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Although coronary artery disease (CAD) and advanced liver fibrosis (AdLF) are commonly associated in patients with non-alcoholic fatty liver disease (NAFLD), the prevalence of AdLF and the diagnostic performance of non-invasive fibrosis tests (NITs) in CAD patients remains unknown. We aimed to prospectively screen for AdLF in patients with documented CAD using NITs and Fibroscan. High and intermediate zones of NITs were combined to define AdLF. AdLF was suspected whenever APRI ≥ 0.5, Forns index ≥ 4.2, NAFLD fibrosis score (NFS) ≥ -1.455/0.12 for age

Background: Diagnostic and patients' management modifications induced by whole-body 18F-FDG-PET/CT had not been evaluated so far in prosthetic valve (PV) or native valve (NV) infective endocarditis (IE)-suspected patients., Methods: In sum, 140 consecutive patients in 8 tertiary care hospitals underwent 18F-FDG-PET/CT. ESC-2015-modified Duke criteria and patients' management plan were established jointly by 2 experts before 18F-FDG-PET/CT. The same experts reestablished Duke classification and patients' management plan immediately after qualitative interpretation of 18F-FDG-PET/CT. A 6-month final Duke classification was established., Results: Among the 70 PV and 70 NV patients, 34 and 46 were classified as definite IE before 18F-FDG-PET/CT. Abnormal perivalvular 18F-FDG uptake was recorded in 67.2% PV and 24.3% NV patients respectively (P < .001) and extracardiac uptake in 44.3% PV and 51.4% NV patients. IE classification was modified in 24.3% and 5.7% patients (P = .005) (net reclassification index 20% and 4.3%). Patients' managements were modified in 21.4% PV and 31.4% NV patients (P = .25). It was mainly due to perivalvular uptake in PV patients and to extra-cardiac uptake in NV patients and consisted in surgery plan modifications in 7 patients, antibiotic plan modifications in 22 patients and both in 5 patients. Altogether, 18F-FDG-PET/CT modified classification and/or care in 40% of the patients (95% confidence interval: 32-48), which was most likely to occur in those with a noncontributing echocardiography (P < .001) or IE classified as possible at baseline (P = .04), while there was no difference between NV and PV., Conclusions: Systematic 18F-FDG-PET/CT did significantly and appropriately impact diagnostic classification and/or IE management in PV and NV-IE suspected patients., Clinical Trials Registration: NCT02287792., (© The Author(s) 2020. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail: journals.permissions@oup.com.)

Aims: EMPEROR-Preserved is an ongoing trial evaluating the effect of empagliflozin in patients with heart failure with preserved ejection fraction (HFpEF). This report describes the baseline characteristics of the EMPEROR-Preserved cohort and compares them with patients enrolled in prior HFpEF trials., Methods and Results: EMPEROR-Preserved is a phase III randomized, international, double-blind, parallel-group, placebo-controlled trial in which 5988 symptomatic HFpEF patients [left ventricular ejection fraction (LVEF) >40%] with and without type 2 diabetes mellitus (T2DM) have been enrolled. Patients were required to have elevated N-terminal pro B-type natriuretic peptide (NT-proBNP) concentrations (i.e. >300 pg/mL in patients without and >900 pg/mL in patients with atrial fibrillation) along with evidence of structural changes in the heart or documented history of heart failure hospitalization. Among patients enrolled from various regions (45% Europe, 11% Asia, 25% Latin America, 12% North America), the mean age was 72 ± 9 years, 45% were women. Almost all patients had New York Heart Association class II or III symptoms (99.6%), and 23% had prior heart failure hospitalization within 12 months. Thirty-three percent of the patients had baseline LVEF of 41-50%. The mean LVEF (54 ± 9%) was slightly lower while the median NT-proBNP [974 (499-1731) pg/mL] was higher compared with previous HFpEF trials. Presence of comorbidities such as diabetes (49%) and chronic kidney disease (50%) were common. The majority of the patients were on angiotensin-converting enzyme inhibitors/angiotensin receptor blockers/angiotensin receptor-neprilysin inhibitors (80%) and beta-blockers (86%), and 37% of patients were on mineralocorticoid receptor antagonists., Conclusion: When compared with prior trials in HFpEF, the EMPEROR-Preserved cohort has a somewhat higher burden of comorbidities, lower LVEF, higher median NT-proBNP and greater use of mineralocorticoid receptor antagonists at baseline. Results of the EMPEROR-Preserved trial will be available in 2021., (© 2020 The Authors. European Journal of Heart Failure published by John Wiley & Sons Ltd on behalf of European Society of Cardiology.)

