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Background There is limited evidence that fractional flow reserve (FFR) is effective in guiding therapeutic strategy in multivessel coronary artery disease (CAD) beyond prespecified percutaneous coronary intervention or coronary graft surgery candidates. Objectives The FUTURE (FUnctional Testing Underlying coronary REvascularization) trial aimed to evaluate whether a treatment strategy based on FFR was superior to a traditional strategy without FFR in the treatment of multivessel CAD. Methods The FUTURE trial is a prospective, randomized, open-label superiority trial. Multivessel CAD candidates were randomly assigned (1:1) to treatment strategy based on FFR in all stenotic (≥50%) coronary arteries or to a traditional strategy without FFR. In the FFR group, revascularization (percutaneous coronary intervention or surgery) was indicated for FFR ≤0.80 lesions. The primary endpoint was a composite of major adverse cardiac or cerebrovascular events at 1 year. Results The trial was stopped prematurely by the data safety and monitoring board after a safety analysis and 927 patients were enrolled. At 1-year follow-up, by intention to treat, there were no significant differences in major adverse cardiac or cerebrovascular events rates between groups (14.6% in the FFR group vs 14.4% in the control group; hazard ratio: 0.97; 95% confidence interval: 0.69-1.36; P = 0.85). The difference in all-cause mortality was nonsignificant, 3.7% in the FFR group versus 1.5% in the control group (hazard ratio: 2.34; 95% confidence interval: 0.97-5.18; P = 0.06), and this was confirmed with a 24 months’ extended follow-up. FFR significantly reduced the proportion of revascularized patients, with more patients referred to exclusively medical treatment (P = 0.02). Conclusions In patients with multivessel CAD, we did not find evidence that an FFR-guided treatment strategy reduced the risk of ischemic cardiovascular events or death at 1-year follow-up. (Functional Testing Underlying Coronary Revascularisation; NCT01881555 )

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

Distal embolization during primary percutaneous coronary intervention (p-PCI) in the treatment of ST-segment elevation myocardial infarction (STEMI) is associated with a poor prognosis. In this situation, thrombectomy is performed to prevent distal embolization and to restore myocardial reperfusion. The aim of our study was to determine angiographic predictors of angiographically visible distal embolization (AVDE) in patients with STEMI treated by p‑PCI with thrombectomy. This prospective study included all consecutive patients who underwent p‑PCI with thrombectomy for STEMI at our institution between October 2011 and December 2014 AVDE was defined as a distal filling defect with an abrupt cut-off in one of the peripheral coronary branches of the infarct-related artery, distal to the angioplasty site. Thrombectomy was considered positive when it removed thrombi, and successful when it improved coronary flow. Among the 346 patients included, 59 (17%) developed AVDE during p‑PCI. In multivariate analysis, the infarct-related right coronary artery (OR: 2.48, 95% CI: 1.36–4.52; p = 0.003) and a culprit lesion diameter of >3 mm (OR : 1.90, 95% CI: 1.01–3.56; p = 0.048) were identified as independent factors associated with AVDE during p‑PCI with thrombectomy for STEMI. The success of thrombectomy and the Syntax score were not associated with AVDE. AVDE complicating p‑PCI with thrombectomy in STEMI is frequent (17%) and a successful thrombectomy does not rule out AVDE.

Tube-building sabellariid polychaetes are hermatypic organisms capable of forming vast reefs in highly turbulent marine habitats. Sabellariid worms assemble their tube by gluing together siliceous and calcareous clastic particles using a polyelectrolytic biocement. Here, we performed transcriptomic analyses to investigate the genes that are differentially expressed in the parathorax region, which contains the adhesive gland and tissues, from the rest of the body. We found a large number of candidate genes to be involved in the composition and formation of biocement in two species: Sabellaria alveolata and Phragmatopoma caudata. Our results indicate that the glue is likely to be composed by a large diversity of cement-related proteins, including Poly(S), GY-rich, H-repeat and miscellaneous categories. However, sequences divergence and differences in expression profiles between S. alveolata and P. caudata of cement-related proteins may reflect adaptation to the type of substratum used to build their tube, and/or to their habitat (temperate vs tropical, amplitude of pH, salinity …). Related to the L-DOPA metabolic pathways and linked with the genes that were differentially expressed in the parathorax region, we found that tyrosinase and peroxidase gene families may have undergone independent expansion in the two Sabellariidae species investigated. Our data also reinforce the importance of protein modifications in cement formation. Altogether these new genomic resources help to identify novel transcripts encoding for cement-related proteins, but also important enzymes putatively involved in the chemistry of the adhesion process, such as kinases, and may correspond to new targets to develop biomimetic approaches. Statements of Significance The diversity of bioadhesives elaborated by marine invertebrates is a tremendous source of inspiration to develop biomimetic approaches for biomedical and technical applications. Recent studies on the adhesion system of mussel, barnacle and sea star had highlighted the usefulness of high-throughput RNA sequencing in accelerating the development of biomimetic adhesives. Adhesion in sandcastle worms, which involves catechol and phosphate chemistries, polyelectrolyte complexes, supramolecular architectures, and a coacervation process, is a useful model to develop multipurpose wet adhesives. Using transcriptomic tools, we have explored the diversity of genes encoding for structural and catalytic proteins involved in cement formation of two sandcastle worm species, Sabellaria alveolata and Phragmatopoma caudata. The important genomic resource generated should help to design novel “blue” adhesives.

Silent atrial fibrillation (AF), assessed by continuous ECG monitoring (CEM), has recently been shown to be common in acute myocardial infarction (AMI), and associated with higher hospital mortality. However, the long-term prognosis is still unknown. We aimed to assess 1-year prognosis in patients experiencing silent AF in AMI.All consecutive patients with AMI who were prospectively analysed by CEM during the first 48 h after admission and who survived at hospital discharge were included. Silent AF was defined as asymptomatic episodes lasting at least 30 s. Patients were followed up at 1 year for cardiovascular (CV) outcomes.Among the 737 patients analysed, 106 (14%) developed silent AF and 32 (4%) symptomatic AF. Compared with the no-AF group, patients with silent AF were markedly older (79 vs 62 years, p0.001), more frequently hypertensive (71% vs 49%, p0.001) and less likely to be smokers (23% vs 37%, p0.001). Also, they were more likely to have impaired LVEF (50% vs 55%, p0.001). Risk factors in patients with silent AF were similar to those in patients with symptomatic AF. However, a history of stroke or AF was less frequent in silent AF than in symptomatic-AF patients (10% vs 25% and 10% vs 38%, respectively). At 1 year, CV events including hospitalisation for heart failure (HF) and CV mortality were markedly higher in silent-AF patients than in no-AF patients (6.6% vs 1.3% and 5.7% vs 2.0%, p0.001, respectively).Our large prospective study showed for the first time that silent AF is associated with worse 1-year prognosis after AMI. Systematic screening and specific management should be investigated in order to improve outcomes of patients after AMI.

