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Background: Towards the end of the 20th century, the city of Dijon, France, had a lower incidence of stroke than that found in other studies. It was hypothesized that genetic and environmental factors were responsible for this so-called French paradox. We aim to evaluate recent changes in stroke incidence to determine whether or not the Dijon exception still exists. Methods: The population-based stroke registry of Dijon ascertained all first-ever strokes from 2000 to 2006. We calculated incidence to compare recent results with those obtained from a previous study period (1985–1999) and those of other population-based studies covering both the end of the 20th and the beginning of the 21st century. Results: From 2000 to 2006, 1205 strokes were recorded. Crude and age-standardized incidence (to European and World population) rates were respectively 113, 107 and 72/100 000/year. No change was observed between 1985–1999 and 2000–2006, whereas other studies reported declining incidence. Conclusion: The incidence of stroke in Dijon remained lower than that found in similar studies, but the difference compared with results observed for the 20th century is shrinking. Therefore, the Dijon exception is decreasing, suggesting that it was rather an advance in prevention strategies that has diminished. [ABSTRACT FROM AUTHOR]

Objective: To analyse the short and long term prognostic significance of admission glycaemia in a large registry of non-diabetic patients with acute myocardial infarction. Methods: Assessment of short and long term prognostic significance of admission blood glucose in a consecutive population of 1604 non-diabetic patients admitted to intensive care units in France in November 2000 for a recent (≤ 48 hours) myocardial infarction. Results: In-hospital mortality, compared with that of patients with admission glycaemia below the median value of 6.88 mmol/1 (3.7%), rose gradually with each of the three upper sextiles of glycaemia: 6.5%, 12.5% and 15.2%. Conversely, one year survival decreased from 92.5% to 88%, 83% and 75% (p < 0.001). Admission glycaemia remained an independent predictor of in-hospital and one year mortality after multivariate analyses accounting for potential confounders. Increased admission glycaemia also was a predictor of poor outcome in all clinical subsets studied: patients without heart failure on admission, younger and older patients, patients with or without reperfusion therapy, and patients with or without ST segment elevation. Conclusion: In non-diabetic patients, raised admission blood glucose is a strong and independent predictor of both in-hospital and long term mortality. [ABSTRACT FROM AUTHOR]

Background: Despite major advances in prevention and treatment, cardiovascular diseases - particularly acute myocardial infarction - remain a leading cause of death worldwide and in France. Collecting contemporary data about the characteristics, management and outcomes of patients with acute myocardial infarction in France is important., Aims: The main objectives are to describe baseline characteristics, contemporary management, in-hospital and long-term outcomes of patients with acute myocardial infarction hospitalized in tertiary care centres in France; secondary objectives are to investigate determinants of prognosis (including periodontal disease and sleep-disordered breathing), to identify gaps between evidence-based recommendations and management and to assess medical care costs for the index hospitalization and during the follow-up period., Methods: FRENCHIE (FRENch CoHort of myocardial Infarction Evaluation) is an ongoing prospective multicentre observational study (ClinicalTrials.gov Identifier: NCT04050956) enrolling more than 19,000 patients hospitalized for acute myocardial infarction with onset of symptoms within 48hours in 35 participating centres in France since March 2019. Main exclusion criteria are age<18 years, lack of health coverage and procedure-related myocardial infarction (types 4a and 5). Detailed information was collected prospectively, starting at admission, including demographic data, risk factors, medical history and treatments, initial management, with prehospital care pathways and medication doses, and outcomes until hospital discharge. The follow-up period (up to 20 years for each patient) is ensured by linking with the French national health database (Système national des données de santé), and includes information on death, hospital admissions, major clinical events, healthcare consumption (including drug reimbursement) and total healthcare costs. FRENCHIE is also used as a platform for cohort-nested studies - currently three randomized trials and two observational studies., Conclusions: This nationwide large contemporary cohort with very long-term follow-up will improve knowledge about acute myocardial infarction management and outcomes in France, and provide a useful platform for nested studies and trials., (Copyright © 2024 Elsevier Masson SAS. All rights reserved.)

Background: Cardiovascular risk is increased in giant cell arteritis (GCA). We aimed to characterize myocardial infarction (MI) in a GCA cohort, and to compare the GCA and non-GCA population affected by MI., Methods: In patients with a biopsy-proven diagnosis of GCA between 1 January 2001 and 31 December 2016 in Côte D'Or (France), we identified patients with MI by crossing data from the territorial myocardial infarction registry (Observatoire des Infarctus de Côte d'Or) database. Five controls (non-GCA + MI) were paired with one case (GCA + MI) after matching for age, sex, cardiovascular risk factors and prior cardiovascular disease. MI were characterized as type 1 MI (T1MI), resulting from thrombus formation due to atherothrombotic disease, or type 2 MI (T2MI), due to a myocardial supply/demand mismatch. GCA-related MI was defined as MI occurring within 3 months of a GCA flare (before or after)., Results: Among 251 biopsy-proven GCA patients, 13 MI cases were identified and paired with 65 controls. MI was GCA-related in 6/13 cases, accounting for 2.4% (6/251) of our cohort. T2MI was more frequently GCA-related than GCA-unrelated (80% vs. 16.7%, p = 0.080), and GCA diagnosis was the only identified triggering factor in 75% of GCA-related T2MI. GCA-unrelated MI were more frequently T1MI and occurred in patients who had received a higher cumulative dose of prednisone (p = 0.032). GCA was not associated with poorer one-year survival., Conclusions: GCA-related MI are mainly T2MI probably caused by systemic inflammation rather than coronaritis. GCA-unrelated MI are predominantly T1MI associated with atherothrombotic coronary artery disease., (Copyright © 2021. Published by Elsevier B.V.)

Introduction: Elevated troponin levels are found in a significant number of patients who are diagnosed with acute embolic stroke (AES) after first diagnosed atrial fibrillation (AF). These myocardial injuries, which are known as cardiocerebral infarction (CCI), are potentially caused by coronary embolism and correspond to simultaneous cardiac and cerebral embolisms. However, this severe condition remains poorly understood. In this prospective study, we aimed to investigate the prevalence and the cardiac magnetic resonance (CMR) characteristics of CCI., Materials and Methods: Consecutive patients with first diagnosed AF hospitalized for AES in a neurovascular intensive care unit from 2019 to 2020 were included. Troponin Ic kinetic were measured <72 h, MRI and coronary angiography or CT scan were performed <7 days after admission. Patients with significant coronary lesions were excluded., Results: During the study period, 1150 patients with strokes were hospitalized in the neurovascular intensive care unit (ICU). Of these patients, 955 had an ischemic stroke and 97 had a transient ischemic attack. Among the 44 patients with AES and with first diagnosed AF, 34 patients underwent CMR and CMR analysis identified 12 MI. A significant rise in troponin (>0.10 µg/L) was observed in 35% of the total population (12/34 patients). More specifically, a rise was seen in 23% of the AES without MI group, 58% of the AES with MI. In addition, coronary embolism was identified in 3 patients who underwent coronary angiography (3/12) and MI was often (30%) localized in infero-latero-medial and infero-apical segments. Most AES were localized in the superficial sylvian territory., Conclusion: We found a high prevalence of CMR-confirmed double embolization sites in the acute phase of an embolic stroke. Further studies are required to better characterize the pathophysiology, clinical course and prognostic value of CCI. Moreover, optimal management strategies, including antiplatelet therapy, remain to be determined., (Copyright © 2021 Elsevier Inc. All rights reserved.)

A high prevalence of cigarette smoking has been documented in France, and new patterns of tobacco and nicotine consumption are emerging, especially in some sports. In the amateur rugby population, data are scarce on harmful consumption and on the awareness of the risk of smoking. We analyzed the consumption of tobacco and other nicotine products in French amateur players, coaches and referees. Amateur players (>12 years old), coaches and referees participating in the Burgundy amateur championship were invited to answer an electronic, anonymous questionnaire during the 2017-2018 sport season. Among the 683 subjects (gender ratio M/F = 0.9), 176 (25.8%) were current smokers, including 32.4% of the referees and 28.2% of the coaches. The prevalence of smokers was higher in females (37.5%) than in males (24.6%). Most (86.4%) smoked within 2 h before/after a rugby session. Only 28 subjects (4.1%) usually vaped; 21 of them (75%) vaped within 2 h before/after a rugby session. Other tobacco or nicotine products were infrequent. The awareness about the risks of smoking before/after sport was incomplete, including in coaches and referees. The prevalence of cigarette smoking is alarming across the whole spectrum of rugby amateur actors. Education programs are urgently needed to reduce tobacco consumption in this at-risk population.

Pharmacovigilance reports of cerebral and cardiovascular events in those who use decongestants have triggered alerts related to their use. We aimed to assess the risk of stroke and myocardial infarction (MI) associated with the use of decongestants. We conducted a nested case-crossover study of patients with incident stroke and MI identified in France between 2013 and 2016 in two systematic disease registries. Decongestant use in the three weeks preceding the event was assessed using a structured telephone interview. Conditional logistic multivariable models were used to estimate the odds of incident MI and stroke, also accounting for transient risk factors and comparing week 1 (index at-risk time window, immediately preceding the event) to week 3 (reference). Time-invariant risk factors were controlled by design. In total, 1394 patients with MI and 1403 patients with stroke, mainly 70 years old or younger, were interviewed, including 3.2% who used decongestants during the three weeks prior to the event (1.0% definite exposure in the index at-risk time window, 1.1% in the referent time window; adjusted odds ratio (aOR), 0.78; 95%CI, 0.43-1.42). Secondary analysis yielded similar results for individual events (MI/stroke). We observed no increased risk of MI or stroke for patients 70 years of age and younger without previous MI or stroke who used decongestants.

