[Show abstract][Hide abstract] ABSTRACT: IntroductionThere are little data about patients with cardiogenic shock (CS) who survive the early phase of acute myocardial infarction (AMI). The aim of this study was to assess long-term (5-year) mortality among early survivors of AMI, according to the presence of CS at the acute stage.Methods
We analyzed 5-year follow-up data from the French registry of Acute ST-elevation and non-ST-elevation Myocardial Infarction (FAST-MI) 2005 registry, a nationwide French survey including consecutive patients admitted for ST or non-ST-elevation AMI at the end of 2005 in 223 institutions.ResultsOf 3670 patients enrolled, shock occurred in 224 (6.1%), and 3411 survived beyond 30 days or hospital discharge, including 99 (2.9%) with shock. Early survivors with CS had a more severe clinical profile, more frequent concomitant in-hospital complications, and were less often managed invasively than those without CS.Five-year survival was 59% in patients with, versus 76% in those without shock (adjusted hazard ratio (HR)¿=¿1.72 [1.24-2.38], P¿=¿0.001). The excess of death associated with CS, however, was observed only during the first year (one-year survival: 77% vs 93%, adjusted HR: 2.87 [1.85 to 4.46] P <0.001), while survival from one to 5 years was similar (76% vs 82%, adjusted HR: 1.06 [0.64 to 1.74]). Propensity score-matched analyses yielded similar results.Conclusions
In patients surviving the early phase of AMI, CS at the initial stage carries an increased risk of death up to one year after the acute event. Beyond one year, however, mortality is similar to that of patients without shock.ClinicalTrials.gov number, NCT00673036, Registered May 5, 2008.
Critical care (London, England) 09/2014; 18(5):516. · 5.04 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Fondaparinux is an alternative to low molecular weight heparin (LMWH) for non-ST-elevation myocardial infarction (NSTEMI) with levels of recommendation that differ according to guidelines. The aim of this study was to assess outcomes in real world practice in NSTEMI patients participating in the French Registry of ST-elevation and non-ST-elevation Myocardial Infarction (FAST-MI) 2010 according to the use of fondaparinux, in comparison with patients receiving enoxaparin.
European heart journal. Acute cardiovascular care. 07/2014;
[Show abstract][Hide abstract] ABSTRACT: The relationship of cardiac magnetic resonance (CMR) late gadolinium enhancement (LGE) with myocardial biomarkers and markers of inflammation in acute viral myocarditis is not clearly defined. We assessed the relationship of LGE with myocardial and inflammatory biomarkers measured during the acute phase of myocarditis and their predictive value on clinical outcome.
Journal of Cardiovascular Medicine 06/2014; · 1.41 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Aims: To assess fractional flow reserve (FFR) variability in case of arterial hypotension in the clinical setting. FFR measurement is supposed to be independent of haemodynamics; there is, however, a strong relationship between trans-stenotic pressure variation and coronary flow. Non-clinical models suggest an inverse relationship between arterial pressure and FFR, but no clinical data have as yet confirmed this hypothesis. Methods and results: In case of arterial hypotension (mean arterial pressure [Pa] ≤80 mmHg) during routine clinical FFR measurement (FFR1), a second measurement (FFR2) was performed after pressure normalisation by 0.5 mg IV phenylephrine. Fourteen intermediate chronic stenoses (%DS 58±21%, FFR1=0.81±11) in 12 male patients showed 70±10 mmHg Pa at the time of measurement. After phenylephrine, Pa increased to 101±14 mmHg and FFR2 decreased to 0.75±12 (p<0.001) without heart rate variation. After Pa elevation, 40% of cases with FFR1 >0.80 changed to FFR2 ≤0.80. Conclusions: In the present study, in case of arterial hypotension, FFR decreased with rising pressure. Whether repeated FFR measurement after haemodynamic normalisation is of clinical benefit remains at this point speculative and should be validated in a larger data set.
EuroIntervention: journal of EuroPCR in collaboration with the Working Group on Interventional Cardiology of the European Society of Cardiology 04/2014; · 3.17 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Proof-of-concept evidence suggests that mechanical ischaemic post-conditioning (PostC) reduces infarct size when applied immediately after culprit coronary artery re-opening in ST-elevation myocardial infarction (STEMI) patients with thrombolysis in myocardial infarction 0-1 (TIMI 0-1) flow grade at admission. Whether PostC might also be protective in patients with a TIMI 2-3 flow grade on admission (corresponding to a delayed application of the post-conditioning algorithm) remains undetermined.
