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Journal of Thrombosis and Haemostasis 01/2011; 9(3):610-2. · 5.73 Impact Factor
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ABSTRACT: To assess the prognostic impact of a therapeutic program based on bioclinical risk-stratification and myocardial-perfusion-imaging (MPI) data on survival and the occurrence of coronary events (CE=death+myocardial infarction) in asymptomatic patients with diabetes.
Five hundred twenty one consecutive asymptomatic diabetic outpatients were prospectively enrolled and clinically classified as being at either low or high cardiac risk. All high-risk patients (n=245, age 61+/-9 years) underwent MPI and an intensive multifactorial medical therapeutic program, including anti-ischaemic agents in cases of moderate ischemia; a coronary angiography was performed in all high-risk patients with severe ischaemia (n=38), followed by immediate revascularization if necessary (n=21). Low-risk patients (n=276, age 57+/-9 years) underwent medical management of their risk factors.
At the 19-month (median) follow-up (range, 12-36 months), both high- and low-risk patients showed similarly low CE rates (2.3% and 1.5% per year, respectively; age- and gender-adjusted log-rank P=NS). None of the patients who underwent myocardial revascularization experienced any CEs, and none of the low-risk patients died during follow-up. The negative predictive value of first-line bioclinical stratification was 0.98 for the occurrence of CEs, and 0.95 when low-risk patients were combined with high-risk patients who had normal MPI findings.
Bioclinical first-line stratification allows identification of diabetic patients who have a good medium-term cardiac prognosis. The CE rate is similar in selected high-risk asymptomatic patients with diabetes using an intensive MPI-guided program that combines medical therapy, coronary angiography in the 16% of cases with severe ischemia and, if appropriate, revascularization.
Diabetes & Metabolism 01/2008; 33(6):459-65. · 2.41 Impact Factor
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ABSTRACT: The prognostic impact of a myocardial ischemia-based therapeutic program in asymptomatic diabetic patients remains controversial. We prospectively assessed the benefit of a stratification algorithm based upon clinical and myocardial perfusion imaging (MPI) data on cardiovascular events in such patients in a non-randomized register. Method: 701 consecutive asymptomatic diabetic patients were classified to be at low or intermediate-to-high cardiac risk according to 13 simple boil-clinical parameters. Intermediate-to-high risk patients were scheduled for MPI and underwent either a conventional (Group 1, n=180) or an intensive multifactorial (Group 2, n=245) therapeutic program. Low risk patients (Group 3, n=276) underwent no specific management.
At the end of the survey and as a consequence of intensive management, lipid lowering therapy, antiplatelet drugs, and beta-blockers were more often prescribed in Group 2 than in Group 1 (55, 31 and 17% versus 36, 23, and 8% respectively, p<0.01). Planned coronary angiography in case of severe ischemia on MPI and revascularization were more frequent in Group 2 (16.2 and 8.9%) than in Group 1 (8.0 and 2.8% - p<0.01). At 19-month follow-up (96.7% completed), major event rate in Group 2 was significantly lower than in Group 1 (3.9 versus 9.8%, p<0.01) and similar to that of Group 3 (2.2%, NS).
Easy-to-perform risk stratification is able to select diabetic patients with good medium-term prognosis. In clinically selected higher risk patients, an intensive medical therapy combined with coronary angiography +/- revascularization in case of large ischemia on MPI is effective to improve prognosis.
Archives des maladies du coeur et des vaisseaux 10/2007; 100(10):845-52. · 0.40 Impact Factor
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ABSTRACT: The aim of this study was to describe the changes in strategy of revascularisation in acute coronary syndromes with ST elevation (ACS ST+) since setting up a health care network. The authors analysed the incidence of coronary angioplasty and of intravenous thrombolysis from a prospective permanent hospital register of patients with ACS ST+ in the three Northern Alps departments from october 1st 2002 to december 31st 2004. Respectively, 171 patients were enrolled in 2002 and 675 in 2003, and 588 in 2004. The use of percutaneous coronary intervention increased (57, 69, and 78% in 2002, 2003, 2004, p< 0.01) in relation to the increased use of immediate secondary percutaneous coronary intervention (27, 36, 43%, p< 0.01) although the use of primary percutaneous coronary intervention did not changed (30, 33, 35%, p= 0.17). These results were observed in hospitals with and without Percutaneous Coronary Intervention facilities. An increase in prehospital (49, 67, 68%, p= 0.02) and hospital thrombolysis (48, 68, 73%, p= 0.03) was only observed in patients managed in institutions without Percutaneous Coronary Intervention facilities. The average delay to arterial punction (120. 124, 100 minutes, p< 0.01) and to intravenous thrombolysis (40, 30, 25 minutes, p< 0.01) decreased during the same period. Patients with ACS ST+ more commonly benefit from coronary revascularisation at increasingly shorter intervals to treatment. This would seem to be related to the better coordination of practitioners after the implantation of a health care network.
