[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. Study design 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. Conclusion 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 · 4.56 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 · 6.15 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: 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.
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 · 6.18 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Intravenous enoxaparin did not reduce significantly the primary end point (p = 0.06) compared with unfractionated heparin (UFH) in the randomized Acute Myocardial Infarction Treated with primary angioplasty and intravenous enoxaparin Or unfractionated heparin to Lower ischemic and bleeding events at short- and Long-term follow-up (ATOLL) trial. We present the results of the prespecified per-protocol analysis excluding patients who did not receive the treatment allocated by randomization or received both enoxaparin and UFH. We evaluated all-cause mortality, complication of myocardial infarction, procedural failure, or major bleeding (primary end point) and all-cause mortality, recurrent acute coronary syndrome, or urgent revascularization (main secondary end point). Baseline and procedural characteristics were well balanced between the 2 treatment groups. Of 910 randomized patients, 795 patients (87.4%) were treated according to the protocol with consistent anticoagulation using intravenous enoxaparin (n = 400) or UFH (n = 395). Enoxaparin reduced significantly the rates of the primary end point (relative risk [RR] 0.76, 95% confidence interval [CI] 0.62 to 0.94, p = 0.012) and the main secondary end point (RR 0.37, 95% CI 0.22 to 0.63, p <0.0001). There was less major bleeding with enoxaparin (RR 0.46, 95% CI 0.21 to 1.01, p = 0.050) contributing to the significant improvement of the net clinical benefit (RR 0.46, 95% CI 0.3 to 0.74, p = 0.0002). All-cause mortality was also reduced with enoxaparin (RR 0.36, 95% CI 0.18 to 0.74, p = 0.003). In conclusion, in the per-protocol analysis of the ATOLL trial, pertinent to >87% of the study population, enoxaparin was superior to UFH in reducing ischemic end points and mortality.
The American journal of cardiology 09/2013; 112(9). DOI:10.1016/j.amjcard.2013.07.003 · 3.43 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Aortic stiffness is an independent predictor of coronary events.
We assessed the predictive value of aortic stiffness for ≥50% asymptomatic coronary artery disease in a stroke/transient ischemic attack population.
We enrolled 300 consecutive patients aged 45-75 years with nondisabling, noncardioembolic ischemic stroke or transient ischemic attack, and no prior history of coronary artery disease. Coronary artery disease was assessed with 64-section computed tomography coronary angiography and all patients had a detailed cervicocephalic arterial work-up. Aortic stiffness was determined from carotid-femoral pulse wave velocity with 9·6 m/s as cutoff value. The predictive value of aortic stiffness was assessed by logistic regression and reclassification tables method after adjustment for the Framingham Risk Score and the presence of cervicocephalic stenosis, which were previously shown to be independent predictor of ≥50% asymptomatic coronary artery disease.
Among the 274 included patients who had computed tomography coronary angiography, 26% (95% CI, 21%-32%) had an increased stiffness (pulse wave velocity > 9·6 m/s) and 18% (14%-23%) had ≥50% asymptomatic coronary artery disease. Increased aortic stiffness was associated with the presence of ≥50% asymptomatic coronary artery disease, both in univariate (odds ratio = 3·4 [1·8-6·4]) and multivariate analyses (odds ratio = 2·3 [1·2-4·7]) after adjustment for Framingham Risk Score and presence of cervicocephalic stenosis. After carotid-femoral pulse wave velocity was added to the standard model including Framingham Risk Score and the presence of cervicocephalic stenosis, net reclassification improvement was 12·6% (P < 0·005), integrated discrimination index was 2·51% (P = 0·025), and model fit was improved (likelihood ratio = 4·99, P = 0·025).
In stroke/transient ischemic attack patients, aortic pulse wave velocity improves the prediction of ≥50% asymptomatic coronary artery disease beyond classical risk factors.
International Journal of Stroke 07/2013; 9(3). DOI:10.1111/ijs.12015 · 4.03 Impact Factor