Outcomes following patent foramen ovale percutaneous closure according to the delay from last ischemic event

Background

Randomized controlled trials evaluating patent foramen ovale (PFO) percutaneous closure only included patients with recent embolic event. We aimed to evaluate outcomes following percutaneous PFO closure outcomes according to the delay from the last embolic episode.

Methods

This international ambispective cohort included consecutive patients from two centers in France and Canada undergoing PFO percutaneous closure for secondary prevention of paradoxical embolic event. The primary endpoint was the composite of stroke or transient ischemic attack (TIA). Logistic regression model was used to evaluate determinants of late PFO closure procedures.

Results

A total of 1,179 patients (mean age 49±12.7 years; 44.4% female) underwent PFO closure from 2001 to 2021 (Figure 1). The median delay from last embolic event to procedure was 6.0 (3.4–11.2) months. Determinants of late PFO closure procedure were the center (France versus Canada) adjusted Odds Ratio (aOR) 1.65 95% confidence interval (CI) 1.25–2.19, year of procedure (≥2018 versus <2018) aOR 1.43 95% CI 1.08–1.90, female sex aOR 1.63 95% CI 1.28–2.07 and lower RoPE score aOR 1.10 95% CI 1.03–1.19. After a median follow-up of 2.61 (1.13–7.25) years, the incidence rate of first stroke or TIA did not differ between early and late PFO procedures with 0.51 versus 0.29 events per 100 patient-years, respectively, incidence rate ratio 1.74 95% CI 0.66–5.08, p=0.25 (Figure 2). In univariate analysis, late PFO percutaneous closure was not associated with the occurrence of stroke or TIA, with hazard ratio 0.54 95% CI 0.22–1.34 p=0.17.

Conclusion

This analysis provides indirect evidence that delay from last ischemic event does not impact outcomes following PFO percutaneous closure for secondary prevention.

Funding Acknowledgement

Type of funding sources: None.

Have the ESC guidelines improved the identification and prevention of individuals at risk of premature myocardial infarction?

Background

Over the last 20 years, the proportion of young patients admitted for MI has increased. It is unknown whether the 5-year changes in ESC/EAS guidelines and the new SCORE2 can improve the detection and treatment of individuals at risk of premature MI.

Purpose

To determine how consecutive changes in the ESC/EAS guidelines affected the identification and treatment of young adults premature STEMI.

Methods

Patients admitted for a first STEMI in the ePARIS between 2010 and 2018 were included (n=2757) and stratified by age categories (<55 y-o; 55–65 y-o; >65 y-o). Using baseline characteristics, we evaluated whether patients in each age group would have been detected as high risk and treated with primary prevention statins before their first STEMI based on the 2021 EAS/ESC guidelines versus 2019 and 2016 guidelines (class I, IIA and IIB recommandations). Eligibility for intensive lipid-lowering therapy in secondary prevention according to age was also assessed.

Results

Among the 2757 individuals admitted for a first STEMI, 1253 (45,7%) were <55 y.o, 633 (22.9%) were [55–65] and 871 (31.4%) were >65. Only 17% and 18% of young individuals would have been considered as high risk and eligible for primary prevention statins prior to their first STEMI according to 2016 and 2019 EAS/ESC guidelines respectively, compared with individuals aged 55–65 years (41% and 35%) and >65 years old (21% and 72%), p<0.01. Following 2021 ESC guidelines, 62.5% of individuals aged <55 y.o would have been detected as eligible for primary prevention statins, without difference with individuals aged 55 to 65 years old (61.7%) and >65 y.o (62.1%) (figure). At discharge, based on the expected reduction of baseline LDL-C with maximal dose statins and ezetimibe, 47% of patients with premature STEMI would be eligible for PCSK9i compared with 50% and 37% in individuals aged 55–65 y-o and >65 y-o, respectively.

Conclusions

While 2016 and 2019 ESC guidelines poorly detected young individuals at risk of premature MI, the 2021 ESC guidelines using the new SCORE2 allowed a much better detection of young individuals at risk for a first STEMI. Young patients were also more likely to be eligible for intensive lipid-lowering therapy after their first premature STEMI.

Funding Acknowledgement

Type of funding sources: None.

Comparison of the safety and efficacy of antithrombotic regimens following TAVR in patients without having an indication for chronic oral anticoagulation

Aims

To compare the safety and efficacy of antithrombotic regimens following transcatheter aortic valve replacement (TAVR) in patients without having an indication for chronic oral anticoagulation

Methods and results

We conducted a Prospero-registered systematic review and network meta-analysis of randomized controlled trials evaluating post-TAVR antithrombotic regimens up to March 2021. We estimated the relative risk and 95% confidence intervals using a fixed effect model in a frequentist pairwise and network metanalytic approach. We included 6 studies comprising of 3,777 patients with a mean weighted follow-up of 13.3 months. Single antiplatelet therapy (SAPT) was associated with a significant reduction of life-threatening, disabling, or major bleeding compared to dual antiplatelet therapy (DAPT) (Risk Ratio [RR] 0.44, 95% confidence interval [CI]: 0.28–0.69), apixaban (RR: 0.47, 95% CI 0.26–0.84) and low-dose rivaroxaban + 3-month SAPT (RR: 0.30, 95% CI: 0.16–0.57). Risk of all-cause death was significantly reduced with DAPT compared to low-dose rivaroxaban + 3-month SAPT (RR: 0.60, 95% CI: 0.41–0.88) and a consistent reduction was observed with SAPT and DAPT compared to apixaban (RR: 0.60, 95% CI: 0.31–1.16 and RR: 0.58, 95% CI: 0.32–1.04, respectively). There were no differences between the various regimens with respect to myocardial infarction and stroke. Apixaban significantly reduced the risk of pulmonary embolism, valve thrombosis and grade 3 or 4 reduced leaflet motion.

Conclusion

Following TAVR in patients without an indication for chronic oral anticoagulant, SAPT was associated with the lowest risk of bleeding compared to DAPT and direct oral anticoagulant-based regimens without significant ischemic offset.

Funding Acknowledgement

Type of funding sources: None.

Supraventricular arrhythmia following patent foramen ovale percutaneous closure

Background

Randomized studies have reported low rates of atrial fibrillation (AF) after patent foramen ovale (PFO) closure (<6%) but have relied on patients-reported symptomatic episodes, thus true incidence and timing of AF after PFO closure remain unknown.

Objective

To prospectively determine the incidence, timing, and determinants of supraventricular arrhythmia following PFO closure based on loop recorder monitoring.

Methods

Cardiac monitoring was proposed to all patients after PFO closure from June 2018 to October 2021 in our center by mean of implantable loop recorder (ILR) monitoring in patients considered at higher risk of AF (age ≥55 years, associated cardiovascular risk factors, prior palpitations, or documented supraventricular ectopic activity) or 4-week external loop recorder (ELR) monitoring in other patients. The primary endpoint was the incidence of AF, flutter, or atrial tachycardia lasting >30 seconds within 28 days of the procedure. Determinants of the primary endpoint were assessed with stepwise logistic regression model.

