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Objectives: To analyse the implementation, applicability and accuracy of the pretest probability calculation provided by NICE clinical guideline 95 for decision making about imaging in patients with chest pain of recent onset. Methods: The definitions for pretest probability calculation in the original Duke clinical score and the NICE guideline were compared. We also calculated the agreement and disagreement in pretest probability and the resulting imaging and management groups based on individual patient data from the Collaborative Meta-Analysis of Cardiac CT (CoMe-CCT). Results: 4,673 individual patient data from the CoMe-CCT Consortium were analysed. Major differences in definitions in the Duke clinical score and NICE guideline were found for the predictors age and number of risk factors. Pretest probability calculation using guideline criteria was only possible for 30.8 % (1,439/4,673) of patients despite availability of all required data due to ambiguity in guideline definitions for risk factors and age groups. Agreement regarding patient management groups was found in only 70 % (366/523) of patients in whom pretest probability calculation was possible according to both models. Conclusions: Our results suggest that pretest probability calculation for clinical decision making about cardiac imaging as implemented in the NICE clinical guideline for patients has relevant limitations. Key Points: • Duke clinical score is not implemented correctly in NICE guideline 95. • Pretest probability assessment in NICE guideline 95 is impossible for most patients. • Improved clinical decision making requires accurate pretest probability calculation. • These refinements are essential for appropriate use of cardiac CT.

Background: ST-segment–elevation myocardial infarction (STEMI) and non–ST-segment–elevation myocardial infarction (NSTEMI) management has evolved considerably over the past 2 decades. Little information on mortality trends in the most recent years is available. We assessed trends in characteristics, treatments, and outcomes for acute myocardial infarction in France between 1995 and 2015. Methods: We used data from 5 one-month registries, conducted 5 years apart, from 1995 to 2015, including 14 423 patients with acute myocardial infarction (59% STEMI) admitted to cardiac intensive care units in metropolitan France. Results: From 1995 to 2015, mean age decreased from 66±14 to 63±14 years in patients with STEMI; it remained stable (68±14 years) in patients with NSTEMI, whereas diabetes mellitus, obesity, and hypertension increased. At the acute stage, intended primary percutaneous coronary intervention increased from 12% (1995) to 76% (2015) in patients with STEMI. In patients with NSTEMI, percutaneous coronary intervention ≤72 hours from admission increased from 9% (1995) to 60% (2015). Six-month mortality consistently decreased in patients with STEMI from 17.2% in 1995 to 6.9% in 2010 and 5.3% in 2015; it decreased from 17.2% to 6.9% in 2010 and 6.3% in 2015 in patients with NSTEMI. Mortality still decreased after 2010 in patients with STEMI without reperfusion therapy, whereas no further mortality gain was found in patients with STEMI with reperfusion therapy or in patients with NSTEMI, whether or not they were treated with percutaneous coronary intervention. Conclusions: Over the past 20 years, 6-month mortality after acute myocardial infarction has decreased considerably for patients with STEMI and NSTEMI. Mortality figures continued to decline in patients with STEMI until 2015, whereas mortality in patients with NSTEMI appears stable since 2010.

Aims Alhough cardiogenic shock (CS) after acute myocardial infarction (AMI) is more common in elderly patients, information on the epidemiology of these patients is scarce. This study aimed to assess the trends in prevalence, characteristics, management, and outcomes of elderly patients admitted with CS complicating AMI between 1995 and 2010, using data from the FAST-MI programme. Methods and results We analysed the incidence and 1-year mortality of CS in four nationwide French surveys carried out 5 years apart from 1995 to 2010, including consecutive AMI patients over 1-month periods. Among the 10 610 patients, 3389 were aged ≥75 years, of whom 9.9% developed CS. The prevalence of CS decreased in elderly patients from 11.6% in 1995 to 6.7% in 2010 (P = 0.02). Over the 15-year period, the characteristics of elderly patients with CS changed, with more diabetes, hypertension, and hypercholesterolaemia. The use of PCI increased markedly in elderly patients with and without CS, reaching 51% and 59%, respectively, in 2010. In addition, medical therapy also evolved, with more patients receiving antithrombotic agents, beta-blockers, and statins. Over time, 1-year mortality decreased by 32% among elderly patients with CS but remained high (59% in 2010). ST-segmet elevation myocardial infarction and previous AMI were independent correlates of increased 1-year death, while study period was associated with decreased mortality (2010 vs, 1995: hazard ratio 0.40, 95% confidence interval 0.27–0.61, P < 0.001), along with early use of PCI. Conclusion Cardiogenic shock in elderly patients with AMI remains a major clinical concern. However, 1-year mortality declined in these patients, a decrease potentially mediated by broader use of PCI and the improvement of global patient management.

The original version of this article, published on 19 March 2018, unfortunately contained a mistake. The following correction has therefore been made in the original: The names of the authors Philipp A. Kaufmann, Ronny Ralf Buechel and Bernhard A. Herzog were presented incorrectly.

BACKGROUND AND AIMS: Although much has been written about the conventional cardiovascular risk factor correlates of the extent of coronary artery calcification (CAC), few studies have been carried out on symptomatic patients. This paper assesses the potential ability of risk factors to associate with an increasing CAC score.METHODS: From the European Calcific Coronary Artery Disease (Euro-CCAD) cohort, we retrospectively investigated 6309 symptomatic patients, 62% male, from Denmark, France, Germany, Italy, Spain and the USA. All had conventional cardiovascular risk factor assessment and CT scanning for CAC scoring.RESULTS: Among all patients, male sex (OR = 4.85, pCONCLUSION: In addition to age and male sex in the total population, diabetes is the most important correlate of CAC extent in both sexes.

Aims To evaluate the prognostic impact of QRS width in patients with low-flow/low-gradient aortic stenosis (LF/LGAS). Methods and results Among 88 consecutive patients referred to our institution for LF/LGAS from September 1994 to March 2007, baseline demographic, clinical, echocardiographic, and electrocardiographic data were collected. This population was divided into two groups according to baseline QRS duration (cut-off QRS ≥130 ms). Follow-up data, including electrocardiographic evolution and overall mortality, were analysed. The mean follow-up duration was 3.1 (2.2–6.2) years. In the whole group, 67 patients underwent surgical aortic valve replacement. Forty-nine patients (56%) had a QRS duration ≥130 ms. Among operated patients, there was no significant change in QRS duration between baseline and latest follow-up (126 ± 26 ms vs. 131 ± 25 ms; P = 0.82). In addition, wider QRS was a strong independent predictor of overall mortality (hazard ratio 2.20, 95% confidence interval 1.15–4.24; P = 0.027). Conclusion Significant intraventricular conduction disturbances are common in patients with LF/LGAS and do not recover after aortic valve replacement. QRS duration is strongly associated with mortality in this selected population.

International audience; Left ventricular remodeling (LVR) typically manifests as compensatory changes in ventricular mass, composition, and volume as a response to cardiac performance inadequacy...

