New onset atrial fibrillation post-transcatheter aortic valve implantation (TAVI) is common and is associated with adverse outcomes. However, silent atrial fibrillation (AF) is poorly documented in the context. This study sought to evaluate the incidence, predictive factors, and prognostic value of Silent AF post-TAVI. All the consecutive patients with TAVI were prospectively analyzed by continuous electrocardiogram monitoring≥48 hours after implantation. Silent AF was defined as asymptomatic episodes lasting at least 30 seconds. The population was divided into 3 groups: history of AF, no-AF, and silent AF. Among the 206 patients implanted with TAVI, 19 (16.1%) developed silent AF. Compared with the no-AF group, patients with silent AF shared the same clinical characteristics and cardiovascular risk factors. Procedural success and echography parameters after the device implantation were similar between groups. Left atrial volume was significantly increased (p <0.001) in the silent AF group, together with preimplantation C-reactive protein (CRP) >3 mg/L and glucose (p = 0.048 and p = 0.002). By multivariate analysis, CRP >3 mg/dl and logistic European System for Cardiac Operative Risk Evaluation were identified as independent predictors of silent AF. In-hospital and 1-year mortalities were higher in pre-existing AF patients, whereas no-AF and the silent AF patients share the same prognosis. Our prospective study showed for the first time that silent AF is frequent after TAVI procedures. In conclusion, our work suggests that CRP could help to predict the risk of developing silent AF. However, the onset of silent AF is not associated with worse prognosis in the year following the procedure in our study.

To evaluate the incremental interest of performing a calcium score before CTO procedures, compared to the angiographic J-CTO score alone. Prospective cohort of 109 consecutive patients with 119 de novo CTO lesions. Angiographic grading with the J-CTO score was compared with CT + angiographic staging (calcium score cut off>400) and a “corrected” J-CTO score, by ROC curve analysis to predict a successful recanalization. Thirty-two lesions (27%) had a calcium score >400.13 (11%) patients were reclassified in the “corrected” J-CTO score because calcifications were not seen in the angiogram. The factors significantly associated with the failure of the procedure were J-CTO score (OR 0.486 [0.32-0.73], p<0.001), corrected J-CTO score (OR 0.494 [0.33-0.73], p<0.001), a blunt lesion (OR 0399 [0182-0871], p=0.021) and a second attempt (OR 0322 [0121-0856], p=0.110). The calcium score >400 was not found associated with the failure of the procedure (OR 0.545 [0239-1243], p<0.149). By multivariate analysis, both J-CTO score (OR 0.645 [0418-0995], p=0.047) and the corrected J-CTO score (OR 0.631 (0410-0972] were significantly associated with a successful recanalization. However, calibration of the corrected J-CTO score was less good than the angiographic J-CTO score alone. This study suggested that calcium score evaluation before CTO procedures is not useful for grading PCI difficulty.Download : Download high-res image (83KB)Download : Download full-size imageAbstract 0489 – Figure: ROC curves analysis to predict success of the CTO Abstract 0489 – Figure: ROC curves analysis to predict success of the CTO

We assessed the interest of systematically using the GRACE scoring system (in addition to clinical assessment) for in-hospital outcomes and bleeding complications in the management of NSTEMI compared with clinical assessments alone. Multicentre, randomized study that included 572 consecutive NSTEMI patients, randomized 1:1, into group A: clinical stratification alone and group B: clinical+ GRACE score stratification. In-hospital outcomes and bleeding complications. There was no significant difference between the two groups for baseline data or for in-hospital MACE. In multivariate analysis, only a GRACE >140 (OR: 3.5, 95% CI: 1.8-6.6, p<0.001) and PCI (OR: 0.55, 95% CI: 0.3-1.0; p=0.05) were independent predictors of in-hospital MACE. The sub-analysis of group B showed that 56 patients (20%) were given a compliance score of 0, showing that diagnostic angiography was performed later than as recommended by the guidelines. Interestingly, 91% had a Grace score>140, and these patients were significantly older, and were more likely to have a history of diabetes, stroke and renal failure, together with symptoms of heart failure. After multivariate analysis, the independent predictors of a lack of compliance with guideline delays were a GRACE score >140 (OR: 9.2; CI: 4.2-20.3, p<0.001) and secondary referral from a non-PCI cardiology department (OR: 2.7; CI: 1.4-5.2, p=0.003). In a real-world setting of patients admitted with NSTEMI, the systematic use of the GRACE scoring system at admission in the PCI centre does not improve in-hospital outcomes and bleeding complications.