Results

A total of 225 patients were included. The primary endpoint occurred in 47/225 (20.9%) patients, including n=13 (9.9%) and n=24 (28.9%) among ELR- and ILR-monitored patients, respectively. Among ILR-monitored patients, median follow-up was 428 (211–752) days, and four more cases of supraventricular arrhythmia were diagnosed beyond 28 days (Figure 1). Overall, median delay from procedure to arrhythmia was 14.0 (6.5–19.0) days and half of these patients reported symptomatic episodes. Determinants of the primary endpoint were older age (adjusted odds ratio [aOR]: 1.67, 95% confidence interval [CI]: 1.18–2.36, per 10-year increase), device left disc diameter ≥25mm (aOR: 2.67, 95% CI: 1.19–5.98) and male sex (aOR: 4.78, 95% CI: 1.96–11.66) (Figure 2).

Conclusion

Using prolonged loop recorder monitoring, supraventricular arrhythmia was diagnosed in one patient out of five with a median delay of 14 days suggesting that this post-procedural event has been so far, underestimated.

Funding Acknowledgement

Type of funding sources: None.

P6454Antithrombotic therapy and cardiovascular events in patients with left ventricular thrombus

Background

Left Ventricular Thrombus (LVT) is associated with a high risk of thromboembolic complications such as stroke. Contemporary data are lacking on the management, prognosis and treatment of LVT, particularly with the emergence of the non-vitamin K antagonist anticoagulants (NOACs).

Purpose

To study the time and predictive factors associated with thrombus regression on treatment and its association with survival, embolic and bleeding complications.

Methods

From January 2011 to January 2018, a computerized case sensitive search of LVT was performed on 90 065 consecutive echocardiogram reports. All patients with a confirmed LVT were included in this analysis after imaging review by two independent experts. Repeated echocardiographic data, treatment management and clinical outcomes were collected during follow-up. Major adverse cardiac events (MACE), defined as the composite of death, ischemic stroke or transient ischemic attack (TIA), myocardial infarction (MI) or embolic peripheral artery occlusion were analyzed as well as major bleeding events (BARC ≥3) and the predictive factors and impact of LVT regression.

Results

We identified 174 patients with a suspected LVT of whom 159 had confirmed LVT on two different cardiac imaging exams. Ischemic cardiomyopathy was the main cause of LVT (n=125, 78.6%) including 56 (35.2%) patients with an acute ST segment elevation MI. The mean left ventricular ejection fraction was 31.9±12.5% with predominant (98.1%) apical location of the LVT.

Anticoagulation therapy was achieved with vitamin K antagonists, NOACs and parenteral heparins in 48.7%, 22.8% and 27.8% of patients, respectively. Concomitant antiplatelet therapy was prescribed in 67.9% of patients. Total LVT regression was reached in two third of patients (62.3%, n=99) within a median time of 103 [32–392] days. Independent predictors of total LVT regression were an ischemic cardiomyopathy (HR: 0.36 [0.19–0.70], p=0.002), a larger baseline thrombus area (HR=0.66 [0.45–0.96], p<0.031) and a prolonged anticoagulation therapy over 3 months (HR=0.11 [0.05–0.22], p<0.0001).

During a median follow-up of 632 [187–1126] days, MACE occurred in 59 (37.1%) patients with a 18.9% rate of mortality and 13.2% of major bleeding. Patients with a total LVT regression had a non-significant lower rate of MACE as compared with patients without total LVT regression (35.4% vs. 40.0%; HR=0.71 [0.42–1.21]; p=0.20), and a significant lower rate of mortality (15.2% vs. 25.0%; HR=0.48 [0.23–0.98]; p=0.039).

Occurence of mortality (A) and MACE (B)

Conclusions

The prognosis of LVT remains severe with a high risk of major cardiovascular event and mortality. Total LVT regression, mostly reached in 3 months, can be obtained with both vitamin K antagonists and NOACs and is associated with a better prognosis.

P5367Indirect comparison of the safety and efficacy of alirocumab and evolocumab: from a comprehensive meta-analysis of 30 randomized controlled trials

Background

Alirocumab and evolocumab, two proprotein convertase subtilisin–kexin type 9 inhibitors, have both been associated with improved outcomes in patients with atherosclerotic cardiovascular disease in addition to standard lipid-lowering therapies. However, their comparative safety and efficacy profiles are unknown.

Purpose

To compare the safety and efficacy of alirocumab versus evolocumab.

Methods

We conducted a systematic review and network meta-analysis of placebo-controlled randomized trials available up to November 2018 evaluating the safety and efficacy of alirocumab and evolocumab. We estimated risk ratio and 95% confidence intervals using fixed effect model in a frequentist pairwise and network metanalytic approach. The primary safety endpoints were any adverse events leading to treatment-discontinuation, injection site reaction, systemic allergic reaction, neurocognitive events, ophthalmologic events and new-onset of diabetes mellitus (DM) or worsening of pre-existing DM. The primary efficacy endpoints were all-cause and cardiovascular (CV) death, myocardial infarction (MI) and stroke. This study was registered in PROSPERO (CRD42018090768).

Results

A total of 30 trials, enrolling 59,026 patients were included in this analysis, of whom 13,607 received alirocumab and 17,931 received evolocumab. Mean weighted follow-up time was 2.5 years, with an exposure time of 144,907 patients-years. Eligibility criteria varied significantly across trials evaluating alirocumab and evolocumab. There were no significant differences between alirocumab and evolocumab in terms of safety endpoints, except for injection site reaction with a 27% increased risk of injection site reaction with alirocumab compared to evolocumab (Figure). Compared with evolocumab, alirocumab was associated with a reduction of all-cause death but not CV death. There were no significant differences in MI or stroke between alirocumab and evolocumab.

Conclusion

Alirocumab and evolocumab share a similar safety profile. No significant differences were observed across the efficacy endpoints, except for all-cause death, which may be related to heterogeneity of the studied populations between the two drugs.

P3855Incidence, risk factors and impact of readmission for heart failure after successful transcatheter aortic valve replacement

Background

Incidence and correlates of readmission for heart failure in all-comers, after successful transcatheter aortic valve replacement (TAVR) remain unclear.

Objective

We sought to evaluate the incidence, risk factors and clinical impact of readmission for HF after successful TAVR in an unselected patient population.

Methods

All patients who underwent successful TAVR in two high-volume French tertiary centers from February 2010 to December 2016 were prospectively included and followed-up for one year. Cox multivariate model was used to assess risk factors of readmission for heart failure, evaluated a time-updated covariate and mortality.

Results

A total of 1139 patients (mean age 82.4±7.7 years, 52.2% male) were included. Readmission for heart failure occurred in 99 (8.7%) patients. Risk factors of readmission for HF were chronic pulmonary disease (adjHR 1.8; 95% CI [1.2–2.8], p=0.008), chronic kidney disease (adjHR 1.7; 95% CI [1.1–2.6], p=0.01), diabetes mellitus (adjHR 1.7; 95% CI [1.1–2.5], p=0.01), prior atrial fibrillation (adjHR 1.6; 95% CI [1.1–2.4], p=0.02) and post-TAVR left ventricular ejection fraction (LVEF) ≤35% (adjHR 2.1 95% CI 1.2–3.7, p=0.009). Readmission for HF was strongly associated with mortality (Figure) along with increased STS score (adjHR 1.07 95% CI 1.03–1.12, p=0.002), prior atrial fibrillation (adjHR 2.13 95% CI 1.53–2.96, p<0.001) and shock during the index hospitalization (adjHR 2.68 95% CI 1.48–4.87, p=0.001).

