: Gender differences in STEMI

International audienceBACKGROUND: Gender differences in presentation, management and outcome in patients with ST-segment elevation myocardial infarction (STEMI) have been reported. AIM: To determine whether female gender is associated with higher inhospital mortality. METHODS: Data from ORBI, a regional STEMI registry of 5 years' standing, were analysed. The main data on presentation, management, inhospital outcome and prescription at discharge were compared between genders. Various adjusted hazard ratios were then calculated for inhospital mortality (women versus men). RESULTS: The analysis included 5000 patients (mean age 62.6±13 years), with 1174 women (23.5%). Women were on average 8 years older than men, with more frequent co-morbidities. Median ischaemia time was 215 minutes (26 minutes longer in women; P<0.05). Reperfusion strategies in women less frequently involved fibrinolysis, coronary angiography, radial access and thrombo-aspiration. Female gender, especially in patients aged<60 years, was associated with poorer inhospital prognosis (including higher inhospital mortality: 9% vs. 4% in men; P<0.0001), and underutilization of recommended treatments at discharge. Moreover, excess female inhospital mortality was independent of presentation, revascularization time and reperfusion strategy (hazard ratio for women 1.33, 95% confidence interval 1.01-1.76; P=0.04). CONCLUSIONS: One in four patients admitted for STEMI was female, with significant differences in presentation. Female gender was associated with less-optimal treatment, both in the acute-phase and at discharge. Efforts should be made to reduce these differences, especially as female gender was independently associated with an elevated risk of inhospital mortality

008: Management of ST-elevation myocardial infarction in octogenarian patients. Data from ORBI, a prospective registry of 5000 patients

PurposeTo determine the actual management of ST-elevation myocardial infarction (STEMI) in octogenarian patients and more.MethodsWe analyzed data collected in “ORBI”, a 6 years prospective registry of STEMI patients admitted within 24h of symptoms onset to an interventional cardiology centre of Brittany (France). Main data about management and intra hospital outcome were compared between patients older (Group 1) and younger (Group 2) than 80.Results550 of the 5000 patients (11%, mean age 84.6 ±3) constituted group 1, with a larger female prevalence (51 vs 20% in group 2, p<0.0001). Group 1 had a much longer median delay between onset of symptom and call for medical assistance (65 vs 45min.), and between admission and reperfusion (53 vs 45min.). Table 1 presents data about the management in the 2 groups, both in the acute phase and at discharge. Last, intra hospital mortality is much higher in group 1 (16.5 vs 4.1%, p<0.0001).ConclusionsOctogenarian patients and more represent a large part of patient treated for STEMI, with significant differences in their presentation and management, and a high mortality.Table 1 – *Percentages are calculated only in patients undergoing coronary angiography.Group 1 >80years old n=550Group 2 ≤ 80 years old _=4450Initial managementFibrinolysis38 (7%)723 (16%)<0.0001GP IIb/IIIa receptor inhibitors223 (40%)2674 (60%)<0.0001Coronary angiography493 (89%)4402 (99%)<0.0001Radial access*140 (28%)1511 (34%)<0.0001Primary angioplasty*386 (78%)3197 (72%)0.4Thrombo aspiration*163 (33%)1874 (42%)<0.0001Intra hospital outcomeHigh degree AV block40 (7%)140 (3%)<0.0001Atrial fibrillation59 (10%)161 (3.6%)<0.0001Left ventricular ejection fraction (%)47.2±1250.6±10<0.0001Total length of stay (days)8.2±56.8±4<0.0001Prescription at dischargeAspirine439 (95,6%)4167 (97,7%)0,007Clopidogrel/Prasugrel413 (90,0%)4086 (95,8%)<0,0001β blockers394 (85,8%)3895 (91,3%)<0,0001ACE inhibitor290 (63,2%)2853 (66,9%)0,1Statine373 (81,3%)4057 (95,1%)<0,0001Cardiovascular rehabilitation22 (5,3%)1822 (46,6%)<0,000

Efficacy and safety of prehospital administration of unfractionated heparin, enoxaparin or bivalirudin in patients undergoing primary percutaneous coronary intervention for ST-segment elevation myocardial infarction: Insights from the ORBI registry

International audienceBACKGROUND: Despite numerous studies in recent years, the best anticoagulant option for primary percutaneous coronary intervention (PCI) remains a matter of debate. AIMS: To compare in-hospital outcomes after prehospital administration of low-dose unfractionated heparin (UFH)±glycoprotein IIb/IIIa inhibitors (GPIs), enoxaparin±GPIs, or bivalirudin in patients undergoing primary PCI for ST-segment elevation myocardial infarction (STEMI). METHODS: A total of 1720 patients (median age 62.0 years, 79.2% male) who had been enrolled in a prospective registry and received an injectable anticoagulant in physician-staffed mobile intensive care units before primary PCI were included in the study. The main outcomes were in-hospital major adverse cardiovascular events (MACE) (a composite of all-cause mortality, non-fatal myocardial infarction, stroke or definite stent thrombosis) and in-hospital major bleeding (Bleeding academic research consortium type 3 or 5). RESULTS: UFH was administered in 420 (24.4%) patients, enoxaparin in 1163 (67.6%) patients and bivalirudin in 137 patients (8.0%). Rates of in-hospital MACE were 7.4% with UFH, 6.0% with enoxaparin and 6.6% with bivalirudin, with no significant differences between groups (P=0.628). In-hospital major bleeding occurred in 1.7% of patients on UFH, 1.4% on enoxaparin and 1.5% on bivalirudin (P=0.851). By multivariable analysis, the prehospital anticoagulant used was not an independent predictor of MACE or major bleeding. CONCLUSION: In this prospective registry, there were no significant differences in the rates of in-hospital MACE or major bleeding after prehospital initiation of UFH, enoxaparin or bivalirudin in patients treated by primary PCI for STEMI

