Abstract Objective To determine whether coronary computed tomography angiography (CTA) should be performed in patients with any clinical probability of coronary artery disease (CAD), and whether the diagnostic performance differs between subgroups of patients. Design Prospectively designed meta-analysis of individual patient data from prospective diagnostic accuracy studies. Data sources Medline, Embase, and Web of Science for published studies. Unpublished studies were identified via direct contact with participating investigators. Eligibility criteria for selecting studies Prospective diagnostic accuracy studies that compared coronary CTA with coronary angiography as the reference standard, using at least a 50% diameter reduction as a cutoff value for obstructive CAD. All patients needed to have a clinical indication for coronary angiography due to suspected CAD, and both tests had to be performed in all patients. Results had to be provided using 2×2 or 3×2 cross tabulations for the comparison of CTA with coronary angiography. Primary outcomes were the positive and negative predictive values of CTA as a function of clinical pretest probability of obstructive CAD, analysed by a generalised linear mixed model; calculations were performed including and excluding non-diagnostic CTA results. The no-treat/treat threshold model was used to determine the range of appropriate pretest probabilities for CTA. The threshold model was based on obtained post-test probabilities of less than 15% in case of negative CTA and above 50% in case of positive CTA. Sex, angina pectoris type, age, and number of computed tomography detector rows were used as clinical variables to analyse the diagnostic performance in relevant subgroups. Results Individual patient data from 5332 patients from 65 prospective diagnostic accuracy studies were retrieved. For a pretest probability range of 7-67%, the treat threshold of more than 50% and the no-treat threshold of less than 15% post-test probability were obtained using CTA. At a pretest probability of 7%, the positive predictive value of CTA was 50.9% (95% confidence interval 43.3% to 57.7%) and the negative predictive value of CTA was 97.8% (96.4% to 98.7%); corresponding values at a pretest probability of 67% were 82.7% (78.3% to 86.2%) and 85.0% (80.2% to 88.9%), respectively. The overall sensitivity of CTA was 95.2% (92.6% to 96.9%) and the specificity was 79.2% (74.9% to 82.9%). CTA using more than 64 detector rows was associated with a higher empirical sensitivity than CTA using up to 64 rows (93.4% v 86.5%, P=0.002) and specificity (84.4% v 72.6%, P<0.001). The area under the receiver-operating-characteristic curve for CTA was 0.897 (0.889 to 0.906), and the diagnostic performance of CTA was slightly lower in women than in with men (area under the curve 0.874 (0.858 to 0.890) v 0.907 (0.897 to 0.916), P<0.001). The diagnostic performance of CTA was slightly lower in patients older than 75 (0.864 (0.834 to 0.894), P=0.018 v all other age groups) and was not significantly influenced by angina pectoris type (typical angina 0.895 (0.873 to 0.917), atypical angina 0.898 (0.884 to 0.913), non-anginal chest pain 0.884 (0.870 to 0.899), other chest discomfort 0.915 (0.897 to 0.934)). Conclusions In a no-treat/treat threshold model, the diagnosis of obstructive CAD using coronary CTA in patients with stable chest pain was most accurate when the clinical pretest probability was between 7% and 67%. Performance of CTA was not influenced by the angina pectoris type and was slightly higher in men and lower in older patients. Systematic review registration PROSPERO CRD42012002780.

The original version of this article, published on 19 March 2018, unfortunately contained a mistake. The following correction has therefore been made in the original: The names of the authors Philipp A. Kaufmann, Ronny Ralf Buechel and Bernhard A. Herzog were presented incorrectly.

