Résistance à l aspirine et renouvellement plaquettaire

PARIS7-Xavier Bichat (751182101) / SudocSudocFranceF

257 Prevalence of aspirin resistance in stable coronary heart diseased patients and correlation with platelet turn-over

BackgroundAspirin resistance has been widely reported but the underlying mechanisms remain unclear. Previous studies have suggested a relationship between accelerated platelet turn-over and aspirin resistance in patients with coronary artery disease. The purpose of this study was to determine whether aspirin resistance could be linked to accelerated platetet turn-over.MethodsWe performed a prospective monocentric study including 50 consecutive patients with stable coronary artery disease treated by aspirin (75 to 250mg/day) without any other antiaggregant treatment. Aspirin resistance was characterized 24 hours after aspirin intake by light transmission aggregometry using 0.5mg/mL arachidonic acid. Aspirin resistance was defined as >20% residual agregation. Platelet turn-over was estimated at the same time by measurement of mean platelet volume, % of reticulated platelets, serum P-selectin, platelet P-selectin and serum thrombopoietin.ResultsAmong 50 patients (70 ± 11 y.o. mean ± 1,5, 76% male, 52% type 2 diabetes mellitus, 16% active smokers), 18 (36%) were identified as aspirin resistants. Table 1 shows the mean value of markers currently linked to platelet turn-over depending on the presence of aspirin resistance. Serum thrombopoietin was significantly increased in patients with aspirin resistance compared to patients with no aspirin resistance. No statistical difference was demonstrated for mean platelet volume, reticulated platelets, platelet P-selectin and serum P-selectin. Serum thrombopoietin values were not correlated with other platelet turn-over parameters. There was no significant correlation between serum thrombopoietin and inflammatory markers.ConclusionSerum thrombopoietin is associated with aspirin resistance, but no other parameters currently linked to platelet turn-over. Further studies are needed to determine whether serum thrombopoietin can predict aspirin resistance in a larger cohort.Aspirin sensitiveAspirin resistantpPlatelet volume (fl)8.78 ± 0.268.82 ± 0.300.92Reticulated platelet (%)8.4 ± 0.528.6 ± 0.760.82Serup P selectin (ng/ml)42.6 ± 4.2942.9 ± 4.750.97Platelet P selectin (%)11.1 ± 1.09.5 ± 1.50.35Serum thrombopoietin (pg/ml)130.6 ± 11.3319.9 ± 97.80.0

Low level exercise echocardiography helps diagnose early stage heart failure with preserved ejection fraction: a study of echocardiography versus catheterization

International audienceBackgroundIncreased left ventricular end-diastolic pressure (LVEDP) with exercise is an early sign of heart failure with preserved left ventricular ejection fraction (LVEF). The abnormal exercise increase in LVEDP is nonlinear, with most change occurring at low-level exercise. Data on non-invasive approach of this condition are scarce. Our objective was assessing E/e′ to estimate low level exercise LVEDP using a direct invasive measurement as the reference method.Methods and resultsSixty patients with LVEF >50 % prospectively underwent both exercise cardiac catheterization and echocardiography. E/e′ was measured at rest and during low-level exercise. Abnormal LVEDP was defined as >16 mmHg. Patients with a history of coronary artery disease and/or abnormal LV morphology were classified as having apparent cardiac disease (CD). Thirty-four (57 %) patients had elevated LVEDP only during exercise. Most of the change in LVEDP occurred since the first exercise level (25 W). There was a correlation between LVEDP and septal E/e′ at rest and during exercise. Lateral E/e′ and E/average e′ ratio had worse correlations with LVEDP. In the whole population, exercise septal E/e′ at 25 W had the best accuracy for abnormal exercise LVEDP, area under curve (AUC) = 0.79. However, while low-level exercise septal E/e′ had a high accuracy in CD patients (n = 26, AUC = 0.96), E/e′ was not linked to LVEDP in patients without CD (n = 34).ConclusionLow-level exercise septal E/e′ is valuable for predicting abnormal exercise LVEDP in patients with preserved LVEF and apparent CD. However, this new diagnosis approach appears not reliable in patients with normal LV morphology and without coronary artery disease

Évaluation à long terme de la transplantation cardiaque effectuée après assistance ventriculaire comparativement à la transplantation cardiaque standard