Iatrogenic complications are defined as adverse reactions that can be induced by non pharmacological cause, including cardiac devices or stimulation techniques. The use of cardiac devices has considerably increased over the last decade. However, only few data are available on non pharmacological iatrogeny (NPI) as cause of admission in coronary care unit (CCU). In patients admitted in CCU for iatrogenic, we aimed to determine the prevalence, characteristics and outcomes of NPI. From 1st April 2008 to 31st December 2013, all the consecutive admissions at the coronary care unit caused by NPI defined as pacemaker (PM), Implantable Cardioverter Defibrillator (ICD), radiofrequency ablation (RFA), coronary angiography, valve surgery or transcatheter aortic valve implantation (TAVI) and any other cardiac procedure were prospectively included. Patients with NPI were compared with the other patients. Among the 11503 patients admitted in CCU over the inclusion period, 225(2%) had NPI. The major cause of admission was conduction disturbance, and acute coronary syndrome or dissection (figure).The most frequent origin was coronary angiography (25%), valve intervention (22%), PM (19%), ICD (18%). The number and rate of admission for NPI markedly increased from 2008(n= 15(1,1%)) to 2013(n=52(2,6%)). This trend was mostly linked to the increase between 2008 and 2013 in new devices such as ICD (n=4 vs n=10), TAVI (n=0 vs n=4) and RFA (n=0 vs n=2). The intra-hospital mortality was stable during this period for the overall patients and patients with NPI (8% and 7%). Non pharmacological iatrogeny represents a non-negligible cause of admission in CCU, characterized by a increased rate of complications due to new techniques over the last 5 years. Multicentric studies are needed to investigate this public health issue. Download : Download full-size imageAbstract 0121 – Figure Abstract 0121 – Figure

The aims of our study were to assess ventricular tachycardia or fibrillation (VT or VF) occurrence after AMI and to analyse the relationship with either symptomatic or silent AF occurrence. Silent or symptomatic AF are known to be common after AMI and to impair patients prognosis. But the reasons of this worse prognosis remain discussed. 849 consecutive AMI were prospectively analyzed by continuous ECG monitoring (CEM) during the first 48 hours after admission. All AF, VT or VF episodes were confirm by standard ECG and sytematically reviewed by two investigators. The population was studied into three groups: No AF, Silent AF, and symptomatic AF after AMI. Forty five patients (5%) developed symptomatic AF and one hundred and thirty five developed silent AF (15.9%). Compared with the no AF group, patients with AF were markedly older 80 (67-85) and 81(71-88) vs. 62 (53-75) years; with p<0.001), more likely to have hypertension (96(72%) and (35(80%) vs 332(50%); with p<0.001) and less smoker (26 (20%) and 3(7%) vs. 242 (36%); with p<0.001). Comparing these three groups at day 1 and day 2, patients with symptomatic AF had higher heart rate (maximum, median or minimum) than patients with silent or no AF. Thus, at day 1 there was trend to a higher rate of VT or VF occurrence in symptomatic AF group, that was confirm at day 2 with 11(24.4%) vs 7(5.2%) in silent AF group and 29(4.3%)in no AF group, with p<0.001. Moreover, in-hospital mortality was higher in symptomatic AF group (8 (17.8%)) than in silent AF group (14 (10.4%)) and in no AF group (9 (1.3%)) with p<0.001. Symptomatic AF is very common after AMI and impacts patient’s outcome with more frequent episodes of VT or VF and higher inhospital mortality (17.8%). Our large prospective study suggests that VT or VF occurrence associated with symptomatic AF could be linked with the higher mortality in this population.

