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Poor oral health has been linked to coronary heart disease (CHD). Clustering clinical oral conditions routinely recorded in adults may identify their CHD risk profile. Participants from the Paris Prospective Study 3 received, between 2008 and 2012, a baseline routine full-mouth clinical examination and an extensive physical examination and were thereafter followed up every 2 y until September 2020. Three axes defined oral health conditions: 1) healthy, missing, filled, and decayed teeth; 2) masticatory capacity denoted by functional masticatory units; and 3) gingival inflammation and dental plaque. Hierarchical cluster analysis was performed with multivariate Cox proportional hazards regression models and adjusted for age, sex, smoking, body mass index, education, deprivation (EPICES score; Evaluation of Deprivation and Inequalities in Health Examination Centres), hypertension, type 2 diabetes, LDL and HDL serum cholesterol (low- and high-density lipoprotein), triglycerides, lipid-lowering medications, NT-proBNP and IL-6 serum level. A sample of 5,294 participants (age, 50 to 75 y; 37.10% women) were included in the study. Cluster analysis identified 3,688 (69.66%) participants with optimal oral health and preserved masticatory capacity (cluster 1), 1,356 (25.61%) with moderate oral health and moderately impaired masticatory capacity (cluster 2), and 250 (4.72%) with poor oral health and severely impaired masticatory capacity (cluster 3). After a median follow-up of 8.32 y (interquartile range, 8.00 to 10.05), 128 nonfatal incident CHD events occurred. As compared with cluster 1, the risk of CHD progressively increased from cluster 2 (hazard ratio, 1.45; 95% CI, 0.98 to 2.15) to cluster 3 (hazard ratio, 2.47; 95% CI, 1.34 to 4.57; P < 0.05 for trend). To conclude, middle-aged individuals with poor oral health and severely impaired masticatory capacity have more than twice the risk of incident CHD than those with optimal oral health and preserved masticatory capacity (ClinicalTrials.gov NCT00741728).

Background/Introduction Most studies on the association between sleep habits and cardiovascular disease (CVD) have focused on one single sleep dimension, essentially sleep duration and sleep apnea. Purpose To examine the joint effect of several dimensions of sleep habits with incident CVD in a community-based prospective cohort. Methods Between 2008 and 2011, 10,157 men and women aged 50 to 75 years were recruited in a preventive medical center. They underwent a standard physical examination coupled with standard biological tests, and provided information related to lifestyle, personal and family medical history, current health status, and medication use on questionnaires. Sleep habits were self-reported on validated questionnaires that assess sleep duration and insomnia complaints (Pittsburg questionnaire), early chronotype, sleep apnea (Berlin questionnaire) and subjective daytime sleepiness (Epworth questionnaire). Each sleep dimension was assigned 1 point if optimal and 0 point otherwise. A healthy sleep score ranging from 0 to 5 (the higher the better) and reflecting the number of optimal sleep dimensions was computed: early chronotype, sleep duration of 7–8 h/day, never/rarely insomnia, no sleep apnea, and no frequent excessive daytime sleepiness. The occurrence of incident CVD events including coronary heart disease and stroke was followed every two years up to September 2020, and events were validated after review of the medical records. The multivariable association between higher healthy sleep score and CVD events was examined in proportional hazard Cox regression analysis. Population-attributable fractions were calculated to estimate the proportion of CVD cases that could be prevented by healthier sleep habits. Results This study included 7203 participants (62% of men, mean age: 59.7 years±6.2) who were free of CVD at baseline and had complete data on sleep habits and covariates. Among them, 6.9% had a poor sleep score (healthy sleep score of 0 or 1), and 10.4% had an optimal sleep score (score= 5). After a median follow-up of 8 years, 275 participants had incident CVD events. After adjustment for age, sex, total alcohol consumption, socioprofessional categories, smoking status, body mass index, physical activity, family history of heart diseases, LDL and HDL cholesterol, and diabetes status, the risk of CVD decreased by 22% (HR=0.78 [95% CI: 0.71–0.86]) per 1 point increment in the healthy sleep score, and there was a 74% risk reduction in CVD risk (HR=0.26 [0.13–0.51]) between participants with the highest (score of 5) and those with the lowest (score of 0–1) healthy sleep score (Table 1). Under the hypothesis that all the participants would achieve an optimal sleep score of 5, 70.8% of incident CVD could be potentially avoided each year. Conclusion(s) In this community-based prospective cohort, a higher healthy sleep score combining 5 sleep dimensions was associated with a lower risk of CHD or stroke. Funding Acknowledgement Type of funding sources: Public Institution(s). Main funding source(s): The National Research Agency (ANR), The Region Ile de France (Domaine d'Intérêt Majeur)

Background Cardiac troponin I (cTnI) as measured by high-sensitive assays has been related to incident cardiovascular disease events (CVD) in the community. With the advent of ultra-sensitive assays, it is now possible to detect troponin I at very low concentration, far below the classical threshold of 1.9 pg/mL. However, the clinical relevance of these low concentrations for predicting CVD is largely unknown. Purpose To examine the association of cTnI as low as 0.013 pg/mL with incident cardiovascular disease events (CVDs) in the primary prevention setting. Methods cTnI was analyzed in the baseline plasma (2008–2012) of CVD free volunteers from the Paris Prospective Study III using for the first time a novel ultra-sensitive immunoassay (Simoa Troponin-I 2.0 Kit, Quanterix, Lexington) with a limit of detection (LOD) of 0.013 pg/mL. Incident CVD hospitalizations for coronary heart disease, stroke, arrhythmias, venous thromboembolism, arterial aneurysms and heart failure were validated by critical review of the hospital records. Hazard ratios were estimated per log-transformed standard deviation (SD) increase of cTnI in Cox models using age as the time scale. The added value (gain in discriminatory capacity) of cTnI for CVD risk prediction was examined by calculating the Harell's C-index boostraped difference of the SCORE 2 risk model with and without cTnI. Results There were 9503 CVD free participants (40% women) aged 59.6 (6.3) years at baseline. cTnI was detected in 99.6% of the participants (median value = 0.63 pg/mL, interquartile range [IQR] 0.39–1.09). After a median follow-up of 8.34 years (IQR, 8.0–10.07), 516 participants suffered 612 events. In fully-adjusted analysis, higher cTnI (per 1 SD increase of log cTnI) was significantly associated with CVD events combined (n=516, HR= 1.21; 1.06; 1.39). In univariate Cox analysis and compared to each single established risk factor, cTnI had the highest discrimination capacity for incident CVD events (C-index=0.6349) (Figure 1). Adding log cTnI to the SCORE 2 algorithm increased significantly albeit moderately discriminatory capacity (C-index 0.698 vs. 0.685; boostraped C index difference: 0.0135 (95% CI: 0.0131; 0.0138)). Conclusion cTnI concentrations as measured by a novel ultra-sensitive immunoassay is associated with a significant increased risk of incident CVD events in the primary prevention setting. Funding Acknowledgement Type of funding sources: Public Institution(s). Main funding source(s): ANR: French National Research AgencyEurope: Horizon 2020

