Aurès Chaib

How to limit radial artery spasm during percutaneous coronary interventions: The spasmolytic agents to avoid spasm during transradial percutaneous coronary interventions (SPASM3) study.

Aims: To compare the efficacy of three vasodilators in preventing radial artery spasm (RAS) in patients undergoing transradial percutaneous coronary interventions (PCI). Methods and Results: 731 patients were randomized to receive diltiazem 5 mg, verapamil 2.5 mg, or isosorbide dinitrate (ISDN) 1 mg before coronary intervention. RAS occurred in 20.1% in the whole population and was significantly reduced by verapamil and ISDN compared to diltiazem (16.2, 17.2, and 26.6%, respectively; P < 0.006). There was also a trend towards less severe pain (more than 8 on a numerical scale from 0 [no pain] to 10 [maximal pain]), and less severe RAS (complete catheter blockage or severe pain), among patients treated by verapamil compared to ISDN and diltiazem (1.3% vs. 2.8% vs. 2.9%, P = 0.43 and 5.1% vs. 6.2% vs. 9.5%, respectively, P = 0.13). No difference was found between the three vasodilators in terms of crossover or safety events. Female gender, failure at first attempt to access the radial artery, emergency procedures, and the use of diltiazem were independent predictors of RAS. Conclusion: Verapamil and ISDN considerably reduce the incidence of RAS compared to diltiazem during transradial PCI.

Performance assessment of a chest pain unit: Preliminary 2-year experience in the European Georges Pompidou Hospital.

BACKGROUND Chest pain units (CPUs) are very popular in the USA for the triage of low-to-intermediate-risk chest pains. However, CPUs do not yet exist in France. AIMS To determine the prevalence and clinical characteristics of patients admitted to a new CPU in France, and to assess the quality of care with regard to identification and exclusion of an acute coronary syndromes (ACS). METHODS This prospective study included 906 consecutive patients with non-traumatic chest pain admitted to our CPU between September 2006 and August 2008. Patients were managed according to their probability of presenting with an ACS. Clinical characteristics, diagnostic tests, final diagnosis, destination and length of stay were recorded. We also assessed the 30-day outcome of patients in whom an ACS was excluded. RESULTS Of the 906 patients, 27.9% had an ACS (1.3% with and 26.6% without ST-segment elevation, respectively). Non-ischaemic cardiac aetiologies and non-cardiac aetiologies were found in 123 (12.6%) and 63 (7.0%) patients, respectively. A final diagnosis of chest pain of undetermined origin was made in 51.5% of patients; among these, 17 (6.5%) patients were re-admitted to the CPU between September 2006 and September 2007. Thirty-day follow-up revealed that only one patient had subsequent confirmation of coronary artery disease requiring further hospitalization. CONCLUSIONS This prospective study reports the first experience of a CPU in a cardiology department in France. Our preliminary results suggest that our CPU can exclude an ACS safely. Further studies are warranted to assess the value of CPUs in France.

Comparison of bleeding complications and one-year survival of low molecular weight heparin versus unfractioned heparin for acute myocardial infarction in elderly patients. The FAST-MI registry

BACKGROUND There are limited data on the safety and efficacy of low molecular weight heparin (LMWH) in elderly patients with acute myocardial infarction (AMI). METHODS We aimed to compare LMWH with unfractioned heparin (UFH) in the management of AMI in elderly patients. FAST-MI is a nationwide registry carried out over a 1-month period in 2005, including consecutive patients with AMI admitted to intensive care unit <48 h from symptom onset in 223 participating centers. We assessed the impact of LMWH on bleeding, the need for blood transfusion and one-year survival in elderly patients (≥ 75 years). RESULTS 963 patients treated with heparin were included (mean age 82 ± 5 years; 51% women; 42.5% ST-elevation myocardial infarction). Major bleeding (2.4% vs. 6.1%, P=0.004) and blood transfusions (4.6% vs. 9.7%, P=0.002) were significantly less frequent with LMWH compared with the UFH, a difference that persisted after multivariate adjustment (OR=0.41, 95% CI: 0.20-0.83 and OR=0.49, 95% CI: 0.28-0.85, respectively). One-year survival and stroke and reinfarction-free survival were also significantly higher with LMWH compared with UFH (OR=0.66, 95% CI: 0.50-0.85 and OR=0.71, 95% CI: 0.56-0.91, respectively). In two cohorts of patients matched on a propensity score for getting LMWH and with similar baseline characteristics (328 patients per group), major bleeding and transfusion were significantly lower while one-year survival was significantly higher in patients receiving LMWH. CONCLUSIONS The present data show that in elderly patients admitted for AMI, use of LMWH is associated with less bleeding, less need for transfusion, and higher survival, compared with the use of UFH.

