Novel scores relevant to antimicrobial resistance and hospital-acquired infections developed with data from a multi-hospital consortium in the Parisian region of France

PURPOSE

Indicators for comparing and understanding differences in antimicrobial resistance (AMR) and healthcare-associated infections (HAIs) for benchmarking are essential to identify priorities for hospitals.

METHODS

This study measured the incidence of hospital-acquired or resistant Gram-negative bacilli bloodstream infections (GNB-BSIs) in a large public healthcare consortium in the Parisian region of France.

RESULTS

Within each hospital, there was a strong positive correlation between the incidence of GNB-BSIs due to resistant GNB and the incidence of hospital-acquired GNB-BSIs. Two scores measuring AMR and HAI rates by combining different GNB-BSI incidence rates were developed as indicators. These scores were highly variable within the hospital consortium. On multi-variate analysis, AMR and HAI scores were significantly associated with the proportion of surgical beds, staff absenteeism and the consumption of alcohol-based hand rub, with the latter two characteristics being amenable to interventions. Carbapenem use was also linked to AMR, but this may be because carbapenems are the preferred drug for treating resistant infections.

CONCLUSION

These results shed light on the incidence of HAIs and AMR in the study hospitals, and suggest possibilities for targeted interventions at healthcare facility level.

Healthcare worker protection against mpox contamination: position paper of the French Society for Hospital Hygiene

In the context of the recent re-emergence of mpox worldwide, the French Society for Hospital Hygiene (SF2H) performed a literature review of the transmission paths and proposed specific recommendations for healthcare workers (HCWs) caring for patients with suspected or confirmed MPXV. In developed countries, the risk of contamination among HCWs in healthcare facilities seemed to be very low, limited to contamination through needle stick injuries. Two additional contamination cases were reported and not fully explained. Beyond healthcare settings, the analysis of the literature highlighted (i) a main contamination route during sexual intercourse, mainly among men who have sex with men, and (ii) a very low secondary attack rate in other contexts, such as schools or jails. Numerous studies have reported molecular or virus identification on surfaces or in the air surrounding patients, without any association with the low secondary case incidence; moreover, the minimum infectious dose through air or mucosal exposure is still unknown. Owing to the lack of evidence of MPXV respiratory transmission in the healthcare setting, the SF2H recommends the implementation of standard and contact precautions combined with medical/surgical mask use. Owing to the lack of evidence of transcutaneous contamination, the SF2H recommends the use of gloves only if contact with cutaneous lesions or mucous membranes occurs. Regarding the risk of contamination from the environment in healthcare facilities, additional studies must be conducted to investigate this.

Diagnostic performance of angiography-derived FFR in patients presenting with NSTE-ACS

Background

Precise non-invasive methods to measure fractional flow reserve (FFR) are actively being explored, aiming to avoid the use of invasive pressure wire and the administration of hyperaemic stimulus. Coronary angiography-derived FFR (FFRangio) has already proved its diagnostic performance in validation studies in the context of stable coronary artery disease. However, its applicability in the context of non-ST-segment elevation acute coronary syndromes (NSTE-ACS) has yet to be established.

Purpose

The study sought to determine the diagnostic performance of FFRangio in patients presenting with NSTE-ACS and evaluate if it could serve as a reliable alternative to invasive FFR.

Methods

This study is a prospective, single-center, single-arm, double-blinded clinical study comparing the FFR calculated by FFRangio to invasive FFR and it represents a sub-study of a protocol evaluating the diagnostic performance of FFR-CT in NSTE-ACS patients, whose design and rationale has been previously published. Invasive FFR was measured in all angiographically intermediate lesions (30%-70% stenoses) in NSTE-ACS patients and was then compared to FFRangio which was measured in the same position, by a blinded operator. The study primary endpoints were the per lesion diagnostic characteristics of FFRangio using invasive FFR as the standard of reference. A value of ≤0.80 was considered as the threshold for a positive result (i.e. functionally significant lesion) for both invasive and FFRangio.

Results

Among the 46 NSTE-ACS patients included in the study according to the inclusion/exclusion criteria, a total of 60 vessels underwent invasive FFR measurement. The mean value of invasive FFR was 0.83±0.3 with 36% being positive. The mean FFRangio was 0.82±0.1 with 36% being positive. FFRangio showed a sensitivity of 95.5%, a specificity of 97.4% and a diagnostic accuracy of 96.7% to detect the functional significance of an angiographically intermediate stenosis. Moreover, it showed similar diagnostic performance across all three coronary arteries. FFRangio values correlated well with invasive FFR measurements (r=0.83, P<0.001) and the Bland–Altman 95% confidence limits were between −0.12 and 0.10.

Conclusions

This study adds to the limited knowledge on the validity of FFRangio in the context of acute coronary syndromes and demonstrates excellent diagnostic performance as well as strong correlation to the invasive FFR for in the setting of NSTE-ACS. It contributes to the growing body of evidence suggesting that FFRangio can precisely calculate FFR in a wide range of clinical situations thus diminishing the risks of an invasive procedure and the use of hyperaemic agent. Since it is non-invasive, simple and cost-effective, the use of FFRangio could be routinely considered to guide treatment decision in angiographically intermediate coronary lesions in the context of NSTE-ACS.

Funding Acknowledgement

Type of funding sources: None.

Feasibility of clinical and electrocardiographic follow-up of prinzmetal angina using the metaverse

Background

The recent pandemic triggered an acceleration in adopting innovative technologies and telemedicine novelties. The metaverse, representing a merge of digital worlds using augmented reality (AR) and virtual reality (VR), promises disruptive transformation in healthcare. The feasibility of combining the metaverse with cardiovascular telemedicine services empowering remote consultation as well as assisting heart disease prevention and diagnosis, has not been investigated yet in cardiology.

Purpose

We evaluated the feasibility of combined clinical and electrocardiographic follow-up inside the metaverse on top of standard of care for a patient who presented with prinzmetal angina.

