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International audience; Background: Percutaneous coronary intervention (PCI)-related myonecrosis is frequent and can affect the long-term prognosis of patients. To our knowledge, ticagrelor has not been evaluated in elective PCI and could reduce periprocedural ischaemic complications compared with clopidogrel, the currently recommended treatment. The aim of the ALPHEUS study was to examine if ticagrelor was superior to clopidogrel in reducing periprocedural myocardial necrosis in stable coronary patients undergoing high-risk elective PCI.Methods: The ALPHEUS study, a phase 3b, randomised, open-label trial, was done at 49 hospitals in France and Czech Republic. Patients with stable coronary artery disease were eligible for the study if they had an indication for PCI and at least one high-risk characteristic. Eligible patients were randomly assigned (1:1) to either ticagrelor (180 mg loading dose, 90 mg twice daily thereafter for 30 days) or clopidogrel (300-600 mg loading dose, 75 mg daily thereafter for 30 days) by use of an interactive web response system, and stratified by centre. The primary outcome was a composite of PCI-related type 4 (a or b) myocardial infarction or major myocardial injury and the primary safety outcome was major bleeding, both of which were evaluated within 48 h of PCI (or at hospital discharge if earlier). The primary analysis was based on all events that occurred in the intention-to-treat population. The trial was registered with ClinicalTrials.gov, NCT02617290.Findings: Between Jan 9, 2017, and May 28, 2020, 1910 patients were randomly assigned at 49 sites, 956 to the ticagrelor group and 954 to the clopidogrel group. 15 patients were excluded from the ticagrelor group and 12 from the clopidogrel group. At 48 h, the primary outcome was observed in 334 (35%) of 941 patients in the ticagrelor group and 341 (36%) of 942 patients in the clopidogrel group (odds ratio [OR] 0·97, 95% CI 0·80-1·17; p=0·75). The primary safety outcome did not differ between the two groups, but minor bleeding events were more frequently observed with ticagrelor than clopidogrel at 30 days (105 [11%] of 941 patients in the ticagrelor group vs 71 [8%] of 942 patients in the clopidogrel group; OR 1·54, 95% CI 1·12-2·11; p=0·0070).Interpretation: Ticagrelor was not superior to clopidogrel in reducing periprocedural myocardial necrosis after elective PCI and did not cause an increase in major bleeding, but did increase the rate of minor bleeding at 30 days. These results support the use of clopidogrel as the standard of care for elective PCI.Funding: ACTION Study Group and AstraZeneca.

Background Infarct evolution rate and response to acute reperfusion therapy may differ between patients, which is important to consider for accurate management and treatment of patients with ST-elevation myocardial infarction (STEMI). The aim of this study was therefore to investigate the association of infarct size and myocardial salvage with gender, smoking status, presence of diabetes or history of hypertension in a cohort of STEMI-patients. Methods Patients (n = 301) with first-time STEMI from the three recent multi-center trials (CHILL-MI, MITOCARE and SOCCER) underwent cardiac magnetic resonance (CMR) imaging to determine myocardium at risk (MaR) and infarct size (IS). Myocardial salvage index (MSI) was calculated as MSI = 1-IS/MaR. Pain to balloon time, culprit vessel, trial treatments, age, TIMI grade flow and collateral flow by Rentrop grading were included as explanatory variables in the statistical model. Results Women (n = 66) had significantly smaller MaR (mean difference: 5.0 ± 1.5% of left ventricle (LV), p

Objectives: This study sought to evaluate the impact of initial platelet reactivity on the benefit of switched strategy. Background: TOPIC (Timing Of Platelet Inhibition after acute Coronary Syndrome) study suggested that switched dual antiplatelet therapy (DAPT) could improve net clinical benefit after acute coronary syndrome by preventing bleeding. Methods: Acute coronary syndrome patients, 1 month after coronary stenting and event free, were randomly assigned to aspirin and clopidogrel (switched DAPT) or continuation of drug regimen (unchanged DAPT). All patients underwent platelet function testing at this time and were classified as low on-treatment platelet reactivity (LTPR) (platelet reactivity index vasodilator-stimulated phosphoprotein ≤20%) or non-LTPR (platelet reactivity index vasodilator-stimulated phosphoprotein >20%). The primary endpoint aimed to evaluate the impact of platelet reactivity on clinical outcomes and benefit of switched DAPT strategy. Results: A total of 645 patients were included, 305 (47%) of whom were classified as LTPR. LTPR patients were less often diabetic (p = 0.01), had lower body mass index (p < 0.01), and were more often on ticagrelor (p < 0.01). Patients defined as LTPR and randomized to unchanged DAPT were at the highest risk of primary endpoint occurrence (31%; p < 0.01). Conversely, in the switched arm, LTPR patients had no significant difference in primary outcome incidence compared with non-LTPR patients (hazard ratio [HR]: 0.78; 95% confidence interval [CI]: 0.40 to 1.49; p = 0.45). The switched strategy was associated with important reduction in primary endpoint incidence in LTPR patients (HR: 0.29; 95% CI: 0.17 to 0.51; p < 0.01) and only numerically lower incidence in non-LTPR patients (HR: 0.79; 95% CI: 0.46 to 1.35; p = 0.39). Conclusions: Switched DAPT was superior regardless of initial platelet reactivity but the benefit was greater in LTPR patients. Indeed, the switched strategy was highly effective in this group, which had impaired prognosis with unchanged DAPT but similar prognosis after switching

Background Recent studies have shown a significant superiority of patent foramen ovale (PFO) closure over antithrombotic therapy in stroke recurrence prevention. However, uncertainty about the guidance technique remains. Most centers perform percutaneous closure of PFO using simultaneously fluoroscopic and intra-procedural echocardiography to select the optimal device. While transoesophageal echocardiography (TEE) requires general anaesthesia, intracardiac echocardiography (ICE) is costly and has inherent risks. Purpose We report the safety and efficiency data of a simplified technique: local anaesthesia, PFO closure under fluoroscopic guidance, with only pulmonary vein opacification using contrast angiography and transthoracic echocardiography control before releasing the device. Methods Single center retrospective registry enrolling 134 consecutive patients who underwent PFO closure between May 2016 and December 2019 to cryptogenic stroke. The closure decision was taken by multidisciplinary team. All the patients underwent a preprocedure TEE for morphological evaluation of PFO. An echocardiography control was done at 1 month. At 6 and 12 months a bubble test was done. Results All procedures were successful, regardless PFO complexity (ASA 62.7%), without major procedural complications. Total fluoroscopic time was 5.1 minutes, the dose-area product was 5047.8 mGy/m2 and the application of contrast medium was 7.2 mL. During a mean follow-up period of 17.2 months, one transient ischemic attack, one deep vein thrombosis and one thrombus on the occluder was reported. Contrast echocardiography at 6 months showed complete closure in 92% of patients, whereas a minimal or moderate residual shunt persisted in 4.6%, 1.8% respectively. At 12 months only 2 patients presented a residual shunt. Conclusion Percutaneous PFO closure with multimodal imaging approach is a safe and effective procedure and allows a lower radiological exposure and contrast administration.

