Search

International audience; Background: Different mortality rates are reported in registries of patients with ST-segment elevation myocardial infarction (STEMI), but comparisons between registries are challenging. Aims: To determine whether the higher mortality rate in our regional French registry (SCALIM) is related to different inclusion criteria and demographic characteristics. Methods: The SCALIM registry included all patients with STEMI within the first 24 h in the region of Limousin, France (06/2011-01/2015). To compare mortality rates with other contemporary registries in France and European neighbouring countries, the others' inclusion criteria were applied to the SCALIM registry. Results: Among 1501 patients included, in-hospital and 1-month mortality were 8.2% and 8.8% respectively, significantly higher than many other registries. The use of inclusion criteria from EMUST (France), MINAP (UK) or LOMBARDIMA (Italy) markedly decreased the number of enrolled patients by 64%, 36%, and 21%, respectively. When those inclusion criteria were applied to the SCALIM registry, difference in in-hospital and 1-month mortality rates between other registries and ours remained significant. In the multivariate analysis, age, initial acute pulmonary oedema (Killip class ≥2), complication occurring before percutaneous coronary intervention, absence of transfer to an interventional cardiology centre for primary angioplasty and lack of reperfusion therapy within 12 h were associated with higher risk of 1-month mortality (all p < 0.05). Age (65 versus 63.3 years, p < 0.001) was higher and reperfusion rate (84.2 versus 74.7%, p < 0.001) was significantly lower in SCALIM than FAST-MI, the national French registry on STEMI patients. Interestingly, the 3% of patients included in SCALIM who would be excluded from FAST-MI registry had 91% mortality at one month. Conclusion: Higher mortality rate in our regional SCALIM registry is in part due to differences in inclusion criteria and demographic data. Consensus should be made to harmonise inclusion criteria in STEMI registries for the sake of comparability.

IntroductionMechanical thrombectomy (MT) increases functional independence in patients with acute ischaemic stroke with anterior circulation large vessel occlusion (LVO), and the probability to achieve functional independence decreases by 20% for each 1-hour delay to reperfusion. Therefore, we aim to investigate whether direct angiosuite transfer (DAT) is superior to standard imaging/emergency department-based management in achieving 90-day functional independence in patients presenting with an acute severe neurological deficit likely due to LVO and requiring emergent treatment with MT.Methods and analysisDIRECT ANGIO (Effect of DIRECT transfer to ANGIOsuite on functional outcome in patient with severe acute stroke treated with thrombectomy: the randomised DIRECT ANGIO Trial) trial is an investigator-initiated, multicentre, prospective, randomised, open-label, blinded endpoint (PROBE) study. Eligibility requires a patient ≤75 years, pre-stroke modified Rankin Scale (mRS) 0–2, presenting an acute severe neurological deficit and admitted within 5 hours of symptoms onset in an endovascular-capable centre. A total of 208 patients are randomly allocated in a 1:1 ratio to DAT or standard management. The primary outcome is the rate of patients achieving a functional independence, assessed as mRS 0–2 at 90 days. Secondary endpoints include patients presenting confirmed LVO, patients eligible to intravenous thrombolysis alone, patients with intracerebral haemorrhage and stroke-mimics, intrahospital time metrics, early neurological improvement (reduction in National Institutes of Health Stroke Scale by ≥8 points or reaching 0–1 at 24 hours) and mRS overall distribution at 90 days and 12 months. Safety outcomes are death and intracerebral haemorrhage transformation. Medico-economics analyses include health-related quality of life and cost utility assessment.Ethics and disseminationThe DIRECT ANGIO trial was approved by the ethics committee of Ile de France 1. Study began in April 2020. Results will be published in an international peer-reviewed medical journal.Trial registration numberNCT03969511.

International audience; More than half of patients under mechanical ventilation in the intensive care unit (ICU) are field-intubated, which is a known risk factor for ventilator associated pneumonia (VAP). We assessed whether field endobronchial intubation (EBI) is associated with the development of subsequent VAP during the ICU stay. This retrospective, nested case-control study was conducted in a cohort of field-intubated patients admitted to an ICU of a teaching hospital during a three-year period. Cases were defined as field-intubated patients with EBI and controls corresponded to field-intubated patients with proper position of the tracheal tube on admission chest X-ray. Primary endpoint was the development of early VAP. Secondary endpoints included the development of early ventilator associated tracheo-bronchitis, late VAP, duration of mechanical ventilation, length of stay and mortality in the ICU. A total of 145 patients were studied (mean age: 54 ± 19 years; men: 74%). Reasons for field intubation were predominantly multiple trauma (49%) and cardiorespiratory arrest (38%). EBI was identified in 33 patients (23%). Fifty-three patients (37%) developed early or late VAP. EBI after field intubation was associated with a nearly two-fold increase of early VAP, though not statistically significant (30% vs. 17%: p = 0.09). No statistically significant difference was found regarding secondary outcomes. The present study suggests that inadvertent prehospital EBI could be associated with a higher incidence of early-onset VAP. Larger studies are required to confirm this hypothesis. Whether strategies aimed at decreasing the incidence and duration of EBI could reduce the incidence of subsequent VAP remains to be determined.