Atrial fibrillation (AF) is the most frequent heart rhythm disorder in the general population and contributes not only to a major deterioration in quality of life but also to an increase in cardiovascular morbimortality. The onset of AF in the acute phase of myocardial infarction (MI) is a major event that can jeopardize the prognosis of patients in the short-, medium- and long-term, and is a powerful predictor of a poor prognosis after MI. The suspected mechanism underlying the excess mortality is the drop in coronary flow linked to the acceleration and arrhythmic nature of the left ventricular contractions, which reduce the left ventricular ejection fraction. The principal causes of AF-associated death after MI are linked to heart failure. Moreover, the excess risk of death in these heart failure patients has also been associated with the onset of sudden death. Whatever its form, AF has a major negative effect on patient prognosis. In recent studies, symptomatic AF was associated with inhospital mortality of 17.8%, to which can be added mortality at 1year of 18.8%. Surprisingly, silent AF also has a negative effect on the prognosis, as it is associated with an inhospital mortality rate of 10.4%, which remains high at 5.7% at 1year. Moreover, both forms of AF are independent predictors of mortality beyond traditional risk factors. The frequency and seriousness of silent AF in the short- and long-term, which were until recently rarely studied, raises the question of systematically screening for it in the acute phase of MI. Consequently, the use of continuous ECG monitoring could be a simple, effective and inexpensive solution to improve screening for AF, even though studies are still necessary to validate this strategy. Finally, complementary studies also effect of oxidative stress and endothelial dysfunction, which seem to play a major role in triggering this rhythm disorder.

Background Silent atrial fibrillation (AF), assessed by continuous ECG monitoring (CEM), has recently been shown to be common in acute myocardial infarction (AMI), and associated with higher hospital mortality. However, the long-term prognosis is still unknown. We aimed to assess 1-year prognosis in patients experiencing silent AF in AMI.Methods All consecutive patients with AMI who were prospectively analysed by CEM during the first 48 h after admission and who survived at hospital discharge were included. Silent AF was defined as asymptomatic episodes lasting at least 30 s. Patients were followed up at 1 year for cardiovascular (CV) outcomes.Results Among the 737 patients analysed, 106 (14%) developed silent AF and 32 (4%) symptomatic AF. Compared with the no-AF group, patients with silent AF were markedly older (79 vs 62 years, p<0.001), more frequently hypertensive (71% vs 49%, p<0.001) and less likely to be smokers (23% vs 37%, p<0.001). Also, they were more likely to have impaired LVEF (50% vs 55%, p<0.001). Risk factors in patients with silent AF were similar to those in patients with symptomatic AF. However, a history of stroke or AF was less frequent in silent AF than in symptomatic-AF patients (10% vs 25% and 10% vs 38%, respectively). At 1 year, CV events including hospitalisation for heart failure (HF) and CV mortality were markedly higher in silent-AF patients than in no-AF patients (6.6% vs 1.3% and 5.7% vs 2.0%, p<0.001, respectively).Conclusions Our large prospective study showed for the first time that silent AF is associated with worse 1-year prognosis after AMI. Systematic screening and specific management should be investigated in order to improve outcomes of patients after AMI.

