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Scar-related atrial tachycardias (ATs) are very challenging. Thus far, no comparative studies have been conducted between the up-to-date systems, namely the new confidense HD colouring mapping module (Carto 3 v. 4, Biosense Webster) (HD) and the new rhythmia (Boston Scientific) (RM) mapping system. Our study sought to compare both strategies in terms of: – diagnosis and immediate treatment success; – procedure parameters in AT presenting patients. Overall, 38 patients (68 ± 9 years old) with complete mapping and ablation were randomised (HD = 20, RM = 18). The HD and RM groups displayed similar characteristics and etiologies. The AT mechanisms did not differ between the groups: macro/small loop re-entrant mechanisms were more common in both groups (12/20 [60%] versus 10/18 [56%], P = 0.9), with the remaining diagnosed as multi-loop (5/20 [25%] versus 4/18 [22%]; P = 0.9); focal (1/20 [5%] versus 2/18 [11%], P = 0.9), and localised re-entrant (2/20 [10%] versus 2/18 [11%]). The procedure parameters were as follows: tachycardia cycle length (275 ± 30 vs. 280 ± 50; P = 0.7); number of activation maps per patient (2 ± 1 vs. 2 ± 1; P = 0.9); procedure time (138 ± 90 vs. 139 ± 90 min; P = 0.98); X-ray time exposure (20 ± 11 vs. 24 ± 18 min; P = 0.42); RF application time (39 ± 36 vs. 25 ± 28 min; P = 0.21); and mean number of circuits per patient (1.8 ± 1 vs. 1.6 ± 0.9; 0.6). Acute success was obtained in 15/20 pts (75%) of the HD group and 14/18 (78%) of the RM group (P = 0.9). Two patients who failed to achieve the primary endpoint with the HD colouring were secondly converted to the RM group without success. No crossover was carried out in the RM group. The preliminary results of this prospective monocentre randomised study demonstrate that HD colouring and rhythmia systems exhibit a similar efficacy in achieving acute AT termination. [ABSTRACT FROM AUTHOR]

Data concerning long-term mortality after percutaneous coronary intervention (PCI) and factors of poor outcomes are scarce. To describe short-term, intermediate-term, and long-term mortality and their correlates after PCI. In this prospective cohort study, we included and followed-up consecutive patients admitted for PCI from 2008 to 2011. Independent adjudicators reviewed the ischemic outcomes and causes of death until January 2019. A survival analysis was performed to compare the occurrence of cardiovascular and non-cardiovascular death at 30 days, one year and up to 8 years. Of the 3524, patients treated with PCI from 2008 to 2011, 2720 (77.2%) were men and 804 (22.8%) were women with a mean age of 65.8 years old. The median follow-up was 7.0 years (IQ1: 5.4; IQ3: 7.2) and complete for 97.6% of the patients. One third of the patients died (30.3%; n = 1070) in a median time of 2.5 years after PCI, with a rate of 5.3 deaths per 100 patient-years. Overall, mortality was mostly related to cardiovascular causes than non-cardiovascular causes (17.7% versus 12.6%, log-rank < 0.001) (Fig. 1). Cardiovascular death was more frequent within 30 days (4.7% vs. 0.3%, P < 0.0001) and the first year after PCI (3.1% vs. 2.2 P = 0.01), but then become similar to non-cardiovascular death one year (9.9% vs. 10.2%, P = 0.67). Cancer was the major cause of non-cardiovascular death (5.6%; 1 per 100 patient-years). Diabetes (adjHR = 1.48 95% [1.29–1.71], p < 0.001), active smoking (adjHR = 1.37, 95% [1.16–1.62]) and chronic kidney disease (adjHR = 1.97, 95% [2.55–3.45], P < 0.001) were the strongest risk factors for all-cause death. Cardiovascular death was more frequent than non-cardiovascular death in patients treated with PCI in the short and intermediate-term but not beyond one year. Cancer accounted for one fifth of the overall mortality. [ABSTRACT FROM AUTHOR]

Recent studies have emphasized the prognostic value of mild left ventricular ejection fraction (LVEF) impairment in severe aortic stenosis. However, despite adaptive mechanisms to pressure overload, subtle impaired systolic function could be worsened by increased after load and partly reversible immediately after its correction. The aim was to evaluate the short terms effects of transcatheter aortic valve replacement (TAVR) on LV systolic function assessed by global longitudinal strain (GLS). We hypothesized that abrupt decrease of LV after load after TAVR could lead to immediate improvement of LV systolic function. Patients referred to our Department for TAVR were included from January 2018 to July 2018 in this observational prospective single center study. Transthoracic echocardiography (TTE) was performed immediately before and 1–5 days after TAVR by the same operator and reviewed in a blind fashion. Thirty-five symptomatic patients with severe aortic stenosis referred for TAVR (age 84 ± 5 y, 18 male, NYHA 2-3, orifice area 0.7 ± 0.2 cm2, LVEF 66 ± 13%, GLS - 15.1 ± 4.7%) were included. Only 9/35 (26%) had a LVEF ≤ 60%. Overall, no significant change in LVEF (65 ± 14%; P = 0.55) or GLS (−16.1 ± 4.8%; P = 0.11) occurred immediately after TAVR despite a dramatic decrease in transoartic mean pressure gradient (44 ± 15 mm Hg versus 6 ± 3 mmHg; P < 0.0001). However in the subgroup of patients with LVEF ≤ 60%, a significant increase in GLS after TAVR was observed (−9.6 ± 4.1% versus −12.1 ± 3.3%; P = 0.0039). Following TAVR, an early improvement in LV systolic function assessed by GLS was observed only in patients with pre-existing mild LV systolic dysfunction. Further studies should evaluate whether this improvement is associated with better long term outcome. [ABSTRACT FROM AUTHOR]

