Effet de la prescription des bêtabloquants sur la stratégie thérapeutique et la morbi-mortalité à un an des patients artériopathes hospitalisés de la cohorte française COPART 2

Introduction: Betablockers are controversial in peripheral arterial disease (PAD). The purpose of this study was to analyze the effect on morbidity and mortality and to evaluate their prescription along with prescription of vascular protective treatment at admission and discharge of hospitalization. Material and Method: 1267 patients with PAD of atheromatous origin hospitalized in 4 vascular medicine departments in France were included in the prospective registry COPART 2 between May 2004 and July 2010. Results: At admission as at discharge, nearly 25% of patients were treated with betablockers. Patients taking this treatment were no impress of mortality (OR: 1.08 p=0.65) or amputation (OR: 0.63 p=0.15) than other patients. At admission, history of hypertension and myocardial infarction (MI) were factors associated with their prescription (respectively OR: 2.6 and 3.02 p <0.05). At discharge, only the history of myocardial infarction was a contributing factor to this prescription (OR = 3.11 p <0.05). At admission and at discharge, they were significantly less prescribed for patients with a history of obstructive pulmonary disease or PAD with trophic disorder. At the entrance, only 71% of the patients were treated with antiplatelet therapy, 54% with statins and 52% with ACE inhibitors or angiotensin II receptor blockers Conclusion: Patient hospitalized for PAD can safely carry on with their beta-blockers treatment if they have an indication. The prescription of the triple vasculo protective therapy need to be improved in this population.Introduction : La prescription des bêtabloquants reste controversée dans l’artériopathie oblitérante des membres inférieurs (AOMI). Le but de cette étude a été d'analyser leurs effets sur la morbi-mortalité puis d’étudier leur prescription et celle des thérapeutiques vasculo-protectrice à l’entrée et à la sortie d’hospitalisation. Matériel et Méthode : 1267 patients porteurs d'AOMI d'origine athéromateuse hospitalisés dans 4 services de médecine vasculaire en France ont été inclus dans le registre prospectif COPART 2 (COhorte des Patients ARTériopathes 2) entre mai 2004 et juillet 2010. Résultats : À l’entrée comme à la sortie de l’hospitalisation près de 25% des patients étaient traités par bêtabloquant. Les patients sous ce traitement n'avaient pas plus de risque de décès ni d'amputation à 1 an que les autres patients (respectivement OR : 1.08 p=0.65 et OR : 0.63 p=0.15). À l’entrée de l’hospitalisation, les antécédents d’HTA et d’infarctus du myocarde (IDM) étaient des facteurs associés à leur prescription (respectivement OR : 2.6 et 3.02 p<0.05). À la sortie de l’hospitalisation, seul l'antécédent d'IDM était un facteur favorisant cette prescription (OR : 3.11 p<0.05). À l’entrée comme à la sortie, ils étaient significativement moins prescrits chez les patients aux antécédents de syndrome obstructif bronchique ou d’AOMI avec trouble trophique. À l’entrée, seuls 71% des patients étaient traités par antiagrégant plaquettaire, 54% par statines et 52% par IEC ou ARA2. Conclusion : Les bêtabloquants peuvent être poursuivis chez les patients artériopathes hospitalisés s'ils présentent une indication. La prescription de la tri-thérapie vasculo-protectrice était à améliorer

Hyposplenism revealed by Plasmodium malariae infection.

International audienceBACKGROUND: Hyposplenism, due to splenectomy, inherited red blood cell disorders or acquired conditions such as celiac disease, has an important impact on the severity of malaria, especially in non-immune patients. Conversely, that malaria may reveal functional hyposplenism has not been described previously. METHODS: A 31-year old gardener was diagnosed with an uncomplicated attack of Plasmodium malariae 11 years after leaving the endemic area. In addition to trophozoites and schizonts, thick and thin smears also showed Howell-Jolly bodies, pointing to functional hyposplenism. This was later confirmed by the presence of a calcified spleen in the context of S/beta + sickle-cell syndrome in a patient previously unaware of this condition. CONCLUSION: Malaria may reveal hyposplenism. Although Howell-Jolly bodies are morphologically similar to nuclei of young Plasmodium trophozoite, distinction on smears is based on the absence of cytoplasm and irregular size of Howell-Jolly bodies. In the patient reported here, hyposplenism was revealed by the occurrence of P. malariae infection relatively late in life. Timely diagnosis of hyposplenism resulted in the implementation of appropriate measures to prevent overwhelming infection with capsulated bacteria. This observation highlights the importance of diagnosing hyposplenism in patients with malaria despite the morphological similarities between ring nuclei and Howell-Jolly bodies on thick smears