BACKGROUND Transcatheter aortic valve replacement (TAVR) has revolutionized management of high-risk patients with severe aortic stenosis. However, survival and the incidence of severe complications have been assessed in relatively small populations and/or with limited follow-up. OBJECTIVES This report details late clinical outcome and its determinants in the FRANCE-2 (FRench Aortic National CoreValve and Edwards) registry. METHODS The FRANCE-2 registry prospectively included all TAVRs performed in France. Follow-up was scheduled at 30 days, at 6 months, and annually from 1 to 5 years. Standardized VARC (Valve Academic Research Consortium) outcome definitions were used. RESULTS A total of 4,201 patients were enrolled between January 2010 and January 2012 in 34 centers. Approaches were transarterial (transfemoral 73%, transapical 18%, subclavian 6%, and transaortic or transcarotid 3%) or, in 18% of patients, transapical. Median follow-up was 3.8 years. Vital status was available for 97.2% of patients at 3 years. The 3-year all-cause mortality was 42.0% and cardiovascular mortality was 17.5%. In a multivariate model, predictors of 3-year all-cause mortality were male sex (p = 2 of 4 (p < 0.001). Severe events according to VARC criteria occurred mainly during the first month and subsequently in < 2% of patients/year. Mean gradient, valve area, and residual aortic regurgitation were stable during follow-up. CONCLUSIONS The FRANCE-2 registry represents the largest database available on late results of TAVR. Late mortality is largely related to noncardiac causes. Incidence rates of severe events are low after the first month. Valve performance remains stable over time. (J Am Coll Cardiol 2016; 68: 1637-47) (C) 2016 by the American College of Cardiology Foundation.

Background It is recommended to perform a functional test (FT) or a coronary angiography (CA) in patients elected for vascular surgery, to predict peri-operative risk of myocardial ischemia. CCTA has proved its benefit for coronary artery disease rule out in case of chest pain and stable angina. However, its effectiveness has never been evaluated in patients’ candidates for vascular surgery. Purpose Compare CCTA, FT and CA for risk assessment of peri-operative myocardial ischemia of patients undergoing vascular surgery. Methods Patients referred for vascular surgery between November 2017 and January 2019 were prospectively included. Three groups were defined according to the pre-operative test performed: FT, CCTA or CA. A CCTA or a CA were considered positive when at least one coronary lesion > 50% was detected. A systematic postoperative troponin assay was performed and considered significant if > 5 N. The primary end point was the comparison of troponin value following vascular surgery according to the pre-operative test performed. The secondary end point was the evaluation of the accuracy of CCTA and FT to detect significant coronary lesions in comparison with CA. Results A total of 172 patients were included: 60 patients in the FT group of which 38 were negative, 59 patients in the CCTA group of which 37 were negative and 53 patients in the CA group of which 18 were negative. Rates of post-operative troponin elevation was significantly lower in the negative CCTA group than in the negative FT group (1(3%) vs. 10 (26%), P = 0,007) but similar to that in the negative CA group (vs. 1(6%)). A total of 4 (22%) patients with positive CCTA had a negative CA and 8 (24%) of positive FT had a negative CA. Conclusion CCTA could be a non-invasive alternative to pre-operative CA in patient referred for vascular surgery with better diagnostic performance than FT for rule out coronary lesion at risk of ischemia. However, CCTA should be reserved to selected patients.

Background— Percutaneous left atrial appendage (LAA) closure is an emerging option for patients with atrial fibrillation at high risk for cerebrovascular events. The multicenter FLAAC registry (French Nationwide Observational LAA Closure Registry) was established to assess LAA closure outcomes in everyday practice. Methods and Results— Four hundred thirty-six patients referred from April 2013 to September 2015 to 33 French interventional cardiology centers for percutaneous LAA closure were included prospectively in the FLAAC registry. Mean age was 75.4±0.4 years. The stroke risk was high (mean CHA 2 DS 2 –VASc score, 4.5±0.1) and most patients had experienced clinically significant bleeding (HAS-BLED score, 3.1±0.05). The device used was Amplatzer LAA occluder in 58% and the Watchman device in 42% of the patients. The procedural success rate was 98.4%. Median postprocedure follow-up was 12.0 (11.8–12.0) months and a single patient was lost to follow-up. During the periprocedural and subsequent follow-up period, procedure-related severe adverse events occurred in 21 (4.9%) and 10 (2.3%) patients, respectively. One-year cumulative incidences of ischemic stroke and cerebral hemorrhage were 2.9% (1.6–5.0) and 1.5% (0.7–3.2), respectively. Overall, 1-year mortality was 9.3% (6.9–12.5) with 7 of the 39 deaths related or possibly related to the device or procedure. Conclusions— This nationwide prospective registry shows that, in the French population, LAA closure is mainly used in patients with high comorbidity rates and a poor prognosis. LAA closure in such patients seems reasonable to decrease the stroke rate. The overall health status of these patients should be taken into account during the preprocedural evaluation process. Clinical Trial Registration— URL: https://www.clinicaltrials.gov . Unique identifier: NCT02252861.

Diagnosis of infective endocarditis (IE) after transcatheter aortic valve replacement (TAVR) remains difficult to establish using modified Duke criteria. We present the value of multi-imaging approach (European Society of Cardiology [ESC]-2015 modified criteria) [(1)][1] in 16 patients referred for

Background - Transcatheter aortic valve replacement (TAVR) is standard therapy for patients with severe aortic stenosis who are at high surgical risk. However, national data regarding procedural characteristics and clinical outcomes over time are limited. Objectives - The aim of this study was to assess nationwide performance trends and clinical outcomes of TAVR during a 6-year period. Methods - TAVRs performed in 48 centers across France between January 2013 and December 2015 were prospectively included in the FRANCE TAVI (French Transcatheter Aortic Valve Implantation) registry. Findings were further compared with those reported from the FRANCE 2 (French Aortic National CoreValve and Edwards 2) registry, which captured all TAVRs performed from January 2010 to January 2012 across 34 centers. Results - A total of 12,804 patients from FRANCE TAVI and 4,165 patients from FRANCE 2 were included in this analysis. The median age of patients was 84.6 years, and 49.7% were men. FRANCE TAVI participants were older but at lower surgical risk (median logistic European System for Cardiac Operative Risk Evaluation [EuroSCORE]: 15.0% vs. 18.4%; p < 0.001). More than 80% of patients in FRANCE TAVI underwent transfemoral TAVR. Transesophageal echocardiography guidance decreased from 60.7% to 32.3% of cases, whereas more recent procedures were increasingly performed in hybrid operating rooms (15.8% vs. 35.7%). Rates of Valve Academic Research Consortium-defined device success increased from 95.3% in FRANCE 2 to 96.8% in FRANCE TAVI (p < 0.001). In-hospital and 30-day mortality rates were 4.4% and 5.4%, respectively, in FRANCE TAVI compared with 8.2% and 10.1%, respectively, in FRANCE 2 (p

Echocardiography plays a new critical role during structural heart interventions (SHIs), although fluoroscopy remains an indispensable tool [(1,2)][1]. Exposure to radiation by staff is directly proportional to the dose the patient receives in interventional cardiology and is affected by higher mean

To assess the value of cardiac magnetic resonance (CMR) using phase-contrast velocity mapping for paravalvular aortic regurgitation (PAR) quantification., All patients undergoing transcatheter aortic valve implantation (TAVI) in our centre between November 2012 and August 2013, without CMR-contraindication were included. PAR severity was assessed 5 days after TAVI using: transthoracic echocardiography (TTE) and CMR [regurgitant volume (RV), regurgitant fraction (RF)]. Aortic regurgitation (AR) index was obtained during TAVI. Thirty of 51 patients who underwent TAVI were included (COREVALVE, n = 10; or EDWARDS SAPIEN XT, n = 20). At TTE, PAR was mild in 22, moderate in 3, and severe in 5 patients. Reliable phase-contrast images were acquired at the sino-tubular junction for SAPIEN and at the tubular portion of the ascending aorta for COREVALVE. The reproducibility of CMR was high (coefficient of correlation = 0.99 for intra- and inter-operator variability). At CMR, RV, and RF were significantly (P < 0.0005) correlated with AR severity at TTE, with mean RF values at 9.2 ± 7.6% in mild, 20.3 ± 4.2% in moderate, and 46.8 ± 10.8% in severe PAR. A cut-off value of RF < 14% at CMR accurately discriminated mild from moderate/severe (sensitivity: 100%, specificity: 82%). The mean AR index was 29.4 ± 6 for mild and 13.8 ± 5 for moderate/severe PAR. Three patients had a RF > 14% and a low AR index, CMR is a reproducible, accurate, and reliable method to assess PAR severity. CMR may allow correcting an underestimation at TTE when AR index is doubtful.

