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Summary Background General practitioners (GPs) play a pivotal role in the long-term management of patients with atrial fibrillation (AF), including anticoagulant prophylaxis for stroke prevention. Aims To investigate the antithrombotic prescription behaviours of GPs in France and compare them with the European Society of Cardiology (ESC) guidelines for stroke prevention, and to identify the major determinants of use of antithrombotic therapy. Methods We conducted a cross-sectional survey, using data from the French Longitudinal Patient Database, on the use of antithrombotic treatments for stroke prevention in 15,623 patients (≥ 18 years of age) with AF who attended at least one GP consultation between July 2010 and June 2011. Data were collected on patient baseline characteristics, stroke risk factors, and prescription of antithrombotic drugs. Results The mean age was 74.6 ± 11.1 years, 59.5% were men, and 83.1% had a CHADS2 score ≥ 1. Over half (52.6%) of the patients with a CHADS2 score ≥ 1 received a vitamin K antagonist (alone or in combination with an antiplatelet), 19.3% received aspirin alone, and 23.4% received no antithrombotic therapy; 3.6% of the patients received dual antiplatelet therapy and 1.1% clopidogrel alone. Over half of the patients (56.3%) were treated in accordance with the ESC 2010 guidelines. Of the remaining patients, 19.4% received no treatment, 13.0% were inadequately treated, and 11.2% were over-treated. Factors associated with antithrombotic treatment were anti-arrhythmic therapy, higher stroke risk, presence of atherothrombotic disease, and use of non-steroidal anti-inflammatory drugs. Female gender was associated with a lower likelihood of antithrombotic treatment. Conclusions In this large French study, approximately 45% of thromboembolic high-risk patients were either not treated or inadequately treated. Better compliance with evidence-based guidelines is needed to reduce the burden of stroke in the AF population.

SummaryHypertension is the leading cause of death in developed countries; its management is the subject of guidelines that are regularly reviewed and updated. However, the guidelines from France, the UK, Europe and the USA differ. Some recommendations are graded, whereas others are not. All recommendations emphasize the role of alternative methods for clinical measurement of blood pressure, such as ambulatory blood pressure measurement (ABPM) or self-measurement. The UK guideline recommends that the diagnosis of hypertension should be established by ABPM. The USA guideline recommends a target of ≤ 150/90mmHg for patients aged>60 years. The French guideline recommends that the target blood pressure remains at80 years. Systolic blood pressure between 130 and 139mmHg and diastolic blood pressure55 years and for black patients. The USA guideline advises treating non-black patients, including those with diabetes, with thiazides, calcium antagonists, ACE inhibitors or ARBs; for black patients, including those with diabetes, it recommends thiazide and calcium antagonists.

SummaryInfective endocarditis (IE) is a life-threatening complication that may impair significantly the long-term prognosis of patients with cardiac disease. The profile of IE has changed over recent decades, with a decreasing prevalence of rheumatic fever and increasing survival of patients with congenital heart disease (CHDs). Given the high rates of morbidity and mortality, and based on previous experimental studies, antibiotic prevention of IE has long been recommended for at-risk groups. Serial revised guidelines for prophylaxis have been published over the years. The most recent recommendations differ dramatically from previous guidelines and provide new insights into the prophylaxis of IE. Emphasis is put on oral activities (particularly brushing teeth) as both buccal and skin hygiene may present the greatest threats for individuals at-risk of IE. Significant limitations in both at-risk patients and procedures result in a potential and substantial change in the practice of clinicians and raise concerns about the safety and reliability of these new recommendations for patients with CHD.

a Centre cardiologique du Nord, 32—36, rue des Moulins-Gemeaux, 93207 St. Denis, France b University Hospital, 76031 Rouen, France c Clinique Pasteur, 31076 Toulouse, France d Hopital de Hautepierre, 67000 Strasbourg, France e University Hospital, 35033 Rennes, France f University Hospital, 38043 Grenoble, France g La Timone University Hospital, 13385 Marseille, France h Nouvelles cliniques nantaises, 44277 Nantes, France i University Hospital, 80054 Amiens, France j University Hospital, 59037 Lille, France k Lariboisiere University Hospita

