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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.

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

Objective. – To assess the use of mobile coronary care units (MCU) in hypertensive patients previously treated for cardiovascular diseases in comparison with those with no history of cardiovascular disease and to estimate the influence of the use of MCU on cardiovascular outcome in this population. Patients. – We used a nationwide prospective registry of all patients admitted for AMI in French intensive care units in 2000. Patients without history of hypertension or patients admitted with pulmonary oedema or cardiogenic shock were excluded. Men (N = 514) and women (N = 291) were analysed separately . Results. – The proportion of patients with history of myocardial infarction, peripheral artery disease and stroke was not significantly higher in subjects who used physician-staffed MCU as compared with patients with no history of myocardial infarction, peripheral artery disease or stroke. In each sex, revascularization (pre hospital fibrinolysis, in hospital fibrinolysis or coronary angioplasty) were more frequent in patients who used MCU. Also, one year cardiovascular mortality was lower in men who used MCU. Conclusion. – known high risk hypertensive patients did not use physician-staffed MCU more than subjects free of such condition. Education of hypertensive patients at risk during routine visits is required to increase of the use of physician-staffed MCU in case of symptoms suggestive of AMI.

Several classes of medications improve survival in patients with coronary artery disease. Whether these medications, as used in the real world, have additive efficacy remains speculative.To assess whether patients discharged on combined secondary prevention medications after acute myocardial infarction (AMI) have improved 1-year survival, compared with the action of any single class of medications.Nationwide registry of consecutive patients admitted to intensive care units for AMI in November 2000 in France. Multivariate Cox regression analysis, including a propensity score for the prescription of combined therapy, was used.Of the 2119 patients discharged alive, 1095 (52%) were prescribed a combination of antiplatelet agents, beta-blockers, and statins (triple therapy), of whom 567 (27%) also received angiotensin-converting enzyme inhibitors (quadruple therapy) and 528 (25%) did not. One-year survival was 97% in patients receiving triple combination therapy versus 88% in those who received either none, 1, or 2 of these medications (P.0001). After multivariate adjustment including the propensity score, the hazard ratio for 1-year mortality in patients with triple combination therapy was 0.52 (95% CI 0.33-0.81). In patients with ejection fractionor = 35%, beta-blockers and angiotensin-converting enzyme inhibitors were independent predictors of survival, and combination therapy had no additional prognostic value.Compared with the prescription of any single class of secondary prevention medications, combination therapy offers additional protection in patients with AMI.

Resume Objectif. – Plusieurs etudes rapportent un pronostic plus sombre apres un infarctus du myocarde (IdM) chez ceux ayant une arteriopathie obliterante des membres inferieurs (AOMI). Notre objectif a ete de decrire la presentation et la prise en charge d'une cohorte de patients avec AOMI victimes d'IdM, comparee a ceux sans AOMI. Materiel et methode. – Le registre USIC 2000, colligeant les donnees des patients pris en charge pour un IdM aigu dans les soins intensifs francais en novembre 2000, a ete utilise. Resultats. – Parmi les 2311 sujets, une AOMI etait rapportee chez 215 sujets (9,3 %). En analyse multivariee, les facteurs positivement lies ( p ≤ 0,05) a une AOMI sont : âge superieur a 75 ans (OR = 2,3), diabete (OR = 2,0), hypertension (OR = 1,4), tabagisme actif (OR = 4,6), insuffisance renale (OR = 3,1), les antiagregants (OR = 3,9), antivitamine K (OR = 1,9), statines (OR = 1,7) et HBPM (OR = 6,8). En introduisant dans le modele les donnees a l'arrivee, le sexe masculin (OR = 1,6) et les antecedents de coronaropathies (OR = 2,2) etaient egalement plus frequents. Ces patients presentaient plus souvent un bloc de branche gauche (OR = 1,8) et moins souvent un sus-decalage du segment ST (OR = 0,7). Une prise en charge tardive superieure six heures etait plus frequente (OR = 1,4). L'introduction des donnees des 48 premieres heures revele un moindre recours au stent (OR = 0,7), et les betabloquants (OR = 0,6). A la sortie de l'hopital, les taux de prescription des therapeutiques de prevention secondaire sont moindres chez l'arteritique. Conclusion. – Au-dela de l'AOMI, un grand nombre de facteurs pejoratifs et une sous-prescription de traitements a interet pronostique, existent chez ces patients.