Methods

A digital consultation room combining AR/VR was created in a metaverse platform (GDPR compliant, CE marked class I medical device). Patient and cardiologist were given a personal and secured login account. Interactions and connections were made via virtual avatars. Patient was instructed to ask for a consultation in case of any cardiac related symptom occurred. The patient was equipped with a previously validated portable hospital-grade 12-lead smartphone-based electrocardiograph device which was directly integrated to the metaverse platform.

Results

A 30 years old obese active smoker patient presented for recurrent episodes of typical cardiac chest pain at rest. ECG showed sinus rhythm, normal atrioventricular and intraventricular conduction and no repolarization abnormalities. Laboratory test were normal, echocardiography showed a normal biventricular function with no focal abnormalities or valvular disease. Coronary angiogram excluded the presence of coronary artery disease, and the most possible diagnostic scenario was prinzmetal angina from coronary artery spasm. The patient was therefore discharged under treatment with diltiazem 120 mg twice daily, a multiple lead smartphone ECG device as well as the access to metaverse via his avatar, since no ECG were available during the episodes. Ten days later, the patient experienced an episode of palpitation accompanied with general discomfort. He subsequently logged into the metaverse where the cardiologist was available. The anamnesis of the episode was collected as well as the auto-recorded ECG by the patient. Although the clinical and electrocardiographic data were reassuring, the physician proposed to seek for medical attention. Hospital work up was consistent with the diagnosis provided in the virtual consultation.

Conclusions

To our knowledge, we conducted the first medical act in cardiology inside the metaverse combining VR environment with existing cardiovascular technological innovations as support information to the standard of care. Exploiting the full potential of the metaverse could serve as an unparalleled leap in the way cardiovascular medicine is delivered and could introduce new dimensions to cardiology in terms of health education, disease prevention and diagnosis.

Funding Acknowledgement

Type of funding sources: None.

Comparison of the 2016 and 2021 European Society of Cardiology and the 2019 American College of Cardiology/American Heart Association guidelines for primary cardiovascular prevention

Introduction

The European Society of Cardiology (ESC) released in 2021 a new cardiovascular risk prediction model, SCORE2. We aimed to: 1) compare the proportion of individuals included in each category of risk according to 2016 and 2021 ESC and 2019 American Heart Association/American College of Cardiology (AHA/ACC) guidelines on cardiovascular prevention; and 2) assess the discriminative and calibration performances of ESC SCORE1, SCORE2, and AHA/ACC Pooled Cohort Equations (PCE) to predict atherosclerotic cardiovascular disease (ASCVD).

Methods

We used data from the first follow-up of the CoLaus|PsyCoLaus study, a Swiss population-based cohort, including individuals (40–80 years) recruited between 2009–2012 and having a 10-year follow-up. We included participants without lipid-lowering treatment and free from ASCVD at baseline. We computed SCORE1, SCORE2 (SCORE2-OP in people >70 years) and PCE in individuals eligible for score computation according to each guidelines separately. We assessed the performance of the scores based on discrimination and calibration metrics using first incident ASCVD as outcome.

Results

Among 4,107 included participants (women, 55.7%), 128 (3.1%) experienced an incident ASCVD during a mean follow-up time of 8.1 (±1.9) years. Statins would be recommended or considered in 40.3% (95% of confident interval [CI], 38.3–42.3), 27.3% (25.4–29.1) and 35.5% (33.6–37.5) of women, and in 62.2% (60.0–64.5), 59.3% (57.0–61.5) and 65.4% (63.2–67.6) of men according to ESC 2016, ESC 2021 and AHA/ACC 2019 guidelines, respectively. Scores were computed in 3,456 (women, 58.2%), 3,318 (women, 57.1%) and 3,384 (women, 56.7%) participants in primary prevention according to ESC 2016, ESC 2021 and AHA/ACC 2019 guidelines, respectively. 50% of women and 17.4% of men developing an incident ASCVD were not eligible for lipid-lowering treatment at baseline according to SCORE2 (compared to 27.5% of women and 14.5% of men using SCORE1, and 42.1% of women and 14.9% of men using PCE). SCORE2 and PCE presented comparable discriminative capacities with area under the receiver operating characteristic (AUROC) of 0.776 (95% CI, 0.730–0.822) and 0.775 (0.729–0.821), respectively. SCORE1 presented a lower AUROC (0.717 [95% CI, 0.665–0.769], p-value=0.0001). All scores underestimated risk in subjects in intermediate deciles of risk and overestimated risk in people in high deciles of risk. SCORE2 was better calibrated in high-risk individuals compared to SCORE1 and PCE.

Conclusions

Based on ESC 2021 guidelines, if fully implemented, less than a third of women would be eligible for a lipid-lowering therapy, which is lower than according to ESC 2016 and AHA/ACC 2019 recommendations. Among women developing an ASCVD in this sample, half of them were not eligible for a lipid-lowering therapy based on ESC 2021 guidelines. Both SCORE2 and PCE presented good predictive capacities and could be interchangeably used in comparable populations.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): The CoLaus|PsyCoLaus study was and is supported by research grants from GlaxoSmithKline, the Faculty of Biology and Medicine of Lausanne, and the Swiss National Science Foundation (grants 3200B0–105993, 3200B0-118308, 33CSCO-122661, 33CS30-139468, 33CS30-148401 and 33CS30_177535/1).

Combining European Society of Cardiology and American College of Cardiology/American Heart Association risk prediction model with polygenic risk scores to refine cardiovascular prevention

Introduction

Polygenic risk scores (PRS) predict the risk of developing atherosclerotic cardiovascular disease (ASCVD). However, their utility in combination with existing clinical risk scores remains uncertain.

Purpose

We first validated four different PRS in a Swiss population-based cohort. Second, using the PRS with the best predictive capacity, we assessed its benefit when combined with two clinical risk scores: the Systematic COronary Risk Evaluation 2 (SCORE2) and the Pooled Cohort Equation (PCE).

