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International audience; Background: If several randomized studies allowed to better apprehend what should be the best antithrombotic strategy in patients with concomitant coronary artery disease (CAD) and atrial fibrillation (AF), there are still several clinical situations with a gap of evidence.Methods: We conducted a national French survey in September-October 2020 among cardiologists in order to assess what are daily practices regarding the antithrombotic management in several specific clinical settings where no or little scientific evidence is available. The questionnaires were built by a committee of 6 cardiologists routinely involved in the field of CAD and/or AF.Results: Among the 6388 French cardiologists, 483 (7.6%) cardiologists participated to the survey. The rate of participation was rather homogeneous across the country. The mean age of participants was 48 +/- 12.7. There were 134 women (27.7%) and 349 men. Altogether, 181 (37.5%) cardiologists worked in private, 153 (31.7%) in non-universitary public and 83 (17.2%) in universitary public centers. The remaining had shared activity. Among the participants, 150 were interventional (coronary) cardiologists (31.1%). Others were general cardiologists (n = 229), specialists in the field of rhythmology (n = 43), heart failure (n = 17) or imaging (n = 44). The survey consisted of 10 questions pertaining to 2 virtual clinical scenarios.Conclusions: The present survey is an illustration of how therapeutic decisions may vary in such situations with little or no scientific evidence. Such surveys may help experts to build consensus (answers with little variability) and to target the need for future trials and more research (answers with a lot of variability).

Although direct oral anticoagulants (DOACs) are associated with an overall favourable safety profile, the risk of gastrointestinal bleeding with DOACs compared with vitamin K antagonists (VKAs) remains controversial. Accordingly, we aimed to provide a focused overview of the risk of gastrointestinal bleeding associated with dabigatran, rivaroxaban, apixaban and edoxaban and its management. We reviewed published studies reporting on DOACs with gastrointestinal bleeding as an outcome, including randomised controlled trials (RCTs), retrospective database studies and large-scale prospective cohort studies. Cumulative evidence confirms no notable difference in major gastrointestinal bleeding risk between DOACs and VKAs. Moreover, gastrointestinal bleeding in DOAC-treated patients seems less severe and requires less intensive management. The main cause of upper gastrointestinal bleeding in DOAC-treated patients appears to be gastroduodenal ulcers, whereas lower gastrointestinal bleedings are mainly due to diverticula followed by angiodysplasia and haemorrhoids. The lack of head-to-head RCTs with DOACs precludes drawing conclusions on the DOAC with the lowest gastrointestinal bleeding risk. Prescribing physicians should be aware of risk factors for DOAC-related gastrointestinal bleeding (e.g. age > 65, heavy alcohol use, uncontrolled hypertension, hepatic or renal dysfunction, active cancer, anaemia) and adopt preventive measures accordingly. Management of DOAC-associated major gastrointestinal bleeding involves temporary discontinuation of the DOAC, investigation of the bleeding source and treatment of bleeding with fluid resuscitation combined with transfusion and endoscopic haemostasis. DOACs as a class do not increase the risk of major gastrointestinal bleeding compared to VKAs, which supports their continued use for different anticoagulant indications.

BackgroundIn contrast with the setting of acute myocardial infarction, there are limited data regarding the impact of diabetes mellitus on clinical outcomes in contemporary cohorts of patients with chronic coronary syndromes. We aimed to investigate the prevalence and prognostic impact of diabetes according to geographical regions and ethnicity.Methods and resultsCLARIFY is an observational registry of patients with chronic coronary syndromes, enrolled across 45 countries in Europe, Asia, America, Middle East, Australia, and Africa in 2009–2010, and followed up yearly for 5 years. Chronic coronary syndromes were defined by ≥1 of the following criteria: prior myocardial infarction, evidence of coronary stenosis >50%, proven symptomatic myocardial ischaemia, or prior revascularization procedure.Among 32 694 patients, 9502 (29%) had diabetes, with a regional prevalence ranging from below 20% in Northern Europe to ∼60% in the Gulf countries. In a multivariable-adjusted Cox proportional hazards model, diabetes was associated with increased risks for the primary outcome (cardiovascular death, myocardial infarction, or stroke) with an adjusted hazard ratio of 1.28 (95% confidence interval 1.18, 1.39) and for all secondary outcomes (all-cause and cardiovascular mortality, myocardial infarction, stroke, heart failure, and coronary revascularization). Differences on outcomes according to geography and ethnicity were modest.ConclusionIn patients with chronic coronary syndromes, diabetes is independently associated with mortality and cardiovascular events, including heart failure, which is not accounted by demographics, prior medical history, left ventricular ejection fraction, or use of secondary prevention medication. This is observed across multiple geographic regions and ethnicities, despite marked disparities in the prevalence of diabetes.ClinicalTrials identifierISRCTN43070564

Background Haemodialysis patients are at risk of developing severe forms of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection: coronavirus disease 2019 (COVID-19). In March 2020, hydroxychloroquine (HCQ) and azithromycin (AZI) were proposed as potential treatments of COVID-19, but with warnings concerning their possible toxicity. No data are available regarding the toxicity of this treatment in haemodialysis patients. Methods We report the use of HCQ and AZI in a cohort of COVID-19 haemodialysis patients with focus on safety concerns. Results Twenty-one patients received 200 mg HCQ thrice daily during 10 days, and AZI 500 mg on Day 1, and 250 mg on the four following days. HCQ plasma concentrations were within the recommended range (0.1–1.0 µg/mL) in all patients except one, in which maximum concentration was 1.1 µg/mL. HCQ concentration raised until the third day and remained stable thereafter. No cardiac event occurred in spite of progressive lengthening of corrected QT interval (QTc) during the treatment. One patient experienced a long QTc syndrome (QTc >500 ms) without any arrhythmia episode, although HCQ concentration was in the target range. Five (23.8%) patients experienced hypoglycaemia, a well-known HCQ side-effect. SARS-CoV-2 RNA remained detectable in nasopharyngeal swabs for a long time in haemodialysis patients (mean time 21 days). Conclusions HCQ and AZI are safe in haemodialysis patients at these doses but can lead to long QTc syndrome and hypoglycaemia. HCQ concentrations were not correlated with side effects. We recommend monitoring of the QTc length throughout treatment, as well as glycaemia. SARS-CoV-2 could persist for longer in haemodialysis patients than in the general population.