Background: We studied the course of plasma concentrations of 4 cardiovascular biomarkers: natriuretic peptides (BNP, NT-proBNP; mid-regional (MR) pro-atrial NP); and soluble endothelial CD146 (sCD146), in patients with severe mitral valve stenosis undergoing percutaneous mitral commissurotomy (PMC) to identify potential markers of procedural success., Methods: Biomarkers were tested in 40 patients the day before and the day after PMC. Success was defined as mitral valve area ≥ 1.5 cm 2 ; or an increase of ≥0.5 cm2 in mitral valve area associated with echocardiographic mitral regurgitation 2 , mean gradient 9.1 ± 3.5 mmHg. PMC was successful in 30 (75%) and unsuccessful in 10 (25%). PMC yielded a significant reduction in MR-proANP and sCD146, driven by a significant reduction in these biomarkers in patients with successful procedure, whereas no reduction was observed in patients with unsuccessful procedure. A significant correlation was found between changes in plasma sCD146 and the relative change in mitral valve area. Elevated pre-procedural sPAP correlated with high sCD146, and accordingly, a significant correlation between the decrease in sPAP and sCD146 after PMC was shown., Conclusions: MR-proANP and plasma sCD146 decreased significantly immediately after successful PMC. They appear to be markers of immediate success of PMC and of the hemodynamic improvement achieved by this procedure in patients with MS., Trial Registration: This study is part of the cohorts registered with ClinicalTrials.gov on June 16, 2011 under the number NCT01374880.

Background: Professional societies call for integration of end-of-life discussions early in the trajectory of heart failure, yet it remains unclear where current practices stand in relation to these recommendations. We sought to describe the perceptions and attitudes of caregivers in cardiology regarding end-of-life situations., Methods: We performed a qualitative study using semi-directive interviews in the cardiology department of a university teaching hospital in France. Physicians, nurses and nurses' aides working full-time in the department at the time of the study were eligible. Participants were asked to describe how they experienced end-of-life situations. Interviews were recorded, transcribed and coded using thematic analysis to identify major and secondary themes., Results: All physicians (N = 16)(average age 43.5 ± 13 years), 16 nurses (average age 38.5 ± 7.6 years) and 5 nurses' aides (average age 49 ± 7.8 years) participated. Interviews were held between 30 March and 17 July 2017. The main themes to emerge from the physicians' discourse were the concept of cardiology being a very active discipline, and a very curative frame of mind was prevalent. Communication (with paramedical staff, patients and families) was deemed to be important. Advance directives were thought to be rare, and not especially useful. Nurses also reported communication as a major issue, but their form of communication is bounded by several factors (physicians' prior discourse, legislation). They commonly engage in reconciling: between the approach (curative or palliative) and the reality of the treatment prescribed; performing curative interventions in patients they deem to be dying cases causes them distress. The emergency context prevents nurses from taking the time necessary to engage in end-of-life discussions. They engage in comfort-giving behaviors to maximize patient comfort., Conclusion: Current perceptions and practices vis-à-vis end-of-life situations in our department are individual, heterogeneous and not yet aligned with recommendations of professional societies.