Methods

We used data from a prospective cohort involving 6733 European participants at baseline (2003–2006). The predictive accuracy of the PRS was assessed with discrimination and calibration metrics. For the second aim, subjects with prevalent ASCVD or statin therapy at baseline were excluded. We tested associations between risk prediction models (PRS alone and combined clinical and PRS) and incident ASCVD, using Cox proportional hazard regressions. Net reclassification index (NRI) detected any improvement of ASCVD risk categorisation following the addition of the PRS to clinical risk scores in overall sample and in subgroups (e.g., sex, age, clinical intermediate-risk category)

Results

For the first aim, 4215 subjects (53% women; mean age 53.7±10.7), with 357 prevalent ASCVD, were analysed. The PRS developed by Inouye et al. [1], comprising >6 million variants, presented the best predictive capacity (area under the receiver operating characteristic of 0.77) and was used in the following analyses. For the second aim, 3390 subjects (mean follow-up of 12.0±3.3 years), with 188 incident ASCVD, were analysed. Individuals in the top 20% of the PRS distribution had the same magnitude of association with ASCVD as current smokers or diabetic subjects (see Figure 1). Combining the PRS with SCORE2 led to a reclassification of 17.1% (95% CI, 4.7–29.5) of subjects in the intermediate-risk category (see Figure 2). Likewise, adding the PRS to PCE translated into an NRI of 19.2% (95% CI, 4.8–22.4) in the intermediate-risk category (not shown).

Conclusion

Using a Swiss population-based cohort, PRS presented good predictive capacities for ASCVD. Combining a PRS with clinical risk scores improved reclassification of risk for ASCVD, especially for subjects in the intermediate-risk category. Introducing PRS in clinical practice may refine cardiovascular prevention for subgroups of patients in whom prevention strategies are uncertain.

Funding Acknowledgement

Type of funding sources: None.

The impact of the COVID-19 pandemic on the management and outcomes of STEMI patients in Switzerland

Introduction

The COVID-19 pandemic has placed unprecedented strain on healthcare systems around the world, with potential repercussions on the quality of care of patients with other diseases. From a cardiological perspective, there have been concerns that the pandemic may have impacted the management of the most acute cardiovascular conditions.

Purpose

We evaluated the impact of the COVID-19 pandemic on the management of ST-elevation myocardial infarction (STEMI) in Switzerland by assessing a range of quality-of-care metrics during the first year of the pandemic, as compared with the preceding year.

Methods

Data on STEMI patients hospitalised in Switzerland from 1st January 2019 to 31st December 2020 were obtained from the Acute Myocardial Infarction in Switzerland (AMIS) registry. Symptom-to-first-medical-contact (symptom-to-FMC) time, symptom-to-door time, and door-to-balloon (DTB) time were compared between 2020 and 2019 in an analysis by year and by month. Additionally, rates of in-hospital all-cause mortality and in-hospital major adverse cardiovascular events (MACE: all-cause mortality, MI, stroke) were compared.

Results

Data on 2192 STEMI patients were available. Compared with the preceding 12 months, the first year of the pandemic was not associated with a significant change in median symptom-to-FMC time (2020: 90 minutes vs 2019: 95 minutes, p=0.32) or median symptom-to-door time (2020: 145 min vs 2019: 157 min, p=0.51). In 2020, February (start of the pandemic) and March (start of national lockdown) were associated with increased DTB times as compared with the same months of 2019 (+7 minutes, +10 minutes, respectively). However, overall median door-to-balloon times remained stable (2020: 40 min vs 2019: 39 min, p=0.06). Furthermore, there was no significant difference in the proportion of patients undergoing percutaneous coronary intervention (2020: 95.6% vs 2019: 95.1%, p=0.54). Finally, there were no significant differences in median length of stay (2020: 4 days vs 2019: 157 min, p=0.51), in-hospital all-cause mortality (2020: 4.9% vs. 2019: 4.2%, p=0.41) or MACE (2020: 6.2% vs. 2019: 5.6%, p=0.52).

Conclusions

Although there are some limitations associated with the present study inherent to its retrospective observational design (for instance, a potentially important number of late comers may not have been included in the registry), the data suggest that despite the impact of COVID-19 on the healthcare system in Switzerland in 2020, STEMI management as defined by a range of quality-of-care metrics remained effective and efficient.

Funding Acknowledgement

Type of funding sources: None.

Quantifying coronary microvascular disease: assessing absolute microvascular resistance reserve (MRR) by continuous coronary thermodilution

Background and aim

Hyperemic absolute coronary blood flow (in mL/min) can be safely and reproducibly measured with intracoronary continuous thermodilution of saline at room temperature at an infusion rate of 20 mL/min. This study aims at assessing whether continuous thermodilution can also measure resting flow and microvascular resistance.

Methods and results

In 87 coronary arteries (58 patients) with angiographic non-significant stenoses absolute flow was assessed by continuous thermodilution of saline at infusion rates of 10 mL/min and 20 mL/min using a pressure/temperature sensored guide wire, a dedicated infusion catheter and a dedicated software. In addition, in 26 arteries, average peak velocity (APV) was measured simultaneously using an intracoronary Doppler-wire.

There was no significant difference between Pd/Pa at baseline and during saline infusion at 10 mL/min, (0.95±0.053 vs 0.94±0.054, respectively (p=0.53) and there was no significant difference in APV at baseline and during the infusion of saline at 10 mL/min (22.2±8.40 vs 23.2±8.39 cm/s, respectively, p=0.63), thus indicating presence of resting coronary blood flow during the infusion of 10 mL/min of saline.