Goal To evaluate routine French atrial fibrillation (AF) ablation procedure. Method A multiple choice questionnaire was e-mailed to 120 French EP physicians in November 2016. Results Ninety-five answers were obtained (80%). Sixty-five percent work in a public center, 35% in a private center. Seventy-six percent ablated AF since 5 years or more. Sixty-five percent worked in center who performed > 300 ablations/year. Sixty-six percent ablate > 50% of persistent AF. Ninety-six percent systematically perform a consultation before ablation. To perform transeptal puncture, 89% use a non-steerable sheath, 50% do it with transoesophageal echocardiography, 41% perform esophageal thermal monitoring. In persistant AF, first line ablation strategy is circumferential isolation of pulmonary veins for 74%, while 12% ad defragmentation, 4% ad lines, 32% ad lines and defragmentation. Ten percent perform defragmentation only. The remaining physicians did not have standardised attitude concerning radiofrequency (RF) ablation for persistent AF. When VKA is prescribed, 85% don’t stop the treatment before the procedure. General anaesthesia is performed systematically by 57% (96% in private structure) and never by 29% of physicians. Cryoablation for paroxysmal AF is performed by 58% of physicians. Conclusion Persistent RF ablation strategy is not fully standardised. Cryoablation is widely used for Paroxysmal AF. General anesthesia is more available in private centers.

Goal To evaluate routine Remote Monitoring (RM) of Cardiovascular Implantable Device (CID). Method A multiple choice questionnaire was e-mailed to 100 French physicians Implanters of CID in November 2017. Results A total of 73 answers were obtained (73%). Seventy five percent work in a public center, twenty three percent in a private center. The rate of Internal Cardiac Defibrillator implantation (ICD)/year per center is > 100 for 63%, 50–100 for 24,7%, 1000 (9.6%), 500–1000 (27.4%), 200–500 (41.1%), Conclusion Remote monitoring of CID is a current practice in France especially for ICD follow up. Collaboration with paramedical staff is partial. Patients are informed but not systematically. Data are archived but partially. Absence of funding may explain incomplete and heterogeneous RM activity in France.

Background Pulmonary vein isolation (PVI) using cryoballoon (CB) catheter is a new technique for atrial fibrillation (AF) ablation. Previous studies used computer tomography (CT) or magnetic resonance imaging (MRI) scan to determine the pulmonary vein (PV) diameter and anatomy for choosing the CB size. We evaluated pre-ablation transoesophageal-echocardiography (TEE) as an alternative to CT/MRI scan in patients undergoing AF ablation for determining the appropriate size of the CB. Methods Fifty-five consecutive patients (men=43, women=12) with a mean age of 63±12.5years, and with drug-refractory paroxysmal AF (34 patients) or persistent AF (21 patients) were included in this prospective study. All patients underwent pre-ablation TEE. Results Hypertension was present in 19 patients (34%). Mean anterior–posterior left atrium diameter was 45.1±8.9mm. In total, 217 PV were targeted using a single 23-mm (n=14) or 28-mm (n=40) CB catheter chosen according to TEE-obtained measurements. PVI was achieved in 195 PV (90%). Mean number of CB applications per patient was 9.8±2.1 (range 8–14). Mean procedure duration and fluoroscopy times were 131±27min (90–190min) and 36±12min (22–66min) respectively. Phrenic nerve palsy occurred in 3 patients (5.4%) and was transient ( Conclusion This study suggests that TEE is an easily available and effective tool to select the size of the CB for PVI according to evaluated PV diameters and anatomy.

Background The Achieve catheter (AC; Medtronic-CryoCath, Pointe-Claire, Canada) is a circular mapping catheter introduced through the lumen of the cryoballoon (CB) catheter which is safe and effective to both navigate the CB to the pulmonary veins (PV) and allow PV potential recording during PV cryoablation. The aim of this study was to evaluate the impact of the use of the AC on procedural outcomes. Methods Sixteen consecutive patients (14 men) underwent AC-guided PV isolation (PVI) for drug-refractory paroxysmal atrial fibrillation (AF; AC group). Clinical and procedural data of these patients were compared to those obtained from 16 consecutive patients who had undergone PVI for paroxysmal AF with the regular “single transseptal” approach (control group). Results Clinical characteristics of patients enrolled in both groups did not differ significantly. In the AC group, 64 PVs were targeted using a single 28-mm (n = 13) or 23-mm (n = 3) CB catheter with PVI achieved in 62 PVs (97%). In the control group, 66 PVs were targeted using a single 28-mm (n = 12) or 23-mm (n = 4) CB catheter with PVI achieved in 62 PVs (94%), (P = non-significant for CB size and PVI rate). Procedure duration and fluoroscopy time were significantly reduced in AC group compared to control group (96.6 ± 26 minutes vs 125.9 ± 25 minutes, P = 0.003 and 24.4 ± 10 minutes vs 32.6 ± 11 minutes, P = 0.04, respectively). Conclusion The use of the AC significantly reduced procedure duration and radiation exposure during PVI with the CB technique. (PACE 2013; 36:24–30)