New onset atrial fibrillation post-transcatheter aortic valve implantation (TAVI) is common and is associated with adverse outcomes. However, silent atrial fibrillation (AF) is poorly documented in the context. This study sought to evaluate the incidence, predictive factors, and prognostic value of Silent AF post-TAVI. All the consecutive patients with TAVI were prospectively analyzed by continuous electrocardiogram monitoring≥48 hours after implantation. Silent AF was defined as asymptomatic episodes lasting at least 30 seconds. The population was divided into 3 groups: history of AF, no-AF, and silent AF. Among the 206 patients implanted with TAVI, 19 (16.1%) developed silent AF. Compared with the no-AF group, patients with silent AF shared the same clinical characteristics and cardiovascular risk factors. Procedural success and echography parameters after the device implantation were similar between groups. Left atrial volume was significantly increased (p0.001) in the silent AF group, together with preimplantation C-reactive protein (CRP)3 mg/L and glucose (p = 0.048 and p = 0.002). By multivariate analysis, CRP3 mg/dl and logistic European System for Cardiac Operative Risk Evaluation were identified as independent predictors of silent AF. In-hospital and 1-year mortalities were higher in pre-existing AF patients, whereas no-AF and the silent AF patients share the same prognosis. Our prospective study showed for the first time that silent AF is frequent after TAVI procedures. In conclusion, our work suggests that CRP could help to predict the risk of developing silent AF. However, the onset of silent AF is not associated with worse prognosis in the year following the procedure in our study.

The French government encourages the development of biogas plants, fulfilling a dual purpose to produce renewable energy and recycle organic residues. This commitment resulted in a reassessment of the price of electricity produced from biogas plants. French government also authorized the Injection of biogas in the natural gas network in 2011. In particular, the agricultural sector is expected to benefit from a strong increase in the coming years. Indeed, a recent Energy Plan (PMAA) carried by the French government schedules a total of 1000 biogas plants in the farms in 2020 whereas only 130 units are present in 2013 . Targeted benefits of anaerobic digestion through this plan are (1) the reduction of methane emissions inherent to conventional manure management, (2) the recycling of organic waste, (3) the contribution to renewable energy (4) the substitution of mineral nitrogen by the digestate. The IPCC estimates biogas leakage between 0 and 10 % (IPCC06), and recommends a default value of 5% in the absence of specific data. According Börjesson and Berglund (2007), these leaks are normally less than 2 %, but can vary between 0.2 % and 13 %. To face this situation on the environmental issue of biogas leakage, data compatible with the life cycle assessment tools are needed, obtained through measurements aiming to identify and quantify the leaks. The ultimate challenge is to prove or move towards an environmental relevance of biogas plants currently and soon implemented in France. The French literature on the subject does not establish specific emission factors to the national context. The international literature shows a range of values which in extreme cases can compromise the environmental benefits foreseen. The proposed project aims at providing new knowledge on the detection and quantification of biogas leaks. An important part of the project will be devoted to experimental work. A validation of a novel method is expected, based on the analysis of optical flow from infrared video imaging.; Les pouvoirs publics français incitent au développement d'installations de méthanisation, répondant ainsi à un double objectif de production d'énergie renouvelable et de valorisation des résidus organiques. Cet engagement de l'Etat s'est traduit en 2011 par une réévaluation du tarif de rachat d'électricité produite à partir de biogaz et par l'autorisation d'injection du biogaz dans le réseau de gaz naturel. Le secteur agricole notamment devrait subir un fort accroissement dans les prochaines années puisque le récent Plan Energie Méthanisation Autonomie Azote (EMAA) porté par le gouvernement français ambitionne un total de 1000 unités de méthanisation à la ferme en 2020 contre un parc de 130 unités en 2012. Les avantages ciblés de la méthanisation à travers ce plan sont (i) la réduction des émissions de méthane inhérentes à la gestion conventionnelle des effluents, (ii) la valorisation matière de résidus organiques, (iii) la contribution à la production d'énergie renouvelable, (iv) le moindre recours à l'azote minéral par substitution de celui-ci par le digestat. Le GIEC estime les fuites de biogaz entre 0 et 10% (IPCC06) au niveau du digesteur, et préconise une valeur par défaut de 5% en l'absence de données spécifiques. D'après Börjesson et Berglund (2007), ces fuites sont normalement inférieures à 2%, mais peuvent varier entre 0,2% et 13%. Face à ce constat sur l'enjeu environnemental des fuites de biogaz et le besoin de données compatibles avec les outils d'évaluation environnementale, l'identification et la quantification des fuites de biogaz se révèlent être un défi majeur, dans le but de conforter la pertinence environnementale des unités de méthanisation actuellement installées et à venir en France. La bibliographie française sur le sujet ne permet pas d'établir de facteurs d'émissions caractéristiques du contexte national et la bibliographie internationale montre une amplitude de valeurs allant dans les cas extrêmes jusqu'à compromettre le bénéfice environnemental pressenti. Aussi, TrackyLeaks ambitionne un travail de recherche en connaissances nouvelles sur l'identification et la quantification des fuites de biogaz sur les sites de méthanisation. Une part importante du projet sera consacrée à des travaux expérimentaux qui permettront de valider une méthode originale d'analyse du flot optique à partir d'imagerie vidéo infrarouge.

Bacterial and fungal communities associated with bark beetles, especially some Dendroctonus species, mediate challenging aspects of the subcortical habitat for their hosts. Filamentous fungi and yeasts are important in various metabolic processes of certain bark beetles, with involvement in nutrition, protection and detoxification of plant defense compounds. The eastern larch beetle, Dendroctonus simplex, is recognized as a serious forest pest in the upper part of North America. Although D. simplex is well studied, the fungal communities and their ecological role remain to be investigated. Here, using 18S rRNA gene pyrosequencing, we provide a comprehensive overview of the yeasts and filamentous fungi associated with the eastern larch beetle and compare fungal communities between different developmental stages and microenvironments. Fungal mycobiome associated with the galleries was also investigated. Our study has unveiled an unexpected fungal diversity associated with the developmental stages. Significant differences in species richness between the developmental stages were determined. Yeasts were found to be predominant in the adult and larval stages, whereas filamentous fungi were most prevalent in the pupae. Our results indicate a possible implication of yeasts in the eastern larch beetle nutrition.