The SYNERGY II Everolimus elutiNg stent In patients Older than 75 years undergoing coronary Revascularisation associated with a short dual antiplatelet therapy (SENIOR) trial: rationale and design of a large-scale randomised multicentre study

AIMS In the elderly population, bare metal stents (BMS) are often preferred over drug-eluting stents (DES) because of the longer duration of dual antiplatelet therapy (DAPT) associated with the latter. The SENIOR trial is designed to determine whether one of the latest generation of DES can reduce major cardiovascular events compared to BMS, despite a similar short DAPT duration. METHODS AND RESULTS The SENIOR trial is a multicentre, single-blind, prospective, randomised trial comparing the latest generation DES (SYNERGY™ II; Boston Scientific, Marlborough, MA, USA) to BMS (Rebel™; Boston Scientific) in 1,200 patients ≥75 years old. DAPT will be given for one or six months according to clinical presentation, irrespective of stent type. The primary outcome is the composite of all-cause mortality, non-fatal myocardial infarction, stroke or ischaemia-driven target lesion revascularisation at one year. Secondary endpoints include the rate of major bleedings and the rate of stent thrombosis at one year. CONCLUSIONS This trial is designed to evaluate a new revascularisation strategy combining DES and short duration DAPT in elderly patients. It has the potential to decrease the need for target lesion revascularisation without a significant DAPT-related increase in bleeding compared to BMS.

Impact de l'adhérence aux traitements médicamenteux sur le pronostic des patients coronariens

Resume La prescription des traitements recommandes s’accompagne d’une amelioration du pronostic des patients coronariens. De meme, l’adherence aux traitements prescrits, souvent moins bonne que les medecins ne le pensent, est significativement correlee au devenir des patients. Cet article passe en revue les donnees recentes sur l’observance therapeutique et son impact pronostique chez les coronariens.

Impact of purely internal thoracic artery T-graft technique on the mode and quality of surgical myocardial revascularization evaluated by early postoperative coronary angiography

BACKGROUND The use of the internal thoracic artery for coronary artery bypass has improved the results of such surgery. However, bypass using only the internal thoracic arteries sometimes requires a T-graft. This purely internal thoracic artery T-graft technique has progressively become part of our surgical protocol for coronary artery bypass surgery. AIMS The aim of the study was to analyse the impact of this surgical technique on the degree and quality of coronary revascularization using early postoperative angiography. METHODS Between January 2004 and December 2006, 148 patients underwent coronary artery bypass surgery exclusively using both internal thoracic arteries in a T-graft configuration. Systematic postoperative angiography was offered to all 148 patients; it was accepted by 108 patients and refused by 40 patients. RESULTS There were no statistically significant differences between the two groups. In-patient mortality was 2.02% (n=3) for the whole population studied, and 1.49% (n=2) for the 134 patients who received only coronary artery bypass grafts. The revascularization rate was 89% and 3.46 coronary anastomoses were constructed per patient (range 2-6). Angiography was performed on 108 right internal thoracic artery to left internal thoracic artery anastomoses, 374 anastomoses of internal thoracic arteries to coronary arteries and 382 inter-anastomosis segments: 98% of the anastomoses and segments were patent. CONCLUSION The exclusive recourse to the purely internal thoracic artery T-graft technique meant that it has been possible to dispense with other types of graft while achieving complete and effective revascularization of the coronary artery.

