Acute coronary syndrome in patients treated by vitamin K antagonists or non-vitamin K antagonist oral anticoagulants: Proposed management algorithm for the first 48hours

Around 10% of patients with acute coronary syndrome are treated by vitamin K antagonists or non-vitamin K antagonist oral anticoagulants for various indications. The initial management of these patients is highly complex, and new guidelines specify that, only during percutaneous coronary intervention, a bolus of unfractionated heparin is recommended in one of the following circumstances: (1) if the patient is receiving a non-vitamin K antagonist oral anticoagulant; or (2) if the international normalized ratio is<2.5 in a patient being treated with a vitamin K antagonist. In this review, we report on five key messages essential for the management of these patients. There are no randomized studies to date, and we propose two diagnostic and/or therapeutic decision algorithms. However, randomized studies are needed to validate these strategies.

Guideline adherence in the management of acute pulmonary oedema: Study protocol for a French survey involving cardiologists, emergency physicians and intensivists

BACKGROUND

Because of their high morbidity and mortality, patients with acute pulmonary oedema (APE) require early recognition of symptoms, identification of precipitating factors and admission to specialized care units (cardiac critical care or intensive care). APE is at the crossroads of different specialties (cardiology, emergency medicine and intensive care medicine). Although multidisciplinary expertise and management may be a strength, it can also be a source of confusion, with unexpected heterogeneity in patient care. We hypothesized that the management of severe APE may be heterogeneous between specialties and, in some situations, may differ from international recommendations.

AIM

We designed a survey to compare management of different APE phenotypes according to the physicians' medical specialty, and to compare the results with what experts would do and European guidelines.

METHODS

Four clinical cases of typical APE with questions pertaining to the latest guidelines were designed by a Scientific Committee designated by the French Scientific Societies for Cardiology, Emergency Medicine and Intensive Care Medicine. We focused on oxygenation and ventilation strategies, management of precipitating factors, including timing of coronary revascularization, use of diuretics and management of diuretic resistance, and discharge coverage. From 20 June 2022 until 09 September 2022, the four cases of APE (two during hypertensive crises, two during acute coronary syndromes) were proposed to French physicians involved in APE care, and to experts, using an open online survey. To avoid any diagnostic ambiguity, the diagnosis of APE was given at the beginning of each clinical case.

RESULTS

The intention is to present the results at national and international conferences and publish them in a peer-reviewed journal.

CONCLUSIONS

The results of this survey are intended to pave the way for the generation of novel hypotheses for future clinical trials in case of equipoise between subsets of therapeutic procedures in APE.

Secondary Prevention Therapies in Real-World Patients with Myocardial Infarction: Eligibility Based on Randomized Trials Supporting European and American Guidelines

OBJECTIVE

We aimed to evaluate the applicability of the eligibility criteria of randomized controlled trials (RCTs) cited in guideline recommendations in a real-world cohort of patients receiving secondary prevention after acute myocardial infarction from the EPICOR registries.

METHODS

Recommendations provided by American and European guidelines for acute myocardial infarction were classified into general (applying to all patients) and specific (applying to patients with left ventricular dysfunction or heart failure). Randomized controlled trials cited in these recommendations were selected, and their entry criteria were applied to our international cohort of 18,117 patients.

RESULTS

There were 91.5% patients eligible for beta blockers (84.6% for general, and 5.9% for specific recommendations), 97.7% eligible for renin-angiotensin system inhibitor (angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers [ACEI/ARB]) recommendations (69.9% for general, 27.9% for specific) and 4.1% eligible for mineralocorticoid receptor antagonists (only specific recommendations). The percentages of patients with eligibility criteria who were discharged with a prescription of the recommended therapies were 80%-85% for beta blockers, 70%-75% for ACEI/ARB, and 29% for mineralocorticoid receptor antagonists. There were large regional variations in the percentage of eligible patients and in those receiving the medications (eg, 95% in Northern Europe and 57% in Southeast Asia for beta blockers).

CONCLUSION

Most real-world acute myocardial infarction patients are eligible for secondary prevention therapy in both general and specific guideline recommendations, and the percentage of those on beta blockers and ACEI/ARB at hospital discharge is high. There are large regional variations in the proportion of patients receiving recommended therapies. Local targeted interventions are needed for quality improvement.

Recalled body silhouette trajectories over the lifespan and oral conditions in adulthood: A cross-sectional analysis of the Paris Prospective Study 3

OBJECTIVES

To examine the association between life-course body silhouette changes and oral conditions in adulthood.

METHODS

At study recruitment (2008-2012), 5430 adults underwent a full-mouth clinical examination and recalled their body silhouettes at ages 8, 15, 25, 35 and 45. Life-course trajectories of body silhouettes were computed using group-based trajectory modelling. Gingival inflammation, dental plaque, masticatory units, numbers of healthy, missing, decayed and filled teeth at study recruitment were clustered. The associations between body silhouette trajectories and clusters of oral conditions were assessed by multinomial logistic regression.

RESULTS

The final analysis included 4472 participants. Five body silhouette trajectories were established: lean-stable (30.0%), lean-increased (19.3%), moderate stable (18.1%), lean-marked increased (25.8%) and heavy stable (6.7%). Three clusters of oral conditions were identified: optimal oral health and preserved masticatory capacity (70.0%, cluster 1), moderate oral health and moderately impaired masticatory capacity (25.4%, cluster 2) and poor oral health and severely impaired masticatory capacity (4.7%, cluster 3). Participants with a lean-increased trajectory were 58% more likely than those with a lean-stable trajectory to be in cluster 3 (aOR 1.58 [95% CI 1.07; 2.35]) relative to cluster 1, independently of covariates measured at study recruitment and including age, sex, smoking, socioeconomic status, BMI, hypertension, type 2 diabetes, cholesterol and triglycerides.

CONCLUSIONS

A life-course lean-increased body silhouette trajectory is associated with higher likelihood of poor oral health and severely impaired masticatory capacity in adulthood.

Coronary artery embolism and acute coronary syndrome: A critical appraisal of existing data

The occurrence of coronary artery embolism (CE) has been associated with various clinical conditions, including aortic and mitral prosthetic heart valve implantation, atrial fibrillation (AF), dilated cardiomyopathy, neoplasia, infective endocarditis, atrial septal defect, cardiac tumors, and hypercoagulable states. CE is also a rare cause of myocardial infarction (MI), with a prevalence of about 5%, a figure probably underestimated. The purpose of this article was to determine the current state of knowledge on acute coronary syndrome (ACS) related to CE. We thus performed a comprehensive structured literature search of the MEDLINE database for articles published between 1 January 1990 and 31 December 2021. The diagnosis of CE remains difficult despite the currently used Shibata classification, which is based on major criteria, including angiographic characteristics: globular filling defects, saddle thrombi or multiple filling defects and absence of atherosclerosis in the coronary arteries. Suspected or confirmed CE requires the identification of an etiology. There are only two published series on CE, including about 50 cases each. The three main causes in these series were: 1) atrial fibrillation (73% vs 28.3%), 2) cardiomyopathy (9.4% vs 25%) and 3) malignancy (9.6% vs 15.1%). Finally, 26.3% of the MI patients with CE had no identifiable cause of CE. When anatomically possible, analyzing the thrombus after thrombectomy may help. MI due to CE requires systematic assessment of other locations, i.e. multiple coronary and extracardiac locations. Simultaneous systemic embolization to the brain (67%), limbs (25%), kidneys (25%) or spleen (4%) is frequent, occurring in approximately 25% of CE-related MI. In the setting of acute MI, CE is associated with significant morbidity and mortality. Coronary artery thromboembolism is a rare, non-atherosclerotic, cause of ACS, and prospective studies are needed to evaluate a systematic diagnostic approach and personalized therapeutic strategies.

Healthy sleep score changes and incident cardiovascular disease in European prospective community-based cohorts

BACKGROUND AND AIMS

Evidence on the link between sleep patterns and cardiovascular diseases (CVDs) in the community essentially relies on studies that investigated one single sleep pattern at one point in time. This study examined the joint effect of five sleep patterns at two time points with incident CVD events.

METHODS

By combining the data from two prospective studies, the Paris Prospective Study III (Paris, France) and the CoLaus|PsyCoLaus study (Lausanne, Switzerland), a healthy sleep score (HSS, range 0-5) combining five sleep patterns (early chronotype, sleep duration of 7-8 h/day, never/rarely insomnia, no sleep apnoea, and no excessive daytime sleepiness) was calculated at baseline and follow-up.

RESULTS

The study sample included 11 347 CVD-free participants aged 53-64 years (44.6% women). During a median follow-up of 8.9 years [interquartile range (IQR): 8.0-10.0], 499 first CVD events occurred (339 coronary heart disease (CHD) and 175 stroke). In multivariate Cox analysis, the risk of CVD decreased by 18% [hazard ratio (HR) 0.82, 95% confidence interval (CI) 0.76-0.89] per one-point increment in the HSS. After a median follow-up of 6.0 years (IQR: 4.0-8.0) after the second follow-up, 262 first CVD events occurred including 194 CHD and 72 stroke. After adjusting for baseline HSS and covariates, the risk of CVD decreased by 16% (HR 0.84, 95% CI 0.73-0.97) per unit higher in the follow-up HSS over 2-5 years.

CONCLUSIONS

Higher HSS and HSS improvement over time are associated with a lower risk of CHD and stroke in the community.

Rationale and design of the direct oral anticoagulants for prevention of left ventricular thrombus after anterior acute myocardial infarction (APERITIF) trial

BACKGROUND

Anterior acute myocardial infarction (AMI) is associated with an increased risk of left ventricular (LV) thrombus formation. We hypothesized that adding low-dose oral rivaroxaban to the usual antiplatelet regimen would reduce the risk of LV thrombus in patients with large AMI.

