Acute coronary syndrome (ACS) refers to a group of clinical conditions caused by myocardial ischemia including unstable angina, non-ST-segment elevation myocardial infarction (NSTEMI), and ST-segmcnt elevation myocardial infarction (STEMI). Appropriate and accurate diagnosis has life-saving implications and requires a quick but thorough evaluation of the patient's history, physical examination, electrocardiogram, radiographic studies, and cardiac biomarkers. The management of patients with suspected or confirmed ACS continues to evolve as new evidence from clinical trials is considered and as new technology becomes available to both primary care physicians and cardiologists. Low- and intermediate-risk patients have frequently been managed in a chest pain center or in the emergency department. While stress testing with or without radionuclide imaging is the most common evaluation method, a CT angiogram is sometimes substituted High-risk patients are often managed with an early invasive strategy involving left heart catheterization with a goal of prompt revascularization of at-risk, viable myocardium. With the increased availability of cardiac catheterization facilities, patients with STEMI are more commonly being managed with primary percutaneous coronary intervention, although thrombolysis is still used where such facilities are not immediately available. This article provides primary care physicians with a concise review of the pathophysiology, clinical evaluation, and management of ACS based on the best available evidence in 2008.

Purpose of Review: To review the clinical evidence on the use of percutaneous coronary intervention (PCI) revascularization options in left main (LM) disease in comparison with coronary artery bypass graft (CABG). Coronary artery disease (CAD) involving the LM is associated with high morbidity and mortality. Though CABG remains the gold standard for complex CAD involving the LM artery, recent trials have shown a trend towards non-inferiority of the LM PCI when compared with CABG in certain subset of patients. Recent Findings: Two recent major randomized trials compared the outcomes of PCI versus CABG in the LM and multi-vessel disease with LM involvement. The NOBLE trial included patients with all range of Synergy Between Percutaneous Coronary Intervention With TAXUS and Cardiac Surgery (SYNTAX) scores and utilized biolimus drug-eluting stent (DES). The trial concluded that MACCE (major adverse cardiac and cerebrovascular event) was significantly higher with PCI (28%) when compared with CABG (18%) but overall stroke and motility were not different. EXCEL trial evaluated the same treatment option in low to intermediate SYNTAX score population with third-generation everolimus DES platform as PCI option. Results showed no significant differences in the composite primary endpoints of death, stroke, and myocardial infarction (MI) at the end of 30 days (22% versus 19.2%, p = 0.13), although repeat revascularization was higher in PCI group (16.9% versus 10%). Summary: Recent evidence suggests that PCI is an acceptable alternative to treat symptomatic LM stenosis in select group of patients. In low to medium SYNTAX score, particularly in patients without diabetes mellitus, PCI remains a viable option. Future trials focusing on evaluating subset of patients who would benefit from one particular revascularization option in comparison with other is warranted.

RATIONALE & OBJECTIVE: Patients receiving maintenance dialysis have higher mortality after primary percutaneous coronary intervention (pPCI) than patients not receiving dialysis. Whether pPCI confers a benefit to patients receiving dialysis that is similar to that which occurs in lower-risk groups remains unknown. We compared the effect of pPCI on in-hospital outcomes among patients hospitalized for ST-elevation myocardial infarction (STEMI) and receiving maintenance dialysis with the effect among patients hospitalized for STEMI but not receiving dialysis. STUDY DESIGN: Retrospective cohort study. SETTING & PARTICIPANTS: We used the National Inpatient Sample (2016-2018) and included all adult hospitalizations with a primary diagnosis of STEMI. PREDICTORS: Primary exposure was PCI. Confounders included dialysis status, demographics, insurance, household income, comorbidities, and the elective nature of the admission. OUTCOME: In-hospital mortality, stroke, acute kidney injury, new dialysis requirement, vascular complications, gastrointestinal bleeding, blood transfusion, mechanical ventilation, palliative care, and discharge destination. ANALYTICAL APPROACH: The average treatment effect (ATE) of pPCI was estimated using propensity score matching independently within the group receiving dialysis and the group not receiving dialysis to explore whether the effect is modified by dialysis status. Additionally, the average marginal effect (AME) was calculated accounting for the clustering within hospitals. RESULTS: Among hospitalizations, 4,220 (1.07%) out of 413,500 were for patients receiving dialysis. The dialysis cohort was older (65.2 ± 12.2 vs 63.4 ± 13.1, P < 0.001), had a higher proportion of women (42.4% vs 30.6%, P < 0.001) and more comorbidities, and had a lower proportion of White patients (41.1% vs 71.7%, P < 0.001). Patients receiving dialysis were less likely to undergo angiography (73.1% vs 85.4%, P < 0.001) or pPCI (57.5% vs 79.8%, P < 0.001). Primary PCI was associated with lower mortality in patients receiving dialysis (15.7% vs 27.1%, P < 0.001) as well as in those who were not (5.0% vs 17.4%, P < 0.001). The ATE on mortality did not differ significantly (P interaction = 0.9) between patients receiving dialysis (-8.6% [95% CI, -15.6% to -1.6%], P = 0.02) and those who were not (-8.2% [95% CI, -8.8% to -7.5%], P < 0.001). The AME method showed similar results among patients receiving dialysis (-9.4% [95% CI, -14.8% to -4.0%], P < 0.001) and those who were not (-7.9% [95% CI, -8.5% to -7.4%], P < 0.001) (P interaction = 0.6). Both the ATE and AME were comparable for other in-hospital outcomes in both groups. LIMITATIONS: Administrative data, lack of pharmacotherapy and long-term outcome data, and residual confounding. CONCLUSIONS: Compared with conservative management, pPCI for STEMI was associated with comparable reductions in short-term mortality among patients irrespective of their receipt of maintenance dialysis.

