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Resume Les betabloquants ont revolutionne le pronostic de l’infarctus du myocarde avec un benefice majeur sur la mortalite. Les etudes randomisees validant incontestablement cet interet sont anciennes et remontent a une periode ou reperfusion coronaire, aspirine et statines ne faisaient pas partie de l’arsenal therapeutique. Les betabloquants ont egalement ameliore les symptomes angineux des coronariens stables faisant de cette classe medicamenteuse le traitement de premiere intention de l’angor. Mais il n’existe aucune etude randomisee validant l’interet pronostique des betabloquants dans ce que l’on appelait maladie coronaire stable et qui s’intitule desormais syndrome coronaire chronique. Depuis quarante ans et avec les nombreuses innovations therapeutiques, le spectre de toute la maladie coronaire a evolue et avec lui son pronostic. Les coronariens aujourd’hui different totalement des coronariens des annees quatre-vingt. Les dernieres etudes observationnelles ont suggere que dans le post-infarctus sans dysfonction ventriculaire gauche, les betabloquants etaient associes a un meilleur pronostic jusqu’a un an post-infarctus. Au-dela, ils etaient associes a un effet neutre sur le pronostic cardiovasculaire. Dans le syndrome coronaire chronique, les dernieres etudes observationnelles ont suggere qu’en l’absence de dysfonction ventriculaire gauche, les betabloquants n’etaient pas associes a un meilleur pronostic. Ils ne l’etaient qu’en cas d’antecedent d’infarctus de moins d’un an. L’interet pronostique des betabloquants dans la maladie coronaire a evolue. Ce changement peut etre lie a une evolution de la maladie coronaire elle-meme puisqu’elle s’est dissociee de l’insuffisance cardiaque avec alteration de fonction ventriculaire gauche. De nouvelles etudes randomisees sont donc indispensables pour statuer sur le sort des betabloquants en prevention secondaire coronaire.

Resumen Las enfermedades cardiovasculares son la primera causa de mortalidad en el mundo. Se estima en 17,7 millones el numero de fallecimientos imputables a las enfermedades cardiovasculares, es decir, el 31% de la mortalidad mundial total. El paciente coronario demostrado es un paciente con un riesgo cardiovascular muy alto. La prevencion secundaria tiene por objetivo limitar el crecimiento de la placa de ateroma y la aparicion de sindrome coronario agudo, con el fin de limitar los sintomas y mejorar el pronostico y la supervivencia. La prevencion secundaria pasa por el control de los factores de riesgo cardiovascular, al que se anade el tratamiento medicamentoso, que comprende de manera inevitable un antiagregante plaquetario y estatinas, pero tambien, despues de un infarto con disfuncion ventricular izquierda, betabloqueantes e inhibidores del sistema renina-angiotensina. A lo largo de los ultimos anos, las clases medicamentosas se han diversificado, como los nuevos antiagregantes plaquetarios y los nuevos anticoagulantes orales directos. Otros han visto la luz, como los anticuerpos anti-PCSK9 con un objetivo hipocolesterolemiante. Los tratamientos especificos de los factores de riesgo cardiovascular tambien se han desarrollado. Por lo tanto, el tratamiento prolongado del paciente coronario ha evolucionado mucho y tiende hacia un control mas complejo y mas personalizado.

Riassunto Le malattie cardiovascolari sono la principale causa di morte nel mondo. E stimato pari a 17,7 milioni il numero di morti per malattie cardiovascolari, ossia il 31% della mortalita globale totale. Il paziente coronarico accertato e un paziente ad alto rischio cardiovascolare. L’obiettivo della prevenzione secondaria e limitare la crescita della placca ateromatosa e l’insorgenza della sindrome coronarica acuta, al fine di limitare i sintomi e di migliorare la prognosi e la sopravvivenza. La prevenzione secondaria prevede il controllo dei fattori di rischio cardiovascolare a cui si aggiunge il trattamento farmacologico, che include inevitabilmente l’antiaggregazione piastrinica e le statine, ma anche, nel postinfarto con disfunzione ventricolare sinistra, dei betabloccanti e degli inibitori del sistema renina-angiotensina. Negli ultimi anni, le classi di farmaci si sono diversificate, come i nuovi antiaggreganti piastrinici e i nuovi anticoagulanti orali diretti. Altre sono emerse, come gli anticorpi anti-PCSK9, per abbassare il colesterolo. Sono stati, inoltre, sviluppati i trattamenti specifici dei fattori di rischio cardiovascolare. Il trattamento a lungo termine della malattia coronarica si e, quindi, evoluto fortemente verso una gestione piu complessa e piu personalizzata.