Congestion is one of the main predictors of poor patient outcome in patients with heart failure. However, congestion is difficult to assess, especially when symptoms are mild. Although numerous clinical scores, imaging tools, and biological tests are available to assist physicians in ascertaining and quantifying congestion, not all are appropriate for use in all stages of patient management. In recent years, multidisciplinary management in the community has become increasingly important to prevent heart failure hospitalizations. Electronic alert systems and communication platforms are emerging that could be used to facilitate patient home monitoring that identifies congestion from heart failure decompensation at an earlier stage. This paper describes the role of congestion detection methods at key stages of patient care: pre-admission, admission to the emergency department, in-hospital management, and lastly, discharge and continued monitoring in the community. The multidisciplinary working group, which consisted of cardiologists, emergency physicians, and a nephrologist with both clinical and research backgrounds, reviewed the current literature regarding the various scores, tools, and tests to detect and quantify congestion. This paper describes the role of each tool at key stages of patient care and discusses the advantages of telemedicine as a means of providing true integrated patient care., (Copyright © 2018. Published by Elsevier Inc.)

Acute heart failure (AHF) is the most common cause of unplanned hospital admissions, and is associated with high mortality rates. Over the next few decades, the combination of improved cardiovascular disease survival and progressive ageing of the population will further increase the prevalence of AHF in developed countries. New recommendations on the management of AHF have been published recently, but as elderly patients are under-represented in clinical trials, and scientific evidence is often lacking, the diagnosis and management of AHF in this population is challenging. The clinical presentation of AHF, especially in patients aged>85years, differs substantially from that in younger patients, with unspecific symptoms, such as fatigue and confusion, often overriding dyspnoea. Older patients also have a different risk profile compared with younger patients: often heart failure with preserved ejection fraction, and infection as the most frequent precipitating factor of AHF. Moreover, co-morbidities, disability and frailty are common, and increase morbidity, recovery time, readmission rates and mortality; their presence should be detected during a geriatric assessment. Diagnostics and treatment for AHF should be tailored according to cardiopulmonary and geriatric status, giving special attention to the patient's preferences for care. Whereas many elderly AHF patients may be managed similarly to younger patients, different strategies should be applied in the presence of relevant co-morbidities, disability and frailty. The option of palliative care should be considered at an early stage, to avoid unnecessary and harmful diagnostics and treatments., (Copyright © 2016 Elsevier Masson SAS. All rights reserved.)

Background: The present study involved both human cohorts and animal experiments to explore the performance of soluble CD146 (sCD146), a marker of endothelial function, as a diagnostic marker of acutely decompensated heart failure (ADHF), to determine the influence of patients' characteristics on that performance and to explore the potential application of CD146 in the pathophysiology of ADHF., Methods and Results: NT-proBNP and sCD146 were measured in three hundred ninety-one patients admitted to the emergency department for acute dyspnea. ROC curve analysis demonstrated that AUCs for ADHF diagnosis in dyspneic patients were 0.86 (95% CI: 0.82-0.90) for sCD146 and 0.90 (95% CI: 0.86-0.92) for NT-proBNP. Subgroup analyses demonstrated that adding sCD146 to NT-proBNP improved the diagnostic performance for patients lying in the gray zone of NT-proBNP (p=0.02) and could be especially useful for ruling-out ADHF. An experimental model of ADHF in rats using thoracic aortic constriction suggests that CD146 is expressed in the intima of large arteries and associated with both left ventricular function and organ congestion., Conclusions: sCD146, a marker of endothelial function, seems to be as powerful as NT-proBNP is used to detect the cardiac origin of an acute dyspnea. The combination of sCD146 and NT-proBNP may have better performance than NT-proBNP used alone in particular for patients underlying in the "gray" zone and could therefore be an improved option for ruling-out ADHF. Both experimental and human data suggest that CD146 is related to systolic left ventricular function and to organ congestion., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