In this multi-centre, randomized, single-blinded, controlled study, STEMI patients with a 2-3 TIMI coronary flow grade at admission underwent direct stenting of the culprit lesion, followed (PostC group) or not (control group) by four cycles of (1 min inflation/1 min deflation) of the angioplasty balloon to trigger post-conditioning. Infarct size was assessed both by cardiac magnetic resonance at Day 5 (primary endpoint) and cardiac enzymes release (secondary endpoint). Ninety-nine patients were prospectively enrolled. Baseline characteristics were comparable between control and PostC groups. Despite comparable size of area at risk (AAR) (38 ± 12 vs. 38 ± 13% of the LV circumference, respectively, P = 0.89) and similar time from onset to intervention (249 ± 148 vs. 263 ± 209 min, respectively, P = 0.93) in the two groups, PostC did not significantly reduce cardiac magnetic resonance infarct size (23 ± 17 and 21 ± 18 g in the treated vs. control group, respectively, P = 0.64). Similar results were found when using creatine kinase and troponin I release, even after adjustment for the size of the AAR.
This study shows that infarct size reduction by mechanical ischaemic PostC is lost when applied to patients with a TIMI 2-3 flow grade at admission. This indicates that the timing of the protective intervention with respect to the onset of reperfusion is a key factor for preventing lethal reperfusion injury in STEMI patients.
European Heart Journal 02/2014; · 14.72 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: After acute myocardial infarction, the presence of no-reflow (or microvascular obstruction: MVO) has been associated with adverse left ventricular (LV) remodeling and worse clinical outcome. This study examined the effects of mechanical ischemic postconditioning on early and late MVO size in acute ST-elevation myocardial infarction (STEMI) patients. Fifty patients undergoing primary coronary angioplasty for a first STEMI with TIMI grade flow 0-1 and no collaterals were randomized to ischemic postconditioning (PC) (n = 25) or control (n = 25) groups. Ischemic PC consisted in the application of four consecutive cycles of a 1-min balloon occlusion, each followed by a 1-min deflation at the onset of reperfusion. Early (3 min post-contrast) and late (10 min post-contrast) MVO size were assessed by contrast-enhanced cardiac-MRI within 96 h after reperfusion. PC was associated with smaller early and late MVO size (3.9 ± 4.8 in PC versus 7.8 ± 6.6 % of LV in controls for early MVO, P = 0.02; and 1.8 ± 3.1 in PC versus 4.1 ± 3.9 % of LV in controls for late MVO; P = 0.01). This significant reduction was persistent after adjustment for thrombus aspiration, which neither had any significant effect on infarct size, nor on early or late MVO (P = NS for all). Attenuation of MVO was associated to infarct size reduction. Mechanical postconditioning significantly reduces MVO in patients with acute STEMI treated with primary angioplasty.
Archiv für Kreislaufforschung 11/2013; 108(6):383. · 5.96 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Deformation imaging is undergoing continuous development with the emergence of new technologies allowing the evaluation of the different components of strain simultaneously in three dimensions. Assessment of all global strain parameters in 2D and 3D modes and comparison with LVEF have been the focus of our study.
Out of 166 patients, 147 were evaluated with the use of both 2D and 3D speckle-tracking echocardiography (STE). Global strain parameters including longitudinal (GLS), circumferential (GCS), radial (GRS) and area strain (AS), as well as left ventricular volumes and ejection fraction were examined. Analysis of strain with 3D STE was faster than with 2D STE (7 ± 2 vs. 24 ± 4 min, P < 0.05). GLS values were similar between 2D and 3D modes (-14 ± 4 vs. -13 ± 3, NS), while slight differences were observed for GCS (-24 ± 7 vs. -27 ± 7, P < 0.05) and GRS (27 ± 9 vs. 24 ± 9, P < 0.05). All 2D and 3D strain parameters showed good accuracy in the identification of 2D-LVEF <55% with AS demonstrating superiority over GCS and GRS but not GLS.
Three-dimensional STE allows accurate and faster analysis of deformation when compared with 2D STE and might represent a viable alternative in the evaluation of global LV function.