Figure 1

Conclusion

Readmission for heart failure occurs in one out of ten patients after successful TAVR and is strong risk factor of mortality. Comorbidities and post-TAVR LVEF≤35% are the main correlates of readmission for heart failure.

Acknowledgement/Funding

ACTION study group

P4569Differential prognostic impact of blood glucose levels at the acute stage of myocardial infarction according to HbA1c. The FAST-MI programme

Background

Hyperglycemia is a well-known prognostic marker in patients with acute myocardial infarction (AMI), associated with higher mortality compared with normoglycemia. Whether the prognostic impact of glycemic status at the acute stage of AMI is similar in patients with chronic dysglycemia has not been extensively explored.

Aims and methods

Using data from the nationwide French FAST-MI cohorts (2005, 2010 and 2015), we analysed the association between glycemia at entry and 30-day death, according to HbA1c level. From the 13,130 patients included, 5,452 had both glycemia and HbA1c assessed at entry. Of those, 1173 (21.5%) had an HbA1c ≥7%.

Results

In patients with HbA1c <7%, LVEF was inversely correlated with glycemic levels (55±11% for glycemia <100, 52±11% for glycemia 100–140, 50±12% for glycemia 140–160 and 49±12% for glycemia >180 mg/dl); a graded association between admission glycemia and 30-day mortality was observed, ranging from 0.7% in normoglycemic patients to 6.3% in patients with admission glycemia >180 mg/dl. In contrast, in patients with HbA1c ≥7%, LVEF was not correlated with glycemia (<100 mg/dl: 49±14%, >180 mg/dl 49±12%), and mortality was the highest in patients with normoglycemia (9.2%) and the lowest in patients with glycemia between 140 and 180 mg/dl (3.1%) (Figure). In multivariate analyses adjusting for baseline characteristics and early management, normoglycemia was associated with a decreased risk of 30-day mortality in patients with HbA1c <7% (HR 0.27, 95% confidence interval 0.10–0.73, P=0.01), while it was associated with a two-fold increase in mortality in patients with HbA1c ≥7% (HR 2.49, 95% confidence interval 1.02–6.09, P=0.046).

Figure 1. 30-day death

Conclusion

In AMI patients with high HbA1c levels on admission, normoglycemia is associated with higher early mortality than hyperglycemia. In contrast, a graded correlation is observed between admission glycemia and early mortality in patients with HbA1c <7%. Management of glycemia at the acute stage of MI might require different measures according to the initial HbA1c level.

Acknowledgement/Funding

Amgen, AstraZeneca, Bayer, Daiichi-Sankyo, Eli-Lilly, GSK, MSD, Novartis, Pfizer, Sanofi, Servier

P961Investigator versus Core Lab evaluation of coronary blood flow in PCI of patients in cardiogenic shock: a substudy of the CULPRIT-SHOCK trial

Background

Thrombolysis In Myocardial Infarction (TIMI) flow is a prognostic factor which assessment is complex in life-threatening situations. Because TIMI flow evaluation by site investigator (SI) is subject to bias, independent Core-Laboratory (CL) adjudication is the reference standard in clinical trials.

Purpose

To evaluate the concordance between CL and SI in the evaluation of the culprit artery TIMI flow, and the associated prognosis in the CULPRIT-SHOCK trial.

Methods

All patients of the CULPRIT-SHOCK trial with CL adjudications were included in this analysis. CL adjudicators were blinded to patient's characteristics and outcomes: pre and post-PCI TIMI flows were solely evaluated on the basis of coronary angiograms. SI determined the TIMI flow before and immediately after PCI of the culprit lesion. The concordance was determined by Cohen's κ coefficient. A multivariate analysis was used to evaluate 1) factors of discordance 2) the association between each method of evaluation and the mortality at 30 days and 1 year.

Results

Among CULPRIT-SHOCK patients, 663 patients were eligible for this analysis. Of the 214 patients adjudicated TIMI flow 3 by CL before PCI, SI over-estimated the obstruction to TIMI flow 0–1-2 in 121 (56.5%). Of the 139 patients scored TIMI flow 0–1-2 by CL after PCI, SI over-graded their results to TIMI flow 3 in 79 (56.8%). Overall, the K coefficient of agreement was 0.44, 95% CI [0.36; 0.51] before PCI and 0.44, 95% CI [0.35; 0.53] after PCI. Mechanical circulatory support and culprit left main were the main factors of discordance of TIMI flow after PCI. The association between TIMI flow 0–1-2 after PCI and 30-days mortality was significant, whether adjudicated by SI or CL (figure). Post-PCI TIMI-flow 0–1-2 was associated to 1-year mortality only when evaluated by SI (figure).

Association between TIMI and mortality

Conclusions

In comparison to the independant CL evaluation, SI overestimated the severity of coronary slow flow before PCI, and the success of PCI in improving coronary flow. The level of agreement between CL and SI was moderate. While both evaluations predicted 30-days mortality, only SI scoring was associated to 1-year mortality.

Acknowledgement/Funding

European Union Seventh Framework Program, the German Heart Research Foundation, German Cardiac Society.

P5575Acute left ventricular mechanics changes after TAVR: the afterload concept revisited

Background

Recent studies have emphasized the prognostic value of mild left ventricular ejection fraction (LVEF) impairment in severe aortic stenosis. However, despite adaptive mechanisms to pressure overload, subtle impaired systolic function could be worsened by increased afterload and partly reversible immediately after its correction.

Objectives

The aim was to evaluate the short terms effects of transcatheter aortic valve replacement (TAVR) on LV systolic function assessed by global longitudinal strain (GLS). We hypothesized that abrupt decrease of LV afterload after TAVR could lead to immediate improvement of LV systolic function.

Methods

Patients referred to our Department for TAVR were included from January 2018 to July 2018 in this observational prospective single center study. Transthoracic echocardiography (TTE) was performed immediately before and 1–5 days after TAVR by the same operator and reviewed in a blind fashion.

Results

35 symptomatic patients with severe aortic stenosis referred for TAVR (age 84±5 y, 18 male, NYHA 2–3, orifice area 0.7±0.2 cm2, LVEF 66±13%, GLS −15.1±4.7%) were included. Only 9/35 (26%) had a LVEF ≤60%. Overall, no significant change in LVEF (65±14%; p=0.55) or GLS (−16.1±4.8%; p=0.11) occurred immediately after TAVR despite a dramatic decrease in transoartic mean pressure gradient (44±15 mm Hg versus 6±3 mmHg; p<0.0001). However in the subgroup of patients with LVEF ≤60%, a significant increase in GLS after TAVR was observed (−9.6±4.1% versus −12.1±3.3%; p=0.0039).

Improvement in GLS according to the LVEF

Conclusion

Following TAVR, an early improvement in LV systolic function assessed by GLS was observed only in patients with pre-existing mild LV systolic dysfunction. Further studies should evaluate whether this improvement is associated with better long term outcome.

Universal screening of newborns for biliary atresia: Cost-effectiveness of alternative strategies

Objective

Biliary atresia, a rare newborn liver disease, is the most common cause of liver-related death in children and the main indication for paediatric liver transplantation. Early detection and surgical intervention with a Kasai portoenterostomy offers the best chance for long-term patient survival. We conducted a cost-effectiveness analysis to compare no universal screening with screening using either a home-based infant stool colour card with passive card distribution strategy, or conjugated bilirubin testing.