Perkutan koronarintervention är en behandlingsmetod vid ischemisk hjärtsjukdom vars syfte är att återställa ett nedsatt flöde i kranskärlen. Via en artär, med hjälp av en metalledare förs en ballong ut i kranskärlet där förträngningen eller ocklusionen sitter. Ballongen blåses upp och öppnar upp kärlet. Behandlingen kan ske akut, subakut eller planerat. När det kommer till information har patienten rättigheter som vården måste ta hänsyn till och genom att arbeta med ett personcentrerat förhållningssätt kan patientens möte med vården individanpassas. Syftet var att undersöka patienters upplevelser under hela händelseförloppet, av att ha genomgått en perkutan koronarintervention. Som metod användes litteraturöversikt med systematisk sökstrategi i enlighet med Polit och Becks niostegsmodell. 17 kvalitativa artiklar från nio olika länder samlades in och analyserades med kvalitativ innehållsanalys. Resultatet sorterades in i tre kategorier och tio underkategorier. Vikten av tidig och adekvat information inför en perkutan koronarintervention belystes. Många patienter kände sig oroliga och de som sökte akut upplevde att de fick livsavgörande vård. Oavsett om förloppet skedde akut eller planerat önskade patienterna att få vara delaktiga och medverka. Symtomen som beskrevs varierade. Tryckkänsla i bröstet, bröstsmärta och illamående förekom hos de som sökte akut medan trötthet och utmattning var vanligare hos de elektiva patienterna. Olika psykiska och fysiska upplevelser beskrevs på interventionssalen där även de flesta beskrev att de kände förtroende för vården. Vidare upplevde patienterna ett behov av fortsatt vård och många betonade frågor kring läkemedel och dess biverkningar. Upplevelsen av att återhämta sig beskrevs på olika sätt. De beskrev även information som saknades och hur de själva sökte den informationen. Anhörigas närvaro kunde påverka upplevelserna. En tacksamhet mot vården och metoden belystes. Slutsatsen var att patienter hade stort förtroende för hälso- och sjukvården. Personcentrerad vård med information på rätt nivå i rätt tid är nyckeln till en bra upplevelse för patienten. / Percutaneous coronary intervention is a treatment method for ischemic heart disease whose purpose is to restore impaired flow in the coronary arteries. Via an artery, with the help of a metal guide, a balloon is inserted into the coronary artery where the narrowing or occlusion is located. The balloon inflates and opens up the vessel. Treatment can be acute, subacute or planned. When it comes to information, the patient has rights that the healthcare system must take into account, and by working with a person-centered approach, the patient's encounter with healthcare can be individualized. The aim was to find out how the patients experienced undergoing percutaneous coronary intervention throughout the course of events. The method used was a literature review with a systematic search strategy in accordance with Polit and Beck's nine-step model. 17 qualitative articles from nine different countries were collected and analyzed with qualitative content analysis. The results were sorted into three categories and ten subcategories. The importance of early and adequate information prior to a percutaneous coronary intervention was highlighted. Many patients felt anxious and those who sought emergency care felt that they received lifesaving care. Regardless of whether the process took place acutely or planned, the patients wanted to be involved and participate. The symptoms described varied. Chest tightness, chest pain and nausea occurred in those who sought emergency care, while tiredness and exhaustion were more common in the elective patients. Different mental and physical experiences were described in the intervention room, where most of them also described that they felt confident in the care. Furthermore, the patients experienced a need for continued care and many emphasized questions about drugs and their side effects. The experience of recovery was described in different ways. They also described information that was missing and how they themselves searched for that information. The presence of relatives could affect the experiences. A gratitude towards the care and the method was highlighted. The conclusion was that patients had great confidence in the healthcare system. Personcentered care with information at the right level at the right time is the key to a good experience for the patient.

Coronary artery disease (CAD) is the leading cause of mortality worldwide and atrial fibrillation (AF) is a prevalent arrhythmia associated with increased risk of mortality and morbidity. Despite improved outcome in both diseases, there is a need to further describe the prevalence, outcome and management of CAD in patients with concomitant AF. AF was a common finding among patients with MI, with 16% having new-onset, paroxysmal or chronic AF. Patients post-MI with concomitant AF, regardless of subtype, were at increased risk of composite cardiovascular outcome of mortality, MI or ischemic stroke, including mortality and ischemic stroke alone. No major difference in outcome was observed between AF subtypes. At discharge, an oral anticoagulant was prescribed to 27% of the patients with MI and AF undergoing percutaneous coronary intervention (PCI). Aspirin or clopidogrel plus warfarin versus dual antiplatelet therapy with aspirin plus clopidogrel were associated with similar 0-90-day and lower 91-365-day risk of cardiovascular outcome, without increased risk of major bleeding events. Triple therapy with aspirin, clopidogrel plus warfarin versus dual antiplatelet therapy was associated with non-significant lower risk of cardiovascular outcome, but with increased risk of bleeding events. Treatment with renin-angiotensin system (RAS) inhibitors post-MI was associated with lower risk of all-cause and cardiovascular mortality in patients with and without congestive heart failure and/or AF. However, RAS inhibition in patients without AF was not associated with lower risk of new-onset AF. Approximately 1 in 3 patients undergoing isolated coronary artery bypass grafting (CABG) had pre- or postoperative AF. Patients with AF, regardless of subtype, were at higher risk of all-cause mortality, cardiovascular mortality and congestive heart failure. Furthermore, postoperative AF was associated with higher risk of recurrent AF. In conclusion, AF was a common finding in the setting of MI and CABG. AF, irrespectively if in the setting of MI or CABG was associated with higher risk of ischemic events and mortality. Also, postoperative AF was associated with recurrent AF. Oral anticoagulants post-MI and PCI in patients with AF was underutilized, however, optimal antithrombotic therapy is still unknown. RAS inhibition post-MI seems beneficial, however, it was not associated with lower incidence of new-onset AF.