STUDY DESIGN

APERITIF is an investigator-initiated, multicenter randomized open-label, blinded end-point (PROBE) trial, nested in the ongoing "FRENCHIE" registry, a French multicenter prospective observational study, in which all consecutive patients admitted within 48 hours of symptom onset in a cardiac Intensive Care Unit (ICU) for AMI are included (NCT04050956). Among them, patients with anterior ST-elevation-myocardial infarction (STEMI) or very high-risk non- ST-elevation-myocardial infarction (NSTEMI) patients with involvement of the left anterior descending artery are randomized into 2 groups: Dual Antiplatelet Therapy (DAPT) alone or DAPT plus rivaroxaban 2.5mg twice daily for 4 weeks, started as soon as possible after completion of the initial percutaneous coronary intervention/angiography procedure. The primary endpoint is the presence of LV thrombus at 1 month, as detected by contrast enhanced CMR (CE-CMR). Secondary endpoints include LV thrombus dimension (greatest diameter), the rate of major bleedings and major cardiovascular events at 1 month. Based on estimated event rates, a sample size of 560 patients is needed to show superiority of DAPT plus rivaroxaban therapy versus DAPT alone, with 80% power.

CONCLUSION

The APERITIF trial will determine whether, in patients with large AMIs, the use of rivaroxaban 2.5mg twice daily in addition to DAPT reduces LV thrombus formation, compared with DAPT alone.

CLINICALTRIALS

gov Identifier: NCT05077683.

Impact of transfusion strategy on platelet aggregation and biomarkers in myocardial infarction patients with anemia

BACKGROUND

Higher rates of thrombotic events have been reported in myocardial infarction (MI) patients requiring blood transfusion. The impact of blood transfusion strategy on thrombosis and inflammation is still unknown.

OBJECTIVE

To compare the impact of a liberal vs. a restrictive transfusion strategy on P2Y12 platelet reactivity and biomarkers in the multicentric randomized REALITY trial.

METHODS

Patients randomized to a liberal (hemoglobin ≤10 g/dL) or a restrictive (hemoglobin ≤8 g/dL) transfusion strategy had VASP-PRI platelet reactivity measured centrally in a blinded fashion and platelet reactivity unit (PRU) measured locally using encrypted VerifyNow; at baseline and after randomization. Biomarkers of thrombosis (P-selectin, PAI-1, vWF) and inflammation (TNF-α) were also measured. The primary endpoint was the change in the VASP-PRI (difference from baseline and post randomization) between the randomized groups.

RESULTS

A total of 100 patients randomized were included in this study (n = 50 in each group). Transfused patients received on average 2.4 ± 1.6 units of blood. We found no differences in change of the VASP PRI (difference 1.2% 95% CI (-10.3-12.7%)) or by the PRU (difference 13.0 95% CI (-21.8-47.8)) before and after randomization in both randomized groups. Similar results were found in transfused patients (n = 71) regardless of the randomized group, VASP PRI (difference 1.7%; 95% CI (-9.5-1.7%)) or PRU (difference 27.0; 95% CI (-45.0-0.0)). We did not find an impact of transfusion strategy or transfusion itself in the levels of P-selectin, PAI-1, vWF, and TNF-α.

CONCLUSION

In this study, we found no impact of a liberal vs. a restrictive transfusion strategy on platelet reactivity and biomarkers in MI patients with anemia. A conclusion that should be tempered due to missing patients with exploitable biological data that has affected our power to show a difference.

Impact of standard modifiable cardiovascular risk factors on 2-year all-cause mortality: Insights from an international cohort of 23,489 patients with acute coronary syndrome

BACKGROUND

Controversial findings have been reported in the literature regarding the impact of the absence of standard modifiable cardiovascular risk factors (SMuRFs) on long-term mortality risk in patients with acute coronary syndrome (ACS). While the prognostic additive value of SMuRFs has been well described, the prognostic role of prior cardiovascular disease (CVD) by sex is less well-known in patients with and without SMuRFs.

METHODS

EPICOR and EPICOR Asia are prospective, observational registries conducted between 2010 and 2014, which enrolled ACS patients in 28 countries across Europe, Latin America, and Asia. Association between SMuRFs (diabetes, dyslipidaemia, hypertension, and smoking) and 2-year postdischarge mortality was evaluated using adjusted Cox models stratified by geographical region.

RESULTS

Among 23,489 patients, the mean age was 60.9 ± 11.9 years, 24.3% were women, 4,582 (20.1%) presented without SMuRFs, and 16,055 (69.5%) without prior CVD. Patients with SMuRFs had a higher crude 2-year postdischarge mortality (HR 1.86; 95% CI, 1.56-2.22; P < .001), compared to those without SMuRFs. After adjustment for potential confounding, the association between SMuRFs and 2-year mortality risk was substantially attenuated (HR 1.17, 95% CI 0.98-1.41; P = .087), regardless of the type of ACS. The risk conferred by prior CVD was added to the underlying risk of SMuRFs to provide risk-specific phenotypes (eg, women with SMuRFs and with prior CVD were at higher risk of dying than women without SMuRFs and without CVD; HR 1.67, 95% CI 1.34-2.06).

CONCLUSIONS

In this large-scale international ACS cohort the absence of SMuRFs was not associated with a lower adjusted 2-year postdischarge mortality risk. Patients with both SMuRFs and prior CVD had a higher mortality irrespective of their sex.

Obstructive sleep apnea, circulating microRNAs, and risk of cardiovascular disease

OBJECTIVE

while obstructive sleep apnea is strongly associated with incident cardiovascular diseases (CVD), the underlying mechanisms remain to be elucidated. This study aimed to compare the patterns of microRNAs expression between OSA and control patients with and without incident CVD.

METHODS

218 matched adult participants with and without OSA and with and without incident CVD were selected from two independent community-based prospective cohorts in France and Switzerland, and 168 microRNAs on average were detected per sample. OSA was diagnosed using the validated Berlin questionnaire in one study (Paris Prospective Study 3) and during a full-night polysomnography in the second study (HypnoLaus Study).

RESULTS

there were 78 OSA patients (39 with and 39 without CVD) and 140 controls (70 with and 70 without CVD). Participants were male in 54.6% (n = 119) and mean age was 58.7 years (±9.2). Of the 183 miRNAs screened, a mean 168 assays were detected per sample, and 129 in all samples. There was no pattern of blood microRNAs expression that discriminated OSA patients with and without CVD events.

CONCLUSIONS

this binational study failed to find any association between a large panel of microRNAs and OSA patients with and without incident CVD.

Association between coffee or tea consumption and cardiovascular outcomes in patients with stable coronary artery disease: Analysis from the CLARIFY registry

BACKGROUND

Conflicting data exist on the association between consumption of coffee or tea and cardiovascular outcomes, and few focus on patients with established coronary artery disease.

AIM

To describe the association between coffee or tea consumption and cardiovascular outcomes in patients with stable coronary artery disease, using an extensive contemporary international registry, allowing the identification of multiple potential confounders.

METHODS

The Prospective Observational Longitudinal Registry of Patients With Stable Coronary Artery Disease (CLARIFY) registry enrolled in 2009 and 2010 in 45 countries, with a 5-year follow-up. Patients were categorized according to daily consumption of coffee or tea, and were compared with those declaring neither. The primary composite outcome of myocardial infarction, stroke or cardiovascular death was analysed at 5years, as well as all-cause mortality. Sensitivity analyses were performed with a multivariable model.

RESULTS

A total of 15,459 and 10,029 patients declared coffee or tea consumption, respectively. At 5years, after full adjustment, no association was found between coffee consumption and the primary outcome: hazard ratio 1.04 (95% confidence interval 0.89-1.21) for 1 cup; 0.94 (0.82-1.08) for 2-3 cups; and 1.04 (0.86-1.27) for ≥4 cups (P=0.51). Drinking tea was not associated with a different incidence of the primary outcome before or after adjustment, with fully adjusted hazard ratios of 1.08 (95% confidence interval 0.84-1.38) for 1 cup, 1.12 (0.96-1.31) for 2-3 cups and 0.95 (0.79-1.14) for ≥4 cups (P=0.30). After full adjustment, neither coffee nor tea drinking was associated with all-cause mortality.

CONCLUSIONS

In outpatients with stable coronary artery disease, there was no association between coffee or tea consumption and ischaemic outcomes or all-cause mortality.

Very long-term outcomes after acute myocardial infarction in young men and women: Insights from the FAST-MI program

AIMS

Conflicting data exists about long-term outcomes in young women and men experiencing acute myocardial infarction (AMI).

METHODS

The FAST-MI program consists of three nationwide French surveys carried out 5years apart from 2005 to 2015, including consecutive patients with AMI over a 1-month period with up to 10-year follow-up. The present analysis focused on adults≤50 yo according to their gender.

RESULTS

Women accounted for 17.5% (335) of the 1912 patients under 50 yo and had a similar age as men (43.9±5.1 vs. 43.9±5.5years, P=0.92). They received less percutaneous coronary interventions (PCI) than men (85.9% vs. 91.3%, P=0.005), even in ST-elevation myocardial infarction (83.6% vs. 93.5%, P<0.001). Recommended secondary prevention medications were less frequently prescribed at discharge in women (40.6% vs. 52.8%, P<0.001), a trend that persisted in 2015 (59.1% vs. 72.8% in 2015, P<0.001). Still, ten-year survival was similar in men (90.5%) and women (92.3%) (crude HR: 0.86 [95% CI: 0.55-1.35], P=0.52, adjusted HR: 0.63 [95% CI: 0.38-1.07], P=0.09); similar results were found for ten-year survival among hospital survivors (91.2% in men vs. 93.7% in women, adjusted HR: 0.87 [95% CI: 0.45-1.66], P=0.66). Of the 1684 patients alive at hospital discharge with morbidity follow-up≥6months available, death, AMI or stroke at 8years occurred in 12.9% men and 11.2% in women (adjusted HR: 0.90 [95% CI: 0.60-1.33], P=0.59).

