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Background: Current data are lacking for incidence, correlates, and prognosis associated with incident myocardial infarction (MI) in patients with stable coronary artery disease (CAD). Furthermore, the contribution of very late stent thrombosis (VLST) to these events remains poorly understood.Objectives: This study aimed to analyze the residual risk of MI, together with relevant associated factors, and related mortality in stable CAD outpatients.Methods: The multicenter CORONOR (Suivi d'une cohorte de patients COROnariens stables en region NORd-Pas-de-Calais) study enrolled 4,184 unselected outpatients with stable CAD (i.e., MI or coronary revascularization >1 year previously). Five-year follow-up was achieved for 4,094 patients (98%).Results: We identified a linear risk of incident MI (0.8% annually), with ST-segment elevation MI constituting one-third of all cases. Current smoking, low-density lipoprotein cholesterol, multivessel CAD, diabetes with glycosylated hemoglobin >7%, and persistent angina were all associated with increased risk, and prior bypass surgery was associated with decreased risk. When used as a time-dependent variable, incident MI was associated with an increased risk of death (hazard ratio: 2.05; p < 0.0001). Among patients with prior stent implantation, VLST was causal in 20% of MI cases and presented more often as ST-segment elevation MI versus MI not related to a stented site (59% vs. 26%, p = 0.001). Adjusted mortality was 4 times higher in patients with VLST than in MI not related to a stented site.Conclusions: In stable CAD outpatients, incident MI occurs at a stable rate of 0.8% annually, is related to VLST in one-fifth of cases, and is associated with an increased mortality risk, especially for VLST. Multivessel CAD and residual uncontrolled risk factors are strongly associated with MI. [ABSTRACT FROM AUTHOR]

Background Although there is evidence that patients who experience major bleeding after an acute coronary event are at higher risk of death in the months after the event, the incidence and impact on outcome of bleeding beyond 1 year of follow-up in patients with stable coronary artery disease (CAD) are largely unknown. Objectives The goal of this study was to assess the incidence, source, determinants, and prognostic impact of major bleeding in stable CAD. Methods We prospectively included 4,184 consecutive CAD outpatients who were free from any myocardial infarction (MI) or coronary revascularization for >1 year at inclusion. Follow-up was performed at 2 years, with major bleeding defined as a type ≥3 bleed using the Bleeding Academic Research Consortium (BARC) definition. Results There were 51 major bleeding events during follow-up (0.6%/year). Most events were BARC type 3a bleeds with 12 fatal bleeds (type 5). In most cases (54.9%), the site of bleeding was gastrointestinal. Major bleeding was significantly associated with mortality (adjusted hazard ratio: 2.89; 95% confidence intervals: 1.73 to 4.83; p < 0.0001). The increased risk of bleeding associated with vitamin K antagonist (VKA) treatment was particularly evident when VKA was combined with an antiplatelet therapy (APT). In contrast, the risk of cardiovascular death, MI, or nonhemorrhagic stroke did not differ in patients who received VKA + APT versus patients on VKA alone. Conclusions In patients with stable CAD (i.e., >1 year, with no acute events), major bleeding events are rare, but such events are an independent predictor of death. When oral anticoagulation is required, concomitant APT should not be prescribed in the absence of a recent cardiovascular event. [ABSTRACT FROM AUTHOR]

There are limited data on the prognosis of patients with stable coronary artery disease (CAD) in modern clinical practice. We conducted a multicenter study enrolling 4,184 outpatients with stable CAD defined as previous myocardial infarction (>1 year ago), previous coronary revascularization (>1 year ago), and/or ≥50% coronary stenosis by angiography. Clinical follow-up was performed after 2 years. All cases of death were adjudicated and the mortality rate was compared with expected mortality of persons of the same age and gender in the same geographical area. Mean age was 66.9 - 11.6 years; 77.7% were men. There was a wide prescription of secondary prevention drugs: antithrombotic drugs, 99.3%; b blockers, 79.4%; statins, 92.2%; and antagonists of the angiotensin system, 81.9%. Two-year follow-up was obtained for 99.2% of the patients. There were 271 deaths (3.3/100 patient-years). The mortality rate was similar to the expected mortality in the general population (p= 0.93). Most deaths were noncardiovascular (1.8/100 patient-years). Among cardiovascular deaths, the leading causes were heart failure death (0.4/100 patientyears) and sudden death (0.4/100 patient-years); in contrast, there were few deaths related to vascular causes (stroke, 0.2/100 patient-years and myocardial infarction, 0.1/100 patientyears). Age, diabetes, multivessel CAD, the absence of previous coronary revascularization, previous hospitalization for decompensated heart failure, a low ejection fraction, a low estimated glomerular filtration rate, and the absence of statin treatment were independent predictors of mortality. In conclusion, the mortality rate of patients with stable CAD in modern clinical practice is similar to that of the general population and is mostly due to noncardiovascular causes. [ABSTRACT FROM AUTHOR]

