[Insight of France PCI registry in 2023]. / État des lieux en 2023 du registre France PCI.

The French PCI Registry collects up to 150 clinical, procedural, and one-year follow-up data on all coronary angiographies and angioplasties performed in the 61 participating centers in September 2023. Thanks to the support of the GACI, the DGOS, the ARS, and numerous hospitals, the registry is continuing to expand its coverage across the entire territory, with 90 centers expected to participate in 2024, accounting for nearly half of the French centers. The high quality of this data has already led to the publication of 18 studies in international journals, and around twenty others are currently being written. The online publication of comprehensive and comparative annual reports, along with the implementation of quality indicators to assess practices, would enhance the performance of all participating centers and ultimately benefit our coronary patients.

Is the duration of dual antiplatelet therapy (DAPT) excessive in post-angioplasty in chronic coronary syndrome? Data from the France-PCI registry (2014-2019).

Background: while the duration of dual antiplatelet therapy (DAPT) following coronary angioplasty for chronic coronary syndrome (CCS) recommended by the European Society of Cardiology has decreased over the last decade, little is known about the adherence to those guidelines in clinical practice in France. Aim: To analyze the real duration of DAPT post coronary angioplasty in CCS, as well as the factors affecting this duration. Methods: Between 2014 and 2019, 8.836 percutaneous coronary interventions for CCS from the France-PCI registry were evaluated, with 1 year follow up, after exclusion of patients receiving oral anticoagulants, procedures performed within one year of an acute coronary syndrome, and repeat angioplasty. Results: Post-percutaneous coronary intervention (PCI) DAPT duration was > 12 months for 53.1% of patients treated for CCS; 30.5% had a DAPT between 7 and 12 months, and 16.4% a DAPT ≤ 6 months. Patients with L-DAPT (>12 months) were at higher ischemic risk [25.0% of DAPT score ≥2 vs. 18.8% DAPT score ≥2 in S&I-DAPT group (≤12 months)]. The most commonly used P2Y12 inhibitor was clopidogrel (82.2%). The prescription of ticagrelor increased over the period. Conclusions: post-PCI DAPT duration in CCS was higher than international recommendations in the France PCI registry between 2014 and 2019. More than half of the angioplasty performed for CCS are followed by a DAPT > 12 months. Ischemic risk assessment influences the duration of DAPT. This risk is probably overestimated nowadays, leading to a prolongation of DAPT beyond the recommended durations, thus increasing the bleeding risk.

[stent thrombosis : A won battle ? (data from the France PCI registry)]. / Thrombose de stent : une bataille gagnée ? (Données du registre France PCI).

GOAL: The aim of the study is to assess the incidence, risk factors and prognosis of definite stent thrombosis (ST) at 1 year in the France PCI multicenter prospective registry. PATIENTS AND METHODS: Only patients who underwent coronary angioplasty with at least one stent implantation between 1st January 2014 and 31 December 2019 were included. The population was separated into 2 groups: the "ST" group with stent thrombosis and the "control" group without stent thrombosis. RESULTS: 35,435 patients were included. 256 patients (0.72%) presented a ST at 1 year. The rate of ST decreased significantly in acute coronary syndrome (1.5% in 2014 vs. 0.73% in 2019; p = 0.05) but not in chronic coronary syndrome (0.46% in 2014 vs 0.40%; p = 0.98). The risk factors are young age (65.8 years vs 68.2; p = 0.002), clinical context (35.27% vs 16.68%; p = 0.0001), diabetes (35.2 % vs 26.4%; p = 0.002), renal failure (11.7% vs 8%; p = 0.009) and history of coronary angioplasty (28.63% vs 21.86%; p = 0.009) and peripheral arterial disease (14.5% vs 10.1%; p = 0.021), LV dysfunction (37% vs 27.5%; p = 0.003), mean length (39.6 mm vs 31, 7mm; p <0.0001) and the mean number of stents per procedure (1.9 vs 1.6; p <0.0001), a TIMI flow ≤1 pre procedure (21.5% vs 12.4%; p <0.0001) and an intrastent restenosis (11% vs 6%; p <0.0001). The 1-year mortality of the ST group was significantly higher than that of the control group (19.14% vs 5.82%; p <0.0001). CONCLUSION: Since 2014, the incidence of ST at 1 year has been decreasing but remains stuck at a floor level of 0.54% in 2019. The battle for ST seems to have been partly won and its risk factors well identified, but its mortality is still high.

[COVID-19 and STEMI]. / COVID-19 et SCA ST.