Background Few data are available about BNP variation and left atrium remodeling after left appendage occlusion (LAAO) technique. Methods Prospective study, including all consecutive patients successfully implanted with a LAAO device. Contrast-enhanced cardiac computed tomography (CT) performed before and 6 weeks after the procedure with reverse left atrial remodeling define by an increase in LA volume > 10%, together with blood sampling obtained before, 48hr after device implantation and at the first visit after discharge (30–45 days) for BNP measurement. Results Among the 44 patients implanted with a complete dataset, mean End-diastolic LA volume was 139 ± 64 mL and 141 ± 62 mL at baseline and during follow-up (45 ± 15 days), respectively, showing no statistical difference (P = 0.45). No thrombus was seen on the atrial side of the device. Peridevice leaks (defined as presence of dye in LAA beyond the device) were observed in 17 patients (40%) but were trivial or mild. Reverse atrial remodeling (RAR) at 6 weeks was observed in 6 patients (13%). Despite no difference in BNP levels on admission, median BNP levels at 48 Hs was slightly increased in RAR patients when compared with controls. During FU, BNP levels were strictly identical in both groups. These results were not modified even when each RAR case was matched with 2 controls on age, LVEF, creatinine levels and ACE inhibitors treatment to avoid potential confounders. Conclusion Our study showed that despite the fact that LAAO technique can induce left atrial remodeling measured by CT-scan, it does not seems to impact BNP levels on the follow-up. The results need to be transposed to clinical outcomes of this expanding population, in future studies.

Background Conductive disorders after TAVI remain frequent, leading to a 10-20% risk of permanent pacemaker implantation (PPI). Pre-existing conduction disorders or anatomical features can offer a good prediction of the risk of PPI, however, inflammatory and hemorrhagic process are responsible of transient abnormalities and 1/3 of the patients does not need the pacemaker at follow-up. In this setting, corticosteroid could be an interesting treatment to prevent or reduce the need of PPI. We aim to assess the influence of chronic or acute corticosteroid treatment in the occurrence of PPI after TAVI. Methods All TAVI performed in our center 2013 and 2018 were prospectively included in the study. Patient treated either with chronic or acute corticosteroid before TAVI were gathered through medical database claim of the University Hospital of Dijon, France. They were matched 1:2 on sex, age, and the valve implanted. Preoperative parameters, corticosteroids dose and indication, and PPI rates after TAVI were collected. Results Among the 691 patients included, 18 (2.6%) patients had a corticosteroid prescription before TAVI procedure. 11(61%) had a chronic corticosteroid prescription, when the remaining patients were treated before and a few days after TAVI as prevention of contrast iodinated product allergy. When compared to the matched population (n = 36), no significant difference was found on PPI rates during hospitalization (2 (11%) vs. 6 (17%), P = 0.70). Among others parameters collected, the only significant difference between the two groups was that corticosteroids patients less frequently had previous diabetes (3 (17%) 17 vs. 18(50%), P = 0.021). Conclusion Corticosteroid treatment is uncommon before TAVI, reducing the statistical power of this analysis. Given the safety of this drug prescription on short duration prescription, a prospective randomized study could be performed to confirm our hypothesis.

article Background: Silent atrial fibrillation (AF) has been suggested to be frequent after acute myocardial infarction (MI). Continuous ECG monitoring (CEM) has been shown to improve AF screening in patients at risk of stroke. Objectives: We aimed to assess the incidence and prognosis of silent AF in patients with acute MI. Methods:All the consecutive patients with acute MI were prospectively analyzed by CEM ≥ 48 h after admission. Silent AF was defined as asymptomatic episodes lasting at least 30 s. The population was divided into three groups: no-AF, silent AF and symptomatic AF. Results:Among the 849 patients, 135(16%) developedsilentAF and45(5%)symptomatic AF.Comparedwith the no-AF group, patients with silent AF were markedly older (80 vs. 62 y, p b 0.001), more frequently women (43% vs. 30%, p = 0.006) and less likely to be smokers (20% vs. 36%, p b 0.001). They had impaired left ventricular ejection fraction (LVEF) and left atrial (LA) enlargement. By multivariate analysis, age, history of AF, indexed LA area and LVEF were identified as independent predictors of silent AF. In-hospital heart failure and death rates were markedly higher in silent AF group when compared with no-AF patients (41.8% vs 21.0% and 10.4% vs. 1.3%, respectively). Conclusion: Our large prospective study showed for the fi rst time that silent AF is more frequent than symptomatic AF after MI. Our work suggests that indexed LA area could help to predict the risk of developing silent AF. Moreover, the onset of silent AF is associated with worse hospital prognosis.

Resume Introduction Les complications iatrogeniques sont definies comme des reactions nocives induites par l’utilisation d’un medicament, mais aussi comme complications suite aux techniques invasives ou a l’implantation de materiel. Les complications iatrogenes survenant durant un sejour hospitalier sont bien connues et associees a une augmentation de la duree du sejour hospitalier et de la mortalite. En revanche, il existe peu de donnees concernant la iatrogenie comme motif d’admission a l’hopital ; particulierement en soins intensifs cardiologiques. Les objectifs de cette etude sont : (a) d’analyser la prevalence de la iatrogenie et ses caracterisques ; (b) de connaitre le retentissement sur les durees d’hospitalisation et sur la mortalite ; (c) d’evaluer les facteurs predictifs de severite et de mortalite. Methodes Du 1 er avril 2008 au 31 janvier 2012, toutes les admissions en soins intensifs cardiologiques causees par une complication iatrogenique ont ete incluses de maniere prospective et classees en deux groupes : (1) iatrogenie pharmacologique (betabloquants, digoxine, cordarone, inhibiteurs calciques, plusieurs antiarrythmiques, anticoagulants, antiagregants, autres), (2) iatrogenie non pharmacologique (pacemakers, defibrillateurs automatiques implantables, ablations par radiofrequence, coronarographie, chirurgie cardiaque dont les remplacements valvulaires). Seuls les patients entres pour intoxication medicamenteuse volontaire ont ete exclus. Dans une seconde partie, les patients sont classes en fonction de leur severite (groupe 1 : patients ne necessitant qu’une surveillance telemetrique, clinique et biologique ; et groupe 2 : patients pour lesquels il y a eu recours a une procedure invasive ou a l’utilisation d’amines vasoactives). Resultats Parmi les 7244 patients admis en soins intensifs cardiologiques pendant la periode d’inclusion, 250 (3,4 %) sont admis pour iatrogenie, 136 dans le groupe pharmacologique et 114 dans le groupe non pharmacologique. Dans le groupe non pharmacologique, on retrouve plus d’homme : 73,7 % versus 47,8 % ( p p p = 0,05) et la mortalite tend a etre plus importante : 12,3 % versus 5,9 % ( p = 0,075). Par ailleurs, en fonction du critere de severite, il n’y a pas de difference significative concernant les medicaments : 7,4 ± 3,4 dans le groupe 2 versus 6,8 ± 2,9 ( p = 0,184). Les patients du groupe 2 restent plus longtemps a l’hopital : 4,7 ± 3,2 versus 3,4 ± 2,4 jours ( p = 0,009) pour la duree en soins intensifs cardiologiques et 15 ± 13,7 versus 10 ± 9,8 jours ( p = 0,003) pour la duree totale d’hospitalisation. Conclusion La iatrogenie represente une cause non negligeable d’admission en soins intensifs cardiologiques, associee a une mortalite significative (8,8 %) et tend a entrainer une augmentation de la duree d’hospitalisation. D’autres etudes seront necessaires pour comprendre l’origine de cette mortalite et pour mieux caracteriser les patients a risques de iatrogenie.

