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Background: If several randomized studies allowed to better apprehend what should be the best antithrombotic strategy in patients with concomitant coronary artery disease (CAD) and atrial fibrillation (AF), there are still several clinical situations with a gap of evidence., Methods: We conducted a national French survey in September-October 2020 among cardiologists in order to assess what are daily practices regarding the antithrombotic management in several specific clinical settings where no or little scientific evidence is available. The questionnaires were built by a committee of 6 cardiologists routinely involved in the field of CAD and/or AF., Results: Among the 6388 French cardiologists, 483 (7.6%) cardiologists participated to the survey. The rate of participation was rather homogeneous across the country. The mean age of participants was 48 +/- 12.7. There were 134 women (27.7%) and 349 men. Altogether, 181 (37.5%) cardiologists worked in private, 153 (31.7%) in non-universitary public and 83 (17.2%) in universitary public centers. The remaining had shared activity. Among the participants, 150 were interventional (coronary) cardiologists (31.1%). Others were general cardiologists (n = 229), specialists in the field of rhythmology (n = 43), heart failure (n = 17) or imaging (n = 44). The survey consisted of 10 questions pertaining to 2 virtual clinical scenarios., Conclusions: The present survey is an illustration of how therapeutic decisions may vary in such situations with little or no scientific evidence. Such surveys may help experts to build consensus (answers with little variability) and to target the need for future trials and more research (answers with a lot of variability)., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Introduction: Triggering receptor expressing on myeloid cells (TREM)-1 is involved in the pathophysiology of ischemic heart disease. Plasma soluble TREM-1 levels (sTREM-1) has been associated with increased risk of major adverse cardiovascular events (MACE) in acute myocardial infarction (AMI) patients. However, the causative link between TREM-1 and MACE remains unknown and requires further investigation before developing potential therapeutic approaches., Methods and Results: Using the serum and DNA data bank from the prospective, nationwide French registry of Acute ST-elevation and non-ST-elevation Myocardial Infarction (FAST-MI 2010, N = 1293), we studied the association of plasma levels of sTREM-1 with 9 common genetic variants at the TREM1 locus and their relationship with recurrent MACE over a 3-year follow up. Plasma levels of sTREM-1 were associated with an increased risk of MACEs (death, recurrent MI or stroke) (adjusted HR = 1.86, 95%CI = 1.06-3.26 and HR = 1.11, 95%CI = 0.61-2.02 respectively for tertiles 3 and 2 versus tertile 1, P < 0.001). The study of common variants identified two major genetic determinants of sTREM-1 (rs4714449: beta = -0.11, P add  = 7.85 × 10 -5 and rs3804276: beta = 0.18, P add  = 2.65 × 10 -11 ) with a potential role on maintenance and/or differentiation of hematopoietic stem cells. However, associated variants only explained 4% of sTREM-1 variance (P = 2.74 × 10 -14 ). Moreover, the rs4714449 variant, individually and in haplotype, was not significantly associated with MACE (HR = 0.61, 95%CI: 0.35-1.05, P = 0.07)., Conclusions: Despite its relationship with increased risk of death, recurrent MI and stroke, genetic determinants of plasma levels of sTREM-1 were not found to be causal prognostic factors in patients with acute myocardial infarction., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Background: We aimed to evaluate the impact of coronavirus disease 2019 (COVID-19)-related lockdown on adherence to lifestyle and drug regimens in stay-at-home chronic coronary syndromes patients living in urban and rural areas., Methods: A cross-sectional population-based study was perfomed in patients with chronic coronary syndromes. A sample of 205 patients was randomly drawn from the RICO (Observatoire des infarctus de Côte d'Or) cohort. Eight trained interviewers collected data by phone interview during week 16 (April 13 to April 19), i.e. 4 weeks after implementation of the French lockdown (start March 17, 2020)., Results: Among the 195 patients interviewed (of the 205, 3 had died, 1 declined, 6 lost), mean age was 65.5 ± 11.1 years. Only six patients (3%) reported drug discontinuation, mainly driven by media influence or family members. All 166 (85%) patients taking aspirin continued their prescribed daily intake. Lifestyle rules were less respected since almost half (45%) declared >25% reduction in physical activity, 26% of smokers increased their tobacco consumption by >25%, and 24% of patients increased their body weight > 2 kg. The decrease in physical activity and the increase in smoking were significantly greater in urban patients (P < .05)., Conclusions: The COVID-19-related lockdown had a negative impact on lifestyle in a representative sample of stay-at-home CCS patients., (Copyright © 2020. Published by Elsevier B.V.)