Agents with vasodilator properties (AVDs) are frequently used in the treatment of acute heart failure (AHF). AVDs rapidly reduce preload and afterload, improve left ventricle to aorta and right ventricle to pulmonary artery coupling, and may improve symptoms. Early biomarker changes after AVD administration have suggested potentially beneficial effects on cardiac stretch, vascular tone, and renal function. AVDs that reduce haemodynamic congestion without causing hypoperfusion might be effective in preventing worsening organ dysfunction. Existing AVDs have been associated with different results on outcomes in randomized clinical trials, and observational studies have suggested that AVDs may be associated with a clinical outcome benefit. Lessons have been learned from past AVD trials in AHF regarding preventing hypotension, selecting the optimal endpoint, refining dyspnoea measurements, and achieving early randomization and treatment initiation. These lessons have been applied to the design of ongoing pivotal clinical trials, which aim to ascertain if AVDs improve clinical outcomes. The developing body of evidence suggests that AVDs may be a clinically effective therapy to reduce symptoms, but more importantly to prevent end-organ damage and improve clinical outcomes for specific patients with AHF. The results of ongoing trials will provide more clarity on the role of AVDs in the treatment of AHF., (© 2015 The Authors. European Journal of Heart Failure © 2015 European Society of Cardiology.)

Rapidly assessing outcome in patients with acute decompensated heart failure is important but prognostic factors may differ from those used routinely for stable chronic heart failure. Multiple plasma biomarkers, besides the classic natriuretic peptides, have recently emerged as potential prognosticators. Furthermore, prognostic scores that combine clinical and biochemical data may also be useful. However, compared with the scores used in chronic heart failure, scores for acute decompensated heart failure have not been validated. This article reviews potential biomarkers, with a special focus on biochemical biomarkers, and possible prognostic scores that could be used by the clinician when assessing outcome in patients with acute heart failure., (Copyright © 2014 Elsevier Masson SAS. All rights reserved.)

Background: We aimed to describe the determinants of discharge heart rate in acute coronary syndrome patients and assess the impact of discharge heart rate on 5-year mortality in hospital survivors., Methods: French Registry of Acute ST-Elevation or non-ST-elevation Myocardial Infarction (FAST-MI) 2005 is a nationwide French registry that included all consecutive patients with acute myocardial infarction over 1 month in 223 institutions in 2005. Discharge heart rate was recorded in 3079 patients discharged alive; all had 5-year follow-up. Logistic regression was used to detect predictors of high heart rate at discharge. Cox's proportional hazards model was used to assess the hazard ratio for mortality at 5 years. Heart rate was categorized into 4 groups by quartiles (<60, 61-67, 68-75, >75 beats per minute). High heart rate was defined as ≥75 beats per minute. Landmark analysis was performed at 1 year., Results: Independent predictors of heart rate ≥75 beats per minute at discharge were female sex, ST-segment elevation myocardial infarction, diabetes, chronic obstructive pulmonary disease, bleeding/transfusion during hospitalization, left ventricular dysfunction, renal dysfunction, and prescription (type, but not dose category) of beta-blockers at discharge. Discharge heart rate was significantly related to mortality at 1 year (hazard ratio 1.13; 95% confidence interval, 1.03-1.24 per 10 beats per minute, P = .02); this was confirmed by landmark analysis, with a 39% increase (hazard ratio 1.39; 95% confidence interval 1.05-1.84) in the risk of 1-year death for discharge heart rate ≥75 beats per minute vs <75 beats per minute. This relationship was no longer significant between 2 and 5 years., Conclusions: After acute myocardial infarction, patients discharged with high heart rate (≥75 beats per minute) are at higher risk of death during the first year, but not later, irrespective of beta-blocker use., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background: We compared diagnostic and prognostic properties of brain natruiretic peptide (BNP), proBNP, NT-proBNP and MR-pro-atrial natriuretic peptide (ANP) in patients admitted with shortness of breath (SOB)., Methods: All 4 NPs were measured in patients admitted to the emergency unit with SOB (in 2 centers) or acute heart failure (AHF) (1 FINN-AKVA cohort) and in a control population of stable chronic HF. Follow-up was 1 (2 centers) and 5 years (1 FINN-AKVA cohort). Area under the curve (AUC) was used to assess diagnostic properties. AUC, multivariate Cox regression, net reclassification improvement (NRI), and Kaplan-Meier analyses were used to assess mortality., Results: We included 710 patients ("Biomarcoeurs" cohort n=336; FINN-AKVA study, n=306; stable chronic HF, n=68). Pro-BNP was almost as powerful as BNP to diagnose AHF (AUC 0.953 vs 0.973 respectively, p=0.003), NT-proBNP also performed well (0.922, p<0.001 vs BNP). MR-proANP performed less well (0.901). AUC over time showed greater MR-proANP values over the first year. At 5 years, MR-proANP had the best prognostic value (AUC 0.668 vs 0.604 for BNP, p=0.042). Kaplan Meier analysis confirmed better survival with MR-proANP≤416.8 pmol/L at 5 years. NRI at 5 years was greater for MR-proANP (0.23, p<0.05) than for proBNP, BNP or NTproBNP (p=NS)., Conclusion: Our study provides firm evidence that all NPs perform equally well for diagnostic purposes, and that MR-proANP has long term prognostic value in patients with acute heart failure., (Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.)

