Gerald Roul

Diagnostic and prognostic value of circulating D-Dimers in patients with acute aortic dissection.

Objective:We sought to determine whether assessing D-Dimer might be helpful for the management of acute aortic dissection (AAD). Design:Single-center retrospective case-control study. Setting:University Hospital of Strasbourg France. Patients:Patients were 94 consecutive patients admitted to our institution with confirmed AAD and in whom D-Dimer test had been performed at presentation. These patients were matched with 94 controls presenting with clinical suspicion of dissection, which was later ruled out. Interventions:Patient characteristics and clinical course were analyzed. Measurements and Main Results:Ninety-three (99%) patients with AAD had elevated D-Dimer (>400 ng/mL) with a median D-Dimer value of 8610 ng/mL (interquartile range, 2982–20,000 ng/mL). Receiver operating characteristic curves analysis showed that D-Dimer, but not C-reactive protein, troponin, lactate dehydrogenase, or leukocyte count, was predictive of a diagnosis of AAD, with a sensitivity and specificity of 99% and 34%, respectively. D-Dimer concentration positively correlated with the anatomical extension of the dissection to the different segments of the aorta (R = .47, p < .0001). A positive relationship was observed between D-Dimer and in-hospital mortality rate among patients with AAD (p = .037). On multivariate analysis, the independent predictors of in-hospital mortality were the presence of pericardial effusion (odds ratio, 6.80; confidence interval, 1.87–27.60), D-Dimer >5200 ng/mL (odds ratio, 5.38; confidence interval, 1.27–30.87), and female gender (odds ratio, 4.96; confidence interval, 1.39–19.95). Conclusions:D-Dimers are elevated in patients with AAD and provide valuable diagnostic and prognostic information. In patients with acute chest pain and elevated D-Dimer, a diagnosis of AAD should also be considered. D-Dimer might be a useful complementary tool to the current diagnostic work-up of patients with suspected AAD.

Troponin I concentrations following primary percutaneous coronary intervention predict large infarct size and left ventricular dysfunction in patients with ST-segment elevation acute myocardial infarction

The aim of this study was to investigate the ability of troponin I (cTnI) levels to predict myocardial infarction size in patients with ST-segment elevation acute myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI). In 87 patients with STEMI undergoing primary PCI, serial plasma concentrations of cTnI and alpha-hydroxybutyrate deshydrogenase (HBDH) were measured before PCI and over the following 72 h. Enzymatic infarct size was estimated by the cumulative release of HBDH during the 72 h following PCI (QHBDH72). Delayed radionuclide left ventricular ejection fraction (LVEF) was measured in 63 patients. While cTnI concentrations at admission did not correlate with QHBDH72 or with LVEF, from the 3rd to the 72nd h following PCI, they did correlated with QHBDH72 (P<0.001; R: 0.76-0.86) and with LVEF (P<0.001; R: -0.42 to -0.50). Receiver-operator characteristic (ROC) curve analysis showed that admission concentrations of cTnI could not predict either a large infarct size (i.e., QHBDH72>10 g-eq l(-1)) or a low LVEF (i.e., LVEF<40%). However, 6 h and up until 72 h after PTCA, cTnI concentrations were predictive of large enzymatic infarct size (sensitivity: 91 and 95%, specificity: 90 and 87%, respectively) and of LVEF under 40% (sensitivity: 75 and 77%, specificity: 90 and 78%, respectively). Thus, our study suggests that in contrast with admission cTnI concentration, cTnI levels following primary PCI represent a reliable tool for predicting large enzymatic infarct size and may help in selecting patients with a high risk of low LVEF at 1 month.

Lower circulating Sta-Liatest D-Di levels in patients with aortic intramural hematoma compared with classical aortic dissection

Objective:To compare the diagnostic value of circulating Sta-Liatest D-Di levels in classic acute aortic dissection (AAD) and in aortic intramural hematoma (AIH), a variant of AAD without a patent false lumen. Design:Single-center retrospective case-control study. Setting:University Hospital of Strasbourg, France. Patients:Ninety-four consecutive patients with both confirmed AAD and d-dimer measurements at entry were included. d-dimer levels were assayed by the immunoturbidimetric method Sta-Liatest D-Di (Diagnostica Stago, Asnieres sur Seine, France). Intervention:Patient characteristics and clinical evolution were analyzed. Measurements and Main Results:Eighty-four patients (89%) presented a classic AAD with patent false lumen and ten (11%) presented an AIH. Clinical presentation did not differ between the two groups. The mortality rate was 0% in AIH and 26% in classic AAD. d-dimer levels were significantly lower in patients with AIH (median, 1230 ng/mL; interquartile range, 685–2645 ng/mL) than in patients with AAD with patent false lumen (median value, 9290 ng/mL; interquartile range, 3890–20,000 ng/mL; p = 0.008). All patients with AAD and patent false lumen had d-dimer levels above the threshold of 400 ng/mL (sensitivity 100%). However, one patient with AIH presented d-dimer levels below the threshold. Therefore, the sensitivity of the d-dimer test in detecting AIH was 90%. Conclusions:Sta-Liatest D-Di levels are lower in AIH than in AAD with patent false lumen. This test can quite possibly be negative in the case of intramural hematoma. This feature must be considered when interpreting d-dimer levels in patients with acute aortic syndrome.