Las declaraciones de conflictos de intereses de los expertos participantes en el desarrollo de esta guia estan disponibles en la pagina web de la ESC: www.escardio.org/guidelines

Objectifs Analyser les habitudes d’ablation de fibrillation atriale (FA) en routine dans les centres francais. Methode Un questionnaire a ete adresse par mail a 120 electrophysiologistes en novembre 2016. 95 medecins ont repondu (80 %). Resultats Soixante cinq pour cent exercent dans un centre public, 35 % dans un centre prive. 76 % pratiquent l’ablation depuis plus de 5 ans, 65 % exercent dans un centre qui pratique plus de 300 ablations par an. 66 % ablatent plus de 50 % de FA persistantes, 96 % realisent systematiquement une consultation avant l’intervention. La ponction transeptale est realisee avec une gaine fixe par 89 % et sous ETO par 50 % des medecins, 41 % utilisent une sonde thermique œsophagienne. La strategie de premiere intention d’ablation de FA persistante est l’isolation des veines pulmonaires pour 74 %. 12 % ajoutent une defragmentation seule, 4 % ajoutent des lignes seules et 32 % ajoutent lignes et defragmentation. 10 % ne realisent que de la defragmentation. Les autres medecins declarent ne pas avoir d’attitude standardisee. Chez les patients sous AVK, 85 % realisent l’ablation sans interruption. L’anesthesie generale est realisee systematiquement par 57 % (96 % dans les structures privees). 29 % ne pratiquent jamais l’anesthesie generale. 58 % pratiquent en routine la cryoablation pour les ablations de FA. Conclusions L’ablation de FA par radiofrequence n’est pas standardisee, particulierement pour les FA persistantes. La cryoablation de FA est utilisee largement pour l’ablation de FA paroxystiques. L’anesthesie generale est plus disponible dans les centres prives.

The 9-French 8-mm tip cryoablation catheter confers a high rate of acute slow pathway (SP) elimination and an acceptable short-term outcome in patients with atrioventricular nodal reentrant tachycardia (AVNRT). The aim of this study was to investigate the long-term outcome of patients treated with this electrode in this indication.Eighty-two patients (female = 52) with a mean age of 54.9 ± 17.7 years underwent SP elimination for typical AVNRT with the 8-mm tip cryocatheter in our institution between November 2009 to June 2012. Clinical and procedural characteristics were prospectively collected.Acute procedural success defined as AVNRT non-inducibility at the end of the procedure was obtained in 81/82 patients (98.7 %). Mean procedure duration and fluoroscopy time were 74.4 ± 28.7 min (range, 35-160 min) and 8.7 ± 5.3 min (range, 2-26 min), respectively. Mean number of energy applications was 4.0 ± 2.4 (range, 2-15). No permanent atrioventricular block was observed. Transient atrioventricular block occurred in 12 patients (14.6 %). Traumatic fast pathway conduction block occurred in one patient before cryoenergy delivery. Using an intention-to-treat analysis, 78 patients (95.1 %) remained free of AVNRT recurrence during a mean follow-up of 17.8 ± 9.3 months.This study confirmed that the 8-mm tip cryocatheter is both safe and highly effective for SP conduction elimination in patients with AVNRT and demonstrated a low recurrence rate during a long-term follow-up.

ACC/AHA : American College of Cardiology/American Heart Association ACCF/AHA : American College of Cardiology Foundation/American Heart Association ACE : angiotensin-converting enzyme ACEI : angiotensin-converting enzyme inhibitor ACS : acute coronary syndrome AF : atrial fibrillation

Summary Background While general practitioners treat most hypertensive patients in France, hypertension is the most frequent pathology treated by cardiologists, raising questions about the differing profiles of such patients. Poor control of hypertension is commonly reported, and yet has not improved over time. Better understanding of the determinants of control, at both patient and physician levels, is necessary to implement improvements in practice. Aims To describe the hypertensive population treated by independent cardiologists in France and to assess the prevalence and determinants of not-at-goal blood pressure (BP), at patient and physician levels. Methods The COLHYGE study was an observational cross-sectional epidemiological study. Consecutive patients ( n = 5798) were selected by 371 independent cardiologists in France. Data concerning patients and physicians were assessed. Results Our study population had an elevated cardiovascular risk, high prevalence of patients in secondary cardiovascular prevention (27.5%) and a high proportion of diabetic patients (22.8%). Only 20.8% of the population presented controlled BP. At the patient level, the following variables were negatively and independently associated with BP control: age; body mass index; heart rate; recently diagnosed hypertension; left ventricular hypertrophy; patient belief that they are taking too many pills; prescription of calcium channel blockers, lipid-lowering agents and antiplatelet agents. Presence of atrial fibrillation and the prescription of renin-angiotensin system blockers and fixed combinations correlated positively with BP control. At the physician level, working in big cities and having an exclusive independent practice were associated with good BP control. There was high heterogeneity among physicians in terms of BP control, independent of the patient and physician characteristics assessed. Conclusion The COLHYGE study has confirmed a high cardiovascular risk and poor BP control among hypertensive patients treated by cardiologists in France. Strategies aiming to control BP should focus on both patient and physician characteristics.