In the setting of low-flow/low-gradient aortic stenosis (LF/LGAS), outcomes of pseudo-severe aortic stenosis (AS) remain poorly described. This study was aimed to assess the outcome of patients with pseudo-severe AS under conservative treatment.Among 305 patients from the European Registry of LF/LGAS, the outcomes of the 107 patients followed under conservative treatment were analysed. Based on the results of dobutamine echocardiography, patients were divided into group IA [left ventricular (LV) contractile reserve present with true-severe AS, n = 43], group IB [pseudo-severe AS (n = 29) defined as LV contractile reserve with a final aortic valve area ≥1.2 cm(2) and a mean transaortic pressure gradient40 mmHg at peak dobutamine infusion], or group II (exhausted LV contractile reserve, n = 35). The rate of death within 5 years was significantly lower in the group IB (43 ± 11%, n = 10), when compared with the group IA (91 ± 6%, n = 33; P = 0.001) and the group II (100%, n = 23; P0.001). The Cox proportional hazard model analysis demonstrated that the hazard ratio for death in the group IB remained significantly lower than in the other groups, even after adjustment for currently established risk factors. Furthermore, the 5-year survival of pseudo-severe AS patients was comparable with that of propensity-matched patients with systolic heart failure and no evidence of valve disease.In patients with pseudo-severe AS, the 5-year survival under conservative treatment is better than in true-severe AS and comparable with that of propensity-matched patients with LV systolic dysfunction and no evidence of valve disease. Further studies are needed to define optimal therapeutic management in these patients.

Strain delay index (SDI) allows quantification of the wasted contraction or gain of myocardial contractility expected after cardiac resynchronization therapy (CRT). The present multicentre prospective study aimed to assess the accuracy of the SDI in predicting responses to CRT in real-life patients with wide and narrow (130 ms) QRS complexes.Implantation of a CRT device was performed in 235 heart failure patients and echocardiography data were analysable in 80% (n= 189) of patients (age 65 ± 12 years, left ventricular ejection fraction = 26 ± 8%, 63 ischaemic, 51 with narrow QRS complexes). Mechanical dyssynchrony before CRT was quantified by the 12-segment standard deviation of peak longitudinal strain by speckle tracking (12SD-ε, 12 standard deviation of time to peak strain by speckle tracking), and SDI, defined as the sum of difference between end-systolic and peak-ε across the 16 segments. Response to CRT was defined as an end-systolic volume reduction (ESVR) at 6 months15%. After CRT, ESVR15% was observed in 60% (n= 114/189) of patients, and was greater in non-ischaemic (68 vs. 44%, P= 0.003) and wide QRS patients (65 vs. 49%, P= 0.04). Correlation between 12SD-ε and ESVR was poor (r = 0.18, P= 0.01). In contrast, SDI correlated with reverse remodelling (r = 0.61, P0.0001 for all) in both wide and narrow QRS patients and ischaemic and non-ischaemic patients. Decrease in SDI after CRT was greater in responders and correlated with ESVR. Finally, SDI25% identified responders to CRT (positive and negative predictive value of 80 and 84%, respectively) with 6% inter-observer variability.The present multicentre study suggests that SDI may identify responders to CRT in ischaemic and non-ischaemic patients.

Objectives In a multicentre series of patients with low-ejection fraction/low-gradient aortic stenosis (LEF/LGAS), we evaluated the prognostic impact of valvuloarterial impedance (Zva). Background Zva in AS, a measure of global afterload taking into account systemic arterial compliance, has been proposed for risk stratification in paradoxical LGAS. We hypothesized that Zva could help risk stratification in LEF/LGAS. Methods and results We retrospectively calculated Zva (5.6 ± 1.7 mmHg/mL/m2) of 184 consecutive patients (mean age: 71 ± 10 years) with severe symptomatic LEF/LGAS (valve area ≤1 cm², EF ≤40%, mean transaortic pressure gradient ≤40 mmHg) included between 1995 and 2005 in a multicentre registry. Zva was higher in patients with LVEF at rest ≤20% (6.6 ± 2.3 vs. 5.5 ± 1.6; P = 0.05) and correlated negatively with LVEF at rest ( R = −0.25; P = 0.001). Zva was lower in patients without contractile reserve (CR) on dobutamine stress echocardiography (DSE) compared with patients with true severe AS (5.3 ± 1.3 vs. 5.8 ± 1.8 mmHg/mL/m2; P = 0.048). Zva and the variation in stroke volume during DSE were positively correlated ( P = 0.0001) but Zva did not allow distinction between true and pseudo-severe AS (5.8 ± 1.8 vs. 5.3 ± 1.8mmHg/mL/m2; P = 0.30). In the total population, Zva was not predictive of long-term mortality. In the 128 patients who underwent aortic valve replacement, Zva was not predictive of operative death and of long-term mortality. Conclusions Increased Zva is related to low LVEF and more frequent CR on DSE in LEF/LGAS. However, Zva did not allow an accurate distinction between true and pseudo-severe AS and failed to predict operative and long-term mortality after aortic valve replacement, in LEF/LGAS.

Sleep-disordered breathing (SDB) is associated with left ventricle (LV) remodelling in patients with normal LV function. Sleep-disordered breathing is common in chronic heart failure (CHF) with systolic LV dysfunction, and may contribute to LV remodelling and CHF progression. Our aim was to determine the consequence of SDB on LV geometry in patients with CHF. We hypothesised that SDB severity was correlated with the degree of LV hypertrophy (LVH). One-hundred and sixty patients with CHF with a non-ischaemic systolic LV dysfunction were assessed by overnight polygraphy and echocardiography. Patients were classified in four groups according to their apnoea-hypopnoea index (AHI)

Background— Real-time 3-dimensional echocardiography (RT3DE) is superior to 2D echocardiography in assessing left ventricular (LV) volumes and ejection fraction (EF), but its feasibility is limited by multibeat acquisition, which requires an optimal breath-hold and a regular heart rhythm. We sought to evaluate the accuracy and feasibility of single- and 2-beat RT3DE for LV volume and EF assessment. Methods and Results— Sixty-six consecutive patients referred for cardiac magnetic resonance (CMR) underwent RT3DE and CMR on the same day. Of the 50 patients (age, 59±18 years; 68%men; 42% coronary artery disease; LVEF=49±14%; limits, 14% to 76%) with an adequate RT3DE image quality, accuracy for LV volumes and EF measurements of single- and 2-beat modalities were compared with the conventional 4-beat acquisition and CMR. Correlations with CMR for LV end-diastolic volume (161±59 mL, r =0.93 to 0.94) and end-systolic volume (86±56 mL, r =0.93 to 0.96) were excellent regardless of the number of cardiac cycles used. However, because of the low temporal resolution (7±2 volumes per second), single-beat underestimated LVEF (bias, −5±8%) with greater bias than 2-beat (bias, 1±6%, P P Conclusions— Compared with conventional multibeat acquisitions, 2-beat modality provides similar accuracy in LV volume and EF measurements and should be preferred due to fewer stitching artifacts. In contrast, the temporal resolution of single-beat modality appears insufficient to provide an accurate estimation of LVEF.