CONCLUSIONS

Young women with AMI undergo less cardiac interventions and are less often prescribed secondary prevention treatment than men, even when significant coronary artery disease is present, but keep a similar long-term prognosis after AMI. Optimal management of these young patients, regardless of gender, is necessary to ensure best outcomes after this major cardiovascular event.

Economic evaluation of restrictive vs. liberal transfusion strategy following acute myocardial infarction (REALITY): trial-based cost-effectiveness and cost-utility analyses

AIMS

To estimate the cost-effectiveness and cost-utility ratios of a restrictive vs. liberal transfusion strategy in acute myocardial infarction (AMI) patients with anaemia.

METHODS AND RESULTS

Patients (n = 666) with AMI and haemoglobin between 7-8 and 10 g/dL recruited in 35 hospitals in France and Spain were randomly assigned to a restrictive (n = 342) or a liberal (n = 324) transfusion strategy with 1-year prospective collection of resource utilization and quality of life using the EQ5D3L questionnaire. The economic evaluation was based on 648 patients from the per-protocol population. The outcomes were 30-day and 1-year cost-effectiveness, with major adverse cardiovascular events (MACEs) averted as the effectiveness outcome. and a 1-year cost-utility ratio.The 30-day incremental cost-effectiveness ratio was €33 065 saved per additional MACE averted with the restrictive vs. liberal strategy, with an 84% probability for the restrictive strategy to be cost-saving and MACE-reducing (i.e. dominant). At 1 year, the point estimate of the cost-utility ratio was €191 500 saved per quality-adjusted life year gained; however, the cumulated MACE was outside the pre-specified non-inferiority margin, resulting in a decremental cost-effectiveness ratio with a point estimate of €72 000 saved per additional MACE with the restrictive strategy.

CONCLUSION

In patients with AMI and anaemia, the restrictive transfusion strategy was dominant (cost-saving and outcome-improving) at 30 days. At 1 year, the restrictive strategy remained cost-saving, but clinical non-inferiority on MACE was no longer maintained.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02648113.

ONE SENTENCE SUMMARY

The use of a restrictive transfusion strategy in patients with acute myocardial infarction is associated with lower healthcare costs, but more evidence is needed to ascertain its long-term clinical impact.

Abstract 29: Change in Healthy Sleep Score and Incident Cardiovascular Disease: A Combined Analysis of Two Independent Community-Based Cohorts

Introduction: Evidence on the link between sleep habits and cardiovascular diseases (CVD) in the community predominantly relies on studies that have investigated only one sleep habit, measure at one timepoint. Therefore, this study examined the joint effect of five sleep habits at baseline and at follow-up with incident CVD events.

Hypothesis: We assessed the hypothesis that change in sleep habits over time including improvement in sleep habits and maintenance of a high level of sleep habits are related to reduced CVD risk.

Methods: We combined data from two large independent community-based cohorts, the Paris Prospective Study 3 (France) and the CoLaus/PsyCoLaus study (Switzerland), involving 11 347 participants in total, aged 53–64 and comprising 44.6% women, initially free from CVD at baseline (respectively 2008-2012 and 2003-2006). Information on participants’ sleep habits were collected twice (median time interval between the 2 time points=2.0; interquartile range [IQR]: 2.0-5.2) by validated questionnaires. A healthy sleep score (HSS) combining five sleep habits (early chronotype, sleep duration of 7-8 h/day, never/rarely insomnia, no sleep apnea, and no frequent excessive daytime sleepiness) was calculated at baseline and follow-up. Each sleep habit was scored 1 point if optimal, otherwise 0 point. The score ranged from 0 to 5, reflecting the number of optimal sleep habits. Associations of HSS at baseline and the change in the score over time with CVD events (coronary heart disease, CHD, or stroke) were examined using Cox proportional hazard models.

Results: During a median follow-up of 8.9 years (IQR: 8.0-10.0), 499 first CVD events occurred (339 CHD and 175 stroke). In multivariate Cox analysis, the risk of CVD decreased by 18% per one-point increment in the HSS (hazard ratio, HR=0.82 [95% confidence interval, CI, 0.76-0.89]). At follow-up, 38% remained in stable high score (score≥3 at both time points, the median of the baseline HSS), 11% had a stable low HSS (score<3 at both time points), 22% increased their scores and 29% decreased their scores respectively. After a median follow-up of 8.1 years (IQR: 8.0-10.0) following the second measure of the HSS, a total of 308 first CVD events occurred (227 CHD and 86 stroke). After adjusting for the baseline HSS and covariates, the risk of CVD decreased by 13% (HR=0.87 [0.76-0.99]) per unit of change in HSS. In particular, compared to participants with a decreasing HSS, those with a high stable HSS had a 39% decrease in CVD risk (HR=0.61 [0.45-0.81]). If all participants in this study had achieved a HSS of four and five, 29% and 60% of new CVD could have been avoided, respectively.

Conclusions: Higher HSS and increase in the HSS are associated with a lower risk of CHD and stroke in the community. This study supports the promotion of healthy sleep habits in the population and strong collaboration between sleep medicine and CVD medicine.

Care of patients with ST-elevation myocardial infarction: an international analysis of quality indicators in the acute coronary syndrome STEMI Registry of the EURObservational Research Programme and ACVC and EAPCI Associations of the European Society of Cardiology in 11 462 patients

AIMS

To use quality indicators to study the management of ST-segment elevation myocardial infarction (STEMI) in different regions.

METHODS AND RESULTS

Prospective cohort study of STEMI within 24 h of symptom onset (11 462 patients, 196 centres, 26 European Society of Cardiology members, and 3 affiliated countries). The median delay between arrival at a percutaneous cardiovascular intervention (PCI) centre and primary PCI was 40 min (interquartile range 20-74) with 65.8% receiving PCI within guideline recommendation of 60 min. A third of patients (33.2%) required transfer from their initial hospital to one that could perform emergency PCI for whom only 27.2% were treated within the quality indicator recommendation of 120 min. Radial access was used in 56.6% of all primary PCI, but with large geographic variation, from 76.4 to 9.1%. Statins were prescribed at discharge to 98.7% of patients, with little geographic variation. Of patients with a history of heart failure or a documented left ventricular ejection fraction ≤40%, 84.0% were discharged on an angiotensin-converting enzyme inhibitor/angiotensin receptor blocker and 88.7% were discharged on beta-blockers.

CONCLUSION

Care for STEMI shows wide geographic variation in the receipt of timely primary PCI, and is in contrast with the more uniform delivery of guideline-recommended pharmacotherapies at time of hospital discharge.

Ventricular fibrillation in acute myocardial infarction: 20-year trends in the FAST-MI study

AIMS

Sudden cardiac arrest remains a major complication of acute myocardial infarction (AMI) and is frequently related to ventricular fibrillation (VF). Incidence and impact of VF among patients hospitalized for AMI were evaluated.

METHODS AND RESULTS

Data from the FAST-MI programme consisting of 5 French nationwide prospective cohort studies between 1995 and 2015 were analysed, totally including 14 423 patients with AMI (66 ± 14 years, 72% males, 59% ST-elevation myocardial infarction). Overall, proportion of patients presenting in-hospital VF decreased from 3.9% in 1995 to 1.8% in 2015 (P < 0.001). One-year mortality decreased from 60.7% to 24.6% (P < 0.001). However, compared with patients who did not develop VF, the over-risk of 1-year mortality associated with VF was stable over time [hazard ratio (HR) 6.78, 95% confidence interval (CI) 5.03-9.14 in 1995 and HR 6.64, 95% CI 4.20-10.49 in 2015, P = 0.52]. This increased mortality in the VF group was mainly related to fatal events occurring prior to hospital discharge, representing 86.2% of 1-year mortality, despite the very low rate of implantable cardioverter defibrillator in the VF group (2.6%).

CONCLUSION

This study demonstrates that in-hospital VF incidence and mortality in the setting of AMI have significantly decreased over the past 20 years. Nevertheless, VF remained steadily associated with approximately a 10-fold increased relative risk of in-hospital mortality, without an impact on post-discharge mortality. Beyond long-term cardiac defibrillation strategy, these results emphasize the need to identify in-hospital interventions to further reduce mortality in VF patients.

STUDY REGISTRATION

ClinicalTrials.gov Identifier: NCT00673036, NCT01237418, NCT02566200.

Cohort profile: the ESC EURObservational Research Programme Non-ST-segment elevation myocardial infraction (NSTEMI) Registry

AIMS

The European Society of Cardiology (ESC) EURObservational Research Programme (EORP) Non-ST-segment elevation myocardial infarction (NSTEMI) Registry aims to identify international patterns in NSTEMI management in clinical practice and outcomes against the 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without ST-segment-elevation.

METHODS AND RESULTS

Consecutively hospitalised adult NSTEMI patients (n = 3620) were enrolled between 11 March 2019 and 6 March 2021, and individual patient data prospectively collected at 287 centres in 59 participating countries during a two-week enrolment period per centre. The registry collected data relating to baseline characteristics, major outcomes (in-hospital death, acute heart failure, cardiogenic shock, bleeding, stroke/transient ischaemic attack, and 30-day mortality) and guideline-recommended NSTEMI care interventions: electrocardiogram pre- or in-hospital, pre-hospitalization receipt of aspirin, echocardiography, coronary angiography, referral to cardiac rehabilitation, smoking cessation advice, dietary advice, and prescription on discharge of aspirin, P2Y12 inhibition, angiotensin converting enzyme inhibitor (ACEi)/angiotensin receptor blocker (ARB), beta-blocker, and statin.

CONCLUSION

The EORP NSTEMI Registry is an international, prospective registry of care and outcomes of patients treated for NSTEMI, which will provide unique insights into the contemporary management of hospitalised NSTEMI patients, compliance with ESC 2015 NSTEMI Guidelines, and identify potential barriers to optimal management of this common clinical presentation associated with significant morbidity and mortality.