BackgroundWe retrospectively studied the impact of the introduction of new P2Y12 inhibitors (prasugrel, ticagrelor) on platelet reactivity and clinical outcomes after Acute Coronary Syndrome (ACS) from a large single center registry.MethodsConsecutive patients admitted for ACS since 2007 and discharged on dual antiplatelet therapy were enrolled. Biological response was assessed one month after discharge by PRI VASP and ADP-induced aggregation (%ADP). Patients were classified according to PRI VASP as very low on-treatment platelet reactivity (VLTPR) (PRI VASP ≤ 10%), low on-treatment platelet reactivity (LTPR) (PRI VASP ≤ 20%) and high on-treatment platelet reactivity HTPR (PRI VASP > 50%). Ischemic and bleeding complications were reported.Results1999 patients were analyzed, 605 before (July 2007–February 2010) and 1394 after introduction of new P2Y12 blockers (February 2010–August 2013). After introduction, we reported a significant lower PRI VASP values (38% ± 0.53 vs. 42% ± 0.81 p = 0.001), %ADP aggregation (52% ± 0.4 vs. 54% ± 0.6 p = 0.03) and HTPR incidence (22% versus 34% OR [95% CI]:0.65 [0.53–0.80]; p < 0.001). Conversely, incidence of VLTPR and LTPR were significantly higher after the introduction of new P2Y12 inhibitors: 6% versus 3% (OR [95% CI]: 2.0 [1.2–3.3]; p < 0.01) and 19% versus 8% (OR [95% CI]: 2.8 [2.0–3.9]; p < 0.001) respectively. Clinical follow-up confirmed biological findings with higher incidence of bleeding 10% versus 5% (OR [95% CI]: 2.1 [1.4–3.2]; p < 0.01) and lower incidence of stent thrombosis 1.3% versus 3.3% (OR [95% CI]: 0.39 [0.20–0.73]; p < 0.01) with new P2Y12 blockers.ConclusionThe introduction of new P2Y12 inhibitors modified both platelet reactivity and clinical outcome of ACS patients, with higher rate of hyper responders and bleedings, and lower rate of non responders and thrombotic events.

Statin therapy is a cornerstone therapy for secondary prevention after acute coronary syndrome (ACS). However, the use of these drugs can be limited by side effects, mainly muscular pain. Ezetimibe is a newer lipid-lowering agent, with fewer side effects.The present study was designed to compare a commercially available association of ezetimibe and simvastatin (E-S) to high dose Rosuvastatin on cholesterol and muscular enzyme levels and occurrence of muscular pain.All consecutive ACS statin-naïve patients with LDL cholesterol (LDL-C)100mg/dL randomly received either high dose statin (Rosuvastatin 20mg) or E-S 10/40-mg. All patients had one-month follow-up with biological testing and clinical examination. We compared the two groups on the biological efficiency and incidence of muscular pain.One hundred and twenty-eight patients were randomized; 64 received E-S and 64 Rosuvastatin. In the two groups, the lowering of LDL-C level (Δ=51%) at one month was significant (P0.01) without any difference in the rate of lowering on LDL-C or HDL-C suggesting that E-S is as effective as high dose Rosuvastatin (P=0.77 and P=0.99). The rate of patients reaching the objective of LDL-C100mg/dL (45%) and LDL-C70mg/dL (51%) was not different in the two clusters (P=0.65). Incidence of muscular pain was 15% higher in patients treated with Rosuvastatin (P=0.01) without any difference on CPK level (P=0.6).Using an association of E-S in an effective alternative strategy to high dose Rosuvastatin with a lower incidence of muscular pain, which might impact adherence to medication after ACS.

International audience; Delay from the last intake of drug could be an important and unexplored variable in the biological response to antiplatelet agents after acute coronary syndrome (ACS) discharge. The objective was to define the impact of the delay from P2Y12 blocker intake on the platelet inhibition level. We compared ticagrelor-, prasugrel-, and clopidogrel-treated patients. All consecutive patients, who had been addressed between 2013 and 2014 for ACS, treated with aspirin and a P2Y12 blocker as maintenance dose, were eligible. One month after discharge, blood sample and a questionnaire were proposed to the patient by a nurse blinded to the protocol. On this questionnaire, three questions about name of the drug, regularity of the intakes, and hour of the last intake were collected. The response to antiplatelet therapy was assessed using platelet reactivity index vasodilator-stimulated phosphoprotein (PRI VASP) and % of adenosine-5'-diphosphate-induced aggregation (%ADP).The primary objective of this study was to evaluate the correlation between platelet inhibition and delay from drug intake. We enrolled 474 ACS treated with clopidogrel 75 mg in 182 cases (38% patients), prasugrel in 190 cases (40%), or ticagrelor in 102 patients (22%). We observed a significant correlation between delay from intake and PRI VASP and %ADP for ticagrelor (r = 0.25, p = 0.01; r = 0.21, p = 0.03; respectively). On clopidogrel (r = 0.09, p = 0.24; r = 0.02, p = 0.80; respectively) and prasugrel (r = 0.02, p = 0.82; r = 0.11, p = 0.12 respectively), no correlation exists. In conclusion, ticagrelor, unlike thienopyridines, is associated with a significant correlation between delay from the last intake and platelet inhibition.

We have read with great interest the letter from Dr. Lozano and colleagues about our paper assessing the impact of on-treatment platelet reactivity on switching strategy after acute coronary syndrome (ACS) [(1)][1]. First, we would like to thank the authors for their comments and the interest

Introduction Trans-catheter left atrial appendage (LAA) occlusion with a Watchman device (WM) (Boston Scientific Corp, MA, USA) is a feasible alternative to long-term anticoagulation for stroke prevention in patients with non-valvular atrial fibrillation (AF). Cardiac computed tomography angiography (CCTA) is routinely used to asses LAA morphology and determine the size of the WM. Trans-esophageal Echocardiography (TEE) may identify minor peri-device leak (PL) that are supposed to be filled later. We sought to assess the mid term evolution of PL. Methods Implantation of a WM was attempted in 74 patients, successfully in 70. CCTA was performed > 45 days after implantation in 44 patients. We compared immediate results of the procedure by TEE to late results by CCTA performed > 1 month after implantation. Results Late CCAT was done in 44 patients, 28 male (64%), mean aged 77 years (57–92). Indications for LAA closure was bleeding in all cases, neurologic in 18 (45%), gastrointestinal in 16 (36%) and miscellaneous in 8 (18%). CHA2DS2-VASc score was 5 (3–9). Anticoagulation was contraindicated in all cases. An anti-platelet agent was given in 37 and no treatment in 7 (16%). None of these patients had had any thromboembolic event at the time of CCTA. A PL was identified by TEE at the time of implantation in 20 pts (45%) and by late CCTA in 22 pts (50%). In 17 pts with a CCTA done > 6 months, 7 had a PL (41%). Late PL was noted in 10 patients with (50%) and 12 patients (50%) without early PL. Conclusion Early PL seems to remain at mid-term in half of the patients. Moreover, TEE could be unable to detect PL that is identified by CCTA later in 1 case over 2. Nevertheless the clinical consequence of PL seems to be marginal in this study and the literature.