The Achieve catheter (AC; Medtronic-CryoCath, Pointe-Claire, Canada) is a circular mapping catheter introduced through the lumen of the cryoballoon (CB) catheter which is safe and effective to both navigate the CB to the pulmonary veins (PV) and allow PV potential recording during PV cryoablation. The aim of this study was to evaluate the impact of the use of the AC on procedural outcomes.Sixteen consecutive patients (14 men) underwent AC-guided PV isolation (PVI) for drug-refractory paroxysmal atrial fibrillation (AF; AC group). Clinical and procedural data of these patients were compared to those obtained from 16 consecutive patients who had undergone PVI for paroxysmal AF with the regular "single transseptal" approach (control group).Clinical characteristics of patients enrolled in both groups did not differ significantly. In the AC group, 64 PVs were targeted using a single 28-mm (n = 13) or 23-mm (n = 3) CB catheter with PVI achieved in 62 PVs (97%). In the control group, 66 PVs were targeted using a single 28-mm (n = 12) or 23-mm (n = 4) CB catheter with PVI achieved in 62 PVs (94%), (P = non-significant for CB size and PVI rate). Procedure duration and fluoroscopy time were significantly reduced in AC group compared to control group (96.6 ± 26 minutes vs 125.9 ± 25 minutes, P = 0.003 and 24.4 ± 10 minutes vs 32.6 ± 11 minutes, P = 0.04, respectively).The use of the AC significantly reduced procedure duration and radiation exposure during PVI with the CB technique.

SummaryBackgroundSeveral studies have shown gender differences in the management of cardiovascular risk factors and diseases. Whether the management of hypertension by cardiologists in France differs according to patient gender has not been fully investigated.AimsThe main objective of this cross-sectional, multicentre study was to examine the management according to gender of hypertensive patients by office-based cardiologists in France.MethodsCardiologists were asked to include consecutively two men and two women attending a routine consultation for essential hypertension. Therapeutic management was evaluated by comparing cardiovascular investigations in the preceding 6 months and hypertension control according to gender and the patients’ global cardiovascular risk.ResultsOverall, data from 3440 adult patients (53% men) referred to 654 cardiologists were analysed. Hypertension was uncontrolled in 76% of both men and women and 69% were at high global cardiovascular risk (75% of men, 62% of women; P

IntroductionDual-chamber (DC) pacing benefits are impaired by the occurrence of atrial arrhythmias (AA). Pacemakers (PM) have been enhanced by a mode-switch function (MSF) which allows the switch from DDD(R) to DDIR pacing in presence of AA.Materials and methodsWe analyzed MSF at 6 and 12-month (m) follow-up in 369 patients (Pts) aged 77+/−9 y, free of permanent AA (59%), implanted with Kappa® DC PMs (Medtronic, MN, USA) for II and III AV block (65%), and sinus dysfunction (SD) (35%). 52% had no cardiopathy and there was no difference in electrical parameters at implant regardless lead and indication.No specific programming was imposed. MS function data was collected at each follow-up: number of MS, average percentage of time in AA. EGM was used to confirm AA in most cases.ResultsThe MSF shows AA episode rate of 61% at 6m and 48% at 12m. Moreover, 29% of pts (Gr1) had no AA during the 12m, 11% had AA only during the last 6m (Gr2), 24% only during the first 6m (Gr3 and Gr5) and 37% during the 12m (Gr4 and Gr6). Statistically, there was no significant difference between groups concerning the number of MS and between the percentage of time in AA at each follow-up.DiscussionLong-term follow-up confirms results already described in the literature, and the MS event counters may predict the existence of AA. EGM confirms the specificity of this function. Number of MS is significantly high in SD (p

SummaryBackgroundThe distribution of left ventricular ejection fraction (LVEF) – a key factor in coronary artery disease (CAD) patient management and prognostication – is poorly documented.ObjectiveTo determine LVEF and heart rate (HR) values, and describe the management of stable CAD patients in France.MethodsThe INDYCE survey was a prospective, multicentre registry of consecutive stable CAD outpatients attending a cardiology consultation. The survey focused on LVEF values measured using the echocardiographic Simpson biplane method. Drug therapy, resting HR, blood pressure and symptoms were also recorded.ResultsOverall, 3119 patients (68.4±11.0years; 80% men) were enrolled. LVEF was 56.1±11.8% on average, and was poor (

Aim to evaluate routine French implanters strategy in device replacement in patients under anticoagulation for atrial Fibrillation (AF pts). Method A questionnaire was e-mailed to 140 French implanters. Results 102 aswers were obtained. In AF patients, admission is on day of procedure D0 (10%) or D-1(80%) whether pts are on vitamine K antagonist(VKA) or New Oral AntiCoagulant (NOAC). In AF pts under VKA, only 4%bridge to Low Weight Heparine (LWH) or Unfractionated Heparine (UH) while treatment is interrupted without substitution (wos) by 61% and continued without interruption by 32%. In AF pts under NOAC, only 5%bridge to UH or LWH while treatment is interrupted on D-3 (13%), D-2(25%), D-1(44%). When interrupted, NOAC are resumed at D0 (23%), D+1(54%), D+2(10%), D+3(3%). Conclusions Most of implanters hospitalize AF pts at D-1 of replacement procedure. Short discontinuation (VKA, NOAC) or uninterruption (VKA) is prefered to bridging strategy.

Background: Patients in permanent atrial fibrillation treated for heart failure and ventricular asynchrony can be implanted with conventional dual chamber pacemakers (DDD) pacemakers used in the biventricular mode. The left ventricular lead is connected to the atrial channel. Case Report: We report the case of a patient who developed ventriculo-ventricular pacemaker-mediated tachycardia (PMT) induced by myopotential sensing in the atrial channel, inhibiting left ventricular pacing. Conclusion: In the absence of specifically designed pacemakers, the use of DDD pacemakers in the biventricular mode requires certain precautions, such as anti-PMT mode activation, disabling automatic sensitivity, and lengthening the postventricular atrial refractory period (PVARP), or mode switch to DVIR.