Introduction Metabolic syndrome (Met Sy) as a highly debatable cluster of traditional risk factors is known to promote cardiometabolic-related morbidity and mortality, but its precise mechanisms remain to be determined. Purpose We sought to determine influence of MetSy on heart failure (HF) morbidity and mortality in the Seven Countries' Study as one of the oldest epidemiological studies. Methods The Seven Countries Study encompassed 12,763 participants from 3 continents who were all healthy men of over 40 years at baseline and who underwent regular check ups every 5 years throughout over a 4 decades' span. Morbidity and mortality was adjudicated according to valid ICD and LPH coding. Results Using the IDF definition of the Metabolic Syndrome, 9,09% of participants were identified (Figure 1). HF was confirmed in 220 patients (16.4% alive at 40y follow up visit), while 8.2% died of HF as well in the same time-frame (Tables 1 & 2). Presence of MetSy has been shown to significantly influence HF mortality (Figures 2) with lowest survival of 22% for 300 months of follow up for patients with both MetSy and HF (Log rank test=4.405, p Conclusion Metabolic syndrome treatment remains in the realm of risk factors' control that now we know influence both ischemic heart disease and heart failure of other origins. Historically, just emerging biomarkers' and targeted imaging weren't available to determine such at the time of HF diagnosis. Also, the sample consisted of men only, mainly Caucasian and a modest proportion of Asian and African-American now known to carry ethnic-specific burden of cardiovascular disease. All of the above, emphasizes the importance of more diversity, equity and inclusion-dedicated long term both observational, as well as interventional research. Funding Acknowledgement Type of funding sources: None.

Background Dual antiplatelet therapy (DAPT), aspirin plus a P2Y12-i (clopidorel, prasugrel or ticagrelor), is recommended for one year after myocardial infarction (MI) for secondary prevention of cardiovascular disease (SP-CVD). Beyond one year maintaining DAPT is controversial. Purpose To compare the 3-year risk of a composite of MI, ischemic stroke (IS), major bleeding (MB) and death between DAPT and single antiplatelet therapy with aspirin (SAPT) beyond one year after MI. Methods All adults hospitalized in 2013 or 2014 for acute MI (trigger event) with intensive care unit stay were identified in the French SDNS nationwide claims database. Patients who survived at least one year without MI or MB, and with a DAPT medication possession ratio (MPR) ≥80% were included in a cohort study. All patients were followed for 3 years after the index date (defined 365 days after the MI trigger event), except right-censored observations for those who died or discontinued aspirin with a 60-day grace period. The 3-year hazard ratios (HR [95% CI]) were estimated using Cox proportional hazards risk model for outcomes including death, and Fine and Gray competing risks model for non-fatal outcomes, with a time-dependent variable for DAPT-SAPT exposure, and adjusted on a high-dimensional disease risk score (hdDRS) plus time dependent variables for SP-CVD drugs, oral antidiabetics, insulin, anticoagulants, NSAIDs, corticoids and proton pump inhibitors. HdDRS were estimated for the composite outcome, a composite of ischemic outcomes, and MB alone, and variables were selected using a combination of Principal Component Analysis and Lasso regression. Results From the 105,080 adults admitted in intensive care units for acute MI in 2013 or 2014, 53,399 were included in the cohort. The most common reasons for non-inclusion were death (n=12,012) and a DAPT MPR Conclusions In this nationwide real-life population-based study in France, DAPT maintained beyond one year after MI is significantly associated with increased harm compared to SAPT with increased risks of 21% (IC95% [13–30]) for the composite of MI, IS, MB and death (net clinical benefit), 22% [7–38] for MI, 89% [55–130] for MB, 16% [6–27] for death, and no difference for IS. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): French Ministry of Health (PHRCN-18-0745)

Aims There is a paucity of data on very long-term outcomes in young women and men experiencing acute myocardial infarction (AMI). Methods and results The FAST-MI program consists of three nationwide French surveys carried out 5 years apart from 2005 to 2015, including consecutive AMI patients over a 1-month period with up to 10-year follow-up. The present analysis focused on adults ≤50 yo according to their gender. Women accounted for 17.5% (N=335) of the 1912 patients under 50 yo and were as old as men (43.9±5.5 vs. 43.9±5.1yo, p=0.92). Non-significant coronary artery disease was more frequent in women (12.8% vs. 5.8%, P Conclusions Ten-year survival in young women with AMI is similar to that of men. However, in those with significant coronary artery disease, improving secondary prevention in women should result in better long-term outcome. Funding Acknowledgement Type of funding sources: Public Institution(s). Main funding source(s): French Society of Cardiology

Assess the feasibility and benefit of a health educational program on global metabolic status in prediabetic deprived subjects.Case control study.693 subjects (466 men, 227 women), aged 16 to 95 years with prediabetes and low socioeconomic status, consulting at the IPC Center were included between September 2015 and June 2016. Subjects were invited to participate in 4 workshops (2 nutrition, 2 physical activities). One year after their inclusion (visit 1), they were offered a second health check-up (visit 2). Participants were classified into 3 groups: 1) Intervention group (INTG, N=133): complete process 2) Control group (CG, N=415): Only a second health check-up, no workshop participation; 3) Abandoned group (AG, N=145). All groups were compared.After considered confounding factors, fasting blood glucose and SBP levels variation between visit 1 and visit 2 differed significantly between the CG and INTG. In the INTG with higher diminution of fasting glucose, 90% reported eating healthy food since nutrition workshop and 51%. reached objectives (The same trend was observed for physical activity.An educational program among deprived prediabetic tended to limit fasting glucose increment, improve metabolic status and encourage healthy lifestyle despite difficulties in convincing subjects to participate.