L'obésité, dont la prévalence est en augmentation constante, est un facteur de risque indépendant de maladie thromboembolique veineuse (MTEV) et est associé à des modifications de la pharmacocinétique (PK) des médicaments. Alors que les anticoagulants oraux directs (AOD) sont administrés à dose fixe sans adaptation au poids, aucune étude spécifique d'efficacité et tolérance des AOD chez les obèses n'est disponible et les données de PK dans cette population sont très limitées. L'objectif principal de cette étude pilote, prospective, bicentrique était d'évaluer les concentrations des AOD chez des patients obèses, traités pour MTEV par apixaban ou rivaroxaban en les comparant à celles des patients non obèses, comme suggéré par le Société Internationale d'Hémostase et Thrombose. L'objectif secondaire était d'évaluer les évènements cliniques durant le suivi. Depuis août 2017 dans un centre et mars 2018 dans le second, les patients obèses (IMC > 30 kg/m2) traités par rivaroxaban ou apixaban pour MTEV et suivis dans la « filière thrombose » de 2 CHU français, ont été inclus dans cette étude. Les concentrations plasmatiques des AOD ont été mesurées à l'issue de la consultation, en utilisant une technique basée sur l'activité anti-Xa (STA-Liquid-anti-Xa®). Les délais entre la dernière prise et le dosage ont été précisément collectés pour chaque patient. Les valeurs de concentration des AOD ont été comparées à celles rapportées dans les études de PK chez les patients, pour les 2 molécules. Tous les évènements hémorragiques ou thrombotiques survenus entre le début du traitement par AOD et la consultation ont été colligés. Soixante-cinq patients ont été inclus (36 hommes et 29 femmes) avec un total de 81 dosages d'AOD. L'IMC moyen (± ds) était de 35 ± 5 kg/m2 dont 12 patients avec un IMC > 40 kg/m2. L'âge moyen était de 55 ± 16 ans et la clairance de la créatinine (Cockcroft) moyenne de 84 ± 24 mL/min. Le traitement au moment du prélèvement était : rivaroxaban 20 mg (n = 40), apixaban 5mgx2 (n = 29) et apixaban 2,5 mgx2 (n = 12). Les concentrations d'AOD variaient entre < 20 et 453 ng/mL. Quelque soit le délai entre la prise et le dosage (moy ± sd : 8 ± 7 h), les concentrations de rivaroxaban et d'apixaban mesurées étaient conformes aux valeurs attendues pour tous les patients sauf 3 : 1 patient traité par apixaban 2,5 mgx2 qui n'avait vraisemblablement pas pris son traitement (< 20 ng/mL au pic) ; deux patients traités par rivaroxaban 20 mg (concentrations : 74 ng/mL, 4 h après la prise et 119 ng/mL au pic) dont 1 avec une interaction médicamenteuse possible avec le phenobarbital. Le délai médian depuis le début du traitement était de 10 mois (Min-Max : 1–84) sans complication thrombotique ou hémorragique reportée durant cette période. Les résultats de cette étude pilote montrent que les concentrations d'apixaban et de rivaroxaban chez les patients obèses traités pour MTEV sont pour la plupart (96 % des dosages) conformes aux valeurs attendues décrites pour les patients non obèses dans les études de PK. Des données supplémentaires et des études spécifiques du patient obèse sont nécessaires pour définir précisément le profil PK de ces molécules et évaluer le bénéfice/risque des AOD dans cette population.

BACKGROUND AND AIMS:Although much has been written about the conventional cardiovascular risk factor correlates of the extent of coronary artery calcification (CAC), few studies have been carried out on symptomatic patients. This paper assesses the potential ability of risk factors to associate with an increasing CAC score.METHODS:From the European Calcific Coronary Artery Disease (Euro-CCAD) cohort, we retrospectively investigated 6309 symptomatic patients, 62% male, from Denmark, France, Germany, Italy, Spain and the USA. All had conventional cardiovascular risk factor assessment and CT scanning for CAC scoring.RESULTS:Among all patients, male sex (OR = 4.85, p<0.001) and diabetes (OR = 2.36, p<0.001) were the most important risk factors of CAC extent, with age, hypertension, dyslipidemia and smoking also showing a relationship. Among patients with CAC, age, diabetes, hypertension and dyslipidemia were associated with an increasing CAC score in males and females, with diabetes being the strongest dichotomous risk factor (p<0.001 for both). These results were echoed in quantile regression, where diabetes was consistently the most important correlate with CAC extent in every quantile in both males and females. To a lesser extent, hypertension and dyslipidemia were also associated in the high CAC quantiles and the low CAC quantiles respectively.CONCLUSION:In addition to age and male sex in the total population, diabetes is the most important correlate of CAC extent in both sexes.