In contrast, at an infusion rate of 20 mL/min, a significant decrease in Pd/Pa was observed compared to baseline: (0.85±0.089 vs 0.95±0.053, respectively, p<0.001) and a significant increase in APV was observed (22.2±8.4 cm/s to 57.8±25.5 cm/s, respectively, p<0.001). The coronary flow reserve (CFR) calculated by thermodilution and by Doppler flow velocity were similar (2.73±0.85 vs 2.72±1.07, respectively) and their individual values correlated closely (r=0.87, 95% CI 0.72–0.94, p<0,001). Microvascular resistance (Rμ), defined as the distal coronary pressure divided by the absolute flow was calculated both at rest (Rμ-rest) and during hyperemia (Rμ-hyper). Microvascular Resistance Reserve (MRR), is calculated as the ratio of Rμ-rest and Rμ-hyper and showed a good correlation with the analogous Doppler-derived parameter (using the APV instead of absolute flow). Mean doppler and thermodilution derived MRR were similar (3.32±1.50 vs 3.23±1.16) and values correlated closely (r=0.91, 95% CI 0.81 - 0.96, p<0.001; Bland-Altman analysis: mean bias = 0.071, limit of agreement −1.195 to 1.338).

Conclusion

Absolute coronary blood flow (in mL/min) can be measured by continuous thermodilution both at rest and during hyperemia. This allows accurate, reproducible, and operator-independent direct volumetric calculation of CFR and MRR. The latter is a quantitative metric which is specific for microvascular function and independent from myocardial mass.

Doppler and Thermodilution derived MRR

Funding Acknowledgement

Type of funding source: None

Thermodilution-derived resting coronary flow measurement: “a reverse dose finding study”

Background

Hyperemic absolute coronary blood flow (in mL/min) can be safely and reproducibly measured with intracoronary continuous thermodilution of saline at room temperature at an infusion rate of 20 mL/min. This study aims at assessing the best infusion rate to measure resting flow by thermodilution, i.e. low enough to avoid microvascular dilation but high enough to allow reliable thermodilution tracings

Methods and results

In 26 coronary arteries (24 patients) with angiographic non-significant stenoses, absolute flow was assessed by continuous saline thermodilution at infusion rates of 10 mL/min and 20 mL/min using a pressure/temperature sensored guide wire, a dedicated infusion catheter and a dedicated software. Average peak velocity (APV) was measured simultaneously using an intracoronary Doppler-wire. In addition, in a subgroup of 10 arteries, absolute flow and APV were also measured during saline infusion at 6 ml/min and 8 ml/min.

In 26 coronary arteries there was no significance difference in the Pd/Pa and in the APV at baseline and during the infusion of saline at 10 ml/min (Pd/Pa: 0.94±0.057 vs 0.94±0.059, p=0.82; APV: 22.2±8.40 vs 23.2±8.39 cm/s, p=0.63). In contrast, at an infusion rate of 20 mL/min, we observed a significant decrease in Pd/Pa compared to baseline (0.85±0.089 vs 0.95±0.053 vs, respectively, p<0.001) and a significant increase in APV (22.2±8.4 cm/s to 57.8±25.5 cm/s, respectively, p<0.001). The coronary flow reserve (CFR) evaluated by Doppler and intracoronary continuous thermodilution correlated well (r=0.87, 95% CI = 0.72–0.94, p<0.001) and Bland-Altman analysis documented a mean bias of −0.003 (limit of agreement −1.05 to 1.04) thus indicating the presence of resting coronary blood flow during the infusion of 10 mL/min of saline. In 10 coronary arteries saline infusions at 6 and 8 ml/min did not produce any significant changes in the Pd/Pa and in the APV compared to baseline and both Doppler and Thermodilution derived CFR correlated well at each infusion rate (6 ml/min: r=0.71, 95% CI 0.14–0.92, p=0.02; 8ml/min: r=0.78, 95% CI=0.31–0.95, p=0.007). However, with an infusion rate of 6 mL/min, an unstable thermodilution tracing was observed. Accordingly, Bland-Altman analysis showed a significantly larger dispersion of the CFR values when 6 ml/min was used to measure resting coronary flow (as compared with 8 m/min): mean bias at 6 ml/min: −0.53, limits of agreement: −2.25 to 1.20: mean bias at 8 ml/min: 0.004, limits of agreement: −0.72 to 0.73.

Conclusion

Absolute resting coronary flow can be measured by intracoronary continuous thermodilution of saline at infusion rate of 8–10 ml/min.

Funding Acknowledgement

Type of funding source: None

Revascularization decisions in patients with stable angina and intermediate lesions: results of the second International Survey on Interventional Strategy (ISIS-2)

Background

ISIS-1 survey (conducted in 2012–2013) demonstrated a significant disconnect between guideline recommendations on invasive functional and imaging assessment of coronary stenosis severity and effective intention to adoption in patients with chronic coronary syndromes (CCS). Ever since, more evidences and new indexes/tools have become available, supposedly resulting into a simplified adoption. Therefore, six years later the second survey was repeated (ISIS-2) with the aim to evaluate a possible evolution in the intended adoption of invasive diagnostic tools.

Methods

ISIS-2 was conducted via a web-based platform from June to December 2019. Here, five complete angiograms were provided, presenting only focal intermediate stenoses. FFR and quantitative coronary angiography (QCA) values were known and kept concealed to the participants. Estimation of stenosis significance was asked for each lesion. In case of uncertainty, the most appropriate adjunctive invasive diagnostic method among QCA, intravascular ultrasound, optical coherence tomography, or invasive functional test (i.e. with FFR or a non-hyperemic index) was to be selected. Primary endpoint of the study was the rate of requested adjunctive functional or imaging assessment, as indicated by guideline recommendations. Secondary endpoint was the rate and accuracy of purely angiography-based decisions.

Results

A total of 411 participants performed 3749 lesion evaluations in ISIS-2: 2237 (60%) decisions were taken solely on angiogram and expressed no need for further evaluation with adjunctive tools. This rate of angiographic reliance was significantly reduced in ISIS-2 as compared with ISIS-1 (3139 [71%]; p<0.001). Here the decision (significant or non-significant) was discordant with the known functional significance in 870 (39%) cases, markedly less as in ISIS-1 (1459, 46%; p<0.001). In ISIS-2, participants expressed the need for either invasive functional assessment or intravascular imaging in 1110 (29%) and 379 (11%) cases, respectively. These rates were significantly higher as compared with ISIS-1 (928 [21%]; p<0.001 and 354 [8%]; p<0.001, respectively).