Aims: We aimed to provide contemporary real-world data on wearable cardioverter-defibrillator (WCD) use, not only in terms of effectiveness and safety but also compliance and acceptability., Methods and Results: Across 88 French centres, the WEARIT-France study enrolled retrospectively patients who used the WCD between May 2014 and December 2016, and prospectively all patients equipped for WCD therapy between January 2017 and March 2018. All patients received systematic education session through a standardized programme across France at the time of initiation of WCD therapy and were systematically enrolled in the LifeVest Network remote services. Overall, 1157 patients were included (mean age 60 ± 12 years, 16% women; 46% prospectively): 82.1% with ischaemic cardiomyopathy, 10.3% after implantable cardioverter-defibrillator explant, and 7.6% before heart transplantation. Median WCD usage period was 62 (37-97) days. Median daily wear time of WCD was 23.4 (22.2-23.8) h. In multivariate analysis, younger age was associated with lower compliance [adjusted odds ratio (OR) 0.97, 95% confidence interval (CI) 0.95-0.99, P < 0.01]. A total of 18 participants (1.6%) received at least one appropriate shock, giving an incidence of appropriate therapy of 7.2 per 100 patient-years. Patient-response button allowed the shock to be aborted in 35.7% of well-tolerated sustained ventricular arrhythmias and in 95.4% of inappropriate ventricular arrhythmia detection, finally resulting in an inappropriate therapy in eight patients (0.7%)., Conclusion: Our real-life findings reinforce previous studies on the efficacy and safety of the WCD in the setting of transient high-risk group in selected patients. Moreover, they emphasize the fact that when prescribed appropriately, in concert with adequate patient education and dedicated follow-up using specific remote monitoring system, compliance with WCD is high and the device well-tolerated by the patient., (© The Author(s) 2020. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Background: We aimed to evaluate the impact of coronavirus disease 2019 (COVID-19)-related lockdown on adherence to lifestyle and drug regimens in stay-at-home chronic coronary syndromes patients living in urban and rural areas., Methods: A cross-sectional population-based study was perfomed in patients with chronic coronary syndromes. A sample of 205 patients was randomly drawn from the RICO (Observatoire des infarctus de Côte d'Or) cohort. Eight trained interviewers collected data by phone interview during week 16 (April 13 to April 19), i.e. 4 weeks after implementation of the French lockdown (start March 17, 2020)., Results: Among the 195 patients interviewed (of the 205, 3 had died, 1 declined, 6 lost), mean age was 65.5 ± 11.1 years. Only six patients (3%) reported drug discontinuation, mainly driven by media influence or family members. All 166 (85%) patients taking aspirin continued their prescribed daily intake. Lifestyle rules were less respected since almost half (45%) declared >25% reduction in physical activity, 26% of smokers increased their tobacco consumption by >25%, and 24% of patients increased their body weight > 2 kg. The decrease in physical activity and the increase in smoking were significantly greater in urban patients (P < .05)., Conclusions: The COVID-19-related lockdown had a negative impact on lifestyle in a representative sample of stay-at-home CCS patients., (Copyright © 2020. Published by Elsevier B.V.)

Background: The COVID-19 pandemic has had a profound effect on general health care. We aimed to evaluate the effect of a nationwide lockdown in France on admissions to hospital for acute myocardial infarction, by patient characteristics and regional prevalence of the pandemic., Methods: In this registry study, we collected data from 21 centres participating in the ongoing French Cohort of Myocardial Infarction Evaluation (FRENCHIE) registry, which collects data from all patients admitted for ST segment elevation myocardial infarction (STEMI) or non-ST segment elevation myocardial infarction (NSTEMI) within 48 h of symptom onset. We analysed weekly hospital admissions over 8 weeks: the 4 weeks preceding the institution of the lockdown and the 4 weeks following lockdown. The primary outcome was the change in the number of hospital admissions for all types of acute myocardial infarction, NSTEMI, and STEMI between the 4 weeks before lockdown and the 4 weeks after lockdown. Comparisons between categorical variables were made using χ 2 tests or Fisher's exact tests. Comparisons of continuous variables were made using Student's t tests or Mann-Whitney tests. Poisson regression was used to determine the significance of change in hospital admissions over the two periods, after verifying the absence of overdispersion. Age category, region, and type of acute myocardial infarction (STEMI or NSTEMI) were used as covariables. The FRENCHIE cohort is registered with ClinicalTrials.gov, NCT04050956., Findings: Between Feb 17 and April 12, 2020, 1167 patients were consecutively admitted within 48 h of acute myocardial infarction (583 with STEMI, 584 with NSTEMI) and were included in the study. Admissions for acute myocardial infarction decreased between the periods before and after lockdown was instituted, from 686 before to 481 after lockdown (30% decrease; incidence rate ratio 0·69 [95% CI 0·51-0·70]). Admissions for STEMI decreased from 331 to 252 (24%; 0·72 [0·62-0·85]), and admissions for NSTEMI decreased from 355 to 229 (35%; 0·64 [0·55-0·76]) following institution of the lockdown, with similar trends according to sex, risk factors, and regional prevalence of hospital admissions for COVID-19., Interpretation: A marked decrease in hospital admissions was observed following the lockdown, irrespective of patient characteristics and regional prevalence of COVID-19. Health authorities should be aware of these findings, in order to adapt their message if the COVID-19 pandemic persists or recurs, or in case of future major epidemics., Funding: Recherche Hospitalo-Universitaire en Santé iVasc., (Copyright © 2020 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Background: Patients with familial hypercholesterolemia (FH) are prone to develop acute myocardial infarction (AMI) at a younger age., Objectives: The aim of the present study was to assess 5-year outcomes after AMI according to the presence of FH in a large multicenter cohort of patients., Methods: The French registry of Acute ST-elevation and non-ST-elevation Myocardial Infarction consists of nationwide surveys recruiting patients over a 1- to 2-month period every 5 years. Patients recruited in 2005 and 2010 were followed up to 5 years., Results: Of 5147 patients discharged alive and in whom FH status could be assessed, 2.8% had probable/definite FH, using an adapted Dutch Lipid Clinic score. They were 12 years younger, on average, than non-FH patients. Before adjustment, their 5-year survival and event-free survival did not differ from non-FH patients. After adjustment, however, both mortality (hazard ratio [HR] 1.82, 95% confidence interval [CI] 1.15-2.89; P = .011) and the combined endpoint of death, AMI, or stroke (HR 2.22, 95% CI: 1.51-3.26; P < .001) were higher in FH patients. The higher risk in FH patients was also present in patients receiving high-intensity lipid-lowering therapy at discharge: adjusted HR for mortality 2.29, 95% CI: 1.18 to 4.47, P = .015; HR for cardiovascular events 2.57, 95% CI: 1.48 to 4.48, P = .001. Concordant results were observed in propensity score-marched cohorts., Conclusions: The risk of long-term mortality and cardiovascular events is twice as high in FH than in non-FH patients, when adjusted on baseline characteristics, even for those receiving high-intensity lipid-lowering therapy. Additional therapeutic measures are needed in these patients., (Copyright © 2020. Published by Elsevier Inc.)

Background: Evidence-based clinical practice guidelines define initial management of acute pulmonary embolism (PE) according to risk stratification for early death., Aims: The aims of the present study were to investigate patterns of non-compliance with guidelines for the acute PE treatment, and the associated risk of adverse events., Methods: We performed an observational, multicentre, cohort study of acute PE. Inclusion criteria were all patients with pulmonary embolism admitted to the participating centres between January 2011 and April 2017. The measure of 100% compliance was used to allocate patients in the compliant or non-compliant groups. The primary outcome was all-cause death at 6 months. Secondary outcomes included recurrent venous thromboembolism and major bleeding., Results: In total, 1285 patients were included. Treatment was not in compliance with the guidelines in 172 patients (13.4%). Four factors were identified to be related to non-compliance with the guidelines: shock or hypotension (relative risk [RR] 5.23, 95% confidence interval [CI] 2.64-10.30; P<0.001), renal insufficiency (RR 1.80, 95% CI 1.41-2.28; P<0.001), active cancer (RR 1.35, 95% CI 1.24-1.48; P<0.001) and right ventricular dysfunction at admission (RR 1.06, 95% CI 1.01-1.11; P=0.01). The primary endpoint of all-cause death at 6 months occurred in 62 of 172 patients (36.0%) in the non-compliant group and in 131 of 1113 patients (11.8%) in the compliant group (hazard ratio 2.02, 95% CI 1.45-2.81; P<0.001). The rates of recurrent venous thromboembolism (8.7% vs 1.1%; P<0.001) and major bleeding (13.4% vs 4.9%, P=0.04) from admission to 6-month follow-up were higher in the non-compliant group., Conclusion: Non-compliance with guidelines was independently associated with worse outcomes, including death, recurrent venous thromboembolism and bleeding., (Copyright © 2019 Elsevier Masson SAS. All rights reserved.)