Aims To determine the current state of the use of reperfusion and adjunctive therapies and in-hospital outcomes in ESC member and affiliated countries for patients with ST segment elevation myocardial infarction (STEMI) complicated by cardiogenic shock (CS). Methods and results ESC EORP prospective international cohort study of admissions with STEMI within 24 hours of symptom onset (196 centers; 26 ESC member and 3 affiliated countries). Of 11462 patients enrolled, 448 (3.9%) had CS. Patients without compared to patients with CS, more frequently received primary PCI (72.5% versus 65.2%) and fibrinolysis (19.0 versus 15.9%) and less frequently had no reperfusion therapy (8.5% versus 19.0%). Mechanical support devices (IABP 11.2%, ECMO 0.7%, other 1.1%) were used infrequently in CS. BARC 2–5 bleeding complications (10.1% versus 3.0%, p Conclusions In this multi-national registry patients with STEMI complicated by CS less frequently receive reperfusion therapy than patients with STEMI without CS. Early mortality in patients with CS not treated with primary PCI is very high. Therefore strategies to improve clinical outcome in STEMI with CS are needed. Funding Acknowledgement Type of funding sources: Other. Main funding source(s): ESC EORP

Resume La maladie coronaire chronique represente une population tres heterogene. L’aspirine reste encore a ce jour le traitement antithrombotique de reference mais des etudes recentes ont montre qu’il peut etre interessant de renforcer ce traitement par une association avec un inhibiteur du P2Y12 ou un anticoagulant oral direct a faible dose chez certains patients bien selectionnes. Les scores de risques ischemique et hemorragique doivent etre utilises pour guider les praticiens dans ce choix, mais ne sont probablement pas les seuls criteres a prendre en compte. Le benefice sur la survenue d’evenements cardiovasculaires majeurs (deces, accident vasculaire cerebral, recidive d’infarctus) ne peut toutefois s’envisager qu’au prix d’une augmentation des saignements mineurs, ce qui amene a individualiser le rapport benefices/risques pour chaque patient. Enfin, pour le cas specifique des patients necessitant un traitement anticoagulant, par exemple en fibrillation atriale chez les patients coronariens stables, il est recommande de privilegier un traitement anticoagulant isole, sans traitement antiagregant associe, a distance d’une revascularisation coronaire (1 an). © 2019 Elsevier Masson SAS. Tous droits reserves.

Aims: Guidelines recommend down-titration of loop diuretics (LD) once euvolaemia is achieved. In outpatients with heart failure (HF), we investigated LD dose changes in daily cardiology practice, agreement with guideline recommendations, predictors of successful LD down-titration and association between dose changes and outcomes. Methods and results: We included 8130 HF patients from the ESC-EORP Heart Failure Long-Term Registry. Among patients who had dose decreased, successful decrease was defined as the decrease not followed by death, HF hospitalization, New York Heart Association class deterioration, or subsequent increase in LD dose. Mean age was 66 ± 13 years, 71% men, 62% HF with reduced ejection fraction, 19% HF with mid-range ejection fraction, 19% HF with preserved ejection fraction. Median [interquartile range (IQR)] LD dose was 40 (25–80) mg. LD dose was increased in 16%, decreased in 8.3% and unchanged in 76%. Median (IQR) follow-up was 372 (363–419) days. Diuretic dose increase (vs. no change) was associated with HF death [hazard ratio (HR) 1.53, 95% confidence interval (CI) 1.12–2.08; P = 0.008] and nominally with cardiovascular death (HR 1.25, 95% CI 0.96–1.63; P = 0.103). Decrease of diuretic dose (vs. no change) was associated with nominally lower HF (HR 0.59, 95% CI 0.33–1.07; P = 0.083) and cardiovascular mortality (HR 0.62,. 95% CI 0.38–1.00; P = 0.052). Among patients who had LD dose decreased, systolic blood pressure [odds ratio (OR) 1.11 per 10 mmHg increase, 95% CI 1.01–1.22; P = 0.032], and absence of (i) sleep apnoea (OR 0.24, 95% CI 0.09–0.69; P = 0.008), (ii) peripheral congestion (OR 0.48, 95% CI 0.29–0.80; P = 0.005), and (iii) moderate/severe mitral regurgitation (OR 0.57, 95% CI 0.37–0.87; P = 0.008) were independently associated with successful decrease. Conclusion: Diuretic dose was unchanged in 76% and decreased in 8.3% of outpatients with chronic HF. LD dose increase was associated with worse outcomes, while the LD dose decrease group showed a trend for better outcomes compared with the no-change group. Higher systolic blood pressure, and absence of (i) sleep apnoea, (ii) peripheral congestion, and (iii) moderate/severe mitral regurgitation were independently associated with successful dose decrease. © 2020 European Society of Cardiology