Background Despite improvement in management of coronary artery disease (CAD), recurrent coronary events remain frequent. The aim of this study is to assess predictive factors of plaque rupture, leading to an acute coronary syndrome (ACS) by combining metabolic evaluation and coronary plaque imaging. Methods This study involved two cohorts of patients, one concerning stable CAD and one ACS patients. In both groups of patients, plaque imaging was performed with standard coronary angiogram and optimal coherence tomography (OCT) in the 3 main coronary vessels defined by diameter superior to 2.5 mm. Recurrent major adverse cardiac events were collected during follow-up. Comparison of stable and unstable CAD patients will be performed to try to characterize criteria of plaque vulnerability. Results The preliminary results regarding the ACS cohort are presented in this abstract. We included 48 patients with mean age of 60.5 years and 87.3% of men. A three-vessel atherosclerotic disease was found in 42% of patients. A total of 142 non-culprit coronary lesions were analysed by OCT for a mean run of 60.4 mm by artery and total of 5854 mm. B2/C complex lesions (AHA/ACC classification) were represented in 28.2% of patients. OCT analysis allowed to define coronary lesions with mean distance from ostium of 22.6 mm, mean stenosis length of 11.9 mm and mean minimum lumen area (MLA) of 3.95 mm 2 with 66.1% of patients with MLA < 4mm 2 . Lesions were distributed in 60% of fibro-fatty plaques, 34% of fibro-calcified plaques and 5% of neo-angiogenesis. Systematic plaque characterization on non-culprit lesions found 7 vulnerable thin-cap fibroatheroma plaques and 3 asymptomatic plaque ruptures. Conclusion OCT analysis of non-culprit coronary lesions is feasible and allows to highlight vulnerable lesions such as asymptomatic plaque ruptures. Analysis of stable cohort, biomarkers and follow-up of patients are necessary to define predictive factors of plaque rupture. [ABSTRACT FROM AUTHOR]

Background: Dual antiplatelet therapy effect on platelet inhibition in elderly patients (>75 y/o) is unknown as this growing proportion of ACS are often excluded from clinical trials. Aim: To compare on-treatment platelet reactivity under dual antiplatelet therapy of elderly (>75 yrs) vs. younger patients (< 75yrs). Methods: We included 652 coronary patients treated by aspirin and clopidogrel in whom platelet response was assessed by light transmission aggregrometry with measure of Maximum (MPA) and Residual Platelet Aggregation (RPA) and VerifyNow with PRU. The population was divided in 5 age categories and compared with elderly patients >75 yrs. Rates of non-response were established using admitted definitions. Results: The mean MD of clopidogrel and aspirin were 86.6mg and 80.6mg in patients <75 y/o respectively, and 81.8mg and 78.6mg in the elderly. On-clopidogrel platelet reactivity was higher in elderly patients when compared to younger patients whatever the test used (figure). The rate of non-responders was 37.1% in the 105 elderly patients when assessed by PRU>235 and 19,01% in the 547 younger patients (<75 y/o; p<0,001). Results were even more striking when RPA was considered with 67.3% non-responders in the elderly patients vs. 22.8% in the 547 younger patients; p<0,001). Mean ARU was similar in both groups with 440U in patients under 75 y/o vs. 452U in elderly (p = 0.8), but the mean AA induced MPA was 5.5% in patients under 75 y/o vs. 10.4% in elderly (p = 0.01). The rate of non-response was 6.25% and 15% with LTA (p = 0.001). Conclusions: Elderly patients have higher levels of on-treatment platelet reactivity for both clopidogrel and aspirin and a 2-fold increase in the rate of non-responders to clopidogrel and a 3-fold increase of non-responders to aspirin, suggesting that they should not be undertreated. Display Omitted [ABSTRACT FROM AUTHOR]

Aim: To determine the optimal timing of catheterization in high risk acute coronary syndromes. Methods: The randomized ABOARD study showed that in patients with acute coronary syndromes without ST-segment elevation, a “primary PCI” strategy compared with a strategy of intervention deferred to the next working day did not result in a difference in clinical outcome. We performed a new analysis of the ABOARD population which was divided into quartiles of time from randomization to catheterization. Like in the main analysis the primary endpoint was the peak troponin value during hospitalization and the key secondary end point was the composite of death, myocardial infarction, or urgent revascularization at 1 month follow-up. Results: The population (n = 352) was divided into four quartile-groups. In the first quartile, catheterization was performed within the first 69 minutes (median: 50 minutes) after randomization, in the second group between 69 and 339 minutes (median: 118 minutes), in the third one between 339 and 1247 min (median: 1048 minutes) and in the last one over 1247 minutes (median 1448 minutes). Patients: received intense antiplatelet therapy with a mean 660mg (±268) loading dose and 111mg (±40) maintenance dose of clopidogrel while 99% of the PCI patients received abciximab. Low-molecular-weight-heparins were used in 68% of patients and radial approach was predominant (84%).The mean (+/−SD) peak of troponin did not differ between the 4 groups (Q1 = 7.5ng/mL±12.3, Q2 = 9ng/mL±22.5, Q3=7ng/mL±12.3, Q4 = 6.4ng/mL±13.5) p = 0.66). The 30-day rate of death, myocardial infarction and urgent revascularization did not differ between the four groups. (Q1 = 20%) (23%), Q2 = 20 (23%) Q3=14 (16.1%), Q4 = 20 (22.7) p = 0.61). Rates of major bleeding complications were also similar in the four groups. Conclusion: This refined analysis of the ABOARD study confirms the primary analysis of the two groups formed by randomization. Time to catheterization has no impact on clinical outcome when performed swiftly within the first 24 hours of admission. [Copyright &y& Elsevier]

Background: Inadequate anticoagulation in patients undergoing percutaneous coronary Intervention (PCI) is associated with more frequent periprocedural ischemic events. Methods: We evaluated the ability of the bedside Hemonox test to identify patients with an anti-Xa activity level out of the therapeutic range in 296 unselected patients undergoing catheterization and/or PCI. Bedside measure of whole blood Hemonox Clotting Time (CT) and activated Partial Prothrombin Time (aPTT) were measured at baseline (T1) and 10’ after the IV administration of enoxaparin (T2) in patients receiving additional enoxaparin and compared to differed plasma chromogenic anti-Xa (AXA) activity measurement. Results: Median [IQR] values were 0.1 [0.1-0.1] and 0.87 [0.74-1.03] IU/mL for AXA; 74 [70-81] and 143 [114-206] sec for Hemonox CT, and 44 [39-50] and 72 [58-93] sec for aPTT at T1 and T2 time points, respectively. Hemonox CT strongly correlated with Anti-Xa level spearman r=0.81 (95% CI 0.77-0.84, p<0.0001). When comparing a total of 486 values to discriminate patients with AXA <0.5 IU/mL, the area under the receiver operating curve (AUC) for Hemonox CT was 0.95±0.01 (95% IC; 0.93-0.97; p<0.0001) versus 0.89±0.01 (95% IC; 0.86-0.92; p<0.0001) for aPTT. A threshold Hemonox CT value of 120 sec was associated with a 94.9% (95% CI 91.1-97.4) sensitivity and a 73.3% (95% IC 67.6-78.5) specificity with a likelihood ratio = 3.5 to detect patients with inadequate anti-Xa level (<0.5UI/mL). With this threshold the positive predictive and negative predictive values of Hemonox CT as a diagnosis test were 73.9% (95% IC 68.7-79.0) and 94.78% (95% IC 91.8-97.8) respectively. Conclusion: According to the results of this study Hemonox CT appears to be a fast and reliable bedside test that could be used to adjust enoxaparin anticoagulation in PCI. Display Omitted [Copyright &y& Elsevier]