Conclusions

ISIS-2 survey suggests an evolving pattern over 6 years in the intention to integrate coronary angiography with invasive coronary physiology and imaging testing in patients with CCS.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Unrestricted grant from Abbott Medical

Delay between symptom onset and hospital admission in patients with ST-elevation myocardial infarction: different trends in men and women

Introduction

The aim of this study was to analyse whether prehospital delay in ST-elevation myocardial infarction (STEMI) has changed in men and women since 2002.

Methods

We used data from the AMIS Plus registry of patients who were admitted for STEMI between 2002 and 2019. Patients who were transferred from another hospital or were resuscitated before admission were excluded. Patient delay was defined as the difference between symptom onset and hospital admission time. Trends in delay according to gender were depicted by medians per year with a 95% confidence interval. Differences between men and women were tested using the Mann-Whitney test. To analyse the adjusted effect of gender on delay, multivariable quantile regression was applied including the interaction between gender and admission year as well as the covariates age, diabetes, pain at presentation and myocardial infarction (MI) history.

Results

Among the 15,154 patients included (74.5% men), the overall median (IQR) delay between 2002 and 2019 was 150 (84; 345) minutes for men and 180 (100; 415) for women. Women were older (71.3y vs. 62.8y, p<0.001), had more often diabetes (20.0% vs. 16.9%, p<0.001), but less often MI history (11.2% vs. 14.9%, p<0.001) and less often pain at presentation (92.0% vs. 94.8%, p<0.001).

The unadjusted median delay decreased over the admission years. The decreasing trend was stronger in women than men: the unadjusted difference in delay between men and women decreased from 60 min in 2002 (p=0.003) to 15 min in 2019 (p=0.155) (Fig 1). The multivariable model confirmed a significant interaction between gender and admission year (p=0.042) indicating that the decrease in delay was stronger for women (−3.1 min per year) than for men (−1.4 min per year) even after adjustment. The adjusted difference between men and women decreased from 27.4 min in 2002 to −1.6 min for women in 2019. Additional independent predictors of longer delay were the covariates age (+1.6 min per additional year, p<0.001) and diabetes (+27.1 min, p<0.001). Conversely, pain at admission (−46.3 min, p<0.001) and MI history (−32.9 min, p<0.001) predicted a shorter delay.

Conclusions

The difference in delay between symptom onset and hospital admission in STEMI patients between men and women steadily diminished from 2002 to 2019. This might indicate that the public and health professionals' awareness of STEMI in women has ameliorated over time.

Unadjusted delay according to gender

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): AMIS Plus Foundation

Gold(I) Complexes Nuclearity in Constrained Ferrocenyl Diphosphines: Dramatic Effect in Gold-Catalyzed Enyne Cycloisomerization

Di-tert-butylated-bis(phosphino)ferrocene ligands bearing phosphino substituents R (R=phenyl, cyclohexyl, iso-propyl, mesityl, or furyl) allow tuning the selective formation of Au(I) halide complexes. Thus, dinuclear linear two-coordinate, but also rare mononuclear trigonal three-coordinate and tetrahedral four-coordinate complexes were formed upon tuning of the conditions. Both Au(I) chloride and rarer Au(I) iodide complexes were synthesized, and their X-ray diffraction analysis are reported. The significance of the control of structure and nuclearity in Au(I) complexes is further illustrated herein by its strong effect on the efficiency and selectivity of gold-catalysed cycloisomerization. Cationic linear digold(I) bis(dicyclohexylphosphino) ferrocenes outperform other catalysts in the demanding regioselective cycloisomerization of enyne sulphonamides into cyclohexadienes. Conversely, tetrahedral and trigonal cationic monogold(I) complexes were found incompetent for enyne cycloaddition. We used the two-coordinate linear electron-rich Au(I) complex 2 b (R=Cy) to extend the scope of selective intramolecular cycloaddition of different 1,6-enyne sulfonylamines with high activity and excellent selectivity to the endo cyclohexadiene products.

3286Fractional flow reserve-guided treatment strategy for left main coronary artery stenoses. Ten-year clinical outcome

Background

Revascularization decisions regarding left main (LM) coronary stenoses are often very challenging. Non-invasive tests can yield false negative results. On the other hand, some technical aspects of fractional flow reserve (FFR) measurement, as well as the interpretation of their results, are less codified than for other coronary segments.

Purpose

To investigate the 10-year clinical outcome of patients with isolated angiographically intermediate LM coronary stenosis in whom the treatment strategy was based on Fractional Flow Reserve (FFR) measurements.

Methods

From 1999 to 2009 we included 96 patients with isolated intermediate LM coronary disease (DS% 30–70%) evaluated with FFR measurement. When FFR was >0.80, patients were deferred to medical therapy (Deferral-group, n=71). When FFR was ≤0.8, surgical revascularization therapy was proposed (Revascularization-group, n=25). Death, the occurrence of myocardial infarction (MI) and the need for target vessel revascularization (TVR) were evaluated in both groups.

Results

There were no significant differences in clinical characteristics between the 2 groups. Mean DS% was 35% in the Deferral-group and 43% in the Revascularization-group (p<0.01). Average FFR was 0.88 in the Deferral-group and 0.71 in the Revascularization-group (p<0.01). In the latter, the 10-year survival estimate was 72% while it was 77% in the Deferral group (HR [95% CI]: 1.28 [0.53–3.10]; p=NS). No difference was found between the 2 groups in terms of MI (4.5% vs. 1.6%; HR [95% CI]: 3.5 [0.22–56.0]; p=NS) or TVR (9% vs. 12%; HR [95% CI]: 0.94 [0.20–4.43]; p=NS).

Conclusions

The use of FFR to defer revascularization in patients with non-significant isolated LM stenosis is safe and is associated with favourable clinical outcome at 10 years.

P3631Impact of manual thrombectomy on microvascular obstruction among STEMI patients

Background

Manual thrombectomy (MT) in ST segment elevation myocardial infarction (STEMI) is not associated with improved outcome and may even be harmful. Microvascular obstruction (MVO) assessed with cardiac magnetic resonance (CMR) imaging is among the strongest outcome predictors after STEMI.