OBJECTIVES: Contrast-enhanced cardiac magnetic resonance (CMR) for infarct sizing has been validated in large animals, but studies and follow-up are restricted. We sought to (1) validate CMR for assessment of myocardial area at risk (MAR) and infarct size (IS) in a rabbit model of reperfused myocardial infarction (MI); (2) analyse the relation between ischaemic substrates and subsequent left ventricular (LV) remodelling. METHODS: Experimental reperfused acute MI was induced in 16 rabbits. Ten animals underwent cross-registered cine and contrast-enhanced CMR and histopathology at day 3 for assessment of MAR and IS (group 1). The remaining six rabbits underwent serial CMR for the study of LV remodelling (group 2). RESULTS: In group 1, mean IS was 12.7 +/- 6.4% and 12.7 +/- 6.9% of total LV myocardial mass on CMR (late-enhancement technique) and histopathology (P = 0.52; r = 0.93). No significant difference occurred between CMR and histopathology for the calculation of MAR and IS/MAR ratio (P = 0.18 and P = 0.17), whereas correlations were strong (r = 0.92 and r = 0.95). In group 2, mean LV end-diastolic, end-systolic volumes and LV mass were significantly increased at 3 weeks compared with measurements at day 3 (P < 0.01). Significant correlations between initial IS and the increase in LV end-diastolic volume (r = 0.66) and the increase in LV mass (r = 0.48) were observed, as well as correlations between initial MAR and the increase in LV end-diastolic volume (r = 0.70) and the increase in LV mass (r = 0.37). CONCLUSIONS: Comprehensive CMR provides accurate assessment of IS and MAR in reperfused rabbit MI. Infarct size is closely related to LV remodelling. Through the infarct size/MAR ratio, this approach has great potential for assessing interventions aimed at cardioprotection.

ObjectivesThis study investigated whether aortic valve replacement (AVR) is associated with improved survival in patients with severe low-flow/low-gradient aortic stenosis (LF/LGAS) without contractile reserve (CR) on dobutamine stress echocardiography (DSE).BackgroundPatients with LF/LGAS without CR have a high mortality rate with conservative therapy. The benefit of AVR in this subset of patients remains controversial.MethodsEighty-one consecutive patients with symptomatic calcified LF/LGAS (valve area ≤1 cm2, left ventricular ejection fraction ≤40%, mean pressure gradient [MPG] ≤40 mm Hg) without CR on DSE were enrolled. Absence of CR was defined as the absence of increase in stroke volume of ≥20% compared with the baseline value. Multivariable analysis and propensity scores were used to compare survival according to whether or not AVR was performed (n = 55).ResultsFive-year survival was higher in AVR patients compared with medically managed patients (54 ± 7% vs. 13 ± 7%, p = 0.001) despite a high operative mortality of 22% (n = 12). An AVR was independently associated with lower 5-year mortality (adjusted hazard ratio from 0.16 to 5.21 varying with time [95% confidence interval: 0.12–3.16 to 0.21–8.50], p = 0.00026). In 42 propensity-matched patients, 5-year survival was markedly improved by AVR (65 ± 11% vs. 11 ± 7%, p = 0.019). Associated bypass surgery (p = 0.007) and MPG ≤20 mm Hg (p = 0.035) were independently predictive of operative mortality. Late survival after AVR (excluding operative death) was 69 ± 8% at 5 years.ConclusionsIn patients with LF/LGAS without CR on DSE, AVR is associated with better outcome compared with medical management. Surgery should not be withheld from this subset of patients solely on the basis of lack of CR on DSE.

To study the impact on outcomes of direct admission versus emergency room (ER) admission in patients with ST-segment elevation myocardial infarction (STEMI) DESIGN: Nationwide observational registry of STEMI patients369 intensive care units in France.Patients were categorised on the basis of the initial management pathway (direct transfer to the coronary care unit or catheterisation laboratory versus transfer via the ER).Delays between symptom onset, admission and reperfusion therapy. Mortality at five days and one year.Of 1204 patients enrolled, 66.9% were admitted direct and 33.1% via the ER. Bypassing the ER was associated with more frequent use of reperfusion (61.7% v 53.1%; p = 0.001) and shorter delays between symptom onset and admission (244 (interquartile range 158) v 292 (172) min; p0.001), thrombolysis (204 (150) v 258 (240) min; p0.01), hospital thrombolysis (228 (156) v 256 (227) min, p = 0.22), and primary percutaneous coronary intervention (294 (246) v 402 (312) min; p0.005). Five day mortality rates were lower in patients who bypassed the ER (4.9% v 8.6%; p = 0.01), regardless of the use and type of reperfusion therapy. After adjusting for the simplified Thrombolysis in Myocardial Infarction (TIMI) risk score, admission via the ER was an independent predictor of five day mortality (odds ratio 1.67, 95% confidence interval 1.01 to 2.75).In this observational analysis, bypassing the ER was associated with more frequent and earlier use of reperfusion therapy, and with an apparent survival benefit compared with admission via the ER.

To analyse the short and long term prognostic significance of admission glycaemia in a large registry of non-diabetic patients with acute myocardial infarction.Assessment of short and long term prognostic significance of admission blood glucose in a consecutive population of 1604 non-diabetic patients admitted to intensive care units in France in November 2000 for a recent (or= 48 hours) myocardial infarction.In-hospital mortality, compared with that of patients with admission glycaemia below the median value of 6.88 mmol/l (3.7%), rose gradually with each of the three upper sextiles of glycaemia: 6.5%, 12.5% and 15.2%. Conversely, one year survival decreased from 92.5% to 88%, 83% and 75% (p0.001). Admission glycaemia remained an independent predictor of in-hospital and one year mortality after multivariate analyses accounting for potential confounders. Increased admission glycaemia also was a predictor of poor outcome in all clinical subsets studied: patients without heart failure on admission, younger and older patients, patients with or without reperfusion therapy, and patients with or without ST segment elevation.In non-diabetic patients, raised admission blood glucose is a strong and independent predictor of both in-hospital and long term mortality.

Background— Dobutamine stress hemodynamics (DSH) has the potential to stratify operative risk in low-gradient aortic stenosis (AS), but little is known about the relation between left ventricle contractile reserve and postoperative left ventricular ejection fraction (LVEF). We sought to assess the value of DSH to predict postoperative improvement in LVEF. Methods and Results— Sixty-six consecutive patients with symptomatic severe AS (aortic valve area ≤1 cm 2 ), LVEF ≤40%, and mean pressure gradient ≤40 mm Hg prospectively enrolled in the French multicenter study on low-gradient AS and who survived to aortic valvular replacement (AVR) were included. Preoperative contractile reserve was present in 46 patients (group I; 70%) and absent in 20 patients (group II; 30%). In the overall sample, 58% of patients improved by 2 New York Heart Association (NYHA) classes after AVR. Mean LVEF improved from 29±6% to 47±11% ( P P =0.54). On multivariable analysis, multivessel coronary artery disease ( P =0.05) and baseline mean transaortic pressure gradient ( P =0.01) were related to LVEF improvement, whereas contractile reserve was not. Conclusions— LVEF increases in the majority of patients with low-gradient AS who survive after AVR. Although the absence of contractile reserve on DSH is related to high operative mortality, it does not predict the absence of LVEF recovery in patients surviving to AVR. These data further support the concept that surgery should not be contraindicated on the basis of absence of contractile reserve alone.

