Luc Cornillet

Early Aldosterone Blockade in Acute Myocardial Infarction: The ALBATROSS Randomized Clinical Trial.

BACKGROUND Mineralocorticoid receptor antagonists (MRA) improve outcome in the setting of post-myocardial infarction (MI) heart failure (HF). OBJECTIVES The study sought to assess the benefit of an early MRA regimen in acute MI irrespective of the presence of HF or left ventricular (LV) dysfunction. METHODS We randomized 1,603 patients to receive an MRA regimen with a single intravenous bolus of potassium canrenoate (200 mg) followed by oral spironolactone (25 mg once daily) for 6 months in addition to standard therapy or standard therapy alone. The primary outcome of the study was the composite of death, resuscitated cardiac arrest, significant ventricular arrhythmia, indication for implantable defibrillator, or new or worsening HF at 6-month follow-up. Key secondary/safety outcomes included death and other individual components of the primary outcome and rates of hyperkalemia at 6 months. RESULTS The primary outcome occurred in 95 (11.8%) and 98 (12.2%) patients in the treatment and control groups, respectively (hazard ratio [HR]: 0.97; 95% confidence interval [CI]: 0.73 to 1.28). Death occurred in 11 (1.4%) and 17 (2.1%) patients in the treatment and control groups, respectively (HR: 0.65; 95% CI: 0.30 to 1.38). In a non-pre-specified exploratory analysis, the odds of death were reduced in the treatment group (3 [0.5%] vs. 15 [2.4%]; HR: 0.20; 95% CI: 0.06 to 0.70) in the subgroup of ST-segment elevation MI (n = 1,229), but not in non-ST-segment elevation MI (p for interaction = 0.01). Hyperkalemia >5.5 mmol/l(-1) occurred in 3% and 0.2% of patients in the treatment and standard therapy groups, respectively (p < 0.0001). CONCLUSIONS The study failed to show the benefit of early MRA use in addition to standard therapy in patients admitted for MI. (Aldosterone Lethal effects Blockade in Acute myocardial infarction Treated with or without Reperfusion to improve Outcome and Survival at Six months follow-up; NCT01059136).

Can troponin elevation predict worse prognosis in patients with acute pericarditis

INTRODUCTION Myopericarditis are common in clinical practice: up to 15% of acute pericarditis have a significant myocardial involvement as assessed by biological markers. This prospective, bicentric study is aimed at describing a myopericarditis population, the clinical and MRI follow-up, and search for prognosis markers. PATIENTS AND METHODS Between May 2005 and September 2007, 103 patients hospitalised for acute pericarditis were prospectively enrolled. Physical examination, ECG, echocardiography, biological screening and cardiac MRI, in case of myopericarditis defined as acute pericarditis with troponin I elevation, were performed. Between December 2007 and July 2008, patients were contacted for new clinical and MRI evaluation. RESULTS Among the initial population of 103 patients admitted for acute pericarditis, 14 myopericarditis and 38 pericarditis were included. Compared with pericarditis, the myopericarditis group was associated with the following features: younger age (34.9 years [95% CI 28.3-41.2]; p=0.01), ST-segment elevation (nine patients between 14; p=0.03), higher troponin I (7.3 microg/L [95% CI 4.4-10.2]; p<10(-4)) and lower systemic inflammation (CRP peak 38.1mg/L [95% CI 7-69.2]; p=0.01). In the case of myopericarditis, infectious etiologies were predominant (12 patients among 14; p=0.002) and patients stayed longer in hospital (5.8 days [95% CI 4.7-6.8]; p=0.01). Follow-up showed no difference in terms of functional status (p=0.3) and global complications (p=0.9) between paired myopericarditis and pericarditis. Nevertheless, cardiac mortality was higher for myopericarditis (p=0.04). MRI follow-up showed myocardial sequelae without clinical impact. CONCLUSION Myopericarditis significantly distinguished from pericarditis. Three years follow-up showed no difference in terms of global complications but a higher cardiac mortality for myopericarditis. MRI myocardial lesions did not develop into symptomatic sequelae.