Mitral regurgitation (MR) is the second most common valvular heart disease in Europe. The aging of the population and the increase in post-infarction survival could increase the prevalence of MR. To estimate the burden of patients hospitalized for MR in France in 2019 and temporal trends by etiology and sex from 2006 to 2020, we selected all patients hospitalized for MR using the national hospital database. In 2019, 49.2% of such patients had mitral valve prolapse (MVP), 17.1% had ischemic MR, 9.9% had rheumatic MR and 4.4% had MR with cardiomyopathy. The mean age of MVP patients was 67.8 years, and 34% were women. Among 89% of MVP inpatients who had received mitral valve repair or replacement, 55% received surgical repair, 13% received percutaneous repair and 25% received replacement. The all-cause mortality of one year after a mitral procedure of MVP was 5.4%. Among ischemic MR inpatients, 29% have had a mitral valve replacement, 16% a surgical repair and 19% a percutaneous repair. Between 2006 and 2019, the age-standardized rates of patients hospitalized for MVP have increased by 60%, especially in men (+80%) with 5.3/100,000 Person-Years (PY). The age-standardized rates of patients hospitalized for ischemic MR have increased by 25% with 1.8/100,000 PY; that of rheumatic MR has decreased by 36%. The study found that the burden of MVP in hospitals has increased substantially, especially among men. These results emphasize the need to monitor these temporal trends and anticipate care needs in the coming years.

Background An increased risk of cardiovascular disease (CVD) was reported in patients coinfected with human immunodeficiency virus (HIV) and hepatitis C virus (HCV), without identifying factors associated with atherosclerotic CVD (ASCVD) events. Methods HIV-HCV coinfected patients were enrolled in the Agence Nationale de Recherches sur le Sida et les hépatites virales (ANRS) CO13 HEPAVIH nationwide cohort. Primary outcome was total ASCVD events. Secondary outcomes were coronary and/or cerebral ASCVD events, and peripheral artery disease (PAD) ASCVD events. Incidences were estimated using the Aalen-Johansen method. Factors associated with ASCVD were identified using cause-specific Cox proportional hazards models. Results At baseline, median age of the study population (N = 1213) was 45.4 (interquartile range [IQR] 42.1−49.0) years and 70.3% were men. After a median follow-up of 5.1 (IQR 3.9−7.0) years, the incidence was 6.98 (95% confidence interval [CI], 5.19−9.38) per 1000 person-years for total ASCVD events, 4.01 (2.78−6.00) for coronary and/or cerebral events, and 3.17 (2.05−4.92) for PAD ASCVD events. Aging (hazard ratio [HR] 1.06; 95% CI, 1.01−1.12), prior CVD (HR 8.48; 95% CI, 3.14−22.91), high total cholesterol (HR 1.43; 95% CI, 1.11−1.83), high-density lipoprotein cholesterol (HR 0.22; 95% CI, 0.08−0.63), statin use (HR 3.31; 95% CI, 1.31−8.38), and high alcohol intake (HR 3.18; 95% CI, 1.35−7.52) were independently associated with total ASCVD events, whereas undetectable baseline viral load (HR 0.41, 95% CI, 0.18−0.96) was associated with coronary and/or cerebral events. Conclusions HIV-HCV coinfected patients experienced a high incidence of ASCVD events. Some traditional cardiovascular risk factors were the main determinants of ASCVD. Controlling cholesterol abnormalities and maintaining undetectable HIV RNA are essential to control cardiovascular risk.

