Low prevalence of colonoscopic surveillance of inflammatory bowel disease patients with longstanding extensive colitis: a clinical practice survey nested in the CESAME cohort

International audienceBackground: Surveillance colonoscopy is recommended for inflammatory bowel disease (IBD) patients with longstanding extensive colitis (LEC). Aims: To assess modalities and results of colonoscopic surveillance in a subset of CESAME cohort patients at high risk of colorectal cancer (CRC) and followed in university French hospitals. Methods: Among 910 eligible patients with more than a 7-year history of extensive colitis at CESAME enrolment, 685 patients completed a questionnaire on surveillance colonoscopy and 102 were excluded because of prior proctocolectomy. Finally, 583 patients provided information spanning a median period of 41 months (IQR 38-43) between cohort enrolment and the end of follow-up. Details of the colonoscopic procedures and histological findings were obtained for 440 colonoscopies in 270 patients. Results: Only 53.5% (n=312) of the patients with LEC had at least one surveillance colonoscopy during the study period, with marked variations across the 9 participating centres (27.3% to 70.0%, p= < 0.0001). Surveillance rate was significantly lower in Crohn's colitis than in ulcerative colitis (UC) (47.6% vs 68.5%, p=< 0.0001). Independent predictors of colonoscopic surveillance were male sex, UC IBD subtype, longer disease duration, previous history of CRC, and disease management in a centre with large IBD population. Random biopsies, targeted biopsies and chromoendoscopy were performed during respectively 70.7%, 26.6 and 30.0% of surveillance colonoscopies. Two cases of high-grade dysplasia were detected in patients undergoing colonoscopic surveillance. Two advanced-stage CRC were diagnosed in patients who did not have colonosocopic surveillance. Conclusions: Colonoscopic surveillance rate is low in IBD patients with longstanding extensive colitis

Disturbance of Vancomycin Infusion Flow during Multidrug Infusion: Influence on Endothelial Cell Toxicity

Background: Phlebitis is a common side effect of vancomycin peripheral intravenous (PIV) infusion. As only one PIV catheter is frequently used to deliver several drugs to hospitalized patients through the same Y-site, perturbation of the infusion flow by hydration or other IV medication may influence vancomycin exposure to endothelial cells and modulate toxicity. Methods: We assessed the toxicity of variations in vancomycin concentration induced by drug mass flow variations in human umbilical vein endothelial cells (HUVECs), simulating a 24 h multi-infusion therapy on the same line. Results were expressed as the percentage of viable cells compared with a 100% control, and the Kruskal&ndash;Wallis test was used to assess the toxicity of vancomycin. Results: Our results showed that variations in vancomycin concentration did not significantly influence local toxicity compared to a fixed concentration of vancomycin. Nevertheless, the loss of cell viability induced by mechanical trauma mimicking multidrug infusion could increase the risk of phlebitis. Conclusion: To ensure that vancomycin-induced phlebitis must have other causes than variation in drug mass flow, further in vitro experiments should be performed to limit mechanical stress to frequent culture medium change

0548: Heart failure with preserved ejection fraction: an echocardiographic based approach to assess the prognosis. A report from the large prospective KaRen study

BackgroundKaRen is a prospective study designed to characterize and follow a cohort of heart failure with preserved ejection fraction (HFpEF) patients. HFpEF remains a challenging syndrome. Patients have clinical signs linked to congestion but left ventricular (LV) EF is > 45%. We sought to test the relevance of echocardiographic parameters as predictors of death or hospitalization for cardiovascular reasons.Methods and resultsFollowing an acute HF accompanied with NT-proBNP >300pg/ml (BNP >100pg/ml) and LVEF >45%, patients were included (n=349). The patients were reassessed by echo-Doppler after 4-8 weeks. Echocardiographies were standardized and the analysis centralized. LVEF was 62±13%, LV global longitudinal strain: – 15±3%, E/e’:12.9±6.2, Left atrial volume: 49±18ml/m², Tricuspid regurgitation: 2.9±0.9m/s. Two parameters are correlated with the survival without any death or hospitalisation for cardiovascular reason and could be combined in a score: 2 x (E / e’) + RA area. This score has a theoretical range between 0 and 14. Based on tertiles of the score, censoring (frequencies of death or hospitalization for heart failure) were 48 (37.80), 67 (57.76) and 85 (75.22) in the 1st tertile – poor prognosis (N = 127), the 2nd tertile – intermediate (N = 116) and the 3rd tertile – good prognosis (N = 113), respectively.ConclusionCombination of simple echocardiographic criteria (right atrial area and E/e’ ratio) was found relevant to predict the long term prognosis in a large cohort of patients diagnosed for heart failure with preserved ejection fraction