Aims To determine whether sex differences of in-hospital and after-discharge mortality differ according to the age. Methods and results Data of 4347 consecutive patients hospitalized within 48 h of the onset of acute myocardial infarction (AMI) were analysed. Patients were classified according to median age (68 years): Group 1 (G1) (308 women, 30–67 years), G2 (1878 men, 30–67 years), G3 (860 women, 68–89 years), and G4 (1301 men, 68–89 years). In both age groups, women were older, had more frequent co-morbidities, lower rate of reperfusion therapy, and received less anti-platelet agents, β-blockers, and statins than men. The overall 1-year mortality was higher in women (25% vs. 16% in men, P

OBJECTIVES We sought to assess the value of transthoracic echocardiography (TTE) using standardized imaging planes for the functional analysis of mitral regurgitation (MR) as well as for postoperative outcome implications. BACKGROUND The feasibility of mitral valve repair is based on functional assessment of MR, mainly by transesophageal echocardiography (TEE). Considering the recent advances in TTE imaging, the incremental value of TEE in this setting needs to be re-examined. METHODS Consecutive patients (n = 279; 181 men; median age 68 years [quartiles, 61 to 74]) who underwent surgery for MR were enrolled prospectively in two tertiary care centers. The accuracy of TTE (harmonic imaging) versus TEE for functional assessment of MR was evaluated against surgical findings. RESULTS Valve repair (n = 237 patients, 85%) or replacement (n = 42) was predicted accurately by TTE in 97% of cases; TEE added significant information for only two patients. In the subgroup of degenerative MR (n = 190), agreement with surgical findings for the localization of prolapsed segments was 91% for TTE (kappa, 0.81) and 93% for TEE (kappa, 0.85) without incremental value of TEE (p = 0.40). Patients with single prolapse of the middle posterior scallop (P2) had a better postoperative outcome as compared with patients who had non-P2 lesions (p = 0.008). Furthermore, mitral replacement predicted by TTE was an independent predictor for postoperative long-term mortality (odds ratio 5.7, 95% confidence interval 1.97 to 16.4, p = 0.001). CONCLUSIONS In experienced hands, functional assessment of MR by TTE can predict accurately valve repairability and has a strong influence on postoperative outcome. Thus, in most cases preoperative TEE is not mandatory, provided intraoperative TEE is performed.

Objective: To assess actual practices and in-hospital outcome of patients with acute myocardial infarction on a nationwide scale. Methods: Of 443 intensive care units in France, 369 (83%) prospectively collected data on all cases of infarction (within < 48 hours of symptom onset) in November 2000. Results: 2320 patients (median age 68 years, 73% men) were included, of whom 83% had ST segment elevation infarction (STEMI). Patients without STEMI were older and had a more frequent history of cardiovascular disease. Median time to admission was 5.0 hours for patients with and 6.5 hours for those without STEMI. Reperfusion therapy was used for 53% of patients with STEMI (thrombolysis 28%, primary angioplasty 25%). In-hospital mortality was 8.7% (5.5% of patients without and 9.3% of those with STEMI). Multivariate analysis found that age, Killip class, lower blood pressure, higher heart rate on admission, anterior location of infarct, STEMI, diabetes mellitus, previous stroke, and no current smoking independently predicted in-hospital mortality. At hospital discharge, 95% received antiplatelet agents, 75% received β blockers, and over 60% received statins. Angiotensin converting enzyme inhibitors were prescribed for 40% of the patients without and 52% of those with ST elevation. Conclusions: This nationwide registry, including all types of centres irrespective of their size and experience, shows continued improvement in patient care and outcomes. Time from symptom onset to admission, however, has not improved in recent years and reperfusion therapy is used for just over 50% of patients with STEMI, with an increasing use of primary angioplasty.

B-type Natriuretic Peptide (BNP) is activated in patients with severe, symptomatic aortic stenosis (AS), but the prognostic value of BNP in this setting has not been extensively studied. This study aimed to assess the prognostic value of the BNP level in symptomatic and asymptomatic patients with severe AS.Seventy consecutive patients referred to our echocardiography laboratory for severe AS with preserved left ventricular function were prospectively enrolled (40 men, median age 74 years [62-82]; aortic valve area 0.7 cm2 [0.6-0.8]; transaortic gradient 48 mmHg [38-60], and left ventricular fractional shortening 38% [32-43]). C-terminal BNP serum level at enrollment was evaluated against baseline functional and echocardiographic parameters as well as clinical outcome.BNP level was elevated in the presence of symptoms and increased with NYHA functional class. BNP serum level66 pg/ml detected symptomatic patients with a sensitivity, specificity and accuracy of 84%, 82% and 84%, respectively. In symptomatic and asymptomatic patients, BNP level was a strong independent predictor for cardiovascular death by multivariable analysis adjusted to age and NYHA functional class.BNP serum level allows to differentiate symptomatic from asymptomatic patients with severe AS. BNP is an independent predictor of outcome in these patients and may be helpful for risk stratification.

Objective: To assess left ventricular remodelling in patients with reperfused acute myocardial infarction and to study its relation to microvascular damage. Patients: 25 patients successfully treated by primary percutaneous coronary angioplasty for acute myocardial infarction. Setting: University hospital Methods: Indexed end diastolic (EDVi) and end systolic (ESVi) volumes were assessed on admission and repeated at days 1 and 8. Coronary flow reserve (CFR) was assessed in the infarct related artery on day 1. Myocardial blood volume was assessed on admission and at day 8 by myocardial contrast echocardiography. In patients who manifested persistent myocardial dysfunction at hospital discharge (n = 21), local inotropic reserve was assessed by dobutamine echocardiography at day 7. Results: On admission, patients with and without local viability had similar EDVi and ESVi (EDVi 67 (9) and 73 (14) ml/m 2 , respectively; ESVi 34 (8) and 40 (11) ml/m 2 , respectively; NS). EDVi increased to 97 (22) ml/m 2 in patients without local viability (p v admission) but remained unchanged at 70 (11) ml/m 2 in patients with viable myocardium (NS v admission). For pooled patient data, the percentage change in EDVi correlated with CFR ( r = 0.76, p r = 0.80, p Conclusion: Left ventricular dilatation may preferably occur in patients without local viability and is correlated with early CFR and extent of myocardial blood volume in the infarct territory.