L’arrêt cardiaque extra-hospitalier (ACREH) touche environ 30 à 40,000 personnes en France chaque année. Dans près de la moitié des cas, la cause de l’ACREH est une occlusion coronaire aiguë provoquant un trouble du rythme ventriculaire létal. Malgré les progrès réalisés ces dernières années en terme de prise en charge pré et intra-hospitalière, le pronostic de ces patients reste sombre, de par les lésions neurologiques se produisant très rapidement après l’arrêt circulatoire. Alors que le pronostic à court terme est relativement bien décrit, les données sur le devenir à long terme, en termes de survie, mais aussi de devenir fonctionnel, neurologique, et de qualité de vie, restent rares. Objectifs : L’objectif de ce travail est de décrire le devenir à long terme des patients victimes d’un ACREH et admis vivants à l’hôpital (qualité de vie liée à l’état de santé, devenir neurologique et fonctionnel) et d’évaluer les facteurs associés à ce devenir (biomarqueurs, revascularisation coronaire précoce). Patients et méthodes : Ce travail a consisté en l’analyse des données de la cohorte des patients victimes d’un ACREH et admis vivants en réanimation mé- dicale à l’hôpital Cochin. Cette cohorte a été constituée rétrospectivement entre 2000 et 2006 sur dossiers archivés puis prospectivement selon les recommandations internationales d’Utstein depuis 2007. Les données de survie ont été collectées. Le devenir neurologique et fonctionnel et les données de qualité de vie ont été collectées lors d’entretiens téléphoniques réalisés auprès des survivants sortis vivants de l’hôpital. Résultats principaux : La mortalité globale à J30 était de 68,2%. La revascu- larisation coronaire (ATL) immédiate était associée à une mortalité à J30 plus faible (ORcoro sans ATL vs. pas coro 0,79 [0,57;1,08], p=0,14 et ORcoro avec ATL vs. pas coro 0,61 [0,43;0,85], p<0,01). Les 466 patients vivants à J30 ont été suivis pendant une durée médiane de 3,2 ans [IQR : 0,7 ;6,7], avec une durée maximale de suivi de 13,5 ans. En analyse multivariée, la revascularisation coronaire immédiate restait inversement associée à la mortalité à long terme (HRcoro sans ATL vs. pas coro 0,78 [0,45 ;1,33], p=0,35 et HRcoro avec ATL vs. pas coro 0,40 [0,23 ;0,70], p<0,01).
La copeptine a été dosée chez 298/510 patients à l’admission et chez 224 patients à J3. Le taux médian à l’admission était de 261,3 [125,2 ;478,6] pmol/L. Le taux de survie à 1 an était inversement proportionnel au quintile de copeptine à l’admission (38,2, 32,6, 27,7, 31 et 13,6%, respectivement; p<0,01). En analyse multivariée, seul le cinquième quintile de copeptine à l’admission était associé à la mortalité à 1 an (HR5ème vs. 1er 1,64 [1,06;2,58], p=0,03). Après ajustement mutuel des taux de copeptine à l’admission et à J3, le taux de copeptine à l’admission n’était plus associé à la mortalité à 1 an mais le taux de copeptine à J3 restait asso- cié à la mortalité à 1 an par une relation concentration-dépendante (HR2ème vs. 1er 1,60 [0,90-3,17], p=0,10 ; HR3ème vs. 1er 1,94 [1,01 ;3,71], p=0,05 ; HR 4ème vs. 1er 2,01 [1,04 ;3,89], p=0,04 et HR5ème vs. er 2,38 [1,19 ;4,74], p=0,01 ; p de tendance =0,02). Au cours du suivi, 255 patients ont pu être recontactés. Le délai médian de recon- tact après la survenue de l’ACREH était de 50 [22-93] mois. 66% des patients sortis de réanimation avec un score CPC coté à 1 gardaient une performance neurolo- gique préservée au moment de l’interview (n=150/231). Les dimensions physiques et mentales agrégées du SF-36 étaient similaires chez les survivants d’ACREH en comparaison avec les individus de la population générale (47,0 vs. 47,1, p=0,88 et 46,4 vs. 46,9, p=0,45, respectivement). Les patients présentaient une altération plus marquée des dimensions physiques que des dimensions mentales du score SF- 36 en comparaison avec la population générale. L’activité physique (74,1 vs. 78,4, p=0,02) et la vitalité (50,7 vs. 56,2, p<0,01) étaient les dimensions les plus altérées. (...) / Out-of-hospital cardiac arrest (OHCA) occurs in about 30-40,000 people in France each year and is related to a culprit coronary occlusion in half cases. Although pre and in-hospital management of such patients dramatically improved last years, outcome remains poor because of the neurological damage related to brain anoxia. Short-term outcome is well-described but data are lacking on long-term outcome, functionnal and neurological outcome and health-related quality of life (HRQOL). Objectives : The main purpose of this work was to describe the long-term outcome of