Ultrasensitive Troponin I and Incident Cardiovascular Disease

BACKGROUND

To examine the association of ultrasensitive cTnI (cardiac troponin I) with incident cardiovascular disease events (CVDs) in the primary prevention setting.

METHODS

cTnI was analyzed in the baseline plasma (2008-2012) of CVD-free volunteers from the Paris Prospective Study III using a novel ultrasensitive immunoassay (Simoa Troponin-I 2.0 Kit, Quanterix, Lexington) with a limit of detection of 0.013 pg/mL. Incident CVD hospitalizations (coronary heart disease, stroke, cardiac arrhythmias, deep venous thrombosis or pulmonary embolism, heart failure, or arterial aneurysm) were validated by critical review of the hospital records. Hazard ratios were estimated per log-transformed SD increase of cTnI in Cox models using age as the time scale.

RESULTS

The study population includes 9503 participants (40% women) aged 59.6 (6.3) years. cTnI was detected in 99.6% of the participants (median value=0.63 pg/mL, interquartile range, 0.39-1.09). After a median follow-up of 8.34 years (interquartile range, 8.0-10.07), 516 participants suffered 612 events. In fully adjusted analysis, higher cTnI (per 1 SD increase of log cTnI) was significantly associated with CVD events combined (hazard ratio, 1.18 [1.08-1.30]). Among all single risk factors, cTnI had the highest discrimination capacity for incident CVD events (C index=0.6349). Adding log cTnI to the SCORE 2 (Systematic Coronary Risk Evaluation) risk improved moderately discriminatory capacity (C index 0.698 versus 0.685; bootstrapped C index difference: 0.0135 [95% CI, 0.0131-0.0138]), and reclassification of the participants (categorical net reclassification index, 0.0628 [95% CI, 0.023-0.102]). Findings were consistent using the US pooled cohort risk equation.

CONCLUSIONS

Ultrasensitive cTnI is an independent marker of CVD events in the primary prevention setting.

Very long-term outcomes after acute myocardial infarction in young men and women

Aims

There is a paucity of data on very long-term outcomes in young women and men experiencing acute myocardial infarction (AMI).

Methods and results

The FAST-MI program consists of three nationwide French surveys carried out 5 years apart from 2005 to 2015, including consecutive AMI patients over a 1-month period with up to 10-year follow-up. The present analysis focused on adults ≤50 yo according to their gender. Women accounted for 17.5% (N=335) of the 1912 patients under 50 yo and were as old as men (43.9±5.5 vs. 43.9±5.1yo, p=0.92). Non-significant coronary artery disease was more frequent in women (12.8% vs. 5.8%, P&lt;0.001). Women with significant coronary artery disease underwent less percutaneous coronary internvention (PCI) than men (85.9% vs. 91.3%, p=0.005), though primary PCI in ST-elevated myocardial infarction was as frequent in women (67.3% vs. 66.8%). Recommended secondary prevention medications were less prescribed at discharge in women (40.6% vs. 52.8%, p&lt;0.001), a trend that persisted in 2015 (59.1% vs. 72.8% in 2015, p&lt;0.001). Still, ten-year survival was similar in men (90.5%) and women (92.6%) (crude HR 0.87 [95% CI 0.55–1.57], adjusted HR 0.77 [95% CI 0.48–1.23], p=0.27) even among hospital survivors (adjusted HR 0.64 [95% CI 0.32–1.30], p=0.22). Ten-year survival was similar in patients with myocardial infarction with non-obstructive coronary arteries compared with those with significant coronary artery disease (91.8% vs. 91.0%, P=0.46)), both among men (91.6% vs. 90.7%) and women (92.9% vs. 93.0%). However, when taking into account early revascularization and discharge medications, in patients with significant coronary artery disease, adjusted 10-year mortality was significantly lower in women (HR 0.53, 95% CI 0.29–0.96, P=0.04).

Conclusions

Ten-year survival in young women with AMI is similar to that of men. However, in those with significant coronary artery disease, improving secondary prevention in women should result in better long-term outcome.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): French Society of Cardiology

Should dual antiplatelet therapy be maintained beyond one year after a myocardial infarction? A cohort study within the French SNDS nationwide claims database

Background

Dual antiplatelet therapy (DAPT), aspirin plus a P2Y12-i (clopidorel, prasugrel or ticagrelor), is recommended for one year after myocardial infarction (MI) for secondary prevention of cardiovascular disease (SP-CVD). Beyond one year maintaining DAPT is controversial.

Purpose

To compare the 3-year risk of a composite of MI, ischemic stroke (IS), major bleeding (MB) and death between DAPT and single antiplatelet therapy with aspirin (SAPT) beyond one year after MI.

Methods

All adults hospitalized in 2013 or 2014 for acute MI (trigger event) with intensive care unit stay were identified in the French SDNS nationwide claims database. Patients who survived at least one year without MI or MB, and with a DAPT medication possession ratio (MPR) ≥80% were included in a cohort study. All patients were followed for 3 years after the index date (defined 365 days after the MI trigger event), except right-censored observations for those who died or discontinued aspirin with a 60-day grace period. The 3-year hazard ratios (HR [95% CI]) were estimated using Cox proportional hazards risk model for outcomes including death, and Fine and Gray competing risks model for non-fatal outcomes, with a time-dependent variable for DAPT-SAPT exposure, and adjusted on a high-dimensional disease risk score (hdDRS) plus time dependent variables for SP-CVD drugs, oral antidiabetics, insulin, anticoagulants, NSAIDs, corticoids and proton pump inhibitors. HdDRS were estimated for the composite outcome, a composite of ischemic outcomes, and MB alone, and variables were selected using a combination of Principal Component Analysis and Lasso regression.

Results

From the 105,080 adults admitted in intensive care units for acute MI in 2013 or 2014, 53,399 were included in the cohort. The most common reasons for non-inclusion were death (n=12,012) and a DAPT MPR &lt;80% (n=25,000). At index date, mean age was 65 years, with 74.6% men, 21.8% diabetes, 9.4% heart failure, 5.6% peripheral arterial disease, 72.2% with DAPT score ≤2, 61.9% Charlson index ≤1; 79.2% had a STEMI trigger event and 82.6% had cardiac revascularization (PCI 98.6%). P2Y12-i used at least once from the trigger event to the index date were clopidogrel (41.5%), ticagrelor (41.1%) and prasugrel (26.2%). Follow-up was 111,770 person-years and 4,268 composite outcomes were recorded. The 3-year HR of DAPT compared to SAPT was 1.21 [1.13–1.30] for the composite of MI, IS, MB and death, 1.22 [1.07–1.38] for MI, 0.98 [0.80–1.20] for IS, 1.89 [1.55–2.30] for MB and 1.16 [1.06–1.27] for death.

Conclusions

In this nationwide real-life population-based study in France, DAPT maintained beyond one year after MI is significantly associated with increased harm compared to SAPT with increased risks of 21% (IC95% [13–30]) for the composite of MI, IS, MB and death (net clinical benefit), 22% [7–38] for MI, 89% [55–130] for MB, 16% [6–27] for death, and no difference for IS.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): French Ministry of Health (PHRCN-18-0745)

Metabolic syndrome and heart failure: 40 years follow up results of the Seven Countries Study

Introduction

Metabolic syndrome (Met Sy) as a highly debatable cluster of traditional risk factors is known to promote cardiometabolic-related morbidity and mortality, but its precise mechanisms remain to be determined.

Purpose

We sought to determine influence of MetSy on heart failure (HF) morbidity and mortality in the Seven Countries' Study as one of the oldest epidemiological studies.

Methods

The Seven Countries Study encompassed 12,763 participants from 3 continents who were all healthy men of over 40 years at baseline and who underwent regular check ups every 5 years throughout over a 4 decades' span. Morbidity and mortality was adjudicated according to valid ICD and LPH coding.

Results

Using the IDF definition of the Metabolic Syndrome, 9,09% of participants were identified (Figure 1). HF was confirmed in 220 patients (16.4% alive at 40y follow up visit), while 8.2% died of HF as well in the same time-frame (Tables 1 & 2). Presence of MetSy has been shown to significantly influence HF mortality (Figures 2) with lowest survival of 22% for 300 months of follow up for patients with both MetSy and HF (Log rank test=4.405, p&lt;0.0001).

Conclusion

Metabolic syndrome treatment remains in the realm of risk factors' control that now we know influence both ischemic heart disease and heart failure of other origins. Historically, just emerging biomarkers' and targeted imaging weren't available to determine such at the time of HF diagnosis. Also, the sample consisted of men only, mainly Caucasian and a modest proportion of Asian and African-American now known to carry ethnic-specific burden of cardiovascular disease. All of the above, emphasizes the importance of more diversity, equity and inclusion-dedicated long term both observational, as well as interventional research.

Funding Acknowledgement

Type of funding sources: None.

Ultra-sensitive troponin-I and incident coronary heart disease, stroke, heart failure, cardiac arrhythmias, arterial aneurysms and venous thromboembolism hospitalizations

Background

Cardiac troponin I (cTnI) as measured by high-sensitive assays has been related to incident cardiovascular disease events (CVD) in the community. With the advent of ultra-sensitive assays, it is now possible to detect troponin I at very low concentration, far below the classical threshold of 1.9 pg/mL. However, the clinical relevance of these low concentrations for predicting CVD is largely unknown.

Purpose

To examine the association of cTnI as low as 0.013 pg/mL with incident cardiovascular disease events (CVDs) in the primary prevention setting.