Archives des maladies du coeur et des vaisseaux 03/2007; 100(2):105-11. · 0.40 Impact Factor
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ABSTRACT: The aim of this study was to compare the mortality associated to primary angioplasty and thrombolysis in patients managed for an elevated ST-segment acute coronary syndrome in less than or more than 3 hours after the onset of symptoms. We analyzed the in-hospital mortality of 846 patients (including 276 [33%] treated by primary angioplasty, 511 [60%] by thrombolysis, and 59 [7%] without revascularisation) included from October 2002 to December 2003 in a registry of patients with an elevated ST-segment acute coronary syndrome managed in less than 12 hours in Northern Alps districts. The overall in-hospital mortality was at 6.0% (51/846). For the 631 managed in <3 hours, the mortality rates were respectively at 5.0%, 4.6% and 11.1% respectively in case of primary angioplasty, thrombolysis and without revascularisation (p=0.21). For the 215 patients with pain lasting more than 3 hours, the mortality rates were at 2.7%, 10.3% and 21.7% in case of primary angioplasty, thrombolysis and no revascularisation, respectively (p=0.01). In the multivariable analysis, the OR of death in case of thrombolysis compared to primary angioplasty was at 1.65 (95% IC: 0.73 - 3.75) for patients with pain " 3 hours, and 4.98 (95% IC: 1.32-18.37) for those with pain > 3 hours. These results are in line with randomized trials conclusions and confirm the international guidelines suggesting primary angioplasty for patients with a chest pain >3 hours and either angioplasty or thrombolysis in case of chest pain < 3 hours.
Archives des maladies du coeur et des vaisseaux 01/2007; 100(1):13-9. · 0.40 Impact Factor
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L Belle,
D Savary,
N Dumonteil,
M Villacèque,
S Charpentier,
L Soulat,
C Loubeyre,
P G Steg,
Y Cottin,
D Miljkovic,
J Puel
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ABSTRACT: The effectiveness of thrombolytics has been clearly demonstrated in more than half the cases in the large cohorts of patients selected for trials during the acute phase of myocardial infarction. At individual level, thrombolysis will clinically either succeed or fail so, for the medical team managing the patient, choice of treatment may be likened to a gamble which in the best of cases (most often) leads to an uncomplicated success and, in the worst of cases, failure worsened by a severe complication. OPTIMAL is a multidisciplinary and multicentre, prospective cohort study associating mobile medical teams and interventional cardiology units to test the hypothesis that the outcome of prehospital thrombolysis does not depend on chance alone but also varies according to demographic, etiological, clinical and logistic factors involved in the occurrence and management of myocardial infarction. The primary objective of this French study, conducted over one year on more than 800 subjects, is to identify the predictors of the results of prehospital thrombolysis from a very early angiographic evaluation. The results for this cohort may be useful for setting up appropriate management strategies for acute myocardial infarction, from the prehospital phase (thrombolysis or not) up to in-hospital orientation of the patients (angiography room or Intensive Care Unit) and to determine the most judicious time for coronary angiography. OPTIMAL is to date the largest prospective serie of prehospital thrombolysis evaluated by an early angiographic control.