successfully resuscitated OHCA patients admitted alive at ICU. We aimed at picking up factors associated with HRQOL as well. Patients and methods : Data from the Paris registry were used. Consecutive sucessfully resuscitated OHCA patients admitted alive at Medical ICU of Cochin hospital, Paris, France are included in the database since 2000, January 1st, accor-ding to Utstein style. We also collected survival data. Neurological and functionnal outcome, as well as HRQOL (SF-36 questionnaire) were recorded during phone in- terviews in OHCA patients discharged alive from hospital. Main results : Overall mortality at day-30 was 68.2%. Immediate percutaneous coronary intervention (PCI) was associated with day-30 mortality (ORcoro w/o PCI vs. no coro 0.79 [0.57,1.08], p=0.14 et ORcoro w/ PCI vs. no coro 0.61 [0.43,0.85], p<0.01). The 466 patients alive at day-30 were followed-up for 3.2 years [IQR : 0.7-6.7]. After adjus- tement for cofounders, immediate PCI remained associated with long-term mor-
tality (HRcoro w/o PCI vs. no coro 0.78 [0.45,1.33], p=0.35 et HRcoro w/ PCI vs. no coro 0.40 [0.23,0.70], p<0.01). Copeptin was assessed in 298/510 patients at ICU admission and in 224 patients at day-3. Median admission copeptin level was 261.3 [125.2,478.6] pmol/L. Survival rates were 38.2, 32.6, 27.7, 31 and 13.6% through admission copeptin quintiles (p<0,01). In multivariate analysis, only the fifth quin-
tile was associated with one-year mortality (HR5ème vs. 1st 1.64 [1.06-2.58], p=0.03). After mutual adjustement of admission and day-3 copeptin levels, admission co- peptin level was not associated anymore with one-year mortality whereas day-3 copeptin level remained associated with one-year mortality in a concentration- dependent manner (HR2nd vs. 1st 1.60 [0.90-3.17], p=0.10; HR3th vs. 1st 1.94 [1.01- 3.71], p=0.05; HR 4th vs. 1st 2.01 [1.04-3.89], p=0.04 et HR5th vs. st 2.38 [1.19-4.74], p=0.01 ; p for trend =0.02). During follow-up, 255 OHCA patients dicharged alive from hospital were phone in- terviewed, after a median duration from cardiac arrest of 50 [22-93] months. 66% of patients kept a good cerebral performance after hospital discharge (n=150/231). Overall physical and mental SF-36 dimensions were similar between OHCA pa- tients and age- and gender-matched individuals from French general population (47.0 vs. 47.1,p=0.88 and 46.4 vs. 46.9, p=0.45, respectively). Physical dimensions were more significantly altered in OHCA patients, especially physical functionning (74.1 vs. 78.4, p=0.02) and vitality (50.7 vs. 56.2, p<0.01). In multivariate analysis, age, male gender, initial shockable rhythm were associated with an improvement in most of the SF-36 dimensions. Immediate PCI was associated with a gain in physical functionning (+7.0, p=0.06), general health (+7.3, p=0.02) and vitality (+4.4, p=0.08). Conclusion : Overall survival in this large cohort of successfully resuscitated OHCA patients was about 20%. Immediate PCI was associated with a decrea- sed short and long-term mortality. HRQOL was similar between OHCA patients and age and gender matched individuals from general population but physical di- mensions appeared significantly altered. Age, male gender and initial shockable rhythm were associated with a better HRQOL. (...)

<p>Uvod: Pacijenti sa akutnim infarktom miokarda sa ST elevacijom treba da budu podvrgnuti reperfuzionoj terapiji, pre svega pPCI, bez obzira na životnu dob, ali zbog&nbsp; veće učestalosti komorbiditeta, faktora rizika za koronarnu bolest i vi&scaron;esudovne koronarne bolesti, kod pacijenata starije životne dobi, odluka o reperfuzionoj terapiji treba da se donese sa dobrom procenom odnosa rizik &ndash; benefit. Cilj: Utvrđene su razlike u kliničkoj slici, angiografskom nalazu, terapijskom pristupu, toku i ishodu akutnog infarkta miokarda sa ST elevacijom u starih osoba u odnosu na mlađu životnu dob (mlađi od 75 godina). Materijal i metode: U studiju je uključeno 240 pacijenata sa akutnim infarktom miokarda sa ST elevacijom, podeljeni u dve komparabilne grupe (120 bolesnika starijih i kontrolna grupa 120 mlađih od 75 godina), koji su izabrani metodom slučajnog izbora, po redosledu prijema u bolnicu. Za pacijente iz obe grupe popunjavan je upitnik, a tretirani su po jedinstvenom protokolu lečenja. Rezultati: U ispitivanom uzorku, u grupi bolesnika starijih od 75 godina reperfuziona terapija je bila primenjena u 85% slučajeva. Intrahospitalni mortalitet za ceo uzorak je 11,7% i u skladu je sa drugim istraživanjima [27]. Mortalitet u grupi pacijenata preko 75 godina je bio 12,5%, a u grupi pacijenata sa manje od 75 godina 10,8% (p=ns). Zaključak: Klinička slika bolesti kod bolesnika starije životne dobi je če&scaron;će atipična &scaron;to korelira sa drugim studijama [31, 35], a tok bolesti komplikovaniji i ishod lo&scaron;iji. Kod bolesnika starijih od 75 godina če&scaron;ća je vi&scaron;esudovna koronarna bolest. Primarna perkutana koronarna intervencija u akutnom infarktu miokarda sa ST elevacijom u pacijenata starije životne dobi potvrđuje benefit u lečenju, toku i ishodu bolesti.