OBJECTIVE—The DIABHYCAR (type 2 DIABetes, Hypertension, CArdiovascular Events and Ramipril) study allowed investigators to analyze factors leading to the development of congestive heart failure (CHF) in type 2 diabetic patients with abnormal urinary albumin concentration. RESEARCH DESIGN AND METHODS—Type 2 diabetic subjects of both sexes aged ≥50 years who had a urinary albumin concentration ≥20 mg/l were randomly allocated to 1.25 mg/day ramipril or placebo in addition to their usual treatment and treated for 3–6 years in a double-blind fashion. Major outcomes including hospitalization for CHF were recorded during the follow-up. RESULTS—Of the 4,912 included patients, 187 developed CHF during the study. There was no significant difference in the incidence of CHF between the two treatment groups. Using a multivariate analysis, independent risk factors for the occurrence of CHF were age, history of cardiovascular disease, baseline urinary albumin concentration, baseline HbA1c, and smoking habits. A total of 68 of the 187 patients (36.4%) died during the 12 ± 11-month period after the first hospitalization for CHF, whereas the annual mortality rate of the population who did not develop CHF was 3.2%. CONCLUSIONS—Presence of atherosclerotic disease, baseline urinary albumin concentration, and HbA1c level were indicators for further development of CHF. Occurrence of CHF is a major prognostic turn in a diabetic patient’s life.

Objective: Epicardial adipose tissue (EAT) is suggested to correlate with metabolic risk factors and to promote plaque development in the coronary arteries. We sought to determine whether EAT thickness was associated or not with the presence and extent of angiographic coronary artery disease (CAD). Methods: We measured epicardial fat thickness by computed tomography and assessed the presence and extent of CAD by coronary angiography in participants from the prospective EVASCAN study. The association of EAT thickness with cardiovascular risk factors, coronary artery calcification scoring and angiographic CAD was assessed using multivariate regression analysis. Results: Of 970 patients (age 60.9 years, 71% male), 75% (n=731) had CAD. Patients with angiographic CAD had thicker EAT on the left ventricle lateral wall when compared with patients without CAD (2.7462.4 mm vs. 2.0862.1 mm; p=0.0001). The adjusted odds ratio (OR) for a patient with a LVLW EAT value $2.8 mm to have CAD was OR=1.46 [1.03–2.08], p=0.0326 after adjusting for risk factors. EAT also correlated with the number of diseased vessels (p=0.0001 for trend). By receiver operating characteristic curve analysis, an EAT value $2.8 mm best predicted the presence of.50% diameter coronary artery stenosis, with a sensitivity and specificity of 46.1% and 66.5% respectively (AUC:0.58). Coronary artery calcium scoring had an AUC of 0.76. Conclusion: Although left ventricle lateral wall EAT thickness correlated with the presence and extent of angiographic CAD, it has a low performance for the diagnosis of CAD. Citation: Picard FA, Gueret P, Laissy J-P, Champagne S, Leclercq F, et al. (2014) Epicardial Adipose Tissue Thickness Correlates with the Presence and Severity of

OBJECTIVES We sought to assess risk stratification by using dobutamine stress echocardiography (DSE) in patients with aortic stenosis (AS) and severe left ventricular (LV) dysfunction. BACKGROUND Few data are available on risk stratification for valve replacement in patients with AS, LV dysfunction and low transvalvular gradients. METHODS Low-dose DSE was performed in 45 patients (16 women and 29 men; median [quartile range] age in years: 75 [69 to 79]; left ventricular ejection fraction: 0.29 [0.23 to 0.32]; aortic valve area [cm2]: 0.7 [0.5 to 0.8]; mean transaortic gradient [mm Hg]: 26 [21 to 33]). Patients were classified into two groups: group I (n = 32, LV contractile reserve on DSE) and group II (n = 13, no contractile reserve). Valve replacement was performed in 24 and 6 patients in groups I and II, respectively. RESULTS Perioperative mortality was 8% in group I and 50% in group II (p = 0.014). Survival at five years after the operation was 88% in group I. Compared with medical therapy, valve surgery was associated with better long-term survival in group I (hazard ratio for death [HR-D] 0.13, 95% confidence interval [CI] 0.002 to 0.49) and reduced survival in group II (HR-D 19.6, 95% CI 2.7 to 142). The effect of valve surgery on survival remained significant in both groups after adjustment for age, diabetes, respiratory disease and hypertension. Medical therapy had the same effect in both groups. CONCLUSIONS In patients with AS, LV dysfunction and low transvalvular gradients, contractile reserve on DSE is associated with a low operative risk and good long-term prognosis after valve surgery. In contrast, operative mortality remains high in the absence of contractile reserve.

OBJECTIVES We sought to evaluate Dobutamine stress echocardiography (DSE) for predicting recovery of viable myocardium after revascularization with cineangiography as a gold standard for left ventricular (LV) function. We studied the influence of late vessel reocclusion on regional LV function. BACKGROUND Dobutamine stress echocardiography is a well established evaluation method for myocardial viability assessment. In previous studies the reference method for assessing LV recovery was echocardiography; long-term vessel patency has not been systematically addressed. METHODS Sixty-eight patients with a first acute myocardial infarction (AMI) and residual stenosis of the infarct related artery (IRA) underwent DSE (mean ± standard deviation) 21 ± 12 days after AMI to evaluate myocardial viability. Revascularization of the IRA was performed in 54 patients by angioplasty (n = 43) or bypass grafting (n = 11). Coronary angiography and LV cineangiography were repeated at four months to assess LV function and IRA patency. RESULTS Sensitivity and specificity of DSE for predicting myocardial recovery after revascularization were 83% and 82%. In the case of late IRA patency, specificity increased to 95%, whereas sensitivity remained unchanged. In the 16 patients with myocardial viability and late IRA patency, echocardiographic wall motion score index decreased after revascularization from 1.83 ± 0.15 to 1.36 ± 0.17 (p = 0.0001), and left ventricular ejection fraction (LVEF) increased from 0.52 ± 0.06 to 0.57 ± 0.06 (p = 0.0004), whereas in five patients, reocclusion of the IRA prevented improvement of segmental or global LV function despite initially viable myocardium. CONCLUSIONS Dobutamine stress echocardiography is reliable to predict recovery of viable myocardium after revascularization in postinfarction patients. Late reocclusion of the IRA may prevent LV recovery and influence the accuracy of DSE.

Objectives. The aim of this study was to assess the effects of ischemia on diastolic function by analyzing flow propagation velocity with color M-mode Doppler echocardiography.Background. Color M-mode Doppler echocardiography has been proposed as a method of assessing left ventricular filling.Methods. Color M-mode Doppler echocardiography and measurement of hemodynamic data were performed simultaneously at baseline and during angioplasty-induced ischemia. Tau was compared with flow propagation velocity. Late diastolic indexes, left ventricular pressure and flow cessation time were also investigated.Results. During ischemia, left ventricular relaxation rate (tau) increased, whereas flow propagation velocity decreased, from (mean ± SD) 46.8 ± 10 ms to 72.6 ± 18.3 ms and from 59.8 ± 15.8 cm/s to 30 ± 8 cm/s, respectively (all p < 0.0001). The maximal slowing of flow propagation velocity was observed 20 to 30 s after the beginning of the inflation, coexisting with a notch on the ascending limb of the negative rate of rise of the left ventricular pressure (dP/dt) curve. Flow propagation velocity was correlated with tau both at baseline (r = 0.53, p < 0.05) and during inflation (r = 0.53, p < 0.03). Left ventricular end-diastolic pressure increased during ischemia from 13.5 ± 8 mm Hg at baseline to 27.5 ± 7 mm Hg, while a premature cessation of the entering flow occurred −13.8 ± 23 ms before the next Q wave onset, compared with 4.5 ± 19.6 ms after the Q wave onset at baseline (all p < 0.0001).Conclusions. The analysis of flow propagation velocity showed that early filling is highly dependent on left ventricular relaxation rate, particularly through the phenomenon of asynchrony. During ischemia, the premature cessation of late filling is associated with increased diastolic pressures.(J Am Coll Cardiol 1997;29:1246–55)