Abnormalities of myocardial energy metabolism appear as a common background of the two major cardiac disorders: ischemic heart disease (IHD) and heart failure (HF). Myocardial ischemia has been recently conceived as a multifaceted syndrome that can be precipitated by a number of mechanisms including metabolic abnormalities. HF is a progressive disorder characterised by a complex interaction of haemodynamic, neurohormonal and metabolic disturbances. HF may further promote metabolic changes, generating a vicious cycle. Thus, targeting cardiac metabolism in IHD patients may prevent the deterioration of left ventricular function, stopping the progression to HF. For these reasons, several studies have explored the potential benefits of trimetazidine (TMZ), an inhibitor of free fatty acids oxidation that shifts cardiac and muscle metabolism to glucose utilization. Because of its mechanism of action, TMZ has been found to provide a cardioprotective effect in patients with angina, diabetes mellitus, and left ventricular (LV) dysfunction, and those undergoing revascularization procedures, without relevant side effects. In addition, the lack of interference with heart rate, arterial pressure, and most of frequent comorbidities, makes TMZ an attractive option for patients and clinicians as well. The impact of TMZ on long term mortality and morbidity in ischemic syndromes and in heart failure need to be conclusively confirmed in properly designed RCT., (Copyright © 2019. Published by Elsevier B.V.)

Background: The cornerstone of the treatment of patients affected by stable angina is based on drugs administration classified as first (beta-blockers, calcium channel blockers, short acting nitrates) or second line treatment (long-acting nitrates, ivabradine, nicorandil, ranolazine and trimetazidine). However, few data on comparison between different classes of drugs justify that one class of drugs is superior to another., Methods: We performed a systematic review of the literature following PRISMA guidelines., Inclusion Criteria: i) paper published in English; ii) diagnosis of stable coronary disease; iii) randomized clinical trial; iv) comparison of two anti-angina drugs; v) a sample size >100 patients; vi) a follow-up lasting at least 2 weeks; vii) paper published after 1999, when a meta-analysis of trials comparing beta-blockers, calcium antagonists, and nitrates for stable angina of Heidenreich et al. was published., Outcome: to establish whether the categorization in first and second line antianginal treatment is scientifically supported., Results: Eleven trials fulfilled inclusion criteria. The results show that there is a paucity of data comparing the efficacy of antianginal agents. The little data available show that there are not compounds superior to others in terms of improvement in exercise test duration, frequency of anginal attacks, need for sub-lingual nitroglycerin., Conclusion: The categorization of antianginal drug in first and second line is not confirmed., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Background: The COMPASS trial assessed the impact of adding low dose rivaroxaban to aspirin in selected patients (pts). After an acute myocardial infarction (MI), when dual antiplatelet treatment is no longer needed, patients might be eligible for aspirin/rivaroxaban co-therapy. The characteristics and risks of such a population are unclear., Methods: Data were extracted from the FAST-MI 2005, 2010 and 2015 nationwide French registries. Characteristics and long-term mortality were compared according to COMPASS eligibility and between registry and trial populations., Results: Among 9954 patients alive and free of events at one year, 4402 (44%) were classified as COMPASS-Like (i.e. meeting COMPASS inclusion and without exclusion criteria), 1720 (17%) COMPASS-Excluded (i.e. meeting any exclusion criterion) and 3832 (39%) Non-COMPASS (i.e. meeting neither COMPASS inclusion nor exclusion criteria). COMPASS-Like patients were at higher risk and had higher 5-year mortality compared with Non-COMPASS patients. COMPASS-Excluded patients had the highest mortality. COMPASS enrichment criteria defined a population at increased risk of death: eligible pts. had 40% higher 5-year adjusted mortality (Hazard Ratio = 1.40 [1.15; 1.70]), while excluded pts. had 57% higher risk (Hazard Ratio = 1.57 [1.25; 1.97]). Patients meeting the COMPASS criteria one year after MI differed from those included in the randomized trial., Conclusions: Based on the population included in the French FAST-MI registries, enrichment criteria used in COMPASS defined a population representing 44% of the overall population of MI patients surviving to one year, and these patients are at high risk of 5-year mortality. They were at higher risk compared to chronic stable vascular patients enrolled in the trial. Registered with Clinicaltrials.gov under the number: NCT00673036., (Copyright © 2018 The Authors. Published by Elsevier B.V. All rights reserved.)