In-hospital complications after invasive strategy for the management of Non STEMI: women fare as well as men

BackgroundTo analyze the in-hospital complication rate in women suffering from non-ST elevation myocardial infarction treated with percutaneous coronary intervention (PCI) compared to men.MethodsThe files of 479 consecutive patients (133 women and 346 men) suffering from a Non STEMI (Non ST-segment elevation myocardial infarction) between the January 1st 2006 and March 21st 2009 were retrospectively analyzed with special attention to every single complication occurring during hospital stay. Data were analyzed using nonparametric tests and are reported as median unless otherwise specified. A p value < .05 was considered significant.ResultsAs compared to men, women were significantly older (75.8 vs. 65.2 years; p < .005). All cardiovascular risk factors but tobacco and hypertension were similar between the groups: men were noticeably more often smoker (p < .0001) and women more hypertensive (p < .005). No difference was noticed for pre-hospital cardiovascular drug treatment. However women were slightly more severe at entry (more Killip class IV; p = .0023; higher GRACE score for in-hospital death - p = .008 and CRUSADE score for bleeding - p < .0001). All the patients underwent PCI of the infarct-related artery after 24 or 48 hrs post admission without sex-related difference either for timing of PCI or primary success rate. During hospitalization, 130 complications were recorded. Though the event rate was slightly higher in women (30% vs. 26% - p = NS), no single event was significantly gender related. The logistic regression identified age and CRP concentration as the only predictive variables in the whole group. After splitting for genders, these parameters were still predictive of events in men. In women however, CRP was the only one with a borderline p value.ConclusionsOur study does not support any gender difference for in-hospital adverse events in patients treated invasively for an acute coronary syndrome without ST-segment elevation and elevated troponin.

Pulmonary hypertension in chronic heart failure: definitions, advances, and unanswered issues: Pulmonary hypertension in chronic heart failure

Pulmonary hypertension (PH) is a common and severe complication of heart failure (HF). Consequently, HF is the leading cause of PH. For many years, specialists have attempted to better understand the pathophysiology of PH in HF, to define its prevalence and its impact on prognosis in order to improve the therapeutic management of these patients. Nowadays, despite the recent guidelines published on the subject, several points remain unclear or debated, and until now, no study has demonstrated the efficacy of any treatment. The aim of this review is to report the evolution of the concepts on post‐capillary PH (diagnosis, prevalence, prognosis, and therapeutics). The main issues are raised, focusing especially on the link between structural alterations and haemodynamic abnormalities, to discuss the possible reasons for treatment failures and future potential targets.

Comparison of the long-term reproducibility of the walk test and of exercise peak oxygen consumption in patients with preserved exercise capacity

Abstract Short-term and long-term reproducibility of the cardiopulmonary (CPX) exercise test have been established. Though short and mid-term reproducibility of the walk test has been ascertained, this was not extensively done for the long-term reproducibility. The aim of the study was to examine the long-term reproducibility of distance walked in an allotted time and to check the stability of the relationship between walked distance and exercise peak VO2 (pVO2). Methods: Forty six subjects (33 men; 57 ± 14 years), referred for functional capacity assessment, were studied twice by CPX and walking test. On the same day, CPX was performed on a bicycle or a treadmill and walk test in a corridor as required by specific guidelines. We performed a 12-minute walk test and the distance covered in six minutes was systematically taken down. A free time interval of 1.5 hours was observed between the exercise tests. Distance walked in the allotted time and pVO2 were analysed. Reproducibility was assessed according to Bland and Altman plots and intra-class coefficient correlation (ICC). The relationship between distance ambulated and pVO2 was analysed by the Spearman coefficient correlation. Results: The time interval between the two evaluations was 290 ± 10 days. During this meantime, for those subjects having drug treatment, no change was recorded in their regimen. BMI remained stable for the entire studied population (28 ± 5 kg/m2). Minute walked distance was respectively 522 ± 83 and 527 ± 76 m in six minutes, 1033 ± 182 and 1041 ± 153 m in 12 minutes. pVO2 was 21 ± 7 and 22 ± 7 ml/kg/min (all p = NS). The walk test was reproducible in the long-term, regardless of the modality (6 or 12-minute walk) as shown by the Bland–Altman plots and the high ICC of .89. Spearman’s rho coefficient between distance ambulated and pVO2 was modest and remained stable over time whatever the allotted time: Spearman’s r = .54; p = .0011 (1st evaluation) and Spearman’s r = .51; p = .0019 (2nd evaluation) between 6-minute distance walked and pVO2. Conclusions: The walking distance in an allotted time seems highly reproducible in the long-term. Its relationship with pVO2 remains stable over time. It could be of value for repeated assessment of patients’ exercise capacity in a first step. Further evaluation in a larger population is needed to confirm our result and its usefulness in clinical practice.