Many single center studies have reported high diagnostic accuracy of computed tomography coronary angiography (CTCA) for the detection of obstructive coronary artery disease (CAD), but multi-center studies have yielded variable results. We perform a meta-analysis of multi-center studies evaluating

International audience; BACKGROUND: The benefit of load expansion is controversial in acute pulmonary embolism (PE). The aim of this study was to evaluate the benefit of furosemide in cases of normotensive acute PE. METHODS AND RESULTS: We retrospectively included 70 consecutive normotensive patients (systolic blood pressure ≥ 90 mmHg) admitted for acute PE with right ventricular dilation. Overall, 40 patients were treated during the first 24h by repeated bolus of furosemide (78 ± 42 mg, range 40-160 mg) and 30 patients received isotonic saline solution (1.6 ± 0.9L). Severity of hemodynamic status was similar in both groups, but patients in the furosemide group were older and had a greater creatinine level. At 24h, only the furosemide group had a decreased shock index (0.82 ± 0.22 vs. 0.63 ± 0.16, P

Objectives. This study sought to evaluate the relation, if any, between fluid overload in congestive heart failure (CHF) and a newly discovered endogenous natriuretic factor acting like loop diuretic drugs: contransport inhibitory factor (CIF).Background. The humoral mechanisms regulating volume overload in CHF are not fully understood. Therefore, we investigated whether there is a role for CIF in this pathologic condition.Methods. Plasma and urinary CIF levels were investigated in 23 patients with chronic CHF and compared with changes in plasma atrial natriuretic peptide (ANP). Twelve patients without CHF served as control subjects.Results. CHF was associated with a highly significant threefold increase in both plasma CIF levels (mean ± SD 7.10 ± 3.01 vs. 2.28 ± 0.92 U/ml, p < 0.0001) and urinary CIF excretion (7,849 ± 3,600 vs. 2,351 ± 1,297 U/day, p < 0.0001) with respect to patients without CHF. CIF increased as a function of impairment in left ventricular ejection fraction (r = −0.703, p < 0.0001) and the severity of clinical status. Plasma ANP was also increased in patients with CHF, although to a lesser extent (68%, p = 0.0501) than plasma CIF, and was also significantly correlated with left ventricular ejection fraction (r = −0.552, p = 0.0004).Conclusions. Plasma and urinary CIF activities were strongly and very significantly increased in chronic CHF. In addition to ANP, this long-term natriuretic agent may be of potential importance in reducing fluid overload in CHF.

Summary Background Currently, several anatomical approaches and intervention sites can be used to perform transcatheter aortic valve implantations (TAVIs), often with no clinical indications for choosing one or another. While these choices can have an impact on resource consumption, no costing study is available in the European context to provide information on resource use and assist decision-making. Aims To provide comparative data on the cost of the TAVI procedure, depending on anatomical approach and intervention site used, from a hospital perspective, and to analyze factors associated with cost of hospital stay. Methods Multicentre national registry data were collected in 16 centres between January and October 2009. For 287 patients, a descriptive costing study and a multivariable analysis of hospital stay cost were performed. Results The mean cost of the TAVI procedure was € 22,876 and the mean initial hospital stay cost was € 35,164. The procedure cost, excluding valve cost, did not differ between anatomical approaches and was highest in the hybrid room and lowest in the catheterization laboratory. Factors associated with higher hospital stay cost were transapical approach, Society of Thoracic Surgeons score > 10%, warfarin use at inclusion, complications during procedure and pacemaker implantation following valve implantation. Conclusions If clinical considerations do not interfere, hospital staff may find it economically favorable to opt for the catheterization laboratory and against the hybrid room. The mean hospital stay cost is higher than the tariff paid in 2011, a difference that has grown since the change in tariff in 2012, representing an economic disincentive for the uptake of TAVI in France.

Background Traumatic disruption of the aorta (TDA) is a life-threatening injury that requires rapid diagnosis and treatment. Emergency aortography, which is the current standard diagnostic imaging modality, is invasive, time-consuming, and difficult to perform in hemodynamically unstable patients with multiple trauma. We performed transesophageal echocardiography (TEE) in patients with suspected TDA to determine the diagnostic accuracy and impact on patient management of this alternative, portable imaging modality. Methods and Results Thirty-two consecutive trauma patients (mean age, 40±16 years) with suspected TDA (violent deceleration accident and mediastinum >8 cm on admission chest x-ray) prospectively underwent a TEE examination in the emergency room. Findings during TEE were compared with those encountered during aortography, surgery, or necropsy. Two subsets of traumatic aortic injuries with distinct echocardiographic signs were observed: (1) subadventitial TDA (n=10) and (2) traumatic intimal tears (n=3). Eighteen patients had normal TEE confirmed by aortography. One 2-mm medial tear was missed by TEE (necropsy). The sensitivity and specificity of TEE for the diagnosis of subadventitial TDA were 91% and 100%, respectively. Patients with subadventitial TDA were taken to surgery immediately, whereas patients with intimal aortic tears were treated conservatively. Eighteen patients (mean age, 57±15 years) with confirmed acute aortic dissection involving the aortic isthmus were also included to establish the echocardiographic differential diagnostic criteria between this entity and TDA. Conclusions TEE should be considered the first-line imaging modality for the evaluation of trauma patients with suspected injuries of the thoracic aorta because of its portability, safety, diagnostic accuracy, and potential impact on patient management.

Abstract The objective of this trial was to assess the effects of 6-month daily treatment with two doses of ramipril on left ventricular mass and the dependence of this on blood pressure changes in hypertensive patients with left ventricular hypertrophy. After a selection phase of 4 to 6 weeks with patients under antihypertensive therapy with 20 mg furosemide daily, 115 patients with either controlled or uncontrolled hypertension and left ventricular hypertrophy were randomized in a double-blind manner to receive either placebo (n=40), 1.25 mg (low dose, n=38), or 5 mg (regular dose, n=37) ramipril daily for 6 months. Treatment with furosemide was continued unchanged during this phase. The main outcome measured was left ventricular hypertrophy regression as assessed from central blind reading of echocardiograms recorded at randomization and after 6 months. No significant differences were observed for changes in casual or ambulatory blood pressure between the three groups. Left ventricular mass index was found to be significantly reduced in patients receiving 5 mg ramipril compared with those receiving placebo (−10.8±3.7 versus +4.1±4.0 g/m 2 , P =.008); in patients receiving 1.25 mg ramipril, the difference was close to borderline significance compared with placebo (−7.0±4.3 g/m 2 , P =.06). Similar results were observed for changes in left ventricular mass (−20.3±6.6 and −13.0±7.8 g in the 5- and 1.25-mg ramipril groups, respectively, versus +9.1±7.2 g in the placebo group; P =.004 and .04, respectively). In a multiple regression model testing 10 potential explicative variables, we found that this reduction was correlated with treatment, both 1.25 and 5.0 mg ramipril ( P =.03 and .01, respectively), and with the baseline value of the left ventricular mass index ( P =.005). Changes in ambulatory or casual systolic and diastolic blood pressures were not predictive of changes in left ventricular mass ( P =.15 and .16, respectively). Ramipril at 1.25 and 5 mg daily for 6 months can induce left ventricular hypertrophy regression, independent of changes in blood pressure, in patients under furosemide (20 mg/d) antihypertensive therapy. The implications of this regression for cardiovascular morbidity and mortality in hypertensive patients should now be assessed.