A temporary pace-maker (TPM) is often used after TAVR due to the risk of atrioventricular block (AVB) in the following days, related to progressive conduction system injuries. However guidelines are unclear as when to safely remove it. Between 2013 and 2014, 195 patients without previous permanent pacemaker, were prospectively followed after TAVR (69 Edwards Sapiens (ES) and 126 CoreValve (CV)). 47 had preoperative bundle branch block, 23 left (LBBB), 24 right sided (RBBB). Peri-operative high degree AVB was noted in 37 patients (20%). 24 were transient, less than 10mn and; 13 persisted at the end of the procedure and were implanted with a permanent pace-maker. New LBBB was observed in 55 patients (28%). In the post-operative period, 23 patients (13%) developped AVB (20 patients within 5 days, and 3 patients after 7 days) (4 ES and 19 CV). No new AV block had occurred at one month in the remaining population. Risk factors for late AVB were peri-operative transient AVB (40%), post-operative RBBB (30%), or LBBB (20%); preexistent RBBB and Corevalve model. Conversely 41 of the 42 patients without AVB or bundle branch block did not need temporary pacing in the post operative time. The only patient without any perioperative event who developed a late AV block at day 7 had a CV inserted in an old surgical valve. However, sinus dysfunction occurred in 2 patients treated with amiodarone for atrial fibrillation in the post operative period, needing temporary pacing. Conclusion: The use of TPM after TAVR is common for the management of delayed high degree AVB. The main risk factors are peri-operative AVB and post-operative BBB. Most of delayed AVB occur within 5 days. Later AVB preceded by prolonged PR interval and BBB should increase the length of TPM. However, in the absence of these factors TPM could be shortened. Abstract 0304 – Figure: Time occurence of AVB (CV=Corevalve, ES=Sapien) [ABSTRACT FROM AUTHOR]

Purpose Cardiac allograft vasculopathy (CAV) constitues a primary cause of death after heart transplantation. Bare metal stents (BMS) have been used for revascularization, but they are associated with a high-risk of restenosis. Abstract 0474 – Figure: Kaplan-Meier estimates of one-year mortality Limited data have shown favourable results with percutaneous coronary interventions (PCI) using drug-eluting stents (DES) in this specific population. Our study focuses on intra-stent restenosis (ISR) for DES in CAV, on new revascularisation and mortality. Methods 97 consecutive heart transplant recipients with successful PCI were treated with DES (n=106) and BMS (n=25). They were prospectively followed-up at one year after PCI. An angiographic lesion-based analysis at 12-month follow-up and a patient-based survival analysis were performed. Results The lesion-based analysis within 12 months after PCI showed an ISR rate with BMS of 12% and an ISR rate with DES of 3.8%. The target lesion revascularization (TLR) was 8% for BMS and 2.8% for DES. However, the target vessel revascularization was higher (16.5%) and the remote lesion revascularization was 8.7%, indicating the rapid occurrence of new significant lesions. Cardiac mortality at one year was 9.7% and extra- cardiac mortality was 2.9%. Conclusions DES are associated with a low rate of TLR and can safely be used in heart transplant recipients with coronary artery disease. However, new significant lesions occurred at one year indicating a progression of CAV. [ABSTRACT FROM AUTHOR]

Aim To compare cardiovascular (CV) outcomes after contemporary PCI in patients with vs. without renal failure (RF) according to clinical presentation (ST-elevated myocardial infarction (STEMI), acute coronary syndrome (ACS), and stable coronary artery disease (sCAD)). Methods Consecutive patients undergoing PCI with stent implantation were prospectively included from 2007 to 2012. RF was defined by a CrCl <60 ml/min. The primary end-point was all cause-mortality. The secondary endpoints were MACCE (cardiovascular death, myocardial infarction, stroke, TLR), TLR (target lesion revascularization), and ARC definite/probable stent thrombosis (ST) at one year. Results Among 5337 patients eligible, 1219 (23%) had PCI for STEMI, 1837 (34%) for ACS and 2281 (43%) for sCAD. There were 1441 (27%) patients with RF. At one year, patients with RF had increased all-cause mortality rates whatever the indication for PCI (Figure), with a 6 fold higher unadjusted all-cause mortality rate in STEMI patients (41% vs. 7.5%) and a 3 fold increase in ACS (19% vs. 6%) and sCAD (10% vs. 3%) patients compared to noRF patients (p< 0.0001 for all comparisons). MACCE were also higher in RF patients in each PCI indication (45% vs. 15% in STEMI, 23% vs. 14% in ACS, and 14% vs. 9% in sCAD, p<0.05 for all). STEMI-noRF patients had comparable mortality (p=0.209) and MACCE rates (p=0.658) than sCAD-RF patients. TLR ranged from 5.5% to 7.4%, and definite/probable ST was <2.5% without any difference in each PCI indication (p>0.05 for both). After multivariable analyses, RF was independently associated with an excess of death with a more than doubled relative risk in STEMI compared to ACS and sCAD patients (OR 5.3: CI 3.627-7.821 in STEMI vs. 2.1: CI 1.465-3.140 and 2.3: CI: 1.507-3.469 in ACS and sCAD, respectively, p<0.0001). Conclusion RF is a stronger independent predictor of death after PCI in patients with STEMI compared to patients with ACS and sCAD. CV prognosis of sCAD-RF patients was found to be comparable to that of STEMI-noRF patients. [ABSTRACT FROM AUTHOR]