Background: Cancer and acute myocardial infarction (AMI) have important prognostic consequences. Treatment of some cancers may affect coronary artery disease, myocardial function and/or AMI management. Whether the early and long-term mortality of patients with AMI differ according to their history of cancer remains questionable., Aims: To determine in-hospital outcomes and 5-year mortality following AMI according to patient history of cancer., Methods: The FAST-MI registry is a nationwide French survey collecting data on characteristics, management and outcomes of 3670 consecutive patients admitted for AMI during October 2005., Results: Overall, 246/3664 patients (6.7%) admitted for an AMI (47.6% with ST-segment elevation myocardial infarction [STEMI]; 52.4% with non-STEMI [NSTEMI]) had a history of cancer. In-hospital mortality was not significantly different for patients with versus without a history of cancer, overall (adjusted odds ratio [OR]: 1.15, 95% confidence interval [CI]: 0.68-1.94; P=0.61) and in patients with STEMI (adjusted OR: 1.37, 95% CI: 0.69-2.71; P=0.37) or NSTEMI (adjusted OR: 0.97, 95% CI: 0.41-2.28; P=0.95). All-cause mortality at 5 years was higher among patients with a history of cancer (adjusted hazard ratio [HR]: 1.36, 95% CI: 1.08-1.69; P=0.008), whereas 5-year cardiovascular mortality did not differ (adjusted HR: 1.17, 95% CI: 0.89-1.53; P=0.25), regardless of whether the patients had STEMI or NSTEMI. Similar results were found in populations matched on a propensity score including baseline characteristics and early management., Conclusion: A history of cancer, per se, does not appear to be a risk factor for increased in-hospital mortality or long-term cardiovascular mortality in patients admitted for AMI., (Copyright © 2019. Published by Elsevier Masson SAS.)

Background and Aim: We aimed to investigate cardiovascular risk factors and health behaviours prospectively in a large population of French amateur rugby players., Methods: An anonymous questionnaire was displayed to rugby players aged over 12 years enrolled in the 2014-2015 French amateur rugby championship from the Burgundy region ( n  = 5140). Questions addressed awareness on: (a) cardiovascular prevention; (b) tobacco, alcohol and highly caffeinated beverages consumption; and (c) adherence to prevention guidelines (ECG checks, training in basic life support, avoidance of sports practice during fever/infectious episodes)., Results: Among the 640 participants who completed the questionnaires, most were male (90%) and were aged under 35 years (80%). Almost half had basic life support training (42%), but only a minority attended an ECG check-up before licensing (37%), and only a few were aware of the cardiovascular prevention information campaign (17%), similarly across the age groups. Surprisingly, playing rugby with fever was commonly reported (44%) and was even more frequent in young women (55%). A high number of respondents were current smokers (35%), of whom most reported consumption less than 2 hours before/after a rugby session. Alcohol drinkers were frequent (69%), of whom most (79%) drank alcohol less than 2 hours before/after a match. Highly caffeinated beverages consumption (34%) was high, particularly in younger players (39%). Half highly caffeinated beverages consumption was in the setting of a rugby session, even greater in women and mainly motivated by performance enhancement (34%)., Conclusion: Our findings from a representative regional cohort may help to identify targets for cardiovascular prevention through the development of educational programmes aiming to improve the knowledge and behaviour of amateur rugby players.

The increased use of reperfusion therapy in ST-segment-elevation myocardial infarction (STEMI) patients in the past decades is generally considered the main determinant of improved outcomes. The aim was to assess 20-year trends in profile, management, and one-year outcomes in STEMI patients in relation with use or non-use of reperfusion therapy (primary percutaneous coronary intervention (pPCI) or fibrinolysis)., Methods: We used data from 5 one-month French nationwide registries, conducted 5 years apart from 2005 to 2015, including 8579 STEMI patients (67% with and 33% without reperfusion therapy) admitted to cardiac intensive care units in France., Results: Use of reperfusion therapy increased from 49% in 1995 to 82% in 2015, with a shift from fibrinolysis (37.5% to 6%) to pPCI (12% to 76%). Early use of evidence-based medications gradually increased over the period in both patients with and without reperfusion therapy, although it remained lower at all times in those without reperfusion therapy. One-year mortality decreased in patients with reperfusion therapy (from 11.9% in 1995 to 5.9% in 2010 and 2015, hazard ratio [HR] adjusted on baseline profile 0.40; 95% CI: 0.29-0.54, P < .001) and in those without reperfusion therapy (from 25.0% to 18.2% in 2010 and 8.1% in 2015, HR: 0.33; 95% CI: 0.24-0.47, P < .001)., Conclusions: In STEMI patients, one-year mortality continues to decline, both related to increased use of reperfusion therapy and progress in overall patient management. In patients with reperfusion therapy, mortality has remained stable since 2010, while it has continued to decline in patients without reperfusion therapy., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Individuals with heterozygous familial hypercholesterolemia (FH) are at high risk of early myocardial infarction (MI). However, coronary artery disease (CAD) burden of FH remains not well described, especially for French patients., Objective: The objective of this study was to assess the prevalence of FH and severity of CAD from a large database of a French regional registry of acute MI., Methods: All consecutive patients hospitalized for an acute MI in a multicenter database from 2001 to 2017 were considered. FH was diagnosed using an algorithm adapted from the Dutch Lipid Clinic Network criteria. The prevalence and clinical features of FH and the severity of CAD were assessed., Results: Among the 11,624 patients included in the study, the proportion of "probable/definite", "possible", and "unlikely" FH in patients with MI was 2.1% (n = 249), 20.7% (n = 2405), and 77.2% (n = 8970), respectively. When compared with patients with "unlikely" FH, patients with "probable/definite" FH were 20 years younger (51 vs 71, P < .001), with a lower rate of diabetes (17% vs 25%, P = .007) and a higher prevalence of personal and familial history of CAD. Chronic statin treatment was only used in 48% of FH patients and ezetimibe in 8%. After adjustment for age, sex, and diabetes, patients with FH were characterized by increased extent of CAD (SYNTAX score 11 vs 7, P < .001) and multivessel disease (55% vs 40%, P < .001)., Conclusions: In this large cohort of French individuals, FH was common in patients with MI, associated with markedly early age of MI and severity of CAD burden and limited use of preventive lipid-lowering therapy., (Copyright © 2019 National Lipid Association. Published by Elsevier Inc. All rights reserved.)

Background: Data regarding the use of direct oral anticoagulants (DOACs) for the treatment of acute pulmonary embolism (PE) are sparse. We conducted a prospective multicentre registry study to describe patterns of DOAC prescription for the treatment of acute PE, and the associated risk of 6-month adverse events in daily practice., Methods: We included all PE patients discharged since the availability of DOACs for the dedicated indication of acute PE treatment. Clinical data and 6-month outcomes, including death, recurrent venous thromboembolism (VTE), bleeding, and chronic thromboembolic pulmonary hypertension (CTEPH) were recorded prospectively. Temporal trends in DOAC prescription were tested., Results: Between 09/2012 and 04/2017, 1082 patients were included: 60.6% (n = 656) were treated with DOACs and 39.4% (n = 426) with another anticoagulant. The prescription rate of DOACs increased sharply just after their release on the market to reach a plateau over time, between 56% and 72% of the total prescription per year in PE patients (p for trend = 0.33). Active malignancy and renal function impairment were factors independently associated with non-prescription of DOACs. Overall, prescription of DOACs was appropriate in 95.3% of patients. The rate of use of non-recommended DOAC doses was 4.2% (n = 28). The rate of death, recurrent VTE, bleeding and CTEPH were 2.4%, 1.2%, 7.2%, and 1.9%, respectively in the DOAC group., Conclusion: The choice to prescribe DOACs or not is related to patient characteristics. The overall appropriateness of prescription is high, while the rate of adverse events observed in patients treated with DOAC is low in our registry., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Aims: We compared the 1-year safety and effectiveness of dabigatran 110 mg (D110) or 150 mg (D150) twice daily to vitamin K antagonists (VKA) in patients with nonvalvular atrial fibrillation., Methods: New user cohort study of patients dispensed D110 or D150 vs. VKA in 2013 for nonvalvular atrial fibrillation, followed 1 year in the French Système National des Données de Santé (66 million persons). D110 and D150 users were matched 1:1 with VKA users on sex, age, date of first drug dispensing and high-dimensional propensity score. Hazard ratios [HR (95% confidence intervals)] for stroke and systemic embolism (SSE), major bleeding (MB) and death were computed using Cox proportional hazards or Fine and Gray models during exposure., Results: In 14 442 matched D110 and VKA patients, mean age 79, 49% male, 91% with CHA 2 DS 2 -VASc ≥2 and 8% with HAS-BLED score >3, incidence rates of SSE were 1.9% and 2.6% person-years [HR 0.69 (0.56-0.84)], MB 1.8% and 2.9% [0.62 (0.51-0.76)], death 7.2% and 8.6% [0.84 (0.76-0.94)]. In 8389 matched D150 and VKA patients, mean age 67, 67% male, 65% with CHA 2 DS 2 -VASC ≥2; < 5% HAS-BLED >3, incidence rates were for SSE 1.4% and 1.9% [0.76 (0.56-1.04)], MB 0.6% and 1.9% [0.30 (0.20-0.46)], death 1.6% and 3.6% [0.46 (0.35-0.59)]. Numbers needed to treat to observe one fewer death were 78 for D110, 88 for D150., Conclusion: In real life D110 and D150 were at least as effective, and safer than VKA., (© 2018 The British Pharmacological Society.)

Aims: Silent and symptomatic atrial fibrillation (AF) are common during acute myocardial infarction (AMI), and associated with higher in-hospital and 1-year mortality. Are silent and symptomatic AF associated with higher rates of AF recurrence after hospitalization for AMI?, Methods and Results: All consecutive patients admitted for AMI between January 2012 and August 2015 were prospectively analysed by continuous electrocardiogram monitoring <48 h after admission. Silent AF was defined as asymptomatic episodes lasting at least 30 s. The population was divided into three groups: no-AF, silent AF, and symptomatic AF. Altogether, 1621 patients were included in the prospective study and discharged alive from hospital. After excluding those with previous AF, permanent AF since the AMI and coronary artery bypass grafting surgeries and those lost to follow-up, 1282 remained. During the AMI, 1058 patients (83%) had a persistent sinus rhythm (SR), 168 (13%) had silent AF, and 55 (4%) had symptomatic AF. After a median follow-up of 1037 days (interquartile range 583-1342), new AF episodes were recorded in 59 patients (6%) of the SR group, 21 (13%) in the silent AF group, and 13 (24%) in the symptomatic AF group (P < 0.001). After Cox multivariate analysis, AF during AMI, indexed left atrial volume, age, and creatinine at discharge were identified as independent risk factors of AF after AMI., Conclusion: The results of our large-scale study suggest that patients experiencing paroxysmal new-onset AF (silent or symptomatic) during AMI are at higher risk of AF at follow-up. Our data raise the question of implementing anticoagulation therapy following these brief and often neglected episodes.