Background: Hypertension is the most frequent chronic pathology in France and in the world. It is one of the main modifiable cardiovascular risk factors. In France, 50% of treated hypertensives are uncontrolled and only 30% of treated patients are fully adherent to their antihypertensive treatment. Poor adherence to drug treatments is considered as one of the main causes of non-control of hypertension. Since 2018, a new profession has entered the French healthcare system: Advanced Practice Nurses (APN). They have many broad skills, at the interface of nursing and medical exercises. The purpose of this interventional study is to assess the impact of APN on blood pressure (BP) control in the context of usual care of hypertension thanks to a better adhesion of patients and a better therapeutic alliance. Methods: The study is designed as prospective, open-label, controlled, randomized 1-to-1 and mono-centric at the Hôtel-Dieu University Hospital, Paris, France. The participants are all hypertensive and recruited during an ambulatory hospitalization (AH) for cardiovascular assessment in the context of the management of their hypertension. Patients are divided into two groups: a control group who keeps a traditional follow-up (AH then consultation with a medical doctor (MD) within approximately two to six months) and an interventional group who will see an APN between the AH and the MD consultation, within 1-3 months. Patients are followed up over six months. The main judgment criterion is BP control (BP < 135/85 mmHg in home BP measurement). The hypothesis formulated is that an individual APN intervention, included in a usual hypertension management, improves BP control. Discussion: This innovative study is a first in France where APNs are at the dawn of their establishment in the healthcare system. It will provide an objective look at this new profession and the impact it can have on the overall management of hypertension. Trial registration: This trial was registered in ClinicalTrials.gov on June 24, 2020: protocol number NCT0448249.

Introduction Transcatheter left atrial appendage (LAA) occlusion is an alternative treatment in patients with atrial fibrillation (AF), high CHADSVASC Score and a contra-indication to anticoagulants. This retrospective cohort study aims to evaluate the impact of LLA morphology on procedure outcomes. Methods Patients from eight French centers who underwent left atrial appendage occlusion from February 2012 to January 2017 were included in this retrospective cohort study. LLA morphology was described by preoperative cardiac computed tomography (CT). Clinical data and Transoesophageal echocardiography (TEE) or CT results were collected during follow-up. Results Among 469 included patients, LAA morphologies were described in 215 cases 45.8%), 150 patients (70%) were implanted with Watchman devices, 57 (26%) with Amplatzer devices and 8 procedures (4%) failed. LAA Morphology was Chicken Wing (34%), Windsock (45%), cauliflower (18%) and 3% had another morphology including Cactus. There was no difference in patient characteristics between the different morphology groups. Mean follow-up was 9.6±11 months, during which 190 patients underwent LAA imaging (TEE in 171 and CT in 19 patients). There was no significant difference in the failure rate (p=0.72), duration of the procedure (p=0.065), peri-device leak (p=0.83) device-related thrombus (p=0.96) and the occurrence of stroke (p=1) during follow-up. Conclusion LLA morphology did not influence complication occurrence after occlusion in this cohort. Funding Acknowledgement Type of funding source: None

Points essentiels L’âge et les comorbidites cardiovasculaires sont des facteurs independants de mortalite et d’hospitalisation en unite de soins intensifs chez les patients atteints de coronavirus 19 (COVID-19), contrairement a l’hypertension arterielle (HTA). La forte prevalence de l’HTA chez les personnes âgees, coronariens ou insuffisants cardiaques, explique l’importante prevalence de l’HTA parmi les patients hospitalises et presentant des formes severes de COVID-19. L’HTA, en tant que premier facteur de risque de morbi-mortalite cardiovasculaire, constitue le lit des comorbidites cardiovasculaires qui favorisent les formes severes de COVID-19. L’hypothese d’une surexpression de l’enzyme de conversion de l’angiotensine de type 2 membranaire par les inhibiteurs de l’enzyme de conversion et antagonistes des recepteurs de l’angiotensine 2, favorisant l’invasion cellulaire par le severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) reste hypothetique, est insuffisante pour expliquer la pathogenie de ce virus, et ne doit pas amener a interrompre ces traitements. Les patients hypertendus et cardiovasculaires doivent faire l’objet d’une surveillance particuliere en raison de leur susceptibilite aux formes graves de COVID-19, de leur risque accru de complications cardiovasculaires aigues ou de decompensation de maladies cardiovasculaires chroniques. Le risque d’infection par le SARS-CoV-2 ne doit pas detourner les soignants et les patients de la prise en charge des urgences cardiovasculaires, meme en temps d’epidemie.