Methods

A Markov model was developed, with structure, costs, and probabilities informed by the literature and clinical expert opinion, to simulate a newborn cohort over a 10-year time horizon. Health benefits were expressed as life-years gained. This analysis was conducted from the perspective of the Canadian publicly funded health care system (all costs in Canadian dollars). Both deterministic and probabilistic analyses were conducted.

Results

Screening using a home-based colour card with passive card distribution was a cost-effective option. For a population of 392,902 annual births in Canada, this strategy cost approximately $192,000 more than no universal screening but led to eight life-years gained (incremental cost-effectiveness ratio (ICER) = $24,065 per life-year gained). Screening using conjugated bilirubin testing versus the colour card cost $2,369,199 more and led to five more life-years gained (ICER= $473,840 per life year gained), and so was not cost-effective.

Conclusions

A home-based screening program using infant stool colour cards with a passive distribution strategy could be highly cost-effective when administered at a low unit cost and with a reasonable screening performance.

Pilot Testing a Robot for Reducing Pain in Hospitalized Preterm Infants

Optimizing neurodevelopment is a key goal of neonatal occupational therapy. In preterm infants, repeated procedural pain is associated with adverse effects on neurodevelopment long term. Calmer is a robot designed to reduce infant pain. The objective of this study was to examine the effects of Calmer on heart rate variability (HRV) during routine blood collection in preterm infants. In a randomized controlled pilot trial, 10 infants were assigned to either standard care ( n = 5, facilitated tucking [FT]) or Calmer treatment ( n = 5). HRV was recorded continuously and quantified using the area (power) of the spectrum in high and low frequency (HF: 0.15-0.40Hz/ms2; LF: 0.04-0.15 Hz/ms2) regions. Changes in HRV during three, 2-min phases (Baseline, Heel Poke, and Recovery) were compared between groups. Calmer infants had 90% greater parasympathetic activation ([PS] reduced stress) during Baseline, 82% greater PS activation during Poke, and 24% greater PS activation during Recovery than FT infants. Calmer reduced physiological preterm infant pain reactivity during blood collection.

Nutritional management of phenylalanine hydroxylase (PAH) deficiency in pediatric patients in Canada: a survey of dietitians' current practices

Background

Phenylalanine hydroxylase (PAH) deficiency is one of 31 targeted inherited metabolic diseases (IMD) for the Canadian Inherited Metabolic Diseases Research Network (CIMDRN). Early diagnosis and initiation of treatment through newborn screening has gradually shifted treatment goals from the prevention of disabling complications to the optimization of long term outcomes. However, clinical evidence demonstrates that subtle suboptimal neurocognitive outcomes are present in the early and continuously diet-treated population with PAH deficiency. This may be attributed to variation in blood phenylalanine levels to outside treatment range and this, in turn, is possibly due to a combination of factors; disease severity, dietary noncompliance and differences in practice related to the management of PAH deficiency. One of CIMDRN’s goals is to understand current practices in the diagnosis and management of PAH deficiency in the pediatric population, from the perspective of both health care providers and patients/families.

Objectives

We investigated Canadian metabolic dietitians’ perspectives on the nutritional management of children with PAH deficiency, awareness of recently published North American treatment and nutritional guidelines in relation to PAH deficiency, and nutritional care practices within and outside these guidelines.

Methods

We invited 33 dietitians to participate in a survey, to ascertain their use of recently published guidelines and their practices in relation to the nutritional care of pediatric patients with PAH deficiency.

Results

We received 19 responses (59% response rate). All participants reported awareness of published guidelines for managing PAH deficiency. To classify disease severity, 89% of dietitians reported using pre-treatment blood phenylalanine (Phe) levels, alone or in combination with other factors. 74% of dietitians reported using blood Phe levels ≥360 μmol/L (6 mg/dL) as the criterion for initiating a Phe-restricted diet. All respondents considered 120-360 μmol/L (2–6 mg/dL) as the optimal treatment range for blood Phe in children 0–9 years old, but there was less agreement on blood Phe targets for older children. Most dietitians reported similar approaches to diet assessment and counseling: monitoring growth trends, use of 3 day diet records for intake analysis, individualization of diet goals, counseling patients to count grams of dietary natural protein or milligrams of dietary Phe, and monitoring blood Phe, tyrosine and ferritin.

Conclusion

While Canadian dietitians’ practices in managing pediatric PAH deficiency are generally aligned with those of the American College of Medical Genetics and Genomics (ACMG), and with the associated treatment and nutritional guidelines from Genetic Metabolic Dietitians International (GMDI), variation in many aspects of care reflects ongoing uncertainty and a need for robust evidence.

A randomized controlled trial of an intervention for infants' behavioral sleep problems

Background

Infant behavioral sleep problems are common, with potential negative consequences. We conducted a randomized controlled trial to assess effects of a sleep intervention comprising a two-hour group teaching session and four support calls over 2 weeks. Our primary outcomes were reduced numbers of nightly wakes or parent report of sleep problem severity. Secondary outcomes included improvement in parental depression, fatigue, sleep, and parent cognitions about infant sleep.

Methods

Two hundred thirty five families of six-to-eight month-old infants were randomly allocated to intervention (n = 117) or to control teaching sessions (n = 118) where parents received instruction on infant safety. Outcome measures were observed at baseline and at 6 weeks post intervention. Nightly observation was based on actigraphy and sleep diaries over six days. Secondary outcomes were derived from the Multidimensional Assessment of Fatigue Scale, Center for Epidemiologic Studies Depression Measure, Pittsburgh Sleep Quality Index, and Maternal (parental) Cognitions about Infant Sleep Questionnaire.

Results

One hundred eight intervention and 107 control families provided six-week follow-up information with complete actigraphy data for 96 in each group: 96.9 % of intervention and 97.9 % of control infants had an average of 2 or more nightly wakes, a risk difference of −0.2 % (95 % CI: −1.32, 0.91). 4 % of intervention and 14 % of control infants had parent-assessed severe sleep problems: relative risk 0.3, a risk difference of −10 % (CI: 0.11, 0.84-16.8 to −2.2). Relative to controls, intervention parents reported improved baseline-adjusted parental depression (CI: −3.7 to −0.4), fatigue (CI: −5.74 to −1.68), sleep quality (CI: −1.5 to −0.2), and sleep cognitions: doubts (CI: −2.0 to −0.6), feeding (CI: − 2.1 to - 0.7), anger (CI: − 1.8 to - 0.4) and setting limits (CI: −3.5 to −1.5).

Conclusions

The intervention improved caregivers' assessments of infant sleep problem severity and parental depression, fatigue, sleep, and sleep cognitions compared with controls.

Trial registration

ISRCTN42169337, NCT00877162

Treatment of Creatine Transporter (SLC6A8) Deficiency With Oral S-Adenosyl Methionine as Adjunct to L-arginine, Glycine, and Creatine Supplements

BACKGROUND

Creatine transporter (SLC6A8) deficiency is an X-linked inborn error of metabolism characterized by cerebral creatine deficiency, behavioral problems, seizures, hypotonia, and intellectual developmental disability. A third of patients are amenable to treatment with high-dose oral creatine, glycine, and L-arginine supplementation.

METHODS

Given the limited treatment response, we initiated an open-label observational study to evaluate the effect of adjunct S-adenosyl methionine to further enhance intracerebral creatine synthesis.