Background: Women show greater mortality after acute myocardial infarction. We decided to investigate whether gender affects delays and impacts in-hospital mortality in a large population., Methods and Results: We performed a patient-level analysis of 7 French MI registries from different regions from January 2005 to December 2012. All patients with acute STEMI were included within 12 h from symptom onset and a first medical contact with a mobile intensive care unit an emergency department of a hospital with percutaneous coronary intervention facility. Primary study outcomes were STEMI, patient and system, delays. Secondary outcome was in-hospital mortality. 16,733 patients were included with 4021 females (24%). Women were significantly older (mean age 70.6 vs 60.6), with higher diabetes (19.6% vs 15.4%) and hypertension rates (58.7% vs 38.8%). Patient delay was longer in women with adjusted mean difference of 14.4 min (p < 0.001); system delay did not differ. In-hospital death occurred 3 times more in women. This disadvantage persisted strongly adjusting for age, therapeutic strategy and delay with a 1.85 (1.32-2.61) adjusted hazard ratio., Conclusions: This overview of 16,733 real-life consecutive STEMI patients in prospective registries over an extensive period strongly indicates gender-related discrepancies, highlighting clinically relevant delays in seeking medical attention. However, higher in-hospital mortality was not totally explained by clinical characteristics or delays. Dedicated studies of specific mechanisms underlying this female disadvantage are mandatory to reduce this gender gap., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Background: There is a shortage of information on regional variations in ST-segment elevation myocardial infarction (STEMI) management and prognosis at a global level. We aimed to compare patient profiles, in-hospital management and post-discharge mortality across several world regions., Methods: In total, 11,559 patients with STEMI were enrolled in two prospective studies of acute coronary syndrome survivors: EPICOR (4943 patients from 555 hospitals in 20 countries in Europe and Latin America recruited between September 2010 and March 2011) and EPICOR Asia (6616 patients from 218 hospitals in eight Asian countries recruited between June 2011 and May 2012). Comparisons were performed by eight pre-defined regions: Northern Europe (NE), Southern Europe (SE), Eastern Europe (EE), Latin America (LA), China (CN), India (IN), Southeast Asia (SA), and South Korea/Hong Kong/Singapore (KS)., Results: Reperfusion therapy rates ranged between 53.9% (IN) and 81.2% (SE), primary percutaneous coronary intervention (PCI) between 24.8% (IN) and 65.6% (NE) and fibrinolysis between 8.1% (CN) and 34.2% (SA). Median time to primary PCI (h) ranged from 3.9 (NE) to 20.9 (IN) and to fibrinolysis from 2.4 (SE) to 6.3 (IN). Two-year mortality ranged between 2.5% in NE and 7.4% in LA. Regional variations in mortality persisted after adjustment for reperfusion therapy and known prognostic factors., Conclusions: Among patients with STEMI, there is a wide regional variation in clinical profiles, hospital care and mortality. Substantial room for improvement remains at a global level for increasing reperfusion rates, reducing delays and post-discharge mortality in patients with STEMI., (Copyright © 2017 The Authors. Published by Elsevier B.V. All rights reserved.)

Background: Few clinical trials have focused on populations with a history of distant myocardial infarction (MI). The PEGASUS trial assessed the impact of dual antiplatelet therapy in such patients, selected by enrichment criteria of high cardiovascular risk. Whether the PEGASUS population reflects the risk of a broader post-MI population is questionable. We analyzed whether 4-year mortality of a routine-practice population would differ according to the inclusion and exclusion criteria used in PEGASUS., Methods: FAST-MI is a nationwide French registry recruiting acute MI patients in November 2005; 2490 patients alive and without recurrent MI at one year were classified into three groups: Group 1 ("PEGASUS-like" population; n=1395; 56%), Group 2 (population having ≥1 exclusion criterion for the trial; n=677; 27%), and group 3 (population meeting neither the PEGASUS inclusion nor exclusion criteria; n=418, 17%)., Results: Group 1 patients were older than Group 3 patients, with higher GRACE scores, more comorbidity, and less STEMI, but were younger than the PEGASUS trial population. Enrichment criteria successfully defined a population at higher risk: 4-year survival 83% in Group 1, 97% in Group 2, and 68% in Group 3 (P<0.001). Among risk-enrichment criteria, age alone was highly discriminant: in PEGASUS-like patients, survival was 78% in those ≥65 versus 94% in those <65years., Conclusions: Enrichment criteria used in PEGAGUS succeed in defining a population at increased risk in patients with prior MI, age being the most discriminant factor. The trial population, however, was notably younger and more masculine than the corresponding real-life population in France. Clinicaltrials.govnumber:NCT00673036., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