The COVID-19 pandemic had an unexpected impact on cardiovascular emergencies, particularly STEMI. The France PCI registry and other studies around the world have highlighted a significant decrease in myocardial infarctions arriving at hospital. This decrease is mainly related to patients' fear of coming to the hospital and being contaminated. Although the STEMI revascularisation time targets (<120min) are often difficult to achieve in normal times, they were almost impossible to achieve in periods of lockdown because of the many obstacles. Longer delays and longer total ischemic time have led to excess mortality, especially in the regions most affected by the epidemic. Recommendations for the management of STEMI during the COVID-19 period have thus been issued by the scientific societies. STEMI in patients with COVID-19 often have an uncommon clinical presentation, and the absence of coronary obstruction on angiography is frequent. Their prognosis is very poor. Only public information campaigns and an organisation adapted to the management of coronary emergencies during epidemics can try to limit their effects and avoid aggravating an already fragile health situation in the future.

[Left main PCI: Current treatment]. / Angioplastie du tronc commun : mise au point.

Percutaneous coronary intervention (PCI) of left main coronary artery has become a strong alternative to coronary artery bypass surgery in selected patients. The treatment decision must be validated by the Heart Team. Several PCI techniques of distal left main PCI have been described but the KISSS (Keep it simple, swift and safe) principle recommended by the European Bifurcation Club must be kept in mind. Provisional stenting is the first-line technique. A two-stent strategy may be needed in the presence of≥2.5mm side branch diameter and significant ostial stenosis as well as in presumably difficult rewiring. In all cases, POT (Proximal Optimisation Technique) is mandatory. Intracoronary imaging can be of great help in perfecting the result or even to improve outcomes.

[Non-ST elevation acute coronary syndrome: CRAC register experience]. / SCA sans sus ST chez le nonagénaire : expérience du CRAC.

PURPOSE: To compare the clinical, angiographic, therapeutic and prognostic characteristics of nonagenarians presenting with non-ST elevation acute coronary syndrome with those of patients under 90 years of age. METHODS: We used the CRAC register database including 6 catheterization laboratories in the Center Val-de-Loire region. Only patients with positive-troponin non-ST elevation ACS included in the registry from 2014 to 2017 were selected for epidemiological and procedural data. Regarding antiplatelet therapy, hospital and one-year follow-up data, only patients in the 2014-2015 period were analyzed. RESULTS: From January 1st, 2014 to December 31st, 2017, 5.964 patients with a positive-troponin non-ST ACS, including 133 nonagenarians (2.2%) were included in the CRAC registry. Arterial hypertension and the history of coronary angioplasty were more common among nonagenarians. They present more multivessel and left main disease. The use of the bare metal stent was predominant in 2014-2015 and then became marginal in 2016-2017. Clopidogrel was the most widely used anti platelet and more than one in two nonagenarians remain on dual therapy after 12 months. One-year stroke and hospital and one-year mortality were higher in this age group. CONCLUSIONS: Nonagenarians with a positive-troponin non-ST elevation ACS have more severe coronary artery disease and a poorer prognosis than those younger than 90 years of age.

The CRAC cohort model: A computerized low cost registry of interventional cardiology with daily update and long-term follow-up.

OBJECTIVES: To assess the reliability and low cost of a computerized interventional cardiology (IC) registry to prospectively and systematically collect high-quality data for all consecutive coronary patients referred for coronary angiogram or/and coronary angioplasty. BACKGROUND: Rigorous clinical practice assessment is a key factor to improve prognosis in IC. A prospective and permanent registry could achieve this goal but, presumably, at high cost and low level of data quality. One multicentric IC registry (CRAC registry), fully integrated to usual coronary activity report software, started in the centre Val-de-Loire (CVL) French region in 2014. METHODS: Quality assessment of CRAC registry was conducted on five IC CathLab of the CVL region, from January 1st to December 31st 2014. Quality of collected data was evaluated by measuring procedure exhaustivity (comparing with data from hospital information system), data completeness (quality controls) and data consistency (by checking complete medical charts as gold standard). Cost per procedure (global registry operating cost/number of collected procedures) was also estimated. RESULTS: CRAC model provided a high-quality level with 98.2% procedure completeness, 99.6% data completeness and 89% data consistency. The operating cost per procedure was €14.70 ($16.51) for data collection and quality control, including ST-segment elevation myocardial infarction (STEMI) preadmission information and one-year follow-up after angioplasty. CONCLUSIONS: This integrated computerized IC registry led to the construction of an exhaustive, reliable and costless database, including all coronary patients entering in participating IC centers in the CVL region. This solution will be developed in other French regions, setting up a national IC database for coronary patients in 2020: France PCI.