Rescue percutaneous coronary intervention (PCI) is associated with improved clinical outcomes for ST-segment myocardial infarction (STEMI) patients after failed fibrinolysis therapy. Hyperglycemia on admission has been shown to be a powerful predictor of mortality after acute myocardial infarction, particularly in non-diabetic patients. The aim of our study was to assess the predictive value of admission glucose levels on long-term mortality in patients with rescue PCI. From the "Observatoire des infarctus de Côte d'Or" (RICO) survey, 510 consecutive non-diabetic STEMI patients admitted to the intensive care unit for rescue PCI after failed fibrinolysis therapy were included in the study. We analyzed one-year cardiovascular mortality in these patients. Rescue PCI was deemed necessary in patients with ST-segment resolution <50% 90 minutes after lysis, or a thrombolysis in myocardial infarction (TIMI) perfusion grade in the infarct-related artery <3 at the time of angiography in patients with persisting equivocal symptoms. Patients were classified according to admission glycemia: <11 mmol/L (group I, n=452) and =11 mmol/L (group II, n=58). One-year cardiovascular (CV) mortality was 6% in group I and 29% in group II (p<0.001). Patients with hyperglycemia on admission were more likely to develop cardiogenic shock (43% vs. 10%, p<0.001) and to have higher peak CPK (4052(2465-6283) vs. 2667 (1303-4865), p=0.007), reflecting a bigger infarct size than the others, although the revascularization results were similar. By multivariate analysis, glycemia on admission =11 mmol/L (odds ratio 6.380, 95% confidence interval 2.075 to 19.617, p=0.001) and GRACE risk score (OR: 1.027, 95% CI 1.012-1.042, p<0,001) were independently associated with 1-year CV mortality. In non-diabetic patients undergoing rescue PCI after failed fibrinolysis, glycemia on admission is a predictive factor for long-term CV survival. This study suggests that evaluating early glycemic control may be useful in the setting of rescue PCI.

BACKGROUND:Silent atrial fibrillation (AF) has been suggested to be frequent after acute myocardial infarction (MI). Continuous ECG monitoring (CEM) has been shown to improve AF screening in patients at risk of stroke.OBJECTIVES:We aimed to assess the incidence and prognosis of silent AF in patients with acute MI.METHODS:All the consecutive patients with acute MI were prospectively analyzed by CEM ≥ 48 h after admission. Silent AF was defined as asymptomatic episodes lasting at least 30s. The population was divided into three groups: no-AF, silent AF and symptomatic AF.RESULTS:Among the 849 patients, 135 (16%) developed silent AF and 45 (5%) symptomatic AF. Compared with the no-AF group, patients with silent AF were markedly older (80 vs. 62 y, p<0.001), more frequently women (43% vs. 30%, p=0.006) and less likely to be smokers (20% vs. 36%, p<0.001). They had impaired left ventricular ejection fraction (LVEF) and left atrial (LA) enlargement. By multivariate analysis, age, history of AF, indexed LA area and LVEF were identified as independent predictors of silent AF. In-hospital heart failure and death rates were markedly higher in silent AF group when compared with no-AF patients (41.8% vs 21.0% and 10.4% vs. 1.3%, respectively).CONCLUSION:Our large prospective study showed for the first time that silent AF is more frequent than symptomatic AF after MI. Our work suggests that indexed LA area could help to predict the risk of developing silent AF. Moreover, the onset of silent AF is associated with worse hospital prognosis.

Background: The relation between fragmented QRS complex (fQRS) and cardiac magnetic resonance parameters is poorly documented in ischemic cardiopathy.Methods: Among 209 consecutive patients, those with fQRS were compared with those without fQRS. Cardiac magnetic resonance studies with late gadolinium-enhanced sequences were done during the week after acute myocardial infarction.Results: fQRS was present in 113 (54%) patients, and associated with a significantly lower left ventricular ejection fraction, increased left ventricular volumes, a larger infarct size (IS), and a larger peri-infarct zone. Microvascular obstruction was more frequent in patients with fQRS (62% vs 45%; P = 0.014) and the extent of the microvascular obstruction was significantly larger (1.6% [range, 0.0-4.4] vs 0.0 [range, 0.0-2.1]; P = 0.004). Finally, the transmurality score in the 2 study populations was identical (48% vs 47%; P = 0.895). In multivariate logistic regression analysis, only IS (odds ratio [OR], 1.06; 95% confidence interval [CI], 1.03-1.09; P < 0.001), systolic blood pressure (OR, 1.02; 95% CI, 1.01-1.04; P < 0.001), and left ventricular endsystolic volume (OR, 1.02; 95% CI, 1.00-1.03; P = 0.013) remained independent predictors of fQRS.Conclusions: This study revealed that fQRS was associated with increased IS, myocardial perfusion abnormalities, decreased left ventricular ejection fraction, and increased left heart volumes. These findings show that fQRS is a reliable marker of infarct size and acute ventricular remodelling.

