Nadia Aissaoui

Improved outcome of cardiogenic shock at the acute stage of myocardial infarction: a report from the USIK 1995, USIC 2000, and FAST-MI French Nationwide Registries

AIMnThe historical evolution of incidence and outcome of cardiogenic shock (CS) in acute myocardial infarction (AMI) patients is debated. This study compared outcomes in AMI patients from 1995 to 2005, according to the presence of CS.nnnMETHOD AND RESULTSnThree nationwide French registries were conducted 5 years apart, using a similar methodology in consecutive patients admitted over a 1-month period. All 7531 AMI patients presenting ≤48 h of symptom onset were included. The evolution of mortality was compared in the 486 patients with CS vs. those without CS. The incidence of CS tended to decrease over time (6.9% in 1995; 5.7% in 2005, P = 0.07). Thirty-day mortality was considerably higher in CS patients (60.9 vs. 5.2%). Over the 10-year period, mortality decreased for both patients with (70-51%, P = 0.003) and without CS (9-4%, P < 0.001). In CS patients, the use of percutaneous coronary intervention (PCI) increased from 20 to 50% (P < 0.001). Time period was an independent predictor of early mortality in CS patients (OR for death, 2005 vs. 1995 = 0.45; 95% CI: 0.27-0.75, P = 0.005), along with age, diabetes, and smoking status. When added to the multivariate model, PCI was associated with decreased mortality (OR = 0.38; 95% CI: 0.24-0.58, P < 0.001). In propensity-score-matched cohorts, CS patients with PCI had a significantly higher survival.nnnCONCLUSIONSnCardiogenic shock remains a clinical concern, although early mortality has decreased. Improved survival is concomitant with a broader use of PCI and recommended medications at the acute stage. Beyond the acute stage, however, 1-year survival has remained unchanged.

Temporary right ventricular mechanical circulatory support for the management of right ventricular failure in critically ill patients

BACKGROUNDnManagement of right ventricular (RV) failure after left ventricular assist device (LVAD) implantation is not evidence based. Temporary circulatory assistance has recently been reported to be of value for managing postoperative RV failure after LVAD implantation, but only in small series of patients or isolated case reports. We report here our experience with the use of temporary right ventricular assist devices (RVADs) in LVAD recipients.nnnMETHODSnForty-five of the 488 (9%) patients undergoing LVAD implantation between 2001 and 2011 at the Clinic for Thoracic and Cardiovascular Surgery in Bad Oeynhausen had RV failure requiring temporary RVAD. We analyzed preoperative data, complications, mortality at 6 months, and risk factors of death.nnnRESULTSnThe LVAD patients receiving temporary RVAD were younger than the 443 recipients of LVAD alone. They were more likely to have mechanical ventilation and haemofiltration and their Michigan right ventricular risk score was higher. The LVAD patients with temporary RVAD had a higher mortality at 6 months: 53%, versus 25% for patients receiving LVAD only (Pxa0<xa0.001). The univariate risk factors for death were high blood urea nitrogen and C-reactive protein concentrations, preoperative mechanical ventilation, preoperative hemofiltration, destination therapy, the use of temporary RVAD, and the development of RV failure. Multivariate analyses did not identify predictors of death.nnnCONCLUSIONSnThe development of RV failure in LVAD recipients is a serious problem associated with high mortality. Temporary RV mechanical support is an acceptable way to manage postoperative RV failure in these severely ill LVAD recipients.

Use of Invasive Strategy in Non–ST-Segment Elevation Myocardial Infarction Is a Major Determinant of Improved Long-Term Survival: FAST-MI (French Registry of Acute Coronary Syndrome)

OBJECTIVESnThis study sought to assess the impact of invasive strategy (IS) versus a conservative strategy (CS) on in-hospital complications and 3-year outcomes in patients with non-ST-segment elevation myocardial infarction (NSTEMI) from the FAST-MI (French Registry of Acute Coronary Syndrome).nnnBACKGROUNDnResults from randomized trials comparing IS and CS in patients with NSTEMI are conflicting.nnnMETHODSnOf the 3,670 patients in FAST-MI, which included patients with acute myocardial infarction (within 48 h) over a 1-month period in France at the end of 2005, 1,645 presented with NSTEMI.nnnRESULTSnOf the 1,645 patients analyzed, 80% had an IS. Patients in the IS group were younger (67 ± 12 years vs. 80 ± 11 years), less often women (29% vs. 51%), and had a lower GRACE (Global Registry of Acute Coronary Events) risk score (137 ± 36 vs. 178 ± 34) than patients treated with CS. In-hospital mortality and blood transfusions were significantly more frequent in patients with CS versus IS (13.1% vs. 2.0%, 9.1% vs. 4.6%). Use of IS was associated with a significant reduction in 3-year mortality and cardiovascular death (17% vs. 60%, adjusted hazard ratio [HR]: 0.44, 95% confidence interval [CI]: 0.35 to 0.55 and 8% vs. 36%, adjusted HR: 0.37, 95% CI: 0.27 to 0.50). After propensity score matching (181 patients per group), 3-year survival was significantly higher in patients treated with IS.nnnCONCLUSIONSnIn a real-world setting of patients admitted with NSTEMI, the use of IS during the initial hospital stay is an independent predictor of improved 3-year survival, regardless of age. (French Registry of Acute Coronary Syndrome [FAST-MI]; NCT00673036).