Objective. - Most evidence-based practice guidelines identify tow-density lipoprotein cholesterol (LDL-C) as the primary target of cholesterol-towering therapy; the optimal LDL-C concentration is based on the patient's individual risk level. The aim of this study was to determine the proportion of patients on lipid-towering drugs who reach the LDL-C goals recommended in guidelines. Methods. - The CEPHEUS study was conducted in eight European countries in patients, who had been treated with lipid-towering drugs for at least three months, with no dose adjustment for a minimum of six weeks. In France, throughout 2006, 560 general practitioners enrolled 2222 patients into the study, 1966 of whom gave a fasting blood sample. Lipid and glucose parameters were measured centrally. Results. - Patients had been on treatment for a mean of 5.5 +/- 5.7 years. Most patients (90.4%) received a single lipid-lowering drug; 84.9% were treated with statins, and the second most frequently used lipid-lowering drugs were fibrates (13.7%). Among the treated subjects, 50% had LDL-C values >3.0 mmol/L, 30% had triglyceride values >11.7 mmol/L and 10% had HDL cholesterol values < 1.1 mmol/L. In high-risk patients, as defined by French guidelines, over 55% were above the recommended goal of 2.6 mmol/L. In the subgroup of high-risk patients who did not reach the goals, the LDL-C values were 0.7-1.4 mmol/L over the recommended concentration. Conclusion. - The results of this survey highlight the suboptimal management of hypercholesterolaemia in France, particularly in the high-risk population, in whom the percentage who achieved the LDL-C goals was the lowest. (c) 2008 Elsevier Masson SAS. All rights reserved.

Over the past 70 years our understanding of hypertension has advanced greatly. Epidemiology has led to a major change in the paradigm concerning high blood pressure (BP). Initially considered as a normal adaptation to thickened vessels, it was later recognized as a major risk factor for cardiovascular events. Since then, the deleterious components of BP have been refined: systolic BP and pulse pressure have progressively overtaken diastolic BP, while central pressure is becoming, for some experts, a more reliable way to measure BP than is peripheral BP. Pharmacology has led to the discovery of powerful and very effective drugs with a good tolerance over the long term. Clinical studies have shown the impact of lowering BP on improving patient outcomes. The benefit is substantial: a reduction in systolic BP of 10-12 mmHg or in diastolic BP of 5-6 mmHg over 5 years resulted in a decrease in the incidences of stroke, coronary artery disease, congestive heart failure and cardiovascular death of 35-40%, 20-25%, 45-55% and 20-25%, respectively [1]. Finally, tremendous efforts are still being directed at identifying new markers for cardiovascular risk stratification. All of these developments are summarized regularly in textbooks and in guidelines that critically review the evidence at hand and propose the best clinical practice in accordance with evidence-based medicine. There are, however, two areas that have been difficult to improve during this period: physicians' compliance with practice guidelines [2] and patients' compliance to the prescribed treatments [3]. The paper by Nicodeme et al. [4] perfectly illustrates the complexity of improving BP control in France. In their survey, the authors identified an approximately 40% rate of BP control based on conventional BP measurement, close to that reported by Wang et al. [5]. While this rate is clearly not sufficient, it is perhaps less disappointing than those from other European countries [5]. More importantly, this paper reports on "clinical inertia", in other words, the reluctance of physicians to modify treatment when the BP goal is not achieved.