Methods

cTnI was analyzed in the baseline plasma (2008–2012) of CVD free volunteers from the Paris Prospective Study III using for the first time a novel ultra-sensitive immunoassay (Simoa Troponin-I 2.0 Kit, Quanterix, Lexington) with a limit of detection (LOD) of 0.013 pg/mL. Incident CVD hospitalizations for coronary heart disease, stroke, arrhythmias, venous thromboembolism, arterial aneurysms and heart failure were validated by critical review of the hospital records. Hazard ratios were estimated per log-transformed standard deviation (SD) increase of cTnI in Cox models using age as the time scale. The added value (gain in discriminatory capacity) of cTnI for CVD risk prediction was examined by calculating the Harell's C-index boostraped difference of the SCORE 2 risk model with and without cTnI.

Results

There were 9503 CVD free participants (40% women) aged 59.6 (6.3) years at baseline. cTnI was detected in 99.6% of the participants (median value = 0.63 pg/mL, interquartile range [IQR] 0.39–1.09). After a median follow-up of 8.34 years (IQR, 8.0–10.07), 516 participants suffered 612 events. In fully-adjusted analysis, higher cTnI (per 1 SD increase of log cTnI) was significantly associated with CVD events combined (n=516, HR= 1.21; 1.06; 1.39). In univariate Cox analysis and compared to each single established risk factor, cTnI had the highest discrimination capacity for incident CVD events (C-index=0.6349) (Figure 1). Adding log cTnI to the SCORE 2 algorithm increased significantly albeit moderately discriminatory capacity (C-index 0.698 vs. 0.685; boostraped C index difference: 0.0135 (95% CI: 0.0131; 0.0138)).

Conclusion

cTnI concentrations as measured by a novel ultra-sensitive immunoassay is associated with a significant increased risk of incident CVD events in the primary prevention setting.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): ANR: French National Research AgencyEurope: Horizon 2020

Ventricular fibrillation complicating acute myocardial infarction in women

Background

Very little data is available in women presenting with ventricular fibrillation in the setting of acute myocardial infarction.

Purpose

To investigate sex-discrepancies in the incidence, characteristics and outcomes of acute myocardial infarction complicated by ventricular fibrillation.

Methods

Data were analyzed from the FAST-MI registry, which prospectively included 14,406 patients with acute myocardial infarction (mean age 66±14 years, 72% male, mean left ventricular ejection fraction 52±12%, 59% with ST elevation myocardial infarction). All consecutive patients admitted to French cardiac intensive care units ≤48 hours from acute myocardial infarction onset during a 1-month period every five years during 1995 and 2015 were included. This analysis focused on ventricular fibrillation occurring during the initial in-hospital stay for acute myocardial infarction in women compared to men.

Results

A total of 359 patients developed ventricular fibrillation during acute myocardial infarction, including 81 women (2.0% of 4,091 women overall) and 278 men (2.7% of 10,315) (p=0.02). ST-elevation myocardial infarction (OR 2.29, 95% CI 1.75–2.99, p&lt;0.001) was independently associated with occurrence of ventricular fibrillation, while female gender (OR 0.73, 95% CI 0.56–0.95, p=0.02), hypertension (OR 0.75, 95% CI 0.60–0.94, p=0.01) and prior MI (OR 0.69, 95% CI 0.50–0.96, p=0.03) were protective factors. Women were less likely to have percutaneous coronary intervention during hospitalization than men (48.1% vs. 69.1%, OR 0.48, 95% CI 0.29–0.80, p&lt;0.001). One-year mortality was higher in women compared to men (23.1% vs. 7.0%, HR 5.5, 95% CI 1.7–17.2, p=0.001). However, after adjustment for age, type of myocardial infarction and percutaneous coronary intervention, female gender was no longer associated with a worse one-year mortality (adjusted HR 1.04, 95% CI 0.71–1.51, p=0.85).

Conclusion and relevance

Women have lower risk of developing ventricular fibrillation during acute myocardial infarction compared to men. However, they are less likely to receive early coronary interventions than men, possibly contributing to worse outcomes.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): French Society of Cardiology

Healthy sleep score and incident cardiovascular diseases: the Paris Prospective Study III (PPS3)

Background/Introduction

Most studies on the association between sleep habits and cardiovascular disease (CVD) have focused on one single sleep dimension, essentially sleep duration and sleep apnea.

Purpose

To examine the joint effect of several dimensions of sleep habits with incident CVD in a community-based prospective cohort.

Methods

Between 2008 and 2011, 10,157 men and women aged 50 to 75 years were recruited in a preventive medical center. They underwent a standard physical examination coupled with standard biological tests, and provided information related to lifestyle, personal and family medical history, current health status, and medication use on questionnaires. Sleep habits were self-reported on validated questionnaires that assess sleep duration and insomnia complaints (Pittsburg questionnaire), early chronotype, sleep apnea (Berlin questionnaire) and subjective daytime sleepiness (Epworth questionnaire). Each sleep dimension was assigned 1 point if optimal and 0 point otherwise. A healthy sleep score ranging from 0 to 5 (the higher the better) and reflecting the number of optimal sleep dimensions was computed: early chronotype, sleep duration of 7–8 h/day, never/rarely insomnia, no sleep apnea, and no frequent excessive daytime sleepiness. The occurrence of incident CVD events including coronary heart disease and stroke was followed every two years up to September 2020, and events were validated after review of the medical records. The multivariable association between higher healthy sleep score and CVD events was examined in proportional hazard Cox regression analysis. Population-attributable fractions were calculated to estimate the proportion of CVD cases that could be prevented by healthier sleep habits.

Results

This study included 7203 participants (62% of men, mean age: 59.7 years±6.2) who were free of CVD at baseline and had complete data on sleep habits and covariates. Among them, 6.9% had a poor sleep score (healthy sleep score of 0 or 1), and 10.4% had an optimal sleep score (score= 5). After a median follow-up of 8 years, 275 participants had incident CVD events. After adjustment for age, sex, total alcohol consumption, socioprofessional categories, smoking status, body mass index, physical activity, family history of heart diseases, LDL and HDL cholesterol, and diabetes status, the risk of CVD decreased by 22% (HR=0.78 [95% CI: 0.71–0.86]) per 1 point increment in the healthy sleep score, and there was a 74% risk reduction in CVD risk (HR=0.26 [0.13–0.51]) between participants with the highest (score of 5) and those with the lowest (score of 0–1) healthy sleep score (Table 1). Under the hypothesis that all the participants would achieve an optimal sleep score of 5, 70.8% of incident CVD could be potentially avoided each year.

Conclusion(s)

In this community-based prospective cohort, a higher healthy sleep score combining 5 sleep dimensions was associated with a lower risk of CHD or stroke.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): The National Research Agency (ANR), The Region Ile de France (Domaine d'Intérêt Majeur)

Adapted educational health program among deprived subjects with prediabetes

AIMS

Assess the feasibility and benefit of a health educational program on global metabolic status in prediabetic deprived subjects.

DESIGN

Case control study.

METHODS

693 subjects (466 men, 227 women), aged 16 to 95 years with prediabetes and low socioeconomic status, consulting at the IPC Center were included between September 2015 and June 2016. Subjects were invited to participate in 4 workshops (2 nutrition, 2 physical activities). One year after their inclusion (visit 1), they were offered a second health check-up (visit 2). Participants were classified into 3 groups: 1) Intervention group (INTG, N=133): complete process 2) Control group (CG, N=415): Only a second health check-up, no workshop participation; 3) Abandoned group (AG, N=145). All groups were compared.

RESULTS

After considered confounding factors, fasting blood glucose and SBP levels variation between visit 1 and visit 2 differed significantly between the CG and INTG. In the INTG with higher diminution of fasting glucose, 90% reported eating healthy food since nutrition workshop and 51%. reached objectives (The same trend was observed for physical activity.

CONCLUSION

An educational program among deprived prediabetic tended to limit fasting glucose increment, improve metabolic status and encourage healthy lifestyle despite difficulties in convincing subjects to participate.

Apolipoprotein B, Residual Cardiovascular Risk After Acute Coronary Syndrome, and Effects of Alirocumab

BACKGROUND

Apolipoprotein B (apoB) provides an integrated measure of atherogenic risk. Whether apoB levels and apoB lowering hold incremental predictive information on residual risk after acute coronary syndrome beyond that provided by low-density lipoprotein cholesterol is uncertain.

METHODS

The ODYSSEY OUTCOMES trial (Evaluation of Cardiovascular Outcomes After an Acute Coronary Syndrome During Treatment With Alirocumab) compared the proprotein convertase subtilisin/kexin type 9 inhibitor alirocumab with placebo in 18 924 patients with recent acute coronary syndrome and elevated atherogenic lipoproteins despite optimized statin therapy. Primary outcome was major adverse cardiovascular events (MACE; coronary heart disease death, nonfatal myocardial infarction, fatal/nonfatal ischemic stroke, hospitalization for unstable angina). Associations between baseline apoB or apoB at 4 months and MACE were assessed in adjusted Cox proportional hazards and propensity score-matched models.

RESULTS

Median follow-up was 2.8 years. In proportional hazards analysis in the placebo group, MACE incidence increased across increasing baseline apoB strata (3.2 [95% CI, 2.9-3.6], 4.0 [95% CI, 3.6-4.5], and 5.5 [95% CI, 5.0-6.1] events per 100 patient-years in strata <75, 75-<90, ≥90 mg/dL, respectively; P_trend<0.0001) and after adjustment for low-density lipoprotein cholesterol (P_trend=0.035). Higher baseline apoB stratum was associated with greater relative (P_trend<0.0001) and absolute reduction in MACE with alirocumab versus placebo. In the alirocumab group, the incidence of MACE after month 4 decreased monotonically across decreasing achieved apoB strata (4.26 [95% CI, 3.78-4.79], 3.09 [95% CI, 2.69-3.54], and 2.41 [95% CI, 2.11-2.76] events per 100 patient-years in strata ≥50, >35-<50, and ≤35 mg/dL, respectively). Compared with propensity score-matched patients from the placebo group, treatment hazard ratios for alirocumab also decreased monotonically across achieved apoB strata. Achieved apoB was predictive of MACE after adjustment for achieved low-density lipoprotein cholesterol or non-high-density lipoprotein cholesterol but not vice versa.