Background: The early mortality of acute myocardial infarction (AMI) has dramatically decreased in the recent past. Whether the previously reported sex disparities in use of invasive strategies (IS) persist and translate into differences in outcomes deserves to be examined., Methods: We used the data from a nationwide French prospective multicentre registry from 3,670 AMI patients (1155 women (31.5%), 2515 men (68.5%)) recruited in 223 centres in 2005 and followed-up for 5 years. We examined in-hospital outcomes and 5-year mortality in patients categorized according to sex and use of IS (i.e. coronary angiography during the hospitalisation with a view to revascularisation)., Results: IS was less frequently used in women than in men (adjusted OR=0.66; 95% CI: 0.52-0.85), regardless of the type of AMI, age group or risk category, while use of recommended medications was similar at 48 hours and discharge. In-hospital mortality did not differ according to sex, whatever the age group and use of an IS. At 5 years, overall and post-discharge mortality were similar in men and women. However, IS was associated with lower 5-year mortality in women (HR=0.66; 95% CI: 0.51-0.86) as in men (HR=0.48; 95% CI: 0.38-0.60) and there was no sex-strategy interaction., Conclusions: Invasive strategy remains less frequently used in women than in men, yet is associated with improved five-year survival irrespective of sex. Whether reducing the sex gap in its use would translate into a higher survival in women remains an open question., Clinical Trial Registration: NCT 00673036., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

Background: We document dual antiplatelet therapy (DAPT) use from discharge to 4 years after acute myocardial infarction (AMI), and investigate whether prolonged DAPT (beyond 1 year) is related to 5-year mortality., Methods: The French Registry of Acute ST-elevation or non-ST-elevation Myocardial Infarction (FAST-MI 2005) included 3670 patients with AMI in 223 French centres. We identified predictors of DAPT (aspirin+clopidogrel) beyond 1 and 2 years, and relation with all-cause 5-year mortality., Results: Among 3319 (96%) patients with discharge data, 2432 (73%) had DAPT, 582 (17%) single antiplatelet therapy (SAPT), and 305 (9%) no antiplatelet treatment. DAPT decreased from 75% at 1 year to 29% at 4 years, with a corresponding increase in SAPT (p<0.05 for trend). Patients with DAPT were more often male, treated with a drug-eluting stent (DES), and without oral anticoagulants. Independent predictors at 1 year of prolonged DAPT were age<75 years, in-hospital bleeding, history of MI, use of DES, discharge use of beta-blockers or statins and no chronic anticoagulation. Predictors at 2 years were age<75 years, male gender, previous MI, diabetes, DES implantation, no chronic oral anticoagulation. By multivariate analysis, there was no difference in 5-year mortality between those on SAPT vs DAPT at 1 year. DAPT at 2 years was also not significantly related to 5-year mortality (Hazard Ratio 1.3, 95% CI [0.9; 1.8], p=0.21)., Conclusion: Prolonged DAPT in selected AMI patients, observed in 47% at 1 year and 21% at 2 years, had no impact on 5-year mortality. These findings do not support the use of DAPT beyond 1 year after an initial ACS., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

Background: Improved early outcome in non-ST elevation myocardial infarction (NSTEMI) patients has been mainly attributed to a broader use of invasive strategies. Little is known about the impact of other changes in early management., Methods: We aimed to assess 15-year trends in one-year mortality and their determinants in NSTEMI patients. We used data from 4 one-month French registries, conducted 5 years apart from 1995 to 2010 including 3903 NSTEMI patients admitted to intensive care units., Results: From 1995 to 2010, no major change was observed in patient characteristics, while therapeutic management evolved considerably. Early use of antiplatelet agents, β-blockers, ACE-inhibitors and statins increased over time (P < 0.001); use of newer anticoagulants (low-molecular-weight heparin, bivalirudin or fondaparinux) increased from 40.8% in 2000 to 78.9% in 2010 (P < 0.001); percutaneous coronary intervention (PCI)≤ 3 days of admission rose from 7.6% to 48.1% (P < 0.001). One-year death decreased from 20% to 9.8% (HR adjusted for baseline parameters, 2010 vs. 1995 = 0.47, 95% CI: 0.35-0.62). Early PCI (HR = 0.67; 95% CI: 0.49-0.90), use of newer anticoagulants (HR = 0.62; 95% CI: 0.48-0.78) and early use of evidence based medical therapy (HR = 0.54; 95% CI: 0.40-0.72) were predictors of improved one year-survival., Conclusions: One-year mortality of NSTEMI patients decreased by 50% in the past 15years. Our data support current guidelines recommending early invasive strategies and use of newer anticoagulants for NSTEMI, and also show a strong positive association between early use of appropriate medical therapies and one-year survival, suggesting that these medications should be used from the start., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