RESULTS

Significant and reproducible issues with sleep and behavior were noted in both male patients on a dose of 50/mg/kg. One of the two patients stopped S-adenosyl methionine and did not come for any follow-up. A safe and tolerable dose (17 mg/kg/day) was identified in the other patient. On magnetic resonance spectroscopy, this 8-year-old male did not show an increase in intracerebral creatine. However, significant improvement in speech/language skills, muscle mass were observed as well as in personal outcomes as defined by the family in activities related to communication and decision making.

DISCUSSION

Further research is needed to assess the potential of S-adenosyl methionine as an adjunctive therapy for creatine transporter deficiency patients and to define the optimal dose. Our study also illustrates the importance of pathophysiology-based treatment, individualized outcome assessment, and patient/family participation in rare diseases research.

Home-based screening for biliary atresia using infant stool colour cards: a large-scale prospective cohort study and cost-effectiveness analysis

OBJECTIVE

Biliary atresia (BA), a leading cause of paediatric liver failure and liver transplantation, manifests by three weeks of life as jaundice with acholic stools. Poor outcomes due to delayed diagnosis remain a problem worldwide. We evaluated and assessed the cost-effectiveness of methods of introducing a BA Infant Stool Colour Card (ISCC) screening programme in Canada.

SETTING AND METHODS

A prospective study at BC Women's Hospital recruited consecutive healthy newborns through six incrementally more intensive screening approaches. Under the baseline "passive" strategy, families received ISCCs at maternity, with instructions to monitor infant stool colour daily and return the ISCC by mail at age 30 days. Additional strategies were: ISCC mailed to family physician; reminder letters or telephone calls to families or physicians. Random telephone surveys of ISCC non-returners assessed total card utilization. Primary outcome was ISCC utilization rate expressed as a composite outcome of the ISCC return rate and non-returned ISCC use. Markov modelling was used to predict incremental costs and life years gained from screening (passive and reminder), compared with no screening, over a 10-year time horizon.

RESULTS

6,187 families were enrolled. Card utilization rates in the passive screening strategy were estimated at 60-94%. For a Canadian population, the increase in cost for passive screening, compared with no screening, is $213,584 and the gain in life years is 9.7 ($22,000 per life-year gained).

CONCLUSIONS

A BA ISCC screening programme targeting families of newborns is feasible in Canada. Passive distribution of ISCC at maternity is potentially effective and highly cost-effective.

Glucocorticoid-related changes in body mass index among children and adolescents with rheumatic diseases

OBJECTIVE

To examine the temporal and dose-related effects of glucocorticoids (GCs) on body mass index (BMI) in children with rheumatic diseases.

METHODS

Children initiating GCs for a rheumatic disease (n = 130) were assessed every 3 months for 18 months. BMI, weight, and height Z score trajectories were described according to GC starting dosage in prednisone equivalents: high (≥1.0 mg/kg/day), low (<0.2 mg/kg/day to a maximum of 7.5 mg/day), and moderate (between high and low) dosage. The impact of GC dosing, underlying diagnosis, pubertal status, physical activity, and disease activity on BMI Z scores and on percent body fat was assessed with longitudinal mixed-effects growth curve models.

RESULTS

The GC starting dose was high in 59% and moderate in 39% of patients. The peak BMI Z score was +1.29 at 4 months with high-dose GCs and +0.69 at 4.2 months with moderate-dose GCs (P < 0.001). Overall, 50% (95% confidence interval 41-59%) of the children returned to within +0.25 SD of their baseline BMI Z score. Oral GC dose over the preceding 3 months was the most significant determinant of BMI Z score and percent body fat. The proportion of days in receipt of GCs, disease activity, and a diagnosis of systemic-onset juvenile idiopathic arthritis were also associated with BMI Z scores. The correlation between changes in BMI and changes in percent body fat was 0.09.

CONCLUSION

In children with rheumatic diseases starting moderate and high doses of GCs, BMI Z scores peaked at 4 months, and only half returned to within +0.25 SD of their baseline BMI Z score after 18 months.

Long-term risk of CKD in children surviving episodes of acute kidney injury in the intensive care unit: a prospective cohort study

BACKGROUND

The development of standardized acute kidney injury (AKI) definitions has allowed for a better understanding of AKI epidemiology, but the long-term renal outcomes of AKI in the pediatric critical care setting have not been well established. This study was designed to: (1) determine the incidence of chronic kidney disease (CKD) in children 1-3 years after an episode of AKI at a tertiary-care pediatric intensive care unit (ICU), (2) identify the proportion of patients at risk of CKD, and (3) compare ICU admission characteristics in those with and without CKD.

DESIGN

Prospective cohort study.

SETTING & PARTICIPANTS

Patients admitted to the British Columbia Children's Hospital pediatric ICU from 2006-2008 with AKI, as defined by AKI Network (AKIN) criteria. Surviving patients, most with short-term recovery from their AKI, were assessed at 1, 2, or 3 years after AKI.

PREDICTORS

Severity of AKI as defined by AKIN and several ICU admission characteristics, including demographics, diagnosis, severity of illness, and ventilation data.

OUTCOMES & MEASUREMENTS

CKD was defined as the presence of albuminuria and/or glomerular filtration rate (GFR) < 60 mL/min/1.73 m2. Being at risk of CKD was defined as having a mildly decreased GFR (60-90 mL/min/1.73 m2), hypertension, and/or hyperfiltration (GFR ≥ 150 mL/min/1.73 m2).

RESULTS

The proportion of patients with AKI stages 1, 2, and 3 were 44 of 126 (35%), 47 of 126 (37%), and 35 of 126 (28%), respectively. The number of patients with CKD 1-3 years after AKI was 13 of 126 (10.3% overall; 2 of 44 [4.5%] with stage 1, 5 of 47 [10.6%] with stage 2, and 6 of 35 [17.1%] with stage 3; P = 0.2). In addition, 59 of 126 (46.8%) patients were identified as being at risk of CKD.

LIMITATIONS

Several patients identified with AKI were lost to follow-up, with the potential of underestimating the incidence of CKD.

CONCLUSIONS

In tertiary-care pediatric ICU patients, ∼10% develop CKD 1-3 years after AKI. The burden of CKD in this population may be higher with further follow-up because several patients were identified as being at risk of CKD. Regardless of the severity of AKI, all pediatric ICU patients should be monitored regularly for long-term kidney damage.

Endoscopy and antiplatelet agents. European Society of Gastrointestinal Endoscopy (ESGE) Guideline

With the increasing use of antiplatelet agents (APA), their management during the periendoscopic period has become a more common and more difficult problem. The increase in use is due to the availability of new drugs and the widespread use of drug-eluting coronary stents. Acute coronary syndromes can occur when APA therapy is withheld for noncardiovascular interventions. Guidelines about APA management during the periendoscopic period are traditionally based on assessments of the procedure-related risk of bleeding and the risk of thrombosis if APA are stopped. New data allow better assessment of these risks, of the necessary duration of APA discontinuation before endoscopy, of the use of alternative procedures (mostly for endoscopic retrograde cholangiopancreatography [ERCP]), and of endoscopic methods that can be used to prevent bleeding (following colonic polypectomy). This guideline makes graded, evidence-based, recommendations for the management of APA for all currently performed endoscopic procedures. A short summary and two tables are included for quick reference.