Bartonellae are fastidious, facultative, intracellular vector-borne bacteria distributed among mammalian reservoirs worldwide. The pathogenic potential of many Bartonella spp. has increased the interest in these bacteria and advanced their research. Isolation of Bartonella spp. is laborious using classical bacteriological methods and requires specific conditions and prolonged incubation periods. In contrast, molecular methods for detection of Bartonella DNA are considered as more practical and sensitive than the former. Among the molecular methods, the use of real-time PCR assays for primary screening of Bartonella spp., followed by several molecular confirmatory assays, using either conventional or real-time PCR, is recommended. Although primary isolation of Bartonella is a laborious task, we encourage its application to all PCR-positive samples as this is the most reliable proof for the presence of live bacteria. Moreover, a successful trial will enable a broader molecular characterization and speciation of isolated colonies. The present guideline gathers and summarizes recommendations, including advantages and limitations of isolation and molecular detection of Bartonella from mammalian and arthropod samples.

International audience; The impact of mechanical site preparation (MSP) on soil biogeochemical structure in young larch plantations was investigated. Soil samples were collected in replicated plots comprising simple trenching, double trenching, mounding and inverting site preparation. Unlogged natural mixed forest areas were used as a reference. Analysis of soil nutrients, abundance of bacteria and gas exchanges unveiled no significant difference among the plots. However, inverting site preparation resulted in higher variations of gas exchanges when compared with trenching, mounding and unlogged natural forest. A combination of the biological and physicochemical variables was used to define a multifunctional classification of the soil samples into four distinct groups categorized as a function of their deviation from baseline ecological conditions. According to this classification model, simple trenching was the approach that represented the lowest ecological risk potential at the microsite level. No relationship was observed between MSP method and soil bacterial community structure as assessed by high-throughput sequencing of bacterial 16S rRNA gene; however, indicator genotypes were identified for each multifunctional soil class. This is the first identification of multifunctional molecular indicators for baseline and disturbed ecological conditions in soil, demonstrating the potential of applied microbial ecology to guide silvicultural practices and ecological risk assessment.

International audience; We report the molecular detection of Borrelia afzelii (11%) and Bartonella spp. (56%) in 447 bank voles trapped in a suburban forest in France. Adult voles were infected by significantly more Borrelia afzelii than juveniles (p

Resume Introduction La thrombectomie coronarienne est frequemment integree aux procedures de prise en charge du syndrome coronarien aigu. De nombreuses etudes ont evalue son benefice dans ce contexte, mais peu suggerent une influence des caracteristiques des coronaires sur son efficacite. L’objectif de ce travail est d’evaluer les facteurs morphologiques qui pourraient expliquer le succes ou l’echec d’une thromboaspiration, a partir d’une etude experimentale. Materiels et methodes Des tubes en verre de 150 mm de long ont ete utilises, avec cinq diametres differents : 2,0 ; 2,6 ; 3,0 ; 3,6 et 4 mm ; et pour chaque diametre, nous avions trois angles differents : pas d’angle, angle a 90° et angle a 120°. A partir d’echantillons de sang total preleves chez des temoins sains, ont ete crees des thombi de trois ou six heures et de meme volume pour chaque essai. Les thrombectomies ont ete realisees avec le dispositif Export® (Medtronic) et le principal critere d’evaluation etait la thrombectomie totale. Un total de 240 thrombectomies a ete effectue. Resultats Une thrombectomie totale a pu etre obtenue dans 71,2 % des essais. Elle etait plus frequente pour les tubes de petit calibre, respectivement 100 % pour 2 mm, 81,3 % pour 2,6 mm, 89,6 % pour 3 mm contre 54,2 % pour 3,6 mm et 31,3 % pour 4 mm (p Conclusions Notre travail met en evidence une forte influence du diametre sur l’efficacite de la thromboaspiration. Il s’agit d’un travail preliminaire et d’autres travaux sont necessaires afin de preciser les modalites d’aspirations et l’impact d’autres catheters pour mieux repondre aux cliniciens.

Resume Les maladies cardiovasculaires representent l’une des plus importantes cause de mortalite et de morbidite precoce dans le monde industriel et deviennent un probleme de sante publique croissant dans de nombreux pays en voie de developpement. Les recommandations americaine et europeenne soulignent que le traitement medical associe a la correction des facteurs de risque et aux modifications de style de vie sont la pierre angulaire du traitement de cette pathologie. En raison de leur impact sur le pronostic, les inhibiteurs de l’enzyme de conversion (IEC) sont systematiques chez le coronarien stable. Recemment, plusieurs grands essais ont demontre l’interet de l’adjonction d’un antagoniste calcique, amlodipine, a un IEC, perindopril, chez le patient a haut risque cardiovasculaire, chez le coronarien stable ou chez le patient hypertendu. Cette association est synergique sur le controle tensionnel et sur la protection des organes cibles, conduisant ainsi a une reduction des evenements cardiovasculaires sur le long terme.

Cardiovascular disease is the leading cause of early death and morbidity in developed countries and is becoming a growing problem in many developing countries. Currently, anti-coagulants play a major role in the management of the acute phase in association or not with reperfusion strategies. The combination of clopidogrel and aspirin, in accordance with the results of large randomized trials, is the treatment of reference. However two new drugs, a thienopyridine (prasugrel), and a cyclo-pentyl-triazolo-pyridine (ticagrelor) have shown their interest in major studies in comparison with clopidogrel. As a result, several effective P2Y12 receptor antagonist anti-platelet agents are now available in the therapeutic arsenal, and the cardiologist have to tailored the best drug scheme according the balance between the risk of hemorrhage and the benefits with regard to the ischemia to determine the optimal prescription for every patient.

Summary Background Thrombus aspiration is applicable in a large majority of patients with acute myocardial infarction (AMI) and results in better reperfusion and clinical outcomes compared with percutaneous coronary intervention alone. Some aspiration procedures are, however, ineffective. To date, few clinical data are available on the predictors of successful thrombectomy in the acute phase of myocardial infarction. Aims To determine the baseline clinical and angiographic characteristics associated with successful thrombectomy. Methods Consecutive patients with ST elevation myocardial infarction with a baseline TIMI flow of 0 or 1, who underwent thrombus aspiration and primary or rescue angioplasty, were included. The main criterion for evaluation was an effective or ineffective aspiration defined, respectively, by the presence or absence of atherothrombotic material in the aspirate samples. Results Among the 180 patients included, material was collected in 155 patients (86%). Patients with the presence of material were younger (61 vs 74 years, P = 0.015), less frequently hypertensive (41% vs 68%, P = 0.023) and had a lower systolic blood pressure at admission (135 vs 148 mmHg, P = 0.031). No difference was observed between the two groups for angiographic parameters except for visible thrombus (61% vs 28%, P = 0.005) and calcification (37% vs 60%, P = 0.048). In multivariable analysis, the ability to remove the clot was affected by: age greater than 70 years (odds ratio 0.18, 95% confidence interval 0.06–0.51; P = 0.001), admission systolic blood pressure (0.97, 0.95–0.99; P = 0.003) and thrombus seen on angiography (4.54, 1.54–13.45, P = 0.006). Conclusion The present study showed that manual thrombus aspiration is effective in most, but not all, patients. Further studies are needed to develop more efficient aspiration techniques and other aspiration devices to improve the results of such procedures.