Background: The frequencies of treated cardiovascular disease (CVD) and their associated risk factors (CVRF) may vary according to socioeconomic and territorial characteristics., Methods: These frequencies have been described for 48million policyholders of the French general health insurance scheme, according to a metropolitan geographical deprivation index in five quintiles (from the least to the most deprived: Q1 to Q5), the existence of universal complementary health cover (CMUC) in individuals under the age of 60, and residence in a French overseas territory (FOT). The information system (SNIIRAM) was used to identify CVDs and anti-diabetic, anti-hypertensive or lipid-lowering treatments by three reimbursements in 2010., Results: After age- and sex-specific adjustment, the inhabitants of the most deprived areas more often suffered from distal arterial disease (Q5/Q1=1.5), coronary artery disease (1.2) and cerebral vascular accident (1.1), as did the CMUC beneficiaries compared to non-beneficiaries (ratios of 1.7, 1.3 and 1.5), and the FOT residents in comparison to the most deprived metropolitan quintile (Q1), with the exception of coronary artery disease (1.2, 0.6 and 1.2). Inhabitants of the most deprived areas more often received anti-diabetic and anti-hypertensive treatment (Q5/Q1=1.4 and 1.2), as did the people on the CMUC (2.0 and 1.2) and the FOT inhabitants (FOT/Q1=2.4 and 1.3). These ratios were of 1.1, 1.0 and 0.8 for lipid-lowering drugs., Conclusion: These results pinpoint populations for which specific preventative initiatives could be supported. While health care service utilisation is facilitated (CMUC), it is probably not yet effective enough in view of the persistent increased cardiovascular risk., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

Background: Evidence on the real effectiveness of statins on acute coronary syndrome (ACS) incidence is scarce. We assessed the effectiveness of real-life statins on the risk of first non-fatal ACS in a low-cardiovascular-risk country., Methods: Systematic case-control study was conducted in 60 cardiology centres and 371 general practices from across France. A total of 2238 cases with first ACS within 1 month from recruitment and 2238 controls without history of ACS were included; controls were matched to ACS cases on sex, age, frequency of visits to GPs, date of recruitment and personal history of chronic diseases. Statin exposure and risk factors were documented through patient telephone interviews and validated against medical records. The index date was the date of ACS for cases. Adjusted odds ratios (OR) of first ACS and statin use were estimated by multiple conditional logistic regression models controlled for risk factors and propensity score for statin exposure., Results: Statin use was associated with lower ACS risk, with an adjusted matched OR of 0.67; 95% confidence interval (CI): 0.56 to 0.79 for current use (within 2 months) and 0.73; 95% CI: 0.62 to 0.86 for any use within 24 months [atorvastatin: 0.83 (0.63-1.10), fluvastatin: 0.75 (0.43-1.30), pravastatin: 0.98 (0.72-1.34), rosuvastatin: 0.49 (0.35-0.68) and simvastatin: 0.62 (0.46-0.84)]. The preventive effect of statins on non-fatal ACS reached its maximum after one to four years of use., Conclusion: A similar magnitude of effect for statin use was observed in real life, as compared to randomised clinical trials in France., (© 2013.)