Background TOPIC (Timing Of Platelet Inhibition after acute Coronary syndrome) trial showed that switched dual antiplatelet therapy (DAPT) improved net clinical benefit after ACS. Purpose The objective of this analysis was to evaluate the impact of initial platelet reactivity on the benefit of this strategy. Methods Patients admitted with ACS requiring coronary intervention were randomly assigned to switch to aspirin and clopidogrel (switched DAPT) or continuation of their drug regimen (unchanged DAPT). All patients underwent platelet function testing at this time and were classified according to PRI VASP as low on-treatment platelet reactivity (LTPR = PRI VASP ≤ 20%) or no LTPR (PRI VASP > 20%). The primary endpoint of this analysis aimed to evaluate the impact of on-treatment platelet reactivity on clinical outcomes (a composite of ischemic and bleeding events at one year) in both groups. Results Six hundred and forty-five patients were included in the analysis, of whom 305 (47%) were classified as LTPR. LTPR patients were less often diabetic ( P = 0.01), had lower BMI ( P P P P Fig. 1 ), and numerically lower incidence in non-LTPR (HR 95% CI 0.71 (0.43–1.18), P = 0.19). In switching arm, LTPR patients had no significant difference in primary outcome incidence in comparison with no LTPR (HR 95% CI 0.79 (0.44–1.44), P = 0.44) ( Fig. 1 ). Conclusion Switching DAPT strategy was superior regardless of initial platelet reactivity. Interestingly, the switching strategy was highly efficient in hyper responders, who had impaired prognosis with unchanged DAPT but similar prognosis after switching.

Background The Timing Of Platelet Inhibition after acute Coronary Syndrome (TOPIC) trial showed that switching dual antiplatelet (DAPT) from aspirin plus a newer P2Y12 blocker (prasugrel or ticagrelor) to aspirin plus clopidogrel 1 month after an acute coronary syndrome (ACS) led to a reduction in bleeding complications with similar risk of ischemic recurrence. Purpose The objective of this prespecified analysis was to evaluate the impact of switching strategy on DAPT adherence. Methods TOPIC study randomized patients admitted for an ACS without adverse event at 1 month on aspirin and a newer P2Y12 blocker, to aspirin and clopidogrel (switched DAPT) or continuation of their drug regimen (unchanged DAPT). Medical adherence to prescribed DAPT was assessed at 6 months and 1 year. Results Six hundred and forty-six patients were randomized and 645 analyzed, corresponding to 322 patients in the switched DAPT and 323 in the unchanged DAPT group. At 6 months and 1 year, the allocated DAPT regimen was significantly used more often in the switched group than in the unchanged DAPT group: 298 (92.5%) vs. 264 (81.7%) (P Fig. 1 ). In multivariable analysis, unchanged DAPT strategy and ischemic or bleeding events were significantly associated with non-adherence to prescribed DAPT ( Table 1 ). Conclusion A switched DAPT was associated with significant improvement in the number of patients on prescribed DAPT at 6 months and 1 year following ACS. This improved adherence was related to reduction of side effects.

Introduction Trans-catheter left atrial appendage (LAA) occlusion is recommended for stroke prevention in patients with non-valvular atrial fibrillation (AF), a CHA2DS2VASc score ≥ 4 (Score) and a contraindication to long-term anticoagulation. The PROTECT AF trial demonstrated that LAA closure with the Watchman (WM) device (Boston Scientific, MA, USA) was non-inferior to warfarin therapy. However, patients included received concomitant warfarin for 6 weeks after WM implantation. The ASAP study suggested that LAA closure with the WM without a warfarin transition was a reasonable alternative for patients with contraindications (CI) to oral anticoagulation (OAC). Our aim was to evaluate this strategy at one year in our institution. Methods From December 2013 to April 2017, the procedure was performed in 74, successfully in 70 (95%). All patients were alive, event free at 45 days for the first on site check-up. Results A one year follow-up was obtained in 50 patients, 32 male (64%), mean age 77 year (51-93), with a CH2DS2VASc score = 5 (3–9), and HASBLED score = 4.5 (3–9). Previous embolic stroke was reported in 23 (46%). Contraindication for OAC was a hemorrhagic event in all, neurologic in 20 (40%) gastroenterologic in 24 (48%). After WM implantation, 26 received Aspirin or Clopidogrel (46%), 16 both (32%) and 8 none (16%). At 45 days, dual anti-platelet therapy was renewed in 19 (38%) with severe coronary. At 1 year, no thromboembolic event was reported. Twelve patients died (24%), 2 after cerebral hemorrhage, 1 terminal liver failure, 1 cancer, 2 pneumonia, 6 suddenly. For the later with multivessel disease, ischemic origin was suspected. Conclusion In patients with a high risk of embolic stroke and permanent CI to OAC, LAA closure may be performed with no anticoagulation. Nevertheless this population is at high risk of short-term death from other origin. A better evaluation of the prognosis should be done before planning the procedure.

Introduction Thrombus aspiration (TA) may be useful to retrieve obstructive blood clot, restore coronary blood flow and prevent distal embolization in patients presenting an acute coronary syndrome. Although a cornerstone study has not demonstrated any benefit in hard clinical endpoints in a population of non-selected patients, TA is still being used in some cases by a number of interventional cardiologists. Purpose To determine if the amount of thrombotic material retrieved could be anticipated before TA. Methods This monocentric, observational and retrospective study was carried out between December 2009 and September 2016. Patients were included in the study if after TA, material could be recovered for an anatomo-pathologic analysis. We present the macroscopic analysis of the study and compare demographic, clinical and angiographic characteristics of patients with thrombus ≥ 1 millimeter of length (TA+) or Results This study included 79 patients (64 men), 54 in group TA+ (68%). As compared with TA−, patients TA+ were not significantly younger (60 years old vs. 63.4 years old; P = 0.39), had more often ST segment elevation myocardial infarction (STEMI) at presentation (90% versus 78%; P = 0.27) and more frequently single vessel disease (59% vs. 38%; P = 0.085). In 24 patients, TA was not followed immediately by stent implantation: 7 required stenting in a second procedure after a mean time of 6.8 days, the 17 others (22%) were not treated by stent implantation because of minor residual stenosis (8), coronary aneurysm (3), stent thrombosis and non-compliance with dual antiplatelet therapy (1), unspecified reason (3) and end stage cardiogenic shock (2), both died in the cath lab. Conclusion The amount of material retrieved by TA may be predicted. Young patients with a STEMI and single vessel disease could be the best candidates. In some cases TA could prevent stent implantation. A dedicated study aiming this population would be of major interest.

Background The TOPIC trial showed that switching dual antiplatelet (DAPT) from aspirin plus a newer P2Y12 blocker (prasugrel or ticagrelor) to aspirin plus clopidogrel led to a reduction in bleeding complications with similar risk of ischemic recurrence. Purpose The objective of this analysis was to evaluate the impact of diabetes on the benefit of switched strategy. Methods TOPIC study randomized patients admitted for an ACS without adverse event at 1 month on aspirin and a newer P2Y12 blocker, to aspirin and clopidogrel (switched DAPT) or continuation of their drug regimen (unchanged DAPT). Results Three hundred and twenty-two patients were randomized to switched DAPT and 323 to unchanged DAPT. The primary endpoint of this analysis aimed to evaluate the impact of diabetes on clinical outcomes (composite of cardiovascular death, urgent revascularization, stroke and bleeding BARC classification ≥ 2) at 1 year. Hundred and seventy-seven patients were diabetics corresponding to 84 (26%) in the switched arm and 93 (29%) in the unchanged. No differences in primary outcome incidence was observed in the unchanged arm between diabetic and non-diabetic (25.8% vs. 26.5%, HR 95% CI 0.96 (0.60–1.54), P = 0.88) while in the switched arm, primary endpoint occurred significantly more in diabetics (22.6% vs. 10.1%, 95% CI 2.72 (1.37–5.42), P Fig. 1 ) despite reduction in bleedings BARC ≥ 2 (HR 0.37, P = 0.04) ( Fig. 1 ). Conclusion Switching DAPT proved its benefit after ACS in terms of bleeding prevention. However, in diabetic patients switching DAPT was associated with excess of ischemic events despite bleeding prevention. Switching DAPT strategy should be preferred in non-diabetic patients.

