Bleed-Myocardial Infarction Study (bleeding Risk in Real-WORLD Patients with ST-Segment Elevation Myocardial Infarction)

INTRODUCTION: Les traitements antiagrégants plaquettaires sont un élément clé du traitement des infarctus du myocarde avec sus-décalage du segment ST (IDM ST+) mais ils sont à l origine d une majoration du risque hémorragique. Ce risque a déjà été évalué dans des essais randomisés mais il existe peu de données chez les patients en condition réelle. METHODES: Recrutement de 1083 patients consécutifs avec un IDM ST+ pendant un an. Suivi à trois mois et à un an. Le critère principal de jugement était la survenue d une complication hémorragique majeure définie selon BARC 3 ou 5 ("Bleeding Academic Research Consortium"). Les critères secondaires étaient les saignements majeurs caractérisés par d autres définitions, les localisations des saignements et le taux d événements cardiaques secondaires majeurs. RESULTATS: Le taux de saignement majeur total a été de 3,8% et le taux extra-hospitalier de 1,3%. Ces taux étaient plus élevés avec la définition BARC. Leur localisation était principalement digestive et les saignements les plus graves étaient cérébraux. Certains saignements ont abouti à un arrêt des traitements antiagrégants (34,2% des saignements) et il s agissait principalement de saignements mineurs. Il y a eu 6,1% d événements secondaires cardiaques majeurs (décès : 4,4%, IDM ST+ non létal : 1,0% , thrombose de stent : 1,5%). Les patients traités par Aspirine + Prasugrel avaient plus de saignement de type BARC 2 mais moins de saignement de type BARC 3 ou 5 que les patients traités par Aspirine + Clopidogrel. CONCLUSION: Les saignements, y compris mineurs, demeurent un problème significatif dans l année qui suit un IDM ST+. Ces saignements, mêmes mineurs, peuvent entraîner l arrêt de traitements antiagrégants plaquettaires. Une sélection des patients susceptibles de recevoir les nouveaux antiagrégants plaquettaires permet de réduire les risques hémorragiques.BACKGROUND: Antiplatelet therapies are a cornerstone in the treatment of ST-elevation myocardial infarction (STEMI) but they are associated with a risk of bleeding. This risk has been evaluated in randomized trials but few data are known in real-world patients. METHODS: A total of 1083 consecutive patients with STEMI were recruited over one year. Follow-up was done at three months and at one year. The primary outcome included any major bleeding according to Bleeding Academic Research Consortium (BARC) 3 or 5 definitions. We also recorded major bleeding according to other definitions, localized the bleeding sites, and analyzed the rate of major adverse cardiac events. RESULTS: Rates of total major bleeding and out-of-hospital major bleeding were 3.8% and 1.3%, respectively. Compared to other bleeding definitions, these rates were higher with BARC definition. Their main localization was gastrointestinal and the most severe were cerebral. Some bleeding led to discontinuation of antiplatelet therapies (34.2% of bleeding) and most of them were not major bleeds. Major adverse cardiac events occurred in 6.1% (including death in 4.4%, non-fatal STEMI in 1.0% and stent thrombosis in 1.5%). Patients treated with aspirin + prasugrel had more BARC 2 bleeding but less BARC 3 or 5 bleeding than patients treated with aspirin + clopidogrel. CONCLUSION: Within one year after a STEMI, bleeding, including minor bleeding, remains a concern. Bleedings, even minor bleeding, can lead to discontinuation of antiplatelet therapies. Selection of patient candidates for new antiplatelet therapies reduces the risk of bleedings.RENNES1-BU Santé (352382103) / SudocSudocFranceF

A novel method for localization and ablation of conduction gaps after wide antral circumferential ablation of pulmonary veins