Background Concomitant COVID-19 in patients with myocardial infarction (MI) may lead to difficulties in acute care management and may impair prognosis. To date, studies have involved a limited number of patients. Purpose To estimate and compare the characteristics, care management and 90-day outcomes of patients hospitalized for MI who didn’t have Covid-19, with those having concomitant hospital diagnosis of Covid-19 from the French National Health Data System, an exhaustive and nationwide database. Methods All patients hospitalised for MI in France between 30 December 2019 and 4 October 2020 were included. Patients with a previous hospitalization with Covid-19 were excluded (n = 135). Patients’ characteristics were compared according to Covid-19 status. 90-day mortality rates and follow-up outcomes were estimated and adjusted on age, sex and comorbidities. Results Among the 55,389 patients hospitalized for MI, 329 had concomitant Covid-19 (21% asymptomatic). MI patients with concomitant Covid-19 were more comorbid than patients without Covid-19. They had longer hospital stays, more admissions to resuscitation unit, underwent less percutaneous coronary intervention, and discharged more often to rehabilitation units than patients without Covid-19. The in-hospital and 90-day-out-of hospital mortality rates of MI patients with Covid-19 were 11.9% and 6.2%, respectively, compared to 3.5% and 2.8% in MI patients without Covid-19. The risk of in-hospital and out-of-hospital death remained increased after adjustment on comorbidities (ORajin-hosp = 3.31[2.32;4.72], ORajout-of-hosp = 1.79 [1.02;3.15]). Conclusions The prognosis of patients hospitalized for MI who had concomitant Covid-19 was impaired in the short term but also in the medium term. These results underline the need of an urgent protection of the population at cardiovascular risk from Covid-19, as well as a systematized and rapid management despite the pandemic context, and then a close follow-up of these patients.

Aims A number of insulin regimens are used in type 2 diabetes. This analysis aims to better understand the evolution of insulin therapy in different regions of Europe. Methods Data from people starting any insulin were collected in eastern Europe (EEur: Croatia, Russia, Ukraine), northern Europe (NEur: Finland, Germany, UK) and southern Europe (SEur: France, Italy, Portugal, Spain). Retrospective data on starting insulin and prospective follow-up data were extracted from clinical records. Results At 4 years, 1699 (76.0%) of 2236 eligible people had data. EEur participants were mostly female, younger and had shorter diabetes duration on starting insulin, yet had highest baseline HbA1c and more micro-/macrovascular disease. A majority (60%–64%) in all regions started on basal insulin alone, declining to 30%–38% at 4 years, with most switching to basal + mealtime insulin regimen (24%–40%). Higher baseline (28%) and 4-year use (34%) of premix insulin was observed in NEur. Change in HbA1c (SD) ranged from −1.2 (2.1)% (−13 [23] mmol/mol) in NEur to −2.4 (2.0)% (−26 [22] mmol/mol) in EEur. Weight change ranged from +1.9 (8.3) kg in NEur to +3.2 (7.0) kg in SEur. Overall documented hypoglycemia ranged from 0.3 (1.3) to 1.3 (4.4) events/person/6-months (NEur vs. EEur, respectively) and was stable with time. Severe hypoglycemia rates remained low. Conclusion When starting insulin, HbA1c and prevalence of complications were higher in EEur. Regional differences exist in choice of insulin regimens in Europe. However, people starting insulin improved and sustained their glycemic control regardless of regional differences or insulin regimens used.

Aims The EURO-ENDO registry aimed to study the management and outcomes of patients with infective endocarditis (IE). Methods and results Prospective cohort of 3116 adult patients (2470 from Europe, 646 from non-ESC countries), admitted to 156 hospitals in 40 countries between January 2016 and March 2018 with a diagnosis of IE based on ESC 2015 diagnostic criteria. Clinical, biological, microbiological, and imaging [echocardiography, computed tomography (CT) scan, 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT)] data were collected. Infective endocarditis was native (NVE) in 1764 (56.6%) patients, prosthetic (PVIE) in 939 (30.1%), and device-related (CDRIE) in 308 (9.9%). Infective endocarditis was community-acquired in 2046 (65.66%) patients. Microorganisms involved were staphylococci in 1085 (44.1%) patients, oral streptococci in 304 (12.3%), enterococci in 390 (15.8%), and Streptococcus gallolyticus in 162 (6.6%). 18F-fluorodeoxyglucose positron emission tomography/computed tomography was performed in 518 (16.6%) patients and presented with cardiac uptake (major criterion) in 222 (42.9%) patients, with a better sensitivity in PVIE (66.8%) than in NVE (28.0%) and CDRIE (16.3%). Embolic events occurred in 20.6% of patients, and were significantly associated with tricuspid or pulmonary IE, presence of a vegetation and Staphylococcus aureus IE. According to ESC guidelines, cardiac surgery was indicated in 2160 (69.3%) patients, but finally performed in only 1596 (73.9%) of them. In-hospital death occurred in 532 (17.1%) patients and was more frequent in PVIE. Independent predictors of mortality were Charlson index, creatinine > 2 mg/dL, congestive heart failure, vegetation length > 10 mm, cerebral complications, abscess, and failure to undertake surgery when indicated. Conclusion Infective endocarditis is still a life-threatening disease with frequent lethal outcome despite profound changes in its clinical, microbiological, imaging, and therapeutic profiles.