Introduction Left atrial appendage (LAA) closure (LAAC) is recommended in patients (pts) with non-valvular atrial fibrillation (AF) and a contra indication (CI) to long-term oral anticoagulation (OAC).We sought to determine incidence and risk factors for WATCHMAN device (WM) thrombosis. Methods LAAC with a WM was done in 100 consecutive pts prospectively included in the monocentric RESET Registry. No thromboembolic event occurred. Transoesophageal echocardiography (TOE) was done in 57 pts at a median of 53 days (22–460) and Cardiac Computed Tomography Angiography (CCTA) in 62 at a median of 175 days (33–792). LAA thrombus against the device was detected by TOE or CCTA in 5 pts. We compared characteristics of the group with (DT) or without (N-DT) device thrombosis. Results A major bleeding was the CI for OAC in 77 pts (96%) and only 8 received anticoagulation for 45 days after LAAC. Thereafter, 58 received aspirin (73%), 20 no treatment (25%) and 2 an OAC. LAA thrombus was detected in 2 pts by TOE (51 and 98 days) and 3 by CCTA (178, 183 and 447 day) and resolved on OAC. Incidence at 1 year was 5.1% (4/78). No significant difference was observed between the 2 groups. Although DT had a tendency of higher CHA2DS2-VASc (5 ± 1.6 vs. 4.6 ± 1.4) or HAS-BLED (4.6 ± 0.5 vs. 4.4 ± 1) scores, permanent AF (60% vs. 48%), intracranial haemorrhage (80% vs. 48%), no difference in term of history of stroke/TIA (60% vs. 70%) or antiplatelet treatment (80% vs. 60%) was noted. Morphology of LAA was in all cases a non-chicken-wing (vs. 67%). Conclusion Although LAAC is limited to patients with multiple comorbidities that are reluctant to TOE, incidence of LAA thrombosis after WM implantation is high enough to strongly recommend device surveillance. Nevertheless, the optimal timing for imaging remains unclear and repetitive studies could be necessary in specific conditions. Medical history and morphologic characteristics of LAA are of limited help to identify high-risk patients.

Background Elderly patients are at high-risk of bleedings, particularly in the setting of acute coronary syndrome treated with an invasive strategy. Treatment adjustment by platelet function testing (PFT) failed to improve clinical outcomes in the randomized ANTARCTIC trial. Purpose This prespecified substudy aims at determining the predictive value of PFT on occurrence of bleedings. Methods We analyzed the 877 patients over the age of 75 years included in the ANTARCTIC trial and randomized to a strategy of dose or drug antiplatelet therapy adjustment or a conventional “one size fits all” strategy without PFT. In the monitoring group, patients received prasugrel 5 mg daily after coronary stenting and PFT was done 14 days after randomization and repeated 14 days after treatment adjustment. Occurrence of bleedings was collected up to one year and correlated with PFT. Results Clinically relevant bleedings (Bleeding Academic Research Consortium types 2, 3 or 5) were frequently observed (20.6%, n = 181 patients) with one third occurring in the first month. Cutaneous and gastro-intestinal bleedings were the two predominant complications. There was no significant difference in the final treatment between patients with or without clinically relevant bleedings (respectively, clopidogrel 75 mg: 19.9% and 19.6%, prasugrel 5 mg: 77.3% and 77.9%, prasugrel 10 mg: 2.6% and 2.8%; P = 0.91) The main predictive factors of major bleedings in multivariate model were age > 85 years [adj.HR(95% CI): 2.48(1.25;4.91); P = 0.0093] and hemoglobin level (per gram of decrease) [adj.HR(95% CI): 1.45(1.18;1.79); P = 0.0004]. The last PFT was an independent predictive factor of clinically relevant bleedings (adj.HR(95% CI): 0.95(0.90;0.99); P = 0.017). Conclusion Clinically relevant bleedings were frequent in elderly patients in the setting of acute coronary syndrome. PFT did not improve clinical outcomes but identified the bleeding risk of these patients when the chronic treatment was installed.

Introduction Left atrial appendage (LAA) closure (LAAC) is indicated in patients with non valvular atrial fibrillation (AF) and contraindication to oral anticoagulation (OAC). Since December 2013, patients referred for LAAC have been included in a prospective registry and have given an informed consent for a five-year follow-up (FU). We compare charca and mid term follow up of those with (group S) and without (group NS) history of embolic stroke/TIA. Methods Contra indication to OAC was established by a multidisciplinary team. Feasibility of LAAC was assessed by Cardiac Computed Tomography angiography. A 45 days TEE was planned. Thereafter patients received a phone call every 6 months. Available data were analyzed in case of adverse event. Results From 100 patients implanted, 29 had history of stroke. Demographics were not significantly different in both groups in term of age (77.1 ± 7.6 vs. 78 ± 7.2 yrs), sex (62% vs. 72% male), AF type (permanent in 55% vs. 49%), congestive heart failure (31% vs. 39%) and HAS BLED score (4.4 ± 1 in both). Obviously CHA2DS2VASc score was higher in S group (5.8 ± 1.4 vs. 4.2 ± 1.2%). LAA morphology was not different in both groups with a majority of Windsock type (59% vs. 55%), and a tendency of more Cactus type (17% vs. 5%) and less Chicken Wind type (24% vs 38%) in S group. Antithombotic treatment after implantation was not different in both groups, antiplatelet (66% vs. 65%), low dose anticoagulant for 45 days (10% vs. 6%), no ATT (24% vs. 27%). At 45 days 1 patient died from refractory bronchospasm in the N-S group. One year FU was obtained in 16 and 44 patients in group S and NS. No fatal or non-fatal embolic event occurred. A tendency of less death was noted in S-Group (6.3% vs. 29.5%). TEE was performed in 17 and 39 cases and a thrombus was detected in 2/17 (11.8%) patients in S group and 1/39 (2.6%) in N-S group. Conclusion Patients with a history of previous stoke/TIA seem to have similar characteristics and prognosis than those without.

Diabetes has been identified as a risk factor for impaired clopidogrel response, and these patients might have greater benefit with new P2Y12 blockers such as prasugrel. The present study was designed to assess response to thienopyridine in diabetic patients undergoing PCI for ACS.107 diabetic patients undergoing PCI for ACS were included and treated by clopidogrel 600 mg loading dose and switched to prasugrel 10mg daily after PCI. Platelet reactivity was assessed by PRI VASP. High-on-treatment platelet reactivity (HTPR) was defined by PRI VASP50% and Low-on-treatment platelet reactivity (LTPR) as PRI VASP below the 75th percentile (PRI VASP20%). After clopidogrel, mean PRI VASP was 47 ± 21% and 54 patients (50%) were non responders. At one month, mean PRI VASP on prasugrel 10mg daily was 31 ± 13%, 9 patients (8%) had HTPR and 23 patients (22%) had LTPR. In multivariate analysis, factors associated with platelet reactivity were waist circumference for HTPR on clopidogrel and body weight for HTPR and LTPR on prasugrel. 10 patients (9%) suffered from BARC bleeding complications. Patients with bleeding complications had significantly lower PRI VASP values: 22 ± 9 vs. 32 ± 13, p=0.02 and ROC curves identified a cut-off value of VASP=28% to predict bleeding complications.The present study confirmed that many diabetic patients treated with clopidogrel for ACS have inadequate platelet inhibition. Switch to prasugrel is effective with acceptable safety in this specific population. We observed a significant relationship between on-treatment platelet reactivity and bleeding complications.

