneous coronary revascularization (balloon angioplasty, coronary stents, brachytherapy, drug eluting stents) are discussed.
Subject(s)
Angioplasty, Balloon, Coronary , Coronary Restenosis/epidemiology , Coronary Restenosis/physiopathology , Coronary Vessels/physiopathology , Angioplasty, Balloon, Coronary/methods , HumansABSTRACT
We assessed the in-hospital management and short- and long-term outcomes of two series of patients admitted for acute myocardial infarction, 5 years apart, in France. The most recent cohort was younger and with a less frequent history of cardiac diseases, but was more often diabetic and with anterior infarcts. Five-day mortality significantly improved from 7.7% to 6.1% (P < 0.03) and 1-year survival was also less in the most recent period (15% versus 19%, P < 0.01). Multivariate analyses showed that the period of inclusion (2000 versus 1995) was an independent predictor of both short- and long-term mortality. In analyses restricted to the patients who were alive by day 5, initial treatment with statins was associated with a 38% decrease in the risk of death at 1 year. Likewise, in patients with left ventricular ejection fraction < or = 35%, the early prescription of ACE inhibitors was associated with a 41% reduction in the risk of 1-year mortality. Thus, in the real world setting, a continued decline in 1-year mortality is observed in patients admitted to intensive care units for recent acute myocardial infarction. This goes along with a shift in reperfusion therapy towards a broader use of coronary angioplasty and with an increased use of the early prescription of recognised secondary prevention medications.
Subject(s)
Mortality/trends , Myocardial Infarction/mortality , Myocardial Infarction/therapy , Aged , Angioplasty , Angiotensin-Converting Enzyme Inhibitors/therapeutic use , Cohort Studies , Female , France/epidemiology , Hospitals/statistics & numerical data , Humans , Male , Middle Aged , Multivariate Analysis , Prognosis , Risk Factors , Stroke Volume , Treatment OutcomeABSTRACT
The aim of the OSCAR observatory was to describe the medical management of patients hospitalised for acute coronary syndrome (ACS). Demographic characteristics, risk factors, history of cardiovascular events, diagnostic and therapeutic procedures on admission and during the stay in hospital were recorded. From september 2000 to february 2001, 869 patients with acute coronary syndrome were enrolled in this survey. This sample of patients is quite similar to the one usually described in such studies with a male/female ratio of 2.7 and a mean age of 66. The initial diagnosis at entry was: 23.6% patients with unstable angina, 34.4% patients with myocardial infarction with ST elevation, and 42.0% of patients with myocardial infarction without ST-elevation. Troponins were used in 65% patients for troponin I, 13% for troponin T and should be more widely used. Whatever the inclusion diagnosis, planned procedures or biological data, only 25% of hospitalized patients for acute coronary syndrome were treated with anti-GPIIb/IIIa. This rate of treatment was lower than expected by the guidelines published by Societies of cardiology.
Subject(s)
Coronary Disease , Registries , Acute Disease , Aged , Coronary Disease/diagnosis , Coronary Disease/drug therapy , Female , Humans , Male , SyndromeABSTRACT
OBJECTIVES: To compare management and short-term outcome of diabetic and non-diabetic patients hospitalized for acute myocardial infarction. METHODS: This was a prospective epidemiological survey. All patients admitted in coronary care units in France in November 2000 for confirmed acute myocardial infarction were eligible to enter the study. RESULTS: Of the 2320 patients recruited from 369 centers, 487 were diabetic (21%). Compared to non-diabetic patients, diabetic patients were 5 years older, more often female, obese and hypertensive; they had more often a history of cardiovascular disease; they had a lower ejection fraction and worse Killip class. Reperfusion therapy was less frequent among diabetic patients (39% versus 51%; p=0.0001), as was the use of beta-blockers (61% versus 72%; p=0.0001), aspirin (83% versus 89%; p=0.0001) and statins (52% versus 60%; p=0.001) during hospitalization. Conversely, the use of ACE-inhibitors was more frequent (54% versus 44%; p=0.0001). 58% of diabetic patients received insulin during hospitalization. Twenty-eight-day mortality was 13.1% in diabetic patients and 7.0% in non-diabetic patients (risk ratio: 1.87; p=0.001). Diabetes remained associated with increased mortality after adjustment for relevant risk factors including age and ejection fraction (risk ratio: 1.51; p=0.07). In patients treated with antidiabetic drugs (chiefly sulfonylureas) before admission, 28-day mortality was 10.4% compared with 19.9% in diabetic patients on diet alone or untreated (p=0.005). CONCLUSION: Despite higher cardiovascular risk and worse prognosis, in-hospital management of diabetic patients with acute myocardial infarction remains sub-optimal. Patients previously treated with antidiabetic drugs including sulfonylureas had a better prognosis than untreated diabetic patients.