010: Prediction of long-term survival in patients receiving optimal secondary prevention therapy after acute myocardial infarction: the FAST-MI registry

BackgroundPredictors of long-term outcome in optimally-treated patients after AMI have not been extensively studied.AimWe assessed 3-year survival in a population of 3,262 patients from the FAST-MI registry who were discharged alive after the acute episode.ResultsAt hospital discharge, 1586 patients (49%) received optimal medical treatment (OMT: antiplatelet + beta-blocker + statin + ACE-I or ARB agents). Patients receiving OMT were younger (64±13 vs 69±14 years, p<0.001), had a lower GRACE risk score (141 ±33 vs 151±36, p<0.001)and had more use of PCI during index hospitalization (75% vs 56%, p<0.001). Three-year survival was 88% in patients with OMT versus 77.5% in patients without (p<0.001). Cox multivariate analysis was used to determine predictors of 3-year mortality and covariates included age, sex, risk factors, comorbidities, type of AMI, CAD extent, use of PCI, use of CABG, in-hospital complications, and other discharge medications. Overall, adjusted HR for 3-year death was 0.82 (0.68-1.00), p=0.048, for patients receiving OMT, confirming the benefit of comprehensive therapy beyond each of its individual components. In the 1586 patients receiving OMT at discharge, independent predictors of long-term death were age ≥75 years [HR 1.93 (1.03-3.64)]; AMI type and severity [STEMI vs NSTEMI: HR 0.64 (0.44-0.93); GRACE score: HR 1.01 (1.00-1.01); LVEF< 40%: HR 2.03 (1.31-3.16); 3-vessel CAD: HR 2.12 (1.28-3.52)]; previous CV history [stroke: HR 1.91 (1.29-2.83), CHF: HR 1.79 (1.11-2.88)]; management with an invasive strategy [HR 0.31 (0.17-0.56)], and associated conditions [history of diabetes HR 1.79 (1.28-2.49); history of cancer HR 2.76 (1.75-4.33); current smoking at the time of AMI HR 1.88 (1.20-2.94)].ConclusionIn patients receiving OMT after AMI, early invasive management remains a significant predictor of improved survival, while associated non cardiac conditions (and in particular cancer, diabetes, previous TIA or stroke, and smoking) are major determinants of higher long-term mortality

Value of exercise echocardiography in heart failure with preserved ejection fraction: a substudy from the KaRen study