Les patients bénéficiant d’une coronarographie sont-ils bien informés ? Évaluation de l’efficacité de l’information écrite. Étude prospective unicentrique

INTRODUCTION Prior information in the realization of an invasive intervention is crucial. Indeed, the patient has to know theoretically his disease, diagnostic and therapeutic means, but also the risks of the used technique. The habits of information vary many from one center to another, in spite of the proposition of an information leaflet written by the French Society of Cardiology. Our aim was to evaluate the effectiveness of written information for patients hospitalized for coronary arteriography. METHODS Among patients hospitalized for realization of a programmed coronarography, a questionnaire was delivered before the information leaflet. The knowledge of the patients was so tested (27 items) before and after the reading of the information sheet (not limited time). The knowledge of the patients concerning coronarography indication, modalities, benefits, possible complications or still later possibilities was informed. RESULTS Thirty-four patients were included: all knew hospitalization reason, 86% were men, middle-aged 65 (IC 95% 60-70). Thirty-four percent (15-54) had studied in higher education. Ninety-seven percent had had information before. Only 56% (38-74) were informed about the mode of anesthesia, 36% (19-53) duration, 69% (53-86) the injection of iodine, 44% the risk of allergy, 53% the risk of bruise, 15% of the cardiac risks, 21% the renal risks. Seventy-one percent knew the diagnostic benefits, 44% the possible coronary angioplasty, 17% the eventuality of a bypass surgery. The delivery of the information leaflet did not modify the knowledge on most of these items, in particular the modalities and the profits. The risks were known significantly better for the allergy (P=0.019), the bruise (P=0.018), the cardiac risks (0.001). CONCLUSIONS The population benefiting from a coronarography considers to be enough informed. However, knowledge of the modalities, profits and risks is very low. The delivery of the consensual leaflet does not allow improving the situation, except as far as concerned the complications. Better information is so indispensable, not only to obtain a better support of the patient in the treatment, but also to prevent the forensic implications. The improvement of the information must be multifactorial, but usually used means could be not sufficient.

Management of acute heart failure: Contribution of daily bedside echocardiographic assessment on therapy adjustment with impact measure on the 30-day readmission rate (JECICA)

There are currently one million heart failure (HF) patients in France and the rate is progressively increases due to population aging. Acute decompensation of HF is the leading cause of hospitalization in people over 65 years of age with a 25% re-hospitalization rate in the first month. Expenses related to the management of HF in France in 2013 amounted to more than one billion euros, of which 65% were for hospitalizations alone. The management of acute decompensation is a challenge, due to the complexity of clinical and laboratory evaluation leading to therapeutic errors, which in turn leads to longer hospitalization, high early re-hospitalization and complications. Therapeutic adjustment, especially diuretic, in the acute phase (during hospitalization) affects early re-hospitalization rates (within 30 days). These adjustments can be based on clinical estimation and laboratory parameters, but echocardiography has been shown to be superior in estimating filling pressures (FP) compared to clinical and laboratory parameters. We hypothesize that a simple daily bedside echocardiographic assessment could provide a reproducible estimation of FP with an evaluation of mitral inflow and the inferior vena cava (IVC). This could allow a more reliable estimate of the true blood volume of the patient and thus lead to a more suitable therapeutic adjustment. This in turn should lead to a decrease in early re-admission rate (primary endpoint) and potentially decrease six-month mortality and rate of complications.

Optical Coherence Tomography Evidence of Spontaneous Healing of an Intramural Coronary Hematoma

A 57-year-old woman with no cardiovascular risk factors was admitted to our institution for noneST-elevation myocardial infarction. An admission electrocardiogram showed inverted negative T waves and a significant elevation of ultrasensitive troponin. A transthoracic echocardiogram showed severe apical hypokinesia with a 45% left ventricular ejection fraction. A coronary angiogram revealed a nonsignificant lesion of the mideleft anterior descending artery (Fig. 1A) without other lesions. Optical coherence tomography (OCT) confirmed an extensive left anterior descending hematoma without intimal tear (Fig. 1, B and C). No angioplasty was proposed given its location and extension. Angiographic (Fig. 1D) and OCT controls (Fig. 1, E and F) were obtained at 1 year and showed the complete healing of coronary hematoma. Intramural coronary hematoma has been reported to be a very rare cause of acute coronary syndrome and is often

0098: One year incidence and clinical impact of bleeding outcomes in STEMI patients treated by prasugrel or clopidogrel in real life: the BLEED-MI study