Archives des maladies du coeur et des vaisseaux 10/2006; 99(9):823-7. · 0.40 Impact Factor
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ABSTRACT: Registers of the management of infarction can complement information obtained from randomised trials evaluating the methods and practice of treatment. In order to do this, the quality of the registers must be assured, and in particular the accuracy of the recorded cases. The objective of this study was to evaluate the accuracy of a register for the in-hospital and pre-hospital management of acute coronary syndromes with ST segment elevation of less than 12 hours' duration. Using a capture-recapture method, the study compared cases in the register with eligible cases present in the hospital and emergency ambulance service databases at two establishments, giving a recruitment rate of 61%. The rate of accuracy was estimated at 84% (95% CI [82 ; 86]). The independent factors associated with failure of notification were female sex (ORa=6.65 [2.04-21.69]), presentation at nights, weekends or bank holidays (ORa=4.13 [1.33-12.85]), direct admission to hospital without passing by the emergency ambulance service (ORa=2.85 [1.03-7.69]), primary angioplasty (ORa=6.18 [1.60-23.79]) and the absence of reperfusion (ORa=40.38 [6.21-262.40]). With more than 80% accuracy, the results produced by the register are robust. The selection bias linked to the under-representation of certain subgroups, while real, has only a marginal impact on estimates derived from the register. Factors associated with failure of notification should be taken into account when operating such a register.
Archives des maladies du coeur et des vaisseaux 10/2006; 99(9):798-803. · 0.40 Impact Factor
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L Belle,
J Labarere,
O Meunier,
V Amon,
M Fourny,
H Bouvaist,
O Guenot,
V Hugon,
P Broin,
P Fromage,
C Haddad,
P François
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ABSTRACT: To identify the factors associated with early cardiac catheterization in patients with a non ST-segment elevation acute coronary syndrome.
We analyzed data collected by retrospective chart review for 208 patients presenting at seven French hospitals with an acute coronary syndrome (chest pain at rest within 24 h prior to presentation with positive cardiac markers and/or electrocardiographic changes) between January and March 2005.
Eighty-seven patients (42%) were first admitted to hospitals with cardiac catheterization facilities. One hundred ten patients (53%, 95% confidence interval [95% CI], 46-60) underwent early cardiac catheterization less than 48 h following presentation. In addition to presentation at hospitals with catheterization facilities, factors independently associated with early catheterization included positive cardiac markers in patients first admitted to hospitals without catheterization facilities (adjusted odds ratio [aOR] 34.5, 95% CI, 4.4-268.0) and diabetes mellitus (aOR, 0.4, 95%CI, 0.2-0.9). With the exception of positive cardiac markers, no risk factors comprising the TIMI risk score were associated with increased odds of early cardiac catheterization. During the index hospital stay, six patients (3%) died, seven patients (3%) had pulmonary edema, three patients (1%) had major or minor bleeding, and none had ST segment elevation myocardial infarction.
Despite the dissemination of international guidelines, the use of early cardiac catheterization remains related to initial presentation at hospitals with catheterization facilities rather than risk assessment in patients with a non ST-segment elevation acute coronary syndrome.
Annales de Cardiologie et d Angéiologie 02/2006; 55(1):39-48. · 0.28 Impact Factor
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ABSTRACT: To compare processes of care for acute myocardial infarction among patients admitted to alpine vs other French hospitals.
Prospective observational study of patients with ST-elevation and non ST-elevation myocardial infarction of less than 48 hours hospitalized in 369 intensive care units in November 2000.
Fifty-five patients were enrolled in nine alpine hospitals and 2265 patients in 360 other French hospitals. Patients baseline characteristics did not differ between the two groups with the exception of ST-elevation myocardial infarction which was less frequent in patients admitted to alpine hospitals (71 vs. 83%, P = 0.02). Patients living in the alpine area were less likely to be admitted to hospitals with on-site cardiac catheterization facilities (42 vs. 60%, P < 0.01) although the use of primary (20%) and rescue (24%) percutaneous coronary intervention did not differ significantly between the two groups. There were no differences in the use of medical treatments between the two groups with the exception of low-molecular-weight heparin. The risk of in-hospital death and complications did not differ significantly between the two groups while the risk of death at one year was lower in patients admitted to alpine hospitals (5 vs. 16%, P = 0.04).
In 2000, a lower proportion of patients living in the alpine area had access to hospitals with cardiac catheterization facilities compared to other French patients. This finding supports the creation of an additional cardiac catheterization laboratory with experienced operators performing percutaneous coronary interventions 24 hours/7 days and the implementation of an emergency medical care network for acute coronary syndromes in the alpine area.