Background Our aim was to examine the hypothesis that the sequential use of the Verigene® rapid CYP2C19 test for genetic profiling and the VerifynowTM bedside test for platelet function measurement in ACS patients may improve P2Y 12 inhibition. Methods and results “Rapid” (CYP2C19*1/*1 or CYP2C19*17 carriers, n=211) and “slow” metabolizers (CYP2C19*2 carriers, n=58) were first put on clopidogrel and prasugrel MD for ≥2 weeks, respectively. Patients with low inhibition >80% on prasugrel or high inhibition <30% on clopidogrel were then switched to clopidogrel and prasugrel, respectively. Our objectives were to demonstrate that the proportion of “rapid” metabolizers on 75mg MD of clopidogrel within 30%-80% of P2Y 12 inhibition is non-inferior to “slow” metabolizers on prasugrel 10mg MD and (ii) to evaluate the same end-point after switching drugs. The proportion of “rapid” and “slow” metabolizers within 30%-80% of P2Y 12 inhibition was 58.5% and 44.8%, respectively, an absolute difference of +13.6% (95% CI (confidence interval), –0.8% to 28.1%) with a non-inferiority margin greater than the predefined margin of –10%. Among patients out of target, all but one “slow” metabolizers displayed low-on prasugrel platelet reactivity while the majority of “rapid” metabolizers (70%) displayed high-on clopidogrel platelet reactivity. After switching, the proportion of patients within 30%-80% of P2Y 12 inhibition was 74.4% and 65.5% in “rapid” and “slow” metabolizers, respectively (+8.9%, 95% CI –4.7% to 22.5%). Conclusions This study demonstrates a loose relationship between genotype and platelet function phenotype approaches but that they are complementary to select prasugrel or clopidogrel MD in stented ACS patients. [ABSTRACT FROM AUTHOR]

Aims To assess middle term outcomes according to SYNTAX score and rates of delayed surgical/bleeding events after unprotected left main (LM) coronary artery (ULMCA) PCI in an unselected patients population. Methods Consecutive patients treated by PCI for ULMCA were included among a single center 3508 PCI database within 36 months. Syntax scores were calculated, post discharge extracardiac surgery or hemorrhage were recorded during follow-up as clinical outcomes (Death, TVR, MACCE=cardiovascular death+MI+stroke+TLR). Results 102 (3.6%) patients underwent PCI of the LM, including 21 protected LM. Among the 81 patients with PCI of ULMCA, mean age was 65±13, 27% had urgent PCI for AMI or cardiogenic shock, 61% had DES. SYNTAX score was 28±14 in mean and ≤22 in 30 (37%), 23 to 32 in 22 (27%) and ≥33 in 29 (36%) patients. At 30±11 months follow up (98% of the patients), death occurred in 24 patients (30%), TVR in 16 (20%) and MACCE in 35 (43%). Clinical events according to the SYNTAX score are shown in figure. No cardiovascular death occurred in patients with syntax ≤22. MACCE rates were significantly lower when DES were used (24% vs. 64%, p<0.05) and in case of non-urgent PCI (36% vs. 71%, p<0.05). During follow-up, 20 (25%) and 12 (15%) patients underwent unplanned extracardiac surgery and/or hemorrhage, leading to antiplatelet withdrawal in 31% of the cases. Conclusions In unselected patients treated by PCI of ULMCA with Syntax score ≤22, outcomes were found to be excellent with no cardiovascular death observed at 30 months. DES and non-urgent PCI were associated with a better prognosis. One patient out of three underwent unplanned extracardiac surgery or hemorrhage during follow up. [ABSTRACT FROM AUTHOR]

Aim: Compare the effectiveness and safety of drug-eluting stent (DES) vs bare metal stent (BMS) in diabetic patients treated by percutaneous coronary intervention (PCI) for short lesions in large vessels (stent diameter ≥3.0mm AND stent length ≤18mm). Methods: Consecutive patients treated with at least one large (≥3.0mm) and short (≤18mm) stent were included over one year. Clinical and angiographic data were prospectively entered into the “Middle-Care” database and outcomes obtained at one year. We compare the occurrence of 1) cardiovascular (CV) death, 2) MACCE (CV death, Myocardial Infarction (MI) and stroke), 3) TVF (CV death, Target vessel MI, Target Vessel Revascularization (TVR)), 4) TVR and 5) Target Lesion Revascularization (TLR) as 6) Stent Thrombosis (ST) in the diabetic population according to the type of stent used (DES vs BMS). Results: Three hundred ninety nine patients fulfilled inclusion criteria. Among the 108 (27%) diabetic patients, 58% (n = 63) underwent PCI with BMS and 42% (n = 45) with DES. Mean age was 65±11 years, 82% (n = 89) were male, 32% (n = 35) had acute coronary syndrome, 16% acute MI. Clinical characteristics were well matched between the two groups, except for prior PCI, acute MI and multivessel disease (19% vs 49%, 24% vs 4% and 49% vs 73%, for BMS vs DES respectively, p<0.05 for all). One year follow-up was completed for 100% of the patients. Four (3.7%) patients died from CV cause, 8 (7.4%) had MACCE, 14 (13.0%) had TVF. Event rates in diabetics were similar whatever the stent used (Figure). TVF rates were similar in diabetic and non diabetic patients. Conclusions: Diabetes does not increase the risk of TVF after PCI with short stents in large vessels. At one year, no additional benefit was found with the use of DES among diabetic patients in this setting. Display Omitted [ABSTRACT FROM AUTHOR]

Title: Aldosterone receptor blockade at presentation for ST elevation myocardial infarction is associated with a reduction in potentially lethal ventricular arrhythmia. Purpose: To assess the benefit of aldosterone receptor blockade on admission for primary PCI for STEMI. Methods: 806 consecutive patients admitted within 12 hours after onset of a STEMI for primary PCI were studied. The latest 111 patients were systematically treated by 200mg IV potassium canrenonate at presentation, followed by soludactone 25mg daily during the hospital stay. The association between aldosterone receptor blockade and in-hospital death, ischemic events and ventricular arrhythmia was assessed using a logistic model adjusted on age, Killip class and reperfusion status. Follow-up was completed in 97% and 96% of patients at 30 days and 6 months. Results: Results are depicted in the table. Baseline characteristics were not different between the 2 groups (age 63±14 vs 62±15, successful reperfusion 87% vs 90% and Killip class IV 5% in both groups).Aldosterone receptor blockade was associated with significantly lower rates of ventricular arrhythmia with an adjusted OR of 0.18 (95%CI 0.07–0.47) and 0.25 (95%CI 0.11–0.57) for the ventricular tachycardia and ventricular tachycardia or fibrillation respectively, and a trend towards lower rates of resuscitated cardiac arrest and high grade atrioventricular block. Mortality rates at 30 days (6 vs 6.7%) and 6 months (6.8 vs 7%) were comparable between the groups. Conclusions: Aldosterone receptor blockade at presentation for STEMI is associated with a marked reduction of the risk of potentially lethal ventricular arrhythmia. These findings underline the anti-arrhythmic effect of aldosterone blockade and the need for adequately sized randomized trials to assess the benefit of such strategy on major cardiovascular events. [ABSTRACT FROM AUTHOR]