</p> / <p>Introduction: Patients with ST segment acute myocardial infarction should undergo reperfusion therapy, PCI in the first place, no matter their life age. However, due to high frequency of comorbidities, risk factors for coronary disease and multi-vessel coronary disease, the decision of reperfusion therapy in elderly patients should be made according to the good evaluation or risk benefit ratio. Aim: The differences have been determined in the clinical picture, angiographic finding, therapeutic approach, course and outcome of ST segment acute myocardial infarction in elderly patients in relation to younger life age (less than 75 years). Material and methods: The study included 240 patients with ST segment acute myocardial infarction. They were randomly divided into two comparable groups according to the date of their hospitalization (120 patients older than 75 and control group of 120 patients younger than 75 years). Both groups of patients filled out the survey and were treated according to the same protocol. Results: In the examined sample of the group of patients older than 75 the reperfusion therapy was performed in 85% of cases. Intrahospital mortality for the entire sample was 11.7% and is in coherence with other researches [27]. Mortality in the group of patients older than 75 years was 12.5%, and it was 10.8% (p=ns) in the group of patients younger than 75.&nbsp; Conclusion: Clinical picture of disease in elderly patients is atypical thus correlating with other studies [31, 35], and course of illness more complicated and with a worse outcome. Multi-vessel disease is more common in patients older than 75 years. Primary percutaneous coronary intervention in STEMI in elderly patients confirms benefits in treatment, course and outcome of disease.</p>

L’arrêt cardiaque extra-hospitalier (ACREH) touche environ 30 à 40,000 personnes en France chaque année. Dans près de la moitié des cas, la cause de l’ACREH est une occlusion coronaire aiguë provoquant un trouble du rythme ventriculaire létal. Malgré les progrès réalisés ces dernières années en terme de prise en charge pré et intra-hospitalière, le pronostic de ces patients reste sombre, de par les lésions neurologiques se produisant très rapidement après l’arrêt circulatoire. Alors que le pronostic à court terme est relativement bien décrit, les données sur le devenir à long terme, en termes de survie, mais aussi de devenir fonctionnel, neurologique, et de qualité de vie, restent rares. Objectifs : L’objectif de ce travail est de décrire le devenir à long terme des patients victimes d’un ACREH et admis vivants à l’hôpital (qualité de vie liée à l’état de santé, devenir neurologique et fonctionnel) et d’évaluer les facteurs associés à ce devenir (biomarqueurs, revascularisation coronaire précoce). Patients et méthodes : Ce travail a consisté en l’analyse des données de la cohorte des patients victimes d’un ACREH et admis vivants en réanimation mé- dicale à l’hôpital Cochin. Cette cohorte a été constituée rétrospectivement entre 2000 et 2006 sur dossiers archivés puis prospectivement selon les recommandations internationales d’Utstein depuis 2007. Les données de survie ont été collectées. Le devenir neurologique et fonctionnel et les données de qualité de vie ont été collectées lors d’entretiens téléphoniques réalisés auprès des survivants sortis vivants de l’hôpital. Résultats principaux : La mortalité globale à J30 était de 68,2%. La revascu- larisation coronaire (ATL) immédiate était associée à une mortalité à J30 plus faible (ORcoro sans ATL vs. pas coro 0,79 [0,57;1,08], p=0,14 et ORcoro avec ATL vs. pas coro 0,61 [0,43;0,85], p<0,01). Les 466 patients vivants à J30 ont été suivis pendant une durée médiane de 3,2 ans [IQR : 0,7 ;6,7], avec une durée maximale de suivi de 13,5 ans. En analyse multivariée, la revascularisation coronaire immédiate restait inversement associée à la mortalité à long terme (HRcoro sans ATL vs. pas coro 0,78 [0,45 ;1,33], p=0,35 et HRcoro avec ATL vs. pas coro 0,40 [0,23 ;0,70], p<0,01).
