[Show abstract][Hide abstract] ABSTRACT: Background:
Elderly patients are at high risk for both ischemic and bleeding events. Platelet monitoring offers the opportunity to individualized antiplatelet therapy to optimize the therapeutic risk/benefit ratio.
The ANTARCTIC study is designed to demonstrate the superiority of a strategy of platelet function monitoring with dose and drug adjustment in patients initially on prasugrel 5 mg as compared with a more conventional strategy using prasugrel 5 mg without monitoring and without adjustment (Conventional Treatment Arm) to reduce the primary end point evaluated 1 year after stent percutaneous coronary intervention in elderly patients presenting with an acute coronary syndrome (ACS). ANTARCTIC is a multicenter, prospective, open-label study with 2 parallel arms. A total of 852 elderly patients (≥ 75 years) undergoing stent percutaneous coronary intervention for ACS are to be enrolled. The primary end point is the time to first occurrence of cardiovascular death, myocardial infarction, stroke, definite stent thrombosis, urgent revascularization, and bleeding complications (Bleeding Academic Research Consortium definition 2, 3, or 5). Platelet function analyses will be performed 14 days after randomization and repeated 14 days later in patients who require a change in treatment.
ANTARCTIC is a nationwide, prospective, open-label study testing a strategy of platelet function monitoring with dose and drug adjustment to reduce ischemic and bleeding complications in elderly ACS patients undergoing coronary stenting.
American Heart Journal 11/2014; 168(5):674-681.e1. DOI:10.1016/j.ahj.2014.07.026 · 4.46 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Determinants of outcome and long-term survival are unknown in elderly patients successfully resuscitated after out-of-hospital cardiac arrest. Our aim was to identify factors associated with short- and long-term neurologic outcome in such patients.
Critical Care Medicine 07/2014; 42(11). DOI:10.1097/CCM.0000000000000512 · 6.31 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Aims:
The pattern of coronary occlusion might contribute to the onset of ventricular arrhythmia and sudden cardiac death (SCD). We hypothesized that the concentrations of microparticles might differ between SCD and ST-elevation myocardial infarction (STEMI) patients without rhythmic disturbances.
Methods and results:
The study sample includes consecutive patients hospitalized in two French tertiary centres between 2006 and 2011 for SCD with angiographically-proven acute coronary occlusion (n=23), for STEMI (n=61) and for a planned percutaneous coronary angioplasty (PCI) (n=35, controls). During PCI blood was collected in the arch of aorta (systemic blood) before and after the procedure and in the culprit coronary lesion with an aspiration catheter. Microparticles were analysed by flow cytometry in a blinded manner to quantify endothelial (CD144+), platelet (CD41+), leucocyte (CD11a+) and erythrocyte (CD235a+) derived microparticles. After multivariate analysis, intracoronary concentrations of endothelial-derived microparticles were significantly higher in SCD than in STEMI patients (129 (74-185) vs. 50 (21-118) nb/µl; p < 0.01). Intracoronary and systemic blood concentrations of platelet-derived microparticles were not different between SCD and controls, suggesting limited impact of cardiac massage and electric defibrillation in microparticle concentrations.
The higher concentrations of endothelial-derived microparticles in SCD due to acute coronary occlusion compared with STEMI without rhythmic disturbances suggests different patterns of acute coronary occlusion.
European Heart Journal: Acute Cardiovascular Care 06/2014; 4(1). DOI:10.1177/2048872614538404
[Show abstract][Hide abstract] ABSTRACT: Background
The leading cause of sudden cardiac death is myocardial ischemia. As for uncomplicated acute myocardial infarction (AMI), international guidelines plead for early coronary angiography with, in case of culprit lesion, angioplasty and stent implantation. However after cardiac arrest (CA), shock, hypothermia and changes in antiplatelet pharmacokinetic may promote stent thrombosis (ST). Incidence of ST in this situation has never been studied.
The aim of this study was to investigate incidence and determinants of ST after ischemic CA successfully revascularized.
We analyzed 208 consecutive patients admitted in our institution for AMI and who underwent PCI with stent implantation. Among these patients, 55 presented a resuscitated CA and were compared to 153 without CA (control group). All patients in the CA group received hypothermia (33 °c for 24 h) following resuscitation and PCI.