Aims: We aimed to assess the cost effectiveness of the sirolimus-eluting stent (SES) in diabetic and non-diabetic patients vs. bare metal stents (BMS)., Methods: EVASTENT was a matched cohort registry of patients undergoing revascularization exclusively with SES; for each diabetic patient (db+) included, stratified according to single (SVD) or multiple (MVD) vessel disease, a non-diabetic patient (db-) was subsequently included. Efficacy, safety and cost data were obtained from the SES database, and then data from the BMS group were derived by using an original method of transition probabilities of events (Markov model and Monte Carlo simulations) if BMS had been implanted in the same patient, over a 3-year time period. Sensitivity analysis was performed by varying the price difference between BMS and SES from 2008 to 2012., Results: In this study, 1731 patients were included with 97% complete follow-up at 3-years. In 2008, compared to BMS the SES was cost effective only in MVD db+ (7494€ per avoided revascularization (PAR) vs. >10,000€ in other groups). In 2012, after a reduction in the price difference between SES and BMS, SES were cost effective in MVD db+ (-891), SVD db+ (3519), MVD db- (3050), and SVD db- (6329) patients. Otherwise, the cardiovascular mortality rate was higher (p<0.0001) in MVD db+ than in SVD db+, MVD db- and SVD db-., Conclusion: The SES is now cost effective in diabetic and non-diabetic patients, after a favorable price evolution between drug eluting and bare metal stents., (Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.)

Background: Meta-analyses of disease management programs have shown favorable effects in chronic heart failure. Therapeutic patient education forms an integral part of these programs and may influence mortality per se. We aimed to determine the relationship between therapeutic patient education applied in routine clinical practice and long-term mortality in chronic heart failure., Methods: From 2007 to 2010 (median follow-up: 27.2 months), heart failure patients were prospectively enrolled in a multicenter, 'real-world', French cohort by centers previously trained in therapeutic patient education. As educated and non-educated patient profiles were expected to differ, mortality was assessed using conventional multivariate analyses and analyses made on propensity-matched cohorts for the application of therapeutic patient education., Results: Of the 3237 patients who participated in the study (67.5 years; 69.5% men), 2347 were educated (72.5%) and 890 were not educated (27.5%). Non-educated patients were older, more often female, and more severely diseased than educated patients. All-cause mortality was 17.3% in the educated group vs. 31.0% in the non-educated group (adjusted HR 0.70, 95% CI 0.58-0.84, P<.001). This association remained in paired groups after adjustment for all baseline covariates excluding (model 1) or including (model 2) cardiovascular medications and propensity score (HR 0.72, 95% CI 0.58-0.90, P=.003; HR 0.73, 95% CI 0.59-0.90, P=.004, respectively)., Conclusion: In chronic heart failure, therapeutic patient education by trained healthcare professionals appears associated with lower all-cause mortality. These data may have important implications in terms of healthcare organization, because they suggest that therapeutic patient education should be developed in all types of cardiology centers., (Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.)

Background: There are limited data on the safety and efficacy of low molecular weight heparin (LMWH) in elderly patients with acute myocardial infarction (AMI)., Methods: We aimed to compare LMWH with unfractioned heparin (UFH) in the management of AMI in elderly patients. FAST-MI is a nationwide registry carried out over a 1-month period in 2005, including consecutive patients with AMI admitted to intensive care unit <48 h from symptom onset in 223 participating centers. We assessed the impact of LMWH on bleeding, the need for blood transfusion and one-year survival in elderly patients (≥ 75 years)., Results: 963 patients treated with heparin were included (mean age 82 ± 5 years; 51% women; 42.5% ST-elevation myocardial infarction). Major bleeding (2.4% vs. 6.1%, P=0.004) and blood transfusions (4.6% vs. 9.7%, P=0.002) were significantly less frequent with LMWH compared with the UFH, a difference that persisted after multivariate adjustment (OR=0.41, 95% CI: 0.20-0.83 and OR=0.49, 95% CI: 0.28-0.85, respectively). One-year survival and stroke and reinfarction-free survival were also significantly higher with LMWH compared with UFH (OR=0.66, 95% CI: 0.50-0.85 and OR=0.71, 95% CI: 0.56-0.91, respectively). In two cohorts of patients matched on a propensity score for getting LMWH and with similar baseline characteristics (328 patients per group), major bleeding and transfusion were significantly lower while one-year survival was significantly higher in patients receiving LMWH., Conclusions: The present data show that in elderly patients admitted for AMI, use of LMWH is associated with less bleeding, less need for transfusion, and higher survival, compared with the use of UFH., (Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.)