Objective: The objective of the study was to assess 24-h ambulatory blood pressure monitoring (ABPM) validity in daily primary healthcare practice in France., Patients and Methods: An observational, longitudinal, prospective, multicenter study was performed in the Burgundy region, France. Participants were patients who had been prescribed ABPM by their general practitioner (GP), whatever its indication. ABPM was performed by employees of the healthcare providers group, which is publicly funded. The validity of ABPM was established according to the European Society of Cardiology (ESC) criteria. GPs interpretation of the ABPM results was collected and compared with the ESC recommendations. Determinants of ABPM validity were identified using logistic regression models., Results: Among the 531 patients included, 357 (67.23%) had a valid ABPM measurement. Multivariate analyses showed that ABPM validity was associated with nonmanual worker status [odds ratio (OR)=1.14; 95% confidence interval (CI)=1.04-1.23], participant's age of at least 65 years (OR=0.88; 95% CI=0.81-0.95) and participant's BMI above 30 kg/m (OR=0.90; 95% CI=0.81-0.99). GPs' interpretation of ABPM results was consistent with the ESC recommendation in 508 (95.67%) cases., Conclusion: ABPM is feasible in daily primary healthcare practice in the studied condition, that is to say relying on trained employees. GPs should be careful when prescribing ABPM to patients aged 65 years and older, to those with BMI over 30 or to manual workers.

Objective: To compare ticagrelor and prasugrel with clopidogrel for recurrent fatal and non-fatal myocardial infarction (reMI) in real-life conditions., Methods: Case-referent study using the Pharmacoepidemiological General Research eXtension (PGRx)-acute coronary syndrome (ACS) registry. Cases were patients with reMI from a cohort with index ACS or external to the cohort (same sites). Referents from the cohort, without recurrent event, were matched on index ACS type and date, age and sex with reMI cases. Multivariate conditional logistic regression assessed the OR (95% CI) for reMI associated with ticagrelor and prasugrel vs clopidogrel, adjusted for aspirin use and cardiovascular risk factors., Results: 1047 cases and 2234 matched referents were included. Compared with clopidogrel, ticagrelor and prasugrel were associated with respective ORs of 0.65 (95% CI 0.52 to 0.81) and 0.71 (95% CI 0.53 to 0.96) for reMI occurrence. ORs for ticagrelor and prasugrel vs clopidogrel were: 0.50 (95% CI 0.38 to 0.67) and 0.66 (95% CI 0.45 to 0.95), 0.39 (95% CI 0.24 to 0.62) and 0.44 (95% CI 0.26 to 0.75), 0.63 (95% CI 0.43 to 0.92) and 1.20 (95% CI 0.69 to 2.07), 1.11 (95% CI 0.72 to 1.72) and 0.82 (95% CI 0.44 to 1.54) when index ACS was a first MI, a first ST-elevated MI (STEMI), a first non-STEMI and a recurrent ACS, respectively, and 0.63 (95% CI 0.45 to 0.87) and 0.77 (95% CI 0.41 to 1.45) for patients aged ≥70  years., Conclusions: This real-world study showed a significant reduction of reMI with new antiplatelets compared with clopidogrel, ticagrelor being associated with a greater decrease of risk notably for first, either STEMI or non-STEMI. The larger magnitude of effect may be attributed to potential residual confounding or higher effectiveness compared with efficacy reported in trials (EMA Post Authorisation Study Registry Number EUPAS5905)., Competing Interests: Competing interests: LG-B is currently employed by PGRx, a company susceptible of collaborating with virtually all the pharmaceutical companies worldwide. NDa declares having received financial support from Abbott France, Amgen SAS, AstraZeneca, Bayer Healthcare SAS, Boehringer Ingelheim France, Bristol-Myers Squibb, GlaxoSmithKline France, Lilly France SAS, MSD France, Novo Nordisk, Pierre Fabre, Re-Imagine Health Agency, Sanofi-Aventis France and Servier during the conduct of the study. JD declares having received personal fees for participating in Scientific Boards from AstraZeneca, Bayer and MSD. BF reports personal fees from AstraZeneca during the conduct of the study. AF, OM, FL, FG and NDe declare no conflict of interest. YC declares having received financial support for participating in Scientific Boards and consulting for Bayer, Boehringer, Novartis, Pfizer and Servier outside the submitted work. LB declares having received financial support in the form of grants and/or personal fees from AstraZeneca during the conduct of the study and also outside the submitted work. EP declares having received fees for lectures and/or consulting from Amgen, AstraZeneca, Bayer, BMS, Daiichi-Sankyo, Lilly, MSD, The Medicine Company, Sanofi and Servier. JB declares having received financial support from Association pour le Développement de l’Enseignement et des Recherches auprès des universités des centres de recherches et des entreprises d’Aquitaine, AstraZeneca, Servier and LASER during the conduct of the study. LA is chairman and stock owner in Analytica LASER, a consultancy susceptible of collaborating with virtually all the pharmaceutical companies worldwide. PGRx has no commercial interests in any of the products studied. Members of the PGRx network have no interest in any drugs or other factors studied using data collected using PGRx., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Background: Type 2 myocardial infarction and nonischemic myocardial injury, corresponding to troponin elevation without atherothrombosis, are emerging concepts suspected of being common in emergency departments (ED). However, their respective frequencies, risk profiles, and short-term prognoses remain to be investigated., Methods: Among all the patients admitted from January 2014 to December 2016 in a university hospital ED (n = 33,669), those with elevated conventional troponin Ic (≥0.10 µg/L) (n = 4436, 13%) were systematically adjudicated as having type 1 or type 2 myocardial infarction in the presence of symptoms or signs of myocardial ischemia (typical chest pain or electrocardiographic changes) or myocardial injury without such signs., Results: Among the 4436 patients included, 1453 (33%) were classified as having myocardial injury, 947 (21%) as having type 2 and 2036 (46%) as having type 1 myocardial infarction. Compared with type 1 patients, patients with type 2 myocardial infarction and myocardial injury were markedly older (respective median ages: 67, 81, and 84 years; P < .001) with more frequent comorbidities. In multivariate analysis, myocardial injury was associated with a lower risk of cardiovascular death (odds ratio 43; 95% confidence interval, 0.29-0.65; P < .001) but a higher risk of all-cause in-hospital death (odds ratio 1.43; 95% confidence interval, 1.02-2.00; P = .037). Systolic blood pressure <90mm Hg and heart rate >100 beats per minute at admission were strongly associated with all-cause mortality, and the troponin rate was associated with cardiovascular mortality in all groups., Conclusions: In a large study of patients with elevated troponins in an ED, myocardial injury and type 2 myocardial infarction were frequent and associated with a worse in-hospital prognosis than type 1 myocardial infarction resulting from noncardiovascular events., (Copyright © 2018. Published by Elsevier Inc.)

Background The optimal timing of administration of dual antiplatelet therapy (DAPT) in acute ST-segment-elevation myocardial infarction patients is debated. Clinical trials have failed to demonstrate the superiority of pretreatment with P2Y12 inhibitors in ST-segment-elevation myocardial infarction, but they were not designed to assess hard clinical end points. We used data from the FAST-MI (French Registry on Acute ST-Segment-Elevation or Non-ST-Segment-Elevation Myocardial Infarction) cohorts to determine 1-year survival and in-hospital outcomes in patients receiving DAPT, comparing prehospital versus in-hospital administration. Methods and Results The FAST-MI program collects extensive data on patients admitted in France for acute myocardial infarction over a 1-month period every 5 years since 2005. For the present analysis, 3548 patients with ST-segment-elevation myocardial infarction ≤12 hours from symptom onset, transported by physician-staffed emergency medical system ambulances, not treated with intravenous fibrinolysis, and receiving DAPT were included, of whom 44% received DAPT in the ambulance. The primary end point was 1-year survival as assessed by multivariate Cox analysis and propensity score analysis. In-hospital bleeding and ischemic complications were also analyzed. Adjusted in-hospital mortality was numerically but not significantly lower in patients with prehospital DAPT. There were no differences in in-hospital bleeding complications. Fully-adjusted hazard ratio for 1-year death in patients with prehospital versus in-hospital DAPT was 0.69 (95% CI, 0.51-0.92; P=0.011), and propensity score-adjusted hazard ratio was 0.55 (95% CI, 0.41-0.73; P=0.001) in the whole population. In the propensity score-matched cohorts (360 patients each), 1-year survival was 93.9% in patients with prehospital versus 90.3% in those with in-hospital DAPT (hazard ratio, 0.62; 95% CI, 0.36-1.05; P=0.077). Results were consistent in subgroups, including by year of survey, age, presence of out-of-hospital cardiac arrest, morphine use, and type of P2Y12 inhibitor used. Conclusions In these cohorts of ST-segment-elevation myocardial infarction patients considered for primary percutaneous coronary intervention, prehospital administration of DAPT was associated with higher 1-year survival and no increase in in-hospital bleeding complications. The magnitude of the decrease in 1-year mortality, however, may suggest the persistence of some degree of residual confounding. Clinical Trial Registration: URL: https://www.clinicaltrials.gov . Unique identifiers: NCT00673036, NCT01237418, and NCT02566200.

