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Systematic prescription of beta-blockers after myocardial infarction remains an open question in the era of revascularization, especially for patients with uncomplicated myocardial infarction.To evaluate in a real-life registry the proportion of patients with uncomplicated myocardial infarction (preserved left ventricular ejection fraction and no cardiovascular event within the first 6 months), and to report their characteristics, outcomes and beta-blocker use.We included 1887 consecutive patients with ST-segment elevation myocardial infarction from the prospective ePARIS registry. Patients were divided into three groups: the "uncomplicated myocardial infarction" group (n=1060), defined by a left ventricular ejection fraction ≥ 40% and a 6-month period free from cardiovascular events; the "complicated myocardial infarction" group (n=366), defined by a left ventricular ejection fraction ≥ 40% and a recurrent cardiovascular event in the first 6 months; and the "left ventricular dysfunction" group (n=461), defined by a left ventricular ejection fraction40%.During a median follow-up of 2.7 years (interquartile range 1.0-4.9 years), the "uncomplicated myocardial infarction" group was at low mortality risk compared with the "complicated myocardial infarction" group (hazard ratio 0.38, 95% confidence interval 0.25-0.58; P0.01) and the "left ventricular dysfunction" group (hazard ratio 0.22, 95% confidence interval 0.15-0.32; P0.01). Beta-blockers were prescribed at discharge predominantly in the "uncomplicated myocardial infarction" group (93%) compared with 87% in the "complicated myocardial infarction" group and 81% in the "left ventricular dysfunction" group.Beta-blockers are less prescribed in patients who may need them the most. The benefit of beta-blockers-largely prescribed in lower-risk patients-remains to be shown beyond the first 6 months for these patients with no left ventricular dysfunction and no recurrent events.

Summary Background Two biomarkers of early acute kidney injury − plasmatic neutrophil gelatinase-associated lipocalin (NGAL) and cystatin C − are not used in routine clinical practice in patients with ST-segment elevation myocardial infarction (STEMI) treated by percutaneous coronary intervention (PCI) because of a lack of supporting data. Aims To evaluate the predictive value of NGAL and cystatin C regarding the incidence of contrast-induced acute kidney injury (CI-AKI) and clinical outcomes after STEMI in patients treated by primary PCI. Methods Plasmatic NGAL and cystatin C were measured on admission, before any contrast exposure, in 701 unselected patients with STEMI. Associations between biomarker concentrations and incidence of CI-AKI (assessed at 48 h), haemodialysis requirement at 1 year and all-cause mortality at 1 year were assessed by logistic regression analyses and receiver operating characteristic area under the curve analysis (c-statistic). Discrimination performance comparison was performed using the DeLong test. Results NGAL and cystatin C had mild discrimination regarding CI-AKI, with c-statistics of 0.60 (P = 0.001) and 0.60 (P = 0.002), respectively. Combining NGAL and cystatin C did not improve their discrimination (c-statistic 0.61; P = 0.001). There was no significant difference in discrimination between NGAL, cystatin C and baseline creatinine (P = 0.57). Regression analyses showed no independent association between NGAL and CI-AKI, haemodialysis or 1-year mortality. Similarly, cystatin C was not associated with these clinical outcomes. Conclusions In this cohort of patients with STEMI treated by primary PCI, plasmatic NGAL and cystatin C did not provide additional value regarding CI-AKI prediction compared with known risk factors such as baseline creatinine.

Summary Background Recent studies have suggested that ticagrelor 90 mg twice daily provides stronger platelet inhibition than prasugrel 10 mg once daily in acute coronary syndrome patients undergoing percutaneous coronary intervention. Objectives To compare the effects of ticagrelor 90 mg twice daily and prasugrel 10 mg once daily on platelet reactivity in patients with ST-segment elevation myocardial infarction (STEMI), using: the VerifyNow ® P2Y 12 (VN-P2Y 12 ) assay, expressed in P2Y 12 reaction units (PRU); measurement of the vasodilator-stimulated phosphoprotein platelet reactivity index (VASP-PRI; %); and light transmission aggregometry (LTA), expressed as residual platelet aggregation (RPA; %). Methods Platelet reactivity was evaluated prospectively using the three assays 30 days after primary PCI in 118 patients with STEMI on a maintenance dose of prasugrel 10 mg once daily ( n = 60) or ticagrelor 90 mg twice daily ( n = 58). Results On-treatment platelet reactivity, assessed by the VN-P2Y 12 assay, was lower for ticagrelor compared with prasugrel (20.91 ± 4.59 PRU vs. 43.50 ± 6.98 PRU; P = 0.008) but was not significantly different when using the more specific VASP-PRI assay (13.05 ± 1.61% vs. 17.44 ± 1.97%; P = 0.09) or RPA assessed by LTA (10.49 ± 1.44% vs. 7.20 ± 1.27%; P = 0.09). Conclusions The difference in platelet reactivity between ticagrelor and prasugrel varies according to the platelet function test in patients with STEMI. The differences observed may be related more to the tests than to the drugs used.

