Marie-Annick Herrmann

Prevalence of peripheral arterial disease in high-risk patients using ankle-brachial index in general practice: a cross-sectional study.

Aims:  The deleterious nature of peripheral arterial disease (PAD) is compounded by a status of underdiagnosed and undertreated disease. We evaluated the prevalence and predictive factors of PAD in high‐risk patients using the ankle‐brachial index (ABI).

Prevalence of unknown peripheral arterial disease in patients with coronary artery disease: Data in primary care from the IPSILON study

BACKGROUND Peripheral arterial disease (PAD) is a marker of increased risk of cardiovascular events and of poor prognosis in patients with coronary artery disease (CAD). The prevalence of unknown PAD among patients with CAD varies between studies according to the mode of diagnosis. AIMS To evaluate the prevalence of unknown PAD, diagnosed using the ankle-brachial index (ABI), in patients from the IPSILON study with a CAD diagnosis; to assess the profile of these patients; and to determine predictors of PAD. METHODS IPSILON was an observational, cross-sectional study. General practitioners measured ABI in 5679 consecutive adults aged 55 years or over with signs or symptoms suggestive of PAD (21.3%), a history of an atherothrombotic event (42.1%) or two or more cardiovascular risk factors (36.6%). This analysis focuses on the subgroup of patients with CAD and no other known overt atherothrombotic disease. RESULTS A total of 1340 patients presented with isolated CAD. PAD (ABI<0.90) was diagnosed in 26.6% of these patients; 16.2% were asymptomatic. Older age, symptoms suggestive of PAD and cardiovascular risk factors were found to be independent predictors of PAD in multivariable analysis. CONCLUSION Over 26% of patients with CAD present with unknown PAD, as diagnosed using ABI measurement. More than half of these patients are asymptomatic. Screening for PAD in patients with CAD will allow detection of a subpopulation at particularly high cardiovascular risk. An aggressive medical treatment strategy could help to improve their outcome.

Comparison of cardiovascular risk factors and drug use in 14,544 French patients with a history of myocardial infarction, ischaemic stroke and/or peripheral arterial disease.

Background Atherothrombosis is a systemic disease affecting coronary, cerebral, and lower limb arteries, and requiring secondary prevention measures. Design Data from three observational studies carried out in 1999-2000 (ECLAT1, APRES, PRISMA) were pooled to describe the prevalence of cardiovascular risk factors and the patterns of drug use in atherothrombotic patients. Methods General practitioners and cardiologists engaged in a private practice and evenly distributed in France recruited consecutive patients who had a history of at least one atherothrombotic event: myocardial infarction (MI), ischaemic stroke, and/or peripheral arterial disease (PAD). Results The sample was composed of 14 544 patients (men: 75.0%, age 75 or older: 31.0%). At least one of the four major risk factors (smoking, hypertension, hypercholesterolemia, diabetes) was present in 94.3% of the sample. Prevalence of drug use was: 78.8% (antiplatelet agents), 48.5% (statins), 36.7% (beta-blockers), and 33.4% [angiotensin-converting enzyme (ACE) inhibitors]. After adjustment for confounders, statins were taken in a significantly larger extent in patients with a history of isolated MI than in those with a previous ischaemic stroke or PAD, or in patients who suffered from both MI and ischaemic stroke. Isolated MI (as compared with ischaemic stroke and PAD) was significantly and independently associated with a higher probability to take antiplatelet agents, beta-blockers or ACE inhibitors. Conclusions At least one conventional risk factor was observed in almost all atherothrombotic patients. Use of preventive drugs was lower in patients with a history of ischaemic stroke or PAD, and should increase, accordingly to the results of recent randomized controlled trials.