Background: The incidence and long term prognosis of women presenting troponin positive NSTE-ACS and a normal angiogram is unknown. Aim: To investigate the incidence, characteristics and long term prognosis of women presenting with a NSTEMI and normal coronary angiogram compared to women with NSTEMI and significant coronary artery disease (CAD) on the angiogram. Methods: Between 1999 and 2008, we screened patients presenting with an acute coronary syndrome (ACS) to identify those with a positive troponin and a normal angiogram. Extra-cardiac causes of troponin elevation were excluded. Women were matched by age and presence or absence of ST-elevation with a 1:2 ratio, to women with significant CAD. We compared characteristics and outcomes of the two groups of women. Results: Over 4085 ACS patients, 1581 had a significant elevation of troponin, with 343 women (21.7%) and 1238 men (78.3%). One hundred and twelve patients (7.1%) had a normal angiogram with a 3-fold higher proportion of women (14.5%; n = 50) compared to men (5.0%, n = 52); p<0.001. When these women with a normal angiogram were compared with 100 women with significant CAD, they were less likely to have a high peak of troponin (> 5 times the upper limit of normal: 46% vs. 80%, p<0.0001). No other significant difference was found between the two groups. Mean follow-up was 4.3 +/− 3.1 years. Women with a normal angiogram had an excellent survival rate of 91.3% compared to 71.2% in women with CAD (p = 0.03), they had also a lower readmission rate for cardiovascular reason, (14% vs. 54%, p = 0.01). Conclusion: Women presenting with NSTEMI who have a normal angiogram, do not differ from women with NSTEMI and angiographic CAD. However, they have a smaller rise of troponin and a much better long-term prognosis. Display Omitted [ABSTRACT FROM AUTHOR]

Background: It has been suggested that delays, quality and outcome of reperfusion therapy provided to ST-Elevation Myocardial Infarction (STEMI) patients during OFF-hours (nights and weekend) are worse than during ON-hours (day working hours). Methods: We studied 736 consecutive STEMI patients transferred for primary percutaneous intervention (PCI) to a single large volume urban Primary PCI center. Characteristics and clinical outcome of patients admitted during ON-hours (Monday through Friday 8 am-6 pm) were compared to OFF-hours patients (admitted during night shifts and weekends). Clinical outcome was 1 year death and death or MI. Results: STEMI patients undergoing primary PCI were admitted more frequently during OFF-hours (n = 449; 61.1%) than ON-hours (n = 287; 38.9%), with no major differences in characteristics or treatment between the two groups. Use of radial approach and the rate of stenting during PCI was 83.3% and 86.1% in ON-hours patients vs. 88.2%.and 88.1% in OFF-hours patients. There was no impact of time of admission on in-hospital mortality before or after adjustment for baseline characteristics OR 1.54; CI [0.71–3.35]. Time from symptom onset to first medical contact was shorter during OFF-hours than ON-hours (105 min [50–225] vs. 114 min [60–367]; p = 0.06). Time from first medical contact to sheath insertion was also identical between the 2 groups (101 min [80–155] and 105 min [78–155]; p = 0.61 respectively). Time to TIMI 3 flow and duration of procedure were also similar. At one year, all cause mortality and the composite end point of death or MI was 8.3% and 12.2% for OFF-hours patients vs. 7.0% and 10,8% in ON-hours patients, p = 0.4 and p = 0.3 respectively. Conclusion: In a well-organized urban STEMI network, were 61% of patients referred for primary PCI are admitted during “OFF” hours, admission time does not impact quality of care or outcomes. Display Omitted [ABSTRACT FROM AUTHOR]

Aim: Whether timing of catheterization (immediate versus delayed intervention) in high risk ACS has an impact on outcome in patients with RF is not known. Methods: In the randomized ABOARD study we showed that in patients with NSTE-ACS, a “primary PCI” strategy compared with a strategy of intervention deferred to the next working day did not result in a difference of clinical outcome. We compared these two strategies according to the renal status at 1-month follow-up. Severe RF was defined by a Creatinin Clearance (CrCl) 30 ml/min and moderate RF by a CrCl >30 and 60ml/min. Results: Eight (2.3%) patients had severe RF, 67 (19.4%) moderate RF and 270 (78.3%) no RF. Baseline characteristics were well matched except for a lower multivessel disease rate in the “primary PCI” strategy group (52% vs 85%, p=0.008) in the moderate RF group. Patients received intense antiplatelet therapy with a mean 660mg (±268) clopidogrel loading dose followed by a 111mg (±40) maintenance dose, while 99% of the PCI patients received abciximab. LMWH were used in 68% of patients and radial approach was predominant (84%). The mean peak of troponin did not differ according to the revascularization strategy wathever the renal function. The 30-day rate of death, MI and urgent revascularization were higher in RF patients but did not differ significantly between the two revascularization strategies whatever the renal function. Recurrent ischemia was however significantly more frequent in the moderate RF group undergoing deferred catheterization in comparison with a primary PCI strategy (33,3% vs. 8.8%, p=0.014). Major bleeding complications were similar whatever the strategy in the different renal function groups. Conclusion: Although renal failure is associated with more ischemic complications, the timing of intervention appears to have no impact on outcome of these patients. Thus, the primary results of the ABOARD study apply also to renal failure patients. [Copyright &y& Elsevier]