Cardiovascular disease is one of the major causes of early morbidity and death in the developed world, and is becoming a serious public health concern in many developing countries. Over the last 30 years, in the USA and France, coronary angioplasty has become a standard treatment for stable angina, and this despite the recommendations of Learned Societies concerning the treatment of this condition. Today, 85 % of angioplasty procedures are performed on patients with stable angina. This study presents meta-analyses that compare medical treatment with angioplasty, and examine the impact of these strategies on more specific populations such as the elderly and post-myocardial infarction patients. To our minds, this synthesis seems to be of particular importance as the COURAGE study has rekindled the debate by showing that improvements in medical treatment and way of life reduced mortality and the recurrence of MI at five years, whereas there was no positive impact of an invasive strategy in any of the subgroups. Nevertheless, as a whole, studies on this subject underscore the value of angioplasty in the medium term for symptom relief in the case of ineffective medical treatment, notably during an acute coronary syndrome both in patients under medical treatment and in those who underwent invasive therapy at the initial phase.

ObjectiveTo evaluate the incremental interest of performing a calcium score before CTO procedures, compared to the angiographic J-CTO score alone.Patients and MethodsProspective cohort of 109 consecutive patients with 119 de novo CTO lesions. Angiographic grading with the J-CTO score was compared with CT+angiographic staging (calcium score cut off>400) and a “corrected” J-CTO score, by ROC curve analysis to predict a successful recanalization.ResultsThirty-two lesions (27%) had a calcium score>400.13 (11%) patients were reclassified in the “corrected” J-CTO score because calcifications were not seen in the angiogram. The factors significantly associated with the failure of the procedure were J-CTO score (OR 0.486 [0.32-0.73], p400 was not found associated with the failure of the procedure (OR 0.545 [0239-1243], p

Epidemiological data concerning acute coronary syndromes in Europe are based on national registries, studies by the European Society of Cardiology within the framework of the EuroHeart Survey and on the study of European population sub-groups in large international cohorts. In this article, recently published studies will be reviewed, and the principal developments in different countries as well as the characteristics and particularities of the most recent epidemiological data will be highlighted. In Europe, the presentation of acute coronary syndromes (ACS) has evolved considerably over the last ten years. This evolution is characterized by a reduction in the proportion of acute coronary syndromes with ST-segment elevation (STEMI) and by ageing populations.

Cardiovascular disease is the primary cause of early death and morbidity in the industrialized world and is becoming a growing problem in many developing countries. Coagulation inhibitors play a major role in the management of the acute phase of ACS whether in association with reperfusion strategies or not. Currently, and in accordance with the results of major randomised studies, for medium and long-term management, the association of Clopidogrel and aspirin is the treatment of choice. However, despite the recognised benefits of this therapeutic strategy and above all the recommendations of learned societies, which have placed this bi-therapy in class I, according to national and international registries it is still underused. Moreover, all of these registries have confirmed, in the real world, the negative impact of not prescribing this antiplatelet therapy on morbidity and mortality after both ST and non-ST elevation acute coronary syndrome. which shows the difficulty of applying to everyday clinical practice the results of major randomised cohorts.

Many bark beetles belonging to the Dendroctonus genus carry bacterial and fungal microbiota, forming a symbiotic complex that helps the insect to colonize the subcortical environment of the host tree. However, the biodiversity of those bacteria at the surface of the cuticle or inside the body parts of bark beetles is not well established. The aim of this study was to characterize the bacterial microbiome associated with the eastern larch beetle, Dendroctonus simplex, using bacterial 16S rRNA gene pyrosequencing. The ecto- and endomicrobiome and the subcortical galleries were investigated. Several bacterial genera were identified, among which Pseudomonas, Serratia and Yersinia are associated with the surface of the beetle cuticle and genera belonging to Enterobacteriaceae and Gammaproteobacteria with the interior of the insect body. The index of dissimilarity indicates that the bacterial microbiome associated with each environment constitutes exclusive groups. These results suggest the presence of distinct bacterial microbiota on the surface of the cuticle and the interior of D. simplex body. Additionally, the bacterial diversity identified in the galleries is substantially different from the ectomicrobiome, which could indicate a selection by the insect. This study reports for the first time the identification of the eastern larch beetle microbiome.

Resume Nous rapportons deux observations de cardiomyopathies aigues, survenues dans les suites d'un stress psychologique. Chacun des patients a presente des anomalies contractiles transitoires de la pointe du ventricule gauche, evoquant un infarctus apical avec une coronarographie normale et une evolution clinique rapidement favorable. Le stress constitue une agression contre l'organisme; celui-ci dispose d'un systeme de defense, mettant en jeu le systeme nerveux sympathique, notamment les catecholamines, et l'axe corticotrope mais peut engendrer un certain nombre de situations pathologiques, notamment cardiovasculaires. Un nouveau syndrome cardiaque, le Tako-Tsubo, caracterise par une ballonisation transitoire de la pointe du ventricule gauche a ete recemment decrit par des equipes japonaises. Ces anomalies sont reversibles, elles surviennent de facon brutale, touchent generalement des femmes menopausees, dans les suites d'un stress intense. Le mode de debut est variable, depuis la douleur angineuse le plus souvent jusqu'au tableau de choc cardiogenique; l'electrocardiogramme retrouve habituellement d'importants troubles de la repolarisation et des coronaires angiographiquement normales. L'evolution se fait generalement vers la guerison sans sequelles, avec une restitution ad integrum de la fonction ventriculaire gauche. Les mecanismes physiopathologiques sont complexes, associant entre autres une suractivation alpha-adrenergique, une dysfonction endotheliale, et une vasoconstriction microvasculaire a opposer sur un plan nosologique a un accident atherothrombotique bref non decelable par la seule coronarographie.

The patients presenting acute coronary syndrome with or without ST segment elevation form a heterogeneous population and thus the short and long-term risk of death or recurrent ischemic events can vary considerably. During ACS without ST elevation (unstable angina and non-ST elevation MI), the evaluation of risk is an essential step in the management of such patients, because it determines ulterior strategy. This evaluation is simple and reliable, and is principally based on three scores: the TIMI, the GRACE Score or the PURSUIT. Thanks to this stratification, high and medium-risk patients are able to benefit from early invasive management (stents and anti-GPIIb/IIIa) as recent studies have clearly shown. Even if immediate management of patients with non-ST elevation ACS does not take account of risk stratification, using such information in the medium and long-term does help determine the prognosis. Finally, the risk profile score, whatever the score used is today an essential tool, which helps qualify and especially compare patients included in international clinical studies.