SummaryAtrial fibrillation (AF) is a common and serious condition in the elderly. AF affects between 600,000 and one million patients in France, two-thirds of whom are aged above 75 years. AF is a predictive factor for mortality in the elderly and a major risk factor for stroke. Co-morbidities are frequent and worsen the prognosis. The management of AF in the elderly should involve a comprehensive geriatric assessment (CGA), which analyses both medical and psychosocial elements, enabling evaluation of the patient's functional status and social situation and the identification of co-morbidities. The CGA enables the detection of “frailty” using screening tools assessing cognitive function, risk of falls, nutritional status, mood disorders, autonomy and social environment. The objectives of AF treatment in the elderly are to prevent AF complications, particularly stroke, and improve quality of life. Specific precautions for treatment must be taken because of the co-morbidities and age-related changes in pharmacokinetics or pharmacodynamics. Preventing AF complications relies mainly on anticoagulant therapy. Anticoagulants are recommended in patients with AF aged 75 years or above after assessing the bleeding risk using the HEMORR2HAGES or HAS-BLED scores. Novel oral anticoagulants (NOACs) are promising treatments, especially due to a lower risk of intracerebral haemorrhage. However, their prescriptions should take into account renal function (creatinine clearance assessed with Cockcroft formula) and cognitive function (for adherence to treatment). Studies including frail patients in “real life” are necessary to evaluate tolerance of NOACs. Management of AF also involves the treatment of underlying cardiomyopathy and heart rate control rather than a rhythm-control strategy as first-line therapy for elderly patients, especially if they are paucisymptomatic. Antiarrhythmic drugs should be used carefully in elderly patients because of the frequency of metabolic abnormalities and higher risk of drug interactions and bradycardia.

Summary Background Guidelines emphasize the implementation of local networks with prehospital emergency medical systems to improve the management of patients with ST-segment elevation myocardial infarction (STEMI); they also define the choice of reperfusion strategies and adjunctive treatments. Aim To assess the compliance of STEMI emergency care with current French guidelines in a large area of France and to identify predictors of compliance with guidelines. Method The RESCA+31 registry was a 2-year, multicentre, prospective, multidisciplinary study, including 512 consecutive patients with STEMI evolving within 12 hours managed by emergency physicians in the prehospital system or emergency department. Data were recorded during the emergency phase and after admission to cardiology. Results First medical contact (FMC) was prehospital emergency care for 80% of patients; 97% received reperfusion treatment and 98% were admitted to a cardiology intensive care unit (CICU) with a catheterization laboratory. The mortality rate was 5%. Guidelines were complied with in 41% of patients for reperfusion strategies, in 47% for adjunctive treatments and in 23% for both. The only factor independently associated with guideline compliance was FMC by prehospital emergency system. In 52% of cases, emergency physicians underestimated the delay between FMC and admission to a CICU. Conclusion Despite the implementation of a network, compliance with guidelines for reperfusion strategies and adjunctive treatments was insufficient in our area. However, very few patients did not receive reperfusion therapy and the mortality rate was low. Efforts should be made to improve the estimation of delay before primary percutaneous coronary intervention.

Summary Background Improvements in the treatment of coronary artery disease mean that an increasing number of patients survive acute cardiovascular events and live as outpatients with or without anginal symptoms. Aim To determine the characteristics and management of contemporary outpatients with stable coronary artery disease in Western Europe, and to compare France with the other Western European countries. Methods CLARIFY (prospeCtive observational LongitudinAl RegIstry oF patients with stable coronary arterY disease) is an international, prospective, observational, longitudinal study. Between November 2009 and July 2010, 32,954 adult outpatients with stable coronary artery disease (defined as a history of documented myocardial infarction [of > 3 months], prior coronary revascularization, chest pain with myocardial ischaemia, or coronary stenosis of > 50% proven by angiography) were enrolled in 45 countries. The demographics and management of CLARIFY patients enrolled in France were compared with those enrolled in other Western European countries (Austria, Belgium, Denmark, Germany, Greece, Ireland, Italy, Netherlands, Portugal, Spain, Switzerland and the UK). Results Of the 14,726 patients enrolled in Western Europe (mean age 66.2 [10.2] years; 79.6% male), 2432 (16.5%) were from France. The use of aspirin was lower in France than in other Western European countries (74.5% vs. 86.9%, respectively), whereas use of thienopyridines (48.5% vs. 21.7%), oral anticoagulants (12.3% vs. 9.0%) and lipid-lowering drugs (95.8% vs. 92.5%) was higher. Beta-blockers were used in 73% of both groups. Angina was less prevalent in France (6.3% vs. 15.5%) and French patients showed higher levels of physical activity than their counterparts in Western Europe. Conclusions The management of patients with stable CAD in France appears favourable, with good adherence to guideline-based therapies, but there remains room for improvement in terms of symptom and risk factor control.