Objectives: This study was designed to define the hyperresponse to thienopyridine (very low on-treatment platelet reactivity [VLTPR]) as the most predictive threshold value of platelet reactivity i...

There are limited data on the safety and efficacy of low molecular weight heparin (LMWH) in elderly patients with acute myocardial infarction (AMI).We aimed to compare LMWH with unfractioned heparin (UFH) in the management of AMI in elderly patients. FAST-MI is a nationwide registry carried out over a 1-month period in 2005, including consecutive patients with AMI admitted to intensive care unit48 h from symptom onset in 223 participating centers. We assessed the impact of LMWH on bleeding, the need for blood transfusion and one-year survival in elderly patients (≥ 75 years).963 patients treated with heparin were included (mean age 82 ± 5 years; 51% women; 42.5% ST-elevation myocardial infarction). Major bleeding (2.4% vs. 6.1%, P=0.004) and blood transfusions (4.6% vs. 9.7%, P=0.002) were significantly less frequent with LMWH compared with the UFH, a difference that persisted after multivariate adjustment (OR=0.41, 95% CI: 0.20-0.83 and OR=0.49, 95% CI: 0.28-0.85, respectively). One-year survival and stroke and reinfarction-free survival were also significantly higher with LMWH compared with UFH (OR=0.66, 95% CI: 0.50-0.85 and OR=0.71, 95% CI: 0.56-0.91, respectively). In two cohorts of patients matched on a propensity score for getting LMWH and with similar baseline characteristics (328 patients per group), major bleeding and transfusion were significantly lower while one-year survival was significantly higher in patients receiving LMWH.The present data show that in elderly patients admitted for AMI, use of LMWH is associated with less bleeding, less need for transfusion, and higher survival, compared with the use of UFH.

The present study was performed to compare the influence of cytochrome P459 2C19 (CYP2C19) *2 and *17 genetic variants on the platelet response to clopidogrel and prasugrel maintenance therapy and to assess the relation between platelet reactivity and bleeding complications. A total of 730 patients were included (517 patients treated with clopidogrel 150 mg/day and 213 discharged with prasugrel 10 mg). Platelet reactivity was assessed at 1 month with the platelet reactivity index vasodilator-stimulated phosphoprotein (PRI VASP). High on-treatment platelet reactivity was defined as PRI VASP >50% and low on-treatment platelet reactivity (LTPR) as PRI VASP

International audience; In patients admitted for acute coronary syndrome (ACS), the guidelines of the European Society of Cardiology give a Class I, Level A recommendation for the prescription of high-intensity statins to be initiated as early as possible, regardless of the low-density lipoprotein cholesterol (LDL-C) level. Although statins are widely prescribed after ACS, the intensity of therapy and the proportion of patients achieving target LDL-C values are often not in line with recommendations due to a lack of compliance with guidelines by the physicians, a lack of compliance with treatment or poor tolerance by patients, and poor dose adaptation. In this context, a group of French physicians came together to define strategies to facilitate and improve the management of lipid-lowering therapy after ACS. This paper outlines the scientific rationale for the use of statins at the acute phase of ACS, the utility of ezetimibe, the measurement of LDL-C during the course of ACS, the opportunities for detecting familial hypercholesterolaemia and the results of the consensus for the management of lipid-lowering therapy, illustrated in two decision-making algorithms.

Newer P2Y12 blockers (prasugrel and ticagrelor) demonstrated significant ischaemic benefit over clopidogrel after acute coronary syndrome (ACS). However, both drugs are associated with an increase in bleeding complications. The objective of the present study was to evaluate the benefit of switching dual antiplatelet therapy (DAPT) from aspirin plus a newer P2Y12 blocker to aspirin plus clopidogrel 1 month after ACS.We performed an open-label, monocentric, and randomized trial. From March 2014 to April 2016, patients admitted with ACS requiring coronary intervention, on aspirin and a newer P2Y12 blocker and without adverse event at 1 month, were assigned to switch to aspirin and clopidogrel (switched DAPT) or continuation of their drug regimen (unchanged DAPT). The primary outcome was a composite of cardiovascular death, urgent revascularization, stroke and bleeding as defined by the Bleeding Academic Research Consortium (BARC) classification ≥2 at 1 year post ACS. Six hundred and forty six patients were randomized and 645 analysed, corresponding to 322 patients in the switched DAPT and 323 in the unchanged DAPT group. The primary endpoint occurred in 43 (13.4%) patients in the switched DAPT group and in 85 (26.3%) patients in the unchanged DAPT (HR 95%CI 0.48 (0.34-0.68), P 0.01). No significant differences were reported on ischaemic endpoints, while BARC ≥ 2 bleeding occurred in 13 (4.0%) patients in the switched DAPT and in 48 (14.9%) in the unchanged DAPT group (HR 95%CI 0.30 (0.18-0.50), P 0.01).A switched DAPT is superior to an unchanged DAPT strategy to prevent bleeding complications without increase in ischaemic events following ACS.

A 72-year-old man was referred because of suspected infective endocarditis. Fifteen years earlier, he had undergone mitral valve replacement with a 33-mm Hancock valve for severe mitral regurgitation. Three months ago, he presented with a first episode of congestive heart failure caused by severe mitral regurgitation reflecting degeneration of the bioprosthetic valve without sign of endocarditis. Because of a high surgical risk based on an estimated Euroscore I of 42.96% and The Society of Thoracic Surgeons (STS) score of 29% (main comorbidity is an advanced Parkinson disease), valve-in-valve implantation was planned. A 29-mm Edwards Sapien 3 (S3) balloon-expandable valve was successfully implanted through transapical puncture of the left ventricle (LV) after direct surgical exposure by mini thoracotomy. Patient was discharged 10 days after the procedure without complications. On his admission, the patient was febrile and examination revealed a purulent discharge at the site of thoracotomy. Transthoracic echocardiography (TTE) and transesophageal echocardiography showed a 15-mm mobile vegetation on the leaflet of the S3 (Movie I in the Data Supplement) and a pseudoaneurysm at the apex of the left ventricle (LVPA) flowing by a large apical defect (Figure 1; Movie II in the Data Supplement). Computed tomographic (CT) scanning confirmed the LVPA free from any thrombus and identified the surgical suture tip in its deep (Figures 1 and 2; Movie III in the Data Supplement). 18F positron-emission tomography demonstrated an uptake on the S3 and LVPA (Figure 2). Blood cultures were positive for Staphylococcus aureus . Antibiotherapy with co-trimoxazole for 6 weeks and clindamycin for 1 week was started, and a quick clinical and biological …

