038 Major bleeding still predicts death with a radial invasive strategy in NSTE-ACS: an analysis from theABOARD Study

AimWe sought to determine the incidence and type of major bleeding in moderate-to-high risk acute coronary syndromes (ACS) treated with intense antiplatelet therapy and systematic invasive strategy using predominantly the radial approach. We also examined whether these bleedings has an impact on mortality after multivariable adjustment.MethodsIn the multicenter randomized ABOARD study, 352 patients with acute coronary syndromes without ST-segment elevation were randomized for a “primary PCI” strategy or a strategy of intervention deferred to the next working day. No difference was observed in clinical outcomes between the two groups. Major bleeding complications (STEEPLE definitions) were correlated to 1 month mortality.ResultsPatients were treated by intense antiplatelet therapy: with a mean 660mg (±268) loading of clopidogrel and 111mg (±40) maintenance dose while 99% of the PCI patients receive abciximab the radial approach was predominant (84%).During the first 30 days major bleeding complications occurred in 19 patients (5.4%) with transfusion in 16 patients (4.5%). Occurrence of major bleeding did not differ between immediate and delayed intervention. The most frequent overt bleeding complications were from the gastrointestinal tract. The composite of GI bleeding and occult bleeding (loss of Hb of >3g/dL) represented n = 11 (57.9%) of all major bleeding complications. Major bleeding was associated with a significantly higher peak of creatinine during hospitalization 170.16 μmol/L ± 169.34 vs. 97.05 μmol/L ± 56.96 (p = 0.005) and a higher mortality rate 26.3% vs. 0.6%. After adjustment for all baseline characteristics, major bleeding was independently associated with an impressive increased hazard of death during the first 30 days (Odd ratio 75.7; 95% CI, 11.3 to 505.3; p<0.0001).ConclusionIn a population of radial catheterization for NSTEACS, GI bleeding is the most frequent bleeding complication. Despite the reduction of access site bleeding, major bleeding still remains a major independent predictor of mortality

Management of low blood pressure in ambulatory heart failure with reduced ejection fraction patients

International audienceLow blood pressure is common in patients with heart failure and reduced ejection fraction (HFrEF). While spontaneous hypotension predicts risk in HFrEF, there is only limited evidence regarding the relationship between hypotension observed during heart failure (HF) drug titration and outcome. Nevertheless, hypotension (especially orthostatic hypotension) is an important factor limiting the titration of HFrEF treatments in routine practice. In patients with signs of shock and/or severe congestion, hospitalization is advised. However, in the very frequent cases of non-severe and asymptomatic hypotension observed while taking drugs with a class I indication in HFrEF, European and US guidelines recommend maintaining the same drug dosage. In instances of symptomatic or severe persistent hypotension (systolic blood pressure < 90 mmHg), it is recommended to first decrease blood pressure reducing drugs not indicated in HFrEF as well as the loop diuretic dose in the absence of associated signs of congestion. Unless the management of hypotension appears urgent, a HF specialist should then be sought rather than stopping or decreasing drugs with a class I indication in HFrEF. If symptoms or severe hypotension persist, no recommendations exist. Our HF group reviewed available evidence and proposes certain steps to follow in such situations in order to improve the pharmacological management of these patients

005 ST-elevation myocardial infarction admission during “ON-” versus “OFF-” hours: is there an impact on outcome for primary PCI?

BackgroundIt has been suggested that delays, quality and outcome of reperfusion therapy provided to ST-Elevation Myocardial Infarction (STEMI) patients during OFF-hours (nights and weekend) are worse than during ON-hours (day working hours).MethodsWe studied 736 consecutive STEMI patients transferred for primary percutaneous intervention (PCI) to a single large volume urban Primary PCI center. Characteristics and clinical outcome of patients admitted during ON-hours (Monday through Friday 8 am-6 pm) were compared to OFF-hours patients (admitted during night shifts and weekends). Clinical outcome was 1 year death and death or MI.ResultsSTEMI patients undergoing primary PCI were admitted more frequently during OFF-hours (n = 449; 61.1%) than ON-hours (n = 287; 38.9%), with no major differences in characteristics or treatment between the two groups. Use of radial approach and the rate of stenting during PCI was 83.3% and 86.1% in ON-hours patients vs. 88.2%.and 88.1% in OFF-hours patients. There was no impact of time of admission on in-hospital mortality before or after adjustment for baseline characteristics OR 1.54; CI [0.71–3.35]. Time from symptom onset to first medical contact was shorter during OFF-hours than ON-hours (105 min [50–225] vs. 114 min [60–367]; p = 0.06). Time from first medical contact to sheath insertion was also identical between the 2 groups (101 min [80–155] and 105 min [78–155]; p = 0.61 respectively). Time to TIMI 3 flow and duration of procedure were also similar. At one year, all cause mortality and the composite end point of death or MI was 8.3% and 12.2% for OFF-hours patients vs. 7.0% and 10,8% in ON-hours patients, p = 0.4 and p = 0.3 respectively.ConclusionIn a well-organized urban STEMI network, were 61% of patients referred for primary PCI are admitted during “OFF” hours, admission time does not impact quality of care or outcomes.Death or MI after one year of follow-u