Purpose

We aimed to investigate the impact of MT on MVO occurrence and extent.

Method

Between December 2010 and June 2017, 401 consecutive STEMI patients admitted for primary PCI, and still hospitalized in our tertiary care hospital at day 3 or later, (i.e. not transferred to another hospital) underwent a CMR during the index hospitalization (routine care at our institution during this period). Among them, 383 patients fulfilled the inclusion criteria and were classified into 2 categories (with or without MT) while 18 patients were excluded because of incomplete CMR data. The 2 co-primary endpoints were the occurrence and the extent of MVO, with these latter being analyzed either as a categorical variable (MVO vs. No-MVO) or as a semi-continuous variable (numbers of segments with MVO), respectively.

Results

In total, 188 (49.1%) patients experienced MVO. Both the incidence of MVO and the median number of segments with MVO were significantly higher in the MT group as compared to the no-MT group (59.5% vs 38.9%, respectively p<0.001, Figure 1A) and (0 [0; 2] vs 1.5 [0; 4]; respectively, p<0.001). When stratifying the analysis on coronary thrombus grade (Figures 1B and 1C), similar results were found only in patients with high thrombus burden (43.5% vs 60.7%, respectively, p=0.004). When adjusting for baseline differences between the 2 groups, MT remained a determinant of MVO (OR 1.90 (CI 95% 1.08 to 3.34); p=0.026) in patients with high thrombus grade.

Figure 1

Conclusion

In STEMI patients undergoing primary PCI, MT is associated with the occurrence and the extent of MVO assessed by CMR, especially in patients with a high thrombus grade. This suggests thrombus fragmentation with distal embolization as a potential mechanistic explanation.

Acknowledgement/Funding

None

464Optimal timing of invasive coronary angiography following NSTEMI

Introduction

Current guidelines recommend angiography within 24 hours of hospitalisation for patients with non-ST elevation myocardial infarction (NSTEMI). The recent VERDICT study found that angiography within 12 hours of hospitalisation was associated with improved cardiovascular outcomes among high-risk patients. We aimed to obtain a real-world perspective of the impact of angiography timing on one-year outcomes of patients admitted with NSTEMI.

Methods

Data was obtained from the SPUM-ACS registry, a cohort of consecutive patients hospitalised with acute coronary syndromes in four university hospitals in Switzerland between 2009 and 2017. Patients without a door-to-catheter (DTC) time and those with life-threatening features were excluded. Cox proportional hazards models evaluated the impact of DTC time on the primary endpoint, defined as one-year major adverse cardiovascular events (MACE: cardiovascular mortality, myocardial infarction, stroke), and on one-year all-cause mortality.

Results

Of 2,672 NSTEMI patients, 1,832 met the inclusion criteria. Among them, 1,464 patients underwent angiography within 12 hours of admission (12h group) while 368 patients underwent angiography between 12 and 24 hours (12–24h group). After 2:1 propensity score matching, 736 patients from the 12h group and 368 patients from the 12–24h group were deemed equivalent in terms of main baseline clinical characteristics. Multiple logistic regression identified admission out-of-hours (night or weekend) as the most significant factor associated with delayed angiography. Cox models found no significant association between early angiography and one-year MACE (12h group: n=57 (7.7%) vs. 12–24h group: n=27 (7.3%), HR: 1.050, 95% CI 0.637- 1.733, p=0.847), or one-year all-cause mortality (12h group: n=25 (3.4%) vs. 12–24h group: n=17 (4.6%), HR: 1.514, 95% CI 0.774- 2.962, p=0.225) (Figure 1A). After stratification based on GRACE score (>140 vs. ≤140), there was no significant difference in one-year MACE or one-year all-cause mortality in the 12h group compared with the 12–24h group (p for interaction=0.601 and 0.463, respectively) (Figure 1A + 1B).

Figure 1

Conclusion

In an unselected real-world cohort of NSTEMI patients, angiography within 12 hours of hospitalisation was not associated with improved one-year outcomes when compared with angiography between 12 and 24 hours, even among patients with an elevated GRACE score.

P2736Hemodynamic and clinical impact in adult patients with anomalous aortic origin of the coronary artery evaluated with quantitative flow reserve

Background

Anomalous origin of the right coronary artery (ARCA) represents the most frequent form of abnormal coronary origin and may potentially increase the risk for sudden cardiac death. Evaluation of ARCA in adult patients referred for invasive coronary angiograms (ICA) is difficult, and clinical impact is unknown. Quantitative flow reserve (QFR) is an available method able to virtually calculate fractional flow reserve using 3-dimensional quantitative coronary angiography (3D-QCA) based on ICA.

Objectives

To evaluate the feasibility of QFR analysis in patients with ARCA and its clinical impact.

Methods

Using the registry of proximal anomalous connections of coronary arteries (ANOCOR registry), a multicentric observational registry including 472 adult patients with ANOCOR between 2010 and 2013, we retrospectively performed QFR analysis from ICA and evaluated the rate of death, myocardial infarction, unplanned revascularization and hospitalization in cardiology at 5 years.

Results

Among 128 patients with ARCA, 41 (32%) could have QFR analysis with median clinical follow-up of 8.3 years. The mean QFR value was 0.90±0.10, and 3D-QCA analysis showed preserved lumen area despite the elliptical shape of the proximal part of the ARCA which in the worst cases appeared on ICA as a significant narrowing. The event rate was 14.6% (n=6), including three deaths (one due to cancer, one due to stroke, and one cause remains unknown), two unplanned revascularizations, and one hospitalization for heart failure at 5 years. No myocardial infarction was reported.

Conclusions

QFR analysis of ARCA is feasible and non-significant QFR values are associated with good clinical outcome at 5 years. QFR of ARCA could be the evaluation of choice to help in clinical decision-making during ICA, when applicable.