Background: Utilisation of coronary angiography (CAG) varies between different countries. For patients with stable angina, the present study aimed to assess whether such differences could be explained by differences in patient characteristics, and whether these differences were related to outcome., Methods: Using data from the ACTION trial, which compared long-acting nifedipine GITS with placebo in 7665 patients with stable angina from 19 countries, we determined by country the ratio of the observed (O) and the expected (E, based on multivariate models) number of patients who had a history of CAG before entry, or underwent CAG during a mean follow-up of 5 years. Similarly, we determined corresponding O/E ratios for the combined occurrence of any death, myocardial infarction (MI) or debilitating stroke (DS) during follow-up., Results: O/E ratios for a history of CAG before entry ranged from 0.68 [95% confidence interval (CI) 0.60-0.77) for Sweden to 1.43 (95%CI 1.36-1.44) for Belgium, and were significantly correlated (p=0.04) to the corresponding O/E ratios for CAG during follow-up. The combined O/E ratio for CAG either before entry or during follow-up was not correlated (p=0.7) to the O/E for death, MI or DS, which ranged from 0.38 (95%CI undetermined) for Austria to 1.34 (95%CI 0.80-1.89) for France., Conclusions: The degree to which CAG is utilised in patients with stable angina varies between countries but is not related to the occurrence of death, MI or stroke. This supports the notion that percutaneous coronary intervention does not reduce the risk of events.

Background: We evaluated correlates of prolonged use of evidence-based therapies in patients discharged after non-ST-segment elevation acute coronary syndrome (NSTE ACS)., Methods: 598 cardiologists enrolled 2443 patients at outpatient clinics 2-12 months after discharge for NSTE ACS. The use of cardiac medications for secondary prevention (antiplatelets, beta-blockers, angiotensin-converting enzymes, and statins) was evaluated., Results: A total of 2386 (97.7%) patients were on either antiplatelet monotherapy (n=623, 26.1%) or combination therapy (n=1763, 73.9%) at follow-up. Combination antiplatelet therapy declined by 23 percentage points (82.3% to 59.4%) 9-12 months after discharge, whereas use of other cardiac medications remained constant or increased. After multivariable analysis, the strongest predictors of combination antiplatelet therapy were PCI with a stent (odds ratio [OR] 3.75, 95% confidence interval [CI] 2.12-6.67), drug-eluting stents (OR 3.25, 95% CI 1.73-6.08), late PCI (OR 3.21, 95% CI 2.12-4.87) and statins at discharge (OR 1.98, 95% CI 1.40-2.80). Among the independent predictors of beta-blocker and statin use were extent of coronary artery disease and cardiac medications prescribed at discharge., Conclusions: After NSTE ACS, implementation of recommendations on long-term use of evidence-based therapies depends largely on in-hospital management. A variety of clinical characteristics are also predictive of long-term use.

Introduction: The reasons why statins are under-utilized in elderly patients remain poorly understood. The aim of this study was to identify the reasons given by cardiologist for the non-prescription of statins in elderly CHD patients., Methods: Two cross-sectional pharmaco-epidemiological surveys were carried out among French cardiologists. The sample consisted of 1148 coronary patients aged 35 to 69 years and 1489 patients aged > or =70 years. Patients' risk factors, medical history, treatments, lipid values and the physicians' various motives for the non-prescription of statins were recorded., Results: Patients not treated with statins reached 37% in the age-group > or =70 years and 14% in the age-group 35-69 years. The main reason given for statin non-prescription was the lack of a medical indication (2.5% of the age-group 35-69 years and 14% of the age-group > or =70 years). Among patients > or =70 years, the lack of indication was more often cited in the following conditions: 1) in very old patients (36% of lack of indication in the age-group >85 years vs. 10% in 70-75 years), 2) when lipid values were not available (20% when data were not available vs. 9%) and 3) when the patient had no prior history of myocardial infarction (MI) (20% when no history of MI vs. 7%). These factors were not associated with lack of indication among patients <70 years. History of intolerance or side effect was given for 1.3% and 14% of patients for each of the groups (35-69 and > or =70) and poor overall patient adherence was cited in 1% and 2%, respectively., Conclusion: The primary reason for the under-prescription of statins in elderly coronary patients is the perceived lack of indication, which stresses the need of extensive guidelines for prescription in elderly patients. Several factors associated with this perception seem to be specific to the elderly.