Stress cardiomyopathies have been increasingly reported these last years, especially in women as a transient left ventricular apical ballooning syndrome. We report six cases in whom, in the context of anxious situations, echocardiograms and ventriculographies revealed mid-ventricular akinesis with preservation of apical and basal contractilities with normal coronary arteriography. This “mid-ventricular ballooning heart syndrome ” should probably be classified as a new type of heart stress related syndrome. [ABSTRACT FROM AUTHOR]

Left ventricular (LV) remodeling after acute myocardial infarction (AMI) has been well described in previous studies. However, there is a paucity of data on the incidence of and risk factors for LV remodeling in modern clinical practice that incorporates widespread use of acute reperfusion strategies and almost systematic use of “antiremodeling” medications, such as angiotensin-converting enzyme inhibitors and β blockers. We enrolled 266 patients with anterior wall Q-wave AMI who had ≥3 segments of the infarct zone that were akinetic on echocardiography before discharge. Echocardiographic follow-up was performed 3 months and 1 year after AMI. LV volumes, ejection fraction, wall motion score index, and mitral flow velocities were determined in a blinded analysis at a core echocardiographic laboratory. Acute reperfusion was attempted in 220 patients (83%; primary angioplasty in 29% and thrombolysis in 54%). During hospitalization, 99% of patients underwent coronary angiography and 87% underwent coronary stenting of the infarct-related lesion. At 1 year, 95% of patients received an antiplatelet agent, 89% a β blocker, 93% an angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker, and 93% a statin. Echocardiographic follow-up was obtained in 215 patients. There was recovery in LV systolic function as shown by a decrease in wall motion score index and an increase in ejection fraction. There was a significant increase in end-diastolic volume (EDV; 56.4 ± 14.7 ml/m2 at baseline, 59.3 ± 15.7 ml/m2 at 3 months, 62.8 ± 18.7 ml/m2 at 1 year, p <0.0001). LV remodeling (>20% increase in EDV) was observed in 67 patients (31%). Peak creatine kinase level, systolic blood pressure, and wall motion score index were independently associated with changes in EDV. In conclusion, recent improvements in AMI management do not abolish LV remodeling, which remains a relatively frequent event after an initial anterior wall AMI. [Copyright &y& Elsevier]

We investigated whether a high white blood cell (WBC) count on admission for acute myocardial infarction (AMI) may be associated with a higher risk of subsequent left ventricular (LV) remodeling. We included 107 patients with anterior AMI. Echocardiographic studies were performed at hospital discharge, at 3 months, and at 1 year after AMI. LV remodeling (>20% increase in end-diastolic volume) was observed in 27% of patients. WBC counts during hospitalization were higher in patients who subsequently underwent LV remodeling (p = 0.003 for WBC count on admission). The increase in end-diastolic volume from baseline to 1 year was greater for patients in the higher tertile of WBC count on admission (p = 0.04). When adjusting for baseline clinical and echocardiographic characteristics by multivariate analysis, WBC count on admission was independently associated with LV remodeling (odds ratio 1.23, 95% confidence interval 1.04 to 1.45, p = 0.018). In conclusion, a high WBC count on admission for AMI is an independent predictor of LV remodeling, even when predischarge echocardiographic variables are taken into account. [Copyright &y& Elsevier]