Resume Objectif Identifier les patients qui n’ont pas recours au systeme d’aide medicale d’urgence (SAMU) pour un infarctus du myocarde (IDM). Patients et methodes L’etude USIC 2000 a ete construite a partir du recueil prospectif des donnees des patients admis en novembre 2000 en France pour un IDM en unite de soins intensifs de cardiologie (USIC). Les antecedents cardiovasculaires, les facteurs de risque, les intervenants avant l’admission, le delai entre le debut des symptomes et l’admission en USIC, les modalites de prise en charge pre-hospitalieres et hospitalieres etaient reportes. Resultats Sur les 1 711 patients analyses, 769 (45 %) n’ont pas eu recours au SAMU. Ces patients sont plus âges (66 ± 14 vs 64 ± 14 ans ; p Conclusion Le sexe feminin, l’absence de sus-decalage du ST, l’intervention d’un medecin dans la gestion de l’IDM durant la phase prehospitaliere sont correles a un moindre recours au SAMU, lui-meme associe a une sous-utilisation des procedures de revascularisation et a un allongement de la duree d’hospitalisation. Ces resultats suggerent l’interet d’une campagne d’information aupres des medecins traitants sur le role du SAMU lors d’un syndrome coronarien aigu.

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.

Background The cardiovascular effects of sulfonylureas (SU) in diabetic patients are controversial and it has been suggested that diabetic patients with acute myocardial infarction while on SU were at increased risk. Objectives To assess the in-hospital outcome of patients with acute myocardial infarction according to the use of SU at the time of the acute episode. Methods Of 443 intensive care units in France, 369 (83%) prospectively collected all cases of infarction admitted within 48 h of symptom onset in November 2000. Results Among the 2320 patients included in the registry, 487 (21%) had diabetes, of whom 215 (44%) were on SU. Patients on SU were older and had a more frequent history of hyperlipidemia than those not receiving SU. Type and location of infarction were similar in the two groups, and there was no difference in Killip class on admission. In-hospital mortality was lower in patients on SU (10.2%) than in those without SU (16.9%) (p = 0.035). There was a trend toward less frequent ventricular fibrillation (2.3% vs 5.9%, p = 0.052). In two models of multivariate analyses, SU therapy was associated with decreased in-hospital mortality (model 1: relative risk: 0.44, p = 0.012; model 2: relative risk: 0.37, p = 0.020). Conclusions In this nationwide registry reflecting real-world practice, the use of sulfonylureas in diabetic patients was not associated with increased in-hospital mortality. Copyright © 2004 John Wiley & Sons, Ltd.

We assessed the in-hospital management and short- and long-term outcomes of two series of patients admitted for acute myocardial infarction, 5 years apart, in France. The most recent cohort was younger and with a less frequent history of cardiac diseases, but was more often diabetic and with anterior infarcts. Five-day mortality significantly improved from 7.7% to 6.1% (P < 0.03) and 1-year survival was also less in the most recent period (15% versus 19%, P < 0.01). Multivariate analyses showed that the period of inclusion (2000 versus 1995) was an independent predictor of both short- and long-term mortality. In analyses restricted to the patients who were alive by day 5, initial treatment with statins was associated with a 38% decrease in the risk of death at 1 year. Likewise, in patients with left ventricular ejection fraction ≤35%, the early prescription of ACE inhibitors was associated with a 41% reduction in the risk of 1-year mortality. Thus, in the real world setting, a continued decline in 1-year mortality is observed in patients admitted to intensive care units for recent acute myocardial infarction. This goes along with a shift in reperfusion therapy towards a broader use of coronary angioplasty and with an increased use of the early prescription of recognised secondary prevention medications.