Summary Background Recent clinical studies suggest that low-molecular-weight heparin (LMWH) could be an effective and safe alternative to unfractionated heparin (UFH) for patients with acute myocardial infarction (AMI). Aims To assess the impact of anticoagulant choice (LMWV vs UFH) on bleeding, the need for blood transfusion and 3-year clinical outcomes in AMI patients from the FAST-MI registry. Methods FAST-MI was a nationwide registry compiled in France over 1 month in 2005, which included consecutive AMI patients admitted to an intensive care unit less than 48 hours from symptom onset in 223 participating centres. Results A total of 2854 patients treated with heparins were included. The risks of major bleeding or transfusion (3.0% vs 7.0%) and in-hospital death (3.2% vs 9.2%) were lower with LMWH compared with UFH, a difference that persisted after multivariable adjustment (odds ratio [OR] 0.51, 95% confidence interval [CI] 0.34–0.76 and OR 0.53, 95% CI 0.37–0.76, respectively). Three-year survival, and stroke and reinfarction-free survival risks were also higher with LMWH compared with UFH (adjusted hazard ratio [HR] 0.73, 95% CI 0.61–0.87 and HR 0.73, 95% CI 0.62–0.85, respectively). In two cohorts of patients matched on propensity score for receiving LMWH and with similar baseline characteristics (834 patients per group), major bleeding and transfusion rates were lower while the 3-year survival rate was significantly higher in patients receiving LMWH. Conclusion Our data suggest that the use of LMWH in AMI patients may have a better benefit/risk profile than UFH, in terms of bleeding, need for transfusion and long-term survival.

SummaryThe concept of clopidogrel resistance emerged several years ago. Since then, many studies have been performed to elucidate the mechanisms and potential clinical impact of this biological finding. These studies identified complex mechanisms, including drug–drug interactions, genetic polymorphisms and clinical factors, and showed consistently the clinical relevance of the variability of clopidogrel response, with higher ischaemic risk in low-responders or non-responders, and higher bleeding risk in hyper-responders. Several strategies for overcoming clopidogrel resistance have been evaluated in small clinical studies, but the benefit of tailored antiplatelet therapy has yet to be validated in large randomized trials, which are currently ongoing. Upcoming antiplatelet drugs that are more potent will change the field of antiplatelet therapy in acute coronary syndromes. The future of antiplatelet therapy sounds more complex, with different drugs, and tailored therapy based on platelet tests and/or genetic testing, but it will lead us to propose a more individualized therapy, which hopefully will improve patient outcome.

SummaryBackgroundWhether outcomes differ for women and men after percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI) remains controversial.AimTo compare 1-year outcomes after primary PCI in women and men with STEMI, matched for age and diabetes.MethodsConsecutive women with STEMI of0.05 for all). After exclusion of patients with shock (10.7%) and out-of-hospital cardiac arrest (6.6%), death rates were even more similar (11.3% vs 11.8%; P=0.10). Female sex was not independently associated with death (odds ratio 1.01, 95% confidence interval 0.55–1.87; P=0.97).ConclusionIn our consecutive unselected patient population, women had similar 1-year outcomes to men matched for age and diabetes, after contemporary primary PCI for STEMI, despite having a higher risk profile at baseline.