Annales de Cardiologie et d Angéiologie 11/2005; 54(6):310-6. · 0.28 Impact Factor
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ABSTRACT: To evaluate the therapeutic impact of an education program on patients undergoing oral anticoagulation treatment, within the hospital of Annecy (France).
Groups of 10 patients were invited to participate to two meetings. The education was carried out by two nurses. Thanks to this prospective study, we compare the population before and after education in terms of treatment knowledge and stability.
Within 9 months 88 patients have been included, amongst which 55 have attended the two meetings. The average of correct answers to the knowledge evaluation questionnaire distributed before and after 6 months of education were, respectively, 6.63/12, 10.09/12 (P < 0.0001). Through INR controls within the 6 months preceding (424 controls) and the 6 months following the education (619 controls), we observe: an increase of the total INR average in therapeutic zone, from 45% to 61% (P < 0.0001); a decrease of the difference average per patient between the INR value observed and the one targeted: 0.54 before education, 0.40 after education (P = 0.0016); at last, the average phasing per patient under the therapeutic zone increases after education, from 49% to 65% (P < 0.001).
The education improves objectively the knowledge of patient undergoing AVK. If the size of patient sample is not large enough to prove any consequence on hemorrhagic or thrombotic complications, the education program still improves significantly the treatment stability.
Annales de Cardiologie et d Angéiologie 12/2003; 52(5):297-301. · 0.28 Impact Factor
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ABSTRACT: We have evaluated the sensitivity of a diagnostic algorithm for all patients suspected of pulmonary embolism using: D-Dimer, lower limb venous ultrasonography and helical computed tomography. To validate this approach, a lung scan is systematically carried out if the pulmonary embolism diagnosis is not withheld as a result of the algorithm. Clinical tests are organised between the 3rd and 6th month.
Two hundred patients were involved between January 1998 and October 1999. One hundred and six pulmonary embolisms were diagnosed. Out of the 200 ultrasonography tests carried out we found: 71 proximal deep-vein thrombosis (popliteal or supra-popliteal), 33 distal thrombosis (infra-popliteal). Ninety-two cases were negative (4 tests non conclusive). We have deduced that a deep-vein thrombosis permits the diagnosis of thrombo-embolic illness without any further diagnostic approach (no computed tomography). Out of the 129 computed tomographies carried out we found: 35 pulmonary embolisms and 23 other diagnoses. Seventy-one lung scans were therefore carried out. We recorded 7 discordances (scans showed high and very high probability for pulmonary embolism whilst computed tomographies did not): pulmonary angiography was negative 4 times and diagnosed pulmonary embolism once and two patients refused to take the test (Table 2). There are two recurrences in the follow-up: proximal thrombosis and a pulmonary embolism. This involved two patients who had refused to undergo pulmonary angiography.
This diagnostic approach therefore seems satisfactory but would require further investigation on a wider scale.
Annales de Cardiologie et d Angéiologie 12/2002; 51(5):243-7. · 0.28 Impact Factor
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ABSTRACT: To assess the generalizability of the medico-economic analysis comparing primary coronary angioplasty and thrombolytic therapy for acute myocardial infarction.
A systematic analysis of published studies was performed by two independent reviewers, in accordance with guidelines promulgated by health economic experts.
Eleven articles, which concerned seven studies, were selected. Respectively, four evaluations were carried out in U.S. and three other in European countries (France, Netherland and Austria). There were three randomized trials, two observational studies and two decision trees. The costs were respectively ranged 2042 to 83,708 1999 US dollars for thrombolytic therapy and 3289 to 83,477 1999 US dollars for angioplasty. In two randomized trials and one decisional tree, the primary coronary angioplasty was both more effective and less costly than the thrombolysis therapy. One observational study concluded that thrombolytic therapy was less costly than primary angioplasty despite comparable effectiveness. Two analysis could not conclude of a difference between the alternatives, because of lack of statistical power.
Published medico-economic analysis remain of a little interest for the French health care system because of lack of transparency in presentation of results. The dominance of the primary angioplasty was sensitive to time required for patient's transfer (ideally less than an hour), to the presence of redundant laboratories in an area and to the presence of an experienced staff for 24 h a day.
Annales de Cardiologie et d Angéiologie 11/2001; 50(6):330-9. · 0.28 Impact Factor