International audience; Background Familial hypercholesterolemia is a monogenic autosomal dominant dyslipidemia characterized by a permanent and isolated increase of cholesterol carried by low-density lipoproteins. The prevalence of its heterozygous form is estimated between 1/500 and 1/250, and in the absence of specific treatment, this form is responsible for an increase by a factor of 13 of the risk of premature coronary artery disease compared to patients non-affected by the disease. Objectives To perform an inventory of the knowledge of heterozygous familial hypercholesterolemia in France for physicians involved in the management of the disease. Methods A survey was conducted (by phone and internet) among a representative sample of 495 physicians (cardiologists, endocrinologists/diabetologists, gynecologists, general practitioners) who, in parallel, completed 579 patient records. Results Thirty-two percent (95% CI [27.8; 36.2]) of physicians reported the difference between polygenic hypercholesterolemia and familial hypercholesterolemia. The presence of tendinous xanthomas, a key element of diagnosis, was spontaneously mentioned by 44% (95% CI [34; 54.2]) of cardiologists. Six percent (95% CI [2.2; 12.6]) of them gave a correct estimate of the prevalence of familial hypercholesterolemia. The likelihood of transmission of heterozygous familial hypercholesterolemia, when one parent is affected, was known for 59% (95% CI [48.7; 68.7]) of surveyed cardiologists. A cascade screening was performed systematically by 4% (95% CI [1.1; 9.9]) of them. Eighteen percent (95% CI [11; 26.9]) of cardiologists gave an accurate estimation of cardiovascular risk of heterozygous familial hypercholesterolemia. Fifty-seven percent (95% CI [46.7; 66.8]) of cardiologists admitted being misinformed about the heterozygous familial hypercholesterolemia and 83% (95% CI [74.1; 89.7]) expressed a need for information about this disease. Conclusion The lack of knowledge of heterozygous familial hypercholesterolemia and its associated cardiovascular risk is probably the cause of a diagnostic default leading to inappropriate management of this disease.; Contexte L’hypercholestérolémie familiale est une dyslipidémie héréditaire monogénique (autosomique dominante) caractérisée par une augmentation permanente et isolée du cholestérol transporté par les lipoprotéines de basse densité. La prévalence de sa forme hétérozygote est estimée entre 1/500 et 1/250, et en l’absence de traitement spécifique, l’hypercholestérolémie familiale hétérozygote est responsable d’une augmentation d’un facteur 13 du risque de coronaropathie précoce par rapport aux patients non atteints par la maladie. Objectifs Faire un état des lieux de la connaissance de l’hypercholestérolémie familiale hétérozygote en France auprès des médecins impliqués dans la prise en charge de la pathologie. Méthodes Au travers de questionnaires soumis par téléphone et par Internet, une enquête a été menée auprès d’un échantillon représentatif de 495 médecins (cardiologues, endocrinologues/diabétologues, gynécologues, médecins généralistes) qui, en parallèle, ont complété 579 fiches patient. Résultats Trente-deux pour cent (IC 95 % [27,8 ; 36,2]) des médecins déclaraient faire la différence entre hypercholestérolémie polygénique et hypercholestérolémie familiale. La présence de xanthomes tendineux, un élément clé du diagnostic, était spontanément citée par 44 % (IC 95 % [34 ; 54,2]) des cardiologues. Six pour cent (IC 95 % [2,2 ; 12,6]) d’entre eux donnaient une estimation correcte de la prévalence de l’hypercholestérolémie familiale. La probabilité de transmission de l’hypercholestérolémie familiale hétérozygote, quand un des parents est atteint, était connue pour 59 % (IC 95 % [48,7 ; 68,7]) des cardiologues interrogés. Un dépistage en cascade était effectué de façon systématique par 4 % (IC 95 % [1,1 ; 9,9]) d’entre eux. Dix-huit pour cent (IC 95 % [11 ; 26,9]) des cardiologues estimaient le risque cardiovasculaire supplémentaire de l’hypercholestérolémie familiale hétérozygote supérieur à 10. Cinquante-sept pour cent (IC 95 % [46,7 ; 66,8]) des cardiologues admettaient être mal informés sur l’hypercholestérolémie familiale hétérozygote et 83 % (IC 95 % [74,1 ; 89,7]) exprimaient un besoin d’informations sur cette pathologie. Conclusion Le manque de connaissance de l’hypercholestérolémie familiale hétérozygote et de son risque cardiovasculaire associé est probablement à l’origine d’un défaut de diagnostic conduisant à une prise en charge inadaptée de cette maladie.

AIMS: To examine the relationships between glycated haemoglobin (HbA1c) and cardiovascular (CV) events in people beginning insulin in routine clinical practice in Europe, North America and Asia in a non-interventional study, the Cardiovascular Risk Evaluation in people with Type 2 Diabetes on Insulin Therapy (CREDIT) study. METHODS: Data on 2999 people were collected prospectively over 4 years from physician reports. The primary outcome was the composite of stroke or myocardial infarction (MI) or CV-specific death. Events were blindly adjudicated. The relative hazards of CV events were described from Cox proportional hazards models incorporating patient risk factors, with updated average HbA1c as a time-dependent covariate. The relationship of severe and symptomatic hypoglycaemia (collected during the 6 months before yearly ascertainment) with CV and all-cause mortality was examined. RESULTS: A total of 147 primary events were accrued during up to 54 months of follow-up. In all, 60 CV-specific deaths, 44 non-fatal MIs and 57 non-fatal strokes occurred, totalling 161 events. There was a significant positive relationship between updated mean HbA1c and primary outcome: hazard ratio (HR) 1.25 [95% confidence interval (CI) 1.12-1.40; p

Resume La fibrinolyse intraveineuse a longtemps ete consideree comme un traitement « autonome » de l’infarctus du myocarde avec sus-decalage du segment ST. Elle est alors moins efficace que l’angioplastie primaire, qui constitue maintenant le traitement de reperfusion de reference. Pourtant, son administration precoce, notamment dans le cadre d’un traitement delivre en phase prehosptaliere, et son integration dans le cadre d’une strategie pharmaco-invasive (fibrinolyse suivie d’une coronarographie rapide en vue d’un geste complementaire d’angioplastie si necessaire) a maintenant demontre une authentique superiorite clinique par rapport a la fibrinolyse administree isolement et les registres du monde reel montrent qu’une telle strategie donne des resultats cliniques comparables a ceux de l’angioplastie primaire. En France, grâce au developpement de la medecine prehospitaliere des Samu et a la disponibilite de nombreux plateaux de catheterisme interventionnel, le choix entre les deux techniques reste ouvert, essentiellement dicte par les delais depuis le debut des symptomes et par le delai previsible pour la realisation d’une angioplastie primaire.