There was no difference between the 2 groups for age, gender, cardiovascular risk factors, coronary lesions and type of stent. In the CA group, patients were less frequently pre-treated with heparin (50,9% vs 98,7%, p < 0,001) and aspirin (52,7% vs 99%, p < 0,001). In the CA group, we observed a significantly higher incidence of confirmed acute or subacute ST than in the control group: 10.9% vs 2.0%, (p = 0,01). None of CA patients had received a dual antiplatelets therapy (0% Vs 99%). LVEF at admission was lower in the CA group (40,3% vs 48%; p < 0,001), and shock was more frequent (83,6% vs 8,5%; p < 0,001). Survival at 28 days was 50,1% in CA group vs 98.0% (p < 0,001). In multivariate analysis, CA before stenting appears to be an independent risk factor for confirmed ST (OR = 12,9; 95%CI 1,3-124,6; p = 0,027).
In CA patients treated with cooling, stenting for AMI is associated with a high risk of ST. Shock, insufficient antithrombotic treatment, pharmacokinetic changes related to hypothermia may contribute to this higher risk. A strategy aiming to reduce this complication may probably improve prognosis of patients who underwent coronary sudden death.
[Show abstract][Hide abstract] ABSTRACT: La prevalencia de la enfermedad coronaria en los países industrializados es alta y se asocia a índices de mortalidad y morbilidad considerables. Los síndromes coronarios agudos (SCA) constituyen, por tanto, un motivo de hospitalización reiterado. El diagnóstico de SCA plantea algunas dificultades debido a la diversidad de las formas clínicas, en ocasiones muy incompletas. Demostrar un SCA en el contexto perioperatorio o en un paciente sedado puede plantear dificultades en términos de diagnóstico y de conducta terapéutica. Necesita, pues, un enfoque multidisciplinario en el que participen anestesistas, especialistas en reanimación y cardiólogos.
[Show abstract][Hide abstract] ABSTRACT: La malattia coronarica ha un’elevata incidenza nei paesi industrializzati, dove è associata a tassi di mortalità e di morbilità ancora importanti. Di conseguenza, le sindromi coronariche acute (SCA) costituiscono un motivo di ricovero ricorrente. La diagnosi di SCA presenta un certo numero di difficoltà, a causa di forme cliniche diverse e, a volte, molto fruste. Così, l’evidenziazione di una SCA al momento di una gestione perioperatoria o in un paziente sedato può porre delle difficoltà tanto sul piano diagnostico che per la scelta della gestione terapeutica. Essa richiede, pertanto, un approccio multidisciplinare che associa anestesisti, rianimatori e cardiologi.
[Show abstract][Hide abstract] ABSTRACT: Early identification of the cause of out-of-hospital cardiac arrest (OHCA) remains a challenge. Our aim was to determine whether high-sensitivity cardiac troponin T (HsTnT) was useful to diagnose a recent coronary artery occlusion as the cause of OHCA.
Retrospective study including OHCA patients evaluated by systematic coronary angiogram at hospital admission. HsTnT was assessed at ICU admission. Predictive factors of a recent coronary occlusion were identified by logistic regression. Net reclassification improvement (NRI) was calculated to estimate the potential enhancement of prediction with HsTnT.
During the 5year study period, 272 patients (median age 60y, 76.5% men) were included, and a culprit coronary occlusion was found in 133 (48.9%). The optimum HsTnT cut-off to predict a recent coronary occlusion was 575ng/l (sensitivity 65.4%, specificity 65.5%). In multivariate analysis, current smoking (OR 3.2 95%, 95%CI 1.62-6.33), time from collapse to BLS<3min (OR 2.11, 95%CI 1.10-4.05), initial shockable rhythm (OR 5.29, 95%CI 2.06-13.62), ST-segment elevation (OR 2.44, 95%CI 1.18-5.03), post-resuscitation shock onset (OR 2.03, 95%CI 1.01-4.07) and HsTnT≥575ng/l (OR 2.22, 95%CI 1.16-4.27) were associated with the presence of a recent coronary occlusion. Nevertheless, adding HsTnT to established risk factors of recent coronary occlusion identified above provided a non-significant NRI of -0.43%.
Admission HsTnT is increased after OHCA and is an independent factor of a recent coronary occlusion. However, HsTnT does not seem to be a strong enough diagnostic tool to select candidates for emergent coronary angiogram in OHCA survivors.
International journal of cardiology 10/2013; 169(6). DOI:10.1016/j.ijcard.2013.10.011 · 4.04 Impact Factor