Dental implants and valvular heart diseases: for an evolution of recommendations. AFSSAPS published in September 2011 new recommendations in odontology about antibiotics prophylaxis. The patients belonging to the former moderate risk group of infectious endocarditis (mitral and aortic insufficiencies, aortic stenosis...) are now considered as the general population and should thus be treated in the same way. However, considering the risk correlated to the evolution of these pathologies, it is necessary to set limits for the implant treatment in order to prevent any infection risk., L’AFSSAPS a publié de nouvelles recommandations en septembre 2011 relatives à l’antibioprophylaxie en odontologie. Les patients appartenant à l’ancien groupe à risque modéré d’endocardite infectieuse (insuffisance mitrale, insuffisance aortique, rétrécissement aortique…) intègrent désormais le groupe de la population générale et devraient donc être, à ce titre, traités de façon identique. Cependant, au vu du risque de l’évolution de ces pathologies, il parait nécessaire de poser des limites au traitement implantaire afin de prévenir le risque infectieux.

Otras entidades de la ESC que han participado en la elaboracion de este documento: Asociaciones: Acute Cardiovascular Care Association (ACCA), European Association for Cardiovascular Prevention and Rehabilitation (EACPR), European Association of Cardiovascular Imaging (EACVI), European Association of Percutaneous Cardiovascular Interventions (EAPCI), Heart Failure Association (HFA). Consejos: Council for Cardiology Practice (CCP), Council on Cardiovascular Nursing and Allied Professions (CCNAP), Council on Cardiovascular Primary Care (CCPC). Grupos de Trabajo: Farmacoterapia Cardiovascular, Cirugia Cardiovascular, Cardiopatias Congenitas en el Adulto, Enfermedades del Miocardio y del Pericardio, Circulacion Pulmonar y Funcion Ventricular Derecha, Valvulopatias. El contenido de esta Guia de Practica Clinica de la Sociedad Europea de Cardiologia (ESC) se publica exclusivamente para uso personal y educativo. No se autoriza su uso comercial. No se autoriza la traduccion o reproduccion de ningun fragmento de esta guia sin la autorizacion escrita de la ESC. La autorizacion se solicitara por escrito a Oxford University Press, editorial de European Heart Journal y representante autorizado de la ESC para gestionar tales permisos. Descargo de responsabilidad. Esta guia recoge la opinion de la ESC y se ha elaborado tras el estudio minucioso de los datos y la evidencia disponibles hasta la fecha. La ESC no es responsable en caso de que haya alguna contradiccion, discrepancia o ambiguedad entre la guia de practica clinica (GPC) de la ESC y cualquier otra recomendacion oficial o GPC publicada por autoridades relevantes de la sanidad publica, particularmente en lo que se refiere al buen uso de la atencion sanitaria y las estrategias terapeuticas. Se espera que los profesionales de la salud tengan en consideracion esta GPC a la hora de tomar decisiones clinicas, asi como al implementar estrategias medicas preventivas, diagnosticas o terapeuticas. No obstante, esta guia no anula la responsabilidad individual de cada profesional al tomar las decisiones oportunas relativas a cada paciente, de acuerdo con dicho paciente y, cuando fuera necesario, con su tutor o representante legal. Ademas, las GPC de la ESC no eximen al profesional medico de su obligacion etica y profesional de consultar y considerar atentamente las recomendaciones y las GPC actualizadas emitidas por autoridades sanitarias competentes. Es tambien responsabilidad del profesional verificar la normativa y la legislacion sobre farmacos y dispositivos medicos a la hora de prescribirlos. Los formularios de autorizacion de todos los autores y revisores se encuentran en la pagina web de la ESC: www.escardio.org/guidelines

BACKGROUND: Normal values and the prognostic significance of right ventricle (RV)-2D strain in chronic heart failure (CHF) patients are unknown. METHODS AND RESULTS: Between 2005 and 2010, we prospectively enrolled 43 controls and 118 stable CHF patients. Standard echocardiographic variables, tricuspid annular plane systolic excursion, peak systolic velocity of tricuspid annular motion using tissue Doppler imaging, and RV and left ventricle (LV) 2D-strain were measured. The primary outcome was death or emergency transplantation or emergency ventricular assist device implantation or acute heart failure. RV-2D strain was measurable in 39 controls (58±17 years, 50% men), whose median value was 30% (95% confidence interval [95%CI], 39%; 20%); and in 104 CHF patients (80% men, mean age 57±11 years, and mean LV ejection fraction 29%±8%), whose median value was 19% (95%CI, 34%; 9%). During the mean follow-up of 37±14 months, 44 experienced the primary outcome. By Cox proportional hazards multivariate analysis, only RV-2D strain and log B-type natriuretic peptide independently predicted experiencing the primary outcome within the first year. The best RV-2D strain cut-off by receiver-operating characteristics analysis was 21%, and patients with values >21% were at greatest risk (χ(2)-log-rank test=14.1, P

SummaryBackgroundCentral venous oxygen saturation (ScvO2) provides an estimation of body oxygen consumption/delivery ratio. Its use has been suggested for monitoring treatment of patients admitted for acute decompensated heart failure (ADHF) but the optimal target value has never been clearly reported.AimsWe aimed to address the prognostic value of ScvO2 in ADHF requiring inotrope support.MethodsScvO2 was prospectively assessed in 60 patients with ADHF requiring inotrope support (mean age 62±16 years; 45 men; left ventricular ejection fraction 25±7%) and was compared with major adverse cardiac events (MACE), defined as heart transplantation, cardiac assistance and death.ResultsMACE occurred in 22 (35%) patients (14 deaths; eight referred for heart transplantation or cardiac assistance). Admission ScvO2 (mean 57±13%) did not differ between patients with and without MACE. At 24hours ScvO2 (mean 62±7%) increased only in patients without MACE (65±6% vs. 58±7%; p60% at 24hours.ConclusionIn patients admitted for ADHF requiring inotrope support, ScvO2≤60% despite optimal treatment is a marker of poor outcome and might be an indicator for considering more aggressive therapy.