Two-Dimensional Strain Rate and Doppler Tissue Myocardial Velocities: Analysis by Echocardiography of Hemodynamic and Functional Changes of the Failed Left Ventricle during Different Degrees of Extracorporeal Life Support

BACKGROUNDnTo evaluate hemodynamic and functional changes of the failed left ventricle by Velocity Vector Imaging (VVI) and tissue Doppler, 22 patients with cardiogenic shock supported by extracorporeal life support (ECLS) were imaged during ECLS output variations inducing severe load manipulations.nnnMETHODSnThe following data were acquired: (1) mean arterial pressure, aortic Doppler velocity-time integral, left ventricular end-diastolic volume, and mitral Doppler E wave; (2) tissue Doppler systolic (Sa) and early diastolic (Ea) velocities; and (3) systolic peak velocity (Sv), strain, and strain rate using VVI.nnnRESULTSnLoad variations were documented by a significant decrease in afterload (mean arterial pressure, -21%), an increase in preload (left ventricular end-diastolic volume, +12%; E, +46%; E/Ea ratio, +22%), and an increase in the velocity-time integral (+45%). VVI parameters increased (Sv, +36%; strain, +81%; and strain rate, +67%; P < .05), unlike tissue Doppler systolic velocities (+2%; P = NS). Whatever the ECLS flow, Sa was higher in patients who survived.nnnCONCLUSIONSnVVI parameters are not useful in characterizing the failed left ventricle with rapidly varying load conditions. Tissue Doppler systolic velocities appear to be load independent and thus could help in the management of ECLS patients.

A meta-analysis of bed rest versus early ambulation in the management of pulmonary embolism, deep vein thrombosis, or both

BACKGROUNDnBed rest is often recommended as part of the management of deep vein thrombosis (DVT) and pulmonary embolism (PE), though this recommendation is not clearly evidence-based.nnnMETHODSnUsing the Cochrane Central Register of Controlled Trials, Medline, and Embase, this meta-analysis considered all randomized studies and prospective registries that compared the outcomes of patients with DVT, PE, or both, managed with bed rest versus early ambulation, in addition to anticoagulation. For each study, data regarding the incidence of new PE, new or progression of DVT, and death from all causes, were used to calculate relative risks (RR) and 95% confidence intervals (CI).nnnRESULTSnThe 5 studies retained in this analysis included a total of 3048 patients. When compared to bed rest, early ambulation was not associated with a higher incidence of a new PE (RR 1.03; 95% CI 0.65-1.63; p=0.90). Furthermore, early ambulation was associated with a trend toward a lower incidence of new PE and new or progression of DVT than bed rest (RR 0.79; 95% CI 0.55-1.14; p=0.21) and lower incidence of new PE and overall mortality (RR 0.79; 95% CI 0.402-1.56; p=0.50).nnnCONCLUSIONSnCompared with bed rest, early ambulation of patients with DVT, PE or both, was not associated with a higher risk of progression of DVT, new PE or death. This meta-analysis does not support the systematic recommendation of bed rest as part of the early management of patients presenting with DVT, PE of both.

How to wean a patient from veno-arterial extracorporeal membrane oxygenation

Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) can rescue patients with medical, postcardiotomy, or post-cardiac arrest refractory cardiogenic shock (CS) [1, 2]. It can be used as a bridge to cardiac transplantation, to a long-term ventricular assist device (VAD), or until recovery of myocardial function. Weaning success from VA-ECMO is defined as device removal and no further requirement for mechanical support because of recurring CS over the following 30 days [3]. However, to date, only very few studies have reported weaning strategies and outcomes in VA-ECMO patients recovering from severe CS.