IntroductionCardiac resynchronization therapy (CRT) has been a major breakthrough in cardiac failure management. However, implantation procedure is not standardized.Aim of the studyTo evaluate routine implantation procedure habits in french practice.Material and methodsA survey was e-mailed to 100 French CRT implanters in November 2011. Physicians were interviewed on their own strategy in the center. Answers had to concern the most frequent routine attitude. If appropriate, physicians could answer “no standardized attitude or “other”.ResultsAmong the 62 physicians who answered, 45% practise in a university hospital, 24% in a non-university hospital and 23% in a private institution. The rate of physician implantations is 50/year in 42%, 25% and 33%, respectively. Implantations are performed by a single operator in 49%, and in 43% by two physicians, 16% of implants being done under general anaesthesia.DefaultCRT-Pacemaker (CRT-P) implantations are right-sided in 18%, left-sided in 51%, unsettled in 20%, and for CRT-Defibrillator (CRT-D) 8%, 82 and 10% respectively.The venous approach is “all cephalic” in 21%, all subclavian in 18% and combined in 62%.First implanted lead is the right ventricular lead (RV) in 74%, and the coronary sinus (CS) lead in 23%. RV lead is placed in apical position in 26% and in septal position in 67%.To catheterize the CS, a sheath isused in first intention in 81%. CS angiography is performed in 90%, with an inflated balloon in 59%.In case of atrial fibrillation with CHA2DS2-vasc4.ConclusionMost of implantations are performed under local anesthesia. Left sided is prefered, especially in case of CRT-D implantation. Most physicians combine the venous accesses, start with the RV septal lead, and perform a CS angiogram via an inflated balloon. In AF patient, VKA interruption is preferred in low risk patients but not in high risk ones. Few implanters choose VKA substitution.

Background and aim The new pacemaker (PM) generations featuring extended memory functions (MF) document the occurrence of arrhythmias over periods of several months. Recordings of all atrial episodes and their characteristics contribute to the efficacious treatment of these patients. However, ventricular arrhythmia (VA) characteristics and occurrences are less well-known in this population. The goal of this study was to evaluate the pertinence of MF at the ventricular level and to describe the MF-documented VAs. Methods & Results the study involved a continuous series of 93 pts (M 66%, aged 75 ± 10 yrs) implanted with SC or DC Kappa and EnPulse PMs (Medtronic, MN, USA) for AVB 41%, SD 55%. 497 visits were analyzed (follow-up at 7 months avg.) over a period from 2 to 81 months after implantation, and occurrences of VA validated by EGMs, defined by at least 5 QRS complexes >175/mn. The number of episodes and the duration and heart rate during the longest arrhythmia episodes were recorded. 24 pts (26%) average ages 74 ± 13 yrs of whom 78% males, showed ventricular arrhythmias in 88 visits (18%). The average number of episodes was 9 per follow-up (1–140), average duration was 4 ± 4 seconds (1–27 sec), and average rate was 214 ± 33 bpm. (174–307). The totality of the episodes were classified as non-sustained ventricular tachycardia (NSVT). The ejection fraction was 51 ± 11%. 84% showed cardiopathy: CAD (12), HCM(4) and DCM (4). Statistical analysis showed that age, pacing indication, pacing mode and cumulated percentage of pacing are not relevant factors in NSVT. Conclusion VAs are observed in π of pts implanted for standard pacing indications. A major determining factor in the occurrence of NSVT is the presence of an associated cardiopathy. FMs featuring EGM recordings are a tool for reliable diagnostic and monitoring of these events. Further studies are required to evaluate the prognostic significance of these VAs.

Background and aim Patients implanted with dual chamber (DC) pacemakers (PM) have frequent episodes of arrhythmia. The interest of memory functions (MF) featuring EGM recordings to recognize and characterize these arrhythmias, particularly at the ventricular level, is still not well evaluated. The goal of this study is to establish the pertinence of MF at the ventricular level by repeated analysis at follow-up of the data recorded in the PM memories. Methods & Results A prospective series of 405 patients (76 +/− 10 yrs), M 59%, F 41% implanted with DC Kappa PMs (Medtronic, MN, USA) for atrio-ventricular block (37%) and sinus dysfunction (50%) were seen at two post implant semestrial follow-ups, at 6 months (F/u1) and at 12 months (F/u2). 83 pts (20%) at F/u1 and/or F/u2 showed ventricular tachycardias (VT) defined as at least 5 consecutive complexes at a frequency > 175 bpm for a total of 102 follow-ups (17%). 55 pts (14%) showed VT at F/u1, 47 (12%) at F/u2 and only 19 (5%) at both F/u1 and F/u2. VT occurrence was statistically independent from mode switch episodes from the atrial level. Analysis showed that age, pacing indication, pacing mode and cumulated percentage of pacing are not factors in the presence of VT. In the VT group, 65% of patients present cardiopathy, with an ejection fraction of 54 +/− 17%. We observe that cardiopathy, is a statistical difference with the rest of the population of this study (52%, p Conclusion In our series, VT is frequent observed in 20% of PM patients implanted for standard indications at 6 and 12 months follow-ups. 2/3 of these patients show arrhythmia from the first 6 months f/u and 1/4 of these patients at both 6 and 12 months f/u. 1 year of follow up seems to demonstrate best sensitivity for VT detection. MF featuring EGM recordings are a tool for reliable diagnostic and monitoring of these events. Further studies are required to evaluate the prognostic significance of these arrhythmias.