Detection and Management of Associated Atherothrombotic Locations in Patients with a Recent Atherothrombotic Ischemic Stroke: Results of the DETECT Survey

Background: Cerebral infarction (CI), myocardial infarction, peripheral artery disease (PAD) and aortic atheroma are the main clinical manifestations of atherothrombosis. Long-term prevention after CI of atherothrombotic origin may require preventive measures at other sites, such as specific drug therapies, surgery, or angioplasty. Therefore the detection of other locations is potentially important. Objectives: The primary objective was to describe the other locations of atherothrombosis in patients hospitalized for a recent cerebral infarct of atherothrombotic origin. Secondary objectives were to describe their vascular risk factor profiles, and their management before and after the cerebral event. Method: This prospective, observational, multicenter survey was conducted in France between September 2003 and July 2004, mainly in neurological departments and stroke units. Results: 753 patients were included (74% men; mean age 69.3 years). Previous coronary events had occurred in 119 (16%). Previous stroke or transient ischemic attacks had occurred in 233 (31%). PAD was already known in 109 (15%). A search for other atherothrombotic locations was positive in 216 patients (29%). The minimum prevalence for any associated atherothrombotic location (either present before or identified during hospitalization) was 47.5% for any location, 33.7% for coronary artery disease, 16.6% for aortic atheroma, and 22.7% for PAD. Conclusion: Fifty percent of the patients with recent atherothrombotic CI have other locations of atherothrombosis. For this reason, a systematic search for these other locations is recommended because of the possible therapeutic consequences. However, the question of the most appropriate period for this search after the cerebral event remains unsettled.

L’artériopathie des membres inférieurs en médecine générale. Quelle prise en charge ?

Resume Objectif Evaluer a partir des resultats de l’etude ATTEST les modalites de prise en charge de l’arteriopathie obliterante des membres inferieurs (AOMI) en medecine generale par reference aux « bonnes pratiques » qui suggerent notamment la mesure de l’index de pression systolique (IPS), la recherche d’autres localisations atherothrombotiques, le traitement des facteurs de risque et en particulier l’arret du tabac, l’entrainement a la marche et un traitement au long cours par anti-agregant plaquettaire. Methode ATTEST est une etude epidemiologique observationnelle transversale et multicentrique realisee en France metropolitaine. Elle a permis de recruter 8 475 patients analysables souffrant d’une AOMI symptomatique isolee (3 811 patients) ou associee a d’autres localisations atherothrombotiques (2 416 patients) ou souffrant d’autres pathologies cardiovasculaires (2 248 patients) sans AOMI suivis chez 3 020 medecins. Six mille deux cent vingt-sept patients arteritiques ont ainsi ete inclus (homme 81,2 %, femme 18,8 % ; âge moyen : 67,2 ans) parmi lesquels 78,8 % au stade de claudication intermittente. Les facteurs de risque etaient representes par le tabagisme actuel ou passe (61 %), l’hypercholesterolemie (66,3 %), l’HTA (63,1 %) et le diabete (26 %). Resultats Tandis que 91,2% des patients ont beneficie d’un echo-doppler arteriel des membres inferieurs, l’IPS, a visee diagnostique, n’a ete mesure que chez 170’entre eux. Les patients ayant ou pas une atteinte coronaire ou cervico-encephalique authentifiee ont beneficie d’un ECG dans 85,8% des cas et d’un echo-doppler des troncs supra-aortiques dans 69,3% des cas. Alors que 39% des patients fumaient encore, une aide a la desintoxication n’etait prescrite que dans 7% des cas, chez les non fumeurs depuis moins d’un an. Pres de deux tiers des patients de cette etude avaient recu des conseils concernant l’activite physique. Enfin, 92,2% d’entre eux recevaient un traitement anti-agregant plaquettaire. Conclusion Le medecin generaliste joue un role cle dans la prise en charge diagnostique et therapeutique de l’AOMI. Bien que la mesure de l’IPS soit la methode recommandee pour le depistage precoce de l’AOMI et l’evaluation de sa severite, moins d’un tiers des arteritiques en beneficie. La recherche d’une autre localisation atherothrombotique concerne en revanche plus de la moitie des patients. D’un point de vue therapeutique, l’exercice physique est souvent recommande et les anti-agregants plaquettaires largement prescrits. En revanche, la lutte contre le tabagisme est manifestement insuffisante. Les resultats de cette etude justifient d’optimiser la collaboration entre medecins generalistes et specialistes des maladies vasculaires. (J Mal Vasc 2004 ; 29 : 249-256).

