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.

[What do registries bring us? The example of acute coronary syndromes]. / Les registres: pour quoi faire? L'exemple des syndromes coronaires aigus.

Prospective, randomised trials are the key to evidence-based medicine. They have brought considerable progress to the field of cardiology. They have, however, methodological constraints that result in the inclusion of only a small proportion of patients presenting with a given disease. In contrast, registries include all patients, without any selection, and therefore reflect everyday practice in the "real world". They are the key to epidemiological data, but they can also be used to tackle questions or issues that are unresolved by randomised trials. Both approaches are complementary and should be used to define the optimal management of patients. Lessons derived from registry data in acute coronary syndromes in the recent past in France are presented.

[Premedication by thienopyridine before percutaneous coronary interventions in unstable angina]. / Prémédication par thiénopyridines avant angioplastie coronaire dans l'angor instable.

Ticlopidine or clopidogrel combined with aspirin decrease major cardiac events (Mace) after PTCA with stent implantation. It has not be proven yet that pretreatment by T or C was superior to conventional post-treatment, especially in unstable patients. The aim of the present study was to determine the influence of thienopyridine pretreatment on the risk of Mace (death, Q wave myocardial infarction, need for repeat PTCA or surgery, angina recurrence, stent thrombosis) during the hospitalization period in a population prospectively included in 2 multicentre registries of patients undergoing placement of a S670 or S7 stent (Medtronic) implanted in native coronary arteries (> or = 3.0 mm). Among the 2929 patients included into the registries, 1205 had unstable angina (41%). 50.2% of the patients were pretreated by T or C (T = 15.7%, C = 34.5%); 85.5% received aspirin before the procedure; definition of pretreatment was the administration of drug at least 6 hours before stent implantation. GPIIb-IIIa antagonists were administered in only 13.9% of patients. Mace were observed in 2% of the patients. Factors correlated with Mace by univariate and multivariate analyses were: age > 73 years (RR: 2.37; 95% CI: 1.05-5.36, P < 0.037), previous myocardial infarction (RR: 2.56; 95% CI: 1.08-6.11, P < 0.034), pretreatment by T or C (RR: 0.389; 95% CI: 0.16-0.95, P < 0.038). In patients who did not receive GPIIb-IIIa antagonists, age > 73, and pretreatment by T or C were the only independent predictors of Mace.

[Efficacy of early reperfusion therapy at the acute stage of myocardial infarction in elderly patients: the USIK database]. / Efficacité du traitement de reperfusion au stade aigu de l'infarctus dans la population âgée: données du registre USIK 1995.

The role of early reperfusion therapy at the acute stage of myocardial infarctus in elderly patients is debated. The aim of this study was to analyze the prognostic role of reperfusion with i.v. thrombolysis or primary PTCA in the nationwide USIK database, which prospectively included all pts admitted to a CCU for an AMI < 48 hours in France in November 1998. For the purpose of the present study, only patients admitted within 24 hours of AMI and with one-year follow-up available were included. Of the 1838 patients included, 785 were > 70 years-old, of whom 225 (29%) had early reperfusion therapy with thrombolysis (N = 173) or primary PTCA (N = 52). Patients treated with early reperfusion had a baseline profile that differed substantially from that of patients treated conventionally: women (31% vs 50%, p < 0.001), admission within six hours of symptom onset (84% vs 55%, p < 0.001), history of systemic hypertension (48% vs 60%, p < 0.002), stroke (5% vs 11%, p < 0.01), peripheral arterial disease (8% vs 18%, p < 0.001); congestive heart failure (5% vs 20%, p < 0.001) or previous MI (12% vs 25%, p < 0.001), more anterior location of current MI (40% vs 28%, p < 0.002). Overall one-year Kaplan-Meier survival was 78% for patients with versus 64% for those without reperfusion therapy (p < 0.01). In patients with Q wave myocardial infarction, Cox multivariate analysis showed that reperfusion therapy was an independent predictor of survival (RR 0.66; 95% Confidence Interval: 0.45-0.96), along with age, anterior location and history of congestive heart failure. Therefore, data from this large "real life" registry indicate that reperfusion therapy with either thrombolysis or primary PTCA is associated with improved one-year survival in patients over 70 years of age.

[Beating heart in "aortic no-touch off-pump" techniques: a simple answer to complex surgical situations]. / Le coeur battant en "no-touch aortique complet": une solution simple à des problémes chirurgicaux complexes.

Three cases reports illustrate the concept of beating heart cardiac surgery and its advantages regarding the prevention of arterial emboli.

[Glycoprotein IIb/IIIa inhibitors in unstable angina]. / Les inhibiteurs de la glycoprotéine IIb IIIa dans l'angor instable.

During the last ten years we have considerably update our knowledge about the pathogenesis of unstable angina or acute coronary syndromes. The platelet activity have in this settings the central role in development of the thrombotic process. Platelet glycoprotein IIb/IIIa inhibitors block fibrinogen binding to platelets, and the effect of this on the final common pathway of platelet aggregation makes these compounds extremely potent antiplatelet drugs. Three intravenous IIb/IIIa receptor antagonists are approved for clinical use, and this class of therapy has update our pharmacologic armatarium to avoid ischemic complication in the settings of percutaneous coronary revascularization at first and now in medical treatment of acute coronary syndromes. Results of large trials using this drugs suggest that this agents are effective in patient with unstable angina particularly in those presenting a high score of risk for acute ischemic events and those requiring coronary intervention.