RationaleHF treatment is often started during hospitalisation. It appeared interesting to describe the evolution of treatment after hospital discharge.ObjectivesTo describe changes in HF treatment since hospital discharge after stratification on the time elapsed between discharge and beginning of the survey.MethodsCross sectional observational survey with retrospective collection of data at hospital discharge. Patients must have been diagnosed with HF and have been hospitalised for HF within the previous 18 months.Results1452 HF patients met the inclusion criteria and started the survey. 1170 (67% males, age 72±11 years, LVEF 40%±13%) have had at least one visit by the cardiologist between hospital discharge and entry in the survey. Patients were stratified according to the time since hospital discharge (

Background In studies and surveys involving stable coronary artery disease (CAD) patients, the global population often seems well managed; however, the question remains to know what is the proportion of patients who benefit from every simple medical intervention improving the prognosis or showing good quality of care. Objective To evaluate medical management of stable CAD outpatients in France by calculating a progressive quality index. Methods and Results The INDYCE survey was conducted in a sample of 343 cardiologists in France in 2008. Each physician had to include consecutively 10 stable CAD patients (absence of acute coronary syndrome or revascularisation in the 6 months preceding enrolment). 3119 patients (male: 80%, 68 ± 11 years old, diabetes: 24.3%, hypertension: 61.6%) were enrolled. Medical therapy was in keeping with Guidelines (antiplatelet agents (AA) : 88.4% ; statins : 85.9% ; ACE-I/ARBs : 78.8%, beta-blockers (BB) : 74.6%). Patients suffered from mild to moderate symptoms (angina : 19.2%, NYHA class 0 or I : 43.5%, NYHA class II : 46.9%, NYHA class III : 9.3% ; NYHA class IV : 0.3%). Mean rest heart rate (HR) was of 64.2 ± 10.8 bpm, mean systolic and diastolic blood pressure (BP) of 131.8 ± 15.4 and 75.8 ± 8.4 mmHg respectively. However, when calculating a progressive quality index: (1) 44.69% of the patients received an AA + a statin + an ACE-I/ARBs + a BB (2) 29.79% had (1) and a systolic BP (3) 23.02% had (1) + (2) and a resting heart rate (4) 12.6% had (1) + (2) + (3) and had a regular physical activity (5) 6.96% had (1) + (2) + (3) + (4) and had performed an exercise test during the last 12 months (6) 4.07% had (1) + (2) + (3) + (4) + (5) and were asymptomatic (no angina and NYHA class 0 or I) Conclusion Stable CAD patients do not raise attention because they are often pauci-symptomatic. At a population level, they appear to be well managed. However, building a quality index allows us to show that very few of these patients benefit from every step of a simple medical management.

The ELECTRA survey aims to know the monitoring practices of French implanters while there exist published referentials.MethodsA questionnaire containing 32 items including single choice answer questions on the support, the type of ECG recording, the timing of controls and the parameters measured was sent to implanting centers in 2008.Résultats103 completed questionnaires (27%) were received. Operators (98% males) had an experience in pacemaker implantation for 10 years(63%). The volume of implantation was in 2007 100 (45%). Implanting centers belonged to the public sector (63%) or private hospitals (37%).1Follow-up (FU): 47% are performed without any support (public 22%, private 78%). 53% receive assistance (public 76%, private24%): nurse 73%, orderly 12%, 15% manufacturing engineer.2Physician alone performs multitrack ECG in 61% vs 77% for assisted physicians, and EGM +/- ECG programmer in 39% vs 23%.31st FU after implant at 1 month (52%), 3 m(44%) or 6 m(3%). Single and dual chamber PM FU: every 3 m(1%), 6 m(36%) or 12 m(63%). For CRT -PM: every 3 m(9%), 6 m(75%) or 12 m(16%).4Manual stimulation thresholds is systematic (84%) or if clinical problem (5%) while 11% trust in automatic function. Manual sensing test is systematic (77%) if clinical problem (9%) while 12% trust in automatic function.5Memories is checked systematically (92%) or if clinical relevance (6%).6Stimulo-dependance is systematically searched (76%) or if clinical relevance(24%), communicated to the patient(54%) and to the GP(75%).ConclusionIf the multitrack ECG is common, physician without support use more often the programmer only, hence the interest in EGM collections and good quality prints. Assistance is common in public centers without any codified rules. Follow-ups are more frequent in CRT-PM. Physicians are interested in memories but they are not confident in the automatic functions.

Rationale Heart Failure (HF) with preserved LVEF has been individualized in recent years as a specific entity, with different mechanisms, special baseline characteristics, a poor prognosis and no clearly recognized treatment. LVEF cut-off has not been clearly defined. If 50% is generally accepted as a rather specific cut-off, there remains a « grey zone » of patients with EF between 40% and 50% not clearly individualized between reduced and preserved LVEF. Objectives to describe the characteristics of patients with LVEF belonging to the “grey zone” and to compare these patients to those with either reduced or preserved LVEF. Methods Cross sectional observational survey with retrospective collection of data at hospital discharge. Patients must have been diagnosed with HF and have been hospitalized for HF within the previous 18 months. Patients are classified according to the LVEF at hospital discharge. Results 412 French outhospital cardiologists included 1 452 patients with the inclusion criteria. Conclusion This is the first French survey in patients managed by cardiologists after hospital discharge for HF. Cardiologists mainly care for patients with low LVEF. Overall, the profile of patients with LVEF 40-50% at hospital discharge is closer to the 50% LVEF group. Characteristics according to LVEF at discharge (n=1 408) are displayed below. Table. Patients characteristics according to EF LVEF LVEF 40-50% n=366 LVEF>50% n=250 P Age 71±12 73±11 † 76±11 0,0001 Men 74% 65% 47% 0,0001 Ischemic etiology 53% 55% † , * 42% 0,003 Hypertensive etiology 30% 51% † 64% Valvular etiology 12% 17% † , * 25% Dilated cardiomyopathy 44% 25% † , * 8% Renal dysfunction 37% 34% † 27% 0,01 Sinus rhythm 71% 69% † 60% 0,008 Discharge BNP (pg/ml) 439 325 320 0,01 DischargeNYHA class III-IV 41% 29% † , * 21% p by ANOVA with Bonferroni correction; † p 50%; * p