Aortic stiffness (AS) is widely associated with hypertension and considered as a major predictor of coronary heart disease (CHD). AS is measured using carotid–femoral pulse wave velocity (PWV), particularly when this parameter is associated with an index involving age, gender, heart rate, and mean blood pressure. The present review focuses on the interest of measurement of PWV and the calculation of individual PWV index for the prediction of CHD, in addition with the use of new statistical nonlinear models enabling results with very high levels of accuracy. PWV index may so constitute a substantial marker of large arteries prediction and damage in CHD and may be also used in cerebrovascular and renal circulations models. PWV index determinations are particularly relevant to consider in angiographic CHD decisions and in the presence of vulnerable plaques with high cardiovascular risk. Due to the variability in symptoms and clinical characteristics of patients, together with some imperfections in results, there is no very simple adequate diagnosis approach enabling to improve the so defined CHD prediction in usual clinical practice. In recent works in relation to “artificial intelligence” and involving “decision tree” models and “artificial neural networks,” it has been possible to determine consistent pathways introducing predictive medicine and enabling to obtain efficient algorithm classification models of coronary prediction.

Purpose of Review: Aortic stiffness (AS) is widely associated with hypertension and considered as a major predictor of coronary heart disease (CHD). AS is measured using carotid–femoral pulse wave velocity (PWV), particularly when this parameter is associated with an index involving age, gender, heart rate, and mean blood pressure. The present review focuses on the interest of measurement of PWV and the calculation of individual PWV index for the prediction of CHD, in addition with the use of new statistical nonlinear models enabling results with very high levels of accuracy. Recent Findings: PWV index may so constitute a substantial marker of large arteries prediction and damage in CHD and may be also used in cerebrovascular and renal circulations models. PWV index determinations are particularly relevant to consider in angiographic CHD decisions and in the presence of vulnerable plaques with high cardiovascular risk. Due to the variability in symptoms and clinical characteristics of patients, together with some imperfections in results, there is no very simple adequate diagnosis approach enabling to improve the so defined CHD prediction in usual clinical practice. Summary: In recent works in relation to “artificial intelligence” and involving “decision tree” models and “artificial neural networks,” it has been possible to determine consistent pathways introducing predictive medicine and enabling to obtain efficient algorithm classification models of coronary prediction. © 2020, Springer Science+Business Media, LLC, part of Springer Nature.

Introduction Several studies highlighted an increased risk of cardiovascular disease (CVD) in HIV-HCV co-infected patients without clearly identifying specific virologic factors associated with atherosclerotic CVD (ASCVD) events. Purpose Hence, we analyzed data collection from the French nationwide ANRS CO13 HEPAVIH cohort to determine the incidence of ASCVD events in HIV-HCV co-infected patients and the predictive factors associated with its occurrence. Methods The French multicenter nationwide ANRS CO13 HEPAVIH clinic-based cohort collected prospective clinical and biological data from HIV-HCV co-infected patients followed-up in 28 different university hospitals between December 2005 to November 2016. Participants with at least one year of follow-up were included. Primary outcome was the occurrence of major ASCVD events (cardiovascular death, acute coronary syndrome, coronary revascularization and stroke). Secondary outcomes were total ASCVD events including major ASCVD events and minor ASCVD events (peripheral arterial disease [PAD]). Incidence rates were estimated using Aalen-Johansen method and factors associated with ASCVD identified with Cox proportional hazards models. Results A total of 1213 patients were included: median age 45.4 years [42.1–49.0], 70.3% men, current smoking 70.2%, overweight 19.5%, liver cirrhosis 18.9%, chronic alcohol consumption 7.8%, diabetes mellitus (5.9%), personal history of CVD 2.7%, and statins use 4.1%. After a median follow-up of 5.1 years [3.9–7.0], 44 participants experienced at least one ASCVD event (26 major ASCVD event, and 20 a minor event). Incidences for total, major and minor ASCVD events were of 6.98 [5.19; 9.38], 4.01 [2.78; 6.00], and 3.17 [2.05; 4.92] per 1000 person-years, respectively. Personal history of CVD (Hazard Ratio (HR)=13.94 [4.25–45.66]), high total cholesterol (HR=1.63 [1.24–2.15]), low HDL cholesterol (HR=0.08 [0.02–0.34]) and undetectable HIV viral load (HR=0.41 [0.18–0.96]) were identified as independent factors associated with major ASCVD events while cirrhosis status, liver fibrosis and HCV sustained viral response were not. Cumulative incidence of CV events Conclusion HIV-HCV co-infected patients experience a high incidence of ASCVD events both coronary and peripheral artery diseases. Traditional CV risk factors are the main determinants of ASCVD whereas undetectable HIV viral load seems to be protective. Management of cholesterol abnormalities and controlling viral load are essential to modify this high cardiovascular risk. Acknowledgement/Funding Agence Natoinale de Recherche sur le SIDA et les Hépatites virales