Impact of betablockers on general and local outcome in patients hospitalized for lower extremity peripheral artery disease

International audienceLower extremity peripheral artery disease (PAD) is one manifestation of atherosclerosis. Patients with PAD have an increased rate of mortality due to concurrent coronary artery disease and hypertension. Betablockers (BB) may, therefore, be prescribed, especially in case of heart failure. However, BB safety in PAD is controversial, because of presumed peripheral hemodynamic consequences of BB that could lead to worsening of symptoms in patients with PAD. In this context, we aimed to determine the impact of BB on all-cause and cardiovascular mortality and amputation rate at 1 year after hospitalization for PAD from the COPART Registry population. This is a prospective multicenter observational study collecting data from consecutive patients hospitalized for PAD in vascular medicine departments of 4 academic hospitals in France. Patients with, either claudication, critical limb ischemia or acute lower limb ischemia related to a documented PAD were included. We compared the outcomes of patients with BB versus those without BB in their prescription list at hospital discharge. The mean age of the study population was 70.9 years, predominantly composed of males (71%). Among the 1267 patients at admission, 28% were treated by BB for hypertension, prior myocardial infarction or heart failure. During their hospital stay, 40% underwent revascularization (including bypass surgery 29% and angioplasty 74%), 17% required an amputation, and 5% died. In a multivariate analysis, only prior myocardial infarction was found associated with BB prescription with an odds ratio (OR) of 3.11, P < 0.001. Conversely, chronic obstructive pulmonary disease or PAD with ulcer impeded BB prescription (OR: 0.57 and 0.64, P = 0.007; P = 0.001, respectively). One-year overall mortality of patients with BB did not differ from those without (23% vs. 23%, P = 0.95). The 1-year amputation rate did not differ either (4% vs. 6%, P = 0.14). Patients hospitalized for PAD with a BB in their prescription did not worsen their outcome at 1 year compared to patients without BB. Based on these safety data, prospective study could be conducted to assess the effect of BB on long-term mortality and amputation rate in patients with mild, moderate, and severe PAD

Non‐invasive recanalization of deep venous thrombosis by high frequency ultrasound in a swine model with follow‐up

International audienceAims: Pulsed cavitational ultrasound therapy (thombotripsy) allows the accurate fractionation of a distant thrombus. We aimed to evaluate the efficacy and safety of non-invasive thrombotripsy using a robotic assisted and high frequency ultrasound approach to recanalize proximal deep venous thrombosis (DVT) in a swine model. Methods: Occlusive thrombosis was obtained with a dual jugular and femoral endoveinous approach. The therapeutic device was composed of a 2.25 MHz focused transducer centered by a linear ultrasound probe, and a robotic arm. The feasibility, security, and efficacy (venous channel patency) assessment after thrombotripsy was performed on 13 pigs with acute occluded DVT. To assess the mid-term efficacy of this technique, 8 pigs were followed up for 14 days after thrombotripsy and compared with 8 control pigs. The primary efficacy endpoint was the venous patency. Safety was assessed by the search for local vessel wall injury and pulmonary embolism. Results: We succeeded in treating all pigs except two with no accessible femoral vein. After median treatment duration of 23 minutes of cavitation, all treated DVT were fully recanalized acutely. At 14 days, in the treated group, six of the eight pigs had a persistent patent vein and two pigs had a venous reocclusion. In the control group all pigs had a persistent venous occlusion. At sacrifice, no local vein nor arterial wall damage were observed as well as no evidence of pulmonary embolism in all pigs. Conclusion: High frequency thrombotripsy seems to be effective and safe for noninvasive venous recanalization of DVT