Background: ST-segment–elevation myocardial infarction (STEMI) and non–ST-segment–elevation myocardial infarction (NSTEMI) management has evolved considerably over the past 2 decades. Little information on mortality trends in the most recent years is available. We assessed trends in characteristics, treatments, and outcomes for acute myocardial infarction in France between 1995 and 2015. Methods: We used data from 5 one-month registries, conducted 5 years apart, from 1995 to 2015, including 14 423 patients with acute myocardial infarction (59% STEMI) admitted to cardiac intensive care units in metropolitan France. Results: From 1995 to 2015, mean age decreased from 66±14 to 63±14 years in patients with STEMI; it remained stable (68±14 years) in patients with NSTEMI, whereas diabetes mellitus, obesity, and hypertension increased. At the acute stage, intended primary percutaneous coronary intervention increased from 12% (1995) to 76% (2015) in patients with STEMI. In patients with NSTEMI, percutaneous coronary intervention ≤72 hours from admission increased from 9% (1995) to 60% (2015). Six-month mortality consistently decreased in patients with STEMI from 17.2% in 1995 to 6.9% in 2010 and 5.3% in 2015; it decreased from 17.2% to 6.9% in 2010 and 6.3% in 2015 in patients with NSTEMI. Mortality still decreased after 2010 in patients with STEMI without reperfusion therapy, whereas no further mortality gain was found in patients with STEMI with reperfusion therapy or in patients with NSTEMI, whether or not they were treated with percutaneous coronary intervention. Conclusions: Over the past 20 years, 6-month mortality after acute myocardial infarction has decreased considerably for patients with STEMI and NSTEMI. Mortality figures continued to decline in patients with STEMI until 2015, whereas mortality in patients with NSTEMI appears stable since 2010.

BACKGROUND:ST-segment-elevation myocardial infarction (STEMI) and non-ST-segment-elevation myocardial infarction (NSTEMI) management has evolved considerably over the past 2 decades. Little information on mortality trends in the most recent years is available. We assessed trends in characteristics, treatments, and outcomes for acute myocardial infarction in France between 1995 and 2015. METHODS:We used data from 5 one-month registries, conducted 5 years apart, from 1995 to 2015, including 14 423 patients with acute myocardial infarction (59% STEMI) admitted to cardiac intensive care units in metropolitan France. RESULTS:From 1995 to 2015, mean age decreased from 66±14 to 63±14 years in patients with STEMI; it remained stable (68±14 years) in patients with NSTEMI, whereas diabetes mellitus, obesity, and hypertension increased. At the acute stage, intended primary percutaneous coronary intervention increased from 12% (1995) to 76% (2015) in patients with STEMI. In patients with NSTEMI, percutaneous coronary intervention ≤72 hours from admission increased from 9% (1995) to 60% (2015). Six-month mortality consistently decreased in patients with STEMI from 17.2% in 1995 to 6.9% in 2010 and 5.3% in 2015; it decreased from 17.2% to 6.9% in 2010 and 6.3% in 2015 in patients with NSTEMI. Mortality still decreased after 2010 in patients with STEMI without reperfusion therapy, whereas no further mortality gain was found in patients with STEMI with reperfusion therapy or in patients with NSTEMI, whether or not they were treated with percutaneous coronary intervention. CONCLUSIONS:Over the past 20 years, 6-month mortality after acute myocardial infarction has decreased considerably for patients with STEMI and NSTEMI. Mortality figures continued to decline in patients with STEMI until 2015, whereas mortality in patients with NSTEMI appears stable since 2010.