A glassy carbon electrode modified by a triply-fused-like Co(ii) polyporphine and its ability for sulphite oxidation and detection

An original Co(ii) porphyrin conductive polymer is electrosynthesized which efficiently catalyzes sulphite oxidation in water offering opportunities for sensor development.

[French recommendations on control measures to reduce the infectious risk in immunocompromised patients]

The increase use of immunosuppressive treatments in patients with solid cancer and/or inflammatory diseases requires revisiting our practices for the prevention of infectious risk in the care setting. A review of the literature by a multidisciplinary working group at the beginning of 2014 wished to answer the following 4 questions to improve healthcare immunocompromised patients: (I) How can we define immunocompromised patients with high, intermediate and low infectious risk, (II) which air treatment should be recommended for this specific population? (III) What additional precautions should be recommended for immunocompromised patients at risk for infection? (IV) Which global environmental control should be recommended? Based on data from the literature and using the GRADE method, we propose 15 recommendations that could help to reduce the risk of infection in these exposed populations.

Evaluation of excreta management in a large French multi-hospital institution

BACKGROUND

Excreta are a major source of multidrug-resistant Enterobacteriaceae including strains that produce extended-spectrum beta-lactamase (ESBL). The increase of ESBL incidence in Assistance Publique - Hôpitaux de Paris (AP-HP) hospitals prompted an evaluation of the equipment and practices used to dispose of excreta.

AIM

To evaluate the use of equipment for the management of excreta and to review practices of healthcare workers in their disposal.

METHODS

A cross-sectional survey was conducted in 2012.

FINDINGS

A total of 28 AP-HP hospitals including 536 units (342 acute care units and 194 rehabilitation and long-term care units) were evaluated. Among the patients on the day of the survey, 5697 (43%) wore diapers and 1767 (13%) were using a bedpan. Sixty-one percent of the beds were equipped with shared toilets and 43% of the toilets were equipped with hand sprayers, a device favouring the spread of faecal material in the environment. Sixty eight percent of the units were equipped with bedpan washer-disinfectors. Only 52% of the bedpan washer-disinfectors were located in rooms where alcohol-based hand rubs (ABHRs) were available. In 71% of the units the bedpan was rinsed before disinfection, mostly in the patient's bathroom (62%). Finally, only 9% of questioned healthcare workers said they followed an educational programme about excreta disposal.

CONCLUSION

This survey shows that, in the field of multidrug-resistant Enterobacteriaceae control and the promotion of hand hygiene with ABHRs, excreta management is a concerning but neglected subject.

French recommendations for the prevention of 'emerging extensively drug-resistant bacteria' (eXDR) cross-transmission

Controlling the spread of multi- or extensively drug-resistant bacteria (MDR or XDR) includes a dual strategy for reducing antibiotic prescriptions and preventing their spread from patient carriers. Standard precautions are applicable to all health professionals caring for any patients; additional barrier precautions (isolation) are recommended for patients carrying transmissible infectious diseases or MDR bacteria in sporadic or epidemic situations. Moreover, additional precautions may be required for populations at particular risk of infection or colonization by emerging XDR (eXDR), defined in our country as carbapenemase-producing Enterobacteriaceae and vancomycin-resistant enterococci. Our ability to detect and identify eXDR carriers early and ensure their follow-up, through effective communication between all those involved, is a significant challenge for controlling their spread. Thus, the French High Committee for Public Health has updated and standardized all French existing recommendations concerning the prevention of the cross-transmission of these bacteria, and these recommendations are summarized in this review. The recommendations are based on scientific and operational knowledge up to 2013. Different preventive strategies are recommended for patients found to be carrying eXDR and those who are considered to be at risk of having eXDR because of a history of contact. The local context, the experience of the infection control team, the different times at which detection of eXDR takes place (during admission, hospitalization, etc.) and the epidemiological situation (sporadic cases, clusters, outbreaks, widespread epidemic) must be included in risk assessments that in turn inform the control measures that should be applied in each clinical circumstance.

Outcome of hepatitis E virus infection in patients with inflammatory arthritides treated with immunosuppressants: a French retrospective multicenter study

The clinical presentation and outcome of hepatitis E virus (HEV) infection in inflammatory rheumatic diseases are unknown. We aimed to investigate the severity of acute HEV infection and the risk of chronic viral replication in patients with inflammatory arthritides treated with immunosuppressive drugs. All rheumatology and internal medicine practitioners belonging to the Club Rhumatismes et Inflammation in France were sent newsletters asking for reports of HEV infection and inflammatory arthritides. Baseline characteristics of patients and the course of HEV infection were retrospectively assessed by use of a standardized questionnaire. From January 2010 to August 2013, we obtained reports of 23 cases of HEV infection in patients with rheumatoid arthritis (n = 11), axial spondyloarthritis (n = 5), psoriatic arthritis (n = 4), other types of arthritides (n = 3). Patients received methotrexate (n = 16), antitumor necrosis factor α agents (n = 10), rituximab (n = 4), abatacept (n = 2), tocilizumab (n = 2), and corticosteroids (n = 10, median dose 6 mg/d, range 2-20). All had acute hepatitis: median aspartate and alanine aminotransferase levels were 679 and 1300 U/L, respectively. Eleven patients were asymptomatic, 4 had jaundice. The HEV infection diagnosis relied on positive PCR results for HEV RNA (n = 14 patients) or anti-HEV IgM positivity (n = 9). Median follow-up was 29 months (range 3-55). Treatment included discontinuation of immunosuppressants for 20 patients and ribavirin treatment for 5. Liver enzyme levels normalized and immunosuppressant therapy could be reinitiated in all patients. No chronic infection was observed. Acute HEV infection should be considered in patients with inflammatory rheumatism and elevated liver enzyme values. The outcome of HEV infection seems favorable, with no evolution to chronic hepatitis or fulminant liver failure.