Two-dimensional transthoracic echocardiography (2D-TTE) is the reference technique for evaluating aortic stenosis (AS) but may be unreliable in some cases. We aimed to assess whether the use of a pressure wire to measure simultaneous transaortic gradient and aortic valve area (AVA) could be helpful in patients in whom initial noninvasive evaluations were considered doubtful for AS. Fifty-seven patients (mean age 76 years; 39 men) underwent cardiac catheterization with single arterial access for assessment of AVA with the Gorlin and Gorlin formula. Transaortic pressure was obtained by 2 invasive methods: (1) conventional pullback method (PM) from the left ventricle toward the aorta and (2) simultaneous method (SM) with transaortic pressure simultaneously recorded with a 0.014-inch pressure wire introduced into the left ventricle and with a diagnostic catheter placed in the ascending aorta. Reasons for inaccurate assessment by 2D-TTE were low flow states (88%) and/or atrial fibrillation (79%). Agreement for severe AS defined by AVA <0.6 cm²/m² between SM and 2D-TTE and between SM and PM was fair, with kappa coefficients of 0.38 (95% confidence interval [CI] 0.14-0.75) and 0.36 (95% CI 0.22-0.7) respectively; agreement was poor between 2D-TTE and PM (kappa: 0.23; 95% CI 0.002-0.36). SM led to a reclassification of the severity of AS in 9 patients (15.8%) compared with 2D-TTE and in 11 patients (19.3%) compared with PM. In conclusion, invasive evaluation of doubtful AS by measuring simultaneous transaortic gradient using a pressure wire may provide an attractive method that can lead to a change in therapeutic strategy in a substantial proportion of patients., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Adjunctive thrombus aspiration (TA) during primary percutaneous coronary intervention improves myocardial perfusion and survival; however, the effect of effective thrombus retrieval remains unclear. We evaluated whether macroscopic-positive TA in patients with ST-segment elevation myocardial infarction would reduce the infarct size (IS) and microvascular obstruction (MVO), as assessed by contrast-enhanced magnetic resonance imaging. A total of 88 patients with ST-segment elevation myocardial infarction were prospectively recruited and assigned to the TA-positive group (n = 38) or TA-negative group (n = 50) according to whether macroscopic aspirate thrombus was visible to the naked eye. The primary end points were the extent of early and late MVO as assessed by contrast-enhanced magnetic resonance imaging performed during in-hospital stay and IS evaluated in the acute phase and at 6 months of follow-up. The incidence of early and late MVO and IS in the acute phase was lower in the TA-positive group than in the TA-negative group (early MVO 3.8 ± 1.1% vs 7.6 ± 2.1%, respectively, p = 0.003; late MVO 2.1 ± 0.9% vs 5.4 ± 2.9%, p = 0.006; and IS 14.9 ± 8.7% vs 28.2 ± 15.8%, p = 0.004). At the 6-month contrast-enhanced magnetic resonance imaging study, the final IS was significantly lower in the TA-positive group (12.0 ± 8.3% vs 22.3 ± 14.3%, respectively) than in the TA-negative group (p = 0.002). After multivariate adjustment, macroscopic-positive TA represented an independent predictor of final IS (odds ratio 0.34, 95% confidence interval 0.03 to 0.71, p = 0.01). In conclusion, effective macroscopic thrombus retrieval before stenting during percutaneous coronary intervention for ST-segment elevation myocardial infarction is associated with an improvement in myocardial reperfusion, as documented by a clear reduction in the MVO extent and IS., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Objective: To evaluate the potential value of intravascular ultrasound (IVUS) imaging in the diagnosis of aortic intramural hematoma (AIH)., Methods: From September 2002 to May 2005, a consecutive series of 15 patients with suspected aortic dissection (AD) underwent both IVUS imaging and spiral computed tomography (CT). Six patients diagnosed as acute type B AIH by CT or IVUS composed the present study group., Results: The study group consisted of five males and one female with mean age of 66 years old. All of them had chest or back pain. In one patient, CT omitted a localized AIH and an associated penetrating atherosclerotic ulcer (PAU), which were detected by IVUS. In another patient, CT mistaken a partly thrombosed false lumen as an AIH, whereas IVUS detected a subtle intimal tear and slow moving blood in the false lumen. In the four rest patients, both CT and IVUS made the diagnosis of AIH, however, IVUS detected three PAUs in three of them, only one of them was also detected by CT, and two of them escaped initial CT and were confirmed by follow up CT or magnetic resonance imaging., Conclusions: IVUS imaging is a safe examination and has high accuracy in the diagnosis of AIH, particularly for diagnosing localized AIH, distinguishing AIH with thrombosed classic AD and detecting accompanied small PAUs.