Summary Background Improvements in the treatment of coronary artery disease mean that an increasing number of patients survive acute cardiovascular events and live as outpatients with or without anginal symptoms. Aim To determine the characteristics and management of contemporary outpatients with stable coronary artery disease in Western Europe, and to compare France with the other Western European countries. Methods CLARIFY (prospeCtive observational LongitudinAl RegIstry oF patients with stable coronary arterY disease) is an international, prospective, observational, longitudinal study. Between November 2009 and July 2010, 32,954 adult outpatients with stable coronary artery disease (defined as a history of documented myocardial infarction [of > 3 months], prior coronary revascularization, chest pain with myocardial ischaemia, or coronary stenosis of > 50% proven by angiography) were enrolled in 45 countries. The demographics and management of CLARIFY patients enrolled in France were compared with those enrolled in other Western European countries (Austria, Belgium, Denmark, Germany, Greece, Ireland, Italy, Netherlands, Portugal, Spain, Switzerland and the UK). Results Of the 14,726 patients enrolled in Western Europe (mean age 66.2 [10.2] years; 79.6% male), 2432 (16.5%) were from France. The use of aspirin was lower in France than in other Western European countries (74.5% vs. 86.9%, respectively), whereas use of thienopyridines (48.5% vs. 21.7%), oral anticoagulants (12.3% vs. 9.0%) and lipid-lowering drugs (95.8% vs. 92.5%) was higher. Beta-blockers were used in 73% of both groups. Angina was less prevalent in France (6.3% vs. 15.5%) and French patients showed higher levels of physical activity than their counterparts in Western Europe. Conclusions The management of patients with stable CAD in France appears favourable, with good adherence to guideline-based therapies, but there remains room for improvement in terms of symptom and risk factor control.

Rationale The part of elderly patients (pts) in heart failure (HF) population is growing. They might pose specific problems due to the greater proportion of HF with preserved LVEF, more frequent comorbidities or contra-indications to recommended HF treatment. Objectives to describe the care management of pts > 80-year treated for HF in France. Methods Cross sectional observational survey with retrospective collection of data at hospital discharge. Pts must have been diagnosed with CHF and have been hospitalised for CHF within the previous 18 months. Pts are classified according to the LVEF at hospital discharge. Results 412 French outhospital cardiologists entered 1 452 pts meeting the inclusion criteria. FEVG at hospital discharge was known for 1408 pts. 355 (25%) were more than 80-year-old. Management care at hospital discharge according to age and LVEF is detailed below. LVEF LVEF 40-50% LVEF > 50% Total Age>80 ACEI/ARB 84% 81% 80% 82% * BB 71% 67% 40% † , ‡ 62% * Loop diuretics 92% 85% 85% 88% Spironolactone/eplerenone 26% 20% 18% 22% * Digoxin 20% 15% 29% 21% * Calcium antagonists 10% 14% 37% † , ‡ 18% Anticoagulants 49% 45% 51% 49% * Age≤80 ACEI/ARB 93% 93% 85% † , ‡ 92% BB 79% 78% 76% 79% Loop diuretics 90% 82% 79% † , § 86% Spironolactone/eplerenone 35% 21% 25% † , § 30% Digoxin 16% 15% 16% 15% Calcium antagonists 9% 19% 21% † , § 13% Anticoagulants 42% 39% 39% 41% † p 50% and LVEF ‡ p 50% and LVEF between 40% and 50%; § : p * p 80 and ≤ 80 years old adjusted for LVEF. Conclusion BB, ACEI/ARB, spironolactone/eplerenone are less often prescribed in elderly patients contrasting with digoxin and anticoagulants prescription. These differences persist after adjustment on LVEF.

Rationale Beta blockers are a corner stone treatment of heart failure (HF) in patients with altered systolic function (LVEF 50%) or for patients belonging to the “grey zone” (LVEF 40-50%). Objectives to describe the prescription rate of beta-blockers in HF patients. Methods Cross sectional observational survey with retrospective collection of data at hospital discharge. Patients must have been diagnosed with CHF and have been hospitalised for CHF within the previous 18 months. Patients are classified according to the LVEF at hospital discharge. Results 1 452 patients were included by 412 French outhospital cardiologists. 1137 with known LVEF at hospital discharge have had at least one visit by the cardiologist between hospital discharge (mean delay 5.76±4.51 months). In a multivariate model, BB prescription was more frequent in HF from ischemic origin (OR=1.39) or with dilated cardiomyopathy (OR=1.44) and less frequent in older patients (OR=0.97 per year) and in case of asthma/COPD (OR=0.31 and if FEVG was >50% (OR=0.62). LVEF LVEF 40-50% N=282 LVEF > 50% N=194 Total N=1137 At hospital discharge/ at entry in the survey BB 78%/ 83% 78%/ 85% 62%/ 70% 76%/ 82% Recommended BB † 75%/ 77% 72%/ 74% 54%/ 62% 71%/ 74% Reaching the target dose 8%/ 16% 7%/ 16% 7%/ 13% 7%/ 15% Changes since discharge BB added * 28% 34% 25% 28% BB stopped ** 1% 1% 2% 1% BB dose increased * 27% 27% 17% 25% BB dose decreased 4% 1% 3% 3% † metoprolol, nebivolol, bisoprolol, carvedilol ; * percentage calculated in patients without BB at hospital discharge (N=278); ** percentage calculated in patients with BB at hospital discharge (N=859). Conclusion Rate of betablockers prescription is high at hospital discharge. Outhospital cardiologists not only pursue but also amplify the care strategies defined during hospitalisation increasing the proportion of patients receiving BB and the percentage reaching the target dose.