The use of cardiovascular secondary prevention medications in patients with acute coronary syndromes was compared in 4 sequential observational surveys carried out in France from 1995 to 2000. The Usik 1995 and Usic 2000 surveys included patients admitted for acute myocardial infarction, while the 2 Prevenir surveys (1998 and 1999) assessed the medications prescribed in patients with acute coronary syndromes. Antiplatelet agents were prescribed in 91% of the patients in 1995, 93% in 1998 and 1999 and 96% in 2000; for beta-blockers, the respective figures were: 64%, 68%, 75% and 76%. For ACE-Inhibitors, the figures were: 46%, 41%, 41% and 50%. For statins, the prescription increased from 10% to 36%, 59% and 64%. In 1995, 8% of the patients received both antiplatelet agents, beta-blockers and statins (4% of them also had an ACE-Inhibitor); in 2000, the respective figures were 53% and 27%. The results of the recent trials of secondary prevention medications have had a considerable impact on real-life practice in France during the late 1990s.

Background Moderate anticoagulation may be proposed to reduce the risk of hemorrhage for certain patients with a mechanical prosthesis, but the consequences for risk of thromboembolism are debated. Methods and Results The purpose of the AREVA trial was to compare moderate oral anticoagulation (international normalized ratio [INR] of 2.0 to 3.0) with the usual regimen (INR of 3.0 to 4.5) after a single-valve replacement with a mechanical prosthesis, either Omnicarbon or St Jude. Patients included were between 18 and 75 years old, in sinus rhythm, and with a left atrial diameter ≤50 mm on the time-motion echocardiogram. Patients were randomized for INR after surgery. From 1991 to 1994, 433 patients underwent valve replacement (aortic, 414; mitral, 19) with 353 St Jude and 80 Omnicarbon prostheses; 380 patients were randomized for INR: 188 for INR 2.0 to 3.0 and 192 for INR 3.0 to 4.5. Mean follow-up was 2.2 years (1 to 4 years). Analysis of 18 001 INR samples showed that the mean of the median of INR was 2.74±0.35 in the 2.0 to 3.0 group and 3.21±0.33 in the 3.0 to 4.5 group ( P P =.78). Hemorrhagic events occurred in 34 patients in the 2.0 to 3.0 INR group and 56 patients in the 3.0 to 4.5 INR group ( P P =.29). Conclusions In selected patients with mechanical prostheses, moderate anticoagulation prevents thromboembolic events as effectively as conventional anticoagulation and reduces the incidence of hemorrhagic events.

We tried to determine the prognostic impact of triple (antiplatelet agents, statins and beta-blockers) and quadruple (the same+ACE inhibitors) combination therapy at hospital discharge after acute myocardial infarction. The USIC 2000 survey is nationwide registry of consecutive patients admitted to intensive care units for acute myocardial infarction in November 2000 in France. Of the 2119 patients discharged alive, 1095 (52%) were prescribed a combination of antiplatelet agents, beta-blockers and statins (triple therapy), including 567 (27%) with a similar combination plus ACE inhibitors (quadruple therapy). One-year survival was 97% in patients receiving triple combination therapy versus 88% in those who received either no, one or two of these medications (p0.0001). After multivariate adjustment, the odds ratio for one-year mortality in patients with triple combination therapy was 0.49 (95% confidence interval: 0.32-0.75). Quadruple combination therapy had no additional predictive value in the entire population. In patients with ejection fractionor = 35%, however, beta-blockers and ACE inhibitors were independent predictors of survival, and combination therapy had no additional prognostic value.compared with the prescription of any single class of secondary prevention medications, combination therapy offers additional protection in patients with acute myocardial infarction.

To determine whether sex differences of in-hospital and after-discharge mortality differ according to the age.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, beta-blockers, and statins than men. The overall 1-year mortality was higher in women (25% vs. 16% in men, P0.0001). After adjustment, in-hospital mortality was higher only for the women in the younger age group. (G1 vs. G2: OR=2.2, 95%CI=1.3-3.8; G3 vs. G4: OR=1.1, 95%CI=the risk of death, after hospital discharge, was no longer related to gender in any age group.The higher 1-year mortality following AMI in women is explained by the higher risk of death in young women during the first days of hospitalization. Further investigations are crucial to determine the cause in order to improve the chance of survival in younger women.