Aim: To use baseline characteristics of the Cardiovascular Risk Evaluation in people with type 2 Diabetes on Insulin Therapy study population to identify factors that could explain the choice of insulin therapy when beginning insulin. Methods: The source, non-interventional, longitudinal, long-term study involves 314 centres in 12 countries in five regions. People were enrolled having started any insulin regimen in the previous 12 months. To identify factors associated with the choice of insulin regimen, multivariable backward logistic regression was performed on eligible physician and participant explanatory variables. Results: Participants (N = 3031) had mean age 62 years, diabetes duration 11 years, body mass index 29.3 kg/m2 and an HbA1c of 9.5%. Participants in Japan had less hypertension, smoked more and used fewer concomitant medications than those of other regions. Only physician location (rural or urban) influenced the choice of insulin in Japan. In the other four-regions-combined, physician location, specialty, sex and practice type influenced choice of insulin as did participant location, baseline HbA1c, use of glucose-lowering therapies and prior insulin secretagogue use. Conclusion: Choice of initial insulin regimen was influenced by several physician and participant characteristics in Canada and Europe, but only by physician location in Japan.

Resume L'enquete ANCOR a eu pour but d'evaluer la prescription des traitements de prevention secondaire avant et apres revascularisation myocardique. Elle a ete realisee entre le 1er septembre 2003 et le 1er avril 2004 aupres de 381 cardiologues liberaux et a permis d'inclure 1535 patients (âge moyen : 64 ans, 79 % d'hommes) revascularises par angioplastie (n = 1214) ou chirurgie (n = 321). A distance du geste, 37 % des patients conservent un angor, le plus souvent pour des circonstances exceptionnelles (classe canadienne I). Les chiffres de pression arterielle sont superieurs aux normes chez 38 % (49 % chez les patients connus comme hypertendus) et 27 % des fumeurs n'ont pas cesse le tabagisme. On constate une augmentation significative de la prescription des traitements de prevention secondaire par rapport a la situation ayant precede le geste de revascularisation pour toutes les classes therapeutiques : antiagregants : de 63,5 a 89 % ; betabloquants, de 53 a 73,5 % ; statines : de 51 a 83 % ; IEC : de 27 a 39 % : nicorandil : de 14 a 21 %. Il n'y a pas de difference dans la qualite de la prise en charge medicamenteuse entre les patients dilates et pontes. Les facteurs associes a la prescription des differentes classes sont parfois logiques (statines chez les hyperlipidemiques, IEC chez les hypertendus) et parfois peu en accord avec les recommandations (moindre prescription de betabloquants chez les diabetiques). Au total, la periode entourant le geste de revascularisation constitue un moment privilegie pour la mise en route du traitement de fond de la maladie atherosclereuse, mais le controle des facteurs de risque reste cependant souvent encore insuffisant.

SummaryThe iso-osmolar contrast medium iodixanol (Visipaque™; GE Healthcare, UK) has been reported to reduce the risk of major adverse cardiac events and to have a higher success rate when used during percutaneous coronary intervention (PCI) compared with the ionic low-osmolar contrast medium ioxaglate (Hexabrix; Guerbet, France) for patients at risk of complications. This study assessed to what extent these clinical benefits translate into economic benefits for patients undergoing PCI in France and Spain using a decision tree model. Clinical data were derived from the COURT and VIP trials. Medical resource use data were obtained from panels of French and Spanish interventional cardiologists. Resource use was converted to costs using country-specific tariffs. The study results suggest that using iodixanol rather than ioxaglate confers an economic benefit in addition to the reported clinical benefit in high-risk patients undergoing PCI in both countries. For low-risk patients, iodixanol may be regarded as ...

This paper presents the protocol of the PACIFIQUE survey, carried out in the most important French interventional cardiology centres (>600 procedures/year) during a 2-week period in January 2004, in order to determine actual practices in terms of medical management at hospital discharge and 6-month follow-up in patients treated with coronary angioplasty.

Beyond its antianginal properties, the specific I f (pacemaker, or ‘funny’, current) channel blocker ivabradine has many possible clinical uses. The first potential application of ivabradine results from its ability to decrease myocardial ischaemia. Because myocardial ischaemia has a definite impact on outcome, its reduction is likely to improve prognosis in patients with coronary artery disease (CAD). In such patients, lowering the heart rate per se might also reduce risk for sudden cardiac death or acute coronary events, as a strong link exists between heart rate and plaque rupture, which is the triggering mechanism of most complications of CAD. Most importantly, I f current inhibition might be useful in patients with congestive heart failure. In such patients, there is a parallel between heart rate reduction and the beneficial clinical effects achieved with beta-blockers. Observational studies, on the other hand, show that only a minority of patients with heart failure receive beta-blockers; I f current inhibition might constitute an alternative in such patients. Diastolic heart failure remains a therapeutic challenge, and prolonging the diastolic time is likely to prove beneficial. Because ivabradine has no negative impact on left ventricular function, it might also be useful for controlling heart rate in patients with acute heart failure treated with agents such as dobutamine. Future studies will determine whether ivabradine fulfils part, or all, of this promise.

Intracoronary brachytherapy aims at a reduction of in-stent restenosis by lessening neo-intimal proliferation. To assess its clinical potential, a systematic review of the literature indexed in the standard biomedical bibliographic databases selected eight prospective randomized clinical trials; seven of them, comparing coronary brachytherapy and non-treatment or placebo, have been included in the present meta-analysis. This analysis confirms the angiographic benefit of this procedure, as reported in the individual studies; it also shows, however an excess of clinical adverse effects not exhibited by any individual trial. Therefore, intracoronary brachytherapy cannot be recommended as routine practice, while one cannot rule out its interest in special situations.

