[Chronic Heart Failure and Telemedecine, remote monitoring : Interest and perspectives]. / Intérêt et avenir de la télésurveillance dans l'insuffisance cardiaque chronique.

Chronic heart failure in France is responsible for 160 000 hospitalizations per year. The treatment of chronic heart failure is multidisciplinary. Telemedicine (TLM) reinforces the therapeutic arsenal of this chronic pathology by the use of remote monitoring (TLS) on patients followed outside the care structure. This paradigm has proven its effectiveness with the help of digital networks and specific algorithms, which communicate through connected tools with the ICC patient. Clinical signs of worsening can trigger an alert that will be taken into account by the TLS. Early intervention on these warning signs avoids acute decompensation and a new hospitalization of the patient. The analysis of the results shows a rate of alerts that require the intervention of TLS teams, from 20 to 35% depending on the centers. The ETAPES program has set the regulatory framework for the TLS experiment for 4 years. It will end at the end of 2021. The feedback from the TLS centers is between 6 and 18 months. The satisfaction index of patients followed by TLS is 95%. The intermediate results (2018, 2019) and the evaluation of the ETAPES program, are in favor of TLS management of ICC patients. Therapeutic education and TLS improve patients' quality of life. The Ministry of Health plans a transition to the common law for TLS in 2022.

Prognostic impact of body mass index on in-hospital bleeding complications after ST-segment elevation myocardial infarction.

BACKGROUND: ST-elevation myocardial infarction (STEMI) remains a major cause of mortality despite early revascularization and optimal medical therapy. Tailoring individual management by considering patients' specificities may help in improving post-STEMI survival. AIM: To evaluate whether in-hospital bleeding complications may be involved in post STEMI prognosis among overweight patients. METHODS: We prospectively included 2070 patients with a STEMI between January 2005 and December 2012 in the French observational cohort, "Registre d'Infarctus Maine-Anjou". Bleeding Academic Research Consortium (BARC) in-hospital bleeding complications were recorded. RESULTS: Of 705 patients (35.3%) were presented as being of normal weight, defined as a body mass index (BMI) < 25 kg/m², 877 (43.9%) had a BMI between 25 and 30 kg/m² and 416 (20.8%) had a BMI ≥ 30 kg/m². One-year cardiovascular mortality was lower for BMI ≥ 25 kg/m² (5.3% and 7.1%) patients than for normal weight patients (10.8%) (P = 0.001). We found an interaction between the effect of BARC 3 on mortality and BMI groups. While a BARC 3 was related to a higher 1-year mortality in general (HR: 2.58, 95%CI: 1.44-4.64, P ≤ 0.001), prognosis was even worse in normal weight patients (HR: 2.97, 95%CI: 1.61-5.5, P < 0.001) than for patients with a BMI ≥ 25 kg/m² (HR: 1.94, 95%CI: 1.02-3.69, P = 0.041). CONCLUSION: Normal weight patients presented higher rates of in-hospital bleeding complications and lower survival after a STEMI. Excess mortality might be due to greater vulnerability to bleeding amongst normal weight patients.

De novo atrial fibrillation as an independent prognostic marker after ST-segment elevation myocardial infarction: Results from the RIMA registry.

BACKGROUND: Atrial fibrillation (AF) is common in ST-segment elevation myocardial infarction (STEMI), but its influence on prognosis remains controversial. AIM: We examined the 1-year prognostic value of AF in STEMI, distinguishing patients with prior AF from patients with de novo AF. METHODS: Between January 2004 and December 2015, 3173 STEMI patients were enrolled in the RIMA registry (Registre des Infarctus en Maine Anjou). They were divided into 3 groups: (1) AF-free patients; (2) patients with known prior AF; and (3) patients with de novo AF during hospitalization (including admission). We defined 3 primary outcomes at 1-year post-discharge: cardiovascular mortality, readmission for heart failure (HF), and stroke. Temporal onset of de novo AF was also studied. RESULTS: A total 158 patients (5%) had prior AF, and 278 (8.8%) presented de novo AF. Prior AF patients were significantly older [81 (73;86) years] with more comorbidities, but de novo AF patients presented with a greater creatine kinase peak and lower left ventricular ejection fraction [LVEF=44 (35;50)% for de novo AF vs 50 (40;55)% for prior AF, p<0.001]. At 1-year follow-up, cardiovascular mortality was higher in cases of AF (13.5% for prior AF vs 9.2% for de novo AF, compared with 2.4% for AF-free patients, p<0.001). After adjustments, only de novo AF was correlated with cardiovascular mortality (hazard ratio 2.49; 95% CI 1.32-4.67; p=0.004), but both types of AF were correlated with readmission for HF. There was no significant difference in respect of stroke between prior AF, de novo AF, and AF-free (2.2%, 0.5%, and 0.8%, respectively, p=0.327). Finally, outcomes did not differ between AF occurring <24h after admission (n=127) and de novo AF occurring within ≥24h (n=151). CONCLUSION: De novo AF was independently associated with 1-year cardiovascular mortality. It should not be considered as an intercurrent event of STEMI, but rather as a strong prognostic marker.

Evaluation of atrial septal defects with 4D flow MRI-multilevel and inter-reader reproducibility for quantification of shunt severity.

PURPOSE: With the hypothesis that 4D flow can be used in evaluation of cardiac shunts, we seek to evaluate the multilevel and interreader reproducibility of measurements of the blood flow, shunt fraction and shunt volume in patients with atrial septum defect (ASD) in practice at multiple clinical sites. MATERIALS AND METHODS: Four-dimensional flow MRI examinations were performed at four institutions across Europe and the US. Twenty-nine patients (mean age, 43 years; 11 male) were included in the study. Flow measurements were performed at three levels (valve, main artery and periphery) in both the pulmonary and systemic circulation by two independent readers and compared against stroke volumes from 4D flow anatomic data. Further, the shunt ratio (Qp/Qs) was calculated. Additionally, shunt volume was quantified at the atrial level by tracking the atrial septum. RESULTS: Measurements of the pulmonary blood flow at multiple levels correlate well whether measuring at the valve, main pulmonary artery or branch pulmonary arteries (r = 0.885-0.886). Measurements of the systemic blood flow show excellent correlation, whether measuring at the valve, ascending aorta or sum of flow from the superior vena cava (SVC) and descending aorta (r = 0.974-0.991). Intraclass agreement between the two observers for the flow measurements varies between 0.96 and 0.99. Compared with stroke volume, pulmonic flow is underestimated with 0.26 l/min at the main pulmonary artery level, and systemic flow is overestimated with 0.16 l/min at the ascending aorta level. Direct measurements of ASD flow are feasible in 20 of 29 (69%) patients. CONCLUSION: Blood flow and shunt quantification measured at multiple levels and performed by different readers are reproducible and consistent with 4D flow MRI.