Left ventricular remodeling (LVR) typically manifests as compensatory changes in ventricular mass, composition, and volume as a response to cardiac performance inadequacy [ [1] Cohn J.N. Ferrari R. Sharpe N. Cardiac remodeling–concepts and clinical implications: a consensus paper from an international forum on cardiac remodeling. Behalf of an International Forum on cardiac remodeling. J. Am. Coll. Cardiol. 2000; 35: 569-582 Abstract Full Text Full Text PDF PubMed Scopus (1924) Google Scholar ]. Cardiac multimodality imaging allows us to investigate both counterparts of remodeling, namely structural and functional remodeling [ 2 Mewton N. Liu C.Y. Croisille P. Bluemke D. Lima J.A. Assessment of myocardial fibrosis with cardiovascular magnetic resonance. J. Am. Coll. Cardiol. 2011; 57: 891-903 Abstract Full Text Full Text PDF PubMed Scopus (677) Google Scholar , 3 Grothues F. Smith G.C. Moon J.C. Bellenger N.G. Collins P. Klein H.U. et al. Comparison of interstudy reproducibility of cardiovascular magnetic resonance with two-dimensional echocardiography in normal subjects and in patients with heart failure or left ventricular hypertrophy. Am. J. Cardiol. 2002; 90: 29-34 Abstract Full Text Full Text PDF PubMed Scopus (1099) Google Scholar ]. Considering the morbi-mortality burden of LVR, these parameters appear to be of value for diagnosing subclinical disease, conducting patient risk stratification, and monitoring response to therapy [ [1] Cohn J.N. Ferrari R. Sharpe N. Cardiac remodeling–concepts and clinical implications: a consensus paper from an international forum on cardiac remodeling. Behalf of an International Forum on cardiac remodeling. J. Am. Coll. Cardiol. 2000; 35: 569-582 Abstract Full Text Full Text PDF PubMed Scopus (1924) Google Scholar ].

Background and aims: The influence of gender and age on risk factor prediction of coronary artery calcification (CAC) in symptomatic patients is unclear.Methods: From the European Calcific Coronary Artery Disease (EURO-CCAD) cohort, we retrospectively investigated 6309 symptomatic patients, 62% male, from Denmark, France, Germany, Italy, Spain and USA. All of them underwent risk factor assessment and CT scanning for CAC scoring.Results: The prevalence of CAC among females was lower than among males in all age groups. Using multivariate logistic regression, age, dyslipidaemia, hypertension, diabetes and smoking were independently predictive of CAC presence in both genders. In addition to a progressive increase in CAC with age, the most important predictors of CAC presence were dyslipidaemia and diabetes (beta = 0.64 and 0.63, respectively) in males and diabetes (beta = 1.08) followed by smoking (beta = 0.68) in females; these same risk factors were also important in predicting increasing CAC scores. There was no difference in the predictive ability of diabetes, hypertension and dyslipidaemia in either gender for CAC presence in patients aged < 50 and 50-70 years. However, in patients aged > 70, only dyslipidaemia predicted CAC presence in males and only smoking and diabetes were predictive in females.Conclusions: In symptomatic patients, there are significant differences in the ability of conventional risk factors to predict CAC presence between genders and between patients aged < 70 and >= 70, indicating the important role of age in predicting CAC presence. (C) 2016 Elsevier Ireland Ltd. All rights reserved.

Alhough cardiogenic shock (CS) after acute myocardial infarction (AMI) is more common in elderly patients, information on the epidemiology of these patients is scarce. This study aimed to assess the trends in prevalence, characteristics, management, and outcomes of elderly patients admitted with CS complicating AMI between 1995 and 2010, using data from the FAST‐MI programme.