New onset atrial fibrillation post-transcatheter aortic valve implantation (TAVI) is common and is associated with adverse outcomes. However, silent atrial fibrillation (AF) is poorly documented in the context. This study sought to evaluate the incidence, predictive factors, and prognostic value of Silent AF post-TAVI. All the consecutive patients with TAVI were prospectively analyzed by continuous electrocardiogram monitoring≥48 hours after implantation. Silent AF was defined as asymptomatic episodes lasting at least 30 seconds. The population was divided into 3 groups: history of AF, no-AF, and silent AF. Among the 206 patients implanted with TAVI, 19 (16.1%) developed silent AF. Compared with the no-AF group, patients with silent AF shared the same clinical characteristics and cardiovascular risk factors. Procedural success and echography parameters after the device implantation were similar between groups. Left atrial volume was significantly increased (p <0.001) in the silent AF group, together with preimplantation C-reactive protein (CRP) >3 mg/L and glucose (p = 0.048 and p = 0.002). By multivariate analysis, CRP >3 mg/dl and logistic European System for Cardiac Operative Risk Evaluation were identified as independent predictors of silent AF. In-hospital and 1-year mortalities were higher in pre-existing AF patients, whereas no-AF and the silent AF patients share the same prognosis. Our prospective study showed for the first time that silent AF is frequent after TAVI procedures. In conclusion, our work suggests that CRP could help to predict the risk of developing silent AF. However, the onset of silent AF is not associated with worse prognosis in the year following the procedure in our study., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Aims: To derive and validate a readily useable risk score to identify patients at high-risk of in-hospital ST-segment elevation myocardial infarction (STEMI)-related cardiogenic shock (CS)., Methods and Results: In all, 6838 patients without CS on admission and treated by primary percutaneous coronary intervention (pPCI), included in the Observatoire Régional Breton sur l'Infarctus (ORBI), served as a derivation cohort, and 2208 patients included in the obseRvatoire des Infarctus de Côte-d'Or (RICO) constituted the external validation cohort. Stepwise multivariable logistic regression was used to build the score. Eleven variables were independently associated with the development of in-hospital CS: age >70 years, prior stroke/transient ischaemic attack, cardiac arrest upon admission, anterior STEMI, first medical contact-to-pPCI delay >90 min, Killip class, heart rate >90/min, a combination of systolic blood pressure <125 mmHg and pulse pressure <45 mmHg, glycaemia >10 mmol/L, culprit lesion of the left main coronary artery, and post-pPCI thrombolysis in myocardial infarction flow grade <3. The score derived from these variables allowed the classification of patients into four risk categories: low (0-7), low-to-intermediate (8-10), intermediate-to-high (11-12), and high (≥13). Observed in-hospital CS rates were 1.3%, 6.6%, 11.7%, and 31.8%, across the four risk categories, respectively. Validation in the RICO cohort demonstrated in-hospital CS rates of 3.1% (score 0-7), 10.6% (score 8-10), 18.1% (score 11-12), and 34.1% (score ≥13). The score demonstrated high discrimination (c-statistic of 0.84 in the derivation cohort, 0.80 in the validation cohort) and adequate calibration in both cohorts., Conclusion: The ORBI risk score provides a readily useable and efficient tool to identify patients at high-risk of developing CS during hospitalization following STEMI, which may aid in further risk-stratification and thus potentially facilitate pre-emptive clinical decision making.

Background: Red blood cell transfusion benefit during acute myocardial infarction remains unclear in the elderly. We aimed to assess the transfusion impact on 1-year mortality in acute myocardial infarction patients aged ≥65 years, according to their age and hemoglobin nadir., Methods: We included 3316 consecutive patients with acute myocardial infarction aged ≥65 years from the "obseRvatoire des Infarctus de Côte d'Or" (RICO) survey. They were categorized according to their hemoglobin nadir (≤8, >8 to ≤10, and >10 g/dL) and age (<80 or ≥80 years)., Results: A total of 1906 patients (57%) were 65-79 years old, and 1410 (43%) were aged ≥80 years, of whom 103 (5%) and 145 (10%) patients received red blood cell transfusion, respectively (P < .001). In Cox regression analysis, transfusion was associated with increased 1-year mortality for hemoglobin nadir >10 g/dL but no significant effect for hemoglobin nadir between 8 and 10 g/dL. When hemoglobin nadir was ≤8 g/dL, transfusion did not influence 1-year mortality for younger patients (65-79 years). However, for older patients (≥80 years), transfusion was associated with lower mortality (hazard ratio 0.43 [95% confidence interval, 0.22-0.86], P = .016)., Conclusion: Among older patients with acute myocardial infarction, the effect of transfusion was largely dependent on hemoglobin threshold and age. Transfusion was associated with increased 1-year mortality when hemoglobin nadir was >10 g/dL. However, in patients aged ≥80 years with hemoglobin nadir <8 g/dL, transfusion was associated with a 50% reduction in 1-year mortality., (Copyright © 2018. Published by Elsevier Inc.)

Results from randomized trials evaluating thrombus aspiration (TA) in patients with ST-elevation myocardial infarction (STEMI) are conflicting. We assessed 1-year survival in STEMI patients participating in the French Registry of Acute ST-Elevation and non-ST-Elevation Myocardial Infarction (FAST-MI) 2010 according to the use of TA during primary percutaneous coronary intervention (PCI). FAST-MI 2010 is a nationwide French registry that included 4,169 patients with acute myocardial infarction at the end of 2010 in 213 centers. Of those, 2,087 patients had STEMI, of whom 1,538 had primary PCI, with TA used in 671 (44%). Patients with TA were younger (61 ± 13.5 vs 63 ± 14 years), with a similar risk score of the Global Registry of Acute Coronary Events (140 ± 31 vs 143 ± 34) and a shorter median time from symptom onset (245 vs 285 minutes); location of acute myocardial infarction, history of myocardial infarction, PCI, or coronary artery bypass surgery did not differ significantly. Thirty-day mortality was 2.1% versus 2.1% (adjusted p = 0.18), and the rate of 1-year survival was 95.5% versus 94.8%. Using fully adjusted Cox multivariate analysis, hazard ratio for 1-year death was 1.13 (95% confidence interval 0.66 to 1.94). After propensity score matching (480 patients per group), 1-year survival was also similar with both strategies. In a real-world setting of patients admitted with STEMI, the use of TA during primary PCI was not associated with improved 1-year survival., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background: Although primary percutaneous coronary intervention (pPCI) is the preferred reperfusion method for ST-segment-elevation myocardial infarction, it remains difficult to implement in many areas, and fibrinolytic therapy is still widely used., Methods and Results: We assessed 5-year mortality in patients with ST-segment-elevation myocardial infarction from the French Registry of Acute ST-Elevation or Non-ST Elevation Myocardial Infarction (FAST-MI) 2005 according to use and type of reperfusion therapy. Of 1492 patients with ST-segment-elevation myocardial infarction with a first call ≤12 hours from onset, 447 (30%) received fibrinolysis (66% prehospital; 97% with subsequent angiography, 84% with subsequent PCI), 583 (39%) had pPCI, and 462 (31%) received no reperfusion. Crude 5-year survival was 88% for the fibrinolytic-based strategy, 83% for pPCI, and 59% for no reperfusion. Adjusted hazard ratios for 5-year death were 0.73 (95% confidence interval, 0.50-1.06) for fibrinolysis versus pPCI, 0.57 (95% confidence interval, 0.36-0.88) for prehospital fibrinolysis versus pPCI, and 0.63 (95% confidence interval, 0.34-0.91) for fibrinolysis versus pPCI beyond 90 minutes of call in patients having called ≤180 minutes from onset. In propensity score-matched populations, however, survival rates were not significantly different for fibrinolysis and pPCI, both in the whole population (88% lysis, 85% pPCI) and in the population seen early (87% fibrinolysis, 85% pPCI beyond 90 minutes from call)., Conclusions: In a real-world setting, on a nationwide scale, a pharmaco-invasive strategy constitutes a valid alternative to pPCI, with 5-year survival at least equivalent to that of the reference reperfusion method., Clinical Trial Registration Url: www.clinicaltrials.gov. Unique identifier: NCT00673036.

Background: Evidence on the real effectiveness of statins on acute coronary syndrome (ACS) incidence is scarce. We assessed the effectiveness of real-life statins on the risk of first non-fatal ACS in a low-cardiovascular-risk country., Methods: Systematic case-control study was conducted in 60 cardiology centres and 371 general practices from across France. A total of 2238 cases with first ACS within 1 month from recruitment and 2238 controls without history of ACS were included; controls were matched to ACS cases on sex, age, frequency of visits to GPs, date of recruitment and personal history of chronic diseases. Statin exposure and risk factors were documented through patient telephone interviews and validated against medical records. The index date was the date of ACS for cases. Adjusted odds ratios (OR) of first ACS and statin use were estimated by multiple conditional logistic regression models controlled for risk factors and propensity score for statin exposure., Results: Statin use was associated with lower ACS risk, with an adjusted matched OR of 0.67; 95% confidence interval (CI): 0.56 to 0.79 for current use (within 2 months) and 0.73; 95% CI: 0.62 to 0.86 for any use within 24 months [atorvastatin: 0.83 (0.63-1.10), fluvastatin: 0.75 (0.43-1.30), pravastatin: 0.98 (0.72-1.34), rosuvastatin: 0.49 (0.35-0.68) and simvastatin: 0.62 (0.46-0.84)]. The preventive effect of statins on non-fatal ACS reached its maximum after one to four years of use., Conclusion: A similar magnitude of effect for statin use was observed in real life, as compared to randomised clinical trials in France., (© 2013.)