Background: Prognosis of patients surviving having an out-of-hospital or an in-hospital cardiac arrest is still very poor. Immediate coronary angiography with successful angioplasty has shown to improve prognosis of these patients. Nevertheless this strategy in the setting of new reanimation techniques using hypothermia or cardiac assistance has not yet been evaluated. Aim: To evaluate the impact of coronarography and ad hoc angioplasty on survival rate. Methods: The Pitié-Salpêtrière registry included 328 consecutive patients who survived a cardiac arrest and were transferred to the cath-lab for emergency coronary angiography followed by ad-hoc PCI and state-of-the art critical care techniques. We present here intermediate results with the follow up of 223 consecutive patients. Results: Most (65.7%) cardiac arrest survivors had angiographic coronary artery disease (at least one lesion >70%), with an attempted angioplasty in 49.1% of the total patients and in 75% of patients with coronary artery disease. Angioplasty was successful in 82.4% of attempted PCI. Total hospital survival rate was 43.8% when it was 45.7% in patients with CAD and 40.8% in patients without CAD, p = 0.1 with non adjusted HR 1.09 (95% CI 0.7–1.6). Survival rate was 48.3% in patients with successful PCI and 40.6% in patients without PCI or PCI failure, p = 0.3 with non adjusted HR 1.2(95% CI 0.8–1.8). Complete follow up pf the cohort is pending. Conclusions: Two third of cardiac arrest survivors present with angiographic coronary artery disease and undergo 75% of attempted PCI. In this intermediate analysis presence of CAD and successful PCI provided trend in a better survival but were not significantly associated with a better outcomes. Display Omitted [ABSTRACT FROM AUTHOR]

Aim: We sought to determine the incidence and type of major bleeding in moderate-to-high risk acute coronary syndromes (ACS) treated with intense antiplatelet therapy and systematic invasive strategy using predominantly the radial approach. We also examined whether these bleedings has an impact on mortality after multivariable adjustment. Methods: In the multicenter randomized ABOARD study, 352 patients with acute coronary syndromes without ST-segment elevation were randomized for a “primary PCI” strategy or a strategy of intervention deferred to the next working day. No difference was observed in clinical outcomes between the two groups. Major bleeding complications (STEEPLE definitions) were correlated to 1 month mortality. Results: Patients were treated by intense antiplatelet therapy: with a mean 660mg (±268) loading of clopidogrel and 111mg (±40) maintenance dose while 99% of the PCI patients receive abciximab the radial approach was predominant (84%). During the first 30 days major bleeding complications occurred in 19 patients (5.4%) with transfusion in 16 patients (4.5%). Occurrence of major bleeding did not differ between immediate and delayed intervention. The most frequent overt bleeding complications were from the gastrointestinal tract. The composite of GI bleeding and occult bleeding (loss of Hb of >3g/dL) represented n = 11 (57.9%) of all major bleeding complications. Major bleeding was associated with a significantly higher peak of creatinine during hospitalization 170.16 μmol/L ± 169.34 vs. 97.05 μmol/L ± 56.96 (p = 0.005) and a higher mortality rate 26.3% vs. 0.6%. After adjustment for all baseline characteristics, major bleeding was independently associated with an impressive increased hazard of death during the first 30 days (Odd ratio 75.7; 95% CI, 11.3 to 505.3; p<0.0001). Conclusion: In a population of radial catheterization for NSTEACS, GI bleeding is the most frequent bleeding complication. Despite the reduction of access site bleeding, major bleeding still remains a major independent predictor of mortality. [Copyright &y& Elsevier]

Aim: Compare the effectiveness and safety of drug-eluting stent (DES) vs bare metal stent (BMS) for percutaneous coronary intervention (PCI) in patients with chronic renal failure (CRF). Methods: 1126 patients treated by PCI over one year were divided in 4 patients groups, according to the type of stent used (DES vs BMS) and the creatinin clearance (CrCl). Clinical and angiographic data were prospectively entered into the web-based “Middle-Care” database. Chronic renal failure (CRF) was defined by a CrCl < 60 ml/min. The occurrence of cardiovascular (CV) death, MACCE (Death, myocardial infarction and stroke) and TLR was recorded at one year follow-up. We report the preliminary (6 months) results of patients treated between August 2007 and January 2008. Results: 497 patients underwent PCI: 250 (50.3%), 120 (24.1%), 81 (16.3%) and 46 (9.3%) patients were allocated in the BMS, DES, BMS CRF and DES CRF groups respectively. Mean age was 64 +/- 13 years, 82.5% were male, 24.4% had diabetes, 62.1% had an acute coronary syndrom (ACS) and 47% multivessel disease. One year follow-up was completed for 485 (97.6%) patients: 36 (7.1%) patients died, 54 (10.7%) had MACCE and 35 (6.9%) underwent TLR. The use of DES was associated with significantly less CV death and MACCE, a trend for less TLR and the same stent thrombosis (ST) rate compared with BMS use in patients with and without CRF (figure). Conclusions: The use of DES appears to be more effective and at least as safe as BMS at one year follow up in patients with CRF. Final results will be available for the meeting. Display Omitted [Copyright &y& Elsevier]

Aim: To identify factors associated with change in thrombus pattern in STEMI patients undergoing primary PCI. Methods: Thrombi (n=45) were obtained using the Export thromboaspiration device in consecutive STEMI early presenters (<12hours from symptoms onset) undergoing primary PCI. Ten different areas of each thrombus were randomly scanned using a Scanning Electronic Microscope (4nm resolution). High definition pictures (Magnification 3000X) were analysed in a blinded way by a semi-quantitative and a visual approach to evaluate fibrin and platelet content (in %). The primary endpoint was fibrin and platelet content according to time delay from symptom onset (SO). All patients were enrolled in the web-based registry (e-PARIS). Results: Mean age was 59+/-14 years, 25 (83%) were male, 16 (53%) were smoker, 12 (40%) had hypertension, 12(40%) dyslipidemia and 7(23%) were diabetic. 4 patients (13.3%) had pre-hospital cardiac arrest and 25 patients (83%) had a single vessel disease. All Patients received aspirin, clopidogrel, enoxaparin or UHF and 25 (83%) received abciximab. Thrombi were composed by 55.9±18% of fibrin (mean±SD), 16.8±18% of platelets, 11.5±9% of red cells, 5.2±8.4% of cholesterol crystal, 1.3±2.0% of white cells, and 2.8±3.7% mixed cell-fibrin. Median time delay from SO to PCI was (182 min +/- 235 IQR). There was a stepwise decrease in platelet content with respect to prolonged time delay from SO to PCI ranging from 25.6±25% in the first tertile down to 8.7±7% in the third tertile (p=0.09) (fig.). On the other hand, there was a stepwise increase in fibrin content ranging from 47.8±24% up to 67.3±9% (p=0.04). Analysis of other determinants of clot composition and relation with myocardial TIMI Blush Grade is pending. Conclusions: Platelet and fibrin content within the occlusive thrombus of early STEMI presenters is a fast evolving process. Time delay from symptom onset is a key determinant of thrombus composition. Thrombus content in STEMI according ischemic time Display Omitted [Copyright &y& Elsevier]

