French expert group proposal for lipid-lowering therapy in the first 3 months after acute myocardial infarction

In patients admitted for acute myocardial infarction (MI), it has been demonstrated that reducing LDL cholesterol (LDL-c) is associated with a reduction in major adverse cardiovascular events. We describe a consensual proposal made by a French group of experts for lipid-lowering therapy at the acute phase of acute myocardial infarction. A group of French experts comprising cardiologists, lipidologists and general practitioners prepared a proposal for a lipid-lowering strategy with a view to optimizing LDL-c levels in patients hospitalized for myocardial infarction. We describe a strategy for the use of statins, ezetimibe and and/or proprotein convertase subtilisin-kexin type 9 (PCSK9) inhibitors, with a view to reaching target LDL-c levels as early as possible. This approach, which is currently feasible in France, could considerably improve lipid management in patients after ACS, thanks to its simplicity, rapidity and the magnitude of the decrease in LDL-c that it achieves.

Lipid-lowering treatment up to one year after acute coronary syndrome: guidance from a French expert panel for the implementation of guidelines in practice

The management of patients with coronary artery disease (CAD) is complex, especially after they have been discharged from hospital after an acute coronary syndrome (ACS), because each patient may have numerous healthcare providers, and follow-up after discharge may be disjointed, or even incomplete. During follow-up after ACS, few patients have treatment intensification; rather, there is actually a major tendency towards reductions in treatment intensity, to the potential detriment of outcomes. We present here guidance from a French expert panel for the optimal management of lipid-lowering therapy up to 1 year after ACS. A French expert panel provides a practical guide for the implementation of guidelines for the management of post-ACS patients in routine practice, from hospital discharge up to one year after the index event, focusing in particular on the achievement of target LDL cholesterol (LDL-C) levels. We discuss the early follow-up (up to 6 months after discharge) and review the lipid-lowering treatment strategies that should be implemented. We discuss the evidence underpinning the prescription of proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors as well as recent evidence about icosapent ethyl. This review should facilitate implementation of a clear and effective lipid-lowering strategy for all patients after ACS. The panel recommends early use of high-intensity statins, in combination with ezetimibe for patients with LDL-c above 100 mg/dL at baseline. PCSK9i should be rapidly added during the first 3 months in high-risk diabetic patients with residual LDL-C above 70 mg/dL (with further benefit for those with residual LDL-C above ≥100 mg/dL) despite maximal tolerated dose statin and ezetimibe, patients with recent ACS, and patients with recurrent ischemic events under optimal medical therapy, multivessel coronary disease (MVD) and/or polyvascular disease (PVD), especially symptomatic PAD diabetic patients. Concerning icosapent ethyl (EPA), this drug should be introduced in patients ≥45 years of age with clinical atherosclerotic cardiovascular disease (ASCVD) or already on high-intensity or maximally tolerated statin therapy or with fasting triglycerides 135-499 mg/dL (with or without ezetimibe). Lipid-lowering treatment should be introduced as early as possible to obtain a rapid and profound decrease of LDL-c from baseline, using high-intensity statins (atorvastatin or rosuvastatin) and ezetimibe in fixed combination before discharge. Then, the strategy should be rapidly intensified by adding a PCSK9 inhibitor if the patient does not reach LDL-c levels below 55 mg/dL. We advocate this intensive strategy, which has demonstrated a further reduction in ischemic events, without safety concerns, even for patients who reach very low LDL-cholesterol levels. This approach, comprising few therapeutic steps, aims to rapidly reach LDL-c goals, improve patient compliance, and is an efficient method to fight therapeutic inertia, which remains a major issue.

High prevalence of unkown dysglycemia and chronotropic response to exercise in patients admitted in cardiac rehabilitation program

Funding Acknowledgements

Type of funding sources: None.

Introduction : Some studies suggest a high rate of unknown glycemic abnormalities in coronary patients. The aim of the study was to determine the prevalence of dysglycemia detected by oral glucose load (OGL)  in patients ongoing Cardiac Rehab , and to analyse chronotropic response to exercise before and after Cardiac rehab in dysglycemic patients.

Patients and methods : We included 838 patients, mostly coronary patients after acute coronary syndrome, including 79% men and 375 were diabetics. OGL has been performed in non-diabetics and ergospirometry test performed in all patients before and after rehabilitation.

