[An independent observatory in Vendée on ST-elevated acute myocardial infarction (the OVISCA Register). A Departmental evaluation of demographic trends, mortality and delays before treatment]

AIM

Mortality from acute myocardial infarction has been falling during the past 30 years. The aim of the study was to evaluate the temporal trends of demographics, mortality rates, and time to treatment in patients admitted for acute ST elevation myocardial infarction (STEMI) in Vendée.

PATIENTS AND METHODS

From 2008 to 2016, 1994 patients hospitalised in CHD Vendée for STEMI <48hours were included. Two groups were compared, 838 patients admitted between 2008 and 2011 (group 1), and 1156 admitted between 2013 and 2016 (group 2).

RESULTS

Between the 2 periods, mean age was comparable (63.8 vs. 64.4 years), the gender ratio decreased (from 3.15 to 2.79 ; P=0.25). The mean duration of hospital stay was 0.8 day shorter (P=0.008). Treatment at discharge was optimum in 97.5% patients versus 92% (P<0.001). Left ventricular ejection fraction was comparable (50.6% vs. 50.2%). There was a non-significant trend to a decrease in hospital mortality (from 6.3% to 4.4%; p=0.12), and 6-month mortality (from 6.9% to 5.9%; P=0.51). There was a reduction in the use of emergency call-outs (74.9% to 68.9%; P<0.01), but an increase in direct presentations from 44% to 48.7% (P<0.05). The time before calling was comparable (2.5hours vs. 2.3hours; P=04.7). The "door-to-balloon" time decreased (0.71 vs. 0.55hour; P<0.001). The mean time between pain and angioplasty increased (5.7 vs. 6.8hours; P<0.05).

CONCLUSIONS

In vendee, from 2011 to 2016, hospital and 6-month mortality of STEMI trend to decrease non-significantly. The door to balloon time decreased, although emergency call-out rates and delays did not. Considerable efforts are still required with respect to patient information and education. Our registry offers an excellent tool to improve practices, the aim being to ensure its integration in the CRAC-France PCI registry.

Indications for fibrinolysis in patients with ST-segment elevation myocardial infarction: From guidelines to practice

BACKGROUND

European guidelines on managing ST segment elevation myocardial infarction (STEMI) during the first 12hours recommend fibrinolysis when the time elapsing between the first medical contact and balloon time (FMCBT) is more than 120minutes.

AIM

To assess the real-life clinical efficacy of guidelines on fibrinolysis in managing STEMI and identify obstacles to their everyday implementation.

METHODS

An observational study based on a permanent registry of reperfusion strategies and timing among patients treated in a French general hospital for STEMI with chest pain lasting for less than two hours. Patients were enrolled between January 1^st 2008 and December 31^st 2014.

RESULTS

The study included 669 patients: 79 (11.8%) benefited from effective fibrinolysis followed by coronary arteriography (PCI) within 24hours, 445 (66.5%) underwent a primary PCI, 99 (14.8%) received a rescue PCI and 46 (6.9%) did not undergo revascularization. The FMCBT was 120minutes or longer in 209 patients: fibrinolysis was performed in 68 of these patients (32.5%), and primary PCI in 141 (114 (54.6%) without contraindications to fibrinolysis and 27 (12.9%) with contraindications). The patient's age, female gender, co-morbidities and clinical management were factors that appeared to be linked to poor compliance with the guidelines, but none were significant (P>00.5). Nor were there significant differences regarding bleeding complications between patients receiving fibrinolysis or primary PCI (P>0.05).

CONCLUSION

The guidelines on fibrinolysis were not followed in 54.6% of patients when the FMCBT was more than 120minutes. Some criteria (age, gender, co-morbidities) may have been responsible for this non-compliance, although underestimating the time between first medical contact and arrival in the catheterisation laboratory could not be excluded. Further studies are necessary to improve estimates of this delay.

[ST elevation myocardial infarction (STEMI) in patients aged 85 and over. Invasive management versus exclusive medical treatment: Departmental study]

INTRODUCTION

Percutaneous coronary intervention (PCI) and/or fibrinolysis for management of an ST elevation myocardial infarction (STEMI) are at high risk in the elderly. Is there any place for an invasive management in this particular population?

METHODS

It is a single-center retrospective study (CHD Vendée, La Roche-sur-Yon) including patients aged 85 and over who had STEMI between January 2008 and December 2013, divided into two groups: coronary angiogram/fibrinolysis ("invasive") versus exclusive medical treatment ("non-invasive"), comparing mortality, morbidity, complications and loss of independence.

RESULTS

Among the 1373 patients hospitalized for STEMI, 118 (8.6%) were included: 71 (60.2%) underwent an invasive procedure for reperfusion whereas 47 had "non-invasive" management. All cause mortality rate was higher in the "non-invasive" group (28% versus 45%; P=0.077 NS). The identified pejorative criteria are age, female gender, past history of severe valvular disease, and delay for primary care. No difference was found in intrahospital complication rate (23 vs 21; P=0.21) nor in loss of independence.

CONCLUSION

The invasive management of STEMI in the elderly may reduce the one-year mortality rate without increasing morbidity.

[Reperfusion delays in acute coronary syndromes with ST segment elevation (STEMI) depending on prehospital care]

INTRODUCTION

Acute coronary syndrome with ST segment elevation (STEMI) remains a major cause of morbidity and mortality in France, directly correlated with the time management of the patient to achieve reperfusion of the artery as early as possible. But the delay of reperfusion is related to the course that will take the patient to the revascularization.