European heart journal cardiovascular Imaging. 09/2013;
[Show abstract][Hide abstract] ABSTRACT: Recent studies have shown that the decrease in ventricular septal rupture (VSR) incidence after acute myocardial infarction is related to the improvement of reperfusion strategies. Our main objective was to explore the influence of therapeutic management changes on post-infarct VSR patient outcomes in a single reference center over a period of 30 years. We analyzed therapeutic management strategies and mortality rates in 228 patients with VSR after acute myocardial infarction admitted from 1981 to 2010. Patients were classified in 3 successive decades. There were no significant differences in clinical characteristics of patients with VSR at admission among those decades. Overall, surgery was performed in 159 patients (71.9%), primary transcatheter VSR closure was attempted in 5 patients (2.2%), and 64 patients (27.6%) were managed medically. Independent predictors of in-hospital mortality were VSR surgical repair (odds ratio [OR] 0.22, 95% confidence interval [CI] 0.1 to 0.7, p = 0.008), cardiogenic shock (OR 6.06, 95% CI 2.8 to 13.1, p <0.0001), and Killip class on admission (OR 1.75, 95% CI 1.1 to 9.9, p = 0.02). We found a significant 1-year mortality reduction between the first and second decades (hazard ratio 0.48, 95% CI 0.28 to 0.80; p = 0.005), with no significant change in the last decade (p = 0.2). This change was related to a systematic referral to surgical repair and shorter delays to VSR surgery (5.2 ± 6.3 vs 1.9 ± 3.2 days from first to second decade; p = 0.012). In conclusion, surgical repair remains the only significant efficient therapy to reduce mortality in patients with VSR (p <10(-3)). In-hospital prognosis remains disappointing. This contrasts with the favorable long-term outcome of patients who survive the perioperative period and are discharged from hospital.
The American journal of cardiology 07/2013; · 3.58 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: This study aimed to determine whether post-conditioning at the time of percutaneous coronary intervention could reduce reperfusion-induced myocardial edema in patients with acute ST-segment elevation myocardial infarction (STEMI).
Myocardial edema is a reperfusion injury with potentially severe consequences. Post-conditioning is a cardioprotective therapy that reduces infarct size after reperfusion, but no previous studies have analyzed the impact of this strategy on reperfusion-induced myocardial edema in humans.
Fifty patients with STEMI were randomly assigned to either a control or post-conditioned group. Cardiac magnetic resonance imaging was performed within 48 to 72 h after admission. Myocardial edema was measured by T2-weighted sequences, and infarct size was determined by late gadolinium enhancement sequences and creatine kinase release.
The post-conditioned and control groups were similar with respect to ischemia time, the size of the area at risk, and the ejection fraction before percutaneous coronary intervention. As expected, post-conditioning was associated with smaller infarct size (13 ± 7 g/m(2) vs. 21 ± 14 g/m(2); p = 0.01) and creatine kinase peak serum level (median [interquartile range]: 1,695 [1,118 to 3,692] IU/l vs. 3,505 [2,307 to 4,929] IU/l; p = 0.003). At reperfusion, the extent of myocardial edema was significantly reduced in the post-conditioned group as compared with the control group (23 ± 16 g/m(2) vs. 34 ± 18 g/m(2); p = 0.03); the relative increase in T2W signal intensity was also significantly lower (p = 0.02). This protective effect was confirmed after adjustment for the size of the area at risk.
This randomized study demonstrated that post-conditioning reduced infarct size and edema in patients with reperfused STEMI.
Journal of the American College of Cardiology 06/2012; 59(24):2175-81. · 15.34 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Accurate understanding of the physiopathology of a coronary stenosis is a major objective in management during diagnostic coronary angiography. Measurement of fractional flow reserve (FFR) by coronary pressure measurement is a reliable method for evaluating the functional consequences of a lesion of the myocardium. This retrospective monocentric study of 114 patients showed that routine coronary pressure measurement for assessing the functional consequences of intermediate (30 to 70% stenosis) lesions or those of ambiguous topography: was necessary in 4% of diagnostic coronary angiographies enabling an immediate management decision. Using this method, 34% of complementary investigations were not performed (stress test, myocardial scintigraphy, dobutamine stress echocardiography). Seventeen per cent of unnecessary angioplasties were also avoided so that acute coronary event were also avoided when lesions with a FFR >0.75 were not treated by angioplasty. A 10-14% reduction in cost was achieved compared with a strategy of systematic angioplasty in respectively mono- or multivessel disease patients and 39% compared with performing ambulatory myocardial scintigraphy in patients with multivessel disease.
Archives des maladies du coeur et des vaisseaux 11/2004; 97(10):957-64. · 0.40 Impact Factor