En France, les dépenses courantes de santé représentaient, en 2016, 266,6 milliards par an. Par ailleurs, les complications induites par les thérapeutiques seraient devenues la troisième cause de morbimortalité après les maladies cardiovasculaires et les cancers. La première angioplastie coronaire percutanée est réalisée en 1977. Le pronostic du syndrome coronaire aigu a été radicalement transformé par l'angioplastie coronaire et les puissants traitements antiplaquettaires. En 2014, environ 226 angioplasties coronaires/100 000 habitants sont recensées en France, la majorité des procédures étant effectuées en situation de maladie coronaire stable, alors qu'aucune étude randomisée n'a démontré à ce jour, dans ce cadre, la supériorité de l'angioplastie coronaire sur un traitement médical optimal en termes de mortalité ou de survenue d'infarctus du myocarde. Le bénéfice d'un dépistage systématique de la maladie coronaire chez les patients asymptomatiques avec fonction ventriculaire normale, diabétiques ou non, n'est pas non plus démontré. Surdiagnostic et surtraitement contribuent, au moins en partie, à l'augmentation constante du nombre de stents par habitant. Dans l'attente des résultats de l'essai prospectif randomisé international ISCHEMIA, des mesures « fortes » de prévention cardiovasculaire – incluant la lutte contre la sédentarité, le tabagisme et la « malbouffe » – sont nécessaires au niveau de la population. Enfin, une meilleure rationalisation de l'offre de soins et de la tarification à l'acte, ainsi qu'une régulation de la prescription des actes devraient être mises en place de façon urgente par les gouvernements sous peine d'une faillite définitive de notre système de santé. [ABSTRACT FROM AUTHOR]

Background: Clopidogrel use as single antiplatelet therapy (SAPT) has never been evaluated in stable coronary artery disease (CAD) outpatients either as compared to placebo or aspirin. Methods: We therefore studied 2,823 outpatients included in a prospective registry. The patients were divided into 2 groups according to their antiplatelet therapy regimen: patients treated with clopidogrel were compared with those treated with aspirin alone. Results: The mean time since CAD diagnosis was 7.9 years. Altogether, 776 (27.5%) patients received clopidogrel as SAPT. Factors independently associated with clopidogrel use were prior aortic or peripheral intervention, drug-eluting stent implantation, stroke, carotid endarterectomy and time since CAD diagnosis. Clopidogrel tended to be used in higher-risk patients: composite of cardiovascular death, myocardial infarction or stroke at 5.8 versus 4.2% (p = 0.056). However, after propensity score matching, similar event rates were observed between the groups: 5.9% when treated with clopidogrel versus 4.4% with aspirin (p = 0.207). The rate of bleeding was also similar between the groups. Conclusions: Our study shows that a significant proportion of stable CAD patients are treated with clopidogrel as SAPT in modern practice. Several correlates of such an attitude were identified. Our results suggest that this strategy is not beneficial as compared to aspirin alone in terms of ischaemic or bleeding events. [ABSTRACT FROM AUTHOR]

Objective: To assess the association of ß-blocker use with cardiovascular mortality in patients with stable coronary artery disease (CAD). Methods: We analysed the data of 4184 outpatients included in a prospective cohort study on stable CAD. Two groups were formed based on ß-blocker use at enrolment. Two propensity score analyses were performed to control for differences in covariates: one with adjustment among the entire cohort, and the other with propensity score matching. The outcome variable was cardiovascular mortality after a 2-year follow-up. Results: There were 3320 patients with ß-blocker use. Younger age, hypertension, diabetes, prior myocardial infarction, multivessel CAD, prior coronary revascularisation, prior stroke, prior hospitalisation for heart failure and a low LVEF were associated with ß-blocker use. Clinical follow-up data were obtained for 4149 patients (99.2%). When adjusted on propensity score, ß-blocker use was associated with a HR for cardiovascular mortality of 0.64 (0.42-0.98) in the whole cohort (p=0.04). After one-to-one propensity score matching, both groups (n=839 in each group) were well matched on covariates. The cardiovascular mortality rate in the propensity-matched cohort was significantly lower in patients with ß-blocker use with a HR of 0.43 (0.22-0.82) (p=0.011). Non-cardiovascular mortality was similar in both groups. These results were consistent across different subgroups. Conclusions: In this observational study of patients with stable CAD, the use of ß-blockers was associated with a lower risk of cardiovascular mortality. [ABSTRACT FROM AUTHOR]