Platelet activation is present in atrial fibrillation (AF), but there is some debate whether this is due to AF itself and/or to underlying cardiovascular diseases. We aim to determine the association between a marker of platelet reactivity (mean platelet volume (MPV)) and systemic inflammation (CRP) measured on admission, and new onset episode of AF in patients with MI. Prospective cohort of 4994 consecutive patients with AMI. Patients with paroxysmal or persistent AF were excluded. 426 (8.5%) patients were diagnosed with a new onset of AF during the in-hospital-stay (mean stay 3±2 days). These patients were older (75 vs 65, p<0.001), predominantly male, and prevalence of hypertension and diabetes was greater. Also less smoker were found among this group. Despite similar reperfusion strategies, clinical presentation with heart failure and increased heart rate (HR) was more frequently found in patients with AF. Left ventricular ejection fraction (LVEF) was significantly depressed in AF patients (47 vs. 55, p<0.001), among with increased NT-proBNP, admission MPV (8.9 vs. 8.6, p<0.001) and CRP (10.7 vs 5.7, p<0.001). Backward logistic regression analysis (model 1) found that age [OR=1.04, 95%CI (1.031–1.050), p<0.001)], HR [OR=1.016, 95%CI (1.011–1.021), p<0.001)], LVEF [OR=0.979, 95%CI (0.970–0.987), p<0.001)] and MPV [OR=1.182, 95%CI (1.064–1.312), p<0.001)] were independent predictors of AF occurrence. A second backward regression analysis (model 2= model 1+CRP) found that age [OR=1.036, 95%CI (1.026–1.046), p<0.001)], HR [OR=1.013, 95%CI (1.008–1.018), p<0.001)], LVEF [OR=0.977, 95%CI (0.968–0.987), p<0.001)] and CRP [OR=1.003, 95%CI (1.001–1.005), p=0.006)] were independent predictors of AF occurrence after MI. This study suggested that new onset of AF early after MI is rather linked to inflammation induced by myocardial damage or the existing atherosclerotic burden than platelet activation.

Background and Aim: Periodontal disease, including bone loss, is thought to be involved in coronary artery disease. Multiple complex coronary lesions relate to multifocal destabilization of coronary plaques. We investigated whether bone loss could be associated with the presence of multiple complex coronary lesions.Methods: This cross-sectional study included 150 patients with recent myocardial infarction (< 1 month). Multiple complex coronary lesions were determined at coronary angiography. A panoramic dental X-ray including bone loss >50% was performed. Patients with no or simple complex lesions were compared to patients with multiple complex lesions.Results: Over 20% of patients had multiple complex coronary lesions. Patients with multiple complex lesion were less likely to be women and more likely to have multivessel disease or elevated C-reactive protein (CRP) than patients with no or single complex lesion. Bone loss >50% tended to be more frequent in patients with multiple complex lesions (p = 0.063). In multivariate analysis, multivessel disease, gender and CRP were associated with multiple complex lesion. Bone loss >50% increased the risk of multiple complex lesion.Conclusion: Bone loss was associated with complex multiple coronary lesions, beyond systemic inflammation. These findings may bear important clinical implications for the prevention and treatment of coronary artery disease.