Background Few data are available about clinical consequences of BNP variation after left appendage occlusion (LAAO) technique. Methods In all consecutive patients successfully implanted with a LAAO device, blood samples were obtained before, 48 h after device implantation and at the first visit after discharge (30–45 days) for BNP measurement. Clinical and echocardiography parameters were gathered. Patients diagnosed with symptoms of heart failure according to the ESC guidelines were classified as HF group. Results Among the 58 patients implanted, 6 (10%) complain with new HF symptoms, mainly breathlessness, and were classified in NYHA class II or III during the FU visit. Symptomatic patients were older, however procedural success and echo parameters after the device implantation were similar between groups. Despite no difference in NTproBNP levels on admission and after 48 h, median NTproBNP levels was increased by about 20% at time of FU in HF patients when compared with asymptomatic patients. To avoid potential confounders, each HF case was matched with 2 controls on age, LVEF and creatinine levels. After matching, the median NTproBNP levels was significantly increased in the HF group vs. control (1048 vs. 521 pg/mL, respectively, P Conclusion Our prospective study showed for the first time that LAAO modifies BNP levels and that trends of variation can have clinical impact during FU. The pathophysiological mechanisms of these findings need to be further investigated.

To further assess the geographic occurrence, possible vectors, and prevalence of Candidatus Neoehrlichia mikurensis, we analyzed spleen tissues from 276 voles trapped close to human settlements in France; 5 were infected with the organism. Sequencing showed the isolates carried the same genotype as the bacteria that caused disease in humans and animals elsewhere in Europe.

International audience; Atrial fibrillation (AF) is the most frequent heart rhythm disorder in the general population and contributes not only to a major deterioration in quality of life but also to an increase in cardiovascular morbimortality. The onset of AF in the acute phase of myocardial infarction (MI) is a major event that can jeopardize the prognosis of patients in the short-, medium- and long-term, and is a powerful predictor of a poor prognosis after MI. The suspected mechanism underlying the excess mortality is the drop in coronary flow linked to the acceleration and arrhythmic nature of the left ventricular contractions, which reduce the left ventricular ejection fraction. The principal causes of AF-associated death after MI are linked to heart failure. Moreover, the excess risk of death in these heart failure patients has also been associated with the onset of sudden death. Whatever its form, AF has a major negative effect on patient prognosis. In recent studies, symptomatic AF was associated with inhospital mortality of 17.8%, to which can be added mortality at 1year of 18.8%. Surprisingly, silent AF also has a negative effect on the prognosis, as it is associated with an inhospital mortality rate of 10.4%, which remains high at 5.7% at 1year. Moreover, both forms of AF are independent predictors of mortality beyond traditional risk factors. The frequency and seriousness of silent AF in the short- and long-term, which were until recently rarely studied, raises the question of systematically screening for it in the acute phase of MI. Consequently, the use of continuous ECG monitoring could be a simple, effective and inexpensive solution to improve screening for AF, even though studies are still necessary to validate this strategy. Finally, complementary studies also effect of oxidative stress and endothelial dysfunction, which seem to play a major role in triggering this rhythm disorder.

BackgroundCurrent guidelines for the management of patients with acute myocardial infarction (AMI) recommend the GRACE score for risk stratification with assessment of admission variables. The syntax score (SS) is a comprehensive angiographic scoring system that is derived entirely from the coronary anatomy and lesion characteristics. We investigated the relationship between severity of coronary artery disease (CAD) assessed with SYNTAX Score (SS) and GRACE Score (GS) in patients with AMI.Patients and MethodsFrom the obseRvatoire des Infarctus de Côte d’Or (RICO) survey, 614 consecutive patients hospitalized for an AMI from 1st march 2011 to 30 august 2012 and who underwent coronary angiography were included. Patients were analyzed into 3 tertiles of risk based on GS.ResultsThe tertiles of risk were defined as low (n=205)(GS165). Age and co-morbidities increase gradually with increased GS risk. Also, the number of diseased vessels on coronary angiography increased across the tertiles (p

International audience; Among the 33 confirmed Bartonella species to date, more than half are hosted by rodent species, and at least five of them have been involved in human illness causing diverse symptoms including fever, myocarditis, endocarditis, lymphadenitis and hepatitis. In almost all countries, wild rodents are infected by extremely diverse Bartonella strains with a high prevalence. In the present paper, in light of new knowledge on rodent-adapted Bartonella species genomics, we bring together knowledge gained in recent years to have an overview of the impact of rodent-adapted Bartonella infection on humans and to determine how diversity of Bartonella helps to understand their mechanisms of adaptation to rodents and the consequences on human health.

International audience; Host-specificity is an intrinsic feature of many bacterial pathogens, resulting from a long history of co-adaptation between bacteria and their hosts. Alpha-proteobacteria belonging to the genus Bartonella infect the erythrocytes of a wide range of mammal orders, including rodents. In this study, we performed genetic analysis of Bartonella colonizing a rodent community dominated by bank voles (Myodes glareolus) and wood mice (Apodemus sylvaticus) in a French suburban forest to evaluate their diversity, their capacity to recombine and their level of host specificity. Following the analysis of 550 rodents, we detected 63 distinct genotypes related to B. taylorii, B. grahamii, B. doshiae and a new B. rochalimae-like species. Investigating the most highly represented species, we showed that B. taylorii strain diversity was markedly higher than that of B. grahamii, suggesting a possible severe bottleneck for the latter species. The majority of recovered genotypes presented a strong association with either bank voles or wood mice, with the exception of three B. taylorii genotypes which had a broader host range. Despite the physical barriers created by host specificity, we observed lateral gene transfer between Bartonella genotypes associated with wood mice and Bartonella adapted to bank voles, suggesting that those genotypes might co-habit during their life cycle.

International audience; BACKGROUND: The relation between fragmented QRS complex (fQRS) and cardiac magnetic resonance parameters is poorly documented in ischemic cardiopathy. METHODS: Among 209 consecutive patients, those with fQRS were compared with those without fQRS. Cardiac magnetic resonance studies with late gadolinium-enhanced sequences were done during the week after acute myocardial infarction. RESULTS: fQRS was present in 113 (54%) patients, and associated with a significantly lower left ventricular ejection fraction, increased left ventricular volumes, a larger infarct size (IS), and a larger peri-infarct zone. Microvascular obstruction was more frequent in patients with fQRS (62% vs 45%; P = 0.014) and the extent of the microvascular obstruction was significantly larger (1.6% [range, 0.0-4.4] vs 0.0 [range, 0.0-2.1]; P = 0.004). Finally, the transmurality score in the 2 study populations was identical (48% vs 47%; P = 0.895). In multivariate logistic regression analysis, only IS (odds ratio [OR], 1.06; 95% confidence interval [CI], 1.03-1.09; P < 0.001), systolic blood pressure (OR, 1.02; 95% CI, 1.01-1.04; P < 0.001), and left ventricular end-systolic volume (OR, 1.02; 95% CI, 1.00-1.03; P = 0.013) remained independent predictors of fQRS. CONCLUSIONS: This study revealed that fQRS was associated with increased IS, myocardial perfusion abnormalities, decreased left ventricular ejection fraction, and increased left heart volumes. These findings show that fQRS is a reliable marker of infarct size and acute ventricular remodelling.