314: Percutaneous left ventricular assistance in post cardiac arrest shock: comparison of intra aortic blood pump and impella recover LP 2.5

Objectives To compare the feasibility, safety and outcome of IMPELLA Recover LP2.5 cardiac assistance and intra aortic balloon pump (IABP) in patients with post-cardiac arrest shock. Background Even after successful resuscitation, the in-hospital survival rate of post-cardiac arrest patients remains very low. Recently, a LV percutaneous mechanical assistance using the IMPELLA Recover LP2.5 has been proposed in order to improve the circulatory abnormalities and to allow further neurological evaluation. Methods Retrospective single center registry performed by the interventional cardiology and intensive care departments. All survivors of out-of-hospital cardiac arrest with patent post-resuscitation shock or predictive factors for the occurrence of shock assisted by either IMPELLA or intra aortic balloon pump (IABP) device immediately after the coronary angiogram were included. Results 78 post-cardiac arrest patients were assisted (35 by IMPELLA and 43 by IABP). Most of the patients had an acute coronary syndrome as cause of OHCA. Median “no flow” and median “low flow” were similar as hemodynamic parameters at admission. The feasibility (97%) of IMPELLA implantation was very satisfying. At 28 days, the survival rate without sequellae was 23.0% in the IMPELLA group and 29.5% in the IABP group (p=0.61). Post-cardiac arrest shock was the leading cause of death in the IMPELLA group (n= 21). Vascular complication were observed equally in both groups (3 vs 2, p=0.9). Serious bleeding complications requiring tranfusion occurred in 26% of IMPELLA patients vs 9% of IABP patients (p=0.06) and bleeding requiring increase in vasopressor occurred in 9% of patients in both groups. Conclusion Emergent LV assistance by the IMPELLA LP 2.5 is feasible in patients with post-resuscitation shock. The rate of complication did not differ substantially in the two groups. These encouraging findings must be confirmed in a larger clinical study.

071 Drug-eluting stents: do we respect the one-label use in our daily practice?

Background Drug-eluting stents (DES) are known to dramatically reduce restenosis. However, they are more expansive than bare-metal stents (BMS) and they require prolonged dual antiplatelet therapy. In France, the French Society of Cardiology and the “Haute autorite de Sante” have defined recommendations for the use of DES (restricted to patients in high-risk group). Aim The aim of this work was to evaluate our practice (whether these recommendations were well respected or not in our center). Between November 2007 and January 2008 then November 2008 and January 2009 we evaluated all Percutaneous Coronary Interventions (PCI). Results Two hundred and sixteen (216) patients (mean age 65 ± 13 years, 164 (76%) were males and, 41 (19%) were diabetics) had a PCI for stable angina or silent ischemia (47%), unstable angina or acute coronary syndrome (ACS) ST- (26%), ACS ST+ 48 hours-1 month (3%). Two hundred and seventy six (276) stents were used, including 35% of DES. The recommendations were well respected in 82% of cases. However, 27% of BMS were implanted in patients in whom DES were indicated. Conclusion The Frenchs recommendations for DES are a reference to help practitioners, but they require to be adapted to each patient, depending on clinical state and their ability to be treated with prolonged dual antiplatelet therapy.

Impact of patient adherence to recommended medications on outcomes in populations with coronary artery disease

Resume La prescription des traitements recommandes s’accompagne d’une amelioration du pronostic des patients coronariens. De meme, l’adherence aux traitements prescrits, souvent moins bonne que les medecins ne le pensent, est significativement correlee au devenir des patients. Cet article passe en revue les donnees recentes sur l’observance therapeutique et son impact pronostique chez les coronariens.

Impact de l’adhérence aux traitements médicamenteux sur le pronostic des patients coronariensImpact of patient adherence to recommended medications on outcomes in populations with coronary artery disease

Resume La prescription des traitements recommandes s’accompagne d’une amelioration du pronostic des patients coronariens. De meme, l’adherence aux traitements prescrits, souvent moins bonne que les medecins ne le pensent, est significativement correlee au devenir des patients. Cet article passe en revue les donnees recentes sur l’observance therapeutique et son impact pronostique chez les coronariens.