Left ventricular (LV) remodeling after myocardial infarction (MI) indicates a high risk of heart failure and death. However, LV remodeling is difficult to predict, and limited information is available on the association of cardiac biomarkers with LV remodeling. Our aim was to study the association of B-type natriuretic peptide (BNP), cardiac troponin I (cTnI), and C-reactive protein with LV remodeling after MI. We designed a prospective multicenter study including 246 patients with a first anterior Q-wave MI. Serial echocardiographic studies were performed at hospital discharge and 3 months and 1 year after MI; quantitative analysis was performed at a core echocardiographic laboratory. Blood samples for determination of BNP, cTnI, and C-reactive protein levels were obtained at hospital discharge and the 1-month, 3-month, and 1-year follow up visits. One-year echocardiographic follow-up was obtained in 226 patients. End-diastolic volume increased from 52.3 ± 13.8 ml/m2 at baseline to 62.3 ± 18.4 ml/m2 at 1 year (p <0.0001); LV remodeling (>20% increase in end-diastolic volume) was observed in 87 patients (38%). At baseline, we found significant univariate relations between LV remodeling and the 3 biomarkers. During follow-up, high BNP levels and persistently detectable levels of cTnI were associated with LV remodeling. In multivariate analysis, none of the 3 biomarkers at baseline was independently predictive of LV remodeling. In contrast, during follow-up, high BNP and positive cTnI were independently associated with LV remodeling. In conclusion, circulating cardiac biomarkers may reflect pathophysiologic processes implicated in LV remodeling after MI. Determination of BNP and cTnI during follow-up can help refine risk stratification. [Copyright &y& Elsevier]

Introduction: Incident heart failure (HF), ischemic stroke and systemic embolism (IS/SE), and major bleeding related to anticoagulation therapy are still the most frequent events occurring in patients with atrial fibrillation (AF). The aim of this study was to assess the 3-year incidence, predictors, and related mortality of IS/SE, major bleeding, and HF in a large cohort of AF outpatients. Methods and results: We studied 4973 outpatients with prevalent AF included in the CARDIONOR registry. The mean age was 72.9 ± 11.2 years, 24.1% had diabetes mellitus and 78.9% had anticoagulant therapy at baseline. The mean CHA2DS2Vasc score was 3.4 ± 1.7. After a median follow-up of 3.2 years (IQR: 2.8 to 3.5), incident HF, IS/SE and major bleeding occurred in 10.5%, 3.3% and 2.1% of patients, respectively. When analyzed as time-dependent variables, IS/SE, major bleeding and hospitalization for decompensated HF were all strongly associated with mortality. The independent predictors of incident HF were age, women, hypertension, diabetes mellitus, coronary artery disease and a previous history of HF. A sensitivity analysis in patients without history of HF at inclusion revealed that incident HF remained the most frequent adverse event, occurring in 5.3% of patients, compared to IS/SE (1.7%) and major bleeding (2.5%). Conclusion: HF is a common residual cardiovascular adverse event occurring in AF outpatients and is associated with a very high mortality. Since modifiable risk factors are associated with incident HF, upstream intensive management of these risk factors would be of interest. [ABSTRACT FROM AUTHOR]

Background: The risk, correlates, and consequences of incident atrial fibrillation (AF) in patients with chronic coronary artery disease (CAD) are largely unknown. Methods and results: We analyzed incident AF during a 3-year follow-up in 5031 CAD outpatients included in the prospective multicenter CARDIONOR registry and with no history of AF at baseline. Incident AF occurred in 266 patients (3-year cumulative incidence: 4.7% (95% confidence interval (CI): 4.1 to 5.3)). Incident AF was diagnosed during cardiology outpatient visits in 177 (66.5%) patients, 87 of whom were asymptomatic. Of note, 46 (17.3%) patients were diagnosed at time of hospitalization for heart failure, and a few patients (n = 5) at the time of ischemic stroke. Five variables were independently associated with incident AF: older age (p < 0.0001), heart failure (p = 0.003), lower left ventricle ejection fraction (p = 0.008), history of hypertension (p = 0.010), and diabetes mellitus (p = 0.033). Anticoagulant therapy was used in 245 (92%) patients and was associated with an antiplatelet drug in half (n = 122). Incident AF was a powerful predictor of all-cause (adjusted hazard ratio: 2.04; 95% CI: 1.47 to 2.83; p < 0.0001) and cardiovascular mortality (adjusted hazard ratio: 2.88; 95% CI: 1.88 to 4.43; p < 0.0001). Conclusions: In CAD outpatients, real-life incident AF occurs at a stable rate of 1.6% annually and is frequently diagnosed in asymptomatic patients during cardiology outpatient visits. Anticoagulation is used in most cases, often combined with antiplatelet therapy. Incident AF is associated with increased mortality. [ABSTRACT FROM AUTHOR]