Antithrombotic Management after an Ischemic Stroke in French Primary Care Practice: Results from Three Pooled Cross-Sectional Studies

Background and Purpose: We aimed at quantifying and explaining the underuse of antithrombotic treatments after an ischemic stroke in patients seen in French primary care. Methods: We pooled all ischemic stroke patients included in 3 observational primary care-based observational studies. French general practitioners and cardiologists recruited 14,544 patients with atherothrombotic disease including 4,322 with an ischemic stroke. Antithrombotic therapies and risk factors were prospectively recorded. Patients with atrial fibrillation (AF) were considered appropriate for oral anticoagulants (OAC) and those without AF for antiplatelet drugs. Results: Out of the 4,322 stroke patients, 3,732 (86.3%) were taking at least one antithrombotic drug. Among the 765 patients with AF, 333 (43.5%) received OAC and 2,718 (86.9%) out of the 3,129 patients appropriate for antiplatelet drug were taking antiplatelet drug. Multivariate analyses did not single out any risk factors for nonuse of OAC and showed that female sex (OR = 1.48; IC 95%: 1.14–1.92) was associated with nonuse of antiplatelet drugs. Conversely, past myocardial infarction (OR = 0.44; IC 95%: 0.26–0.71) and hypercholesterolemia (OR = 0.64; IC 95%: 0.50–0.81) were associated with appropriate use of antiplatelet drugs. Conclusion: More than 50% of stroke patients with AF do not receive OAC and 15% of those without AF do not receive antiplatelet drugs. These findings are not satisfactorily explained by the main patients’ characteristics and practitioner’s speciality and underline the complexity of the process which allows the transfer of scientific evidence in clinical practice.

Observational study of adherence to European clinical practice guidelines for the management of acute coronary syndrome in revascularized versus non-revascularized patients – the CONNECT Study

BACKGROUND The CONNECT study compared clinician adherence to guideline-recommended secondary prevention therapies prescribed at discharge for patients hospitalized for acute coronary syndrome (ACS) in those managed initially with percutaneous coronary intervention (PCI; revascularized) and those who did not undergo revascularization. METHODS Patients aged greater than or equal to 18 years, hospitalized for a documented ST-segment elevation or non-ST-segment elevation ACS, were enrolled consecutively over 1 month at 238 sites in France. RESULTS Compared with revascularized patients (n=870), non-revascularized patients (n=706) were significantly older, and a greater proportion were women, had high-blood pressure, type-2 diabetes or a history of atherothrombotic or cardiac disease, but a smaller proportion had a history of coronary angioplasty. On discharge, non-revascularized patients were prescribed beta-blockers, aspirin, statins, angiotensin-converting enzyme inhibitors or adenosine diphosphate receptor antagonists less frequently than revascularized patients. An adherence score greater than or equal to 80% (at least four of the five recommended agents prescribed at discharge) was found in 96.7% of revascularized patients and 74.4% of non-revascularized patients (P<0.001). CONCLUSIONS Despite a similar or even higher level of cardiovascular risk, non-revascularized ACS patients were prescribed guideline-recommended secondary prevention therapy less frequently than revascularized patients.

Predictors of long-term use of evidence-based therapies after non-ST-segment elevation acute coronary syndrome. The S-Témoin survey☆