International audienceBACKGROUND:Data on the long-term outcome of heart transplantation in patients with a ventricular assist device (VAD) are scarce.AIM:To evaluate long-term outcome after heart transplantation in patients with a VAD compared with no mechanical circulatory support.METHODS:Consecutive all-comers who underwent heart transplantation were included at a single high-volume centre from January 2005 until December 2012, with 5 years of follow-up. Clinical and biological characteristics, operative results, outcomes and survival were recorded. Regression analyses were performed to determine predictors of 1-year and 5-year mortality.RESULTS:Fifty-two patients with bridge to transplantation by VAD (VAD group) and 289 patients transplanted without a VAD (standard group) were enrolled. The mean age was 46±11 years in the VAD group compared with 51±13 years in the standard group (P=0.01); 17% of the VAD group and 25% of the standard group were women (P=0.21). Ischaemic time was longer in the VAD group (207±54 vs 169±60minutes; P<0.01). There was no difference in primary graft failure (33% vs 25%; P=0.22) or 1-year mortality (17% vs 28%; P=0.12). In the multivariable analysis, preoperative VAD was an independent protective factor for 1-year mortality (odds ratio 0.40, 95% confidence interval 0.17-0.97; P=0.04). Independent risk factors for 1-year mortality were recipient age>60 years, recipient creatinine, body surface area mismatch and ischaemic time. The VAD and standard groups had similar long-term survival, with 5-year mortality rates of 35% and 40%, respectively (P=0.72).CONCLUSIONS:Bridge to transplantation by VAD was associated with a reduction in 1-year mortality, leading critically ill patients to similar long-term survival compared with patients who underwent standard heart transplantation. This alternative strategy may benefit carefully selected patientsContextePeu de données sont disponibles concernant le devenir des patients transplantés après l’implantation d’un dispositif d’assistance ventriculaire (DAV).ObjectifsÉvaluer le devenir à long terme après transplantation cardiaque des patients implantés d’un DAV, comparativement aux patients transplantés sans dispositif.MéthodesTous les patients consécutifs qui ont bénéficié d’une transplantation cardiaque entre janvier 2005 et décembre 2012 ont été inclus au sein d’un unique centre à haut volume, avec un suivi de 5 ans. Les caractéristiques cliniques, biologiques, les résultats opératoires, le devenir et la mortalité totale ont été relevés. Des analyses de régression ont été effectuées pour déterminer les facteurs prédictifs de mortalité à 1 et 5 ans.RésultatsCinquante-deux patients « DAV » et 289 patients « standards » transplantés sans DAV ont été inclus. L’âge moyen était de 46 ± 11 ans dans le groupe DAV vs 51 ± 13 ans dans le groupe standard (p = 0,01) et 17% des patients DAV étaient de sexe féminin vs 25% (p = 0,21). Le temps d’ischémie froide était plus long dans le groupe DAV (207 ± 54 vs 169 ± 60 min, p < 0,01). Il n’y avait pas de différence de défaillance primaire du greffon (33% vs 25%, p = 0,22) ou de mortalité à 1 an (17% vs 28%, p = 0,12). Le DAV pré-transplantation était un facteur protecteur indépendant de mortalité à 1 an (OR 0,40 [0,17-0,97], p = 0,04). Les facteurs de risque indépendants de mortalité à 1 an étaient l’âge du receveur>60 ans, la créatinine de receveur, le mismatch de surface corporelle et la durée d’ischémie. Les patients DAV et standards avaient une survie à long terme similaire, avec une mortalité à 5 ans respectivement de 35% et 40% (p = 0,72).ConclusionsLe pont vers la transplantation par un DAV était associé à une réduction de la mortalité à 1 an, conduisant les patients les plus critiques à une survie à long terme comparable à celle des patients transplantés de façon standard. Cette stratégie alternative est susceptible de bénéficier à une population de patients sélectionnés

PRADOC: a trial on the efficiency of a transition care management plan for hospitalized patients with heart failure in France

International audienceAims: Transition care programmes are designed to improve coordination of care between hospital and home. For heart failure patients, meta-analyses show a high efficacy but with moderate evidence level. Moreover, difficulties for implementation of such programmes limit their extrapolation.Methods and results: We designed a mixed-method study to assess the implementation of the PRADO-IC, a nationwide transition programme that aims to be offered to every patient with heart failure in France. This programme consists essentially in an administrative assistance to schedule follow-up visits and in a nurse follow-up during 2 to 6 months and aims to reduce the annual heart failure readmission rate by 30%. This study assessed three quantitative aims: the cost to avoid a readmission for heart failure within 1 year (primary aim, intended sample size 404 patients), clinical care pathways, and system economic outcomes; and two qualitative aims: perceived problems and benefits of the PRADO-IC. All analyses will be gathered at the end of study for a joint interpretation. Strengths of this study design are the randomized controlled design, the population included in six centres with low motivation bias, the primary efficiency analysis, the secondary efficacy analyses on care pathway and clinical outcomes, and the joint qualitative analysis. Limits are the heterogeneity of centres and of intervention in a control group and parallel development of other new therapeutic interventions in this field.Conclusions: The results of this study may help decision-makers to support an administratively managed transition programme