Dilated Cardiomyopathy (DCM) is one of the leading causes of heart failure with high morbidity and mortality. More than 30 genes have been reported to cause DCM. To provide new insights into the pathophysiology of dilated cardiomyopathy, a mutational screening on 4 DCM-causing genes (MYH7, TNNT2, TNNI3 and LMNA) was performed in a cohort of 105 unrelated DCM (64 familial cases and 41 sporadic cases) using a High Resolution Melting (HRM)/sequencing strategy. Screening of a highly conserved arginine/serine (RS)-rich region in exon 9 of RBM20 was also performed. Nineteen different mutations were identified in 20 index patients (19%), including 10 novels. These included 8 LMNA variants in 9 (8.6%) probands, 5 TNNT2 variants in 5 probands (4.8%), 4 MYH7 variants in 3 probands (3.8%), 1 TNNI3 variant in 1 proband (0.9%), and 1 RBM20 variant in 1 proband (0.9%). One proband was double-heterozygous. LMNA mutations represent the most prevalent genetic DCM cause. Most patients carrying LMNA mutations exhibit conduction system defects and/or cardiac arrhythmias. Our study also showed than prevalence of mutations affecting TNNI3 or the (RS)-rich region of RBM20 is lower than 1%. The discovery of novel DCM mutations is crucial for clinical management of patients and their families because pre-symptomatic diagnosis is possible and precocious intervention could prevent or ameliorate the prognosis., (Copyright © 2011 Elsevier Masson SAS. All rights reserved.)