Background The presence of pre-infarction angina (PIA) has been shown to confer cardioprotection after ST-segment elevation myocardial infarction (STEMI). However, the clinical impact of PIA in non-ST-segment elevation myocardial infarction (NSTEMI) remains to be determined. Methods and Results From the obseRvatoire des Infarctus de Côte d'Or (RICO) survey, 1541 consecutive patients admitted in intensive care unit with a first NSTEMI were included. Patients who experienced chest pain <7 days before the episode leading to admission were defined as having PIA and were compared with patients without PIA. Incidence of in-hospital ventricular arrhythmias (VAs), heart failure and 30-day mortality were collected. Among the 1541 patients included in the study, 693 (45%) patients presented PIA. PIA was associated with a lower creatine kinase peak, as a reflection of infarct size (231(109–520) vs. 322(148–844) IU/L, p<0.001) when compared with the group without PIA. Patients with PIA developed fewer VAs, by 3 fold (1.6% vs. 4.0%, p = 0.008) and heart failure (18.0% vs. 22.4%, p = 0.040) during the hospital stay. Overall, there was a decrease in early CV events by 26% in patients with PIA (19.2% vs. 25.9%, p = 0.002). By multivariate analysis, PIA remained independently associated with less VAs. Conclusion From this large contemporary prospective study, our work showed that PIA is very frequent in patients admitted for a first NSTEMI, and is associated with a better prognosis, including reduced infarct size and in hospital VAs. Accordingly, protecting the myocardium by ischemic or pharmacological conditioning not only in STEMI, but in all type of MI merits further attention.

Background. - Myocardial infarction with ST-segment elevation (STEMI) is a medical emergency requiring specific management, with the main aim of achieving reperfusion as quickly as possible. Guidelines from medical societies have defined optimal management, with proven efficacy on morbi-mortality.Aims. - Our study aimed to evaluate trends in practices between 2002 and 2010 in the emergency management of STEMI in a single French department, namely Cote d'Or.Methods. - All patients admitted with a first STEMI to one of the six participating coronary care units (private or public) in Cote d'Or since January 2001 were included in a prospective registry (obseRvatoire des Infarctus de Cote d'Or [RICO]). Based on these data, we analysed trends in prehospital times between 2002 and 2010.Results. - A total of 4114 patients were included in this analysis. Between 2002 and 2010, there was an increase in the proportion of patients who contacted the emergency services (by dialling 15) as first medical contact; however, the time from onset of symptoms to first medical contact remained stable over the study period. Overall, there was little change in prehospital management times but we noted a slight reduction in time to reperfusion.Conclusion. - Despite some improvement in prehospital management practices between 2002 and 2010 in Cote d'Or, there is still significant room for improvement to achieve earlier reperfusion in STEMI patients. (c) 2012 Elsevier Masson SAS. All rights reserved.

Cardiovascular diseases are one of the main causes of early morbidity and mortality within occidental world as well as in developing countries where they become a growing burden of public health. North-American recommendations and the ones of the European Society of Cardiology underline that medical treatment, risk factor management and life-style modifications are cornerstone of the treatment. Thanks to their impact on prognosis, angiotensin converting enzyme (ACE) inhibitors are obvious in stable coronary patients. Recently, some large trials have supported the benefits of combining calcium antagonist, amlodipine, and ACE inhibitor, perindopril, in patients with high cardiovascular risk, stable coronary patients or hypertensive patients. This combination has synergistic properties on blood pressure control and target-organ protection, thus reducing cardiovascular events over the long term.

Aim: Early post-acute myocardial infarction pericardial effusion are the major pericardial complications . We aimed to analyse the frequency, treatments, characteristics and prognostic significance of pericardial effusion (PE) following acute myocardial infarction. Methods: From the French regional RICO survey database, all the patients hospitalized between January 1 st 2001 and december 31 st 2009 for an acute myocardial infarction from the 6 private or public center of Cote d9Or with echocardiographic examination were included in the study. The diagnosis of PE was made by echocardiography, which was performed within 48H after hospital admission. Data from patients with and without PE were compared at baseline and at follow-up. Results. During the inclusion period, 8680 patients were included in the study, of whom 135 (1.5%) were diagnosed with PE. Patients with and without PE had similar risk factors, including age and sex ratio and time delays to admission. Interestingly, dyslipidemia and history of MI was less frequent in PE group (respectively 31 vs 45%, p=0.002 and 4 vs 13%, p=0.004). Plasma CRP levels on admission were markedly higher in PE patients (21 vs 6 mg/l, p Conclusions. Our large study showed that, although PE is uncommon in the contemporary era of acute MI, this complication is still associated with worse short term prognosis, characterized by high rate of mechanical complications. Our works also suggest a preventive effect of some CV drugs against the development of PE following acute MI.