Summary Background In primary percutaneous coronary intervention (pPCI), conflicting data exist on the relative importance of patient presentation time (time from symptom onset (SO) to first medical contact [FMC]) and transfer time (time from FMC to sheath insertion). Objectives To evaluate the impact of transfer time on mortality in an unselected ST-elevation myocardial infarction (STEMI) population treated with pPCI. Methods In a well-organized urban network, using mobile intensive care units (MICU) whenever possible, the impact of transfer time on inhospital mortality was evaluated in 703 unselected consecutive STEMI patients transferred for pPCI. Results Our STEMI population included patients with cardiogenic shock (5.3%) and out-of-hospital cardiac arrest (3.7%). Longer transfer times were found to be associated with a stepwise increase in mortality ranging from 2.99% in the first quartile (Q1) up to 8.65% in the fourth quartile (Q4) ( P = 0.005). This result was noted in patients presenting early (≤ 2 h of SO, 0.96% for Q1 vs. 9.8% for Q4, P = 0.006) but not in late presenters (> 2 h of SO, 7.00% for Q1 vs. 7.8% for Q4, P = 0.85). After adjustment for confounding variables such as the severity of patients, the relationship between mortality and transfer time was no longer apparent. Conclusions In a well-organized urban network dedicated to pPCI, including unselected STEMI patients, transfer time does not appear to be a major contributor to mortality. The relationship of transfer time to mortality seems to be dependent on presentation time and patients’ clinical severity.

MOTS CLES Infarctus myocarde ; Anticoagulation ; Heparine ; Heparine de bas poids moleculaire ; Bivalirudine Rates of shortand long-term mortality after an acute coronary syndrome (ACS) have been reduced dramatically through advances in percutaneous coronary intervention (PCI) techniques and the availability of new antithrombotic agents. This is particularly true for patients with ST-elevation myocardial infarction (STEMI) treated with primary PCI. On the antiplatelet side, we have, besides clopidogrel, two new P2Y12 inhibitors — prasugrel and ticagrelor — for which data and subset analyses have allowed a better understanding of which patients with an ACS would truly benefit from these drugs. On the anticoagulant side, besides unfractionated heparin (UFH), we have three newer anticoagulants that can be used in ACS: enoxaparin, fondaparinux and bivalirudin. In this competitive field, the past decade has provided a large flow of evidence-based information in terms of the safety and efficacy of these antithrombotic agents. This information needs to be implemented both in guidelines and in our daily clinical practice. As always, there is no simple rule or conclusion; rather, different options exist according to current practice and our own personal environment and experiences. The efficacy of anticoagulation therapy is evaluated on the basis of ischaemic complications of ACS and sometimes the outcome of PCI itself, both of which have a real impact on shortand long-term mortality. The first goal of anticoagulation therapy during primary PCI of STEMI is therefore to avoid or control at all times the development of thrombus and in doing so obtain or maintain blood flow through the coronary circulation and protect the myocardium from harmful damage related to ischaemia and necrosis. If the drug efficacy translates into a mortality reduction, there is a good chance of recognition and acceptation of the new treatment by practising physicians.

Summary Background It is unknown whether the efficacy and safety of drug-eluting stents (DES) apply in patients with chronic renal failure (CRF). Aims To compare DES with bare metal stents (BMS) for percutaneous coronary intervention (PCI) in CRF patients. Patients and methods Consecutive patients treated by PCI were allocated to four groups according to type of stent used (DES versus BMS) and creatinine clearance (CrCl). CRF was defined as CrCl less than 60 mL/minute. Cardiovascular death, major adverse cardiac events (MACE, defined as cardiovascular death, myocardial infarction, stroke and target lesion revascularization [TLR]), TLR and definite stent thrombosis (ST) were recorded at 1 year. Results We note that 1376 consecutive patients underwent PCI with stent within 18 months: 534 (39%) and 492 (36%) patients without CRF and 224 (16%) and 126 (9%) patients with CRF were treated with BMS and DES, respectively. In the entire cohort, patients treated with DES had a higher restenosis risk profile. BMS were predominantly (87%) used for ST-segment elevation myocardial infarction. At 1 year, 6.2% had cardiovascular death, 15.8% MACE, 7.3% TLR and 1.5% ST. Cardiovascular death and MACE occurred less frequently in DES groups. The TLR rate was not significantly different in the CRF groups (BMS 9.8% vs DES 7.1%; P = 0.44). No excess of ST was observed in the DES groups and use of DES was independently associated with absence of MACE and TLR. Conclusions In patients with CRF, DES appear to be at least as effective as BMS — despite a higher restenosis risk profile — with no excess of ST at 1 year.