International audienceBackground - Atrial fibrillation ablation is often performed by achieving pulmonary vein isolation using the "wide antral circumferential ablation" (WACA) technique, but many pulmonary veins remain connected because of conduction gaps in the ablation line. Aim - To analyse the efficacy of a novel technique based on pacing manoeuvres to detect gaps in an initial WACA lesion. Methods - Patients referred for radiofrequency atrial fibrillation ablation were enrolled prospectively. A WACA lesion set was performed, isolating ipsilateral pulmonary veins together. If pulmonary vein isolation was not achieved, the atria were paced using an ablation catheter. For each pacing site, "activation delay" and "activation sequence" were analysed using a circular mapping catheter positioned at the pulmonary vein ostium. Results - Twenty-one patients were included. A total of 25 non-isolated WACA lesion sets were studied. Three patterns were identified: (1) the activation delays converged towards one point with the shortest delay; no modification of the activation sequence (indicating one gap); (2) the activation delays converged towards at least two close locations; no change in the activation sequence (indicating at least two close gaps); (3) the activation delays converged towards at least two remote locations; modification of the activation sequence (indicating at least two remote gaps). Pacing manoeuvres and effect of ablation allowed precise localization of gaps, ultimately leading to pulmonary vein isolation in all patients. Conclusion - This simple pacing method accurately detected the location of residual connections after WACA lesion sets performed for atrial fibrillation ablation, allowing pulmonary vein isolation to be achieved

Safety of prasugrel in real-world patients with ST-segment elevation myocardial infarction: 1-year results from a prospective observational study (Bleeding and Myocardial Infarction Study).

International audienceBackground - Antiplatelet therapies, including prasugrel, are a cornerstone in the treatment of ST-segment elevation myocardial infarction (STEMI), but are associated with a bleeding risk. This risk has been evaluated in randomized trials, but few data on real-world patients are available. Aim - To evaluate prasugrel safety in real-world patients with STEMI. Methods - Consecutive patients with STEMI were recruited over 1 year. Follow-up was done at 3 months and 1 year to evaluate prasugrel safety from hospital discharge to the STEMI anniversary date. The primary outcome was occurrence of any major bleeding according to the Bleeding Academic Research Consortium (BARC) 3 or 5 definitions, or minor bleeding according to the BARC 2 definition. Results - Overall, 1083 patients were recruited. Compared to patients treated with aspirin+clopidogrel, patients treated with aspirin+prasugrel had fewer BARC 3 or 5 bleedings (two [0.4%] patients vs. nine [1.8%] patients; P=0.04), but more BARC 2 bleedings (45 [9.3%] patients vs. 20 [4.0%] patients; P<0.001). The baseline characteristics of prasugrel- and clopidogrel-treated patients differed because the former were carefully selected (younger, higher body mass index, less frequent history of stroke). In the overall population, rates of in-hospital and out-of-hospital major bleeding were 2.6% (n=28) and 1.3% (n=13), respectively. Conclusion - The rate of major bleeding, particularly out-of-hospital bleeding, in patients treated with prasugrel is low within 1 year after a STEMI. Accurate selection of patient candidates for prasugrel is likely to have reduced the risk of bleeding

Recurrences of Atrial Fibrillation Despite Durable Pulmonary Vein Isolation: The PARTY-PVI Study

International audienceBACKGROUND: Recurrences of atrial fibrillation (AF) after pulmonary vein isolation (PVI) are mainly due to pulmonary vein reconnection. However, a growing number of patients have AF recurrences despite durable PVI. The optimal ablative strategy for these patients is unknown. We analyzed the impact of current ablation strategies in a large multicenter study. METHODS: Patients undergoing a redo ablation for AF and presenting durable PVI were included. The freedom from atrial arrhythmia after pulmonary vein-based, linear-based, electrogram-based, and trigger-based ablation strategies were compared. RESULTS: Between 2010 and 2020, 367 patients (67% men, 63±10 years, 44% paroxysmal) underwent a redo ablation for AF recurrences despite durable PVI at 39 centers. After durable PVI was confirmed, linear-based ablation was performed in 219 (60%) patients, electrogram-based ablation in 168 (45%) patients, trigger-based ablation in 101 (27%) patients, and pulmonary vein-based ablation in 56 (15%) patients. Seven patients (2%) did not undergo any additional ablation during the redo procedure. After 22±19 months of follow-up, 122 (33%) and 159 (43%) patients had a recurrence of atrial arrhythmia at 12 and 24 months, respectively. No significant difference in arrhythmia-free survival was observed between the different ablation strategies. Left atrial dilatation was the only independent factor associated with arrhythmia-free survival (HR, 1.59 [95% CI, 1.13–2.23]; P =0.006). CONCLUSIONS: In patients with recurrent AF despite durable PVI, no ablation strategy used alone or in combination during the redo procedure appears to be superior in improving arrhythmia-free survival. Left atrial size is a significant predictor of ablation outcome in this population