Outcomes of AMI patients have substantially improved over the past 2 decades. Whether similar trends are observed in elderly (≥75 years of age) and younger patients has not been extensively studied. We analysed one-year mortality of elderly vs younger patients in 4 nationwide French survey carried out 5 years apart from 1995 to 2010. Consecutive STEMI and NSTEMI patients (≤48 hours from onset) were recruited over one-month periods. Among 10610 patients included in the 4 surveys, 3389 (32%) were aged 75+. From 1995 to 2010, the proportion of 75+ remained stable in NSTEMI (1995: 36%, 2010: 38%), but decreased in STEMI patients (1995: 30%, 2010: 25.5%, P=0.006). Use of PCI ≤72 hours of admission increased from 6.0% to 54.9% in tin the past 15 years he 75+, and from 19% to 77% in the younger pts, use of new anticoagulants increased from 0 to 62% and 0 to 79%, respectively, and use of recommended secondary prevention medications from 2% to 43% and from 9% to 69% respectively. All clinical outcomes improved both in the 75+ and <75 age groups (Table). Risk of one-year death in 2010 vs 1995 was HR 0.48 (0.40-0.59) in the 75+ and HR 0.38 (0.29-0.50) in younger patients. When early use of PCI, recommended medications and new anticoagulants were added to the models, survey period was no longer significantly associated with one-year death. In these 4 nationwide surveys of AMI pts conducted over a 15-year period, outcomes improved markedly in elderly as in younger patients. Most of the improvement in outcomes appear mediated by improved early management (use of PCI and medications).Abstract 0112 – Table: Evolution of outcomes from 1995 to 2010 across age groupsEmpty Cell<75 years (n=7.221) 1995-2000-2005-2010≥75 years (n=3.389) 1995-2000-2005-2010VF4.0 – 2.3 – 1.5 – 1.2%4.6 – 4.9 – 2.0 – 1.0%AF7.7 – 5.0 – 3.7 – 2.9%21.5 – 16.8 – 9.5 – 10.1%ReinfarctionNA – 2.3 – 1.5 – 0.8%NA – 2.9 – 2.4 – 1.8%StrokeNA – 0.7 – 0.7 – 0.4%NA – 1.6 – 1.4 – 0.5%Shock4.7 – 4.4 – 4.0 – 2.7%11.6 – 13.6 – 9.3 – 6.7%30-day death7.2 – 4.8 – 2.9 – 1.4%25.0 – 16.8 – 13.0 – 8.4%One-year death10.9 – 8.8 – 5.9 – 3.9%36.2 – 30.0 – 26.9 – 20 0% Abstract 0112 – Table: Evolution of outcomes from 1995 to 2010 across age groups