Background and Aim: The problem of a possible gender bias in coronary heart disease management is still controversial. We studied gender differences in secondary preventive drug prescriptions and in referral to cardiac rehabilitation after acute coronary events in France., Methods: An observational survey was carried out in 1998-1999 in 150 French intensive cardiac care units. A sample of 2626 consecutive patients admitted for myocardial infarction or unstable angina and alive at discharge was included. Data were retrospectively collected from medical records after discharge., Results: The sample was composed of 1921 men and 705 women. At discharge, antiplatelet agents were prescribed in 93.4% of men and 91.5% of women (p=0.09), beta-blockers in 73.4% and 63.7% (p<0.0001), angiotensin-converting enzyme (ACE) inhibitors in 39.9% and 44.3% (p<0.05), and statins in 47.0% and 40.7% (p<0.01). The percentage of subjects referred to a cardiac rehabilitation program at discharge was 26.2% in men and 15.5% in women (p<0.0001). In multivariate analysis, taking into account confounding factors, gender did not appear as an independent determinant of drug prescriptions. Conversely, being a woman was independently associated with a lower probability to be referred to a cardiac rehabilitation program at discharge (adjusted female-to-male odds ratio: 0.44 (95% confidence interval: [0.31-0.64], p<0.0001)., Conclusions: In this study, gender was not an independent determinant of secondary preventive drug prescriptions after acute coronary events. Conversely, we found a gender bias in referral to cardiac rehabilitation programs at discharge.

The prognostic significance of ventricular tachyarrhythmias induced by programmed ventricular stimulation was evaluated in 492 consecutive survivors of acute myocardial infarction (AMI). Holter monitoring, signal-averaged electrocardiogram (ECG) and measurement of left ventricular ejection fraction (EF) were also performed. The protocol used up to 3 extrastimuli. Sustained monomorphic ventricular tachycardia (VT) < 270 beats/min, > 270 beats/min (ventricular flutter) (VFI), and ventricular fibrillation (VF) were induced in 99, 66 and 52 patients, respectively. Long term follow-up (mean 3.7 +/- 2.2 years) showed that most episodes of VT occurred during the first months following AMI (n = 14), but some patients (n = 6) could develop VT as late as 4 years after AMI. Sudden death (SD) (n = 22) always occurred during the first year following AMI. Multivariate analysis demonstrated that EF < 30% and induction of a VT < 270 beats/min were the only predictors for total cardiac death (P < 0.001). EF < 30%, induction of a VT < 270 beats/min and also of VFI (P < 0.05) were predictors for VT and SD: the risk was 4% in patients without inducible VT, 12% in those with inducible VF1, and 21% in those with inducible VT < 270 beats/min. In conclusion, induction of a sustained monomorphic VT < 270 beats/min or > 270 beats/min is a predictor of arrhythmic events during the first year as well as 4 years after myocardial infarction. However the risk of arrhythmic sudden death decreases after the first year, while the risk of VT persists. Because of the low positive predictive value of programmed stimulation (respectively 21% and 12% for the induction of a sustained VT and VFI), we recommended the indication of programmed stimulation in only the patients with one abnormal non-invasive investigation.

Over 4 yr, 102 consecutive patients more than 75 yr old (56 men, 46 women; mean age 78 +/- 3 years, range: 76-89 years) underwent 120 percutaneous transluminal coronary angioplasty procedures. At baseline, 86% had severe anginal symptoms (Canadian class III or IV), 43% had a history of prior myocardial infarction; 61% had multivessel coronary artery disease, and mean left ventricular ejection fraction was 60 +/- 11%. Calcifications were observed on 66% of the dilated arteries. A total of 158 vessels (1.3 vessel per procedure) were attempted: 1 vessel in 89 procedures (74%), 2 vessels in 24 (20%) and 3 vessels in 7 (6%). The primary success rate was 80% per lesion (126/158) and 77% per procedure (92/120). Complications included 3 deaths (3%), 9 Q-wave infarctions (7.5%) and there was no emergency coronary bypass surgery. The primary success rate was significantly related to the absence of coronary calcifications on the dilated segment (88% versus 75%, p < 0.05) and to the initial patency of the dilated artery (subtotal stenosis: 83% versus total occlusion: 53%, p < 0.05). Follow-up data were obtained in the 79 consecutive patients with a duration of follow-up exceeding 8 months. The mean duration of follow-up was 23 +/- 13 months (range 8 to 61 months). No patient was lost to follow-up; 11 patients died (cardiac causes: 7), 2 had a non-fatal infarction, 7 had aortocoronary bypass surgery and 18 had repeat percutaneous transluminal coronary angioplasty.(ABSTRACT TRUNCATED AT 250 WORDS)