Introduction Chest pain is a frequent cause of admission to the emergency department (ED). The diagnosis and medical care of acute coronary syndrome (ACS) with ST-segment elevation (ST+ ACS) are more standardized than non ST-segment elevation ACS (NST ACS). There is very few series on patients classified as low ACS-diagnosis probability. We aimed to assess the 1-year outcome of patients admitted for chest pain in ED and discharged with low risk of ACS. Methods This restrospective study included all patients admitted in the ED of University Hospital Center of Limoges between January and March 2013 for chest pain, without ST-segment elevation and normal troponin level. Patients’ characteristics and initial diagnosis were collected in ED records. Final diagnosis was obtained by phone one year later, from general practitioners or alternatively directly from the patients themselves. Results Among the 244 patients studied, 38 (15.6%) were lost during follow-up. Mean age was 50±17 years, 58% being males. Among the 41% of cases in whom the initial diagnosis (i.e. ED discharge) was modified during follow-up, 9% (n=8) were diagnosed with coronary disease, and 38% (n=32) with panic attack. Major adverse cardiac events rate was 2.4% (n=5) in the whole population, and 60% of them were directly discharged to home. In the ED, the detection of a cardiovascular etiology of chest pain was accurate with good specificity (96%) but lower sensibility (61%). Of note, the rate of false negative patients was 8.5%. Conclusion Low probability NST SCA diagnosis is complex in the ED and may frequently lead to erroneous diagnosis associated with therapeutic delay. Nevertheless, cardiac disorders are uncommonly misdiagnosed. A systematic, individualized and close monitoring after ED discharge is mandatory.

PurposeDespite public campaigns for calling rapidly the emergency phone number in case of chest pain, many patients still delay their call. We sought to determine factors influencing the call delay in case of STEMI.MethodsWe studied 206 consecutive patients admitted for STEMI. They were classified according to tertiles of delay between symptoms onset and the first call (« early-callers » for 1st & 2nd tertiles, « late-callers » for the 3rd tertile). We compared these 2 groups according to the registry data. We contacted the survivors to obtain further information on socio-economic status and events during symptoms onset.ResultsThe patients (age 64±14 y, 75% males) called on average in 2.5±3.5 hours (early-callers 1.6±1.8 vs. 4.4±5.0 for late-callers). In multivariate analysis, the following factors were significantly associated with late call: age (OR=1.03, 95%CI: 1.00-1.05), living >30 min. from cath lab (OR=2.8, 1.1-7.1), symptoms onset between 00:00-05:59 am (OR=2.3, 1.1-4.8) and first call to the family physician (OR=1.9, 1.8-3.6). The respondents to interview did not differ from others regarding age and call delay. Main variables during interview are compared between in the 2 groups in Figure. In a second model using interview variables, following factors were associated with late call, adjusted for age and sex: symptoms onset between 00:00-05:59 am (OR=3.8, 1.00-14.5), self-medication (OR=7.7, 2.2-27.0), mild pain (visual scale

Purpose While cardiac troponins (C-Tn) are widely used in the emergency room in case of chest pain, there is an increasing rate of prescription of this test by general practitioners (GPs) in outpatients. Limited data are available on the motivations and the issue of C-Tn requested by GPs. We sought to assess the reasons for C-Tn test prescribed by GPs in our community in France, and the management of the positive cases. Methods We retrospectively retrieved all the C-Tn test requests made by GPs to the 2 major laboratories in our community of 250,000 inhabitants, within a period of 4 months. The GPs were contacted by phone to assess their motivations. Results During this period, 306 C-Tn tests were requested by 157 GPs. We excluded 64 cases because of insufficient data. They were comparable to those included in the study in terms of age, gender, and positive test rates. Among the 242 cases studied (median age 70 years, 51% males), 41% had ≥3 coronary risk factors. C-Tn was requested because of chest pain in 202 patients (83%). 71% had atypical pain. The prescription was made in more than 6 and 24 hours after symptom’s onset in 78% and 55% of cases, respectively. ECG was performed before C-Tn test prescription in only 15% of cases. In 92% of cases, C-Tn test was negative. Among the 18 positive cases, 5 (19%) remained at home (3 very old patients, mean age 91 years, and 2 cases considered as false positives). Among the 13 remaining positive cases, 7 were referred directly to cardiologists and 6 to an emergency department. Among these 13 patients, 11 were referred without medical transportation. Only 1 patient was transferred medically directly to the cath lab, 24 hours after chest pain onset. Conclusion Cardiac troponin is mainly requested by GPs to exclude acute coronary syndrome in case of atypical chest pain with delayed consultation. However, the positivity of this test was useless in 1 out of 5 patients since it has not changed their management. While in the majority, the C-Tn tests requested by GPs are negative and avoid hospitalization, the management of patients with positive test is delayed and not secured.