Efficacy of pre-hospital use of glycoprotein IIb/IIIa inhibitors in ST-segment elevation myocardial infarction before mechanical reperfusion in a rapid-transfer network (from the Acute Myocardial Infarction Registry of Brittany).

International audiencePrevious studies investigating prehospital use of glycoprotein IIb/IIIa inhibitors (GPIs) in patients with ST-segment elevation myocardial infarction reached conflicting conclusions. The benefit of this strategy in addition to in-ambulance loading of dual-antiplatelet therapy remains controversial. The aim of this study was to analyze data from a prospective registry of patients with ST-segment elevation myocardial infarctions admitted 2 hours after symptom onset, of whom only 12.7% reached the primary end point. There was no significant difference between groups in the rate of in-hospital major adverse cardiac events. In conclusion, prehospital GPI use in patients with ST-segment elevation myocardial infarctions<12 hours after symptom onset scheduled for PPCI neither improved pre-PPCI infarct-related artery patency nor reduced in-hospital major adverse cardiac events

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

Door-to-balloon delays before primary angioplasty in the Regional Acute Myocardial Infarction Registry of Brittany. An analysis of the Observatoire Régional Breton sur l'Infarctus du myocarde (ORBI).

International audienceBACKGROUND: Minimizing delays to coronary reperfusion is critical in the management of acute myocardial infarction (AMI). AIMS: To determine delays in in-hospital management and factors associated with delays of over 45min. METHODS: We analysed data from the Observatoire Régional Breton sur l'Infarctus, a registry of AMI patients admitted within 24h of symptom onset (July 2007 to December 2008) to an interventional cardiology centre in Brittany. Prehospital delay was defined as time between first responder arrival at the patient and patient arrival at an interventional cardiovascular centre. In-hospital delay was defined as time between admission to the interventional cardiovascular centre and first balloon inflation. Patients were grouped according to duration of in-hospital delay (>45 v

High-degree atrioventricular block complicating ST segment elevation myocardial infarction in the contemporary era

International audienceBackground High-degree atrioventricular block (HAVB) is a common complication of ST segment elevation myocardial infarction (STEMI). HAVB in STEMI is historically considered as a marker of worse outcome but overall data about HAVB in the contemporary era of mechanical reperfusion and potent antiplatelet therapies are scarce. Aim Analysing incidence, clinical correlates and impact on inhospital outcomes of HAVB in a large prospective registry (Observatoire Régional Breton sur l'Infarctus, ORBI) of modern management of STEMI with a special focus on potential differences between patients with HAVB on admission and those who developed HAVB during hospitalisation. Methods All patients enrolled in ORBI between June 2006 and December 2013 were included in the present analysis and were divided into 3 groups: patients without HAVB at any time, patients with HAVB on admission and those who developed HAVB during hospitalisation. Results A total of 6662 patients (age: 62.0 (52.0–74.0) years; male: 76.3%) were included in the present analysis. HAVB was documented in 3.5% of patients, present on admission in 63.7% of patients and occurring during hospitalisation in 36.3%. Patients with HAVB on admission or occurring during the first 24 h of hospitalisation had higher inhospital mortality rates (18.1% and 28.6%, respectively) than patients without (4.5%) or with HAVB occurring beyond the first 24 h of hospitalisation (8.0%). However by multivariable analysis, HAVB was not independently associated with inhospital mortality contrarily to age, presentation as cardiac arrest, anterior STEMI location, reperfusion therapy, cardiogenic shock, mechanical ventilation and occurrence of sustained ventricular tachyarrhythmias or mechanical complication. Conclusions Patients with HAVB had a higher mortality rate than patients without. However HAVB is not an independent predictor of inhospital mortalit

0019: High-degree atrioventricular block complicating ST-segment elevation myocardial infarction in the contemporary era: data from the ORBI prospective French regional registry