Acute Myocardial Infarction: Changes in Patient Characteristics, Management, and 6-Month Outcomes Over a Period of 20 Years in the FAST-MI Program (French Registry of Acute ST-Elevation or Non-ST-elevation Myocardial Infarction) 1995 to 2015

Background: ST-segment–elevation myocardial infarction (STEMI) and non–ST-segment–elevation myocardial infarction (NSTEMI) management has evolved considerably over the past 2 decades. Little information on mortality trends in the most recent years is available. We assessed trends in characteristics, treatments, and outcomes for acute myocardial infarction in France between 1995 and 2015. Methods: We used data from 5 one-month registries, conducted 5 years apart, from 1995 to 2015, including 14u2009423 patients with acute myocardial infarction (59% STEMI) admitted to cardiac intensive care units in metropolitan France. Results: From 1995 to 2015, mean age decreased from 66±14 to 63±14 years in patients with STEMI; it remained stable (68±14 years) in patients with NSTEMI, whereas diabetes mellitus, obesity, and hypertension increased. At the acute stage, intended primary percutaneous coronary intervention increased from 12% (1995) to 76% (2015) in patients with STEMI. In patients with NSTEMI, percutaneous coronary intervention ⩽72 hours from admission increased from 9% (1995) to 60% (2015). Six-month mortality consistently decreased in patients with STEMI from 17.2% in 1995 to 6.9% in 2010 and 5.3% in 2015; it decreased from 17.2% to 6.9% in 2010 and 6.3% in 2015 in patients with NSTEMI. Mortality still decreased after 2010 in patients with STEMI without reperfusion therapy, whereas no further mortality gain was found in patients with STEMI with reperfusion therapy or in patients with NSTEMI, whether or not they were treated with percutaneous coronary intervention. Conclusions: Over the past 20 years, 6-month mortality after acute myocardial infarction has decreased considerably for patients with STEMI and NSTEMI. Mortality figures continued to decline in patients with STEMI until 2015, whereas mortality in patients with NSTEMI appears stable since 2010.

Correlates of pre-hospital morphine use in ST-elevation myocardial infarction patients and its association with in-hospital outcomes and long-term mortality: the FAST-MI (French Registry of Acute ST-elevation and non-ST-elevation Myocardial Infarction) programme.

AIMSnThe use of opioids is recommended for pain relief in patients with myocardial infarction (MI) but may delay antiplatelet agent absorption, potentially leading to decreased treatment efficacy.nnnMETHODS AND RESULTSnIn-hospital complications (death, non-fatal re-MI, stroke, stent thrombosis, and bleeding) and 1-year survival according to pre-hospital morphine use were assessed in 2438 ST-elevation MI (STEMI) patients from the French Registry of Acute ST-elevation and non-ST-elevation Myocardial Infarction (FAST-MI) 2010. The analyses were replicated in the 1726 STEMI patients of the FAST-MI 2005 cohort, in which polymorphisms of CYP2C19 and ABCB1 had been assessed. Specific subgroup analyses taking into account these genetic polymorphisms were performed in patients pre-treated with thienopyridines. The 453 patients (19%) receiving morphine pre-hospital were younger, more often male, with a lower GRACE score and higher chest pain levels. After adjustment for baseline differences, in-hospital complications and 1-year survival (hazard ratio = 0.69; 95% confidence interval: 0.35-1.37) were not increased according to pre-hospital morphine use. After propensity score matching, 1-year survival according to pre-hospital morphine was also similar. Consistent results were found in the replication cohort, including in those receiving pre-hospital thienopyridines and whatever the genetic polymorphisms of CYP2C19 and ABCB1.nnnCONCLUSIONnIn two independent everyday-life cohorts, pre-hospital morphine use in STEMI patients was not associated with worse in-hospital complications and 1-year mortality.nnnCLINICAL TRIAL REGISTRATIONnClinicaltrials.gov identifier: NCT00673036 (FAST-MI 2005); NCT01237418 (FAST-MI 2010).

Fifteen-year trends in the management of cardiogenic shock and associated 1-year mortality in elderly patients with acute myocardial infarction: the FAST-MI programme.

Alhough cardiogenic shock (CS) after acute myocardial infarction (AMI) is more common in elderly patients, information on the epidemiology of these patients is scarce. This study aimed to assess the trends in prevalence, characteristics, management, and outcomes of elderly patients admitted with CS complicating AMI between 1995 and 2010, using data from the FAST‐MI programme.

Cardiogenic shock in intensive care units: evolution of prevalence, patient profile, management and outcomes, 1997–2012

To address the paucity of data on the characteristics, outcome and temporal trends in mortality of cardiogenic shock (CS) patients admitted to intensive care units (ICUs) we examined key features, variations in mortality from CS, and predictors of death in ICU patients over the past 15 years.