International audienceBackground KaRen is a multicentre study designed to characterize and follow patients with heart failure and preserved ejection fraction (HFpEF). In a subgroup of patients with clinical signs of congestion but left ventricular ejection fraction (LVEF) \textgreater45%, we sought to describe and analyse the potential prognostic value of echocardiographic parameters recorded not only at rest but also during a submaximal exercise stress echocardiography. Exercise-induced changes in echo parameters might improve our ability to characterize HFpEF patients.Method and results Patients were prospectively recruited in a single tertiary centre following an acute HF episode with NT-pro-BNP \textgreater300 pg/mL (BNP \textgreater 100 pg/mL) and LVEF \textgreater 45% and reassessed by exercise echo-Doppler after 4–8 weeks of dedicated treatment. Image acquisitions were standardized, and analysis made at end of follow-up blinded to patients' clinical status and outcome. In total, 60 patients having standardized echocardiographic acquisitions were included in the analysis. Twenty-six patients (43%) died or were hospitalized for HF (primary outcome). The mean ± SD workload was 45 ± 14 watts (W). Mean ± SD resting LVEF and LV global longitudinal strain was 57.6 ± 9.5% and −14.5 ± 4.2%, respectively. Mean ± SD resting E/e′ was 11.3 ± 4.7 and 13.1 ± 5.3 in those patients who did not and those who did experience the primary outcome, respectively (P = 0.03). Tricuspid regurgitation (TR) peak velocity during exercise were 3.3 ± 0.5 and 3.7 ± 0.5 m/s (P = 0.01). Exercise TR was independently associated with HF-hospitalization or death after adjustment on baseline clinical and biological characteristics.Conclusion Exercise echocardiography may contribute to identify HFpEF patients and especially high-risk ones. Our study suggested a prognostic value of TR recorded during an exercise. That was demonstrated independently of the value of resting E/e

Importance of combined left atrial size and estimated pulmonary pressure for clinical outcome in patients presenting with heart failure with preserved ejection fraction

International audienceAims: Heart failure with preserved ejection fraction (HFpEF) is a complex syndrome with various phenotypes and outcomes. The prognostic relevance of echocardiography and the E/e' ratio has previously been reported. We sought to study in addition, the value of estimated pulmonary pressure and left atrial size for diagnosing and determining a prognosis for HFpEF-patients in a prospective multi-centric cohort. Methods and results: Patients with an acute-HF event accompanied with NT-proBNP >300 pg/mL (BNP >100 pg/mL) and LVEF >45% were included (n = 237) and clinically reassessed using echo-Doppler after 4-8 weeks of HF treatment as part of the prospective KaRen HFpEF study. A core-centre performed the echocardiographic analyses. A combined primary endpoint of either HF hospitalizations and mortality over a span of 18-month, or simply mortality (secondary endpoint) were used. The mean LVEF was 62 ± 7%, E/e':12.9 ± 6.0, left atrial volume index (LAVI): 48.1 ± 15.9 ml/m2, TR: 2.9 ± 0.9 m/s. Patients with both LAVI > 40 ml/m2 and TR > 3.1 m/s had a significantly greater risk of death or heart failure related hospitalization than others (P = 0.014 after adjustment). Conclusion: The combination of enlarged LA and elevated estimated pulmonary pressure has a strong prognostic impact in patients suffering from HFpEF. Our results indicate that such patients constitute a risk group in HFpEF which requires dedicated medical attention. ClinicalTrials.gov: NCT00774709

Heart failure with a preserved ejection fraction additive value of an exercise stress echocardiography.

International audienceBACKGROUND: Heart failure (HF) with a preserved (P) left ventricular (LV) ejection fraction (EF) is common, though its diagnosis and physiopathology remains unclear. We sought to analyse the myocardial characteristics at rest and during a sub-maximal exercise test in patients with HFPEF. METHODS AND RESULTS: Standardized sub-maximal exercise stress echocardiography was performed in (i) 21 patients from the Karolinska Rennes Prospective Study of Heart Failure with Preserved Left Ventricular Ejection Fraction HFPEF registry, whose LVEF was ≥45% and (ii) 15 control patients free of any manifestations of HF. During a sub-maximal exercise test, LV systolic function measured as a global four-chamber longitudinal strain was -17±5% in patients with HFPEF vs. -22±4% in controls (P<0.001), LV longitudinal diastolic relaxation, expressed as e' (septal and lateral walls averaged) was 9±2 cm/s in patients vs. 15±4 cm/s in controls (P<0.001), and RV longitudinal systolic function, expressed as RV s', was 14±3 cm/s in patients vs. 18±1 cm/s in controls (P=0.03). LV afterload (arterial elastance) was 2.7±1 mmHg/mL and was correlated with a decrease in LV longitudinal strain (R=0.51, P<0.01) during exercise. CONCLUSION: The assessment of longitudinal systolic and diastolic LV and RV functions is valuable during a sub-maximal exercise stress echocardiography to confirm the heart dysfunction related to the HFPEF symptoms. It might be used as a diagnostic test for difficult clinical situations. ClinicalTrials.gov identifier: NCT01091467