International audienceBackground High-degree atrioventricular block (HAVB) is a common complication of ST-segment elevation myocardial infarction (STEMI). HAVB in STEMI is historically considered as a marker of worse outcome but overall data about HAVB in the contemporary era of mechanical reperfusion and potent antiplatelet therapies are scarce. Aim We aimed at analyzing incidence, clinical correlates and impact on inhospital outcomes of HAVB in a large prospective registry (ORBI) of modern management of STEMI with a special focus on potential differences between patients with HAVB on admission and those who developed HAVB during hospitalization. Methods All patients enrolled in ORBI between June 2006 and December 2013 were included in the present analysis and were divided into 3 groups: patients without HAVB at any time, patients with HAVB on admission and those who developed HAVB during hospitalization. Results 6662 patients (age: 62.0 [52.0-74.0]; male: 76.3%) were included in the present analysis. HAVB was documented in 3.5% of patients, present on admission in 63.7% of patients and occurring during hospitalization in 36.3%. Patients with HAVB on admission or occurring during the first 24h of hospitalization had higher in-hospital mortality rates (18.1% and 28.6% respectively) than patients without (4.5%) or with HAVB occurring beyond the first 24h of hospitalization (8.0%). However by multivariable analysis, HAVB was not independently associated with in-hospital mortality. Conclusion Patients with HAVB had a higher mortality rate than patients without. However HAVB is not an independent predictor of in-hospital mortality. Abstract 0019 – Figure: Multivariable analysi

Immediate complete revascularization in patients with ST-segment elevation myocardial infarction and multivessel disease treated by primary percutaneous coronary intervention Insights from the ORBI registry

International audienceBackground - Recent studies demonstrated the superiority of complete revascularization (CR) in patients treated by primary percutaneous coronary intervention (pPCI) in ST-elevation myocardial infarction (STEMI). Aim - To evaluate whether immediate CR improves in-hospital outcomes in patients with STEMI with multivessel disease. Methods - Data from a prospective multicentre registry including 9365 patients with STEMI were analysed. Patients with multivessel disease and treated with pPCI (n=3412) were included and separated into two groups according to whether immediate CR was performed during the index procedure. The primary endpoint was in-hospital major adverse cardiovascular events (MACE), defined as a composite of all-cause death, non-fatal myocardial infarction, stroke and definite stent thrombosis. Secondary endpoints were individual components of MACE and major bleeding. Multivariable Cox regression and propensity-score adjustment were performed to account for confounders. Results - Immediate CR was performed in 98 patients (2.9%), whereas 3314 patients (97.1%) were incompletely revascularized. The prevalence of severe heart failure (Killip class III or IV) and significant lesions of the left main coronary artery were higher in the immediate CR group (21.6% vs. 13.5% and 24.5% vs. 6.7%, respectively; P<0.001 for both). After adjustment, immediate CR was not associated with reduced rates of MACE (hazard ratio [HR] 0.64, 95% confidence interval [CI]: 0.31-1.35; P=0.24) or all-cause death (HR: 0.52, 95% CI: 0.23-1.16; P=0.11), but with increased risks of definite stent thrombosis (HR: 3.93, 95% CI: 1.12-13.75; P=0.03) and major bleeding (HR: 17.46, 95% CI: 2.29-133.17; P=0.006). Conclusion - Immediate CR did not improve in-hospital outcomes of patients with STEMI with multivessel disease in this analysis. Randomized studies are warranted to elucidate the optimal timing of CR in patients with STEMI

Early and late ventricular arrhythmias complicating ST-segment elevation myocardial infarction

International audienceBACKGROUND: Ventricular arrhythmias can be life-threatening complications of ST-segment elevation myocardial infarction (STEMI). AIMS: To describe the incidence, predictors and in-hospital impact of early ventricular arrhythmia (EVA, occurring&lt;day 2 after STEMI) and late ventricular arrhythmia (LVA, occurring≥day 2 after STEMI) in patients with STEMI. METHODS: Data from 13,523 patients enrolled in a prospective registry were analysed. Logistic and Cox regressions were performed to identify predictors of EVA, LVA and in-hospital all-cause mortality. Predictors of LVA were used to build a risk score. RESULTS: EVA occurred in 678 patients (5%), whereas 120 patients (0.9%) experienced LVA, at a median timing of 3days after STEMI. EVA was associated with a significantly higher risk of all-cause mortality (hazard ratio: 1.44, 95% confidence interval: 1.17-1.76; P=0.001), whereas no association was observed with LVA (hazard ratio 0.86, 95% confidence interval 0.57-1.28; P=0.45). Multivariable predictors of LVA were: age≥65years; serum creatinine≥85μmol/L on admission; pulse pressure≤45mmHg on admission; presence of a Q wave on admission electrocardiogram; Thrombolysis In Myocardial Infarction flow grade&lt;3 after percutaneous coronary intervention; and left ventricular ejection fraction≤45%. The score derived from these variables allowed the classification of patients into four risk categories: low (0-21); low-to-intermediate (22-34); intermediate-to-high (35-44); and high (≥45). Observed LVA rates were 0.2%, 0.3%, 0.9% and 2.5%, across the four risk categories, respectively. The model demonstrated good discrimination (20-fold cross-validated c-statistic of 0.76) and adequate calibration (Hosmer-Lemeshow P=0.23). CONCLUSIONS: EVA is 5-fold more common than LVA in the setting of STEMI, and portends a higher risk of in-hospital all-cause mortality. LVA is mainly associated with the patient’s baseline risk profile and surrogate markers of larger infarct size. We developed and internally validated a risk score identifying patients at high risk of LVA for whom early intensive care unit discharge may not be suitable