BackgroundIt is well recognized that left ventricular function is a crucial factor influencing management and prognosis in coronary artery disease (CAD). Little is known however about left ventricular ejection fraction (LVEF) distribution in stable CAD patients.ObjectiveTo evaluate LVEF in stable CAD outpatients in France.MethodsThe INDYCE survey was conducted in a sample of 343 cardiologists in 2008). Each physician had to include consecutively 10 stable (absence of acute coronary syndrome or revascularisation in the 6 months preceding enrolment) CAD patients. LVEF measurement (with the biplane simpson method) was the main endpoint of the survey.Results3 119 patients were enrolled. Medical therapy was in keeping with Guidelines. Patients suffered from mild to moderate symptoms (Table).Mean LVEF was 56 ± 11%; poor (LVEF < 40%) and moderately impaired (40 ≤ LVEF ≤ 50%) systolic ventricular function were reported in 9.6% (n = 298) and 19.8% (n = 619) of the cases respectively. 14% of the patients with LVEF < 40%, 29.4% of the patients with 40 ≤ LVEF ≤ 50% and 47.3% of the patients with LVEF > 50% were completely asymptomatic (i.e no angina and NYHA class 0 or I).ConclusionAmong stable CAD patients, even if LVEF is globally preserved, about 30% of the patients have a moderate or severe left ventricular systolic dysfunction. It can be completely asymptomatic and therefore unrecognized in some patients although it should modify prognosis and management. This suggests that regular systolic ventricular function assessment is necessary in stable CAD patients.LVEF< 40% n= 298 (9.6%)40-50% n = 619 (19.8%)>50% n = 2202 (70.6%)pTotal population n = 3119Intra-group mean LVEF (%)32.3 ± 5.845.9 ± 3.462.1 ± 6.856.1 ± 11.8NYHAclass I14.8%31.9%50.8%p

Goal to evaluate routine anesthesia strategy in ablation procedures by French electrophysiologists (EPs). Method A questionnaire was e-mailed to 110 French EP. Results Answers were obtained from 95 EP (86.4%): 25% working in a private center, 75% in a public center. Anesthesiologists are always available in 70.8% of private centers vs 11.4% of public centers. When available, 54.2% are entirely dedicated to electrophysiology in private vs 18.6% in public centers. When an anesthesiologist is not available, sedation is obtained using midazolam associated with nalbuphin (32%), morphine (16%) or fentanyl (9%). Propofol is used occasionally by 29% of EPs (35% in public, 9% in private centers). Nitrous oxide inhalation gas is available in 40% of private and 34.3% of public centers. Private EPs are satisfied with the anesthesiologist strategy in 100% of cases versus only 41% of public EP. A good or very good relationship with anesthesiologists is declared by 92% of private EPs versus only 56% of public EPs. Conclusions Collaboration of anesthesiologists with EPs seems to be more operational in private centers. Deep sedation seems to be used as an alternative when anesthesiologists are not available more often in public centers.

Rationale Heart failure (HF) treatment is often started during hospitalisation and patients are generally taken over after discharge by outhospital cardiologists. Objectives To describe changes in HF treatment implemented by the outhospital cardiologist after hospital discharge. Methods Cross sectional observational survey with retrospective collection of data at hospital discharge. Patients must have been diagnosed with HF and hospitalized for HF within the previous 18 months. Results 1 452 patients were included by 412 French outhospital cardiologists. 1170 have had at least one visit by the cardiologist between hospital discharge (mean delay 5.76±4.51 months). At hospital discharge, target doses were reached in 10.5% of patients receiving betablockers, 50.9% of patients with ACEI and in 4.1% of patients with ARB. Doses were increased in 25.3% of patients receiving betablockers, in 11.7% of patients receiving ACEI and in 10.3% of patients treated with ARB enabling a target dose in 20.4% of patients with betablockers, and in 83.2% of patients with ACEI or an ARB. Table. Evolution of treatment after discharge At hospital discharge At start of the survey Medication prescribed after discharge Medication discontinued after discharge Betablocker 826 (70,6%) 863 (73,8%) 87 (25,3%) * 50 (6,1%) * ACEI †† 807 (69,0%) 788 (67,4%) 46 (12,7%) * 65 (8,1%) ** ARB ‡ 170 (14,5%) 210 (18,0%) 56 (5,6%) * 16 (9,4%) ** ACEI or ARB 961 (82,1%) 973 (83,2%) - - * percentages calculated on the number of patients without the treatment at hospital discharge; ** percentages calculated on the number of patients without the treatment at hospital discharge; metoprolol, nebivolol, bisoprolol, carvedilol; †† captopril, enalapril, lisinopril, trandolapril, ramipril, perindopril (at an accepted target dose of 4mg); ‡ candesartan, valsartan Conclusion Outhospital cardiologists play a critical role in care management of HF patients. Not only do they implement but they also amplify the care strategies defined during hospitalisation.