Summary. Background: Platelet activation by antistreptokinase (SK) antibodies could impair the clinical effect of SK administration. Objective: To better describe anti-SK antibodies with particular emphasis on procoagulant activities as a result of platelet activation. Patients and methods: Sera were collected from 146 patients with coronary artery disease: non-SK-treated, 95 from mainland France, 31 from French Polynesia; 20 patients from mainland in year 2 after SK treatment. Serum-induced SK-dependent platelet activation resulting in procoagulant activities was assessed with washed platelets from five donors representative of the known patterns of reactivities to IgG. Results: Concentrations (2–5252 µg mL−1) and fibrinolytic neutralization titres ( 1280) were found in the expected wide range and correlated (ρ = 0.66, P

Resume Le sildenafil (Viagra®), inhibiteur de la phosphodiesterase 5, a une action vasodilatatrice puissante au niveau des corps caverneux, qui en a fait un medicament de premier plan dans le traitement de la dysfonction erectile. Pourtant, le sildenafil avait debute sa carriere en tant que medicament antiangineux, en raison de son potentiel vasodilatateur. Ce sont ces proprietes qui ont suscite un regain d'interet pour le sildenafil dans diverses situations cardiovasculaires et qui ont egalement conduit a formellement contre-indiquer l'association aux nitres et apparentes. La securite d'emploi du sildenafil chez les patients cardiaques a continue d'etre evaluee au fil du temps, apres sa mise sur le marche, aux Etats-Unis et au Royaume-Uni. Sa tolerance a egalement ete evaluee au cours d'etudes controlees chez 3975 patients : la tolerance a ete comparable chez les patients sous ou sans antihypertenseurs, et elle n'a pas varie en fonction du type de traitement antihypertenseur et du nombre des medicaments. Chez l'hypertendu equilibre, la prise de sildenafil s'accompagne d'une baisse de la pression arterielle systolique et diastolique. Dans l'insuffisance cardiaque, la vasodilatation debit-dependante est amelioree par la prise de 25 ou 50 mg de sildenafil. Chez des patients ayant une maladie coronaire documentee ou probable, le sildenafil n'influence pas la survenue de symptomes, la duree ni l'importance de l'ischemie d'effort, lors d'echocardiographies de stress. De meme, chez des hommes ayant une maladie coronaire documentee, le sildenafil n'entraine pas de modification de la pression capillaire pulmonaire ni de l'index cardiaque, tandis que la reserve coronaire augmente sous sildenafil, aussi bien au niveau des arteres coronaires saines que des arteres coronaires stenosees (sans phenomene de vol coronaire ). Dans l'hypertension arterielle pulmonaire primitive, le sildenafil, isolement ou en association avec l'iloprost en inhalation abaisse de facon durable la pression arterielle pulmonaire moyenne et les resistances vasculaires pulmonaires. Le sildenafil diminue l'hypertension arterielle pulmonaire induite par l'hypoxie, chez le volontaire sain ; sur des modeles murins, le sildenafil diminue les consequences hemodynamiques et anatomiques de l'exposition chronique a l'hypoxie. Enfin, dans l'hypertension arterielle pulmonaire, le sildenafil provoque une baisse des pressions pulmonaires proche de celle obtenue avec l'inhalation de NO, mais sans provoquer d'augmentation de la pression capillaire ; en association, les deux traitements se potentialisent.

Among agents that can act directly on myocyte metabolism in order to ensure myocardial protection during revascularization procedures, trimetazidine is already available because of its anti-ischaemic properties in patients with angina pectoris, whereas others are still under investigation. In elective coronary angioplasty, trimetazidine delays ST-segment shift and reduces its extent by more than 40% during balloon inflation as compared with placebo. In the GUARD During Ischaemia Against Necrosis (GUARDIAN) trial, cariporide, an inhibitor of the sodium-hydrogen exchanger, had no effect on death or myocardial infarction. With regard to primary angioplasty for acute myocardial infarction, both the Limitation of Infarct Size by Trimetazidine (LIST) study and a trial that employed cariporide showed that metabolic intervention before angioplasty had favourable effects. Regarding coronary surgery, in the GUARDIAN trial, high-dose cariporide was associated with fewer cardiac events. Likewise, during coronary surgery, patients who were pretreated with trimetazidine exhibited lesser release of markers of myocardial injury. Therefore, metabolic intervention appears a promising way to lessen myocardial injury associated with revascularization procedures. Its long-term benefit, however, should be studied in large-scale therapeutic trials.

Homocysteine and vitamins B were correlated with coronary artery disease in patients undergoing diagnostic coronary angiography. 160 patients havingor =1 stenosis (G1), 55 patients having normal coronary arteries (G2) and 171 healthy volunteers (G3) were prospectively recruited. Homocysteine levels were significantly higher in patients, particularly in those with normal coronary angiograms, than in healthy subjects (13.8 +/-6.3 micromol/L in G1 (p0.0001) and 15.2 +/- 8.8 micromol/L in G2 (p0.0001) versus 10.1 +/- 3.1 micromol/L in G3). Homocysteine levels were not related to the extent of coronary artery disease. In patients with normal angiogram, vitamin B12 and folate levels were significantly higher compared with the other groups (p0.05 and p0.001, respectively) showing that vitamin B deficiency was not involved in the hyperhomocysteinemia. In conclusion, homocysteine and vitamins B levels do not contribute to discriminate for the presence of coronary artery disease in patients undergoing diagnostic coronary angiography. Homocysteine levels, however, were higher in patients referred for coronary angiography than in healthy controls.

To assess gender differences in characteristics, management, and hospital outcomes in patients participating in the French FAST-MI 2010 registry.Three thousand and seventy-nine patients hospitalised for ST-elevation (STEMI) or non-ST-elevation (NSTEMI) myocardial infarction in 213 French centres during a 1-month period at the end of 2010.Women account for 27% of the population and more frequently present with NSTEMI. They are 9 years older than men on average, although 25% of women with STEMI are less than 60 years of age. Management of STEMI is similar, after adjustment for baseline characteristics. However, fewer women are treated with primary percutaneous coronary angioplasty. In NSTEMI, although use of coronary angiography is similar, fewer women get treated with angioplasty. Most medications are used in a similar way in men and women, except thienopyridines, with fewer women receive prasugrel. After adjustment, in-hospital mortality is similar for men and women.Myocardial infarction is not specific to men: one out of four patients admitted for myocardial infarction is a woman. Initial management is rather similar for men and women, after taking into account differences in baseline characteristics. Percutaneous coronary angioplasty, however, remains less frequently used in women. In-hospital complications have become rarer and do not differ according to sex.