Transcatheter left atrial appendage (LAA) closure is an alternative strategy for stroke prevention in atrial fibrillation (AF) patients with an inacceptable risk of bleeding with oral anticoagulation (OAC). A better characterization of major adverse clinical events after LAA closure in daily practice is still needed. Methods We analysed data from all AF patients treated with Watchman or Amplatzer LAA closure according to European guidelines in 8 French cardiology departments. Antithrombotic management was decided for each patient on an individual basis. A Cox regression model was used for multivariable analysis of major adverse events. Yearly rate of ischemic stroke during follow-up was calculated and compared to that expected for a same risk score population. Yearly rate of bleeding was extrapolated from that reported with the HASBLED score. Results A total of 469 consecutive AF patients (299 males, 74.9±8.9 years old, mean CHA2DS2-VASc score 4.5±1.4, HASBLED score 3.7±1.0) received LAA closure from March 2012 to January 2017. There were 272 Watchman devices (58%) and 197 ACP devices (42%) implanted. At discharge, 36% received a single anti platelet therapy (APT), 23% received dual APT, 29% received OAC and no APT, 5% received OAC plus APT and 8% received no antithrombotic therapy. Mean follow up was 11.4 months (median 7, interquartile 3–22 months) during which 70 major adverse events (19 ischemic strokes, 18 major haemorrhages and 33 deaths) were recorded in 69 patients. The annual rate of ischemic stroke was 3.96%, which translates into a 13% relative risk reduction (95% CI −59 to 52%) as compared with the calculated stroke rate for similar CHA2DS2-VASc score after adjustment for exposure to APT and OAC. The annual rate of major bleeding in the study was 3.75%, which corresponds to a 48% relative risk reduction (95% CI 9 to 70%) as compared with the rate that would have been expected based on a comparable HAS-BLED score. Yearly rate of mortality was 7.4% (2.5 to 3 fold higher than in previous randomized trials) and the rate of non-cardiovascular death was 82%. None of the baseline characteristics was predictive of major adverse events, neither in univariate nor in multivariable analysis, which highlights the difficulty in identifying a risk of unfavourable outcome with simple tools. Conclusions AF patients treated with LAA closure may have a lower risk of stroke and bleeding events compared to their theoretical risk. However, our findings indicate that a high rate of major adverse events is observed in these patients during follow-up. This questions the suggested cost-effectiveness of the procedure (with models based on previous trials) for a real-life perspective. A better identification of patients with a relevant benefit of LAA closure is needed among those with long-term anticoagulation contraindication, both for an optimal management of each patient on an individual basis and for a global perspective with limited healthcare resources.

Transcatheter left atrial appendage (LAA) closure is an alternative strategy for stroke prevention in atrial fibrillation (AF) patients with contraindications for long-term anticoagulant treatment. A better characterization of clinical events after LAA closure for these patients in daily practice is

Background Cardiovascular disease, such as coronary heart disease (CHD), are the main cause of mortality and morbidity worldwide. CHD is not entirely predicted by classic risk factors; however, they are preventable. Facing this major problem, the development of novel methods for CHD risk prediction is of practical interest. The purpose of our study was to construct an artificial neural networks (ANNs)-based diagnostic model for CHD risk using a complex of clinical and haemodynamics factors of this disease and aortic pulse wave velocity (PWV) index. Methods A total of 437 patients were included from 2012 to 2017: 99 CHD and 338 non-CHD patients. Theoretical PWV was calculated, on 93 patients free of hypertension, diabetes and CHD, according to age, blood pressure, sex and heart rate. The results were expressed as an index [(measured PWV - theoretical PWV)/theoretical PWV] for each patient. The original database for ANNs included clinical, haemodynamic and laboratory characteristics. Multilayered perceptron ANNs architecture were applied. The performance of prediction was evaluated by accuracy values based on standard definitions. Results By changing the types of ANNs and the number of input factors applied, we created models that demonstrated 0.63-0.93 accuracy. The best accuracy was obtained with ANNs topology of multilayer perceptron with three hidden layers for models, parameters included by both biological factors, carotid plaque and PWV index. Conclusion ANNs models including a PWV index could be used as promising approaches for predicting CHD risk without the need for invasive diagnostic methods and may help in the clinical decision.