The efficacy of early versus delayed P2Y12 inhibition in percutaneous coronary intervention for ST-elevation myocardial infarction: a systematic review and meta-analysis

International audienc

Post-Discharge and Long-Term Follow-Up After an Acute Coronary Syndrome: International Collaborative Group of CNCF Position Paper

Introduction: Long-term follow-up after an acute coronary syndrome (ACS) presents a crucial challenge due to the high residual cardiovascular risk and the potential for major bleeding events. Although several treatment strategies are available, this article focuses on patients who have undergone percutaneous coronary intervention (PCI) for ACS, which is a frequent clinical situation. This position paper aims to support physicians in daily practice to improve the management of ACS patients. Material and methods: A group of recognized international and French experts in the field provides an overview of current evidence-based recommendations - supplemented by expert opinion where such evidence is lacking - and a practical guide for the management of patients with ACS after hospital discharge. Results: The International Collaborative Group underlines the need of a shared collaborative approach, and a care plan individualized to the patient\u27s risk profile for both ischaemia and bleeding. Each follow-up appointment should be viewed as an opportunity to optimize the personalized approach, to reduce adverse clinical outcomes and improve quality of life. As risks - both ischaemic and haemorrhagic - evolve over time, the risk-benefit balance should be assessed in an ongoing dynamic process to ensure that patients are given the most suitable treatment at each time point. Conclusions: This Expert Opinion aims to help clinicians with a practical guide underlying the proven strategies and the remaining gaps of evidence to optimize the management of coronary patients

Composition of Coronary Thrombus in Acute Myocardial Infarction

ObjectivesWe sought to analyze the composition of coronary thrombus in vivo in ST-segment elevation myocardial infarction (STEMI) patients.BackgroundThe dynamic process of intracoronary thrombus formation in STEMI patients is poorly understood.MethodsIntracoronary thrombi (n = 45) were obtained by thromboaspiration in 288 consecutive STEMI patients presenting for primary percutaneous intervention, and analyzed using high-definition pictures taken with a scanning electron microscope. Plasma biomarkers (TnI, CRPus, IL-6, PAI-1, sCD40 ligand, and TNF-α) and plasma fibrin clot viscoelastic properties were measured simultaneously on peripheral blood.ResultsThrombi were mainly composed of fibrin (55.9 ± 18%) with platelets (16.8 ± 18%), erythrocytes (11.5 ± 9%), cholesterol crystals (5.2 ± 8.4%), and leukocytes (1.3 ± 2.0%). The median ischemic time was 175 min (interquartile range: 140 to 297). Ischemic time impacted thrombi composition, resulting in a positive correlation with intracoronary thrombus fibrin content, r = 0.38, p = 0.01, and a negative correlation with platelet content, r = −0.34, p = 0.02. Thus, fibrin content increased with ischemic time, ranging from 48.4 ± 21% (<3 h) up to 66.9 ± 9% (>6 h) (p = 0.02), whereas platelet content decreased from 24.9 ± 23% (<3 h) to 9.1 ± 6% (>6 h) (p = 0.07). Soluble CD40 ligand was positively correlated to platelet content in the thrombus (r = 0.40, p = 0.02) and negatively correlated with fibrin content (r = −0.36; p = 0.04). Multivariate analysis indicated that ischemic time was the only predictor of thrombus composition, with a 2-fold increase of fibrin content per ischemic hour (adjusted odds ratio: 2.00 [95% confidence interval: 1.03 to 3.7]; p = 0.01).ConclusionsIn acute STEMI, platelet and fibrin contents of the occlusive thrombus are highly dependent on ischemia time, which may have a direct impact on the efficacy of drugs or devices used for coronary reperfusion