Summary Background Elderly patients are at high risk of ischaemic and bleeding events. Platelet function monitoring offers the possibility to individualise antiplatelet therapy to improve the therapeutic risk–benefit ratio. We aimed to assess the effect of platelet function monitoring with treatment adjustment in elderly patients stented for an acute coronary syndrome. Methods We did this multicentre, open-label, blinded-endpoint, randomised controlled superiority study at 35 centres in France. Patients aged 75 years or older who had undergone coronary stenting for acute coronary syndrome were randomly assigned (1:1), via a central interactive voice-response system based on a computer-generated permuted-block randomisation schedule with randomly selected block sizes, to receive oral prasugrel 5 mg daily with dose or drug adjustment in case of inadequate response (monitoring group) or oral prasugrel 5 mg daily with no monitoring or treatment adjustment (conventional group). Randomisation was stratified by centre. Platelet function testing was done 14 days after randomisation and repeated 14 days after treatment adjustment in patients in the monitoring group. Study investigators and patients were not masked to treatment allocation, but allocation was concealed from an independent clinical events committee responsible for endpoint adjudication. The primary endpoint was a composite of cardiovascular death, myocardial infarction, stroke, stent thrombosis, urgent revascularisation, and Bleeding Academic Research Consortium-defined bleeding complications (types 2, 3, or 5) at 12 months' follow-up. We did analysis by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT01538446. Findings Between March 27, 2012, and May 19, 2015, we randomly assigned 877 patients to the monitoring group (n=442) or the conventional group (n=435). The primary endpoint occurred in 120 (28%) patients in the monitoring group compared with 123 (28%) patients in the conventional group (hazard ratio [HR], 1·003, 95% CI 0·78–1·29; p=0·98). Rates of bleeding events did not differ significantly between groups. Interpretation Platelet function monitoring with treatment adjustment did not improve the clinical outcome of elderly patients treated with coronary stenting for an acute coronary syndrome. Platelet function testing is still being used in many centres and international guidelines still recommend platelet function testing in high-risk situations. Our study does not support this practice or these recommendations. Funding Eli Lilly and Company, Daiichi Sankyo, Stentys, Accriva Diagnostics, Medtronic, and Fondation Coeur et Recherche.

Objectives The aim of this landmark exploratory analysis, ATLANTIC-H 24 , was to evaluate the effects of pre-hospital ticagrelor during the first 24 h after primary percutaneous coronary intervention (PCI) in the ATLANTIC (Administration of Ticagrelor in the cath Lab or in the Ambulance for New ST elevation myocardial infarction to open the Coronary artery) study. Background The ATLANTIC trial in patients with ongoing ST-segment elevation myocardial infarction showed that pre-hospital ticagrelor was safe but did not improve pre-PCI coronary reperfusion compared with in-hospital ticagrelor. We hypothesized that the effect of pre-hospital ticagrelor may not have manifested until after PCI due to the rapid transfer time (31 min). Methods The ATLANTIC-H 24 analysis included 1,629 patients who underwent PCI, evaluating platelet reactivity, Thrombolysis In Myocardial Infarction flow grade 3, ≥70% ST-segment elevation resolution, and clinical endpoints over the first 24 h. Results Following PCI, largest between-group differences in platelet reactivity occurred at 1 to 6 h; coronary reperfusion rates numerically favored pre-hospital ticagrelor, and the degree of ST-segment elevation resolution was significantly greater in the pre-hospital group (median, 75.0% vs. 71.4%; p = 0.049). At 24 h, the composite ischemic endpoint was lower with pre-hospital ticagrelor (10.4% vs. 13.7%; p = 0.039), as were individual endpoints of definite stent thrombosis (p = 0.0078) and myocardial infarction (p = 0.031). All endpoints except death (1.1% vs. 0.2%; p = 0.048) favored pre-hospital ticagrelor, with no differences in bleeding events. Conclusions The effects of pre-hospital ticagrelor became apparent after PCI, with numerical differences in platelet reactivity and immediate post-PCI reperfusion, associated with reductions in ischemic endpoints, over the first 24 h, whereas there was a small excess of mortality. (Administration of Ticagrelor in the cath Lab or in the Ambulance for New ST elevation myocardial infarction to open the Coronary artery [ATLANTIC, NCT01347580 ])

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Background CD40 Ligand (CD40L) is expressed on platelets upon ADP stimulation and is involved in haemostasis. CD40L deficient mice exhibit thrombus instability and increased bleeding time. Methods We investigated the relationships between plasma and platelet-associated CD40L, ADP signaling and bleeding event occurrence in patients receiving thienopyridines one month after a stented Acute Coronary Syndrome (ACS). Basal platelet CD40L surface expression (pCD40L), pCD40L after PAR-1 agonist stimulation (TRAP pCD40L) and platelet released CD40L (rCD40L) were quantified. Results were compared to VASP as a measure of P2Y12 inhibition level. Results We included 318 patients between November 2012 and June 2014. Thienopyridines treated patients exhibit low pCD40L, TRAP pCD40L and rCD40L in comparison with controls. pCD40L and rCD40L were correlated with PRI-VASP. Thienopyridine treatment strongly reduces rCD40L. Hyperesponder to thienopyridine status is associated with high levels of TRAP pCD40L. pCD40L and TRAP pCD40L levels are reduced in the bleeding cohort. In multivariate analysis pCD40L significantly contributes to bleeding risk independently of PRI-VASP. Conclusion pCD40L and rCD40L levels are reduced by thienopyridines. pCD40L associates with the bleeding risk independently of the VASP levels and may represent a novel target to assess bleeding risk in thienopyridine-treated ACS patients.

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Studies have addressed the benefit of tailored therapy based on initial response to clopidogrel loading dose. However, the appropriate timing for platelet testing remains uncertain.The present study was performed to compare initial clopidogrel response after 600 mg loading dose and 1-month platelet response and their relationship with ischemic and bleedings events. A total of 475 patients with non-ST-segment elevation acute coronary syndrome undergoing percutaneous coronary intervention have been included in the present study. All patients were treated with 600 mg clopidogrel followed by 150 mg daily. Clopidogrel low response was defined by high on-treatment platelet reactivity (HPR) with vasoactive stimulated phosphoprotein50%, and "hyperresponse," as platelet reactivity index vasoactive stimulated phosphoprotein (PRI VASP)95th percentile after 600 mg.After 600 mg, 210 patients were identified with HPR (44%), and 23 patients (5%), with hyperresponse (PRI VASP8%). At 1 month on 150 mg clopidogrel daily, 184 patients (39%) had HPR (39%), 14 patients (3 %) had hyperresponse, and mean PRI VASP was significantly lower (43% ± 19% vs 46% ± 21%, P = .04). At 1 month, among the 210 patients with HPR after 600 mg, 127 (60%) remained, whereas among the 265 patients responders after 600 mg, only 57 (22%) remained with HPR (60% vs 22%, P.0001). Initial response was significantly associated with risk of stent thrombosis and bleeding complications, whereas 1-month assessment was only linked with bleeding events.In conclusion, the present study showed that initial clopidogrel response in patients with acute coronary syndrome is not a reliable predictor of response to maintenance therapy and their values for prediction of clinical outcome are likely to be different.

International audience; BackgroundDifferential Item Functioning (DIF) is investigated to ensure that each item displays a consistent pattern of responses irrespective of the characteristics of the respondents. Assessing DIF helps to understand the nature of instruments, to assess the quality of a measure and to interpret results. This study aimed to examine whether the items of the Quality of Life Enjoyment and Satisfaction Questionnaire-Short Form (Q-LES-Q-SF) and Short-Form 12 (SF-12) exhibit DIF.MethodA total of 124 outpatients diagnosed with substance dependence participated in a cross-sectional, multicenter study. In addition to the Q-LES-Q-SF and SF-12 results, demographic data such as age, sex, type of substance dependence and education level were collected. Rasch analysis was conducted (using RUMM2020 software) to assess DIF of the Q-LES-Q-SF and SF-12 items.ResultsFor SF-12, significant age-related uniform DIF was found in two of the 12 items, and sex-related DIF was found in one of the 12 items. All of the observed DIF effects in SF-12 were found among the mental health items. Three items showed DIF on the Q-LES-Q-SF; however, the impact of DIF item on the delta score calculation for the comparisons of self-reported health status between the groups was minimal in the SF-12 and small in the Q-LES-Q-SF.ConclusionThese results indicated that no major measurement bias affects the validity of the self-reported health status assessed using the Q-LES-Q-SF or SF-12. Thus, these questionnaires are largely robust measures of self-reported health status among substance users.