La copeptine a été dosée chez 298/510 patients à l’admission et chez 224 patients à J3. Le taux médian à l’admission était de 261,3 [125,2 ;478,6] pmol/L. Le taux de survie à 1 an était inversement proportionnel au quintile de copeptine à l’admission (38,2, 32,6, 27,7, 31 et 13,6%, respectivement; p<0,01). En analyse multivariée, seul le cinquième quintile de copeptine à l’admission était associé à la mortalité à 1 an (HR5ème vs. 1er 1,64 [1,06;2,58], p=0,03). Après ajustement mutuel des taux de copeptine à l’admission et à J3, le taux de copeptine à l’admission n’était plus associé à la mortalité à 1 an mais le taux de copeptine à J3 restait asso- cié à la mortalité à 1 an par une relation concentration-dépendante (HR2ème vs. 1er 1,60 [0,90-3,17], p=0,10 ; HR3ème vs. 1er 1,94 [1,01 ;3,71], p=0,05 ; HR 4ème vs. 1er 2,01 [1,04 ;3,89], p=0,04 et HR5ème vs. er 2,38 [1,19 ;4,74], p=0,01 ; p de tendance =0,02). Au cours du suivi, 255 patients ont pu être recontactés. Le délai médian de recon- tact après la survenue de l’ACREH était de 50 [22-93] mois. 66% des patients sortis de réanimation avec un score CPC coté à 1 gardaient une performance neurolo- gique préservée au moment de l’interview (n=150/231). Les dimensions physiques et mentales agrégées du SF-36 étaient similaires chez les survivants d’ACREH en comparaison avec les individus de la population générale (47,0 vs. 47,1, p=0,88 et 46,4 vs. 46,9, p=0,45, respectivement). Les patients présentaient une altération plus marquée des dimensions physiques que des dimensions mentales du score SF- 36 en comparaison avec la population générale. L’activité physique (74,1 vs. 78,4, p=0,02) et la vitalité (50,7 vs. 56,2, p<0,01) étaient les dimensions les plus altérées. (...) / Out-of-hospital cardiac arrest (OHCA) occurs in about 30-40,000 people in France each year and is related to a culprit coronary occlusion in half cases. Although pre and in-hospital management of such patients dramatically improved last years, outcome remains poor because of the neurological damage related to brain anoxia. Short-term outcome is well-described but data are lacking on long-term outcome, functionnal and neurological outcome and health-related quality of life (HRQOL). Objectives : The main purpose of this work was to describe the long-term outcome of successfully resuscitated OHCA patients admitted alive at ICU. We aimed at picking up factors associated with HRQOL as well. Patients and methods : Data from the Paris registry were used. Consecutive sucessfully resuscitated OHCA patients admitted alive at Medical ICU of Cochin hospital, Paris, France are included in the database since 2000, January 1st, accor-ding to Utstein style. We also collected survival data. Neurological and functionnal outcome, as well as HRQOL (SF-36 questionnaire) were recorded during phone in- terviews in OHCA patients discharged alive from hospital. Main results : Overall mortality at day-30 was 68.2%. Immediate percutaneous coronary intervention (PCI) was associated with day-30 mortality (ORcoro w/o PCI vs. no coro 0.79 [0.57,1.08], p=0.14 et ORcoro w/ PCI vs. no coro 0.61 [0.43,0.85], p<0.01). The 466 patients alive at day-30 were followed-up for 3.2 years [IQR : 0.7-6.7]. After adjus- tement for cofounders, immediate PCI remained associated with long-term mor-
tality (HRcoro w/o PCI vs. no coro 0.78 [0.45,1.33], p=0.35 et HRcoro w/ PCI vs. no coro 0.40 [0.23,0.70], p<0.01). Copeptin was assessed in 298/510 patients at ICU admission and in 224 patients at day-3. Median admission copeptin level was 261.3 [125.2,478.6] pmol/L. Survival rates were 38.2, 32.6, 27.7, 31 and 13.6% through admission copeptin quintiles (p<0,01). In multivariate analysis, only the fifth quin-
tile was associated with one-year mortality (HR5ème vs. 1st 1.64 [1.06-2.58], p=0.03). After mutual adjustement of admission and day-3 copeptin levels, admission co- peptin level was not associated anymore with one-year mortality whereas day-3 copeptin level remained associated with one-year mortality in a concentration- dependent manner (HR2nd vs. 1st 1.60 [0.90-3.17], p=0.10; HR3th vs. 1st 1.94 [1.01- 3.71], p=0.05; HR 4th vs. 1st 2.01 [1.04-3.89], p=0.04 et HR5th vs. st 2.38 [1.19-4.74], p=0.01 ; p for trend =0.02). During follow-up, 255 OHCA patients dicharged alive from hospital were phone in- terviewed, after a median duration from cardiac arrest of 50 [22-93] months. 66% of patients kept a good cerebral performance after hospital discharge (n=150/231). Overall physical and mental SF-36 dimensions were similar between OHCA pa- tients and age- and gender-matched individuals from French general population (47.0 vs. 47.1,p=0.88 and 46.4 vs. 46.9, p=0.45, respectively). Physical dimensions were more significantly altered in OHCA patients, especially physical functionning (74.1 vs. 78.4, p=0.02) and vitality (50.7 vs. 56.2, p<0.01). In multivariate analysis, age, male gender, initial shockable rhythm were associated with an improvement in most of the SF-36 dimensions. Immediate PCI was associated with a gain in physical functionning (+7.0, p=0.06), general health (+7.3, p=0.02) and vitality (+4.4, p=0.08). Conclusion : Overall survival in this large cohort of successfully resuscitated OHCA patients was about 20%. Immediate PCI was associated with a decrea- sed short and long-term mortality. HRQOL was similar between OHCA patients and age and gender matched individuals from general population but physical di- mensions appeared significantly altered. Age, male gender and initial shockable rhythm were associated with a better HRQOL. (...)