The cardiovascular effects of sulfonylureas (SU) in diabetic patients are controversial and it has been suggested that diabetic patients with acute myocardial infarction while on SU were at increased risk.To assess the in-hospital outcome of patients with acute myocardial infarction according to the use of SU at the time of the acute episode.Of 443 intensive care units in France, 369 (83%) prospectively collected all cases of infarction admitted within 48 h of symptom onset in November 2000.Among the 2320 patients included in the registry, 487 (21%) had diabetes, of whom 215 (44%) were on SU. Patients on SU were older and had a more frequent history of hyperlipidemia than those not receiving SU. Type and location of infarction were similar in the two groups, and there was no difference in Killip class on admission. In-hospital mortality was lower in patients on SU (10.2%) than in those without SU (16.9%) (p = 0.035). There was a trend toward less frequent ventricular fibrillation (2.3% vs 5.9%, p = 0.052). In two models of multivariate analyses, SU therapy was associated with decreased in-hospital mortality (model 1: relative risk: 0.44, p = 0.012; model 2: relative risk: 0.37, p = 0.020).In this nationwide registry reflecting real-world practice, the use of sulfonylureas in diabetic patients was not associated with increased in-hospital mortality.

We evaluated the association of statin initiation within 48 hours of admission for an acute myocardial infarction with a 1-year prognosis on a nationwide scale. Patients who received a statin within 48 hours of admission but not before hospitalization had an improved prognosis (hazard ratio 0.57, 95% confidence interval 0.38 to 0.86, p

Heparin is indicated to replace warfarin in patients with valve disease requiring antithrombotic treatment. Its use in thus necessary for short periods during which warfarin is contraindicated, but the thromboembolic risk persists. These circumstances, which are common in patients with mechanical prostheses, include: hemorrhagic risk or event complicating an existing thromboembolic risk (heart or extracardiac surgery, severe hemorrhage, end of pregnancy); when an unstable situation develops and imposes the rapid diminution or interruption of anticoagulants (stroke, infectious endocarditis); when immediate efficacy is required, rather than the delayed action of warfarin (onset of atrial fibrillation); and when warfarin is contraindicated (early pregnancy). Regardless of whether unfractionated or low molecular-weight heparin (LMWH) is used, therapeutic doses must be prescribed: continuously perfused intravenous and subcutaneous injections (t.i.d.) with repeated biological monitoring for the former, or subcutaneous injections (b.i.d.) with initial biological controls preferred and repeated in elderly subjects or those suffering from renal insufficiency. International guidelines have specified the respective roles of heparin in general, and each preparation individually with an ever-increasing use of LMWH, the efficacy of which has been proven in the majority of common thromboembolic pathologies and in pregnant women.

Summary Objectives To compare management and short-term outcome of diabetic and non-diabetic patients hospitalized for acute myocardial infarction. Methods This was a prospective epidemiological survey. All patients admitted in coronary care units in France in November 2000 for confirmed acute myocardial infarction were eligible to enter the study. Results Of the 2320 patients recruited from 369 centers, 487 were diabetic (21%). Compared to non-diabetic patients, diabetic patients were 5 years older, more often female, obese and hypertensive; they had more often a history of cardiovascular disease; they had a lower ejection fraction and worse Killip class. Reperfusion therapy was less frequent among diabetic patients (39% versus 51%; p=0.0001), as was the use of beta-blockers (61% versus 72%; p=0.0001), aspirin (83% versus 89%; p=0.0001) and statins (52% versus 60%; p=0.001) during hospitalization. Conversely, the use of ACE-inhibitors was more frequent (54% versus 44%; p=0.0001). 58% of diabetic patients received insulin during hospitalization. Twenty-eight-day mortality was 13.1% in diabetic patients and 7.0% in non-diabetic patients (risk ratio: 1.87; p=0.001). Diabetes remained associated with increased mortality after adjustment for relevant risk factors including age and ejection fraction (risk ratio: 1.51; p=0.07). In patients treated with antidiabetic drugs (chiefly sulfonylureas) before admission, 28-day mortality was 10.4% compared with 19.9% in diabetic patients on diet alone or untreated (p = 0.005). Conclusion Despite higher cardiovascular risk and worse prognosis, in-hospital management of diabetic patients with acute myocardial infarction remains sub-optimal. Patients previously treated with antidiabetic drugs including sulfonylureas had a better prognosis than untreated diabetic patients.