Les maladies cardiovasculaires représentent la première cause de décès chez les patients hémodialysés. Sur ce terrain, les calcifications cardiovasculaires surviennent à un âge plus précoce et progressent plus rapidement que dans la population générale.Dans le but de définir la prévalence et les facteurs de risque des calcifications cardiaques, 49 patients en hémodialyse chronique ont bénéficié d’un dépistage au niveau des artères coronaires et au niveau des valves cardiaques par le cardioscanner 64 barrettes ultra-rapide et par l’échocardiographie transthoracique. Différents paramètres cliniques et biologiques étaient étudiés par le logiciel statistique SPSS 10.0 pour définir des facteurs de risques.Les calcifications cardiaques étaient identifiées chez 81,6 % des cas dans au moins l’un des deux sites étudiés. L’atteinte des artères coronaires était plus fréquente que l’atteinte valvulaire et concernait 69,4 % des cas. Le score calcique coronaire d’Agatston (SCCA) moyen était de 331,1 et de 522,2 chez les patients coronariens. Il était corrélé à l’altération de la fonction systolique du VG (r = −0,287, p = 0,045). La sévérité du SCC était corrélée positivement avec l’âge (r = 0,332, p = 0,02). Les calcifications coronaires étaient associées à des facteurs de risques cardiovasculaires communs à la population générale (âge, sexe masculin, pression artérielle systolique, diabète, antécédent de cardiopathie ischémique), mais aussi à une moindre qualité de dialyse. Les calcifications valvulaires étaient présentes dans 49 % des cas et étaient corrélées à l’hypertrophie ventriculaire gauche (p = 0,006). L’atteinte exclusive de la valve aortique était l’anomalie valvulaire la plus fréquente. Les paramètres phosphocalciques, lipidiques, les taux de l’hémoglobine, de la CRP et de l’acide urique ne prédisposaient pas aux calcifications cardiaques dans notre série.Chez les patients hémodialysés, la pathogenèse des calcifications cardiovasculaires est complexe et ne peut être attribuée à un simple processus passif. Ce processus comprend plusieurs facteurs qui peuvent favoriser ou inhiber les calcifications. Le nouveau scanner multi-coupe ultra-rapide est une méthode très sensible pour l’évaluation topographique et quantitative des calcifications coronaires et constitue une meilleure alternative aux techniques invasives.Notre étude confirme la grande prévalence des calcifications cardiaques chez l’hémodialysé, et souligne l’intérêt du dépistage précoce, et de la prise en charge des facteurs prédisposant.Cardiovascular disease is the first leading cause of death in hemodialysis patients. In this population, cardiovascular calcifications occur at an earlier age and progress faster than in general population.In order to determine the prevalence and risk factors of cardiac calcifications, 49 patients on chronic hemodialysis were screened in the coronary arteries and cardiac valves by the 64 multi-slice ultra-fast CT and the transthoracic echocardiography. Different clinical and biological parameters were studied by the SPSS 10.0 statistical software to determine risk factors.Cardiac calcifications were identified in 81.6% of cases in at least one of the two studied sites. The coronary artery involvement was more common than valvular and concerned 69.4% of cases. The mean Agatston coronary artery calcium score (ACACS) was 331.1 and 522.2 in coronary patients and was correlated to alteration of systolic function of LV (r = −0.287, P = 0.045). The severity of CACS was positively correlated with age (r = 0.332, P = 0.02). Coronary calcifications were associated with cardiovascular risk common to those of the general population (age, male sex, systolic blood pressure, diabetes, history of ischemic heart disease), but also to a lesser quality of dialysis. Valvular calcifications were present in 49% of cases and were correlated with left ventricular hypertrophy (P = 0.006). The exclusive involvement of the aortic valve was the most common valvular abnormality. Phosphocalcic and lipid parameters, levels of hemoglobin, CRP and uric acid did not predisposed to cardiac calcifications in our patients.In hemodialysis patients, the pathogenesis of cardiovascular calcification is complex and cannot be attributed to a passive process. This process involves several factors that can promote or inhibit calcification. The new multi-slice ultra-fast scanner is a very sensitive method for topographic and quantitative assessment of coronary calcification and is a better alternative to invasive techniques.Our study confirms the high prevalence of cardiac calcification in hemodialysis, and highlights the importance of early screening and treatment of predisposing factors.

AimsIn this retrospective study we assessed the predictive value of the coronary calcium score for significant (>50%) stenosis relative to conventional risk factors.Methods and ResultsWe investigated 5515 symptomatic patients from Denmark, France, Germany, Italy, Spain and the USA. All had risk factor assessment, computed tomographic coronary angiogram (CTCA) or conventional angiography and a CT scan for coronary artery calcium (CAC) scoring. 1539 (27.9%) patients had significant stenosis, 5.5% of whom had zero CAC. In 5074 patients, multiple binary regression showed the most important predictor of significant stenosis to be male gender (B=1.07) followed by diabetes mellitus (B=0.70) smoking, hypercholesterolaemia, hypertension, family history of CAD and age but not obesity. When the log transformed CAC score was included, it became the most powerful predictor (B=1.25), followed by male gender (B=0.48), diabetes, smoking, family history and age but hypercholesterolaemia and hypertension lost significance. The CAC score is a more accurate predictor of >50% stenosis than risk factors regardless of the means of assessment of stenosis. The sensitivity of risk factors, CAC score and the combination for prediction of >50% stenosis when measured by conventional angiogram was considerably higher than when assessed by CTCA but the specificity was considerably higher when assessed by CTCA. The accuracy of CTCA for predicting >50% stenosis using the CAC score alone was higher (AUC=0.85) than using a combination of the CAC score and risk factors with conventional angiography (AUC=0.81).ConclusionIn symptomatic patients, the CAC score is a more accurate predictor of significant coronary stenosis than conventional risk factors.

To determine the costs and cost-effectiveness of a diagnostic strategy including computed tomography coronary angiography (CTCA) in comparison with invasive conventional coronary angiography (CA) for the detection of significant coronary artery disease from the point of view of the healthcare provider.