Objectifs. L'infarctus aigu du myocarde (IDM) touche chaque année plus de 120 000 personnes en France. Nous nous sommes intéressés à la prise en charge du SCA avec sus-décalage du segment ST (ST+). Deux stratégies de revascularisation coronaires s'offrent à nous : la thrombolyse intraveineuse et l'angioplastie primaire. Notre travail a évalué l'impact du choix de ces stratégies dans la phase aiguë de l'infarctus du myocarde, à travers la mise en place d'un réseau associant la médecine d'urgence et la cardiologie interventionnelle autour d'un référentiel partagé. Méthode. Nous avons mis en place un réseau cardiologie - urgence (RESCUe), qui a fédéré au sein d'une association 37 structures d'urgence (SU), 19 structures mobiles d'urgence et de réanimation (SMUR) et 10 centres de cardiologie interventionnelle (CCI) dans un bassin géographique de 3 millions d'habitants. Notre méthode de travail s'articulait autour de trois axes : édition de référentiels partagés, formation et évaluation. Résultats. Dès la mise en place de RESCUe, nous avons lancé un essai multicentrique, contrôlé et randomisé, l'étude AGIR². En douze mois 320 SCA ST+ ont été inclus. Dès la prise en charge en SMUR tous les patients ont reçu 250 mg d'aspirine, 600 mg de clopidogrel, un bolus intraveineux de 60 IU/kg d'héparine avant d'être transférés en CCI pour une angioplastie primaire. Si le bénéfice d'une administration de tirofiban en SMUR n'était pas supérieur à son administration en CCI, AGIR² a conforté les bases d'une collaboration en réseau entre médecine d'urgence et cardiologie interventionnelle autour d'un référentiel thérapeutique partagé. Depuis, l'angioplastie primaire est progressivement devenue la stratégie de reperfusion de référence du SCA ST+ sur notre bassin. Pour évaluer son impact nous avons mis en place un registre observationnel couvrant l'ensemble des SU, SMUR et CCI du réseau. Entre 2009 et 2013 nous avons pris en charge 2418 patients en SMUR avec un diagnostic d'infarctus aigu du myocarde. Parmi eux, 2119 (87.6%) ont bénéficié d'une angioplastie primaire et 299 (12.4%) d'une thrombolyse intraveineuse. Nous avons observé une augmentation du recours à l'angioplastie primaire de 78.4% en 2009 à 95.9% en 2013 (P<0.001). Le délai médian ECG - arrivée en CCI était de 48 min, ECG - angioplastie 94 min et arrivée – angioplastie 43 min. Les délais symptôme – ECG et ECG – thrombolyse sont restés stables de 2009 à 2013, mais les délais symptôme – angioplastie et ECG – arrivée en CCI – angioplastie ont diminué (P<0.001). Au total 2146 (89.2%) patients avaient un délai ECG – arrivée en CCI ≤90 min, un délai confortant le choix d'une angioplastie primaire chez 97.7% d'entre eux en 2013, conformément aux recommandations. De 2009 à 2013, la mortalité hospitalière (4-6%) et celle à 30 jours (6-8%) est restée stable. Nous avons complété notre travail par une analyse de la conformité des mesures de prévention secondaire aux recommandations. A un an post-IDM, l'association bétabloquants – aspirine – statines – inhibiteurs de l'enzyme de conversion et la correction des facteurs de risque était liée à une meilleure survie. Parmi les 5161 patients pris en charge dans nos SU et en SMUR et sortis vivant de CCI, 2991 (58%) ont bénéficié de cette stratégie optimale avec un HR de 0.12 (95% CI 0.07–0.22; P<0.001). Les patients les plus graves étaient ceux les moins bien traités, à cause des contre-indications aux traitements (insuffisance rénale, risque hémorragique). Conclusion. Dans notre bassin géographique, la mise en place d'un réseau cardiologie urgence a abouti à l'augmentation du recours à l'angioplastie primaire, conformément aux recommandations. Il n'y a pas eu d'effet sur la mortalité précoce. Un bénéfice sur la mortalité à un an est observé chez les patients qui ont bénéficié de mesures de prévention secondaire optimales / Objective. Acute myocardial infarction (AMI) annually affects more than 120 000 people in France. We studied the management of ST elevation MI (STEMI). Two reperfusion strategies are available: intravenous thrombolysis (TL) and primary percutaneous coronary intervention (PPCI). Our study aimed to evaluate the impact of these strategies in the acute phase of myocardial infarction through the establishment of an emergency network based on a shared protocol with interventional cardiology. Methods. We established a regional emergency cardiovascular network (RESCUe Network) that covers a population of 3 million inhabitants across five administrative counties, including urban and rural territories. All nineteen MICUs, thirty seven emergency departments and 10 catheterization laboratories participate in the network. We edited regularly updated guidelines, set up a doctors’ training program and implemented an evaluation registry. Results. We setup the AGIR-2 study, a multicenter, controlled, randomized study, to explore prehospital high-dose tirofiban in patients undergoing PPCI. Three hundred and twenty patients with STEMI were included over a period of 12 months. All of them received 250 mg of aspirin, 600 mg of clopidogrel and 60 IU/kg bolus of high molecular weight heparin before admission to the catheterization laboratory. If prehospital initiation of high-dose bolus of tirofiban did not improve outcome, AGIR-2 study reinforced the collaborative network between emergency medicine and interventional cardiology. Since then, PPCI has gradually become the reference reperfusion strategy for STEMI in our network. Using data from our registry, we studied STEMI patients treated in mobile intensive care units (MICUs) between 2009 and 2013. Among 2418 patients, 2119 (87.6%) underwent PPCI and 299 (12.4%) prehospital TL (94.0% of whom went on to undergo PPCI). Use of PPCI increased from 78.4% in 2009 to 95.9% in 