Results : At OGL, 189 of 463 non-diabetics (41%) had dysglycemia: Diabetes (n = 42 including 17 according to fasting glycemia), Glucose intolerance (GI) (n = 102 including 32 with fasting hyperglycemia (FH),  FH isolated (n = 45). We compared 417 patients with known or discovered diabetes, GI and 319 normoglycemic or FH. Diabetics were older and had a higher BMI than GI and normoglycemic-FH (p <0.001). Resting heart rate (HR) was higher and maximal HR on exercise is lower in diabetics than other 2 groups (p <0.001) without significantly differing between GI and normoglycaemia-FH. VO2max was lower in diabetics and GI than normoglycemic-FH s (p <0.001 and 0.01). After cardiac rehabilitation, resting HR is changed little, HR max and VO2max increased in 3 groups but kept the same inter-group differences

Conclusion :This data confirms the high prevalence of unknown dysglycemia and the importance of OGL  for their screening, especially in coronary patients. In diabetics, the higher resting HR and the lack of chronotropic reserve probably indicate autonomic dysregulation which partially improves after cardiac rehabilitation.

Effect of an educational program (PEGASE) on cardiovascular risk in hypercholesterolaemic patients

BACKGROUND

Many studies have demonstrated a gap between guidelines for the prevention of cardiovascular disease (CVD) and their implementation in clinical practice.

AIM

The PEGASE education program has been devised with an aim to improve the management of patients at high risk of CVD.

METHODS

In a multicentre study carried out from 2001-2004 in France, 96 participating physicians were randomized into a "trained" group, which included 398 "educated" patients, and a "non-trained" group, which included 242 "non-educated" patients. Educated patients received six hospital-based educational sessions, four collective and two individual. Framingham score, smoking, lipid levels, glycaemia, blood pressure, dietary intake and drug compliance, as well as quality of life, were evaluated at baseline (M0) and 6 months (M6). The primary endpoint of the study was the efficacy of the PEGASE program in reducing global CVD risk in high-risk patients.

RESULTS

The Framingham score was calculated for 473 patients. The Framingham score improved significantly at M6 vs M0 in the educated group (13.0 +/- 8.21 vs 13.6 +/- 8.48, d = -0.658, p = 0.016), but not in the non-educated group (12.5 +/- 8.19 vs 12.4 +/- 7.81, d = +0.064, p = 0.836); the mean change between the two groups did not reach significance. Quality of life, LDL-c level and diet scores improved in the "educated" group only.

CONCLUSIONS

The PEGASE education program improved risk factors for CVD, although global assessment by Framingham score was not significantly different between groups. This program, aimed at meeting needs and expectations of patients and physicians, was easily implemented in all hospital centres.

Environmental tobacco smoke exposure in public places of European cities

BACKGROUND

Exposure to environmental tobacco smoke (ETS) has important public health implications. The results of the first European multi-centre study that measured ETS exposure in a range of public places (transport, educational settings, and leisure facilities such as bars and restaurants) are presented.

METHOD

Nicotine vapour phase was measured using ETS passive samplers containing a filter treated with sodium bisulfate.

RESULTS

Bars and discos are the places with the highest concentrations of nicotine from ETS, median ranging from 19 to 122 microg/m(3). Restaurants had the next highest values. Concentrations of nicotine generally range from 0.1-5 microg/m(3) in airports, and from 0.5-10 microg/m(3) in train stations. Nicotine was also found in schools and universities, yet schools tended to have the lowest concentrations compared to all the other public places sampled. In hospitals levels were generally below 5 microg/m(3).

CONCLUSIONS

Although there is some variability between cities, this study shows that tobacco smoke is present in most of the studied public places. The study also showed that in areas where smoking is prohibited, concentrations of nicotine are lower than in areas where smoking is allowed but they are not zero. The results of this study indicate that policies should be implemented that would effectively reduce levels of tobacco smoke in public areas.

[Smoking in teenagers: a priority issue]

In France, the age that young people light up the first cigarette is particularly early, and thus in terms of public health tobacco use among the youth represents a high stake in the epidemiological projections of the mortality rate of illnesses linked to tobacco for the next twenty years. Measures to "deregulate" tobacco in society must intensify in association with programs that assist the breaking of tobacco dependence among those who have already begun to smoke. In adolescents, the best known treatment is to never start smoking, and to achieve this, what is needed are information campaigns on health education, well-adapted and solidly anchored in the public school curriculum, as well as the accompanying application of existing "deregulation" measures.