Painful neuropathic disorders: an analysis of the Régie de l'Assurance Maladie du Québec database

BACKGROUND/OBJECTIVE

Painful neuropathic disorders (PNDs) refer to neurological disorders involving nerves in which pain is a predominant symptom. In most cases, PNDs involve the peripheral nerves. Treatment of PNDs is likely to use large health care resources. However, little is known about the economic burden of PNDs in Canada.

METHOD

The present study was performed using data from a random sample of patients covered by the Régie de l'Assurance Maladie du Quebec drug plan. Subjects with a diagnosis of a peripheral PND were identified. Comorbidities, pain-related medication use and resource utilization were compared between PND patients and control patients without PNDs matched for age and sex in a 1:1 ratio.

RESULTS

A total of 4912 patients with PNDs were identified. A higher level of comorbidities was found in the PND group (Von Korff chronic disease score 3.91 versus 2.54; P<0.001). The proportion of users of pain-related medications was significantly higher in the PND cohort than in the control group (chi-squared; P<0.001). The average annual number of physician visits was also significantly higher in the PND group than in the control group (14.7 versus 6.4; P<0.001). From a health ministry perspective, costs of health care resources were significantly higher in the PND group (4,163 dollars versus 1,846 dollars; P<0.001). The proportion of potentially inappropriate medications was 34% among those 65 years of age or older.

CONCLUSIONS

PNDs are associated with a higher level of comorbidities, higher medical resources utilization and higher health care costs than non-PND conditions.

Trial on endovascular treatment of unruptured aneurysms (TEAM): study monitoring and rationale for trial interruption or continuation

Preventive treatment of unruptured intracranial aneurysms is often performed but has never been proved beneficial as compared to conservative management. In a context of uncertainty, the 'best treatment' that can be offered to each individual is a chance to be treated and thus to be protected from rupture of the aneurysm, and an equal chance not to be treated, and hence to be exempted from possible immediate complications, using randomization. Such action is optimal unless or until an independent committee with privileged access to data judges that, given the comparative outcome of the 2 groups, preventive treatment or conservative management, is generally warranted. Potential reasons to interrupt such a study are reviewed, including insufficient recruitment, poor compliance, excessive cross-overs, unacceptable iatrogenia, and treatments being convincingly different or equivalent. We conclude that insufficient recruitment is the sole realistic event that could lead to premature interruption. This review may provide a deeper understanding of the principles justifying the necessity of the study.

[The best of epidemiology and cardiovascular prevention in 2006]

The recent analysis of the French MONICA registries report a reduction in the incidence of fatal MI related to improvement of care whereas the overall incidence of coronary events remain stable, suggesting the need for a better primary prevention. The extensive review of the death certificates and the analysis of the death classification from the same registries indicate an under estimation of MI-related death in the national death registry. It is also confirmed that instead of 50%, approximately 80% of coronary death are explained by the four major risk factors including smoking, hypercholesterolemia, hypertension and diabetes. The international REACH registry has enrolled more than 67 000 individuals including patients with symptomatic atherothrombotic disease and patients with multiple risk factors. The analysis of baseline characteristics and of the one year FU shows a high residual risk and a lack of efficacy of secondary prevention. The existence of a symptomatic disease and the number of symptomatic localization of atherothrombosis are critical factors to predict recurrence of major vascular events Secondary analysis of the INTERHEART study provide the essence of what should any physician know about the relationship between coronary heart disease and smoking, either active or passive. Prevention with respect to this risk factor remains very insufficient. Varenicline, a new nicotinic receptor partial agonist, should help patients involved in smoking cessation program. The established detrimental effects of perioperative smoking represent a unique opportunity to promote smoking cessation in individuals scheduled for surgery. The major cardiovascular impact of second hand smoking has been recently demonstrated by the short-term effects of banning smoking in public places on the incidence of acute coronary events. The SPARCL study has demonstrated the benefit of high dose of atorvastatine to prevent recurrent acute ischemic cerebrovascular event in patients with a prior history of stroke or TIA. In the open ASTEROID study, high doses of rosuvastatine confirm the possibility of reducing the volume of coronary atheroma analyzed by IVUS. The expected benefit of glitazones to reduce the incidence of death, MI and stroke in diabetes patients with a prior history of vascular event has been confirmed in the PROactive study. Pioglitazone provided a clear reduction of recurrent vascular events in diabetes patient with a prior MI at a cost of a significant increase of the risk of heart failure. In the DREAM study, neither ramipril nor rosiglitazone have reduced the incidence of cardiovascular events significantly. The moderate benefit of the fenofibrate to prevent cardiovascular events in the FIELD study, which was carried out in diabetics mostly in primary prevention, needs to be considered after adjustment on statin use in a higher proportion of patients of the placebo group. Postprandial hyperglycaemia, analyzed by the peak of glycaemia after a load in glucose, has been confirmed as a more powerful independent predictive factor of the risk of cardiovascular event than fasting glycaemia. The systematic screening postprandial hyperglycaemia represents an interesting strategy for primary prevention which warrants further investigation. If obesity is a risk factor whose impact on morbi-mortality is well established, a French study shows that body mass index has an unfavourable influence on the cognitive functions in middle-aged men and women.

[Fibreoptic bronchoscopy and anti-platelet agents: a risk-benefit analysis]

INTRODUCTION

Respiratory physicians are confronted increasingly often by patients, in whom a fibreoptic bronchoscopy (FB) is planned, who are taking anti-platelet agents (APAs) prescribed by their cardiologist. It is necessary therefore to weigh the indications for bronchoscopy and the subsequent benefits against the risks, not only of haemorrhage, but of thrombosis if the APAs are withdrawn.

METHODS/RESULTS

In the absence of agreed guidelines on the subject this article reviews the literature and reports the results of a survey conducted among 138 members of the French Respiratory Endoscopy Group. Five questions were considered: 1) what is the risk of haemorrhage during the procedure? 2) what are the pharmacological characteristics of current APAs? 3) what is the risk of thrombosis on withdrawal of APAs? 4) what are the circumstances in which the FB may be delayed? 5) what should be the therapeutic strategy if the APAs are withdrawn?

CONCLUSIONS

While awaiting clinical studies that will allow a better understanding of these questions, and the subsequent publication of practice guidelines, it is crucial that respiratory physicians are aware of the need, prior to FB, to inquire routinely about treatment with APAs, to identify the indication, and never to interrupt such treatment without consulting the prescriber.

Altered Fibrin Architecture Is Associated With Hypofibrinolysis and Premature Coronary Atherothrombosis

OBJECTIVE

Hypofibrinolysis promotes atherosclerosis progression and recurrent ischemic events in premature coronary artery disease. We investigated the role of fibrin physical properties in this particular setting.

METHODS AND RESULTS

Biomarkers of recurrent thrombosis and premature coronary artery disease (CAD) were measured in 33 young post-myocardial infarction patients with angiographic-proven CAD and in 33 healthy volunteers matched for age and sex. Ex vivo plasma fibrin physical properties were assessed by measuring fibrin rigidity and fibrin morphological properties using a torsion pendulum and optical confocal microscopy. The fibrinolysis rate was derived from continuous monitoring of the viscoelastic properties after addition of lytic enzymes. Young CAD patients had a significant increase in plasma concentration of fibrinogen, von Willebrand factor, plasminogen activator inhibitor type 1, and lipoprotein(a) as compared with controls (P<0.05). Fibrin of young CAD patients was stiffer (P=0.002), made of numerous (P=0.002) and shorter fibers (P=0.04), and lysed at a slower rate than that of controls (P=0.03). Fibrin stiffness was an independent predictor for both premature CAD and hypofibrinolysis.

