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Aim: The historical evolution of incidence and outcome of cardiogenic shock (CS) in acute myocardial infarction (AMI) patients is debated. This study compared outcomes in AMI patients from 1995 to 2005, according to the presence of CS., Method and Results: Three nationwide French registries were conducted 5 years apart, using a similar methodology in consecutive patients admitted over a 1-month period. All 7531 AMI patients presenting ≤48 h of symptom onset were included. The evolution of mortality was compared in the 486 patients with CS vs. those without CS. The incidence of CS tended to decrease over time (6.9% in 1995; 5.7% in 2005, P = 0.07). Thirty-day mortality was considerably higher in CS patients (60.9 vs. 5.2%). Over the 10-year period, mortality decreased for both patients with (70-51%, P = 0.003) and without CS (9-4%, P < 0.001). In CS patients, the use of percutaneous coronary intervention (PCI) increased from 20 to 50% (P < 0.001). Time period was an independent predictor of early mortality in CS patients (OR for death, 2005 vs. 1995 = 0.45; 95% CI: 0.27-0.75, P = 0.005), along with age, diabetes, and smoking status. When added to the multivariate model, PCI was associated with decreased mortality (OR = 0.38; 95% CI: 0.24-0.58, P < 0.001). In propensity-score-matched cohorts, CS patients with PCI had a significantly higher survival., Conclusions: Cardiogenic shock remains a clinical concern, although early mortality has decreased. Improved survival is concomitant with a broader use of PCI and recommended medications at the acute stage. Beyond the acute stage, however, 1-year survival has remained unchanged.

Background: In patients with atrial fibrillation (AF), adherence to guidelines for antithrombotic treatment is poorly followed, and undertreatment (or nonadherence with guidelines) is associated with a worse prognosis. The study objective was to evaluate whether this was also the case in a large contemporary series of unselected patients with AF in real-world clinical practice., Methods: All patients with AF or atrial flutter seen in our institution between 2000 and 2007 were identified in a database and followed up for mortality and stroke. Antithrombotic guideline adherence was assessed according to the 2006 American College of Cardiology/American Heart Association/European Society of Cardiology guidelines., Results: We reviewed outcomes in 3,646 consecutive patients with AF or atrial flutter (aged 71 ± 14 years; mean CHADS(2) [congestive heart failure, hypertension, aged ≥ 75 years, diabetes mellitus, prior stroke or transient ischemic attack] score, 1.5 ± 1.1). Antithrombotic treatment was in agreement with the guidelines in 53% of patients, whereas 31% were classified as undertreated and 16% as overtreated. Among other parameters, nonpermanent AF and atrial flutter were independently associated with an increased risk of undertreatment. After a follow-up of 953 ± 767 days (median, 771 days; interquartile range, 1,286 days), guideline adherence was associated with a lower risk of adverse events (death from all causes or stroke) compared with undertreatment (relative risk, 0.47; 95% CI, 0.40-0.55; P < .0001). Overtreatment was associated with a lower risk of adverse events compared with the guideline-adherent population (relative risk, 0.40; 95% CI, 0.28-0.58; P < .0001). Factors independently associated with increased risk of mortality or stroke were antithrombotic undertreatment, older age, heart failure, renal failure, diabetes, male sex, and previous history of stroke., Conclusions: Guideline nonadherence and undertreatment with antithrombotic agents in unselected real-world patients with AF or atrial flutter are independently associated with a high risk of stroke and mortality.

Background: Atrial fibrillation developing at the acute stage of myocardial infarction is associated with untoward clinical outcomes. The aim of this study was to determine correlations between early statin therapy and atrial fibrillation in acute myocardial infarction., Methods: Patients (3396) with sinus rhythm developing acute myocardial infarction were enrolled in the French registry of Acute ST-elevation and non-ST-elevation Myocardial Infarction (FAST-MI)., Results: Atrial fibrillation developed in 7.0% of patients without and 3.9% of patients with early (≤48 h of admission) statin therapy (p<0.001). Multivariable analysis, including the propensity score for early statin treatment, showed that statin therapy was associated with reduced risk of atrial fibrillation (OR 0.64; 95% CI 0.45 to 0.92, p=0.017). Compared to patients without early statin therapy, the OR for atrial fibrillation were 0.72 (0.49 to 1.04, p=0.080), 0.52 (0.28 to 0.95, p=0.034) and 0.40 (0.18 to 0.92, p=0.030) in patients on conventional, intermediate and high doses respectively., Conclusions: This study is the first to document a correlation between early statin therapy and atrial fibrillation at the early stage of acute myocardial infarction.

Background: thrombolysis (THL) and primary percutaneous coronary intervention (PCI) are therapeutic options in acute myocardial infarction (MI). These strategies have similar efficiency, particularly in the early phase. However, in these randomized studies, different times to treatment (TT) threshold are recognized as discriminant., Objectives: to validate, on a one year mortality criteria the best TT threshold in the real life., Methods: 794 patients, admitted directly in our institution with a Ml< or =12 hours; 299 were treated by THL and 495 by PCI. The primary end-point was 1-year mortality according to TT and strategy of revascularization. Three TT thresholds were tested (120, 150 and 180 min) to define the best strategy of revascularisation., Results: only the 150 min TT threshold showed a significant difference between the two strategies. If TT was less than 150 min, relative risk of 1-year mortality was 1.36 (p=0.62) for patients treated by THL compared to those treated with PCI. By contrast, the relative risk of one year mortality was 1.95 if Tr was greater than 150 min (p=0.02)., Conclusion: TT is a key factor to define the best strategy of reperfusion. The critical threshold seems to be at 150 min. THL should be considered as a therapeutic choice only if administered within the first 150 min. After this delay, primary PCI should be preferred.

The incidence of binodal, sinoatrial (SA) and atrioventricular (AV), block was determined in a series of 362 patients, 90 of whom had chronic sinoatrial block (group I), 162 suprahisian, infrahisian or diffuse AV block (group II), 38 with paroxysmal supraventricular tachycardia (group III), and 70 with slow atrial fibrillation, 54 of whom were studied in sinus rhythm (group IV). Electrophysiological investigation revealed: overt or latent AV block in 71% of group I, 48% of group III, and 100% of group IV; overt or latent SA block in 40 to 61% of group II, 87% of group III and 78% of group IV; paroxysmal atrial fibrillation in 61% of group I, 25% of group II and 50% of group IV; intra-atrial block in 26% of group I, 20% of group II, 16% of group III and 31% group IV. An ECG syndrome associating binodal block and disturbances or atrial conduction and excitability is suggested. The pathogenesis and anatomical basis are discussed, the prime lesion of which may be fibrosis of the atrial tissues which may ultimately result in partial or total atrial standstill.