Over the last 10 years, the French Federation of Cardiology has circulated recommendations regarding the use of chemoprophylaxis in patients at risk for infective endocarditis. A national survey conducted in 1991, however, showed that the vast majority of both general practitioners and dentists were unaware of these recommendations. Therefore, a Consensus Conference was convened in 1992, with the object of defining and circulating new guidelines which were to be as practical as possible, for the prophylaxis of infective endocarditis. The Consensus Conference first defined which categories of subjects were at risk for infective endocarditis and which types of procedures were potential causes of endocarditis. The second task of the Conference was to determine recommendations for chemoprophylaxis before procedures at risk. For ambulatory dental procedures, a single oral dose of 3 g of amoxicillin administered in the hour preceding the procedure was recommended. Additional recommendations were made for subjects with an allergy to penicillin, for procedures requiring general anaesthesia or for urologic or digestive tract procedures. These recommendations were printed on credit-card format cards and distributed to all practising cardiologists, who were encouraged to give each of their patients at risk a personal card bearing his/her name and the type of heart condition at risk. It is hoped that these measures to both simplify the prophylactic antibiotic regimen and circulate the recommendations from the Consensus Conference may reduce the incidence of this still severe disease.

To evaluate incidence and determinants of arterial hypertension after 60 years.Four thousand nine hundred and forty one subjects aged 60 years or above (2505 men: 64.2±4.2 years; 2436 women: 64.8±4.3 years) were explored two times at the IPC center, Paris, between 1992 and 2007, and were normotensive at the first visit (V1): systolic BP (SBP) less than 140mmHg and diastolic BP (DBP) less than 90mmHg without treatment. The delay between the two visits was 5.8±2.2 years. At the second visit, population was analysed as normotensives and hypertensives. An age-adjusted Anova compared groups.In men, incidence of hypertension is 41.5% and 25.9% for isolated systolic hypertension. In women, incidences were 37.8% and 27.8% respectively. Baseline characteristics for V2-hypertensives showed higher SBP, DBP, BMI, heart rate, glycemia, ECG abnormalities thanV2-normotensives but they had lower physical activity. The determinants of hypertension were: SBP, age, BMI, DBP, glycemia, and lack of physical activity for this age class.From 60 years old, 6-year incidence of hypertension is about 40% and 26% for isolated systolic hypertension, this latter being higher in women. Regular physical activity is protective.

In France, the incidence of myocardial infarctions leading to hospitalisations can be estimated between 60,000 and 65,000 each year. With the addition of cases of unstable angina, about 80,000 to 100,000 hospital stays each year are caused by acute coronary syndromes. Cases of out-of-hospital cardiac arrest of ischaemic origin should also be taken into account when estimating the annual incidence of myocardial infarction. In Europe, a North-South gradient, and even more an East-West gradient is observed for the incidence of ischaemic heart disease, with the highest figures found in central and eastern European countries. A consistent trend to a decrease in the incidence of myocardial infarction is observed on both sides of the Atlantic. In parallel, progress in the management of acute coronary syndromes has led to a marked decrease in early case fatality rates. Overall, these trends explain the spectacular decrease in cardiovascular mortality observed over the past 25 years in most European countries. Acute coronary syndromes, however, remain severe clinical conditions, which carry a high mid-term and long-term morbi-mortality and deserve further efforts to develop new therapeutic tools.

BACKGROUND The renarrowing process after successful percutaneous transluminal coronary angioplasty (PTCA) is now believed to be caused by a response-to-injury vessel wall reaction. The magnitude of this process can be assessed by the change in minimal lumen diameter (MLD) at follow-up angiography. The aim of the present study was to find independent patient-related, lesion-related, and procedure-related risk factors for this luminal narrowing process. A model that accurately predicts the amount of luminal narrowing could be an aid in patient or lesion selection for the procedure, and it could improve assessment of medium-term (6 months) prognosis. Modification or control of the identified risk factors could reduce overall restenosis rates, and it could assist in the selection of patients at risk for a large loss in lumen diameter. This population could then constitute the target population for pharmacological intervention studies. METHODS AND RESULTS Quantitative angiography was performed on 666 successfully dilated lesions at angioplasty and at 6-month follow-up. Multivariate linear regression analysis was performed to obtain variables with an independent contribution to the prediction of the absolute change in minimal lumen diameter. Diabetes mellitus, duration of angina < 2.3 months, gain in MLD at angioplasty, pre-PTCA MLD, lesion length > or = 6.8 mm, and thrombus after PTCA were independently predictive of change in MLD. Overall prediction of the model was poor, however, percentage-correct classification for a predicted change between -0.1 to -0.4 mm was approximately 10%. Lesions showing no change or regression (change > -0.1 mm) and lesions showing large progression (< or = -0.4 mm) were more predictable (correct classification, 59.5% and 49.7%, respectively). CONCLUSIONS Renarrowing after successful PTCA as determined with contrast angiography is a process that cannot be accurately predicted by simple clinical, morphological, and lesion characteristics.

In the first part of this review article, the prognostic impact of weight and weight changes in terms of clinical outcomes and metabolic control is reviewed, through the analysis of the results of several large cohorts and prospective studies of diabetic patients followed in "real world" settings. The second part of the review focuses on the impact of antidiabetic medications on weight, emphasising the importance of a comprehensive approach, taking into account weight, in the management of diabetic patients.

Right atrial myxoma is a rare disease and its clinical presentation is not specific. The usual mode of revelation is heart failure. The most frequent complications are pulmonary embolism and atrioventricular valve obstruction by the tumor. A 49-year-old woman was admitted to intensive care unit for heart failure. The echocardiogram showed a voluminous right atrial myxoma, appending to the interatrial septum. Its surgical excision under extracorporeal circulation was successfully performed. Histology confirmed the final diagnosis of myxoma. No complication was observed at 6 months follow-up.