Numerous mammal species, including domestic and wild animals such as ruminants, dogs, cats and rodents, as well as humans, serve as reservoir hosts for various Bartonella species. Some of those species that exploit non-human mammals as reservoir hosts have zoonotic potential. Our understanding of interactions between bartonellae and reservoir hosts has been greatly improved by the development of animal models for infection and the use of molecular tools allowing large scale mutagenesis of Bartonella species. By reviewing and combining the results of these and other approaches we can obtain a comprehensive insight into the molecular interactions that underlie the exploitation of reservoir hosts by Bartonella species, particularly the well-studied interactions with vascular endothelial cells and erythrocytes.

Periodontal disease, including bone loss, is thought to be involved in coronary artery disease. Multiple complex coronary lesions relate to multifocal destabilization of coronary plaques. We investigated whether bone loss could be associated with the presence of multiple complex coronary lesions.This cross-sectional study included 150 patients with recent myocardial infarction (1 month). Multiple complex coronary lesions were determined at coronary angiography. A panoramic dental X-ray including bone loss50% was performed. Patients with no or simple complex lesions were compared to patients with multiple complex lesions.Over 20% of patients had multiple complex coronary lesions. Patients with multiple complex lesion were less likely to be women and more likely to have multivessel disease or elevated C-reactive protein (CRP) than patients with no or single complex lesion. Bone loss50% tended to be more frequent in patients with multiple complex lesions (p = 0.063). In multivariate analysis, multivessel disease, gender and CRP were associated with multiple complex lesion. Bone loss50% increased the risk of multiple complex lesion.Bone loss was associated with complex multiple coronary lesions, beyond systemic inflammation. These findings may bear important clinical implications for the prevention and treatment of coronary artery disease.

To examine the influence of obesity on the predictive value of the pro-B-type natriuretic peptide (NT-proBNP) assay in acute myocardial infarction.Prospective observational study.All intensive care units in one region of France. Patients 2217 consecutive patients admitted for an acute myocardial infarction matched with respect to age, gender, Killip class and renal function.Cardiovascular death at one year.There were three groups (according to body mass index (BMI): obese, overweight and normal) of 739 matched patients. Median levels of NT-proBNP were considerably lower in high BMI patients, by about 20% in overweight and by 60% in obese patients, compared with normal BMI patients. An inverse relationship between the propeptide values and BMI was found in the overall study population (r = -0.20, p0.0001), and for both genders. In multivariate linear regression, BMI as a continuous variable was a predictor of the log NT-proBNP level, even when adjusted for potential confounders. CV mortality at 1-year follow-up was similar for the three BMI groups (p = 0.691). In multivariate logistic regression analysis, log NT-proBNP predicted mortality in normal (OR (95% CI) 3.48 (2.00 to 6.12)) and overweight (OR (95% CI) 3.96 (1.95 to 8.06)) patients, even when adjusted for confounders (GRACE risk score, left ventricular ejection fraction). However, in obese patients, propeptide levels failed to retain their independent prognostic value (OR (95% CI) 1.34 (0.86 to 2.08)).In this large population of patients with myocardial infarction, circulating NT-proBNP levels were considerably lower in obese patients; the significance of the propeptide level as an independent prognostic factor is severely compromised.

International audience; Background and aim: Reactive oxygen species (ROS) play an important role in the pathogenesis of many diseases including cardiovascular diseases. Several methods have been developed for the direct or indirect measurement of oxygen free radical and its by-products. The current study was designed to validate the new Free Oxygen Radicals Test (FORT) and to investigate the potential relationships between ROS and clinical or biological factors in male patients with acute myocardial infarction (AMI). Methods: We analysed FORT values in samples from 66 patients with AMI. Results: FORT values ranged from 324 to 1198 FORT units, with a median value of 581 (494-754) FORT units. In univariate analysis, FORT values were positively related only to LVEF

Cardiovascular diseases are one of the main causes of early morbidity and mortality within occidental world as well as in developing countries where they become a growing burden of public health. North-American recommendations and the ones of the European Society of Cardiology underline that medical treatment, risk factor management and life-style modifications are cornerstone of the treatment. Thanks to their impact on prognosis, angiotensin converting enzyme (ACE) inhibitors are obvious in stable coronary patients. Recently, some large trials have supported the benefits of combining calcium antagonist, amlodipine, and ACE inhibitor, perindopril, in patients with high cardiovascular risk, stable coronary patients or hypertensive patients. This combination has synergistic properties on blood pressure control and target-organ protection, thus reducing cardiovascular events over the long term.

Over 4 yr, 102 consecutive patients more than 75 yr old (56 men, 46 women; mean age 78 +/- 3 years, range: 76-89 years) underwent 120 percutaneous transluminal coronary angioplasty procedures. At baseline, 86% had severe anginal symptoms (Canadian class III or IV), 43% had a history of prior myocardial infarction; 61% had multivessel coronary artery disease, and mean left ventricular ejection fraction was 60 +/- 11%. Calcifications were observed on 66% of the dilated arteries. A total of 158 vessels (1.3 vessel per procedure) were attempted: 1 vessel in 89 procedures (74%), 2 vessels in 24 (20%) and 3 vessels in 7 (6%). The primary success rate was 80% per lesion (126/158) and 77% per procedure (92/120). Complications included 3 deaths (3%), 9 Q-wave infarctions (7.5%) and there was no emergency coronary bypass surgery. The primary success rate was significantly related to the absence of coronary calcifications on the dilated segment (88% versus 75%, p0.05) and to the initial patency of the dilated artery (subtotal stenosis: 83% versus total occlusion: 53%, p0.05). Follow-up data were obtained in the 79 consecutive patients with a duration of follow-up exceeding 8 months. The mean duration of follow-up was 23 +/- 13 months (range 8 to 61 months). No patient was lost to follow-up; 11 patients died (cardiac causes: 7), 2 had a non-fatal infarction, 7 had aortocoronary bypass surgery and 18 had repeat percutaneous transluminal coronary angioplasty.(ABSTRACT TRUNCATED AT 250 WORDS)