Background: We aimed to assess in-hospital case fatality and 1-year prognosis in HIV-infected patients with acute myocardial infarction., Methods and Results: From the PMSI (Program de Medicalisation des Systèmes d'informatique) database, data from 277 303 consecutive acute myocardial infarction patients hospitalized from January 1, 2005, to December 31, 2009, were analyzed. Surviving patients were followed up for 1 year after discharge. HIV-infected patients were compared with uninfected patients. Among the cohort, HIV-infected patients (n=608) accounted for 0.22%. All-cause hospital and 1-year mortality rates were lower in the HIV-infected group than in uninfected patients (3.1% versus 8.1% [P<0.001] and 1.4% versus 5.5% [P<0.001], respectively). From the database, we then analyzed a cohort derived from a matching procedure, with 1 HIV patient matched with 2 patients without HIV, based on age and sex (n=1824). Ischemic cardiomyopathy was more frequent in the HIV group (7.6% versus 4.2%, P=0.003). Hospitalization and 1-year mortality rates were similar in the 2 groups (3.1% versus 2.1% [P=0.168] and 1.4% versus 1.7% [P=0.642], respectively). However, at 12 months, hospitalizations for episodes of heart failure were significantly more frequent in HIV-infected than in uninfected patients (3.3% versus 1.4%, respectively; P=0.020). HIV infection, diabetes mellitus, history of ischemic cardiomyopathy, and undergoing percutaneous coronary intervention were associated in univariate analysis with occurrence of heart failure. By multivariable analysis, HIV infection (odds ratio 2.82, 95% confidence interval 1.32-6.01), diabetes mellitus, and undergoing percutaneous coronary intervention remained independent predictors of heart failure., Conclusions: The present study demonstrates that after acute myocardial infarction, HIV status influences long-term risk, although the short-term risk in HIV patients is comparable to that in uninfected patients.

Introduction: Iatrogenic complications are defined as adverse drug reactions or complications induced by non-drug interventions, such as cardiac devices or stimulation techniques. Iatrogenic complications occurring during hospital stay are known to be associated with increased hospital length of stay and mortality. Only few data are available on iatrogenic as cause of hospital admission, particularly in coronary care unit. In patient admitted in coronary care unit for iatrogenic, we aimed: (a) to analyse their prevalence, type and characteristics, (b) to analyse their in-hospital length of stay and mortality and (c) to evaluate the predictive factors of severity and mortality., Methods: From 1st April 2008 to 31 January 2012, all the consecutive admissions caused by iatrogenic complications at the coronary care unit were prospectively included and classified in two groups: (1) pharmacological iatrogenic (beta-blockers, digoxin, calcium channel blockers, cordarone, several antiarrhythmic , anticoagulants, antiplatelets and others), (2) non-pharmacological iatrogenic (pacemaker, cardioverter-defibrillator, radiofrequency, coronary angiography and cardiac surgery including valve surgery). We excluded patients with intentional overdose. We also compared patients according to the severity (group 1: patients who just need a monitoring; and group 2: patients for whom there was invasive procedure or for whom we used vasoactive amine)., Results: Among 7244 patients admitted in coronary care unit during the inclusion period, 250 (3.4%) were admitted for iatrogenic complication, 136 in pharmacological group and 114 in non-pharmacological group. In non-pharmacological group, there was more men: 73.7% vs. 47.8% (P < 0.001), patients are younger: 67.3 ± 13.2 vs. 75.4 ± 15.8 (P < 0.001) and are more severe: 80.4% in group 2 vs. 69.4% (P = 0.05). The mortality in this group tends to be more important. According to the severity, there is no difference about drugs: 7.4 ± 3.4 vs. 6.8 ± 2.9 (P = 0.184) and are staying longer in hospital: 4.7 ± 3.2 days vs. 3.4 ± 2.4 (P = 0.009) for coronary care unit length of stay and 15 ± 13.7 vs. 10 ± 9.8 (P = 0.003) for total length of stay., Conclusion: Iatrogenic represent a non-negligible cause of admission in coronary care unit, which associated with significant mortality (8.8%) and with a trend toward a higher length of stay. Further studies are needed to determinate the origin of mortality and to better characterize patients at risk of iatrogenic., (Copyright © 2012. Published by Elsevier SAS.)

Objectives: To investigate the premorbid use of secondary prevention medications in patients with recurrent vascular events., Design: Prospective, observational, population based study., Setting: The Dijon Stroke Registry and the registry of myocardial infarction of Dijon and Côte d'Or, France., Patients: All patients with cerebral ischaemia (ischaemic stroke or transient ischaemic attacks) or coronary artery disease (CAD) and a history of vascular disease (cerebral ischaemia, CAD or peripheral arterial disease (PAD)) in Dijon, France from 2006 to 2010., Main Outcome Measures: Data on medical history and prior use of treatments were collected. Mutivariate analyses were performed to identify predictors of the use of medications., Results: 867 patients (614 cerebral ischaemia and 253 CAD) were recorded including 448 (51.7%) with a history of cerebral ischaemia only, 191 (22.0%) with a history of CAD only, 68 (7.8%) with a history of PAD only and 160 (18.5%) with a history of polyvascular disease. In these 867 patients, 57.3% were on antithrombotic therapy, 61.2% were treated with antihypertensive drugs, 32.9% received statins and only 23.6% were on an optimal regimen, defined as a combination of the three therapies. Compared with patients with previous CAD only, those with previous cerebral ischaemia only were less likely to be receiving each of these treatments or to receive an optimal regimen (OR=0.17, 95% CI 0.14 to 0.26, p<0.001)., Conclusions: Our findings underline the fact that the underuse of secondary preventive therapies is common in patients with recurrent vascular events, especially those with previous cerebral ischaemia. This underuse could be targeted to reduce recurrent vascular events.

Background: Myocardial infarction with ST-segment elevation (STEMI) is a medical emergency requiring specific management, with the main aim of achieving reperfusion as quickly as possible. Guidelines from medical societies have defined optimal management, with proven efficacy on morbi-mortality., Aims: Our study aimed to evaluate trends in practices between 2002 and 2010 in the emergency management of STEMI in a single French department, namely Cote d'Or., Methods: All patients admitted with a first STEMI to one of the six participating coronary care units (private or public) in Cote d'Or since January 2001 were included in a prospective registry (obseRvatoire des Infarctus de Côte d'Or [RICO]). Based on these data, we analysed trends in prehospital times between 2002 and 2010., Results: A total of 4114 patients were included in this analysis. Between 2002 and 2010, there was an increase in the proportion of patients who contacted the emergency services (by dialling 15) as first medical contact; however, the time from onset of symptoms to first medical contact remained stable over the study period. Overall, there was little change in prehospital management times but we noted a slight reduction in time to reperfusion., Conclusion: Despite some improvement in prehospital management practices between 2002 and 2010 in Cote d'Or, there is still significant room for improvement to achieve earlier reperfusion in STEMI patients., (Copyright © 2012 Elsevier Masson SAS. All rights reserved.)

France was chosen to be one of the six first pilot countries of the "Stent for Life" European initiative. First, a prospective registry was set up in five representative French regions, including all admissions within the first 48 hours of ST-elevated acute cardiac syndrome between 1st and 30th November 2010. The second step was to improve results. The main objective was to encourage members of the public experiencing chest pain to call immediately the SAMU's direct line (phone number "15"). Another action was to organise medical meetings in order to improve the management of these patients. Letters were also sent to general physicians to alert them to the issue and to the Stent for Life project. The third step consisted of creating a new registry, in November 2011, to assess the impact of the above actions on an area basis. It has resulted in streamlining the networks and bringing the rate of non-reperfusion down below the 10% threshold. Much remains to be done to improve public awareness of life-saving actions.

Background: Recent clinical studies suggest that low-molecular-weight heparin (LMWH) could be an effective and safe alternative to unfractionated heparin (UFH) for patients with acute myocardial infarction (AMI)., Aims: To assess the impact of anticoagulant choice (LMWV vs UFH) on bleeding, the need for blood transfusion and 3-year clinical outcomes in AMI patients from the FAST-MI registry., Methods: FAST-MI was a nationwide registry compiled in France over 1 month in 2005, which included consecutive AMI patients admitted to an intensive care unit less than 48 hours from symptom onset in 223 participating centres., Results: A total of 2854 patients treated with heparins were included. The risks of major bleeding or transfusion (3.0% vs 7.0%) and in-hospital death (3.2% vs 9.2%) were lower with LMWH compared with UFH, a difference that persisted after multivariable adjustment (odds ratio [OR] 0.51, 95% confidence interval [CI] 0.34-0.76 and OR 0.53, 95% CI 0.37-0.76, respectively). Three-year survival, and stroke and reinfarction-free survival risks were also higher with LMWH compared with UFH (adjusted hazard ratio [HR] 0.73, 95% CI 0.61-0.87 and HR 0.73, 95% CI 0.62-0.85, respectively). In two cohorts of patients matched on propensity score for receiving LMWH and with similar baseline characteristics (834 patients per group), major bleeding and transfusion rates were lower while the 3-year survival rate was significantly higher in patients receiving LMWH., Conclusion: Our data suggest that the use of LMWH in AMI patients may have a better benefit/risk profile than UFH, in terms of bleeding, need for transfusion and long-term survival., (Copyright © 2012. Published by Elsevier Masson SAS.)