CONCLUSIONS

This first detailed study of clot properties in such a group of patients demonstrated that abnormal plasma fibrin architecture is an important feature of both premature CAD and fibrinolysis rate. The determinants of this particular phenotype warrant further investigation.

[The value of active stents for coronary angioplasty in patients with chronic renal failure]

The risk of intra-stent restenosis has diminished considerably with the advent of endoprostheses which actively release sirolimus or paclitaxel. Patients with chronic renal failure constitute a high cardiovascular risk population, in whom the incidence of coronary heart disease is particularly high, representing one of the principal causes of death. The aim of this study, which included 152 patients, was to quantify the value of active stents for coronary angioplasty in patients with chronic renal failure. Thirty eight patients with chronic renal failure who underwent angioplasty with active stents were matched for age, sex and the presence of diabetes with 3 other groups of patients: one group with active stents but without renal failure, one group with inactive stents and no renal failure, and one group with inactive stents and chronic renal failure. The average follow up was 16 +/- 5 months. The acute stent thrombosis rate (2%) was not elevated in cases of renal failure nor after active stent implantation. Chronic renal failure significantly increased the mortality rate 16 months after angioplasty, whichever type of stent was used: 8 versus 2% deaths in patients with an inactive stent (p = 0.001). In renal failure, the risk of death was lower with an active stent (8 vs 26% with an inactive stent, p<0.05). Similarly, there was a non-significant trend towards a lower risk of death and/or infarction in renal failure after active stents (8 vs 21% with an inactive stent, NS).

CONCLUSIONS

In this study, coronary angioplasty with an active stent in patients with chronic renal failure was associated with a lower mortality rate compared with inactive stents, with no increase in the risk of acute thrombosis.

Side effects of hyperbaric oxygen therapy in children with cerebral palsy

BACKGROUND

This article reports the side effects observed in a double-blind placebo-controlled multi-center randomized clinical trial carried out to assess the efficacy and safety of hyperbaric oxygen (HBO2) therapy in children with cerebral palsy. Intention-to-treat analysis did not prove to have a beneficial effect.

MATERIAL AND METHODS

111 children aged 3 to 12 years were included and followed for 8 weeks. They all received 40 compressions of 1 hour (5 days per week). In the treated group (n=57), HBO2 sessions consisted of an exposure to 100% oxygen at 1.75 atmosphere absolute (atm abs) while children in the control group (n=54) received air at 1.3 atm abs. A physician carried out a general health surveillance including an ear examination prior to and immediately following each session. All clinical events occurring during the course of the study were recorded.

FINDINGS

Events were classified in 3 categories: Events related to pressure/volume changes, events related to oxygen toxicity, and other events. No events due to oxygen toxicity were noted. Only middle ear barotrauma significantly differed according to the groups (50% in HBO2 session group versus 27.8% in control group). Other events were rare and equivalent in both groups.

CONCLUSION

Short-term exposure to HBO2 at medium level pressure (1.75 atm abs) was responsible for a significant increase of middle ear barotrauma compared to children that received very low external pressure (1.3 atm abs).

Multicenter randomized clinical trial comparing surgery and collagen injections for treatment of female stress urinary incontinence

OBJECTIVES

To compare, in a multicenter, randomized clinical trial, collagen injections versus surgery with regard to efficacy, quality of life, satisfaction, and complications.

METHODS

Of 133 women with stress urinary incontinence, 66 were randomized to collagen injection and 67 to surgery (6 needle bladder neck suspensions, 19 Burch, and 29 slings). After randomization, 15 women refused their allocated treatment. "Intent-to-treat" and "per protocol" analyses were applied. Women assigned to collagen injection could receive up to three injections before it was considered a failure. A "top-up" injection was allowed within 3 months after cure. Success as the primary outcome at 12 months was defined as a dry 24-hour pad test (2.5 g or less of urine) after having received only the allocated intervention.

RESULTS

The per protocol analysis showed that the success rate 12 months after collagen injections (53.1%) was much lower than that after surgery (72.2%). The difference was 19.1% (95% confidence interval -36.2% to -2%). The general and disease-specific quality-of-life scores measured by the Rand Medical Outcomes Study 36-item Health Survey and Incontinence Impact Questionnaire were similar in the two groups (P = 0.306). Women treated by surgery were, on average, more satisfied (79.6%) than those treated by collagen injection (67.2%), but the difference was not significant (P = 0.228). Finally, complications were less frequent and severe with collagen injection: 36 events in 23 subjects for collagen injection versus 84 events in 34 subjects for surgery (P = 0.03).

CONCLUSIONS

One year after intervention, the success rate of collagen injection as a treatment for stress urinary incontinence was about 19% lower than that after surgery. This has to be tempered by the similar changes in quality of life and satisfaction in both groups and that the number and severity of complications were much greater after surgery than after collagen injection. The results of this study indicate that collagen injections might be a worthwhile alternative to surgery for the treatment of stress urinary incontinence.

[Value of biochemistry performed in pre-hospital cardiology]

For a long time, the diagnosis of an acute myocardial infarction (AMI) seen in outdoor patients, was only relying on ECG findings. For that reason a certain amount of patients suffering from an AMI showing an atypical or not contributive ECG had not been identified as such and in consequence did not benefit from any prehospital treatment or had not been admitted in coronary care unit (CCU). With the arrival of the biological bed side monitoring in the SAMU, it became possible to measure via TRIAGE Cardiac the biological parameters of an AMI (myoglobin, troponin Ic and CKMB) and so confirm or exclude the diagnosis in certain cases. Other markers became measurable, such as BNP (brain natriuretic protein) a marker for early detection of heart failure. This natriuretic peptide is used during hospitalisation as a prognostic value in acute coronary syndrome with no cardiac insufficiency associated. More recently a semi quantitative test CardioDetect using the early release of h-FABP (heart fatty acid binding) showed a better sensibility in the first hours after chest-pain onset in out-door patients. The experience of the use of these biological bed side tests in the prehospital phase is only recent, but already permits a better management of out door patients. The future of there employ is promising. The combined use of these different markers in out door patients will probably allow in the near future identifying high risk patients.

[Antithrombotics in pre-hospital phase of acute coronary syndromes]

Antithrombotic therapies are the corner stone of acute coronary syndrome management. We have the proof that many of them should be initiated during the prehospital care because their clinical benefit is time-dependent. The hypothesis that anticoagulation therapy is an effective treatment of STEMI, which benefit is time-dependent, is now validated. It is also fair to affirm that GP lIb/IIIa receptor inhibitors are the adjuvant therapy of choice for primary PCI. Indeed, these medications reduce short-term and long-term mortality. This clinical benefit is time dependent. Clopidogrel therapy is probably also a medication of the prehospital phase. It is well established now that the biological efficacy of this pro drug is loading dose dependent. It is also demonstrated that its clinical efficacy depends on the time delay between symptom onset and initiation of the therapy. However, the clinical benefit of prehospital administration remains to be established.