CONCLUSIONS

In patients with recent acute coronary syndrome and elevated atherogenic lipoproteins, MACE increased across baseline apoB strata. Alirocumab reduced MACE across all strata of baseline apoB, with larger absolute reductions in patients with higher baseline levels. Lower achieved apoB was associated with lower risk of MACE, even after accounting for achieved low-density lipoprotein cholesterol or non-high-density lipoprotein cholesterol, indicating that apoB provides incremental information. Achievement of apoB levels as low as ≤35 mg/dL may reduce lipoprotein-attributable residual risk after acute coronary syndrome.

REGISTRATION

URL: https://www.

CLINICALTRIALS

gov; Unique identifier: NCT01663402.

Apixaban versus other anticoagulants in patients with nonvalvular fibrillation: a comparison of all-cause and event-related costs in real-life setting in France

OBJECTIVES

Compare costs associated with all-cause healthcare resource use (HCRU), stroke/systemic thromboembolism (STE) and major bleedings (MB) between patients with non-valvular atrial fibrillation (NVAF) initiating apixaban or other oral anticoagulants (OACs).

METHODS

We performed a retrospective cohort study using the French healthcare claims database, including NVAF patients between 2014/01/01 and 2016/12/31, followed until 2016/12/31. We used 4 sub-cohorts of OAC-naive patients, respectively initiating apixaban, dabigatran, rivaroxaban or VKAs. We matched patients initiating apixaban with patients initiating each other OACs using 1:n propensity score matching. All-cause HCRU and event-related costs by OAC treatment were estimated and compared between matched patients using generalised-linear models with gamma-distribution and two-part models.

RESULTS

There were 175,766 patients in the apixaban-VKA, 181,809 in the apixaban-rivaroxaban, and 42,490 in the apixaban-dabigatran matched cohorts. Patients initiating apixaban had significantly lower HCRU costs than patients initiating VKA (€1,105 vs. €1,578, p < 0.0001), dabigatran (€993 vs. €1,140, p < 0.0001) and rivaroxaban (€1,013 vs. €1,088 p < 0.0001). They have had significantly lower costs related to stroke/STE and MB than patients initiating VKA (respectively, €183 vs. €449 and €147 vs. €413; p < 0.0001), rivaroxaban (respectively, €145 vs. €197 and €129 vs. €193; p < 0.0001), and lower costs related to stroke/STE than patients initiating dabigatran (€135 vs. €192, p < 0.02). Costs related to MB were not significantly different in patients initiating apixaban and those initiating dabigatran (€119 vs. €149, p = 0.07).

CONCLUSIONS

HCRU and most event-related costs were lower in patients initiating apixaban compared to other OACs. Apixaban may be cost-saving compared to VKAs, and significantly cheaper than other DOACs, although cost differences are limited.

Incidence, Characteristics, and Outcomes of Ventricular Fibrillation Complicating Acute Myocardial Infarction in Women Admitted Alive in the Hospital

Background

Little data are available in women presenting with ventricular fibrillation (VF) in the setting of acute myocardial infarction (AMI). We assessed frequency, predictors of VF, and outcomes, with a special focus on women compared with men.

Methods and Results

Data were analyzed from the FAST‐MI (French Registry of Acute ST‐Elevation or Non‐ST‐Elevation Myocardial Infarction) program, which prospectively included 14 406 patients admitted to French cardiac intensive care units ≤48 hours from AMI onset between 1995 and 2015 (mean age, 66±14 years; 72% men; mean left ventricular ejection fraction, 52±12%; 59% with ST‐segment–elevation myocardial infarction). A total of 359 patients developed VF during AMI, including 81 women (2.0% of 4091 women) and 278 men (2.7% of 10 315 men, P=0.02). ST‐segment–elevation myocardial infarction (odds ratio [OR], 2.29 [95% CI, 1.75–2.99]; P<0.001) was independently associated with the onset of VF during AMI. In contrast, female sex (OR, 0.73 [95% CI, 0.56–0.95]; P=0.02), hypertension (OR, 0.75 [95% CI, 0.60–0.94]; P=0.01), and prior myocardial infarction (OR, 0.69 [95% CI, 0.50–0.96]; P=0.03) were protective factors. Women were less likely to have cardiac intervention than men (percutaneous coronary intervention during hospitalization 48.1% versus 66.9%, respectively; P=0.04) with a higher 1‐year mortality in women compared with men (50.6% versus 37.4%, respectively; P=0.03), including increased in‐hospital mortality (42.0% versus 32.7%, respectively; P=0.12). After adjustment, female sex was no longer associated with a worse 1‐year mortality (adjusted hazard ratio, 1.10 [95% CI, 0.75–1.61]; P=0.63).

Conclusions

Women have lower risk of developing VF during AMI compared with men. However, they are less likely to receive cardiac interventions than men, possibly contributing to missed opportunities of improved outcomes.

Gender gap in annual preventive care services in France

BACKGROUND

In France, screening for cardiovascular risk factors is recommended during annual preventive visits. However, data are lacking on the temporal trend in women's uptake to preventive care services, and in cardiovascular and mortality outcomes. The aim of the study was to investigate the participation and mortality of women in annual preventive care services in a major preventive medicine center in France.

METHOD

Ee conducted repeated cross-sectional studies including a total of 366,270 individuals who had a first examination at the Centre d'Investigations Préventives et Cliniques, France, between January 1992 and December 2011.

FINDINGS

Women's participation was low below 50 years of age, then increases from 50 to 70 years, and is lower for women older than 70 years. The gap in female participation was more pronounced among individuals with high education, low social deprivation, and no depressive symptoms. Compared with the general population, the screened population had significantly lower standardized mortality ratios (SMRs) among both men and women, for all age ranges. Screened women aged 18-49 years showed a lower mortality gain compared with men of the same age; SMRs did not differ significantly by sex for individuals over 50 years.

INTERPRETATION

In this community-based sample, compared with men, women's participation to annual preventive care services was lower, and screened women had a lower mortality gain. Despite the demonstrated benefit of annual check-ups on health, there is a gender gap in adherence to preventive programs and in efficiency of screening programs, especially in the young age range. This gap in cardiovascular disease prevention may result in poorer cardiovascular health in women. Urgent adaptations to overcome this gender gap in preventive screening in France are warranted.

FUNDING

Bamba Gaye is supported by the Fondation Recherche Médicale grant.

Economic evaluation of fractional flow reserve-guided versus angiography-guided multivessel revascularisation in ST-segment elevation myocardial infarction patients in the FLOWER-MI randomised trial

BACKGROUND

In patients with ST-segment elevation myocardial infarction (STEMI) who have multivessel disease, the FLOWER-MI trial found no significant clinical benefit to fractional flow reserve (FFR)-guided percutaneous coronary intervention (PCI) compared to angiography-guided PCI.

AIMS

Our aim was to estimate the cost-effectiveness and cost-utility of FFR-guided PCI, the secondary endpoint of the FLOWER-MI trial.

METHODS

Costs, major adverse cardiovascular events (composite of all-cause death, non-fatal myocardial infarction [MI], and unplanned hospitalisation leading to urgent revascularisation), and quality-adjusted life years were calculated in both groups. The incremental cost-effectiveness and cost-utility ratios were estimated. Uncertainty was explored by probabilistic bootstrapping. The analysis was conducted from the perspective of the health care provider with a time horizon of one year.

RESULTS

At one year, the average cost per patient was 7,560€ (±2,218) in the FFR-guided group and 7,089€ (±1,991) in the angiography-guided group (p-value<0.01). The point estimates for the incremental cost-effectiveness and cost-utility ratios found that the angiography-guided strategy was cost saving and improved outcomes, with a probabilistic sensitivity analysis confirming dominance.

CONCLUSIONS

The FFR-guided strategy at one year is unlikely to be cost effective compared to the angiography-guided strategy on both clinical and quality of life outcomes.

Reperfusion therapy for ST-elevation myocardial infarction complicated by cardiogenic shock: the European Society of Cardiology EurObservational programme acute cardiovascular care-European association of PCI ST-elevation myocardial infarction registry

AIMS

To determine the current state of the use of reperfusion and adjunctive therapies and in-hospital outcomes in European Society of Cardiology (ESC) member and affiliated countries for patients with ST-segment elevation myocardial infarction (STEMI) complicated by cardiogenic shock (CS).

METHODS AND RESULTS

ESC EurObservational Research Programme prospective international cohort study of admissions with STEMI within 24 h of symptom onset (196 centres; 26 ESC member and 3 affiliated countries). Of 11 462 patients enrolled, 448 (3.9%) had CS. Patients with compared to patients without CS, less frequently received primary percutaneous coronary intervention (PCI) (65.5% vs. 72.2%) and fibrinolysis (15.9% vs. 19.0), and more often had no reperfusion therapy (19.0% vs. 8.5%). Mechanical support devices (intraaortic ballon pump 11.2%, extracoporeal membrane oxygenation 0.7%, other 1.1%) were used infrequently in CS. Bleeding definition academic research consortium 2-5 bleeding complications (10.1% vs. 3.0%, P < 0.01) and stroke (4.2% vs. 0.9%, P < 0.01) occurred more frequently in patients with CS. In-hospital mortality was 10-fold higher (35.5% vs. 3.1%) in patients with CS. Mortality in patients with CS in the groups with PCI, fibrinolysis, and no reperfusion therapy were 27.4%, 36.6%, and 62.4%, respectively.

CONCLUSION

In this multi-national registry, patients with STEMI complicated by CS less frequently receive reperfusion therapy than patients with STEMI without CS. Early mortality in patients with CS not treated with primary PCI is very high. Therefore, strategies to improve clinical outcome in STEMI with CS are needed.