Background: Gamma’ fibrinogen (γ’Fg) is a Fg isoform that constitutes about 15% of total plasma Fg and contains an additional binding site for factor XIII and for IIa forming clots that are resistant to fibrinolysis in vitro. Little is known about γ’Fg in the pathophysiology of Acute Coronary Syndrome (ACS) patients. Aim: To compare γ’Fg level and the relation with fibrin clot physical properties in a young post-MI patients matched for age and gender and age with healthy controls. Method: γ’Fg was measured in duplicates in 260 young post-MI patients and n=260 controls. Maximum fibrin elastic modulus (EM in dyne/cm2), a measure of clot stiffness (G’) and Clot Lysis Time (CLT in sec) a measure of fibrinolysis rate were measured in all subject. Results: Patients produced stiffer plasma fibrin with increased EM (24.4±15.9 vs 13.5±5.9 kdynes/cm2 ; p<0.0001) with reduced fibrinolysis speed (1038±797 vs 595±416 sec; p<0.0001) in comparison with controls. γ’Fg concentration was significantly higher in patients compared to control (Figure 1) (p=0.037). However the ratio of γ’Fg over total Fg concentration (% of γ’Fg) was similar in both groups (3.7± 2% vs 3.5± 2.7% in controls; p=0.49). In patients there was a stepwise increase in clot stiffness (EM) with tertile of γ’Fg concentration (T1=13.7±7 T2=19.8±14 T3=23.7±16 in kdynes/cm2) with a similar effect on hypofibrinolysis (CLT) (T1=675±550 T2=829±680 T3= 940±750) (p<0.0001 for both). Conclusion: γ’Fg concentration was found to be significantly higher in young post-MI patients as compared to healthy controls matched for age and gender and may account for the great differences in fibrin clot physical properties between patients and controls, an independent correlate of premature coronary artery disease. Display Omitted [Copyright &y& Elsevier]

Aim: In STEMI, controversial data exist on the relative importance of patient-dependent time (Symptom-Onset (SO) to first medical contact (FMC)) and Transfer Time (TT=time from FMC to sheath insertion). We assessed the impact of TT on in-hospital (IH) mortality in a well organized urban network using Mobile Intensive Care Units (MICU). Methods: In a web-based registry (e-PARIS), we evaluated delay in care of 705 consecutive STEMI patients transferred to the Pitié-Salpêtrière cath-lab for primary PCI. Results: Population was 63±14 y/o, 75.6% were male, 46.9% had anterior MI, 16.7% were in Killip class 2, and 3.8% had out-of-hospital cardiac arrest. Abciximab was used in 82.4%, radial approach in 87.7% and stenting in 89.7% of patients. Median time (IQR) from SO to FMC was 110 (248) min (102 (190) min when FMC was MICU and 160 (381) min when FMC was a referring hospital, p<0.0001). Median TT was 104 (75) min (95 (45) min for MICU and 151 (178)min for patients transferred from a primary hospital, p<0.0001). When divided into quartiles, increasing TT was associated with higher IH mortality. This relation to IH mortality was striking in patients presenting early (within 2 hours of SO), and not significant in late presenters (>2 hours of SO) (fig). After adjustment for baseline characteristics, TT was not associated with mortality anymore suggesting that the sicker patients had the longest TT. Conclusions: The association between TT and early mortality is strongly dependent on patients’ characteristics and time to presentation. After adjustment for these parameters, TT does not appear to be a major contributor of IH mortality in a well organized urban network for primary PCI. Improving time-to-first medical contact may be more critical. Display Omitted [Copyright &y& Elsevier]

Background: The *2 variant of the CYP2C19 gene encodes a defective enzyme that likely fails to adequately convert clopidogrel to its active metabolite, leading to diminished cardiovascular protection. Objectives: We performed a meta-analysis of trials that determined the CYP2C19*2 genetic variant in patients exposed to clopidogrel therapy after stent implantation. The primary objective was to evaluate whether carriage of the CYP2C19*2 was associated with the occurrence of stent thrombosis, recurrent myocardial infarction and cardiovascular death. Methods and results: Eight trials (9427 patients) with data available data on death, recurrent myocardial infarction, stent thrombosis and any ischemic events were selected. The odds ratio (OR) as the parameter of efficacy with a fixed effect model was used. Carriers of the genetic variant associated with a loss-of-function of the CYP2C19 enzyme (28%, n=2674) displayed a 30% increase in the risk in any ischemic events compared to non carriers (10.4% vs 8.3%) (OR, 1.31; 95% CI, 1.12-1.53; p<0.001). This metanalysis confirmed the excess of stent thrombosis (2.9% vs 0.9%) (OR 3.01; 95% CI: 1.89-4.80, p<0.001)(n=4975) but also of death or MI (12.1% vs 5.3%)(OR 2.51; 95% CI: 2.07-3.05, p<0.001)(n=7022). This single gene variant (CYP2C19*2) was also associated with an excess of cardiovascular mortality (1.8% vs 1.0%)(OR 1.79; 95% CI: 1.10-2.91, p<0.019)(n=6225). Conclusions: Our findings support rapid genetic testing for the CYP2C19*2 to identify patients with a deficient clopidogrel metabolic activation. The clinical relevance of such approach remains to be established by adequately powered randomized studies. [Copyright &y& Elsevier]