Impact of Age-Adjusted Insulin-Like Growth Factor 1 on Major Cardiovascular Events After Acute Myocardial Infarction: Results From the Fast-MI Registry

International audienceBackground: The GH/IGF-1 axis is being targeted for therapeutic development in diseases such as short stature, cancer, and metabolic disorders. The impact of IGF-1 in cardiovascular disease remains controversial. We therefore studied whether IGF-1 at admission for acute myocardial infarction (AMI) predicted death, recurrent AMI, and stroke over a 2-year follow-up. Methods: Using data from the French registry of Acute ST-elevation and non-ST-elevation Myocardial Infarction registry, we measured IGF-1 among all the 1005 patients with AMI who participated in the serum data bank. Because IGF-1 decreases with age, a standardized IGF-1 score was calculated as previously described [IGF-1 score = (log [IGF-1 (micrograms per liter)] + 0.00625 x age - 2.555)/0.104]. Impact of IGF-1 score (continuous and quartiles) on outcomes were compared using Cox proportional hazards regression models. Results: During follow-up, 190 patients died or had a recurrent AMI or stroke. Patients in the lowest quartile of IGF-1 were older and more frequently female and diabetic compared with patients in the other quartiles. After adjustment for known cardiovascular factors, an increase of five units of IGF-1 score was associated with a 30% decrease of the risk of events during follow-up (adjusted hazard ratio 0.70; 95% confidence interval 0.54-0.92; P = .0093). Similarly, the lowest quartile of IGF-1 was associated with an increased risk of events (adjusted hazard ratio 1.52, 95% confidence interval 1.11-2.08; compared with others quartiles, P = .010). Conclusions: Low IGF-1 score is associated with an increased risk of all-cause death, recurrent myocardial infarction, and stroke in AMI patients. Whether patients treated by IGF-1 axis inhibitors have a specific clinical course after AMI would be worth studying

Quality of care for myocardial infarction at academic and nonacademic hospitals.

International audienceBACKGROUND: Whether academic hospitals provide better quality of care for patients with acute myocardial infarction is widely debated. The aim of this study was to compare processes of care and mortality between academic and nonacademic hospitals in the contemporary era of acute myocardial infarction management. METHODS: We analyzed the original data from a prospective cohort study of 3059 patients, including 1714 with ST-segment elevation and 1345 with non-ST-segment elevation myocardial infarction, enrolled at 39 and 183 academic and nonacademic hospitals, respectively, in France. RESULTS: Unadjusted 1-year mortality for academic and nonacademic hospitals was 10% versus 15% for patients with ST-segment elevation myocardial infarction (P=.01) and 13% versus 14% for patients with non-ST-segment elevation myocardial infarction (P=.75). Patients treated in academic or nonacademic hospitals with percutaneous coronary intervention capability were more likely to receive reperfusion and recommended drug therapies than those treated in nonacademic hospitals without percutaneous coronary intervention capability. After adjusting for baseline characteristics, the hazards of death associated with admission to nonacademic hospitals with and without percutaneous coronary intervention capability relative to academic hospitals were 1.13 (95% confidence interval [CI], 0.79-1.62) and 1.65 (95% CI, 1.09-2.49) for those with ST-segment elevation myocardial infarction and 0.95 (95% CI, 0.66-1.36) and 1.06 (95% CI, 0.72-1.58) for those with non-ST-segment elevation myocardial infarction, respectively. Further adjustment for receipt of acute reperfusion and recommended drug therapies eliminated all differences in mortality between the study groups. CONCLUSION: Admission to academic hospitals was associated with a more frequent use of recommended therapies, conveying a survival advantage for patients with ST-segment elevation myocardial infarction