A data-driven pipeline to extract potential adverse drug reactions through prescription, procedures and medical diagnoses analysis: application to a cohort study of 2,010 patients taking hydroxychloroquine with an 11-year follow-up

Context

Real-life data consist of exhaustive data which are not subject to selection bias. These data enable to study drug-safety profiles but are underused because of their temporality, necessitating complex models (i.e., safety depends on the dose, timing, and duration of treatment). We aimed to create a data-driven pipeline strategy that manages the complex temporality of real-life data to highlight the safety profile of a given drug.

Methods

We proposed to apply the weighted cumulative exposure (WCE) statistical model to all health events occurring after a drug introduction (in this paper HCQ) and performed bootstrap to select relevant diagnoses, drugs and interventions which could reflect an adverse drug reactions (ADRs). We applied this data-driven pipeline on a French national medico-administrative database to extract the safety profile of hydroxychloroquine (HCQ) from a cohort of 2,010 patients.

Results

The proposed method selected eight drugs (metopimazine, anethole trithione, tropicamide, alendronic acid & colecalciferol, hydrocortisone, chlormadinone, valsartan and tixocortol), twelve procedures (six ophthalmic procedures, two dental procedures, two skin lesions procedures and osteodensitometry procedure) and two medical diagnoses (systemic lupus erythematous, unspecified and discoid lupus erythematous) to be significantly associated with HCQ exposure.

Conclusion

We provide a method extracting the broad spectrum of diagnoses, drugs and interventions associated to any given drug, potentially highlighting ADRs. Applied to hydroxychloroquine, this method extracted among others already known ADRs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12874-022-01628-3.

• The challenge of drug-safety signal detection methods is to handle four types of difficulties:

○ The data source, the study of long-term adverse drug reactions or effects not suspected by healthcare professionals, requires the use of a real-life data source.

○ The consideration of a broad spectrum of potential adverse drug reactions (ADRs), and not only candidate ADRs.

○ The temporal impact (meaning that safety depends on the dose, date and duration of treatment).

○ The difference between true ADRs and disease natural course.

• We aimed to create a data-driven pipeline strategy, without any assumption of any ADRs, which take into account the complex temporality of real-life data to provide the safety profile of a given drug.

• Our pipeline used three sources of real-life data to establish a safety profile of a given drug: drug prescriptions, procedures and medical diagnoses.

• We successfully applied our data-driven pipeline strategy to hydroxychloroquine (HCQ). Our pipeline enabled us to find diagnoses, drugs and interventions related to HCQ and which could reflect an ADR due to HCQ or the disease itself.

• This data-driven pipeline strategy may be of interest to other experts involved in the pharmacovigilance discipline.

Smoking in Patients With Chronic Cardiovascular Disease During COVID-19 Lockdown

Objectives

This cross-sectional study aims to investigate health-related behaviors including tobacco consumption among patients with cardiovascular diseases (CVD), during the first COVID-19-related lockdown.

Methods

After 5 weeks of COVID-19 lockdown, 220 patients with chronic coronary syndromes (CCS) and 124 with congestive heart failure (CHF) answered a phone questionnaire.

Results

Among these 344 patients, 43 (12.5%) were current smokers, and none had quit during the lockdown. When compared with non-smokers, smokers were 15 years younger, more often diabetic, more likely to live in an urban than a rural lockdown location, and more often in the CCS cohort (p = 0.011). Smokers described greater psychological impairment, but their rates of decrease in physical activity and of increase in screen time were similar to non-smokers. More than one-third (13/43) increased their tobacco consumption, which was mainly related to stress or boredom, but not driven by media messages on a protective effect of nicotine.

Conclusions

During the first COVID-19 lockdown, we found a decrease in favorable lifestyle behaviors among patients with CVD. Strikingly, one-third of smokers with CCS or CHF increased their tobacco consumption. Given the major impact of persistent smoking in patients with CVD, this highlights the need for targeted prevention strategies, in particular during such periods.

Sex differences in mortality after an acute coronary syndrome increase with lower country wealth and higher income inequality

INTRODUCTION AND OBJECTIVES

Although several factors associated with sex differences in the management and outcomes after acute coronary syndrome (ACS) have been reported, little is known about the influence of socioeconomic factors on sex disparities. Our aim was to evaluate the influence of country wealth and income inequality on national sex differences in mortality after ACS.

METHODS

Sex differences in 2-year postdischarge mortality were evaluated in 23 489 ACS patients from the EPICOR and EPICOR Asia registries. Adjusted Cox regression models by country-based terciles of gross national income per capita and income inequality were used.

RESULTS

Women (24.3%) were older than men (65.5 vs 59.4 years, P <.001), had more comorbidities, were less often revascularized (63.6% vs 75.6%, P <.001) and received fewer guideline recommended therapies at discharge. Compared with men, a higher percentage of women died during follow-up (6.4% vs 4.9%, P <.001). The association between sex and mortality changed direction from hazard ratio (HR) 1.32 (95%CI, 1.17-1.49) in the univariate assessment to HR 0.76 (95%CI, 0.67-0.87) after adjustment for confounders. These differences were more evident with increasing country wealth (HR_{low-incomecountries} = 0.85; 95%CI, 0.72-1.00; HR_{mid-incomecountries} = 0.66; 95%CI, 0.50-0.87; HR_{high-incomecountries} = 0.60; 95%CI, 0.40-0.90; trend test P = .115) and with decreasing income inequality (HR_{low-inequalityindex} = 0.54; 95%CI, 0.36-0.81; HR_{intermediate-inequalityindex} = 0.66; 95%CI, 0.50-0.88; HR_{high-inequalityindex} = 0.87; 95%CI, 0.74-1.03; trend test P = .031).

CONCLUSIONS

Women with ACS living in high socioeconomic countries showed a lower postdischarge mortality risk compared with men. This risk was attenuated in countries with poorer socioeconomic background, where adjusted mortality rates were similar between women and men.

Coronary artery calcifications and 6-month mortality in patients with COVID-19 without known atheromatous disease

BACKGROUND

Coronary artery calcium (CAC) is an independent risk factor for major adverse cardiovascular events; however, its impact on coronavirus disease 2019 (COVID-19) mortality remains unclear, especially in patients without known atheromatous disease.

AIMS

To evaluate the association between CAC visual score and 6-month mortality in patients without history of atheromatous disease hospitalized with COVID-19 pneumonia.

METHODS

A single-centre observational cohort study was conducted, involving 293 consecutive patients with COVID-19 in Paris, France, between 13 March and 30 April 2020, with a 6-month follow-up. Patients with a history of ischaemic stroke or coronary or peripheral artery disease were excluded. The primary outcome was all-cause mortality at 6 months according to CAC score, which was assessed by analysing images obtained after the first routine non-electrocardiogram-gated computed tomography scan performed to detect COVID-19 pneumonia.

RESULTS

A total of 251 patients (mean age 64.8±16.7 years) were included in the analysis. Fifty-one patients (20.3%) died within 6 months. The mortality rate increased with the magnitude of calcifications, and was 10/101 (9.9%), 15/66 (22.7%), 10/34 (29.4%) and 16/50 (32.0%) for the no CAC, mild CAC, moderate CAC and heavy CAC groups, respectively (p=0.004). Compared with the no calcification group, adjusted risk of death increased progressively with CAC: hazard ratio (HR) 2.37 (95% confidence interval [CI] 1.06-5.27), HR 3.1 (95% CI 1.29-7.45) and HR 4.02 (95% CI 1.82-8.88) in the mild, moderate and heavy CAC groups, respectively.

CONCLUSIONS

Non-electrocardiogram-gated computed tomography during the initial pulmonary assessment of patients with COVID-19 without atherosclerotic cardiovascular disease showed a high prevalence of mild, moderate and heavy CAC. CAC score was related to 6-month mortality, independent of conventional cardiovascular risk factors. These results highlight the importance of CAC scoring for patients hospitalized with COVID-19, and calls for attention to patients with high CAC.

Les infarctus du myocarde pendant un an de pandémie de COVID-19 - Étude nationale française des taux d'hospitalisation, du pronostic et de la mortalité à 90 jours

Introduction

Au début de la pandémie de COVID-19, plusieurs études ont signalé une diminution des séjours hospitaliers hors COVID-19. L'objectif de cette étude était de décrire les tendances nationales des admissions pour infarctus du myocarde (IDM) à l'hôpital en 2020 et comparer les caractéristiques, le pronostic hospitalier et la mortalité à 90 jours des patients admis en 2020, à ceux des patients admis en 2017-19.

Méthodes

Tous les patients hospitalisés pour IDM en France entre 2017 et 2020 ont été inclus à partir du PMSI-MCO. Les analyses ont comparé les tendances temporelles d'admissions pour IDM, les taux de complications cardiaques hospitalières, la réadmission et la mortalité hospitalière et à 90 jours en 2020 versus 2017-19 ; puis ont été stratifiées par période d'admission, type d'IDM, sexe, âge et régions.

Résultats

En 2020, 94 747 patients ont été hospitalisés pour IDM, correspondant à une diminution de 6 % des admissions pour IDM par rapport à 2017-2019. Cette diminution était plus importante durant le premier confinement (-24 %, p<0,0001) que pendant le deuxième (-8 %, p<0,0001), et a atteint -40 % en semaine 13. Les diminutions d'hospitalisation pour IDM étaient plus élevées et ont persisté plus longtemps pour les NSTEMI, pour les personnes âgées et pour les femmes. Une augmentation des hospitalisations pour STEMI a été observée entre les confinements (+4 %, p=0,0005). Globalement et après ajustement sur l’âge, le sexe et l'effet temporel, les taux de mortalité hospitalière et dans les 90 jours qui suivaient la sortie d'hospitalisation ne différaient pas entre 2020 et 2017-2019 (IRRaj-hosp =1,03[0,98 ; 1,08], p=0,19 - IRRaj 90j-post-sortie=1,06[0,98 ; 1,13], p=0,14).