Purposes The aim of this study was to evaluate one-year incidence of bleeding events and their impact on compliance in patients admitted for ST Elevation Myocardial Infarction (STEMI) and treated by prasugrel or clopidogrel in « real-world ». Methods Patients admitted for a STEMI were treated by either clopidogrel or prasugrel according to the physician with respect of guidelines. The primary endpoint was the first occurrence of bleeding events within 12 months assessed by the Bleeding Academic Research Consortium (BARC) classification using a dedicated questionnaire focused on bleeding events. Topography bleedings, causes of premature cessation and ischemic events were also compared. Results 390 patients were enrolled, 211 in prasugrel group and 179 in clopidogrel group. Patients in the prasugrel group were younger, with higher body weight and were more frequently men. At 12 months, a bleeding complication occurred in 40% of patients regardless of its severity or treatment prescribed. Major bleedings (BARC 3) were significantly lower with prasugrel than clopidogrel (1% versus 6%, p=0.001). Minimal bleedings (BARC 1) were more frequent in clopidogrel group than prasugrel group (respectively 27% and 18%; p=0.05). However BARC 2 bleedings occurred more often in prasugrel group (14% versus 6%, p=0.01) (figure). Subcutaneous and gastrointestinal haemorraghes were the most frequent. Over one-year, the rate of cessation was 18% in the prasugrel group and only 10% in the clopidogrel group (p=0.04). Respectively for prasugrel and clopidogrel, rates of recommend discontinuation were 10% and 4% (p=0.02) and of disruption were 8% and 5% (p=0.3). Despite more frequent discontinuation, mortality remains very low in the prasugrel group (0.5% versus 7%, p=0.0003). Conclusion In real-world, in a low bleeding risk population, the rate of major bleedings with prasugrel at 12 months was low but nuisance bleedings were frequent with significant impact on premature cessation Download : Download full-size image Abstract 0098 – Figure: 12 months bleedings classification

Évolution des stents pharmacoactifs

L’intervention coronarienne percutanee (ICP) a ete introduite dans les annees 1970 et le premier stent metallique nu (Bare-Metal Stent, BMS) a ete implante par le Pr Jacques Puel en 1986. Les stents a elution de medicaments ( drug-eluting stent, DES) ont ete developpes pour lutter contre la restenose rencontree avec les stents nus. L’arrivee des stents actifs a permis une importante reduction de la restenose intrastent mais, de maniere parallele, une augmentation des thromboses de stent tres tardives a ete observee avec la premiere generation de stents actifs. L’arrivee des stents actifs « nouvelle generation » avec amelioration des plateformes mais aussi des polymeres (biocompatibles ou resorbables) a permis une amelioration des resultats cliniques notamment une reduction des thromboses de stent tres tardives permettant d’envisager une reduction de la duree de la bitherapie antiplaquettaire a 6 mois pour l’angioplastie elective. Dans le meme temps, les stents integralement bioresorbables sont maintenant disponibles, mais ne peuvent pas etre proposes dans toutes les situations cliniques.

075 - Identification of patients at risk for premature discontinuation of oral antiplatelet therapy after elective percutaneous coronary intervention

Background Premature discontinuation of antiplatelet therapy is a major risk factor of stent thrombosis after drug-eluting stent placement leading to an increased risk of death. Objectives We sought to determine by a simple questionnaire the prevalence of patients at risk for premature discontinuation of oral antiplatelet therapy in elective percutaneous coronary intervention (PCI). Methods Patients scheduled for elective PCI underwent a routine interview (RI) and a specific questionnaire (SQ) by two independent physicians the day before the intervention. The SQ was designed to identify bleeding disorders, suspected cancer, planned invasive procedures and self evaluation of compliance. The final decision of drug eluting stent (DES) implantation was made by a third independent physician who performed the planned PCI and who had full access to the patient record. Results At least one contraindication to DES implantation was found in one third of the study population (82/302, 27%) after the RI. All these patients were also identified by the SQ. At total of 31 additional patients were identified by the SQ as non eligible for DES implantation. Active bleeding (n = 14) and scheduled biopsies (n = 4) were the two main contraindications to DES implantation isolated by the SQ. Patients characteristics and angiographic findings identified 59.9% patients (n = 181/302) eligible for a DES implantation. Finally the physician performing the PCI excluded 66.3% of the patients (n = 79/302) who could receive a DES and implanted a bare metal stent (BMS) instead. This decision was based on the findings of the dedicated questionnaire on top of the interview in 30 patients (38%) and in 49 patients (62%) for other reasons. Conclusions In elective PCI, a simple questionnaire used before DES implantation can improve identification of patients at high risk for premature discontinuation of antiplatelet therapy.