Although pregnancy induces a state of hypercoagulability, the thromoboembolic risks during a normal pregnancy are minor. This is not the case when the pregnant women has a native valvulopathy in atrial fibrillation, a mechanical prosthesis or a coagulation anomaly. The respective indications for heparin and oral anticoagulants reflect their respective advantages and disadvantages for the mother and child. Historically, recommendations for anticoagulants during pregnancy have evolved with each new publication of results concerning their use. Very early, coumarin induced embryopathies,1 especially during the first trimester, led to restricted use of oral anticoagulants in favour of heparin. However, it rapidly became apparent that heparin also had disadvantages, especially in women with prostheses. Heparin in these patients facilitated the evolution of the pregnancy by limiting fetal accidents but increased maternal haemorrhagic and thromboembolic risks. The ease of use and safety provided by low molecular weight heparins (LMWH) led to their widespread use, other than in pregnancy, to treat and prevent arterial and venous thromboembolic events. At present, their use during pregnancy is hampered by the lack of large randomised prospective studies, which are difficult to conduct in light of the ethical constraints which understandably apply. The risks associated with oral anticoagulants occur primarily …

On the basis of data collected from general hospital centres in France on 704 patients initially presenting with acute myocardial infarction, the mean 1-year cost of treatment was calculated to be 52,160 French francs (F) per patient (1994 values). This was independent of whether the patient received thrombolysis, and included all costs associated with initial hospitalisation including a stay in intensive care, cardiology or medical units, as well as rehospitalisations, revascularisation procedures and any drugs prescribed. When only those patients who survived the initial hospitalisation were considered, the mean cost of treatment was F58,184 per patient. Among patients who received thrombolysis during their initial hospitalisation, the respective mean 1-year costs were F74,684 per patient for those treated with alteplase and F64,866 per patient for those treated with streptokinase (p = 0.09). This nonsignificant difference can be explained by the higher cost of alteplase relative to that of streptokinase, the lower mortality rate associated with alteplase during the initial hospitalisation period (9.2% versus 10.6%) and the difference in the percentage of additional revascularisations required in the 2 treatment groups (32.8% versus 42.3%). Combining the pharmacoeconomic data collected in the French general hospital setting with incremental patient survival data stemming from the Global Utilisation of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries (GUSTO) trial showed that the incremental cost-effectiveness ratio of alteplase versus streptokinase amounted to F70128 per life-year saved for the total group, and F52035 per life-year saved for those patients who survived the initial period of hospitalisation.

The aim of this study was to evaluate the role of echocardiography in the diagnosis of sinus of Valsalva aneurysms projecting toward the right heart cavities. Three patients who had a ruptured aneurysm of a sinus of Valsalva diagnosed by echocardiography and confirmed by catheterization underwent cardiac surgery. In two patients, the aneurysm originated from the right coronary sinus and had perforated into either the inflow or outflow tract of the right ventricle. In the third patient, the aneurysm, which originated from the noncoronary sinus, ruptured into the right atrium. A fourth patient was also investigated and had an unruptured aneurysm of the right coronary sinus projecting into the right ventricular outflow tract. M-mode, two-dimensional and contrast echocardio-graphic studies were performed before cardiac catheterization in all patients and after surgery in three pa- tients. M-mode echocardiography was Useful only when the aneurysm had an anterior projection, whether or not the aneurysm was ruptured. Conversely, two-dimensional echocardiography was always able to identify the aneurysmal sac which appeared as an abnormal circular thin-walled structure protruding into the right heart cavities. By using multiple views, it was possible to investigate the whole abnormal structure and locate the sinus from which the aneurysm originated. The use of the echo contrast technique allowed more precise definition of the aneurysmal sac and diagnosis of a left to right shunt by demonstrating a negative contrast image in the right cavities. On the other hand, no negative contrast image was recorded in the patient with an unruptured aneurysm or in the two instances of a successful surgically reconstructed aorta.