METHODS

To make an observation of departmental practices, we conducted a retrospective monocentric study on the STEMI supported on 4years in the Departmental Hospital of La Roche-sur-Yon by comparing the time of reperfusion in two groups: patients who used the recommended chain=diRect chain (Call the emergency number-specialist mobile emergency unit-Cardiac intensive care unit or cardiac catheterization laboratory), and patients who used another chain=Long chain.

RESULTS

On 838 patients with STEMI, 356 (42.5%) used the Direct chain. The average time of reperfusion in the Direct chain group is 4.26hours (±3.12), 6.17hours (±4.82) in the Long chain group. There is a significant difference between the two groups of 1.9hours (P<0.001). Of 186 patients who consulted a general practitioner, 40.3% of patients were not supported by the mobile emergency unit.

CONCLUSION

These results should lead to improved practices, to carry on continuing medical education with all actors in the chain and patient information to shorten up the time of reperfusion.

[Cardiologic emergencies and natural disaster. Prospective study with Xynthia tempest]

BACKGROUND

Stress-induced cardiomyopathy and ischemic cardiopathy have been described after natural disasters such as earthquakes.

OBJECTIVES OF THE STUDY

Count stress-induced cardiomyopathies and ischemic cardiopathies just after Xynthia tempest which damaged the Vendean coast on February2010, in order to study epidemiology.

PATIENTS AND METHOD

Included patients were living in a tempest damaged village, and admitted in Vendee hospital just after or in the week following the tempest, and presenting a suspected acute coronary syndrome or stress-induced cardiomyopathy.

RESULTS

Among 3350 inhabitants of the two damaged Vendean towns, we count three acute coronary syndromes, two Tako-Tsubo cardiomyopathies, and one coronary spasm. We count five women and one man, average age is 76.

CONCLUSION

The diagnosis of ischemic cardiopathy and stress-induced cardiomyopathy is over-represented in this tempest damaged population, that have been little described.

[Care of ST elevated myocardial infarction patients in Vendée in 2008: observational and descriptive study]

PURPOSE OF THE STUDY

Estimating the quality of care of the patients presenting an ST-elevation myocardial infarction in Vendee.

PATIENTS AND METHOD

Prospective observational study carried out over the year 2008. Included patients presenting a myocardial infarction for less than 24 hours, they were alive when emergency team arrived, and were taken care of by the SMUR, the emergencies or the cardiology of the hospital of La Roche-sur-Yon.

RESULTS

Two hundred and seventeen patients were included, 163 men and 54 women, average age: 65 years. Fifty-six percent of the patients called initially the emergency medical service, half of those within an hour after pain began. Seventy-two percent of them were looked after by a SMUR. Twenty-six percent consulted initially a general practitioner, and one third of those were redirected towards the emergency medical service. Thirty percent of all patients followed the ideal procedure defined by succession of chest pain, emergency medical service call, SMUR, angioplasty or fibrinolysis. The average time between the ECG and the fibrinolysis is 36 minutes, or of the arrival in coronarography room is 105 minutes. The balloon is inflated 42 minutes later. Eighty-six percent of the patients taken care of in the acute phase benefited from a strategy of reperfusion, primary angioplasty (63%) or fibrinolysis (21%). Ninety percent of revascularisations were successful.

CONCLUSION

In the case of the chest pain, the emergency medical service is under-used. The number of revascularised patients is satisfactory, but the whole procedure takes too much time, especially when the treatment is the angioplasty.

[Coronary embolism: a not so rare cause of myocardial infarction? Review of the literature about five suspected cases of patients in atrial fibrillation]

Five cases of myocardial infarction suspected to be due to coronary embolism are presented. All five patients had atrial fibrillation (AF), four of them with nonvalvular AF. The literature regarding coronary embolism is reviewed; the clinical manifestations and the place of AF are discussed.

[Non-ruptured calcified aneurysm of the Valsalva's sinus with angina pectoris and aortic insufficiency. Surgical treatment]

We report a case of aneurysm of the straight frontal, and not coronary, aortic sinus, non ruptured and calcified, responsible for a refractory angina pectoris and a massive aortic failure in a 71 year old woman. The surgical treatment consisted in the exclusion of the aneurysm of the aortic sinus by a tubular prosthesis in which only two thirds of the circumference have been used, associated with the replacement of an aortic valve by a bioprosthesis, without associated coronary by-pass.

[Contribution of nuclear magnetic resonance in right atrial angiosarcoma. Apropos of a case]

A 25-year old female patient was admitted to hospital for respiratory failure with pulmonary miliary. Subsequently, clinical signs of pericardial tamponade developed. Echocardiography showed a tumour of the right atrium. Malignancy of the tumour was strongly suspected on the basis of magnetic resonance findings. At surgery, the tumour could not be removed and multiple biopsies showed that it was an angiosarcoma with metastases in the lymph nodes and the lungs, the latter presenting as carcinomatous miliary. This case is of interest because of the unusual way the tumour was discovered with a possible alternative diagnosis of cardiac tuberculoma, and because of the usefulness of magnetic resonance imaging to diagnose cardiac tumours and evaluate the extension of those which are malignant.