Discussion/Conclusion

En 2020, une diminution significative des hospitalisations pour IDM a été observée et était particulièrement importante au début de l'année. L'impact de la crise du COVID-19 sur les complications aiguës et le pronostic à trois mois des patients admis apparaît limité. Néanmoins, la surveillance des complications chroniques de l'IDM et de l'impact sur les personnes non hospitalisées devra être poursuivie.

Association between common cardiovascular risk factors and clinical phenotype in patients with hypertrophic cardiomyopathy from the European Society of Cardiology (ESC) EurObservational Research Programme (EORP) Cardiomyopathy/Myocarditis registry

AIMS

The interaction between common cardiovascular risk factors (CVRF) and hypertrophic cardiomyopathy (HCM) is poorly studied. We sought to explore the relation between CVRF and the clinical characteristics of patients with HCM enrolled in the EURObservational Research Programme (EORP) Cardiomyopathy registry.

METHODS AND RESULTS

1739 patients with HCM were studied. The relation between hypertension (HT), diabetes (DM), body mass index (BMI), and clinical traits was analysed. Analyses were stratified according to the presence or absence of a pathogenic variant in a sarcomere gene. The prevalence of HT, DM, and obesity (Ob) was 37, 10, and 21%, respectively. HT, DM, and Ob were associated with older age (P<0.001), less family history of HCM (HT and DM P<0.001), higher New York Heart Association (NYHA) class (P<0.001), atrial fibrillation (HT and DM P<0.001; Ob p = 0.03) and LV (left ventricular) diastolic dysfunction (HT and Ob P<0.001; DM P = 0.003). Stroke was more frequent in HT (P<0.001) and mutation-positive patients with DM (P = 0.02). HT and Ob were associated with higher provocable LV outflow tract gradients (HT P<0.001, Ob P = 0.036). LV hypertrophy was more severe in Ob (P = 0.018). HT and Ob were independently associated with NYHA class (OR 1.419, P = 0.017 and OR 1.584, P = 0.004, respectively). Other associations, including a higher proportion of females in HT and of systolic dysfunction in HT and Ob, were observed only in mutation-positive patients.

CONCLUSION

Common CVRF are associated with a more severe HCM phenotype, suggesting a proactive management of CVRF should be promoted. An interaction between genotype and CVRF was observed for some traits.

Association Between Exposure to Effervescent Paracetamol and Hospitalization for Acute Heart Failure: A Case-Crossover Study

We investigated whether effervescent paracetamol, as an important source of non-dietary sodium and fluid load, is associated with a transient increase in the risk of hospitalization for acute heart failure (AHF). We conducted a unidirectional case-crossover study using data from the 1/97^th representative sample from the French healthcare database. Subjects aged 18 years or more, hospitalized for AHF during the 2014-2016 period were included. Exposure to effervescent paracetamol was compared between a risk period (i.e. 15 days immediately prior to admission for AHF) and three earlier 15-day control periods, to test a possible trigger effect of effervescent paracetamol intake on AHF. Adjusted odds ratios (aOR) were estimated with a conditional logistic regression. We identified 4,301 patients hospitalized for AHF. We found that 5.7% of AHF subjects were exposed to effervescent paracetamol during the risk period, as compared with 4.1% during the control periods (aOR 1.56 [CI_95% : 1.27 - 1.90], p < 0.001). This association was also found in the subgroup of subjects with hypertension (aOR 1.45 [CI_95% : 1.13 - 1.87], p = 0.004, n = 2,648) and in the subgroup of subjects aged 83 years or more (aOR 1.70 [CI_95% : 1.28 - 2.24], p < 0.001, n = 2,238). A similar analysis, considering exposure to non-effervescent paracetamol, did not support the existence of an indication bias likely to explain the association observed for effervescent paracetamol. This study suggests an association between effervescent paracetamol and admission for AHF and should be confirmed with other complementary study designs. This article is protected by copyright. All rights reserved.

Care management and 90-day mortality in patients hospitalized for myocardial infarction and COVID-19 in France

Background

Concomitant COVID-19 in patients with myocardial infarction (MI) may lead to difficulties in acute care management and may impair prognosis. To date, studies have involved a limited number of patients.

Purpose

To estimate and compare the characteristics, care management and 90-day outcomes of patients hospitalized for MI who didn’t have Covid-19, with those having concomitant hospital diagnosis of Covid-19 from the French National Health Data System, an exhaustive and nationwide database.

Methods

All patients hospitalised for MI in France between 30 December 2019 and 4 October 2020 were included. Patients with a previous hospitalization with Covid-19 were excluded (n = 135). Patients’ characteristics were compared according to Covid-19 status. 90-day mortality rates and follow-up outcomes were estimated and adjusted on age, sex and comorbidities.

Results

Among the 55,389 patients hospitalized for MI, 329 had concomitant Covid-19 (21% asymptomatic). MI patients with concomitant Covid-19 were more comorbid than patients without Covid-19. They had longer hospital stays, more admissions to resuscitation unit, underwent less percutaneous coronary intervention, and discharged more often to rehabilitation units than patients without Covid-19. The in-hospital and 90-day-out-of hospital mortality rates of MI patients with Covid-19 were 11.9% and 6.2%, respectively, compared to 3.5% and 2.8% in MI patients without Covid-19. The risk of in-hospital and out-of-hospital death remained increased after adjustment on comorbidities (OR_ajin-hosp = 3.31[2.32;4.72], OR_{ajout-of-hosp} = 1.79 [1.02;3.15]).

Conclusions

The prognosis of patients hospitalized for MI who had concomitant Covid-19 was impaired in the short term but also in the medium term. These results underline the need of an urgent protection of the population at cardiovascular risk from Covid-19, as well as a systematized and rapid management despite the pandemic context, and then a close follow-up of these patients.

One year of Covid-19: French nationwide study of hospitalisation, 90-day readmission and mortality rates from myocardial infarction

Background

Studies reported a decrease in hospital admissions for myocardial infarction (MI) in early 2020 due to Covid19 crisis, but these were restricted to the early weeks of the pandemic.

Purpose

To describe patient characteristics, in-hospital management and 90-day mortality of MI patients throughout the year 2020, in particular during periods of lockdowns.

Methods

All patients hospitalised for MI in France from 2017 to 2020 were selected from the national hospital discharge database. Incidence rate ratios were computed to analyze time trends in MI admissions and mortality rates and stratified by type of MI, sex, age, and period of admission. Characteristics and management of patients in 2020 were described and compared to 2017-19 (OR adjusted on temporality, sex, age)

Results

In 2020, 94,747 patients were hospitalized for MI corresponding to a 6% decrease in MI admissions compared to 2017-19. This decrease was more significant during the first lockdown (−24%, P < 0.0001), in particular in week 13 (−40%) than during the second lockdown (−8%). Decreases in MI admissions were more pronounced and longer for NSTEMI, older people and for women. An increase in the rate of STEMI admissions was observed between the two 2020 lockdowns (+4%, P = 0.0005). Admission to a resuscitation unit and complications rates did not differ between 2017-19 and 2020. In early 2020, there was also a decrease in 90-days readmission. In 2020, the in-hospital and 90-days-out-of hospital mortality rates were 5.5% and 3.8%, compared to 5.7% and 3.6% in reference years. Globally and after adjustment, mortality rates did not differ in 2020 vs. 2017-19 (IRR_in-hosp = 1.03[0.98;1.08], P = 0.19 - IRR_out-hosp = 1.04[0.97;1.27], P = 0.21).

Conclusions

This nationwide study showed significant decrease in MI hospitalization during 2020, in particular during the first lockdown, with a slight STEMI increase during the summer. However, these trends were not associated with more cardiac complications or mortality.

Care management and 90-day post discharge mortality in patients hospitalized for myocardial infarction and COVID-19: A French nationwide observational study

BACKGROUND

Concomitant or cured coronavirus disease 2019 (COVID-19) in patients with myocardial infarction (MI) may lead to difficulties in acute care management and impair prognosis.

AIMS

To describe and compare the characteristics, care management and 90-day post discharge outcomes of patients hospitalized for MI who did not have COVID-19 with those of patients with concomitant or previous hospital-diagnosed COVID-19.

METHODS

This population-based French study included all patients hospitalized for MI in France (30 December 2019 to 04 October 2020) from the French National Health Data System. Outcomes were described for each COVID-19 group and compared using adjusted logistic regression analysis.

RESULTS

Among 55,524 patients hospitalized for MI, 135 had previous hospital-diagnosed COVID-19 and 329 had concomitant COVID-19. Patients with previous hospital-diagnosed COVID-19 had more personal history of cardiovascular diseases than those without concomitant/previous confirmed COVID-19. In-hospital and 90-day post discharge mortality rates of patients with previous COVID-19 were 8.1% and 4.0%, respectively, compared with 3.5% and 3.0% in patients without concomitant/previous confirmed COVID-19 (odds ratio [OR]_{adjin-hospital} 1.83, 95% confidence interval [CI] 0.97-3.46; OR_{adjpostdischarge} 0.77, 95% CI 0.28-2.13). Patients with concomitant COVID-19 had more personal history of cardiovascular diseases, but also a poorer prognosis than their no concomitant/no previous confirmed COVID-19 counterparts; they presented excess cardiac complications during hospitalization (OR_adj 1.62, 95% CI 1.29-2.04), in-hospital mortality (OR_adj 3.31, 95% CI 2.32-4.72) and 90-day post discharge mortality (OR_adj 2.09, 95% CI 1.24-3.51).

CONCLUSIONS

In-hospital and 90-day post discharge mortality of patients hospitalized for MI who had previous hospital-diagnosed COVID-19 did not seem to differ from those hospitalized for MI alone. Conversely, concomitant COVID-19 and MI carried a poorer prognosis extending beyond the hospital stay. Special attention should be given to patients with simultaneous COVID-19 and MI, in terms of acute care and secondary prevention.