Occurrence of Major Local Lower Limb Events in Type 2 Diabetic Patients with Lower Extremity Arterial Disease: Impact of Metformin

International audienceBackgroundsPatients with type 2 diabetes mellitus (T2DM) are particularly at risk of developing major adverse cardiovascular events (MACE) and peripheral artery disease (PAD) due to an acceleration of the atherosclerotic process linked to hyperglycemia and inflammation with a greater risk of local complications. We aimed to identify the predictive factors for major adverse limb events (MALE) in T2DM patients with PAD to manage modifiable factors at an early stage.MethodsThis is a prospective study in which T2DM patients with PAD were included from November 2017 to May 2018 and followed over 12 months. The predictive factors for the onset of MALE, MACE, and death from all causes have been identified.ResultsA total of 100 patients were included; 37% of the patients developed a MALE. After multivariate analysis, metformin was associated with a decrease of MALE (odds ratio (OR) = 0.26; 95% confidence interval (CI) [0.10; 0.68]; P = 0.007), and a history of the treatment of intravenous iloprost was associated with an increased risk of MALE (OR = 5.70; 95% CI [1.31; 31.93]; P = 0.029). Regular physical activity was associated with a decreased risk of MACE (OR = 0.07; 95% CI [0; 0.44]; P = 0.021). A history of stroke and a history of venous thromboembolism were associated with an increased all-cause mortality risk with OR = 3.68; 95% CI [1.17; 11.5]; P = 0.025 and OR = 3.78; 95% CI [1.16; 12.3]; P = 0.027.ConclusionsMetformin is protective against local complications in people with diabetes with PAD and should be prescribed to diabetic patients with PAD at an early stage

Women Specific Characteristics and 1-Year Outcome Among Patients Hospitalized for Peripheral Artery Disease: A Monocentric Cohort Analysis in a Tertiary Center

International audienceAlthough women have lower age-standardized cardiovascular disease incidence, prevalence, and death-related rates than men, there are also reports indicating that women with cardiovascular disease receive less care, fewer investigations, and have poorer outcomes after a coronary event. The aims of this study were to compare the characteristics of men and women hospitalized for peripheral artery disease (PAD), their cardiovascular and limb outcomes, and their 1-year mortality. The study is a prospective registry collecting data about all consecutive patients hospitalized for PAD within the vascular department of the tertiary center Georges-Pompidou European Hospital (Paris, France). Patients were required to have one of three inclusion criteria: previous revascularization of the lower limb or any lower limb artery occlusion due to an atherosclerotic vascular disease or hemodynamic evidence of PAD. Exclusion criteria were patients with lower extremity arterial occlusion due to another cause. All patients were followed-up for at least 12 months after the initial hospitalization. Among the 235 patients included, there were 61 women (26%), older than men with a median age of 75.6 and 68.3 years, respectively. Main cardiovascular risk factors and comorbidities were similar for men and women except more former or current smokers [145 (83.4%) vs. 33 (54.1%)] and more history of coronary heart disease [42 (24.1%) vs. 7 (11.5%)] in men. Most patients [138 (58.8%)] had critical limb ischemia and 97 (41.3%) had claudication, with no difference for sex. After discharge, 218 patients received an antithrombotic therapy (93.2%), 195 a lipid-lowering drug (83.3%), 185 an angiotensin converting enzyme inhibitor or angiotensin-receptor blocker (78.9%), similarly between sex. At 1-year, overall mortality, major adverse cardiovascular events, major adverse limb events did not differ with 23 (13.2%), 11 (6.3%) and 32 (18.4%) in men, and 8 (13.1%), 3 (4.9%), 15 (24.6%) in women, respectively, despite the difference in age. Overall mortality, cardiovascular outcomes, limb revascularization or amputation did not differ between men and women, 1-year after hospitalization for PAD although the latter were older, less smoker and had less coronary artery disease. Due to the small size of this cohort, larger studies and future research are needed to better understand sex-specific mechanisms in the pathophysiology and natural history of PAD