0121: Heart rate variability in elderly ischemic patients with ventricular arrhythmias

Background Heart rate variability and autonomic nervous system dysfunction have a recognised value in the assessment of the prognostic of heart disease and it is well known that variability decreases with age and in heart failure or ischemic patients, as a predictor for worsen outcome and for an increase in mortality and morbidity. Materials and methods We retrospectively investigated 12 lead Holter ECG monitoring in the past 2 years for ischemic patients aged 50 or older who had ventricular arrhythmias. We included in our observational study 25 patients, 16 women and 9 men with a mean age of 64,71±9,09. For each of the participants we evaluated the heart rate variability parameters: SDNN, SDANN, MSSD, pNN50. Results Our analysis revealed that there is a good correlation between the number of ventricular escape beats on a 24 hours monitoring and the heart rate variability parameters SDNN (y=8,7266x – 757,02 R2=0,8171) and rMSSD (y=8,6658x – 65,347 R2=0,6395). Conclusions The results may be a starting point for future research for improving the prognostic in elderly with cardio-vascular disease, taking into consideration that both parameters (heart rate variability and ventricular arrhythmias) may be influenced and improved either by adequate physical activity or by antiarrhythmic drugs with strong implications in deciding for primary and secondary prevention. Download : Download high-res image (293KB) Download : Download full-size image Abstract 0121 – Figure

0208: Impact of fondaparinux versus enoxaparin on in-hospital bleeding and one-year death in non-ST-segment elevation myocardial infarction. FAST-MI 2010 registry

Aims Fondaparinux is an alternative to low molecular weight heparin (LMWH) for non-ST-elevation myocardial infarction (NSTEMI) with levels of recommendation that differ according to guidelines. The aim of this study was to assess one-year survival in real world practice in NSTEMI patients participating in the French Registry of ST-elevation and non-ST-elevation Myocardial Infarction (FAST-MI) 2010 according to the use of fondaparinux, in comparison with patients receiving enoxaparin. Methods and Results FAST-MI 2010 is a nationwide French registry that included 4,169 patients with acute myocardial infarction (AMI) at the end of 2010 in 213 centres (76% of active centres in France). Of those, 1,734 had NSTEMI, of whom 240 received fondaparinux and 1,027 enoxaparin. Patients receiving enoxaparin vs. fondaparinux were similar for many characteristics; especially with a similar GRACE (Global Registry of Acute Coronary Events) score (133±36 vs. 134±38). Invasive strategy was used in 69% in both groups. In-hospital bleeding was similar with both anticoagulant strategies and one-year survival was 94.6% vs. 91.7% respectively. Using fully adjusted Cox multivariate analysis, the use of fondaparinux was not associated with a reduced risk of death (hazard ratio [HR]: 1.35; 95% confidence interval [CI]: 0.70-2.51). After propensity score matching (207 patients per group), one-year survival was similar with both strategies. Conclusions In this real-world cohort of NSTEMI patients, most of whom were managed invasively, there was no evidence that fondaparinux was superior to enoxaparin as regards bleeding events or one-year mortality. (FAST-MI 2010; NCT01237418)

159 Coronary plaque burden in asymptomatic patients with metabolic syndrome

rior leads) and all these patients underwent an urgent coronary angiography. In 13 patients (65%), a significant coronary stenosis was observed: ST elevation was observed in case of critical coronary stenosis in 6 patients and in case of chronic coronary occlusion in 7 patients. Finally, 7 patients (35% of patients presenting with ST elevation during dobutamine stress echocardiography; 6 men, mean age: 67±11 years) had no significant coronary stenosis. The prevalence of coronary artery spasm during dobutamine stress echocardiography was 0.3%. Coronary artery spasm during coronary angiography was induced with methergin testing or dobutamine perfusion.

115 Ventriculo-arterial coupling in heart failure with preserved or altered ejection fraction. Preliminary data

Signs of congestion were No signs; right (RHC: oedema, jugular venous distension); left (LHC: lung crackles); or both (R+LHC). Of 1881 patients referred, 707 did not have CHF, 853 had S-HF, and 321 had HeFNEF. Their median (IQR) age was 72 years (64-78), 40% were women and LVEF was 47% (35-59). 417 had RHC of whom 49% had S-HF and 21% HeFNEF. 85 had LHC of whom 43% had S-HF and 20% had HeFNEF. 172 had R+LHC of whom 71% had S-HF and 16% HeFNEF. During a median (IQR) follow up of 64(44-76) months, 40% died. R+LHC signs was an independent maker of prognostic and indicated a bad prognosis ( 2-log-Rank test=186.1, p<0.0001).