In 2014, a joint consensus document dealing with the management of antithrombotic therapy in atrial fibrillation (AF) patients presenting with acute coronary syndrome (ACS) and/or undergoing percutaneous coronary or valve interventions was published, which represented an effort of the European Society of Cardiology Working Group on Thrombosis, European Heart Rhythm Association (EHRA), European Association of Percutaneous Cardiovascular Interventions (EAPCI), and European Association of Acute Cardiac Care (ACCA) endorsed by the Heart Rhythm Society (HRS) and Asia-Pacific Heart Rhythm Society (APHRS). Since publication of this document, additional data from observational cohorts, randomized controlled trials, and percutaneous interventions as well as new guidelines have been published. Moreover, new drugs and devices/interventions are also available, with an increasing evidence base. The approach to managing AF has also evolved towards a more integrated or holistic approach. In recognizing these advances since the last consensus document, EHRA, WG Thrombosis, EAPCI, and ACCA, with additional contributions from HRS, APHRS, Latin America Heart Rhythm Society (LAHRS), and Cardiac Arrhythmia Society of Southern Africa (CASSA), proposed a focused update, to include the new data, with the remit of comprehensively reviewing the available evidence and publishing a focused update consensus document on the management of antithrombotic therapy in AF patients presenting with ACS and/or undergoing percutaneous coronary or valve interventions, and providing up-to-date consensus recommendations for use in clinical practice.

Background Transcatheter left atrial appendage (LAA) occlusion is an alternative strategy for stroke prevention in patients with atrial fibrillation (AF). Objectives This study sought to determine the incidence, predictors, and prognosis of thrombus formation on devices in patients with AF who were treated with LAA closure. Methods The study retrospectively analyzed data from patients treated with 2 LAA closure devices seen in 8 centers in France from February 2012 to January 2017. Results A total of 469 consecutive patients with AF underwent LAA closure (272 Watchman devices [Atritech, Boston Scientific, Natick, Massachusetts] and 197 Amplatzer devices [St. Jude Medical, Minneapolis, Minnesota]). Mean follow-up was 13 ± 13 months, during which 339 (72.3%) patients underwent LAA imaging at least once. There were 98 major adverse events (26 thrombi on devices, 19 ischemic strokes, 2 transient ischemic attacks, 18 major hemorrhages, 33 deaths) recorded in 89 patients. The incidence of device-related thrombus in patients with LAA imaging was 7.2% per year. Older age (hazard ratio [HR]: 1.07 per 1-year increase; 95% confidence interval [CI]: 1.01 to 1.14; p = 0.02) and history of stroke (HR: 3.68; 95% CI: 1.17 to 11.62; p = 0.03) were predictors of thrombus formation on the devices, whereas dual antiplatelet therapy (HR: 0.10; 95% CI: 0.01 to 0.76; p = 0.03) and oral anticoagulation at discharge (HR: 0.26; 95% CI: 0.09 to 0.77; p = 0.02) were protective factors. Thrombus on the device (HR: 4.39; 95% CI: 1.05 to 18.43; p = 0.04) and vascular disease (HR: 5.03; 95% CI: 1.39 to 18.23; p = 0.01) were independent predictors of ischemic strokes and transient ischemic attacks during follow-up. Conclusions Thrombus formation on the device is not uncommon in patients with AF who are treated by LAA closure. Such events are strongly associated with a higher risk of ischemic stroke during follow-up. (REgistry on Real-Life EXperience With Left Atrial Appendage Occlusion [RELEXAO]; NCT03279406)

We thank Dr. So and colleagues for their comments about our paper on device-related thrombus (DRT) after left atrial appendage occlusion (LAAO) in patients with atrial fibrillation (AF) [(1)][1]. The data from their “real-life” registry found a lower rate of DRT and lower annual rate of