Objective: To determine the prevalence of chronic oral anticoagulant drug treatment (COA) among patients with acute myocardial infarction (AMI) and its impact on management and outcome. Methods: All patients with ST segment elevation AMI on the RICO (a French regional survey for AMI) database were included in this analysis. COA was defined as continuous use ⩾ 48 hours before AMI. Results: Among the 2112 patients with ST elevation myocardial infarction (STEMI), 93 (4%) patients were receiving COA. These patients were older and more likely to have a history of hypertension, diabetes and prior myocardial infarction than patients without COA. In addition, fewer patients who received COA underwent reperfusion therapy or received an antiplatelet agent (aspirin/thienopyridines). Moreover, patients receiving COA experienced a higher incidence of in-hospital major adverse events (death, recurrent myocardial infarction or major bleeding, p = 0.005). Multivariate analysis showed that only ejection fraction, current smoking and multiple vessel disease, but not COA, were independent predictive factors for major adverse events. In contrast, COA was an independent predictive factor for heart failure when adjusted for age, diabetes, creatinine clearance, reperfusion, heparin and glycoprotein IIb/IIIa inhibitors (odds ratio 2.06, CI 95% 1.23 to 3.43, p = 0.005). Conclusion: In this population based registry, patients with STEMI with prior use of COA constituted a fairly large group (4%) with an overall higher baseline risk profile than that of patients without COA. Fewer in the COA group received reperfusion therapy or aggressive antithrombotic treatment and they experienced more adverse in-hospital outcomes. Thus, further studies are warranted to develop specific management strategies for this high risk group.

To the Editor: The Ixodes ricinus tick is a predominant vector of a large variety of pathogens of veterinary and medical consequence in Europe (1). The most prevalent I. ricinus–borne infection of persons in Europe is Lyme borreliosis, a multisystemic disorder caused by spirochetes of the Borrelia burgdorferi sensu lato complex (2). Persons bitten by ticks can also become infected with many other pathogens, such as bacteria (Anaplasma spp., Francisella spp., Coxiella burnetii, Bartonella spp., Rickettsiae spp., and Neoerhlichia mikurensis); parasites (Babesia spp., Theileria spp.); and arboviruses (tick-borne encephalitis virus, Crimean-Congo hemorrhagic fever virus, and Eyach virus) (1). Symptoms induced by such pathogens are often diverse and nonspecific, complicating accurate diagnosis of the disease. In Romania, cases of Lyme disease and tick-borne encephalitis (caused by tick-borne encephalitis virus) have been identified (3). However, little is known about the public health impact of these diseases, and none of the other tick-borne pathogens present in Europe have been reported as causes of infection in Romania. Although I. ricinus is the most abundant and widespread tick in Romania (3), the public health impact of I. ricinus–borne disease is likely to be underestimated. Therefore, the first step in evaluating the distribution of these potential pathogens is to establish their presence in ticks from previously unexplored areas. We conducted a study to identify the main tick-borne bacterial and parasitic human pathogens known to be present in Europe but not previously detected in Romania. We tested for the presence of DNA from spotted fever group Rickettsia spp., Anaplasma spp., Francisella tularensis, and Babesia spp. in 147 I. ricinus ticks collected from roe deer and goats at 2 sites in eastern Romania: Bacau (46°35′0″N, 26°55′0″E) and Galati (45°26′22″N, 28°2′4″E). Specimens were tested by PCR, using specific primers for each pathogen or group of pathogens, as described (4). Sequences obtained from Eurofins MWG Operon (Ebersberg, Germany) were identified by using BLAST (www.ncbi.nlm.nih.gov/BLAST) and compared with sequences available in GenBank. DNA from Rickettsia spp. was detected in 20 (13.6%) ticks. Sequence analyses revealed that 9 (6.1%) sequences were related to the R. monacensis strain IRd/Serbia glta gene (99%–100% nt similarity) (GenBank accession no. {"type":"entrez-nucleotide","attrs":{"text":"GQ925820","term_id":"262181579","term_text":"GQ925820"}}GQ925820) and 11 (7.48%) were related to R. helvetica gltA gene (99%–100% nt similarity) (GenBank accession no. {"type":"entrez-nucleotide","attrs":{"text":"AM418450","term_id":"118918333","term_text":"AM418450"}}AM418450). DNA from Anaplasma spp. was identified in 33 (22.4%) ticks. Analysis revealed that 30 of the 33 amplified fragments showed 100% identity to the 16S rDNA gene of a symbiont in the family Anaplasmataceae, Candidatus Midichloria mitochondrii (GenBank accession no. {"type":"entrez-nucleotide","attrs":{"text":"EU780455","term_id":"190607147","term_text":"EU780455"}}EU780455), and the remaining 3 were related to known pathogenic species identified in Romania: 2 (1.4%) exhibited 100% identity to Anaplasma phagocytophilum (GenBank accession no. {"type":"entrez-nucleotide","attrs":{"text":"EU982548","term_id":"197360744","term_text":"EU982548"}}EU982548), and 1 (0.7%) showed 99% similarity to Ehrlichia muris (GenBank accession no. {"type":"entrez-nucleotide","attrs":{"text":"GU358691","term_id":"284975291","term_text":"GU358691"}}GU358691). Francisella tularensis–specific DNA was amplified from 4 DNA extracts (2.7%). All 4 sequences were identical and shared 99% similarity with the F. tularensis peptidyl-propyl cis-trans isomerase gene (GenBank accession no. {"type":"entrez-nucleotide","attrs":{"text":"CP003048","term_id":"377828067","term_text":"CP003048"}}CP003048). Babesia spp.–specific DNA was amplified in 1 DNA extract (0.7%), and it shared 99% sequence identity with the Babesia sp. EU1 18S rDNA gene (GenBank accession no. {"type":"entrez-nucleotide","attrs":{"text":"HQ830266","term_id":"317383279","term_text":"HQ830266"}}HQ830266). This is a report on the identification of the human pathogens R. monacensis, R. helvetica, A. phagocytophilum, E. muris, and Babesia EU1 in Romania. R. monacensis (also known as the Cadiz agent or Rickettsia IRS3 and IRS4) was first identified in I. ricinus tick samples from Germany (5) and was recently recognized as the cause of Mediterranean spotted fever-like rickettsiosis in Spain (6). R. helvetica was isolated from I. ricinus ticks in Switzerland in 1979, and, since then, it has been isolated in many other European countries (7). R. helvetica was associated with human infections in the late 1990s (8). The role of animals as reservoirs for these pathogens is unknown. A. phagocytophilum is the causative agent of granulocytic anaplasmosis in humans, cattle, horses, and dogs, and is widespread throughout Europe (8). E. muris has been detected in ticks from Finland and European Russia and from ticks and rodents from Slovakia. In 2009, E. muris was also detected in patients with febrile illness in the United States (9). Babesia sp. EU1 has been detected in roe deer and ticks in several countries, and in 2003 was associated with human disease in Italy and Austria (4,10). Tularemia is known to be present in Romania and is thought to be exclusively and directly transmitted by hares. However, detection of F. tularensis DNA in I. ricinus ticks suggests that this bacterium might also be tick-borne. In conclusion, the detection of DNA of various human pathogens in ticks in Romania strongly suggests that these microorganisms circulate in the country. Because all of these pathogens affect humans, our study highlights the urgent requirement for further research to assess their impact on public health in Romania.