[Carbapenemase-producing enterobacteriae: epidemiology, strategies to control their spread and issues]

The increasing bacterial resistance to antibiotics has become a major public health concern bringing the threat of therapeutic impasses. In this context, control of the spread of highly-resistant bacteria emerging antibiotics (BHRe), such as glycopeptide-resistant enterococci (VRE) and Enterobacteriaceae producing carbapenemases (CPE), is based on a dual strategy of reducing the prescription of antibiotics to limit the pressure selection and preventing the spread from carriers. Prevention strategy is based on three different levels such as standard precautions for all patients with a particular focus on the management of excreta, and additional precautions for BHRe carriers. What makes it difficult is that carriage is usually completely asymptomatic, enterobacteria and enterococci are normal commensal of gut microbiota. Explosive dissemination of Enterobacteriaceae producing extended spectrum beta-lactamases in hospital and community heralds the emergence of CPE whose import by patients with a history of hospitalization in abroad may be the main source of spread in France.

Long-term control of carbapenemase-producing Enterobacteriaceae at the scale of a large French multihospital institution: a nine-year experience, France, 2004 to 2012

In 2009, following the occurrence of several outbreaks of carbapenemase-producing Enterobacteriaceae (CPE), a programme for controlling the spread of CPE was implemented in the 38 hospitals of the Assistance Publique-Hôpitaux de Paris, a 21,000-bed institution. This programme included recommendations to isolate, and screen for CPE, patients previously hospitalised abroad, and bundled measures to control cross transmission (barrier precautions, dedicated staff and screening of contact patients). From 2004 to 2012, 140 CPE index cases were identified, 17 leading to outbreaks. After application of the programme, in spite of an increase in the number of CPE index cases epidemiologically linked with a recent stay or hospitalisation abroad, the proportion of cases followed by outbreaks, which was 40% (4/10) before 2009, decreased to 10% (13/130) (p=0.02), and the proportion of secondary cases among all CPE cases decreased from 69% (22/32) to 23% (38/168), (p<0.001). The number of secondary cases varied significantly depending on the speed and strength of the measures implemented around the CPE index case: quick (within two days of patient admission at the hospital) setting of nursing staff dedicated to the patient, quick setting of simple barrier precautions, or delayed measures of control (p=0.001). A sustained and coordinated strategy can lead to control CPE at the level of a large regional multi-hospital institution in a country where CPE are at an emerging stage.

Long-term control of vancomycin-resistant Enterococcus faecium at the scale of a large multihospital institution: a seven-year experience

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Long-term control of vancomycin-resistant Enterococcus faecium at the scale of a large multihospital institution: a seven-year experience

Repeated outbreaks of vancomycin-resistant Enterococcus faecium (VRE) occurred between 2004 and 2010 in Assistance Publique--Hôpitaux de Paris (AP-HP), a 23,000-bed multi-hospital institution. From August 2004 to December 2005, the French guidelines for preventing cross-transmission of multiresistant bacteria were applied. Because the number of VRE cases continued to increase, an institutional control programme was implemented from January 2006 onwards: it foresees stopping transfer of VRE and contact patients, separating VRE and contact patients in distinct cohorts, intervention of a central infection control team to support local teams, and quick application of measures as soon as first VRE cases are identified. Between August 2004 and December 2010, 45 VRE outbreaks occurred in 21 of the 38 AP-HP hospitals, comprising 533 cases. Time series analysis showed that the mean number of cases increased by 0.8 cases per month (95% confidence interval (CI): 0.3 to 1.3, p=0.001) before, and decreased by 0.7 cases per month after implementation of the programme (95% CI: -0.9 to -0.5, p<0.001), resulting in a significant trend change of -1.5 cases per month (95% CI: -2.1 to -0.9, p<0.001). The number of cases per outbreak was significantly lower after implementation of the programme. A sustained and coordinated strategy can control emerging bacteria at the level of a large regional multihospital institution.

[Description and investigation of an outbreak of extended-spectrum beta-lactamase producing Escherichia coli strain in a neonatal unit]

An outbreak of colonization and infection with an Escherichia coli strain producing extended-spectrum beta-lactamase (ESBL) occurred in a neonatal unit : a high rate of cases was observed, 27/59 neonates were colonized : one of them developed meningitis with favourable outcome and another baby developed conjunctivitis. Despite intensive efforts to control the outbreak by standard methods of hand hygiene, patients screening and isolation, the spread was uncontrolled and the unit was closed to all admission in order to stop the outbreak. The investigation was not able to identify a single outbreak's source. Emergence and spread of ESBL producing E. coli strains from community and hospital acquired infections are a significant public health problem with difficult choice of treatment for serious infections.

Control of a multi-hospital outbreak of KPC-producing Klebsiella pneumoniae type 2 in France, September to October 2009

An outbreak of Klebsiella pneumoniae carbapenemase (KPC)-producing Klebsiella pneumoniae type 2 was detected in September 2009 in two hospitals in a suburb south of Paris, France. In total, 13 KPC-producing K. pneumoniae type 2 cases (four with infections and nine with digestive-tract colonisations) were identified, including a source case transferred from a Greek hospital. Of the 13 cases, seven were secondary cases associated with use of a contaminated duodenoscope used to examine the source case (attack rate: 41%) and five were secondary cases associated with patient-to-patient transmission in hospital. All isolated strains from the 13 patients: (i) exhibited resistance to all antibiotics except gentamicin and colistin, (ii) were more resistant to ertapenem (minimum inhibitory concentration (MIC) always greater than 4 mg/L) than to imipenem (MIC: 1–8 mg/L, depending on the isolate), (iii) carried the blaKPC-2 and blaSHV12 genes and (iv) had an indistinguishable pulsed-field gel electrophoresis (PFGE) pattern. These cases occurred in three hospitals: some were transferred to four other hospitals. Extended infection control measures implemented in the seven hospitals included: (i) limiting transfer of cases and contact patients to other wards, (ii) cohorting separately cases and contact patients, (iii) reinforcing hand hygiene and contact precautions and (iv) systematic screening of contact patients. Overall, 341 contact patients were screened. A year after the outbreak, no additional case has been identified in these seven hospitals. This outbreak emphasises the importance of rapid identification and notification of emerging highly resistant K. pneumoniae strains in order to implement reinforced control measures.