Background: Acute coronary syndrome (ACS) with normal coronary angiography is a frequent clinical situation with an uncertain prognosis. Cardiac magnetic resonance imaging (CMRI) is a powerful tool for differential diagnosis between myocardial infarction (MI), acute myocarditis and Tako-tsubo cardiomyopathy (TTC). Data are sparse regarding the evolution of patients presenting an ACS with normal coronary arteries and normal CMRI., Aims: To evaluate the evolution of patients presenting an ACS with normal coronary arteries and normal CMRI, with a 1-year follow-up., Methods: Eighty-seven consecutive patients (mean age, 53 years; 40.2% men) presenting an ACS with troponin elevation and normal coronary arteries by angiography were prospectively included. All patients underwent CMRI at 3-Tesla. Adverse events were recorded with 1-year follow-up., Results: A likely aetiology for the acute clinical presentation was established by CMRI in 63.2% of patients (22.7% MI, 26.4% acute myocarditis, 11.5% TTC). During follow-up, one patient in the MI group had a stroke (1.2%). In the myocarditis group, there was one initial cardiogenic shock, one episode of congestive heart failure (1.2%) and nine patients had recurrent chest pain without troponin elevation (10.3%). Two TTC group patients initially presented with cardiogenic shock (2.4%); there were no other adverse events in this group during follow-up. In the remaining 36.7% patients, no clear diagnosis could be identified by CMRI, and no adverse events occurred during follow-up., Conclusion: CMRI is a useful tool for the management of ACS presenting with normal coronary angiography, as it helps to ascertain the diagnosis and adapt treatment in a large proportion of cases. Nonetheless, patients with no abnormalities identified by CMRI have an excellent evolution., (Copyright © 2011. Published by Elsevier Masson SAS.)

The greater mortality observed in women compared to men after acute myocardial infarction remains unexplained. Using an analysis of pairs, matched on a conditional probability of being male (propensity score), we assessed the effect of the baseline characteristics and management on 30-day mortality. Consecutive patients were included from January 2006 to December 2007. Two propensity scores (for being male) were calculated, 1 from the baseline characteristics and 1 from both the baseline characteristics and treatment. Two matched cohorts were composed using 1:1 matching and computed using the best 8 digits of the propensity score. Paired analyses were performed using conditional regression analysis. During the study period, 3,510 patients were included in the registry; 1,119 (32%) were women. Compared to the men, the women were 10 years older, had more co-morbidities, less often underwent angiography and reperfusion, and received less medical treatment. The 30-day mortality rate was 12.3% (130 of 1,060) for the women and 7.2% (167 of 2,324) for the men (p <0.001). The 2 matched populations represented 1,298 and 1,168 patients. After matching using the baseline characteristics, the only difference in treatment was a lower rate of angiography and reperfusion, with a trend toward greater 30-day mortality in women. After matching using both baseline characteristics and treatment, the 30-day mortality was similar for the men and women, suggesting that the increased use of invasive procedures in women could potentially be beneficial. In conclusion, compared to men, the 30-day mortality is greater in women and explained primarily by differences in baseline characteristics and to a lesser degree by differences in management. The difference in the use of invasive procedures persisted after matching by characteristics. In contrast, after matching using the baseline characteristics and treatment, the 30-day mortality was comparable across the genders., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Background: Fondaparinux has recently been approved in patients with acute coronary syndromes. The primary aim of this study was to describe the changes in use of anticoagulants between January 2006 and December 2007. The secondary aim was to compare 30-day mortality and rate of a combined end point (30-day death or major bleeding) according to the initial and final anticoagulant agent used., Methods: The rates of use of unfractionated heparin (UFH), enoxaparin, and fondaparinux were compared by periods of 1 month in a multicenter registry. The initial anticoagulant (first used at admission), the final anticoagulant (last used during hospitalization), and switches in anticoagulation were recorded. Temporal trends in monthly use of each anticoagulant were assessed; 30-day mortality rates and the combined end point were compared according to initial and final anticoagulant., Results: Among 2,874 patients included, the first anticoagulant used was UFH in 26%, enoxaparin in 59%, and fondaparinux in 15%. Respective figures for final anticoagulant were 17%, 56%, and 27%. Although 3 centers did not use fondaparinux (community centers with catheterization laboratory), the overall rate of use of fondaparinux, as initial and final anticoagulant, increased at the expense of the use of enoxaparin. We observed a growing proportion of patients with a switch from UFH to either enoxaparin or fondaparinux, ranging from 5% at the beginning to 25% at the end of the study. Patients treated with UFH were older, had more comorbidities, were at higher risk, and received fewer guidelines-recommended treatments. In patients submitted to angioplasty and treated with fondaparinux, a bolus of 60 IU/kg of UFH was added. After adjustment, 30-day mortality and combined end point rates were higher in patients treated with UFH. Irrespective of the type of acute coronary syndromes, patients treated with enoxaparin or fondaparinux had similar outcomes., Conclusions: Between 2006 and 2007, the use of fondaparinux in patients with acute coronary syndromes increased considerably, either because it was used instead of enoxaparin or because of a switch from UFH. Adjusted mortality in patients treated with fondaparinux was lower than with UFH and similar to enoxaparin., (Copyright (c) 2010 Mosby, Inc. All rights reserved.)