[Prevalence of asymptomatic atherothrombotic lesions and risk of vascular events in patients with documented coronary artery disease]

Coronary arteries are the most frequent location of atherosclerosis. Coronary artery disease is the first cause of death related to atherothrombosis. In addition, patients with a prior history of acute coronary syndromes exhibit a 10% annual risk of recurrence. Although there seems to be a close correlation between the extension of CAD and the severity of atherosclerotic lesions in extra coronary arterial beds, the prevalence of these extracoronary asymptomatic lesions depends on their location. Hence, the prevalence of renal artery disease defined as stenosis > or = 50% or of peripheral artery disease defined as an ABI < 0.9 is estimated to be 20% up to 30%, whereas the prevalence of both carotid artery disease defined as stenosis > or = 70% or aortic aneurysm is estimated to be 5%. Conversely, the annual absolute risk of stroke among CAD patients is estimated at 1% while it remains unknown for vascular events related to PAD or aortic lesions. These data suggest that a systematic screening for asymptomatic extracoronary atherosclerotic lesions among CAD patients cannot be justified without a better knowledge of the prevalence of these lesions. In addition, the identification of the predicting factors for the presence and the development of these asymptomatic lesions is warranted. Finally, the potential benefit in terms of therapeutic intervention of such screening needs to be evaluated. These important issues warrant further clinical studies with appropriate design.

[Screening strategies for the diagnosis of asymptomatic arterial lesions in patients with atherothrombosis]

Atherosclerosis is a ubiquitous inflammatory disease. Patients presenting an acute atherothrombotic event (acute coronary syndrom, stroke, aortic aneurysm, ...) have an increased risk of events in remote arterial territories affected by atherosclerosis. These patients could benefit from systematic screening of asymptomatic atherosclerotic lesions to avoid these complications. For each atherosclerotic territory (coronary artery, carotid artery, aorta, peripheral arteries including renal arteries), we review the methods for screening asymptomatic atherothrombotic lesions which could justify specific treatments: coronary artery stenosis > or = 50%, carotid artery stenosis > or = 60%, renal artery stenosis > or = 50%, and abdominal aortic aneurysm > or = 30 mm. This review shows that non invasive methods (ie, echography, tomodensitometry) are widely available for diagnosis of asymptomatic lesions in carotid and renal arteries, and in the aorta. Despite its invasive caracteristic, coronarory angiography remains the gold-standard for the diagnosis of coronary artery disease. However, cardiac multi-slices CT-scan appears a promising technique for asymptomatic patients.

[Does diabetes affect the choice of pharmaceutical treatment in coronary artery disease?]

Coronary artery disease is the principal cause of death in diabetic patients. The choice of pharmaceutical treatment used in diabetic patients with coronary artery disease should be based on that of non-diabetic coronary patients (BASIC). However, diabetes has its own specificities. First of all, dietetic measures and physical exercise should be continually encouraged. The questions about the basic treatment concern mainly the choice of oral platelet antiaggregants and the need to associate these drugs systematically and definitively. With regards to the management of acute coronary syndromes, the important point is the improved short and long-term benefits of GP IIb/IIIa on the survival of diabetic coronary patients, especially when angioplasty is performed. Finally, intravenous insulin therapy is promising in the initial phase of treatment of acute coronary syndromes with better defined blood glucose objectives.

New Devices Designed to Improve the Long-Term Results of Endovascular Treatment of Intracranial Aneurysms. A Proposition for a Randomized Clinical Trial to Assess their Safety and Efficacy

SUMMARY

Endovascular coiling can improve the outcome of patients with ruptured intracranial aneurysms, but angiographic recurrences are frequent compared to surgical clipping. New coils or devices have been introduced to improve long-term results of endovascular treatment but none have been the object of a valid clinical trial. We have proposed a multicentric randomized double-blind study comparing radioactive and standard coil occlusion of aneurysms. The purpose of this article is to review issues that are specific to the design of clinical trials to assess embolic agents that could improve the long-term efficacy of endovascular treatment of intracranial aneurysms. The proposed trial is a randomized, multi-center, prospective, controlled trial comparing the new generation coils to standard platinum coils. Blinding, if at all possible, is preferable to minimize bias, at least for follow-up angiographic studies that should cover a period of 18 months. All patients with an intracranial aneurysm eligible for endovascular treatment would be proposed to participate. The study would enrol approximately 500 patients equally divided between the two groups, recruited within two years, to demonstrate a decrease in the recurrence rate, the primary outcome measure, from 20% to 10%. Secondary outcome measures should assure that complications, initial clinical and angiographic results remain unchanged. Independent data safety and monitoring committees are crucial to the credibility of trials and to ensure scientific rigor and objectivity. The scientific demonstration of an improved long-term efficacy, without significant compromise regarding safety, is mandatory before considering the widespread use of a new embolic device for the endovascular treatment of aneurysms.

A randomized trial on the safety and efficacy of endovascular treatment of unruptured intracranial aneurysms is feasible

SUMMARY

The safety and efficacy of endovascular treatment of unruptured intracranial aneurysms remain undetermined. A randomized trial may be the best way to demonstrate the potential benefits of endovascular management. We propose a randomized, prospective, controlled trial comparing the incidence of subarachnoid haemorrage of patients treated by endovascular coiling as compared to conservative management. We would also study a composite outcome combining SAH and the morbidity of treatment. All patients with one or more unruptured aneurysm >> 3 mm eligible for endovascular treatment would be proposed to participate. The study would be conducted in 40-50 centres. The entire study would enrol 1800 patients, recruited over three years and followed for five years, but would be preceded by a feasibility study on 200 patients. A randomized trial comparing endovascular and conservative treatment could have an important impact on the clinical management of intracranial aneurysms.

Impact of prior use or recent withdrawal of oral antiplatelet agents on acute coronary syndromes

BACKGROUND

Oral antiplatelet agents (OAAs) can prevent further vascular events in cardiovascular disease. How prior use or recent discontinuation of OAA affects clinical presentation of acute coronary syndromes (ACS) and clinical outcomes (death, myocardial infarction [MI]) is unclear.

METHODS AND RESULTS

We studied and followed up for up to 30 days a cohort of 1358 consecutive patients admitted for a suspected ACS; of these, 930 were nonusers, 355 were prior users of OAA, and 73 had recently withdrawn OAA. Nonusers were at lower risk, more frequently presented with ST-elevation MI on admission, and more frequently had Q-wave MI at discharge than prior users (36.6% versus 17.5%, P<0.001; and 47.8% versus 28.2%, P<0.001, respectively). However, there was no difference regarding the incidence of death or MI at 30 days between nonusers and prior users (10.3% versus 12.4%, P=NS). In addition, prior users experienced more major bleeds within 30 days compared with nonusers (3.4% versus 1.4%, respectively; P=0.04). Recent withdrawers were admitted on average 11.9+/-0.8 days after OAA withdrawal. Interruption was primarily a physician decision for scheduled surgery (n=47 of 73). Despite a similar cardiovascular risk profile, recent withdrawers had higher 30-day rates of death or MI (21.9% versus 12.4%, P=0.04) and bleedings (13.7% versus 5.9%, P=0.03) than prior users. After multivariate analysis, OAA withdrawal was found to be an independent predictor of both mortality and bleedings at 30 days.

CONCLUSIONS

Among ACS patients, prior users represent a higher-risk population and present more frequently with non-ST-elevation ACS than nonusers. Although patients with a recent interruption of OAA resemble those chronically treated by OAA, they display worse clinical outcomes.