Summary Background Alcohol septal ablation (ASA) is a therapeutic catheter-based option and an alternative to surgical myectomy in the treatment of patients with hypertrophic obstructive cardiomyopathy. Although the safety of the ASA procedure has been consistently improved, a temporary transvenous pacemaker is recommended for at least 48 h postprocedure, with several drawbacks, including the risk of cardiac perforation and infection, and the absence of any fixation mechanism. In addition, femoral artery catheterization has resulted in a concomitant increase in bleedings and iatrogenic femoral artery injuries. Aims To evaluate and validate the feasibility of less invasive management of ASA using the transradial approach and a subclavian wired temporary pacemaker. Methods To avoid transfemoral temporary pacing, we used a subclavian bipolar active-fixation permanent pacing lead, stitched to the skin and connected to a desterilized recuperation pacemaker. The day before discharge, if there was no high-degree atrioventricular block, the pacemaker lead was removed. In all patients, we used the right radial access and the left main was cannulated with a 6F Judkins left 3.5 guiding catheter. Results Thirty consecutive patients were prospectively and successfully included in our study. No complication was observed during the hospital stay, neither access-site nor stimulation-lead related. Conclusions Our study shows the feasibility and safety of a transradial approach and a subclavian wired temporary pacemaker. The reduction in periprocedural complications offered by this strategy reflects the less invasive nature of ASA, without increasing the cost and complexity of the procedure.

ST elevation myocardial infarction (STEMI) is related to acute occlusion of a coronary artery by a fibrin reach thrombus. Early reperfusion may reduce infarct size and improve prognosis. Percutaneous coronary intervention (PCI) is more effective than intravenous fibrinolysis (IVF). Fibrinolysis remains useful in patients when PCI is not feasible. IVF has largely contributed to the knowledge of the physiopathology of STEMI and its management.

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Coronary of angiography may be normal or without significant lesion after myocardial infarction (MI) in about 10% of cases. Our aim was to evaluate intravascular ultrasound (IVUS) findings, mainly remodelling, in patients with normal or near normal angiography early after MI.We prospectively included 17 patients, admitted for STEMI or non-STEMI with no lesion30% (QCA) on early coronary angiography. Culprit vessel was defined by evidence of a thrombus in a proximal segment, distal embolization or focal akinesia of the left ventricle. Negative remodelling (NR) was defined as a remodelling index (lesion/reference external elastic membrane cross sectional area [CSA])0.95, no remodelling as between 0.95-1.05, and positive remodelling (PR) as1.05. IVUS could identify a short, single, minor, eccentric and hypoechogenic lesion in all patients, of proximal location in 76.4% cases. PR was observed in only 1 patient (5.9%).A discrete lesion was observed in all patients with apparently normal arteries. Although previous reports have shown an association between PR and vulnerability, in our study PR was unusual. Our study supports the hypothesis that in some patients, vulnerability may appear very early in the natural history of coronary artery disease before any vessel remodelling.

Introduction Percutaneous occlusion of left atrial appendage (LAA) with a Watchman device (WM) is indicated in patients with non-valvular atrial fibrillation, a CHA2DS2VASc score ≥ 4 and contraindication on long-term anticoagulation. Even though minor (m) peri-device leak (PL) has not been associated with recurrence of embolic event, obtaining a complete occlusion of LAA remains a primary objective when implanting a WM. Complex anatomy of LAA has led Debiase to define 4 main categories based on the morphology of the dominant lobe (DL) and localisation of secondary lobes (SL), Windsock, Cactus and Cauliflower and Chicken Wing type (CW). Beside, LAA ostium may be round or more ovale. Success of implantation is obtained when no major PL or protrusion is noted by trans oesophageal echocardiography (TEE) with good anchoring to prevent migration. Purpose We aimed to evaluate the impact of anatomy or LAA defined by its type and shape of the ostium (os) on the incidence of mPL. Cardiac Computed Tomography Angiography (CCTA) was done before implantation to assess LAA morphology and measure maximal (Dmax) and minimal (Dmin) diameter at the os. Os was round if Dmax/Dmin was ≤ 1.13. Perileak was defined by TEE as residual flow Results From 70 out of 74 patients (95%) with successful implantation, 45 (64%) had a non-CW morphology (6 cactus) and os was not-round in 45 (64%). A 24 with mPL was detected in 24 patients (34%) with difference between CW and non-CW type [20 (44%) vs. 4 (26%), P = ns] or round or not-round os [15(33%) vs. 9 (36%), P = 1). Conclusion Even if a tendency to more mPL is noted in patients with CW type, other parameters should be studied as proximal location of SL or diameter of DL distal to the ostium. A classification of LAA anatomy dedicated to the procedure should be established to optimize implantation.

Introduction Long-term prognosis of myocardial infarction (MI) in young patients is highly pejorative even in non-diabetics or those with preserved left ventricular function. Nevertheless incidence of their admission for MI remained stable suggesting the need for an improvement of preventive strategies and detection of specific risk factors. Methods Consecutive patients ≤ 45 years with a first acute myocardial infarction with (STEMI) or without (NSTEMI) ST elevation and a coronary angiography (angio) performed where included in this study. A post-hoc analysis of angio determined for each a coronary score (score) to reflect extent of coronary atherosclerosis (CAD). Results Hundred and forty patients where included,113 male (81%), mean age 38 ± 5 years,73 with STEMI (52%). Risk factors were tobacco smoking in 116 (84%), HTN in 18 (13%), diabetes in 21 (15%), family history in 32 (23%) and dyslipidemia in 98 (71%) with no difference between sex. The score was 2.69 ± 1,83 (0–9) not significantly different between STEMI and NSTEMI, higher in male (2.98 ± 1.8 vs. 1.8 ± 1.6; P Conclusion CAD is already diffused in a majority of young patients with a first MI. Non-HDL Cholesterol is associated with extension of CAD. Prevention should not forget this metabolic risk factor.

Background Newer P2Y12 blockers (prasugrel and ticagrelor) demonstrated significant ischemic benefit over clopidogrel after acute coronary syndrome (ACS). However, both drugs are associated with an increase in bleeding complications. Purpose The objective of the present study was to evaluate the benefit of switching dual antiplatelet therapy (DAPT) from aspirin plus a newer P2Y12 blocker to aspirin plus clopidogrel 1 month after ACS. Methods We performed an open-label, monocentric, randomized trial. From March 2014 to April 2016, patients admitted with ACS requiring coronary intervention, on aspirin and a newer P2Y12 blocker and without adverse event at 1 month, were assigned to switch to aspirin and clopidogrel (switched DAPT) or continuation of their drug regimen (unchanged DAPT). The primary outcome was a composite of cardiovascular death, urgent revascularization, stroke and bleeding as defined by the BARC classification ≥ 2 at 1 year post-ACS. Results Six hundred and forty-six patients were randomized and 645 analyzed, corresponding to 322 patients in the switched DAPT and 323 in the unchanged DAPT group. The primary endpoint occurred in 43 (13.4%) patients in the switched DAPT group and in 85 (26.3%) patients in the unchanged DAPT (HR 95% CI 0.48 (0.34–0.68), P Fig. 1 ). No significant differences were reported on ischemic endpoints, while BARC ≥ 2 bleeding occurred in 13 (4.0%) patients in the switched DAPT and in 48 (14.9%) in the unchanged DAPT group (HR 95% CI 0.30 (0.18–0.50), P Fig. 1 ). Conclusion A switched DAPT is superior to an unchanged DAPT strategy to prevent bleeding complications without increase in ischemic events following ACS.