Aim: We evaluated the rates, types and prognosis impact of bleeding complications in all-comers presenting with STEMI treated with aggressive antithrombotic treatment and radial access for primary PCI. Methods: Consecutive STEMI patients (n=695) were evaluated for bleeding complications using a web-based registry (e-PARIS). In-hospital bleedings were adjudicated using various definitions (TIMI, GUSTO, STEEPLE). In-hospital ischemic events were the composite of MI, stroke and recurrent ischemia leading to urgent revascularization. Results: Mean age was 63+/-14 years, 531 (76.4%) were male, 142 (20.4%) diabetic, 141 (20.3%) had known coronary disease. In this non-selected, high risk population, 5.2% had cardiogenic choc on admission, 3.7% had pre-hospital cardiac arrest, 49.4% had multivessel disease and in 45.2% the left anterior descending artery or left main was the culprit artery. Radial access (88%) was used as often as possible as well as abciximab (82%). The loading dose of clopidogrel ranged from 300 to 900mg. Pre-hospital fibrinolysis was used in 5.9%. Cardiac assist devices (IABP, ECMO, Tandem Heart) all requiring a femoral access, were used in 7.5% of patients. In-hospital death rate was 5.3%. In-hospital bleeding rates varied widely according to the definitions used: 2.3%, 1.4%, 5.3%, 9.2% and 10.8% with TIMI Major, GUSTO Severe, TIMI Major & Minor, GUSTO Severe & Moderate or STEEPLE Major, respectively. One year mortality according to bleeding or ischemic events are shown in the figure. The most frequent TIMI Major Bleeding (MB) complications were gastrointestinal (GI) (44%) and assistance device related (33%) MB. Conclusions: Although bleeding rates vary a lot with the definitions used, major or minor bleedings strongly relate to 1-yr mortality after primary PCI and weigh at least as much as recurrent ischemic complications. The most frequent MB with radial primary PCI is GI bleeding. Display Omitted [Copyright &y& Elsevier]

Aim: The CHADS2 score is a reliable, easy-to-use, and popular bedside score to assess the risk of stroke in patients with atrial fibrillation (AF). The items of the score are all key determinants of prognosis in vascular patients. We compare CHADS2 to established scores (the Framingham score and the European SCORE) for their ability to predict adverse cardiovascular outcome in atherothrombotic patients without AF. Methods: Individual risk scores were calculated in 18,888 stable atherothrombotic patients without AF included in the European REACH registry in 18 European countries between 2003 and 2004. Each scheme was divided into low, intermediate and high predicted risk categories and applied to the cohort. MACCE (CV Death, MI or Stroke) were recorded at 2 years follow-up. Results: Two hundred six deaths and 987 MACCE occurred during 37776 patients-years follow up. According to CHADS2 score, 38.2% (7234 patients with CHADS2=0-1) had low, 48.2% (9101 patients with CHADS2=2-3) had intermediate and 13.5% had high predicted CV risk (2553 patients with CHADS2=4-6) (figure A). The proportion of individual assigned to individual risk categories varied widely across schemes (low risk ranged from 26.6% to 88.6%, high risk from 1.5% to 25.0%). Although the risk scores had only poor discriminating ability, CHADS2 had the higher c-statistics of 0.613 (figure B). In multivariable logistic regression, the CHADS2 score (high vs low risk) remains an independent predictor of MACCE even after adjustement to Framingham score (OR 2.78 [95% CI 2.3 to 3.3]) or european SCORE (OR 2.94 [95% CI 2.45 to 3.5]). Conclusions: The CHADS2, a reliable, easy-to-use, bedside score, appears to predict more accurately, adverse cardiovascular outcome in atherothrombotic patients without atrial fibrillation, than established scores. But current risk scheme have limited ability and better scores are needed. Display Omitted [Copyright &y& Elsevier]

Background: Erythrocytes transfusion is an independent risk factor for recurrent ischemic events and mortality in patients suffering from acute coronary syndrome. There is no evidence regarding the underlying mechanism of such association. Aim: We hypothesized that red blood cell transfusion would activate platelet aggregation and we sought to identify which are the pathway involved in this activation process. Methods: Healthy volunteers (n=15) provided blood samples that were mixed with red blood cell (tRBC) obtained from transfusion packs. We explored platelet activation using light transmission agregometry with four different agonist (ADP, Arachidonic Acid (AA), Collagen and Epinephrin) in 10 volunteers and with flow cytometry for P-selectin and VASP in 5 volunteers. Measures were obtained at baseline (whole blood from healthy volunteers), after in vitro transfusion with a 1:4 ratio of tRBC and after in vitro transfusion with a 1:4 ratio of tRBC and hematocrit adjustement with platelet poor plasma. All experiment were performed in duplicates. Results: Theses are preliminary results from the ongoing TRANSFUSION study. Numerical values are given in table 1. 1/ RBC transfusion activates platelet aggregation thought ADP and AA pathway. 2/ This effect was confirmed by increase in P-Selectin platelet content with flow cytometry and is independent of an increase in hematocrit. 3/ P2Y12 activation pathways is involved with an increase in VASP. Conclusions: Red Blood Cell transfusion activates platelet thought ADP and AA pathway in healthy volunteers. This may explain the independent association between transfusion and recurrent ischemic events including mortality in ACS patients. [Copyright &y& Elsevier]

Based on age and simple history data of patients, the CHADS2 score provides accurate assessment of the 1 year risk of stroke in the setting of atrial fibrillation. We sought to assess the hypothesis that the CHADS2 score may be as useful in the setting of STEMI, in comparison with more complex validated scores. Methods: We assessed CHADS2, TIMI and GRACE risk scores, in 697 consecutive patients admitted for STEMI within 24 hours after the onset of the symptom. In-hospital, 30-days, 6-months and 1-year mortality rates were assessed according to the CHADS score (0 to 6). Low, intermediate and high risk patients were identified by different scores : <2, 2-3, >3 for CHADS; <4, 4-6, >6 for TIMI; <126, 126-154, > 154 for GRACE respectively. Results: The cumulative in-hospital, 30-day, 6-month and 1-year mortality rates were 5.3%, 6.3%, 7.8% and 8.8% respectively. CHADS2 score was significantly associated with all mortality rates (p<0.0001) with ORs of 2.2 (95%CI 1.7-2.8), 2.1 (95%CI 1.6-2.7), 2 (95%CI 1.6-2.7), and 2 (95%CI 1.6-2.6) per score point respectively. The concordance between the scores in predicting 1-year mortality was fair as shown by kappa values of 0.53 and 0.50 for CHADS2 versus the 2 other and 0.53 between GRACE and TIMI scores (Figure). Conclusions: CHADS2 score is highly correlated to early and late mortality after STEMI. The risk prediction by this simple purely clinical and available at first medical contact score, is concordant with more sophisticated scores. Display Omitted [Copyright &y& Elsevier]