[Stent thrombosis: what's up in 2017?] / Thrombose de stent : quoi de neuf en 2017 ?

Stent thrombosis (ST) is still a dreadful and threatening complication of percutaneous coronary intervention (PCI) with a high risk of morbi-mortality. Nevertheless, it becomes exceptional (0.6% at 1 year and 0.15%/year later) thanks to improvement of stents and use of new P2Y12 inhibitors. Endo-coronary imaging and especially Optical Coherence Tomography (OCT) change radically its understanding with revealing quiet systematic morphologic endoluminal abnormalities (97% of the cases). OCT becomes an essential tool in practice (ESC recommendation class IIa) and allows a therapeutic strategy optimization. Its prevention is based on mechanical causes correction and a personalized adaptation of anti-platelet treatment.

[Interventricular management of patients over the age of 75 with acute coronary syndromes without persistent ST elevation]. / Stratégie interventionnelle de prise en charge des patients âgés de plus de 75 ans hospitalises pour syndrome coronaire aigu sans sus-décalage persistant du segment ST: resultats d'un registre prospectif multicentrique regional.

The aim ot tnis study was to assess the results of interventional strategy in patients over 75 years of age admitted to hospital with acute coronary syndromes (ACS) without persistent ST elevation. Over three months, patients over the age of 75 undergoing coronary angiography for ACS were included in a multicentre register and followed up for 6 months. A total of 126 patients with an average age of 79 were included: 70% had at least one poor prognostic factor. The treatment on admission included: Aspirin (84%), Clopidogrel (60%), anti GpIIb-IIIa (12%) and Heparin (81%, of which 3/4 of cases were low molecular weight heparins). Coronary angiography (average delay 80 hours) showed single, double and triple vessel disease in 21, 29 and 35% of cases respectively. Coronary angioplasty was proposed in 83 patients and carried out in 82. Eleven patients underwent coronary artery bypass grafting and 31 were treated medically. During the hospital phase, there were 3 major cardiovascular complications: 1 death during coronary angiography, 1 intra-stent thrombosis and 1 death in the group undergoing bypass grafting, with no major bleeding complications. At 6 months, there were 8 (6.5%) major cardiovascular adverse events with 6 in the "angioplasty" group; 5 deaths (3 cardiac deaths), 3 myocardial infarcts. Two thirds of patients were asymptomatic. The authors conclude that interventional strategy in ACS of elderly patients is associated with a low rate of major adverse events. The benefits of this strategy should be confirmed by randomised trial.

[Potential pro-thrombotic effects of cyclooxygenase-2. inhibitors Two cases pf myocardial infarction]. / Effet pro-thrombotique potentiel des inhibiteurs de la cyclo-oxygénase de type 2. A propos de deux observations d'infarctus du myocarde.

Type 2 cyclo-oxygenase inhibitors are new anti-inflammatory drugs with better gastrointestinal tolerance than traditional non-steroidal anti-inflammatory drugs. They have no platelet anti-aggregant effects and there is still some discussion as to whether this new therapeutic class has any pro-thrombotic effects. The authors report two cases of myocardial infarction in patients considered to be at low risk treated by type 2 cyclo-oxygenase inhibitors.

A randomized placebo-controlled trial to assess the efficacy of antiinflammatory therapy with methylprednisolone in unstable angina (MUNA trial).

AIMS: The purpose of this study was to assess the efficacy of antiinflammatory therapy with methylprednisolone during the acute phase of unstable angina. METHODS: This is a randomized 'prospective' double-blind, placebo-controlled trial. Patients with the diagnosis of unstable angina were randomized to a 48-h course of methylprednisolone (n=81) or placebo (n=85). Patient care and therapy were otherwise decided by their attending cardiologist. The primary end-point was a composite of in-hospital recurrence of angina, silent ischaemia on Holter recording, emergency coronary revascularization, readmission with unstable angina, and myocardial infarction or death during the 30-day follow-up. RESULTS: The two groups were well balanced and had similar clinical characteristics at baseline. Forty-eight hours after randomization, mean C-reactive protein levels decreased by 2.6 mg. l(-1)in the methylprednisolone group, but increased by 1.6 mg. l(-1)in the placebo group (P=0.03). The primary end-point occurred in 44% of the methylprednisolone patients and in 33% of the placebo patients (P=0.12). Coronary revascularization rates were equal between the two groups (38% and 40%). When adjustment was made for the difference in revascularization times, a trend towards better event-free survival was seen in the control group (67% vs 57%;P=0.09). CONCLUSION: A 48 h course of antiinflammatory therapy with methylprednisolone given at the doses of this study did not improve the short-term outcome of patients with unstable angina.