AIM OF FAST-MI 2010: To gather data on characteristics, management and outcomes of patients hospitalised for acute myocardial infarction (AMI) at the end of 2010 in France., Interventions: To provide cardiologists and health authorities national and regional data on AMI management every 5 years., Setting: Metropolitan France. 213 academic (n=38), community (n=110), army hospitals (n=2), private clinics (n=63), representing 76% of centres treating AMI patients. Inclusion from 1 October 2010., Population: Consecutive patients included during 1 month, with a possible extension of recruitment up to one additional month (132 centres); 4169 patients included over the entire recruitment period, 3079 during the first 31 days; 249 additional patients declining participation (5.6%)., Startpoints: Consecutive adults with ST-elevation and non-ST-elevation AMI with symptom onset ≤48 h. Patients with AMI following cardiovascular procedures excluded., Data Capture: Web-based collection of 385 items (demographic, medical, biologic, management data) recorded online from source files by external research technicians; case-record forms with automatic quality checks. Centralised biology in voluntary centres to collect DNA samples and serum. Long-term follow-up organised centrally with interrogation of municipal registry offices, patients' physicians, and direct contact with the patients., Data Quality: Data management in Toulouse University., Statistical Analyses: Université Paris Descartes, Université de Toulouse, Université Pierre et Marie Curie-Paris 06, Paris., Endpoints and Linkages to Other Data: In-hospital events; cardiovascular events, hospital admissions and mortality during follow-up. Linkage with Institute for National Statistics., Access to Data: Available for research to any participating clinician upon request to executive committee (fastmi2010@yahoo.fr).

Background: The presence of pre-infarction angina (PIA) has been shown to confer cardioprotection after ST-segment elevation myocardial infarction (STEMI). However, the clinical impact of PIA in non-ST-segment elevation myocardial infarction (NSTEMI) remains to be determined., Methods and Results: From the obseRvatoire des Infarctus de Côte d'Or (RICO) survey, 1541 consecutive patients admitted in intensive care unit with a first NSTEMI were included. Patients who experienced chest pain <7 days before the episode leading to admission were defined as having PIA and were compared with patients without PIA. Incidence of in-hospital ventricular arrhythmias (VAs), heart failure and 30-day mortality were collected. Among the 1541 patients included in the study, 693 (45%) patients presented PIA. PIA was associated with a lower creatine kinase peak, as a reflection of infarct size (231(109-520) vs. 322(148-844) IU/L, p<0.001) when compared with the group without PIA. Patients with PIA developed fewer VAs, by 3 fold (1.6% vs. 4.0%, p = 0.008) and heart failure (18.0% vs. 22.4%, p = 0.040) during the hospital stay. Overall, there was a decrease in early CV events by 26% in patients with PIA (19.2% vs. 25.9%, p = 0.002). By multivariate analysis, PIA remained independently associated with less VAs., Conclusion: From this large contemporary prospective study, our work showed that PIA is very frequent in patients admitted for a first NSTEMI, and is associated with a better prognosis, including reduced infarct size and in hospital VAs. Accordingly, protecting the myocardium by ischemic or pharmacological conditioning not only in STEMI, but in all type of MI merits further attention.

Objective: The objective of this study was to explore the association of non-steroidal anti-inflammatory drugs (NSAID) with ST-segment elevation myocardial infarction (STEMI) and non-ST segment elevation myocardial infarction (NSTEMI)., Design, Setting & Patients: A matched case-control study comparing patients with incident non-fatal myocardial infarction (MI) collected by cardiologists with controls. Cases were retrieved from the Pharmacoepidemiological General Research on Myocardial Infarction (PGRx-MI) registry, a French nationwide registry consisting of 55 cardiology centres, whereas controls were selected from general practice settings. Both cases and controls were recruited from the same geographically diverse areas across continental France., Main Outcome Measures: The association between NSAID and MI was assessed by matched adjusted OR from conditional logistic regression., Results: Between 2007 and 2009, 1125 incident cases were included (67.3% and 32.7% for STEMI and NSTEMI, respectively), with 2790 controls matched to MI cases by age and sex. Current use (previous 2 months) of either diclofenac or naproxen and other arylpropionic acid NSAID was not associated with STEMI (OR 0.9, 95% CI 0.4 to 1.9 and OR 1.0, 95% CI 0.6 to 1.7, respectively), instead it showed significant association with NSTEMI (OR 2.8, 95% CI 1.2 to 6.4 and OR 0.4, 95% CI 0.2 to 0.9, respectively). Our study confirms results from previously published analyses on the association of MI with NSAID (OR 1.5, 0.9, and 1.0 for diclofenac, naproxen and related NSAID, and all NSAID combined, respectively)., Conclusions: Our study shows that the MI risk modification associated with NSAID is limited to NSTEMI.

Background: To evaluate potential neuroprotection afforded by prior transient ischaemic attack (TIA) on functional and survival outcomes after ischaemic stroke., Methods: All cases of first-ever ischaemic strokes, diagnosed between 1985 and 2008, were identified from the Dijon Stroke Registry. Patients were analysed in three groups according to the time interval between prior TIA and stroke (<4 weeks, ≥ 4 weeks, no TIA) or the duration of TIA (≤ 30 min, >30 min, no TIA). Outcomes were severe functional handicap (unable to walk, bedridden or death) at hospital discharge or at outpatient consultation, and 1-month and 1-year any-cause mortality. Stratified analyses were performed by stroke subtypes (non-lacunar, lacunar). Generalised linear mixed models and Cox proportional hazard models with a sandwich covariance matrix accounting for the treatment centre as a random effect were used for multivariate analyses., Results: Among the 3015 patients with first-ever ischaemic stroke, 389 had had a prestroke TIA <4 weeks and 97 a prestroke TIA ≥ 4 weeks. Patients with TIAs had better ambulatory status (adjusted OR 0.61, 95% CI 0.45 to 0.81; p = 0.008) and better survival at 1 month (adjusted HR 0.76, 95% CI 0.65 to 0.89; p = 0.0006) and at 1 year (adjusted HR 0.72, 95% CI 0.67 to 0.76; p<0.0001) than those with no TIAs. Prestroke TIA <4 weeks and TIA duration ≤ 30 min also significantly improved the outcomes in overall, non-lacunar and lacunar strokes., Conclusions: Recent prestroke TIA was associated with better functional outcome and lower 1-month and 1-year mortality after stroke, suggesting a neuroprotective effect.

Objective: To examine the influence of obesity on the predictive value of the pro-B-type natriuretic peptide (NT-proBNP) assay in acute myocardial infarction., Design: Prospective observational study., Setting: All intensive care units in one region of France. Patients 2217 consecutive patients admitted for an acute myocardial infarction matched with respect to age, gender, Killip class and renal function., Main Outcome Measure: Cardiovascular death at one year., Results: There were three groups (according to body mass index (BMI): obese, overweight and normal) of 739 matched patients. Median levels of NT-proBNP were considerably lower in high BMI patients, by about 20% in overweight and by 60% in obese patients, compared with normal BMI patients. An inverse relationship between the propeptide values and BMI was found in the overall study population (r = -0.20, p < 0.0001), and for both genders. In multivariate linear regression, BMI as a continuous variable was a predictor of the log NT-proBNP level, even when adjusted for potential confounders. CV mortality at 1-year follow-up was similar for the three BMI groups (p = 0.691). In multivariate logistic regression analysis, log NT-proBNP predicted mortality in normal (OR (95% CI) 3.48 (2.00 to 6.12)) and overweight (OR (95% CI) 3.96 (1.95 to 8.06)) patients, even when adjusted for confounders (GRACE risk score, left ventricular ejection fraction). However, in obese patients, propeptide levels failed to retain their independent prognostic value (OR (95% CI) 1.34 (0.86 to 2.08))., Conclusions: In this large population of patients with myocardial infarction, circulating NT-proBNP levels were considerably lower in obese patients; the significance of the propeptide level as an independent prognostic factor is severely compromised.

Background: Nationwide evaluations of the epidemiology of acute coronary syndrome (ACS) or cerebrovascular syndrome (CVS) are scarce. We aimed to analyze nationwide French data on patients referred to hospital for either ACS or CVS., Methods: Using the French national hospital discharge diagnosis records, all patients hospitalized between 2005 and 2008 with a diagnosis of ACS and CVS based on the ICD-10 were identified. We analyzed vascular risk factors and early outcomes in patients with a single hospitalization for ACS or CVS or for both ACV and CVS in a 2-month time window., Results: 1,187,643 patients were recorded. Among these, 638,061 (53.7%) had CVS alone, 525,419 (44.3%) had ACS alone, and 24,163 (2%) had both. Patients of the latter group were older, had a higher prevalence of hypertension, diabetes, and atrial fibrillation, a longer length of stay, were less likely to be discharged to home, and had a higher in-hospital risk of death after adjustment for age, sex, and vascular risk factors compared with patients with either CVS alone (OR = 1.71, 95% CI: 1.66-1.77) or ACS alone (OR = 2.95, 95% CI: 2.85-3.05)., Conclusion: Patients with both CVS and ACS have a high vascular risk profile and a marked excess risk of early death., (Copyright © 2011 S. Karger AG, Basel.)