2013 (Ptrend<0.001). Median delays included: first medical contact (FMC)–PCI centre 48 min, FMC–balloon inflation 94 min, and PCI centre– balloon inflation 43 min. Times from symptom onset to FMC and FMC to TL remained stable during 2009 to 2013, but times from symptom onset to first balloon inflation and FMC to PCI centre to first balloon inflation decreased (P<0.001). In total, 2146 (89.2%) had an FMC–PCI centre delay ≤90 min with PPCI use up to 97.7% in 2013 in accordance with guidelines. Inhospital (4–6%) and 30-day (6–8%) mortalities remained stable from 2009 to 2013. Finally, we sought to assess the effect of strict adherence to current international guidelines on 1-year all-cause mortality in a prospective cohort of patients with STEMI. After multivariable adjustment, the association between the optimal therapy (OT) group (Betablockers, Antiplatelet agents, Statins, angiotensin-converting enzyme [ACE] Inhibitors, and Correction of all risk factors) and survival remained significant, with a hazard ratio of 0.12 (95% CI 0.07–0.22; P<0.001). Of the 5161 patients discharged alive, 2991 (58%) were prescribed OT. Patients characteristics in the under treatment (UT) group were worse than those in the OT group because of contraindications to optimal treatment (renal failure, bleeding risk). Conclusion. The establishment of an emergency network in our area resulted in an increased use of PPCI in accordance with ESC guidelines with no effect on early mortality. Reduction of one year mortality was observed in patients who received optimal secondary prevention treatment

INTRODUÇÃO: Poucas são as estratégias testadas para reduzir o volume de contraste durante angioplastia coronária. Levantamos a hipótese de que o ultrassom intravascular teria o potencial de substituir muitas informações fornecidas pela angiografia, reduzindo, dessa forma, o volume total de contraste utilizado durante a angioplastia coronária. MÉTODOS: No total, 83 pacientes foram randomizados para realização de angioplastia guiada pela angiografia isolada ou angioplastia guiada pelo ultrassom intravascular. Ambos os grupos foram tratados com estratégias rigorosas para redução de contraste, tendo como objetivo primário o volume final de contraste utilizado na angioplastia coronária. Os pacientes foram acompanhados por um período médio de 4 meses. RESULTADOS: A mediana do volume total de contraste foi de 64,5 ml (intervalo interquartil [ITQ], 42,8-97 ml; mínimo de 19 ml e máximo de 170 ml) no grupo angioplastia guiada pela angiografia isolada vs. 20 ml (ITQ, 12,5-30 ml; mínimo de 3 ml e máximo de 54 ml) no grupo angioplastia guiada pelo ultrassom intravascular (P < 0,001). De forma semelhante, a mediana da razão entre o volume de contraste e o clearance de creatinina foi significantemente menor entre os pacientes submetidos a angioplastia guiada pelo ultrassom intravascular, quando comparados aos pacientes do grupo angioplastia guiada pela angiografia isolada (1 [ITQ, 0,6-1,9] vs. 0,4 [ITQ, 0,2- 0,5], respectivamente; P < 0,001). Os desfechos intra-hospitalares e aos 4 meses de acompanhamento não foram diferentes entre os pacientes randomizados para o grupo angioplastia guiada pela angiografia isolada e aqueles do grupo angioplastia guiada pelo ultrassom intravascular. CONCLUSÕES: A utilização racional do ultrassom intravascular como método de imagem para guiar a angioplastia foi segura e reduziu de forma significativa o volume de contraste, comparativamente à angioplastia guiada pela angiografia isolada. O uso do ultrassom intravascular para esse propósito deve ser considerado para pacientes de elevado risco para o desenvolvimento de nefropatia induzida pelo contraste ou sobrecarga de volume e que serão submetidos a angioplastia coronária / BACKGROUND: To date, few approaches have been described to reduce the final dose of contrast agent in percutaneous coronary intervention. We hypothesized that intravascular ultrasound might serve as an alternative imaging tool to angiography in many steps during percutaneous coronary intervention, thereby reducing the use of iodine contrast. METHODS: A total of 83 patients were randomized to angiography alone-guided percutaneous coronary intervention or intravascular ultrasound-guided percutaneous coronary intervention. Both groups were treated according to a pre-defined meticulous procedural strategy, and the primary endpoint was the total volume contrast agent used during percutaneous coronary intervention. Patients were followed clinically for an average of 4 months. RESULTS: The median total volume of contrast was 64.5 mL (interquartile range [IQR], 42.8 to 97 mL; minimum, 19 mL; maximum, 170 mL) in the angiography alone-guided group vs. 20 mL (IQR, 12.5 to 30 mL; minimum, 3 mL; maximum, 54 mL) in the intravascular ultrasound-guided group (P < 0.001). Similarly, the median volume of contrast/creatinine clearance ratio was significantly lower among patients treated with intravascular ultrasound-guided percutaneous coronary intervention when compared with patients treated with angiography alone-guided percutaneous coronary intervention (1 [IQR, 0.6 to 1.9] vs. 0.4 [IQR, 0.2 to 0.6], respectively; P < 0.001). In-hospital and 4-month outcomes were not different between patients randomized to angiography alone-guided and intravascular ultrasound-guided percutaneous coronary intervention. CONCLUSIONS: Thoughtful and extensive use of intravascular ultrasound as the primary imaging tool to guide percutaneous coronary intervention was safe and markedly reduced the volume of iodine contrast compared with angiographyalone guidance. The use of intravascular ultrasound should be considered for patients at high risk of contrast-induced acute kidney injury or volume overload undergoing coronary angioplasty