Subject(s)
Diabetic Angiopathies/therapy , Hospitalization , Myocardial Infarction/therapy , Adrenergic beta-Antagonists/therapeutic use , Aged , Aspirin/therapeutic use , Body Mass Index , Diabetic Angiopathies/drug therapy , Female , France , Health Surveys , Humans , Hypercholesterolemia/epidemiology , Insulin/therapeutic use , Length of Stay , Male , Middle Aged , Myocardial Infarction/prevention & control , Myocardial Reperfusion , Predictive Value of Tests , Risk Factors , Smoking , Stroke/epidemiology , Thrombolytic Therapy , Time Factors , Treatment OutcomeABSTRACT
The use of cardiovascular secondary prevention medications in patients with acute coronary syndromes was compared in 4 sequential observational surveys carried out in France from 1995 to 2000. The Usik 1995 and Usic 2000 surveys included patients admitted for acute myocardial infarction, while the 2 Prevenir surveys (1998 and 1999) assessed the medications prescribed in patients with acute coronary syndromes. Antiplatelet agents were prescribed in 91% of the patients in 1995, 93% in 1998 and 1999 and 96% in 2000; for beta-blockers, the respective figures were: 64%, 68%, 75% and 76%. For ACE-Inhibitors, the figures were: 46%, 41%, 41% and 50%. For statins, the prescription increased from 10% to 36%, 59% and 64%. In 1995, 8% of the patients received both antiplatelet agents, beta-blockers and statins (4% of them also had an ACE-Inhibitor); in 2000, the respective figures were 53% and 27%. The results of the recent trials of secondary prevention medications have had a considerable impact on real-life practice in France during the late 1990s.
Subject(s)
Angina, Unstable/drug therapy , Coronary Disease/drug therapy , Health Care Surveys/statistics & numerical data , Myocardial Infarction/drug therapy , Patient Discharge , Acute Disease , Adrenergic beta-Antagonists/therapeutic use , Aged , Angina, Unstable/prevention & control , Angiotensin-Converting Enzyme Inhibitors/therapeutic use , Aspirin/therapeutic use , Coronary Disease/prevention & control , Drug Therapy, Combination , Drug Utilization/trends , Female , France , Hospitalization/statistics & numerical data , Humans , Hydroxymethylglutaryl-CoA Reductase Inhibitors/therapeutic use , Male , Myocardial Infarction/prevention & control , Platelet Aggregation Inhibitors/therapeutic useABSTRACT
The identification of coronary thrombosis in humans has important prognostic and therapeutic implications. Its recognition calls for invasive techniques: angioscopy, coronarography, and endocoronary ultrasound. Angioscopy allows visualisation of the arterial surface and the detection of thrombus with great sensitivity. Its presence is exclusive to the acute coronary syndromes: 67% in unstable angina, and 75% in myocardial infarction, although it is only present in 27% of cases of stable angina. The relative complexity of its use has led to the abandonment of this technique. Coronarography allows an indirect approach to coronary thrombosis. Certain aspects are evocative such as: intraluminal filling defect, complete occlusion with upstream convexity, ulceration and eccentric type 2 Ambrose classification plaques. As a function of the clinical presentation, the coronarographic views allow a good specificity for the diagnosis of thrombus. The sensitivity is weak, however, compared to angioscopy. Endocoronary ultrasound does not allow identification of fresh thrombus which is not echogenic and does not allow differentiation between older thrombus and lipid plaque. In the future, magnetic resonance imaging could prove interesting in the detection of recent thrombus.
Subject(s)
Angioscopy/methods , Coronary Angiography/methods , Coronary Thrombosis/diagnostic imaging , Endosonography/methods , Diagnosis, Differential , Humans , Magnetic Resonance Imaging , Sensitivity and SpecificityABSTRACT
BACKGROUND: Restenosis after percutaneous coronary intervention (PCI) is a major problem affecting 15% to 30% of patients after stent placement. No oral agent has shown a beneficial effect on restenosis or on associated major adverse cardiovascular events. In limited trials, the oral agent tranilast has been shown to decrease the frequency of angiographic restenosis after PCI. METHODS AND RESULTS: In this double-blind, randomized, placebo-controlled trial of tranilast (300 and 450 mg BID for 1 or 3 months), 11 484 patients were enrolled. Enrollment and drug were initiated within 4 hours after successful PCI of at least 1 vessel. The primary end point was the first occurrence of death, myocardial infarction, or ischemia-driven target vessel revascularization within 9 months and was 15.8% in the placebo group and 15.5% to 16.1% in the tranilast groups (P=0.77 to 0.81). Myocardial infarction was the only component of major adverse cardiovascular events to show some evidence of a reduction with tranilast (450 mg BID for 3 months): 1.1% versus 1.8% with placebo (P=0.061 for intent-to-treat population). The primary reason for not completing treatment was > or =1 hepatic laboratory test abnormality (11.4% versus 0.2% with placebo, P<0.01). In the angiographic substudy composed of 2018 patients, minimal lumen diameter (MLD) was measured by quantitative coronary angiography. At follow-up, MLD was 1.76+/-0.77 mm in the placebo group, which was not different from MLD in the tranilast groups (1.72 to 1.78+/-0.76 to 80 mm, P=0.49 to 0.89). In a subset of these patients (n=1107), intravascular ultrasound was performed at follow-up. Plaque volume was not different between the placebo and tranilast groups (39.3 versus 37.5 to 46.1 mm(3), respectively; P=0.16 to 0.72). CONCLUSIONS: Tranilast does not improve the quantitative measures of restenosis (angiographic and intravascular ultrasound) or its clinical sequelae.