Objectives: To confirm the effects of short-term exposure to ozone (O(3)) on ischaemic heart and cerebrovascular disease., Methods: Daily levels of urban O(3) pollution, the incidence of first-ever, recurrent, fatal and non-fatal ischaemic cerebrovascular events (ICVE) and myocardial infarction (MI) were correlated using a case-crossover design. The authors analysed 1574 ICVE and 913 MI that occurred in Dijon, France (150,000 inhabitants) from 2001 to 2007. Sulfur dioxide (SO(2)), nitrogen dioxide (NO(2)), carbon monoxide (CO) and particulate matter with an aerodiameter of ≤10 μg/m(3) (PM(10)) were used to create bi-pollutant models. Using the adjusted OR, the effects of O(3) exposure were calculated for every 10 μg/m(3) increase in pollutants in multivariate logistic models adjusted for temperature, humidity, flu outbreaks and holidays., Results: The authors found a significant association between exposure to O(3) and recurrent ICVE with a 3-day lag (OR=1.115; 95% CI 1.027 to 1.209). The direction and magnitude of the association between exposure to O(3) and recurrent MI were similar but not statistically significant. For incident events, the authors detected only a non-significant association for ICVE with a 2-day lag (OR=1.041; 95% CI 0.996 to 1.089). In the subgroup analysis for ICVE, the authors observed an increased association with cardiovascular risk factors (OR=1.523; 95% CI 1.149 to 2.018). For MI, the authors found an association with O(3) when hypercholesterolaemia was present (OR=1.111; 95% CI 1.020 to 1.211), and the association became stronger with the number of cardiovascular risk factors. The authors found a marked dose-response relationship., Conclusion: Recurrent ICVE and MI could be triggered by short-term exposure to even low levels of O(3), especially among subjects with severe vascular risk factors.

Background: A substantial number of patients with acute myocardial infarction (AMI) have polyvascular disease (PolyVD), defined as cerebrovascular disease (CVD), peripheral arterial disease (PAD) or both., Aim: To investigate the impact of PolyVD on baseline characteristics, management and outcomes., Methods: The Alliance project is a multicentre, cross-sectional database of patients with myocardial infarction throughout France from 2000 to 2005. A pooled analysis of individual patient data was performed by aggregating data from five registries, representing 9783 patients hospitalized for acute coronary syndromes. Data were collected on history of PAD and CVD and correlated to baseline characteristics, management and hospital outcomes., Results: Eight thousand nine hundred and four patients had full datasets for this analysis (13% with a history of CVD or PAD, 87% without). Patients with PolyVD were older (72 vs 65 years, p<0.0001), had a more frequent history of AMI (26% vs 15%, p<0.0001), percutaneous coronary intervention (PCI), coronary artery bypass graft (CABG), renal insufficiency (12% vs 3%, p<0.0001) and consistently more risk factors for atherosclerosis (hypertension, dyslipidaemia, smoking, diabetes), but less frequently a body mass index>30 kg/m(2) (14.0% vs 20.1%, p<0.0001) compared to patients with coronary artery disease (CAD) alone. Killip class, left-ventricular ejection fraction and GUSTO risk score were all worse among patients with PolyVD. Management of patients with PolyVD was less aggressive (with later admission and less frequent use of in-hospital angiography or evidence-based therapies at discharge). Mortality of patients with PolyVD was consistently higher than in those with CAD alone, regardless of age. Multivariable analysis, adjusting for age, showed that both PAD (odds ratio 1.36 95% confidence interval 1.03-1.79) and history of CVD (odds ratio 1.74, 95% confidence interval 1.27-2.40) were independent predictors of hospital mortality relative to patients with CAD only., Conclusion: Patients with PolyVD represented a substantial group among AMI patients, at particularly high risk of death, yet were managed less aggressively than patients with CAD alone. This was associated with markedly higher in-hospital mortality. Further research is warranted to design and test strategies to decrease mortality in this high-risk subset., (Copyright 2010. Published by Elsevier Masson SAS.)

Background: Despite a common pathophysiological mechanism (ie, atherosclerosis) and similar vascular risk factors, few reliable studies have compared the epidemiology of stroke and acute myocardial infarction (AMI)., Methods: All first ever cases of stroke and AMI in Dijon, France (151 846 inhabitants) from 2001 to 2006 were prospectively recorded. The 30 day case fatality rates (CFRs) and vascular risk factors were assessed in both groups., Results: Over the 6 years, 1660 events (1020 strokes and 640 AMI) were recorded. Crude incidence of stroke was higher than that of AMI (112 vs 70.2/100 000/year; p<0.001). With regard to sex, the relative incidence of stroke compared with AMI was 0.88 (95% CI 0.60 to 1.29; p = 0.51) in women <65 years and 2.32 (95% CI 1.95 to 2.75; p<0.001) in those >65 years whereas it was 0.60 (95% CI 0.42 to 0.86; p<0.001) in men below 55 years, 1.01 (0.81 to 1.24, p = 0.96) in those between 55 and 75 years and 2.01 (95% CI 1.48 to 2.71; p<0.001) at 75 years and older. CFRs at 30 days were similar for stroke and AMI (9.80% vs 9.84%; p = 0.5). Hyperglycaemia (>7.8 mmol/l) at onset was significantly associated with higher CFR in both stroke and AMI patients. The prevalence of male sex, hypercholesterolaemia and diabetes was higher in AMI patients whereas hypertension was more frequent in stroke patients., Conclusion: These findings will help health care authorities to evaluate future needs for stroke and AMI services, and to develop secondary prevention strategies.

Background: Heart rate is a key determinant of both myocardial ischaemia and prognosis in patients with coronary disease. Reducing heart rate is known to relieve ischaemia and improve cardiovascular prognosis. Currently there is no information about heart rate distribution and predictors of high heart rate in patients with stable coronary artery disease (CAD)., Methods: The L'Hypertendu Coronarien Vu En Médecine Générale (LHYCORNE) cohort was a prospective observational study involving consecutive stable CAD patients with treated hypertension. Patients with atrial fibrillation were excluded from the analysis. Heart rate distribution and factors independently associated with heart rate above that of the cohort mean were analysed., Results: The study population comprised 8922 stable CAD patients in sinus rhythm (76% were men; mean age 66+/-11 years; mean systolic/diastolic blood pressures 141/82mmHg; 26% had diabetes). The mean resting heart rate was 70+/-6 bpm; the distribution was: 7% for <60 bpm, 38% for 60-69, 38% for 70-79bpm, 14% for 80-89bpm, and 2% for>90bpm. The mean resting heart rate of the patients on beta-blockers (62% of the population) was 69+/-8bpm versus 73+/-8bpm in subjects not on beta-blockers (p<0.001). Eight independent predictors of heart rate>/=70bpm were identified., Conclusion: Data from this large cohort demonstrate that few patients meet recommendations to lower heart rate to <60bpm. Over 50% of stable CAD patients had a heart rate>/=70bpm, presenting a particularly high-risk profile. Given the therapeutic and prognostic role of resting heart rate in CAD patients, our findings emphasize the need to consider heart rate in these high-risk patients.

Objective: To examine the influence of age on the predictive value of N-terminal pro-brain natriuretic (NT-proBNP) peptide assay in acute myocardial infarction., Design: Prospective observational study., Setting: All intensive care units in one French region., Participants: 3291 consecutive patients admitted for an acute myocardial infarction, from the RICO survey (a French regional survey for acute myocardial infarction)., Main Outcome Measure: Cardiovascular death at 1 year., Results: Among the 3291 participants, mean age was 68 (SD 14) years and 2356 (72%) were men. In the study population, the median NT-proBNP concentration was 1053 (interquartile range 300-3472) pg/ml. Median values for age quarters 1 to 4 were 367 (119-1050), 696 (201-1950), 1536 (534-4146), and 3774 (1168-9724) pg/ml (P<0.001). A multiple linear regression analysis was done to determine the factors associated with the pro-peptide concentrations in the overall population. NT-proBNP was mainly associated with age, left ventricular ejection fraction, creatinine clearance, female sex, hypertension, diabetes, and anterior wall infarction. At one year's follow-up, 384 (12%) patients had died from all causes and 372 (11%) from cardiovascular causes. In multivariate analysis, NT-proBNP remained strongly associated with the outcome, beyond traditional risk factors including creatinine clearance and left ventricular ejection fraction, in each age group except in the youngest one (<54 years) (P=0.29). The addition of NT-proBNP significantly improved the performance of the statistical model in the overall study population (-2log likelihood 3179.58 v 3099.74, P<0.001) and in each age quarter including the upper one (1523.52 v 1495.01, P<0.001).The independent discriminative value of NT-proBNP compared with the GRACE score was tested by a diagonal stratification using the median value of the GRACE score and NT-proBNP in older patients (upper quarter). Such stratification strikingly identified a high risk group-patients from the higher NT-proBNP group and with a high risk score-characterised by a risk of death of almost 50% at one year., Conclusions: In this large contemporary non-selected cohort of patients with myocardial infarction, NT-proBNP concentration had incremental prognostic value even in the oldest patients, above and beyond the GRACE risk score and traditional biomarkers after acute myocardial infarction. These data further support the potential interest of clinical trials specifically assessing NT-proBNP measurement as a guide to current treatment strategies, as well as novel strategies, in older patients with acute myocardial infarction.

Objective: The aim of this study is to show that differences of mortality, in acute myocardial infarction, observed between hospitals are not necessarily linked to a bad application of guidelines but can be linked to differences in the risk profile of the populations., Methods: Two populations admitted for ST and non-ST elevation myocardial infarction in the same region in 2006 were compared: the population of Chalon-sur-Saône's hospital with a standard population from the observatoire des Infarctus de Côte d'Or (RICO). The risk profile of the two populations has been realised with the risk scores GRACE, EMMACE and the Simple Risk Index (SRI)., Results: The three scores are applicable for our populations according to the "C statistic". Moreover, there is a significant difference of in-hospital mortality between Chalon-sur-Saône and RICO. But, the population of Chalon-sur-Saône presents a higher risk. Finally, in-hospital rate mortality expected by the three scores is not different from the actual mortality., Conclusion: GRACE, EMMACE and SRI are valid scores for the comparison of risk profile of populations in acute myocardial infarction. Comparisons between hospitals are only possible after risk adjustment of the populations.