Aims To evaluate the impact of acoustic window on the feasibility and accuracy of longitudinal global strain (global- ɛ ) by speckle tracking for assessing left ventricular (LV) systolic function. Methods and results The study included 70 patients (57 ± 17 years, 64% men), 28 selected patients with a suboptimal image quality (IQ) defined by three or more segments (4 ± 3 segments/patient) with wall motion score not analysable visually and 42 patients with an optimal two-dimensional (2D) echocardiography IQ. Left ventricular ejection fraction (LVEF) by Simpson's biplane method (2D-EF), global- ɛ by speckle tracking, and peak systolic mitral annulus velocity [systolic tissue Doppler imaging (S-TDI)] were compared with LVEF by cardiac magnetic resonance (EF-CMR; 45 ± 18%, range 9–76%). Speckle-tracking analysis was feasible in all segments with an optimal acoustic window and in 85% (103/121) of segments poorly visualized. Global- ɛ similarly correlated with LVEF by CMR in patients with and without optimal IQ ( r = 0.81 vs. 0.82 for good vs. poor IQ). In contrast, 2D-EF ( r = 0.76) and S-TDI ( r = 0.64) less correlated with LVEF by CMR in patients with a suboptimal IQ. Importantly, IQ only impacted on 2D-EF inter-observer reproducibility (9 ± 5 vs. 24 ± 22% for good vs. poor IQ) but not on global- ɛ reproducibility (9 ± 1 vs. 8 ± 7% for good vs. poor IQ). Conclusion In patients with a limited acoustic window, longitudinal strain by speckle tracking remains accurate and reproducible for assessing global and regional LV systolic function.

Background The impact of antidiabetic medications on clinical outcomes in patients developing acute myocardial infarction (MI) is controversial. We sought to determine whether in-hospital outcomes in patients who were on sulfonylureas (SUs) when they developed their MIs differed from those of diabetic patients not receiving SUs, and whether clinical outcomes were related to the pancreatic cell specificity of SUs. Methods and Results we analyzed the outcomes of the 1310 diabetic patients included in the nationwide French registry of Acute ST-elevation and non ST-elevation myocardial infarction (FAST-MI) in 2005. Medications used before the acute episode were recorded. In-hospital complications were analyzed according to prior antidiabetic treatment. Mortality was lower in patients previously treated with SUs (3.9%), versus those on other oral medications (6.4%), insulin (9.4%) or no medication (8.4%) (p = 0.014). Among SU-treated patients, in-hospital mortality was lower in patients receiving pancreatic cell-specific SUs (gliclazide or glimepiride)(2.7%), compared with those on glibenclamide (7.5%) (p = 0.019). Arrhythmias and ischemic complications were also less frequent in patients receiving gliclazide/glimepiride. The lower risk in patients receiving gliclazide/glimepiride versus glibenclamide persisted after multivariate adjustment (OR = 0.15; 95%CI: 0.04–0.56) and in propensity score-matched cohorts. Conclusion In this nationwide registry of patients hospitalized for acute MI, no hazard was associated with the use of SUs before the acute episode. In addition, patients who had previously received gliclazide/glimepiride had better in-hospital outcomes, compared to those on glibenclamide.

Background Diffusion weighted magnetic resonance imaging (DWI) is used to identify tissue injury area in patients admitted for stroke. Limited study has been performed to evaluate its clinical interest in patients with acute ST elevation myocardial infarction (STEMI). Methods The study included 17 patients (14 men, 55 ± 14years, 12 anterior) with a recent STEMI ( Results Large area of hypersignal correlated with impaired baseline LVEF whatever b value (r value range between 0.58 and 0.60, p Conclusion In patients with acute MI, hypersignal area from diffusion weighted magnetic resonance imaging with b = 50 sec/mm2 seems to provide an accurate assessment of myocardial injury and may be used to predict LVEF recovery.

Aims To assess the usefulness of miniature transoesophageal echocardiography using a 10 F intracardiac probe (ICE-TEE) for transseptal catheterization during atrial fibrillation (AF) ablation. Methods and results Intracardiac echocardiography probe was used transoesophageally in 79 consecutive patients (56 ± 11 years, 73% male) referred for AF ablation (60% paroxysmal and 38% persistent) to guide transseptal puncture. Transseptal catheterization monitored by ICE-TEE was well tolerated and successfully performed in all patients without any sedation. No mechanical oesophageal complication was noted. Moreover, the mean duration between ICE-TEE probe insertion and successful transseptal puncture was 4.5 min and the mean time of ICE-TEE was 10 min. Finally, no tamponade occurred during the AF ablation procedure. Conclusion Intracardiac echocardiography-TEE is safe and well tolerated for the guidance of transseptal catheterization during AF ablation. Moreover, this technique was performed without requiring any anaesthesia.

Background— Longitudinal myocardial deformation indexes appear superior to left ventricular ejection fraction (LVEF) in assessing myocardial contractility. However, few studies have addressed the prognostic value of longitudinal motion markers (velocity, strain, and strain rate) in predicting outcome in heart failure patients. Methods and Results— The study included 125 consecutive symptomatic heart failure patients (63�16 years, 77% male, LVEF=31�10%). All patients underwent a complete echocardiographic and clinical examination, and brain natriuretic peptide level was assessed in 93 patients. Longitudinal myocardial velocity by tissue Doppler imaging, global-ε, and strain rate by speckle tracking were computed from apical views (4-, 3-, and 2-chambers views) and compared with the occurrence of major adverse cardiac events. On the whole, peak longitudinal velocity, global-ε, and strain rate averaged 5�2 cm/s (range, 1 to 9), −8�3% (range, −3 to −18), and −0.33�0.16 s −1 (range, −0.83 to −0.05), respectively. During the follow-up period (266�177 days), major adverse cardiac events occurred in 47 (38%) patients (15 deaths, 29 recurrent heart failure, and 4 heart transplantations). By univariable analysis using Cox model global-ε, strain rate, and LVEF were associated with the occurrence of major adverse cardiac events, whereas only global-ε remained independently predictive of outcome by multivariate analysis. Conclusions— In the heart failure population, longitudinal global strain by speckle tracking is superior to LVEF and other longitudinal markers in identifying patients with poor outcome.

PurposePost systolic shortening (PSS) and stretching motion occur early during ischemia. Delayed contraction in PSS and stretching motion does not fully contribute to left ventricular end systolic (ES) function and contribute to the left ventricular dysfunction. The wasted energy can be quantified as the difference between peak strain and end systolic strain and used to identify ischemic segments.MethodsAcute myocardial ischemia was induced in 9 anesthetized pigs by balloon coronary occlusion (left coronary descending artery, n=6). Circumferential strain by speckle tracking was computed from short axis view during ischemia at 5’, 30’and 60’. PSS was defined as peak strain occurring after ES and stretching motion as positive systolic peak strain.ResultsBefore induced ischemia, PSS was observed in 38% segments and stretching motion was low (0±1%), then the wasted energy was limited (1±0%). During acute (5’) and prolonged (60’) coronary occlusion, stretching motion increased (4±2% at 5’, and 8±2% at 60’) and PSS became more prevalent (54% and 54%, respectively) and delayed in ischemic segment (3% and 12% of RR interval, respectively). This result the wasted energy was greater in ischemic than non ischemic segment (5±1% vs. 1±1% at 5’, p