BACKGROUND We evaluated correlates of prolonged use of evidence-based therapies in patients discharged after non-ST-segment elevation acute coronary syndrome (NSTE ACS). METHODS 598 cardiologists enrolled 2443 patients at outpatient clinics 2-12 months after discharge for NSTE ACS. The use of cardiac medications for secondary prevention (antiplatelets, beta-blockers, angiotensin-converting enzymes, and statins) was evaluated. RESULTS A total of 2386 (97.7%) patients were on either antiplatelet monotherapy (n=623, 26.1%) or combination therapy (n=1763, 73.9%) at follow-up. Combination antiplatelet therapy declined by 23 percentage points (82.3% to 59.4%) 9-12 months after discharge, whereas use of other cardiac medications remained constant or increased. After multivariable analysis, the strongest predictors of combination antiplatelet therapy were PCI with a stent (odds ratio [OR] 3.75, 95% confidence interval [CI] 2.12-6.67), drug-eluting stents (OR 3.25, 95% CI 1.73-6.08), late PCI (OR 3.21, 95% CI 2.12-4.87) and statins at discharge (OR 1.98, 95% CI 1.40-2.80). Among the independent predictors of beta-blocker and statin use were extent of coronary artery disease and cardiac medications prescribed at discharge. CONCLUSIONS After NSTE ACS, implementation of recommendations on long-term use of evidence-based therapies depends largely on in-hospital management. A variety of clinical characteristics are also predictive of long-term use.

Évaluation en pratique quotidienne des lésions athérothrombotiques associées chez des patients hospitalisés pour infarctus cérébral récent

Introduction L’atherothrombose constitue une atteinte diffuse et globale de l’arbre arteriel dont l’infarctus cerebral (IC) est l’une des principales manifestations cliniques. Elle peut egalement se reveler par un infarctus du myocarde (IDM) ou une arteriopathie obliterante des membres inferieurs (AOMI). Methodologie DETECT (Enquete observationnelle sur la Detection et l’Evaluation des differenTes localisations athErothrombotiques associees chez des patients hospiTalises pour un infarctus cerebral recent) est une etude observationnelle, descriptive, prospective, multicentrique, menee en France en neurologie hospitaliere, dont l’objectif principal est de decrire la frequence des localisations atherothrombotiques associees (AOMI, localisations atherothrombotiques coronariennes (AC) et de l’aorte (AA)) chez des patients des 2 sexes, âges de plus de 18 ans, hospitalises pour un IC recent ( Resultats Entre fevrier 2003 et juillet 2004, 84 neurologues repartis sur le territoire francais ont inclus 725 patients. Les caracteristiques de ces patients sont resumees ci-dessous : Âge (annees) (moy. (ET): 69,5 (11,5) — Sexe masculin: 74.2% - IMC (kg/m2) (moy. (ET) : 25,6 ± 3,8 Facteurs de risque cardiovasculaire : HTA (69,2 %), Dyslipidemie (40,9 %), Fumeur actuel (27,8 %), Diabete (25,8 %), Obesite (10,6 %), Aucun (3,6 %). Antecedents cardiovasculaires (25,5 %) : IDM (14,0 %), Angor stable ( 11,4 %), Angor instable (2,9 %), Ischemie myocardique silencieuse (2,6 %). Antecedents ischemiques cerebrovasculaires (31,4 %) : Accdent Ischemique Transitoire (17,8 %), AVC ischemique (15,6 %), AVC d’origine indeterminee (0,8 %), AVC hemorragique (0,7 %). Antecedents d’AOMI (14,5 %), AOMI stade III-IV (4,8 %). Diagnostic de la nature ischemique de l’AVC : Scanner (94,5 %), IRM (37,8 %), delai en jours (moy ./ET) : 0,8 (2,3). Diagnostic de l’origine atherothrombotique presumee : Echo-Doppler cervical (92,3 %), Angiographie cerebrale (34,6 %), Doppler transcrânien (21,3 %), delai en jours (moy /ET) : 4,1 (14,8). Localisations atherothrombotiques associees : aucune (54,5%), 1 localisation (34,1%), 2 ou 3 localisations (11,7%): AC (localisation coronaire): 23,2%, AOMI: 20.3%, AA (localisation aortique) : 15,7 %. Conclusion Dans une population de patients hospitalises pour un infarctus cerebral recent, quand une exploration est realisee, on constate dans pres d’un cas sur deux, l’existence d’une ou plusieurs lesions atherothrombotiques dans un territoire different de celui initialement atteint. Cette frequence elevee, quoique probablement sous-estimee, peut justifier la recherche systematique de telles lesions associees, apres un infarctus cerebral recent, dans le cadre du bilan d’extension de la maladie atherothrombotique.