In patients admitted with acute coronary syndromes, those with anemia are at higher risk. However, current risk score systems do not take into account the presence of anemia. The impact of anemia on mortality was studied, and its incremental predictive value was evaluated. Demographic, clinical, and biologic characteristics at admission, as well as treatments and mortality, were recorded for 1,410 consecutive patients with acute coronary syndromes. The incremental value of adding anemia information to risk score evaluation was determined using changes in the appropriateness of Cox models when anemia was added. Anemia was detected in 381 patients (27%). They were older, had more co-morbidities, had higher Global Registry of Acute Coronary Events (GRACE) risk scores, received fewer guideline-recommended treatments, and, as a result, had 4-fold higher mortality. When included in a prediction model based on the GRACE risk score, anemia remained an independent predictor of mortality. The addition of anemia improved both the discriminatory capacity and calibration of the models. According to the GRACE risk score, the population was divided into 4 groups of different risk levels of <1%, 1% to <5%, 5% to <10%, and > or =10%. The addition of anemia to the model made it possible to reclassify 9%, 43%, 47%, and 23% of patients into the different risk categories, respectively. In conclusion, our data confirmed that anemia was an independent predictive factor of mortality and had incremental predictive value to the GRACE score system for early clinical outcomes.

Background: Aortic penetrating atherosclerotic ulcer (PAU) is one of the causes of acute aortic syndrome. Few studies have evaluated the value of intravascular ultrasound (IVUS) imaging in the diagnosis of PAU., Objectives: We aimed to evaluate the value of IVUS imaging in diagnosis of PAU., Methods and Results: From September 2002 to May 2005, a consecutive series of 15 patients with suspected aortic dissection underwent both IVUS imaging and spiral Computed Tomography (CT).CT documented 4 PAUs in three patients. There were no complications related to IVUS imaging. The common IVUS features of these four PAUs appeared as a crescentic, localized, outpouching thickened aortic wall with heterogeneous echoic density that communicated with the lumen via a discontinuous intima. By using these features, IVUS detected five other PAUs in four patients, which were overlooked by CT. The width of PAU detected by CT was significantly wider than that of PAU not detected by CT (1.33+/-0.67cm vs 0.43+/-0.27cm, P=0.027). Two of five PAUs omitted by initial CT were confirmed by follow-up CT or magnetic resonance imaging (MRI). During follow up, three PAUs, including two of those overlooked by CT, developed into aneurysms., Conclusion: IVUS imaging is a safe examination, and more sensitive than spiral CT to diagnose PAU.